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" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nLeg pain\n \nMajor Surgical or Invasive Procedure:\nSkin Biopsy\n\n \nHistory of Present Illness:\nMs. ___ is a ___ woman with history of\nhypertension who presents with leg pain.\n\nThe patient is interviewed with the assistance of a ___\ntranslator. The patient reports that she began to develop\nbilateral leg pain ___ weeks ago. She develop sored that began \nto\nweep fluid. The fluid was purulent and foul swelling. She \nreports\nthat she has a severe pain in her legs, and also a cramping in\nthe calves. She denies fevers or chills. Denies trauma to the\nleg. She saw her PCP for this issue, and was given a cream to\napply that did not help. She has been using Tylenol without much\nrelief of her pain. She has been able to ambulate, but is has\nbeen more difficult due to pain.\n\nIn the ED, vitals: 97.7 103 146/68 18 100% RA \nExam notable for significant bilateral lower extremity edema and\nchronic skin changes, with erythema and warmth most notable in\nthe left leg. Erosion along left medial ankle. Wounds/legs are\nmalodorous.\nLabs notable for: WBC 6.6, Hb 10.8\nImaging: Plain films negative for fracture; LENIs negative for\nDVT\nPatient given:\n___ 01:18 PO Acetaminophen 1000 mg \n___ 02:13 IV Piperacillin-Tazobactam 4.5 g\n___ 03:53 IV Vancomycin 1500 mg \n___ 03:53 IVF NS 1000 mL\n\nOn arrival to the floor, she reports that her leg pain is a ___\ndecreased from a ___. She implores us to help with her legs.\n\nROS: Pertinent positives and negatives as noted in the HPI. All\nother systems were reviewed and are negative. \n\n \nPast Medical History:\n- Hypertension\n \nSocial History:\n___\nFamily History:\n Reviewed and found to be not relevant to this\nillness/reason for hospitalization.\n \nPhysical Exam:\nGENERAL: Alert and in no apparent distress\nEYES: Anicteric, pupils equally round\nENT: Ears and nose without visible erythema, masses, or trauma. \nOropharynx without visible lesion, erythema or exudate\nCV: Heart regular, no murmur, no S3, no S4. No JVD.\nRESP: Lungs clear to auscultation with good air movement\nbilaterally. Breathing is non-labored\nGI: Abdomen soft, non-distended, non-tender to palpation. Bowel\nsounds present. \nGU: No suprapubic fullness or tenderness to palpation\nMSK: Neck supple, moves all extremities, strength grossly full\nand symmetric bilaterally in all limbs\nSKIN: Ulcer of left medial ankle with purulent and malodorous\ndrainage; edema and chronic brawny skin changes of left calf;\nright calf with thick crusting/scaling with appearance of \nhealthy\nskin beneath with peau d'orange, hyperpigmentation, and\nnodules/plaques \nNEURO: Alert, oriented, face symmetric, gaze conjugate with \nEOMI,\nspeech fluent, moves all limbs, sensation to light touch grossly\nintact throughout\nPSYCH: Pleasant, appropriate affect\n\nDischarge Exam: \nGen - not in distress. A&Ox3\nRS: CTAB\n___: S1S2 normal, no murmurs\nAbd: No tenderness, BS normal. \nExtremities: \n RLE: Extensive hyperkeratotic plaques from calf to foot \nwith\nulceration over L medial ankle with purulent drainage. Tender to\npalpation over calf\n LLE: Ulcer with purulent discharge over left medial\nmalleolus and some hyperkeratotic plaques over foot. Very tender\nto touch over calf. \n BLE: Pulses palpable\n \nPertinent Results:\nLabs:\n___ 10:40PM BLOOD WBC: 6.6 RBC: 4.03 Hgb: 10.8* Hct: 33.6*\nMCV: 83 MCH: 26.8 MCHC: 32.1 RDW: 16.1* RDWSD: 49.1* Plt Ct: 374 \n\n___ 10:40PM BLOOD Glucose: 100 UreaN: 7 Creat: 0.8 Na: 142\nK: 4.7 Cl: 101 HCO3: 26 AnGap: 15 \n___ 10:41PM BLOOD Lactate: 1.8 \n\nMicro:\n- Blood cultures negative\n\nImaging:\n- Bilateral ankle/tib/fib: Mild degenerative changes without\nevidence of acute fracture or dislocation. \n\n- LENIs: No evidence of deep venous thrombosis in the right or\nleft lower extremity veins to the level of the popliteal fossa.\nSuboptimal imaging of the vessels in the calves limits their \nevaluation.\n\n___ 3:39 pm SWAB Source: left medial ankle ulcer. \n\n **FINAL REPORT ___\n\n WOUND CULTURE (Final ___: \n PROTEUS MIRABILIS. SPARSE GROWTH. \n STAPH AUREUS COAG +. QUANTITATION NOT AVAILABLE. \n MIXED BACTERIAL FLORA. \n This culture contains mixed bacterial types (>=3) so an\n abbreviated workup is performed. Any growth of \nP.aeruginosa,\n S.aureus and beta hemolytic streptococci will be \nreported. IF\n THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT \nin this\n culture. \n Work-up of organism(s) listed discontinued (except \nscreened\n organisms) due to the presence of mixed bacterial flora \ndetected\n after further incubation. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n PROTEUS MIRABILIS\n | STAPH AUREUS COAG +\n | | \nAMPICILLIN------------ <=2 S\nAMPICILLIN/SULBACTAM-- <=2 S\nCEFEPIME-------------- <=1 S\nCEFTAZIDIME----------- <=1 S\nCEFTRIAXONE----------- <=1 S\nCIPROFLOXACIN---------<=0.25 S\nCLINDAMYCIN----------- <=0.25 S\nERYTHROMYCIN---------- <=0.25 S\nGENTAMICIN------------ <=1 S <=0.5 S\nMEROPENEM-------------<=0.25 S\nOXACILLIN------------- 0.5 S\nPIPERACILLIN/TAZO----- <=4 S\nTETRACYCLINE---------- <=1 S\nTOBRAMYCIN------------ <=1 S\nTRIMETHOPRIM/SULFA---- <=1 S <=0.5 S\n \nBrief Hospital Course:\nMs. ___ is a ___ woman with history of hypertension \nwho presents with leg pain found to have retention \nhyperkeratosis complicated by superimposed cellulitis. \n\n# Skin and soft tissue infection - likely Retention \nhyperkeratosis based on prelim skin biopsy findings\n# L medial malleolus ulcer with infection - superimposed \ncellulitis\n# Leg pain\nPatient presented with several weeks of leg pain and skin \nchanges. On left leg there is a purulent and malodorous ulcer. \nOn both legs, there are brawny skin changes with overlying \ncrusting. Plain films of legs without clear bony changes. LENIs \nnegative for DVT. B/l pulses well-palpable. Venous stasis ulcer \nis a possibility. ESR 39. Ultimately treated for cellulitis and \nstarted on topical treatments for retention hyperkeratosis by \ndermatology as below. Referral placed to dermatology for \noutpatient follow up on discharge. She will continue to require \ndaily dressing changes on discharge. Home ___ was arranged for \nthis though patient continues to be reluctant about home ___ \nvisits stating she will go to nearby clinic for her daily \ndressing changes instead. \n- Wound care recs: \nRLE: \"urea cream or amlactin, then vaseline then wrapped in \nkerlix gauze from toes to knees\"\nLLE: \"mupirocin ointment then wrapped in kerlix gauze from toes \nto mid calf\"\n-Change dressings daily\n-F/U blood and wound cultures - negative blood cultures, wound \ncultures positive for MSSA and proteus with sensitivities as \nlisted. De-scalated antibiotics to Doxy and Keflex with plan to \ncomplete ___ day course on discharge. \n- Tylenol for pain, Tramadol for breakthrough\n\nCHRONIC/STABLE PROBLEMS:\n# Hypertension: Not currently on any medications\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. This patient is not taking any preadmission medications\n\n \nDischarge Medications:\n1. Cephalexin 500 mg PO Q6H \nRX *cephalexin [Keflex] 500 mg 1 capsule(s) by mouth four times \na day Disp #*20 Capsule Refills:*0 \n2. Doxycycline Hyclate 100 mg PO Q12H \nRX *doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day \nDisp #*10 Capsule Refills:*0 \n3. Mupirocin Ointment 2% 1 Appl TP DAILY \nRX *mupirocin 2 % 1 APP DAILY Refills:*1 \n4. TraMADol 25 mg PO Q6H:PRN Pain - Severe \n5. Ureacin-20 (urea) 20 % topical DAILY \nRX *urea [Ureacin-20] 20 % 1 APP Daily Refills:*1 \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nRetention Hyperkeratosis\nSuperimposed Cellulitis\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nClean biopsy site with soap, water, then pad dry every day for 2 \nweeks. Cover with a thin layer of vaseline and perform dressing \nchange every day for 2 weeks.\n- RIGHT lower extremity: urea cream or amlactin, then Vaseline \nthen wrapped in kerlix gauze from toes to knees\n- for the LEFT lower extremity: mupirocin ointment then wrapped \nin kerlix gauze from toes to mid calf\n- Both of these dressings to be changed daily\n\nContinue with antibiotics for another 5 days. \n\n \nFollowup Instructions:\n___\n"
] | Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Leg pain Major Surgical or Invasive Procedure: Skin Biopsy History of Present Illness: Ms. [MASKED] is a [MASKED] woman with history of hypertension who presents with leg pain. The patient is interviewed with the assistance of a [MASKED] translator. The patient reports that she began to develop bilateral leg pain [MASKED] weeks ago. She develop sored that began to weep fluid. The fluid was purulent and foul swelling. She reports that she has a severe pain in her legs, and also a cramping in the calves. She denies fevers or chills. Denies trauma to the leg. She saw her PCP for this issue, and was given a cream to apply that did not help. She has been using Tylenol without much relief of her pain. She has been able to ambulate, but is has been more difficult due to pain. In the ED, vitals: 97.7 103 146/68 18 100% RA Exam notable for significant bilateral lower extremity edema and chronic skin changes, with erythema and warmth most notable in the left leg. Erosion along left medial ankle. Wounds/legs are malodorous. Labs notable for: WBC 6.6, Hb 10.8 Imaging: Plain films negative for fracture; LENIs negative for DVT Patient given: [MASKED] 01:18 PO Acetaminophen 1000 mg [MASKED] 02:13 IV Piperacillin-Tazobactam 4.5 g [MASKED] 03:53 IV Vancomycin 1500 mg [MASKED] 03:53 IVF NS 1000 mL On arrival to the floor, she reports that her leg pain is a [MASKED] decreased from a [MASKED]. She implores us to help with her legs. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: - Hypertension Social History: [MASKED] Family History: Reviewed and found to be not relevant to this illness/reason for hospitalization. Physical Exam: GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: Ulcer of left medial ankle with purulent and malodorous drainage; edema and chronic brawny skin changes of left calf; right calf with thick crusting/scaling with appearance of healthy skin beneath with peau d'orange, hyperpigmentation, and nodules/plaques NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: Pleasant, appropriate affect Discharge Exam: Gen - not in distress. A&Ox3 RS: CTAB [MASKED]: S1S2 normal, no murmurs Abd: No tenderness, BS normal. Extremities: RLE: Extensive hyperkeratotic plaques from calf to foot with ulceration over L medial ankle with purulent drainage. Tender to palpation over calf LLE: Ulcer with purulent discharge over left medial malleolus and some hyperkeratotic plaques over foot. Very tender to touch over calf. BLE: Pulses palpable Pertinent Results: Labs: [MASKED] 10:40PM BLOOD WBC: 6.6 RBC: 4.03 Hgb: 10.8* Hct: 33.6* MCV: 83 MCH: 26.8 MCHC: 32.1 RDW: 16.1* RDWSD: 49.1* Plt Ct: 374 [MASKED] 10:40PM BLOOD Glucose: 100 UreaN: 7 Creat: 0.8 Na: 142 K: 4.7 Cl: 101 HCO3: 26 AnGap: 15 [MASKED] 10:41PM BLOOD Lactate: 1.8 Micro: - Blood cultures negative Imaging: - Bilateral ankle/tib/fib: Mild degenerative changes without evidence of acute fracture or dislocation. - LENIs: No evidence of deep venous thrombosis in the right or left lower extremity veins to the level of the popliteal fossa. Suboptimal imaging of the vessels in the calves limits their evaluation. [MASKED] 3:39 pm SWAB Source: left medial ankle ulcer. **FINAL REPORT [MASKED] WOUND CULTURE (Final [MASKED]: PROTEUS MIRABILIS. SPARSE GROWTH. STAPH AUREUS COAG +. QUANTITATION NOT AVAILABLE. MIXED BACTERIAL FLORA. This culture contains mixed bacterial types (>=3) so an abbreviated workup is performed. Any growth of P.aeruginosa, S.aureus and beta hemolytic streptococci will be reported. IF THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT in this culture. Work-up of organism(s) listed discontinued (except screened organisms) due to the presence of mixed bacterial flora detected after further incubation. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] PROTEUS MIRABILIS | STAPH AUREUS COAG + | | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S CLINDAMYCIN----------- <=0.25 S ERYTHROMYCIN---------- <=0.25 S GENTAMICIN------------ <=1 S <=0.5 S MEROPENEM-------------<=0.25 S OXACILLIN------------- 0.5 S PIPERACILLIN/TAZO----- <=4 S TETRACYCLINE---------- <=1 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=0.5 S Brief Hospital Course: Ms. [MASKED] is a [MASKED] woman with history of hypertension who presents with leg pain found to have retention hyperkeratosis complicated by superimposed cellulitis. # Skin and soft tissue infection - likely Retention hyperkeratosis based on prelim skin biopsy findings # L medial malleolus ulcer with infection - superimposed cellulitis # Leg pain Patient presented with several weeks of leg pain and skin changes. On left leg there is a purulent and malodorous ulcer. On both legs, there are brawny skin changes with overlying crusting. Plain films of legs without clear bony changes. LENIs negative for DVT. B/l pulses well-palpable. Venous stasis ulcer is a possibility. ESR 39. Ultimately treated for cellulitis and started on topical treatments for retention hyperkeratosis by dermatology as below. Referral placed to dermatology for outpatient follow up on discharge. She will continue to require daily dressing changes on discharge. Home [MASKED] was arranged for this though patient continues to be reluctant about home [MASKED] visits stating she will go to nearby clinic for her daily dressing changes instead. - Wound care recs: RLE: "urea cream or amlactin, then vaseline then wrapped in kerlix gauze from toes to knees" LLE: "mupirocin ointment then wrapped in kerlix gauze from toes to mid calf" -Change dressings daily -F/U blood and wound cultures - negative blood cultures, wound cultures positive for MSSA and proteus with sensitivities as listed. De-scalated antibiotics to Doxy and Keflex with plan to complete [MASKED] day course on discharge. - Tylenol for pain, Tramadol for breakthrough CHRONIC/STABLE PROBLEMS: # Hypertension: Not currently on any medications Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. Cephalexin 500 mg PO Q6H RX *cephalexin [Keflex] 500 mg 1 capsule(s) by mouth four times a day Disp #*20 Capsule Refills:*0 2. Doxycycline Hyclate 100 mg PO Q12H RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day Disp #*10 Capsule Refills:*0 3. Mupirocin Ointment 2% 1 Appl TP DAILY RX *mupirocin 2 % 1 APP DAILY Refills:*1 4. TraMADol 25 mg PO Q6H:PRN Pain - Severe 5. Ureacin-20 (urea) 20 % topical DAILY RX *urea [Ureacin-20] 20 % 1 APP Daily Refills:*1 Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Retention Hyperkeratosis Superimposed Cellulitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Clean biopsy site with soap, water, then pad dry every day for 2 weeks. Cover with a thin layer of vaseline and perform dressing change every day for 2 weeks. - RIGHT lower extremity: urea cream or amlactin, then Vaseline then wrapped in kerlix gauze from toes to knees - for the LEFT lower extremity: mupirocin ointment then wrapped in kerlix gauze from toes to mid calf - Both of these dressings to be changed daily Continue with antibiotics for another 5 days. Followup Instructions: [MASKED] | [
"L03116",
"L97329",
"L570",
"I10"
] | [
"L03116: Cellulitis of left lower limb",
"L97329: Non-pressure chronic ulcer of left ankle with unspecified severity",
"L570: Actinic keratosis",
"I10: Essential (primary) hypertension"
] | [
"I10"
] | [] |
13,981,687 | 22,194,755 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nswollen ear, severe headache, fevers\n \nMajor Surgical or Invasive Procedure:\nintubation\n\n \nHistory of Present Illness:\n___ is a ___ yo M with a history of afib on anticoag,\ndiabetes, HTN who presented to ___ with severe headache,\nfever 102, shaking chills, and toxic appearance. ___ reports\ngradual onset headache that began 1 day ago, associated with\nright ear pain. Headache throbbing, dull, frontal. Subjective\nfevers, chills, nausea.\nConcern for mastoiditis vs meningitis, was started on Vanc,\nZosyn, Ceftriaxone. CT head negative for acute pathology. and\ntransferred to our ___ remained A&Ox3. \n\n___ in Afib with RVR, stable BPs; given diltiazem with\nappropriate response by time of transfer to ICU. ENT consulted\nwhile in ___ and thought to be auriculitis, were less concerned\nfor meningitis and unable to do LP as ___ on anticoag.\n___ continued on zosyn. \n\nIn the ___, \n\nInitial Vitals: T: 99.2 HR: 120 BP; 126/90 RR: 18 SpO2: 94% 4L\nNC \n\nExam: no menigismus, neck stiffness\n erythematous and indurated R ear \n\nLabs: WBC 12.5 (82% neutrophils)\n Lactate: 2.0 \n\nImaging: \n\nConsults: ENT \n\nInterventions: Diltiazem, Zosyn\n\nVS Prior to Transfer: T: 98.7 HR: 115-131 BP: 170/87 RR: 20 92%\n2L NC \n\n \nPast Medical History:\nA fib on anticoagulation\nDiabetes \nHypertension\nesophageal cancer ___ CRT in remission \nHeart failure with reduced ejection fraction\nT2DM\n \nSocial History:\n___\nFamily History:\nMarried. Lives with his wife.\n \nPhysical Exam:\nADMISSION EXAM: \n================\nVS: T: 98.5 BP:131/81 HR:93 afib RR: 16 \nGEN: pleasant, no apparent distress\nHEENT: right ear is erythematous indurated and edematous, behind\nthe right ear is markedly tender and swollen, the right TM is\nerythematous, the canal is erythematous \nNECK: wide full \nCV: irregular rhythm \nRESP: CTAB\nGI: abd soft, non tender to palpation\nMSK: \nSKIN: \nNEURO: no gross deficits \nPSYCH: appropriate affect\n\nDISCHARGE EXAM\n===============\n24 HR Data (last updated ___ @ 1308)\n Temp: 97.7 (Tm 98.4), BP: 123/77 (116-134/59-93), HR: 79 \n(68-103), RR: 18 (___), O2 sat: 98% (92-98), O2 delivery: Ra, \nWt: 231.8 lb/105.14 kg \n\nGeneral: Alert, oriented, no acute distress \nHEENT: Sclera anicteric, MMM, oropharynx clear \nNeck: Supple, JVP not elevated, no LAD \nLungs: Scant crackles in lower lung bilaterally\nCV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,\ngallops \nAbdomen: Soft, non-tender, non-distended, bowel sounds present,\nno rebound tenderness or guarding, no organomegaly \nExt: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or\nedema \nNeuro: AAOx3. Some difficulty with months-of-year-backwards. \n \nPertinent Results:\nADMISSON LABS\n==============\n___ 05:22AM BLOOD WBC-12.1* RBC-5.20 Hgb-15.1 Hct-46.6 \nMCV-90 MCH-29.0 MCHC-32.4 RDW-14.8 RDWSD-48.9* Plt ___\n___ 05:22AM BLOOD Neuts-78.6* Lymphs-13.9* Monos-6.6 \nEos-0.1* Baso-0.4 Im ___ AbsNeut-9.48* AbsLymp-1.67 \nAbsMono-0.79 AbsEos-0.01* AbsBaso-0.05\n___ 05:22AM BLOOD ___ PTT-47.2* ___\n___ 05:22AM BLOOD Glucose-101* UreaN-16 Creat-1.1 Na-142 \nK-4.1 Cl-105 HCO3-22 AnGap-15\n___ 05:22AM BLOOD ALT-29 AST-25 LD(LDH)-209 AlkPhos-63 \nTotBili-0.6\n___ 05:22AM BLOOD Albumin-3.8 Calcium-8.5 Phos-3.5 Mg-1.8\n___ 02:15AM BLOOD ___ pO2-83* pCO2-37 pH-7.43 \ncalTCO2-25 Base XS-0 Comment-GREEN TOP\n___ 02:15AM BLOOD Lactate-1.5\n\nDISCHARGE LABS:\n===============\n___ 08:18AM BLOOD WBC-9.9 RBC-4.63 Hgb-13.2* Hct-42.2 \nMCV-91 MCH-28.5 MCHC-31.3* RDW-14.5 RDWSD-48.5* Plt ___\n___ 08:18AM BLOOD Glucose-248* UreaN-18 Creat-1.0 Na-138 \nK-4.8 Cl-98 HCO3-24 AnGap-16\n___ 08:17AM URINE Color-Yellow Appear-Hazy* Sp ___\n___ 08:17AM URINE Blood-SM* Nitrite-NEG Protein-300* \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.5 Leuks-SM*\n___ 08:17AM URINE RBC-47* WBC-43* Bacteri-FEW* Yeast-NONE \nEpi-<1\n\nMICRO\n======\nNo significant micro data from admission\n\nIMAGING\n=======\nCXR ___\nIMPRESSION: \n \nRetrocardiac opacities may reflect atelectasis and/or \nconsolidation. \n \nProminence of the hila bilaterally may reflect enlarged \npulmonary arteries. \nAttention on follow-up imaging is recommended. \n\nCT Neck ___\nIMPRESSION: \n \n \n1. Venous contrast pooling and dental amalgam streak artifact \nand ___ body \nhabitus limits study. \n2. Edema and stranding inferior to the right external auditory \ncanal involving \nthe right parotid gland and right-sided platysma with slight \nprominence of the \nright tonsillar tissue relative to the left and suggestion of \nlymphadenopathy \nas described. Findings concerning for cellulitis and/or \nparotitis. \n3. Asymmetric edema of right or occult compatible with provided \nhistory of \nAuriculitis. \n4. Within limits of study, no definite evidence of focal \nperipherally \nenhancing fluid collections. \n5. Limited imaging lungs demonstrate biapical septal thickening \nand patchy \nopacities. If concern for pulmonary edema or \ninfectious/inflammatory \netiologies, consider correlation with dedicated chest imaging. \n6. Paranasal sinus disease, as described. \n7. Multilevel cervical spondylosis with at least mild to \nmoderate vertebral \ncanal narrowing C5-6. \n \nCT Chest ___\nIMPRESSION: \n \n \n1. Interlobular septal thickening and ground-glass \nopacification, \npredominantly within the mid to upper bilateral lungs, in an \natypical \ndistribution for pulmonary edema, although this cannot be \nexcluded. \nDifferential includes atypical multifocal infection, organizing \npneumonia, \nhypersensitivity pneumonitis. \n2. Nodular opacities measuring up to 1.3 cm are likely \ninfectious or \ninflammatory with similar differential as mentioned above, \nalthough separate \nprocess cannot be excluded. \n3. Trace bilateral pleural effusions. \n4. Mediastinal lymphadenopathy is likely reactive. \n5. Main pulmonary arterial dilatation suggests pulmonary \nhypertension. \n \nCXR ___\nIMPRESSION: \n \nRight-sided PICC line terminates at the level of the cavoatrial \njunction. No \nevidence of pneumothorax. \n \nRe-demonstrated are diffuse ill-defined bilateral opacities. \n \nDense left basilar atelectasis and small left pleural effusion. \n\nTTE ___\nIMPRESSION: Suboptimal image quality. Mild symmetric left \nventricular hypertrophy with normal\ncavity size and mild-moderate global biventricular hypokinesis. \nMild aortic regurgitation. Mildly\ndilated thoracic aorta. Mild pulmonary artery systolic \nhypertension.\n\nCLINICAL IMPLICATIONS: The ___ LVEF is less than 40%; a \nthreshold for which they may benefit\nfrom a beta blocker and an ACE inhibitor (or ___ and a \nmineralocorticoid receptor antagonist. The ___\nhas a mildly dilated ascending aorta. Based on ___ ACCF/AHA \nThoracic Aortic Guidelines, if not previously\nknown or a change, a follow-up echocardiogram is suggested in ___ \nyear; if previously known and stable, a\nfollow-up echocardiogram is suggested in ___ years.\n\nCXR ___\nIMPRESSION: \n \nInterval increase of ill-defined opacities at the bilateral \nlungs in the \nabsence of mediastinal venous engorgement suggests differential \ndiagnoses \nwhich include ARDS, pulmonary hemorrhage, drug reaction to \nantibiotics or \ninfection. \n\nCXR ___\nIMPRESSION: \n \nLungs are well expanded with moderate pulmonary edema. \nCardiomediastinal \nsilhouette is stable. Right-sided PICC line projects to the \nSVC. The ET tube \nand NG tube are unchanged. Left pleural effusions unchanged. \nNo \npneumothorax. \n\nCXR ___\nIMPRESSION: \n \nPulmonary edema has improved. Right-sided PICC line is \nunchanged. The ET, NG \ntube are also unchanged. Cardiomediastinal silhouette is \nstable. Bilateral \neffusions right greater than left are also stable. No \npneumothorax. \n\nCXR ___\nIMPRESSION: \n \nIn comparison with the study of ___, the monitoring and \nsupport devices are \nunchanged and in standard position. Cardiomediastinal \nsilhouette is stable. \nThere is little change in the degree of pulmonary vascular \ncongestion. The \nbilateral pleural effusions, right greater than left, appear \nslightly less \nprominent, though this could merely reflect a more upright \nposition of the \n___. \n\nCXR ___\nIMPRESSION: \n \nComparison to ___. Stable monitoring and support \ndevices. Moderate \ncardiomegaly persists. Small right pleural effusion, minimal \nleft pleural \neffusion. Bilateral areas of basilar atelectasis are unchanged. \n No pulmonary \nedema \n\nCXR ___\nIMPRESSION: \n \nComparison to ___. The ___ is now extubated, the \nfeeding tube is \nremoved. The right PICC line stays in correct position. \nIncreased lung \nvolumes likely reflect improved ventilation. The current \nradiograph shows \nmild cardiomegaly but no evidence of pneumonia, pulmonary edema \nor \npneumothorax. \n\n \nBrief Hospital Course:\nOutpatient Providers: ___ for Admission\n==============================\nMr. ___ is a ___ yo M with a history of afib on dabigitran, \ndiabetes (A1c unknown, on oral antihyperglycemic meds at home), \nand HTN who presented to ___ with a severe headache and \nright ear pain/swelling x 1 day, fever, and chills with concern \nfor auriculitis. ENT was consulted. CT head was negative for \nacute pathology. He was started on Vanc, Zosyn, and Ceftriaxone, \nand transferred to ___ ___. He was initially admitted to the \ngeneral medicine floor but was then transferred to the ICU in \nthe setting of hypoxemic respiratory failure. Respiratory \nfailure felt to be mixed picture in the setting of multifocal \npneumonia and fluid overload. He was treated with cefepime for a \n___nd diuresed to euvolemia with Lasix. He was \nintubated for four days, and after extubation, transferred to a \nmedicine floor. Post-extubation course complicated by agitation \nand ICU delirium. This improved with BID Seroquel which was \nweaned off once transferred back to medicine floor. Though \n___ was alert and oriented most of the time, at discharge he \nwas still intermittently confused which was felt to be \ncombination of ICU delirium resolving and possible UTI. Hospital \ncourse also complicated by rapid ventricular rates in the \nsetting of his known atrial fibrillation and his home rate \ncontrol medications were uptitrated. At discharge ___ \ncomplained of dysuria and a UA revealed pyuria/bactiuria \nconcerning for cystitis. He was afebrile and otherwise \nhemodynamically stable at this time and was felt safe to be \ndischarged to rehab on an oral course of nitrofurantoin for 5 \ndays. \n\nTRANSITIONAL ISSUES:\n====================\n[ ] ___ was prescribed Macrobid (nitrofurantoin) for a \nurinary tract infection. He will take this antibiotic twice a \nday for five days ending ___\n\n[ ] Will need a repeat urinalysis after completion of the \nantibiotic to ensure the resolution of microscopic hematuria \nseen on UA ___. F/u with urology if repeat UA positive for \nblood. \n\n[ ] ___ would likely benefit from weaning off diltiazem \ngiven heart failure with ejection fraction of 35%.\n\nAcute issues:\n=============\n#Hypoxemic respiratory failure. \n#Pulmonary Edema\n#Multifocal Pneumonia\n___ was transferred to the ICU in the setting of respiratory \nfailure requiring intubation. Hypoxia felt to be multifactorial \nin the setting of multifocal pneumonia and pulmonary edema \nrelated to acute on chronic HFrEF exacerbation. He received IV \nLasix and a 7 day course of cefepime. Successfully extubated \nafter several days. His hypoxia had resolved at the time of \ndischarge. \n\n#Acute on Chronic HFrEF: \nLV EF 35-40%. ___ has a history of Heart failure with \nreduced ejection fraction. Per cardiology records at ___, the \n___ EF was 31% as far back as ___. Acute exacerbation \nof heart failure and volume overload felt to play a role in \nrespiratory failure as above. Upon return to the medicine floor, \nthe ___ continued his outpatient Lasix schedule of 20mg \nQday. Captopril was started to add ACEi for guideline directed \nmedical therapy of HFrEF. Diltiazem was attempted to be weaned \noff during admission given increased mortality in heart failure \nhowever ___ HRs would not tolerate lowering of his dose \ndespite increased metoprolol dosing.\n\n#A fib w/ RVR: \nOn dabigatran, diltiazem, digoxin, and metoprolol at home. The \n___ experienced rapid ventricular rate that was terminated \nusing IV diltiazem. During his hospital course his heart rate \nfluctuated from the 100-150's. Per the patients wife, his heart \nrate is consistently over 100, even when on medications at home. \nHis dosing of diltiazem and metoprolol were uptitrated over the \ncourse of his hospitalization and at discharge HRs mostly \n___. Would benefit from weaning of dilt as outpatient if \nable given contraindication in HFrEF. \n\n#Delirium: \nPost-extubation ___ became acutely agitated and delirium. \nFelt to be ICU delirium. He was treated with melatonin and \nquetiapine with improvement in mental status. Despite return to \ncomplete orientation, at discharge ___ still intermittently \nconfused occasionally forgetting he is in the hospital or that \nhe is in fact in his own hospital room though able to complete \n___ backwards and recount hospitalization. \n\n___: \nDeveloped an acute kidney injury with Cr uptrending to 1.3 from \nbaseline 0.9 in the setting of IV diuresis for acute HFrEF \nexacerbation causing pulmonary edema. Further diuresis held with \ndevelopment ___ and renal function improved. that was \nresolved by the time of discharge. \n\n#Auriculitis: \nPresented with a swollen ear, fevers, and chills concerning for \nauriculitis. ENT was consulted. A CT scan did not reveal any \nacute pathology such as mastoiditis. He complete a course of \ncefepime 7 days on ___ for pneumonia as above which \nconcomitantly treated his auriculitis. Can follow-up with ENT as \noutpatient if new symptoms but no indication for routine f/u. \n\nCHRONIC/RESOLVED ISSUES \n======================= \n#Diabetes:\nProvided sliding scale scale insulin while hospitalized. The \nhome medications, metformin, glipizide, and empagliflozin, were \nwithheld then restarted at discharge. \n\n#HTN: \n-Home metoprolol and diltiazem were uptitrated as above. Started \ncaptopril while inpatient\n\n#Hyperlipidemia:\nContinued home atorvastatin 20mg daily\n\n#Abdominal pain:\n#heartburn\n-Continued home ppi, provided calcium carbonate prn\n\n#Constipation\n-Senna, bisacodyl, miralax\n\n___ was seen on day of discharge and examined. >30 minutes \nspent on discharge planning and care coordination on day of \ndischarge. \n \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Metoprolol Succinate XL 100 mg PO DAILY \n2. Gabapentin 100 mg PO BID \n3. Dabigatran Etexilate 150 mg PO BID \n4. GlipiZIDE 5 mg PO BID \n5. MetFORMIN (Glucophage) 500 mg PO 2 TABS IN AM, 1 TAB IN ___ \n6. Furosemide 20 mg PO DAILY \n7. Jardiance (empagliflozin) 10 mg oral DAILY \n8. Digoxin 0.125 mg PO DAILY \n9. Diltiazem Extended-Release 360 mg PO DAILY \n10. Atorvastatin 20 mg PO QPM \n11. Omeprazole 40 mg PO BID \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever \n2. Bisacodyl ___AILY \n3. Calcium Carbonate 500 mg PO QID:PRN gerd \n4. Captopril 6.25 mg PO TID \n5. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q4H:PRN throat \nirritation \n6. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H urinary \ntracr infection Duration: 7 Days \n7. Polyethylene Glycol 17 g PO DAILY \n8. Ramelteon 8 mg PO QPM:PRN sleep \n9. Selenium Sulfide 5 mL TP Q12H:PRN seborrheic dermatitis on \nface and neck \n10. Senna 8.6 mg PO BID \nPlease hold for loose stools \n11. Sodium Chloride Nasal ___ SPRY NU TID:PRN dry mucous \nmembranes \n12. Diltiazem Extended-Release 240 mg PO DAILY \n13. Metoprolol Succinate XL 200 mg PO DAILY \n14. Omeprazole 40 mg PO DAILY \n15. Atorvastatin 20 mg PO QPM \n16. Dabigatran Etexilate 150 mg PO BID \n17. Digoxin 0.125 mg PO DAILY \n18. Furosemide 20 mg PO DAILY \n19. Gabapentin 100 mg PO BID \n20. GlipiZIDE 5 mg PO BID \n21. Jardiance (empagliflozin) 10 mg oral DAILY \n22. MetFORMIN (Glucophage) 500 mg PO 2 TABS IN AM, 1 TAB IN ___ \n\n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nAtrial Fibrilation with Rapid Ventricular Rates\nAcute Hypoxemic Respiratory Failure\nMultifocal Pneumonia\nPulmonary Edema\nVolume OVerload\nAcute on Chronic Heart Failure with Reduced Ejection Fraction\nDelirium\nDeconditioning\nAcute Kidney Injury\nDiabetes\nAuriculitis\nHTN\nHLD\nGERD\nConstipation\n\n \nDischarge Condition:\nMental Status: Confused - sometimes.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear ___\n\n___ was a privilege taking care of you at ___ \n___. \n\nWHY WAS I ADMITTED TO THE HOSPITAL?\n===================================\n- You were admitted to the hospital for an infection of your ear \n(auriculitis). \n\nWHAT HAPPENED WHILE I WAS IN THE HOSPITAL?\n==========================================\n- You were treated with antibiotics for the infection in your \near\n\n- You needed to go to the intensive care unit because your heart \nwas beating too fast and your oxygen levels dropped\n\n- You were unable to breathe on your own due to an infection and \nfluid in your lungs. You were intubated so a machine could help \nyou breathe while you recovered from these things. Your \npneumonia was treated with antibiotics and the fluid in your \nlungs was treated with a medication called Lasix which helps you \npee out that extra fluid\n\n-The doses of the medications you are on for your blood pressure \nand heart rate were changed to help control your heart rate \nbetter\n\n- An infection developed in your bladder. You were given \nantibiotics to treat this when you go to rehab\n\nWHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?\n============================================ \n- Please continue to take all your medications and follow up \nwith your doctors at your ___ appointments. \n\n-Please see your cardiologist for managing your Atrial \nFibrillation. Changes were made to the medications that you take \nat home for your heart.\n\n-Please take the antibiotic (Macrobid) to treat an infection in \nyour bladder. Follow up with your primary care doctor for ___ \nrepeat urine analysis to make sure the infection is cleared and \nthere is no more blood in your urine\n\nWe wish you all the best!\n\nSincerely, \nYour ___ Care Team \n\n \nFollowup Instructions:\n___\n"
] | Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: swollen ear, severe headache, fevers Major Surgical or Invasive Procedure: intubation History of Present Illness: [MASKED] is a [MASKED] yo M with a history of afib on anticoag, diabetes, HTN who presented to [MASKED] with severe headache, fever 102, shaking chills, and toxic appearance. [MASKED] reports gradual onset headache that began 1 day ago, associated with right ear pain. Headache throbbing, dull, frontal. Subjective fevers, chills, nausea. Concern for mastoiditis vs meningitis, was started on Vanc, Zosyn, Ceftriaxone. CT head negative for acute pathology. and transferred to our [MASKED] remained A&Ox3. [MASKED] in Afib with RVR, stable BPs; given diltiazem with appropriate response by time of transfer to ICU. ENT consulted while in [MASKED] and thought to be auriculitis, were less concerned for meningitis and unable to do LP as [MASKED] on anticoag. [MASKED] continued on zosyn. In the [MASKED], Initial Vitals: T: 99.2 HR: 120 BP; 126/90 RR: 18 SpO2: 94% 4L NC Exam: no menigismus, neck stiffness erythematous and indurated R ear Labs: WBC 12.5 (82% neutrophils) Lactate: 2.0 Imaging: Consults: ENT Interventions: Diltiazem, Zosyn VS Prior to Transfer: T: 98.7 HR: 115-131 BP: 170/87 RR: 20 92% 2L NC Past Medical History: A fib on anticoagulation Diabetes Hypertension esophageal cancer [MASKED] CRT in remission Heart failure with reduced ejection fraction T2DM Social History: [MASKED] Family History: Married. Lives with his wife. Physical Exam: ADMISSION EXAM: ================ VS: T: 98.5 BP:131/81 HR:93 afib RR: 16 GEN: pleasant, no apparent distress HEENT: right ear is erythematous indurated and edematous, behind the right ear is markedly tender and swollen, the right TM is erythematous, the canal is erythematous NECK: wide full CV: irregular rhythm RESP: CTAB GI: abd soft, non tender to palpation MSK: SKIN: NEURO: no gross deficits PSYCH: appropriate affect DISCHARGE EXAM =============== 24 HR Data (last updated [MASKED] @ 1308) Temp: 97.7 (Tm 98.4), BP: 123/77 (116-134/59-93), HR: 79 (68-103), RR: 18 ([MASKED]), O2 sat: 98% (92-98), O2 delivery: Ra, Wt: 231.8 lb/105.14 kg General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: Supple, JVP not elevated, no LAD Lungs: Scant crackles in lower lung bilaterally 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: AAOx3. Some difficulty with months-of-year-backwards. Pertinent Results: ADMISSON LABS ============== [MASKED] 05:22AM BLOOD WBC-12.1* RBC-5.20 Hgb-15.1 Hct-46.6 MCV-90 MCH-29.0 MCHC-32.4 RDW-14.8 RDWSD-48.9* Plt [MASKED] [MASKED] 05:22AM BLOOD Neuts-78.6* Lymphs-13.9* Monos-6.6 Eos-0.1* Baso-0.4 Im [MASKED] AbsNeut-9.48* AbsLymp-1.67 AbsMono-0.79 AbsEos-0.01* AbsBaso-0.05 [MASKED] 05:22AM BLOOD [MASKED] PTT-47.2* [MASKED] [MASKED] 05:22AM BLOOD Glucose-101* UreaN-16 Creat-1.1 Na-142 K-4.1 Cl-105 HCO3-22 AnGap-15 [MASKED] 05:22AM BLOOD ALT-29 AST-25 LD(LDH)-209 AlkPhos-63 TotBili-0.6 [MASKED] 05:22AM BLOOD Albumin-3.8 Calcium-8.5 Phos-3.5 Mg-1.8 [MASKED] 02:15AM BLOOD [MASKED] pO2-83* pCO2-37 pH-7.43 calTCO2-25 Base XS-0 Comment-GREEN TOP [MASKED] 02:15AM BLOOD Lactate-1.5 DISCHARGE LABS: =============== [MASKED] 08:18AM BLOOD WBC-9.9 RBC-4.63 Hgb-13.2* Hct-42.2 MCV-91 MCH-28.5 MCHC-31.3* RDW-14.5 RDWSD-48.5* Plt [MASKED] [MASKED] 08:18AM BLOOD Glucose-248* UreaN-18 Creat-1.0 Na-138 K-4.8 Cl-98 HCO3-24 AnGap-16 [MASKED] 08:17AM URINE Color-Yellow Appear-Hazy* Sp [MASKED] [MASKED] 08:17AM URINE Blood-SM* Nitrite-NEG Protein-300* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.5 Leuks-SM* [MASKED] 08:17AM URINE RBC-47* WBC-43* Bacteri-FEW* Yeast-NONE Epi-<1 MICRO ====== No significant micro data from admission IMAGING ======= CXR [MASKED] IMPRESSION: Retrocardiac opacities may reflect atelectasis and/or consolidation. Prominence of the hila bilaterally may reflect enlarged pulmonary arteries. Attention on follow-up imaging is recommended. CT Neck [MASKED] IMPRESSION: 1. Venous contrast pooling and dental amalgam streak artifact and [MASKED] body habitus limits study. 2. Edema and stranding inferior to the right external auditory canal involving the right parotid gland and right-sided platysma with slight prominence of the right tonsillar tissue relative to the left and suggestion of lymphadenopathy as described. Findings concerning for cellulitis and/or parotitis. 3. Asymmetric edema of right or occult compatible with provided history of Auriculitis. 4. Within limits of study, no definite evidence of focal peripherally enhancing fluid collections. 5. Limited imaging lungs demonstrate biapical septal thickening and patchy opacities. If concern for pulmonary edema or infectious/inflammatory etiologies, consider correlation with dedicated chest imaging. 6. Paranasal sinus disease, as described. 7. Multilevel cervical spondylosis with at least mild to moderate vertebral canal narrowing C5-6. CT Chest [MASKED] IMPRESSION: 1. Interlobular septal thickening and ground-glass opacification, predominantly within the mid to upper bilateral lungs, in an atypical distribution for pulmonary edema, although this cannot be excluded. Differential includes atypical multifocal infection, organizing pneumonia, hypersensitivity pneumonitis. 2. Nodular opacities measuring up to 1.3 cm are likely infectious or inflammatory with similar differential as mentioned above, although separate process cannot be excluded. 3. Trace bilateral pleural effusions. 4. Mediastinal lymphadenopathy is likely reactive. 5. Main pulmonary arterial dilatation suggests pulmonary hypertension. CXR [MASKED] IMPRESSION: Right-sided PICC line terminates at the level of the cavoatrial junction. No evidence of pneumothorax. Re-demonstrated are diffuse ill-defined bilateral opacities. Dense left basilar atelectasis and small left pleural effusion. TTE [MASKED] IMPRESSION: Suboptimal image quality. Mild symmetric left ventricular hypertrophy with normal cavity size and mild-moderate global biventricular hypokinesis. Mild aortic regurgitation. Mildly dilated thoracic aorta. Mild pulmonary artery systolic hypertension. CLINICAL IMPLICATIONS: The [MASKED] LVEF is less than 40%; a threshold for which they may benefit from a beta blocker and an ACE inhibitor (or [MASKED] and a mineralocorticoid receptor antagonist. The [MASKED] has a mildly dilated ascending aorta. Based on [MASKED] ACCF/AHA Thoracic Aortic Guidelines, if not previously known or a change, a follow-up echocardiogram is suggested in [MASKED] year; if previously known and stable, a follow-up echocardiogram is suggested in [MASKED] years. CXR [MASKED] IMPRESSION: Interval increase of ill-defined opacities at the bilateral lungs in the absence of mediastinal venous engorgement suggests differential diagnoses which include ARDS, pulmonary hemorrhage, drug reaction to antibiotics or infection. CXR [MASKED] IMPRESSION: Lungs are well expanded with moderate pulmonary edema. Cardiomediastinal silhouette is stable. Right-sided PICC line projects to the SVC. The ET tube and NG tube are unchanged. Left pleural effusions unchanged. No pneumothorax. CXR [MASKED] IMPRESSION: Pulmonary edema has improved. Right-sided PICC line is unchanged. The ET, NG tube are also unchanged. Cardiomediastinal silhouette is stable. Bilateral effusions right greater than left are also stable. No pneumothorax. CXR [MASKED] IMPRESSION: In comparison with the study of [MASKED], the monitoring and support devices are unchanged and in standard position. Cardiomediastinal silhouette is stable. There is little change in the degree of pulmonary vascular congestion. The bilateral pleural effusions, right greater than left, appear slightly less prominent, though this could merely reflect a more upright position of the [MASKED]. CXR [MASKED] IMPRESSION: Comparison to [MASKED]. Stable monitoring and support devices. Moderate cardiomegaly persists. Small right pleural effusion, minimal left pleural effusion. Bilateral areas of basilar atelectasis are unchanged. No pulmonary edema CXR [MASKED] IMPRESSION: Comparison to [MASKED]. The [MASKED] is now extubated, the feeding tube is removed. The right PICC line stays in correct position. Increased lung volumes likely reflect improved ventilation. The current radiograph shows mild cardiomegaly but no evidence of pneumonia, pulmonary edema or pneumothorax. Brief Hospital Course: Outpatient Providers: [MASKED] for Admission ============================== Mr. [MASKED] is a [MASKED] yo M with a history of afib on dabigitran, diabetes (A1c unknown, on oral antihyperglycemic meds at home), and HTN who presented to [MASKED] with a severe headache and right ear pain/swelling x 1 day, fever, and chills with concern for auriculitis. ENT was consulted. CT head was negative for acute pathology. He was started on Vanc, Zosyn, and Ceftriaxone, and transferred to [MASKED] [MASKED]. He was initially admitted to the general medicine floor but was then transferred to the ICU in the setting of hypoxemic respiratory failure. Respiratory failure felt to be mixed picture in the setting of multifocal pneumonia and fluid overload. He was treated with cefepime for a nd diuresed to euvolemia with Lasix. He was intubated for four days, and after extubation, transferred to a medicine floor. Post-extubation course complicated by agitation and ICU delirium. This improved with BID Seroquel which was weaned off once transferred back to medicine floor. Though [MASKED] was alert and oriented most of the time, at discharge he was still intermittently confused which was felt to be combination of ICU delirium resolving and possible UTI. Hospital course also complicated by rapid ventricular rates in the setting of his known atrial fibrillation and his home rate control medications were uptitrated. At discharge [MASKED] complained of dysuria and a UA revealed pyuria/bactiuria concerning for cystitis. He was afebrile and otherwise hemodynamically stable at this time and was felt safe to be discharged to rehab on an oral course of nitrofurantoin for 5 days. TRANSITIONAL ISSUES: ==================== [ ] [MASKED] was prescribed Macrobid (nitrofurantoin) for a urinary tract infection. He will take this antibiotic twice a day for five days ending [MASKED] [ ] Will need a repeat urinalysis after completion of the antibiotic to ensure the resolution of microscopic hematuria seen on UA [MASKED]. F/u with urology if repeat UA positive for blood. [ ] [MASKED] would likely benefit from weaning off diltiazem given heart failure with ejection fraction of 35%. Acute issues: ============= #Hypoxemic respiratory failure. #Pulmonary Edema #Multifocal Pneumonia [MASKED] was transferred to the ICU in the setting of respiratory failure requiring intubation. Hypoxia felt to be multifactorial in the setting of multifocal pneumonia and pulmonary edema related to acute on chronic HFrEF exacerbation. He received IV Lasix and a 7 day course of cefepime. Successfully extubated after several days. His hypoxia had resolved at the time of discharge. #Acute on Chronic HFrEF: LV EF 35-40%. [MASKED] has a history of Heart failure with reduced ejection fraction. Per cardiology records at [MASKED], the [MASKED] EF was 31% as far back as [MASKED]. Acute exacerbation of heart failure and volume overload felt to play a role in respiratory failure as above. Upon return to the medicine floor, the [MASKED] continued his outpatient Lasix schedule of 20mg Qday. Captopril was started to add ACEi for guideline directed medical therapy of HFrEF. Diltiazem was attempted to be weaned off during admission given increased mortality in heart failure however [MASKED] HRs would not tolerate lowering of his dose despite increased metoprolol dosing. #A fib w/ RVR: On dabigatran, diltiazem, digoxin, and metoprolol at home. The [MASKED] experienced rapid ventricular rate that was terminated using IV diltiazem. During his hospital course his heart rate fluctuated from the 100-150's. Per the patients wife, his heart rate is consistently over 100, even when on medications at home. His dosing of diltiazem and metoprolol were uptitrated over the course of his hospitalization and at discharge HRs mostly [MASKED]. Would benefit from weaning of dilt as outpatient if able given contraindication in HFrEF. #Delirium: Post-extubation [MASKED] became acutely agitated and delirium. Felt to be ICU delirium. He was treated with melatonin and quetiapine with improvement in mental status. Despite return to complete orientation, at discharge [MASKED] still intermittently confused occasionally forgetting he is in the hospital or that he is in fact in his own hospital room though able to complete [MASKED] backwards and recount hospitalization. [MASKED]: Developed an acute kidney injury with Cr uptrending to 1.3 from baseline 0.9 in the setting of IV diuresis for acute HFrEF exacerbation causing pulmonary edema. Further diuresis held with development [MASKED] and renal function improved. that was resolved by the time of discharge. #Auriculitis: Presented with a swollen ear, fevers, and chills concerning for auriculitis. ENT was consulted. A CT scan did not reveal any acute pathology such as mastoiditis. He complete a course of cefepime 7 days on [MASKED] for pneumonia as above which concomitantly treated his auriculitis. Can follow-up with ENT as outpatient if new symptoms but no indication for routine f/u. CHRONIC/RESOLVED ISSUES ======================= #Diabetes: Provided sliding scale scale insulin while hospitalized. The home medications, metformin, glipizide, and empagliflozin, were withheld then restarted at discharge. #HTN: -Home metoprolol and diltiazem were uptitrated as above. Started captopril while inpatient #Hyperlipidemia: Continued home atorvastatin 20mg daily #Abdominal pain: #heartburn -Continued home ppi, provided calcium carbonate prn #Constipation -Senna, bisacodyl, miralax [MASKED] was seen on day of discharge and examined. >30 minutes spent on discharge planning and care coordination on day of discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 100 mg PO DAILY 2. Gabapentin 100 mg PO BID 3. Dabigatran Etexilate 150 mg PO BID 4. GlipiZIDE 5 mg PO BID 5. MetFORMIN (Glucophage) 500 mg PO 2 TABS IN AM, 1 TAB IN [MASKED] 6. Furosemide 20 mg PO DAILY 7. Jardiance (empagliflozin) 10 mg oral DAILY 8. Digoxin 0.125 mg PO DAILY 9. Diltiazem Extended-Release 360 mg PO DAILY 10. Atorvastatin 20 mg PO QPM 11. Omeprazole 40 mg PO BID Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever 2. Bisacodyl AILY 3. Calcium Carbonate 500 mg PO QID:PRN gerd 4. Captopril 6.25 mg PO TID 5. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q4H:PRN throat irritation 6. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H urinary tracr infection Duration: 7 Days 7. Polyethylene Glycol 17 g PO DAILY 8. Ramelteon 8 mg PO QPM:PRN sleep 9. Selenium Sulfide 5 mL TP Q12H:PRN seborrheic dermatitis on face and neck 10. Senna 8.6 mg PO BID Please hold for loose stools 11. Sodium Chloride Nasal [MASKED] SPRY NU TID:PRN dry mucous membranes 12. Diltiazem Extended-Release 240 mg PO DAILY 13. Metoprolol Succinate XL 200 mg PO DAILY 14. Omeprazole 40 mg PO DAILY 15. Atorvastatin 20 mg PO QPM 16. Dabigatran Etexilate 150 mg PO BID 17. Digoxin 0.125 mg PO DAILY 18. Furosemide 20 mg PO DAILY 19. Gabapentin 100 mg PO BID 20. GlipiZIDE 5 mg PO BID 21. Jardiance (empagliflozin) 10 mg oral DAILY 22. MetFORMIN (Glucophage) 500 mg PO 2 TABS IN AM, 1 TAB IN [MASKED] Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Atrial Fibrilation with Rapid Ventricular Rates Acute Hypoxemic Respiratory Failure Multifocal Pneumonia Pulmonary Edema Volume OVerload Acute on Chronic Heart Failure with Reduced Ejection Fraction Delirium Deconditioning Acute Kidney Injury Diabetes Auriculitis HTN HLD GERD Constipation 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 [MASKED] [MASKED] was a privilege taking care of you at [MASKED] [MASKED]. WHY WAS I ADMITTED TO THE HOSPITAL? =================================== - You were admitted to the hospital for an infection of your ear (auriculitis). WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? ========================================== - You were treated with antibiotics for the infection in your ear - You needed to go to the intensive care unit because your heart was beating too fast and your oxygen levels dropped - You were unable to breathe on your own due to an infection and fluid in your lungs. You were intubated so a machine could help you breathe while you recovered from these things. Your pneumonia was treated with antibiotics and the fluid in your lungs was treated with a medication called Lasix which helps you pee out that extra fluid -The doses of the medications you are on for your blood pressure and heart rate were changed to help control your heart rate better - An infection developed in your bladder. You were given antibiotics to treat this when you go to rehab WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? ============================================ - Please continue to take all your medications and follow up with your doctors at your [MASKED] appointments. -Please see your cardiologist for managing your Atrial Fibrillation. Changes were made to the medications that you take at home for your heart. -Please take the antibiotic (Macrobid) to treat an infection in your bladder. Follow up with your primary care doctor for [MASKED] repeat urine analysis to make sure the infection is cleared and there is no more blood in your urine We wish you all the best! Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED] | [
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"H6011: Cellulitis of right external ear",
"J189: Pneumonia, unspecified organism",
"A419: Sepsis, unspecified organism",
"J9601: Acute respiratory failure with hypoxia",
"I5023: Acute on chronic systolic (congestive) heart failure",
"E872: Acidosis",
"F05: Delirium due to known physiological condition",
"N179: Acute kidney failure, unspecified",
"E119: Type 2 diabetes mellitus without complications",
"I4891: Unspecified atrial fibrillation",
"E785: Hyperlipidemia, unspecified",
"K5900: Constipation, unspecified",
"G4733: Obstructive sleep apnea (adult) (pediatric)",
"E669: Obesity, unspecified",
"E8770: Fluid overload, unspecified",
"I110: Hypertensive heart disease with heart failure",
"K219: Gastro-esophageal reflux disease without esophagitis",
"N3090: Cystitis, unspecified without hematuria",
"Z8501: Personal history of malignant neoplasm of esophagus"
] | [
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19,573,705 | 23,263,183 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: NEUROLOGY\n \nAllergies: \nshellfish derived\n \nAttending: ___\n \nChief Complaint:\nRight-sided weakness\n \nMajor Surgical or Invasive Procedure:\nLumbar puncture\n \nHistory of Present Illness:\nMr. ___ is a ___ man with a past medical history of\nthyroid cancer status post resection followed by ___,\nhyperlipidemia who presents with 10 days of discrete episodes of\nheadache, lightheadedness, and focal neurologic deficits. \nHistory is obtained by wife at the bedside as patient not able \nto\nparticipate.\n\nOn ___, wife notes that patient had sudden \nonset\n\"massive headache\" with associated lightheadedness and tunnel\nvision. He also experienced numbness in his right arm. There\nwas no vertigo. It is unclear how long this episode lasted but\npatient went to bed and slept for approximately 15 hours. On\nawakening the following day, patient felt back to baseline. He\ncalled his primary care physician and went in for evaluation \nthat\nday. His PCP performed ___ \"lightheadedness workup\" and found no\nneurologic deficits. He felt his symptoms were most likely\nsecondary to migraine headache.\n\nTwo days later, on ___, patient sent wife \"incoherent\"\ntext message via phone. She called him afterward and he had\ndifficulty getting the words out when speaking with her. The\nwife took patient to ___ where he had a\nnoncontrast ___ CT which was unremarkable. He would that he \nwas\ndiagnosed with migraine and sent home. The whole episode lasted\napproximately 1 hour.\n\nPatient and his wife followed up with a neurologist through\n___ the following day and he had an MRI brain\nwithout contrast/MRA ___ and neck as an outpatient. Imaging \nwas\nunremarkable. There are no notes to review from this encounter,\nbut the wife reports the neurologist agreed the etiology of his\nsymptoms was most likely migraine.\n\nThe following day, patient complained of headache which felt \nlike\na headband putting pressure on his whole ___, right worse than\nleft side. The wife began to document his symptoms and she\nnotes: \n12 ___ lightheadedness and vision issues\n12:15 ___ went to bed and slept until 2 ___ \n2:05 ___ woke up with a raging headache behind eyes and\nphotophobia. \nShe documents an exaggerated startle, jumping every time she\nwalks by her opens a soda can. He went to sleep shortly\nafterward and awoke 4 hours later.\n6:15 ___ awoke with continued lightheadedness and headache\n9 ___ out of bed, feeling better\nHe slept until 8:30 AM.\n\nHe was asymptomatic the following day.\n\nToday at 7 ___ he experienced sudden onset right hand numbness\nwhich traveled to his right arm and leg. He also had twitching\nof his right face and clenched his right eye in pain. He also\nhad difficulty speaking, getting any words out. EMS was called\nand he was brought to ___ where code stroke was called. \nNoncontrast ___ CT was negative for bleed or other intracranial\nabnormality. Shortly after arrival to the ED his symptoms\nresolved and TPA was deferred. He began to complain of a\nheadache at this time. \n\nHe was transferred to ___ for further management. Neurology\nwas consulted for question of seizures versus atypical migraine.\n\nUnable to complete review of systems, though positive neurologic\nreview of systems are noted as above. Specifically, patient's\nwife denies a history of headache or migraines. She denies any\nrecent fever or chills. \n\n \nPast Medical History:\nThyroid cancer status post resection. No chemo or radiation. \nDiagnosed in ___, managed at ___. On maintenance \nlevothyroxine.\nHyperlipidemia\n \nSocial History:\n___\nFamily History:\nNo family history of stroke, seizure, or migraine.\n \nPhysical Exam:\n==============\nADMISSION EXAM\n==============\nVitals: Tm: 102.5 P: 40-70 r: 16 BP: 136/90 SaO2: 99% on room \nair\nBlood glucose 89 \nGeneral: Agitated, thrashing in bed, pulling off telemetry \nleads,\nand trying to get out of bed, holding ___ periodically and\nmoaning\nHEENT: NC/AT, positive photophobia, no scleral icterus noted,\nMMM, no lesions noted in oropharynx, incessant yawning\nNeck: Supple, No nuchal rigidity\nPulmonary: Normal work of breathing\nCardiac: Bradycardic, regular rhythm, warm, well-perfused\nAbdomen: soft, non-distended\nExtremities: No ___ edema. He repeatedly lifts his left arm \nabove\nhis ___ and then yawns and almost stereotyped fashion multiple\ntimes throughout the examination. \nSkin: no rashes or lesions noted.\n\nNeurologic:\n\n-Mental Status: Agitated, moving back and forth in bed, appears\nuncomfortable, grimacing and moaning. Will attend to examiner\nbriefly when shouting his name but then turns away and\nrepositions himself. Does not track. When asked his name, he\nreplies \"okay.\" He perseverates on \"I am sorry.\" He attempts \nto\nanswer the question, but there is never a straight response. At\ntimes, he repeats \"what?\" over and over. He then appears to get\nagitated and says \"leave me alone.\" Other spontaneous speech\nincludes \"oh God.\" It is difficult to say if he follows any\ncommands. His speech does not sound dysarthric. He is unable \nto\nparticipate in any further language testing. \n\n-Cranial Nerves:\nHe is severely photophobic so pupil examination is limited. \nOverall pupils appear symmetric and reactive. He moves eyes in\nboth horizontal directions. He has bilateral blink to threat. \nUnable to visualize fundi bilaterally. No facial droop, facial\nmusculature symmetric. Palate elevates symmetrically. Tongue\nprotrudes in midline.\n\n-Motor: Normal bulk, tone throughout. No adventitious movements,\nsuch as tremor, noted. Arms and legs are antigravity and appear\nstrong, though formal confrontational testing is not possible.\n \n-Sensory: He withdraws to noxious stimuli in all 4 extremities. \n\n-DTRs:\n Bi Tri ___ Pat Ach\nL 2 2 2 2 2\nR 2 2 2 2 2\nPlantar response was flexor bilaterally.\n\n-Coordination: Grabs for his IV with his left hand and pulls off\ntelemetry leads with his right hand. \n\n-Gait: Able to bring himself to a standing position unassisted. \n\nDISCHARGE EXAM:\nNonfocal\n \nPertinent Results:\n====\nLABS\n====\n- CBC\n___ 10:00PM BLOOD WBC-6.7 RBC-4.63 Hgb-14.0 Hct-42.4 MCV-92 \nMCH-30.2 MCHC-33.0 RDW-12.6 RDWSD-42.2 Plt ___\n___ 10:00PM BLOOD Neuts-57.0 ___ Monos-8.8 Eos-2.1 \nBaso-0.3 Im ___ AbsNeut-3.83 AbsLymp-2.13 AbsMono-0.59 \nAbsEos-0.14 AbsBaso-0.02\n___ 05:59AM BLOOD WBC-7.8 RBC-4.43* Hgb-13.3* Hct-40.4 \nMCV-91 MCH-30.0 MCHC-32.9 RDW-12.4 RDWSD-41.8 Plt ___\n___ 05:25AM BLOOD WBC-4.8 RBC-4.46* Hgb-13.6* Hct-41.8 \nMCV-94 MCH-30.5 MCHC-32.5 RDW-12.7 RDWSD-43.9 Plt ___\n___ 05:25AM BLOOD Neuts-53.2 ___ Monos-10.9 Eos-2.7 \nBaso-0.4 Im ___ AbsNeut-2.52 AbsLymp-1.55 AbsMono-0.52 \nAbsEos-0.13 AbsBaso-0.02\n\n- Coag\n___ 10:23PM BLOOD ___ PTT-27.2 ___\n___ 05:59AM BLOOD ___ PTT-26.5 ___\n\n- CMP\n___ 10:00PM BLOOD Glucose-98 UreaN-19 Creat-1.2 Na-140 \nK-3.7 Cl-100 HCO3-28 AnGap-16\n___ 10:00PM BLOOD ALT-15 AST-16 CK(CPK)-56 AlkPhos-25* \nTotBili-0.2\n___ 05:59AM BLOOD Glucose-126* UreaN-17 Creat-1.1 Na-139 \nK-3.9 Cl-103 HCO3-22 AnGap-18\n___ 05:25AM BLOOD ALT-13 AST-17 AlkPhos-22* TotBili-0.3\n___ 05:25AM BLOOD Glucose-125* UreaN-9 Creat-1.0 Na-141 \nK-4.2 Cl-103 HCO3-29 AnGap-13\n\n___ 10:00PM BLOOD Albumin-4.3 Calcium-9.1 Phos-3.8 Mg-2.0\n___ 05:59AM BLOOD Calcium-8.6 Phos-3.2 Mg-1.8\n___ 05:25AM BLOOD Calcium-8.6 Phos-3.8 Mg-2.1\n\n- Other\n___ 10:00PM BLOOD cTropnT-<0.01\n___ 05:59AM BLOOD TSH-0.37\n___ 10:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nBnzodzp-NEG Barbitr-NEG Tricycl-NEG\n___ 10:14PM BLOOD Lactate-1.0\n\n- Urine\n___ 02:47AM URINE Blood-TR Nitrite-NEG Protein-TR \nGlucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG\n___ 02:47AM URINE Color-Straw Appear-Clear Sp ___\n___ 02:47AM URINE RBC-3* WBC-1 Bacteri-NONE Yeast-NONE \nEpi-0\n___ 02:47AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG \ncocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG\n\n- CSF\n___ 12:43AM CEREBROSPINAL FLUID (CSF) WBC-270 RBC-0 Polys-0 \n___ ___ 12:43AM CEREBROSPINAL FLUID (CSF) WBC-244 RBC-0 Polys-0 \n___ Monos-4 Other-2\n___ 12:43AM CEREBROSPINAL FLUID (CSF) TotProt-211* \nGlucose-63\n___ 01:00PM CEREBROSPINAL FLUID (CSF) WBC-230 RBC-1* \nPolys-0 ___ Monos-3 Other-3\n___ 09:42AM CEREBROSPINAL FLUID (CSF) TotProt-212* \nGlucose-58 LD(LDH)-23\n___ 09:42AM CEREBROSPINAL FLUID (CSF) HIV1 VL-NOT DETECT\n- Micro\n___ CSF;SPINAL FLUID GRAM STAIN-FINAL; FLUID \nCULTURE-PRELIMINARY \n GRAM STAIN (Final ___:\n NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. \n NO MICROORGANISMS SEEN. \n This is a concentrated smear made by cytospin method, \nplease refer to\n hematology for a quantitative white blood cell count.. \n FLUID CULTURE (Preliminary): \n___ CSF;SPINAL FLUID GRAM STAIN-FINAL; FLUID \nCULTURE-PRELIMINARY \n GRAM STAIN (Final ___:\n NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. \n NO MICROORGANISMS SEEN. \n This is a concentrated smear made by cytospin method, \nplease refer to\n hematology for a quantitative white blood cell count. \n FLUID CULTURE (Preliminary): \n___ CSF VDRL, VZV, CMV, EBB, Autoimmune Encephalopathy \nPanel, Paraneoplastic Panel, Enterovirus pending\n___ Blood (LYME) Lyme IgG-PENDING; Lyme \nIgM-PENDING \n___ BLOOD CULTURE Blood Culture, Routine-PENDING \n\n___ BLOOD CULTURE Blood Culture, Routine-PENDING \n\n___ URINE URINE CULTURE-PENDING \n___ 12:43AM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS \nPCR-negative\n___ 05:10AM BLOOD WBC-5.6 RBC-4.46* Hgb-13.4* Hct-41.5 \nMCV-93 MCH-30.0 MCHC-32.3 RDW-12.7 RDWSD-43.0 Plt ___\n___ 05:10AM BLOOD ___ PTT-25.8 ___\n___ 05:10AM BLOOD Glucose-94 UreaN-11 Creat-1.0 Na-140 \nK-3.8 Cl-100 HCO3-26 AnGap-18\n___ 05:25AM BLOOD ALT-13 AST-17 AlkPhos-22* TotBili-0.3\n___ 05:10AM BLOOD Calcium-8.8 Phos-4.7* Mg-2.0\n___ 05:59AM BLOOD TSH-0.37\n___ 05:10AM BLOOD HIV Ab-Negative\n\n=========\nPATHOLOGY\n=========\n___ CSF Cytology-negative for malignant cells\n___- CSF Cytology pending\n\n=======\nIMAGING\n=======\n- ___ MR ___ CONTRAST\n1. Study is moderately degraded by motion. \n2. No evidence of venous sinus thrombosis. \n3. Within limits of study, no definite leptomeningeal \nenhancement identified. \n4. New nonspecific diffuse subarachnoid signal abnormality, as \ndescribed. \nWhile finding is compatible with meningitis, differential \nconsiderations \ninclude subarachnoid hemorrhage, leptomeningeal carcinomatosis, \nsequelae of hyperoxygenation therapy or artifact. If clinically \nindicated, noncontrast ___ CT may be obtained to evaluate for \npresence of new subarachnoid hemorrhage since ___ \nnoncontrast ___ CT prior exam. \n5. Paranasal sinus disease as described. \n\n- ___ EEG \nThis is an abnormal continuous ICU monitoring study because of \ncontinuous slowing on the left, maximal temporally, indicative \nof focal \ndysfunction. No pushbutton activations, epileptiform discharges, \nor seizures are recorded. Compared to the prior day's recording, \nthere are no significant changes. Of note, sinus bradycardia to \nthe ___ is seen during portions of the record. \n\n \nBrief Hospital Course:\nMr. ___ is a ___ year old man with history of thyroid cancer \n(s/p resection in ___ and hyperlipidemia who presented with a \nten day course of episodic headaches, lightheadedness and focal \nneurological deficits (extremity numbness, aphasia). He was \nfound to have CSF pleomorphic lymphocytosis, and nonspecific \ndiffuse subarachnoid signal abnormality on MRI. He was given a \nprovisional diagnosis of HaNDL syndrome, pending additional \ntests and CSF studies, and was discharged on Verapamil 120mg for \nprophylactic headache treatment. He will follow-up with \noutpatient neurologist.\n\n#Neuro\nOn presentation at ___, the patient was acutely agitated and \nconfused, with a low grade fever and sinus bradycardia. He had a \nsevere headache, multiple neurological deficits and exhibited \nstereotyped movements. ___ at outside hospital revealed no \nacute intracranial process. Patient was admitted to the ICU for \nEEG and neurological monitoring, out of concern for \nmeningoencephalitis vs seizure vs neoplastic process. LP \n(___) revealed elevated opening pressure, lymphocytic \npleiocytosis, elevated protein level, and no malignant cells. \nThe patient was initially maintained on droplet precautions, and \ntreated empirically for meningitis with ceftriaxone, vancomycin \nand acyclovir until HSV PCR was negative and CSF cultures showed \nno bacterial growth. His symptoms had largely resolved the \nmorning after admission and he was subsequently transferred to \nthe floor. His symptoms did not reoccur throughout the rest of \nhis hospital stay. EEG showed continuous slowing on the left, \nmaximal temporally, indicative of focal dysfunction, with no \nepileptiform discharges. MRI revealed new nonspecific diffuse \nsubarachnoid FLAIR hyperintensities, but no evidence of venous \nsinus thrombosis or definite leptomeningeal enhancement. An \nadditional ___ LP was obtained on ___ for further \nCSF studies, with results showing continued lymphocytic \npleocytosis w/ elevated protein level but improved from previous \ntap.\nAt the time of discharge, the patient most closely fit the \ncriteria for syndrome of transient Headache and Neurological \nDeficits with cerebrospinal fluid Lymphocytosis (HaNDL). \nHowever, HaNDL remains a provisional diagnosis until all pending \nresults are back and other etiologies are excluded. If HaNDL is \ndeemed to be the final diagnosis, it should be noted that it is \nusually a self-limiting disease and only prophylactic therapy \nfor associated headaches is recommended. The patient was thus \nstarted on verapamil 120mg for symptomatic improvement and \nheadache prophylaxis.\n\n#Cardiovascular\nCXR showed no acute cardiopulmonary process. The patient was \nmonitored on telemetry with no evidence of atrial fibrillation. \nAtorvastatin 40mg daily was continued per home regimen. \n\nTransition Issues:\n-Pt will need to continue taking Verapamil SR 120mg daily in the \nnear future as prophylactic therapy for migrainous headaches\n-Pt will need to follow up with Neurology as scheduled\n-Pt instructed to present to ED for evaluation if develops \nrecurrent neurologic deficits\n-Pt to be informed if abnormal CSF studies present\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Levothyroxine Sodium 150 mcg PO DAILY \n2. Atorvastatin 40 mg PO QPM \n3. ValACYclovir 2 g PO BID:PRN Cold sore \n\n \nDischarge Medications:\n1. Verapamil SR 120 mg PO Q24H \nRX *verapamil 120 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet \nRefills:*2 \n2. Atorvastatin 40 mg PO QPM \n3. Levothyroxine Sodium 150 mcg PO DAILY \n4. ValACYclovir 2 g PO BID:PRN Cold sore \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nMigraine w/ focal neurologic deficits and lymphocytic \npleocytosis\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nYou were hospitalized at ___ due to recurrent migraines \nassociated w/ focal neurologic deficits. You were initially in \nthe NeuroICU and later transferred to the general floor. You \nunderwent extensive laboratory workup indicative of inflammation \nin your cerebrospinal fluid. You were empirically treated with \nantibiotics and antiviral agents which were stopped when \nsubsequent cultures were negative. You underwent EEG which \nshowed no sign of seizure activity. Due to appearing clinically \nstable on exam and w/ no recurrent symptoms, you will be \ndischarged from the hospital.\n\nPlease continue taking Verapamil SR 120mg daily at this time. \nPlease continue your other home medications.\n\nPlease follow up with your PCP and ___ as listed below. If \nyou find yourself having acute focal neurologic deficits in the \nfuture, please go to your nearest ED for evaluation.\n\nIt was a pleasure taking care of you,\n\n___ Neurology Team \n \nFollowup Instructions:\n___\n"
] | Allergies: shellfish derived Chief Complaint: Right-sided weakness Major Surgical or Invasive Procedure: Lumbar puncture History of Present Illness: Mr. [MASKED] is a [MASKED] man with a past medical history of thyroid cancer status post resection followed by [MASKED], hyperlipidemia who presents with 10 days of discrete episodes of headache, lightheadedness, and focal neurologic deficits. History is obtained by wife at the bedside as patient not able to participate. On [MASKED], wife notes that patient had sudden onset "massive headache" with associated lightheadedness and tunnel vision. He also experienced numbness in his right arm. There was no vertigo. It is unclear how long this episode lasted but patient went to bed and slept for approximately 15 hours. On awakening the following day, patient felt back to baseline. He called his primary care physician and went in for evaluation that day. His PCP performed [MASKED] "lightheadedness workup" and found no neurologic deficits. He felt his symptoms were most likely secondary to migraine headache. Two days later, on [MASKED], patient sent wife "incoherent" text message via phone. She called him afterward and he had difficulty getting the words out when speaking with her. The wife took patient to [MASKED] where he had a noncontrast [MASKED] CT which was unremarkable. He would that he was diagnosed with migraine and sent home. The whole episode lasted approximately 1 hour. Patient and his wife followed up with a neurologist through [MASKED] the following day and he had an MRI brain without contrast/MRA [MASKED] and neck as an outpatient. Imaging was unremarkable. There are no notes to review from this encounter, but the wife reports the neurologist agreed the etiology of his symptoms was most likely migraine. The following day, patient complained of headache which felt like a headband putting pressure on his whole [MASKED], right worse than left side. The wife began to document his symptoms and she notes: 12 [MASKED] lightheadedness and vision issues 12:15 [MASKED] went to bed and slept until 2 [MASKED] 2:05 [MASKED] woke up with a raging headache behind eyes and photophobia. She documents an exaggerated startle, jumping every time she walks by her opens a soda can. He went to sleep shortly afterward and awoke 4 hours later. 6:15 [MASKED] awoke with continued lightheadedness and headache 9 [MASKED] out of bed, feeling better He slept until 8:30 AM. He was asymptomatic the following day. Today at 7 [MASKED] he experienced sudden onset right hand numbness which traveled to his right arm and leg. He also had twitching of his right face and clenched his right eye in pain. He also had difficulty speaking, getting any words out. EMS was called and he was brought to [MASKED] where code stroke was called. Noncontrast [MASKED] CT was negative for bleed or other intracranial abnormality. Shortly after arrival to the ED his symptoms resolved and TPA was deferred. He began to complain of a headache at this time. He was transferred to [MASKED] for further management. Neurology was consulted for question of seizures versus atypical migraine. Unable to complete review of systems, though positive neurologic review of systems are noted as above. Specifically, patient's wife denies a history of headache or migraines. She denies any recent fever or chills. Past Medical History: Thyroid cancer status post resection. No chemo or radiation. Diagnosed in [MASKED], managed at [MASKED]. On maintenance levothyroxine. Hyperlipidemia Social History: [MASKED] Family History: No family history of stroke, seizure, or migraine. Physical Exam: ============== ADMISSION EXAM ============== Vitals: Tm: 102.5 P: 40-70 r: 16 BP: 136/90 SaO2: 99% on room air Blood glucose 89 General: Agitated, thrashing in bed, pulling off telemetry leads, and trying to get out of bed, holding [MASKED] periodically and moaning HEENT: NC/AT, positive photophobia, no scleral icterus noted, MMM, no lesions noted in oropharynx, incessant yawning Neck: Supple, No nuchal rigidity Pulmonary: Normal work of breathing Cardiac: Bradycardic, regular rhythm, warm, well-perfused Abdomen: soft, non-distended Extremities: No [MASKED] edema. He repeatedly lifts his left arm above his [MASKED] and then yawns and almost stereotyped fashion multiple times throughout the examination. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Agitated, moving back and forth in bed, appears uncomfortable, grimacing and moaning. Will attend to examiner briefly when shouting his name but then turns away and repositions himself. Does not track. When asked his name, he replies "okay." He perseverates on "I am sorry." He attempts to answer the question, but there is never a straight response. At times, he repeats "what?" over and over. He then appears to get agitated and says "leave me alone." Other spontaneous speech includes "oh God." It is difficult to say if he follows any commands. His speech does not sound dysarthric. He is unable to participate in any further language testing. -Cranial Nerves: He is severely photophobic so pupil examination is limited. Overall pupils appear symmetric and reactive. He moves eyes in both horizontal directions. He has bilateral blink to threat. Unable to visualize fundi bilaterally. No facial droop, facial musculature symmetric. Palate elevates symmetrically. Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No adventitious movements, such as tremor, noted. Arms and legs are antigravity and appear strong, though formal confrontational testing is not possible. -Sensory: He withdraws to noxious stimuli in all 4 extremities. -DTRs: Bi Tri [MASKED] Pat Ach L 2 2 2 2 2 R 2 2 2 2 2 Plantar response was flexor bilaterally. -Coordination: Grabs for his IV with his left hand and pulls off telemetry leads with his right hand. -Gait: Able to bring himself to a standing position unassisted. DISCHARGE EXAM: Nonfocal Pertinent Results: ==== LABS ==== - CBC [MASKED] 10:00PM BLOOD WBC-6.7 RBC-4.63 Hgb-14.0 Hct-42.4 MCV-92 MCH-30.2 MCHC-33.0 RDW-12.6 RDWSD-42.2 Plt [MASKED] [MASKED] 10:00PM BLOOD Neuts-57.0 [MASKED] Monos-8.8 Eos-2.1 Baso-0.3 Im [MASKED] AbsNeut-3.83 AbsLymp-2.13 AbsMono-0.59 AbsEos-0.14 AbsBaso-0.02 [MASKED] 05:59AM BLOOD WBC-7.8 RBC-4.43* Hgb-13.3* Hct-40.4 MCV-91 MCH-30.0 MCHC-32.9 RDW-12.4 RDWSD-41.8 Plt [MASKED] [MASKED] 05:25AM BLOOD WBC-4.8 RBC-4.46* Hgb-13.6* Hct-41.8 MCV-94 MCH-30.5 MCHC-32.5 RDW-12.7 RDWSD-43.9 Plt [MASKED] [MASKED] 05:25AM BLOOD Neuts-53.2 [MASKED] Monos-10.9 Eos-2.7 Baso-0.4 Im [MASKED] AbsNeut-2.52 AbsLymp-1.55 AbsMono-0.52 AbsEos-0.13 AbsBaso-0.02 - Coag [MASKED] 10:23PM BLOOD [MASKED] PTT-27.2 [MASKED] [MASKED] 05:59AM BLOOD [MASKED] PTT-26.5 [MASKED] - CMP [MASKED] 10:00PM BLOOD Glucose-98 UreaN-19 Creat-1.2 Na-140 K-3.7 Cl-100 HCO3-28 AnGap-16 [MASKED] 10:00PM BLOOD ALT-15 AST-16 CK(CPK)-56 AlkPhos-25* TotBili-0.2 [MASKED] 05:59AM BLOOD Glucose-126* UreaN-17 Creat-1.1 Na-139 K-3.9 Cl-103 HCO3-22 AnGap-18 [MASKED] 05:25AM BLOOD ALT-13 AST-17 AlkPhos-22* TotBili-0.3 [MASKED] 05:25AM BLOOD Glucose-125* UreaN-9 Creat-1.0 Na-141 K-4.2 Cl-103 HCO3-29 AnGap-13 [MASKED] 10:00PM BLOOD Albumin-4.3 Calcium-9.1 Phos-3.8 Mg-2.0 [MASKED] 05:59AM BLOOD Calcium-8.6 Phos-3.2 Mg-1.8 [MASKED] 05:25AM BLOOD Calcium-8.6 Phos-3.8 Mg-2.1 - Other [MASKED] 10:00PM BLOOD cTropnT-<0.01 [MASKED] 05:59AM BLOOD TSH-0.37 [MASKED] 10:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [MASKED] 10:14PM BLOOD Lactate-1.0 - Urine [MASKED] 02:47AM URINE Blood-TR Nitrite-NEG Protein-TR Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [MASKED] 02:47AM URINE Color-Straw Appear-Clear Sp [MASKED] [MASKED] 02:47AM URINE RBC-3* WBC-1 Bacteri-NONE Yeast-NONE Epi-0 [MASKED] 02:47AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG - CSF [MASKED] 12:43AM CEREBROSPINAL FLUID (CSF) WBC-270 RBC-0 Polys-0 [MASKED] [MASKED] 12:43AM CEREBROSPINAL FLUID (CSF) WBC-244 RBC-0 Polys-0 [MASKED] Monos-4 Other-2 [MASKED] 12:43AM CEREBROSPINAL FLUID (CSF) TotProt-211* Glucose-63 [MASKED] 01:00PM CEREBROSPINAL FLUID (CSF) WBC-230 RBC-1* Polys-0 [MASKED] Monos-3 Other-3 [MASKED] 09:42AM CEREBROSPINAL FLUID (CSF) TotProt-212* Glucose-58 LD(LDH)-23 [MASKED] 09:42AM CEREBROSPINAL FLUID (CSF) HIV1 VL-NOT DETECT - Micro [MASKED] CSF;SPINAL FLUID GRAM STAIN-FINAL; FLUID CULTURE-PRELIMINARY GRAM STAIN (Final [MASKED]: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Preliminary): [MASKED] CSF;SPINAL FLUID GRAM STAIN-FINAL; FLUID CULTURE-PRELIMINARY GRAM STAIN (Final [MASKED]: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count. FLUID CULTURE (Preliminary): [MASKED] CSF VDRL, VZV, CMV, EBB, Autoimmune Encephalopathy Panel, Paraneoplastic Panel, Enterovirus pending [MASKED] Blood (LYME) Lyme IgG-PENDING; Lyme IgM-PENDING [MASKED] BLOOD CULTURE Blood Culture, Routine-PENDING [MASKED] BLOOD CULTURE Blood Culture, Routine-PENDING [MASKED] URINE URINE CULTURE-PENDING [MASKED] 12:43AM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS PCR-negative [MASKED] 05:10AM BLOOD WBC-5.6 RBC-4.46* Hgb-13.4* Hct-41.5 MCV-93 MCH-30.0 MCHC-32.3 RDW-12.7 RDWSD-43.0 Plt [MASKED] [MASKED] 05:10AM BLOOD [MASKED] PTT-25.8 [MASKED] [MASKED] 05:10AM BLOOD Glucose-94 UreaN-11 Creat-1.0 Na-140 K-3.8 Cl-100 HCO3-26 AnGap-18 [MASKED] 05:25AM BLOOD ALT-13 AST-17 AlkPhos-22* TotBili-0.3 [MASKED] 05:10AM BLOOD Calcium-8.8 Phos-4.7* Mg-2.0 [MASKED] 05:59AM BLOOD TSH-0.37 [MASKED] 05:10AM BLOOD HIV Ab-Negative ========= PATHOLOGY ========= [MASKED] CSF Cytology-negative for malignant cells [MASKED]- CSF Cytology pending ======= IMAGING ======= - [MASKED] MR [MASKED] CONTRAST 1. Study is moderately degraded by motion. 2. No evidence of venous sinus thrombosis. 3. Within limits of study, no definite leptomeningeal enhancement identified. 4. New nonspecific diffuse subarachnoid signal abnormality, as described. While finding is compatible with meningitis, differential considerations include subarachnoid hemorrhage, leptomeningeal carcinomatosis, sequelae of hyperoxygenation therapy or artifact. If clinically indicated, noncontrast [MASKED] CT may be obtained to evaluate for presence of new subarachnoid hemorrhage since [MASKED] noncontrast [MASKED] CT prior exam. 5. Paranasal sinus disease as described. - [MASKED] EEG This is an abnormal continuous ICU monitoring study because of continuous slowing on the left, maximal temporally, indicative of focal dysfunction. No pushbutton activations, epileptiform discharges, or seizures are recorded. Compared to the prior day's recording, there are no significant changes. Of note, sinus bradycardia to the [MASKED] is seen during portions of the record. Brief Hospital Course: Mr. [MASKED] is a [MASKED] year old man with history of thyroid cancer (s/p resection in [MASKED] and hyperlipidemia who presented with a ten day course of episodic headaches, lightheadedness and focal neurological deficits (extremity numbness, aphasia). He was found to have CSF pleomorphic lymphocytosis, and nonspecific diffuse subarachnoid signal abnormality on MRI. He was given a provisional diagnosis of HaNDL syndrome, pending additional tests and CSF studies, and was discharged on Verapamil 120mg for prophylactic headache treatment. He will follow-up with outpatient neurologist. #Neuro On presentation at [MASKED], the patient was acutely agitated and confused, with a low grade fever and sinus bradycardia. He had a severe headache, multiple neurological deficits and exhibited stereotyped movements. [MASKED] at outside hospital revealed no acute intracranial process. Patient was admitted to the ICU for EEG and neurological monitoring, out of concern for meningoencephalitis vs seizure vs neoplastic process. LP ([MASKED]) revealed elevated opening pressure, lymphocytic pleiocytosis, elevated protein level, and no malignant cells. The patient was initially maintained on droplet precautions, and treated empirically for meningitis with ceftriaxone, vancomycin and acyclovir until HSV PCR was negative and CSF cultures showed no bacterial growth. His symptoms had largely resolved the morning after admission and he was subsequently transferred to the floor. His symptoms did not reoccur throughout the rest of his hospital stay. EEG showed continuous slowing on the left, maximal temporally, indicative of focal dysfunction, with no epileptiform discharges. MRI revealed new nonspecific diffuse subarachnoid FLAIR hyperintensities, but no evidence of venous sinus thrombosis or definite leptomeningeal enhancement. An additional [MASKED] LP was obtained on [MASKED] for further CSF studies, with results showing continued lymphocytic pleocytosis w/ elevated protein level but improved from previous tap. At the time of discharge, the patient most closely fit the criteria for syndrome of transient Headache and Neurological Deficits with cerebrospinal fluid Lymphocytosis (HaNDL). However, HaNDL remains a provisional diagnosis until all pending results are back and other etiologies are excluded. If HaNDL is deemed to be the final diagnosis, it should be noted that it is usually a self-limiting disease and only prophylactic therapy for associated headaches is recommended. The patient was thus started on verapamil 120mg for symptomatic improvement and headache prophylaxis. #Cardiovascular CXR showed no acute cardiopulmonary process. The patient was monitored on telemetry with no evidence of atrial fibrillation. Atorvastatin 40mg daily was continued per home regimen. Transition Issues: -Pt will need to continue taking Verapamil SR 120mg daily in the near future as prophylactic therapy for migrainous headaches -Pt will need to follow up with Neurology as scheduled -Pt instructed to present to ED for evaluation if develops recurrent neurologic deficits -Pt to be informed if abnormal CSF studies present Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 150 mcg PO DAILY 2. Atorvastatin 40 mg PO QPM 3. ValACYclovir 2 g PO BID:PRN Cold sore Discharge Medications: 1. Verapamil SR 120 mg PO Q24H RX *verapamil 120 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*2 2. Atorvastatin 40 mg PO QPM 3. Levothyroxine Sodium 150 mcg PO DAILY 4. ValACYclovir 2 g PO BID:PRN Cold sore Discharge Disposition: Home Discharge Diagnosis: Migraine w/ focal neurologic deficits and lymphocytic pleocytosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], You were hospitalized at [MASKED] due to recurrent migraines associated w/ focal neurologic deficits. You were initially in the NeuroICU and later transferred to the general floor. You underwent extensive laboratory workup indicative of inflammation in your cerebrospinal fluid. You were empirically treated with antibiotics and antiviral agents which were stopped when subsequent cultures were negative. You underwent EEG which showed no sign of seizure activity. Due to appearing clinically stable on exam and w/ no recurrent symptoms, you will be discharged from the hospital. Please continue taking Verapamil SR 120mg daily at this time. Please continue your other home medications. Please follow up with your PCP and [MASKED] as listed below. If you find yourself having acute focal neurologic deficits in the future, please go to your nearest ED for evaluation. It was a pleasure taking care of you, [MASKED] Neurology Team Followup Instructions: [MASKED] | [
"G43809",
"R001",
"R29818",
"E785",
"R509",
"Z85850"
] | [
"G43809: Other migraine, not intractable, without status migrainosus",
"R001: Bradycardia, unspecified",
"R29818: Other symptoms and signs involving the nervous system",
"E785: Hyperlipidemia, unspecified",
"R509: Fever, unspecified",
"Z85850: Personal history of malignant neoplasm of thyroid"
] | [
"E785"
] | [] |
12,756,651 | 23,520,792 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nBactrim / codeine / doxycycline / metronidazole\n \nAttending: ___.\n \nChief Complaint:\nacute onset dyspnea\n \nMajor Surgical or Invasive Procedure:\nNone \n\n \nHistory of Present Illness:\n___ y/o F with history of CAD, CHF, and COPD presenting with SOB. \nPatient reports 1 month of gradually worsening SOB in the \nsetting of stopping her HCTZ. However, her breathing became much \nworse in last 3 days, and she ultimately went to the ___. She had a mild non-productive cough but denied fevers, \nchills, paroxysmal nocturnal dyspnea, orthopnea, and weight \ngain. Patient also has had bilateral ___ edema that has been \nworsening in the last ___ days. At the OSH, she was hypoxic in \nthe ___ and CXR showed concern for CHF. She was given 40mg of \nLasix and started on a nitro gtt. She became briefly hypotensive \nand was started on levophed via peripheral IV. She was placed on \nBiPAP for transport. Upon arrival to the Cardiology floor, she \nwas hemodynamically stable and was satting comfortably on room \nair. She put out about 1L of urine after receiving Lasix and \ndenied CP and SOB.\n \nPast Medical History:\n3 vessel CAD (cath at ___ in ___\nHTN\nCOPD\nDepression/anxiety\n \nSocial History:\n___\nFamily History:\nnoncontributory\n \nPhysical Exam:\nADMISSION\n=========\nPHYSICAL EXAMINATION: \nVS: T AF, BP 151-156/45-74, HR 64-91, RR 18, O2 sat ___ RA\nWeight: 58.7 kg\nGENERAL: NAD \nHEENT: AT/NC, EOMI, PERRL, anicteric sclera\nCARDIAC: RRR, S1/S2, systolic murmur heard loudest at LLSB and \napex, JVP ~ 11 \nLUNG: bibasilar crackles, no wheezing \nABDOMEN: nondistended, +BS, nontender in all quadrants, no \nrebound/guarding, no hepatosplenomegaly \nEXTREMITIES: WWP, trace ___ edema, +DP b/l\nNEURO: CN II-XII grossly intact \nSKIN: warm and well perfused, no excoriations or lesions, no \nrashes \n\nDISCHARGE\n==========\nVS: T Afebrile, BP 103-117/36-43, P 57-80, RR 18, O2sat 98-100% \non RA\nWeight: 52.3 kg (58.7 on admission)\nI/O: since midnight ___\n24 hours: 1136/850\nGENERAL: NAD \nHEENT: AT/NC, EOMI, PERRL, anicteric sclera\nCARDIAC: RRR, S1/S2, systolic murmur heard loudest at LLSB and \napex, JVP not elevated \nLUNG: No audible crackles, no wheezing \nABDOMEN: nondistended, nontender in all quadrants\nEXTREMITIES: no ___ edema\nNEURO: CN II-XII grossly intact \n \nPertinent Results:\nADMISSION LABS:\n=====================\n___ 09:00PM BLOOD WBC-13.2* RBC-4.27 Hgb-12.7 Hct-39.0 \nMCV-91 MCH-29.7 MCHC-32.6 RDW-13.8 RDWSD-46.5* Plt ___\n___ 09:00PM BLOOD Neuts-90.4* Lymphs-7.1* Monos-1.6* \nEos-0.0* Baso-0.1 Im ___ AbsNeut-11.89* AbsLymp-0.94* \nAbsMono-0.21 AbsEos-0.00* AbsBaso-0.01\n___ 10:29PM BLOOD ___ PTT-29.3 ___\n___ 10:29PM BLOOD Glucose-128* UreaN-17 Creat-0.6 Na-136 \nK-3.6 Cl-99 HCO3-26 AnGap-15\n___ 10:29PM BLOOD ___\n___ 10:29PM BLOOD cTropnT-0.15*\n___ 09:09PM BLOOD ___ pO2-177* pCO2-34* pH-7.46* \ncalTCO2-25 Base XS-1 Intubat-NOT INTUBA\n___ 09:09PM BLOOD Lactate-1.4\n___ 09:09PM BLOOD O2 Sat-96\n___ 09:00PM URINE Color-Yellow Appear-Clear Sp ___\n___ 09:00PM URINE Blood-NEG Nitrite-NEG Protein-30 \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG\n___ 09:00PM URINE RBC-<1 WBC-2 Bacteri-FEW Yeast-NONE \nEpi-<1\n___ 09:00PM URINE Mucous-RARE\n\nOTHER RELEVANT LABS:\n========================\n___ 05:34AM BLOOD WBC-11.8* RBC-3.97 Hgb-11.7 Hct-35.3 \nMCV-89 MCH-29.5 MCHC-33.1 RDW-13.7 RDWSD-44.9 Plt ___\n___ 07:00AM BLOOD WBC-6.0 RBC-3.73* Hgb-11.1* Hct-33.8* \nMCV-91 MCH-29.8 MCHC-32.8 RDW-14.2 RDWSD-47.0* Plt ___\n___ 09:20PM BLOOD PTT-40.7*\n___ 03:23AM BLOOD PTT-52.8*\n___ 03:49AM BLOOD PTT-70.9*\n___ 08:05AM BLOOD ___ PTT-75.6* ___\n___ 03:05PM BLOOD Glucose-129* UreaN-24* Creat-0.8 Na-135 \nK-3.8 Cl-95* HCO3-29 AnGap-15\n___ 07:00AM BLOOD Glucose-71 UreaN-24* Creat-0.7 Na-137 \nK-4.3 Cl-99 HCO3-29 AnGap-13\n___ 07:00AM BLOOD Glucose-80 UreaN-15 Creat-0.7 Na-138 \nK-4.1 Cl-102 HCO3-27 AnGap-13\n___ 07:00AM BLOOD ALT-31 AST-32 LD(LDH)-187 CK(CPK)-22* \nAlkPhos-91 TotBili-0.7\n___ 07:00AM BLOOD ALT-30 AST-34 LD(LDH)-174 AlkPhos-88 \nTotBili-0.7\n___ 02:01AM BLOOD CK-MB-13* cTropnT-0.13*\n___ 07:00AM BLOOD CK-MB-3 cTropnT-0.18*\n___ 09:05PM BLOOD CK-MB-2 cTropnT-0.18*\n___ 07:00AM BLOOD %HbA1c-5.5 eAG-111\nURINE CULTURE (Final ___: NO GROWTH\nStaph aureus Screen (Final ___: NO STAPHYLOCOCCUS AUREUS \nISOLATED.\n\nDISCHARGE LABS:\n====================\n___ 08:05AM BLOOD WBC-4.7 RBC-4.10 Hgb-11.8 Hct-37.6 MCV-92 \nMCH-28.8 MCHC-31.4* RDW-13.9 RDWSD-46.9* Plt ___\n___ 03:29PM BLOOD PTT-66.8*\n___ 08:05AM BLOOD Glucose-92 UreaN-14 Creat-0.7 Na-138 \nK-4.6 Cl-104 HCO3-25 AnGap-14\n___ 08:05AM BLOOD Calcium-9.2 Phos-4.6* Mg-2.3\n\nTTE ___:\nThe left atrium is moderately dilated. Left ventricular wall \nthickness, cavity size and regional/global systolic function are \nnormal (LVEF >55%). Doppler parameters are indeterminate for \nleft ventricular diastolic function. Right ventricular chamber \nsize and free wall motion are normal. The aortic valve leaflets \nare mildly thickened (?#). There is no aortic valve stenosis. \nModerate (2+) aortic regurgitation is seen. The mitral valve \nleaflets are mildly thickened. There is no mitral valve \nprolapse. Mild to moderate (___) mitral regurgitation is seen. \nThe pulmonary artery systolic pressure could not be determined. \nThere is no pericardial effusion. \n\nIMPRESSION: Normal biventricular cavity sizes with preserved \nglobal and regional biventricular systolic function. Moderate \naortic regurgitation. Mild to moderate mitral regurgitation. \n\nCXR (___): IMPRESSION: Heart size is normal. Mediastinum \nis normal. Lungs are hyperinflated but overall clear. Minimal \ninterstitial opacities are unchanged since the prior study. Mild \nincrease in overall interstitial opacities might represent \nslight volume overload, similar to ___ that had \nshown an interval resolution on ___ and in can be \nseen again on today's radiograph. \n\nCT Chest w/o contrast (___): \nRECOMMENDATION(S):\n1. ___ recommendations for follow up of pulmonary \nnodules: \nSolid nodules >4 - 6 mm: Low risk: Follow-up at 12 months and if \nno change, no further imaging needed. High risk: Follow-up at \n___ months and if no change, again at ___ months. The \n___ pulmonary nodule recommendations are intended \nas guidelines for follow-up and management of newly incidentally \ndetected pulmonary nodules smaller than 8 mm, in patients ___ \nyears of age or ___. Low risk patients have minimal or absent \nhistory of smoking or other known risk factors for primary lung \nneoplasm. High risk patients have a history of smoking or other \nknown risk factors for primary lung neoplasm. \n2. Echocardiography, if pop already performed elsewhere, for \nfurther \nevaluation of aortic valvular calcifications. \n3. Diagnostic mammography and axillary ultrasound is recommended \nif \nmammography has not been obtained recently. \n \nBrief Hospital Course:\nMs. ___ is a ___ F with 3 vessel CAD (had a cath at \n___ in ___ that indicated need for \nCABG), HTN and COPD who presented with new acute CHF and \nelevated troponins c/f possible type 2 NSTEMI. She was \nhemodynamically stable at ___ after having briefly been on NRB \nand pressors at ___. She was initially started on \na heparin drip on ___, diuresed for acute HFpEF, and had her BP \nmedications optimized. Her Plavix was dc'd on ___ to prepare \nfor possible CABG later that week. She had a preop workup done, \nincluding CXR, CT chest, and ECHO. However, she was deemed to \nnot be a surgical candidate and was managed medically. \n\n# Multivessel coronary artery disease- Patient had known 3 \nvessel disease on recent cath recommending CABG Cardiac Surgery \nwas consulted to perform CABG this admission. In preparation for \nCABG, Plavix was dc'd ___. Cardiac surgery completed a preop \nworkup including CXR, CT chest w/o contrast, and ECHO. Patient \nwas deemed not a surgical candidate during this admission and \nmanaged medically with metoprolol tartate 12.5 mg BID, ISMN \nshort acting 20 mg BID, ASA 81 mg daily, pravastatin 20 mg qPM, \nand lisinopril 20 mg BID. Heparin drip was discontinued and \nPlavix was restarted on ___. \n\n#Acute diastolic heart failure- New dx of acute heart failure \nduring this admission. pBNP on admission was ___. Elevated \ntroponin was thought to be secondary to demand from CHF given \nknown severe CAD. She was started on a heparin drip ___ that \nwas discontinued on ___ when patient was deemed not a surgical \ncandidate. Patient appeared volume overloaded on admission and \nwas given 40 mg IV Lasix x2. However, she did not require \nfurther diuresis during this admission. TTE was obtained ___ \nthat showed LVEF of >55%. To optimize her afterload reduction, \nhome lisinopril was increased to 20 daily, isosorbide MN was \nincreased to 20 BID, and her HCTZ was dc'd. She was continued on \nher home metoprolol tartrate 12.5 mg BID.\n\n#Oral thrush- Patient had oral thrush during this admission and \nwas started on nystatin for a 2 week course (___). \n \n#COPD: Patient was continued on her Advair and given Fluticasone \nPropionate NASAL 2 SPRY NU DAILY and Fluticasone-Salmeterol \nDiskus (100/50) 1 INH IH BID. \n\n#HTN: Patient was treated with ISMN, lisinopril, and metoprolol \nas above.\n \n#Depression/anxiety: Patient was continued on home Ativan and \nDuloxetine. \n\nTRANSITIONAL ISSUES:\n=========================\n-Discharge weight: 115 lbs\n-Medications added: Aspirin 81, Nystatin Oral Solution (for \nthrush), Pravastatin 20 mg qpm \n-Medications changed: Isosorbide increased to 20 mg BID, \nLisinopril 20 mg daily \n-Medications stopped: Blood pressures stable on above regimen, \nHydrochlorothiazide 12.5 mg daily held, please resume as needed \n-Patient initially presented with shortness of breath, and was \ngiven IV Lasix 40x2. She did not need further diuresis and thus \nis not being discharged with PO Lasix. If symptoms re-develop, \nplease consider low dose oral diuretic. \n-Patient was given a 1 month supply of all her medications \nthrough the ___ Pharmacy at ___. Two home medications that \ncould not be filled were: Duloxetine (may need prior \nauthorization) and Methylphenidate. Please follow up. \n-On non-contrast CT chest, numerous pulmonary nodules measuring \nup to 6 mm for which follow-up chest CT is recommended in ___ \nmonths. \n-On non-contrast CT chest there was borderline left axillary \nlymph node, which may be reactive. Correlation with axillary \nultrasound and mammography is recommended, if not already \nperformed elsewhere. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Lisinopril 10 mg PO DAILY \n2. Hydrochlorothiazide 12.5 mg PO DAILY \n3. Metoprolol Tartrate 12.5 mg PO BID \n4. DULoxetine 60 mg PO DAILY \n5. MethylPHENIDATE (Ritalin) 10 mg PO QID \n6. LORazepam 1 mg PO Q8H:PRN anxiety \n7. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB \n8. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID \n9. Isosorbide Mononitrate (Extended Release) 15 mg PO BID \n10. Mirtazapine 15 mg PO QHS \n11. Clopidogrel 75 mg PO DAILY \n12. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n\n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \nRX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0 \n2. Nicotine Patch 14 mg TD DAILY \nRX *nicotine 14 mg/24 hour once daily Disp #*15 Patch \nRefills:*0 \n3. Nystatin Oral Suspension 5 mL PO QID \nRX *nystatin 100,000 unit/mL 5 mL by mouth four times a day \nRefills:*0 \n4. Pravastatin 20 mg PO QPM \nRX *pravastatin 20 mg 1 tablet(s) by mouth at bedtime Disp #*30 \nTablet Refills:*0 \n5. Isosorbide Mononitrate 20 mg PO BID \nRX *isosorbide mononitrate 20 mg 1 tablet(s) by mouth twice a \nday Disp #*60 Tablet Refills:*0 \n6. Lisinopril 20 mg PO DAILY \nRX *lisinopril 20 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0 \n7. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB \nRX *albuterol sulfate [ProAir HFA] 90 mcg 1 inhalation every six \n(6) hours Disp #*1 Inhaler Refills:*0 \n8. Clopidogrel 75 mg PO DAILY \nRX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0 \n9. DULoxetine 60 mg PO DAILY \nRX *duloxetine 60 mg 1 capsule(s) by mouth once a day Disp #*30 \nCapsule Refills:*0 \n10. Fluticasone Propionate NASAL 2 SPRY NU DAILY \nRX *fluticasone 50 mcg/actuation 2 sprays once a day Disp #*1 \nSpray Refills:*0 \n11. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID \nRX *fluticasone-salmeterol [Advair Diskus] 100 mcg-50 mcg/dose 1 \ninhalation twice a day Disp #*1 Disk Refills:*3 \n12. LORazepam 1 mg PO Q8H:PRN anxiety \nRX *lorazepam 1 mg 1 tablet by mouth every eight (8) hours Disp \n#*20 Tablet Refills:*0 \n13. MethylPHENIDATE (Ritalin) 10 mg PO QID \nRX *methylphenidate 10 mg 1 capsule(s) by mouth four times a day \nDisp #*120 Capsule Refills:*0 \n14. Metoprolol Tartrate 12.5 mg PO BID \nRX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth \ntwice a day Disp #*30 Tablet Refills:*0 \n15. Mirtazapine 15 mg PO QHS \nRX *mirtazapine 15 mg 1 tablet(s) by mouth at bedtime Disp #*30 \nTablet Refills:*0 \n16. HELD- Hydrochlorothiazide 12.5 mg PO DAILY This medication \nwas held. Do not restart Hydrochlorothiazide until your doctor \nsays it is okay to do so\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary diagnosis:\n-Multivessel coronary artery disease\n-Acute diastolic heart failure\n\nSecondary diagnosis:\n-Chronic obstructive pulmonary disease\n-Hypertension\n-Oral thrush\n-Depression\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___, \n\nYou were admitted to ___ on ___ for shortness of breath. \nWe gave you some medications to help your heart. We also talked \nto the heart surgeons. However, surgery was unable to be \nperformed so we continued to manage your heart with medications \nthat you should continue taking when you go home. \n\nPlease follow up with your PCP and cardiologist. It was a \npleasure taking care of you.\n\nSymptoms to look out for:\n-Shortness of Breath: you were given IV medications to get fluid \nout of your lungs, but did not need this medication in the last \nfew days of your hospitalization. Please weigh yourself \neveryday. If you feel short of breath or your weight goes up by \n3 lbs in a week, let Dr. ___ know as you may need a water \npill (diuretic).\n\n-Chest Pain: Please come to your nearest emergency room if you \nhave any chest pain. Symptoms of pain from your heart can also \nbe arm, shoulder and jaw pain, so if you are worried, please do \nnot hesitate to seek out care.\n\nSincerely, \nYour ___ Team\n \nFollowup Instructions:\n___\n"
] | Allergies: Bactrim / codeine / doxycycline / metronidazole Chief Complaint: acute onset dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] y/o F with history of CAD, CHF, and COPD presenting with SOB. Patient reports 1 month of gradually worsening SOB in the setting of stopping her HCTZ. However, her breathing became much worse in last 3 days, and she ultimately went to the [MASKED]. She had a mild non-productive cough but denied fevers, chills, paroxysmal nocturnal dyspnea, orthopnea, and weight gain. Patient also has had bilateral [MASKED] edema that has been worsening in the last [MASKED] days. At the OSH, she was hypoxic in the [MASKED] and CXR showed concern for CHF. She was given 40mg of Lasix and started on a nitro gtt. She became briefly hypotensive and was started on levophed via peripheral IV. She was placed on BiPAP for transport. Upon arrival to the Cardiology floor, she was hemodynamically stable and was satting comfortably on room air. She put out about 1L of urine after receiving Lasix and denied CP and SOB. Past Medical History: 3 vessel CAD (cath at [MASKED] in [MASKED] HTN COPD Depression/anxiety Social History: [MASKED] Family History: noncontributory Physical Exam: ADMISSION ========= PHYSICAL EXAMINATION: VS: T AF, BP 151-156/45-74, HR 64-91, RR 18, O2 sat [MASKED] RA Weight: 58.7 kg GENERAL: NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera CARDIAC: RRR, S1/S2, systolic murmur heard loudest at LLSB and apex, JVP ~ 11 LUNG: bibasilar crackles, no wheezing ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: WWP, trace [MASKED] edema, +DP b/l NEURO: CN II-XII grossly intact SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE ========== VS: T Afebrile, BP 103-117/36-43, P 57-80, RR 18, O2sat 98-100% on RA Weight: 52.3 kg (58.7 on admission) I/O: since midnight [MASKED] 24 hours: 1136/850 GENERAL: NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera CARDIAC: RRR, S1/S2, systolic murmur heard loudest at LLSB and apex, JVP not elevated LUNG: No audible crackles, no wheezing ABDOMEN: nondistended, nontender in all quadrants EXTREMITIES: no [MASKED] edema NEURO: CN II-XII grossly intact Pertinent Results: ADMISSION LABS: ===================== [MASKED] 09:00PM BLOOD WBC-13.2* RBC-4.27 Hgb-12.7 Hct-39.0 MCV-91 MCH-29.7 MCHC-32.6 RDW-13.8 RDWSD-46.5* Plt [MASKED] [MASKED] 09:00PM BLOOD Neuts-90.4* Lymphs-7.1* Monos-1.6* Eos-0.0* Baso-0.1 Im [MASKED] AbsNeut-11.89* AbsLymp-0.94* AbsMono-0.21 AbsEos-0.00* AbsBaso-0.01 [MASKED] 10:29PM BLOOD [MASKED] PTT-29.3 [MASKED] [MASKED] 10:29PM BLOOD Glucose-128* UreaN-17 Creat-0.6 Na-136 K-3.6 Cl-99 HCO3-26 AnGap-15 [MASKED] 10:29PM BLOOD [MASKED] [MASKED] 10:29PM BLOOD cTropnT-0.15* [MASKED] 09:09PM BLOOD [MASKED] pO2-177* pCO2-34* pH-7.46* calTCO2-25 Base XS-1 Intubat-NOT INTUBA [MASKED] 09:09PM BLOOD Lactate-1.4 [MASKED] 09:09PM BLOOD O2 Sat-96 [MASKED] 09:00PM URINE Color-Yellow Appear-Clear Sp [MASKED] [MASKED] 09:00PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG [MASKED] 09:00PM URINE RBC-<1 WBC-2 Bacteri-FEW Yeast-NONE Epi-<1 [MASKED] 09:00PM URINE Mucous-RARE OTHER RELEVANT LABS: ======================== [MASKED] 05:34AM BLOOD WBC-11.8* RBC-3.97 Hgb-11.7 Hct-35.3 MCV-89 MCH-29.5 MCHC-33.1 RDW-13.7 RDWSD-44.9 Plt [MASKED] [MASKED] 07:00AM BLOOD WBC-6.0 RBC-3.73* Hgb-11.1* Hct-33.8* MCV-91 MCH-29.8 MCHC-32.8 RDW-14.2 RDWSD-47.0* Plt [MASKED] [MASKED] 09:20PM BLOOD PTT-40.7* [MASKED] 03:23AM BLOOD PTT-52.8* [MASKED] 03:49AM BLOOD PTT-70.9* [MASKED] 08:05AM BLOOD [MASKED] PTT-75.6* [MASKED] [MASKED] 03:05PM BLOOD Glucose-129* UreaN-24* Creat-0.8 Na-135 K-3.8 Cl-95* HCO3-29 AnGap-15 [MASKED] 07:00AM BLOOD Glucose-71 UreaN-24* Creat-0.7 Na-137 K-4.3 Cl-99 HCO3-29 AnGap-13 [MASKED] 07:00AM BLOOD Glucose-80 UreaN-15 Creat-0.7 Na-138 K-4.1 Cl-102 HCO3-27 AnGap-13 [MASKED] 07:00AM BLOOD ALT-31 AST-32 LD(LDH)-187 CK(CPK)-22* AlkPhos-91 TotBili-0.7 [MASKED] 07:00AM BLOOD ALT-30 AST-34 LD(LDH)-174 AlkPhos-88 TotBili-0.7 [MASKED] 02:01AM BLOOD CK-MB-13* cTropnT-0.13* [MASKED] 07:00AM BLOOD CK-MB-3 cTropnT-0.18* [MASKED] 09:05PM BLOOD CK-MB-2 cTropnT-0.18* [MASKED] 07:00AM BLOOD %HbA1c-5.5 eAG-111 URINE CULTURE (Final [MASKED]: NO GROWTH Staph aureus Screen (Final [MASKED]: NO STAPHYLOCOCCUS AUREUS ISOLATED. DISCHARGE LABS: ==================== [MASKED] 08:05AM BLOOD WBC-4.7 RBC-4.10 Hgb-11.8 Hct-37.6 MCV-92 MCH-28.8 MCHC-31.4* RDW-13.9 RDWSD-46.9* Plt [MASKED] [MASKED] 03:29PM BLOOD PTT-66.8* [MASKED] 08:05AM BLOOD Glucose-92 UreaN-14 Creat-0.7 Na-138 K-4.6 Cl-104 HCO3-25 AnGap-14 [MASKED] 08:05AM BLOOD Calcium-9.2 Phos-4.6* Mg-2.3 TTE [MASKED]: The left atrium is moderately dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Doppler parameters are indeterminate for left ventricular diastolic function. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. Moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([MASKED]) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. Moderate aortic regurgitation. Mild to moderate mitral regurgitation. CXR ([MASKED]): IMPRESSION: Heart size is normal. Mediastinum is normal. Lungs are hyperinflated but overall clear. Minimal interstitial opacities are unchanged since the prior study. Mild increase in overall interstitial opacities might represent slight volume overload, similar to [MASKED] that had shown an interval resolution on [MASKED] and in can be seen again on today's radiograph. CT Chest w/o contrast ([MASKED]): RECOMMENDATION(S): 1. [MASKED] recommendations for follow up of pulmonary nodules: Solid nodules >4 - 6 mm: Low risk: Follow-up at 12 months and if no change, no further imaging needed. High risk: Follow-up at [MASKED] months and if no change, again at [MASKED] months. The [MASKED] pulmonary nodule recommendations are intended as guidelines for follow-up and management of newly incidentally detected pulmonary nodules smaller than 8 mm, in patients [MASKED] years of age or [MASKED]. Low risk patients have minimal or absent history of smoking or other known risk factors for primary lung neoplasm. High risk patients have a history of smoking or other known risk factors for primary lung neoplasm. 2. Echocardiography, if pop already performed elsewhere, for further evaluation of aortic valvular calcifications. 3. Diagnostic mammography and axillary ultrasound is recommended if mammography has not been obtained recently. Brief Hospital Course: Ms. [MASKED] is a [MASKED] F with 3 vessel CAD (had a cath at [MASKED] in [MASKED] that indicated need for CABG), HTN and COPD who presented with new acute CHF and elevated troponins c/f possible type 2 NSTEMI. She was hemodynamically stable at [MASKED] after having briefly been on NRB and pressors at [MASKED]. She was initially started on a heparin drip on [MASKED], diuresed for acute HFpEF, and had her BP medications optimized. Her Plavix was dc'd on [MASKED] to prepare for possible CABG later that week. She had a preop workup done, including CXR, CT chest, and ECHO. However, she was deemed to not be a surgical candidate and was managed medically. # Multivessel coronary artery disease- Patient had known 3 vessel disease on recent cath recommending CABG Cardiac Surgery was consulted to perform CABG this admission. In preparation for CABG, Plavix was dc'd [MASKED]. Cardiac surgery completed a preop workup including CXR, CT chest w/o contrast, and ECHO. Patient was deemed not a surgical candidate during this admission and managed medically with metoprolol tartate 12.5 mg BID, ISMN short acting 20 mg BID, ASA 81 mg daily, pravastatin 20 mg qPM, and lisinopril 20 mg BID. Heparin drip was discontinued and Plavix was restarted on [MASKED]. #Acute diastolic heart failure- New dx of acute heart failure during this admission. pBNP on admission was [MASKED]. Elevated troponin was thought to be secondary to demand from CHF given known severe CAD. She was started on a heparin drip [MASKED] that was discontinued on [MASKED] when patient was deemed not a surgical candidate. Patient appeared volume overloaded on admission and was given 40 mg IV Lasix x2. However, she did not require further diuresis during this admission. TTE was obtained [MASKED] that showed LVEF of >55%. To optimize her afterload reduction, home lisinopril was increased to 20 daily, isosorbide MN was increased to 20 BID, and her HCTZ was dc'd. She was continued on her home metoprolol tartrate 12.5 mg BID. #Oral thrush- Patient had oral thrush during this admission and was started on nystatin for a 2 week course ([MASKED]). #COPD: Patient was continued on her Advair and given Fluticasone Propionate NASAL 2 SPRY NU DAILY and Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID. #HTN: Patient was treated with ISMN, lisinopril, and metoprolol as above. #Depression/anxiety: Patient was continued on home Ativan and Duloxetine. TRANSITIONAL ISSUES: ========================= -Discharge weight: 115 lbs -Medications added: Aspirin 81, Nystatin Oral Solution (for thrush), Pravastatin 20 mg qpm -Medications changed: Isosorbide increased to 20 mg BID, Lisinopril 20 mg daily -Medications stopped: Blood pressures stable on above regimen, Hydrochlorothiazide 12.5 mg daily held, please resume as needed -Patient initially presented with shortness of breath, and was given IV Lasix 40x2. She did not need further diuresis and thus is not being discharged with PO Lasix. If symptoms re-develop, please consider low dose oral diuretic. -Patient was given a 1 month supply of all her medications through the [MASKED] Pharmacy at [MASKED]. Two home medications that could not be filled were: Duloxetine (may need prior authorization) and Methylphenidate. Please follow up. -On non-contrast CT chest, numerous pulmonary nodules measuring up to 6 mm for which follow-up chest CT is recommended in [MASKED] months. -On non-contrast CT chest there was borderline left axillary lymph node, which may be reactive. Correlation with axillary ultrasound and mammography is recommended, if not already performed elsewhere. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 10 mg PO DAILY 2. Hydrochlorothiazide 12.5 mg PO DAILY 3. Metoprolol Tartrate 12.5 mg PO BID 4. DULoxetine 60 mg PO DAILY 5. MethylPHENIDATE (Ritalin) 10 mg PO QID 6. LORazepam 1 mg PO Q8H:PRN anxiety 7. Albuterol Inhaler [MASKED] PUFF IH Q6H:PRN SOB 8. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID 9. Isosorbide Mononitrate (Extended Release) 15 mg PO BID 10. Mirtazapine 15 mg PO QHS 11. Clopidogrel 75 mg PO DAILY 12. Fluticasone Propionate NASAL 2 SPRY NU DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 2. Nicotine Patch 14 mg TD DAILY RX *nicotine 14 mg/24 hour once daily Disp #*15 Patch Refills:*0 3. Nystatin Oral Suspension 5 mL PO QID RX *nystatin 100,000 unit/mL 5 mL by mouth four times a day Refills:*0 4. Pravastatin 20 mg PO QPM RX *pravastatin 20 mg 1 tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*0 5. Isosorbide Mononitrate 20 mg PO BID RX *isosorbide mononitrate 20 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 6. Lisinopril 20 mg PO DAILY RX *lisinopril 20 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 7. Albuterol Inhaler [MASKED] PUFF IH Q6H:PRN SOB RX *albuterol sulfate [ProAir HFA] 90 mcg 1 inhalation every six (6) hours Disp #*1 Inhaler Refills:*0 8. Clopidogrel 75 mg PO DAILY RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 9. DULoxetine 60 mg PO DAILY RX *duloxetine 60 mg 1 capsule(s) by mouth once a day Disp #*30 Capsule Refills:*0 10. Fluticasone Propionate NASAL 2 SPRY NU DAILY RX *fluticasone 50 mcg/actuation 2 sprays once a day Disp #*1 Spray Refills:*0 11. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID RX *fluticasone-salmeterol [Advair Diskus] 100 mcg-50 mcg/dose 1 inhalation twice a day Disp #*1 Disk Refills:*3 12. LORazepam 1 mg PO Q8H:PRN anxiety RX *lorazepam 1 mg 1 tablet by mouth every eight (8) hours Disp #*20 Tablet Refills:*0 13. MethylPHENIDATE (Ritalin) 10 mg PO QID RX *methylphenidate 10 mg 1 capsule(s) by mouth four times a day Disp #*120 Capsule Refills:*0 14. Metoprolol Tartrate 12.5 mg PO BID RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth twice a day Disp #*30 Tablet Refills:*0 15. Mirtazapine 15 mg PO QHS RX *mirtazapine 15 mg 1 tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*0 16. HELD- Hydrochlorothiazide 12.5 mg PO DAILY This medication was held. Do not restart Hydrochlorothiazide until your doctor says it is okay to do so Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: -Multivessel coronary artery disease -Acute diastolic heart failure Secondary diagnosis: -Chronic obstructive pulmonary disease -Hypertension -Oral thrush -Depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You were admitted to [MASKED] on [MASKED] for shortness of breath. We gave you some medications to help your heart. We also talked to the heart surgeons. However, surgery was unable to be performed so we continued to manage your heart with medications that you should continue taking when you go home. Please follow up with your PCP and cardiologist. It was a pleasure taking care of you. Symptoms to look out for: -Shortness of Breath: you were given IV medications to get fluid out of your lungs, but did not need this medication in the last few days of your hospitalization. Please weigh yourself everyday. If you feel short of breath or your weight goes up by 3 lbs in a week, let Dr. [MASKED] know as you may need a water pill (diuretic). -Chest Pain: Please come to your nearest emergency room if you have any chest pain. Symptoms of pain from your heart can also be arm, shoulder and jaw pain, so if you are worried, please do not hesitate to seek out care. Sincerely, Your [MASKED] Team Followup Instructions: [MASKED] | [
"I214",
"B370",
"Z006",
"J449",
"F17210",
"I10",
"F329",
"F419",
"I2510"
] | [
"I214: Non-ST elevation (NSTEMI) myocardial infarction",
"B370: Candidal stomatitis",
"Z006: Encounter for examination for normal comparison and control in clinical research program",
"J449: Chronic obstructive pulmonary disease, unspecified",
"F17210: Nicotine dependence, cigarettes, uncomplicated",
"I10: Essential (primary) hypertension",
"F329: Major depressive disorder, single episode, unspecified",
"F419: Anxiety disorder, unspecified",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris"
] | [
"J449",
"F17210",
"I10",
"F329",
"F419",
"I2510"
] | [] |
15,896,763 | 21,847,118 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: NEUROLOGY\n \nAllergies: \nSulfa (Sulfonamide Antibiotics) / Flagyl / Keflex / lactated \nringers / NSAIDS (Non-Steroidal Anti-Inflammatory Drug)\n \nAttending: ___.\n \nChief Complaint:\nHeadache, Left arm weakness\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n Mr. ___ is a ___ year-old right-handed man with\na history of myoclonic and abdominal seizures, undifferentiated\nmitochondrial disorder, migraines, and radiculoneuropathy, \nrecent\nprolonged hospitalization in ___ for perforated\ndiverticulitis s/p ___ repair and stomal retraction, now \ns/p\nreversal of colostomy who presents for evaluation of an 11 day\nhistory of progressively severe headache and left arm weakness. \nHistory provided by the patient.\n\nPatient reports he was in his usual state of health until 11 \ndays\nprior to presentation. At that time, he began developing \ngradual\nonset of a headache. The headache was different than his\nbaseline headaches, which are discussed below. This pain was\ndifferent and that it was described as pain \"deep inside\"his\nhead, located over the occipital region with radiation towards\nthe left neck. He notes that it was somewhat similar to the\nheadache he experienced after having a post epidural headache\nduring his recent hospitalization in ___. However, it is\ndifferent from even that headache in that it is not as severe \nand\nis associated with left arm weakness. When the headache started\n11 days ago, he did not make much of the headache as it was \nquite\nmild in severity. He was able to go about his usual activities. \n\n___ days after the headache started, he tried taking his home\nZomig nasal spray, which typically aborts his migraines, and it\ndid not help. He also tried taking over-the-counter Tylenol,\nAleve, and Advil without relief. Over the last 11 days, the \npain\ngradually became more severe and more debilitating. The pain\nbegan to spread throughout his head, not just occipital but\nspread into the right temporal area, and then the left temporal\narea. The headache eventually became so severe, that it did \nwake\nhim up from sleep multiple times (he is explicit about this). \nHeadache is not worsened with Valsalva. It is not positional. \nIt is associated with mild phonophobia and nausea. He denies\nassociated visual symptoms, denies any associated\nnumbness/tingling, denies vomiting, denies\nlightheadedness/dizziness. It is not the worst headache of his\nlife.\n\nAlso, at some point throughout this time, his left arm began to\nfeel weak. He cannot pinpoint when exactly this started. He\nnoticed that the left arm did not have quite the same strength\nand was slower to move than the right. Nonetheless, he was able\nto do all the things with this arm that he wanted to do,\nincluding opening and closing hands, and opening and closing\ndoors. He had never had associated weakness with his headaches\nbefore.\n\nRegarding his baseline headaches, he has what he describes as\nmigraines. These are characterized by throbbing pain located\nbetween his eyes, associate with intense photophobia. These are\nrelieved by lying in a dark room and taking his sumatriptan \nnasal\nspray. He has no preceding aura. He has mild nausea without\nvomiting associated with it. He has never had associated\nweakness or sensory symptoms with a headache. Headaches\ntypically last for 6 hours and occur once a month.\n\nGiven his ongoing, refractory headache, he was planned to see \nhis\noutpatient neurologist Dr. ___ 2 days ago, however the\nappointment was canceled due to the ___ parade. As a \nresult,\ndue to ongoing symptoms that have led to his inability to\nfunction and sleep properly, he came to the emergency room today\nfor further evaluation.\n\nOf note, prior to onset of the symptoms above, patient denies \nany\nrecent changes in his routine. He denies any recent new or\nmissed medications. His blood pressure have been running high\nrecently, and his nephrologist have plan to start losartan,\nhowever patient was reluctant to do so due to difficulty\ntolerating losartan in the past. No recent illness. No\nfevers/chills, no recent upper respiratory symptoms. No recent\ntrauma. No recent neck manipulations. He has gone to the \nbarber\nshop where his hair was washed on the open end sink 5 weeks ago.\n\nPatient recently had a prolonged hospitalization in ___,\nafter presenting with perforated diverticulitis, status post\nrepair and stoma retraction, subsequently status post reversal \nof\ncolostomy on ___. He required epidural placement for the\noperation at T11/T12. Neurology was consulted postoperatively\ndue to intermittent severe headache status post procedure. This\nheadache was notably postural, worse with sitting or elevation\nand improved with lying flat. He was felt to be likely due to\npost epidural headache, less likely due to migraine. He \nimproved\nwith aggressive hydration and symptomatic treatment. For \nworkup,\nhe underwent MRI of the cervical spine which showed moderate to\nsevere degenerative disease without cord enhancement. He did \nnot\nrequire placement of an epidural blood patch. There also was a\nsignificant component of cervicalgia.\n\nRegarding the remainder of his neurologic history:\n- Per Dr. ___ consult note in ___: \"Mr.\n___ has a history of abdominal seizures, first diagnosed \nin\n___. While abroad for work in ___, he described eating tainted\nfish that made him feel nauseous. On his trip back\nto ___, he had fits of vomiting followed by severe fatigue.\nHis vomiting continued whenever he ate, and he lost 55 lb in 3\nmonths. Around this time, he experienced myoclonic seizures with\nfull-body jerks as well, with occasional waves of pain that felt\nlike lanceting electrical shocks down the anterior aspects of \nhis\nthighs. He began seeing Dr. ___ at ___ for his seizures in\n___, and reports that his seizures have been well-controlled on\nLamictal 400mg/500mg and Onfi 20mg qhs with recent lamictal \nlevel\nin ___ being therapeutic. He reports that he has not had a\nseizure in several years. Dr. ___ notes that Mr.\n___ previously has had temporal seizures where he feels a\nsense of familiarity/ unfamiliarity. These episodes usually last\na minute and are followed by fatigue.\"\n- He has an undifferentiated Mitochondrial encephalomyopathy, \nfor\nwhich he also follows w/ Dr. ___. Per OMR, in ___, Mr. ___ developed myoclonic jerks and lost 55 pounds in 3.5\nmonths. He had additional symptoms including elevated lactic\nacid, global fatigue, exercise-induced myalgias, small fiber\npolyneuropathy, pain, and intermittent hypoxia with REM\nhypoventilation. He was on a feeding tube for ___ years and was\ndiagnosed with abdominal epilepsy. \n-At baseline, on neurologic exam he has \"significant decreased\nrapid coordinated function, specifically,rapid finger movements,\nforearm alterations, hand tapping and also some cerebellar signs\nwith dysdiadochokinesis where he has difficulty doing\nfinger-nose-finger testing\" per Dr. ___. \n \n\n \nPast Medical History:\n- recent hospitalization for diverticulitis as above\n- Mitochondrial encephalomyopathy\n- Migraines\n-Benign prostatic hypertrophy\n-OSA: Mild; Failed CPAP ___ inability to tolerate mask.\n-Radicular leg pain: s/p epidural injections \n-Positive PPD\n-Ulceration in the terminal ileum ___\n- Diverticulosis of the sigmoid colon & descending colon \n___\n- Anal fistula repair\n-Right knee partial medial menisectomy\n-Transurethral prostate resection ___ adenocarcinoma ___\n \nSocial History:\n___\nFamily History:\n- Mother had dementia and died at ___ ___ stroke.\n- Father had DM and died at ___ ___ \"old age\". \n- Oldest brother has colon and prostate cancer. \n- Another brother has ankylosing spondylitis. \n \nPhysical Exam:\n==============\nADMISSION EXAM\n==============\n\nPhysical Exam:\nVitals: T 98.5F, HR 94, BP 153/90, RR 18, O2 97% RA\n\nGeneral: Awake, cooperative, NAD.\nHEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in\noropharynx\nNeck: no palpable muscle tension in neck. Supple, No nuchal\nrigidity\nPulmonary: Normal work of breathing\nCardiac: RRR, warm, well-perfused\nAbdomen: soft, non-distended\nExtremities: No ___ edema.\nSkin: no rashes or lesions noted.\n \nNeurologic:\n-Mental Status: Alert, oriented x 3. Able to relate history\nwithout difficulty. Attentive, able to name ___ backward without\ndifficulty. Language is fluent with intact repetition and\ncomprehension. Normal prosody. There were no paraphasic errors.\nPt was able to name both high and low frequency objects. Able \nto\nread without difficulty. Speech was not dysarthric. Able to\nfollow both midline and appendicular commands.There was no\nevidence of apraxia or neglect.\n\n-Cranial Nerves:\nII, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without\nnystagmus. Normal saccades. VFF to confrontation. Fundoscopic\nexam performed, revealed no papilledema, exudates, or\nhemorrhages.\nV: Facial sensation intact to light touch.\nVII: No facial droop, facial musculature symmetric.\nVIII: Hearing intact to finger-rub bilaterally.\nIX, X: Palate elevates symmetrically.\nXI: ___ strength in trapezii bilaterally.\nXII: Tongue protrudes in midline with good excursions. Strength\nfull with tongue-in-cheek testing.\n\n-Motor: Normal bulk, tone throughout. No pronator drift\nbilaterally. No adventitious movements, such as tremor, noted. \nNo\nasterixis noted.\n+ Orbiting around L hand\n Delt Bic Tri WrE FE IP Quad Ham TA ___ ___ \nL 4+* 5 4+* 5 4+* 5 5 5 5 5 5\nR 5 5 5 5 5 5 5 5 5 5 5 \n4+/5 in bilateral ADM \n*there is a give way weakness component, but even when asked to\ngive 2 seconds of best effort it is easily breakable. \n\n-Sensory: No deficits to light touch, pinprick, proprioception\nthroughout. No extinction to DSS. Romberg with sway but not\npositive. \n \n-DTRs:\n Bi Tri ___ Pat Ach\nL ___ 1 0\nR ___ 1 0\nPlantar response was flexor on right, extensor on left.\n\n-Coordination: No intention tremor. reduced speed and amplitude \nof rapid alternating movements of hands, though not overtly \nataxic. No clear overshoot on cerebellar mirroring. No dysmetria \non HKS bilaterally. \n\n-Gait: Good initiation. Gait is hesistant and somewhat wide \nbase, sways back and forth but not to either direction. No \ntruncal ataxia. Falls back in bed when asked to do tandem walk. \nCan take a few steps without assistance, but is unsteady. Unable \nto do Unteberger due to unsteadiness. \n\n==============\nDISCHARGE EXAM\n==============\nUnchanged except as noted below: \n\n-Motor: Normal bulk, tone throughout. No pronator drift\nbilaterally.\n Delt Bic Tri WrE FE IP Quad Ham TA ___ ___ \nL 5 5 5 5 5 5 5 5 5 5 5\nR 5 5 5 5 5 5 5 5 5 5 5 \n* Give-way weakness on every muscle tested on left side. All \nwere full strength on momentary best effort. \n\n-Sensory: Proprioception intact to fine movements of bilateral \nindex fingers and great toes. No deficits to light touch \nthroughout. \n\n-Coordination: FNF intact bilaterally. \n\n-Gait: Ambulating independently with normal gait, stride, base. \n \nPertinent Results:\n====\nLABS\n====\n___ 04:30AM BLOOD WBC-11.1* RBC-4.75 Hgb-15.5 Hct-46.2 \nMCV-97 MCH-32.6* MCHC-33.5 RDW-12.9 RDWSD-46.5* Plt ___\n___ 04:30AM BLOOD Neuts-44.2 ___ Monos-6.7 Eos-3.9 \nBaso-0.5 Im ___ AbsNeut-4.90 AbsLymp-4.91* AbsMono-0.74 \nAbsEos-0.43 AbsBaso-0.06\n___ 04:30AM BLOOD Glucose-83 UreaN-18 Creat-1.0 Na-145 \nK-4.7 Cl-105 HCO3-26 AnGap-14\n___ 10:50AM BLOOD ALT-16 AST-14 CK(CPK)-70 AlkPhos-75 \nTotBili-0.3\n___ 04:30AM BLOOD Calcium-9.4 Phos-4.2 Mg-1.9\n___ 10:50AM BLOOD Triglyc-275* HDL-35* CHOL/HD-6.1 \nLDLcalc-123\n___ 10:50AM BLOOD %HbA1c-5.4 eAG-108\n___ 10:50AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nTricycl-NEG\n\n=======\nIMAGING\n=======\n- ___ MRI & MRA Brain WITHOUT Contrast, MRA Neck WITH \nContrast\n1. No significant intracranial abnormality. No evidence of acute \ninfarction, hemorrhage or mass. \n2. Patent intracranial and cervical vasculature without evidence \nof \ndissection, stenosis, occlusion or aneurysm formation. \n \n\n \nBrief Hospital Course:\nMr. ___ is a ___ year-old right-handed man with a history \nof myoclonic and abdominal seizures, undifferentiated \nmitochondrial disorder, migraines, and radiculoneuropathy, \nrecent prolonged hospitalization in ___ for perforated \ndiverticulitis s/p ___ repair and stomal retraction, now \ns/p reversal of colostomy who presents for evaluation of an 11 \nday history of progressively severe headache and left arm \nweakness. Given his history and constellation of symptoms, he \nwas admitted for neuroimaging to evaluate for central process. \nMRI was negative for stroke or other CNS lesion. Exam was \nnotable for give-way weakness on left side with normal \nproprioception and sensation. His headache improved moderately \nwith a migraine cocktail. He endorsed significant \nmusculoskeletal discomfort and was seen by ___. He will be \ndischarged home with a cervical soft collar and will follow-up \nwith Dr. ___ week. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Clobazam 20 mg PO QHS \n2. ZOLMitriptan 5 mg nasal ASDIR \n3. TraZODone ___ mg PO QHS:PRN insomnia \n4. LamoTRIgine 400 mg PO BID mitochondrial seizure disorder \n\n \nDischarge Medications:\n1. Clobazam 20 mg PO QHS \n2. LamoTRIgine 400 mg PO BID mitochondrial seizure disorder \n3. TraZODone ___ mg PO QHS:PRN insomnia \n4. ZOLMitriptan 5 mg nasal ASDIR \n5.Outpatient Physical Therapy\nCervical musculoskeletal pain \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nHeadache\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nMr. ___, \n\nYou were admitted to the neurology service for symptoms of left \narm weakness which was concerning for stroke. Your brain MRI was \nnormal and did not show any stroke or other abnormalities. On \nexamination, you did not have physiologic weakness. We \nrecommended a cervical soft-collar for your neck pain which was \nexacerbating your headache. You were seen by physical therapy \nwho recommended outpatient ___. \n\nPlease follow-up with Dr. ___ as already scheduled. \n\nBest, \nYour ___ Neurology Team\n\n \nFollowup Instructions:\n___\n"
] | Allergies: Sulfa (Sulfonamide Antibiotics) / Flagyl / Keflex / lactated ringers / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) Chief Complaint: Headache, Left arm weakness Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is a [MASKED] year-old right-handed man with a history of myoclonic and abdominal seizures, undifferentiated mitochondrial disorder, migraines, and radiculoneuropathy, recent prolonged hospitalization in [MASKED] for perforated diverticulitis s/p [MASKED] repair and stomal retraction, now s/p reversal of colostomy who presents for evaluation of an 11 day history of progressively severe headache and left arm weakness. History provided by the patient. Patient reports he was in his usual state of health until 11 days prior to presentation. At that time, he began developing gradual onset of a headache. The headache was different than his baseline headaches, which are discussed below. This pain was different and that it was described as pain "deep inside"his head, located over the occipital region with radiation towards the left neck. He notes that it was somewhat similar to the headache he experienced after having a post epidural headache during his recent hospitalization in [MASKED]. However, it is different from even that headache in that it is not as severe and is associated with left arm weakness. When the headache started 11 days ago, he did not make much of the headache as it was quite mild in severity. He was able to go about his usual activities. [MASKED] days after the headache started, he tried taking his home Zomig nasal spray, which typically aborts his migraines, and it did not help. He also tried taking over-the-counter Tylenol, Aleve, and Advil without relief. Over the last 11 days, the pain gradually became more severe and more debilitating. The pain began to spread throughout his head, not just occipital but spread into the right temporal area, and then the left temporal area. The headache eventually became so severe, that it did wake him up from sleep multiple times (he is explicit about this). Headache is not worsened with Valsalva. It is not positional. It is associated with mild phonophobia and nausea. He denies associated visual symptoms, denies any associated numbness/tingling, denies vomiting, denies lightheadedness/dizziness. It is not the worst headache of his life. Also, at some point throughout this time, his left arm began to feel weak. He cannot pinpoint when exactly this started. He noticed that the left arm did not have quite the same strength and was slower to move than the right. Nonetheless, he was able to do all the things with this arm that he wanted to do, including opening and closing hands, and opening and closing doors. He had never had associated weakness with his headaches before. Regarding his baseline headaches, he has what he describes as migraines. These are characterized by throbbing pain located between his eyes, associate with intense photophobia. These are relieved by lying in a dark room and taking his sumatriptan nasal spray. He has no preceding aura. He has mild nausea without vomiting associated with it. He has never had associated weakness or sensory symptoms with a headache. Headaches typically last for 6 hours and occur once a month. Given his ongoing, refractory headache, he was planned to see his outpatient neurologist Dr. [MASKED] 2 days ago, however the appointment was canceled due to the [MASKED] parade. As a result, due to ongoing symptoms that have led to his inability to function and sleep properly, he came to the emergency room today for further evaluation. Of note, prior to onset of the symptoms above, patient denies any recent changes in his routine. He denies any recent new or missed medications. His blood pressure have been running high recently, and his nephrologist have plan to start losartan, however patient was reluctant to do so due to difficulty tolerating losartan in the past. No recent illness. No fevers/chills, no recent upper respiratory symptoms. No recent trauma. No recent neck manipulations. He has gone to the barber shop where his hair was washed on the open end sink 5 weeks ago. Patient recently had a prolonged hospitalization in [MASKED], after presenting with perforated diverticulitis, status post repair and stoma retraction, subsequently status post reversal of colostomy on [MASKED]. He required epidural placement for the operation at T11/T12. Neurology was consulted postoperatively due to intermittent severe headache status post procedure. This headache was notably postural, worse with sitting or elevation and improved with lying flat. He was felt to be likely due to post epidural headache, less likely due to migraine. He improved with aggressive hydration and symptomatic treatment. For workup, he underwent MRI of the cervical spine which showed moderate to severe degenerative disease without cord enhancement. He did not require placement of an epidural blood patch. There also was a significant component of cervicalgia. Regarding the remainder of his neurologic history: - Per Dr. [MASKED] consult note in [MASKED]: "Mr. [MASKED] has a history of abdominal seizures, first diagnosed in [MASKED]. While abroad for work in [MASKED], he described eating tainted fish that made him feel nauseous. On his trip back to [MASKED], he had fits of vomiting followed by severe fatigue. His vomiting continued whenever he ate, and he lost 55 lb in 3 months. Around this time, he experienced myoclonic seizures with full-body jerks as well, with occasional waves of pain that felt like lanceting electrical shocks down the anterior aspects of his thighs. He began seeing Dr. [MASKED] at [MASKED] for his seizures in [MASKED], and reports that his seizures have been well-controlled on Lamictal 400mg/500mg and Onfi 20mg qhs with recent lamictal level in [MASKED] being therapeutic. He reports that he has not had a seizure in several years. Dr. [MASKED] notes that Mr. [MASKED] previously has had temporal seizures where he feels a sense of familiarity/ unfamiliarity. These episodes usually last a minute and are followed by fatigue." - He has an undifferentiated Mitochondrial encephalomyopathy, for which he also follows w/ Dr. [MASKED]. Per OMR, in [MASKED], Mr. [MASKED] developed myoclonic jerks and lost 55 pounds in 3.5 months. He had additional symptoms including elevated lactic acid, global fatigue, exercise-induced myalgias, small fiber polyneuropathy, pain, and intermittent hypoxia with REM hypoventilation. He was on a feeding tube for [MASKED] years and was diagnosed with abdominal epilepsy. -At baseline, on neurologic exam he has "significant decreased rapid coordinated function, specifically,rapid finger movements, forearm alterations, hand tapping and also some cerebellar signs with dysdiadochokinesis where he has difficulty doing finger-nose-finger testing" per Dr. [MASKED]. Past Medical History: - recent hospitalization for diverticulitis as above - Mitochondrial encephalomyopathy - Migraines -Benign prostatic hypertrophy -OSA: Mild; Failed CPAP [MASKED] inability to tolerate mask. -Radicular leg pain: s/p epidural injections -Positive PPD -Ulceration in the terminal ileum [MASKED] - Diverticulosis of the sigmoid colon & descending colon [MASKED] - Anal fistula repair -Right knee partial medial menisectomy -Transurethral prostate resection [MASKED] adenocarcinoma [MASKED] Social History: [MASKED] Family History: - Mother had dementia and died at [MASKED] [MASKED] stroke. - Father had DM and died at [MASKED] [MASKED] "old age". - Oldest brother has colon and prostate cancer. - Another brother has ankylosing spondylitis. Physical Exam: ============== ADMISSION EXAM ============== Physical Exam: Vitals: T 98.5F, HR 94, BP 153/90, RR 18, O2 97% RA General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: no palpable muscle tension in neck. Supple, No nuchal rigidity Pulmonary: Normal work of breathing Cardiac: RRR, warm, well-perfused Abdomen: soft, non-distended Extremities: No [MASKED] edema. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name [MASKED] backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt was able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands.There was no evidence of apraxia or neglect. -Cranial Nerves: II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without nystagmus. Normal saccades. VFF to confrontation. Fundoscopic exam performed, revealed no papilledema, exudates, or hemorrhages. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: [MASKED] strength in trapezii bilaterally. XII: Tongue protrudes in midline with good excursions. Strength full with tongue-in-cheek testing. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. + Orbiting around L hand Delt Bic Tri WrE FE IP Quad Ham TA [MASKED] [MASKED] L 4+* 5 4+* 5 4+* 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 4+/5 in bilateral ADM *there is a give way weakness component, but even when asked to give 2 seconds of best effort it is easily breakable. -Sensory: No deficits to light touch, pinprick, proprioception throughout. No extinction to DSS. Romberg with sway but not positive. -DTRs: Bi Tri [MASKED] Pat Ach L [MASKED] 1 0 R [MASKED] 1 0 Plantar response was flexor on right, extensor on left. -Coordination: No intention tremor. reduced speed and amplitude of rapid alternating movements of hands, though not overtly ataxic. No clear overshoot on cerebellar mirroring. No dysmetria on HKS bilaterally. -Gait: Good initiation. Gait is hesistant and somewhat wide base, sways back and forth but not to either direction. No truncal ataxia. Falls back in bed when asked to do tandem walk. Can take a few steps without assistance, but is unsteady. Unable to do Unteberger due to unsteadiness. ============== DISCHARGE EXAM ============== Unchanged except as noted below: -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. Delt Bic Tri WrE FE IP Quad Ham TA [MASKED] [MASKED] L 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 * Give-way weakness on every muscle tested on left side. All were full strength on momentary best effort. -Sensory: Proprioception intact to fine movements of bilateral index fingers and great toes. No deficits to light touch throughout. -Coordination: FNF intact bilaterally. -Gait: Ambulating independently with normal gait, stride, base. Pertinent Results: ==== LABS ==== [MASKED] 04:30AM BLOOD WBC-11.1* RBC-4.75 Hgb-15.5 Hct-46.2 MCV-97 MCH-32.6* MCHC-33.5 RDW-12.9 RDWSD-46.5* Plt [MASKED] [MASKED] 04:30AM BLOOD Neuts-44.2 [MASKED] Monos-6.7 Eos-3.9 Baso-0.5 Im [MASKED] AbsNeut-4.90 AbsLymp-4.91* AbsMono-0.74 AbsEos-0.43 AbsBaso-0.06 [MASKED] 04:30AM BLOOD Glucose-83 UreaN-18 Creat-1.0 Na-145 K-4.7 Cl-105 HCO3-26 AnGap-14 [MASKED] 10:50AM BLOOD ALT-16 AST-14 CK(CPK)-70 AlkPhos-75 TotBili-0.3 [MASKED] 04:30AM BLOOD Calcium-9.4 Phos-4.2 Mg-1.9 [MASKED] 10:50AM BLOOD Triglyc-275* HDL-35* CHOL/HD-6.1 LDLcalc-123 [MASKED] 10:50AM BLOOD %HbA1c-5.4 eAG-108 [MASKED] 10:50AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG ======= IMAGING ======= - [MASKED] MRI & MRA Brain WITHOUT Contrast, MRA Neck WITH Contrast 1. No significant intracranial abnormality. No evidence of acute infarction, hemorrhage or mass. 2. Patent intracranial and cervical vasculature without evidence of dissection, stenosis, occlusion or aneurysm formation. Brief Hospital Course: Mr. [MASKED] is a [MASKED] year-old right-handed man with a history of myoclonic and abdominal seizures, undifferentiated mitochondrial disorder, migraines, and radiculoneuropathy, recent prolonged hospitalization in [MASKED] for perforated diverticulitis s/p [MASKED] repair and stomal retraction, now s/p reversal of colostomy who presents for evaluation of an 11 day history of progressively severe headache and left arm weakness. Given his history and constellation of symptoms, he was admitted for neuroimaging to evaluate for central process. MRI was negative for stroke or other CNS lesion. Exam was notable for give-way weakness on left side with normal proprioception and sensation. His headache improved moderately with a migraine cocktail. He endorsed significant musculoskeletal discomfort and was seen by [MASKED]. He will be discharged home with a cervical soft collar and will follow-up with Dr. [MASKED] week. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Clobazam 20 mg PO QHS 2. ZOLMitriptan 5 mg nasal ASDIR 3. TraZODone [MASKED] mg PO QHS:PRN insomnia 4. LamoTRIgine 400 mg PO BID mitochondrial seizure disorder Discharge Medications: 1. Clobazam 20 mg PO QHS 2. LamoTRIgine 400 mg PO BID mitochondrial seizure disorder 3. TraZODone [MASKED] mg PO QHS:PRN insomnia 4. ZOLMitriptan 5 mg nasal ASDIR 5.Outpatient Physical Therapy Cervical musculoskeletal pain Discharge Disposition: Home Discharge Diagnosis: Headache Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [MASKED], You were admitted to the neurology service for symptoms of left arm weakness which was concerning for stroke. Your brain MRI was normal and did not show any stroke or other abnormalities. On examination, you did not have physiologic weakness. We recommended a cervical soft-collar for your neck pain which was exacerbating your headache. You were seen by physical therapy who recommended outpatient [MASKED]. Please follow-up with Dr. [MASKED] as already scheduled. Best, Your [MASKED] Neurology Team Followup Instructions: [MASKED] | [
"R51",
"R531",
"Z23",
"G40802",
"E8840",
"G43909",
"M5410",
"G4733",
"Z8546",
"Z87891"
] | [
"R51: Headache",
"R531: Weakness",
"Z23: Encounter for immunization",
"G40802: Other epilepsy, not intractable, without status epilepticus",
"E8840: Mitochondrial metabolism disorder, unspecified",
"G43909: Migraine, unspecified, not intractable, without status migrainosus",
"M5410: Radiculopathy, site unspecified",
"G4733: Obstructive sleep apnea (adult) (pediatric)",
"Z8546: Personal history of malignant neoplasm of prostate",
"Z87891: Personal history of nicotine dependence"
] | [
"G4733",
"Z87891"
] | [] |
16,921,126 | 24,116,257 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nChest Pain\n\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ yo woman originally from ___ with PMHx pos\nfor hypertension, asthma, OSA (has APAP, doesn't use), obesity,\nGERD, depression, presenting with sx concerning for \npericarditis.\nShe recently had a laparascopic cholecystectomy on ___. She is\nnoted to have tolerated the procedure well, and only has mild\nresidual tenderness surrounding the central incision site. \n\nShe reports acute onset of chest pain in the morning 2 days ago,\nwith gradual progression to ___ severity when presenting to \nthe\nED. Pain was located in the midsternal region and radiated up\ntowards clavicles. Pain worse with inspiration and lying flat,\nand improves with leaning forwards. Also has mild-mod dysp, no\npain while swallowing. She denies fevers, chills, nausea,\nvomiting, abdominal pain, diarrhea, or dysuria. She endorses\ncough sx, feeling light-headed recently, nocturia over months,\nand bilateral knee arthritis. Her grandchildren have recently\nbeen sick with GI illness. \n\nIn the ED, initial VS: Tmax in ED 101.4 HR 99 107 128/80 16 \n100%\nRA \nExam notable for: rub on cardiac auscultation, surgical site\nfrom whole c/d/I. Cardiology and Surgery were consulted. \n\nWhile in ED Pt given: \nAcetaminophen 1000 mg \nMorphine Sulfate 4 mg \nOndansetron 4 mg \nIbuprofen 600 mg \nColchicine .6 mg \namLODIPine 10 mg \nFLUoxetine 40 mg \nIVF NS \nColchicine .6 mg \n\nOn the floor, pt endorses improvement in chest pain symptoms s/p\nbeginning treatment. She denies feeling faint. Denies fever,\nchills, abdominal pain, nausea, vomiting, diarrhea, dysuria.\nComplete ROS obtained and is otherwise negative. \n\n \nPast Medical History:\nPAST MEDICAL HISTORY: \n-obesity \n-seasonal allergies \n-gastroesophageal reflux disease\n-fibroid uterus \n-hypertension \n-anxiety \n-depression \n-asthma\n-obstructive sleep anemia\n-Fe deficiency anemia\n\nPast Surgical History: \n-tubal ligation \n-breast lumpectomy \n-s/p fibroid embolization \n-s/p laparascopic cholecystectomy\n \nSocial History:\n___\nFamily History:\nMother with DM and breast CA, living in ___\nFather, deceased ___, patient does not know much about her \nbiological father.\nHas 6 sisters, 3 brothers. Only one sister in the ___ with \nher, living in ___. Has one sister with fibroids, who \nlives in ___.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \n============================== \nWeight 135.81 kg\nVITALS: Temp 99.3 PO BP 110 / 79 HR 98 RR 18 SAT 94 RA \nGENERAL: AOx3, NAD, obese. \nHEENT: Normocephalic, atraumatic. Pupils equal, round, and\nreactive bilaterally, extraocular muscles intact. Sclera\nanicteric and without injection. Moist mucous membranes, good\ndentition. Oropharynx is clear. \nNECK: Thyroid is normal in size and texture, no nodules. No\ncervical lymphadenopathy. \nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No\nrubs/gallops. No JVD. +friction rub. \nLUNGS: Clear to auscultation bilaterally w/appropriate breath\nsounds appreciated in all fields. No wheezes, rhonchi or rales.\nNo increased work of breathing. \nABDOMEN: Normal bowels sounds, non distended, non-tender to deep\npalpation in all four quadrants. No organomegaly. \nEXTREMITIES: No clubbing, cyanosis, or edema, no sign of\natrophy/hypertrophy. Pulses DP/Radial 2+ bilaterally. \nSKIN: Abdominal incision sites x3 c/d/I with mild tenderness. \nNEUROLOGIC: CN2-12 intact. ___ strength througout. Normal\nsensation.\n\nDISCHARGE PHYSICAL EXAM: \n==============================\nVITALS: 98.7PO, 124/87, 92, 30, 95% Ra \nGENERAL: AOx3, NAD, obese. \nHEENT: PERRL, EOMI, sclera anicteric, MMM.\nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No \nrubs/gallops. No JVD. +friction rub. \nLUNGS: decreased breath sounds throughout but otherwise clear to \nauscultation bilaterally. \nABDOMEN: Normal bowels sounds, non distended, non-tender to\npalpation in all four quadrants. No organomegaly. \nEXTREMITIES: No clubbing, cyanosis, or edema.\nSKIN: hypopigmented patches consistent with vitiligo on the \nface, Abdominal incision sites x3 c/d/I. \nNEUROLOGIC: CN2-12 grossly intact, no focal deficits.\n\n \nPertinent Results:\nADMISSION LABS:\n======================= \n___ 09:57PM BLOOD WBC-18.2* RBC-4.34 Hgb-11.3 Hct-33.7* \nMCV-78* MCH-26.0 MCHC-33.5 RDW-14.4 RDWSD-40.5 Plt ___\n___ 09:57PM BLOOD Neuts-75.2* Lymphs-8.9* Monos-14.9* \nEos-0.1* Baso-0.1 Im ___ AbsNeut-13.68* AbsLymp-1.62 \nAbsMono-2.71* AbsEos-0.01* AbsBaso-0.01\n___ 09:57PM BLOOD Hypochr-1+* Anisocy-NORMAL Poiklo-2+* \nMacrocy-NORMAL Microcy-1+* Polychr-NORMAL Target-2+*\n___ 11:48PM BLOOD ___ PTT-25.5 ___\n___ 09:57PM BLOOD Glucose-120* UreaN-12 Creat-0.9 Na-139 \nK-3.7 Cl-95* HCO3-28 AnGap-16\n___ 09:57PM BLOOD ALT-20 AST-28 AlkPhos-53 TotBili-1.3\n___ 09:57PM BLOOD Lipase-13\n___ 09:57PM BLOOD cTropnT-0.04*\n___ 09:57PM BLOOD Albumin-3.6\n___ 09:57PM BLOOD CRP-258.6*\n___ 10:45PM BLOOD Lactate-1.1\n___ 06:30AM URINE Color-Yellow Appear-Clear Sp ___\n___ 06:30AM URINE Blood-NEG Nitrite-NEG Protein-30* \nGlucose-NEG Ketone-NEG Bilirub-SM* Urobiln-8* pH-6.5 Leuks-MOD*\n___ 06:30AM URINE RBC-1 WBC-5 Bacteri-FEW* Yeast-NONE Epi-1\n\nPERTINENT LABS:\n=======================\n___ 09:57PM BLOOD CRP-258.6*\n___ 09:57PM BLOOD cTropnT-0.04*\n___ 06:10AM BLOOD cTropnT-0.04*\n___ 02:37PM BLOOD cTropnT-0.03*\n\nMICROBIOLOGY:\n=======================\n__________________________________________________________\n___ 10:32 pm Rapid Respiratory Viral Screen & Culture\n Source: Nasopharyngeal swab. \n\n Respiratory Viral Culture (Pending): \n\n Respiratory Viral Antigen Screen (Pending): \n__________________________________________________________\n___ 10:15 pm URINE\n\n URINE CULTURE (Pending): \n__________________________________________________________\n___ 12:15 am BLOOD CULTURE\n\n Blood Culture, Routine (Pending): \n__________________________________________________________\n___ 5:18 pm URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT \nWITH SKIN\n AND/OR GENITAL CONTAMINATION. \n__________________________________________________________\n___ 10:45 pm BLOOD CULTURE\n\n Blood Culture, Routine (Pending): \n__________________________________________________________\n___ 3:55 am URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT \nWITH SKIN\n AND/OR GENITAL CONTAMINATION. \n\nIMAGING:\n=======================\n___: CXR: Bilateral low lung volumes. Mild bilateral\npulmonary vascular congestion. Left retrocardiac opacity likely\nrepresents atelectasis. Probable bilateral small pleural\neffusions. No pneumothorax. The cardiac and mediastinal\nsilhouettes are unchanged. \n \n___ Echo: \nThe left atrial volume index is normal. The estimated right \natrial pressure is ___ mmHg. Mild symmetric left ventricular \nhypertrophy with normal cavity size, and regional/global \nsystolic function (biplane LVEF = 68 %). The estimated cardiac \nindex is normal (>=2.5L/min/m2). Right ventricular chamber size \nand free wall motion are normal. The diameters of aorta at the \nsinus, ascending and arch levels are normal. The aortic valve \nleaflets (3) appear structurally normal with good leaflet \nexcursion and no aortic stenosis or aortic regurgitation. The \nmitral valve appears structurally normal with trivial mitral \nregurgitation. There is mild pulmonary artery systolic \nhypertension. There is a very small circumferential pericardial \neffusion. \n\nIMPRESSION: Suboptimal image quality. Mild symmetric left \nventricular hypertrophy with preserved regional and global \nbiventricular systolic function. Very small inferolateral \npericardial effusion. Mild pulmonary artery systolic \nhypertension. \n\nDISCHARGE LABS:\n=======================\n___ 05:40AM BLOOD WBC-7.6 RBC-3.46* Hgb-9.0* Hct-27.2* \nMCV-79* MCH-26.0 MCHC-33.1 RDW-14.5 RDWSD-41.4 Plt ___\n___ 05:40AM BLOOD Glucose-79 UreaN-15 Creat-0.8 Na-142 \nK-3.7 Cl-102 HCO3-29 AnGap-11\n___ 05:40AM BLOOD Calcium-8.5 Phos-3.6 Mg-2.1\nOTHER BODY FLUID VIRAL, MOLECULAR FluAPCR FluBPCR \n___ 13:30 NEGATIVE NEGATIVE \nSource: Nasopharyngeal swab \n___ 22:32 NEGATIVE NEGATIVE \nSource: Nasopharyngeal swab \n___ 23:35 NEGATIVE NEGATIVE \n\n \nBrief Hospital Course:\n___ year old ___ woman with history of hypertension, \nobstructive sleep apnea, GERD, and recent laparascopic \ncholecystectomy (___) who presented with acute onset chest \npain consistent with pericarditis. She was discharged on \nibuprofen and colchicine for 3 months, per cardiology. \n\nACUTE ISSUES: \n======================= \n# Pericarditis: \nPt presented with acute onset chest pain with history, exam and \nEKG consistent pericarditis, likely secondary to viral illness \ngiven cough and fever. Flu negative x3, CXR without evidence of \npneumonia, UA without evidence of infection. Troponin peaked at \n0.04. TTE ___ showed minimal inferolateral effusion, with no \nsignificant valvular abnormalities or focal wall motion \nabnormalities and ejection fraction 68%. She remained \nhemodynamically stable and was discharged on ibuprofen and \nColchicine for 3 month course for likely viral pericarditis. \n\n#Microcytic Anemia\nLikely secondary to iron deficiency, given she has history of \nthis and only intermittently takes her iron supplementation due \nto constipation. \n\n#Recent cholecystectomy: Cholecystectomy on ___ done \nlaparoscopically with well healing wounds. LFTs unremarkable. \nShe was seen by surgery while in house without concern for \ninfection. \n\nCHRONIC ISSUES:\n=======================\n# Obstructive Sleep Apnea: Pt has APAP at home however does not \nuse it due to comfort issues. \n\n# Depression: Continued home Fluoxetine. \n\n# HTN: Continued home Amlodipine. \n\n# GERD: Continued home Zantac 150 mg BID. \n\n# Seasonal Allergies: Continued home Loratadine and fluticasone \nnasal spray. \n\nTRANSITIONAL ISSUES:\n======================\nDischarge hemoglobin/hematocrit: 9.0 / 27.2\n\n[] Patient was discharged on colchicine with plan for three \nmonth course [Day 1: ___ and ibuprofen as needed. \n[] Patient needs PCP follow up in ___ weeks.\n[] Please obtain follow up EKG in ___ weeks. \n[] Please monitor anemia and encourage adherence to ion \nsupplementation. \n[] Please follow up on pending lab studies: Respiratory viral \nculture, Respiratory viral antigen screening, urine culture, \nblood cultures. \n\n#CODE: Full Code, presumed. \n#CONTACT:\n Next of Kin: ___ \n Relationship: BROTHER \n Phone: ___ \n\n[x]>30 minutes spent on discharge planning and care coordination\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. amLODIPine 10 mg PO DAILY \n2. FLUoxetine 40 mg PO DAILY \n3. Loratadine 10 mg PO DAILY \n4. Ranitidine 150 mg PO BID \n5. Ferrous Sulfate 325 mg PO DAILY \n6. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n7. Ibuprofen 800 mg PO Q8H:PRN AS DIR \n8. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild \n9. Docusate Sodium 100 mg PO BID:PRN constipation \n10. Senna 8.6 mg PO BID:PRN constipation \n\n \nDischarge Medications:\n1. Colchicine 0.6 mg PO BID Duration: 3 Months \nRX *colchicine 0.6 mg 1 tablet(s) by mouth twice a day Disp \n#*172 Tablet Refills:*0 \n2. Ibuprofen 600 mg PO Q8H \nRX *ibuprofen 600 mg 1 tablet(s) by mouth every eight (8) hours \nDisp #*30 Tablet Refills:*0 \n3. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild \n4. amLODIPine 10 mg PO DAILY \n5. Docusate Sodium 100 mg PO BID:PRN constipation \n6. Ferrous Sulfate 325 mg PO DAILY \n7. FLUoxetine 40 mg PO DAILY \n8. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n9. Loratadine 10 mg PO DAILY \n10. Ranitidine 150 mg PO BID \n11. Senna 8.6 mg PO BID:PRN constipation \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary Diagnoses:\nPericarditis\n\nSecondary Diagnoses:\nMicrocytic Anemia\nObstructive Sleep Apnea\nSeasonal Allergies\nDepression\nHypertension\nGERD\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nWHY WAS I ADMITTED?\nYou were admitted to the hospital because you had chest pain.\n\nWHAT HAPPENED WHILE I WAS IN THE HOSPITAL?\n-You were diagnosed with a condition called pericarditis, which \nis caused by inflammation of the lining around your heart.\n- You had an echo (an ultrasound of your heart) which showed \nyour heart is pumping normally and your heart valves are normal. \n\n- The cardiologists (heart specialists) evaluated you and \nrecommended medicines called ibuprofen and colchicine to treat \nyour pericarditis. \n- The surgeons saw you. They felt you were recovering well from \nyour gallbladder surgery earlier this week.\n\nWHAT SHOULD I DO WHEN I GO HOME?\n-Continue to take all home medications as prescribed. \n-Follow up with your primary care doctor within ___ weeks. \n-Please return to the emergency room if you develop worsening \nchest pain, or any other symptoms of concern. \n\nIt was a pleasure caring for you, and we wish you all the best.\n\nSincerely,\nYour ___ team\n\n \nFollowup Instructions:\n___\n"
] | Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] yo woman originally from [MASKED] with PMHx pos for hypertension, asthma, OSA (has APAP, doesn't use), obesity, GERD, depression, presenting with sx concerning for pericarditis. She recently had a laparascopic cholecystectomy on [MASKED]. She is noted to have tolerated the procedure well, and only has mild residual tenderness surrounding the central incision site. She reports acute onset of chest pain in the morning 2 days ago, with gradual progression to [MASKED] severity when presenting to the ED. Pain was located in the midsternal region and radiated up towards clavicles. Pain worse with inspiration and lying flat, and improves with leaning forwards. Also has mild-mod dysp, no pain while swallowing. She denies fevers, chills, nausea, vomiting, abdominal pain, diarrhea, or dysuria. She endorses cough sx, feeling light-headed recently, nocturia over months, and bilateral knee arthritis. Her grandchildren have recently been sick with GI illness. In the ED, initial VS: Tmax in ED 101.4 HR 99 107 128/80 16 100% RA Exam notable for: rub on cardiac auscultation, surgical site from whole c/d/I. Cardiology and Surgery were consulted. While in ED Pt given: Acetaminophen 1000 mg Morphine Sulfate 4 mg Ondansetron 4 mg Ibuprofen 600 mg Colchicine .6 mg amLODIPine 10 mg FLUoxetine 40 mg IVF NS Colchicine .6 mg On the floor, pt endorses improvement in chest pain symptoms s/p beginning treatment. She denies feeling faint. Denies fever, chills, abdominal pain, nausea, vomiting, diarrhea, dysuria. Complete ROS obtained and is otherwise negative. Past Medical History: PAST MEDICAL HISTORY: -obesity -seasonal allergies -gastroesophageal reflux disease -fibroid uterus -hypertension -anxiety -depression -asthma -obstructive sleep anemia -Fe deficiency anemia Past Surgical History: -tubal ligation -breast lumpectomy -s/p fibroid embolization -s/p laparascopic cholecystectomy Social History: [MASKED] Family History: Mother with DM and breast CA, living in [MASKED] Father, deceased [MASKED], patient does not know much about her biological father. Has 6 sisters, 3 brothers. Only one sister in the [MASKED] with her, living in [MASKED]. Has one sister with fibroids, who lives in [MASKED]. Physical Exam: ADMISSION PHYSICAL EXAM: ============================== Weight 135.81 kg VITALS: Temp 99.3 PO BP 110 / 79 HR 98 RR 18 SAT 94 RA GENERAL: AOx3, NAD, obese. HEENT: Normocephalic, atraumatic. Pupils equal, round, and reactive bilaterally, extraocular muscles intact. Sclera anicteric and without injection. Moist mucous membranes, good dentition. Oropharynx is clear. NECK: Thyroid is normal in size and texture, no nodules. No cervical lymphadenopathy. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No rubs/gallops. No JVD. +friction rub. LUNGS: Clear to auscultation bilaterally w/appropriate breath sounds appreciated in all fields. No wheezes, rhonchi or rales. No increased work of breathing. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES: No clubbing, cyanosis, or edema, no sign of atrophy/hypertrophy. Pulses DP/Radial 2+ bilaterally. SKIN: Abdominal incision sites x3 c/d/I with mild tenderness. NEUROLOGIC: CN2-12 intact. [MASKED] strength througout. Normal sensation. DISCHARGE PHYSICAL EXAM: ============================== VITALS: 98.7PO, 124/87, 92, 30, 95% Ra GENERAL: AOx3, NAD, obese. HEENT: PERRL, EOMI, sclera anicteric, MMM. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No rubs/gallops. No JVD. +friction rub. LUNGS: decreased breath sounds throughout but otherwise clear to auscultation bilaterally. ABDOMEN: Normal bowels sounds, non distended, non-tender to palpation in all four quadrants. No organomegaly. EXTREMITIES: No clubbing, cyanosis, or edema. SKIN: hypopigmented patches consistent with vitiligo on the face, Abdominal incision sites x3 c/d/I. NEUROLOGIC: CN2-12 grossly intact, no focal deficits. Pertinent Results: ADMISSION LABS: ======================= [MASKED] 09:57PM BLOOD WBC-18.2* RBC-4.34 Hgb-11.3 Hct-33.7* MCV-78* MCH-26.0 MCHC-33.5 RDW-14.4 RDWSD-40.5 Plt [MASKED] [MASKED] 09:57PM BLOOD Neuts-75.2* Lymphs-8.9* Monos-14.9* Eos-0.1* Baso-0.1 Im [MASKED] AbsNeut-13.68* AbsLymp-1.62 AbsMono-2.71* AbsEos-0.01* AbsBaso-0.01 [MASKED] 09:57PM BLOOD Hypochr-1+* Anisocy-NORMAL Poiklo-2+* Macrocy-NORMAL Microcy-1+* Polychr-NORMAL Target-2+* [MASKED] 11:48PM BLOOD [MASKED] PTT-25.5 [MASKED] [MASKED] 09:57PM BLOOD Glucose-120* UreaN-12 Creat-0.9 Na-139 K-3.7 Cl-95* HCO3-28 AnGap-16 [MASKED] 09:57PM BLOOD ALT-20 AST-28 AlkPhos-53 TotBili-1.3 [MASKED] 09:57PM BLOOD Lipase-13 [MASKED] 09:57PM BLOOD cTropnT-0.04* [MASKED] 09:57PM BLOOD Albumin-3.6 [MASKED] 09:57PM BLOOD CRP-258.6* [MASKED] 10:45PM BLOOD Lactate-1.1 [MASKED] 06:30AM URINE Color-Yellow Appear-Clear Sp [MASKED] [MASKED] 06:30AM URINE Blood-NEG Nitrite-NEG Protein-30* Glucose-NEG Ketone-NEG Bilirub-SM* Urobiln-8* pH-6.5 Leuks-MOD* [MASKED] 06:30AM URINE RBC-1 WBC-5 Bacteri-FEW* Yeast-NONE Epi-1 PERTINENT LABS: ======================= [MASKED] 09:57PM BLOOD CRP-258.6* [MASKED] 09:57PM BLOOD cTropnT-0.04* [MASKED] 06:10AM BLOOD cTropnT-0.04* [MASKED] 02:37PM BLOOD cTropnT-0.03* MICROBIOLOGY: ======================= [MASKED] [MASKED] 10:32 pm Rapid Respiratory Viral Screen & Culture Source: Nasopharyngeal swab. Respiratory Viral Culture (Pending): Respiratory Viral Antigen Screen (Pending): [MASKED] [MASKED] 10:15 pm URINE URINE CULTURE (Pending): [MASKED] [MASKED] 12:15 am BLOOD CULTURE Blood Culture, Routine (Pending): [MASKED] [MASKED] 5:18 pm URINE **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. [MASKED] [MASKED] 10:45 pm BLOOD CULTURE Blood Culture, Routine (Pending): [MASKED] [MASKED] 3:55 am URINE **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. IMAGING: ======================= [MASKED]: CXR: Bilateral low lung volumes. Mild bilateral pulmonary vascular congestion. Left retrocardiac opacity likely represents atelectasis. Probable bilateral small pleural effusions. No pneumothorax. The cardiac and mediastinal silhouettes are unchanged. [MASKED] Echo: The left atrial volume index is normal. The estimated right atrial pressure is [MASKED] mmHg. Mild symmetric left ventricular hypertrophy with normal cavity size, and regional/global systolic function (biplane LVEF = 68 %). The estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is mild pulmonary artery systolic hypertension. There is a very small circumferential pericardial effusion. IMPRESSION: Suboptimal image quality. Mild symmetric left ventricular hypertrophy with preserved regional and global biventricular systolic function. Very small inferolateral pericardial effusion. Mild pulmonary artery systolic hypertension. DISCHARGE LABS: ======================= [MASKED] 05:40AM BLOOD WBC-7.6 RBC-3.46* Hgb-9.0* Hct-27.2* MCV-79* MCH-26.0 MCHC-33.1 RDW-14.5 RDWSD-41.4 Plt [MASKED] [MASKED] 05:40AM BLOOD Glucose-79 UreaN-15 Creat-0.8 Na-142 K-3.7 Cl-102 HCO3-29 AnGap-11 [MASKED] 05:40AM BLOOD Calcium-8.5 Phos-3.6 Mg-2.1 OTHER BODY FLUID VIRAL, MOLECULAR FluAPCR FluBPCR [MASKED] 13:30 NEGATIVE NEGATIVE Source: Nasopharyngeal swab [MASKED] 22:32 NEGATIVE NEGATIVE Source: Nasopharyngeal swab [MASKED] 23:35 NEGATIVE NEGATIVE Brief Hospital Course: [MASKED] year old [MASKED] woman with history of hypertension, obstructive sleep apnea, GERD, and recent laparascopic cholecystectomy ([MASKED]) who presented with acute onset chest pain consistent with pericarditis. She was discharged on ibuprofen and colchicine for 3 months, per cardiology. ACUTE ISSUES: ======================= # Pericarditis: Pt presented with acute onset chest pain with history, exam and EKG consistent pericarditis, likely secondary to viral illness given cough and fever. Flu negative x3, CXR without evidence of pneumonia, UA without evidence of infection. Troponin peaked at 0.04. TTE [MASKED] showed minimal inferolateral effusion, with no significant valvular abnormalities or focal wall motion abnormalities and ejection fraction 68%. She remained hemodynamically stable and was discharged on ibuprofen and Colchicine for 3 month course for likely viral pericarditis. #Microcytic Anemia Likely secondary to iron deficiency, given she has history of this and only intermittently takes her iron supplementation due to constipation. #Recent cholecystectomy: Cholecystectomy on [MASKED] done laparoscopically with well healing wounds. LFTs unremarkable. She was seen by surgery while in house without concern for infection. CHRONIC ISSUES: ======================= # Obstructive Sleep Apnea: Pt has APAP at home however does not use it due to comfort issues. # Depression: Continued home Fluoxetine. # HTN: Continued home Amlodipine. # GERD: Continued home Zantac 150 mg BID. # Seasonal Allergies: Continued home Loratadine and fluticasone nasal spray. TRANSITIONAL ISSUES: ====================== Discharge hemoglobin/hematocrit: 9.0 / 27.2 [] Patient was discharged on colchicine with plan for three month course [Day 1: [MASKED] and ibuprofen as needed. [] Patient needs PCP follow up in [MASKED] weeks. [] Please obtain follow up EKG in [MASKED] weeks. [] Please monitor anemia and encourage adherence to ion supplementation. [] Please follow up on pending lab studies: Respiratory viral culture, Respiratory viral antigen screening, urine culture, blood cultures. #CODE: Full Code, presumed. #CONTACT: Next of Kin: [MASKED] Relationship: BROTHER Phone: [MASKED] [x]>30 minutes spent on discharge planning and care coordination Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. FLUoxetine 40 mg PO DAILY 3. Loratadine 10 mg PO DAILY 4. Ranitidine 150 mg PO BID 5. Ferrous Sulfate 325 mg PO DAILY 6. Fluticasone Propionate NASAL 2 SPRY NU DAILY 7. Ibuprofen 800 mg PO Q8H:PRN AS DIR 8. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild 9. Docusate Sodium 100 mg PO BID:PRN constipation 10. Senna 8.6 mg PO BID:PRN constipation Discharge Medications: 1. Colchicine 0.6 mg PO BID Duration: 3 Months RX *colchicine 0.6 mg 1 tablet(s) by mouth twice a day Disp #*172 Tablet Refills:*0 2. Ibuprofen 600 mg PO Q8H RX *ibuprofen 600 mg 1 tablet(s) by mouth every eight (8) hours Disp #*30 Tablet Refills:*0 3. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild 4. amLODIPine 10 mg PO DAILY 5. Docusate Sodium 100 mg PO BID:PRN constipation 6. Ferrous Sulfate 325 mg PO DAILY 7. FLUoxetine 40 mg PO DAILY 8. Fluticasone Propionate NASAL 2 SPRY NU DAILY 9. Loratadine 10 mg PO DAILY 10. Ranitidine 150 mg PO BID 11. Senna 8.6 mg PO BID:PRN constipation Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: Pericarditis Secondary Diagnoses: Microcytic Anemia Obstructive Sleep Apnea Seasonal Allergies Depression Hypertension GERD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], WHY WAS I ADMITTED? You were admitted to the hospital because you had chest pain. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? -You were diagnosed with a condition called pericarditis, which is caused by inflammation of the lining around your heart. - You had an echo (an ultrasound of your heart) which showed your heart is pumping normally and your heart valves are normal. - The cardiologists (heart specialists) evaluated you and recommended medicines called ibuprofen and colchicine to treat your pericarditis. - The surgeons saw you. They felt you were recovering well from your gallbladder surgery earlier this week. WHAT SHOULD I DO WHEN I GO HOME? -Continue to take all home medications as prescribed. -Follow up with your primary care doctor within [MASKED] weeks. -Please return to the emergency room if you develop worsening chest pain, or any other symptoms of concern. It was a pleasure caring for you, and we wish you all the best. Sincerely, Your [MASKED] team Followup Instructions: [MASKED] | [
"I301",
"Z6843",
"B9789",
"D509",
"J302",
"G4733",
"F329",
"I10",
"K219",
"E669",
"F419",
"L988"
] | [
"I301: Infective pericarditis",
"Z6843: Body mass index [BMI] 50.0-59.9, adult",
"B9789: Other viral agents as the cause of diseases classified elsewhere",
"D509: Iron deficiency anemia, unspecified",
"J302: Other seasonal allergic rhinitis",
"G4733: Obstructive sleep apnea (adult) (pediatric)",
"F329: Major depressive disorder, single episode, unspecified",
"I10: Essential (primary) hypertension",
"K219: Gastro-esophageal reflux disease without esophagitis",
"E669: Obesity, unspecified",
"F419: Anxiety disorder, unspecified",
"L988: Other specified disorders of the skin and subcutaneous tissue"
] | [
"D509",
"G4733",
"F329",
"I10",
"K219",
"E669",
"F419"
] | [] |
15,315,015 | 27,569,778 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: NEUROSURGERY\n \nAllergies: \nBactrim / Iodinated Contrast Media - IV Dye / erythromycin base \n/ Cipro / Flexeril / azithromycin / codeine\n \nAttending: ___.\n \nChief Complaint:\nAVM\n \nMajor Surgical or Invasive Procedure:\n___- Right frontal craniotomy for resection of AVM\n___- Diagnostic cerebral angiogram\n\n \nHistory of Present Illness:\n___ year-old female, who underwent a left sided craniotomy and \naneurysm clipping in ___. She was recently seen for a left \nsided weakness and underwent MRI imaging of the brain and spine, \nwhich demonstrated a right sided venous anomaly. Diagnostic \nangiogram confirmed AVM. She presents this admission for \nelective right craniotomy for resection of AVM. \n \nPast Medical History:\nHypertension\nGERD\nCOPD\nL sided craniotomy with aneurysm clipping ___\n___\n \nSocial History:\n___\nFamily History:\nSignificant for pulmonary embolism and diabetes.\n\n \nPhysical Exam:\nON DISCHARGE: \n=============\n***\nOpens eyes: [X]spontaneous [ ]to voice [ ]to noxious\n\nOrientation: [X]Person [X]Place [X]Time\n\nFollows commands: [ ]Simple [X]Complex [ ]None\n\nPupils: Right 3mm/briskly reactive Left 3mm/briskly reactive\n\nEOM: [X]Full [ ]Restricted\n\nFace Symmetric: [X]Yes [ ]NoTongue Midline: [X]Yes [ ]No\n\nPronator Drift [ ]Yes [X]No Speech Fluent: [X]Yes [ ]No\n\nComprehension intact [X]Yes [ ]No\n\nMotor:\nTrapDeltoidBicepTricepGrip\n___\n\nIPQuadHamATEHLGast\n___\nLeft4+4+4+4+4+4+\n\n[X]Sensation intact to light touch\n\nWound: Right frontal crani\n[X]Clean, dry, intact \n[X]Monocryl (dissolvable) sutures\n\n \nPertinent Results:\nPlease see OMR for pertinent lab and imaging results. \n \nBrief Hospital Course:\n#AVM resection\nPatient presented to ___ for elective right craniotomy for \nresection of AVM. Please see dedicated operative note for \nfurther detail. OR case was uncomplicated. Post-operatively she \nunderwent diagnostic cerebral angiogram that was negative for \nresidual AVM. Patient was extubated and recovered from \nanesthesia in the PACU. On POD 1, patient was lethargic and \nslightly confused; NCHCT was obtained that showed a small amount \nof hematoma in the resection cavity and expected pneumocephalus. \nKeppra dose was increased to 750mg BID for concern of seizure \nactivity. Patient's post-operative pain was managed with PRN \nanalgesics. Patient remained neurologically intact throughout \nthe remainder of her hospitalization. \n\n#Respiratory insufficiency\nPatient has a history of COPD and was requiring supplemental O2 \non POD 1. She was in no respiratory distress. She was started on \nduonebs and encouraged to ambulate and use incentive spirometry. \nPatient was able to wean off supplemental O2 prior to discharge \nand was tolerating room air. \n\n#Hyperglycemia\nBlood sugar was noted to be 419 while in the PACU and she \nreceived 18u Lispro insulin. Repeat blood sugar was 375 and \n___ was consulted for further management. Patient was \ninitiated on insulin gtt with good effect. Patient was weaned \noff insulin gtt overnight into POD 1 and ___ made \nrecommendations for adding lantus and RISS. ___ continued to \nfollow throughout the patient's hospitalization and adjusted \ninsulin as needed. Patient's blood sugars continued to be \nintermittently elevated on ___ and she was restarted on her \nhome Glipizide on ___ as she was tolerating PO diet. Overnight \non ___ patient began to complain of diaphoresis and dizziness, \nher blood sugar was checks and she was noted to have a blood \nsugar of 47. Patient was given glucose at that time and her \nsymptoms resolved. ___ team was made aware of this event and \nstated that patient required additional close monitoring for \nblood sugars and some medication related changes were made on \n___. She was transitioned back to oral hypoglycemic (Januvia \nand Glipizide) at discharge. Patient was discharged with close \nfollow up with ___ continued management. \n\n#Discharge Planning\n___ evaluated the patient and recommended initially on ___ to \nbe discharged to home with the assistance of her daughter in ___ \nmore ___ visits. Patient was re-evaluated on ___ requesting and \nadditional visit prior to discharge. She was re-evaluated on \n___ and she was discharged to her daughters house with ___ \nservices on ___.\n \nMedications on Admission:\n1. Atorvastatin 40 mg PO QPM \n2. BuPROPion XL (Once Daily) 150 mg PO DAILY \n3. Calcium Carbonate 1000 mg PO DAILY:PRN GERD \n4. Cyclobenzaprine 10 mg PO HS \n5. Gabapentin 300 mg PO QHS \n6. GlipiZIDE 5 mg PO BID \n7. Januvia (SITagliptin) 100 mg oral DAILY \n8. Pantoprazole 40 mg PO Q24H \n9. Senna 17.2 mg PO QHS:PRN Constipation - First Line \n10. TraZODone 50 mg PO QHS:PRN insomnia \n11. HELD- MetFORMIN XR (Glucophage XR) 500 mg PO DAILY This \nmedication was held. Do not restart MetFORMIN XR (Glucophage XR) \n\nuntil you see your primary care doctor\n\n \nDischarge Medications:\n1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild \n2. Docusate Sodium 100 mg PO BID \n3. FreeStyle Lancets (lancets) 28 gauge miscellaneous QID \nOK to substitute \nRX *lancets [FreeStyle Lancets] 28 gauge to use with glucometer \nfour times a day Disp #*30 Each Refills:*1 \n4. FreeStyle Lite Meter (blood-glucose meter) 1 meter \nmiscellaneous DAILY \nOK to substitute \nRX *blood-glucose meter [FreeStyle Lite Meter] use to check \nblood sugar four times a day Disp #*1 Kit Refills:*0 \n5. FreeStyle Lite Strips (blood sugar diagnostic) \nmiscellaneous QID \nOK to substitute \nRX *blood sugar diagnostic [FreeStyle Lite Strips] to use with \nglucometer four times a day Disp #*30 Strip Refills:*1 \n6. GlipiZIDE 5 mg PO BID \nRX *glipizide 5 mg 1 tablet(s) by mouth twice a day Disp #*60 \nTablet Refills:*0 \n7. Januvia (SITagliptin) 100 mg oral DAILY \nRX *sitagliptin [Januvia] 100 mg 1 tablet(s) by mouth once a day \nDisp #*30 Tablet Refills:*0 \n8. LevETIRAcetam 750 mg PO BID \nRX *levetiracetam 750 mg 1 tablet(s) by mouth twice a day Disp \n#*60 Tablet Refills:*0 \n9. Metoclopramide 5 mg PO TID prior to meals \nRX *metoclopramide HCl 5 mg 1 mg by mouth three times daily as \nneeded Disp #*21 Tablet Refills:*0 \n10. Nicotine Patch 14 mg/day TD DAILY \nRX *nicotine 14 mg/24 hour Apply daily for 12 hours once a day \nDisp #*7 Patch Refills:*0 \n11. Atorvastatin 40 mg PO QPM \n12. BuPROPion XL (Once Daily) 150 mg PO DAILY \n13. Gabapentin 300 mg PO QHS \n14. Pantoprazole 40 mg PO Q24H \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nArteriovenous Malformation\nCOPD\nDiabetes\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDischarge Instructions\nCraniotomy for resection of AVM\nDr. ___\n\n___\n You underwent surgery to remove an Arteriovenous Malformation \n(AVM) from your brain. \n Please keep your incision clean and dry. Your incision is \nclosed with dissolvable sutures and dermabond. \n You may shower at this time but keep your incision dry, if \nyour incision becomes wet please pat dry. Try not to rub/scrub \nyour incision.\n It is best to keep your incision open to air but it is ok to \ncover it when outside. \n Call your surgeon if there are any signs of infection like \nredness, fever, or drainage. \n\nActivity\n We recommend that you avoid heavy lifting, running, climbing, \nor other strenuous exercise until your follow-up appointment. \nThis is also to prevent bleeding from your groin.\n You make take leisurely walks and slowly increase your \nactivity at your own pace once you are symptom free at rest. \n___ try to do too much all at once.\n Do not go swimming or submerge yourself in water until your \nsutures are removed.\n You make take a shower.\n No driving while taking any narcotic or sedating medication. \n If you experienced a seizure while admitted, you are NOT \nallowed to drive by law. \n No contact sports until cleared by your neurosurgeon. You \nshould avoid contact sports for 6 months. \n\nMedications\n Please do NOT take any blood thinning medication (Aspirin, \nIbuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. \n You have been discharged on Keppra (Levetiracetam). This \nmedication helps to prevent seizures. Please continue this \nmedication as indicated on your discharge instruction. It is \nimportant that you take this medication consistently and on \ntime. \n You may use Acetaminophen (Tylenol) for minor discomfort if \nyou are not otherwise restricted from taking this medication.\n You were taking Metformin (Glucophage) however this was \nstopped at your last admission to the hospital. Please continue \nto hold this medication. ___ Diabetes helped with your \ndiabetes management while inpatient. You are being discharged \nhome on Januvia 100mg once daily and Glipizide 5mg BID. Please, \ncheck blood sugars daily while at home. Follow-up with either \nyour PCP or the ___ Diabetes Clinic in 1 week. \n\nCare of the Puncture Site (Right groin):\n Keep the site clean with soap and water and dry it carefully.\n You may use a band-aid if you wish however not necessary.\n\nWhat You ___ Experience:\n Mild tenderness and bruising at the puncture site (groin).\n You may experience headaches and incisional pain. \n You may also experience some post-operative swelling around \nyour face and eyes. This is normal after surgery and most \nnoticeable on the second and third day of surgery. You apply \nice or a cool or warm washcloth to your eyes to help with the \nswelling. The swelling will be its worse in the morning after \nlaying flat from sleeping but decrease when up. \n You may experience soreness with chewing. This is normal from \nthe surgery and will improve with time. Softer foods may be \neasier during this time. \n Feeling more tired or restlessness is also common.\n Constipation is common. Be sure to drink plenty of fluids and \neat a high-fiber diet. If you are taking narcotics (prescription \npain medications), try an over-the-counter stool softener.\n\nWhen to Call Your Doctor at ___ for:\n Severe pain, swelling, redness or drainage from the incision \nsite. \n Severe pain, swelling, redness or drainage from the puncture \nsite. \n Fever greater than 101.5 degrees Fahrenheit\n Nausea and/or vomiting\n Extreme sleepiness and not being able to stay awake\n Severe headaches not relieved by pain relievers\n Seizures\n Any new problems with your vision or ability to speak\n Weakness or changes in sensation in your face, arms, or leg\n \nCall ___ and go to the nearest Emergency Room if you experience \nany of the following:\n Sudden numbness or weakness in the face, arm, or leg\n Sudden confusion or trouble speaking or understanding\n Sudden trouble walking, dizziness, or loss of balance or \ncoordination\n Sudden severe headaches with no known reason\n Signs/symptoms of hypoglycemia \n\n \nFollowup Instructions:\n___\n"
] | Allergies: Bactrim / Iodinated Contrast Media - IV Dye / erythromycin base / Cipro / Flexeril / azithromycin / codeine Chief Complaint: AVM Major Surgical or Invasive Procedure: [MASKED]- Right frontal craniotomy for resection of AVM [MASKED]- Diagnostic cerebral angiogram History of Present Illness: [MASKED] year-old female, who underwent a left sided craniotomy and aneurysm clipping in [MASKED]. She was recently seen for a left sided weakness and underwent MRI imaging of the brain and spine, which demonstrated a right sided venous anomaly. Diagnostic angiogram confirmed AVM. She presents this admission for elective right craniotomy for resection of AVM. Past Medical History: Hypertension GERD COPD L sided craniotomy with aneurysm clipping [MASKED] [MASKED] Social History: [MASKED] Family History: Significant for pulmonary embolism and diabetes. Physical Exam: ON DISCHARGE: ============= *** Opens eyes: [X]spontaneous [ ]to voice [ ]to noxious Orientation: [X]Person [X]Place [X]Time Follows commands: [ ]Simple [X]Complex [ ]None Pupils: Right 3mm/briskly reactive Left 3mm/briskly reactive 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 [MASKED] IPQuadHamATEHLGast [MASKED] Left4+4+4+4+4+4+ [X]Sensation intact to light touch Wound: Right frontal crani [X]Clean, dry, intact [X]Monocryl (dissolvable) sutures Pertinent Results: Please see OMR for pertinent lab and imaging results. Brief Hospital Course: #AVM resection Patient presented to [MASKED] for elective right craniotomy for resection of AVM. Please see dedicated operative note for further detail. OR case was uncomplicated. Post-operatively she underwent diagnostic cerebral angiogram that was negative for residual AVM. Patient was extubated and recovered from anesthesia in the PACU. On POD 1, patient was lethargic and slightly confused; NCHCT was obtained that showed a small amount of hematoma in the resection cavity and expected pneumocephalus. Keppra dose was increased to 750mg BID for concern of seizure activity. Patient's post-operative pain was managed with PRN analgesics. Patient remained neurologically intact throughout the remainder of her hospitalization. #Respiratory insufficiency Patient has a history of COPD and was requiring supplemental O2 on POD 1. She was in no respiratory distress. She was started on duonebs and encouraged to ambulate and use incentive spirometry. Patient was able to wean off supplemental O2 prior to discharge and was tolerating room air. #Hyperglycemia Blood sugar was noted to be 419 while in the PACU and she received 18u Lispro insulin. Repeat blood sugar was 375 and [MASKED] was consulted for further management. Patient was initiated on insulin gtt with good effect. Patient was weaned off insulin gtt overnight into POD 1 and [MASKED] made recommendations for adding lantus and RISS. [MASKED] continued to follow throughout the patient's hospitalization and adjusted insulin as needed. Patient's blood sugars continued to be intermittently elevated on [MASKED] and she was restarted on her home Glipizide on [MASKED] as she was tolerating PO diet. Overnight on [MASKED] patient began to complain of diaphoresis and dizziness, her blood sugar was checks and she was noted to have a blood sugar of 47. Patient was given glucose at that time and her symptoms resolved. [MASKED] team was made aware of this event and stated that patient required additional close monitoring for blood sugars and some medication related changes were made on [MASKED]. She was transitioned back to oral hypoglycemic (Januvia and Glipizide) at discharge. Patient was discharged with close follow up with [MASKED] continued management. #Discharge Planning [MASKED] evaluated the patient and recommended initially on [MASKED] to be discharged to home with the assistance of her daughter in [MASKED] more [MASKED] visits. Patient was re-evaluated on [MASKED] requesting and additional visit prior to discharge. She was re-evaluated on [MASKED] and she was discharged to her daughters house with [MASKED] services on [MASKED]. Medications on Admission: 1. Atorvastatin 40 mg PO QPM 2. BuPROPion XL (Once Daily) 150 mg PO DAILY 3. Calcium Carbonate 1000 mg PO DAILY:PRN GERD 4. Cyclobenzaprine 10 mg PO HS 5. Gabapentin 300 mg PO QHS 6. GlipiZIDE 5 mg PO BID 7. Januvia (SITagliptin) 100 mg oral DAILY 8. Pantoprazole 40 mg PO Q24H 9. Senna 17.2 mg PO QHS:PRN Constipation - First Line 10. TraZODone 50 mg PO QHS:PRN insomnia 11. HELD- MetFORMIN XR (Glucophage XR) 500 mg PO DAILY This medication was held. Do not restart MetFORMIN XR (Glucophage XR) until you see your primary care doctor Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild 2. Docusate Sodium 100 mg PO BID 3. FreeStyle Lancets (lancets) 28 gauge miscellaneous QID OK to substitute RX *lancets [FreeStyle Lancets] 28 gauge to use with glucometer four times a day Disp #*30 Each Refills:*1 4. FreeStyle Lite Meter (blood-glucose meter) 1 meter miscellaneous DAILY OK to substitute RX *blood-glucose meter [FreeStyle Lite Meter] use to check blood sugar four times a day Disp #*1 Kit Refills:*0 5. FreeStyle Lite Strips (blood sugar diagnostic) miscellaneous QID OK to substitute RX *blood sugar diagnostic [FreeStyle Lite Strips] to use with glucometer four times a day Disp #*30 Strip Refills:*1 6. GlipiZIDE 5 mg PO BID RX *glipizide 5 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 7. Januvia (SITagliptin) 100 mg oral DAILY RX *sitagliptin [Januvia] 100 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 8. LevETIRAcetam 750 mg PO BID RX *levetiracetam 750 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 9. Metoclopramide 5 mg PO TID prior to meals RX *metoclopramide HCl 5 mg 1 mg by mouth three times daily as needed Disp #*21 Tablet Refills:*0 10. Nicotine Patch 14 mg/day TD DAILY RX *nicotine 14 mg/24 hour Apply daily for 12 hours once a day Disp #*7 Patch Refills:*0 11. Atorvastatin 40 mg PO QPM 12. BuPROPion XL (Once Daily) 150 mg PO DAILY 13. Gabapentin 300 mg PO QHS 14. Pantoprazole 40 mg PO Q24H Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Arteriovenous Malformation COPD Diabetes Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Discharge Instructions Craniotomy for resection of AVM Dr. [MASKED] [MASKED] You underwent surgery to remove an Arteriovenous Malformation (AVM) from your brain. Please keep your incision clean and dry. Your incision is closed with dissolvable sutures and dermabond. You may shower at this time but keep your incision dry, if your incision becomes wet please pat dry. Try not to rub/scrub your incision. It is best to keep your incision open to air but it is ok to cover it when outside. Call your surgeon if there are any signs of infection like redness, fever, or drainage. Activity We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. This is also to prevent bleeding from your groin. You make take leisurely walks and slowly increase your activity at your own pace once you are symptom free at rest. [MASKED] try to do too much all at once. Do not go swimming or submerge yourself in water until your sutures are removed. You make take a shower. No driving while taking any narcotic or sedating medication. If you experienced a seizure while admitted, you are NOT allowed to drive by law. No contact sports until cleared by your neurosurgeon. You should avoid contact sports for 6 months. Medications Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. You have been discharged on Keppra (Levetiracetam). This medication helps to prevent seizures. Please continue this medication as indicated on your discharge instruction. It is important that you take this medication consistently and on time. You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. You were taking Metformin (Glucophage) however this was stopped at your last admission to the hospital. Please continue to hold this medication. [MASKED] Diabetes helped with your diabetes management while inpatient. You are being discharged home on Januvia 100mg once daily and Glipizide 5mg BID. Please, check blood sugars daily while at home. Follow-up with either your PCP or the [MASKED] Diabetes Clinic in 1 week. Care of the Puncture Site (Right groin): Keep the site clean with soap and water and dry it carefully. You may use a band-aid if you wish however not necessary. What You [MASKED] Experience: Mild tenderness and bruising at the puncture site (groin). You may experience headaches and incisional pain. You may also experience some post-operative swelling around your face and eyes. This is normal after surgery and most noticeable on the second and third day of surgery. You apply ice or a cool or warm washcloth to your eyes to help with the swelling. The swelling will be its worse in the morning after laying flat from sleeping but decrease when up. You may experience soreness with chewing. This is normal from the surgery and will improve with time. Softer foods may be easier during this time. Feeling more tired or restlessness is also common. Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. If you are taking narcotics (prescription pain medications), try an over-the-counter stool softener. When to Call Your Doctor at [MASKED] for: Severe pain, swelling, redness or drainage from the incision site. Severe pain, swelling, redness or drainage from the puncture 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 [MASKED] 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 Signs/symptoms of hypoglycemia Followup Instructions: [MASKED] | [
"Q282",
"J441",
"E1165",
"F17210",
"I10",
"E785",
"K219",
"Z7984",
"Z86718",
"Z86711"
] | [
"Q282: Arteriovenous malformation of cerebral vessels",
"J441: Chronic obstructive pulmonary disease with (acute) exacerbation",
"E1165: Type 2 diabetes mellitus with hyperglycemia",
"F17210: Nicotine dependence, cigarettes, uncomplicated",
"I10: Essential (primary) hypertension",
"E785: Hyperlipidemia, unspecified",
"K219: Gastro-esophageal reflux disease without esophagitis",
"Z7984: Long term (current) use of oral hypoglycemic drugs",
"Z86718: Personal history of other venous thrombosis and embolism",
"Z86711: Personal history of pulmonary embolism"
] | [
"E1165",
"F17210",
"I10",
"E785",
"K219",
"Z86718"
] | [] |
14,993,494 | 25,076,564 | [
" \nName: ___. Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nTetracycline / Daypro / Tramadol / Hydrocodone / bee venom \nprotein (honey bee) / hydrocodone-homatropine\n \nAttending: ___\n \nChief Complaint:\nfever, dyspnea\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\n___ with hx of RA-ILD on 4L home O2 and chronic prednisone, mild \npHTN, HFpEF, presents to the ED with fever and respiratory \ndistress. \n\nPatient states for the past ___ days she's been experiencing \nworsening shortness of breath and dyspnea on exertion, such that \nshe has had episodes of incontinence from being unable to make \nit to the bathroom on time. She's noted that her home O2 sats \nwhich typically range in low ___ at rest and ___ with exertion \nhave been in the ___ at rest and ___ during exertion. She's \nadditionally had chills with shaking though with no known fevers \nover the past ___ days. Has a new cough for the past couple of \nweeks with sputum production (unknown color as swallows it back \ndown).\n\nEarlier today she went to her scheduled palliative care \nappointment and was still feeling well. Later in the evening she \ndeveloped persistently worsening shortness of breath and her \ndaughter called EMS. When EMS arrived they found the patient \nhypoxic to ___ despite supplemental oxygen, and a tympanic \nthermometer reading \"HIGH.\" Upon arrival to the ED the patient \nstates she feels cold and has shortness of breath. \n\nIn the ED, \n\nInitial Vitals: T101, HR 132, BP 160/81, RR 20, 100% on \nnonrebreather \n\nExam: tachycardic, mild respiratory distress, coarse breath \nsounds bilaterally, b/l peripheral edema \n\nLabs: WBC 16 (76.4% PMNs), H/H ___, Plt 257 Na 139, K 4.3, Cl \n95, Bicarb 28, BUN 11, Cr 0.7 LFTs WNL proBNP 372, Trop <0.01 \nlactate 1.6 VBG 7.44/48/34 Flu A/B negative \n\nImaging: CXR - no read. On comparison to CXR from ___ no \nobvious changes. No pleural effusion, obvious consolidations, or \nsigns of gross pulmonary edema. \n\nBedside ultrasound: no pericardial effusion, unclear if \npulmonary edema\n\nConsults: none\n\nInterventions: Cefepime/azithromycin, hydrocort 100mg, home MMF \n1500mg \n\nVS Prior to Transfer: HR 129, BP 131/57, RR 31, 93% 7L NC \n\nOn arrival to the ICU, she reports significant improvement in \nher subjective dyspnea. She continues to have a productive cough \nand some sweats/chills. \n\nROS: Positives as per HPI; otherwise negative. \n \nPast Medical History:\n-Interstitial lung disease (UIP) on chronic prednisone, 4L home \nO2\n-HFpEF\n-Pulmonary hypertension\n-Rheumatoid arthritis\n-Bilateral knee osteoarthritis\n-HTN\n-Iron deficiency anemia \n-Depression \n-Diet controlled borderline diabetes\n-Right total knee replacement\n-Left total knee replacement \n-Cyst removed from left wrist (age ___\n-Cholecystitis ___\n \nSocial History:\n___\nFamily History:\nMother with rheumatoid arthritis, CHF, and a ___\nOldest brother had CHF\nFather with OA\nNo history of ischemic heart disease or stroke\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \n======================== \nVS: T99.6, HR 108, RR 29, 95% on 5L NC \nGEN: comfortably lying in bed \nEYES: PERRLA\nHENNT: MMM\nCV: tachycardic, regular rhythm, no m/r/g \nRESP: bilateral crackles, no wheezes/rales/rhonchi, good air\nmovement throughout\nGI: +BS, soft, NTND\nMSK: WWP, trace ___ edema, no calf tenderness\nNEURO: A&Ox3, moving all 4 extremities with purpose, face\nsymmetric \n\nDISCHARGE EXAM:\n=======================\nVS: 24 HR Data (last updated ___ @ 1125)\n Temp: 98.0 (Tm 98.6), BP: 119/75 (115-155/66-88), HR: 80 \n(71-106), RR: 18 (___), O2 sat: 95% (94-99), O2 delivery: 3L, \nWt: 217.15 lb/98.5 kg \nGEN: NAD\nHEENT: MMM\nCV: JVP not elevated, tachycardic, regular rhythm, no murmurs\nRESP: normal WOB at rest, bibasilar crackles, wheezes resolved\nGI: soft, NT, ND\nEXT/MSK: WWP, no ___ edema, no calf tenderness. Healing furuncle \non thigh without erythema or purulence.\nNEURO: A&Ox3, PERRL, EOMI, moving all 4 extremities with \npurpose, face symmetric \n\n \nPertinent Results:\nADMISSION LABS: \n===============\n___ 12:00AM BLOOD WBC-16.0* RBC-4.08 Hgb-10.0* Hct-33.0* \nMCV-81* MCH-24.5* MCHC-30.3* RDW-17.3* RDWSD-49.7* Plt ___\n___ 12:00AM BLOOD Neuts-76.4* Lymphs-10.2* Monos-11.5 \nEos-0.8* Baso-0.5 Im ___ AbsNeut-12.22* AbsLymp-1.63 \nAbsMono-1.84* AbsEos-0.12 AbsBaso-0.08\n___ 12:00AM BLOOD ___ PTT-25.9 ___\n___ 12:00AM BLOOD Glucose-114* UreaN-11 Creat-0.7 Na-139 \nK-4.3 Cl-95* HCO3-28 AnGap-16\n___ 12:00AM BLOOD ALT-8 AST-15 AlkPhos-63 TotBili-0.5\n___ 12:00AM BLOOD Lipase-10\n___ 12:00AM BLOOD cTropnT-<0.01\n___ 12:00AM BLOOD proBNP-372\n___ 05:27AM BLOOD Calcium-7.6* Phos-3.0 Mg-1.3*\n___ 12:00AM BLOOD Albumin-3.7\n___ 12:08AM BLOOD ___ pO2-40* pCO2-48* pH-7.44 \ncalTCO2-34* Base XS-6\n___ 12:08AM BLOOD Lactate-1.6\n___ 08:22PM BLOOD freeCa-1.08*\n\nDISCHARGE LABS:\n================\nHgb 8.3\nCr 0.6\nBUN 18\nHCO3 34\n\nIMAGING & STUDIES: \n===============\nTTE ___\nThe left atrium is mildly dilated. The right atrium is mildly \nenlarged. There is no evidence for an atrial septal defect by \n2D/color Doppler. The estimated right atrial pressure is ___ \nmmHg. There is normal left ventricular wall thickness with a \nnormal cavity size. There is normal regional and global left \nventricular systolic function. Quantitative biplane left \nventricular ejection fraction is 56 %. There is no resting left \nventricular outflow tract gradient. Normal right ventricular \ncavity size with low normal free wall motion. The aortic sinus \ndiameter is normal for gender with normal ascending aorta \ndiameter for gender. The aortic arch diameter is normal with a \nnormal descending aorta diameter. The aortic valve leaflets (3) \nare mildly thickened. There is no aortic valve stenosis. There \nis no aortic regurgitation. The mitral valve leaflets appear \nstructurally normal with no mitral valve prolapse. There is \ntrivial mitral regurgitation. The pulmonic valve leaflets are \nnormal. There is significant pulmonic regurgitation. The \ntricuspid valve leaflets appear structurally normal. There is \nmoderate [2+] tricuspid regurgitation. There is moderate \npulmonary artery systolic hypertension. The end-diastolic PR \nvelocity is elevated suggesting pulmonary artery diastolic \nhypertension. There is no pericardial effusion.\nIMPRESSION: \nNormal left ventricular wall thickness and cavity size with \nnormal regional/global systolic function. Borderline right \nventricular free wall systolic function. Moderate tricuspid \nregurgitation. Moderate pulmonary systolic hypertension.\n \n\nCXR ___ \nInterstitial markings are coarsened, as before. There is \nill-defined \nincreased density in the left mid lung. The cardiac silhouette \nremains \nprominent. The aorta is tortuous and calcified. Mediastinal \nstructures \nappear stable, allowing for differences in technique. The bony \nthorax is \ngrossly intact. \nIMPRESSION: \nFindings consistent with known chronic interstitial lung \ndisease. Ill defined increased density in the left mid lung may \nrepresent superimposed pneumonia and clinical correlation is \nrecommended. \n\nCXR ___ \nDiffuse bilateral interstitial markings are again seen, \npredominantly \nunchanged, but potentially increased in the left midlung. \nRetrocardiac \nopacification appears overall similar, although patchy opacities \nin the left midlung are more apparent. No large pleural effusion \nor pneumothorax. The cardiomediastinal silhouette is stable. \nIMPRESSION:\nChronic diffuse interstitial abnormality with new opacities in \nthe left midlung which raises the possibility of superimposed \npneumonia. \n\nMICROBIOLOGY: \n===============\n__________________________________________________________\n___ 8:00 pm BLOOD CULTURE Source: Venipuncture. \n\n Blood Culture, Routine (Pending): No growth to date. \n__________________________________________________________\n___ 8:10 pm BLOOD CULTURE Source: Venipuncture. \n\n Blood Culture, Routine (Pending): No growth to date. \n__________________________________________________________\n___ 7:55 pm URINE Source: ___. \n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT \nWITH SKIN\n AND/OR GENITAL CONTAMINATION. \n__________________________________________________________\n___ 9:51 am Rapid Respiratory Viral Screen & Culture\n Source: Nasopharyngeal swab. \n\n **FINAL REPORT ___\n\n Respiratory Viral Culture (Final ___: \n TEST CANCELLED, PATIENT CREDITED. \n Inadequate specimen for respiratory viral culture. \n PLEASE SUBMIT ANOTHER SPECIMEN. \n\n Respiratory Viral Antigen Screen (Final ___: \n Less than 60 columnar epithelial cells;. \n Inadequate specimen for DFA detection of respiratory \nviruses.. \n Interpret all negative DFA and/or culture results from \nthis specimen\n with caution.. \n Negative results should not be used to discontinue \nprecautions.. \n Recommend new sample be submitted for confirmation.. \n Refer to respiratory viral culture and/or Influenza PCR \n(results\n listed under \"OTHER\" tab) for further information.. \n Reported to and read back by ___ ___ AT \n15:30. \n__________________________________________________________\n___ 2:46 am URINE Source: ___. \n\n **FINAL REPORT ___\n\n Legionella Urinary Antigen (Final ___: \n NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. \n (Reference Range-Negative). \n Performed by Immunochromogenic assay. \n A negative result does not rule out infection due to other \nL.\n pneumophila serogroups or other Legionella species. \nFurthermore, in\n infected patients the excretion of antigen in urine may \nvary. \n__________________________________________________________\n___ 2:46 am URINE Source: ___. \n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT \nWITH SKIN\n AND/OR GENITAL CONTAMINATION. \n__________________________________________________________\n___ 2:46 am MRSA SCREEN Source: Nasal swab. \n\n **FINAL REPORT ___\n\n MRSA SCREEN (Final ___: No MRSA isolated. \n__________________________________________________________\n___ 11:50 pm BLOOD CULTURE Site: ARM\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: NO GROWTH. \n__________________________________________________________\n___ 12:00 am BLOOD CULTURE Site: ARM\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: NO GROWTH. \n\n \nBrief Hospital Course:\nTRANSITIONAL ISSUES\n====================\nDischarge weight: 98.5 kg (217 lb) \nDischarge Cr 0.6, bicarb 34\n\nFOR REHAB:\n[] Patient was started on Oxymizer this admission. Please \narrange for patient to have Oxymizer at home.\n[] Monitor weight and BUN/Cr/bicarb, adjust torsemide as needed\n\nFOR PULMONOLOGY:\n[] Patient has not been taking MMF - continued to hold this on \ndischarge, discuss with patient risk/benefit of restarting\n\nFOR PCP:\n[] Started iron supplementation for ___ - may help somewhat with \ndyspnea and exercise capacity. Could consider IV iron \nsupplementation if not improving.\n[] Aspirin was held in setting of prednisone burst. Discuss \nrisk/benefit of restarting.\n\nCODE STATUS: DNR/DNI\nEMERGENCY CONTACT: \n- ___ (daughter/HCP): Phone ___\n- ___ (son): Phone ___\n\nPATIENT SUMMARY \n===============\n___ with hx of RA and RA-associated ILD on chronic prednisone \nand 4L home O2, mild pHTN, HFpEF, initially admitted to MICU for \nfevers and worsening hypoxemia. She was treated with \nbroad-spectrum antibiotics for CAP and gradually improved, \nthough still had increased O2 requirement from baseline at \ndischarge. Discharged to rehab with close Pulmonology f/u.\n\nACUTE ISSUES \n===============\n#Sepsis:\n#Acute on chronic hypoxemic respiratory failure, likely due to:\n#Community acquired pneumonia in an immunocompromised host:\nPresented with ___ days of shaking chills, dyspnea at rest and \nexertion, and hypoxemia worse than baseline (rest: 90s-->80s; \nexertion: 70s-->60s); also with new productive cough for ~14d. \nFebrile and tachycardic in ED, with increased O2 requirement to \n7L. Broad infectious studies sent, largely negative except for \nCXR which demonstrated subtle new L midlung opacification c/f \npneumonia. Admitted to the MICU where O2 was weaned, on the \nfloor, the patient was placed on an Oxymizer. Initially treated \nwith vancomycin/cefepime/azithro, narrowed to levofloxacin for \ntotal 7-day course. Remained hemodynamically stable throughout \nwithout need for IVF or stress dose steroids.\n\n#RA-related interstitial lung disease:\nWe considered the possibility that her hypoxemia might be \nsecondary to a flare of her RA-related ILD, especially as she \nhad been off of MMF for the past several weeks, but given the \nrepeated fevers felt that infection was more likely. Her \noutpatient pulmonologist was consulted and she was treated with \na brief prednisone 40mg burst without much improvement in her \nsymptoms or hypoxemia, so prednisone 10mg was resumed on \ndischarge. MMF continued to be held and close Pulmonology f/u \narranged.\n\n#Chronic diastolic heart failure:\n#Pulmonary hypertension:\nProBNP not elevated. no severe RV dysfunction on echo, euvolemic \non exam and CXR. Torsemide 10mg briefly held then restarted. \nWould monitor weight and renal function at rehab.\n\n#Goals of care:\nFollows with palliative care as outpatient for symptomatic \nmanagement of dyspnea with morphine PRN. Previously documented \nas DNR/DNI, reconfirmed upon admission. In the MICU, patient \nstated she would prefer no CPAP/BiPAP as she finds it \ndiscomforting. She reported this admission that she felt worse \nthan any previous insult and that she is concerned about wanting \nto continue interventions in the future if she is unable to \nreturn to basic activities such as eating without dyspnea. She \nwas discharged on Oxymizer to maximize her functional capacity \nand her prior morphine for dyspnea/pain was continued. Defered \nadditional Palliative Care conversation to the outpatient \nsetting with her established providers.\n\n#Anemia of chronic inflammation:\n#Iron deficiency anemia:\nHgb ranged ___. Iron studies were consistent with both chronic \ninflammation and concomitant iron deficiency. No evidence of \nbleeding or hemolysis. Started oral iron supplementation as may \nhelp with dyspnea.\n\n#Hypophosphatemia:\nTransient, likely contributing somewhat to her fatigue, repleted \nand improved.\n\nCHRONIC ISSUES \n===============\n#Rheumatoid arthritis\n#Osteoarthritis of neck and shoulder\nFollows with Rheumatology (last ___. Cannot be on other \nDMARDs in conjunction with MMF. Continue home morphine and added \nTylenol.\n\n#Depression\nFollows with Palliative Care as outpatient (last seen ___. \nContinued home escitalopram 15mg daily.\n\n# Paroxysmal A-Fib\nNSR/sinus tach since admission without rate or rhythm control. \nNot on anticoagulation given no recurrence of AFib.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. PredniSONE 10 mg PO DAILY \n2. Alendronate Sodium 70 mg PO QMON \n3. Torsemide 10 mg PO DAILY \n4. Escitalopram Oxalate 10 mg PO DAILY \n5. Vitamin D 1000 UNIT PO DAILY \n6. Aspirin 81 mg PO DAILY \n7. Multivitamins 1 TAB PO DAILY \n8. Morphine Sulfate (Oral Solution) 2 mg/mL 10 mg PO Q4H:PRN \nPain - Moderate \n9. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation \ninhalation BID \n10. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing, shortness of \nbreath \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild \n2. Benzonatate 100 mg PO TID:PRN cough \n3. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q4H:PRN throat \ndiscomfort, irritative cough \n4. Ferrous Sulfate 325 mg PO HS \n5. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First \nLine \n6. Senna 17.2 mg PO DAILY \n7. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing, shortness of \nbreath \n8. Alendronate Sodium 70 mg PO QMON \n9. Escitalopram Oxalate 10 mg PO DAILY \n10. Morphine Sulfate (Oral Solution) 2 mg/mL 10 mg PO Q4H:PRN \nPain - Moderate \nRX *morphine 10 mg/5 mL 5 ml by mouth every 4 hours as needed \nRefills:*0 \n11. Multivitamins 1 TAB PO DAILY \n12. PredniSONE 10 mg PO DAILY \n13. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation \ninhalation BID \n14. Torsemide 10 mg PO DAILY \n15. Vitamin D 1000 UNIT PO DAILY \n16. HELD- Aspirin 81 mg PO DAILY This medication was held. Do \nnot restart Aspirin until you speak with your outpatient doctor \n17.Oxymizer\nOxymizer\nDiagnosis: Interstitial pulmonary disease, unspecified (___.9)\nLength of need: >90 days\n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY:\n========\n# Sepsis\n# Acute on chronic hypoxic respiratory failure\n# Community acquired pneumonia in an immunocompromised host\n# Interstitial lung disease\n# Chronic diastolic congestive heart failure \n# Pulmonary hypertension\n# Rheumatoid arthritis\n# Anemia of chronic inflammation\n# Iron deficiency anemia\n\nSECONDARY:\n==========\n# Chronic pain\n# Depression\n# Paroxysmal atrial fibrillation\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - independent but requires oxygen \n\n \nDischarge Instructions:\nDear ___,\n\nIt was a pleasure caring for you at ___ \n___.\n\nWHY WAS I IN THE HOSPITAL? \n- You had a great deal of difficulty breathing even while not \nmoving\n- You had a fever \n\nWHAT HAPPENED TO ME IN THE HOSPITAL? \n- We tried to find the cause of your difficulty breathing\n- We believe you had a pneumonia that, on top of your \ninterstitial lung disease, made breathing difficult \n- We gave you antibiotics to treat your infection and you got \nbetter\n\nWHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?\n- Continue to take all your medicines and keep your \nappointments.\n- Weigh yourself every morning, call your doctor if weight goes \nup more than 3 lbs.\n\nWe wish you the best!\n\nSincerely, \nYour ___ Team\n \nFollowup Instructions:\n___\n"
] | Allergies: Tetracycline / Daypro / Tramadol / Hydrocodone / bee venom protein (honey bee) / hydrocodone-homatropine Chief Complaint: fever, dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] with hx of RA-ILD on 4L home O2 and chronic prednisone, mild pHTN, HFpEF, presents to the ED with fever and respiratory distress. Patient states for the past [MASKED] days she's been experiencing worsening shortness of breath and dyspnea on exertion, such that she has had episodes of incontinence from being unable to make it to the bathroom on time. She's noted that her home O2 sats which typically range in low [MASKED] at rest and [MASKED] with exertion have been in the [MASKED] at rest and [MASKED] during exertion. She's additionally had chills with shaking though with no known fevers over the past [MASKED] days. Has a new cough for the past couple of weeks with sputum production (unknown color as swallows it back down). Earlier today she went to her scheduled palliative care appointment and was still feeling well. Later in the evening she developed persistently worsening shortness of breath and her daughter called EMS. When EMS arrived they found the patient hypoxic to [MASKED] despite supplemental oxygen, and a tympanic thermometer reading "HIGH." Upon arrival to the ED the patient states she feels cold and has shortness of breath. In the ED, Initial Vitals: T101, HR 132, BP 160/81, RR 20, 100% on nonrebreather Exam: tachycardic, mild respiratory distress, coarse breath sounds bilaterally, b/l peripheral edema Labs: WBC 16 (76.4% PMNs), H/H [MASKED], Plt 257 Na 139, K 4.3, Cl 95, Bicarb 28, BUN 11, Cr 0.7 LFTs WNL proBNP 372, Trop <0.01 lactate 1.6 VBG 7.44/48/34 Flu A/B negative Imaging: CXR - no read. On comparison to CXR from [MASKED] no obvious changes. No pleural effusion, obvious consolidations, or signs of gross pulmonary edema. Bedside ultrasound: no pericardial effusion, unclear if pulmonary edema Consults: none Interventions: Cefepime/azithromycin, hydrocort 100mg, home MMF 1500mg VS Prior to Transfer: HR 129, BP 131/57, RR 31, 93% 7L NC On arrival to the ICU, she reports significant improvement in her subjective dyspnea. She continues to have a productive cough and some sweats/chills. ROS: Positives as per HPI; otherwise negative. Past Medical History: -Interstitial lung disease (UIP) on chronic prednisone, 4L home O2 -HFpEF -Pulmonary hypertension -Rheumatoid arthritis -Bilateral knee osteoarthritis -HTN -Iron deficiency anemia -Depression -Diet controlled borderline diabetes -Right total knee replacement -Left total knee replacement -Cyst removed from left wrist (age [MASKED] -Cholecystitis [MASKED] Social History: [MASKED] Family History: Mother with rheumatoid arthritis, CHF, and a [MASKED] Oldest brother had CHF Father with OA No history of ischemic heart disease or stroke Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: T99.6, HR 108, RR 29, 95% on 5L NC GEN: comfortably lying in bed EYES: PERRLA HENNT: MMM CV: tachycardic, regular rhythm, no m/r/g RESP: bilateral crackles, no wheezes/rales/rhonchi, good air movement throughout GI: +BS, soft, NTND MSK: WWP, trace [MASKED] edema, no calf tenderness NEURO: A&Ox3, moving all 4 extremities with purpose, face symmetric DISCHARGE EXAM: ======================= VS: 24 HR Data (last updated [MASKED] @ 1125) Temp: 98.0 (Tm 98.6), BP: 119/75 (115-155/66-88), HR: 80 (71-106), RR: 18 ([MASKED]), O2 sat: 95% (94-99), O2 delivery: 3L, Wt: 217.15 lb/98.5 kg GEN: NAD HEENT: MMM CV: JVP not elevated, tachycardic, regular rhythm, no murmurs RESP: normal WOB at rest, bibasilar crackles, wheezes resolved GI: soft, NT, ND EXT/MSK: WWP, no [MASKED] edema, no calf tenderness. Healing furuncle on thigh without erythema or purulence. NEURO: A&Ox3, PERRL, EOMI, moving all 4 extremities with purpose, face symmetric Pertinent Results: ADMISSION LABS: =============== [MASKED] 12:00AM BLOOD WBC-16.0* RBC-4.08 Hgb-10.0* Hct-33.0* MCV-81* MCH-24.5* MCHC-30.3* RDW-17.3* RDWSD-49.7* Plt [MASKED] [MASKED] 12:00AM BLOOD Neuts-76.4* Lymphs-10.2* Monos-11.5 Eos-0.8* Baso-0.5 Im [MASKED] AbsNeut-12.22* AbsLymp-1.63 AbsMono-1.84* AbsEos-0.12 AbsBaso-0.08 [MASKED] 12:00AM BLOOD [MASKED] PTT-25.9 [MASKED] [MASKED] 12:00AM BLOOD Glucose-114* UreaN-11 Creat-0.7 Na-139 K-4.3 Cl-95* HCO3-28 AnGap-16 [MASKED] 12:00AM BLOOD ALT-8 AST-15 AlkPhos-63 TotBili-0.5 [MASKED] 12:00AM BLOOD Lipase-10 [MASKED] 12:00AM BLOOD cTropnT-<0.01 [MASKED] 12:00AM BLOOD proBNP-372 [MASKED] 05:27AM BLOOD Calcium-7.6* Phos-3.0 Mg-1.3* [MASKED] 12:00AM BLOOD Albumin-3.7 [MASKED] 12:08AM BLOOD [MASKED] pO2-40* pCO2-48* pH-7.44 calTCO2-34* Base XS-6 [MASKED] 12:08AM BLOOD Lactate-1.6 [MASKED] 08:22PM BLOOD freeCa-1.08* DISCHARGE LABS: ================ Hgb 8.3 Cr 0.6 BUN 18 HCO3 34 IMAGING & STUDIES: =============== TTE [MASKED] The left atrium is mildly dilated. The right atrium is mildly enlarged. There is no evidence for an atrial septal defect by 2D/color Doppler. The estimated right atrial pressure is [MASKED] mmHg. There is normal left ventricular wall thickness with a normal cavity size. There is normal regional and global left ventricular systolic function. Quantitative biplane left ventricular ejection fraction is 56 %. There is no resting left ventricular outflow tract gradient. Normal right ventricular cavity size with low normal free wall motion. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. The aortic arch diameter is normal with a normal descending aorta diameter. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral valve leaflets appear structurally normal with no mitral valve prolapse. There is trivial mitral regurgitation. The pulmonic valve leaflets are normal. There is significant pulmonic regurgitation. The tricuspid valve leaflets appear structurally normal. There is moderate [2+] tricuspid regurgitation. There is moderate pulmonary artery systolic hypertension. The end-diastolic PR velocity is elevated suggesting pulmonary artery diastolic hypertension. There is no pericardial effusion. IMPRESSION: Normal left ventricular wall thickness and cavity size with normal regional/global systolic function. Borderline right ventricular free wall systolic function. Moderate tricuspid regurgitation. Moderate pulmonary systolic hypertension. CXR [MASKED] Interstitial markings are coarsened, as before. There is ill-defined increased density in the left mid lung. The cardiac silhouette remains prominent. The aorta is tortuous and calcified. Mediastinal structures appear stable, allowing for differences in technique. The bony thorax is grossly intact. IMPRESSION: Findings consistent with known chronic interstitial lung disease. Ill defined increased density in the left mid lung may represent superimposed pneumonia and clinical correlation is recommended. CXR [MASKED] Diffuse bilateral interstitial markings are again seen, predominantly unchanged, but potentially increased in the left midlung. Retrocardiac opacification appears overall similar, although patchy opacities in the left midlung are more apparent. No large pleural effusion or pneumothorax. The cardiomediastinal silhouette is stable. IMPRESSION: Chronic diffuse interstitial abnormality with new opacities in the left midlung which raises the possibility of superimposed pneumonia. MICROBIOLOGY: =============== [MASKED] [MASKED] 8:00 pm BLOOD CULTURE Source: Venipuncture. Blood Culture, Routine (Pending): No growth to date. [MASKED] [MASKED] 8:10 pm BLOOD CULTURE Source: Venipuncture. Blood Culture, Routine (Pending): No growth to date. [MASKED] [MASKED] 7:55 pm URINE Source: [MASKED]. **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. [MASKED] [MASKED] 9:51 am Rapid Respiratory Viral Screen & Culture Source: Nasopharyngeal swab. **FINAL REPORT [MASKED] Respiratory Viral Culture (Final [MASKED]: TEST CANCELLED, PATIENT CREDITED. Inadequate specimen for respiratory viral culture. PLEASE SUBMIT ANOTHER SPECIMEN. Respiratory Viral Antigen Screen (Final [MASKED]: Less than 60 columnar epithelial cells;. Inadequate specimen for DFA detection of respiratory viruses.. Interpret all negative DFA and/or culture results from this specimen with caution.. Negative results should not be used to discontinue precautions.. Recommend new sample be submitted for confirmation.. Refer to respiratory viral culture and/or Influenza PCR (results listed under "OTHER" tab) for further information.. Reported to and read back by [MASKED] [MASKED] AT 15:30. [MASKED] [MASKED] 2:46 am URINE Source: [MASKED]. **FINAL REPORT [MASKED] Legionella Urinary Antigen (Final [MASKED]: NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). Performed by Immunochromogenic assay. A negative result does not rule out infection due to other L. pneumophila serogroups or other Legionella species. Furthermore, in infected patients the excretion of antigen in urine may vary. [MASKED] [MASKED] 2:46 am URINE Source: [MASKED]. **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. [MASKED] [MASKED] 2:46 am MRSA SCREEN Source: Nasal swab. **FINAL REPORT [MASKED] MRSA SCREEN (Final [MASKED]: No MRSA isolated. [MASKED] [MASKED] 11:50 pm BLOOD CULTURE Site: ARM **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] [MASKED] 12:00 am BLOOD CULTURE Site: ARM **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. Brief Hospital Course: TRANSITIONAL ISSUES ==================== Discharge weight: 98.5 kg (217 lb) Discharge Cr 0.6, bicarb 34 FOR REHAB: [] Patient was started on Oxymizer this admission. Please arrange for patient to have Oxymizer at home. [] Monitor weight and BUN/Cr/bicarb, adjust torsemide as needed FOR PULMONOLOGY: [] Patient has not been taking MMF - continued to hold this on discharge, discuss with patient risk/benefit of restarting FOR PCP: [] Started iron supplementation for [MASKED] - may help somewhat with dyspnea and exercise capacity. Could consider IV iron supplementation if not improving. [] Aspirin was held in setting of prednisone burst. Discuss risk/benefit of restarting. CODE STATUS: DNR/DNI EMERGENCY CONTACT: - [MASKED] (daughter/HCP): Phone [MASKED] - [MASKED] (son): Phone [MASKED] PATIENT SUMMARY =============== [MASKED] with hx of RA and RA-associated ILD on chronic prednisone and 4L home O2, mild pHTN, HFpEF, initially admitted to MICU for fevers and worsening hypoxemia. She was treated with broad-spectrum antibiotics for CAP and gradually improved, though still had increased O2 requirement from baseline at discharge. Discharged to rehab with close Pulmonology f/u. ACUTE ISSUES =============== #Sepsis: #Acute on chronic hypoxemic respiratory failure, likely due to: #Community acquired pneumonia in an immunocompromised host: Presented with [MASKED] days of shaking chills, dyspnea at rest and exertion, and hypoxemia worse than baseline (rest: 90s-->80s; exertion: 70s-->60s); also with new productive cough for ~14d. Febrile and tachycardic in ED, with increased O2 requirement to 7L. Broad infectious studies sent, largely negative except for CXR which demonstrated subtle new L midlung opacification c/f pneumonia. Admitted to the MICU where O2 was weaned, on the floor, the patient was placed on an Oxymizer. Initially treated with vancomycin/cefepime/azithro, narrowed to levofloxacin for total 7-day course. Remained hemodynamically stable throughout without need for IVF or stress dose steroids. #RA-related interstitial lung disease: We considered the possibility that her hypoxemia might be secondary to a flare of her RA-related ILD, especially as she had been off of MMF for the past several weeks, but given the repeated fevers felt that infection was more likely. Her outpatient pulmonologist was consulted and she was treated with a brief prednisone 40mg burst without much improvement in her symptoms or hypoxemia, so prednisone 10mg was resumed on discharge. MMF continued to be held and close Pulmonology f/u arranged. #Chronic diastolic heart failure: #Pulmonary hypertension: ProBNP not elevated. no severe RV dysfunction on echo, euvolemic on exam and CXR. Torsemide 10mg briefly held then restarted. Would monitor weight and renal function at rehab. #Goals of care: Follows with palliative care as outpatient for symptomatic management of dyspnea with morphine PRN. Previously documented as DNR/DNI, reconfirmed upon admission. In the MICU, patient stated she would prefer no CPAP/BiPAP as she finds it discomforting. She reported this admission that she felt worse than any previous insult and that she is concerned about wanting to continue interventions in the future if she is unable to return to basic activities such as eating without dyspnea. She was discharged on Oxymizer to maximize her functional capacity and her prior morphine for dyspnea/pain was continued. Defered additional Palliative Care conversation to the outpatient setting with her established providers. #Anemia of chronic inflammation: #Iron deficiency anemia: Hgb ranged [MASKED]. Iron studies were consistent with both chronic inflammation and concomitant iron deficiency. No evidence of bleeding or hemolysis. Started oral iron supplementation as may help with dyspnea. #Hypophosphatemia: Transient, likely contributing somewhat to her fatigue, repleted and improved. CHRONIC ISSUES =============== #Rheumatoid arthritis #Osteoarthritis of neck and shoulder Follows with Rheumatology (last [MASKED]. Cannot be on other DMARDs in conjunction with MMF. Continue home morphine and added Tylenol. #Depression Follows with Palliative Care as outpatient (last seen [MASKED]. Continued home escitalopram 15mg daily. # Paroxysmal A-Fib NSR/sinus tach since admission without rate or rhythm control. Not on anticoagulation given no recurrence of AFib. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. PredniSONE 10 mg PO DAILY 2. Alendronate Sodium 70 mg PO QMON 3. Torsemide 10 mg PO DAILY 4. Escitalopram Oxalate 10 mg PO DAILY 5. Vitamin D 1000 UNIT PO DAILY 6. Aspirin 81 mg PO DAILY 7. Multivitamins 1 TAB PO DAILY 8. Morphine Sulfate (Oral Solution) 2 mg/mL 10 mg PO Q4H:PRN Pain - Moderate 9. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation inhalation BID 10. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing, shortness of breath Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild 2. Benzonatate 100 mg PO TID:PRN cough 3. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q4H:PRN throat discomfort, irritative cough 4. Ferrous Sulfate 325 mg PO HS 5. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First Line 6. Senna 17.2 mg PO DAILY 7. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing, shortness of breath 8. Alendronate Sodium 70 mg PO QMON 9. Escitalopram Oxalate 10 mg PO DAILY 10. Morphine Sulfate (Oral Solution) 2 mg/mL 10 mg PO Q4H:PRN Pain - Moderate RX *morphine 10 mg/5 mL 5 ml by mouth every 4 hours as needed Refills:*0 11. Multivitamins 1 TAB PO DAILY 12. PredniSONE 10 mg PO DAILY 13. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation inhalation BID 14. Torsemide 10 mg PO DAILY 15. Vitamin D 1000 UNIT PO DAILY 16. HELD- Aspirin 81 mg PO DAILY This medication was held. Do not restart Aspirin until you speak with your outpatient doctor 17.Oxymizer Oxymizer Diagnosis: Interstitial pulmonary disease, unspecified ([MASKED].9) Length of need: >90 days Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: PRIMARY: ======== # Sepsis # Acute on chronic hypoxic respiratory failure # Community acquired pneumonia in an immunocompromised host # Interstitial lung disease # Chronic diastolic congestive heart failure # Pulmonary hypertension # Rheumatoid arthritis # Anemia of chronic inflammation # Iron deficiency anemia SECONDARY: ========== # Chronic pain # Depression # Paroxysmal atrial fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - independent but requires oxygen Discharge Instructions: Dear [MASKED], It was a pleasure caring for you at [MASKED] [MASKED]. WHY WAS I IN THE HOSPITAL? - You had a great deal of difficulty breathing even while not moving - You had a fever WHAT HAPPENED TO ME IN THE HOSPITAL? - We tried to find the cause of your difficulty breathing - We believe you had a pneumonia that, on top of your interstitial lung disease, made breathing difficult - We gave you antibiotics to treat your infection and you got better WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Continue to take all your medicines and keep your appointments. - Weigh yourself every morning, call your doctor if weight goes up more than 3 lbs. We wish you the best! Sincerely, Your [MASKED] Team Followup Instructions: [MASKED] | [
"A419",
"J189",
"J9621",
"I5032",
"I2720",
"M0510",
"J8489",
"I480",
"D638",
"Z66",
"Z9981",
"E8339",
"D509",
"G8929",
"F329",
"M479",
"M19019",
"Z96653"
] | [
"A419: Sepsis, unspecified organism",
"J189: Pneumonia, unspecified organism",
"J9621: Acute and chronic respiratory failure with hypoxia",
"I5032: Chronic diastolic (congestive) heart failure",
"I2720: Pulmonary hypertension, unspecified",
"M0510: Rheumatoid lung disease with rheumatoid arthritis of unspecified site",
"J8489: Other specified interstitial pulmonary diseases",
"I480: Paroxysmal atrial fibrillation",
"D638: Anemia in other chronic diseases classified elsewhere",
"Z66: Do not resuscitate",
"Z9981: Dependence on supplemental oxygen",
"E8339: Other disorders of phosphorus metabolism",
"D509: Iron deficiency anemia, unspecified",
"G8929: Other chronic pain",
"F329: Major depressive disorder, single episode, unspecified",
"M479: Spondylosis, unspecified",
"M19019: Primary osteoarthritis, unspecified shoulder",
"Z96653: Presence of artificial knee joint, bilateral"
] | [
"I5032",
"I480",
"Z66",
"D509",
"G8929",
"F329"
] | [] |
10,821,939 | 28,879,056 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nDyspnea\n \nMajor Surgical or Invasive Procedure:\nEGD ___: for evaluation of esophageal anatomy to see if TEE \nwould be possible. \n \nHistory of Present Illness:\nHISTORY OF PRESENTING ILLNESS: \n___ y.o. M with a history of HTN, HLD, CHFrEF (30%, severe 4+ MR,\n4+ TR), prior stomach and esophageal adenocarcinoma s/p \nresection\nand chemoradiation ___ years ago now in remission, pulmonary \nHTN,\nprior L pneumonectomy for childhood bronchiectasis, with known\ninferior wall motion abnormality s/p myocardial perfusion \nimaging\nstudy showing no perfusion defects ___ and coronary\nangiography which demonstrated no obstructive disease ___, \nnow\npresents here for further evaluation worsening dyspnea on\nexertion and cardiomyopathy. He was referred for inpatient\nadmission by his cardiologist, Dr. ___ consideration of\ninpatient evaluation of possible valve replacement. \n\nPatient states that he has increased SOB with ambulation,\northopnea, and fatigue/weakness over the past month. He also has\nchronic orthopnea, and sleeps in a semi-upright position. He\nattributes his progressive fatigue to his difficulties sleeping,\ngiven his orthopnea. He was recently changed from furosemide to\ntorsemide given the presence of biventricular failure, which\nresulted in a significant reduction of water weight, but then\nwith subsequent trailing off. His weight has decreased from \n128bs\nto 124 lbs over the last ___ days. He has noted worsening ___\nedema over the past 2 days despite being compliant with his\ntorsemide, although he reportedly has had intermittent edema \nthat\n\"comes and goes\" in the past as well. He denies any chest\npain/pressure, palpitations, N/V, abdominal pain, dysuria, or\nconstipation/diarrhea. \n\nOf note, orthopnea is in part due to gastroesophageal reflux and\nunderlying lung disease (he has chronic dyspnea due to extensive\nlung disease involving bronchiectasis and left pneumonectomy\nduring childhood), which has made it necessary for him to sleep\nin a semi-upright position for many years. \n\nREVIEW OF SYSTEMS: Good appetite. He does not adhere to a\nsodium-restricted diet. He denies any recent heat or cold\nintolerance, night sweats, fevers, chills, chest pain,\npalpitations, lightheadedness, dizziness, presyncope, actual\nsyncope. \n\n \nPast Medical History:\nPAST MEDICAL HISTORY: \n======================= \n1. CARDIAC RISK FACTORS \n- Hypertension, not on treatment since ___. \n- Hyperlipidemia, not on treatment since ___. \n2. CARDIAC HISTORY \n- Coronary angiography which demonstrated no obstructive disease\n___ \n- CHFrEF (30%, severe 4+ MR, 4+ TR) \n- Permanent atrial flutter/fibrillation (patient declined\nanticoagulation). \n3. OTHER PAST MEDICAL HISTORY \n- Left pneumonectomy for childhood bronchiectasis before the\nage of ___.\n- Superficial spreading adenocarcinoma of the stomach and\nesophagus in ___ status post esophageal gastrectomy.\n- Recurrent esophageal adenocarcinoma at the GE junction, T3,\nN0, M0, however, technically unresectable, status post\nchemotherapy with ___ and cisplatin as well as radiation.\nReportedly in remission.\n- Subclinical hypothyroidism with TSH of 11.8. Normal T4, T3\nlevels. Commenced levothyroxine at 50 mcg daily in mid ___.\n\n \nSocial History:\n___\nFamily History:\nFAMILY HISTORY: Significant for heart disease in his father and\nhis sister. He father died of a heart problem when the patient\nwas ___ years old. He does not know the etiology of the heart\ndisease. His sister died in her ___ from a valvular heart\nproblem. No known family history of CAD or sudden cardiac \ndeath.\n\n \nPhysical Exam:\nPHYSICAL EXAMINATION: \n======================= \nVS: ___ 1800 Temp: 98.1 PO BP: 124/91 HR: 86 RR: 18 O2 sat:\n95% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: ___ \nWeight: 125.1lbs \nGENERAL: Cachectic, chronically ill-appearing, NAD \nHEENT: Normocephalic and atraumatic. The oropharynx is benign.\nNECK: Elevated jugular venous pressure, ~10cm \nCHEST: Decreased breath sounds on the left, clear on the right. \n\nScattered rhonchi heard diffusely in all lung fields. \nHEART: Irregular rhythm, the heart sounds are best heard in the\nleft axilla due to prior left pneumonectomy causing a shift in\nthe heart position. There is a prominent holosystolic murmur \nthat\nradiates to the left posterior thorax.\nABDOMEN: Benign, without masses, tenderness, bruits,\nabdominojugular reflux, or fluid wave. Bowel sounds are normal.\nEXTREMITIES: Warm and well perfused. There is edema in the legs\nup to the mid shin.\nNEUROLOGIC: The patient is awake, alert, fully oriented, and\nfluently conversant. There are no focal neurologic\nabnormalities. \n\n \nPertinent Results:\nDischarge Labs:\n\n___ 07:55AM BLOOD WBC-6.3 RBC-4.13* Hgb-13.8 Hct-43.7 \nMCV-106* MCH-33.4* MCHC-31.6* RDW-17.6* RDWSD-69.0* Plt ___\n___ 07:55AM BLOOD Glucose-71 UreaN-37* Creat-1.4* Na-142 \nK-5.0 Cl-96 HCO3-34* AnGap-12\n___ 07:55AM BLOOD Calcium-9.6 Phos-3.7 Mg-2.2\n\nInitial Labs:\n\n___ 03:30PM BLOOD WBC-6.1 RBC-4.47* Hgb-15.2 Hct-45.7 \nMCV-102* MCH-34.0* MCHC-33.3 RDW-17.6* RDWSD-66.0* Plt ___\n___ 03:30PM BLOOD Plt ___\n___ 03:30PM BLOOD ___\n___ 03:30PM BLOOD UreaN-39* Creat-1.5* Na-139 K-4.8 Cl-96 \nHCO3-30 AnGap-13\n___ 03:30PM BLOOD ALT-9 AST-18 AlkPhos-108 TotBili-1.1\n___ 03:30PM BLOOD Calcium-9.9 Mg-2.1\n\nEGD:\nTortuous esophagus with rightward angulation at 20cm. Able to \npass standard gastroscope through area\n\n \nBrief Hospital Course:\nPatient Summary\n===============\n___ y.o. M with a history of HTN, HLD, CHFrEF (30%, severe 4+ MR,\n4+ TR), prior stomach and esophageal adenocarcinoma s/p \nresection\nand chemoradiation ___ years ago now in remission, pHTN,\nprior L pneumonectomy for childhood bronchiectasis, with known\ninferior wall motion abnormality s/p myocardial perfusion \nimaging\nstudy showing no perfusion defects ___ and coronary\nangiography which demonstrated no obstructive disease ___, \nwho presented for further evaluation of worsening dyspnea on \nexertion and cardiomyopathy with potential evaluation for \nMitraClip. Structural heart and Cardiac Surgery were consulted \nfor possible valvular intervention. An EGD was done to see if a \nTEE wold be feasible given history of esophageal adenocarcinoma. \nAlthough he successfully had the EGD, a TEE was deferred because \nit was thought to be too risky to perform based on the anatomy \nof the esophagus seen on the EGD. \n\nAcute Issues\n============\n# Acute decompensation of HFrEF\n# Severe MR, TR\nPatient presents with worsening dyspnea on exertion and \northopnea for the past month, despite more aggressive diuresis \n(was on furosemide, changed over to torsemide). Unclear dry \nweight, although his weight has declined from 129lbs to 125lbs \nover the few days prior to admission. On physical exam, he \nseemed volume overloaded with\nworsening ___ edema. His proBNP was elevated at ___ (no \nbaseline proBNP on file for comparison). Etiology for \ndecompensation is multifactorial, likely including progression \nof mitral and tricuspid regurgitation, as well as his severe \npulmonary HTN from progression of his progressive lung disease, \nand possible ischemic mitral regurgitation from a previous \ninferior posterior infarct. Worsening hypothyroidism may also \nhave contributed to exacerbation. No sxs to suggest possible \ninfectious etiology of decompensation. He was given IV Lasix \n40mg BID until his volume status improved. He was given \nlisinopril 20mg and uptitrated to 30mg for afterload control, \nbut BP did not allow further increase to home dose of 40 mg \ndaily. He was continued on ASA 81 and metoprolol succinate 50mg. \nTEE was required for evaluation of MR for potential MitraClip. \nGiven his anatomy and history of esophageal cancer, GI was \nconsulted and performed and EGD to assess feasibility of TEE. \nEsophageal anatomy was tortuous on EGD and ___ team decided it \nwas too risky to perform study. MitraClip will be an ongoing \ndiscussion with outpatient cardiology.\n\n#Elevated TSH\nPatient had an elevated TSH to 36 on ___. Last TSH done in \n___ and was elevated to 6.46. He is very diligent about \ntaking his medications and makes sure to wait 40 min before \neating anything after taking levothyroxine. He does endorse \nprogressively increased fatigue. Endocrine was consulted who \nfelt that it is likely that he is not absorbing his medication \nwhich may be due to hx of gastric/esophageal adenocarcinoma and \npossible recurrence. His levothyroxine was increased to 88mg \ndaily. We decided not to titrate it up too aggressively iso \nHFrEF exacerbation.\n\n# ___ \nCr 1.4 from apparent recent baseline of ___, appears to have \nup-titrated with torsemide dose. Most likely cardiorenal \nsyndrome, iso HF exacerbation, as above. Avoided nephrotoxins. \nDischarge Cr is 1.2. \n\nChronic Issues\n==============\n# Bronchiectasis\n# Pulmonary Hypertension\nPatient has a history of extensive lung disease with\nbronchiectasis, pneumonectomy, and most likely extensive \nscarring\nof pulmonary parenchymal tissue. He follows with pulmonology, \nand\nhas derived some benefit from an appropriate pulmonary toilet\nregimen. We continued his home ipratropium bromide converted to \nnebulizer\ntreatments while inpatient and continued his guaifenesin.\n\n# Atrial Fibrillation\nPer review of records, patient has a history of atrial\nfibrillation/atrial flutter, but has declined anticoagulation in\nthe past. His rhythm on EKG was irregular. He was monitored on \ntele and his metoprolol was continued for rate control.\n\n# Back Pain \nPatient has severe chronic back pain, attributed to his\nosteoarthritis, which has been exacerbating his orthopnea. He\ndeclined any narcotics at this time, stating that they make him\n\"loopy.\" He received Tylenol PRN and Lidocaine patches.\n\n# GERD\n- Continued lansoprazole 30 mg capsule BID \n\n# HLD\n- Continue home simvastatin 5 mg tablet QHS\n\nTRANSITIONAL ISSUES \n==================== \nDISCHARGE WEIGHT:52.5kg (115.74lb)\nDISCHARGE Cr/BUN: 1.3/35\nDISCHARGE DIURETIC: Torsemide 20mg BID \n\nCode Status: Full Code \nContact: ___ (wife), ___\n ___ (son) ___\n ___ (son) ___\n\nFOR CARDIOLOGY:\n[] During admission had EGD that showed that showed a rightward \nturn 20cm in the esophagus. The decision was made to defer TEE \nto further evaluate the valves given the high risk of traversing \nthis turn and likely low image quality. Continue discussion \nregarding MitraClip and GOC. \n[] MitraClip consideration as outpatient\n[] Consider adding spironolactone to HF regimen\n[] Lisinopril 40mg was held upon admission due to elevated Cr. \nWas able to uptitrate to lisinopril 30mg by discharge, but \nfurther increase limited by hypotension. Consider titrating back \nup to Lisinopril 40mg.\n\nFOR PCP:\n[] Elevated TSH to 36 on ___. Last TSH done in\n___ and was elevated to 6.46. He is very diligent about \ntaking\nhis medications and makes sure to wait 40 min before eating\nanything after taking levothyroxine. Levothyroxine increased to \n88mcg daily. Consider careful uptitration of levothyroxine as he \nhas HFrEF and could cause an exacerbation. Patient should have \nrepeat TSH in 6 weeks\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Ipratropium Bromide MDI 2 PUFF IH TID \n2. Lansoprazole Oral Disintegrating Tab 30 mg PO BID \n3. Levothyroxine Sodium 50 mcg PO 4X/WEEK (___) \n4. Levothyroxine Sodium 100 mcg PO 3X/WEEK (___) \n5. Lisinopril 40 mg PO DAILY \n6. Metoprolol Succinate XL 50 mg PO DAILY \n7. Simvastatin 5 mg PO QPM \n8. Torsemide 20 mg PO DAILY \n9. Aspirin 81 mg PO DAILY \n10. Cyanocobalamin 1000 mcg PO DAILY \n\n \nDischarge Medications:\n1. Levothyroxine Sodium 88 mcg PO DAILY \n2. Lisinopril 30 mg PO DAILY \n3. Aspirin 81 mg PO DAILY \n4. Cyanocobalamin 1000 mcg PO DAILY \n5. Ipratropium Bromide MDI 2 PUFF IH TID \n6. Lansoprazole Oral Disintegrating Tab 30 mg PO BID \n7. Metoprolol Succinate XL 50 mg PO DAILY \n8. Simvastatin 5 mg PO QPM \n9. Torsemide 20 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nHeart Failure with reduced Ejection Fraction (HFrEF)\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory\n \nDischarge Instructions:\nDear Mr. ___,\n\nIt was a pleasure taking care of you at ___ \n___.\n\nWHY WAS I ADMITTED TO THE HOSPITAL? \n=====================================\nYou were feeling short of breath because you had fluid in your \nlungs. This was caused by a condition called heart failure, \nwhere your heart does not pump hard enough and fluid backs up \ninto your lungs. \n\nWHAT HAPPENED WHILE I WAS IN THE HOSPITAL? \n==============================================\nYou were given medications to help get the fluid out. Your \nbreathing got better and were ready to leave the hospital. Your \ncardiologist felt that if you had a procedure on your heart \nvalve, your symptoms would improve. You had a test called an \nendoscopy/EGD to see if you could get another test called a \ntransesophageal echocardiogram (TEE). After the EGD, The \ncardiologists felt that it was high risk to do the TEE. It was \ndecided that the procedure on your heart valve would have to be \nan ongoing discussion with your outpatient cardiologist. \n\nWHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? \n=========================================================\n - Take all of your medications as prescribed (listed below) \n - Follow up with your doctors as listed below \n - Weigh yourself every morning. Your weight on discharge is \n52.8kg (116.4lb). Call your doctor if your weight goes up more \nthan 3 pounds (increases to a weight of 119.4 lb). \n - Call you doctor if you notice any of the \"danger signs\" \nbelow. \n \nWe wish you the best! \n\nYour ___ Team \n\n \nFollowup Instructions:\n___\n"
] | Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: EGD [MASKED]: for evaluation of esophageal anatomy to see if TEE would be possible. History of Present Illness: HISTORY OF PRESENTING ILLNESS: [MASKED] y.o. M with a history of HTN, HLD, CHFrEF (30%, severe 4+ MR, 4+ TR), prior stomach and esophageal adenocarcinoma s/p resection and chemoradiation [MASKED] years ago now in remission, pulmonary HTN, prior L pneumonectomy for childhood bronchiectasis, with known inferior wall motion abnormality s/p myocardial perfusion imaging study showing no perfusion defects [MASKED] and coronary angiography which demonstrated no obstructive disease [MASKED], now presents here for further evaluation worsening dyspnea on exertion and cardiomyopathy. He was referred for inpatient admission by his cardiologist, Dr. [MASKED] consideration of inpatient evaluation of possible valve replacement. Patient states that he has increased SOB with ambulation, orthopnea, and fatigue/weakness over the past month. He also has chronic orthopnea, and sleeps in a semi-upright position. He attributes his progressive fatigue to his difficulties sleeping, given his orthopnea. He was recently changed from furosemide to torsemide given the presence of biventricular failure, which resulted in a significant reduction of water weight, but then with subsequent trailing off. His weight has decreased from 128bs to 124 lbs over the last [MASKED] days. He has noted worsening [MASKED] edema over the past 2 days despite being compliant with his torsemide, although he reportedly has had intermittent edema that "comes and goes" in the past as well. He denies any chest pain/pressure, palpitations, N/V, abdominal pain, dysuria, or constipation/diarrhea. Of note, orthopnea is in part due to gastroesophageal reflux and underlying lung disease (he has chronic dyspnea due to extensive lung disease involving bronchiectasis and left pneumonectomy during childhood), which has made it necessary for him to sleep in a semi-upright position for many years. REVIEW OF SYSTEMS: Good appetite. He does not adhere to a sodium-restricted diet. He denies any recent heat or cold intolerance, night sweats, fevers, chills, chest pain, palpitations, lightheadedness, dizziness, presyncope, actual syncope. Past Medical History: PAST MEDICAL HISTORY: ======================= 1. CARDIAC RISK FACTORS - Hypertension, not on treatment since [MASKED]. - Hyperlipidemia, not on treatment since [MASKED]. 2. CARDIAC HISTORY - Coronary angiography which demonstrated no obstructive disease [MASKED] - CHFrEF (30%, severe 4+ MR, 4+ TR) - Permanent atrial flutter/fibrillation (patient declined anticoagulation). 3. OTHER PAST MEDICAL HISTORY - Left pneumonectomy for childhood bronchiectasis before the age of [MASKED]. - Superficial spreading adenocarcinoma of the stomach and esophagus in [MASKED] status post esophageal gastrectomy. - Recurrent esophageal adenocarcinoma at the GE junction, T3, N0, M0, however, technically unresectable, status post chemotherapy with [MASKED] and cisplatin as well as radiation. Reportedly in remission. - Subclinical hypothyroidism with TSH of 11.8. Normal T4, T3 levels. Commenced levothyroxine at 50 mcg daily in mid [MASKED]. Social History: [MASKED] Family History: FAMILY HISTORY: Significant for heart disease in his father and his sister. He father died of a heart problem when the patient was [MASKED] years old. He does not know the etiology of the heart disease. His sister died in her [MASKED] from a valvular heart problem. No known family history of CAD or sudden cardiac death. Physical Exam: PHYSICAL EXAMINATION: ======================= VS: [MASKED] 1800 Temp: 98.1 PO BP: 124/91 HR: 86 RR: 18 O2 sat: 95% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: [MASKED] Weight: 125.1lbs GENERAL: Cachectic, chronically ill-appearing, NAD HEENT: Normocephalic and atraumatic. The oropharynx is benign. NECK: Elevated jugular venous pressure, ~10cm CHEST: Decreased breath sounds on the left, clear on the right. Scattered rhonchi heard diffusely in all lung fields. HEART: Irregular rhythm, the heart sounds are best heard in the left axilla due to prior left pneumonectomy causing a shift in the heart position. There is a prominent holosystolic murmur that radiates to the left posterior thorax. ABDOMEN: Benign, without masses, tenderness, bruits, abdominojugular reflux, or fluid wave. Bowel sounds are normal. EXTREMITIES: Warm and well perfused. There is edema in the legs up to the mid shin. NEUROLOGIC: The patient is awake, alert, fully oriented, and fluently conversant. There are no focal neurologic abnormalities. Pertinent Results: Discharge Labs: [MASKED] 07:55AM BLOOD WBC-6.3 RBC-4.13* Hgb-13.8 Hct-43.7 MCV-106* MCH-33.4* MCHC-31.6* RDW-17.6* RDWSD-69.0* Plt [MASKED] [MASKED] 07:55AM BLOOD Glucose-71 UreaN-37* Creat-1.4* Na-142 K-5.0 Cl-96 HCO3-34* AnGap-12 [MASKED] 07:55AM BLOOD Calcium-9.6 Phos-3.7 Mg-2.2 Initial Labs: [MASKED] 03:30PM BLOOD WBC-6.1 RBC-4.47* Hgb-15.2 Hct-45.7 MCV-102* MCH-34.0* MCHC-33.3 RDW-17.6* RDWSD-66.0* Plt [MASKED] [MASKED] 03:30PM BLOOD Plt [MASKED] [MASKED] 03:30PM BLOOD [MASKED] [MASKED] 03:30PM BLOOD UreaN-39* Creat-1.5* Na-139 K-4.8 Cl-96 HCO3-30 AnGap-13 [MASKED] 03:30PM BLOOD ALT-9 AST-18 AlkPhos-108 TotBili-1.1 [MASKED] 03:30PM BLOOD Calcium-9.9 Mg-2.1 EGD: Tortuous esophagus with rightward angulation at 20cm. Able to pass standard gastroscope through area Brief Hospital Course: Patient Summary =============== [MASKED] y.o. M with a history of HTN, HLD, CHFrEF (30%, severe 4+ MR, 4+ TR), prior stomach and esophageal adenocarcinoma s/p resection and chemoradiation [MASKED] years ago now in remission, pHTN, prior L pneumonectomy for childhood bronchiectasis, with known inferior wall motion abnormality s/p myocardial perfusion imaging study showing no perfusion defects [MASKED] and coronary angiography which demonstrated no obstructive disease [MASKED], who presented for further evaluation of worsening dyspnea on exertion and cardiomyopathy with potential evaluation for MitraClip. Structural heart and Cardiac Surgery were consulted for possible valvular intervention. An EGD was done to see if a TEE wold be feasible given history of esophageal adenocarcinoma. Although he successfully had the EGD, a TEE was deferred because it was thought to be too risky to perform based on the anatomy of the esophagus seen on the EGD. Acute Issues ============ # Acute decompensation of HFrEF # Severe MR, TR Patient presents with worsening dyspnea on exertion and orthopnea for the past month, despite more aggressive diuresis (was on furosemide, changed over to torsemide). Unclear dry weight, although his weight has declined from 129lbs to 125lbs over the few days prior to admission. On physical exam, he seemed volume overloaded with worsening [MASKED] edema. His proBNP was elevated at [MASKED] (no baseline proBNP on file for comparison). Etiology for decompensation is multifactorial, likely including progression of mitral and tricuspid regurgitation, as well as his severe pulmonary HTN from progression of his progressive lung disease, and possible ischemic mitral regurgitation from a previous inferior posterior infarct. Worsening hypothyroidism may also have contributed to exacerbation. No sxs to suggest possible infectious etiology of decompensation. He was given IV Lasix 40mg BID until his volume status improved. He was given lisinopril 20mg and uptitrated to 30mg for afterload control, but BP did not allow further increase to home dose of 40 mg daily. He was continued on ASA 81 and metoprolol succinate 50mg. TEE was required for evaluation of MR for potential MitraClip. Given his anatomy and history of esophageal cancer, GI was consulted and performed and EGD to assess feasibility of TEE. Esophageal anatomy was tortuous on EGD and [MASKED] team decided it was too risky to perform study. MitraClip will be an ongoing discussion with outpatient cardiology. #Elevated TSH Patient had an elevated TSH to 36 on [MASKED]. Last TSH done in [MASKED] and was elevated to 6.46. He is very diligent about taking his medications and makes sure to wait 40 min before eating anything after taking levothyroxine. He does endorse progressively increased fatigue. Endocrine was consulted who felt that it is likely that he is not absorbing his medication which may be due to hx of gastric/esophageal adenocarcinoma and possible recurrence. His levothyroxine was increased to 88mg daily. We decided not to titrate it up too aggressively iso HFrEF exacerbation. # [MASKED] Cr 1.4 from apparent recent baseline of [MASKED], appears to have up-titrated with torsemide dose. Most likely cardiorenal syndrome, iso HF exacerbation, as above. Avoided nephrotoxins. Discharge Cr is 1.2. Chronic Issues ============== # Bronchiectasis # Pulmonary Hypertension Patient has a history of extensive lung disease with bronchiectasis, pneumonectomy, and most likely extensive scarring of pulmonary parenchymal tissue. He follows with pulmonology, and has derived some benefit from an appropriate pulmonary toilet regimen. We continued his home ipratropium bromide converted to nebulizer treatments while inpatient and continued his guaifenesin. # Atrial Fibrillation Per review of records, patient has a history of atrial fibrillation/atrial flutter, but has declined anticoagulation in the past. His rhythm on EKG was irregular. He was monitored on tele and his metoprolol was continued for rate control. # Back Pain Patient has severe chronic back pain, attributed to his osteoarthritis, which has been exacerbating his orthopnea. He declined any narcotics at this time, stating that they make him "loopy." He received Tylenol PRN and Lidocaine patches. # GERD - Continued lansoprazole 30 mg capsule BID # HLD - Continue home simvastatin 5 mg tablet QHS TRANSITIONAL ISSUES ==================== DISCHARGE WEIGHT:52.5kg (115.74lb) DISCHARGE Cr/BUN: 1.3/35 DISCHARGE DIURETIC: Torsemide 20mg BID Code Status: Full Code Contact: [MASKED] (wife), [MASKED] [MASKED] (son) [MASKED] [MASKED] (son) [MASKED] FOR CARDIOLOGY: [] During admission had EGD that showed that showed a rightward turn 20cm in the esophagus. The decision was made to defer TEE to further evaluate the valves given the high risk of traversing this turn and likely low image quality. Continue discussion regarding MitraClip and GOC. [] MitraClip consideration as outpatient [] Consider adding spironolactone to HF regimen [] Lisinopril 40mg was held upon admission due to elevated Cr. Was able to uptitrate to lisinopril 30mg by discharge, but further increase limited by hypotension. Consider titrating back up to Lisinopril 40mg. FOR PCP: [] Elevated TSH to 36 on [MASKED]. Last TSH done in [MASKED] and was elevated to 6.46. He is very diligent about taking his medications and makes sure to wait 40 min before eating anything after taking levothyroxine. Levothyroxine increased to 88mcg daily. Consider careful uptitration of levothyroxine as he has HFrEF and could cause an exacerbation. Patient should have repeat TSH in 6 weeks Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ipratropium Bromide MDI 2 PUFF IH TID 2. Lansoprazole Oral Disintegrating Tab 30 mg PO BID 3. Levothyroxine Sodium 50 mcg PO 4X/WEEK ([MASKED]) 4. Levothyroxine Sodium 100 mcg PO 3X/WEEK ([MASKED]) 5. Lisinopril 40 mg PO DAILY 6. Metoprolol Succinate XL 50 mg PO DAILY 7. Simvastatin 5 mg PO QPM 8. Torsemide 20 mg PO DAILY 9. Aspirin 81 mg PO DAILY 10. Cyanocobalamin 1000 mcg PO DAILY Discharge Medications: 1. Levothyroxine Sodium 88 mcg PO DAILY 2. Lisinopril 30 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Cyanocobalamin 1000 mcg PO DAILY 5. Ipratropium Bromide MDI 2 PUFF IH TID 6. Lansoprazole Oral Disintegrating Tab 30 mg PO BID 7. Metoprolol Succinate XL 50 mg PO DAILY 8. Simvastatin 5 mg PO QPM 9. Torsemide 20 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Heart Failure with reduced Ejection Fraction (HFrEF) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory Discharge Instructions: Dear Mr. [MASKED], It was a pleasure taking care of you at [MASKED] [MASKED]. WHY WAS I ADMITTED TO THE HOSPITAL? ===================================== You were feeling short of breath because you had fluid in your lungs. This was caused by a condition called heart failure, where your heart does not pump hard enough and fluid backs up into your lungs. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? ============================================== You were given medications to help get the fluid out. Your breathing got better and were ready to leave the hospital. Your cardiologist felt that if you had a procedure on your heart valve, your symptoms would improve. You had a test called an endoscopy/EGD to see if you could get another test called a transesophageal echocardiogram (TEE). After the EGD, The cardiologists felt that it was high risk to do the TEE. It was decided that the procedure on your heart valve would have to be an ongoing discussion with your outpatient cardiologist. WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? ========================================================= - Take all of your medications as prescribed (listed below) - Follow up with your doctors as listed below - Weigh yourself every morning. Your weight on discharge is 52.8kg (116.4lb). Call your doctor if your weight goes up more than 3 pounds (increases to a weight of 119.4 lb). - Call you doctor if you notice any of the "danger signs" below. We wish you the best! Your [MASKED] Team Followup Instructions: [MASKED] | [
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"I110: Hypertensive heart disease with heart failure",
"I5021: Acute systolic (congestive) heart failure",
"N179: Acute kidney failure, unspecified",
"R64: Cachexia",
"I4892: Unspecified atrial flutter",
"Z681: Body mass index [BMI] 19.9 or less, adult",
"E785: Hyperlipidemia, unspecified",
"K219: Gastro-esophageal reflux disease without esophagitis",
"E039: Hypothyroidism, unspecified",
"I482: Chronic atrial fibrillation",
"Z7901: Long term (current) use of anticoagulants",
"Z87891: Personal history of nicotine dependence",
"I2720: Pulmonary hypertension, unspecified",
"J479: Bronchiectasis, uncomplicated",
"Z85028: Personal history of other malignant neoplasm of stomach",
"Z8501: Personal history of malignant neoplasm of esophagus",
"Z9221: Personal history of antineoplastic chemotherapy",
"Z923: Personal history of irradiation",
"Z903: Acquired absence of stomach [part of]",
"K228: Other specified diseases of esophagus",
"M47819: Spondylosis without myelopathy or radiculopathy, site unspecified",
"I081: Rheumatic disorders of both mitral and tricuspid valves",
"K2970: Gastritis, unspecified, without bleeding"
] | [
"I110",
"N179",
"E785",
"K219",
"E039",
"Z7901",
"Z87891"
] | [] |
12,385,857 | 29,372,911 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nmorphine\n \nAttending: ___.\n \nChief Complaint:\nAbdominal pain\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ w/ PMH poorly-controlled IDDM (c/b retinopathy/blindness, \nneuropathy, nephropathy, and gastroparesis), CAD s/p NSTEMI \n___, NSCLC (LLL Stage 1a s/p XRT), HCV (not on tx), aortic \ndissection, CVA ___ c/w shower emboli on Plavix and w/ \nresidual LLE weakness), chronic pain on narcotics contract, \npresenting with ___ weeks of epigastric abd pain worsening in \nthe past ___ days which feels like his previous gastroparesis \nflares. Also with NBNB vomiting, unable to eat/drink. Feels pain \nis triggered by Denies CP, shortness of breath, diarrhea.\n\nIn the ED, \nInitial vitals were: T 99.5, HR 96, 178/96, 16, 96% RA \nExam notable for diffusely mildly tender abdomen, diffuse \ncrackles and congestion on auscultation of the lungs, known LLE \nweakness \nLabs notable for Hgb 12.7 (chronic microcytic anemia) and Na 132 \n(chronic hypoNa)\nImaging notable for CXR CT TORSO with no acute changes\nPatient was given Zofran\nDecision was made to admit for gastroparesis / failure to \ntolerate PO\n \nOn the floor, \nPatient is doing well, the Zofran in the ED helped his nausea \nsignificantly, and he is now sipping on ginger ale.\n \nPast Medical History:\n # CAD: NSTEMI in ___, treated with TPA \n- LHC minimal disease; thought d/t vasospasm. \n# infrarenal aortic dissection in ___ stable on CT in ED \n# DM2: poorly controlled, c/b neuropathy, nephropathy, \ngastropathy, retinopathy (legally blind) \n# Gastroparesis: gastric emptying study (___): Gastroparesis, \nat 4 hr 34% ingested activity remains in stomach \n# Chronic pancreatitis: dx by EUS (___)\n# NSCLC (LLL and precarinal LN) s/p XRT \n- CT scan (___) 2cm LLL mass w/spiculation \n- Bronch w/EUS, TBBx (___): no endobronchial lesions, no \nsuspicious LN, path adenocarcinoma \n- cervical mediastinoscopy (___): limited by cervical \narthritis, \nno malignancy at 4L/4R LN \n- CyberKnife SBRT LLL: 5400 cGy (3x1800 cGy), 76% isodose line \n- PET (___): Interval decrease in the avidity of the \nneoplastic lesion the LLL. Stable avidity in L hilum without \nclear anatomic \ncorrelate. \n# gastritis \n# Hemorrhoids \n# Hep C liver bx (___), hepC PCR (> 5,000,000 in ___. \n- Rebetron (Interferon plus Ribaviron) therapy stopped ___ for \nlack of response. \n# h/o IVDU, stopped in ___ \n# Neuropathy: on narcotics contract with Dr. ___ \n# glaucoma \n \nSocial History:\n___\nFamily History:\nMother-DM \nFather-DM \n \nPhysical Exam:\n==============================\nADMISSION PHYSICAL EXAM\n==============================\nVS: 98.4, 153/82, 87, 19, 100% RA \nGeneral: Alert, oriented\nHEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL \nCV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, \ngallops \nLungs: CTAB, no w/r/r\nAbdomen: Soft, non-distended, BS+, No HSM, mildly TTP in \nepigastrium but with no rebound or guarding \nGU: No foley \nExt: Warm and well perfused.\nNeuro: CNII-XII intact. Strength ___ in LLE. Otherwise strength \nand sensation intact. \n\n=============================\nDISCHARGE PHYSICAL EXAM\n=============================\nGENERAL: Chronically ill, thin.\nHEENT: Blind\nLUNGS: Clear\nABD: Soft, not distended, minimally tender, BS+\nEXT: Thin, WWP\nNEURO: Alert and oriented, speech fluent.\nPSYCH: Irritable, Flat affect\n \nPertinent Results:\n===============\nLABS\n===============\n___ 03:31AM BLOOD WBC-6.9 RBC-5.57 Hgb-12.7* Hct-41.2 \nMCV-74* MCH-22.8* MCHC-30.8* RDW-14.3 RDWSD-37.3 Plt ___\n___ 03:31AM BLOOD Glucose-189* UreaN-20 Creat-0.8 Na-132* \nK-3.8 Cl-96 HCO3-25 AnGap-15\n___ 03:31AM BLOOD ALT-10 AST-22 AlkPhos-73 TotBili-0.3\n===============\nIMAGING\n===============\nCT CHEST AND ABDOMEN ___:\n1. Unchanged chronic infrarenal abdominal aortic dissection \nextending into the\ncommon left iliac artery.\n2. Unchanged appearance of the left lower lobe region treated \nwith CyberKnife\nradiation with no findings to suggest recurrence.\n3. Right middle lobe bronchiectasis is unchanged.\n4. Small hiatal hernia.\n5. Bladder wall thickening is likely related to underdistention.\n---------------\nCT HEAD ___:\n1. Stable exam.\n2. No new infarct or hemorrhage.\n================\nDischarge labs\n================\n___ 06:40AM BLOOD WBC-10.2* RBC-5.55 Hgb-12.9* Hct-41.0 \nMCV-74* MCH-23.2* MCHC-31.5* RDW-14.5 RDWSD-37.9 Plt ___\n___ 06:40AM BLOOD Glucose-126* UreaN-16 Creat-0.9 Na-129* \nK-4.5 Cl-92* HCO3-24 AnGap-18\n___ 06:40AM BLOOD Calcium-8.7 Phos-3.0 Mg-1.___ w/ PMH poorly-controlled IDDM (c/b retinopathy/blindness, \nneuropathy, nephropathy, and gastroparesis), CAD s/p NSTEMI \n___, NSCLC (LLL Stage 1a s/p XRT), HCV (not on tx), aortic \ndissection, CVA ___ c/w shower emboli on Plavix and w/ \nresidual LLE weakness), chronic pain on narcotics contract, \npresenting with 1 week of worsening epigastric abd pain, n/v \nconsistent with gastroparesis flare. CT Abdomen and Chest ___ \nshowed no acute process. He was started on a liquid diet, nausea \nwas treated with zofran, and he was encouraged to take small \nfrequent meals with reglan three times per day before meals. \nOver the course of the hospitalization, his abdominal pain \nimproved and he was able to take PO. He was discharged with a \nfollow up appointment with his PCP.\n\n***Transitional issues***\n- continue to address patient's compliance with blood glucose \ncontrol\n- would continue to minimize narcotics and encourage \nnon-narcotic agents for pain control \n- home glargine decreased to 10 U qHS from 12 U. \n- lisinopril increased to 40 mg by time of discharge, consider \nchecking lytes and titrating dose as needed \nFC \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Docusate Sodium 200 mg PO DAILY \n2. Metoclopramide 10 mg PO TID \n3. Morphine SR (MS ___ 30 mg PO Q8H \n4. Omeprazole 20 mg PO BID \n5. Ondansetron 8 mg PO Q8H:PRN Nausea \n6. OxycoDONE (Immediate Release) 15 mg PO TID \n7. Senna 17.2 mg PO DAILY \n8. Simvastatin 20 mg PO QPM \n9. Sucralfate 1 gm PO QID \n10. Clopidogrel 75 mg PO DAILY \n11. Lisinopril 20 mg PO DAILY \n12. Glargine 12 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin\n\n \nDischarge Medications:\n1. Glargine 10 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin\nRX *insulin glargine [Lantus] 100 unit/mL AS DIR 10 Units before \nBED Disp #*5 Vial Refills:*0 \n2. Lisinopril 40 mg PO DAILY \nRX *lisinopril 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0 \n3. Clopidogrel 75 mg PO DAILY \n4. Docusate Sodium 200 mg PO DAILY \n5. Metoclopramide 10 mg PO TID \n6. Morphine SR (MS ___ 30 mg PO Q8H \n7. Omeprazole 20 mg PO BID \n8. Ondansetron 8 mg PO Q8H:PRN Nausea \n9. OxycoDONE (Immediate Release) 15 mg PO TID \n10. Senna 17.2 mg PO DAILY \n11. Simvastatin 20 mg PO QPM \n12. Sucralfate 1 gm PO QID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary Diagnosis: \nGastroparesis\n\nSecondary Diagnoses:\nHypertension\nDiabetes\nHeadache\nNeuropathy\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane) due to blindness\n\n \nDischarge Instructions:\nDear Mr ___,\n\nYou came to the hospital because you were having belly pain and \nwere unable to eat or drink for the last several days. You felt \nthis was consistent with a flare of your slow stomach emptying. \nA picture of your belly and chest was done in the emergency \ndepartment which showed no changes from prior. A CT scan of your \nhead showed no new abnormalities. You were started on a liquid \ndiet, your nausea was treated with zofran, and encouraged to \ntake small frequent meals with reglan three times per day before \nmeals. Over the course of your hospitalization, you improved and \nwere able to eventually eat and drink without a problem. You \nwere allowed to go home with a follow up appointment with your \nprimary doctor.\n\nWe wish you the best!\nYour ___ Care Team\n \nFollowup Instructions:\n___\n"
] | Allergies: morphine Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] w/ PMH poorly-controlled IDDM (c/b retinopathy/blindness, neuropathy, nephropathy, and gastroparesis), CAD s/p NSTEMI [MASKED], NSCLC (LLL Stage 1a s/p XRT), HCV (not on tx), aortic dissection, CVA [MASKED] c/w shower emboli on Plavix and w/ residual LLE weakness), chronic pain on narcotics contract, presenting with [MASKED] weeks of epigastric abd pain worsening in the past [MASKED] days which feels like his previous gastroparesis flares. Also with NBNB vomiting, unable to eat/drink. Feels pain is triggered by Denies CP, shortness of breath, diarrhea. In the ED, Initial vitals were: T 99.5, HR 96, 178/96, 16, 96% RA Exam notable for diffusely mildly tender abdomen, diffuse crackles and congestion on auscultation of the lungs, known LLE weakness Labs notable for Hgb 12.7 (chronic microcytic anemia) and Na 132 (chronic hypoNa) Imaging notable for CXR CT TORSO with no acute changes Patient was given Zofran Decision was made to admit for gastroparesis / failure to tolerate PO On the floor, Patient is doing well, the Zofran in the ED helped his nausea significantly, and he is now sipping on ginger ale. Past Medical History: # CAD: NSTEMI in [MASKED], treated with TPA - LHC minimal disease; thought d/t vasospasm. # infrarenal aortic dissection in [MASKED] stable on CT in ED # DM2: poorly controlled, c/b neuropathy, nephropathy, gastropathy, retinopathy (legally blind) # Gastroparesis: gastric emptying study ([MASKED]): Gastroparesis, at 4 hr 34% ingested activity remains in stomach # Chronic pancreatitis: dx by EUS ([MASKED]) # NSCLC (LLL and precarinal LN) s/p XRT - CT scan ([MASKED]) 2cm LLL mass w/spiculation - Bronch w/EUS, TBBx ([MASKED]): no endobronchial lesions, no suspicious LN, path adenocarcinoma - cervical mediastinoscopy ([MASKED]): limited by cervical arthritis, no malignancy at 4L/4R LN - CyberKnife SBRT LLL: 5400 cGy (3x1800 cGy), 76% isodose line - PET ([MASKED]): Interval decrease in the avidity of the neoplastic lesion the LLL. Stable avidity in L hilum without clear anatomic correlate. # gastritis # Hemorrhoids # Hep C liver bx ([MASKED]), hepC PCR (> 5,000,000 in [MASKED]. - Rebetron (Interferon plus Ribaviron) therapy stopped [MASKED] for lack of response. # h/o IVDU, stopped in [MASKED] # Neuropathy: on narcotics contract with Dr. [MASKED] # glaucoma Social History: [MASKED] Family History: Mother-DM Father-DM Physical Exam: ============================== ADMISSION PHYSICAL EXAM ============================== VS: 98.4, 153/82, 87, 19, 100% RA General: Alert, oriented HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: CTAB, no w/r/r Abdomen: Soft, non-distended, BS+, No HSM, mildly TTP in epigastrium but with no rebound or guarding GU: No foley Ext: Warm and well perfused. Neuro: CNII-XII intact. Strength [MASKED] in LLE. Otherwise strength and sensation intact. ============================= DISCHARGE PHYSICAL EXAM ============================= GENERAL: Chronically ill, thin. HEENT: Blind LUNGS: Clear ABD: Soft, not distended, minimally tender, BS+ EXT: Thin, WWP NEURO: Alert and oriented, speech fluent. PSYCH: Irritable, Flat affect Pertinent Results: =============== LABS =============== [MASKED] 03:31AM BLOOD WBC-6.9 RBC-5.57 Hgb-12.7* Hct-41.2 MCV-74* MCH-22.8* MCHC-30.8* RDW-14.3 RDWSD-37.3 Plt [MASKED] [MASKED] 03:31AM BLOOD Glucose-189* UreaN-20 Creat-0.8 Na-132* K-3.8 Cl-96 HCO3-25 AnGap-15 [MASKED] 03:31AM BLOOD ALT-10 AST-22 AlkPhos-73 TotBili-0.3 =============== IMAGING =============== CT CHEST AND ABDOMEN [MASKED]: 1. Unchanged chronic infrarenal abdominal aortic dissection extending into the common left iliac artery. 2. Unchanged appearance of the left lower lobe region treated with CyberKnife radiation with no findings to suggest recurrence. 3. Right middle lobe bronchiectasis is unchanged. 4. Small hiatal hernia. 5. Bladder wall thickening is likely related to underdistention. --------------- CT HEAD [MASKED]: 1. Stable exam. 2. No new infarct or hemorrhage. ================ Discharge labs ================ [MASKED] 06:40AM BLOOD WBC-10.2* RBC-5.55 Hgb-12.9* Hct-41.0 MCV-74* MCH-23.2* MCHC-31.5* RDW-14.5 RDWSD-37.9 Plt [MASKED] [MASKED] 06:40AM BLOOD Glucose-126* UreaN-16 Creat-0.9 Na-129* K-4.5 Cl-92* HCO3-24 AnGap-18 [MASKED] 06:40AM BLOOD Calcium-8.7 Phos-3.0 Mg-1.[MASKED] w/ PMH poorly-controlled IDDM (c/b retinopathy/blindness, neuropathy, nephropathy, and gastroparesis), CAD s/p NSTEMI [MASKED], NSCLC (LLL Stage 1a s/p XRT), HCV (not on tx), aortic dissection, CVA [MASKED] c/w shower emboli on Plavix and w/ residual LLE weakness), chronic pain on narcotics contract, presenting with 1 week of worsening epigastric abd pain, n/v consistent with gastroparesis flare. CT Abdomen and Chest [MASKED] showed no acute process. He was started on a liquid diet, nausea was treated with zofran, and he was encouraged to take small frequent meals with reglan three times per day before meals. Over the course of the hospitalization, his abdominal pain improved and he was able to take PO. He was discharged with a follow up appointment with his PCP. ***Transitional issues*** - continue to address patient's compliance with blood glucose control - would continue to minimize narcotics and encourage non-narcotic agents for pain control - home glargine decreased to 10 U qHS from 12 U. - lisinopril increased to 40 mg by time of discharge, consider checking lytes and titrating dose as needed FC Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Docusate Sodium 200 mg PO DAILY 2. Metoclopramide 10 mg PO TID 3. Morphine SR (MS [MASKED] 30 mg PO Q8H 4. Omeprazole 20 mg PO BID 5. Ondansetron 8 mg PO Q8H:PRN Nausea 6. OxycoDONE (Immediate Release) 15 mg PO TID 7. Senna 17.2 mg PO DAILY 8. Simvastatin 20 mg PO QPM 9. Sucralfate 1 gm PO QID 10. Clopidogrel 75 mg PO DAILY 11. Lisinopril 20 mg PO DAILY 12. Glargine 12 Units Bedtime Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Glargine 10 Units Bedtime Insulin SC Sliding Scale using HUM Insulin RX *insulin glargine [Lantus] 100 unit/mL AS DIR 10 Units before BED Disp #*5 Vial Refills:*0 2. Lisinopril 40 mg PO DAILY RX *lisinopril 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. Clopidogrel 75 mg PO DAILY 4. Docusate Sodium 200 mg PO DAILY 5. Metoclopramide 10 mg PO TID 6. Morphine SR (MS [MASKED] 30 mg PO Q8H 7. Omeprazole 20 mg PO BID 8. Ondansetron 8 mg PO Q8H:PRN Nausea 9. OxycoDONE (Immediate Release) 15 mg PO TID 10. Senna 17.2 mg PO DAILY 11. Simvastatin 20 mg PO QPM 12. Sucralfate 1 gm PO QID Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Gastroparesis Secondary Diagnoses: Hypertension Diabetes Headache Neuropathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane) due to blindness Discharge Instructions: Dear Mr [MASKED], You came to the hospital because you were having belly pain and were unable to eat or drink for the last several days. You felt this was consistent with a flare of your slow stomach emptying. A picture of your belly and chest was done in the emergency department which showed no changes from prior. A CT scan of your head showed no new abnormalities. You were started on a liquid diet, your nausea was treated with zofran, and encouraged to take small frequent meals with reglan three times per day before meals. Over the course of your hospitalization, you improved and were able to eventually eat and drink without a problem. You were allowed to go home with a follow up appointment with your primary doctor. We wish you the best! Your [MASKED] Care Team Followup Instructions: [MASKED] | [
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"E1143: Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy",
"E1121: Type 2 diabetes mellitus with diabetic nephropathy",
"I69354: Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side",
"F1120: Opioid dependence, uncomplicated",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"I252: Old myocardial infarction",
"Z85118: Personal history of other malignant neoplasm of bronchus and lung",
"Z7902: Long term (current) use of antithrombotics/antiplatelets",
"D509: Iron deficiency anemia, unspecified",
"E1140: Type 2 diabetes mellitus with diabetic neuropathy, unspecified",
"E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema",
"H548: Legal blindness, as defined in USA",
"Z720: Tobacco use",
"Z794: Long term (current) use of insulin",
"J479: Bronchiectasis, uncomplicated"
] | [
"I2510",
"I252",
"Z7902",
"D509",
"Z794"
] | [] |
13,288,557 | 26,949,466 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nCodeine / Aspirin / Children's Advil Allergy Sinus / Quinine / \nAdvil\n \nAttending: ___.\n \nChief Complaint:\nNonhealing right first toe amputation site\n \nMajor Surgical or Invasive Procedure:\n___ Right lower extremity diagnostic angiogram\n___ Right below knee amputation\n\n \nHistory of Present Illness:\n___ woman with known PAD status post right SFA stent in \n___ secondary to right hallux gangrene. She eventually \nunderwent right hallux amputation by Dr. ___. She presents \nto clinic with progressive infection in the right hallux \namputation site and is admitted to the hospital for IV \nantibiotics and to reassess perfusion.\n\n \nPast Medical History:\nPast medical history: PAD, HTN, Amyloid cardiomyopathy, HFrEF \nEF ~20% with apical thrombus, Afib. \n\nPast surgical history\n___ Right hallux amputation.\n___ right lower extremity angiogram. Angioplasty of the \nposterior tibial artery/ peroneal artery. Stenting of the SFA \nwith two 5 x 80 Zilver stents\n___ Mesenteric angiogram \n___ Laparoscopic repair of paraesophageal hernia \n \nSocial History:\n___\nFamily History:\nNon-contributory\n \nPhysical Exam:\nDISCHARGE PHSYICAL EXAM:\n\nVitals: 98.2 68 112/66 18 100%/RA\n\nGeneral: awake, alert, no acute distress\nHEENT: trachea midline\nCV: irregularly irregular rhythm, normal S1/2\nPulm: normal respiratory effort, clear to auscultation \nbilaterally\nGI: abdomen soft, non-distended, non-tender\nExtremities: warm and well perfused, s/p right below knee \namputation\nWounds: right lower extremity amputation incision \nclean/dry/intact with staples; left heel ulcer dry without \ngangrene\n \nPertinent Results:\nDISCHARGE LABS:\n\n___ 06:04AM BLOOD WBC-6.5 RBC-3.16* Hgb-9.2* Hct-29.6* \nMCV-94 MCH-29.1 MCHC-31.1* RDW-14.3 RDWSD-48.5* Plt ___\n___ 06:40AM BLOOD ___\n___ 06:40AM BLOOD Glucose-80 UreaN-8 Creat-0.5 Na-138 K-4.3 \nCl-100 HCO3-26 AnGap-12\n___ 06:40AM BLOOD Calcium-8.4 Phos-4.1 Mg-1.___ with history of amyloid cardiomyopathy (EF 20%), left \nventricular ___, and AFib on warfarin presented \nwith nonhealing right first toe ulcer following amputation. \nPatient was admitted to the vascular surgery service and started \non IV antibiotics. She underwent a right lower extremity \nangiogram to evaluate for possible revascularization, however \nthere were no intervenable lesions. Given the extent of her \ntissue loss and associated infection without revascularization \noptions. She underwent a right below knee amputation on ___. \nHer operative course was uncomplicated. \n.\nGiven her history of systolic heart failure, cardiology was \nconsulted for management of her heart failure pre and post \nprocedure. Her medications were adjusted per their \nrecommendations. Her blood pressures remained in the ___ \nsystolic, so hold parameters were implemented for her \nlisinopril, metoprolol, and spironolactone. She continued to \nreceive her home Lasix dose per cardiology. For her atrial \nfibrillation, she was bridged from heparin to Coumadin \nperioperatively. She was therapeutic on Coumadin at the time of \ndischarge. She was also restarted on her Plavix (held \n___ for her right lower extremity drug eluting \nstents. \n.\nPain management also was consulted due to severe pain post \namputation, refractory to femoral and popliteal blocks as well \nas dilaudid boluses. Her PO oxycodone was increased, as was her \nTylenol, and she was started on low dose gabapentin with good \nresult. \n.\nPatient received a nutrition consult per ___ policy of \nextended stays. This consult resulted in no intervention at \nthis time as patient reports consuming 3 full meals per day and \nweight has been stable per patient report. \n.\nShe worked with ___ who recommended rehab. Patient is scheduled \nto follow up with vascular surgery for a wound check. She will \nrequire continued adjustment of her Coumadin dosing based on INR \nchecks after discharge. \n.\nPatient is discharged to rehab in an improved and stable \ncondition.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Clopidogrel 75 mg PO DAILY \n2. Acetaminophen 1000 mg PO Q6H \n3. Atorvastatin 40 mg PO QPM \n4. Flovent HFA (fluticasone) 44 mcg/actuation inhalation BID \n5. FoLIC Acid 1 mg PO DAILY \n6. Furosemide 40 mg PO DAILY \n7. Lisinopril 2.5 mg PO DAILY \n8. Metoprolol Succinate XL 25 mg PO DAILY \n9. Multivitamins 1 TAB PO DAILY \n10. Spironolactone 12.5 mg PO DAILY \n11. Vitamin D ___ UNIT PO DAILY \n12. Pantoprazole 40 mg PO Q24H \n13. Warfarin 2.5 mg PO 6X/WEEK (___) \n14. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \n15. Warfarin 5 mg PO 1X/WEEK (TH) \n16. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB \n17. Docusate Sodium 100 mg PO BID \n18. Simethicone 40-80 mg PO QID:PRN gas pain \n\n \nDischarge Medications:\n1. Gabapentin 200 mg PO TID \n2. Senna 17.2 mg PO HS \n3. Metoprolol Succinate XL 12.5 mg PO DAILY \nHOLD FOR HR < 70, SYSTOLIC BLOOD PRESSURE < 110 \n4. ___ MD to order daily dose PO DAILY16 \n5. Acetaminophen 1000 mg PO Q6H \n6. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB \n7. Atorvastatin 40 mg PO QPM \n8. Clopidogrel 75 mg PO DAILY \n9. Docusate Sodium 100 mg PO BID \n10. Flovent HFA (fluticasone) 44 mcg/actuation inhalation BID \n11. FoLIC Acid 1 mg PO DAILY \n12. Furosemide 40 mg PO DAILY \n13. Lisinopril 2.5 mg PO DAILY \nHOLD FOR SYSTOLIC BLOOD PRESSURE < 110 \n14. Multivitamins 1 TAB PO DAILY \n15. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \nHOLD FOR SEDATION \nRX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours \nDisp #*40 Tablet Refills:*0 \n16. Pantoprazole 40 mg PO Q24H \n17. Simethicone 40-80 mg PO QID:PRN gas pain \n18. Spironolactone 12.5 mg PO DAILY \nHOLD FOR SYSTOLIC BLOOD PRESSURE < 110 \n19. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___ \n___)\n \nDischarge Diagnosis:\nPrimary: Peripheral vascular disease with critical limb ischemia\n\nSecondary: systolic heart failure, Atrial fibrillation on \ncoumadin\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou were admitted to ___ with a \nnon healing ulcer on your right first toe. You underwent a right \nlower extremity angiogram and, unfortunately, we were unable to \nperform any intervention to improve your blood flow. Given the \nextent of your right toe ulcer and associated infection, you \nunderwent a right below knee amputation. You have now recovered \nfrom surgery and are ready to be discharged. Please follow the \ninstructions below to continue your recovery:\nIt was a pleasure taking care of you at ___ \n___. During your hospitalization, you had surgery to \nremove unhealthy tissue on your lower extremity. You tolerated \nthe procedure well and are now ready to be discharged from the \nhospital. Please follow the recommendations below to ensure a \nspeedy and uneventful recovery.\n\nLOWER EXTREMITY AMPUTATION \nDISCHARGE INSTRUCTIONS\nACTIVITY \nYou should keep your amputation site elevated and straight \nwhenever possible. This will prevent swelling of the stump and \nmaintain flexibility in your joint. \nIt is very important that you put no weight or pressure on \nyour stump with activity or at rest to allow the wound to heal \nproperly. \nYou may use the opposite foot for transfers and pivots, if \napplicable. It will take time to learn to use a walker and \nlearn to transfer into and out of a wheelchair. \n\nMEDICATION\nBefore you leave the hospital, you will be given a list of all \nthe medicine you should take at home. If a medication that you \nnormally take is not on the list or a medication that you do not \ntake is on the list please discuss it with the team! \n\nYou will likely be prescribed narcotic pain medication on \ndischarge which can be very constipating. If you take \nnarcotics, please also take a stool softener such as Colace. \nIf constipation becomes a problem, your pharmacist can suggest \nan additional over the counter laxative. \n\nYou should take Tylenol ___ every 6 hours, as needed for \npain. If this is not enough, take your prescription narcotic \npain medication. You should require less pain medication each \nday. Do not take more than a daily total of 3000mg of Tylenol. \nTylenol is used as an ingredient in some other over-the-counter \nand prescription medications. Be aware of how much Tylenol you \nare taking in a day.\n\nBATHING/SHOWERING: \nYou may shower when you feel strong enough but no tub baths or \npools until you have permission from your surgeon and the \nincision is fully healed.\nAfter your shower, gently dry the incision well. Do not rub \nthe area. \n\nWOUND CARE:\nPlease keep the wound clean and dry. It is very important that \nthere is no pressure on the stump. If there is no drainage, \nyou may leave the incision open to air. \nYour staples/sutures will remain in for at least 4 weeks. At \nyour followup appointment, we will see if the incision has \nhealed enough to remove the staples. \nBefore you can be fitted for prosthesis (a man-made limb to \nreplace the limb that was removed) your incision needs to be \nfully healed. \n\nCALL THE OFFICE FOR: ___\nOpening, bleeding or drainage or odor from your stump incision \n\nRedness, swelling or warmth in your stump.\nFever greater than 101 degrees, chills, or worsening \nincisional/stump pain \n\nNO OTHER PROVIDER, EXCEPT YOUR VASCULAR SURGEON, SHOULD \nDETERMINE IF YOUR STAPLES ARE READY TO BE REMOVED FROM YOUR \nSTUMP! \nIF THERE ARE ANY QUESTIONS, THE PROVIDER SHOULD CALL THE \nVASCULAR SURGERY OFFICE AT ___ TO DISCUSS. THE \nSTAPLES WILL BE REMOVED IN THE OFFICE AT YOUR FOLLOWUP \nAPPOINTMENT WHEN IT IS DETERMINED BY THE VASCULAR SURGEON THAT \nTHE WOUND HAS SUFFICIENTLY HEALED.\nOn the discharge worksheet, Key Information for Other \nProviders must include:\nANTIBIOTICS: including duration \nANTICOAGULATION: including duration\nANTIPLATELET: including duration IE: Aspirin lifelong and \nplavix for the next ___ days.\nWEIGHTBEARING: \nCHANGES TO MEDICATION REGIMEN\n\nACTIVITY: \n On the side of your amputation you are non weight bearing for \n___ weeks. \n You should keep this amputation site elevated when ever \npossible. \n You may use the opposite foot for transfers and pivots.\n No driving until cleared by your Surgeon.\n No heavy lifting greater than 20 pounds for the next 3 weeks.\n\nBATHING/SHOWERING: \n You may shower when you get home\n No tub baths or pools / do not soak your foot for 4 weeks from \nyour date of surgery\n\nWOUND CARE:\n Sutures / Staples may have been removed before discharge. If \nthey are not, an appointment will be made for you to return for \nstaple removal. \n When the sutures are removed the doctor may or may not place \npieces of tape called steri-strips over the incision. These will \nstay on about a week and you may shower with them on. If these \ndo not fall off after 10 days, you may peel them off with warm \nwater and soap in the shower\n\nCAUTIONS:\n If you smoke, please make every attempt to quit. Your primary \ncare physician can help with this. Smoking causes narrowing of \nyour blood vessels which in turn decreases circulation. \n\nDIET:\n Low fat, low cholesterol / if you are diabetic follow your \ndietary restrictions as before \n\nCALL THE OFFICE FOR: ___\n Bleeding, redness of, or drainage from your foot wound\n New pain, numbness or discoloration of the skin on the \neffected foot\n Fever greater than 101 degrees, chills, increased redness, or \npus draining from the incision site.\n\nWeigh yourself every morning, call MD if weight goes up more \nthan 3 lbs.\n\nThank you for allowing us to participate in your care!\n\nSincerely, \nYour ___ Team\n\n \nFollowup Instructions:\n___\n"
] | Allergies: Codeine / Aspirin / Children's Advil Allergy Sinus / Quinine / Advil Chief Complaint: Nonhealing right first toe amputation site Major Surgical or Invasive Procedure: [MASKED] Right lower extremity diagnostic angiogram [MASKED] Right below knee amputation History of Present Illness: [MASKED] woman with known PAD status post right SFA stent in [MASKED] secondary to right hallux gangrene. She eventually underwent right hallux amputation by Dr. [MASKED]. She presents to clinic with progressive infection in the right hallux amputation site and is admitted to the hospital for IV antibiotics and to reassess perfusion. Past Medical History: Past medical history: PAD, HTN, Amyloid cardiomyopathy, HFrEF EF ~20% with apical thrombus, Afib. Past surgical history [MASKED] Right hallux amputation. [MASKED] right lower extremity angiogram. Angioplasty of the posterior tibial artery/ peroneal artery. Stenting of the SFA with two 5 x 80 Zilver stents [MASKED] Mesenteric angiogram [MASKED] Laparoscopic repair of paraesophageal hernia Social History: [MASKED] Family History: Non-contributory Physical Exam: DISCHARGE PHSYICAL EXAM: Vitals: 98.2 68 112/66 18 100%/RA General: awake, alert, no acute distress HEENT: trachea midline CV: irregularly irregular rhythm, normal S1/2 Pulm: normal respiratory effort, clear to auscultation bilaterally GI: abdomen soft, non-distended, non-tender Extremities: warm and well perfused, s/p right below knee amputation Wounds: right lower extremity amputation incision clean/dry/intact with staples; left heel ulcer dry without gangrene Pertinent Results: DISCHARGE LABS: [MASKED] 06:04AM BLOOD WBC-6.5 RBC-3.16* Hgb-9.2* Hct-29.6* MCV-94 MCH-29.1 MCHC-31.1* RDW-14.3 RDWSD-48.5* Plt [MASKED] [MASKED] 06:40AM BLOOD [MASKED] [MASKED] 06:40AM BLOOD Glucose-80 UreaN-8 Creat-0.5 Na-138 K-4.3 Cl-100 HCO3-26 AnGap-12 [MASKED] 06:40AM BLOOD Calcium-8.4 Phos-4.1 Mg-1.[MASKED] with history of amyloid cardiomyopathy (EF 20%), left ventricular [MASKED], and AFib on warfarin presented with nonhealing right first toe ulcer following amputation. Patient was admitted to the vascular surgery service and started on IV antibiotics. She underwent a right lower extremity angiogram to evaluate for possible revascularization, however there were no intervenable lesions. Given the extent of her tissue loss and associated infection without revascularization options. She underwent a right below knee amputation on [MASKED]. Her operative course was uncomplicated. . Given her history of systolic heart failure, cardiology was consulted for management of her heart failure pre and post procedure. Her medications were adjusted per their recommendations. Her blood pressures remained in the [MASKED] systolic, so hold parameters were implemented for her lisinopril, metoprolol, and spironolactone. She continued to receive her home Lasix dose per cardiology. For her atrial fibrillation, she was bridged from heparin to Coumadin perioperatively. She was therapeutic on Coumadin at the time of discharge. She was also restarted on her Plavix (held [MASKED] for her right lower extremity drug eluting stents. . Pain management also was consulted due to severe pain post amputation, refractory to femoral and popliteal blocks as well as dilaudid boluses. Her PO oxycodone was increased, as was her Tylenol, and she was started on low dose gabapentin with good result. . Patient received a nutrition consult per [MASKED] policy of extended stays. This consult resulted in no intervention at this time as patient reports consuming 3 full meals per day and weight has been stable per patient report. . She worked with [MASKED] who recommended rehab. Patient is scheduled to follow up with vascular surgery for a wound check. She will require continued adjustment of her Coumadin dosing based on INR checks after discharge. . Patient is discharged to rehab in an improved and stable condition. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Clopidogrel 75 mg PO DAILY 2. Acetaminophen 1000 mg PO Q6H 3. Atorvastatin 40 mg PO QPM 4. Flovent HFA (fluticasone) 44 mcg/actuation inhalation BID 5. FoLIC Acid 1 mg PO DAILY 6. Furosemide 40 mg PO DAILY 7. Lisinopril 2.5 mg PO DAILY 8. Metoprolol Succinate XL 25 mg PO DAILY 9. Multivitamins 1 TAB PO DAILY 10. Spironolactone 12.5 mg PO DAILY 11. Vitamin D [MASKED] UNIT PO DAILY 12. Pantoprazole 40 mg PO Q24H 13. Warfarin 2.5 mg PO 6X/WEEK ([MASKED]) 14. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain - Moderate 15. Warfarin 5 mg PO 1X/WEEK (TH) 16. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB 17. Docusate Sodium 100 mg PO BID 18. Simethicone 40-80 mg PO QID:PRN gas pain Discharge Medications: 1. Gabapentin 200 mg PO TID 2. Senna 17.2 mg PO HS 3. Metoprolol Succinate XL 12.5 mg PO DAILY HOLD FOR HR < 70, SYSTOLIC BLOOD PRESSURE < 110 4. [MASKED] MD to order daily dose PO DAILY16 5. Acetaminophen 1000 mg PO Q6H 6. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB 7. Atorvastatin 40 mg PO QPM 8. Clopidogrel 75 mg PO DAILY 9. Docusate Sodium 100 mg PO BID 10. Flovent HFA (fluticasone) 44 mcg/actuation inhalation BID 11. FoLIC Acid 1 mg PO DAILY 12. Furosemide 40 mg PO DAILY 13. Lisinopril 2.5 mg PO DAILY HOLD FOR SYSTOLIC BLOOD PRESSURE < 110 14. Multivitamins 1 TAB PO DAILY 15. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain - Moderate HOLD FOR SEDATION RX *oxycodone 5 mg [MASKED] tablet(s) by mouth every four (4) hours Disp #*40 Tablet Refills:*0 16. Pantoprazole 40 mg PO Q24H 17. Simethicone 40-80 mg PO QID:PRN gas pain 18. Spironolactone 12.5 mg PO DAILY HOLD FOR SYSTOLIC BLOOD PRESSURE < 110 19. Vitamin D [MASKED] UNIT PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] [MASKED]) Discharge Diagnosis: Primary: Peripheral vascular disease with critical limb ischemia Secondary: systolic heart failure, Atrial fibrillation on coumadin Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You were admitted to [MASKED] with a non healing ulcer on your right first toe. You underwent a right lower extremity angiogram and, unfortunately, we were unable to perform any intervention to improve your blood flow. Given the extent of your right toe ulcer and associated infection, you underwent a right below knee amputation. You have now recovered from surgery and are ready to be discharged. Please follow the instructions below to continue your recovery: It was a pleasure taking care of you at [MASKED] [MASKED]. During your hospitalization, you had surgery to remove unhealthy tissue on your lower extremity. You tolerated the procedure well and are now ready to be discharged from the hospital. Please follow the recommendations below to ensure a speedy and uneventful recovery. LOWER EXTREMITY AMPUTATION DISCHARGE INSTRUCTIONS ACTIVITY You should keep your amputation site elevated and straight whenever possible. This will prevent swelling of the stump and maintain flexibility in your joint. It is very important that you put no weight or pressure on your stump with activity or at rest to allow the wound to heal properly. You may use the opposite foot for transfers and pivots, if applicable. It will take time to learn to use a walker and learn to transfer into and out of a wheelchair. MEDICATION Before you leave the hospital, you will be given a list of all the medicine you should take at home. If a medication that you normally take is not on the list or a medication that you do not take is on the list please discuss it with the team! You will likely be prescribed narcotic pain medication on discharge which can be very constipating. If you take narcotics, please also take a stool softener such as Colace. If constipation becomes a problem, your pharmacist can suggest an additional over the counter laxative. You should take Tylenol [MASKED] every 6 hours, as needed for pain. If this is not enough, take your prescription narcotic pain medication. You should require less pain medication each day. Do not take more than a daily total of 3000mg of Tylenol. Tylenol is used as an ingredient in some other over-the-counter and prescription medications. Be aware of how much Tylenol you are taking in a day. BATHING/SHOWERING: You may shower when you feel strong enough but no tub baths or pools until you have permission from your surgeon and the incision is fully healed. After your shower, gently dry the incision well. Do not rub the area. WOUND CARE: Please keep the wound clean and dry. It is very important that there is no pressure on the stump. If there is no drainage, you may leave the incision open to air. Your staples/sutures will remain in for at least 4 weeks. At your followup appointment, we will see if the incision has healed enough to remove the staples. Before you can be fitted for prosthesis (a man-made limb to replace the limb that was removed) your incision needs to be fully healed. CALL THE OFFICE FOR: [MASKED] Opening, bleeding or drainage or odor from your stump incision Redness, swelling or warmth in your stump. Fever greater than 101 degrees, chills, or worsening incisional/stump pain NO OTHER PROVIDER, EXCEPT YOUR VASCULAR SURGEON, SHOULD DETERMINE IF YOUR STAPLES ARE READY TO BE REMOVED FROM YOUR STUMP! IF THERE ARE ANY QUESTIONS, THE PROVIDER SHOULD CALL THE VASCULAR SURGERY OFFICE AT [MASKED] TO DISCUSS. THE STAPLES WILL BE REMOVED IN THE OFFICE AT YOUR FOLLOWUP APPOINTMENT WHEN IT IS DETERMINED BY THE VASCULAR SURGEON THAT THE WOUND HAS SUFFICIENTLY HEALED. On the discharge worksheet, Key Information for Other Providers must include: ANTIBIOTICS: including duration ANTICOAGULATION: including duration ANTIPLATELET: including duration IE: Aspirin lifelong and plavix for the next [MASKED] days. WEIGHTBEARING: CHANGES TO MEDICATION REGIMEN ACTIVITY: On the side of your amputation you are non weight bearing for [MASKED] weeks. You should keep this amputation site elevated when ever possible. You may use the opposite foot for transfers and pivots. No driving until cleared by your Surgeon. No heavy lifting greater than 20 pounds for the next 3 weeks. BATHING/SHOWERING: You may shower when you get home No tub baths or pools / do not soak your foot for 4 weeks from your date of surgery WOUND CARE: Sutures / Staples may have been removed before discharge. If they are not, an appointment will be made for you to return for staple removal. When the sutures are removed the doctor may or may not place pieces of tape called steri-strips over the incision. These will stay on about a week and you may shower with them on. If these do not fall off after 10 days, you may peel them off with warm water and soap in the shower CAUTIONS: If you smoke, please make every attempt to quit. Your primary care physician can help with this. Smoking causes narrowing of your blood vessels which in turn decreases circulation. DIET: Low fat, low cholesterol / if you are diabetic follow your dietary restrictions as before CALL THE OFFICE FOR: [MASKED] Bleeding, redness of, or drainage from your foot wound New pain, numbness or discoloration of the skin on the effected foot Fever greater than 101 degrees, chills, increased redness, or pus draining from the incision site. Weigh yourself every morning, call MD if weight goes up more than 3 lbs. Thank you for allowing us to participate in your care! Sincerely, Your [MASKED] Team Followup Instructions: [MASKED] | [
"I70261",
"T8743",
"L97518",
"E854",
"I43",
"I5022",
"M868X7",
"K551",
"I480",
"R54",
"M0600",
"I2510",
"J45909",
"M545",
"E782",
"I110",
"I2722",
"G909",
"M810",
"Z95820",
"Z993",
"Z7901",
"Y929",
"Y835",
"I951",
"Z89411",
"G8918",
"I513",
"I701"
] | [
"I70261: Atherosclerosis of native arteries of extremities with gangrene, right leg",
"T8743: Infection of amputation stump, right lower extremity",
"L97518: Non-pressure chronic ulcer of other part of right foot with other specified severity",
"E854: Organ-limited amyloidosis",
"I43: Cardiomyopathy in diseases classified elsewhere",
"I5022: Chronic systolic (congestive) heart failure",
"M868X7: Other osteomyelitis, ankle and foot",
"K551: Chronic vascular disorders of intestine",
"I480: Paroxysmal atrial fibrillation",
"R54: Age-related physical debility",
"M0600: Rheumatoid arthritis without rheumatoid factor, unspecified site",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"J45909: Unspecified asthma, uncomplicated",
"M545: Low back pain",
"E782: Mixed hyperlipidemia",
"I110: Hypertensive heart disease with heart failure",
"I2722: Pulmonary hypertension due to left heart disease",
"G909: Disorder of the autonomic nervous system, unspecified",
"M810: Age-related osteoporosis without current pathological fracture",
"Z95820: Peripheral vascular angioplasty status with implants and grafts",
"Z993: Dependence on wheelchair",
"Z7901: Long term (current) use of anticoagulants",
"Y929: Unspecified place or not applicable",
"Y835: Amputation of limb(s) as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure",
"I951: Orthostatic hypotension",
"Z89411: Acquired absence of right great toe",
"G8918: Other acute postprocedural pain",
"I513: Intracardiac thrombosis, not elsewhere classified",
"I701: Atherosclerosis of renal artery"
] | [
"I480",
"I2510",
"J45909",
"I110",
"Z7901",
"Y929"
] | [] |
18,717,557 | 23,171,903 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nPenicillins / Ether For Anesthesia\n \nAttending: ___.\n \nChief Complaint:\nabdominal pain\n \nMajor Surgical or Invasive Procedure:\nERCP\n\n \nHistory of Present Illness:\n___ is a ___ w/ stage IIA pancreatic cancer, status\npost FOLFIRINOX x 4 months and SBRT, with recent imaging\nconcerning for hepatic recurrence who is admitted from the ED\nwith abdominal pain. \n\nPatient initially treated n ___. No evidence of \nrecurrence.\nHowever, on PET-CT ___ there was new lesion in liver and\nparatracheal/para-aortic nodes. Liver biopsy on ___\nnon-diagnostic. Repeat MRI on ___ showed concern for acute\ncholangitis vs met lesion in segment 8. He was started on\nciprofloxacin/flagyl empirically for cholangitis on ___. \n\nFor the last 1.5-2 months has been overall feeling unwell. Notes\nintermittent low grade fevers, last yesterday. +poor PO intake,\nnausea with +10lb weight loss over the past 2 mo, fatigue. Has\nstable abdominal pain and back pain. Unable to take PO since \nthis\nAM despite taking antiemetics. The pain comes on ___ min post\nprandial, and lasts x several hours, w/ minimal nausea, and very\nseldomly vomiting. Pain improves w/ ambulation. Hence he has\nlimited his po intake in attempt to prvent pain. no dysphagia \nnor\nodynophagia. \n\nIn the ED, initial VS were pain 5, T 99.2, HR 101, BP 130/86, RR\n20, O2 96%RA. Received 0.25 mg IV dilaudid and 10 mg po\noxycodone. RUQ US revealed according to the prelim ED report\n\"unchanged IHBD, known pancreatic ductal dilatation, fatty \nliver,\nRight lobe hypoechoic area DDx mass/fatty changes, no signs of\nabscess, will need further non-emergent imaging.\" \n\nREVIEW OF SYSTEMS: \nA complete 10-point review of systems was performed and was\nnegative unless otherwise noted in the HPI.\n \nPast Medical History:\nPancreatic cancer stage IIA (___)\n- ___ Noted decreased appetite, post prandial cramping, and\nultimately new jaundice. Also had a 25 lbs weight loss over a\nmonth or so. \n- ___bdomen showed intrahepatic and pancreatic\nductal dilation, but mass not clearly visualized.\n- ___ Tbili found to be 19.5, CEA 7.2, AlkPhos 269. ERCP\nshowed a tight stricture 4 cm long at the lower third of the\ncommon bile duct with post-obstructive dilation of the CBD, CHD\nand right and left main hepatic ducts. No filling defects were\nidentified in the CBD and CHD. Opacification of the gallbladder\nwas incomplete. Brushings of CBD were obtained for cytology. A\n___ x 7cm straight plastic stent was placed in the CBD. \nBiopsies\nconfirmed pancreatic adenocarcinoma\n- ___ CTA pancreas showed suggestion of an isodense mass in\nthe head of the pancreas without vascular involvement. Note was\nmade of gall bladder thickening which may be post procedural. \n- ___ Underwent ERCP with placement of the fully covered 10\nmm x 60 mm WallFlex biliary stent, ERCP demonstrated 4 cm CBD\nstricture. Managed on Cipro Flagyl for cholecystitis until ___\nor so. \n- ___ C1D1 FOLFOX\n- ___ C2D1 FOLFOX \n- ___ C2D15 w FOLFIRINOX\n- ___ CT torso showed stable disease with no metastatic\nspread. Mild reduction in ___\n- ___ C3D1 FOLFIRINOX\n- ___ Start CK\n- ___ Finish CK with 25 Gy to the tumor bed in 3 fractions\n- ___ C4D1 FOLFIRINOX\n- ___ C4D15 dose of FOLFIRINOX given after delay for\nsignificant fatigue after chemo and CK therapy\n- ___ Admitted to ___ with spontaneous pneumothorax\n- ___ Admitted with enteritis and Cdiff sepsis. \n- ___ CT showed stable pancreatic head mass\n- ___ Exploratory laparoscopy showed no evidence of\nmetastatic or unresectable disease, however developed severe\nhypoxia making him medically inoperable. \n- ___ CT torso showed stable disease in the pancreatic head\nwith a vascular filling defect in the liver that is unlikely to\nrepresent metastatic disease. \n- ___ CT torso showed stable pancreatic mass, no\nmetastatic disease\n- ___ CT torso showed stable pancreatic mass, no\nmetastatic disease\n- ___ CT torso showed stable disease, no metastatic\ndisease\n- ___ CT torso showed stable pancreatic mass, no\nmetastatic disease\n- ___ PET concerning for metastatic disease in liver and \nparatracheal/para-aoritc lymph nodes\n- ___ Liver biopsy negative for malignancy\n- ___ MR liver showed concern for acute cholangitis vs \nmet\nlesion in segment 8\n\nPAST MEDICAL HISTORY: \nPancreatic cancer, as above\nRecurrent cholangitis\nCOPD\nUmbilical Hernia\nH/O Inguinal hernia \nH/O Appendicitis \n\n \nSocial History:\n___\nFamily History:\nNo known family history of cancer\n \nPhysical Exam:\nVSS\nGENERAL: Pleasant, lying in bed comfortably\nEYES: Anicteric sclerea, PERLL, EOMI; \nENT: multiple white patches on tongue and scattered white spots\nin post pharynx, no cervical adenopathy\nCARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or\ngallops; 2+ radial pulses, 2+ DP pulses\nRESPIRATORY: Appears in no respiratory distress, clear to\nauscultation bilaterally, no crackles, wheezes, or rhonchi\nGASTROINTESTINAL: Normal bowel sounds; nondistended; soft,\nnontender without rebound or guarding; no hepatomegaly\nMUSKULOSKELATAL: Warm, well perfused extremities without lower\nextremity edema; Normal bulk \nNEURO: Alert, oriented, CN II-XII intact, motor and sensory\nfunction grossly intact\nSKIN: No significant rashes\nLYMPHATIC: No cervical, supraclavicular, submandibular\nlymphadenopathy. No significant ecchymoses\n\nDischarge Exam\n98.1 111 / 63 84 18 98 2lnc \n93% on RA \n88-89% with ambulation\nGen: NAD\nLung: Diffusely decrased bs throughout, no wheeze\nCV: RRR distant heart sounds\nAbd: Mild distension, nabs, soft\nExt: No edema\n \n\n \nPertinent Results:\n___ 08:33PM LACTATE-1.3\n___ 08:27PM GLUCOSE-97 UREA N-12 CREAT-0.8 SODIUM-137 \nPOTASSIUM-3.9 CHLORIDE-98 TOTAL CO2-26 ANION GAP-17\n___ 08:27PM estGFR-Using this\n___ 08:27PM ALT(SGPT)-23 AST(SGOT)-19 ALK PHOS-56 TOT \nBILI-0.4\n___ 08:27PM LIPASE-7\n___ 08:27PM cTropnT-<0.01\n___ 08:27PM ALBUMIN-4.2\n___ 08:27PM WBC-5.6 RBC-5.65 HGB-15.7 HCT-48.6 MCV-86 \nMCH-27.8 MCHC-32.3 RDW-13.3 RDWSD-41.7\n___ 08:27PM NEUTS-69.1 LYMPHS-18.5* MONOS-10.2 EOS-1.3 \nBASOS-0.4 IM ___ AbsNeut-3.86 AbsLymp-1.03* AbsMono-0.57 \nAbsEos-0.07 AbsBaso-0.02\n___ 08:27PM PLT COUNT-227\n___ 08:27PM ___ PTT-29.0 ___\n \nBrief Hospital Course:\n___ y.o male with h.o COPD, cholangitis, pancreatic cancer who\npresents with continued abdominal pain, recent dx cholangitis on\ncipro/flagyl, and reports of SOB. \n\n#abdominal pain \n#anorexia\n#pancreatic cancer\n#possible cholangitis. Recent imaging with concern for tumor \ninfiltration but also\nconcern for cholangitis. Pt without fever, leukocytosis, and \nLFTS. He was treated with antibiotics (before and during \nhospitalization) and MRCP suggested improvement in findings with \nantibiotics, so he went for ERCP. No evidence of cholangitis on \nERCP; stent replaced. He appeared stable during \nhospitalization, tolerated po before and after ERCP. HE will \ncontinue ciprofloxacin for four days after discharge as per ERCP \nprotocol. Ultimately, it appears that tumor progression may \nexplain his symptoms. He will f/u with oncology after \ndischarge. \n\n#dyspnea\n#copd, chronic -no hypoxia. No signs of infection or CHF at this \ntime. Has h.o COPD but no obvious signs of acute flare at this \ntime. He appears to have advanced COPD based on his exam and \nhypoxia, and he qualified for oxygen with ambulation. Home \noxygen set up on discharge. \n\n#h.o c.diff, fulminant, ___ years ago. Will continue flagyl while \nhe is on cipro and for one week afterwards. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID \n2. Ranitidine 150 mg PO DAILY:PRN indigestion \n3. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB \n4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain \n5. Ciprofloxacin HCl 500 mg PO Q12H \n6. MetroNIDAZOLE 500 mg PO TID \n7. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation \nDAILY \n\n \nDischarge Medications:\n1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB \n2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 4 Days \n3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID \n4. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation \nDAILY \n5. MetroNIDAZOLE 500 mg PO TID \nTake for 11 days \n6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain \n7. Ranitidine 150 mg PO DAILY:PRN indigestion \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nAbdominal pain\nCOPD\nPancreatic cancer\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nYou were admitted for abdominal pain and fevers. You were \ntreated with antibiotics because we were concerned that your \nsymptoms may have come from an infection in your bile duct. You \nhad an ERCP that did not show infection at this time. You will \nneed a repeat ERCP in ___ months to have the stent in your bile \nduct changed. Our team will contact you to have that scheduled.\n\nWe still recommend that you finish four days of ciprofloxacin to \nprevent infection, and that you take 11 days of the antibiotic \nflagyl to prevent C diff infection. You can use the pills of \ncipro and flagyl that you already have. \n\nWe also noted that your oxygen level is low when you walk, so we \nhave set you up with oxygen to use when you are walking. \n \nFollowup Instructions:\n___\n"
] | Allergies: Penicillins / Ether For Anesthesia Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: ERCP History of Present Illness: [MASKED] is a [MASKED] w/ stage IIA pancreatic cancer, status post FOLFIRINOX x 4 months and SBRT, with recent imaging concerning for hepatic recurrence who is admitted from the ED with abdominal pain. Patient initially treated n [MASKED]. No evidence of recurrence. However, on PET-CT [MASKED] there was new lesion in liver and paratracheal/para-aortic nodes. Liver biopsy on [MASKED] non-diagnostic. Repeat MRI on [MASKED] showed concern for acute cholangitis vs met lesion in segment 8. He was started on ciprofloxacin/flagyl empirically for cholangitis on [MASKED]. For the last 1.5-2 months has been overall feeling unwell. Notes intermittent low grade fevers, last yesterday. +poor PO intake, nausea with +10lb weight loss over the past 2 mo, fatigue. Has stable abdominal pain and back pain. Unable to take PO since this AM despite taking antiemetics. The pain comes on [MASKED] min post prandial, and lasts x several hours, w/ minimal nausea, and very seldomly vomiting. Pain improves w/ ambulation. Hence he has limited his po intake in attempt to prvent pain. no dysphagia nor odynophagia. In the ED, initial VS were pain 5, T 99.2, HR 101, BP 130/86, RR 20, O2 96%RA. Received 0.25 mg IV dilaudid and 10 mg po oxycodone. RUQ US revealed according to the prelim ED report "unchanged IHBD, known pancreatic ductal dilatation, fatty liver, Right lobe hypoechoic area DDx mass/fatty changes, no signs of abscess, will need further non-emergent imaging." REVIEW OF SYSTEMS: A complete 10-point review of systems was performed and was negative unless otherwise noted in the HPI. Past Medical History: Pancreatic cancer stage IIA ([MASKED]) - [MASKED] Noted decreased appetite, post prandial cramping, and ultimately new jaundice. Also had a 25 lbs weight loss over a month or so. - bdomen showed intrahepatic and pancreatic ductal dilation, but mass not clearly visualized. - [MASKED] Tbili found to be 19.5, CEA 7.2, AlkPhos 269. ERCP showed a tight stricture 4 cm long at the lower third of the common bile duct with post-obstructive dilation of the CBD, CHD and right and left main hepatic ducts. No filling defects were identified in the CBD and CHD. Opacification of the gallbladder was incomplete. Brushings of CBD were obtained for cytology. A [MASKED] x 7cm straight plastic stent was placed in the CBD. Biopsies confirmed pancreatic adenocarcinoma - [MASKED] CTA pancreas showed suggestion of an isodense mass in the head of the pancreas without vascular involvement. Note was made of gall bladder thickening which may be post procedural. - [MASKED] Underwent ERCP with placement of the fully covered 10 mm x 60 mm WallFlex biliary stent, ERCP demonstrated 4 cm CBD stricture. Managed on Cipro Flagyl for cholecystitis until [MASKED] or so. - [MASKED] C1D1 FOLFOX - [MASKED] C2D1 FOLFOX - [MASKED] C2D15 w FOLFIRINOX - [MASKED] CT torso showed stable disease with no metastatic spread. Mild reduction in [MASKED] - [MASKED] C3D1 FOLFIRINOX - [MASKED] Start CK - [MASKED] Finish CK with 25 Gy to the tumor bed in 3 fractions - [MASKED] C4D1 FOLFIRINOX - [MASKED] C4D15 dose of FOLFIRINOX given after delay for significant fatigue after chemo and CK therapy - [MASKED] Admitted to [MASKED] with spontaneous pneumothorax - [MASKED] Admitted with enteritis and Cdiff sepsis. - [MASKED] CT showed stable pancreatic head mass - [MASKED] Exploratory laparoscopy showed no evidence of metastatic or unresectable disease, however developed severe hypoxia making him medically inoperable. - [MASKED] CT torso showed stable disease in the pancreatic head with a vascular filling defect in the liver that is unlikely to represent metastatic disease. - [MASKED] CT torso showed stable pancreatic mass, no metastatic disease - [MASKED] CT torso showed stable pancreatic mass, no metastatic disease - [MASKED] CT torso showed stable disease, no metastatic disease - [MASKED] CT torso showed stable pancreatic mass, no metastatic disease - [MASKED] PET concerning for metastatic disease in liver and paratracheal/para-aoritc lymph nodes - [MASKED] Liver biopsy negative for malignancy - [MASKED] MR liver showed concern for acute cholangitis vs met lesion in segment 8 PAST MEDICAL HISTORY: Pancreatic cancer, as above Recurrent cholangitis COPD Umbilical Hernia H/O Inguinal hernia H/O Appendicitis Social History: [MASKED] Family History: No known family history of cancer Physical Exam: VSS GENERAL: Pleasant, lying in bed comfortably EYES: Anicteric sclerea, PERLL, EOMI; ENT: multiple white patches on tongue and scattered white spots in post pharynx, no cervical adenopathy CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or gallops; 2+ radial pulses, 2+ DP pulses RESPIRATORY: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi GASTROINTESTINAL: Normal bowel sounds; nondistended; soft, nontender without rebound or guarding; no hepatomegaly MUSKULOSKELATAL: Warm, well perfused extremities without lower extremity edema; Normal bulk NEURO: Alert, oriented, CN II-XII intact, motor and sensory function grossly intact SKIN: No significant rashes LYMPHATIC: No cervical, supraclavicular, submandibular lymphadenopathy. No significant ecchymoses Discharge Exam 98.1 111 / 63 84 18 98 2lnc 93% on RA 88-89% with ambulation Gen: NAD Lung: Diffusely decrased bs throughout, no wheeze CV: RRR distant heart sounds Abd: Mild distension, nabs, soft Ext: No edema Pertinent Results: [MASKED] 08:33PM LACTATE-1.3 [MASKED] 08:27PM GLUCOSE-97 UREA N-12 CREAT-0.8 SODIUM-137 POTASSIUM-3.9 CHLORIDE-98 TOTAL CO2-26 ANION GAP-17 [MASKED] 08:27PM estGFR-Using this [MASKED] 08:27PM ALT(SGPT)-23 AST(SGOT)-19 ALK PHOS-56 TOT BILI-0.4 [MASKED] 08:27PM LIPASE-7 [MASKED] 08:27PM cTropnT-<0.01 [MASKED] 08:27PM ALBUMIN-4.2 [MASKED] 08:27PM WBC-5.6 RBC-5.65 HGB-15.7 HCT-48.6 MCV-86 MCH-27.8 MCHC-32.3 RDW-13.3 RDWSD-41.7 [MASKED] 08:27PM NEUTS-69.1 LYMPHS-18.5* MONOS-10.2 EOS-1.3 BASOS-0.4 IM [MASKED] AbsNeut-3.86 AbsLymp-1.03* AbsMono-0.57 AbsEos-0.07 AbsBaso-0.02 [MASKED] 08:27PM PLT COUNT-227 [MASKED] 08:27PM [MASKED] PTT-29.0 [MASKED] Brief Hospital Course: [MASKED] y.o male with h.o COPD, cholangitis, pancreatic cancer who presents with continued abdominal pain, recent dx cholangitis on cipro/flagyl, and reports of SOB. #abdominal pain #anorexia #pancreatic cancer #possible cholangitis. Recent imaging with concern for tumor infiltration but also concern for cholangitis. Pt without fever, leukocytosis, and LFTS. He was treated with antibiotics (before and during hospitalization) and MRCP suggested improvement in findings with antibiotics, so he went for ERCP. No evidence of cholangitis on ERCP; stent replaced. He appeared stable during hospitalization, tolerated po before and after ERCP. HE will continue ciprofloxacin for four days after discharge as per ERCP protocol. Ultimately, it appears that tumor progression may explain his symptoms. He will f/u with oncology after discharge. #dyspnea #copd, chronic -no hypoxia. No signs of infection or CHF at this time. Has h.o COPD but no obvious signs of acute flare at this time. He appears to have advanced COPD based on his exam and hypoxia, and he qualified for oxygen with ambulation. Home oxygen set up on discharge. #h.o c.diff, fulminant, [MASKED] years ago. Will continue flagyl while he is on cipro and for one week afterwards. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 2. Ranitidine 150 mg PO DAILY:PRN indigestion 3. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB 4. OxycoDONE (Immediate Release) [MASKED] mg PO Q4H:PRN pain 5. Ciprofloxacin HCl 500 mg PO Q12H 6. MetroNIDAZOLE 500 mg PO TID 7. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation DAILY Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB 2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 4 Days 3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 4. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation DAILY 5. MetroNIDAZOLE 500 mg PO TID Take for 11 days 6. OxycoDONE (Immediate Release) [MASKED] mg PO Q4H:PRN pain 7. Ranitidine 150 mg PO DAILY:PRN indigestion Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Abdominal pain COPD Pancreatic cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for abdominal pain and fevers. You were treated with antibiotics because we were concerned that your symptoms may have come from an infection in your bile duct. You had an ERCP that did not show infection at this time. You will need a repeat ERCP in [MASKED] months to have the stent in your bile duct changed. Our team will contact you to have that scheduled. We still recommend that you finish four days of ciprofloxacin to prevent infection, and that you take 11 days of the antibiotic flagyl to prevent C diff infection. You can use the pills of cipro and flagyl that you already have. We also noted that your oxygen level is low when you walk, so we have set you up with oxygen to use when you are walking. Followup Instructions: [MASKED] | [
"R1011",
"B370",
"C250",
"J449",
"T85520A",
"R509",
"R630",
"R1013",
"Z87891",
"Z6826",
"Y848",
"Y929"
] | [
"R1011: Right upper quadrant pain",
"B370: Candidal stomatitis",
"C250: Malignant neoplasm of head of pancreas",
"J449: Chronic obstructive pulmonary disease, unspecified",
"T85520A: Displacement of bile duct prosthesis, initial encounter",
"R509: Fever, unspecified",
"R630: Anorexia",
"R1013: Epigastric pain",
"Z87891: Personal history of nicotine dependence",
"Z6826: Body mass index [BMI] 26.0-26.9, adult",
"Y848: Other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure",
"Y929: Unspecified place or not applicable"
] | [
"J449",
"Z87891",
"Y929"
] | [] |
11,653,610 | 27,244,714 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: OBSTETRICS/GYNECOLOGY\n \nAllergies: \nerythromycin base / Macrolide Antibiotics / Sulfa (Sulfonamide \nAntibiotics) / Quinolones\n \nAttending: ___.\n \nChief Complaint:\nmenorrhagia, fibroids\n \nMajor Surgical or Invasive Procedure:\nTotal abdominal hysterectomy\nBilateral Salpingo-oophorectomy\nCystoscopy \n\n \nHistory of Present Illness:\nMs. ___ presented with her partner for MIGS consult due to \nDUB, menorrhagia, fibroids. She was seen in ___ for a \nconsult for the same sx, but at that time was not ready to \ndiscuss surgery. She reports q2month menses, heavy in nature \nuntil this past cycle, which occurred late in ___. She noted \nnormal bleeding the first day, but then started soaking through \na super tampon and heavy pad q30min for 12 hours. She was seen \nat ___ with stable H./H, but noted to have enlarged \nfibroid uterus and endometrial stripe not able to be visualized. \n She denies nocturia and urinates ___. She does note \noccasional dyspareunia and can palpate her fibroid through her \nabdomen. She also notes severe pain when she sneezes. She is \nnow very interested in surgery and wants definitive solution for \nher sx.\n \nChart review-\n___ Pap/HPV wnl\n___ EMB: menstrual endometrium\n Cervical polypectomy: Benign endocervical polyp\n___ Pelvic ultrasound: Multi fibroid uterus with over 25 \nfibroids, largest 9.3cm. The largest fibroid has a submucosal \ncompanent ~30%. 10mm endometrial stripe, but mass effect \ndistorting lining due to fibroids. Left 2.1cm functional cyst, \nnl right ovary.\n___ H/H 12.7/37.7, HgbA1c 7.3\n___ Pelvic ultrasound (___)- 8.0 x 7.9 x 10.4cm \nfibroid and 5.8 x 5.2 x 4.8cm fibroid. Cannot evaluate \nendometrial stripe. Uterus 16.4 x 11.0 x 13.3cm. \n___ Depot Lupron 11.25mg\n \nPast Medical History:\nPMH: Anemia, T2DM, thyroid cancer, htn, depression \nPSH: thyroidectomy, breast biopsy, c/s x3 \n\n \nSocial History:\ndenies t/e/d\n \nPhysical Exam:\nInitial Physical Exam:\nEstimated body mass index is 28.39 kg/(m^2) as calculated from \nthe following:\n Height as of this encounter: 5' 7.5\" (1.715 m).\n Weight as of this encounter: 184 lb (83.5 kg).\n General: \nwell developed, well nourished female, appearing in no acute \ndistress\n Lymphatic: \nno cervical, supraclavicular, or inguinal adenopathy\n Neck: supple and no masses\n Thyroid: \nnon-tender, not enlarged, no palpable mass\n Chest: clear to auscultation and normal respiratory effort \n Heart: regular rate, rhythm and no murmur, rub, gallop \n Abdomen: \nsoft, non-tender and uterus palpable to umbilicus\n \n Extremities: \nnormal, no cyanosis, no clubbing, no edema\n \n Neurological: \nalert and oriented x 3 and normal to confrontation\n Pelvic:\n External Genitalia: \nno lesions or inflammation\n Vagina: \nno lesions, well estrogenized and patient tolerates introduction \nof speculum with no difficulty\n Pelvic Supports: \nnormal, no cystocele, rectocele, enterocele, or prolapse\n Cervix: \ncervical polyp and Tests done: Pap and HPV\n Uterus: \nirregular contour, decreased mobility, bulky and 20 week sized\n Adnexa: \nno palpable mass, no tenderness, ovaries palpated bilaterally\n Anus and Perineum: normal\n Rectum: not indicated\n\nPhysical Exam on Day of Discharge:\n___ 03:19 Temp: 98.7 PO BP: 111/73 L Lying HR: 82 RR: 20 O2\nsat: 95% O2 delivery: RA \n\nI/Os:\nLast Shift: 100cc PO / 280cc UOP \nLast 24hrs: 2414cc IVF + 850cc PO / 1546cc UOP\n\nGeneral: NAD, comfortable, sitting up in bed \nCV: RRR\nLungs: CTAB, nl work of breathing \nAbdomen: soft, mildly distended, appropriately tender to\npalpation, incision clean/dry/intact\nGU: pad with no spotting\nExtremities: no edema, no TTP, pneumoboots in place bilaterally \n \nPertinent Results:\n___ 03:55PM HBsAg-NEG\n___ 03:55PM HBs Ab-NEG HBc Ab-NEG\n___ 03:55PM HIV Ab-NEG\n___ 03:55PM HCV Ab-NEG\n \nBrief Hospital Course:\nOn ___, Ms. ___ was admitted to the gynecology service after \nundergoing a laparoscopy converted to total abdominal \nhysterectomy, bilateral salpingectomies, and cystoscopy for \nsymptom. Please see the operative report for full details.\nHer post-operative course was uncomplicated. Immediately \npost-op, her pain was controlled with IV Dilaudid and Toradol.\n\nOn post-operative day 1, her urine output was adequate, so her \nfoley was removed, and she voided spontaneously. Her diet was \nadvanced without difficulty, and she was transitioned to oral \noxycodone, ibuprofen, and tylenol.\n\nShe was continued on hydrochlorothiazide, atenolol, enalapril \nfor hypertension, atorvastatin for hyperlipidemia, sertraline \nfor depression, levothyroxine for history of thyroidectomy, and \ncalcium carbonate and zantac for acid reflux. For her type II \ndiabetes, she was continued on glimepiride and metformin and was \nwritten for an insulin sliding scale while inpatient.\n\nBy post-operative day 2, she was tolerating a regular diet, \nvoiding spontaneously, ambulating independently, and pain was \ncontrolled with oral medications. She was then discharged home \nin stable condition with outpatient follow-up scheduled.\n \nMedications on Admission:\natenolol, atorvastatin, enalapril, glimedpiride, hctz, iron, \nlevothyroxine, lorazepam, metformin, ranitidine, sertraline, MV\n \nDischarge Medications:\n1. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - \nModerate \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity\nDo not drive or drink alcohol while taking medication \nRX *oxycodone 5 mg ___ tablet(s) by mouth q4h prn Disp #*10 \nTablet Refills:*0 \n2. Atenolol 50 mg PO DAILY \n3. Atorvastatin 40 mg PO QPM \n4. Enalapril Maleate 40 mg PO DAILY \n5. glimepiride 1 mg oral QAM \n6. Hydrochlorothiazide 25 mg PO DAILY \n7. Levothyroxine Sodium 50 mcg PO DAILY \n8. MetFORMIN (Glucophage) 1000 mg PO BID \n9. Ranitidine 75 mg PO DAILY \n10. Sertraline 50 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nFibroid Uterus \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou were admitted to the gynecology service after your \nprocedure. You have recovered well and the team believes you are \nready to be discharged home. Please call Dr. ___ office \nwith any questions or concerns. Please follow the instructions \nbelow.\n\nGeneral instructions:\n* Take your medications as prescribed.\n* Do not drive while taking narcotics.\n* Take a stool softener such as colace while taking narcotics to \nprevent constipation.\n* Do not combine narcotic and sedative medications or alcohol.\n* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs.\n* No strenuous activity until your post-op appointment.\n* Nothing in the vagina (no tampons, no douching, no sex) for 6 \nweeks.\n* No heavy lifting of objects >10 lbs for 6 weeks.\n* You may eat a regular diet.\n* You may walk up and down stairs.\n\nIncision care:\n* You may shower and allow soapy water to run over incision; no \nscrubbing of incision. No tub baths for 6 weeks.\n* Since you have steri-strips, leave them on. They will fall off \non their own or be removed during your followup visit.\n\n \nFollowup Instructions:\n___\n"
] | Allergies: erythromycin base / Macrolide Antibiotics / Sulfa (Sulfonamide Antibiotics) / Quinolones Chief Complaint: menorrhagia, fibroids Major Surgical or Invasive Procedure: Total abdominal hysterectomy Bilateral Salpingo-oophorectomy Cystoscopy History of Present Illness: Ms. [MASKED] presented with her partner for MIGS consult due to DUB, menorrhagia, fibroids. She was seen in [MASKED] for a consult for the same sx, but at that time was not ready to discuss surgery. She reports q2month menses, heavy in nature until this past cycle, which occurred late in [MASKED]. She noted normal bleeding the first day, but then started soaking through a super tampon and heavy pad q30min for 12 hours. She was seen at [MASKED] with stable H./H, but noted to have enlarged fibroid uterus and endometrial stripe not able to be visualized. She denies nocturia and urinates [MASKED]. She does note occasional dyspareunia and can palpate her fibroid through her abdomen. She also notes severe pain when she sneezes. She is now very interested in surgery and wants definitive solution for her sx. Chart review- [MASKED] Pap/HPV wnl [MASKED] EMB: menstrual endometrium Cervical polypectomy: Benign endocervical polyp [MASKED] Pelvic ultrasound: Multi fibroid uterus with over 25 fibroids, largest 9.3cm. The largest fibroid has a submucosal companent ~30%. 10mm endometrial stripe, but mass effect distorting lining due to fibroids. Left 2.1cm functional cyst, nl right ovary. [MASKED] H/H 12.7/37.7, HgbA1c 7.3 [MASKED] Pelvic ultrasound ([MASKED])- 8.0 x 7.9 x 10.4cm fibroid and 5.8 x 5.2 x 4.8cm fibroid. Cannot evaluate endometrial stripe. Uterus 16.4 x 11.0 x 13.3cm. [MASKED] Depot Lupron 11.25mg Past Medical History: PMH: Anemia, T2DM, thyroid cancer, htn, depression PSH: thyroidectomy, breast biopsy, c/s x3 Social History: denies t/e/d Physical Exam: Initial Physical Exam: Estimated body mass index is 28.39 kg/(m^2) as calculated from the following: Height as of this encounter: 5' 7.5" (1.715 m). Weight as of this encounter: 184 lb (83.5 kg). General: well developed, well nourished female, appearing in no acute distress Lymphatic: no cervical, supraclavicular, or inguinal adenopathy Neck: supple and no masses Thyroid: non-tender, not enlarged, no palpable mass Chest: clear to auscultation and normal respiratory effort Heart: regular rate, rhythm and no murmur, rub, gallop Abdomen: soft, non-tender and uterus palpable to umbilicus Extremities: normal, no cyanosis, no clubbing, no edema Neurological: alert and oriented x 3 and normal to confrontation Pelvic: External Genitalia: no lesions or inflammation Vagina: no lesions, well estrogenized and patient tolerates introduction of speculum with no difficulty Pelvic Supports: normal, no cystocele, rectocele, enterocele, or prolapse Cervix: cervical polyp and Tests done: Pap and HPV Uterus: irregular contour, decreased mobility, bulky and 20 week sized Adnexa: no palpable mass, no tenderness, ovaries palpated bilaterally Anus and Perineum: normal Rectum: not indicated Physical Exam on Day of Discharge: [MASKED] 03:19 Temp: 98.7 PO BP: 111/73 L Lying HR: 82 RR: 20 O2 sat: 95% O2 delivery: RA I/Os: Last Shift: 100cc PO / 280cc UOP Last 24hrs: 2414cc IVF + 850cc PO / 1546cc UOP General: NAD, comfortable, sitting up in bed CV: RRR Lungs: CTAB, nl work of breathing Abdomen: soft, mildly distended, appropriately tender to palpation, incision clean/dry/intact GU: pad with no spotting Extremities: no edema, no TTP, pneumoboots in place bilaterally Pertinent Results: [MASKED] 03:55PM HBsAg-NEG [MASKED] 03:55PM HBs Ab-NEG HBc Ab-NEG [MASKED] 03:55PM HIV Ab-NEG [MASKED] 03:55PM HCV Ab-NEG Brief Hospital Course: On [MASKED], Ms. [MASKED] was admitted to the gynecology service after undergoing a laparoscopy converted to total abdominal hysterectomy, bilateral salpingectomies, and cystoscopy for symptom. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV Dilaudid and Toradol. On post-operative day 1, her urine output was adequate, so her foley was removed, and she voided spontaneously. Her diet was advanced without difficulty, and she was transitioned to oral oxycodone, ibuprofen, and tylenol. She was continued on hydrochlorothiazide, atenolol, enalapril for hypertension, atorvastatin for hyperlipidemia, sertraline for depression, levothyroxine for history of thyroidectomy, and calcium carbonate and zantac for acid reflux. For her type II diabetes, she was continued on glimepiride and metformin and was written for an insulin sliding scale while inpatient. By post-operative day 2, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled. Medications on Admission: atenolol, atorvastatin, enalapril, glimedpiride, hctz, iron, levothyroxine, lorazepam, metformin, ranitidine, sertraline, MV Discharge Medications: 1. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity Do not drive or drink alcohol while taking medication RX *oxycodone 5 mg [MASKED] tablet(s) by mouth q4h prn Disp #*10 Tablet Refills:*0 2. Atenolol 50 mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. Enalapril Maleate 40 mg PO DAILY 5. glimepiride 1 mg oral QAM 6. Hydrochlorothiazide 25 mg PO DAILY 7. Levothyroxine Sodium 50 mcg PO DAILY 8. MetFORMIN (Glucophage) 1000 mg PO BID 9. Ranitidine 75 mg PO DAILY 10. Sertraline 50 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Fibroid Uterus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. [MASKED] office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. * Since you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. Followup Instructions: [MASKED] | [
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"N920",
"N938",
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"Z7984",
"Z85850",
"I10",
"F329",
"E890",
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"N3289",
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] | [
"D250: Submucous leiomyoma of uterus",
"N920: Excessive and frequent menstruation with regular cycle",
"N938: Other specified abnormal uterine and vaginal bleeding",
"D649: Anemia, unspecified",
"E119: Type 2 diabetes mellitus without complications",
"Z7984: Long term (current) use of oral hypoglycemic drugs",
"Z85850: Personal history of malignant neoplasm of thyroid",
"I10: Essential (primary) hypertension",
"F329: Major depressive disorder, single episode, unspecified",
"E890: Postprocedural hypothyroidism",
"K219: Gastro-esophageal reflux disease without esophagitis",
"N736: Female pelvic peritoneal adhesions (postinfective)",
"N3289: Other specified disorders of bladder",
"R0683: Snoring"
] | [
"D649",
"E119",
"I10",
"F329",
"K219"
] | [] |
15,536,444 | 24,806,649 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nmirtazapine / Flagyl\n \nAttending: ___.\n \nChief Complaint:\nGIB, UTI\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nHPI: Pt is a ___ y/o F with PMHx of mild dementia, HFpEF, severe \nmitral regurgitation, diverticulosis, h/o c.diff, as well as \nseveral prior UTIs, here with several days of melena as well as \npositive UA. Of note, pt is quite HOH and was tired on arrival \nto the floor after spending all day in the ED. Much of history \nwas obtain from her grandson.\n\nPt recently moved into ___ in ___. At that time, \nher omeprazole was stopped as it was felt to not be needed. Over \nthe past 2 days, she has been noted to have melena. Hct was \nchecked at ___ and was down to 20.5 from 29 recently.\n\nShe was sent to the ED for evaluation.\n\nOf note, pt also has been having some more confusion recently. \nShe also reportedly had a fall several days ago (reported that \nshe slid out of bed). \n\nED Course:\nInitial VS: 98.3, 78, 100/63, 16, 97% RA, Pain ___\nLabs significant for Hct 22.9 -> 20.3, positive UA.\nImaging: CXR and CT head without acute process.\nMeds given:\n___ 13:00 IV Pantoprazole 40 mg\n___ 15:20 IV CeftriaXONE 1 gm\nVS prior to transfer: 98.3, 91, 145/60, 20, 98% RA, Pain ___\n\nCase discussed with GI, who recommended transfusion as well as \nIV PPI.\n\nOn arrival to the floor, the patient denies any complaints. She \nknows that she is in the \"hospital\" for \"bleeding.\" She denies \nany lightheadedness, dizziness, chest pain, palps, or abdominal \npain. She does not recall her recent fall. Per discussion with \nher grandson, she has not reported any dysuria.\n\nROS: As above. Denies lightheadedness, dizziness, chest pain, \nheart palpitations, shortness of breath, cough, nausea, \nvomiting. The remainder of the 10-point ROS was negative.\n\n \nPast Medical History:\nmild dementia\nHFpEF\nsevere mitral regurgitation\nrecurrent UTIs\ndiverticulosis\nC.diff\nGERD\nosteoporosis\n \nSocial History:\n___\nFamily History:\nNo significant family history of GI malignancies.\n \nPhysical Exam:\nADMISSION\nVS - 99.1, 146/54, 93, 18, 97%RA\nGEN - Sleeping but arousable to voice, very HOH\nHEENT - NC/AT, MMM\nNECK - Supple, JVP difficult to assess\nCV - RRR, ___ holosystolic murmur loudest at the apex\nRESP - Breathing comfortably, faint rales at the left base\nABD - S/NT/ND, BS present\nEXT - No ___ edema or calf tenderess noted\nSKIN - No apparent rashes\nNEURO - Orientation as per HPI\nPSYCH - Calm\n\nDISCAHRGE\nVS: AF, 97.6, 123/99, 81, 18, 93% RA\nPain: zero out of 10.\nGen: NAD, comfortable, sitting in chair wearing home clothes\nHEENT: MMM, anicteric\nCV: RRR, + systolic murmur\nPulm: CTAB anterior lung fields\nAbd: soft, NT, ND, NABS\nExt: thin, no edema\nSkin: warm, dry\nNeuro: \"hospital,\" \"I am not familiar with him, but due to be \nreplaced\" when asked about current president. Alert, fluent \nspeech.\nPsych: calm, appropriate\n \nPertinent Results:\nADMISSION\n___ 12:50PM BLOOD WBC-8.2 RBC-2.37* Hgb-7.1* Hct-22.9* \nMCV-97 MCH-30.0 MCHC-31.0* RDW-15.7* RDWSD-54.2* Plt ___\n___ 12:50PM BLOOD Neuts-78.0* Lymphs-13.1* Monos-6.8 \nEos-1.1 Baso-0.5 Im ___ AbsNeut-6.43* AbsLymp-1.08* \nAbsMono-0.56 AbsEos-0.09 AbsBaso-0.04\n___ 12:50PM BLOOD Glucose-105* UreaN-23* Creat-0.8 Na-143 \nK-4.0 Cl-106 HCO3-28 AnGap-13\n___ 12:50PM BLOOD ALT-13 AST-19 AlkPhos-104 TotBili-0.5\n\nMICRO\n___ 12:50 pm URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. \n PRESUMPTIVE IDENTIFICATION OF TWO COLONIAL \nMORPHOLOGIES. \n Cefazolin interpretative criteria are based on a dosage \nregimen of\n 2g every 8h. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n ESCHERICHIA COLI\n | \nAMPICILLIN------------ 4 S\nAMPICILLIN/SULBACTAM-- 4 S\nCEFAZOLIN------------- <=4 S\nCEFEPIME-------------- <=1 S\nCEFTAZIDIME----------- <=1 S\nCEFTRIAXONE----------- <=1 S\nCIPROFLOXACIN---------<=0.25 S\nGENTAMICIN------------ <=1 S\nMEROPENEM-------------<=0.25 S\nNITROFURANTOIN-------- <=16 S\nPIPERACILLIN/TAZO----- <=4 S\nTOBRAMYCIN------------ <=1 S\nTRIMETHOPRIM/SULFA---- <=1 S\n\nDischarge Labs:\n___ 07:03AM BLOOD WBC-9.9 RBC-3.30* Hgb-10.0* Hct-31.3* \nMCV-95 MCH-30.3 MCHC-31.9* RDW-14.7 RDWSD-51.3* Plt ___\n___ 07:03AM BLOOD Glucose-95 UreaN-11 Creat-1.0 Na-141 \nK-3.2* Cl-100 HCO3-29 AnGap-___ year old female with past medical history of dementia, \ndiastolic CHF, GERD previously on a PPI, admitted ___ acute \nblood loss anemia and melena, now on empiric PPI therapy with \nstability of hemoglobin, also acute bacterial UTI.\n\n# Acute GI Bleed / Acute Blood Loss Anemia - Patient presented \nwith melena in setting of recent discontinuation of her PPI. \nHgb nadired at 6.2, prompting transfusion of 2 units pRBCs \n___ x 1 unit, ___ x 1 unit). Patient started on IV PPI \nBID. Patient seen by GI, who felt that risk-benefit in this \npatient favored PPI BID with close observation over urgent \nendoscopy. Patient subsequently observed over 48 hours with \nstable Hgb and no signs of additional bleeding. Patient \ntolerated advancing of diet to regular without issue. Patient \ndischarged on BID PPI x 8 weeks, afterwards can transition to \ndaily indefinitely. Per GI should have Hpylori stool antigen \nsent. Discharge Hgb was 10.\n\n# Acute bacterial UTI - Confused and lethargic on admission, \nfound to have bacteruria. Per family, this is consistent with \nprior UTIs. Culture grew out Ecoli, S to cipro. Patient \nreceived 2 doses of IV CTX in the ED ___ on PO \nCipro with improvement. Will complete 5 day course on ___.\n\nTransitional Issues\n- Would recheck a Hgb in 1 week to ensure stability. Discharge \nHgb = 10.\n- Would check Hpylori Stool Antigen\n- Treat with pantoprazole BID x 8 weeks, then daily indefinitely\n- If signs of bleeding again, ___ GI will evaluate for \nendoscopy\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Omeprazole 20 mg PO BID \n2. LORazepam 0.125 mg PO Q8H:PRN oral dystonia / dysarthria \n3. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n4. Acetaminophen 650 mg PO BID:PRN pain \n5. Acetaminophen 650 mg PO BID \n6. Bisacodyl 10 mg PR QHS:PRN constipation \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO BID:PRN pain \n2. Acetaminophen 650 mg PO BID \n3. Bisacodyl 10 mg PR QHS:PRN constipation \n4. LORazepam 0.125 mg PO Q8H:PRN oral dystonia / dysarthria \n5. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n6. Ciprofloxacin HCl 250 mg PO Q24H \nlast day = ___ \nRX *ciprofloxacin HCl 250 mg 1 tablet(s) by mouth every 24 hours \nDisp #*1 Tablet Refills:*0\n7. Pantoprazole 40 mg PO Q12H \nBID x 8 weeks, then continue daily indefinitely \nRX *pantoprazole 40 mg 1 tablet(s) by mouth every 12 hours Disp \n#*60 Tablet Refills:*0\n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\n# Acute GI Bleed / Acute Blood Loss Anemia\n# Acute bacterial UTI\n\n \nDischarge Condition:\nMental Status: Confused - sometimes.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nMs ___: \n\nIt was a pleasure caring for you at ___. You were admitted \nwith bleeding from your GI tract. You were seen by GI \nspecialists and treated with medications to decrease the acid in \nyour stomach and allow it to heal. Your bleeding stopped and \nyou are now ready for discharge back to ___\n\nWe also found that you had a urinary tract infection. You were \ntreated with antibiotics and improved\n \nFollowup Instructions:\n___\n"
] | Allergies: mirtazapine / Flagyl Chief Complaint: GIB, UTI Major Surgical or Invasive Procedure: None History of Present Illness: HPI: Pt is a [MASKED] y/o F with PMHx of mild dementia, HFpEF, severe mitral regurgitation, diverticulosis, h/o c.diff, as well as several prior UTIs, here with several days of melena as well as positive UA. Of note, pt is quite HOH and was tired on arrival to the floor after spending all day in the ED. Much of history was obtain from her grandson. Pt recently moved into [MASKED] in [MASKED]. At that time, her omeprazole was stopped as it was felt to not be needed. Over the past 2 days, she has been noted to have melena. Hct was checked at [MASKED] and was down to 20.5 from 29 recently. She was sent to the ED for evaluation. Of note, pt also has been having some more confusion recently. She also reportedly had a fall several days ago (reported that she slid out of bed). ED Course: Initial VS: 98.3, 78, 100/63, 16, 97% RA, Pain [MASKED] Labs significant for Hct 22.9 -> 20.3, positive UA. Imaging: CXR and CT head without acute process. Meds given: [MASKED] 13:00 IV Pantoprazole 40 mg [MASKED] 15:20 IV CeftriaXONE 1 gm VS prior to transfer: 98.3, 91, 145/60, 20, 98% RA, Pain [MASKED] Case discussed with GI, who recommended transfusion as well as IV PPI. On arrival to the floor, the patient denies any complaints. She knows that she is in the "hospital" for "bleeding." She denies any lightheadedness, dizziness, chest pain, palps, or abdominal pain. She does not recall her recent fall. Per discussion with her grandson, she has not reported any dysuria. ROS: As above. Denies lightheadedness, dizziness, chest pain, heart palpitations, shortness of breath, cough, nausea, vomiting. The remainder of the 10-point ROS was negative. Past Medical History: mild dementia HFpEF severe mitral regurgitation recurrent UTIs diverticulosis C.diff GERD osteoporosis Social History: [MASKED] Family History: No significant family history of GI malignancies. Physical Exam: ADMISSION VS - 99.1, 146/54, 93, 18, 97%RA GEN - Sleeping but arousable to voice, very HOH HEENT - NC/AT, MMM NECK - Supple, JVP difficult to assess CV - RRR, [MASKED] holosystolic murmur loudest at the apex RESP - Breathing comfortably, faint rales at the left base ABD - S/NT/ND, BS present EXT - No [MASKED] edema or calf tenderess noted SKIN - No apparent rashes NEURO - Orientation as per HPI PSYCH - Calm DISCAHRGE VS: AF, 97.6, 123/99, 81, 18, 93% RA Pain: zero out of 10. Gen: NAD, comfortable, sitting in chair wearing home clothes HEENT: MMM, anicteric CV: RRR, + systolic murmur Pulm: CTAB anterior lung fields Abd: soft, NT, ND, NABS Ext: thin, no edema Skin: warm, dry Neuro: "hospital," "I am not familiar with him, but due to be replaced" when asked about current president. Alert, fluent speech. Psych: calm, appropriate Pertinent Results: ADMISSION [MASKED] 12:50PM BLOOD WBC-8.2 RBC-2.37* Hgb-7.1* Hct-22.9* MCV-97 MCH-30.0 MCHC-31.0* RDW-15.7* RDWSD-54.2* Plt [MASKED] [MASKED] 12:50PM BLOOD Neuts-78.0* Lymphs-13.1* Monos-6.8 Eos-1.1 Baso-0.5 Im [MASKED] AbsNeut-6.43* AbsLymp-1.08* AbsMono-0.56 AbsEos-0.09 AbsBaso-0.04 [MASKED] 12:50PM BLOOD Glucose-105* UreaN-23* Creat-0.8 Na-143 K-4.0 Cl-106 HCO3-28 AnGap-13 [MASKED] 12:50PM BLOOD ALT-13 AST-19 AlkPhos-104 TotBili-0.5 MICRO [MASKED] 12:50 pm URINE **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION OF TWO COLONIAL MORPHOLOGIES. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] ESCHERICHIA COLI | AMPICILLIN------------ 4 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 Discharge Labs: [MASKED] 07:03AM BLOOD WBC-9.9 RBC-3.30* Hgb-10.0* Hct-31.3* MCV-95 MCH-30.3 MCHC-31.9* RDW-14.7 RDWSD-51.3* Plt [MASKED] [MASKED] 07:03AM BLOOD Glucose-95 UreaN-11 Creat-1.0 Na-141 K-3.2* Cl-100 HCO3-29 AnGap-[MASKED] year old female with past medical history of dementia, diastolic CHF, GERD previously on a PPI, admitted [MASKED] acute blood loss anemia and melena, now on empiric PPI therapy with stability of hemoglobin, also acute bacterial UTI. # Acute GI Bleed / Acute Blood Loss Anemia - Patient presented with melena in setting of recent discontinuation of her PPI. Hgb nadired at 6.2, prompting transfusion of 2 units pRBCs [MASKED] x 1 unit, [MASKED] x 1 unit). Patient started on IV PPI BID. Patient seen by GI, who felt that risk-benefit in this patient favored PPI BID with close observation over urgent endoscopy. Patient subsequently observed over 48 hours with stable Hgb and no signs of additional bleeding. Patient tolerated advancing of diet to regular without issue. Patient discharged on BID PPI x 8 weeks, afterwards can transition to daily indefinitely. Per GI should have Hpylori stool antigen sent. Discharge Hgb was 10. # Acute bacterial UTI - Confused and lethargic on admission, found to have bacteruria. Per family, this is consistent with prior UTIs. Culture grew out Ecoli, S to cipro. Patient received 2 doses of IV CTX in the ED [MASKED] on PO Cipro with improvement. Will complete 5 day course on [MASKED]. Transitional Issues - Would recheck a Hgb in 1 week to ensure stability. Discharge Hgb = 10. - Would check Hpylori Stool Antigen - Treat with pantoprazole BID x 8 weeks, then daily indefinitely - If signs of bleeding again, [MASKED] GI will evaluate for endoscopy Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Omeprazole 20 mg PO BID 2. LORazepam 0.125 mg PO Q8H:PRN oral dystonia / dysarthria 3. Polyethylene Glycol 17 g PO DAILY:PRN constipation 4. Acetaminophen 650 mg PO BID:PRN pain 5. Acetaminophen 650 mg PO BID 6. Bisacodyl 10 mg PR QHS:PRN constipation Discharge Medications: 1. Acetaminophen 650 mg PO BID:PRN pain 2. Acetaminophen 650 mg PO BID 3. Bisacodyl 10 mg PR QHS:PRN constipation 4. LORazepam 0.125 mg PO Q8H:PRN oral dystonia / dysarthria 5. Polyethylene Glycol 17 g PO DAILY:PRN constipation 6. Ciprofloxacin HCl 250 mg PO Q24H last day = [MASKED] RX *ciprofloxacin HCl 250 mg 1 tablet(s) by mouth every 24 hours Disp #*1 Tablet Refills:*0 7. Pantoprazole 40 mg PO Q12H BID x 8 weeks, then continue daily indefinitely RX *pantoprazole 40 mg 1 tablet(s) by mouth every 12 hours Disp #*60 Tablet Refills:*0 Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: # Acute GI Bleed / Acute Blood Loss Anemia # Acute bacterial UTI Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Ms [MASKED]: It was a pleasure caring for you at [MASKED]. You were admitted with bleeding from your GI tract. You were seen by GI specialists and treated with medications to decrease the acid in your stomach and allow it to heal. Your bleeding stopped and you are now ready for discharge back to [MASKED] We also found that you had a urinary tract infection. You were treated with antibiotics and improved Followup Instructions: [MASKED] | [
"K921",
"N390",
"I5032",
"F0390",
"D62",
"B9620",
"H9190",
"Z66",
"I340",
"K5790",
"K219",
"M810",
"K5900"
] | [
"K921: Melena",
"N390: Urinary tract infection, site not specified",
"I5032: Chronic diastolic (congestive) heart failure",
"F0390: Unspecified dementia without behavioral disturbance",
"D62: Acute posthemorrhagic anemia",
"B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere",
"H9190: Unspecified hearing loss, unspecified ear",
"Z66: Do not resuscitate",
"I340: Nonrheumatic mitral (valve) insufficiency",
"K5790: Diverticulosis of intestine, part unspecified, without perforation or abscess without bleeding",
"K219: Gastro-esophageal reflux disease without esophagitis",
"M810: Age-related osteoporosis without current pathological fracture",
"K5900: Constipation, unspecified"
] | [
"N390",
"I5032",
"D62",
"Z66",
"K219",
"K5900"
] | [] |
17,756,342 | 21,698,914 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nKeflex / erythromycin (bulk)\n \nAttending: ___.\n \nChief Complaint:\nShortness of breath \n \nMajor Surgical or Invasive Procedure:\n___ CRP-P placement\n \nHistory of Present Illness:\n___ with PMH HFrEF, SVT, LBBB, AF on apixaban, HTN, hx of DVT \ns/p IVC filter who was initially admitted to ___ for acute \ndecompensated HFrEF exacerbation. \n\nPatient was recently admitted to ___ from ___ for \nAfib with RVR and CHF. TTE showed new EF 25% (>55% in ___. She \nunderwent unsuccessful DCCV on ___, and was started on \namiodarone with spontaneous conversion to sinus bradycardia. She \ndeveloped CHF symptoms post-procedurally, requiring diuresis. \nShe was started on Eliquis prior to that discharge.\n\nShe was admitted to ___ on ___ after presenting to CDAC with \nsignificant orthopnea, DOE, and worsening ADHF (12 lbs above \nEDW). At that time she was in AFib with RVR (HR 120s-130s); this \nwas thought to be the trigger for her HF exacerbation. During \nthis hospitalization she was diuresed and received Amiodarone, \nDigoxin, and Metoprolol for her AFib. \n\nShe was going to be discharged today, but developed bradycardia \ndown to the 30's as well as hypotension to the 100/50's. She \nwas asymptomatic throughout this time, but given the degree of \nher bradycardia and hypotension she was admitted to the CCU for \ninitiation of dopamine gtt, as well as monitoring in the setting \nof borderline hypotension.\n\nOn arrival to the CCU, Pt feels well. She denies any \nlightheadedness, dizziness, CP, SOB, palpitations, or other \nconcerns.\n\n \nPast Medical History:\nPAST MEDICAL HISTORY: \n1. CARDIAC RISK FACTORS \n -Hypertension \n2. CARDIAC HISTORY \n - Known LBBB \n - CABG: None \n - PERCUTANEOUS CORONARY INTERVENTIONS: None \n - PACING/ICD: None\n - Syncope in ___ due to wide complex tachycardia with QRS \nmorphology similar to baseline LBBB, consistent with SVT with \nLBBB, or bundle branch reentry.\n - S/p aborted EP study due to inability to advance catheter \nbeyond IVC filter.\n3. OTHER PAST MEDICAL HISTORY \n - DVT with IVC filter \n - Osteoarthritis \n - Brain aneurysm s/p clipping in ___, negative CT in ___ \n - Varicose veins s/p RLE microphlebectomy in ___ \n - ___ of notes s/p MOHs in ___ \n - Vaginal deliveries x 3 \n \nSocial History:\n___\nFamily History:\nNo family history of cardiac disease or sudden cardiac death.\n \nPhysical Exam:\nON ADMISSION:\nVS: Reviewed in metavision.\nGENERAL: Well developed, thin appearing elderly woman in NAD. \nOriented x3. Mood, affect appropriate. \nHEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. \nConjunctiva were pink. No xanthelasma. \nNECK: Supple. No JVP appreciated\nCARDIAC: Regular rate and rhythm. Normal S1, S2. ___ \nholosystolic murmur best heard at apex.\nLUNGS: No chest wall deformities or tenderness. Respiration is \nunlabored with no accessory muscle use. No crackles, wheezes or \nrhonchi. \nABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No \nsplenomegaly. \nEXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or \nperipheral edema. \nSKIN: No significant skin lesions or rashes. \nPULSES: Distal pulses palpable and symmetric. \n\nON DISCHARGE:\nPHYSICAL EXAMINATION: \nVS: afebrile, HR 80, BP 99-124/51-64, HR 80-120s, RR ___, O2\n92-95% on RA\n24hr I/O: 530/600, since MN: 560/100\nAdm Wt: 62.7\nWt: 62.7 -> 61.7 --> 61.1 --> 59.9 --> 54.8 --> 53 --> 52.7 -->\n52.2kg-->51.7\nEDW: 58.6kg (___)\nGENERAL: Well developed, thin appearing elderly woman in NAD.\nOriented x3. Mood, affect appropriate. \nHEENT: Sclerae anicteric. \nNECK: Supple. No JVD appreciated\nCARDIAC: Regular rate and rhythm. Normal S1, S2. ___ \nholosystolic\nmurmur best heard at apex. Pacer site with dressing c/d/I, no\nTTP, no hematoma\nLUNGS: No chest wall deformities or tenderness. Respiration is\nunlabored with no accessory muscle use. No crackles, wheezes or\nrhonchi. \nABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No\nsplenomegaly. \nEXTREMITIES: 1+ bilateral ___ pitting edema. Warm, well perfused.\nNo clubbing, cyanosis \nSKIN: No significant skin lesions or rashes. \nPULSES: Distal pulses palpable and symmetric.\n\n \nPertinent Results:\n___ 08:18PM URINE HOURS-RANDOM TOT PROT-6\n___ 08:18PM URINE U-PEP-NO PROTEIN\n___ 07:11PM LACTATE-2.2*\n___ 06:50PM GLUCOSE-186* UREA N-25* CREAT-0.9 SODIUM-138 \nPOTASSIUM-3.6 CHLORIDE-101 TOTAL CO2-24 ANION GAP-17\n___ 06:50PM CK(CPK)-51\n___ 06:50PM CK-MB-3 cTropnT-<0.01\n___ 06:50PM TOT PROT-5.1* CALCIUM-8.7 PHOSPHATE-3.2 \nMAGNESIUM-1.8\n___ 06:50PM PEP-NO SPECIFI Free K-21.1* Free ___ Fr \nK/L-1.1\n___ 10:45AM ___ TEMP-36.6 PO2-232* PCO2-34* PH-7.38 \nTOTAL CO2-21 BASE XS--3 INTUBATED-NOT INTUBA\n___ 10:45AM LACTATE-2.2*\n___ 10:35AM GLUCOSE-178* UREA N-24* CREAT-0.8 SODIUM-139 \nPOTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-21* ANION GAP-18\n___ 10:35AM estGFR-Using this\n___ 10:35AM LD(LDH)-374*\n___ 10:35AM CK-MB-4 cTropnT-<0.01 ___\n___ 10:35AM MAGNESIUM-2.0\n___ 10:35AM TSH-1.0\n___ 10:35AM WBC-5.2 RBC-4.46 HGB-13.0 HCT-41.8 MCV-94 \nMCH-29.1 MCHC-31.1* RDW-14.5 RDWSD-49.6*\n___ 10:35AM PLT COUNT-223\n___ 10:35AM ___\n \nBrief Hospital Course:\n___ with PMH HFrEF, SVT, LBBB, AF on apixaban, HTN, hx of DVT \ns/p IVC filter who is admitted for worsening shortness of breath \nwith exertion and PND, particularly night before the admission.\n\nThe patient was started on IV diuretics for significant edema in \nthe thigh. On admission the patient was noted to be in AFib with \nsoft BP. However, prior to EP evaluating her, her rhythm \nconverted back to sinus bradycardia. Due to holding parameters, \nwe often held her BB. on ___ she went back into AF with \nsoft BP. she was started on digoxin while diuresis continued \nwith Lasix ggt. Her ventricular rate improved with diuresis and \nher weight was reduced to 52.7 kg (62.7 kg on admission). She \nwas transitioned to po torsemide and was started on \nspironolactone 12.5 daily.\n\nThe patient underwent a stress echo which did showed LV \ndysfunction in the absence of angina or interpretable ST \nsegments. The echo showed no new regional wall motion \nabnormalities. The patient converted to symptomatic sinus \nbradycardia with starting digoxin, increasing her metop. During \nher episode of bradycardia the patient was observed in the CCU. \nShe developed TdP which terminated spontaneously without \nintervention. ATherefore a pacemaker was inserted with no \ncomplications to prevent bradycardia. On the day of discharge \nthe patient went into AF again without HD compromise. We \nincreased her metoprolol PO which controlled her rate but did \nnot convert her to sinus. Due to the acceptable functional \nstatus of the patient the patient was discharged with close \nmonitoring with ___\n\n# DISCHARGE WEIGHT: 52.7 kg (standing with only gown on)\n\nTRANSITIONAL ISSUE:\n[] The patient has a newly implanted pacemaker and will require \nfollow up with the device clinic. \n[] She was started on digoxin 0.125 po daily after an IV load. \nPlease check her digoxin level on follow up.\n[] On discharge her metoprolol dose was 50mg succinate. Please \nevaluated for need to up titrate this dose as tolerated. \n[] The patient has CKD and would require further monitoring of \nher kidney failure.\n[] she was started on torsemide 20 during this admission, close \nto the day of discharge. Please recheck her lytes and renal \nfunction in 1 week.\n[] the patient was started on spironolactone 12.5 daily\n[] the patient has recently lost her husband. We would recommend \nproviding support and evaluating her for grief in the following \nvisit.\n[] cah as outpatient\n[] her valsartan dose was reduced due to hypotension. She was \ndischarged on valsartan 80mg daily. \n\n# CONTACT: ___ ___\n# DISPO: ___ \n \n___ on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild \n2. Acyclovir 400 mg PO Q12H \n3. Apixaban 5 mg PO BID \n4. Albuterol Inhaler 2 PUFF IH Q6H:PRN Shortness of breath \n5. Valsartan 160 mg PO DAILY \n6. Amiodarone 200 mg PO DAILY \n7. Metoprolol Succinate XL 25 mg PO DAILY \n\n \nDischarge Medications:\n1. Digoxin 0.125 mg PO Q48H \nRX *digoxin [Digitek] 125 mcg 1 tablet(s) by mouth daily Disp \n#*14 Tablet Refills:*0 \n2. Spironolactone 12.5 mg PO DAILY \nRX *spironolactone [Aldactone] 25 mg 0.5 (One half) tablet(s) by \nmouth daily Disp #*7 Tablet Refills:*0 \n3. Torsemide 20 mg PO DAILY \nRX *torsemide [Demadex] 20 mg 1 tablet(s) by mouth daily Disp \n#*14 Tablet Refills:*0 \n4. Metoprolol Succinate XL 50 mg PO DAILY \n5. Valsartan 80 mg PO DAILY \n6. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild \n7. Acyclovir 400 mg PO Q12H \n8. Albuterol Inhaler 2 PUFF IH Q6H:PRN Shortness of breath \n9. Amiodarone 200 mg PO DAILY \n10. Apixaban 5 mg PO BID \nRX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day \nDisp #*60 Tablet Refills:*3 \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nprimary diagnosis:\n=======================\n-Acute in chronic heart failure\n-Atrial fibrillation\n\nsecondary diagnoses: \n====================\n -Hypertension \n - Known LBBB \n - S/p aborted EP study due to inability to advance catheter \n beyond IVC filter. \n - DVT with IVC filter \n - Osteoarthritis \n - Brain aneurysm s/p clipping in ___, negative CT in ___ \n - Varicose veins s/p RLE microphlebectomy in ___ \n - ___ of notes s/p MOHs in ___ \n - Vaginal deliveries x 3 \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nInstructions: \n\nDear Mr. ___,\n\nIt was a pleasure to help care for you during this \nhospitalization.\n\nWHY WERE YOU ADMITTED: You were admitted because you had \ndifficulty breathing.\n\nWHAT WE DID FOR YOU: We gave you medications to help remove \nfluid from your body. We also treated you for your heart \narrhythmia called atrial fibrillation. We started you on new \nmedications including: \n- digoxin (a medication that slows you fast heart rate)\n- Torsemide (a medication that helps you pee more)\n- spironolactone (a medication that helps you pee more)\n\nBecause your heart rhythm goes from too fast to too slow you had \na pacemaker installed with no complications.\n \nWHAT YOU SHOULD DO AFTER YOU LEAVE:\n-Please take all of your medications as prescribed\n-Please attend all of your follow up appointments\n-Please weigh yourself every day and call your doctors if your \n___ increases by 3 pounds in 1 day or 5 pounds in 2 days.\n\nWe wish you all the best.\n\nSincerely,\n\nYour ___ team \n \nFollowup Instructions:\n___\n"
] | Allergies: Keflex / erythromycin (bulk) Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: [MASKED] CRP-P placement History of Present Illness: [MASKED] with PMH HFrEF, SVT, LBBB, AF on apixaban, HTN, hx of DVT s/p IVC filter who was initially admitted to [MASKED] for acute decompensated HFrEF exacerbation. Patient was recently admitted to [MASKED] from [MASKED] for Afib with RVR and CHF. TTE showed new EF 25% (>55% in [MASKED]. She underwent unsuccessful DCCV on [MASKED], and was started on amiodarone with spontaneous conversion to sinus bradycardia. She developed CHF symptoms post-procedurally, requiring diuresis. She was started on Eliquis prior to that discharge. She was admitted to [MASKED] on [MASKED] after presenting to CDAC with significant orthopnea, DOE, and worsening ADHF (12 lbs above EDW). At that time she was in AFib with RVR (HR 120s-130s); this was thought to be the trigger for her HF exacerbation. During this hospitalization she was diuresed and received Amiodarone, Digoxin, and Metoprolol for her AFib. She was going to be discharged today, but developed bradycardia down to the 30's as well as hypotension to the 100/50's. She was asymptomatic throughout this time, but given the degree of her bradycardia and hypotension she was admitted to the CCU for initiation of dopamine gtt, as well as monitoring in the setting of borderline hypotension. On arrival to the CCU, Pt feels well. She denies any lightheadedness, dizziness, CP, SOB, palpitations, or other concerns. Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS -Hypertension 2. CARDIAC HISTORY - Known LBBB - CABG: None - PERCUTANEOUS CORONARY INTERVENTIONS: None - PACING/ICD: None - Syncope in [MASKED] due to wide complex tachycardia with QRS morphology similar to baseline LBBB, consistent with SVT with LBBB, or bundle branch reentry. - S/p aborted EP study due to inability to advance catheter beyond IVC filter. 3. OTHER PAST MEDICAL HISTORY - DVT with IVC filter - Osteoarthritis - Brain aneurysm s/p clipping in [MASKED], negative CT in [MASKED] - Varicose veins s/p RLE microphlebectomy in [MASKED] - [MASKED] of notes s/p MOHs in [MASKED] - Vaginal deliveries x 3 Social History: [MASKED] Family History: No family history of cardiac disease or sudden cardiac death. Physical Exam: ON ADMISSION: VS: Reviewed in metavision. GENERAL: Well developed, thin appearing elderly woman in NAD. Oriented x3. Mood, affect appropriate. HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. Conjunctiva were pink. No xanthelasma. NECK: Supple. No JVP appreciated CARDIAC: Regular rate and rhythm. Normal S1, S2. [MASKED] holosystolic murmur best heard at apex. LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No splenomegaly. EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. SKIN: No significant skin lesions or rashes. PULSES: Distal pulses palpable and symmetric. ON DISCHARGE: PHYSICAL EXAMINATION: VS: afebrile, HR 80, BP 99-124/51-64, HR 80-120s, RR [MASKED], O2 92-95% on RA 24hr I/O: 530/600, since MN: 560/100 Adm Wt: 62.7 Wt: 62.7 -> 61.7 --> 61.1 --> 59.9 --> 54.8 --> 53 --> 52.7 --> 52.2kg-->51.7 EDW: 58.6kg ([MASKED]) GENERAL: Well developed, thin appearing elderly woman in NAD. Oriented x3. Mood, affect appropriate. HEENT: Sclerae anicteric. NECK: Supple. No JVD appreciated CARDIAC: Regular rate and rhythm. Normal S1, S2. [MASKED] holosystolic murmur best heard at apex. Pacer site with dressing c/d/I, no TTP, no hematoma 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: 1+ bilateral [MASKED] pitting edema. Warm, well perfused. No clubbing, cyanosis SKIN: No significant skin lesions or rashes. PULSES: Distal pulses palpable and symmetric. Pertinent Results: [MASKED] 08:18PM URINE HOURS-RANDOM TOT PROT-6 [MASKED] 08:18PM URINE U-PEP-NO PROTEIN [MASKED] 07:11PM LACTATE-2.2* [MASKED] 06:50PM GLUCOSE-186* UREA N-25* CREAT-0.9 SODIUM-138 POTASSIUM-3.6 CHLORIDE-101 TOTAL CO2-24 ANION GAP-17 [MASKED] 06:50PM CK(CPK)-51 [MASKED] 06:50PM CK-MB-3 cTropnT-<0.01 [MASKED] 06:50PM TOT PROT-5.1* CALCIUM-8.7 PHOSPHATE-3.2 MAGNESIUM-1.8 [MASKED] 06:50PM PEP-NO SPECIFI Free K-21.1* Free [MASKED] Fr K/L-1.1 [MASKED] 10:45AM [MASKED] TEMP-36.6 PO2-232* PCO2-34* PH-7.38 TOTAL CO2-21 BASE XS--3 INTUBATED-NOT INTUBA [MASKED] 10:45AM LACTATE-2.2* [MASKED] 10:35AM GLUCOSE-178* UREA N-24* CREAT-0.8 SODIUM-139 POTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-21* ANION GAP-18 [MASKED] 10:35AM estGFR-Using this [MASKED] 10:35AM LD(LDH)-374* [MASKED] 10:35AM CK-MB-4 cTropnT-<0.01 [MASKED] [MASKED] 10:35AM MAGNESIUM-2.0 [MASKED] 10:35AM TSH-1.0 [MASKED] 10:35AM WBC-5.2 RBC-4.46 HGB-13.0 HCT-41.8 MCV-94 MCH-29.1 MCHC-31.1* RDW-14.5 RDWSD-49.6* [MASKED] 10:35AM PLT COUNT-223 [MASKED] 10:35AM [MASKED] Brief Hospital Course: [MASKED] with PMH HFrEF, SVT, LBBB, AF on apixaban, HTN, hx of DVT s/p IVC filter who is admitted for worsening shortness of breath with exertion and PND, particularly night before the admission. The patient was started on IV diuretics for significant edema in the thigh. On admission the patient was noted to be in AFib with soft BP. However, prior to EP evaluating her, her rhythm converted back to sinus bradycardia. Due to holding parameters, we often held her BB. on [MASKED] she went back into AF with soft BP. she was started on digoxin while diuresis continued with Lasix ggt. Her ventricular rate improved with diuresis and her weight was reduced to 52.7 kg (62.7 kg on admission). She was transitioned to po torsemide and was started on spironolactone 12.5 daily. The patient underwent a stress echo which did showed LV dysfunction in the absence of angina or interpretable ST segments. The echo showed no new regional wall motion abnormalities. The patient converted to symptomatic sinus bradycardia with starting digoxin, increasing her metop. During her episode of bradycardia the patient was observed in the CCU. She developed TdP which terminated spontaneously without intervention. ATherefore a pacemaker was inserted with no complications to prevent bradycardia. On the day of discharge the patient went into AF again without HD compromise. We increased her metoprolol PO which controlled her rate but did not convert her to sinus. Due to the acceptable functional status of the patient the patient was discharged with close monitoring with [MASKED] # DISCHARGE WEIGHT: 52.7 kg (standing with only gown on) TRANSITIONAL ISSUE: [] The patient has a newly implanted pacemaker and will require follow up with the device clinic. [] She was started on digoxin 0.125 po daily after an IV load. Please check her digoxin level on follow up. [] On discharge her metoprolol dose was 50mg succinate. Please evaluated for need to up titrate this dose as tolerated. [] The patient has CKD and would require further monitoring of her kidney failure. [] she was started on torsemide 20 during this admission, close to the day of discharge. Please recheck her lytes and renal function in 1 week. [] the patient was started on spironolactone 12.5 daily [] the patient has recently lost her husband. We would recommend providing support and evaluating her for grief in the following visit. [] cah as outpatient [] her valsartan dose was reduced due to hypotension. She was discharged on valsartan 80mg daily. # CONTACT: [MASKED] [MASKED] # DISPO: [MASKED] [MASKED] on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild 2. Acyclovir 400 mg PO Q12H 3. Apixaban 5 mg PO BID 4. Albuterol Inhaler 2 PUFF IH Q6H:PRN Shortness of breath 5. Valsartan 160 mg PO DAILY 6. Amiodarone 200 mg PO DAILY 7. Metoprolol Succinate XL 25 mg PO DAILY Discharge Medications: 1. Digoxin 0.125 mg PO Q48H RX *digoxin [Digitek] 125 mcg 1 tablet(s) by mouth daily Disp #*14 Tablet Refills:*0 2. Spironolactone 12.5 mg PO DAILY RX *spironolactone [Aldactone] 25 mg 0.5 (One half) tablet(s) by mouth daily Disp #*7 Tablet Refills:*0 3. Torsemide 20 mg PO DAILY RX *torsemide [Demadex] 20 mg 1 tablet(s) by mouth daily Disp #*14 Tablet Refills:*0 4. Metoprolol Succinate XL 50 mg PO DAILY 5. Valsartan 80 mg PO DAILY 6. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild 7. Acyclovir 400 mg PO Q12H 8. Albuterol Inhaler 2 PUFF IH Q6H:PRN Shortness of breath 9. Amiodarone 200 mg PO DAILY 10. Apixaban 5 mg PO BID RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*3 Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: primary diagnosis: ======================= -Acute in chronic heart failure -Atrial fibrillation secondary diagnoses: ==================== -Hypertension - Known LBBB - S/p aborted EP study due to inability to advance catheter beyond IVC filter. - DVT with IVC filter - Osteoarthritis - Brain aneurysm s/p clipping in [MASKED], negative CT in [MASKED] - Varicose veins s/p RLE microphlebectomy in [MASKED] - [MASKED] of notes s/p MOHs in [MASKED] - Vaginal deliveries x 3 Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Instructions: Dear Mr. [MASKED], It was a pleasure to help care for you during this hospitalization. WHY WERE YOU ADMITTED: You were admitted because you had difficulty breathing. WHAT WE DID FOR YOU: We gave you medications to help remove fluid from your body. We also treated you for your heart arrhythmia called atrial fibrillation. We started you on new medications including: - digoxin (a medication that slows you fast heart rate) - Torsemide (a medication that helps you pee more) - spironolactone (a medication that helps you pee more) Because your heart rhythm goes from too fast to too slow you had a pacemaker installed with no complications. WHAT YOU SHOULD DO AFTER YOU LEAVE: -Please take all of your medications as prescribed -Please attend all of your follow up appointments -Please weigh yourself every day and call your doctors if your [MASKED] increases by 3 pounds in 1 day or 5 pounds in 2 days. We wish you all the best. Sincerely, Your [MASKED] team Followup Instructions: [MASKED] | [
"I130",
"I5023",
"I472",
"N179",
"I959",
"I428",
"I272",
"E875",
"I495",
"H209",
"I447",
"Z86718",
"Z66",
"N189",
"M1990",
"Z85828",
"I480",
"R0902",
"I340",
"I361",
"I493",
"R748",
"Z45018"
] | [
"I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease",
"I5023: Acute on chronic systolic (congestive) heart failure",
"I472: Ventricular tachycardia",
"N179: Acute kidney failure, unspecified",
"I959: Hypotension, unspecified",
"I428: Other cardiomyopathies",
"I272: Other secondary pulmonary hypertension",
"E875: Hyperkalemia",
"I495: Sick sinus syndrome",
"H209: Unspecified iridocyclitis",
"I447: Left bundle-branch block, unspecified",
"Z86718: Personal history of other venous thrombosis and embolism",
"Z66: Do not resuscitate",
"N189: Chronic kidney disease, unspecified",
"M1990: Unspecified osteoarthritis, unspecified site",
"Z85828: Personal history of other malignant neoplasm of skin",
"I480: Paroxysmal atrial fibrillation",
"R0902: Hypoxemia",
"I340: Nonrheumatic mitral (valve) insufficiency",
"I361: Nonrheumatic tricuspid (valve) insufficiency",
"I493: Ventricular premature depolarization",
"R748: Abnormal levels of other serum enzymes",
"Z45018: Encounter for adjustment and management of other part of cardiac pacemaker"
] | [
"I130",
"N179",
"Z86718",
"Z66",
"N189",
"I480"
] | [] |
10,651,088 | 27,058,147 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: PSYCHIATRY\n \nAllergies: \nCompazine\n \nAttending: ___.\n \nChief Complaint:\n\"I am fed up with my life\"\n\n \nMajor Surgical or Invasive Procedure:\nnone\n \nHistory of Present Illness:\n___ is a ___ year old female with history of\ndepression, anxiety and opioid use disorder (including IV heroin\nuse) who self-presents to the ___ ED for worsening depression\nand SI after relapsing on heroin. Psychiatry is consulted for\nsafety evaluation and management recommendations.\n\nOn interview patient endorses a long standing history of\ndepression and opioid use. She began using oxycodone at age ___\nand transitioned to snorting heroin at age ___ after her\nprescriber was allegedly arrested. She then began using IV\nheroin but was able to achieve abstinence in ___ using\nmethadone, and later suboxone. She has had several relapses; \none\nin ___ and another approximately one week ago over which she\nfeels severely distressed.\n\nOver the past year her depression has worsened and has had\npassive thoughts that life is not worth living or that \"it would\nbe better if I just gave up.\" Sine her relapse last week,\nhowever, the depressed mood has intensified and she has\nfantasized about overdosing on heroin to end her life, though\ndenies active intent. The patient states she has felt depressed\nboth when using heroin and while abstinent. In addition to\ndepressed mood she endorses extreme guilt, amotivation, poor\nsleep, low energy, poor appetite, worthlessness and feeling like\na burden. Stressors include chronic drug use, losing custody of\nher five children (currently live with her parents) and relapse. \n\nToday she called her psychiatrist's office in distress but was\nunable to reach her provider; the on-call psychiatrist told her\nto come to the ED for further evaluation.\n\nPatient denies HI, AVH, paranoia or symptoms of mania or PTSD. \nStates she is currently feeling mild withdrawal (nausea) which\nshe attributes to missing her ___ suboxone dose. Denies opioid\nuse since her relapse last week. She has had several inpatient\ndual diagnosis admissions in the past which she felt to be\nhelpful and is seeking an inpatient psych or dual diagnosis\ncurrently.\n\n \nPast Medical History:\nPAST PSYCHIATRIC HISTORY:\nDiagnoses: depression, anxiety\nHospitalizations: multiple dual diagnosis admissions - some at\n___, most recently at ___ several months ago\nCurrent treaters and treatment: Dr. ___ (psychiatrist\nand therapist) at ___\nMedication and ECT trials: multiple past medication trials\nSelf-injury: denies\nHarm to others: denies\n\nPAST MEDICAL HISTORY:\n* PCP: ___\nHCV\nUnspecified disk disease\nMigraine\n\nSUBSTANCE ABUSE HISTORY:\nAlcohol: denies\nTobacco: denies (former use but none current)\nIllicts:\nOpioids: Pt began using oxycodone at age ___ and transitioned to\nsnorting heroin at age ___ after her prescriber was arrested. \nShe\nthen began using IV heroin but was able to achieve abstinence in\n___ using methadone, and later suboxone. She has had several\nrelapses; one in ___ and another approximately one week ago.\nCocaine: remote use, as well as one week ago when she relapsed \non\nheroin\nMarijuana: remote use, as well as one week ago when she relapsed\non heroin\n\nFORENSIC HISTORY:\nArrests: Denies\nConvictions and jail terms: Denies\nCurrent status (pending charges, probation, parole): Denies\n\n \nSocial History:\n___\nFamily History:\nFAMILY PSYCHIATRIC HISTORY:\nDenies family hx of depression, bipolar, schizophrenia, \nsubstance\nuse disorders or suicides\n\n \nPhysical Exam:\nADMISSION EXAM:\n*VS: Temp: 98.9. Pulse: 98. RR: 18. BP: 112/73. O2 sat: 98% on \nRA\nNeurological:\n *station and gait: not observed, patient laying down in \nhospital\ngurney\n *tone and strength: antigravitational in all 4 ext\n cranial nerves: CN II-XII no gross deficits\n abnormal movements: no PMA/PMR\n frontal release: not formally tested\n\nCognition:\n Wakefulness/alertness: awake and alert\n *Attention (digit span, MOYB): MOYB without error\n *Orientation: ___, correct month/day/year\n Executive function (go-no go, Luria, trails, FAS): not formally\ntested\n *Memory: ___ immediate and ___ spontaneous after 5 min\n *Fund of knowledge: knows first president of ___\n Calculations: $1.75 as 7 quarters\n Abstraction: apple/orange as \"round, fruits, good for you\"\n Visuospatial: not formally tested\n *Speech: normal rate, normal tone, normal prosody, verbose\n *Language: fluent in ___\n\nMental Status:\n *Appearance: disheveled, appears older than stated age, wearing\neye liner and jewelry, has tattoos and several scratches on arms\n Behavior: friendly, cooperative with interview, jokes at times\n *Mood and Affect: \"depressed\" / dysphoric but brightens\nappropriately, generally congruent with stated mood\n *Thought process / *associations: over-inclusive but generally\nlinear and goal oriented, no LOA\n *Thought Content: pos for passive SI, denies HI, AVH, paranoia\n *Judgment and Insight: limited/limited\n\n============================================\nDISCHARGE EXAM:\nVS: Temp 98.6 BP 124/86 HR 99 R 16 O2 sat 96% RA\nMental Status Exam:\nAppearance: fair grooming, taking showers\nFacial expression: neutral\nEye contact: direct\nBuild: overweight\nBehavior: engaging, cooperative\nPsychomotor: no abnormal involuntary movements, gait - normal\nSpeech: normal tone, rate and volume\nMood/affect: \"I am OK, I want to go home today\", brighter, no\nirritability /angry outbursts\nThought Process/content: reality oriented, goal directed, denies \n\nSI/HI, denies AH/VH/paranoid delusions\nIntellectual Functioning: fair concentration\nOriented: x4\nMemory: grossly intact\nInsight: fair\nJudgment: fair\n\n \nPertinent Results:\nLABS:\n___ 09:35PM ALT(SGPT)-74* AST(SGOT)-56* ALK PHOS-93 TOT \nBILI-0.2\n___ 09:35PM TSH-1.8\n___ 09:35PM HCG-<5\n___ 09:23PM URINE UCG-NEGATIVE\n___ 09:23PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG \ncocaine-POS* amphetmn-NEG oxycodn-NEG mthdone-NEG\n___ 09:23PM URINE COLOR-Yellow APPEAR-Clear SP ___\n___ 09:23PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 \nLEUK-NEG\n___ 09:23PM URINE RBC-3* WBC-1 BACTERIA-FEW YEAST-NONE \nEPI-1\n___ 09:23PM URINE MUCOUS-RARE\n___ 09:20PM GLUCOSE-154* UREA N-12 CREAT-1.0 SODIUM-140 \nPOTASSIUM-3.6 CHLORIDE-101 TOTAL CO2-24 ANION GAP-19\n___ 09:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG \nbnzodzpn-NEG barbitrt-NEG tricyclic-NEG\n___ 09:20PM WBC-5.5 RBC-4.11 HGB-11.6 HCT-36.2 MCV-88 \nMCH-28.2 MCHC-32.0 RDW-12.8 RDWSD-41.1\n___ 09:20PM NEUTS-56.4 ___ MONOS-9.2 EOS-1.6 \nBASOS-0.5 IM ___ AbsNeut-3.12 AbsLymp-1.76 AbsMono-0.51 \nAbsEos-0.09 AbsBaso-0.03\n___ 09:20PM PLT COUNT-293\n\nMICROBIOLOGY:\n___ 9:23 pm URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT \nWITH SKIN\n AND/OR GENITAL CONTAMINATION. \n\n \nBrief Hospital Course:\nMs. ___ is a ___ year old woman with a history of depression, \nanxiety and IV heroin use who self-presented to the ___ ED for \nworsening depression and SI. She has had worsening depression \nand SI over the past year, with particular worsening in the \nsetting of her recent heroin relapse. She has fantasized about \noverdosing\non heroin, though denies active intent and believes this to be \nnormal for all heroin users. Exam is notable for a clean, \nolder-than-stated-age appearing woman who becomes easily \nirritated when discussing medication changes. The patient's \ncurrent presentation is most consistent with opioid use disorder \nand MDD.\n\nDIAGNOSES:\n1. MDD\n2. PTSD\n3. anxiety nos\n4. opiate use dis\n5. MJ use dis\n6. cocaine use dis\n7. migraine headaches\n8. HCV\n\n1. LEGAL & SAFETY: \nOn admission, the patient signed a conditional voluntary \nagreement (Section 10 & 11) and remained on that level \nthroughout their admission. They were also placed on 15 minute \nchecks status on admission and remained on that level of \nobservation throughout while being unit restricted.\n\n2. PSYCHIATRIC:\n#) Major Depressive Disorder, PTSD, and anxiety NOS.\nShe was continued on her home Duloxetine 30mg PO daily, \nClonidine 0.1mg PO TID PRN anxiety, and Doxepin 50mg PO QHS PRN \ninsomnia. Her Clonazepam was decreased to 1mg PO BID given her \nrecent relapse with a plan (discussed with her outpatient \npsychiatrist) to wean this off outpatient. She was started on \nTrileptal 150mg BID for mood.\n\n3. SUBSTANCE USE DISORDERS:\n#) She was maintained Suboxone for her opioid use disorder at \nher home dosing throughout the admission.\n\n4. MEDICAL: Migraine, hepatitis C\n#) She continued her home migraine medications for her migraine \nheadaches. Her LFTs were checked given her history of hep c and \nwere mildly elevated (baseline unknown). She can follow up with \nher PCP outpatient for further evaluation.\n\n5. PSYCHOSOCIAL\n#) GROUPS/MILIEU: \nThe patient was encouraged to participate in the various groups \nand milieu therapy opportunities offered by the unit. The \npatient often attended these groups that focused on teaching \npatients various coping skills. \n\n#) COLLATERAL CONTACTS & FAMILY INVOLVEMENT: \nObtained collateral from the patient's outpatient Dr. ___ \n___, who presumed she relapsed because she had missed \nappointments. Dr. ___ agreed with getting her off Klonopin in \nlight of her relapse. Follow up appointment was made.\n\n#) INTERVENTIONS\n- Medications: Clonazepam dose was decreased. Trileptal was \nstarted.\n- Psychotherapeutic Interventions: Individual, group, and milieu \ntherapy.\n- Coordination of aftercare: psychiatry and PCP follow up \nappointments were scheduled. She was referred to ___ clinic \nthe day after discharge and referred to a partial program.\n- Behavioral Interventions (e.g. encouraged DBT skills, ect): \nencouraged participation in groups\n- Guardianships: n/a\n\nINFORMED CONSENT: The team discussed the indications for, \nintended benefits of, and possible side effects and risks of \nstarting this medication, and risks and benefits of possible \nalternatives, including not taking the medication, with this \npatient. We discussed the patient's right to decide whether to \ntake this medication as well as the importance of the patient's \nactively participating in the treatment and discussing any \nquestions about medications with the treatment team, and I \nanswered the patient's questions. The patient appeared able to \nunderstand and consented to begin the medication.\n\nRISK ASSESSMENT\nOn presentation, the patient was evaluated and felt to be at an \nincreased risk of harm to herself and/or others based upon \nhistory of suicide attempts, chronic mental illness, history of \nsubstance abuse, Caucasian race, age, chronic pain and chronic \nmedical illness. The patient also has modifiable risk factors, \nincluding the\npresence of suicidal ideation hopelessness, limited social \nsupports, limited coping skills, insomnia, active substance \nabuse/intoxication and recent loss. These risk factors were \naddressed while inpatient, particularly regarding her mood, \nsubstance use, and sleep. Protective factors include the \npatient's help-seeking nature, future-oriented viewpoint, sense \nof responsibility to family, access to care, positive\ntherapeutic relationship with outpatient providers, no history \nof abuse. Based on the totality of our assessment at this time, \nthe patient is not at an acutely elevated risk of self-harm nor \ndanger to others. \n\nOur Prognosis of this patient is fair. \n\nTRANSITIONAL ISSUES:\n- she was discharged with medication Rx to bridge to her next \npsychiatry follow up appointment 2 days after discharge\n- she was scheduled in ___ clinic the day after discharge \nsince she does not have any Suboxone at home\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Promethazine 25 mg PO QID:PRN nausea with migraine \n2. Ibuprofen 400 mg PO Q8H:PRN Pain - Moderate \n3. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL BID \n4. Doxepin HCl 75 mg PO QHS:PRN insomnia \n5. CloNIDine 0.1 mg PO QID:PRN anxiety \n6. DULoxetine 30 mg PO DAILY \n7. ClonazePAM 1 mg PO TID \n\n \nDischarge Medications:\n1. OXcarbazepine 150 mg PO BID \nRX *oxcarbazepine 150 mg 1 tablet(s) by mouth twice a day Disp \n#*4 Tablet Refills:*0 \n2. ClonazePAM 1 mg PO BID \nRX *clonazepam 1 mg 1 tablet(s) by mouth twice a day Disp #*4 \nTablet Refills:*0 \n3. CloNIDine 0.1 mg PO TID anxiety \nRX *clonidine HCl 0.1 mg 1 tablet(s) by mouth three times a day \nDisp #*6 Tablet Refills:*0 \n4. Doxepin HCl 50 mg PO QHS:PRN insomnia, anxiety \nRX *doxepin 50 mg 1 capsule(s) by mouth at bedtime Disp #*2 \nCapsule Refills:*0 \n5. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL BID \n6. DULoxetine 30 mg PO DAILY \nRX *duloxetine 30 mg 1 capsule(s) by mouth once a day Disp #*2 \nCapsule Refills:*0 \n7. Ibuprofen 400 mg PO Q8H:PRN Pain - Moderate \n8. Promethazine 25 mg PO QID:PRN nausea with migraine \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\n1. Opioid use disorder\n2. Major depressive disorder \n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nYou were hospitalized at ___ for depression and suicidal \nideation in the context of a heroin relapse. \n\n-Please follow up with all outpatient appointments as listed - \ntake this discharge paperwork to your appointments.\n-Please continue all medications as directed.\n-Please avoid abusing alcohol and any drugs--whether \nprescription drugs or illegal drugs--as this can further worsen \nyour medical and psychiatric illnesses.\n-Please contact your outpatient psychiatrist or other providers \nif you have any concerns.\n-Please call ___ or go to your nearest emergency room if you \nfeel unsafe in any way and are unable to immediately reach your \nhealth care providers.\n\nIt was a pleasure to have worked with you, and we wish you the \nbest of health.\n\nWe strongly recommend engaging in NA recovery meetings for \nongoing help with sobriety. Here is a website with links to \nmeetings near your area: ___\n\n \nFollowup Instructions:\n___\n"
] | Allergies: Compazine Chief Complaint: "I am fed up with my life" Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] is a [MASKED] year old female with history of depression, anxiety and opioid use disorder (including IV heroin use) who self-presents to the [MASKED] ED for worsening depression and SI after relapsing on heroin. Psychiatry is consulted for safety evaluation and management recommendations. On interview patient endorses a long standing history of depression and opioid use. She began using oxycodone at age [MASKED] and transitioned to snorting heroin at age [MASKED] after her prescriber was allegedly arrested. She then began using IV heroin but was able to achieve abstinence in [MASKED] using methadone, and later suboxone. She has had several relapses; one in [MASKED] and another approximately one week ago over which she feels severely distressed. Over the past year her depression has worsened and has had passive thoughts that life is not worth living or that "it would be better if I just gave up." Sine her relapse last week, however, the depressed mood has intensified and she has fantasized about overdosing on heroin to end her life, though denies active intent. The patient states she has felt depressed both when using heroin and while abstinent. In addition to depressed mood she endorses extreme guilt, amotivation, poor sleep, low energy, poor appetite, worthlessness and feeling like a burden. Stressors include chronic drug use, losing custody of her five children (currently live with her parents) and relapse. Today she called her psychiatrist's office in distress but was unable to reach her provider; the on-call psychiatrist told her to come to the ED for further evaluation. Patient denies HI, AVH, paranoia or symptoms of mania or PTSD. States she is currently feeling mild withdrawal (nausea) which she attributes to missing her [MASKED] suboxone dose. Denies opioid use since her relapse last week. She has had several inpatient dual diagnosis admissions in the past which she felt to be helpful and is seeking an inpatient psych or dual diagnosis currently. Past Medical History: PAST PSYCHIATRIC HISTORY: Diagnoses: depression, anxiety Hospitalizations: multiple dual diagnosis admissions - some at [MASKED], most recently at [MASKED] several months ago Current treaters and treatment: Dr. [MASKED] (psychiatrist and therapist) at [MASKED] Medication and ECT trials: multiple past medication trials Self-injury: denies Harm to others: denies PAST MEDICAL HISTORY: * PCP: [MASKED] HCV Unspecified disk disease Migraine SUBSTANCE ABUSE HISTORY: Alcohol: denies Tobacco: denies (former use but none current) Illicts: Opioids: Pt began using oxycodone at age [MASKED] and transitioned to snorting heroin at age [MASKED] after her prescriber was arrested. She then began using IV heroin but was able to achieve abstinence in [MASKED] using methadone, and later suboxone. She has had several relapses; one in [MASKED] and another approximately one week ago. Cocaine: remote use, as well as one week ago when she relapsed on heroin Marijuana: remote use, as well as one week ago when she relapsed on heroin FORENSIC HISTORY: Arrests: Denies Convictions and jail terms: Denies Current status (pending charges, probation, parole): Denies Social History: [MASKED] Family History: FAMILY PSYCHIATRIC HISTORY: Denies family hx of depression, bipolar, schizophrenia, substance use disorders or suicides Physical Exam: ADMISSION EXAM: *VS: Temp: 98.9. Pulse: 98. RR: 18. BP: 112/73. O2 sat: 98% on RA Neurological: *station and gait: not observed, patient laying down in hospital gurney *tone and strength: antigravitational in all 4 ext cranial nerves: CN II-XII no gross deficits abnormal movements: no PMA/PMR frontal release: not formally tested Cognition: Wakefulness/alertness: awake and alert *Attention (digit span, MOYB): MOYB without error *Orientation: [MASKED], correct month/day/year Executive function (go-no go, Luria, trails, FAS): not formally tested *Memory: [MASKED] immediate and [MASKED] spontaneous after 5 min *Fund of knowledge: knows first president of [MASKED] Calculations: $1.75 as 7 quarters Abstraction: apple/orange as "round, fruits, good for you" Visuospatial: not formally tested *Speech: normal rate, normal tone, normal prosody, verbose *Language: fluent in [MASKED] Mental Status: *Appearance: disheveled, appears older than stated age, wearing eye liner and jewelry, has tattoos and several scratches on arms Behavior: friendly, cooperative with interview, jokes at times *Mood and Affect: "depressed" / dysphoric but brightens appropriately, generally congruent with stated mood *Thought process / *associations: over-inclusive but generally linear and goal oriented, no LOA *Thought Content: pos for passive SI, denies HI, AVH, paranoia *Judgment and Insight: limited/limited ============================================ DISCHARGE EXAM: VS: Temp 98.6 BP 124/86 HR 99 R 16 O2 sat 96% RA Mental Status Exam: Appearance: fair grooming, taking showers Facial expression: neutral Eye contact: direct Build: overweight Behavior: engaging, cooperative Psychomotor: no abnormal involuntary movements, gait - normal Speech: normal tone, rate and volume Mood/affect: "I am OK, I want to go home today", brighter, no irritability /angry outbursts Thought Process/content: reality oriented, goal directed, denies SI/HI, denies AH/VH/paranoid delusions Intellectual Functioning: fair concentration Oriented: x4 Memory: grossly intact Insight: fair Judgment: fair Pertinent Results: LABS: [MASKED] 09:35PM ALT(SGPT)-74* AST(SGOT)-56* ALK PHOS-93 TOT BILI-0.2 [MASKED] 09:35PM TSH-1.8 [MASKED] 09:35PM HCG-<5 [MASKED] 09:23PM URINE UCG-NEGATIVE [MASKED] 09:23PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-POS* amphetmn-NEG oxycodn-NEG mthdone-NEG [MASKED] 09:23PM URINE COLOR-Yellow APPEAR-Clear SP [MASKED] [MASKED] 09:23PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [MASKED] 09:23PM URINE RBC-3* WBC-1 BACTERIA-FEW YEAST-NONE EPI-1 [MASKED] 09:23PM URINE MUCOUS-RARE [MASKED] 09:20PM GLUCOSE-154* UREA N-12 CREAT-1.0 SODIUM-140 POTASSIUM-3.6 CHLORIDE-101 TOTAL CO2-24 ANION GAP-19 [MASKED] 09:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [MASKED] 09:20PM WBC-5.5 RBC-4.11 HGB-11.6 HCT-36.2 MCV-88 MCH-28.2 MCHC-32.0 RDW-12.8 RDWSD-41.1 [MASKED] 09:20PM NEUTS-56.4 [MASKED] MONOS-9.2 EOS-1.6 BASOS-0.5 IM [MASKED] AbsNeut-3.12 AbsLymp-1.76 AbsMono-0.51 AbsEos-0.09 AbsBaso-0.03 [MASKED] 09:20PM PLT COUNT-293 MICROBIOLOGY: [MASKED] 9:23 pm URINE **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. Brief Hospital Course: Ms. [MASKED] is a [MASKED] year old woman with a history of depression, anxiety and IV heroin use who self-presented to the [MASKED] ED for worsening depression and SI. She has had worsening depression and SI over the past year, with particular worsening in the setting of her recent heroin relapse. She has fantasized about overdosing on heroin, though denies active intent and believes this to be normal for all heroin users. Exam is notable for a clean, older-than-stated-age appearing woman who becomes easily irritated when discussing medication changes. The patient's current presentation is most consistent with opioid use disorder and MDD. DIAGNOSES: 1. MDD 2. PTSD 3. anxiety nos 4. opiate use dis 5. MJ use dis 6. cocaine use dis 7. migraine headaches 8. HCV 1. LEGAL & SAFETY: On admission, the patient signed a conditional voluntary agreement (Section 10 & 11) and remained on that level throughout their admission. They were also placed on 15 minute checks status on admission and remained on that level of observation throughout while being unit restricted. 2. PSYCHIATRIC: #) Major Depressive Disorder, PTSD, and anxiety NOS. She was continued on her home Duloxetine 30mg PO daily, Clonidine 0.1mg PO TID PRN anxiety, and Doxepin 50mg PO QHS PRN insomnia. Her Clonazepam was decreased to 1mg PO BID given her recent relapse with a plan (discussed with her outpatient psychiatrist) to wean this off outpatient. She was started on Trileptal 150mg BID for mood. 3. SUBSTANCE USE DISORDERS: #) She was maintained Suboxone for her opioid use disorder at her home dosing throughout the admission. 4. MEDICAL: Migraine, hepatitis C #) She continued her home migraine medications for her migraine headaches. Her LFTs were checked given her history of hep c and were mildly elevated (baseline unknown). She can follow up with her PCP outpatient for further evaluation. 5. PSYCHOSOCIAL #) GROUPS/MILIEU: The patient was encouraged to participate in the various groups and milieu therapy opportunities offered by the unit. The patient often attended these groups that focused on teaching patients various coping skills. #) COLLATERAL CONTACTS & FAMILY INVOLVEMENT: Obtained collateral from the patient's outpatient Dr. [MASKED] [MASKED], who presumed she relapsed because she had missed appointments. Dr. [MASKED] agreed with getting her off Klonopin in light of her relapse. Follow up appointment was made. #) INTERVENTIONS - Medications: Clonazepam dose was decreased. Trileptal was started. - Psychotherapeutic Interventions: Individual, group, and milieu therapy. - Coordination of aftercare: psychiatry and PCP follow up appointments were scheduled. She was referred to [MASKED] clinic the day after discharge and referred to a partial program. - Behavioral Interventions (e.g. encouraged DBT skills, ect): encouraged participation in groups - Guardianships: n/a INFORMED CONSENT: The team discussed the indications for, intended benefits of, and possible side effects and risks of starting this medication, and risks and benefits of possible alternatives, including not taking the medication, with this patient. We discussed the patient's right to decide whether to take this medication as well as the importance of the patient's actively participating in the treatment and discussing any questions about medications with the treatment team, and I answered the patient's questions. The patient appeared able to understand and consented to begin the medication. RISK ASSESSMENT On presentation, the patient was evaluated and felt to be at an increased risk of harm to herself and/or others based upon history of suicide attempts, chronic mental illness, history of substance abuse, Caucasian race, age, chronic pain and chronic medical illness. The patient also has modifiable risk factors, including the presence of suicidal ideation hopelessness, limited social supports, limited coping skills, insomnia, active substance abuse/intoxication and recent loss. These risk factors were addressed while inpatient, particularly regarding her mood, substance use, and sleep. Protective factors include the patient's help-seeking nature, future-oriented viewpoint, sense of responsibility to family, access to care, positive therapeutic relationship with outpatient providers, no history of abuse. Based on the totality of our assessment at this time, the patient is not at an acutely elevated risk of self-harm nor danger to others. Our Prognosis of this patient is fair. TRANSITIONAL ISSUES: - she was discharged with medication Rx to bridge to her next psychiatry follow up appointment 2 days after discharge - she was scheduled in [MASKED] clinic the day after discharge since she does not have any Suboxone at home Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Promethazine 25 mg PO QID:PRN nausea with migraine 2. Ibuprofen 400 mg PO Q8H:PRN Pain - Moderate 3. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL BID 4. Doxepin HCl 75 mg PO QHS:PRN insomnia 5. CloNIDine 0.1 mg PO QID:PRN anxiety 6. DULoxetine 30 mg PO DAILY 7. ClonazePAM 1 mg PO TID Discharge Medications: 1. OXcarbazepine 150 mg PO BID RX *oxcarbazepine 150 mg 1 tablet(s) by mouth twice a day Disp #*4 Tablet Refills:*0 2. ClonazePAM 1 mg PO BID RX *clonazepam 1 mg 1 tablet(s) by mouth twice a day Disp #*4 Tablet Refills:*0 3. CloNIDine 0.1 mg PO TID anxiety RX *clonidine HCl 0.1 mg 1 tablet(s) by mouth three times a day Disp #*6 Tablet Refills:*0 4. Doxepin HCl 50 mg PO QHS:PRN insomnia, anxiety RX *doxepin 50 mg 1 capsule(s) by mouth at bedtime Disp #*2 Capsule Refills:*0 5. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL BID 6. DULoxetine 30 mg PO DAILY RX *duloxetine 30 mg 1 capsule(s) by mouth once a day Disp #*2 Capsule Refills:*0 7. Ibuprofen 400 mg PO Q8H:PRN Pain - Moderate 8. Promethazine 25 mg PO QID:PRN nausea with migraine Discharge Disposition: Home Discharge Diagnosis: 1. Opioid use disorder 2. Major depressive disorder Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were hospitalized at [MASKED] for depression and suicidal ideation in the context of a heroin relapse. -Please follow up with all outpatient appointments as listed - take this discharge paperwork to your appointments. -Please continue all medications as directed. -Please avoid abusing alcohol and any drugs--whether prescription drugs or illegal drugs--as this can further worsen your medical and psychiatric illnesses. -Please contact your outpatient psychiatrist or other providers if you have any concerns. -Please call [MASKED] or go to your nearest emergency room if you feel unsafe in any way and are unable to immediately reach your health care providers. It was a pleasure to have worked with you, and we wish you the best of health. We strongly recommend engaging in NA recovery meetings for ongoing help with sobriety. Here is a website with links to meetings near your area: [MASKED] Followup Instructions: [MASKED] | [
"F329",
"F419",
"F4310",
"G43909",
"F1490",
"F1290",
"F1190",
"Z87891",
"Z8619"
] | [
"F329: Major depressive disorder, single episode, unspecified",
"F419: Anxiety disorder, unspecified",
"F4310: Post-traumatic stress disorder, unspecified",
"G43909: Migraine, unspecified, not intractable, without status migrainosus",
"F1490: Cocaine use, unspecified, uncomplicated",
"F1290: Cannabis use, unspecified, uncomplicated",
"F1190: Opioid use, unspecified, uncomplicated",
"Z87891: Personal history of nicotine dependence",
"Z8619: Personal history of other infectious and parasitic diseases"
] | [
"F329",
"F419",
"Z87891"
] | [] |
15,874,847 | 24,182,798 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nStreptomycin\n \nAttending: ___.\n \nChief Complaint:\nDyspnea\n \nMajor Surgical or Invasive Procedure:\nnone\n \nHistory of Present Illness:\n___ male with hx of HTN, T2DM and severe COPD on ___ \nhome NC (PFTs with stable very severe obstruction, FEV1 21%), \nhad a flare in ___ that required intubation, and was recently \nadmitted from ___ for COPD exacerbation who presents \nwith 2 days of progressively worsening shortness of breath. \n\nFor the recent admission for COPD exacerbation, patient recieved \na 5-day course of azithromycin, nebulizers, IV steroids and \ncompleted steroid taper on ___.\n\nPatient ran out of Symbicort a few days ago and developed \nprogressively worsening SOB in the past 2 days. He has been \nusing his inhalers with some improvement in symptoms. At \nbaseline, he can only walk a few feet without becoming short of \nbreath. \n\nPatient denies having cough, fever, chest pain, dysuria, leg \nswelling.\nHe denies any history of DVT, PE, cancer, recent travel, recent \nsurgery, recent trauma. Denies any anticoagulation use. Patient \nis a ___, but denies recent long car rides.\n\nIn the ED, initial vitals were T 97.4, HR 114, BP 104/91, RR 30, \nO2sat 82% RA. Exam was notable for no chest tenderness, distant \nbreath sounds, poor aeration. Pursed lip breathing, tripoding. \nPursed lip breathing. Labs notable for CBC with no leukocytosis \n(WBC 9.1), H/H 11.8/40. BMP notable for HCO3 40. Trop 0.05, VBG \npH 7.30, pCO2 97, pO2 24, lactate 1.5. INR 1.0. Blood culture x2 \nwas obtained. Imaging: CXR showed no interval change in \nappearance of the chest compared to the previous radiograph. No \nnew focal consolidation to suggest pneumonia. EKG with sinus \ntachycardia, slight ST changes in inferior leads similar to \nprior EKG.\n\nPatient received duonebs, albuterol, azithromycin, \nmethylprednisolone 80mg IV. Patient was put on BiPAP, with \nimprovement of O2 saturation to 99%. Vital signs prior to \ntransfer were T 97.3, HR 102, BP 126/53, RR 22, O2sat 99% BiPAP \n\nIn the ICU, patient is hemodynamically stable. Continues to be \nin sinus tachycardia. Denies chest pain, cough, leg pain, \nnausea.\n\n \nPast Medical History:\n-COPD, on ___ home O2\n-Pulmonary TB in ___, treated \n-Had Left rib removed for \"pleurisy\" in youth\n-HTN\n-HLD\n-BPH\n-Gout\n-h/o Cecal adenoma with ileocecectomy ___\n-low B12\n-DMII \n\n \nSocial History:\n___\nFamily History:\nHis father had heart disease. His mother died at ___ of \"old \nage\".\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \n======================== \nVS: temp 98, HR 102, BP 137/91, RR 21, O2 sat 96% on BiPAP\nGEN: in no acute distress \nHEENT: normocephalic, atraumatic. EOMI, PERRLA. Sclera anicteric \n\nNECK: no JVP elevation\nCV: tachycardic, regular rhythm. No murmurs/rubs/gallops \nRESP: decreased breath sounds, scattered wheezes \nGI: soft, non-tender. Positive bowel sounds. \nMSK: trace ___ edema\nSKIN: no rash \nNEURO: AAOx3. Strength ___ in all extremities. Sensation intact. \n\nPSYCH: Appropriate \n\nDISCHARGE PHYSICAL EXAM:\n=========================\nGeneral: Alert, oriented, no acute distress , laying in bed with\nBiPAP mask on.\nHEENT: Sclera anicteric, MMM \nLungs: Decreased breath sounds throughout but otherwise clear to\nauscultation bilaterally, no crackles or wheeze\nCV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,\ngallops \nAbdomen: soft, non-tender, non-distended, bowel sounds present,\nno rebound tenderness or guarding, no organomegaly \nExt: Warm, well perfused, trace ___ edema \nNeuro: Face grossly symmetric. Moving all limbs with purpose\nagainst gravity.\n\n \nPertinent Results:\nINITIAL LABS\n================\n___ 10:15PM BLOOD WBC-9.1 RBC-4.16* Hgb-11.8* Hct-40.0 \nMCV-96 MCH-28.4 MCHC-29.5* RDW-12.4 RDWSD-44.4 Plt ___\n___ 10:15PM BLOOD Neuts-77.4* Lymphs-11.4* Monos-9.9 \nEos-0.8* Baso-0.1 Im ___ AbsNeut-7.00* AbsLymp-1.03* \nAbsMono-0.90* AbsEos-0.07 AbsBaso-0.01\n___ 10:15PM BLOOD ___ PTT-29.0 ___\n___ 10:15PM BLOOD Glucose-98 UreaN-15 Creat-0.7 Na-144 \nK-4.4 Cl-91* HCO3-40* AnGap-13\n___ 10:15PM BLOOD cTropnT-0.05*\n___ 02:23AM BLOOD cTropnT-0.02*\n___ 02:23AM BLOOD Calcium-9.1 Phos-3.8 Mg-1.8\n___ 10:21PM BLOOD ___ pO2-24* pCO2-97* pH-7.30* \ncalTCO2-50* Base XS-15\n___ 10:21PM BLOOD Lactate-1.5\n___:44AM BLOOD Lactate-0.7\n\nINTERVAL LABS\n===================\n___ 06:25AM BLOOD ___ pO2-44* pCO2-84* pH-7.31* \ncalTCO2-44* Base XS-11\n\nIMAGING\n============\n___ CXR (portable AP)\nIMPRESSION: \nNo interval change in appearance of the chest compared to the \nprevious \nradiograph. No new focal consolidation to suggest pneumonia. \n\n___ CXR PA and Lat\nIMPRESSION: \n \nCurvilinear band of likely atelectasis on the right, but \notherwise \nstable-appearing chest. No signs of pulmonary edema or \nconsolidation to \nsuggest pneumonia. \n\nDISCHARGE LABS\n===============\n\n___ 06:11AM BLOOD WBC-6.4 RBC-3.49* Hgb-9.8* Hct-33.6* \nMCV-96 MCH-28.1 MCHC-29.2* RDW-12.3 RDWSD-42.9 Plt ___\n___ 06:11AM BLOOD Neuts-63.3 ___ Monos-10.0 \nEos-0.8* Baso-0.3 Im ___ AbsNeut-4.03 AbsLymp-1.58 \nAbsMono-0.64 AbsEos-0.05 AbsBaso-0.02\n___ 06:11AM BLOOD Plt ___\n___ 06:11AM BLOOD Glucose-93 UreaN-16 Creat-0.6 Na-149* \nK-4.1 Cl-92* HCO3-38* AnGap-19*\n___ 06:11AM BLOOD Calcium-9.1 Phos-3.4 Mg-1.9\n___ 12:30PM BLOOD Type-ART pO2-69* pCO2-93* pH-7.32* \ncalTCO2-50* Base XS-16\n \nBrief Hospital Course:\nPatient Summary\n================\n___ is a ___ male with severe\nCOPD on ___ home NC (PFTs with stable very severe obstruction,\nFEV1 21%, pCO2 60-90s baseline) who was recently admitted from\n___ for acute hypoxemic respiratory failure who p/w 2 \ndays of progressively worsening shortness of breath d/t COPD \nexacerbation because he ran out of Symbicort.\nHe was admitted to the MICU for acute on chronic hypercarbic \nrespiratory failure. His respiratory status was stabilized on \nBiPAP and quickly weaned to ___ NC and was felt to need \nnocturnal BiPAP moving forward. He received IV methylpred 60mg, \nazithro,\nDuonebs. Has been persistently in sinus tachy 100-120s, but this \nis his baseline. He was transferred to the floor and was given \nnocturnal BiPAP, home inhalers and started on a prolonged \nprednisone taper given the severity of his disease. His \nrespiratory status improved to his baseline and was stable on \n___ O2 via NC. He initially did not tolerate nocturnal BiPAP \nbut the settings were titrated inpatient with respiratory \ntherapy and this improved. Serial ABGs were done which showed \npersistent acidemia (pH 7.31-7.35) and hypercarbia. Pulm was \nconsulted and he was advised to have BiPAP at home upon \ndischarge and close follow up with outpatient Pulm. \n\nAcute Issues\n============\n# Acute on chronic hypercarbic respiratory failure\nPatient with severe COPD (2 COPD exacerbations in past year) on\n___ O2 at home who presented with 2 days SOB after running out \nof home\nsymbicort. Presentation was most consistent with COPD \nexacerbation,\nlikely due to lack of Symbicort. Home meds were restarted and he \nrequired BiPAP requiring 1 day in MICU but was soon weaned off \nto home O2 supplementation. He was continued on BiPAP at night \nwith titration of settings per respiratory therapy. ABG on ___ \nimmediately\nafter taking off BiPAP with modest improvement in pCO2 and\nacidosis and was determined to need BiPAP at home. He completed \nAzithromycin 5 day\ncourse for coverage of CAP. He was placed on a prolonged \nprednisone taper as outlined below. He was arranged for close \nfollowup with Dr. ___ outpatient pulmonologist.\n\n#Chest pain\nTroponin 0.05 -> 0.02 on admission, likely due to demand \nischemia iso hypercarbic respiratory failure.\n\nChronic Issues\n==============\n# Tachycardia \nHR 120s-110s. Asymptomatic. EKG with sinus tachycardia, as is \nhis\nbaseline. \n\n#Anemia\nNormocytic. Stable Hgb 10.6, history of low Vitamin B12 on home\nsupplementation, likely anemia of chronic disease. \n\n# Type 2 DM\nWas placed on sliding scale insulin\n\n# Hypertension\nContinued home amlodipine 5mg PO\n\n#BPH\nContinued home finasteride, prazosin\n\nTransitional Issues\n===================\n\nFollow Up Labs:\n[] Please obtain CBC at first follow up (DC Hgb 9.8)\n[] Please obtain BMP at first f/u: Had transient hypernatremia \nwhich improved on DC with improved PO water intake\n\nFollow Up Imaging:\nnone\n\nIncidental Findings:\nnone\n\nOther:\n\n[]BiPAP settings on discharge: ___, 6L O2\n\n[] Pt has had persistent hypercarbic and acidemia likely due to \nsevere COPD. Would advise to have GOC conversation with patient\n\n[] Outpatient ___\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Amlodipine 5 mg PO DAILY \n2. Finasteride 5 mg PO DAILY \n3. Prazosin 2 mg PO QHS \n4. Tiotropium Bromide 1 CAP IH DAILY \n5. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath \n6. Cyanocobalamin 500 mcg PO DAILY \n7. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation \nINHALATION 2 PUFFS PO BID \n8. Omeprazole 20 mg PO DAILY \n\n \nDischarge Medications:\n1. PredniSONE 30 mg PO DAILY Duration: 7 Doses \n2. PredniSONE 20 mg PO DAILY Duration: 7 Doses \n3. PredniSONE 10 mg PO DAILY Duration: 7 Doses \n4. PredniSONE 5 mg PO DAILY \n5. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath \n6. Amlodipine 5 mg PO DAILY \n7. Cyanocobalamin 500 mcg PO DAILY \n8. Finasteride 5 mg PO DAILY \n9. Omeprazole 20 mg PO DAILY \n10. Prazosin 2 mg PO QHS \n11. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation \nINHALATION 2 PUFFS PO BID \n12. Tiotropium Bromide 1 CAP IH DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary Diagnosis\n=================\nCOPD\n\nSecondary Diagnosis\n===================\nHTN\nBPH\nDMT2\nGout\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nDear ___, \n\nIt was a pleasure caring for you at ___ \n___. \n\nWHY WERE YOU IN THE HOSPITAL? \n- You were admitted to the hospital for difficulty breathing\n\nWHAT HAPPENED WHEN YOU WERE IN THE HOSPITAL? \n- You were given a breathing machine called BIPAP with helped \nyour breathing\n- You were given inhalers\n- You were started on steroid medications \n- You had blood tests to evaluate your oxygen level\n\nWHAT SHOULD YOU DO AFTER YOU LEAVE THE HOSPITAL? \n- Continue to take all your medicines as prescribed below. \n- Show up to your appointments as listed below.\n\nWe wish you the best! \n\nSincerely, \n\nYour ___ Team\n\n \nFollowup Instructions:\n___\n"
] | Allergies: Streptomycin Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] male with hx of HTN, T2DM and severe COPD on [MASKED] home NC (PFTs with stable very severe obstruction, FEV1 21%), had a flare in [MASKED] that required intubation, and was recently admitted from [MASKED] for COPD exacerbation who presents with 2 days of progressively worsening shortness of breath. For the recent admission for COPD exacerbation, patient recieved a 5-day course of azithromycin, nebulizers, IV steroids and completed steroid taper on [MASKED]. Patient ran out of Symbicort a few days ago and developed progressively worsening SOB in the past 2 days. He has been using his inhalers with some improvement in symptoms. At baseline, he can only walk a few feet without becoming short of breath. Patient denies having cough, fever, chest pain, dysuria, leg swelling. He denies any history of DVT, PE, cancer, recent travel, recent surgery, recent trauma. Denies any anticoagulation use. Patient is a [MASKED], but denies recent long car rides. In the ED, initial vitals were T 97.4, HR 114, BP 104/91, RR 30, O2sat 82% RA. Exam was notable for no chest tenderness, distant breath sounds, poor aeration. Pursed lip breathing, tripoding. Pursed lip breathing. Labs notable for CBC with no leukocytosis (WBC 9.1), H/H 11.8/40. BMP notable for HCO3 40. Trop 0.05, VBG pH 7.30, pCO2 97, pO2 24, lactate 1.5. INR 1.0. Blood culture x2 was obtained. Imaging: CXR showed no interval change in appearance of the chest compared to the previous radiograph. No new focal consolidation to suggest pneumonia. EKG with sinus tachycardia, slight ST changes in inferior leads similar to prior EKG. Patient received duonebs, albuterol, azithromycin, methylprednisolone 80mg IV. Patient was put on BiPAP, with improvement of O2 saturation to 99%. Vital signs prior to transfer were T 97.3, HR 102, BP 126/53, RR 22, O2sat 99% BiPAP In the ICU, patient is hemodynamically stable. Continues to be in sinus tachycardia. Denies chest pain, cough, leg pain, nausea. Past Medical History: -COPD, on [MASKED] home O2 -Pulmonary TB in [MASKED], treated -Had Left rib removed for "pleurisy" in youth -HTN -HLD -BPH -Gout -h/o Cecal adenoma with ileocecectomy [MASKED] -low B12 -DMII Social History: [MASKED] Family History: His father had heart disease. His mother died at [MASKED] of "old age". Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: temp 98, HR 102, BP 137/91, RR 21, O2 sat 96% on BiPAP GEN: in no acute distress HEENT: normocephalic, atraumatic. EOMI, PERRLA. Sclera anicteric NECK: no JVP elevation CV: tachycardic, regular rhythm. No murmurs/rubs/gallops RESP: decreased breath sounds, scattered wheezes GI: soft, non-tender. Positive bowel sounds. MSK: trace [MASKED] edema SKIN: no rash NEURO: AAOx3. Strength [MASKED] in all extremities. Sensation intact. PSYCH: Appropriate DISCHARGE PHYSICAL EXAM: ========================= General: Alert, oriented, no acute distress , laying in bed with BiPAP mask on. HEENT: Sclera anicteric, MMM Lungs: Decreased breath sounds throughout but otherwise clear to auscultation bilaterally, no crackles or wheeze 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, trace [MASKED] edema Neuro: Face grossly symmetric. Moving all limbs with purpose against gravity. Pertinent Results: INITIAL LABS ================ [MASKED] 10:15PM BLOOD WBC-9.1 RBC-4.16* Hgb-11.8* Hct-40.0 MCV-96 MCH-28.4 MCHC-29.5* RDW-12.4 RDWSD-44.4 Plt [MASKED] [MASKED] 10:15PM BLOOD Neuts-77.4* Lymphs-11.4* Monos-9.9 Eos-0.8* Baso-0.1 Im [MASKED] AbsNeut-7.00* AbsLymp-1.03* AbsMono-0.90* AbsEos-0.07 AbsBaso-0.01 [MASKED] 10:15PM BLOOD [MASKED] PTT-29.0 [MASKED] [MASKED] 10:15PM BLOOD Glucose-98 UreaN-15 Creat-0.7 Na-144 K-4.4 Cl-91* HCO3-40* AnGap-13 [MASKED] 10:15PM BLOOD cTropnT-0.05* [MASKED] 02:23AM BLOOD cTropnT-0.02* [MASKED] 02:23AM BLOOD Calcium-9.1 Phos-3.8 Mg-1.8 [MASKED] 10:21PM BLOOD [MASKED] pO2-24* pCO2-97* pH-7.30* calTCO2-50* Base XS-15 [MASKED] 10:21PM BLOOD Lactate-1.5 [MASKED]:44AM BLOOD Lactate-0.7 INTERVAL LABS =================== [MASKED] 06:25AM BLOOD [MASKED] pO2-44* pCO2-84* pH-7.31* calTCO2-44* Base XS-11 IMAGING ============ [MASKED] CXR (portable AP) IMPRESSION: No interval change in appearance of the chest compared to the previous radiograph. No new focal consolidation to suggest pneumonia. [MASKED] CXR PA and Lat IMPRESSION: Curvilinear band of likely atelectasis on the right, but otherwise stable-appearing chest. No signs of pulmonary edema or consolidation to suggest pneumonia. DISCHARGE LABS =============== [MASKED] 06:11AM BLOOD WBC-6.4 RBC-3.49* Hgb-9.8* Hct-33.6* MCV-96 MCH-28.1 MCHC-29.2* RDW-12.3 RDWSD-42.9 Plt [MASKED] [MASKED] 06:11AM BLOOD Neuts-63.3 [MASKED] Monos-10.0 Eos-0.8* Baso-0.3 Im [MASKED] AbsNeut-4.03 AbsLymp-1.58 AbsMono-0.64 AbsEos-0.05 AbsBaso-0.02 [MASKED] 06:11AM BLOOD Plt [MASKED] [MASKED] 06:11AM BLOOD Glucose-93 UreaN-16 Creat-0.6 Na-149* K-4.1 Cl-92* HCO3-38* AnGap-19* [MASKED] 06:11AM BLOOD Calcium-9.1 Phos-3.4 Mg-1.9 [MASKED] 12:30PM BLOOD Type-ART pO2-69* pCO2-93* pH-7.32* calTCO2-50* Base XS-16 Brief Hospital Course: Patient Summary ================ [MASKED] is a [MASKED] male with severe COPD on [MASKED] home NC (PFTs with stable very severe obstruction, FEV1 21%, pCO2 60-90s baseline) who was recently admitted from [MASKED] for acute hypoxemic respiratory failure who p/w 2 days of progressively worsening shortness of breath d/t COPD exacerbation because he ran out of Symbicort. He was admitted to the MICU for acute on chronic hypercarbic respiratory failure. His respiratory status was stabilized on BiPAP and quickly weaned to [MASKED] NC and was felt to need nocturnal BiPAP moving forward. He received IV methylpred 60mg, azithro, Duonebs. Has been persistently in sinus tachy 100-120s, but this is his baseline. He was transferred to the floor and was given nocturnal BiPAP, home inhalers and started on a prolonged prednisone taper given the severity of his disease. His respiratory status improved to his baseline and was stable on [MASKED] O2 via NC. He initially did not tolerate nocturnal BiPAP but the settings were titrated inpatient with respiratory therapy and this improved. Serial ABGs were done which showed persistent acidemia (pH 7.31-7.35) and hypercarbia. Pulm was consulted and he was advised to have BiPAP at home upon discharge and close follow up with outpatient Pulm. Acute Issues ============ # Acute on chronic hypercarbic respiratory failure Patient with severe COPD (2 COPD exacerbations in past year) on [MASKED] O2 at home who presented with 2 days SOB after running out of home symbicort. Presentation was most consistent with COPD exacerbation, likely due to lack of Symbicort. Home meds were restarted and he required BiPAP requiring 1 day in MICU but was soon weaned off to home O2 supplementation. He was continued on BiPAP at night with titration of settings per respiratory therapy. ABG on [MASKED] immediately after taking off BiPAP with modest improvement in pCO2 and acidosis and was determined to need BiPAP at home. He completed Azithromycin 5 day course for coverage of CAP. He was placed on a prolonged prednisone taper as outlined below. He was arranged for close followup with Dr. [MASKED] outpatient pulmonologist. #Chest pain Troponin 0.05 -> 0.02 on admission, likely due to demand ischemia iso hypercarbic respiratory failure. Chronic Issues ============== # Tachycardia HR 120s-110s. Asymptomatic. EKG with sinus tachycardia, as is his baseline. #Anemia Normocytic. Stable Hgb 10.6, history of low Vitamin B12 on home supplementation, likely anemia of chronic disease. # Type 2 DM Was placed on sliding scale insulin # Hypertension Continued home amlodipine 5mg PO #BPH Continued home finasteride, prazosin Transitional Issues =================== Follow Up Labs: [] Please obtain CBC at first follow up (DC Hgb 9.8) [] Please obtain BMP at first f/u: Had transient hypernatremia which improved on DC with improved PO water intake Follow Up Imaging: none Incidental Findings: none Other: []BiPAP settings on discharge: [MASKED], 6L O2 [] Pt has had persistent hypercarbic and acidemia likely due to severe COPD. Would advise to have GOC conversation with patient [] Outpatient [MASKED] Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Amlodipine 5 mg PO DAILY 2. Finasteride 5 mg PO DAILY 3. Prazosin 2 mg PO QHS 4. Tiotropium Bromide 1 CAP IH DAILY 5. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath 6. Cyanocobalamin 500 mcg PO DAILY 7. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation INHALATION 2 PUFFS PO BID 8. Omeprazole 20 mg PO DAILY Discharge Medications: 1. PredniSONE 30 mg PO DAILY Duration: 7 Doses 2. PredniSONE 20 mg PO DAILY Duration: 7 Doses 3. PredniSONE 10 mg PO DAILY Duration: 7 Doses 4. PredniSONE 5 mg PO DAILY 5. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath 6. Amlodipine 5 mg PO DAILY 7. Cyanocobalamin 500 mcg PO DAILY 8. Finasteride 5 mg PO DAILY 9. Omeprazole 20 mg PO DAILY 10. Prazosin 2 mg PO QHS 11. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation INHALATION 2 PUFFS PO BID 12. Tiotropium Bromide 1 CAP IH DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Primary Diagnosis ================= COPD Secondary Diagnosis =================== HTN BPH DMT2 Gout Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear [MASKED], It was a pleasure caring for you at [MASKED] [MASKED]. WHY WERE YOU IN THE HOSPITAL? - You were admitted to the hospital for difficulty breathing WHAT HAPPENED WHEN YOU WERE IN THE HOSPITAL? - You were given a breathing machine called BIPAP with helped your breathing - You were given inhalers - You were started on steroid medications - You had blood tests to evaluate your oxygen level WHAT SHOULD YOU DO AFTER YOU LEAVE THE HOSPITAL? - Continue to take all your medicines as prescribed below. - Show up to your appointments as listed below. We wish you the best! Sincerely, Your [MASKED] Team Followup Instructions: [MASKED] | [
"J9602",
"J441",
"E872",
"I248",
"E870",
"Z9981",
"D638",
"E119",
"I10",
"E785",
"N400",
"R000",
"M109",
"E669",
"L258",
"T486X6A",
"Z91138",
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] | [
"J9602: Acute respiratory failure with hypercapnia",
"J441: Chronic obstructive pulmonary disease with (acute) exacerbation",
"E872: Acidosis",
"I248: Other forms of acute ischemic heart disease",
"E870: Hyperosmolality and hypernatremia",
"Z9981: Dependence on supplemental oxygen",
"D638: Anemia in other chronic diseases classified elsewhere",
"E119: Type 2 diabetes mellitus without complications",
"I10: Essential (primary) hypertension",
"E785: Hyperlipidemia, unspecified",
"N400: Benign prostatic hyperplasia without lower urinary tract symptoms",
"R000: Tachycardia, unspecified",
"M109: Gout, unspecified",
"E669: Obesity, unspecified",
"L258: Unspecified contact dermatitis due to other agents",
"T486X6A: Underdosing of antiasthmatics, initial encounter",
"Z91138: Patient's unintentional underdosing of medication regimen for other reason",
"Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause",
"Z87891: Personal history of nicotine dependence"
] | [
"E872",
"E119",
"I10",
"E785",
"N400",
"M109",
"E669",
"Z87891"
] | [] |
16,826,748 | 29,737,533 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nCompazine\n \nAttending: ___.\n \nChief Complaint:\nAbdominal Pain \n \nMajor Surgical or Invasive Procedure:\n___ ERCP with balloon sweep sludge removal and placement of \n10mm 6cm straight metal fully covered biliary stent.\n\n \nHistory of Present Illness:\n___ PMH of Pancreatic adenocarcinoma (s/p neoadjuvant FOLFIRINOX\nfor 6 months followed by SBRT & distal\npancreatectomy/splenectomy, now with recently diagnosed\nrecurrence), Asymptomatic Duodenal Ulcer (dx ___, presented\nwith severe abdominal pain + jaundice \n\nAs per review of notes, patient recently admitted for jaundice\nthought to be ___ disease progression. Found to have malignant\nbiliary obstruction s/p plastic stent placement and biopsy.\nBiopsies confirmed recurrence of pancreatic adenocarcinoma,\ntreatment not yet re-initiated. Of note, found to have\nasymptomatic duodenal ulcer at the time, hpylori negative, was\nstarted on omeprazole. \n\nOn this admission, patient presented with severe abdominal pain,\nwhich was epigastric, crampy in nature, ___, not radiating, \na/w\nnausea/vomiting, but no constipation/diarrhea/abdominal\ndistension. Endorsed chills but no fever. Reported that he has\nnever had symptoms like this before. Noted that pain decreased\nfrom ___ prior to ERCP to ___ afterward. Reported that his\nepigastric area remains tender/sore. \n\nIn the ED, initial vitals: 98.0 89 132/83 16 100% RA. WBC 20.6,\nHgb 14.9, plt 438, alt 81, ast 43, ap 210, tbILI 9.3, dbILI 6.5,\naLB 4., LIP 10, chem W/ hco3 21, lACTATE 1.4, ua + glc/prot but\nnegative for infection.\n\nRUQUS:\n1. Pneumobilia due to recent stenting. Improved but persistent\nintrahepatic biliary dilatation.\n2. The gallbladder appears distended with wall thickening.\nHowever, no\ncholelithiasis or pericholecystic fluid is identified. Recommend\nclinical correlation for acute cholecystitis. If clinical \nconcern\nfor acute cholecystitis remains, can consider HIDA scan for\nfurther evaluation.\n\nGiven persistent bilirubin elevation + leukocytosis, there was\nconcern that patient had cholangitis, so was started on zosyn,\nmorphine, LR, Zofran and taken for ERCP. In ERCP plastic stent\nwas removed, sludge cleared out, and metal stent placed. Patient\nthen admitted to oncology for further care. \n \nPast Medical History:\nPAST ONCOLOGIC HISTORY: \nAs per last outpatient note by Dr ___:\n\" Following this, he experienced pain that lasted for\nweeks. He was seen by his PCP and noted to have an elevated\nlipase as well as pre-diabetes. Due to persistent symptoms, he\nwas admitted to ___ in ___ with pain and his\nlipase was again >3000. He had a CT which showed extensive\nperipancreatic stranding with decreased enhancement in the\nproximal pancreatic body. He was managed conservatively and\nsubsequently referred to Dr. ___ further evaluation and\nlipase remained elevated to almost 600. \n\nMRCP was performed which showed findings of acute on chronic\npancreatitis with suspected main PD stricture in the proximal\nbody with upstream irregularity. Given these findings, he was\nreferred for EUS which was performed on ___ which showed a\n2.7cm pancreatic body/neck mass with involvement of the PV, SMV,\nportal confluence, and splenic vein. Several enlarged\n___ LNs were seen (largest 10mm), as well as\n___ varices, and possible invasion into the gastric\nwall. FNB of mass was consistent with ductal adenocarcinoma, \nFNB\nof LN and gastric wall both negative. \n\n___ C1D1 FOLFIRINOX \n___ C1D15 FOLFIRINOX \n___ C2D1 FOLFIRINOX\n___ C3D1 FOLFIRINOX \n___ C3D15 FOLFIRINOX \n___ C4D1 FOLFIRINOX due to thrombocytopenia \n___ C4D1 FOLFIRINOX \n___ C4D15 FOLFIRINOX \n___ C5 D1 FOLFIRINOX\n___ C5 D18 FOLFIRINOX\n___ CyberKnife \n___ C6 D1 FOLFIRINOX \n___ - Surgery\"\n\nPAST MEDICAL HISTORY: \n-ITP (age ___\n-Prior DVT ___ years ago) - treated Xarelto x 3 months. \n-s/p deviated septum repair and T&A (age ___\n-Malignant biliary obstruction s/p stent\n-Duodenal ulcer (diagnosed incidentally during ERCP ___,\nHPylori negative)\n-Pancreatic adenocarcinoma (s/p neoadjuvant FOLFIRINOX for 6\nmonths followed by SBRT & distal pacreatectomy/splenectomy, now\nwith recently diagnosed recurrence)\n \nSocial History:\n___\nFamily History:\nHis sister died of stomach cancer at age ___. MGM died in her \n___\nfrom some form of cancer (his father was ___). \nThere is a family history of thrombosis.\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\nVitals: 24 HR Data (last updated ___ @ ___\n Temp: 98.4 (Tm 98.4), BP: 144/83, HR: 54, RR: 18, O2 sat:\n95%, O2 delivery: RA, Wt: 181.3 lb/82.24 kg \nGENERAL: Laying in bed, appears tired but NAD, calm, pleasant\nEYES: PERRLA, icteric sclera\nHEENT: OP clear, MMM\nNECK: supple, normal ROM\nLUNGS: CTA b/l, no wheezes/rales/rhonchi, normal RR, no \nincreased\nWOB\nCV: RRR normal distal perfusion, no peripheral edema\nABD: soft, moderate tenderness in epigastric area, no rebound or\nguarding, hypoactive BS, no RUQ tenderness, negative ___ sign\nGENITOURINARY: no foley or suprapubic tenderness\nEXT: warm, no deformity, normal muscle bulk\nSKIN: warm, dry, no rash\nNEURO: AOx3, fluent speech\n\nDISCHARGE PHYSICAL EXAM\n___ 0812 Temp: 98.7 PO BP: 143/74 HR: 61 RR: 18 O2 sat: 96% \nO2 delivery: RA FSBG: 131 \nGENERAL: Laying in bed, in NAD, calm, pleasant\nEYES: PERRLA, icteric sclera\nHEENT: OP clear, MMM\nNECK: supple, normal ROM\nLUNGS: CTA b/l, no wheezes/rales/rhonchi, no increased WOB\nCV: RRR, normal S1 and S2 with no murmurs, rubs, gallops, no \nperipheral edema\nABD: soft, non-tender, no rebound or guarding, normal BS\nGENITOURINARY: no foley or suprapubic tenderness\nEXT: warm, no deformity, normal muscle bulk\nSKIN: Skin type III. Mild jaundice, warm, dry, no rash\nNEURO: AOx3, fluent speech\n \nPertinent Results:\nADMISSION LABS\n====================\n___ 10:25AM BLOOD WBC: 20.6* RBC: 4.56* Hgb: 14.9 Hct: 42.9\nMCV: 94 MCH: 32.7* MCHC: 34.7 RDW: 17.6* RDWSD: 60.4* Plt Ct:\n438* \n___ 10:25AM BLOOD ___: 12.0 PTT: 34.7 ___: 1.1 \n___ 10:25AM BLOOD Glucose: 247* UreaN: 18 Creat: 0.7 Na: \n137\nK: 4.6 Cl: 102 HCO3: 21* AnGap: 14 \n___ 10:25AM BLOOD ALT: 81* AST: 43* AlkPhos: 210* TotBili:\n9.3* DirBili: 6.5* IndBili: 2.8 \n___ 10:25AM BLOOD Albumin: 4.1 \n___ 10:30AM BLOOD Lactate: 1.4 \n___ 05:03AM BLOOD %HbA1c-7.2* eAG-160*\n\nDISCHARGE LABS\n====================\n___ 06:00AM BLOOD WBC-14.7* RBC-3.72* Hgb-12.2* Hct-35.3* \nMCV-95 MCH-32.8* MCHC-34.6 RDW-17.1* RDWSD-58.5* Plt ___\n___ 06:00AM BLOOD Neuts-65.0 Lymphs-17.9* Monos-10.4 \nEos-4.0 Baso-0.4 Im ___ AbsNeut-9.57* AbsLymp-2.63 \nAbsMono-1.53* AbsEos-0.59* AbsBaso-0.06\n___ 06:00AM BLOOD Glucose-124* UreaN-11 Creat-0.5 Na-138 \nK-4.2 Cl-102 HCO3-28 AnGap-8*\n___ 06:00AM BLOOD Albumin-2.8* Calcium-8.2* Phos-3.1 Mg-2.0\n___ 06:00AM BLOOD ALT-84* AST-72* LD(LDH)-195 AlkPhos-123 \nTotBili-3.2*\n\nREPORTS \n====================\n___ OR GALLBLADDER US\n1. Pneumobilia due to recent stenting. Improved but persistent \nintrahepatic biliary dilatation.\n2. The gallbladder appears distended with wall thickening. \nHowever, no\ncholelithiasis or pericholecystic fluid is identified. If there \nis clinical concern for acute cholecystitis, consider HIDA scan \nfor further evaluation.\n\n___\nSuccessful ERCP with duct clearance and placement of fully \ncovered metal stent. \n\n___ ABD & PELVIS WITH CO\n1. Interval placement of a CBD stent with increased periportal \nand\npericholecystic fluid and increase in now small volume ascites. \nCentral\nbiliary tree remains slightly hyperemic and thickened suggesting \nongoing\ncholangitis.\n2. Similar appearance of nodular lesion along the left anterior \npararenal\nfascia which remains concerning for recurrence. Unchanged soft \ntissue\nencasement of the common and proper hepatic artery.\n3. Increased atelectasis in the posterior lung bases with trace \nright pleural effusion new from prior.\n4. Additional nonemergent findings as above.\n\n \nBrief Hospital Course:\nPATIENT SUMMARY\n======================\nMr. ___ is a ___ PMH of Pancreatic adenocarcinoma (s/p \nneoadjuvant FOLFIRINOX for 6 months followed by SBRT & distal \npancreatectomy/splenectomy, now with recently diagnosed \nrecurrence), asymptomatic Duodenal Ulcer (dx ___, who \npresented with severe abdominal pain and jaundice. Improved \nafter ERCP and broad spectrum antibiotics.\n\nACUTE ISSUES\n======================\n#Abdominal Pain\n#Malignant biliary obstruction s/p stent exchange\n#Cholangitis\nPresented with abdominal pain, rising LFTs, leukocytosis, and \nfevers in setting of recent ERCP, concerning for biliary \nobstruction and cholangitis. Started empiric treatment with \npip-tazo on ___. Surgery was consulted, felt low conern for \ncholecystitis. Underwent repeat ERCP on ___ with drainage of \nsludge and replacement of plastic stent with a metal stent. \nInitially symptoms improved, but LFTs and white count continued \nto rise, improved after broadening to \nvancomcycin/cefepime/flagyl on ___, afebrile since ___. \nTransitioned to PO ciprofloxacin/metronidazole on ___. BCx \nnegative. Discharged with plan to complete two week course of \nantibiotics with end date ___.\n\n#Recent Duodenal Ulcer\nAsymptomatic on diagnosis 1 week ago, now with severe abd pain \nwhich improved s/p ERCP so is thought to be unrelated to ulcer. \nContinued omeprazole 20mg BID.\n\n#Recurrent Pancreatic Cancer\n(s/p neoadjuvant FOLFIRINOX for 6 months followed by SBRT & \ndistal pancreatectomy/splenectomy, now with recently diagnosed \nrecurrence). Primary oncologist planning for chemo next week \npending resolution of cholangitis.\n\n#Diabetes\nHistory of pre-diabetes, noted to have fasting BG up to 240s \nthis admission in the setting of infection. A1c 7.2. No sliding \nscale insulin received since ___, FSBG 110s-140s at time of \ndischarge. Transitionally should consider starting metformin. \n\n#Constipation\nPt reported constipation and hard stools, resolved with \naggressive bowel regimen including standing miralax and prn \nsenna and bisacodyl.\n\nCHRONIC ISSUES\n======================\n#S/p splenectomy\nPer ID recommendations, he was discharged with Augmentin \nprescription and pill in pocket instructions to take one dose of \nAugmentin 875/125 should he develop a fever and then to seek \nmedical attention immediately thereafter.\n\nTRANSITIONAL ISSUES\n======================\n[] Check WBC and LFTs on ___, discharged on PO \nciprofloxacin/metronidazole for empiric treatment of cholangitis \nwith end date ___.\n[] F/u BG, consider starting diabetes medications (A1c 7.2 this \nadmission). \n[] Scheduled to start chemotherapy on ___ for recurrent \npancreatic adenocarcinoma.\n[] Due for post splenectomy vaccinations next week, appointment \non ___.\n\n#HCP/Contact: daughter ___ is his HCP ___\n#Code: Full presumed \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Omeprazole 20 mg PO BID \n\n \nDischarge Medications:\n1. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line \nRX *bisacodyl 5 mg 2 tablet(s) by mouth once a day Disp #*90 \nTablet Refills:*0 \n2. Ciprofloxacin HCl 500 mg PO BID \nRX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day \nDisp #*12 Tablet Refills:*0 \n3. MetroNIDAZOLE 500 mg PO Q8H \nRX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8) \nhours Disp #*24 Tablet Refills:*0 \n4. Polyethylene Glycol 17 g PO DAILY \nRX *polyethylene glycol 3350 [Miralax] 17 gram/dose 1 dose by \nmouth once a day Refills:*0 \n5. Senna 8.6-17.2 mg PO QHS:PRN Constipation - First Line \nRX *sennosides [senna] 8.6 mg 1 tablet by mouth once a day Disp \n#*90 Tablet Refills:*0 \n6. Omeprazole 20 mg PO BID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY\n=======\n- Cholangitis \n- Recurrent pancreatic cancer \n\nSECONDARY\n=========\n- Diabetes\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nYou came into the hospital because you were having abdominal \npain. You had an ERCP during which they replaced your bile duct \nstent. You were treated with IV antibiotics for an infection in \nyour bile ducts, then transitioned to PO antibiotics. \n\nWhen you leave the hospital you should:\n- Take all of your medications as prescribed.\n- Attend all scheduled clinic appointments.\n- Continue to take oral ciprofloxacin and metronidazole \nantibiotics for the next 6 weeks.\n- Because you have had your spleen removed, you are at higher \nrisk of infection. Please always carry Augmentin 875/125. If you \ndevelop a fever, take one pill and then seek medical attention \nimmediately.\n\nIt was a pleasure taking care of you, \nYour ___ Care Team\n\n \nFollowup Instructions:\n___\n"
] | Allergies: Compazine Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: [MASKED] ERCP with balloon sweep sludge removal and placement of 10mm 6cm straight metal fully covered biliary stent. History of Present Illness: [MASKED] PMH of Pancreatic adenocarcinoma (s/p neoadjuvant FOLFIRINOX for 6 months followed by SBRT & distal pancreatectomy/splenectomy, now with recently diagnosed recurrence), Asymptomatic Duodenal Ulcer (dx [MASKED], presented with severe abdominal pain + jaundice As per review of notes, patient recently admitted for jaundice thought to be [MASKED] disease progression. Found to have malignant biliary obstruction s/p plastic stent placement and biopsy. Biopsies confirmed recurrence of pancreatic adenocarcinoma, treatment not yet re-initiated. Of note, found to have asymptomatic duodenal ulcer at the time, hpylori negative, was started on omeprazole. On this admission, patient presented with severe abdominal pain, which was epigastric, crampy in nature, [MASKED], not radiating, a/w nausea/vomiting, but no constipation/diarrhea/abdominal distension. Endorsed chills but no fever. Reported that he has never had symptoms like this before. Noted that pain decreased from [MASKED] prior to ERCP to [MASKED] afterward. Reported that his epigastric area remains tender/sore. In the ED, initial vitals: 98.0 89 132/83 16 100% RA. WBC 20.6, Hgb 14.9, plt 438, alt 81, ast 43, ap 210, tbILI 9.3, dbILI 6.5, aLB 4., LIP 10, chem W/ hco3 21, lACTATE 1.4, ua + glc/prot but negative for infection. RUQUS: 1. Pneumobilia due to recent stenting. Improved but persistent intrahepatic biliary dilatation. 2. The gallbladder appears distended with wall thickening. However, no cholelithiasis or pericholecystic fluid is identified. Recommend clinical correlation for acute cholecystitis. If clinical concern for acute cholecystitis remains, can consider HIDA scan for further evaluation. Given persistent bilirubin elevation + leukocytosis, there was concern that patient had cholangitis, so was started on zosyn, morphine, LR, Zofran and taken for ERCP. In ERCP plastic stent was removed, sludge cleared out, and metal stent placed. Patient then admitted to oncology for further care. Past Medical History: PAST ONCOLOGIC HISTORY: As per last outpatient note by Dr [MASKED]: " Following this, he experienced pain that lasted for weeks. He was seen by his PCP and noted to have an elevated lipase as well as pre-diabetes. Due to persistent symptoms, he was admitted to [MASKED] in [MASKED] with pain and his lipase was again >3000. He had a CT which showed extensive peripancreatic stranding with decreased enhancement in the proximal pancreatic body. He was managed conservatively and subsequently referred to Dr. [MASKED] further evaluation and lipase remained elevated to almost 600. MRCP was performed which showed findings of acute on chronic pancreatitis with suspected main PD stricture in the proximal body with upstream irregularity. Given these findings, he was referred for EUS which was performed on [MASKED] which showed a 2.7cm pancreatic body/neck mass with involvement of the PV, SMV, portal confluence, and splenic vein. Several enlarged [MASKED] LNs were seen (largest 10mm), as well as [MASKED] varices, and possible invasion into the gastric wall. FNB of mass was consistent with ductal adenocarcinoma, FNB of LN and gastric wall both negative. [MASKED] C1D1 FOLFIRINOX [MASKED] C1D15 FOLFIRINOX [MASKED] C2D1 FOLFIRINOX [MASKED] C3D1 FOLFIRINOX [MASKED] C3D15 FOLFIRINOX [MASKED] C4D1 FOLFIRINOX due to thrombocytopenia [MASKED] C4D1 FOLFIRINOX [MASKED] C4D15 FOLFIRINOX [MASKED] C5 D1 FOLFIRINOX [MASKED] C5 D18 FOLFIRINOX [MASKED] CyberKnife [MASKED] C6 D1 FOLFIRINOX [MASKED] - Surgery" PAST MEDICAL HISTORY: -ITP (age [MASKED] -Prior DVT [MASKED] years ago) - treated Xarelto x 3 months. -s/p deviated septum repair and T&A (age [MASKED] -Malignant biliary obstruction s/p stent -Duodenal ulcer (diagnosed incidentally during ERCP [MASKED], HPylori negative) -Pancreatic adenocarcinoma (s/p neoadjuvant FOLFIRINOX for 6 months followed by SBRT & distal pacreatectomy/splenectomy, now with recently diagnosed recurrence) Social History: [MASKED] Family History: His sister died of stomach cancer at age [MASKED]. MGM died in her [MASKED] from some form of cancer (his father was [MASKED]). There is a family history of thrombosis. Physical Exam: ADMISSION PHYSICAL EXAM Vitals: 24 HR Data (last updated [MASKED] @ [MASKED] Temp: 98.4 (Tm 98.4), BP: 144/83, HR: 54, RR: 18, O2 sat: 95%, O2 delivery: RA, Wt: 181.3 lb/82.24 kg GENERAL: Laying in bed, appears tired but NAD, calm, pleasant EYES: PERRLA, icteric sclera HEENT: OP clear, MMM NECK: supple, normal ROM LUNGS: CTA b/l, no wheezes/rales/rhonchi, normal RR, no increased WOB CV: RRR normal distal perfusion, no peripheral edema ABD: soft, moderate tenderness in epigastric area, no rebound or guarding, hypoactive BS, no RUQ tenderness, negative [MASKED] sign GENITOURINARY: no foley or suprapubic tenderness EXT: warm, no deformity, normal muscle bulk SKIN: warm, dry, no rash NEURO: AOx3, fluent speech DISCHARGE PHYSICAL EXAM [MASKED] 0812 Temp: 98.7 PO BP: 143/74 HR: 61 RR: 18 O2 sat: 96% O2 delivery: RA FSBG: 131 GENERAL: Laying in bed, in NAD, calm, pleasant EYES: PERRLA, icteric sclera HEENT: OP clear, MMM NECK: supple, normal ROM LUNGS: CTA b/l, no wheezes/rales/rhonchi, no increased WOB CV: RRR, normal S1 and S2 with no murmurs, rubs, gallops, no peripheral edema ABD: soft, non-tender, no rebound or guarding, normal BS GENITOURINARY: no foley or suprapubic tenderness EXT: warm, no deformity, normal muscle bulk SKIN: Skin type III. Mild jaundice, warm, dry, no rash NEURO: AOx3, fluent speech Pertinent Results: ADMISSION LABS ==================== [MASKED] 10:25AM BLOOD WBC: 20.6* RBC: 4.56* Hgb: 14.9 Hct: 42.9 MCV: 94 MCH: 32.7* MCHC: 34.7 RDW: 17.6* RDWSD: 60.4* Plt Ct: 438* [MASKED] 10:25AM BLOOD [MASKED]: 12.0 PTT: 34.7 [MASKED]: 1.1 [MASKED] 10:25AM BLOOD Glucose: 247* UreaN: 18 Creat: 0.7 Na: 137 K: 4.6 Cl: 102 HCO3: 21* AnGap: 14 [MASKED] 10:25AM BLOOD ALT: 81* AST: 43* AlkPhos: 210* TotBili: 9.3* DirBili: 6.5* IndBili: 2.8 [MASKED] 10:25AM BLOOD Albumin: 4.1 [MASKED] 10:30AM BLOOD Lactate: 1.4 [MASKED] 05:03AM BLOOD %HbA1c-7.2* eAG-160* DISCHARGE LABS ==================== [MASKED] 06:00AM BLOOD WBC-14.7* RBC-3.72* Hgb-12.2* Hct-35.3* MCV-95 MCH-32.8* MCHC-34.6 RDW-17.1* RDWSD-58.5* Plt [MASKED] [MASKED] 06:00AM BLOOD Neuts-65.0 Lymphs-17.9* Monos-10.4 Eos-4.0 Baso-0.4 Im [MASKED] AbsNeut-9.57* AbsLymp-2.63 AbsMono-1.53* AbsEos-0.59* AbsBaso-0.06 [MASKED] 06:00AM BLOOD Glucose-124* UreaN-11 Creat-0.5 Na-138 K-4.2 Cl-102 HCO3-28 AnGap-8* [MASKED] 06:00AM BLOOD Albumin-2.8* Calcium-8.2* Phos-3.1 Mg-2.0 [MASKED] 06:00AM BLOOD ALT-84* AST-72* LD(LDH)-195 AlkPhos-123 TotBili-3.2* REPORTS ==================== [MASKED] OR GALLBLADDER US 1. Pneumobilia due to recent stenting. Improved but persistent intrahepatic biliary dilatation. 2. The gallbladder appears distended with wall thickening. However, no cholelithiasis or pericholecystic fluid is identified. If there is clinical concern for acute cholecystitis, consider HIDA scan for further evaluation. [MASKED] Successful ERCP with duct clearance and placement of fully covered metal stent. [MASKED] ABD & PELVIS WITH CO 1. Interval placement of a CBD stent with increased periportal and pericholecystic fluid and increase in now small volume ascites. Central biliary tree remains slightly hyperemic and thickened suggesting ongoing cholangitis. 2. Similar appearance of nodular lesion along the left anterior pararenal fascia which remains concerning for recurrence. Unchanged soft tissue encasement of the common and proper hepatic artery. 3. Increased atelectasis in the posterior lung bases with trace right pleural effusion new from prior. 4. Additional nonemergent findings as above. Brief Hospital Course: PATIENT SUMMARY ====================== Mr. [MASKED] is a [MASKED] PMH of Pancreatic adenocarcinoma (s/p neoadjuvant FOLFIRINOX for 6 months followed by SBRT & distal pancreatectomy/splenectomy, now with recently diagnosed recurrence), asymptomatic Duodenal Ulcer (dx [MASKED], who presented with severe abdominal pain and jaundice. Improved after ERCP and broad spectrum antibiotics. ACUTE ISSUES ====================== #Abdominal Pain #Malignant biliary obstruction s/p stent exchange #Cholangitis Presented with abdominal pain, rising LFTs, leukocytosis, and fevers in setting of recent ERCP, concerning for biliary obstruction and cholangitis. Started empiric treatment with pip-tazo on [MASKED]. Surgery was consulted, felt low conern for cholecystitis. Underwent repeat ERCP on [MASKED] with drainage of sludge and replacement of plastic stent with a metal stent. Initially symptoms improved, but LFTs and white count continued to rise, improved after broadening to vancomcycin/cefepime/flagyl on [MASKED], afebrile since [MASKED]. Transitioned to PO ciprofloxacin/metronidazole on [MASKED]. BCx negative. Discharged with plan to complete two week course of antibiotics with end date [MASKED]. #Recent Duodenal Ulcer Asymptomatic on diagnosis 1 week ago, now with severe abd pain which improved s/p ERCP so is thought to be unrelated to ulcer. Continued omeprazole 20mg BID. #Recurrent Pancreatic Cancer (s/p neoadjuvant FOLFIRINOX for 6 months followed by SBRT & distal pancreatectomy/splenectomy, now with recently diagnosed recurrence). Primary oncologist planning for chemo next week pending resolution of cholangitis. #Diabetes History of pre-diabetes, noted to have fasting BG up to 240s this admission in the setting of infection. A1c 7.2. No sliding scale insulin received since [MASKED], FSBG 110s-140s at time of discharge. Transitionally should consider starting metformin. #Constipation Pt reported constipation and hard stools, resolved with aggressive bowel regimen including standing miralax and prn senna and bisacodyl. CHRONIC ISSUES ====================== #S/p splenectomy Per ID recommendations, he was discharged with Augmentin prescription and pill in pocket instructions to take one dose of Augmentin 875/125 should he develop a fever and then to seek medical attention immediately thereafter. TRANSITIONAL ISSUES ====================== [] Check WBC and LFTs on [MASKED], discharged on PO ciprofloxacin/metronidazole for empiric treatment of cholangitis with end date [MASKED]. [] F/u BG, consider starting diabetes medications (A1c 7.2 this admission). [] Scheduled to start chemotherapy on [MASKED] for recurrent pancreatic adenocarcinoma. [] Due for post splenectomy vaccinations next week, appointment on [MASKED]. #HCP/Contact: daughter [MASKED] is his HCP [MASKED] #Code: Full presumed Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Omeprazole 20 mg PO BID Discharge Medications: 1. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line RX *bisacodyl 5 mg 2 tablet(s) by mouth once a day Disp #*90 Tablet Refills:*0 2. Ciprofloxacin HCl 500 mg PO BID RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #*12 Tablet Refills:*0 3. MetroNIDAZOLE 500 mg PO Q8H RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #*24 Tablet Refills:*0 4. Polyethylene Glycol 17 g PO DAILY RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 1 dose by mouth once a day Refills:*0 5. Senna 8.6-17.2 mg PO QHS:PRN Constipation - First Line RX *sennosides [senna] 8.6 mg 1 tablet by mouth once a day Disp #*90 Tablet Refills:*0 6. Omeprazole 20 mg PO BID Discharge Disposition: Home Discharge Diagnosis: PRIMARY ======= - Cholangitis - Recurrent pancreatic cancer SECONDARY ========= - Diabetes Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], You came into the hospital because you were having abdominal pain. You had an ERCP during which they replaced your bile duct stent. You were treated with IV antibiotics for an infection in your bile ducts, then transitioned to PO antibiotics. When you leave the hospital you should: - Take all of your medications as prescribed. - Attend all scheduled clinic appointments. - Continue to take oral ciprofloxacin and metronidazole antibiotics for the next 6 weeks. - Because you have had your spleen removed, you are at higher risk of infection. Please always carry Augmentin 875/125. If you develop a fever, take one pill and then seek medical attention immediately. It was a pleasure taking care of you, Your [MASKED] Care Team Followup Instructions: [MASKED] | [
"K8309",
"K831",
"C259",
"Z9081",
"Z90411",
"K269",
"K5900",
"E119"
] | [
"K8309: Other cholangitis",
"K831: Obstruction of bile duct",
"C259: Malignant neoplasm of pancreas, unspecified",
"Z9081: Acquired absence of spleen",
"Z90411: Acquired partial absence of pancreas",
"K269: Duodenal ulcer, unspecified as acute or chronic, without hemorrhage or perforation",
"K5900: Constipation, unspecified",
"E119: Type 2 diabetes mellitus without complications"
] | [
"K5900",
"E119"
] | [] |
15,723,414 | 28,399,467 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nSeptic shock secondary to cellulitis of the right upper limb.\n \nMajor Surgical or Invasive Procedure:\n___ - Right dorsal forearm irrigation and debridement with \ndorsal and volar fasciotomies. \n\n \nHistory of Present Illness:\n___ is a ___ yo F who presented with a one day \nhistory of worsening right arm erythema and pain. She scraped \nher arm manipulating a car seat on ___. On ___, she \ndeveloped worsening pain form her hand to her shoulder and \nerythema. She had subjective fevers and chills and went promptly \nto the ED at ___. There, she was given vancomycin and \nclindamycin. The erythema was noted to have spread over the \ncourse of her several hours of observation and she was thus \ntransferred to ___ for operative evaluation. On the morning of \n___, she became hypotensive, unresponsive to 4L IVF, was \ngiven meropenem and pressors started ___ transit. \nPatient was seen by ACS and plastic surgery, and was taken to \nthe OR for incision & drainage of RUE by Plastic surgery and \nsent to the SICU for critical care management postoperatively. \nDuring her stay ___ the SICU, she was given vancomycin and Zosyn \nfor infection source control. She was also given one dose of \nphenobarbital (CIWA score 15) and the vasopressors were weaned \nappropriately.\n\nTransitional issues:\n___: Admission Cr 1.2. Resolved with fluid administration.\n#EtOH abuse - ___ precautions - 1 dose of phenobarbital.\n#Acute blood loss anemia: Hct 39.3-30.4. Did not require any \ntransfusions.\n \nPast Medical History:\nNone.\n \nSocial History:\n___\nFamily History:\nNot relevant.\n \nPhysical Exam:\nED PHYSICAL EXAM: \n================\nTemp: 98.4 HR: 87 BP: 83/66 Resp: 17 O(2)Sat: 100 Normal\nConstitutional: Uncomfortable\nHEENT: Normocephalic, atraumatic, Pupils equal, round and\nreactive to light\nOropharynx within normal limits\nChest: Clear to auscultation\nCardiovascular: Regular Rate and Rhythm, Normal first and\nsecond heart sounds\nAbdominal: Soft, Nontender\nExtr/Back: Marked edema to RUE, tender to palpation, 1.5 cm\nulceration, erythema warmth, pain with palpation. Erythema\nbeyond demarcated lines of distal humerus area\nNeuro: Speech fluent\nPsych: Normal mood, Normal mentation\n\nDISCHARGE PHYSICAL EXAM: \n=======================\nVS: T99.2, BP 125/78, HR65, RR 18, 94% on RA\nGENERAL: Alert and interactive. ___ no acute distress.\nHEENT: Normocephalic, atraumatic. Sclera anicteric and without \ninjection. Moist mucous membranes, oropharynx is clear.\nNECK: no JVD \nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2. no \nmurmurs, rubs ___ \nLUNGS: Good airflow, but decreased at the bases. No w/r/r. \nABDOMEN: normal BS. non- distended. non-tender.\nEXTREMITIES: R forearm wound vac ___ place c/d/i. +erythema and \nedema of right hand, improving compared to yesterday. No edema \nof lower extremities. ___ negative. +radial & DP b/l. \nNEUROLOGIC: A&Ox3, moving all 4 limbs with purpose. intact \nsensation to light touch ___ b/l hands. able to wiggle all \nfingers of right hand.\n\n \nPertinent Results:\nADMISSION LABS: \n===============\n___ 04:02PM BLOOD WBC-19.8* RBC-3.97 Hgb-12.8 Hct-41.4 \nMCV-104* MCH-32.2* MCHC-30.9* RDW-13.5 RDWSD-51.7* Plt ___\n___ 04:02PM BLOOD Neuts-89* Bands-4 Lymphs-4* Monos-3* \nEos-0* Baso-0 AbsNeut-18.41* AbsLymp-0.79* AbsMono-0.59 \nAbsEos-0.00* AbsBaso-0.00*\n___ 04:02PM BLOOD Anisocy-1+* Poiklo-1+* Macrocy-1+* \nOvalocy-1+* Tear Dr-1+* Acantho-1+* RBC Mor-SLIDE REVI\n___ 04:02PM BLOOD Plt Smr-NORMAL Plt ___\n___ 03:31AM BLOOD ___\n___ 06:05PM BLOOD Glucose-141* UreaN-24* Creat-1.2* Na-135 \nK-4.8 Cl-104 HCO3-12* AnGap-19*\n___ 06:05PM BLOOD ALT-32 AST-47* AlkPhos-76 TotBili-0.8\n___ 06:05PM BLOOD Lipase-11\n___ 06:05PM BLOOD cTropnT-<0.01\n___ 06:05PM BLOOD Albumin-3.5 Calcium-8.1* Phos-3.7 Mg-1.6\n___ 06:05PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nTricycl-NEG\n___ 12:08AM BLOOD Type-ART pO2-112* pCO2-55* pH-7.20* \ncalTCO2-22 Base XS--6\n___ 04:20PM BLOOD Lactate-3.6*\n___ 06:15PM BLOOD Lactate-4.0*\n\nDISCHARGE LABS: \n===============\n___ 06:10AM BLOOD WBC-5.5 RBC-3.43* Hgb-10.6* Hct-32.2* \nMCV-94 MCH-30.9 MCHC-32.9 RDW-13.2 RDWSD-45.4 Plt ___\n___ 06:10AM BLOOD Glucose-90 UreaN-10 Creat-0.8 Na-142 \nK-3.7 Cl-104 HCO3-25 AnGap-13\n___ 06:10AM BLOOD Albumin-2.8* Calcium-8.2* Phos-2.7 Mg-2.0\n\nOTHER PERTINENT LABS: \n====================\n___ 05:44AM BLOOD %HbA1c-4.9 eAG-94\n\nIMAGING: \n========\nCXR (___): \nNo previous images. There is enlargement of the cardiac \nsilhouette with mild\npulmonary vascular congestion. There is bibasilar opacification \nwith poor\ndefinition of the hemidiaphragms, much more prominent on the \nright, consistent\nwith pleural effusion and underlying compressive atelectasis.\nOf incidental note is an azygos fissure on the right, of no \nclinical\nsignificance.\n\nMICROBIOLOGY: \n=============\n___ 6:37 pm SWAB Site: ARM RT ARM # 1. \n\n **FINAL REPORT ___\n\n GRAM STAIN (Final ___: \n NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. \n 2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. \n ___ PAIRS AND SINGLY. \n\n WOUND CULTURE (Final ___: \n BETA STREPTOCOCCUS GROUP A. SPARSE GROWTH. \n\n ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. \n\n\n \nBrief Hospital Course:\nBRIEF HOSPITAL COURSE: \n====================\n___ is a ___ yo F who presented from OSH with a \none day history of worsening right arm erythema and pain ___ s/o \nrecent scrape. At OSH was given vanc/clinda. On ___ she was \ntransferred to ___ for operative evaluation. ___ transit, \nrequired initiation of IVF, pressors, & meropenem. Patient was \nseen by ACS and plastic surgery, and was taken to the OR for \nincision & drainage of RUE by Plastic surgery and sent to the \nSICU for critical care management postoperatively. During her \nstay ___ the SICU, she was given vancomycin and Zosyn for \ninfection source control. She was also given one dose of \nphenobarbital (CIWA score 15) and the vasopressors were weaned \nappropriately. On the floor, pt experienced dyspnea without \nhypoxia which we attributed to atelectasis ___ setting of her \nrecent operation and ICU stay. She successfully transitioned to \np.o. cephalexin for a 2-week course. Her hypoxemia resolved with \nincentive spirometry. She was discharged home with ___ and ___ \nfor wound vac management.\n\nTRANSITIONAL ISSUES: \n================================= \n[] \nMEDICATIONS: \n- New Meds: cephalexin (end ___, thiamine, MVI\n- Stopped Meds: none\n- Changed Meds: none\nFOLLOW-UP \n[]PCP: pt endorsed average of two drinks every night & received \nphenobarb ___ ICU. recommend alcohol cessation counseling. \n[]PCP: pt with acute normocytic-macrocytic anemia, please check \nrepeat CBC ___ 2 weeks to ensure resolution. if still anemic, \nwould also recommend B12 & folate. \n[]PCP: incidentally found EKGs with signs of prior ischemic \ndisease and T-wave inversions that resolve with reduction ___ \nheart rate, concerning for demand ischemia. consider stress \ntest, lipids, & further cardiac work up if indicated\n[]PCP: ___ screening pt for HIV given presentation with \nsevere infection\n[]Plastics: follow-up re: wound vac & split thickness skin graft\n___: please see wound vac care instructions below \n\nWOUND VAC CARE:\nPlease cover skin bridge between incisions with duoderm and \naround the incisions.\nCut black sponge to size over both incisions (approx 15 cm x 13 \ncm) and cover maintain -125 mmHg\nChange every ___ days\n\nOTHER ISSUES: \n- Discharge Hemoglobin: 10.6 \n- Discharge Cr: 0.8\n\n# CODE: Full, presumed\n# CONTACT: husband, ___ ___\n\nACUTE/ACTIVE ISSUES:\n====================\n#Right arm cellulitis: reportedly from scrape on car door\n#Necrotizing fasciitis: \n#Septic shock, now improved: \ns/p debridement and fasciotomy by hand surgery; wound cultures \ngrew Group A Strep; no PMH (DM,steroid use) to suggest increased \nsusceptibility to severe wound infection. S/p IV abx \n(vanc/zosyn/clinda) now on 2 week course of PO cephalexin. wound \nvac placed by hand surgery team on ___. \n- continue cephalexin (end ___\n- Tylenol, ibuprofen, & oxycodone w/ wound vac changes for pain \nmanagement\n- F/u blood cultures\n- plastics follow-up for wound vac & STSG (likely ___\n- ___ for wound care and vac management\n\n#Dyspnea\nPt had new onset dyspnea with inspiratory pain. Likely \natelectasis ___ s/o recent operation & ICU stay. CXR supports \nthis. Concern for DVT low (no ___ swelling, tachycardia). Wells \nscore 1. Do not believe PNA as afebrile & non-prod cough. \nSuccessfully weaned off sup O2 and working with incentive \nspirometer. \n\n#?Alcohol withdrawal/DTs: s/p IV phenobarb load 520mg for\n\"nausea, chills, tremors, labile BP\" with reported good effect;\nunclear if true withdrawal; pt confirms ___ \"glasses of wine\" 5\nnights a week. Has only been scoring on CIWA for headache to\nscores <3. \n-outpt alcohol cessation counseling\n-MIV & thiamine\n\n#New onset A-fib (resolved): ___ the setting of septic shock and\nself terminated. CHADS2VASC is 1. no episodes on tele thusfar\nwhile on the floor. \n- if needs anti-hypertensive ___ future, would consider \ncarvedilol\n\n#Anemia: likely from combination of hemodilution and septic \nshock. Hgb on discharge 10.6 (admission 12.4). has ranged from \nnormocytic to macrocytic.\n-outpt follow-up for B12 and folate studies\n\n#Thrombocytopenia, resolved: at 148 post-op, back to baseline at \n212 on discharge. \n\n#Transitional Issues \n#?CAD: EKGs with signs of prior ischemic disease and T-wave\ninversions that resolve with reduction ___ heart rate (likely\ndemand ischemia)\n- F/u as outpatient for further workup\n\nThis patient was prescribed, or continued on, an opioid pain \nmedication at the time of discharge (please see the attached \nmedication list for details). As part of our safe opioid \nprescribing process, all patients are provided with an opioid \nrisks and treatment resource education sheet and encouraged to \ndiscuss this therapy with their outpatient providers to \ndetermine if opioid pain medication is still indicated.\n\nATTENDING ADDENDUM TO DISCHARGE SUMMARY:\n>30minutes was spent ___ care coordination and safe discharge \nplanning\n\n___ Attending\n___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. This patient is not taking any preadmission medications\n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q6H \nRX *acetaminophen [8HR Muscle Aches-Pain] 650 mg 1 tablet(s) by \nmouth every 8 hours as needed Disp #*30 Tablet Refills:*0 \n2. Cephalexin 500 mg PO Q6H Duration: 12 Days \nRX *cephalexin 500 mg 1 capsule(s) by mouth every six (6) hours \nDisp #*42 Capsule Refills:*0 \n3. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild \nRX *ibuprofen [IBU] 400 mg 1 tablet(s) by mouth every eight (8) \nhours Disp #*30 Tablet Refills:*0 \n4. Multivitamins 1 TAB PO DAILY \nRX *multivitamin 1 capsule(s) by mouth once a day Disp #*30 \nCapsule Refills:*0 \n5. OxyCODONE (Immediate Release) 2.5 mg PO Q8H:PRN Pain - \nModerate \nplease use for wound vac changes if painful \nRX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth with wound \nvac changes Disp #*5 Tablet Refills:*0 \n6. Thiamine 100 mg PO DAILY \nRX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a \nday Disp #*30 Tablet Refills:*0 \n7. Rolling walker\nR26.2\nPrognosis: good\nLength of need: 13 months \n8.Rolling walker\nR26.2\nPrognosis: good\nLength of need: 13 months\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary: \nCellulitis of right upper extremity\nSeptic Shock\n\nSecondary:\nacute kidney injury\nAnemia\nat risk alcohol use\natelectasis\natrial fibrilation\nthrombocytopenia\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - with S and RW. \n\n \nDischarge Instructions:\nDear ___, \n \n___ was a pleasure taking part ___ your care here at ___! \n\nWhy was I admitted to the hospital? \nYou were admitted to the hospital for acute infection near \nright.\n \nWhat was done for me while I was ___ the hospital? \n- You had to undergo surgery due to an acute infection on your \nright hand. Some of the tissue from your hand had to be removed \ndue to infection. \n- You were then admitted to the Surgical Intensive Care Unit for \nmonitoring of your wound, blood pressure, and kidney function. \nFor these, you received intravenous fluids, antibiotics, and \nmedication to treat low blood pressure. \n- You were transferred to the medicine floor to continue your \nantibiotics. \n- You were evaluated by physical therapy & occupational therapy. \n\n\nWhat should I do when I leave the hospital? \n-Take all of your medications as prescribed.\n-Follow-up with all of your doctors as directed. \n\nSincerely, \nYour ___ Care Team \n\n \nFollowup Instructions:\n___\n"
] | Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Septic shock secondary to cellulitis of the right upper limb. Major Surgical or Invasive Procedure: [MASKED] - Right dorsal forearm irrigation and debridement with dorsal and volar fasciotomies. History of Present Illness: [MASKED] is a [MASKED] yo F who presented with a one day history of worsening right arm erythema and pain. She scraped her arm manipulating a car seat on [MASKED]. On [MASKED], she developed worsening pain form her hand to her shoulder and erythema. She had subjective fevers and chills and went promptly to the ED at [MASKED]. There, she was given vancomycin and clindamycin. The erythema was noted to have spread over the course of her several hours of observation and she was thus transferred to [MASKED] for operative evaluation. On the morning of [MASKED], she became hypotensive, unresponsive to 4L IVF, was given meropenem and pressors started [MASKED] transit. Patient was seen by ACS and plastic surgery, and was taken to the OR for incision & drainage of RUE by Plastic surgery and sent to the SICU for critical care management postoperatively. During her stay [MASKED] the SICU, she was given vancomycin and Zosyn for infection source control. She was also given one dose of phenobarbital (CIWA score 15) and the vasopressors were weaned appropriately. Transitional issues: [MASKED]: Admission Cr 1.2. Resolved with fluid administration. #EtOH abuse - [MASKED] precautions - 1 dose of phenobarbital. #Acute blood loss anemia: Hct 39.3-30.4. Did not require any transfusions. Past Medical History: None. Social History: [MASKED] Family History: Not relevant. Physical Exam: ED PHYSICAL EXAM: ================ Temp: 98.4 HR: 87 BP: 83/66 Resp: 17 O(2)Sat: 100 Normal Constitutional: Uncomfortable HEENT: Normocephalic, atraumatic, Pupils equal, round and reactive to light Oropharynx within normal limits Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Soft, Nontender Extr/Back: Marked edema to RUE, tender to palpation, 1.5 cm ulceration, erythema warmth, pain with palpation. Erythema beyond demarcated lines of distal humerus area Neuro: Speech fluent Psych: Normal mood, Normal mentation DISCHARGE PHYSICAL EXAM: ======================= VS: T99.2, BP 125/78, HR65, RR 18, 94% on RA GENERAL: Alert and interactive. [MASKED] no acute distress. HEENT: Normocephalic, atraumatic. Sclera anicteric and without injection. Moist mucous membranes, oropharynx is clear. NECK: no JVD CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. no murmurs, rubs [MASKED] LUNGS: Good airflow, but decreased at the bases. No w/r/r. ABDOMEN: normal BS. non- distended. non-tender. EXTREMITIES: R forearm wound vac [MASKED] place c/d/i. +erythema and edema of right hand, improving compared to yesterday. No edema of lower extremities. [MASKED] negative. +radial & DP b/l. NEUROLOGIC: A&Ox3, moving all 4 limbs with purpose. intact sensation to light touch [MASKED] b/l hands. able to wiggle all fingers of right hand. Pertinent Results: ADMISSION LABS: =============== [MASKED] 04:02PM BLOOD WBC-19.8* RBC-3.97 Hgb-12.8 Hct-41.4 MCV-104* MCH-32.2* MCHC-30.9* RDW-13.5 RDWSD-51.7* Plt [MASKED] [MASKED] 04:02PM BLOOD Neuts-89* Bands-4 Lymphs-4* Monos-3* Eos-0* Baso-0 AbsNeut-18.41* AbsLymp-0.79* AbsMono-0.59 AbsEos-0.00* AbsBaso-0.00* [MASKED] 04:02PM BLOOD Anisocy-1+* Poiklo-1+* Macrocy-1+* Ovalocy-1+* Tear Dr-1+* Acantho-1+* RBC Mor-SLIDE REVI [MASKED] 04:02PM BLOOD Plt Smr-NORMAL Plt [MASKED] [MASKED] 03:31AM BLOOD [MASKED] [MASKED] 06:05PM BLOOD Glucose-141* UreaN-24* Creat-1.2* Na-135 K-4.8 Cl-104 HCO3-12* AnGap-19* [MASKED] 06:05PM BLOOD ALT-32 AST-47* AlkPhos-76 TotBili-0.8 [MASKED] 06:05PM BLOOD Lipase-11 [MASKED] 06:05PM BLOOD cTropnT-<0.01 [MASKED] 06:05PM BLOOD Albumin-3.5 Calcium-8.1* Phos-3.7 Mg-1.6 [MASKED] 06:05PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG [MASKED] 12:08AM BLOOD Type-ART pO2-112* pCO2-55* pH-7.20* calTCO2-22 Base XS--6 [MASKED] 04:20PM BLOOD Lactate-3.6* [MASKED] 06:15PM BLOOD Lactate-4.0* DISCHARGE LABS: =============== [MASKED] 06:10AM BLOOD WBC-5.5 RBC-3.43* Hgb-10.6* Hct-32.2* MCV-94 MCH-30.9 MCHC-32.9 RDW-13.2 RDWSD-45.4 Plt [MASKED] [MASKED] 06:10AM BLOOD Glucose-90 UreaN-10 Creat-0.8 Na-142 K-3.7 Cl-104 HCO3-25 AnGap-13 [MASKED] 06:10AM BLOOD Albumin-2.8* Calcium-8.2* Phos-2.7 Mg-2.0 OTHER PERTINENT LABS: ==================== [MASKED] 05:44AM BLOOD %HbA1c-4.9 eAG-94 IMAGING: ======== CXR ([MASKED]): No previous images. There is enlargement of the cardiac silhouette with mild pulmonary vascular congestion. There is bibasilar opacification with poor definition of the hemidiaphragms, much more prominent on the right, consistent with pleural effusion and underlying compressive atelectasis. Of incidental note is an azygos fissure on the right, of no clinical significance. MICROBIOLOGY: ============= [MASKED] 6:37 pm SWAB Site: ARM RT ARM # 1. **FINAL REPORT [MASKED] GRAM STAIN (Final [MASKED]: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 2+ [MASKED] per 1000X FIELD): GRAM POSITIVE COCCI. [MASKED] PAIRS AND SINGLY. WOUND CULTURE (Final [MASKED]: BETA STREPTOCOCCUS GROUP A. SPARSE GROWTH. ANAEROBIC CULTURE (Final [MASKED]: NO ANAEROBES ISOLATED. Brief Hospital Course: BRIEF HOSPITAL COURSE: ==================== [MASKED] is a [MASKED] yo F who presented from OSH with a one day history of worsening right arm erythema and pain [MASKED] s/o recent scrape. At OSH was given vanc/clinda. On [MASKED] she was transferred to [MASKED] for operative evaluation. [MASKED] transit, required initiation of IVF, pressors, & meropenem. Patient was seen by ACS and plastic surgery, and was taken to the OR for incision & drainage of RUE by Plastic surgery and sent to the SICU for critical care management postoperatively. During her stay [MASKED] the SICU, she was given vancomycin and Zosyn for infection source control. She was also given one dose of phenobarbital (CIWA score 15) and the vasopressors were weaned appropriately. On the floor, pt experienced dyspnea without hypoxia which we attributed to atelectasis [MASKED] setting of her recent operation and ICU stay. She successfully transitioned to p.o. cephalexin for a 2-week course. Her hypoxemia resolved with incentive spirometry. She was discharged home with [MASKED] and [MASKED] for wound vac management. TRANSITIONAL ISSUES: ================================= [] MEDICATIONS: - New Meds: cephalexin (end [MASKED], thiamine, MVI - Stopped Meds: none - Changed Meds: none FOLLOW-UP []PCP: pt endorsed average of two drinks every night & received phenobarb [MASKED] ICU. recommend alcohol cessation counseling. []PCP: pt with acute normocytic-macrocytic anemia, please check repeat CBC [MASKED] 2 weeks to ensure resolution. if still anemic, would also recommend B12 & folate. []PCP: incidentally found EKGs with signs of prior ischemic disease and T-wave inversions that resolve with reduction [MASKED] heart rate, concerning for demand ischemia. consider stress test, lipids, & further cardiac work up if indicated []PCP: [MASKED] screening pt for HIV given presentation with severe infection []Plastics: follow-up re: wound vac & split thickness skin graft [MASKED]: please see wound vac care instructions below WOUND VAC CARE: Please cover skin bridge between incisions with duoderm and around the incisions. Cut black sponge to size over both incisions (approx 15 cm x 13 cm) and cover maintain -125 mmHg Change every [MASKED] days OTHER ISSUES: - Discharge Hemoglobin: 10.6 - Discharge Cr: 0.8 # CODE: Full, presumed # CONTACT: husband, [MASKED] [MASKED] ACUTE/ACTIVE ISSUES: ==================== #Right arm cellulitis: reportedly from scrape on car door #Necrotizing fasciitis: #Septic shock, now improved: s/p debridement and fasciotomy by hand surgery; wound cultures grew Group A Strep; no PMH (DM,steroid use) to suggest increased susceptibility to severe wound infection. S/p IV abx (vanc/zosyn/clinda) now on 2 week course of PO cephalexin. wound vac placed by hand surgery team on [MASKED]. - continue cephalexin (end [MASKED] - Tylenol, ibuprofen, & oxycodone w/ wound vac changes for pain management - F/u blood cultures - plastics follow-up for wound vac & STSG (likely [MASKED] - [MASKED] for wound care and vac management #Dyspnea Pt had new onset dyspnea with inspiratory pain. Likely atelectasis [MASKED] s/o recent operation & ICU stay. CXR supports this. Concern for DVT low (no [MASKED] swelling, tachycardia). Wells score 1. Do not believe PNA as afebrile & non-prod cough. Successfully weaned off sup O2 and working with incentive spirometer. #?Alcohol withdrawal/DTs: s/p IV phenobarb load 520mg for "nausea, chills, tremors, labile BP" with reported good effect; unclear if true withdrawal; pt confirms [MASKED] "glasses of wine" 5 nights a week. Has only been scoring on CIWA for headache to scores <3. -outpt alcohol cessation counseling -MIV & thiamine #New onset A-fib (resolved): [MASKED] the setting of septic shock and self terminated. CHADS2VASC is 1. no episodes on tele thusfar while on the floor. - if needs anti-hypertensive [MASKED] future, would consider carvedilol #Anemia: likely from combination of hemodilution and septic shock. Hgb on discharge 10.6 (admission 12.4). has ranged from normocytic to macrocytic. -outpt follow-up for B12 and folate studies #Thrombocytopenia, resolved: at 148 post-op, back to baseline at 212 on discharge. #Transitional Issues #?CAD: EKGs with signs of prior ischemic disease and T-wave inversions that resolve with reduction [MASKED] heart rate (likely demand ischemia) - F/u as outpatient for further workup 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. ATTENDING ADDENDUM TO DISCHARGE SUMMARY: >30minutes was spent [MASKED] care coordination and safe discharge planning [MASKED] Attending [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H RX *acetaminophen [8HR Muscle Aches-Pain] 650 mg 1 tablet(s) by mouth every 8 hours as needed Disp #*30 Tablet Refills:*0 2. Cephalexin 500 mg PO Q6H Duration: 12 Days RX *cephalexin 500 mg 1 capsule(s) by mouth every six (6) hours Disp #*42 Capsule Refills:*0 3. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild RX *ibuprofen [IBU] 400 mg 1 tablet(s) by mouth every eight (8) hours Disp #*30 Tablet Refills:*0 4. Multivitamins 1 TAB PO DAILY RX *multivitamin 1 capsule(s) by mouth once a day Disp #*30 Capsule Refills:*0 5. OxyCODONE (Immediate Release) 2.5 mg PO Q8H:PRN Pain - Moderate please use for wound vac changes if painful RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth with wound vac changes Disp #*5 Tablet Refills:*0 6. Thiamine 100 mg PO DAILY RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 7. Rolling walker R26.2 Prognosis: good Length of need: 13 months 8.Rolling walker R26.2 Prognosis: good Length of need: 13 months Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Primary: Cellulitis of right upper extremity Septic Shock Secondary: acute kidney injury Anemia at risk alcohol use atelectasis atrial fibrilation thrombocytopenia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - with S and RW. Discharge Instructions: Dear [MASKED], [MASKED] was a pleasure taking part [MASKED] your care here at [MASKED]! Why was I admitted to the hospital? You were admitted to the hospital for acute infection near right. What was done for me while I was [MASKED] the hospital? - You had to undergo surgery due to an acute infection on your right hand. Some of the tissue from your hand had to be removed due to infection. - You were then admitted to the Surgical Intensive Care Unit for monitoring of your wound, blood pressure, and kidney function. For these, you received intravenous fluids, antibiotics, and medication to treat low blood pressure. - You were transferred to the medicine floor to continue your antibiotics. - You were evaluated by physical therapy & occupational therapy. What should I do when I leave the hospital? -Take all of your medications as prescribed. -Follow-up with all of your doctors as directed. Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED] | [
"A419",
"R6521",
"L03113",
"F10231",
"N179",
"J9811",
"D62",
"I4891",
"D696",
"I2510"
] | [
"A419: Sepsis, unspecified organism",
"R6521: Severe sepsis with septic shock",
"L03113: Cellulitis of right upper limb",
"F10231: Alcohol dependence with withdrawal delirium",
"N179: Acute kidney failure, unspecified",
"J9811: Atelectasis",
"D62: Acute posthemorrhagic anemia",
"I4891: Unspecified atrial fibrillation",
"D696: Thrombocytopenia, unspecified",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris"
] | [
"N179",
"D62",
"I4891",
"D696",
"I2510"
] | [] |
14,156,347 | 24,815,629 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nleft hand swelling \n \nMajor Surgical or Invasive Procedure:\nNone.\n\n \nHistory of Present Illness:\n___ female with hx IVDU, recent admission for sepsis \nsecondary to IVDU at a hospital in ___, intermittently \nnoncompliant with p.o. antibiotics presenting with several days \nof left hand erythema and swelling as well as intermittent chest \npain transferred to ___ from OSH ER for further management.\n\nPer records from the ___, the patient reports progressively \nworsening redness and swelling to the left first finger and the \nmid dorsal aspect of her left forearm for the past several days. \nShe states that she relapsed with IV drug use and last used this \nmorning. She pointed to an area on her dorsal left wrist where \nshe has been injecting. She had chest pain which was \nintermittent, lasting several minutes and then resolving. She \ndenies associated dyspnea. She denies fevers during this time. \nShe also reports that she has had a yeast infection since \nstarting antibiotics with white vaginal discharge, red bumps, \nulceration and some swelling of her labia.\n\nPatient was initially presented to ___. She was given \nvancomycin, IM toradol, and 1L NS. She was transferred to ___ \nfor further management. \n\nIn the ___, initial vitals were: ___ pain, 99.4 102 102/60 4 \n100% RA \n- Exam notable for: \nCellulitis of left hand\nNo murmur\nLungs clear to auscultation\nNo ___ nodes ___ lesions\nPelvic: No CMT or masses, bilateral small Bartholin cysts \n\n- Labs notable for: \nCBC: 5.6 > 10.2/31.6 < 164 \nChem: Na 137 K 3.4 Cl 103 HCO# 23BUN 4 Cr 0.6\nAST 187 ALT 253 AP 90 Tbili 1.2\n\n- Imaging was notable for:\nPOC Echo: No large vegitations, grossly normal EF\nCTA: No evidence of pulmonary emboli to the segmental level. \nUnremarkable examination. (prelim)\n\n- Patient was given: \n___ 02:42 PO Azithromycin 1000 mg \n___ 02:42 IM CeftriaXONE 250 mg \n___ 02:43 PO MetRONIDAZOLE (FLagyl) ___ mg\n___ 04:31 IV CefePIME 2 g \n\n***Concern for continued IV drug abuse on ___ arrival - pt spent \nsignificant amount of time in bathroom, then became somnolent*** \nA bed search was performed when patient was leaving ___ and no \ndrugs were found. \n\n- Vitals prior to transfer: 91 106/63 16 100% RA \n\nUpon arrival to the floor, patient reports being frustrated with \nso many questions. She asks to just be alone by herself for 5 \nminutes. She does not recall where her infection was while she \nwas in ___. She thinks maybe her blood. She states that she \nis on 2 antibiotics that she is taking every day since discharge \n2 weeks ago. She denies ever using drugs. \n\nREVIEW OF SYSTEMS: \n(+) Per HPI \n(-) 10 point ROS reviewed and negative unless stated above in \nHPI \n\n \nPast Medical History:\nIVDU\n \nSocial History:\n___\nFamily History:\nPatient denies any family history of heart conditions\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n=======================\nVital Signs: 98.3 ___ 18 97 Ra \nGeneral: Alert, oriented, no acute distress \nHEENT: No ___ spots, Sclerae anicteric, MMM, oropharynx clear, \nPERRL. \nNeck: Supple. JVP not elevated. no LAD \nCV: tachycardic with regular rhythm. Normal S1+S2, no murmurs, \nrubs, gallops. \nLungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \nAbdomen: Soft, non-tender, non-distended, bowel sounds present, \nno organomegaly, no rebound or guarding \nExt: Warm, well perfused, 2+ pulses, no clubbing, no edema. \nTrack marks on arms. Left ___ and ___ fingers with mild erythema \nwith indiscrete borders, no prurulence. No ___ lesions or \n___ nodes. Joints without erythema or warmth. Full ROM \nPelvic: exam declined by patient \n\nDISCHARGE PHYSICAL EXAM\n=======================\nVitals: PO 100 / 65 L Lying 92 18 96 Ra \nGeneral: Alert, oriented, no acute distress \nHEENT: No ___ spots, Sclerae anicteric, MMM, oropharynx clear, \nPERRL. \nNeck: Supple. JVP not elevated. no LAD \nCV: tachycardic with regular rhythm. Normal S1+S2, no murmurs, \nrubs, gallops. \nLungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \nAbdomen: Soft, non-tender, non-distended, bowel sounds present, \nno organomegaly, no rebound or guarding \nExt: Warm, well perfused, 2+ pulses, no clubbing, no edema. \nTrack marks on arms. Left ___ and ___ fingers with mild erythema \nwith indiscrete borders, no prurulence. No ___ lesions or \n___ nodes. Joints without erythema or warmth. Full ROM \nPelvic: exam declined by patient \n \nPertinent Results:\nADMISSION LABS\n==============\n___ 11:20PM BLOOD WBC-5.6 RBC-3.46* Hgb-10.2* Hct-31.6* \nMCV-91 MCH-29.5 MCHC-32.3 RDW-14.6 RDWSD-49.1* Plt ___\n___ 11:20PM BLOOD Neuts-51.9 ___ Monos-13.9* \nEos-5.2 Baso-0.5 Im ___ AbsNeut-2.92 AbsLymp-1.59 \nAbsMono-0.78 AbsEos-0.29 AbsBaso-0.03\n___ 11:20PM BLOOD Plt ___\n___ 09:30AM BLOOD ___ PTT-29.9 ___\n___ 11:20PM BLOOD Glucose-103* UreaN-4* Creat-0.6 Na-137 \nK-3.4 Cl-103 HCO3-23 AnGap-14\n___ 11:20PM BLOOD ALT-253* AST-187* CK(CPK)-85 AlkPhos-90 \nTotBili-1.2\n___ 11:20PM BLOOD Albumin-3.4*\n___ 11:30PM BLOOD Lactate-1.2\n\nIMAGING\n=======\nCTA:\nIMPRESSION: \nPoor bolus timing, but no evidence of pulmonary emboli to the \nsegmental level. \nUnremarkable examination.\n \nRUQ ULTRASOUND:\nIMPRESSION: \n1. Unremarkable appearance of the liver. No biliary dilatation. \n\n2. Prominent celiac and periportal lymph nodes are noted. \n3. Mild splenomegaly. \n \n\nDISCHARGE LABS\n==============\n\n___ 09:30AM BLOOD WBC-5.1 RBC-3.58* Hgb-10.5* Hct-32.6* \nMCV-91 MCH-29.3 MCHC-32.2 RDW-14.5 RDWSD-48.5* Plt ___\n___ 09:30AM BLOOD Plt ___\n___ 09:30AM BLOOD ___ PTT-29.9 ___\n___ 09:30AM BLOOD Glucose-87 UreaN-3* Creat-0.6 Na-135 \nK-3.8 Cl-104 HCO3-24 AnGap-11\n___ 09:30AM BLOOD ALT-254* AST-187* LD(LDH)-222 AlkPhos-100 \nTotBili-1.1\n___ 09:30AM BLOOD Calcium-8.3* Phos-2.9 Mg-1.___ female with hx IVDU, recent admission for sepsis \nsecondary to cholecystitis and enterobacter bacteremia at a \nhospital in ___ presenting with several days of left hand \nerythema and swelling transferred to ___ from OSH ER for \nfurther management.\n\n# Cellulitis: mild, no obvious prurulence, but with edema and \nmild erythema. Likely in the setting of IV drug use. She will be \ntreated with Bactrim and Keflex for 7 days. \n\n# Vaginal discharge: s/p empiric treatment for GC/chlamydia and \ntrichomonas in the ___. Received fluconazole 150 mg x 1 for yeast \ninfection. HIV, RPR were ordered and need to be follow up. \n\n# IVDU: Urine tox positive for opiates and cocaine. Patient had \nenterobacter bacteremia from cholecystitis, not IVDU. Please \nfollow up HIV and hepatitis panel. \n\n# Transaminitis: Patient was recently admitted to ___ \n___ on ___ with cholecytitis and enterobacter bacteremia and \nwas treated with 14 days of ciprofloxacin. Patient has \ntransaminitis (ALT/AST 254/187) that is stable. Hepatitis \nserology are pending. RUQ ultrasound showed no liver/biliary \npathology but there were prominent celiac and periportal lymph \nnodes measuring up to 1.8 cm. Patient has no abdominal pain. \n\n# CODE: full (presumed) \n# CONTACT: None per patient \n\nTRANSITIONAL ISSUES\n===================\n[] Please repeat LFTs as patient had stably elevated LFTs \nwithout clear reason (ALT/AST 254/187). Please follow up on \npending labs for ___. \n[] Patient has history of IVDU. She should have social work \nfollow up and be provided resources IVDU cessation.\n[] Please follow up STI labs. If positive, patient will require \ncounseling and possible treatment. She was already empirically \ntreated for gonorrhea, chlamydia. \n[] New Medications:\n-Keflex, Bactrim (___) for 7 days to end on ___\n-Held Medication: enalapril. Patient has been normotensive.\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Ciprofloxacin HCl 500 mg PO Q12H \n2. Enalapril Maleate 5 mg PO DAILY \n\n \nDischarge Medications:\n1. Cephalexin 500 mg PO Q6H \nRX *cephalexin 500 mg 1 capsule(s) by mouth everry 6 hours Disp \n#*22 Capsule Refills:*0 \n2. Sulfameth/Trimethoprim DS 2 TAB PO BID \nRX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 2 \ntablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0 \n3. HELD- Enalapril Maleate 5 mg PO DAILY This medication was \nheld. Do not restart Enalapril Maleate until instructed by your \nnew PCP\n\n \n___:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n=================\nLeft hand cellulitis \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nIt was a pleasure taking care of you at ___.\n\nYou were admitted to the hospital because you had a left hand \nskin infection. We treated you with two antibiotics and you \nshould continue to take these even if you feel better. If you \nnotice that your hand is more swollen, more red, or that you \nhave trouble moving your hand, you should seek medical attention \nimmediately. \n\nIt is important that you follow up with your primary care doctor \nas noted below. \n\nWe wish you the best,\nYour care team at ___\n \nFollowup Instructions:\n___\n"
] | Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: left hand swelling Major Surgical or Invasive Procedure: None. History of Present Illness: [MASKED] female with hx IVDU, recent admission for sepsis secondary to IVDU at a hospital in [MASKED], intermittently noncompliant with p.o. antibiotics presenting with several days of left hand erythema and swelling as well as intermittent chest pain transferred to [MASKED] from OSH ER for further management. Per records from the [MASKED], the patient reports progressively worsening redness and swelling to the left first finger and the mid dorsal aspect of her left forearm for the past several days. She states that she relapsed with IV drug use and last used this morning. She pointed to an area on her dorsal left wrist where she has been injecting. She had chest pain which was intermittent, lasting several minutes and then resolving. She denies associated dyspnea. She denies fevers during this time. She also reports that she has had a yeast infection since starting antibiotics with white vaginal discharge, red bumps, ulceration and some swelling of her labia. Patient was initially presented to [MASKED]. She was given vancomycin, IM toradol, and 1L NS. She was transferred to [MASKED] for further management. In the [MASKED], initial vitals were: [MASKED] pain, 99.4 102 102/60 4 100% RA - Exam notable for: Cellulitis of left hand No murmur Lungs clear to auscultation No [MASKED] nodes [MASKED] lesions Pelvic: No CMT or masses, bilateral small Bartholin cysts - Labs notable for: CBC: 5.6 > 10.2/31.6 < 164 Chem: Na 137 K 3.4 Cl 103 HCO# 23BUN 4 Cr 0.6 AST 187 ALT 253 AP 90 Tbili 1.2 - Imaging was notable for: POC Echo: No large vegitations, grossly normal EF CTA: No evidence of pulmonary emboli to the segmental level. Unremarkable examination. (prelim) - Patient was given: [MASKED] 02:42 PO Azithromycin 1000 mg [MASKED] 02:42 IM CeftriaXONE 250 mg [MASKED] 02:43 PO MetRONIDAZOLE (FLagyl) [MASKED] mg [MASKED] 04:31 IV CefePIME 2 g ***Concern for continued IV drug abuse on [MASKED] arrival - pt spent significant amount of time in bathroom, then became somnolent*** A bed search was performed when patient was leaving [MASKED] and no drugs were found. - Vitals prior to transfer: 91 106/63 16 100% RA Upon arrival to the floor, patient reports being frustrated with so many questions. She asks to just be alone by herself for 5 minutes. She does not recall where her infection was while she was in [MASKED]. She thinks maybe her blood. She states that she is on 2 antibiotics that she is taking every day since discharge 2 weeks ago. She denies ever using drugs. REVIEW OF SYSTEMS: (+) Per HPI (-) 10 point ROS reviewed and negative unless stated above in HPI Past Medical History: IVDU Social History: [MASKED] Family History: Patient denies any family history of heart conditions Physical Exam: ADMISSION PHYSICAL EXAM ======================= Vital Signs: 98.3 [MASKED] 18 97 Ra General: Alert, oriented, no acute distress HEENT: No [MASKED] spots, Sclerae anicteric, MMM, oropharynx clear, PERRL. Neck: Supple. JVP not elevated. no LAD CV: tachycardic with regular rhythm. Normal S1+S2, no murmurs, rubs, gallops. Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding Ext: Warm, well perfused, 2+ pulses, no clubbing, no edema. Track marks on arms. Left [MASKED] and [MASKED] fingers with mild erythema with indiscrete borders, no prurulence. No [MASKED] lesions or [MASKED] nodes. Joints without erythema or warmth. Full ROM Pelvic: exam declined by patient DISCHARGE PHYSICAL EXAM ======================= Vitals: PO 100 / 65 L Lying 92 18 96 Ra General: Alert, oriented, no acute distress HEENT: No [MASKED] spots, Sclerae anicteric, MMM, oropharynx clear, PERRL. Neck: Supple. JVP not elevated. no LAD CV: tachycardic with regular rhythm. Normal S1+S2, no murmurs, rubs, gallops. Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding Ext: Warm, well perfused, 2+ pulses, no clubbing, no edema. Track marks on arms. Left [MASKED] and [MASKED] fingers with mild erythema with indiscrete borders, no prurulence. No [MASKED] lesions or [MASKED] nodes. Joints without erythema or warmth. Full ROM Pelvic: exam declined by patient Pertinent Results: ADMISSION LABS ============== [MASKED] 11:20PM BLOOD WBC-5.6 RBC-3.46* Hgb-10.2* Hct-31.6* MCV-91 MCH-29.5 MCHC-32.3 RDW-14.6 RDWSD-49.1* Plt [MASKED] [MASKED] 11:20PM BLOOD Neuts-51.9 [MASKED] Monos-13.9* Eos-5.2 Baso-0.5 Im [MASKED] AbsNeut-2.92 AbsLymp-1.59 AbsMono-0.78 AbsEos-0.29 AbsBaso-0.03 [MASKED] 11:20PM BLOOD Plt [MASKED] [MASKED] 09:30AM BLOOD [MASKED] PTT-29.9 [MASKED] [MASKED] 11:20PM BLOOD Glucose-103* UreaN-4* Creat-0.6 Na-137 K-3.4 Cl-103 HCO3-23 AnGap-14 [MASKED] 11:20PM BLOOD ALT-253* AST-187* CK(CPK)-85 AlkPhos-90 TotBili-1.2 [MASKED] 11:20PM BLOOD Albumin-3.4* [MASKED] 11:30PM BLOOD Lactate-1.2 IMAGING ======= CTA: IMPRESSION: Poor bolus timing, but no evidence of pulmonary emboli to the segmental level. Unremarkable examination. RUQ ULTRASOUND: IMPRESSION: 1. Unremarkable appearance of the liver. No biliary dilatation. 2. Prominent celiac and periportal lymph nodes are noted. 3. Mild splenomegaly. DISCHARGE LABS ============== [MASKED] 09:30AM BLOOD WBC-5.1 RBC-3.58* Hgb-10.5* Hct-32.6* MCV-91 MCH-29.3 MCHC-32.2 RDW-14.5 RDWSD-48.5* Plt [MASKED] [MASKED] 09:30AM BLOOD Plt [MASKED] [MASKED] 09:30AM BLOOD [MASKED] PTT-29.9 [MASKED] [MASKED] 09:30AM BLOOD Glucose-87 UreaN-3* Creat-0.6 Na-135 K-3.8 Cl-104 HCO3-24 AnGap-11 [MASKED] 09:30AM BLOOD ALT-254* AST-187* LD(LDH)-222 AlkPhos-100 TotBili-1.1 [MASKED] 09:30AM BLOOD Calcium-8.3* Phos-2.9 Mg-1.[MASKED] female with hx IVDU, recent admission for sepsis secondary to cholecystitis and enterobacter bacteremia at a hospital in [MASKED] presenting with several days of left hand erythema and swelling transferred to [MASKED] from OSH ER for further management. # Cellulitis: mild, no obvious prurulence, but with edema and mild erythema. Likely in the setting of IV drug use. She will be treated with Bactrim and Keflex for 7 days. # Vaginal discharge: s/p empiric treatment for GC/chlamydia and trichomonas in the [MASKED]. Received fluconazole 150 mg x 1 for yeast infection. HIV, RPR were ordered and need to be follow up. # IVDU: Urine tox positive for opiates and cocaine. Patient had enterobacter bacteremia from cholecystitis, not IVDU. Please follow up HIV and hepatitis panel. # Transaminitis: Patient was recently admitted to [MASKED] [MASKED] on [MASKED] with cholecytitis and enterobacter bacteremia and was treated with 14 days of ciprofloxacin. Patient has transaminitis (ALT/AST 254/187) that is stable. Hepatitis serology are pending. RUQ ultrasound showed no liver/biliary pathology but there were prominent celiac and periportal lymph nodes measuring up to 1.8 cm. Patient has no abdominal pain. # CODE: full (presumed) # CONTACT: None per patient TRANSITIONAL ISSUES =================== [] Please repeat LFTs as patient had stably elevated LFTs without clear reason (ALT/AST 254/187). Please follow up on pending labs for [MASKED]. [] Patient has history of IVDU. She should have social work follow up and be provided resources IVDU cessation. [] Please follow up STI labs. If positive, patient will require counseling and possible treatment. She was already empirically treated for gonorrhea, chlamydia. [] New Medications: -Keflex, Bactrim ([MASKED]) for 7 days to end on [MASKED] -Held Medication: enalapril. Patient has been normotensive. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Ciprofloxacin HCl 500 mg PO Q12H 2. Enalapril Maleate 5 mg PO DAILY Discharge Medications: 1. Cephalexin 500 mg PO Q6H RX *cephalexin 500 mg 1 capsule(s) by mouth everry 6 hours Disp #*22 Capsule Refills:*0 2. Sulfameth/Trimethoprim DS 2 TAB PO BID RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 2 tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0 3. HELD- Enalapril Maleate 5 mg PO DAILY This medication was held. Do not restart Enalapril Maleate until instructed by your new PCP [MASKED]: Home Discharge Diagnosis: PRIMARY DIAGNOSIS ================= Left hand cellulitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], It was a pleasure taking care of you at [MASKED]. You were admitted to the hospital because you had a left hand skin infection. We treated you with two antibiotics and you should continue to take these even if you feel better. If you notice that your hand is more swollen, more red, or that you have trouble moving your hand, you should seek medical attention immediately. It is important that you follow up with your primary care doctor as noted below. We wish you the best, Your care team at [MASKED] Followup Instructions: [MASKED] | [
"L03114",
"R740",
"B373",
"F1190"
] | [
"L03114: Cellulitis of left upper limb",
"R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]",
"B373: Candidiasis of vulva and vagina",
"F1190: Opioid use, unspecified, uncomplicated"
] | [] | [] |
13,344,731 | 23,375,155 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nclindamycin / Sulfa (Sulfonamide Antibiotics)\n \nAttending: ___.\n \nChief Complaint:\nLLE redness, swelling\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\n___ with uncontrolled pyoderma gangrenosum on chronic high dose \nsteroids and chronic opiates with multiple admissions for \npyoderma gangrenosum with superimposed cellulitis, with \ndeveloping pseudomonal resistance, LLE DVT, and chronic LLE \npain, who presented with worsening LLE pain/erythema/drainage. \nHe states that he was recently seen by his dermatologist and \ndiscussion was to initiate infliximab, but due to concern for \ninfection he was referred to ___. His pain is significantly \nworse than usual, interfering with walking - he has been using \ncrutches and even a wheelchair sometimes due to worsened pain. \nROS: denies fevers, chills. Notes foul odor from the wounds, \nincreased swelling and erythema. No nausea, vomiting, diarrhea, \nconsitpation. 10 pt ROS otherwise negative. \n \nPast Medical History:\nPyoderma gangrenosum with Chronic non-healing LLE ulcer \nChronic pain with opiate dependence\nADHD\n \nSocial History:\n___\nFamily History:\nno IBD/rashes/sarcoid, no h/o cancer\n \nPhysical Exam:\nAdmission Physical Exam: \nVSS\nGENERAL: young gentleman sitting up in bed, AxOx3, NAD\nHEENT: normocephalic, atraumatic, no conjunctival pallor or\nscleral icterus, PERRLA, EOMI, OP clear. \nNECK: Supple, no LAD, no thyromegaly, JVP flat.\nCARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops. \nPULMONARY: Clear to auscultation bilaterally, without wheezes or\nrhonchi. \nABDOMEN: Normal bowel sounds, soft, non-tender, non-distended, \nno\norganomegaly. \nNEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation,\nwith strength ___ throughout.\nEXT:LLE ulcers:\nAnterior tibial: 7.5 x 5.5 cm, lateral 4.5 x 2.5cm,\nAnterior tibial inferior: 8.5 x 18 cm,\nLateral superior: 9 x 8.5 cm,\nLateral inferior: 7 x 7 cm, \nAll ulcers have nearly 100% yellow slough, irreg wound edges;\nyellow and green exudative drainage, odorous. \nSurrounding erythema and swelling\nRight lateral malleolus: full thickness ulcer 1.8 x 1 cm.\n\nAdmission Physical Exam: \nVSS\nGENERAL: young gentleman sitting up in bed, AxOx3, NAD\nHEENT: normocephalic, atraumatic, no conjunctival pallor or \nscleral icterus, PERRLA, EOMI, OP clear. \nNECK: Supple, no LAD, no thyromegaly, JVP flat.\nCARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops. \nPULMONARY: Clear to auscultation bilaterally, without wheezes or \nrhonchi. \nABDOMEN: Normal bowel sounds, soft, non-tender, non-distended, \nno organomegaly. \nNEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation, \nwith strength ___ throughout.\nEXT:LLE ulcers:\nAnterior tibial: 7.5 x 5.5 cm, lateral 4.5 x 2.5cm,\nAnterior tibial inferior: 8.5 x 18 cm,\nLateral superior: 9 x 8.5 cm,\nLateral inferior: 7 x 7 cm, \nRight lateral malleolus: full thickness ulcer 1.8 x 1 cm.,\nAll ulcers are now fairly clean based, no drainage, no malodor, \nirreg wound edges;\n\n \nPertinent Results:\n___ 12:54AM BLOOD WBC-9.8 RBC-3.89* Hgb-10.9* Hct-35.0* \nMCV-90 MCH-28.0 MCHC-31.1* RDW-14.6 RDWSD-47.2* Plt ___\n___ 12:54AM BLOOD ___ PTT-31.4 ___\n___ 12:54AM BLOOD Glucose-131* UreaN-13 Creat-0.7 Na-137 \nK-4.7 Cl-101 HCO3-23 AnGap-18\n___ 12:54AM BLOOD Calcium-8.7 Phos-4.0 Mg-2.1\n___ 01:05AM BLOOD Lactate-1.5\n\n___ 2:14 pm SWAB Source: skin ulcer L ANTERIOR FIB. \n\n **FINAL REPORT ___\n\n WOUND CULTURE (Final ___: \n MIXED BACTERIAL FLORA. \n This culture contains mixed bacterial types (>=3) so an\n abbreviated workup is performed. Any growth of \nP.aeruginosa,\n S.aureus and beta hemolytic streptococci will be \nreported. IF\n THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT \nin this\n culture. \n STAPH AUREUS COAG +. RARE GROWTH. \n Staphylococcus species may develop resistance during \nprolonged\n therapy with quinolones. Therefore, isolates that are \ninitially\n susceptible may become resistant within three to four \ndays after\n initiation of therapy. Testing of repeat isolates may \nbe\n warranted. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n STAPH AUREUS COAG +\n | \nCLINDAMYCIN-----------<=0.25 S\nERYTHROMYCIN----------<=0.25 S\nGENTAMICIN------------ <=0.5 S\nLEVOFLOXACIN----------<=0.12 S\nOXACILLIN------------- 0.5 S\nTETRACYCLINE---------- =>16 R\nTRIMETHOPRIM/SULFA---- <=0.5 S\n\n \nBrief Hospital Course:\n___ with uncontrolled pyoderma gangrenosum on chronic steroids \nand chronic opiates with multiple admissions for pyoderma \ngangrenosum with superimposed cellulitis, with\ndeveloping pseudomonal resistance, LLE DVT, and chronic LLE \npain, who presented with worsening LLE pain/erythema/drainage \nconcerning for cellulitic superinfection. \n \n# Uncontrolled pyoderma gangrenosum with acute cellulitis: \nRecurrent cellulitis and clear worsening of his pyoderma ulcers \nin comparison to his last admission. He is unsure why he did not \nstart on infliximab after his last admission, but states his\noutpatient dermatologist sent him here instead of starting \ninfliximab for this admission due to infection. Increased pain, \nerythema, warmth is consistent with soft tissue infection. He \nwas seen by Dermatology and ID. He was treated with vanc \nmeropenem initially, then narrowed to Augmentin based on wound \nswab culture results. Wounds were managed locally with daily \ndressing changes and Dakins solution.\n- Augmentin 500 TID for 6 more days for a 10 day course\n- Continue derm followup\n- Continue wound care with daily dressing changes, dakins, as \nfollows: Dakin's ___ strength x 15 minute soak, followed by \nrinse with sterile water. Cover wounds in Xeroform followed by \nAdaptic, then softsorb and kerlix. \n\n# Acute on chronic pain: Chronic opiate use with acute worsening \nof pain secondary to infection. Saw chronic pain service here, \nreceived the following\n- continue home oxyContin, home oxycodone increased per pain \nteam\nto 45mg PO q4h\n- can receive additional PO dose of 30mg-45mg oxycodone \n- for dressing changes, IV dilaudid in minibag 30 min prior\n- chronic pain c/s recs appreciated\n\n# LLE DVT: Diagnosed in ___. Should have completed course of \nanticoagulation but given inability to repeat ultrasound at this \ntime, will give Lovenox bridge until able to clarify whether \ndecision was made to continue warfarin for extended course or\nstopped. Per patient, outpatient MD has continued his course. \nReasonable due to ongoing inflammation, infection, but should be \nreassessed as he is unlikely to require lifelong treatment at \nthis point. \n- Consider repeat LLE US when pain better controlled, infection \nimproving\n- Consider DC AC after better control of disease\n\nBilling: >30 minutes spent coordinating his discharge home\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Atovaquone Suspension 1500 mg PO DAILY \n2. Calcium Carbonate 500 mg PO BID \n3. Docusate Sodium 100 mg PO BID constipation \n4. Gabapentin 600 mg PO TID \n5. Omeprazole 20 mg PO DAILY \n6. OxycoDONE (Immediate Release) 30 mg PO Q4H:PRN pain \n7. OxyCODONE SR (OxyconTIN) 80 mg PO Q8H \n8. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n9. PredniSONE 70 mg PO DAILY \n10. Senna 8.6 mg PO BID:PRN constipation \n11. Vitamin D 1000 UNIT PO DAILY \n12. Warfarin 7.5 mg PO DAILY16 \n13. Acetaminophen 1000 mg PO Q8H:PRN pain \n14. Amphetamine-Dextroamphetamine 20 mg PO NOON \n15. Amphetamine-Dextroamphetamine XR 30 mg PO BID \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H:PRN pain \n2. Atovaquone Suspension 1500 mg PO DAILY \n3. Calcium Carbonate 500 mg PO BID \n4. Docusate Sodium 100 mg PO BID constipation \n5. Gabapentin 600 mg PO TID \n6. Omeprazole 20 mg PO DAILY \n7. OxycoDONE (Immediate Release) 30 mg PO Q4H:PRN pain \n8. OxyCODONE SR (OxyconTIN) 80 mg PO Q8H \n9. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n10. PredniSONE 70 mg PO DAILY \n11. Senna 8.6 mg PO BID:PRN constipation \n12. Vitamin D 1000 UNIT PO DAILY \n13. Warfarin 7.5 mg PO DAILY16 \n14. Amoxicillin-Clavulanic Acid ___ mg PO Q8H \nRX *amoxicillin-pot clavulanate 500 mg-125 mg 1 tablet(s) by \nmouth three times daily Disp #*18 Tablet Refills:*0\n15. Amphetamine-Dextroamphetamine 20 mg PO NOON \n16. Amphetamine-Dextroamphetamine XR 30 mg PO BID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nCellulitis\nPyoderma gangrenosum, uncontrolled\nAcute on chronic pain with opiate dependence\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nDear Mr. ___, \n\nYou were admitted with increased pain and drainage from your \npyoderma ulcers and found to have an infection. You were given \nIV antibiotics and pain medications and your wound care was \nchanged, and your infection improved. \n\nPlease make sure to follow up with your primary care and pain \ndoctor and your dermatologist. \n \nFollowup Instructions:\n___\n"
] | Allergies: clindamycin / Sulfa (Sulfonamide Antibiotics) Chief Complaint: LLE redness, swelling Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] with uncontrolled pyoderma gangrenosum on chronic high dose steroids and chronic opiates with multiple admissions for pyoderma gangrenosum with superimposed cellulitis, with developing pseudomonal resistance, LLE DVT, and chronic LLE pain, who presented with worsening LLE pain/erythema/drainage. He states that he was recently seen by his dermatologist and discussion was to initiate infliximab, but due to concern for infection he was referred to [MASKED]. His pain is significantly worse than usual, interfering with walking - he has been using crutches and even a wheelchair sometimes due to worsened pain. ROS: denies fevers, chills. Notes foul odor from the wounds, increased swelling and erythema. No nausea, vomiting, diarrhea, consitpation. 10 pt ROS otherwise negative. Past Medical History: Pyoderma gangrenosum with Chronic non-healing LLE ulcer Chronic pain with opiate dependence ADHD Social History: [MASKED] Family History: no IBD/rashes/sarcoid, no h/o cancer Physical Exam: Admission Physical Exam: VSS GENERAL: young gentleman sitting up in bed, AxOx3, NAD HEENT: normocephalic, atraumatic, no conjunctival pallor or scleral icterus, PERRLA, EOMI, OP clear. NECK: Supple, no LAD, no thyromegaly, JVP flat. CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops. PULMONARY: Clear to auscultation bilaterally, without wheezes or rhonchi. ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended, no organomegaly. NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation, with strength [MASKED] throughout. EXT:LLE ulcers: Anterior tibial: 7.5 x 5.5 cm, lateral 4.5 x 2.5cm, Anterior tibial inferior: 8.5 x 18 cm, Lateral superior: 9 x 8.5 cm, Lateral inferior: 7 x 7 cm, All ulcers have nearly 100% yellow slough, irreg wound edges; yellow and green exudative drainage, odorous. Surrounding erythema and swelling Right lateral malleolus: full thickness ulcer 1.8 x 1 cm. Admission Physical Exam: VSS GENERAL: young gentleman sitting up in bed, AxOx3, NAD HEENT: normocephalic, atraumatic, no conjunctival pallor or scleral icterus, PERRLA, EOMI, OP clear. NECK: Supple, no LAD, no thyromegaly, JVP flat. CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops. PULMONARY: Clear to auscultation bilaterally, without wheezes or rhonchi. ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended, no organomegaly. NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation, with strength [MASKED] throughout. EXT:LLE ulcers: Anterior tibial: 7.5 x 5.5 cm, lateral 4.5 x 2.5cm, Anterior tibial inferior: 8.5 x 18 cm, Lateral superior: 9 x 8.5 cm, Lateral inferior: 7 x 7 cm, Right lateral malleolus: full thickness ulcer 1.8 x 1 cm., All ulcers are now fairly clean based, no drainage, no malodor, irreg wound edges; Pertinent Results: [MASKED] 12:54AM BLOOD WBC-9.8 RBC-3.89* Hgb-10.9* Hct-35.0* MCV-90 MCH-28.0 MCHC-31.1* RDW-14.6 RDWSD-47.2* Plt [MASKED] [MASKED] 12:54AM BLOOD [MASKED] PTT-31.4 [MASKED] [MASKED] 12:54AM BLOOD Glucose-131* UreaN-13 Creat-0.7 Na-137 K-4.7 Cl-101 HCO3-23 AnGap-18 [MASKED] 12:54AM BLOOD Calcium-8.7 Phos-4.0 Mg-2.1 [MASKED] 01:05AM BLOOD Lactate-1.5 [MASKED] 2:14 pm SWAB Source: skin ulcer L ANTERIOR FIB. **FINAL REPORT [MASKED] WOUND CULTURE (Final [MASKED]: MIXED BACTERIAL FLORA. This culture contains mixed bacterial types (>=3) so an abbreviated workup is performed. Any growth of P.aeruginosa, S.aureus and beta hemolytic streptococci will be reported. IF THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT in this culture. STAPH AUREUS COAG +. RARE GROWTH. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN------------- 0.5 S TETRACYCLINE---------- =>16 R TRIMETHOPRIM/SULFA---- <=0.5 S Brief Hospital Course: [MASKED] with uncontrolled pyoderma gangrenosum on chronic steroids and chronic opiates with multiple admissions for pyoderma gangrenosum with superimposed cellulitis, with developing pseudomonal resistance, LLE DVT, and chronic LLE pain, who presented with worsening LLE pain/erythema/drainage concerning for cellulitic superinfection. # Uncontrolled pyoderma gangrenosum with acute cellulitis: Recurrent cellulitis and clear worsening of his pyoderma ulcers in comparison to his last admission. He is unsure why he did not start on infliximab after his last admission, but states his outpatient dermatologist sent him here instead of starting infliximab for this admission due to infection. Increased pain, erythema, warmth is consistent with soft tissue infection. He was seen by Dermatology and ID. He was treated with vanc meropenem initially, then narrowed to Augmentin based on wound swab culture results. Wounds were managed locally with daily dressing changes and Dakins solution. - Augmentin 500 TID for 6 more days for a 10 day course - Continue derm followup - Continue wound care with daily dressing changes, dakins, as follows: Dakin's [MASKED] strength x 15 minute soak, followed by rinse with sterile water. Cover wounds in Xeroform followed by Adaptic, then softsorb and kerlix. # Acute on chronic pain: Chronic opiate use with acute worsening of pain secondary to infection. Saw chronic pain service here, received the following - continue home oxyContin, home oxycodone increased per pain team to 45mg PO q4h - can receive additional PO dose of 30mg-45mg oxycodone - for dressing changes, IV dilaudid in minibag 30 min prior - chronic pain c/s recs appreciated # LLE DVT: Diagnosed in [MASKED]. Should have completed course of anticoagulation but given inability to repeat ultrasound at this time, will give Lovenox bridge until able to clarify whether decision was made to continue warfarin for extended course or stopped. Per patient, outpatient MD has continued his course. Reasonable due to ongoing inflammation, infection, but should be reassessed as he is unlikely to require lifelong treatment at this point. - Consider repeat LLE US when pain better controlled, infection improving - Consider DC AC after better control of disease Billing: >30 minutes spent coordinating his discharge home Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atovaquone Suspension 1500 mg PO DAILY 2. Calcium Carbonate 500 mg PO BID 3. Docusate Sodium 100 mg PO BID constipation 4. Gabapentin 600 mg PO TID 5. Omeprazole 20 mg PO DAILY 6. OxycoDONE (Immediate Release) 30 mg PO Q4H:PRN pain 7. OxyCODONE SR (OxyconTIN) 80 mg PO Q8H 8. Polyethylene Glycol 17 g PO DAILY:PRN constipation 9. PredniSONE 70 mg PO DAILY 10. Senna 8.6 mg PO BID:PRN constipation 11. Vitamin D 1000 UNIT PO DAILY 12. Warfarin 7.5 mg PO DAILY16 13. Acetaminophen 1000 mg PO Q8H:PRN pain 14. Amphetamine-Dextroamphetamine 20 mg PO NOON 15. Amphetamine-Dextroamphetamine XR 30 mg PO BID Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN pain 2. Atovaquone Suspension 1500 mg PO DAILY 3. Calcium Carbonate 500 mg PO BID 4. Docusate Sodium 100 mg PO BID constipation 5. Gabapentin 600 mg PO TID 6. Omeprazole 20 mg PO DAILY 7. OxycoDONE (Immediate Release) 30 mg PO Q4H:PRN pain 8. OxyCODONE SR (OxyconTIN) 80 mg PO Q8H 9. Polyethylene Glycol 17 g PO DAILY:PRN constipation 10. PredniSONE 70 mg PO DAILY 11. Senna 8.6 mg PO BID:PRN constipation 12. Vitamin D 1000 UNIT PO DAILY 13. Warfarin 7.5 mg PO DAILY16 14. Amoxicillin-Clavulanic Acid [MASKED] mg PO Q8H RX *amoxicillin-pot clavulanate 500 mg-125 mg 1 tablet(s) by mouth three times daily Disp #*18 Tablet Refills:*0 15. Amphetamine-Dextroamphetamine 20 mg PO NOON 16. Amphetamine-Dextroamphetamine XR 30 mg PO BID Discharge Disposition: Home Discharge Diagnosis: Cellulitis Pyoderma gangrenosum, uncontrolled Acute on chronic pain with opiate dependence Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], You were admitted with increased pain and drainage from your pyoderma ulcers and found to have an infection. You were given IV antibiotics and pain medications and your wound care was changed, and your infection improved. Please make sure to follow up with your primary care and pain doctor and your dermatologist. Followup Instructions: [MASKED] | [
"L03116",
"L88",
"F17210",
"F1290",
"Z86718",
"Z7901",
"B965"
] | [
"L03116: Cellulitis of left lower limb",
"L88: Pyoderma gangrenosum",
"F17210: Nicotine dependence, cigarettes, uncomplicated",
"F1290: Cannabis use, unspecified, uncomplicated",
"Z86718: Personal history of other venous thrombosis and embolism",
"Z7901: Long term (current) use of anticoagulants",
"B965: Pseudomonas (aeruginosa) (mallei) (pseudomallei) as the cause of diseases classified elsewhere"
] | [
"F17210",
"Z86718",
"Z7901"
] | [] |
15,613,540 | 24,724,480 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\nchest pain, shortness of breath\n \nMajor Surgical or Invasive Procedure:\nCardiac catheterization, PCI in left circumflex artery (___)\n\n \nHistory of Present Illness:\n___ man with depression/PTSD and severe COPD \n(complicated by respiratory arrest ___ year ago, who presented to \nthe ED with sudden onset \"vice-like\" chest pain and shortness of \nbreath. He was in his usual state of health until 11:00 AM, when \nthe chest pain began, followed shortly by SOB. It's hard for him \nto say how long the pain lasted, as his breathing was so poor he \nwas focused more on that, but he believes the worst pain lasted \n___ minutes, and that it resolved completely by the time he \nwas on a nitro gtt in the ED. He's never had anything like this \nchest pain before. \n Patient is unclear about some details of his PMH, but I spoke \nwith his sister, ___, a cardiac nurse: she believes the pt \nhad a respiratory arrest ___ year ago from COPD/pneumonia. He \nnormally receives his care at ___. An ECHO at that time showed \nmoderate AS, normal EF, and elevated R-sided pressures \nconsistent with pulmonary HTN. He had a R-heart cath a year ago, \nconsistent with pulmonary HTN. Has never had a L-heart cath. \nHe's followed by pulmonologist Dr. ___ at ___ for \nCOPD/emyphesema, and is on ___ L home O2. She believes his other \nPMH includes only depression/PTSD. He lives in an assisted \nliving facility for the last year, and prior to this had \nunstable housing including times of being homeless. Of note, he \nhas an extensive smoking history \n In the ED: \n - initial vitals were: 139 145/90 40 78% RA \n - EKG \n - Labs: notable for lactate 3.2, trop 0.06, CKMB 7, WBC 12 \n - chest xray: moderate to severe pulmonary edema and a small \nright pleural effusion. \n - he was initially placed on bi-pap, but weaned to NC prior to \ntransfer \n - patient was given: Lasix 60mg, duonebs, methylpred 125mg, Mg \n2g, nitro gtt \n - VS prior to transfer: 103 118/95 24 95% NC \n\n \nPast Medical History:\n- depression/PTSD \n- COPD (on ___ O2 at baseline)\n- pulmonary hypertension (followed by Dr. ___ at ___\n- chronic venous stasis \n \nSocial History:\n___\nFamily History:\nNo family history of early MI, arrhythmia, cardiomyopathies, or \nsudden cardiac death; otherwise non-contributory.\n \nPhysical Exam:\nADMISSION EXAM:\n==================\nWt: 124 kg \nGeneral: NAD, pleasant, anxious \nHEENT: atraumatic, anicteric sclera \nNeck: JVP mildly elevated, supple \nCV: RRR, no murmurs \nLungs: NC in place, speaking in full sentences, no accessory \nmuscle use, bilateral crackles in lower ___ of lungs and diffuse \nwheezing throughout \nAbdomen: soft, non-tender, non-distended \nExtr: ruddy, edematous ___ consistent with chronic venous stasis. \nNo skin breakdown. Pitting edema to knees. \nNeuro: symmetrical facial features, clear speech, moving all \nlimbs \n\nDISCHARGE EXAM:\n==================\nVS: 97.7 104/74 (90-130/50-90) ___ 18 95%2L\nI/O: 2180 /4000 // ___\nWeight: 123.0 kg\nGENERAL: WDWN, obese man in NAD. Oriented x3.\nHEENT: NCAT. Sclera anicteric. PERRL, \nNECK: Supple. Could not appreciate JVP. \nCARDIAC: HRRR, S1/S2, ___ at ___. prominent S2 \nLUNGS: No chest wall deformities, scoliosis or kyphosis. Resp \nwere unlabored, no accessory muscle use. CTAB. No crackles, \nwheezes or rhonchi. \nABDOMEN: Soft, NTND. No HSM or tenderness. \nEXTREMITIES: warm, well-perfused. trace ___ edema\nSKIN: mild stasis dermatitis, on ___\n \nPertinent Results:\nADMISSION LABS:\n==================\n___ 12:15PM BLOOD WBC-12.8* RBC-5.02 Hgb-14.3 Hct-44.1 \nMCV-88 MCH-28.5 MCHC-32.4 RDW-13.7 RDWSD-43.8 Plt ___\n___ 12:15PM BLOOD Neuts-54.5 ___ Monos-10.2 Eos-1.8 \nBaso-0.5 Im ___ AbsNeut-6.97* AbsLymp-4.01* AbsMono-1.30* \nAbsEos-0.23 AbsBaso-0.07\n___ 12:15PM BLOOD Glucose-154* UreaN-11 Creat-0.9 Na-131* \nK-5.5* Cl-93* HCO3-23 AnGap-21*\n___ 12:15PM BLOOD CK(CPK)-165\n___ 12:15PM BLOOD CK-MB-7\n___ 12:15PM BLOOD cTropnT-0.06*\n___ 12:23PM BLOOD %HbA1c-6.4* eAG-137*\n___ 12:25PM BLOOD Lactate-3.2* K-5.8*\n\nPERTINENT LABS:\n==================\n___ 12:15PM BLOOD cTropnT-0.06*\n___ 07:00PM BLOOD CK-MB-174* MB Indx-15.9* cTropnT-1.07* \nproBNP-481*\n___ 03:25AM BLOOD CK-MB-121* MB Indx-14.9* cTropnT-0.94*\n___ 05:45PM BLOOD cTropnT-1.___ 03:25AM BLOOD D-Dimer-657*\n___ 12:23PM BLOOD %HbA1c-6.4* eAG-137*\n___ 09:31AM BLOOD Type-ART pO2-77* pCO2-45 pH-7.47* \ncalTCO2-34* Base XS-7\n___ 12:25PM BLOOD Lactate-3.2* \n___ 04:13AM BLOOD Lactate-3.8*\n___ 09:31AM BLOOD Lactate-2.0\n\nDISCHARGE LABS:\n==================\n___ 07:30AM BLOOD WBC-10.5* RBC-4.54* Hgb-12.8* Hct-39.4* \nMCV-87 MCH-28.2 MCHC-32.5 RDW-13.5 RDWSD-41.7 Plt ___\n___ 07:30AM BLOOD Glucose-117* UreaN-13 Creat-0.7 Na-132* \nK-4.0 Cl-91* HCO3-31 AnGap-14\n\nIMAGING:\n==================\nCXR (___):\nModerate to severe pulmonary edema and a small right pleural \neffusion. There may be some superimposed patchy density in the \nright base. \n\nLHC (___):\nDominance: Right\n* Left Main Coronary Artery\nThe LMCA is without angiographically apparent disease.\n\n* Left Anterior Descending\nThe LAD is with mild luminal irregularities.\nThe ___ Diagonal is without angiographically apparent disease.\n\n* Circumflex\nThe LCx is without angiographically apparent disease.\nThere is a 90% proximal hazy stenosis in a large branching ___ \nMarginal. The lesion has a TIMI flow of 3\nand has no noted calcification. This lesion is further described \nas focal. An intervention was performed on the ___ Marginal with \na final stenosis of 0%. There were no lesion complications.\n\n* Right Coronary Artery\nThe RCA is with mild luminal irregularities.\nThe Right PDA is without angiographically apparent disease.\n\nIMPRESSION:\nSuccessful PCI of the OM with drug-eluting stent\n\nCTA Chest (___):\n1. No evidence of pulmonary embolism or aortic abnormality. \n2. Pulmonary edema. \n3. Pulmonary nodules measuring up to 9 mm. Although these may \nrepresent an early infectious or inflammatory process, recommend \nfollowup after resolution of acute illness. \n4. 2.6 cm hyperdense right thyroid nodule. Recommend \nnonemergent thyroid \nultrasound for further evaluation, if this has not already been \nperformed. \n\nRECOMMENDATION(S): \n1. Pulmonary nodules measuring up to 9 mm. Although \nthese may represent an early infectious or inflammatory process, \nrecommend \nfollowup after resolution of acute illness. \n \n2. 2.6 cm hyperdense right thyroid nodule. Recommend \nnonemergent thyroid \nultrasound for further evaluation, if this has not already been \nperformed.\n\nTTE (___):\nThe left atrium and right atrium are normal in cavity size. No \natrial septal defect is seen by 2D or color Doppler. Left \nventricular wall thicknesses are normal. The left ventricular \ncavity size is normal. Overall left ventricular systolic \nfunction is mildly depressed (LVEF = 45 %) secondary to \nhypokinesis of the inferior and posterior walls. Right \nventricular chamber size and free wall motion are normal. The \nnumber of aortic valve leaflets cannot be determined. The aortic \nvalve leaflets are moderately thickened. There is moderate \naortic valve stenosis (valve area = 1.2 cm2). Trace aortic \nregurgitation is seen. The mitral valve leaflets are \nstructurally normal. There is no mitral valve prolapse. Mild \n(1+) mitral regurgitation is seen. There is moderate pulmonary \nartery systolic hypertension. There is no pericardial effusion. \n\n\nMICROBIOLOGY:\n==================\n___ 12:15 pm BLOOD CULTURE: NGTD\n___ 12:43 pm BLOOD CULTURE\nBlood Culture, Routine (Preliminary): \n STAPHYLOCOCCUS, COAGULASE NEGATIVE. \n \nAnaerobic Bottle Gram Stain (Final ___: \n GRAM POSITIVE COCCI IN CLUSTERS. \n \n___ 3:20 pm BLOOD CULTURE: NGTD\n \nBrief Hospital Course:\n___ man with depression/PTSD and severe COPD (complicated by \nrespiratory arrest ___ year ago), pulmonary HTN who presented to \nthe ED with sudden onset \"vice-like\" chest pain and shortness of \nbreath found to have NSTEMI with PCI to LCX/OM1.\n\n# NSTEMI: He presented to the Emergency Department with anginal \nchest pain relieved with nitro drip, an EKG with lateral lead ST \ndepressions, rising tropononemia, and elevated lactate. CTA \nruled out PE, however on LHC, was found to have 99% occlusion of \nleft circumflex artery occlusion that was stented with apical \nhypokinesis on TTE with LVEF 45%. He was then medically \noptimized with atorvastatin, Metoprolol succinate, ASA, Plavix. \n\n# Pulmonary edema: This was likely secondary to NSTEMI as above \ncausing acute left-sided heart failure on chronic RH failure \nfrom pulmonary HTN. He was then diuresed with IV Lasix and was \ndischarged on 60 mg PO Lasix BID. Discharge weight 123.0 kg.\n\n# Pulmonary Hypertension: Patient followed at ___ for by Dr. \n___ pulmonary HTN thought to be secondary to COPD/obesity \nhypoventilation/OSA confirmed with RHC. \n\n# COPD: The patient has underlying COPD but shortness of breath \non this admission was more consistent with pulmonary edema. He \nwas given 125 methylprednisolone in the ED but subsequently just \nreceived his home inhalers, with no indication for further \nsteroids. He continued to use his home CPAP during sleep and \noxygenated well on ___ oxygen, which he uses at home at \nbaseline. \n\n# Depression/PTSD: The patient endorsed feeling very anxious at \nbaseline exacerbated by his new health problems and is concerned \nthat conditions at his rehab are not safe. For his baseline \nanxiety he continued to receive his home citalopram and also \nparticipated in Social Work consultations to help him cope with \nhis challenges.\n\nTransitional Issues:\n-discharge weight: 123.0 kg\n-patient started on Plavix given PCI\n-uptitrate BB/ACE as BP/HR tolerates \n-CTA chest showed pulmonary nodules that will need to be \nfollowed-up in 6 months (___)\n-CTA chest showed 2.6cm R thyroid nodule; will need outpatient \nthyroid ultrasound to further characterize\n-will need to complete work-up for pulmonary hypertension as \noutpatient\n-will need optimization of anxiety/depression as outpatient \n-code: full\n-contact: Patient, sister (nurse) ___ ___, \n___ \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Citalopram 30 mg PO DAILY \n2. Tiotropium Bromide 1 CAP IH DAILY \n3. Vitamin D 1000 UNIT PO DAILY \n4. Loratadine 10 mg PO DAILY:PRN congestion \n5. TraZODone 50 mg PO QHS:PRN insomnia \n6. Furosemide 40 mg PO BID \n7. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n8. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H \n9. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation \nQ4H:PRN SOB \n10. Cyanocobalamin 500 mcg PO DAILY \n \nDischarge Medications:\n1. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H \n2. Tiotropium Bromide 1 CAP IH DAILY \n3. Aspirin 81 mg PO DAILY \nRX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0\n4. Atorvastatin 80 mg PO QPM \nRX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*0\n5. Clopidogrel 75 mg PO DAILY \nPlease talk to your doctor about how long you should continue to \ntake this medication. \nRX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*0\n6. Lisinopril 2.5 mg PO DAILY \nRX *lisinopril 2.5 mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*0\n7. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n8. Loratadine 10 mg PO DAILY \n9. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation \nQ4H:PRN SOB \n10. TraZODone 50 mg PO QHS:PRN insomnia \n11. Vitamin D 1000 UNIT PO DAILY \n12. Citalopram 30 mg PO DAILY \n13. Furosemide 60 mg PO BID \nRX *furosemide 20 mg 3 tablet(s) by mouth twice a day Disp #*180 \nTablet Refills:*0\n14. Metoprolol Succinate XL 50 mg PO DAILY \nRX *metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp \n#*30 Tablet Refills:*0\n15. Cyanocobalamin 500 mcg PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary Diagnosis\n-non-ST elevation myocardial infaction\n\nSecondary Diagnosis\n-hypertension\n-pulmonary hypertension\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nThank you for coming to ___. It \nwas a pleasure to participate in your care.\n\nYou came to the hospital because you felt chest pain and short \nof breath. We did an echocardiogram showing that your heart was \nnot pumping as powerfully as expected. You then underwent a \ncardiac catheterization showing that one of the arteries \nsupplying blood to your heart (your left circumflex artery) was \n99% blocked. You had a stent placed in that artery to open it \nup.\n\nIn the hospital you received nitroglycerin to relived the pain \nin your chest and several medications that prevent blood clots \nand help protect your heart muscle: heparin, clopidogrel, \naspirin, and atorvastatin.\n\nTo help protect your heart from more blockages, it will be very \nimportant for you to take clopidogrel and aspirin every day to \nprevent the stent from closing. Please do not stop these \nmedications unless directed by your new cardiologist, Dr. \n___. \n\nYou can also help protect your heart by eating a heart healthy \ndiet and getting regular exercise. Your doctors ___ help ___ get \nmore information on these topics. You have already made a big \nstep in protecting your health by quitting smoking. \n\nPlease continue taking your medications as instructed below and \nfollow-up with the appointments listed below. \n\nWishing you the best,\nYour ___ team\n \nFollowup Instructions:\n___\n"
] | Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: chest pain, shortness of breath Major Surgical or Invasive Procedure: Cardiac catheterization, PCI in left circumflex artery ([MASKED]) History of Present Illness: [MASKED] man with depression/PTSD and severe COPD (complicated by respiratory arrest [MASKED] year ago, who presented to the ED with sudden onset "vice-like" chest pain and shortness of breath. He was in his usual state of health until 11:00 AM, when the chest pain began, followed shortly by SOB. It's hard for him to say how long the pain lasted, as his breathing was so poor he was focused more on that, but he believes the worst pain lasted [MASKED] minutes, and that it resolved completely by the time he was on a nitro gtt in the ED. He's never had anything like this chest pain before. Patient is unclear about some details of his PMH, but I spoke with his sister, [MASKED], a cardiac nurse: she believes the pt had a respiratory arrest [MASKED] year ago from COPD/pneumonia. He normally receives his care at [MASKED]. An ECHO at that time showed moderate AS, normal EF, and elevated R-sided pressures consistent with pulmonary HTN. He had a R-heart cath a year ago, consistent with pulmonary HTN. Has never had a L-heart cath. He's followed by pulmonologist Dr. [MASKED] at [MASKED] for COPD/emyphesema, and is on [MASKED] L home O2. She believes his other PMH includes only depression/PTSD. He lives in an assisted living facility for the last year, and prior to this had unstable housing including times of being homeless. Of note, he has an extensive smoking history In the ED: - initial vitals were: 139 145/90 40 78% RA - EKG - Labs: notable for lactate 3.2, trop 0.06, CKMB 7, WBC 12 - chest xray: moderate to severe pulmonary edema and a small right pleural effusion. - he was initially placed on bi-pap, but weaned to NC prior to transfer - patient was given: Lasix 60mg, duonebs, methylpred 125mg, Mg 2g, nitro gtt - VS prior to transfer: 103 118/95 24 95% NC Past Medical History: - depression/PTSD - COPD (on [MASKED] O2 at baseline) - pulmonary hypertension (followed by Dr. [MASKED] at [MASKED] - chronic venous stasis Social History: [MASKED] Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION EXAM: ================== Wt: 124 kg General: NAD, pleasant, anxious HEENT: atraumatic, anicteric sclera Neck: JVP mildly elevated, supple CV: RRR, no murmurs Lungs: NC in place, speaking in full sentences, no accessory muscle use, bilateral crackles in lower [MASKED] of lungs and diffuse wheezing throughout Abdomen: soft, non-tender, non-distended Extr: ruddy, edematous [MASKED] consistent with chronic venous stasis. No skin breakdown. Pitting edema to knees. Neuro: symmetrical facial features, clear speech, moving all limbs DISCHARGE EXAM: ================== VS: 97.7 104/74 (90-130/50-90) [MASKED] 18 95%2L I/O: 2180 /4000 // [MASKED] Weight: 123.0 kg GENERAL: WDWN, obese man in NAD. Oriented x3. HEENT: NCAT. Sclera anicteric. PERRL, NECK: Supple. Could not appreciate JVP. CARDIAC: HRRR, S1/S2, [MASKED] at [MASKED]. prominent S2 LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB. No crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: warm, well-perfused. trace [MASKED] edema SKIN: mild stasis dermatitis, on [MASKED] Pertinent Results: ADMISSION LABS: ================== [MASKED] 12:15PM BLOOD WBC-12.8* RBC-5.02 Hgb-14.3 Hct-44.1 MCV-88 MCH-28.5 MCHC-32.4 RDW-13.7 RDWSD-43.8 Plt [MASKED] [MASKED] 12:15PM BLOOD Neuts-54.5 [MASKED] Monos-10.2 Eos-1.8 Baso-0.5 Im [MASKED] AbsNeut-6.97* AbsLymp-4.01* AbsMono-1.30* AbsEos-0.23 AbsBaso-0.07 [MASKED] 12:15PM BLOOD Glucose-154* UreaN-11 Creat-0.9 Na-131* K-5.5* Cl-93* HCO3-23 AnGap-21* [MASKED] 12:15PM BLOOD CK(CPK)-165 [MASKED] 12:15PM BLOOD CK-MB-7 [MASKED] 12:15PM BLOOD cTropnT-0.06* [MASKED] 12:23PM BLOOD %HbA1c-6.4* eAG-137* [MASKED] 12:25PM BLOOD Lactate-3.2* K-5.8* PERTINENT LABS: ================== [MASKED] 12:15PM BLOOD cTropnT-0.06* [MASKED] 07:00PM BLOOD CK-MB-174* MB Indx-15.9* cTropnT-1.07* proBNP-481* [MASKED] 03:25AM BLOOD CK-MB-121* MB Indx-14.9* cTropnT-0.94* [MASKED] 05:45PM BLOOD cTropnT-1.[MASKED] 03:25AM BLOOD D-Dimer-657* [MASKED] 12:23PM BLOOD %HbA1c-6.4* eAG-137* [MASKED] 09:31AM BLOOD Type-ART pO2-77* pCO2-45 pH-7.47* calTCO2-34* Base XS-7 [MASKED] 12:25PM BLOOD Lactate-3.2* [MASKED] 04:13AM BLOOD Lactate-3.8* [MASKED] 09:31AM BLOOD Lactate-2.0 DISCHARGE LABS: ================== [MASKED] 07:30AM BLOOD WBC-10.5* RBC-4.54* Hgb-12.8* Hct-39.4* MCV-87 MCH-28.2 MCHC-32.5 RDW-13.5 RDWSD-41.7 Plt [MASKED] [MASKED] 07:30AM BLOOD Glucose-117* UreaN-13 Creat-0.7 Na-132* K-4.0 Cl-91* HCO3-31 AnGap-14 IMAGING: ================== CXR ([MASKED]): Moderate to severe pulmonary edema and a small right pleural effusion. There may be some superimposed patchy density in the right base. LHC ([MASKED]): Dominance: Right * Left Main Coronary Artery The LMCA is without angiographically apparent disease. * Left Anterior Descending The LAD is with mild luminal irregularities. The [MASKED] Diagonal is without angiographically apparent disease. * Circumflex The LCx is without angiographically apparent disease. There is a 90% proximal hazy stenosis in a large branching [MASKED] Marginal. The lesion has a TIMI flow of 3 and has no noted calcification. This lesion is further described as focal. An intervention was performed on the [MASKED] Marginal with a final stenosis of 0%. There were no lesion complications. * Right Coronary Artery The RCA is with mild luminal irregularities. The Right PDA is without angiographically apparent disease. IMPRESSION: Successful PCI of the OM with drug-eluting stent CTA Chest ([MASKED]): 1. No evidence of pulmonary embolism or aortic abnormality. 2. Pulmonary edema. 3. Pulmonary nodules measuring up to 9 mm. Although these may represent an early infectious or inflammatory process, recommend followup after resolution of acute illness. 4. 2.6 cm hyperdense right thyroid nodule. Recommend nonemergent thyroid ultrasound for further evaluation, if this has not already been performed. RECOMMENDATION(S): 1. Pulmonary nodules measuring up to 9 mm. Although these may represent an early infectious or inflammatory process, recommend followup after resolution of acute illness. 2. 2.6 cm hyperdense right thyroid nodule. Recommend nonemergent thyroid ultrasound for further evaluation, if this has not already been performed. TTE ([MASKED]): The left atrium and right atrium are normal in cavity size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed (LVEF = 45 %) secondary to hypokinesis of the inferior and posterior walls. Right ventricular chamber size and free wall motion are normal. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are moderately thickened. There is moderate aortic valve stenosis (valve area = 1.2 cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. MICROBIOLOGY: ================== [MASKED] 12:15 pm BLOOD CULTURE: NGTD [MASKED] 12:43 pm BLOOD CULTURE Blood Culture, Routine (Preliminary): STAPHYLOCOCCUS, COAGULASE NEGATIVE. Anaerobic Bottle Gram Stain (Final [MASKED]: GRAM POSITIVE COCCI IN CLUSTERS. [MASKED] 3:20 pm BLOOD CULTURE: NGTD Brief Hospital Course: [MASKED] man with depression/PTSD and severe COPD (complicated by respiratory arrest [MASKED] year ago), pulmonary HTN who presented to the ED with sudden onset "vice-like" chest pain and shortness of breath found to have NSTEMI with PCI to LCX/OM1. # NSTEMI: He presented to the Emergency Department with anginal chest pain relieved with nitro drip, an EKG with lateral lead ST depressions, rising tropononemia, and elevated lactate. CTA ruled out PE, however on LHC, was found to have 99% occlusion of left circumflex artery occlusion that was stented with apical hypokinesis on TTE with LVEF 45%. He was then medically optimized with atorvastatin, Metoprolol succinate, ASA, Plavix. # Pulmonary edema: This was likely secondary to NSTEMI as above causing acute left-sided heart failure on chronic RH failure from pulmonary HTN. He was then diuresed with IV Lasix and was discharged on 60 mg PO Lasix BID. Discharge weight 123.0 kg. # Pulmonary Hypertension: Patient followed at [MASKED] for by Dr. [MASKED] pulmonary HTN thought to be secondary to COPD/obesity hypoventilation/OSA confirmed with RHC. # COPD: The patient has underlying COPD but shortness of breath on this admission was more consistent with pulmonary edema. He was given 125 methylprednisolone in the ED but subsequently just received his home inhalers, with no indication for further steroids. He continued to use his home CPAP during sleep and oxygenated well on [MASKED] oxygen, which he uses at home at baseline. # Depression/PTSD: The patient endorsed feeling very anxious at baseline exacerbated by his new health problems and is concerned that conditions at his rehab are not safe. For his baseline anxiety he continued to receive his home citalopram and also participated in Social Work consultations to help him cope with his challenges. Transitional Issues: -discharge weight: 123.0 kg -patient started on Plavix given PCI -uptitrate BB/ACE as BP/HR tolerates -CTA chest showed pulmonary nodules that will need to be followed-up in 6 months ([MASKED]) -CTA chest showed 2.6cm R thyroid nodule; will need outpatient thyroid ultrasound to further characterize -will need to complete work-up for pulmonary hypertension as outpatient -will need optimization of anxiety/depression as outpatient -code: full -contact: Patient, sister (nurse) [MASKED] [MASKED], [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Citalopram 30 mg PO DAILY 2. Tiotropium Bromide 1 CAP IH DAILY 3. Vitamin D 1000 UNIT PO DAILY 4. Loratadine 10 mg PO DAILY:PRN congestion 5. TraZODone 50 mg PO QHS:PRN insomnia 6. Furosemide 40 mg PO BID 7. Fluticasone Propionate NASAL 2 SPRY NU DAILY 8. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H 9. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q4H:PRN SOB 10. Cyanocobalamin 500 mcg PO DAILY Discharge Medications: 1. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H 2. Tiotropium Bromide 1 CAP IH DAILY 3. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. Atorvastatin 80 mg PO QPM RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 5. Clopidogrel 75 mg PO DAILY Please talk to your doctor about how long you should continue to take this medication. RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 6. Lisinopril 2.5 mg PO DAILY RX *lisinopril 2.5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 7. Fluticasone Propionate NASAL 2 SPRY NU DAILY 8. Loratadine 10 mg PO DAILY 9. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q4H:PRN SOB 10. TraZODone 50 mg PO QHS:PRN insomnia 11. Vitamin D 1000 UNIT PO DAILY 12. Citalopram 30 mg PO DAILY 13. Furosemide 60 mg PO BID RX *furosemide 20 mg 3 tablet(s) by mouth twice a day Disp #*180 Tablet Refills:*0 14. Metoprolol Succinate XL 50 mg PO DAILY RX *metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 15. Cyanocobalamin 500 mcg PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Primary Diagnosis -non-ST elevation myocardial infaction Secondary Diagnosis -hypertension -pulmonary hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], Thank you for coming to [MASKED]. It was a pleasure to participate in your care. You came to the hospital because you felt chest pain and short of breath. We did an echocardiogram showing that your heart was not pumping as powerfully as expected. You then underwent a cardiac catheterization showing that one of the arteries supplying blood to your heart (your left circumflex artery) was 99% blocked. You had a stent placed in that artery to open it up. In the hospital you received nitroglycerin to relived the pain in your chest and several medications that prevent blood clots and help protect your heart muscle: heparin, clopidogrel, aspirin, and atorvastatin. To help protect your heart from more blockages, it will be very important for you to take clopidogrel and aspirin every day to prevent the stent from closing. Please do not stop these medications unless directed by your new cardiologist, Dr. [MASKED]. You can also help protect your heart by eating a heart healthy diet and getting regular exercise. Your doctors [MASKED] help [MASKED] get more information on these topics. You have already made a big step in protecting your health by quitting smoking. Please continue taking your medications as instructed below and follow-up with the appointments listed below. Wishing you the best, Your [MASKED] team Followup Instructions: [MASKED] | [
"I214",
"I5033",
"I272",
"Z9981",
"J449",
"I878",
"Z87891",
"I2510",
"G4733",
"F329",
"F419",
"F4310",
"Z7902",
"R0902",
"D72829",
"E669",
"Z6837",
"R0689"
] | [
"I214: Non-ST elevation (NSTEMI) myocardial infarction",
"I5033: Acute on chronic diastolic (congestive) heart failure",
"I272: Other secondary pulmonary hypertension",
"Z9981: Dependence on supplemental oxygen",
"J449: Chronic obstructive pulmonary disease, unspecified",
"I878: Other specified disorders of veins",
"Z87891: Personal history of nicotine dependence",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"G4733: Obstructive sleep apnea (adult) (pediatric)",
"F329: Major depressive disorder, single episode, unspecified",
"F419: Anxiety disorder, unspecified",
"F4310: Post-traumatic stress disorder, unspecified",
"Z7902: Long term (current) use of antithrombotics/antiplatelets",
"R0902: Hypoxemia",
"D72829: Elevated white blood cell count, unspecified",
"E669: Obesity, unspecified",
"Z6837: Body mass index [BMI] 37.0-37.9, adult",
"R0689: Other abnormalities of breathing"
] | [
"J449",
"Z87891",
"I2510",
"G4733",
"F329",
"F419",
"Z7902",
"E669"
] | [] |
15,966,360 | 24,604,221 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\nChest pain\n \nMajor Surgical or Invasive Procedure:\n___ PCI of the LM and ___ with 2 non-overlapping DES\n \nHistory of Present Illness:\nMr. ___ is a ___ year old gentleman with history of CAD s/p \n___ PCI ___ and ___, CABG ___ (LIMA-LAD, Y SVG-RI and \ndiagonal, SVG-OM) with last angiogram ___ with 80% distal \nLMCA into CX ostial 90% with distal occlusion with patent LIMA \nand previously documented occlusion of all SVGs, hypertension, \nhyperlipidemia, GERD, type 2 diabetes mellitus, obesity, \nsmoking, presenting with retrosternal chest pain that woke him \nup from sleep.\n\nHe was in usual state of health until the evening of \npresentation when he had retrosternal chest discomfort that \nawoke him from sleep. Pain was similar to prior MI a few yars \nago. He took aspirin and 4 nitroglycerin with minor improvement. \nUpon arrival to ED, his chest pain had resolved.\n\nIn the ED initial vitals were: Afebrile, HR 82-86, BP \n116-125/74-78, SaO2 94-96% on RA. EKG showed sinus rhythm at 72 \nbpm, normal axis, normal intervals, good R wave progression, T \nwave inversion in aVL and V2, sub-mm ST elevation in V1, sub-mm \nST depression in V4-V6, new from prior. Labs/studies notable for \nTroponin-T initially negative, then rose minimally to 0.02. \nLeukocytosis to 11.8. Lactate 2.6. Serum EtOH 85. CXR without \nany focal consolidation.\n\nAfter arrival to the cardiology ward, he confirmed the above \nhistory. He has not had any chest pain since arriving to the \nhospital. He denied any exertional dyspnea, orthopnea, or \nparoxysmal nocturnal dyspnea. He had consumed 3 glasses of wine \nthe night before.\n \nPast Medical History:\n1. CAD RISK FACTORS \n- Diabetes, type 2\n- Hypertension \n- Dyslipidemia \n- Obesity\n- Tobacco use\n\n2. CARDIAC HISTORY \n- CAD s/p multiple PCI to ___ and NSTEMI in ___, CABG ___ (LIMA-LAD, Y SVG-ramus and diagonal, SVG-OM; all SVGs \nknown occluded)\n\n3. OTHER PAST MEDICAL HISTORY \n- GERD\n- Anxiety\n- Depression\n- Kidney stones s/p laser surgery\n \nSocial History:\n___\nFamily History:\n- Mother: colon cancer\n \nPhysical Exam:\nOn admission\nGENERAL: Well developed, well nourished middle aged man in NAD. \nOriented x3. Mood, affect appropriate.\nVS: T 97.7 PO BP 129/80 left arm supine HR 72 RR 20 SaO2 95% on \nRoom Air\nHEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. \nConjunctiva were pink. No pallor or cyanosis of the oral mucosa\nNECK: NO JVD\nCARDIAC: Regular rate and rhythm. Normal S1, S2. No murmurs, \nrubs, or gallops.\nLUNGS: No chest wall deformities or tenderness. Respiration is \nunlabored with no accessory muscle use. No crackles, wheezes or \nrhonchi.\nABDOMEN: Soft, non-tender, not distended\nEXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or \nperipheral edema.\nSKIN: No significant skin lesions or rashes.\n\nAt discharge\nGENERAL: well appearing man, lying in bed\nVITALS: \n24 HR Data (last updated ___ @ 534) Temp: 97.6 (Tm 98.2), \nBP: 100/68 (93-118/53-70), HR: 53 (50-64), RR: 18, O2 sat: 97% \n(94-99), O2 delivery: Ra\nWt: 182.54 lb/82.8 kg \nFluid Balance (last updated ___ @ 2128) \n Last 8 hours No data found\n Last 24 hours Total cumulative 1295ml\n IN: Total 2320ml, PO Amt 720ml, IV Amt Infused 1600ml\n OUT: Total 1025ml, Urine Amt 1025ml \nHEENT: Mucous membranes moist\nNECK: No JVD\nCARDIAC: RRR, normal S1, S2; no murmurs, gallops, rubs\nLUNGS: CTAB in posterior fields\nABDOMEN: soft, non-tender, not distended\n \nPertinent Results:\n___ 12:12AM BLOOD WBC-11.8* RBC-4.57* Hgb-14.0 Hct-44.3 \nMCV-97 MCH-30.6 MCHC-31.6* RDW-13.8 RDWSD-49.1* Plt ___\n___ 12:12AM BLOOD Neuts-58.9 ___ Monos-8.1 Eos-1.7 \nBaso-0.6 Im ___ AbsNeut-6.93* AbsLymp-3.52 AbsMono-0.96* \nAbsEos-0.20 AbsBaso-0.07\n___ 12:12AM BLOOD ___ PTT-24.5* ___\n\n___ 12:12AM BLOOD Glucose-98 UreaN-17 Creat-0.9 Na-143 \nK-4.5 Cl-103 HCO3-25 AnGap-15\n___ 12:12AM BLOOD ALT-16 AST-16 AlkPhos-97 TotBili-<0.2\n___ 12:12AM BLOOD Albumin-4.0 Calcium-9.4 Phos-3.9 Mg-2.1\n\n___ 12:12AM BLOOD cTropnT-<0.01\n___ 04:03AM BLOOD cTropnT-0.02*\n___ 08:40AM BLOOD CK-MB-3 cTropnT-0.02*\n\n___ 12:25AM BLOOD Lactate-2.6*\n___ 09:09AM BLOOD Lactate-1.3\n\nECG ___ 23:45:56\nSinus arrhythmia. Intra-atrial conduction delay. Inferior MI - \nindeterminate age. Abnrm T, consider ischemia, anterolateral \nlds. compared to previous ECG anterior ST elevation has \nincreased\n\nCXR ___\nMid sternotomy wires are intact. Mediastinal surgical clips are \nunchanged. Increased opacity in the lingula and small left \nfissural pleural effusion. No pneumothorax. The \ncardiomediastinal silhouette is normal.\nIMPRESSION: Increased opacity in the lingula with small left \nfissural pleural effusion concerning for pneumonia with \nparapneumonic pleural effusion. \n\nCoronary Angiogram ___\nThe coronary circulation is right dominant.\nLM: The Left Main, arising from the left cusp, is a large \ncaliber vessel. This vessel trifurcates into the Left Anterior \nDescending, Left Circumflex, and Ramus Intermedius. There is a \n50% stenosis in the proximal, mid, and distal segments. There is \na 90% stenosis in the mid segment extending to the ostium of the \nLAD.\nLAD: The Left Anterior Descending artery, which arises from the \nLM, is a large caliber vessel. There is a 100% stenosis in the \nproximal segment. Collaterals from the mid segment of the LAD \nconnect to the proximal segment. The Diagonal, arising from the \nproximal segment, is a medium caliber vessel.\nCx: The Circumflex artery, which arises from the LM, is a large \ncaliber vessel. There is a 90% stenosis in the ostium. There is \na stent in the proximal and mid segments. There is a 70% \nin-stent restenosis in the proximal segment. There is a 100% \nin-stent restenosis in the mid segment. Collaterals from the mid \nsegment of the RPLA connect to the mid segment. The ___ Obtuse \nMarginal, arising from the proximal segment, is a medium caliber \nvessel. There is a 70% stenosis in the proximal segment. The ___ \nObtuse Marginal, arising from the mid segment, is a small \ncaliber vessel.\nRI: The Ramus Intermedius, which arises from the LM, is a small \ncaliber vessel.\nRCA: The Right Coronary Artery, arising from the right cusp, is \na large caliber vessel. There is a stent\nin the distal segment. The Right Posterior Descending Artery, \narising from the distal segment, is a medium caliber vessel. The \nRight Posterolateral Artery, arising from the distal segment, is \na medium caliber vessel.\nBypass Grafts:\nLIMA: A medium caliber arterial LIMA graft connects to the mid \nsegment of the LAD. This graft is patent.\nInterventional details: A 6 ___ EBU3.75 guide provided \nadequate support. The ___ into OM was crossed with a Runthrough \nwire into the distal OM. A second wire was placed into the Ramus \nfor protection. Predilated with a 2.0 mm balloon in the distal \nand ___ and distal left main. IVUS was then performed for \nvessel sizing - there was extensive disease in the entire ___ \nas well as the LM. Further predilation with a 2.5 NC balloon at \nhigh pressure and 2.2.5 NC at high pressure in the distal OM. \nPredilation with a3.0 NC in the proximal ___ and left main. We \nplaced a 2.25 x 26 mm Onyx DES in the distal OM. Post-dilated \nwith a 2.75 distally and 3.0proximally at high pressure. We \nplaced an additional 3.5 x 22 mm Onyx DES from LM to proximal \n___, post-dilated to 4.0 at high pressure. TIMI III flow, 0% \nresidual throughout. Final IVUS confirmed excellent expansion \nthroughout.\n\nDISCHARGE LABS:\n___ 06:47AM BLOOD WBC-14.2* RBC-4.57* Hgb-14.1 Hct-45.1 \nMCV-99* MCH-30.9 MCHC-31.3* RDW-13.9 RDWSD-50.8* Plt ___\n___ 06:47AM BLOOD Glucose-90 UreaN-14 Creat-1.0 Na-141 \nK-4.8 Cl-103 HCO3-28 AnGap-10\n \nBrief Hospital Course:\nMr. ___ is a ___ year old gentleman with history of CAD s/p \n___ PCI ___ and ___, CABG ___ (LIMA-LAD; known occlusion \nof Y SVG-RI and diagonal, known occlusion of SVG-OM), \nhypertension, hyperlipidemia, GERD, type 2 diabetes mellitus, \nobesity, ongoing smoking, presenting with retrosternal chest \npain that woke him up from sleep with NSTEMI with troponin-T \n0.02. He was known to have critical stenosis of the distal LM \ninto the ___ from before and underwent PCI of LM and ___ \nwith 2 non-overlapping DES.\n\nACTIVE ISSUES: \n# NSTEMI, CAD (90% L main, occluded distal ___, patent LIMA-LAD \nand minimally\ndiseased RCA): He initially presented with chest pain and \ntroponin-T that peaked at 0.02. He was treated with a heparin \ndrip, home metoprolol, ASA, clopidogrel. Coronary angiogram ___ \nwhich again demonstrated critical stenosis of the distal LM into \nthe proximal ___. He also had distal severe OM disease. He is \nnow s/p successful PCI of the LM and ___ with 2 \nnon-overlapping DES.\n\n# Leukocytosis: Patient with mild leukocytosis that rose to 14.2 \nat discharge. Patient denied any infectious symptoms and \nremained afebrile. Admission CXR showed increased opacity in the \nlingula with small left fissural pleural effusion concerning for \npneumonia with parapneumonic pleural effusion at a time when WBC \n11.8 with 59% PMNs. He had no cough or sputum production. He \nlooked well, and we had a low clinical suspicion for pneumonia. \nPatient instructed at discharge to follow up with PCP's office \non ___ for repeat CBC and for evaluation. He was instructed to \ncontact his PCP if he develops symptoms of infection. \n\nCHRONIC ISSUES: \n# Hypertension: Continued home HCTZ, metoprolol, lisinopril.\n\n# GERD: Continued ranitidine.\n\n# Depression: Continued sertraline and trazodone.\n\n# BPH: Continued tamsulosin.\n\n# Tobacco use: Discharged with prescription for nicotine patch.\n\nTRANSITIONAL ISSUES:\n[ ]Patient started on nicotine patches and provided information \nabout smoking cessation. Educated patient on risks associated \nwith smoking. \n[ ] Patient with mild leukocytosis to 14.2 at discharge. Patient \ndenied any infectious symptoms. Patient was afebrile and without \nadditional evidence of infection. Patient instructed at \ndischarge to follow up with PCP's office on ___ for repeat CBC \nand for evaluation. Instructed to contact PCP if he develops \nsymptoms of infection.\n\nCORE MEASURES: \n# CODE STATUS: Full (presumed)\n# CONTACT: ___ \nRelationship: Partner \nPhone number: ___ \n \n___ on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Lisinopril 20 mg PO DAILY \n2. BuPROPion XL (Once Daily) 300 mg PO DAILY \n3. Metoprolol Succinate XL 50 mg PO DAILY \n4. Ranitidine 300 mg PO DAILY \n5. Atorvastatin 80 mg PO DAILY \n6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY \n7. Clopidogrel 75 mg PO DAILY \n8. Aspirin 81 mg PO DAILY \n9. Tamsulosin 0.4 mg PO DAILY \n10. Sertraline 200 mg PO DAILY \n11. Hydrochlorothiazide 12.5 mg PO DAILY \n12. TraZODone 150 mg PO QHS:PRN insomnia\n \nDischarge Medications:\n1. Nicotine Patch 14 mg/day TD DAILY \nRX *nicotine 14 mg/24 hour Apply patch to skin once a day Disp \n#*30 Patch Refills:*0 \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 80 mg PO DAILY \n4. BuPROPion XL (Once Daily) 300 mg PO DAILY \n5. Clopidogrel 75 mg PO DAILY \n6. Hydrochlorothiazide 12.5 mg PO DAILY \n7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY \n8. Lisinopril 20 mg PO DAILY \n9. Metoprolol Succinate XL 50 mg PO DAILY \n10. Ranitidine 300 mg PO DAILY \n11. Sertraline 200 mg PO DAILY \n12. Tamsulosin 0.4 mg PO DAILY \n13. TraZODone 150 mg PO QHS:PRN insomnia\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\n-Non-ST segment elevation Myocardial Infarction \n-Native and bypass graft coronary artery disease\n-Hypertension\n-Hyperlipidemia\n-Type 2 diabetes mellitus\n-Cigarette use\n-Gastroesophageal reflux disease\n-Leukocytosis\n-Abnormal chest radiography with low clinical suspicion for \npneumonia\n-Depression\n-Benign prostatic hypertrophy\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nDear Mr. ___,\n\nIt was a pleasure taking care of you at ___!\n\nWHY DID YOU COME TO THE HOSPITAL?\n- You had chest pain that woke you up from sleep.\n\nWHAT HAPPENED WHILE YOU WERE HERE?\n- You had a heart catherization where they saw the vessels \naround your heart were blocked. The cardiologists placed two \nstents which opened the vessels back up to let blood flow back \nto your heart. \n\nWHAT TO DO WHEN YOU LEAVE?\n- Continue to take all your medicines as listed below. \n- Go to all your follow-up appointments as listed below. \n\nBest wishes,\nYour ___ Team\n \nFollowup Instructions:\n___\n"
] | Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [MASKED] PCI of the LM and [MASKED] with 2 non-overlapping DES History of Present Illness: Mr. [MASKED] is a [MASKED] year old gentleman with history of CAD s/p [MASKED] PCI [MASKED] and [MASKED], CABG [MASKED] (LIMA-LAD, Y SVG-RI and diagonal, SVG-OM) with last angiogram [MASKED] with 80% distal LMCA into CX ostial 90% with distal occlusion with patent LIMA and previously documented occlusion of all SVGs, hypertension, hyperlipidemia, GERD, type 2 diabetes mellitus, obesity, smoking, presenting with retrosternal chest pain that woke him up from sleep. He was in usual state of health until the evening of presentation when he had retrosternal chest discomfort that awoke him from sleep. Pain was similar to prior MI a few yars ago. He took aspirin and 4 nitroglycerin with minor improvement. Upon arrival to ED, his chest pain had resolved. In the ED initial vitals were: Afebrile, HR 82-86, BP 116-125/74-78, SaO2 94-96% on RA. EKG showed sinus rhythm at 72 bpm, normal axis, normal intervals, good R wave progression, T wave inversion in aVL and V2, sub-mm ST elevation in V1, sub-mm ST depression in V4-V6, new from prior. Labs/studies notable for Troponin-T initially negative, then rose minimally to 0.02. Leukocytosis to 11.8. Lactate 2.6. Serum EtOH 85. CXR without any focal consolidation. After arrival to the cardiology ward, he confirmed the above history. He has not had any chest pain since arriving to the hospital. He denied any exertional dyspnea, orthopnea, or paroxysmal nocturnal dyspnea. He had consumed 3 glasses of wine the night before. Past Medical History: 1. CAD RISK FACTORS - Diabetes, type 2 - Hypertension - Dyslipidemia - Obesity - Tobacco use 2. CARDIAC HISTORY - CAD s/p multiple PCI to [MASKED] and NSTEMI in [MASKED], CABG [MASKED] (LIMA-LAD, Y SVG-ramus and diagonal, SVG-OM; all SVGs known occluded) 3. OTHER PAST MEDICAL HISTORY - GERD - Anxiety - Depression - Kidney stones s/p laser surgery Social History: [MASKED] Family History: - Mother: colon cancer Physical Exam: On admission GENERAL: Well developed, well nourished middle aged man in NAD. Oriented x3. Mood, affect appropriate. VS: T 97.7 PO BP 129/80 left arm supine HR 72 RR 20 SaO2 95% on Room Air HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. Conjunctiva were pink. No pallor or cyanosis of the oral mucosa NECK: NO JVD CARDIAC: Regular rate and rhythm. Normal S1, S2. No murmurs, rubs, or gallops. LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, non-tender, not distended EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. SKIN: No significant skin lesions or rashes. At discharge GENERAL: well appearing man, lying in bed VITALS: 24 HR Data (last updated [MASKED] @ 534) Temp: 97.6 (Tm 98.2), BP: 100/68 (93-118/53-70), HR: 53 (50-64), RR: 18, O2 sat: 97% (94-99), O2 delivery: Ra Wt: 182.54 lb/82.8 kg Fluid Balance (last updated [MASKED] @ 2128) Last 8 hours No data found Last 24 hours Total cumulative 1295ml IN: Total 2320ml, PO Amt 720ml, IV Amt Infused 1600ml OUT: Total 1025ml, Urine Amt 1025ml HEENT: Mucous membranes moist NECK: No JVD CARDIAC: RRR, normal S1, S2; no murmurs, gallops, rubs LUNGS: CTAB in posterior fields ABDOMEN: soft, non-tender, not distended Pertinent Results: [MASKED] 12:12AM BLOOD WBC-11.8* RBC-4.57* Hgb-14.0 Hct-44.3 MCV-97 MCH-30.6 MCHC-31.6* RDW-13.8 RDWSD-49.1* Plt [MASKED] [MASKED] 12:12AM BLOOD Neuts-58.9 [MASKED] Monos-8.1 Eos-1.7 Baso-0.6 Im [MASKED] AbsNeut-6.93* AbsLymp-3.52 AbsMono-0.96* AbsEos-0.20 AbsBaso-0.07 [MASKED] 12:12AM BLOOD [MASKED] PTT-24.5* [MASKED] [MASKED] 12:12AM BLOOD Glucose-98 UreaN-17 Creat-0.9 Na-143 K-4.5 Cl-103 HCO3-25 AnGap-15 [MASKED] 12:12AM BLOOD ALT-16 AST-16 AlkPhos-97 TotBili-<0.2 [MASKED] 12:12AM BLOOD Albumin-4.0 Calcium-9.4 Phos-3.9 Mg-2.1 [MASKED] 12:12AM BLOOD cTropnT-<0.01 [MASKED] 04:03AM BLOOD cTropnT-0.02* [MASKED] 08:40AM BLOOD CK-MB-3 cTropnT-0.02* [MASKED] 12:25AM BLOOD Lactate-2.6* [MASKED] 09:09AM BLOOD Lactate-1.3 ECG [MASKED] 23:45:56 Sinus arrhythmia. Intra-atrial conduction delay. Inferior MI - indeterminate age. Abnrm T, consider ischemia, anterolateral lds. compared to previous ECG anterior ST elevation has increased CXR [MASKED] Mid sternotomy wires are intact. Mediastinal surgical clips are unchanged. Increased opacity in the lingula and small left fissural pleural effusion. No pneumothorax. The cardiomediastinal silhouette is normal. IMPRESSION: Increased opacity in the lingula with small left fissural pleural effusion concerning for pneumonia with parapneumonic pleural effusion. Coronary Angiogram [MASKED] The coronary circulation is right dominant. LM: The Left Main, arising from the left cusp, is a large caliber vessel. This vessel trifurcates into the Left Anterior Descending, Left Circumflex, and Ramus Intermedius. There is a 50% stenosis in the proximal, mid, and distal segments. There is a 90% stenosis in the mid segment extending to the ostium of the LAD. LAD: The Left Anterior Descending artery, which arises from the LM, is a large caliber vessel. There is a 100% stenosis in the proximal segment. Collaterals from the mid segment of the LAD connect to the proximal segment. The Diagonal, arising from the proximal segment, is a medium caliber vessel. Cx: The Circumflex artery, which arises from the LM, is a large caliber vessel. There is a 90% stenosis in the ostium. There is a stent in the proximal and mid segments. There is a 70% in-stent restenosis in the proximal segment. There is a 100% in-stent restenosis in the mid segment. Collaterals from the mid segment of the RPLA connect to the mid segment. The [MASKED] Obtuse Marginal, arising from the proximal segment, is a medium caliber vessel. There is a 70% stenosis in the proximal segment. The [MASKED] Obtuse Marginal, arising from the mid segment, is a small caliber vessel. RI: The Ramus Intermedius, which arises from the LM, is a small caliber vessel. RCA: The Right Coronary Artery, arising from the right cusp, is a large caliber vessel. There is a stent in the distal segment. The Right Posterior Descending Artery, arising from the distal segment, is a medium caliber vessel. The Right Posterolateral Artery, arising from the distal segment, is a medium caliber vessel. Bypass Grafts: LIMA: A medium caliber arterial LIMA graft connects to the mid segment of the LAD. This graft is patent. Interventional details: A 6 [MASKED] EBU3.75 guide provided adequate support. The [MASKED] into OM was crossed with a Runthrough wire into the distal OM. A second wire was placed into the Ramus for protection. Predilated with a 2.0 mm balloon in the distal and [MASKED] and distal left main. IVUS was then performed for vessel sizing - there was extensive disease in the entire [MASKED] as well as the LM. Further predilation with a 2.5 NC balloon at high pressure and 2.2.5 NC at high pressure in the distal OM. Predilation with a3.0 NC in the proximal [MASKED] and left main. We placed a 2.25 x 26 mm Onyx DES in the distal OM. Post-dilated with a 2.75 distally and 3.0proximally at high pressure. We placed an additional 3.5 x 22 mm Onyx DES from LM to proximal [MASKED], post-dilated to 4.0 at high pressure. TIMI III flow, 0% residual throughout. Final IVUS confirmed excellent expansion throughout. DISCHARGE LABS: [MASKED] 06:47AM BLOOD WBC-14.2* RBC-4.57* Hgb-14.1 Hct-45.1 MCV-99* MCH-30.9 MCHC-31.3* RDW-13.9 RDWSD-50.8* Plt [MASKED] [MASKED] 06:47AM BLOOD Glucose-90 UreaN-14 Creat-1.0 Na-141 K-4.8 Cl-103 HCO3-28 AnGap-10 Brief Hospital Course: Mr. [MASKED] is a [MASKED] year old gentleman with history of CAD s/p [MASKED] PCI [MASKED] and [MASKED], CABG [MASKED] (LIMA-LAD; known occlusion of Y SVG-RI and diagonal, known occlusion of SVG-OM), hypertension, hyperlipidemia, GERD, type 2 diabetes mellitus, obesity, ongoing smoking, presenting with retrosternal chest pain that woke him up from sleep with NSTEMI with troponin-T 0.02. He was known to have critical stenosis of the distal LM into the [MASKED] from before and underwent PCI of LM and [MASKED] with 2 non-overlapping DES. ACTIVE ISSUES: # NSTEMI, CAD (90% L main, occluded distal [MASKED], patent LIMA-LAD and minimally diseased RCA): He initially presented with chest pain and troponin-T that peaked at 0.02. He was treated with a heparin drip, home metoprolol, ASA, clopidogrel. Coronary angiogram [MASKED] which again demonstrated critical stenosis of the distal LM into the proximal [MASKED]. He also had distal severe OM disease. He is now s/p successful PCI of the LM and [MASKED] with 2 non-overlapping DES. # Leukocytosis: Patient with mild leukocytosis that rose to 14.2 at discharge. Patient denied any infectious symptoms and remained afebrile. Admission CXR showed increased opacity in the lingula with small left fissural pleural effusion concerning for pneumonia with parapneumonic pleural effusion at a time when WBC 11.8 with 59% PMNs. He had no cough or sputum production. He looked well, and we had a low clinical suspicion for pneumonia. Patient instructed at discharge to follow up with PCP's office on [MASKED] for repeat CBC and for evaluation. He was instructed to contact his PCP if he develops symptoms of infection. CHRONIC ISSUES: # Hypertension: Continued home HCTZ, metoprolol, lisinopril. # GERD: Continued ranitidine. # Depression: Continued sertraline and trazodone. # BPH: Continued tamsulosin. # Tobacco use: Discharged with prescription for nicotine patch. TRANSITIONAL ISSUES: [ ]Patient started on nicotine patches and provided information about smoking cessation. Educated patient on risks associated with smoking. [ ] Patient with mild leukocytosis to 14.2 at discharge. Patient denied any infectious symptoms. Patient was afebrile and without additional evidence of infection. Patient instructed at discharge to follow up with PCP's office on [MASKED] for repeat CBC and for evaluation. Instructed to contact PCP if he develops symptoms of infection. CORE MEASURES: # CODE STATUS: Full (presumed) # CONTACT: [MASKED] Relationship: Partner Phone number: [MASKED] [MASKED] on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 20 mg PO DAILY 2. BuPROPion XL (Once Daily) 300 mg PO DAILY 3. Metoprolol Succinate XL 50 mg PO DAILY 4. Ranitidine 300 mg PO DAILY 5. Atorvastatin 80 mg PO DAILY 6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 7. Clopidogrel 75 mg PO DAILY 8. Aspirin 81 mg PO DAILY 9. Tamsulosin 0.4 mg PO DAILY 10. Sertraline 200 mg PO DAILY 11. Hydrochlorothiazide 12.5 mg PO DAILY 12. TraZODone 150 mg PO QHS:PRN insomnia Discharge Medications: 1. Nicotine Patch 14 mg/day TD DAILY RX *nicotine 14 mg/24 hour Apply patch to skin once a day Disp #*30 Patch Refills:*0 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 80 mg PO DAILY 4. BuPROPion XL (Once Daily) 300 mg PO DAILY 5. Clopidogrel 75 mg PO DAILY 6. Hydrochlorothiazide 12.5 mg PO DAILY 7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 8. Lisinopril 20 mg PO DAILY 9. Metoprolol Succinate XL 50 mg PO DAILY 10. Ranitidine 300 mg PO DAILY 11. Sertraline 200 mg PO DAILY 12. Tamsulosin 0.4 mg PO DAILY 13. TraZODone 150 mg PO QHS:PRN insomnia Discharge Disposition: Home Discharge Diagnosis: -Non-ST segment elevation Myocardial Infarction -Native and bypass graft coronary artery disease -Hypertension -Hyperlipidemia -Type 2 diabetes mellitus -Cigarette use -Gastroesophageal reflux disease -Leukocytosis -Abnormal chest radiography with low clinical suspicion for pneumonia -Depression -Benign prostatic hypertrophy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], It was a pleasure taking care of you at [MASKED]! WHY DID YOU COME TO THE HOSPITAL? - You had chest pain that woke you up from sleep. WHAT HAPPENED WHILE YOU WERE HERE? - You had a heart catherization where they saw the vessels around your heart were blocked. The cardiologists placed two stents which opened the vessels back up to let blood flow back to your heart. WHAT TO DO WHEN YOU LEAVE? - Continue to take all your medicines as listed below. - Go to all your follow-up appointments as listed below. Best wishes, Your [MASKED] Team Followup Instructions: [MASKED] | [
"I214",
"Z9861",
"I252",
"I25119",
"I10",
"Z951",
"Z720",
"D72829",
"E785",
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"Z6827",
"K219",
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"F329",
"N400"
] | [
"I214: Non-ST elevation (NSTEMI) myocardial infarction",
"Z9861: Coronary angioplasty status",
"I252: Old myocardial infarction",
"I25119: Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris",
"I10: Essential (primary) hypertension",
"Z951: Presence of aortocoronary bypass graft",
"Z720: Tobacco use",
"D72829: Elevated white blood cell count, unspecified",
"E785: Hyperlipidemia, unspecified",
"E669: Obesity, unspecified",
"Z6827: Body mass index [BMI] 27.0-27.9, adult",
"K219: Gastro-esophageal reflux disease without esophagitis",
"F419: Anxiety disorder, unspecified",
"F329: Major depressive disorder, single episode, unspecified",
"N400: Benign prostatic hyperplasia without lower urinary tract symptoms"
] | [
"I252",
"I10",
"Z951",
"E785",
"E669",
"K219",
"F419",
"F329",
"N400"
] | [] |
16,791,831 | 28,504,193 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nmorphine / Tylenol / Sulfa (Sulfonamide Antibiotics)\n \nAttending: ___\n \nChief Complaint:\nLabile blood sugars, abdominal pain\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMr. ___ is a ___ with history of chronic pancreatitis \nsecondary to pancreas divisum and CFTR mutation (does not have \nCF) s/p pancreatectomy and splenectomy now with diabetes on \ninsulin pump and chronic abdominal pain, recurrent SBOs iso \nsurgical adhesions and chronic opioid use who presents as \ntransfer from BI-N for labile blood sugars and evaluation of CT \nshowing partial SBO given his complex surgical history. \n\nPer ED note, He initially presented to outside hospital with \nconcern about his\nglycemic control in setting of diabetes but also with abdominal \npain, decreased flatus, and constipation. He has had \nintermittent chills since yesterday but denies fever. He denies \nany new back pain or dysuria. He denies chest pain or shortness \nof breath. He also relates that he recently had a URI with a dry \ncough that he thinks he acquired while traveling in ___ with \nhis husband. This is resolving. He was called back to the ED \nafter CT found a partial\nSBO without definite transition point. NG tube was not placed \nand he was felt to be better served at our facility given his \ncomplex surgical history. Briefly, he is status post \ngastric/duodenal/pancreatic/splenic resection for chronic \npancreatitis that was thought to be due to pancreas divisum and \nCFTR mutation (patient has had genetic testing and reports a \nmutation that causes pancreas findings but no lung pathology). \nHe last passed gas in the ambulance ride over. He has decreased \nappetite currently.\n\n- In the ED, initial vitals were:\nPain ___, T 97.2, HR 70, BP 132/78, RR 16, O2 98% RA, Gluc 149\n \n- Exam was notable for: \nCon: In no acute distress, non-toxic\nHEENT: Normocephalic, atraumatic, Pupils equal, round and\nreactive to light, Extraocular muscles intact. No meningismus or\nneck TTP. No lymphadenopathy. Oropharynx benign. \nResp: Clear to auscultation, normal work of breathing\nCV: Regular rate and rhythm, normal ___ and ___ heart sounds, 2+\ndistal pulses in arms and legs. Capillary refill less than 2\nseconds. No clinically significant murmur. \nAbd: Soft, right lower quadrant tenderness to palpation,\nNondistended. No masses or overlying skin changes. No\norganomegaly. \nGU: No costovertebral angle tenderness\nMSK: No deformity or edema. No back TTP.\nSkin: No rash, Warm and dry\nNeuro: No lateralizing signs, cranial nerves II-XII grossly\nintact, strength and sensation grossly intact all ext\nPsych: Normal mood/mentation\n\n- Labs were notable for: \nWBC 9.7, Hb 14.6, Plt 278, Cr 0.9, Glucose 158, lactate 1.1\n \n- The patient was given: \n___ 16:57 IV HYDROmorphone (Dilaudid) .5 mg \n___ 18:23 IV HYDROmorphone (Dilaudid) .5 mg \n___ 19:35 IV HYDROmorphone (Dilaudid) 1 mg \n___ 20:28 IVF NS 1000 mL \n___ 22:24 IV HYDROmorphone (Dilaudid) 1 mg \n\n- SURGERY was consulted\nSurgery recommending presentation not suggestive of bowel \nobstruction, more likely slow transit. Recommend admission to \nmedicine for management of labile blood sugars. will need upper \nGI consult and GI series with contrast follow-through as \ninpatient.\n\nOn arrival to the floor, he confirms the above history. He \nreports that his abdomen is mildly more tender than usual, he \nthinks because he had a salad a few days ago when he normally \nsticks to a low fiber diet. He is still passing gas and had a \nlarge formed BM in the ED. He has no n/v. Normally when he has \nan\nSBO he reports intense pain and nausea. He has these flares once \nevery few months. He recalls he had a small bowel follow through \nstudy a few years ago and it did show slowed motility. He \nnormally takes his methylnaltrexone every day. He reports that \nhe really came to the hospital because he is concerned about his \nsugars.\n\nTwo nights ago his sugars kept dropping down to the 60-70s. \nDinner the night before his admission it went up to 405, he \nbolused, and then dropped down to 35 two hours later. He talked \nto his endocrinologist Dr. ___ encouraged him to come \ninto the ED. He reports coming back from a trip to ___ with\nhis husband on ___, and both have felt unwell snice then. \nThey both felt feverish (he had a 99.5 temperature a few nights \nago) and have a \"chest cold\" with symptoms of runny nose, \nfeeling phlegmy, and sore throat. He has not taken any OTC meds \nfor this.\n\nPer HPI, otherwise, 10-point review of systems was within normal \nlimits. \n\n \nPast Medical History:\nHistory of recurrent pancreatitis ___ CFTR mutation and pancreas \ndivisum\nHistory of intraabdominal abscess\ns/p total pancreatectomy and splenectomy with islet cell\ntransplantation in ___ leading to type IIIc diabetes\ns/p cholecystectomy\ns/p appendectomy\ns/p partial gastrectomy with gastrojejunostomy \nRecurrent SBOs s/p LOA\n \nSocial History:\n___\nFamily History:\nMaternal and Paternal Hx: Pancreatic Cancer, CFTR Mutation \nMother: cancer, cholecystectomy \nFather: Heart Disease \nSister: ___ Abuse \nBrother: ___ Abuse \n___ Aunt: Cancer, ___ \nPaternal Uncle: Cancer, ___ \nMaternal side: IBS \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n========================\nVitals: T 97.2, HR 70, BP 132/78, RR 16, O2 98% RA,\nGen: appears well, comfortable\nHEENT: no cobblestoning or exudates, no lymphadenopathy \nCV: RRR, normal s1/s2, no murmurs\nPulm: clear to auscultation, comfortable on room air\nGI: soft, nontender, nondistended\nExt: warm, well perfused, no edema\n\nDISCHARGE PHYSICAL EXAM:\n========================\nVITALS: 24 HR Data (last updated ___ @ 837)\nTemp: 98.0 (Tm 98.3), BP: 106/66 (106-134/61-76), HR: 54 \n(54-69),\nRR: 16 (___), O2 sat: 94% (93-96), O2 delivery: Ra \nGeneral: Alert, oriented, no acute distress \nHEENT: NC/AT, Sclera anicteric, MMM, oropharynx clear \nNeck: supple, JVP not elevated, no LAD \nLungs: Clear to auscultation bilaterally, no wheezes, rales,\nrhonchi \nCV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,\ngallops \nAbdomen: Soft, non-distended. Mild TTP diffusely though improved\nfrom yesterday. No rebound tenderness or guarding. +BS. No\norganomegaly.\nExt: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or\nedema. Insulin pump and CGM on bilateral medial thighs without\nerythema or swelling. \nSkin: No rashes or bruising\nNeuro: A&Ox3, moving all extremities with purpose. \n\n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 05:04PM BLOOD WBC-9.7 RBC-4.64 Hgb-14.6 Hct-44.1 MCV-95 \nMCH-31.5 MCHC-33.1 RDW-14.5 RDWSD-50.4* Plt ___\n___ 05:04PM BLOOD Neuts-49.5 ___ Monos-12.7 Eos-6.4 \nBaso-1.2* Im ___ AbsNeut-4.78 AbsLymp-2.89 AbsMono-1.23* \nAbsEos-0.62* AbsBaso-0.12*\n___ 05:04PM BLOOD Glucose-158* UreaN-9 Creat-0.9 Na-140 \nK-4.4 Cl-101 HCO3-29 AnGap-10\n___ 05:04PM BLOOD Calcium-8.2* Phos-3.2 Mg-1.9\n___ 05:11PM BLOOD Lactate-1.1\n\nDISCHARGE LABS:\n===============\n___ 06:44AM BLOOD WBC-7.3 RBC-4.82 Hgb-15.2 Hct-45.8 MCV-95 \nMCH-31.5 MCHC-33.2 RDW-14.4 RDWSD-50.0* Plt ___\n___ 06:44AM BLOOD ___ PTT-27.8 ___\n___ 06:44AM BLOOD Glucose-133* UreaN-7 Creat-0.9 Na-141 \nK-4.3 Cl-103 HCO3-28 AnGap-10\n___ 06:44AM BLOOD ALT-43* AST-42* AlkPhos-101 TotBili-0.5\n___ 06:44AM BLOOD Calcium-8.7 Phos-2.6* Mg-1.9\n\nMICROBIOLOGY:\n=============\n___ 6:20 pm URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: NO GROWTH\n\nBlood Culture no growth as of discharge\n\nDIAGNOSTIC STUDIES:\n===================\nCXR ___ (OSH): Lungs are clear. Heart size is normal. \nThere is no pleural effusion. No pneumothorax is seen. No \nevidence of pneumonia\n\nCT Abd/Pelv w/ contrast ___ (OSH): 1. Postsurgical changes \nof gastrojejunostomy. Since prior study there is distension of \nthe gastrojejunostomy and proximal jejunal limb with debris. \nAlthough definite transition point is not identified, a partial \nobstruction of the\nproximal jejunal limb is difficult to exclude. This may be \nbetter evaluated with an upper GI series.\n2. Stable 6 mm nonobstructing left renal calculus.\n\n \nBrief Hospital Course:\nBRIEF HOSPITAL COURSE:\n======================\nMr. ___ is a ___ M with history of chronic pancreatitis \nsecondary to pancreas divisum and CFTR mutation s/p \npancreatectomy and splenectomy w/ islet cell transplant leading \nto diabetes, non insulin pump, and chronic abdominal pain, \nhistory of recurrent SBOs I/s/o surgical adhesions and chronic \nopioid use who presented as a transfer from ___ for \nlabile blood sugars felt to be most likely in the setting of a \nviral URI and evaluation of a CT scan felt to be concerning for \na partial small bowel obstruction. Abdominal exam was \nreassuringly stable throughout admission, notable only for \ndiffuse tenderness but without peritoneal signs. The patient \npassed flatus and had normal BMs throughout admission. Surgery \nwas consulted based on imaging findings and they felt that there \nwas no concern for obstruction and no need for a surgical \nintervention at this time. Blood sugars normalized to ___ \nby the time of transfer to ___. The patient initially had poor \nappetite but by the time of discharge was tolerating a normal \ndiet and felt his abdominal pain was at baseline for him.\n\nTRANSITIONAL ISSUES:\n====================\n[] Continue bowel regimen of senna, miralax, bisocodyl, \nmethylnaltrexone as needed. \n[] Has had concern for slow transit during prior workups. ___ \nbenefit from further evaluation/treatment of possible \ngastroparesis.\n\nACUTE/ACTIVE ISSUES: \n==================== \n# Labile blood sugars\n# Type IIIc diabetes secondary to pancreatectomy with insulin \npump \nPatient has history of chronic pancreatitis secondary to \npancreas divisum and CFTR mutation, s/p total pancreatectomy and \nsplenectomy with islet cell transplantation in ___, followed by \n___. Patient manages his diabetes with insulin \npump, usually with excellent control though reports recently \nlabile sugars at home from ___ to 400s with rapid drops after \nbolus. This was felt to be most likely in the setting of an \nacute viral illness as patient returned from trip to ___ and \n___ he and his husband developed URI symptoms. No evidence of \npump malfunction on evaluation of his device. Patient managed \nhis own pump and reassuringly had good blood sugar control \nin-house. He was evaluated by ___ endocrinology team who felt \nthat his diabetes management is excellent and recommended no \nchanges. He was maintained on aspart via insulin pump \n(patient-administered) and home dose of 3 caps Creon with each \nmeal.\n\n# Acute on chronic abdominal pain \n# Recurrent SBOs\nPatient presented with mild belching, abdominal cramping, and \ndecreased flatus. There was initial concern for partial SBO per \nCT at ___, but per surgery evaluation in ED presentation \nwas not suggestive of bowel obstruction and more likely \nrepresents slow transit. Patient agrees that this is not \nconsistent with his prior presentations for obstruction, and \nreassuringly he had normal BMs and passed flatus throughout stay \nat ___. Further GI imaging including UGI series w/ SBFT was \ndeferred given that the patient was well-appearing with good \nbowel function on our exam. He has a long history of epigastric \npain ___ slow motility in the setting of adhesions after \nextensive surgeries, diabetes, and chronic opioid use. His pain \nwas initially increased from baseline on admission, requiring \nmultiple doses of IV dilaudid. By the time of discharge he was \nback to baseline abdominal pain with good control on home PO \noxy/dilaudid regimen, with plans to decrease opiates soon with \n___ team. He had a poor appetite on transfer but \nwas subsequently able to tolerate toast and soft foods, and felt \ncomfortable eating regular low-fiber diet at time of discharge.\n\nCHRONIC/STABLE ISSUES: \n====================== \n# Depression\n- Continued home Lexapro 20mg PO daily \n\n# Insomnia\n- continued home zolpidem .25mg PO QHS PRN \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Escitalopram Oxalate 20 mg PO DAILY \n2. HYDROmorphone (Dilaudid) 4 mg PO Q4-6H PRN Pain - Severe \n3. Fiasp U-100 Insulin (insulin aspart (niacinamide)) 45 units \nsubcutaneous PRN \n4. OxyCODONE SR (OxyCONTIN) 15 mg PO Q12H \n5. Creon 12 3 CAP PO TID W/MEALS \n6. LORazepam 0.5 mg PO DAILY:PRN nausea \n7. Ondansetron ODT 4 mg PO Q8H:PRN Nausea/Vomiting - First Line \n8. Methylnaltrexone 150 mg Subcut DAILY:PRN constipation \n9. Pantoprazole 40 mg PO Q12H \n10. Zolpidem Tartrate 2.5 mg PO QHS:PRN insomnia \n11. Testosterone Cypionate 200 mg IM 1X/WEEK (___) \n12. Vitamin D ___ UNIT PO EVERY OTHER DAY \n\n \nDischarge Medications:\n1. Polyethylene Glycol 17 g PO DAILY \n2. Senna 8.6 mg PO BID \n3. Creon 12 3 CAP PO TID W/MEALS \n4. Escitalopram Oxalate 20 mg PO DAILY \n5. Fiasp U-100 Insulin (insulin aspart (niacinamide)) 45 units \nsubcutaneous PRN \n6. HYDROmorphone (Dilaudid) 4 mg PO Q4-6H PRN Pain - Severe \n7. Insulin Pump SC (Self Administering Medication)Insulin \nAspart (Novolog) (non-formulary)\nBasal rate minimum: 0 units/hr\nBasal rate maximum: 42 units/hr\nTarget glucose: 80-180\nMD has ordered ___ consult\nUse of ___ medical equipment: Insulin pump\nReason for use: medically necessary and justified as ___ \ncannot provide this type of equipment or suitable alternative \nnot appropriate.\nProvider acknowledges patient competent\n \n8. LORazepam 0.5 mg PO DAILY:PRN nausea \n9. Methylnaltrexone 150 mg Subcut DAILY:PRN constipation \n10. Ondansetron ODT 4 mg PO Q8H:PRN Nausea/Vomiting - First \nLine \n11. OxyCODONE SR (OxyCONTIN) 15 mg PO Q12H \n12. Pantoprazole 40 mg PO Q12H \n13. Testosterone Cypionate 200 mg IM 1X/WEEK (___) \n14. Vitamin D ___ UNIT PO EVERY OTHER DAY \n15. Zolpidem Tartrate 2.5 mg PO QHS:PRN insomnia \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary Diagnoses:\nAbdominal Pain\nHypoglycemia\nHyperglycemia\n\nSecondary Diagnoses:\nInsulin-dependent diabetes mellitus \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nIt was a privilege taking care of you at ___ \n___. \n\nWHY WAS I ADMITTED TO THE HOSPITAL?\n===================================\n- You came to the hospital because you were having very low and \nvery high blood sugars. You were also experiencing abdominal \npain.\n\nWHAT HAPPENED WHILE I WAS IN THE HOSPITAL?\n==========================================\n- You had a CT scan of your abdomen at another hosptial which \nshowed that you might have had a partial obstruction. \nFortunately, you were able to eat and pass bowel movements, and \nthe surgeons who evaluated you determined that you did not have \na full obstruction.\n- Diabetes doctors saw ___ and determined that your blood sugar \ncontrol was back to normal.\n\nWHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?\n============================================ \n- Please continue to take all your medications and follow up \nwith your doctors at your ___ appointments. \n\nWe wish you all the best!\n\nSincerely, \nYour ___ Care Team \n\n \nFollowup Instructions:\n___\n"
] | Allergies: morphine / Tylenol / Sulfa (Sulfonamide Antibiotics) Chief Complaint: Labile blood sugars, abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is a [MASKED] with history of chronic pancreatitis secondary to pancreas divisum and CFTR mutation (does not have CF) s/p pancreatectomy and splenectomy now with diabetes on insulin pump and chronic abdominal pain, recurrent SBOs iso surgical adhesions and chronic opioid use who presents as transfer from BI-N for labile blood sugars and evaluation of CT showing partial SBO given his complex surgical history. Per ED note, He initially presented to outside hospital with concern about his glycemic control in setting of diabetes but also with abdominal pain, decreased flatus, and constipation. He has had intermittent chills since yesterday but denies fever. He denies any new back pain or dysuria. He denies chest pain or shortness of breath. He also relates that he recently had a URI with a dry cough that he thinks he acquired while traveling in [MASKED] with his husband. This is resolving. He was called back to the ED after CT found a partial SBO without definite transition point. NG tube was not placed and he was felt to be better served at our facility given his complex surgical history. Briefly, he is status post gastric/duodenal/pancreatic/splenic resection for chronic pancreatitis that was thought to be due to pancreas divisum and CFTR mutation (patient has had genetic testing and reports a mutation that causes pancreas findings but no lung pathology). He last passed gas in the ambulance ride over. He has decreased appetite currently. - In the ED, initial vitals were: Pain [MASKED], T 97.2, HR 70, BP 132/78, RR 16, O2 98% RA, Gluc 149 - Exam was notable for: Con: In no acute distress, non-toxic HEENT: Normocephalic, atraumatic, Pupils equal, round and reactive to light, Extraocular muscles intact. No meningismus or neck TTP. No lymphadenopathy. Oropharynx benign. Resp: Clear to auscultation, normal work of breathing CV: Regular rate and rhythm, normal [MASKED] and [MASKED] heart sounds, 2+ distal pulses in arms and legs. Capillary refill less than 2 seconds. No clinically significant murmur. Abd: Soft, right lower quadrant tenderness to palpation, Nondistended. No masses or overlying skin changes. No organomegaly. GU: No costovertebral angle tenderness MSK: No deformity or edema. No back TTP. Skin: No rash, Warm and dry Neuro: No lateralizing signs, cranial nerves II-XII grossly intact, strength and sensation grossly intact all ext Psych: Normal mood/mentation - Labs were notable for: WBC 9.7, Hb 14.6, Plt 278, Cr 0.9, Glucose 158, lactate 1.1 - The patient was given: [MASKED] 16:57 IV HYDROmorphone (Dilaudid) .5 mg [MASKED] 18:23 IV HYDROmorphone (Dilaudid) .5 mg [MASKED] 19:35 IV HYDROmorphone (Dilaudid) 1 mg [MASKED] 20:28 IVF NS 1000 mL [MASKED] 22:24 IV HYDROmorphone (Dilaudid) 1 mg - SURGERY was consulted Surgery recommending presentation not suggestive of bowel obstruction, more likely slow transit. Recommend admission to medicine for management of labile blood sugars. will need upper GI consult and GI series with contrast follow-through as inpatient. On arrival to the floor, he confirms the above history. He reports that his abdomen is mildly more tender than usual, he thinks because he had a salad a few days ago when he normally sticks to a low fiber diet. He is still passing gas and had a large formed BM in the ED. He has no n/v. Normally when he has an SBO he reports intense pain and nausea. He has these flares once every few months. He recalls he had a small bowel follow through study a few years ago and it did show slowed motility. He normally takes his methylnaltrexone every day. He reports that he really came to the hospital because he is concerned about his sugars. Two nights ago his sugars kept dropping down to the 60-70s. Dinner the night before his admission it went up to 405, he bolused, and then dropped down to 35 two hours later. He talked to his endocrinologist Dr. [MASKED] encouraged him to come into the ED. He reports coming back from a trip to [MASKED] with his husband on [MASKED], and both have felt unwell snice then. They both felt feverish (he had a 99.5 temperature a few nights ago) and have a "chest cold" with symptoms of runny nose, feeling phlegmy, and sore throat. He has not taken any OTC meds for this. Per HPI, otherwise, 10-point review of systems was within normal limits. Past Medical History: History of recurrent pancreatitis [MASKED] CFTR mutation and pancreas divisum History of intraabdominal abscess s/p total pancreatectomy and splenectomy with islet cell transplantation in [MASKED] leading to type IIIc diabetes s/p cholecystectomy s/p appendectomy s/p partial gastrectomy with gastrojejunostomy Recurrent SBOs s/p LOA Social History: [MASKED] Family History: Maternal and Paternal Hx: Pancreatic Cancer, CFTR Mutation Mother: cancer, cholecystectomy Father: Heart Disease Sister: [MASKED] Abuse Brother: [MASKED] Abuse [MASKED] Aunt: Cancer, [MASKED] Paternal Uncle: Cancer, [MASKED] Maternal side: IBS Physical Exam: ADMISSION PHYSICAL EXAM: ======================== Vitals: T 97.2, HR 70, BP 132/78, RR 16, O2 98% RA, Gen: appears well, comfortable HEENT: no cobblestoning or exudates, no lymphadenopathy CV: RRR, normal s1/s2, no murmurs Pulm: clear to auscultation, comfortable on room air GI: soft, nontender, nondistended Ext: warm, well perfused, no edema DISCHARGE PHYSICAL EXAM: ======================== VITALS: 24 HR Data (last updated [MASKED] @ 837) Temp: 98.0 (Tm 98.3), BP: 106/66 (106-134/61-76), HR: 54 (54-69), RR: 16 ([MASKED]), O2 sat: 94% (93-96), O2 delivery: Ra General: Alert, oriented, no acute distress HEENT: NC/AT, Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Soft, non-distended. Mild TTP diffusely though improved from yesterday. No rebound tenderness or guarding. +BS. No organomegaly. Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. Insulin pump and CGM on bilateral medial thighs without erythema or swelling. Skin: No rashes or bruising Neuro: A&Ox3, moving all extremities with purpose. Pertinent Results: ADMISSION LABS: =============== [MASKED] 05:04PM BLOOD WBC-9.7 RBC-4.64 Hgb-14.6 Hct-44.1 MCV-95 MCH-31.5 MCHC-33.1 RDW-14.5 RDWSD-50.4* Plt [MASKED] [MASKED] 05:04PM BLOOD Neuts-49.5 [MASKED] Monos-12.7 Eos-6.4 Baso-1.2* Im [MASKED] AbsNeut-4.78 AbsLymp-2.89 AbsMono-1.23* AbsEos-0.62* AbsBaso-0.12* [MASKED] 05:04PM BLOOD Glucose-158* UreaN-9 Creat-0.9 Na-140 K-4.4 Cl-101 HCO3-29 AnGap-10 [MASKED] 05:04PM BLOOD Calcium-8.2* Phos-3.2 Mg-1.9 [MASKED] 05:11PM BLOOD Lactate-1.1 DISCHARGE LABS: =============== [MASKED] 06:44AM BLOOD WBC-7.3 RBC-4.82 Hgb-15.2 Hct-45.8 MCV-95 MCH-31.5 MCHC-33.2 RDW-14.4 RDWSD-50.0* Plt [MASKED] [MASKED] 06:44AM BLOOD [MASKED] PTT-27.8 [MASKED] [MASKED] 06:44AM BLOOD Glucose-133* UreaN-7 Creat-0.9 Na-141 K-4.3 Cl-103 HCO3-28 AnGap-10 [MASKED] 06:44AM BLOOD ALT-43* AST-42* AlkPhos-101 TotBili-0.5 [MASKED] 06:44AM BLOOD Calcium-8.7 Phos-2.6* Mg-1.9 MICROBIOLOGY: ============= [MASKED] 6:20 pm URINE **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: NO GROWTH Blood Culture no growth as of discharge DIAGNOSTIC STUDIES: =================== CXR [MASKED] (OSH): Lungs are clear. Heart size is normal. There is no pleural effusion. No pneumothorax is seen. No evidence of pneumonia CT Abd/Pelv w/ contrast [MASKED] (OSH): 1. Postsurgical changes of gastrojejunostomy. Since prior study there is distension of the gastrojejunostomy and proximal jejunal limb with debris. Although definite transition point is not identified, a partial obstruction of the proximal jejunal limb is difficult to exclude. This may be better evaluated with an upper GI series. 2. Stable 6 mm nonobstructing left renal calculus. Brief Hospital Course: BRIEF HOSPITAL COURSE: ====================== Mr. [MASKED] is a [MASKED] M with history of chronic pancreatitis secondary to pancreas divisum and CFTR mutation s/p pancreatectomy and splenectomy w/ islet cell transplant leading to diabetes, non insulin pump, and chronic abdominal pain, history of recurrent SBOs I/s/o surgical adhesions and chronic opioid use who presented as a transfer from [MASKED] for labile blood sugars felt to be most likely in the setting of a viral URI and evaluation of a CT scan felt to be concerning for a partial small bowel obstruction. Abdominal exam was reassuringly stable throughout admission, notable only for diffuse tenderness but without peritoneal signs. The patient passed flatus and had normal BMs throughout admission. Surgery was consulted based on imaging findings and they felt that there was no concern for obstruction and no need for a surgical intervention at this time. Blood sugars normalized to [MASKED] by the time of transfer to [MASKED]. The patient initially had poor appetite but by the time of discharge was tolerating a normal diet and felt his abdominal pain was at baseline for him. TRANSITIONAL ISSUES: ==================== [] Continue bowel regimen of senna, miralax, bisocodyl, methylnaltrexone as needed. [] Has had concern for slow transit during prior workups. [MASKED] benefit from further evaluation/treatment of possible gastroparesis. ACUTE/ACTIVE ISSUES: ==================== # Labile blood sugars # Type IIIc diabetes secondary to pancreatectomy with insulin pump Patient has history of chronic pancreatitis secondary to pancreas divisum and CFTR mutation, s/p total pancreatectomy and splenectomy with islet cell transplantation in [MASKED], followed by [MASKED]. Patient manages his diabetes with insulin pump, usually with excellent control though reports recently labile sugars at home from [MASKED] to 400s with rapid drops after bolus. This was felt to be most likely in the setting of an acute viral illness as patient returned from trip to [MASKED] and [MASKED] he and his husband developed URI symptoms. No evidence of pump malfunction on evaluation of his device. Patient managed his own pump and reassuringly had good blood sugar control in-house. He was evaluated by [MASKED] endocrinology team who felt that his diabetes management is excellent and recommended no changes. He was maintained on aspart via insulin pump (patient-administered) and home dose of 3 caps Creon with each meal. # Acute on chronic abdominal pain # Recurrent SBOs Patient presented with mild belching, abdominal cramping, and decreased flatus. There was initial concern for partial SBO per CT at [MASKED], but per surgery evaluation in ED presentation was not suggestive of bowel obstruction and more likely represents slow transit. Patient agrees that this is not consistent with his prior presentations for obstruction, and reassuringly he had normal BMs and passed flatus throughout stay at [MASKED]. Further GI imaging including UGI series w/ SBFT was deferred given that the patient was well-appearing with good bowel function on our exam. He has a long history of epigastric pain [MASKED] slow motility in the setting of adhesions after extensive surgeries, diabetes, and chronic opioid use. His pain was initially increased from baseline on admission, requiring multiple doses of IV dilaudid. By the time of discharge he was back to baseline abdominal pain with good control on home PO oxy/dilaudid regimen, with plans to decrease opiates soon with [MASKED] team. He had a poor appetite on transfer but was subsequently able to tolerate toast and soft foods, and felt comfortable eating regular low-fiber diet at time of discharge. CHRONIC/STABLE ISSUES: ====================== # Depression - Continued home Lexapro 20mg PO daily # Insomnia - continued home zolpidem .25mg PO QHS PRN Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Escitalopram Oxalate 20 mg PO DAILY 2. HYDROmorphone (Dilaudid) 4 mg PO Q4-6H PRN Pain - Severe 3. Fiasp U-100 Insulin (insulin aspart (niacinamide)) 45 units subcutaneous PRN 4. OxyCODONE SR (OxyCONTIN) 15 mg PO Q12H 5. Creon 12 3 CAP PO TID W/MEALS 6. LORazepam 0.5 mg PO DAILY:PRN nausea 7. Ondansetron ODT 4 mg PO Q8H:PRN Nausea/Vomiting - First Line 8. Methylnaltrexone 150 mg Subcut DAILY:PRN constipation 9. Pantoprazole 40 mg PO Q12H 10. Zolpidem Tartrate 2.5 mg PO QHS:PRN insomnia 11. Testosterone Cypionate 200 mg IM 1X/WEEK ([MASKED]) 12. Vitamin D [MASKED] UNIT PO EVERY OTHER DAY Discharge Medications: 1. Polyethylene Glycol 17 g PO DAILY 2. Senna 8.6 mg PO BID 3. Creon 12 3 CAP PO TID W/MEALS 4. Escitalopram Oxalate 20 mg PO DAILY 5. Fiasp U-100 Insulin (insulin aspart (niacinamide)) 45 units subcutaneous PRN 6. HYDROmorphone (Dilaudid) 4 mg PO Q4-6H PRN Pain - Severe 7. Insulin Pump SC (Self Administering Medication)Insulin Aspart (Novolog) (non-formulary) Basal rate minimum: 0 units/hr Basal rate maximum: 42 units/hr Target glucose: 80-180 MD has ordered [MASKED] consult Use of [MASKED] medical equipment: Insulin pump Reason for use: medically necessary and justified as [MASKED] cannot provide this type of equipment or suitable alternative not appropriate. Provider acknowledges patient competent 8. LORazepam 0.5 mg PO DAILY:PRN nausea 9. Methylnaltrexone 150 mg Subcut DAILY:PRN constipation 10. Ondansetron ODT 4 mg PO Q8H:PRN Nausea/Vomiting - First Line 11. OxyCODONE SR (OxyCONTIN) 15 mg PO Q12H 12. Pantoprazole 40 mg PO Q12H 13. Testosterone Cypionate 200 mg IM 1X/WEEK ([MASKED]) 14. Vitamin D [MASKED] UNIT PO EVERY OTHER DAY 15. Zolpidem Tartrate 2.5 mg PO QHS:PRN insomnia Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: Abdominal Pain Hypoglycemia Hyperglycemia Secondary Diagnoses: Insulin-dependent diabetes mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], It was a privilege taking care of you at [MASKED] [MASKED]. WHY WAS I ADMITTED TO THE HOSPITAL? =================================== - You came to the hospital because you were having very low and very high blood sugars. You were also experiencing abdominal pain. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? ========================================== - You had a CT scan of your abdomen at another hosptial which showed that you might have had a partial obstruction. Fortunately, you were able to eat and pass bowel movements, and the surgeons who evaluated you determined that you did not have a full obstruction. - Diabetes doctors saw [MASKED] and determined that your blood sugar control was back to normal. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? ============================================ - Please continue to take all your medications and follow up with your doctors at your [MASKED] appointments. We wish you all the best! Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED] | [
"E891",
"E13649",
"Z9641",
"F329",
"G4700",
"E1365",
"K660",
"R109",
"G8929",
"Z800",
"Z794",
"Z90410",
"Z141",
"Z79891"
] | [
"E891: Postprocedural hypoinsulinemia",
"E13649: Other specified diabetes mellitus with hypoglycemia without coma",
"Z9641: Presence of insulin pump (external) (internal)",
"F329: Major depressive disorder, single episode, unspecified",
"G4700: Insomnia, unspecified",
"E1365: Other specified diabetes mellitus with hyperglycemia",
"K660: Peritoneal adhesions (postprocedural) (postinfection)",
"R109: Unspecified abdominal pain",
"G8929: Other chronic pain",
"Z800: Family history of malignant neoplasm of digestive organs",
"Z794: Long term (current) use of insulin",
"Z90410: Acquired total absence of pancreas",
"Z141: Cystic fibrosis carrier",
"Z79891: Long term (current) use of opiate analgesic"
] | [
"F329",
"G4700",
"G8929",
"Z794"
] | [] |
17,216,531 | 27,016,424 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\n___ h/o stroke, PVD, HTN, HLD, DM w/ CKD p/w dry gangrene of the \nleft forefoot \n \nMajor Surgical or Invasive Procedure:\n___ left BKA\n \nHistory of Present Illness:\n___ with a history of stroke, PVD, HTN and CKD presented to \nclinic ___ for preoperative evaluation prior to her scheduled \nleft below knee amputation for dry gangrene. She was seen in the \nemergency department where the CT of the head was concerning for \npunctate hemorrhages. She was admitted to the medical service\nhowever overnight the patients mental status seemed to have \nimproved according to her daughter and healthcare proxy. The \npatient is nonverbal and nonambulatory and her daughter assesses \nher baseline.\n \nPast Medical History:\n -CVA (___) with seizure causing loss of functional \nabilities including ambulation and speech \n -DM \n -PVD \n -HTN \n-CKD\n-right upper extremity contracture (s/p stroke)\n -HLD \n -L eye stent (___?) \n -L foot debridement (x2?) ___ \n \nSocial History:\n___\nFamily History:\n unknown--adopted \n \nPhysical Exam:\nVitals stable. Nonverbal at baseline. \n \nPertinent Results:\n___ 04:26PM URINE HOURS-RANDOM\n___ 04:26PM URINE UHOLD-HOLD\n___ 04:26PM URINE COLOR-Straw APPEAR-Clear SP ___\n___ 04:26PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 \nLEUK-NEG\n___ 04:08PM LACTATE-1.4\n___ 03:20PM GLUCOSE-142* UREA N-57* CREAT-1.0 SODIUM-134 \nPOTASSIUM-4.5 CHLORIDE-91* TOTAL CO2-30 ANION GAP-18\n___ 03:20PM estGFR-Using this\n___ 03:20PM WBC-9.6 RBC-3.50* HGB-9.1* HCT-29.7* MCV-85 \nMCH-26.0 MCHC-30.6* RDW-16.3* RDWSD-48.2*\n___ 03:20PM NEUTS-67.0 ___ MONOS-8.9 EOS-2.4 \nBASOS-0.4 IM ___ AbsNeut-6.43* AbsLymp-1.97 AbsMono-0.86* \nAbsEos-0.23 AbsBaso-0.04\n___ 03:20PM PLT SMR-NORMAL PLT COUNT-161\n___ 03:20PM ___ PTT-31.3 ___\n \nBrief Hospital Course:\nThe patient was brought to the operating room on ___ and \nunderwent L BKA. The procedure was without complications. She \nwas closely monitored in the PACU and then transferred to the \nVICU in stable condition where she remained hemodynamically \nstable. Her post-op course was complicated by a drop in Hct \n28.5 --> 21.1 over 2 days and was given 1U pRBC. She continued \nto make graduate progress thereafter. She spiked a mild fever \nand was found to have a UTI, which was treated with cipro which \nshe will continue after discharge. She was discharged to rehab \non POD 6 in stable condition. Follow-up has been arranged with \nDr. ___ on ___ at 10am.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Enoxaparin Sodium 30 mg SC DAILY \nStart: ___, First Dose: Next Routine Administration Time \n2. HYDROmorphone (Dilaudid) 0.5 mg PO Q8H \n3. Ascorbic Acid ___ mg PO BID \n4. Acetaminophen (Liquid) 975 mg PO TID:PRN Pain - Mild \n5. NovoLIN R (insulin regular human) unknown sc bid \n6. HydrALAZINE 30 mg PO TID \n7. LevETIRAcetam 750 mg PO BID \n8. Ranitidine 150 mg PO BID \n9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n10. amLODIPine 10 mg PO DAILY \n11. Aspirin 325 mg PO DAILY \n12. Lisinopril 30 mg PO DAILY \n13. Ferrous Sulfate (Liquid) 325 mg PO DAILY \n14. Atenolol 100 mg PO DAILY \n15. Chlorthalidone 25 mg PO DAILY \n16. Pravastatin 80 mg PO QPM \n17. Senna 8.6 mg PO QHS \n18. Neomycin-Polymyxin-Bacitracin 1 Appl TP DAILY \n19. Levemir (insulin detemir) 32 u subcutaneous qhs \n20. Insulin SC \n Sliding Scale\nInsulin SC Sliding Scale using HUM Insulin\n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nChronic dry gangrene of the left leg.\n\n \nDischarge Condition:\nPt is at high risk for deconditioning and skin breakdown please\nencourage frequent repositioning and transferring OOB to chair\nvia lift for prevention of further delirium and PNA.\n\nMental Status: Confused - always. nonverbal\nActivity Status: Bedbound.\n\n \nDischarge Instructions:\nAMPUTATION DISCHARGE INSTRUCTIONS\n\nACTIVITY: \n On the side of your amputation you are non weight bearing for \n___ weeks. \n You should keep this amputation site elevated when ever \npossible. \n You may use the opposite foot for transfers and pivots.\n No driving until cleared by your Surgeon.\n No heavy lifting greater than 20 pounds for the next 3 weeks. \n\nBATHING/SHOWERING: \n You may shower when you get home\n No tub baths or pools / do not soak your foot for 4 weeks from \nyour date of surgery \n\nWOUND CARE:\n Sutures / Staples may have been removed before discharge. If \nthey are not, an appointment will be made for you to return for \nstaple removal. \n When the sutures are removed the doctor may or may not place \npieces of tape called steri-strips over the incision. These will \nstay on about a week and you may shower with them on. If these \ndo not fall off after 10 days, you may peel them off with warm \nwater and soap in the shower.\n\nCAUTIONS:\n If you smoke, please make every attempt to quit. Your primary \ncare physician can help with this. Smoking causes narrowing of \nyour blood vessels which in turn decreases circulation. \nDIET:\n Low fat, low cholesterol / if you are diabetic follow your \ndietary restrictions as before \nCALL THE OFFICE FOR: ___\n Bleeding, redness of, or drainage from your foot wound\n New pain, numbness or discoloration of the skin on the \neffected foot\n Fever greater than 101 degrees, chills, increased redness, or \npus draining from the incision site. \n \nFollowup Instructions:\n___\n"
] | Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: [MASKED] h/o stroke, PVD, HTN, HLD, DM w/ CKD p/w dry gangrene of the left forefoot Major Surgical or Invasive Procedure: [MASKED] left BKA History of Present Illness: [MASKED] with a history of stroke, PVD, HTN and CKD presented to clinic [MASKED] for preoperative evaluation prior to her scheduled left below knee amputation for dry gangrene. She was seen in the emergency department where the CT of the head was concerning for punctate hemorrhages. She was admitted to the medical service however overnight the patients mental status seemed to have improved according to her daughter and healthcare proxy. The patient is nonverbal and nonambulatory and her daughter assesses her baseline. Past Medical History: -CVA ([MASKED]) with seizure causing loss of functional abilities including ambulation and speech -DM -PVD -HTN -CKD -right upper extremity contracture (s/p stroke) -HLD -L eye stent ([MASKED]?) -L foot debridement (x2?) [MASKED] Social History: [MASKED] Family History: unknown--adopted Physical Exam: Vitals stable. Nonverbal at baseline. Pertinent Results: [MASKED] 04:26PM URINE HOURS-RANDOM [MASKED] 04:26PM URINE UHOLD-HOLD [MASKED] 04:26PM URINE COLOR-Straw APPEAR-Clear SP [MASKED] [MASKED] 04:26PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [MASKED] 04:08PM LACTATE-1.4 [MASKED] 03:20PM GLUCOSE-142* UREA N-57* CREAT-1.0 SODIUM-134 POTASSIUM-4.5 CHLORIDE-91* TOTAL CO2-30 ANION GAP-18 [MASKED] 03:20PM estGFR-Using this [MASKED] 03:20PM WBC-9.6 RBC-3.50* HGB-9.1* HCT-29.7* MCV-85 MCH-26.0 MCHC-30.6* RDW-16.3* RDWSD-48.2* [MASKED] 03:20PM NEUTS-67.0 [MASKED] MONOS-8.9 EOS-2.4 BASOS-0.4 IM [MASKED] AbsNeut-6.43* AbsLymp-1.97 AbsMono-0.86* AbsEos-0.23 AbsBaso-0.04 [MASKED] 03:20PM PLT SMR-NORMAL PLT COUNT-161 [MASKED] 03:20PM [MASKED] PTT-31.3 [MASKED] Brief Hospital Course: The patient was brought to the operating room on [MASKED] and underwent L BKA. The procedure was without complications. She was closely monitored in the PACU and then transferred to the VICU in stable condition where she remained hemodynamically stable. Her post-op course was complicated by a drop in Hct 28.5 --> 21.1 over 2 days and was given 1U pRBC. She continued to make graduate progress thereafter. She spiked a mild fever and was found to have a UTI, which was treated with cipro which she will continue after discharge. She was discharged to rehab on POD 6 in stable condition. Follow-up has been arranged with Dr. [MASKED] on [MASKED] at 10am. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Enoxaparin Sodium 30 mg SC DAILY Start: [MASKED], First Dose: Next Routine Administration Time 2. HYDROmorphone (Dilaudid) 0.5 mg PO Q8H 3. Ascorbic Acid [MASKED] mg PO BID 4. Acetaminophen (Liquid) 975 mg PO TID:PRN Pain - Mild 5. NovoLIN R (insulin regular human) unknown sc bid 6. HydrALAZINE 30 mg PO TID 7. LevETIRAcetam 750 mg PO BID 8. Ranitidine 150 mg PO BID 9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 10. amLODIPine 10 mg PO DAILY 11. Aspirin 325 mg PO DAILY 12. Lisinopril 30 mg PO DAILY 13. Ferrous Sulfate (Liquid) 325 mg PO DAILY 14. Atenolol 100 mg PO DAILY 15. Chlorthalidone 25 mg PO DAILY 16. Pravastatin 80 mg PO QPM 17. Senna 8.6 mg PO QHS 18. Neomycin-Polymyxin-Bacitracin 1 Appl TP DAILY 19. Levemir (insulin detemir) 32 u subcutaneous qhs 20. Insulin SC Sliding Scale Insulin SC Sliding Scale using HUM Insulin Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Chronic dry gangrene of the left leg. Discharge Condition: Pt is at high risk for deconditioning and skin breakdown please encourage frequent repositioning and transferring OOB to chair via lift for prevention of further delirium and PNA. Mental Status: Confused - always. nonverbal Activity Status: Bedbound. Discharge Instructions: AMPUTATION DISCHARGE INSTRUCTIONS ACTIVITY: On the side of your amputation you are non weight bearing for [MASKED] weeks. You should keep this amputation site elevated when ever possible. You may use the opposite foot for transfers and pivots. No driving until cleared by your Surgeon. No heavy lifting greater than 20 pounds for the next 3 weeks. BATHING/SHOWERING: You may shower when you get home No tub baths or pools / do not soak your foot for 4 weeks from your date of surgery WOUND CARE: Sutures / Staples may have been removed before discharge. If they are not, an appointment will be made for you to return for staple removal. When the sutures are removed the doctor may or may not place pieces of tape called steri-strips over the incision. These will stay on about a week and you may shower with them on. If these do not fall off after 10 days, you may peel them off with warm water and soap in the shower. CAUTIONS: If you smoke, please make every attempt to quit. Your primary care physician can help with this. Smoking causes narrowing of your blood vessels which in turn decreases circulation. DIET: Low fat, low cholesterol / if you are diabetic follow your dietary restrictions as before CALL THE OFFICE FOR: [MASKED] Bleeding, redness of, or drainage from your foot wound New pain, numbness or discoloration of the skin on the effected foot Fever greater than 101 degrees, chills, increased redness, or pus draining from the incision site. Followup Instructions: [MASKED] | [
"I70262",
"L97429",
"N179",
"N390",
"I69351",
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"G4089",
"L97219",
"Z931",
"E780",
"I129",
"Z794",
"N182",
"Z66",
"I69398",
"H409",
"L98429",
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] | [
"I70262: Atherosclerosis of native arteries of extremities with gangrene, left leg",
"L97429: Non-pressure chronic ulcer of left heel and midfoot with unspecified severity",
"N179: Acute kidney failure, unspecified",
"N390: Urinary tract infection, site not specified",
"I69351: Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side",
"E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease",
"G4089: Other seizures",
"L97219: Non-pressure chronic ulcer of right calf with unspecified severity",
"Z931: Gastrostomy status",
"E780: Pure hypercholesterolemia",
"I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease",
"Z794: Long term (current) use of insulin",
"N182: Chronic kidney disease, stage 2 (mild)",
"Z66: Do not resuscitate",
"I69398: Other sequelae of cerebral infarction",
"H409: Unspecified glaucoma",
"L98429: Non-pressure chronic ulcer of back with unspecified severity",
"Z87891: Personal history of nicotine dependence",
"Z7401: Bed confinement status",
"K5900: Constipation, unspecified"
] | [
"N179",
"N390",
"E1122",
"I129",
"Z794",
"Z66",
"Z87891",
"K5900"
] | [] |
16,780,339 | 24,298,083 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nRight flank pain/hematuria \n \nMajor Surgical or Invasive Procedure:\nRenal arteriogram with coil embolization of a right lower pole \nrenal artery pseudoaneurysm. \n\n \nHistory of Present Illness:\nMr. ___ is a ___ y/o man w/ h/o schizoaffective disorder, COPD \nnot on home O2, seizure disorder ___ TBI, and recent R PCN \nplaced ___ obstructive nephrolithiasis ___ at ___ ~1 week \nPTA), presenting as transfer from OSH with 1 day of hematuria, \nright sided flank pain, and inability to urinate. \n Per prior documentation, he was recently admitted (?___) ___ - \n___ with nephrolithiasis, treated with ureteral stent. The stent \nwas removed and replaced with PCN about 1 week ago (although \npatient thinks it may have been longer. At around midnight on \nthe night prior to presentation, he developed acute onset right \nflank pain. He then noticed spasm of his suprpubic region as \nwell as intermittent hematuria, which progressed to steady, \ndribbling of blood urine. He describes his pain as crampy and \nintermittent. He denies any fevers, chills, N/V, chest \npain/pressure, SOB, other abdominal pain, or increased ___ \nswelling. He is chronically LH/dizzy from his vertigo, but \nwithout worsening of these symptoms. He was at rehab (detailed \nbelow) at time of symptom onset and was brought to the hospital \nfor further evaluation. \n Of note, the patient has been admitted to ___ multiple times, \nincluding the admission as above for nephrolithiasis. He was \nalso admitted just before that in ___ due to concern for \nworsening ataxia/vertigo i/s/o frequent falls. He was ruled out \nfor stroke and his vertigo/ataxia was felt to be ___ chronic \ncerebellar toxicity from heavy prior ETOH use. Most recently, he \nwas admitted to ___ between ___ for URI sx consistent with \nCOPD exacerbation triggered by parainfluenza infection. He was \ntreated with azithro, prednisone, and supportive care. Given his \nfrequent falls as above, he was discharged to rehab, from where \nhe presented to the hospital. \n Regarding this admission, he initially presented to ___, \nwhere vitals on arrival were: \n -98.5, 102, 126/79, 100% on RA \n -Per report, he did not have any fevers, n/v/d, HA, neck pain, \nCP, SOB, parasthesia, weakness, or abdominal pain at that time \n -He was endorsing R flank pain with associated R CVA tenderness \non exam \n Labs at ___ notable for: \n -Chem10 with Na 132, K 3.6, Cl 101, Bicarb 24, BUN/Cr ___ \n -Lactate 3.1 initially, to 2.8 on recheck \n -CBC showing WBC 21 (57% PMNs, 19 bands), Hgb 11.2, Plts 335 \n -U/A showing ___ whites, + blood \n -Blood cultures x2 drawn, pending \n He was given Vanc 1g iV x1, levofloxacin 500mg IV x1, Morphine \n4mg IV x2. CBI was placed, and evidently 15L CBI thus far, with \ninability to turn it off ___ urinary retention. He also had CT \nshowing possible pseudoaneurysm potentially associated with \nrecent urologic manipulation and was transferred to ___ for \nfurther evaluation by vascular, urology, and ___. \n In the ___ ED, initial VS were: \n -98.0 82 125/76 19 95% RA \n \n Exam notable for: \n -comfortable NAD appears very well pleasant and conversant \n -lungs CTABL \n -no ST, R CVAT \n -abd soft, nontender, nondistended throughout \n -BLE wwp, radial and DP intact \n -RRR +S1S2 no m/r/g \n Labs showed: \n -CBC with WBC 13.1 (73.1% PMNs), Hgb 9.5, Plts 267 \n -normal coags \n -chem 10 notable for Biarb 21, BUN/Cr ___ \n -U/A with trace leuks, large blood, negative nitrites, trace \nprotein, >182 RBCs, 4 WBCs, Few bacteria \n -Ucx drawn pending \n Received: \n -4mg IV morphine x1 \n Urology, vascular, and ___ were consulted and decision was made \nto pursue angiographic intervention with ___. \n Per discussion/verbal signout with the ___ team, the patient \nunderwent successful embolization of R-pseudoaneurysm with 2 \ncoils via R femoral access. No filling was noted after coiling \ninto pseudoaneurysm. No complications from the procedure and R \ngroin access site was felt to be without visible hematoma or \nongoing bleeding. Patient was recommended to remain flat with \nknee immobilizer in place and to be continued on CBI. \n On arrival to the floor, the patient states that he feels \nbetter. He endorses the above history, adding that he did drink \ngingerale too quickly after the procedure and vomited once. \nDenies any current nausea. No further bladder spasm, R flank \npain improving. Again without other complaints. \n\n \nPast Medical History:\n-Hypertension \n-Hyperlipidemia \n-Prior h/o UGIB bleed at ___ in ___ \n-Prior aspiration PNA \n-COPD not on home O2 \n-Hypothyroidism \n-Nephrolithiasis, obstructive R-sided nephropathy treated with \nstenting and PCN placement (removed ___ \n-Migraine H/A \n-History of TBI (attacked with baseball bat, hospitalized at \n___ \n-Seizure disorder, ___ TBI \n-Schizoaffective disorder \n-Anxiety \n-History of ETOH and cocaine abuse, distant, non-active \n-Recurrent falls in setting of vertigo/ataxia \n-Reported h/o vertigo/cerebellar ataxia - possibly ___ ETOH use \nper prior neurology notes \n-Osteoporosis on alendronate \n-Macrocytic anemia (recent w/u at ___ with ?ETOH effects vs. \nMDS, normal nutritional labs) - baseline Hgb reportedly ~10 \n-GERD\n \nSocial History:\n___\nFamily History:\nPer prior notes \n-father-ETOH \n-cousin-autism \n-sister-crack cocaine\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n========================\nVITAL SIGNS: 99.2 128/75 92 20 93 Ra \nGENERAL: Well appearing, lying flat in bed, in NAD \nHEENT: NC/AT, EOMI, PERRL, MMM, tongue midline on protrusion; \nupper dentures in, no oral ulcers; fair-to-poor dentition \nNECK: symmetric, supple \nCARDIAC: RRR, normal S1, S2; ___ SEM, no r/g \nLUNGS: CTAB, no c/r/w \nABDOMEN: Soft, ND, NTTP, no r/g \nGU: three-way foley in place draining pink urine; old PCN site \nc/d/i \nEXTREMITIES: WWP, no pitting edema in b/l ___ right knee \nimmobilizer in place \nNEUROLOGIC: alert, interactive; frequently moving his feet and \nturning to look at different parts of the room during exam, but \nappropriately following directions and answering questions; \nsymmetric smile and eyebrow raise with midline tongue on \nprotrusion; strength ___ in b/l UE, moving ___ spontaneously but \nunable to fully access given need to remain flat and keep right \nknee in immobilizer; sensation to light touch grossly intact and \nsymmetric along b/l UE, torso and ___ \nSKIN: R groin with angioseal in place, c/d/I, no bruits \nappreciated; no visible hematoma \n\nDISCHARGE PHYSICAL EXAM:\n========================\nVS: T 98.3, HR 75, BP 133/72, RR 18, O2 94% RA\nGENERAL: NAD, alert, interactive \nHEENT: NC/AT, sclerae anicteric, MMM \nLUNGS: Coarse crackles in the lung bases bilaterally\nHEART: RRR, nml s1 s2, III/VI systolic ejection murmur \nABDOMEN: NABS, soft/NT/ND. \nGU: No foley\nEXTREMITIES: WWP, no peripheral edema. Dressing over R femoral \naccess site c/d/I; no visible or palpable hematoma.\nNEURO: awake, A&Ox3, moving all extremities. \n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 05:30PM BLOOD WBC-13.1*# RBC-2.61*# Hgb-9.5*# \nHct-28.9*# MCV-111*# MCH-36.4*# MCHC-32.9 RDW-24.0* RDWSD-99.2* \nPlt ___\n___ 05:30PM BLOOD Neuts-73.1* Lymphs-16.4* Monos-9.0 \nEos-0.7* Baso-0.2 NRBC-0.2* Im ___ AbsNeut-9.56* \nAbsLymp-2.15 AbsMono-1.18* AbsEos-0.09 AbsBaso-0.03\n___ 05:39PM BLOOD ___ PTT-22.7* ___\n___ 05:30PM BLOOD Glucose-106* UreaN-19 Creat-0.9 Na-138 \nK-4.1 Cl-105 HCO3-21* AnGap-16\n\nDISCHARGE LABS:\n===============\n___ 05:58AM BLOOD WBC-5.6 RBC-2.18* Hgb-7.9* Hct-24.4* \nMCV-112* MCH-36.2* MCHC-32.4 RDW-23.7* RDWSD-97.1* Plt ___\n___ 06:05AM BLOOD Glucose-91 UreaN-10 Creat-0.8 Na-136 \nK-4.1 Cl-103 HCO3-22 AnGap-15\n\nIMAGING/STUDIES:\n================\nCXR ___:\nNo comparison. Lung volumes are low. Signs of mild pulmonary \nedema present. Moderate cardiomegaly. Overinflation of the \nstomach. The patient is rotated and a moderate scoliosis causes \nasymmetry of the ribcage. No larger pleural effusions. No \npneumothorax. \n\nRENAL ARTERIOGRAM ___:\n1. Bilobed right lower pole renal artery pseudoaneurysm. \n2. No residual filling of the pseudoaneurysm after coil \nembolization. \n\nRENAL US ___:\n1. Mild to moderate right hydroureteronephrosis. \n2. Echogenic area in the right upper pole likely corresponds to \narea of \ninfarction on outside hospital CT. \n3. Partially evaluated intraluminal bladder mass, better seen on \nrecent \noutside hospital CT. \n\n \nBrief Hospital Course:\n___ with h/o schizoaffective disorder, seizure disorder ___ TBI, \nCOPD, nephrolithiasis s/p recent PCN removal admitted for \nhematuria due to renal pseudoaneurysm, now s/p angiographic \ncoiling by ___. Today, his CBI was clamped overnight and his \nFoley is draining yellow urine with no issues.\n\n#R Renal Pseudoaneurysm\n#Hematuria\nHematuria due to R renal pseudoaneurysm, most likely due to PCN \nplacement/removal. No evidence of current nephrolithiasis. Per \n___, embolization was successful w/ no residual filling into \npseudoaneurysm. Continued on CBI for several days until urine \ncleared. Pain control for bladder spasms with oxybutynin and BNO \nsuppositories. Repeat US showed mild-moderate hydronephrosis not \nmeeting criteria for PCN placement. Urology and ___ recommended \nfollow-up with outpatient urologist at ___. Voiding well without \nfoley prior to discharge, no bladder spasms.\n\n#Obstructive nephropathy/uropathy: R hydronephrosis seen on \nimaging is most likely multifactorial, including obstructing \nclot seen on CT, h/o nephrolithiasis and multiple interventions \nin the affected ureter/renal pelvis, urinary retention due to \npain/pain medications, and the pseudoaneurysm itself. No signs \nof ___, creatinine stable at 1.0 up from 0.7 on presentation to \nOSH. Repeat renal US showed ongoing hydronephrosis despite \ndecompressed bladder, suggesting some obstruction in the ureter, \nbut not meeting criteria for PCN. ___ signed off and should f/u \noutpatient at ___. Home tamsulosin increased to BID\n\n#Macrocytic Anemia: Pt has chronic macrocytic anemia. However, \nHgb downtrended from 11.2 at OSH to 7.2 ultimately at ___, \nmost likely due to hematuria. Reticulocyte count inappropriately \nnormal. Iron studies with low transferrin sat (14.7%), but high \nferritin and low TIBC, suggesting mixed iron deficiency/anemia \nof chronic disease. B12 and folate within normal limits. ___ \nneed further outpatient workup if persists. Hgb 7.9 on discharge\n\nCHRONIC ISSUES:\n===============\n#Hyperlipidemia: Continued home simvastatin and ASA\n#COPD not on home O2: Continued tiotropium, albuterol PRN \n#Hypothyroidism: Continued home levothyroxine \n#Seizure disorder, ___ TBI: Continued home trileptal and \nlamotrigine \n\n#Anxiety: \n#Schizoaffective disorder:\n - Continued home trileptal, lamotrigine, Seroquel, \namitriptyline, and SSRI \n\n#Recurrent falls in setting of vertigo/ataxia: extensively \nworked up at ___ \n - Continued home meclizine PRN \n\n#Osteoporosis: on alendronate and calcium/vitamin D \nsupplementation at home. \n#GERD: Continued home omeprazole\n\nTRANSITIONAL ISSUES:\n====================\n[] Tamsulosin increased to 0.4mg BID\n[] Renal US with mild to moderate right hydroureteronephrosis, \nnot meeting criteria for PCN. Please follow-up.\n[] Oxybutynin discontinued prior to discharge as not having \nbladder spasms. If has suprapubic pain would be concerned for \nmore bleeding and recommend urology evaluation.\n[] Hemoglobin 7.9 on discharge, iron studies with mixed iron \ndeficiency/anemia of chronic inflammation. Please monitor and \nconsider treating iron deficiency if needed.\n\n# CONTACT: ___ (Sister ___\n\n>30 minutes spent coordinating discharge to rehab\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. OXcarbazepine 600 mg PO QAM \n2. OXcarbazepine 900 mg PO QPM \n3. Tamsulosin 0.4 mg PO QHS \n4. Tiotropium Bromide 1 CAP IH DAILY \n5. Simvastatin 20 mg PO QPM \n6. QUEtiapine Fumarate 50 mg PO BID \n7. Albuterol Inhaler 1 PUFF IH Q6H:PRN shortness of breath \n8. Omeprazole 40 mg PO DAILY \n9. Levothyroxine Sodium 25 mcg PO DAILY \n10. LamoTRIgine 300 mg PO BID \n11. FLUoxetine 40 mg PO DAILY \n12. Amitriptyline 50 mg PO QHS \n13. Alendronate Sodium 70 mg PO QMON \n14. Thiamine 100 mg PO DAILY \n15. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild \n16. Aspirin 81 mg PO DAILY \n17. Meclizine 12.5 mg PO Q8H:PRN vertigo \n18. Calcium 500 + D (calcium carbonate-vitamin D3) 500 \nmg(1,250mg) -200 unit oral DAILY \n19. Vitamin D 1000 UNIT PO DAILY \n20. Docusate Sodium 100 mg PO BID \n21. magnesium hydroxide 400 mg (170 mg) oral DAILY \n22. Multivitamins 1 TAB PO DAILY \n23. Polyethylene Glycol 17 g PO DAILY \n\n \nDischarge Medications:\n1. Tamsulosin 0.4 mg PO BID \n2. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild \n3. Albuterol Inhaler 1 PUFF IH Q6H:PRN shortness of breath \n4. Alendronate Sodium 70 mg PO QMON \n5. Amitriptyline 50 mg PO QHS \n6. Aspirin 81 mg PO DAILY \n7. Calcium 500 + D (calcium carbonate-vitamin D3) 500 \nmg(1,250mg) -200 unit oral DAILY \n8. Docusate Sodium 100 mg PO BID \n9. FLUoxetine 40 mg PO DAILY \n10. LamoTRIgine 300 mg PO BID \n11. Levothyroxine Sodium 25 mcg PO DAILY \n12. magnesium hydroxide 400 mg (170 mg) oral DAILY \n13. Meclizine 12.5 mg PO Q8H:PRN vertigo \n14. Multivitamins 1 TAB PO DAILY \n15. Omeprazole 40 mg PO DAILY \n16. OXcarbazepine 600 mg PO QAM \n17. OXcarbazepine 900 mg PO QPM \n18. Polyethylene Glycol 17 g PO DAILY \n19. QUEtiapine Fumarate 50 mg PO BID \n20. Simvastatin 20 mg PO QPM \n21. Thiamine 100 mg PO DAILY \n22. Tiotropium Bromide 1 CAP IH DAILY \n23. Vitamin D 1000 UNIT PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___ \n \nDischarge Diagnosis:\nRight renal pseudoaneurysm\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nIt was a pleasure caring for you at ___ \n___!\n\nWHY WERE YOU ADMITTED?\n-You were having back pain and blood in your urine\n\nWHAT HAPPENED IN THE HOSPITAL?\n-You were found to have a bleed in your kidney from the tube you \nhad placed\n-You had a procedure to clot off the bleed\n-You had a catheter placed to irrigate your bladder until the \nbleeding stopped and your urine appeared normal\n\nWHAT SHOULD YOU DO AT HOME?\n-Please follow-up with your urologist at ___, your appointment \nis listed below\n\nThank you for allowing us be involved in your care, we wish you \nall the best!\n\nYour ___ Team\n\n \nFollowup Instructions:\n___\n"
] | Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Right flank pain/hematuria Major Surgical or Invasive Procedure: Renal arteriogram with coil embolization of a right lower pole renal artery pseudoaneurysm. History of Present Illness: Mr. [MASKED] is a [MASKED] y/o man w/ h/o schizoaffective disorder, COPD not on home O2, seizure disorder [MASKED] TBI, and recent R PCN placed [MASKED] obstructive nephrolithiasis [MASKED] at [MASKED] ~1 week PTA), presenting as transfer from OSH with 1 day of hematuria, right sided flank pain, and inability to urinate. Per prior documentation, he was recently admitted (?[MASKED]) [MASKED] - [MASKED] with nephrolithiasis, treated with ureteral stent. The stent was removed and replaced with PCN about 1 week ago (although patient thinks it may have been longer. At around midnight on the night prior to presentation, he developed acute onset right flank pain. He then noticed spasm of his suprpubic region as well as intermittent hematuria, which progressed to steady, dribbling of blood urine. He describes his pain as crampy and intermittent. He denies any fevers, chills, N/V, chest pain/pressure, SOB, other abdominal pain, or increased [MASKED] swelling. He is chronically LH/dizzy from his vertigo, but without worsening of these symptoms. He was at rehab (detailed below) at time of symptom onset and was brought to the hospital for further evaluation. Of note, the patient has been admitted to [MASKED] multiple times, including the admission as above for nephrolithiasis. He was also admitted just before that in [MASKED] due to concern for worsening ataxia/vertigo i/s/o frequent falls. He was ruled out for stroke and his vertigo/ataxia was felt to be [MASKED] chronic cerebellar toxicity from heavy prior ETOH use. Most recently, he was admitted to [MASKED] between [MASKED] for URI sx consistent with COPD exacerbation triggered by parainfluenza infection. He was treated with azithro, prednisone, and supportive care. Given his frequent falls as above, he was discharged to rehab, from where he presented to the hospital. Regarding this admission, he initially presented to [MASKED], where vitals on arrival were: -98.5, 102, 126/79, 100% on RA -Per report, he did not have any fevers, n/v/d, HA, neck pain, CP, SOB, parasthesia, weakness, or abdominal pain at that time -He was endorsing R flank pain with associated R CVA tenderness on exam Labs at [MASKED] notable for: -Chem10 with Na 132, K 3.6, Cl 101, Bicarb 24, BUN/Cr [MASKED] -Lactate 3.1 initially, to 2.8 on recheck -CBC showing WBC 21 (57% PMNs, 19 bands), Hgb 11.2, Plts 335 -U/A showing [MASKED] whites, + blood -Blood cultures x2 drawn, pending He was given Vanc 1g iV x1, levofloxacin 500mg IV x1, Morphine 4mg IV x2. CBI was placed, and evidently 15L CBI thus far, with inability to turn it off [MASKED] urinary retention. He also had CT showing possible pseudoaneurysm potentially associated with recent urologic manipulation and was transferred to [MASKED] for further evaluation by vascular, urology, and [MASKED]. In the [MASKED] ED, initial VS were: -98.0 82 125/76 19 95% RA Exam notable for: -comfortable NAD appears very well pleasant and conversant -lungs CTABL -no ST, R CVAT -abd soft, nontender, nondistended throughout -BLE wwp, radial and DP intact -RRR +S1S2 no m/r/g Labs showed: -CBC with WBC 13.1 (73.1% PMNs), Hgb 9.5, Plts 267 -normal coags -chem 10 notable for Biarb 21, BUN/Cr [MASKED] -U/A with trace leuks, large blood, negative nitrites, trace protein, >182 RBCs, 4 WBCs, Few bacteria -Ucx drawn pending Received: -4mg IV morphine x1 Urology, vascular, and [MASKED] were consulted and decision was made to pursue angiographic intervention with [MASKED]. Per discussion/verbal signout with the [MASKED] team, the patient underwent successful embolization of R-pseudoaneurysm with 2 coils via R femoral access. No filling was noted after coiling into pseudoaneurysm. No complications from the procedure and R groin access site was felt to be without visible hematoma or ongoing bleeding. Patient was recommended to remain flat with knee immobilizer in place and to be continued on CBI. On arrival to the floor, the patient states that he feels better. He endorses the above history, adding that he did drink gingerale too quickly after the procedure and vomited once. Denies any current nausea. No further bladder spasm, R flank pain improving. Again without other complaints. Past Medical History: -Hypertension -Hyperlipidemia -Prior h/o UGIB bleed at [MASKED] in [MASKED] -Prior aspiration PNA -COPD not on home O2 -Hypothyroidism -Nephrolithiasis, obstructive R-sided nephropathy treated with stenting and PCN placement (removed [MASKED] -Migraine H/A -History of TBI (attacked with baseball bat, hospitalized at [MASKED] -Seizure disorder, [MASKED] TBI -Schizoaffective disorder -Anxiety -History of ETOH and cocaine abuse, distant, non-active -Recurrent falls in setting of vertigo/ataxia -Reported h/o vertigo/cerebellar ataxia - possibly [MASKED] ETOH use per prior neurology notes -Osteoporosis on alendronate -Macrocytic anemia (recent w/u at [MASKED] with ?ETOH effects vs. MDS, normal nutritional labs) - baseline Hgb reportedly ~10 -GERD Social History: [MASKED] Family History: Per prior notes -father-ETOH -cousin-autism -sister-crack cocaine Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VITAL SIGNS: 99.2 128/75 92 20 93 Ra GENERAL: Well appearing, lying flat in bed, in NAD HEENT: NC/AT, EOMI, PERRL, MMM, tongue midline on protrusion; upper dentures in, no oral ulcers; fair-to-poor dentition NECK: symmetric, supple CARDIAC: RRR, normal S1, S2; [MASKED] SEM, no r/g LUNGS: CTAB, no c/r/w ABDOMEN: Soft, ND, NTTP, no r/g GU: three-way foley in place draining pink urine; old PCN site c/d/i EXTREMITIES: WWP, no pitting edema in b/l [MASKED] right knee immobilizer in place NEUROLOGIC: alert, interactive; frequently moving his feet and turning to look at different parts of the room during exam, but appropriately following directions and answering questions; symmetric smile and eyebrow raise with midline tongue on protrusion; strength [MASKED] in b/l UE, moving [MASKED] spontaneously but unable to fully access given need to remain flat and keep right knee in immobilizer; sensation to light touch grossly intact and symmetric along b/l UE, torso and [MASKED] SKIN: R groin with angioseal in place, c/d/I, no bruits appreciated; no visible hematoma DISCHARGE PHYSICAL EXAM: ======================== VS: T 98.3, HR 75, BP 133/72, RR 18, O2 94% RA GENERAL: NAD, alert, interactive HEENT: NC/AT, sclerae anicteric, MMM LUNGS: Coarse crackles in the lung bases bilaterally HEART: RRR, nml s1 s2, III/VI systolic ejection murmur ABDOMEN: NABS, soft/NT/ND. GU: No foley EXTREMITIES: WWP, no peripheral edema. Dressing over R femoral access site c/d/I; no visible or palpable hematoma. NEURO: awake, A&Ox3, moving all extremities. Pertinent Results: ADMISSION LABS: =============== [MASKED] 05:30PM BLOOD WBC-13.1*# RBC-2.61*# Hgb-9.5*# Hct-28.9*# MCV-111*# MCH-36.4*# MCHC-32.9 RDW-24.0* RDWSD-99.2* Plt [MASKED] [MASKED] 05:30PM BLOOD Neuts-73.1* Lymphs-16.4* Monos-9.0 Eos-0.7* Baso-0.2 NRBC-0.2* Im [MASKED] AbsNeut-9.56* AbsLymp-2.15 AbsMono-1.18* AbsEos-0.09 AbsBaso-0.03 [MASKED] 05:39PM BLOOD [MASKED] PTT-22.7* [MASKED] [MASKED] 05:30PM BLOOD Glucose-106* UreaN-19 Creat-0.9 Na-138 K-4.1 Cl-105 HCO3-21* AnGap-16 DISCHARGE LABS: =============== [MASKED] 05:58AM BLOOD WBC-5.6 RBC-2.18* Hgb-7.9* Hct-24.4* MCV-112* MCH-36.2* MCHC-32.4 RDW-23.7* RDWSD-97.1* Plt [MASKED] [MASKED] 06:05AM BLOOD Glucose-91 UreaN-10 Creat-0.8 Na-136 K-4.1 Cl-103 HCO3-22 AnGap-15 IMAGING/STUDIES: ================ CXR [MASKED]: No comparison. Lung volumes are low. Signs of mild pulmonary edema present. Moderate cardiomegaly. Overinflation of the stomach. The patient is rotated and a moderate scoliosis causes asymmetry of the ribcage. No larger pleural effusions. No pneumothorax. RENAL ARTERIOGRAM [MASKED]: 1. Bilobed right lower pole renal artery pseudoaneurysm. 2. No residual filling of the pseudoaneurysm after coil embolization. RENAL US [MASKED]: 1. Mild to moderate right hydroureteronephrosis. 2. Echogenic area in the right upper pole likely corresponds to area of infarction on outside hospital CT. 3. Partially evaluated intraluminal bladder mass, better seen on recent outside hospital CT. Brief Hospital Course: [MASKED] with h/o schizoaffective disorder, seizure disorder [MASKED] TBI, COPD, nephrolithiasis s/p recent PCN removal admitted for hematuria due to renal pseudoaneurysm, now s/p angiographic coiling by [MASKED]. Today, his CBI was clamped overnight and his Foley is draining yellow urine with no issues. #R Renal Pseudoaneurysm #Hematuria Hematuria due to R renal pseudoaneurysm, most likely due to PCN placement/removal. No evidence of current nephrolithiasis. Per [MASKED], embolization was successful w/ no residual filling into pseudoaneurysm. Continued on CBI for several days until urine cleared. Pain control for bladder spasms with oxybutynin and BNO suppositories. Repeat US showed mild-moderate hydronephrosis not meeting criteria for PCN placement. Urology and [MASKED] recommended follow-up with outpatient urologist at [MASKED]. Voiding well without foley prior to discharge, no bladder spasms. #Obstructive nephropathy/uropathy: R hydronephrosis seen on imaging is most likely multifactorial, including obstructing clot seen on CT, h/o nephrolithiasis and multiple interventions in the affected ureter/renal pelvis, urinary retention due to pain/pain medications, and the pseudoaneurysm itself. No signs of [MASKED], creatinine stable at 1.0 up from 0.7 on presentation to OSH. Repeat renal US showed ongoing hydronephrosis despite decompressed bladder, suggesting some obstruction in the ureter, but not meeting criteria for PCN. [MASKED] signed off and should f/u outpatient at [MASKED]. Home tamsulosin increased to BID #Macrocytic Anemia: Pt has chronic macrocytic anemia. However, Hgb downtrended from 11.2 at OSH to 7.2 ultimately at [MASKED], most likely due to hematuria. Reticulocyte count inappropriately normal. Iron studies with low transferrin sat (14.7%), but high ferritin and low TIBC, suggesting mixed iron deficiency/anemia of chronic disease. B12 and folate within normal limits. [MASKED] need further outpatient workup if persists. Hgb 7.9 on discharge CHRONIC ISSUES: =============== #Hyperlipidemia: Continued home simvastatin and ASA #COPD not on home O2: Continued tiotropium, albuterol PRN #Hypothyroidism: Continued home levothyroxine #Seizure disorder, [MASKED] TBI: Continued home trileptal and lamotrigine #Anxiety: #Schizoaffective disorder: - Continued home trileptal, lamotrigine, Seroquel, amitriptyline, and SSRI #Recurrent falls in setting of vertigo/ataxia: extensively worked up at [MASKED] - Continued home meclizine PRN #Osteoporosis: on alendronate and calcium/vitamin D supplementation at home. #GERD: Continued home omeprazole TRANSITIONAL ISSUES: ==================== [] Tamsulosin increased to 0.4mg BID [] Renal US with mild to moderate right hydroureteronephrosis, not meeting criteria for PCN. Please follow-up. [] Oxybutynin discontinued prior to discharge as not having bladder spasms. If has suprapubic pain would be concerned for more bleeding and recommend urology evaluation. [] Hemoglobin 7.9 on discharge, iron studies with mixed iron deficiency/anemia of chronic inflammation. Please monitor and consider treating iron deficiency if needed. # CONTACT: [MASKED] (Sister [MASKED] >30 minutes spent coordinating discharge to rehab Medications on Admission: The Preadmission Medication list is accurate and complete. 1. OXcarbazepine 600 mg PO QAM 2. OXcarbazepine 900 mg PO QPM 3. Tamsulosin 0.4 mg PO QHS 4. Tiotropium Bromide 1 CAP IH DAILY 5. Simvastatin 20 mg PO QPM 6. QUEtiapine Fumarate 50 mg PO BID 7. Albuterol Inhaler 1 PUFF IH Q6H:PRN shortness of breath 8. Omeprazole 40 mg PO DAILY 9. Levothyroxine Sodium 25 mcg PO DAILY 10. LamoTRIgine 300 mg PO BID 11. FLUoxetine 40 mg PO DAILY 12. Amitriptyline 50 mg PO QHS 13. Alendronate Sodium 70 mg PO QMON 14. Thiamine 100 mg PO DAILY 15. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild 16. Aspirin 81 mg PO DAILY 17. Meclizine 12.5 mg PO Q8H:PRN vertigo 18. Calcium 500 + D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -200 unit oral DAILY 19. Vitamin D 1000 UNIT PO DAILY 20. Docusate Sodium 100 mg PO BID 21. magnesium hydroxide 400 mg (170 mg) oral DAILY 22. Multivitamins 1 TAB PO DAILY 23. Polyethylene Glycol 17 g PO DAILY Discharge Medications: 1. Tamsulosin 0.4 mg PO BID 2. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild 3. Albuterol Inhaler 1 PUFF IH Q6H:PRN shortness of breath 4. Alendronate Sodium 70 mg PO QMON 5. Amitriptyline 50 mg PO QHS 6. Aspirin 81 mg PO DAILY 7. Calcium 500 + D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -200 unit oral DAILY 8. Docusate Sodium 100 mg PO BID 9. FLUoxetine 40 mg PO DAILY 10. LamoTRIgine 300 mg PO BID 11. Levothyroxine Sodium 25 mcg PO DAILY 12. magnesium hydroxide 400 mg (170 mg) oral DAILY 13. Meclizine 12.5 mg PO Q8H:PRN vertigo 14. Multivitamins 1 TAB PO DAILY 15. Omeprazole 40 mg PO DAILY 16. OXcarbazepine 600 mg PO QAM 17. OXcarbazepine 900 mg PO QPM 18. Polyethylene Glycol 17 g PO DAILY 19. QUEtiapine Fumarate 50 mg PO BID 20. Simvastatin 20 mg PO QPM 21. Thiamine 100 mg PO DAILY 22. Tiotropium Bromide 1 CAP IH DAILY 23. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Right renal pseudoaneurysm Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], It was a pleasure caring for you at [MASKED] [MASKED]! WHY WERE YOU ADMITTED? -You were having back pain and blood in your urine WHAT HAPPENED IN THE HOSPITAL? -You were found to have a bleed in your kidney from the tube you had placed -You had a procedure to clot off the bleed -You had a catheter placed to irrigate your bladder until the bleeding stopped and your urine appeared normal WHAT SHOULD YOU DO AT HOME? -Please follow-up with your urologist at [MASKED], your appointment is listed below Thank you for allowing us be involved in your care, we wish you all the best! Your [MASKED] Team Followup Instructions: [MASKED] | [
"I722",
"N131",
"R561",
"J449",
"D62",
"T8383XA",
"R270",
"R319",
"R338",
"N3289",
"I10",
"E785",
"E039",
"K219",
"Z87820",
"F419",
"F259",
"R296",
"M810",
"D539",
"Z87891",
"Y846",
"Y9289",
"G43909"
] | [
"I722: Aneurysm of renal artery",
"N131: Hydronephrosis with ureteral stricture, not elsewhere classified",
"R561: Post traumatic seizures",
"J449: Chronic obstructive pulmonary disease, unspecified",
"D62: Acute posthemorrhagic anemia",
"T8383XA: Hemorrhage due to genitourinary prosthetic devices, implants and grafts, initial encounter",
"R270: Ataxia, unspecified",
"R319: Hematuria, unspecified",
"R338: Other retention of urine",
"N3289: Other specified disorders of bladder",
"I10: Essential (primary) hypertension",
"E785: Hyperlipidemia, unspecified",
"E039: Hypothyroidism, unspecified",
"K219: Gastro-esophageal reflux disease without esophagitis",
"Z87820: Personal history of traumatic brain injury",
"F419: Anxiety disorder, unspecified",
"F259: Schizoaffective disorder, unspecified",
"R296: Repeated falls",
"M810: Age-related osteoporosis without current pathological fracture",
"D539: Nutritional anemia, unspecified",
"Z87891: Personal history of nicotine dependence",
"Y846: Urinary catheterization as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure",
"Y9289: Other specified places as the place of occurrence of the external cause",
"G43909: Migraine, unspecified, not intractable, without status migrainosus"
] | [
"J449",
"D62",
"I10",
"E785",
"E039",
"K219",
"F419",
"Z87891"
] | [] |
17,072,793 | 25,344,234 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nmetformin\n \nAttending: ___\n \nChief Complaint:\nDyspnea\n \nMajor Surgical or Invasive Procedure:\nLeft chest tube placement ___\n\n \nHistory of Present Illness:\nMr. ___ is a ___ year old male with history of afib on eliquis,\nHFpEF w/chronic pericardial effusions and chronic bilateral\npleural effusions, R empyema s/p R VATS and decortication\n(___) and ESRD s/p LURT in ___ recently started on \ndialysis\nwho presents from dialysis/rehab with SOB and found to have\ninterval increase in the size of his left pleural effusion on\nCXR.\n\nOver past few weeks, has had increasing shortness of breath,\nworse with laying down. Dialysis was initiated within last few\nweeks and was sent in from dialysis today due to shortness of\nbreath.\n\nHe had a recent admission ___ for dyspnea, and multiple\nadmissions for same concern over last few months. Previous\nadmissions thought to be combination of CHF exacerbation with\npossible pulmonary hypertension and a restrictive lung disease,\niso persistent pericardial effusion concerning for prior\npericarditis for which he received colchicine course. R side\npleural fluid was nonspecific transudative with an elevated BNP,\nhowever given recurrence and loculations of the effusion, he\nunderwent a R VATS\nand decortication by ___ (___) and has had minimal \nright\nsided effusion since then. During the most recent admission he\nalso had several syncopal episodes that resolved with midodrine.\nHis hospital course was also complicated by MDR klebsiella UTI,\nacute on chronic anemia requiring 1u pRBCs, and hospital \nacquired\npneumonia treated with ceftazidime. Dry weight on discharge was\n68.5 Kg with torsemide 40 mg PO on non-HD days (still makes\nurine). \n \nPast Medical History:\n1. CARDIAC RISK FACTORS \n- Diabetes \n- Hypertension \n- Dyslipidemia \n\n2. CARDIAC HISTORY \n- Coronary artery disease (s/p ___ 2 to proximal-LAD ___,\ns/p ___ 2 to mid-LAD ___.\n- HFpEF\n- Afib\n\n3. OTHER PAST MEDICAL HISTORY \nClaudication/Aorto iliac occlusive disease (ABI 0.88/0.76).\nMorbid obesity.\nObstructive sleep apnea\nC diff enterocolitis\nRenal artery stenosis\nS/p kidney transplant with CKD stage IV transplanted kidney\nKlepbsiella UTI\nProstate cancer\nHyperparathyroidism\n \nSocial History:\n___\nFamily History:\nFather: ___ \nMother: ___, ESRD on hemodialysis, CHF, stroke, HTN\nBrothers: Lung cancer, CAD, MI \nFather: ___, gout \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n========================\nVITALS: 97.7F, BP 123 / 73, HR 111, RR 18, 92% on 2L Nc\nGENERAL: Laying on right side, moaning in pain intermittently,\nappears uncomfortable\nHEENT: Moist mucus membranes, left sided tunneled HD line in\nplace \nCARDIAC: Irregular rhythm, tachycardic \nLUNGS: No increased work of breathing. Diminished breath sounds\nat the right base with crackles in the mid lung fields, left \nside\nwith crackles present and decreased breath sounds at the bases \nas\nwell \nABDOMEN: Non distended, non-tender to deep palpation in all four\nquadrants.\nEXTREMITIES: W/W/P, no ___ edema. Pulses DP/Radial 2+ \nbilaterally.\nSKIN: no rash, lesions\nNEUROLOGIC: A&Ox3, moving all 4 limbs spontaneously\n\nDISCHARGE PHYSICAL EXAM:\n========================\n___ 2342 Temp: 98.0 PO BP: 131/63 HR: 77 RR: 16 O2 sat: 92%\nO2 delivery: Ra % \nGENERAL: NAD\nHEENT: MMM, left sided tunneled HD line in place \nCARDIAC: RRR nl s1/s2\nLUNGS: CTAB\nABDOMEN: NT ND\nEXTREMITIES: W/W/P, no ___ edema. \nNEUROLOGIC: A&Ox3\n \nPertinent Results:\nAdmission Labs:\n\n___ 12:00PM BLOOD WBC-6.9 RBC-2.89* Hgb-7.9* Hct-27.1* \nMCV-94 MCH-27.3 MCHC-29.2* RDW-19.2* RDWSD-65.0* Plt ___\n___ 12:00PM BLOOD Glucose-136* UreaN-10 Creat-1.4* Na-140 \nK-5.5* Cl-98 HCO3-27 AnGap-15\n___ 12:00PM BLOOD TotProt-7.7 Albumin-3.7 Globuln-4.0 \nCalcium-9.2 Phos-2.5* Mg-1.9\n___ 12:35PM BLOOD ___ pO2-100 pCO2-37 pH-7.51* \ncalTCO2-31* Base XS-6 Comment-GREEN TOP \n\nDischarge Labs:\n\n___ 06:19AM BLOOD WBC-5.9 RBC-3.41* Hgb-9.4* Hct-30.9* \nMCV-91 MCH-27.6 MCHC-30.4* RDW-18.3* RDWSD-59.7* Plt ___\n___ 06:19AM BLOOD Glucose-193* UreaN-27* Creat-1.9* Na-135 \nK-4.8 Cl-93* HCO3-25 AnGap-17\n___ 06:19AM BLOOD Calcium-8.4 Phos-3.5 Mg-1.9\n\nStudies:\nCT Chest ___. Trace Left hydropneumothorax, left-sided pigtail drain in \nplace. \n \n2. Trace right pleural effusion. \n \n3. Small pericardial effusion. \n \n4. Probable mild interstitial edema. \n \n5. Persistent diffuse bronchovascular nodules with lower lobe \npredominance, \nsuggestive of small airways disease or other \ninfectious/inflammatory etiology. \n\nCXR ___\n \n1. Stable left apical pneumothorax. \n2. Mild pulmonary vascular congestion with stable cardiomegaly. \n3. Improved left hemidiaphragmatic contour consistent with \nimproving left base \natelectasis. Bilateral pleural effusions are unchanged. \n\n \nBrief Hospital Course:\n___ year old male with history of afib on eliquis, HFpEF \nw/chronic pericardial effusions and chronic bilateral pleural \neffusions, R empyema s/p R VATS and decortication (___) and \nESRD s/p LURT in ___ recently started on dialysis who \npresents from dialysis/rehab with SOB and found to have interval \nincrease in the size of his left pleural effusion on CXR now s/p \nchest tube placement with good drainage of left sided pleural \neffusion. He was treated with antibiotics for a 5 day course \ngiven mildly exudative fluid, but gram stain and cytology was \nnegative. The chest tube was pulled with plan for close follow \nup with interventional pulmonary team. He will also need further \ndialysis access planning as an outpatient\n\nTRANSITIONAL ISSUES\n===================\n\nRenal/Dialysis\n[ ] Continue TTS dialysis\n[ ] F/u ___ with transplant surgery for dialysis access planning \nand placement of graft/fistula\n\nIP:\n[ ] F/u ___ with interventional pulmonary for chronic effusions \n[ ] Follow up in 3 months for repeat CT scan for resolution of \nnodules found on CT imaging during prior hospitalization \n\n[] Neurology/automonics: follow up for further workup of \northostatic hypotension\n\n[ ] Dermatology: follow up for ___'s surgery for squamous cell \ncarcinoma of head\n\n[] PCP: follow up of incidentally discovered 1.9mm cystic lesion \n\nin body of pancreas with slow growth since ___, ___ year follow \nup recommended.\n\n#CODE: DNR/DNI - MOLST in chart and confirmed with patient \n#CONTACT: ___ (wife) ___ \n\nACUTE/ACTIVE ISSUES:\n====================\n# Pleural effusion\n# Hypoxic respiratory failure. Patient presented with worsening\ndyspnea and orthopnea and increased left sided effusion. CHF\npossibly contributing as proBNP elevated compared to prior.\nHowever exudative unilateral effusion with elevated WBC suggests\nalternate, possibly secondary to inflammatory or malignant\nprocess. Cultures and cytology negative. S/p 5 day course of \nvanc\nand ceftaz.\n\n# Acute on chronic HFpEF\nLast echo ___ LVEF 60-65%. Utilized HD for volume management \nwith torsemide on non-HD days. \n\n#ESRD on HD TThS\n#ESRD s/p LURT \ns/p pre-emptive LURT in ___, CKD Stage IV of allograft \n(biopsy ___, dialysis imitated last hospitalization via \ntunneled line. Continued tacrolimus per renal. Continued HD \nwhile inpatient. Needs outpatient evaluation for long term \naccess for HD. \n\nCHRONIC/STABLE ISSUES:\n======================\n#Atrial fibrillation\nH/o embolic CVA. s/p DVVC ___.\n-Continued home apixaban 2.5mg BID\n-Continued home Metoprolol Succinate XL 25 mg PO DAILY\n\n#Type II Diabetes Mellitus\n-Continued home lantus, decreased to 8 U with HISS\n\n#Gout\n-Continued home allopurinol \n\n#CAD\nS/p ___ 2 to proximal-LAD ___, s/p ___ 2 to mid-LAD \n___\n-Continued home pravastatin 40mg qhs\n-Continued home ASA 81mg\n\n#Depression \n-Continued home sertraline 100mg qPM \n\n# ADHD\n-Will continue home methylphenidate at discharge\n\n#Hyperlipidemia:\n- Continued pravastatin 40mg PO QPM\n\nGreater than 30 minutes spent providing discharge services for \nthis patient\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Aspirin 81 mg PO DAILY \n2. Calcitriol 0.25 mcg PO DAILY \n3. Pravastatin 40 mg PO QPM \n4. Sertraline 100 mg PO DAILY \n5. Tacrolimus 2.5 mg PO Q12H \n6. Tamsulosin 0.4 mg PO QHS \n7. melatonin 10 mg oral daily \n8. Apixaban 2.5 mg PO BID \n9. Allopurinol ___ mg PO DAILY \n10. Midodrine 10 mg PO TID \n11. Nephrocaps 1 CAP PO DAILY \n12. Pantoprazole 40 mg PO Q12H \n13. Metoprolol Succinate XL 25 mg PO DAILY \n14. Gabapentin 100 mg PO BID \n15. Torsemide 40 mg PO 4X/WEEK (___) \n16. Glargine 12 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin\n17. MethylPHENIDATE (Ritalin) 2.5 mg PO BID \n\n \nDischarge Medications:\n1. Glargine 8 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin \n2. Allopurinol ___ mg PO DAILY \n3. Apixaban 2.5 mg PO BID \n4. Aspirin 81 mg PO DAILY \n5. Calcitriol 0.25 mcg PO DAILY \n6. Gabapentin 100 mg PO BID \n7. melatonin 10 mg oral daily \n8. MethylPHENIDATE (Ritalin) 2.5 mg PO BID \n9. Metoprolol Succinate XL 25 mg PO DAILY \n10. Midodrine 10 mg PO TID \n11. Nephrocaps 1 CAP PO DAILY \n12. Pantoprazole 40 mg PO Q12H \n13. Pravastatin 40 mg PO QPM \n14. Sertraline 100 mg PO DAILY \n15. Tacrolimus 2.5 mg PO Q12H \n16. Tamsulosin 0.4 mg PO QHS \n17. Torsemide 40 mg PO 4X/WEEK (___) \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS:\n=================\nAcute on Chronic Pleural Effusion\n\nSECONDARY DIAGNOSES:\n=====================\nafib on Eliquis\nHFpEF \nChronic bilateral pleural effusions \nESRD s/p LURT \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Mr. ___, \n \n WHY WERE YOU ADMITTED TO THE HOSPITAL?\n - You were admitted to the hospital because you were feeling \nshort of breath.\n\n WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL? \n - You were found to have fluid around your lungs called pleural \neffusion.\n - We placed a tube in your chest to drain the fluid around your \nlungs.\n - You improved and were ready to leave the hospital. \n\n WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? \n - Please take all of your medications as prescribed and go to \nyour follow up appointments with your doctors ___ below) \n - Seek medical attention if you have new or concerning symptoms \n\n\n It was a pleasure participating in your care. We wish you the \nbest!\n \n - Your ___ Care Team \n \nFollowup Instructions:\n___\n"
] | Allergies: metformin Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Left chest tube placement [MASKED] History of Present Illness: Mr. [MASKED] is a [MASKED] year old male with history of afib on eliquis, HFpEF w/chronic pericardial effusions and chronic bilateral pleural effusions, R empyema s/p R VATS and decortication ([MASKED]) and ESRD s/p LURT in [MASKED] recently started on dialysis who presents from dialysis/rehab with SOB and found to have interval increase in the size of his left pleural effusion on CXR. Over past few weeks, has had increasing shortness of breath, worse with laying down. Dialysis was initiated within last few weeks and was sent in from dialysis today due to shortness of breath. He had a recent admission [MASKED] for dyspnea, and multiple admissions for same concern over last few months. Previous admissions thought to be combination of CHF exacerbation with possible pulmonary hypertension and a restrictive lung disease, iso persistent pericardial effusion concerning for prior pericarditis for which he received colchicine course. R side pleural fluid was nonspecific transudative with an elevated BNP, however given recurrence and loculations of the effusion, he underwent a R VATS and decortication by [MASKED] ([MASKED]) and has had minimal right sided effusion since then. During the most recent admission he also had several syncopal episodes that resolved with midodrine. His hospital course was also complicated by MDR klebsiella UTI, acute on chronic anemia requiring 1u pRBCs, and hospital acquired pneumonia treated with ceftazidime. Dry weight on discharge was 68.5 Kg with torsemide 40 mg PO on non-HD days (still makes urine). Past Medical History: 1. CARDIAC RISK FACTORS - Diabetes - Hypertension - Dyslipidemia 2. CARDIAC HISTORY - Coronary artery disease (s/p [MASKED] 2 to proximal-LAD [MASKED], s/p [MASKED] 2 to mid-LAD [MASKED]. - HFpEF - Afib 3. OTHER PAST MEDICAL HISTORY Claudication/Aorto iliac occlusive disease (ABI 0.88/0.76). Morbid obesity. Obstructive sleep apnea C diff enterocolitis Renal artery stenosis S/p kidney transplant with CKD stage IV transplanted kidney Klepbsiella UTI Prostate cancer Hyperparathyroidism Social History: [MASKED] Family History: Father: [MASKED] Mother: [MASKED], ESRD on hemodialysis, CHF, stroke, HTN Brothers: Lung cancer, CAD, MI Father: [MASKED], gout Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VITALS: 97.7F, BP 123 / 73, HR 111, RR 18, 92% on 2L Nc GENERAL: Laying on right side, moaning in pain intermittently, appears uncomfortable HEENT: Moist mucus membranes, left sided tunneled HD line in place CARDIAC: Irregular rhythm, tachycardic LUNGS: No increased work of breathing. Diminished breath sounds at the right base with crackles in the mid lung fields, left side with crackles present and decreased breath sounds at the bases as well ABDOMEN: Non distended, non-tender to deep palpation in all four quadrants. EXTREMITIES: W/W/P, no [MASKED] edema. Pulses DP/Radial 2+ bilaterally. SKIN: no rash, lesions NEUROLOGIC: A&Ox3, moving all 4 limbs spontaneously DISCHARGE PHYSICAL EXAM: ======================== [MASKED] 2342 Temp: 98.0 PO BP: 131/63 HR: 77 RR: 16 O2 sat: 92% O2 delivery: Ra % GENERAL: NAD HEENT: MMM, left sided tunneled HD line in place CARDIAC: RRR nl s1/s2 LUNGS: CTAB ABDOMEN: NT ND EXTREMITIES: W/W/P, no [MASKED] edema. NEUROLOGIC: A&Ox3 Pertinent Results: Admission Labs: [MASKED] 12:00PM BLOOD WBC-6.9 RBC-2.89* Hgb-7.9* Hct-27.1* MCV-94 MCH-27.3 MCHC-29.2* RDW-19.2* RDWSD-65.0* Plt [MASKED] [MASKED] 12:00PM BLOOD Glucose-136* UreaN-10 Creat-1.4* Na-140 K-5.5* Cl-98 HCO3-27 AnGap-15 [MASKED] 12:00PM BLOOD TotProt-7.7 Albumin-3.7 Globuln-4.0 Calcium-9.2 Phos-2.5* Mg-1.9 [MASKED] 12:35PM BLOOD [MASKED] pO2-100 pCO2-37 pH-7.51* calTCO2-31* Base XS-6 Comment-GREEN TOP Discharge Labs: [MASKED] 06:19AM BLOOD WBC-5.9 RBC-3.41* Hgb-9.4* Hct-30.9* MCV-91 MCH-27.6 MCHC-30.4* RDW-18.3* RDWSD-59.7* Plt [MASKED] [MASKED] 06:19AM BLOOD Glucose-193* UreaN-27* Creat-1.9* Na-135 K-4.8 Cl-93* HCO3-25 AnGap-17 [MASKED] 06:19AM BLOOD Calcium-8.4 Phos-3.5 Mg-1.9 Studies: CT Chest [MASKED]. Trace Left hydropneumothorax, left-sided pigtail drain in place. 2. Trace right pleural effusion. 3. Small pericardial effusion. 4. Probable mild interstitial edema. 5. Persistent diffuse bronchovascular nodules with lower lobe predominance, suggestive of small airways disease or other infectious/inflammatory etiology. CXR [MASKED] 1. Stable left apical pneumothorax. 2. Mild pulmonary vascular congestion with stable cardiomegaly. 3. Improved left hemidiaphragmatic contour consistent with improving left base atelectasis. Bilateral pleural effusions are unchanged. Brief Hospital Course: [MASKED] year old male with history of afib on eliquis, HFpEF w/chronic pericardial effusions and chronic bilateral pleural effusions, R empyema s/p R VATS and decortication ([MASKED]) and ESRD s/p LURT in [MASKED] recently started on dialysis who presents from dialysis/rehab with SOB and found to have interval increase in the size of his left pleural effusion on CXR now s/p chest tube placement with good drainage of left sided pleural effusion. He was treated with antibiotics for a 5 day course given mildly exudative fluid, but gram stain and cytology was negative. The chest tube was pulled with plan for close follow up with interventional pulmonary team. He will also need further dialysis access planning as an outpatient TRANSITIONAL ISSUES =================== Renal/Dialysis [ ] Continue TTS dialysis [ ] F/u [MASKED] with transplant surgery for dialysis access planning and placement of graft/fistula IP: [ ] F/u [MASKED] with interventional pulmonary for chronic effusions [ ] Follow up in 3 months for repeat CT scan for resolution of nodules found on CT imaging during prior hospitalization [] Neurology/automonics: follow up for further workup of orthostatic hypotension [ ] Dermatology: follow up for [MASKED]'s surgery for squamous cell carcinoma of head [] PCP: follow up of incidentally discovered 1.9mm cystic lesion in body of pancreas with slow growth since [MASKED], [MASKED] year follow up recommended. #CODE: DNR/DNI - MOLST in chart and confirmed with patient #CONTACT: [MASKED] (wife) [MASKED] ACUTE/ACTIVE ISSUES: ==================== # Pleural effusion # Hypoxic respiratory failure. Patient presented with worsening dyspnea and orthopnea and increased left sided effusion. CHF possibly contributing as proBNP elevated compared to prior. However exudative unilateral effusion with elevated WBC suggests alternate, possibly secondary to inflammatory or malignant process. Cultures and cytology negative. S/p 5 day course of vanc and ceftaz. # Acute on chronic HFpEF Last echo [MASKED] LVEF 60-65%. Utilized HD for volume management with torsemide on non-HD days. #ESRD on HD TThS #ESRD s/p LURT s/p pre-emptive LURT in [MASKED], CKD Stage IV of allograft (biopsy [MASKED], dialysis imitated last hospitalization via tunneled line. Continued tacrolimus per renal. Continued HD while inpatient. Needs outpatient evaluation for long term access for HD. CHRONIC/STABLE ISSUES: ====================== #Atrial fibrillation H/o embolic CVA. s/p DVVC [MASKED]. -Continued home apixaban 2.5mg BID -Continued home Metoprolol Succinate XL 25 mg PO DAILY #Type II Diabetes Mellitus -Continued home lantus, decreased to 8 U with HISS #Gout -Continued home allopurinol #CAD S/p [MASKED] 2 to proximal-LAD [MASKED], s/p [MASKED] 2 to mid-LAD [MASKED] -Continued home pravastatin 40mg qhs -Continued home ASA 81mg #Depression -Continued home sertraline 100mg qPM # ADHD -Will continue home methylphenidate at discharge #Hyperlipidemia: - Continued pravastatin 40mg PO QPM Greater than 30 minutes spent providing discharge services for this patient Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Calcitriol 0.25 mcg PO DAILY 3. Pravastatin 40 mg PO QPM 4. Sertraline 100 mg PO DAILY 5. Tacrolimus 2.5 mg PO Q12H 6. Tamsulosin 0.4 mg PO QHS 7. melatonin 10 mg oral daily 8. Apixaban 2.5 mg PO BID 9. Allopurinol [MASKED] mg PO DAILY 10. Midodrine 10 mg PO TID 11. Nephrocaps 1 CAP PO DAILY 12. Pantoprazole 40 mg PO Q12H 13. Metoprolol Succinate XL 25 mg PO DAILY 14. Gabapentin 100 mg PO BID 15. Torsemide 40 mg PO 4X/WEEK ([MASKED]) 16. Glargine 12 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 17. MethylPHENIDATE (Ritalin) 2.5 mg PO BID Discharge Medications: 1. Glargine 8 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 2. Allopurinol [MASKED] mg PO DAILY 3. Apixaban 2.5 mg PO BID 4. Aspirin 81 mg PO DAILY 5. Calcitriol 0.25 mcg PO DAILY 6. Gabapentin 100 mg PO BID 7. melatonin 10 mg oral daily 8. MethylPHENIDATE (Ritalin) 2.5 mg PO BID 9. Metoprolol Succinate XL 25 mg PO DAILY 10. Midodrine 10 mg PO TID 11. Nephrocaps 1 CAP PO DAILY 12. Pantoprazole 40 mg PO Q12H 13. Pravastatin 40 mg PO QPM 14. Sertraline 100 mg PO DAILY 15. Tacrolimus 2.5 mg PO Q12H 16. Tamsulosin 0.4 mg PO QHS 17. Torsemide 40 mg PO 4X/WEEK ([MASKED]) Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSIS: ================= Acute on Chronic Pleural Effusion SECONDARY DIAGNOSES: ===================== afib on Eliquis HFpEF Chronic bilateral pleural effusions ESRD s/p LURT 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. [MASKED], WHY WERE YOU ADMITTED TO THE HOSPITAL? - You were admitted to the hospital because you were feeling short of breath. WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL? - You were found to have fluid around your lungs called pleural effusion. - We placed a tube in your chest to drain the fluid around your lungs. - You improved and were ready to leave the hospital. WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? - Please take all of your medications as prescribed and go to your follow up appointments with your doctors [MASKED] below) - Seek medical attention if you have new or concerning symptoms It was a pleasure participating in your care. We wish you the best! - Your [MASKED] Care Team Followup Instructions: [MASKED] | [
"J90",
"I5033",
"N186",
"J9691",
"I132",
"Z940",
"I482",
"E1122",
"M1A9XX0",
"I2510",
"Z955",
"F329",
"F909",
"E785",
"T17990A",
"G4700",
"G4733",
"Z87891",
"Z7901",
"Z992",
"Z794",
"Z8546",
"Z801",
"Z833",
"Z823",
"Z8249"
] | [
"J90: Pleural effusion, not elsewhere classified",
"I5033: Acute on chronic diastolic (congestive) heart failure",
"N186: End stage renal disease",
"J9691: Respiratory failure, unspecified with hypoxia",
"I132: Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease",
"Z940: Kidney transplant status",
"I482: Chronic atrial fibrillation",
"E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease",
"M1A9XX0: Chronic gout, unspecified, without tophus (tophi)",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"Z955: Presence of coronary angioplasty implant and graft",
"F329: Major depressive disorder, single episode, unspecified",
"F909: Attention-deficit hyperactivity disorder, unspecified type",
"E785: Hyperlipidemia, unspecified",
"T17990A: Other foreign object in respiratory tract, part unspecified in causing asphyxiation, initial encounter",
"G4700: Insomnia, unspecified",
"G4733: Obstructive sleep apnea (adult) (pediatric)",
"Z87891: Personal history of nicotine dependence",
"Z7901: Long term (current) use of anticoagulants",
"Z992: Dependence on renal dialysis",
"Z794: Long term (current) use of insulin",
"Z8546: Personal history of malignant neoplasm of prostate",
"Z801: Family history of malignant neoplasm of trachea, bronchus and lung",
"Z833: Family history of diabetes mellitus",
"Z823: Family history of stroke",
"Z8249: Family history of ischemic heart disease and other diseases of the circulatory system"
] | [
"E1122",
"I2510",
"Z955",
"F329",
"E785",
"G4700",
"G4733",
"Z87891",
"Z7901",
"Z794"
] | [] |
12,722,192 | 27,309,240 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nClaritin-D 12 Hour / immune globulin,gamma (IgG) human\n \nAttending: ___.\n \nChief Complaint:\nfever and neck pain\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\n___ PMH of COPD, dCHF, pAFIB (apixaban), CKD, Neuropathy, MM (on\nPomalinomide/Dex/Ninlaro), presented to ED with fever and neck\npain, found to have gram positive bacteremia\n\nPatient noted that he had episode of chills while in ___ two\nweeks ago so took a zpack as per prior instructions from Dr\n___ felt that symptoms resolved the same day. He\ncompleted the zpack which ended 1 week prior to this admission.\nHe noted that 3 days ago he developed neck pain that was ___ ___nd ___ with lateral rotation. He denied any changes in \nhis\nupper/lower extremity sensation/strength. He noted that symptoms\nhave been stable since onset, but since they haven't gone away \nhe\npresented to ED for evaluation, and it was there that he was\nfound to have a fever. \n\nPatient noted that he has no oral lesions, rash, open wounds,\nsore throat, cough, sob, chest discomfort, nausea, vomiting,\nabdominal pain, diarrhea, dysuria. \n\nIn the ED, initial vitals: 99.9 78 156/62 25 94% RA. Tmax in ED\nwas 103. Pt briefly requiring 2L NC but was returned to ___ prior\nto transfer. WBC ___. Hgb 8.5, plt 133, INR 1.4, BNP 1625, AP \n39,\nLFTs otherwise wnl, Chem w/ Cr 1.4, trop 0.01, UA negative for\ninfection, flu negative. WBC 3.6 on repeat, Hgb 8.0, plt 111. \n \n\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY: \nPer OMR:\nFollowing his presentation as above, SPEP showed monoclonal IgA\nelevation. Beta-2 microglobulin was 7. He was initially treated\nwith Velcade, pamidronate, and spine radiation (T9-L1) for\nimpending spinal cord compression and back pain. He received \nfive\ncycles of Velcade from ___ \n\n___ with significant decrease in IgA level. However, he\ndeveloped neuropathy in his legs and back.\n\nHe was switched to Revlimid/Decadron, but his creatinine bumped\nto 2.1 after 10 days of treatment requiring hospitalization. \nThis\nwas attributed to Revlimid. \n\nHe was switched back to weekly Velcade with Decadron in ___, then every two weeks in ___, and weekly again in\n___ with 3 weeks on, 1 week off. \n\n-___: Underwent debridement of left leg ulcers and\ndrainage of hematoma/abscess. Velcade/dex was held.\n\n-___: Due to rapidly increasing FLCs and slight Cr bump off\ntreatment, started on a steroid pulse and Velcade/dex. Also\nstarted on atovaquone PCP ___.\n\n-___: C1 (C9 lifetime) Velcade/dex\n\n-___: C2 (C10 lifetime) Velcade/dex (D11 omitted prior to\nsurgery)\n\n-___: I&D of left leg abscess near prior surgical site. On\n___, he underwent split thickness skin graft, left\nthigh to left leg. Post-op course was uncomplicated.\n\n-___: C11 Velcade/dex with dex only on treatment days\nWe decided to start pomalidomide on ___ for ongoing FLC\nincrease. However, he developed a pruritic rash. Pomalidomide \nwas\nstopped, rash resolved, pomalidomide was restarted, and rash\nrecurred, so we decided to discontinue this entirely.\n\n-___: C12 Velcade/dex with dex only on treatment days\n-___: Restarted Zometa\n-___: C13 Velcade/dex on usual dex schedule\n-___: C14 Velcade/dex\n-___: C15 Velcade/dex with dex only on treatment days\n-___: C16 Vd with dex only on treatment days\n-___: C17 Vd with dex only on treatment days\n-___: C18 VD with dex only on treatment days\n-___: C19 VD with dex only on treatment days\nIgA and free kappa stabilized on Velcade/dex on the\nD1,4,8,11 schedule with dex only on days of treatment. \nTherefore,\nand per pt request, we tried transitioning him to a weekly\nschedule of Velcade/dex on D1,8,15 of a 28-day cycle. \n-___: C20 VD on D1,8,15\n-___: C21 VD on D1,8,15\n-___: C22 VD on D1,8,15, IgA was trending up to 410 on\n___, 431 on ___\n\n___, 482. planned to increase velcade back to twice weekly, \naccomplished this starting ___. Dapsone switched back to\npentamidine out of concern for possible hemolysis, however\nhemolysis not likely in retrospect as this change did not affect\nhis mild macrocytic anemia. \n\n___- received pentamidine without getting albuterol prior,\nhad bronchospasm, responded well to bronchodilators\n___: Again noted to have a rise in FLC and worsening lower\nextremity neuropathy. Started on Revlimid therapy 10mg daily\n___ days without rise in his creatinine. \n___: After 2 cycles Revlimid, developed mild rash.\nStopped Revlimid. Rash resolved within several days with topical\nsteroids. \n\n___: Restarted Revlimid with antihistamine. No recurrence \nof\nrash. \n \n___: New C-spine lytic lesion concerning for multiple \nmyeloma\ndid move forward with radiation therapy start followed by\ninitiation of Ninlaro plus dexamethasone.\n\n___: Sustained a RLE laceration while on vacation. \nSubsequent\ncellulitis. Delay in myeloma treatment with subsequent rise in\nIgA. \n\n___- Improvement in wound, restarted ninlaro plus Dex\n___: Progression if IGA. Continue on Ninlaro/Dex with\naddition of Pomalidomide. \n \nPAST MEDICAL HISTORY: \nAFib \nIgA kappa MM \nProstate cancer s/p brachytherapy (___)\nHypertension\nHearing loss\nEmphysema without clinical diagnosis of COPD\nChronic venous insufficiency\nHFpEF (grade 2 diastolic dysfunction, but no significant \nclinical heart failure at baseline)\nRelapsing polychondritis\nCoronary artery calcifications/disease\nColonic polyps\nCompression fractures\nRetinal nevus\nEczema\n \n\n \nSocial History:\n___\nFamily History:\nMother had hypertension, died at age of ___;\nfather had stomach cancer, died at age ___. One sister had colon\ncancer with brain cancer. She passed away at the age of ___. The\nother sister had possible lymphoma. She died at age ___.\n \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n================================ \nVitals: ___ Temp: 98.3 PO BP: 144/67 HR: 69 RR: 20 O2\nsat: 95% O2 delivery: RA \nGENERAL: sitting in chair appears comfortable NAD, calm,\npleasant, son at bedside\nEYES: EOMI, anicteric\nHEENT: OP clear, MMM no mucositis\nNECK: no tenderness to palpation along midline or lateral\naspects, no mass identified. Has visible discomfort when ranging\nneck from side to side, but is comfortable appearing looking\nstraight ahead \nLUNGS: globally decreased breath sounds but no focality, normal\nRR, no increased WOB no cough\nCV: RRR normal distal perfusion, 2+ edema to knees b/l\nABD: soft, NT, ND, normoactive BS\nGENITOURINARY:no foley or suprapubic tenderness \nEXT: warm, has biopsy site on left medial ankle, has xerosis of\nbl legs and feet, severe onychomycosis b/l, no cellulitis\nSKIN: see extremity exam\nNEURO: AOx3, fluent speech\nACCESS: PIV\n\nDISCHARGE PHYSICAL EXAM\n===============================\n24 HR Data (last updated ___ @ 718)\n Temp: 97.8 (Tm 98.2), BP: 147/73 (147-159/73-77), HR: 71 \n(66-71), RR: 18 (___), O2 sat: 93% (92-95), O2 delivery: Ra \nGEN: Well appearing, no acute distress\nHEENT: OP clear. MMM. No mucositis or thrush\nNECK: No tenderness to palpation along midline or lateral\naspects, no mass identified.\nLUNGS: Decreased breath sounds at bilateral bases but no\nadventitious LS. Normal respiratory effort.\nCV: RRR. Normal distal perfusion, ___ ankle and lower shin \nedema b/l \nABD: soft, NT/ND, normoactive BS\nGENITOURINARY: No Foley or suprapubic tenderness \nSKIN: No acute skin changes. ___ stasis dermatitis changes noted.\nLeft medial ankle wound.\nNEURO: AOx3, fluent speech.\nACCESS: PIV\n\n \nPertinent Results:\nADMISSION LABS\n=====================\n___ 01:20PM ___ PTT-31.4 ___\n___ 01:20PM PLT COUNT-133*\n___ 01:20PM NEUTS-65.0 LYMPHS-6.0* MONOS-27.9* EOS-0.0* \nBASOS-0.2 IM ___ AbsNeut-3.06 AbsLymp-0.28* AbsMono-1.31* \nAbsEos-0.00* AbsBaso-0.01\n___ 01:20PM WBC-4.7 RBC-2.51* HGB-8.5* HCT-27.3* MCV-109* \nMCH-33.9* MCHC-31.1* RDW-16.6* RDWSD-66.4*\n___ 01:20PM ALBUMIN-3.7 CALCIUM-8.9 PHOSPHATE-2.6* \nMAGNESIUM-1.9\n___ 01:20PM proBNP-1625*\n___ 01:20PM cTropnT-0.01\n___ 01:20PM ALT(SGPT)-8 AST(SGOT)-13 ALK PHOS-39* TOT \nBILI-0.8\n___ 01:20PM GLUCOSE-112* UREA N-19 CREAT-1.4* SODIUM-136 \nPOTASSIUM-4.3 CHLORIDE-98 TOTAL CO2-27 ANION GAP-11\n___ 01:34PM LACTATE-1.8\n___ 05:29PM URINE MUCOUS-RARE*\n___ 05:29PM URINE AMORPH-RARE*\n___ 05:29PM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE \nEPI-0\n___ 05:29PM URINE COLOR-Yellow APPEAR-Hazy* SP ___\n___ 05:29PM URINE UHOLD-HOLD\n___ 05:29PM URINE UHOLD-HOLD\n___ 05:29PM URINE HOURS-RANDOM\n\nIMAGING STUDIES\n========================\nCXR ___: Streaky basilar opacity best seen on the lateral \nview could be due to atelectasis, aspiration, and/or pneumonia. \n\n\nMRI C/T/L Spine ___:\n1. Diffuse bone marrow heterogeneity with stable T1-T2 hypodense\nlesion at T1 vertebral body, compatible with history of multiple\nmyeloma. \n2. Stable vertebral plana of T10 vertebral body with unchanged\nsevere bilateral neural foraminal stenosis. Moderate spinal\nstenosis at this level is slightly increased compared to the\nprior study. \n3. Stable compression deformity with anterior wedging of L1\nvertebral body. \n4. No abnormal signal within the spinal cord. \n5. Additional multilevel degenerative changes as described \nabove.\nThe degenerative changes in the cervical spine appear to have\nslightly progressed from the previous MRI examination. \n\nDISCHARGE LABS\n=====================\n___ 05:50AM BLOOD WBC: 3.9* RBC: 2.48* Hgb: 8.0* Hct: 26.8* \nMCV: 108* MCH: 32.3* MCHC: 29.9* RDW: 17.0* RDWSD: 67.6* Plt Ct: \n225 \n___ 05:50AM BLOOD Neuts: 74.1* Lymphs: 13.3* Monos: 9.2 \nEos: 1.3 Baso: 1.3* Im ___: 0.8* AbsNeut: 2.89 AbsLymp: 0.52* \nAbsMono: 0.36 AbsEos: 0.05 AbsBaso: 0.05 \n___ 05:50AM BLOOD Glucose: 80 UreaN: 20 Creat: 1.5* Na: 146 \nK: 4.7 Cl: 105 HCO3: 28 AnGap: 13 \n___ 05:50AM BLOOD ALT: 11 AST: 14 LD(LDH): 272* AlkPhos: \n39* TotBili: 0.2 \n___ 05:50AM BLOOD Calcium: 9.2 Phos: 3.9 Mg: 2.___SSESSMENT & PLAN: ___ PMH of COPD, dCHF, pAFIB (apixaban), CKD, \nNeuropathy, MM (on\nPomalinomide/Dex/Ninlaro), presented to ED with fever and neck\npain, found to have strep viridans BSI.\n\n#Fever\n#Strep Viridans BSI\nFever identified in ED, likely caused by GP blood stream \ninfection, but etiology of bacteremia unclear as no obvious \ncellulitis, mucositis, indwelling catheter etc...Has xerosis and \nonychomycosis which may have been portal of entry though no\ncellulitis. Meningitis considered, but does not fit clinical \npicture as patient essentially asymptomatic aside from minor \nneck pain which could be explained by worsening degenerative \nchanges seen on MRI. Patient briefly on O2 in ED as precaution, \nbut says his baseline O2 is 90% and has no clinical symptoms of \npneumonia. That said, his CXR identified streaky basilar \nopacity. He was initially started on cefepime/vanco and then \nnarrowed to ceftriaxone. He completed a 10 day course of \nantibiotics. \n\n#Neck Pain: As per review of past radiology notes, had same \ndifficulty with\nranging his next in ___ when he had T5-T8 and clivus radiated \nto good effect. Now with similar symptoms and MRI revealing \nworsening degenerative changes in cervical spine + stable T1 \nlesion. No tenderness to suggest muscular sprain. Oxycodone as \nneeded for pain as an inpatient. Pt declined script for home \nstating has supply already. \n\n#left medial ankle, lesion Non-healing lesion x months biopsied \n___ (as an outpatient). Contacted Dr. ___ stated \nresults benign and letter written to patient with results. Wound \ncare consult and DCed with ___. \n\n#Moderate Spinal Stenosis and severe foraminal stenosis at T10\nWorsening on MRI as compared to prior though is not having any\nlower extremity symptoms\n\n#dCHF: Patient has lower extremity edema which he notes is \nbaseline but no shortness of breath, and is currently on room \nair\n-Lasix 20mg daily, would consider increasing dose once no longer \nseptic if remains overloaded\n\n#CKD: At baseline. \n-trend daily\n-renally dose meds\n\n#AFib: Continue apixaban\n\n#Multiple Myeloma\nCurrently on an off week for his pomalyst\n-Hold pomalyst, ninlaro, dex \n-Continue ppx with acyclovir, dapsone\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acyclovir 400 mg PO Q12H \n2. amLODIPine 10 mg PO DAILY \n3. Apixaban 2.5 mg PO BID \n4. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation \ninhalation Q12H \n5. Dapsone 100 mg PO DAILY \n6. Dexamethasone 40 mg PO 1X/WEEK (MO) \n7. pomalidomide 2 mg oral ASDIR \n8. Furosemide 20 mg PO DAILY:PRN leg swelling \n9. Ninlaro (ixazomib) 4 mg oral ASDIR \n10. Metoprolol Succinate XL 25 mg PO DAILY \n11. Omeprazole 20 mg PO Q12H \n12. Vitamin D 1000 UNIT PO DAILY \n13. Cyanocobalamin 1000 mcg PO DAILY \n\n \nDischarge Medications:\n1. Acyclovir 400 mg PO Q12H \n2. amLODIPine 10 mg PO DAILY \n3. Apixaban 2.5 mg PO BID \n4. Cyanocobalamin 1000 mcg PO DAILY \n5. Dapsone 100 mg PO DAILY \n6. Furosemide 20 mg PO DAILY:PRN leg swelling \n7. Metoprolol Succinate XL 25 mg PO DAILY \n8. Omeprazole 20 mg PO Q12H \n9. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation \ninhalation Q12H \n10. Vitamin D 1000 UNIT PO DAILY \n11. HELD- Dexamethasone 40 mg PO 1X/WEEK (MO) This medication \nwas held. Do not restart Dexamethasone until instructed to \nrestart by your primary team \n12. HELD- Ninlaro (ixazomib) 4 mg oral ASDIR This medication \nwas held. Do not restart Ninlaro until instructed to restart by \nyour healthcare team\n13. HELD- pomalidomide 2 mg oral ASDIR This medication was \nheld. Do not restart pomalidomide until instructed to restart by \nyour healthcare team\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \n___ Diagnosis:\nPrimary:\nMultiple Myeloma\nStrep virdians bacteremia\nPneumonia\nHypoxia\nT1 lytic lesion\n\nSecondary:\nHTN\nEmphysema/COPD\nchronic venous insufficiency\nCHF\ncompression fractures\nCAD\natrial fibrillation\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nMr. ___,\n\nYou were admitted due to fever and found to have a bloodstream \ninfection likely due to pneumonia. You completed a course of IV \nantibiotics and now are safe for discharged home. You also had \nneck pain and found to have a new neck lesion due to your \nmultiple myeloma. You completed a course of radiation to help \nwith the pain. \n\nYou will follow up with Dr. ___ as stated below. It was a \npleasure taking care of you.\n \nFollowup Instructions:\n___\n"
] | Allergies: Claritin-D 12 Hour / immune globulin,gamma (IgG) human Chief Complaint: fever and neck pain Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] PMH of COPD, dCHF, pAFIB (apixaban), CKD, Neuropathy, MM (on Pomalinomide/Dex/Ninlaro), presented to ED with fever and neck pain, found to have gram positive bacteremia Patient noted that he had episode of chills while in [MASKED] two weeks ago so took a zpack as per prior instructions from Dr [MASKED] felt that symptoms resolved the same day. He completed the zpack which ended 1 week prior to this admission. He noted that 3 days ago he developed neck pain that was [MASKED] nd [MASKED] with lateral rotation. He denied any changes in his upper/lower extremity sensation/strength. He noted that symptoms have been stable since onset, but since they haven't gone away he presented to ED for evaluation, and it was there that he was found to have a fever. Patient noted that he has no oral lesions, rash, open wounds, sore throat, cough, sob, chest discomfort, nausea, vomiting, abdominal pain, diarrhea, dysuria. In the ED, initial vitals: 99.9 78 156/62 25 94% RA. Tmax in ED was 103. Pt briefly requiring 2L NC but was returned to [MASKED] prior to transfer. WBC [MASKED]. Hgb 8.5, plt 133, INR 1.4, BNP 1625, AP 39, LFTs otherwise wnl, Chem w/ Cr 1.4, trop 0.01, UA negative for infection, flu negative. WBC 3.6 on repeat, Hgb 8.0, plt 111. Past Medical History: PAST ONCOLOGIC HISTORY: Per OMR: Following his presentation as above, SPEP showed monoclonal IgA elevation. Beta-2 microglobulin was 7. He was initially treated with Velcade, pamidronate, and spine radiation (T9-L1) for impending spinal cord compression and back pain. He received five cycles of Velcade from [MASKED] [MASKED] with significant decrease in IgA level. However, he developed neuropathy in his legs and back. He was switched to Revlimid/Decadron, but his creatinine bumped to 2.1 after 10 days of treatment requiring hospitalization. This was attributed to Revlimid. He was switched back to weekly Velcade with Decadron in [MASKED], then every two weeks in [MASKED], and weekly again in [MASKED] with 3 weeks on, 1 week off. -[MASKED]: Underwent debridement of left leg ulcers and drainage of hematoma/abscess. Velcade/dex was held. -[MASKED]: Due to rapidly increasing FLCs and slight Cr bump off treatment, started on a steroid pulse and Velcade/dex. Also started on atovaquone PCP [MASKED]. -[MASKED]: C1 (C9 lifetime) Velcade/dex -[MASKED]: C2 (C10 lifetime) Velcade/dex (D11 omitted prior to surgery) -[MASKED]: I&D of left leg abscess near prior surgical site. On [MASKED], he underwent split thickness skin graft, left thigh to left leg. Post-op course was uncomplicated. -[MASKED]: C11 Velcade/dex with dex only on treatment days We decided to start pomalidomide on [MASKED] for ongoing FLC increase. However, he developed a pruritic rash. Pomalidomide was stopped, rash resolved, pomalidomide was restarted, and rash recurred, so we decided to discontinue this entirely. -[MASKED]: C12 Velcade/dex with dex only on treatment days -[MASKED]: Restarted Zometa -[MASKED]: C13 Velcade/dex on usual dex schedule -[MASKED]: C14 Velcade/dex -[MASKED]: C15 Velcade/dex with dex only on treatment days -[MASKED]: C16 Vd with dex only on treatment days -[MASKED]: C17 Vd with dex only on treatment days -[MASKED]: C18 VD with dex only on treatment days -[MASKED]: C19 VD with dex only on treatment days IgA and free kappa stabilized on Velcade/dex on the D1,4,8,11 schedule with dex only on days of treatment. Therefore, and per pt request, we tried transitioning him to a weekly schedule of Velcade/dex on D1,8,15 of a 28-day cycle. -[MASKED]: C20 VD on D1,8,15 -[MASKED]: C21 VD on D1,8,15 -[MASKED]: C22 VD on D1,8,15, IgA was trending up to 410 on [MASKED], 431 on [MASKED] [MASKED], 482. planned to increase velcade back to twice weekly, accomplished this starting [MASKED]. Dapsone switched back to pentamidine out of concern for possible hemolysis, however hemolysis not likely in retrospect as this change did not affect his mild macrocytic anemia. [MASKED]- received pentamidine without getting albuterol prior, had bronchospasm, responded well to bronchodilators [MASKED]: Again noted to have a rise in FLC and worsening lower extremity neuropathy. Started on Revlimid therapy 10mg daily [MASKED] days without rise in his creatinine. [MASKED]: After 2 cycles Revlimid, developed mild rash. Stopped Revlimid. Rash resolved within several days with topical steroids. [MASKED]: Restarted Revlimid with antihistamine. No recurrence of rash. [MASKED]: New C-spine lytic lesion concerning for multiple myeloma did move forward with radiation therapy start followed by initiation of Ninlaro plus dexamethasone. [MASKED]: Sustained a RLE laceration while on vacation. Subsequent cellulitis. Delay in myeloma treatment with subsequent rise in IgA. [MASKED]- Improvement in wound, restarted ninlaro plus Dex [MASKED]: Progression if IGA. Continue on Ninlaro/Dex with addition of Pomalidomide. PAST MEDICAL HISTORY: AFib IgA kappa MM Prostate cancer s/p brachytherapy ([MASKED]) Hypertension Hearing loss Emphysema without clinical diagnosis of COPD Chronic venous insufficiency HFpEF (grade 2 diastolic dysfunction, but no significant clinical heart failure at baseline) Relapsing polychondritis Coronary artery calcifications/disease Colonic polyps Compression fractures Retinal nevus Eczema Social History: [MASKED] Family History: Mother had hypertension, died at age of [MASKED]; father had stomach cancer, died at age [MASKED]. One sister had colon cancer with brain cancer. She passed away at the age of [MASKED]. The other sister had possible lymphoma. She died at age [MASKED]. Physical Exam: ADMISSION PHYSICAL EXAM ================================ Vitals: [MASKED] Temp: 98.3 PO BP: 144/67 HR: 69 RR: 20 O2 sat: 95% O2 delivery: RA GENERAL: sitting in chair appears comfortable NAD, calm, pleasant, son at bedside EYES: EOMI, anicteric HEENT: OP clear, MMM no mucositis NECK: no tenderness to palpation along midline or lateral aspects, no mass identified. Has visible discomfort when ranging neck from side to side, but is comfortable appearing looking straight ahead LUNGS: globally decreased breath sounds but no focality, normal RR, no increased WOB no cough CV: RRR normal distal perfusion, 2+ edema to knees b/l ABD: soft, NT, ND, normoactive BS GENITOURINARY:no foley or suprapubic tenderness EXT: warm, has biopsy site on left medial ankle, has xerosis of bl legs and feet, severe onychomycosis b/l, no cellulitis SKIN: see extremity exam NEURO: AOx3, fluent speech ACCESS: PIV DISCHARGE PHYSICAL EXAM =============================== 24 HR Data (last updated [MASKED] @ 718) Temp: 97.8 (Tm 98.2), BP: 147/73 (147-159/73-77), HR: 71 (66-71), RR: 18 ([MASKED]), O2 sat: 93% (92-95), O2 delivery: Ra GEN: Well appearing, no acute distress HEENT: OP clear. MMM. No mucositis or thrush NECK: No tenderness to palpation along midline or lateral aspects, no mass identified. LUNGS: Decreased breath sounds at bilateral bases but no adventitious LS. Normal respiratory effort. CV: RRR. Normal distal perfusion, [MASKED] ankle and lower shin edema b/l ABD: soft, NT/ND, normoactive BS GENITOURINARY: No Foley or suprapubic tenderness SKIN: No acute skin changes. [MASKED] stasis dermatitis changes noted. Left medial ankle wound. NEURO: AOx3, fluent speech. ACCESS: PIV Pertinent Results: ADMISSION LABS ===================== [MASKED] 01:20PM [MASKED] PTT-31.4 [MASKED] [MASKED] 01:20PM PLT COUNT-133* [MASKED] 01:20PM NEUTS-65.0 LYMPHS-6.0* MONOS-27.9* EOS-0.0* BASOS-0.2 IM [MASKED] AbsNeut-3.06 AbsLymp-0.28* AbsMono-1.31* AbsEos-0.00* AbsBaso-0.01 [MASKED] 01:20PM WBC-4.7 RBC-2.51* HGB-8.5* HCT-27.3* MCV-109* MCH-33.9* MCHC-31.1* RDW-16.6* RDWSD-66.4* [MASKED] 01:20PM ALBUMIN-3.7 CALCIUM-8.9 PHOSPHATE-2.6* MAGNESIUM-1.9 [MASKED] 01:20PM proBNP-1625* [MASKED] 01:20PM cTropnT-0.01 [MASKED] 01:20PM ALT(SGPT)-8 AST(SGOT)-13 ALK PHOS-39* TOT BILI-0.8 [MASKED] 01:20PM GLUCOSE-112* UREA N-19 CREAT-1.4* SODIUM-136 POTASSIUM-4.3 CHLORIDE-98 TOTAL CO2-27 ANION GAP-11 [MASKED] 01:34PM LACTATE-1.8 [MASKED] 05:29PM URINE MUCOUS-RARE* [MASKED] 05:29PM URINE AMORPH-RARE* [MASKED] 05:29PM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE EPI-0 [MASKED] 05:29PM URINE COLOR-Yellow APPEAR-Hazy* SP [MASKED] [MASKED] 05:29PM URINE UHOLD-HOLD [MASKED] 05:29PM URINE UHOLD-HOLD [MASKED] 05:29PM URINE HOURS-RANDOM IMAGING STUDIES ======================== CXR [MASKED]: Streaky basilar opacity best seen on the lateral view could be due to atelectasis, aspiration, and/or pneumonia. MRI C/T/L Spine [MASKED]: 1. Diffuse bone marrow heterogeneity with stable T1-T2 hypodense lesion at T1 vertebral body, compatible with history of multiple myeloma. 2. Stable vertebral plana of T10 vertebral body with unchanged severe bilateral neural foraminal stenosis. Moderate spinal stenosis at this level is slightly increased compared to the prior study. 3. Stable compression deformity with anterior wedging of L1 vertebral body. 4. No abnormal signal within the spinal cord. 5. Additional multilevel degenerative changes as described above. The degenerative changes in the cervical spine appear to have slightly progressed from the previous MRI examination. DISCHARGE LABS ===================== [MASKED] 05:50AM BLOOD WBC: 3.9* RBC: 2.48* Hgb: 8.0* Hct: 26.8* MCV: 108* MCH: 32.3* MCHC: 29.9* RDW: 17.0* RDWSD: 67.6* Plt Ct: 225 [MASKED] 05:50AM BLOOD Neuts: 74.1* Lymphs: 13.3* Monos: 9.2 Eos: 1.3 Baso: 1.3* Im [MASKED]: 0.8* AbsNeut: 2.89 AbsLymp: 0.52* AbsMono: 0.36 AbsEos: 0.05 AbsBaso: 0.05 [MASKED] 05:50AM BLOOD Glucose: 80 UreaN: 20 Creat: 1.5* Na: 146 K: 4.7 Cl: 105 HCO3: 28 AnGap: 13 [MASKED] 05:50AM BLOOD ALT: 11 AST: 14 LD(LDH): 272* AlkPhos: 39* TotBili: 0.2 [MASKED] 05:50AM BLOOD Calcium: 9.2 Phos: 3.9 Mg: 2. SSESSMENT & PLAN: [MASKED] PMH of COPD, dCHF, pAFIB (apixaban), CKD, Neuropathy, MM (on Pomalinomide/Dex/Ninlaro), presented to ED with fever and neck pain, found to have strep viridans BSI. #Fever #Strep Viridans BSI Fever identified in ED, likely caused by GP blood stream infection, but etiology of bacteremia unclear as no obvious cellulitis, mucositis, indwelling catheter etc...Has xerosis and onychomycosis which may have been portal of entry though no cellulitis. Meningitis considered, but does not fit clinical picture as patient essentially asymptomatic aside from minor neck pain which could be explained by worsening degenerative changes seen on MRI. Patient briefly on O2 in ED as precaution, but says his baseline O2 is 90% and has no clinical symptoms of pneumonia. That said, his CXR identified streaky basilar opacity. He was initially started on cefepime/vanco and then narrowed to ceftriaxone. He completed a 10 day course of antibiotics. #Neck Pain: As per review of past radiology notes, had same difficulty with ranging his next in [MASKED] when he had T5-T8 and clivus radiated to good effect. Now with similar symptoms and MRI revealing worsening degenerative changes in cervical spine + stable T1 lesion. No tenderness to suggest muscular sprain. Oxycodone as needed for pain as an inpatient. Pt declined script for home stating has supply already. #left medial ankle, lesion Non-healing lesion x months biopsied [MASKED] (as an outpatient). Contacted Dr. [MASKED] stated results benign and letter written to patient with results. Wound care consult and DCed with [MASKED]. #Moderate Spinal Stenosis and severe foraminal stenosis at T10 Worsening on MRI as compared to prior though is not having any lower extremity symptoms #dCHF: Patient has lower extremity edema which he notes is baseline but no shortness of breath, and is currently on room air -Lasix 20mg daily, would consider increasing dose once no longer septic if remains overloaded #CKD: At baseline. -trend daily -renally dose meds #AFib: Continue apixaban #Multiple Myeloma Currently on an off week for his pomalyst -Hold pomalyst, ninlaro, dex -Continue ppx with acyclovir, dapsone Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q12H 2. amLODIPine 10 mg PO DAILY 3. Apixaban 2.5 mg PO BID 4. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation inhalation Q12H 5. Dapsone 100 mg PO DAILY 6. Dexamethasone 40 mg PO 1X/WEEK (MO) 7. pomalidomide 2 mg oral ASDIR 8. Furosemide 20 mg PO DAILY:PRN leg swelling 9. Ninlaro (ixazomib) 4 mg oral ASDIR 10. Metoprolol Succinate XL 25 mg PO DAILY 11. Omeprazole 20 mg PO Q12H 12. Vitamin D 1000 UNIT PO DAILY 13. Cyanocobalamin 1000 mcg PO DAILY Discharge Medications: 1. Acyclovir 400 mg PO Q12H 2. amLODIPine 10 mg PO DAILY 3. Apixaban 2.5 mg PO BID 4. Cyanocobalamin 1000 mcg PO DAILY 5. Dapsone 100 mg PO DAILY 6. Furosemide 20 mg PO DAILY:PRN leg swelling 7. Metoprolol Succinate XL 25 mg PO DAILY 8. Omeprazole 20 mg PO Q12H 9. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation inhalation Q12H 10. Vitamin D 1000 UNIT PO DAILY 11. HELD- Dexamethasone 40 mg PO 1X/WEEK (MO) This medication was held. Do not restart Dexamethasone until instructed to restart by your primary team 12. HELD- Ninlaro (ixazomib) 4 mg oral ASDIR This medication was held. Do not restart Ninlaro until instructed to restart by your healthcare team 13. HELD- pomalidomide 2 mg oral ASDIR This medication was held. Do not restart pomalidomide until instructed to restart by your healthcare team Discharge Disposition: Home With Service Facility: [MASKED] [MASKED] Diagnosis: Primary: Multiple Myeloma Strep virdians bacteremia Pneumonia Hypoxia T1 lytic lesion Secondary: HTN Emphysema/COPD chronic venous insufficiency CHF compression fractures CAD atrial fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [MASKED], You were admitted due to fever and found to have a bloodstream infection likely due to pneumonia. You completed a course of IV antibiotics and now are safe for discharged home. You also had neck pain and found to have a new neck lesion due to your multiple myeloma. You completed a course of radiation to help with the pain. You will follow up with Dr. [MASKED] as stated below. It was a pleasure taking care of you. Followup Instructions: [MASKED] | [
"A408",
"J189",
"M4854XA",
"C9000",
"I5032",
"I130",
"R0902",
"J439",
"I480",
"Z7901",
"I2510",
"Z87891",
"I872",
"L309",
"M4804",
"Z9221",
"B351",
"L853",
"S91002A",
"X58XXXA",
"M941",
"Z8546",
"N183"
] | [
"A408: Other streptococcal sepsis",
"J189: Pneumonia, unspecified organism",
"M4854XA: Collapsed vertebra, not elsewhere classified, thoracic region, initial encounter for fracture",
"C9000: Multiple myeloma not having achieved remission",
"I5032: Chronic diastolic (congestive) heart failure",
"I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease",
"R0902: Hypoxemia",
"J439: Emphysema, unspecified",
"I480: Paroxysmal atrial fibrillation",
"Z7901: Long term (current) use of anticoagulants",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"Z87891: Personal history of nicotine dependence",
"I872: Venous insufficiency (chronic) (peripheral)",
"L309: Dermatitis, unspecified",
"M4804: Spinal stenosis, thoracic region",
"Z9221: Personal history of antineoplastic chemotherapy",
"B351: Tinea unguium",
"L853: Xerosis cutis",
"S91002A: Unspecified open wound, left ankle, initial encounter",
"X58XXXA: Exposure to other specified factors, initial encounter",
"M941: Relapsing polychondritis",
"Z8546: Personal history of malignant neoplasm of prostate",
"N183: Chronic kidney disease, stage 3 (moderate)"
] | [
"I5032",
"I130",
"I480",
"Z7901",
"I2510",
"Z87891"
] | [] |
10,773,055 | 23,623,758 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nVicodin / Vasotec / Morphine / Codeine\n \nAttending: ___.\n \nChief Complaint:\nShortness of Breath \n \nMajor Surgical or Invasive Procedure:\n___ ERCP \n\n \nHistory of Present Illness:\n___ with systolic (EF 45-50%) heart failure, atrial fibrillation \non flecainide and no a/c (GI bleeds), sick sinus syndrome status \npost PPM c/b lead mass, cholecystectomy c/b recurrent infections \n___ \"sump syndrome\", cholangitis and ESRD secondary to PCKD s/p \nLRRT (___) who presents with shortness of breath, edema, and \njaundice.\n\nNotably, the patient was recently admitted to ___ from \n___ for unexplained hyperbilirubinemia and \njaundice. She remained clinically stable without evidence of \ninfection, and underwent uncomplicated diagnostic/therapeutic \nERCP with placement of a stent. She tolerated the procedure \nwell, but bilirubin remained elevated. The pathology results of \nbrushings taken during ERCP were negative for malignancy. Given \nthat MRCP was not possible given incompatible pacemaker lead, no \nfurther interventions were taken. The patient's dyspnea was \nattributed to a subacute exacerbation of her known diastolic \nheart failure, leading to pulmonary effusions and lower \nextremity edema. ECHO showed evidence of pacemaker RA mass \nconcerning for vegetation (unlikely given afebrile, neg BCx) vs \nthrombus (not on AC except aspirin). Patient decided that ___ is \nnot within her goals of care, and has declined further \nevaluation of the pacemaker lead mass after a thoughtful \ndiscussion of all options with MDs. \n\nOf note, family and rehab are concerned she is not getting the \nright level of care. She notes worsening ___ edema over the last \ntwo weeks and SOB yesterday with a new oxygen requirement. She \ndenies any PND. she also denies any palpitations. She denies any \nfevers, chills, cough, chest pain, abdominal pain, N/V/D, \ndysuria. She is not able to say whether her jaundice is worse. \n\nIn the ED, initial VS were: (___) temperature 97.6, heart rate \n52, blood pressure 109/71, respiratory rate 18, 95% on 2 L. On \ntransfer, vitals were temperature 90.9, heart rate 95, blood \npressure 100/52, respiratory 20, 100% on room air\n \nEKG: Atrial fibrillation with a ventricular rate of 120 bpm, \nintraventricular conduction delay with associated nonspecific \nST/T-wave changes.\n\nLabs showed: Creatinine 0.8, AST 38, ALT 23, total bilirubin \n9.7, white blood cell count 5.5, he will be 30.6, platelet count \n187, lactate 1.8 Troponin 0.02 and second set was less than \nassay\n\nImaging showed: Chest x-ray showed moderate right and small left \npleural effusions that are likely unchanged from prior CT scan\n \nConsults: Cardiology and hepatology were both consulted who \nrecommended diuresis and admission to heart failure team\n\nPatient received: Home medications and electrolyte repletion\n \nOn arrival to the floor, patient recounts above history. She is \ninterested in having her shortness of breath and leg swelling \nfixed.\n\n \nPast Medical History:\n***___'s Disease, new diagnosis (related to \nhyperbilirubinemia and abnormal biliary anatomy). \n1. Polycystic kidney disease - daughter also has this. \n2. ESRD ___ PCKD s/p living donor in ___ \n3. Diverticulosis with sigmoid colectomy prior to renal \ntransplant, then one episode of diverticulitis just after renal \ntransplant. \n4. Paroxysmal atrial fibrillation - on rate control, states that \nshe converts to afib when dig stopped \n5. Dyslipidemia\n6. Hypertension\n7. Migraines \n8. h/o upper gastrointestinal bleed with gastritis \n9. h/o recurrent Escherichia coli bacteremia prior to \ncholecystectomy in ___. \n10. Infected right index finger in ___. \"stump\" syndrome resulting in polymicrobial bacteremia, incl \n\nE.coli, E. faecium, and B.frag ****** PLEASE NOT. THOUGHT NOT TO \nHAVE SUMP SYNDROME AS GI ANATOMY NOT ALIGNED WITH THIS \nDIAGNOSIS.\n12. Recurrent skin cancers, which are closely followed by Dr. \n___\n13. Gout - affected her right great toe\n14. Chronic venous stasis - complains of chronic left lower \nextremity edema. \n15. Renal osteodystrophy\n \nSocial History:\n___\nFamily History:\nMother died of liver cancer. \n___ daughters has PKD (not needing HD, not on transplant).\nPt's kidney donor was her sister.\n \nPhysical Exam:\n=======================\nADMISSION PHYSICAL EXAM\n=======================\nVS: Temperature 97.4, blood pressure 96/60, heart rate 105 \n(irregular), respiratory rate 18, 97% on 2 L\nGENERAL: NAD \nHEENT: Sclera and sublinguals space icteric\nNECK: supple, no LAD, JVP at 14 cm at 45°\nHEART: Irregularly irregular with soft 2 out of 6 systolic \nmurmur\nLUNGS: Poor air movement with crackles up to the midlung fields\nbilaterally\nABDOMEN: nondistended, nontender in all quadrants, no \nrebound/guarding \nEXTREMITIES: Cool distal lower extremities with extensive venous \nstasis changes and ulceration, particularly on the left shin. \n3+ pitting edema up to the knees bilaterally\nPULSES: Difficult to palpate\nNEURO: A&Ox3, moving all 4 extremities with purpose \n\n=======================\nDISCHARGE PHYSICAL EXAM\n=======================\n24 HR Data (last updated ___ @ 337)\nTemp: 97.5 (Tm 97.8), \nBP: 106/51 (64-108/39-68), \nHR: 108 (63-108), \nRR: 18, \nO2 sat: 96% (96-98), O2 delivery: RA \n\nHEENT: Sclera and sublinguals space icteric\nNECK: Supple, no LAD, JVP to mid neck at 60 degrees\nHEART: Irregularly irregular with soft 2 out of 6 systolic \nmurmur\nLUNGS: Poor air movements, clear to auscultation \nABDOMEN: Nondistended, nontender in all quadrants, no\nrebound/guarding \nEXTREMITIES: 1+ pitting edema at the knees, continues to improve\non a daily basis. Shins wrapped in ace bandages. Warm and\nwell-perfused.\nNEURO: A&Ox3, moving all 4 extremities with purpose \n \nPertinent Results:\n============================\nADMISSION LABORATORY RESULTS\n============================\n___ 07:59PM GLUCOSE-83 UREA N-21* CREAT-0.7 SODIUM-132* \nPOTASSIUM-5.2* CHLORIDE-95* TOTAL CO2-21* ANION GAP-16\n___ 05:48PM WBC-6.1 RBC-4.38 HGB-14.3 HCT-42.3 MCV-97 \nMCH-32.6* MCHC-33.8 RDW-20.4* RDWSD-71.9*\n___ 07:59PM ___\n___ 07:59PM CALCIUM-7.5* PHOSPHATE-2.7 MAGNESIUM-1.8\n___ 07:59PM ALT(SGPT)-26 AST(SGOT)-47* ALK PHOS-287* TOT \nBILI-11.7*\n___ 05:48PM cTropnT-0.02*\n___ 03:45AM cTropnT-<0.01\n___ 03:45AM TSH-5.8*\n___ 04:04AM LACTATE-1.8\n\n==========================================\nDISCHARGE AND PERTINENT LABORATORY RESULTS\n==========================================\n___ 08:00AM BLOOD WBC-8.8# RBC-4.08 Hgb-13.2 Hct-39.7 \nMCV-97 MCH-32.4* MCHC-33.2 RDW-20.5* RDWSD-72.7* Plt ___\n___ 08:00AM BLOOD ___ PTT-34.7 ___\n___ 08:00AM BLOOD Plt ___\n___ 08:00AM BLOOD Glucose-69* UreaN-21* Creat-0.9 Na-139 \nK-3.3 Cl-88* HCO3-35* AnGap-16\n___ 08:00AM BLOOD ALT-26 AST-48* LD(LDH)-324* AlkPhos-256* \nTotBili-12.1*\n___ 08:00AM BLOOD Calcium-8.1* Phos-3.5 Mg-1.8\n\n============\nMICROBIOLOGY\n============\n___ C diff negative\n___ Urine culture negative\n\n===============\nIMAGING REPORTS\n===============\n---------------\n___ ERCP \n---------------\nImpression: The scout film was normal. \nThe major papilla was seen on the lateral rim of a large \n___ diverticulum. \nEvidence of a previous sphincterotomy was noted at the major \npapilla. \nThe bile duct was successfully cannulated using balloon \ncatheter. \nContrast was injected and there was brisk flow through the \nducts. \nContrast extended to the entire biliary tree. \nContrast injection revealed a dilated CBD and CHD up to 15 mm. \nAt the bifurcation, marked caliber change was noted. \nThe intrahepatic ducts were tortuous, irregular with multiple \nfilling defects consistent with patient's underlying disease of \npolycystic liver disease, although ___' disease or \nintrahepatic stones could not be ruled out. \nNo dominant stricture was seen. \nPlan for MRCP to evaluate the intrahepatics. \nPrevious migrated stent was removed with a rat tooth and no new \nstent was placed.\nOtherwise normal ercp to third part of the duodenum\n \n\nRecommendations: Clear fluids when awake then advance diet as \ntolerated.\nFollow-up with Dr. ___ as previously scheduled.\nFollow for response and complications. If any abdominal pain, \nfever, jaundice, gastrointestinal bleeding please call Advanced \nEndoscopy Fellow on call ___\nContinue with antibiotics - to complete at least 5 days\nIf any abdominal pain, fever, jaundice, gastrointestinal \nbleeding please call Advanced Endoscopy Fellow on call \n___\nMRCP to evaluate the intrahepatics \n\n___ Pacemaker Interrogation\nAS - VS 18.5%\nAS - VP 5.1%\nAP - VS 73.2%\nAP - VP 3.2%\nMVP On\n\n \n___ RUQ Ultrasound\nIMPRESSION: \nLeft hepatic vein waveform is biphasic is nonspecific and could \nbe seen in the setting of advanced cardiac disease. Previously \nseen thrombus in the left portal vein not visualized on the \ncurrent study. \nMildly prominent pancreatic duct as seen on prior CT. \nSmall right pleural effusion. 2.8 cm echogenic lesion in the \nright hepatic lobe not definitively seen on prior CT from ___. Differential considerations include hemangioma. \n\n-----------\n___ CXR\n-----------\nFINDINGS: \nThere is a moderate right pleural effusion which is seen within \nthe fissure with likely adjacent right middle and lower lobe \nlobe atelectasis. Small left pleural effusion is again noted \nwith adjacent atelectasis. Given differences in technique and \npositioning, these are likely unchanged since prior CT scan. \nSuperiorly, lungs are clear. There is no edema. Cardiac \nsilhouette is likely unchanged but difficult to assess. Left \nchest wall dual lead pacing device is again noted. No acute \nosseous abnormalities. \n \nIMPRESSION: \nModerate right and small left pleural effusions, likely \nunchanged from prior CT scan. \n \nBrief Hospital Course:\n___ with systolic heart failure (EF 45-50%), atrial fibrillation \non flecainide and no a/c (GI bleeds), PPM c/b lead mass, \ncholecystectomy c/b recurrent infections ___ \"sump syndrome\", \ncholangitis and ESRD secondary to PCKD s/p LRRT (___) who \npresents with shortness of breath, edema, and jaundice.\n\n#Acute on chronic heart failure exacerbation\nPatient presented at this admission with worsening fluid \noverload. Cause is unclear but may be due to worsening tricuspid \nregurgitation from pacemaker mass, ongoing atrial fibrillation, \nor liver failure; however more likely due to patient report and \nfamily report that her diuretic regimen had not been properly \ntitrated at her outpatient rehab. She was discharged on Lasix \n20mg PO daily. Volume status improved with IV diuresis, and \ntransitioned to an oral diuretic regimen which she was very \nresponsive to. She was discharged on torsemide 20mg daily with \nplan to take torsemide 10mg if her weight is found to be \ndropping by <3 lbs in one day or if she should become more \nhypotensive. Her home Lasix 20mg was discontinued. We also began \nwrapping her legs in ace wraps in order to mobilize her \nextravascular fluid, which she was responsive to. \n\nDischarge Weight = 76.7 kg (169.09 lb)\n\n# Hyperbilirubinemia\nMs. ___ has had recently multiple hospitalizations for \ncholangitis thought to be secondary to \"sump syndrome,\" however \nwe believe this to be an erroneous diagnosis as she does not \nhave GI anatomy compatible with sump syndrome. Last month, she \nunderwent a CT Abd w/ contrast which showed increased intra and \nextrahepatic biliary ductal dilatation. She underwent ERCP with \nplacement of a stent at her last hospitalization. Patient \nremained afebrile, but bilirubin remained elevated. Hepatology \nwas consulted during this admission for follow up of this issue; \npreviousl autoimmune workup was completed, which was negative. \nUltimately, it was felt that her symptoms were due to ___'s \ndisease. She does not require further diagnostics at this time, \nand can continue taking ursodiol. Her jaundice is not evidence \nof worsening disease. Hepatology consult team recommended \nfurther outpatient management and monitoring for any signs or \nsymptoms of abdominal pain or fevers.\n\n#Sick sinus syndrome status post pacer (___) complicated \nby mass\nThe patient is ventricularly pacing 8% of the time. On previous \nadmissions, has refused anticoagulation. Confirmed this with her \nagain on ___ and she again declines anticoagulation given her \nconcern for bleeding risk. \n\n# H/o ESRD secondary to PCKD s/p LRRT (___)\nFollowed by renal transplant during hospitalization. No concern \nfor graft function. Continued on prednisone 5mg and azathioprine \n50mg. She follows with Dermatology regularly given her history \nof skin cancers. Sirolimus therapy has been tried in the past; \nhowever, it was stopped due to pneumonitis. Her renal function \nremained at baseline without evidence of kidney injury during \nher hospital course.\n\n#Atrial Fibrillation\nPer device interrogation, the patient has been a persistent \natrial fibrillation for the last 2 months. Notably, she is not \nanticoagulation due to history of significant GI bleed in the \ndistant past. The patient is unwilling to trial any \nanticoagulation regimen. Cardioversion was not offered due to \nthe fact that patient declined TEE and anticoagulation. \nContinued on home metoprolol 25mg BID. She had been on \nflecanide, but this was discontinued as she was still in atrial \nfibrillation, with adequate rate control (80-110s and \nasymptomatic) and has structural heart disease which is a \ncontraindication to flecanide; this was discussed with her \noutpatient cardiologist Dr. ___. Patient continues on \naspirin. \n\n#Hypotension\nPatient had a few brief episodes of hypotension to 70-80s \nsystolic while an inpatient. These were isolated episodes \nthought to be related to hypovolemia and overdiuresis; her BPs \nimproved to baseline 90-110s with small amount of fluid \nresuscitation and improved PO intake; she was asymptomatic \nduring these episodes.\n====================\nTRANSITIONAL ISSUES:\n====================\n- New Meds: Torsemide 20mg daily (take 10mg daily if losing \nweight)\n- Stopped/Held Meds: Flecanide, Furosemide (Lasix), \nCiprofloxacin \n- Changed Meds: None\n\n- Post-Discharge Follow-up Labs Needed: \nPlease check Chem 10 , CBC, (Na, K, Cl, HCO3, BUN, Cr, Mag, Ca, \nPhos) on ___ to monitor electrolytes and renal function\n\n- Incidental Findings: None\n- Discharge weight: 76.7 kg (169.09 lb)\n\n[ ] Now carries diagnosis of Caroli's Disease (not Caroli's \nsyndrome). She is believed NOT to have sump syndrome. If patient \nexperiences fevers in the future, she should present to an \nemergency department (previously had an antibiotic \n(Ciprofloxacin) she would take at home to medicate this). \n[ ] this patient's jaundice was discussed with the inpatient \nHepatology team this admission. She will likely continue to have \njaundice and LFT/bilirubin abnormalities. The patient should be \nsent for urgent medical attention/to the emergency room if she \ndevelops abdominal pain or fevers; however hyperbilirubinemia \nalone should not be a reason to rehospitalize. \n[ ] Continue to titrate outpatient diuresis. Previously on Lasix \n20mg daily. Discharged on torsemide 20mg daily with instructions \nto decrease to 10mg daily if she is losing weight. Please \nmonitor Cr and electrolytes carefully\n[] please monitor BPs; patient was occasionally hypotensive to \nthe ___ when she was \"dry\" and hypovolemic (taking poor PO \nintake, overdiuresed). please consider titrating diuretics if \npatient's BP is low.\n[ ] Patient needs to take weights on a daily basis. \n[ ] please ensure that patient has appropriate follow up with \nHepatology\n[ ] please ensure that patient has appropriate follow up with \nRenal Transplant team\n[ ] please ensure that patient has appropriate follow up with \noutpatient Cardiologist\n\n#CODE: DNR/DNI\n#CONTACT: ___Daughter) ___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. ALPRAZolam 0.25 mg PO QHS:PRN insomnia \n2. Aspirin 81 mg PO DAILY \n3. AzaTHIOprine 50 mg PO DAILY \n4. Flecainide Acetate 50 mg PO Q12H \n5. FLUoxetine 10 mg PO DAILY \n6. Metoprolol Tartrate 25 mg PO BID \n7. Pravastatin 10 mg PO QNOON \n8. PredniSONE 5 mg PO DAILY \n9. Omeprazole 20 mg PO DAILY \n10. Ursodiol 300 mg PO BID \n11. Ciprofloxacin HCl 500 mg PO DAILY:PRN if you have a fever \n12. Furosemide 20 mg PO DAILY \n13. Magnesium Oxide 400 mg PO DAILY \n14. Potassium Chloride 10 mEq PO DAILY \n\n \nDischarge Medications:\n1. Torsemide 20 mg PO DAILY \nTake 20mg daily. If you lose weight, take 10mg for one day. \nRX *torsemide 10 mg 2 tablet(s) by mouth Daily Disp #*60 Tablet \nRefills:*0 \n2. Ursodiol 375mg mg PO BID \nRX *ursodiol 250 mg 1.5 tablet(s) by mouth Twice Daily Disp #*90 \nTablet Refills:*0 \n3. ALPRAZolam 0.25 mg PO QHS:PRN insomnia \n4. Aspirin 81 mg PO DAILY \n5. AzaTHIOprine 50 mg PO DAILY \n6. FLUoxetine 10 mg PO DAILY \n7. Metoprolol Tartrate 25 mg PO BID \n8. Omeprazole 20 mg PO DAILY \n9. Pravastatin 10 mg PO QNOON \n10. PredniSONE 5 mg PO DAILY \n11. HELD- Magnesium Oxide 400 mg PO DAILY This medication was \nheld. Do not restart Magnesium Oxide until you repeat your \nbloodwork as an outpatient and talk about it with Dr. ___\n12. HELD- Potassium Chloride 10 mEq PO DAILY This medication \nwas held. Do not restart Potassium Chloride until you repeat \nyour bloodwork as an outpatient and talk about it with Dr. \n___\n\n \n___ Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\n================= \nPRIMARY DIAGNOSIS \n================= \nAcute heart failure exacerbation \n \n=================== \nSECONDARY DIAGNOSES \n=================== \nPolycystic kidney disease \nESRD ___ PCKD s/p living donor in ___ \nParoxysmal atrial fibrillation - on rate control \nDyslipidemia \nHypertension \nSick sinus syndrome status post pacemaker placement in ___ \ncomplicated by pacemaker lead mass found ___ \n___'s disease \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Out of Bed with assistance to chair or \nwheelchair.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou were admitted to ___ \nbecause you had shortness of breath as well as weight gain.\n\nWe gave the diuretics to help remove fluid through the IV. Once \nwe had a lot of fluid off, we put you on an oral diuretic (water \npill.)\n\nWe have made changes to your medication list, so please make \nsure to take your medications as directed. You will also need to \nhave close follow up with your heart doctor and your primary \ncare doctor. \n\nDischarge weight: 76.7 kg (169.09 lb) \n\nPlease weigh yourself every day in the morning after you go to \nthe bathroom and before you get dressed. If your weight goes up \nby more than 3 lbs in 1 day or more than 5 lbs in 2 days, please \ncall your heart doctor or your primary care doctor and alert \nthem to this change. Alternatively, if you lose more than 3 lbs \nin 1 day or more than 5lbs in 2 days, you can take HALF the dose \nof your torsemide (take 10mg instead of 20mg). \n\nPlease check your bloodwork at your rehabilitation facility on \n___.\n\nIt was a pleasure to take care of you. We wish you the best with \nyour health!\n\nYour ___ Cardiac Care Team \n\n \nFollowup Instructions:\n___\n"
] | Allergies: Vicodin / Vasotec / Morphine / Codeine Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: [MASKED] ERCP History of Present Illness: [MASKED] with systolic (EF 45-50%) heart failure, atrial fibrillation on flecainide and no a/c (GI bleeds), sick sinus syndrome status post PPM c/b lead mass, cholecystectomy c/b recurrent infections [MASKED] "sump syndrome", cholangitis and ESRD secondary to PCKD s/p LRRT ([MASKED]) who presents with shortness of breath, edema, and jaundice. Notably, the patient was recently admitted to [MASKED] from [MASKED] for unexplained hyperbilirubinemia and jaundice. She remained clinically stable without evidence of infection, and underwent uncomplicated diagnostic/therapeutic ERCP with placement of a stent. She tolerated the procedure well, but bilirubin remained elevated. The pathology results of brushings taken during ERCP were negative for malignancy. Given that MRCP was not possible given incompatible pacemaker lead, no further interventions were taken. The patient's dyspnea was attributed to a subacute exacerbation of her known diastolic heart failure, leading to pulmonary effusions and lower extremity edema. ECHO showed evidence of pacemaker RA mass concerning for vegetation (unlikely given afebrile, neg BCx) vs thrombus (not on AC except aspirin). Patient decided that [MASKED] is not within her goals of care, and has declined further evaluation of the pacemaker lead mass after a thoughtful discussion of all options with MDs. Of note, family and rehab are concerned she is not getting the right level of care. She notes worsening [MASKED] edema over the last two weeks and SOB yesterday with a new oxygen requirement. She denies any PND. she also denies any palpitations. She denies any fevers, chills, cough, chest pain, abdominal pain, N/V/D, dysuria. She is not able to say whether her jaundice is worse. In the ED, initial VS were: ([MASKED]) temperature 97.6, heart rate 52, blood pressure 109/71, respiratory rate 18, 95% on 2 L. On transfer, vitals were temperature 90.9, heart rate 95, blood pressure 100/52, respiratory 20, 100% on room air EKG: Atrial fibrillation with a ventricular rate of 120 bpm, intraventricular conduction delay with associated nonspecific ST/T-wave changes. Labs showed: Creatinine 0.8, AST 38, ALT 23, total bilirubin 9.7, white blood cell count 5.5, he will be 30.6, platelet count 187, lactate 1.8 Troponin 0.02 and second set was less than assay Imaging showed: Chest x-ray showed moderate right and small left pleural effusions that are likely unchanged from prior CT scan Consults: Cardiology and hepatology were both consulted who recommended diuresis and admission to heart failure team Patient received: Home medications and electrolyte repletion On arrival to the floor, patient recounts above history. She is interested in having her shortness of breath and leg swelling fixed. Past Medical History: ***[MASKED]'s Disease, new diagnosis (related to hyperbilirubinemia and abnormal biliary anatomy). 1. Polycystic kidney disease - daughter also has this. 2. ESRD [MASKED] PCKD s/p living donor in [MASKED] 3. Diverticulosis with sigmoid colectomy prior to renal transplant, then one episode of diverticulitis just after renal transplant. 4. Paroxysmal atrial fibrillation - on rate control, states that she converts to afib when dig stopped 5. Dyslipidemia 6. Hypertension 7. Migraines 8. h/o upper gastrointestinal bleed with gastritis 9. h/o recurrent Escherichia coli bacteremia prior to cholecystectomy in [MASKED]. 10. Infected right index finger in [MASKED]. "stump" syndrome resulting in polymicrobial bacteremia, incl E.coli, E. faecium, and B.frag ****** PLEASE NOT. THOUGHT NOT TO HAVE SUMP SYNDROME AS GI ANATOMY NOT ALIGNED WITH THIS DIAGNOSIS. 12. Recurrent skin cancers, which are closely followed by Dr. [MASKED] 13. Gout - affected her right great toe 14. Chronic venous stasis - complains of chronic left lower extremity edema. 15. Renal osteodystrophy Social History: [MASKED] Family History: Mother died of liver cancer. [MASKED] daughters has PKD (not needing HD, not on transplant). Pt's kidney donor was her sister. Physical Exam: ======================= ADMISSION PHYSICAL EXAM ======================= VS: Temperature 97.4, blood pressure 96/60, heart rate 105 (irregular), respiratory rate 18, 97% on 2 L GENERAL: NAD HEENT: Sclera and sublinguals space icteric NECK: supple, no LAD, JVP at 14 cm at 45° HEART: Irregularly irregular with soft 2 out of 6 systolic murmur LUNGS: Poor air movement with crackles up to the midlung fields bilaterally ABDOMEN: nondistended, nontender in all quadrants, no rebound/guarding EXTREMITIES: Cool distal lower extremities with extensive venous stasis changes and ulceration, particularly on the left shin. 3+ pitting edema up to the knees bilaterally PULSES: Difficult to palpate NEURO: A&Ox3, moving all 4 extremities with purpose ======================= DISCHARGE PHYSICAL EXAM ======================= 24 HR Data (last updated [MASKED] @ 337) Temp: 97.5 (Tm 97.8), BP: 106/51 (64-108/39-68), HR: 108 (63-108), RR: 18, O2 sat: 96% (96-98), O2 delivery: RA HEENT: Sclera and sublinguals space icteric NECK: Supple, no LAD, JVP to mid neck at 60 degrees HEART: Irregularly irregular with soft 2 out of 6 systolic murmur LUNGS: Poor air movements, clear to auscultation ABDOMEN: Nondistended, nontender in all quadrants, no rebound/guarding EXTREMITIES: 1+ pitting edema at the knees, continues to improve on a daily basis. Shins wrapped in ace bandages. Warm and well-perfused. NEURO: A&Ox3, moving all 4 extremities with purpose Pertinent Results: ============================ ADMISSION LABORATORY RESULTS ============================ [MASKED] 07:59PM GLUCOSE-83 UREA N-21* CREAT-0.7 SODIUM-132* POTASSIUM-5.2* CHLORIDE-95* TOTAL CO2-21* ANION GAP-16 [MASKED] 05:48PM WBC-6.1 RBC-4.38 HGB-14.3 HCT-42.3 MCV-97 MCH-32.6* MCHC-33.8 RDW-20.4* RDWSD-71.9* [MASKED] 07:59PM [MASKED] [MASKED] 07:59PM CALCIUM-7.5* PHOSPHATE-2.7 MAGNESIUM-1.8 [MASKED] 07:59PM ALT(SGPT)-26 AST(SGOT)-47* ALK PHOS-287* TOT BILI-11.7* [MASKED] 05:48PM cTropnT-0.02* [MASKED] 03:45AM cTropnT-<0.01 [MASKED] 03:45AM TSH-5.8* [MASKED] 04:04AM LACTATE-1.8 ========================================== DISCHARGE AND PERTINENT LABORATORY RESULTS ========================================== [MASKED] 08:00AM BLOOD WBC-8.8# RBC-4.08 Hgb-13.2 Hct-39.7 MCV-97 MCH-32.4* MCHC-33.2 RDW-20.5* RDWSD-72.7* Plt [MASKED] [MASKED] 08:00AM BLOOD [MASKED] PTT-34.7 [MASKED] [MASKED] 08:00AM BLOOD Plt [MASKED] [MASKED] 08:00AM BLOOD Glucose-69* UreaN-21* Creat-0.9 Na-139 K-3.3 Cl-88* HCO3-35* AnGap-16 [MASKED] 08:00AM BLOOD ALT-26 AST-48* LD(LDH)-324* AlkPhos-256* TotBili-12.1* [MASKED] 08:00AM BLOOD Calcium-8.1* Phos-3.5 Mg-1.8 ============ MICROBIOLOGY ============ [MASKED] C diff negative [MASKED] Urine culture negative =============== IMAGING REPORTS =============== --------------- [MASKED] ERCP --------------- Impression: The scout film was normal. The major papilla was seen on the lateral rim of a large [MASKED] diverticulum. Evidence of a previous sphincterotomy was noted at the major papilla. The bile duct was successfully cannulated using balloon catheter. Contrast was injected and there was brisk flow through the ducts. Contrast extended to the entire biliary tree. Contrast injection revealed a dilated CBD and CHD up to 15 mm. At the bifurcation, marked caliber change was noted. The intrahepatic ducts were tortuous, irregular with multiple filling defects consistent with patient's underlying disease of polycystic liver disease, although [MASKED]' disease or intrahepatic stones could not be ruled out. No dominant stricture was seen. Plan for MRCP to evaluate the intrahepatics. Previous migrated stent was removed with a rat tooth and no new stent was placed. Otherwise normal ercp to third part of the duodenum Recommendations: Clear fluids when awake then advance diet as tolerated. Follow-up with Dr. [MASKED] as previously scheduled. Follow for response and complications. If any abdominal pain, fever, jaundice, gastrointestinal bleeding please call Advanced Endoscopy Fellow on call [MASKED] Continue with antibiotics - to complete at least 5 days If any abdominal pain, fever, jaundice, gastrointestinal bleeding please call Advanced Endoscopy Fellow on call [MASKED] MRCP to evaluate the intrahepatics [MASKED] Pacemaker Interrogation AS - VS 18.5% AS - VP 5.1% AP - VS 73.2% AP - VP 3.2% MVP On [MASKED] RUQ Ultrasound IMPRESSION: Left hepatic vein waveform is biphasic is nonspecific and could be seen in the setting of advanced cardiac disease. Previously seen thrombus in the left portal vein not visualized on the current study. Mildly prominent pancreatic duct as seen on prior CT. Small right pleural effusion. 2.8 cm echogenic lesion in the right hepatic lobe not definitively seen on prior CT from [MASKED]. Differential considerations include hemangioma. ----------- [MASKED] CXR ----------- FINDINGS: There is a moderate right pleural effusion which is seen within the fissure with likely adjacent right middle and lower lobe lobe atelectasis. Small left pleural effusion is again noted with adjacent atelectasis. Given differences in technique and positioning, these are likely unchanged since prior CT scan. Superiorly, lungs are clear. There is no edema. Cardiac silhouette is likely unchanged but difficult to assess. Left chest wall dual lead pacing device is again noted. No acute osseous abnormalities. IMPRESSION: Moderate right and small left pleural effusions, likely unchanged from prior CT scan. Brief Hospital Course: [MASKED] with systolic heart failure (EF 45-50%), atrial fibrillation on flecainide and no a/c (GI bleeds), PPM c/b lead mass, cholecystectomy c/b recurrent infections [MASKED] "sump syndrome", cholangitis and ESRD secondary to PCKD s/p LRRT ([MASKED]) who presents with shortness of breath, edema, and jaundice. #Acute on chronic heart failure exacerbation Patient presented at this admission with worsening fluid overload. Cause is unclear but may be due to worsening tricuspid regurgitation from pacemaker mass, ongoing atrial fibrillation, or liver failure; however more likely due to patient report and family report that her diuretic regimen had not been properly titrated at her outpatient rehab. She was discharged on Lasix 20mg PO daily. Volume status improved with IV diuresis, and transitioned to an oral diuretic regimen which she was very responsive to. She was discharged on torsemide 20mg daily with plan to take torsemide 10mg if her weight is found to be dropping by <3 lbs in one day or if she should become more hypotensive. Her home Lasix 20mg was discontinued. We also began wrapping her legs in ace wraps in order to mobilize her extravascular fluid, which she was responsive to. Discharge Weight = 76.7 kg (169.09 lb) # Hyperbilirubinemia Ms. [MASKED] has had recently multiple hospitalizations for cholangitis thought to be secondary to "sump syndrome," however we believe this to be an erroneous diagnosis as she does not have GI anatomy compatible with sump syndrome. Last month, she underwent a CT Abd w/ contrast which showed increased intra and extrahepatic biliary ductal dilatation. She underwent ERCP with placement of a stent at her last hospitalization. Patient remained afebrile, but bilirubin remained elevated. Hepatology was consulted during this admission for follow up of this issue; previousl autoimmune workup was completed, which was negative. Ultimately, it was felt that her symptoms were due to [MASKED]'s disease. She does not require further diagnostics at this time, and can continue taking ursodiol. Her jaundice is not evidence of worsening disease. Hepatology consult team recommended further outpatient management and monitoring for any signs or symptoms of abdominal pain or fevers. #Sick sinus syndrome status post pacer ([MASKED]) complicated by mass The patient is ventricularly pacing 8% of the time. On previous admissions, has refused anticoagulation. Confirmed this with her again on [MASKED] and she again declines anticoagulation given her concern for bleeding risk. # H/o ESRD secondary to PCKD s/p LRRT ([MASKED]) Followed by renal transplant during hospitalization. No concern for graft function. Continued on prednisone 5mg and azathioprine 50mg. She follows with Dermatology regularly given her history of skin cancers. Sirolimus therapy has been tried in the past; however, it was stopped due to pneumonitis. Her renal function remained at baseline without evidence of kidney injury during her hospital course. #Atrial Fibrillation Per device interrogation, the patient has been a persistent atrial fibrillation for the last 2 months. Notably, she is not anticoagulation due to history of significant GI bleed in the distant past. The patient is unwilling to trial any anticoagulation regimen. Cardioversion was not offered due to the fact that patient declined TEE and anticoagulation. Continued on home metoprolol 25mg BID. She had been on flecanide, but this was discontinued as she was still in atrial fibrillation, with adequate rate control (80-110s and asymptomatic) and has structural heart disease which is a contraindication to flecanide; this was discussed with her outpatient cardiologist Dr. [MASKED]. Patient continues on aspirin. #Hypotension Patient had a few brief episodes of hypotension to 70-80s systolic while an inpatient. These were isolated episodes thought to be related to hypovolemia and overdiuresis; her BPs improved to baseline 90-110s with small amount of fluid resuscitation and improved PO intake; she was asymptomatic during these episodes. ==================== TRANSITIONAL ISSUES: ==================== - New Meds: Torsemide 20mg daily (take 10mg daily if losing weight) - Stopped/Held Meds: Flecanide, Furosemide (Lasix), Ciprofloxacin - Changed Meds: None - Post-Discharge Follow-up Labs Needed: Please check Chem 10 , CBC, (Na, K, Cl, HCO3, BUN, Cr, Mag, Ca, Phos) on [MASKED] to monitor electrolytes and renal function - Incidental Findings: None - Discharge weight: 76.7 kg (169.09 lb) [ ] Now carries diagnosis of Caroli's Disease (not Caroli's syndrome). She is believed NOT to have sump syndrome. If patient experiences fevers in the future, she should present to an emergency department (previously had an antibiotic (Ciprofloxacin) she would take at home to medicate this). [ ] this patient's jaundice was discussed with the inpatient Hepatology team this admission. She will likely continue to have jaundice and LFT/bilirubin abnormalities. The patient should be sent for urgent medical attention/to the emergency room if she develops abdominal pain or fevers; however hyperbilirubinemia alone should not be a reason to rehospitalize. [ ] Continue to titrate outpatient diuresis. Previously on Lasix 20mg daily. Discharged on torsemide 20mg daily with instructions to decrease to 10mg daily if she is losing weight. Please monitor Cr and electrolytes carefully [] please monitor BPs; patient was occasionally hypotensive to the [MASKED] when she was "dry" and hypovolemic (taking poor PO intake, overdiuresed). please consider titrating diuretics if patient's BP is low. [ ] Patient needs to take weights on a daily basis. [ ] please ensure that patient has appropriate follow up with Hepatology [ ] please ensure that patient has appropriate follow up with Renal Transplant team [ ] please ensure that patient has appropriate follow up with outpatient Cardiologist #CODE: DNR/DNI #CONTACT: Daughter) [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ALPRAZolam 0.25 mg PO QHS:PRN insomnia 2. Aspirin 81 mg PO DAILY 3. AzaTHIOprine 50 mg PO DAILY 4. Flecainide Acetate 50 mg PO Q12H 5. FLUoxetine 10 mg PO DAILY 6. Metoprolol Tartrate 25 mg PO BID 7. Pravastatin 10 mg PO QNOON 8. PredniSONE 5 mg PO DAILY 9. Omeprazole 20 mg PO DAILY 10. Ursodiol 300 mg PO BID 11. Ciprofloxacin HCl 500 mg PO DAILY:PRN if you have a fever 12. Furosemide 20 mg PO DAILY 13. Magnesium Oxide 400 mg PO DAILY 14. Potassium Chloride 10 mEq PO DAILY Discharge Medications: 1. Torsemide 20 mg PO DAILY Take 20mg daily. If you lose weight, take 10mg for one day. RX *torsemide 10 mg 2 tablet(s) by mouth Daily Disp #*60 Tablet Refills:*0 2. Ursodiol 375mg mg PO BID RX *ursodiol 250 mg 1.5 tablet(s) by mouth Twice Daily Disp #*90 Tablet Refills:*0 3. ALPRAZolam 0.25 mg PO QHS:PRN insomnia 4. Aspirin 81 mg PO DAILY 5. AzaTHIOprine 50 mg PO DAILY 6. FLUoxetine 10 mg PO DAILY 7. Metoprolol Tartrate 25 mg PO BID 8. Omeprazole 20 mg PO DAILY 9. Pravastatin 10 mg PO QNOON 10. PredniSONE 5 mg PO DAILY 11. HELD- Magnesium Oxide 400 mg PO DAILY This medication was held. Do not restart Magnesium Oxide until you repeat your bloodwork as an outpatient and talk about it with Dr. [MASKED] 12. HELD- Potassium Chloride 10 mEq PO DAILY This medication was held. Do not restart Potassium Chloride until you repeat your bloodwork as an outpatient and talk about it with Dr. [MASKED] [MASKED] Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: ================= PRIMARY DIAGNOSIS ================= Acute heart failure exacerbation =================== SECONDARY DIAGNOSES =================== Polycystic kidney disease ESRD [MASKED] PCKD s/p living donor in [MASKED] Paroxysmal atrial fibrillation - on rate control Dyslipidemia Hypertension Sick sinus syndrome status post pacemaker placement in [MASKED] complicated by pacemaker lead mass found [MASKED] [MASKED]'s disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. [MASKED], You were admitted to [MASKED] because you had shortness of breath as well as weight gain. We gave the diuretics to help remove fluid through the IV. Once we had a lot of fluid off, we put you on an oral diuretic (water pill.) We have made changes to your medication list, so please make sure to take your medications as directed. You will also need to have close follow up with your heart doctor and your primary care doctor. Discharge weight: 76.7 kg (169.09 lb) Please weigh yourself every day in the morning after you go to the bathroom and before you get dressed. If your weight goes up by more than 3 lbs in 1 day or more than 5 lbs in 2 days, please call your heart doctor or your primary care doctor and alert them to this change. Alternatively, if you lose more than 3 lbs in 1 day or more than 5lbs in 2 days, you can take HALF the dose of your torsemide (take 10mg instead of 20mg). Please check your bloodwork at your rehabilitation facility on [MASKED]. It was a pleasure to take care of you. We wish you the best with your health! Your [MASKED] Cardiac Care Team Followup Instructions: [MASKED] | [
"I110",
"Z940",
"I959",
"E861",
"I071",
"L97829",
"I480",
"E8342",
"E8351",
"K761",
"I471",
"Q446",
"T85520A",
"Q612",
"K838",
"N250",
"I5023",
"Z950",
"Z66",
"E785",
"I878",
"M109",
"Z85828",
"Y838",
"Y929",
"F329",
"L859"
] | [
"I110: Hypertensive heart disease with heart failure",
"Z940: Kidney transplant status",
"I959: Hypotension, unspecified",
"E861: Hypovolemia",
"I071: Rheumatic tricuspid insufficiency",
"L97829: Non-pressure chronic ulcer of other part of left lower leg with unspecified severity",
"I480: Paroxysmal atrial fibrillation",
"E8342: Hypomagnesemia",
"E8351: Hypocalcemia",
"K761: Chronic passive congestion of liver",
"I471: Supraventricular tachycardia",
"Q446: Cystic disease of liver",
"T85520A: Displacement of bile duct prosthesis, initial encounter",
"Q612: Polycystic kidney, adult type",
"K838: Other specified diseases of biliary tract",
"N250: Renal osteodystrophy",
"I5023: Acute on chronic systolic (congestive) heart failure",
"Z950: Presence of cardiac pacemaker",
"Z66: Do not resuscitate",
"E785: Hyperlipidemia, unspecified",
"I878: Other specified disorders of veins",
"M109: Gout, unspecified",
"Z85828: Personal history of other malignant neoplasm of skin",
"Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure",
"Y929: Unspecified place or not applicable",
"F329: Major depressive disorder, single episode, unspecified",
"L859: Epidermal thickening, unspecified"
] | [
"I110",
"I480",
"Z66",
"E785",
"M109",
"Y929",
"F329"
] | [] |
16,921,397 | 26,557,647 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nabdominal pain\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMrs. ___ is a ___ woman with generalized \nanxiety disorder, migraines, and history of bowel discomfort \nsince childhood who presents with one day significant lower \nabdominal pain. Six days prior to presentation she experienced \nsharp pain in her lower abdomen, which was follow by several \ndays of general abdominal discomfort that was less intense and \nmore crampy in nature and not relieved by Gas-x or omeprazole. \nOne day prior to admission she again developed sharp \nlower-midline abdominal pain, which woke her from sleep. The \npain was not positional, did not radiate, and was not relieved \nby sumatriptan. There was associated nausea and decreased \nappetite, but no fever, vomiting, or diarrhea. She has a long \nhistory of irritable bowels but has not had this type of pain \nbefore. She has not had flank pain, dysuria, vaginal bleeding or \nabnormal discharge. Her LMP was about one month ago (her period \nstarted on the day of admission) and has not had a STI. \nCurrently in a monogamous relationship with her boyfriend, using \n___ for protection, tested yearly for STIs, never positive in \nthe past. She has not had recent illnesses, travel, or eaten \nuncooked foods that she is aware of. She has not noticed blood \nin her stools. She works at a pharmacy so is around sick people \nbut no specific sick contacts. \n\nOn ROS she reports intermittent night sweats, which seemed to \nbegin about a year ago when she began taking Effexor. She has \nnot had significant weight loss or weight gain.\n\nIn the ED, initial vitals: 98.0, 101, 111/75, 16, 99%RA \n- Labs were significant for 12.0 > 11.6/34.7 < 262 \n;AST/ALT/ALKPHOS wnl; hCG negative ; UA with small bactiurea \n- CT abdomen and pelvis was performed. The appendix did not \nappear dilated or inflamed; there was mucosal enhancement of the \nterminal ileum concerning for inflammatory or infectious \nterminal ileitis. \nand mild edema of the cecal wall and associated lymphadenopathy. \n\n- In the ED, she received IVF and was started on cipro/flagyl.\n\nUpon arrival to the floor, she was afebrile and comfortable in \nbed. She reports having mild abdominal pain, centered in the \nmiddle of the abdomen below the umbilicus. Her appetite is \nimproving. \n \nREVIEW OF SYSTEMS: \nPositive as per HPI; otherwise negative. \nNo fevers, chills, or weight changes. No changes in vision or \nhearing, no changes in balance. No cough, no shortness of \nbreath, no dyspnea on exertion. No chest pain or palpitations. \nNo vomiting. No diarrhea or constipation. No dysuria or \nhematuria. No hematochezia, no melena. No numbness or weakness, \nno focal deficits. \n \nPast Medical History:\nMEDICAL HISTORY: \n- Generalized anxiety disorder \n- Migraines\n\nSURGICAL HISTORY:\n- Tonsillectomy\n- Wisdom teeth extraction \n \n \nSocial History:\n___\nFamily History:\nNo known personal or family history of IBD, cancer, bleeding or \nclotting disorders (both parents adopted, so does not know \nextensive family history)\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \nVital Signs: 98.1 117/78 110 18 96 Ra \nGeneral: Alert, oriented, no acute distress \nSkin: No lesions or rashes \nHEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, \nneck supple, no LAD \nCV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, \ngallops \nLungs: Clear to auscultation bilaterally\nAbdomen: Bowel sounds present, soft, non-distended, tender to \nmoderate palpation in RLQ, no tap tenderness, no rebound or \nguarding, negative psoas and obturator signs, no masses or \norganomegaly, no scars\nGU: Deferred\nExt: Warm, well perfused, 2+ pulses, no edema \nNeuro: CNII-XII intact, ___ strength upper/lower extremities, \ngrossly normal sensation, 2+ reflexes bilaterally, gait \ndeferred. \n\nDISCHARGE PHYSICAL EXAM:\nVitals: 97.9 ___ 20 98 Ra \nGeneral: alert, oriented, in no acute distress \nHEENT: sclera anicteric, EOMI, MMM, 4mm oral ulcer on left \ncheek/lip, oropharynx clear\nNeck: no LAD \nLungs: clear to auscultation bilaterally\nCV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs, \ngallops \nAbdomen: soft, non-tender, non-distended, bowel sounds present, \nno rebound tenderness or guarding, no organomegaly \nGU: no foley \nExt: warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \n \nPertinent Results:\nLABORATORY RESULTS ON ADMISSION\n===================================\n___ 09:49PM BLOOD WBC-12.0* RBC-4.02 Hgb-11.6 Hct-34.7 \nMCV-86 MCH-28.9 MCHC-33.4 RDW-12.9 RDWSD-40.4 Plt ___\n___ 09:49PM BLOOD Neuts-75.1* Lymphs-16.3* Monos-7.5 \nEos-0.2* Baso-0.3 Im ___ AbsNeut-8.99* AbsLymp-1.95 \nAbsMono-0.90* AbsEos-0.02* AbsBaso-0.03\n___ 09:49PM BLOOD Plt ___\n___ 09:49PM BLOOD Glucose-88 UreaN-9 Creat-0.7 Na-136 K-3.6 \nCl-101 HCO3-20* AnGap-19\n___ 09:49PM BLOOD HCG-<5\n\nLABORATORY RESULTS ON DISCHARGE\n===================================\n___ 07:50AM BLOOD WBC-6.7 RBC-3.95 Hgb-11.1* Hct-34.2 \nMCV-87 MCH-28.1 MCHC-32.5 RDW-12.9 RDWSD-40.7 Plt ___\n___ 07:50AM BLOOD Glucose-88 UreaN-5* Creat-0.7 Na-138 \nK-4.2 Cl-104 HCO3-23 AnGap-15\n___ 07:50AM BLOOD Calcium-8.7 Phos-2.6* Mg-2.0\n___ 01:00PM BLOOD CRP-151.8*\n\nIMAGING\n===================================\nCT ABD/PELVIS\n1. Mucosal enhancement of the terminal ileum, concerning for \ninflammatory or \ninfectious terminal ileitis. Mild edema of the cecal wall and \nassociated \nlymphadenopathy. Please correlate clinically. \n2. Normal appendix is visualized in right lower quadrant. \n3. Redundant colon with large volume of stool throughout. \n\nMICROBIOLOGY\n===================================\nSTOOL VIRAL CULTURE: PENDING\nSTOOL CULTURE: PENDING\nBLOOD CULTURES: NO GROWTH TO DATE\nURINE CULTURE: MIXED FLORA\n\n \nBrief Hospital Course:\nMs. ___ is a ___ woman with a history of generalized \nanxiety disorder and migraines admitted with abdominal pain and \nfound to have terminal ileitis.\n\n#) Terminal ileitis\nPt admitted with lower abdominal pain and found to have right \nlower quadrant tenderness and labs were only significant for a \nmildly elevated WBC. Beta hCG was negative. CT scan of the \nabdomen and pelvis showed evidence of terminal ileitis with a \nnormal appearing appendix. She was admitted and managed \nconservatively with IV hydration and acetaminophen for pain \ncontrol. Bacterial and viral stool studies were collected and \nwere pending at the time of discharge. Her abdominal pain \nimprove overnight and on the morning of discharge she was able \nto tolerate a regular diet. The etiology of her terminal \nileitis remained unclear, possibly secondary to infectious \nversus inflammatory etiologies. Patient was discharged with a \nplan to follow up with her PCP and an outpatient \ngastroenterolgist.\n\nCHRONIC ISSUES\n==============\n# GAD: continued on home effexor \n\nTRANSITIONAL ISSUES\n=============================\n1. Pt will schedule appointment with gastroenterologist for \nfurther management of terminal ileitis. If ileitis persists and \nstool studies unrevealing, patient may need outpatient \ncolonoscopy.\n2. Need to follow up stool studies (pending on discharge)\n\n# CONTACT: Mother, ___, no number provided \n# CODE: presumed full\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Venlafaxine XR 150 mg PO DAILY \n2. Tri-Sprintec (28) (norgestimate-ethinyl estradiol) \n0.18/0.215/0.25 mg-35 mcg (28) oral DAILY \n\n \nDischarge Medications:\n1. Tri-Sprintec (28) (norgestimate-ethinyl estradiol) \n0.18/0.215/0.25 mg-35 mcg (28) oral DAILY \n2. Venlafaxine XR 150 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nTerminal ilieitus \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nIt was a pleasure taking care of you during your hospital stay \nat ___. You were hospitalized \nfor abdominal pain.\n\nYou were treated for terminal ilieitus (inflammation of the \nsmall intestine). Specifically you received fluids through the \nIV and your diet was advanced from clear liquids, to full \nliquids, and then regular diet. You continued on your home \nmedications.\n\nOn discharge, it is important for you to follow up with your \nprimary care physician and ___ gastroenterologist as described \nbelow and to call your doctor or return to the emergency room if \nyou develop any of the concerning symptoms listed below.\n\nPlease follow up with your primary care physician (an \nappointment has been scheduled), and a gastroenterologist upon \ndischarge from the hospital. Please continue to take your home \nmedications as prescribed. \n\nTake Care,\nYour ___ Team. \n \nFollowup Instructions:\n___\n"
] | Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: Mrs. [MASKED] is a [MASKED] woman with generalized anxiety disorder, migraines, and history of bowel discomfort since childhood who presents with one day significant lower abdominal pain. Six days prior to presentation she experienced sharp pain in her lower abdomen, which was follow by several days of general abdominal discomfort that was less intense and more crampy in nature and not relieved by Gas-x or omeprazole. One day prior to admission she again developed sharp lower-midline abdominal pain, which woke her from sleep. The pain was not positional, did not radiate, and was not relieved by sumatriptan. There was associated nausea and decreased appetite, but no fever, vomiting, or diarrhea. She has a long history of irritable bowels but has not had this type of pain before. She has not had flank pain, dysuria, vaginal bleeding or abnormal discharge. Her LMP was about one month ago (her period started on the day of admission) and has not had a STI. Currently in a monogamous relationship with her boyfriend, using [MASKED] for protection, tested yearly for STIs, never positive in the past. She has not had recent illnesses, travel, or eaten uncooked foods that she is aware of. She has not noticed blood in her stools. She works at a pharmacy so is around sick people but no specific sick contacts. On ROS she reports intermittent night sweats, which seemed to begin about a year ago when she began taking Effexor. She has not had significant weight loss or weight gain. In the ED, initial vitals: 98.0, 101, 111/75, 16, 99%RA - Labs were significant for 12.0 > 11.6/34.7 < 262 ;AST/ALT/ALKPHOS wnl; hCG negative ; UA with small bactiurea - CT abdomen and pelvis was performed. The appendix did not appear dilated or inflamed; there was mucosal enhancement of the terminal ileum concerning for inflammatory or infectious terminal ileitis. and mild edema of the cecal wall and associated lymphadenopathy. - In the ED, she received IVF and was started on cipro/flagyl. Upon arrival to the floor, she was afebrile and comfortable in bed. She reports having mild abdominal pain, centered in the middle of the abdomen below the umbilicus. Her appetite is improving. REVIEW OF SYSTEMS: Positive as per HPI; otherwise negative. No fevers, chills, or weight changes. No changes in vision or hearing, no changes in balance. No cough, no shortness of breath, no dyspnea on exertion. No chest pain or palpitations. No vomiting. No diarrhea or constipation. No dysuria or hematuria. No hematochezia, no melena. No numbness or weakness, no focal deficits. Past Medical History: MEDICAL HISTORY: - Generalized anxiety disorder - Migraines SURGICAL HISTORY: - Tonsillectomy - Wisdom teeth extraction Social History: [MASKED] Family History: No known personal or family history of IBD, cancer, bleeding or clotting disorders (both parents adopted, so does not know extensive family history) Physical Exam: ADMISSION PHYSICAL EXAM: Vital Signs: 98.1 117/78 110 18 96 Ra General: Alert, oriented, no acute distress Skin: No lesions or rashes HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally Abdomen: Bowel sounds present, soft, non-distended, tender to moderate palpation in RLQ, no tap tenderness, no rebound or guarding, negative psoas and obturator signs, no masses or organomegaly, no scars GU: Deferred Ext: Warm, well perfused, 2+ pulses, no edema Neuro: CNII-XII intact, [MASKED] strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. DISCHARGE PHYSICAL EXAM: Vitals: 97.9 [MASKED] 20 98 Ra General: alert, oriented, in no acute distress HEENT: sclera anicteric, EOMI, MMM, 4mm oral ulcer on left cheek/lip, oropharynx clear Neck: no LAD Lungs: clear to auscultation bilaterally CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: LABORATORY RESULTS ON ADMISSION =================================== [MASKED] 09:49PM BLOOD WBC-12.0* RBC-4.02 Hgb-11.6 Hct-34.7 MCV-86 MCH-28.9 MCHC-33.4 RDW-12.9 RDWSD-40.4 Plt [MASKED] [MASKED] 09:49PM BLOOD Neuts-75.1* Lymphs-16.3* Monos-7.5 Eos-0.2* Baso-0.3 Im [MASKED] AbsNeut-8.99* AbsLymp-1.95 AbsMono-0.90* AbsEos-0.02* AbsBaso-0.03 [MASKED] 09:49PM BLOOD Plt [MASKED] [MASKED] 09:49PM BLOOD Glucose-88 UreaN-9 Creat-0.7 Na-136 K-3.6 Cl-101 HCO3-20* AnGap-19 [MASKED] 09:49PM BLOOD HCG-<5 LABORATORY RESULTS ON DISCHARGE =================================== [MASKED] 07:50AM BLOOD WBC-6.7 RBC-3.95 Hgb-11.1* Hct-34.2 MCV-87 MCH-28.1 MCHC-32.5 RDW-12.9 RDWSD-40.7 Plt [MASKED] [MASKED] 07:50AM BLOOD Glucose-88 UreaN-5* Creat-0.7 Na-138 K-4.2 Cl-104 HCO3-23 AnGap-15 [MASKED] 07:50AM BLOOD Calcium-8.7 Phos-2.6* Mg-2.0 [MASKED] 01:00PM BLOOD CRP-151.8* IMAGING =================================== CT ABD/PELVIS 1. Mucosal enhancement of the terminal ileum, concerning for inflammatory or infectious terminal ileitis. Mild edema of the cecal wall and associated lymphadenopathy. Please correlate clinically. 2. Normal appendix is visualized in right lower quadrant. 3. Redundant colon with large volume of stool throughout. MICROBIOLOGY =================================== STOOL VIRAL CULTURE: PENDING STOOL CULTURE: PENDING BLOOD CULTURES: NO GROWTH TO DATE URINE CULTURE: MIXED FLORA Brief Hospital Course: Ms. [MASKED] is a [MASKED] woman with a history of generalized anxiety disorder and migraines admitted with abdominal pain and found to have terminal ileitis. #) Terminal ileitis Pt admitted with lower abdominal pain and found to have right lower quadrant tenderness and labs were only significant for a mildly elevated WBC. Beta hCG was negative. CT scan of the abdomen and pelvis showed evidence of terminal ileitis with a normal appearing appendix. She was admitted and managed conservatively with IV hydration and acetaminophen for pain control. Bacterial and viral stool studies were collected and were pending at the time of discharge. Her abdominal pain improve overnight and on the morning of discharge she was able to tolerate a regular diet. The etiology of her terminal ileitis remained unclear, possibly secondary to infectious versus inflammatory etiologies. Patient was discharged with a plan to follow up with her PCP and an outpatient gastroenterolgist. CHRONIC ISSUES ============== # GAD: continued on home effexor TRANSITIONAL ISSUES ============================= 1. Pt will schedule appointment with gastroenterologist for further management of terminal ileitis. If ileitis persists and stool studies unrevealing, patient may need outpatient colonoscopy. 2. Need to follow up stool studies (pending on discharge) # CONTACT: Mother, [MASKED], no number provided # CODE: presumed full Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Venlafaxine XR 150 mg PO DAILY 2. Tri-Sprintec (28) (norgestimate-ethinyl estradiol) 0.18/0.215/0.25 mg-35 mcg (28) oral DAILY Discharge Medications: 1. Tri-Sprintec (28) (norgestimate-ethinyl estradiol) 0.18/0.215/0.25 mg-35 mcg (28) oral DAILY 2. Venlafaxine XR 150 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Terminal ilieitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], It was a pleasure taking care of you during your hospital stay at [MASKED]. You were hospitalized for abdominal pain. You were treated for terminal ilieitus (inflammation of the small intestine). Specifically you received fluids through the IV and your diet was advanced from clear liquids, to full liquids, and then regular diet. You continued on your home medications. On discharge, it is important for you to follow up with your primary care physician and [MASKED] gastroenterologist as described below and to call your doctor or return to the emergency room if you develop any of the concerning symptoms listed below. Please follow up with your primary care physician (an appointment has been scheduled), and a gastroenterologist upon discharge from the hospital. Please continue to take your home medications as prescribed. Take Care, Your [MASKED] Team. Followup Instructions: [MASKED] | [
"K5000",
"F411",
"G43909"
] | [
"K5000: Crohn's disease of small intestine without complications",
"F411: Generalized anxiety disorder",
"G43909: Migraine, unspecified, not intractable, without status migrainosus"
] | [] | [] |
11,658,087 | 24,558,458 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nprednisone / procainamide\n \nAttending: ___\n \n___ Complaint:\npost-operative leak from laparoscopic sigmoid colectomy on \n___ for medically refractory sigmoid diverticulitis\n \nMajor Surgical or Invasive Procedure:\nLaparoscopic washout and loop ileostomy ___\n\n \nHistory of Present Illness:\n___ with past medical history of medically refractory sigmoid \ndiverticulitis status post laparoscopic sigmoid colectomy on \n___ complicated by postoperative leak, now status post \nlaparoscopic washout and loop ileostomy on ___\n \nPast Medical History:\nPMH: Diverticulitis, AFib s/p ablation not on anticoagulation \nfollowed at ___ Cardiology \nPSH: Right Shoulder Surgery \n\n \nSocial History:\n___\nFamily History:\nRelative Status Age Problem Comments \nMother ___ ___ \n\nFather ___ ___ MOTOR VEHICLE \n ACCIDENT \n DIABETES MELLITUS \n CATARACTS \n\nBrother Living ___ BRAIN TUMOR \n\nSister Living 77 PALPITATIONS \n HYPERTENSION\nSister Living ___ BREAST CANCER s/p mastectomy, no\nchemo per wife and patient)\n\n \nPhysical Exam:\nAdmission physical exam (ED note):\nPHYSICAL EXAM:\nGeneral appearance:[x] WNL- globally orientated, awake, alert\n [] other\nHeent: [x] WNL- N/C: PERRLA,\n [] other\nHeart: [x] WNL- RRR, no M/R/G\n [] other\nLungs: [x] WNL- CTA\n [] other\nAbdomen: [] WNL- S/NT/ND\n [x] other: soft, tender on RLQ, non-distended\nMusculoskeletal: [x] WNL\n [] other\nSkin: [x] WNL\n [] other\n\nDischarge Physical Exam:\nVS: AVSS\nGen: well appearing female, NAD\nHEENT: no lymphadenopathy, moist mucous membranes\nLungs: CTAB\nHeart: rrr\nAbd: soft, nt, nd\nIncisions: cdi\nExtremities: wwp\n\n \nPertinent Results:\n___ 08:40PM GLUCOSE-112* UREA N-11 CREAT-0.9 SODIUM-135 \nPOTASSIUM-4.2 CHLORIDE-95* TOTAL CO2-30 ANION GAP-14\n___ 08:40PM CALCIUM-9.0 PHOSPHATE-3.6 MAGNESIUM-2.1\n___ 08:40PM WBC-16.6* RBC-5.32 HGB-15.2 HCT-47.1 MCV-89 \nMCH-28.6 MCHC-32.3 RDW-13.2 RDWSD-42.3\n___ 08:40PM PLT COUNT-302\n\nCT Abd/Pelvis ___: \nIMPRESSION: \n\n1. No evidence of bowel obstruction. \n2. Status post sigmoid resection. Evaluation is limited in this \nregion due to CT artifact. Fluid and locules of air in the \nsurgical bed appear to be extraluminal, unclear if related to \nrecent surgery versus anastomotic leak. \n3. Moderate intraperitoneal free air and subcutaneous tissues is \nwithin \nexpected range for a recent laparoscopic procedure. It is \ndifficult to \nevaluate for perforation, given the presence of free air after \nsurgery. \n4. Wall thickening of the distal descending colon is likely \nrelated to \nsurgery. \n\n \nBrief Hospital Course:\nMr. ___ presented to the emergency room at ___ on \n___ for complaints of severe lower abdominal pain. Of note, \nhe had received a laparoscopic sigmoid colectomy on ___ and \nhad been discharged on ___ without issues. This was thought \nto be due to a post-operative leak. He was taken for a \nlaparoscopic washout and creation of loop ileostomy on ___. \nHe tolerated the procedure well without complications (Please \nsee operative note for further details). After a brief and \nuneventful stay in the PACU, the patient was transferred to the \nfloor for further post-operative management. He did of note \nhave some issues with tolerating diet advancement which are \nnoted in the GI section below in detail.\n\nNeuro: Pain was well controlled on IV pain medications until \ntolerating a regular diet.\nCV: Vital signs were routinely monitored during the patient's \nlength of stay. There were no cardiovascular issues during his \nhospitalization.\nPulm: The patient was encouraged to ambulate, sit and get out \nof bed, use the incentive spirometer, and had oxygen saturation \nlevels monitored as indicated.\nGI: The patient was initially kept NPO after the procedure. He \nhad some difficulty with nausea and vomiting and on ___ the \nileostomy was cannulated with a red rubber which led to a large \nvolume output. He continued to be distended with nausea and \nvomiting and thus an NGT was placed on ___. The NGT was kept \nin until resolution of his symptoms and was removed on ___, \nafter w___ he tolerated clears. He continued to slowly improve \nand his diet was cautiously advanced. Given his protracted \ncourse of not tolerating diet, he was also started on TPN, this \nwas discontinued on ___ before discharge. With regard to his \nhigh ileostomy output, he was also given loperamide and wafers \nuntil his output slowed to acceptable ranges. He was given a \nscript at discharge for loperamide. He tolerated a regular diet \nat time of discharge. \nGU: Patient had a Foley catheter that was removed at time of \ndischarge. Urine output was monitored as indicated. The patient \nwas kept on IV fluids when NPO and all I/Os were closely \nmonitored. At time of discharge, the patient was voiding without \ndifficulty. \nID: The patient's vital signs were monitored for signs of \ninfection and fever. He was given ciprofloxacin and flagyl for \nantibiotic coverage during his stay and these were discontinued \non day of discharge. \nHeme: The patient had blood levels checked post operatively \nduring the hospital course to monitor for signs of bleeding. The \npatient had vital signs, including heart rate and blood \npressure, monitored throughout the hospital stay. \nOn ___, the patient was discharged to home with services. \nAt discharge, he was tolerating a regular diet, passing flatus, \nstooling, voiding, and ambulating independently. He will \nfollow-up in the clinic in ___ weeks. This information was \ncommunicated to the patient directly prior to discharge. \n \nPost-Surgical Complications During Inpatient Admission: \n[ ] Post-Operative Ileus resolving w/o NGT \n[ ] Post-Operative Ileus requiring management with NGT \n[ ] UTI \n[ ] Wound Infection \n[ ] Anastomotic Leak \n[ ] Staple Line Bleed \n[ ] Congestive Heart failure \n[ ] ARF \n[ ] Acute Urinary retention, failure to void after Foley D/C'd \n[ ] Acute Urinary Retention requiring discharge with Foley \nCatheter \n[ ] DVT \n[ ] Pneumonia \n[ ] Abscess \n[x] None \n\nSocial Issues Causing a Delay in Discharge: \n[ ] Delay in organization of ___ services \n[ ] Difficulty finding appropriate rehab hospital disposition. \n[ ] Lack of insurance coverage for ___ services \n[ ] Lack of insurance coverage for prescribed medications. \n[ ] Family not agreeable to discharge plan. \n[ ] Patient knowledge deficit related to ileostomy delaying \ndispo\n[x] No social factors contributing in delay of discharge. \n\n \nMedications on Admission:\nPropranolol 20 mg PO daily, Vitamin D3 1000 PO daily, Magnesium \n250 mg PO daily, Muti-Vite 1 PO daily \n \nDischarge Medications:\n1. LOPERamide 2 mg PO TID \nRX *loperamide [Anti-Diarrhea] 2 mg 1 tablet by mouth three \ntimes a day Disp #*100 Tablet Refills:*0 \n2. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - \nModerate \nRX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours \nDisp #*30 Tablet Refills:*0 \n3. Propranolol 20 mg PO DAILY \n4. Vitamin D3 1000 PO daily, Magnesium 250 mg PO daily, \nMuti-Vite 1 PO daily \n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nsigmoid diverticulitis\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\n___ were admitted to the hospital from the ED for a \npost-operative leak from your Laparoscopic Sigmoid Colectomy on \n___ for surgical management of your sigmoid diverticulitis. \nThis postoperative leak required a laparoscpic washout and loop \nileostomy on ___. ___ since recovered well and ___ are now \nready to return home. Samples from your colon were taken and \nthis tissue has been sent to the pathology department for \nanalysis. ___ will receive these pathology results at your \nfollow-up appointment. If there is an urgent need for the \nsurgeon to contact ___ regarding these results they will contact \n___ before this time. ___ have tolerated a regular diet, are \npassing gas and your pain is controlled with pain medications by \nmouth. ___ may return home to finish your recovery. \n\n___ have a new ileostomy. The most common complication from a \nnew ileostomy placement is dehydration. The output from the \nstoma is stool from the small intestine and the water content is \nvery high. The stool is no longer passing through the large \nintestine which is where the water from the stool is reabsorbed \ninto the body and the stool becomes formed. ___ must measure \nyour ileostomy output for the next few weeks. The output from \nthe stoma should not be more than 1200cc or less than 500cc. If \n___ find that your output has become too much or too little, \nplease call the office for advice. The office nurse or nurse \npractitioner can recommend medications to increase or slow the \nileostomy output. Keep yourself well hydrated, if ___ notice \nyour ileostomy output increasing, take in more electrolyte drink \nsuch as Gatorade. Please monitor yourself for signs and symptoms \nof dehydration including: dizziness (especially upon standing), \nweakness, dry mouth, headache, or fatigue. If ___ notice these \nsymptoms please call the office or return to the emergency room \nfor evaluation if these symptoms are severe. ___ may eat a \nregular diet with your new ileostomy. However it is a good idea \nto avoid fatty or spicy foods and follow diet suggestions made \nto ___ by the ostomy nurses. ___ have also been prescribed \nImodium (loperamide). This medication will help to reduce \nexcessive output from your ostomy. Please continue to take this \nmedication until directed otherwise.\n \nPlease monitor the appearance of the ostomy and stoma and care \nfor it as instructed by the wound/ostomy nurses. ___ stoma \n(intestine that protrudes outside of your abdomen) should be \nbeefy red or pink, it may ooze small amounts of blood at times \nwhen touched and this should subside with time. The skin around \nthe ostomy site should be kept clean and intact. Monitor the \nskin around the stoma for bulging or signs of infection listed \nabove. Please care for the ostomy as ___ have been instructed by \nthe wound/ostomy nurses. ___ will be able to make an appointment \nwith the ostomy nurse in the clinic 7 days after surgery. ___ \nwill have a visiting nurse at home for the next few weeks \nhelping to monitor your ostomy until ___ are comfortable caring \nfor it on your own. \n\nCurrently your ileostomy is allowing the surgery in your large \nintestine to heal, which does take some time. ___ will come back \nto the hospital for reversal of this ileostomy when decided by \nyour surgical team. At your follow-up appointment in the clinic, \nwe will decide when is the best time for your second surgery. \nUntil this time there is healthy intestine that is still \nfunctioning as it normally would. This functioning healthy \nintestine will continue to produce mucus. Some of this mucus may \nleak or ___ may feel as though ___ need to have a bowel movement \n- ___ may sit on the toilet and empty this mucus as though ___ \nwere having a bowel movement or wear clothing that prevents \nleakage of this material such as a disposable pad. Please \ncontinue to take loperamide as prescribed to slow your ostomy \noutput.\n\n___ have ___ laparoscopic surgical incisions on your abdomen \nwhich are closed with internal sutures and a skin glue called \nDermabond. These are healing well however it is important that \n___ monitor these areas for signs and symptoms of infection \nincluding: increasing redness of the incision lines, \nwhite/green/yellow/malodorous drainage, increased pain at the \nincision, increased warmth of the skin at the incision, or \nswelling of the area. Please call the office if ___ develop any \nof these symptoms or a fever. ___ may go to the emergency room \nif your symptoms are severe. \n\n___ may shower; pat the incisions dry with a towel, do not rub. \nThe small incisions may be left open to the air. If closed with \nsteri-strips (little white adhesive strips) instead of \nDermabond, these will fall off over time, please do not remove \nthem. Please no baths or swimming for 6 weeks after surgery \nunless told otherwise by your surgical team.\n \n___ will be prescribed narcotic pain medication (oxycodone). \nThis medication should be taken when ___ have pain and as needed \nas written on the bottle. This is not a standing medication. ___ \nshould continue to take Tylenol for pain around the clock and \n___ can also take Advil. Please do not take more than 3000mg of \nTylenol in 24 hours. Do not drink alcohol while taking narcotic \npain medication or Tylenol. Please do not drive a car while \ntaking narcotic pain medication.\n \nNo heavy lifting greater than 6 lbs for until your first \npost-operative visit after surgery. Please no strenuous activity \nuntil this time unless instructed otherwise by Dr. ___, Dr. \n___ Dr. ___. \n \nThank ___ for allowing us to participate in your care! Our hope \nis that ___ will have a quick return to your life and usual \nactivities. \n\nGood luck! \n\n \n \nFollowup Instructions:\n___\n"
] | Allergies: prednisone / procainamide [MASKED] Complaint: post-operative leak from laparoscopic sigmoid colectomy on [MASKED] for medically refractory sigmoid diverticulitis Major Surgical or Invasive Procedure: Laparoscopic washout and loop ileostomy [MASKED] History of Present Illness: [MASKED] with past medical history of medically refractory sigmoid diverticulitis status post laparoscopic sigmoid colectomy on [MASKED] complicated by postoperative leak, now status post laparoscopic washout and loop ileostomy on [MASKED] Past Medical History: PMH: Diverticulitis, AFib s/p ablation not on anticoagulation followed at [MASKED] Cardiology PSH: Right Shoulder Surgery Social History: [MASKED] Family History: Relative Status Age Problem Comments Mother [MASKED] [MASKED] Father [MASKED] [MASKED] MOTOR VEHICLE ACCIDENT DIABETES MELLITUS CATARACTS Brother Living [MASKED] BRAIN TUMOR Sister Living 77 PALPITATIONS HYPERTENSION Sister Living [MASKED] BREAST CANCER s/p mastectomy, no chemo per wife and patient) Physical Exam: Admission physical exam (ED note): PHYSICAL EXAM: General appearance:[x] WNL- globally orientated, awake, alert [] other Heent: [x] WNL- N/C: PERRLA, [] other Heart: [x] WNL- RRR, no M/R/G [] other Lungs: [x] WNL- CTA [] other Abdomen: [] WNL- S/NT/ND [x] other: soft, tender on RLQ, non-distended Musculoskeletal: [x] WNL [] other Skin: [x] WNL [] other Discharge Physical Exam: VS: AVSS Gen: well appearing female, NAD HEENT: no lymphadenopathy, moist mucous membranes Lungs: CTAB Heart: rrr Abd: soft, nt, nd Incisions: cdi Extremities: wwp Pertinent Results: [MASKED] 08:40PM GLUCOSE-112* UREA N-11 CREAT-0.9 SODIUM-135 POTASSIUM-4.2 CHLORIDE-95* TOTAL CO2-30 ANION GAP-14 [MASKED] 08:40PM CALCIUM-9.0 PHOSPHATE-3.6 MAGNESIUM-2.1 [MASKED] 08:40PM WBC-16.6* RBC-5.32 HGB-15.2 HCT-47.1 MCV-89 MCH-28.6 MCHC-32.3 RDW-13.2 RDWSD-42.3 [MASKED] 08:40PM PLT COUNT-302 CT Abd/Pelvis [MASKED]: IMPRESSION: 1. No evidence of bowel obstruction. 2. Status post sigmoid resection. Evaluation is limited in this region due to CT artifact. Fluid and locules of air in the surgical bed appear to be extraluminal, unclear if related to recent surgery versus anastomotic leak. 3. Moderate intraperitoneal free air and subcutaneous tissues is within expected range for a recent laparoscopic procedure. It is difficult to evaluate for perforation, given the presence of free air after surgery. 4. Wall thickening of the distal descending colon is likely related to surgery. Brief Hospital Course: Mr. [MASKED] presented to the emergency room at [MASKED] on [MASKED] for complaints of severe lower abdominal pain. Of note, he had received a laparoscopic sigmoid colectomy on [MASKED] and had been discharged on [MASKED] without issues. This was thought to be due to a post-operative leak. He was taken for a laparoscopic washout and creation of loop ileostomy on [MASKED]. He tolerated the procedure well without complications (Please see operative note for further details). After a brief and uneventful stay in the PACU, the patient was transferred to the floor for further post-operative management. He did of note have some issues with tolerating diet advancement which are noted in the GI section below in detail. Neuro: Pain was well controlled on IV pain medications until tolerating a regular diet. CV: Vital signs were routinely monitored during the patient's length of stay. There were no cardiovascular issues during his hospitalization. Pulm: The patient was encouraged to ambulate, sit and get out of bed, use the incentive spirometer, and had oxygen saturation levels monitored as indicated. GI: The patient was initially kept NPO after the procedure. He had some difficulty with nausea and vomiting and on [MASKED] the ileostomy was cannulated with a red rubber which led to a large volume output. He continued to be distended with nausea and vomiting and thus an NGT was placed on [MASKED]. The NGT was kept in until resolution of his symptoms and was removed on [MASKED], after w he tolerated clears. He continued to slowly improve and his diet was cautiously advanced. Given his protracted course of not tolerating diet, he was also started on TPN, this was discontinued on [MASKED] before discharge. With regard to his high ileostomy output, he was also given loperamide and wafers until his output slowed to acceptable ranges. He was given a script at discharge for loperamide. He tolerated a regular diet at time of discharge. GU: Patient had a Foley catheter that was removed at time of discharge. Urine output was monitored as indicated. The patient was kept on IV fluids when NPO and all I/Os were closely monitored. At time of discharge, the patient was voiding without difficulty. ID: The patient's vital signs were monitored for signs of infection and fever. He was given ciprofloxacin and flagyl for antibiotic coverage during his stay and these were discontinued on day of discharge. Heme: The patient had blood levels checked post operatively during the hospital course to monitor for signs of bleeding. The patient had vital signs, including heart rate and blood pressure, monitored throughout the hospital stay. On [MASKED], the patient was discharged to home with services. At discharge, he was tolerating a regular diet, passing flatus, stooling, voiding, and ambulating independently. He will follow-up in the clinic in [MASKED] weeks. This information was communicated to the patient directly prior to discharge. Post-Surgical Complications During Inpatient Admission: [ ] 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 [ ] Abscess [x] None Social Issues Causing a Delay in Discharge: [ ] Delay in organization of [MASKED] services [ ] Difficulty finding appropriate rehab hospital disposition. [ ] Lack of insurance coverage for [MASKED] services [ ] Lack of insurance coverage for prescribed medications. [ ] Family not agreeable to discharge plan. [ ] Patient knowledge deficit related to ileostomy delaying dispo [x] No social factors contributing in delay of discharge. Medications on Admission: Propranolol 20 mg PO daily, Vitamin D3 1000 PO daily, Magnesium 250 mg PO daily, Muti-Vite 1 PO daily Discharge Medications: 1. LOPERamide 2 mg PO TID RX *loperamide [Anti-Diarrhea] 2 mg 1 tablet by mouth three times a day Disp #*100 Tablet Refills:*0 2. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg [MASKED] tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills:*0 3. Propranolol 20 mg PO DAILY 4. Vitamin D3 1000 PO daily, Magnesium 250 mg PO daily, Muti-Vite 1 PO daily Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: sigmoid diverticulitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], [MASKED] were admitted to the hospital from the ED for a post-operative leak from your Laparoscopic Sigmoid Colectomy on [MASKED] for surgical management of your sigmoid diverticulitis. This postoperative leak required a laparoscpic washout and loop ileostomy on [MASKED]. [MASKED] since recovered well and [MASKED] are now ready to return home. Samples from your colon were taken and this tissue has been sent to the pathology department for analysis. [MASKED] will receive these pathology results at your follow-up appointment. If there is an urgent need for the surgeon to contact [MASKED] regarding these results they will contact [MASKED] before this time. [MASKED] have tolerated a regular diet, are passing gas and your pain is controlled with pain medications by mouth. [MASKED] may return home to finish your recovery. [MASKED] have a new 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. [MASKED] 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 [MASKED] 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 [MASKED] 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 [MASKED] notice these symptoms please call the office or return to the emergency room for evaluation if these symptoms are severe. [MASKED] 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 [MASKED] by the ostomy nurses. [MASKED] have also been prescribed Imodium (loperamide). This medication will help to reduce excessive output from your ostomy. Please continue to take this medication until directed otherwise. Please monitor the appearance of the ostomy and stoma and care for it as instructed by the wound/ostomy nurses. [MASKED] 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 [MASKED] have been instructed by the wound/ostomy nurses. [MASKED] will be able to make an appointment with the ostomy nurse in the clinic 7 days after surgery. [MASKED] will have a visiting nurse at home for the next few weeks helping to monitor your ostomy until [MASKED] are comfortable caring for it on your own. Currently your ileostomy is allowing the surgery in your large intestine to heal, which does take some time. [MASKED] will come back to the hospital for reversal of this ileostomy when decided by your surgical team. At your follow-up appointment in the clinic, we will decide when is the best time for your second surgery. Until this time there is healthy intestine that is still functioning as it normally would. This functioning healthy intestine will continue to produce mucus. Some of this mucus may leak or [MASKED] may feel as though [MASKED] need to have a bowel movement - [MASKED] may sit on the toilet and empty this mucus as though [MASKED] were having a bowel movement or wear clothing that prevents leakage of this material such as a disposable pad. Please continue to take loperamide as prescribed to slow your ostomy output. [MASKED] have [MASKED] laparoscopic surgical incisions on your abdomen which are closed with internal sutures and a skin glue called Dermabond. These are healing well however it is important that [MASKED] monitor these areas for signs and symptoms of infection including: increasing redness of the incision lines, white/green/yellow/malodorous drainage, increased pain at the incision, increased warmth of the skin at the incision, or swelling of the area. Please call the office if [MASKED] develop any of these symptoms or a fever. [MASKED] may go to the emergency room if your symptoms are severe. [MASKED] may shower; pat the incisions dry with a towel, do not rub. The small incisions may be left open to the air. If closed with steri-strips (little white adhesive strips) instead of Dermabond, these will fall off over time, please do not remove them. Please no baths or swimming for 6 weeks after surgery unless told otherwise by your surgical team. [MASKED] will be prescribed narcotic pain medication (oxycodone). This medication should be taken when [MASKED] have pain and as needed as written on the bottle. This is not a standing medication. [MASKED] should continue to take Tylenol for pain around the clock and [MASKED] can also take Advil. Please do not take more than 3000mg of Tylenol in 24 hours. Do not drink alcohol while taking narcotic pain medication or Tylenol. Please do not drive a car while taking narcotic pain medication. No heavy lifting greater than 6 lbs for until your first post-operative visit after surgery. Please no strenuous activity until this time unless instructed otherwise by Dr. [MASKED], Dr. [MASKED] Dr. [MASKED]. Thank [MASKED] for allowing us to participate in your care! Our hope is that [MASKED] will have a quick return to your life and usual activities. Good luck! Followup Instructions: [MASKED] | [
"K9189",
"K651",
"K5732",
"T814XXA",
"Y832",
"Y929",
"E780",
"F419",
"I4891",
"K910",
"K660"
] | [
"K9189: Other postprocedural complications and disorders of digestive system",
"K651: Peritoneal abscess",
"K5732: Diverticulitis of large intestine without perforation or abscess without bleeding",
"T814XXA: Infection following a procedure",
"Y832: Surgical operation with anastomosis, bypass or graft as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure",
"Y929: Unspecified place or not applicable",
"E780: Pure hypercholesterolemia",
"F419: Anxiety disorder, unspecified",
"I4891: Unspecified atrial fibrillation",
"K910: Vomiting following gastrointestinal surgery",
"K660: Peritoneal adhesions (postprocedural) (postinfection)"
] | [
"Y929",
"F419",
"I4891"
] | [] |
15,589,086 | 22,050,603 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \n___\n \nAttending: ___\n \nChief Complaint:\nHematochezia, anemia\n\n \nMajor Surgical or Invasive Procedure:\nEndoscopy and colonoscopy ___\n\n \nHistory of Present Illness:\n___ s/p deceased donor kidney transplant x2, most recently on \n___, with recent diagnosis of thrush, now presenting \nwith bloody loose stools and anemia. Loose stools started on \n___ with some bright red blood in the toilet. \nPatient's wife was unable to quantify volume, but feels it was a \nsignificant amount. Also has mild abdominal cramping, which \nquickly subsided. No F/C/N/V/SOB/CP.\n\nOf note, patient was recently in the ED on for thrush and was \nstarted on Nystatin. He attributes his loose stools to the \nnystatin.\n\nOn arrival to the ED on ___ morning, pt was \ntachycardic and had a tender abdomen. He refused a rectal exam \ndue to his neutropenia.\n\n- Initial Vitals: 98.9, 98, 141/41, 22, 97% RA \n- EKG: Sinus rhythm, LBBB\n\n#Labs: Neutropenia with WBC=1.4, H/H=7.9/26.0, Cr=1.0, Na=131, \nCa=7.7, Mg=1.5.\n\n#Consults: Renal transplant, recommending-\n - Allograft function stable and Cr is at baseline; no \ntenderness over graft site\n - Check CMV VL, retic%\n - Add-on tacro level to 6:30am labs\n - Ensure patient receives home meds in ED including prednisone \n5mg PO qday, tacrolimus 5mg PO BID, Bactrim SS 1 tab PO daily, \nsodium bicarb 650mg 3 tabs PO TID, isoniazid ___ PO daily, \npyridoxine 100mg PO daily\n - Admission pending to ET (___)\n\n# Pt was given:\n- 1U of packed red blood cells.\n- IV Pantoprazole 40 mg ___ \n- PredniSONE 5 mg ___ \n- Tacrolimus 5 mg ___ \n- Sulfameth/Trimethoprim SS 1 TAB ___ \n- Sodium Bicarbonate ___ mg ___ \n- Isoniazid ___ mg ___ \n- Pyridoxine 100 mg ___ \n- Magnesium Oxide 400 mg ___ \n- Sodium Bicarbonate ___ Not Given \n- Nystatin Oral Suspension 5 mL ___ \n\nUpon arrival to the floor, patient was comfortable with no \ncomplaints. He was accompanied by his wife, who provided \nadditional history.\n \nPast Medical History:\n1. Renal transplant as above.\n2. Adult onset diabetes mellitus.\n3. Frontal cognitive deficits.\n4. History of hepatitis C, not previously treated.\n5. Hypertension.\n6. Sexual dysfunction.\n7. Vascular dementia.\n8. Anemia.\n9. Prior sarcoidosis.\n\nNoted ___:\nESRD ___ HTN and DM2, s/p creation of a LUE AVF in ___, s/p \ntransplant ___ years ago \n-Diabetes Mellitus Type 2, Last HgA1c 7.3% in ___ \n-Hypertension \n-Hyperlipidemia \n-Sarcoidosis with recurrent hypercalcemia when off prednisone \n-UGIB, once ___ EtOH gastritis, once ___ duodenal ulcer \n-Anemia, microcytic \n-Hepatitis C \n-Depression/Anxiety \n-Osteopenia \n-Hx of Migraines with photophobia \n-Sexual Dysfunction \n-___ renal transplant \n\n \nSocial History:\n___\nFamily History:\nThe patient brother died of DM. His father lived until age ___, \nand his mother died at age ___ secondary to a poisoning. There is \nno family history of kidney disease. \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n========================\nVS: T 98.0 BP 137/72 HR 85 RR 18 O2 100%RA \nWeight: (admit wt: 63.05 kg)\nGENERAL: Pleasant, thin elderly male. No apparent distress. \nHEENT: Normocephalic, atraumatic. No conjunctival pallor or \nscleral icterus. Pupils 2mm b/L, sluggish reaction to light. \nEOMI. MMM, clear OP with minimal thrush and poor dentition. \nNECK: Supple.\nCARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops. \nPULMONARY: Clear to auscultation bilaterally, without wheezes or \nrhonchi. \nABDOMEN: Soft, non-tender, non-distended, no organomegaly. \nEXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or \nedema.\nSKIN: Without rash. \nNEUROLOGIC: A&Ox3, CN II-XII grossly normal. Moving all \nextremities equally b/L. \n\nDISCHARGE PHYSICAL EXAM:\n========================\nVitals: 98.3 BP 140/70 HR 81 RR 18 O2 97% RA \nWeight: ___ kg (admit wt: 63.05 kg)\nGENERAL: Pleasant, thin elderly male. No apparent distress. \nHEENT: Normocephalic, atraumatic. No conjunctival pallor or \nscleral icterus. Pupils 2mm b/L, sluggish reaction to light. \nEOMI. MMM, clear OP with minimal thrush and poor dentition. \nNECK: Supple.\nCARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops. \nPULMONARY: Clear to auscultation bilaterally, without wheezes or \nrhonchi. \nABDOMEN: Soft, non-tender, non-distended, no organomegaly. \nEXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or \nedema.\nSKIN: Without rash. \nNEUROLOGIC: A&Ox3, CN II-XII grossly normal. Moving all \nextremities equally b/L. \n\n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 01:55AM BLOOD WBC-1.4* RBC-3.78*# Hgb-7.9*# Hct-26.0*# \nMCV-69* MCH-20.9* MCHC-30.4* RDW-18.7* RDWSD-45.1 Plt ___\n___ 01:55AM BLOOD Neuts-26* Bands-12* ___ Monos-34* \nEos-0 Baso-0 ___ Myelos-0 AbsNeut-0.53* \nAbsLymp-0.39* AbsMono-0.48 AbsEos-0.00* AbsBaso-0.00*\n___ 01:55AM BLOOD Hypochr-NORMAL Anisocy-NORMAL \nPoiklo-NORMAL Macrocy-NORMAL Microcy-3+ Polychr-NORMAL\n___ 02:54AM BLOOD ___ PTT-27.7 ___\n___ 07:35AM BLOOD Ret Aut-1.1 Abs Ret-0.04\n___ 01:55AM BLOOD Glucose-264* UreaN-21* Creat-1.0 Na-131* \nK-4.6 Cl-98 HCO3-22 AnGap-16\n___ 01:55AM BLOOD ALT-14 AST-41* AlkPhos-53 TotBili-0.3 \nDirBili-<0.2 IndBili-0.3\n___ 01:55AM BLOOD Albumin-3.1* Calcium-7.7* Mg-1.5*\n___ 09:34PM BLOOD calTIBC-139* Ferritn-1030* TRF-107*\n___ 06:59AM BLOOD %HbA1c-6.7* eAG-146*\n___ 04:05PM BLOOD tacroFK-9.2\n\nDISCHARGE LABS:\n================\n___ 06:46AM BLOOD WBC-2.9* RBC-3.20* Hgb-8.2* Hct-25.7* \nMCV-80* MCH-25.6* MCHC-31.9* RDW-22.8* RDWSD-66.4* Plt ___\n___ 06:46AM BLOOD Neuts-41 Bands-0 ___ Monos-37* \nEos-0 Baso-0 ___ Metas-1* Myelos-0 Plasma-1* AbsNeut-1.19* \nAbsLymp-0.58* AbsMono-1.07* AbsEos-0.00* AbsBaso-0.00*\n___ 06:46AM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-1+ \nMacrocy-NORMAL Microcy-NORMAL Polychr-2+ Ovalocy-1+ Target-1+ \nSchisto-1+ Envelop-1+ Bite-1+\n___ 06:46AM BLOOD ___ PTT-26.0 ___\n___ 06:46AM BLOOD Glucose-113* UreaN-14 Creat-1.1 Na-131* \nK-4.4 Cl-95* HCO3-26 AnGap-14\n___ 06:46AM BLOOD ALT-14 AST-23 AlkPhos-60 TotBili-0.2\n___ 06:46AM BLOOD Albumin-3.0* Calcium-8.0* Phos-3.0 Mg-1.6\n___ 06:46AM BLOOD tacroFK-6.6\n\nMICRO:\n======\n___: URINE CX NEGATIVE\n___: CMV VIRAL LOAD NEGATIVE\n\nPATHOLOGY:\n==========\n___ Terminal ileum, mucosal biopsy:\n- Terminal ileal mucosa with prominent lymphoid tissue (Peyer's \npatches), rare superficial erosion,\nfocal adjacent mildly active inflammation, and increased basal \ncrypt apoptoses. See note.\n- No diagnostic chronic enteritis or granulomata are identified.\n- CMV immunohistochemical stain is negative for viral \ninclusions, with satisfactory control.\nNote: The findings are mild and non-specific, but raise the \npossibility of a drug effect or an\nacute/self-limited infectious process. Early inflammatory bowel \ndisease (Crohn's disease) is less\nlikely, but cannot be excluded; further clinical correlation is \nrecommended. Dr. ___ was\nnotified of the diagnosis on ___.\n\n \nBrief Hospital Course:\n___ PMHx of renal transplant x2 (most recently in ___, \nneutropenia ___ immunosuppression and T2DM admitted with acute \nanemia in the setting of hematochezia. \n\n# Anemia, # GIB:\nOn presentation patient had multiple episodes of hematochezia \nrequiring 4 units pRBCs to maintain hemoglobin>7. Patient \nunderwent EGD and colonoscopy. Given that the patient was \nneutropenic, he was at higher risk of infection during the \nprocedure. He was found to have esophagitis and healed ulcers on \nEGD, and colonoscopy showed ulcerations in the terminal ileum, \nwhich were biopsied and stained for CMV. Pathology indicated \nulcerations were consistent with drug effect--attributed to \nCellcept, which was discontinued prior to admission. Patient was \nneutropenic prior to undergoing colonoscopy. Case was discussed \nwith gastroenterology and most studies suggest that therapeutic \nand diagnostic yield of endoscopies are high and the risk of \ninfectious and non-infectious complications are low. (___ et al \n___ ___. In addition, ASGE recommends considering antibiotic \nprophylaxis for neutropenic patients with ANC <500, for which \nthis patient did not meet criteria. No transfusions were \nrequired for several days prior to discharge. He is now having \nformed bowel movements without visible blood. Hemoglobin \nremained stable around 8 g/dL.\n\n#Neutropenia\nPatient was neutropenic at the time of admission with ANC of \n530, which was secondary to Cellcept, which had been \ndiscontinued prior to admission. At the time of discharge he was \nno longer neutropenic with ANC of 1190. \n\n#Kidney transplant/Immunosuppression\nHe was maintained on immunosuppression during his \nhospitalization. At the time of discharge he was taking \nTacrolimus 8mg BID, Prednisone 5mg and prophylactic single \nstrength bactrium. \n\n# Oral Candidiasis: \nMinimal thrush on admission exam; patient had recently started \nnystatin. Likely due to neutropenia from immunosuppression. He \nwas continued on nystatin 5 mL QID x14 days.\n\n# Hypertension: \nInitially held home amlodipine 5mg in setting of active bleed. \nHe was hypertensive during admission and restarted on home \nmedication prior to discharge. \n\n# DM2: \nWell controlled on glargine 6U at breakfast. HbA1c=6.7%. He was \non a Humalog sliding scale during admission requiring insulin to \nmaintain glycemic control. Would monitor blood glucose and \nconsider sliding scale as an outpatient. \n\n# Latent Tuberculosis \nContinued on isoniazid ___ PO daily and pyridoxine 100mg PO \ndaily \n\nFULL CODE CONFIRMED\nName of health care proxy: ___\nRelationship: wife\nPhone number: ___\n\n====================\nTRANSITIONAL ISSUES:\n====================\nGeneral: 62.1 kg\nDischarge Cr: 1.1\n\nGI BLEED/ANEMIA:\n[ ] Monitor Hb after discharge.\n[ ] Labs scheduled for ___ (standing)\n[ ] Verify resolution of hematochezia with discontinuation of \nCellcept\n[ ] Aspirin 81 mg daily was held during hospitalization and NOT \nrestarted at the time of discharge. This can be restarted at the \ndiscretion of his outpatient providers if his blood counts \nremain stable.\n\nIMMUNOSUPPRESSION:\n[ ] Monitor Tacrolimus levels after discharge\n[ ] Labs scheduled for ___ (standing)\n\nDM\n[ ] Consider an insulin sliding scale at mealtimes. Sliding \nscale was required during hospitalization to maintain glycemic \ncontrol.\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Acetaminophen 650 mg PO Q6H:PRN Pain \n2. amLODIPine 5 mg PO DAILY \n3. Aspirin 81 mg PO DAILY \n4. Ferrous Sulfate 325 mg PO DAILY \n5. Isoniazid ___ mg PO DAILY \n6. Multivitamins 1 TAB PO DAILY \n7. Omeprazole 20 mg PO DAILY \n8. PredniSONE 5 mg PO DAILY \n9. Pyridoxine 100 mg PO DAILY \n10. Tacrolimus 5 mg PO Q12H \n11. Tamsulosin 0.4 mg PO QHS \n12. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY \n13. Vitamin D ___ UNIT PO DAILY \n14. Sodium Bicarbonate 650 mg PO TID \n15. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \n16. Glargine 6 Units Breakfast\n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain \n2. Nystatin Oral Suspension 5 mL PO QID thrush \n3. Pantoprazole 40 mg PO Q12H \nRX *pantoprazole 40 mg 1 tablet(s) by mouth twice daily Disp \n#*60 Tablet Refills:*1 \n4. Glargine 6 Units Breakfast \n5. Tacrolimus 8 mg PO Q12H \nRX *tacrolimus 1 mg 8 capsule(s) by mouth twice daily Disp #*480 \nCapsule Refills:*0 \n6. amLODIPine 5 mg PO DAILY \n7. Ferrous Sulfate 325 mg PO DAILY \n8. Isoniazid ___ mg PO DAILY \n9. Multivitamins 1 TAB PO DAILY \n10. PredniSONE 5 mg PO DAILY \n11. Pyridoxine 100 mg PO DAILY \n12. Sodium Bicarbonate 650 mg PO TID \n13. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \n14. Tamsulosin 0.4 mg PO QHS \n15. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY \n16. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary: Terminal Ilium Ulcerations secondary to Cellcept\nSecondary: Microcytic anemia, Neutropenia, Latent tuberculosis, \nDiabetes Mellitus, Hypertension\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nYou were admitted to ___ because you had blood in your stool. \nYou were given blood transfusions to help replace the blood you \nlost. You had a colonoscopy and there were ulcers in your small \nintestine that were likely caused by a medication you were \npreviously taking called Cellcept. You had stopped this \nmedication before coming to the hospital. Before you went home \nthe amount of blood in your stool had decreased and your blood \ncounts were stable.\n\nYour Tacrolimus dose was increased to 8mg twice a day. Continue \nto take your Prednisone and your Bactrim at the same doses as \nbefore.\n\nIt was a pleasure taking care of you.\n\nYour ___ Team\n \nFollowup Instructions:\n___\n"
] | Allergies: [MASKED] Chief Complaint: Hematochezia, anemia Major Surgical or Invasive Procedure: Endoscopy and colonoscopy [MASKED] History of Present Illness: [MASKED] s/p deceased donor kidney transplant x2, most recently on [MASKED], with recent diagnosis of thrush, now presenting with bloody loose stools and anemia. Loose stools started on [MASKED] with some bright red blood in the toilet. Patient's wife was unable to quantify volume, but feels it was a significant amount. Also has mild abdominal cramping, which quickly subsided. No F/C/N/V/SOB/CP. Of note, patient was recently in the ED on for thrush and was started on Nystatin. He attributes his loose stools to the nystatin. On arrival to the ED on [MASKED] morning, pt was tachycardic and had a tender abdomen. He refused a rectal exam due to his neutropenia. - Initial Vitals: 98.9, 98, 141/41, 22, 97% RA - EKG: Sinus rhythm, LBBB #Labs: Neutropenia with WBC=1.4, H/H=7.9/26.0, Cr=1.0, Na=131, Ca=7.7, Mg=1.5. #Consults: Renal transplant, recommending- - Allograft function stable and Cr is at baseline; no tenderness over graft site - Check CMV VL, retic% - Add-on tacro level to 6:30am labs - Ensure patient receives home meds in ED including prednisone 5mg PO qday, tacrolimus 5mg PO BID, Bactrim SS 1 tab PO daily, sodium bicarb 650mg 3 tabs PO TID, isoniazid [MASKED] PO daily, pyridoxine 100mg PO daily - Admission pending to ET ([MASKED]) # Pt was given: - 1U of packed red blood cells. - IV Pantoprazole 40 mg [MASKED] - PredniSONE 5 mg [MASKED] - Tacrolimus 5 mg [MASKED] - Sulfameth/Trimethoprim SS 1 TAB [MASKED] - Sodium Bicarbonate [MASKED] mg [MASKED] - Isoniazid [MASKED] mg [MASKED] - Pyridoxine 100 mg [MASKED] - Magnesium Oxide 400 mg [MASKED] - Sodium Bicarbonate [MASKED] Not Given - Nystatin Oral Suspension 5 mL [MASKED] Upon arrival to the floor, patient was comfortable with no complaints. He was accompanied by his wife, who provided additional history. Past Medical History: 1. Renal transplant as above. 2. Adult onset diabetes mellitus. 3. Frontal cognitive deficits. 4. History of hepatitis C, not previously treated. 5. Hypertension. 6. Sexual dysfunction. 7. Vascular dementia. 8. Anemia. 9. Prior sarcoidosis. Noted [MASKED]: ESRD [MASKED] HTN and DM2, s/p creation of a LUE AVF in [MASKED], s/p transplant [MASKED] years ago -Diabetes Mellitus Type 2, Last HgA1c 7.3% in [MASKED] -Hypertension -Hyperlipidemia -Sarcoidosis with recurrent hypercalcemia when off prednisone -UGIB, once [MASKED] EtOH gastritis, once [MASKED] duodenal ulcer -Anemia, microcytic -Hepatitis C -Depression/Anxiety -Osteopenia -Hx of Migraines with photophobia -Sexual Dysfunction -[MASKED] renal transplant Social History: [MASKED] Family History: The patient brother died of DM. His father lived until age [MASKED], and his mother died at age [MASKED] secondary to a poisoning. There is no family history of kidney disease. Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: T 98.0 BP 137/72 HR 85 RR 18 O2 100%RA Weight: (admit wt: 63.05 kg) GENERAL: Pleasant, thin elderly male. No apparent distress. HEENT: Normocephalic, atraumatic. No conjunctival pallor or scleral icterus. Pupils 2mm b/L, sluggish reaction to light. EOMI. MMM, clear OP with minimal thrush and poor dentition. NECK: Supple. CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops. PULMONARY: Clear to auscultation bilaterally, without wheezes or rhonchi. ABDOMEN: Soft, non-tender, non-distended, no organomegaly. EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or edema. SKIN: Without rash. NEUROLOGIC: A&Ox3, CN II-XII grossly normal. Moving all extremities equally b/L. DISCHARGE PHYSICAL EXAM: ======================== Vitals: 98.3 BP 140/70 HR 81 RR 18 O2 97% RA Weight: [MASKED] kg (admit wt: 63.05 kg) GENERAL: Pleasant, thin elderly male. No apparent distress. HEENT: Normocephalic, atraumatic. No conjunctival pallor or scleral icterus. Pupils 2mm b/L, sluggish reaction to light. EOMI. MMM, clear OP with minimal thrush and poor dentition. NECK: Supple. CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops. PULMONARY: Clear to auscultation bilaterally, without wheezes or rhonchi. ABDOMEN: Soft, non-tender, non-distended, no organomegaly. EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or edema. SKIN: Without rash. NEUROLOGIC: A&Ox3, CN II-XII grossly normal. Moving all extremities equally b/L. Pertinent Results: ADMISSION LABS: =============== [MASKED] 01:55AM BLOOD WBC-1.4* RBC-3.78*# Hgb-7.9*# Hct-26.0*# MCV-69* MCH-20.9* MCHC-30.4* RDW-18.7* RDWSD-45.1 Plt [MASKED] [MASKED] 01:55AM BLOOD Neuts-26* Bands-12* [MASKED] Monos-34* Eos-0 Baso-0 [MASKED] Myelos-0 AbsNeut-0.53* AbsLymp-0.39* AbsMono-0.48 AbsEos-0.00* AbsBaso-0.00* [MASKED] 01:55AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-3+ Polychr-NORMAL [MASKED] 02:54AM BLOOD [MASKED] PTT-27.7 [MASKED] [MASKED] 07:35AM BLOOD Ret Aut-1.1 Abs Ret-0.04 [MASKED] 01:55AM BLOOD Glucose-264* UreaN-21* Creat-1.0 Na-131* K-4.6 Cl-98 HCO3-22 AnGap-16 [MASKED] 01:55AM BLOOD ALT-14 AST-41* AlkPhos-53 TotBili-0.3 DirBili-<0.2 IndBili-0.3 [MASKED] 01:55AM BLOOD Albumin-3.1* Calcium-7.7* Mg-1.5* [MASKED] 09:34PM BLOOD calTIBC-139* Ferritn-1030* TRF-107* [MASKED] 06:59AM BLOOD %HbA1c-6.7* eAG-146* [MASKED] 04:05PM BLOOD tacroFK-9.2 DISCHARGE LABS: ================ [MASKED] 06:46AM BLOOD WBC-2.9* RBC-3.20* Hgb-8.2* Hct-25.7* MCV-80* MCH-25.6* MCHC-31.9* RDW-22.8* RDWSD-66.4* Plt [MASKED] [MASKED] 06:46AM BLOOD Neuts-41 Bands-0 [MASKED] Monos-37* Eos-0 Baso-0 [MASKED] Metas-1* Myelos-0 Plasma-1* AbsNeut-1.19* AbsLymp-0.58* AbsMono-1.07* AbsEos-0.00* AbsBaso-0.00* [MASKED] 06:46AM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-1+ Macrocy-NORMAL Microcy-NORMAL Polychr-2+ Ovalocy-1+ Target-1+ Schisto-1+ Envelop-1+ Bite-1+ [MASKED] 06:46AM BLOOD [MASKED] PTT-26.0 [MASKED] [MASKED] 06:46AM BLOOD Glucose-113* UreaN-14 Creat-1.1 Na-131* K-4.4 Cl-95* HCO3-26 AnGap-14 [MASKED] 06:46AM BLOOD ALT-14 AST-23 AlkPhos-60 TotBili-0.2 [MASKED] 06:46AM BLOOD Albumin-3.0* Calcium-8.0* Phos-3.0 Mg-1.6 [MASKED] 06:46AM BLOOD tacroFK-6.6 MICRO: ====== [MASKED]: URINE CX NEGATIVE [MASKED]: CMV VIRAL LOAD NEGATIVE PATHOLOGY: ========== [MASKED] Terminal ileum, mucosal biopsy: - Terminal ileal mucosa with prominent lymphoid tissue (Peyer's patches), rare superficial erosion, focal adjacent mildly active inflammation, and increased basal crypt apoptoses. See note. - No diagnostic chronic enteritis or granulomata are identified. - CMV immunohistochemical stain is negative for viral inclusions, with satisfactory control. Note: The findings are mild and non-specific, but raise the possibility of a drug effect or an acute/self-limited infectious process. Early inflammatory bowel disease (Crohn's disease) is less likely, but cannot be excluded; further clinical correlation is recommended. Dr. [MASKED] was notified of the diagnosis on [MASKED]. Brief Hospital Course: [MASKED] PMHx of renal transplant x2 (most recently in [MASKED], neutropenia [MASKED] immunosuppression and T2DM admitted with acute anemia in the setting of hematochezia. # Anemia, # GIB: On presentation patient had multiple episodes of hematochezia requiring 4 units pRBCs to maintain hemoglobin>7. Patient underwent EGD and colonoscopy. Given that the patient was neutropenic, he was at higher risk of infection during the procedure. He was found to have esophagitis and healed ulcers on EGD, and colonoscopy showed ulcerations in the terminal ileum, which were biopsied and stained for CMV. Pathology indicated ulcerations were consistent with drug effect--attributed to Cellcept, which was discontinued prior to admission. Patient was neutropenic prior to undergoing colonoscopy. Case was discussed with gastroenterology and most studies suggest that therapeutic and diagnostic yield of endoscopies are high and the risk of infectious and non-infectious complications are low. ([MASKED] et al [MASKED] [MASKED]. In addition, ASGE recommends considering antibiotic prophylaxis for neutropenic patients with ANC <500, for which this patient did not meet criteria. No transfusions were required for several days prior to discharge. He is now having formed bowel movements without visible blood. Hemoglobin remained stable around 8 g/dL. #Neutropenia Patient was neutropenic at the time of admission with ANC of 530, which was secondary to Cellcept, which had been discontinued prior to admission. At the time of discharge he was no longer neutropenic with ANC of 1190. #Kidney transplant/Immunosuppression He was maintained on immunosuppression during his hospitalization. At the time of discharge he was taking Tacrolimus 8mg BID, Prednisone 5mg and prophylactic single strength bactrium. # Oral Candidiasis: Minimal thrush on admission exam; patient had recently started nystatin. Likely due to neutropenia from immunosuppression. He was continued on nystatin 5 mL QID x14 days. # Hypertension: Initially held home amlodipine 5mg in setting of active bleed. He was hypertensive during admission and restarted on home medication prior to discharge. # DM2: Well controlled on glargine 6U at breakfast. HbA1c=6.7%. He was on a Humalog sliding scale during admission requiring insulin to maintain glycemic control. Would monitor blood glucose and consider sliding scale as an outpatient. # Latent Tuberculosis Continued on isoniazid [MASKED] PO daily and pyridoxine 100mg PO daily FULL CODE CONFIRMED Name of health care proxy: [MASKED] Relationship: wife Phone number: [MASKED] ==================== TRANSITIONAL ISSUES: ==================== General: 62.1 kg Discharge Cr: 1.1 GI BLEED/ANEMIA: [ ] Monitor Hb after discharge. [ ] Labs scheduled for [MASKED] (standing) [ ] Verify resolution of hematochezia with discontinuation of Cellcept [ ] Aspirin 81 mg daily was held during hospitalization and NOT restarted at the time of discharge. This can be restarted at the discretion of his outpatient providers if his blood counts remain stable. IMMUNOSUPPRESSION: [ ] Monitor Tacrolimus levels after discharge [ ] Labs scheduled for [MASKED] (standing) DM [ ] Consider an insulin sliding scale at mealtimes. Sliding scale was required during hospitalization to maintain glycemic control. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Acetaminophen 650 mg PO Q6H:PRN Pain 2. amLODIPine 5 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Ferrous Sulfate 325 mg PO DAILY 5. Isoniazid [MASKED] mg PO DAILY 6. Multivitamins 1 TAB PO DAILY 7. Omeprazole 20 mg PO DAILY 8. PredniSONE 5 mg PO DAILY 9. Pyridoxine 100 mg PO DAILY 10. Tacrolimus 5 mg PO Q12H 11. Tamsulosin 0.4 mg PO QHS 12. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY 13. Vitamin D [MASKED] UNIT PO DAILY 14. Sodium Bicarbonate 650 mg PO TID 15. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 16. Glargine 6 Units Breakfast Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain 2. Nystatin Oral Suspension 5 mL PO QID thrush 3. Pantoprazole 40 mg PO Q12H RX *pantoprazole 40 mg 1 tablet(s) by mouth twice daily Disp #*60 Tablet Refills:*1 4. Glargine 6 Units Breakfast 5. Tacrolimus 8 mg PO Q12H RX *tacrolimus 1 mg 8 capsule(s) by mouth twice daily Disp #*480 Capsule Refills:*0 6. amLODIPine 5 mg PO DAILY 7. Ferrous Sulfate 325 mg PO DAILY 8. Isoniazid [MASKED] mg PO DAILY 9. Multivitamins 1 TAB PO DAILY 10. PredniSONE 5 mg PO DAILY 11. Pyridoxine 100 mg PO DAILY 12. Sodium Bicarbonate 650 mg PO TID 13. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 14. Tamsulosin 0.4 mg PO QHS 15. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY 16. Vitamin D [MASKED] UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary: Terminal Ilium Ulcerations secondary to Cellcept Secondary: Microcytic anemia, Neutropenia, Latent tuberculosis, Diabetes Mellitus, Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], You were admitted to [MASKED] because you had blood in your stool. You were given blood transfusions to help replace the blood you lost. You had a colonoscopy and there were ulcers in your small intestine that were likely caused by a medication you were previously taking called Cellcept. You had stopped this medication before coming to the hospital. Before you went home the amount of blood in your stool had decreased and your blood counts were stable. Your Tacrolimus dose was increased to 8mg twice a day. Continue to take your Prednisone and your Bactrim at the same doses as before. It was a pleasure taking care of you. Your [MASKED] Team Followup Instructions: [MASKED] | [
"K633",
"D688",
"B370",
"D702",
"E871",
"D62",
"Z940",
"T451X5A",
"Y92009",
"E119",
"I10",
"K219",
"K209",
"Y929",
"K5730",
"K635",
"K648",
"D869",
"R7611",
"Z794",
"F0150",
"E785",
"Z87891"
] | [
"K633: Ulcer of intestine",
"D688: Other specified coagulation defects",
"B370: Candidal stomatitis",
"D702: Other drug-induced agranulocytosis",
"E871: Hypo-osmolality and hyponatremia",
"D62: Acute posthemorrhagic anemia",
"Z940: Kidney transplant status",
"T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter",
"Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause",
"E119: Type 2 diabetes mellitus without complications",
"I10: Essential (primary) hypertension",
"K219: Gastro-esophageal reflux disease without esophagitis",
"K209: Esophagitis, unspecified",
"Y929: Unspecified place or not applicable",
"K5730: Diverticulosis of large intestine without perforation or abscess without bleeding",
"K635: Polyp of colon",
"K648: Other hemorrhoids",
"D869: Sarcoidosis, unspecified",
"R7611: Nonspecific reaction to tuberculin skin test without active tuberculosis",
"Z794: Long term (current) use of insulin",
"F0150: Vascular dementia without behavioral disturbance",
"E785: Hyperlipidemia, unspecified",
"Z87891: Personal history of nicotine dependence"
] | [
"E871",
"D62",
"E119",
"I10",
"K219",
"Y929",
"Z794",
"E785",
"Z87891"
] | [] |
17,612,019 | 28,843,588 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nMenthol / oxaliplatin / Amoxicillin\n \nAttending: ___\n \nChief Complaint:\nELECTIVE CHEMO\n \nMajor Surgical or Invasive Procedure:\nC13B D1 Oxaliplatin 3 bag intermediate desensitization \n \nHistory of Present Illness:\nPRIMARY DIAGNOSIS: Colon Cancer\nPRIMARY ONCOLOGIST: Dr. ___ COMPLAINT: Elective admission for chemotherapy\n\nHISTORY OF PRESENT ILLNESS:\nMs. ___ is a pleasant ___ w/ metastatic KRAS mutated colon\ncancer on modified FOLFOX who presents for C11D1 oxaliplatin\ndesensitization. In ___, she had a reaction to oxaliplatin\nwith shortness of breath, throat tightness, tongue swelling, and\nHTN which were relatively slow to improve. Her prior doses of\noxaliplatin was well tolerated with desensitization, however on\n___ developed hemolysis. \n\nShe has since tolerated her prior doses well. She states she has\notherwise been doing well. Denied any F/C/N/V/abd pain. Bowel \nmovements\nregular. ___ started and she is appropriately not fasting. \n \nPast Medical History:\nPAST ONCOLOGIC HISTORY (per OMR):\nColon cancer stage IV (T3N2bM1b) KRAS mutated, MSI stable\n- ___ Had a few episodes where she felt hot and dizzy, \nfor\nwhich she was seen in urgent care. \n- ___ She experienced a similar episode with dizziness,\nlightheadedness, nausea, vomiting, and abdominal pain and\npresented to the ___ ED. \n- ___ CT abdomen/pelvis showed abnormal thickening of the\nterminal ileum and cecum. A left adnexal hypodense tubular area\nwas also seen. \n- ___ Pelvic US showed a 5.4 x 5.5 x 6.3 cm solid and \ncystic\nmass arising from the left ovary. Colonoscopy found a large\nfriable mass in the proximal portion of the ascending colon,\nwhich the scope could not pass. Biopsy revealed low grade\nadenocarcinoma. CEA on ___ was 10. \n- ___ CT chest was negative. \n- ___ Underwent a right colectomy and left\nsalpingo-oophorectomy. Intraoperatively, the small bowel was run\nand no lesions were found. At the conclusion of the case the\namount of remaining gross disease included a 1-cm nodule on the\nbladder serosa as well as a small rind of tumor on the left\npelvic sidewall overlying the ureter. Pathology revealed\nlow-grade adenocarcinoma, pT3, pN2b (13 of 28 positive lymph\nnodes), pM1 based on involvement of the left ovary. Margins from\nthe colectomy were negative. Lymphovascular invasion and\nperineural invasion was seen. KRAS was mutated and MMR proteins\nwere intact by IHC. \n- ___: CT a/p with interval increase in left paraaortic\nlymph node, now 2.5 cm. Focally prominent lymph nodes along the\ncourse of the SMV. At surgical staple line from right colectomy\nthere is a 1.6 x 1.7 cm soft tissue density mass within the\nproximal most portions of residual colon. 4.8 x 4.2 cm mass in\nthe left adnexal surgical bed concerning for residual or\nrecurrent disease. In the right ovary there is a 2.4 x 1.3 cm\nenhancing structure with an area of central low density with \nmore\nsolid enhancing components than would be expected for a corpus\nluteal cyst, concerning for a new metastatic lesion. \n- ___: C1D1 FOLFOX\n- ___: C2D1 FOLFOX-avastin\n- ___: C3D1 FOLFOX-avastin given after two week delay for\nneutropenia. ___ bolus held. Neulasta given. \n- ___: CT torso: no intrathoracic disease. 13 x 11 mm soft\ntissue density adjacent to anastomosis decreased from prior\n(previously 17 x 16 mm). 19 x 14 mm left retroperitoneal lymph\nnode decreased, previously 26 x 28 mm. 3.7 x 3.0 cm left adnexal\nsoft tissue mass decreased in size, previously 4.8 x 4.2 cm.\nRight adnexal mass no longer seen, may have been corpus luteum.\n- ___: C4D1 FOLFOX-avastin, ___ bolus restarted. Neulasta\ngiven. \n- ___: C5D1 FOLFOX-avastin. Reacted to oxaliplatin,\ndiscontinued from further treatments.\n- ___ C6D1 ___ with Neulasta \n- ___ CT torso showed, \"Minimal interval decrease in size\nof the soft tissue density lesion in the ascending colon\nadjacent to the anastomosis, which may represent malignant\ndisease. Interval decrease in size of the left paraaortic lymph\nnode. Interval decrease in size of the left adnexal soft tissue\ndensity mass.\"\n- ___ C7D1 ___ with Neulasta \n- ___ C8D1 ___ with Neulasta \n- ___ C9D1 ___ with Neulasta \n- ___ CT torso with slight interval progression of \ndisease\n- ___ C1D1 irinotecan 350 mg/m2 Q21 days\n- ___ C2D1 irinotecan 350 mg/m2 Q21 days\n- ___ C3D1 irinotecan 350 mg/m2 Q21 days\n- ___ CT torso showed progression of her adnexal mass and\nmultiple small pulmonary nodules\n- ___ C1D1 FOLFIRI + Avastin\n- ___ C2D1 FOLFIRI + Avastin\n- ___ C3D1 FOLFIRI + Avastin\n- ___ CT torso showed slight decrease in lung mets but\nslight increase in size of a left adnexal mass. CEA rising. \n- ___ C1D1 Regorafenib 120 mg D1-21 - held after D12 or so\n- ___ C2D1 Regorafenib 80 mg D1-14 of a 21 day cycle \ndelayed\nfor vacation\n- ___ C3D1 Regorafenib 80 mg D1-14 of a 21 day cycle \n- ___ C4D1 Regorafenib 80 mg D1-14 of a 21 day cycle \n- ___ CT torso showed growth of lung mets and possible 2 \nnew\nsmall mets, increase of left adnexal mass, new right adnexal\nmass, enlarging left periaortic lymph node, and new right\npericolic gutter implant all consistent with metastatic disease.\nThere is also a new anterior uterine lesion, which may also\nrepresent a metastasis. \n- ___ C5D1 Regorafenib 80 mg D1-14 of a 21 day cycle \n- ___ CT torso showed progression of liver mets\n- ___ Skin testing for oxaliplatin sensitivity negative. \n- ___ C1D1 FOLFOX6 with 3 bag desensitization\n- ___ C2D1 FOLFOX6 with 3 bag desensitization\n- ___ C2D15 dose of FOLFOX6 with 3 bag desensitization\ndelayed for cytopenias\n- ___ CT torso showed decrease in metastatic disease\n- ___ C3D1 FOLFOX6 with 3 bag desensitization plus\nNeulasta\n- ___ C3D15 FOLFOX (ci5FU 1800 mg/mg) with 3 bag\ndesensitization plus Neulasta\n- ___ CT torso showed progression of lung mets\n- ___ C10D1 FOLFOX (ci5FU 1800 mg/mg) with 3 bag\ndesensitization plus Neulasta\n- ___ C11D1 FOLFOX (ci5FU 1800 mg/mg) with 3 bag\ndesensitization plus Neulasta\n- ___ C11D15 FOLFOX with 3 bag desensitization \nPMH: HTN\n- ___ C12D1 oxali desens\n- ___ C12D1 admit for oxali desens as above\n \nSocial History:\n___\nFamily History:\nMother died at ___ of breast cancer, HTN \nNo breast cancer in female siblings, colon cancer in male \nrelatives. \nNo FH of Crohn's, UC, IBD. \nFather- HTN, DM, ESRD on HD\n \nPhysical Exam:\nVITAL SIGNS: ___ ___ 18 100% RA\nGeneral: NAD, Resting in bed comfortably\nHEENT: MMM\nCV: RR, NL S1S2 no S3S4 No MRG\nPULM: No C/W/R, No respiratory distress\nABD: BS+, soft, NTND, no palpable masses or HSM\nLIMBS: WWP, no edema, no tremors\nSKIN: No rashes on the extremities, mole on RLE stable \nNEURO: Grossly normal\nCHEST: Port dressing C/D/I\n \nPertinent Results:\nNo labs drawn\n \nBrief Hospital Course:\n___ w/ metastatic KRAS mutated colon cancer on modified FOLFOX\nwho presents for C13b oxaliplatin desensitization.\n\n# Metastatic Colorectal Ca\nThis is metastatic to her omentum. She tolerated her oxaliplatin \nwell \nvia 3 bag intermediate desensitization. \n- f/u onc tomorrow for remaining ___\n\n# HTN\nNow on labetalol. Ideal SBP goal <140. \n- cont labetalol 200 tid\n\n# Left ___ Mole\nStable and will f/u oncology. \n\n# Wheezing on exertion:\nNo h/o asthma. Using albuterol intermittently. No wheezing on \nthis admission.\n\n# HA: mild, cont APAP prn\n\nFEN: Regular no-cold-food diet\nDVT PROPHYLAXIS: None, Low Risk\nACCESS: PORT\nCODE STATUS: Full code, presumed\nPCP: ___, MD\nDISPO: Home tonight\n________________\n___, D.___.\nHeme/Onc Hospitalist\np: ___\n\nADDENDUM\n\nThis note will suffice as H&P and D/C Summary. Patient was \nadmitted and discharged same day. She tolerated her \ndesensitization well. Her initial BP was 176/102 HR 74 and this \nis off her morning labetalol. After receiving chemo and \nsteroids, her BP rose to 204/103. She received 6.25 mg of PO \nCaptopril with improvement to the 160s. She was instructed to \ndiscuss this with her primary onc team tomorrow when she will \nhave her BP rechecked. Would recommend she take the labetalol \nnext time in the morning prior to coming into the hospital now \nthat she has tolerated the desensitization well.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Cetirizine 10 mg PO ASDIR \n2. TraMADol 50 mg PO Q4H:PRN pain \n3. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob or wheezing \n4. Ondansetron 8 mg PO Q8H:PRN nausea \n5. Prochlorperazine 10 mg PO Q6H:PRN nausea \n6. Labetalol 200 mg PO TID \n\n \nDischarge Medications:\n1. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob or wheezing \n2. Cetirizine 10 mg PO ASDIR \n3. Labetalol 200 mg PO TID \n4. Ondansetron 8 mg PO Q8H:PRN nausea \n5. Prochlorperazine 10 mg PO Q6H:PRN nausea \n6. TraMADol 50 mg PO Q4H:PRN pain \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nColon Cancer\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nDear ___,\n\n___ tolerated your oxaliplatin desensitization well. Please \ncontinue discussing with your primary care doctor management of \nyour high blood pressure. ___ will continue the rest of the \nchemotherapy tomorrow. \n \nFollowup Instructions:\n___\n"
] | Allergies: Menthol / oxaliplatin / Amoxicillin Chief Complaint: ELECTIVE CHEMO Major Surgical or Invasive Procedure: C13B D1 Oxaliplatin 3 bag intermediate desensitization History of Present Illness: PRIMARY DIAGNOSIS: Colon Cancer PRIMARY ONCOLOGIST: Dr. [MASKED] COMPLAINT: Elective admission for chemotherapy HISTORY OF PRESENT ILLNESS: Ms. [MASKED] is a pleasant [MASKED] w/ metastatic KRAS mutated colon cancer on modified FOLFOX who presents for C11D1 oxaliplatin desensitization. In [MASKED], she had a reaction to oxaliplatin with shortness of breath, throat tightness, tongue swelling, and HTN which were relatively slow to improve. Her prior doses of oxaliplatin was well tolerated with desensitization, however on [MASKED] developed hemolysis. She has since tolerated her prior doses well. She states she has otherwise been doing well. Denied any F/C/N/V/abd pain. Bowel movements regular. [MASKED] started and she is appropriately not fasting. Past Medical History: PAST ONCOLOGIC HISTORY (per OMR): Colon cancer stage IV (T3N2bM1b) KRAS mutated, MSI stable - [MASKED] Had a few episodes where she felt hot and dizzy, for which she was seen in urgent care. - [MASKED] She experienced a similar episode with dizziness, lightheadedness, nausea, vomiting, and abdominal pain and presented to the [MASKED] ED. - [MASKED] CT abdomen/pelvis showed abnormal thickening of the terminal ileum and cecum. A left adnexal hypodense tubular area was also seen. - [MASKED] Pelvic US showed a 5.4 x 5.5 x 6.3 cm solid and cystic mass arising from the left ovary. Colonoscopy found a large friable mass in the proximal portion of the ascending colon, which the scope could not pass. Biopsy revealed low grade adenocarcinoma. CEA on [MASKED] was 10. - [MASKED] CT chest was negative. - [MASKED] Underwent a right colectomy and left salpingo-oophorectomy. Intraoperatively, the small bowel was run and no lesions were found. At the conclusion of the case the amount of remaining gross disease included a 1-cm nodule on the bladder serosa as well as a small rind of tumor on the left pelvic sidewall overlying the ureter. Pathology revealed low-grade adenocarcinoma, pT3, pN2b (13 of 28 positive lymph nodes), pM1 based on involvement of the left ovary. Margins from the colectomy were negative. Lymphovascular invasion and perineural invasion was seen. KRAS was mutated and MMR proteins were intact by IHC. - [MASKED]: CT a/p with interval increase in left paraaortic lymph node, now 2.5 cm. Focally prominent lymph nodes along the course of the SMV. At surgical staple line from right colectomy there is a 1.6 x 1.7 cm soft tissue density mass within the proximal most portions of residual colon. 4.8 x 4.2 cm mass in the left adnexal surgical bed concerning for residual or recurrent disease. In the right ovary there is a 2.4 x 1.3 cm enhancing structure with an area of central low density with more solid enhancing components than would be expected for a corpus luteal cyst, concerning for a new metastatic lesion. - [MASKED]: C1D1 FOLFOX - [MASKED]: C2D1 FOLFOX-avastin - [MASKED]: C3D1 FOLFOX-avastin given after two week delay for neutropenia. [MASKED] bolus held. Neulasta given. - [MASKED]: CT torso: no intrathoracic disease. 13 x 11 mm soft tissue density adjacent to anastomosis decreased from prior (previously 17 x 16 mm). 19 x 14 mm left retroperitoneal lymph node decreased, previously 26 x 28 mm. 3.7 x 3.0 cm left adnexal soft tissue mass decreased in size, previously 4.8 x 4.2 cm. Right adnexal mass no longer seen, may have been corpus luteum. - [MASKED]: C4D1 FOLFOX-avastin, [MASKED] bolus restarted. Neulasta given. - [MASKED]: C5D1 FOLFOX-avastin. Reacted to oxaliplatin, discontinued from further treatments. - [MASKED] C6D1 [MASKED] with Neulasta - [MASKED] CT torso showed, "Minimal interval decrease in size of the soft tissue density lesion in the ascending colon adjacent to the anastomosis, which may represent malignant disease. Interval decrease in size of the left paraaortic lymph node. Interval decrease in size of the left adnexal soft tissue density mass." - [MASKED] C7D1 [MASKED] with Neulasta - [MASKED] C8D1 [MASKED] with Neulasta - [MASKED] C9D1 [MASKED] with Neulasta - [MASKED] CT torso with slight interval progression of disease - [MASKED] C1D1 irinotecan 350 mg/m2 Q21 days - [MASKED] C2D1 irinotecan 350 mg/m2 Q21 days - [MASKED] C3D1 irinotecan 350 mg/m2 Q21 days - [MASKED] CT torso showed progression of her adnexal mass and multiple small pulmonary nodules - [MASKED] C1D1 FOLFIRI + Avastin - [MASKED] C2D1 FOLFIRI + Avastin - [MASKED] C3D1 FOLFIRI + Avastin - [MASKED] CT torso showed slight decrease in lung mets but slight increase in size of a left adnexal mass. CEA rising. - [MASKED] C1D1 Regorafenib 120 mg D1-21 - held after D12 or so - [MASKED] C2D1 Regorafenib 80 mg D1-14 of a 21 day cycle delayed for vacation - [MASKED] C3D1 Regorafenib 80 mg D1-14 of a 21 day cycle - [MASKED] C4D1 Regorafenib 80 mg D1-14 of a 21 day cycle - [MASKED] CT torso showed growth of lung mets and possible 2 new small mets, increase of left adnexal mass, new right adnexal mass, enlarging left periaortic lymph node, and new right pericolic gutter implant all consistent with metastatic disease. There is also a new anterior uterine lesion, which may also represent a metastasis. - [MASKED] C5D1 Regorafenib 80 mg D1-14 of a 21 day cycle - [MASKED] CT torso showed progression of liver mets - [MASKED] Skin testing for oxaliplatin sensitivity negative. - [MASKED] C1D1 FOLFOX6 with 3 bag desensitization - [MASKED] C2D1 FOLFOX6 with 3 bag desensitization - [MASKED] C2D15 dose of FOLFOX6 with 3 bag desensitization delayed for cytopenias - [MASKED] CT torso showed decrease in metastatic disease - [MASKED] C3D1 FOLFOX6 with 3 bag desensitization plus Neulasta - [MASKED] C3D15 FOLFOX (ci5FU 1800 mg/mg) with 3 bag desensitization plus Neulasta - [MASKED] CT torso showed progression of lung mets - [MASKED] C10D1 FOLFOX (ci5FU 1800 mg/mg) with 3 bag desensitization plus Neulasta - [MASKED] C11D1 FOLFOX (ci5FU 1800 mg/mg) with 3 bag desensitization plus Neulasta - [MASKED] C11D15 FOLFOX with 3 bag desensitization PMH: HTN - [MASKED] C12D1 oxali desens - [MASKED] C12D1 admit for oxali desens as above Social History: [MASKED] Family History: Mother died at [MASKED] of breast cancer, HTN No breast cancer in female siblings, colon cancer in male relatives. No FH of Crohn's, UC, IBD. Father- HTN, DM, ESRD on HD Physical Exam: VITAL SIGNS: [MASKED] [MASKED] 18 100% RA General: NAD, Resting in bed comfortably HEENT: MMM CV: RR, NL S1S2 no S3S4 No MRG PULM: No C/W/R, No respiratory distress ABD: BS+, soft, NTND, no palpable masses or HSM LIMBS: WWP, no edema, no tremors SKIN: No rashes on the extremities, mole on RLE stable NEURO: Grossly normal CHEST: Port dressing C/D/I Pertinent Results: No labs drawn Brief Hospital Course: [MASKED] w/ metastatic KRAS mutated colon cancer on modified FOLFOX who presents for C13b oxaliplatin desensitization. # Metastatic Colorectal Ca This is metastatic to her omentum. She tolerated her oxaliplatin well via 3 bag intermediate desensitization. - f/u onc tomorrow for remaining [MASKED] # HTN Now on labetalol. Ideal SBP goal <140. - cont labetalol 200 tid # Left [MASKED] Mole Stable and will f/u oncology. # Wheezing on exertion: No h/o asthma. Using albuterol intermittently. No wheezing on this admission. # HA: mild, cont APAP prn FEN: Regular no-cold-food diet DVT PROPHYLAXIS: None, Low Risk ACCESS: PORT CODE STATUS: Full code, presumed PCP: [MASKED], MD DISPO: Home tonight [MASKED] [MASKED], D.[MASKED]. Heme/Onc Hospitalist p: [MASKED] ADDENDUM This note will suffice as H&P and D/C Summary. Patient was admitted and discharged same day. She tolerated her desensitization well. Her initial BP was 176/102 HR 74 and this is off her morning labetalol. After receiving chemo and steroids, her BP rose to 204/103. She received 6.25 mg of PO Captopril with improvement to the 160s. She was instructed to discuss this with her primary onc team tomorrow when she will have her BP rechecked. Would recommend she take the labetalol next time in the morning prior to coming into the hospital now that she has tolerated the desensitization well. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Cetirizine 10 mg PO ASDIR 2. TraMADol 50 mg PO Q4H:PRN pain 3. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob or wheezing 4. Ondansetron 8 mg PO Q8H:PRN nausea 5. Prochlorperazine 10 mg PO Q6H:PRN nausea 6. Labetalol 200 mg PO TID Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob or wheezing 2. Cetirizine 10 mg PO ASDIR 3. Labetalol 200 mg PO TID 4. Ondansetron 8 mg PO Q8H:PRN nausea 5. Prochlorperazine 10 mg PO Q6H:PRN nausea 6. TraMADol 50 mg PO Q4H:PRN pain Discharge Disposition: Home Discharge Diagnosis: Colon Cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear [MASKED], [MASKED] tolerated your oxaliplatin desensitization well. Please continue discussing with your primary care doctor management of your high blood pressure. [MASKED] will continue the rest of the chemotherapy tomorrow. Followup Instructions: [MASKED] | [
"Z5111",
"C181",
"C786",
"Z888",
"I10",
"D367",
"R51"
] | [
"Z5111: Encounter for antineoplastic chemotherapy",
"C181: Malignant neoplasm of appendix",
"C786: Secondary malignant neoplasm of retroperitoneum and peritoneum",
"Z888: Allergy status to other drugs, medicaments and biological substances",
"I10: Essential (primary) hypertension",
"D367: Benign neoplasm of other specified sites",
"R51: Headache"
] | [
"I10"
] | [] |
13,080,738 | 21,910,378 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nadhesive tape / Bactrim\n \nAttending: ___\n \n___ Complaint:\nfacial swelling\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMrs. ___ is a ___ female with CVID (on monthly IVIG) \nand a initially 3B follicular lymphoma originally treated for 3b \nFL in ___ with 6 cycles of R-CHOP, relapsed in ___ \nwith DLBCL. autologous transplant ___ Relapse ___, got \n2 cycles R-GemOx with significant cytopenias and persistence of \ncirculating lymphoma cells, changed to lenalidomide-rituximab. \nShe has been on lenalidomide 10 mg for the last 5 days (C1D1 = \n___.\n\nShe was seen in clinic today for feeling tired and new swelling \nof her face. She states that over the weekend she noticed a \ndecrease in her energy. Then on ___ she started to have \nswelling of her bilateral parotid glands. Worsening with each \nday. Now associated with pain upon opening mouth. Seen in \nclinic today and there was concern for infection vs recurrent \ndisease vs reaction to Revlimid.\n\nOn the floor she endorses a dry cough for the past ___ days. \nAlso notes some recent am diarrhea. Endorses mild abdominal \npain. Denies open lesions in mouth, sore throat, trouble \nbreathing, chest pain, dysuria, myalgias, arthralgias. \nAccording to her, her most concerning symptoms include facial \nswelling and lethargy. \n\nOf note, she was recently diagnosed with UTI and given 5-day rx \nfor cefpodoxime (day 1 = ___.\n\nReview of Systems: \n(+) Per HPI.\nDenies fever, chills, night sweats, headache, vision changes, \nrhinorrhea, congestion, sore throat, cough, shortness of breath, \nchest pain, abdominal pain, nausea, vomiting, diarrhea, \nconstipation, BRBPR, melena, hematochezia, dysuria, hematuria. \n \nPast Medical History:\nONCOLOGIC HISTORY: \n * Diagnosed in ___ with grade IIIB follicular lymphoma. \n * Treated with R-CHOP from ___ through ___. \n * Noted for persistent diffuse parotid gland swelling, dry \nmouth\nand weight loss with increased splenomegaly. \n * ___, splenectomy for diagnostic purposes showed\nprobable lymphoproliferative disorder. \n * Started on maintenance rituximab from ___ through\n___. \n * Also noted for CVID and getting IVIG until ___. \n * ___, CT scan halfway through Rituxan maintenance showed\nsome new hilar lymphadenopathy and left lower lobe opacities \nwith\nenhancing structures within the retroperitoneum. Short interim\nfollow up CT scan showed interval growth in the left lower lobe\nmass with concern for recurrent or transformed lymphoma versus\ngranulomatous disease related to her CVID.\n * ___, Bronchoscopy and biopsy of left lower lobe mass\nrevealed a monoclonal population of B cells. \n * ___, PET scan showed interval growth and increase in\nFDG avidity. \n * ___, Excisional biopsy of one of her abdominal nodes\nrevealed diffuse large B-cell lymphoma likely relapsed or\ntransformed from her initial grade IIIB follicular lymphoma.\n * Started aggressive therapy with Rituxan and ICE with Cycle 1\non ___ and Cycle 2 on ___. \n * ___, PET scan showed overall interval improvement of\ndisease, with decrease in size and FDG avidity of the left lower\nlobe pulmonary consolidation and pelvic adenopathy, although\nresidual FDG uptake was seen in some of the lesions. Also noted\na foci of FDG avidity in right pelvis which was difficult to\nseparate from ureter but concerning for residual\ndisease. \n * Received Cycle 3 of R-IE on ___ (carboplatin removed to\nhelp with planned stem cell mobilization). \n * Stem cell collections over 3 days from ___ to ___ for\ntotal collection of 4.64 x 10e6 CD34/kg. Did not feel well\nfollowing collections with persistent nausea, fatigue and night\nterrors. \n * ___, CT imaging showed continued response and no\nevidence for recurrent lymphoma except note was made of new\nhypoattenuating lesions involving the periphery of the left\nkidney with differential diagnosis including lymphomatous\ninvolvement of the left kidney or pyelonephritis. \n * Blood cultures and urinalysis and urine cultures were\nnegative. \n * ___, MRI imaging of the kidney showed no\nlymphadenopathy with note of multifocal scarring of the upper\nleft kidney, with cortical volume loss, likely representing\nsequela of prior infection or infarction in the interim between\n___ and ___. No renal mass or evidence\nof renal lymphoma. \n * ___, Admission for autologous stem cell transplant \nwith\nBEAM conditioning. D0 = ___. Post-transplant course was\ncomplicated by persistent FN, aspiration PNA, dilated\nesophagus/esophagitis(retained food in esophagus), mucositis,\npersistent diarrhea, hypoxia, and possible DAH/inflammatory\nreconstitution. Noted to have RLL infiltrates as part of work up\nfor fever in immediate post transplant period. Developed\nsignificant respiratory distress requiring ICU transfer and\neventually was electively intubated for bronchoscopy on ___ and\n___. Bronch consistent with DAH, cultures negative, and\nshe was started on high dose steroids. These were quickly \nweaned\nafter a galactomannin from serum on ___ returned elevated\nand she was started on antifungals (BAL galactoma was negative).\nShe clinically improved from respiratory standpoint, but a \nrepeat\nCT scan on ___ noted for increase in multinodular\nperibronchial infiltration and consolidations. Underwent lung\nbiopsy ___ to evaluate for organizing pneumonia vs fungal\ninfection as noted for elevated beta glucan to 81 on ___.\nAspergillus galactomannin from serum on ___ \nand\n___ have been negative (only positive on ___. \nPathology showed organizing pneumonitis with no bacteria or \nfungi\nseen on special staining. She recovered slowly from prolonged\nhospitalization and finally discharged to own home on ___.\nShe was discharged on voriconazole in the setting of the \nelevated\nB-glucan. \n___: DLCO on day +43 75% CT chest showed extensive multi\nfocal pulmonary abnormality, mildly improved in nearly all areas\ncompared to ___, though not as significantly improved as \nthe\nearlier change between ___ and ___. No new lung\nlesions to suggest a second pathogen or second, non infectious,\ninflammatory condition.\n___: Admitted for elevated tranaminases, RUQ\nunrevealing. CT torso with no ___ or evidence of lymphoma. Most\nlikely secondary to drug effect (voriconazole). Received\npentamidine prior to d/c. Given 3 days of cipro for Proteus UTI.\n___: She initially presented with diarrhea and was \nfound\nto have C. difficile infection. She also had fever, which led to\nchest imaging; CT showed a multifocal bronchocentric pulmonary\ninflammation that appeared to be more likely infectious than\nnoninfectious. Given concern for pulmonary aspergillosis during\nher transplant admission, she went on to have a bronchoscopy and\nBAL on ___. Cytology was negative for malignant cells. \nGram stain showed 1+ gram-negative rods. However, the culture\nonly grew ___ commensal respiratory flora. No CMV was\nnoted. ___ prep was negative. PCP was negative. Galactomannan\nwas sent off the BAL and was negative. In her serum, beta-glucan\nwas slightly positive on ___ at 85 pg/mL. Galactomannan\nwas also slightly positive at 0.52. She then had a repeat serum\nbeta-glucan and galactomannan on ___. Beta-glucan was\npositive at 150 and the galactomannan was again negative. It is\nworth noting that she received 10 g of IVIG on ___. \nShe\ncompleted a course of initially IV vancomycin, cefepime, and\nFlagyl, which was ultimately narrowed to cefepime. She completed\na total of seven days of cefepime. She was also discharged on\nvoriconazole given potential concern for fungal infection. Her\ninpatient course was also complicated by tender enlarged parotid\nglands, and her CT abdomen and pelvis showed slightly enlarged\nright common iliac nodes, the largest of which measured 1.4 x \n1.1\ncm.\n\nPROBLEM LIST:\n\nProblems (Last Verified ___ by ___, MD):\nNON-HODGKIN'S LYMPHOMA \narising from MCCD? CUMULATIVE ANTHRACYCLINE DOSE Doxorubicin: \n250mg/m2 Originally treated for 3b FL in ___ with 6 cycles of \nR-CHOP, relapsed in ___ with DLBCL. autologous \ntransplant ___ \n\nACTINIC KERATOSIS \n(ICD-702.0) \n\nDEPRESSION \nminor, seeing psychotherapist, recent stress-daughter staph \ninfection, s/p skin graft, (ICD-311) \n\nGASTROESOPHAGEAL REFLUX \n(ICD-530.11) \n\nIGA DEFICIENCY \n\nIGG DEFICIENCY \nselective IgG deficiency of classes 2 and 4 \n\nLOW HIGH DENSITY LIPOPROTEIN \nhdl 38, ratio 5.9, (ICD-272.9) \n\nMALIGNANT NEOPLASM \nthyroid gland, Dr ___ \n\nMIGRAINES \nclassic, (ICD-346.00) \n\nMITRAL REGURGITATION \nmod-mv repair w/ ring annuloplasty, mri to 3.0 tesla ___, \n(ICD-424.0) \n\nOVERWEIGHT \n(ICD-278.00) \n\nTHYROID CANCER ___ \nHurthle cell cancer status post total thyroidectomy on \n___ and radioiodine remnant ablation with 100 mCi of \nI-131 on ___ \n\nUMBILICAL HERNIA \n(ICD-553.1) \n\nVITAMIN D DEFICIENCY \n(ICD-268.9) \n\nSPLENECTOMY \n\nBONE MARROW TRANSPLANT ___\nAutologous HPC, Apheresis 4 Bags Infused Total CD34/KG X \n10^6=4.64 auto HPCA# ___ yield = 2.74e6 CD34/kg ___ auto HPCA#2\n= 1.02e6 CD34/kg Cumulative total = 3.76e6 CD34/kg auto HPCA #3 \n= 0.88e6 CD34/kg Cumulative total = 4.64e6 CD34/kg \n\nG6PD DEFICIENCY \n+ ___ body prep in ___, Bactrim d/ced pentamidine ___ \n\nURINARY INCONTINENCE \n\nPROBABLE ASPERGILLOSIS \n\nCLOSTRIDIUM DIFFICILE ENTEROCOLITIS \n\nH/O KERATITIS \nand uveitis lt eye \n\n \nSocial History:\n___\nFamily History:\nFamily History (Last Verified ___ by ___, \nMD):\nRelative Status Age Problem Comments \nOther DIABETES MELLITUS B, son, ___, uncle,\n (ICD-250.00) \n ALZHEIMER'S DISEASE M, (ICD-V17.0) \n\n___ HODGKIN'S DISEASE \n\nFather Living CORONARY ARTERY \n BYPASS GRAFT \n\nMother ___ HIGH CHOLESTEROL\n \nPhysical Exam:\nADMISSION\nVitals: 98.6 91/58 76 18 94RA\nGen: Pleasant, calm \nHEENT: No conjunctival pallor. No icterus. MMM. OP clear. There \nis significant rock-hard swelling of bilateral parotids and \nsubmandibular glands in addition to post-auricular glands; also \nnote supraclavicular ___ on right\nCV: Normocardic, regular. Normal S1,S2. No MRG. \nLUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi. \nABD: soft, slightly TTP diffusely, NABS \nEXT: WWP. No ___ edema. \nSKIN: vitiligo on L face, mostly very pale \nNEURO: A&Ox3.\nLINES: port R chest CDI\n\nDISCHARGE\nVitals: 98 96-112/50-60 52-66 18 96RA\nGen: Pleasant, calm \nHEENT: No conjunctival pallor. No icterus. MMM. OP clear. \nSwelling in bilateral parotids and submandibular area improved. \nEye swelling significantly decreased\nCV: Normocardic, regular. Normal S1,S2. No MRG. \nLUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi. \nABD: soft, slightly TTP diffusely, NABS \nEXT: WWP. No ___ edema. \nSKIN: vitiligo on L face, mostly very pale \nNEURO: A&Ox3.\nLINES: port R chest CDI\n \nPertinent Results:\nADMISSION LABS\n___ 11:50AM BLOOD WBC-10.8*# RBC-2.58* Hgb-8.6* Hct-26.1* \nMCV-101* MCH-33.3* MCHC-33.0 RDW-19.8* RDWSD-72.6* Plt ___\n___ 11:50AM BLOOD Neuts-52 Bands-3 ___ Monos-16* \nEos-3 Baso-0 ___ Myelos-0 AbsNeut-5.94 AbsLymp-2.81 \nAbsMono-1.73* AbsEos-0.32 AbsBaso-0.00*\n___ 05:51AM BLOOD ___ PTT-30.0 ___\n___ 11:50AM BLOOD UreaN-14 Creat-1.2* Na-136 K-3.5 Cl-101 \nHCO3-25 AnGap-14\n___ 11:50AM BLOOD ALT-45* AST-100* LD(LDH)-333* \nAlkPhos-495* TotBili-0.3\n___ 11:50AM BLOOD GGT-349*\n___ 11:50AM BLOOD Calcium-10.1 Phos-3.8 Mg-1.6 UricAcd-3.1\n\nDISCHARGE LABS\n___ 06:19AM BLOOD WBC-10.3* RBC-2.45* Hgb-8.3* Hct-24.5* \nMCV-100* MCH-33.9* MCHC-33.9 RDW-19.5* RDWSD-70.8* Plt ___\n___ 06:19AM BLOOD Neuts-66.2 ___ Monos-12.9 \nEos-0.0* Baso-0.1 NRBC-0.2* Im ___ AbsNeut-6.79* \nAbsLymp-2.05 AbsMono-1.32* AbsEos-0.00* AbsBaso-0.01\n___ 06:19AM BLOOD ___ PTT-27.7 ___\n___ 06:19AM BLOOD Glucose-192* UreaN-25* Creat-0.9 Na-138 \nK-3.7 Cl-104 HCO3-25 AnGap-13\n___ 06:19AM BLOOD ALT-52* AST-75* LD(LDH)-204 AlkPhos-444* \nTotBili-0.3\n___ 06:19AM BLOOD Albumin-3.9 Calcium-9.5 Phos-3.4 Mg-2.1\n\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n================================================================\n___ 9:47 am STOOL CONSISTENCY: SOFT Source: Stool. \n\n\n **FINAL REPORT ___\n\n C. difficile DNA amplification assay (Final ___: \n Reported to and read back by ___ @ 10:42 AM ON \n___. \n CLOSTRIDIUM DIFFICILE. \n Positive for toxigenic C. difficile by the Illumigene \nDNA\n amplification. (Reference Range-Negative). \n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n================================================================\n\nCT NECK ___. Continued increased size and homogeneous enhancement of the \nbilateral \nparotid glands when compared to prior neck examinations of \n___. \n2. There appears to be subtle increased prominence of the \nbilateral lacrimal glands. \n3. Diffusely enlarged cervical, axillary and mediastinal lymph \nnodes as \ndescribed above, when compared to examinations of ___. \n4. The constellation of findings is highly concerning for \ndisease recurrence. \n5. No focal mass is noted within the parotid glands. No \nevidence of prominent surrounding fatty inflammatory stranding \nor fluid collection to suggest infectious process. \n\nCT CHEST ___\nCentral adenopathy and left axillary have improved since ___, a dramatically larger right axillary lymph node \nis the only exception. \n \n2 parenchymal pulmonary abnormalities are of concern, the 2 new \nperipheral \nnodules in the left lower lobe and the persistent consolidation \nin the right middle lobe are now and bronchiectasis. Both of \nthese can be due to \ninfection, though probably different pathogens. Alternatively \nlung nodules could be cryptogenic organizing pneumonia. \n \nPrevious extensive peribronchovascular infiltration, presumably \ngraft-versus-host disease, improved substantially between \n___ and \n___, has resolved. \n\nRUQ US ___\nNo abnormal biliary process identified.\n\n \nBrief Hospital Course:\n___ yo F with follicular lymphoma transformed into DLBCL s/p \nautoSCT ___ and recently treated with Revlimid/Rituxan who \npresents from clinic for increased facial swelling with CT \nfindings concerning for Revlimid reaction vs recurrent disease \nvs mumps. Leading diagnosis was Revlimid reaction so treated \nwith dexamethasone pulse which provided significant improvement. \n Also found to have C diff colitis as well as new lung nodules, \nprompting attempted initiation of posaconazole as outpatient. \nPlease see below. \n\nInvestigations/Interventions:\n1. Facial swelling: acute increase in size of bilateral parotids \nas well as tissue around eyes for 3 days. CT neck showed \nenlarged parotids, cervical, and supraclavicular lymph nodes \nwith pattern of contrast uptake not consistent with infection. \nWe considered this change perhaps due to a Revlimid side effect, \nso patient was given dexamethasone 40 mg x 4 days (first dose \n___ with dramatic improvement. Patient remained afebrile and \nhad no leukocytosis. Follow up on ___.\n\n2. Elevated LFTs: patient's alk phos up to 450's on admission. \nGGT was also elevated indicating likely biliary source. RUQ US \nobtained was normal. Recommend outpatient trend/follow up.\n\n3. Lung nodules: CT Chest obtained on admission to evaluate \nmediastinal lymph nodes noted 2 new peripheral lung nodules in \nLLL. Patient has a history of elevated fungal markers and is on \nvoriconazole as outpatient. ID consulted and recommended \nchanging outpatient regimen to posaconazole 300 mg qd. \nMycolytic blood cultures, fungal markers, cryptococcal antigen, \nand histoplasma antigen obtained. ID further recommends \noutpatient workup, potentially including ___ peripheral \nlung nodule biopsy. Patient received loading dose of \nposaconazole 300 mg bid on ___. *******Unfortunately her copay \nfor this drug will be $800. We spoke with case manager ___ \n___ who said there is a coupon that would reduce ___ to $80, \nbut patient is being denied for an unknown reason. The coupon \ncompany is closed on weekends and can be contacted on ___, \n___ to resolve the issue. ID maintains recommendation of \noutpatient posaconazole use, but we felt comfortable discharging \nher on voriconazole while our case management team works on this \nissue for ___\n\n4. C diff colitis: patient reported diarrhea on admission; has a \nhistory of cdiff colitis so sample was obtained and tested \npositive. Given po vancomycin 125 mg q6 with planned 14-day \ncourse through ___.\n\n5. DLBCL: was treated with 6 cycles of R-CHOP followed by \nrituximab maintenance; then had relapsed disease, started on \nR-ICE and had auto SCT in ___. In the end of ___ had \nenlarging lymphadenopathy consistent with relapsed DLBCL. \nStarted on R-GEMOx and then C1D1 of Rituxan/Revlimid is \n___. Revlimid continued in house. Will follow up with \nheme/onc on ___.\n\nTransitional Issues\n[]Patient received last dose of 5-day regimen of cefpodoxime for \nUTI in house\n[]Follow up heme/onc appointment: ___ @ 12:00pm\n[]New medications: Vancomycin 125mg po q6h x 14 days\n[]Please continue trend of LFTs as outpatient\n\n****Please refer patient to case management on ___ for \nresolution of posaconazole prescription. ___ is \nemailing ___ to give a heads up. The ID \nattending Dr. ___ has also emailed Dr. ___ her of \nthe situation.****\n\n# CODE: Full\n# EMERGENCY CONTACT: ___ (husband) ___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Voriconazole 250 mg PO Q12H \n2. Sertraline 75 mg PO DAILY \n3. Omeprazole 40 mg PO DAILY \n4. Loratadine 10 mg PO DAILY \n5. Levothyroxine Sodium 112 mcg PO 6X/WEEK (___) \n6. FoLIC Acid 1 mg PO DAILY \n7. Acyclovir 400 mg PO Q8H \n8. Lorazepam 0.5-1 mg PO Q8H:PRN anxiety/nausea \n9. Levothyroxine Sodium 56 mcg PO 1X/WEEK (___) \n10. Prochlorperazine 10 mg PO Q6H:PRN nausea \n11. Ondansetron 4 mg PO Q8H:PRN nausea \n12. lactobacillus combination ___ billion cell oral DAILY \n13. Aspirin 81 mg PO DAILY \n\n \nDischarge Medications:\n1. Acyclovir 400 mg PO Q8H \n2. Aspirin 81 mg PO DAILY \n3. FoLIC Acid 1 mg PO DAILY \n4. Levothyroxine Sodium 112 mcg PO 6X/WEEK (___) \n5. Levothyroxine Sodium 56 mcg PO 1X/WEEK (___) \n6. Loratadine 10 mg PO DAILY \n7. Lorazepam 0.5-1 mg PO Q8H:PRN anxiety/nausea \n8. Omeprazole 40 mg PO DAILY \n9. Ondansetron 4 mg PO Q8H:PRN nausea \n10. Prochlorperazine 10 mg PO Q6H:PRN nausea \n11. Sertraline 75 mg PO DAILY \n12. Vancomycin Oral Liquid ___ mg PO Q6H \nRX *vancomycin 125 mg 1 capsule(s) by mouth four times a day \nDisp #*54 Capsule Refills:*0\n13. lactobacillus combination ___ billion cell oral DAILY \n14. Voriconazole 250 mg PO Q12H \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary:\nC diff colitis\nDrug reaction\nLung nodules\n\nSecondary:\nDiffuse large B cell lymphoma\nTransaminitis\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nMrs. ___,\n\n___ were hospitalized for facial swelling, likely a reaction to \nRevlimid. This improved after a short course of steroids. ___ \nwere also found to have C diff colitis, for which ___ need to \ntake vancomycin tablets through ___. We also found some \nlung nodules concerning for infection, and ___ will require \nfurther outpatient workup. The infectious disease doctors did \nrecommend switching voriconazole to posaconazole until they can \nsee ___ again. This will be worked out at your appointment on \n___.\n\nIt was a pleasure taking care of ___!\nYour ___ team\n \nFollowup Instructions:\n___\n"
] | Allergies: adhesive tape / Bactrim [MASKED] Complaint: facial swelling Major Surgical or Invasive Procedure: None History of Present Illness: Mrs. [MASKED] is a [MASKED] female with CVID (on monthly IVIG) and a initially 3B follicular lymphoma originally treated for 3b FL in [MASKED] with 6 cycles of R-CHOP, relapsed in [MASKED] with DLBCL. autologous transplant [MASKED] Relapse [MASKED], got 2 cycles R-GemOx with significant cytopenias and persistence of circulating lymphoma cells, changed to lenalidomide-rituximab. She has been on lenalidomide 10 mg for the last 5 days (C1D1 = [MASKED]. She was seen in clinic today for feeling tired and new swelling of her face. She states that over the weekend she noticed a decrease in her energy. Then on [MASKED] she started to have swelling of her bilateral parotid glands. Worsening with each day. Now associated with pain upon opening mouth. Seen in clinic today and there was concern for infection vs recurrent disease vs reaction to Revlimid. On the floor she endorses a dry cough for the past [MASKED] days. Also notes some recent am diarrhea. Endorses mild abdominal pain. Denies open lesions in mouth, sore throat, trouble breathing, chest pain, dysuria, myalgias, arthralgias. According to her, her most concerning symptoms include facial swelling and lethargy. Of note, she was recently diagnosed with UTI and given 5-day rx for cefpodoxime (day 1 = [MASKED]. Review of Systems: (+) 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: ONCOLOGIC HISTORY: * Diagnosed in [MASKED] with grade IIIB follicular lymphoma. * Treated with R-CHOP from [MASKED] through [MASKED]. * Noted for persistent diffuse parotid gland swelling, dry mouth and weight loss with increased splenomegaly. * [MASKED], splenectomy for diagnostic purposes showed probable lymphoproliferative disorder. * Started on maintenance rituximab from [MASKED] through [MASKED]. * Also noted for CVID and getting IVIG until [MASKED]. * [MASKED], CT scan halfway through Rituxan maintenance showed some new hilar lymphadenopathy and left lower lobe opacities with enhancing structures within the retroperitoneum. Short interim follow up CT scan showed interval growth in the left lower lobe mass with concern for recurrent or transformed lymphoma versus granulomatous disease related to her CVID. * [MASKED], Bronchoscopy and biopsy of left lower lobe mass revealed a monoclonal population of B cells. * [MASKED], PET scan showed interval growth and increase in FDG avidity. * [MASKED], Excisional biopsy of one of her abdominal nodes revealed diffuse large B-cell lymphoma likely relapsed or transformed from her initial grade IIIB follicular lymphoma. * Started aggressive therapy with Rituxan and ICE with Cycle 1 on [MASKED] and Cycle 2 on [MASKED]. * [MASKED], PET scan showed overall interval improvement of disease, with decrease in size and FDG avidity of the left lower lobe pulmonary consolidation and pelvic adenopathy, although residual FDG uptake was seen in some of the lesions. Also noted a foci of FDG avidity in right pelvis which was difficult to separate from ureter but concerning for residual disease. * Received Cycle 3 of R-IE on [MASKED] (carboplatin removed to help with planned stem cell mobilization). * Stem cell collections over 3 days from [MASKED] to [MASKED] for total collection of 4.64 x 10e6 CD34/kg. Did not feel well following collections with persistent nausea, fatigue and night terrors. * [MASKED], CT imaging showed continued response and no evidence for recurrent lymphoma except note was made of new hypoattenuating lesions involving the periphery of the left kidney with differential diagnosis including lymphomatous involvement of the left kidney or pyelonephritis. * Blood cultures and urinalysis and urine cultures were negative. * [MASKED], MRI imaging of the kidney showed no lymphadenopathy with note of multifocal scarring of the upper left kidney, with cortical volume loss, likely representing sequela of prior infection or infarction in the interim between [MASKED] and [MASKED]. No renal mass or evidence of renal lymphoma. * [MASKED], Admission for autologous stem cell transplant with BEAM conditioning. D0 = [MASKED]. Post-transplant course was complicated by persistent FN, aspiration PNA, dilated esophagus/esophagitis(retained food in esophagus), mucositis, persistent diarrhea, hypoxia, and possible DAH/inflammatory reconstitution. Noted to have RLL infiltrates as part of work up for fever in immediate post transplant period. Developed significant respiratory distress requiring ICU transfer and eventually was electively intubated for bronchoscopy on [MASKED] and [MASKED]. Bronch consistent with DAH, cultures negative, and she was started on high dose steroids. These were quickly weaned after a galactomannin from serum on [MASKED] returned elevated and she was started on antifungals (BAL galactoma was negative). She clinically improved from respiratory standpoint, but a repeat CT scan on [MASKED] noted for increase in multinodular peribronchial infiltration and consolidations. Underwent lung biopsy [MASKED] to evaluate for organizing pneumonia vs fungal infection as noted for elevated beta glucan to 81 on [MASKED]. Aspergillus galactomannin from serum on [MASKED] and [MASKED] have been negative (only positive on [MASKED]. Pathology showed organizing pneumonitis with no bacteria or fungi seen on special staining. She recovered slowly from prolonged hospitalization and finally discharged to own home on [MASKED]. She was discharged on voriconazole in the setting of the elevated B-glucan. [MASKED]: DLCO on day +43 75% CT chest showed extensive multi focal pulmonary abnormality, mildly improved in nearly all areas compared to [MASKED], though not as significantly improved as the earlier change between [MASKED] and [MASKED]. No new lung lesions to suggest a second pathogen or second, non infectious, inflammatory condition. [MASKED]: Admitted for elevated tranaminases, RUQ unrevealing. CT torso with no [MASKED] or evidence of lymphoma. Most likely secondary to drug effect (voriconazole). Received pentamidine prior to d/c. Given 3 days of cipro for Proteus UTI. [MASKED]: She initially presented with diarrhea and was found to have C. difficile infection. She also had fever, which led to chest imaging; CT showed a multifocal bronchocentric pulmonary inflammation that appeared to be more likely infectious than noninfectious. Given concern for pulmonary aspergillosis during her transplant admission, she went on to have a bronchoscopy and BAL on [MASKED]. Cytology was negative for malignant cells. Gram stain showed 1+ gram-negative rods. However, the culture only grew [MASKED] commensal respiratory flora. No CMV was noted. [MASKED] prep was negative. PCP was negative. Galactomannan was sent off the BAL and was negative. In her serum, beta-glucan was slightly positive on [MASKED] at 85 pg/mL. Galactomannan was also slightly positive at 0.52. She then had a repeat serum beta-glucan and galactomannan on [MASKED]. Beta-glucan was positive at 150 and the galactomannan was again negative. It is worth noting that she received 10 g of IVIG on [MASKED]. She completed a course of initially IV vancomycin, cefepime, and Flagyl, which was ultimately narrowed to cefepime. She completed a total of seven days of cefepime. She was also discharged on voriconazole given potential concern for fungal infection. Her inpatient course was also complicated by tender enlarged parotid glands, and her CT abdomen and pelvis showed slightly enlarged right common iliac nodes, the largest of which measured 1.4 x 1.1 cm. PROBLEM LIST: Problems (Last Verified [MASKED] by [MASKED], MD): NON-HODGKIN'S LYMPHOMA arising from MCCD? CUMULATIVE ANTHRACYCLINE DOSE Doxorubicin: 250mg/m2 Originally treated for 3b FL in [MASKED] with 6 cycles of R-CHOP, relapsed in [MASKED] with DLBCL. autologous transplant [MASKED] ACTINIC KERATOSIS (ICD-702.0) DEPRESSION minor, seeing psychotherapist, recent stress-daughter staph infection, s/p skin graft, (ICD-311) GASTROESOPHAGEAL REFLUX (ICD-530.11) IGA DEFICIENCY IGG DEFICIENCY selective IgG deficiency of classes 2 and 4 LOW HIGH DENSITY LIPOPROTEIN hdl 38, ratio 5.9, (ICD-272.9) MALIGNANT NEOPLASM thyroid gland, Dr [MASKED] MIGRAINES classic, (ICD-346.00) MITRAL REGURGITATION mod-mv repair w/ ring annuloplasty, mri to 3.0 tesla [MASKED], (ICD-424.0) OVERWEIGHT (ICD-278.00) THYROID CANCER [MASKED] Hurthle cell cancer status post total thyroidectomy on [MASKED] and radioiodine remnant ablation with 100 mCi of I-131 on [MASKED] UMBILICAL HERNIA (ICD-553.1) VITAMIN D DEFICIENCY (ICD-268.9) SPLENECTOMY BONE MARROW TRANSPLANT [MASKED] Autologous HPC, Apheresis 4 Bags Infused Total CD34/KG X 10^6=4.64 auto HPCA# [MASKED] yield = 2.74e6 CD34/kg [MASKED] auto HPCA#2 = 1.02e6 CD34/kg Cumulative total = 3.76e6 CD34/kg auto HPCA #3 = 0.88e6 CD34/kg Cumulative total = 4.64e6 CD34/kg G6PD DEFICIENCY + [MASKED] body prep in [MASKED], Bactrim d/ced pentamidine [MASKED] URINARY INCONTINENCE PROBABLE ASPERGILLOSIS CLOSTRIDIUM DIFFICILE ENTEROCOLITIS H/O KERATITIS and uveitis lt eye Social History: [MASKED] Family History: Family History (Last Verified [MASKED] by [MASKED], MD): Relative Status Age Problem Comments Other DIABETES MELLITUS B, son, [MASKED], uncle, (ICD-250.00) ALZHEIMER'S DISEASE M, (ICD-V17.0) [MASKED] HODGKIN'S DISEASE Father Living CORONARY ARTERY BYPASS GRAFT Mother [MASKED] HIGH CHOLESTEROL Physical Exam: ADMISSION Vitals: 98.6 91/58 76 18 94RA Gen: Pleasant, calm HEENT: No conjunctival pallor. No icterus. MMM. OP clear. There is significant rock-hard swelling of bilateral parotids and submandibular glands in addition to post-auricular glands; also note supraclavicular [MASKED] on right CV: Normocardic, regular. Normal S1,S2. No MRG. LUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi. ABD: soft, slightly TTP diffusely, NABS EXT: WWP. No [MASKED] edema. SKIN: vitiligo on L face, mostly very pale NEURO: A&Ox3. LINES: port R chest CDI DISCHARGE Vitals: 98 96-112/50-60 52-66 18 96RA Gen: Pleasant, calm HEENT: No conjunctival pallor. No icterus. MMM. OP clear. Swelling in bilateral parotids and submandibular area improved. Eye swelling significantly decreased CV: Normocardic, regular. Normal S1,S2. No MRG. LUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi. ABD: soft, slightly TTP diffusely, NABS EXT: WWP. No [MASKED] edema. SKIN: vitiligo on L face, mostly very pale NEURO: A&Ox3. LINES: port R chest CDI Pertinent Results: ADMISSION LABS [MASKED] 11:50AM BLOOD WBC-10.8*# RBC-2.58* Hgb-8.6* Hct-26.1* MCV-101* MCH-33.3* MCHC-33.0 RDW-19.8* RDWSD-72.6* Plt [MASKED] [MASKED] 11:50AM BLOOD Neuts-52 Bands-3 [MASKED] Monos-16* Eos-3 Baso-0 [MASKED] Myelos-0 AbsNeut-5.94 AbsLymp-2.81 AbsMono-1.73* AbsEos-0.32 AbsBaso-0.00* [MASKED] 05:51AM BLOOD [MASKED] PTT-30.0 [MASKED] [MASKED] 11:50AM BLOOD UreaN-14 Creat-1.2* Na-136 K-3.5 Cl-101 HCO3-25 AnGap-14 [MASKED] 11:50AM BLOOD ALT-45* AST-100* LD(LDH)-333* AlkPhos-495* TotBili-0.3 [MASKED] 11:50AM BLOOD GGT-349* [MASKED] 11:50AM BLOOD Calcium-10.1 Phos-3.8 Mg-1.6 UricAcd-3.1 DISCHARGE LABS [MASKED] 06:19AM BLOOD WBC-10.3* RBC-2.45* Hgb-8.3* Hct-24.5* MCV-100* MCH-33.9* MCHC-33.9 RDW-19.5* RDWSD-70.8* Plt [MASKED] [MASKED] 06:19AM BLOOD Neuts-66.2 [MASKED] Monos-12.9 Eos-0.0* Baso-0.1 NRBC-0.2* Im [MASKED] AbsNeut-6.79* AbsLymp-2.05 AbsMono-1.32* AbsEos-0.00* AbsBaso-0.01 [MASKED] 06:19AM BLOOD [MASKED] PTT-27.7 [MASKED] [MASKED] 06:19AM BLOOD Glucose-192* UreaN-25* Creat-0.9 Na-138 K-3.7 Cl-104 HCO3-25 AnGap-13 [MASKED] 06:19AM BLOOD ALT-52* AST-75* LD(LDH)-204 AlkPhos-444* TotBili-0.3 [MASKED] 06:19AM BLOOD Albumin-3.9 Calcium-9.5 Phos-3.4 Mg-2.1 = = = = = = = = = = ================================================================ [MASKED] 9:47 am STOOL CONSISTENCY: SOFT Source: Stool. **FINAL REPORT [MASKED] C. difficile DNA amplification assay (Final [MASKED]: Reported to and read back by [MASKED] @ 10:42 AM ON [MASKED]. CLOSTRIDIUM DIFFICILE. Positive for toxigenic C. difficile by the Illumigene DNA amplification. (Reference Range-Negative). = = = = = = = = = = ================================================================ CT NECK [MASKED]. Continued increased size and homogeneous enhancement of the bilateral parotid glands when compared to prior neck examinations of [MASKED]. 2. There appears to be subtle increased prominence of the bilateral lacrimal glands. 3. Diffusely enlarged cervical, axillary and mediastinal lymph nodes as described above, when compared to examinations of [MASKED]. 4. The constellation of findings is highly concerning for disease recurrence. 5. No focal mass is noted within the parotid glands. No evidence of prominent surrounding fatty inflammatory stranding or fluid collection to suggest infectious process. CT CHEST [MASKED] Central adenopathy and left axillary have improved since [MASKED], a dramatically larger right axillary lymph node is the only exception. 2 parenchymal pulmonary abnormalities are of concern, the 2 new peripheral nodules in the left lower lobe and the persistent consolidation in the right middle lobe are now and bronchiectasis. Both of these can be due to infection, though probably different pathogens. Alternatively lung nodules could be cryptogenic organizing pneumonia. Previous extensive peribronchovascular infiltration, presumably graft-versus-host disease, improved substantially between [MASKED] and [MASKED], has resolved. RUQ US [MASKED] No abnormal biliary process identified. Brief Hospital Course: [MASKED] yo F with follicular lymphoma transformed into DLBCL s/p autoSCT [MASKED] and recently treated with Revlimid/Rituxan who presents from clinic for increased facial swelling with CT findings concerning for Revlimid reaction vs recurrent disease vs mumps. Leading diagnosis was Revlimid reaction so treated with dexamethasone pulse which provided significant improvement. Also found to have C diff colitis as well as new lung nodules, prompting attempted initiation of posaconazole as outpatient. Please see below. Investigations/Interventions: 1. Facial swelling: acute increase in size of bilateral parotids as well as tissue around eyes for 3 days. CT neck showed enlarged parotids, cervical, and supraclavicular lymph nodes with pattern of contrast uptake not consistent with infection. We considered this change perhaps due to a Revlimid side effect, so patient was given dexamethasone 40 mg x 4 days (first dose [MASKED] with dramatic improvement. Patient remained afebrile and had no leukocytosis. Follow up on [MASKED]. 2. Elevated LFTs: patient's alk phos up to 450's on admission. GGT was also elevated indicating likely biliary source. RUQ US obtained was normal. Recommend outpatient trend/follow up. 3. Lung nodules: CT Chest obtained on admission to evaluate mediastinal lymph nodes noted 2 new peripheral lung nodules in LLL. Patient has a history of elevated fungal markers and is on voriconazole as outpatient. ID consulted and recommended changing outpatient regimen to posaconazole 300 mg qd. Mycolytic blood cultures, fungal markers, cryptococcal antigen, and histoplasma antigen obtained. ID further recommends outpatient workup, potentially including [MASKED] peripheral lung nodule biopsy. Patient received loading dose of posaconazole 300 mg bid on [MASKED]. *******Unfortunately her copay for this drug will be $800. We spoke with case manager [MASKED] [MASKED] who said there is a coupon that would reduce [MASKED] to $80, but patient is being denied for an unknown reason. The coupon company is closed on weekends and can be contacted on [MASKED], [MASKED] to resolve the issue. ID maintains recommendation of outpatient posaconazole use, but we felt comfortable discharging her on voriconazole while our case management team works on this issue for [MASKED] 4. C diff colitis: patient reported diarrhea on admission; has a history of cdiff colitis so sample was obtained and tested positive. Given po vancomycin 125 mg q6 with planned 14-day course through [MASKED]. 5. DLBCL: was treated with 6 cycles of R-CHOP followed by rituximab maintenance; then had relapsed disease, started on R-ICE and had auto SCT in [MASKED]. In the end of [MASKED] had enlarging lymphadenopathy consistent with relapsed DLBCL. Started on R-GEMOx and then C1D1 of Rituxan/Revlimid is [MASKED]. Revlimid continued in house. Will follow up with heme/onc on [MASKED]. Transitional Issues []Patient received last dose of 5-day regimen of cefpodoxime for UTI in house []Follow up heme/onc appointment: [MASKED] @ 12:00pm []New medications: Vancomycin 125mg po q6h x 14 days []Please continue trend of LFTs as outpatient ****Please refer patient to case management on [MASKED] for resolution of posaconazole prescription. [MASKED] is emailing [MASKED] to give a heads up. The ID attending Dr. [MASKED] has also emailed Dr. [MASKED] her of the situation.**** # CODE: Full # EMERGENCY CONTACT: [MASKED] (husband) [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Voriconazole 250 mg PO Q12H 2. Sertraline 75 mg PO DAILY 3. Omeprazole 40 mg PO DAILY 4. Loratadine 10 mg PO DAILY 5. Levothyroxine Sodium 112 mcg PO 6X/WEEK ([MASKED]) 6. FoLIC Acid 1 mg PO DAILY 7. Acyclovir 400 mg PO Q8H 8. Lorazepam 0.5-1 mg PO Q8H:PRN anxiety/nausea 9. Levothyroxine Sodium 56 mcg PO 1X/WEEK ([MASKED]) 10. Prochlorperazine 10 mg PO Q6H:PRN nausea 11. Ondansetron 4 mg PO Q8H:PRN nausea 12. lactobacillus combination [MASKED] billion cell oral DAILY 13. Aspirin 81 mg PO DAILY Discharge Medications: 1. Acyclovir 400 mg PO Q8H 2. Aspirin 81 mg PO DAILY 3. FoLIC Acid 1 mg PO DAILY 4. Levothyroxine Sodium 112 mcg PO 6X/WEEK ([MASKED]) 5. Levothyroxine Sodium 56 mcg PO 1X/WEEK ([MASKED]) 6. Loratadine 10 mg PO DAILY 7. Lorazepam 0.5-1 mg PO Q8H:PRN anxiety/nausea 8. Omeprazole 40 mg PO DAILY 9. Ondansetron 4 mg PO Q8H:PRN nausea 10. Prochlorperazine 10 mg PO Q6H:PRN nausea 11. Sertraline 75 mg PO DAILY 12. Vancomycin Oral Liquid [MASKED] mg PO Q6H RX *vancomycin 125 mg 1 capsule(s) by mouth four times a day Disp #*54 Capsule Refills:*0 13. lactobacillus combination [MASKED] billion cell oral DAILY 14. Voriconazole 250 mg PO Q12H Discharge Disposition: Home Discharge Diagnosis: Primary: C diff colitis Drug reaction Lung nodules Secondary: Diffuse large B cell lymphoma Transaminitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mrs. [MASKED], [MASKED] were hospitalized for facial swelling, likely a reaction to Revlimid. This improved after a short course of steroids. [MASKED] were also found to have C diff colitis, for which [MASKED] need to take vancomycin tablets through [MASKED]. We also found some lung nodules concerning for infection, and [MASKED] will require further outpatient workup. The infectious disease doctors did recommend switching voriconazole to posaconazole until they can see [MASKED] again. This will be worked out at your appointment on [MASKED]. It was a pleasure taking care of [MASKED]! Your [MASKED] team Followup Instructions: [MASKED] | [
"C8333",
"C8332",
"T865",
"D550",
"A047",
"D802",
"C8298",
"D803",
"N390",
"R220",
"T451X5A",
"Y92019",
"Z8701",
"Z87440",
"M3500",
"F329",
"K219",
"Z85850",
"E890",
"G43909",
"Z9889",
"E559",
"R911",
"K429",
"Z9081"
] | [
"C8333: Diffuse large B-cell lymphoma, intra-abdominal lymph nodes",
"C8332: Diffuse large B-cell lymphoma, intrathoracic lymph nodes",
"T865: Complications of stem cell transplant",
"D550: Anemia due to glucose-6-phosphate dehydrogenase [G6PD] deficiency",
"A047: Enterocolitis due to Clostridium difficile",
"D802: Selective deficiency of immunoglobulin A [IgA]",
"C8298: Follicular lymphoma, unspecified, lymph nodes of multiple sites",
"D803: Selective deficiency of immunoglobulin G [IgG] subclasses",
"N390: Urinary tract infection, site not specified",
"R220: Localized swelling, mass and lump, head",
"T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter",
"Y92019: Unspecified place in single-family (private) house as the place of occurrence of the external cause",
"Z8701: Personal history of pneumonia (recurrent)",
"Z87440: Personal history of urinary (tract) infections",
"M3500: Sicca syndrome, unspecified",
"F329: Major depressive disorder, single episode, unspecified",
"K219: Gastro-esophageal reflux disease without esophagitis",
"Z85850: Personal history of malignant neoplasm of thyroid",
"E890: Postprocedural hypothyroidism",
"G43909: Migraine, unspecified, not intractable, without status migrainosus",
"Z9889: Other specified postprocedural states",
"E559: Vitamin D deficiency, unspecified",
"R911: Solitary pulmonary nodule",
"K429: Umbilical hernia without obstruction or gangrene",
"Z9081: Acquired absence of spleen"
] | [
"N390",
"F329",
"K219"
] | [] |
17,382,794 | 21,442,873 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \n___ Complaint:\nMuscle weakness\n \nMajor Surgical or Invasive Procedure:\nEMG ___\nLeft Deltoid Muscle Biopsy ___\nBone Marrow Biopsy ___ \n \nHistory of Present Illness:\nMs. ___ is a very pleasant ___ year old woman with a history \nof right breast cancer s/p resection, axillary LN dissection, \nand chemoradiation (cyclophosphamide, adriamycin, and \nmethotrexate) with subsequent separate primary in same breast \nand AML s/p MRD allo SCT on ___ who presented with proximal \nmuscle weakness of one month's duration.\n\nMs. ___ reports approximately one month ago she had a \nmechanical fall down some stairs, which resulted in back and \nright flank pain. She was not evaluated after the fall, as she \nhad no dizziness, LOC, chest pain, or other concerning symptoms. \nShe later found out she had rib fractures on CT scan. \n Since the fall she has had progressive weakness. It started \nwith soreness in both of her biceps, and she gradually developed \nsome right arm swelling. The soreness progressed to frank \nweakness in her upper arms, and she also developed swelling of \nher bilateral lower extremities and difficulty walking up \nstairs. The right arm swelling resolved about a week ago, but \nshe has continued to have progressive weakness, now to the point \nshe has difficulty raising her arms above her head, getting out \nof bed, and walking up stairs. She has also had increasing \nfatigue. Several days ago, she began developing the sensation \nthat she could not take in a full breath. She was seen in \n___ clinic for these symptoms. Echo and spirometry were \ndone in clinic. Echo was unremarkable, but spirometry revealed \nFVC of 42% (previously 80% last year). Patient was directed to \nthe ED give concern of possible GBS. \n\nIn the ED, initial VS were pain 0, T 98.2, HR 102, BP 124/80, RR \n18, O2 95% RA. Labs notable for WBC 13.7, HCT 31.2, PLT 198, Na \n130, K 4.6, HCO3 27, Cr 0.6, ALT 154, AST 169, ALP 117, LDH 572, \nTBili 0.4, Alb 2.9. TSH 2.9, FT4 1.1. CRP 134.1, CK 1719, \nhepatitis serologies negative, UA negative. CXR showed small new \nright pleural effusion, but no other abnormalities. Neurology \nwas consulted who recommended serial NIF, EMG with possible \nmuscle biopsy, and immune workup. Patient was given her normal \noral acyclovir. VS prior to admission were T 99.2, HR 103, BP \n124/78, RR 16, O2 97% RA. \n\nOn arrival to the floor, patient reports progressive proximal \nweakness and fatigue as above. She has no frank shortness of \nbreath. She describes the weakness as if her arms and legs were \nvery heavy. She continues to have soreness in her biceps with \nuse, but no pain at rest. No new rashes or joint pains. No \ndouble vision. She has developed some dysphagia to solids but \nnot liquids. No headaches, no fevers. No recent URI symptoms \naside from a runny nose the last few days. No chest pain or \ncough. No nausea, vomiting, or diarrhea. No abdominal pain. \nRecently decreased her prednisone to 5mg daily. No other recent \nmed changes. \n\n REVIEW OF SYSTEMS: \n A complete 10-point review of systems was performed and was \nnegative unless otherwise noted in the HPI. \n \nPast Medical History:\n- ___ - at age ___ she had right breast cancer s/p resection,\naxillary dissection, chemotherapy with cyclophosphamide,\nadriamycin, and methotrexate\nPrior treatment history (per Dr. ___: 21 days for four \ncycles: cyclophosphamide (500 mg/m2 IV, day 1); doxorubicin (45 \nmg/m2 IV, day 3); methotrexate (200 mg/m2 IV, days 1 and 15); \nfluorouracil (500 mg/m2 IV, day 1); prednisone (40 mg/m2 PO, \ndays ___ and leucovorin (10 mg/m2 PO q6h. days ___.\n- ___ - right breast cancer reportedly a separate primary\ntreated with chemotherapy, unknown details. has remained on\ntamoxifen since that time\n- she has not been tested for BRCA1/2 or other inherited cancer\nsyndromes\n- early onset osteoarthritis of hands\n \nSocial History:\n___\nFamily History:\nMaternal aunt had melanoma. No other known cancers in family. No \nknown hematologic diseases. She has a healthy younger brother.\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n=================\n VS: T 98.9 HR 100 BP 123/66 RR 20 SAT 95% O2 on RA \n GENERAL: Pleasant, sitting up in chair comfortably \n HEENT: Anicteric, PERLL, EOMI, no lid lag, OP clear \n CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops \n\n LUNG: Appears in no respiratory distress and speaks in full \nsentences while sitting up. Somewhat more labored appearing \nwhile lying flat. Clear to auscultation bilaterally, no \ncrackles, wheezes, or rhonchi \n ABD: Normal bowel sounds, soft, nontender, nondistended, no \nhepatomegaly, no splenomegaly \n EXT: Warm, well perfused, 1+ lower extremity edema to mid calf \nbilaterally \n PULSES: 2+ radial pulses, 1+ DP pulses \n NEURO: Alert, orientedx3, CN II-XII intact, no lid lag, FTN \nintact. 3+/5 abduction of delts bilaterally. ___ bicep strength \nbilaterally. Full strength in triceps and wrists. Full strength \nin hands. ___ hip flexors bilaterally with ___ knee extension. \nFull distal strength in lower extremities. Is able to stand from \nchair without using hands. Unable to get legs into bed after \nsitting. Sensory intact to light touch. \n SKIN: Rosacea on face, not clearly heliotrope rash. \n\nDISCHARGE PHYSICAL EXAM\n================== \n VS: 97.6 BP 108/66 (108-114/62-70) HR 95 (95-102) RR 2095% RA\n GENERAL: Pleasant, sitting in bed comfortably.\n HEENT: Anicteric, PERLL, EOMI, OP clear. Flat right nasolabial \nfold, otherwise face symmetric with intact VII.\n CARDIAC: Regular rate, normal rhythm. No MRG\n LUNG: No sign of increased respiratory effort. Clear to \nauscultation bilaterally, no crackles, wheezes, or rhonchi\n ABD: Normal bowel sounds, soft, nontender, nondistended, no \nhepatomegaly, no splenomegaly \n EXT: Warm, well perfused, 1+ lower extremity edema to mid calf \nbilaterally \n PULSES: 2+ radial pulses, 1+ DP pulses \n NEURO: CN II-XII intact, no lid lag, FTN intact. Neuro exam \ntoday largely stable, still with weakness greatest to abduction \nat the shoulder bilaterally, ___ on adduction. ___ bicep \nstrength bilaterally. Able to raise arms to midshoulder (GvHD \nphotographic scale 4), able to bend elbows to 45 degrees with \nhands together (scale 5) and can dorsiflex foot almost fully. \nGood grip strength. ___ hip flexors bilaterally with ___+ Patellar reflexes, +1 biceps reflex\n SKIN: Rosacea on face. Clean bandage over biopsy site, no \noverlying hematoma or tenderness.\n\n \nPertinent Results:\nLABS ON ADMISSION\n=============\n___ 10:40AM BLOOD WBC-13.7* RBC-3.05* Hgb-9.7* Hct-31.2* \nMCV-102* MCH-31.8 MCHC-31.1* RDW-17.3* RDWSD-64.5* Plt ___\n___ 10:40AM BLOOD Neuts-82* Bands-1 Lymphs-6* Monos-1* \nEos-9* Baso-0 ___ Metas-1* Myelos-0 AbsNeut-11.37* \nAbsLymp-0.82* AbsMono-0.14* AbsEos-1.23* AbsBaso-0.00*\n___ 10:40AM BLOOD Hypochr-NORMAL Anisocy-OCCASIONAL \nPoiklo-OCCASIONAL Macrocy-1+ Microcy-NORMAL Polychr-1+ \nOvalocy-1+ Target-OCCASIONAL Burr-OCCASIONAL Pappenh-OCCASIONAL\n___ 10:40AM BLOOD Plt Smr-NORMAL Plt ___\n___ 10:40AM BLOOD Glucose-94 UreaN-12 Creat-0.6 Na-130* \nK-4.6 Cl-93* HCO3-27 AnGap-15\n___ 10:40AM BLOOD ALT-154* AST-169* LD(LDH)-572* \nCK(CPK)-1719* AlkPhos-117* TotBili-0.4\n___ 10:40AM BLOOD Albumin-2.9* Calcium-8.3* Mg-2.1\n___ 10:40AM BLOOD CRP-134.1*\n\nNOTABLE LABS\n=========\n___ 10:40AM BLOOD ALT-154* AST-169* LD(LDH)-572* \nCK(CPK)-1719* AlkPhos-117* TotBili-0.4\n___ 12:22AM BLOOD ALT-148* AST-159* LD(LDH)-561* \nCK(CPK)-1586* AlkPhos-130* Amylase-17 TotBili-0.3\n___ 08:04AM BLOOD ALT-122* AST-135* CK(CPK)-1433* \nAlkPhos-105 TotBili-0.3\n___ 12:01AM BLOOD ALT-112* AST-138* LD(LDH)-534* \nCK(CPK)-1180* AlkPhos-128* TotBili-0.2 DirBili-<0.2 IndBili-0.2\n___ 12:00AM BLOOD ALT-117* AST-138* LD(___)-515* \nCK(CPK)-1178* AlkPhos-147* TotBili-0.2\n___ 12:00AM BLOOD ALT-129* AST-125* LD(___)-562* \nCK(CPK)-534* AlkPhos-169* TotBili-0.2\n___ 12:01AM BLOOD Hapto-272*\n___ 12:22AM BLOOD calTIBC-169* Ferritn-2146* TRF-130*\n___ 11:16AM BLOOD VitB12-197*\n___ 10:40AM BLOOD CRP-134.1*\n___ 12:00AM BLOOD ___\n___ 10:40AM BLOOD T4-6.2 Free T4-1.1\n___ 10:40AM BLOOD TSH-2.9\n___ 12:00AM BLOOD Osmolal-275\n___ 11:16AM BLOOD VitB12-197*\n___ 12:22AM BLOOD calTIBC-169* Ferritn-2146* TRF-130*\n___ 12:01AM BLOOD Hapto-272*\n___ 10:40AM BLOOD HCV Ab-Negative\n___ 12:00AM BLOOD ALDOLASE-Test \n___ 04:40PM BLOOD VITAMIN E-Test \n___ 04:40PM BLOOD PARVOVIRUS B19 DNA-Test \n___ 06:00AM BLOOD POSACONAZOLE-Test Name \n___ 12:00AM BLOOD INTRINSIC FACTOR ANTIBODY-Test \n___ 12:29PM BLOOD BK VIRUS, PCR-Test \n___ 12:38PM BLOOD METHYLMALONIC ACID-Test \n___ 12:22AM BLOOD MI-2 AUTOANTIBODIES-Test \n___ 12:22AM BLOOD SRP AUTOANTIBODIES-Test \n___ 12:22AM BLOOD ANTI-JO1 ANTIBODY-Test \n___ 12:22AM BLOOD PARANEOPLASTIC AUTOANTIBODY \nEVALUATION-PND\n___ 10:40AM BLOOD ALDOLASE-Test \n___ 10:40AM BLOOD SED RATE-Test \n___ 10:40AM BLOOD EBV PCR, QUANTITATIVE, WHOLE BLOOD-Test \n \n___ 10:40AM BLOOD EBV PCR, QUANTITATIVE, WHOLE BLOOD-Test \n \n\nLABS ON DISCHARGE\n=============\n___ 12:00AM BLOOD WBC-18.8* RBC-2.68* Hgb-8.6* Hct-28.3* \nMCV-106* MCH-32.1* MCHC-30.4* RDW-19.8* RDWSD-74.1* Plt ___\n___ 12:00AM BLOOD Neuts-85* Bands-6* Lymphs-1* Monos-1* \nEos-0 Baso-0 ___ Metas-5* Myelos-2* NRBC-10* AbsNeut-17.11* \nAbsLymp-0.19* AbsMono-0.19* AbsEos-0.00* AbsBaso-0.00*\n___ 12:00AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-2+ \nMacrocy-3+ Microcy-NORMAL Polychr-OCCASIONAL Spheroc-OCCASIONAL \nOvalocy-OCCASIONAL Burr-2+ Tear Dr-OCCASIONAL\n___ 12:00AM BLOOD Plt Smr-NORMAL Plt ___\n___ 12:00AM BLOOD Glucose-221* UreaN-17 Creat-0.5 Na-132* \nK-4.7 Cl-95* HCO3-27 AnGap-15\n___ 12:00AM BLOOD ALT-129* AST-125* LD(LDH)-562* \nCK(CPK)-534* AlkPhos-169* TotBili-0.2\n___ 12:00AM BLOOD Albumin-2.8* Calcium-8.8 Phos-4.2 Mg-2.1\n\nIMAGING & PROCEDURES\n===============\nPET CT (___)\nIMPRESSION: 1. Moderate, bilateral symmetric FDG avidity in \nthe muscles of\nthe shoulder girdles and paraspinal musculature of the upper \nback could\nrepresent myositis in the appropriate clinical setting. Glucose \nwas documented\nas 110 mg/dL at the time of the injection and the patient \nreports following the\ndiet carefully. Normal glucose and the regional nature of the \nuptake argue\nagainst elevated insulin as a cause of uptake.\n2. Small to moderate bilateral low-density pleural effusions \nare new. No\npulmonary nodules or lymphadenopathy are seen within the chest.\n3. Posttreatment changes are noted in the right breast and \nanterior abdominal\nwall. Grouped calcifications in the left breast are difficult \nto compare to the\nprior study due to technique. Attention on follow-up \nmammography is\nrecommended.\n4. Mild diffuse anasarca.\n\nMRI Cervical, Thoracic, Lumbar Spine (___)\n1. Small disc protrusion and endplate osteophyte indenting the \nventral thecal\nsac and flattening the ventral cord at C5-C6. Otherwise no \nsignificant spinal\ncanal narrowing.\n2. Moderate right and mild left neural foraminal narrowing at \nC5-C6. \nOtherwise no significant neural foraminal narrowing.\n3. No cord signal abnormality.\n4. Diffuse loss of bone marrow fat without focal lesion, \npresumably relating\nto changes from myeloablation and bone marrow transplant.\n5. Moderate right and small left pleural effusions.\n6. Diffusely decreased parenchymal signal of the visualized \nliver and spleen\nmay reflect changes secondary to treatment of AML or possibly \niron deposition\nfrom repeated prior transfusions.\n\nEMG ___\nAbnormal study. There is electrophysiologic evidence of a \nmyopathy with\ndenervating features. Concomitant lumbosacral radiculopathies \ncannot be\nexcluded. There is no evidence of a generalized polyneuropathy.\n\nRUQ Ultrasound ___. Normal hepatic parenchyma without focal lesions or biliary \ndilation.\n2. Small right pleural effusion new from ___.\n\nOutpatient PFTS ___\nResults are consistent with a restrictive ventilatory defect. \nTLC was low normal when measured on ___ compared \nto that study the FVC has decreased by 1.49 L (-48%) and the \nFEV1 has decreased by 1.05 L (-44%). Suggest repeat lung volume \nmeasurements to assess interval change if clinically indicated. \n\nMICROBIOLOGY\n===========\n CMV Viral Load (Final ___: \n CMV DNA not detected. \n Performed by Cobas Ampliprep / Cobas Taqman CMV Test. \n Linear range of quantification: 137 IU/mL - 9,100,000 \nIU/mL. \n Limit of detection 91 IU/mL. \n This test has been verified for use in the ___ patient \npopulation\n\nUrine Culture (___)\n URINE CULTURE (Final ___: < 10,000 CFU/mL. \n \nBrief Hospital Course:\nMs. ___ is a ___ year old woman with PMHx right breast cancer \ns/p (cyclophosphamide, methotrexate, adriamycin) and radiation \nwith subsequent separate primary s/p chemotherapy NOS, and AML \ns/p allo MRD on ___ who is admitted from the ED with \nproximal muscle weakness, found to have elevated CK and CRP \nconcerning for possible myositis. \n\n# Mysositis. Ms. ___ reported progressive proximal muscle \nweakness over last 4 weeks along with elevated CK and CRP (134.1 \non presentation). Initial CK was 1719 and downtrended steadily \nduring hospital stay. Found to be areflexic in upper extremities \nand hyporeflexic lower extremities, with some work of breathing \nand orthopnea. No ptosis, full EOMs, no diplopia on sustained \nupgaze. Outpatient PFTs resulted while patient was in hospital, \nshowing a moderate restrictive pattern, FVC 1.6 (42% predicted), \nFEV1 1.35 (44% predicted) and FEV1/FVC 84% (49% predicted). EMG \nshowed evidence of myopathy with deenervating features. On ___ \npatient underwent biopsy of left deltoid without issue. An MRI \ncervical, thoracic and lumbar spine was also pursued as EMG \ncould not rule out concomitant radiculopathy. This showed small \ndisc protrusion and an osteophyte flattening the ventral cord at \nC5-C6 and moderate right and mild left neural foraminal \nnarrowing at C5-C6. Otherwise no significant spinal canal \nnarrowing. Work-up, including ___, Mi2, SRP, BK virus, \nparvo, paraneoplastic panel and myositis panel all unrevealing. \nHCV and HBsAG, Ab and HBcAb were negative, though the utility of \nserology in this patient who is s/p SCT, is of limited value. \nMs. ___ remained stable throughout her hospital stay, with \nlow but stable NIFs ranging from -50 - -60 and stable vital \ncapacity. At this time it was felt that Ms. ___ \npresentation is most consistent with polymyositis of GvHD. She \nwas started on methylprednisolone 125 mg daily (2mg/kg) on \n___. On ___ she reported that the heavy feeling in her chest \nhad abated some; NIFs remained the same. She was cautiously \ndischarged after discussion of padding sharp edges and taking \nspecial fall precautions at home and with home ___, ___ and OT. \nShe agreed that if she experience worsening of her weakness, \ntrouble breathing or feels unsafe in any way, she will contact \nher primary oncologist or come to the emergency department \nimmediately.\n \n# Flt3+ AML. Required 3 induction therapies before achieving \nminimal disease state and proceeded with myeloablative (BuCy) \nMRD alloSCT (D0 = ___. She has been on Sorafenib for \ncontinued suppressive therapy post transplant despite hand-foot \nsyndrome, which has resolved. Complicated by GVHD of skin. Also \nwith slowly increasing EBV VL. Recipient is CMV(+), ABO:Oneg \nDonor (brother ___, ABO:Oneg; Chimerism from \n___: 99.5% donor. Sorafenib was held during the course of \nMs. ___ hospital stay, as this was thought to be a \npossible cause of her myositis (can cause a necrotizing \nmyositis). Patient was continued on Acyclovir BID, Posaconazole \n100 mg daily. A PET scan was eventually obtained in the work-up \nof her myositis and showed bilateral symmetric FDG avidity in \nthe muscles of the shoulder girdle and paraspinal muscules but \nno new areas concerning for malignancy. On ___, patient \nunderwent bone marrow biopsy; results pending.\n\n# GVHD and Transaminitis. Primarily manifests with mouth \nlesions. Patient also with recent transamanitis as an \noutpatient, redemonstrated in the hospital, with low-grade \ntransaminitis consistent with hepatocellular injury. This was \nthought to be due to drug effect versus GvHD. Patient was seen \nhepatology consulting team, who thought that picture could \ncertainly be explained by chronic GvHD. Recommended ___ \nliver biopsy and proceding with steroid as above. If after 1 \nweek of steroid treatment, LFT abnormality persists, then \nrecommended reconsidering utility of liver biopsy. We continued \npatient's cyclosporine 50 mg PO BID. Held prednisone and \ndecadron mouth rinse one methylprednisolone was started.\n\n# Misplaced line. Patient with tunneled line in azygos vein on \nimaging. On ___ underwent wire-guided exchange. Tolerated \nwell.\n\n# Water Retention. Ms. ___ was noted to have significant \nlower extremity swelling as well as anasarca noted on PET CT. On \n___ was noted to have gone from 155.9 lb to 158.7 lbs (147.1 \non admission). Patient was diuresed with 10 mg PO lasix for 3 \ndays prior to discharge and was sent home with a prescription \nfor 10 mg lasix to take if she gains more than 2 lbs at home.\n\n# HTN: Developed in setting of sorafnib. Patient with SBPs in \nthe 110s-120s. Continued home amlodipine 10mg daily, held home \nhydrochlorothiazide 3x per week. \n\n# Hx of breast cancer: Previously on tamoxifen maintenance. Has \nbeen on hold given risk of thrombosis. Did not resume treatment \nwhile in-house.\n\nTRANSITIONAL ISSUES\n==============\n- Pending Muscle Biopsy and Bone Marrow Biopsy Result\n- Consider discontinuing or decreasing amlodipine if patient is \nnot to start sorafenib again. Hypertension was in setting of \nsorafenib.\n- Discussed padding sharp edges and taking special fall \nprecautions at home. Ms. ___ agreed that if she experience \nworsening of her weakness, trouble breathing or feels unsafe in \nany way, she will contact her primary oncologist or come to the \nemergency department immediately.\n- Ms. ___ had persistent water retention in her legs. She \nwas given a prescription for 10 mg PO Lasix to take whenever she \nexperience a >2 lb weight gain\n- Patient was repleted with IM B12 from ___ to ___. She will \nneed weekly B12 injections for the next 4 weeks, starting ___. \nPlease check B12 level after 4 B12 injections.\n- Medication changes:\n-- Started Furosemide 10 mg PO to take if gains >2 lbs\n-- Started MethylPREDNISolone Sodium Succ 125 mg IV Q24H. \nPatient will have help administering this medication with the \n___. Final time course to be decided by Dr. ___\n-- ___ Hydrochlorothiazide 12.5 mg PO 3X/WEEK (___) \n-- ___ Dexamethasone Oral Soln (0.1mg/1mL) 5 mL ORAL TID \nwhile on methylprednisololne\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acyclovir 400 mg PO Q12H \n2. amLODIPine 10 mg PO DAILY \n3. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry \neyes \n4. Clindamycin 1% Solution 1 Appl TP DAILY \n5. CycloSPORINE (Neoral) MODIFIED 50 mg PO Q12H \n6. Dexamethasone Oral Soln (0.1mg/1mL) 5 mL ORAL TID \n7. Fexofenadine 180 mg PO ASDIR \n8. FoLIC Acid 1 mg PO DAILY \n9. Hydrochlorothiazide 12.5 mg PO 3X/WEEK (___) \n10. LORazepam 0.5 mg PO Q8H:PRN nausea/anxiety \n11. Potassium Chloride 20 mEq PO 3X/WEEK (___) \n12. PredniSONE 5 mg PO DAILY \n13. Sorafenib 400 mg PO BID \n14. sulfacetamide sodium 10 % topical DAILY \n15. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \n16. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID \n17. urea 40 % topical BID:PRN \n18. Vitamin D 1000 UNIT PO DAILY \n19. MetronidAZOLE Topical 1 % Gel 1 Appl TP BID:PRN facial rash \n20. Posaconazole Delayed Release Tablet 100 mg PO DAILY \n\n \nDischarge Medications:\n1. Furosemide 20 mg PO ASDIR \nTake one half tab if weight increase of more than 2 pounds \n2. MethylPREDNISolone Sodium Succ 125 mg IV Q24H \nRX *methylprednisolone sodium succ 1,000 mg 125 mg IV Q24 Disp \n#*7 Vial Refills:*0 \n3. Acyclovir 400 mg PO Q12H \n4. amLODIPine 10 mg PO DAILY \n5. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry \neyes \n6. Clindamycin 1% Solution 1 Appl TP DAILY \n7. CycloSPORINE (Neoral) MODIFIED 50 mg PO Q12H \n8. Fexofenadine 180 mg PO ASDIR \n9. FoLIC Acid 1 mg PO DAILY \n10. LORazepam 0.5 mg PO Q8H:PRN nausea/anxiety \nRX *lorazepam 0.5 mg 1 tab by mouth Q8H PRN Disp #*30 Tablet \nRefills:*0 \n11. MetronidAZOLE Topical 1 % Gel 1 Appl TP BID:PRN facial rash \n \n12. Posaconazole Delayed Release Tablet 100 mg PO DAILY \n13. Potassium Chloride 20 mEq PO 3X/WEEK (___) \n14. sulfacetamide sodium 10 % topical DAILY \n15. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \n16. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID \n17. urea 40 % topical BID:PRN \n18. Vitamin D 1000 UNIT PO DAILY \n19. HELD- Dexamethasone Oral Soln (0.1mg/1mL) 5 mL ORAL TID \nThis medication was held. Do not restart Dexamethasone Oral Soln \n(0.1mg/1mL) until you have stopped your methylprednisone \ntreatments\n20. HELD- Hydrochlorothiazide 12.5 mg PO 3X/WEEK (___) \nThis medication was held. Do not restart Hydrochlorothiazide \nuntil you speak with Dr. ___. We are substituting furosemide \ncurrently\n21. HELD- Sorafenib 400 mg PO BID This medication was held. Do \nnot restart Sorafenib until discussing with Dr. ___\n\n \n___ Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary\n=====\nMyositis\nAML\nGvHD\nHyponatremia\nTransaminitis\n\nSecondary\n========\nHypertension\nHistory of breast cancer\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nMs. ___,\n\nIt was a pleasure caring for you at ___ \n___. You presented to ___ with one month of muscle \nweakness and swelling in your arms and legs. We sent and \nperformed numerous tests while you here, including an \nelectromyogram which showed myopathy and a biopsy of one of the \naffected muscles in your shoulders; we are still waiting for the \nresults of this. You were started on methylprednisone injection \nwhile here to treat what we believe is a manifestation of your \ngraft versus host disease. You did well in the hospital overall. \nYour breathing remained stable and you were discharged on \n___ with close follow-up, visiting nursing and with \nthe understanding that if anything changes in your breathing or \nyour muscle function you will call Dr. ___ come to the \nemergency department immediately. \n\nPlease take your medications as detailed in this discharge \nsummary. If you experience any of the danger signs below, please \ncall your primary oncologist or come to the emergency department \nimmediately.\n\nBest Wishes,\n\nYour ___ Care Team\n \nFollowup Instructions:\n___\n"
] | Allergies: No Known Allergies / Adverse Drug Reactions [MASKED] Complaint: Muscle weakness Major Surgical or Invasive Procedure: EMG [MASKED] Left Deltoid Muscle Biopsy [MASKED] Bone Marrow Biopsy [MASKED] History of Present Illness: Ms. [MASKED] is a very pleasant [MASKED] year old woman with a history of right breast cancer s/p resection, axillary LN dissection, and chemoradiation (cyclophosphamide, adriamycin, and methotrexate) with subsequent separate primary in same breast and AML s/p MRD allo SCT on [MASKED] who presented with proximal muscle weakness of one month's duration. Ms. [MASKED] reports approximately one month ago she had a mechanical fall down some stairs, which resulted in back and right flank pain. She was not evaluated after the fall, as she had no dizziness, LOC, chest pain, or other concerning symptoms. She later found out she had rib fractures on CT scan. Since the fall she has had progressive weakness. It started with soreness in both of her biceps, and she gradually developed some right arm swelling. The soreness progressed to frank weakness in her upper arms, and she also developed swelling of her bilateral lower extremities and difficulty walking up stairs. The right arm swelling resolved about a week ago, but she has continued to have progressive weakness, now to the point she has difficulty raising her arms above her head, getting out of bed, and walking up stairs. She has also had increasing fatigue. Several days ago, she began developing the sensation that she could not take in a full breath. She was seen in [MASKED] clinic for these symptoms. Echo and spirometry were done in clinic. Echo was unremarkable, but spirometry revealed FVC of 42% (previously 80% last year). Patient was directed to the ED give concern of possible GBS. In the ED, initial VS were pain 0, T 98.2, HR 102, BP 124/80, RR 18, O2 95% RA. Labs notable for WBC 13.7, HCT 31.2, PLT 198, Na 130, K 4.6, HCO3 27, Cr 0.6, ALT 154, AST 169, ALP 117, LDH 572, TBili 0.4, Alb 2.9. TSH 2.9, FT4 1.1. CRP 134.1, CK 1719, hepatitis serologies negative, UA negative. CXR showed small new right pleural effusion, but no other abnormalities. Neurology was consulted who recommended serial NIF, EMG with possible muscle biopsy, and immune workup. Patient was given her normal oral acyclovir. VS prior to admission were T 99.2, HR 103, BP 124/78, RR 16, O2 97% RA. On arrival to the floor, patient reports progressive proximal weakness and fatigue as above. She has no frank shortness of breath. She describes the weakness as if her arms and legs were very heavy. She continues to have soreness in her biceps with use, but no pain at rest. No new rashes or joint pains. No double vision. She has developed some dysphagia to solids but not liquids. No headaches, no fevers. No recent URI symptoms aside from a runny nose the last few days. No chest pain or cough. No nausea, vomiting, or diarrhea. No abdominal pain. Recently decreased her prednisone to 5mg daily. No other recent med changes. REVIEW OF SYSTEMS: A complete 10-point review of systems was performed and was negative unless otherwise noted in the HPI. Past Medical History: - [MASKED] - at age [MASKED] she had right breast cancer s/p resection, axillary dissection, chemotherapy with cyclophosphamide, adriamycin, and methotrexate Prior treatment history (per Dr. [MASKED]: 21 days for four cycles: cyclophosphamide (500 mg/m2 IV, day 1); doxorubicin (45 mg/m2 IV, day 3); methotrexate (200 mg/m2 IV, days 1 and 15); fluorouracil (500 mg/m2 IV, day 1); prednisone (40 mg/m2 PO, days [MASKED] and leucovorin (10 mg/m2 PO q6h. days [MASKED]. - [MASKED] - right breast cancer reportedly a separate primary treated with chemotherapy, unknown details. has remained on tamoxifen since that time - she has not been tested for BRCA1/2 or other inherited cancer syndromes - early onset osteoarthritis of hands Social History: [MASKED] Family History: Maternal aunt had melanoma. No other known cancers in family. No known hematologic diseases. She has a healthy younger brother. Physical Exam: ADMISSION PHYSICAL EXAM ================= VS: T 98.9 HR 100 BP 123/66 RR 20 SAT 95% O2 on RA GENERAL: Pleasant, sitting up in chair comfortably HEENT: Anicteric, PERLL, EOMI, no lid lag, OP clear CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops LUNG: Appears in no respiratory distress and speaks in full sentences while sitting up. Somewhat more labored appearing while lying flat. Clear to auscultation bilaterally, no crackles, wheezes, or rhonchi ABD: Normal bowel sounds, soft, nontender, nondistended, no hepatomegaly, no splenomegaly EXT: Warm, well perfused, 1+ lower extremity edema to mid calf bilaterally PULSES: 2+ radial pulses, 1+ DP pulses NEURO: Alert, orientedx3, CN II-XII intact, no lid lag, FTN intact. 3+/5 abduction of delts bilaterally. [MASKED] bicep strength bilaterally. Full strength in triceps and wrists. Full strength in hands. [MASKED] hip flexors bilaterally with [MASKED] knee extension. Full distal strength in lower extremities. Is able to stand from chair without using hands. Unable to get legs into bed after sitting. Sensory intact to light touch. SKIN: Rosacea on face, not clearly heliotrope rash. DISCHARGE PHYSICAL EXAM ================== VS: 97.6 BP 108/66 (108-114/62-70) HR 95 (95-102) RR 2095% RA GENERAL: Pleasant, sitting in bed comfortably. HEENT: Anicteric, PERLL, EOMI, OP clear. Flat right nasolabial fold, otherwise face symmetric with intact VII. CARDIAC: Regular rate, normal rhythm. No MRG LUNG: No sign of increased respiratory effort. Clear to auscultation bilaterally, no crackles, wheezes, or rhonchi ABD: Normal bowel sounds, soft, nontender, nondistended, no hepatomegaly, no splenomegaly EXT: Warm, well perfused, 1+ lower extremity edema to mid calf bilaterally PULSES: 2+ radial pulses, 1+ DP pulses NEURO: CN II-XII intact, no lid lag, FTN intact. Neuro exam today largely stable, still with weakness greatest to abduction at the shoulder bilaterally, [MASKED] on adduction. [MASKED] bicep strength bilaterally. Able to raise arms to midshoulder (GvHD photographic scale 4), able to bend elbows to 45 degrees with hands together (scale 5) and can dorsiflex foot almost fully. Good grip strength. [MASKED] hip flexors bilaterally with [MASKED]+ Patellar reflexes, +1 biceps reflex SKIN: Rosacea on face. Clean bandage over biopsy site, no overlying hematoma or tenderness. Pertinent Results: LABS ON ADMISSION ============= [MASKED] 10:40AM BLOOD WBC-13.7* RBC-3.05* Hgb-9.7* Hct-31.2* MCV-102* MCH-31.8 MCHC-31.1* RDW-17.3* RDWSD-64.5* Plt [MASKED] [MASKED] 10:40AM BLOOD Neuts-82* Bands-1 Lymphs-6* Monos-1* Eos-9* Baso-0 [MASKED] Metas-1* Myelos-0 AbsNeut-11.37* AbsLymp-0.82* AbsMono-0.14* AbsEos-1.23* AbsBaso-0.00* [MASKED] 10:40AM BLOOD Hypochr-NORMAL Anisocy-OCCASIONAL Poiklo-OCCASIONAL Macrocy-1+ Microcy-NORMAL Polychr-1+ Ovalocy-1+ Target-OCCASIONAL Burr-OCCASIONAL Pappenh-OCCASIONAL [MASKED] 10:40AM BLOOD Plt Smr-NORMAL Plt [MASKED] [MASKED] 10:40AM BLOOD Glucose-94 UreaN-12 Creat-0.6 Na-130* K-4.6 Cl-93* HCO3-27 AnGap-15 [MASKED] 10:40AM BLOOD ALT-154* AST-169* LD(LDH)-572* CK(CPK)-1719* AlkPhos-117* TotBili-0.4 [MASKED] 10:40AM BLOOD Albumin-2.9* Calcium-8.3* Mg-2.1 [MASKED] 10:40AM BLOOD CRP-134.1* NOTABLE LABS ========= [MASKED] 10:40AM BLOOD ALT-154* AST-169* LD(LDH)-572* CK(CPK)-1719* AlkPhos-117* TotBili-0.4 [MASKED] 12:22AM BLOOD ALT-148* AST-159* LD(LDH)-561* CK(CPK)-1586* AlkPhos-130* Amylase-17 TotBili-0.3 [MASKED] 08:04AM BLOOD ALT-122* AST-135* CK(CPK)-1433* AlkPhos-105 TotBili-0.3 [MASKED] 12:01AM BLOOD ALT-112* AST-138* LD(LDH)-534* CK(CPK)-1180* AlkPhos-128* TotBili-0.2 DirBili-<0.2 IndBili-0.2 [MASKED] 12:00AM BLOOD ALT-117* AST-138* LD([MASKED])-515* CK(CPK)-1178* AlkPhos-147* TotBili-0.2 [MASKED] 12:00AM BLOOD ALT-129* AST-125* LD([MASKED])-562* CK(CPK)-534* AlkPhos-169* TotBili-0.2 [MASKED] 12:01AM BLOOD Hapto-272* [MASKED] 12:22AM BLOOD calTIBC-169* Ferritn-2146* TRF-130* [MASKED] 11:16AM BLOOD VitB12-197* [MASKED] 10:40AM BLOOD CRP-134.1* [MASKED] 12:00AM BLOOD [MASKED] [MASKED] 10:40AM BLOOD T4-6.2 Free T4-1.1 [MASKED] 10:40AM BLOOD TSH-2.9 [MASKED] 12:00AM BLOOD Osmolal-275 [MASKED] 11:16AM BLOOD VitB12-197* [MASKED] 12:22AM BLOOD calTIBC-169* Ferritn-2146* TRF-130* [MASKED] 12:01AM BLOOD Hapto-272* [MASKED] 10:40AM BLOOD HCV Ab-Negative [MASKED] 12:00AM BLOOD ALDOLASE-Test [MASKED] 04:40PM BLOOD VITAMIN E-Test [MASKED] 04:40PM BLOOD PARVOVIRUS B19 DNA-Test [MASKED] 06:00AM BLOOD POSACONAZOLE-Test Name [MASKED] 12:00AM BLOOD INTRINSIC FACTOR ANTIBODY-Test [MASKED] 12:29PM BLOOD BK VIRUS, PCR-Test [MASKED] 12:38PM BLOOD METHYLMALONIC ACID-Test [MASKED] 12:22AM BLOOD MI-2 AUTOANTIBODIES-Test [MASKED] 12:22AM BLOOD SRP AUTOANTIBODIES-Test [MASKED] 12:22AM BLOOD ANTI-JO1 ANTIBODY-Test [MASKED] 12:22AM BLOOD PARANEOPLASTIC AUTOANTIBODY EVALUATION-PND [MASKED] 10:40AM BLOOD ALDOLASE-Test [MASKED] 10:40AM BLOOD SED RATE-Test [MASKED] 10:40AM BLOOD EBV PCR, QUANTITATIVE, WHOLE BLOOD-Test [MASKED] 10:40AM BLOOD EBV PCR, QUANTITATIVE, WHOLE BLOOD-Test LABS ON DISCHARGE ============= [MASKED] 12:00AM BLOOD WBC-18.8* RBC-2.68* Hgb-8.6* Hct-28.3* MCV-106* MCH-32.1* MCHC-30.4* RDW-19.8* RDWSD-74.1* Plt [MASKED] [MASKED] 12:00AM BLOOD Neuts-85* Bands-6* Lymphs-1* Monos-1* Eos-0 Baso-0 [MASKED] Metas-5* Myelos-2* NRBC-10* AbsNeut-17.11* AbsLymp-0.19* AbsMono-0.19* AbsEos-0.00* AbsBaso-0.00* [MASKED] 12:00AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-2+ Macrocy-3+ Microcy-NORMAL Polychr-OCCASIONAL Spheroc-OCCASIONAL Ovalocy-OCCASIONAL Burr-2+ Tear Dr-OCCASIONAL [MASKED] 12:00AM BLOOD Plt Smr-NORMAL Plt [MASKED] [MASKED] 12:00AM BLOOD Glucose-221* UreaN-17 Creat-0.5 Na-132* K-4.7 Cl-95* HCO3-27 AnGap-15 [MASKED] 12:00AM BLOOD ALT-129* AST-125* LD(LDH)-562* CK(CPK)-534* AlkPhos-169* TotBili-0.2 [MASKED] 12:00AM BLOOD Albumin-2.8* Calcium-8.8 Phos-4.2 Mg-2.1 IMAGING & PROCEDURES =============== PET CT ([MASKED]) IMPRESSION: 1. Moderate, bilateral symmetric FDG avidity in the muscles of the shoulder girdles and paraspinal musculature of the upper back could represent myositis in the appropriate clinical setting. Glucose was documented as 110 mg/dL at the time of the injection and the patient reports following the diet carefully. Normal glucose and the regional nature of the uptake argue against elevated insulin as a cause of uptake. 2. Small to moderate bilateral low-density pleural effusions are new. No pulmonary nodules or lymphadenopathy are seen within the chest. 3. Posttreatment changes are noted in the right breast and anterior abdominal wall. Grouped calcifications in the left breast are difficult to compare to the prior study due to technique. Attention on follow-up mammography is recommended. 4. Mild diffuse anasarca. MRI Cervical, Thoracic, Lumbar Spine ([MASKED]) 1. Small disc protrusion and endplate osteophyte indenting the ventral thecal sac and flattening the ventral cord at C5-C6. Otherwise no significant spinal canal narrowing. 2. Moderate right and mild left neural foraminal narrowing at C5-C6. Otherwise no significant neural foraminal narrowing. 3. No cord signal abnormality. 4. Diffuse loss of bone marrow fat without focal lesion, presumably relating to changes from myeloablation and bone marrow transplant. 5. Moderate right and small left pleural effusions. 6. Diffusely decreased parenchymal signal of the visualized liver and spleen may reflect changes secondary to treatment of AML or possibly iron deposition from repeated prior transfusions. EMG [MASKED] Abnormal study. There is electrophysiologic evidence of a myopathy with denervating features. Concomitant lumbosacral radiculopathies cannot be excluded. There is no evidence of a generalized polyneuropathy. RUQ Ultrasound [MASKED]. Normal hepatic parenchyma without focal lesions or biliary dilation. 2. Small right pleural effusion new from [MASKED]. Outpatient PFTS [MASKED] Results are consistent with a restrictive ventilatory defect. TLC was low normal when measured on [MASKED] compared to that study the FVC has decreased by 1.49 L (-48%) and the FEV1 has decreased by 1.05 L (-44%). Suggest repeat lung volume measurements to assess interval change if clinically indicated. MICROBIOLOGY =========== CMV Viral Load (Final [MASKED]: 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 [MASKED] patient population Urine Culture ([MASKED]) URINE CULTURE (Final [MASKED]: < 10,000 CFU/mL. Brief Hospital Course: Ms. [MASKED] is a [MASKED] year old woman with PMHx right breast cancer s/p (cyclophosphamide, methotrexate, adriamycin) and radiation with subsequent separate primary s/p chemotherapy NOS, and AML s/p allo MRD on [MASKED] who is admitted from the ED with proximal muscle weakness, found to have elevated CK and CRP concerning for possible myositis. # Mysositis. Ms. [MASKED] reported progressive proximal muscle weakness over last 4 weeks along with elevated CK and CRP (134.1 on presentation). Initial CK was 1719 and downtrended steadily during hospital stay. Found to be areflexic in upper extremities and hyporeflexic lower extremities, with some work of breathing and orthopnea. No ptosis, full EOMs, no diplopia on sustained upgaze. Outpatient PFTs resulted while patient was in hospital, showing a moderate restrictive pattern, FVC 1.6 (42% predicted), FEV1 1.35 (44% predicted) and FEV1/FVC 84% (49% predicted). EMG showed evidence of myopathy with deenervating features. On [MASKED] patient underwent biopsy of left deltoid without issue. An MRI cervical, thoracic and lumbar spine was also pursued as EMG could not rule out concomitant radiculopathy. This showed small disc protrusion and an osteophyte flattening the ventral cord at C5-C6 and moderate right and mild left neural foraminal narrowing at C5-C6. Otherwise no significant spinal canal narrowing. Work-up, including [MASKED], Mi2, SRP, BK virus, parvo, paraneoplastic panel and myositis panel all unrevealing. HCV and HBsAG, Ab and HBcAb were negative, though the utility of serology in this patient who is s/p SCT, is of limited value. Ms. [MASKED] remained stable throughout her hospital stay, with low but stable NIFs ranging from -50 - -60 and stable vital capacity. At this time it was felt that Ms. [MASKED] presentation is most consistent with polymyositis of GvHD. She was started on methylprednisolone 125 mg daily (2mg/kg) on [MASKED]. On [MASKED] she reported that the heavy feeling in her chest had abated some; NIFs remained the same. She was cautiously discharged after discussion of padding sharp edges and taking special fall precautions at home and with home [MASKED], [MASKED] and OT. She agreed that if she experience worsening of her weakness, trouble breathing or feels unsafe in any way, she will contact her primary oncologist or come to the emergency department immediately. # Flt3+ AML. Required 3 induction therapies before achieving minimal disease state and proceeded with myeloablative (BuCy) MRD alloSCT (D0 = [MASKED]. She has been on Sorafenib for continued suppressive therapy post transplant despite hand-foot syndrome, which has resolved. Complicated by GVHD of skin. Also with slowly increasing EBV VL. Recipient is CMV(+), ABO:Oneg Donor (brother [MASKED], ABO:Oneg; Chimerism from [MASKED]: 99.5% donor. Sorafenib was held during the course of Ms. [MASKED] hospital stay, as this was thought to be a possible cause of her myositis (can cause a necrotizing myositis). Patient was continued on Acyclovir BID, Posaconazole 100 mg daily. A PET scan was eventually obtained in the work-up of her myositis and showed bilateral symmetric FDG avidity in the muscles of the shoulder girdle and paraspinal muscules but no new areas concerning for malignancy. On [MASKED], patient underwent bone marrow biopsy; results pending. # GVHD and Transaminitis. Primarily manifests with mouth lesions. Patient also with recent transamanitis as an outpatient, redemonstrated in the hospital, with low-grade transaminitis consistent with hepatocellular injury. This was thought to be due to drug effect versus GvHD. Patient was seen hepatology consulting team, who thought that picture could certainly be explained by chronic GvHD. Recommended [MASKED] liver biopsy and proceding with steroid as above. If after 1 week of steroid treatment, LFT abnormality persists, then recommended reconsidering utility of liver biopsy. We continued patient's cyclosporine 50 mg PO BID. Held prednisone and decadron mouth rinse one methylprednisolone was started. # Misplaced line. Patient with tunneled line in azygos vein on imaging. On [MASKED] underwent wire-guided exchange. Tolerated well. # Water Retention. Ms. [MASKED] was noted to have significant lower extremity swelling as well as anasarca noted on PET CT. On [MASKED] was noted to have gone from 155.9 lb to 158.7 lbs (147.1 on admission). Patient was diuresed with 10 mg PO lasix for 3 days prior to discharge and was sent home with a prescription for 10 mg lasix to take if she gains more than 2 lbs at home. # HTN: Developed in setting of sorafnib. Patient with SBPs in the 110s-120s. Continued home amlodipine 10mg daily, held home hydrochlorothiazide 3x per week. # Hx of breast cancer: Previously on tamoxifen maintenance. Has been on hold given risk of thrombosis. Did not resume treatment while in-house. TRANSITIONAL ISSUES ============== - Pending Muscle Biopsy and Bone Marrow Biopsy Result - Consider discontinuing or decreasing amlodipine if patient is not to start sorafenib again. Hypertension was in setting of sorafenib. - Discussed padding sharp edges and taking special fall precautions at home. Ms. [MASKED] agreed that if she experience worsening of her weakness, trouble breathing or feels unsafe in any way, she will contact her primary oncologist or come to the emergency department immediately. - Ms. [MASKED] had persistent water retention in her legs. She was given a prescription for 10 mg PO Lasix to take whenever she experience a >2 lb weight gain - Patient was repleted with IM B12 from [MASKED] to [MASKED]. She will need weekly B12 injections for the next 4 weeks, starting [MASKED]. Please check B12 level after 4 B12 injections. - Medication changes: -- Started Furosemide 10 mg PO to take if gains >2 lbs -- Started MethylPREDNISolone Sodium Succ 125 mg IV Q24H. Patient will have help administering this medication with the [MASKED]. Final time course to be decided by Dr. [MASKED] -- [MASKED] Hydrochlorothiazide 12.5 mg PO 3X/WEEK ([MASKED]) -- [MASKED] Dexamethasone Oral Soln (0.1mg/1mL) 5 mL ORAL TID while on methylprednisololne Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q12H 2. amLODIPine 10 mg PO DAILY 3. Artificial Tears Preserv. Free [MASKED] DROP BOTH EYES PRN dry eyes 4. Clindamycin 1% Solution 1 Appl TP DAILY 5. CycloSPORINE (Neoral) MODIFIED 50 mg PO Q12H 6. Dexamethasone Oral Soln (0.1mg/1mL) 5 mL ORAL TID 7. Fexofenadine 180 mg PO ASDIR 8. FoLIC Acid 1 mg PO DAILY 9. Hydrochlorothiazide 12.5 mg PO 3X/WEEK ([MASKED]) 10. LORazepam 0.5 mg PO Q8H:PRN nausea/anxiety 11. Potassium Chloride 20 mEq PO 3X/WEEK ([MASKED]) 12. PredniSONE 5 mg PO DAILY 13. Sorafenib 400 mg PO BID 14. sulfacetamide sodium 10 % topical DAILY 15. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 16. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID 17. urea 40 % topical BID:PRN 18. Vitamin D 1000 UNIT PO DAILY 19. MetronidAZOLE Topical 1 % Gel 1 Appl TP BID:PRN facial rash 20. Posaconazole Delayed Release Tablet 100 mg PO DAILY Discharge Medications: 1. Furosemide 20 mg PO ASDIR Take one half tab if weight increase of more than 2 pounds 2. MethylPREDNISolone Sodium Succ 125 mg IV Q24H RX *methylprednisolone sodium succ 1,000 mg 125 mg IV Q24 Disp #*7 Vial Refills:*0 3. Acyclovir 400 mg PO Q12H 4. amLODIPine 10 mg PO DAILY 5. Artificial Tears Preserv. Free [MASKED] DROP BOTH EYES PRN dry eyes 6. Clindamycin 1% Solution 1 Appl TP DAILY 7. CycloSPORINE (Neoral) MODIFIED 50 mg PO Q12H 8. Fexofenadine 180 mg PO ASDIR 9. FoLIC Acid 1 mg PO DAILY 10. LORazepam 0.5 mg PO Q8H:PRN nausea/anxiety RX *lorazepam 0.5 mg 1 tab by mouth Q8H PRN Disp #*30 Tablet Refills:*0 11. MetronidAZOLE Topical 1 % Gel 1 Appl TP BID:PRN facial rash 12. Posaconazole Delayed Release Tablet 100 mg PO DAILY 13. Potassium Chloride 20 mEq PO 3X/WEEK ([MASKED]) 14. sulfacetamide sodium 10 % topical DAILY 15. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 16. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID 17. urea 40 % topical BID:PRN 18. Vitamin D 1000 UNIT PO DAILY 19. HELD- Dexamethasone Oral Soln (0.1mg/1mL) 5 mL ORAL TID This medication was held. Do not restart Dexamethasone Oral Soln (0.1mg/1mL) until you have stopped your methylprednisone treatments 20. HELD- Hydrochlorothiazide 12.5 mg PO 3X/WEEK ([MASKED]) This medication was held. Do not restart Hydrochlorothiazide until you speak with Dr. [MASKED]. We are substituting furosemide currently 21. HELD- Sorafenib 400 mg PO BID This medication was held. Do not restart Sorafenib until discussing with Dr. [MASKED] [MASKED] Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Primary ===== Myositis AML GvHD Hyponatremia Transaminitis Secondary ======== Hypertension History of breast cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [MASKED], It was a pleasure caring for you at [MASKED] [MASKED]. You presented to [MASKED] with one month of muscle weakness and swelling in your arms and legs. We sent and performed numerous tests while you here, including an electromyogram which showed myopathy and a biopsy of one of the affected muscles in your shoulders; we are still waiting for the results of this. You were started on methylprednisone injection while here to treat what we believe is a manifestation of your graft versus host disease. You did well in the hospital overall. Your breathing remained stable and you were discharged on [MASKED] with close follow-up, visiting nursing and with the understanding that if anything changes in your breathing or your muscle function you will call Dr. [MASKED] come to the emergency department immediately. Please take your medications as detailed in this discharge summary. If you experience any of the danger signs below, please call your primary oncologist or come to the emergency department immediately. Best Wishes, Your [MASKED] Care Team Followup Instructions: [MASKED] | [
"T8609",
"S2231XB",
"C9200",
"D61818",
"R1310",
"E871",
"T82524A",
"E8770",
"D89813",
"M609",
"K1230",
"W108XXA",
"Y92018",
"R509",
"Z853",
"Z9221",
"Z923",
"L818",
"R740",
"I10",
"Y849",
"Y92230",
"L719"
] | [
"T8609: Other complications of bone marrow transplant",
"S2231XB: Fracture of one rib, right side, initial encounter for open fracture",
"C9200: Acute myeloblastic leukemia, not having achieved remission",
"D61818: Other pancytopenia",
"R1310: Dysphagia, unspecified",
"E871: Hypo-osmolality and hyponatremia",
"T82524A: Displacement of infusion catheter, initial encounter",
"E8770: Fluid overload, unspecified",
"D89813: Graft-versus-host disease, unspecified",
"M609: Myositis, unspecified",
"K1230: Oral mucositis (ulcerative), unspecified",
"W108XXA: Fall (on) (from) other stairs and steps, initial encounter",
"Y92018: Other place in single-family (private) house as the place of occurrence of the external cause",
"R509: Fever, unspecified",
"Z853: Personal history of malignant neoplasm of breast",
"Z9221: Personal history of antineoplastic chemotherapy",
"Z923: Personal history of irradiation",
"L818: Other specified disorders of pigmentation",
"R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]",
"I10: Essential (primary) hypertension",
"Y849: Medical procedure, unspecified as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure",
"Y92230: Patient room in hospital as the place of occurrence of the external cause",
"L719: Rosacea, unspecified"
] | [
"E871",
"I10",
"Y92230"
] | [] |
14,289,751 | 23,615,165 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nPain, dysuria, dark stools\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ woman with stage IV, EGFR, exon 19 \nmutated lung adenocarcinoma maintained on erlotinib 150 mg daily \nsince ___ recently on clinical trial DF/HCC ___ \n(stopped ___, now presenting with worsening pain.\n\nOf note, the patient was recently admitted to ___ from ___ to \n___ following a syncopal event. It was thought her syncope was \ndue to orthostasis. She was started on midodrine with good \nresponse. She was also treated for a UTI. CTA chest revealed a \nnew pulmonary embolism of unclear significance; it was small and \nnot thought to be the cause of her syncope. She had been on \ntherapeutic enoxaparin for over a year, and she reported good \ncompliance. After discussion with primary oncologist, the \npatient was continued on her home dose. In addition, she was \nfound to have progression of her cancer with an increased lung \nmass and a new left hip pain caused by metastatic lesion to the \nleft pelvic ramus. She received a dose of zoledronic acid on \narrival. During this admission, the patient was seen by \northopedic surgery and deemed safe to weight bear as tolerated \nwith no need for surgical intervention. Radiation oncology was \nconsulted and initiated \nradiation to the area, with completion of radiation as an \noutpatient on ___. ___ guided biopsy of the pelvic lesion was \nobtained, which showed adenocarcinoma; genetic studies pending. \n\nSince discharge on the ___, the patient stopped taking her \nerlotinib; she says she ran out of the medication. In addition, \nshe ran out of her oxycodone and advil. She's been using just \nTylenol instead and thus her pain has gotten much worse. Pain is \nin her tailbone radiating to right leg. Her pain was well \ncontrolled with oxycodone. States that pain is better since \nradiation to the area.\n\nIn addition, she has had dark black stools for the past couple \ndays while on lovenox. The stools are well formed. Noted that \nshe had nausea and diarrhea last week that have resolved. No \nabdominal pain, vomiting. Had black stools a few months ago for \nseveral days that self resolved. Endorses bloating. Per patient \nhad colonoscopy at age ___ and is overdue for one. Has never had \na GIB in past. \n\nIn clinic, her physicians thought she seemed more confused than \nnormal. She also reported dysuria for many days. Given the \nconfusion, melena, dysuria, and severe pain she was admitted to \nthe oncology service.\n\nEndorsed occasional sweats and feeling cold. No problems \nswallowing, vision changes, SOB, CP, palpitations. Notes some \nchronic ___ weakness and has been using walker. \n\n \nPast Medical History:\nONCOLOGICAL HISTORY: \n- Ms. ___ is a ___ female with a 10-pack-year remote \nsmoking history. She started to feel fatigued since ___. She felt the fatigue is associated with worsening \nshortness of breath upon exertion. She also had night sweats. \nThis led to the workup, which showed right basilar lung nodule \nwith a right-sided pleural effusion. \n- She was hospitalized at ___ from ___ through ___. \nDuring the hospitalization, she received a thoracentesis to \nremove her pleural effusions. She reports feeling significantly \nbetter after those pleural effusions. Cytology analysis \nrevealed adenocarcinoma of the lung. After discharge, she \nunderwent a PET CT scan, which showed FDG avid lung mass, hilar \nlymphadenopathy and a sacrum lesion on the left. \n- She was found to have ALK transplocation. Started on \nCrizotinib from ___ at 250mg BID. \n- acute chest pain on ___, suspected to have PE. She was \nhospitalized from ___. \n- She presented to the ED on ___ due to abdominal pain and \nhemoptysis. \n- Start erlotinib on trial ___ on ___ at 150 mg daily \n- ___ restaging CT showed response. \n- surveillance imaging through ___ with stable without local \nrecurrence or metastasis\n\nPAST MEDICAL HISTORY (outside lung cancer):\n1. Hydrocephalus status post shunt placement since 1990s, \nstatus post three different shunts.\n2. Prior gastroesophageal reflux disease.\n3. Hyperlipidemia.\n4. Prior kidney stones.\n5. Prior recurrent urinary tract infections.\n \nSocial History:\n___\nFamily History:\n8 siblings total, multiple with history of cancer as below\nSister - ovarian cancer\nSister - breast cancer\nBrother - lung cancer\nBrother - prostate cancer\nBrother - colon cancer\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n=======================\nVS: 98.0 87 132/67 18 98% O2 on RA\nGENERAL: A&Ox3, Pleasant, sitting in bed\nHEENT: MMM, Oropharynx without lesions, PERRLA, EOMI, no \ncervical, supraclavicular or axillary lymphadenopathy. VP shunt \nfelt on R of neck. \nCARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops\nLUNG: Appears in no respiratory distress, clear to auscultation \nbilaterally, no crackles, wheezes, or rhonchi\nABD: Normal bowel sounds, soft, nontender, nondistended, no \nhepatomegaly, no splenomegaly\nEXT: Warm, well perfused, no lower extremity edema\nPULSES: 2+ radial pulses, 2+ ___ pulses, 2+ DP pulses\nNEURO: Alert, oriented x3, CN II-XII intact, motor and sensory \nfunction grossly intact. ___ upper and lower extremity strength \nbilat. \nSKIN: No significant rashes\n\nDISCHARGE PHYSICAL EXAM\n=======================\nVS: 98.6 ___ 105-115/50-60 18 98%RA \nGENERAL: A&Ox3, Pleasant, lying in bed\nHEENT: MMM, Oropharynx without lesions, PERRLA, EOMI, no \ncervical, supraclavicular or axillary lymphadenopathy. VP shunt \nfelt on R of neck. \nCARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops\nLUNG: No respiratory distress, clear to auscultation \nbilaterally, no crackles, wheezes, or rhonchi\nABD: Normal bowel sounds, soft, nontender, nondistended, no \nhepatomegaly, no splenomegaly\nEXT: Warm, well perfused, no lower extremity edema\nPULSES: 2+ radial pulses, 2+ ___ pulses, 2+ DP pulses\nNEURO: Alert, oriented x3, CN II-XII intact, motor and sensory \nfunction grossly intact. ___ upper and lower extremity strength \nbilat. \nSKIN: No significant rashes\n\n \nPertinent Results:\nADMISSION LABS\n==============\n___ 10:10AM BLOOD WBC-6.8 RBC-4.42 Hgb-11.3 Hct-36.0 \nMCV-81* MCH-25.6* MCHC-31.4* RDW-15.8* RDWSD-46.4* Plt ___\n___ 10:10AM BLOOD Neuts-64.7 ___ Monos-8.6 Eos-3.6 \nBaso-0.7 Im ___ AbsNeut-4.37# AbsLymp-1.47 AbsMono-0.58 \nAbsEos-0.24 AbsBaso-0.05\n___ 10:10AM BLOOD ___ PTT-39.1* ___\n___ 10:10AM BLOOD UreaN-7 Creat-0.6 Na-138 K-4.0 Cl-101\n___ 10:10AM BLOOD ALT-32 AST-25 AlkPhos-127* TotBili-0.3\n___ 10:10AM BLOOD TotProt-7.0 Albumin-4.0 Globuln-3.0 \nCalcium-9.1 Phos-2.4* Mg-1.8\n\nDISCHARGE AND PERTINENT LABS\n============================\n___ 07:40AM BLOOD WBC-5.4 RBC-4.03 Hgb-10.2* Hct-32.8* \nMCV-81* MCH-25.3* MCHC-31.1* RDW-15.7* RDWSD-46.3 Plt ___\n___ 07:40AM BLOOD ___ PTT-27.5 ___\n___ 07:40AM BLOOD Glucose-76 UreaN-9 Creat-0.6 Na-138 K-4.3 \nCl-100 HCO3-28 AnGap-14\n\nMICROBIOLOGY\n============\n___ 12:15 pm URINE\n **FINAL REPORT ___\n URINE CULTURE (Final ___: \n MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT \nWITH SKIN\n AND/OR GENITAL CONTAMINATION. \n\n___ 7:05 pm BLOOD CULTURE 1 OF 2. \n Blood Culture, Routine (Pending): \n___ 7:15 pm BLOOD CULTURE 2 OF 2. \n Blood Culture, Routine (Pending): \n\nIMAGING\n========\n___ Head CT with and without contrast\nFINDINGS: \nA VP shunt is in unchanged position, entering the right parietal \ncalvarium and terminating in the frontal horn of the left \nlateral ventricle. There is no evidence of fracture, \ninfarction, hemorrhage, edema or mass. There is stable \nprominence of the sulci suggestive of involutional changes. \nStable configuration of the ventricles. There is no abnormal \nenhancement on the post contrast images. \n\nBilateral, frontal, postsurgical calvarial defects are \nunchanged. Mild \nmucosal thickening in the maxillary sinuses bilaterally, greater \non the right. The visualized portion of the paranasal sinuses, \nmastoid air cells, and middle ear cavities are clear. The \nvisualized portion of the orbits are unremarkable. \n \nIMPRESSION: \n1. No abnormal enhancement. \n2. No evidence of acute intracranial hemorrhage or large \nterritorial infarct. \n\n \nBrief Hospital Course:\nMs. ___ is a ___ woman with stage IV, EGFR, exon 19 \nmutated lung adenocarcinoma maintained on erlotinib 150 mg daily \nsince ___ directly admitted from clinic for worsening \npain, urinary tract infection, and dark stools. \n\n#UTI: In clinic patient's UA positive for leukocyte esterase and \nWBCs. In addition she was experiencing dysuria. Was started on \ntreatment for UTI on ceftriaxone then switched to Bactrim. Start \non pyridium to help with dysuria. However, continued to \nexperience dysuria and switched to nitrofurantoin on ___ to \ncomplete a 3 day course on ___ as she had enterococcus and \nklebsiella sensitive to it grown on prior cultures. Current \nurine culture still pending. \n\n#Pain: Patient's pain was well controlled with home dose of \noxycodone which she ran out of two weeks prior to \nhospitalization and Tylenol. Was restarted on oxycodone with \nwell controlled pain.\n\n#Dark stools: Questionable melena per patient report. Patient \nreported dark stools but hemoglobin remained stable at baseline \nand there was no evidence of active GI bleeding. There were no \nbowel movements during the 2 day hospitalization. She should \nhave a colonoscopy as outpatient as she is overdue for screening \nper patient report. Instructed patient to avoid NSAIDs as they \ncan cause gastritis. \n\n#Confusion: Per report patient was confused in ___ clinic. \nUpon admission there was no evidence of altered mental status \nwhich was not waxing or waning. Patient had a Head CT with \ncontrast which did not show acute changes and no evidence of \nmets. An MRI was not performed as she has a VP shunt in place \nfrom ___. \n\n#Lung Adenocarcinoma, stage IV: Patient also ran out of \nerlotinib and is no longer part of clinical trial. Outpatient \noncologists are aware and will follow up as outpatient regarding \nrestarting medication. \n\nTRANSITIONAL ISSUES\n===================\n[] treatment for UTI with nitrofurantoin 50mg q6h and pyridium. \nLast day ___.\n[] follow up with patient to ensure dysuria resolves\n[] patient does not have erlotinib supply for lung CA treatment \nand is no longer part of clinical trial. Outpatient oncologist \nto determine need to restart as outpatient.\n[] patient is past due for screening colonoscopy and has \nmicrocytosis \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. LOPERamide 2 mg PO QID:PRN diarrhea \n2. Magnesium Oxide 500 mg PO BID \n3. Naproxen 220 mg PO Q12H:PRN pain \n4. Vitamin D 1000 UNIT PO DAILY \n5. Pantoprazole 40 mg PO Q24H \n6. Acetaminophen 650 mg PO Q12H:PRN pain fever \n7. Codeine Sulfate ___ mg PO QHS \n8. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain \n9. Midodrine 2.5 mg PO TID \n10. Enoxaparin Sodium 120 mg SC DAILY \nStart: ___, First Dose: Next Routine Administration Time \n11. Erlotinib 150 mg PO QD \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q12H:PRN pain fever \n2. Enoxaparin Sodium 120 mg SC Q24H \nStart: ___, First Dose: Next Routine Administration Time \n3. Midodrine 2.5 mg PO TID \n4. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain \nRX *oxycodone 5 mg 1 tablet(s) by mouth Q4H:PRN Disp #*72 Tablet \nRefills:*0\n5. Pantoprazole 40 mg PO Q24H \n6. Vitamin D 1000 UNIT PO DAILY \n7. Codeine Sulfate ___ mg PO QHS \n8. Erlotinib 150 mg PO QD \n9. LOPERamide 2 mg PO QID:PRN diarrhea \n10. Magnesium Oxide 500 mg PO BID \n11. Nitrofurantoin (Macrodantin) 50 mg PO Q6H Duration: 3 Days \nRX *nitrofurantoin macrocrystal 50 mg 1 capsule(s) by mouth \nevery six (6) hours Disp #*11 Capsule Refills:*0\n12. Phenazopyridine 100 mg PO TID Duration: 3 Days \nRX *phenazopyridine 100 mg 1 tablet(s) by mouth three times a \nday Disp #*9 Tablet Refills:*0\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n=================\nChronic Pain\nUrinary Tract Infection\n\nSECONDARY DIAGNOSES\n===================\nMetastatic Lung Carcinoma\nAltered Mental Status\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nIt was a pleasure taking care of you at the ___ \n___. You were admitted to the hospital \nafter you developed worsening pain, dark stools, and pain with \nurination. Upon work-up we determined that you have a urinary \ntract infection and started you on antibiotics for treatment. \nFor your pain we restarted you on oxycodone and Tylenol which \ncontrolled your pain well. Your blood counts remained stable and \na head CAT scan showed no changes. We also recommend that you \nshould stop taking advil(ibuprofen) or naproxen(Naprosyn) as \nthey can have negative side effects. We also recommend that you \nobtain a colonoscopy as you are past due for screening. \n \nFollowup Instructions:\n___\n"
] | Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Pain, dysuria, dark stools Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] woman with stage IV, EGFR, exon 19 mutated lung adenocarcinoma maintained on erlotinib 150 mg daily since [MASKED] recently on clinical trial DF/HCC [MASKED] (stopped [MASKED], now presenting with worsening pain. Of note, the patient was recently admitted to [MASKED] from [MASKED] to [MASKED] following a syncopal event. It was thought her syncope was due to orthostasis. She was started on midodrine with good response. She was also treated for a UTI. CTA chest revealed a new pulmonary embolism of unclear significance; it was small and not thought to be the cause of her syncope. She had been on therapeutic enoxaparin for over a year, and she reported good compliance. After discussion with primary oncologist, the patient was continued on her home dose. In addition, she was found to have progression of her cancer with an increased lung mass and a new left hip pain caused by metastatic lesion to the left pelvic ramus. She received a dose of zoledronic acid on arrival. During this admission, the patient was seen by orthopedic surgery and deemed safe to weight bear as tolerated with no need for surgical intervention. Radiation oncology was consulted and initiated radiation to the area, with completion of radiation as an outpatient on [MASKED]. [MASKED] guided biopsy of the pelvic lesion was obtained, which showed adenocarcinoma; genetic studies pending. Since discharge on the [MASKED], the patient stopped taking her erlotinib; she says she ran out of the medication. In addition, she ran out of her oxycodone and advil. She's been using just Tylenol instead and thus her pain has gotten much worse. Pain is in her tailbone radiating to right leg. Her pain was well controlled with oxycodone. States that pain is better since radiation to the area. In addition, she has had dark black stools for the past couple days while on lovenox. The stools are well formed. Noted that she had nausea and diarrhea last week that have resolved. No abdominal pain, vomiting. Had black stools a few months ago for several days that self resolved. Endorses bloating. Per patient had colonoscopy at age [MASKED] and is overdue for one. Has never had a GIB in past. In clinic, her physicians thought she seemed more confused than normal. She also reported dysuria for many days. Given the confusion, melena, dysuria, and severe pain she was admitted to the oncology service. Endorsed occasional sweats and feeling cold. No problems swallowing, vision changes, SOB, CP, palpitations. Notes some chronic [MASKED] weakness and has been using walker. Past Medical History: ONCOLOGICAL HISTORY: - Ms. [MASKED] is a [MASKED] female with a 10-pack-year remote smoking history. She started to feel fatigued since [MASKED]. She felt the fatigue is associated with worsening shortness of breath upon exertion. She also had night sweats. This led to the workup, which showed right basilar lung nodule with a right-sided pleural effusion. - She was hospitalized at [MASKED] from [MASKED] through [MASKED]. During the hospitalization, she received a thoracentesis to remove her pleural effusions. She reports feeling significantly better after those pleural effusions. Cytology analysis revealed adenocarcinoma of the lung. After discharge, she underwent a PET CT scan, which showed FDG avid lung mass, hilar lymphadenopathy and a sacrum lesion on the left. - She was found to have ALK transplocation. Started on Crizotinib from [MASKED] at 250mg BID. - acute chest pain on [MASKED], suspected to have PE. She was hospitalized from [MASKED]. - She presented to the ED on [MASKED] due to abdominal pain and hemoptysis. - Start erlotinib on trial [MASKED] on [MASKED] at 150 mg daily - [MASKED] restaging CT showed response. - surveillance imaging through [MASKED] with stable without local recurrence or metastasis PAST MEDICAL HISTORY (outside lung cancer): 1. Hydrocephalus status post shunt placement since 1990s, status post three different shunts. 2. Prior gastroesophageal reflux disease. 3. Hyperlipidemia. 4. Prior kidney stones. 5. Prior recurrent urinary tract infections. Social History: [MASKED] Family History: 8 siblings total, multiple with history of cancer as below Sister - ovarian cancer Sister - breast cancer Brother - lung cancer Brother - prostate cancer Brother - colon cancer Physical Exam: ADMISSION PHYSICAL EXAM ======================= VS: 98.0 87 132/67 18 98% O2 on RA GENERAL: A&Ox3, Pleasant, sitting in bed HEENT: MMM, Oropharynx without lesions, PERRLA, EOMI, no cervical, supraclavicular or axillary lymphadenopathy. VP shunt felt on R of neck. CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops LUNG: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi ABD: Normal bowel sounds, soft, nontender, nondistended, no hepatomegaly, no splenomegaly EXT: Warm, well perfused, no lower extremity edema PULSES: 2+ radial pulses, 2+ [MASKED] pulses, 2+ DP pulses NEURO: Alert, oriented x3, CN II-XII intact, motor and sensory function grossly intact. [MASKED] upper and lower extremity strength bilat. SKIN: No significant rashes DISCHARGE PHYSICAL EXAM ======================= VS: 98.6 [MASKED] 105-115/50-60 18 98%RA GENERAL: A&Ox3, Pleasant, lying in bed HEENT: MMM, Oropharynx without lesions, PERRLA, EOMI, no cervical, supraclavicular or axillary lymphadenopathy. VP shunt felt on R of neck. CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops LUNG: No respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi ABD: Normal bowel sounds, soft, nontender, nondistended, no hepatomegaly, no splenomegaly EXT: Warm, well perfused, no lower extremity edema PULSES: 2+ radial pulses, 2+ [MASKED] pulses, 2+ DP pulses NEURO: Alert, oriented x3, CN II-XII intact, motor and sensory function grossly intact. [MASKED] upper and lower extremity strength bilat. SKIN: No significant rashes Pertinent Results: ADMISSION LABS ============== [MASKED] 10:10AM BLOOD WBC-6.8 RBC-4.42 Hgb-11.3 Hct-36.0 MCV-81* MCH-25.6* MCHC-31.4* RDW-15.8* RDWSD-46.4* Plt [MASKED] [MASKED] 10:10AM BLOOD Neuts-64.7 [MASKED] Monos-8.6 Eos-3.6 Baso-0.7 Im [MASKED] AbsNeut-4.37# AbsLymp-1.47 AbsMono-0.58 AbsEos-0.24 AbsBaso-0.05 [MASKED] 10:10AM BLOOD [MASKED] PTT-39.1* [MASKED] [MASKED] 10:10AM BLOOD UreaN-7 Creat-0.6 Na-138 K-4.0 Cl-101 [MASKED] 10:10AM BLOOD ALT-32 AST-25 AlkPhos-127* TotBili-0.3 [MASKED] 10:10AM BLOOD TotProt-7.0 Albumin-4.0 Globuln-3.0 Calcium-9.1 Phos-2.4* Mg-1.8 DISCHARGE AND PERTINENT LABS ============================ [MASKED] 07:40AM BLOOD WBC-5.4 RBC-4.03 Hgb-10.2* Hct-32.8* MCV-81* MCH-25.3* MCHC-31.1* RDW-15.7* RDWSD-46.3 Plt [MASKED] [MASKED] 07:40AM BLOOD [MASKED] PTT-27.5 [MASKED] [MASKED] 07:40AM BLOOD Glucose-76 UreaN-9 Creat-0.6 Na-138 K-4.3 Cl-100 HCO3-28 AnGap-14 MICROBIOLOGY ============ [MASKED] 12:15 pm URINE **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. [MASKED] 7:05 pm BLOOD CULTURE 1 OF 2. Blood Culture, Routine (Pending): [MASKED] 7:15 pm BLOOD CULTURE 2 OF 2. Blood Culture, Routine (Pending): IMAGING ======== [MASKED] Head CT with and without contrast FINDINGS: A VP shunt is in unchanged position, entering the right parietal calvarium and terminating in the frontal horn of the left lateral ventricle. There is no evidence of fracture, infarction, hemorrhage, edema or mass. There is stable prominence of the sulci suggestive of involutional changes. Stable configuration of the ventricles. There is no abnormal enhancement on the post contrast images. Bilateral, frontal, postsurgical calvarial defects are unchanged. Mild mucosal thickening in the maxillary sinuses bilaterally, greater on the right. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: 1. No abnormal enhancement. 2. No evidence of acute intracranial hemorrhage or large territorial infarct. Brief Hospital Course: Ms. [MASKED] is a [MASKED] woman with stage IV, EGFR, exon 19 mutated lung adenocarcinoma maintained on erlotinib 150 mg daily since [MASKED] directly admitted from clinic for worsening pain, urinary tract infection, and dark stools. #UTI: In clinic patient's UA positive for leukocyte esterase and WBCs. In addition she was experiencing dysuria. Was started on treatment for UTI on ceftriaxone then switched to Bactrim. Start on pyridium to help with dysuria. However, continued to experience dysuria and switched to nitrofurantoin on [MASKED] to complete a 3 day course on [MASKED] as she had enterococcus and klebsiella sensitive to it grown on prior cultures. Current urine culture still pending. #Pain: Patient's pain was well controlled with home dose of oxycodone which she ran out of two weeks prior to hospitalization and Tylenol. Was restarted on oxycodone with well controlled pain. #Dark stools: Questionable melena per patient report. Patient reported dark stools but hemoglobin remained stable at baseline and there was no evidence of active GI bleeding. There were no bowel movements during the 2 day hospitalization. She should have a colonoscopy as outpatient as she is overdue for screening per patient report. Instructed patient to avoid NSAIDs as they can cause gastritis. #Confusion: Per report patient was confused in [MASKED] clinic. Upon admission there was no evidence of altered mental status which was not waxing or waning. Patient had a Head CT with contrast which did not show acute changes and no evidence of mets. An MRI was not performed as she has a VP shunt in place from [MASKED]. #Lung Adenocarcinoma, stage IV: Patient also ran out of erlotinib and is no longer part of clinical trial. Outpatient oncologists are aware and will follow up as outpatient regarding restarting medication. TRANSITIONAL ISSUES =================== [] treatment for UTI with nitrofurantoin 50mg q6h and pyridium. Last day [MASKED]. [] follow up with patient to ensure dysuria resolves [] patient does not have erlotinib supply for lung CA treatment and is no longer part of clinical trial. Outpatient oncologist to determine need to restart as outpatient. [] patient is past due for screening colonoscopy and has microcytosis Medications on Admission: The Preadmission Medication list is accurate and complete. 1. LOPERamide 2 mg PO QID:PRN diarrhea 2. Magnesium Oxide 500 mg PO BID 3. Naproxen 220 mg PO Q12H:PRN pain 4. Vitamin D 1000 UNIT PO DAILY 5. Pantoprazole 40 mg PO Q24H 6. Acetaminophen 650 mg PO Q12H:PRN pain fever 7. Codeine Sulfate [MASKED] mg PO QHS 8. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain 9. Midodrine 2.5 mg PO TID 10. Enoxaparin Sodium 120 mg SC DAILY Start: [MASKED], First Dose: Next Routine Administration Time 11. Erlotinib 150 mg PO QD Discharge Medications: 1. Acetaminophen 650 mg PO Q12H:PRN pain fever 2. Enoxaparin Sodium 120 mg SC Q24H Start: [MASKED], First Dose: Next Routine Administration Time 3. Midodrine 2.5 mg PO TID 4. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain RX *oxycodone 5 mg 1 tablet(s) by mouth Q4H:PRN Disp #*72 Tablet Refills:*0 5. Pantoprazole 40 mg PO Q24H 6. Vitamin D 1000 UNIT PO DAILY 7. Codeine Sulfate [MASKED] mg PO QHS 8. Erlotinib 150 mg PO QD 9. LOPERamide 2 mg PO QID:PRN diarrhea 10. Magnesium Oxide 500 mg PO BID 11. Nitrofurantoin (Macrodantin) 50 mg PO Q6H Duration: 3 Days RX *nitrofurantoin macrocrystal 50 mg 1 capsule(s) by mouth every six (6) hours Disp #*11 Capsule Refills:*0 12. Phenazopyridine 100 mg PO TID Duration: 3 Days RX *phenazopyridine 100 mg 1 tablet(s) by mouth three times a day Disp #*9 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSIS ================= Chronic Pain Urinary Tract Infection SECONDARY DIAGNOSES =================== Metastatic Lung Carcinoma Altered Mental Status 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. [MASKED], It was a pleasure taking care of you at the [MASKED] [MASKED]. You were admitted to the hospital after you developed worsening pain, dark stools, and pain with urination. Upon work-up we determined that you have a urinary tract infection and started you on antibiotics for treatment. For your pain we restarted you on oxycodone and Tylenol which controlled your pain well. Your blood counts remained stable and a head CAT scan showed no changes. We also recommend that you should stop taking advil(ibuprofen) or naproxen(Naprosyn) as they can have negative side effects. We also recommend that you obtain a colonoscopy as you are past due for screening. Followup Instructions: [MASKED] | [
"N390",
"G919",
"C7951",
"C3491",
"D473",
"E785",
"Z982",
"G893",
"R195",
"Z86711",
"Z7901",
"R4182",
"Z87891",
"Z801"
] | [
"N390: Urinary tract infection, site not specified",
"G919: Hydrocephalus, unspecified",
"C7951: Secondary malignant neoplasm of bone",
"C3491: Malignant neoplasm of unspecified part of right bronchus or lung",
"D473: Essential (hemorrhagic) thrombocythemia",
"E785: Hyperlipidemia, unspecified",
"Z982: Presence of cerebrospinal fluid drainage device",
"G893: Neoplasm related pain (acute) (chronic)",
"R195: Other fecal abnormalities",
"Z86711: Personal history of pulmonary embolism",
"Z7901: Long term (current) use of anticoagulants",
"R4182: Altered mental status, unspecified",
"Z87891: Personal history of nicotine dependence",
"Z801: Family history of malignant neoplasm of trachea, bronchus and lung"
] | [
"N390",
"E785",
"Z7901",
"Z87891"
] | [] |
17,708,869 | 29,632,629 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nAtivan / shellfish derived\n \nAttending: ___.\n \nChief Complaint:\n___\n \nMajor Surgical or Invasive Procedure:\nPCN tube placement\n \nHistory of Present Illness:\nThis is a ___ year old male past medical history of atrial\nfibrillation, recurrent UTIs on suppressive bactrim, locally\nadvanced rectal cancer status status post palliative diverting\ncolostomy, prior hydronephrosis treated with R ureteral stent\nthat was complicated by recurrent UTIs necessitating stent\nremoval, being treated with Keytruda (first dose ___ by\nDr. ___ at ___, presenting with worsening ___.\n\nPer patient report and review of records, 10 days prior to\npresentation, patient was treated for a UTI with PO cipro. 5\ndays prior to admission he noted new incontinence. On day of\nadmission patient presented to see his primary oncologist, and\nreported these symptoms, as well as associated pain/pressure in\nhis rectum. Labs were notable for Cr 4.59 (baseline 1.5), K \n4.3.\nHe was referred to ___ for further management. CT scan\nthere showed \"severe bilateral hydronephrosis\". He was given\nempiric antibiotics and transferred to ___ ED. \n\nIn ___ ED, initial VS were 98.1 57 111/62 24 100% RA. Labs\nnotable for WBC 15.6, Hgb 7.3, Plt 329; Cr 4.4, K 5.4; Lactate\n1.9; WBC >182, No Bacteria. Patient was seen by urology who\nrecommended ___ evaluation for percutaneous nephrostomy tubes. \n___\nrecommended NPO for per nephrostomy tubes. There was question\nwhether or not urine could be draining into the colostomy bag. \nPatient was given IV LR and admitted to oncology service. \n\nOn the floor, patient reported feeling more spacey than lately. \nFull 10 point review of systems positive where noted, otherwise\nnegative. \n\n \nPast Medical History:\nOncology History\n- Started ___ on Radiation therapy with continuous\n___ infusion at a dose of 225 mg/m² ___ days per week\nconcurrently with radiation; completed on ___. \n- Diverting colostomy on ___ ___. The\npatient was not a candidate for pelvic exenteration surgery due\nto comorbidities. \n- FOLFOX chemotherapy started on ___ treatment \non\n___, discontinued due to progression. \n- Keytruda every 3 weeks started on ___.\n\nPAST MEDICAL HISTORY: \n- Nephrolithiasis \n- Atrial fibrillation \n- Rectal cancer \n\n \nSocial History:\n___\nFamily History:\nMother and father with history of diabetes and cardiac disease.\n \nPhysical Exam:\nADMISSION EXAM: \nVS: ___ 0448 Temp: 97.6 PO BP: 93/62 HR: 63 RR: 18 O2 sat:\n100% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: ___ \nGen - supine in bed, comfortable, chronically ill appearing\nEyes - EOMI\nENT - OP clear, MMM\nHeart - RRR no mrg\nLungs - CTA bilaterally\nAbd - soft nontender, normal bowel sounds; ostomy pink; ostomy\nbag with minimal liquid stool\nExt - no edema\nSkin - no rashes\nVasc - 2+ DP/radial pulses; R port c/d/i\nNeuro - AOx3, moving all extremities\nPsych - appropriate \n \nDISCHARGE EXAM: \nGENERAL: Alert and in no apparent distress, frequent hiccups\nEYES: Anicteric, pupils equally round\nENT: Ears and nose without visible erythema, masses, or trauma. \nMMMs\nCV: RRR no m/r/g\nRESP: Lungs clear to auscultation with good air movement\nbilaterally. Breathing is non-labored\nGI: Abdomen soft, non-distended, non-tender to palpation, ostomy\ndraining brown stool\nGU: both nephrostomy tubes draining minimally tinged clear urine\nMSK: No erythema or swelling of joints\nSKIN: No rashes or ulcerations noted\nEXTR: wwp no edema\nNEURO: Alert, interactive, face symmetric, gaze conjugate with\nEOMI, speech fluent but dysphonic, motor function grossly\nintact/symmetric\nPSYCH: pleasant, appropriate affect\n \nPertinent Results:\nPERTINENT RESULTS:\n\nWBC 15.6 -> 13.1 -> 11.0 -> 11.8 -> 10.7 -> 11.4 -> 12.6 -> 10.1 \n-> 8.6 -> 11.5\n\nHgb 6.2-8.0 (received several transfusions)\n\nCre peaked 4.6, then gradually trended down over one week to 2.1 \nat discharge (still trending down)\n\nBicarb nadired at 16, gradually rose to 22 on day of discharge\n\nUrine and blood cultures negative\n \nBrief Hospital Course:\n___ year old male with atrial fibrillation, recurrent UTIs on \nsuppressive bactrim, locally advanced rectal cancer status \nstatus post palliative diverting colostomy, prior hydronephrosis \ntreated with R ureteral stent that was complicated by recurrent \nUTIs necessitating stent removal, being treated with \npembrolizumab (first dose ___ by Dr. ___ at \n___, presenting with worsening ___, now s/p bilateral \nPCN tubes with initially persistent renal failure that is now \nimproving\n\n#Post-renal obstructive ___ - improving\n#Hydronephrosis s/p bilateral PCN\n#Metabolic acidosis - improved\nPCN tubes placed on ___, with initially bloody urine now more \nclear. Per urology, right draining considerably less d/t \natrophic collection system, may be able to remove in the future. \n___ slowly improving since ___ (4.7 ->2.1, and still \nimproving). Has ___ follow-up in 12 weeks for tube change, and \nhas instructions and ___ for tube care. Will have labs next week \nwith oncology follow-up appointment. \n\n#History of right apical clot. \nHad been on edoxaban at home, but stopped in setting of renal \nfailure. Was on renally dosed lovenox during admission, but due \nto improvement in renal failure was able to be restarted on \nedoxaban at discharge. \n\n#Afib/RVR, likely tachy-brady\n#Baseline hypotension\nUpon admission digoxin was held, metoprolol was reduced \nsignificantly due to renal failure and sinus with low-normal and \nmildly bradycardic rates. Around ___ he had some periods of \nafib/RVR with associated hypotension. this occurred in the \nsetting of lower PO intake and improved with fluids. \nSubsequently the patient's PO intake improved somewhat and the \nRVR did not recur. Systolic BPs remained in the ___, which \nappears to be his baseline and is asymptomatic. Digoxin was not \nrestarted prior to discharge.\n\n#Anemia\nChronic multifactorial normocytic anemia that has been \nintermittently transfusion dependent as an outpatient, often \nworse during acute illness. Suspected to be related to \nmalignancy, renal failure, chemotherapy, and some acute/chronic \nblood loss through ostomy and neph tubes. No evidence of \nbleeding in days preceding discharge and hemoglobin relatively \nstable. Received 3 units of RBCs while inpatient. Will have \nlabs in outpatient follow-up\n\n#Rectal cancer with invasion into bladder\n#Known colovesicular fistula\nPatient will follow-up closely with oncology next week and will \nresume pembro. He receives prophylactic Bactrim at baseline, \nwhich was switched to cipro during the admission due to his \nrenal failure, but switched back to Bactrim at discharge. \n\n# Depression\nContinued Mirtazapine \n\n# Chronic severe protein calorie malnutrition \nNutrition provided recommendations. patient restarted on \nmultivitamin and supplements. His PO intake improved during the \nadmission with treatment of his obstruction and renal failure. \n\n#Intermittent abdominal pain and hiccups - treated effectively \nwith dicyclomine and baclofen\n\n====================================\nTRANSITIONAL ISSUES:\n\n- ___ and onc follow-up arranged\n- check BMP, CBC at follow-up next week\n- continue to titrate afib regimen\n- ___ follow-up in 12 weeks for tube exchange, possible removal \nof R tube\n- consider further work-up of anemia if indicated\n====================================\n\n>30 minutes in patient care and coordination of discharge\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Digoxin 0.125 mg PO EVERY OTHER DAY \n2. Mirtazapine 15 mg PO QHS \n3. Sulfameth/Trimethoprim DS 1 TAB PO DAILY \n4. Metoprolol Succinate XL 200 mg PO BID \n5. edoxaban 30 mg oral DAILY \n6. Senna 8.6 mg PO EVERY OTHER DAY \n7. Ciprofloxacin HCl 500 mg PO Q12H \n\n \nDischarge Medications:\n1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild \n2. Multivitamins 1 TAB PO DAILY \n3. Metoprolol Succinate XL 37.5 mg PO DAILY \nRX *metoprolol succinate 25 mg 1.5 tablet(s) by mouth Daily Disp \n#*45 Tablet Refills:*0 \n4. Baclofen 5 mg PO QID:PRN hiccups \n5. DICYCLOMine 10 mg PO QID:PRN for abdominal pain \n6. edoxaban 30 mg oral DAILY \n7. Mirtazapine 15 mg PO QHS \n8. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First \nLine \n9. Senna 8.6 mg PO EVERY OTHER DAY \n10. Sulfameth/Trimethoprim DS 1 TAB PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\n#Post-renal obstructive uropathy\n#Acute kidney injury\n#Hydronephrosis s/p bilateral PCN\n#Metabolic acidosis \n#Atrial fibrillation with rapid ventricular response\n#Hypotension\n#History of right apical clot\n#Anemia\n#Rectal cancer\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nYou were admitted to the hospital due to obstruction of your \nurinary tract, which was causing kidney failure. You had \nnephrostomy tubes placed to drain the urine, which helped to \nimprove your kidney function. You also developed atrial \nfibrillation with fast heart rates and low blood pressures, \nwhich improved with changes to your medications, IV fluids, and \nimproved oral intake. \n \nFollowup Instructions:\n___\n"
] | Allergies: Ativan / shellfish derived Chief Complaint: [MASKED] Major Surgical or Invasive Procedure: PCN tube placement History of Present Illness: This is a [MASKED] year old male past medical history of atrial fibrillation, recurrent UTIs on suppressive bactrim, locally advanced rectal cancer status status post palliative diverting colostomy, prior hydronephrosis treated with R ureteral stent that was complicated by recurrent UTIs necessitating stent removal, being treated with Keytruda (first dose [MASKED] by Dr. [MASKED] at [MASKED], presenting with worsening [MASKED]. Per patient report and review of records, 10 days prior to presentation, patient was treated for a UTI with PO cipro. 5 days prior to admission he noted new incontinence. On day of admission patient presented to see his primary oncologist, and reported these symptoms, as well as associated pain/pressure in his rectum. Labs were notable for Cr 4.59 (baseline 1.5), K 4.3. He was referred to [MASKED] for further management. CT scan there showed "severe bilateral hydronephrosis". He was given empiric antibiotics and transferred to [MASKED] ED. In [MASKED] ED, initial VS were 98.1 57 111/62 24 100% RA. Labs notable for WBC 15.6, Hgb 7.3, Plt 329; Cr 4.4, K 5.4; Lactate 1.9; WBC >182, No Bacteria. Patient was seen by urology who recommended [MASKED] evaluation for percutaneous nephrostomy tubes. [MASKED] recommended NPO for per nephrostomy tubes. There was question whether or not urine could be draining into the colostomy bag. Patient was given IV LR and admitted to oncology service. On the floor, patient reported feeling more spacey than lately. Full 10 point review of systems positive where noted, otherwise negative. Past Medical History: Oncology History - Started [MASKED] on Radiation therapy with continuous [MASKED] infusion at a dose of 225 mg/m² [MASKED] days per week concurrently with radiation; completed on [MASKED]. - Diverting colostomy on [MASKED] [MASKED]. The patient was not a candidate for pelvic exenteration surgery due to comorbidities. - FOLFOX chemotherapy started on [MASKED] treatment on [MASKED], discontinued due to progression. - Keytruda every 3 weeks started on [MASKED]. PAST MEDICAL HISTORY: - Nephrolithiasis - Atrial fibrillation - Rectal cancer Social History: [MASKED] Family History: Mother and father with history of diabetes and cardiac disease. Physical Exam: ADMISSION EXAM: VS: [MASKED] 0448 Temp: 97.6 PO BP: 93/62 HR: 63 RR: 18 O2 sat: 100% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: [MASKED] Gen - supine in bed, comfortable, chronically ill appearing Eyes - EOMI ENT - OP clear, MMM Heart - RRR no mrg Lungs - CTA bilaterally Abd - soft nontender, normal bowel sounds; ostomy pink; ostomy bag with minimal liquid stool Ext - no edema Skin - no rashes Vasc - 2+ DP/radial pulses; R port c/d/i Neuro - AOx3, moving all extremities Psych - appropriate DISCHARGE EXAM: GENERAL: Alert and in no apparent distress, frequent hiccups EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. MMMs CV: RRR no m/r/g RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation, ostomy draining brown stool GU: both nephrostomy tubes draining minimally tinged clear urine MSK: No erythema or swelling of joints SKIN: No rashes or ulcerations noted EXTR: wwp no edema NEURO: Alert, interactive, face symmetric, gaze conjugate with EOMI, speech fluent but dysphonic, motor function grossly intact/symmetric PSYCH: pleasant, appropriate affect Pertinent Results: PERTINENT RESULTS: WBC 15.6 -> 13.1 -> 11.0 -> 11.8 -> 10.7 -> 11.4 -> 12.6 -> 10.1 -> 8.6 -> 11.5 Hgb 6.2-8.0 (received several transfusions) Cre peaked 4.6, then gradually trended down over one week to 2.1 at discharge (still trending down) Bicarb nadired at 16, gradually rose to 22 on day of discharge Urine and blood cultures negative Brief Hospital Course: [MASKED] year old male with atrial fibrillation, recurrent UTIs on suppressive bactrim, locally advanced rectal cancer status status post palliative diverting colostomy, prior hydronephrosis treated with R ureteral stent that was complicated by recurrent UTIs necessitating stent removal, being treated with pembrolizumab (first dose [MASKED] by Dr. [MASKED] at [MASKED], presenting with worsening [MASKED], now s/p bilateral PCN tubes with initially persistent renal failure that is now improving #Post-renal obstructive [MASKED] - improving #Hydronephrosis s/p bilateral PCN #Metabolic acidosis - improved PCN tubes placed on [MASKED], with initially bloody urine now more clear. Per urology, right draining considerably less d/t atrophic collection system, may be able to remove in the future. [MASKED] slowly improving since [MASKED] (4.7 ->2.1, and still improving). Has [MASKED] follow-up in 12 weeks for tube change, and has instructions and [MASKED] for tube care. Will have labs next week with oncology follow-up appointment. #History of right apical clot. Had been on edoxaban at home, but stopped in setting of renal failure. Was on renally dosed lovenox during admission, but due to improvement in renal failure was able to be restarted on edoxaban at discharge. #Afib/RVR, likely tachy-brady #Baseline hypotension Upon admission digoxin was held, metoprolol was reduced significantly due to renal failure and sinus with low-normal and mildly bradycardic rates. Around [MASKED] he had some periods of afib/RVR with associated hypotension. this occurred in the setting of lower PO intake and improved with fluids. Subsequently the patient's PO intake improved somewhat and the RVR did not recur. Systolic BPs remained in the [MASKED], which appears to be his baseline and is asymptomatic. Digoxin was not restarted prior to discharge. #Anemia Chronic multifactorial normocytic anemia that has been intermittently transfusion dependent as an outpatient, often worse during acute illness. Suspected to be related to malignancy, renal failure, chemotherapy, and some acute/chronic blood loss through ostomy and neph tubes. No evidence of bleeding in days preceding discharge and hemoglobin relatively stable. Received 3 units of RBCs while inpatient. Will have labs in outpatient follow-up #Rectal cancer with invasion into bladder #Known colovesicular fistula Patient will follow-up closely with oncology next week and will resume pembro. He receives prophylactic Bactrim at baseline, which was switched to cipro during the admission due to his renal failure, but switched back to Bactrim at discharge. # Depression Continued Mirtazapine # Chronic severe protein calorie malnutrition Nutrition provided recommendations. patient restarted on multivitamin and supplements. His PO intake improved during the admission with treatment of his obstruction and renal failure. #Intermittent abdominal pain and hiccups - treated effectively with dicyclomine and baclofen ==================================== TRANSITIONAL ISSUES: - [MASKED] and onc follow-up arranged - check BMP, CBC at follow-up next week - continue to titrate afib regimen - [MASKED] follow-up in 12 weeks for tube exchange, possible removal of R tube - consider further work-up of anemia if indicated ==================================== >30 minutes in patient care and coordination of discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Digoxin 0.125 mg PO EVERY OTHER DAY 2. Mirtazapine 15 mg PO QHS 3. Sulfameth/Trimethoprim DS 1 TAB PO DAILY 4. Metoprolol Succinate XL 200 mg PO BID 5. edoxaban 30 mg oral DAILY 6. Senna 8.6 mg PO EVERY OTHER DAY 7. Ciprofloxacin HCl 500 mg PO Q12H Discharge Medications: 1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild 2. Multivitamins 1 TAB PO DAILY 3. Metoprolol Succinate XL 37.5 mg PO DAILY RX *metoprolol succinate 25 mg 1.5 tablet(s) by mouth Daily Disp #*45 Tablet Refills:*0 4. Baclofen 5 mg PO QID:PRN hiccups 5. DICYCLOMine 10 mg PO QID:PRN for abdominal pain 6. edoxaban 30 mg oral DAILY 7. Mirtazapine 15 mg PO QHS 8. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First Line 9. Senna 8.6 mg PO EVERY OTHER DAY 10. Sulfameth/Trimethoprim DS 1 TAB PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: #Post-renal obstructive uropathy #Acute kidney injury #Hydronephrosis s/p bilateral PCN #Metabolic acidosis #Atrial fibrillation with rapid ventricular response #Hypotension #History of right apical clot #Anemia #Rectal cancer 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 hospital due to obstruction of your urinary tract, which was causing kidney failure. You had nephrostomy tubes placed to drain the urine, which helped to improve your kidney function. You also developed atrial fibrillation with fast heart rates and low blood pressures, which improved with changes to your medications, IV fluids, and improved oral intake. Followup Instructions: [MASKED] | [
"N138",
"E43",
"N170",
"E872",
"C20",
"C7911",
"K632",
"N131",
"N390",
"C7919",
"I495",
"I959",
"D638",
"D6481",
"D500",
"F329",
"R066",
"R109",
"Z7902",
"Z6820",
"B9620",
"R339",
"I482",
"Z933",
"E8339"
] | [
"N138: Other obstructive and reflux uropathy",
"E43: Unspecified severe protein-calorie malnutrition",
"N170: Acute kidney failure with tubular necrosis",
"E872: Acidosis",
"C20: Malignant neoplasm of rectum",
"C7911: Secondary malignant neoplasm of bladder",
"K632: Fistula of intestine",
"N131: Hydronephrosis with ureteral stricture, not elsewhere classified",
"N390: Urinary tract infection, site not specified",
"C7919: Secondary malignant neoplasm of other urinary organs",
"I495: Sick sinus syndrome",
"I959: Hypotension, unspecified",
"D638: Anemia in other chronic diseases classified elsewhere",
"D6481: Anemia due to antineoplastic chemotherapy",
"D500: Iron deficiency anemia secondary to blood loss (chronic)",
"F329: Major depressive disorder, single episode, unspecified",
"R066: Hiccough",
"R109: Unspecified abdominal pain",
"Z7902: Long term (current) use of antithrombotics/antiplatelets",
"Z6820: Body mass index [BMI] 20.0-20.9, adult",
"B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere",
"R339: Retention of urine, unspecified",
"I482: Chronic atrial fibrillation",
"Z933: Colostomy status",
"E8339: Other disorders of phosphorus metabolism"
] | [
"E872",
"N390",
"F329",
"Z7902"
] | [] |
18,959,921 | 22,092,483 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nlisinopril\n \nAttending: ___.\n \nChief Complaint:\nCrohn's disease, Terminal Ileum Strictures \n \nMajor Surgical or Invasive Procedure:\nLaparoscopic ileocecectomy for Crohn's strictures\n \nHistory of Present Illness:\nMr. ___ is a very pleasant ___ man with longstanding \ndiagnosis of Crohn's. His symptoms\nactually have been quite minimal until ___ when he started \nhaving episodes of obstruction with strictures in the terminal \nileum with some dilatation of the proximal bowel. This was \nconfirmed by both CTs and MRIs. He had some response to \nprednisone eventually was weaned off and transitioned to Humira; \nhowever, developed respiratory problems with Humira and had to \nstop it. He had another course of steroids which he eventually \nweaned. This year he has seen more attacks, when they happen he\nis having abdominal pain, distention, some nausea. He had a \nrecent one that he did not want to go to emergency room and was \nable to get himself through with clear liquids and relative \nbowel rest. He is currently on ___. He is not on any \nsteroids. He reports that his abdomen is \"sensitive\" and he \nhears a lot of gurgling. He has been having diarrhea, which is \ntypical for him after he has an obstruction with no pain, no \nnausea at this point.\n \nPast Medical History:\nCrohn's diagnosed in ___, followed at ___. No past \nsurgeries for Crohn's, no immunomodulators. \nDepression\nHTN\nvitamin B 12 deficiency\nBasal cell carcinoma\n\nPSH:\nAppendectomy\ns/p ACL repair\ns/p subscapular ganglion removal\n \nSocial History:\n___\nFamily History:\nPossible history of IBD in his dad (never formally diagnosed).\n \nPhysical Exam:\nAfebrile, vitals within normal limits\nGen - A&O, NAD\nCV - RRR\nPulm - CTAB\nAbd - soft, appropriately TTP, incisions CDI, mild erythema \nalong incisions \nExtrem - warm, well perfused \n \nPertinent Results:\n___ 11:15AM HCT-36.6*\n___ 11:15AM MAGNESIUM-2.2\n___ 11:15AM SODIUM-132* POTASSIUM-6.0* CHLORIDE-101\n \nBrief Hospital Course:\nMr ___ presented to ___ holding at ___ on ___ for \na laparoscopic ileocecectomy. He tolerated the procedure well \nwithout complications (Please see operative note for further \ndetails). After a brief and uneventful stay in the PACU, the \npatient was transferred to the floor for further post-operative \nmanagement. \nNeuro: Pain was well controlled on a dilaudid PCA and toradol \nthrough POD 1. Once tolerating PO he was transitioned to PO \noxycodone and PO tylenol.\nCV: Vital signs were routinely monitored during the patient's \nlength of stay and his heart rate remained within normal limits. \n\nPulm: The patient was encouraged to ambulate, sit up in bed and \nget out of bed, use the incentive spirometer, and had oxygen \nsaturation levels monitored as indicated.\nGI: The patient was initially kept NPO after the procedure. The \npatient was advanced to sips and then clears on POD 1. On POD 2 \nhe was transitioned to a regular diet which he tolerated. \nGU: Patient had a Foley catheter that was removed POD 1. Urine \noutput was monitored as indicated. At time of discharge, the \npatient was voiding without difficulty. \nID: The patient's vital signs were monitored for signs of \ninfection and fever. He was discharged on Cephalexin to treat \nhis incisional erythema.\nHeme: The patient had blood levels checked post operatively \nduring the hospital course to monitor for signs of bleeding and \nwere appropriate. The patient had vital signs, including heart \nrate and blood pressure, monitored throughout the hospital stay. \n \nOn ___, the patient was discharged to home. At discharge, he \nwas tolerating a regular diet and passing flatus, voiding, and \nambulating independently. He will follow-up in the clinic in ___ \nweeks. This information was communicated to the patient directly \nprior to discharge. \n \nPost-Surgical Complications During Inpatient Admission: \n[ ] Post-Operative Ileus resolving w/o NGT \n[ ] Post-Operative Ileus requiring management with NGT \n[ ] UTI \n[ ] Wound Infection \n[ ] Anastomotic Leak \n[ ] Staple Line Bleed \n[ ] Congestive Heart failure \n[ ] ARF \n[ ] Acute Urinary retention, failure to void after Foley D/C'd \n[ ] Acute Urinary Retention requiring discharge with Foley \nCatheter \n[ ] DVT \n[ ] Pneumonia \n[ ] Abscess \n[x] None \n\nSocial Issues Causing a Delay in Discharge: \n[ ] Delay in organization of ___ services \n[ ] Difficulty finding appropriate rehab hospital disposition. \n[ ] Lack of insurance coverage for ___ services \n[ ] Lack of insurance coverage for prescribed medications. \n[ ] Family not agreeable to discharge plan. \n[ ] Patient knowledge deficit related to ileostomy delaying \ndispo\n[x] No social factors contributing in delay of discharge. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Fluoxetine 40 mg PO DAILY \n2. Vitamin D 1000 UNIT PO DAILY \n3. Cyanocobalamin 1000 mcg PO DAILY \n4. Losartan Potassium 25 mg PO DAILY \n5. Calcium Citrate + D (calcium citrate-vitamin D3) 200/250 mg/U \noral QD \n6. LOPERamide ___ mg PO QD PRN diarrhea \n7. Mercaptopurine 50 mg PO QD \n\n \nDischarge Medications:\n1. Fluoxetine 40 mg PO DAILY \n2. Losartan Potassium 25 mg PO DAILY \n3. Acetaminophen ___ mg PO Q6H:PRN pain \ndo not take more than 3000mg of Tylenol in 24 hours or drink \nalcohol while taking \nRX *acetaminophen 500 mg 2 tablet(s) by mouth every six (6) \nhours Disp #*50 Tablet Refills:*0\n4. Cephalexin 500 mg PO Q6H \nplease take for 1 week \nRX *cephalexin [Keflex] 500 mg 1 capsule(s) by mouth every six \n(6) hours Disp #*28 Capsule Refills:*0\n5. Ranitidine 150 mg PO DAILY \n6. Calcium Citrate + D (calcium citrate-vitamin D3) 200/250 mg/U \noral QD \n7. Cyanocobalamin 1000 mcg PO DAILY \n8. Vitamin D 1000 UNIT PO DAILY \n9. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain \ndo not drink alcohol or drive a car while taking this medication \n\nRX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours \nDisp #*50 Tablet Refills:*0\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nIleocecal strictures due to Crohn's disease\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nMr. ___,\n\nYou were admitted to the hospital after a Laparoscopic \nIleocecectomy for surgical management of your bowel strictures \ndue to Crohn's disease. You have recovered from this procedure \nwell and you are now ready to return home. Samples from your \ncolon were taken and this tissue has been sent to the pathology \ndepartment for analysis. You will receive these pathology \nresults at your follow-up appointment. If there is an urgent \nneed for the surgeon to contact you regarding these results they \nwill contact you before this time. You have tolerated a regular \ndiet, are passing gas and your pain is controlled with pain \nmedications by mouth. You may return home to finish your \nrecovery. \n\nYour wound is slightly red. You will take the antibiotics Keflex \nfor 7 more days. Please call for worsening redness or pain. \n \nPlease monitor your bowel function closely. You may or may not \nhave had a bowel movement prior to your discharge which is \nacceptable, however it is important that you have a bowel \nmovement in the next ___ days. After anesthesia it is not \nuncommon for patients to have some decrease in bowel function \nbut you should not have prolonged constipation. Some loose stool \nand passing of small amounts of dark, old appearing blood are \nexpected. However, if you notice that you are passing bright red \nblood with bowel movements or having loose stool without \nimprovement please call the office or go to the emergency room \nif the symptoms are severe. If you are taking narcotic pain \nmedications there is a risk that you will have some \nconstipation. Please take an over the counter stool softener \nsuch as Colace, and if the symptoms do not improve call the \noffice. If you have any of the following symptoms please call \nthe office for advice or go to the emergency room if severe: \nincreasing abdominal distension, increasing abdominal pain, \nnausea, vomiting, inability to tolerate food or liquids, \nprolonged loose stool, or extended constipation. \n \nYou have ___ laparoscopic surgical incisions on your abdomen \nwhich are closed with internal sutures and a skin glue called \nDermabond. These are healing well however it is important that \nyou monitor these areas for signs and symptoms of infection \nincluding: increasing redness of the incision lines, \nwhite/green/yellow/malodorous drainage, increased pain at the \nincision, increased warmth of the skin at the incision, or \nswelling of the area. Please call the office if you develop any \nof these symptoms or a fever. You may go to the emergency room \nif your symptoms are severe. \n\nYou may shower; pat the incisions dry with a towel, do not rub. \nThe small incisions may be left open to the air. If closed with \nsteri-strips (little white adhesive strips) instead of \nDermabond, these will fall off over time, please do not remove \nthem. Please no baths or swimming for 6 weeks after surgery \nunless told otherwise by your surgical team.\n \nYou will be prescribed narcotic pain medication oxycodone. This \nmedication should be taken when you have pain and as needed as \nwritten on the bottle. This is not a standing medication. You \nshould continue to take Tylenol for pain around the clock and \nyou can also take Advil. Please do not take more than 3000mg of \nTylenol in 24 hours. Do not drink alcohol while taking narcotic \npain medication or Tylenol. Please do not drive a car while \ntaking narcotic pain medication.\n\nNo heavy lifting greater than 6 lbs for until your first \npost-operative visit after surgery. Please no strenuous activity \nuntil this time unless instructed otherwise by Dr. ___ Dr. \n___. \n \nThank you for allowing us to participate in your care! Our hope \nis that you will have a quick return to your life and usual \nactivities. \n\nGood luck! \n\n \nFollowup Instructions:\n___\n"
] | Allergies: lisinopril Chief Complaint: Crohn's disease, Terminal Ileum Strictures Major Surgical or Invasive Procedure: Laparoscopic ileocecectomy for Crohn's strictures History of Present Illness: Mr. [MASKED] is a very pleasant [MASKED] man with longstanding diagnosis of Crohn's. His symptoms actually have been quite minimal until [MASKED] when he started having episodes of obstruction with strictures in the terminal ileum with some dilatation of the proximal bowel. This was confirmed by both CTs and MRIs. He had some response to prednisone eventually was weaned off and transitioned to Humira; however, developed respiratory problems with Humira and had to stop it. He had another course of steroids which he eventually weaned. This year he has seen more attacks, when they happen he is having abdominal pain, distention, some nausea. He had a recent one that he did not want to go to emergency room and was able to get himself through with clear liquids and relative bowel rest. He is currently on [MASKED]. He is not on any steroids. He reports that his abdomen is "sensitive" and he hears a lot of gurgling. He has been having diarrhea, which is typical for him after he has an obstruction with no pain, no nausea at this point. Past Medical History: Crohn's diagnosed in [MASKED], followed at [MASKED]. No past surgeries for Crohn's, no immunomodulators. Depression HTN vitamin B 12 deficiency Basal cell carcinoma PSH: Appendectomy s/p ACL repair s/p subscapular ganglion removal Social History: [MASKED] Family History: Possible history of IBD in his dad (never formally diagnosed). Physical Exam: Afebrile, vitals within normal limits Gen - A&O, NAD CV - RRR Pulm - CTAB Abd - soft, appropriately TTP, incisions CDI, mild erythema along incisions Extrem - warm, well perfused Pertinent Results: [MASKED] 11:15AM HCT-36.6* [MASKED] 11:15AM MAGNESIUM-2.2 [MASKED] 11:15AM SODIUM-132* POTASSIUM-6.0* CHLORIDE-101 Brief Hospital Course: Mr [MASKED] presented to [MASKED] holding at [MASKED] on [MASKED] for a laparoscopic ileocecectomy. He tolerated the procedure well without complications (Please see operative note for further details). After a brief and uneventful stay in the PACU, the patient was transferred to the floor for further post-operative management. Neuro: Pain was well controlled on a dilaudid PCA and toradol through POD 1. Once tolerating PO he was transitioned to PO oxycodone and PO tylenol. CV: Vital signs were routinely monitored during the patient's length of stay and his heart rate remained within normal limits. Pulm: The patient was encouraged to ambulate, sit up in bed and get out of bed, use the incentive spirometer, and had oxygen saturation levels monitored as indicated. GI: The patient was initially kept NPO after the procedure. The patient was advanced to sips and then clears on POD 1. On POD 2 he was transitioned to a regular diet which he tolerated. GU: Patient had a Foley catheter that was removed POD 1. Urine output was monitored as indicated. At time of discharge, the patient was voiding without difficulty. ID: The patient's vital signs were monitored for signs of infection and fever. He was discharged on Cephalexin to treat his incisional erythema. Heme: The patient had blood levels checked post operatively during the hospital course to monitor for signs of bleeding and were appropriate. The patient had vital signs, including heart rate and blood pressure, monitored throughout the hospital stay. On [MASKED], the patient was discharged to home. At discharge, he was tolerating a regular diet and passing flatus, voiding, and ambulating independently. He will follow-up in the clinic in [MASKED] weeks. This information was communicated to the patient directly prior to discharge. Post-Surgical Complications During Inpatient Admission: [ ] 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 [ ] Abscess [x] None Social Issues Causing a Delay in Discharge: [ ] Delay in organization of [MASKED] services [ ] Difficulty finding appropriate rehab hospital disposition. [ ] Lack of insurance coverage for [MASKED] services [ ] Lack of insurance coverage for prescribed medications. [ ] Family not agreeable to discharge plan. [ ] Patient knowledge deficit related to ileostomy delaying dispo [x] No social factors contributing in delay of discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Fluoxetine 40 mg PO DAILY 2. Vitamin D 1000 UNIT PO DAILY 3. Cyanocobalamin 1000 mcg PO DAILY 4. Losartan Potassium 25 mg PO DAILY 5. Calcium Citrate + D (calcium citrate-vitamin D3) 200/250 mg/U oral QD 6. LOPERamide [MASKED] mg PO QD PRN diarrhea 7. Mercaptopurine 50 mg PO QD Discharge Medications: 1. Fluoxetine 40 mg PO DAILY 2. Losartan Potassium 25 mg PO DAILY 3. Acetaminophen [MASKED] mg PO Q6H:PRN pain do not take more than 3000mg of Tylenol in 24 hours or drink alcohol while taking RX *acetaminophen 500 mg 2 tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills:*0 4. Cephalexin 500 mg PO Q6H please take for 1 week RX *cephalexin [Keflex] 500 mg 1 capsule(s) by mouth every six (6) hours Disp #*28 Capsule Refills:*0 5. Ranitidine 150 mg PO DAILY 6. Calcium Citrate + D (calcium citrate-vitamin D3) 200/250 mg/U oral QD 7. Cyanocobalamin 1000 mcg PO DAILY 8. Vitamin D 1000 UNIT PO DAILY 9. OxycoDONE (Immediate Release) [MASKED] mg PO Q4H:PRN pain do not drink alcohol or drive a car while taking this medication RX *oxycodone 5 mg [MASKED] tablet(s) by mouth every four (4) hours Disp #*50 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Ileocecal strictures due to Crohn's disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [MASKED], You were admitted to the hospital after a Laparoscopic Ileocecectomy for surgical management of your bowel strictures due to Crohn's disease. You have recovered from this procedure well and you are now ready to return home. Samples from your colon were taken and this tissue has been sent to the pathology department for analysis. You will receive these pathology results at your follow-up appointment. If there is an urgent need for the surgeon to contact you regarding these results they will contact you before this time. You have tolerated a regular diet, are passing gas and your pain is controlled with pain medications by mouth. You may return home to finish your recovery. Your wound is slightly red. You will take the antibiotics Keflex for 7 more days. Please call for worsening redness or pain. Please monitor your bowel function closely. You may or may not have had a bowel movement prior to your discharge which is acceptable, however it is important that you have a bowel movement in the next [MASKED] days. After anesthesia it is not uncommon for patients to have some decrease in bowel function but you should not have prolonged constipation. Some loose stool and passing of small amounts of dark, old appearing blood are expected. However, if you notice that you 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 you are taking narcotic pain medications there is a risk that you 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 you 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. You have [MASKED] laparoscopic surgical incisions on your abdomen which are closed with internal sutures and a skin glue called Dermabond. These are healing well however it is important that you monitor these areas for signs and symptoms of infection including: increasing redness of the incision lines, white/green/yellow/malodorous drainage, increased pain at the incision, increased warmth of the skin at the incision, or swelling of the area. Please call the office if you develop any of these symptoms or a fever. You may go to the emergency room if your symptoms are severe. You may shower; pat the incisions dry with a towel, do not rub. The small incisions may be left open to the air. If closed with steri-strips (little white adhesive strips) instead of Dermabond, these will fall off over time, please do not remove them. Please no baths or swimming for 6 weeks after surgery unless told otherwise by your surgical team. You will be prescribed narcotic pain medication oxycodone. This medication should be taken when you have pain and as needed as written on the bottle. This is not a standing medication. You should continue to take Tylenol for pain around the clock and you can also take Advil. Please do not take more than 3000mg of Tylenol in 24 hours. Do not drink alcohol while taking narcotic pain medication or Tylenol. Please do not drive a car while taking narcotic pain medication. No heavy lifting greater than 6 lbs for until your first post-operative visit after surgery. Please no strenuous activity until this time unless instructed otherwise by Dr. [MASKED] Dr. [MASKED]. Thank you for allowing us to participate in your care! Our hope is that you will have a quick return to your life and usual activities. Good luck! Followup Instructions: [MASKED] | [
"K50012",
"L539",
"Z006",
"Y836",
"Y92239"
] | [
"K50012: Crohn's disease of small intestine with intestinal obstruction",
"L539: Erythematous condition, unspecified",
"Z006: Encounter for examination for normal comparison and control in clinical research program",
"Y836: Removal of other organ (partial) (total) as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure",
"Y92239: Unspecified place in hospital as the place of occurrence of the external cause"
] | [] | [] |
18,754,935 | 25,828,574 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \n___\n \nAttending: ___.\n \nChief Complaint:\nAbdominal distention, AMS, failure to thrive\n \nMajor Surgical or Invasive Procedure:\nDiagnostic paracentesis ___\nDiagnostic and therapeutic paracentesis ___\n\n \nHistory of Present Illness:\nHISTORY OF PRESENTING ILLNESS: \n___ with history of EtOH/HCV cirrhosis complicated by HE and\nascites currently listed for liver transplant and history of\nesophageal stricture complicated by esophageal perforation\n(medically managed) who was referred to the ED from liver clinic\nwith abdominal distention and malnutrition with plans for \nfeeding\ntube placement. Otherwise, the patient has been in his usual\nstate of health. States that he has been incorrectly taking his\nlactulose recently as the instructions on the prescription were\nconfusing for him. Reports he has been only having ___ bowel\nmovements per day for the past couple days. Patient currently\ndenies any fevers, chills, chest pain, abdominal pain, dysuria,\nhematochezia, or lower extremity swelling worse than baseline. \nHe\ndoes admit to a non-productive cough but otherwise denies recent\ntravel or sick contacts. Patient also reports decreased p.o.\nintake and some dysphagia without odynophagia. Of note, patient\nlast had a paracentesis approximately 10 days ago where 6 L of\nfluid was removed. Patient reports that he is compliant with \nhis\nLasix and spironolactone but notes an accelerated rate of\nreaccumulation of ascitic fluid recently.\n\nIn the ED initial vitals: \n97.4, 87, 127/66, 18, 100% RA \n\n- Exam notable for: \nGeneral: Appearing stated age\nHEENT: NCAT, PEERL, MMM \nNeck: Supple, trachea midline\nHeart: RRR, no MRG. 1+ bilateral peripheral edema. \nLungs: CTAB. No wheezes, rales, or rhonchi.\nAbd: Soft, NT. Distended and tense. Tennis ball sized umbilical\numbilical hernia that is nontender.\nGU: No CVA tenderness\nMSK: No obvious limb deformities.\nDerm: Skin warm and dry\nNeuro: Awake, alert, moves all extremities. Asterixis present \nPsych: Appropriate affect and behavior.\n\n- Labs notable for:\n\n6.5 >12.9/38.1< 176 \n\n134 | 99 | 21 AGap=12 \n-------------< 98\n4.8 | 23 | 1.1 \n\nALT: 41 AP: 144 Tbili: 2.9 Alb: 3.2 \nAST: 81 \n\n___: 13.4 INR: 1.2 \n\nUA: few bacs, 3 wbc, 3 rbc, trace protein\n\nSerum EtOH Negative \n\n- Imaging notable for: \nCXR ___\nNo acute cardiopulmonary abnormalities. \n\nRUQUS ___. Patent main, right and left portal veins. Left portal vein\nflow is\nreversed.\n2. Hepatic cirrhosis with splenomegaly and moderate volume\nascites, likely representing portal hypertension.\n\n- Transfer vitals: \n98.1, 84, 94/73, 16, 100% RA \n \nPast Medical History:\nPAST MEDICAL HISTORY:\nAlcoholic Cirrhosis\nHepatitis C\nEsophageal Stricture\n \nSocial History:\n___\nFamily History:\nFAMILY HISTORY: \nMother-gastric Cancer \nFather-lung cancer\nBrother-bone cancer\nBrother-bone cancer\nSister-brain cancer\nSister-breast cancer \n \nPhysical Exam:\nADMISSION PHYSICAL EXAMINATION: \nVS:97.3, 115/68, 85, 20, 98% Ra\nGENERAL: NAD \nHEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,\nMMM \nNECK: supple, no LAD, no JVD \nHEART: RRR, S1/S2, no murmurs, gallops, or rubs \nLUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably\nwithout use of accessory muscles \nABDOMEN: distended, nontender in all quadrants, +fluid wave,\n3-4cm umbilical hernia that is soft, no rebound/guarding, para\nsite c/d/i\nEXTREMITIES: 1+ pitting edema bilaterally \nPULSES: 2+ DP pulses bilaterally \nNEURO: A&Ox3, moving all 4 extremities with purpose, +asterixis \n\nSKIN: warm and well perfused, no excoriations or lesions, no\nrashes\n\nDISCHARGE PHYSICAL EXAM\n___ ___ Temp: 98.3 PO BP: 98/63 L Lying HR: 81 RR: 17 O2 \nsat: 93% O2 delivery: Ra \nGeneral: Sitting on bed comfortably. In no acute distress.\nHEENT: Jaundiced, +scleral icterus, PERRL, EOMI. +Temporal \nwasting\nNeck: Thin neck, no lymphadenopathy\nLungs: Breathing comfortably on room air, lungs clear to \nauscultation.\nCV: Regular rate and rhythm, no murmurs appreciated\nGI: Distended abdomen, less tense than before, no caput medusa, \n+shifting dullness to percussion, not tender to palpation, \nnotable for ~4 cm fluid containing umbilicus that is no longer \ntight appearing. \nExt: +Palmar erythema, minimal nonpitting edema at ankles, \ndistal pulses 2+\nSkin: Slightly jaundiced, +spider angiomata (most concentrated \non chest), ecchymoses on arms, otherwise warm and well-perfused. \n\nNeuro: Alert, oriented x3. Able to list days of week backwards. \nAble to relay his history. Otherwise, CN II-XI intact, strength \nfull and symmetric in arms and legs, sensation intact to light \ntouch in extremities. \n\n \nPertinent Results:\nLAB RESULTS ON ADMISSION:\n=========================\n___ 10:10AM BLOOD WBC-7.3 RBC-4.16* Hgb-13.0* Hct-38.5* \nMCV-93 MCH-31.3 MCHC-33.8 RDW-14.1 RDWSD-47.7* Plt ___\n___ 10:10AM BLOOD ___\n___ 10:10AM BLOOD UreaN-21* Creat-1.2 Na-133* K-5.2 Cl-94* \nHCO3-24 AnGap-15\n___ 10:10AM BLOOD ALT-42* AST-84* AlkPhos-151* TotBili-2.4*\n___ 10:10AM BLOOD Albumin-3.3*\n\nPERTINENT INTERVAL LABS:\n========================\n___ 08:30PM ASCITES TNC-342* RBC-7436* Polys-1* Lymphs-39* \nMonos-29* Macroph-31*\n___ 10:16AM ASCITES TNC-380* RBC-6959* Polys-3* Lymphs-49* \nMonos-0 Eos-1* Macroph-47*\n\nMICROBIOLOGY:\n=============\n___ 10:16 am PERITONEAL FLUID PERITONEAL FLUID. \n\n GRAM STAIN (Final ___: \n 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR \nLEUKOCYTES. \n NO MICROORGANISMS SEEN. \n\n FLUID CULTURE (Preliminary): \n\n ANAEROBIC CULTURE (Preliminary): \n\n FUNGAL CULTURE (Preliminary): \n\n___ 8:30 pm PERITONEAL FLUID PERITONEAL FLUID. \n\n GRAM STAIN (Final ___: \n NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. \n NO MICROORGANISMS SEEN. \n This is a concentrated smear made by cytospin method, \nplease refer to\n hematology for a quantitative white blood cell count.. \n\n FLUID CULTURE (Final ___: NO GROWTH. \n\n ANAEROBIC CULTURE (Preliminary): NO GROWTH. \n\n \n___ 6:30 pm BLOOD CULTURE\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: NO GROWTH. \n\n \n \n___ 5:41 pm URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: NO GROWTH. \n\nLAB RESULTS ON DISCHARGE:\n=========================\n___ 06:30AM BLOOD WBC-7.1 RBC-3.29* Hgb-10.6* Hct-29.9* \nMCV-91 MCH-32.2* MCHC-35.5 RDW-14.0 RDWSD-46.3 Plt ___\n___ 06:23AM BLOOD ___ PTT-35.1 ___\n___ 06:30AM BLOOD Glucose-91 UreaN-22* Creat-1.1 Na-130* \nK-4.9 Cl-97 HCO3-23 AnGap-10\n___ 06:30AM BLOOD ALT-36 AST-73* LD(LDH)-337* AlkPhos-123 \nTotBili-2.0*\n___ 06:30AM BLOOD Albumin-2.6* Calcium-8.3* Phos-3.1 Mg-2.0\n\nIMAGING:\n========\nCXR ___: No acute cardiopulmonary abnormalities. \n\nRUQ U/S ___: \n1. Patent main, right and left portal veins. Left portal vein \nflow is \nreversed. \n2. Hepatic cirrhosis with splenomegaly and moderate volume \nascites, likely \nrepresenting portal hypertension. \n\nParacentesis ___: \n1. Technically successful ultrasound guided diagnostic and \ntherapeutic \nparacentesis. \n2. 6 L of fluid were removed. \n\n \nBrief Hospital Course:\n===========================\nBRIEF HOSPITAL COURSE\n===========================\n___ yo M w/ hx of HCV/EtOH cirrhosis c/b ascites and HE, also \nwith hx of esophageal stricture s/p balloon dilation c/b \nperforation that resolved with medical mgmt, who was sent to the \nED from outpatient liver clinic with worsening abd distention, \nHE, and malnutrition with plans for paracentesis and feeding \ntube placement. During his stay he underwent diagnostic and \ntherapeutic paracentesis. His diuretic regimen was increased. \nHis lactulose was uptitrated with good effect in clearing his \nencephalopathy. A feeding tube was note placed because his \ninsurance would not cover the tube feeds. \n\n====================\nAcute Issues\n====================\n\n# Decompensated Alcoholic/HCV Cirrhosis\nAdmission MELD-Na: ___ (___ on discharge), Childs Class C. Liver \ndisease complicated by HE and ascites, currently listed on the \nliver transplant list. No history of SBP or varices. Admitted \nfrom liver clinic for feeding tube placement, workup for \nworsening HE, and possible therapeutic para. The patient was \nafebrile with no leukocytosis throughout his stay. Dx \nparacentesis, UA, CXR, serum EtOH level, RUQUS w/ dopplers were \nall unremarkable. The patient had a distended belly and a \nconcerning fluid-filled, tense umbilical hernia on exam. He \nunderwent ___ therapeutic paracentesis on ___ with \nremoval of 6L of fluid, and was repleted with albumin. his \ndiuretics were uptitrated by 50%, to Lasix 120 mg and \nspironolactone 150 mg daily. With respect to his encephalopathy \nhe denied ingestions of new drugs. Was taking lactulose and \nrifaximin, but lactulose only BID and only having 1 BM/day, \nlikely contributing to encephalopathy. During his stay his \nlactulose was titrated to ___ BM/day and his rifaximin was \ncontinued with significant improvement in his mental status. \n\n# Moderate Protein Calorie Malnutrition\nPatient with poor PO intake. Does have hx of esophageal \nstricture, but unclear if this is predominant cause of sx. \nLikely mostly due to early satiety/small capacity due to \nascites. Initially planned for dobhoff placement for nutritional\naugmentation, but this was deferred given that insurance \nwouldn't cover tube feeds and patient cannot afford them on his \nown. Nutrition evaluated the patient and recommended a 2g Na \ndiet and small frequent meals, as well as Ensure Enlive BID and \nCarnation Instant Breakfast BID. The patient was given some on \ndischarge, but his family also planned to buy them for him. \n\n# Hyponatremia\nMild baseline hyponatremia between 133-134 on admission, \nslightly worsening to 130 by discharge, likely secondary to the \nincrease in his diuretics. The baseline level is likely due to \nineffective circulating volume due from his cirrhosis.\n\n========================\nCHRONIC ISSUES\n========================\n# H/o Esophageal Stricture\nPatient has hx of esophageal perforation. Patient denying \ndysphagia/odynophagia during his admission.\n\n# Anemia \nHgb dropped during the patients stay to slightly below baseline. \nThe anemia is likely secondary to his cirrhosis. There was no \nevidence of bleeding during his stay; notably EGD ___ showed \nno varices at that time. His hgb was monitored throughout his \nstay. \n\n# GERD\nThe patient's home pantoprazole 40mg daily was continued. \n\n========================\nTRANSITIONAL ISSUES\n========================\n# Decompensated Alcoholic/HCV Cirrhosis\n* Encephalopathy\n - TID lactulose 30 mL at discharge\n [] Please help reinforce need to titrate lactulose for ___ BMs \ndaily; \n [] Follow up pending blood and peritoneal fluid cultures\n* Volume/Ascites\n- S/p therapeutic paracentesis ___ with 6L removed\n- On 120 mg lasix, 150 mg spironolactone\n[] Please check Chem 10 within one week after discharge\n[] Patient may require therapeutic paracentesis every ___ weeks \nfor control of ascites\n[] ___ also consider small TIPS, although note that patient \nalready has signs of HE\n\n# Moderate Protein Calorie Malnutrition\n[] Please help patient obtain calorie supplementation in form of \nnutritional shakes\n[] Please work with patient insurance to obtain approval for \ntube feeds\n\n# Hyponatremia\n[] Please check Chem10 one week after discharge, Na 131 at time \nof discharge\n\n# CODE: FULL\n# CONTACT: ___ (daughter) ___\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Lactulose 30 mL PO TID \n2. Furosemide 80 mg PO DAILY \n3. Spironolactone 100 mg PO DAILY \n4. Omeprazole 40 mg PO DAILY \n5. Rifaximin 550 mg PO BID \n\n \nDischarge Medications:\n1. Furosemide 120 mg PO DAILY \nRX *furosemide [Lasix] 40 mg 3 tablet(s) by mouth daily Disp \n#*90 Tablet Refills:*0 \n2. Spironolactone 150 mg PO DAILY \nRX *spironolactone 50 mg 3 tablet(s) by mouth daily Disp #*90 \nTablet Refills:*0 \n3. Lactulose 30 mL PO TID \nPlease take lactulose as frequently as you need to have ___ \nbowel movements daily. \n4. Omeprazole 40 mg PO DAILY \n5. Rifaximin 550 mg PO BID \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nDecompensated Alcoholic/HCV Cirrhosis\nModerate Protein Calorie Malnutrition\nH/o Esophageal Stricture\nHyponatremia\nAnemia\n\n \nDischarge Condition:\nMental Status: Intermittently confused, but generally able to \nrelay events and history. \nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\n====================== \nDISCHARGE INSTRUCTIONS \n====================== \n\nDear Mr. ___, \nIt was a pleasure caring for you at ___ \n___.\n\nWHY WAS I IN THE HOSPITAL? \nYou were in the hospital because when you were seen at ___ \n___ there was concern that your thinking was confused, that \nyour belly had too much fluid in it, and because you have not \nbeen eating enough food.\n\nWHAT HAPPENED TO ME IN THE HOSPITAL? \nWhile you were in the hospital, the fluid in your belly was \ntested; there was no infection of the fluid. Our interventional \nradiology doctors ___ 6L of fluid to reduce the pressure on \nyour belly. Your doses of diuretic pills (lasix and \nspironolactone) were increased to help you keep the fluid off. \nWe also adjusted your lactulose dose to help you have more BMs, \nwhich helped clear your thinking. You were originally planned \nto have a feeding tube in your nose, but your insurance would \nnot pay for the feeds through the tube, so this was not done. \nInstead, you were encouraged to drink nutrition shakes and eat \nwell to keep your strength up. Finally, you were set up with a \nvisiting nurse to help you at home. \n\nWHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?\nIt is very important that you take your medications as \nprescribed. It is particularly important that you take enough \nlactulose to have ___ bowel movements every day, even if these \nare diarrhea. You should also try to eat very well; you and your \nfamily have a plan to drink more ensures at home. Finally, if \nyou ever see fluid leaking from your belly, or find a lot of \nfluid in bed, you should go the emergency room right away. \n\nWe wish you the best!\n\nSincerely, \nYour ___ Team \n\n \nFollowup Instructions:\n___\n"
] | Allergies: [MASKED] Chief Complaint: Abdominal distention, AMS, failure to thrive Major Surgical or Invasive Procedure: Diagnostic paracentesis [MASKED] Diagnostic and therapeutic paracentesis [MASKED] History of Present Illness: HISTORY OF PRESENTING ILLNESS: [MASKED] with history of EtOH/HCV cirrhosis complicated by HE and ascites currently listed for liver transplant and history of esophageal stricture complicated by esophageal perforation (medically managed) who was referred to the ED from liver clinic with abdominal distention and malnutrition with plans for feeding tube placement. Otherwise, the patient has been in his usual state of health. States that he has been incorrectly taking his lactulose recently as the instructions on the prescription were confusing for him. Reports he has been only having [MASKED] bowel movements per day for the past couple days. Patient currently denies any fevers, chills, chest pain, abdominal pain, dysuria, hematochezia, or lower extremity swelling worse than baseline. He does admit to a non-productive cough but otherwise denies recent travel or sick contacts. Patient also reports decreased p.o. intake and some dysphagia without odynophagia. Of note, patient last had a paracentesis approximately 10 days ago where 6 L of fluid was removed. Patient reports that he is compliant with his Lasix and spironolactone but notes an accelerated rate of reaccumulation of ascitic fluid recently. In the ED initial vitals: 97.4, 87, 127/66, 18, 100% RA - Exam notable for: General: Appearing stated age HEENT: NCAT, PEERL, MMM Neck: Supple, trachea midline Heart: RRR, no MRG. 1+ bilateral peripheral edema. Lungs: CTAB. No wheezes, rales, or rhonchi. Abd: Soft, NT. Distended and tense. Tennis ball sized umbilical umbilical hernia that is nontender. GU: No CVA tenderness MSK: No obvious limb deformities. Derm: Skin warm and dry Neuro: Awake, alert, moves all extremities. Asterixis present Psych: Appropriate affect and behavior. - Labs notable for: 6.5 >12.9/38.1< 176 134 | 99 | 21 AGap=12 -------------< 98 4.8 | 23 | 1.1 ALT: 41 AP: 144 Tbili: 2.9 Alb: 3.2 AST: 81 [MASKED]: 13.4 INR: 1.2 UA: few bacs, 3 wbc, 3 rbc, trace protein Serum EtOH Negative - Imaging notable for: CXR [MASKED] No acute cardiopulmonary abnormalities. RUQUS [MASKED]. Patent main, right and left portal veins. Left portal vein flow is reversed. 2. Hepatic cirrhosis with splenomegaly and moderate volume ascites, likely representing portal hypertension. - Transfer vitals: 98.1, 84, 94/73, 16, 100% RA Past Medical History: PAST MEDICAL HISTORY: Alcoholic Cirrhosis Hepatitis C Esophageal Stricture Social History: [MASKED] Family History: FAMILY HISTORY: Mother-gastric Cancer Father-lung cancer Brother-bone cancer Brother-bone cancer Sister-brain cancer Sister-breast cancer Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS:97.3, 115/68, 85, 20, 98% Ra GENERAL: NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM NECK: supple, no LAD, no JVD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: distended, nontender in all quadrants, +fluid wave, 3-4cm umbilical hernia that is soft, no rebound/guarding, para site c/d/i EXTREMITIES: 1+ pitting edema bilaterally PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, moving all 4 extremities with purpose, +asterixis SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAM [MASKED] [MASKED] Temp: 98.3 PO BP: 98/63 L Lying HR: 81 RR: 17 O2 sat: 93% O2 delivery: Ra General: Sitting on bed comfortably. In no acute distress. HEENT: Jaundiced, +scleral icterus, PERRL, EOMI. +Temporal wasting Neck: Thin neck, no lymphadenopathy Lungs: Breathing comfortably on room air, lungs clear to auscultation. CV: Regular rate and rhythm, no murmurs appreciated GI: Distended abdomen, less tense than before, no caput medusa, +shifting dullness to percussion, not tender to palpation, notable for ~4 cm fluid containing umbilicus that is no longer tight appearing. Ext: +Palmar erythema, minimal nonpitting edema at ankles, distal pulses 2+ Skin: Slightly jaundiced, +spider angiomata (most concentrated on chest), ecchymoses on arms, otherwise warm and well-perfused. Neuro: Alert, oriented x3. Able to list days of week backwards. Able to relay his history. Otherwise, CN II-XI intact, strength full and symmetric in arms and legs, sensation intact to light touch in extremities. Pertinent Results: LAB RESULTS ON ADMISSION: ========================= [MASKED] 10:10AM BLOOD WBC-7.3 RBC-4.16* Hgb-13.0* Hct-38.5* MCV-93 MCH-31.3 MCHC-33.8 RDW-14.1 RDWSD-47.7* Plt [MASKED] [MASKED] 10:10AM BLOOD [MASKED] [MASKED] 10:10AM BLOOD UreaN-21* Creat-1.2 Na-133* K-5.2 Cl-94* HCO3-24 AnGap-15 [MASKED] 10:10AM BLOOD ALT-42* AST-84* AlkPhos-151* TotBili-2.4* [MASKED] 10:10AM BLOOD Albumin-3.3* PERTINENT INTERVAL LABS: ======================== [MASKED] 08:30PM ASCITES TNC-342* RBC-7436* Polys-1* Lymphs-39* Monos-29* Macroph-31* [MASKED] 10:16AM ASCITES TNC-380* RBC-6959* Polys-3* Lymphs-49* Monos-0 Eos-1* Macroph-47* MICROBIOLOGY: ============= [MASKED] 10:16 am PERITONEAL FLUID PERITONEAL FLUID. GRAM STAIN (Final [MASKED]: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Preliminary): ANAEROBIC CULTURE (Preliminary): FUNGAL CULTURE (Preliminary): [MASKED] 8:30 pm PERITONEAL FLUID PERITONEAL FLUID. GRAM STAIN (Final [MASKED]: 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 [MASKED]: NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. [MASKED] 6:30 pm BLOOD CULTURE **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] 5:41 pm URINE **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: NO GROWTH. LAB RESULTS ON DISCHARGE: ========================= [MASKED] 06:30AM BLOOD WBC-7.1 RBC-3.29* Hgb-10.6* Hct-29.9* MCV-91 MCH-32.2* MCHC-35.5 RDW-14.0 RDWSD-46.3 Plt [MASKED] [MASKED] 06:23AM BLOOD [MASKED] PTT-35.1 [MASKED] [MASKED] 06:30AM BLOOD Glucose-91 UreaN-22* Creat-1.1 Na-130* K-4.9 Cl-97 HCO3-23 AnGap-10 [MASKED] 06:30AM BLOOD ALT-36 AST-73* LD(LDH)-337* AlkPhos-123 TotBili-2.0* [MASKED] 06:30AM BLOOD Albumin-2.6* Calcium-8.3* Phos-3.1 Mg-2.0 IMAGING: ======== CXR [MASKED]: No acute cardiopulmonary abnormalities. RUQ U/S [MASKED]: 1. Patent main, right and left portal veins. Left portal vein flow is reversed. 2. Hepatic cirrhosis with splenomegaly and moderate volume ascites, likely representing portal hypertension. Paracentesis [MASKED]: 1. Technically successful ultrasound guided diagnostic and therapeutic paracentesis. 2. 6 L of fluid were removed. Brief Hospital Course: =========================== BRIEF HOSPITAL COURSE =========================== [MASKED] yo M w/ hx of HCV/EtOH cirrhosis c/b ascites and HE, also with hx of esophageal stricture s/p balloon dilation c/b perforation that resolved with medical mgmt, who was sent to the ED from outpatient liver clinic with worsening abd distention, HE, and malnutrition with plans for paracentesis and feeding tube placement. During his stay he underwent diagnostic and therapeutic paracentesis. His diuretic regimen was increased. His lactulose was uptitrated with good effect in clearing his encephalopathy. A feeding tube was note placed because his insurance would not cover the tube feeds. ==================== Acute Issues ==================== # Decompensated Alcoholic/HCV Cirrhosis Admission MELD-Na: [MASKED] ([MASKED] on discharge), Childs Class C. Liver disease complicated by HE and ascites, currently listed on the liver transplant list. No history of SBP or varices. Admitted from liver clinic for feeding tube placement, workup for worsening HE, and possible therapeutic para. The patient was afebrile with no leukocytosis throughout his stay. Dx paracentesis, UA, CXR, serum EtOH level, RUQUS w/ dopplers were all unremarkable. The patient had a distended belly and a concerning fluid-filled, tense umbilical hernia on exam. He underwent [MASKED] therapeutic paracentesis on [MASKED] with removal of 6L of fluid, and was repleted with albumin. his diuretics were uptitrated by 50%, to Lasix 120 mg and spironolactone 150 mg daily. With respect to his encephalopathy he denied ingestions of new drugs. Was taking lactulose and rifaximin, but lactulose only BID and only having 1 BM/day, likely contributing to encephalopathy. During his stay his lactulose was titrated to [MASKED] BM/day and his rifaximin was continued with significant improvement in his mental status. # Moderate Protein Calorie Malnutrition Patient with poor PO intake. Does have hx of esophageal stricture, but unclear if this is predominant cause of sx. Likely mostly due to early satiety/small capacity due to ascites. Initially planned for dobhoff placement for nutritional augmentation, but this was deferred given that insurance wouldn't cover tube feeds and patient cannot afford them on his own. Nutrition evaluated the patient and recommended a 2g Na diet and small frequent meals, as well as Ensure Enlive BID and Carnation Instant Breakfast BID. The patient was given some on discharge, but his family also planned to buy them for him. # Hyponatremia Mild baseline hyponatremia between 133-134 on admission, slightly worsening to 130 by discharge, likely secondary to the increase in his diuretics. The baseline level is likely due to ineffective circulating volume due from his cirrhosis. ======================== CHRONIC ISSUES ======================== # H/o Esophageal Stricture Patient has hx of esophageal perforation. Patient denying dysphagia/odynophagia during his admission. # Anemia Hgb dropped during the patients stay to slightly below baseline. The anemia is likely secondary to his cirrhosis. There was no evidence of bleeding during his stay; notably EGD [MASKED] showed no varices at that time. His hgb was monitored throughout his stay. # GERD The patient's home pantoprazole 40mg daily was continued. ======================== TRANSITIONAL ISSUES ======================== # Decompensated Alcoholic/HCV Cirrhosis * Encephalopathy - TID lactulose 30 mL at discharge [] Please help reinforce need to titrate lactulose for [MASKED] BMs daily; [] Follow up pending blood and peritoneal fluid cultures * Volume/Ascites - S/p therapeutic paracentesis [MASKED] with 6L removed - On 120 mg lasix, 150 mg spironolactone [] Please check Chem 10 within one week after discharge [] Patient may require therapeutic paracentesis every [MASKED] weeks for control of ascites [] [MASKED] also consider small TIPS, although note that patient already has signs of HE # Moderate Protein Calorie Malnutrition [] Please help patient obtain calorie supplementation in form of nutritional shakes [] Please work with patient insurance to obtain approval for tube feeds # Hyponatremia [] Please check Chem10 one week after discharge, Na 131 at time of discharge # CODE: FULL # CONTACT: [MASKED] (daughter) [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lactulose 30 mL PO TID 2. Furosemide 80 mg PO DAILY 3. Spironolactone 100 mg PO DAILY 4. Omeprazole 40 mg PO DAILY 5. Rifaximin 550 mg PO BID Discharge Medications: 1. Furosemide 120 mg PO DAILY RX *furosemide [Lasix] 40 mg 3 tablet(s) by mouth daily Disp #*90 Tablet Refills:*0 2. Spironolactone 150 mg PO DAILY RX *spironolactone 50 mg 3 tablet(s) by mouth daily Disp #*90 Tablet Refills:*0 3. Lactulose 30 mL PO TID Please take lactulose as frequently as you need to have [MASKED] bowel movements daily. 4. Omeprazole 40 mg PO DAILY 5. Rifaximin 550 mg PO BID Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Decompensated Alcoholic/HCV Cirrhosis Moderate Protein Calorie Malnutrition H/o Esophageal Stricture Hyponatremia Anemia Discharge Condition: Mental Status: Intermittently confused, but generally able to relay events and history. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ====================== DISCHARGE INSTRUCTIONS ====================== Dear Mr. [MASKED], It was a pleasure caring for you at [MASKED] [MASKED]. WHY WAS I IN THE HOSPITAL? You were in the hospital because when you were seen at [MASKED] [MASKED] there was concern that your thinking was confused, that your belly had too much fluid in it, and because you have not been eating enough food. WHAT HAPPENED TO ME IN THE HOSPITAL? While you were in the hospital, the fluid in your belly was tested; there was no infection of the fluid. Our interventional radiology doctors [MASKED] 6L of fluid to reduce the pressure on your belly. Your doses of diuretic pills (lasix and spironolactone) were increased to help you keep the fluid off. We also adjusted your lactulose dose to help you have more BMs, which helped clear your thinking. You were originally planned to have a feeding tube in your nose, but your insurance would not pay for the feeds through the tube, so this was not done. Instead, you were encouraged to drink nutrition shakes and eat well to keep your strength up. Finally, you were set up with a visiting nurse to help you at home. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? It is very important that you take your medications as prescribed. It is particularly important that you take enough lactulose to have [MASKED] bowel movements every day, even if these are diarrhea. You should also try to eat very well; you and your family have a plan to drink more ensures at home. Finally, if you ever see fluid leaking from your belly, or find a lot of fluid in bed, you should go the emergency room right away. We wish you the best! Sincerely, Your [MASKED] Team Followup Instructions: [MASKED] | [
"K7290",
"E440",
"E871",
"R1310",
"K7031",
"Z87891",
"B1920",
"T473X6A",
"Z91138",
"K429",
"Z7682",
"K219",
"D649",
"D638"
] | [
"K7290: Hepatic failure, unspecified without coma",
"E440: Moderate protein-calorie malnutrition",
"E871: Hypo-osmolality and hyponatremia",
"R1310: Dysphagia, unspecified",
"K7031: Alcoholic cirrhosis of liver with ascites",
"Z87891: Personal history of nicotine dependence",
"B1920: Unspecified viral hepatitis C without hepatic coma",
"T473X6A: Underdosing of saline and osmotic laxatives, initial encounter",
"Z91138: Patient's unintentional underdosing of medication regimen for other reason",
"K429: Umbilical hernia without obstruction or gangrene",
"Z7682: Awaiting organ transplant status",
"K219: Gastro-esophageal reflux disease without esophagitis",
"D649: Anemia, unspecified",
"D638: Anemia in other chronic diseases classified elsewhere"
] | [
"E871",
"Z87891",
"K219",
"D649"
] | [] |
19,854,363 | 21,228,584 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nBactrim DS / Sulfa (Sulfonamide Antibiotics)\n \nAttending: ___.\n \nChief Complaint:\nChest pain, shortness of breath\n \nMajor Surgical or Invasive Procedure:\n___ Pigtail Catheter Placement\n___ Thoracoscopy guided Talc Pleurodesis\n \nHistory of Present Illness:\n___ w/ PMHx emphysema, lung cancer s/p palliative radiation at \n___, HFpEF, HTN, TIAs, a-fib on Eliquis presented with R sided \nchest pain and SOB. She says she woke up at 6 AM on the morning \nof ___ with pain in the R side of her chest that worsened with \ninspiration. Also reports progressive worsening of shortness of \nbreath and fatigue so she came to ED for further evaluation. \n\nUpon initial evaluation in the ED, the patient had stable vital \nsigns and an unremarkable ECG. She then developed acute onset \nSOB and desatted to the ___ on RA. She was placed on NRB w/ \nimprovement in her sats. Portable CXR was obtained which showed \na large R sided PTX w/ some shifting of the mediastinum c/f \ntension pneumo. IP was then consulted and placed a pigtail \ncatheter. \n\nIn the ED: \n\n Initial vital signs were notable for:\n - 96.9 92 140/79 16 99% RA \n Labs were notable for: \n - CBC wnl \n - Na 135, K 4.1, BUN 23 \n - Trop neg x1 \n - Lactate 1.5 \n - VBG 7.31/62 \n - ___ 13.7, PTT 29.3, INR 1.3 \n - proBNP 2554 \n Studies performed include: \n - CXR (___) \n - Large right pneumothorax with contralateral shift of the \n mediastinal structures, raising the possibility of tension \n\n pneumothorax. \n - CXR (___) \n - Interval re-expansion of the right lung status post \n placement of a right-sided chest tube. There is trace \n residual right apical and basilar pneumothorax. \n - CXR (___) \n - FINDINGS: Right-sided pigtail chest tube is unchanged in \n position as compared to most recent chest radiograph. \n Previously noted right pneumothorax is no longer seen.\n Otherwise no change. \n - IMPRESSION: No residual right pneumothorax.\n Right chest tube in place. \n - CT Chest w/o contrast (___) \n 1. Difficult to distinguish between presumed interval growth \n\n of a pre-existing right upper lobe pulmonary nodule into \n a larger mass and its resulting postobstructive \n atelectasis, noting obstruction of the adjacent right \n upper lobe posterior segment bronchus. The confluent area \n\n of opacification measures approximately 4.8 cm. \n 2. A right middle lobe pulmonary nodule has slightly \n increased in size and measures 0.7 cm. \n 3. A small right hydropneumothorax is decreased in size \n since radiographs obtained 1 day prior status-post \n pigtail pleural drainage catheter placement. \n 4. Ground-glass opacities in the peripheral left upper lobe \n apicoposterior segment could reflect sequela of \n aspiration or developing infection. \n 5. Severe centrilobular and paraseptal pulmonary emphysema. \n\n 6. Severe calcified coronary and aortic atherosclerosis. \n 7. Unchanged main pulmonary artery enlargement suggests \n pulmonary hypertension. \n - CXR (___) \n - Unchanged appearance of the chest since 1.5 hours prior. \n The pigtail pleural drainage catheter is unchanged in \n position. \n\n Patient was given: \n - ___ 08:56 IV Morphine Sulfate 4 mg \n - ___ 10:03 IV Fentanyl Citrate 50 mcg \n - ___ 10:03 PO Acetaminophen 1000 mg \n - ___ 13:12 IV Morphine Sulfate 2 mg \n - ___ 18:35 IV Morphine Sulfate 2 mg \n - ___ 18:35 PO/NG Apixaban 2.5 mg \n - ___ 00:16 IV Morphine Sulfate 2 mg \n - ___ 00:17 PO Pravastatin 40 mg \n - ___ 05:38 IV Morphine Sulfate 2 mg \n\n Consults:\n - IP as above, placed pigtail, PTX improved. \n\nVitals on transfer: T98.0 BP132/69 HR85 RR16 O2sat 91%RA \n\nUpon arrival to the floor, patient was hemodynamically stable. \nShe corroborates the above history. She denies current SOB, \nchest pain, fevers, chills, abdominal pain, nausea, diaphoresis, \northopnea, vomiting, diarrhea.\n\nREVIEW OF SYSTEMS: Otherwise negative.\n\n \nPast Medical History:\nPAST MEDICAL HISTORY:\n - Emphysema\n - FDG avid lung nodule, s/p palliative XRT at ___ in ___\n - HFpEF\n - HTN \n - AFib \n - TIA x 2 \n - HLD \n - Hypothyroidism \n - Anxiety \n - s/p b/l cataract surgery \n - Varicose veins \n - Dizziness ___ diagnosed with BPPV, resolved\n - BSO \n - cholecystecomy \n - appendectomy \n\n \nSocial History:\n___\nFamily History:\nNoncontributory.\nMother: with stroke, DM\nPaternal aunt: stroke\n \nPhysical ___:\nADMISSION PHYSICAL EXAM: \n======================\nVITALS: T98.0 BP132/69 HR85 RR16 O2sat 91%RA\nGENERAL: lying in bed in NAD\nHEENT: NC/AT \nNECK: No JVD\nCARDIAC: RRR, nl s1/s2, no mrg\nLUNGS: CTABL, no increased WOB, no decreased breath sounds over \nR lung fields\nABDOMEN: soft, NT/ND, +BS\nEXTREMITIES: no edema over BLE\nNEUROLOGIC: AOx3\n\nDISCHARGE PHYSICAL EXAM:\n=========================\nVITALS: T 97.7 PO BP 106 / 57 L Lying HR 74 RR 17 93% RA \nGENERAL: pleasant elderly lady, lying in bed in NAD\nHEENT: NC/AT, anicteric sclera, PERRL\nNECK: supple, no lymphadenopathy\nCARDIAC: irregularly irregular, nl s1/s2, no mrg\nLUNGS: CTABL, no increased WOB, slightly decreased breath sounds\nRLL posteriorly\n-- chest tube incision site in right anterio-lateral chest wall, \nhealing well with no induration or erythema\nABDOMEN: soft, NT/ND, +BS\nEXTREMITIES: warm well perfused, 2+ pulses, no edema\nNEUROLOGIC: AOx3, CN ___ grossly intact; no focal neurologic \ndeficits\n \nPertinent Results:\nADMISSION LABS:\n==============\n___ 08:03AM BLOOD WBC-5.6 RBC-4.18 Hgb-12.9 Hct-39.6 MCV-95 \nMCH-30.9 MCHC-32.6 RDW-14.4 RDWSD-50.1* Plt ___\n___ 08:03AM BLOOD Neuts-73.3* Lymphs-18.3* Monos-5.9 \nEos-1.1 Baso-0.9 Im ___ AbsNeut-4.07 AbsLymp-1.02* \nAbsMono-0.33 AbsEos-0.06 AbsBaso-0.05\n___ 08:43AM BLOOD ___ PTT-29.3 ___\n___ 08:03AM BLOOD Glucose-116* UreaN-23* Creat-0.9 Na-135 \nK-7.8* Cl-96 HCO3-26 AnGap-13\n___ 08:03AM BLOOD ALT-<5 AST-63* AlkPhos-40 TotBili-0.5\n___ 08:03AM BLOOD proBNP-2554*\n___ 08:03AM BLOOD cTropnT-<0.01\n___ 08:16AM BLOOD ___ pO2-30* pCO2-62* pH-7.31* \ncalTCO2-33* Base XS-2\n___ 08:16AM BLOOD Lactate-1.5 K-4.1\n\nPERTINENT LABS:\n==============\n___ 06:05AM BLOOD CK-MB-1 cTropnT-<0.01\n___ 03:54PM BLOOD CK-MB-1 cTropnT-<0.01\n___ 06:45AM BLOOD ALT-18 AST-22 LD(LDH)-183 AlkPhos-61 \nTotBili-0.7\n\nMICROBIOLOGY:\n=============\n___ 8:03 am BLOOD CULTURE\n Blood Culture, Routine (Final ___: NO GROWTH. \n___ 8:08 am BLOOD CULTURE\n Blood Culture, Routine (Final ___: NO GROWTH. \n\nIMAGING:\n========\nCXR (___) \n- IMPRESSION: Large right pneumothorax with contralateral shift \nof the mediastinal structures, raising the possibility of \ntension pneumothorax. \n\nCXR (___) \n- IMPRESSION: Interval re-expansion of the right lung status \npost placement of a right-sided chest tube. There is trace \nresidual right apical and basilar pneumothorax. \n\nCXR (___) \n- IMPRESSION: No residual right pneumothorax. Right chest tube \nin place.\n\nCT Chest w/o contrast (___) \n- IMPRESSION:\n-- 1. Difficult to distinguish between presumed interval growth \nof a pre-existing right upper lobe pulmonary nodule into a \nlarger mass and its resulting postobstructive atelectasis, \nnoting obstruction of the adjacent right upper lobe posterior \nsegment bronchus. The confluent area of opacification measures \napproximately 4.8 cm. \n-- 2. A right middle lobe pulmonary nodule has slightly \nincreased in size and measures 0.7 cm. \n-- 3. A small right hydropneumothorax is decreased in size since \nradiographs obtained 1 day prior status-post pigtail pleural \ndrainage catheter placement. \n-- 4. Ground-glass opacities in the peripheral left upper lobe \napicoposterior segment could reflect sequela of aspiration or \ndeveloping infection.\n-- 5. Severe centrilobular and paraseptal pulmonary emphysema. \n-- 6. Severe calcified coronary and aortic atherosclerosis. \n-- 7. Unchanged main pulmonary artery enlargement suggests \npulmonary hypertension.\n\nRepeat CXRs were conducted daily or more frequently ___, \n___ x2, ___ x2, ___ which showed stability.\n\nDISCHARGE CXR (___): \nIMPRESSION: \n1. Stable subcutaneous emphysema over the right chest wall. \n2. Stable right apical pneumothorax. \n3. Worsening pulmonary edema. \n\n___ Bilateral ___\n- IMPRESSION: No evidence of deep venous thrombosis in the right \nor left lower extremity veins.\n\nPROCEDURES:\n===========\n___ Medical Thoracoscopy, Talc Pleurodesis, Chest Tube \nPlacement\n- A cluster of apical blebs were noted. 4g talc was insufflated.\n\nDISCHARGE LABS:\n==============\n\n___ 06:50AM BLOOD WBC-5.6 RBC-3.86* Hgb-11.9 Hct-36.9 \nMCV-96 MCH-30.8 MCHC-32.2 RDW-14.0 RDWSD-49.1* Plt ___\n___ 06:50AM BLOOD Glucose-95 UreaN-16 Creat-0.8 Na-137 \nK-3.8 Cl-93* HCO3-30 AnGap-14\n___ 06:50AM BLOOD Calcium-9.1 Phos-2.9 Mg-1.9\n \nBrief Hospital Course:\nPATIENT SUMMARY:\n====================\nMs. ___ is a ___ year old woman with PMH of severe emphysema, \nlung cancer s/p palliative XRT, HFpEF, HTN, TIAs, a-fib on \nEliquis who presented with R sided chest pain and dyspnea and \nwas found to have a large R sided pneumothorax. A pigtail \ncatheter was placed by IP with re-expansion of the lung. Patient \nthen underwent talc pleurodesis to prevent recurrence. Course \ncomplicated by development of UTI which was treated with PO \nmacrobid (continued through ___. \n\nACUTE ISSUES: \n============= \n#Spontaneous Pneumothorax\n#Emphysema\nAs above, Ms. ___ presented with acute R sided chest pain, \nSOB, and hypoxemia and was found to have large R sided PTX. It \nwas felt this was secondary to her underlying severe emphysema. \nInterventional Pulmonology placed a pigtail catheter with \ncomplete re-expansion of the lung, then eventually performed a \ntalc pleurodesis via thoracoscopy ___. Daily CXRs were \nperformed to assess interval change, which demonstrated \nstability. Pre-procedure, her DOAC was held but restarted \nuneventfully ___. Her pain was controlled with tylenol and \noxycodone 2.5mg q4hr:PRN (NSAIDs avoided due to interference \nwith anti-inflammatory response required for successful \npleurodesis -- IVF also avoided for this reason). Follow-up with \ninterventional pulmonology arranged prior to discharge. \n\n#Atrial fibrillation with rapid ventricular response\nCHADS2-VASc 7. During her hospitalization, Ms. ___ developed \nnew-onset pleuritic chest pain with tachycardia. ECG notable for \natrial fibrillation with rapid ventricular response. ECG with \nnew TWI but cardiac enzymes persistently negative, so ACS felt \nto be unlikely. Some concern for PE as trigger given held \nanticoagulation prior to procedure, but LENIs negative and \npatient without worsening hypoxemia. Ultimately attributed to \npain post-pleurodesis and resolved with treatment of pain. Home \ndiltiazem continued. Home apixaban initially held for \npleurodesis, then re-started post-procedure.\n\n#Lung Nodule, malignant\nPer review of records here and at ___, Ms. ___ has had \nmultiple pulmonary nodules seen on CT chest since ___, with \none FDG-avid spiculated nodule. Has received palliative \nradiation at ___, but no definitive biopsy in concordance with \npatient's wishes. On CT here, possible progression of nodule to \nmass. Further conversations with the patient confirmed that she \ndid not want biopsy. \n\n#Urinary Tract Infection\nPatient is followed in ___ clinic and has history of \nrecurrent UTIs, although per chart review may also be \nchronically colonized with E.Coli. She has been taking \nprophylactic methenamine +Vitamin C at home. On ___, she \ndeveloped urinary frequency and dysuria, with UA showing \nmultiple WBCs, ___ positive with bacteria. She was started on a 5 \nday course of Macrobid, and prophylactic methenamine/Vit C was \nheld. She will finish her course of Macrobid ___, after which \nshe will resume taking methenamine + Vit C.\n\nCHRONIC & RESOLVED ISSUES: \n============================ \n#HFpEF:\nAppeared euvolemic on admission. Continued home furosemide 20mg \ndaily and diltiazem. Home Lisinopril discontinued due to soft \nblood pressures. Discharge weight: 129.9lbs. \n\nTRANSITIONAL ISSUES:\n====================\n[] Discharge weight: 129.9 lbs. \n[] Please ensure patient does not receive anti-inflammatory \nmedications for several weeks post-pleurodesis.\n[] Discharged on 5 day course of Macrobid (___) for \nempiric treatment of UTI, urine culture pending at time of \ndischarge. \n[] Methenamine-Ascorbic Acid was held on discharge due to \nstarting Macrobid 5 day course. Patient can restart \nmethamine-ascorbic acid on ___ after macrobid course is \ncomplete.\n[] Lisinopril was discontinued this hospitalization due to \nrelatively low blood pressures. Follow-up pressure and consider \nre-starting if needed\n[] Ensure ongoing goals of care discussions and follow-up \nregarding enlarging pulmonary mass \n\n#CODE: DNR/DNI (confirmed); ok to reverse for procedures\n#CONTACT: ___ \n Relationship: Daughter / HCP\n Phone number: ___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Pravastatin 40 mg PO QPM \n2. Apixaban 2.5 mg PO BID \n3. Lisinopril 10 mg PO QPM \n4. Levothyroxine Sodium 50 mcg PO QAM \n5. Diltiazem Extended-Release 360 mg PO DAILY \n6. Furosemide 20 mg PO DAILY \n7. Oxybutynin XL (*NF*) 5 mg Other DAILY \n8. Ascorbic Acid ___ mg PO BID \n9. Calcium Carbonate 500 mg PO DAILY \n10. Vitamin D 400 UNIT PO DAILY \n11. Docusate Sodium 100 mg PO DAILY:PRN Constipation - First \nLine \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO TID \nRX *acetaminophen [Acetaminophen Extra Strength] 500 mg 2 \ntablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0 \n\n2. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H Duration: 5 \nDays \ndo not take methenamine + vitamin C with this medication. \nRX *nitrofurantoin monohyd/m-cryst [Macrobid] 100 mg 1 \ncapsule(s) by mouth twice daily Disp #*9 Capsule Refills:*0 \n3. Apixaban 2.5 mg PO BID \n4. Calcium Carbonate 500 mg PO DAILY \n5. Diltiazem Extended-Release 360 mg PO DAILY \n6. Docusate Sodium 100 mg PO DAILY:PRN Constipation - First \nLine \n7. Furosemide 20 mg PO DAILY \n8. Levothyroxine Sodium 50 mcg PO QAM \n9. Oxybutynin XL (*NF*) 5 mg Other DAILY \n10. Pravastatin 40 mg PO QPM \n11. Vitamin D 400 UNIT PO DAILY \n12. HELD- Ascorbic Acid ___ mg PO BID This medication was held. \nDo not restart Ascorbic Acid until you complete your course of \nantibiotics\n13. HELD- methenamine hippurate 1 gram oral BID This medication \nwas held. Do not restart methenamine hippurate until finishing \nyour antibiotics for your UTI\n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \n___ Diagnosis:\nPrimary:\n----------\nSpontaneous pneumothorax\nEmphysema\nUrinary tract infection\n\nSecondary:\n------------\nMalignant lung nodule\nAfib\nHFpEF\nHypothyroidism\nRecurrent UTIs (on prophylactic methenamine-vitC)\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Ms. ___,\nIt was a privilege caring for you at ___. \n\nWHY WAS I IN THE HOSPITAL? \n- You were having trouble breathing and imaging showed that your \nlung had collapsed.\n\nWHAT HAPPENED TO ME IN THE HOSPITAL? \n- A chest tube was placed to help your lung re-expand.\n- To prevent this from happening again, you had a procedure \ncalled a pleurodesis.\n- You were found to have a urinary tract infection and were \nstarted on antibiotics to treat this. \n\nWHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? \n- Please continue to take all of your medications as prescribed, \nincluding your new antibiotic (macrobid), and follow-up with \nyour appointments as listed below. \n- Do not take non-steroidal anti inflammatory medications to \ntreat your pain for the next ___ weeks (these include drugs like \nAdvil, Ibuprofen, Motrin, Naproxen). If you are having pain, \nplease take Tylenol, or acetaminophen. You can take 1 gram of \nTylenol up to three times a day, as needed for pain. \n- Do not take methenamine or vitamin C for the next 5 days while \nyou are taking Macrobid\n- After you finish a 5 day course of Macrobid on ___, you can \nstart taking methenamine and vitamin c again.\n\nWe wish you the best! \n\nSincerely, \nYour ___ Team \n \nFollowup Instructions:\n___\n"
] | Allergies: Bactrim DS / Sulfa (Sulfonamide Antibiotics) Chief Complaint: Chest pain, shortness of breath Major Surgical or Invasive Procedure: [MASKED] Pigtail Catheter Placement [MASKED] Thoracoscopy guided Talc Pleurodesis History of Present Illness: [MASKED] w/ PMHx emphysema, lung cancer s/p palliative radiation at [MASKED], HFpEF, HTN, TIAs, a-fib on Eliquis presented with R sided chest pain and SOB. She says she woke up at 6 AM on the morning of [MASKED] with pain in the R side of her chest that worsened with inspiration. Also reports progressive worsening of shortness of breath and fatigue so she came to ED for further evaluation. Upon initial evaluation in the ED, the patient had stable vital signs and an unremarkable ECG. She then developed acute onset SOB and desatted to the [MASKED] on RA. She was placed on NRB w/ improvement in her sats. Portable CXR was obtained which showed a large R sided PTX w/ some shifting of the mediastinum c/f tension pneumo. IP was then consulted and placed a pigtail catheter. In the ED: Initial vital signs were notable for: - 96.9 92 140/79 16 99% RA Labs were notable for: - CBC wnl - Na 135, K 4.1, BUN 23 - Trop neg x1 - Lactate 1.5 - VBG 7.31/62 - [MASKED] 13.7, PTT 29.3, INR 1.3 - proBNP 2554 Studies performed include: - CXR ([MASKED]) - Large right pneumothorax with contralateral shift of the mediastinal structures, raising the possibility of tension pneumothorax. - CXR ([MASKED]) - Interval re-expansion of the right lung status post placement of a right-sided chest tube. There is trace residual right apical and basilar pneumothorax. - CXR ([MASKED]) - FINDINGS: Right-sided pigtail chest tube is unchanged in position as compared to most recent chest radiograph. Previously noted right pneumothorax is no longer seen. Otherwise no change. - IMPRESSION: No residual right pneumothorax. Right chest tube in place. - CT Chest w/o contrast ([MASKED]) 1. Difficult to distinguish between presumed interval growth of a pre-existing right upper lobe pulmonary nodule into a larger mass and its resulting postobstructive atelectasis, noting obstruction of the adjacent right upper lobe posterior segment bronchus. The confluent area of opacification measures approximately 4.8 cm. 2. A right middle lobe pulmonary nodule has slightly increased in size and measures 0.7 cm. 3. A small right hydropneumothorax is decreased in size since radiographs obtained 1 day prior status-post pigtail pleural drainage catheter placement. 4. Ground-glass opacities in the peripheral left upper lobe apicoposterior segment could reflect sequela of aspiration or developing infection. 5. Severe centrilobular and paraseptal pulmonary emphysema. 6. Severe calcified coronary and aortic atherosclerosis. 7. Unchanged main pulmonary artery enlargement suggests pulmonary hypertension. - CXR ([MASKED]) - Unchanged appearance of the chest since 1.5 hours prior. The pigtail pleural drainage catheter is unchanged in position. Patient was given: - [MASKED] 08:56 IV Morphine Sulfate 4 mg - [MASKED] 10:03 IV Fentanyl Citrate 50 mcg - [MASKED] 10:03 PO Acetaminophen 1000 mg - [MASKED] 13:12 IV Morphine Sulfate 2 mg - [MASKED] 18:35 IV Morphine Sulfate 2 mg - [MASKED] 18:35 PO/NG Apixaban 2.5 mg - [MASKED] 00:16 IV Morphine Sulfate 2 mg - [MASKED] 00:17 PO Pravastatin 40 mg - [MASKED] 05:38 IV Morphine Sulfate 2 mg Consults: - IP as above, placed pigtail, PTX improved. Vitals on transfer: T98.0 BP132/69 HR85 RR16 O2sat 91%RA Upon arrival to the floor, patient was hemodynamically stable. She corroborates the above history. She denies current SOB, chest pain, fevers, chills, abdominal pain, nausea, diaphoresis, orthopnea, vomiting, diarrhea. REVIEW OF SYSTEMS: Otherwise negative. Past Medical History: PAST MEDICAL HISTORY: - Emphysema - FDG avid lung nodule, s/p palliative XRT at [MASKED] in [MASKED] - HFpEF - HTN - AFib - TIA x 2 - HLD - Hypothyroidism - Anxiety - s/p b/l cataract surgery - Varicose veins - Dizziness [MASKED] diagnosed with BPPV, resolved - BSO - cholecystecomy - appendectomy Social History: [MASKED] Family History: Noncontributory. Mother: with stroke, DM Paternal aunt: stroke Physical [MASKED]: ADMISSION PHYSICAL EXAM: ====================== VITALS: T98.0 BP132/69 HR85 RR16 O2sat 91%RA GENERAL: lying in bed in NAD HEENT: NC/AT NECK: No JVD CARDIAC: RRR, nl s1/s2, no mrg LUNGS: CTABL, no increased WOB, no decreased breath sounds over R lung fields ABDOMEN: soft, NT/ND, +BS EXTREMITIES: no edema over BLE NEUROLOGIC: AOx3 DISCHARGE PHYSICAL EXAM: ========================= VITALS: T 97.7 PO BP 106 / 57 L Lying HR 74 RR 17 93% RA GENERAL: pleasant elderly lady, lying in bed in NAD HEENT: NC/AT, anicteric sclera, PERRL NECK: supple, no lymphadenopathy CARDIAC: irregularly irregular, nl s1/s2, no mrg LUNGS: CTABL, no increased WOB, slightly decreased breath sounds RLL posteriorly -- chest tube incision site in right anterio-lateral chest wall, healing well with no induration or erythema ABDOMEN: soft, NT/ND, +BS EXTREMITIES: warm well perfused, 2+ pulses, no edema NEUROLOGIC: AOx3, CN [MASKED] grossly intact; no focal neurologic deficits Pertinent Results: ADMISSION LABS: ============== [MASKED] 08:03AM BLOOD WBC-5.6 RBC-4.18 Hgb-12.9 Hct-39.6 MCV-95 MCH-30.9 MCHC-32.6 RDW-14.4 RDWSD-50.1* Plt [MASKED] [MASKED] 08:03AM BLOOD Neuts-73.3* Lymphs-18.3* Monos-5.9 Eos-1.1 Baso-0.9 Im [MASKED] AbsNeut-4.07 AbsLymp-1.02* AbsMono-0.33 AbsEos-0.06 AbsBaso-0.05 [MASKED] 08:43AM BLOOD [MASKED] PTT-29.3 [MASKED] [MASKED] 08:03AM BLOOD Glucose-116* UreaN-23* Creat-0.9 Na-135 K-7.8* Cl-96 HCO3-26 AnGap-13 [MASKED] 08:03AM BLOOD ALT-<5 AST-63* AlkPhos-40 TotBili-0.5 [MASKED] 08:03AM BLOOD proBNP-2554* [MASKED] 08:03AM BLOOD cTropnT-<0.01 [MASKED] 08:16AM BLOOD [MASKED] pO2-30* pCO2-62* pH-7.31* calTCO2-33* Base XS-2 [MASKED] 08:16AM BLOOD Lactate-1.5 K-4.1 PERTINENT LABS: ============== [MASKED] 06:05AM BLOOD CK-MB-1 cTropnT-<0.01 [MASKED] 03:54PM BLOOD CK-MB-1 cTropnT-<0.01 [MASKED] 06:45AM BLOOD ALT-18 AST-22 LD(LDH)-183 AlkPhos-61 TotBili-0.7 MICROBIOLOGY: ============= [MASKED] 8:03 am BLOOD CULTURE Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] 8:08 am BLOOD CULTURE Blood Culture, Routine (Final [MASKED]: NO GROWTH. IMAGING: ======== CXR ([MASKED]) - IMPRESSION: Large right pneumothorax with contralateral shift of the mediastinal structures, raising the possibility of tension pneumothorax. CXR ([MASKED]) - IMPRESSION: Interval re-expansion of the right lung status post placement of a right-sided chest tube. There is trace residual right apical and basilar pneumothorax. CXR ([MASKED]) - IMPRESSION: No residual right pneumothorax. Right chest tube in place. CT Chest w/o contrast ([MASKED]) - IMPRESSION: -- 1. Difficult to distinguish between presumed interval growth of a pre-existing right upper lobe pulmonary nodule into a larger mass and its resulting postobstructive atelectasis, noting obstruction of the adjacent right upper lobe posterior segment bronchus. The confluent area of opacification measures approximately 4.8 cm. -- 2. A right middle lobe pulmonary nodule has slightly increased in size and measures 0.7 cm. -- 3. A small right hydropneumothorax is decreased in size since radiographs obtained 1 day prior status-post pigtail pleural drainage catheter placement. -- 4. Ground-glass opacities in the peripheral left upper lobe apicoposterior segment could reflect sequela of aspiration or developing infection. -- 5. Severe centrilobular and paraseptal pulmonary emphysema. -- 6. Severe calcified coronary and aortic atherosclerosis. -- 7. Unchanged main pulmonary artery enlargement suggests pulmonary hypertension. Repeat CXRs were conducted daily or more frequently [MASKED], [MASKED] x2, [MASKED] x2, [MASKED] which showed stability. DISCHARGE CXR ([MASKED]): IMPRESSION: 1. Stable subcutaneous emphysema over the right chest wall. 2. Stable right apical pneumothorax. 3. Worsening pulmonary edema. [MASKED] Bilateral [MASKED] - IMPRESSION: No evidence of deep venous thrombosis in the right or left lower extremity veins. PROCEDURES: =========== [MASKED] Medical Thoracoscopy, Talc Pleurodesis, Chest Tube Placement - A cluster of apical blebs were noted. 4g talc was insufflated. DISCHARGE LABS: ============== [MASKED] 06:50AM BLOOD WBC-5.6 RBC-3.86* Hgb-11.9 Hct-36.9 MCV-96 MCH-30.8 MCHC-32.2 RDW-14.0 RDWSD-49.1* Plt [MASKED] [MASKED] 06:50AM BLOOD Glucose-95 UreaN-16 Creat-0.8 Na-137 K-3.8 Cl-93* HCO3-30 AnGap-14 [MASKED] 06:50AM BLOOD Calcium-9.1 Phos-2.9 Mg-1.9 Brief Hospital Course: PATIENT SUMMARY: ==================== Ms. [MASKED] is a [MASKED] year old woman with PMH of severe emphysema, lung cancer s/p palliative XRT, HFpEF, HTN, TIAs, a-fib on Eliquis who presented with R sided chest pain and dyspnea and was found to have a large R sided pneumothorax. A pigtail catheter was placed by IP with re-expansion of the lung. Patient then underwent talc pleurodesis to prevent recurrence. Course complicated by development of UTI which was treated with PO macrobid (continued through [MASKED]. ACUTE ISSUES: ============= #Spontaneous Pneumothorax #Emphysema As above, Ms. [MASKED] presented with acute R sided chest pain, SOB, and hypoxemia and was found to have large R sided PTX. It was felt this was secondary to her underlying severe emphysema. Interventional Pulmonology placed a pigtail catheter with complete re-expansion of the lung, then eventually performed a talc pleurodesis via thoracoscopy [MASKED]. Daily CXRs were performed to assess interval change, which demonstrated stability. Pre-procedure, her DOAC was held but restarted uneventfully [MASKED]. Her pain was controlled with tylenol and oxycodone 2.5mg q4hr:PRN (NSAIDs avoided due to interference with anti-inflammatory response required for successful pleurodesis -- IVF also avoided for this reason). Follow-up with interventional pulmonology arranged prior to discharge. #Atrial fibrillation with rapid ventricular response CHADS2-VASc 7. During her hospitalization, Ms. [MASKED] developed new-onset pleuritic chest pain with tachycardia. ECG notable for atrial fibrillation with rapid ventricular response. ECG with new TWI but cardiac enzymes persistently negative, so ACS felt to be unlikely. Some concern for PE as trigger given held anticoagulation prior to procedure, but LENIs negative and patient without worsening hypoxemia. Ultimately attributed to pain post-pleurodesis and resolved with treatment of pain. Home diltiazem continued. Home apixaban initially held for pleurodesis, then re-started post-procedure. #Lung Nodule, malignant Per review of records here and at [MASKED], Ms. [MASKED] has had multiple pulmonary nodules seen on CT chest since [MASKED], with one FDG-avid spiculated nodule. Has received palliative radiation at [MASKED], but no definitive biopsy in concordance with patient's wishes. On CT here, possible progression of nodule to mass. Further conversations with the patient confirmed that she did not want biopsy. #Urinary Tract Infection Patient is followed in [MASKED] clinic and has history of recurrent UTIs, although per chart review may also be chronically colonized with E.Coli. She has been taking prophylactic methenamine +Vitamin C at home. On [MASKED], she developed urinary frequency and dysuria, with UA showing multiple WBCs, [MASKED] positive with bacteria. She was started on a 5 day course of Macrobid, and prophylactic methenamine/Vit C was held. She will finish her course of Macrobid [MASKED], after which she will resume taking methenamine + Vit C. CHRONIC & RESOLVED ISSUES: ============================ #HFpEF: Appeared euvolemic on admission. Continued home furosemide 20mg daily and diltiazem. Home Lisinopril discontinued due to soft blood pressures. Discharge weight: 129.9lbs. TRANSITIONAL ISSUES: ==================== [] Discharge weight: 129.9 lbs. [] Please ensure patient does not receive anti-inflammatory medications for several weeks post-pleurodesis. [] Discharged on 5 day course of Macrobid ([MASKED]) for empiric treatment of UTI, urine culture pending at time of discharge. [] Methenamine-Ascorbic Acid was held on discharge due to starting Macrobid 5 day course. Patient can restart methamine-ascorbic acid on [MASKED] after macrobid course is complete. [] Lisinopril was discontinued this hospitalization due to relatively low blood pressures. Follow-up pressure and consider re-starting if needed [] Ensure ongoing goals of care discussions and follow-up regarding enlarging pulmonary mass #CODE: DNR/DNI (confirmed); ok to reverse for procedures #CONTACT: [MASKED] Relationship: Daughter / HCP Phone number: [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Pravastatin 40 mg PO QPM 2. Apixaban 2.5 mg PO BID 3. Lisinopril 10 mg PO QPM 4. Levothyroxine Sodium 50 mcg PO QAM 5. Diltiazem Extended-Release 360 mg PO DAILY 6. Furosemide 20 mg PO DAILY 7. Oxybutynin XL (*NF*) 5 mg Other DAILY 8. Ascorbic Acid [MASKED] mg PO BID 9. Calcium Carbonate 500 mg PO DAILY 10. Vitamin D 400 UNIT PO DAILY 11. Docusate Sodium 100 mg PO DAILY:PRN Constipation - First Line Discharge Medications: 1. Acetaminophen 1000 mg PO TID RX *acetaminophen [Acetaminophen Extra Strength] 500 mg 2 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0 2. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H Duration: 5 Days do not take methenamine + vitamin C with this medication. RX *nitrofurantoin monohyd/m-cryst [Macrobid] 100 mg 1 capsule(s) by mouth twice daily Disp #*9 Capsule Refills:*0 3. Apixaban 2.5 mg PO BID 4. Calcium Carbonate 500 mg PO DAILY 5. Diltiazem Extended-Release 360 mg PO DAILY 6. Docusate Sodium 100 mg PO DAILY:PRN Constipation - First Line 7. Furosemide 20 mg PO DAILY 8. Levothyroxine Sodium 50 mcg PO QAM 9. Oxybutynin XL (*NF*) 5 mg Other DAILY 10. Pravastatin 40 mg PO QPM 11. Vitamin D 400 UNIT PO DAILY 12. HELD- Ascorbic Acid [MASKED] mg PO BID This medication was held. Do not restart Ascorbic Acid until you complete your course of antibiotics 13. HELD- methenamine hippurate 1 gram oral BID This medication was held. Do not restart methenamine hippurate until finishing your antibiotics for your UTI Discharge Disposition: Extended Care Facility: [MASKED] [MASKED] Diagnosis: Primary: ---------- Spontaneous pneumothorax Emphysema Urinary tract infection Secondary: ------------ Malignant lung nodule Afib HFpEF Hypothyroidism Recurrent UTIs (on prophylactic methenamine-vitC) 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. [MASKED], It was a privilege caring for you at [MASKED]. WHY WAS I IN THE HOSPITAL? - You were having trouble breathing and imaging showed that your lung had collapsed. WHAT HAPPENED TO ME IN THE HOSPITAL? - A chest tube was placed to help your lung re-expand. - To prevent this from happening again, you had a procedure called a pleurodesis. - You were found to have a urinary tract infection and were started on antibiotics to treat this. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Please continue to take all of your medications as prescribed, including your new antibiotic (macrobid), and follow-up with your appointments as listed below. - Do not take non-steroidal anti inflammatory medications to treat your pain for the next [MASKED] weeks (these include drugs like Advil, Ibuprofen, Motrin, Naproxen). If you are having pain, please take Tylenol, or acetaminophen. You can take 1 gram of Tylenol up to three times a day, as needed for pain. - Do not take methenamine or vitamin C for the next 5 days while you are taking Macrobid - After you finish a 5 day course of Macrobid on [MASKED], you can start taking methenamine and vitamin c again. We wish you the best! Sincerely, Your [MASKED] Team Followup Instructions: [MASKED] | [
"J9383",
"I5032",
"C3411",
"N390",
"J439",
"I110",
"E039",
"Z923",
"E785",
"F419",
"K219",
"I2510",
"Z87440",
"Z8673",
"I4891",
"Z7901",
"R000",
"K5900",
"R0781",
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] | [
"J9383: Other pneumothorax",
"I5032: Chronic diastolic (congestive) heart failure",
"C3411: Malignant neoplasm of upper lobe, right bronchus or lung",
"N390: Urinary tract infection, site not specified",
"J439: Emphysema, unspecified",
"I110: Hypertensive heart disease with heart failure",
"E039: Hypothyroidism, unspecified",
"Z923: Personal history of irradiation",
"E785: Hyperlipidemia, unspecified",
"F419: Anxiety disorder, unspecified",
"K219: Gastro-esophageal reflux disease without esophagitis",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"Z87440: Personal history of urinary (tract) infections",
"Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits",
"I4891: Unspecified atrial fibrillation",
"Z7901: Long term (current) use of anticoagulants",
"R000: Tachycardia, unspecified",
"K5900: Constipation, unspecified",
"R0781: Pleurodynia",
"Z66: Do not resuscitate"
] | [
"I5032",
"N390",
"I110",
"E039",
"E785",
"F419",
"K219",
"I2510",
"Z8673",
"I4891",
"Z7901",
"K5900",
"Z66"
] | [] |
16,417,262 | 29,073,187 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nLotrel / Aggrenox / Crestor / aspirin\n \nAttending: ___.\n \nChief Complaint:\nMotor vehicle collision / loss of consciousness\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n(Taken with phone interpreter at the bedside)\nMr. ___ is a pleasant ___ year old male with PMH of \nDMII, HTN, CAD s/p drug coated stent (RCA), aortic \ninsufficiency, and carotid stenosis (b/l), who presents due to \nsingle vehicle motor collision after blacking out while driving. \nHe was a restrained driver with his two grandchildren as \npassengers, with air bag deployment and impact into a tree.\n\nPt. denies any recollection of a preceding event. Denies HA, \nvision changes, chest pain, SOB, abdominal pain, or n/v. He \nstates he did not have any loss of bowel or urinary continence \nafter the accident. Denies any tongue biting or confusion after \nthe event. \n\nIn the ED, initial vitals: 97.3 72 144/68 16 99% on RA\nExam notable for abrasions on b/l knees\nLabs were significant for Trop-T x2 <0.01, INR 1.9\nImaging showed no evidence of acute hemorrhage or fracture on CT \nHead w/o contrast, with age related global atrophy and chronic \nmicroangiopathy\nPatient was seen by Cardiology\nDecision made to admit for syncope \nVitals prior to transfer: 97.7 77 109/64 20 97% on RA\n\nOn arrival to the floor, he was HD stable, stating he was \nfeeling well and had a good appetite. \n\nOf note, he states that he snores, and has been noted to fall \nasleep during the day mid-conversation. He on occasion gets \ndizzy when standing up too quickly. No witnessed syncopal \nepisodes.\n\n \nPast Medical History:\nDiabetes\nHTN\nHypercholesterolemia\nchronic renal disease, stage 3\nAortic insufficiency \nCoronary artery disease s/p RCA drug coated stent \n___\nStroke, ___\nB/l Carotid Stenosis\nBPH\nCOPD\n \nSocial History:\n___\nFamily History:\nNo hx of strokes\nBrothers passed away due to \"tumors,\" unknown which location.\n \nPhysical Exam:\nOn Admission:\nVS: 98.1 174/87 70 18 96% on RA \nGEN: Alert, sitting at bedside eating lunch, no acute distress \nHEENT: Moist MM, anicteric sclerae, no conjunctival pallor, EOMI \n \nNECK: no JVD\nPULM: Generally CTA b/l without wheeze or rhonchi \nCOR: RRR, III/VI holosystolic murmur heard best at left upper \nsternal border \nABD: Soft, non-tender, non-distended \nEXTREM: Warm, well-perfused, no edema, abrasions on both knees, \nlarge bruising on R medial aspect of thigh\nNEURO: CN II-XII grossly intact, motor function grossly normal, \ngait normal \n\nOn Discharge:\nVitals: 98.1 156/82 64 20 95% on RA \nGEN: Alert, sitting at bedside eating lunch, no acute distress \nHEENT: Moist MM, anicteric sclerae, no conjunctival pallor, EOMI \n \nNECK: no JVD\nPULM: Generally CTA b/l without wheeze or rhonchi \nCOR: RRR, III/VI holosystolic murmur heard best at left upper \nsternal border \nABD: Soft, non-tender, non-distended \nEXTREM: Warm, well-perfused, no edema, abrasions on both knees, \nlarge bruising on R medial aspect of thigh\nNEURO: CN II-XII grossly intact, motor function grossly normal, \ngait normal \n\n \nPertinent Results:\nOn Admission:\n___ 04:00PM BLOOD WBC-5.6 RBC-4.54* Hgb-14.1 Hct-42.2 \nMCV-93 MCH-31.1 MCHC-33.4 RDW-12.4 RDWSD-42.3 Plt ___\n___ 04:00PM BLOOD Neuts-71.8* Lymphs-15.2* Monos-9.7 \nEos-2.7 Baso-0.4 Im ___ AbsNeut-4.01 AbsLymp-0.85* \nAbsMono-0.54 AbsEos-0.15 AbsBaso-0.02\n___ 04:00PM BLOOD ___ PTT-32.6 ___\n___ 04:00PM BLOOD Plt ___\n___ 04:00PM BLOOD Glucose-134* UreaN-28* Creat-1.5* Na-139 \nK-4.4 Cl-102 HCO3-23 AnGap-18\n___ 04:00PM BLOOD cTropnT-<0.01\n___ 10:05PM BLOOD cTropnT-<0.01\n___ 04:00PM BLOOD Calcium-9.5 Phos-3.7 Mg-2.2\n\nMicro:\nNone\n\nImaging:\n+ EKG ___ rhythm, normal rate, first degree heart \nblock, normal axis, no QTC prolongation, no ischemic changes\n\n+ ___: \nImpression: No acute cardiopulmonary process\n \nCT Head w/o contrast (___)\nImpression:\n1. Mildly limited exam due to motion artifact. Given this \nlimitation, there is no evidence of acute hemorrhage or \nfracture. \n2. Age related global atrophy and chronic microangiopathy. \n\nOn Discharge:\n___ 07:08AM BLOOD WBC-6.0 RBC-4.14* Hgb-12.8* Hct-38.0* \nMCV-92 MCH-30.9 MCHC-33.7 RDW-12.5 RDWSD-41.9 Plt ___\n___ 07:08AM BLOOD Plt ___\n___ 07:08AM BLOOD Glucose-104* UreaN-28* Creat-1.3* Na-141 \nK-3.7 Cl-103 HCO3-26 AnGap-16\n___ 07:08AM BLOOD Calcium-9.4 Phos-3.6 Mg-2.1\n \nBrief Hospital Course:\nMr. ___ is a pleasant ___ year old male with PMH of \nDMII, HTN, CAD s/p drug coated stent (RCA), aortic \ninsufficiency, and carotid stenosis (b/l), who presents due to \nsingle vehicle motor collision after blacking out while driving. \nHe was a restrained driver with his two grandchildren as \npassengers, with air bag deployment and impact into a tree. \n\nACTIVE ISSUES: \n===============\n#Syncope\n#Motor vehicle collision - Given cardiac factors and abrupt \noccurrence, presentation initially most concerning for acute \ncardiac ischemia or arrhythmia. Cardiology saw him in the ED who \nrecommended serial trops and ECG with continuous monitoring. \nTrop-Tx2 were flat, ECG showed with no ischemic changes. He was \nmonitored on tele with intermittent disruptions due to \nagitation/confusion, which was unremarkable. He also had recent \noutpatient cardiac monitoring which was unrevealing for \narrhythmia. Differential also included seizures or stroke, \nhowever, he did not have any post-ictal symptoms, or any \nevidence of acute intracranial hemorrhage or ischemia. He was \nalso seen by neurology (Dr. ___ within the past \nmonth, whose assessment was that similar episodes of \"blacking \nout\" do not appear to be \"characteristically cerebrovascular\". \nHis story was not necessarily consistent with a vasovagal \nepisode, but he did have orthostatic hypotension by vitals, for \nwhich we gave him 1.5L NS with resolution. He gave us a history \nof snoring and falling asleep during the day while talking, OSA \nresulting in excessive daytime sleepiness may be a plausible \nexplanation for his loss of consciousness.\n- Sleep study already scheduled in early ___\n- Patient and family were notified that should not drive for at \nleast 6 months after this episode of loss of consciousness. \nFamily has stated that the patient's license has already been \nrevoked.\n\n# Delirium:\nPatient had an episode of agitated delirium overnight the night \nof admission. No infection, metabolic derangements, or \nmedication culprits identified. Mental status improved the \nfollowing morning and patient had no recollection of this \nepisode. Family corroborates that patient has had increased \nconfusion / disorientation at home.\n- Recommend outpatient neuro-cognitive evaluation\n\nCHRONIC ISSUES: \n===============\n#HTN- Continue irbesartan \n#DMII - Does not appear to be on Metformin anymore. Did not have \nhim on ISS and blood glucose levels were 100-130s.\n#CAD s/p drug coated stent - Continue clopidogrel \n#BPH - Continue tamsulosin \n\nTRANSITIONAL ISSUES: \n===============\n# Syncope: Further work up for the syncope should include follow \nup of the holter monitor 24-study performed on ___. OSA \nworkup as already scheduled\n#Mental status: patient exhibited symptoms of characteristic of \npotential cognitive impairment. Patient should follow-up with \ncomplete Cognitive evaluation to better assess deficiency with \nin-person ___ translator, as this may be convoluted with to \npoorly characterized \"syncope\" events.\n# CODE STATUS: Full (confirmed) \n# CONTACT: HCP: ___ (wife) ___, Cell: \n___\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. irbesartan 150 mg oral DAILY \n2. Atorvastatin 40 mg PO QPM \n3. Clopidogrel 75 mg PO DAILY \n4. Tamsulosin 0.4 mg PO QHS \n5. mirabegron 25 mg oral DAILY \n\n \nDischarge Medications:\n1. Atorvastatin 40 mg PO QPM \n2. Clopidogrel 75 mg PO DAILY \n3. irbesartan 150 mg oral DAILY \n4. mirabegron 25 mg oral DAILY \n5. Tamsulosin 0.4 mg PO QHS \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary: Syncope\n\n \nDischarge Condition:\nMental Status: Confused - sometimes.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___, \n\nYou were admitted to ___ \n(___) after you were in a single motor vehicle crash into a \ntree that was caused after you blacked out while driving. We did \ntests on your brain and heart, and fortunately they were all \nnormal. We gave you fluids because you were dehydrated and may \nhave contributed to this event. \n\nPlease be sure to follow up with your outpatient providers at \nyour scheduled appointments. Thank you for allowing us to be \napart of your care. \n\nSincerely, \n\nYour ___ Care Team\n \nFollowup Instructions:\n___\n"
] | Allergies: Lotrel / Aggrenox / Crestor / aspirin Chief Complaint: Motor vehicle collision / loss of consciousness Major Surgical or Invasive Procedure: None History of Present Illness: (Taken with phone interpreter at the bedside) Mr. [MASKED] is a pleasant [MASKED] year old male with PMH of DMII, HTN, CAD s/p drug coated stent (RCA), aortic insufficiency, and carotid stenosis (b/l), who presents due to single vehicle motor collision after blacking out while driving. He was a restrained driver with his two grandchildren as passengers, with air bag deployment and impact into a tree. Pt. denies any recollection of a preceding event. Denies HA, vision changes, chest pain, SOB, abdominal pain, or n/v. He states he did not have any loss of bowel or urinary continence after the accident. Denies any tongue biting or confusion after the event. In the ED, initial vitals: 97.3 72 144/68 16 99% on RA Exam notable for abrasions on b/l knees Labs were significant for Trop-T x2 <0.01, INR 1.9 Imaging showed no evidence of acute hemorrhage or fracture on CT Head w/o contrast, with age related global atrophy and chronic microangiopathy Patient was seen by Cardiology Decision made to admit for syncope Vitals prior to transfer: 97.7 77 109/64 20 97% on RA On arrival to the floor, he was HD stable, stating he was feeling well and had a good appetite. Of note, he states that he snores, and has been noted to fall asleep during the day mid-conversation. He on occasion gets dizzy when standing up too quickly. No witnessed syncopal episodes. Past Medical History: Diabetes HTN Hypercholesterolemia chronic renal disease, stage 3 Aortic insufficiency Coronary artery disease s/p RCA drug coated stent [MASKED] Stroke, [MASKED] B/l Carotid Stenosis BPH COPD Social History: [MASKED] Family History: No hx of strokes Brothers passed away due to "tumors," unknown which location. Physical Exam: On Admission: VS: 98.1 174/87 70 18 96% on RA GEN: Alert, sitting at bedside eating lunch, no acute distress HEENT: Moist MM, anicteric sclerae, no conjunctival pallor, EOMI NECK: no JVD PULM: Generally CTA b/l without wheeze or rhonchi COR: RRR, III/VI holosystolic murmur heard best at left upper sternal border ABD: Soft, non-tender, non-distended EXTREM: Warm, well-perfused, no edema, abrasions on both knees, large bruising on R medial aspect of thigh NEURO: CN II-XII grossly intact, motor function grossly normal, gait normal On Discharge: Vitals: 98.1 156/82 64 20 95% on RA GEN: Alert, sitting at bedside eating lunch, no acute distress HEENT: Moist MM, anicteric sclerae, no conjunctival pallor, EOMI NECK: no JVD PULM: Generally CTA b/l without wheeze or rhonchi COR: RRR, III/VI holosystolic murmur heard best at left upper sternal border ABD: Soft, non-tender, non-distended EXTREM: Warm, well-perfused, no edema, abrasions on both knees, large bruising on R medial aspect of thigh NEURO: CN II-XII grossly intact, motor function grossly normal, gait normal Pertinent Results: On Admission: [MASKED] 04:00PM BLOOD WBC-5.6 RBC-4.54* Hgb-14.1 Hct-42.2 MCV-93 MCH-31.1 MCHC-33.4 RDW-12.4 RDWSD-42.3 Plt [MASKED] [MASKED] 04:00PM BLOOD Neuts-71.8* Lymphs-15.2* Monos-9.7 Eos-2.7 Baso-0.4 Im [MASKED] AbsNeut-4.01 AbsLymp-0.85* AbsMono-0.54 AbsEos-0.15 AbsBaso-0.02 [MASKED] 04:00PM BLOOD [MASKED] PTT-32.6 [MASKED] [MASKED] 04:00PM BLOOD Plt [MASKED] [MASKED] 04:00PM BLOOD Glucose-134* UreaN-28* Creat-1.5* Na-139 K-4.4 Cl-102 HCO3-23 AnGap-18 [MASKED] 04:00PM BLOOD cTropnT-<0.01 [MASKED] 10:05PM BLOOD cTropnT-<0.01 [MASKED] 04:00PM BLOOD Calcium-9.5 Phos-3.7 Mg-2.2 Micro: None Imaging: + EKG [MASKED] rhythm, normal rate, first degree heart block, normal axis, no QTC prolongation, no ischemic changes + [MASKED]: Impression: No acute cardiopulmonary process CT Head w/o contrast ([MASKED]) Impression: 1. Mildly limited exam due to motion artifact. Given this limitation, there is no evidence of acute hemorrhage or fracture. 2. Age related global atrophy and chronic microangiopathy. On Discharge: [MASKED] 07:08AM BLOOD WBC-6.0 RBC-4.14* Hgb-12.8* Hct-38.0* MCV-92 MCH-30.9 MCHC-33.7 RDW-12.5 RDWSD-41.9 Plt [MASKED] [MASKED] 07:08AM BLOOD Plt [MASKED] [MASKED] 07:08AM BLOOD Glucose-104* UreaN-28* Creat-1.3* Na-141 K-3.7 Cl-103 HCO3-26 AnGap-16 [MASKED] 07:08AM BLOOD Calcium-9.4 Phos-3.6 Mg-2.1 Brief Hospital Course: Mr. [MASKED] is a pleasant [MASKED] year old male with PMH of DMII, HTN, CAD s/p drug coated stent (RCA), aortic insufficiency, and carotid stenosis (b/l), who presents due to single vehicle motor collision after blacking out while driving. He was a restrained driver with his two grandchildren as passengers, with air bag deployment and impact into a tree. ACTIVE ISSUES: =============== #Syncope #Motor vehicle collision - Given cardiac factors and abrupt occurrence, presentation initially most concerning for acute cardiac ischemia or arrhythmia. Cardiology saw him in the ED who recommended serial trops and ECG with continuous monitoring. Trop-Tx2 were flat, ECG showed with no ischemic changes. He was monitored on tele with intermittent disruptions due to agitation/confusion, which was unremarkable. He also had recent outpatient cardiac monitoring which was unrevealing for arrhythmia. Differential also included seizures or stroke, however, he did not have any post-ictal symptoms, or any evidence of acute intracranial hemorrhage or ischemia. He was also seen by neurology (Dr. [MASKED] within the past month, whose assessment was that similar episodes of "blacking out" do not appear to be "characteristically cerebrovascular". His story was not necessarily consistent with a vasovagal episode, but he did have orthostatic hypotension by vitals, for which we gave him 1.5L NS with resolution. He gave us a history of snoring and falling asleep during the day while talking, OSA resulting in excessive daytime sleepiness may be a plausible explanation for his loss of consciousness. - Sleep study already scheduled in early [MASKED] - Patient and family were notified that should not drive for at least 6 months after this episode of loss of consciousness. Family has stated that the patient's license has already been revoked. # Delirium: Patient had an episode of agitated delirium overnight the night of admission. No infection, metabolic derangements, or medication culprits identified. Mental status improved the following morning and patient had no recollection of this episode. Family corroborates that patient has had increased confusion / disorientation at home. - Recommend outpatient neuro-cognitive evaluation CHRONIC ISSUES: =============== #HTN- Continue irbesartan #DMII - Does not appear to be on Metformin anymore. Did not have him on ISS and blood glucose levels were 100-130s. #CAD s/p drug coated stent - Continue clopidogrel #BPH - Continue tamsulosin TRANSITIONAL ISSUES: =============== # Syncope: Further work up for the syncope should include follow up of the holter monitor 24-study performed on [MASKED]. OSA workup as already scheduled #Mental status: patient exhibited symptoms of characteristic of potential cognitive impairment. Patient should follow-up with complete Cognitive evaluation to better assess deficiency with in-person [MASKED] translator, as this may be convoluted with to poorly characterized "syncope" events. # CODE STATUS: Full (confirmed) # CONTACT: HCP: [MASKED] (wife) [MASKED], Cell: [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. irbesartan 150 mg oral DAILY 2. Atorvastatin 40 mg PO QPM 3. Clopidogrel 75 mg PO DAILY 4. Tamsulosin 0.4 mg PO QHS 5. mirabegron 25 mg oral DAILY Discharge Medications: 1. Atorvastatin 40 mg PO QPM 2. Clopidogrel 75 mg PO DAILY 3. irbesartan 150 mg oral DAILY 4. mirabegron 25 mg oral DAILY 5. Tamsulosin 0.4 mg PO QHS Discharge Disposition: Home Discharge Diagnosis: Primary: Syncope Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], You were admitted to [MASKED] ([MASKED]) after you were in a single motor vehicle crash into a tree that was caused after you blacked out while driving. We did tests on your brain and heart, and fortunately they were all normal. We gave you fluids because you were dehydrated and may have contributed to this event. Please be sure to follow up with your outpatient providers at your scheduled appointments. Thank you for allowing us to be apart of your care. Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED] | [
"R55",
"G92",
"E1122",
"J449",
"I6523",
"I2510",
"Z955",
"N400",
"Z7902",
"I351",
"V470XXA",
"Y92410",
"I129",
"N183",
"Z8673",
"G4733",
"S80211A",
"I951",
"G3184"
] | [
"R55: Syncope and collapse",
"G92: Toxic encephalopathy",
"E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease",
"J449: Chronic obstructive pulmonary disease, unspecified",
"I6523: Occlusion and stenosis of bilateral carotid arteries",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"Z955: Presence of coronary angioplasty implant and graft",
"N400: Benign prostatic hyperplasia without lower urinary tract symptoms",
"Z7902: Long term (current) use of antithrombotics/antiplatelets",
"I351: Nonrheumatic aortic (valve) insufficiency",
"V470XXA: Car driver injured in collision with fixed or stationary object in nontraffic accident, initial encounter",
"Y92410: Unspecified street and highway as the place of occurrence of the external cause",
"I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease",
"N183: Chronic kidney disease, stage 3 (moderate)",
"Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits",
"G4733: Obstructive sleep apnea (adult) (pediatric)",
"S80211A: Abrasion, right knee, initial encounter",
"I951: Orthostatic hypotension",
"G3184: Mild cognitive impairment, so stated"
] | [
"E1122",
"J449",
"I2510",
"Z955",
"N400",
"Z7902",
"I129",
"Z8673",
"G4733"
] | [] |
10,770,039 | 26,950,400 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\nSyncope\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ with EtOH use disorder c/b cirrhosis, portal HTN \n(splenomegaly), ascites requiring paracenteses in past, varices, \nh/o EtOH hepatitis p/w lethargy and syncope. Recently admitted \nhere at ___ for presumed EtOH hepatitis, during which she \nsyncopized, however left AMA for ___. While at ___ continued to \nhave syncope, for which she was worked up with CXR, UA/UCx, bcx, \nECG, tele, CT A/P, EEG, TTE which were all unrevealing. Since \ndischarge 3 days ago, has been somnolent at home per sister at \nbedside. Also was found down/not easily aroused this AM when \nsister was gone for roughly 20min. Unclear what triggers \nepisodes, not immediate LOC but no prodrome either, no seizure \nsymptoms though she does report some brief confusion ~1min after \nthe episodes. Of note, per pt no EtOH since before ___ \nadmission. She denies any use of drugs or opiates. \n\nROS \n(+)alternating chills/sweats, RUQ pain, improved nausea/vomiting \ncompared to previous admission, constipated, generalized \nweakness (-)SOB, chest pain, rash\n\nIn the ED, initial VS were: 6 | 97.6 | 93 | 123/81 | 16 | 100% \nRA\n\nED Exam notable for:\nGen: lying in bed, weak appearing\nCV: RRR nl s1/s2 no mrg\nLungs: CTABL no increased WOB\nAbd: soft, exquisitely tender at RUQ, liver edge palpable,\notherwise NT/ND, +BS\nExtr: no pitting edema\nNeuro: AOx3, no asterixis\n\nECG: nsr, rate in ___, normal axis, no ST changes\n\nLabs showed:\n\n5.4 > 11.3/32.6 < 6 \n\n146 | 108 | 25\n---------------< 126\n4.4 | 25 | 0.9\n\nCa ___ | Mg 1.9 | Phos 2.0\n\nAST 59 | ALT 31 | AP 99 | Tbili 1.8\n\nTrop neg x2, CK 31\n\nLactate 3.0 \n\nSerum ASA/EtOH/APAP/Tricyclic - neg\nUrine benzos/opiates POSITIVE\nUrine barbs, cocaine, ampheatmines, methadone, oxy - neg \n\nUA with 15 WBC, few bacteria, 1 epi, neg nitrites\n\nImaging showed:\n___ CT HEAD W/O CONTRAST:\nNo acute intracranial process.\n\n___ C-SPINE W/O CONTRAST:\nNo cervical spine fracture or malalignment.\n\n___ LIVER ULTRASOUND:\n1. Cirrhotic liver morphology with patent portal venous system \nwith hepatopetal flow.\n2. Cholelithiasis without suggestion of cholecystitis.\n3. No ascites. Borderline splenomegaly, measuring 12.5 cm.\n\n___ CXR: \nNo acute cardiopulmonary process.\n\nPatient received:\n- hydromorphone 0.5mg IV\n- NS\n- hydroxyzine 50mg\n- propranolol 10mg \n- ursodiol 300mg\n- acetaminophen IV 1000mg\n- hydromorphone 0.5mg IV\n\nTransfer VS were: 98.6 | 79 | 128/73 | 16 | 99% RA \n\nOn arrival to the floor, patient endorses \"shakiness\" and some \nmild abdominal pain. The shakiness began at the time of her \ninitial syncopal episode and has been ongoing since. She also \nhas noticed R sided abdominal pain since she began collapsing. \nThe pain is associated with nausea and occasional non-bilious, \nnon-bloody emesis, and constipation with occasional dark red \nstools. No fevers, chills, URI symptoms, cough. Denies any \npalpitations, chest pain, or dyspnea. \n \nPast Medical History:\nEBV infection c/b cytopenias and transaminitis alcoholic \nhepatitis with cirrhosis (biopsy proven) complicated the \njaundice, ascities and portal hypertension -- three small to\nmedium sized varicies \n \nSocial History:\n___\nFamily History:\n-Maternal Grandmother with ovarian cancer \n-Aunt with breast cancer \n-Father with colon cancer \n-Cousin with breast cancer diagnosed at ___ (negative for BRCA, \npatient and sister tested negative for BRCA) \n-No family history of cirrhosis or autoimmune conditions \n-Grandfather with DM \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n======================\n___ 0614 Temp: 97.8 PO BP: 112/63 HR: 66 RR: 16 O2 sat: \n100% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: ___ \nGENERAL: NAD\nHEENT: AT/NC, icteric sclera, MMM\nNECK: supple, no LAD\nCV: RRR, S1/S2, no murmurs, gallops, or rubs\nPULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably \nwithout use of accessory muscles\nGI: abdomen soft, nondistended, TTP RUQ, no rebound/guarding, no \nhepatosplenomegaly\nEXTREMITIES: no cyanosis, clubbing, or edema\nPULSES: 2+ radial pulses bilaterally\nNEURO: Alert, moving all 4 extremities with purpose, face \nsymmetric\nDERM: warm and well perfused, no excoriations or lesions, no \nrashes\n\nDISCHARGE PHYSICAL EXAM:\n======================\nVITALS: ___ 0744 Temp: 98.9 PO BP: 103/68 R HR: 78 RR: 18 \nO2\nsat: 98% O2 delivery: Ra \nGENERAL: WDWN female in NAD. \nHEENT: AT/NC, icteric sclera, MMM. \nNECK: supple \nCV: RRR with normal S1 and S2. No murmurs, rubs or gallops. \nPULM: Normal respiratory effort. CTAB without wheezes, rales or\nrhonchi. \nGI: Abdomen soft, nondistended, diffusely tender to palpation\nover entire abdomen. No rebound\nor guarding. Normoactive BS. \nEXTREMITIES: Warm, well perfused. No ___ edema or erythema. \nNEURO: Alert and interactive. CN II-XII intact. ___ strength and\nnormal sensation throughout. \nDERM: Skin type II. Warm, dry. No rashes.\nPSYCH: Normal mood.\n\n \nPertinent Results:\nADMISSION LABS:\n==============\n___ 06:10PM BLOOD WBC-5.4 RBC-3.37* Hgb-11.3 Hct-32.6* \nMCV-97 MCH-33.5* MCHC-34.7 RDW-13.9 RDWSD-49.1* Plt Ct-86*\n___ 06:10PM BLOOD Neuts-49.5 ___ Monos-16.8* \nEos-5.5 Baso-0.7 Im ___ AbsNeut-2.69 AbsLymp-1.47 \nAbsMono-0.91* AbsEos-0.30 AbsBaso-0.04\n___ 06:10PM BLOOD Glucose-126* UreaN-25* Creat-0.9 Na-146 \nK-4.4 Cl-108 HCO3-25 AnGap-13\n___ 06:10PM BLOOD ALT-31 AST-59* LD(LDH)-208 CK(CPK)-31 \nAlkPhos-99 TotBili-1.8*\n___ 06:10PM BLOOD Calcium-10.0 Phos-2.0* Mg-1.9\n___ 06:18PM BLOOD Lactate-3.0*\n\nPERTINENT LABS/MICRO:\n===================\n___ 06:10PM BLOOD cTropnT-<0.01\n___ 06:10PM BLOOD Osmolal-307\n___ 09:13AM BLOOD TSH-3.8\n___ 06:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nTricycl-NEG\n___ 06:18PM BLOOD Lactate-3.0*\n___ 09:24AM BLOOD Lactate-1.4\n\n___ BCx: No growth to date\n___ Urine culture: No growth\n\nDISCHARGE LABS:\n==============\n___ 05:56AM BLOOD WBC-5.1 RBC-3.32* Hgb-11.1* Hct-32.6* \nMCV-98 MCH-33.4* MCHC-34.0 RDW-13.8 RDWSD-48.9* Plt ___\n___ 05:56AM BLOOD Glucose-102* UreaN-15 Creat-0.9 Na-140 \nK-4.9 Cl-103 HCO3-25 AnGap-12\n___ 05:56AM BLOOD ALT-24 AST-47* LD(LDH)-251* AlkPhos-81 \nTotBili-1.7*\n___ 05:56AM BLOOD Albumin-3.5 Calcium-9.8 Phos-3.4 Mg-1.9\n\nPERTINENT IMAGING:\n================\n___ CT Head:\nNo acute intracranial process.\n\n___ CT Neck w/o Contrast:\nNo cervical spine fracture or malalignment.\n\n___ RUQ Ultrasound:\n1. Cirrhotic liver morphology with patent portal venous system \nwith\nhepatopetal flow.\n2. Cholelithiasis without suggestion of cholecystitis.\n3. No ascites. Borderline splenomegaly, measuring 12.5 cm.\n\n___ CXR:\nNo acute cardiopulmonary process.\n\n \nBrief Hospital Course:\nMs. ___ is a ___ y/o female with a history of EOTH use \ndisorder, ETOH cirrhosis c/b spenomegaly, ascites, and varices \nwho presented with lethargy, syncope, and abdominal pain. CT \nhead and neck was unremarkable. The patient was monitored \nclinically and had no recurrent syncopal episodes. Her pain \nimproved with medications and time. \n\n#Syncope/Altered mental status\nShe reported having several AMS/syncopal episodes over the last \ntwo weeks. An extensive work up done at ___, including CXR, \nUCx/BCx, ECG, tele, CT A/P, EEG, and TTE, was unrevealing. She \npresented this admission after being found \nlethargic/unresponsive at home. CT head and neck was negative. \nSerum drug screen was negative and urine drug screen was \npositive for opiates and benzos, neither of which she was on at \nhome, though unclear if she had received them during her recent \nadmissions. There was no serum osmolarity gap to suggest \ningestion and the history was inconsistent with seizures. \n___ maneuver was positive, possible pointing towards \nBPPV though this was felt to be inconsistent with her \npresentation given that it does not present with syncope. \nOrthostatic vital signs were negative and she was monitored on \ntelemetry without events. There was also concern for a potential \npsychosomatic component in the setting of recent life stressors. \nWith time, she began to feel better and her symptoms did not \nrecur. She was seen by physical therapy who cleared her to go \nhome.\n\n#Abdominal Pain\nPresented with two weeks of RUQ abdominal pain, since a recent \nadmission for alcoholic hepatitis. LFTS remained elevated (AST \n59, Tbili 1.8), though unchanged from prior. Prior CT A/P and \nRUQUS were unrevealing, and repeat RUQ this admission showed \ncholelithiasis without signs of obstruction or infection. \nCharacteristics of her pain were felt to be inconsistent with \ncholelithiasis. She had no evidence of ascites on imaging or \nexam. Etiology of her pain was felt to be capsular irritation in \nthe setting of liver inflammation. She will follow up in Liver \nClinic for further management. During hospitalization, the \npatient started having lower abdominal pain. Transvaginal U/S \nwas wnl. Gynecology was consulted and performed a normal pelvic \nexam and had low suspicion of gynecologic contribution to her \npain. She was discharged on a short course of oxycodone and \nTylenol for her pain and was instructed to follow up with pain \nclinic and her outpatient gynecologist for further pain \nmanagement.\n\n#EtOH Cirrhosis \nHistory of alcoholic cirrhosis (biopsy proven) c/b portal \nhypertension with splenomegaly, ascites, and varices. She had no \nsigns of decompensation, including bleeding, hepatic \nencephalopathy, or ascites and her LFTs were stable from prior. \nShe was continued on propranolol and lactulose and her home \ndiuretics were held given euvolemic exam and poor oral intake. \nDiuretics were restarted on discharge. She will need q6month HCC \nscreening. Her lactulose was stopped due to diarrhea and \ndiscomfort, she did not have any signs of encephalopathy after \nthis medication change.\n\n#Life stressors \nDescribed having several life stressors, including a family \ndeath, prior to her current presentations. Psychiatry was \nconsulted and felt that she could benefit from outpatient \ntreatment. Recommended a partial program at ___ or \none in ___. The patient plans to follow up with this \nplan as an outpatient.\n\n#Malnutrition\nPt endorses poor oral intake iso nausea and abd pain. She was \nmonitored with improvement in her intake. She was continued on \nhome multivitamins and drank Ensures while inpatient.\n\nTRANSITIONAL ISSUES:\n==================\n[ ] Repeat CBC, BMP, LFTs, coags at follow up PCP appointment in \n___ weeks \n[ ] Abdominal pain: \n [] Follow up AMS/abdominal pain for improvement in symptoms\n [] Pt recommended to f/u with outpt gynecology PRN\n [] Pt recommended to f/u with Pain Clinic\n[ ] Liver: \n [] Recommend q6month HCC screening, last ultrasound done on \n___\n [ ] From last hospitalization: \"MRI liver in 3 months to \nevaluate liver lesion seen on CT abdomen\"\n [ ] Continue to encourage abstinence from alcohol\n[ ] Anxiety, life stressors: Will need outpatient psychiatry \nfollow-up, ideally at a partial program at ___ or \nnear ___\n\n#CODE: Full (presumed)\n#CONTACT: ___ (FATHER) ___ \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Propranolol 10 mg PO BID \n2. Furosemide 40 mg PO DAILY ascites \n3. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild \n4. Bisacodyl 10 mg PO DAILY:PRN constipation \n5. Docusate Sodium 200 mg PO BID \n6. FoLIC Acid 1 mg PO DAILY \n7. HydrOXYzine 50 mg PO Q6H:PRN PRURITUS \n8. Lactulose 15 mL PO DAILY:PRN constipation \n9. Ondansetron 4 mg PO Q6H:PRN nausea \n10. Polyethylene Glycol 17 g PO BID:PRN constipation \n11. Sarna Lotion 1 Appl TP QID:PRN itching \n12. Senna 17.2 mg PO BID \n13. Ursodiol 300 mg PO TID \n14. B Complex ___ (vit B1-B2-B3-B5-B6;<br>vitamin B \ncomplex-folic acid) 0.4 mg oral DAILY \n\n \nDischarge Medications:\n1. LORazepam 0.25 mg PO Q6H:PRN anxiety \nRX *lorazepam 0.5 mg 0.5 (One half) mg by mouth twice a day Disp \n#*14 Tablet Refills:*0 \n2. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - \nModerate \nRX *oxycodone 5 mg 1 tablet(s) by mouth every eight (8) hours \nDisp #*21 Tablet Refills:*0 \n3. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild \n4. B Complex ___ (vit B1-B2-B3-B5-B6;<br>vitamin B \ncomplex-folic acid) 0.4 mg oral DAILY \n5. Bisacodyl 10 mg PO DAILY:PRN constipation \n6. Docusate Sodium 200 mg PO BID \n7. FoLIC Acid 1 mg PO DAILY \n8. Furosemide 40 mg PO DAILY ascites \n9. HydrOXYzine 50 mg PO Q6H:PRN PRURITUS \n10. Lactulose 15 mL PO DAILY:PRN constipation \n11. Ondansetron 4 mg PO Q6H:PRN nausea \n12. Polyethylene Glycol 17 g PO BID:PRN constipation \n13. Propranolol 10 mg PO BID \n14. Sarna Lotion 1 Appl TP QID:PRN itching \n15. Senna 17.2 mg PO BID \n16. Ursodiol 300 mg PO TID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\n#Primary:\nAlcoholic cirrhosis \n\n#Secondary:\nSyncope, etiology unknown\nAbdominal pain\nTransaminitis \nMalnutrition\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___, \n\nIt was a pleasure caring for you at ___ \n___!\n\nWhy you presented to the hospital:\n- You passed out while at home. Additionally, you have been \nhaving abdominal pain the last few weeks. \n\nWhat happened while you were here:\n- Imaging of your head and neck showed no signs of bleeding or \nfracture \n- You were monitored and had no further syncopal episodes \noccurred while in the hospital\n- Imaging of your belly showed gallstones without signs of \ninfection or obstruction. We did not believe that this was \ncontributing to your pain\n- Imaging of your pelvis did not show any ovarian cysts or \ngynecologic reason for your pain\n- Ultimately, your pain was attributed to inflammation in the \nliver. We did not find a cause of your lower abdominal pain.\n- Given several life stressors recently, you were seen by \npsychiatry who recommended that you participate in a partial \nprogram.\n\nWhat you should do once you return home:\n- Please continue taking your medications as prescribed \n- Please follow up with your primary care provider in the next \n___ weeks\n- We also recommended a follow-up with your gynecologist and at \nour pain clinic \n- You also have follow up in the Liver Clinic on ___ \n- Consider enrolling in a partial program at ___ \nor a partial program in ___\n\nSincerely, \nYour ___ Care Team \n \nFollowup Instructions:\n___\n"
] | Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Syncope Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] with EtOH use disorder c/b cirrhosis, portal HTN (splenomegaly), ascites requiring paracenteses in past, varices, h/o EtOH hepatitis p/w lethargy and syncope. Recently admitted here at [MASKED] for presumed EtOH hepatitis, during which she syncopized, however left AMA for [MASKED]. While at [MASKED] continued to have syncope, for which she was worked up with CXR, UA/UCx, bcx, ECG, tele, CT A/P, EEG, TTE which were all unrevealing. Since discharge 3 days ago, has been somnolent at home per sister at bedside. Also was found down/not easily aroused this AM when sister was gone for roughly 20min. Unclear what triggers episodes, not immediate LOC but no prodrome either, no seizure symptoms though she does report some brief confusion ~1min after the episodes. Of note, per pt no EtOH since before [MASKED] admission. She denies any use of drugs or opiates. ROS (+)alternating chills/sweats, RUQ pain, improved nausea/vomiting compared to previous admission, constipated, generalized weakness (-)SOB, chest pain, rash In the ED, initial VS were: 6 | 97.6 | 93 | 123/81 | 16 | 100% RA ED Exam notable for: Gen: lying in bed, weak appearing CV: RRR nl s1/s2 no mrg Lungs: CTABL no increased WOB Abd: soft, exquisitely tender at RUQ, liver edge palpable, otherwise NT/ND, +BS Extr: no pitting edema Neuro: AOx3, no asterixis ECG: nsr, rate in [MASKED], normal axis, no ST changes Labs showed: 5.4 > 11.3/32.6 < 6 146 | 108 | 25 ---------------< 126 4.4 | 25 | 0.9 Ca [MASKED] | Mg 1.9 | Phos 2.0 AST 59 | ALT 31 | AP 99 | Tbili 1.8 Trop neg x2, CK 31 Lactate 3.0 Serum ASA/EtOH/APAP/Tricyclic - neg Urine benzos/opiates POSITIVE Urine barbs, cocaine, ampheatmines, methadone, oxy - neg UA with 15 WBC, few bacteria, 1 epi, neg nitrites Imaging showed: [MASKED] CT HEAD W/O CONTRAST: No acute intracranial process. [MASKED] C-SPINE W/O CONTRAST: No cervical spine fracture or malalignment. [MASKED] LIVER ULTRASOUND: 1. Cirrhotic liver morphology with patent portal venous system with hepatopetal flow. 2. Cholelithiasis without suggestion of cholecystitis. 3. No ascites. Borderline splenomegaly, measuring 12.5 cm. [MASKED] CXR: No acute cardiopulmonary process. Patient received: - hydromorphone 0.5mg IV - NS - hydroxyzine 50mg - propranolol 10mg - ursodiol 300mg - acetaminophen IV 1000mg - hydromorphone 0.5mg IV Transfer VS were: 98.6 | 79 | 128/73 | 16 | 99% RA On arrival to the floor, patient endorses "shakiness" and some mild abdominal pain. The shakiness began at the time of her initial syncopal episode and has been ongoing since. She also has noticed R sided abdominal pain since she began collapsing. The pain is associated with nausea and occasional non-bilious, non-bloody emesis, and constipation with occasional dark red stools. No fevers, chills, URI symptoms, cough. Denies any palpitations, chest pain, or dyspnea. Past Medical History: EBV infection c/b cytopenias and transaminitis alcoholic hepatitis with cirrhosis (biopsy proven) complicated the jaundice, ascities and portal hypertension -- three small to medium sized varicies Social History: [MASKED] Family History: -Maternal Grandmother with ovarian cancer -Aunt with breast cancer -Father with colon cancer -Cousin with breast cancer diagnosed at [MASKED] (negative for BRCA, patient and sister tested negative for BRCA) -No family history of cirrhosis or autoimmune conditions -Grandfather with DM Physical Exam: ADMISSION PHYSICAL EXAM: ====================== [MASKED] 0614 Temp: 97.8 PO BP: 112/63 HR: 66 RR: 16 O2 sat: 100% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: [MASKED] GENERAL: NAD HEENT: AT/NC, icteric sclera, MMM NECK: supple, no LAD CV: RRR, S1/S2, no murmurs, gallops, or rubs PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles GI: abdomen soft, nondistended, TTP RUQ, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ radial pulses bilaterally NEURO: Alert, moving all 4 extremities with purpose, face symmetric DERM: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAM: ====================== VITALS: [MASKED] 0744 Temp: 98.9 PO BP: 103/68 R HR: 78 RR: 18 O2 sat: 98% O2 delivery: Ra GENERAL: WDWN female in NAD. HEENT: AT/NC, icteric sclera, MMM. NECK: supple CV: RRR with normal S1 and S2. No murmurs, rubs or gallops. PULM: Normal respiratory effort. CTAB without wheezes, rales or rhonchi. GI: Abdomen soft, nondistended, diffusely tender to palpation over entire abdomen. No rebound or guarding. Normoactive BS. EXTREMITIES: Warm, well perfused. No [MASKED] edema or erythema. NEURO: Alert and interactive. CN II-XII intact. [MASKED] strength and normal sensation throughout. DERM: Skin type II. Warm, dry. No rashes. PSYCH: Normal mood. Pertinent Results: ADMISSION LABS: ============== [MASKED] 06:10PM BLOOD WBC-5.4 RBC-3.37* Hgb-11.3 Hct-32.6* MCV-97 MCH-33.5* MCHC-34.7 RDW-13.9 RDWSD-49.1* Plt Ct-86* [MASKED] 06:10PM BLOOD Neuts-49.5 [MASKED] Monos-16.8* Eos-5.5 Baso-0.7 Im [MASKED] AbsNeut-2.69 AbsLymp-1.47 AbsMono-0.91* AbsEos-0.30 AbsBaso-0.04 [MASKED] 06:10PM BLOOD Glucose-126* UreaN-25* Creat-0.9 Na-146 K-4.4 Cl-108 HCO3-25 AnGap-13 [MASKED] 06:10PM BLOOD ALT-31 AST-59* LD(LDH)-208 CK(CPK)-31 AlkPhos-99 TotBili-1.8* [MASKED] 06:10PM BLOOD Calcium-10.0 Phos-2.0* Mg-1.9 [MASKED] 06:18PM BLOOD Lactate-3.0* PERTINENT LABS/MICRO: =================== [MASKED] 06:10PM BLOOD cTropnT-<0.01 [MASKED] 06:10PM BLOOD Osmolal-307 [MASKED] 09:13AM BLOOD TSH-3.8 [MASKED] 06:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG [MASKED] 06:18PM BLOOD Lactate-3.0* [MASKED] 09:24AM BLOOD Lactate-1.4 [MASKED] BCx: No growth to date [MASKED] Urine culture: No growth DISCHARGE LABS: ============== [MASKED] 05:56AM BLOOD WBC-5.1 RBC-3.32* Hgb-11.1* Hct-32.6* MCV-98 MCH-33.4* MCHC-34.0 RDW-13.8 RDWSD-48.9* Plt [MASKED] [MASKED] 05:56AM BLOOD Glucose-102* UreaN-15 Creat-0.9 Na-140 K-4.9 Cl-103 HCO3-25 AnGap-12 [MASKED] 05:56AM BLOOD ALT-24 AST-47* LD(LDH)-251* AlkPhos-81 TotBili-1.7* [MASKED] 05:56AM BLOOD Albumin-3.5 Calcium-9.8 Phos-3.4 Mg-1.9 PERTINENT IMAGING: ================ [MASKED] CT Head: No acute intracranial process. [MASKED] CT Neck w/o Contrast: No cervical spine fracture or malalignment. [MASKED] RUQ Ultrasound: 1. Cirrhotic liver morphology with patent portal venous system with hepatopetal flow. 2. Cholelithiasis without suggestion of cholecystitis. 3. No ascites. Borderline splenomegaly, measuring 12.5 cm. [MASKED] CXR: No acute cardiopulmonary process. Brief Hospital Course: Ms. [MASKED] is a [MASKED] y/o female with a history of EOTH use disorder, ETOH cirrhosis c/b spenomegaly, ascites, and varices who presented with lethargy, syncope, and abdominal pain. CT head and neck was unremarkable. The patient was monitored clinically and had no recurrent syncopal episodes. Her pain improved with medications and time. #Syncope/Altered mental status She reported having several AMS/syncopal episodes over the last two weeks. An extensive work up done at [MASKED], including CXR, UCx/BCx, ECG, tele, CT A/P, EEG, and TTE, was unrevealing. She presented this admission after being found lethargic/unresponsive at home. CT head and neck was negative. Serum drug screen was negative and urine drug screen was positive for opiates and benzos, neither of which she was on at home, though unclear if she had received them during her recent admissions. There was no serum osmolarity gap to suggest ingestion and the history was inconsistent with seizures. [MASKED] maneuver was positive, possible pointing towards BPPV though this was felt to be inconsistent with her presentation given that it does not present with syncope. Orthostatic vital signs were negative and she was monitored on telemetry without events. There was also concern for a potential psychosomatic component in the setting of recent life stressors. With time, she began to feel better and her symptoms did not recur. She was seen by physical therapy who cleared her to go home. #Abdominal Pain Presented with two weeks of RUQ abdominal pain, since a recent admission for alcoholic hepatitis. LFTS remained elevated (AST 59, Tbili 1.8), though unchanged from prior. Prior CT A/P and RUQUS were unrevealing, and repeat RUQ this admission showed cholelithiasis without signs of obstruction or infection. Characteristics of her pain were felt to be inconsistent with cholelithiasis. She had no evidence of ascites on imaging or exam. Etiology of her pain was felt to be capsular irritation in the setting of liver inflammation. She will follow up in Liver Clinic for further management. During hospitalization, the patient started having lower abdominal pain. Transvaginal U/S was wnl. Gynecology was consulted and performed a normal pelvic exam and had low suspicion of gynecologic contribution to her pain. She was discharged on a short course of oxycodone and Tylenol for her pain and was instructed to follow up with pain clinic and her outpatient gynecologist for further pain management. #EtOH Cirrhosis History of alcoholic cirrhosis (biopsy proven) c/b portal hypertension with splenomegaly, ascites, and varices. She had no signs of decompensation, including bleeding, hepatic encephalopathy, or ascites and her LFTs were stable from prior. She was continued on propranolol and lactulose and her home diuretics were held given euvolemic exam and poor oral intake. Diuretics were restarted on discharge. She will need q6month HCC screening. Her lactulose was stopped due to diarrhea and discomfort, she did not have any signs of encephalopathy after this medication change. #Life stressors Described having several life stressors, including a family death, prior to her current presentations. Psychiatry was consulted and felt that she could benefit from outpatient treatment. Recommended a partial program at [MASKED] or one in [MASKED]. The patient plans to follow up with this plan as an outpatient. #Malnutrition Pt endorses poor oral intake iso nausea and abd pain. She was monitored with improvement in her intake. She was continued on home multivitamins and drank Ensures while inpatient. TRANSITIONAL ISSUES: ================== [ ] Repeat CBC, BMP, LFTs, coags at follow up PCP appointment in [MASKED] weeks [ ] Abdominal pain: [] Follow up AMS/abdominal pain for improvement in symptoms [] Pt recommended to f/u with outpt gynecology PRN [] Pt recommended to f/u with Pain Clinic [ ] Liver: [] Recommend q6month HCC screening, last ultrasound done on [MASKED] [ ] From last hospitalization: "MRI liver in 3 months to evaluate liver lesion seen on CT abdomen" [ ] Continue to encourage abstinence from alcohol [ ] Anxiety, life stressors: Will need outpatient psychiatry follow-up, ideally at a partial program at [MASKED] or near [MASKED] #CODE: Full (presumed) #CONTACT: [MASKED] (FATHER) [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Propranolol 10 mg PO BID 2. Furosemide 40 mg PO DAILY ascites 3. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild 4. Bisacodyl 10 mg PO DAILY:PRN constipation 5. Docusate Sodium 200 mg PO BID 6. FoLIC Acid 1 mg PO DAILY 7. HydrOXYzine 50 mg PO Q6H:PRN PRURITUS 8. Lactulose 15 mL PO DAILY:PRN constipation 9. Ondansetron 4 mg PO Q6H:PRN nausea 10. Polyethylene Glycol 17 g PO BID:PRN constipation 11. Sarna Lotion 1 Appl TP QID:PRN itching 12. Senna 17.2 mg PO BID 13. Ursodiol 300 mg PO TID 14. B Complex [MASKED] (vit B1-B2-B3-B5-B6;<br>vitamin B complex-folic acid) 0.4 mg oral DAILY Discharge Medications: 1. LORazepam 0.25 mg PO Q6H:PRN anxiety RX *lorazepam 0.5 mg 0.5 (One half) mg by mouth twice a day Disp #*14 Tablet Refills:*0 2. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate RX *oxycodone 5 mg 1 tablet(s) by mouth every eight (8) hours Disp #*21 Tablet Refills:*0 3. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild 4. B Complex [MASKED] (vit B1-B2-B3-B5-B6;<br>vitamin B complex-folic acid) 0.4 mg oral DAILY 5. Bisacodyl 10 mg PO DAILY:PRN constipation 6. Docusate Sodium 200 mg PO BID 7. FoLIC Acid 1 mg PO DAILY 8. Furosemide 40 mg PO DAILY ascites 9. HydrOXYzine 50 mg PO Q6H:PRN PRURITUS 10. Lactulose 15 mL PO DAILY:PRN constipation 11. Ondansetron 4 mg PO Q6H:PRN nausea 12. Polyethylene Glycol 17 g PO BID:PRN constipation 13. Propranolol 10 mg PO BID 14. Sarna Lotion 1 Appl TP QID:PRN itching 15. Senna 17.2 mg PO BID 16. Ursodiol 300 mg PO TID Discharge Disposition: Home Discharge Diagnosis: #Primary: Alcoholic cirrhosis #Secondary: Syncope, etiology unknown Abdominal pain Transaminitis Malnutrition Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], It was a pleasure caring for you at [MASKED] [MASKED]! Why you presented to the hospital: - You passed out while at home. Additionally, you have been having abdominal pain the last few weeks. What happened while you were here: - Imaging of your head and neck showed no signs of bleeding or fracture - You were monitored and had no further syncopal episodes occurred while in the hospital - Imaging of your belly showed gallstones without signs of infection or obstruction. We did not believe that this was contributing to your pain - Imaging of your pelvis did not show any ovarian cysts or gynecologic reason for your pain - Ultimately, your pain was attributed to inflammation in the liver. We did not find a cause of your lower abdominal pain. - Given several life stressors recently, you were seen by psychiatry who recommended that you participate in a partial program. What you should do once you return home: - Please continue taking your medications as prescribed - Please follow up with your primary care provider in the next [MASKED] weeks - We also recommended a follow-up with your gynecologist and at our pain clinic - You also have follow up in the Liver Clinic on [MASKED] - Consider enrolling in a partial program at [MASKED] or a partial program in [MASKED] Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED] | [
"K7010",
"K766",
"E872",
"E46",
"K7030",
"R55",
"D6959",
"K8020",
"R1011",
"Z6821",
"R197",
"L299",
"F419"
] | [
"K7010: Alcoholic hepatitis without ascites",
"K766: Portal hypertension",
"E872: Acidosis",
"E46: Unspecified protein-calorie malnutrition",
"K7030: Alcoholic cirrhosis of liver without ascites",
"R55: Syncope and collapse",
"D6959: Other secondary thrombocytopenia",
"K8020: Calculus of gallbladder without cholecystitis without obstruction",
"R1011: Right upper quadrant pain",
"Z6821: Body mass index [BMI] 21.0-21.9, adult",
"R197: Diarrhea, unspecified",
"L299: Pruritus, unspecified",
"F419: Anxiety disorder, unspecified"
] | [
"E872",
"F419"
] | [] |
12,227,693 | 25,565,517 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: ORTHOPAEDICS\n \nAllergies: \nMorphine / Tizanidine / Zofran / Gabapentin / Soma / \nOpioids-Morphine & Related / Demerol / Neurontin / Lyrica / \nIndocin / tramadol\n \nAttending: ___.\n \nChief Complaint:\nback pain\n \nMajor Surgical or Invasive Procedure:\n___ right L2-4 XLIF\n\n \nHistory of Present Illness:\nPatient returns to the office for follow-up. Since her\nlast visit, she had a cervical MRI to evaluate and cervical\nstenosis. Shehas a history of C4-7 ACDF. She continues to have\nsevere lower back pain. She has known adjacent level disc\ndegneration at L2/3, L3/4. This pain is limiting her actvities \nof\ndaily living. She has been taking percocet for pain. She hs\noccasional radiculopathy down her thighs. \n\n \nPast Medical History:\nPMHx: \nneck/arm pain ___ bulging disk and bone spurs s/p neck surgery\nback and leg pain s/p 3 lower back surgeries\nstress urinary incontinence s/p TVT ___\ninsomnia\nblepharospasm -- occ botox injections\nheartburn -- occ after a night shift\nthyroid cysts s/p yearly biopsies by Dr. ___ -- all have been \nbenign\n\nPSHx: \nsurgical plate in neck ___\n3 lower back surgeries -- laminectomy ___, then two stage \nanterior and posterior deccompression and fusion ___\nHistory of C-section (via vertical incision) \nInguinal hernia repair \nTension free vaginal tape (TVT) ___\nL tubal surgery for torsion (via vertical C-section incision) \nUterine cyst removal ___ ago\nRotator cuff surgery \nDupuytren's contracture release\nBreast augmentation\nTonsillectomy\nWisdom teeth removal\n\n \nSocial History:\n___\nFamily History:\nFHx: \nFather died of esophageal cancer at age ___\nSister with ___ esophagus\nNo other cancers\n\n \nPhysical Exam:\nGeneral: NAD. AAO x3. Lying awake in bed. \nSkin: warm, dry, no rash\nCV: RRR, s1 and S2 nl\nPulm: normal effort, lungs are clear\nAbd: soft, NT/ND, + BS\nWound: C/D/I. No swelling, redness, or warmth\nExtremities: calves are soft, no edema\nNeurologic: PERRL. Face symmetrical. Speech clear and fluent.\nTongue ML. EOMs intact. Negative pronator drift. Normal tone and\nbulk universally. \n \nMotor Strength:\n Delt Bi Tri BR WF/WE HI\nRight 5 5 5 5 5 5 \nLeft 5 5 5 5 5 5\n \n\n IP Quad Ham TA Gas ___\nRight 3 3 5 5 5 5 \nLeft 5 5 5 5 5 5\n\n \nBrief Hospital Course:\nPatient was admitted to Orthopedic Spine Service on ___ and \nunderwent the above stated procedure. Please review dictated \noperative report for details. Patient was extubated without \nincident and was transferred to PACU then floor in stable \ncondition. \n\n \n\nDuring the patient's course ___ were used for \npostoperative DVT prophylaxis. Intravenous antibiotics were \ncontinued for 24hrs postop per standard protocol. Initial postop \npain was controlled with oral and IV pain medication. Diet was \nadvanced as tolerated. Hospital course was otherwise \nunremarkable.\n\n \n\nNow, Day of Discharge, patient is afebrile, VSS, and neuro \nintact with improvement of radiculopathy. Patient tolerated a \ngood oral diet and pain was controlled on oral pain medications. \nPatient ambulated independently. Patient's wound is clean, dry \nand intact. Patient noted improvement in radicular pain. Patient \nis set for discharge to home on ___ in stable condition.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild \n2. LORazepam 0.5 mg PO QHS:PRN insomnia \n3. Metoprolol Succinate XL 25 mg PO QAM \n4. Metoprolol Succinate XL 12.5 mg PO QPM \n5. ivabradine 2.5 mg oral BID \n6. Rivaroxaban 10 mg PO DAILY \n7. Tamoxifen Citrate 20 mg PO DAILY \n8. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain - \nModerate \n\n \nDischarge Medications:\n1. Cyclobenzaprine 5 mg PO TID:PRN spasms \nRX *cyclobenzaprine 5 mg 1 tablet(s) by mouth three times a day \nDisp #*40 Tablet Refills:*0 \n2. Docusate Sodium 100 mg PO BID \n3. Senna 8.6 mg PO BID \n4. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild \n5. ivabradine 2.5 mg oral BID \n6. LORazepam 0.5 mg PO QHS:PRN insomnia \n7. Metoprolol Succinate XL 25 mg PO QAM \n8. Metoprolol Succinate XL 12.5 mg PO QPM \n9. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain - \nModerate \nRX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth \nQ4-6h Disp #*80 Tablet Refills:*0 \n10. Rivaroxaban 10 mg PO DAILY \n11. Tamoxifen Citrate 20 mg PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nlumbar disc degeneration\nchronic opioid use\nlumbar spondylosis\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nLumbar Decompression With Fusion:\n\nYou have undergone the following operation: Lumbar Decompression \nWith Fusion\n\n \n\n \n\nFollow-up Appointments \nAfter you are discharged from the hospital and settled at home \nor rehab, please make sure you have two appointments: \n1.2 week post-operative wound check visit after surgery\n2.a post-operative visit with your surgeon for ___ weeks after \nsurgery. \nYou can reach the office at ___ and ask to speak \nwith your surgeons surgical coordinator/staff to schedule or \nconfirm your appointments\n\nWound Care\nIf not already done in the hospital, remove the incision \ndressing on day 2 after surgery. \nYou may shower day 3 after surgery. Starting on this ___ day, \nyou should gently cleanse the incision and surrounding area \ndaily with mild soap and water, patting it dry when you are \nfinished. \nSome swelling and bruising around the incision is normal. Your \nmuscles have been cut, separated and sewn back together as part \nof your surgical procedure. You will leave the hospital with \nback discomfort from the surgical incision. As you become more \nactive and the incision and muscles continue to heal, the \nswelling and pain will decrease.\nHave someone look at the incision daily for 2 weeks. Call the \nsurgeons office if you notice any of the following: \n___ redness along the length of the incision \n___ swelling of the area around your incision \n___ from the incision \n___ of your extremities greater than before surgery \n \n___ of bowel or bladder control \n \n___ of severe headache \n___ swelling or calf tenderness \n \n \n___ above 101.5 \n\nDo not soak or immerse your incision in water for 1 month. For \nexample, no tub baths, swimming pools or jacuzzi.\n\n \n\nActivity Guidelines \nYou MAY be given a RIGID BRACE that you will wear whenever \nsitting up, standing, or walking. You will wear it for ___ \nweeks after surgery. See the last page of these instructions for \ndetails on wearing the brace.\nAvoid strenuous activity, bending, pushing or holding your \nbreath. For example, do not vacuum, wash the car, do large \nloads of laundry, or walk the dog until your follow-up visit \nwith your surgeon.\nAvoid heavy lifting. Do not lift anything over ___ pounds for \nthe first few weeks that you are home from the hospital. \nIncrease your activities a little each day. Walking is good \nexercise. Plan rest periods and try to avoid hills if possible. \n Remember, exercise should not increase your back pain or cause \nleg pain. \nReaching: When you have to reach things on or near the floor, \nalways squat (bending the knees), rather than bending over at \nthe waist.\nLying down: when lying on your back, you may find that a pillow \nunder the knees is more comfortable. When on your side, a \npillow between the knees will help keep your back straight. \nSitting: should be limited to 40-60 minutes at a time for the \nfirst week. Slowly increase the amount of sitting time, \nremembering that it should not increase your back pain.\nStairs: use stairs only once or twice a day for the first week, \nor as directed by the surgeon. Climb steps one at a time, \nplacing both feet on the step before moving to the next one.\nDriving: you should not drive for ___ weeks after surgery. You \nshould discuss driving with your surgeon /nurse practitioner \n/physician ___. You may ride in a car for short distances. \n When in the car, avoid sitting in one position for too long. \nIf you must take long car rides, do not ride for more than 60 \nminutes without taking a break to stretch (walk for several \nminutes and change position.).\nSexual activity: you may resume sexual activity ___ weeks after \nsurgery (avoiding pain or stress on the back).\nReduction in symptoms: patients who have experienced back and \nradiating leg pain for a short window of time before surgery \nshould anticipate a significant decrease in pre-operative \nsymptoms. If the pain has been present for a longer period \n(months to years), the pre-operative symptoms will recover on a \nmore gradual basis week by week. It is not practical to expect \nimmediate relief of symptoms. Routinely, pain will gradually \nimprove on a weekly basis, weakness on a monthly basis, and \nnumbness in a range of 6 months to ___ year. \n\nPhysical Therapy\nOutpatient Physical Therapy (if appropriate) will not begin \nuntil after your post-operative visit with your surgeon. A \nprescription is needed for formal outpatient therapy. \nYou may be given simple stretching exercises or a prescription \nfor formal outpatient physical therapy, based on what your needs \nare after surgery. \n\nMedications\nYou will be given prescriptions for pain medications and stool \nsofteners upon discharge from the hospital.\nPain medications should be taken as prescribed by your surgeon \nor nurse practitioner/ physician ___. You are allowed to \ngradually reduce the number of pills you take when the pain \nbegins to subside. \nIf you are taking more than the recommended dose, please \ncontact the office to discuss this with a practitioner ___ \nmedication may need to be increased or changed).\nConstipation: Pain medications (narcotics) may cause \nconstipation. It is important to be aware of your bowel habits \nso you ___ develop severe constipation that cannot be treated \nwith simple, over the counter laxatives.\n\nMost prescription pain medications cannot be called into the \npharmacy for renewal. The following are 2 options you may \nexplore to obtain a renewal of your narcotic medications:\n1.Call the office ___ days before your prescription runs out and \nspeak with office staff about mailing a prescription to your \nhome/pharmacy. (Prescriptions will not be sent by Fed Ex/UPS) \n2.Call the office 24 hours in advance and speak with our office \nstaff about coming into the office to pick up a prescription.\nIf you continue to require medications, you may be referred to \na pain management specialist or your medical doctor for ongoing \nmanagement of your pain medications \nAvoid NSAIDS for ___ weeks post-operative. These medications \ninclude, but are not limited to the following:\n1.Non-steroidal Anti-inflammatory drugs: Advil, Aleve, Cataflam, \nClinoril, Diclofenac, Dolobid, Feldene, Ibuprofen, Indocin, \nMedipren, Motrin, Nalfon, Naprosyn, Nuprin, Relafen, Rufen, \nTolectin, Toradol, Trilisate, Voltarin\n\n \n\nBlood Clots in the Leg \n1.It is not uncommon for patients who recently had surgery to \ndevelop blood clots in leg veins. \nSymptoms include low-grade fever, and/or redness, swelling, \ntenderness, and/or an \naching/cramping pain in your calf. \nYou should call your doctor immediately if you have these \nsymptoms. \nTo prevent blood clots in legs, try walking and/ or pumping \nankles several times during the day. \nIf the blood clot breaks free from the leg vein, it can travel \nto the lungs and cause severe breathing difficulty and/or chest \npain. If you experience this, call ___ immediately.\n\nQuestions\nAny questions may be directed to your surgeon or physician \n___. \n1.During normal business hours (8:30am- 5:00pm), you can call \nthe office directly at ___. Turn around time for a \nphone call is 24 hours. After normal business hours, you can \ncall the on-call service and we will get back to you the next \nbusiness day.\nIf you are calling with an urgent medical issue, please tell \nthe coordinator that it is an urgent issue and needs to be \ndiscussed in less than 24 hours (i.e. pain unrelieved with \nmedications, wound breakdown/infection, or new neurological \nsymptoms).\n\n \n\nLumbar Corset or (TLSO) Brace Guidelines\n\nYou MAY have been given a rigid brace that you will wear for \n___ weeks after surgery. \nYou should put on your brace as you have been instructed by the \northotist (brace maker). Instructions will be reviewed in the \nhospital by the nursing staff and Physical Therapist. \nIt is a good idea to start practicing with your brace before \nsurgery (putting it on/taking it off, sitting, standing, \nwalking, and climbing steps with the brace) so you can assist \nwith your post-operative care in the hospital.\nKeep the name and phone number of the person who fitted and \ndispensed your brace close by in case you need to have the brace \nchecked and/or adjusted. \nYou should always have a barrier between your surgical incision \nand the brace. For example, you may want to put on a light \nt-shirt and then the brace before getting dressed for the day. \nDuring periods of rest, take off the brace and expose the \nincision to the air by lying on your side for a few hours. This \nwill reduce the chance of your wound breaking down. \n1.The brace must be worn at all times with the following 3 \nexceptions: 1.Lying flat in bed during a rest period or at \nnight to sleep.\n2.Getting out of bed at night to go to the bathroom, returning \nto bed immediately when you are finished.\n3.Showering. You may wish to use a shower chair to help prevent \nbending/twisting while bathing. You should have someone help \nwash your back and legs.\n\n \nFollowup Instructions:\n___\n"
] | Allergies: Morphine / Tizanidine / Zofran / Gabapentin / Soma / Opioids-Morphine & Related / Demerol / Neurontin / Lyrica / Indocin / tramadol Chief Complaint: back pain Major Surgical or Invasive Procedure: [MASKED] right L2-4 XLIF History of Present Illness: Patient returns to the office for follow-up. Since her last visit, she had a cervical MRI to evaluate and cervical stenosis. Shehas a history of C4-7 ACDF. She continues to have severe lower back pain. She has known adjacent level disc degneration at L2/3, L3/4. This pain is limiting her actvities of daily living. She has been taking percocet for pain. She hs occasional radiculopathy down her thighs. Past Medical History: PMHx: neck/arm pain [MASKED] bulging disk and bone spurs s/p neck surgery back and leg pain s/p 3 lower back surgeries stress urinary incontinence s/p TVT [MASKED] insomnia blepharospasm -- occ botox injections heartburn -- occ after a night shift thyroid cysts s/p yearly biopsies by Dr. [MASKED] -- all have been benign PSHx: surgical plate in neck [MASKED] 3 lower back surgeries -- laminectomy [MASKED], then two stage anterior and posterior deccompression and fusion [MASKED] History of C-section (via vertical incision) Inguinal hernia repair Tension free vaginal tape (TVT) [MASKED] L tubal surgery for torsion (via vertical C-section incision) Uterine cyst removal [MASKED] ago Rotator cuff surgery Dupuytren's contracture release Breast augmentation Tonsillectomy Wisdom teeth removal Social History: [MASKED] Family History: FHx: Father died of esophageal cancer at age [MASKED] Sister with [MASKED] esophagus No other cancers Physical Exam: General: NAD. AAO x3. Lying awake in bed. Skin: warm, dry, no rash CV: RRR, s1 and S2 nl Pulm: normal effort, lungs are clear Abd: soft, NT/ND, + BS Wound: C/D/I. No swelling, redness, or warmth Extremities: calves are soft, no edema Neurologic: PERRL. Face symmetrical. Speech clear and fluent. Tongue ML. EOMs intact. Negative pronator drift. Normal tone and bulk universally. Motor Strength: Delt Bi Tri BR WF/WE HI Right 5 5 5 5 5 5 Left 5 5 5 5 5 5 IP Quad Ham TA Gas [MASKED] Right 3 3 5 5 5 5 Left 5 5 5 5 5 5 Brief Hospital Course: Patient was admitted to Orthopedic Spine Service on [MASKED] and underwent the above stated procedure. Please review dictated operative report for details. Patient was extubated without incident and was transferred to PACU then floor in stable condition. During the patient's course [MASKED] were used for postoperative DVT prophylaxis. Intravenous antibiotics were continued for 24hrs postop per standard protocol. Initial postop pain was controlled with oral and IV pain medication. Diet was advanced as tolerated. Hospital course was otherwise unremarkable. Now, Day of Discharge, patient is afebrile, VSS, and neuro intact with improvement of radiculopathy. Patient tolerated a good oral diet and pain was controlled on oral pain medications. Patient ambulated independently. Patient's wound is clean, dry and intact. Patient noted improvement in radicular pain. Patient is set for discharge to home on [MASKED] in stable condition. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild 2. LORazepam 0.5 mg PO QHS:PRN insomnia 3. Metoprolol Succinate XL 25 mg PO QAM 4. Metoprolol Succinate XL 12.5 mg PO QPM 5. ivabradine 2.5 mg oral BID 6. Rivaroxaban 10 mg PO DAILY 7. Tamoxifen Citrate 20 mg PO DAILY 8. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain - Moderate Discharge Medications: 1. Cyclobenzaprine 5 mg PO TID:PRN spasms RX *cyclobenzaprine 5 mg 1 tablet(s) by mouth three times a day Disp #*40 Tablet Refills:*0 2. Docusate Sodium 100 mg PO BID 3. Senna 8.6 mg PO BID 4. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild 5. ivabradine 2.5 mg oral BID 6. LORazepam 0.5 mg PO QHS:PRN insomnia 7. Metoprolol Succinate XL 25 mg PO QAM 8. Metoprolol Succinate XL 12.5 mg PO QPM 9. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain - Moderate RX *oxycodone-acetaminophen 5 mg-325 mg [MASKED] tablet(s) by mouth Q4-6h Disp #*80 Tablet Refills:*0 10. Rivaroxaban 10 mg PO DAILY 11. Tamoxifen Citrate 20 mg PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: lumbar disc degeneration chronic opioid use lumbar spondylosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Lumbar Decompression With Fusion: You have undergone the following operation: Lumbar Decompression With Fusion Follow-up Appointments After you are discharged from the hospital and settled at home or rehab, please make sure you have two appointments: 1.2 week post-operative wound check visit after surgery 2.a post-operative visit with your surgeon for [MASKED] weeks after surgery. You can reach the office at [MASKED] and ask to speak with your surgeons surgical coordinator/staff to schedule or confirm your appointments Wound Care If not already done in the hospital, remove the incision dressing on day 2 after surgery. You may shower day 3 after surgery. Starting on this [MASKED] day, you should gently cleanse the incision and surrounding area daily with mild soap and water, patting it dry when you are finished. Some swelling and bruising around the incision is normal. Your muscles have been cut, separated and sewn back together as part of your surgical procedure. You will leave the hospital with back discomfort from the surgical incision. As you become more active and the incision and muscles continue to heal, the swelling and pain will decrease. Have someone look at the incision daily for 2 weeks. Call the surgeons office if you notice any of the following: [MASKED] redness along the length of the incision [MASKED] swelling of the area around your incision [MASKED] from the incision [MASKED] of your extremities greater than before surgery [MASKED] of bowel or bladder control [MASKED] of severe headache [MASKED] swelling or calf tenderness [MASKED] above 101.5 Do not soak or immerse your incision in water for 1 month. For example, no tub baths, swimming pools or jacuzzi. Activity Guidelines You MAY be given a RIGID BRACE that you will wear whenever sitting up, standing, or walking. You will wear it for [MASKED] weeks after surgery. See the last page of these instructions for details on wearing the brace. Avoid strenuous activity, bending, pushing or holding your breath. For example, do not vacuum, wash the car, do large loads of laundry, or walk the dog until your follow-up visit with your surgeon. Avoid heavy lifting. Do not lift anything over [MASKED] pounds for the first few weeks that you are home from the hospital. Increase your activities a little each day. Walking is good exercise. Plan rest periods and try to avoid hills if possible. Remember, exercise should not increase your back pain or cause leg pain. Reaching: When you have to reach things on or near the floor, always squat (bending the knees), rather than bending over at the waist. Lying down: when lying on your back, you may find that a pillow under the knees is more comfortable. When on your side, a pillow between the knees will help keep your back straight. Sitting: should be limited to 40-60 minutes at a time for the first week. Slowly increase the amount of sitting time, remembering that it should not increase your back pain. Stairs: use stairs only once or twice a day for the first week, or as directed by the surgeon. Climb steps one at a time, placing both feet on the step before moving to the next one. Driving: you should not drive for [MASKED] weeks after surgery. You should discuss driving with your surgeon /nurse practitioner /physician [MASKED]. You may ride in a car for short distances. When in the car, avoid sitting in one position for too long. If you must take long car rides, do not ride for more than 60 minutes without taking a break to stretch (walk for several minutes and change position.). Sexual activity: you may resume sexual activity [MASKED] weeks after surgery (avoiding pain or stress on the back). Reduction in symptoms: patients who have experienced back and radiating leg pain for a short window of time before surgery should anticipate a significant decrease in pre-operative symptoms. If the pain has been present for a longer period (months to years), the pre-operative symptoms will recover on a more gradual basis week by week. It is not practical to expect immediate relief of symptoms. Routinely, pain will gradually improve on a weekly basis, weakness on a monthly basis, and numbness in a range of 6 months to [MASKED] year. Physical Therapy Outpatient Physical Therapy (if appropriate) will not begin until after your post-operative visit with your surgeon. A prescription is needed for formal outpatient therapy. You may be given simple stretching exercises or a prescription for formal outpatient physical therapy, based on what your needs are after surgery. Medications You will be given prescriptions for pain medications and stool softeners upon discharge from the hospital. Pain medications should be taken as prescribed by your surgeon or nurse practitioner/ physician [MASKED]. You are allowed to gradually reduce the number of pills you take when the pain begins to subside. If you are taking more than the recommended dose, please contact the office to discuss this with a practitioner [MASKED] medication may need to be increased or changed). Constipation: Pain medications (narcotics) may cause constipation. It is important to be aware of your bowel habits so you [MASKED] develop severe constipation that cannot be treated with simple, over the counter laxatives. Most prescription pain medications cannot be called into the pharmacy for renewal. The following are 2 options you may explore to obtain a renewal of your narcotic medications: 1.Call the office [MASKED] days before your prescription runs out and speak with office staff about mailing a prescription to your home/pharmacy. (Prescriptions will not be sent by Fed Ex/UPS) 2.Call the office 24 hours in advance and speak with our office staff about coming into the office to pick up a prescription. If you continue to require medications, you may be referred to a pain management specialist or your medical doctor for ongoing management of your pain medications Avoid NSAIDS for [MASKED] weeks post-operative. These medications include, but are not limited to the following: 1.Non-steroidal Anti-inflammatory drugs: Advil, Aleve, Cataflam, Clinoril, Diclofenac, Dolobid, Feldene, Ibuprofen, Indocin, Medipren, Motrin, Nalfon, Naprosyn, Nuprin, Relafen, Rufen, Tolectin, Toradol, Trilisate, Voltarin Blood Clots in the Leg 1.It is not uncommon for patients who recently had surgery to develop blood clots in leg veins. Symptoms include low-grade fever, and/or redness, swelling, tenderness, and/or an aching/cramping pain in your calf. You should call your doctor immediately if you have these symptoms. To prevent blood clots in legs, try walking and/ or pumping ankles several times during the day. If the blood clot breaks free from the leg vein, it can travel to the lungs and cause severe breathing difficulty and/or chest pain. If you experience this, call [MASKED] immediately. Questions Any questions may be directed to your surgeon or physician [MASKED]. 1.During normal business hours (8:30am- 5:00pm), you can call the office directly at [MASKED]. Turn around time for a phone call is 24 hours. After normal business hours, you can call the on-call service and we will get back to you the next business day. If you are calling with an urgent medical issue, please tell the coordinator that it is an urgent issue and needs to be discussed in less than 24 hours (i.e. pain unrelieved with medications, wound breakdown/infection, or new neurological symptoms). Lumbar Corset or (TLSO) Brace Guidelines You MAY have been given a rigid brace that you will wear for [MASKED] weeks after surgery. You should put on your brace as you have been instructed by the orthotist (brace maker). Instructions will be reviewed in the hospital by the nursing staff and Physical Therapist. It is a good idea to start practicing with your brace before surgery (putting it on/taking it off, sitting, standing, walking, and climbing steps with the brace) so you can assist with your post-operative care in the hospital. Keep the name and phone number of the person who fitted and dispensed your brace close by in case you need to have the brace checked and/or adjusted. You should always have a barrier between your surgical incision and the brace. For example, you may want to put on a light t-shirt and then the brace before getting dressed for the day. During periods of rest, take off the brace and expose the incision to the air by lying on your side for a few hours. This will reduce the chance of your wound breaking down. 1.The brace must be worn at all times with the following 3 exceptions: 1.Lying flat in bed during a rest period or at night to sleep. 2.Getting out of bed at night to go to the bathroom, returning to bed immediately when you are finished. 3.Showering. You may wish to use a shower chair to help prevent bending/twisting while bathing. You should have someone help wash your back and legs. Followup Instructions: [MASKED] | [
"M47896",
"M5136"
] | [
"M47896: Other spondylosis, lumbar region",
"M5136: Other intervertebral disc degeneration, lumbar region"
] | [] | [] |
19,147,061 | 28,846,217 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: ORTHOPAEDICS\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nRight shoulder pain\n \nMajor Surgical or Invasive Procedure:\nRight reverse total shoulder arthroplasty\n\n \nHistory of Present Illness:\n___ is an ___, right- hand-dominant \ngentleman who was referred to my attention for a right shoulder \ninjury that occurred at work on ___. At that time, he was \nworking at a ___ station when he was lifting trash out of the \ntrash barrel, had a sudden onset of pain. He was seen by Dr. \n___ and referred to my attention. He had an MRI that \nconfirmed a ruptured long head of the biceps and a ruptured \nrotator cuff. He and I discussed conservative versus surgical \ntreatment. He tried conservative modalities for awhile, but \nunfortunately had residual dysfunction in his right arm, \nweakness when working away from his body, weakness when working \noverhead. He and discussed the difference between an \narthroscopic rotator cuff repair and a reverse total shoulder \narthroplasty. Understanding the risks and benefits, it was his \npreference to proceed with a right reverse total shoulder \narthroplasty.\n \nPast Medical History:\nSeropositive erosive RA dx ___ \nOsteoarthritis \nVitamin D deficiency \nBPH s/p TURP ___ \n \nSocial History:\n___\nFamily History:\nFather: arthritis\nMother: healthy\n \nPhysical Exam:\nAfebrile\nVitals stable\nRight shoulder dressing clean and dry.\nHe is intact distally with + APB/EPL/ADQ\nThe fingers are warm to touch with good capillary refill\n \nBrief Hospital Course:\nThe patient was admitted to the Orthopaedic Sports Medicine \nService for advanced right rotator cuff arthropathy. The \npatient was taken to the OR and underwent a right reverse total \nshoulder arthroplasty on ___ . Please see operative report \nfor full details. The patient tolerated the procedure without \ndifficulty and was transferred to the PACU in stable condition, \nand then transferred to the floor in the usual fashion. \nPostoperatively, pain was controlled with an interscalene nerve \nblock, with transition to oral pain medication as tolerated. \nPerioperative antibiotics and Aspirin for DVT prophylaxis were \ngiven as per routine. Diet was advanced without complication and \nthe patient made steady progress. The hospitalization has \notherwise been uneventful and the patient has done well.\n \nAt discharge, vital signs are stable, the patient is afebrile, \ntolerating a regular diet, voiding spontaneously every shift and \npain is well controlled. The extremities are neurovascularly \nintact distally throughout the right upper extremity. All \nincisions are clean, dry and intact without evidence of \ninfection, hematoma or seroma.\n \nThe patient is discharged home in stable condition. Patient \ngiven detailed precautionary instructions and instructions for \nthe appropriate follow up care.\n \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Moderate \n2. metHOTREXate sodium 20 mg oral 1X/WEEK \n3. TraMADol 50 mg PO Q8H:PRN Pain - Moderate \n4. Ibuprofen 600 mg PO BID:PRN Pain - Moderate \n5. Omeprazole 20 mg PO DAILY \n\n \nDischarge Medications:\n1. Aspirin EC 325 mg PO DAILY \n2. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain \n3. Acetaminophen 1000 mg PO Q8H:PRN Pain - Moderate \n4. Omeprazole 20 mg PO DAILY \n5. HELD- Ibuprofen 600 mg PO BID:PRN Pain - Moderate This \nmedication was held. Do not restart Ibuprofen until 6 weeks \nafter surgery\n6. HELD- metHOTREXate sodium 20 mg oral 1X/WEEK This medication \nwas held. Do not restart metHOTREXate sodium until your first \npost-operative office visit in two weeks\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nRight rotator cuff arthropathy\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nReverse Total Shoulder Arthroplasty\n Post-Operative Instructions\n(with/without Biceps Tenodesis)\n\nMedications\nYou will be given a prescription for pain medicine. The pain \nmedication is a codeine derivative and should be taken as \ndirected. \n\nPlease take one full strength aspirin (325 mg) each day for six \nweeks to decrease the risk of having a complication related to a \nblood clot.\n\nPlease take a stool softener, like Colace (Docusate Sodium \n100mg), twice a day while taking narcotics to prevent \nconstipation.\n\nDressing\nLeave your dressing on for 48 hours after your surgery. After \n48 hours, you may remove your dressing. LEAVE THE TAPE STRIPS \nOVER YOUR INCISIONS. These will stay on for 1.5 to 2 weeks and \nwill peel off slowly.\n\nShowering\nYou may shower 72 hours after your surgery and get your \nincisions wet. Do NOT immerse in a tub or pool for 7 10 days \nto avoid excessive scarring and risk of infection.\n\nWhen you shower, let your arm hang at your side. Do NOT raise or \nlift your arm. \n\nTo wash under your arm, lean forward carefully and let your arm \nhang. Using your other hand, wash under your operative arm. Do \nNOT scrub the incision. \n\nWhen you are done washing, stand up and let your arm hang at \nyour side. \n\nPat yourself dry and put your sling on.\n\nIce Packs\nKeep Ice Packs on at all times exchanging every hour while \nawake. Icing is very important to decrease swelling and pain \nand improve mobility. After 24 hours, continue to use the cuff \n3 4 times a day, 15 20 minutes each time to keep swelling to \na minimum.\n\nActivity\nTake it easy.\nWear your sling for comfort and safety. \nKeep your arm at your side at ALL TIMES no reaching, \ngrabbing or pulling with your operative arm.\n\nWhen to Contact Us\nIf you experience severe pain that your pain medication does not \nhelp, please let us know.\n\nIf you have a temperature over 101.5º, please contact our office \nat ___.\n\n \nFollowup Instructions:\n___\n"
] | Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Right shoulder pain Major Surgical or Invasive Procedure: Right reverse total shoulder arthroplasty History of Present Illness: [MASKED] is an [MASKED], right- hand-dominant gentleman who was referred to my attention for a right shoulder injury that occurred at work on [MASKED]. At that time, he was working at a [MASKED] station when he was lifting trash out of the trash barrel, had a sudden onset of pain. He was seen by Dr. [MASKED] and referred to my attention. He had an MRI that confirmed a ruptured long head of the biceps and a ruptured rotator cuff. He and I discussed conservative versus surgical treatment. He tried conservative modalities for awhile, but unfortunately had residual dysfunction in his right arm, weakness when working away from his body, weakness when working overhead. He and discussed the difference between an arthroscopic rotator cuff repair and a reverse total shoulder arthroplasty. Understanding the risks and benefits, it was his preference to proceed with a right reverse total shoulder arthroplasty. Past Medical History: Seropositive erosive RA dx [MASKED] Osteoarthritis Vitamin D deficiency BPH s/p TURP [MASKED] Social History: [MASKED] Family History: Father: arthritis Mother: healthy Physical Exam: Afebrile Vitals stable Right shoulder dressing clean and dry. He is intact distally with + APB/EPL/ADQ The fingers are warm to touch with good capillary refill Brief Hospital Course: The patient was admitted to the Orthopaedic Sports Medicine Service for advanced right rotator cuff arthropathy. The patient was taken to the OR and underwent a right reverse total shoulder arthroplasty on [MASKED] . Please see operative report for full details. The patient tolerated the procedure without difficulty and was transferred to the PACU in stable condition, and then transferred to the floor in the usual fashion. Postoperatively, pain was controlled with an interscalene nerve block, with transition to oral pain medication as tolerated. Perioperative antibiotics and Aspirin for DVT prophylaxis were given as per routine. Diet was advanced without complication and the patient made steady progress. The hospitalization has otherwise been uneventful and the patient has done well. At discharge, vital signs are stable, the patient is afebrile, tolerating a regular diet, voiding spontaneously every shift and pain is well controlled. The extremities are neurovascularly intact distally throughout the right upper extremity. All incisions are clean, dry and intact without evidence of infection, hematoma or seroma. The patient is discharged home in stable condition. Patient given detailed precautionary instructions and instructions for the appropriate follow up care. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Moderate 2. metHOTREXate sodium 20 mg oral 1X/WEEK 3. TraMADol 50 mg PO Q8H:PRN Pain - Moderate 4. Ibuprofen 600 mg PO BID:PRN Pain - Moderate 5. Omeprazole 20 mg PO DAILY Discharge Medications: 1. Aspirin EC 325 mg PO DAILY 2. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain 3. Acetaminophen 1000 mg PO Q8H:PRN Pain - Moderate 4. Omeprazole 20 mg PO DAILY 5. HELD- Ibuprofen 600 mg PO BID:PRN Pain - Moderate This medication was held. Do not restart Ibuprofen until 6 weeks after surgery 6. HELD- metHOTREXate sodium 20 mg oral 1X/WEEK This medication was held. Do not restart metHOTREXate sodium until your first post-operative office visit in two weeks Discharge Disposition: Home Discharge Diagnosis: Right rotator cuff arthropathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Reverse Total Shoulder Arthroplasty Post-Operative Instructions (with/without Biceps Tenodesis) Medications You will be given a prescription for pain medicine. The pain medication is a codeine derivative and should be taken as directed. Please take one full strength aspirin (325 mg) each day for six weeks to decrease the risk of having a complication related to a blood clot. Please take a stool softener, like Colace (Docusate Sodium 100mg), twice a day while taking narcotics to prevent constipation. Dressing Leave your dressing on for 48 hours after your surgery. After 48 hours, you may remove your dressing. LEAVE THE TAPE STRIPS OVER YOUR INCISIONS. These will stay on for 1.5 to 2 weeks and will peel off slowly. Showering You may shower 72 hours after your surgery and get your incisions wet. Do NOT immerse in a tub or pool for 7 10 days to avoid excessive scarring and risk of infection. When you shower, let your arm hang at your side. Do NOT raise or lift your arm. To wash under your arm, lean forward carefully and let your arm hang. Using your other hand, wash under your operative arm. Do NOT scrub the incision. When you are done washing, stand up and let your arm hang at your side. Pat yourself dry and put your sling on. Ice Packs Keep Ice Packs on at all times exchanging every hour while awake. Icing is very important to decrease swelling and pain and improve mobility. After 24 hours, continue to use the cuff 3 4 times a day, 15 20 minutes each time to keep swelling to a minimum. Activity Take it easy. Wear your sling for comfort and safety. Keep your arm at your side at ALL TIMES no reaching, grabbing or pulling with your operative arm. When to Contact Us If you experience severe pain that your pain medication does not help, please let us know. If you have a temperature over 101.5º, please contact our office at [MASKED]. Followup Instructions: [MASKED] | [
"M12511",
"S46011A",
"X509XXA",
"Y92524",
"M059",
"K219",
"N400"
] | [
"M12511: Traumatic arthropathy, right shoulder",
"S46011A: Strain of muscle(s) and tendon(s) of the rotator cuff of right shoulder, initial encounter",
"X509XXA: Other and unspecified overexertion or strenuous movements or postures, initial encounter",
"Y92524: Gas station as the place of occurrence of the external cause",
"M059: Rheumatoid arthritis with rheumatoid factor, unspecified",
"K219: Gastro-esophageal reflux disease without esophagitis",
"N400: Benign prostatic hyperplasia without lower urinary tract symptoms"
] | [
"K219",
"N400"
] | [] |
15,554,295 | 22,080,443 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nWound care unable to be performed by ___\n \nMajor Surgical or Invasive Procedure:\nNone \n\n \nHistory of Present Illness:\nThis is a ___ year old man who is well known to the ACS service, \nwho has a complex abdominal history after GSW ___ s/p multiple \noperations (ex lap/EIA primary repair/sigmoidectomy ___ and \nex lap/LOA/diverting ileostomy/drainage of colonic leak ___ \nc/b enterocutaneous fistulas x2 who recently underwent \nexploratory laparotomy, Removal of skin graft, extensive LOA, \ntakedown of Ileostomy, takedown of entero-atmospheric fistula x \n2, ileal resection with stapled anastomosis, ventral \nherniorrhaphy, b/l component separation with mesh; removal of \nbilateral tissue expanders and takedown of\nenterocutaneous fistula on ___ as a combined case between \nACS and PRS. That last case was complicated by EC fistula for \nwhich the patient was seen in the ED on ___. The patient \nwas admitted at that time and kept NPO with TPN, and octreotide \nwas started. Initially a complex abdominal appliance was placed \nin order to contain the succus from the midline incision, and \nthis\nwas later converted to a wound vac by PRS in the OR. Output \nfrom the fistula decreased significantly when kept NPO with \noctreotide. He was discharged to home with ___ scheduled to \nchange the wound vac every 3 days. The patient was seen in \nclinic by Dr. ___ ___ for wound care and at that time \nhis\nvac and ostomy appliances were changed. The patient's wife now \nreports speaking with ___ and essentially she was told ___ said \nthey would be unable to change his wound vac and ostomy \nappliance. The patient was then advised to come to ___ as a \ndirect admission, but he is now in the ED waiting room. He\ndenies abdominal pain, fever, chills. Reports the most minimal \nof po intake (a tiny sip of sprite, a spoonful of chicken \nbroth). Has had continued ostomy function.\n\n \nPast Medical History:\nPast Medical History: GSW, hypertension, hypothyroid\n\nPast Surgical History:\nthe patient has undergone 25 surgeries at ___ including:\n-ex lap/EIA primary repair/sigmoidectomy ___\n-ex lap/LOA/diverting ileostomy/drainage of colonic leak ___\n-exploratory laparotomy, Removal of skin graft, extensive LOA,\ntakedown of Ileostomy, takedown of entero-atmospheric fistula x\n2, ileal resection with stapled anastomosis, ventral\nherniorrhaphy, b/l component separation with mesh; removal of\nbilateral tissue expanders and takedown of enterocutaneous\nfistula on ___ \n-many washouts with vac placement\n\n \nSocial History:\n___\nFamily History:\nnon-contributory \n \nPhysical Exam:\nAdmission Physical Exam:\n\nGEN: A&O, NAD\nHEENT: No scleral icterus, mucus membranes moist\nCV: RRR, No M/G/R\nPULM: Clear to auscultation b/l, No W/R/R\nABD: Soft, nondistended, nontender. Vac in place to good\nsuction, there is no visible succus backing up into the\nappliance. Ostomy is PPP, gas and stool in bag. \nExt: No ___ edema, ___ warm and well perfused\n\nDischarge Physical Exam:\nVS: T: 98.4 PO BP: 114/78 L Sitting HR: 92 RR: 18 O2: 99% Ra \nGEN: A+Ox3, NAD\nHEENT atraumatic, MMM\nCV: RRR\nPULM: breathing comfortably on room air, no respiratory distress\nABD: soft, non-distended, appropriately tender at wound. Ostomy \npouch in place over fistula and wound bed. \nEXT: wwp, no edema b/l \n \nPertinent Results:\nIMAGING:\n\n___: CXR:\nRight PICC tip projecting over the mid SVC.\n\n___: SMALL BOWEL ONLY (GASTROGRAF):\nEnteric contrast passes through the small bowel into the ostomy \nbag with no evidence of obstruction, stricture or extraluminal \ncontrast extravasation. \n\nLABS:\n\n___ 05:53PM LACTATE-1.7\n___ 05:50PM GLUCOSE-91 UREA N-23* CREAT-0.8 SODIUM-141 \nPOTASSIUM-4.9 CHLORIDE-105 TOTAL CO2-21* ANION GAP-15\n___ 05:50PM WBC-10.3* RBC-3.76* HGB-9.9* HCT-32.0* MCV-85 \nMCH-26.3 MCHC-30.9* RDW-18.1* RDWSD-55.5*\n___ 05:50PM NEUTS-64.3 ___ MONOS-4.9* EOS-3.8 \nBASOS-0.7 IM ___ AbsNeut-6.62* AbsLymp-2.64 AbsMono-0.50 \nAbsEos-0.39 AbsBaso-0.07\n___ 05:50PM PLT COUNT-___ y/o M w/ complex abdominal history after ___ ___ s/p \nmultiple operations who was recently discharged with \ncomplication of EC fistula, who re-presented this admission for \nwound care after the ___ was unable to manage the patient's \nwound at home. The patient was admitted to the Acute Care \nSurgery service for care. He was continued on TPN and remained \nNPO. He was written for octreotide. His wound was evaluated by \nPlastic Surgery as well. He initially continued to have his \nwound managed with a black vac sponge in the wound bed with an \nostomy appliance over the fistula, however, this appliance \nleaked several times. Wound care nursing was consulted and \nplaced ___ pouch over the entire wound (containing both the \nwound tissue and the fistula). \n\nThe patient was alert and oriented throughout hospitalization; \npain was managed with oxycodone and gabapentin (both of which \nare home medications). He received IV morphine prior to the \nwound vac changes, but he did not require IV morphine with the \nmost recent pouch change. \n\nThe patient remained stable from a cardiovascular and pulmonary \nstandpoint; vital signs were routinely monitored. Good pulmonary \ntoilet and early ambulation were encouraged throughout \nhospitalization. The patient's intake and output were closely \nmonitored. The patient's fever curves were closely watched for \nsigns of infection, of which there were none. The patient's \nblood counts were closely watched for signs of bleeding, of \nwhich there were none. The patient received subcutaneous heparin \nand ___ dyne boots were used during this stay and was \nencouraged to get up and ambulate as early as possible.\n\nAt the time of discharge, the patient was doing well, afebrile \nand hemodynamically stable. The patient was tolerating a diet, \nambulating, voiding without assistance, and pain was well \ncontrolled. On ___, wound care nursing performed a pouch \nchange with the wife present. A powerpoint of the dressing \nchange instructions with pictures was provided to the wife as \nwell as to the ___. The patient received discharge teaching and \nfollow-up instructions with understanding verbalized and \nagreement with the discharge plan. ___ was arranged for home \npouch changes and TPN at home. \n\n \nMedications on Admission:\n___ POUCH REF# ___ - ___ Pouch REF#\n___ . Apply and change as needed as needed Diagnosis:\nEnterocutaneous fistula\nGABAPENTIN - gabapentin 600 mg tablet. tablet(s) by mouth 1 in\nam 1 in afternoon 2 at bedtime - (Prescribed by Other Provider)\nLEVOTHYROXINE - levothyroxine 75 mcg tablet. 1 tablet(s) by \nmouth\nonce a day - (Prescribed by Other Provider)\nNORTRIPTYLINE - nortriptyline 50 mg capsule. 1 capsule(s) by\nmouth at bedtime - (Prescribed by Other Provider)\nOMEPRAZOLE - omeprazole 20 mg capsule,delayed release. 1\ncapsule(s) by mouth once a day - (Prescribed by Other Provider)\nOXYCODONE - oxycodone 10 mg tablet. 1 tablet(s) by mouth every\nfour (4) hours as needed for pain Do not drive while on this\nmedication. - (Prescribed by Other Provider)\n \nMedications - OTC\nASCORBIC ACID (VITAMIN C) - ascorbic acid (vitamin C) 500 mg\ntablet. 1 tablet(s) by mouth twice a day - (Prescribed by Other\nProvider)\nFERROUS SULFATE - ferrous sulfate 325 mg (65 mg iron) tablet. 1\ntablet(s) by mouth twice a day - (Prescribed by Other Provider)\nMELATONIN - melatonin 5 mg capsule. 1 capsule(s) by mouth at\nbedtime - (Prescribed by Other Provider)\nMULTIVITAMIN - multivitamin tablet. 1 tablet(s) by mouth once a\nday - (Prescribed by Other Provider)\n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild \n2. Octreotide Acetate 100 mcg SC Q8H \nRX *octreotide acetate 100 mcg/mL (1 mL) 100 mcg subcutaneous \nevery eight (8) hours Disp #*90 Syringe Refills:*1 \n3. Nortriptyline 50 mg PO QHS pain \n4. Gabapentin 600 mg PO TID pain \n5. Levothyroxine Sodium 75 mcg PO DAILY \n6. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - \nModerate \n7. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line \nflush \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nEnterocutaneous fistula \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nYou were admitted to ___ for \nwound care. You initially had a black sponge vac dressing and \nan ostomy pouch applied to your wound, however, this dressing \nwas not able to hold long enough without leaking. You therefore \nhad ___ pouch placed to cover the entire wound and this has \nheld up well. You will have the wound cared for at home by a \nvisiting nurse and you will also continue to receive TPN at \nhome. \n\nYou are now ready to be discharged home. Please note the \nfollowing discharge instructions:\n\nPlease call your doctor or nurse practitioner or return to the \nEmergency Department for any of the following:\n\n*You experience new chest pain, pressure, squeezing or \ntightness.\n*New or worsening cough, shortness of breath, or wheeze.\n*If you are vomiting and cannot keep down fluids or your \nmedications.\n*You are getting dehydrated due to continued vomiting, diarrhea, \nor other reasons. Signs of dehydration include dry mouth, rapid \nheartbeat, or feeling dizzy or faint when standing.\n*You see blood or dark/black material when you vomit or have a \nbowel movement.\n*You experience burning when you urinate, have blood in your \nurine, or experience a discharge.\n*Your pain in not improving within ___ hours or is not gone \nwithin 24 hours. Call or return immediately if your pain is \ngetting worse or changes location or moving to your chest or \nback.\n*You have shaking chills, or fever greater than 101.5 degrees \nFahrenheit or 38 degrees Celsius.\n*Any change in your symptoms, or any new symptoms that concern \nyou.\n\nPlease resume all regular home medications, unless specifically \nadvised not to take a particular medication. Also, please take \nany new medications as prescribed.\n\nPlease get plenty of rest, continue to ambulate several times \nper day, and drink adequate amounts of fluids. Avoid lifting \nweights greater than ___ lbs until you follow-up with your \nsurgeon.\nAvoid driving or operating heavy machinery while taking pain \nmedications.\n\nGeneral Drain Care:\n*Please look at the site every day for signs of infection \n(increased redness or pain, swelling, odor, yellow or bloody \ndischarge, warm to touch, fever).\n*please note color, consistency, and amount of fluid in the \npouch. Call the doctor, ___, or ___ nurse if the \namount increases significantly or changes in character. Be sure \nto empty the drain frequently. Record the output, if instructed \nto do so.\n*Wash the area gently with warm, soapy water.\n*Keep the insertion site clean and dry otherwise.\n*Avoid swimming, baths, hot tubs; do not submerge yourself in \nwater.\n*Make sure to keep the drain attached securely to your body to \nprevent pulling or dislocation.\n \n \nFollowup Instructions:\n___\n"
] | Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Wound care unable to be performed by [MASKED] Major Surgical or Invasive Procedure: None History of Present Illness: This is a [MASKED] year old man who is well known to the ACS service, who has a complex abdominal history after GSW [MASKED] s/p multiple operations (ex lap/EIA primary repair/sigmoidectomy [MASKED] and ex lap/LOA/diverting ileostomy/drainage of colonic leak [MASKED] c/b enterocutaneous fistulas x2 who recently underwent exploratory laparotomy, Removal of skin graft, extensive LOA, takedown of Ileostomy, takedown of entero-atmospheric fistula x 2, ileal resection with stapled anastomosis, ventral herniorrhaphy, b/l component separation with mesh; removal of bilateral tissue expanders and takedown of enterocutaneous fistula on [MASKED] as a combined case between ACS and PRS. That last case was complicated by EC fistula for which the patient was seen in the ED on [MASKED]. The patient was admitted at that time and kept NPO with TPN, and octreotide was started. Initially a complex abdominal appliance was placed in order to contain the succus from the midline incision, and this was later converted to a wound vac by PRS in the OR. Output from the fistula decreased significantly when kept NPO with octreotide. He was discharged to home with [MASKED] scheduled to change the wound vac every 3 days. The patient was seen in clinic by Dr. [MASKED] [MASKED] for wound care and at that time his vac and ostomy appliances were changed. The patient's wife now reports speaking with [MASKED] and essentially she was told [MASKED] said they would be unable to change his wound vac and ostomy appliance. The patient was then advised to come to [MASKED] as a direct admission, but he is now in the ED waiting room. He denies abdominal pain, fever, chills. Reports the most minimal of po intake (a tiny sip of sprite, a spoonful of chicken broth). Has had continued ostomy function. Past Medical History: Past Medical History: GSW, hypertension, hypothyroid Past Surgical History: the patient has undergone 25 surgeries at [MASKED] including: -ex lap/EIA primary repair/sigmoidectomy [MASKED] -ex lap/LOA/diverting ileostomy/drainage of colonic leak [MASKED] -exploratory laparotomy, Removal of skin graft, extensive LOA, takedown of Ileostomy, takedown of entero-atmospheric fistula x 2, ileal resection with stapled anastomosis, ventral herniorrhaphy, b/l component separation with mesh; removal of bilateral tissue expanders and takedown of enterocutaneous fistula on [MASKED] -many washouts with vac placement Social History: [MASKED] Family History: non-contributory Physical Exam: Admission Physical Exam: GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, nontender. Vac in place to good suction, there is no visible succus backing up into the appliance. Ostomy is PPP, gas and stool in bag. Ext: No [MASKED] edema, [MASKED] warm and well perfused Discharge Physical Exam: VS: T: 98.4 PO BP: 114/78 L Sitting HR: 92 RR: 18 O2: 99% Ra GEN: A+Ox3, NAD HEENT atraumatic, MMM CV: RRR PULM: breathing comfortably on room air, no respiratory distress ABD: soft, non-distended, appropriately tender at wound. Ostomy pouch in place over fistula and wound bed. EXT: wwp, no edema b/l Pertinent Results: IMAGING: [MASKED]: CXR: Right PICC tip projecting over the mid SVC. [MASKED]: SMALL BOWEL ONLY (GASTROGRAF): Enteric contrast passes through the small bowel into the ostomy bag with no evidence of obstruction, stricture or extraluminal contrast extravasation. LABS: [MASKED] 05:53PM LACTATE-1.7 [MASKED] 05:50PM GLUCOSE-91 UREA N-23* CREAT-0.8 SODIUM-141 POTASSIUM-4.9 CHLORIDE-105 TOTAL CO2-21* ANION GAP-15 [MASKED] 05:50PM WBC-10.3* RBC-3.76* HGB-9.9* HCT-32.0* MCV-85 MCH-26.3 MCHC-30.9* RDW-18.1* RDWSD-55.5* [MASKED] 05:50PM NEUTS-64.3 [MASKED] MONOS-4.9* EOS-3.8 BASOS-0.7 IM [MASKED] AbsNeut-6.62* AbsLymp-2.64 AbsMono-0.50 AbsEos-0.39 AbsBaso-0.07 [MASKED] 05:50PM PLT COUNT-[MASKED] y/o M w/ complex abdominal history after [MASKED] [MASKED] s/p multiple operations who was recently discharged with complication of EC fistula, who re-presented this admission for wound care after the [MASKED] was unable to manage the patient's wound at home. The patient was admitted to the Acute Care Surgery service for care. He was continued on TPN and remained NPO. He was written for octreotide. His wound was evaluated by Plastic Surgery as well. He initially continued to have his wound managed with a black vac sponge in the wound bed with an ostomy appliance over the fistula, however, this appliance leaked several times. Wound care nursing was consulted and placed [MASKED] pouch over the entire wound (containing both the wound tissue and the fistula). The patient was alert and oriented throughout hospitalization; pain was managed with oxycodone and gabapentin (both of which are home medications). He received IV morphine prior to the wound vac changes, but he did not require IV morphine with the most recent pouch change. The patient remained stable from a cardiovascular and pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet and early ambulation were encouraged throughout hospitalization. The patient's intake and output were closely monitored. 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 [MASKED] dyne boots were used during this stay and was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile and hemodynamically stable. The patient was tolerating a diet, ambulating, voiding without assistance, and pain was well controlled. On [MASKED], wound care nursing performed a pouch change with the wife present. A powerpoint of the dressing change instructions with pictures was provided to the wife as well as to the [MASKED]. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. [MASKED] was arranged for home pouch changes and TPN at home. Medications on Admission: [MASKED] POUCH REF# [MASKED] - [MASKED] Pouch REF# [MASKED] . Apply and change as needed as needed Diagnosis: Enterocutaneous fistula GABAPENTIN - gabapentin 600 mg tablet. tablet(s) by mouth 1 in am 1 in afternoon 2 at bedtime - (Prescribed by Other Provider) LEVOTHYROXINE - levothyroxine 75 mcg tablet. 1 tablet(s) by mouth once a day - (Prescribed by Other Provider) NORTRIPTYLINE - nortriptyline 50 mg capsule. 1 capsule(s) by mouth at bedtime - (Prescribed by Other Provider) OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. 1 capsule(s) by mouth once a day - (Prescribed by Other Provider) OXYCODONE - oxycodone 10 mg tablet. 1 tablet(s) by mouth every four (4) hours as needed for pain Do not drive while on this medication. - (Prescribed by Other Provider) Medications - OTC ASCORBIC ACID (VITAMIN C) - ascorbic acid (vitamin C) 500 mg tablet. 1 tablet(s) by mouth twice a day - (Prescribed by Other Provider) FERROUS SULFATE - ferrous sulfate 325 mg (65 mg iron) tablet. 1 tablet(s) by mouth twice a day - (Prescribed by Other Provider) MELATONIN - melatonin 5 mg capsule. 1 capsule(s) by mouth at bedtime - (Prescribed by Other Provider) MULTIVITAMIN - multivitamin tablet. 1 tablet(s) by mouth once a day - (Prescribed by Other Provider) Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild 2. Octreotide Acetate 100 mcg SC Q8H RX *octreotide acetate 100 mcg/mL (1 mL) 100 mcg subcutaneous every eight (8) hours Disp #*90 Syringe Refills:*1 3. Nortriptyline 50 mg PO QHS pain 4. Gabapentin 600 mg PO TID pain 5. Levothyroxine Sodium 75 mcg PO DAILY 6. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Moderate 7. Sodium Chloride 0.9% Flush [MASKED] mL IV DAILY and PRN, line flush Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Enterocutaneous fistula Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], You were admitted to [MASKED] for wound care. You initially had a black sponge vac dressing and an ostomy pouch applied to your wound, however, this dressing was not able to hold long enough without leaking. You therefore had [MASKED] pouch placed to cover the entire wound and this has held up well. You will have the wound cared for at home by a visiting nurse and you will also continue to receive TPN at home. You are now ready to be discharged home. Please note the following discharge instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within [MASKED] 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 [MASKED] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. General Drain Care: *Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). *please note color, consistency, and amount of fluid in the pouch. Call the doctor, [MASKED], or [MASKED] nurse if the amount increases significantly or changes in character. Be sure to empty the drain frequently. Record the output, if instructed to do so. *Wash the area gently with warm, soapy water. *Keep the insertion site clean and dry otherwise. *Avoid swimming, baths, hot tubs; do not submerge yourself in water. *Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. Followup Instructions: [MASKED] | [
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"E43",
"Y839",
"I10",
"E039",
"Z932"
] | [
"T8183XA: Persistent postprocedural fistula, initial encounter",
"E43: Unspecified severe protein-calorie malnutrition",
"Y839: Surgical procedure, unspecified as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure",
"I10: Essential (primary) hypertension",
"E039: Hypothyroidism, unspecified",
"Z932: Ileostomy status"
] | [
"I10",
"E039"
] | [] |
19,867,779 | 22,408,506 | [
" \nName: ___ ___ No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: ORTHOPAEDICS\n \nAllergies: \netodolac / meloxicam\n \nAttending: ___\n \nChief Complaint:\nbilateral knee osteoarthritis \n \nMajor Surgical or Invasive Procedure:\nleft knee replacement ___, ___\n\n \nHistory of Present Illness:\n___ year old female with a history of bilateral knee \nosteoarthritis s/p right total knee replacement on ___ who \nis now here for left total knee replacement surgery. \n \nPast Medical History:\nHTN, OA of hands, DM2 (A1c 6.5), Empty sella syndrome, meniere's \ndisease\n \nSocial History:\n___\nFamily History:\nNon-contributory\n \nPhysical Exam:\nWell appearing in no acute distress \nAfebrile with stable vital signs \nPain well-controlled \nRespiratory: CTAB \nCardiovascular: RRR \nGastrointestinal: NT/ND \nGenitourinary: Voiding independently \nNeurologic: Intact with no focal deficits \nPsychiatric: Pleasant, A&O x3 \nMusculoskeletal Lower Extremity: \n* Aquacel dressing with scant serosanguinous drainage \n* Thigh full but soft \n* No calf tenderness \n* ___ strength \n* SILT, NVI distally \n* Toes warm\n \nPertinent Results:\n___ 06:31AM BLOOD WBC-8.0 RBC-2.91* Hgb-8.7* Hct-26.7* \nMCV-92 MCH-29.9 MCHC-32.6 RDW-13.2 RDWSD-44.1 Plt ___\n___ 06:24AM BLOOD WBC-6.0 RBC-3.11* Hgb-9.1* Hct-28.2* \nMCV-91 MCH-29.3 MCHC-32.3 RDW-12.9 RDWSD-42.1 Plt ___\n___ 06:31AM BLOOD Plt ___\n___ 06:24AM BLOOD Plt ___\n___ 06:24AM BLOOD Glucose-130* UreaN-15 Creat-0.9 Na-141 \nK-4.4 Cl-102 HCO3-27 AnGap-12\n___ 06:24AM BLOOD Calcium-8.8 Phos-3.9 Mg-1.8\n \nBrief Hospital Course:\nThe patient was admitted to the Orthopaedic surgery service and \nwas taken to the operating room for above described procedure. \nPlease see separately dictated operative report for details. The \nsurgery was uncomplicated and the patient tolerated the \nprocedure well. Patient received perioperative IV antibiotics.\n\nPostoperative course was remarkable for the following:\nPOD#0, the patient was due to void, but was unable to do so. \nShe was bladder scanned for 838 mL and was therefore straight \ncath'ed x1.\nPOD #1, patient was voiding adequately independently.\nPOD #2, patient cleared ___ without further issues.\n\nOtherwise, pain was controlled with a combination of IV and oral \npain medications. The patient received Aspirin 81 mg twice \ndaily for DVT prophylaxis starting on the morning of POD#1. The \nsurgical dressing will remain on until POD#7 after surgery. The \npatient was seen daily by physical therapy. Labs were checked \nthroughout the hospital course and repleted accordingly. At the \ntime of discharge the patient was tolerating a regular diet and \nfeeling well. The patient was afebrile with stable vital signs. \nThe patient's hematocrit was acceptable and pain was adequately \ncontrolled on an oral regimen. The operative extremity was \nneurovascularly intact and the dressing was intact.\n\nThe patient's weight-bearing status is weight bearing as \ntolerated on the operative extremity. No range of motion \nrestrictions. Please use walker or 2 crutches, wean as able. \n \nMs. ___ is discharged to home with services in stable \ncondition.\n \nMedications on Admission:\n1. Atorvastatin 10 mg PO DAILY \n2. Lisinopril 10 mg PO DAILY \n3. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild \n4. Metoprolol Tartrate 25 mg PO BID \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H \n2. Aspirin EC 81 mg PO BID Duration: 4 Weeks \n3. Docusate Sodium 100 mg PO BID \n4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - \nModerate \n5. Pantoprazole 40 mg PO Q24H \n6. Senna 8.6 mg PO BID \n7. Atorvastatin 10 mg PO DAILY \n8. Lisinopril 10 mg PO DAILY \n9. Metoprolol Tartrate 25 mg PO BID \n10. HELD- Ibuprofen 600 mg PO Q8H:PRN Pain - Mild This \nmedication was held. Do not restart Ibuprofen until cleared by \nsurgeon.\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nbilateral knee osteoarthritis \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\n1. Please return to the emergency department or notify your \nphysician if you experience any of the following: severe pain \nnot relieved by medication, increased swelling, decreased \nsensation, difficulty with movement, fevers greater than 101.5, \nshaking chills, increasing redness or drainage from the incision \nsite, chest pain, shortness of breath or any other concerns.\n \n2. Please follow up with your primary physician regarding this \nadmission and any new medications and refills. \n \n3. Resume your home medications unless otherwise instructed.\n \n4. You have been given medications for pain control. Please do \nnot drive, operate heavy machinery, or drink alcohol while \ntaking these medications. As your pain decreases, take fewer \ntablets and increase the time between doses. This medication can \ncause constipation, so you should drink plenty of water daily \nand take a stool softener (such as Colace) as needed to prevent \nthis side effect. Call your surgeons office 3 days before you \nare out of medication so that it can be refilled. These \nmedications cannot be called into your pharmacy and must be \npicked up in the clinic or mailed to your house. Please allow \nan extra 2 days if you would like your medication mailed to your \nhome.\n \n5. You may not drive a car until cleared to do so by your \nsurgeon.\n \n6. Please call your surgeon's office to schedule or confirm your \nfollow-up appointment.\n \n7. SWELLING: Ice the operative joint 20 minutes at a time, \nespecially after activity or physical therapy. Do not place ice \ndirectly on the skin. You may wrap the knee with an ace bandage \nfor added compression. Please DO NOT take any non-steroidal \nanti-inflammatory medications (NSAIDs such as Celebrex, \nibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by \nyour physician.\n \n8. ANTICOAGULATION: Please continue your Aspirin 81 mg twice \ndaily with food for four (4) weeks to help prevent deep vein \nthrombosis (blood clots). Continue Pantoprazole daily while on \nAspirin to prevent GI upset (x 4 weeks). If you were taking \nAspirin prior to your surgery, take it at 81 mg twice daily \nuntil the end of the 4 weeks, then you can go back to your \nnormal dosing. \n \n9. WOUND CARE: Please remove Aquacel dressing on POD#7 after \nsurgery. It is okay to shower after surgery after 5 days but no \ntub baths, swimming, or submerging your incision until after \nyour four (4) week checkup. Please place a dry sterile dressing \non the wound after aqaucel is removed each day if there is \ndrainage, otherwise leave it open to air. Check wound regularly \nfor signs of infection such as redness or thick yellow drainage. \nStaples will be removed by your doctor at follow-up appointment \napproximately 2 weeks after surgery.\n\n10. ___ (once at home): Home ___, dressing changes as \ninstructed, and wound checks.\n \n11. ACTIVITY: Weight bearing as tolerated on the operative \nextremity. Two crutches or walker. Wean assistive device as \nable. Mobilize. ROM as tolerated. No strenuous exercise or \nheavy lifting until follow up appointment. \n\nPhysical Therapy:\nWBAT LLE\nNo range of motion restrictions\nWean assistive device as able (i.e. 2 crutches or walker)\nMobilize frequently\nTreatments Frequency:\nremove aquacel POD#7 after surgery\napply dry sterile dressing daily if needed after aquacel \ndressing is removed\nwound checks daily after aquacel removed\nstaple removal and replace with steri-strips at follow up visit \nin clinic \n \nFollowup Instructions:\n___\n"
] | Allergies: etodolac / meloxicam Chief Complaint: bilateral knee osteoarthritis Major Surgical or Invasive Procedure: left knee replacement [MASKED], [MASKED] History of Present Illness: [MASKED] year old female with a history of bilateral knee osteoarthritis s/p right total knee replacement on [MASKED] who is now here for left total knee replacement surgery. Past Medical History: HTN, OA of hands, DM2 (A1c 6.5), Empty sella syndrome, meniere's disease Social History: [MASKED] Family History: Non-contributory Physical Exam: Well appearing in no acute distress Afebrile with stable vital signs Pain well-controlled Respiratory: CTAB Cardiovascular: RRR Gastrointestinal: NT/ND Genitourinary: Voiding independently Neurologic: Intact with no focal deficits Psychiatric: Pleasant, A&O x3 Musculoskeletal Lower Extremity: * Aquacel dressing with scant serosanguinous drainage * Thigh full but soft * No calf tenderness * [MASKED] strength * SILT, NVI distally * Toes warm Pertinent Results: [MASKED] 06:31AM BLOOD WBC-8.0 RBC-2.91* Hgb-8.7* Hct-26.7* MCV-92 MCH-29.9 MCHC-32.6 RDW-13.2 RDWSD-44.1 Plt [MASKED] [MASKED] 06:24AM BLOOD WBC-6.0 RBC-3.11* Hgb-9.1* Hct-28.2* MCV-91 MCH-29.3 MCHC-32.3 RDW-12.9 RDWSD-42.1 Plt [MASKED] [MASKED] 06:31AM BLOOD Plt [MASKED] [MASKED] 06:24AM BLOOD Plt [MASKED] [MASKED] 06:24AM BLOOD Glucose-130* UreaN-15 Creat-0.9 Na-141 K-4.4 Cl-102 HCO3-27 AnGap-12 [MASKED] 06:24AM BLOOD Calcium-8.8 Phos-3.9 Mg-1.8 Brief Hospital Course: The patient was admitted to the Orthopaedic surgery service and was taken to the operating room for above described procedure. Please see separately dictated operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Patient received perioperative IV antibiotics. Postoperative course was remarkable for the following: POD#0, the patient was due to void, but was unable to do so. She was bladder scanned for 838 mL and was therefore straight cath'ed x1. POD #1, patient was voiding adequately independently. POD #2, patient cleared [MASKED] without further issues. Otherwise, pain was controlled with a combination of IV and oral pain medications. The patient received Aspirin 81 mg twice daily for DVT prophylaxis starting on the morning of POD#1. The surgical dressing will remain on until POD#7 after surgery. The patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was acceptable and pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact and the dressing was intact. The patient's weight-bearing status is weight bearing as tolerated on the operative extremity. No range of motion restrictions. Please use walker or 2 crutches, wean as able. Ms. [MASKED] is discharged to home with services in stable condition. Medications on Admission: 1. Atorvastatin 10 mg PO DAILY 2. Lisinopril 10 mg PO DAILY 3. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild 4. Metoprolol Tartrate 25 mg PO BID Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Aspirin EC 81 mg PO BID Duration: 4 Weeks 3. Docusate Sodium 100 mg PO BID 4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate 5. Pantoprazole 40 mg PO Q24H 6. Senna 8.6 mg PO BID 7. Atorvastatin 10 mg PO DAILY 8. Lisinopril 10 mg PO DAILY 9. Metoprolol Tartrate 25 mg PO BID 10. HELD- Ibuprofen 600 mg PO Q8H:PRN Pain - Mild This medication was held. Do not restart Ibuprofen until cleared by surgeon. Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: bilateral knee osteoarthritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as Colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon. 6. Please call your surgeon's office to schedule or confirm your follow-up appointment. 7. SWELLING: Ice the operative joint 20 minutes at a time, especially after activity or physical therapy. Do not place ice directly on the skin. You may wrap the knee with an ace bandage for added compression. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as Celebrex, ibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by your physician. 8. ANTICOAGULATION: Please continue your Aspirin 81 mg twice daily with food for four (4) weeks to help prevent deep vein thrombosis (blood clots). Continue Pantoprazole daily while on Aspirin to prevent GI upset (x 4 weeks). If you were taking Aspirin prior to your surgery, take it at 81 mg twice daily until the end of the 4 weeks, then you can go back to your normal dosing. 9. WOUND CARE: Please remove Aquacel dressing on POD#7 after surgery. It is okay to shower after surgery after 5 days but no tub baths, swimming, or submerging your incision until after your four (4) week checkup. Please place a dry sterile dressing on the wound after aqaucel is removed each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed by your doctor at follow-up appointment approximately 2 weeks after surgery. 10. [MASKED] (once at home): Home [MASKED], dressing changes as instructed, and wound checks. 11. ACTIVITY: Weight bearing as tolerated on the operative extremity. Two crutches or walker. Wean assistive device as able. Mobilize. ROM as tolerated. No strenuous exercise or heavy lifting until follow up appointment. Physical Therapy: WBAT LLE No range of motion restrictions Wean assistive device as able (i.e. 2 crutches or walker) Mobilize frequently Treatments Frequency: remove aquacel POD#7 after surgery apply dry sterile dressing daily if needed after aquacel dressing is removed wound checks daily after aquacel removed staple removal and replace with steri-strips at follow up visit in clinic Followup Instructions: [MASKED] | [
"M170",
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"M19042",
"M19041",
"I10",
"E119",
"H8109",
"Z87891"
] | [
"M170: Bilateral primary osteoarthritis of knee",
"R339: Retention of urine, unspecified",
"M19042: Primary osteoarthritis, left hand",
"M19041: Primary osteoarthritis, right hand",
"I10: Essential (primary) hypertension",
"E119: Type 2 diabetes mellitus without complications",
"H8109: Ménière's disease, unspecified ear",
"Z87891: Personal history of nicotine dependence"
] | [
"I10",
"E119",
"Z87891"
] | [] |
19,076,317 | 23,750,446 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: NEUROLOGY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nSeizures\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\nMs. ___ is a ___ year old right handed woman with a\nhistory of epilepsy secondary to cerebral venous thrombosis with\nrecurrent multifocal hemorrhages who presents as a transfer from\nan OSH for multiple breakthrough seizures.\n\nPatient is too lethargic to give detailed history though she\nanswers some questions with repeated prompting. History \nobtained\nmostly from chart review.\n\nPer notes from ___:\n\"Per mother, witnessed seizure at 3 pm on sofa. Per mother, \nsince\nthen has been slow to respond and keeps turning head to left \nside\nbecoming unresponsive. Pt appeared postictal.\"\nPatient's mother said she had at least 10 episodes of\nunresponsive with head turn all the way to the left and slight\nshake of L hand. Resolved each time within ___ minutes.\nImmediately awake and alert when they resolve. Patient was at \nthe\nsame ED yesterday for headache but CT wnl. The OSH discussed \nwith\n___ neurology who recommended 1.5g Keppra IV and increased\nKeppra from 500 to 750 mg BID. Then, patient was transferred to\n___ for cvEEG. \n\nIn ___ ED, she was noted to have \"a brief period of\nunresponsiveness with head turn to the side.\" She received \nAtivan\n2mg IV at 00:05 am with symptomatic improvement. \n\nPer patient, she is here due to seizures and she feels sleepy.\nShe said she did not sleep all night the previous night due to\nheadaches. She denies a headache currently. \nShe denies any illness or feeling unwell recently. Denies fever,\nchills, cough, n/v, diarrhea. \nShe says she has been adherent to all medications and did not\nmiss any doses of her AEDs. When asked, she was able to tell me\nthat she takes keppra and lamotrigine twice a day in addition to\nzonisamide 2 pills in the morning and 3 pills at night. \nShe was unable to say whether these seizures are her typical\nseizures, but per chart review, left head turn and leftward eye\ndeviation was not recorded as a typical semiology. \n\nPer most recent Epilepsy Clinic note on ___ by Dr. ___\nDr. ___: \n\"#Typical Events:\n1. Mouth shaking, tongue heaviness and a sensation that \"left\nvision is not okay.\" There is no loss of awareness with these.\nShe is not sure how often these are occurring. None since her\nlast visit.\n2. Palpitations, dizziness, things are spinning around and right\nmouth twitching, tongue feels heavy, cannot talk. Again with\nmaintained awareness. None since her last visit.\n3. Left hand clenches and cannot see well, feels like she does\nnot have an arm. There is left sided body pain, feels like \nbones\nare breaking. Last time lasted more than 6 minutes. None\nrecently.\n4. Receptive aphasia for up to 2 minutes. Frequency is unclear.\nNone since her last visit.\n5. Left arm shaking. Preceded by feeling of\ndizziness/lightheadedness, left arm tremor, and left lip and\neyelid twitchings. No LOC, confusion, tongue biting, or\nincontinence. Once in ___, and none since.\n\n#History of AEDs \n-Initially, since CVT in ___, was on levetiracetam 500 \nBID\n+ valproate qdaily.\n-During ___, she started having seizures. Levetiracetam\nwas titrated up several times during this month (up to 1.5 g BID\nat one point). Valproate was discontinued in concern for its\npotential adverse effects on a female. \n-Levetiracetam was weaned off during the same month due to mood\nside effects (irritability). She was switched to oxcarbazepine.\n-During ___, levetiracetam was resumed (500 BID) due to\ncontinuing breakthrough seizures on oxcarbazepine with dose up \nto\n750 BID (level 31.4). \n-In ___, oxcarbazepine was weaned off due to inefficacy\nand she was switched to zonisamide 400 mg qdaily. Levetiracetam\nwas left unchanged.\n-In ___, zonisamide was increased to 500 mg qdaily due to\ncontinuing episodes of breakthrough seizures (1/ month, \n?provoked\nby her periods). Levetiracetam was left unchanged.\n-In ___, lamotrigine 100 mg BID was added due to\ncontinuing episodes of breakthrough seizures. Significant\nreduction in seizure frequency was noted during subsequent\nfollow-up visits on this dose.\n-Lamotrigine was increased to 150 mg BID in ___ due to\nepisodes of breakthrough seizures and low serum level. Increased\nfurther up to 200 BID on ___ due to an electrographic\nseizure captured on ambulatory EEG in ___ and another\nbreakthrough seizure the same month.\"\n\nRegarding her intracerebral hemorrhage history, chart notes \nshows\nthat she had a superior sagittal sinus thrombosis in ___ with subsequent bilateral SAH and right SDH, status post\nevacuation. Later in ___, she had a new left\ntemporoparietal\nhemorrhage, right frontal hemorrhage, and right SDH and slow \nflow\nin the left transverse sinus. Patient appears to have been kept\non anticoagulation since then. She saw a hematologist at ___\nonce in ___.\n\n \nPast Medical History:\nHLD\nMigraine headaches\nthyromegaly\nuterine fibroids.\ncerebral venous sinus thrombosis complicated by intracranial\nhemorrhages and ___ s/p R craniotomy, S/p trach and peg, now\nreversed(For details please see Dr. ___ note on ___ and\n___ \nICH and R frontal SDH, left sided thrombosis found on post\nhospital imaging\nanticardiolpin antibody in undetermined significance\n \nSocial History:\n___\nFamily History:\nDM, denies strokes or blood disorders. \n \nPhysical Exam:\nOn admission:\nPHYSICAL EXAMINATION\nVitals: T 98.8, HR 66, BP 106/70, SpO2 99% on RA. ___ pain. \n\nGeneral: woman trying to sleep in stretcher, lethargic, NAD\nHEENT: EEG and cap in place, no oropharyngeal lesions, neck\nsupple\n___: warm, well-perfused\nPulmonary: no increased work of breathing\nAbdomen: Soft, ND\nExtremities: Warm, no edema\n\nNeurologic Examination:\n- Mental status: somnolent but rousable to voice, oriented to\nself, ___, ___. Too sleepy to relate history but\nanswering some questions. Inattentive, able to name ___ forwards\n(started to use ___ for weekend days), but unable to\nname ___ backwards. Naming is intact to high frequency objects\nbut not to low frequency objects, which patient says she does \nnot\nknow the ___ words for. No dysarthria. No left-right\nconfusion. Able to follow both midline and appendicular \ncommands.\n\n- Cranial Nerves: PERRL 4->2 brisk. VF full to number counting.\nEOMI, no nystagmus. V1-V3 without deficits to light touch\nbilaterally. Slightly delayed activation of L lower face. \nHearing\nintact to voice. Palate elevation symmetric. Trapezius strength\n___ bilaterally. Tongue midline with good excursions.\n\n- Motor: increased tone in LUE, LLE. L pronation. No tremor or\nasterixis.\n [Delt][Bic][Tri] [___]\nL 4 5 5 4 4 4 4 4\nR 5 5 5 5 5 5 5 5 \nPatient not participating consistently for formal \nconfrontational\ntesting.\n- Reflexes: +suprapatellar on L. \n [Bic] [Tri] [___] [Quad] [Gastroc]\n L 3 2+ 2+ 3 1\n R 2 2 2 2 1 \n\nPlantar response downgoing on R, upgoing on L. \n\n- Sensory: No deficits to light touch bilaterally. \n\n- Coordination: No dysmetria with finger to nose testing on R.\nDysmetria on FNF on LUE is proportional to weakness. \n\n- Gait: unable to assess\n\nAt discharge:\n\n24 HR Data (last updated ___ @ 2358)\n Temp: 98.3 (Tm 98.7), BP: 94/58 (93-106/58-71), HR: 81\n(79-110), RR: 18, O2 sat: 98%, O2 delivery: Ra \nGeneral: Awake Alert, lying in bed , In no acute distress. \nHEENT: neck supple\n___: warm, well-perfused\nPulmonary: no increased work of breathing\nExtremities: Warm, no edema\n\nNeurologic Examination:\n- Mental status: Alert Awake. oriented to ___, date, and\nperson. No dysarthria. Able to follow both midline and\nappendicular commands. some word finding difficulty. No apraxia\nnoted. Able to say she is doing fine today. ___ is not her\nprimary language. \n\n- Cranial Nerves: hearing intact to voice. Delayed but symmetric\nactivation of lower face. EOMI. Trapezius strength ___\nbilaterally. Tongue midline with good excursions. Hearing\nsymmetric to finger rub.\n\n- Motor: No pronator drift. Resting tremor L>R. No asterixis. \nExam limited by effort. \n [Delt][Bic][Tri] [IP] [Quad] [Ham] [TA] [Gas] [___]\nL 4+ 5 5 5 5 5 3 4+ 4+ \nR 5 5 5 5 5 5 5 5 5\n- Reflexes: Brisk on left and plantar upgoing on left. Downgoing\non right\n- Sensory: notes symmetric to light touch\n- Coordination: No dysmetria with reaching, action tremor worse\non right. \n\n \nPertinent Results:\n___ 06:10AM BLOOD WBC-4.9 RBC-5.28* Hgb-11.6 Hct-38.5 \nMCV-73* MCH-22.0* MCHC-30.1* RDW-22.5* RDWSD-55.9* Plt ___\n___ 06:00AM BLOOD Neuts-55.1 ___ Monos-12.6 Eos-2.8 \nBaso-0.3 Im ___ AbsNeut-3.32 AbsLymp-1.73 AbsMono-0.76 \nAbsEos-0.17 AbsBaso-0.02\n___ 06:05AM BLOOD ___\n___ 05:50AM BLOOD ___\n___ 06:10AM BLOOD ___\n___ 06:10AM BLOOD ___\n___ 06:05AM BLOOD ___\n___ 06:10AM BLOOD Glucose-86 UreaN-14 Creat-0.9 Na-146 \nK-4.4 Cl-114* HCO3-22 AnGap-10\n___ 06:00AM BLOOD ALT-14 AST-14 AlkPhos-83 TotBili-0.2\n___ 06:10AM BLOOD Calcium-9.2 Phos-2.9 Mg-2.2\n___ 01:37AM BLOOD LEVETIRACETAM (KEPPRA)-Test \n___ 01:37AM BLOOD ZONISAMIDE(ZONEGRAN)-Test \n___ 01:37AM BLOOD LAMOTRIGINE-Test \n___ 07:47AM URINE Color-Yellow Appear-Hazy* Sp ___\n___ 07:47AM URINE Blood-NEG Nitrite-NEG Protein-NEG \nGlucose-NEG Ketone-TR* Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-MOD*\n___ 07:47AM URINE RBC-2 WBC-1 Bacteri-FEW* Yeast-NONE Epi-2\n___ 07:47AM URINE UCG-NEGATIVE\n___ 07:47AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG \ncocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG\n\nTime Taken Not Noted Log-In Date/Time: ___ 7:48 am\n URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT \nWITH SKIN\n AND/OR GENITAL CONTAMINATION. \n\nChest PA/Lat\n\n \n FINDINGS: \n \nLow lung volumes. Patchy opacifications are demonstrated at \nboth lower lobes \nwhich likely reflect atelectasis. Cardiomediastinal and hilar \ncontours are \nunremarkable. No pulmonary edema. No pleural effusions or \npneumothorax. The \nvisualized osseous structures are grossly unremarkable. \n \nThe upper abdomen demonstrates a nonobstructive gas pattern. \n \nIMPRESSION: \n \nPatchy opacifications of lobes likely reflect atelectasis. \nNo pulmonary edema or pleural effusions. \n\nEXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD \n \nINDICATION: ___ year old woman with H/o venous sinus thrombosis \nand epilepsy \npresenting with seizures, ? Right frontal hyper density. PLEASE \nPERFORM WITH \nPOST CONTRAST MP RAGE SEQUENCES// presenting with seizures, ? \nRight frontal \nhyper density. PLEASE PERFORM WITH POST CONTRAST MP RAGE \nSEQUENCES \n \nTECHNIQUE: Sagittal and axial T1 weighted imaging were \nperformed. After \nadministration of intravenous contrast, axial imaging was \nperformed with \ngradient echo, FLAIR, diffusion, and T1 technique. Sagittal \nMPRAGE imaging was \nperformed and re-formatted in axial and coronal orientations. \n \nCOMPARISON: CT head dated ___, MRI dated ___. \n \nFINDINGS: \n \nStable appearance of the right frontoparietotemporal craniotomy \nwith unchanged \nadjacent subdural fluid collection. Encephalomalacia with \ngliosis and \nsurrounding T2/FLAIR hyperintensity are again noted in the \nbifrontal, right \nparietal, and right temporal lobes, grossly unchanged since \nprior exam. There \nis stable ex vacuo dilatation of the right ventricle. There is \nunchanged \nappearance of susceptibility artifact within the area of known \nencephalomalacia. No evidence of intracranial hemorrhage is \nappreciated. \n \nThere are multiple foci of diffusion restriction with associated \nFLAIR \nhyperintensity and peripheral enhancement. These lesions appear \ndecreased in \nsize compared to MRI dated ___, with the largest \nlesion now \nmeasuring up to 1.5 cm. \n \nThere is no large vascular distribution infarct. The visualized \nvascular flow \nvoids are grossly unremarkable. The dural venous sinuses are \npatent. The \nparanasal sinuses and mastoid air cells are clear. No abnormal \nmarrow signal. \n \n \nIMPRESSION: \n \n \n1. No acute intracranial findings. No evidence of an acute \ninfarction, or new \nhemorrhage. \n2. Stable postsurgical changes with unchanged encephalomalacia \nin the \nbifrontal, and right parietotemporal region. Interval decrease \nof enhancement \nwithin the area of encephalomalacia compared to MRI dated ___. \n3. No evidence of acute dural venous sinus thrombosis. \n\ncvEEG - FINDINGS: \n\n___\n\nFINDINGS: \nCONTINUOUS EEG RECORDING: Began at 02:17 on the morning of \n___ and \ncontinued until 07:00 on the same day. From the beginning, the \nbackground was \ncontinuous and generally dominated by low-voltage faster \npattern, but with \ncontinuous 1.5 Hz delta slowing over the right hemisphere, \nmaximal over the \nright temporal region and somewhat more broadly over the right \nposterior \nquadrant. There was abundant superimposed faster, beta activity, \nparticularly \nanteriorly. \n \nThere were six clinical and electrographic seizures, all arising \nfrom the \nright hemisphere. The seizures had two patterns. \n\" The first seizure began at 02:43:51 with rhythmic, high \namplitude sharp \nalpha activity at 13 Hz over the right frontocentral and \nparietal regions, \nmaximal at F4-C4, and sometimes at P4 , which rapidly extended \nto the rest of \nthe right hemisphere, and then, approximately ___ seconds \nlater, to the \nmidline and left posterior quadrant by 02:43:56 and over the \nentire left \nhemisphere by 02:44:18. By 02:44:44, there was more ___ Hz \nslowing broadly \nover the left hemisphere and to a lesser extent on the right. \nThe faster sharp \nwaves continued on the right side through 02:45, with modest \nvoltage \ndiminution in the right temporal region for several seconds. On \nvideo, the \npatient was supine with her head tilted to the left prior to the \nevent. At \n02:43:54, she had intermittent mouth puckering movements. At \n02:44:14, the \nleft arm became flexed and had low amplitude shaking movements. \nBy 02:44:30, \nthere was some left head version and sustained left gaze \ndeviation. These \nstopped at 02:44:53, as she returned to the midline. She then \nblinked for a \nfew seconds and returned to her previous state. Similar seizures \nwere noted at \n03:48 (with an onset more readily localized to about C4 ; \nlasting 1 minute and \n22 seconds), 04:36 (lasting 1 minute and 25 seconds), 05:23 \n(lasting 1 minute \nand 20 seconds), and 06:32 (lasting 1 minute and 29 seconds). \n\" There was a seizure with a somewhat different pattern at \n05:05:40, with \nright temporal onset, best seen at T4 in the right mid temporal \nregion. It \nbegan with high voltage rhythmic delta slow wave activity with \nsuperimposed \nsharp waves at 5 Hz, maximal at F8-T4. By 05:05:45, it involved \nthe rest of \nthe right temporal chain and posterior quadrant, and the \nmorphology changed to \nhigh amplitude sharp alpha frequency activity. The rest of the \nright \nhemisphere was involved by 05:05:52. By 05:05:55, there was \ninvolvement of the \nleft frontal and midline regions, which gradually increased in \nfrequency and \namplitude. By 05:07:09, the background returned to rhythmic \ndelta slowing with \nsuperimposed sharp waves at ___ Hz, which gradually decreased in \nfrequency and \namplitude before stopping at 05:07:24. On video, the patient was \nin bed and \nappeared drowsy, with her head tilted to the left. The examiner \nasked her \nquestions and she did not answer. The left arm appeared to be in \nsustained \nflexion under the covers. Her face was not well visualized for \nmuch of the \nseizure, but there was a clear left gaze deviation when her head \nwas turned \ntoward the end of the event. \n \nSLEEP: No normal waking or sleep patterns were evident. \n \nCARDIAC MONITORING: showed a generally regular rhythm, with an \naverage rate of \n65-80 bpm. \n \nSPIKE DETECTION PROGRAMS: Showed no definite epileptiform \nfeatures. \n \nSEIZURE DETECTION PROGRAMS: Captured the seizures described \nabove. \n \nPUSHBUTTON ACTIVATIONS: There were two pushbutton activations, \none at 5:08, \nand the other at 5:24, for 2 of the seizures detailed above. \n \n \nQUANTITATIVE EEG: Trend analysis was performed with Persyst \nMagic Marker \nsoftware. Panels included automated seizure detection, rhythmic \nrun detection \nand display, color spectral density array, absolute and relative \nasymmetry \nindices, asymmetry spectrogram, amplitude integrated EEG, burst \nsuppression \nratio, envelope trend, and alpha delta ratios. Segments showing \nabnormal \ntrends were reviewed. \n \nIMPRESSION: This telemetry captured 2 pushbutton activations, \nand showing two \nof the seizures described above. Overall, however, there were 6 \nseizures \nrecorded, all lasting under 2 minutes, all beginning on the \nright side, and \nall but one beginning in the right frontocentral region. The \nfinal seizure \nbegan in the right mid temporal region. During the events, the \npatient had \nsome head turning to the left and some eye deviation to the \nleft, but there \nwas no convulsion. Between seizures, there was very prominent \nright temporal \nand right posterior quadrant ___ Hz delta slowing, suggesting \nthe \npossibility of a structural lesion in that area. Interictally, \nthere was also \nfrequent low-voltage rapid beta activity, likely reflective of \nmedication. \n\n___\n\nFINDINGS: \nCONTINUOUS EEG RECORDING: Began at 07:01 on the morning of \n___ and \ncontinued until 07:00 on the following morning. From the \nbeginning, the \nbackground was continuous and asymmetric. Over the right \nhemisphere, there was \ncontinuous delta slowing at ___ Hz with superimposed low voltage \nfaster \nactivity, maximal temporally (particularly over T4). Over the \nleft hemisphere, \nthere was a moderate amount of 8 Hz activity with brief periods \nof admixed ___ \nHz slowing. As the record progressed, the background frequencies \nover the \nright hemisphere increased, particularly by 14:00, with some \nsuperimposed \nfaster rhythms admixed with the continuous slowing at ___ Hz. At \ntimes, the \ndelta slowing was rhythmic over the right posterior quadrant, \nparticularly \nafter 02:00. The leads were disconnected at 18:13 and \nreconnected at 19:32, \nbut there was no change to the background in the interim. \n \nThere were 8 clinical and electrographic seizures noted during \nthe earlier \npart of the recording, all with right hemispheric onset. Three \nof these \nseizures occurred in a cluster between 07:23 and 07:28, as \ndetailed below. \n \nThe first seizure began at 07:23:21 with rhythmic, high voltage \nsharp 14 Hz \nrhythms over the right temporal region, maximal at F8-T4, which \nrapidly \nextended to the rest of the right hemisphere over ___ seconds, \nthen to the \nmidline and left posterior quadrant by 07:23:28, and was \ngeneralized by \n07:23:34. There was diminution in voltage and frequency over the \nleft \nhemisphere by 07:24:07, then decreasing to ___ Hz, before \nstopping at \n07:24:32. The faster sharp waves on the right hemisphere \npersisted until \n07:24:36, then again diminished in voltage and frequency \ngradually until the \nseizure ended at 07:24:43, followed by slowing over the right \nhemisphere and \nthen return to the previous background. On video, the patient \nwas awake and \nlooking around the room prior to the event. At 07:23:31, there \nwas left head \nversion, followed by left arm flexion a few seconds later, with \nlow amplitude \nclonic left arm movements by 07:23:47, and sustained left gaze \ndeviation by \n07:23:50. By 07:24:18, there was right arm elevation with flexor \nposturing of \nthe wrist for a few seconds. The head and gaze deviation \nreturned to ___ \nby 07:24:38. \n \nThe next seizure began at 07:25:33 with 14 Hz sharp wave \nactivity in right \nfrontocentral region, maximal F4-C4, initially moderate voltage, \nbecoming high \nvoltage a few seconds later. It extended to the remainder of the \nhemisphere, \nmidline and left posterior quadrant by 07:25:41. The sharp alpha \nactivity \ndiminished in voltage and frequency over the left hemisphere by \n07:26:26, then \nover the right hemisphere by 07:26:37, with persistent high \namplitude delta \nslowing over the right until stopping at 07:26:50. This was \nfollowed by 1.5 \nminutes of widespread slowing, most prominently over the right \ntemporal \nregion. On video, the patient was awake and scratching her EKG \nleads prior to \nthe event. On video, she gradually turned her head to the left \nby 07:26:00, \nand there was again left gaze deviation. There appeared to be \nsome abduction \nof the right arm, though it was unclear if this was volitional. \nSimilar \nseizures of right frontocentral onset occurred at 08:24 (1 \nminute and 36 \nseconds, onset more prominent over C4-P4), 09:47 (1 minute and \n24 seconds, F4- \nC4 onset), 09:58 (1 minute and 14 seconds, F4-C4 onset, \ninitially is able to \ncommunicate with the nurse early in seizure but later cannot), \n10:17 (1 minute \nand 22 seconds, F4-C4 onset), 11:13 (1 minute and 16 seconds, \nonset more \nprominent over C4-P4), 11:46 (1 minute and 8 seconds, F4-C4 \nonset). \n \nLater in the recording, there were two brief electrographic \nseizures lasting \nabout 25 seconds each. The first began at 22:04:47 with \nlateralized rhythmic \ndelta slowing with superimposed sharp waves and fast activity \n(___) \narising from the right frontotemporal region (maximal at F8-T4) \nat ___ Hz, \nspreading to the right posterior quadrant after a few seconds, \nthen to the \nmidline and left posterior quadrant by 22:04:54, increasing in \nvoltage and \nfrequency to become a sharp alpha rhythm before abruptly \nstopping at 22:05:11. \nThis was followed by 2 seconds of widespread voltage attenuation \nand slowing, \nfollowed by a 3 second burst of generalized sharply contoured \nalpha rhythms. \nOn video, the patient was sleeping; there was no apparent \nclinical correlate. \nA similar seizure occurred at 22:25:13 lasting 24 seconds, which \nagain \noccurred during sleep and did not have a clear clinical \ncorrelate. \n \n \nSLEEP: No normal waking or sleep patterns were evident. \n \nCARDIAC MONITORING: showed a generally regular rhythm, with an \naverage rate of \n60-95 bpm. \n \nSPIKE DETECTION PROGRAMS: Showed no definite epileptiform \nfeatures. \n \nSEIZURE DETECTION PROGRAMS: Captured the seizures described \nabove. \n \nPUSHBUTTON ACTIVATIONS: There were none. \n \nQUANTITATIVE EEG: Trend analysis was performed with Persyst \nMagic Marker \nsoftware. Panels included automated seizure detection, rhythmic \nrun detection \nand display, color spectral density array, absolute and relative \nasymmetry \nindices, asymmetry spectrogram, amplitude integrated EEG, burst \nsuppression \nratio, envelope trend, and alpha delta ratios. Segments showing \nabnormal \ntrends were reviewed. \n \nIMPRESSION: This telemetry captured no pushbutton activations. \nThere were 8 \nclinical and electrographic seizures recorded, all arising from \nthe right \nhemisphere, and all but one beginning in the right frontocentral \nregion. The \nclinical correlate was left head turning, left gaze deviation, \nand behavioral \narrest. There were also 2 brief electrographic seizures arising \nfrom the right \nfrontocentral and temporal regions, lasting about 20 seconds, \nwithout any \nobvious clinical correlate, later in the recording. Otherwise, \nthere was \nprominent delta slowing over the right hemisphere, maximal \ntemporally, \nsuggesting the possibility of a structural lesion in that area. \nInterictally, \nthere were also frequent low-voltage faster, beta rhythms, \nlikely reflective \nof medication. \n\n___\n\nFINDINGS: \nCONTINUOUS EEG: The background activity was asymmetric. On the \nleft side, a \nmoderate voltage, poorly sustained ___ Hz posterior dominant \nrhythm was seen. \nOn the right side, there was continuous polymorphic delta>theta \nslowing over \nthe posterior quadrant, maximal in the right temporal region, \nwhich \noccasionally became semirhythmic. Higher amplitude and sharply \ncontoured \nactivities were noted in the right posterior quadrant. \n \nSLEEP: The patient progressed from wakefulness to N1, N2 sleep \nwith no \nadditional findings. \n \nPUSHBUTTON ACTIVATIONS: There were no push button activations. \n \nCARDIAC MONITOR: Showed a generally regular rhythm with an \naverage rate of \n60-80 bpm. \n \nIMPRESSION: This was an abnormal continuous video-EEG monitoring \nstud due to \ncontinuous polymorphic or semi-rhythmic delta slowing over the \nright posterior \nquadrant (maximal in the right temporal region), indicative of \nfocal cerebral \ndysfunction. The higher amplitude activity with sharp features \nin that region \nwas consistent with breach artifact due to known skull defect. \nThere were no \nclinical events. There were no electrographic seizures. Compared \nto the \nprevious day' recording, there was no significant change \n\n___\n\nCONTINUOUS EEG: The background activity was asymmetric. On the \nleft side, a \nmoderate voltage, fairly sustained ___ Hz posterior dominant \nrhythm was seen. \nOn the right side, there was continuous polymorphic delta>theta \nslowing over \nthe posterior quadrant, maximal in the right temporal region, \nwhich \noccasionally became semirhythmic. Higher amplitude and sharply \ncontoured \nactivities were noted in the right posterior quadrant. \n \nSLEEP: The patient progressed from wakefulness to N1, N2 sleep \nwith no \nadditional findings. \n \nPUSHBUTTON ACTIVATIONS: There were no push button activations. \n \nCARDIAC MONITOR: Showed a generally regular rhythm with an \naverage rate of \n60-80 bpm. \n \nIMPRESSION: This was an abnormal continuous video-EEG monitoring \nstud due to \ncontinuous polymorphic or semi-rhythmic delta slowing over the \nright posterior \nquadrant (maximal in the right temporal region), indicative of \nfocal cerebral \ndysfunction. The higher amplitude activity with sharp features \nin that region \nwas consistent with breach artifact due to known skull defect. \nThere were no \nclinical events. There were no electrographic seizures. Compared \nto the \nprevious day' recording, there was no significant change. \n \n\n___\n\nFINDINGS: \nCONTINUOUS EEG: The waking background showed fair organization \nand consisted \nof a moderate voltage, fairly sustained ___ Hz posterior \ndominant rhythm, \nwhich was better visualized on the left side. There were \ncontinuous higher \namplitude polymorphic delta>theta activities with sharp contours \nover the \nright temporal region. \n \nSLEEP: The patient progressed from wakefulness to N1, N2 sleep \nwith no \nadditional findings. \n \nPUSHBUTTON ACTIVATIONS: There were no push button activations. \n \nCARDIAC MONITOR: Showed a generally regular rhythm with an \naverage rate of \n60-80 bpm. \n \nIMPRESSION: This was an abnormal continuous video-EEG monitoring \nstud due to \ncontinuous polymorphic delta>theta slowing over the right \ntemporal region, \nindicative of focal cerebral dysfunction. The higher amplitude \nactivity with \nsharp contours in that region was consistent with breach \nartifact due to known \nskull defect. There were no clinical events. There were no \nelectrographic \nseizures or epileptiform discharges. Compared to the previous \nday's recording, \nthe right posterior focal slowing became less prominent with PDR \nnoted also on \nthe right side. \n\n___\n\nCONTINUOUS EEG: The waking background showed fair organization \nand consisted \nof a moderate voltage, fairly sustained ___ Hz posterior \ndominant rhythm, \nwhich was better visualized on the left side. There were \ncontinuous higher \namplitude polymorphic delta>theta activities with sharp contours \nover the \nright temporal region. \n \nSLEEP: The patient progressed from wakefulness to N1, N2 sleep \nwith no \nadditional findings. \n \nPUSHBUTTON ACTIVATIONS: There were no push button activations. \n \nCARDIAC MONITOR: Showed a generally regular rhythm with an \naverage rate of \n60-80 bpm. \n \nIMPRESSION: This was an abnormal continuous video-EEG monitoring \nstudy due to continuous polymorphic delta>theta slowing over \nthe right temporal region, indicative of focal cerebral \ndysfunction. The higher amplitude activity with sharp contours \nin that region was consistent with breach artifact due to known \nskull defect. There were no clinical events. There were no \nelectrographic seizures or epileptiform discharges. Compared to \nthe previous day's recording, there was no significant change. \n\n \n\n \nBrief Hospital Course:\nMs. ___ is a ___ year old F with history of bilateral \nsuperior sagittal cerebral venous thrombosis with R frontal \nintracranial hemorrhage, subarachnoid hemorrhage (___) status \npost craniotomy and discharged on Coumadin, complicated by \nseizures, with follow up brain MRI at the time showing L \ntemporoparietal hemorrhage and subacute R frontal subdural \nhematoma in setting of warfarin use; you presented with \nbreakthrough seizures on ___ at an outside hospital, and you \nare transferred to ___ for continuous EEG monitoring and \nongoing management.\n\nOn initial presentation, she had seizure semiology with L head \nturn and L eye deviation with R temporal focality correlation on \nEEG. Patient was loaded with IV Keppra, IV Vimpat in addition to \nas needed IV Ativan and admitted to ICU with continuous EEG \nmonitoring. Her seizures were controlled with these medication \nchanges and her mental status gradually improved. Her home \nmedications lamotrigine and zonisamide were resumed orally. \nCT brain and MR head did not reveal any new infarction or acute \nhemorrhage or dural venous sinus thrombosis. With improvement in \nclinical status she was transferred to floor for continuation of \ncare. Patient's lamotrigine level was found to be \nsubtherapeutic, likely secondary to medication noncompliance, \nand explaining the increased frequency of her seizures. \nPatient's seizures were well-controlled with her medication \nmodifications, and continuous EEG was able to be discontinued in \npreparation for discharge. At time of discharge patient oriented \nto person, place, month, year. Patient had some peripheral \nweakness, which will hopefully improve with home physical \ntherapy. \n\nPatient's INR target of ___ was met with daily warfarin dosing, \nwith the average dose of 8 to 10 mg at night. \n\n___ OT were consulted and she participated fairly well, with plan \nfor home physical therapy.\n\nTransitional issues:\n- Continue daily warfarin dosing with an INR target of ___.\n- Follow up with ___ Neurology Epilepsy Nursing in 2 weeks for \nmed review and with Dr. ___ ___ months.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Zonisamide 200 mg PO DAILY \n2. Zonisamide 300 mg PO QHS \n3. LevETIRAcetam 500 mg PO BID \n4. Warfarin 10 mg PO DAILY16 \n5. Baclofen 10 mg PO BID \n6. LamoTRIgine 200 mg PO BID \n7. Pravastatin 20 mg PO DAILY \n8. FoLIC Acid 1 mg PO DAILY \n9. Ranitidine 300 mg PO DAILY \n10. Amantadine 100 mg PO DAILY \n11. Sertraline 125 mg PO DAILY \n\n \nDischarge Medications:\n1. Artificial Tears ___ DROP BOTH EYES Q4H:PRN dry eyes \n2. LACOSamide 100 mg PO BID 8AM, 8PM \nRX *lacosamide [Vimpat] 100 mg 1 tablet(s) by mouth twice a day \nDisp #*60 Tablet Refills:*4 \n3. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third \nLine \n4. LevETIRAcetam 1000 mg PO Q12H \nRX *levetiracetam [Keppra] 1,000 mg 1 tablet(s) by mouth twice a \nday Disp #*60 Tablet Refills:*4 \n5. Pravastatin 20 mg PO QPM \n6. Ranitidine 300 mg PO DAILY:PRN heartburn \n7. Ultra Fresh ___ (artificial tears with lanolin) Other 1 \nophthalmic (eye) QHS \n8. ___ MD to order daily dose PO DAILY16 \nINR Goal of ___.\nPatient requiring ___ daily while inpatient to achieve this \ngoal. \nRX *warfarin [Coumadin] 2 mg 1 tablet(s) by mouth once a day \nDisp #*150 Tablet Refills:*0 \n9. white petrolatum-mineral oil Other 1 topical DAILY:PRN dry \nskin \n10. Zonisamide 200 mg PO QAM \nRX *zonisamide [Zonegran] 100 mg 2 capsule(s) by mouth once a \nday Disp #*60 Capsule Refills:*4 \n11. Zonisamide 300 mg PO QPM \nRX *zonisamide [Zonegran] 100 mg 3 capsule(s) by mouth at \nbedtime Disp #*90 Capsule Refills:*4 \n12. Amantadine Syrup 100 MG PO DAILY \nRX *amantadine HCl 50 mg/5 mL 10 ml by mouth once a day \nRefills:*3 \n13. Baclofen 10 mg PO BID \n14. clotrimazole-betamethasone ___ % topical Other As needed \n \n15. FoLIC Acid 1 mg PO DAILY \n16. Hydrocortisone Cream 2.5% 1 Appl TP SEE BELOW \n17. Ketoconazole 2% 1 Appl TP BID As needed \n18. Ketoconazole Shampoo 1 Appl TP ASDIR \n19. LamoTRIgine 200 mg PO BID \nRX *lamotrigine [Lamictal] 200 mg 1 tablet(s) by mouth twice a \nday Disp #*60 Tablet Refills:*4 \n20. nystatin 100,000 unit/gram topical Other \n21. pyrithione zinc 2 % Other Other See below \n22. Senna 8.6 mg PO BID:PRN Constipation - First Line \n23. Sertraline 125 mg PO DAILY \n24. Vitamin D 1000 UNIT PO DAILY \n25. HELD- Miconazole Nitrate Vag Cream 2% 1 Appl VG QHS \nDuration: 7 Days This medication was held. Do not restart \nMiconazole Nitrate Vag Cream 2% until you review with your \nprimary care provider \n26. HELD- Omeprazole 20 mg PO DAILY This medication was held. \nDo not restart Omeprazole until untill reviewing need with \nprimary care provider \n\n \n___:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\n#Seizures\n\n \nDischarge Condition:\nMental Status: Confused - sometimes.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou were admitted to the hospital for management of your \nseizures. You had multiple seizures in the emergency room and \nwere started on intravenous medication. At presentation, your \nlabs came back to show your lamotrigine dose was subtherapeutic. \n You also underwent EEG, a test to monitor electrical activity \nof the brain which showed many focal onset seizures. You were \nstarted on lacosamide (VIMPAT) in addition to your home \nmedications Keppra, lamotrigine and zonisamide. Keppra dose was \nalso increased to 1000mg twice daily. Your seizures were \ncontrolled with these medication changes and your mental status \nreturned to normal. Physical and Occupational Therapy were \nconsulted who recommended continuing therapy in a rehab \nfacility. The most likely etiology of your worsening seizure \nfrequency was medication noncompliance.\n\nMedication changes:\nKeppra dose increased to 1000 mg twice daily\nVimpat 100 mg twice daily added\n\nPlease follow all seizure precautions, which includes not \npartaking in any activities where a seizure can place you in \ngreat harm without supervision.. Even though it is not \nnecessarily applicable, ___ law prohibits you from \ndriving for the next 6 months. You should not consider driving, \nor operating heavy machinery until cleared by your neurologist. \n\n\nThank you for the opportunity to partake in your care,\n\nThe ___ neurology team.\n \nFollowup Instructions:\n___\n"
] | Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Seizures Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] year old right handed woman with a history of epilepsy secondary to cerebral venous thrombosis with recurrent multifocal hemorrhages who presents as a transfer from an OSH for multiple breakthrough seizures. Patient is too lethargic to give detailed history though she answers some questions with repeated prompting. History obtained mostly from chart review. Per notes from [MASKED]: "Per mother, witnessed seizure at 3 pm on sofa. Per mother, since then has been slow to respond and keeps turning head to left side becoming unresponsive. Pt appeared postictal." Patient's mother said she had at least 10 episodes of unresponsive with head turn all the way to the left and slight shake of L hand. Resolved each time within [MASKED] minutes. Immediately awake and alert when they resolve. Patient was at the same ED yesterday for headache but CT wnl. The OSH discussed with [MASKED] neurology who recommended 1.5g Keppra IV and increased Keppra from 500 to 750 mg BID. Then, patient was transferred to [MASKED] for cvEEG. In [MASKED] ED, she was noted to have "a brief period of unresponsiveness with head turn to the side." She received Ativan 2mg IV at 00:05 am with symptomatic improvement. Per patient, she is here due to seizures and she feels sleepy. She said she did not sleep all night the previous night due to headaches. She denies a headache currently. She denies any illness or feeling unwell recently. Denies fever, chills, cough, n/v, diarrhea. She says she has been adherent to all medications and did not miss any doses of her AEDs. When asked, she was able to tell me that she takes keppra and lamotrigine twice a day in addition to zonisamide 2 pills in the morning and 3 pills at night. She was unable to say whether these seizures are her typical seizures, but per chart review, left head turn and leftward eye deviation was not recorded as a typical semiology. Per most recent Epilepsy Clinic note on [MASKED] by Dr. [MASKED] Dr. [MASKED]: "#Typical Events: 1. Mouth shaking, tongue heaviness and a sensation that "left vision is not okay." There is no loss of awareness with these. She is not sure how often these are occurring. None since her last visit. 2. Palpitations, dizziness, things are spinning around and right mouth twitching, tongue feels heavy, cannot talk. Again with maintained awareness. None since her last visit. 3. Left hand clenches and cannot see well, feels like she does not have an arm. There is left sided body pain, feels like bones are breaking. Last time lasted more than 6 minutes. None recently. 4. Receptive aphasia for up to 2 minutes. Frequency is unclear. None since her last visit. 5. Left arm shaking. Preceded by feeling of dizziness/lightheadedness, left arm tremor, and left lip and eyelid twitchings. No LOC, confusion, tongue biting, or incontinence. Once in [MASKED], and none since. #History of AEDs -Initially, since CVT in [MASKED], was on levetiracetam 500 BID + valproate qdaily. -During [MASKED], she started having seizures. Levetiracetam was titrated up several times during this month (up to 1.5 g BID at one point). Valproate was discontinued in concern for its potential adverse effects on a female. -Levetiracetam was weaned off during the same month due to mood side effects (irritability). She was switched to oxcarbazepine. -During [MASKED], levetiracetam was resumed (500 BID) due to continuing breakthrough seizures on oxcarbazepine with dose up to 750 BID (level 31.4). -In [MASKED], oxcarbazepine was weaned off due to inefficacy and she was switched to zonisamide 400 mg qdaily. Levetiracetam was left unchanged. -In [MASKED], zonisamide was increased to 500 mg qdaily due to continuing episodes of breakthrough seizures (1/ month, ?provoked by her periods). Levetiracetam was left unchanged. -In [MASKED], lamotrigine 100 mg BID was added due to continuing episodes of breakthrough seizures. Significant reduction in seizure frequency was noted during subsequent follow-up visits on this dose. -Lamotrigine was increased to 150 mg BID in [MASKED] due to episodes of breakthrough seizures and low serum level. Increased further up to 200 BID on [MASKED] due to an electrographic seizure captured on ambulatory EEG in [MASKED] and another breakthrough seizure the same month." Regarding her intracerebral hemorrhage history, chart notes shows that she had a superior sagittal sinus thrombosis in [MASKED] with subsequent bilateral SAH and right SDH, status post evacuation. Later in [MASKED], she had a new left temporoparietal hemorrhage, right frontal hemorrhage, and right SDH and slow flow in the left transverse sinus. Patient appears to have been kept on anticoagulation since then. She saw a hematologist at [MASKED] once in [MASKED]. Past Medical History: HLD Migraine headaches thyromegaly uterine fibroids. cerebral venous sinus thrombosis complicated by intracranial hemorrhages and [MASKED] s/p R craniotomy, S/p trach and peg, now reversed(For details please see Dr. [MASKED] note on [MASKED] and [MASKED] ICH and R frontal SDH, left sided thrombosis found on post hospital imaging anticardiolpin antibody in undetermined significance Social History: [MASKED] Family History: DM, denies strokes or blood disorders. Physical Exam: On admission: PHYSICAL EXAMINATION Vitals: T 98.8, HR 66, BP 106/70, SpO2 99% on RA. [MASKED] pain. General: woman trying to sleep in stretcher, lethargic, NAD HEENT: EEG and cap in place, no oropharyngeal lesions, neck supple [MASKED]: warm, well-perfused Pulmonary: no increased work of breathing Abdomen: Soft, ND Extremities: Warm, no edema Neurologic Examination: - Mental status: somnolent but rousable to voice, oriented to self, [MASKED], [MASKED]. Too sleepy to relate history but answering some questions. Inattentive, able to name [MASKED] forwards (started to use [MASKED] for weekend days), but unable to name [MASKED] backwards. Naming is intact to high frequency objects but not to low frequency objects, which patient says she does not know the [MASKED] words for. No dysarthria. No left-right confusion. Able to follow both midline and appendicular commands. - Cranial Nerves: PERRL 4->2 brisk. VF full to number counting. EOMI, no nystagmus. V1-V3 without deficits to light touch bilaterally. Slightly delayed activation of L lower face. Hearing intact to voice. Palate elevation symmetric. Trapezius strength [MASKED] bilaterally. Tongue midline with good excursions. - Motor: increased tone in LUE, LLE. L pronation. No tremor or asterixis. [Delt][Bic][Tri] [[MASKED]] L 4 5 5 4 4 4 4 4 R 5 5 5 5 5 5 5 5 Patient not participating consistently for formal confrontational testing. - Reflexes: +suprapatellar on L. [Bic] [Tri] [[MASKED]] [Quad] [Gastroc] L 3 2+ 2+ 3 1 R 2 2 2 2 1 Plantar response downgoing on R, upgoing on L. - Sensory: No deficits to light touch bilaterally. - Coordination: No dysmetria with finger to nose testing on R. Dysmetria on FNF on LUE is proportional to weakness. - Gait: unable to assess At discharge: 24 HR Data (last updated [MASKED] @ 2358) Temp: 98.3 (Tm 98.7), BP: 94/58 (93-106/58-71), HR: 81 (79-110), RR: 18, O2 sat: 98%, O2 delivery: Ra General: Awake Alert, lying in bed , In no acute distress. HEENT: neck supple [MASKED]: warm, well-perfused Pulmonary: no increased work of breathing Extremities: Warm, no edema Neurologic Examination: - Mental status: Alert Awake. oriented to [MASKED], date, and person. No dysarthria. Able to follow both midline and appendicular commands. some word finding difficulty. No apraxia noted. Able to say she is doing fine today. [MASKED] is not her primary language. - Cranial Nerves: hearing intact to voice. Delayed but symmetric activation of lower face. EOMI. Trapezius strength [MASKED] bilaterally. Tongue midline with good excursions. Hearing symmetric to finger rub. - Motor: No pronator drift. Resting tremor L>R. No asterixis. Exam limited by effort. [Delt][Bic][Tri] [IP] [Quad] [Ham] [TA] [Gas] [[MASKED]] L 4+ 5 5 5 5 5 3 4+ 4+ R 5 5 5 5 5 5 5 5 5 - Reflexes: Brisk on left and plantar upgoing on left. Downgoing on right - Sensory: notes symmetric to light touch - Coordination: No dysmetria with reaching, action tremor worse on right. Pertinent Results: [MASKED] 06:10AM BLOOD WBC-4.9 RBC-5.28* Hgb-11.6 Hct-38.5 MCV-73* MCH-22.0* MCHC-30.1* RDW-22.5* RDWSD-55.9* Plt [MASKED] [MASKED] 06:00AM BLOOD Neuts-55.1 [MASKED] Monos-12.6 Eos-2.8 Baso-0.3 Im [MASKED] AbsNeut-3.32 AbsLymp-1.73 AbsMono-0.76 AbsEos-0.17 AbsBaso-0.02 [MASKED] 06:05AM BLOOD [MASKED] [MASKED] 05:50AM BLOOD [MASKED] [MASKED] 06:10AM BLOOD [MASKED] [MASKED] 06:10AM BLOOD [MASKED] [MASKED] 06:05AM BLOOD [MASKED] [MASKED] 06:10AM BLOOD Glucose-86 UreaN-14 Creat-0.9 Na-146 K-4.4 Cl-114* HCO3-22 AnGap-10 [MASKED] 06:00AM BLOOD ALT-14 AST-14 AlkPhos-83 TotBili-0.2 [MASKED] 06:10AM BLOOD Calcium-9.2 Phos-2.9 Mg-2.2 [MASKED] 01:37AM BLOOD LEVETIRACETAM (KEPPRA)-Test [MASKED] 01:37AM BLOOD ZONISAMIDE(ZONEGRAN)-Test [MASKED] 01:37AM BLOOD LAMOTRIGINE-Test [MASKED] 07:47AM URINE Color-Yellow Appear-Hazy* Sp [MASKED] [MASKED] 07:47AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-TR* Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-MOD* [MASKED] 07:47AM URINE RBC-2 WBC-1 Bacteri-FEW* Yeast-NONE Epi-2 [MASKED] 07:47AM URINE UCG-NEGATIVE [MASKED] 07:47AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG Time Taken Not Noted Log-In Date/Time: [MASKED] 7:48 am URINE **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. Chest PA/Lat FINDINGS: Low lung volumes. Patchy opacifications are demonstrated at both lower lobes which likely reflect atelectasis. Cardiomediastinal and hilar contours are unremarkable. No pulmonary edema. No pleural effusions or pneumothorax. The visualized osseous structures are grossly unremarkable. The upper abdomen demonstrates a nonobstructive gas pattern. IMPRESSION: Patchy opacifications of lobes likely reflect atelectasis. No pulmonary edema or pleural effusions. EXAMINATION: MR HEAD W AND W/O CONTRAST T MR HEAD INDICATION: [MASKED] year old woman with H/o venous sinus thrombosis and epilepsy presenting with seizures, ? Right frontal hyper density. PLEASE PERFORM WITH POST CONTRAST MP RAGE SEQUENCES// presenting with seizures, ? Right frontal hyper density. PLEASE PERFORM WITH POST CONTRAST MP RAGE SEQUENCES TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After administration of intravenous contrast, axial imaging was performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was performed and re-formatted in axial and coronal orientations. COMPARISON: CT head dated [MASKED], MRI dated [MASKED]. FINDINGS: Stable appearance of the right frontoparietotemporal craniotomy with unchanged adjacent subdural fluid collection. Encephalomalacia with gliosis and surrounding T2/FLAIR hyperintensity are again noted in the bifrontal, right parietal, and right temporal lobes, grossly unchanged since prior exam. There is stable ex vacuo dilatation of the right ventricle. There is unchanged appearance of susceptibility artifact within the area of known encephalomalacia. No evidence of intracranial hemorrhage is appreciated. There are multiple foci of diffusion restriction with associated FLAIR hyperintensity and peripheral enhancement. These lesions appear decreased in size compared to MRI dated [MASKED], with the largest lesion now measuring up to 1.5 cm. There is no large vascular distribution infarct. The visualized vascular flow voids are grossly unremarkable. The dural venous sinuses are patent. The paranasal sinuses and mastoid air cells are clear. No abnormal marrow signal. IMPRESSION: 1. No acute intracranial findings. No evidence of an acute infarction, or new hemorrhage. 2. Stable postsurgical changes with unchanged encephalomalacia in the bifrontal, and right parietotemporal region. Interval decrease of enhancement within the area of encephalomalacia compared to MRI dated [MASKED]. 3. No evidence of acute dural venous sinus thrombosis. cvEEG - FINDINGS: [MASKED] FINDINGS: CONTINUOUS EEG RECORDING: Began at 02:17 on the morning of [MASKED] and continued until 07:00 on the same day. From the beginning, the background was continuous and generally dominated by low-voltage faster pattern, but with continuous 1.5 Hz delta slowing over the right hemisphere, maximal over the right temporal region and somewhat more broadly over the right posterior quadrant. There was abundant superimposed faster, beta activity, particularly anteriorly. There were six clinical and electrographic seizures, all arising from the right hemisphere. The seizures had two patterns. " The first seizure began at 02:43:51 with rhythmic, high amplitude sharp alpha activity at 13 Hz over the right frontocentral and parietal regions, maximal at F4-C4, and sometimes at P4 , which rapidly extended to the rest of the right hemisphere, and then, approximately [MASKED] seconds later, to the midline and left posterior quadrant by 02:43:56 and over the entire left hemisphere by 02:44:18. By 02:44:44, there was more [MASKED] Hz slowing broadly over the left hemisphere and to a lesser extent on the right. The faster sharp waves continued on the right side through 02:45, with modest voltage diminution in the right temporal region for several seconds. On video, the patient was supine with her head tilted to the left prior to the event. At 02:43:54, she had intermittent mouth puckering movements. At 02:44:14, the left arm became flexed and had low amplitude shaking movements. By 02:44:30, there was some left head version and sustained left gaze deviation. These stopped at 02:44:53, as she returned to the midline. She then blinked for a few seconds and returned to her previous state. Similar seizures were noted at 03:48 (with an onset more readily localized to about C4 ; lasting 1 minute and 22 seconds), 04:36 (lasting 1 minute and 25 seconds), 05:23 (lasting 1 minute and 20 seconds), and 06:32 (lasting 1 minute and 29 seconds). " There was a seizure with a somewhat different pattern at 05:05:40, with right temporal onset, best seen at T4 in the right mid temporal region. It began with high voltage rhythmic delta slow wave activity with superimposed sharp waves at 5 Hz, maximal at F8-T4. By 05:05:45, it involved the rest of the right temporal chain and posterior quadrant, and the morphology changed to high amplitude sharp alpha frequency activity. The rest of the right hemisphere was involved by 05:05:52. By 05:05:55, there was involvement of the left frontal and midline regions, which gradually increased in frequency and amplitude. By 05:07:09, the background returned to rhythmic delta slowing with superimposed sharp waves at [MASKED] Hz, which gradually decreased in frequency and amplitude before stopping at 05:07:24. On video, the patient was in bed and appeared drowsy, with her head tilted to the left. The examiner asked her questions and she did not answer. The left arm appeared to be in sustained flexion under the covers. Her face was not well visualized for much of the seizure, but there was a clear left gaze deviation when her head was turned toward the end of the event. SLEEP: No normal waking or sleep patterns were evident. CARDIAC MONITORING: showed a generally regular rhythm, with an average rate of 65-80 bpm. SPIKE DETECTION PROGRAMS: Showed no definite epileptiform features. SEIZURE DETECTION PROGRAMS: Captured the seizures described above. PUSHBUTTON ACTIVATIONS: There were two pushbutton activations, one at 5:08, and the other at 5:24, for 2 of the seizures detailed above. QUANTITATIVE EEG: Trend analysis was performed with Persyst Magic Marker software. Panels included automated seizure detection, rhythmic run detection and display, color spectral density array, absolute and relative asymmetry indices, asymmetry spectrogram, amplitude integrated EEG, burst suppression ratio, envelope trend, and alpha delta ratios. Segments showing abnormal trends were reviewed. IMPRESSION: This telemetry captured 2 pushbutton activations, and showing two of the seizures described above. Overall, however, there were 6 seizures recorded, all lasting under 2 minutes, all beginning on the right side, and all but one beginning in the right frontocentral region. The final seizure began in the right mid temporal region. During the events, the patient had some head turning to the left and some eye deviation to the left, but there was no convulsion. Between seizures, there was very prominent right temporal and right posterior quadrant [MASKED] Hz delta slowing, suggesting the possibility of a structural lesion in that area. Interictally, there was also frequent low-voltage rapid beta activity, likely reflective of medication. [MASKED] FINDINGS: CONTINUOUS EEG RECORDING: Began at 07:01 on the morning of [MASKED] and continued until 07:00 on the following morning. From the beginning, the background was continuous and asymmetric. Over the right hemisphere, there was continuous delta slowing at [MASKED] Hz with superimposed low voltage faster activity, maximal temporally (particularly over T4). Over the left hemisphere, there was a moderate amount of 8 Hz activity with brief periods of admixed [MASKED] Hz slowing. As the record progressed, the background frequencies over the right hemisphere increased, particularly by 14:00, with some superimposed faster rhythms admixed with the continuous slowing at [MASKED] Hz. At times, the delta slowing was rhythmic over the right posterior quadrant, particularly after 02:00. The leads were disconnected at 18:13 and reconnected at 19:32, but there was no change to the background in the interim. There were 8 clinical and electrographic seizures noted during the earlier part of the recording, all with right hemispheric onset. Three of these seizures occurred in a cluster between 07:23 and 07:28, as detailed below. The first seizure began at 07:23:21 with rhythmic, high voltage sharp 14 Hz rhythms over the right temporal region, maximal at F8-T4, which rapidly extended to the rest of the right hemisphere over [MASKED] seconds, then to the midline and left posterior quadrant by 07:23:28, and was generalized by 07:23:34. There was diminution in voltage and frequency over the left hemisphere by 07:24:07, then decreasing to [MASKED] Hz, before stopping at 07:24:32. The faster sharp waves on the right hemisphere persisted until 07:24:36, then again diminished in voltage and frequency gradually until the seizure ended at 07:24:43, followed by slowing over the right hemisphere and then return to the previous background. On video, the patient was awake and looking around the room prior to the event. At 07:23:31, there was left head version, followed by left arm flexion a few seconds later, with low amplitude clonic left arm movements by 07:23:47, and sustained left gaze deviation by 07:23:50. By 07:24:18, there was right arm elevation with flexor posturing of the wrist for a few seconds. The head and gaze deviation returned to [MASKED] by 07:24:38. The next seizure began at 07:25:33 with 14 Hz sharp wave activity in right frontocentral region, maximal F4-C4, initially moderate voltage, becoming high voltage a few seconds later. It extended to the remainder of the hemisphere, midline and left posterior quadrant by 07:25:41. The sharp alpha activity diminished in voltage and frequency over the left hemisphere by 07:26:26, then over the right hemisphere by 07:26:37, with persistent high amplitude delta slowing over the right until stopping at 07:26:50. This was followed by 1.5 minutes of widespread slowing, most prominently over the right temporal region. On video, the patient was awake and scratching her EKG leads prior to the event. On video, she gradually turned her head to the left by 07:26:00, and there was again left gaze deviation. There appeared to be some abduction of the right arm, though it was unclear if this was volitional. Similar seizures of right frontocentral onset occurred at 08:24 (1 minute and 36 seconds, onset more prominent over C4-P4), 09:47 (1 minute and 24 seconds, F4- C4 onset), 09:58 (1 minute and 14 seconds, F4-C4 onset, initially is able to communicate with the nurse early in seizure but later cannot), 10:17 (1 minute and 22 seconds, F4-C4 onset), 11:13 (1 minute and 16 seconds, onset more prominent over C4-P4), 11:46 (1 minute and 8 seconds, F4-C4 onset). Later in the recording, there were two brief electrographic seizures lasting about 25 seconds each. The first began at 22:04:47 with lateralized rhythmic delta slowing with superimposed sharp waves and fast activity ([MASKED]) arising from the right frontotemporal region (maximal at F8-T4) at [MASKED] Hz, spreading to the right posterior quadrant after a few seconds, then to the midline and left posterior quadrant by 22:04:54, increasing in voltage and frequency to become a sharp alpha rhythm before abruptly stopping at 22:05:11. This was followed by 2 seconds of widespread voltage attenuation and slowing, followed by a 3 second burst of generalized sharply contoured alpha rhythms. On video, the patient was sleeping; there was no apparent clinical correlate. A similar seizure occurred at 22:25:13 lasting 24 seconds, which again occurred during sleep and did not have a clear clinical correlate. SLEEP: No normal waking or sleep patterns were evident. CARDIAC MONITORING: showed a generally regular rhythm, with an average rate of 60-95 bpm. SPIKE DETECTION PROGRAMS: Showed no definite epileptiform features. SEIZURE DETECTION PROGRAMS: Captured the seizures described above. PUSHBUTTON ACTIVATIONS: There were none. QUANTITATIVE EEG: Trend analysis was performed with Persyst Magic Marker software. Panels included automated seizure detection, rhythmic run detection and display, color spectral density array, absolute and relative asymmetry indices, asymmetry spectrogram, amplitude integrated EEG, burst suppression ratio, envelope trend, and alpha delta ratios. Segments showing abnormal trends were reviewed. IMPRESSION: This telemetry captured no pushbutton activations. There were 8 clinical and electrographic seizures recorded, all arising from the right hemisphere, and all but one beginning in the right frontocentral region. The clinical correlate was left head turning, left gaze deviation, and behavioral arrest. There were also 2 brief electrographic seizures arising from the right frontocentral and temporal regions, lasting about 20 seconds, without any obvious clinical correlate, later in the recording. Otherwise, there was prominent delta slowing over the right hemisphere, maximal temporally, suggesting the possibility of a structural lesion in that area. Interictally, there were also frequent low-voltage faster, beta rhythms, likely reflective of medication. [MASKED] FINDINGS: CONTINUOUS EEG: The background activity was asymmetric. On the left side, a moderate voltage, poorly sustained [MASKED] Hz posterior dominant rhythm was seen. On the right side, there was continuous polymorphic delta>theta slowing over the posterior quadrant, maximal in the right temporal region, which occasionally became semirhythmic. Higher amplitude and sharply contoured activities were noted in the right posterior quadrant. SLEEP: The patient progressed from wakefulness to N1, N2 sleep with no additional findings. PUSHBUTTON ACTIVATIONS: There were no push button activations. CARDIAC MONITOR: Showed a generally regular rhythm with an average rate of 60-80 bpm. IMPRESSION: This was an abnormal continuous video-EEG monitoring stud due to continuous polymorphic or semi-rhythmic delta slowing over the right posterior quadrant (maximal in the right temporal region), indicative of focal cerebral dysfunction. The higher amplitude activity with sharp features in that region was consistent with breach artifact due to known skull defect. There were no clinical events. There were no electrographic seizures. Compared to the previous day' recording, there was no significant change [MASKED] CONTINUOUS EEG: The background activity was asymmetric. On the left side, a moderate voltage, fairly sustained [MASKED] Hz posterior dominant rhythm was seen. On the right side, there was continuous polymorphic delta>theta slowing over the posterior quadrant, maximal in the right temporal region, which occasionally became semirhythmic. Higher amplitude and sharply contoured activities were noted in the right posterior quadrant. SLEEP: The patient progressed from wakefulness to N1, N2 sleep with no additional findings. PUSHBUTTON ACTIVATIONS: There were no push button activations. CARDIAC MONITOR: Showed a generally regular rhythm with an average rate of 60-80 bpm. IMPRESSION: This was an abnormal continuous video-EEG monitoring stud due to continuous polymorphic or semi-rhythmic delta slowing over the right posterior quadrant (maximal in the right temporal region), indicative of focal cerebral dysfunction. The higher amplitude activity with sharp features in that region was consistent with breach artifact due to known skull defect. There were no clinical events. There were no electrographic seizures. Compared to the previous day' recording, there was no significant change. [MASKED] FINDINGS: CONTINUOUS EEG: The waking background showed fair organization and consisted of a moderate voltage, fairly sustained [MASKED] Hz posterior dominant rhythm, which was better visualized on the left side. There were continuous higher amplitude polymorphic delta>theta activities with sharp contours over the right temporal region. SLEEP: The patient progressed from wakefulness to N1, N2 sleep with no additional findings. PUSHBUTTON ACTIVATIONS: There were no push button activations. CARDIAC MONITOR: Showed a generally regular rhythm with an average rate of 60-80 bpm. IMPRESSION: This was an abnormal continuous video-EEG monitoring stud due to continuous polymorphic delta>theta slowing over the right temporal region, indicative of focal cerebral dysfunction. The higher amplitude activity with sharp contours in that region was consistent with breach artifact due to known skull defect. There were no clinical events. There were no electrographic seizures or epileptiform discharges. Compared to the previous day's recording, the right posterior focal slowing became less prominent with PDR noted also on the right side. [MASKED] CONTINUOUS EEG: The waking background showed fair organization and consisted of a moderate voltage, fairly sustained [MASKED] Hz posterior dominant rhythm, which was better visualized on the left side. There were continuous higher amplitude polymorphic delta>theta activities with sharp contours over the right temporal region. SLEEP: The patient progressed from wakefulness to N1, N2 sleep with no additional findings. PUSHBUTTON ACTIVATIONS: There were no push button activations. CARDIAC MONITOR: Showed a generally regular rhythm with an average rate of 60-80 bpm. IMPRESSION: This was an abnormal continuous video-EEG monitoring study due to continuous polymorphic delta>theta slowing over the right temporal region, indicative of focal cerebral dysfunction. The higher amplitude activity with sharp contours in that region was consistent with breach artifact due to known skull defect. There were no clinical events. There were no electrographic seizures or epileptiform discharges. Compared to the previous day's recording, there was no significant change. Brief Hospital Course: Ms. [MASKED] is a [MASKED] year old F with history of bilateral superior sagittal cerebral venous thrombosis with R frontal intracranial hemorrhage, subarachnoid hemorrhage ([MASKED]) status post craniotomy and discharged on Coumadin, complicated by seizures, with follow up brain MRI at the time showing L temporoparietal hemorrhage and subacute R frontal subdural hematoma in setting of warfarin use; you presented with breakthrough seizures on [MASKED] at an outside hospital, and you are transferred to [MASKED] for continuous EEG monitoring and ongoing management. On initial presentation, she had seizure semiology with L head turn and L eye deviation with R temporal focality correlation on EEG. Patient was loaded with IV Keppra, IV Vimpat in addition to as needed IV Ativan and admitted to ICU with continuous EEG monitoring. Her seizures were controlled with these medication changes and her mental status gradually improved. Her home medications lamotrigine and zonisamide were resumed orally. CT brain and MR head did not reveal any new infarction or acute hemorrhage or dural venous sinus thrombosis. With improvement in clinical status she was transferred to floor for continuation of care. Patient's lamotrigine level was found to be subtherapeutic, likely secondary to medication noncompliance, and explaining the increased frequency of her seizures. Patient's seizures were well-controlled with her medication modifications, and continuous EEG was able to be discontinued in preparation for discharge. At time of discharge patient oriented to person, place, month, year. Patient had some peripheral weakness, which will hopefully improve with home physical therapy. Patient's INR target of [MASKED] was met with daily warfarin dosing, with the average dose of 8 to 10 mg at night. [MASKED] OT were consulted and she participated fairly well, with plan for home physical therapy. Transitional issues: - Continue daily warfarin dosing with an INR target of [MASKED]. - Follow up with [MASKED] Neurology Epilepsy Nursing in 2 weeks for med review and with Dr. [MASKED] [MASKED] months. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Zonisamide 200 mg PO DAILY 2. Zonisamide 300 mg PO QHS 3. LevETIRAcetam 500 mg PO BID 4. Warfarin 10 mg PO DAILY16 5. Baclofen 10 mg PO BID 6. LamoTRIgine 200 mg PO BID 7. Pravastatin 20 mg PO DAILY 8. FoLIC Acid 1 mg PO DAILY 9. Ranitidine 300 mg PO DAILY 10. Amantadine 100 mg PO DAILY 11. Sertraline 125 mg PO DAILY Discharge Medications: 1. Artificial Tears [MASKED] DROP BOTH EYES Q4H:PRN dry eyes 2. LACOSamide 100 mg PO BID 8AM, 8PM RX *lacosamide [Vimpat] 100 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*4 3. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line 4. LevETIRAcetam 1000 mg PO Q12H RX *levetiracetam [Keppra] 1,000 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*4 5. Pravastatin 20 mg PO QPM 6. Ranitidine 300 mg PO DAILY:PRN heartburn 7. Ultra Fresh [MASKED] (artificial tears with lanolin) Other 1 ophthalmic (eye) QHS 8. [MASKED] MD to order daily dose PO DAILY16 INR Goal of [MASKED]. Patient requiring [MASKED] daily while inpatient to achieve this goal. RX *warfarin [Coumadin] 2 mg 1 tablet(s) by mouth once a day Disp #*150 Tablet Refills:*0 9. white petrolatum-mineral oil Other 1 topical DAILY:PRN dry skin 10. Zonisamide 200 mg PO QAM RX *zonisamide [Zonegran] 100 mg 2 capsule(s) by mouth once a day Disp #*60 Capsule Refills:*4 11. Zonisamide 300 mg PO QPM RX *zonisamide [Zonegran] 100 mg 3 capsule(s) by mouth at bedtime Disp #*90 Capsule Refills:*4 12. Amantadine Syrup 100 MG PO DAILY RX *amantadine HCl 50 mg/5 mL 10 ml by mouth once a day Refills:*3 13. Baclofen 10 mg PO BID 14. clotrimazole-betamethasone [MASKED] % topical Other As needed 15. FoLIC Acid 1 mg PO DAILY 16. Hydrocortisone Cream 2.5% 1 Appl TP SEE BELOW 17. Ketoconazole 2% 1 Appl TP BID As needed 18. Ketoconazole Shampoo 1 Appl TP ASDIR 19. LamoTRIgine 200 mg PO BID RX *lamotrigine [Lamictal] 200 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*4 20. nystatin 100,000 unit/gram topical Other 21. pyrithione zinc 2 % Other Other See below 22. Senna 8.6 mg PO BID:PRN Constipation - First Line 23. Sertraline 125 mg PO DAILY 24. Vitamin D 1000 UNIT PO DAILY 25. HELD- Miconazole Nitrate Vag Cream 2% 1 Appl VG QHS Duration: 7 Days This medication was held. Do not restart Miconazole Nitrate Vag Cream 2% until you review with your primary care provider 26. HELD- Omeprazole 20 mg PO DAILY This medication was held. Do not restart Omeprazole until untill reviewing need with primary care provider [MASKED]: Home With Service Facility: [MASKED] Discharge Diagnosis: #Seizures 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. [MASKED], You were admitted to the hospital for management of your seizures. You had multiple seizures in the emergency room and were started on intravenous medication. At presentation, your labs came back to show your lamotrigine dose was subtherapeutic. You also underwent EEG, a test to monitor electrical activity of the brain which showed many focal onset seizures. You were started on lacosamide (VIMPAT) in addition to your home medications Keppra, lamotrigine and zonisamide. Keppra dose was also increased to 1000mg twice daily. Your seizures were controlled with these medication changes and your mental status returned to normal. Physical and Occupational Therapy were consulted who recommended continuing therapy in a rehab facility. The most likely etiology of your worsening seizure frequency was medication noncompliance. Medication changes: Keppra dose increased to 1000 mg twice daily Vimpat 100 mg twice daily added Please follow all seizure precautions, which includes not partaking in any activities where a seizure can place you in great harm without supervision.. Even though it is not necessarily applicable, [MASKED] law prohibits you from driving for the next 6 months. You should not consider driving, or operating heavy machinery until cleared by your neurologist. Thank you for the opportunity to partake in your care, The [MASKED] neurology team. Followup Instructions: [MASKED] | [
"G40919",
"I69154",
"Z86718",
"Z7901",
"E7849",
"G43909",
"E010",
"Z9114",
"K219",
"D573",
"R4189",
"F329"
] | [
"G40919: Epilepsy, unspecified, intractable, without status epilepticus",
"I69154: Hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left non-dominant side",
"Z86718: Personal history of other venous thrombosis and embolism",
"Z7901: Long term (current) use of anticoagulants",
"E7849: Other hyperlipidemia",
"G43909: Migraine, unspecified, not intractable, without status migrainosus",
"E010: Iodine-deficiency related diffuse (endemic) goiter",
"Z9114: Patient's other noncompliance with medication regimen",
"K219: Gastro-esophageal reflux disease without esophagitis",
"D573: Sickle-cell trait",
"R4189: Other symptoms and signs involving cognitive functions and awareness",
"F329: Major depressive disorder, single episode, unspecified"
] | [
"Z86718",
"Z7901",
"K219",
"F329"
] | [] |
15,080,981 | 28,478,412 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nClindamycin / FLU Vaccine ___\n \nAttending: ___.\n \nChief Complaint:\nFever\n \nMajor Surgical or Invasive Procedure:\n___ placement ___ under anesthesia \n\n \nHistory of Present Illness:\n___ year old bedbound male with complicated PMH included multiple\nUTI iso nephrolithiasis including most recently proteus\nbacteremia, chronic DVT/PE on lovenox, ankylosing spondylitis on\nprednisone who presents from ___ with new\nbacteremia Coagulase Negative Staph and klebsiella ESBL UTI in\nsetting of PICC line in place since ___. \n\n Patient was recently admitted to ___ from ___ for\nProteus bacteremia/urosepsis in setting of nephrolithiasis. That\nhospital course was complicated by c. diff colitis requiring\nvancomycin with taper completing ___ ___s very difficult\nIV access, requiring intubation for placement of PICC for\nceftriaxone course scheduled from ___. He was discharged\nwith one remaining day of IV ceftriaxone, his PICC was never\nremoved. He was also supposed to follow up with his urologist \nDr.\n___ had planned to consider further lithotripsy as an\noutpatient.\n \n Mr. ___ reports new right sided arm pain at the ___ site \nfor\nabout a week as well as fevers since around ___, he denies\nabdominal pain, back pain, pain with urination or foul smelling\nurine. Spoke with ___ at ___\n(___)\n- slurred speech and drowsy at baseline secondary to pain\nmedication\n- ___ Director ordered BCx and UCx on ___ which since grew\nout two biotypes of Coagulase Negative Staph in aerobic and\nanaerobic bottles (R oxacillin, susceptible to vancomycin) as\nwell as UCx with Klebsiella ESBL susceptible to levofloxacin,\nciprofloxacin, imipenem, ertapenem\n- BP typically 120-130s/70-80, facility staff usually takes BP \non\nthe left leg with ___\n- facility medication list confirmed, notably was ordered for\nertapenem on ___ but did not receive\n- overnight facility staff, and patient, unsure as to why PICC\nline had not been removed\n\nIn the ED, initial vital signs were: T: 101.1 HR: 68 BP: \n119/70\nRR: 16 SO2: 96% RA \n- Exam notable for: Abd: Soft ND NT. Surgically reconstructed\nabdominal wall Ext: WWP no edema. Partial Amputation of R foot\nLines: R PICC with dried purulence.\n- Labs were notable for... \n WBC: 15.8 Hgb: 10.1 Plt: 269 \n Crt: 1.1\n Ca: 8.6 Mg: 1.3 P: 1.5\n lactate: 3.0 -> 1.0\n- Studies performed include... CXR with Right PICC tip appears\nto terminate at the confluence of the brachiocephalic \n veins. Retrocardiac opacity could reflect atelectasis. \n\n- Patient was given... \n___ 21:11 IVF NS ___ Started \n___ 21:11 PO/NG Acetaminophen 650 mg ___ \n___ 22:19 PO/NG HYDROmorphone (Dilaudid) 6 mg\n___ \n___ 22:19 PO/NG ClonazePAM 1 mg ___ \n___ 22:19 PO/NG Gabapentin 900 mg ___ \n___ 22:19 PO/NG QUEtiapine Fumarate 300 mg ___ \n\n\n___ 22:25 IV Vancomycin ___ Started \n___ 23:22 IVF NS 1 mL ___ Stopped (2h ___ \n___ 23:22 PO/NG Methadone (Oral Solution) 2 mg/1 mL 15 mg\n___ \n___ 00:50 IV Vancomycin 1 mg ___ Stopped (2h\n___ \n\n- Vitals on transfer: T: 99.8 HR: 98 BP: 115/70 RR: 20 SO2: \n\n96% RA \n\nUpon arrival to the floor, the patient's PICC was removed,\npatient was given meorpenem as well as 1 additional L LR. \nPatient\nconfirmed history as above. \n\n \nPast Medical History:\n___:\nCHRONOLOGICALLY ORGANIZED PAST MEDICAL AND SURGICAL HISTORY:\n___ s/p Removal right nephrostomy tube, Right Ureteroscopy\nComplex; insertion temporary right ureteral catheter and foley\ncatheter\nNo stones or stricture seen.\n___ s/p PERCUTANEOUS LITHOTRIPSY LASER RIGHT, difficult,\nantegrade/retrograde ureteroscopy with laser lithotripsy, right\nPCN placement\n___ Admitted with sepsis secondary to a ESBI Ecoli\ntreated with 14 days of zosyn\n- ___- Patient was recently admitted in ___, discharged on ___ for malfunctioning nephrostomy tube \ns/p R PCN exchange. Course was uncomplicated. \n- ___- Admission for pyelonephritis and sepsis. He \nwas initially on ___ given prior h/o MDR organisms. Urine\nculture grew ESBL E. coli and he was narrowed to ciprofloxacin \nto complete fourteen day course. Foley catheter was exchanged.\nNo exchange of R sided PCN (draining well). \n- ___- klebsiella bacteremia in the setting of R \nsided nephrolithiasis and PCN obstruction. Records from OSH ___ \nbottles with Klebsiella resistant to ampicillin and TMP/SMX but \notherwise sensitive. Also with staph epi bacteremia, thought to \nbe related to infection at his central line site. Treated with 2 \n\nweeks of ceftriaxone and vancomycin. \n- ___ he underwent an operation with a gluteal \nadvancement muscle flap for closure of this complex ischial and \nsacral wound overlying site of previous osteo from ___. Per \nnotes the wound extended down to the bone through dermis and \nepidermis intraoperatively. \n- ___ skin culture from L knee grew light amount of \nCORYNEBACTERIUM SPECIES (no polys) and from the R thigh grew \nCORYNEBACTERIUM SPECIES and COAG NEG STAPHYLOCOCCUS (no polys) \nbut skin culture from the R gluteus area grew PSEUDOMONAS \nAERUGINOSA (pan-sensitive) and ACINETOBACTER BAUMANNII (I to \nceftaz and pip/tazo, R to ceftriaxone but sensitive to \nCipro/levo, imipenem, gentamycin and Bactrim). Complete a 2 week \n\ncourse of Bactrim and no MRSA was isolated afterwards, but \ncorynebacterium was \n- ___ A skin graft procedure using a bioengineered skin \nsubstitute/cellular or tissue based product was performed by \n___ on the right medial upper leg \n- ___ A skin graft procedure using a bioengineered skin \nsubstitute/cellular or tissue based product was performed on \npressure ulcer located on the Left Knee. Unfortunately this \ngraft did not take. \n- Patient has been maintained on daily Bactrim therapy since \nthat time. \n- Followed at ___ for non healing ulcers on \n\nhis L knee (over a prior PJI s/p hardware removal) and R thigh \nprior skin graft site. \n- ___ Ischial Osteomyelitis - bone cultures grew \npan-sensitive enterococcus, pan sensitive klebsiella, and \npan-sensitive Acinetobacter. Treated with 6 wks IV Zosyn \n- ___ Transmetatarsal amputation for right toe gangrene \n- ___ Hx A-flutter w/ RVR s/p cardioversion \n- Provoked ___ Right lower extremity DVT requiring IVC filter \n- ___ multiple surgeries for necrotizing citrobacter, VRE \n\nfasciitis of chest requiring skin grafting and abdominal walls \nplus drainage of intra-abdominal collections; also Trach & \nCecostomy\n- L TKR ___ c/b wound dehiscence & septic arthritis in ___ \n- L prosthetic knee infection ___? with C. albicans and CoNS - \n\nnow \nwith spacer\n- R THR ___ \n- L THR ___ \n- R TKR ___ \n- L4-L5 laminectomy ___ (s/p MVA with traumatic disc \nherniation) \n- L tibial osteotomy \n\nOTHER MEDICAL ISSUES:\n- Seronegative arthritis, possibly ankylosing spondylitis, of \nhips, knees, wrist, on steroids/immunosuppressants since ___ \n(methotrexate, sulfasalazine, Enbrel, Humira, Remicade; as of \n___ is on 20mg daily prednisone) \n- History of PUD (on problem list since age ___, unclear)\n- Anemia of Chronic Disease\n- Onychomycosis \n- Atrial fibrillation - per ___ med list\n- Testicular hypofunction\n \nSocial History:\n___\nFamily History:\nMother: CAD/MI \nFather: Cancer \n\n \nPhysical ___:\nADMISSION EXAM\n==============\nVitals- T: 100.5 PO BP: 84/60 HR: 97 RR: 18 SO2: 93 Ra \nGENERAL: AOx3, NAD\nHEENT: NCAT, anicteric MMM L neck torticolis\nCV: RRR, ___ RUSB SEM w/o r/g \nRESP: clear B/L anterior auscultation. Exam limited by habitus\nGI: +bs, soft, NT, mildly distended, no guarding or rebound.\nmultiple scars. ___ patent, draining liquid brown\nstool. \nSKIN: significant nail changes b/l hands. Flushing of\nNEURO: dysarthia but speech fluent \nPSYCH: calm, cooperative, appropriately answering questions\nEXT: s/p R TMA. Contracted arms and upper extremities b/l\nSKIN: Erythema on right arm, ___ site with mild erythema,\ntenderness to palpation. Multiple pressure ulcers but no obvious\ncellulitis on back. significant onychomycosis on bilateral hands\nNEUROLOGIC: CN2-12 grossly intact. Speech dysarthic, arousbale,\nchronically contracted \n\nDISCHARGE EXAM\n==============\nVitals- 98.3 90/55 93 16 97RA \nGENERAL: AOx3, NAD\nHEENT: NCAT, anicteric, L neck torticolis \nRESP: No increased work of breathing \nGI: Scars from multiple prior abdominal surgeries. Mildly \ndistended. Ostomy is pink, patent, draining liquid brown stool. \nEXT: s/p R TMA. Contracted arms and upper extremities b/l.\nSKIN: PICC site c/d/i. Significant onychomycosis on bilateral \nhands.\nNEUROLOGIC: CN2-12 grossly intact. Speech dysarthic, but fluent. \n\n \nPertinent Results:\nADMISSION LABS\n==============\n___ 08:08PM BLOOD WBC-15.8*# RBC-3.57*# Hgb-10.1*# \nHct-34.8*# MCV-98 MCH-28.3 MCHC-29.0* RDW-16.9* RDWSD-60.8* Plt \n___\n___ 08:08PM BLOOD Neuts-81.5* Lymphs-9.7* Monos-5.2 Eos-1.4 \nBaso-0.3 Im ___ AbsNeut-12.83*# AbsLymp-1.53 AbsMono-0.82* \nAbsEos-0.22 AbsBaso-0.05\n___ 08:08PM BLOOD Plt ___\n___ 08:08PM BLOOD Glucose-101* UreaN-11 Creat-1.1 Na-138 \nK-4.4 Cl-98 HCO3-24 AnGap-16\n___ 08:08PM BLOOD Calcium-8.6 Phos-1.5* Mg-1.3*\n___ 08:30PM BLOOD Lactate-3.0*\n___ 12:14AM BLOOD Lactate-1.0\n\nMICRO\n=====\n___ 8:08 pm BLOOD CULTURE\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: \n STAPHYLOCOCCUS HAEMOLYTICUS. \n Isolated from only one set in the previous five days. \n COAG NEG STAPH does NOT require contact precautions, \nregardless of\n resistance Oxacillin RESISTANT Staphylococci MUST be \nreported as\n also RESISTANT to other penicillins, cephalosporins, \ncarbacephems,\n carbapenems, and beta-lactamase inhibitor combinations. \n\n RIFAMPIN should not be used alone for therapy ___ \n___ ___. \n FINAL SENSITIVITIES. \n KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n STAPHYLOCOCCUS HAEMOLYTICUS\n | KLEBSIELLA PNEUMONIAE\n | | \nAMIKACIN-------------- 8 S\nAMPICILLIN/SULBACTAM-- =>32 R\nCEFAZOLIN------------- =>64 R\nCEFEPIME-------------- R\nCEFTAZIDIME----------- =>64 R\nCEFTRIAXONE----------- 16 R\nCIPROFLOXACIN--------- <=0.25 S\nCLINDAMYCIN----------- =>8 R\nERYTHROMYCIN---------- =>8 R\nGENTAMICIN------------ 8 I =>16 R\nLEVOFLOXACIN---------- =>8 R\nMEROPENEM------------- <=0.25 S\nOXACILLIN------------- =>4 R\nRIFAMPIN-------------- <=0.5 S\nTOBRAMYCIN------------ =>16 R\nTRIMETHOPRIM/SULFA---- =>16 R\nVANCOMYCIN------------ 1 S\n\nIMAGING\n=======\n___ TTE\nIMPRESSION: \nThe left atrium is normal in size. No atrial septal defect is \nseen by 2D or color Doppler. Left ventricular wall thickness, \ncavity size and regional/global systolic function are normal \n(LVEF >55%). The estimated cardiac index is normal \n(>=2.5L/min/m2). Doppler parameters are indeterminate for left \nventricular diastolic function. Right ventricular chamber size \nand free wall motion are normal. The aortic valve leaflets are \nmildly thickened (?#). No masses or vegetations are seen on the \naortic valve, but cannot be fully excluded due to suboptimal \nimage quality. There is no aortic valve stenosis. No aortic \nregurgitation is seen. The mitral valve appears structurally \nnormal with trivial mitral regurgitation. There is no mitral \nvalve prolapse. No mass or vegetation is seen on the mitral \nvalve. There is mild pulmonary artery systolic hypertension. No \nmasses or vegetations are seen on the pulmonic valve, but cannot \nbe fully excluded due to suboptimal image quality. There is a \ntrivial/physiologic pericardial effusion. \n\nIMPRESSION: No echocardiographic evidence of endocarditis or \npathologic flow. Normal biventricular cavity sizes with \npreserved global and regional biventricular systolic function. \nMild pulmonary hypertension. \n\nCompared with the prior study (images reviewed) of ___, \nthe findings are similar. \n\nDISCHARGE LABS\n==============\n___ 05:22AM BLOOD WBC-7.5 RBC-2.80* Hgb-8.0* Hct-27.7* \nMCV-99* MCH-28.6 MCHC-28.9* RDW-16.9* RDWSD-60.5* Plt ___\n___ 05:22AM BLOOD Plt ___\n___ 05:22AM BLOOD Glucose-118* UreaN-16 Creat-0.6 Na-141 \nK-4.5 Cl-102 HCO3-27 AnGap-12\n___ 05:22AM BLOOD Calcium-8.3* Phos-3.4 Mg-1.9\n \nBrief Hospital Course:\nHOSPITAL COURSE\n===============\n___ year old bedbound male with complicated PMH included multiple \nUTI iso nephrolithiasis including most recently proteus \nbacteremia, chronic DVT/PE on lovenox, ankylosing spondylitis on \nprednisone who presented from ___ with new\nbacteremia Coagulase Negative Staph and klebsiella bacteremia in \nsetting of UTI and PICC line.\n\nACTIVE ISSUES\n=============\n# SEPSIS \n# STREP AND KLEBSIELLA BACTEREMIA: Coagulase negative staph \nbacteremia i/s/o retained PICC scheduled to be removed ___ \n(placed ___. PICC removed on arrival to floor ___ BCx \npositive for CoNS and Klebsiella, no growth from PICC culture. \nPossible new murmur, TTE with no evidence for endocarditis, per \nID no need for further investigation. PICC placed ___. Will \ncontinue daptomycin 6mg/kg and meropenem 500mg q6hrs until \n___ (2 week course).\n\n# COMPLICATED UTI: h/o nephroloithiasis, now w/ ESBL klebsiella. \nRecurrent infections in past months. Antibiotics as above for \nbactermia. Could consider prophylactic antibiotics given \nrecurrent infections. \n\n# h/o C. DIFF COLITIS: Will continue vancomycin 125mg PO qday \nuntil ___ for prophylaxis. \n\nCHRONIC ISSUES\n==============\n# AFIB/ and h/o of DVTs: CHADs-VAsc ___. Continued lovenox. Held \nhome metoprolol given sepsis on presentation and borderline \nhypotension, to be restarted if blood pressure stable.\n\n# h/o PRESSURE ULCERS: previously documented two stage II ulcers \n on R buttocks, 1 stage II on L buttocks. Wound care consulted, \nrecs followed.\n\n# H/o PJI: Continued home Bactrim.\n\n# Continued vitamin D ppx given steroid use. \n\n# DIABETES MELLITUS: Monitored, no treatment needed.\n\n# ANEMIA: Baseline Hbg 8s-9s, stable in house.\n\n# PSYCH: Continued home Seroquel & benzodiazepine. \n\n# Pain: Continued neurontin/dilaudid/methadone.\n\n# SERONEGATIVE SPONDYLOARTHROPATHY: Continue home pain regimen \nof gabapentin, diluadid and methadone and prednisone.\n\nTRANSITIONAL ISSUES\n===================\n[] Started daptomycin 6mg/kg and meropenem 500mg q6hrs until \n___ (___acteremia)\n[] Started Vancomycin Oral Liquid ___ mg PO/NG DAILY until \n___ for c. diff prophylaxis\n[] Metoprolol held in patient given infection systolic blood \npressure occasionally 80-90's restart as outpatient if SBP \nconsistently stable > 90 and HR > 60\n\n[] Please pull PICC line as soon as antibiotics are completed on \n___\n[] Assess whether prednisone is needed in the future given \nimmunosuppressive risk\n[] Consider outpatient infectious disease appointment to \ndetermine need for prophylactic antibiotics for UTI\n\nI have seen and examined Mr. ___, reviewed the findings, \ndata, and plan of care documented by Dr. ___, MD dated \n___ and agree with the discharge summary and plan.\n\n___, MD, PharmD\nSection of Hospital Medicine\n___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild \n2. Bisacodyl 10 mg PO DAILY:PRN constipation \n3. ClonazePAM 1 mg PO DAILY:PRN anxiety \n4. ClonazePAM 1 mg PO BID \n5. Docusate Sodium 200 mg PO BID \n6. Enoxaparin Sodium 100 mg SC Q12H \n7. Ferrous Sulfate 325 mg PO DAILY \n8. Gabapentin 600 mg PO TID \n9. HYDROmorphone (Dilaudid) 6 mg PO Q3H:PRN Pain - Severe \n10. Metoprolol Succinate XL 25 mg PO DAILY \n11. Multivitamins 1 TAB PO DAILY \n12. Omeprazole 20 mg PO DAILY \n13. PredniSONE 20 mg PO DAILY \n14. QUEtiapine Fumarate 300 mg PO QHS \n15. Simethicone 40-80 mg PO QID \n16. Sulfameth/Trimethoprim DS 1 TAB PO DAILY \n17. Tamsulosin 0.4 mg PO QHS \n18. Vitamin D 800 UNIT PO DAILY \n19. Acidophilus (Lactobacillus acidophilus) 1 tablet daily DAILY \n\n20. Generlac (lactulose) 40 gm oral BID \n21. Ondansetron ODT 4 mg PO Q8H:PRN nausea \n22. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line \nflush \n23. Miconazole Powder 2% 1 Appl TP PRN to affected area \n24. Methadone (Oral Solution) 2 mg/1 mL 15 mg PO TID \n\n \nDischarge Medications:\n1. Daptomycin 600 mg IV Q24H \n2. Meropenem 500 mg IV Q6H \n3. Vancomycin Oral Liquid ___ mg PO/NG DAILY \n4. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild \n5. Acidophilus (Lactobacillus acidophilus) 1 tablet daily DAILY \n \n6. Bisacodyl 10 mg PO DAILY:PRN constipation \n7. ClonazePAM 1 mg PO DAILY:PRN anxiety \n8. ClonazePAM 1 mg PO BID \n9. Docusate Sodium 200 mg PO BID \n10. Enoxaparin Sodium 100 mg SC Q12H \nStart: Today - ___, First Dose: Next Routine Administration \nTime \n11. Ferrous Sulfate 325 mg PO DAILY \n12. Gabapentin 600 mg PO TID \n13. Generlac (lactulose) 40 gm oral BID \n14. HYDROmorphone (Dilaudid) 6 mg PO Q3H:PRN Pain - Severe \n15. Methadone (Oral Solution) 2 mg/1 mL 15 mg PO TID \n16. Miconazole Powder 2% 1 Appl TP PRN to affected area \n17. Multivitamins 1 TAB PO DAILY \n18. Omeprazole 20 mg PO DAILY \n19. Ondansetron ODT 4 mg PO Q8H:PRN nausea \n20. PredniSONE 20 mg PO DAILY \n21. QUEtiapine Fumarate 300 mg PO QHS \n22. Simethicone 40-80 mg PO QID \n23. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line \nflush \n24. Sulfameth/Trimethoprim DS 1 TAB PO DAILY \n25. Tamsulosin 0.4 mg PO QHS \n26. Vitamin D 800 UNIT PO DAILY \n27. HELD- Metoprolol Succinate XL 25 mg PO DAILY This \nmedication was held. Do not restart Metoprolol Succinate XL \nuntil SBP consistently above 90 and HR above 60.\n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nKlebsiella urinary tract infection and bacteremia\nStaph bacteremia\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Bedbound.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nYou came to the hospital with a blood stream infection from two \nbacteria: Klebsiella from your urine, and Staph from your PICC \nline. We pulled the PICC line and started daptomycin and \nmeropenem, which you will take for a total of 2 weeks. Your PICC \nline should be pulled afterwards.\n\nIt was a privilege to care for you in the hospital, and we wish \nyou all the best.\n\nSincerely,\n\nYour ___ Health Team\nDear Mr. ___,\n\nYou came to the hospital with a blood stream infection from two \nbacteria: Klebsiella from your urine, and Staph from your PICC \nline. We pulled the PICC line and started daptomycin and \nmeropenem, which you will take for a total of 2 weeks. Your PICC \nline should be pulled afterwards.\n\nIt was a privilege to care for you in the hospital, and we wish \nyou all the best.\n\nSincerely,\n\nYour ___ Health Team\n \n ___ MD ___\n \nCompleted by: ___\n"
] | Allergies: Clindamycin / FLU Vaccine [MASKED] Chief Complaint: Fever Major Surgical or Invasive Procedure: [MASKED] placement [MASKED] under anesthesia History of Present Illness: [MASKED] year old bedbound male with complicated PMH included multiple UTI iso nephrolithiasis including most recently proteus bacteremia, chronic DVT/PE on lovenox, ankylosing spondylitis on prednisone who presents from [MASKED] with new bacteremia Coagulase Negative Staph and klebsiella ESBL UTI in setting of PICC line in place since [MASKED]. Patient was recently admitted to [MASKED] from [MASKED] for Proteus bacteremia/urosepsis in setting of nephrolithiasis. That hospital course was complicated by c. diff colitis requiring vancomycin with taper completing [MASKED] s very difficult IV access, requiring intubation for placement of PICC for ceftriaxone course scheduled from [MASKED]. He was discharged with one remaining day of IV ceftriaxone, his PICC was never removed. He was also supposed to follow up with his urologist Dr. [MASKED] had planned to consider further lithotripsy as an outpatient. Mr. [MASKED] reports new right sided arm pain at the [MASKED] site for about a week as well as fevers since around [MASKED], he denies abdominal pain, back pain, pain with urination or foul smelling urine. Spoke with [MASKED] at [MASKED] ([MASKED]) - slurred speech and drowsy at baseline secondary to pain medication - [MASKED] Director ordered BCx and UCx on [MASKED] which since grew out two biotypes of Coagulase Negative Staph in aerobic and anaerobic bottles (R oxacillin, susceptible to vancomycin) as well as UCx with Klebsiella ESBL susceptible to levofloxacin, ciprofloxacin, imipenem, ertapenem - BP typically 120-130s/70-80, facility staff usually takes BP on the left leg with [MASKED] - facility medication list confirmed, notably was ordered for ertapenem on [MASKED] but did not receive - overnight facility staff, and patient, unsure as to why PICC line had not been removed In the ED, initial vital signs were: T: 101.1 HR: 68 BP: 119/70 RR: 16 SO2: 96% RA - Exam notable for: Abd: Soft ND NT. Surgically reconstructed abdominal wall Ext: WWP no edema. Partial Amputation of R foot Lines: R PICC with dried purulence. - Labs were notable for... WBC: 15.8 Hgb: 10.1 Plt: 269 Crt: 1.1 Ca: 8.6 Mg: 1.3 P: 1.5 lactate: 3.0 -> 1.0 - Studies performed include... CXR with Right PICC tip appears to terminate at the confluence of the brachiocephalic veins. Retrocardiac opacity could reflect atelectasis. - Patient was given... [MASKED] 21:11 IVF NS [MASKED] Started [MASKED] 21:11 PO/NG Acetaminophen 650 mg [MASKED] [MASKED] 22:19 PO/NG HYDROmorphone (Dilaudid) 6 mg [MASKED] [MASKED] 22:19 PO/NG ClonazePAM 1 mg [MASKED] [MASKED] 22:19 PO/NG Gabapentin 900 mg [MASKED] [MASKED] 22:19 PO/NG QUEtiapine Fumarate 300 mg [MASKED] [MASKED] 22:25 IV Vancomycin [MASKED] Started [MASKED] 23:22 IVF NS 1 mL [MASKED] Stopped (2h [MASKED] [MASKED] 23:22 PO/NG Methadone (Oral Solution) 2 mg/1 mL 15 mg [MASKED] [MASKED] 00:50 IV Vancomycin 1 mg [MASKED] Stopped (2h [MASKED] - Vitals on transfer: T: 99.8 HR: 98 BP: 115/70 RR: 20 SO2: 96% RA Upon arrival to the floor, the patient's PICC was removed, patient was given meorpenem as well as 1 additional L LR. Patient confirmed history as above. Past Medical History: [MASKED]: CHRONOLOGICALLY ORGANIZED PAST MEDICAL AND SURGICAL HISTORY: [MASKED] s/p Removal right nephrostomy tube, Right Ureteroscopy Complex; insertion temporary right ureteral catheter and foley catheter No stones or stricture seen. [MASKED] s/p PERCUTANEOUS LITHOTRIPSY LASER RIGHT, difficult, antegrade/retrograde ureteroscopy with laser lithotripsy, right PCN placement [MASKED] Admitted with sepsis secondary to a ESBI Ecoli treated with 14 days of zosyn - [MASKED]- Patient was recently admitted in [MASKED], discharged on [MASKED] for malfunctioning nephrostomy tube s/p R PCN exchange. Course was uncomplicated. - [MASKED]- Admission for pyelonephritis and sepsis. He was initially on [MASKED] given prior h/o MDR organisms. Urine culture grew ESBL E. coli and he was narrowed to ciprofloxacin to complete fourteen day course. Foley catheter was exchanged. No exchange of R sided PCN (draining well). - [MASKED]- klebsiella bacteremia in the setting of R sided nephrolithiasis and PCN obstruction. Records from OSH [MASKED] bottles with Klebsiella resistant to ampicillin and TMP/SMX but otherwise sensitive. Also with staph epi bacteremia, thought to be related to infection at his central line site. Treated with 2 weeks of ceftriaxone and vancomycin. - [MASKED] he underwent an operation with a gluteal advancement muscle flap for closure of this complex ischial and sacral wound overlying site of previous osteo from [MASKED]. Per notes the wound extended down to the bone through dermis and epidermis intraoperatively. - [MASKED] skin culture from L knee grew light amount of CORYNEBACTERIUM SPECIES (no polys) and from the R thigh grew CORYNEBACTERIUM SPECIES and COAG NEG STAPHYLOCOCCUS (no polys) but skin culture from the R gluteus area grew PSEUDOMONAS AERUGINOSA (pan-sensitive) and ACINETOBACTER BAUMANNII (I to ceftaz and pip/tazo, R to ceftriaxone but sensitive to Cipro/levo, imipenem, gentamycin and Bactrim). Complete a 2 week course of Bactrim and no MRSA was isolated afterwards, but corynebacterium was - [MASKED] A skin graft procedure using a bioengineered skin substitute/cellular or tissue based product was performed by [MASKED] on the right medial upper leg - [MASKED] A skin graft procedure using a bioengineered skin substitute/cellular or tissue based product was performed on pressure ulcer located on the Left Knee. Unfortunately this graft did not take. - Patient has been maintained on daily Bactrim therapy since that time. - Followed at [MASKED] for non healing ulcers on his L knee (over a prior PJI s/p hardware removal) and R thigh prior skin graft site. - [MASKED] Ischial Osteomyelitis - bone cultures grew pan-sensitive enterococcus, pan sensitive klebsiella, and pan-sensitive Acinetobacter. Treated with 6 wks IV Zosyn - [MASKED] Transmetatarsal amputation for right toe gangrene - [MASKED] Hx A-flutter w/ RVR s/p cardioversion - Provoked [MASKED] Right lower extremity DVT requiring IVC filter - [MASKED] multiple surgeries for necrotizing citrobacter, VRE fasciitis of chest requiring skin grafting and abdominal walls plus drainage of intra-abdominal collections; also Trach & Cecostomy - L TKR [MASKED] c/b wound dehiscence & septic arthritis in [MASKED] - L prosthetic knee infection [MASKED]? with C. albicans and CoNS - now with spacer - R THR [MASKED] - L THR [MASKED] - R TKR [MASKED] - L4-L5 laminectomy [MASKED] (s/p MVA with traumatic disc herniation) - L tibial osteotomy OTHER MEDICAL ISSUES: - Seronegative arthritis, possibly ankylosing spondylitis, of hips, knees, wrist, on steroids/immunosuppressants since [MASKED] (methotrexate, sulfasalazine, Enbrel, Humira, Remicade; as of [MASKED] is on 20mg daily prednisone) - History of PUD (on problem list since age [MASKED], unclear) - Anemia of Chronic Disease - Onychomycosis - Atrial fibrillation - per [MASKED] med list - Testicular hypofunction Social History: [MASKED] Family History: Mother: CAD/MI Father: Cancer Physical [MASKED]: ADMISSION EXAM ============== Vitals- T: 100.5 PO BP: 84/60 HR: 97 RR: 18 SO2: 93 Ra GENERAL: AOx3, NAD HEENT: NCAT, anicteric MMM L neck torticolis CV: RRR, [MASKED] RUSB SEM w/o r/g RESP: clear B/L anterior auscultation. Exam limited by habitus GI: +bs, soft, NT, mildly distended, no guarding or rebound. multiple scars. [MASKED] patent, draining liquid brown stool. SKIN: significant nail changes b/l hands. Flushing of NEURO: dysarthia but speech fluent PSYCH: calm, cooperative, appropriately answering questions EXT: s/p R TMA. Contracted arms and upper extremities b/l SKIN: Erythema on right arm, [MASKED] site with mild erythema, tenderness to palpation. Multiple pressure ulcers but no obvious cellulitis on back. significant onychomycosis on bilateral hands NEUROLOGIC: CN2-12 grossly intact. Speech dysarthic, arousbale, chronically contracted DISCHARGE EXAM ============== Vitals- 98.3 90/55 93 16 97RA GENERAL: AOx3, NAD HEENT: NCAT, anicteric, L neck torticolis RESP: No increased work of breathing GI: Scars from multiple prior abdominal surgeries. Mildly distended. Ostomy is pink, patent, draining liquid brown stool. EXT: s/p R TMA. Contracted arms and upper extremities b/l. SKIN: PICC site c/d/i. Significant onychomycosis on bilateral hands. NEUROLOGIC: CN2-12 grossly intact. Speech dysarthic, but fluent. Pertinent Results: ADMISSION LABS ============== [MASKED] 08:08PM BLOOD WBC-15.8*# RBC-3.57*# Hgb-10.1*# Hct-34.8*# MCV-98 MCH-28.3 MCHC-29.0* RDW-16.9* RDWSD-60.8* Plt [MASKED] [MASKED] 08:08PM BLOOD Neuts-81.5* Lymphs-9.7* Monos-5.2 Eos-1.4 Baso-0.3 Im [MASKED] AbsNeut-12.83*# AbsLymp-1.53 AbsMono-0.82* AbsEos-0.22 AbsBaso-0.05 [MASKED] 08:08PM BLOOD Plt [MASKED] [MASKED] 08:08PM BLOOD Glucose-101* UreaN-11 Creat-1.1 Na-138 K-4.4 Cl-98 HCO3-24 AnGap-16 [MASKED] 08:08PM BLOOD Calcium-8.6 Phos-1.5* Mg-1.3* [MASKED] 08:30PM BLOOD Lactate-3.0* [MASKED] 12:14AM BLOOD Lactate-1.0 MICRO ===== [MASKED] 8:08 pm BLOOD CULTURE **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: STAPHYLOCOCCUS HAEMOLYTICUS. Isolated from only one set in the previous five days. 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 [MASKED] [MASKED] [MASKED]. FINAL SENSITIVITIES. KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] STAPHYLOCOCCUS HAEMOLYTICUS | KLEBSIELLA PNEUMONIAE | | AMIKACIN-------------- 8 S AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- R CEFTAZIDIME----------- =>64 R CEFTRIAXONE----------- 16 R CIPROFLOXACIN--------- <=0.25 S CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ 8 I =>16 R LEVOFLOXACIN---------- =>8 R MEROPENEM------------- <=0.25 S OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TOBRAMYCIN------------ =>16 R TRIMETHOPRIM/SULFA---- =>16 R VANCOMYCIN------------ 1 S IMAGING ======= [MASKED] TTE IMPRESSION: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The estimated cardiac index is normal (>=2.5L/min/m2). Doppler parameters are indeterminate for left ventricular diastolic function. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened (?#). No masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. There is mild pulmonary artery systolic hypertension. No masses or vegetations are seen on the pulmonic valve, but cannot be fully excluded due to suboptimal image quality. There is a trivial/physiologic pericardial effusion. IMPRESSION: No echocardiographic evidence of endocarditis or pathologic flow. Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. Mild pulmonary hypertension. Compared with the prior study (images reviewed) of [MASKED], the findings are similar. DISCHARGE LABS ============== [MASKED] 05:22AM BLOOD WBC-7.5 RBC-2.80* Hgb-8.0* Hct-27.7* MCV-99* MCH-28.6 MCHC-28.9* RDW-16.9* RDWSD-60.5* Plt [MASKED] [MASKED] 05:22AM BLOOD Plt [MASKED] [MASKED] 05:22AM BLOOD Glucose-118* UreaN-16 Creat-0.6 Na-141 K-4.5 Cl-102 HCO3-27 AnGap-12 [MASKED] 05:22AM BLOOD Calcium-8.3* Phos-3.4 Mg-1.9 Brief Hospital Course: HOSPITAL COURSE =============== [MASKED] year old bedbound male with complicated PMH included multiple UTI iso nephrolithiasis including most recently proteus bacteremia, chronic DVT/PE on lovenox, ankylosing spondylitis on prednisone who presented from [MASKED] with new bacteremia Coagulase Negative Staph and klebsiella bacteremia in setting of UTI and PICC line. ACTIVE ISSUES ============= # SEPSIS # STREP AND KLEBSIELLA BACTEREMIA: Coagulase negative staph bacteremia i/s/o retained PICC scheduled to be removed [MASKED] (placed [MASKED]. PICC removed on arrival to floor [MASKED] BCx positive for CoNS and Klebsiella, no growth from PICC culture. Possible new murmur, TTE with no evidence for endocarditis, per ID no need for further investigation. PICC placed [MASKED]. Will continue daptomycin 6mg/kg and meropenem 500mg q6hrs until [MASKED] (2 week course). # COMPLICATED UTI: h/o nephroloithiasis, now w/ ESBL klebsiella. Recurrent infections in past months. Antibiotics as above for bactermia. Could consider prophylactic antibiotics given recurrent infections. # h/o C. DIFF COLITIS: Will continue vancomycin 125mg PO qday until [MASKED] for prophylaxis. CHRONIC ISSUES ============== # AFIB/ and h/o of DVTs: CHADs-VAsc [MASKED]. Continued lovenox. Held home metoprolol given sepsis on presentation and borderline hypotension, to be restarted if blood pressure stable. # h/o PRESSURE ULCERS: previously documented two stage II ulcers on R buttocks, 1 stage II on L buttocks. Wound care consulted, recs followed. # H/o PJI: Continued home Bactrim. # Continued vitamin D ppx given steroid use. # DIABETES MELLITUS: Monitored, no treatment needed. # ANEMIA: Baseline Hbg 8s-9s, stable in house. # PSYCH: Continued home Seroquel & benzodiazepine. # Pain: Continued neurontin/dilaudid/methadone. # SERONEGATIVE SPONDYLOARTHROPATHY: Continue home pain regimen of gabapentin, diluadid and methadone and prednisone. TRANSITIONAL ISSUES =================== [] Started daptomycin 6mg/kg and meropenem 500mg q6hrs until [MASKED] ( acteremia) [] Started Vancomycin Oral Liquid [MASKED] mg PO/NG DAILY until [MASKED] for c. diff prophylaxis [] Metoprolol held in patient given infection systolic blood pressure occasionally 80-90's restart as outpatient if SBP consistently stable > 90 and HR > 60 [] Please pull PICC line as soon as antibiotics are completed on [MASKED] [] Assess whether prednisone is needed in the future given immunosuppressive risk [] Consider outpatient infectious disease appointment to determine need for prophylactic antibiotics for UTI I have seen and examined Mr. [MASKED], reviewed the findings, data, and plan of care documented by Dr. [MASKED], MD dated [MASKED] and agree with the discharge summary and plan. [MASKED], MD, PharmD Section of Hospital Medicine [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild 2. Bisacodyl 10 mg PO DAILY:PRN constipation 3. ClonazePAM 1 mg PO DAILY:PRN anxiety 4. ClonazePAM 1 mg PO BID 5. Docusate Sodium 200 mg PO BID 6. Enoxaparin Sodium 100 mg SC Q12H 7. Ferrous Sulfate 325 mg PO DAILY 8. Gabapentin 600 mg PO TID 9. HYDROmorphone (Dilaudid) 6 mg PO Q3H:PRN Pain - Severe 10. Metoprolol Succinate XL 25 mg PO DAILY 11. Multivitamins 1 TAB PO DAILY 12. Omeprazole 20 mg PO DAILY 13. PredniSONE 20 mg PO DAILY 14. QUEtiapine Fumarate 300 mg PO QHS 15. Simethicone 40-80 mg PO QID 16. Sulfameth/Trimethoprim DS 1 TAB PO DAILY 17. Tamsulosin 0.4 mg PO QHS 18. Vitamin D 800 UNIT PO DAILY 19. Acidophilus (Lactobacillus acidophilus) 1 tablet daily DAILY 20. Generlac (lactulose) 40 gm oral BID 21. Ondansetron ODT 4 mg PO Q8H:PRN nausea 22. Sodium Chloride 0.9% Flush [MASKED] mL IV DAILY and PRN, line flush 23. Miconazole Powder 2% 1 Appl TP PRN to affected area 24. Methadone (Oral Solution) 2 mg/1 mL 15 mg PO TID Discharge Medications: 1. Daptomycin 600 mg IV Q24H 2. Meropenem 500 mg IV Q6H 3. Vancomycin Oral Liquid [MASKED] mg PO/NG DAILY 4. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild 5. Acidophilus (Lactobacillus acidophilus) 1 tablet daily DAILY 6. Bisacodyl 10 mg PO DAILY:PRN constipation 7. ClonazePAM 1 mg PO DAILY:PRN anxiety 8. ClonazePAM 1 mg PO BID 9. Docusate Sodium 200 mg PO BID 10. Enoxaparin Sodium 100 mg SC Q12H Start: Today - [MASKED], First Dose: Next Routine Administration Time 11. Ferrous Sulfate 325 mg PO DAILY 12. Gabapentin 600 mg PO TID 13. Generlac (lactulose) 40 gm oral BID 14. HYDROmorphone (Dilaudid) 6 mg PO Q3H:PRN Pain - Severe 15. Methadone (Oral Solution) 2 mg/1 mL 15 mg PO TID 16. Miconazole Powder 2% 1 Appl TP PRN to affected area 17. Multivitamins 1 TAB PO DAILY 18. Omeprazole 20 mg PO DAILY 19. Ondansetron ODT 4 mg PO Q8H:PRN nausea 20. PredniSONE 20 mg PO DAILY 21. QUEtiapine Fumarate 300 mg PO QHS 22. Simethicone 40-80 mg PO QID 23. Sodium Chloride 0.9% Flush [MASKED] mL IV DAILY and PRN, line flush 24. Sulfameth/Trimethoprim DS 1 TAB PO DAILY 25. Tamsulosin 0.4 mg PO QHS 26. Vitamin D 800 UNIT PO DAILY 27. HELD- Metoprolol Succinate XL 25 mg PO DAILY This medication was held. Do not restart Metoprolol Succinate XL until SBP consistently above 90 and HR above 60. Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Klebsiella urinary tract infection and bacteremia Staph bacteremia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: Dear Mr. [MASKED], You came to the hospital with a blood stream infection from two bacteria: Klebsiella from your urine, and Staph from your PICC line. We pulled the PICC line and started daptomycin and meropenem, which you will take for a total of 2 weeks. Your PICC line should be pulled afterwards. It was a privilege to care for you in the hospital, and we wish you all the best. Sincerely, Your [MASKED] Health Team Dear Mr. [MASKED], You came to the hospital with a blood stream infection from two bacteria: Klebsiella from your urine, and Staph from your PICC line. We pulled the PICC line and started daptomycin and meropenem, which you will take for a total of 2 weeks. Your PICC line should be pulled afterwards. It was a privilege to care for you in the hospital, and we wish you all the best. Sincerely, Your [MASKED] Health Team [MASKED] MD [MASKED] Completed by: [MASKED] | [
"T80211A",
"A411",
"L89312",
"N390",
"B961",
"L89322",
"I4891",
"B351",
"E119",
"Z7401",
"Z86718",
"D638",
"E291",
"F17210",
"Z96653",
"Z89431",
"Z933",
"Z7984",
"F319",
"F419",
"M47899"
] | [
"T80211A: Bloodstream infection due to central venous catheter, initial encounter",
"A411: Sepsis due to other specified staphylococcus",
"L89312: Pressure ulcer of right buttock, stage 2",
"N390: Urinary tract infection, site not specified",
"B961: Klebsiella pneumoniae [K. pneumoniae] as the cause of diseases classified elsewhere",
"L89322: Pressure ulcer of left buttock, stage 2",
"I4891: Unspecified atrial fibrillation",
"B351: Tinea unguium",
"E119: Type 2 diabetes mellitus without complications",
"Z7401: Bed confinement status",
"Z86718: Personal history of other venous thrombosis and embolism",
"D638: Anemia in other chronic diseases classified elsewhere",
"E291: Testicular hypofunction",
"F17210: Nicotine dependence, cigarettes, uncomplicated",
"Z96653: Presence of artificial knee joint, bilateral",
"Z89431: Acquired absence of right foot",
"Z933: Colostomy status",
"Z7984: Long term (current) use of oral hypoglycemic drugs",
"F319: Bipolar disorder, unspecified",
"F419: Anxiety disorder, unspecified",
"M47899: Other spondylosis, site unspecified"
] | [
"N390",
"I4891",
"E119",
"Z86718",
"F17210",
"F419"
] | [] |
11,604,900 | 28,595,817 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nBenadryl / zolpidem\n \nAttending: ___.\n \nChief Complaint:\n___\n \nMajor Surgical or Invasive Procedure:\nEGD ___\n\n \nHistory of Present Illness:\nMs. ___ is a ___ woman with hx alcoholic cirrhosis \n(Child class B, MELD baseline ___ c/b varices, \nencephalopathy, medically-controlled ascites, recurrent GIBs, \nC.diff, presenting with BRBPR and tachycardia to 102. \n She reports tarry black stool since yesterday. She reports \nepisodes normally resolve after ___ bm but has had at least 3 \ntarry stools yesterday and 4 today. She also reports getting \nover a \"cold\" the last few days and diffuse weakness. Her most \nrecent EGD in ___ 2 cords of grade I varices were seen in \nthe distal esophagus. \n On presentation to the ED she was slightly diaphoretic. No \nfluid wave shift but diffuse abdominal pain and slight abdominal \ndistension as well as 1 + asterixis bilaterally. She had no \nperipheral edema or JVP and no overt CVAT but slight abdominal \npain on deep palpation on CVA. She also had positive guaiac, \ndark brown stool in rectal vault. \n On past admissions work-up has not revealed clear source of \nGIB. Prior colonoscopy showed no evidence of recent or active \nbleeding on this examination. Prior capsule endoscopy in ___ \nrevealed mild gastritis but otherwise normal capsule endoscopy. \n\n On prior admission her symptoms along with history of frequent \nhospitalizations for similar symptoms suggest a diagnosis of \nIBS. \n In the ED, initial vitals were: 96.6 106 127/80 20 100% RA \n Labs were notable for: WBC 12.6 Plt 237 Hg 11.1 AST 45 ALT 33 \nAP 154 T bili 0.2. Crt 1 (baseline 0.9-1). The patient was seen \nby the hepatology team and per their recommendations the patient \nwas initiated on IV PPI, octreotide, and ceftriaxone 1g (PPX \nGIB). She was made NPO for possible scope. She asditional \nreceived 2 mg IV morphine for pain. For her tachycardia she \nreceived a 500 cc bolus with improvement of HR to 69. Abdominal \nU/S with Doppler revealed patent hepatic vasculature. \n Currently she feels tired but has no complaints. No abdominal \npain, no lightheadedness, no nausea. \n \n\n \nPast Medical History:\n- EtOH cirrhosis (CHILDS B, MELD 12) c/b varices, \nencephalopathy, and diuretic-controlled ascites \n- History of recurrent UTIs \n- Constipation \n- Recurrent Abdominal pain \n- Anxiety \n- Pneumonia \n- Duodenal ulcers \n- Positive PPD \n- T10 Paraspinal mass - 1.7 cm (from MRI ___ likely a \nneurogenic tumor, unchanged in size from ___\n- recurrent GI bleed of unclear source \n \nSocial History:\n___\nFamily History:\nNo family history of stroke, blood clots or seizure. A lot of \ndiabetes in family. Father deceased from cirrhosis secondary to \nalcoholism. History of TB in her family (mother and other \nmembers). Mother was treated for TB prior to the patient's \nbirth. \n\n \nPhysical Exam:\nADMISSION EXAM\n==================\n VS: 97 123/68 56 16 100%RA \n General: lying in bed, NAD \n HEENT: anicteric sclera, atraumatic, PERLL \n Neck: supple, no JVD \n CV: RRR, no murmurs \n Lungs: CTAB \n Abdomen: no fluid wave, +BS, non-tender to palpation \n Ext: WWP, no edema \n Neuro: grossly intact \n\nDISCHARGE EXAM\n===================\nVS: 97 100s/60s ___ 16 100%RA \n General: sleeping comfortably, NAD \n HEENT: anicteric sclera, atraumatic, PERLL \n Neck: supple, no JVD \n CV: RRR, no murmurs \n Lungs: CTAB \n Abdomen: no fluid wave, +BS, non-tender to palpation \n Ext: WWP, no edema \n Neuro: grossly intact \n \nPertinent Results:\nADMISSION LABS\n===================\n___ 05:26PM LACTATE-1.9\n___ 05:15PM GLUCOSE-82 UREA N-20 CREAT-1.0 SODIUM-138 \nPOTASSIUM-4.2 CHLORIDE-108 TOTAL CO2-17* ANION GAP-17\n___ 05:15PM estGFR-Using this\n___ 05:15PM ALT(SGPT)-33 AST(SGOT)-45* ALK PHOS-154* TOT \nBILI-0.2\n___ 05:15PM LIPASE-41\n___ 05:15PM ALBUMIN-4.5 CALCIUM-9.6 PHOSPHATE-3.6 \nMAGNESIUM-2.3\n___ 05:15PM WBC-12.6* RBC-5.09 HGB-11.1* HCT-37.4 MCV-74* \nMCH-21.8* MCHC-29.7* RDW-19.2* RDWSD-49.2*\n___ 05:15PM NEUTS-59.2 ___ MONOS-5.9 EOS-1.9 \nBASOS-0.7 IM ___ AbsNeut-7.48*# AbsLymp-4.05* AbsMono-0.74 \nAbsEos-0.24 AbsBaso-0.09*\n___ 05:15PM PLT COUNT-237\n___ 05:15PM ___ PTT-38.6* ___\n\nIMAGES/STUDIES\n====================\nDupplex Abd u/s ___:\nIMPRESSION: \n1. Patent hepatic vasculature. \n2. Cirrhotic liver. \n \nChest Xray ___:\nIMPRESSION: \n1. Patent hepatic vasculature. \n2. Cirrhotic liver. \n \nEGD ___:\nFindings: \nEsophagus: \nProtruding Lesions 2 cords of grade I varices were seen in the \nlower third of the esophagus with no high risk features of \nbleeding. \nStomach: \nContents: Food was found in the stomach \nMucosa: Diffuse erythema of the mucosa was noted in the antrum. \nThese findings are compatible with Mild gastritis. \nDuodenum: Normal duodenum. \nImpression: Varices at the lower third of the esophagus\nErythema in the antrum compatible with Mild gastritis\nFood in the stomach\nOtherwise normal EGD to third part of the duodenum \n\nDISCHARGE LABS\n=====================\n___ 05:25AM BLOOD WBC-8.2 RBC-4.33 Hgb-9.3* Hct-31.5* \nMCV-73* MCH-21.5* MCHC-29.5* RDW-18.0* RDWSD-46.7* Plt ___\n___ 05:25AM BLOOD ___ PTT-41.3* ___\n___ 05:25AM BLOOD Glucose-97 UreaN-10 Creat-0.9 Na-136 \nK-4.1 Cl-105 HCO3-21* AnGap-14\n___ 05:25AM BLOOD ALT-20 AST-33 AlkPhos-127* TotBili-0.2\n___ 05:25AM BLOOD Albumin-4.0 Calcium-9.3 Phos-3.8 Mg-2.___ woman with ETOH cirrhosis (Child class B, MELD \nbaseline ___, history of varices and reccurrent admissions \nfor GIB of unclear source. Has also had diffuse weakness, \nmyalgias, and recent URI. \n\n # Tarry stools with stable H/H:Tachycardia resolved after \nfluids. Patient was started on PO PPI BID. EGD on ___ showed \n2 cords of grade I varices, no high risk features, no active \nbleeding. Patient's H/H remained stable throughout admission. No \nmelena during hospitalization. Was discharged with close follow \nup with outpatient hepatology and PCP. \n\n # Viral illness: Presentation most consistent with viral URI \ngiven myalgias, absence of fever, or infiltrate on CXR. No \nadditional interventions.\n\n # CIRRHOSIS: Due to alcohol (last alcohol ___ years ago). Childs \nclass B, MELD 9. \n * Transplant status: potential transplant in the future \n * Hepatic encephalopathy: Cont lactulose/rifaximin \n * Fluid status: not on diuretics \n * Variceal status: grade I varices \n\n # HEPATIC ENCEPHALOPATHY: reportedly had asterixis in the ED, \nnone on arrival to the floor. Continue Lactulose 30mL TID and \nRifaximin 550 BID. \n\n # GIB/VARICES: Patient has 2 cords of grade I varices. Last EGD \nduring this admission. See above. \n\n # ASCITES: Patint has not had ascites in the past, and patient \nis not on Lasix/spironolactone. \n\nTRANSITIONAL ISSUES\n[ ] Patient received Ferrlecit Infusion on ___. Please \nrepeat another four infusions for a total of 5.\n[ ] patient started on Pantoprazole 40mg BID\n #CODE: Full \n #CONTACT: Patient, HCP ___ (son) ___ \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 325 mg PO Q6H:PRN pain \n2. Citalopram 20 mg PO DAILY \n3. Lactulose 30 mL PO QID \n4. Lidocaine 5% Patch 1 PTCH TD QAM \n5. Multivitamins 1 TAB PO DAILY \n6. RISperidone 0.25 mg PO QHS \n7. Sertraline 50 mg PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 325 mg PO Q6H:PRN pain \n2. Citalopram 20 mg PO DAILY \n3. Lactulose 30 mL PO QID \n4. Lidocaine 5% Patch 1 PTCH TD QAM \n5. Multivitamins 1 TAB PO DAILY \n6. RISperidone 0.25 mg PO QHS \n7. Pantoprazole 40 mg PO Q12H \nRX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp \n#*60 Tablet Refills:*0\n8. Sertraline 50 mg PO DAILY \n9. FoLIC Acid 1 mg PO DAILY \nRX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0\n10. Thiamine 100 mg PO DAILY \nRX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a \nday Disp #*30 Tablet Refills:*0\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___ \n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n======================\nMelena\n\nSECONDARY DIAGNOSIS\n=======================\n- EtOH cirrhosis \n - UTIs \n - Constipation \n - Recurrent Abdominal pain \n - Anxiety \n - Pneumonia \n - Duodenal ulcers \n - Positive PPD \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nIt was a pleasure to care for you at ___. You came to us for \ntarry, black stools. While here, we monitored your blood counts \nand made sure they remained stable. We also did an endoscopy \nstudy to look for sources of bleeding in your gastrointestinal \ntract. Thankfully there were no sources of bleeding. \n\nWhile here we gave you an iron infusion to help with your anemia \n(low red blood cell count). It is unclear why you may have had \ntarry stools. Please return to the emergency department or call \nyour doctor if you develop dark stools again.\n\nThank you for choosing ___. \n\nWe wish you the best,\n\nYour ___ team\n \nFollowup Instructions:\n___\n"
] | Allergies: Benadryl / zolpidem Chief Complaint: [MASKED] Major Surgical or Invasive Procedure: EGD [MASKED] History of Present Illness: Ms. [MASKED] is a [MASKED] woman with hx alcoholic cirrhosis (Child class B, MELD baseline [MASKED] c/b varices, encephalopathy, medically-controlled ascites, recurrent GIBs, C.diff, presenting with BRBPR and tachycardia to 102. She reports tarry black stool since yesterday. She reports episodes normally resolve after [MASKED] bm but has had at least 3 tarry stools yesterday and 4 today. She also reports getting over a "cold" the last few days and diffuse weakness. Her most recent EGD in [MASKED] 2 cords of grade I varices were seen in the distal esophagus. On presentation to the ED she was slightly diaphoretic. No fluid wave shift but diffuse abdominal pain and slight abdominal distension as well as 1 + asterixis bilaterally. She had no peripheral edema or JVP and no overt CVAT but slight abdominal pain on deep palpation on CVA. She also had positive guaiac, dark brown stool in rectal vault. On past admissions work-up has not revealed clear source of GIB. Prior colonoscopy showed no evidence of recent or active bleeding on this examination. Prior capsule endoscopy in [MASKED] revealed mild gastritis but otherwise normal capsule endoscopy. On prior admission her symptoms along with history of frequent hospitalizations for similar symptoms suggest a diagnosis of IBS. In the ED, initial vitals were: 96.6 106 127/80 20 100% RA Labs were notable for: WBC 12.6 Plt 237 Hg 11.1 AST 45 ALT 33 AP 154 T bili 0.2. Crt 1 (baseline 0.9-1). The patient was seen by the hepatology team and per their recommendations the patient was initiated on IV PPI, octreotide, and ceftriaxone 1g (PPX GIB). She was made NPO for possible scope. She asditional received 2 mg IV morphine for pain. For her tachycardia she received a 500 cc bolus with improvement of HR to 69. Abdominal U/S with Doppler revealed patent hepatic vasculature. Currently she feels tired but has no complaints. No abdominal pain, no lightheadedness, no nausea. Past Medical History: - EtOH cirrhosis (CHILDS B, MELD 12) c/b varices, encephalopathy, and diuretic-controlled ascites - History of recurrent UTIs - Constipation - Recurrent Abdominal pain - Anxiety - Pneumonia - Duodenal ulcers - Positive PPD - T10 Paraspinal mass - 1.7 cm (from MRI [MASKED] likely a neurogenic tumor, unchanged in size from [MASKED] - recurrent GI bleed of unclear source Social History: [MASKED] Family History: No family history of stroke, blood clots or seizure. A lot of diabetes in family. Father deceased from cirrhosis secondary to alcoholism. History of TB in her family (mother and other members). Mother was treated for TB prior to the patient's birth. Physical Exam: ADMISSION EXAM ================== VS: 97 123/68 56 16 100%RA General: lying in bed, NAD HEENT: anicteric sclera, atraumatic, PERLL Neck: supple, no JVD CV: RRR, no murmurs Lungs: CTAB Abdomen: no fluid wave, +BS, non-tender to palpation Ext: WWP, no edema Neuro: grossly intact DISCHARGE EXAM =================== VS: 97 100s/60s [MASKED] 16 100%RA General: sleeping comfortably, NAD HEENT: anicteric sclera, atraumatic, PERLL Neck: supple, no JVD CV: RRR, no murmurs Lungs: CTAB Abdomen: no fluid wave, +BS, non-tender to palpation Ext: WWP, no edema Neuro: grossly intact Pertinent Results: ADMISSION LABS =================== [MASKED] 05:26PM LACTATE-1.9 [MASKED] 05:15PM GLUCOSE-82 UREA N-20 CREAT-1.0 SODIUM-138 POTASSIUM-4.2 CHLORIDE-108 TOTAL CO2-17* ANION GAP-17 [MASKED] 05:15PM estGFR-Using this [MASKED] 05:15PM ALT(SGPT)-33 AST(SGOT)-45* ALK PHOS-154* TOT BILI-0.2 [MASKED] 05:15PM LIPASE-41 [MASKED] 05:15PM ALBUMIN-4.5 CALCIUM-9.6 PHOSPHATE-3.6 MAGNESIUM-2.3 [MASKED] 05:15PM WBC-12.6* RBC-5.09 HGB-11.1* HCT-37.4 MCV-74* MCH-21.8* MCHC-29.7* RDW-19.2* RDWSD-49.2* [MASKED] 05:15PM NEUTS-59.2 [MASKED] MONOS-5.9 EOS-1.9 BASOS-0.7 IM [MASKED] AbsNeut-7.48*# AbsLymp-4.05* AbsMono-0.74 AbsEos-0.24 AbsBaso-0.09* [MASKED] 05:15PM PLT COUNT-237 [MASKED] 05:15PM [MASKED] PTT-38.6* [MASKED] IMAGES/STUDIES ==================== Dupplex Abd u/s [MASKED]: IMPRESSION: 1. Patent hepatic vasculature. 2. Cirrhotic liver. Chest Xray [MASKED]: IMPRESSION: 1. Patent hepatic vasculature. 2. Cirrhotic liver. EGD [MASKED]: Findings: Esophagus: Protruding Lesions 2 cords of grade I varices were seen in the lower third of the esophagus with no high risk features of bleeding. Stomach: Contents: Food was found in the stomach Mucosa: Diffuse erythema of the mucosa was noted in the antrum. These findings are compatible with Mild gastritis. Duodenum: Normal duodenum. Impression: Varices at the lower third of the esophagus Erythema in the antrum compatible with Mild gastritis Food in the stomach Otherwise normal EGD to third part of the duodenum DISCHARGE LABS ===================== [MASKED] 05:25AM BLOOD WBC-8.2 RBC-4.33 Hgb-9.3* Hct-31.5* MCV-73* MCH-21.5* MCHC-29.5* RDW-18.0* RDWSD-46.7* Plt [MASKED] [MASKED] 05:25AM BLOOD [MASKED] PTT-41.3* [MASKED] [MASKED] 05:25AM BLOOD Glucose-97 UreaN-10 Creat-0.9 Na-136 K-4.1 Cl-105 HCO3-21* AnGap-14 [MASKED] 05:25AM BLOOD ALT-20 AST-33 AlkPhos-127* TotBili-0.2 [MASKED] 05:25AM BLOOD Albumin-4.0 Calcium-9.3 Phos-3.8 Mg-2.[MASKED] woman with ETOH cirrhosis (Child class B, MELD baseline [MASKED], history of varices and reccurrent admissions for GIB of unclear source. Has also had diffuse weakness, myalgias, and recent URI. # Tarry stools with stable H/H:Tachycardia resolved after fluids. Patient was started on PO PPI BID. EGD on [MASKED] showed 2 cords of grade I varices, no high risk features, no active bleeding. Patient's H/H remained stable throughout admission. No melena during hospitalization. Was discharged with close follow up with outpatient hepatology and PCP. # Viral illness: Presentation most consistent with viral URI given myalgias, absence of fever, or infiltrate on CXR. No additional interventions. # CIRRHOSIS: Due to alcohol (last alcohol [MASKED] years ago). Childs class B, MELD 9. * Transplant status: potential transplant in the future * Hepatic encephalopathy: Cont lactulose/rifaximin * Fluid status: not on diuretics * Variceal status: grade I varices # HEPATIC ENCEPHALOPATHY: reportedly had asterixis in the ED, none on arrival to the floor. Continue Lactulose 30mL TID and Rifaximin 550 BID. # GIB/VARICES: Patient has 2 cords of grade I varices. Last EGD during this admission. See above. # ASCITES: Patint has not had ascites in the past, and patient is not on Lasix/spironolactone. TRANSITIONAL ISSUES [ ] Patient received Ferrlecit Infusion on [MASKED]. Please repeat another four infusions for a total of 5. [ ] patient started on Pantoprazole 40mg BID #CODE: Full #CONTACT: Patient, HCP [MASKED] (son) [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 325 mg PO Q6H:PRN pain 2. Citalopram 20 mg PO DAILY 3. Lactulose 30 mL PO QID 4. Lidocaine 5% Patch 1 PTCH TD QAM 5. Multivitamins 1 TAB PO DAILY 6. RISperidone 0.25 mg PO QHS 7. Sertraline 50 mg PO DAILY Discharge Medications: 1. Acetaminophen 325 mg PO Q6H:PRN pain 2. Citalopram 20 mg PO DAILY 3. Lactulose 30 mL PO QID 4. Lidocaine 5% Patch 1 PTCH TD QAM 5. Multivitamins 1 TAB PO DAILY 6. RISperidone 0.25 mg PO QHS 7. Pantoprazole 40 mg PO Q12H RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 8. Sertraline 50 mg PO DAILY 9. FoLIC Acid 1 mg PO DAILY RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 10. Thiamine 100 mg PO DAILY RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSIS ====================== Melena SECONDARY DIAGNOSIS ======================= - EtOH cirrhosis - UTIs - Constipation - Recurrent Abdominal pain - Anxiety - Pneumonia - Duodenal ulcers - Positive PPD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], It was a pleasure to care for you at [MASKED]. You came to us for tarry, black stools. While here, we monitored your blood counts and made sure they remained stable. We also did an endoscopy study to look for sources of bleeding in your gastrointestinal tract. Thankfully there were no sources of bleeding. While here we gave you an iron infusion to help with your anemia (low red blood cell count). It is unclear why you may have had tarry stools. Please return to the emergency department or call your doctor if you develop dark stools again. Thank you for choosing [MASKED]. We wish you the best, Your [MASKED] team Followup Instructions: [MASKED] | [
"K921",
"K766",
"K7031",
"D649",
"I8510",
"R109",
"F419",
"Z87440",
"Z87891",
"K7290"
] | [
"K921: Melena",
"K766: Portal hypertension",
"K7031: Alcoholic cirrhosis of liver with ascites",
"D649: Anemia, unspecified",
"I8510: Secondary esophageal varices without bleeding",
"R109: Unspecified abdominal pain",
"F419: Anxiety disorder, unspecified",
"Z87440: Personal history of urinary (tract) infections",
"Z87891: Personal history of nicotine dependence",
"K7290: Hepatic failure, unspecified without coma"
] | [
"D649",
"F419",
"Z87891"
] | [] |
18,625,820 | 24,042,561 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nPenicillins / Codeine / Lodine (not iodine) / Prochlorperazine\n \nAttending: ___.\n \nChief Complaint:\nLeaking around G-tube\n \nMajor Surgical or Invasive Procedure:\n___: Revision and re-siting ___ gastrostomy tube.\n\n \nHistory of Present Illness:\nMrs ___ is a ___ female with a history of stage 1B squamous \ncell esophageal cancer initially diagnosed in ___ and treated \nwith chemoradiation with recurrent strictures requiring Gtube \nand multiple esophageal dilations. She was hospitalized in \n___ and at that time was having difficulties managing \nher secretions. EGD was\nattempted to dilate her esophageal stricture. This was unable \nto\nbe done orally so it was done retrograde via her Gtube site \nwhich\nwas a ___. Salivary dilation was performed from ___ to\n___ successfully and her Gtube was replaced. She reports\nthat since then she has had constant problems with severe \nleaking\nfrom the tube and it has had to be replaced five times.\n\n \nPast Medical History:\nPast Oncologic History:\n-___: heartburn with EGD at ___ showing \nesophagitis, with initiation of a PPI\n-___: repeat EGD at ___ - positive for an \ninvasive moderately differentiated squamous cell carcinoma at \nthe distal esophagus. \n-___: CT torso - circumferential thickening of the distal \nesophageal wall, two separate 0.3-cm left lower lung nodules\n-___: EUS demonstrated T3 disease, with esophageal mass at \nthe lower third of the esophagus, maximal 0.37 cm depth. There \nwas a less than 0.5 cm lymph node adjacent to the mass. \n-___: PET CT - FDG avidity only at the known tumor. \n-___: started radiation therapy\n-___: began cisplatin and ___\n-___: Inpatient hospitalization at ___ for nausea,\nvomiting, p.o. intolerance, and dehydration.\n-___: Barium swallow with limited images showing barium \npassage to the stomach with no evidence of obstruction seen. No \ngross evidence of obstruction or dysmotility.\n-___: Inpatient hospitalization at ___ for nausea,\nvomiting, p.o. intolerance, and dehydration.\n-___: completed radiation therapy\n.\nOther Past Medical History: \n1. History of sigmoid diverticulitis requiring three\nhospitalizations in her lifetime, most recently in ___.\n2. Left hip replacement in ___, right hip replacement in\n___.\n3. ___ abdominal surgery for gastric outlet obstruction,\nwith vagotomy.\n4. Hypothyroidism, stable.\n5. History of appendectomy, stable.\n6. History of hysterectomy, stable.\n7. History of hernia repair, stable.\n8. Gastroesophageal reflux disease. \n9. Esophageal stricture seen ___ s/p chemorads, s/p serial\ndilations by Dr. ___\n\n \n___ History:\n___\nFamily History:\nFAMILY HISTORY:\n.\nMother deceased age ___ secondary to MI\nFather deceased age ___ secondary to PNA.\nBrother deceased, lung cancer\nSister deceased, history of CVA\n\n \nPhysical Exam:\nPrior To Discharge:\nVS: 98.7, 85, 117/48, 18, 97% RA\nGEN: Pleasant, thin female with NAD\nCV: RRR, no m/r/g\nPULM: CTAB\nABD: Abdominal binder on, abdomen with large ventral hernia. LUQ \nwith new G-tube capped, site with occlusive dressing and c/d/I. \nOld RLQ G-tube site packed with moist-to-dry 2x2 gauze and \ncovered with dry 4x4 gauze, site with minimal serosanguinous \ndrainage. \nEXTR: Warm, no c/c/e \n \nPertinent Results:\nNone\n \nBrief Hospital Course:\nThe patient with history of esophageal cancer, chronic \nesophageal stricture and chronic G-tube was admitted to the \nGeneral Surgical Service for elective G-tube revision and \nre-siting. She underwent procedure on ___ and was admitted \nfor observation. After a brief, uneventful stay in the PACU, the \npatient arrived on the floor on sips, with G-tube to gravity \ndrainage, and IV dilaudid for pain control. The patient was \nhemodynamically stable.\nOn POD 1, patient G-tube was capped, diet was advanced to clear \nliquid diet. Patient's Foley was removed post operatively and \nshe voided without difficulties. Patient's pain was well \ncontrolled with Vicodin, she ambulated independently. Patient \nwas discharged home with ___ services to continue old G-tube \nsite wound care. She was instructed to restart her tube feeds at \nhome as ordered. \n \nMedications on Admission:\nERGOCALCIFEROL (VITAMIN D2) [VITAMIN D2] - Vitamin D2 50,000 \nunit\ncapsule. capsule(s) by mouth \n\nHYDROCODONE-ACETAMINOPHEN - hydrocodone 5 mg-acetaminophen 500 \nmg\ntablet. 1 Tablet(s) by mouth every 6 hours prn\n\nLANSOPRAZOLE 30 mg twice a day \n\nLORAZEPAM [ATIVAN] - Ativan 0.5 mg 1 tablet(s) by mouth\nat bedtime as needed for insomnia\n\nSUCRALFATE [CARAFATE] - Carafate 100 mg/mL oral suspension. 10 \nmL\nby mouth q6 hours\n\nASPIRIN-ACETAMINOPHEN-CAFFEINE Excedrin Migraine 250 mg-250 \nmg-65 mg tablet. 2 tablet(s) by mouth daily prn\n\nCYANOCOBALAMIN (VITAMIN B-12) \n\nMAGNESIUM HYDROXIDE \n\n \nDischarge Medications:\n1. Lansoprazole Oral Disintegrating Tab 30 mg PO BID \n2. Excedrin Extra Strength (aspirin-acetaminophen-caffeine) \n250-250-65 mg oral DAILY:PRN headache \n3. CarafATE (sucralfate) 100 mg/mL oral Q6H \n4. LORazepam 0.5 mg PO QHS:PRN insomnia \n5. Vitamin D ___ UNIT PO MONTHLY \n6. HYDROcodone-Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN Pain \n- Moderate \nRX *hydrocodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth \nevery six (6) hours Disp #*30 Tablet Refills:*0\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\n1. Esophageal strictures secondary to esophageal cancer\n2. Leaking gastrostomy tube \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nYou were admitted to the surgery service at ___ for surgical \nrevision and re-siting of your G-tube. You have done well in the \npost operative period and are now safe to return home to \ncomplete your recovery with the following instructions:\n.\nPlease call Dr. ___ office at ___ if you have any \nquestions or concerns. \n.\nPlease resume all regular home medications , unless specifically \nadvised not to take a particular medication. Also, please take \nany new medications as prescribed.\nPlease get plenty of rest, continue to ambulate several times \nper day, and drink adequate amounts of fluids. Avoid lifting \nweights greater than ___ lbs until you follow-up with your \nsurgeon, who will instruct you further regarding activity \nrestrictions.\nAvoid driving or operating heavy machinery while taking pain \nmedications.\nPlease follow-up with your surgeon and Primary Care Provider \n(PCP) as advised.\n.\nIncision Care:\n*Your old G-tube site will be packed with 2x2 gauze daily by ___ \nnurses.\n*Please call your doctor or nurse practitioner if you have \nincreased pain, swelling, redness, or drainage from the incision \nsite.\n*Avoid swimming and baths until your follow-up appointment.\n*You may shower, and wash surgical incisions with a mild soap \nand warm water. Gently pat the area dry.\n\n \n\n \nFollowup Instructions:\n___\n"
] | Allergies: Penicillins / Codeine / Lodine (not iodine) / Prochlorperazine Chief Complaint: Leaking around G-tube Major Surgical or Invasive Procedure: [MASKED]: Revision and re-siting [MASKED] gastrostomy tube. History of Present Illness: Mrs [MASKED] is a [MASKED] female with a history of stage 1B squamous cell esophageal cancer initially diagnosed in [MASKED] and treated with chemoradiation with recurrent strictures requiring Gtube and multiple esophageal dilations. She was hospitalized in [MASKED] and at that time was having difficulties managing her secretions. EGD was attempted to dilate her esophageal stricture. This was unable to be done orally so it was done retrograde via her Gtube site which was a [MASKED]. Salivary dilation was performed from [MASKED] to [MASKED] successfully and her Gtube was replaced. She reports that since then she has had constant problems with severe leaking from the tube and it has had to be replaced five times. Past Medical History: Past Oncologic History: -[MASKED]: heartburn with EGD at [MASKED] showing esophagitis, with initiation of a PPI -[MASKED]: repeat EGD at [MASKED] - positive for an invasive moderately differentiated squamous cell carcinoma at the distal esophagus. -[MASKED]: CT torso - circumferential thickening of the distal esophageal wall, two separate 0.3-cm left lower lung nodules -[MASKED]: EUS demonstrated T3 disease, with esophageal mass at the lower third of the esophagus, maximal 0.37 cm depth. There was a less than 0.5 cm lymph node adjacent to the mass. -[MASKED]: PET CT - FDG avidity only at the known tumor. -[MASKED]: started radiation therapy -[MASKED]: began cisplatin and [MASKED] -[MASKED]: Inpatient hospitalization at [MASKED] for nausea, vomiting, p.o. intolerance, and dehydration. -[MASKED]: Barium swallow with limited images showing barium passage to the stomach with no evidence of obstruction seen. No gross evidence of obstruction or dysmotility. -[MASKED]: Inpatient hospitalization at [MASKED] for nausea, vomiting, p.o. intolerance, and dehydration. -[MASKED]: completed radiation therapy . Other Past Medical History: 1. History of sigmoid diverticulitis requiring three hospitalizations in her lifetime, most recently in [MASKED]. 2. Left hip replacement in [MASKED], right hip replacement in [MASKED]. 3. [MASKED] abdominal surgery for gastric outlet obstruction, with vagotomy. 4. Hypothyroidism, stable. 5. History of appendectomy, stable. 6. History of hysterectomy, stable. 7. History of hernia repair, stable. 8. Gastroesophageal reflux disease. 9. Esophageal stricture seen [MASKED] s/p chemorads, s/p serial dilations by Dr. [MASKED] [MASKED] History: [MASKED] Family History: FAMILY HISTORY: . Mother deceased age [MASKED] secondary to MI Father deceased age [MASKED] secondary to PNA. Brother deceased, lung cancer Sister deceased, history of CVA Physical Exam: Prior To Discharge: VS: 98.7, 85, 117/48, 18, 97% RA GEN: Pleasant, thin female with NAD CV: RRR, no m/r/g PULM: CTAB ABD: Abdominal binder on, abdomen with large ventral hernia. LUQ with new G-tube capped, site with occlusive dressing and c/d/I. Old RLQ G-tube site packed with moist-to-dry 2x2 gauze and covered with dry 4x4 gauze, site with minimal serosanguinous drainage. EXTR: Warm, no c/c/e Pertinent Results: None Brief Hospital Course: The patient with history of esophageal cancer, chronic esophageal stricture and chronic G-tube was admitted to the General Surgical Service for elective G-tube revision and re-siting. She underwent procedure on [MASKED] and was admitted for observation. After a brief, uneventful stay in the PACU, the patient arrived on the floor on sips, with G-tube to gravity drainage, and IV dilaudid for pain control. The patient was hemodynamically stable. On POD 1, patient G-tube was capped, diet was advanced to clear liquid diet. Patient's Foley was removed post operatively and she voided without difficulties. Patient's pain was well controlled with Vicodin, she ambulated independently. Patient was discharged home with [MASKED] services to continue old G-tube site wound care. She was instructed to restart her tube feeds at home as ordered. Medications on Admission: ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D2] - Vitamin D2 50,000 unit capsule. capsule(s) by mouth HYDROCODONE-ACETAMINOPHEN - hydrocodone 5 mg-acetaminophen 500 mg tablet. 1 Tablet(s) by mouth every 6 hours prn LANSOPRAZOLE 30 mg twice a day LORAZEPAM [ATIVAN] - Ativan 0.5 mg 1 tablet(s) by mouth at bedtime as needed for insomnia SUCRALFATE [CARAFATE] - Carafate 100 mg/mL oral suspension. 10 mL by mouth q6 hours ASPIRIN-ACETAMINOPHEN-CAFFEINE Excedrin Migraine 250 mg-250 mg-65 mg tablet. 2 tablet(s) by mouth daily prn CYANOCOBALAMIN (VITAMIN B-12) MAGNESIUM HYDROXIDE Discharge Medications: 1. Lansoprazole Oral Disintegrating Tab 30 mg PO BID 2. Excedrin Extra Strength (aspirin-acetaminophen-caffeine) 250-250-65 mg oral DAILY:PRN headache 3. CarafATE (sucralfate) 100 mg/mL oral Q6H 4. LORazepam 0.5 mg PO QHS:PRN insomnia 5. Vitamin D [MASKED] UNIT PO MONTHLY 6. HYDROcodone-Acetaminophen (5mg-325mg) [MASKED] TAB PO Q6H:PRN Pain - Moderate RX *hydrocodone-acetaminophen 5 mg-325 mg [MASKED] tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: 1. Esophageal strictures secondary to esophageal cancer 2. Leaking gastrostomy tube 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 [MASKED] for surgical revision and re-siting of your G-tube. You have done well in the post operative period and are now safe to return home to complete your recovery with the following instructions: . Please call Dr. [MASKED] office at [MASKED] if you have any questions or concerns. . 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 [MASKED] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. . Incision Care: *Your old G-tube site will be packed with 2x2 gauze daily by [MASKED] nurses. *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. Followup Instructions: [MASKED] | [
"K9423",
"Y833",
"Y929",
"G8918",
"K660",
"K222",
"K219",
"K439",
"E039",
"F1120",
"Z8501",
"Z87891"
] | [
"K9423: Gastrostomy malfunction",
"Y833: Surgical operation with formation of external stoma as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure",
"Y929: Unspecified place or not applicable",
"G8918: Other acute postprocedural pain",
"K660: Peritoneal adhesions (postprocedural) (postinfection)",
"K222: Esophageal obstruction",
"K219: Gastro-esophageal reflux disease without esophagitis",
"K439: Ventral hernia without obstruction or gangrene",
"E039: Hypothyroidism, unspecified",
"F1120: Opioid dependence, uncomplicated",
"Z8501: Personal history of malignant neoplasm of esophagus",
"Z87891: Personal history of nicotine dependence"
] | [
"Y929",
"K219",
"E039",
"Z87891"
] | [] |
10,903,847 | 24,214,917 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nbupropion\n \nAttending: ___.\n \nChief Complaint:\ntransfer for altered mental status \n \nMajor Surgical or Invasive Procedure:\nIntubation \n \nHistory of Present Illness:\nMs ___ is a ___ woman with history of CHF, \nafib\nnot on a/c (GI bleed), who was found down by EMS, found to have\naltered mental status in the setting of hyponatremia, ___, and\nrhabdo. \n\nShe has had many recent hospitalizations for CHF in the setting\nof confusion over her medications and accidental med\nmismanagement. She most recently was discharged ___ at which\ntime she refused rehab and was discharged home with elder\nservices. \n\n___ she was brought in to the ___ by EMS after\nactivating her life alert. She was found down in her apartment,\nwas foul smelling, and was reporting visual hallucinations of\n\"people in her apartment cutting and tying down lines.\"\n\nIn the ___ at ___ there was concern that her inner thigh\nerythema was necrotizing fascitis. Due to this concern, and her\nworsening confusion and somnolence, she was intubated to protect\nher airway and in anticipation of her clinical course. After\nintubation she was hypotensive and was started on \nnorepinephrine.\n\nLabs at ___ were significant for sodium 120, potassium\n6.0, BUN 110 and creatinine 5.24 (from 1.70 on ___, T bili\n1.55, alk phos 251, and ck 643. She had a leukocytsis to 24.71,\nHb was above recent baseline at 11.1, and TSH was normal at \n2.69,\nand her troponin was slightly elevated without correlation on\nEKG. \n\nC diff was negative, urine cultures were sent.\n\nCT scan was performed of the head, cervical spine, chest,\nabdomen, and pelvis. These images were reviewed with radiology \non\narrival to ___ ___, and they revealed no evidence of an\nintracranial bleed, stroke, or cervical spine fracture. \nPatient's\nchest, abdomen, and pelvis CT did not show any acute findings.\nThere was no soft tissue gas on the pelvic CT to suggest a\nnecrotizing soft tissue infection.\n \n\nShe was given calcium, dextrose and glucose given elevated\npotassium, clindamycin, vanc, and zosyn. As well as 100 cc\nhypertonic saline for presumed acute hyponatremia. She also was\nnoted to have an elevation in her CK and acute renal failure.\nErythema in her groin was concerning for Fournier's gangrene, so\nshe was intubated for presumed imminent deterioration and\nworsening mental status and transferred to ___ for Surgical\nevaluation. \n\nUpon arrival to ___ ___, exam wasn otable for erythema to the\ngroin, no soft tissue crepitus, no overlying skin bullae. She \nwas\nevaluated by ___ who felt this was not necrotizing fasciitis, \nand\nshe was continued on vancomycin, zosy, and clinda. \n \nPast Medical History:\nAcute on chronic diastolic heart failure\nDepression\nHypothyroidism\nA fib\nCKD baseline Cr\nT2DM\nHTN\n \nSocial History:\n___\nFamily History:\nMother with dilated cardiomyopathy and MI at age ___\nFather died of MI at ___\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \n======================== \nVS: Reviewed in metavision\nGEN: Intubated, not arousable to voice or noxious stimuli \nHEENT: NCAT, PERRLA, \nNECK: right IJ. No lymphadenopathy. \nCV: RRR\nRESP: Intubated, course breath sounds bilaterally anteriorly\nSKIN: Diffuse bruising on abdomen. lower extremity bilateral\nstasis changes. Inguinal erythema, no crepitus or palpable\nabscess. Sacral decubitus ulcer.\n\nDISCHARGE PHYSICAL EXAM:\n========================\n24 HR Data (last updated ___ @ 334)\n Temp: 97.5 (Tm 98.3), BP: 124/74 (107-124/69-75), HR: 94\n(79-94), RR: 18, O2 sat: 98% (98-100), O2 delivery: RA \nFluid Balance (last updated ___ @ 649) \n Last 8 hours Total cumulative -250ml\n IN: Total 100ml, PO Amt 100ml\n OUT: Total 350ml, Urine Amt 350ml\n Last 24 hours Total cumulative 70ml\n IN: Total 870ml, PO Amt 870ml\n OUT: Total 800ml, Urine Amt 800ml, Flexiseal 0ml \n\nGEN: older woman in NAD\nCV: RRR, no m/g/r\nPULM: CTAB in anterior fields, early inspiratory crackles of ___\nposteroinferior fields. \nEXT: ___ ___ edema 1+\n\n \nPertinent Results:\n===============\nAdmission labs\n===============\n___ 03:45AM BLOOD WBC-15.5* RBC-3.31* Hgb-9.0* Hct-26.9* \nMCV-81* MCH-27.2 MCHC-33.5 RDW-13.5 RDWSD-39.9 Plt ___\n___ 03:45AM BLOOD Neuts-90.6* Lymphs-4.1* Monos-4.8* \nEos-0.0* Baso-0.1 Im ___ AbsNeut-14.03* AbsLymp-0.64* \nAbsMono-0.74 AbsEos-0.00* AbsBaso-0.02\n___ 03:45AM BLOOD ___ PTT-25.6 ___\n___ 03:45AM BLOOD Glucose-241* UreaN-102* Creat-5.0* \nNa-126* K-4.2 Cl-85* HCO3-21* AnGap-20*\n___ 03:45AM BLOOD ALT-7 AST-23 CK(CPK)-618* AlkPhos-187* \nTotBili-1.4\n___ 03:45AM BLOOD cTropnT-<0.01\n___ 03:45AM BLOOD Albumin-3.4* Calcium-9.9 Phos-3.5 Mg-1.6\n___ 03:45AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nTricycl-NEG\n___ 03:45AM BLOOD CRP-154.5*\n___ 03:58AM BLOOD Type-CENTRAL VE pO2-39* pCO2-40 pH-7.41 \ncalTCO2-26 Base XS-0 Intubat-INTUBATED\n___ 03:58AM BLOOD Lactate-3.4* K-3.9\n\n===============\nDischarge labs\n===============\n___ 04:07AM BLOOD WBC-4.8 RBC-2.84* Hgb-7.6* Hct-25.3* \nMCV-89 MCH-26.8 MCHC-30.0* RDW-14.7 RDWSD-48.1* Plt ___\n___ 04:07AM BLOOD Plt ___\n___ 04:07AM BLOOD Glucose-135* UreaN-13 Creat-1.2* Na-138 \nK-4.0 Cl-103 HCO3-25 AnGap-10\n___ 04:07AM BLOOD Calcium-9.3 Phos-3.7 Mg-1.3*\n\n===============\nStudies\n===============\nCXR ___: IMPRESSION: In comparison with the study earlier in \nthis date, the tip of the endotracheal tube now measures \napproximately 2.5 cm above the carina. Nasogastric tube tip is \nin the upper stomach, though the side port is in the distal \nesophagus. No change in the appearance of the heart and lungs. \n\nLENIs ___: IMPRESSION: No evidence of deep vein thrombosis in \nthe visualized right upper extremity veins. \n\n===============\nMicrobiology \n===============\n URINE CULTURE (Final ___: \n ENTEROCOCCUS SP.. >100,000 CFU/mL. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n ENTEROCOCCUS SP.\n | \nAMPICILLIN------------ <=2 S\nNITROFURANTOIN-------- <=16 S\nTETRACYCLINE---------- =>16 R\nVANCOMYCIN------------ 1 S\n\n___ BCx x2- no growth, final \n\n \nBrief Hospital Course:\n___ F with CHF found down by EMS, found have hyperkalemia, acute \nrenal failure, and leukocytosis, intubated due to worsening \nmental status, transferred to ___ for concern for necrotizing \nfasciitis, found to have cellulitis and enterococcus UTI. \n\nDISCHARGE H/H = 7.6/25.3\nDISCHARGE PLT = 171\nDISCHARGE Cr = 1.2\n\nTRNASITIONAL ISSUES:\n====================\n[] Patient was discharged on bumex 3mg BID, decreased from her \nhome dose of 6mg BID in setting ___ that was improving. \nPlease continue to monitor her weight daily and BMP every ___ \ndays while titrating her diuretic dose. If she gains >3 pounds \nand her creatinine remains stable, please increase bumex to 6mg \nBID (as tolerated by her BPs). If her weight remains stable and \nher creatinine is also stable, can also continue to uptitrate to \noriginal dose of bumex 6mg BID as allowed by BP. Can also \ncontact her cardiologist ___ with additional questions \nregarding diuretic dosing. \n[] Please check BMP q3 days while titrating diuretics and \nreplete Mag and K as necessary. Currently holding home potassium \nsupplement but can restart as needed for low potassium. \n[] Spironolactone and metolazone were held during \nhospitalization and should not be restarted until discussed with \nher cardiologist ___ at next appointment. \n[] Patient developed pancytopenia thought to be in the setting \nof septic shock effect on bone marrow. Marrow now recovering. Hb \non discharge was 7.6, platelets were 171, WBC was 4.8. Please \ncheck CBC weekly. \n[] Can uptitrate loperamide PRN for diarrhea \n[] Discharged on augmentin for enterococcus UTI and non-purulent \n___ cellulitis, 14 day course to end on ___.\n\nADVANCED CARE PLANNING:\n=======================\n#CODE STATUS: Full (presumed) \n# Name of health care proxy: ___ \nRelationship: Son \n\nACUTE ISSUES \n===============\n# ___ ___ UTI and thigh cellulitis\nEvaluated by ACS in the ___ for concern for ___ gangrene, \nwhich they felt she did not have. Patient initially received \nvancomycin, clindamycin, and Zosyn at ___. She was \ntransitioned to ceftriaxone at ___ with improvement in her \ncellulitis. Her urine grew enterococcus, so she was also given \nvancomycin. Based on sensitivities, she was narrowed to \nAugmentin for a total of 14 days (D14 ___. \n\n# Hypotension:\nPatient became hypotensive after sedation for intubation and \nresolved after extubation. Briefly on norepinephrine. Likely ___ \nsedation and infection. BPs improved. \n\n# Acute renal failure:\nPatient with history of CKD (recent creatinine 1.4-1.6), \nCreatinine 5 on admission. Still making urine. Suspect \ncombination of prerenal and possible pigment nephropathy. \nPatient seemed total body fluid overloaded with massive lower \nextremity edema. Her Cr improved to 1.2 on discharge. Bumex was \nrestarted at reduced dose 3mg BID, with plan for active \ntitration while in rehab.\n\n# Altered mental status\nPer report of EMS, was having visual hallucinations when found \ndown. Likely secondary to infection and hyponatremia. Head CT \nwas per report negative at ___. Urine tox screen was \nnegative. Per chart, had previous alcohol use, but EtOH level \nhere negative. Per report, she was responding but confused \nbefore intubation at ___. Patient mental status improved. \nOn discharge, she was AOx3. \n\n# Heart failure\nTTE ___ with EF 66% with regional/global systolic function, \nborderline pulmonary artery systolic hypertension, mild MR and \nnormal valve morphology. Patient with significant lower \nextremity edema and chronic stasis changes bilaterally. Diuresis \nwas held was intubated and on pressors. Per son, patient with \nmultiple hospitalizations due to dehydration iso over diuresis. \nPatient was started on bumex 3mg BID and will need to follow up \nwith Dr. ___. Home metoprolol was restarted as below. Should \ndiscuss restarting metolazone and spironolactone with Dr. \n___ in outpatient setting. \n\n# Atrial fibrillation\nMetoprolol briefly held for hypotension. Not on anticoagulation \ndue to history of GI bleed. \n\n# EtOH history\nPrevious admissions with alcohol in system, none this admission. \nNot clear when last drink. She was given high dose thiamine, \nfolate, and MVI. \n\n# Hyponatremia\nResolved. \n\n# Elevated CK (redolved)\nCK elevated to 600 in setting of being found down for a few \nhours. Not to level of needing IVF for renal protection. \n\nCHRONIC ISSUES \n=============== \n# DM\nHdld home Januvia. Given insulin sliding scale while in the \nhospital. Restarted home med on discharge.\n\n# HLD\nContinued home simvastatin 20mg\n\n# Hypothyroidism\nContinued home levothyroxine\n\n# Neuropathy\nContinued home duloxetine.\n\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfurther investigation.\n1. Bumetanide 6 mg PO BID \n2. DULoxetine ___ 60 mg PO DAILY \n3. FoLIC Acid 1 mg PO DAILY \n4. Gabapentin 200 mg PO QHS \n5. Levothyroxine Sodium 125 mcg PO DAILY \n6. MetOLazone 7.5 mg PO 1X/WEEK (MO) \n7. Metoprolol Succinate XL 12.5 mg PO DAILY \n8. Pantoprazole 40 mg PO Q24H \n9. Potassium Chloride 20 mEq PO DAILY \n10. Simvastatin 20 mg PO QPM \n11. SITagliptin 25 mg oral DAILY \n12. Spironolactone 25 mg PO DAILY \n\n \nDischarge Medications:\n1. Amoxicillin-Clavulanic Acid ___ mg PO BID \nRX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by \nmouth twice a day Disp #*14 Tablet Refills:*0 \n2. LOPERamide 2 mg PO QID diarrhea \nRX *loperamide 2 mg 1 capsule by mouth four times a day Disp \n#*12 Capsule Refills:*0 \n3. Multivitamins 1 TAB PO DAILY \nRX *multivitamin 1 capsule(s) by mouth once a day Disp #*30 \nCapsule Refills:*0 \n4. Thiamine 100 mg PO DAILY \nRX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a \nday Disp #*30 Tablet Refills:*0 \n5. Bumetanide 3 mg PO BID \n6. DULoxetine ___ 60 mg PO DAILY \n7. FoLIC Acid 1 mg PO DAILY \n8. Gabapentin 200 mg PO QHS \n9. Levothyroxine Sodium 125 mcg PO DAILY \n10. Metoprolol Succinate XL 12.5 mg PO DAILY \n11. Pantoprazole 40 mg PO Q24H \n12. Simvastatin 20 mg PO QPM \n13. SITagliptin 25 mg oral DAILY \n14. HELD- MetOLazone 7.5 mg PO 1X/WEEK (MO) This medication was \nheld. Do not restart MetOLazone until you see your cardiologist\n15. HELD- Potassium Chloride 20 mEq PO DAILY This medication \nwas held. Do not restart Potassium Chloride until BMP indicates \nK <3.5\n16. HELD- Spironolactone 25 mg PO DAILY This medication was \nheld. Do not restart Spironolactone until you see your \ncardiologist\n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \n___ Diagnosis:\n#enterococcus UTI\n___ and ___ cellulitis\n#HFpEF\n#pancytopenia\n___ iso CKD\n#Afib\n#T2DM c/b neuropathy \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear ___,\n\nIt was a privilege taking care of you at ___ \n___. \n\nWHY WAS I ADMITTED TO THE HOSPITAL?\n- You were transferred from ___ after being found on the \nground with altered mental status and suspension of severe skin \ninfection. \n\nWHAT HAPPENED WHILE I WAS IN THE HOSPITAL?\n- You were admitted to the intensive care unit (ICU) as your \nblood pressure was low, and were started on medications to \nmaintain your blood pressure. \n- You were intubated at ___ as they were concerned about \nyour ability to maintain patent airways. \n- You were found to have skin infection in the groin and lower \nextremity area. \n- You were started on very strong IV antibiotics. Theses were \nswitched to oral ones once you condition stabilized. \n- You were found to have acute renal failure as you were \ndehydrated. This improved with hydration and holding your \ndiuretics (water pills). \n- Your diuretics were started restarted at a lower dose. \n\nWHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?\n- Please continue to take all your medications and follow up \nwith your doctors at your ___ appointments. \n- Please weigh yourself everyday. If you gain 3 lbs in 2 days or \n5 lbs in 7 days, please contact your doctor. \n\nWe wish you all the best!\n\nSincerely, \nYour ___ Care Team \n \nFollowup Instructions:\n___\n"
] | Allergies: bupropion Chief Complaint: transfer for altered mental status Major Surgical or Invasive Procedure: Intubation History of Present Illness: Ms [MASKED] is a [MASKED] woman with history of CHF, afib not on a/c (GI bleed), who was found down by EMS, found to have altered mental status in the setting of hyponatremia, [MASKED], and rhabdo. She has had many recent hospitalizations for CHF in the setting of confusion over her medications and accidental med mismanagement. She most recently was discharged [MASKED] at which time she refused rehab and was discharged home with elder services. [MASKED] she was brought in to the [MASKED] by EMS after activating her life alert. She was found down in her apartment, was foul smelling, and was reporting visual hallucinations of "people in her apartment cutting and tying down lines." In the [MASKED] at [MASKED] there was concern that her inner thigh erythema was necrotizing fascitis. Due to this concern, and her worsening confusion and somnolence, she was intubated to protect her airway and in anticipation of her clinical course. After intubation she was hypotensive and was started on norepinephrine. Labs at [MASKED] were significant for sodium 120, potassium 6.0, BUN 110 and creatinine 5.24 (from 1.70 on [MASKED], T bili 1.55, alk phos 251, and ck 643. She had a leukocytsis to 24.71, Hb was above recent baseline at 11.1, and TSH was normal at 2.69, and her troponin was slightly elevated without correlation on EKG. C diff was negative, urine cultures were sent. CT scan was performed of the head, cervical spine, chest, abdomen, and pelvis. These images were reviewed with radiology on arrival to [MASKED] [MASKED], and they revealed no evidence of an intracranial bleed, stroke, or cervical spine fracture. Patient's chest, abdomen, and pelvis CT did not show any acute findings. There was no soft tissue gas on the pelvic CT to suggest a necrotizing soft tissue infection. She was given calcium, dextrose and glucose given elevated potassium, clindamycin, vanc, and zosyn. As well as 100 cc hypertonic saline for presumed acute hyponatremia. She also was noted to have an elevation in her CK and acute renal failure. Erythema in her groin was concerning for Fournier's gangrene, so she was intubated for presumed imminent deterioration and worsening mental status and transferred to [MASKED] for Surgical evaluation. Upon arrival to [MASKED] [MASKED], exam wasn otable for erythema to the groin, no soft tissue crepitus, no overlying skin bullae. She was evaluated by [MASKED] who felt this was not necrotizing fasciitis, and she was continued on vancomycin, zosy, and clinda. Past Medical History: Acute on chronic diastolic heart failure Depression Hypothyroidism A fib CKD baseline Cr T2DM HTN Social History: [MASKED] Family History: Mother with dilated cardiomyopathy and MI at age [MASKED] Father died of MI at [MASKED] Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: Reviewed in metavision GEN: Intubated, not arousable to voice or noxious stimuli HEENT: NCAT, PERRLA, NECK: right IJ. No lymphadenopathy. CV: RRR RESP: Intubated, course breath sounds bilaterally anteriorly SKIN: Diffuse bruising on abdomen. lower extremity bilateral stasis changes. Inguinal erythema, no crepitus or palpable abscess. Sacral decubitus ulcer. DISCHARGE PHYSICAL EXAM: ======================== 24 HR Data (last updated [MASKED] @ 334) Temp: 97.5 (Tm 98.3), BP: 124/74 (107-124/69-75), HR: 94 (79-94), RR: 18, O2 sat: 98% (98-100), O2 delivery: RA Fluid Balance (last updated [MASKED] @ 649) Last 8 hours Total cumulative -250ml IN: Total 100ml, PO Amt 100ml OUT: Total 350ml, Urine Amt 350ml Last 24 hours Total cumulative 70ml IN: Total 870ml, PO Amt 870ml OUT: Total 800ml, Urine Amt 800ml, Flexiseal 0ml GEN: older woman in NAD CV: RRR, no m/g/r PULM: CTAB in anterior fields, early inspiratory crackles of [MASKED] posteroinferior fields. EXT: [MASKED] [MASKED] edema 1+ Pertinent Results: =============== Admission labs =============== [MASKED] 03:45AM BLOOD WBC-15.5* RBC-3.31* Hgb-9.0* Hct-26.9* MCV-81* MCH-27.2 MCHC-33.5 RDW-13.5 RDWSD-39.9 Plt [MASKED] [MASKED] 03:45AM BLOOD Neuts-90.6* Lymphs-4.1* Monos-4.8* Eos-0.0* Baso-0.1 Im [MASKED] AbsNeut-14.03* AbsLymp-0.64* AbsMono-0.74 AbsEos-0.00* AbsBaso-0.02 [MASKED] 03:45AM BLOOD [MASKED] PTT-25.6 [MASKED] [MASKED] 03:45AM BLOOD Glucose-241* UreaN-102* Creat-5.0* Na-126* K-4.2 Cl-85* HCO3-21* AnGap-20* [MASKED] 03:45AM BLOOD ALT-7 AST-23 CK(CPK)-618* AlkPhos-187* TotBili-1.4 [MASKED] 03:45AM BLOOD cTropnT-<0.01 [MASKED] 03:45AM BLOOD Albumin-3.4* Calcium-9.9 Phos-3.5 Mg-1.6 [MASKED] 03:45AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG [MASKED] 03:45AM BLOOD CRP-154.5* [MASKED] 03:58AM BLOOD Type-CENTRAL VE pO2-39* pCO2-40 pH-7.41 calTCO2-26 Base XS-0 Intubat-INTUBATED [MASKED] 03:58AM BLOOD Lactate-3.4* K-3.9 =============== Discharge labs =============== [MASKED] 04:07AM BLOOD WBC-4.8 RBC-2.84* Hgb-7.6* Hct-25.3* MCV-89 MCH-26.8 MCHC-30.0* RDW-14.7 RDWSD-48.1* Plt [MASKED] [MASKED] 04:07AM BLOOD Plt [MASKED] [MASKED] 04:07AM BLOOD Glucose-135* UreaN-13 Creat-1.2* Na-138 K-4.0 Cl-103 HCO3-25 AnGap-10 [MASKED] 04:07AM BLOOD Calcium-9.3 Phos-3.7 Mg-1.3* =============== Studies =============== CXR [MASKED]: IMPRESSION: In comparison with the study earlier in this date, the tip of the endotracheal tube now measures approximately 2.5 cm above the carina. Nasogastric tube tip is in the upper stomach, though the side port is in the distal esophagus. No change in the appearance of the heart and lungs. LENIs [MASKED]: IMPRESSION: No evidence of deep vein thrombosis in the visualized right upper extremity veins. =============== Microbiology =============== URINE CULTURE (Final [MASKED]: ENTEROCOCCUS SP.. >100,000 CFU/mL. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] ENTEROCOCCUS SP. | AMPICILLIN------------ <=2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- =>16 R VANCOMYCIN------------ 1 S [MASKED] BCx x2- no growth, final Brief Hospital Course: [MASKED] F with CHF found down by EMS, found have hyperkalemia, acute renal failure, and leukocytosis, intubated due to worsening mental status, transferred to [MASKED] for concern for necrotizing fasciitis, found to have cellulitis and enterococcus UTI. DISCHARGE H/H = 7.6/25.3 DISCHARGE PLT = 171 DISCHARGE Cr = 1.2 TRNASITIONAL ISSUES: ==================== [] Patient was discharged on bumex 3mg BID, decreased from her home dose of 6mg BID in setting [MASKED] that was improving. Please continue to monitor her weight daily and BMP every [MASKED] days while titrating her diuretic dose. If she gains >3 pounds and her creatinine remains stable, please increase bumex to 6mg BID (as tolerated by her BPs). If her weight remains stable and her creatinine is also stable, can also continue to uptitrate to original dose of bumex 6mg BID as allowed by BP. Can also contact her cardiologist [MASKED] with additional questions regarding diuretic dosing. [] Please check BMP q3 days while titrating diuretics and replete Mag and K as necessary. Currently holding home potassium supplement but can restart as needed for low potassium. [] Spironolactone and metolazone were held during hospitalization and should not be restarted until discussed with her cardiologist [MASKED] at next appointment. [] Patient developed pancytopenia thought to be in the setting of septic shock effect on bone marrow. Marrow now recovering. Hb on discharge was 7.6, platelets were 171, WBC was 4.8. Please check CBC weekly. [] Can uptitrate loperamide PRN for diarrhea [] Discharged on augmentin for enterococcus UTI and non-purulent [MASKED] cellulitis, 14 day course to end on [MASKED]. ADVANCED CARE PLANNING: ======================= #CODE STATUS: Full (presumed) # Name of health care proxy: [MASKED] Relationship: Son ACUTE ISSUES =============== # [MASKED] [MASKED] UTI and thigh cellulitis Evaluated by ACS in the [MASKED] for concern for [MASKED] gangrene, which they felt she did not have. Patient initially received vancomycin, clindamycin, and Zosyn at [MASKED]. She was transitioned to ceftriaxone at [MASKED] with improvement in her cellulitis. Her urine grew enterococcus, so she was also given vancomycin. Based on sensitivities, she was narrowed to Augmentin for a total of 14 days (D14 [MASKED]. # Hypotension: Patient became hypotensive after sedation for intubation and resolved after extubation. Briefly on norepinephrine. Likely [MASKED] sedation and infection. BPs improved. # Acute renal failure: Patient with history of CKD (recent creatinine 1.4-1.6), Creatinine 5 on admission. Still making urine. Suspect combination of prerenal and possible pigment nephropathy. Patient seemed total body fluid overloaded with massive lower extremity edema. Her Cr improved to 1.2 on discharge. Bumex was restarted at reduced dose 3mg BID, with plan for active titration while in rehab. # Altered mental status Per report of EMS, was having visual hallucinations when found down. Likely secondary to infection and hyponatremia. Head CT was per report negative at [MASKED]. Urine tox screen was negative. Per chart, had previous alcohol use, but EtOH level here negative. Per report, she was responding but confused before intubation at [MASKED]. Patient mental status improved. On discharge, she was AOx3. # Heart failure TTE [MASKED] with EF 66% with regional/global systolic function, borderline pulmonary artery systolic hypertension, mild MR and normal valve morphology. Patient with significant lower extremity edema and chronic stasis changes bilaterally. Diuresis was held was intubated and on pressors. Per son, patient with multiple hospitalizations due to dehydration iso over diuresis. Patient was started on bumex 3mg BID and will need to follow up with Dr. [MASKED]. Home metoprolol was restarted as below. Should discuss restarting metolazone and spironolactone with Dr. [MASKED] in outpatient setting. # Atrial fibrillation Metoprolol briefly held for hypotension. Not on anticoagulation due to history of GI bleed. # EtOH history Previous admissions with alcohol in system, none this admission. Not clear when last drink. She was given high dose thiamine, folate, and MVI. # Hyponatremia Resolved. # Elevated CK (redolved) CK elevated to 600 in setting of being found down for a few hours. Not to level of needing IVF for renal protection. CHRONIC ISSUES =============== # DM Hdld home Januvia. Given insulin sliding scale while in the hospital. Restarted home med on discharge. # HLD Continued home simvastatin 20mg # Hypothyroidism Continued home levothyroxine # Neuropathy Continued home duloxetine. Medications on Admission: The Preadmission Medication list may be inaccurate and requires further investigation. 1. Bumetanide 6 mg PO BID 2. DULoxetine [MASKED] 60 mg PO DAILY 3. FoLIC Acid 1 mg PO DAILY 4. Gabapentin 200 mg PO QHS 5. Levothyroxine Sodium 125 mcg PO DAILY 6. MetOLazone 7.5 mg PO 1X/WEEK (MO) 7. Metoprolol Succinate XL 12.5 mg PO DAILY 8. Pantoprazole 40 mg PO Q24H 9. Potassium Chloride 20 mEq PO DAILY 10. Simvastatin 20 mg PO QPM 11. SITagliptin 25 mg oral DAILY 12. Spironolactone 25 mg PO DAILY Discharge Medications: 1. Amoxicillin-Clavulanic Acid [MASKED] mg PO BID RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0 2. LOPERamide 2 mg PO QID diarrhea RX *loperamide 2 mg 1 capsule by mouth four times a day Disp #*12 Capsule Refills:*0 3. Multivitamins 1 TAB PO DAILY RX *multivitamin 1 capsule(s) by mouth once a day Disp #*30 Capsule Refills:*0 4. Thiamine 100 mg PO DAILY RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 5. Bumetanide 3 mg PO BID 6. DULoxetine [MASKED] 60 mg PO DAILY 7. FoLIC Acid 1 mg PO DAILY 8. Gabapentin 200 mg PO QHS 9. Levothyroxine Sodium 125 mcg PO DAILY 10. Metoprolol Succinate XL 12.5 mg PO DAILY 11. Pantoprazole 40 mg PO Q24H 12. Simvastatin 20 mg PO QPM 13. SITagliptin 25 mg oral DAILY 14. HELD- MetOLazone 7.5 mg PO 1X/WEEK (MO) This medication was held. Do not restart MetOLazone until you see your cardiologist 15. HELD- Potassium Chloride 20 mEq PO DAILY This medication was held. Do not restart Potassium Chloride until BMP indicates K <3.5 16. HELD- Spironolactone 25 mg PO DAILY This medication was held. Do not restart Spironolactone until you see your cardiologist Discharge Disposition: Extended Care Facility: [MASKED] [MASKED] Diagnosis: #enterococcus UTI [MASKED] and [MASKED] cellulitis #HFpEF #pancytopenia [MASKED] iso CKD #Afib #T2DM c/b neuropathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear [MASKED], It was a privilege taking care of you at [MASKED] [MASKED]. WHY WAS I ADMITTED TO THE HOSPITAL? - You were transferred from [MASKED] after being found on the ground with altered mental status and suspension of severe skin infection. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? - You were admitted to the intensive care unit (ICU) as your blood pressure was low, and were started on medications to maintain your blood pressure. - You were intubated at [MASKED] as they were concerned about your ability to maintain patent airways. - You were found to have skin infection in the groin and lower extremity area. - You were started on very strong IV antibiotics. Theses were switched to oral ones once you condition stabilized. - You were found to have acute renal failure as you were dehydrated. This improved with hydration and holding your diuretics (water pills). - Your diuretics were started restarted at a lower dose. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Please continue to take all your medications and follow up with your doctors at your [MASKED] appointments. - Please weigh yourself everyday. If you gain 3 lbs in 2 days or 5 lbs in 7 days, please contact your doctor. We wish you all the best! Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED] | [
"A4181",
"R6521",
"G9341",
"N179",
"L03116",
"L03115",
"K610",
"N390",
"E871",
"M6282",
"D61818",
"I130",
"I5032",
"I4891",
"R159",
"L89159",
"E1140",
"E1122",
"F329",
"N189",
"Z87891",
"Z7289",
"Z7984",
"E785",
"E039",
"I878",
"E860",
"K279"
] | [
"A4181: Sepsis due to Enterococcus",
"R6521: Severe sepsis with septic shock",
"G9341: Metabolic encephalopathy",
"N179: Acute kidney failure, unspecified",
"L03116: Cellulitis of left lower limb",
"L03115: Cellulitis of right lower limb",
"K610: Anal abscess",
"N390: Urinary tract infection, site not specified",
"E871: Hypo-osmolality and hyponatremia",
"M6282: Rhabdomyolysis",
"D61818: Other pancytopenia",
"I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease",
"I5032: Chronic diastolic (congestive) heart failure",
"I4891: Unspecified atrial fibrillation",
"R159: Full incontinence of feces",
"L89159: Pressure ulcer of sacral region, unspecified stage",
"E1140: Type 2 diabetes mellitus with diabetic neuropathy, unspecified",
"E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease",
"F329: Major depressive disorder, single episode, unspecified",
"N189: Chronic kidney disease, unspecified",
"Z87891: Personal history of nicotine dependence",
"Z7289: Other problems related to lifestyle",
"Z7984: Long term (current) use of oral hypoglycemic drugs",
"E785: Hyperlipidemia, unspecified",
"E039: Hypothyroidism, unspecified",
"I878: Other specified disorders of veins",
"E860: Dehydration",
"K279: Peptic ulcer, site unspecified, unspecified as acute or chronic, without hemorrhage or perforation"
] | [
"N179",
"N390",
"E871",
"I130",
"I5032",
"I4891",
"E1122",
"F329",
"N189",
"Z87891",
"E785",
"E039"
] | [] |
17,253,389 | 29,184,738 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nLatex / Penicillins / Morphine / Demerol / Percocet / \nErythromycin Base / Bactrim / Statins-Hmg-Coa Reductase \nInhibitors / Diltiazem / Nsaids / Trileptal\n \nAttending: ___\n \nChief Complaint:\nChest pain and weakness\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ with h/o asthma, HTN, HLD, coronary artery \ndisease, and GERD who presents with chest pain, dyspnea on \nexertion, and left upper extremity weakness.\n\nThe patient reports not feeling well for the past few months. \nHas been receiving treament for trigeminal neuralgia with \nTrileptal. Pt reports many side effects to medications including \nconfusion, disequilibrium, and changes in her gait. Two weeks \nago, dose was uptitrated to 450mg po BID, and her symptoms \nworsened with confusion, cough, and generalized weakness. \nSubsequently developed a rash on her torso and face. Was placed \non prednisone taper for concern for allergic reaction, and \nstarted on gabapentin for tx of her trigeminal neuralgia. Also \nreported dyspnea on exertion when climbing stairs, which \nresolved after stopping Trileptal. Has also noticed swelling of \nher feet, abdomen, and thighs, which she feels has also resolved \nafter stopping Trileptal. \n\nTrileptal was stopped on ___. On ___, noticed that her \nsymptoms had greatly improved. However, the next day felt \nlightheaded and uncoordinated. Was trying to climb stairs and \nher right knee gave out on her. This morning the patient \nreported ongoing generalized weakness. Was at a store, and was \nhaving trouble signing a receipt. was able to walk to her car. \nAt that time developed left-sided squeezing chest pain with pain \ndown her left arm. She called her PCPs office who referred her \nto the ED via ambulance. In the ambulance, she recalls being \nvery hypertensive. She received nitro for her chest pain, which \nhelped both her chest pain and hypertension. \n\nIn the ED, initial vitals were: 98.1 60 146/74 17 97% RA \n- Exam notable for: 3+/5 left ___ strength on straight leg \nraise; left arm pronater drift\n- Labs notable for: trop <0.01, cre 1.0, CK 160, WBC 6.3\n- Imaging was notable for: CT Head w/o contrast: No acute \nintracranial abnormality; CXR without acute process.\n- Neurology was consulted: Felt weakness was unlikely a primary \nneurologic issue, given functional features to her exam. \nRecommended noncontrast MRI of brain.\n- Vitals prior to transfer: 97.9 62 186/78 15 100% RA \n\nUpon arrival to the floor, patient reports feeling generally \nunwell. Feels most of her symptoms are in her head, describing \nfogginess and \"disequilibrium.\" Currently reports headache \nacross her forehead, left sided neck pain and upper back pain, \nwith radiation down her left arm and into her chest. Feels most \nof her symptoms were due to Trileptal. Her dypnea on exertion \nand leg swelling have both resolved. No fevers/chills. Does \nendorse intermittent constipation with IBS and dysuria, which \nalso resolved after stopping Trileptal.\n\nOf note, last week while at work she developed acute onset \ncough, congestion, and pounding headache. Went home early from \nwork. Symptoms lasted about 24 hours, and resolved with rest. \n\nREVIEW OF SYSTEMS: \n(+) Per HPI \n(-) 10 point ROS reviewed and negative unless stated above in \nHPI \n \nPast Medical History:\nOB/GYN HISTORY: Menarche at age ___. She cycles every 30 to 60\ndays. She continues with uterine cramping and increased \nbleeding\nwith clotting. She is sexually active at present with a male\npartner. In terms of fertility control, condoms are method of\nchoice, she is very happy with this.\n\nDELIVERY HISTORY: In ___, she had a term baby, pregnancy\ncomplicated by gestational diabetes, she was delivered by\ncesarean section. In ___, she had a term infant, that\npregnancy was complicated by her being in a motor vehicle\naccident, this baby was also delivered by cesarean section. In\n___, she had a first trimester termination of pregnancy, in\n___ and ___, she had first trimester SABs, all without\ncomplications (she is a gravida 5, para 2). Her last Pap she \nwas\nin ___ and was normal. She has a remote history of dysplasia\nand having undergone cryotherapy for this. She has a history of\ngonorrhea and question history of herpes, there was a question \nof\noutbreak in ___.\n\nAsthma\nTrigeminal neuralgia\nImpaired glucose tolerance\nMonoclonal gammopathy\nHyperlipidemia\nCarpal Tunnel Syndrome\nHTN\nOSA\nJoint pain\nMorbid obesity\nCoronary artery disease\nGastroesophageal Reflux\nHerniated disc with left leg sciatica\nDepression\nHeart murmur\nIBS\nDiverticulosis\nInternal and external hemorrhoids\n?episode of left leg paralysis after a car accident in ___, \nwhich resolved with Valium (per patient report)\nStatus post right ankle fusion\n \nSocial History:\n___\nFamily History:\nSon with schizoaffective disorder, sister with\n___ disease, mother with meningioma and mother with \ncoronary\nartery disease, Paget's disease of the bone, and hypertensive. \nFather esophageal cancer and maternal aunt with diabetes type 1.\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nVital Signs: 98.2PO 125/72 63 18 95 Ra\nGeneral: Alert, oriented x 3; minimal eye contact throughout \nconversation\nHEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, although \nwith some dicomfort, PERRL.\nNeck: Supple. JVP not elevated. no LAD\nCV: Regular rate and rhythm. Normal S1+S2, no appreciable \nmurmurs\nLungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi\nAbdomen: Soft, non-tender, non-distended, bowel sounds present, \nno hepatomegaly\nGU: No foley\nExt: Warm, well perfused, 2+ pulses, no edema\nNeuro: CNII-XII intact, 4+/5 strength in deltoid, bicep, tricep \non left upper extremity; 4+ IP on left lower extremity; strength \nfull ___ in right upper and lower extremity; diminished \nsensation to light touch on medial left lower extremity; gait \ndeferred. Finger to nose intact. \n\nDISCHARGE PHYSICAL EXAM: \n\n \nPertinent Results:\n_____________________\nADMISSION LABS:\n\n___ 02:48PM BLOOD WBC-6.3# RBC-3.66* Hgb-11.8 Hct-34.6 \nMCV-95 MCH-32.2* MCHC-34.1 RDW-12.7 RDWSD-43.8 Plt ___\n___ 02:48PM BLOOD Neuts-75.4* ___ Monos-4.0* \nEos-0.3* Baso-0.2 Im ___ AbsNeut-4.72# AbsLymp-1.24 \nAbsMono-0.25 AbsEos-0.02* AbsBaso-0.01\n___ 02:48PM BLOOD ___ PTT-28.3 ___\n___ 02:48PM BLOOD Glucose-99 UreaN-27* Creat-1.0 Na-141 \nK-3.4 Cl-104 HCO3-23 AnGap-17\n___ 02:48PM BLOOD cTropnT-<0.01\n___ 04:00AM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-64\n___ 02:48PM BLOOD Calcium-9.1 Phos-2.5* Mg-2.0\n_____________________\nNOTABLE LABS:\n\n___ 04:00AM BLOOD VitB12-693\n___ 04:00AM BLOOD %HbA1c-5.4 eAG-108\n___ 04:00AM BLOOD Triglyc-195* HDL-66 CHOL/HD-3.5 \nLDLcalc-129\n___ 04:00AM BLOOD TSH-6.6*\n___ 04:00AM BLOOD Free T4-0.9*\n_____________________\nIMAGING/STUDIES:\n\n___ CT HEAD W/O CONTRAST:\n- No acute intracranial abnormality.\n\n___ MR CERVICAL SPINE W/O CONTRAST: \n- Disc protrusions spanning C2-3 through C5-6 which partially \nefface the ventral\nCSF and result in mild canal narrowing at C4-5.\n\n___ MR HEAD W/O CONTRAST:\n1. No evidence of acute infarct.\n2. Possible chronic micro hemorrhages in the right temporal \nlobe.\n_____________________\nDISCHARGE LABS:\n\n___ 07:50AM BLOOD WBC-4.3 RBC-3.71* Hgb-12.0 Hct-35.9 \nMCV-97 MCH-32.3* MCHC-33.4 RDW-12.7 RDWSD-44.3 Plt ___\n___ 07:50AM BLOOD Glucose-85 UreaN-19 Creat-1.0 Na-144 \nK-4.0 Cl-106 HCO3-28 AnGap-___ is a ___ year old woman with a history of \natypical chest pain (non-obstructive CAD), trigeminal neuralgia, \nwho presented with new onset left sided weakness and chest pain. \nACS ruled out with unremarkable ECG (unchanged from prior) and \nnegative enzymes. The patient's cardiologist Dr. ___ \nstopped by to see the patient and agreed that her chest pain was \nunchanged from prior evaluation. She has had stress echoes in \nthe past with chest pain while walking on the treadmill and no \nECG changes or focal wall motion abnormalities. \nStroke was ruled out with a negative MRI. MRI of the c-spine was \nalso done with some mild C2-C6 spinal canal narrowing but \nnothing to explain weakness. The patient was also noted to have \na TSH of 6.6 on labs, confirmed hypothyroidism with a FT4 of \n0.9. \nShe was started on levothyroxine 50 mcg. Medication effect from \noxcarbazepine (previously, as this was stopped), gabapentin \nwhich was started in its place, baclofen, and/or dicyclomine \nwere other considerations as causes of her mental fogginess, \nfatigue, and disequilibrium and the decision was made to defer \nfurther management of these to the patient's outpatient \nproviders.\n\nHere individual active issues were assessed, diagnosed and \ntreated as follows: \n\n#LEFT SIDED WEAKNESS: \n#HEADACHE/MENTAL FOGGINESS/DISEQUILIBRIUM: \nNoted to have 4+ strength in deltoid, triceps, and biceps, as \nwell as the left lower extremity. All of which she reported new \nsince ___. Pt reporting left sided neck pain and upper back \npain as well. Neuro felt the focal weakness was functional and \nthat with enough effort the patient could give full strength. \nLikely secondary to med effect and/or newly diagnosed \nhypothyroidism. \nReporting month long history of feeling foggy in the setting of \ntaking Trileptal for her trigeminal neuralgia. Thought that this \nimproved off Trileptal initially but then was still having \nsymptoms over the weekend (she was of note started on gabapentin \nto continue managing her trigeminal neuralgia). ___ recommended \noutpatient ___. Stroke was ruled out with MRI as noted above. \nStarted on levothyroxine for high TSH low FT4. \n\n#TRIGEMINAL NEURALGIA: \nRecently had d/c'ed trileptal for allergic rxn. Presented on \ngabapentin uptitrating to 300mg qhs. Completed prednisone taper \nfor allergic reaction. Continued gabapentin, deferring further \nmanagement to PCP. \n\n#ATYPICAL CHEST PAIN: \nHas hx of atypical chest pain as well as CAD without significant \ndisease with 30% ___ RCA lesion on cath from ___. According to \npast cardiology notes, also felt that chest pain may be due to \nesophageal spasm. ___ also be musculoskeletal given predominant \nneck pain with radiation down left arm. Patient endorsed \northopnea and states that she sleeps on 3 pillows which is \nchronic for her. BNP normal though here. Follows with Dr. ___ \n___ cardiology and last saw him about a year ago. Dr. ___ \nthe patient here and felt this was consistent with her previous \nchest pain, no further work up required at this time. \n\nTRANSITIONAL ISSUES: \n====================================\n#CODE STATUS: Full Code\n#CONTACT: ___ (friend) ___, Son (lives in ___ \n___ \n_________________________\nFYI: \n- Evaluated by cardiology here. Recommended to have an exercise \nMIBI outpatient if she continues to have crescendo atypical \nangina symptoms. \n- Patient started on felodipine 2.5mg QD as recommended by \noutpatient cardiologist for hypertension\n- Neurology did not feel the findings on the patient's MRI brain \nwere significant enough to start secondary stroke prevention. \nThere were just questionable chronic micro hemorrhages in the \nright temporal lobe.\n- Patient was discharged with outpatient ___\n- Patient was started on levothyroxine 50mcg QD for \nhypothyroidism\n_________________________\nTO DO: \n[ ] Re-check TSH/FT4 in 6 weeks \n[ ] Would consider stopping any of the following medications to \nsee if the patient's dizziness/disequilibrium/fatigue improve: \ngabapentin, baclofen, dicyclomine\n[ ] anti-TPO antibodies sent and were pending on discharge for \nhypothyroidism\n \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Gabapentin 100 mg PO QHS \n2. PredniSONE 10 mg PO DAILY \nTapered dose - DOWN \n3. Baclofen 10 mg PO TID:PRN Pain - Mild \n4. Hydrochlorothiazide 25 mg PO DAILY \n5. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild \n6. Albuterol Inhaler 2 PUFF IH Q4-6H PRN wheezing \n7. Ipratropium Bromide MDI 2 PUFF IH QID:PRN wheezing \n8. Ketoconazole Shampoo 1 Appl TP ASDIR \n9. Albuterol 0.083% Neb Soln 1 NEB IH Q4-6H PRN wheezing \n10. clindamycin phosphate 1 % topical BID \n11. DICYCLOMine 10 mg PO DAILY \n12. Hemorrhoidal Suppository ___ID PRN hemorrhoids \n13. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n14. DiphenhydrAMINE 25 mg PO QHS:PRN insomnia \n15. Loratadine 10 mg PO DAILY \n16. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain \n17. mometasone 0.1 % topical DAILY \n18. Nexium 20 mg Other BID \n19. FoLIC Acid 1 mg PO DAILY \n20. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3) \n600 mg(1,500mg) -400 unit oral BID \n21. Multivitamins 1 TAB PO DAILY \n22. Ascorbic Acid ___ mg PO DAILY \n\n \nDischarge Medications:\n1. Felodipine 2.5 mg PO DAILY \nRX *felodipine 2.5 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0 \n2. Levothyroxine Sodium 50 mcg PO DAILY \nRX *levothyroxine 50 mcg 1 tablet(s) by mouth once a day Disp \n#*30 Tablet Refills:*0 \n3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n4. Albuterol 0.083% Neb Soln 1 NEB IH Q4-6H PRN wheezing \n5. Albuterol Inhaler 2 PUFF IH Q4-6H PRN wheezing \n6. Ascorbic Acid ___ mg PO DAILY \n7. Baclofen 10 mg PO TID:PRN Pain - Mild \n8. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3) \n600 mg(1,500mg) -400 unit oral BID \n9. clindamycin phosphate 1 % topical BID \n10. DICYCLOMine 10 mg PO DAILY \n11. DiphenhydrAMINE 25 mg PO QHS:PRN insomnia \n12. FoLIC Acid 1 mg PO DAILY \n13. Gabapentin 100 mg PO QHS \n14. Hemorrhoidal Suppository ___ID PRN hemorrhoids \n15. Hydrochlorothiazide 25 mg PO DAILY \n16. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild \n17. Ipratropium Bromide MDI 2 PUFF IH QID:PRN wheezing \n18. Ketoconazole Shampoo 1 Appl TP ASDIR \n19. Loratadine 10 mg PO DAILY \n20. mometasone 0.1 % topical DAILY \n21. Multivitamins 1 TAB PO DAILY \n22. Nexium 20 mg Other BID \n23. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain \n24.Outpatient Physical Therapy\nDx: Left-sided weakness | ICD10: R53.1\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY: \n- Hypothyroidism\n- Atypical chest pain\n- Functional left sided weakness\n\nSECONDARY: \n- Trigeminal neuralgia\n- Hypertension\n- Irritable bowel syndrome\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou were admitted to ___ because you were feeling weak on your \nleft side and had chest pain.\n\nIn the hospital, the following was done and found: \n- We found no evidence of a heart attack\n- We found no evidence of stroke\n- We did find that you have hypothyroidism and started you on a \nnew medication for this. This may explain your weakness. \n\nWhen you leave the hospital you should do the following: \n- Follow up with your doctor appointments below\n- ___ note all of your new and/or changed medications listed \nbelow\n- Your primary care doctor may discuss changes for some of your \nmedications to see if those are also a cause of your on-going \nweakness. \n\nIt was a pleasure caring for you!\nYour ___ Team\n \nFollowup Instructions:\n___\n"
] | Allergies: Latex / Penicillins / Morphine / Demerol / Percocet / Erythromycin Base / Bactrim / Statins-Hmg-Coa Reductase Inhibitors / Diltiazem / Nsaids / Trileptal Chief Complaint: Chest pain and weakness Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] with h/o asthma, HTN, HLD, coronary artery disease, and GERD who presents with chest pain, dyspnea on exertion, and left upper extremity weakness. The patient reports not feeling well for the past few months. Has been receiving treament for trigeminal neuralgia with Trileptal. Pt reports many side effects to medications including confusion, disequilibrium, and changes in her gait. Two weeks ago, dose was uptitrated to 450mg po BID, and her symptoms worsened with confusion, cough, and generalized weakness. Subsequently developed a rash on her torso and face. Was placed on prednisone taper for concern for allergic reaction, and started on gabapentin for tx of her trigeminal neuralgia. Also reported dyspnea on exertion when climbing stairs, which resolved after stopping Trileptal. Has also noticed swelling of her feet, abdomen, and thighs, which she feels has also resolved after stopping Trileptal. Trileptal was stopped on [MASKED]. On [MASKED], noticed that her symptoms had greatly improved. However, the next day felt lightheaded and uncoordinated. Was trying to climb stairs and her right knee gave out on her. This morning the patient reported ongoing generalized weakness. Was at a store, and was having trouble signing a receipt. was able to walk to her car. At that time developed left-sided squeezing chest pain with pain down her left arm. She called her PCPs office who referred her to the ED via ambulance. In the ambulance, she recalls being very hypertensive. She received nitro for her chest pain, which helped both her chest pain and hypertension. In the ED, initial vitals were: 98.1 60 146/74 17 97% RA - Exam notable for: 3+/5 left [MASKED] strength on straight leg raise; left arm pronater drift - Labs notable for: trop <0.01, cre 1.0, CK 160, WBC 6.3 - Imaging was notable for: CT Head w/o contrast: No acute intracranial abnormality; CXR without acute process. - Neurology was consulted: Felt weakness was unlikely a primary neurologic issue, given functional features to her exam. Recommended noncontrast MRI of brain. - Vitals prior to transfer: 97.9 62 186/78 15 100% RA Upon arrival to the floor, patient reports feeling generally unwell. Feels most of her symptoms are in her head, describing fogginess and "disequilibrium." Currently reports headache across her forehead, left sided neck pain and upper back pain, with radiation down her left arm and into her chest. Feels most of her symptoms were due to Trileptal. Her dypnea on exertion and leg swelling have both resolved. No fevers/chills. Does endorse intermittent constipation with IBS and dysuria, which also resolved after stopping Trileptal. Of note, last week while at work she developed acute onset cough, congestion, and pounding headache. Went home early from work. Symptoms lasted about 24 hours, and resolved with rest. REVIEW OF SYSTEMS: (+) Per HPI (-) 10 point ROS reviewed and negative unless stated above in HPI Past Medical History: OB/GYN HISTORY: Menarche at age [MASKED]. She cycles every 30 to 60 days. She continues with uterine cramping and increased bleeding with clotting. She is sexually active at present with a male partner. In terms of fertility control, condoms are method of choice, she is very happy with this. DELIVERY HISTORY: In [MASKED], she had a term baby, pregnancy complicated by gestational diabetes, she was delivered by cesarean section. In [MASKED], she had a term infant, that pregnancy was complicated by her being in a motor vehicle accident, this baby was also delivered by cesarean section. In [MASKED], she had a first trimester termination of pregnancy, in [MASKED] and [MASKED], she had first trimester SABs, all without complications (she is a gravida 5, para 2). Her last Pap she was in [MASKED] and was normal. She has a remote history of dysplasia and having undergone cryotherapy for this. She has a history of gonorrhea and question history of herpes, there was a question of outbreak in [MASKED]. Asthma Trigeminal neuralgia Impaired glucose tolerance Monoclonal gammopathy Hyperlipidemia Carpal Tunnel Syndrome HTN OSA Joint pain Morbid obesity Coronary artery disease Gastroesophageal Reflux Herniated disc with left leg sciatica Depression Heart murmur IBS Diverticulosis Internal and external hemorrhoids ?episode of left leg paralysis after a car accident in [MASKED], which resolved with Valium (per patient report) Status post right ankle fusion Social History: [MASKED] Family History: Son with schizoaffective disorder, sister with [MASKED] disease, mother with meningioma and mother with coronary artery disease, Paget's disease of the bone, and hypertensive. Father esophageal cancer and maternal aunt with diabetes type 1. Physical Exam: ADMISSION PHYSICAL EXAM: Vital Signs: 98.2PO 125/72 63 18 95 Ra General: Alert, oriented x 3; minimal eye contact throughout conversation HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, although with some dicomfort, PERRL. Neck: Supple. JVP not elevated. no LAD CV: Regular rate and rhythm. Normal S1+S2, no appreciable murmurs Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no hepatomegaly GU: No foley Ext: Warm, well perfused, 2+ pulses, no edema Neuro: CNII-XII intact, 4+/5 strength in deltoid, bicep, tricep on left upper extremity; 4+ IP on left lower extremity; strength full [MASKED] in right upper and lower extremity; diminished sensation to light touch on medial left lower extremity; gait deferred. Finger to nose intact. DISCHARGE PHYSICAL EXAM: Pertinent Results: [MASKED] ADMISSION LABS: [MASKED] 02:48PM BLOOD WBC-6.3# RBC-3.66* Hgb-11.8 Hct-34.6 MCV-95 MCH-32.2* MCHC-34.1 RDW-12.7 RDWSD-43.8 Plt [MASKED] [MASKED] 02:48PM BLOOD Neuts-75.4* [MASKED] Monos-4.0* Eos-0.3* Baso-0.2 Im [MASKED] AbsNeut-4.72# AbsLymp-1.24 AbsMono-0.25 AbsEos-0.02* AbsBaso-0.01 [MASKED] 02:48PM BLOOD [MASKED] PTT-28.3 [MASKED] [MASKED] 02:48PM BLOOD Glucose-99 UreaN-27* Creat-1.0 Na-141 K-3.4 Cl-104 HCO3-23 AnGap-17 [MASKED] 02:48PM BLOOD cTropnT-<0.01 [MASKED] 04:00AM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-64 [MASKED] 02:48PM BLOOD Calcium-9.1 Phos-2.5* Mg-2.0 [MASKED] NOTABLE LABS: [MASKED] 04:00AM BLOOD VitB12-693 [MASKED] 04:00AM BLOOD %HbA1c-5.4 eAG-108 [MASKED] 04:00AM BLOOD Triglyc-195* HDL-66 CHOL/HD-3.5 LDLcalc-129 [MASKED] 04:00AM BLOOD TSH-6.6* [MASKED] 04:00AM BLOOD Free T4-0.9* [MASKED] IMAGING/STUDIES: [MASKED] CT HEAD W/O CONTRAST: - No acute intracranial abnormality. [MASKED] MR CERVICAL SPINE W/O CONTRAST: - Disc protrusions spanning C2-3 through C5-6 which partially efface the ventral CSF and result in mild canal narrowing at C4-5. [MASKED] MR HEAD W/O CONTRAST: 1. No evidence of acute infarct. 2. Possible chronic micro hemorrhages in the right temporal lobe. [MASKED] DISCHARGE LABS: [MASKED] 07:50AM BLOOD WBC-4.3 RBC-3.71* Hgb-12.0 Hct-35.9 MCV-97 MCH-32.3* MCHC-33.4 RDW-12.7 RDWSD-44.3 Plt [MASKED] [MASKED] 07:50AM BLOOD Glucose-85 UreaN-19 Creat-1.0 Na-144 K-4.0 Cl-106 HCO3-28 AnGap-[MASKED] is a [MASKED] year old woman with a history of atypical chest pain (non-obstructive CAD), trigeminal neuralgia, who presented with new onset left sided weakness and chest pain. ACS ruled out with unremarkable ECG (unchanged from prior) and negative enzymes. The patient's cardiologist Dr. [MASKED] stopped by to see the patient and agreed that her chest pain was unchanged from prior evaluation. She has had stress echoes in the past with chest pain while walking on the treadmill and no ECG changes or focal wall motion abnormalities. Stroke was ruled out with a negative MRI. MRI of the c-spine was also done with some mild C2-C6 spinal canal narrowing but nothing to explain weakness. The patient was also noted to have a TSH of 6.6 on labs, confirmed hypothyroidism with a FT4 of 0.9. She was started on levothyroxine 50 mcg. Medication effect from oxcarbazepine (previously, as this was stopped), gabapentin which was started in its place, baclofen, and/or dicyclomine were other considerations as causes of her mental fogginess, fatigue, and disequilibrium and the decision was made to defer further management of these to the patient's outpatient providers. Here individual active issues were assessed, diagnosed and treated as follows: #LEFT SIDED WEAKNESS: #HEADACHE/MENTAL FOGGINESS/DISEQUILIBRIUM: Noted to have 4+ strength in deltoid, triceps, and biceps, as well as the left lower extremity. All of which she reported new since [MASKED]. Pt reporting left sided neck pain and upper back pain as well. Neuro felt the focal weakness was functional and that with enough effort the patient could give full strength. Likely secondary to med effect and/or newly diagnosed hypothyroidism. Reporting month long history of feeling foggy in the setting of taking Trileptal for her trigeminal neuralgia. Thought that this improved off Trileptal initially but then was still having symptoms over the weekend (she was of note started on gabapentin to continue managing her trigeminal neuralgia). [MASKED] recommended outpatient [MASKED]. Stroke was ruled out with MRI as noted above. Started on levothyroxine for high TSH low FT4. #TRIGEMINAL NEURALGIA: Recently had d/c'ed trileptal for allergic rxn. Presented on gabapentin uptitrating to 300mg qhs. Completed prednisone taper for allergic reaction. Continued gabapentin, deferring further management to PCP. #ATYPICAL CHEST PAIN: Has hx of atypical chest pain as well as CAD without significant disease with 30% [MASKED] RCA lesion on cath from [MASKED]. According to past cardiology notes, also felt that chest pain may be due to esophageal spasm. [MASKED] also be musculoskeletal given predominant neck pain with radiation down left arm. Patient endorsed orthopnea and states that she sleeps on 3 pillows which is chronic for her. BNP normal though here. Follows with Dr. [MASKED] [MASKED] cardiology and last saw him about a year ago. Dr. [MASKED] the patient here and felt this was consistent with her previous chest pain, no further work up required at this time. TRANSITIONAL ISSUES: ==================================== #CODE STATUS: Full Code #CONTACT: [MASKED] (friend) [MASKED], Son (lives in [MASKED] [MASKED] [MASKED] FYI: - Evaluated by cardiology here. Recommended to have an exercise MIBI outpatient if she continues to have crescendo atypical angina symptoms. - Patient started on felodipine 2.5mg QD as recommended by outpatient cardiologist for hypertension - Neurology did not feel the findings on the patient's MRI brain were significant enough to start secondary stroke prevention. There were just questionable chronic micro hemorrhages in the right temporal lobe. - Patient was discharged with outpatient [MASKED] - Patient was started on levothyroxine 50mcg QD for hypothyroidism [MASKED] TO DO: [ ] Re-check TSH/FT4 in 6 weeks [ ] Would consider stopping any of the following medications to see if the patient's dizziness/disequilibrium/fatigue improve: gabapentin, baclofen, dicyclomine [ ] anti-TPO antibodies sent and were pending on discharge for hypothyroidism Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Gabapentin 100 mg PO QHS 2. PredniSONE 10 mg PO DAILY Tapered dose - DOWN 3. Baclofen 10 mg PO TID:PRN Pain - Mild 4. Hydrochlorothiazide 25 mg PO DAILY 5. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild 6. Albuterol Inhaler 2 PUFF IH Q4-6H PRN wheezing 7. Ipratropium Bromide MDI 2 PUFF IH QID:PRN wheezing 8. Ketoconazole Shampoo 1 Appl TP ASDIR 9. Albuterol 0.083% Neb Soln 1 NEB IH Q4-6H PRN wheezing 10. clindamycin phosphate 1 % topical BID 11. DICYCLOMine 10 mg PO DAILY 12. Hemorrhoidal Suppository ID PRN hemorrhoids 13. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 14. DiphenhydrAMINE 25 mg PO QHS:PRN insomnia 15. Loratadine 10 mg PO DAILY 16. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 17. mometasone 0.1 % topical DAILY 18. Nexium 20 mg Other BID 19. FoLIC Acid 1 mg PO DAILY 20. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral BID 21. Multivitamins 1 TAB PO DAILY 22. Ascorbic Acid [MASKED] mg PO DAILY Discharge Medications: 1. Felodipine 2.5 mg PO DAILY RX *felodipine 2.5 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 2. Levothyroxine Sodium 50 mcg PO DAILY RX *levothyroxine 50 mcg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 4. Albuterol 0.083% Neb Soln 1 NEB IH Q4-6H PRN wheezing 5. Albuterol Inhaler 2 PUFF IH Q4-6H PRN wheezing 6. Ascorbic Acid [MASKED] mg PO DAILY 7. Baclofen 10 mg PO TID:PRN Pain - Mild 8. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral BID 9. clindamycin phosphate 1 % topical BID 10. DICYCLOMine 10 mg PO DAILY 11. DiphenhydrAMINE 25 mg PO QHS:PRN insomnia 12. FoLIC Acid 1 mg PO DAILY 13. Gabapentin 100 mg PO QHS 14. Hemorrhoidal Suppository ID PRN hemorrhoids 15. Hydrochlorothiazide 25 mg PO DAILY 16. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild 17. Ipratropium Bromide MDI 2 PUFF IH QID:PRN wheezing 18. Ketoconazole Shampoo 1 Appl TP ASDIR 19. Loratadine 10 mg PO DAILY 20. mometasone 0.1 % topical DAILY 21. Multivitamins 1 TAB PO DAILY 22. Nexium 20 mg Other BID 23. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 24.Outpatient Physical Therapy Dx: Left-sided weakness | ICD10: R53.1 Discharge Disposition: Home Discharge Diagnosis: PRIMARY: - Hypothyroidism - Atypical chest pain - Functional left sided weakness SECONDARY: - Trigeminal neuralgia - Hypertension - Irritable bowel syndrome Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You were admitted to [MASKED] because you were feeling weak on your left side and had chest pain. In the hospital, the following was done and found: - We found no evidence of a heart attack - We found no evidence of stroke - We did find that you have hypothyroidism and started you on a new medication for this. This may explain your weakness. When you leave the hospital you should do the following: - Follow up with your doctor appointments below - [MASKED] note all of your new and/or changed medications listed below - Your primary care doctor may discuss changes for some of your medications to see if those are also a cause of your on-going weakness. It was a pleasure caring for you! Your [MASKED] Team Followup Instructions: [MASKED] | [
"E039",
"R0789",
"R531",
"G500",
"K589",
"E6601",
"Z6839",
"R410",
"K219",
"J45909",
"G4700",
"Z87891",
"I160",
"I10",
"R401",
"I2510"
] | [
"E039: Hypothyroidism, unspecified",
"R0789: Other chest pain",
"R531: Weakness",
"G500: Trigeminal neuralgia",
"K589: Irritable bowel syndrome without diarrhea",
"E6601: Morbid (severe) obesity due to excess calories",
"Z6839: Body mass index [BMI] 39.0-39.9, adult",
"R410: Disorientation, unspecified",
"K219: Gastro-esophageal reflux disease without esophagitis",
"J45909: Unspecified asthma, uncomplicated",
"G4700: Insomnia, unspecified",
"Z87891: Personal history of nicotine dependence",
"I160: Hypertensive urgency",
"I10: Essential (primary) hypertension",
"R401: Stupor",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris"
] | [
"E039",
"K219",
"J45909",
"G4700",
"Z87891",
"I10",
"I2510"
] | [] |
15,411,704 | 20,876,149 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\npathologic right femoral neck fracture\n \nMajor Surgical or Invasive Procedure:\nRight hip hemiarthroplasty ___\nBone marrow biopsy ___\n\n \nHistory of Present Illness:\n___ PMH of HTN, Osteoporosis, Arthritis, Gout, presented with\nright groin pain ___ right pathologic femoral neck fracture,\nadmitted to ___ for expedited workup prior to eventual surgical\nintervention\n\nAs per review of outpatient notes, patient was referred to\northopedics in light of right groin pain leading to\nidentification of a right femoral neck lesion which was\nconcerning for impending fracture. She underwent biopsy of the\nright femoral lesion with pathology consistent with skeletal\nmuscle and adipose tissue with abundant amyloid deposits. Her\nblood work as an outpatient was notable for detection of light\nchains. She also had an aspiration at that time that showed 30\nnucleated cells (88% polys) with a negative gram stain. She was\nscheduled for outpatient oncologic workup but has been immobile\nand in significant pain prompting her visit to the ED.\n\nPt reports that she has had significant right groin pain for\nseveral days, which is severe when moving, less when immobile.\nAccordingly, she has been moving less and is developing\nrecurrence of pressure ulcer. She noted that she otherwise felt\nwell, and denied fever, chills, shortness of breath, decreased\nappetite, bowel/bladder dysfunction. Denied trauma history.\n\nIn the ED, initial vitals: 10 97.8 96 152/67 18 98% RA. WBC \n8.8,\nHgb 11.3, plt 426, INR 1.0, CHEM wnl, UA with proteinuria. \n\nFemur Xray:\n1.7 cm displaced subcapital pathologic right femoral neck\nfracture.\n\nCXR:\nCardiomegaly without superimposed acute cardiopulmonary process.\n \nPatient was given Tylenol and admitted to ___ for expedited\nworkup\n \nPast Medical History:\nMultiple myeloma\nAmyloidosis\nAfib\nHFrEF (EF 45%)\nHypertension\nosteoporosis\nArthritis\nGout\n \nSocial History:\n___\nFamily History:\nLiver cancer-son\nStomach cancer-sister\nCVA-mother\n___\nJoint disease/arthritis-mother positive for\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n=======================\nVitals: ___ ___ Temp: 98.1 PO BP: 105/58 HR: 90 RR: 18 O2\nsat: 94% O2 delivery: Ra \nGENERAL: laying in bed, appears comfortable, calm, NAD\nEYES: PERRLA, anicteric\nHEENT: OP clear, MMM \nNECK: supple \nLUNGS: CTA b/l, no wheezes/rales/rhonchi, normal RR\nCV: RRR no m/r/g, normal distal perfusion, no edema\nABD: Soft, NT, ND, normoactive BS\nGENITOURINARY: no foley\nEXT: warm, decreased muscle bulk, has discomfort in right groin\nwith any movement of right leg\nSKIN: warm, dry, no rash\nNEURO: AOx3, fluent speech\nACCESS: PIV\n\nDISCHARGE PHYSICAL EXAM:\n========================\nVitals: T 98.3, BP 121/73, HR 83, RR 18, 94% on RA.\nGENERAL: lying in bed, appears comfortable, NAD.\nHEENT: NCAT, sclera anicteric, PERRL, OP clear, MMM.\nLUNGS: CTAB, no wheezes rales or rhonchi.\nCV: irregular rhythm, regular rate, no m/r/g.\nABD: Soft, NT, ND, normoactive BS.\nEXT: warm; no ___ edema.\nNEURO: AOx3, fluent speech\nACCESS: PIV\n\n \nPertinent Results:\nADMISSION LABS:\n==============\n___ 10:30PM BLOOD WBC-8.8 RBC-3.67* Hgb-11.3 Hct-36.0 \nMCV-98 MCH-30.8 MCHC-31.4* RDW-15.7* RDWSD-57.1* Plt ___\n___ 10:30PM BLOOD Neuts-65.3 ___ Monos-7.8 Eos-1.3 \nBaso-0.6 Im ___ AbsNeut-5.73 AbsLymp-2.14 AbsMono-0.68 \nAbsEos-0.11 AbsBaso-0.05\n___ 10:30PM BLOOD ___ PTT-27.8 ___\n___ 10:30PM BLOOD Glucose-105* UreaN-33* Creat-0.9 Na-141 \nK-5.2 Cl-100 HCO3-24 AnGap-17\n___ 10:30PM BLOOD Albumin-3.7\n___ 10:30PM BLOOD ALT-15 AST-23 AlkPhos-122* TotBili-0.2\n\nPERTINENT LABS/MICRO/IMAGING:\n============================\n___ 10:30PM BLOOD ___ FreeLam-6010* Fr K/L-0.00*\n___ 06:10AM BLOOD IgG-354* IgA-28* IgM-7*\n___ 06:30AM BLOOD ___ FreeLam-6912* Fr K/L-0.00* \nIgG-254* IgA-22* IgM-5*\n\n___ 06:10AM BLOOD Calcium-8.9 Phos-4.1 Mg-2.0 UricAcd-9.2* \nIron-37\n___ 06:10AM BLOOD calTIBC-274 VitB12-757 Folate-12 \nFerritn-305* TRF-211\n___ 06:15AM BLOOD 25VitD-25*\n___ 06:30AM BLOOD TSH-1.2\n___ 06:30AM BLOOD Cortsol-15.1\n___ 03:15PM BLOOD GGT-48*\n___ 07:20AM BLOOD GGT-54*\n\nMICRO:\n-----------\n___ 02:03AM URINE Color-Yellow Appear-Clear Sp ___\n___ 02:03AM URINE Blood-SM* Nitrite-NEG Protein-30* \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM*\n___ 02:03AM URINE RBC-10* WBC-6* Bacteri-FEW* Yeast-NONE \nEpi-0\n___ 02:03AM URINE CastGr-6* CastHy-23*\n\n___ 2:03 am URINE Source: Catheter. \n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE \nIDENTIFICATION. \n Cefepime test result confirmed by ___. \n Piperacillin/Tazobactam test result performed by ___ \n___. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n ESCHERICHIA COLI\n | \nAMPICILLIN------------ =>32 R\nAMPICILLIN/SULBACTAM-- =>32 R\nCEFAZOLIN------------- =>64 R\nCEFEPIME-------------- <=1 S\nCEFTAZIDIME----------- =>64 R\nCEFTRIAXONE----------- 16 R\nCIPROFLOXACIN---------<=0.25 S\nGENTAMICIN------------ <=1 S\nMEROPENEM-------------<=0.25 S\nNITROFURANTOIN-------- <=16 S\nPIPERACILLIN/TAZO----- S\nTOBRAMYCIN------------ <=1 S\nTRIMETHOPRIM/SULFA---- <=1 S\n\n___ 10:30 am URINE Source: ___. \n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: < 10,000 CFU/mL.\n\nIMAGING:\n-------------\nCXR ___:\nCardiomegaly without superimposed acute cardiopulmonary process.\n\nR Femur XR ___:\n1.7 cm displaced subcapital pathologic right femoral neck \nfracture.\n\nTTE ___:\nThe left atrial volume index is mildly increased. There is \nnormal left ventricular wall thickness with a\nnormal cavity size. Overall left ventricular systolic function \nis mildly-to-moderately depressed\nsecondary to inferior, posterior, and apical hypokinesis. The \nvisually estimated left ventricular\nejection fraction is 45%. There is no resting left ventricular \noutflow tract gradient. Normal right\nventricular cavity size with normal free wall motion. The aortic \nsinus diameter is normal for gender with\nnormal ascending aorta diameter for gender. The aortic arch \ndiameter is normal. The aortic valve leaflets\n(3) are moderately thickened. There is no aortic valve stenosis. \nThere is trace aortic regurgitation. The\nmitral valve leaflets are moderately thickened with no mitral \nvalve prolapse. There is trivial mitral\nregurgitation. The tricuspid valve leaflets are mildly \nthickened. There is mild to moderate [___]\ntricuspid regurgitation. There is mild pulmonary artery systolic \nhypertension. There is no pericardial\neffusion.\n\nPelvic XR ___:\nStatus post bilateral hip arthroplasty.\nExtensive subcutaneous emphysema and postsurgical changes are \nseen surrounding\nthe right hip arthroplasty.\n\nRLE Doppler ___:\nNo evidence of DVT in the right lower extremity.\n\nSkeletal Survey ___:\n1. Erosive changes along the left ischial tuberosity, which are \nsimilar in\nappearance to prior CT and MRI studies. No additional lytic \nlesions are\nidentified.\n2. Diffuse osteopenia.\n\nRUQUS ___:\n1. Normal liver parenchyma without evidence of concerning focal \nliver lesions.\n2. Cholelithiasis without evidence of cholecystitis.\n3. Common hepatic duct is 2 mm.\n\nCXR ___:\nLungs are low volume with moderate pulmonary edema. \nCardiomediastinal \nsilhouette is stable. There are small bilateral effusions left \ngreater than right. No pneumothorax is seen. \n\nCXR ___:\nLungs are low volume with slight improvement in the interstitial \nedema. \nCardiomediastinal silhouette is stable. There is no pleural \neffusion. No \npneumothorax is seen \n\nDISCHARGE LABS:\n===============\n___ 06:47AM BLOOD WBC-8.5 RBC-2.96* Hgb-9.3* Hct-29.5* \nMCV-100* MCH-31.4 MCHC-31.5* RDW-17.9* RDWSD-62.5* Plt ___\n___ 06:47AM BLOOD Neuts-67.0 Lymphs-16.3* Monos-9.0 Eos-5.9 \nBaso-0.4 Im ___ AbsNeut-5.71 AbsLymp-1.39 AbsMono-0.77 \nAbsEos-0.50 AbsBaso-0.03\n___ 06:47AM BLOOD ___ PTT-36.0 ___\n___ 06:47AM BLOOD Glucose-93 UreaN-21* Creat-0.7 Na-140 \nK-4.2 Cl-100 HCO3-28 AnGap-12\n___ 06:47AM BLOOD ALT-14 AST-15 LD(LDH)-191 AlkPhos-114* \nTotBili-0.4\n___ 06:47AM BLOOD Albumin-3.0* Calcium-8.4 Phos-4.5 Mg-1.8\n\n \nBrief Hospital Course:\nPATIENT SUMMARY: \n================\n___ with PMH of HTN, osteoporosis, arthritis, and gout who \npresented with right groin pain due to right pathologic femoral \nneck fracture, admitted to ___ for expedited workup of \namyloidosis/multiple myeloma and right hip hemiarthroplasty. S/p \nright hip hemiarthroplasty on ___. Bone marrow biopsy on ___ \nconfirmed the diagnosis of multiple myeloma, and she is s/p \ndexamethasone 10mg IV x 4 days (___) and Velcade ___ \nand ___. Course c/b new-onset Afib, HFrEF, ___, hyponatremia, \nand UTI. \n\nACUTE ISSUES:\n=============\n#Amyloidosis:\n#Multiple myeloma:\nAt OSH, patient noted to have right femur lesion on XR, with \nbiopsy of skeletal muscle and adipose tissue showing abundant \namyloid deposits (staining ___ red). She then presented with \nworsening R groin pain and r/p hip XR showed pathologic fracture \nin area of lesion. SPEP revealed monoclonal free lambda light \nchain and UPEP showed monoclonal free lambda light chain making \nup 36% of total urinary protein. She was therefore admitted to \n___ for expedited workup of amyloid/multiple myeloma in the \nsetting of this pathologic fracture. Lambda light chains 6000 up \nto 6900 a week later c/w diagnosis of multiple myeloma. Bone \nmarrow biopsy ___ confirmed diagnosis. Skeletal survey did not \nshow any additional lytic lesions. She was treated with \ndexamethasone 10mg IV x 4 days (___) and Velcade ___ \nand ___, with plan for weekly Velcade and possibly starting \nRevlimid outpatient. She was also started on vitamin D \nsupplementation and acyclovir and allopurinol ppx.\n\n#Right femoral neck fracture:\nPatient had been noted to have lytic lesion in right femoral \nneck on XR, and then was subsequently noted to have worsening R \ngroin pain with XR showing displaced subcapital pathologic right \nfemoral neck fracture. She is s/p R hip hemiarthroplasty ___. \nWound vac placed ___. She has been working with ___ daily \nand has been making great progress. She has been taking tramadol \nfor pain control, but notes no pain on discharge.\n\n#Afib:\nPatient noted on initial exam to be in Afib, confirmed on EKG. \nPatient does not note any history of Afib or irregular rhythm, \nand reports she has not been on a blood thinner. Her daughter, \nhowever, does note that something about her heart was \"off\" when \nshe was undergoing biopsy of hip lesion a few weeks back. She \nwas started on metoprolol tartrate, which was uptitrated and \nconverted to metoprolol succinate prior to discharge. CHADS-Vasc \nof 5 favors initiation of anticoagulation given patient is \nfunctionally independent and does not have contraindication to \nanticoagulation. She was started on lovenox qd for DVT ppx after \northopedic surgery, which was increased to BID prior to \ndischarge. After initial discussion with patient's daughter, she \nwas hesitant about lifelong anticoagulation. Cardiology, who was \nconsulted, recommends xarelto 20mg daily. Further discussions \nwith patient and family should be had to determine whether \npatient is amenable to further anticoagulation.\n\n#HFrEF:\nTTE ___ showed EF 45% with inferior, posterior, and apical \nhypokinesis. Cardiology was consulted, believed to be due to \nischemia iso hypertension. She was intermittently diuresed in \nthe setting of volume overload post-op. Her home amlodipine was \nuptitrated, however her home lisinopril was held in the setting \n___ (see below) and the possibility of renal dysfunction iso \nmultiple myeloma. She was also started on metoprolol (see \nabove).\n\n#UTI:\nNoted to have decreased UOP post-op, with foley in place since \npre-op. UA with small ___, neg nitrites, 6 WBC and few bacteria. \nUrine cx growing E.coli >100k and she was treated with a 3-day \ncourse of cipro. Foley was removed and patient was asymptomatic \non discharge with repeat urine culture negative.\n\n#Hyperuricemia:\n#Gout:\nPatient noted to have uric acid 9.2 on admission, previously in \nthe ___. No other lab data concerning for TLS at this time. Noted \nto have history of gout, no current flare, not on any home meds \nfor gout. Started on allopurinol ___ daily.\n\n#Decreased UOP, resolved:\n___, resolved:\nPatient noted to have poor UOP following surgery, had gotten \nbolused intra-op and then again the following day and started on \nmIVF without much effect. Started to become volume overloaded by \nexam, so d/c IVF and given IV Lasix pulses with improved UOP. \nAlso noted to have increase in Cr from baseline 0.7-0.9 to 1.1 \nwith urine studies more consistent with pre-renal/ATN given \nurine Na <20 and presence of hyaline/granular casts, now \nimproved back to baseline.\n\n#Hyponatremia, resolved:\nPatient noted to be hyponatremic to 131-->129 from 136. Urine \nNa<20 likely c/whypovolemic hyponatremia in the setting of poor \nPO intake/surgery. TSH wnl and AM cortisol 15. Initially \nappeared dry on exam so gave IVF boluses and mIVF however no \nimprovement in Na and then became overloaded so d/c IVF and \ngiven IV Lasix pulses and Na now improved.\n\n#Sacral Pressure Ulcer:\nLikely due to immobility from hip pain. Wound care consulted.\n\nCHRONIC ISSUES:\n===============\n#HTN:\nIncreased home amlodipine and held home lisinopril. Also started \non metoprolol per above.\n\nTRANSITIONAL ISSUES:\n===================\nDISCHARGE WEIGHT: 54.89 kg / 121 lbs\nDISCHARGE Cr: 0.7\n\n[] Due for Velcade ___ (would get Day 15 on Day ___). Consider \nstarting Revlimid.\n[] Anticoagulation: should be on Lovenox for DVT ppx through \n___ (28 days post-op). Sent out on BID for near full \nanticoagulation in the setting of Afib. Then should discuss \nanticoagulation for Afib given CHADSVasc 5. Cardiology \nrecommended Xarelto 20mg daily.\n[] Patient was intermittently diuresed post-op, not sent out on \ndiuretics but can consider in the future if gets overloaded in \nthe setting of EF 45%.\n[] Held home lisinopril given ___ and possibility for renal \ndysfunction in multiple myeloma/amyloid.\n[] Patient may benefit from outpatient cardiology follow-up for \nAfib/HFrEF.\n\n#HCP/Contact: daughter ___ who is her HCP ___\n#Code: Full confirmed \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. amLODIPine 2.5 mg PO DAILY \n2. Cyanocobalamin 1000 mcg IM/SC DAILY \n3. Lisinopril 40 mg PO DAILY \n4. TraMADol 50 mg PO Q8H:PRN Pain - Moderate \n5. Calcium Carbonate 500 mg PO BID \n\n \nDischarge Medications:\n1. Acyclovir 400 mg PO Q12H \nRX *acyclovir 400 mg 1 tablet(s) by mouth every twelve (12) \nhours Disp #*60 Tablet Refills:*0 \n2. Allopurinol ___ mg PO DAILY \nRX *allopurinol ___ mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*0 \n3. Enoxaparin Sodium 40 mg SC Q12H \nRX *enoxaparin 40 mg/0.4 mL 40 mg SC every twelve (12) hours \nDisp #*60 Syringe Refills:*0 \n4. Metoprolol Succinate XL 100 mg PO DAILY \nRX *metoprolol succinate 100 mg 1 tablet(s) by mouth daily Disp \n#*30 Tablet Refills:*0 \n5. Vitamin D 4000 UNIT PO DAILY \nRX *ergocalciferol (vitamin D2) 2,000 unit 2 tablet(s) by mouth \ndaily Disp #*60 Tablet Refills:*0 \n6. amLODIPine 5 mg PO DAILY \nRX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0 \n7. Calcium Carbonate 500 mg PO BID \n8. Cyanocobalamin 1000 mcg IM/SC DAILY \n9. TraMADol 50 mg PO Q8H:PRN Pain - Moderate \n10. HELD- Lisinopril 40 mg PO DAILY This medication was held. \nDo not restart Lisinopril until you speak with Dr. ___.\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY:\n-Multiple myeloma\n-Amyloidosis\n-Pathologic right femoral neck fracture\n\nSECONDARY:\n-Urinary tract infection\n-Heart failure with reduced ejection fraction\n-Atrial fibrillation\n-Acute kidney injury\n-Hyponatremia\n-Hyperuricemia\n-Sacral pressure ulcer\n-Hypertension\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nIt was a pleasure taking care of you at ___.\n\nWHY WAS I ADMITTED TO THE HOSPITAL?\n-You were admitted to the hospital because you broke your hip \nand needed to be worked up for myeloma.\n\nWHAT HAPPENED WHILE I WAS IN THE HOSPITAL?\n-You had right hip surgery, and you have been working with \nphysical therapy to get stronger on your feet.\n-You had a bone marrow biopsy which confirmed the diagnosis of \nmultiple myeloma (a type of cancer in the bone). A series of \nx-rays did not show any additional bone lesions like the one \nfound in your hip. You were treated with steroids and Velcade \n(an injection).\n-You were treated for a urinary tract infection with \nantibiotics.\n-You were found to have an irregular heart rhythm (atrial \nfibrillation) and your heart was beating a little fast, so you \nwere started on a medication (metoprolol) to control your heart \nrate. An ultrasound of your heart also showed a slightly \ndecreased pumping function.\n-Your legs were starting to swell so you were given a medication \nto help you pee out some of the extra fluid in your body.\n\nWHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?\n-Continue to take all of your medications as prescribed.\n-Please attend all follow up clinic appointments.\n-You are currently on a blood thinner (Lovenox), which is \nrecommended after orthopedic surgery. Because you have an \nirregular heart rhythm that increases your risk of stroke, it is \nrecommended that you stay on a blood thinner long-term to reduce \nthe risk of stroke. Your outpatient doctors ___ discuss this \nwith you in more detail.\n\nWe wish you all the best,\n\nYour ___ Care Team\n\n \nFollowup Instructions:\n___\n"
] | Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: pathologic right femoral neck fracture Major Surgical or Invasive Procedure: Right hip hemiarthroplasty [MASKED] Bone marrow biopsy [MASKED] History of Present Illness: [MASKED] PMH of HTN, Osteoporosis, Arthritis, Gout, presented with right groin pain [MASKED] right pathologic femoral neck fracture, admitted to [MASKED] for expedited workup prior to eventual surgical intervention As per review of outpatient notes, patient was referred to orthopedics in light of right groin pain leading to identification of a right femoral neck lesion which was concerning for impending fracture. She underwent biopsy of the right femoral lesion with pathology consistent with skeletal muscle and adipose tissue with abundant amyloid deposits. Her blood work as an outpatient was notable for detection of light chains. She also had an aspiration at that time that showed 30 nucleated cells (88% polys) with a negative gram stain. She was scheduled for outpatient oncologic workup but has been immobile and in significant pain prompting her visit to the ED. Pt reports that she has had significant right groin pain for several days, which is severe when moving, less when immobile. Accordingly, she has been moving less and is developing recurrence of pressure ulcer. She noted that she otherwise felt well, and denied fever, chills, shortness of breath, decreased appetite, bowel/bladder dysfunction. Denied trauma history. In the ED, initial vitals: 10 97.8 96 152/67 18 98% RA. WBC 8.8, Hgb 11.3, plt 426, INR 1.0, CHEM wnl, UA with proteinuria. Femur Xray: 1.7 cm displaced subcapital pathologic right femoral neck fracture. CXR: Cardiomegaly without superimposed acute cardiopulmonary process. Patient was given Tylenol and admitted to [MASKED] for expedited workup Past Medical History: Multiple myeloma Amyloidosis Afib HFrEF (EF 45%) Hypertension osteoporosis Arthritis Gout Social History: [MASKED] Family History: Liver cancer-son Stomach cancer-sister CVA-mother [MASKED] Joint disease/arthritis-mother positive for Physical Exam: ADMISSION PHYSICAL EXAM: ======================= Vitals: [MASKED] [MASKED] Temp: 98.1 PO BP: 105/58 HR: 90 RR: 18 O2 sat: 94% O2 delivery: Ra GENERAL: laying in bed, appears comfortable, calm, NAD EYES: PERRLA, anicteric HEENT: OP clear, MMM NECK: supple LUNGS: CTA b/l, no wheezes/rales/rhonchi, normal RR CV: RRR no m/r/g, normal distal perfusion, no edema ABD: Soft, NT, ND, normoactive BS GENITOURINARY: no foley EXT: warm, decreased muscle bulk, has discomfort in right groin with any movement of right leg SKIN: warm, dry, no rash NEURO: AOx3, fluent speech ACCESS: PIV DISCHARGE PHYSICAL EXAM: ======================== Vitals: T 98.3, BP 121/73, HR 83, RR 18, 94% on RA. GENERAL: lying in bed, appears comfortable, NAD. HEENT: NCAT, sclera anicteric, PERRL, OP clear, MMM. LUNGS: CTAB, no wheezes rales or rhonchi. CV: irregular rhythm, regular rate, no m/r/g. ABD: Soft, NT, ND, normoactive BS. EXT: warm; no [MASKED] edema. NEURO: AOx3, fluent speech ACCESS: PIV Pertinent Results: ADMISSION LABS: ============== [MASKED] 10:30PM BLOOD WBC-8.8 RBC-3.67* Hgb-11.3 Hct-36.0 MCV-98 MCH-30.8 MCHC-31.4* RDW-15.7* RDWSD-57.1* Plt [MASKED] [MASKED] 10:30PM BLOOD Neuts-65.3 [MASKED] Monos-7.8 Eos-1.3 Baso-0.6 Im [MASKED] AbsNeut-5.73 AbsLymp-2.14 AbsMono-0.68 AbsEos-0.11 AbsBaso-0.05 [MASKED] 10:30PM BLOOD [MASKED] PTT-27.8 [MASKED] [MASKED] 10:30PM BLOOD Glucose-105* UreaN-33* Creat-0.9 Na-141 K-5.2 Cl-100 HCO3-24 AnGap-17 [MASKED] 10:30PM BLOOD Albumin-3.7 [MASKED] 10:30PM BLOOD ALT-15 AST-23 AlkPhos-122* TotBili-0.2 PERTINENT LABS/MICRO/IMAGING: ============================ [MASKED] 10:30PM BLOOD [MASKED] FreeLam-6010* Fr K/L-0.00* [MASKED] 06:10AM BLOOD IgG-354* IgA-28* IgM-7* [MASKED] 06:30AM BLOOD [MASKED] FreeLam-6912* Fr K/L-0.00* IgG-254* IgA-22* IgM-5* [MASKED] 06:10AM BLOOD Calcium-8.9 Phos-4.1 Mg-2.0 UricAcd-9.2* Iron-37 [MASKED] 06:10AM BLOOD calTIBC-274 VitB12-757 Folate-12 Ferritn-305* TRF-211 [MASKED] 06:15AM BLOOD 25VitD-25* [MASKED] 06:30AM BLOOD TSH-1.2 [MASKED] 06:30AM BLOOD Cortsol-15.1 [MASKED] 03:15PM BLOOD GGT-48* [MASKED] 07:20AM BLOOD GGT-54* MICRO: ----------- [MASKED] 02:03AM URINE Color-Yellow Appear-Clear Sp [MASKED] [MASKED] 02:03AM URINE Blood-SM* Nitrite-NEG Protein-30* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM* [MASKED] 02:03AM URINE RBC-10* WBC-6* Bacteri-FEW* Yeast-NONE Epi-0 [MASKED] 02:03AM URINE CastGr-6* CastHy-23* [MASKED] 2:03 am URINE Source: Catheter. **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE IDENTIFICATION. Cefepime test result confirmed by [MASKED]. Piperacillin/Tazobactam test result performed by [MASKED] [MASKED]. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- =>64 R CEFTRIAXONE----------- 16 R CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S [MASKED] 10:30 am URINE Source: [MASKED]. **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: < 10,000 CFU/mL. IMAGING: ------------- CXR [MASKED]: Cardiomegaly without superimposed acute cardiopulmonary process. R Femur XR [MASKED]: 1.7 cm displaced subcapital pathologic right femoral neck fracture. TTE [MASKED]: The left atrial volume index is mildly increased. There is normal left ventricular wall thickness with a normal cavity size. Overall left ventricular systolic function is mildly-to-moderately depressed secondary to inferior, posterior, and apical hypokinesis. The visually estimated left ventricular ejection fraction is 45%. There is no resting left ventricular outflow tract gradient. Normal right ventricular cavity size with normal free wall motion. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. The aortic arch diameter is normal. The aortic valve leaflets (3) are moderately thickened. There is no aortic valve stenosis. There is trace aortic regurgitation. The mitral valve leaflets are moderately thickened with no mitral valve prolapse. There is trivial mitral regurgitation. The tricuspid valve leaflets are mildly thickened. There is mild to moderate [[MASKED]] tricuspid regurgitation. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Pelvic XR [MASKED]: Status post bilateral hip arthroplasty. Extensive subcutaneous emphysema and postsurgical changes are seen surrounding the right hip arthroplasty. RLE Doppler [MASKED]: No evidence of DVT in the right lower extremity. Skeletal Survey [MASKED]: 1. Erosive changes along the left ischial tuberosity, which are similar in appearance to prior CT and MRI studies. No additional lytic lesions are identified. 2. Diffuse osteopenia. RUQUS [MASKED]: 1. Normal liver parenchyma without evidence of concerning focal liver lesions. 2. Cholelithiasis without evidence of cholecystitis. 3. Common hepatic duct is 2 mm. CXR [MASKED]: Lungs are low volume with moderate pulmonary edema. Cardiomediastinal silhouette is stable. There are small bilateral effusions left greater than right. No pneumothorax is seen. CXR [MASKED]: Lungs are low volume with slight improvement in the interstitial edema. Cardiomediastinal silhouette is stable. There is no pleural effusion. No pneumothorax is seen DISCHARGE LABS: =============== [MASKED] 06:47AM BLOOD WBC-8.5 RBC-2.96* Hgb-9.3* Hct-29.5* MCV-100* MCH-31.4 MCHC-31.5* RDW-17.9* RDWSD-62.5* Plt [MASKED] [MASKED] 06:47AM BLOOD Neuts-67.0 Lymphs-16.3* Monos-9.0 Eos-5.9 Baso-0.4 Im [MASKED] AbsNeut-5.71 AbsLymp-1.39 AbsMono-0.77 AbsEos-0.50 AbsBaso-0.03 [MASKED] 06:47AM BLOOD [MASKED] PTT-36.0 [MASKED] [MASKED] 06:47AM BLOOD Glucose-93 UreaN-21* Creat-0.7 Na-140 K-4.2 Cl-100 HCO3-28 AnGap-12 [MASKED] 06:47AM BLOOD ALT-14 AST-15 LD(LDH)-191 AlkPhos-114* TotBili-0.4 [MASKED] 06:47AM BLOOD Albumin-3.0* Calcium-8.4 Phos-4.5 Mg-1.8 Brief Hospital Course: PATIENT SUMMARY: ================ [MASKED] with PMH of HTN, osteoporosis, arthritis, and gout who presented with right groin pain due to right pathologic femoral neck fracture, admitted to [MASKED] for expedited workup of amyloidosis/multiple myeloma and right hip hemiarthroplasty. S/p right hip hemiarthroplasty on [MASKED]. Bone marrow biopsy on [MASKED] confirmed the diagnosis of multiple myeloma, and she is s/p dexamethasone 10mg IV x 4 days ([MASKED]) and Velcade [MASKED] and [MASKED]. Course c/b new-onset Afib, HFrEF, [MASKED], hyponatremia, and UTI. ACUTE ISSUES: ============= #Amyloidosis: #Multiple myeloma: At OSH, patient noted to have right femur lesion on XR, with biopsy of skeletal muscle and adipose tissue showing abundant amyloid deposits (staining [MASKED] red). She then presented with worsening R groin pain and r/p hip XR showed pathologic fracture in area of lesion. SPEP revealed monoclonal free lambda light chain and UPEP showed monoclonal free lambda light chain making up 36% of total urinary protein. She was therefore admitted to [MASKED] for expedited workup of amyloid/multiple myeloma in the setting of this pathologic fracture. Lambda light chains 6000 up to 6900 a week later c/w diagnosis of multiple myeloma. Bone marrow biopsy [MASKED] confirmed diagnosis. Skeletal survey did not show any additional lytic lesions. She was treated with dexamethasone 10mg IV x 4 days ([MASKED]) and Velcade [MASKED] and [MASKED], with plan for weekly Velcade and possibly starting Revlimid outpatient. She was also started on vitamin D supplementation and acyclovir and allopurinol ppx. #Right femoral neck fracture: Patient had been noted to have lytic lesion in right femoral neck on XR, and then was subsequently noted to have worsening R groin pain with XR showing displaced subcapital pathologic right femoral neck fracture. She is s/p R hip hemiarthroplasty [MASKED]. Wound vac placed [MASKED]. She has been working with [MASKED] daily and has been making great progress. She has been taking tramadol for pain control, but notes no pain on discharge. #Afib: Patient noted on initial exam to be in Afib, confirmed on EKG. Patient does not note any history of Afib or irregular rhythm, and reports she has not been on a blood thinner. Her daughter, however, does note that something about her heart was "off" when she was undergoing biopsy of hip lesion a few weeks back. She was started on metoprolol tartrate, which was uptitrated and converted to metoprolol succinate prior to discharge. CHADS-Vasc of 5 favors initiation of anticoagulation given patient is functionally independent and does not have contraindication to anticoagulation. She was started on lovenox qd for DVT ppx after orthopedic surgery, which was increased to BID prior to discharge. After initial discussion with patient's daughter, she was hesitant about lifelong anticoagulation. Cardiology, who was consulted, recommends xarelto 20mg daily. Further discussions with patient and family should be had to determine whether patient is amenable to further anticoagulation. #HFrEF: TTE [MASKED] showed EF 45% with inferior, posterior, and apical hypokinesis. Cardiology was consulted, believed to be due to ischemia iso hypertension. She was intermittently diuresed in the setting of volume overload post-op. Her home amlodipine was uptitrated, however her home lisinopril was held in the setting [MASKED] (see below) and the possibility of renal dysfunction iso multiple myeloma. She was also started on metoprolol (see above). #UTI: Noted to have decreased UOP post-op, with foley in place since pre-op. UA with small [MASKED], neg nitrites, 6 WBC and few bacteria. Urine cx growing E.coli >100k and she was treated with a 3-day course of cipro. Foley was removed and patient was asymptomatic on discharge with repeat urine culture negative. #Hyperuricemia: #Gout: Patient noted to have uric acid 9.2 on admission, previously in the [MASKED]. No other lab data concerning for TLS at this time. Noted to have history of gout, no current flare, not on any home meds for gout. Started on allopurinol [MASKED] daily. #Decreased UOP, resolved: [MASKED], resolved: Patient noted to have poor UOP following surgery, had gotten bolused intra-op and then again the following day and started on mIVF without much effect. Started to become volume overloaded by exam, so d/c IVF and given IV Lasix pulses with improved UOP. Also noted to have increase in Cr from baseline 0.7-0.9 to 1.1 with urine studies more consistent with pre-renal/ATN given urine Na <20 and presence of hyaline/granular casts, now improved back to baseline. #Hyponatremia, resolved: Patient noted to be hyponatremic to 131-->129 from 136. Urine Na<20 likely c/whypovolemic hyponatremia in the setting of poor PO intake/surgery. TSH wnl and AM cortisol 15. Initially appeared dry on exam so gave IVF boluses and mIVF however no improvement in Na and then became overloaded so d/c IVF and given IV Lasix pulses and Na now improved. #Sacral Pressure Ulcer: Likely due to immobility from hip pain. Wound care consulted. CHRONIC ISSUES: =============== #HTN: Increased home amlodipine and held home lisinopril. Also started on metoprolol per above. TRANSITIONAL ISSUES: =================== DISCHARGE WEIGHT: 54.89 kg / 121 lbs DISCHARGE Cr: 0.7 [] Due for Velcade [MASKED] (would get Day 15 on Day [MASKED]). Consider starting Revlimid. [] Anticoagulation: should be on Lovenox for DVT ppx through [MASKED] (28 days post-op). Sent out on BID for near full anticoagulation in the setting of Afib. Then should discuss anticoagulation for Afib given CHADSVasc 5. Cardiology recommended Xarelto 20mg daily. [] Patient was intermittently diuresed post-op, not sent out on diuretics but can consider in the future if gets overloaded in the setting of EF 45%. [] Held home lisinopril given [MASKED] and possibility for renal dysfunction in multiple myeloma/amyloid. [] Patient may benefit from outpatient cardiology follow-up for Afib/HFrEF. #HCP/Contact: daughter [MASKED] who is her HCP [MASKED] #Code: Full confirmed Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 2.5 mg PO DAILY 2. Cyanocobalamin 1000 mcg IM/SC DAILY 3. Lisinopril 40 mg PO DAILY 4. TraMADol 50 mg PO Q8H:PRN Pain - Moderate 5. Calcium Carbonate 500 mg PO BID Discharge Medications: 1. Acyclovir 400 mg PO Q12H RX *acyclovir 400 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*60 Tablet Refills:*0 2. Allopurinol [MASKED] mg PO DAILY RX *allopurinol [MASKED] mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. Enoxaparin Sodium 40 mg SC Q12H RX *enoxaparin 40 mg/0.4 mL 40 mg SC every twelve (12) hours Disp #*60 Syringe Refills:*0 4. Metoprolol Succinate XL 100 mg PO DAILY RX *metoprolol succinate 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 5. Vitamin D 4000 UNIT PO DAILY RX *ergocalciferol (vitamin D2) 2,000 unit 2 tablet(s) by mouth daily Disp #*60 Tablet Refills:*0 6. amLODIPine 5 mg PO DAILY RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 7. Calcium Carbonate 500 mg PO BID 8. Cyanocobalamin 1000 mcg IM/SC DAILY 9. TraMADol 50 mg PO Q8H:PRN Pain - Moderate 10. HELD- Lisinopril 40 mg PO DAILY This medication was held. Do not restart Lisinopril until you speak with Dr. [MASKED]. Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: PRIMARY: -Multiple myeloma -Amyloidosis -Pathologic right femoral neck fracture SECONDARY: -Urinary tract infection -Heart failure with reduced ejection fraction -Atrial fibrillation -Acute kidney injury -Hyponatremia -Hyperuricemia -Sacral pressure ulcer -Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [MASKED], It was a pleasure taking care of you at [MASKED]. WHY WAS I ADMITTED TO THE HOSPITAL? -You were admitted to the hospital because you broke your hip and needed to be worked up for myeloma. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? -You had right hip surgery, and you have been working with physical therapy to get stronger on your feet. -You had a bone marrow biopsy which confirmed the diagnosis of multiple myeloma (a type of cancer in the bone). A series of x-rays did not show any additional bone lesions like the one found in your hip. You were treated with steroids and Velcade (an injection). -You were treated for a urinary tract infection with antibiotics. -You were found to have an irregular heart rhythm (atrial fibrillation) and your heart was beating a little fast, so you were started on a medication (metoprolol) to control your heart rate. An ultrasound of your heart also showed a slightly decreased pumping function. -Your legs were starting to swell so you were given a medication to help you pee out some of the extra fluid in your body. WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL? -Continue to take all of your medications as prescribed. -Please attend all follow up clinic appointments. -You are currently on a blood thinner (Lovenox), which is recommended after orthopedic surgery. Because you have an irregular heart rhythm that increases your risk of stroke, it is recommended that you stay on a blood thinner long-term to reduce the risk of stroke. Your outpatient doctors [MASKED] discuss this with you in more detail. We wish you all the best, Your [MASKED] Care Team Followup Instructions: [MASKED] | [
"C9000",
"M84551A",
"E859",
"I5020",
"N179",
"E871",
"N390",
"I4891",
"I110",
"M810",
"M109",
"M1990",
"B9620"
] | [
"C9000: Multiple myeloma not having achieved remission",
"M84551A: Pathological fracture in neoplastic disease, right femur, initial encounter for fracture",
"E859: Amyloidosis, unspecified",
"I5020: Unspecified systolic (congestive) heart failure",
"N179: Acute kidney failure, unspecified",
"E871: Hypo-osmolality and hyponatremia",
"N390: Urinary tract infection, site not specified",
"I4891: Unspecified atrial fibrillation",
"I110: Hypertensive heart disease with heart failure",
"M810: Age-related osteoporosis without current pathological fracture",
"M109: Gout, unspecified",
"M1990: Unspecified osteoarthritis, unspecified site",
"B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere"
] | [
"N179",
"E871",
"N390",
"I4891",
"I110",
"M109"
] | [] |
16,377,002 | 20,299,578 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: NEUROLOGY\n \nAllergies: \nPenicillins / ACE Inhibitors\n \nAttending: ___\n \nChief Complaint:\nfeeling spacey, high blood pressure, facial droop\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ is a ___ year-old right-handed female with HTN \nand \"petit mal\" epilepsy who presents with hypertension and \nfacial droop. \n\nShe reports that she woke up this morning feeling \"ok\" but then \nquickly began to feel \"spacey.\" She has a difficult time further \nelaborating on her symptoms, but denies any cognitive or speech \ndifficulties, paresthesias, numbness, weakness, clumsiness, or \ndifficulty with her gait. Nonetheless, she felt \"off\" and this \nfeeling only worsened throughout the morning. She ran a few \nerrands and then went to have her blood drawn, which needed to \nbe done today before her scheduled neurology appointment this \nupcoming ___. While there, she continued to feel \nunwell, so asked if they would take her blood pressure, which \nwas found to be very elevated (212/90). She was then evaluated \nby someone who expressed concern for a left facial droop, \nprompting referral to the ___ ED for further evaluation. \n\nShe looked at herself and did not notice any facial asymmetry, \nnor did her husband who is at her bedside. \n\nShe is now feeling much better and is no longer having the \n\"spacey\" feeling. \n\nOn neuro ROS, she denies headache, loss of vision, blurred \nvision, diplopia, dysarthria, dysphagia, vertigo, tinnitus or \nhearing difficulty. Denies difficulties producing or \ncomprehending speech. Denies focal weakness (except for the \nwitnessed facial droop, which she nor her husband appreciated), \nnumbness, parasthesiae. No bowel or bladder incontinence or \nretention. Denies difficulty with gait.\n\nOn general review of systems, she denies recent fever or chills. \n No night sweats or recent weight loss or gain. Denies cough, \nshortness of breath. Denies chest pain or tightness, \npalpitations. Denies nausea, vomiting, diarrhea, constipation \nor abdominal pain. No recent change in bowel or bladder habits. \n No dysuria. Denies arthralgias or myalgias. Denies rash.\n\n \nPast Medical History:\nHYPERTENSION \n\nEPILEPSY ___ \n\"petit mal\" \n\n \nSocial History:\nSocial History (Last Verified - None on file):\nMarital status: Married \nName ___ ___ \n___: \nChildren: Yes \nLives with: ___ \nTobacco use: Never smoker \nAlcohol use: Present \ndrinks per week: ___ \nAlcohol use \"occasional wine\" \ncomments: \nRecreational drugs Denies \n(marijuana, heroin, \ncrack pills or \nother): \n\nComments: She is retired, but used to work with \n special needs children through BPS. She is \n married to her husband, ___, and they \n live with their 2 dogs. \n\n \nFamily History:\nFamily History (Last Verified - None on file):\nRelative Status Age Problem Onset Comments \nMother ___ ___ STROKE \n \nPhysical Exam:\nEXAM ON ADMISSION:\n==================\nVitals ___, time: 12:23): \nT: 97.6\nHR: 82\nRR: 18 \nBP: 192/83\nSaO2: 99% on RA\n\nGeneral: Awake, cooperative, NAD.\nHEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in \noropharynx\nNeck: Supple, full ROM. No carotid bruits. \nPulmonary: breathing comfortably on RA\nCardiac: warm and well-perfused with brisk capillary refill\nAbdomen: ND\nExtremities: No C/C/E bilaterally.\nSkin: no rashes or lesions noted.\n\nNeurologic:\n\n-Mental Status: Alert, oriented x 3. Able to relate history \nwithout difficulty. Attentive, able to name ___ backward with \nminimal difficulty (made 1 error, but self-corrected). She \nincorrectly calculated the value of 7 quarters as $1.50. \nLanguage is fluent with intact comprehension. Normal prosody. \nThere were no paraphasic errors. Speech was not dysarthric. Able \nto follow both midline and appendicular commands. There was no \nevidence of apraxia or neglect.\n\n-Cranial Nerves:\nI: Olfaction not tested.\nII: PERRL 3 to 2mm and brisk. VFF to confrontation. \nIII, IV, VI: EOMI without nystagmus. Normal saccades.\nV: Facial sensation intact to light touch and temperature. \nMuscles of mastication strong and symmetric\nVII: + nasolabial fold flattening (R), which was not present in \nrecent photographs on her husband's phone. Forehead wrinkle, eye \nclosure, and smile are all symmetric without evidence of delayed \nactivation.\nIX, X: Palate elevates symmetrically.\nXI: ___ strength in trapezii and SCM bilaterally.\nXII: Tongue protrudes in midline.\n\n-Motor: Normal bulk, tone throughout. No pronator drift or \norbiting bilaterally. No adventitious movements, such as tremor, \nnoted. \n Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___\nL 5 ___ ___ 5 5 5 5 5 5 5\nR 5 ___ ___ 5 5 5 5 5 5 5\n\n-Sensory: No deficits to light touch, pinprick, cold sensation, \nor proprioception throughout. Distally decreased sensation to \nvibration in the lower extremities (L: 5 seconds of perception, \nR: 8 seconds) > upper extremities (bilateral: ~20 seconds). \n\n-DTRs:\n Bi ___ Pat Ach\nL 2 2 tr* 0*\nR 2 2 tr* 0*\n*: with reinforcement\nPlantar response was mute bilaterally.\n\n-Coordination: No intention tremor, no dysdiadochokinesia noted. \nNo dysmetria on FNF or HKS bilaterally.\n\n-Gait: Good initiation. Narrow-based, normal stride and arm \nswing. Able to walk in tandem without difficulty. Romberg \nabsent.\n\nEXAM ON DISCHARGE:\nnon-focal\nslight left NLFF that was confirmed to be present on very old \nphotographs (baseline)\n \nPertinent Results:\n___ 07:55AM BLOOD WBC-7.3 RBC-4.88 Hgb-14.8 Hct-44.5 MCV-91 \nMCH-30.3 MCHC-33.3 RDW-13.3 RDWSD-44.7 Plt ___\n___ 10:50PM BLOOD WBC-11.3* RBC-4.88 Hgb-15.1 Hct-43.7 \nMCV-90 MCH-30.9 MCHC-34.6 RDW-13.3 RDWSD-43.8 Plt ___\n___ 01:32PM BLOOD Neuts-62.0 ___ Monos-10.2 Eos-1.0 \nBaso-0.5 Im ___ AbsNeut-5.70 AbsLymp-2.38 AbsMono-0.94* \nAbsEos-0.09 AbsBaso-0.05\n___ 07:55AM BLOOD Plt ___\n___ 07:55AM BLOOD Glucose-100 UreaN-13 Na-142 K-3.6 Cl-99 \nHCO3-27 AnGap-16\n___ 07:55AM BLOOD TotProt-7.1 Albumin-4.1 Globuln-3.0 \nCholest-PND\n___ 10:50PM BLOOD Triglyc-138 HDL-57 CHOL/HD-2.6 LDLcalc-64\n___ 10:50PM BLOOD TSH-11*\n___ 07:55AM BLOOD CRP-4.2\n___ 01:32PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nBnzodzp-NEG Barbitr-NEG Tricycl-NEG\n\nCT HEAD/CTA HEAD AND NECK: wnl\n \nBrief Hospital Course:\n___ yo woman, pmh of HTN and epilepsy, presents with ? R NLFF and \nfeeling \"spacy\" in setting of BP 210/90. There was no change in \nactivation of face and compared to prior photographs, her face \nwas unchanged. Her feeling of \"spacey\" was likely hypertensive \nencephalopathy, which improved when her blood pressure control \nimproved. Overnight, her BP were 120s-170s, while off of her \nhome antihypertensives (held for concern of TIA workup), and \nthey were restarted prior to discharge. \nRegarding her history of seizures, her semiology is \"talking out \nof context\" with immediate return to baseline. She has not had a \nseizure in years and she has not had a post ictal sensation \npreviously. There was low concern for TIA, given absence of new \nneurologic symptoms or signs. Her CT/CTA did not have any acute \nabnormalities or flow-limiting stenosis. Her A1c 5.9%, LDL 64. \nC: Continued on home meds\n\nTransitional Issues:\n- BP management per PCP \n \n___ on ___:\nThe Preadmission Medication list is accurate and complete.\n1. Divalproex (EXTended Release) 500 mg PO DAILY \n2. irbesartan 300 mg oral Other \n3. Hydrochlorothiazide 25 mg PO DAILY \n4. Aspirin 81 mg PO DAILY \n5. amLODIPine 5 mg PO DAILY \n\n \nDischarge Medications:\n1. amLODIPine 5 mg PO DAILY \n2. Aspirin 81 mg PO DAILY \n3. Divalproex (EXTended Release) 500 mg PO DAILY \n4. Hydrochlorothiazide 25 mg PO DAILY \n5. irbesartan 300 mg oral Other \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nHypertensive urgency. \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___, \n\nYou were admitted for concern for a Right nasolabial fold \nflattening, feeling \"spacy\" and high blood pressure. Your face \ndoes not have any new changes, when compared to your prior \nphotographs. The high blood pressure likely resulted in symptoms \nof \"spacy-ness\". We recommend you monitor your blood pressures \nat home daily and follow up with your primary care provider ___ \n___ weeks for any changes in your blood pressure regimen. \n\nYour medications were not changed during your inpatient stay. \n\nSincerely, \nYOUR ___ NEUROLOGY TEAM \n \nFollowup Instructions:\n___\n"
] | Allergies: Penicillins / ACE Inhibitors Chief Complaint: feeling spacey, high blood pressure, facial droop Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] is a [MASKED] year-old right-handed female with HTN and "petit mal" epilepsy who presents with hypertension and facial droop. She reports that she woke up this morning feeling "ok" but then quickly began to feel "spacey." She has a difficult time further elaborating on her symptoms, but denies any cognitive or speech difficulties, paresthesias, numbness, weakness, clumsiness, or difficulty with her gait. Nonetheless, she felt "off" and this feeling only worsened throughout the morning. She ran a few errands and then went to have her blood drawn, which needed to be done today before her scheduled neurology appointment this upcoming [MASKED]. While there, she continued to feel unwell, so asked if they would take her blood pressure, which was found to be very elevated (212/90). She was then evaluated by someone who expressed concern for a left facial droop, prompting referral to the [MASKED] ED for further evaluation. She looked at herself and did not notice any facial asymmetry, nor did her husband who is at her bedside. She is now feeling much better and is no longer having the "spacey" feeling. On neuro ROS, she denies headache, loss of vision, blurred vision, diplopia, dysarthria, dysphagia, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal weakness (except for the witnessed facial droop, which she nor her husband appreciated), numbness, parasthesiae. No bowel or bladder incontinence or retention. Denies difficulty with gait. On general review of systems, she denies recent fever or chills. No night sweats or recent weight loss or gain. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: HYPERTENSION EPILEPSY [MASKED] "petit mal" Social History: Social History (Last Verified - None on file): Marital status: Married Name [MASKED] [MASKED] [MASKED]: Children: Yes Lives with: [MASKED] Tobacco use: Never smoker Alcohol use: Present drinks per week: [MASKED] Alcohol use "occasional wine" comments: Recreational drugs Denies (marijuana, heroin, crack pills or other): Comments: She is retired, but used to work with special needs children through BPS. She is married to her husband, [MASKED], and they live with their 2 dogs. Family History: Family History (Last Verified - None on file): Relative Status Age Problem Onset Comments Mother [MASKED] [MASKED] STROKE Physical Exam: EXAM ON ADMISSION: ================== Vitals [MASKED], time: 12:23): T: 97.6 HR: 82 RR: 18 BP: 192/83 SaO2: 99% on RA General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, full ROM. No carotid bruits. Pulmonary: breathing comfortably on RA Cardiac: warm and well-perfused with brisk capillary refill Abdomen: ND Extremities: 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 [MASKED] backward with minimal difficulty (made 1 error, but self-corrected). She incorrectly calculated the value of 7 quarters as $1.50. Language is fluent with intact comprehension. Normal prosody. There were no paraphasic errors. Speech was not dysarthric. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch and temperature. Muscles of mastication strong and symmetric VII: + nasolabial fold flattening (R), which was not present in recent photographs on her husband's phone. Forehead wrinkle, eye closure, and smile are all symmetric without evidence of delayed activation. IX, X: Palate elevates symmetrically. XI: [MASKED] strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift or orbiting bilaterally. No adventitious movements, such as tremor, noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [MASKED] L 5 [MASKED] [MASKED] 5 5 5 5 5 5 5 R 5 [MASKED] [MASKED] 5 5 5 5 5 5 5 -Sensory: No deficits to light touch, pinprick, cold sensation, or proprioception throughout. Distally decreased sensation to vibration in the lower extremities (L: 5 seconds of perception, R: 8 seconds) > upper extremities (bilateral: ~20 seconds). -DTRs: Bi [MASKED] Pat Ach L 2 2 tr* 0* R 2 2 tr* 0* *: with reinforcement Plantar response was mute bilaterally. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. -Gait: Good initiation. Narrow-based, normal stride and arm swing. Able to walk in tandem without difficulty. Romberg absent. EXAM ON DISCHARGE: non-focal slight left NLFF that was confirmed to be present on very old photographs (baseline) Pertinent Results: [MASKED] 07:55AM BLOOD WBC-7.3 RBC-4.88 Hgb-14.8 Hct-44.5 MCV-91 MCH-30.3 MCHC-33.3 RDW-13.3 RDWSD-44.7 Plt [MASKED] [MASKED] 10:50PM BLOOD WBC-11.3* RBC-4.88 Hgb-15.1 Hct-43.7 MCV-90 MCH-30.9 MCHC-34.6 RDW-13.3 RDWSD-43.8 Plt [MASKED] [MASKED] 01:32PM BLOOD Neuts-62.0 [MASKED] Monos-10.2 Eos-1.0 Baso-0.5 Im [MASKED] AbsNeut-5.70 AbsLymp-2.38 AbsMono-0.94* AbsEos-0.09 AbsBaso-0.05 [MASKED] 07:55AM BLOOD Plt [MASKED] [MASKED] 07:55AM BLOOD Glucose-100 UreaN-13 Na-142 K-3.6 Cl-99 HCO3-27 AnGap-16 [MASKED] 07:55AM BLOOD TotProt-7.1 Albumin-4.1 Globuln-3.0 Cholest-PND [MASKED] 10:50PM BLOOD Triglyc-138 HDL-57 CHOL/HD-2.6 LDLcalc-64 [MASKED] 10:50PM BLOOD TSH-11* [MASKED] 07:55AM BLOOD CRP-4.2 [MASKED] 01:32PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG CT HEAD/CTA HEAD AND NECK: wnl Brief Hospital Course: [MASKED] yo woman, pmh of HTN and epilepsy, presents with ? R NLFF and feeling "spacy" in setting of BP 210/90. There was no change in activation of face and compared to prior photographs, her face was unchanged. Her feeling of "spacey" was likely hypertensive encephalopathy, which improved when her blood pressure control improved. Overnight, her BP were 120s-170s, while off of her home antihypertensives (held for concern of TIA workup), and they were restarted prior to discharge. Regarding her history of seizures, her semiology is "talking out of context" with immediate return to baseline. She has not had a seizure in years and she has not had a post ictal sensation previously. There was low concern for TIA, given absence of new neurologic symptoms or signs. Her CT/CTA did not have any acute abnormalities or flow-limiting stenosis. Her A1c 5.9%, LDL 64. C: Continued on home meds Transitional Issues: - BP management per PCP [MASKED] on [MASKED]: The Preadmission Medication list is accurate and complete. 1. Divalproex (EXTended Release) 500 mg PO DAILY 2. irbesartan 300 mg oral Other 3. Hydrochlorothiazide 25 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. amLODIPine 5 mg PO DAILY Discharge Medications: 1. amLODIPine 5 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Divalproex (EXTended Release) 500 mg PO DAILY 4. Hydrochlorothiazide 25 mg PO DAILY 5. irbesartan 300 mg oral Other Discharge Disposition: Home Discharge Diagnosis: Hypertensive urgency. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You were admitted for concern for a Right nasolabial fold flattening, feeling "spacy" and high blood pressure. Your face does not have any new changes, when compared to your prior photographs. The high blood pressure likely resulted in symptoms of "spacy-ness". We recommend you monitor your blood pressures at home daily and follow up with your primary care provider [MASKED] [MASKED] weeks for any changes in your blood pressure regimen. Your medications were not changed during your inpatient stay. Sincerely, YOUR [MASKED] NEUROLOGY TEAM Followup Instructions: [MASKED] | [
"I160",
"I6523",
"G40909"
] | [
"I160: Hypertensive urgency",
"I6523: Occlusion and stenosis of bilateral carotid arteries",
"G40909: Epilepsy, unspecified, not intractable, without status epilepticus"
] | [] | [] |
19,199,958 | 29,919,986 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nCholecystitis\n \nMajor Surgical or Invasive Procedure:\nCHOLECYSTECTOMY LAPAROSCOPIC COMPLEX , CONVERTED TO OPEN, on \n___\n\n \nHistory of Present Illness:\nMr. ___ is a ___ year old man with a past medical history\nnotable for IgG4 disease affecting lungs/liver (on high dose\nprednisone) who was recently hospitalized for acute \ncholecystitis\ncomplicated by gallbladder perforation and polymicrobial sepsis.\nHe underwent percutaneous cholecystostomy (___) tube and \nbiliary\nstent exchange ___ initially placed ___ when he\npresented with obstructive jaundice and had ERCP that revealed\nmalignant appearing stricture of 1.5cm). As for bacteremia\ntreatment, he is now s/p ciprofloxacin for E. Cloacae coverage\nand daptomycin (last dose + PICC removal ___ for MSSA and E.\nFaecalis coverage with bacteremia clearance (___). \n\nHe presents today at the ED after percutaneous cholecystostomy\ntube dislodgment. No pain. Tube had no drainage over past two\nweeks. No fever, chills, or pain except yesterday night. \n\nOf note, TTE and TEE were negative for endocarditis. MRCP (___)\nshowed reduction in the hepatic mass attributed to IgG4 disease\nand is now on slow prednisone taper.\n\nPatient reports minimal abdominal discomfort at site of perc\nchole tube. No nausea/vomiting, blood per rectum, constipation,\ndiarrhea, or abdominal pain.\n \nPast Medical History:\nSystemic IgG4 disease with lung and hepatobiliary involvement\nDepression\nInsomnia\nGout\nHL\nAnxiety\n\n \nSocial History:\n___\nFamily History:\nprostate ca\n \nPhysical Exam:\nPE on discharge:\nGen: NAD\nCV: RRR\nPulm: nonlabored breathing on RA\nAbd: soft, nontender, nondistended\n\n \nPertinent Results:\n___ 05:06PM HCT-46.4\n \nBrief Hospital Course:\nMr. ___ was admitted on ___ to undergo laparoscopic \ncholecystectomy, which was converted to open cholecystectomy. \nPlease see operative note for details. He was transferred to the \nPACU without issue. Post operatively, he was able to void and \ntolerated a regular diet. Pain was well controlled and vitals \nremained stable. On ___, he was stable and safe for discharge \nto home, and was given the appropriate medications and follow-up \nappointments.\n \nMedications on Admission:\n \nMedications - Prescription\nALLOPURINOL - allopurinol ___ mg tablet. 1 tablet(s) by mouth\ntwice a day - (Prescribed by Other Provider)\nALPRAZOLAM - alprazolam 0.5 mg tablet. 1 tablet(s) by mouth \nthree\ntimes a day as needed - (Prescribed by Other Provider)\nDAPTOMYCIN - Dosage uncertain - (Prescribed by Other Provider)\nFAMOTIDINE - famotidine 20 mg tablet. 1 tablet(s) by mouth daily\nINDOMETHACIN - indomethacin 25 mg capsule. ___ capsule(s) by\nmouth every six (6) hours as needed for as needed for gout - \n(Prescribed by Other Provider)\nPREDNISONE - prednisone 5 mg tablet. 7 tablet(s) by mouth daily\ndecrease by 5 mg every 7 days\nSULFAMETHOXAZOLE-TRIMETHOPRIM - sulfamethoxazole 400\nmg-trimethoprim 80 mg tablet. 1 tablet(s) by mouth Daily\nVENLAFAXINE - venlafaxine ER 75 mg capsule,extended release 24\nhr. 1 capsule(s) by mouth daily\nZOLPIDEM [AMBIEN] - Ambien 10 mg tablet. 1 tablet(s) by mouth at\nbedtime - (Prescribed by Other Provider)\n--------------- --------------- --------------- ---------------\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n2. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line \n3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity\nRX *oxycodone 5 mg ___ tablet(s) by mouth every 4-six (6) hours \nDisp #*15 Tablet Refills:*0 \n4. Senna 8.6 mg PO BID:PRN Constipation - First Line \n5. Allopurinol ___ mg PO BID \n6. PredniSONE 10 mg PO DAILY \n7. Venlafaxine XR 75 mg PO DAILY \n8. Zolpidem Tartrate 10 mg PO QHS \n\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n2. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line \n3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity\nRX *oxycodone 5 mg ___ tablet(s) by mouth every 4-six (6) hours \nDisp #*15 Tablet Refills:*0 \n4. Senna 8.6 mg PO BID:PRN Constipation - First Line \n5. Allopurinol ___ mg PO BID \n6. PredniSONE 10 mg PO DAILY \n7. Venlafaxine XR 75 mg PO DAILY \n8. Zolpidem Tartrate 10 mg PO QHS \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nCHOLECYSTITIS\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nYou were admitted to ___ and \nunderwent open cholecystectomy. You are recovering well and are \nnow ready for discharge. Please follow the instructions below to \ncontinue your recovery:\n\nPlease call your doctor or nurse practitioner or return to the \nEmergency Department for any of the following:\n*You experience new chest pain, pressure, squeezing or \ntightness.\n*New or worsening cough, shortness of breath, or wheeze.\n*If you are vomiting and cannot keep down fluids or your \nmedications.\n*You are getting dehydrated due to continued vomiting, diarrhea, \nor other reasons. Signs of dehydration include dry mouth, rapid \nheartbeat, or feeling dizzy or faint when standing.\n*You see blood or dark/black material when you vomit or have a \nbowel movement.\n*You experience burning when you urinate, have blood in your \nurine, or experience a discharge.\n*Your pain in not improving within ___ hours or is not gone \nwithin 24 hours. Call or return immediately if your pain is \ngetting worse or changes location or moving to your chest or \nback.\n*You have shaking chills, or fever greater than 101.5 degrees \nFahrenheit or 38 degrees Celsius.\n*Any change in your symptoms, or any new symptoms that concern \nyou.\n\nPlease resume all regular home medications, unless specifically \nadvised not to take a particular medication. Also, please take \nany new medications as prescribed.\n\nPlease get plenty of rest, continue to ambulate several times \nper day, and drink adequate amounts of fluids. Avoid lifting \nweights greater than ___ lbs until you follow-up with your \nsurgeon.\nAvoid driving or operating heavy machinery while taking pain \nmedications.\n\nIncision Care:\n*Please call your doctor or nurse practitioner if you have \nincreased pain, swelling, redness, or drainage from the incision \nsite.\n*Avoid swimming and baths until your follow-up appointment.\n*You may shower, and wash surgical incisions with a mild soap \nand warm water. Gently pat the area dry.\n*If you have staples, they will be removed at your follow-up \nappointment.\n*If you have steri-strips, they will fall off on their own. \nPlease remove any remaining strips ___ days after surgery.\n\n \nFollowup Instructions:\n___\n"
] | Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Cholecystitis Major Surgical or Invasive Procedure: CHOLECYSTECTOMY LAPAROSCOPIC COMPLEX , CONVERTED TO OPEN, on [MASKED] History of Present Illness: Mr. [MASKED] is a [MASKED] year old man with a past medical history notable for IgG4 disease affecting lungs/liver (on high dose prednisone) who was recently hospitalized for acute cholecystitis complicated by gallbladder perforation and polymicrobial sepsis. He underwent percutaneous cholecystostomy ([MASKED]) tube and biliary stent exchange [MASKED] initially placed [MASKED] when he presented with obstructive jaundice and had ERCP that revealed malignant appearing stricture of 1.5cm). As for bacteremia treatment, he is now s/p ciprofloxacin for E. Cloacae coverage and daptomycin (last dose + PICC removal [MASKED] for MSSA and E. Faecalis coverage with bacteremia clearance ([MASKED]). He presents today at the ED after percutaneous cholecystostomy tube dislodgment. No pain. Tube had no drainage over past two weeks. No fever, chills, or pain except yesterday night. Of note, TTE and TEE were negative for endocarditis. MRCP ([MASKED]) showed reduction in the hepatic mass attributed to IgG4 disease and is now on slow prednisone taper. Patient reports minimal abdominal discomfort at site of perc chole tube. No nausea/vomiting, blood per rectum, constipation, diarrhea, or abdominal pain. Past Medical History: Systemic IgG4 disease with lung and hepatobiliary involvement Depression Insomnia Gout HL Anxiety Social History: [MASKED] Family History: prostate ca Physical Exam: PE on discharge: Gen: NAD CV: RRR Pulm: nonlabored breathing on RA Abd: soft, nontender, nondistended Pertinent Results: [MASKED] 05:06PM HCT-46.4 Brief Hospital Course: Mr. [MASKED] was admitted on [MASKED] to undergo laparoscopic cholecystectomy, which was converted to open cholecystectomy. Please see operative note for details. He was transferred to the PACU without issue. Post operatively, he was able to void and tolerated a regular diet. Pain was well controlled and vitals remained stable. On [MASKED], he was stable and safe for discharge to home, and was given the appropriate medications and follow-up appointments. Medications on Admission: Medications - Prescription ALLOPURINOL - allopurinol [MASKED] mg tablet. 1 tablet(s) by mouth twice a day - (Prescribed by Other Provider) ALPRAZOLAM - alprazolam 0.5 mg tablet. 1 tablet(s) by mouth three times a day as needed - (Prescribed by Other Provider) DAPTOMYCIN - Dosage uncertain - (Prescribed by Other Provider) FAMOTIDINE - famotidine 20 mg tablet. 1 tablet(s) by mouth daily INDOMETHACIN - indomethacin 25 mg capsule. [MASKED] capsule(s) by mouth every six (6) hours as needed for as needed for gout - (Prescribed by Other Provider) PREDNISONE - prednisone 5 mg tablet. 7 tablet(s) by mouth daily decrease by 5 mg every 7 days SULFAMETHOXAZOLE-TRIMETHOPRIM - sulfamethoxazole 400 mg-trimethoprim 80 mg tablet. 1 tablet(s) by mouth Daily VENLAFAXINE - venlafaxine ER 75 mg capsule,extended release 24 hr. 1 capsule(s) by mouth daily ZOLPIDEM [AMBIEN] - Ambien 10 mg tablet. 1 tablet(s) by mouth at bedtime - (Prescribed by Other Provider) --------------- --------------- --------------- --------------- Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line 3. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity RX *oxycodone 5 mg [MASKED] tablet(s) by mouth every 4-six (6) hours Disp #*15 Tablet Refills:*0 4. Senna 8.6 mg PO BID:PRN Constipation - First Line 5. Allopurinol [MASKED] mg PO BID 6. PredniSONE 10 mg PO DAILY 7. Venlafaxine XR 75 mg PO DAILY 8. Zolpidem Tartrate 10 mg PO QHS 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line 3. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity RX *oxycodone 5 mg [MASKED] tablet(s) by mouth every 4-six (6) hours Disp #*15 Tablet Refills:*0 4. Senna 8.6 mg PO BID:PRN Constipation - First Line 5. Allopurinol [MASKED] mg PO BID 6. PredniSONE 10 mg PO DAILY 7. Venlafaxine XR 75 mg PO DAILY 8. Zolpidem Tartrate 10 mg PO QHS Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: CHOLECYSTITIS Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], You were admitted to [MASKED] and underwent open cholecystectomy. You are recovering well and are now ready for discharge. Please follow the instructions below to continue your recovery: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within [MASKED] 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 [MASKED] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips [MASKED] days after surgery. Followup Instructions: [MASKED] | [
"K819",
"D803",
"K828",
"Z5331",
"M109",
"F419",
"E785",
"G4700",
"F1290",
"F329"
] | [
"K819: Cholecystitis, unspecified",
"D803: Selective deficiency of immunoglobulin G [IgG] subclasses",
"K828: Other specified diseases of gallbladder",
"Z5331: Laparoscopic surgical procedure converted to open procedure",
"M109: Gout, unspecified",
"F419: Anxiety disorder, unspecified",
"E785: Hyperlipidemia, unspecified",
"G4700: Insomnia, unspecified",
"F1290: Cannabis use, unspecified, uncomplicated",
"F329: Major depressive disorder, single episode, unspecified"
] | [
"M109",
"F419",
"E785",
"G4700",
"F329"
] | [] |
15,767,531 | 28,431,462 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nCephalosporins / Penicillins / Keflex / Macrodantin / Septra\n \nAttending: ___\n \nChief Complaint:\nleft distal femur fracture\n \nMajor Surgical or Invasive Procedure:\n___: s/p left distal femur periprosthetic fracture \nsurgical fixation\n\n \nHistory of Present Illness:\n___ female with multiple prior medical problems, currently \nanticoagulated on warfarin, presents with a distal femur \nfracture status post mechanical fall. She was at home earlier \ntoday. She is being helped to the bathroom by her home 24-hour \naide. However she lost her balance and fell down onto her left \nknee. She had immediate severe pain. Of note, the patient \nrecently underwent a trochanteric fixation nail of the left hip \nin ___. Prior to today, she was doing very well ambulating \nindependently at home. She denies any numbness or paresthesias \nin her lower extremities. She is currently having ___ pain \njust proximal to her left knee. She is also status post \nbilateral total knee replacements previously.\n\nAside from the knee pain, she denies any pain in her head, \nchest, arms, or right leg. She denies abdominal pain nausea \nvomiting diarrhea or urinary symptoms.\n\n \nPast Medical History:\n___ cirrhosis\nDVT and PE\nRecurrent urinary tract infections\nTransient ischemic attack\n1. PE/DVT\n2. NASH cirrhosis\n3. Type II Diabetes\n4. Graves Disease s/p radio-iodine therapy now on levothyroxine\n5. Osteoarhtritis\n6. Osteoporosis\n7. Obesity\n8. Hypercholesterolemia\n9. Anemia\n10. Depression\n \nSocial History:\n___\nFamily History:\nReviewed and not relevant to this admission for L femoral \nfracture.\n \nPhysical Exam:\nADMISSION EXAM\n==============\nVitals: Reviewed, stable \nGeneral: Well-appearing female in no acute distress.\nLeft lower extremity:\n- Skin intact\n- Diffuse swelling and edema involving the proximal knee \n- Soft, non-tender leg\n- Full, painless ROM at hip and ankle\n- Painful ROM\n- Fires ___\n- SILT S/S/SP/DP/T distributions\n- 1+ ___ pulses, WWP\n\nDISCHARGE EXAM\n==============\nVS: Temp: 98.2 PO BP: 135/67 HR: 59 RR: 18 O2 sat: 97% O2\ndelivery: Ra \nGENERAL: NAD, AOx3, pleasant in conversation. \nHEENT: EOMI, PERRL, MMM.\nNECK: No JVP elevation.\nHEART: RRR, late peaking systolic murmur ___ best heard at the\nRUSB with radiation to the carotids.\nLUNGS: CTAB.\nABDOMEN: Soft, normoactive BS throughout, NDNT.\nEXTREMITIES: LLE is wrapped. Extremities are warm and\nwell-perfused. 1+ edema at the ankles L>R.\nNEURO: Alert and oriented, intact attention, fluent speech,\nPERRL, EOMI, CN ___ intact.\nSKIN: Warm and well perfused, no new rashes or lesions.\n \nPertinent Results:\nADMISSION LABS\n==============\n___ 05:00PM BLOOD WBC-5.1 RBC-3.16* Hgb-9.3* Hct-30.6* \nMCV-97 MCH-29.4 MCHC-30.4* RDW-16.2* RDWSD-57.3* Plt ___\n___ 05:00PM BLOOD Neuts-82.4* Lymphs-8.6* Monos-6.8 Eos-1.2 \nBaso-0.4 Im ___ AbsNeut-4.21 AbsLymp-0.44* AbsMono-0.35 \nAbsEos-0.06 AbsBaso-0.02\n___ 05:00PM BLOOD ___ PTT-32.3 ___\n___ 05:00PM BLOOD Glucose-128* UreaN-23* Creat-0.9 Na-145 \nK-4.7 Cl-110* HCO3-24 AnGap-11\n___ 02:18PM BLOOD Calcium-9.0 Phos-4.7* Mg-1.9\n\nDISCHARGE LABS\n==============\n___ 04:21AM BLOOD WBC-1.7* RBC-2.63* Hgb-7.8* Hct-25.3* \nMCV-96 MCH-29.7 MCHC-30.8* RDW-17.1* RDWSD-57.5* Plt Ct-95*\n___ 04:21AM BLOOD Neuts-64.8 Lymphs-18.8* Monos-9.1 Eos-6.1 \nBaso-0.6 Im ___ AbsNeut-1.07* AbsLymp-0.31* AbsMono-0.15* \nAbsEos-0.10 AbsBaso-0.01\n___ 04:21AM BLOOD ___ PTT-40.2* ___\n___ 04:21AM BLOOD Glucose-110* UreaN-26* Creat-1.0 Na-139 \nK-4.1 Cl-103 HCO3-30 AnGap-6*\n___ 04:21AM BLOOD Calcium-8.8 Phos-3.0 Mg-1.8\n\nNOTABLE LABS\n============\n___ 04:21AM BLOOD Neuts-64.8 Lymphs-18.8* Monos-9.1 Eos-6.1 \nBaso-0.6 Im ___ AbsNeut-1.07* AbsLymp-0.31* AbsMono-0.15* \nAbsEos-0.10 AbsBaso-0.01\n___ 04:48AM BLOOD Neuts-64.9 Lymphs-16.1* Monos-9.5 \nEos-8.0* Baso-1.0 Im ___ AbsNeut-1.29* AbsLymp-0.32* \nAbsMono-0.19* AbsEos-0.16 AbsBaso-0.02\n___ 12:49PM BLOOD Neuts-77.0* Lymphs-8.9* Monos-10.5 \nEos-2.4 Baso-0.4 Im ___ AbsNeut-1.90 AbsLymp-0.22* \nAbsMono-0.26 AbsEos-0.06 AbsBaso-0.01\n___ 05:00PM BLOOD Neuts-82.4* Lymphs-8.6* Monos-6.8 Eos-1.2 \nBaso-0.4 Im ___ AbsNeut-4.21 AbsLymp-0.44* AbsMono-0.35 \nAbsEos-0.06 AbsBaso-0.02\n___ 12:49PM BLOOD Ret Aut-3.0* Abs Ret-0.06\n___ 12:49PM BLOOD ___ 04:47PM BLOOD ___ 04:48AM BLOOD ___ 03:11AM BLOOD %HbA1c-5.5 eAG-111\n___ 12:49PM BLOOD Hapto-50\n___ 03:11AM BLOOD Triglyc-81 HDL-24* CHOL/HD-3.5 LDLcalc-43 \nLDLmeas-53\n___ 03:08AM BLOOD TSH-1.3\n___ 05:40PM URINE Color-Straw Appear-Hazy* Sp ___\n___ 05:40PM URINE Blood-SM* Nitrite-POS* Protein-TR* \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG*\n___ 05:40PM URINE RBC-16* WBC-21* Bacteri-MOD* Yeast-NONE \nEpi-2\n\nMICRO\n=====\n___ 5:40 pm URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE \nIDENTIFICATION. \n Cefazolin interpretative criteria are based on a dosage \nregimen of\n 2g every 8h. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n ESCHERICHIA COLI\n | \nAMIKACIN-------------- 16 S\nAMPICILLIN------------ =>32 R\nAMPICILLIN/SULBACTAM-- =>32 R\nCEFAZOLIN------------- <=4 S\nCEFEPIME-------------- <=1 S\nCEFTAZIDIME----------- <=1 S\nCEFTRIAXONE----------- <=1 S\nCIPROFLOXACIN--------- =>4 R\nGENTAMICIN------------ =>16 R\nMEROPENEM-------------<=0.25 S\nNITROFURANTOIN-------- <=16 S\nPIPERACILLIN/TAZO----- 8 S\nTOBRAMYCIN------------ =>16 R\nTRIMETHOPRIM/SULFA---- <=1 S\n\nSTUDIES/IMAGING\n===============\nCXR ___\nIMPRESSION: \nNo acute intrathoracic process. \n\nCT LLE ___\nIMPRESSION: \n1. Impacted and comminuted distal femoral metastasis fracture \nabutting the \nsuperior margin of the total knee arthroplasty femoral \ncomponent. \n2. Subtle nondisplaced proximal fibula fracture. \n3. Hematoma in the proximal gastrocnemius muscle concerning for \npartial-thickness injury. \n\nFLUORO LLE ___\nIMPRESSION: \nIntraoperative study demonstrates placement of a large lateral \nfracture plate and associated screws stabilizing a \nperiprosthetic fracture of the distal femur. There is a total \nknee arthroplasty. Total intraservice fluoroscopic time is 85.4 \nseconds. Please refer to the operative note for additional \ndetails.\n\n___ ___\nIMPRESSION: \n1. Overlying hardware streak artifact and motion limits \nexamination. \n2. Within limits of study, no definite evidence of acute \nintracranial \nhemorrhage or large territory infarction. Please note MRI of \nthe brain is \nmore sensitive for the detection of acute infarct. \n3. Atrophy, probable small vessel ischemic changes, and \natherosclerotic \nvascular disease as described. \n\nABDOMINAL US ___\nIMPRESSION: \n1. Coarse and nodular hepatic architecture consistent with the \npatient's known cirrhosis. No concerning liver lesion \nidentified. \n2. Patent portal and hepatic veins. A patent umbilical vein \nwith midline \nvarices are again noted. \n3. Splenomegaly. \n4. Cholelithiasis. \n5. Nonobstructing stone measuring 1.0 cm is again noted in the \nright renal \nhilum. \n6. Scant trace ascites only seen in the perisplenic space. \n\nCT A/P ___\nIMPRESSION: \n1. No evidence of hematoma within the abdomen, pelvis or \nvisualized lower \nextremities. \n2. Extensive orthopedic fixation hardware of the left femur with \nexpected \npostsurgical changes. \n3. Cirrhotic liver morphology with extensive abdominal varices \nand stable \nmoderate splenomegaly. \n4. Cholelithiasis without evidence of acute cholecystitis. \n\nMRI/MRA BRAIN ___\nIMPRESSION: \n1. No evidence of acute infarction, hemorrhage or intracranial \nmass. \n2. Severe right and moderate left stenosis at the origin of the \nexternal \ncarotid arteries. Mild stenosis at the origin of the bilateral \nvertebral \narteries. \n3. Nonvisualization of the right PCA distal to its P1 segment, \npossibly due to motion artifact, however, vessel occlusion and \ncollateralization of flow is not excluded. \n4. Otherwise patent intracranial and cervical vasculature \nwithout evidence of dissection or aneurysm formation. \n\nSHOULDER PLAIN FILM ___\nIMPRESSION: \nNo acute fracture or dislocation. \n\n \n\n \nBrief Hospital Course:\nPatient is a ___ y/o woman with a history of PE/DVT on warfarin, \nsevere AS, RV dysfunction, NASH cirrhosis, Graves' disease s/p \nradioactive iodine therapy now on levothyroxine, recent left \nintertrochanteric hip fracture s/p left ITN on ___, who \npresented with a left distal femur fracture after a mechanical \nfall (s/p operative fixation of femur with ___ plate ___, \nhospital course c/b stable pancytopenia and aphasia \n(subsequently improved, thought to be transcortical motor \naphasia in the setting of infection).\n\nTRANSITIONAL ISSUES:\n====================\n**Discharge weight (bed): 89kg (196.21 lbs) \n**Discharge hemoglobin: 7.8\n**Discharge INR: 2.4 (dosed 2mg Warfarin ___\n- Patient will continue cephalexin 500mg TID through ___ \nfor E. coli UTI\n- Patient should have repeat CBC drawn within ___ to ensure \nstability of pancytopenia, follow-up with outpatient \nhematologist is currently being arranged\n- f/u pending SPEP/UPEP (sent given pancytopenia and low anion \ngap)\n- Continue to monitor volume status closely and adjust \nfurosemide as needed, follow-up with outpatient cardiologist is \ncurrently being arranged\n- Of note, patient's E coli was resistant to multiple abx \n(ampicillin, ampicillin/sulbactam, ciprofloxacin, \ngentamicin/tobramycin)\n- Patient will need ongoing osteoporosis screening/treatment as \nan outpatient, has previously been on prolia, should continue \nvitamin D/Calcium supplementation\n- Orthopedics recommended at least 4wks DVT ppx, patient was \nresumed on warfarin ___ as outlined below\n\nACTIVE ISSUES: \n==============\n# Normocytic anemia: \nPatient with acute anemia hcg 9->5.9 postoperatively. Reported \n50cc blood loss during procedure with no evidence of hematoma in \nthe thigh. No concern for RP bleed and no other obvious sources \nof bleeding (CT A/P ___ was unremarkable). Fibrinogen normal \nmaking DIC less likely. B12 level ___, patient has been \nreceiving monthly injections as an outpatient. Haptoglobin \nnegative and LDH 238 ___, thus not intravascular hemolysis. \nReticulocyte studies from ___ were consistent with a \nhypoproliferative process. s/p 3u pRBCs, most recently___. Of \nnote, patient has been followed by an outpatient hematologist \n___ at ___), will be seen again as an outpatient. \nSPEP/UPEP pending at time of discharge, sent iso cytopenias and \nlow anion gap. Hb 7.8 on day of discharge.\n\n# Thrombocytopenia: \nPatient with baseline thrombocytopenia in the 90-100s, this \nadmission with acute drop to the ___ post-operatively. Initial \nconcern for consumption but no active bleeding as above. Given \ndrop in all\ncell lines, less likely due solely to acute rise in portal \nhypertension (there is a history of cirrhosis as below). s/p 1u \nplt ___, subsequently with counts stable in mid ___. Hematology \nf/u as an outpatient as above.\n\n# Leukopenia: \nPatient with drop in WBC this admission in addition to hgb and \nplts as above. Very likely due to BM suppression iso UTI as well \nas acute illness iso recent orthopedic intervention. CBC with \ndiff notable for ANC 1290 and ALC .32 ___, no signs of new \nacute/evolving infection. Hematology f/u as an outpatient as \nabove.\n\n# Global non-fluent aphasia, transcortical motor aphasia \n(resolved):\n# Microvascular disease:\n# Hx transient ischemic attack:\nPatient was noted to have global aphasia after her orthopedic \nprocedure, likely recrudescence of prior insults iso UTI and \n___ stress. MRI/MRA brain without evidence of new \nstroke and exam subsequently normalized. Neurology was \nconsulted, suspected recrudescence in the setting of UTI, no \nfurther recommendations. \n\n# Shoulder discomfort:\nPatient was complaining of significant R shoulder pain while \nworking with ___. No evidence of fracture on plain film of R \nshoulder ___. Patient was started on a lidocaine patch.\n\n# Coagulopathy: \nINR was 1.8 on admission, subsequently rose to 3.2 \npost-operatively. Patient receive 1U FFP ___. Fibrinogen \nnormal. History of NASH cirrhosis as above. Warfarin was \ninitially held, restarted 2mg qd ___. INR is managed by PCP \n(Dr. ___ at ___).\n\n# L distal femur fracture s/p mechanical fall - s/p ___ (___):\nOrthopedics followed throughout the admission, would like 4wks \nDVT ppx, patient is currently with therapeutic INR after \nresumption of coumadin ___. Patient will f/u in ___ clinic \n14days after discharge. Activity: TDWB LLE in unlocked ___. \nPain control with standing acetaminophen and oxycodone prn. \nBowel regimen with docusate and bisacodyl.\n\n# E. Coli UTIs\n# Recurrent UTIs: \nPatient with hx recurrent UTIs and UA this admission with large \n___, positive nitrites, 21 WBCs, and moderate bacteria. Remained \nAF and HD stable. Patient was treated with ceftriaxone, narrowed \nto cephalexin given E coli sensitivities, plan to continue \nthrough ___.\n\nCHRONIC/STABLE ISSUES: \n======================\n# Severe AS\n# RV dysfunction\n# Diastolic dysfunction: \nLast echo with valve area 0.8, peak velocity 3.6, mean gradient \n29. Volume status is difficult, though patient did not appear \nmarkedly volume overload. Patient pre-admission had no sx from \nAS including exertional syncope, dizziness, CP, or SOB, was \nfollowed by Dr. ___ and now Dr. ___ at ___ \n___ in ___. Patient's furosemide was initially held \nin the perioperative period, furosemide 20mg qd was restarted \n___ (she actually received 40mg ___ given confusion as to her \nhome dose).\n\n# NASH Cirrhosis:\nFollows at ___ with transplant team. Trace ascites on US from \nlast visit. No EGD in our system, appears to have varices on CT \nthis admission. Likely has portal HTN given use of nadolol. No \nevidence of decompensation on exam throughout this admission. \nFurosemide was initially held as above, restarted ___. Of note, \npatient told team that her hepatologist had previously \ndiscontinued spironolactone last year. Patient was otherwise \ncontinued on nadolol 20mg qd. \n\n# DVT/PE: \nWarfarin was initially held and patient was on a heparin gtt. \nWarfarin was restarted ___ as above, received 2mg ___ prior to \ndischarge with therapeutic INR 2.4 (goal ___.\n\n# DM2: \nOf note, patient has not on any DM agents at home, had \npreviously been\ntaking glipizide. Maintained on ISS while inpatient, though she \nhardly required any insulin (FSBGs largely ___, she did \nreceive 4U regular insulin ___ for FSBG 203). \n\n# Osteoporosis:\nOn prolia as outpatient, though has not received in some time \ngiven recurrent hospitalizations, has been managed by her \noutpatient PCP. \n\n# Graves Disease s/p radio-iodine therapy now on levothyroxine:\nTSH 1.3 this admission. Continued home levothyroxine 150mg.\n\nThis patient was prescribed, or continued on, an opioid pain \nmedication at the time of discharge (please see the attached \nmedication list for details). As part of our safe opioid \nprescribing process, all patients are provided with an opioid \nrisks and treatment resource education sheet and encouraged to \ndiscuss this therapy with their outpatient providers to \ndetermine if opioid pain medication is still indicated.\n\nGreater than 30 minutes spent on discharge planning and \ncoordination. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Denosumab (Prolia) 60 mg SC EVERY 6MONTHS \n2. Furosemide 20 mg PO DAILY \n3. Levothyroxine Sodium 200 mcg PO DAILY \n4. Nadolol 20 mg PO DAILY \n5. Calcium Soft Chew (calcium-vitamin D3-vitamin K) 500 mg-1,000 \nunit-40 mcg oral QAM \n6. Cyanocobalamin 1000 mcg IM/SC ONCE MONTHLY \n7. Warfarin ___ mg PO DAILY16 \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Moderate \n2. Bisacodyl 10 mg PO/PR DAILY \n3. Cephalexin 250 mg PO TID Duration: 3 Days \nShould continue through ___ for treatment of UTI. \n4. Docusate Sodium 100 mg PO BID \n5. Lidocaine 5% Patch 1 PTCH TD QAM \n6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain \nRX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours \nDisp #*10 Tablet Refills:*0 \n7. Warfarin 2 mg PO DAILY16 \nGoal INR ___, next INR should be drawn ___ \n8. Calcium Soft Chew (calcium-vitamin D3-vitamin K) 500 \nmg-1,000 unit-40 mcg oral QAM \n9. Cyanocobalamin 1000 mcg IM/SC ONCE MONTHLY \n10. Denosumab (Prolia) 60 mg SC EVERY 6MONTHS \n11. Furosemide 20 mg PO DAILY \n12. Levothyroxine Sodium 200 mcg PO DAILY \n13. Nadolol 20 mg PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary Diagnoses\n=================\nLeft distal femur periprosthetic fracture\nPancytopenia\nTranscortical motor aphasia\n\nSecondary Diagnoses\n===================\nUrinary tract infection\nCoaguloapthy\nSevere Aortic Stenosis\nRight shoulder pain\nNASH Cirrhosis\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Out of Bed with assistance to chair or \nwheelchair.\n- ___ LLE in unlocked ___\n\n \nDischarge Instructions:\nDear Ms. ___, \n\nIt was a pleasure caring for you at ___ \n___. \n\nWHY WAS I IN THE HOSPITAL? \n- You had a fall at home and unfortunately experienced a \nfracture to your left leg. \n\nWHAT HAPPENED TO ME IN THE HOSPITAL? \n- You underwent surgery with our orthopedics team ___ to \nfix your broken leg.\n- You were transferred to the general medicine service for \nongoing care after you were found to have low blood counts as \nwell as issues with your speech.\n- You were treated with antibiotics for a urinary tract \ninfection.\n- You were given blood transfusions as well as a transfusion of \nplatelets to help maintain your blood counts. \n- You were evaluated by the neurologists and had an MRI of your \nbrain, which did not show any new problems (for example a \nstroke).\n- Thankfully, your speech improved back to normal and your prior \ndifficulties were attributed to your urinary tract infection as \nwell as the stress cause by your fracture and surgery. \n\nWHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? \n- Please follow the instructions left by your orthopedic surgery \nteam below.\n- Please take your medications and go to your follow up \nappointments as described in this discharge summary. \n- If you experience any of the danger signs listed below, please \ncall your primary care doctor or go to the emergency department \nimmediately. \n\nWe wish you the best! \n\nSincerely, \nYour ___ Team \n\nINSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:\n\n- You were in the hospital for orthopedic surgery. It is normal \nto feel tired or \"washed out\" after surgery, and this feeling \nshould improve over the first few days to week. \n- Resume your regular activities as tolerated, but please follow \nyour weight bearing precautions strictly at all times.\n\nACTIVITY AND WEIGHT BEARING:\n- TDWB LLE in unlocked ___\n\nMEDICATIONS:\n 1) Take Tylenol ___ every 6 hours around the clock. This is \nan over the counter medication.\n 2) Add OXYCODONE as needed for increased pain. Aim to wean \noff this medication in 1 week or sooner. This is an example on \nhow to wean down:\nTake 1 tablet every 3 hours as needed x 1 day,\nthen 1 tablet every 4 hours as needed x 1 day,\nthen 1 tablet every 6 hours as needed x 1 day,\nthen 1 tablet every 8 hours as needed x 2 days, \nthen 1 tablet every 12 hours as needed x 1 day,\nthen 1 tablet every before bedtime as needed x 1 day. \nThen continue with Tylenol for pain.\n 3) Do not stop the Tylenol until you are off of the narcotic \nmedication.\n 4) Per state regulations, we are limited in the amount of \nnarcotics we can prescribe. If you require more, you must \ncontact the office to set up an appointment because we cannot \nrefill this type of pain medication over the phone. \n 5) Narcotic pain relievers can cause constipation, so you \nshould drink eight 8oz glasses of water daily and continue \nfollowing the bowel regimen as stated on your medication \nprescription list. These meds (senna, colace, miralax) are over \nthe counter and may be obtained at any pharmacy.\n 6) Do not drink alcohol, drive a motor vehicle, or operate \nmachinery while taking narcotic pain relievers.\n 7) Please take all medications as prescribed by your \nphysicians at discharge.\n 8) Continue all home medications unless specifically \ninstructed to stop by your surgeon.\n \nANTICOAGULATION:\n- Resume home coumadin\n\nWOUND CARE:\n- You may shower. No baths or swimming for at least 4 weeks.\n- Any stitches or staples that need to be removed will be taken \nout at your 2-week follow up appointment.\n- Incision may be left open to air unless actively draining. If \ndraining, you may apply a gauze dressing secured with paper \ntape.\n- If you have a splint in place, splint must be left on until \nfollow up appointment unless otherwise instructed. Do NOT get \nsplint wet.\n\nDANGER SIGNS:\nPlease call your PCP or surgeon's office and/or return to the \nemergency department if you experience any of the following:\n- Increasing pain that is not controlled with pain medications\n- Increasing redness, swelling, drainage, or other concerning \nchanges in your incision\n- Persistent or increasing numbness, tingling, or loss of \nsensation\n- Fever > 101.4\n- Shaking chills\n- Chest pain\n- Shortness of breath\n- Nausea or vomiting with an inability to keep food, liquid, \nmedications down\n- Any other medical concerns\n\nTHIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB\n\n \nFollowup Instructions:\n___\n"
] | Allergies: Cephalosporins / Penicillins / Keflex / Macrodantin / Septra Chief Complaint: left distal femur fracture Major Surgical or Invasive Procedure: [MASKED]: s/p left distal femur periprosthetic fracture surgical fixation History of Present Illness: [MASKED] female with multiple prior medical problems, currently anticoagulated on warfarin, presents with a distal femur fracture status post mechanical fall. She was at home earlier today. She is being helped to the bathroom by her home 24-hour aide. However she lost her balance and fell down onto her left knee. She had immediate severe pain. Of note, the patient recently underwent a trochanteric fixation nail of the left hip in [MASKED]. Prior to today, she was doing very well ambulating independently at home. She denies any numbness or paresthesias in her lower extremities. She is currently having [MASKED] pain just proximal to her left knee. She is also status post bilateral total knee replacements previously. Aside from the knee pain, she denies any pain in her head, chest, arms, or right leg. She denies abdominal pain nausea vomiting diarrhea or urinary symptoms. Past Medical History: [MASKED] cirrhosis DVT and PE Recurrent urinary tract infections Transient ischemic attack 1. PE/DVT 2. NASH cirrhosis 3. Type II Diabetes 4. Graves Disease s/p radio-iodine therapy now on levothyroxine 5. Osteoarhtritis 6. Osteoporosis 7. Obesity 8. Hypercholesterolemia 9. Anemia 10. Depression Social History: [MASKED] Family History: Reviewed and not relevant to this admission for L femoral fracture. Physical Exam: ADMISSION EXAM ============== Vitals: Reviewed, stable General: Well-appearing female in no acute distress. Left lower extremity: - Skin intact - Diffuse swelling and edema involving the proximal knee - Soft, non-tender leg - Full, painless ROM at hip and ankle - Painful ROM - Fires [MASKED] - SILT S/S/SP/DP/T distributions - 1+ [MASKED] pulses, WWP DISCHARGE EXAM ============== VS: Temp: 98.2 PO BP: 135/67 HR: 59 RR: 18 O2 sat: 97% O2 delivery: Ra GENERAL: NAD, AOx3, pleasant in conversation. HEENT: EOMI, PERRL, MMM. NECK: No JVP elevation. HEART: RRR, late peaking systolic murmur [MASKED] best heard at the RUSB with radiation to the carotids. LUNGS: CTAB. ABDOMEN: Soft, normoactive BS throughout, NDNT. EXTREMITIES: LLE is wrapped. Extremities are warm and well-perfused. 1+ edema at the ankles L>R. NEURO: Alert and oriented, intact attention, fluent speech, PERRL, EOMI, CN [MASKED] intact. SKIN: Warm and well perfused, no new rashes or lesions. Pertinent Results: ADMISSION LABS ============== [MASKED] 05:00PM BLOOD WBC-5.1 RBC-3.16* Hgb-9.3* Hct-30.6* MCV-97 MCH-29.4 MCHC-30.4* RDW-16.2* RDWSD-57.3* Plt [MASKED] [MASKED] 05:00PM BLOOD Neuts-82.4* Lymphs-8.6* Monos-6.8 Eos-1.2 Baso-0.4 Im [MASKED] AbsNeut-4.21 AbsLymp-0.44* AbsMono-0.35 AbsEos-0.06 AbsBaso-0.02 [MASKED] 05:00PM BLOOD [MASKED] PTT-32.3 [MASKED] [MASKED] 05:00PM BLOOD Glucose-128* UreaN-23* Creat-0.9 Na-145 K-4.7 Cl-110* HCO3-24 AnGap-11 [MASKED] 02:18PM BLOOD Calcium-9.0 Phos-4.7* Mg-1.9 DISCHARGE LABS ============== [MASKED] 04:21AM BLOOD WBC-1.7* RBC-2.63* Hgb-7.8* Hct-25.3* MCV-96 MCH-29.7 MCHC-30.8* RDW-17.1* RDWSD-57.5* Plt Ct-95* [MASKED] 04:21AM BLOOD Neuts-64.8 Lymphs-18.8* Monos-9.1 Eos-6.1 Baso-0.6 Im [MASKED] AbsNeut-1.07* AbsLymp-0.31* AbsMono-0.15* AbsEos-0.10 AbsBaso-0.01 [MASKED] 04:21AM BLOOD [MASKED] PTT-40.2* [MASKED] [MASKED] 04:21AM BLOOD Glucose-110* UreaN-26* Creat-1.0 Na-139 K-4.1 Cl-103 HCO3-30 AnGap-6* [MASKED] 04:21AM BLOOD Calcium-8.8 Phos-3.0 Mg-1.8 NOTABLE LABS ============ [MASKED] 04:21AM BLOOD Neuts-64.8 Lymphs-18.8* Monos-9.1 Eos-6.1 Baso-0.6 Im [MASKED] AbsNeut-1.07* AbsLymp-0.31* AbsMono-0.15* AbsEos-0.10 AbsBaso-0.01 [MASKED] 04:48AM BLOOD Neuts-64.9 Lymphs-16.1* Monos-9.5 Eos-8.0* Baso-1.0 Im [MASKED] AbsNeut-1.29* AbsLymp-0.32* AbsMono-0.19* AbsEos-0.16 AbsBaso-0.02 [MASKED] 12:49PM BLOOD Neuts-77.0* Lymphs-8.9* Monos-10.5 Eos-2.4 Baso-0.4 Im [MASKED] AbsNeut-1.90 AbsLymp-0.22* AbsMono-0.26 AbsEos-0.06 AbsBaso-0.01 [MASKED] 05:00PM BLOOD Neuts-82.4* Lymphs-8.6* Monos-6.8 Eos-1.2 Baso-0.4 Im [MASKED] AbsNeut-4.21 AbsLymp-0.44* AbsMono-0.35 AbsEos-0.06 AbsBaso-0.02 [MASKED] 12:49PM BLOOD Ret Aut-3.0* Abs Ret-0.06 [MASKED] 12:49PM BLOOD [MASKED] 04:47PM BLOOD [MASKED] 04:48AM BLOOD [MASKED] 03:11AM BLOOD %HbA1c-5.5 eAG-111 [MASKED] 12:49PM BLOOD Hapto-50 [MASKED] 03:11AM BLOOD Triglyc-81 HDL-24* CHOL/HD-3.5 LDLcalc-43 LDLmeas-53 [MASKED] 03:08AM BLOOD TSH-1.3 [MASKED] 05:40PM URINE Color-Straw Appear-Hazy* Sp [MASKED] [MASKED] 05:40PM URINE Blood-SM* Nitrite-POS* Protein-TR* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG* [MASKED] 05:40PM URINE RBC-16* WBC-21* Bacteri-MOD* Yeast-NONE Epi-2 MICRO ===== [MASKED] 5:40 pm URINE **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: 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 [MASKED] ESCHERICHIA COLI | AMIKACIN-------------- 16 S AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ =>16 R TRIMETHOPRIM/SULFA---- <=1 S STUDIES/IMAGING =============== CXR [MASKED] IMPRESSION: No acute intrathoracic process. CT LLE [MASKED] IMPRESSION: 1. Impacted and comminuted distal femoral metastasis fracture abutting the superior margin of the total knee arthroplasty femoral component. 2. Subtle nondisplaced proximal fibula fracture. 3. Hematoma in the proximal gastrocnemius muscle concerning for partial-thickness injury. FLUORO LLE [MASKED] IMPRESSION: Intraoperative study demonstrates placement of a large lateral fracture plate and associated screws stabilizing a periprosthetic fracture of the distal femur. There is a total knee arthroplasty. Total intraservice fluoroscopic time is 85.4 seconds. Please refer to the operative note for additional details. [MASKED] [MASKED] IMPRESSION: 1. Overlying hardware streak artifact and motion limits examination. 2. Within limits of study, no definite evidence of acute intracranial hemorrhage or large territory infarction. Please note MRI of the brain is more sensitive for the detection of acute infarct. 3. Atrophy, probable small vessel ischemic changes, and atherosclerotic vascular disease as described. ABDOMINAL US [MASKED] IMPRESSION: 1. Coarse and nodular hepatic architecture consistent with the patient's known cirrhosis. No concerning liver lesion identified. 2. Patent portal and hepatic veins. A patent umbilical vein with midline varices are again noted. 3. Splenomegaly. 4. Cholelithiasis. 5. Nonobstructing stone measuring 1.0 cm is again noted in the right renal hilum. 6. Scant trace ascites only seen in the perisplenic space. CT A/P [MASKED] IMPRESSION: 1. No evidence of hematoma within the abdomen, pelvis or visualized lower extremities. 2. Extensive orthopedic fixation hardware of the left femur with expected postsurgical changes. 3. Cirrhotic liver morphology with extensive abdominal varices and stable moderate splenomegaly. 4. Cholelithiasis without evidence of acute cholecystitis. MRI/MRA BRAIN [MASKED] IMPRESSION: 1. No evidence of acute infarction, hemorrhage or intracranial mass. 2. Severe right and moderate left stenosis at the origin of the external carotid arteries. Mild stenosis at the origin of the bilateral vertebral arteries. 3. Nonvisualization of the right PCA distal to its P1 segment, possibly due to motion artifact, however, vessel occlusion and collateralization of flow is not excluded. 4. Otherwise patent intracranial and cervical vasculature without evidence of dissection or aneurysm formation. SHOULDER PLAIN FILM [MASKED] IMPRESSION: No acute fracture or dislocation. Brief Hospital Course: Patient is a [MASKED] y/o woman with a history of PE/DVT on warfarin, severe AS, RV dysfunction, NASH cirrhosis, Graves' disease s/p radioactive iodine therapy now on levothyroxine, recent left intertrochanteric hip fracture s/p left ITN on [MASKED], who presented with a left distal femur fracture after a mechanical fall (s/p operative fixation of femur with [MASKED] plate [MASKED], hospital course c/b stable pancytopenia and aphasia (subsequently improved, thought to be transcortical motor aphasia in the setting of infection). TRANSITIONAL ISSUES: ==================== **Discharge weight (bed): 89kg (196.21 lbs) **Discharge hemoglobin: 7.8 **Discharge INR: 2.4 (dosed 2mg Warfarin [MASKED] - Patient will continue cephalexin 500mg TID through [MASKED] for E. coli UTI - Patient should have repeat CBC drawn within [MASKED] to ensure stability of pancytopenia, follow-up with outpatient hematologist is currently being arranged - f/u pending SPEP/UPEP (sent given pancytopenia and low anion gap) - Continue to monitor volume status closely and adjust furosemide as needed, follow-up with outpatient cardiologist is currently being arranged - Of note, patient's E coli was resistant to multiple abx (ampicillin, ampicillin/sulbactam, ciprofloxacin, gentamicin/tobramycin) - Patient will need ongoing osteoporosis screening/treatment as an outpatient, has previously been on prolia, should continue vitamin D/Calcium supplementation - Orthopedics recommended at least 4wks DVT ppx, patient was resumed on warfarin [MASKED] as outlined below ACTIVE ISSUES: ============== # Normocytic anemia: Patient with acute anemia hcg 9->5.9 postoperatively. Reported 50cc blood loss during procedure with no evidence of hematoma in the thigh. No concern for RP bleed and no other obvious sources of bleeding (CT A/P [MASKED] was unremarkable). Fibrinogen normal making DIC less likely. B12 level [MASKED], patient has been receiving monthly injections as an outpatient. Haptoglobin negative and LDH 238 [MASKED], thus not intravascular hemolysis. Reticulocyte studies from [MASKED] were consistent with a hypoproliferative process. s/p 3u pRBCs, most recently . Of note, patient has been followed by an outpatient hematologist [MASKED] at [MASKED]), will be seen again as an outpatient. SPEP/UPEP pending at time of discharge, sent iso cytopenias and low anion gap. Hb 7.8 on day of discharge. # Thrombocytopenia: Patient with baseline thrombocytopenia in the 90-100s, this admission with acute drop to the [MASKED] post-operatively. Initial concern for consumption but no active bleeding as above. Given drop in all cell lines, less likely due solely to acute rise in portal hypertension (there is a history of cirrhosis as below). s/p 1u plt [MASKED], subsequently with counts stable in mid [MASKED]. Hematology f/u as an outpatient as above. # Leukopenia: Patient with drop in WBC this admission in addition to hgb and plts as above. Very likely due to BM suppression iso UTI as well as acute illness iso recent orthopedic intervention. CBC with diff notable for ANC 1290 and ALC .32 [MASKED], no signs of new acute/evolving infection. Hematology f/u as an outpatient as above. # Global non-fluent aphasia, transcortical motor aphasia (resolved): # Microvascular disease: # Hx transient ischemic attack: Patient was noted to have global aphasia after her orthopedic procedure, likely recrudescence of prior insults iso UTI and [MASKED] stress. MRI/MRA brain without evidence of new stroke and exam subsequently normalized. Neurology was consulted, suspected recrudescence in the setting of UTI, no further recommendations. # Shoulder discomfort: Patient was complaining of significant R shoulder pain while working with [MASKED]. No evidence of fracture on plain film of R shoulder [MASKED]. Patient was started on a lidocaine patch. # Coagulopathy: INR was 1.8 on admission, subsequently rose to 3.2 post-operatively. Patient receive 1U FFP [MASKED]. Fibrinogen normal. History of NASH cirrhosis as above. Warfarin was initially held, restarted 2mg qd [MASKED]. INR is managed by PCP (Dr. [MASKED] at [MASKED]). # L distal femur fracture s/p mechanical fall - s/p [MASKED] ([MASKED]): Orthopedics followed throughout the admission, would like 4wks DVT ppx, patient is currently with therapeutic INR after resumption of coumadin [MASKED]. Patient will f/u in [MASKED] clinic 14days after discharge. Activity: TDWB LLE in unlocked [MASKED]. Pain control with standing acetaminophen and oxycodone prn. Bowel regimen with docusate and bisacodyl. # E. Coli UTIs # Recurrent UTIs: Patient with hx recurrent UTIs and UA this admission with large [MASKED], positive nitrites, 21 WBCs, and moderate bacteria. Remained AF and HD stable. Patient was treated with ceftriaxone, narrowed to cephalexin given E coli sensitivities, plan to continue through [MASKED]. CHRONIC/STABLE ISSUES: ====================== # Severe AS # RV dysfunction # Diastolic dysfunction: Last echo with valve area 0.8, peak velocity 3.6, mean gradient 29. Volume status is difficult, though patient did not appear markedly volume overload. Patient pre-admission had no sx from AS including exertional syncope, dizziness, CP, or SOB, was followed by Dr. [MASKED] and now Dr. [MASKED] at [MASKED] [MASKED] in [MASKED]. Patient's furosemide was initially held in the perioperative period, furosemide 20mg qd was restarted [MASKED] (she actually received 40mg [MASKED] given confusion as to her home dose). # NASH Cirrhosis: Follows at [MASKED] with transplant team. Trace ascites on US from last visit. No EGD in our system, appears to have varices on CT this admission. Likely has portal HTN given use of nadolol. No evidence of decompensation on exam throughout this admission. Furosemide was initially held as above, restarted [MASKED]. Of note, patient told team that her hepatologist had previously discontinued spironolactone last year. Patient was otherwise continued on nadolol 20mg qd. # DVT/PE: Warfarin was initially held and patient was on a heparin gtt. Warfarin was restarted [MASKED] as above, received 2mg [MASKED] prior to discharge with therapeutic INR 2.4 (goal [MASKED]. # DM2: Of note, patient has not on any DM agents at home, had previously been taking glipizide. Maintained on ISS while inpatient, though she hardly required any insulin (FSBGs largely [MASKED], she did receive 4U regular insulin [MASKED] for FSBG 203). # Osteoporosis: On prolia as outpatient, though has not received in some time given recurrent hospitalizations, has been managed by her outpatient PCP. # Graves Disease s/p radio-iodine therapy now on levothyroxine: TSH 1.3 this admission. Continued home levothyroxine 150mg. 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. Greater than 30 minutes spent on discharge planning and coordination. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Denosumab (Prolia) 60 mg SC EVERY 6MONTHS 2. Furosemide 20 mg PO DAILY 3. Levothyroxine Sodium 200 mcg PO DAILY 4. Nadolol 20 mg PO DAILY 5. Calcium Soft Chew (calcium-vitamin D3-vitamin K) 500 mg-1,000 unit-40 mcg oral QAM 6. Cyanocobalamin 1000 mcg IM/SC ONCE MONTHLY 7. Warfarin [MASKED] mg PO DAILY16 Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Moderate 2. Bisacodyl 10 mg PO/PR DAILY 3. Cephalexin 250 mg PO TID Duration: 3 Days Should continue through [MASKED] for treatment of UTI. 4. Docusate Sodium 100 mg PO BID 5. Lidocaine 5% Patch 1 PTCH TD QAM 6. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain RX *oxycodone 5 mg [MASKED] tablet(s) by mouth every four (4) hours Disp #*10 Tablet Refills:*0 7. Warfarin 2 mg PO DAILY16 Goal INR [MASKED], next INR should be drawn [MASKED] 8. Calcium Soft Chew (calcium-vitamin D3-vitamin K) 500 mg-1,000 unit-40 mcg oral QAM 9. Cyanocobalamin 1000 mcg IM/SC ONCE MONTHLY 10. Denosumab (Prolia) 60 mg SC EVERY 6MONTHS 11. Furosemide 20 mg PO DAILY 12. Levothyroxine Sodium 200 mcg PO DAILY 13. Nadolol 20 mg PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Primary Diagnoses ================= Left distal femur periprosthetic fracture Pancytopenia Transcortical motor aphasia Secondary Diagnoses =================== Urinary tract infection Coaguloapthy Severe Aortic Stenosis Right shoulder pain NASH Cirrhosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. - [MASKED] LLE in unlocked [MASKED] Discharge Instructions: Dear Ms. [MASKED], It was a pleasure caring for you at [MASKED] [MASKED]. WHY WAS I IN THE HOSPITAL? - You had a fall at home and unfortunately experienced a fracture to your left leg. WHAT HAPPENED TO ME IN THE HOSPITAL? - You underwent surgery with our orthopedics team [MASKED] to fix your broken leg. - You were transferred to the general medicine service for ongoing care after you were found to have low blood counts as well as issues with your speech. - You were treated with antibiotics for a urinary tract infection. - You were given blood transfusions as well as a transfusion of platelets to help maintain your blood counts. - You were evaluated by the neurologists and had an MRI of your brain, which did not show any new problems (for example a stroke). - Thankfully, your speech improved back to normal and your prior difficulties were attributed to your urinary tract infection as well as the stress cause by your fracture and surgery. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Please follow the instructions left by your orthopedic surgery team below. - Please take your medications and go to your follow up appointments as described in this discharge summary. - If you experience any of the danger signs listed below, please call your primary care doctor or go to the emergency department immediately. We wish you the best! Sincerely, Your [MASKED] Team 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: - TDWB LLE in unlocked [MASKED] MEDICATIONS: 1) Take Tylenol [MASKED] every 6 hours around the clock. This is an over the counter medication. 2) Add OXYCODONE as needed for increased pain. Aim to wean off this medication in 1 week or sooner. This is an example on how to wean down: Take 1 tablet every 3 hours as needed x 1 day, then 1 tablet every 4 hours as needed x 1 day, then 1 tablet every 6 hours as needed x 1 day, then 1 tablet every 8 hours as needed x 2 days, then 1 tablet every 12 hours as needed x 1 day, then 1 tablet every before bedtime as needed x 1 day. Then continue with Tylenol for pain. 3) Do not stop the Tylenol until you are off of the narcotic medication. 4) Per state regulations, we are limited in the amount of narcotics we can prescribe. If you require more, you must contact the office to set up an appointment because we cannot refill this type of pain medication over the phone. 5) Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and continue following the bowel regimen as stated on your medication prescription list. These meds (senna, colace, miralax) are over the counter and may be obtained at any pharmacy. 6) Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. 7) Please take all medications as prescribed by your physicians at discharge. 8) Continue all home medications unless specifically instructed to stop by your surgeon. ANTICOAGULATION: - Resume home coumadin WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - Incision may be left open to air unless actively draining. If draining, you may apply a gauze dressing secured with paper tape. - If you have a splint in place, splint must be left on until follow up appointment unless otherwise instructed. Do NOT get splint wet. DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever > 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB Followup Instructions: [MASKED] | [
"S72402A",
"M9712XA",
"I5032",
"D61818",
"R4701",
"N390",
"K766",
"I8510",
"I350",
"K7581",
"K7469",
"B9620",
"E119",
"M810",
"W1839XA",
"Y92002",
"M25511",
"R791",
"Z7901",
"Z86711",
"Z86718",
"Z8673",
"Z96653",
"Z87891"
] | [
"S72402A: Unspecified fracture of lower end of left femur, initial encounter for closed fracture",
"M9712XA: Periprosthetic fracture around internal prosthetic left knee joint, initial encounter",
"I5032: Chronic diastolic (congestive) heart failure",
"D61818: Other pancytopenia",
"R4701: Aphasia",
"N390: Urinary tract infection, site not specified",
"K766: Portal hypertension",
"I8510: Secondary esophageal varices without bleeding",
"I350: Nonrheumatic aortic (valve) stenosis",
"K7581: Nonalcoholic steatohepatitis (NASH)",
"K7469: Other cirrhosis of liver",
"B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere",
"E119: Type 2 diabetes mellitus without complications",
"M810: Age-related osteoporosis without current pathological fracture",
"W1839XA: Other fall on same level, initial encounter",
"Y92002: Bathroom of unspecified non-institutional (private) residence as the place of occurrence of the external cause",
"M25511: Pain in right shoulder",
"R791: Abnormal coagulation profile",
"Z7901: Long term (current) use of anticoagulants",
"Z86711: Personal history of pulmonary embolism",
"Z86718: Personal history of other venous thrombosis and embolism",
"Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits",
"Z96653: Presence of artificial knee joint, bilateral",
"Z87891: Personal history of nicotine dependence"
] | [
"I5032",
"N390",
"E119",
"Z7901",
"Z86718",
"Z8673",
"Z87891"
] | [] |
14,671,791 | 27,542,802 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \ndoxycycline / Belladonna Alkaloids / Codeine / NSAIDS \n(Non-Steroidal Anti-Inflammatory Drug) / Erythromycin Base / \nrisperidone / Azelastine / Chantix / tramadol / atovaquone / \nprednisone / Augmentin / everolimus / morphine / morphine\n \nAttending: ___\n \nChief Complaint:\nabdominal pain\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ is a ___ female with ESRD secondary to \nlithium toxicity who underwent SCD kidney transplant on ___ \nwho presented with abdominal pain 2 weeks after she was \ndischarged after an admission for pyelonephritis. \n\nSince discharge, usual state of health until ___. Started to \nhave a cough, productive of yellow sputum, breathing was okay, \nand this is improving and no fevers until last night when she \nchecked her temp and it was 99.9 temporally on ___ night, \nwhich prompted her to come into the ED.\n\nShe also started to have right lower pelvic pain that has since \nstarted to move in location into her vaginal area. This has been \ngoing on for 3 days, overall this getting worse. She has a thin \nwhite discharge \"like water\". Overall this is a hot and burning \npain. \n\nShe started having diarrhea on ___, about 4 soft bowel \nmovements. \n\n \nPast Medical History:\n-Renal transplant ___ for lithium nephropathy \n-CVA vs complex migraine ___ \n-bipolar \n-HTN \n-hyperparathyroidism \n-spinal stenosis\n-?cervical cancer \n-Basal cell carcinoma \n-Vitreous detachment \n\nSurgical history:\n-SCD renal transplant ___\n-L forearm loop AVG ___ Raven), angioplasty of outflow vein \nx3 (last ___ by ___ that included thrombectomy)\n-Hysterectomy\n \nSocial History:\n___\nFamily History:\nMother and grandmother - ___ d/o \n \nPhysical Exam:\nADMISSION EXAM:\nVS: 98.0 170/91 79 18 95 Ra \nGen: anxious appearing, well versed in her medical history \nChest: CTAB \nCV: RRR, S1S2, no m/r/g\nAbd: no skin changes, overall soft, minimal discomfort in the \nlower right pelvic area, scant yellow vaginal discharge on her \nunderwear\nExt: warm, no edema \n\nDISCHARGE EXAM:\nTemp: 98.4 (Tm 98.4), BP: 115/71 (99-133/66-82), HR: 78 (66-78),\nRR: 18 (___), O2 sat: 94% (92-94), O2 delivery: RA, Wt: 151.0\nlb/68.49 kg \nLast 24 hours Total cumulative 1530ml\n IN: Total 2830ml, PO Amt 2830ml\n OUT: Total 1300ml, Urine Amt 1300ml \nGen: anxious, not in distress\nCV: RRR, no murmurs\nResp: no cough this AM. CTAB.\nAbd: Soft. Mild TTP in RLQ, no rebound or guarding. NABS.\nWell-healed surgical scar.\nExt: warm, no edema \nSkin: no rashes or lesions.\n \n \nPertinent Results:\nADMISSION LABS:\n___ 07:50PM BLOOD WBC-2.5* RBC-3.33* Hgb-10.0* Hct-31.8* \nMCV-96 MCH-30.0 MCHC-31.4* RDW-14.2 RDWSD-49.6* Plt ___\n___ 07:50PM BLOOD Neuts-55.7 ___ Monos-8.0 Eos-4.0 \nBaso-0.4 AbsNeut-1.40* AbsLymp-0.80* AbsMono-0.20 AbsEos-0.10 \nAbsBaso-0.01\n___ 07:50PM BLOOD Glucose-93 UreaN-15 Creat-0.9 Na-141 \nK-4.2 Cl-104 HCO3-24 AnGap-13\n___ 09:10AM BLOOD ALT-12 AST-18 LD(LDH)-273* AlkPhos-84 \nTotBili-0.5\n___ 07:57PM BLOOD Lactate-1.0\n___ 09:10AM BLOOD tacroFK-9.6\n\nDISCHARGE LABS:\n___ 04:20AM BLOOD WBC-2.6* RBC-3.17* Hgb-9.7* Hct-30.4* \nMCV-96 MCH-30.6 MCHC-31.9* RDW-14.6 RDWSD-51.1* Plt ___\n___ 04:20AM BLOOD Glucose-100 UreaN-13 Creat-0.9 Na-144 \nK-4.0 Cl-108 HCO3-25 AnGap-11\n___ 04:20AM BLOOD Calcium-9.2 Phos-3.9 Mg-1.6\n\nMICRO:\n\n___ 10:10PM URINE Blood-NEG Nitrite-NEG Protein-NEG \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG\n\nURINE CULTURE: ENTEROCOCCUS SP.. 10,000-100,000 CFU/mL. \n\n Respiratory Viral Antigen Screen (Final ___: \n Negative for Respiratory Viral Antigen. \n Specimen screened for: Adeno, Parainfluenza 1, 2, 3, \nInfluenza A, B,\n and RSV by immunofluorescence. \n\nIMAGING & STUDIES:\n___ ABD & PELVIS WITH CONTRAST\n1. No acute intra-abdominal process to explain the patient's \nsymptoms.\n2. Unremarkable right iliac fossa transplant kidney.\n3. Diffuse osseous sclerosis is likely related to renal \nosteodystrophy,\nunchanged.\n\n___ TRANSPLANT U.S.\nUnremarkable renal transplant ultrasound. No evidence of renal \nartery or\nvenous occlusion.\n \n___ (PA & LAT)\nThere is no focal consolidation, effusion, or pneumothorax. The\ncardiomediastinal silhouette is normal. Imaged osseous \nstructures are intact. \nNo free air below the right hemidiaphragm is seen.\n \n\n \nBrief Hospital Course:\n====================\nPATIENT SUMMARY:\n====================\n___ with h/o renal transplant in ___, recent admission for\npyelonephritis, presenting with RLQ/pelvic pain of unclear \netiology. Hemodynamically stable.\n\n====================\nACUTE ISSUES:\n====================\n# Pancytopenia:\n# Leukopenia:\nHas not resolved despite stopping MMF. Atrius records indicate\noutpatient oncologist is considering bone marrow biopsy. flu \nnegative.\nImproving WC to 2.6 on day of discharge. f/u respiratory viral \npanel was negative, EBV, CMV pending at time of discharge. \noutpatient Hematology f/u as scheduled, per patient bone marrow \nbiopsy scheduled for next ___\n\n# Abdominal/pelvic pain, resolved on ___\nUnclear etiology but very low suspicion for serious pathology\ngiven reassuring exam, labs, and imaging. Recurrent pyelo or\nstone highly unlikely given negative UA. enterococcus in urine \nlikely asymptomatic bacteruria as UA was negative and patient \nafebrile. No e/o appendicitis or adnexal masses on CT. No \noverlying skin changes to suggest\nzoster. \n\n# Dry cough, resolved on ___\nConsistent with viral URI/post-viral syndrome. Exam and CXR\nunremarkable. Treated with tessalon, guaifenesin, \ndextromethorphan. Can continue tessalon as outpatient. \n\n# DDRT ___: \nStable graft function on tacro monotherapy (MMF discontinued to\ncytopenias, and steroids due to tremors/agitation).\n- Continued tacrolimus 4 mg PO BID\n- Continued dapsone 100 mg daily for PJP ppx\n- Continued sodium bicarbonate\n\n====================\nCHRONIC ISSUES:\n====================\n\n# Anxiety/Bipolar disorder: \n- Continued home clonazepam, lamotrigine, quetiapine \n\n# History of CVA vs. complex migraine ___: \n- Continued home pravastatin and clopidogrel \n\n# Hypothyroidism: \n- Continued on home levothyroxine \n\n# Osteopenia: \n- Continued home cholecalciferol, sodium bicarbonate \n\n# Osteoarthritis: \n- Continued home oxycontin and oxycodone \n\n# Constipation: \n- Continued home docusate and lactulose \n\n====================\nTRANSITIONAL ISSUES:\n====================\n[] follow up pending EBV, CMV\n[] continue workup of leukopenia with bone marrow biopsy \nscheduled for next week\n- New Meds: tessalon pearls for cough \n- Discharge weight: 150.99 lb\n- Discharge creatinine: 0.9\n- Discharge WBC: 2.6\n\n#CODE: confirmed DNR/DNI\nName of health care proxy: ___ \nRelationship: husband \nPhone number: ___ \nCell phone: ___ \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. ClonazePAM 0.5 mg PO QHS \n2. ClonazePAM 0.25 mg PO QAM \n3. Clopidogrel 75 mg PO DAILY \n4. Dapsone 100 mg PO DAILY \n5. Docusate Sodium 100 mg PO BID \n6. Fexofenadine 180 mg PO DAILY \n7. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n8. FoLIC Acid 1 mg PO DAILY \n9. Lactulose 15 mL PO BID \n10. LamoTRIgine 125 mg PO BID \n11. Levothyroxine Sodium 88 mcg PO DAILY \n12. OxyCODONE SR (OxyconTIN) 20 mg PO QHS \n13. OxyCODONE--Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN Pain \n- Severe \n14. Pravastatin 80 mg PO QPM \n15. QUEtiapine Fumarate 300 mg PO QHS \n16. Sodium Bicarbonate 650 mg PO QAM \n17. Sodium Bicarbonate 1300 mg PO QPM \n18. Tacrolimus 3 mg PO Q12H \n19. Thiamine 100 mg PO DAILY \n20. Vitamin D ___ UNIT PO DAILY \n21. carboxymethylcellulose-glycern 0.5-0.9 % ophthalmic (eye) \nPRN \n22. Fish Oil (Omega 3) 1000 mg PO DAILY \n\n \nDischarge Medications:\n1. Benzonatate 100 mg PO TID \nRX *benzonatate 100 mg 1 capsule(s) by mouth three times a day \nDisp #*21 Capsule Refills:*0 \n2. Lactulose 15 mL PO BID:PRN constipation \nDon't take this if you have diarrhea, bloating, or stomach pain \n\n3. carboxymethylcellulose-glycern 0.5-0.9 % ophthalmic (eye) \nPRN \n4. ClonazePAM 0.5 mg PO QHS \n5. ClonazePAM 0.25 mg PO QAM \n6. Clopidogrel 75 mg PO DAILY \n7. Dapsone 100 mg PO DAILY \n8. Docusate Sodium 100 mg PO BID \n9. Fexofenadine 180 mg PO DAILY \n10. Fish Oil (Omega 3) 1000 mg PO DAILY \n11. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n12. FoLIC Acid 1 mg PO DAILY \n13. LamoTRIgine 125 mg PO BID \n14. Levothyroxine Sodium 88 mcg PO DAILY \n15. OxyCODONE SR (OxyconTIN) 20 mg PO QHS \n16. OxyCODONE--Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN \nPain - Severe \n17. Pravastatin 80 mg PO QPM \n18. QUEtiapine Fumarate 300 mg PO QHS \n19. Sodium Bicarbonate 1300 mg PO QPM \n20. Sodium Bicarbonate 650 mg PO QAM \n21. Tacrolimus 3 mg PO Q12H \n22. Thiamine 100 mg PO DAILY \n23. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY:\n#Abdominal pain of unclear etiology\n#Kidney transplant on chronic immunosuppresion\n#Post-viral cough\n#Chronic pancytopenia\n\nSECONDARY:\n# Anxiety/Bipolar disorder\n# History of CVA vs. complex migraine ___\n# Hypothyroidism\n# Osteopenia\n# Osteoarthritis\n# Constipation \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nIt was a pleasure taking care of you at ___ Deaconess.\n\nWHY YOU WERE ADMITTED:\n- You had stomach pain and cough\n\nWHAT HAPPENED WHILE YOU WERE HERE:\n- We did tests to try to figure out the cause of your pain which \nshowed no infection which is reassuring\n- You received medicine for your cough.\n- We monitored you closely.\n- Your cough and pain resolved prior to discharge.\n\nWHAT TO DO WHEN YOU LEAVE THE HOSPITAL:\n- Follow up with your doctors. ___ below for details.\n\nWe wish you all the best.\n\nSincerely,\nYour ___ Care Team\n \nFollowup Instructions:\n___\n"
] | Allergies: doxycycline / Belladonna Alkaloids / Codeine / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / Erythromycin Base / risperidone / Azelastine / Chantix / tramadol / atovaquone / prednisone / Augmentin / everolimus / morphine / morphine Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] is a [MASKED] female with ESRD secondary to lithium toxicity who underwent SCD kidney transplant on [MASKED] who presented with abdominal pain 2 weeks after she was discharged after an admission for pyelonephritis. Since discharge, usual state of health until [MASKED]. Started to have a cough, productive of yellow sputum, breathing was okay, and this is improving and no fevers until last night when she checked her temp and it was 99.9 temporally on [MASKED] night, which prompted her to come into the ED. She also started to have right lower pelvic pain that has since started to move in location into her vaginal area. This has been going on for 3 days, overall this getting worse. She has a thin white discharge "like water". Overall this is a hot and burning pain. She started having diarrhea on [MASKED], about 4 soft bowel movements. Past Medical History: -Renal transplant [MASKED] for lithium nephropathy -CVA vs complex migraine [MASKED] -bipolar -HTN -hyperparathyroidism -spinal stenosis -?cervical cancer -Basal cell carcinoma -Vitreous detachment Surgical history: -SCD renal transplant [MASKED] -L forearm loop AVG [MASKED] Raven), angioplasty of outflow vein x3 (last [MASKED] by [MASKED] that included thrombectomy) -Hysterectomy Social History: [MASKED] Family History: Mother and grandmother - [MASKED] d/o Physical Exam: ADMISSION EXAM: VS: 98.0 170/91 79 18 95 Ra Gen: anxious appearing, well versed in her medical history Chest: CTAB CV: RRR, S1S2, no m/r/g Abd: no skin changes, overall soft, minimal discomfort in the lower right pelvic area, scant yellow vaginal discharge on her underwear Ext: warm, no edema DISCHARGE EXAM: Temp: 98.4 (Tm 98.4), BP: 115/71 (99-133/66-82), HR: 78 (66-78), RR: 18 ([MASKED]), O2 sat: 94% (92-94), O2 delivery: RA, Wt: 151.0 lb/68.49 kg Last 24 hours Total cumulative 1530ml IN: Total 2830ml, PO Amt 2830ml OUT: Total 1300ml, Urine Amt 1300ml Gen: anxious, not in distress CV: RRR, no murmurs Resp: no cough this AM. CTAB. Abd: Soft. Mild TTP in RLQ, no rebound or guarding. NABS. Well-healed surgical scar. Ext: warm, no edema Skin: no rashes or lesions. Pertinent Results: ADMISSION LABS: [MASKED] 07:50PM BLOOD WBC-2.5* RBC-3.33* Hgb-10.0* Hct-31.8* MCV-96 MCH-30.0 MCHC-31.4* RDW-14.2 RDWSD-49.6* Plt [MASKED] [MASKED] 07:50PM BLOOD Neuts-55.7 [MASKED] Monos-8.0 Eos-4.0 Baso-0.4 AbsNeut-1.40* AbsLymp-0.80* AbsMono-0.20 AbsEos-0.10 AbsBaso-0.01 [MASKED] 07:50PM BLOOD Glucose-93 UreaN-15 Creat-0.9 Na-141 K-4.2 Cl-104 HCO3-24 AnGap-13 [MASKED] 09:10AM BLOOD ALT-12 AST-18 LD(LDH)-273* AlkPhos-84 TotBili-0.5 [MASKED] 07:57PM BLOOD Lactate-1.0 [MASKED] 09:10AM BLOOD tacroFK-9.6 DISCHARGE LABS: [MASKED] 04:20AM BLOOD WBC-2.6* RBC-3.17* Hgb-9.7* Hct-30.4* MCV-96 MCH-30.6 MCHC-31.9* RDW-14.6 RDWSD-51.1* Plt [MASKED] [MASKED] 04:20AM BLOOD Glucose-100 UreaN-13 Creat-0.9 Na-144 K-4.0 Cl-108 HCO3-25 AnGap-11 [MASKED] 04:20AM BLOOD Calcium-9.2 Phos-3.9 Mg-1.6 MICRO: [MASKED] 10:10PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG URINE CULTURE: ENTEROCOCCUS SP.. 10,000-100,000 CFU/mL. Respiratory Viral Antigen Screen (Final [MASKED]: Negative for Respiratory Viral Antigen. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. IMAGING & STUDIES: [MASKED] ABD & PELVIS WITH CONTRAST 1. No acute intra-abdominal process to explain the patient's symptoms. 2. Unremarkable right iliac fossa transplant kidney. 3. Diffuse osseous sclerosis is likely related to renal osteodystrophy, unchanged. [MASKED] TRANSPLANT U.S. Unremarkable renal transplant ultrasound. No evidence of renal artery or venous occlusion. [MASKED] (PA & LAT) There is no focal consolidation, effusion, or pneumothorax. The cardiomediastinal silhouette is normal. Imaged osseous structures are intact. No free air below the right hemidiaphragm is seen. Brief Hospital Course: ==================== PATIENT SUMMARY: ==================== [MASKED] with h/o renal transplant in [MASKED], recent admission for pyelonephritis, presenting with RLQ/pelvic pain of unclear etiology. Hemodynamically stable. ==================== ACUTE ISSUES: ==================== # Pancytopenia: # Leukopenia: Has not resolved despite stopping MMF. Atrius records indicate outpatient oncologist is considering bone marrow biopsy. flu negative. Improving WC to 2.6 on day of discharge. f/u respiratory viral panel was negative, EBV, CMV pending at time of discharge. outpatient Hematology f/u as scheduled, per patient bone marrow biopsy scheduled for next [MASKED] # Abdominal/pelvic pain, resolved on [MASKED] Unclear etiology but very low suspicion for serious pathology given reassuring exam, labs, and imaging. Recurrent pyelo or stone highly unlikely given negative UA. enterococcus in urine likely asymptomatic bacteruria as UA was negative and patient afebrile. No e/o appendicitis or adnexal masses on CT. No overlying skin changes to suggest zoster. # Dry cough, resolved on [MASKED] Consistent with viral URI/post-viral syndrome. Exam and CXR unremarkable. Treated with tessalon, guaifenesin, dextromethorphan. Can continue tessalon as outpatient. # DDRT [MASKED]: Stable graft function on tacro monotherapy (MMF discontinued to cytopenias, and steroids due to tremors/agitation). - Continued tacrolimus 4 mg PO BID - Continued dapsone 100 mg daily for PJP ppx - Continued sodium bicarbonate ==================== CHRONIC ISSUES: ==================== # Anxiety/Bipolar disorder: - Continued home clonazepam, lamotrigine, quetiapine # History of CVA vs. complex migraine [MASKED]: - Continued home pravastatin and clopidogrel # Hypothyroidism: - Continued on home levothyroxine # Osteopenia: - Continued home cholecalciferol, sodium bicarbonate # Osteoarthritis: - Continued home oxycontin and oxycodone # Constipation: - Continued home docusate and lactulose ==================== TRANSITIONAL ISSUES: ==================== [] follow up pending EBV, CMV [] continue workup of leukopenia with bone marrow biopsy scheduled for next week - New Meds: tessalon pearls for cough - Discharge weight: 150.99 lb - Discharge creatinine: 0.9 - Discharge WBC: 2.6 #CODE: confirmed DNR/DNI Name of health care proxy: [MASKED] Relationship: husband Phone number: [MASKED] Cell phone: [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ClonazePAM 0.5 mg PO QHS 2. ClonazePAM 0.25 mg PO QAM 3. Clopidogrel 75 mg PO DAILY 4. Dapsone 100 mg PO DAILY 5. Docusate Sodium 100 mg PO BID 6. Fexofenadine 180 mg PO DAILY 7. Fluticasone Propionate NASAL 2 SPRY NU DAILY 8. FoLIC Acid 1 mg PO DAILY 9. Lactulose 15 mL PO BID 10. LamoTRIgine 125 mg PO BID 11. Levothyroxine Sodium 88 mcg PO DAILY 12. OxyCODONE SR (OxyconTIN) 20 mg PO QHS 13. OxyCODONE--Acetaminophen (5mg-325mg) [MASKED] TAB PO Q6H:PRN Pain - Severe 14. Pravastatin 80 mg PO QPM 15. QUEtiapine Fumarate 300 mg PO QHS 16. Sodium Bicarbonate 650 mg PO QAM 17. Sodium Bicarbonate 1300 mg PO QPM 18. Tacrolimus 3 mg PO Q12H 19. Thiamine 100 mg PO DAILY 20. Vitamin D [MASKED] UNIT PO DAILY 21. carboxymethylcellulose-glycern 0.5-0.9 % ophthalmic (eye) PRN 22. Fish Oil (Omega 3) 1000 mg PO DAILY Discharge Medications: 1. Benzonatate 100 mg PO TID RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day Disp #*21 Capsule Refills:*0 2. Lactulose 15 mL PO BID:PRN constipation Don't take this if you have diarrhea, bloating, or stomach pain 3. carboxymethylcellulose-glycern 0.5-0.9 % ophthalmic (eye) PRN 4. ClonazePAM 0.5 mg PO QHS 5. ClonazePAM 0.25 mg PO QAM 6. Clopidogrel 75 mg PO DAILY 7. Dapsone 100 mg PO DAILY 8. Docusate Sodium 100 mg PO BID 9. Fexofenadine 180 mg PO DAILY 10. Fish Oil (Omega 3) 1000 mg PO DAILY 11. Fluticasone Propionate NASAL 2 SPRY NU DAILY 12. FoLIC Acid 1 mg PO DAILY 13. LamoTRIgine 125 mg PO BID 14. Levothyroxine Sodium 88 mcg PO DAILY 15. OxyCODONE SR (OxyconTIN) 20 mg PO QHS 16. OxyCODONE--Acetaminophen (5mg-325mg) [MASKED] TAB PO Q6H:PRN Pain - Severe 17. Pravastatin 80 mg PO QPM 18. QUEtiapine Fumarate 300 mg PO QHS 19. Sodium Bicarbonate 1300 mg PO QPM 20. Sodium Bicarbonate 650 mg PO QAM 21. Tacrolimus 3 mg PO Q12H 22. Thiamine 100 mg PO DAILY 23. Vitamin D [MASKED] UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY: #Abdominal pain of unclear etiology #Kidney transplant on chronic immunosuppresion #Post-viral cough #Chronic pancytopenia SECONDARY: # Anxiety/Bipolar disorder # History of CVA vs. complex migraine [MASKED] # Hypothyroidism # Osteopenia # Osteoarthritis # Constipation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], It was a pleasure taking care of you at [MASKED] Deaconess. WHY YOU WERE ADMITTED: - You had stomach pain and cough WHAT HAPPENED WHILE YOU WERE HERE: - We did tests to try to figure out the cause of your pain which showed no infection which is reassuring - You received medicine for your cough. - We monitored you closely. - Your cough and pain resolved prior to discharge. WHAT TO DO WHEN YOU LEAVE THE HOSPITAL: - Follow up with your doctors. [MASKED] below for details. We wish you all the best. Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED] | [
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"R1032: Left lower quadrant pain",
"D61818: Other pancytopenia",
"Z940: Kidney transplant status",
"B349: Viral infection, unspecified",
"R102: Pelvic and perineal pain",
"R1110: Vomiting, unspecified",
"T40605A: Adverse effect of unspecified narcotics, initial encounter",
"Y92238: Other place in hospital as the place of occurrence of the external cause",
"F319: Bipolar disorder, unspecified",
"F419: Anxiety disorder, unspecified",
"Z66: Do not resuscitate",
"F1011: Alcohol abuse, in remission",
"E039: Hypothyroidism, unspecified",
"M8580: Other specified disorders of bone density and structure, unspecified site",
"M1990: Unspecified osteoarthritis, unspecified site",
"K5900: Constipation, unspecified",
"J310: Chronic rhinitis",
"R5381: Other malaise",
"J069: Acute upper respiratory infection, unspecified",
"N898: Other specified noninflammatory disorders of vagina",
"Z7902: Long term (current) use of antithrombotics/antiplatelets",
"Z87891: Personal history of nicotine dependence",
"Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits",
"Z85828: Personal history of other malignant neoplasm of skin",
"Z8541: Personal history of malignant neoplasm of cervix uteri"
] | [
"F419",
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"K5900",
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"Z8673"
] | [] |
11,150,501 | 27,213,989 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nPenicillins / lisinopril\n \nAttending: ___\n \n___ Complaint:\nhyperkalemia \n \nMajor Surgical or Invasive Procedure:\nnone \n\n \nHistory of Present Illness:\n___ gentleman past medical history of CAD s/p LAD PCI \nin ___, ischemic HFrEF (LVEF 20%), recent VF arrest s/p ICD\n___, pulmonary HTN, ESRD (due to left nephrectomy for renal\ncell carcinoma, right partial nephrectomy for renal cyst) s/p\nDDRT ___ presenting for hyperkalemia on outpatient labs. \n\nPatient has been in usual state of health and had been to ___ \nfor\nroutine lab work where he was found to have K 6.5 and Cr 3.1 \nfrom\nrecent baseline of 2.8 on ___. He was also found to have Ca \n___\nint he setting of daily use of calcium carbonate per patient.\nOverall he denies missing any of his home medications. Normal Po\nintake without recent illnesses, diarrhea, fever/chills,\nabdominal pain, cough or dysuria. \n\n- In the ED, initial vitals were:\nT 97.5 HR 52 BP 152/61 RR 18 Sat 100% RA \n\n- Labs were notable for:\n133/109/75\n-----------<96\n6.5/14/3.4 \n\nCa ___ (11.7)\npH 7.25, PCO2 35 \nUA negative \n\n- Studies were notable for:\nRenal u/s:\n1. No hydronephrosis.\n2. Mildly elevated resistive indices, similar to the prior \nstudy.\n\nEKG:\nSinus bradycardia, 1st degree AV delay, LVH with repolirzation\nabnormalities in V4-V6, TW flattening I, AVL, V1, no peaked T\nwaves, simialr EKG compared to ___\n\n- The patient was given:\n500cc LR \n\nOn arrival to the floor, patient states that he is feeling well\noverall without any complaints. 10 point ROS negative. \n\n \nPast Medical History:\n- L renal cell CA s/p nephrectomy\n- R kidney benign cyst, s/p partial nephrectomy\n- ESRD s/p DDKT in ___\n- Gout\n- HTN\n- HLD\n- Cardiomyopathy\n- CAD\n- Pulmonary HTN\nPSH:\n- L total nephrectomy ___\n- R partial nephrectomy ___: Transplant kidney biopsy\nDeceased donor renal transplant ___\ndouble J ureteral stent placement with ___ drain by Dr. \n___ on ___\n- ___: multiple PEA/VF arrests as outpatient, hospitalized,\nreceived ICD placement at here ___\n \nSocial History:\n___\nFamily History:\nMother deceased from MI\nFather deceased from esophageal cancer\nHas one sibling with HYN\n \nPhysical Exam:\nADMISSION EXAM\n====================\n___ 0205 Temp: 98.0 PO BP: 168/73 R Sitting HR: 50 RR: 17 \nO2\nsat: 98% O2 delivery: Ra \nGENERAL: Alert and interactive. In no acute distress.\nHEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.\nNECK: No cervical lymphadenopathy. JVD 10 cm\nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No\nmurmurs/rubs/gallops.\nLUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or\nrales. No increased work of breathing.\nABDOMEN: Normal bowels sounds, non distended, non-tender to deep\npalpation in all four quadrants. LLQ renal transplant site\nwtihotu TTP\nEXTREMITIES: RUE fistula with thrill and +bruit\nSKIN: Warm. No ___ edema. No rashes.\nNEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs\nspontaneously. Normal sensation.\n\nDISCHARGE EXAM\n======================\n24 HR Data (last updated ___ @ 2321)\n Temp: 98.1 (Tm 98.2), BP: 153/71 (118-154/48-71), HR: 54\n(50-54), RR: 18, O2 sat: 95% (93-96), O2 delivery: Ra, Wt: \n164.02\nlb/74.4 kg \nGENERAL: Alert and interactive. In no acute distress.\nHEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.\nNECK: No cervical lymphadenopathy. JVD 8 cm\nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No\nmurmurs/rubs/gallops.\nLUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or\nrales. No increased work of breathing.\nABDOMEN: Normal bowels sounds, non distended, non-tender to deep\npalpation in all four quadrants. LLQ renal transplant site\nwtihotu TTP\nEXTREMITIES: RUE fistula with thrill and +bruit\nSKIN: Warm. No ___ edema. No rashes.\nNEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs\nspontaneously. Normal sensation. \n \nPertinent Results:\nADMISSION LABS\n====================\n___ 09:06AM BLOOD WBC-3.6* RBC-5.25 Hgb-12.0* Hct-39.9* \nMCV-76* MCH-22.9* MCHC-30.1* RDW-21.5* RDWSD-56.9* Plt ___\n___ 08:21PM BLOOD Neuts-65.3 Lymphs-16.5* Monos-15.3* \nEos-2.0 Baso-0.6 Im ___ AbsNeut-2.26 AbsLymp-0.57* \nAbsMono-0.53 AbsEos-0.07 AbsBaso-0.02\n___ 09:06AM BLOOD Plt ___\n___ 09:06AM BLOOD UreaN-75* Creat-3.1* Na-139 K-6.5* \nCl-109* HCO3-15* AnGap-15\n___ 09:06AM BLOOD Albumin-4.5 Calcium-11.7* Phos-4.4 Mg-2.0\n___ 09:06AM BLOOD rapmycn-3.9*\n___ 09:06AM BLOOD tacroFK-6.2\n___ 09:00PM BLOOD pO2-46* pCO2-35 pH-7.25* calTCO2-16* Base \nXS--10\n\nMicro\n======\nUrine culture ___:\n MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH \nSKIN\n AND/OR GENITAL CONTAMINATION.\n\nImaging\n========\nRenal Transplant U/S ___. No hydronephrosis.\n2. Mildly elevated resistive indices, similar to the prior \nstudy.\n\nCXR ___\nCompared to chest radiographs in ___, most recently ___.\n \nSevere cardiomegaly is chronic but there is no evidence of acute \ncardiac\ndecompensation. No pleural effusion or pulmonary edema, \nmediastinal or\npulmonary vascular engorgement. Lungs clear.\n \nSubcutaneous defibrillator device unchanged in right lower \nparamedian\nposition.\n\nTTE ___:\nModerately dilated left ventricle with moderately depressed left \nventricular systolic\nfunction Increased left ventricular filling pressure. Moderately \ndilated right ventricle with mild\nright ventricular hypokinesis. Increased left ventricular \nfilling pressure. Moderate pulmonary\nhypertension. Mild aortic regurgitation. Moderate, predominantly \ninferolateral pericardial effusion\nwithout echocardiographic evidence of tamponade.\n\nDischarge Labs\n===============\n\n___ 07:20AM BLOOD WBC-4.6 RBC-5.17 Hgb-11.8* Hct-37.8* \nMCV-73* MCH-22.8* MCHC-31.2* RDW-21.8* RDWSD-54.0* Plt ___\n___ 07:20AM BLOOD Plt ___\n___ 07:20AM BLOOD ___ PTT-33.8 ___\n___ 07:20AM BLOOD Glucose-90 UreaN-63* Creat-2.9* Na-139 \nK-5.1 Cl-111* HCO3-16* AnGap-12\n___ 07:20AM BLOOD Calcium-10.0 Phos-3.0 Mg-1.9\n \nBrief Hospital Course:\nTRANSITIONAL ISSUES\n====================\n[]patient was persistently bradycardic on reduced doses of home \ncoreg; patient requires beta blockers for HF. Coreg dose was \nreduced but should be titirated in the outpatient setting\n[]patients coreg was decreased ___ bradycardia. Subsequently \npatient was hypertensive in the 150's. Would consider \nuptitrating patient's antihypertensives if continued HTN as an \noutpatient\n[]patient likely has chronic rejection of his transplant with \nnewly elevated Cr, would closely trend Cr and monitor Ca, K, Cr \nweekly, starting on ___. \n\nSUMMARY STATEMENT\n==================\n___ gentleman past medical history of CAD s/p LAD PCI \nin ___, ischemic HFrEF (LVEF 20%), recent VF arrest s/p ICD\n___, pulmonary HTN, ESRD (due to left nephrectomy for renal\ncell carcinoma, right partial nephrectomy for renal cyst) s/p\nDDRT ___ presenting for hyperkalemia on outpatient labs found\nto have ___ and acidemia. His electrolytes and acidemia \nnormalized with fluids and bicarbonate. \n\nACUTE/ACTIVE ISSUES:\n====================\n#Hyperkalemia\nAdmitted for hyperkalemia to 6.5 at the outpatient clinic though \nrepeat testing\nin ED with K 5.5 without intervention. EKG at did not \ndemonstrate hyperkalemic changes. Likely in the setting of \nworsening renal function while on spirinolactone.\nHyperkalemia improved with fluids and stopping spironolactone. \n\n#Hypercalemia\nOn home calcitriol and calcium carbonate- D3 which were likely\ncontributing to hypercalcemia. Recieved ~750cc fluid in the ED\nwith improvement in Ca. Given additional doses of fluids with\nimprovement of his Cr and improvement of his hypercalcemia. PTH \nwas noted to be 45 and therefore supplemental ca was \ndiscontinued upon discharge. \n\n___ on CKD\n#ESRD s/p renal transplant ___ \nCr baseline 2.7 in ___ with increase to 3.1 on admission.\nThe patient appeared clinically hypovolemic on exam. Urine \nelectrolytes demonstrated a mixed picture as not sodium avid but \nwith low Fe Urea. Renal transplant ultrasound did not show any \nsigns of acute rejection or postrenal obstruction. The patient's \ntacro and sirolimus were continued at home doses with \nappropriate levels. While the patient's creatinine improved \nsomewhat with fluids and bicarbonate, the primary driver of the \npatient's ___ was thought to be intrarenal secondary to chronic \ntransplant rejection/tacro side effect. A renal biopsy was \ndeferred as the patient's renal function and acid base status \nimproved. The patient's renal function stabilized and Creatinine \nwas 2.9 at the time of discharge. \n\n#Metabolic acidosis \nThe patient initially presented inappropriately elevated PCO2 \nwith acidemia and low\nbicarb representing a primary metabolic acidosis. Primary driver \nof metabolic acidosis likely worsening\nrenal function and bicarbonate loss given bicarbonate nadir of \n12. Unclear trigger for respiratory acidosis though\nlikely some OSA as rising CO2 with sleep which resolved during \nthe day. The patient's bicarbonate and acidemia improved with IV \nand po bicarbonate. The patient was discharged on 1300mg po \nbicarbonate. \n\n#HFrEF (20%)\nDry weight on discharge in ___ of 188lb with admission \nweight\nof 165lb. The patient appeared hypovolemic on exam and given his \n___ and acidemia was given IVF in addition to holding his home \nLasix and spirinolactone. He was noted to be bradycardic to the \nhigh 40's while sleeping which prompted decreasing his home \ncoreg to 12.5 BID. The patient underwent repeat TTE which showed \nEF of 35%. The patient did not have any signs of decompensation. \nHe was subsequently restarted on his home Lasix without change \nin Cr. The patient was continued on his home ASA, atorvastatin. \n\nCHRONIC/STABLE ISSUES:\n======================\n#ESRD s/p DDRT ___\nHistory of end-stage renal disease secondary to left nephrectomy\nfor renal cell carcinoma along with right partial nephrectomy \nfor\nrenal cyst who is status post deceased-donor kidney\ntransplantation from ___ complicated by BK nephropathy and\nsubsequent ___ DSA development and borderline acute cellular\nrejection.\n- Continue sirolimus 1mg daily\n- Continue tacro 1mg Qam and 2mg QPM\n- Tacro level daily \n\n#VT arrest s/p ICD\nICD last interrogated this month without VT.\n- Continue amiodarone 200mg daily \n\n#Pulmonary HTN\nSurgical reduction of flow in AV fistulat given pulm HTN. \n- Continue furosemide \n\n#Gout\n- Continue allopurinol\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Allopurinol ___ mg PO DAILY \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 80 mg PO QPM \n4. Calcitriol 0.5 mcg PO DAILY \n5. Carvedilol 25 mg PO BID \n6. NIFEdipine (Extended Release) 30 mg PO DAILY \n7. Sirolimus 0.5 mg PO DAILY \n8. Tacrolimus 1 mg PO QAM \n9. Amiodarone 200 mg PO DAILY \n10. calcium carbonate-vitamin D3 500 mg(1,250mg) -200 unit oral \nDAILY \n11. Tacrolimus 2 mg PO QPM \n12. Furosemide 40 mg PO DAILY \n13. Spironolactone 25 mg PO BID \n\n \nDischarge Medications:\n1. Sodium Bicarbonate 1300 mg PO BID \nRX *sodium bicarbonate 650 mg 2 tablet(s) by mouth twice a day \nDisp #*60 Tablet Refills:*0 \n2. CARVedilol 12.5 mg PO BID \nRX *carvedilol 12.5 mg 1 tablet(s) by mouth twice a day Disp \n#*60 Tablet Refills:*0 \n3. Allopurinol ___ mg PO DAILY \n4. Amiodarone 200 mg PO DAILY \n5. Aspirin 81 mg PO DAILY \n6. Atorvastatin 80 mg PO QPM \n7. Furosemide 40 mg PO DAILY \n8. NIFEdipine (Extended Release) 30 mg PO DAILY \n9. Sirolimus 0.5 mg PO DAILY \n10. Tacrolimus 1 mg PO QAM \n11. Tacrolimus 2 mg PO QPM \n12. HELD- Calcitriol 0.5 mcg PO DAILY This medication was held. \nDo not restart Calcitriol until you discuss with your doctor\n13. HELD- calcium carbonate-vitamin D3 500 mg(1,250mg) -200 unit \noral DAILY This medication was held. Do not restart calcium \ncarbonate-vitamin D3 until you discuss with your doctor\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary Diagnosis\n=================\nAcute kidney injury\nHypocalcemia\nHyperkalemia\nMetabolic acidosis \n\nSecondary diagnosis\n==================== \nHFrEF\nrenal transplant \nGout \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr ___, \n\nIt was a privilege caring for you at ___. \n\nWHY WAS I IN THE HOSPITAL? \n-You were admitted to the hospital because your kidney numbers \nare getting worse. \n\nWHAT HAPPENED TO ME IN THE HOSPITAL? \n- You were seen by the kidney doctors ___ and \nmonitor your kidney function. You are continued on all of your \nmedications for your transplant. You were given medications to \nhelp balance the electrolytes in your blood. Your kidney \nfunction stabilized and you were felt be monitored outside the \nhospital. \n- You improved considerably and were felt well enough to leave \nthe hospital \n\nWHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? \n- Continue to take all your medicines and keep your \nappointments. \n- We recommend seeing your primary care physician to discuss \nyour medications within the next 2 weeks. \n-Please have your standing labs drawn on ___ and sent \nto Dr. ___. \n\nWe wish you the best! \n\nSincerely, \nYour ___ Team \n\n \nFollowup Instructions:\n___\n"
] | Allergies: Penicillins / lisinopril [MASKED] Complaint: hyperkalemia Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] gentleman past medical history of CAD s/p LAD PCI in [MASKED], ischemic HFrEF (LVEF 20%), recent VF arrest s/p ICD [MASKED], pulmonary HTN, ESRD (due to left nephrectomy for renal cell carcinoma, right partial nephrectomy for renal cyst) s/p DDRT [MASKED] presenting for hyperkalemia on outpatient labs. Patient has been in usual state of health and had been to [MASKED] for routine lab work where he was found to have K 6.5 and Cr 3.1 from recent baseline of 2.8 on [MASKED]. He was also found to have Ca [MASKED] int he setting of daily use of calcium carbonate per patient. Overall he denies missing any of his home medications. Normal Po intake without recent illnesses, diarrhea, fever/chills, abdominal pain, cough or dysuria. - In the ED, initial vitals were: T 97.5 HR 52 BP 152/61 RR 18 Sat 100% RA - Labs were notable for: 133/109/75 -----------<96 6.5/14/3.4 Ca [MASKED] (11.7) pH 7.25, PCO2 35 UA negative - Studies were notable for: Renal u/s: 1. No hydronephrosis. 2. Mildly elevated resistive indices, similar to the prior study. EKG: Sinus bradycardia, 1st degree AV delay, LVH with repolirzation abnormalities in V4-V6, TW flattening I, AVL, V1, no peaked T waves, simialr EKG compared to [MASKED] - The patient was given: 500cc LR On arrival to the floor, patient states that he is feeling well overall without any complaints. 10 point ROS negative. Past Medical History: - L renal cell CA s/p nephrectomy - R kidney benign cyst, s/p partial nephrectomy - ESRD s/p DDKT in [MASKED] - Gout - HTN - HLD - Cardiomyopathy - CAD - Pulmonary HTN PSH: - L total nephrectomy [MASKED] - R partial nephrectomy [MASKED]: Transplant kidney biopsy Deceased donor renal transplant [MASKED] double J ureteral stent placement with [MASKED] drain by Dr. [MASKED] on [MASKED] - [MASKED]: multiple PEA/VF arrests as outpatient, hospitalized, received ICD placement at here [MASKED] Social History: [MASKED] Family History: Mother deceased from MI Father deceased from esophageal cancer Has one sibling with HYN Physical Exam: ADMISSION EXAM ==================== [MASKED] 0205 Temp: 98.0 PO BP: 168/73 R Sitting HR: 50 RR: 17 O2 sat: 98% O2 delivery: Ra GENERAL: Alert and interactive. In no acute distress. HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM. NECK: No cervical lymphadenopathy. JVD 10 cm CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. LLQ renal transplant site wtihotu TTP EXTREMITIES: RUE fistula with thrill and +bruit SKIN: Warm. No [MASKED] edema. No rashes. NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs spontaneously. Normal sensation. DISCHARGE EXAM ====================== 24 HR Data (last updated [MASKED] @ 2321) Temp: 98.1 (Tm 98.2), BP: 153/71 (118-154/48-71), HR: 54 (50-54), RR: 18, O2 sat: 95% (93-96), O2 delivery: Ra, Wt: 164.02 lb/74.4 kg GENERAL: Alert and interactive. In no acute distress. HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM. NECK: No cervical lymphadenopathy. JVD 8 cm CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. LLQ renal transplant site wtihotu TTP EXTREMITIES: RUE fistula with thrill and +bruit SKIN: Warm. No [MASKED] edema. No rashes. NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs spontaneously. Normal sensation. Pertinent Results: ADMISSION LABS ==================== [MASKED] 09:06AM BLOOD WBC-3.6* RBC-5.25 Hgb-12.0* Hct-39.9* MCV-76* MCH-22.9* MCHC-30.1* RDW-21.5* RDWSD-56.9* Plt [MASKED] [MASKED] 08:21PM BLOOD Neuts-65.3 Lymphs-16.5* Monos-15.3* Eos-2.0 Baso-0.6 Im [MASKED] AbsNeut-2.26 AbsLymp-0.57* AbsMono-0.53 AbsEos-0.07 AbsBaso-0.02 [MASKED] 09:06AM BLOOD Plt [MASKED] [MASKED] 09:06AM BLOOD UreaN-75* Creat-3.1* Na-139 K-6.5* Cl-109* HCO3-15* AnGap-15 [MASKED] 09:06AM BLOOD Albumin-4.5 Calcium-11.7* Phos-4.4 Mg-2.0 [MASKED] 09:06AM BLOOD rapmycn-3.9* [MASKED] 09:06AM BLOOD tacroFK-6.2 [MASKED] 09:00PM BLOOD pO2-46* pCO2-35 pH-7.25* calTCO2-16* Base XS--10 Micro ====== Urine culture [MASKED]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. Imaging ======== Renal Transplant U/S [MASKED]. No hydronephrosis. 2. Mildly elevated resistive indices, similar to the prior study. CXR [MASKED] Compared to chest radiographs in [MASKED], most recently [MASKED]. Severe cardiomegaly is chronic but there is no evidence of acute cardiac decompensation. No pleural effusion or pulmonary edema, mediastinal or pulmonary vascular engorgement. Lungs clear. Subcutaneous defibrillator device unchanged in right lower paramedian position. TTE [MASKED]: Moderately dilated left ventricle with moderately depressed left ventricular systolic function Increased left ventricular filling pressure. Moderately dilated right ventricle with mild right ventricular hypokinesis. Increased left ventricular filling pressure. Moderate pulmonary hypertension. Mild aortic regurgitation. Moderate, predominantly inferolateral pericardial effusion without echocardiographic evidence of tamponade. Discharge Labs =============== [MASKED] 07:20AM BLOOD WBC-4.6 RBC-5.17 Hgb-11.8* Hct-37.8* MCV-73* MCH-22.8* MCHC-31.2* RDW-21.8* RDWSD-54.0* Plt [MASKED] [MASKED] 07:20AM BLOOD Plt [MASKED] [MASKED] 07:20AM BLOOD [MASKED] PTT-33.8 [MASKED] [MASKED] 07:20AM BLOOD Glucose-90 UreaN-63* Creat-2.9* Na-139 K-5.1 Cl-111* HCO3-16* AnGap-12 [MASKED] 07:20AM BLOOD Calcium-10.0 Phos-3.0 Mg-1.9 Brief Hospital Course: TRANSITIONAL ISSUES ==================== []patient was persistently bradycardic on reduced doses of home coreg; patient requires beta blockers for HF. Coreg dose was reduced but should be titirated in the outpatient setting []patients coreg was decreased [MASKED] bradycardia. Subsequently patient was hypertensive in the 150's. Would consider uptitrating patient's antihypertensives if continued HTN as an outpatient []patient likely has chronic rejection of his transplant with newly elevated Cr, would closely trend Cr and monitor Ca, K, Cr weekly, starting on [MASKED]. SUMMARY STATEMENT ================== [MASKED] gentleman past medical history of CAD s/p LAD PCI in [MASKED], ischemic HFrEF (LVEF 20%), recent VF arrest s/p ICD [MASKED], pulmonary HTN, ESRD (due to left nephrectomy for renal cell carcinoma, right partial nephrectomy for renal cyst) s/p DDRT [MASKED] presenting for hyperkalemia on outpatient labs found to have [MASKED] and acidemia. His electrolytes and acidemia normalized with fluids and bicarbonate. ACUTE/ACTIVE ISSUES: ==================== #Hyperkalemia Admitted for hyperkalemia to 6.5 at the outpatient clinic though repeat testing in ED with K 5.5 without intervention. EKG at did not demonstrate hyperkalemic changes. Likely in the setting of worsening renal function while on spirinolactone. Hyperkalemia improved with fluids and stopping spironolactone. #Hypercalemia On home calcitriol and calcium carbonate- D3 which were likely contributing to hypercalcemia. Recieved ~750cc fluid in the ED with improvement in Ca. Given additional doses of fluids with improvement of his Cr and improvement of his hypercalcemia. PTH was noted to be 45 and therefore supplemental ca was discontinued upon discharge. [MASKED] on CKD #ESRD s/p renal transplant [MASKED] Cr baseline 2.7 in [MASKED] with increase to 3.1 on admission. The patient appeared clinically hypovolemic on exam. Urine electrolytes demonstrated a mixed picture as not sodium avid but with low Fe Urea. Renal transplant ultrasound did not show any signs of acute rejection or postrenal obstruction. The patient's tacro and sirolimus were continued at home doses with appropriate levels. While the patient's creatinine improved somewhat with fluids and bicarbonate, the primary driver of the patient's [MASKED] was thought to be intrarenal secondary to chronic transplant rejection/tacro side effect. A renal biopsy was deferred as the patient's renal function and acid base status improved. The patient's renal function stabilized and Creatinine was 2.9 at the time of discharge. #Metabolic acidosis The patient initially presented inappropriately elevated PCO2 with acidemia and low bicarb representing a primary metabolic acidosis. Primary driver of metabolic acidosis likely worsening renal function and bicarbonate loss given bicarbonate nadir of 12. Unclear trigger for respiratory acidosis though likely some OSA as rising CO2 with sleep which resolved during the day. The patient's bicarbonate and acidemia improved with IV and po bicarbonate. The patient was discharged on 1300mg po bicarbonate. #HFrEF (20%) Dry weight on discharge in [MASKED] of 188lb with admission weight of 165lb. The patient appeared hypovolemic on exam and given his [MASKED] and acidemia was given IVF in addition to holding his home Lasix and spirinolactone. He was noted to be bradycardic to the high 40's while sleeping which prompted decreasing his home coreg to 12.5 BID. The patient underwent repeat TTE which showed EF of 35%. The patient did not have any signs of decompensation. He was subsequently restarted on his home Lasix without change in Cr. The patient was continued on his home ASA, atorvastatin. CHRONIC/STABLE ISSUES: ====================== #ESRD s/p DDRT [MASKED] History of end-stage renal disease secondary to left nephrectomy for renal cell carcinoma along with right partial nephrectomy for renal cyst who is status post deceased-donor kidney transplantation from [MASKED] complicated by BK nephropathy and subsequent [MASKED] DSA development and borderline acute cellular rejection. - Continue sirolimus 1mg daily - Continue tacro 1mg Qam and 2mg QPM - Tacro level daily #VT arrest s/p ICD ICD last interrogated this month without VT. - Continue amiodarone 200mg daily #Pulmonary HTN Surgical reduction of flow in AV fistulat given pulm HTN. - Continue furosemide #Gout - Continue allopurinol Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol [MASKED] mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. Calcitriol 0.5 mcg PO DAILY 5. Carvedilol 25 mg PO BID 6. NIFEdipine (Extended Release) 30 mg PO DAILY 7. Sirolimus 0.5 mg PO DAILY 8. Tacrolimus 1 mg PO QAM 9. Amiodarone 200 mg PO DAILY 10. calcium carbonate-vitamin D3 500 mg(1,250mg) -200 unit oral DAILY 11. Tacrolimus 2 mg PO QPM 12. Furosemide 40 mg PO DAILY 13. Spironolactone 25 mg PO BID Discharge Medications: 1. Sodium Bicarbonate 1300 mg PO BID RX *sodium bicarbonate 650 mg 2 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 2. CARVedilol 12.5 mg PO BID RX *carvedilol 12.5 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 3. Allopurinol [MASKED] mg PO DAILY 4. Amiodarone 200 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 80 mg PO QPM 7. Furosemide 40 mg PO DAILY 8. NIFEdipine (Extended Release) 30 mg PO DAILY 9. Sirolimus 0.5 mg PO DAILY 10. Tacrolimus 1 mg PO QAM 11. Tacrolimus 2 mg PO QPM 12. HELD- Calcitriol 0.5 mcg PO DAILY This medication was held. Do not restart Calcitriol until you discuss with your doctor 13. HELD- calcium carbonate-vitamin D3 500 mg(1,250mg) -200 unit oral DAILY This medication was held. Do not restart calcium carbonate-vitamin D3 until you discuss with your doctor Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis ================= Acute kidney injury Hypocalcemia Hyperkalemia Metabolic acidosis Secondary diagnosis ==================== HFrEF renal transplant Gout Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr [MASKED], It was a privilege caring for you at [MASKED]. WHY WAS I IN THE HOSPITAL? -You were admitted to the hospital because your kidney numbers are getting worse. WHAT HAPPENED TO ME IN THE HOSPITAL? - You were seen by the kidney doctors [MASKED] and monitor your kidney function. You are continued on all of your medications for your transplant. You were given medications to help balance the electrolytes in your blood. Your kidney function stabilized and you were felt be monitored outside the hospital. - You improved considerably and were felt well enough to leave the hospital WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Continue to take all your medicines and keep your appointments. - We recommend seeing your primary care physician to discuss your medications within the next 2 weeks. -Please have your standing labs drawn on [MASKED] and sent to Dr. [MASKED]. We wish you the best! Sincerely, Your [MASKED] Team Followup Instructions: [MASKED] | [
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] | [
"E875: Hyperkalemia",
"N186: End stage renal disease",
"T8611: Kidney transplant rejection",
"N179: Acute kidney failure, unspecified",
"I5020: Unspecified systolic (congestive) heart failure",
"I429: Cardiomyopathy, unspecified",
"N141: Nephropathy induced by other drugs, medicaments and biological substances",
"T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter",
"Y92018: Other place in single-family (private) house as the place of occurrence of the external cause",
"I110: Hypertensive heart disease with heart failure",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"Z955: Presence of coronary angioplasty implant and graft",
"Z8674: Personal history of sudden cardiac arrest",
"Z95810: Presence of automatic (implantable) cardiac defibrillator",
"I2720: Pulmonary hypertension, unspecified",
"Z905: Acquired absence of kidney",
"Z85528: Personal history of other malignant neoplasm of kidney",
"I440: Atrioventricular block, first degree",
"M109: Gout, unspecified",
"E7849: Other hyperlipidemia",
"E8352: Hypercalcemia",
"E874: Mixed disorder of acid-base balance",
"Z87891: Personal history of nicotine dependence"
] | [
"N179",
"I110",
"I2510",
"Z955",
"M109",
"Z87891"
] | [] |
16,907,087 | 26,684,049 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: ORTHOPAEDICS\n \nAllergies: \nMorphine / codeine / prednisone / gatorade\n \nAttending: ___\n \nChief Complaint:\nLeft Knee Osteoarthritis \n \nMajor Surgical or Invasive Procedure:\nLeft Total Knee Replacement ___, ___\n \nHistory of Present Illness:\n___ female with left knee osteoarthritis who has failed \nconservative management is now here for definitive surgery.\n \nPast Medical History:\nHDL, HTN, migraine, osteopenia, preDM, h/o fatty liver \n\n \nSocial History:\n___\nFamily History:\nNon-contributory\n \nPhysical Exam:\nWell appearing in no acute distress \nAfebrile with stable vital signs \nPain well-controlled \nRespiratory: CTAB \nCardiovascular: RRR \nGastrointestinal: NT/ND \nGenitourinary: Voiding independently \nNeurologic: Intact with no focal deficits \nPsychiatric: Pleasant, A&O x3 \nMusculoskeletal Lower Extremity: \n* Aquacel dressing with scant serosanguinous drainage \n* Thigh full but soft \n* No calf tenderness \n* ___ strength \n* SILT, NVI distally \n* Toes warm\n \nPertinent Results:\n___ 06:50AM BLOOD Hgb-11.9 Hct-36.3\n___ 06:50AM BLOOD Hgb-11.5 Hct-34.0\n___ 06:50AM BLOOD Creat-0.7\n \nBrief Hospital Course:\nThe patient was admitted to the Orthopaedic surgery service and \nwas taken to the operating room for above described procedure. \nPlease see separately dictated operative report for details. The \nsurgery was uncomplicated and the patient tolerated the \nprocedure well. Patient received perioperative IV antibiotics.\n\nPostoperative course was remarkable for the following:\nPOD #1, Aspirin was switched to Lovenox due to history of \nnausea/stomach pain on Aspirin. Patient did not receive any \nAspirin.\nPOD #2, no acute events. Patient cleared ___ without further \nissues.\n\nOtherwise, pain was controlled with a combination of IV and oral \npain medications. The patient received Lovenox twice daily for \nDVT prophylaxis starting on the morning of POD#1. The surgical \ndressing will remain on until POD#7 after surgery. The patient \nwas seen daily by physical therapy. Labs were checked throughout \nthe hospital course and repleted accordingly. At the time of \ndischarge the patient was tolerating a regular diet and feeling \nwell. The patient was afebrile with stable vital signs. The \npatient's hematocrit was acceptable and pain was adequately \ncontrolled on an oral regimen. The operative extremity was \nneurovascularly intact and the dressing was intact.\n\nThe patient's weight-bearing status is weight bearing as \ntolerated on the operative extremity with no range of motion \nrestrictions. Please use walker or 2 crutches, wean as able. \n \nMs. ___ is discharged to home with services in stable \ncondition.\n \nMedications on Admission:\n1. amLODIPine 5 mg PO DAILY \n2. ClonazePAM 0.5 mg PO TID:PRN anxiety \n3. CloNIDine 0.3 mg PO BID \n4. Zolpidem Tartrate 5 mg PO QHS \n5. ZOLMitriptan 5 mg oral PRN Migraine \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H \n2. Docusate Sodium 100 mg PO BID \n3. Enoxaparin Sodium 40 mg SC DAILY Duration: 28 Days \nStart: ___, First Dose: Next Routine Administration Time \n4. Gabapentin 300 mg PO TID \n5. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain - \nModerate \n6. Senna 8.6 mg PO BID \n7. amLODIPine 5 mg PO DAILY \n8. ClonazePAM 0.5 mg PO TID:PRN anxiety \n9. CloNIDine 0.3 mg PO BID \n10. ZOLMitriptan 5 mg oral PRN Migraine \n11. Zolpidem Tartrate 5 mg PO QHS \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \n___ Diagnosis:\nLeft Knee Osteoarthritis \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\n1. Please return to the emergency department or notify your \nphysician if you experience any of the following: severe pain \nnot relieved by medication, increased swelling, decreased \nsensation, difficulty with movement, fevers greater than 101.5, \nshaking chills, increasing redness or drainage from the incision \nsite, chest pain, shortness of breath or any other concerns.\n \n2. Please follow up with your primary physician regarding this \nadmission and any new medications and refills. \n \n3. Resume your home medications unless otherwise instructed.\n \n4. You have been given medications for pain control. Please do \nnot drive, operate heavy machinery, or drink alcohol while \ntaking these medications. As your pain decreases, take fewer \ntablets and increase the time between doses. This medication can \ncause constipation, so you should drink plenty of water daily \nand take a stool softener (such as Colace) as needed to prevent \nthis side effect. Call your surgeons office 3 days before you \nare out of medication so that it can be refilled. These \nmedications cannot be called into your pharmacy and must be \npicked up in the clinic or mailed to your house. Please allow \nan extra 2 days if you would like your medication mailed to your \nhome.\n \n5. You may not drive a car until cleared to do so by your \nsurgeon.\n \n6. Please call your surgeon's office to schedule or confirm your \nfollow-up appointment.\n \n7. SWELLING: Ice the operative joint 20 minutes at a time, \nespecially after activity or physical therapy. Do not place ice \ndirectly on the skin. You may wrap the knee with an ace bandage \nfor added compression. Please DO NOT take any non-steroidal \nanti-inflammatory medications (NSAIDs such as Celebrex, \nibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by \nyour physician.\n \n8. ANTICOAGULATION: Please continue your Lovenox for four (4) \nweeks to help prevent deep vein thrombosis (blood clots). If you \nwere taking Aspirin prior to your surgery, you should hold this \nmedication while on the one-month course of anticoagulation \nmedication. \n \n9. WOUND CARE: Please remove Aquacel dressing on POD#7 after \nsurgery. It is okay to shower after surgery after 5 days but no \ntub baths, swimming, or submerging your incision until after \nyour four (4) week checkup. Please place a dry sterile dressing \non the wound after aqaucel is removed each day if there is \ndrainage, otherwise leave it open to air. Check wound regularly \nfor signs of infection such as redness or thick yellow drainage. \n Staples will be removed by your doctor at follow-up appointment \napproximately 2 weeks after surgery.\n\n10. ___ (once at home): Home ___, dressing changes as \ninstructed, and wound checks.\n \n11. ACTIVITY: Weight bearing as tolerated on the operative \nextremity. Two crutches or walker. Wean assistive device as \nable. Mobilize. ROM as tolerated. No strenuous exercise or \nheavy lifting until follow up appointment. \n\nPhysical Therapy:\nWBAT LLE\nNo range of motion restrictions\nMobilize frequently\nWean from assistive device as able (i.e., 2 crutches, walker)\nTreatments Frequency:\nremove aquacel POD#7 after surgery\napply dry sterile dressing daily if needed after aquacel \ndressing is removed\nwound checks daily after aquacel removed\nstaple removal and replace with steri-strips at follow up visit \nin clinic \n \nFollowup Instructions:\n___\n"
] | Allergies: Morphine / codeine / prednisone / gatorade Chief Complaint: Left Knee Osteoarthritis Major Surgical or Invasive Procedure: Left Total Knee Replacement [MASKED], [MASKED] History of Present Illness: [MASKED] female with left knee osteoarthritis who has failed conservative management is now here for definitive surgery. Past Medical History: HDL, HTN, migraine, osteopenia, preDM, h/o fatty liver Social History: [MASKED] Family History: Non-contributory Physical Exam: Well appearing in no acute distress Afebrile with stable vital signs Pain well-controlled Respiratory: CTAB Cardiovascular: RRR Gastrointestinal: NT/ND Genitourinary: Voiding independently Neurologic: Intact with no focal deficits Psychiatric: Pleasant, A&O x3 Musculoskeletal Lower Extremity: * Aquacel dressing with scant serosanguinous drainage * Thigh full but soft * No calf tenderness * [MASKED] strength * SILT, NVI distally * Toes warm Pertinent Results: [MASKED] 06:50AM BLOOD Hgb-11.9 Hct-36.3 [MASKED] 06:50AM BLOOD Hgb-11.5 Hct-34.0 [MASKED] 06:50AM BLOOD Creat-0.7 Brief Hospital Course: The patient was admitted to the Orthopaedic surgery service and was taken to the operating room for above described procedure. Please see separately dictated operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Patient received perioperative IV antibiotics. Postoperative course was remarkable for the following: POD #1, Aspirin was switched to Lovenox due to history of nausea/stomach pain on Aspirin. Patient did not receive any Aspirin. POD #2, no acute events. Patient cleared [MASKED] without further issues. Otherwise, pain was controlled with a combination of IV and oral pain medications. The patient received Lovenox twice daily for DVT prophylaxis starting on the morning of POD#1. The surgical dressing will remain on until POD#7 after surgery. The patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was acceptable and pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact and the dressing was intact. The patient's weight-bearing status is weight bearing as tolerated on the operative extremity with no range of motion restrictions. Please use walker or 2 crutches, wean as able. Ms. [MASKED] is discharged to home with services in stable condition. Medications on Admission: 1. amLODIPine 5 mg PO DAILY 2. ClonazePAM 0.5 mg PO TID:PRN anxiety 3. CloNIDine 0.3 mg PO BID 4. Zolpidem Tartrate 5 mg PO QHS 5. ZOLMitriptan 5 mg oral PRN Migraine Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Docusate Sodium 100 mg PO BID 3. Enoxaparin Sodium 40 mg SC DAILY Duration: 28 Days Start: [MASKED], First Dose: Next Routine Administration Time 4. Gabapentin 300 mg PO TID 5. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain - Moderate 6. Senna 8.6 mg PO BID 7. amLODIPine 5 mg PO DAILY 8. ClonazePAM 0.5 mg PO TID:PRN anxiety 9. CloNIDine 0.3 mg PO BID 10. ZOLMitriptan 5 mg oral PRN Migraine 11. Zolpidem Tartrate 5 mg PO QHS Discharge Disposition: Home With Service Facility: [MASKED] [MASKED] Diagnosis: Left Knee Osteoarthritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as Colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon. 6. Please call your surgeon's office to schedule or confirm your follow-up appointment. 7. SWELLING: Ice the operative joint 20 minutes at a time, especially after activity or physical therapy. Do not place ice directly on the skin. You may wrap the knee with an ace bandage for added compression. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as Celebrex, ibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by your physician. 8. ANTICOAGULATION: Please continue your Lovenox for four (4) weeks to help prevent deep vein thrombosis (blood clots). If you were taking Aspirin prior to your surgery, you should hold this medication while on the one-month course of anticoagulation medication. 9. WOUND CARE: Please remove Aquacel dressing on POD#7 after surgery. It is okay to shower after surgery after 5 days but no tub baths, swimming, or submerging your incision until after your four (4) week checkup. Please place a dry sterile dressing on the wound after aqaucel is removed each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed by your doctor at follow-up appointment approximately 2 weeks after surgery. 10. [MASKED] (once at home): Home [MASKED], dressing changes as instructed, and wound checks. 11. ACTIVITY: Weight bearing as tolerated on the operative extremity. Two crutches or walker. Wean assistive device as able. Mobilize. ROM as tolerated. No strenuous exercise or heavy lifting until follow up appointment. Physical Therapy: WBAT LLE No range of motion restrictions Mobilize frequently Wean from assistive device as able (i.e., 2 crutches, walker) Treatments Frequency: remove aquacel POD#7 after surgery apply dry sterile dressing daily if needed after aquacel dressing is removed wound checks daily after aquacel removed staple removal and replace with steri-strips at follow up visit in clinic Followup Instructions: [MASKED] | [
"M1712",
"I10",
"G43909",
"F419"
] | [
"M1712: Unilateral primary osteoarthritis, left knee",
"I10: Essential (primary) hypertension",
"G43909: Migraine, unspecified, not intractable, without status migrainosus",
"F419: Anxiety disorder, unspecified"
] | [
"I10",
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] | [] |
12,579,086 | 23,227,370 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nBeta-Blockers (Beta-Adrenergic Blocking Agts) / Vicodin / \nhydrochlorothiazide\n \nAttending: ___.\n \nChief Complaint:\nRespiratory distress, bradycardia, AMS\n \nMajor Surgical or Invasive Procedure:\nEndotracheal intubation\n \nHistory of Present Illness:\n___ with a hx recurrent MRSA PNA c/b hypercarbic respiratory \nfailure s/p trach and PEG ___, CVA, s/p C spine injury with \nresultant C3-C6 laminectomy and quadriplegia, DVT (previously on \nCoumadin), COPD, HTN, with recent diagnosis of LLL Klebsiella \nPNA on Augmentin who presented to the ED from ___ after \nbeing found bradycardic with worsening hypoxia.\n\nThe patient was diagnosed with LLL PNA a week ago and has been \non Augmentin for that since ___ ___s doxycycline, which \nwas discontinued. She has also has been on prednisone 40 mg \ndaily. Since diagnosis she has had a new oxygen requirement of \n2L NC. Day prior to admission teh patient was noted to be \nincreasingly fatigued with complaints of shortness of breath. \nShe was evaluated and was found to be bradycardic to the ___ and \nso presented to the ED.\n\nOf note, the patient has been previously hospitalized for acute \nrespiratory failure in the setting of PNA requiring trach/PEG. \nShe had a MICU admission in ___ that has been complicated \nby PEA arrest which was secondary from tracheal obstruction with \ngranulation tissue with resultant upsizing of trach tube. Her \ntrach tube has since been removed.\n\nIn the ED, VS: 38 143/39 99% Non-Rebreather \nShe triggered for bradycardia in the ___. EKG showed new \ncomplete heart block with peaked T waves.\nExam was notable for a somnolent patient who opens her eyes to \nvoice and is AAOx2, plegic at baseline.\n\nLabs were notable for: \nWBC 20.9 H/H 8.8/28.5 Plt 247\nNa 133 K 5.7 ___ 92 HCO3 16 BUN 125 Cr 2.8 (baseline ~1.2)\nUrinalysis was grossly positive, but with 15 epis.\n\nImaging showed: \nEKG: new complete heart block, peaked T\nPortable chest x-ray was normal. \nCT abd/pelvis was ordered.\n\nThe patient was given vanc/zosyn/flagyl, calcium gluconate, \ninsulin, dextrose, 1L NS and an albuterol neb.\n\nEP was consulted in the ED and determined there to be no need \nfor a pacemaker given the patient's hemodynamic stability. They \nrecommended admission to MICU with EP following in consultation. \n\n\nThe patient then converted to 1:1 conduction. \n\nVitals upon transfer: 98.4 36 117/55 16 98% RA \nOn arrival to the ___, patient reports that she \"doesn't feel \ngood\". She endorses some shortness of breath and some \nlightheadedness. Denies chest pain, abdominal pain. She is a \npoor historian.\n\nCode anesthesia was called ___ for hypoxia to mid 70's on 5L \nNC. She was also hypertensive to 200's and EKG showed complete \nheart block again. She was placed on facemask oxygen with \nimproved saturations. ABG showed ___ with HCO3 12. \nAnesthesia intubated patient. Son called and asked to come in \nfor a goals of care discussion.\n\nREVIEW OF SYSTEMS: \n(+) Per HPI \n \nPast Medical History:\nMRSA PNA c/b hypercarbic respiratory failure s/p trach and PEG \n___ \nDVT diagnosed ___, previously on coumadin \nLUE superficial thrombus ___ \ns/p C3-C6 laminectomy for cervical cord compression w/ residual \nquadraparesis \nHypertension \nIschemic stroke, on ASA \nHyperkalemia \nHLD \nCOPD \nC. diff recurrent colitis \nGlaucoma \n\n \nSocial History:\n___\nFamily History:\nMother: HTN \nFather: Lung Ca \nBrother: CAD s/p CABG \n\n \nPhysical Exam:\nADMISSION EXAM:\nVitals: T 97.7 HR 42 BP 126/26 92% 6L NC R 18\nGENERAL: Ill-appearing, diaphoretic woman with some work of \nbreathing\nHEENT: PERRL, MM dry, anicteric sclerae\nNECK: JVD elevated to earlobe\nLUNGS: Diffuse rhonchi heard anteriorly. Diminished lung sounds \nat the bases, no wheezes\nCV: Diminished heart sounds, S1+S2, no m/r/g\nABD: PEG tube in place. Abdomen soft, pt complains of \nnondescript tenderness throughout, no rebound or guarding\nEXT: Warm, well-perfused, no ___ edema.\n\nDISCHARGE EXAM:\nExpired\n \nPertinent Results:\nADMISSION LABS:\n___ 09:32AM ___ PTT-37.0* ___\n___ 09:32AM PLT COUNT-247\n___ 09:32AM NEUTS-85.9* LYMPHS-4.0* MONOS-8.8 EOS-0.0* \nBASOS-0.1 IM ___ AbsNeut-17.96*# AbsLymp-0.83* \nAbsMono-1.85* AbsEos-0.01* AbsBaso-0.02\n___ 09:32AM WBC-20.9*# RBC-2.82* HGB-8.8* HCT-28.5* \nMCV-101* MCH-31.2 MCHC-30.9* RDW-15.7* RDWSD-58.0*\n___ 09:32AM CALCIUM-10.8* PHOSPHATE-8.2*# MAGNESIUM-2.3\n___ 09:32AM CK-MB-4\n___ 09:32AM cTropnT-0.17*\n___ 09:32AM CK(CPK)-31\n___ 09:32AM estGFR-Using this\n___ 09:32AM GLUCOSE-147* UREA N-125* CREAT-2.8*# \nSODIUM-133 POTASSIUM-5.7* CHLORIDE-92* TOTAL CO2-16* ANION \nGAP-31*\n___ 09:45AM O2 SAT-84\n___ 09:45AM LACTATE-1.7 K+-5.6*\n___ 09:45AM ___ PO2-56* PCO2-40 PH-7.24* TOTAL \nCO2-18* BASE XS--9\n___ 10:00AM URINE WBCCLUMP-FEW MUCOUS-FEW\n___ 10:00AM URINE AMORPH-FEW\n___ 10:00AM URINE HYALINE-9*\n___ 10:00AM URINE RBC-135* WBC->182* BACTERIA-FEW \nYEAST-MANY EPI-15\n___ 10:00AM URINE BLOOD-SM NITRITE-NEG PROTEIN-300 \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 \nLEUK-LG\n___ 10:00AM URINE COLOR-Yellow APPEAR-Cloudy SP ___\n___ 10:00AM URINE UHOLD-HOLD\n___ 10:00AM URINE HOURS-RANDOM\n___ 03:00PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG \nbarbitrt-NEG tricyclic-NEG\n___ 03:00PM OSMOLAL-322*\n___ 03:00PM ALBUMIN-3.7 CALCIUM-10.4* PHOSPHATE-7.3* \nMAGNESIUM-2.2\n___ 03:00PM cTropnT-0.16* ___\n___ 03:00PM GLUCOSE-137* UREA N-125* CREAT-3.0* \nSODIUM-134 POTASSIUM-5.6* CHLORIDE-96 TOTAL CO2-12* ANION \nGAP-32*\n___ 05:47PM URINE BLOOD-SM NITRITE-NEG PROTEIN-300 \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 \nLEUK-LG\n___ 05:47PM URINE COLOR-Yellow APPEAR-Cloudy SP ___\n___ 06:10PM TYPE-ART PO2-97 PCO2-41 PH-7.14* TOTAL \nCO2-15* BASE XS--14\n___ 12:00AM CALCIUM-10.5* PHOSPHATE-6.9* MAGNESIUM-2.0\n___ 12:00AM CK-MB-4 cTropnT-0.17*\n___ 12:00AM CK(CPK)-18*\n___ 12:00AM GLUCOSE-78 UREA N-126* CREAT-2.8* SODIUM-141 \nPOTASSIUM-3.8 CHLORIDE-97 TOTAL CO2-23 ANION GAP-25*\n\nIMAGING/STUDIES:\n+ ECG - complete heart block with ventricular escape. peaked TW\nTelemetry - alternating between above and sinus rhythm with\nprolonged PR\n\n+ ___ Imaging CHEST (PORTABLE AP) \nIMPRESSION: \nNo focal consolidation \n\n+ ___ Imaging CT HEAD W/O CONTRAST \nIMPRESSION: \nNo definite acute intracranial process given slight motion \ndegradation. \n\n+ ___BD & PELVIS W/O CON \nWet Read by ___ on TUE ___ 1:27 ___ \nNo evidence of colitis. Re-demonstrated sacral decubitus ulcer. \n\nDiverticulosis without diverticulitis. \n\nTTE\nConclusions \nThe left atrial volume index is severely increased. No atrial \nseptal defect is seen by 2D or color Doppler. The estimated \nright atrial pressure is ___ mmHg. There is mild symmetric left \nventricular hypertrophy with normal cavity size. Due to \nsuboptimal technical quality, a focal wall motion abnormality \ncannot be fully excluded. Left ventricular systolic function is \nhyperdynamic (EF>75%). Doppler parameters are indeterminate for \nleft ventricular diastolic function. There is a mild resting \nleft ventricular outflow tract obstruction. Right ventricular \nchamber size and free wall motion are normal. The aortic valve \nleaflets are moderately thickened. There is aortic stenosis (not \nquantified by aortic valve area given the presence of a LV \noutflow tract gradient). Mild (1+) aortic regurgitation is seen. \nThe mitral valve leaflets are moderately thickened. There is \nmoderate functional mitral stenosis (mean gradient 10 mmHg) due \nto mitral annular calcification. Mild (1+) mitral regurgitation \nis seen. [Due to acoustic shadowing, the severity of mitral \nregurgitation may be significantly UNDERestimated.] There is \nmild pulmonary artery systolic hypertension. There is no \npericardial effusion. \n\nCompared with the prior study (images reviewed) of ___, \nleft ventricular systolic function is hyperdynamic and there is \nevidence of an outflow tract obstruction. There is less aortic \nregurgitation. Other findings are probably similar (degree of \ncalcific aortic stenosis could not be quantified on the current \nstudy). \n\n___ CT abd:\nFINDINGS: \n \nLOWER CHEST: Mild bibasilar atelectasis and possible trace \neffusion. \nModerate cardiomegaly. There is no evidence of pleural or \npericardial \neffusion. \n \nABDOMEN: \nHEPATOBILIARY: Examination is limited secondary to lack of \nintravenous \ncontrast. Within this limitation, the liver appears \nunremarkable. There is no evidence of focal lesions. There is \nno evidence of intrahepatic biliary dilatation. Dilation of the \ncommon bile duct up to 14 mm is unchanged from prior. Patient \nis status post cholecystectomy. \n \nPANCREAS: The pancreas is unremarkable. \n \nSPLEEN: The spleen is unremarkable. \n \nADRENALS: The right and left adrenal glands are normal in size \nand shape. \n \nURINARY: The kidneys are of normal and symmetric size. There is \nno \nhydronephrosis. \n \nGASTROINTESTINAL: The distal esophagus is normal without a \nhiatal hernia. A gastrostomy tube is present. Small bowel \nloops demonstrate normal caliber, wall thickness, and \nenhancement throughout. Fluid levels are seen within the \nascending colon, compatible with diarrhea. Diverticulosis \nwithout diverticulitis. The appendix is normal. \n \nPELVIS: Foley catheter is in place within a decompressed \nurinary bladder. A left inguinal hernia is again seen, not \nsignificantly changed from prior study. There is no free fluid \nin the pelvis. \n \nREPRODUCTIVE ORGANS: The reproductive organs are unremarkable. \n \nLYMPH NODES: There is no retroperitoneal or mesenteric \nlymphadenopathy. There is no pelvic or inguinal \nlymphadenopathy. \n \nVASCULAR: Focal ectasia of the infrarenal abdominal aorta is \nagain seen, \nmeasuring 2.2 cm. The abdominal aorta is heavily calcified \nbranching into the right iliac vessels. \n \nBONES: Moderate multilevel degenerative changes of the lumbar \nspine. There is no evidence of worrisome osseous lesions or \nacute fracture. \n \nSOFT TISSUES: There is skin thickening overlying the sacrum in \nthe region of prior sacral decubitus ulcer. The abdominal and \npelvic wall is within normal limits. \n \nIMPRESSION: \n1. No acute intraabdominal process. No evidence of colitis. \nFluid within the colon which can be seen in setting of diarrhea. \n\n2. Diverticulosis without evidence of diverticulitis. \n3. Thickening of the skin overlying the sacrum in the region of \nprior sacral decubitus ulcer which can be clinically correlated. \n\n\nCXR ___: \nFINDINGS: \nLower lung volumes seen on the current exam. Linear right \nmidlung opacity is likely secondary to atelectasis. There is no \ndefinite focal consolidation. Moderate cardiac enlargement is \nagain noted. Chronic deformity of the proximal right humerus \nsuggests prior fracture. Rounded structure projecting over left \nupper quadrant could represent a percutaneous gastrostomy tube. \nIMPRESSION: No focal consolidation \n\n___ ___\nIMPRESSION: \n \nNo evidence of deep vein thrombosis in the right upper \nextremity.\n\nCXR ___ \nIn comparison with the study of ___, there is some \nincreasing \nopacification at the right base, consistent with substantial \nvolume loss in the right middle and lower lobes associated with \npleural effusion. The left lung remains essentially clear. \nEnlargement of the cardiac silhouette is unchanged. Of \nincidental note is an apparent healed fracture with displacement \nof the proximal right humerus. \n\nCXR ___\nIn comparison with the study of ___, there is mild \nimprovement in aeration at the right base. This could reflect \ndecrease collapse of the right middle and lower lobes, \npresumably related to a expectoration of mucous plugging, and \nmild decrease in the degree of pleural effusion. The left \nhemithorax remains essentially clear. \n\nCXR ___\nIn comparison with the earlier study of this ___, there is some \nincreased opacification at the right base, consistent with some \ncombination of worsening volume loss in the right lower lung and \npleural effusion. Otherwise little change. \n\n \nBrief Hospital Course:\n___ year old female with past medical history of prior CVA with L \npartial hemiparesis, dysphagia s/p PEG, COPD, HTN, admitted \n___ from ___ with severe sepsis from acute \nbacterial pneumonia, ___, complete heart block, requiring \nintubation, on empiric broad spectrum antibiotics, extubated and \nfurther floor course notable for hypertension and hypernatremia. \n\n\nHospitalization: \nFICU course ___\n\nIn brief, ___ with complex hospital course who was transferred \nto\nthe MICU for hypotension, respiratory failure, and nursing\nconcern. This morning decision was made with patient's family to\npursue aggressive comfort-focused care given her clinical\ndeterioration. \n\nDuring the day, we provided this care; when, come evening, the\npatient remained stable, we called her out to a floor bed. On\nspeaking with the patient's son about moving her from the ICU to\na floor bed, he became very angry and felt we were treating his\nmother like \"a piece of trash.\" He felt that, by moving her, we\nwere \"disrespecting her dying.\"\n\nAfter a period of attentive listening, we discussed that we \nwould\nlike to make the ICU bed available for another critically ill\npatient and that his mother would receive the same attentive\nnursing care on the floor. He iterated that moving her was \"part\nof a business model for the hospital\" and that we were \"just\nfollowing a protocol to make more money for the hospital.\" I\ninitially shared that we had no financial interest in moving \nher,\nand that in so doing we were attempting to provide the best care\nto all of ___ patients while still providing respectful and\naggressive comfort care to his mother. \n\nUnpersuaded by these statements, he repeated that if we moved\nher, we would be disrespecting her and treating her like trash. \n\nAfter discussion with our overnight attending Dr. ___,\nwe agreed to keep the patient in the MICU overnight. We promised\nthat we would not relocate her overnight without discussing\nfurther with him except in the event of an emergency need for \nthe\nbed. He understood this. He intends to come in during the \nmorning\nand is willing for her to be moved at that time.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen (Liquid) 650 mg NG Q6H \n2. Acetylcysteine 20% 200 mg NEB TID \n3. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H \n4. Allopurinol ___ mg NG EVERY OTHER DAY \n5. Amoxicillin-Clavulanic Acid ___ mg PO/NG Q12H \n6. Baclofen 12.5 mg NG QAM \n7. Baclofen 12.5 mg PO BID \n8. Famotidine 10 mg PO/NG QHS \n9. Fluticasone Propionate 110mcg 1 PUFF IH BID \n10. Heparin 5000 UNIT SC BID \n11. Levothyroxine Sodium 112 mcg NG DAILY \n12. miconazole nitrate 2 % topical BID \n13. Mupirocin Ointment 2% 1 Appl NU BID \n14. Omeprazole 20 mg PO DAILY \n15. Amlodipine 5 mg PO DAILY \n16. Fentanyl Patch 12 mcg/h TD Q72H \n17. HydrALAzine 5 mg PO TID \n18. PredniSONE 40 mg PO DAILY \n19. Tizanidine 4 mg NG QHS \n20. Albuterol 0.083% Neb Soln 1 NEB IH Q6H \n21. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q2H:PRN SOB, \nwheeze \n22. Artificial Tears 1 DROP RIGHT EYE TID \n23. Hydrocortisone (Rectal) 2.5% Cream 1 Appl PR Q6H \n24. HYDROmorphone (Dilaudid) 2 mg PO QHS:PRN pain \n25. HYDROmorphone (Dilaudid) 2 mg PO Q4H \n26. ondansetron 4 mg oral TID \n27. Senna 17.2 mg NG DAILY \n28. Simethicone 40-80 mg NG TID \n29. Sodium Chloride Nasal 1 SPRY NU Q4H \n30. DiphenhydrAMINE 12.5 mg PO Q8H:PRN itching \n31. Guaifenesin-Dextromethorphan 5 mL PO Q4H:PRN cough \n\n \nDischarge Medications:\nExpired\n \nDischarge Disposition:\nExpired\n \nFacility:\n___\n \nDischarge Diagnosis:\nExpired\n \nDischarge Condition:\nExpired\n \nDischarge Instructions:\nExpired\n \nFollowup Instructions:\n___\n"
] | Allergies: Beta-Blockers (Beta-Adrenergic Blocking Agts) / Vicodin / hydrochlorothiazide Chief Complaint: Respiratory distress, bradycardia, AMS Major Surgical or Invasive Procedure: Endotracheal intubation History of Present Illness: [MASKED] with a hx recurrent MRSA PNA c/b hypercarbic respiratory failure s/p trach and PEG [MASKED], CVA, s/p C spine injury with resultant C3-C6 laminectomy and quadriplegia, DVT (previously on Coumadin), COPD, HTN, with recent diagnosis of LLL Klebsiella PNA on Augmentin who presented to the ED from [MASKED] after being found bradycardic with worsening hypoxia. The patient was diagnosed with LLL PNA a week ago and has been on Augmentin for that since [MASKED] s doxycycline, which was discontinued. She has also has been on prednisone 40 mg daily. Since diagnosis she has had a new oxygen requirement of 2L NC. Day prior to admission teh patient was noted to be increasingly fatigued with complaints of shortness of breath. She was evaluated and was found to be bradycardic to the [MASKED] and so presented to the ED. Of note, the patient has been previously hospitalized for acute respiratory failure in the setting of PNA requiring trach/PEG. She had a MICU admission in [MASKED] that has been complicated by PEA arrest which was secondary from tracheal obstruction with granulation tissue with resultant upsizing of trach tube. Her trach tube has since been removed. In the ED, VS: 38 143/39 99% Non-Rebreather She triggered for bradycardia in the [MASKED]. EKG showed new complete heart block with peaked T waves. Exam was notable for a somnolent patient who opens her eyes to voice and is AAOx2, plegic at baseline. Labs were notable for: WBC 20.9 H/H 8.8/28.5 Plt 247 Na 133 K 5.7 [MASKED] 92 HCO3 16 BUN 125 Cr 2.8 (baseline ~1.2) Urinalysis was grossly positive, but with 15 epis. Imaging showed: EKG: new complete heart block, peaked T Portable chest x-ray was normal. CT abd/pelvis was ordered. The patient was given vanc/zosyn/flagyl, calcium gluconate, insulin, dextrose, 1L NS and an albuterol neb. EP was consulted in the ED and determined there to be no need for a pacemaker given the patient's hemodynamic stability. They recommended admission to MICU with EP following in consultation. The patient then converted to 1:1 conduction. Vitals upon transfer: 98.4 36 117/55 16 98% RA On arrival to the [MASKED], patient reports that she "doesn't feel good". She endorses some shortness of breath and some lightheadedness. Denies chest pain, abdominal pain. She is a poor historian. Code anesthesia was called [MASKED] for hypoxia to mid 70's on 5L NC. She was also hypertensive to 200's and EKG showed complete heart block again. She was placed on facemask oxygen with improved saturations. ABG showed [MASKED] with HCO3 12. Anesthesia intubated patient. Son called and asked to come in for a goals of care discussion. REVIEW OF SYSTEMS: (+) Per HPI Past Medical History: MRSA PNA c/b hypercarbic respiratory failure s/p trach and PEG [MASKED] DVT diagnosed [MASKED], previously on coumadin LUE superficial thrombus [MASKED] s/p C3-C6 laminectomy for cervical cord compression w/ residual quadraparesis Hypertension Ischemic stroke, on ASA Hyperkalemia HLD COPD C. diff recurrent colitis Glaucoma Social History: [MASKED] Family History: Mother: HTN Father: Lung Ca Brother: CAD s/p CABG Physical Exam: ADMISSION EXAM: Vitals: T 97.7 HR 42 BP 126/26 92% 6L NC R 18 GENERAL: Ill-appearing, diaphoretic woman with some work of breathing HEENT: PERRL, MM dry, anicteric sclerae NECK: JVD elevated to earlobe LUNGS: Diffuse rhonchi heard anteriorly. Diminished lung sounds at the bases, no wheezes CV: Diminished heart sounds, S1+S2, no m/r/g ABD: PEG tube in place. Abdomen soft, pt complains of nondescript tenderness throughout, no rebound or guarding EXT: Warm, well-perfused, no [MASKED] edema. DISCHARGE EXAM: Expired Pertinent Results: ADMISSION LABS: [MASKED] 09:32AM [MASKED] PTT-37.0* [MASKED] [MASKED] 09:32AM PLT COUNT-247 [MASKED] 09:32AM NEUTS-85.9* LYMPHS-4.0* MONOS-8.8 EOS-0.0* BASOS-0.1 IM [MASKED] AbsNeut-17.96*# AbsLymp-0.83* AbsMono-1.85* AbsEos-0.01* AbsBaso-0.02 [MASKED] 09:32AM WBC-20.9*# RBC-2.82* HGB-8.8* HCT-28.5* MCV-101* MCH-31.2 MCHC-30.9* RDW-15.7* RDWSD-58.0* [MASKED] 09:32AM CALCIUM-10.8* PHOSPHATE-8.2*# MAGNESIUM-2.3 [MASKED] 09:32AM CK-MB-4 [MASKED] 09:32AM cTropnT-0.17* [MASKED] 09:32AM CK(CPK)-31 [MASKED] 09:32AM estGFR-Using this [MASKED] 09:32AM GLUCOSE-147* UREA N-125* CREAT-2.8*# SODIUM-133 POTASSIUM-5.7* CHLORIDE-92* TOTAL CO2-16* ANION GAP-31* [MASKED] 09:45AM O2 SAT-84 [MASKED] 09:45AM LACTATE-1.7 K+-5.6* [MASKED] 09:45AM [MASKED] PO2-56* PCO2-40 PH-7.24* TOTAL CO2-18* BASE XS--9 [MASKED] 10:00AM URINE WBCCLUMP-FEW MUCOUS-FEW [MASKED] 10:00AM URINE AMORPH-FEW [MASKED] 10:00AM URINE HYALINE-9* [MASKED] 10:00AM URINE RBC-135* WBC->182* BACTERIA-FEW YEAST-MANY EPI-15 [MASKED] 10:00AM URINE BLOOD-SM NITRITE-NEG PROTEIN-300 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-LG [MASKED] 10:00AM URINE COLOR-Yellow APPEAR-Cloudy SP [MASKED] [MASKED] 10:00AM URINE UHOLD-HOLD [MASKED] 10:00AM URINE HOURS-RANDOM [MASKED] 03:00PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [MASKED] 03:00PM OSMOLAL-322* [MASKED] 03:00PM ALBUMIN-3.7 CALCIUM-10.4* PHOSPHATE-7.3* MAGNESIUM-2.2 [MASKED] 03:00PM cTropnT-0.16* [MASKED] [MASKED] 03:00PM GLUCOSE-137* UREA N-125* CREAT-3.0* SODIUM-134 POTASSIUM-5.6* CHLORIDE-96 TOTAL CO2-12* ANION GAP-32* [MASKED] 05:47PM URINE BLOOD-SM NITRITE-NEG PROTEIN-300 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-LG [MASKED] 05:47PM URINE COLOR-Yellow APPEAR-Cloudy SP [MASKED] [MASKED] 06:10PM TYPE-ART PO2-97 PCO2-41 PH-7.14* TOTAL CO2-15* BASE XS--14 [MASKED] 12:00AM CALCIUM-10.5* PHOSPHATE-6.9* MAGNESIUM-2.0 [MASKED] 12:00AM CK-MB-4 cTropnT-0.17* [MASKED] 12:00AM CK(CPK)-18* [MASKED] 12:00AM GLUCOSE-78 UREA N-126* CREAT-2.8* SODIUM-141 POTASSIUM-3.8 CHLORIDE-97 TOTAL CO2-23 ANION GAP-25* IMAGING/STUDIES: + ECG - complete heart block with ventricular escape. peaked TW Telemetry - alternating between above and sinus rhythm with prolonged PR + [MASKED] Imaging CHEST (PORTABLE AP) IMPRESSION: No focal consolidation + [MASKED] Imaging CT HEAD W/O CONTRAST IMPRESSION: No definite acute intracranial process given slight motion degradation. + BD & PELVIS W/O CON Wet Read by [MASKED] on TUE [MASKED] 1:27 [MASKED] No evidence of colitis. Re-demonstrated sacral decubitus ulcer. Diverticulosis without diverticulitis. TTE Conclusions The left atrial volume index is severely increased. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is [MASKED] mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Left ventricular systolic function is hyperdynamic (EF>75%). Doppler parameters are indeterminate for left ventricular diastolic function. There is a mild resting left ventricular outflow tract obstruction. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. There is aortic stenosis (not quantified by aortic valve area given the presence of a LV outflow tract gradient). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is moderate functional mitral stenosis (mean gradient 10 mmHg) due to mitral annular calcification. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [MASKED], left ventricular systolic function is hyperdynamic and there is evidence of an outflow tract obstruction. There is less aortic regurgitation. Other findings are probably similar (degree of calcific aortic stenosis could not be quantified on the current study). [MASKED] CT abd: FINDINGS: LOWER CHEST: Mild bibasilar atelectasis and possible trace effusion. Moderate cardiomegaly. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: Examination is limited secondary to lack of intravenous contrast. Within this limitation, the liver appears unremarkable. There is no evidence of focal lesions. There is no evidence of intrahepatic biliary dilatation. Dilation of the common bile duct up to 14 mm is unchanged from prior. Patient is status post cholecystectomy. PANCREAS: The pancreas is unremarkable. SPLEEN: The spleen is unremarkable. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size. There is no hydronephrosis. GASTROINTESTINAL: The distal esophagus is normal without a hiatal hernia. A gastrostomy tube is present. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. Fluid levels are seen within the ascending colon, compatible with diarrhea. Diverticulosis without diverticulitis. The appendix is normal. PELVIS: Foley catheter is in place within a decompressed urinary bladder. A left inguinal hernia is again seen, not significantly changed from prior study. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The reproductive organs are unremarkable. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: Focal ectasia of the infrarenal abdominal aorta is again seen, measuring 2.2 cm. The abdominal aorta is heavily calcified branching into the right iliac vessels. BONES: Moderate multilevel degenerative changes of the lumbar spine. There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: There is skin thickening overlying the sacrum in the region of prior sacral decubitus ulcer. The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. No acute intraabdominal process. No evidence of colitis. Fluid within the colon which can be seen in setting of diarrhea. 2. Diverticulosis without evidence of diverticulitis. 3. Thickening of the skin overlying the sacrum in the region of prior sacral decubitus ulcer which can be clinically correlated. CXR [MASKED]: FINDINGS: Lower lung volumes seen on the current exam. Linear right midlung opacity is likely secondary to atelectasis. There is no definite focal consolidation. Moderate cardiac enlargement is again noted. Chronic deformity of the proximal right humerus suggests prior fracture. Rounded structure projecting over left upper quadrant could represent a percutaneous gastrostomy tube. IMPRESSION: No focal consolidation [MASKED] [MASKED] IMPRESSION: No evidence of deep vein thrombosis in the right upper extremity. CXR [MASKED] In comparison with the study of [MASKED], there is some increasing opacification at the right base, consistent with substantial volume loss in the right middle and lower lobes associated with pleural effusion. The left lung remains essentially clear. Enlargement of the cardiac silhouette is unchanged. Of incidental note is an apparent healed fracture with displacement of the proximal right humerus. CXR [MASKED] In comparison with the study of [MASKED], there is mild improvement in aeration at the right base. This could reflect decrease collapse of the right middle and lower lobes, presumably related to a expectoration of mucous plugging, and mild decrease in the degree of pleural effusion. The left hemithorax remains essentially clear. CXR [MASKED] In comparison with the earlier study of this [MASKED], there is some increased opacification at the right base, consistent with some combination of worsening volume loss in the right lower lung and pleural effusion. Otherwise little change. Brief Hospital Course: [MASKED] year old female with past medical history of prior CVA with L partial hemiparesis, dysphagia s/p PEG, COPD, HTN, admitted [MASKED] from [MASKED] with severe sepsis from acute bacterial pneumonia, [MASKED], complete heart block, requiring intubation, on empiric broad spectrum antibiotics, extubated and further floor course notable for hypertension and hypernatremia. Hospitalization: FICU course [MASKED] In brief, [MASKED] with complex hospital course who was transferred to the MICU for hypotension, respiratory failure, and nursing concern. This morning decision was made with patient's family to pursue aggressive comfort-focused care given her clinical deterioration. During the day, we provided this care; when, come evening, the patient remained stable, we called her out to a floor bed. On speaking with the patient's son about moving her from the ICU to a floor bed, he became very angry and felt we were treating his mother like "a piece of trash." He felt that, by moving her, we were "disrespecting her dying." After a period of attentive listening, we discussed that we would like to make the ICU bed available for another critically ill patient and that his mother would receive the same attentive nursing care on the floor. He iterated that moving her was "part of a business model for the hospital" and that we were "just following a protocol to make more money for the hospital." I initially shared that we had no financial interest in moving her, and that in so doing we were attempting to provide the best care to all of [MASKED] patients while still providing respectful and aggressive comfort care to his mother. Unpersuaded by these statements, he repeated that if we moved her, we would be disrespecting her and treating her like trash. After discussion with our overnight attending Dr. [MASKED], we agreed to keep the patient in the MICU overnight. We promised that we would not relocate her overnight without discussing further with him except in the event of an emergency need for the bed. He understood this. He intends to come in during the morning and is willing for her to be moved at that time. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen (Liquid) 650 mg NG Q6H 2. Acetylcysteine 20% 200 mg NEB TID 3. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H 4. Allopurinol [MASKED] mg NG EVERY OTHER DAY 5. Amoxicillin-Clavulanic Acid [MASKED] mg PO/NG Q12H 6. Baclofen 12.5 mg NG QAM 7. Baclofen 12.5 mg PO BID 8. Famotidine 10 mg PO/NG QHS 9. Fluticasone Propionate 110mcg 1 PUFF IH BID 10. Heparin 5000 UNIT SC BID 11. Levothyroxine Sodium 112 mcg NG DAILY 12. miconazole nitrate 2 % topical BID 13. Mupirocin Ointment 2% 1 Appl NU BID 14. Omeprazole 20 mg PO DAILY 15. Amlodipine 5 mg PO DAILY 16. Fentanyl Patch 12 mcg/h TD Q72H 17. HydrALAzine 5 mg PO TID 18. PredniSONE 40 mg PO DAILY 19. Tizanidine 4 mg NG QHS 20. Albuterol 0.083% Neb Soln 1 NEB IH Q6H 21. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q2H:PRN SOB, wheeze 22. Artificial Tears 1 DROP RIGHT EYE TID 23. Hydrocortisone (Rectal) 2.5% Cream 1 Appl PR Q6H 24. HYDROmorphone (Dilaudid) 2 mg PO QHS:PRN pain 25. HYDROmorphone (Dilaudid) 2 mg PO Q4H 26. ondansetron 4 mg oral TID 27. Senna 17.2 mg NG DAILY 28. Simethicone 40-80 mg NG TID 29. Sodium Chloride Nasal 1 SPRY NU Q4H 30. DiphenhydrAMINE 12.5 mg PO Q8H:PRN itching 31. Guaifenesin-Dextromethorphan 5 mL PO Q4H:PRN cough Discharge Medications: Expired Discharge Disposition: Expired Facility: [MASKED] Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: [MASKED] | [
"R6521",
"J9601",
"N179",
"J150",
"J441",
"I5032",
"E875",
"R1310",
"N183",
"J9811",
"I129",
"Z66",
"Z86718",
"E785",
"H409",
"Z7982",
"M109",
"Z87891",
"R197",
"E039",
"G8929",
"Z720"
] | [
"R6521: Severe sepsis with septic shock",
"J9601: Acute respiratory failure with hypoxia",
"N179: Acute kidney failure, unspecified",
"J150: Pneumonia due to Klebsiella pneumoniae",
"J441: Chronic obstructive pulmonary disease with (acute) exacerbation",
"I5032: Chronic diastolic (congestive) heart failure",
"E875: Hyperkalemia",
"R1310: Dysphagia, unspecified",
"N183: Chronic kidney disease, stage 3 (moderate)",
"J9811: Atelectasis",
"I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease",
"Z66: Do not resuscitate",
"Z86718: Personal history of other venous thrombosis and embolism",
"E785: Hyperlipidemia, unspecified",
"H409: Unspecified glaucoma",
"Z7982: Long term (current) use of aspirin",
"M109: Gout, unspecified",
"Z87891: Personal history of nicotine dependence",
"R197: Diarrhea, unspecified",
"E039: Hypothyroidism, unspecified",
"G8929: Other chronic pain",
"Z720: Tobacco use"
] | [
"J9601",
"N179",
"I5032",
"I129",
"Z66",
"Z86718",
"E785",
"M109",
"Z87891",
"E039",
"G8929"
] | [] |
14,585,180 | 28,240,469 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: PSYCHIATRY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\n\"I tried to commit suicide today\"\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\nPer Dr. ___ accept note dated ___:\n\nPer Dr. ___ ED Initial Psychiatry Consult \nnote:\n\n\"Ms. ___ is a ___ year old female w/ GAD, depression, \nanorexia, and self-reported diagnosis of borderline personality \ndisorder brought in by ambulance following suicide attempt via \nconsumption of ___ pills of Trazodone 50mg earlier today in \nsetting of worsening sense of hopelessness and increasing\nfrequency of suicidal ideation.\"\n.\nMs. ___ reports worsening depressive symptoms most \npredominantly feelings of worthlessness, difficulty staying \nasleep, low mood, decreased energy, poor motivation, loss of \nconcentration and intermittent thoughts of suicidal ideation \nworsening acutely since last ___ in to college at \n___. Per patient report, she has also had increasing anxiety \nregarding class burden and social interaction, including \nincreasing frequency of \"panic attacks\" or episodes of heart \nracing, shortness of breath, intense fear lasting for ___ \nminutes followed by fatigue. This morning was the first day of \nclasses at ___. Patient attended her 08:00 AM class successfully \nand then returned to her dorm to have a conference call/meeting \nwith her therapist. She reported feeling intense anxiety \nfollowing the class and acute worsening of her depressive \nsymptoms which was not ameliorated by her discussion with her \ntherapist. Ms. ___ proceeded to end her conversation with \nher therapist prematurely and felt an overwhelming sense of \nhopelessness that she would never escape these feelings of \nanxiety. Patient reports that she proceeded to ingest ___ \npills of her Trazodone with intention of \"going to sleep and not \nwaking up.\" She states that following this her therapist called \nher father who arrived shortly before the ambulance. She reports \nvomiting multiple times and but does not express regret \nregarding her decision. She states that this is her first \nsuicide attempt but reports that in ___ she poured multiple \npills of trazadone in her hand but did not ingest them at this \npoint in time. Patient reports that she has had suicidal \nideation multiple times per day for the last several days \nacutely worsening today with specific plan to overdose. She \nstates that she also thought about cutting her wrists and \nbleeding out. Previous to the event today, patient reports \nfeelings of emptiness, fatigue, and feeling like the \"day is \ndragging.\" She cites her bed as her only sense of relief from \nthe anxiety and stress of the day. Patient endorses ongoing\nfeelings of hopelessness and helplessness following this attempt \nand states that she continues to feel like a burden to friends \nand family. \n.\nCOLLATERAL\nEMS run report: \n___ female.. admits to ingestion of her own Trazadone 50 mg tab. \nless than (2)hr prior.. and admits to having \" 15 pills.. \nPatient admits to being stressed in her new freshman ___ \nenvironment.. but otherwise was cooperative and in no acute \ndistress.\"\n.\nPARENTS at bedside:\nPatients mother reports that patient has struggled with anxiety, \nand depression for many years and more recently with restrictive \neating resulting in multiple partial hospitalizations and \ninpatient hospitalization at ___. Mother reports that patient \nwas living at home with parents since withdrawing from school \nafter completion of the first semester of college last year. \nPatient was hopeful that she return to college and was accepted \nas a transfer to ___ for this semester. Over the course of the \n___ patient has been working with therapist and psychiatrist \nto have a plan for return to school. Since patient moved in to \n___ on ___ mother has been back and forth visiting patient \non a daily basis. Today was the first day of classes and mother \nspoke with patient on phone prior to her attending her 0800 am \nclass. Patient had an online video appointment with therapist \nfollowing first class. Patient's father received a call from \ndaughter at approximately 11AM stating that she needed him to \ncome to her dorm but patient did not provide details. Patient's \ntherapist called father and therapist also alerted ___ police who \nwere at scene when father arrived. Patient was awake, vomited \nseveral times and continued to do so on way to the hospital. \nParents are concerned for patient's safety at home. Report that \npatient has expressed suicidal ideation in past but has never \nacted on these thoughts until now. Parent's do not feel safe \ntaking daughter home and believe inpatient level of care is best \nfor patient at this time.\" \n.\nIn the ED patient was calm and cooperative. Sleeping \nintermittently with parents at bedside. Received dinner, ate \nsparingly.\n.\nOn interview on the unit patient appeared visibly anxious but \nwas calm and cooperative. Endorsed ongoing anxiety but also a \ndesire to go to bed for the evening. Reported persistence of \npoor mood, feelings of hopelessness, thoughts of death without \nactive plan at this time. Patient confirmed that she received \nevening meds (aripiprazole and buspar) in the ED this evening. \nREVIEW OF SYSTEMS:\n=PSYCHIATRIC\n -Positive per HPI\n+avoidance of social situations\n+panic attacks\n -Denies the following:\npsychomotor agitation/retardation, delusions, thought \nbroadcasting/insertion, hallucinations, elevated mood, increased \nactivity/energy, decreased need for sleep, grandiosity, \nincreased speech, social/economic indiscretion \n=MEDICAL\n -Pertinent Positives:\n -Denies:\nfever, HA, visual changes, chest pain, SOB, nausea, vomiting, \nconstipation, diarrhea, rashes, joint pain, dysuria\n \nPast Medical History:\nPAST PSYCHIATRIC HISTORY:\nPer Dr. ___ ED Initial Psychiatry \nConsult note with revision/supplementation as provided per \nhistory at time of admission to unit.\n- Past diagnoses:\n Borderline PD (___)\n Anorexia (___)\n Depression ___ yo)\n GAD ___ yo Social Anxiety --> GAD ___ yo)\n- Hospitalizations:\n ___ years - Suicidal ideation (Arbour HRI)\n 2 week inpatient stay\n Partial program at ___ ___\n ___ ___- Suicidal ideation\n ___ ___- Suicidal ideation\n Partial Program ___ --> Inpatient ___ for eating d/o\n 1 week. \n- Psychiatrist & Therapist:\n ___ MD (___) \n ___ (___ in ___\n- Medication and ECT trials (reason for d/c if known):\n Effexor\n Citalopram\n Zoloft \n- Self-injury/Suicide attempts:\n Middle School\n Couple Months ago \n- Trauma: denies\n.\nPAST MEDICAL HISTORY:\n-denies chronic medical conditions\n-denies hx of seizure or head trauma\n \nSocial History:\nSOCIAL HISTORY:\nPer Dr. ___ ED Initial Psychiatry \nConsult note with revision/supplementation as provided per \nhistory at time of admission to unit.\n.\n___ for one semester until depression and anxiety \nprevented patient from continuing. Was able to make it to class \ninitially but struggled academically, receiving C's. Transferred \nto ___ for this academic year. Studying psychology. Living in a \ndorm at ___. Stable friend group there; knows some friends from \nhome and made some new friends already. Patient grew up in \n___. Parents live there now, patient has been living \nwith them since ___.\n.\nSUBSTANCE USE HISTORY:\nPer Dr. ___ ED Initial Psychiatry \nConsult note with revision/supplementation as provided per \nhistory at time of admission to unit.\n - EtOH: never \n - Tobacco: never \n - Cannabis: Marijuana ___, At night, \n - Illicits: never \n.\nFORENSIC HISTORY:\n___\nFamily History:\nFAMILY PSYCHIATRIC HISTORY:\nPer Dr. ___ ED Initial Psychiatry \nConsult note with revision/supplementation as provided per \nhistory at time of admission to unit.\n-Paternal side relatives w/ ___\n-Maternal side Alcohol Use Disorder\n \nPhysical Exam:\nVITAL SIGNS:\nT: 98.0\nBP: 92/60 \nHR: 87 \nRR: 18 \nspO2: 97 \n. \nEXAM:\nGeneral:\n -HEENT: Normocephalic, atraumatic. Moist mucous membranes, \noropharynx clear. No scleral icterus\n -Cardiovascular: Regular rate and rhythm, normal S1,S2, no \nmurmurs/rubs/gallops. \n -Pulmonary: No increased work of breathing. Lungs clear to \nauscultation bilaterally. No wheezes/rhonchi/rales.\n -Abdominal: Non-distended, bowel sounds normoactive.\n -Extremities: Warm and well-perfused. No edema of the limbs.\n -Skin: No rashes or lesions noted.\n.\nNeurological:\n-Cranial Nerves:\n ---I: Olfaction not tested.\n ---II: pupils equal round \n ---III, IV, VI: EOMI without nystagmus\n ---V: Masseter intact symmetrically and bilaterally\n ---VII: nasolabial folds symmetric bilaterally\n ---VIII: deferred\n ---IX, X: Palate elevates symmetrically\n ---XI: ___ strength in trapezii and SCM bilaterally\n ---XII: Tongue protrudes midline\n -Motor: Normal bulk and tone bilaterally. Strength ___ in \ndeltoids, biceps, triceps, quadriceps, hamstrings,\n -Sensory: deferred\n -DTRs: deferred\n ___: Normal on finger to nose test, no intention \ntremor noted\n -Gait/station: normal station; gait not observed directly\nAbsence of rigidity or spasticity\nAbsence of resting tremor\nAbsence of asterixis\n.\nCognition: \n -Wakefulness/alertness: Awake and alert\n -Attention: WORLD backwards w/ 0 errors\n -Orientation: ___, ___, summer\n -Executive function: test of ideomotor apraxia intact to brush \nteeth, comb hair\n -Memory: Violet, Church, ___\n -Fund of knowledge: Consistent with education; intact to last 3 \npresidents\n -Calculations: deferred\n -Abstraction: Interprets \"the grass is always greener on the \nother side\" as \"the other perspective looks better but this is \nnot always true\"\n -Visuospatial: right thumb to left ear\n -Language: Native ___ speaker, no paraphasic errors,\n appropriate to conversation\n.\nMental Status:\n -Appearance/behavior: woman appearing stated age, in hospital \ngown, sitting in chair w/ notable psychomotor agitation of right \nupper and lower extremity. appears visibly anxious, makes good \neye contact. \n -Attitude: Cooperative, engaged, friendly\n -Mood: \"low\"\n -Affect: Mood-congruent, dysphoric and anxious, mildly \nrestricted range, appropriate to situation\n -Speech: Normal rate, volume, and tone\n -Thought process: Linear, coherent, goal-oriented, no loose \nassociations\n -Thought Content:\n ---Safety: SI+\n ---Delusions: No evidence of paranoia, etc. \n ---Obsessions/Compulsions: No evidence based on current \nencounter\n ---Hallucinations: Denies AVH, not appearing to be attending to \ninternal stimuli\n -Insight: Limited\n -Judgment: Limited\n \nPertinent Results:\n___ 02:30PM BLOOD WBC-7.8 RBC-3.87* Hgb-10.9* Hct-33.6* \nMCV-87 MCH-28.2 MCHC-32.4 RDW-14.1 RDWSD-43.9 Plt ___\n___ 02:30PM BLOOD Glucose-105* UreaN-12 Creat-0.6 Na-142 \nK-3.6 Cl-107 HCO3-21* AnGap-14\n___ 02:30PM BLOOD ALT-10 AST-15 AlkPhos-60 TotBili-0.2\n___ 02:30PM BLOOD Albumin-4.2 Calcium-9.2 Phos-3.8 Mg-1.8\n___ 02:30PM BLOOD TSH-1.6\n___ 02:30PM BLOOD HCG-<5\n___ 02:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nTricycl-NEG\n___ 03:15PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG \ncocaine-NEG amphetm-POS* oxycodn-NEG mthdone-NEG\n\n___ 06:46AM BLOOD %HbA1c-5.0 eAG-97\n___ 06:46AM BLOOD Triglyc-49 HDL-40* CHOL/HD-3.2 LDLcalc-___. LEGAL & SAFETY: \nOn admission, the patient signed a conditional voluntary \nagreement (Section 10 & 11) and remained on that level \nthroughout their admission. She was also placed on 15 minute \nchecks status on admission which was escalated to 5 minute \nchecks at time because of self-harming behavior and remained on \nthat level of observation throughout while being unit \nrestricted.\n.\n2. PSYCHIATRIC:\nMs. ___ is a ___ year old female w/ GAD, depression, \nanorexia, and self reported diagnosis of borderline personality \ndisorder who presented with worsening sense of hopelessness and \nincreasing frequency of suicidal ideation resulting in a suicide \nattempt by overdosing on ___ pills of Trazadone 50mg earlier \ntoday. Psychiatry was consulted for safety assessment and \ntreatment recommendations. Ms. ___ was presenting following \nacutely worsening depressive and anxiety symptoms in setting of \nrecent psychosocial stressors. Despite excellent social support \nand outpatient resources (therapist) patient endorsed ongoing \nfeelings of hopelessness and worthlessness in setting of acutely \nworsening symptoms. Feelings of intense hopelessness led patient \nto consume multiple pills on day of admission with intention of \ngoing to sleep and not waking up. Collateral was concerning for \npatient's ongoing safety at home and inability to function \nindependently in a stressful environment at time of admission. \nMental status exam was notable\nfor low mood congruent with a dysphoric tearful affect that is \nrestricted in range. Patient reported ongoing suicidal ideation \nand had limited insight and judgment. Because of this, at time \nof admission patient was found to meet ___ criteria \nrequired involuntary hospitalization for ongoing crisis \nmanagement and acute stabilization, medication management as \nindicated, coordination with outpatient providers, and aftercare \nplanning.\n.\nDifferential diagnosis includes generalized anxiety disorder vs. \nunspecified mood disorder. However, the diagnosis which most \npertains to the patient's admission is likely a diagnosis of \nborderline personality disorder. While admitted, patient \ndemonstrated many behaviors consistent with this diagnosis \nincluding her efforts to avoid abandonment by the treatment \nteam, alternating between idealizing and evaluating others, \nunstable sense of self demonstrated by her perceived inability \nand decision making and other such tasks, impulsivity \nspecifically with regards to eating related behaviors, chronic \nsuicidality, affective instability, recurrent self harming \nbehaviors. Early in admission patient was able to identify a \nfew things which were helpful for anxiety, but she was able to \nsay that her buspirone was somewhat helpful. Because of this \nher buspirone was increased to a total of 20 mg twice a day by \ntime of discharge. Overall patient found this increase in dose \nto be somewhat helpful for anxiety and was well-tolerated. To \nprovide further affect of stability, patient was also started on \nlamotrigine at 25 mg nightly. Patient tolerated this medication \nwell without any reported side effects. Further consideration \nand outpatient treatment should be given to increasing this dose \nif patient finds it helpful. The starting dose was initiated on \n___. By time of discharge, patient demonstrated \nimprovements in her mood, with brightening of her affect, and \ncessation of active suicidal ideation. Patient's \nhospitalization was quite notable for intermittent suicidality \nand thoughts of self-harm, with intermittent self harming \nbehavior via scratching on forearms.\n.\n3. SUBSTANCE USE DISORDERS:\nNone\n.\n4. MEDICAL\nNone\n.\n5. PSYCHOSOCIAL\n#) GROUPS/MILIEU: \nThe patient was encouraged to participate in the various groups \nand milieu therapy opportunities offered by the unit. Patient \noften abstained from attending group therapy sessions, and was \noften isolate of remaining in her room throughout much of the \nday. She would interact intermittently with select peers in the \nday room. The\n.\n#) COLLATERAL INFORMATION AND FAMILY INVOLVEMENT\nCollateral from patient's primary psychiatrist consistent with \nprimary diagnosis of borderline personality disorder with \nrecommendation for intensive outpatient treatment. Collateral \nfrom patient's parents significant for reported history of \ndecompensation of self-harming behavior when in inpatient \nsetting and further emotional dysregulation. The patient's \nparents were invited onto the unit for several family meetings \nthroughout the patient's admission, and parents had the \nopportunity to ask questions about diagnostic clarification and \ntreatment planning. They were present on day of discharge and \nin agreement with discharge plan.\n.\n#) INTERVENTIONS\n- Medications: Increase of buspirone dose and initiation of \nlamotrigine\n- Psychotherapeutic Interventions: Individual, group, and milieu \ntherapy.\n- Coordination of aftercare: Provided with follow-up \nappointments and partial hospitalization program intake\n- Behavioral Interventions (e.g. encouraged DBT skills, ect): \nEncourage utilization of DBT skills\n-Guardianships: Not applicable\n.\nINFORMED CONSENT: Lamotrigine\nThe team discussed the indications for, intended benefits of, \nand possible side effects and risks of starting this medication \nincluding life-threatening rash, and risks and benefits of \npossible alternatives, including not taking the medication, with \nthis patient. We discussed the patient's right to decide \nwhether to take this medication as well as the importance of the \npatient's actively participating in the treatment and discussing \nany questions about medications with the treatment team. The \npatient appeared able to understand and consented to begin the \nmedication.\n.\nOn ___, Ms. ___ shared that she is ready for the discharge. \nshe reported that anxiety is at a manageable level (___). She \nshared that she slept well last night (from 11pm to 8am). She \nshared that she doesn't have any suicidal thoughts: \"I am not \nhaving any\". Ms. ___ shared about positive plans for future: she \nwill have meeting with therapist in the afternoon. She plans to \ngo to the B-day upcoming weekend. Pt was educated about risks of \nETOH. Specifically, we discussed concern of increased \nimpulsivity when intoxicated. Also, discussed negative effect on \nmood, cognition, gen-medical health. Pt expressed formal \nunderstanding.\nMs. ___ shared that her father will pick her up upon discharge \nfrom the unit.\n\nRISK ASSESSMENT & PROGNOSIS\nOn presentation, the patient was evaluated and felt to be at an \nincreased risk of harm to herself based upon worsening depressed \nmood with suicidal ideation and suicide attempt. Her static \nfactors noted at that time include history of suicide attempt, \nchronic mental illness, recent discharge from an inpatient \npsychiatric unit, Caucasian race, age, LGBT identity, and the \npresence of a concurrent personality disorder. At time of \nadmission patient was found to be at acutely elevated risk of \nharm to herself even her modifiable risk factors of her ongoing \nsuicidal ideation, hopelessness, recklessness, social \nwithdrawal, limited coping skills, impulsivity, and her ongoing \nthoughts of self-harm. These modifiable risk factors were \naddressed via acute stabilization and therapeutic milieu, \nmedication adjustment, provision of individual and group \ntherapy, and aftercare planning. Finally, the patient is being \ndischarged with many protective risk factors, including her \nfuture oriented viewpoint, sense of responsibility to family, \nreality testing ability, good problem solving skills, positive \ntherapeutic relationships with outpatient providers, lack of \nsuicidal ideation, and strong social supports. Overall, at the \ntime of discharge, the patient is not at an acutely elevated \nrisk of self-harm nor danger to others due to acutely \ndecompensated psychiatric illness. Thus, I feel the patient does \nnot meet criteria for involuntary treatment. \n.\nHer prognosis for this patient remains guarded at this time as \npt has several static risk factors. However, her prognosis is \nlikely to improve if pt chooses to follow up on treatment \nrecommendations.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. ARIPiprazole 7.5 mg PO BID \n2. BusPIRone 15 mg PO BID \n3. Escitalopram Oxalate 10 mg PO QAM \n4. Benztropine Mesylate 0.5 mg PO BID \n5. FoLIC Acid 1 mg PO DAILY \n6. LORazepam 0.5 mg PO BID:PRN anxiety \n\n \nDischarge Medications:\n1. HydrOXYzine 25 mg PO Q4H:PRN anxiety \n2. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild NOT relieved by \nAcetaminophen \n3. LamoTRIgine 25 mg PO QHS \n4. BusPIRone 20 mg PO BID \n5. ARIPiprazole 7.5 mg PO BID \n6. Benztropine Mesylate 0.5 mg PO BID \n7. Escitalopram Oxalate 10 mg PO QAM \n8. FoLIC Acid 1 mg PO DAILY \n9. LORazepam 0.5 mg PO BID:PRN anxiety \n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nGeneral anxiety disorder.\nMajor depressive disorder, recurrent, moderate.\nEating disorder, not otherwise specified.\nBorderline Personality Disorder\n\n \nDischarge Condition:\nVitals:\nTemp: 97.2 PO BP: 102/71 HR: 84 RR: 16 O2 sat: 98% \n\nMental Status:\n-Appearance: ___ female appearing stated age, wearing\ncasual clothing, good hygiene and grooming, no acute distress.\n-Behavior: Sitting up, good eye contact, no psychomotor \nagitation\nor retardation \n-Attitude: Cooperative\n-Mood: 'better'. Reports that anxiety is still present but \nbetter (placed ___\n-Affect: Mood-congruent, restricted range, no tearfulness, \nexchanged smile\n-Speech: Normal rate, volume, and tone\n-Thought process: Linear, coherent, goal-oriented, no loose\nassociations\n-Thought Content:\n---Safety: reports feeling safe today. Denies S/I. Shared about \npositive plans for future (seeing psychiatrist later today, \ngoing to B-day party tomorrow, appointment with therapist on \n___.\n---Delusions: No evidence of paranoia, etc. \n---Obsessions/Compulsions: No evidence based on current \nencounter\n---Hallucinations: Denies AVH, not appearing to be attending to\ninternal stimuli\n\nMs. ___ was engaged in discussion about her d/c plan. Reported \nfeeling ready for discharge today. Writer has met with Ms. \n___ and ___ father who came to pick her up.\n\n \nDischarge Instructions:\n-Please follow up with all outpatient appointments as listed - \ntake this discharge paperwork to your appointments.\n-Unless a limited duration is specified in the prescription, \nplease continue all medications as directed until your \nprescriber tells you to stop or change.\n-Please avoid abusing alcohol and any drugs--whether \nprescription drugs or illegal drugs--as this can further worsen \nyour medical and psychiatric illnesses.\n-Please contact your outpatient psychiatrist or other providers \nif you have any concerns.\n-Please call ___ or go to your nearest emergency room if you \nfeel unsafe in any way and are unable to immediately reach your \nhealth care providers.\nIt was a pleasure to have worked with you, and we wish you the \nbest of health.\n \nFollowup Instructions:\n___\n"
] | Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: "I tried to commit suicide today" Major Surgical or Invasive Procedure: None History of Present Illness: Per Dr. [MASKED] accept note dated [MASKED]: Per Dr. [MASKED] ED Initial Psychiatry Consult note: "Ms. [MASKED] is a [MASKED] year old female w/ GAD, depression, anorexia, and self-reported diagnosis of borderline personality disorder brought in by ambulance following suicide attempt via consumption of [MASKED] pills of Trazodone 50mg earlier today in setting of worsening sense of hopelessness and increasing frequency of suicidal ideation." . Ms. [MASKED] reports worsening depressive symptoms most predominantly feelings of worthlessness, difficulty staying asleep, low mood, decreased energy, poor motivation, loss of concentration and intermittent thoughts of suicidal ideation worsening acutely since last [MASKED] in to college at [MASKED]. Per patient report, she has also had increasing anxiety regarding class burden and social interaction, including increasing frequency of "panic attacks" or episodes of heart racing, shortness of breath, intense fear lasting for [MASKED] minutes followed by fatigue. This morning was the first day of classes at [MASKED]. Patient attended her 08:00 AM class successfully and then returned to her dorm to have a conference call/meeting with her therapist. She reported feeling intense anxiety following the class and acute worsening of her depressive symptoms which was not ameliorated by her discussion with her therapist. Ms. [MASKED] proceeded to end her conversation with her therapist prematurely and felt an overwhelming sense of hopelessness that she would never escape these feelings of anxiety. Patient reports that she proceeded to ingest [MASKED] pills of her Trazodone with intention of "going to sleep and not waking up." She states that following this her therapist called her father who arrived shortly before the ambulance. She reports vomiting multiple times and but does not express regret regarding her decision. She states that this is her first suicide attempt but reports that in [MASKED] she poured multiple pills of trazadone in her hand but did not ingest them at this point in time. Patient reports that she has had suicidal ideation multiple times per day for the last several days acutely worsening today with specific plan to overdose. She states that she also thought about cutting her wrists and bleeding out. Previous to the event today, patient reports feelings of emptiness, fatigue, and feeling like the "day is dragging." She cites her bed as her only sense of relief from the anxiety and stress of the day. Patient endorses ongoing feelings of hopelessness and helplessness following this attempt and states that she continues to feel like a burden to friends and family. . COLLATERAL EMS run report: [MASKED] female.. admits to ingestion of her own Trazadone 50 mg tab. less than (2)hr prior.. and admits to having " 15 pills.. Patient admits to being stressed in her new freshman [MASKED] environment.. but otherwise was cooperative and in no acute distress." . PARENTS at bedside: Patients mother reports that patient has struggled with anxiety, and depression for many years and more recently with restrictive eating resulting in multiple partial hospitalizations and inpatient hospitalization at [MASKED]. Mother reports that patient was living at home with parents since withdrawing from school after completion of the first semester of college last year. Patient was hopeful that she return to college and was accepted as a transfer to [MASKED] for this semester. Over the course of the [MASKED] patient has been working with therapist and psychiatrist to have a plan for return to school. Since patient moved in to [MASKED] on [MASKED] mother has been back and forth visiting patient on a daily basis. Today was the first day of classes and mother spoke with patient on phone prior to her attending her 0800 am class. Patient had an online video appointment with therapist following first class. Patient's father received a call from daughter at approximately 11AM stating that she needed him to come to her dorm but patient did not provide details. Patient's therapist called father and therapist also alerted [MASKED] police who were at scene when father arrived. Patient was awake, vomited several times and continued to do so on way to the hospital. Parents are concerned for patient's safety at home. Report that patient has expressed suicidal ideation in past but has never acted on these thoughts until now. Parent's do not feel safe taking daughter home and believe inpatient level of care is best for patient at this time." . In the ED patient was calm and cooperative. Sleeping intermittently with parents at bedside. Received dinner, ate sparingly. . On interview on the unit patient appeared visibly anxious but was calm and cooperative. Endorsed ongoing anxiety but also a desire to go to bed for the evening. Reported persistence of poor mood, feelings of hopelessness, thoughts of death without active plan at this time. Patient confirmed that she received evening meds (aripiprazole and buspar) in the ED this evening. REVIEW OF SYSTEMS: =PSYCHIATRIC -Positive per HPI +avoidance of social situations +panic attacks -Denies the following: psychomotor agitation/retardation, delusions, thought broadcasting/insertion, hallucinations, elevated mood, increased activity/energy, decreased need for sleep, grandiosity, increased speech, social/economic indiscretion =MEDICAL -Pertinent Positives: -Denies: fever, HA, visual changes, chest pain, SOB, nausea, vomiting, constipation, diarrhea, rashes, joint pain, dysuria Past Medical History: PAST PSYCHIATRIC HISTORY: Per Dr. [MASKED] ED Initial Psychiatry Consult note with revision/supplementation as provided per history at time of admission to unit. - Past diagnoses: Borderline PD ([MASKED]) Anorexia ([MASKED]) Depression [MASKED] yo) GAD [MASKED] yo Social Anxiety --> GAD [MASKED] yo) - Hospitalizations: [MASKED] years - Suicidal ideation (Arbour HRI) 2 week inpatient stay Partial program at [MASKED] [MASKED] [MASKED] [MASKED]- Suicidal ideation [MASKED] [MASKED]- Suicidal ideation Partial Program [MASKED] --> Inpatient [MASKED] for eating d/o 1 week. - Psychiatrist & Therapist: [MASKED] MD ([MASKED]) [MASKED] ([MASKED] in [MASKED] - Medication and ECT trials (reason for d/c if known): Effexor Citalopram Zoloft - Self-injury/Suicide attempts: Middle School Couple Months ago - Trauma: denies . PAST MEDICAL HISTORY: -denies chronic medical conditions -denies hx of seizure or head trauma Social History: SOCIAL HISTORY: Per Dr. [MASKED] ED Initial Psychiatry Consult note with revision/supplementation as provided per history at time of admission to unit. . [MASKED] for one semester until depression and anxiety prevented patient from continuing. Was able to make it to class initially but struggled academically, receiving C's. Transferred to [MASKED] for this academic year. Studying psychology. Living in a dorm at [MASKED]. Stable friend group there; knows some friends from home and made some new friends already. Patient grew up in [MASKED]. Parents live there now, patient has been living with them since [MASKED]. . SUBSTANCE USE HISTORY: Per Dr. [MASKED] ED Initial Psychiatry Consult note with revision/supplementation as provided per history at time of admission to unit. - EtOH: never - Tobacco: never - Cannabis: Marijuana [MASKED], At night, - Illicits: never . FORENSIC HISTORY: [MASKED] Family History: FAMILY PSYCHIATRIC HISTORY: Per Dr. [MASKED] ED Initial Psychiatry Consult note with revision/supplementation as provided per history at time of admission to unit. -Paternal side relatives w/ [MASKED] -Maternal side Alcohol Use Disorder Physical Exam: VITAL SIGNS: T: 98.0 BP: 92/60 HR: 87 RR: 18 spO2: 97 . EXAM: General: -HEENT: Normocephalic, atraumatic. Moist mucous membranes, oropharynx clear. No scleral icterus -Cardiovascular: Regular rate and rhythm, normal S1,S2, no murmurs/rubs/gallops. -Pulmonary: No increased work of breathing. Lungs clear to auscultation bilaterally. No wheezes/rhonchi/rales. -Abdominal: Non-distended, bowel sounds normoactive. -Extremities: Warm and well-perfused. No edema of the limbs. -Skin: No rashes or lesions noted. . Neurological: -Cranial Nerves: ---I: Olfaction not tested. ---II: pupils equal round ---III, IV, VI: EOMI without nystagmus ---V: Masseter intact symmetrically and bilaterally ---VII: nasolabial folds symmetric bilaterally ---VIII: deferred ---IX, X: Palate elevates symmetrically ---XI: [MASKED] strength in trapezii and SCM bilaterally ---XII: Tongue protrudes midline -Motor: Normal bulk and tone bilaterally. Strength [MASKED] in deltoids, biceps, triceps, quadriceps, hamstrings, -Sensory: deferred -DTRs: deferred [MASKED]: Normal on finger to nose test, no intention tremor noted -Gait/station: normal station; gait not observed directly Absence of rigidity or spasticity Absence of resting tremor Absence of asterixis . Cognition: -Wakefulness/alertness: Awake and alert -Attention: WORLD backwards w/ 0 errors -Orientation: [MASKED], [MASKED], summer -Executive function: test of ideomotor apraxia intact to brush teeth, comb hair -Memory: Violet, Church, [MASKED] -Fund of knowledge: Consistent with education; intact to last 3 presidents -Calculations: deferred -Abstraction: Interprets "the grass is always greener on the other side" as "the other perspective looks better but this is not always true" -Visuospatial: right thumb to left ear -Language: Native [MASKED] speaker, no paraphasic errors, appropriate to conversation . Mental Status: -Appearance/behavior: woman appearing stated age, in hospital gown, sitting in chair w/ notable psychomotor agitation of right upper and lower extremity. appears visibly anxious, makes good eye contact. -Attitude: Cooperative, engaged, friendly -Mood: "low" -Affect: Mood-congruent, dysphoric and anxious, mildly restricted range, appropriate to situation -Speech: Normal rate, volume, and tone -Thought process: Linear, coherent, goal-oriented, no loose associations -Thought Content: ---Safety: SI+ ---Delusions: No evidence of paranoia, etc. ---Obsessions/Compulsions: No evidence based on current encounter ---Hallucinations: Denies AVH, not appearing to be attending to internal stimuli -Insight: Limited -Judgment: Limited Pertinent Results: [MASKED] 02:30PM BLOOD WBC-7.8 RBC-3.87* Hgb-10.9* Hct-33.6* MCV-87 MCH-28.2 MCHC-32.4 RDW-14.1 RDWSD-43.9 Plt [MASKED] [MASKED] 02:30PM BLOOD Glucose-105* UreaN-12 Creat-0.6 Na-142 K-3.6 Cl-107 HCO3-21* AnGap-14 [MASKED] 02:30PM BLOOD ALT-10 AST-15 AlkPhos-60 TotBili-0.2 [MASKED] 02:30PM BLOOD Albumin-4.2 Calcium-9.2 Phos-3.8 Mg-1.8 [MASKED] 02:30PM BLOOD TSH-1.6 [MASKED] 02:30PM BLOOD HCG-<5 [MASKED] 02:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG [MASKED] 03:15PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-POS* oxycodn-NEG mthdone-NEG [MASKED] 06:46AM BLOOD %HbA1c-5.0 eAG-97 [MASKED] 06:46AM BLOOD Triglyc-49 HDL-40* CHOL/HD-3.2 LDLcalc-[MASKED]. LEGAL & SAFETY: On admission, the patient signed a conditional voluntary agreement (Section 10 & 11) and remained on that level throughout their admission. She was also placed on 15 minute checks status on admission which was escalated to 5 minute checks at time because of self-harming behavior and remained on that level of observation throughout while being unit restricted. . 2. PSYCHIATRIC: Ms. [MASKED] is a [MASKED] year old female w/ GAD, depression, anorexia, and self reported diagnosis of borderline personality disorder who presented with worsening sense of hopelessness and increasing frequency of suicidal ideation resulting in a suicide attempt by overdosing on [MASKED] pills of Trazadone 50mg earlier today. Psychiatry was consulted for safety assessment and treatment recommendations. Ms. [MASKED] was presenting following acutely worsening depressive and anxiety symptoms in setting of recent psychosocial stressors. Despite excellent social support and outpatient resources (therapist) patient endorsed ongoing feelings of hopelessness and worthlessness in setting of acutely worsening symptoms. Feelings of intense hopelessness led patient to consume multiple pills on day of admission with intention of going to sleep and not waking up. Collateral was concerning for patient's ongoing safety at home and inability to function independently in a stressful environment at time of admission. Mental status exam was notable for low mood congruent with a dysphoric tearful affect that is restricted in range. Patient reported ongoing suicidal ideation and had limited insight and judgment. Because of this, at time of admission patient was found to meet [MASKED] criteria required involuntary hospitalization for ongoing crisis management and acute stabilization, medication management as indicated, coordination with outpatient providers, and aftercare planning. . Differential diagnosis includes generalized anxiety disorder vs. unspecified mood disorder. However, the diagnosis which most pertains to the patient's admission is likely a diagnosis of borderline personality disorder. While admitted, patient demonstrated many behaviors consistent with this diagnosis including her efforts to avoid abandonment by the treatment team, alternating between idealizing and evaluating others, unstable sense of self demonstrated by her perceived inability and decision making and other such tasks, impulsivity specifically with regards to eating related behaviors, chronic suicidality, affective instability, recurrent self harming behaviors. Early in admission patient was able to identify a few things which were helpful for anxiety, but she was able to say that her buspirone was somewhat helpful. Because of this her buspirone was increased to a total of 20 mg twice a day by time of discharge. Overall patient found this increase in dose to be somewhat helpful for anxiety and was well-tolerated. To provide further affect of stability, patient was also started on lamotrigine at 25 mg nightly. Patient tolerated this medication well without any reported side effects. Further consideration and outpatient treatment should be given to increasing this dose if patient finds it helpful. The starting dose was initiated on [MASKED]. By time of discharge, patient demonstrated improvements in her mood, with brightening of her affect, and cessation of active suicidal ideation. Patient's hospitalization was quite notable for intermittent suicidality and thoughts of self-harm, with intermittent self harming behavior via scratching on forearms. . 3. SUBSTANCE USE DISORDERS: None . 4. MEDICAL None . 5. PSYCHOSOCIAL #) GROUPS/MILIEU: The patient was encouraged to participate in the various groups and milieu therapy opportunities offered by the unit. Patient often abstained from attending group therapy sessions, and was often isolate of remaining in her room throughout much of the day. She would interact intermittently with select peers in the day room. The . #) COLLATERAL INFORMATION AND FAMILY INVOLVEMENT Collateral from patient's primary psychiatrist consistent with primary diagnosis of borderline personality disorder with recommendation for intensive outpatient treatment. Collateral from patient's parents significant for reported history of decompensation of self-harming behavior when in inpatient setting and further emotional dysregulation. The patient's parents were invited onto the unit for several family meetings throughout the patient's admission, and parents had the opportunity to ask questions about diagnostic clarification and treatment planning. They were present on day of discharge and in agreement with discharge plan. . #) INTERVENTIONS - Medications: Increase of buspirone dose and initiation of lamotrigine - Psychotherapeutic Interventions: Individual, group, and milieu therapy. - Coordination of aftercare: Provided with follow-up appointments and partial hospitalization program intake - Behavioral Interventions (e.g. encouraged DBT skills, ect): Encourage utilization of DBT skills -Guardianships: Not applicable . INFORMED CONSENT: Lamotrigine The team discussed the indications for, intended benefits of, and possible side effects and risks of starting this medication including life-threatening rash, and risks and benefits of possible alternatives, including not taking the medication, with this patient. We discussed the patient's right to decide whether to take this medication as well as the importance of the patient's actively participating in the treatment and discussing any questions about medications with the treatment team. The patient appeared able to understand and consented to begin the medication. . On [MASKED], Ms. [MASKED] shared that she is ready for the discharge. she reported that anxiety is at a manageable level ([MASKED]). She shared that she slept well last night (from 11pm to 8am). She shared that she doesn't have any suicidal thoughts: "I am not having any". Ms. [MASKED] shared about positive plans for future: she will have meeting with therapist in the afternoon. She plans to go to the B-day upcoming weekend. Pt was educated about risks of ETOH. Specifically, we discussed concern of increased impulsivity when intoxicated. Also, discussed negative effect on mood, cognition, gen-medical health. Pt expressed formal understanding. Ms. [MASKED] shared that her father will pick her up upon discharge from the unit. RISK ASSESSMENT & PROGNOSIS On presentation, the patient was evaluated and felt to be at an increased risk of harm to herself based upon worsening depressed mood with suicidal ideation and suicide attempt. Her static factors noted at that time include history of suicide attempt, chronic mental illness, recent discharge from an inpatient psychiatric unit, Caucasian race, age, LGBT identity, and the presence of a concurrent personality disorder. At time of admission patient was found to be at acutely elevated risk of harm to herself even her modifiable risk factors of her ongoing suicidal ideation, hopelessness, recklessness, social withdrawal, limited coping skills, impulsivity, and her ongoing thoughts of self-harm. These modifiable risk factors were addressed via acute stabilization and therapeutic milieu, medication adjustment, provision of individual and group therapy, and aftercare planning. Finally, the patient is being discharged with many protective risk factors, including her future oriented viewpoint, sense of responsibility to family, reality testing ability, good problem solving skills, positive therapeutic relationships with outpatient providers, lack of suicidal ideation, and strong social supports. Overall, at the time of discharge, the patient is not at an acutely elevated risk of self-harm nor danger to others due to acutely decompensated psychiatric illness. Thus, I feel the patient does not meet criteria for involuntary treatment. . Her prognosis for this patient remains guarded at this time as pt has several static risk factors. However, her prognosis is likely to improve if pt chooses to follow up on treatment recommendations. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ARIPiprazole 7.5 mg PO BID 2. BusPIRone 15 mg PO BID 3. Escitalopram Oxalate 10 mg PO QAM 4. Benztropine Mesylate 0.5 mg PO BID 5. FoLIC Acid 1 mg PO DAILY 6. LORazepam 0.5 mg PO BID:PRN anxiety Discharge Medications: 1. HydrOXYzine 25 mg PO Q4H:PRN anxiety 2. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild NOT relieved by Acetaminophen 3. LamoTRIgine 25 mg PO QHS 4. BusPIRone 20 mg PO BID 5. ARIPiprazole 7.5 mg PO BID 6. Benztropine Mesylate 0.5 mg PO BID 7. Escitalopram Oxalate 10 mg PO QAM 8. FoLIC Acid 1 mg PO DAILY 9. LORazepam 0.5 mg PO BID:PRN anxiety Discharge Disposition: Home Discharge Diagnosis: General anxiety disorder. Major depressive disorder, recurrent, moderate. Eating disorder, not otherwise specified. Borderline Personality Disorder Discharge Condition: Vitals: Temp: 97.2 PO BP: 102/71 HR: 84 RR: 16 O2 sat: 98% Mental Status: -Appearance: [MASKED] female appearing stated age, wearing casual clothing, good hygiene and grooming, no acute distress. -Behavior: Sitting up, good eye contact, no psychomotor agitation or retardation -Attitude: Cooperative -Mood: 'better'. Reports that anxiety is still present but better (placed [MASKED] -Affect: Mood-congruent, restricted range, no tearfulness, exchanged smile -Speech: Normal rate, volume, and tone -Thought process: Linear, coherent, goal-oriented, no loose associations -Thought Content: ---Safety: reports feeling safe today. Denies S/I. Shared about positive plans for future (seeing psychiatrist later today, going to B-day party tomorrow, appointment with therapist on [MASKED]. ---Delusions: No evidence of paranoia, etc. ---Obsessions/Compulsions: No evidence based on current encounter ---Hallucinations: Denies AVH, not appearing to be attending to internal stimuli Ms. [MASKED] was engaged in discussion about her d/c plan. Reported feeling ready for discharge today. Writer has met with Ms. [MASKED] and [MASKED] father who came to pick her up. Discharge Instructions: -Please follow up with all outpatient appointments as listed - take this discharge paperwork to your appointments. -Unless a limited duration is specified in the prescription, please continue all medications as directed until your prescriber tells you to stop or change. -Please avoid abusing alcohol and any drugs--whether prescription drugs or illegal drugs--as this can further worsen your medical and psychiatric illnesses. -Please contact your outpatient psychiatrist or other providers if you have any concerns. -Please call [MASKED] or go to your nearest emergency room if you feel unsafe in any way and are unable to immediately reach your health care providers. It was a pleasure to have worked with you, and we wish you the best of health. Followup Instructions: [MASKED] | [
"F331",
"F411",
"F509",
"F603",
"Z915",
"Z79899",
"Z818",
"F1290"
] | [
"F331: Major depressive disorder, recurrent, moderate",
"F411: Generalized anxiety disorder",
"F509: Eating disorder, unspecified",
"F603: Borderline personality disorder",
"Z915: Personal history of self-harm",
"Z79899: Other long term (current) drug therapy",
"Z818: Family history of other mental and behavioral disorders",
"F1290: Cannabis use, unspecified, uncomplicated"
] | [] | [] |
10,323,492 | 20,551,947 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: OBSTETRICS/GYNECOLOGY\n \nAllergies: \nPenicillins / Sulfa (Sulfonamide Antibiotics) / oxycodone\n \nAttending: ___\n \nChief Complaint:\nepigastric pain, nausea, vomiting\n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\n___ yo ___ s/p en bloc radical hysterectomy/BSO/rectosigmoid\nresection, small bowel resection and anastomosis, end colostomy,\nfor stage IIIC possible fallopian tube primary adenocarcinoma,\nintestinal type, on ___ s/p cycle 1 of FOLFOX, presenting\nwith N/V, abdominal pain x 1 day starting ___ AM. She had been\nhaving mild abd discomfort ___ weeks ago with N/V and was seen \nin\nED with CT c/f enteritis. She was started on Cipro/Flagyl ___\nand is completing a 2 week course with improvement of her N/V \nand\npain. This AM, she had breakfast and soon after had significant\nepigastric pain with an episode of emesis and nausea around \n1130.\nNo futher emesis since. She presented to the ED for eval. \n\nShe continues to have epigastric pain that comes in waves,\nimproved with APAP. No CP/SOB, F/C, diarrhea, Dizziness, \ndysuria,\nhematuria, vaginal bleeding, rectal bleeding. She did not have\nflatus today and minimal stool on her ostomy bag until after her\nPO contrast, which led to passage of some loose stool. \nno known sick contacts. \n\nROS otherwise neg\n\n \nPast Medical History:\nPAST MEDICAL HISTORY:\n- benign positional vertigo\n- thyroid nodule\n- osteopenia\n- tinnitus\n- Denies hypertension, diabetes, asthma, thromboembolic disease\n- stage IIIC possible fallopian tube primary adenocarcinoma\n\nPAST SURGICAL HISTORY:\n- ___ en bloc radical hysterectomy/BSO/rectosigmoid resection,\nsmall bowel resection and anastomosis, end colostomy\n- ___ arthroscopy of right knee\n- ___ vulvar cyst excision\n\nPOB Hx: G2P1\n- ___ TAB\n- ___ SVD\n\nPGYN: \n- LMP ___\n- Used estring x ___ yrs, no other hormonal replacement therapy\n- Denies history of abnormal Pap smears; last Pap/HPV neg/neg\n___\n- Denies history of pelvic infections or sexually transmitted\ninfections\n\n \nSocial History:\n___\nFamily History:\n- Mother had MI age ___\n- Father died of myeloma age ___\n- MGM diagnosed with colon cancer in her ___\n- Maternal first cousin diagnosed with breast cancer in her \nearly\n___\n- No known family history of uterine, ovarian, or cervical \ncancer\n \nPhysical Exam:\nOn day of discharge:\nAfebrile, vitals stable\nNo acute distress\nCV: regular rate and rhythm\nPulm: clear to auscultation bilaterally\nAbd: soft, non tender, nondistended, normoactive bowel sounds, \nincision, no rebound/guarding\n___: nontender, nonedematous\n\n \nPertinent Results:\n___ 05:37AM BLOOD WBC-5.7 RBC-3.89* Hgb-11.1* Hct-34.3 \nMCV-88 MCH-28.5 MCHC-32.4 RDW-14.1 RDWSD-45.0 Plt ___\n___ 06:14AM BLOOD WBC-6.6 RBC-4.05 Hgb-11.7 Hct-35.6 MCV-88 \nMCH-28.9 MCHC-32.9 RDW-14.1 RDWSD-45.1 Plt ___\n___ 03:10PM BLOOD WBC-10.9*# RBC-4.39 Hgb-12.6 Hct-38.3 \nMCV-87 MCH-28.7 MCHC-32.9 RDW-14.1 RDWSD-43.8 Plt ___\n___ 05:37AM BLOOD Neuts-42.5 ___ Monos-11.8 \nEos-0.9* Baso-1.0 Im ___ AbsNeut-2.44 AbsLymp-2.50 \nAbsMono-0.68 AbsEos-0.05 AbsBaso-0.06\n___ 06:14AM BLOOD Neuts-42.8 ___ Monos-9.6 Eos-1.2 \nBaso-0.8 Im ___ AbsNeut-2.82# AbsLymp-2.96 AbsMono-0.63 \nAbsEos-0.08 AbsBaso-0.05\n___ 03:10PM BLOOD Neuts-79.7* Lymphs-15.3* Monos-3.9* \nEos-0.1* Baso-0.4 Im ___ AbsNeut-8.69*# AbsLymp-1.67 \nAbsMono-0.42 AbsEos-0.01* AbsBaso-0.04\n___ 05:37AM BLOOD Glucose-81 UreaN-4* Creat-0.6 Na-143 \nK-4.0 Cl-105 HCO3-24 AnGap-18\n___ 06:14AM BLOOD Glucose-102* UreaN-5* Creat-0.6 Na-143 \nK-3.6 Cl-105 HCO3-28 AnGap-14\n___ 03:10PM BLOOD Glucose-102* UreaN-7 Creat-0.6 Na-142 \nK-3.8 Cl-101 HCO3-25 AnGap-20\n___ 03:10PM BLOOD ALT-79* AST-49* AlkPhos-92 TotBili-0.4\n___ 03:10PM BLOOD Lipase-77*\n___ 05:37AM BLOOD Calcium-8.5 Phos-4.0 Mg-2.1\n___ 06:14AM BLOOD Calcium-8.7 Phos-4.5 Mg-2.3\n___ 03:10PM BLOOD Albumin-3.6\n___ 03:16PM BLOOD Lactate-1.0\n \nBrief Hospital Course:\nMs. ___ was admitted to the gynecologic oncology service for \nmanagement of a small bowel obstruction. On admission a CT scan \nshowed a small-bowel obstruction with the transition point at \nthe anastomosis in the left lower quadrant. A nasogastric tube \nwas placed. She was kept NPO and put on maintenance IV fluids. \nOnce her nausea resolved and her NG tube output decreased, her \nNG tube was clamped, which she tolerated well. Her NG tube was \nremoved on ___ (day after admission), and her diet was \ngradually advanced. She was tolerating a regular diet by \n___. She was seen by nutrition for dietary counseling.\nOf note, she was continued on her 2-week course of cipro/flagyl \nthrough ___ for her enteritis, diagnosed prior to admission. \nBy ___, she was tolerating a regular diet and was \nsymptomatically improved. She was then discharged home in stable \ncondition with outpatient follow-up scheduled.\n \nMedications on Admission:\nMedications - Prescription\nCIPROFLOXACIN HCL [CIPRO] - Cipro 500 mg tablet. 1 tablet(s) by\nmouth twice a day\nIBUPROFEN - ibuprofen 400 mg tablet. 1 tablet(s) by mouth every\nfour (4) hours -6 hours/last dose was ___ - (Prescribed by\nOther Provider)\nLORAZEPAM - lorazepam 0.5 mg tablet. 1 tablet(s) by mouth three\ntimes a day as needed for nausea, anxiety\nMETRONIDAZOLE [FLAGYL] - Flagyl 500 mg tablet. 1 tablet(s) by\nmouth twice a day\nONDANSETRON HCL - ondansetron HCl 8 mg tablet. 1 tablet(s) by\nmouth every eight (8) hours as needed for nausea ICD 10\nCode:C57.00 Malignant neoplasm of unspecified fallopian tube\nPNV W/O CALCIUM-IRON FUM-FA [M-VIT] - M-Vit 27 mg-1 mg tablet. 1\ntablet(s) by mouth once a day - (Prescribed by Other Provider)\nPROCHLORPERAZINE MALEATE - prochlorperazine maleate 10 mg \ntablet.\n1 tablet(s) by mouth every six (6) hours as needed for nausea\n \nMedications - OTC\nACETAMINOPHEN - acetaminophen 500 mg tablet. 1 tablet(s) by \nmouth\nevery six (6) hours as needed for pain - (Prescribed by Other\nProvider)\nCALCIUM-VITAMIN D3-VITAMIN K [CALCIUM SOFT CHEW] - Calcium Soft\nChew 500 mg-1,000 unit-40 mcg tablet. 1 tablet(s) by mouth once \na\nday - (Prescribed by Other Provider)\nDOCUSATE SODIUM - docusate sodium 100 mg capsule. 1 capsule(s) \nby\nmouth twice a day - (Prescribed by Other Provider)\n\n \nDischarge Medications:\n1. Ciprofloxacin HCl 500 mg PO Q12H \n2. MetroNIDAZOLE 500 mg PO BID \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \n___ Diagnosis:\nsmall bowel obstruction\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n.\nYou were admitted to the gynecologic oncology service with a \nsmall bowel obstruction. You were managed conservatively, with a \nNG tube and with backing down on your diet. Your symptoms \nresolved. You have recovered well, and the team feels that you \nare safe to be discharged home. Please follow these \ninstructions: \n.\nCall your doctor at ___ for: \n* fever > 100.4 \n* severe abdominal pain \n* difficulty urinating \n* vaginal bleeding requiring >1 pad/hr \n* abnormal vaginal discharge \n* redness or drainage from incision \n* nausea/vomiting where you are unable to keep down fluids/food \nor your medication \n* chest pain or difficulty breathing \n* onset of any concerning symptoms \n.\nTo reach medical records to get the records from this \nhospitalization sent to your doctor at home, call ___. \n\n \nFollowup Instructions:\n___\n"
] | Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) / oxycodone Chief Complaint: epigastric pain, nausea, vomiting Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] yo [MASKED] s/p en bloc radical hysterectomy/BSO/rectosigmoid resection, small bowel resection and anastomosis, end colostomy, for stage IIIC possible fallopian tube primary adenocarcinoma, intestinal type, on [MASKED] s/p cycle 1 of FOLFOX, presenting with N/V, abdominal pain x 1 day starting [MASKED] AM. She had been having mild abd discomfort [MASKED] weeks ago with N/V and was seen in ED with CT c/f enteritis. She was started on Cipro/Flagyl [MASKED] and is completing a 2 week course with improvement of her N/V and pain. This AM, she had breakfast and soon after had significant epigastric pain with an episode of emesis and nausea around 1130. No futher emesis since. She presented to the ED for eval. She continues to have epigastric pain that comes in waves, improved with APAP. No CP/SOB, F/C, diarrhea, Dizziness, dysuria, hematuria, vaginal bleeding, rectal bleeding. She did not have flatus today and minimal stool on her ostomy bag until after her PO contrast, which led to passage of some loose stool. no known sick contacts. ROS otherwise neg Past Medical History: PAST MEDICAL HISTORY: - benign positional vertigo - thyroid nodule - osteopenia - tinnitus - Denies hypertension, diabetes, asthma, thromboembolic disease - stage IIIC possible fallopian tube primary adenocarcinoma PAST SURGICAL HISTORY: - [MASKED] en bloc radical hysterectomy/BSO/rectosigmoid resection, small bowel resection and anastomosis, end colostomy - [MASKED] arthroscopy of right knee - [MASKED] vulvar cyst excision POB Hx: G2P1 - [MASKED] TAB - [MASKED] SVD PGYN: - LMP [MASKED] - Used estring x [MASKED] yrs, no other hormonal replacement therapy - Denies history of abnormal Pap smears; last Pap/HPV neg/neg [MASKED] - Denies history of pelvic infections or sexually transmitted infections Social History: [MASKED] Family History: - Mother had MI age [MASKED] - Father died of myeloma age [MASKED] - MGM diagnosed with colon cancer in her [MASKED] - Maternal first cousin diagnosed with breast cancer in her early [MASKED] - No known family history of uterine, ovarian, or cervical cancer Physical Exam: On day of discharge: Afebrile, vitals stable No acute distress CV: regular rate and rhythm Pulm: clear to auscultation bilaterally Abd: soft, non tender, nondistended, normoactive bowel sounds, incision, no rebound/guarding [MASKED]: nontender, nonedematous Pertinent Results: [MASKED] 05:37AM BLOOD WBC-5.7 RBC-3.89* Hgb-11.1* Hct-34.3 MCV-88 MCH-28.5 MCHC-32.4 RDW-14.1 RDWSD-45.0 Plt [MASKED] [MASKED] 06:14AM BLOOD WBC-6.6 RBC-4.05 Hgb-11.7 Hct-35.6 MCV-88 MCH-28.9 MCHC-32.9 RDW-14.1 RDWSD-45.1 Plt [MASKED] [MASKED] 03:10PM BLOOD WBC-10.9*# RBC-4.39 Hgb-12.6 Hct-38.3 MCV-87 MCH-28.7 MCHC-32.9 RDW-14.1 RDWSD-43.8 Plt [MASKED] [MASKED] 05:37AM BLOOD Neuts-42.5 [MASKED] Monos-11.8 Eos-0.9* Baso-1.0 Im [MASKED] AbsNeut-2.44 AbsLymp-2.50 AbsMono-0.68 AbsEos-0.05 AbsBaso-0.06 [MASKED] 06:14AM BLOOD Neuts-42.8 [MASKED] Monos-9.6 Eos-1.2 Baso-0.8 Im [MASKED] AbsNeut-2.82# AbsLymp-2.96 AbsMono-0.63 AbsEos-0.08 AbsBaso-0.05 [MASKED] 03:10PM BLOOD Neuts-79.7* Lymphs-15.3* Monos-3.9* Eos-0.1* Baso-0.4 Im [MASKED] AbsNeut-8.69*# AbsLymp-1.67 AbsMono-0.42 AbsEos-0.01* AbsBaso-0.04 [MASKED] 05:37AM BLOOD Glucose-81 UreaN-4* Creat-0.6 Na-143 K-4.0 Cl-105 HCO3-24 AnGap-18 [MASKED] 06:14AM BLOOD Glucose-102* UreaN-5* Creat-0.6 Na-143 K-3.6 Cl-105 HCO3-28 AnGap-14 [MASKED] 03:10PM BLOOD Glucose-102* UreaN-7 Creat-0.6 Na-142 K-3.8 Cl-101 HCO3-25 AnGap-20 [MASKED] 03:10PM BLOOD ALT-79* AST-49* AlkPhos-92 TotBili-0.4 [MASKED] 03:10PM BLOOD Lipase-77* [MASKED] 05:37AM BLOOD Calcium-8.5 Phos-4.0 Mg-2.1 [MASKED] 06:14AM BLOOD Calcium-8.7 Phos-4.5 Mg-2.3 [MASKED] 03:10PM BLOOD Albumin-3.6 [MASKED] 03:16PM BLOOD Lactate-1.0 Brief Hospital Course: Ms. [MASKED] was admitted to the gynecologic oncology service for management of a small bowel obstruction. On admission a CT scan showed a small-bowel obstruction with the transition point at the anastomosis in the left lower quadrant. A nasogastric tube was placed. She was kept NPO and put on maintenance IV fluids. Once her nausea resolved and her NG tube output decreased, her NG tube was clamped, which she tolerated well. Her NG tube was removed on [MASKED] (day after admission), and her diet was gradually advanced. She was tolerating a regular diet by [MASKED]. She was seen by nutrition for dietary counseling. Of note, she was continued on her 2-week course of cipro/flagyl through [MASKED] for her enteritis, diagnosed prior to admission. By [MASKED], she was tolerating a regular diet and was symptomatically improved. She was then discharged home in stable condition with outpatient follow-up scheduled. Medications on Admission: Medications - Prescription CIPROFLOXACIN HCL [CIPRO] - Cipro 500 mg tablet. 1 tablet(s) by mouth twice a day IBUPROFEN - ibuprofen 400 mg tablet. 1 tablet(s) by mouth every four (4) hours -6 hours/last dose was [MASKED] - (Prescribed by Other Provider) LORAZEPAM - lorazepam 0.5 mg tablet. 1 tablet(s) by mouth three times a day as needed for nausea, anxiety METRONIDAZOLE [FLAGYL] - Flagyl 500 mg tablet. 1 tablet(s) by mouth twice a day ONDANSETRON HCL - ondansetron HCl 8 mg tablet. 1 tablet(s) by mouth every eight (8) hours as needed for nausea ICD 10 Code:C57.00 Malignant neoplasm of unspecified fallopian tube PNV W/O CALCIUM-IRON FUM-FA [M-VIT] - M-Vit 27 mg-1 mg tablet. 1 tablet(s) by mouth once a day - (Prescribed by Other Provider) PROCHLORPERAZINE MALEATE - prochlorperazine maleate 10 mg tablet. 1 tablet(s) by mouth every six (6) hours as needed for nausea Medications - OTC ACETAMINOPHEN - acetaminophen 500 mg tablet. 1 tablet(s) by mouth every six (6) hours as needed for pain - (Prescribed by Other Provider) CALCIUM-VITAMIN D3-VITAMIN K [CALCIUM SOFT CHEW] - Calcium Soft Chew 500 mg-1,000 unit-40 mcg tablet. 1 tablet(s) by mouth once a day - (Prescribed by Other Provider) DOCUSATE SODIUM - docusate sodium 100 mg capsule. 1 capsule(s) by mouth twice a day - (Prescribed by Other Provider) Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q12H 2. MetroNIDAZOLE 500 mg PO BID Discharge Disposition: Home With Service Facility: [MASKED] [MASKED] Diagnosis: small bowel obstruction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], . You were admitted to the gynecologic oncology service with a small bowel obstruction. You were managed conservatively, with a NG tube and with backing down on your diet. Your symptoms resolved. You have recovered well, and the team feels that you are safe to be discharged home. Please follow these instructions: . Call your doctor at [MASKED] for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication * chest pain or difficulty breathing * onset of any concerning symptoms . To reach medical records to get the records from this hospitalization sent to your doctor at home, call [MASKED]. Followup Instructions: [MASKED] | [
"K5660",
"Z8589",
"Z933"
] | [
"K5660: Unspecified intestinal obstruction",
"Z8589: Personal history of malignant neoplasm of other organs and systems",
"Z933: Colostomy status"
] | [] | [] |
10,146,735 | 21,277,496 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nPenicillins / Keflex\n \nAttending: ___.\n \nChief Complaint:\nback pain, g tube eval\n \nMajor Surgical or Invasive Procedure:\nParacentesis ___\n\n \nHistory of Present Illness:\nMr. ___ is a ___ EtOH cirrhosis (Childs Class C; \ndecompensations including variceal bleed, hepatic \nencephalopathy, and refractory ascites), anxiety, and past \nopiate abuse, recently admitted to ___ with SBO, umbilical \nhernia (now s/p repair), HRS, hyponatremia and seizure who \npresents ___ rehab for NG tube replacement. Pt states his NG \ntube fell out 5 days ago. He has been tolerating PO intake \nwithout difficulty, without nausea, vomitting, diarrhea. He \npresented to ___ today for scheduled therapeutic paracentesis \nwith removal of 4.1L of fluid. He was called that he needed to \nreturn to the hospital for NG tube replacement. Patient also \nreports 5 days of deep bilateral flank pain with difficulty \nurinating and occasional dysuria. He denies fevers, hematuria, \nabdominal pain, difficulty ambulating, SOB, CP or redness, \ndrainage or pain at the incision site of his recent surgery. \n In the ED, initial vitals: 99.0 66 118/76 16 99% RA \n - Exam notable for: NTND abdomen, incision site is C/D/I. RRR. \nCTAB. No c/c/e. Generalized mild jaundice. \n - Labs notable for: Hgb 8.0, INR 1.4, nl LFTs, TB, lactate 1.5, \nneg UA, Cr 1.1 \n - Imaging notable for: N/A \n - Patient given: oxycodone 10mg PO x1, mirtazapine 30mg, \nlorazepam 1mg \n - Vitals prior to transfer: 98.1 70 118/70 14 96% RA \n On arrival to the floor, pt reports feeling well. He denies \nflank pain, instead reports worsening back pain in his lumbar \nand cervical spine. He has chronic back pain in these areas at \nbaseline, denies numbness, weakness. He denies difficulty \nurinating or decreased UOP. He denies nausea, vomiting or any \nrecurrence of similar SBO symptoms. \n\n \nPast Medical History:\n1.Chronic cirrhosis alcoholic, with associated ascites and \nencephalopathy; grade 2 esophageal varices & portal gastropathy \non EGD in ___. \n2. Previous opiate abuse on suboxone, no suboxone since several \nmonths ago \n3. Tobacco abuse \n4. Anxiety \n5. History of hyperplastic colonic polyp \n \nSocial History:\n___\nFamily History:\nFather died of cardiac disease, mother was alcoholic \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n==========================\nVitals: 98.5 PO 131 / 88 82 16 95 RA \nGeneral: Alert, oriented, no acute distress \nHEENT: Sclera anicteric, MMM \nLungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \nCV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, \ngallops \nAbdomen: soft, non-tender, distended, bowel sounds present, \n+hepatomegaly \nExt: Warm, well perfused, 2+ edema \nSkin: hyperpigmentation on ___ \nNeuro: A&Ox3. Grossly intact.\n\nDISCHARGE PHYSICAL EXAM:\n=========================\nVS: 98.6 PO 116/70 74 18 96%RA \nI/O: 1160/725+3void+3 BM(24hr); 200/350 (8hr)\nMELD: ___: 19|\nGeneral: Sitting up in bed, alert, oriented, no acute distress\nHEENT: Sclera anicteric, MMM, no temporal wasting\nLungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \nCV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, \ngallops \nAbdomen: soft, non-tender, mildly distended, bowel sounds \npresent, +hepatomegaly \nExt: Warm, well perfused, 1+ edema R>L (chronic)\nSkin: hyperpigmentation on ___ \nNeuro: A&Ox3. Grossly intact. \n \nPertinent Results:\nLABS ON ADMISSION:\n==================\n___ 09:20PM URINE HOURS-RANDOM\n___ 09:20PM URINE COLOR-Yellow APPEAR-Clear SP ___\n___ 09:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.0 \nLEUK-NEG\n___ 12:05AM WBC-6.0 RBC-2.74* HGB-8.0* HCT-25.1* MCV-92 \nMCH-29.2 MCHC-31.9* RDW-18.6* RDWSD-62.2*\n___ 12:05AM NEUTS-58.4 ___ MONOS-11.5 EOS-2.7 \nBASOS-1.0 IM ___ AbsNeut-3.51# AbsLymp-1.57 AbsMono-0.69 \nAbsEos-0.16 AbsBaso-0.06\n___ 12:05AM ALBUMIN-3.9\n___ 12:05AM LIPASE-44\n___ 12:05AM ALT(SGPT)-11 AST(SGOT)-25 ALK PHOS-127 TOT \nBILI-1.5\n___ 12:05AM GLUCOSE-87 UREA N-19 CREAT-1.1 SODIUM-137 \nPOTASSIUM-3.8 CHLORIDE-96 TOTAL CO2-27 ANION GAP-18\n___ 12:19AM ___ PTT-33.9 ___\n___ 12:47AM LACTATE-1.5\n___ 05:21AM ___ PTT-35.2 ___\n___ 05:21AM PLT COUNT-158\n___ 05:21AM WBC-5.6 RBC-2.54* HGB-7.6* HCT-23.6* MCV-93 \nMCH-29.9 MCHC-32.2 RDW-18.6* RDWSD-62.7*\n___ 05:21AM CALCIUM-8.5 PHOSPHATE-4.1 MAGNESIUM-2.0\n___ 05:21AM ALT(SGPT)-10 AST(SGOT)-27 ALK PHOS-115 TOT \nBILI-1.5\n___ 05:21AM GLUCOSE-174* UREA N-18 CREAT-1.2 SODIUM-136 \nPOTASSIUM-3.5 CHLORIDE-97 TOTAL CO2-23 ANION GAP-20\n\nMICRO:\n======\nUCX ___: NO GROWTH\nBCX ___: NO GROWTH\nPERITONEAL FLUID ___: \n___ 2:45 pm PERITONEAL FLUID\n GRAM STAIN (Final ___: \n NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. \n NO MICROORGANISMS SEEN. \n FLUID CULTURE (Final ___: NO GROWTH. \n ANAEROBIC CULTURE (Preliminary): NO GROWTH. \n\nSTUDIES:\n========\nPARACENTESIS ___: \n1. Technically successful ultrasound guided therapeutic \nparacentesis. \n2. 4.1 L of fluid were removed \n\n___ Renal US: IMPRESSION: \n1. Normal renal ultrasound. \n2. Small ascites. \n\n___ PARACENTESIS:\nIMPRESSION:\n1. Technically successful ultrasound guided diagnostic and \ntherapeutic\nparacentesis.\n2. 3 L of clear straw-colored fluid were removed.\n\nLABS ON DISCHARGE:\n==================\n___ 04:46AM BLOOD WBC-5.7 RBC-2.47* Hgb-7.6* Hct-22.6* \nMCV-92 MCH-30.8 MCHC-33.6 RDW-18.0* RDWSD-60.5* Plt ___\n___ 04:46AM BLOOD ___ PTT-34.8 ___\n___ 04:46AM BLOOD Glucose-82 UreaN-18 Creat-1.2 Na-132* \nK-4.0 Cl-97 HCO3-26 AnGap-13\n___ 04:46AM BLOOD ALT-11 AST-26 AlkPhos-117 TotBili-1.3\n___ 04:46AM BLOOD Albumin-3.2* Calcium-8.5 Phos-3.9 Mg-1.___ EtOH cirrhosis (Childs Class C; decompensations including \nvariceal bleed, hepatic encephalopathy, and refractory ascites), \nanxiety, and past opiate abuse, recently admitted to ___ with \nSBO, umbilical hernia (now s/p repair), HRS, hyponatremia and \nseizure who presented from rehab for NG tube replacement, with \nconcern for nausea and urinary symptoms. Mr ___ NG tube had \nfallen out 5 days prior and patient reported excellent caloric \nintake; thus, he was given a trial of po intake only with \ncalorie counts. He was able to consume 100% of his meals and \nmeet his caloric requirements, thus feeding tube was not deemed \nnecessary. Further, patient had previously reports nausea and \nvomiting during an outpatient visit, concerning for new SBO or \ncomplication from previous SBO; clarification inpatient, \nhowever, revealed it was a one-time episode, thus further workup \nwas not needed. Finally, pt had endorsed urinary hesitancy, weak \nstream and sensation of incomplete voiding without dysuria or \nhematuria. UA was normal. Renal ultrasound did not show any \nevidence of hydronephrosis. Patient was started back on \ntamsulosin (previously held due to hypotension), with resolution \nof symptoms and stable blood pressure.\n\nTRANSITIONAL ISSUES:\n=====================\n[ ] Medication changes:\n- tamsulosin 0.4 mg QHS added\n[ ] Follow up appointments:\n- Therapeutic parancentesis ___ and ___. \n- with Dr. ___ ___ at 2pm and with Dr. ___ ___ at \n11 am\n- with Dr. ___ ___ am \n(post-paracentesis)\n[ ] Blood culture pending at the time of discharge\n[ ] Patient is not on diuretics due to diuretic-resistant \nascites and continued to be held during this hospitalization\n[ ] Dr ___ Palliative ___ will handle patient's \nopioid prescriptions at this time.\n[ ] Diagnostic peritoneal studies pending at the time of \ndischarge\n# Code status: FULL\n# HCP: ___ Relationship: Wife Phone: ___ \n \n___ on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Gabapentin 300 mg PO TID \n2. Mirtazapine 30 mg PO QHS \n3. Pantoprazole 40 mg PO Q24H \n4. Thiamine 100 mg PO DAILY \n5. Acetaminophen 650 mg PO Q8H \n6. FoLIC Acid 1 mg PO DAILY \n7. Sulfameth/Trimethoprim DS 1 TAB PO/NG DAILY \n8. LevETIRAcetam 1000 mg PO BID \n9. Rifaximin 550 mg PO BID \n10. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 \nmg(1,500mg) -200 unit oral DAILY \n11. Escitalopram Oxalate 20 mg PO DAILY \n12. Sucralfate 1 gm PO QID \n13. TraZODone 50 mg PO QHS:PRN sleep \n14. Sodium Chloride Nasal ___ SPRY NU QID:PRN dry nose \n15. Simethicone 80 mg PO QID \n16. Lactulose 15 mL PO TID \n17. Fish Oil (Omega 3) 1000 mg PO DAILY \n18. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Severe \n\n19. Midodrine 10 mg PO BID \n\n \nDischarge Medications:\n1. Tamsulosin 0.4 mg PO QHS \nRX *tamsulosin 0.4 mg 1 capsule by mouth at bedtime Disp #*30 \nCapsule Refills:*0 \n2. Lactulose 30 mL PO TID \n3. Acetaminophen 650 mg PO Q8H \n4. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 \nmg(1,500mg) -200 unit oral DAILY \n5. Escitalopram Oxalate 20 mg PO DAILY \nRX *escitalopram oxalate 20 mg 1 tablet(s) by mouth daily Disp \n#*30 Tablet Refills:*0 \n6. Fish Oil (Omega 3) 1000 mg PO DAILY \n7. FoLIC Acid 1 mg PO DAILY \n8. Gabapentin 300 mg PO TID \n9. LevETIRAcetam 1000 mg PO BID \nRX *levetiracetam [Keppra] 1,000 mg 1 tablet(s) by mouth twice a \nday Disp #*60 Tablet Refills:*0 \n10. Midodrine 10 mg PO BID \nRX *midodrine 10 mg 1 tablet(s) by mouth twice a day Disp #*60 \nTablet Refills:*0 \n11. Mirtazapine 30 mg PO QHS \n12. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - \nSevere \nRX *oxycodone 10 mg 1 tablet(s) by mouth q4 Disp #*42 Tablet \nRefills:*0 \n13. Pantoprazole 40 mg PO Q24H \n14. Rifaximin 550 mg PO BID \nRX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day \nDisp #*60 Tablet Refills:*0 \n15. Simethicone 80 mg PO QID \n16. Sodium Chloride Nasal ___ SPRY NU QID:PRN dry nose \n17. Sucralfate 1 gm PO QID \n18. Sulfameth/Trimethoprim DS 1 TAB PO DAILY \nRX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1 \ntablet(s) by mouth daily Disp #*30 Tablet Refills:*0 \n19. Thiamine 100 mg PO DAILY \nRX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily \nDisp #*30 Tablet Refills:*5 \n20. TraZODone 50 mg PO QHS:PRN sleep \nRX *trazodone 50 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0 \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary:\nMalnutrition\nBenign Prostatic Hyperplasia\n\nSecondary:\nAlcoholic cirrhosis\nHyponatremia\nSeizure Disorder\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nIt was a pleasure being a part of your ___ during your stay at \n___!\n\nWhy were you hospitalized?\n-Because NJ tube had fallen out and you were experiencing some \nurinary symptoms. \n\nWhat was done for your this hospitalization?\n-While you were here, we monitored your nutrition and found that \nyou were able to eat enough to keep up with your nutritional \nneeds. Therefore, we did not replace the feeding tube. \n-We checked you for urine infection, which you do NOT have.\n-We did an ultrasound of your kidneys which was normal.\n-We started you on a medication called 'Flomax' or 'tamsulosin' \nwhich could help relieve your urinary symptoms.\n-You underwent a paracentesis on ___.\n\nWhat should you do after you leave the hospital?\n-Work with ___ at home\n-Continue to eat a high calorie diet and work on getting \nstronger.\n-Follow up with Dr. ___ your primary ___ doctor.\n- Please seek medical attention if you develop fevers, chills, \nshortness of breath, chest pain, abdominal pain, persistent \nnausea or vomiting, or any other symptoms that concerns you.\n\nWe wish you all the best! \n\nSincerely,\nYour ___ doctors\n \n___ Instructions:\n___\n"
] | Allergies: Penicillins / Keflex Chief Complaint: back pain, g tube eval Major Surgical or Invasive Procedure: Paracentesis [MASKED] History of Present Illness: Mr. [MASKED] is a [MASKED] EtOH cirrhosis (Childs Class C; decompensations including variceal bleed, hepatic encephalopathy, and refractory ascites), anxiety, and past opiate abuse, recently admitted to [MASKED] with SBO, umbilical hernia (now s/p repair), HRS, hyponatremia and seizure who presents [MASKED] rehab for NG tube replacement. Pt states his NG tube fell out 5 days ago. He has been tolerating PO intake without difficulty, without nausea, vomitting, diarrhea. He presented to [MASKED] today for scheduled therapeutic paracentesis with removal of 4.1L of fluid. He was called that he needed to return to the hospital for NG tube replacement. Patient also reports 5 days of deep bilateral flank pain with difficulty urinating and occasional dysuria. He denies fevers, hematuria, abdominal pain, difficulty ambulating, SOB, CP or redness, drainage or pain at the incision site of his recent surgery. In the ED, initial vitals: 99.0 66 118/76 16 99% RA - Exam notable for: NTND abdomen, incision site is C/D/I. RRR. CTAB. No c/c/e. Generalized mild jaundice. - Labs notable for: Hgb 8.0, INR 1.4, nl LFTs, TB, lactate 1.5, neg UA, Cr 1.1 - Imaging notable for: N/A - Patient given: oxycodone 10mg PO x1, mirtazapine 30mg, lorazepam 1mg - Vitals prior to transfer: 98.1 70 118/70 14 96% RA On arrival to the floor, pt reports feeling well. He denies flank pain, instead reports worsening back pain in his lumbar and cervical spine. He has chronic back pain in these areas at baseline, denies numbness, weakness. He denies difficulty urinating or decreased UOP. He denies nausea, vomiting or any recurrence of similar SBO symptoms. Past Medical History: 1.Chronic cirrhosis alcoholic, with associated ascites and encephalopathy; grade 2 esophageal varices & portal gastropathy on EGD in [MASKED]. 2. Previous opiate abuse on suboxone, no suboxone since several months ago 3. Tobacco abuse 4. Anxiety 5. History of hyperplastic colonic polyp Social History: [MASKED] Family History: Father died of cardiac disease, mother was alcoholic Physical Exam: ADMISSION PHYSICAL EXAM: ========================== Vitals: 98.5 PO 131 / 88 82 16 95 RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, distended, bowel sounds present, +hepatomegaly Ext: Warm, well perfused, 2+ edema Skin: hyperpigmentation on [MASKED] Neuro: A&Ox3. Grossly intact. DISCHARGE PHYSICAL EXAM: ========================= VS: 98.6 PO 116/70 74 18 96%RA I/O: 1160/725+3void+3 BM(24hr); 200/350 (8hr) MELD: [MASKED]: 19| General: Sitting up in bed, alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, no temporal wasting Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, mildly distended, bowel sounds present, +hepatomegaly Ext: Warm, well perfused, 1+ edema R>L (chronic) Skin: hyperpigmentation on [MASKED] Neuro: A&Ox3. Grossly intact. Pertinent Results: LABS ON ADMISSION: ================== [MASKED] 09:20PM URINE HOURS-RANDOM [MASKED] 09:20PM URINE COLOR-Yellow APPEAR-Clear SP [MASKED] [MASKED] 09:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.0 LEUK-NEG [MASKED] 12:05AM WBC-6.0 RBC-2.74* HGB-8.0* HCT-25.1* MCV-92 MCH-29.2 MCHC-31.9* RDW-18.6* RDWSD-62.2* [MASKED] 12:05AM NEUTS-58.4 [MASKED] MONOS-11.5 EOS-2.7 BASOS-1.0 IM [MASKED] AbsNeut-3.51# AbsLymp-1.57 AbsMono-0.69 AbsEos-0.16 AbsBaso-0.06 [MASKED] 12:05AM ALBUMIN-3.9 [MASKED] 12:05AM LIPASE-44 [MASKED] 12:05AM ALT(SGPT)-11 AST(SGOT)-25 ALK PHOS-127 TOT BILI-1.5 [MASKED] 12:05AM GLUCOSE-87 UREA N-19 CREAT-1.1 SODIUM-137 POTASSIUM-3.8 CHLORIDE-96 TOTAL CO2-27 ANION GAP-18 [MASKED] 12:19AM [MASKED] PTT-33.9 [MASKED] [MASKED] 12:47AM LACTATE-1.5 [MASKED] 05:21AM [MASKED] PTT-35.2 [MASKED] [MASKED] 05:21AM PLT COUNT-158 [MASKED] 05:21AM WBC-5.6 RBC-2.54* HGB-7.6* HCT-23.6* MCV-93 MCH-29.9 MCHC-32.2 RDW-18.6* RDWSD-62.7* [MASKED] 05:21AM CALCIUM-8.5 PHOSPHATE-4.1 MAGNESIUM-2.0 [MASKED] 05:21AM ALT(SGPT)-10 AST(SGOT)-27 ALK PHOS-115 TOT BILI-1.5 [MASKED] 05:21AM GLUCOSE-174* UREA N-18 CREAT-1.2 SODIUM-136 POTASSIUM-3.5 CHLORIDE-97 TOTAL CO2-23 ANION GAP-20 MICRO: ====== UCX [MASKED]: NO GROWTH BCX [MASKED]: NO GROWTH PERITONEAL FLUID [MASKED]: [MASKED] 2:45 pm PERITONEAL FLUID GRAM STAIN (Final [MASKED]: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [MASKED]: NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. STUDIES: ======== PARACENTESIS [MASKED]: 1. Technically successful ultrasound guided therapeutic paracentesis. 2. 4.1 L of fluid were removed [MASKED] Renal US: IMPRESSION: 1. Normal renal ultrasound. 2. Small ascites. [MASKED] PARACENTESIS: IMPRESSION: 1. Technically successful ultrasound guided diagnostic and therapeutic paracentesis. 2. 3 L of clear straw-colored fluid were removed. LABS ON DISCHARGE: ================== [MASKED] 04:46AM BLOOD WBC-5.7 RBC-2.47* Hgb-7.6* Hct-22.6* MCV-92 MCH-30.8 MCHC-33.6 RDW-18.0* RDWSD-60.5* Plt [MASKED] [MASKED] 04:46AM BLOOD [MASKED] PTT-34.8 [MASKED] [MASKED] 04:46AM BLOOD Glucose-82 UreaN-18 Creat-1.2 Na-132* K-4.0 Cl-97 HCO3-26 AnGap-13 [MASKED] 04:46AM BLOOD ALT-11 AST-26 AlkPhos-117 TotBili-1.3 [MASKED] 04:46AM BLOOD Albumin-3.2* Calcium-8.5 Phos-3.9 Mg-1.[MASKED] EtOH cirrhosis (Childs Class C; decompensations including variceal bleed, hepatic encephalopathy, and refractory ascites), anxiety, and past opiate abuse, recently admitted to [MASKED] with SBO, umbilical hernia (now s/p repair), HRS, hyponatremia and seizure who presented from rehab for NG tube replacement, with concern for nausea and urinary symptoms. Mr [MASKED] NG tube had fallen out 5 days prior and patient reported excellent caloric intake; thus, he was given a trial of po intake only with calorie counts. He was able to consume 100% of his meals and meet his caloric requirements, thus feeding tube was not deemed necessary. Further, patient had previously reports nausea and vomiting during an outpatient visit, concerning for new SBO or complication from previous SBO; clarification inpatient, however, revealed it was a one-time episode, thus further workup was not needed. Finally, pt had endorsed urinary hesitancy, weak stream and sensation of incomplete voiding without dysuria or hematuria. UA was normal. Renal ultrasound did not show any evidence of hydronephrosis. Patient was started back on tamsulosin (previously held due to hypotension), with resolution of symptoms and stable blood pressure. TRANSITIONAL ISSUES: ===================== [ ] Medication changes: - tamsulosin 0.4 mg QHS added [ ] Follow up appointments: - Therapeutic parancentesis [MASKED] and [MASKED]. - with Dr. [MASKED] [MASKED] at 2pm and with Dr. [MASKED] [MASKED] at 11 am - with Dr. [MASKED] [MASKED] am (post-paracentesis) [ ] Blood culture pending at the time of discharge [ ] Patient is not on diuretics due to diuretic-resistant ascites and continued to be held during this hospitalization [ ] Dr [MASKED] Palliative [MASKED] will handle patient's opioid prescriptions at this time. [ ] Diagnostic peritoneal studies pending at the time of discharge # Code status: FULL # HCP: [MASKED] Relationship: Wife Phone: [MASKED] [MASKED] on Admission: The Preadmission Medication list is accurate and complete. 1. Gabapentin 300 mg PO TID 2. Mirtazapine 30 mg PO QHS 3. Pantoprazole 40 mg PO Q24H 4. Thiamine 100 mg PO DAILY 5. Acetaminophen 650 mg PO Q8H 6. FoLIC Acid 1 mg PO DAILY 7. Sulfameth/Trimethoprim DS 1 TAB PO/NG DAILY 8. LevETIRAcetam 1000 mg PO BID 9. Rifaximin 550 mg PO BID 10. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -200 unit oral DAILY 11. Escitalopram Oxalate 20 mg PO DAILY 12. Sucralfate 1 gm PO QID 13. TraZODone 50 mg PO QHS:PRN sleep 14. Sodium Chloride Nasal [MASKED] SPRY NU QID:PRN dry nose 15. Simethicone 80 mg PO QID 16. Lactulose 15 mL PO TID 17. Fish Oil (Omega 3) 1000 mg PO DAILY 18. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Severe 19. Midodrine 10 mg PO BID Discharge Medications: 1. Tamsulosin 0.4 mg PO QHS RX *tamsulosin 0.4 mg 1 capsule by mouth at bedtime Disp #*30 Capsule Refills:*0 2. Lactulose 30 mL PO TID 3. Acetaminophen 650 mg PO Q8H 4. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -200 unit oral DAILY 5. Escitalopram Oxalate 20 mg PO DAILY RX *escitalopram oxalate 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 6. Fish Oil (Omega 3) 1000 mg PO DAILY 7. FoLIC Acid 1 mg PO DAILY 8. Gabapentin 300 mg PO TID 9. LevETIRAcetam 1000 mg PO BID RX *levetiracetam [Keppra] 1,000 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 10. Midodrine 10 mg PO BID RX *midodrine 10 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 11. Mirtazapine 30 mg PO QHS 12. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Severe RX *oxycodone 10 mg 1 tablet(s) by mouth q4 Disp #*42 Tablet Refills:*0 13. Pantoprazole 40 mg PO Q24H 14. Rifaximin 550 mg PO BID RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 15. Simethicone 80 mg PO QID 16. Sodium Chloride Nasal [MASKED] SPRY NU QID:PRN dry nose 17. Sucralfate 1 gm PO QID 18. Sulfameth/Trimethoprim DS 1 TAB PO DAILY RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 19. Thiamine 100 mg PO DAILY RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*5 20. TraZODone 50 mg PO QHS:PRN sleep RX *trazodone 50 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Primary: Malnutrition Benign Prostatic Hyperplasia Secondary: Alcoholic cirrhosis Hyponatremia Seizure Disorder Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], It was a pleasure being a part of your [MASKED] during your stay at [MASKED]! Why were you hospitalized? -Because NJ tube had fallen out and you were experiencing some urinary symptoms. What was done for your this hospitalization? -While you were here, we monitored your nutrition and found that you were able to eat enough to keep up with your nutritional needs. Therefore, we did not replace the feeding tube. -We checked you for urine infection, which you do NOT have. -We did an ultrasound of your kidneys which was normal. -We started you on a medication called 'Flomax' or 'tamsulosin' which could help relieve your urinary symptoms. -You underwent a paracentesis on [MASKED]. What should you do after you leave the hospital? -Work with [MASKED] at home -Continue to eat a high calorie diet and work on getting stronger. -Follow up with Dr. [MASKED] your primary [MASKED] doctor. - Please seek medical attention if you develop fevers, chills, shortness of breath, chest pain, abdominal pain, persistent nausea or vomiting, or any other symptoms that concerns you. We wish you all the best! Sincerely, Your [MASKED] doctors [MASKED] Instructions: [MASKED] | [
"E46",
"K766",
"E871",
"Z681",
"K3189",
"M549",
"G8929",
"D649",
"F1021",
"G40909",
"F419",
"F329",
"Z720",
"N401",
"R3912",
"R3911",
"R3914"
] | [
"E46: Unspecified protein-calorie malnutrition",
"K766: Portal hypertension",
"E871: Hypo-osmolality and hyponatremia",
"Z681: Body mass index [BMI] 19.9 or less, adult",
"K3189: Other diseases of stomach and duodenum",
"M549: Dorsalgia, unspecified",
"G8929: Other chronic pain",
"D649: Anemia, unspecified",
"F1021: Alcohol dependence, in remission",
"G40909: Epilepsy, unspecified, not intractable, without status epilepticus",
"F419: Anxiety disorder, unspecified",
"F329: Major depressive disorder, single episode, unspecified",
"Z720: Tobacco use",
"N401: Benign prostatic hyperplasia with lower urinary tract symptoms",
"R3912: Poor urinary stream",
"R3911: Hesitancy of micturition",
"R3914: Feeling of incomplete bladder emptying"
] | [
"E871",
"G8929",
"D649",
"F419",
"F329"
] | [] |
19,093,092 | 23,434,917 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nSulfa (Sulfonamide Antibiotics)\n \nAttending: ___.\n \nChief Complaint:\nthrombosed AV fistula\n \nMajor Surgical or Invasive Procedure:\nFistulogram and Thrombectomy ___.\n\n \nHistory of Present Illness:\n___ with DM, ESRD on HD (___) s/p multiple failed AVF \n(thrombectomies x8), h/o necrotizing fasciitis s/p L AKA \n___, peripheral vascular disease, neuropathy w/recent \nadmission ___ for thrombectomy who presented to ED\nwith clotted left femoral AV graft fistula (placed ___. \n\nPatient went to dialysis as scheduled on ___ they were unable \nto access his fistula. Last dialysis was ___. Of note, his most \nrecent thrombectomy was on ___. He was referred to the ED for \nangiogram/thrombectomy ___.\n\nIN THE ED:\nInitial vitals were T 97.7 P 72 BP 138/83 RR 18 O2 99% RA\n\nLabs of note were K 4.7, BUN 37, Cr 8.4. CBC revealed WBC 9.3, \nHb 9.2 (baseline).\n\nPatient was evaluated by transplant surgery who recommended \nthrombectomy ___ and subsequent admission to medicine for HD\n\nOn the floor, patient feels well and has no acute complaints. \n \nPast Medical History:\n- ESRD on HD (___) s/p multiple failed AVF (thrombectomies \n x8), Left femoral AV graft placed on ___ by Dr. ___ \n- ___ syndrome, can no longer have upper extremity access, had \nmultiple UE left and right AV grafts \n- Necrotizing fasciitis s/p L AKA ___\n- DM Type 1 c/b nephropathy and peripheral neuropathy \n- Hypertension \n- Diabetic Myonecrosis (wheelchair-bound) \n- Left knee charcot joint \n- H/o alcohol dependence (last drink ___ ago) \n- H/o mood disorder \n - Left AKA ___ in setting of necrotizing fasciitis \n \nSocial History:\n___\nFamily History:\nDM, HTN in multiple family members\n \nPhysical ___ Exam\n================\nGENERAL: Pleasant, well-appearing, in no apparent distress. \nCARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops. \nPULMONARY: Lungs clear to auscultation bilaterally. \nABDOMEN: Normal bowel sounds, soft, non-tender, non-distended, \nno organomegaly. \nEXTREMITIES: L femoral fistula w/o thrill. L AKA stump with \nwound that is clean/ intact/ dry, without drainage or erythema. \nSKIN: Without rash. \nNEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation, \nwith strength ___ throughout. \n\nDischarge Exam\n===============\nVS: 97.9 94/56 76 18 95% RA\nGENERAL: Pleasant, well-appearing, in no apparent distress. \nCARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops. \nPULMONARY: Lungs clear to auscultation bilaterally. \nABDOMEN: Normal bowel sounds, soft, non-tender, non-distended, \nno organomegaly. \nEXTREMITIES: L femoral fistula w/o thrill. L AKA stump with \nwound that is clean/ intact/ dry, without drainage or erythema. \nSKIN: Without rash. \nNEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation, \nwith strength ___ throughout. \n \nPertinent Results:\nAdmission Labs\n==============\n___ 12:35PM BLOOD WBC-9.3# RBC-3.42* Hgb-9.2* Hct-28.4* \nMCV-83 MCH-26.9 MCHC-32.4 RDW-17.5* RDWSD-53.1* Plt ___\n___ 12:35PM BLOOD Neuts-36.8 Lymphs-15.8* Monos-6.2 \nEos-40.5* Baso-0.2 Im ___ AbsNeut-3.41 AbsLymp-1.47 \nAbsMono-0.58 AbsEos-3.76* AbsBaso-0.02\n___ 12:35PM BLOOD ___ PTT-27.9 ___\n___ 12:35PM BLOOD Glucose-215* UreaN-37* Creat-8.4*# Na-140 \nK-4.7 Cl-96 HCO3-26 AnGap-23*\n___ 12:35PM BLOOD Calcium-9.0 Phos-6.7* Mg-2.2\n\nProcedure\n=========\nAV fistulogram ___\nFINDINGS: \n1. Complete thrombosis of the left lower extremity AV graft to \nthe level of the outflow vein. \n2. Outflow vein stenosis with improvement following angioplasty \nto 10 mm. \n3. Satisfactory appearance of the arterial anastomosis. No \nin-graft or central venous stenosis. \n \nIMPRESSION: \nSatisfactory restoration of flow following chemical and \nmechanical \nthrombolysis with a good angiographic and clinical result.\n\nDischarge Labs\n==============\n___ 07:10AM BLOOD WBC-6.8 RBC-3.28* Hgb-9.0* Hct-27.2* \nMCV-83 MCH-27.4 MCHC-33.1 RDW-17.7* RDWSD-53.1* Plt ___\n___ 07:10AM BLOOD Plt ___\n___ 07:10AM BLOOD ___ PTT-27.4 ___\n___ 07:10AM BLOOD Glucose-86 UreaN-41* Creat-8.9* Na-137 \nK-4.9 Cl-96 HCO3-23 AnGap-23*\n___ 07:10AM BLOOD Calcium-8.8 Phos-7.0* Mg-2.___ with DM, ESRD on HD (___) s/p multiple failed AVF \n(thrombectomies x8), h/o necrotizing fasciitis s/p L AKA \n___, peripheral vascular disease, neuropathy w/recent \nadmission ___ for thrombectomy who presented to ED with \nclotted left femoral AV graft fistula (placed ___. \n\n#Clotted fistula: Evaluated by transplant surgery and now s/p \nfistulogram and thrombectomy by ___ on admission. Patient \ntolerated the procedure well and had successful HD session on \n___. Patient discharged with instructions to return to \noutpatient ___ HD and follow up with outpatient nephrologist. \n\n#ESRD on HD (MWF): ___ T1DM, has been on HD for approximately ___ \nyears. \nPatient was continued on home medications Cinacalcet, Nephrocaps \nand Sevelamer. \n\n#DMI: Continued home insulin glargine 7U qHS w/ISS\n\n#Anemia: Patient has normocytic anemia requiring EPO injections \nw/HD. Hb on admission 9.2, close to baseline of 10. Hemoglobin \nmonitored and remained stable. \n\n#Mood disorder: Continued home olanzapine. \n\n#Hyperlipidemia: Continued home statin, aspirin 81 mg daily.\n\nTransitional Issues\n===================\n[ ] patient should resume outpatient HD on normal schedule.\n[ ] patient should follow up with outpatient nephrologist. \nContact: ___ (brother) ___ \nCode Status: Full (confirmed) \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Aspirin 81 mg PO DAILY \n2. Atorvastatin 40 mg PO QPM \n3. Cinacalcet 60 mg PO DAILY \n4. Docusate Sodium 100 mg PO BID:PRN constipation \n5. Epoetin Alfa ___ UNIT IV DAILY:PRN HD \n6. Nephrocaps 1 CAP PO DAILY \n7. OLANZapine 10 mg PO QHS \n8. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain \n9. Senna 8.6 mg PO BID:PRN constipation \n10. sevelamer CARBONATE 1600 mg PO TID W/MEALS \n11. Calcitriol 1 mcg PO 3X/WEEK (___) \n12. Calcium Acetate ___ mg PO TID W/MEALS \n13. Guaifenesin 15 mL PO Q4H:PRN cough \n14. Glargine 7 Units Bedtime\n\n \nDischarge Medications:\n1. Glargine 7 Units Bedtime \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 40 mg PO QPM \n4. Calcitriol 1 mcg PO 3X/WEEK (___) \n5. Cinacalcet 60 mg PO DAILY \n6. Docusate Sodium 100 mg PO BID:PRN constipation \n7. Epoetin Alfa ___ UNIT IV DAILY:PRN HD \n8. Guaifenesin 15 mL PO Q4H:PRN cough \n9. Nephrocaps 1 CAP PO DAILY \n10. OLANZapine 10 mg PO QHS \n11. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain \n12. Senna 8.6 mg PO BID:PRN constipation \n13. sevelamer CARBONATE 1600 mg PO TID W/MEALS \n\n \nDischarge Disposition:\nExtended Care\n \nDischarge Diagnosis:\nPrimary Diagnosis\n==================\nThrombosed AV Fistula\n\nSecondary Diagnosis\n===================\nEnd Stage Renal Disease\nType 1 Diabetes Mellitus\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nIt was a pleasure caring for you at ___ \n___.\n\nWhy were you admitted?\n-You were admitted because your AV fistula was clotted and you \nwere unable to receive dialysis.\n\nWhat did we do for you?\n-You underwent fistulogram and thrombectomy with Interventional \nRadiology.\n-You had dialysis while inpatient.\n\nWhat should you do at home?\n-You should go to outpatient dialysis on your normal schedule.\n-You should follow up with your kidney doctor as outpatient.\n\nWe wish you all the best!\n\nSincerely,\nYour ___ Care Team\n \nFollowup Instructions:\n___\n"
] | Allergies: Sulfa (Sulfonamide Antibiotics) Chief Complaint: thrombosed AV fistula Major Surgical or Invasive Procedure: Fistulogram and Thrombectomy [MASKED]. History of Present Illness: [MASKED] with DM, ESRD on HD ([MASKED]) s/p multiple failed AVF (thrombectomies x8), h/o necrotizing fasciitis s/p L AKA [MASKED], peripheral vascular disease, neuropathy w/recent admission [MASKED] for thrombectomy who presented to ED with clotted left femoral AV graft fistula (placed [MASKED]. Patient went to dialysis as scheduled on [MASKED] they were unable to access his fistula. Last dialysis was [MASKED]. Of note, his most recent thrombectomy was on [MASKED]. He was referred to the ED for angiogram/thrombectomy [MASKED]. IN THE ED: Initial vitals were T 97.7 P 72 BP 138/83 RR 18 O2 99% RA Labs of note were K 4.7, BUN 37, Cr 8.4. CBC revealed WBC 9.3, Hb 9.2 (baseline). Patient was evaluated by transplant surgery who recommended thrombectomy [MASKED] and subsequent admission to medicine for HD On the floor, patient feels well and has no acute complaints. Past Medical History: - ESRD on HD ([MASKED]) s/p multiple failed AVF (thrombectomies x8), Left femoral AV graft placed on [MASKED] by Dr. [MASKED] - [MASKED] syndrome, can no longer have upper extremity access, had multiple UE left and right AV grafts - Necrotizing fasciitis s/p L AKA [MASKED] - DM Type 1 c/b nephropathy and peripheral neuropathy - Hypertension - Diabetic Myonecrosis (wheelchair-bound) - Left knee charcot joint - H/o alcohol dependence (last drink [MASKED] ago) - H/o mood disorder - Left AKA [MASKED] in setting of necrotizing fasciitis Social History: [MASKED] Family History: DM, HTN in multiple family members Physical [MASKED] Exam ================ GENERAL: Pleasant, well-appearing, in no apparent distress. CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops. PULMONARY: Lungs clear to auscultation bilaterally. ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended, no organomegaly. EXTREMITIES: L femoral fistula w/o thrill. L AKA stump with wound that is clean/ intact/ dry, without drainage or erythema. SKIN: Without rash. NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation, with strength [MASKED] throughout. Discharge Exam =============== VS: 97.9 94/56 76 18 95% RA GENERAL: Pleasant, well-appearing, in no apparent distress. CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops. PULMONARY: Lungs clear to auscultation bilaterally. ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended, no organomegaly. EXTREMITIES: L femoral fistula w/o thrill. L AKA stump with wound that is clean/ intact/ dry, without drainage or erythema. SKIN: Without rash. NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation, with strength [MASKED] throughout. Pertinent Results: Admission Labs ============== [MASKED] 12:35PM BLOOD WBC-9.3# RBC-3.42* Hgb-9.2* Hct-28.4* MCV-83 MCH-26.9 MCHC-32.4 RDW-17.5* RDWSD-53.1* Plt [MASKED] [MASKED] 12:35PM BLOOD Neuts-36.8 Lymphs-15.8* Monos-6.2 Eos-40.5* Baso-0.2 Im [MASKED] AbsNeut-3.41 AbsLymp-1.47 AbsMono-0.58 AbsEos-3.76* AbsBaso-0.02 [MASKED] 12:35PM BLOOD [MASKED] PTT-27.9 [MASKED] [MASKED] 12:35PM BLOOD Glucose-215* UreaN-37* Creat-8.4*# Na-140 K-4.7 Cl-96 HCO3-26 AnGap-23* [MASKED] 12:35PM BLOOD Calcium-9.0 Phos-6.7* Mg-2.2 Procedure ========= AV fistulogram [MASKED] FINDINGS: 1. Complete thrombosis of the left lower extremity AV graft to the level of the outflow vein. 2. Outflow vein stenosis with improvement following angioplasty to 10 mm. 3. Satisfactory appearance of the arterial anastomosis. No in-graft or central venous stenosis. IMPRESSION: Satisfactory restoration of flow following chemical and mechanical thrombolysis with a good angiographic and clinical result. Discharge Labs ============== [MASKED] 07:10AM BLOOD WBC-6.8 RBC-3.28* Hgb-9.0* Hct-27.2* MCV-83 MCH-27.4 MCHC-33.1 RDW-17.7* RDWSD-53.1* Plt [MASKED] [MASKED] 07:10AM BLOOD Plt [MASKED] [MASKED] 07:10AM BLOOD [MASKED] PTT-27.4 [MASKED] [MASKED] 07:10AM BLOOD Glucose-86 UreaN-41* Creat-8.9* Na-137 K-4.9 Cl-96 HCO3-23 AnGap-23* [MASKED] 07:10AM BLOOD Calcium-8.8 Phos-7.0* Mg-2.[MASKED] with DM, ESRD on HD ([MASKED]) s/p multiple failed AVF (thrombectomies x8), h/o necrotizing fasciitis s/p L AKA [MASKED], peripheral vascular disease, neuropathy w/recent admission [MASKED] for thrombectomy who presented to ED with clotted left femoral AV graft fistula (placed [MASKED]. #Clotted fistula: Evaluated by transplant surgery and now s/p fistulogram and thrombectomy by [MASKED] on admission. Patient tolerated the procedure well and had successful HD session on [MASKED]. Patient discharged with instructions to return to outpatient [MASKED] HD and follow up with outpatient nephrologist. #ESRD on HD (MWF): [MASKED] T1DM, has been on HD for approximately [MASKED] years. Patient was continued on home medications Cinacalcet, Nephrocaps and Sevelamer. #DMI: Continued home insulin glargine 7U qHS w/ISS #Anemia: Patient has normocytic anemia requiring EPO injections w/HD. Hb on admission 9.2, close to baseline of 10. Hemoglobin monitored and remained stable. #Mood disorder: Continued home olanzapine. #Hyperlipidemia: Continued home statin, aspirin 81 mg daily. Transitional Issues =================== [ ] patient should resume outpatient HD on normal schedule. [ ] patient should follow up with outpatient nephrologist. Contact: [MASKED] (brother) [MASKED] Code Status: Full (confirmed) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 40 mg PO QPM 3. Cinacalcet 60 mg PO DAILY 4. Docusate Sodium 100 mg PO BID:PRN constipation 5. Epoetin Alfa [MASKED] UNIT IV DAILY:PRN HD 6. Nephrocaps 1 CAP PO DAILY 7. OLANZapine 10 mg PO QHS 8. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain 9. Senna 8.6 mg PO BID:PRN constipation 10. sevelamer CARBONATE 1600 mg PO TID W/MEALS 11. Calcitriol 1 mcg PO 3X/WEEK ([MASKED]) 12. Calcium Acetate [MASKED] mg PO TID W/MEALS 13. Guaifenesin 15 mL PO Q4H:PRN cough 14. Glargine 7 Units Bedtime Discharge Medications: 1. Glargine 7 Units Bedtime 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. Calcitriol 1 mcg PO 3X/WEEK ([MASKED]) 5. Cinacalcet 60 mg PO DAILY 6. Docusate Sodium 100 mg PO BID:PRN constipation 7. Epoetin Alfa [MASKED] UNIT IV DAILY:PRN HD 8. Guaifenesin 15 mL PO Q4H:PRN cough 9. Nephrocaps 1 CAP PO DAILY 10. OLANZapine 10 mg PO QHS 11. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain 12. Senna 8.6 mg PO BID:PRN constipation 13. sevelamer CARBONATE 1600 mg PO TID W/MEALS Discharge Disposition: Extended Care Discharge Diagnosis: Primary Diagnosis ================== Thrombosed AV Fistula Secondary Diagnosis =================== End Stage Renal Disease Type 1 Diabetes Mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [MASKED], It was a pleasure caring for you at [MASKED] [MASKED]. Why were you admitted? -You were admitted because your AV fistula was clotted and you were unable to receive dialysis. What did we do for you? -You underwent fistulogram and thrombectomy with Interventional Radiology. -You had dialysis while inpatient. What should you do at home? -You should go to outpatient dialysis on your normal schedule. -You should follow up with your kidney doctor as outpatient. We wish you all the best! Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED] | [
"T82868A",
"N186",
"E1022",
"I120",
"I871",
"T82858A",
"Y832",
"Y929",
"Z992",
"Z794",
"E1051",
"E1040",
"Z89612",
"E1069",
"M6220",
"Z993",
"F1021",
"F17210",
"F1290",
"D649",
"F39",
"E785"
] | [
"T82868A: Thrombosis due to vascular prosthetic devices, implants and grafts, initial encounter",
"N186: End stage renal disease",
"E1022: Type 1 diabetes mellitus with diabetic chronic kidney disease",
"I120: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease",
"I871: Compression of vein",
"T82858A: Stenosis of other vascular prosthetic devices, implants and grafts, initial encounter",
"Y832: Surgical operation with anastomosis, bypass or graft as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure",
"Y929: Unspecified place or not applicable",
"Z992: Dependence on renal dialysis",
"Z794: Long term (current) use of insulin",
"E1051: Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene",
"E1040: Type 1 diabetes mellitus with diabetic neuropathy, unspecified",
"Z89612: Acquired absence of left leg above knee",
"E1069: Type 1 diabetes mellitus with other specified complication",
"M6220: Nontraumatic ischemic infarction of muscle, unspecified site",
"Z993: Dependence on wheelchair",
"F1021: Alcohol dependence, in remission",
"F17210: Nicotine dependence, cigarettes, uncomplicated",
"F1290: Cannabis use, unspecified, uncomplicated",
"D649: Anemia, unspecified",
"F39: Unspecified mood [affective] disorder",
"E785: Hyperlipidemia, unspecified"
] | [
"Y929",
"Z794",
"F17210",
"D649",
"E785"
] | [] |
13,121,825 | 28,305,948 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nAsacol / Allopurinol\n \nAttending: ___\n \nChief Complaint:\nunintentional weight loss, anemia, and failure to thrive\n \nMajor Surgical or Invasive Procedure:\nColonoscopy with biopsy\nUpper endoscopy\n \nHistory of Present Illness:\n___ with hx of UC, HLD, gout, prostate ca s/p prostatectomy,\ndiverticular colitis presenting with unintentional weight loss,\nanemia, and failure to thrive.\n\nPt endorses anemia, progressive weakness, decreased PO intake,\nand associated loose stools, with 20 lb unintentional weight \nloss\nover the preceding 5 months. He endorses difficulty swallowing,\nsolids>liquids, without odynophagia, as well as some early\nsatiety. He has 3 watery BMs per day, has not noticed\nhematochezia (although notes that he has difficulty\ndiscriminating between red and brown), and had black stools only\nwhile taking OTC PO iron supplements. He also noticed \"just a\ndrop\" of blood in his urine on one occasion, which has since\nresolved. He underwent CT torso on ___ for further\nevaluation of weight loss and anemia, which revealed sigmoid\ndiverticulitis, with negative C. diff testing at that time. He\nwas started on cipro/flagyl on ___ with very modest\nimprovement in his diarrhea. Pt presented for routine f/u to PCP\nand GI providers on ___, who recommended admission for\nfailure to thrive, inpatient colonoscopy (has failed prep as\noutpatient), nutrition c/s, and heme/onc review of smear. Pt\ndenies F/C, N/V, chest pain, SOB, dysuria, night sweats,\nabdominal pain. He endorses chronic ___ edema, which is \nsymmetric.\n\nPt has undergone two colonoscopies in ___, neither\nof which were adequately prepped for full evaluation. An EGD\nperformed on ___ was notable only for a hiatal hernia. \n\nIn the ___ ED:\nVS 97.1, 77, 127/55, 100% RA\nExam notable for \"no belly tenderness\"\nLabs notable for WBC 7.9, Hb 9.4, Plt 320, BUN 40, Cr 1.1, INR\n2.2, CK 520, TnT 0.05->0.04, Lactate 1.5\nBCx sent\n\nImaging: \nCXR - no acute process\n\nReceived:\nNo intervention\n\nOn arrival to the floor, he denies pain, discomfort.\n\nROS: 10 point review of system reviewed and negative except as\notherwise described in HPI\n\n \nPast Medical History:\n1. Atrial fibrillation\n2. Hypertension \n3. Peripheral vascular disease\n4. Chronic renal insufficiency: Baseline Cr=1.3-1.6\n5. Impaired fasting glucose \n6. Chronic lower extremity edema \n7. h/o prostate cancer\n8. Hyperlipidemia \n9. Gout\n10. Erectile dysfunction\n11. OSA \n12. History of melanoma\n13. Restless leg syndrome\n14. Osteoarthritis\n15. h/o tremor\n \nSocial History:\n___\nFamily History:\nBrother - died of stomach cancer. \nFather - ___ Disease \nMother - ___ Disease.\n \nPhysical Exam:\nVS: 97.5, 137/51, 87, 18, 100% RA\nGEN: elderly male, cachetic with marked temporal wasting, alert \nand interactive, comfortable, no acute distress\nHEENT: PERRL, anicteric, conjunctiva pink, oropharynx without \nlesion or exudate, moist mucus membranes, ears without lesions \nor apparent trauma\nLYMPH: no anterior/posterior cervical, supraclavicular \nadenopathy\nCARDIOVASCULAR: Irregularly irregular with ___ systolic murmur \nat RUSB\nLUNGS: clear to auscultation bilaterally without rhonchi, \nwheezes, or crackles\nGI: soft, NTND, normal bowel sounds no organomegaly\nEXTREMITIES: WWP, trace pitting edema to midshins bilat, \nsymmetric, with chronic venous stasis changes, compression \nstockings on\nGU: no foley\nSKIN: no rashes, petechia, lesions, or echymoses; warm to \npalpation\nNEURO: A&Ox3, cranial nerves II-XII grossly intact, strength ___ \nin ___\nPSYCH: normal mood and affect\n \nPertinent Results:\nADMISSION LABS\n___ 05:09PM BLOOD WBC-10.2* RBC-3.49* Hgb-9.9* Hct-31.8* \nMCV-91 MCH-28.4 MCHC-31.1* RDW-18.4* RDWSD-58.8* Plt ___\n___ 05:09PM BLOOD Neuts-75.2* Lymphs-9.8* Monos-12.8 \nEos-1.4 Baso-0.3 Im ___ AbsNeut-7.71* AbsLymp-1.00* \nAbsMono-1.31* AbsEos-0.14 AbsBaso-0.03\n___ 05:09PM BLOOD ___\n___ 05:09PM BLOOD UreaN-36* Creat-1.1 Na-142 K-3.9 Cl-97 \nHCO3-29 AnGap-16\n___ 05:09PM BLOOD ALT-17 AST-27 CK(CPK)-532* AlkPhos-60 \nTotBili-0.4 DirBili-<0.2 IndBili-0.4\n___ 12:38PM BLOOD cTropnT-0.05*\n___ 05:09PM BLOOD TotProt-7.3 Albumin-3.4* Globuln-3.9 \nCalcium-8.6 Phos-2.9 Mg-2.1 Iron-23*\n___ 05:09PM BLOOD calTIBC-225* Ferritn-264 TRF-173*\n___ 05:09PM BLOOD %HbA1c-5.6 eAG-114\n___ 05:09PM BLOOD TSH-2.8\n___ 05:09PM BLOOD Free T4-1.2\n___ 06:00AM BLOOD Cortsol-23.7*\n___ 06:00AM BLOOD PSA-<0.03\n___ 05:09PM BLOOD CRP-42.3*\n___ 06:00AM BLOOD PEP-AWAITING F I___-___ IgA-___* IgM-70 \nIFE-PND\n___ 01:02PM BLOOD Lactate-1.5\n\nIMAGING\nEKG: Atrial fibrillation at 83 bpm, normal axis, normal\nintervals, RBBB, TW flattening in III, TWI in V1-V3, no ST\nsegment changes, no pathologic Q waves, no significant change\ncompared to prior\n\nColonoscopy ___\n***\n\nUpper endoscopy ___\n***\n\nDISCHARGE LABS\n \nBrief Hospital Course:\n___ with hx of UC, htn, HLD, gout, prostate ca\ns/p prostatectomy, diverticular colitis presenting with\nunintentional weight loss, anemia, and failure to thrive likely \nfrom UC flare\n\n# Failure to thrive:\n# Unintentional weight loss:\n# Ulcerative colitis: Pt has progressive, marked, and\nunintentional weight loss over the past 5 months, with cachexia\nand progressive weakness. CRP is elevated and UPTRENDING now at\n___, ESR 87, suggestive of systemic inflammatory process, with\nddx including occult malignancy, vasculitis, other noninfectious\ninflammatory process, less likely infectious given chronicity. I\nnow have a moderate suspicion of inflammatory bowel disease \nbeing\nthe driver, as cobblestones obvious on ___ and ___ CRP. CT\ntorso did not reveal a malignancy. Other clue may be anemia\n(although this may also reflect sequelae of chronic \ninflammation,\nrather than part of the primary process). He denies abdominal\npain to suggest bowel ischemia. TSH and T4 WNL. DDx also \nincludes\nsarcoidosis. Of note, beta 2 microglobulin was elevated to 5.0 \non\n___, but so far SPEP negative for oligoclonal bands. PSA\nnormal. B12 normal. Cortisol 23.7. SPEP no oligoclonal bands, \nK/L ratio normal.\n___ showed severe inflammation and cobblestoning, EGD normal.\nStarted mesalamine ___ ___ enema per GI.\n- mesalamine ___ 4.8g daily\n- ___ 100mg enema qhs\n- outpatient repeat ___ in 1mo\n- Nutrition consult\n- regular diet\n- encouraged daily weight\n\n# Anemia: Iron studies suggestive of anemia of chronic\ninflammation. Iron is low at 23, ferritin WNL, low TIBC and low\ntransferrin. \n- Transfuse for Hb<7.0\n\n# Elevated CK: Unclear etiology, baseline levels over the past ___\nyears appears to be ___. Downtrended.\n- will consider rheum consult\n\n# Afib: CHADS2 is 2 (no longer hypertensive), on apixaban, per \npt\nno longer on rate control. \n- cont apixaban\n\n# Chronic diastolic heart failure: He does have b/l ___ pitting\nedema which is chronic. By report is worse now\n- cont home torsemide\n- compression stocking\n\n# Gout:\n- Continue home febuxostat\n\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Torsemide 20 mg PO DAILY \n2. Apixaban 5 mg PO BID \n3. Mesalamine 1500 mg PO BID \n4. Febuxostat 40 mg PO DAILY \n\n \nDischarge Medications:\n1. Hydrocortisone Enema 100 mg PR QHS Duration: 21 Days \nRX *hydrocortisone 100 mg/60 mL 1 enema(s) rectally at bedtime \nDisp #*1800 Milliliter Milliliter Refills:*0 \n2. Mesalamine ___ 4800 mg PO DAILY \nRX *mesalamine [Lialda] 1.2 gram 4 tablet(s) by mouth once a day \nDisp #*120 Tablet Refills:*0 \n3. Multivitamins W/minerals 1 TAB PO DAILY \nRX *multivitamin,tx-minerals 1 tablet(s) by mouth once a day \nDisp #*30 Tablet Refills:*2 \n4. walker 1 ea miscellaneous ONCE \nRX *walker Once Disp #*1 Each Refills:*0 \n5. Apixaban 5 mg PO BID \n6. Febuxostat 40 mg PO DAILY \n7. Torsemide 20 mg PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nFailure to thrive\nUlcerative colitis\nDiarrhea\nAnemia of chronic disease\nelevated creatinine kinase\nAtrial fibrillation\nGout\n\n \nDischarge Condition:\nFair\nA/Ox3\nAmbulatory with walker\n\n \nDischarge Instructions:\nDear Mr. ___,\nYou were admitted to the hospital to evaluate your recent weight \nloss, anemia and diarrhea. As part of this evaluation, the \ngastroenterology team did a colonoscopy and endoscopy, which \nshowed severe inflammatory changes due to ulcerative colitis. We \ncould not advance the scope fully due to the inflammation. No \ncancer was identified on biopsy. In addition, laboratory testing \nwas significant for high inflammatory markers. We think the \ncause of your weight loss could be from ulcerative colitis, and \nwe increased your mesalamine and started hydrocortisone enema. \nOur GI specialist plans to do colonoscopy again in 1 month after \ninflammation in the colon calms with the steroids. Please keep \ntrack of your weight at home.\n\nIt was a pleasure taking care of you.\n\nSincerely,\nYour ___ team\n \nFollowup Instructions:\n___\n"
] | Allergies: Asacol / Allopurinol Chief Complaint: unintentional weight loss, anemia, and failure to thrive Major Surgical or Invasive Procedure: Colonoscopy with biopsy Upper endoscopy History of Present Illness: [MASKED] with hx of UC, HLD, gout, prostate ca s/p prostatectomy, diverticular colitis presenting with unintentional weight loss, anemia, and failure to thrive. Pt endorses anemia, progressive weakness, decreased PO intake, and associated loose stools, with 20 lb unintentional weight loss over the preceding 5 months. He endorses difficulty swallowing, solids>liquids, without odynophagia, as well as some early satiety. He has 3 watery BMs per day, has not noticed hematochezia (although notes that he has difficulty discriminating between red and brown), and had black stools only while taking OTC PO iron supplements. He also noticed "just a drop" of blood in his urine on one occasion, which has since resolved. He underwent CT torso on [MASKED] for further evaluation of weight loss and anemia, which revealed sigmoid diverticulitis, with negative C. diff testing at that time. He was started on cipro/flagyl on [MASKED] with very modest improvement in his diarrhea. Pt presented for routine f/u to PCP and GI providers on [MASKED], who recommended admission for failure to thrive, inpatient colonoscopy (has failed prep as outpatient), nutrition c/s, and heme/onc review of smear. Pt denies F/C, N/V, chest pain, SOB, dysuria, night sweats, abdominal pain. He endorses chronic [MASKED] edema, which is symmetric. Pt has undergone two colonoscopies in [MASKED], neither of which were adequately prepped for full evaluation. An EGD performed on [MASKED] was notable only for a hiatal hernia. In the [MASKED] ED: VS 97.1, 77, 127/55, 100% RA Exam notable for "no belly tenderness" Labs notable for WBC 7.9, Hb 9.4, Plt 320, BUN 40, Cr 1.1, INR 2.2, CK 520, TnT 0.05->0.04, Lactate 1.5 BCx sent Imaging: CXR - no acute process Received: No intervention On arrival to the floor, he denies pain, discomfort. ROS: 10 point review of system reviewed and negative except as otherwise described in HPI Past Medical History: 1. Atrial fibrillation 2. Hypertension 3. Peripheral vascular disease 4. Chronic renal insufficiency: Baseline Cr=1.3-1.6 5. Impaired fasting glucose 6. Chronic lower extremity edema 7. h/o prostate cancer 8. Hyperlipidemia 9. Gout 10. Erectile dysfunction 11. OSA 12. History of melanoma 13. Restless leg syndrome 14. Osteoarthritis 15. h/o tremor Social History: [MASKED] Family History: Brother - died of stomach cancer. Father - [MASKED] Disease Mother - [MASKED] Disease. Physical Exam: VS: 97.5, 137/51, 87, 18, 100% RA GEN: elderly male, cachetic with marked temporal wasting, alert and interactive, comfortable, no acute distress HEENT: PERRL, anicteric, conjunctiva pink, oropharynx without lesion or exudate, moist mucus membranes, ears without lesions or apparent trauma LYMPH: no anterior/posterior cervical, supraclavicular adenopathy CARDIOVASCULAR: Irregularly irregular with [MASKED] systolic murmur at RUSB LUNGS: clear to auscultation bilaterally without rhonchi, wheezes, or crackles GI: soft, NTND, normal bowel sounds no organomegaly EXTREMITIES: WWP, trace pitting edema to midshins bilat, symmetric, with chronic venous stasis changes, compression stockings on GU: no foley SKIN: no rashes, petechia, lesions, or echymoses; warm to palpation NEURO: A&Ox3, cranial nerves II-XII grossly intact, strength [MASKED] in [MASKED] PSYCH: normal mood and affect Pertinent Results: ADMISSION LABS [MASKED] 05:09PM BLOOD WBC-10.2* RBC-3.49* Hgb-9.9* Hct-31.8* MCV-91 MCH-28.4 MCHC-31.1* RDW-18.4* RDWSD-58.8* Plt [MASKED] [MASKED] 05:09PM BLOOD Neuts-75.2* Lymphs-9.8* Monos-12.8 Eos-1.4 Baso-0.3 Im [MASKED] AbsNeut-7.71* AbsLymp-1.00* AbsMono-1.31* AbsEos-0.14 AbsBaso-0.03 [MASKED] 05:09PM BLOOD [MASKED] [MASKED] 05:09PM BLOOD UreaN-36* Creat-1.1 Na-142 K-3.9 Cl-97 HCO3-29 AnGap-16 [MASKED] 05:09PM BLOOD ALT-17 AST-27 CK(CPK)-532* AlkPhos-60 TotBili-0.4 DirBili-<0.2 IndBili-0.4 [MASKED] 12:38PM BLOOD cTropnT-0.05* [MASKED] 05:09PM BLOOD TotProt-7.3 Albumin-3.4* Globuln-3.9 Calcium-8.6 Phos-2.9 Mg-2.1 Iron-23* [MASKED] 05:09PM BLOOD calTIBC-225* Ferritn-264 TRF-173* [MASKED] 05:09PM BLOOD %HbA1c-5.6 eAG-114 [MASKED] 05:09PM BLOOD TSH-2.8 [MASKED] 05:09PM BLOOD Free T4-1.2 [MASKED] 06:00AM BLOOD Cortsol-23.7* [MASKED] 06:00AM BLOOD PSA-<0.03 [MASKED] 05:09PM BLOOD CRP-42.3* [MASKED] 06:00AM BLOOD PEP-AWAITING F I -[MASKED] IgA-[MASKED]* IgM-70 IFE-PND [MASKED] 01:02PM BLOOD Lactate-1.5 IMAGING EKG: Atrial fibrillation at 83 bpm, normal axis, normal intervals, RBBB, TW flattening in III, TWI in V1-V3, no ST segment changes, no pathologic Q waves, no significant change compared to prior Colonoscopy [MASKED] *** Upper endoscopy [MASKED] *** DISCHARGE LABS Brief Hospital Course: [MASKED] with hx of UC, htn, HLD, gout, prostate ca s/p prostatectomy, diverticular colitis presenting with unintentional weight loss, anemia, and failure to thrive likely from UC flare # Failure to thrive: # Unintentional weight loss: # Ulcerative colitis: Pt has progressive, marked, and unintentional weight loss over the past 5 months, with cachexia and progressive weakness. CRP is elevated and UPTRENDING now at [MASKED], ESR 87, suggestive of systemic inflammatory process, with ddx including occult malignancy, vasculitis, other noninfectious inflammatory process, less likely infectious given chronicity. I now have a moderate suspicion of inflammatory bowel disease being the driver, as cobblestones obvious on [MASKED] and [MASKED] CRP. CT torso did not reveal a malignancy. Other clue may be anemia (although this may also reflect sequelae of chronic inflammation, rather than part of the primary process). He denies abdominal pain to suggest bowel ischemia. TSH and T4 WNL. DDx also includes sarcoidosis. Of note, beta 2 microglobulin was elevated to 5.0 on [MASKED], but so far SPEP negative for oligoclonal bands. PSA normal. B12 normal. Cortisol 23.7. SPEP no oligoclonal bands, K/L ratio normal. [MASKED] showed severe inflammation and cobblestoning, EGD normal. Started mesalamine [MASKED] [MASKED] enema per GI. - mesalamine [MASKED] 4.8g daily - [MASKED] 100mg enema qhs - outpatient repeat [MASKED] in 1mo - Nutrition consult - regular diet - encouraged daily weight # Anemia: Iron studies suggestive of anemia of chronic inflammation. Iron is low at 23, ferritin WNL, low TIBC and low transferrin. - Transfuse for Hb<7.0 # Elevated CK: Unclear etiology, baseline levels over the past [MASKED] years appears to be [MASKED]. Downtrended. - will consider rheum consult # Afib: CHADS2 is 2 (no longer hypertensive), on apixaban, per pt no longer on rate control. - cont apixaban # Chronic diastolic heart failure: He does have b/l [MASKED] pitting edema which is chronic. By report is worse now - cont home torsemide - compression stocking # Gout: - Continue home febuxostat Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Torsemide 20 mg PO DAILY 2. Apixaban 5 mg PO BID 3. Mesalamine 1500 mg PO BID 4. Febuxostat 40 mg PO DAILY Discharge Medications: 1. Hydrocortisone Enema 100 mg PR QHS Duration: 21 Days RX *hydrocortisone 100 mg/60 mL 1 enema(s) rectally at bedtime Disp #*1800 Milliliter Milliliter Refills:*0 2. Mesalamine [MASKED] 4800 mg PO DAILY RX *mesalamine [Lialda] 1.2 gram 4 tablet(s) by mouth once a day Disp #*120 Tablet Refills:*0 3. Multivitamins W/minerals 1 TAB PO DAILY RX *multivitamin,tx-minerals 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*2 4. walker 1 ea miscellaneous ONCE RX *walker Once Disp #*1 Each Refills:*0 5. Apixaban 5 mg PO BID 6. Febuxostat 40 mg PO DAILY 7. Torsemide 20 mg PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Failure to thrive Ulcerative colitis Diarrhea Anemia of chronic disease elevated creatinine kinase Atrial fibrillation Gout Discharge Condition: Fair A/Ox3 Ambulatory with walker Discharge Instructions: Dear Mr. [MASKED], You were admitted to the hospital to evaluate your recent weight loss, anemia and diarrhea. As part of this evaluation, the gastroenterology team did a colonoscopy and endoscopy, which showed severe inflammatory changes due to ulcerative colitis. We could not advance the scope fully due to the inflammation. No cancer was identified on biopsy. In addition, laboratory testing was significant for high inflammatory markers. We think the cause of your weight loss could be from ulcerative colitis, and we increased your mesalamine and started hydrocortisone enema. Our GI specialist plans to do colonoscopy again in 1 month after inflammation in the colon calms with the steroids. Please keep track of your weight at home. It was a pleasure taking care of you. Sincerely, Your [MASKED] team Followup Instructions: [MASKED] | [
"K5190",
"E870",
"I5032",
"D638",
"I4891",
"I739",
"R627",
"R778",
"M109",
"G4733",
"K5730",
"Z7901",
"Z87891",
"Z8546"
] | [
"K5190: Ulcerative colitis, unspecified, without complications",
"E870: Hyperosmolality and hypernatremia",
"I5032: Chronic diastolic (congestive) heart failure",
"D638: Anemia in other chronic diseases classified elsewhere",
"I4891: Unspecified atrial fibrillation",
"I739: Peripheral vascular disease, unspecified",
"R627: Adult failure to thrive",
"R778: Other specified abnormalities of plasma proteins",
"M109: Gout, unspecified",
"G4733: Obstructive sleep apnea (adult) (pediatric)",
"K5730: Diverticulosis of large intestine without perforation or abscess without bleeding",
"Z7901: Long term (current) use of anticoagulants",
"Z87891: Personal history of nicotine dependence",
"Z8546: Personal history of malignant neoplasm of prostate"
] | [
"I5032",
"I4891",
"M109",
"G4733",
"Z7901",
"Z87891"
] | [] |
14,666,832 | 20,664,607 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nchest pain, dyspnea \n \nMajor Surgical or Invasive Procedure:\nRHC/LHC - ___\n\n \nHistory of Present Illness:\n___ woman with hx of discoid lupus not on any medication \npresenting with 1 week of shortness of breath and mild chest \npain. \n\nShe states that since about a week ago she has been developing \nsome worsening dyspnea. She states that it worsened with \nexertion and when she lies down flat. She is been trying to prop \nherself up with more pillows with little avail; also notes PND \nas well as increased abdominal girth. She notices she is also \nbeen urinating more but denies any leg swelling. She has no \nknown history of CHF and is not on Lasix. Additionally, she has \nhad some mild substernal chest pain that is worsened with \nexertion and is not pleuritic. She has been having a \nnonproductive cough and some night sweats but denies any \nfever/chills. She also has an associated sore throat and some \nnasal discharge but attributes this to seasonal allergies. She \ndenies any leg swelling, calf pain, recent surgeries, \nhemoptysis, oncologic history, or history of DVTs. She denies \nany headache, vision changes, arm pain, jaw pain, back pain, \nabdominal pain, nausea, vomiting, diarrhea, urinary symptoms, \nrashes, paresthesias, or difficulty ambulating.\n\nShe has no known history of hypertension, hyperlipidemia, \ndiabetes but a significant family history for both her brother \nand her sister having coronary artery disease with MIs. Her \nbrother had one at the age of ___. \n\nWhile in the ED, she had worsening tachypnea and was becoming \nprogressively more hypoxic - requiring 6L to sat 88%. She was \ninitiated on BiPAP, with O2 sat improved to 96%. She was also \nstarted on nitro gtt for SBPs>170s. \n\nIn the ED, - Initial vitals were: T99.7, HR 108, BP 128/95, RR \n16, 95% RA \n\n- Exam notable for: tachycardia, +JVD, otherwise exam normal \n\n- Labs notable for: proBNP 5501, Trop-T<0.01, D-dimer 2492, WBC \n3.9, H/H 10.8/32.9\n\n- Studies notable for: EKG: sinus tachycardia with LAD and Q \nwaves in V1 and V2 with no STE/STD CXR: with mild cardiomegaly \nwith mild pulmonary edema CTA: with no evidence of PE - \nscattered ground glass opacities c/w moderate pulmonary edema, \nnodular opacities in LLL - superimposed infection cannot be \nexcluded, likely reactive mediastinal hilar lymphadenopathy \n\n- Patient was given: IV lasix 40mg, started on nitro gtt\n\nOn arrival to the CCU, patient reported breathing more \ncomfortably on BiPAP and was switched to 5L NC and breathing \ncomfortably. She reports some chest discomfort upon deep \ninspiration. \n\nROS: Positive per HPI. Remaining 10 point ROS reviewed and \nnegative. \n \nPast Medical History:\nCardiac History: \n -no known cardiac history\nOther PMH: \n - SLE - followed at ___, not seen for past ___ years, not on\nmedications \n\n \nSocial History:\n___\nFamily History:\nBrother and sister with coronary artery disease and MIs; brother \nwith MI at age of ___ \n \nPhysical Exam:\nADMISSION EXAM\n==============\nVS: afebrile, BP 120/90, HR 100, 98% on 5L O2 \nGENERAL: Well developed, well nourished in NAD. Oriented x3.\nMood, affect appropriate. \nHEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI.\nNECK: Supple. JVP at base of neck \nCARDIAC: Normal rate, regular rhythm. No murmurs, rubs, or\ngallops. \nLUNGS: bibasilar crackles. Breathing comfortably on 5L NC. No\nchest wall deformities or tenderness. \nABDOMEN: Soft, non-tender, non-distended. No palpable\nhepatomegaly or splenomegaly. \nEXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or\nperipheral edema. \nSKIN: Small 1cm lesion with surrounding erythema on R anterior\nneck - pt reports this is from ingrown hair. significant lesions\nor rashes. \nPULSES: Distal pulses palpable and symmetric. \nNEURO: A&Ox3, moving all 4 extremities with purpose \n\nDISCHARGE EXAM\n==============\nVS: 24 HR Data (last updated ___ @ 707)\n Temp: 97.6 (Tm 98.7), BP: 90/57 (90-110/57-75), HR: 72\n(72-90), RR: 17 (___), O2 sat: 99% (92-99), O2 delivery: Ra,\nWt: 155.1 lb/70.35 kg \nFluid Balance (last updated ___ @ ___) \n Last 8 hours No data found\n Last 24 hours Total cumulative 5ml\n IN: Total 780ml, PO Amt 780ml\n OUT: Total 775ml, Urine Amt 775ml \nGENERAL: NAD. \nHEENT: MMM. \nNECK: Supple. JVP at base of neck. \nCARDIAC: Normal rate, regular rhythm. S3 appreciated. No \nmurmurs, rubs, or gallops. \nLUNGS: bibasilar crackles. Breathing comfortably on RA. \nABDOMEN: Soft, non-tender, non-distended. No palpable \nhepatomegaly or splenomegaly. \nEXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or \nperipheral edema. \nPULSES: Distal pulses palpable and symmetric. \nNEURO: A&Ox3, moving all 4 extremities with purpose \n \nPertinent Results:\nADMISSION LABS\n==============\n___ 12:37PM BLOOD Neuts-56.4 ___ Monos-12.4 \nEos-0.5* Baso-0.3 Im ___ AbsNeut-2.22 AbsLymp-1.16* \nAbsMono-0.49 AbsEos-0.02* AbsBaso-0.01\n___ 08:50PM BLOOD ___ PTT-37.3* ___\n___ 02:04PM BLOOD D-Dimer-2492*\n___ 12:37PM BLOOD Glucose-123* UreaN-11 Creat-0.6 Na-140 \nK-3.3* Cl-105 HCO3-22 AnGap-13\n___ 12:37PM BLOOD cTropnT-<0.01 proBNP-5501*\n___ 08:50PM BLOOD CK-MB-3 cTropnT-<0.01\n___ 12:37PM BLOOD Calcium-8.4 Phos-2.5* Mg-1.6\n___ 05:12PM BLOOD ___ pO2-45* pCO2-35 pH-7.45 \ncalTCO2-25 Base XS-0\n___ 09:13PM BLOOD Lactate-1.3\n___ 05:12PM BLOOD O2 Sat-77\n___ 08:50PM BLOOD calTIBC-230* Ferritn-346* TRF-177*\n___ 08:50PM BLOOD %HbA1c-5.3 eAG-105\n___ 08:50PM BLOOD Triglyc-51 HDL-36* CHOL/HD-3.4 LDLcalc-76 \nLDLmeas-82\n___ 08:50PM BLOOD TSH-2.0\n___ 08:50PM BLOOD dsDNA-POSITIVE*\n___ 08:50PM BLOOD PEP-NO SPECIFI FreeKap-65.8* \nFreeLam-39.0* Fr K/L-1.69*\n___ 08:50PM BLOOD C3-74* C4-11\n\nDISCHARGE LABS\n===============\n___ 06:46AM BLOOD WBC-2.9* RBC-3.20* Hgb-10.5* Hct-32.6* \nMCV-102* MCH-32.8* MCHC-32.2 RDW-13.0 RDWSD-47.2* Plt ___\n___ 06:46AM BLOOD ___ PTT-35.9 ___\n___ 06:46AM BLOOD Glucose-82 UreaN-14 Creat-0.6 Na-143 \nK-4.2 Cl-108 HCO3-22 AnGap-13\n___ 06:46AM BLOOD Calcium-8.6 Phos-3.9 Mg-1.8\n\nIMAGING\n=======\nCHEST PA AND LATERAL ___\nModerate cardiomegaly with mild pulmonary edema. No focal \nconsolidation is\nappreciated.\n\nCTA CHEST ___\n1.No evidence of pulmonary embolism or aortic abnormality.\n2.Septal thickening and scattered ground glass opacities are \nconsistent with moderate pulmonary edema, despite respiratory \nmotion artifact.\n3.Bibasilar atelectasis with scattered more nodular opacities in \nthe left\nlower lobe. Superimposed infection cannot be excluded.\n4.Scattered bilateral upper lobe fibrotic changes including \nbronchiectasis and peripheral reticulation, which may be sequela \nof known history of systemiclupus erythematosus.\n5.Diffuse bronchial wall thickening, which may be \ninfection/inflammation.\n6.Likely reactive mediastinal hilar lymphadenopathy. Bilateral \ngreater than left small pleural effusions.\n\nSTUDIES/PROCEDURES\n====================\nCTA CHEST Study Date of ___ 3:08 ___ \n1. No evidence of pulmonary embolism or aortic abnormality. \n2. Septal thickening and scattered ground glass opacities are \nconsistent with moderate pulmonary edema, despite respiratory \nmotion artifact. \n3. Bibasilar atelectasis with scattered more nodular opacities \nin the left lower lobe. Superimposed infection cannot be \nexcluded. \n4. Scattered bilateral upper lobe fibrotic changes including \nbronchiectasis and peripheral reticulation, which may be sequela \nof known history of systemic lupus erythematosus. \n5. Diffuse bronchial wall thickening, which may be \ninfection/inflammation. \n6. Likely reactive mediastinal hilar lymphadenopathy. \nBilateral greater than left small pleural effusions. \n\nTTE ___\nEF ___. Moderately dilated left ventricle. Severe regional \nleft ventricular systolic dysfunction consistent with \nmultivessel coronary artery disease. Heavy trabeculations noted \nin the left ventricle. Moderate mitral and tricuspid \nregurgitation. Moderate to severe pulmonary hypertension.\n\nCardiac Catheterization\n The right and left heart filling pressures were elevated\n Moderate pulmonary hypertension.\n Mild coronary coronary artery disease.\n\nMICROBIOLOGY\n=============\n___ 1:13 pm URINE ___. \n **FINAL REPORT ___\n URINE CULTURE (Final ___: < 10,000 CFU/mL. \n\n___ 8:50 pm BLOOD CULTURE Source: Venipuncture. \n Blood Culture, Routine (Pending): No growth to date.\n\n___ 5:32 am BLOOD CULTURE Source: Venipuncture. \n Blood Culture, Routine (Pending): No growth to date. \n\n \nBrief Hospital Course:\n___ woman with hx of discoid lupus not on any medication \npresenting with 1 week of shortness of breath and mild chest \npain likely in setting of new onset HF. \n\n #CORONARIES: unknown\n #PUMP: EF ___\n #RHYTHM: NSR\n\nACUTE ISSUES: \n============= \n#new onset HFrEF, EF 25% \nPt with no known cardiac history presenting with 1 week of \nworsening DOE, orthopnea, PND and mild exertional substernal \nchest pain found to have elevated BNP with evidence of \ncardiomegaly and pulmonary edema on CXR. Patient denied any \nhistory of cardiac risk factors asides from 30 pack year smoking \nhistory and family history of CAD. TTE with reduced EF ___ \nwith severe regional LV systolic dysfunction consistent with \nmultivessel CAD. Cardiac catherization showed non-ischemic \ncardiomyopathy. Workup included: normal A1c 5.3, lipid panel \n(chol 122 TAG 51 LDL 76 HDL 36), TSH WNL, and iron studies WNL. \nRheumatology felt that it was unlikely her new HFrEF was related \nto her known hx of discoid lupus. She was started on lisinopril \n5mg daily, metoprolol XL 100mg, and she will have cardiology \nfollow up with Dr. ___.\n\n#Hypoxic respiratory failure - resolved\nPatient with worsening hypoxia while in the ED requiring BiPAP - \nlikely in setting of new onset HF. Initial concern for PNA on CT \nchest, but afebrile with no leukocytosis - was not given \nantibiotics. She was weaned to room air following diuresis. \n\n#discoid lupus\n#fibrotic vs emphysematous lung changes\nPt with hx of discoid lupus with positive antibodies, not on any \nmedications. No history of systemic lupus despite prior \ntransient proteinuria. Last office Cr 0.67, dsDNA 536, C3 73. \nRepeat C3 here was 74, stable from prior. Followed by Dr. \n___ at ___ though not seen in the last \n___ years. Noted on CT chest to have scattered bilateral upper \nlobe changes questionable for fibrotic vs emphysematous changes. \nRheumatology was consulted and did not feel that her current \npresentation was consistent with an SLE flair. She should have \noutpatient PFTs given emphysematous changes seen on her CT \nchest, and be considered for repeat lung imaging as an \noutpatient. She should have follow up with her rheumatologist \nand be considered for initiation of hydroxychloroquine.\n\nTRANSITIONAL ISSUES: \n====================\nPCP:\n[]recommend repeat CT chest to re-assess mediastinal \nlymphadenopathy once euvolemic. If still significant, would \nconsider heme/onc regarding lymphoma vs other \nlymphoproliferative disorder.\n\nCardiology:\n[]Cardiac MR as cath showed no ischemic disease\n[]Consider addition aldosterone inhibitor.\n[]Consider hydralazine/nitrate as needed for afterload.\n[]Repeat TTE in three months. Consider ICD then.\n\nRheumatology:\n[]nonurgent initiation of hydroxychloroquine. Seen by Rheum and \nthought to not be in a flare. Patient encouraged to re-establish \ncare with Dr. ___.\n\nNew meds: \nlisinopril 5mg \nmetoprolol XL 100mg\n\n#CODE: FULL CODE confirmed \n#CONTACT/HCP: ___ (daughter, ___) ___ ___ (son) \n___ \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Ibuprofen 600 mg PO Frequency is Unknown \n\n \nDischarge Medications:\n1. Lisinopril 5 mg PO DAILY \nRX *lisinopril 5 mg 1 tablet(s) by mouth once a day Disp #*60 \nTablet Refills:*0 \n2. Metoprolol Succinate XL 100 mg PO DAILY \nRX *metoprolol succinate 100 mg 1 tablet(s) by mouth once a day \nDisp #*60 Tablet Refills:*0 \n3. Ibuprofen 600 mg PO DAILY:PRN Pain - Mild \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS: \n==================\nAcute HFrEF \n\nSECONDARY DIAGNOSIS: \n====================\nDiscoid lupus\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n \nPlease see below for more information on your hospitalization. \nIt was a pleasure taking part in your care here at ___!\n\n \nWHY WERE YOU ADMITTED TO THE HOSPITAL?\n-You were having increasing shortness of breath at home \n \nWHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL? \n-You had an echocardiogram which showed that your heart is not \npumping as effectively as it should, and that you have \ncongestive heart failure. \n-You were given a medication called Lasix to help you pee off \nthe excess fluid in your body - your breathing improved with \nthis. \n-You underwent a procedure called a catheterization to help us \nassess your coronary arteries for any blockages. This showed \nthat your coronary arteries were clear. \n \nWHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? \n- Take all of your medications as prescribed (listed below) \n- Follow up with your doctors as listed below \n- Weigh yourself every morning, seek medical attention if your \nweight goes up more than 3 lbs. \n- It is very important with your new heart disease that you stop \nsmoking! Please let your primary care physician if you need any \nassistance with nicotine patches/gum or any other medications \nthat can help you do this. \n- Seek medical attention if you have new or concerning symptoms \nor you develop swelling in your legs, abdominal distention, \nshortness of breath at night, chest pain, or palpitations. \n\nWe wish you all the best!\n- Your ___ Care Team\n \nFollowup Instructions:\n___\n"
] | Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: chest pain, dyspnea Major Surgical or Invasive Procedure: RHC/LHC - [MASKED] History of Present Illness: [MASKED] woman with hx of discoid lupus not on any medication presenting with 1 week of shortness of breath and mild chest pain. She states that since about a week ago she has been developing some worsening dyspnea. She states that it worsened with exertion and when she lies down flat. She is been trying to prop herself up with more pillows with little avail; also notes PND as well as increased abdominal girth. She notices she is also been urinating more but denies any leg swelling. She has no known history of CHF and is not on Lasix. Additionally, she has had some mild substernal chest pain that is worsened with exertion and is not pleuritic. She has been having a nonproductive cough and some night sweats but denies any fever/chills. She also has an associated sore throat and some nasal discharge but attributes this to seasonal allergies. She denies any leg swelling, calf pain, recent surgeries, hemoptysis, oncologic history, or history of DVTs. She denies any headache, vision changes, arm pain, jaw pain, back pain, abdominal pain, nausea, vomiting, diarrhea, urinary symptoms, rashes, paresthesias, or difficulty ambulating. She has no known history of hypertension, hyperlipidemia, diabetes but a significant family history for both her brother and her sister having coronary artery disease with MIs. Her brother had one at the age of [MASKED]. While in the ED, she had worsening tachypnea and was becoming progressively more hypoxic - requiring 6L to sat 88%. She was initiated on BiPAP, with O2 sat improved to 96%. She was also started on nitro gtt for SBPs>170s. In the ED, - Initial vitals were: T99.7, HR 108, BP 128/95, RR 16, 95% RA - Exam notable for: tachycardia, +JVD, otherwise exam normal - Labs notable for: proBNP 5501, Trop-T<0.01, D-dimer 2492, WBC 3.9, H/H 10.8/32.9 - Studies notable for: EKG: sinus tachycardia with LAD and Q waves in V1 and V2 with no STE/STD CXR: with mild cardiomegaly with mild pulmonary edema CTA: with no evidence of PE - scattered ground glass opacities c/w moderate pulmonary edema, nodular opacities in LLL - superimposed infection cannot be excluded, likely reactive mediastinal hilar lymphadenopathy - Patient was given: IV lasix 40mg, started on nitro gtt On arrival to the CCU, patient reported breathing more comfortably on BiPAP and was switched to 5L NC and breathing comfortably. She reports some chest discomfort upon deep inspiration. ROS: Positive per HPI. Remaining 10 point ROS reviewed and negative. Past Medical History: Cardiac History: -no known cardiac history Other PMH: - SLE - followed at [MASKED], not seen for past [MASKED] years, not on medications Social History: [MASKED] Family History: Brother and sister with coronary artery disease and MIs; brother with MI at age of [MASKED] Physical Exam: ADMISSION EXAM ============== VS: afebrile, BP 120/90, HR 100, 98% on 5L O2 GENERAL: Well developed, well nourished in NAD. Oriented x3. Mood, affect appropriate. HEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI. NECK: Supple. JVP at base of neck CARDIAC: Normal rate, regular rhythm. No murmurs, rubs, or gallops. LUNGS: bibasilar crackles. Breathing comfortably on 5L NC. No chest wall deformities or tenderness. ABDOMEN: Soft, non-tender, non-distended. No palpable hepatomegaly or splenomegaly. EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. SKIN: Small 1cm lesion with surrounding erythema on R anterior neck - pt reports this is from ingrown hair. significant lesions or rashes. PULSES: Distal pulses palpable and symmetric. NEURO: A&Ox3, moving all 4 extremities with purpose DISCHARGE EXAM ============== VS: 24 HR Data (last updated [MASKED] @ 707) Temp: 97.6 (Tm 98.7), BP: 90/57 (90-110/57-75), HR: 72 (72-90), RR: 17 ([MASKED]), O2 sat: 99% (92-99), O2 delivery: Ra, Wt: 155.1 lb/70.35 kg Fluid Balance (last updated [MASKED] @ [MASKED]) Last 8 hours No data found Last 24 hours Total cumulative 5ml IN: Total 780ml, PO Amt 780ml OUT: Total 775ml, Urine Amt 775ml GENERAL: NAD. HEENT: MMM. NECK: Supple. JVP at base of neck. CARDIAC: Normal rate, regular rhythm. S3 appreciated. No murmurs, rubs, or gallops. LUNGS: bibasilar crackles. Breathing comfortably on RA. ABDOMEN: Soft, non-tender, non-distended. No palpable hepatomegaly or splenomegaly. EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. PULSES: Distal pulses palpable and symmetric. NEURO: A&Ox3, moving all 4 extremities with purpose Pertinent Results: ADMISSION LABS ============== [MASKED] 12:37PM BLOOD Neuts-56.4 [MASKED] Monos-12.4 Eos-0.5* Baso-0.3 Im [MASKED] AbsNeut-2.22 AbsLymp-1.16* AbsMono-0.49 AbsEos-0.02* AbsBaso-0.01 [MASKED] 08:50PM BLOOD [MASKED] PTT-37.3* [MASKED] [MASKED] 02:04PM BLOOD D-Dimer-2492* [MASKED] 12:37PM BLOOD Glucose-123* UreaN-11 Creat-0.6 Na-140 K-3.3* Cl-105 HCO3-22 AnGap-13 [MASKED] 12:37PM BLOOD cTropnT-<0.01 proBNP-5501* [MASKED] 08:50PM BLOOD CK-MB-3 cTropnT-<0.01 [MASKED] 12:37PM BLOOD Calcium-8.4 Phos-2.5* Mg-1.6 [MASKED] 05:12PM BLOOD [MASKED] pO2-45* pCO2-35 pH-7.45 calTCO2-25 Base XS-0 [MASKED] 09:13PM BLOOD Lactate-1.3 [MASKED] 05:12PM BLOOD O2 Sat-77 [MASKED] 08:50PM BLOOD calTIBC-230* Ferritn-346* TRF-177* [MASKED] 08:50PM BLOOD %HbA1c-5.3 eAG-105 [MASKED] 08:50PM BLOOD Triglyc-51 HDL-36* CHOL/HD-3.4 LDLcalc-76 LDLmeas-82 [MASKED] 08:50PM BLOOD TSH-2.0 [MASKED] 08:50PM BLOOD dsDNA-POSITIVE* [MASKED] 08:50PM BLOOD PEP-NO SPECIFI FreeKap-65.8* FreeLam-39.0* Fr K/L-1.69* [MASKED] 08:50PM BLOOD C3-74* C4-11 DISCHARGE LABS =============== [MASKED] 06:46AM BLOOD WBC-2.9* RBC-3.20* Hgb-10.5* Hct-32.6* MCV-102* MCH-32.8* MCHC-32.2 RDW-13.0 RDWSD-47.2* Plt [MASKED] [MASKED] 06:46AM BLOOD [MASKED] PTT-35.9 [MASKED] [MASKED] 06:46AM BLOOD Glucose-82 UreaN-14 Creat-0.6 Na-143 K-4.2 Cl-108 HCO3-22 AnGap-13 [MASKED] 06:46AM BLOOD Calcium-8.6 Phos-3.9 Mg-1.8 IMAGING ======= CHEST PA AND LATERAL [MASKED] Moderate cardiomegaly with mild pulmonary edema. No focal consolidation is appreciated. CTA CHEST [MASKED] 1.No evidence of pulmonary embolism or aortic abnormality. 2.Septal thickening and scattered ground glass opacities are consistent with moderate pulmonary edema, despite respiratory motion artifact. 3.Bibasilar atelectasis with scattered more nodular opacities in the left lower lobe. Superimposed infection cannot be excluded. 4.Scattered bilateral upper lobe fibrotic changes including bronchiectasis and peripheral reticulation, which may be sequela of known history of systemiclupus erythematosus. 5.Diffuse bronchial wall thickening, which may be infection/inflammation. 6.Likely reactive mediastinal hilar lymphadenopathy. Bilateral greater than left small pleural effusions. STUDIES/PROCEDURES ==================== CTA CHEST Study Date of [MASKED] 3:08 [MASKED] 1. No evidence of pulmonary embolism or aortic abnormality. 2. Septal thickening and scattered ground glass opacities are consistent with moderate pulmonary edema, despite respiratory motion artifact. 3. Bibasilar atelectasis with scattered more nodular opacities in the left lower lobe. Superimposed infection cannot be excluded. 4. Scattered bilateral upper lobe fibrotic changes including bronchiectasis and peripheral reticulation, which may be sequela of known history of systemic lupus erythematosus. 5. Diffuse bronchial wall thickening, which may be infection/inflammation. 6. Likely reactive mediastinal hilar lymphadenopathy. Bilateral greater than left small pleural effusions. TTE [MASKED] EF [MASKED]. Moderately dilated left ventricle. Severe regional left ventricular systolic dysfunction consistent with multivessel coronary artery disease. Heavy trabeculations noted in the left ventricle. Moderate mitral and tricuspid regurgitation. Moderate to severe pulmonary hypertension. Cardiac Catheterization The right and left heart filling pressures were elevated Moderate pulmonary hypertension. Mild coronary coronary artery disease. MICROBIOLOGY ============= [MASKED] 1:13 pm URINE [MASKED]. **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: < 10,000 CFU/mL. [MASKED] 8:50 pm BLOOD CULTURE Source: Venipuncture. Blood Culture, Routine (Pending): No growth to date. [MASKED] 5:32 am BLOOD CULTURE Source: Venipuncture. Blood Culture, Routine (Pending): No growth to date. Brief Hospital Course: [MASKED] woman with hx of discoid lupus not on any medication presenting with 1 week of shortness of breath and mild chest pain likely in setting of new onset HF. #CORONARIES: unknown #PUMP: EF [MASKED] #RHYTHM: NSR ACUTE ISSUES: ============= #new onset HFrEF, EF 25% Pt with no known cardiac history presenting with 1 week of worsening DOE, orthopnea, PND and mild exertional substernal chest pain found to have elevated BNP with evidence of cardiomegaly and pulmonary edema on CXR. Patient denied any history of cardiac risk factors asides from 30 pack year smoking history and family history of CAD. TTE with reduced EF [MASKED] with severe regional LV systolic dysfunction consistent with multivessel CAD. Cardiac catherization showed non-ischemic cardiomyopathy. Workup included: normal A1c 5.3, lipid panel (chol 122 TAG 51 LDL 76 HDL 36), TSH WNL, and iron studies WNL. Rheumatology felt that it was unlikely her new HFrEF was related to her known hx of discoid lupus. She was started on lisinopril 5mg daily, metoprolol XL 100mg, and she will have cardiology follow up with Dr. [MASKED]. #Hypoxic respiratory failure - resolved Patient with worsening hypoxia while in the ED requiring BiPAP - likely in setting of new onset HF. Initial concern for PNA on CT chest, but afebrile with no leukocytosis - was not given antibiotics. She was weaned to room air following diuresis. #discoid lupus #fibrotic vs emphysematous lung changes Pt with hx of discoid lupus with positive antibodies, not on any medications. No history of systemic lupus despite prior transient proteinuria. Last office Cr 0.67, dsDNA 536, C3 73. Repeat C3 here was 74, stable from prior. Followed by Dr. [MASKED] at [MASKED] though not seen in the last [MASKED] years. Noted on CT chest to have scattered bilateral upper lobe changes questionable for fibrotic vs emphysematous changes. Rheumatology was consulted and did not feel that her current presentation was consistent with an SLE flair. She should have outpatient PFTs given emphysematous changes seen on her CT chest, and be considered for repeat lung imaging as an outpatient. She should have follow up with her rheumatologist and be considered for initiation of hydroxychloroquine. TRANSITIONAL ISSUES: ==================== PCP: []recommend repeat CT chest to re-assess mediastinal lymphadenopathy once euvolemic. If still significant, would consider heme/onc regarding lymphoma vs other lymphoproliferative disorder. Cardiology: []Cardiac MR as cath showed no ischemic disease []Consider addition aldosterone inhibitor. []Consider hydralazine/nitrate as needed for afterload. []Repeat TTE in three months. Consider ICD then. Rheumatology: []nonurgent initiation of hydroxychloroquine. Seen by Rheum and thought to not be in a flare. Patient encouraged to re-establish care with Dr. [MASKED]. New meds: lisinopril 5mg metoprolol XL 100mg #CODE: FULL CODE confirmed #CONTACT/HCP: [MASKED] (daughter, [MASKED]) [MASKED] [MASKED] (son) [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ibuprofen 600 mg PO Frequency is Unknown Discharge Medications: 1. Lisinopril 5 mg PO DAILY RX *lisinopril 5 mg 1 tablet(s) by mouth once a day Disp #*60 Tablet Refills:*0 2. Metoprolol Succinate XL 100 mg PO DAILY RX *metoprolol succinate 100 mg 1 tablet(s) by mouth once a day Disp #*60 Tablet Refills:*0 3. Ibuprofen 600 mg PO DAILY:PRN Pain - Mild Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: ================== Acute HFrEF SECONDARY DIAGNOSIS: ==================== Discoid lupus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], Please see below for more information on your hospitalization. It was a pleasure taking part in your care here at [MASKED]! WHY WERE YOU ADMITTED TO THE HOSPITAL? -You were having increasing shortness of breath at home WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL? -You had an echocardiogram which showed that your heart is not pumping as effectively as it should, and that you have congestive heart failure. -You were given a medication called Lasix to help you pee off the excess fluid in your body - your breathing improved with this. -You underwent a procedure called a catheterization to help us assess your coronary arteries for any blockages. This showed that your coronary arteries were clear. WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? - Take all of your medications as prescribed (listed below) - Follow up with your doctors as listed below - Weigh yourself every morning, seek medical attention if your weight goes up more than 3 lbs. - It is very important with your new heart disease that you stop smoking! Please let your primary care physician if you need any assistance with nicotine patches/gum or any other medications that can help you do this. - Seek medical attention if you have new or concerning symptoms or you develop swelling in your legs, abdominal distention, shortness of breath at night, chest pain, or palpitations. We wish you all the best! - Your [MASKED] Care Team Followup Instructions: [MASKED] | [
"I5021",
"J9601",
"I428",
"I472",
"I2720",
"L930",
"J449",
"R590",
"I4581",
"F17210",
"Z8249"
] | [
"I5021: Acute systolic (congestive) heart failure",
"J9601: Acute respiratory failure with hypoxia",
"I428: Other cardiomyopathies",
"I472: Ventricular tachycardia",
"I2720: Pulmonary hypertension, unspecified",
"L930: Discoid lupus erythematosus",
"J449: Chronic obstructive pulmonary disease, unspecified",
"R590: Localized enlarged lymph nodes",
"I4581: Long QT syndrome",
"F17210: Nicotine dependence, cigarettes, uncomplicated",
"Z8249: Family history of ischemic heart disease and other diseases of the circulatory system"
] | [
"J9601",
"J449",
"F17210"
] | [] |
16,548,855 | 26,275,792 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nTagamet / Percocet / Cortisone / Keflex / Erythromycin Base / \nmetoprolol tartrate\n \nAttending: ___.\n \nChief Complaint:\nHemodialysis initiation\n \nMajor Surgical or Invasive Procedure:\nTunneled Right Internal Jugular Hemodialysis Line\n\n \nHistory of Present Illness:\n___ male with a PMHx of CKD IV of hypertension, DM2 \n(diet controlled), CAD s/p CABG and subsequent PCI, and \nhyperlipidemia who is being admitted for initiation of \nhemodialysis. He is followed by Dr. ___ in ___ clinic. \nHis renal function has been slowly worsening over the past \nseveral years and he began to develop some mild uremic symptoms \nin ___ with weight loss and decreased appetite. He was going \nto be seen in dialysis access clinic for fistula placement. \nHowever, just last week he returned from a vacation early \nbecause of worsening nausea and fatigue. He reports very poor \nappetite; he often just chews his food and spits it out because \nof altered taste and nausea. He, his wife, and Dr. ___ \n___ it was time to initiate dialysis. \n He had a right tunneled HD catheter ___. His Plavix has \nbeen on hold for 4 days in anticipation for line placement. \nReportedly did well in HD. No volume off. \n Transferred to the floor after dialysis. Reports feeling well. \nDenies CP, SOB, dizziness, fatigue, chills, fevers. Denies \nanuria or oliguria at baseline. He continues to walk a lot for \nexercise. Needs walker for long distances and uses cane to \nambulate. \n Review of systems: \n (+) Per HPI \n (-) Denies fever, chills, night sweats, recent weight loss or \ngain. Denies headache, sinus tenderness, rhinorrhea or \ncongestion. Denies cough, shortness of breath. Denies chest pain \nor tightness, palpitations. Denies abdominal pain. No recent \nchange in bowel or bladder habits. No dysuria. Denies \narthralgias or myalgias. \n\n \nPast Medical History:\n CAD status post 4-vessel CABG in ___, MI \n in ___, >10 stents placed since CABG \n - AAA s/p abdominal aortic stent placed in ___ for AAA \n - Type II DM \n - Hyperlipidemia \n - Hypertension \n - Hearing impairment \n - S/p lip surgery for malignant growth in ___ \n - ___ s/p fall in ___- admitted for non-op monitoring \n - DM2- good control on no meds \n\n \nSocial History:\n___\nFamily History:\nNo family history of kidney disease\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \n=======================\nVS: 98.2 PO 142/59 70 18 97 ra \nGen: Older, pleasant gentleman in NAD surrounded by family \nHEENT: Sclera anicteric, mild conjunctival pallor, OP clear with \nMMM and no lesions, PERRLA \nNECK: Supple, RIJ in place w/ ttp \nCARDIAC: RRR with soft S1, no M/R/G \nPULM: Non-labored, CTAB \nABDOMEN: Soft, nontender, nondistended, NABS \nEXTREMITIES: Warm, well-perfused, no edema \nNEURO: Gross motor intact ___. No focal deficits. Alert and \noriented to ___ ___ at ___ \n___, here for dialysis\" \nACCESS: Right IJ tunneled HD line with dressing c/d/I \n\nDISCHARGE PHYSICAL EXAM: \n=======================\nVS: 98.3 PO 118 / 51 R Lying 66 12 97 RA \nGen: Older, pleasant gentleman in NAD \nHEENT: Sclera anicteric, mild conjunctival pallor, OP clear with \nMMM and no lesions, PERRLA \nNECK: Supple, RIJ in place w/ appropriate ttp, no purulence \nCARDIAC: RRR with soft S1, no M/R/G \nPULM: Non-labored, CTAB \nABDOMEN: Soft, nontender, nondistended, NABS \nEXTREMITIES: Warm, well-perfused, no edema \nNEURO: Gross motor intact ___. No focal deficits. \nACCESS: Right IJ tunneled HD line with dressing c/d/I \n\n \nPertinent Results:\nADMISISON LABS:\n==============\n___ 02:15PM GLUCOSE-153* UREA N-72* CREAT-3.0* SODIUM-141 \nPOTASSIUM-3.7 CHLORIDE-107 TOTAL CO2-20* ANION GAP-18\n___ 02:15PM estGFR-Using this\n___ 02:15PM CALCIUM-9.9 PHOSPHATE-3.3 MAGNESIUM-1.4*\n___ 02:15PM HBsAg-Negative HBs Ab-Negative HBc \nAb-Negative\n___ 02:15PM HCV Ab-Negative\n___ 02:15PM WBC-6.7 RBC-2.58* HGB-8.9* HCT-26.8* MCV-104* \nMCH-34.5* MCHC-33.2 RDW-13.4 RDWSD-51.4*\n___ 02:15PM PLT COUNT-202\n\nINTERIM LABS: \n=============\n___ 05:12PM BLOOD WBC-8.7 RBC-2.77* Hgb-9.5* Hct-28.7* \nMCV-104* MCH-34.3* MCHC-33.1 RDW-13.2 RDWSD-49.8* Plt ___\n___ 05:12PM BLOOD Glucose-97 UreaN-16 Creat-2.1* Na-136 \nK-3.9 Cl-96 HCO3-30 AnGap-14\n___ 05:12PM BLOOD Calcium-9.7 Phos-2.6* Mg-1.7\n___ 06:16AM BLOOD calTIBC-233* Ferritn-492* TRF-179*\n___ 06:16AM BLOOD PTH-292*\n\nMICRO: \n======\nx2 BCx pending on D/C\n\nIMAGING: \n========\n___ CXR: \nInterval placement of an HD catheter in standard position with \ntip of one \nlumen in the right atrium. Linear opacity in the right lung \nbase consistent \nwith scarring or atelectasis. Left lung is clear. No pleural \neffusion or \npneumothorax is seen. Mild cardiomegaly unchanged. Median \nsternotomy wires \nand mediastinal clips are unchanged. \n \nIMPRESSION: \n \nHD catheter in standard position. Right base atelectasis or \nscarring, new \nsince ___. \n\n___ Fistula mapping: \nFINDINGS: \n \nThere is normal flow with respiratory variation in the left \nsubclavian vein. The right subclavian vein was not visualized \ndue to the presence of \nintravenous access. The right cephalic vein is patent with \ndiameters ranging between 0.21 and 0.23 cm. The right basilic \nvein is patent with diameters ranging between 0.17 and 0.55 cm. \n The right brachial artery is patent with diameter measuring \n0.56 cm. The right radial artery is patent with diameter \nmeasuring 0.28 cm. The left cephalic vein is patent with \ndiameters ranging between 0.19 and 0.52 \ncm. The left basilic vein is patent with diameters ranging \nbetween 0.17 and 0.40 cm. The left brachial arteries patent \nwith diameter of 0.39 cm and the left radial artery is patent \nwith diameter measuring 0.25 cm. \n \nIMPRESSION: \n \nPatent bilateral cephalic and basilic veins with diameters as \ndescribed above. \n\n \nBrief Hospital Course:\n___ male with a PMHx of CKD IV in the setting of \ndiabetes and hypertension, CAD s/p CABG and subsequent PCI, and \nhyperlipidemia who was hospitalized for initiation of \nhemodialysis.\n\n# CKD IV: Thought to be due to HTN, DM w/ increasing uremic \nsymptoms of fatigue and nausea. S/p tunneled RIJ catheter ___. \ns/p HD initiation for ___. Patient tolerated HD with no \ncomplications. Please follow-up PPD at HD center. Vein mapping \ndone ___. \n\n #Fever: patient febrile after midnight ___ to 100.3. No \nleukocytosis, VSS and no localizing signs. Resolved without\nintervention. Possible atelectasis on CXR yesterday. Follow-up \nBCx, UCx as outpatient. Patient counseled to seek medical care \nif he is febrile at home. His Blood cultures were no growth \nfollowing 5 days. \n\n # BONE/MINERAL: PTH was slightly above goal at 86 in ___ and \nhis cinacalcet was increased to 30mg PO daily in ___. PTH \nduring initiation was 292. Will need optimization at HD. \n\n # NUTRITION: Change multivitamins to nephrocaps daily, low \nK/Phos/Na diet. Patient spoke with nutritionist re diet. \n\nCHRONIC ISSUES: \n==========================\n # Anemia: Will need change from Aranesp to ESAs with HD. \n # HTN: Continue home torsemide, lowered amlodipine to 5 mg.\n # CAD s/p CABG, stents: continued statin, plavix\n # DM2: on no meds, diet controlled\n\nTRANSITIONAL ISSUES: \n[] PPD- will be read at dialysis center 3P ___\n[] Continue monitoring BP and wean anti-HTN PRN\n[] Patient had fever to 100.3 on night before discharge. No \nlocalizing symptoms and thought to be due to atelectasis. \nCultures pending at discharge which will be followed by \ninpatient team. Patient instructed to seek medical care if \nhaving signs or symptoms of infection. Infectious work-up \nnegative. \n[] Patient's amlodipine was reduced to 5mg daily, please follow\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. amLODIPine 10 mg PO DAILY \n2. Atorvastatin 80 mg PO QPM \n3. Cinacalcet 30 mg PO DAILY \n4. Clopidogrel 75 mg PO DAILY \n5. Cyanocobalamin 1000 mcg IM/SC ONCE MONTHLY \n6. Aranesp (in polysorbate) (darbepoetin alfa in polysorbat) 100 \nmcg/mL injection once monthly \n7. Ezetimibe 10 mg PO DAILY \n8. Febuxostat 40 mg PO DAILY \n9. Omeprazole 40 mg PO DAILY \n10. QuiNINE Sulfate 324 mg PO QHS \n11. Torsemide 20 mg PO DAILY \n12. Ascorbic Acid ___ mg PO DAILY \n13. Calcium Carbonate 500 mg PO DAILY \n14. Vitamin D 400 UNIT PO DAILY \n15. Ferrous Sulfate 325 mg PO DAILY \n16. FoLIC Acid ___ mcg PO DAILY \n17. Magnesium Oxide 250 mg PO DAILY \n18. Pyridoxine 50 mg PO DAILY \n19. Multivitamins 1 TAB PO DAILY \n20. Fish Oil (Omega 3) 1000 mg PO DAILY \n21. TraZODone 50 mg PO QHS:PRN insomnia \n\n \nDischarge Medications:\n1. Nephrocaps 1 CAP PO DAILY \nRX *B complex with C#20-folic acid [Nephrocaps] 1 mg 1 \ncapsule(s) by mouth once a day Disp #*30 Capsule Refills:*0 \n2. amLODIPine 5 mg PO DAILY \nRX *amlodipine 5 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0 \n3. Atorvastatin 80 mg PO QPM \n4. Calcium Carbonate 500 mg PO DAILY \n5. Cinacalcet 30 mg PO DAILY \n6. Clopidogrel 75 mg PO DAILY \n7. Ezetimibe 10 mg PO DAILY \n8. Febuxostat 40 mg PO DAILY \n9. Ferrous Sulfate 325 mg PO DAILY \n10. Fish Oil (Omega 3) 1000 mg PO DAILY \n11. FoLIC Acid ___ mcg PO DAILY \n12. Multivitamins 1 TAB PO DAILY \n13. Omeprazole 40 mg PO DAILY \n14. QuiNINE Sulfate 324 mg PO QHS \n15. Torsemide 20 mg PO DAILY \n16. TraZODone 50 mg PO QHS:PRN insomnia \n17. Vitamin D 400 UNIT PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS: \n- End Stage Renal Disease\n\nSECONDARY DIAGNOSIS\n- Coronary Artery Disease\n- Type 2 Diabetes Mellitus \n- Hypertension\n- Hyperlipidemia\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nMr. ___, \n\nYou were admitted to the hospital because you needed to be \nstarted on hemodialysis for worsening symptoms (fatigue, poor \nappetite) of your chronic kidney disease.\n\nWhat was done while I was in the hospital?\n- You had a temporary hemodialysis line placed\n- You had several studies and tests to ensure you were safe for \ndialysis\n- You had three dialysis sessions\n\nWhat should I do now that I am leaving the hospital?\n- Continue to go to your dialysis sessions (___) at 11:15a at \nthe Dialysis Center At ___\n- Go to the dialysis center at 3PM on ___ to have your PPD read\n- Seek medical attention if you are feeling ill or having \nfevers, chills or sweats. \n\n- Please see your PCP at your next scheduled appointment\n \nFollowup Instructions:\n___\n"
] | Allergies: Tagamet / Percocet / Cortisone / Keflex / Erythromycin Base / metoprolol tartrate Chief Complaint: Hemodialysis initiation Major Surgical or Invasive Procedure: Tunneled Right Internal Jugular Hemodialysis Line History of Present Illness: [MASKED] male with a PMHx of CKD IV of hypertension, DM2 (diet controlled), CAD s/p CABG and subsequent PCI, and hyperlipidemia who is being admitted for initiation of hemodialysis. He is followed by Dr. [MASKED] in [MASKED] clinic. His renal function has been slowly worsening over the past several years and he began to develop some mild uremic symptoms in [MASKED] with weight loss and decreased appetite. He was going to be seen in dialysis access clinic for fistula placement. However, just last week he returned from a vacation early because of worsening nausea and fatigue. He reports very poor appetite; he often just chews his food and spits it out because of altered taste and nausea. He, his wife, and Dr. [MASKED] [MASKED] it was time to initiate dialysis. He had a right tunneled HD catheter [MASKED]. His Plavix has been on hold for 4 days in anticipation for line placement. Reportedly did well in HD. No volume off. Transferred to the floor after dialysis. Reports feeling well. Denies CP, SOB, dizziness, fatigue, chills, fevers. Denies anuria or oliguria at baseline. He continues to walk a lot for exercise. Needs walker for long distances and uses cane to ambulate. 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 abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Past Medical History: CAD status post 4-vessel CABG in [MASKED], MI in [MASKED], >10 stents placed since CABG - AAA s/p abdominal aortic stent placed in [MASKED] for AAA - Type II DM - Hyperlipidemia - Hypertension - Hearing impairment - S/p lip surgery for malignant growth in [MASKED] - [MASKED] s/p fall in [MASKED]- admitted for non-op monitoring - DM2- good control on no meds Social History: [MASKED] Family History: No family history of kidney disease Physical Exam: ADMISSION PHYSICAL EXAM: ======================= VS: 98.2 PO 142/59 70 18 97 ra Gen: Older, pleasant gentleman in NAD surrounded by family HEENT: Sclera anicteric, mild conjunctival pallor, OP clear with MMM and no lesions, PERRLA NECK: Supple, RIJ in place w/ ttp CARDIAC: RRR with soft S1, no M/R/G PULM: Non-labored, CTAB ABDOMEN: Soft, nontender, nondistended, NABS EXTREMITIES: Warm, well-perfused, no edema NEURO: Gross motor intact [MASKED]. No focal deficits. Alert and oriented to [MASKED] [MASKED] at [MASKED] [MASKED], here for dialysis" ACCESS: Right IJ tunneled HD line with dressing c/d/I DISCHARGE PHYSICAL EXAM: ======================= VS: 98.3 PO 118 / 51 R Lying 66 12 97 RA Gen: Older, pleasant gentleman in NAD HEENT: Sclera anicteric, mild conjunctival pallor, OP clear with MMM and no lesions, PERRLA NECK: Supple, RIJ in place w/ appropriate ttp, no purulence CARDIAC: RRR with soft S1, no M/R/G PULM: Non-labored, CTAB ABDOMEN: Soft, nontender, nondistended, NABS EXTREMITIES: Warm, well-perfused, no edema NEURO: Gross motor intact [MASKED]. No focal deficits. ACCESS: Right IJ tunneled HD line with dressing c/d/I Pertinent Results: ADMISISON LABS: ============== [MASKED] 02:15PM GLUCOSE-153* UREA N-72* CREAT-3.0* SODIUM-141 POTASSIUM-3.7 CHLORIDE-107 TOTAL CO2-20* ANION GAP-18 [MASKED] 02:15PM estGFR-Using this [MASKED] 02:15PM CALCIUM-9.9 PHOSPHATE-3.3 MAGNESIUM-1.4* [MASKED] 02:15PM HBsAg-Negative HBs Ab-Negative HBc Ab-Negative [MASKED] 02:15PM HCV Ab-Negative [MASKED] 02:15PM WBC-6.7 RBC-2.58* HGB-8.9* HCT-26.8* MCV-104* MCH-34.5* MCHC-33.2 RDW-13.4 RDWSD-51.4* [MASKED] 02:15PM PLT COUNT-202 INTERIM LABS: ============= [MASKED] 05:12PM BLOOD WBC-8.7 RBC-2.77* Hgb-9.5* Hct-28.7* MCV-104* MCH-34.3* MCHC-33.1 RDW-13.2 RDWSD-49.8* Plt [MASKED] [MASKED] 05:12PM BLOOD Glucose-97 UreaN-16 Creat-2.1* Na-136 K-3.9 Cl-96 HCO3-30 AnGap-14 [MASKED] 05:12PM BLOOD Calcium-9.7 Phos-2.6* Mg-1.7 [MASKED] 06:16AM BLOOD calTIBC-233* Ferritn-492* TRF-179* [MASKED] 06:16AM BLOOD PTH-292* MICRO: ====== x2 BCx pending on D/C IMAGING: ======== [MASKED] CXR: Interval placement of an HD catheter in standard position with tip of one lumen in the right atrium. Linear opacity in the right lung base consistent with scarring or atelectasis. Left lung is clear. No pleural effusion or pneumothorax is seen. Mild cardiomegaly unchanged. Median sternotomy wires and mediastinal clips are unchanged. IMPRESSION: HD catheter in standard position. Right base atelectasis or scarring, new since [MASKED]. [MASKED] Fistula mapping: FINDINGS: There is normal flow with respiratory variation in the left subclavian vein. The right subclavian vein was not visualized due to the presence of intravenous access. The right cephalic vein is patent with diameters ranging between 0.21 and 0.23 cm. The right basilic vein is patent with diameters ranging between 0.17 and 0.55 cm. The right brachial artery is patent with diameter measuring 0.56 cm. The right radial artery is patent with diameter measuring 0.28 cm. The left cephalic vein is patent with diameters ranging between 0.19 and 0.52 cm. The left basilic vein is patent with diameters ranging between 0.17 and 0.40 cm. The left brachial arteries patent with diameter of 0.39 cm and the left radial artery is patent with diameter measuring 0.25 cm. IMPRESSION: Patent bilateral cephalic and basilic veins with diameters as described above. Brief Hospital Course: [MASKED] male with a PMHx of CKD IV in the setting of diabetes and hypertension, CAD s/p CABG and subsequent PCI, and hyperlipidemia who was hospitalized for initiation of hemodialysis. # CKD IV: Thought to be due to HTN, DM w/ increasing uremic symptoms of fatigue and nausea. S/p tunneled RIJ catheter [MASKED]. s/p HD initiation for [MASKED]. Patient tolerated HD with no complications. Please follow-up PPD at HD center. Vein mapping done [MASKED]. #Fever: patient febrile after midnight [MASKED] to 100.3. No leukocytosis, VSS and no localizing signs. Resolved without intervention. Possible atelectasis on CXR yesterday. Follow-up BCx, UCx as outpatient. Patient counseled to seek medical care if he is febrile at home. His Blood cultures were no growth following 5 days. # BONE/MINERAL: PTH was slightly above goal at 86 in [MASKED] and his cinacalcet was increased to 30mg PO daily in [MASKED]. PTH during initiation was 292. Will need optimization at HD. # NUTRITION: Change multivitamins to nephrocaps daily, low K/Phos/Na diet. Patient spoke with nutritionist re diet. CHRONIC ISSUES: ========================== # Anemia: Will need change from Aranesp to ESAs with HD. # HTN: Continue home torsemide, lowered amlodipine to 5 mg. # CAD s/p CABG, stents: continued statin, plavix # DM2: on no meds, diet controlled TRANSITIONAL ISSUES: [] PPD- will be read at dialysis center 3P [MASKED] [] Continue monitoring BP and wean anti-HTN PRN [] Patient had fever to 100.3 on night before discharge. No localizing symptoms and thought to be due to atelectasis. Cultures pending at discharge which will be followed by inpatient team. Patient instructed to seek medical care if having signs or symptoms of infection. Infectious work-up negative. [] Patient's amlodipine was reduced to 5mg daily, please follow Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Atorvastatin 80 mg PO QPM 3. Cinacalcet 30 mg PO DAILY 4. Clopidogrel 75 mg PO DAILY 5. Cyanocobalamin 1000 mcg IM/SC ONCE MONTHLY 6. Aranesp (in polysorbate) (darbepoetin alfa in polysorbat) 100 mcg/mL injection once monthly 7. Ezetimibe 10 mg PO DAILY 8. Febuxostat 40 mg PO DAILY 9. Omeprazole 40 mg PO DAILY 10. QuiNINE Sulfate 324 mg PO QHS 11. Torsemide 20 mg PO DAILY 12. Ascorbic Acid [MASKED] mg PO DAILY 13. Calcium Carbonate 500 mg PO DAILY 14. Vitamin D 400 UNIT PO DAILY 15. Ferrous Sulfate 325 mg PO DAILY 16. FoLIC Acid [MASKED] mcg PO DAILY 17. Magnesium Oxide 250 mg PO DAILY 18. Pyridoxine 50 mg PO DAILY 19. Multivitamins 1 TAB PO DAILY 20. Fish Oil (Omega 3) 1000 mg PO DAILY 21. TraZODone 50 mg PO QHS:PRN insomnia Discharge Medications: 1. Nephrocaps 1 CAP PO DAILY RX *B complex with C#20-folic acid [Nephrocaps] 1 mg 1 capsule(s) by mouth once a day Disp #*30 Capsule Refills:*0 2. amLODIPine 5 mg PO DAILY RX *amlodipine 5 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 3. Atorvastatin 80 mg PO QPM 4. Calcium Carbonate 500 mg PO DAILY 5. Cinacalcet 30 mg PO DAILY 6. Clopidogrel 75 mg PO DAILY 7. Ezetimibe 10 mg PO DAILY 8. Febuxostat 40 mg PO DAILY 9. Ferrous Sulfate 325 mg PO DAILY 10. Fish Oil (Omega 3) 1000 mg PO DAILY 11. FoLIC Acid [MASKED] mcg PO DAILY 12. Multivitamins 1 TAB PO DAILY 13. Omeprazole 40 mg PO DAILY 14. QuiNINE Sulfate 324 mg PO QHS 15. Torsemide 20 mg PO DAILY 16. TraZODone 50 mg PO QHS:PRN insomnia 17. Vitamin D 400 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: - End Stage Renal Disease SECONDARY DIAGNOSIS - Coronary Artery Disease - Type 2 Diabetes Mellitus - 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). Discharge Instructions: Mr. [MASKED], You were admitted to the hospital because you needed to be started on hemodialysis for worsening symptoms (fatigue, poor appetite) of your chronic kidney disease. What was done while I was in the hospital? - You had a temporary hemodialysis line placed - You had several studies and tests to ensure you were safe for dialysis - You had three dialysis sessions What should I do now that I am leaving the hospital? - Continue to go to your dialysis sessions ([MASKED]) at 11:15a at the Dialysis Center At [MASKED] - Go to the dialysis center at 3PM on [MASKED] to have your PPD read - Seek medical attention if you are feeling ill or having fevers, chills or sweats. - Please see your PCP at your next scheduled appointment Followup Instructions: [MASKED] | [
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"E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease",
"I120: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease",
"N186: End stage renal disease",
"D649: Anemia, unspecified",
"Z992: Dependence on renal dialysis",
"Z87891: Personal history of nicotine dependence",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"Z951: Presence of aortocoronary bypass graft",
"Z955: Presence of coronary angioplasty implant and graft",
"I252: Old myocardial infarction",
"E785: Hyperlipidemia, unspecified",
"I714: Abdominal aortic aneurysm, without rupture",
"Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits",
"R509: Fever, unspecified"
] | [
"E1122",
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15,384,486 | 28,559,957 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: ORTHOPAEDICS\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\nright knee osteoarthritis/pain\n \nMajor Surgical or Invasive Procedure:\n___: right total knee arthroplasty\n\n \nHistory of Present Illness:\n___ year old female w/right knee osteoarthritis/pain who failed \nconservative measures, now admitted for right total knee \narthroplasty. \n \nPast Medical History:\nsystolic CHF (LV function improved from EF 40% in ___ to 65% in \n___, dyslipidemia, atrial fibrillation (s/p DCV, treated \nw/Eliquis, Amiodarone), heart murmur, hypertension, mitral \nregurgitation, impaired glucose (A1C 6.2%), hypothyroidism, \ncolon cancer (GIB in setting of Xarelto, s/p colectomy ___, \nrenal insufficiency (baseline ___, s/p L TKA (___), lap \nband surgery, left knee arthroscopy (___), tonsillectomy \n \nSocial History:\n___\nFamily History:\nNon-contributory\n \nPhysical Exam:\nWell appearing in no acute distress \n Afebrile with stable vital signs \n Pain well-controlled \n Respiratory: CTAB \n Cardiovascular: RRR \n Gastrointestinal: NT/ND \n Genitourinary: Voiding independently \n Neurologic: Intact with no focal deficits \n Psychiatric: Pleasant, A&O x3 \n Musculoskeletal Lower Extremity: \n * Incision healing well with staples \n * Scant serosanguinous drainage \n * Thigh full but soft \n * No calf tenderness \n * ___ strength \n * SILT, NVI distally \n * Toes warm \n \nPertinent Results:\n___ 06:51AM BLOOD WBC-9.3 RBC-2.93* Hgb-8.8* Hct-27.9* \nMCV-95 MCH-30.0 MCHC-31.5* RDW-15.0 RDWSD-52.3* Plt ___\n___ 06:05AM BLOOD WBC-9.7 RBC-3.00* Hgb-9.1* Hct-28.4* \nMCV-95 MCH-30.3 MCHC-32.0 RDW-15.2 RDWSD-52.0* Plt ___\n___ 05:58AM BLOOD WBC-12.3* RBC-3.13* Hgb-9.5* Hct-29.0* \nMCV-93 MCH-30.4 MCHC-32.8 RDW-15.2 RDWSD-51.2* Plt ___\n___ 06:00AM BLOOD WBC-15.0*# RBC-3.66* Hgb-10.9* Hct-34.3 \nMCV-94 MCH-29.8 MCHC-31.8* RDW-15.1 RDWSD-52.2* Plt ___\n___ 06:51AM BLOOD Glucose-101* UreaN-32* Creat-1.1 Na-136 \nK-3.9 Cl-96 HCO3-26 AnGap-18\n___ 06:05AM BLOOD Glucose-84 UreaN-44* Creat-1.6* Na-133 \nK-3.8 Cl-92* HCO3-26 AnGap-19\n___ 11:12PM BLOOD UreaN-43* Creat-1.8* Na-130*\n___ 03:33PM BLOOD Glucose-97 UreaN-41* Creat-1.9* Na-127* \nK-3.3 Cl-89* HCO3-26 AnGap-15\n___ 05:58AM BLOOD Glucose-105* UreaN-43* Creat-2.1* Na-130* \nK-3.2* Cl-89* HCO3-25 AnGap-19\n___ 05:58AM BLOOD Osmolal-275\n___ 02:48PM URINE Color-Straw Appear-Clear Sp ___\n___ 02:48PM URINE Blood-NEG Nitrite-NEG Protein-TR \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG\n___ 02:48PM URINE RBC-2 WBC-<1 Bacteri-NONE Yeast-NONE \nEpi-1\n___ 02:48PM URINE Hours-RANDOM Creat-106 Na-<20\n___ 02:48PM URINE Osmolal-281\n \nBrief Hospital Course:\nThe patient was admitted to the Orthopaedic surgery service and \nwas taken to the operating room for above described procedure. \nPlease see separately dictated operative report for details. The \nsurgery was uncomplicated and the patient tolerated the \nprocedure well. Patient received perioperative IV antibiotics.\n\nPostoperative course was remarkable for the following:\nOn postoperative day 1, the patient was found to have low urine \noutput. She was given a 1000ml bolus of normal saline with \nimprovement in her urine output. Overnight, she triggered for \nhypotension and low urine output. Another bolus of one-liter of \nfluid was given. On POD#2, she had low urine output. She was \ngiven another 500ml bolus of normal saline. Her creatinine \nbumped from 1.1 to 2.1. Her chlorthalidone, valsartan, and \namlodipine were held. She was also found to have new \nhyponatremia with a nadir of 127. A FeNa was also sent and \nshowed likely prerenal causes. Renal was consulted, and \nrecommendations were for a renal ultrasound and normal saline at \n75mls/hour. Renal ultrasound showed no acute process. The \nfollowing morning the patient's sodium had normalized and her \ncreatinine had decreased to 1.6 and her sodium had normalized. \nOn day of discharge her creatinine had normalized at 1.1. \n\nOtherwise, pain was controlled with a combination of IV and oral \npain medications. The patient received Eliquis for DVT \nprophylaxis starting on the evening of POD#0. The surgical \ndressing was changed and the SIlverlon dressing was removed on \nPOD#2. The surgical incision was found to be clean and intact \nwithout erythema or abnormal drainage. The patient was seen \ndaily by physical therapy. Labs were checked throughout the \nhospital course and repleted accordingly. At the time of \ndischarge the patient was tolerating a regular diet and feeling \nwell. The patient was afebrile with stable vital signs. The \npatient's hematocrit was acceptable and pain was adequately \ncontrolled on an oral regimen. The operative extremity was \nneurovascularly intact and the wound was benign.\n\nThe patient's weight-bearing status is weight bearing as \ntolerated on the operative extremity. Please use walker or 2 \ncrutches at all times for 6 weeks.\n\nMs. ___ is discharged to rehab in stable condition.\n \nMedications on Admission:\n1. Amiodarone 200 mg PO DAILY \n2. amlodipine-valsartan ___ mg oral DAILY \n3. Apixaban 5 mg PO BID \n4. Atorvastatin 80 mg PO QPM \n5. Chlorthalidone 50 mg PO DAILY \n6. Gabapentin 300 mg PO BID \n7. Levothyroxine Sodium 125 mcg PO DAILY \n8. Metoprolol Succinate XL 100 mg PO DAILY \n9. biotin 300 mcg oral DAILY \n10. Calcium with Vitamin D (calcium carbonate-vitamin D3) 600 \nmg(1,500mg) -400 unit oral DAILY \n11. Centrum (multivit-iron-min-folic \nacid;<br>multivit-mins-ferrous gluconat) 3,500-18-0.4 unit-mg-mg \noral DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H \n2. Docusate Sodium 100 mg PO BID \nstop taking if having loose stool. \n3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain \n4. Senna 8.6 mg PO BID \n5. Amiodarone 200 mg PO DAILY \n6. amlodipine-valsartan ___ mg oral DAILY \n7. Apixaban 5 mg PO BID \n8. Atorvastatin 80 mg PO QPM \n9. biotin 300 mcg oral DAILY \n10. Calcium with Vitamin D (calcium carbonate-vitamin D3) 600 \nmg(1,500mg) -400 unit oral DAILY \n11. Centrum (multivit-iron-min-folic \nacid;<br>multivit-mins-ferrous gluconat) 3,500-18-0.4 unit-mg-mg \noral DAILY \n12. Chlorthalidone 50 mg PO DAILY \n13. Gabapentin 300 mg PO BID \n14. Levothyroxine Sodium 125 mcg PO DAILY \n15. Metoprolol Succinate XL 100 mg PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nright knee osteoarthritis/pain\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nWeigh yourself every morning, call MD if weight goes up more \nthan 3 lbs.\n\n1. Please return to the emergency department or notify your \nphysician if you experience any of the following: severe pain \nnot relieved by medication, increased swelling, decreased \nsensation, difficulty with movement, fevers greater than 101.5, \nshaking chills, increasing redness or drainage from the incision \nsite, chest pain, shortness of breath or any other concerns.\n\n2. Please follow up with your primary physician regarding this \nadmission and any new medications and refills. \n\n3. Resume your home medications unless otherwise instructed.\n\n4. You have been given medications for pain control. Please do \nnot drive, operate heavy machinery, or drink alcohol while \ntaking these medications. As your pain decreases, take fewer \ntablets and increase the time between doses. This medication can \ncause constipation, so you should drink plenty of water daily \nand take a stool softener (such as Colace) as needed to prevent \nthis side effect. Call your surgeons office 3 days before you \nare out of medication so that it can be refilled. These \nmedications cannot be called into your pharmacy and must be \npicked up in the clinic or mailed to your house. Please allow \nan extra 2 days if you would like your medication mailed to your \nhome.\n\n5. You may not drive a car until cleared to do so by your \nsurgeon.\n\n6. Please call your surgeon's office to schedule or confirm your \nfollow-up appointment.\n\n7. SWELLING: Ice the operative joint 20 minutes at a time, \nespecially after activity or physical therapy. Do not place ice \ndirectly on the skin. You may wrap the knee with an ace bandage \nfor added compression. Please DO NOT take any non-steroidal \nanti-inflammatory medications (NSAIDs such as Celebrex, \nibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by \nyour physician.\n\n8. ANTICOAGULATION: Please continue your home dose of Eliquis to \nhelp prevent deep vein thrombosis (blood clots). \n\n9. WOUND CARE: Please keep your incision clean and dry. It is \nokay to shower five days after surgery but no tub baths, \nswimming, or submerging your incision until after your four (4) \nweek checkup. Please place a dry sterile dressing on the wound \neach day if there is drainage, otherwise leave it open to air. \nCheck wound regularly for signs of infection such as redness or \nthick yellow drainage. Staples will be removed at follow-up \nappointment approximately two weeks after surgery. \n\n10. ___ (once at home): Home ___, dressing changes as \ninstructed, and wound checks.\n\n11. ACTIVITY: Weight bearing as tolerated on the operative \nextremity. Two crutches or walker at all times for 6 weeks. \nMobilize. ROM as tolerated. No strenuous exercise or heavy \nlifting until follow up appointment. \nPhysical Therapy:\nWBAT RLE\nNo range of motion restrictions\nAssistive device x 6 weeks post-op (i.e., 2 crutches, walker)\nMobilize frequently\nTreatments Frequency:\ndaily dressing changes as needed for drainage\nwound checks daily\nice\nstaple removal and replace with steri-strips (at follow up \nvisit)\n \nFollowup Instructions:\n___\n"
] | Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: right knee osteoarthritis/pain Major Surgical or Invasive Procedure: [MASKED]: right total knee arthroplasty History of Present Illness: [MASKED] year old female w/right knee osteoarthritis/pain who failed conservative measures, now admitted for right total knee arthroplasty. Past Medical History: systolic CHF (LV function improved from EF 40% in [MASKED] to 65% in [MASKED], dyslipidemia, atrial fibrillation (s/p DCV, treated w/Eliquis, Amiodarone), heart murmur, hypertension, mitral regurgitation, impaired glucose (A1C 6.2%), hypothyroidism, colon cancer (GIB in setting of Xarelto, s/p colectomy [MASKED], renal insufficiency (baseline [MASKED], s/p L TKA ([MASKED]), lap band surgery, left knee arthroscopy ([MASKED]), tonsillectomy Social History: [MASKED] Family History: Non-contributory Physical Exam: Well appearing in no acute distress Afebrile with stable vital signs Pain well-controlled Respiratory: CTAB Cardiovascular: RRR Gastrointestinal: NT/ND Genitourinary: Voiding independently Neurologic: Intact with no focal deficits Psychiatric: Pleasant, A&O x3 Musculoskeletal Lower Extremity: * Incision healing well with staples * Scant serosanguinous drainage * Thigh full but soft * No calf tenderness * [MASKED] strength * SILT, NVI distally * Toes warm Pertinent Results: [MASKED] 06:51AM BLOOD WBC-9.3 RBC-2.93* Hgb-8.8* Hct-27.9* MCV-95 MCH-30.0 MCHC-31.5* RDW-15.0 RDWSD-52.3* Plt [MASKED] [MASKED] 06:05AM BLOOD WBC-9.7 RBC-3.00* Hgb-9.1* Hct-28.4* MCV-95 MCH-30.3 MCHC-32.0 RDW-15.2 RDWSD-52.0* Plt [MASKED] [MASKED] 05:58AM BLOOD WBC-12.3* RBC-3.13* Hgb-9.5* Hct-29.0* MCV-93 MCH-30.4 MCHC-32.8 RDW-15.2 RDWSD-51.2* Plt [MASKED] [MASKED] 06:00AM BLOOD WBC-15.0*# RBC-3.66* Hgb-10.9* Hct-34.3 MCV-94 MCH-29.8 MCHC-31.8* RDW-15.1 RDWSD-52.2* Plt [MASKED] [MASKED] 06:51AM BLOOD Glucose-101* UreaN-32* Creat-1.1 Na-136 K-3.9 Cl-96 HCO3-26 AnGap-18 [MASKED] 06:05AM BLOOD Glucose-84 UreaN-44* Creat-1.6* Na-133 K-3.8 Cl-92* HCO3-26 AnGap-19 [MASKED] 11:12PM BLOOD UreaN-43* Creat-1.8* Na-130* [MASKED] 03:33PM BLOOD Glucose-97 UreaN-41* Creat-1.9* Na-127* K-3.3 Cl-89* HCO3-26 AnGap-15 [MASKED] 05:58AM BLOOD Glucose-105* UreaN-43* Creat-2.1* Na-130* K-3.2* Cl-89* HCO3-25 AnGap-19 [MASKED] 05:58AM BLOOD Osmolal-275 [MASKED] 02:48PM URINE Color-Straw Appear-Clear Sp [MASKED] [MASKED] 02:48PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG [MASKED] 02:48PM URINE RBC-2 WBC-<1 Bacteri-NONE Yeast-NONE Epi-1 [MASKED] 02:48PM URINE Hours-RANDOM Creat-106 Na-<20 [MASKED] 02:48PM URINE Osmolal-281 Brief Hospital Course: The patient was admitted to the Orthopaedic surgery service and was taken to the operating room for above described procedure. Please see separately dictated operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Patient received perioperative IV antibiotics. Postoperative course was remarkable for the following: On postoperative day 1, the patient was found to have low urine output. She was given a 1000ml bolus of normal saline with improvement in her urine output. Overnight, she triggered for hypotension and low urine output. Another bolus of one-liter of fluid was given. On POD#2, she had low urine output. She was given another 500ml bolus of normal saline. Her creatinine bumped from 1.1 to 2.1. Her chlorthalidone, valsartan, and amlodipine were held. She was also found to have new hyponatremia with a nadir of 127. A FeNa was also sent and showed likely prerenal causes. Renal was consulted, and recommendations were for a renal ultrasound and normal saline at 75mls/hour. Renal ultrasound showed no acute process. The following morning the patient's sodium had normalized and her creatinine had decreased to 1.6 and her sodium had normalized. On day of discharge her creatinine had normalized at 1.1. Otherwise, pain was controlled with a combination of IV and oral pain medications. The patient received Eliquis for DVT prophylaxis starting on the evening of POD#0. The surgical dressing was changed and the SIlverlon dressing was removed on POD#2. The surgical incision was found to be clean and intact without erythema or abnormal drainage. The patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was acceptable and pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact and the wound was benign. The patient's weight-bearing status is weight bearing as tolerated on the operative extremity. Please use walker or 2 crutches at all times for 6 weeks. Ms. [MASKED] is discharged to rehab in stable condition. Medications on Admission: 1. Amiodarone 200 mg PO DAILY 2. amlodipine-valsartan [MASKED] mg oral DAILY 3. Apixaban 5 mg PO BID 4. Atorvastatin 80 mg PO QPM 5. Chlorthalidone 50 mg PO DAILY 6. Gabapentin 300 mg PO BID 7. Levothyroxine Sodium 125 mcg PO DAILY 8. Metoprolol Succinate XL 100 mg PO DAILY 9. biotin 300 mcg oral DAILY 10. Calcium with Vitamin D (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral DAILY 11. Centrum (multivit-iron-min-folic acid;<br>multivit-mins-ferrous gluconat) 3,500-18-0.4 unit-mg-mg oral DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Docusate Sodium 100 mg PO BID stop taking if having loose stool. 3. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain 4. Senna 8.6 mg PO BID 5. Amiodarone 200 mg PO DAILY 6. amlodipine-valsartan [MASKED] mg oral DAILY 7. Apixaban 5 mg PO BID 8. Atorvastatin 80 mg PO QPM 9. biotin 300 mcg oral DAILY 10. Calcium with Vitamin D (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral DAILY 11. Centrum (multivit-iron-min-folic acid;<br>multivit-mins-ferrous gluconat) 3,500-18-0.4 unit-mg-mg oral DAILY 12. Chlorthalidone 50 mg PO DAILY 13. Gabapentin 300 mg PO BID 14. Levothyroxine Sodium 125 mcg PO DAILY 15. Metoprolol Succinate XL 100 mg PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: right knee osteoarthritis/pain 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: Weigh yourself every morning, call MD if weight goes up more than 3 lbs. 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as Colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon. 6. Please call your surgeon's office to schedule or confirm your follow-up appointment. 7. SWELLING: Ice the operative joint 20 minutes at a time, especially after activity or physical therapy. Do not place ice directly on the skin. You may wrap the knee with an ace bandage for added compression. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as Celebrex, ibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by your physician. 8. ANTICOAGULATION: Please continue your home dose of Eliquis to help prevent deep vein thrombosis (blood clots). 9. WOUND CARE: Please keep your incision clean and dry. It is okay to shower five days after surgery but no tub baths, swimming, or submerging your incision until after your four (4) week checkup. Please place a dry sterile dressing on the wound each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed at follow-up appointment approximately two weeks after surgery. 10. [MASKED] (once at home): Home [MASKED], dressing changes as instructed, and wound checks. 11. ACTIVITY: Weight bearing as tolerated on the operative extremity. Two crutches or walker at all times for 6 weeks. Mobilize. ROM as tolerated. No strenuous exercise or heavy lifting until follow up appointment. Physical Therapy: WBAT RLE No range of motion restrictions Assistive device x 6 weeks post-op (i.e., 2 crutches, walker) Mobilize frequently Treatments Frequency: daily dressing changes as needed for drainage wound checks daily ice staple removal and replace with steri-strips (at follow up visit) Followup Instructions: [MASKED] | [
"M1711",
"N179",
"I429",
"E871",
"I110",
"I5022",
"E6601",
"I4891",
"E861",
"M21061",
"I340",
"I9581",
"E039",
"E785",
"R7303",
"Z6836",
"R339",
"I952",
"T465X5A",
"T502X5A",
"Y92230",
"Z7901",
"Z9884",
"Z85038",
"Z9049",
"Z96652",
"Z87891"
] | [
"M1711: Unilateral primary osteoarthritis, right knee",
"N179: Acute kidney failure, unspecified",
"I429: Cardiomyopathy, unspecified",
"E871: Hypo-osmolality and hyponatremia",
"I110: Hypertensive heart disease with heart failure",
"I5022: Chronic systolic (congestive) heart failure",
"E6601: Morbid (severe) obesity due to excess calories",
"I4891: Unspecified atrial fibrillation",
"E861: Hypovolemia",
"M21061: Valgus deformity, not elsewhere classified, right knee",
"I340: Nonrheumatic mitral (valve) insufficiency",
"I9581: Postprocedural hypotension",
"E039: Hypothyroidism, unspecified",
"E785: Hyperlipidemia, unspecified",
"R7303: Prediabetes",
"Z6836: Body mass index [BMI] 36.0-36.9, adult",
"R339: Retention of urine, unspecified",
"I952: Hypotension due to drugs",
"T465X5A: Adverse effect of other antihypertensive drugs, initial encounter",
"T502X5A: Adverse effect of carbonic-anhydrase inhibitors, benzothiadiazides and other diuretics, initial encounter",
"Y92230: Patient room in hospital as the place of occurrence of the external cause",
"Z7901: Long term (current) use of anticoagulants",
"Z9884: Bariatric surgery status",
"Z85038: Personal history of other malignant neoplasm of large intestine",
"Z9049: Acquired absence of other specified parts of digestive tract",
"Z96652: Presence of left artificial knee joint",
"Z87891: Personal history of nicotine dependence"
] | [
"N179",
"E871",
"I110",
"I4891",
"E039",
"E785",
"Y92230",
"Z7901",
"Z87891"
] | [] |
17,309,889 | 21,204,109 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nshrimp\n \nAttending: ___.\n \nChief Complaint:\nVomiting, Weakness \n \nMajor Surgical or Invasive Procedure:\nNONE\n\n \nHistory of Present Illness:\nHistory Obtained From: ED Dashboard\nMr. ___ is a ___ w/ PMH of atria fibrillation on\ncoumadin, multiple hernia repairs, LBO ___ partial colectomy, \nwho\npresents w/ weakness and emesis. Sudden onset of nausea, NBNB\nprojectile vomiting x1, irregular heartbeat a/w weakness this \nAM.\nCalled PCP who told him to report to ED. Symptoms lasted for 5\nhours. He had symptomatically improved in the ED and was\npreparing to be discharged home when he became febrile and\nhypotensive requiring fluid resuscitation and initiation of\nantibiotics.\n\nIn the ED, initial vitals: \nPain 0 Temp 97.7 HR 79 BP 123/80 RR 16 pO2 97% RA Glucose 106 \n\n- Exam notable for: \nGeneral: in NAD\nHEENT: atraumatic, no scleral icterus\nChest: CTAB\nCardiac: irregular rate\nAbdomen: soft, non-distended, non-tender \nExtremities: no c/c/e\n\n- Labs notable for: \nLactate 2.6\nFlu negative\nTrop-T <0.01 x2\nPTT 38.2, INR 3.3\nUA Leuk Tr, Ket Tr, Pro Tr\n\n \n- Imaging notable for: \nCT abdomen and pelvis w/ contrast\nMultiple dilated loops of small bowel without evidence of\ntransition point to suggest obstruction may represent an ileus.\nOtherwise, no acute intraabdominal abnormality.\n\nCXR \nNo acute cardiopulmonary abnormality.\n\n- Pt given: \n___ 20:00 IVF LR 500 mL \n___ 21:42 IV CefTRIAXone (1 g ordered) \n___ 22:12 IVF LR 1000 mL \n___ 01:08 IV Vancomycin \n___ 01:08 IVF LR ( 1000 mL ordered) \n___ 01:08 PO/NG Aspirin 81 mg \n___ 02:30 IV Vancomycin 1000 mg \n\n- Vitals prior to transfer: \nPain 0 Temp 99.9 HR 72 BP 111/80 RR 18 pO2 97% RA\n \nUpon arrival to the floor, the patient reports... Similar\nhistory per above. He had leftover meatloaf the night prior\naround 5:30 pm when he vomiting and was nauseous about 12 hours\nafter. His wife also had this meal but did not have his \nsymptoms.\nOtherwise has had intermittent nausea but no diarrhea or\nvomiting. \n\nREVIEW OF SYSTEMS: \nEndorses nausea, congestion for ___ months, intermittently\nfeeling weak and lightheaded. SBP typically runs in ___.\nDenies diarrhea, sick contacts, fever/chills/nightsweats, cough,\nskin breakages, chest pain, shortness of breath, leg swelling,\northopnea, melena, BRBPR, reduced PO, urinary retention, \ndysuria.\n \n \nPast Medical History:\nMEDICAL HISTORY:\n================\nAflutter ___ cardioversion ___\n?reactive airway disease \nmitral regurgitation ___ MVrepair/P2 triangular resection/36mm\nring\nHFrEF 40% ___\ncolon polyps ___ resection\npostprandial \nreactive hypoglycemia\nmild macular degeneration\nBPH\nh/o sigmoid volvulus \n\nSurgical history:\n================\nAppendectomy\nCholecystostomy\nPartial removal of bowel\n \nSocial History:\n___\nFamily History:\nNon-contributory\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \n==========================\nVITALS: 97.6 PO 113 / 72 R Sitting 95 18 95 ra \nGeneral: Alert, oriented, no acute distress \nHEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,\nneck supple, JVP not elevated, no JVD, no LAD \nCV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,\ngallops \nLungs: Clear to auscultation bilaterally, no wheezes, rales,\nrhonchi \nAbdomen: Soft, scar tissue on anterior abdomen with anterior\nsurgical scar, non-tender, non-distended, bowel sounds present,\nno organomegaly, no rebound or guarding \nGU: No foley \nExt: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or\nedema \nSkin: Warm, dry, no rashes or notable lesions. \nNeuro: CNII-XII intact, moving all extremities appropriately \n\nDISCHARGE PHYSICAL EXAM:\n========================\n24 HR Data (last updated ___ @ 319)\n Temp: 97.7 (Tm 98.4), BP: 102/68 (91-123/60-72), HR: 79\n(63-79), RR: 17 (___), O2 sat: 97% (95-97), O2 delivery: Ra,\nWt: 151.46 lb/68.7 kg \nGeneral: Alert, oriented, no acute distress \nHEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,\nneck supple, JVP not elevated, no JVD, no LAD \nCV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,\ngallops \nLungs: Clear to auscultation bilaterally, no wheezes, rales,\nrhonchi \nAbdomen: Soft, scar tissue on anterior abdomen with anterior\nsurgical scar, non-tender, non-distended, bowel sounds present,\nno organomegaly, no rebound or guarding \nGU: No foley \nExt: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or\nedema \nSkin: Warm, dry, no rashes or notable lesions. \nNeuro: CNII-XII intact, moving all extremities appropriately \n \nPertinent Results:\nADMISSION LABS:\n==============\n\n___ 04:10PM BLOOD WBC-7.1 RBC-4.60 Hgb-15.0 Hct-45.5 \nMCV-99* MCH-32.6* MCHC-33.0 RDW-12.8 RDWSD-46.8* Plt ___\n___ 05:34PM BLOOD ___ PTT-38.2* ___\n___ 04:10PM BLOOD Glucose-103* UreaN-18 Creat-0.8 Na-144 \nK-4.2 Cl-107 HCO3-26 AnGap-11\n___ 04:10PM BLOOD ALT-12 AST-19 AlkPhos-76 TotBili-0.8\n___ 04:10PM BLOOD cTropnT-<0.01\n___ 07:15PM BLOOD cTropnT-<0.01\n___ 04:10PM BLOOD Lipase-45\n___ 04:10PM BLOOD Albumin-4.0\n___ 07:05AM BLOOD Calcium-8.2* Phos-2.7 Mg-2.0\n___ 09:15PM BLOOD Lactate-2.6*\n\nMICROBIOLOGY:\n============\n__________________________________________________________\n___ 9:12 pm BLOOD CULTURE\n\n Blood Culture, Routine (Pending): No growth to date. \n__________________________________________________________\n___ 9:00 pm BLOOD CULTURE\n\n Blood Culture, Routine (Pending): No growth to date. \n__________________________________________________________\n___ 5:30 pm URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT \nWITH SKIN\n AND/OR GENITAL CONTAMINATION. \n\nIMAGING:\n========\nCTAP ___:\nMultiple dilated loops of small bowel without evidence of \ntransition point,\nmay represent a mild ileus or enteritis. Otherwise, no acute \nintraabdominal\nabnormality.\n \nCXR ___:\nNo acute cardiopulmonary abnormality.\n\nDISCHARGE LABS:\n================\n\n___ 07:55AM BLOOD WBC-4.0 RBC-4.24* Hgb-14.1 Hct-42.6 \nMCV-101* MCH-33.3* MCHC-33.1 RDW-12.9 RDWSD-48.0* Plt ___\n___ 07:55AM BLOOD ___ PTT-32.9 ___\n___ 07:55AM BLOOD Glucose-88 UreaN-13 Creat-0.7 Na-147 \nK-3.9 Cl-109* HCO3-27 AnGap-___RIEF HOSPITAL COURSE:\n======================\nMr. ___ is a ___ w/ PMH of atrial fibrillation on \ncoumadin, MVP with severe MR ___ repair, multiple hernia \nrepairs, ___ partial colectomy (for sigmoid volvulus), who \npresents w/ weakness and emesis. ED course complicated by fever \nand hypotension. Hypotension was attributed to GI losses. There \nwas initial concern for septic shock; however, given quick \nrecovery with IVF and no clear source of infection, antibiotics \nwere held and patient remained stable over 24hrs of observation. \n\n\nACUTE/ACTIVE PROBLEMS: \n======================\n# Hypotension:\nThe patient initally presented to the ED with emesis and \nweakness which improved and while pending discharge from ED, \ndeveloped temperature of 100.3 and hypotensive to the ___ \nsystolic. Pt was lightheaded and dizzy and SBP improved after 2L \nof IVF. Received vanc/CTX in the ED empirically but given normal \nimaging including CT abd and pelvis, CXR without PNA, U/A clear, \nand Bcx without infection, antibiotics were stopped. Unlikely \ncardiogenic cause given negative trops. Likely ___ viral illness \nas below with transient symptoms. The patient's BP remained \nstable for 24hrs and was discharged back on his home \nantihypertensives after BPs remained stable once started prior \nto discharge. \n\n# Nausea/vomiting: \nPatient developed 1 episode of emesis prior to admission after \neating meatloaf. CT abdomen/pelvis showed no evidence of \nobstruction and he had normal lipase, LFTS, BMP. Symptoms were \nattributed to a viral or toxin-mediated gastroenteritis. \n\n# HFrEF: \nLVEF of 40% on TTE in ___ per ___ summary. Echo in ___ \nshowed LVEF 45% in ___ with well seated mitral annuloplasty \nring with no significant change from prior. Not on diuretics at \nhome. Patient is on a beta blocker metoprolol 25mg XL at home \nwhich was held. Lisinopril was also held. Prior to discharge, \nbeta-blocker and lisinopril were both restarted.\n\nCHRONIC/STABLE PROBLEMS: \n# Afib paroxysmal: \nPatient had supratherapeutic INR at 3.3 which uptrended to 3.5. \nWarfarin dose was held. Prior to admission was on 4mg 2x/week \n(Mo, Fr) and 5mg 5x/week ___, ___. Received dose \nof 5mg Coumadin on day of discharge with INR 2.1. Resumed \nmetoprolol prior to discharge.\n\n# Hypertension:\nInitially held Lisinopril though restarted prior to discharge.\n\n#BPH:\nContinued home finasteride\n\nTRANSITIONAL ISSUES:\n=====================\nDischarge Wt: 68.95 kg\nDischarge Cr: 0.7\nDischarge BP: 118 / 81\nDischarge plt: 147\nDischarge INR: 2.1\n\n[] Discharge INR 2.1, received home dose Coumadin 5mg on \n___. Scheduled to go to ___ primary care clinic ___ \nto have labs drawn to make sure INR at goal. Continue with home \nCoumadin regimen otherwise \n\n#CODE: full code (confirmed)\n#CONTACT: ___ (wife) ___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Aspirin 81 mg PO DAILY \n2. Docusate Sodium 100 mg PO BID \n3. Finasteride 5 mg PO QHS \n4. Fluticasone Propionate NASAL 2 SPRY NU BID:PRN congestion \n5. Warfarin 4 mg PO 2X/WEEK (MO,FR) \n6. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation \nQ4H:PRN \n7. Ascorbic Acid ___ mg PO DAILY \n8. Donepezil 5 mg PO DAILY \n9. Metoprolol Succinate XL 25 mg PO DAILY \n10. Sodium Chloride 1 gm PO DAILY \n11. Lisinopril 2.5 mg PO DAILY \n12. Omeprazole 20 mg PO DAILY \n13. Spectravite Mens (mv,Ca,min-iron-FA-lycopene) 8 mg iron- 200 \nmcg-600 mcg oral QHS \n14. Warfarin 5 mg PO 5X/WEEK (___) \n\n \nDischarge Medications:\n1. Ascorbic Acid ___ mg PO DAILY \n2. Aspirin 81 mg PO DAILY \n3. Docusate Sodium 100 mg PO BID \n4. Donepezil 5 mg PO DAILY \n5. Finasteride 5 mg PO QHS \n6. Fluticasone Propionate NASAL 2 SPRY NU BID:PRN congestion \n7. Lisinopril 2.5 mg PO DAILY \n8. Metoprolol Succinate XL 25 mg PO DAILY \n9. Omeprazole 20 mg PO DAILY \n10. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation \nQ4H:PRN \n11. Sodium Chloride 1 gm PO DAILY \n12. Spectravite Mens (mv,Ca,min-iron-FA-lycopene) 8 mg iron- \n200 mcg-600 mcg oral QHS \n13. Warfarin 4 mg PO 2X/WEEK (MO,FR) \n14. Warfarin 5 mg PO 5X/WEEK (___) \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n==================\nHypotension\n\nSECONDARY DIAGNOSIS\n=====================\nAtrial fibrillation\nHeart failure with reduced ejection fraction\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\n====================== \nDISCHARGE INSTRUCTIONS \n====================== \nDear Mr. ___, \n\nIt was a privilege caring for you at ___. \n\nWHY WAS I IN THE HOSPITAL? \n- You came to the hospital after feeling weak and having one \nepisode of vomiting.\n\nWHAT HAPPENED TO ME IN THE HOSPITAL? \n- You developed low blood pressure while in the emergency \ndepartment and received IV fluids in order to help with your \nblood pressure.\n- We initially started you on antibiotics which were stopped and \nyour blood pressure remained stable. We started you back on your \nhome Metoprolol and home Lisinopril and your blood pressures \nremained stable.\n Given your stable blood pressure you are safe to go home \ntoday.\n\nWHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? \n- Continue to take all your medicines and keep your \nappointments. \n\nWe wish you the best! \n\nSincerely, \nYour ___ Team \nWeigh yourself every morning, call MD if weight goes up more \nthan 3 lbs.\n \nFollowup Instructions:\n___\n"
] | Allergies: shrimp Chief Complaint: Vomiting, Weakness Major Surgical or Invasive Procedure: NONE History of Present Illness: History Obtained From: ED Dashboard Mr. [MASKED] is a [MASKED] w/ PMH of atria fibrillation on coumadin, multiple hernia repairs, LBO [MASKED] partial colectomy, who presents w/ weakness and emesis. Sudden onset of nausea, NBNB projectile vomiting x1, irregular heartbeat a/w weakness this AM. Called PCP who told him to report to ED. Symptoms lasted for 5 hours. He had symptomatically improved in the ED and was preparing to be discharged home when he became febrile and hypotensive requiring fluid resuscitation and initiation of antibiotics. In the ED, initial vitals: Pain 0 Temp 97.7 HR 79 BP 123/80 RR 16 pO2 97% RA Glucose 106 - Exam notable for: General: in NAD HEENT: atraumatic, no scleral icterus Chest: CTAB Cardiac: irregular rate Abdomen: soft, non-distended, non-tender Extremities: no c/c/e - Labs notable for: Lactate 2.6 Flu negative Trop-T <0.01 x2 PTT 38.2, INR 3.3 UA Leuk Tr, Ket Tr, Pro Tr - Imaging notable for: CT abdomen and pelvis w/ contrast Multiple dilated loops of small bowel without evidence of transition point to suggest obstruction may represent an ileus. Otherwise, no acute intraabdominal abnormality. CXR No acute cardiopulmonary abnormality. - Pt given: [MASKED] 20:00 IVF LR 500 mL [MASKED] 21:42 IV CefTRIAXone (1 g ordered) [MASKED] 22:12 IVF LR 1000 mL [MASKED] 01:08 IV Vancomycin [MASKED] 01:08 IVF LR ( 1000 mL ordered) [MASKED] 01:08 PO/NG Aspirin 81 mg [MASKED] 02:30 IV Vancomycin 1000 mg - Vitals prior to transfer: Pain 0 Temp 99.9 HR 72 BP 111/80 RR 18 pO2 97% RA Upon arrival to the floor, the patient reports... Similar history per above. He had leftover meatloaf the night prior around 5:30 pm when he vomiting and was nauseous about 12 hours after. His wife also had this meal but did not have his symptoms. Otherwise has had intermittent nausea but no diarrhea or vomiting. REVIEW OF SYSTEMS: Endorses nausea, congestion for [MASKED] months, intermittently feeling weak and lightheaded. SBP typically runs in [MASKED]. Denies diarrhea, sick contacts, fever/chills/nightsweats, cough, skin breakages, chest pain, shortness of breath, leg swelling, orthopnea, melena, BRBPR, reduced PO, urinary retention, dysuria. Past Medical History: MEDICAL HISTORY: ================ Aflutter [MASKED] cardioversion [MASKED] ?reactive airway disease mitral regurgitation [MASKED] MVrepair/P2 triangular resection/36mm ring HFrEF 40% [MASKED] colon polyps [MASKED] resection postprandial reactive hypoglycemia mild macular degeneration BPH h/o sigmoid volvulus Surgical history: ================ Appendectomy Cholecystostomy Partial removal of bowel Social History: [MASKED] Family History: Non-contributory Physical Exam: ADMISSION PHYSICAL EXAM: ========================== VITALS: 97.6 PO 113 / 72 R Sitting 95 18 95 ra General: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not elevated, no JVD, 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, scar tissue on anterior abdomen with anterior surgical scar, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: Warm, dry, no rashes or notable lesions. Neuro: CNII-XII intact, moving all extremities appropriately DISCHARGE PHYSICAL EXAM: ======================== 24 HR Data (last updated [MASKED] @ 319) Temp: 97.7 (Tm 98.4), BP: 102/68 (91-123/60-72), HR: 79 (63-79), RR: 17 ([MASKED]), O2 sat: 97% (95-97), O2 delivery: Ra, Wt: 151.46 lb/68.7 kg General: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not elevated, no JVD, 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, scar tissue on anterior abdomen with anterior surgical scar, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: Warm, dry, no rashes or notable lesions. Neuro: CNII-XII intact, moving all extremities appropriately Pertinent Results: ADMISSION LABS: ============== [MASKED] 04:10PM BLOOD WBC-7.1 RBC-4.60 Hgb-15.0 Hct-45.5 MCV-99* MCH-32.6* MCHC-33.0 RDW-12.8 RDWSD-46.8* Plt [MASKED] [MASKED] 05:34PM BLOOD [MASKED] PTT-38.2* [MASKED] [MASKED] 04:10PM BLOOD Glucose-103* UreaN-18 Creat-0.8 Na-144 K-4.2 Cl-107 HCO3-26 AnGap-11 [MASKED] 04:10PM BLOOD ALT-12 AST-19 AlkPhos-76 TotBili-0.8 [MASKED] 04:10PM BLOOD cTropnT-<0.01 [MASKED] 07:15PM BLOOD cTropnT-<0.01 [MASKED] 04:10PM BLOOD Lipase-45 [MASKED] 04:10PM BLOOD Albumin-4.0 [MASKED] 07:05AM BLOOD Calcium-8.2* Phos-2.7 Mg-2.0 [MASKED] 09:15PM BLOOD Lactate-2.6* MICROBIOLOGY: ============ [MASKED] [MASKED] 9:12 pm BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date. [MASKED] [MASKED] 9:00 pm BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date. [MASKED] [MASKED] 5:30 pm URINE **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. IMAGING: ======== CTAP [MASKED]: Multiple dilated loops of small bowel without evidence of transition point, may represent a mild ileus or enteritis. Otherwise, no acute intraabdominal abnormality. CXR [MASKED]: No acute cardiopulmonary abnormality. DISCHARGE LABS: ================ [MASKED] 07:55AM BLOOD WBC-4.0 RBC-4.24* Hgb-14.1 Hct-42.6 MCV-101* MCH-33.3* MCHC-33.1 RDW-12.9 RDWSD-48.0* Plt [MASKED] [MASKED] 07:55AM BLOOD [MASKED] PTT-32.9 [MASKED] [MASKED] 07:55AM BLOOD Glucose-88 UreaN-13 Creat-0.7 Na-147 K-3.9 Cl-109* HCO3-27 AnGap- RIEF HOSPITAL COURSE: ====================== Mr. [MASKED] is a [MASKED] w/ PMH of atrial fibrillation on coumadin, MVP with severe MR [MASKED] repair, multiple hernia repairs, [MASKED] partial colectomy (for sigmoid volvulus), who presents w/ weakness and emesis. ED course complicated by fever and hypotension. Hypotension was attributed to GI losses. There was initial concern for septic shock; however, given quick recovery with IVF and no clear source of infection, antibiotics were held and patient remained stable over 24hrs of observation. ACUTE/ACTIVE PROBLEMS: ====================== # Hypotension: The patient initally presented to the ED with emesis and weakness which improved and while pending discharge from ED, developed temperature of 100.3 and hypotensive to the [MASKED] systolic. Pt was lightheaded and dizzy and SBP improved after 2L of IVF. Received vanc/CTX in the ED empirically but given normal imaging including CT abd and pelvis, CXR without PNA, U/A clear, and Bcx without infection, antibiotics were stopped. Unlikely cardiogenic cause given negative trops. Likely [MASKED] viral illness as below with transient symptoms. The patient's BP remained stable for 24hrs and was discharged back on his home antihypertensives after BPs remained stable once started prior to discharge. # Nausea/vomiting: Patient developed 1 episode of emesis prior to admission after eating meatloaf. CT abdomen/pelvis showed no evidence of obstruction and he had normal lipase, LFTS, BMP. Symptoms were attributed to a viral or toxin-mediated gastroenteritis. # HFrEF: LVEF of 40% on TTE in [MASKED] per [MASKED] summary. Echo in [MASKED] showed LVEF 45% in [MASKED] with well seated mitral annuloplasty ring with no significant change from prior. Not on diuretics at home. Patient is on a beta blocker metoprolol 25mg XL at home which was held. Lisinopril was also held. Prior to discharge, beta-blocker and lisinopril were both restarted. CHRONIC/STABLE PROBLEMS: # Afib paroxysmal: Patient had supratherapeutic INR at 3.3 which uptrended to 3.5. Warfarin dose was held. Prior to admission was on 4mg 2x/week (Mo, Fr) and 5mg 5x/week [MASKED], [MASKED]. Received dose of 5mg Coumadin on day of discharge with INR 2.1. Resumed metoprolol prior to discharge. # Hypertension: Initially held Lisinopril though restarted prior to discharge. #BPH: Continued home finasteride TRANSITIONAL ISSUES: ===================== Discharge Wt: 68.95 kg Discharge Cr: 0.7 Discharge BP: 118 / 81 Discharge plt: 147 Discharge INR: 2.1 [] Discharge INR 2.1, received home dose Coumadin 5mg on [MASKED]. Scheduled to go to [MASKED] primary care clinic [MASKED] to have labs drawn to make sure INR at goal. Continue with home Coumadin regimen otherwise #CODE: full code (confirmed) #CONTACT: [MASKED] (wife) [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Docusate Sodium 100 mg PO BID 3. Finasteride 5 mg PO QHS 4. Fluticasone Propionate NASAL 2 SPRY NU BID:PRN congestion 5. Warfarin 4 mg PO 2X/WEEK (MO,FR) 6. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q4H:PRN 7. Ascorbic Acid [MASKED] mg PO DAILY 8. Donepezil 5 mg PO DAILY 9. Metoprolol Succinate XL 25 mg PO DAILY 10. Sodium Chloride 1 gm PO DAILY 11. Lisinopril 2.5 mg PO DAILY 12. Omeprazole 20 mg PO DAILY 13. Spectravite Mens (mv,Ca,min-iron-FA-lycopene) 8 mg iron- 200 mcg-600 mcg oral QHS 14. Warfarin 5 mg PO 5X/WEEK ([MASKED]) Discharge Medications: 1. Ascorbic Acid [MASKED] mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Donepezil 5 mg PO DAILY 5. Finasteride 5 mg PO QHS 6. Fluticasone Propionate NASAL 2 SPRY NU BID:PRN congestion 7. Lisinopril 2.5 mg PO DAILY 8. Metoprolol Succinate XL 25 mg PO DAILY 9. Omeprazole 20 mg PO DAILY 10. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q4H:PRN 11. Sodium Chloride 1 gm PO DAILY 12. Spectravite Mens (mv,Ca,min-iron-FA-lycopene) 8 mg iron- 200 mcg-600 mcg oral QHS 13. Warfarin 4 mg PO 2X/WEEK (MO,FR) 14. Warfarin 5 mg PO 5X/WEEK ([MASKED]) Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS ================== Hypotension SECONDARY DIAGNOSIS ===================== Atrial fibrillation Heart failure with reduced ejection fraction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ====================== DISCHARGE INSTRUCTIONS ====================== Dear Mr. [MASKED], It was a privilege caring for you at [MASKED]. WHY WAS I IN THE HOSPITAL? - You came to the hospital after feeling weak and having one episode of vomiting. WHAT HAPPENED TO ME IN THE HOSPITAL? - You developed low blood pressure while in the emergency department and received IV fluids in order to help with your blood pressure. - We initially started you on antibiotics which were stopped and your blood pressure remained stable. We started you back on your home Metoprolol and home Lisinopril and your blood pressures remained stable. Given your stable blood pressure you are safe to go home today. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Continue to take all your medicines and keep your appointments. We wish you the best! Sincerely, Your [MASKED] Team Weigh yourself every morning, call MD if weight goes up more than 3 lbs. Followup Instructions: [MASKED] | [
"I9589",
"I110",
"I5020",
"R509",
"N400",
"I480",
"Z9049",
"Z87891",
"Z7901"
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"I9589: Other hypotension",
"I110: Hypertensive heart disease with heart failure",
"I5020: Unspecified systolic (congestive) heart failure",
"R509: Fever, unspecified",
"N400: Benign prostatic hyperplasia without lower urinary tract symptoms",
"I480: Paroxysmal atrial fibrillation",
"Z9049: Acquired absence of other specified parts of digestive tract",
"Z87891: Personal history of nicotine dependence",
"Z7901: Long term (current) use of anticoagulants"
] | [
"I110",
"N400",
"I480",
"Z87891",
"Z7901"
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10,746,056 | 29,840,369 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \namoxicillin / levofloxacin / vancomycin / Augmentin / gabapentin \n/ Lyrica / Neurontin / pregabalin\n \nAttending: ___.\n \nChief Complaint:\nGI tube malfunction\nSuicidal ideation\n \nMajor Surgical or Invasive Procedure:\n___ GJ tube replaced with ___\n\n \nHistory of Present Illness:\nMs. ___ is a ___ PMH depression, anxiety, T1DM c/b\nretinopathy (legally blind), gastroparesis with GJ tube placed \nby\n___ on ___ who presents with GJ malpositioned in the esophagus \nas\nwell as suicidal ideation.\n\nShe arrived to an OSH ED on ___ after feeling like something \nhad\npopped. Imaging at ___ ED showed retrograde tube in\nesophagus, and as she had just had it placed at ___ by ___ she\nwas transferred here for further management. She was also\nexpressing suicidal ideation and reported that she asked her \nhome\nhealth aid to crush a bunch of sleeping pills and put them in \nher\ntube. She had a tox screen done there which was positive for\ncannabinoids and oxycodone. Her vital signs on transfer were\n97.6, 87, 18, 162/87, 95% on RA.\n\nOn arrival to the ___ ED her VS were 98.7, ___, 99% \non\nRA. ___ was consulted and took her for GJ tube replacement on\n___. Psychiatry was also consulted given her suicidal ideation.\nthey placed her on a ___ and started a bed search. She\nremained in the ED since ___ while awaiting psychiatry bed\nplacement. Given prolonged time waiting for a bed, she was\nadmitted to the inpatient medicine service. Psychiatry\nrecommended that Haldol and lorazepam IV could be used if needed\nfor agitation that is not redirectable which she did not \nrequire.\n\nWhile waiting for a bed she was put on her home medications.\nNotably she was continued on her home psychiatry medications:\nmirtazapine, duloxetine, trazodone and clonidine. \n\nUpon arrival to the floor, she says she is having some pain near\nher G tube site and has a h/o chronic pain for which she is on\nboth methadone and oxy. She says she is no longer suicidal or \nhas\nany intention to harm herself/others and feels strongly about\nbeing DNR/DNI. She tells me her grandmother-in-law recently\npassed away and her marriage has been strained (recently\nseparated with husband); however, he is still somewhat involved\nin her care. She would also like to make it to her daughter's\nprom on ___. \n\nREVIEW OF SYSTEMS: Complete ROS obtained and is otherwise\nnegative.\n \nPast Medical History:\nDM1; last HgB A1C 7.4\nRetinopathy (legally blind)\nGlaucoma\nMacular degeneration\nNeuropathy in hands & feet\nSevere gastroparesis x ___ years (had gastric emptying study)\nDepression\nAnxiety\nh/o frequent UTIs\nHypertension\npituitary macroadenoma\n \nSocial History:\n___\nFamily History:\nNotable for depression and DM in several family members. \n \nPhysical Exam:\nADMISSION EXAM:\n===============\n98.5F, 178/109, HR 106, RR 18, SpO2 98 on RA \nGENERAL: Tearful at times, otherwise in NAD. \nHEENT: NCAT, PEERL, EOMI, MMM. Skin tag on L. eyelid. \nCARDIAC: RRR, nml s1 s2, no mrg. \nLUNGS: On RA, CTAB. \nABDOMEN: ___ c/d/i. Soft, nd, ttp in LUQ. \nEXTREMITIES: Warm, no ___. \nSKIN: No visible rashes. \nNEUROLOGIC: AOx4. No focal neurologic deficits. \nPSYCH: Slightly disheveled. Tearful at times when discussing her\nstrained marriage and possible inability to make it to \ndaughter's\nprom. Mood: \"I feel like I'm back to normal self... I do not \nwant\nto hurt myself anymore.\" Full affect. Poor judgment, limited\ninsight. Denies SI/HI at this time.\n\nDISCHARGE EXAM:\n===============\nT 98.2 POBP 147 / 98HR 91RR1698%RA\nGENERAL: pleasant, interactive, NAD eating breakfast in bed\nHEENT: NCAT, PEERL, EOMI, MMM. \nCARDIAC: RRR, nml s1 s2, no mrg. \nLUNGS: CTAB no wheezes/crackles\nABDOMEN: ___ c/d/i. Soft, nd, nontender\nEXTREMITIES: Warm, no edema.\nSKIN: No visible rashes. \nNEUROLOGIC: AOx4. No focal neurologic deficits. \nPSYCH: Slightly disheveled. elevated mood, forward thinking with \nmany things to look forward to this month; no SI/HI.\n \nPertinent Results:\nADMISSION LABS:\n==================\n\n___ 09:15PM BLOOD WBC-9.8 RBC-4.45 Hgb-11.2 Hct-36.6 MCV-82 \nMCH-25.2* MCHC-30.6* RDW-16.2* RDWSD-48.7* Plt ___\n___ 09:15PM BLOOD Neuts-76.2* Lymphs-13.6* Monos-9.2 \nEos-0.2* Baso-0.4 Im ___ AbsNeut-7.49* AbsLymp-1.34 \nAbsMono-0.90* AbsEos-0.02* AbsBaso-0.04\n___ 09:15PM BLOOD Glucose-238* UreaN-14 Creat-1.0 Na-135 \nK-3.8 Cl-96 HCO3-26 AnGap-13\n___ 09:15PM BLOOD Glucose-238* UreaN-14 Creat-1.0 Na-135 \nK-3.8 Cl-96 HCO3-26 AnGap-13\n___ 07:05PM BLOOD %HbA1c-8.7* eAG-203*\n___ 09:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nTricycl-NEG\n\nDISCHARGE LABS:\n================\n___ 07:38AM BLOOD WBC-7.2 RBC-4.71 Hgb-11.9 Hct-38.0 \nMCV-81* MCH-25.3* MCHC-31.3* RDW-15.9* RDWSD-46.0 Plt ___\n___ 07:38AM BLOOD Glucose-255* UreaN-14 Creat-1.0 Na-140 \nK-4.6 Cl-98 HCO3-26 AnGap-16\n\nIMAGING:\n==========\npercutaneous ___ placement check ___: \nSuccessful placement of an 18 ___ MIC gastric tube with its \ntip in the \nstomach. The tube may be used for venting and medications \nimmediately. \n\n \nBrief Hospital Course:\nTRANSITIONAL ISSUES:\n========================\n[]Has not followed up with CRS. Will need removal of \ntubulovillous adenoma by CRS ___.\n[]Per ___, if pt requires conversion back to GJ tube in future, \nan AMT tube could be considered to the MIC.\n[] Noted to have hypertension (190s/100s) this hospitalization; \npt attributed to not being home where she smokes marijuana \nregularly that brings down her BP. Started on Carvedilol 6.25 \nBID, discontinue or uptitrate as appropriate based on outpatient \nblood pressures.\n[] Check blood pressure daily; if BPs <130 systolic, discontinue \nCarvedilol.\n[] Prescribed Ativan PRN at home, did not require this here. \nGiven hx SI and depression, consider discontinuing this as \noutpatient and using higher dose Benadryl instead for anxiety.\n[] Mental health plan: follow up with PCP who will secure \nPsychiatry referral as needed. Inpatient social work will \ndetermine appropriate referral to intensive outpatient program \nand contact patient after discharge.\n[] Continue to monitor BG, titrate insulin as needed\n\nMEDICATION CHANGES:\n====================\n- Started carvedilol 6.25mg BID\n\nPATIENT SUMMARY:\n====================\n___ PMH T1DM c/b diabetic retinopathy and gastroparesis, \ndepression and anxiety who presented with misplaced GJ tube and \nsuicidal ideation.\n\nACUTE ISSUES:\n===============\n#GJ tube misplaced:\nAn imaging study was done at ___ which showed the GJ tube \nhad flipped up into her esophagus. As she had had it placed at \n___, she was transferred here for ___ evaluation. ___ removed \nthe GJ tube and replaced it with a G tube as she was no longer \nusing the J portion. Previously she would eat for comfort, vent \nwith the ___ and give herself tube feeds through the J. She \nwas doing better with taking in and absorbing nutrition PO so \nshe was no longer requiring tube feeds through the J. As the GJ \ntube replacement is more technically difficult and she was not \nusing the J portion, a G tube was placed.\n\n#Suicidal Ideation:\nPsychiatry evaluated her and placed her on a ___. Over \nthe course of her stay in the ED and the hospital, her suicidal \nideation improved. She was admitted to the medicine service for \nongoing psychiatric evaluation. She was continued on her home \npsychiatric medications while inpatient, and eventually the \npsychiatric team felt that she was safe to discharge home as she \nwas no longer having suicidal ideation. Social work was involved \nin ongoing discussions of outpatient day programs, and will \ncontinue to work with patient after discharge along with \npatient's outpatient social worker. Pt and husband understand \nthey should call ___ or go to nearest emergency room should \nsuicidal ideation return.\n\nCHRONIC ISSUES:\n=================\n#Chronic pain:\nShe has chronic abdominal pain from her gastroparesis and prior \ntube placements. Confirmed her home medications with ___ \nthat at home she is taking Methadone 5mg PO BID and oxycodone \n10mg Q8-12H:PRN. She was continued on this while inpatient and \nsaid her pain was at her baseline ___ which she was happy with.\n\n#T1DM:\nShe was continue on her home 50U basal insulin while in house. \nHer standing Humalog with meals was held given changes with PO \nintake while in the hospital and she was treated with sliding \nscale.\n\n#HTN:\nShe was continued on her home antihypertensive regimen while \ninpatient yet remained hypertensive. Even with pain control her \nBP remained elevated so she was started on 6.25 BID Carvedilol. \nTo be discontinued as appropriate if BPs improve when pt returns \nhome and resumes daily marijuana use.\n\n#CODE: Full\n#Contact: ___ (daughter, ___\n#ALT CONTACT: ___ (Husband, ___ - currently\nseparated, but still involved in pt's care\n\nThis patient was prescribed, or continued on, an opioid pain \nmedication at the time of discharge (please see the attached \nmedication list for details). As part of our safe opioid \nprescribing process, all patients are provided with an opioid \nrisks and treatment resource education sheet and encouraged to \ndiscuss this therapy with their outpatient providers to \ndetermine if opioid pain medication is still indicated.\n\n>30 minutes were spent in discharge planning and coordination of \ncare on the day of discharge\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. amLODIPine 10 mg PO DAILY \n2. CloNIDine 0.2 mg PO BID \n3. DICYCLOMine 20 mg PO QID:PRN abd pain \n4. DULoxetine ___ 60 mg PO DAILY \n5. Toujeo Max U-300 SoloStar (insulin glargine U-300 conc) 300 \nunit/mL (3 mL) subcutaneous QHS \n6. Humalog Unknown Dose\ntoujeo 50 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin\n7. Lactulose 30 mL PO QHS:PRN severe constipation \n8. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY \n9. Lisinopril 40 mg PO DAILY \n10. LORazepam 0.5 mg PO Q8H:PRN anxiety \n11. Methadone 5 mg PO BID \n12. Mirtazapine 15 mg PO QHS \n13. OxycoDONE (Concentrated Oral Soln) 10 mg PO TID:PRN pain \n14. Acetaminophen 325-650 mg PO Q4H:PRN Pain - Mild/Fever \n15. TraZODone 50 mg PO QHS \n16. DiphenhydrAMINE 50 mg PO Q4H:PRN nausea \n\n \nDischarge Medications:\n1. CARVedilol 6.25 mg PO BID \n2. tujeo 50 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin \n3. LORazepam 0.5 mg PO Q8H:PRN anxiety \n4. Acetaminophen 325-650 mg PO Q4H:PRN Pain - Mild/Fever \n5. amLODIPine 10 mg PO DAILY \n6. CloNIDine 0.2 mg PO BID \n7. DICYCLOMine 20 mg PO QID:PRN abd pain \n8. DiphenhydrAMINE 50 mg PO Q4H:PRN nausea \n9. DULoxetine ___ 60 mg PO DAILY \n10. Lactulose 30 mL PO QHS:PRN severe constipation \n11. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY \n12. Lisinopril 40 mg PO DAILY \n13. Methadone 5 mg PO BID \nConsider prescribing naloxone at discharge \n14. Mirtazapine 15 mg PO QHS \n15. OxycoDONE (Concentrated Oral Soln) 10 mg PO TID:PRN pain \n16. Toujeo Max U-300 SoloStar (insulin glargine U-300 conc) 300 \nunit/mL (3 mL) subcutaneous QHS \n17. TraZODone 50 mg PO QHS \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary:\nGastroparesis with misplaced GJ tube s/p ___ replacement\nSuicidal Ideation\n\nSecondary:\nType 1 diabetes mellitus c/b gastroparesis and retinopathy\nChronic pain\nHTN\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou came to the hospital because your GJ-tube was misplaced and \nyou were having suicidal thoughts. \n\nThe interventional radiology doctors replaced your ___. \nPlease be aware that your tube no longer has the J portion to \ngive feeds as you were not needing this. The tube that is in \nplace has only the G (gastric) port so that you can vent your \nstomach contents if you are having symptoms from your \ngastroparesis.\n\nThe psychiatry team evaluated you and felt that it was safe for \nyou to go home, with close follow up with your primary care \ndoctor and with your home health services.\n\nPlease take all of your medications as prescribed and attend \nyour follow up appointments as listed below.\n\nAt the time of discharge, our social work team is working with \nyour outpatient social worker to arrange for a day program for \nyou and for additional mental health resources after you leave \nthe hospital.\n\nIt was a pleasure caring for you. We wish you all the best!\n\nSincerely,\nYour ___ Team\n \nFollowup Instructions:\n___\n"
] | Allergies: amoxicillin / levofloxacin / vancomycin / Augmentin / gabapentin / Lyrica / Neurontin / pregabalin Chief Complaint: GI tube malfunction Suicidal ideation Major Surgical or Invasive Procedure: [MASKED] GJ tube replaced with [MASKED] History of Present Illness: Ms. [MASKED] is a [MASKED] PMH depression, anxiety, T1DM c/b retinopathy (legally blind), gastroparesis with GJ tube placed by [MASKED] on [MASKED] who presents with GJ malpositioned in the esophagus as well as suicidal ideation. She arrived to an OSH ED on [MASKED] after feeling like something had popped. Imaging at [MASKED] ED showed retrograde tube in esophagus, and as she had just had it placed at [MASKED] by [MASKED] she was transferred here for further management. She was also expressing suicidal ideation and reported that she asked her home health aid to crush a bunch of sleeping pills and put them in her tube. She had a tox screen done there which was positive for cannabinoids and oxycodone. Her vital signs on transfer were 97.6, 87, 18, 162/87, 95% on RA. On arrival to the [MASKED] ED her VS were 98.7, [MASKED], 99% on RA. [MASKED] was consulted and took her for GJ tube replacement on [MASKED]. Psychiatry was also consulted given her suicidal ideation. they placed her on a [MASKED] and started a bed search. She remained in the ED since [MASKED] while awaiting psychiatry bed placement. Given prolonged time waiting for a bed, she was admitted to the inpatient medicine service. Psychiatry recommended that Haldol and lorazepam IV could be used if needed for agitation that is not redirectable which she did not require. While waiting for a bed she was put on her home medications. Notably she was continued on her home psychiatry medications: mirtazapine, duloxetine, trazodone and clonidine. Upon arrival to the floor, she says she is having some pain near her G tube site and has a h/o chronic pain for which she is on both methadone and oxy. She says she is no longer suicidal or has any intention to harm herself/others and feels strongly about being DNR/DNI. She tells me her grandmother-in-law recently passed away and her marriage has been strained (recently separated with husband); however, he is still somewhat involved in her care. She would also like to make it to her daughter's prom on [MASKED]. REVIEW OF SYSTEMS: Complete ROS obtained and is otherwise negative. Past Medical History: DM1; last HgB A1C 7.4 Retinopathy (legally blind) Glaucoma Macular degeneration Neuropathy in hands & feet Severe gastroparesis x [MASKED] years (had gastric emptying study) Depression Anxiety h/o frequent UTIs Hypertension pituitary macroadenoma Social History: [MASKED] Family History: Notable for depression and DM in several family members. Physical Exam: ADMISSION EXAM: =============== 98.5F, 178/109, HR 106, RR 18, SpO2 98 on RA GENERAL: Tearful at times, otherwise in NAD. HEENT: NCAT, PEERL, EOMI, MMM. Skin tag on L. eyelid. CARDIAC: RRR, nml s1 s2, no mrg. LUNGS: On RA, CTAB. ABDOMEN: [MASKED] c/d/i. Soft, nd, ttp in LUQ. EXTREMITIES: Warm, no [MASKED]. SKIN: No visible rashes. NEUROLOGIC: AOx4. No focal neurologic deficits. PSYCH: Slightly disheveled. Tearful at times when discussing her strained marriage and possible inability to make it to daughter's prom. Mood: "I feel like I'm back to normal self... I do not want to hurt myself anymore." Full affect. Poor judgment, limited insight. Denies SI/HI at this time. DISCHARGE EXAM: =============== T 98.2 POBP 147 / 98HR 91RR1698%RA GENERAL: pleasant, interactive, NAD eating breakfast in bed HEENT: NCAT, PEERL, EOMI, MMM. CARDIAC: RRR, nml s1 s2, no mrg. LUNGS: CTAB no wheezes/crackles ABDOMEN: [MASKED] c/d/i. Soft, nd, nontender EXTREMITIES: Warm, no edema. SKIN: No visible rashes. NEUROLOGIC: AOx4. No focal neurologic deficits. PSYCH: Slightly disheveled. elevated mood, forward thinking with many things to look forward to this month; no SI/HI. Pertinent Results: ADMISSION LABS: ================== [MASKED] 09:15PM BLOOD WBC-9.8 RBC-4.45 Hgb-11.2 Hct-36.6 MCV-82 MCH-25.2* MCHC-30.6* RDW-16.2* RDWSD-48.7* Plt [MASKED] [MASKED] 09:15PM BLOOD Neuts-76.2* Lymphs-13.6* Monos-9.2 Eos-0.2* Baso-0.4 Im [MASKED] AbsNeut-7.49* AbsLymp-1.34 AbsMono-0.90* AbsEos-0.02* AbsBaso-0.04 [MASKED] 09:15PM BLOOD Glucose-238* UreaN-14 Creat-1.0 Na-135 K-3.8 Cl-96 HCO3-26 AnGap-13 [MASKED] 09:15PM BLOOD Glucose-238* UreaN-14 Creat-1.0 Na-135 K-3.8 Cl-96 HCO3-26 AnGap-13 [MASKED] 07:05PM BLOOD %HbA1c-8.7* eAG-203* [MASKED] 09:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG DISCHARGE LABS: ================ [MASKED] 07:38AM BLOOD WBC-7.2 RBC-4.71 Hgb-11.9 Hct-38.0 MCV-81* MCH-25.3* MCHC-31.3* RDW-15.9* RDWSD-46.0 Plt [MASKED] [MASKED] 07:38AM BLOOD Glucose-255* UreaN-14 Creat-1.0 Na-140 K-4.6 Cl-98 HCO3-26 AnGap-16 IMAGING: ========== percutaneous [MASKED] placement check [MASKED]: Successful placement of an 18 [MASKED] MIC gastric tube with its tip in the stomach. The tube may be used for venting and medications immediately. Brief Hospital Course: TRANSITIONAL ISSUES: ======================== []Has not followed up with CRS. Will need removal of tubulovillous adenoma by CRS [MASKED]. []Per [MASKED], if pt requires conversion back to GJ tube in future, an AMT tube could be considered to the MIC. [] Noted to have hypertension (190s/100s) this hospitalization; pt attributed to not being home where she smokes marijuana regularly that brings down her BP. Started on Carvedilol 6.25 BID, discontinue or uptitrate as appropriate based on outpatient blood pressures. [] Check blood pressure daily; if BPs <130 systolic, discontinue Carvedilol. [] Prescribed Ativan PRN at home, did not require this here. Given hx SI and depression, consider discontinuing this as outpatient and using higher dose Benadryl instead for anxiety. [] Mental health plan: follow up with PCP who will secure Psychiatry referral as needed. Inpatient social work will determine appropriate referral to intensive outpatient program and contact patient after discharge. [] Continue to monitor BG, titrate insulin as needed MEDICATION CHANGES: ==================== - Started carvedilol 6.25mg BID PATIENT SUMMARY: ==================== [MASKED] PMH T1DM c/b diabetic retinopathy and gastroparesis, depression and anxiety who presented with misplaced GJ tube and suicidal ideation. ACUTE ISSUES: =============== #GJ tube misplaced: An imaging study was done at [MASKED] which showed the GJ tube had flipped up into her esophagus. As she had had it placed at [MASKED], she was transferred here for [MASKED] evaluation. [MASKED] removed the GJ tube and replaced it with a G tube as she was no longer using the J portion. Previously she would eat for comfort, vent with the [MASKED] and give herself tube feeds through the J. She was doing better with taking in and absorbing nutrition PO so she was no longer requiring tube feeds through the J. As the GJ tube replacement is more technically difficult and she was not using the J portion, a G tube was placed. #Suicidal Ideation: Psychiatry evaluated her and placed her on a [MASKED]. Over the course of her stay in the ED and the hospital, her suicidal ideation improved. She was admitted to the medicine service for ongoing psychiatric evaluation. She was continued on her home psychiatric medications while inpatient, and eventually the psychiatric team felt that she was safe to discharge home as she was no longer having suicidal ideation. Social work was involved in ongoing discussions of outpatient day programs, and will continue to work with patient after discharge along with patient's outpatient social worker. Pt and husband understand they should call [MASKED] or go to nearest emergency room should suicidal ideation return. CHRONIC ISSUES: ================= #Chronic pain: She has chronic abdominal pain from her gastroparesis and prior tube placements. Confirmed her home medications with [MASKED] that at home she is taking Methadone 5mg PO BID and oxycodone 10mg Q8-12H:PRN. She was continued on this while inpatient and said her pain was at her baseline [MASKED] which she was happy with. #T1DM: She was continue on her home 50U basal insulin while in house. Her standing Humalog with meals was held given changes with PO intake while in the hospital and she was treated with sliding scale. #HTN: She was continued on her home antihypertensive regimen while inpatient yet remained hypertensive. Even with pain control her BP remained elevated so she was started on 6.25 BID Carvedilol. To be discontinued as appropriate if BPs improve when pt returns home and resumes daily marijuana use. #CODE: Full #Contact: [MASKED] (daughter, [MASKED] #ALT CONTACT: [MASKED] (Husband, [MASKED] - currently separated, but still involved in pt's care 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. >30 minutes were spent in discharge planning and coordination of care on the day of discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. CloNIDine 0.2 mg PO BID 3. DICYCLOMine 20 mg PO QID:PRN abd pain 4. DULoxetine [MASKED] 60 mg PO DAILY 5. Toujeo Max U-300 SoloStar (insulin glargine U-300 conc) 300 unit/mL (3 mL) subcutaneous QHS 6. Humalog Unknown Dose toujeo 50 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 7. Lactulose 30 mL PO QHS:PRN severe constipation 8. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY 9. Lisinopril 40 mg PO DAILY 10. LORazepam 0.5 mg PO Q8H:PRN anxiety 11. Methadone 5 mg PO BID 12. Mirtazapine 15 mg PO QHS 13. OxycoDONE (Concentrated Oral Soln) 10 mg PO TID:PRN pain 14. Acetaminophen 325-650 mg PO Q4H:PRN Pain - Mild/Fever 15. TraZODone 50 mg PO QHS 16. DiphenhydrAMINE 50 mg PO Q4H:PRN nausea Discharge Medications: 1. CARVedilol 6.25 mg PO BID 2. tujeo 50 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 3. LORazepam 0.5 mg PO Q8H:PRN anxiety 4. Acetaminophen 325-650 mg PO Q4H:PRN Pain - Mild/Fever 5. amLODIPine 10 mg PO DAILY 6. CloNIDine 0.2 mg PO BID 7. DICYCLOMine 20 mg PO QID:PRN abd pain 8. DiphenhydrAMINE 50 mg PO Q4H:PRN nausea 9. DULoxetine [MASKED] 60 mg PO DAILY 10. Lactulose 30 mL PO QHS:PRN severe constipation 11. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY 12. Lisinopril 40 mg PO DAILY 13. Methadone 5 mg PO BID Consider prescribing naloxone at discharge 14. Mirtazapine 15 mg PO QHS 15. OxycoDONE (Concentrated Oral Soln) 10 mg PO TID:PRN pain 16. Toujeo Max U-300 SoloStar (insulin glargine U-300 conc) 300 unit/mL (3 mL) subcutaneous QHS 17. TraZODone 50 mg PO QHS Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Primary: Gastroparesis with misplaced GJ tube s/p [MASKED] replacement Suicidal Ideation Secondary: Type 1 diabetes mellitus c/b gastroparesis and retinopathy Chronic pain HTN Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [MASKED], You came to the hospital because your GJ-tube was misplaced and you were having suicidal thoughts. The interventional radiology doctors replaced your [MASKED]. Please be aware that your tube no longer has the J portion to give feeds as you were not needing this. The tube that is in place has only the G (gastric) port so that you can vent your stomach contents if you are having symptoms from your gastroparesis. The psychiatry team evaluated you and felt that it was safe for you to go home, with close follow up with your primary care doctor and with your home health services. Please take all of your medications as prescribed and attend your follow up appointments as listed below. At the time of discharge, our social work team is working with your outpatient social worker to arrange for a day program for you and for additional mental health resources after you leave the hospital. It was a pleasure caring for you. We wish you all the best! Sincerely, Your [MASKED] Team Followup Instructions: [MASKED] | [
"K9423",
"R45851",
"F339",
"F419",
"E1040",
"E1043",
"K3184",
"E10319",
"Z781",
"Z87440",
"I10",
"Z87891",
"Y833",
"H409",
"H3530",
"Z818",
"H548",
"D126",
"K5900",
"G8929",
"R109",
"F4310"
] | [
"K9423: Gastrostomy malfunction",
"R45851: Suicidal ideations",
"F339: Major depressive disorder, recurrent, unspecified",
"F419: Anxiety disorder, unspecified",
"E1040: Type 1 diabetes mellitus with diabetic neuropathy, unspecified",
"E1043: Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy",
"K3184: Gastroparesis",
"E10319: Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema",
"Z781: Physical restraint status",
"Z87440: Personal history of urinary (tract) infections",
"I10: Essential (primary) hypertension",
"Z87891: Personal history of nicotine dependence",
"Y833: Surgical operation with formation of external stoma as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure",
"H409: Unspecified glaucoma",
"H3530: Unspecified macular degeneration",
"Z818: Family history of other mental and behavioral disorders",
"H548: Legal blindness, as defined in USA",
"D126: Benign neoplasm of colon, unspecified",
"K5900: Constipation, unspecified",
"G8929: Other chronic pain",
"R109: Unspecified abdominal pain",
"F4310: Post-traumatic stress disorder, unspecified"
] | [
"F419",
"I10",
"Z87891",
"K5900",
"G8929"
] | [] |
19,271,750 | 20,385,975 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nconfusion\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\n___ with congestive heart failure (EF ___, alcoholic \ncirrhosis (with history of variceal bleeding, TIPS ___ and \nrevision TIPS ___, and encephalopathy), known hepatocellular \ncarcinoma, gastric polyps and recent admission ___ for \ntremors and altered mental status, presenting on ___ with \nAMS and reported med non-compliance. \n \nOn the morning of admission, his visiting nurse arrived for \nroutine care and noted that patient was confused at home, with \nincontinence and lethargy. His PCP was called and ___ was \ninstructed to bring to ED for further workup. \n \nIn ED he was alert and oriented. He reported missing a dose of \nlactulose when driving to visit his daughter, and had trouble \nmaking up for the missed dose, with increasing confusion over \nensuing days. He denied recurrence of tremors, rigors, fevers or \nchills. Denies abdominal pain. \n \nIn the Emergency Department, patient was stable and alert, \noriented x1 but hypotensive to SBP=90s. \n \n ED Physical Exam significant for: \n VS: 98.4 95 93/58 18 100% RA \n AOx3 \n RRR, CTAB \n abdomen NDNT \n Positive for asterixis \n Guaiac negative \n\nLabs were notable for baseline CBC and chem-7. Studies included \na CXR as below which was negative, and pt was given: 25 grams \nalbumin, lactulose, rifaximin. \n\nOn the floor, patient's encephalopathy was already improving \nthough not entirely resolved. He claimed he had a stomach bug \naround ___ days ago where he was nauseous and vomited once, but \nsince cleared. He reported that because he drove down to his \ndaughter's house on ___ last week, he messed up his \nschedule of taking lactulose, and as a result, he slowly became \nslightly more confused over the week, resulting in messing up \nhis lactulose schedule even more.\n \nPast Medical History:\n- Alcoholic cirrhosis c/b esophageal varices s/p banding x 3 \n(___), s/p TIPS ___, redo TIPS ___, also h/o hepatic \nencephalopathy \n- ETOH abuse: No history of DTs or withdrawal symptoms, even \nwhile hospitalized for prior surgeries. Has not drank since \n___ \n- Chronic baseline hypotension \n- Moderate Aortic Stenosis (aortic valve area=1.0-1.2 cm2 \n ___ \n- CAD: Inferior fixed defect on ___ stress perfusion \n imaging consistent with old MI; not on aspirin since ___ due \nto GI bleeding. \n- Ischemic cardiomyopathy / systolic CHF (last EF ___ \n- s/p left rotator cuff repair over ___ yrs ago \n- Hx prostate cancer s/p prostatectomy about ___ yrs ago \n- ___ Tear requiring banding ___ \n\n \nSocial History:\n___\nFamily History:\nFAMILY HISTORY (obtained from ___): \nStrong family history of prostate cancer in brothers, father, \npaternal grandfather. \nFather died age ___. Had CAD, MI in ___.\nMother had ___ and DM.\nNo family history of liver disease. No alcoholism in the family.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n=======================\nVITALS: 98.1 | 98/47 | 108 | 19 | 97%RA \nGENERAL: Alert, No acute distress.\nHEENT: Sclera anicteric, MMM \nCV: Regular rate and rhythm, normal S1 + S2, ___ systolic murmur \n \nLUNGS: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \nABDOMEN: Soft, non-tender, mild distension, bowel sounds \npresent, no organomegaly, no rebound or guarding \nGU: No foley\nEXT: Warm, well perfused. ___ ___ ___ edema and brawny erythema. \n\nNeuro: +mild asterixis, face symmetric, moving all limbs against \ngravity. Oriented to self, month, day of week and hospital, not \noriented to year or date. Attentive to only a few days of the \nweek backwards.\n\nDISCHARGE PHYSICAL EXAM\n=======================\nVITALS: 97.8 | 84/48 | 101 | 18 | 100%RA\nGENERAL: Alert, sitting and eating breakfast, no acute distress.\nHEENT: Sclera anicteric, MMM \nCV: Regular rate and rhythm, normal S1 + S2, ___ systolic murmur \n \nLUNGS: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \nABDOMEN: Soft, non-tender, mild distension, bowel sounds \npresent, no organomegaly, no rebound or guarding \nGU: No foley\nEXT: Warm, well perfused. 1+ ___ ___ edema and brawny erythema. \nNeuro: +mild asterixis, face symmetric, moving all limbs against \ngravity. Oriented to self, month, year, weekend ___, not ___, \nknew to look at wall for date. Could count backwards from 10 \nafter counting forwards from 10 (hesitant at first with \nbackwards). Aware of his plans for tomorrow (going to his \ndaughter's while his girlfriend is in ___)\n \nPertinent Results:\nADMISSION LABS\n===============\n___ 10:55AM BLOOD WBC-2.7* RBC-3.40* Hgb-9.2* Hct-30.7* \nMCV-90 MCH-27.1 MCHC-30.0* RDW-19.2* RDWSD-63.8* Plt Ct-97*\n___ 10:55AM BLOOD Neuts-36.2 ___ Monos-23.0* \nEos-4.1 Baso-2.2* Im ___ AbsNeut-0.98* AbsLymp-0.92* \nAbsMono-0.62 AbsEos-0.11 AbsBaso-0.06\n___ 10:55AM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-2+ \nMacrocy-2+ Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Burr-2+ Tear \nDr-1+ Fragmen-OCCASIONAL\n___ 10:55AM BLOOD ___ PTT-36.6* ___\n___ 10:55AM BLOOD Glucose-158* UreaN-13 Creat-1.0 Na-135 \nK-4.1 Cl-102 HCO3-24 AnGap-13\n___ 10:55AM BLOOD ALT-21 AST-30 AlkPhos-83 TotBili-1.1 \nDirBili-0.3 IndBili-0.8\n___ 10:55AM BLOOD Lipase-102*\n\nMICRO\n======\nURINE CULTURE (Final ___: NO GROWTH. \n\nIMAGING:\n========\n___ CHEST X-RAY FINDINGS: Mild to moderate enlargement of \nthe cardiac silhouette is unchanged. The mediastinal contour is \nsimilar with mild unfolding of thoracic aorta again noted. \nThere is mild pulmonary vascular congestion, minimally improved \nfrom the previous exam. No focal consolidation or pneumothorax \nis seen, however assessment of the lung apices medially is \nslightly limited by the patient's neck and chin projecting over \nthis area. Small bilateral pleural effusions are noted. No \nsubdiaphragmatic free air is visualized. A TIPS catheter within \nthe right upper quadrant of the abdomen is again noted. \nIMPRESSION: Mild pulmonary vascular congestion and small \nbilateral pleural effusions. No subdiaphragmatic free air.\n\nIMPRESSION:\n___ DUPLEX DOPP ABD/PEL IMPRESSION: \n1. Patent TIPS with stable velocities. No portal vein thrombus \nidentified.\n2. Coarse and nodular hepatic architecture. Lesions and cysts \nwithin the\nliver have been more accurately evaluated with prior MRI ___. One\nsmall lesion is noted within the right lobe of the liver.\n\nDISCHARGE LABS\n==============\n___ 06:07AM BLOOD WBC-2.4* RBC-2.99* Hgb-7.8* Hct-26.6* \nMCV-89 MCH-26.1 MCHC-29.3* RDW-18.7* RDWSD-61.1* Plt Ct-86*\n___ 06:07AM BLOOD ___ PTT-40.7* ___\n___ 06:07AM BLOOD Glucose-143* UreaN-12 Creat-0.8 Na-132* \nK-3.5 Cl-101 HCO3-22 AnGap-13\n___ 06:07AM BLOOD ALT-19 AST-27 AlkPhos-75 TotBili-1.1\n___ 06:07AM BLOOD Calcium-9.1 Phos-2.9 Mg-2.___ y/o M with a h/o EtOH cirrhosis and ischemic systolic CHF who \npresents with hepatic encephalopathy in the setting of missing \nhome lactulose several days prior to admission and no bowel \nmovements for several days, improved with increased lactulose.\n\n#RECURRENT HEPATIC ENCEPHALOPATHY, in the setting of \n #ALCOHOLIC CIRRHOSIS: MELD-Na 18 on admission and discharge. \nWas encephalopathic w/asterixs likely due to missed lactulose 1 \nweek prior, inability to \"catch up\" as increasing confusion led \nto more missed doses, resulting in no bowel movement x3 days \nprior to admission. Improved with lactulose. No signs of GIB; \nHemoglobin/Hematocrit low but at baseline. Not currently on \ntransplant list. Of note, he has a history of variceal bleeding \nrequiring TIPS in ___ followed by a TIPS revision for \nworsening hepatic encephalopathy. If he were to re-present again \nwith hepatic encephalopathy, may benefit from discussion of a \nscope for ongoing bleed vs. revisiting TIPS. Continued on \nlactulose q3-4h, titrating to ___ bowel movements per day, as \nwell as home rifaximin 550mg BID. Maintained potassium greater \nthan 4. Additionally with known HCC from MRI ___. \n\n#CHRONIC HYPOTENSION: In setting of cirrhosis. On midodrine \n7.5mg TID at home, increased to 10mg given MAP persistently <82 \nand possibility that confusion is due to hypoperfusion. Held \nhome torsemide in setting of soft pressures but will discharge \non normal regimen. Continued home spironolactone. \n\n#HYPONATREMIA: Mild, to 129 on ___, started on 1500mL fluid \nrestriction. Improved to 132 on ___. Will recommend continued \nfluid restriction on discharge. \n\n# COAGULOPATHY: INR 1.5 which is at baseline, consistent with \ncoagulopathy due to cirrhosis. No current signs of bleeding. \n\n# MILD PULMONARY VASCULAR CONGESTION: On CXR in ED, status-post \nalbumin in ED without clear indication. No respiratory symptoms, \noxygen requirement, or crackles on lung exam. \n \nSTABLE CHRONIC ISSUES \n=====================\n#ISCHEMIC CHRONIC SYSTOLIC CHF (EF ___: Currently does not \nappear in acute exacerbation, though does have some ___ edema. \nContinued home regimen of torsemide (40 mg M-F, 60 mg S-S) and \nspironolactone. \n\n#PREDIABETES: Started on metformin several admissions ago, but \nheld on a prior discharge. He did have several sugars >150, so \nwill continue on discharge given stable creatinine.\n\n#CORONARY ARTERY DISEASE: complicated by ischemic \ncardiomyopathy. Intolerant of beta blocker due to hypotension. \nNot on ASA due to GI bleeds. Continued home atorvastatin 40mg. \n\n#ISCHEMIC CHRONIC SYSTOLIC CHF: No evidence of acute \nexacerbation, though does have some ___ edema and with some \ncongestion on ED CXR in setting of albumin. Will discharge on \nhome Torsemide (40mg M-F, 60mg S-S), Spironolactone 50mg.\n \n#GIB/VARICES: H/o varices, s/p banding ___, most recent EGD \nshowing small esophageal varices ___. H/o TIPS ___, redo \nTIPS ___. Continued Pantoprazole 40mg BID, though this may \nbe able to be discontinued soon if no further evidence of bleed. \nNot on beta blocker due to hypotension.\n \n#COAGULOPATHY: INR 1.5 which is at baseline, consistent with \ncoagulopathy due to cirrhosis. \n\n#NUTRITION: Albumin 3.3. Given Thiamine, Multivitamin with \nminerals, and folate. Restricted to 1.5L fluid daily. \n \n\nTRANSITIONAL ISSUES\n===================\n#CODE: Full confirmed\n#CONTACT: Daughter/HCP ___ ___\n*MEDICATION CHANGES:\n[] Increased midodrine to 10mg TID given MAP well below 82 and \npotential role of hypoperfusion in predisposition to hepatic \nencephalopathy/confusion.\n[] Fluid restriction to 1500mL per day\n[] Lactulose should be given up to 4 times per day, with goal of \n___ bowel movements per day.\n*MANAGEMENT:\n[] If he continues to have recurrent hepatic encephalopathy, he \nmay benefit from EGD to evaluate for ongoing bleeding (perhaps \nportal hypertensive gastropathy), and possible discussion \nregarding risks/benefits of a second revision of his TIPS. \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Atorvastatin 40 mg PO QPM \n2. Ferrous GLUCONATE 324 mg PO BID \n3. FoLIC Acid 1 mg PO DAILY \n4. Lactulose 30 mL PO QID \n5. Midodrine 7.5 mg PO TID \n6. Multivitamins W/minerals 1 TAB PO DAILY \n7. Pantoprazole 40 mg PO Q12H \n8. Potassium Chloride 40 mEq PO DAILY \n9. Rifaximin 550 mg PO BID \n10. Sucralfate 1 gm PO QID \n11. Thiamine 100 mg PO DAILY \n12. MetFORMIN (Glucophage) 500 mg PO DAILY \n13. Spironolactone 50 mg PO DAILY \n14. Torsemide 40 mg PO M, ___, WED, THURS, FRI \n15. Torsemide 60 mg PO SAT, SUN \n\n \nDischarge Medications:\n1. Midodrine 10 mg PO TID \nRX *midodrine 10 mg 1 tablet(s) by mouth three times per day \nDisp #*90 Tablet Refills:*0 \n2. Atorvastatin 40 mg PO QPM \n3. Ferrous GLUCONATE 324 mg PO BID \n4. FoLIC Acid 1 mg PO DAILY \n5. Lactulose 30 mL PO QID \n6. MetFORMIN (Glucophage) 500 mg PO DAILY \n7. Multivitamins W/minerals 1 TAB PO DAILY \n8. Pantoprazole 40 mg PO Q12H \n9. Potassium Chloride 40 mEq PO DAILY \n10. Rifaximin 550 mg PO BID \n11. Spironolactone 50 mg PO DAILY \n12. Sucralfate 1 gm PO QID \n13. Thiamine 100 mg PO DAILY \n14. Torsemide 40 mg PO M, ___, WED, THURS, FRI \n15. Torsemide 60 mg PO SAT, SUN \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSES\n==================\n#HEPATIC ENCEPHALOPATHY, in the setting of\n #ALCOHOLIC CIRRHOSIS\n\nSECONDARY DIAGNOSES\n===================\n#HYPOTENSION\n \nDischarge Condition:\nMental Status: Confused - sometimes.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear ___,\n\nWHY WERE YOU HERE?\nYou were admitted to ___ \nbecause of confusion. You were confused because you missed a \ndose of lactulose, a medicine that makes you go to the bathroom \nto help get rid of toxins. \n\nWHAT DID WE DO?\n* Gave extra doses of lactulose until you were less confused\n* Increased your home midodrine, a medicine that increases your \nblood pressure. It is possible that some of your confusion at \nhome is due to your blood pressure being too low. \n* Limited how much fluid you can drink in a day to 1.5 litres \n(33 ounces). This helped your blood salts stay in a better \nrange. \n\nWHAT SHOULD YOU DO WHEN YOU GET HOME?\n* Continue to take all your medicine. \n* Come back to the hospital if you are confused again, or if you \nnotice any black or bright read bowel movements. \n* Weigh yourself every morning, call MD if weight goes up more \nthan 3 lbs.\n\nIt was a pleasure caring for you!\nWe wish you the best.\n-Your Care Team at ___\n \nFollowup Instructions:\n___\n"
] | Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: confusion Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] with congestive heart failure (EF [MASKED], alcoholic cirrhosis (with history of variceal bleeding, TIPS [MASKED] and revision TIPS [MASKED], and encephalopathy), known hepatocellular carcinoma, gastric polyps and recent admission [MASKED] for tremors and altered mental status, presenting on [MASKED] with AMS and reported med non-compliance. On the morning of admission, his visiting nurse arrived for routine care and noted that patient was confused at home, with incontinence and lethargy. His PCP was called and [MASKED] was instructed to bring to ED for further workup. In ED he was alert and oriented. He reported missing a dose of lactulose when driving to visit his daughter, and had trouble making up for the missed dose, with increasing confusion over ensuing days. He denied recurrence of tremors, rigors, fevers or chills. Denies abdominal pain. In the Emergency Department, patient was stable and alert, oriented x1 but hypotensive to SBP=90s. ED Physical Exam significant for: VS: 98.4 95 93/58 18 100% RA AOx3 RRR, CTAB abdomen NDNT Positive for asterixis Guaiac negative Labs were notable for baseline CBC and chem-7. Studies included a CXR as below which was negative, and pt was given: 25 grams albumin, lactulose, rifaximin. On the floor, patient's encephalopathy was already improving though not entirely resolved. He claimed he had a stomach bug around [MASKED] days ago where he was nauseous and vomited once, but since cleared. He reported that because he drove down to his daughter's house on [MASKED] last week, he messed up his schedule of taking lactulose, and as a result, he slowly became slightly more confused over the week, resulting in messing up his lactulose schedule even more. Past Medical History: - Alcoholic cirrhosis c/b esophageal varices s/p banding x 3 ([MASKED]), s/p TIPS [MASKED], redo TIPS [MASKED], also h/o hepatic encephalopathy - ETOH abuse: No history of DTs or withdrawal symptoms, even while hospitalized for prior surgeries. Has not drank since [MASKED] - Chronic baseline hypotension - Moderate Aortic Stenosis (aortic valve area=1.0-1.2 cm2 [MASKED] - CAD: Inferior fixed defect on [MASKED] stress perfusion imaging consistent with old MI; not on aspirin since [MASKED] due to GI bleeding. - Ischemic cardiomyopathy / systolic CHF (last EF [MASKED] - s/p left rotator cuff repair over [MASKED] yrs ago - Hx prostate cancer s/p prostatectomy about [MASKED] yrs ago - [MASKED] Tear requiring banding [MASKED] Social History: [MASKED] Family History: FAMILY HISTORY (obtained from [MASKED]): Strong family history of prostate cancer in brothers, father, paternal grandfather. Father died age [MASKED]. Had CAD, MI in [MASKED]. Mother had [MASKED] and DM. No family history of liver disease. No alcoholism in the family. Physical Exam: ADMISSION PHYSICAL EXAM ======================= VITALS: 98.1 | 98/47 | 108 | 19 | 97%RA GENERAL: Alert, No acute distress. HEENT: Sclera anicteric, MMM CV: Regular rate and rhythm, normal S1 + S2, [MASKED] systolic murmur LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi ABDOMEN: Soft, non-tender, mild distension, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley EXT: Warm, well perfused. [MASKED] [MASKED] [MASKED] edema and brawny erythema. Neuro: +mild asterixis, face symmetric, moving all limbs against gravity. Oriented to self, month, day of week and hospital, not oriented to year or date. Attentive to only a few days of the week backwards. DISCHARGE PHYSICAL EXAM ======================= VITALS: 97.8 | 84/48 | 101 | 18 | 100%RA GENERAL: Alert, sitting and eating breakfast, no acute distress. HEENT: Sclera anicteric, MMM CV: Regular rate and rhythm, normal S1 + S2, [MASKED] systolic murmur LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi ABDOMEN: Soft, non-tender, mild distension, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley EXT: Warm, well perfused. 1+ [MASKED] [MASKED] edema and brawny erythema. Neuro: +mild asterixis, face symmetric, moving all limbs against gravity. Oriented to self, month, year, weekend [MASKED], not [MASKED], knew to look at wall for date. Could count backwards from 10 after counting forwards from 10 (hesitant at first with backwards). Aware of his plans for tomorrow (going to his daughter's while his girlfriend is in [MASKED]) Pertinent Results: ADMISSION LABS =============== [MASKED] 10:55AM BLOOD WBC-2.7* RBC-3.40* Hgb-9.2* Hct-30.7* MCV-90 MCH-27.1 MCHC-30.0* RDW-19.2* RDWSD-63.8* Plt Ct-97* [MASKED] 10:55AM BLOOD Neuts-36.2 [MASKED] Monos-23.0* Eos-4.1 Baso-2.2* Im [MASKED] AbsNeut-0.98* AbsLymp-0.92* AbsMono-0.62 AbsEos-0.11 AbsBaso-0.06 [MASKED] 10:55AM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-2+ Macrocy-2+ Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Burr-2+ Tear Dr-1+ Fragmen-OCCASIONAL [MASKED] 10:55AM BLOOD [MASKED] PTT-36.6* [MASKED] [MASKED] 10:55AM BLOOD Glucose-158* UreaN-13 Creat-1.0 Na-135 K-4.1 Cl-102 HCO3-24 AnGap-13 [MASKED] 10:55AM BLOOD ALT-21 AST-30 AlkPhos-83 TotBili-1.1 DirBili-0.3 IndBili-0.8 [MASKED] 10:55AM BLOOD Lipase-102* MICRO ====== URINE CULTURE (Final [MASKED]: NO GROWTH. IMAGING: ======== [MASKED] CHEST X-RAY FINDINGS: Mild to moderate enlargement of the cardiac silhouette is unchanged. The mediastinal contour is similar with mild unfolding of thoracic aorta again noted. There is mild pulmonary vascular congestion, minimally improved from the previous exam. No focal consolidation or pneumothorax is seen, however assessment of the lung apices medially is slightly limited by the patient's neck and chin projecting over this area. Small bilateral pleural effusions are noted. No subdiaphragmatic free air is visualized. A TIPS catheter within the right upper quadrant of the abdomen is again noted. IMPRESSION: Mild pulmonary vascular congestion and small bilateral pleural effusions. No subdiaphragmatic free air. IMPRESSION: [MASKED] DUPLEX DOPP ABD/PEL IMPRESSION: 1. Patent TIPS with stable velocities. No portal vein thrombus identified. 2. Coarse and nodular hepatic architecture. Lesions and cysts within the liver have been more accurately evaluated with prior MRI [MASKED]. One small lesion is noted within the right lobe of the liver. DISCHARGE LABS ============== [MASKED] 06:07AM BLOOD WBC-2.4* RBC-2.99* Hgb-7.8* Hct-26.6* MCV-89 MCH-26.1 MCHC-29.3* RDW-18.7* RDWSD-61.1* Plt Ct-86* [MASKED] 06:07AM BLOOD [MASKED] PTT-40.7* [MASKED] [MASKED] 06:07AM BLOOD Glucose-143* UreaN-12 Creat-0.8 Na-132* K-3.5 Cl-101 HCO3-22 AnGap-13 [MASKED] 06:07AM BLOOD ALT-19 AST-27 AlkPhos-75 TotBili-1.1 [MASKED] 06:07AM BLOOD Calcium-9.1 Phos-2.9 Mg-2.[MASKED] y/o M with a h/o EtOH cirrhosis and ischemic systolic CHF who presents with hepatic encephalopathy in the setting of missing home lactulose several days prior to admission and no bowel movements for several days, improved with increased lactulose. #RECURRENT HEPATIC ENCEPHALOPATHY, in the setting of #ALCOHOLIC CIRRHOSIS: MELD-Na 18 on admission and discharge. Was encephalopathic w/asterixs likely due to missed lactulose 1 week prior, inability to "catch up" as increasing confusion led to more missed doses, resulting in no bowel movement x3 days prior to admission. Improved with lactulose. No signs of GIB; Hemoglobin/Hematocrit low but at baseline. Not currently on transplant list. Of note, he has a history of variceal bleeding requiring TIPS in [MASKED] followed by a TIPS revision for worsening hepatic encephalopathy. If he were to re-present again with hepatic encephalopathy, may benefit from discussion of a scope for ongoing bleed vs. revisiting TIPS. Continued on lactulose q3-4h, titrating to [MASKED] bowel movements per day, as well as home rifaximin 550mg BID. Maintained potassium greater than 4. Additionally with known HCC from MRI [MASKED]. #CHRONIC HYPOTENSION: In setting of cirrhosis. On midodrine 7.5mg TID at home, increased to 10mg given MAP persistently <82 and possibility that confusion is due to hypoperfusion. Held home torsemide in setting of soft pressures but will discharge on normal regimen. Continued home spironolactone. #HYPONATREMIA: Mild, to 129 on [MASKED], started on 1500mL fluid restriction. Improved to 132 on [MASKED]. Will recommend continued fluid restriction on discharge. # COAGULOPATHY: INR 1.5 which is at baseline, consistent with coagulopathy due to cirrhosis. No current signs of bleeding. # MILD PULMONARY VASCULAR CONGESTION: On CXR in ED, status-post albumin in ED without clear indication. No respiratory symptoms, oxygen requirement, or crackles on lung exam. STABLE CHRONIC ISSUES ===================== #ISCHEMIC CHRONIC SYSTOLIC CHF (EF [MASKED]: Currently does not appear in acute exacerbation, though does have some [MASKED] edema. Continued home regimen of torsemide (40 mg M-F, 60 mg S-S) and spironolactone. #PREDIABETES: Started on metformin several admissions ago, but held on a prior discharge. He did have several sugars >150, so will continue on discharge given stable creatinine. #CORONARY ARTERY DISEASE: complicated by ischemic cardiomyopathy. Intolerant of beta blocker due to hypotension. Not on ASA due to GI bleeds. Continued home atorvastatin 40mg. #ISCHEMIC CHRONIC SYSTOLIC CHF: No evidence of acute exacerbation, though does have some [MASKED] edema and with some congestion on ED CXR in setting of albumin. Will discharge on home Torsemide (40mg M-F, 60mg S-S), Spironolactone 50mg. #GIB/VARICES: H/o varices, s/p banding [MASKED], most recent EGD showing small esophageal varices [MASKED]. H/o TIPS [MASKED], redo TIPS [MASKED]. Continued Pantoprazole 40mg BID, though this may be able to be discontinued soon if no further evidence of bleed. Not on beta blocker due to hypotension. #COAGULOPATHY: INR 1.5 which is at baseline, consistent with coagulopathy due to cirrhosis. #NUTRITION: Albumin 3.3. Given Thiamine, Multivitamin with minerals, and folate. Restricted to 1.5L fluid daily. TRANSITIONAL ISSUES =================== #CODE: Full confirmed #CONTACT: Daughter/HCP [MASKED] [MASKED] *MEDICATION CHANGES: [] Increased midodrine to 10mg TID given MAP well below 82 and potential role of hypoperfusion in predisposition to hepatic encephalopathy/confusion. [] Fluid restriction to 1500mL per day [] Lactulose should be given up to 4 times per day, with goal of [MASKED] bowel movements per day. *MANAGEMENT: [] If he continues to have recurrent hepatic encephalopathy, he may benefit from EGD to evaluate for ongoing bleeding (perhaps portal hypertensive gastropathy), and possible discussion regarding risks/benefits of a second revision of his TIPS. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 40 mg PO QPM 2. Ferrous GLUCONATE 324 mg PO BID 3. FoLIC Acid 1 mg PO DAILY 4. Lactulose 30 mL PO QID 5. Midodrine 7.5 mg PO TID 6. Multivitamins W/minerals 1 TAB PO DAILY 7. Pantoprazole 40 mg PO Q12H 8. Potassium Chloride 40 mEq PO DAILY 9. Rifaximin 550 mg PO BID 10. Sucralfate 1 gm PO QID 11. Thiamine 100 mg PO DAILY 12. MetFORMIN (Glucophage) 500 mg PO DAILY 13. Spironolactone 50 mg PO DAILY 14. Torsemide 40 mg PO M, [MASKED], WED, THURS, FRI 15. Torsemide 60 mg PO SAT, SUN Discharge Medications: 1. Midodrine 10 mg PO TID RX *midodrine 10 mg 1 tablet(s) by mouth three times per day Disp #*90 Tablet Refills:*0 2. Atorvastatin 40 mg PO QPM 3. Ferrous GLUCONATE 324 mg PO BID 4. FoLIC Acid 1 mg PO DAILY 5. Lactulose 30 mL PO QID 6. MetFORMIN (Glucophage) 500 mg PO DAILY 7. Multivitamins W/minerals 1 TAB PO DAILY 8. Pantoprazole 40 mg PO Q12H 9. Potassium Chloride 40 mEq PO DAILY 10. Rifaximin 550 mg PO BID 11. Spironolactone 50 mg PO DAILY 12. Sucralfate 1 gm PO QID 13. Thiamine 100 mg PO DAILY 14. Torsemide 40 mg PO M, [MASKED], WED, THURS, FRI 15. Torsemide 60 mg PO SAT, SUN Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES ================== #HEPATIC ENCEPHALOPATHY, in the setting of #ALCOHOLIC CIRRHOSIS SECONDARY DIAGNOSES =================== #HYPOTENSION Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear [MASKED], WHY WERE YOU HERE? You were admitted to [MASKED] because of confusion. You were confused because you missed a dose of lactulose, a medicine that makes you go to the bathroom to help get rid of toxins. WHAT DID WE DO? * Gave extra doses of lactulose until you were less confused * Increased your home midodrine, a medicine that increases your blood pressure. It is possible that some of your confusion at home is due to your blood pressure being too low. * Limited how much fluid you can drink in a day to 1.5 litres (33 ounces). This helped your blood salts stay in a better range. WHAT SHOULD YOU DO WHEN YOU GET HOME? * Continue to take all your medicine. * Come back to the hospital if you are confused again, or if you notice any black or bright read bowel movements. * Weigh yourself every morning, call MD if weight goes up more than 3 lbs. It was a pleasure caring for you! We wish you the best. -Your Care Team at [MASKED] Followup Instructions: [MASKED] | [
"K7290",
"C220",
"I5022",
"D684",
"E871",
"I9589",
"K7030",
"I255",
"I2510",
"Y929",
"T473X6A",
"Z91138",
"I252",
"Z8546",
"R7309",
"F1021"
] | [
"K7290: Hepatic failure, unspecified without coma",
"C220: Liver cell carcinoma",
"I5022: Chronic systolic (congestive) heart failure",
"D684: Acquired coagulation factor deficiency",
"E871: Hypo-osmolality and hyponatremia",
"I9589: Other hypotension",
"K7030: Alcoholic cirrhosis of liver without ascites",
"I255: Ischemic cardiomyopathy",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"Y929: Unspecified place or not applicable",
"T473X6A: Underdosing of saline and osmotic laxatives, initial encounter",
"Z91138: Patient's unintentional underdosing of medication regimen for other reason",
"I252: Old myocardial infarction",
"Z8546: Personal history of malignant neoplasm of prostate",
"R7309: Other abnormal glucose",
"F1021: Alcohol dependence, in remission"
] | [
"E871",
"I2510",
"Y929",
"I252"
] | [] |
17,707,835 | 22,634,512 | [
" \nName: ___ ___ No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nNo Allergies/ADRs on File\n \nAttending: ___\n \nChief Complaint:\nFall\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\nMr. ___ is a ___ year old male s/p witnessed fall off horse, \nunhelmeted, and landed on right side with cardiac arrest s/p CPR \nw/ ROSC found to have C1/C2 fracture. EMS arrived ___nd found to be pulseless and apneic. He was \nintubated with ___ airway and CPR was started with 3 rounds of \nepinephrine. He arrived to ___ in ___ and received \nanother 2x epinephrine. ___ was replaced with ETT with C-spine \nstabilization and OGT was also placed. Bilateral chest tubes \nwere placed along with right femoral ___ line. He had ROSC \napproximately ___ minutes after initial EMS evaluation and \nCPR. Bilateral chest tubes were placed, the right aimed \napically, but the left was placed inferomedially with small \ninferolateral PTX. His injuries noted on transfer include \noblique C2 fracture, C1 lateral mass fracture, R lobe liver \nhematoma. The patient did not have purposeful movements with a \nBIS monitor of 0. On arrival to the TSICU, he was intubated, \nsedated, exam notable for fixed dilated pupils, and no other \nneuro exam illicited. Per contact\nwith patient's family, his wife will be arriving from ___ \novernight.\n \nPast Medical History:\nunknown\n \nSocial History:\n___\nFamily History:\nunknown\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\nVS - brady to 40's, BP 110/65 on phenylepherine \nGeneral: intubated, ett in place, og tube in place, no sedation \n\nHEENT: fixed 5mm bilaterally, pt is making spontaneous movements\nwith his mouth biting the ETT, no other movements are\nappreciated. no signs of trauma \nNeck: ATNC no clear stepoffs \nCV: bradycardic rate, regular rhythm \nLungs: b.l breath sounds, equal, CT with dressing slight\nsanguinous drainage \nAbdomen: soft, nt no bruising, no signs of trauma, nondistended \n\nGU: foley in place \nExt: no signs of trauma appreciated, distal pulses intact \nNeuro: no purposeful movements, no movement ___ bilaterally, \npt\ndoes not withdraw from pain. reflexes intact, neg babinski \nSkin: pink, well perfused, no diaphoresis \n \nBrief Hospital Course:\nThe patient was admitted and stabilized in the ICU. The patient \nwas normothermic and his electrolyte abnormalities were \ncorrected. A brain death exam was performed and the patient was \nfound to be absent of all brain activity. Given that the patient \nhad a C1/C2 cord injury, an apnea test could not be completed. \nTherefore a cerebral completion scan was completed confirming \nbrain death. The patient was pronounced brain dead when the \nreport of this scan was finalized by the attending radiologist. \nThe family agreed to organ donation and the patient's body was \nmanaged by the NEOB and the office of the medical examiner from \nthat point forward. \n \nMedications on Admission:\nunknown\n \nDischarge Medications:\nn/a\n \nDischarge Disposition:\nExpired\n \nDischarge Diagnosis:\nAnoxic Brain Injury\nBrain Death\n\n \nDischarge Condition:\nexpired\n\n \nDischarge Instructions:\nn/a\n \nFollowup Instructions:\n___\n"
] | Allergies: No Allergies/ADRs on File Chief Complaint: Fall Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is a [MASKED] year old male s/p witnessed fall off horse, unhelmeted, and landed on right side with cardiac arrest s/p CPR w/ ROSC found to have C1/C2 fracture. EMS arrived nd found to be pulseless and apneic. He was intubated with [MASKED] airway and CPR was started with 3 rounds of epinephrine. He arrived to [MASKED] in [MASKED] and received another 2x epinephrine. [MASKED] was replaced with ETT with C-spine stabilization and OGT was also placed. Bilateral chest tubes were placed along with right femoral [MASKED] line. He had ROSC approximately [MASKED] minutes after initial EMS evaluation and CPR. Bilateral chest tubes were placed, the right aimed apically, but the left was placed inferomedially with small inferolateral PTX. His injuries noted on transfer include oblique C2 fracture, C1 lateral mass fracture, R lobe liver hematoma. The patient did not have purposeful movements with a BIS monitor of 0. On arrival to the TSICU, he was intubated, sedated, exam notable for fixed dilated pupils, and no other neuro exam illicited. Per contact with patient's family, his wife will be arriving from [MASKED] overnight. Past Medical History: unknown Social History: [MASKED] Family History: unknown Physical Exam: ADMISSION PHYSICAL EXAM VS - brady to 40's, BP 110/65 on phenylepherine General: intubated, ett in place, og tube in place, no sedation HEENT: fixed 5mm bilaterally, pt is making spontaneous movements with his mouth biting the ETT, no other movements are appreciated. no signs of trauma Neck: ATNC no clear stepoffs CV: bradycardic rate, regular rhythm Lungs: b.l breath sounds, equal, CT with dressing slight sanguinous drainage Abdomen: soft, nt no bruising, no signs of trauma, nondistended GU: foley in place Ext: no signs of trauma appreciated, distal pulses intact Neuro: no purposeful movements, no movement [MASKED] bilaterally, pt does not withdraw from pain. reflexes intact, neg babinski Skin: pink, well perfused, no diaphoresis Brief Hospital Course: The patient was admitted and stabilized in the ICU. The patient was normothermic and his electrolyte abnormalities were corrected. A brain death exam was performed and the patient was found to be absent of all brain activity. Given that the patient had a C1/C2 cord injury, an apnea test could not be completed. Therefore a cerebral completion scan was completed confirming brain death. The patient was pronounced brain dead when the report of this scan was finalized by the attending radiologist. The family agreed to organ donation and the patient's body was managed by the NEOB and the office of the medical examiner from that point forward. Medications on Admission: unknown Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: Anoxic Brain Injury Brain Death Discharge Condition: expired Discharge Instructions: n/a Followup Instructions: [MASKED] | [
"G931",
"G9382",
"I469",
"S14102A",
"G936",
"J9600",
"S12000A",
"S12100A",
"S36112A",
"E872",
"V80010A",
"Y929",
"I2510",
"R578"
] | [
"G931: Anoxic brain damage, not elsewhere classified",
"G9382: Brain death",
"I469: Cardiac arrest, cause unspecified",
"S14102A: Unspecified injury at C2 level of cervical spinal cord, initial encounter",
"G936: Cerebral edema",
"J9600: Acute respiratory failure, unspecified whether with hypoxia or hypercapnia",
"S12000A: Unspecified displaced fracture of first cervical vertebra, initial encounter for closed fracture",
"S12100A: Unspecified displaced fracture of second cervical vertebra, initial encounter for closed fracture",
"S36112A: Contusion of liver, initial encounter",
"E872: Acidosis",
"V80010A: Animal-rider injured by fall from or being thrown from horse in noncollision accident, initial encounter",
"Y929: Unspecified place or not applicable",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"R578: Other shock"
] | [
"E872",
"Y929",
"I2510"
] | [] |
19,246,279 | 22,154,192 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: ORTHOPAEDICS\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nwound dehiscence\n\n \nMajor Surgical or Invasive Procedure:\nN/A\n\n \nHistory of Present Illness:\n___ is an ___ yo F with lumbar stenosis s/p \nlaminectomy/fusion on ___ who presented with subjective fevers \nand persistent back pain since surgery. She had elevated CRP/ESR \nbut afebrile and without leukocytosis during hospitalization. \nTeam is treating for possible superficial wound infection in \nsetting of distal dehiscence of wound. No purulence or evidence \nof deeper infection has been noted.\n\n \nPast Medical History:\nBACK PAIN \nLOW BACK PAIN \nLEG PAIN \nNECK PAIN \nHYPERTENSION \nGASTRITIS \nMORBID OBESITY \nVITAMIN D DEFICIENCY \nPROTEINURIA \nLUMBAR SPINAL STENOSIS \nOSTEOARTHRITIS \nKNEE PAIN \nSHOULDER PAIN \nCESAREAN SECTION \n \n \n\n \nSocial History:\nLives with: Children \nTobacco use: Never smoker \nDepression: Based on a PHQ-2 evaluation, the patient \n\n \nPhysical Exam:\nLast 24h: NAE o/n. AFVSS. WBC ___ yesterday, CRP ___ yesterday\n(down from 263 on admission). Today's labs pending. Sleeping on\nexam today. Should d/c to rehab today.\n \nPE: \n___ 0421 Temp: 98.5 PO BP: 130/71 HR: 81 RR: 18 O2 sat: 94%\nO2 delivery: RA \nNAD, A&Ox4\nnl resp effort\nRRR\nVAC changed ___ with healthy fibrinous exudate to distal\nincision. VAC is intact to ___ mm hg suction. \n \nGeneral: \nNAD, A&Ox3\nnl resp effort\nRR\nWound vac to suction\n\nSensory:\n___ \n L2 L3 L4 L5 S1 S2\n (Groin) (Knee) (Med Calf) (Grt Toe) (Sm Toe) (Post Thigh)\nR SILT SILT SILT SILT SILT SILT \nL SILT SILT SILT SILT SILT SILT \n\nMotor:\n___ Flex(L1) Add(L2) Quad(L3) TA(L4) ___ ___\nR 5 5 5 5 5 5 5 \nL 5 5 5 5 5 5 5\n\n \nPertinent Results:\n___ 06:42AM BLOOD WBC-6.0 RBC-3.52* Hgb-9.1* Hct-29.8* \nMCV-85 MCH-25.9* MCHC-30.5* RDW-13.7 RDWSD-42.0 Plt ___\n___ 09:45AM BLOOD WBC-7.0 RBC-3.44* Hgb-8.9* Hct-29.0* \nMCV-84 MCH-25.9* MCHC-30.7* RDW-13.6 RDWSD-42.5 Plt ___\n___ 09:52AM BLOOD WBC-7.3 RBC-3.51* Hgb-9.1* Hct-29.7* \nMCV-85 MCH-25.9* MCHC-30.6* RDW-13.7 RDWSD-42.0 Plt ___\n___ 01:50PM BLOOD WBC-7.7 RBC-3.74* Hgb-9.9* Hct-32.2* \nMCV-86 MCH-26.5 MCHC-30.7* RDW-13.6 RDWSD-42.9 Plt ___\n___ 01:50PM BLOOD Neuts-68.3 ___ Monos-8.2 Eos-0.5* \nBaso-0.4 Im ___ AbsNeut-5.28 AbsLymp-1.72 AbsMono-0.63 \nAbsEos-0.04 AbsBaso-0.03\n___ 06:42AM BLOOD Plt ___\n___ 09:45AM BLOOD Plt ___\n___ 07:00PM BLOOD ___ PTT-34.9 ___\n___ 06:42AM BLOOD Glucose-104* UreaN-6 Creat-0.5 Na-141 \nK-4.4 Cl-101 HCO3-26 AnGap-14\n___ 09:45AM BLOOD Glucose-118* UreaN-8 Creat-0.6 Na-140 \nK-4.4 Cl-100 HCO3-29 AnGap-11\n___ 09:52AM BLOOD Glucose-109* UreaN-10 Creat-0.5 Na-141 \nK-4.7 Cl-101 HCO3-28 AnGap-12\n___ 01:50PM BLOOD Glucose-111* UreaN-11 Creat-0.6 Na-138 \nK-4.4 Cl-98 HCO3-26 AnGap-14\n___ 09:45AM BLOOD Calcium-9.4 Phos-3.9 Mg-1.8\n___ 09:52AM BLOOD Calcium-9.3 Phos-4.1 Mg-1.8\n___ 06:42AM BLOOD CRP-122.1*\n___ 09:45AM BLOOD CRP-187.6*\n___ 09:52AM BLOOD CRP-266.3*\n___ 01:50PM BLOOD CRP-263.6*\n___ 07:38AM BLOOD Vanco-15.7\n___ 01:50PM BLOOD Lactate-1.2\n___ 04:23PM URINE Color-Yellow Appear-Hazy* Sp ___\n___ 04:23PM URINE Blood-NEG Nitrite-NEG Protein-30* \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG\n___ 04:23PM URINE RBC-18* WBC-2 Bacteri-NONE Yeast-NONE \nEpi-9\n___ 04:23PM URINE Mucous-OCC*\n___ 4:23 pm URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n ESCHERICHIA COLI. 10,000-100,000 CFU/mL. \n PRESUMPTIVE IDENTIFICATION. \n Piperacillin/tazobactam sensitivity testing available \non request. \n PROTEUS MIRABILIS. 10,000-100,000 CFU/mL. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n ESCHERICHIA COLI\n | PROTEUS MIRABILIS\n | | \nAMPICILLIN------------ =>32 R =>32 R\nAMPICILLIN/SULBACTAM-- =>32 R 8 S\nCEFAZOLIN------------- =>64 R 8 R\nCEFEPIME-------------- <=1 S <=1 S\nCEFTAZIDIME----------- <=1 S <=1 S\nCEFTRIAXONE----------- <=1 S <=1 S\nCIPROFLOXACIN---------<=0.25 S <=0.25 S\nGENTAMICIN------------ <=1 S <=1 S\nMEROPENEM-------------<=0.25 S <=0.25 S\nNITROFURANTOIN-------- <=16 S\nPIPERACILLIN/TAZO----- <=4 S\nTOBRAMYCIN------------ <=1 S <=1 S\nTRIMETHOPRIM/SULFA---- =>16 R =>16 R\n\n___ 01:06PM BLOOD WBC-6.7 RBC-3.41* Hgb-8.7* Hct-28.8* \nMCV-85 MCH-25.5* MCHC-30.2* RDW-13.9 RDWSD-43.0 Plt ___\n___ 01:06PM BLOOD Plt ___\n___ 01:06PM BLOOD Glucose-92 UreaN-6 Creat-0.4 Na-141 K-4.8 \nCl-102 HCO3-26 AnGap-13\n___ 01:06PM BLOOD CRP-116.0*\n \nBrief Hospital Course:\n___ is an ___ yo F with lumbar stenosis s/p \nlaminectomy/fusion on ___ who presented with subjective fevers, \npersistent back pain since surgery, and distal wound dehiscence \nconcerning for infection. Inflammatory markers were elevated on\nadmission but Ms. ___ persists without leukocytosis and \nstable vital sigs. Her distal wound dehiscence appears \nsuperficial with fibrinous exudate to\ndistal incision and without purulence or evidence of deeper \ninfection. ID was consulted and she was treated medically with a \nwound VAC and empirically with Vanco/Cefepime per ID \nrecommendations. She remained afebrile during hospital course \nand has transitioned to oral antibiotics per ID recommendation \non today on ___. Most recent VAC change was done on ___ and \nshould\nbe changed every 5 days at rehab. \n-Transitioned to oral antibiotics today ___: Keflex and Bactrim \nDS X 5ays\n-Activity as tolerated\n-Wvac to suction changed on ___ should be changed every 5 days\nwhile at rehab. \n-Inflammatory markers continue to trend down:Vitals are WNL's. \n-Discharge planning: REHAB when bed available. \n \nMedications on Admission:\nASA\nCetirizine\nGabapentin\nMVI\nNortryptyline\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO TID \n2. Cephalexin 500 mg PO Q6H \n5 days \n3. Docusate Sodium 100 mg PO BID \n4. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - \nModerate \nRX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp \n#*28 Tablet Refills:*0 \n5. Sulfameth/Trimethoprim DS 2 TAB PO BID \n5 days \n6. Aspirin 81 mg PO DAILY \n7. Cetirizine 10 mg PO DAILY \n8. Gabapentin 300 mg PO QHS \n9. Multivitamins 1 TAB PO DAILY \n10. Nortriptyline 10 mg PO QHS \n11. Polyethylene Glycol 17 g PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nwound dehiscence \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\n Activity:You should not lift anything greater \nthan 10 lbs for 2 weeks.You will be more comfortable if you do \nnot sit or stand more than~45 minutes without getting up and \nwalking around.\n\n Rehabilitation/ Physical ___ times a \nday you should go for a walk for ___ minutes as part of your \nrecovery.You can walk as much as you can tolerate.Limit any kind \nof lifting.\n\n Diet: Eat a normal healthy diet.You may have \nsome constipation after surgery.You have been given medication \nto help with this issue.\n\n Brace: No Brace\n\n Wound Care:Incisional VAC changed on ___. Ms. \n___ will need VAC changes done at least every ___ days. If \npossible, please e-mail weekly wound care pictures to \n___ with Attention Dr. ___ \nupdates. She will need VAC dressings for at least 1 month. \nPlease call the ___ with any increased drainage, \nconcerns for non-healing wound, or further wound dehiscence. \n\n You should resume taking your normal home \nmedications.\n\n You have also been given Additional Medications \nto control your pain.Please allow 72 hours for refill of \nnarcotic prescriptions,so please plan ahead.You can either have \nthem mailed to your home or pick them up at the clinic located \non ___ 2.We are not allowed to call in or fax narcotic \nprescriptions(oxycontin,oxycodone,percocet) to your pharmacy.In \naddition,we are only allowed to write for pain medications for \n90 days from the date of surgery.\n\n Follow up:\n\nPlease call the office if you have a fever>101.5 degrees \nFahrenheit and/or drainage from your wound.\nPhysical Therapy:\n1)Weight bearing as tolerated.2)Gait, balance training.3)No \nlifting >10 lbs.4)No significant bending/twisting. \nTreatments Frequency:\nIncisional VAC changed on ___. Ms. ___ will need VAC \nchanges done at least every ___ days. If possible, please e-mail \nweekly wound care pictures to ___ with \nAttention Dr. ___ updates. She will need VAC dressings \nfor at least 1 month. Please call the ___ with any \nincreased drainage, concerns for non-healing wound, or further \nwound dehiscence. \n\n \nFollowup Instructions:\n___\n"
] | Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: wound dehiscence Major Surgical or Invasive Procedure: N/A History of Present Illness: [MASKED] is an [MASKED] yo F with lumbar stenosis s/p laminectomy/fusion on [MASKED] who presented with subjective fevers and persistent back pain since surgery. She had elevated CRP/ESR but afebrile and without leukocytosis during hospitalization. Team is treating for possible superficial wound infection in setting of distal dehiscence of wound. No purulence or evidence of deeper infection has been noted. Past Medical History: BACK PAIN LOW BACK PAIN LEG PAIN NECK PAIN HYPERTENSION GASTRITIS MORBID OBESITY VITAMIN D DEFICIENCY PROTEINURIA LUMBAR SPINAL STENOSIS OSTEOARTHRITIS KNEE PAIN SHOULDER PAIN CESAREAN SECTION Social History: Lives with: Children Tobacco use: Never smoker Depression: Based on a PHQ-2 evaluation, the patient Physical Exam: Last 24h: NAE o/n. AFVSS. WBC [MASKED] yesterday, CRP [MASKED] yesterday (down from 263 on admission). Today's labs pending. Sleeping on exam today. Should d/c to rehab today. PE: [MASKED] 0421 Temp: 98.5 PO BP: 130/71 HR: 81 RR: 18 O2 sat: 94% O2 delivery: RA NAD, A&Ox4 nl resp effort RRR VAC changed [MASKED] with healthy fibrinous exudate to distal incision. VAC is intact to [MASKED] mm hg suction. General: NAD, A&Ox3 nl resp effort RR Wound vac to suction Sensory: [MASKED] L2 L3 L4 L5 S1 S2 (Groin) (Knee) (Med Calf) (Grt Toe) (Sm Toe) (Post Thigh) R SILT SILT SILT SILT SILT SILT L SILT SILT SILT SILT SILT SILT Motor: [MASKED] Flex(L1) Add(L2) Quad(L3) TA(L4) [MASKED] [MASKED] R 5 5 5 5 5 5 5 L 5 5 5 5 5 5 5 Pertinent Results: [MASKED] 06:42AM BLOOD WBC-6.0 RBC-3.52* Hgb-9.1* Hct-29.8* MCV-85 MCH-25.9* MCHC-30.5* RDW-13.7 RDWSD-42.0 Plt [MASKED] [MASKED] 09:45AM BLOOD WBC-7.0 RBC-3.44* Hgb-8.9* Hct-29.0* MCV-84 MCH-25.9* MCHC-30.7* RDW-13.6 RDWSD-42.5 Plt [MASKED] [MASKED] 09:52AM BLOOD WBC-7.3 RBC-3.51* Hgb-9.1* Hct-29.7* MCV-85 MCH-25.9* MCHC-30.6* RDW-13.7 RDWSD-42.0 Plt [MASKED] [MASKED] 01:50PM BLOOD WBC-7.7 RBC-3.74* Hgb-9.9* Hct-32.2* MCV-86 MCH-26.5 MCHC-30.7* RDW-13.6 RDWSD-42.9 Plt [MASKED] [MASKED] 01:50PM BLOOD Neuts-68.3 [MASKED] Monos-8.2 Eos-0.5* Baso-0.4 Im [MASKED] AbsNeut-5.28 AbsLymp-1.72 AbsMono-0.63 AbsEos-0.04 AbsBaso-0.03 [MASKED] 06:42AM BLOOD Plt [MASKED] [MASKED] 09:45AM BLOOD Plt [MASKED] [MASKED] 07:00PM BLOOD [MASKED] PTT-34.9 [MASKED] [MASKED] 06:42AM BLOOD Glucose-104* UreaN-6 Creat-0.5 Na-141 K-4.4 Cl-101 HCO3-26 AnGap-14 [MASKED] 09:45AM BLOOD Glucose-118* UreaN-8 Creat-0.6 Na-140 K-4.4 Cl-100 HCO3-29 AnGap-11 [MASKED] 09:52AM BLOOD Glucose-109* UreaN-10 Creat-0.5 Na-141 K-4.7 Cl-101 HCO3-28 AnGap-12 [MASKED] 01:50PM BLOOD Glucose-111* UreaN-11 Creat-0.6 Na-138 K-4.4 Cl-98 HCO3-26 AnGap-14 [MASKED] 09:45AM BLOOD Calcium-9.4 Phos-3.9 Mg-1.8 [MASKED] 09:52AM BLOOD Calcium-9.3 Phos-4.1 Mg-1.8 [MASKED] 06:42AM BLOOD CRP-122.1* [MASKED] 09:45AM BLOOD CRP-187.6* [MASKED] 09:52AM BLOOD CRP-266.3* [MASKED] 01:50PM BLOOD CRP-263.6* [MASKED] 07:38AM BLOOD Vanco-15.7 [MASKED] 01:50PM BLOOD Lactate-1.2 [MASKED] 04:23PM URINE Color-Yellow Appear-Hazy* Sp [MASKED] [MASKED] 04:23PM URINE Blood-NEG Nitrite-NEG Protein-30* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG [MASKED] 04:23PM URINE RBC-18* WBC-2 Bacteri-NONE Yeast-NONE Epi-9 [MASKED] 04:23PM URINE Mucous-OCC* [MASKED] 4:23 pm URINE **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: ESCHERICHIA COLI. 10,000-100,000 CFU/mL. PRESUMPTIVE IDENTIFICATION. Piperacillin/tazobactam sensitivity testing available on request. PROTEUS MIRABILIS. 10,000-100,000 CFU/mL. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] ESCHERICHIA COLI | PROTEUS MIRABILIS | | AMPICILLIN------------ =>32 R =>32 R AMPICILLIN/SULBACTAM-- =>32 R 8 S CEFAZOLIN------------- =>64 R 8 R CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CIPROFLOXACIN---------<=0.25 S <=0.25 S GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- =>16 R =>16 R [MASKED] 01:06PM BLOOD WBC-6.7 RBC-3.41* Hgb-8.7* Hct-28.8* MCV-85 MCH-25.5* MCHC-30.2* RDW-13.9 RDWSD-43.0 Plt [MASKED] [MASKED] 01:06PM BLOOD Plt [MASKED] [MASKED] 01:06PM BLOOD Glucose-92 UreaN-6 Creat-0.4 Na-141 K-4.8 Cl-102 HCO3-26 AnGap-13 [MASKED] 01:06PM BLOOD CRP-116.0* Brief Hospital Course: [MASKED] is an [MASKED] yo F with lumbar stenosis s/p laminectomy/fusion on [MASKED] who presented with subjective fevers, persistent back pain since surgery, and distal wound dehiscence concerning for infection. Inflammatory markers were elevated on admission but Ms. [MASKED] persists without leukocytosis and stable vital sigs. Her distal wound dehiscence appears superficial with fibrinous exudate to distal incision and without purulence or evidence of deeper infection. ID was consulted and she was treated medically with a wound VAC and empirically with Vanco/Cefepime per ID recommendations. She remained afebrile during hospital course and has transitioned to oral antibiotics per ID recommendation on today on [MASKED]. Most recent VAC change was done on [MASKED] and should be changed every 5 days at rehab. -Transitioned to oral antibiotics today [MASKED]: Keflex and Bactrim DS X 5ays -Activity as tolerated -Wvac to suction changed on [MASKED] should be changed every 5 days while at rehab. -Inflammatory markers continue to trend down:Vitals are WNL's. -Discharge planning: REHAB when bed available. Medications on Admission: ASA Cetirizine Gabapentin MVI Nortryptyline Discharge Medications: 1. Acetaminophen 650 mg PO TID 2. Cephalexin 500 mg PO Q6H 5 days 3. Docusate Sodium 100 mg PO BID 4. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp #*28 Tablet Refills:*0 5. Sulfameth/Trimethoprim DS 2 TAB PO BID 5 days 6. Aspirin 81 mg PO DAILY 7. Cetirizine 10 mg PO DAILY 8. Gabapentin 300 mg PO QHS 9. Multivitamins 1 TAB PO DAILY 10. Nortriptyline 10 mg PO QHS 11. Polyethylene Glycol 17 g PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: wound dehiscence 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: Activity:You should not lift anything greater than 10 lbs for 2 weeks.You will be more comfortable if you do not sit or stand more than~45 minutes without getting up and walking around. Rehabilitation/ Physical [MASKED] times a day you should go for a walk for [MASKED] minutes as part of your recovery.You can walk as much as you can tolerate.Limit any kind of lifting. Diet: Eat a normal healthy diet.You may have some constipation after surgery.You have been given medication to help with this issue. Brace: No Brace Wound Care:Incisional VAC changed on [MASKED]. Ms. [MASKED] will need VAC changes done at least every [MASKED] days. If possible, please e-mail weekly wound care pictures to [MASKED] with Attention Dr. [MASKED] updates. She will need VAC dressings for at least 1 month. Please call the [MASKED] with any increased drainage, concerns for non-healing wound, or further wound dehiscence. You should resume taking your normal home medications. You have also been given Additional Medications to control your pain.Please allow 72 hours for refill of narcotic prescriptions,so please plan ahead.You can either have them mailed to your home or pick them up at the clinic located on [MASKED] 2.We are not allowed to call in or fax narcotic prescriptions(oxycontin,oxycodone,percocet) to your pharmacy.In addition,we are only allowed to write for pain medications for 90 days from the date of surgery. Follow up: Please call the office if you have a fever>101.5 degrees Fahrenheit and/or drainage from your wound. Physical Therapy: 1)Weight bearing as tolerated.2)Gait, balance training.3)No lifting >10 lbs.4)No significant bending/twisting. Treatments Frequency: Incisional VAC changed on [MASKED]. Ms. [MASKED] will need VAC changes done at least every [MASKED] days. If possible, please e-mail weekly wound care pictures to [MASKED] with Attention Dr. [MASKED] updates. She will need VAC dressings for at least 1 month. Please call the [MASKED] with any increased drainage, concerns for non-healing wound, or further wound dehiscence. Followup Instructions: [MASKED] | [
"T8131XA",
"Z6842",
"Y838",
"Y92099",
"I10",
"E6601",
"E559",
"M48061",
"F329",
"Z7982",
"R809"
] | [
"T8131XA: Disruption of external operation (surgical) wound, not elsewhere classified, initial encounter",
"Z6842: Body mass index [BMI] 45.0-49.9, adult",
"Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure",
"Y92099: Unspecified place in other non-institutional residence as the place of occurrence of the external cause",
"I10: Essential (primary) hypertension",
"E6601: Morbid (severe) obesity due to excess calories",
"E559: Vitamin D deficiency, unspecified",
"M48061: Spinal stenosis, lumbar region without neurogenic claudication",
"F329: Major depressive disorder, single episode, unspecified",
"Z7982: Long term (current) use of aspirin",
"R809: Proteinuria, unspecified"
] | [
"I10",
"F329"
] | [] |
12,167,940 | 27,983,916 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nheparin / Lovenox / Percocet\n \nAttending: ___.\n \nChief Complaint:\nAbdominal pain\n \nMajor Surgical or Invasive Procedure:\n___: cystic duct stump embolization (coils/glue), exchange \nof R PTBD for ___ internal-external drain\n\n___: cystic duct stump embolization with coils / glue\n\n \nHistory of Present Illness:\nMs. ___ is a ___ female with complex\npast medical history most notable for recent cholecystectomy c/b\nbiliary leak requiring ERCP/PTBD, history of Roux-en-Y, remote \nPE\non rivaroxaban and history of HIT, who presents for worsening\nabdominal pain.\n\nIn review of recent hospitalization, patient was admitted from\n___ here for management of bile leak after recent\ncholecystectomy at ___ ___. During last stay, \npatient\nreceived ERCP (biliary cannulation unsuccessful), and PTBD.\nUltimately thought patient likely had cystic duct stump leak\nversus CBD/hepatic duct leak. She failed PTBD cap trial with\nincreasing JP drain output and increasing alk phos, hence was\ndischarged with uncapped PTBD with 2 week follow up with ___.\nCourse was complicated opioid induced constipation as well as\nquestion of atrial fibrillation (per patient report, no EKG to\ndocument this in our system). She was discharged on ___ home \nwith\n___.\n\nWhile in ___, patient received IV pip/tazo in \nsetting\nof leukocytosis. Abdominal XR was obtained; unable to view\nimaging. Labs were notable for: WBC 13.9 Hgb 11.7 Plt 992, Na \n132\nK 5.5 Cl 94 CO2 21 BUN 20 Cr 0.86, lactate 1.4, Ca ___, AST 22,\nALT 26, AlkPhos 288, lipase 35, ___ 16, INR 1.27. She was\nsubsequently transferred her for further management given recent\nadmission here.\n\nIn the ED, initial vitals: 98.1 BP 135/74 HR 75 RR 18 SpO2 98% \nRA\nExam not documented.\nLabs here: WBC 13.9 Hgb 9.8 Plt 663\n136 | 101 | 18\n--------------\n5.1 | 19 | 0.8\nU/A: WBC 2 RBC 1 neg leuk, neg epi\nLactate 1.7\n\nImaging:\n1. Prominent loops of large bowel containing a moderate amount \nof\nstool,\nmildly increased from prior study, compatible with colonic \nileus.\nNo evidence\nof obstruction.\n2. Stable appearance of the percutaneous biliary drainage\ncatheter and right\nupper quadrant surgical drains.\n3. Interval resolution of the previously seen right pleural\neffusion.\n4. Stable subcapsular fluid collection overlying the right\nhepatic lobe\nmeasuring 3.2 cm\n\nShe received: IV hydromorphone 0.5 mg x 2 doses, NS 1000 mL,\nondansetron 4 mg, and was transferred to us for further care. \n\nIn discussion with patient, she shares that she was just\ndischarged on ___. She was feeling well at time of discharge\nwhile on 2 mg hydromorphone q3H PRN (was taking it around 5\ntimes/day), went home and had to take some of her husband's left\nover hydrocodone to manage the pain until she could fill the\nprescription (took 2 tabs total). She then reports that her R\nsided abdominal pain worsened; this was described in R side, \nboth\nupper and lower quadrant, sharp, stabbing, and radiating from \nRUQ\ntowards center, up to ___. The pain is sometimes worse with\nbreathing at its worst. This was associated with nausea, but no\nvomiting. She reports that she took 1 tab of hydromorphone PO at\nthat time, but the pain did not improve, hence she presented \nhere\nfor care. She denies any fevers, chest pain, shortness of \nbreath,\nor dysuria. She also reports that in the last 2 weeks, she has\nonly had 1 bowel movement which was described as 3 small hard\nballs. In addition, she does report that her drain output has\nincreased. \n\nROS: Pertinent positives and negatives as noted in the HPI. 10\npoint systems were reviewed and are negative. \n\n \nPast Medical History:\nPAST MEDICAL/SURGICAL HISTORY:\n-Anxiety-breast cancer\n-Depression\n-Hypothyroidism\n-Essential thrombocytosis\n-Gallstones\n-Heparin-induced thrombocytopenia (HIT)\n-Hearing loss\n-Hypercholesterolemia\n-Morbid obesity status post Roux-en-Y\n-Pancreatitis due to biliary obstruction\n-Pulmonary embolus\n-Lumpectomy\n-IVC filter retrieval\n-Laparoscopic cholecystectomy\n-Roux-en-Y\n \nSocial History:\n___\nFamily History:\nMother and sister with breast cancer. Mother and\nfather with lung disease.\n \nPhysical Exam:\nPHYSICAL EXAM ON ADMISSION:\nVITALS: ___ 0749 Temp: 98.3 PO BP: 136/89 R Lying HR: 74 \nRR:\n18 O2 sat: 97% O2 delivery: RA \nGENERAL: Alert and in no apparent distress, lying in bed\ncomfortably\nEYES: Anicteric, pupils equally round\nENT: Ears and nose without visible erythema, masses, or trauma. \nOropharynx without visible lesion, erythema or exudate\nCV: Heart regular, no murmur, no S3, no S4. No JVD.\nRESP: Lungs clear to auscultation with good air movement\nbilaterally. Breathing is non-labored\nGI: Abdomen soft, non-distended, mildly tender to palpation in\nRUQ and RLQ but no rebound or guarding. Drain site appears \nc/d/I;\n2 JP drains, PTBD drain with bilious drainage\nGU: No suprapubic fullness or tenderness to palpation\nMSK: Neck supple, moves all extremities, strength grossly full\nand symmetric bilaterally in all limbs\nSKIN: No rashes or ulcerations noted\nNEURO: Alert, oriented, face symmetric, gaze conjugate with \nEOMI,\nspeech fluent, moves all limbs, sensation to light touch grossly\nintact throughout\nPSYCH: pleasant, appropriate affect\n\nPatient examined on day of discharge. AVSS. Abd S/Nt/ND, PTBD in \nplace and capped.\n \nPertinent Results:\nLAB RESULTS ON ADMISSION:\n\n___ 04:12AM BLOOD WBC-13.9* RBC-3.87* Hgb-9.8* Hct-32.2* \nMCV-83 MCH-25.3* MCHC-30.4* RDW-15.3 RDWSD-45.7 Plt ___\n___ 04:12AM BLOOD Glucose-86 UreaN-18 Creat-0.8 Na-136 \nK-5.1 Cl-101 HCO3-19* AnGap-16\n___ 04:12AM BLOOD ALT-18 AST-16 AlkPhos-254* TotBili-0.8\n___ 04:12AM BLOOD Albumin-3.3* Calcium-9.3 Phos-4.4 Mg-2.2\n___ 04:39AM BLOOD Lactate-1.7 K-4.6\n\nPERTINENT INTERVAL LABS:\n\nIMAGING:\n\nUpper Extremity venous duplex ___\nIMPRESSION: \n1. No substantial change in occlusive thrombus of the proximal\nleft basilic vein. \n2. Interval resolution of occlusive thrombus of the right\ncephalic vein. \n\nCT A/P with IV and PO contrast ___\nIMPRESSION: \n-Interval resolution of the previously visualized swirling of\nmesenteric vessels, of which the previous cause and significance\nis unclear. No evidence of bowel obstruction. \n-Internal/external PTBD and infrahepatic abdominal drain in situ\nwith stable trace perihepatic fluid, a portion of which indents\nthe posterior right hepatic lobe. No abdominopelvic ascites\nelsewhere. \n-Near complete resolution of trace right pleural effusion. \n-Stable left lower lobe and right middle lobe pulmonary nodules\nmeasuring up to 4 mm. \n\nCT A/P with IV and PO contrast ___ \nIMPRESSION: \n1. No evidence of bowel obstruction. \n2. Incidentally noted is swirling of the mesenteric vessels,\nwithout evidence \nof associated dilated bowel. \n3. Perihepatic percutaneous drains and PTBD in similar\nconfiguration to prior. \nSlight interval decrease in trace perihepatic ascites. \n4. Slight interval decrease in right small pleural effusion with\nassociated \ncompressive atelectasis. \n5. Stable nonsuspicious left lower lobe and right middle lobe\nmillimetric \npulmonary nodules. \n\nCT scan ___. Small amount of fluid and stranding inferior to the right\nhepatic lobe and tracking along the right paracolic gutter, new\nfrom prior. Cannot exclude an ongoing bile leak. \n2. Unchanged position of surgical drains and biliary drainage\ncatheter. \nPreviously seen subcapsular fluid collection overlying the\nlateral aspect of the right hepatic lobe has nearly resolved. \n3. New small right pleural effusion. \n\nCT A/P WITH CONTRAST ___:\n1. Moderate amount of stool throughout the colon without bowel \nobstruction. The stool burden is slightly improved compared to \nthe prior exam.\n2. Stable appearance of the percutaneous biliary drainage \ncatheter and right upper quadrant surgical drains.\n3. Trace right pleural effusion, decreased from prior study.\n4. Stable subcapsular fluid collection overlying the right \nhepatic lobe\nmeasuring 3.2 cm.\n\nPROCEDURES:\n___ procedure ___\nPROCEDURE: \n1. Over-the-wire cholangiogram through existing right\npercutaneous transhepatic biliary drainage access. \n2. Selective cholangiogram of the cystic duct. \n3. Coil and glue embolization of the cystic duct \n4. Exchange of the existing percutaneous trans-hepatic biliary\ndrainage catheter with a new 12 ___ internal external PTBD\ncatheter. \nFINDINGS: \n1. Right percutaneous transhepatic biliary drainage catheters. \n2. Cholangiogram showing antegrade biliary flow with \nquestionable\narea of small persistent biliary leak along the cystic duct\nstump. \n3. Coil and glue embolization of cystic duct stump. \n4. Successful exchange of right percutaneous transhepatic \nbiliary\ndrainage catheters with new 12 ___ internal external biliary\ncatheters. \nIMPRESSION: \nSuccessful coil and glue embolization of questionable area of\ncystic duct stump leak. \nSuccessful exchange of existing percutaneous transhepatic \nbiliary\ndrainage catheters with new 12 ___ internal external\ncatheters. \n \nBrief Hospital Course:\nSUMMARY:\n___ yo F complex past medical history most notable for recent \ncholecystectomy c/b biliary leak requiring ERCP/PTBD and JP \ndrain placement, history of Roux-en-Y, remote PE on rivaroxaban \nand history of HIT, who presented with worsening abdominal pain, \nfound to have persistent cystic duct stump leak. She underwent \nPTBD drain exchange, and then subsequently failed PTBD drain \ncapping trial with development of sepsis and CT scan showing an \nenlarging ___ fluid collection ___ persistent cystic \nduct stump leak. She then underwent glue and coil embolization \nx2 with clinical improvement. She subsequently tolerated a PTBD \ncapping trial. Her hospital course was complicated by \nconstipation and a question of \"mesenteric swirling\" seen on CT \nA/P.\n\n___ HOSPITAL COURSE:\n# Cystic duct stump leak\n# Sepsis from ___ fluid collection, likely abscess\nPatient presented with a persistent cystic duct stump leak after \nrecent Cholecystectomy. She had 2 JP drains and a PTBD drain in \nplace. This admission, she underwent PTBD drain exchange and \nupsize. She underwent ___ guided glue and coil embolization x2 \nwith subsequent clinical stability. PTBD has been capped since\n___. JP abscess drain output minimized so JP drains were \nremoved. There was no change in abdominal exam or labs after \ndrains removed. She completed a 7d course of antibiotics for \ncystic duct stump leak. She will follow-up with ___ after \ndischarge for further drain management.\n\n# Mesenteric swirling\n# C/f bowel obstruction\n# Severe constipation\nPatient had an episode of worsening abdominal pain, nausea, \nvomiting, and lack of flatus during this hospitalization. CT \nA/P with IV and PO contrast showed mesenteric swirling. CT \nfindings raised suspicion for possible volvulus vs. development \nof internal hernia. However, patient subsequently clinically \nimproved with less abdominal pain and a benign abdominal exam. \nACS surgery was consulted. After a period of bowel rest and \naggressive bowel regimen, a repeat CT A/P showed resolution of \nthe mesenteric swirling and decreased stool burden. She will \ncontinue an aggressive bowel regimen at discharge.\n\n# Left upper extremity superficial thrombus\nWarm compress applied. Though low likelihood of embolization, \npatient does continue on rivaroxaban for indications below. \nBlood pressure was preferentially taken in right arm.\n\n# Anemia\nHb trended down this admission, ___. She had no signs of \nactive bleeding. No signs of hemolysis. Suspect a component of \nAoCD with elevated ferritin, though also component of iron \ndeficiency based on low transferrin sat. Iron deficiency\ncould have developed in setting of multiple procedures and \nhospitalizations. When she is more clinically stable, having \nregular bowel movements, please consider starting PO iron \nsupplementation.\n\n# Reactive thrombocytosis. Platelets topped out near one \nmillion, and drifted back down to normal with resolution of her \nbiliary leak.\n\n# History of PE\n# HIT\nShe was continued on her home rivaroxaban.\n\n# ?Atrial fibrillation. She did not have any signs of atrial \nfibrillation during this hospitalization. She can consider a \nZiopatch as an outpatient.\n\n# Depression: Continued home quetiapine 300 mg qHS + 25 mg qHS\nPRN, buproprion 175 mg BID, citalopram 20 mg daily. QTc 430.\n\n# Hypothyroidism: Continued home levothyroxine 175 mg daily \n\n# Moderate malnutrition. Continue home multivitamin.\n\nTRANSITIONAL ISSUES\n======================\n- Consider ziopatch as outpatient\n- ___ at ___ to manage drains going forward\n\n> 30 minutes spent on discharge activities.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. BuPROPion 175 mg PO BID \n2. Citalopram 20 mg PO QAM \n3. QUEtiapine extended-release 300 mg PO QHS \n4. Cyanocobalamin 500 mcg PO DAILY \n5. Multivitamins 1 TAB PO DAILY \n6. Calcium 500 With D (calcium carbonate-vitamin D3) 500 \nmg(1,250mg) -400 unit oral DAILY \n7. Levothyroxine Sodium 175 mcg PO DAILY \n8. Rivaroxaban 20 mg PO DAILY \n9. amLODIPine 5 mg PO DAILY \n10. Bisacodyl 10 mg PO DAILY \n11. Polyethylene Glycol 34 g PO TID \n12. Senna 17.2 mg PO QHS \n13. QUEtiapine Fumarate 25 mg PO QHS:PRN insomnia \n14. HYDROmorphone (Dilaudid) 2 mg PO Q3H:PRN Pain - Severe \n Reason for PRN duplicate override: changing\n\n \nDischarge Medications:\n1. Magnesium Citrate 300 mL PO ONCE Duration: 1 Dose \nRX *magnesium citrate [Citrate of Magnesia] 300 ml by mouth \nDaily PRN Disp #*5 Bottle Refills:*2 \n2. amLODIPine 5 mg PO DAILY \n3. Bisacodyl 10 mg PO DAILY \n4. BuPROPion 175 mg PO BID \n5. Calcium 500 With D (calcium carbonate-vitamin D3) 500 \nmg(1,250mg) -400 unit oral DAILY \n6. Citalopram 20 mg PO QAM \n7. Cyanocobalamin 500 mcg PO DAILY \n8. HYDROmorphone (Dilaudid) 2 mg PO Q3H:PRN Pain - Severe \n Reason for PRN duplicate override: changing \n9. Levothyroxine Sodium 175 mcg PO DAILY \n10. Multivitamins 1 TAB PO DAILY \n11. Polyethylene Glycol 34 g PO TID \n12. QUEtiapine extended-release 300 mg PO QHS \n13. QUEtiapine Fumarate 25 mg PO QHS:PRN insomnia \n14. Rivaroxaban 20 mg PO DAILY \n15. Senna 17.2 mg PO QHS \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nCyst duct stump leak\nIleus\nConstipation\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear ___, \n\nYou were admitted due to worsening abdominal pain in the setting \nof increased PTBD drainage. You were found to have a leak in \none of the biliary ducts. You underwent PTBD drain exchange, \nand an embolization procedure to stop the leakage. You improved \nafter the procedure. The 2 extra drains were able to be removed \nand the PTBD drain was capped. You will go home with the PTBD \ndrain capped. ___ will see you in clinic in ___ weeks to \nre-evaluate the drain.\n\nWhile in the hospital, you were found to have severe \nconstipation. It is important that you continue to take the \nbowel regimen to ensure you continue to move your bowels daily.\n\nIt was a pleasure being part of your care at ___.\n-- Your ___ team\n \nFollowup Instructions:\n___\n"
] | Allergies: heparin / Lovenox / Percocet Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: [MASKED]: cystic duct stump embolization (coils/glue), exchange of R PTBD for [MASKED] internal-external drain [MASKED]: cystic duct stump embolization with coils / glue History of Present Illness: Ms. [MASKED] is a [MASKED] female with complex past medical history most notable for recent cholecystectomy c/b biliary leak requiring ERCP/PTBD, history of Roux-en-Y, remote PE on rivaroxaban and history of HIT, who presents for worsening abdominal pain. In review of recent hospitalization, patient was admitted from [MASKED] here for management of bile leak after recent cholecystectomy at [MASKED] [MASKED]. During last stay, patient received ERCP (biliary cannulation unsuccessful), and PTBD. Ultimately thought patient likely had cystic duct stump leak versus CBD/hepatic duct leak. She failed PTBD cap trial with increasing JP drain output and increasing alk phos, hence was discharged with uncapped PTBD with 2 week follow up with [MASKED]. Course was complicated opioid induced constipation as well as question of atrial fibrillation (per patient report, no EKG to document this in our system). She was discharged on [MASKED] home with [MASKED]. While in [MASKED], patient received IV pip/tazo in setting of leukocytosis. Abdominal XR was obtained; unable to view imaging. Labs were notable for: WBC 13.9 Hgb 11.7 Plt 992, Na 132 K 5.5 Cl 94 CO2 21 BUN 20 Cr 0.86, lactate 1.4, Ca [MASKED], AST 22, ALT 26, AlkPhos 288, lipase 35, [MASKED] 16, INR 1.27. She was subsequently transferred her for further management given recent admission here. In the ED, initial vitals: 98.1 BP 135/74 HR 75 RR 18 SpO2 98% RA Exam not documented. Labs here: WBC 13.9 Hgb 9.8 Plt 663 136 | 101 | 18 -------------- 5.1 | 19 | 0.8 U/A: WBC 2 RBC 1 neg leuk, neg epi Lactate 1.7 Imaging: 1. Prominent loops of large bowel containing a moderate amount of stool, mildly increased from prior study, compatible with colonic ileus. No evidence of obstruction. 2. Stable appearance of the percutaneous biliary drainage catheter and right upper quadrant surgical drains. 3. Interval resolution of the previously seen right pleural effusion. 4. Stable subcapsular fluid collection overlying the right hepatic lobe measuring 3.2 cm She received: IV hydromorphone 0.5 mg x 2 doses, NS 1000 mL, ondansetron 4 mg, and was transferred to us for further care. In discussion with patient, she shares that she was just discharged on [MASKED]. She was feeling well at time of discharge while on 2 mg hydromorphone q3H PRN (was taking it around 5 times/day), went home and had to take some of her husband's left over hydrocodone to manage the pain until she could fill the prescription (took 2 tabs total). She then reports that her R sided abdominal pain worsened; this was described in R side, both upper and lower quadrant, sharp, stabbing, and radiating from RUQ towards center, up to [MASKED]. The pain is sometimes worse with breathing at its worst. This was associated with nausea, but no vomiting. She reports that she took 1 tab of hydromorphone PO at that time, but the pain did not improve, hence she presented here for care. She denies any fevers, chest pain, shortness of breath, or dysuria. She also reports that in the last 2 weeks, she has only had 1 bowel movement which was described as 3 small hard balls. In addition, she does report that her drain output has increased. ROS: Pertinent positives and negatives as noted in the HPI. 10 point systems were reviewed and are negative. Past Medical History: PAST MEDICAL/SURGICAL HISTORY: -Anxiety-breast cancer -Depression -Hypothyroidism -Essential thrombocytosis -Gallstones -Heparin-induced thrombocytopenia (HIT) -Hearing loss -Hypercholesterolemia -Morbid obesity status post Roux-en-Y -Pancreatitis due to biliary obstruction -Pulmonary embolus -Lumpectomy -IVC filter retrieval -Laparoscopic cholecystectomy -Roux-en-Y Social History: [MASKED] Family History: Mother and sister with breast cancer. Mother and father with lung disease. Physical Exam: PHYSICAL EXAM ON ADMISSION: VITALS: [MASKED] 0749 Temp: 98.3 PO BP: 136/89 R Lying HR: 74 RR: 18 O2 sat: 97% O2 delivery: RA GENERAL: Alert and in no apparent distress, lying in bed comfortably EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, mildly tender to palpation in RUQ and RLQ but no rebound or guarding. Drain site appears c/d/I; 2 JP drains, PTBD drain with bilious drainage GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: pleasant, appropriate affect Patient examined on day of discharge. AVSS. Abd S/Nt/ND, PTBD in place and capped. Pertinent Results: LAB RESULTS ON ADMISSION: [MASKED] 04:12AM BLOOD WBC-13.9* RBC-3.87* Hgb-9.8* Hct-32.2* MCV-83 MCH-25.3* MCHC-30.4* RDW-15.3 RDWSD-45.7 Plt [MASKED] [MASKED] 04:12AM BLOOD Glucose-86 UreaN-18 Creat-0.8 Na-136 K-5.1 Cl-101 HCO3-19* AnGap-16 [MASKED] 04:12AM BLOOD ALT-18 AST-16 AlkPhos-254* TotBili-0.8 [MASKED] 04:12AM BLOOD Albumin-3.3* Calcium-9.3 Phos-4.4 Mg-2.2 [MASKED] 04:39AM BLOOD Lactate-1.7 K-4.6 PERTINENT INTERVAL LABS: IMAGING: Upper Extremity venous duplex [MASKED] IMPRESSION: 1. No substantial change in occlusive thrombus of the proximal left basilic vein. 2. Interval resolution of occlusive thrombus of the right cephalic vein. CT A/P with IV and PO contrast [MASKED] IMPRESSION: -Interval resolution of the previously visualized swirling of mesenteric vessels, of which the previous cause and significance is unclear. No evidence of bowel obstruction. -Internal/external PTBD and infrahepatic abdominal drain in situ with stable trace perihepatic fluid, a portion of which indents the posterior right hepatic lobe. No abdominopelvic ascites elsewhere. -Near complete resolution of trace right pleural effusion. -Stable left lower lobe and right middle lobe pulmonary nodules measuring up to 4 mm. CT A/P with IV and PO contrast [MASKED] IMPRESSION: 1. No evidence of bowel obstruction. 2. Incidentally noted is swirling of the mesenteric vessels, without evidence of associated dilated bowel. 3. Perihepatic percutaneous drains and PTBD in similar configuration to prior. Slight interval decrease in trace perihepatic ascites. 4. Slight interval decrease in right small pleural effusion with associated compressive atelectasis. 5. Stable nonsuspicious left lower lobe and right middle lobe millimetric pulmonary nodules. CT scan [MASKED]. Small amount of fluid and stranding inferior to the right hepatic lobe and tracking along the right paracolic gutter, new from prior. Cannot exclude an ongoing bile leak. 2. Unchanged position of surgical drains and biliary drainage catheter. Previously seen subcapsular fluid collection overlying the lateral aspect of the right hepatic lobe has nearly resolved. 3. New small right pleural effusion. CT A/P WITH CONTRAST [MASKED]: 1. Moderate amount of stool throughout the colon without bowel obstruction. The stool burden is slightly improved compared to the prior exam. 2. Stable appearance of the percutaneous biliary drainage catheter and right upper quadrant surgical drains. 3. Trace right pleural effusion, decreased from prior study. 4. Stable subcapsular fluid collection overlying the right hepatic lobe measuring 3.2 cm. PROCEDURES: [MASKED] procedure [MASKED] PROCEDURE: 1. Over-the-wire cholangiogram through existing right percutaneous transhepatic biliary drainage access. 2. Selective cholangiogram of the cystic duct. 3. Coil and glue embolization of the cystic duct 4. Exchange of the existing percutaneous trans-hepatic biliary drainage catheter with a new 12 [MASKED] internal external PTBD catheter. FINDINGS: 1. Right percutaneous transhepatic biliary drainage catheters. 2. Cholangiogram showing antegrade biliary flow with questionable area of small persistent biliary leak along the cystic duct stump. 3. Coil and glue embolization of cystic duct stump. 4. Successful exchange of right percutaneous transhepatic biliary drainage catheters with new 12 [MASKED] internal external biliary catheters. IMPRESSION: Successful coil and glue embolization of questionable area of cystic duct stump leak. Successful exchange of existing percutaneous transhepatic biliary drainage catheters with new 12 [MASKED] internal external catheters. Brief Hospital Course: SUMMARY: [MASKED] yo F complex past medical history most notable for recent cholecystectomy c/b biliary leak requiring ERCP/PTBD and JP drain placement, history of Roux-en-Y, remote PE on rivaroxaban and history of HIT, who presented with worsening abdominal pain, found to have persistent cystic duct stump leak. She underwent PTBD drain exchange, and then subsequently failed PTBD drain capping trial with development of sepsis and CT scan showing an enlarging [MASKED] fluid collection [MASKED] persistent cystic duct stump leak. She then underwent glue and coil embolization x2 with clinical improvement. She subsequently tolerated a PTBD capping trial. Her hospital course was complicated by constipation and a question of "mesenteric swirling" seen on CT A/P. [MASKED] HOSPITAL COURSE: # Cystic duct stump leak # Sepsis from [MASKED] fluid collection, likely abscess Patient presented with a persistent cystic duct stump leak after recent Cholecystectomy. She had 2 JP drains and a PTBD drain in place. This admission, she underwent PTBD drain exchange and upsize. She underwent [MASKED] guided glue and coil embolization x2 with subsequent clinical stability. PTBD has been capped since [MASKED]. JP abscess drain output minimized so JP drains were removed. There was no change in abdominal exam or labs after drains removed. She completed a 7d course of antibiotics for cystic duct stump leak. She will follow-up with [MASKED] after discharge for further drain management. # Mesenteric swirling # C/f bowel obstruction # Severe constipation Patient had an episode of worsening abdominal pain, nausea, vomiting, and lack of flatus during this hospitalization. CT A/P with IV and PO contrast showed mesenteric swirling. CT findings raised suspicion for possible volvulus vs. development of internal hernia. However, patient subsequently clinically improved with less abdominal pain and a benign abdominal exam. ACS surgery was consulted. After a period of bowel rest and aggressive bowel regimen, a repeat CT A/P showed resolution of the mesenteric swirling and decreased stool burden. She will continue an aggressive bowel regimen at discharge. # Left upper extremity superficial thrombus Warm compress applied. Though low likelihood of embolization, patient does continue on rivaroxaban for indications below. Blood pressure was preferentially taken in right arm. # Anemia Hb trended down this admission, [MASKED]. She had no signs of active bleeding. No signs of hemolysis. Suspect a component of AoCD with elevated ferritin, though also component of iron deficiency based on low transferrin sat. Iron deficiency could have developed in setting of multiple procedures and hospitalizations. When she is more clinically stable, having regular bowel movements, please consider starting PO iron supplementation. # Reactive thrombocytosis. Platelets topped out near one million, and drifted back down to normal with resolution of her biliary leak. # History of PE # HIT She was continued on her home rivaroxaban. # ?Atrial fibrillation. She did not have any signs of atrial fibrillation during this hospitalization. She can consider a Ziopatch as an outpatient. # Depression: Continued home quetiapine 300 mg qHS + 25 mg qHS PRN, buproprion 175 mg BID, citalopram 20 mg daily. QTc 430. # Hypothyroidism: Continued home levothyroxine 175 mg daily # Moderate malnutrition. Continue home multivitamin. TRANSITIONAL ISSUES ====================== - Consider ziopatch as outpatient - [MASKED] at [MASKED] to manage drains going forward > 30 minutes spent on discharge activities. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. BuPROPion 175 mg PO BID 2. Citalopram 20 mg PO QAM 3. QUEtiapine extended-release 300 mg PO QHS 4. Cyanocobalamin 500 mcg PO DAILY 5. Multivitamins 1 TAB PO DAILY 6. Calcium 500 With D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -400 unit oral DAILY 7. Levothyroxine Sodium 175 mcg PO DAILY 8. Rivaroxaban 20 mg PO DAILY 9. amLODIPine 5 mg PO DAILY 10. Bisacodyl 10 mg PO DAILY 11. Polyethylene Glycol 34 g PO TID 12. Senna 17.2 mg PO QHS 13. QUEtiapine Fumarate 25 mg PO QHS:PRN insomnia 14. HYDROmorphone (Dilaudid) 2 mg PO Q3H:PRN Pain - Severe Reason for PRN duplicate override: changing Discharge Medications: 1. Magnesium Citrate 300 mL PO ONCE Duration: 1 Dose RX *magnesium citrate [Citrate of Magnesia] 300 ml by mouth Daily PRN Disp #*5 Bottle Refills:*2 2. amLODIPine 5 mg PO DAILY 3. Bisacodyl 10 mg PO DAILY 4. BuPROPion 175 mg PO BID 5. Calcium 500 With D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -400 unit oral DAILY 6. Citalopram 20 mg PO QAM 7. Cyanocobalamin 500 mcg PO DAILY 8. HYDROmorphone (Dilaudid) 2 mg PO Q3H:PRN Pain - Severe Reason for PRN duplicate override: changing 9. Levothyroxine Sodium 175 mcg PO DAILY 10. Multivitamins 1 TAB PO DAILY 11. Polyethylene Glycol 34 g PO TID 12. QUEtiapine extended-release 300 mg PO QHS 13. QUEtiapine Fumarate 25 mg PO QHS:PRN insomnia 14. Rivaroxaban 20 mg PO DAILY 15. Senna 17.2 mg PO QHS Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Cyst duct stump leak Ileus Constipation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear [MASKED], You were admitted due to worsening abdominal pain in the setting of increased PTBD drainage. You were found to have a leak in one of the biliary ducts. You underwent PTBD drain exchange, and an embolization procedure to stop the leakage. You improved after the procedure. The 2 extra drains were able to be removed and the PTBD drain was capped. You will go home with the PTBD drain capped. [MASKED] will see you in clinic in [MASKED] weeks to re-evaluate the drain. While in the hospital, you were found to have severe constipation. It is important that you continue to take the bowel regimen to ensure you continue to move your bowels daily. It was a pleasure being part of your care at [MASKED]. -- Your [MASKED] team Followup Instructions: [MASKED] | [
"K6811",
"K9189",
"K567",
"E440",
"I82612",
"N179",
"T8144XA",
"T8143XA",
"F419",
"F329",
"D7582",
"E039",
"D473",
"E7800",
"E6601",
"F1290",
"D649",
"I4891",
"K5903",
"R935",
"R110",
"L538",
"T402X5A",
"Y733",
"Y92019",
"Y836",
"Z86711",
"Z9884",
"Z853",
"Z6825",
"Z87891",
"Z7901"
] | [
"K6811: Postprocedural retroperitoneal abscess",
"K9189: Other postprocedural complications and disorders of digestive system",
"K567: Ileus, unspecified",
"E440: Moderate protein-calorie malnutrition",
"I82612: Acute embolism and thrombosis of superficial veins of left upper extremity",
"N179: Acute kidney failure, unspecified",
"T8144XA: Sepsis following a procedure, initial encounter",
"T8143XA: Infection following a procedure, organ and space surgical site, initial encounter",
"F419: Anxiety disorder, unspecified",
"F329: Major depressive disorder, single episode, unspecified",
"D7582: Heparin induced thrombocytopenia (HIT)",
"E039: Hypothyroidism, unspecified",
"D473: Essential (hemorrhagic) thrombocythemia",
"E7800: Pure hypercholesterolemia, unspecified",
"E6601: Morbid (severe) obesity due to excess calories",
"F1290: Cannabis use, unspecified, uncomplicated",
"D649: Anemia, unspecified",
"I4891: Unspecified atrial fibrillation",
"K5903: Drug induced constipation",
"R935: Abnormal findings on diagnostic imaging of other abdominal regions, including retroperitoneum",
"R110: Nausea",
"L538: Other specified erythematous conditions",
"T402X5A: Adverse effect of other opioids, initial encounter",
"Y733: Surgical instruments, materials and gastroenterology and urology devices (including sutures) associated with adverse incidents",
"Y92019: Unspecified place in single-family (private) house as the place of occurrence of the external cause",
"Y836: Removal of other organ (partial) (total) as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure",
"Z86711: Personal history of pulmonary embolism",
"Z9884: Bariatric surgery status",
"Z853: Personal history of malignant neoplasm of breast",
"Z6825: Body mass index [BMI] 25.0-25.9, adult",
"Z87891: Personal history of nicotine dependence",
"Z7901: Long term (current) use of anticoagulants"
] | [
"N179",
"F419",
"F329",
"E039",
"D649",
"I4891",
"Z87891",
"Z7901"
] | [] |
18,196,441 | 27,061,952 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: ORTHOPAEDICS\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\ncervical stenosis with myelopathy\n \nMajor Surgical or Invasive Procedure:\nPosterior cervical decompression and instrumented fusion, C3-7\n\n \nHistory of Present Illness:\n___ with PMH of diabetes on insulin, HLD, HTN, OSA, obesity, \nwith cervical myelopathy and stenosis C3-7. \n \nPast Medical History:\n- Sleep apnea on CPAP\n- HTN\n- HLD\n- DMII\n- B12 deficiency - diagnosed by PCP, she was told to take \nmonthly B12. Sometimes she misses this medication. \n \nSocial History:\n___\nFamily History:\nNo family history of stroke. Family history of diabetes. No \nfamily history of autoimmune disease. \n \nPhysical Exam:\nSensory:\nUE (all intact, but diminished at fingertips per pt which is her\nbaseline)\n C5 C6 C7 C8 T1\n (lat arm) (thumb) (mid fing) (sm finger) (med arm)\nR SILT SILT SILT SILT SILT\nL SILT SILT SILT SILT SILT\n\n___ \n L2 L3 L4 L5 S1 S2\n (Groin) (Knee) (Med Calf) (Grt Toe) (Sm Toe) (Post Thigh)\nR SILT SILT SILT SILT SILT SILT \nL SILT SILT SILT SILT SILT SILT \n\nMotor: Limited by pain and participation - pt reporting pain in\nshoulders and back surrounding incision\nUE Dlt(C5) Bic(C6) WE(C6) Tri(C7) WF(C7) FF(C8)FinAbd(T1)\nR 4 4- 4 4- 4 3 3\nL 4 4- 4 4- 4 3 3\n\n___ Flex(L1) Add(L2) Quad(L3) TA(L4) ___ ___\nR 4 4 4 4 4 4 4 \nL 4 4 4 4 4 4 4\n\nReflexes \n Bic(C4-5) BR(C5-6) Tri(C6-7) \nR 0 0 0 \nL 0 0 0 \n \n___: Negative\nBabinski: toes mute\nClonus: No beats\n\n \nPertinent Results:\n___ 06:55AM BLOOD WBC-19.1* RBC-4.48 Hgb-12.1 Hct-38.9 \nMCV-87 MCH-27.0 MCHC-31.1* RDW-13.0 RDWSD-40.7 Plt ___\n \nBrief Hospital Course:\nPatient was admitted to the ___ Spine Surgery Service and \ntaken to the Operating Room for the above procedure. Refer to \nthe dictated operative note for further details. The surgery \nwas without complication and the patient was transferred to the \nPACU in a stable condition. TEDs/pnemoboots were used for \npostoperative DVT prophylaxis. Intravenous antibiotics were \ncontinued for 24hrs postop per standard protocol. Initial postop \npain was controlled with a IV and PO pain medications. Diet was \nadvanced as tolerated. The patient was transitioned to oral \npain medication when tolerating PO diet. Foley was removed \npostoperatively without issue and patient had a purewick \ncatheter in place after this. Physical therapy was consulted \nfor mobilization OOB to ambulate. Hospital course was otherwise \nunremarkable. She had an in-patient ___ Diabetes consult in \nhouse to manage her insulin regimen and blood sugars while in \nhouse and they recommended she resume her outpatient regimen on \ndischarge. On the day of discharge the patient was afebrile \nwith stable vital signs, comfortable on oral pain control and \ntolerating a regular diet.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. aMILoride-hydrochlorothiazide ___ mg oral daily \n2. Aspirin EC 325 mg PO DAILY \n3. CARVedilol 12.5 mg PO BID \n4. Diclofenac Sodium ___ 75 mg PO BID \n5. MetFORMIN (Glucophage) 1000 mg PO BID \n6. Pregabalin 100 mg PO TID \n7. Simvastatin 20 mg PO QPM \n8. TraMADol 50 mg PO DAILY:PRN Pain - Moderate \n\n \nDischarge Medications:\n1. Diazepam 5 mg PO BID:PRN pain \nRX *diazepam 5 mg 1 tablet by mouth twice a day Disp #*14 Tablet \nRefills:*0 \n2. Docusate Sodium 100 mg PO BID \nUse only when taking oxycodone. \n3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - \nModerate \nDo not take at the same time as gabapentin or valium. Alternate \nthese agents. \nRX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours \nDisp #*40 Tablet Refills:*0 \n4. aMILoride-hydrochlorothiazide ___ mg oral daily \n5. Aspirin EC 325 mg PO DAILY \n6. CARVedilol 12.5 mg PO BID \n7. MetFORMIN (Glucophage) 1000 mg PO BID \n8. Pregabalin 100 mg PO TID \n9. Simvastatin 20 mg PO QPM \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nCervical stenosis, C3-7\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nYou have undergone the following operation: Posterior Cervical \nDecompression and Fusion\n\nImmediately after the operation:\n Activity: You should not lift anything greater \nthan 10 lbs for 2 weeks. You will be more comfortable if you do \nnot sit in a car or chair for more than ~45 minutes without \ngetting up and walking around.\n Rehabilitation/ Physical Therapy:\n___ times a day you should go for a walk for ___ minutes as \npart of your recovery. You can walk as much as you can \ntolerate. Isometric Extension Exercise in the collar: \n2x/day x ___xercises as instructed.\n\n Cervical Collar / Neck Brace: You need to wear the brace at \nall times until your follow-up appointment which should be in 2 \nweeks. You may remove the collar to take a shower. Limit your \nmotion of your neck while the collar is off. Place the collar \nback on your neck immediately after the shower.\n\n Wound Care: Wound Care: Leave the Prevena vacuum dressing \non until ___. After this, place a clean gauze dressing on the \nwound and keep the wound covered. Change the dressing as needed. \n Keep it clean and dry and do not submerge the wound. If it \nbecomes saturated, replace it with a dry sterile dressing and \ncall the office.\n\n You should resume taking your normal home \nmedications.\n\n You have also been given Additional Medications \nto control your pain. Please allow 72 hours for refill of \nnarcotic prescriptions, so please plan ahead. You can either \nhave them mailed to your home or pick them up at the clinic \nlocated on ___. We are not allowed to call in narcotic \nprescriptions (oxycontin, oxycodone, percocet) to the pharmacy. \nIn addition, we are only allowed to write for pain medications \nfor 90 days from the date of surgery. \n\n Follow up: \n Please Call the office and make an appointment for 2 weeks \nafter the day of your operation if this has not been done \nalready. At the 2-week visit we will check your incision, take \nbaseline x rays and answer any questions. We will then see you \nat 6 weeks from the day of the operation. At that time we will \nmost likely obtain Flexion/Extension X-rays and often able to \nplace you in a soft collar which you will wean out of over 1 \nweek. \n \nPlease call the office if you have a fever>101.5 degrees \nFahrenheit, drainage from your wound, or have any questions.\n\nPhysical Therapy:\nActivity: You should not lift anything greater than 10 lbs for 2 \nweeks. You will be more comfortable if you do not sit in a car \nor chair for more than ~45 minutes without getting up and \nwalking around.\n Rehabilitation/ Physical Therapy:\n ___ times a day you should go for a walk for ___ \nminutes as part of your recovery. You can walk as much as you \ncan tolerate. \n\n Cervical Collar / Neck Brace: You need to wear \nthe brace at all times until your follow-up appointment which \nshould be in 2 weeks. You may remove the collar to take a \nshower. Limit your motion of your neck while the collar is off. \nPlace the collar back on your neck immediately after the shower.\nTreatments Frequency:\nWound Care: Leave the Prevena vacuum dressing on until ___. \nAfter this, place a clean gauze dressing on the wound and keep \nthe wound covered. Change the dressing as needed. \n\nKeep the wound covered, clean and dry and do not submerge the \nwound. If it becomes saturated, replace it with a dry sterile \ndressing and call the office.\n \nFollowup Instructions:\n___\n"
] | Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: cervical stenosis with myelopathy Major Surgical or Invasive Procedure: Posterior cervical decompression and instrumented fusion, C3-7 History of Present Illness: [MASKED] with PMH of diabetes on insulin, HLD, HTN, OSA, obesity, with cervical myelopathy and stenosis C3-7. Past Medical History: - Sleep apnea on CPAP - HTN - HLD - DMII - B12 deficiency - diagnosed by PCP, she was told to take monthly B12. Sometimes she misses this medication. Social History: [MASKED] Family History: No family history of stroke. Family history of diabetes. No family history of autoimmune disease. Physical Exam: Sensory: UE (all intact, but diminished at fingertips per pt which is her baseline) C5 C6 C7 C8 T1 (lat arm) (thumb) (mid fing) (sm finger) (med arm) R SILT SILT SILT SILT SILT L SILT SILT SILT SILT SILT [MASKED] L2 L3 L4 L5 S1 S2 (Groin) (Knee) (Med Calf) (Grt Toe) (Sm Toe) (Post Thigh) R SILT SILT SILT SILT SILT SILT L SILT SILT SILT SILT SILT SILT Motor: Limited by pain and participation - pt reporting pain in shoulders and back surrounding incision UE Dlt(C5) Bic(C6) WE(C6) Tri(C7) WF(C7) FF(C8)FinAbd(T1) R 4 4- 4 4- 4 3 3 L 4 4- 4 4- 4 3 3 [MASKED] Flex(L1) Add(L2) Quad(L3) TA(L4) [MASKED] [MASKED] R 4 4 4 4 4 4 4 L 4 4 4 4 4 4 4 Reflexes Bic(C4-5) BR(C5-6) Tri(C6-7) R 0 0 0 L 0 0 0 [MASKED]: Negative Babinski: toes mute Clonus: No beats Pertinent Results: [MASKED] 06:55AM BLOOD WBC-19.1* RBC-4.48 Hgb-12.1 Hct-38.9 MCV-87 MCH-27.0 MCHC-31.1* RDW-13.0 RDWSD-40.7 Plt [MASKED] Brief Hospital Course: Patient was admitted to the [MASKED] Spine Surgery Service and taken to the Operating Room for the above procedure. Refer to the dictated operative note for further details. The surgery was without complication and the patient was transferred to the PACU in a stable condition. TEDs/pnemoboots were used for postoperative DVT prophylaxis. Intravenous antibiotics were continued for 24hrs postop per standard protocol. Initial postop pain was controlled with a IV and PO pain medications. Diet was advanced as tolerated. The patient was transitioned to oral pain medication when tolerating PO diet. Foley was removed postoperatively without issue and patient had a purewick catheter in place after this. Physical therapy was consulted for mobilization OOB to ambulate. Hospital course was otherwise unremarkable. She had an in-patient [MASKED] Diabetes consult in house to manage her insulin regimen and blood sugars while in house and they recommended she resume her outpatient regimen on discharge. On the day of discharge the patient was afebrile with stable vital signs, comfortable on oral pain control and tolerating a regular diet. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. aMILoride-hydrochlorothiazide [MASKED] mg oral daily 2. Aspirin EC 325 mg PO DAILY 3. CARVedilol 12.5 mg PO BID 4. Diclofenac Sodium [MASKED] 75 mg PO BID 5. MetFORMIN (Glucophage) 1000 mg PO BID 6. Pregabalin 100 mg PO TID 7. Simvastatin 20 mg PO QPM 8. TraMADol 50 mg PO DAILY:PRN Pain - Moderate Discharge Medications: 1. Diazepam 5 mg PO BID:PRN pain RX *diazepam 5 mg 1 tablet by mouth twice a day Disp #*14 Tablet Refills:*0 2. Docusate Sodium 100 mg PO BID Use only when taking oxycodone. 3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate Do not take at the same time as gabapentin or valium. Alternate these agents. RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*40 Tablet Refills:*0 4. aMILoride-hydrochlorothiazide [MASKED] mg oral daily 5. Aspirin EC 325 mg PO DAILY 6. CARVedilol 12.5 mg PO BID 7. MetFORMIN (Glucophage) 1000 mg PO BID 8. Pregabalin 100 mg PO TID 9. Simvastatin 20 mg PO QPM Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Cervical stenosis, C3-7 Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You have undergone the following operation: Posterior Cervical Decompression and Fusion Immediately after the operation: Activity: You should not lift anything greater than 10 lbs for 2 weeks. You will be more comfortable if you do not sit in a car or chair for more than ~45 minutes without getting up and walking around. Rehabilitation/ Physical Therapy: [MASKED] times a day you should go for a walk for [MASKED] minutes as part of your recovery. You can walk as much as you can tolerate. Isometric Extension Exercise in the collar: 2x/day x xercises as instructed. Cervical Collar / Neck Brace: You need to wear the brace at all times until your follow-up appointment which should be in 2 weeks. You may remove the collar to take a shower. Limit your motion of your neck while the collar is off. Place the collar back on your neck immediately after the shower. Wound Care: Wound Care: Leave the Prevena vacuum dressing on until [MASKED]. After this, place a clean gauze dressing on the wound and keep the wound covered. Change the dressing as needed. Keep it clean and dry and do not submerge the wound. If it becomes saturated, replace it with a dry sterile dressing and call the office. You should resume taking your normal home medications. You have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so please plan ahead. You can either have them mailed to your home or pick them up at the clinic located on [MASKED]. We are not allowed to call in narcotic prescriptions (oxycontin, oxycodone, percocet) to the pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. Follow up: Please Call the office and make an appointment for 2 weeks after the day of your operation if this has not been done already. At the 2-week visit we will check your incision, take baseline x rays and answer any questions. We will then see you at 6 weeks from the day of the operation. At that time we will most likely obtain Flexion/Extension X-rays and often able to place you in a soft collar which you will wean out of over 1 week. Please call the office if you have a fever>101.5 degrees Fahrenheit, drainage from your wound, or have any questions. Physical Therapy: Activity: You should not lift anything greater than 10 lbs for 2 weeks. You will be more comfortable if you do not sit in a car or chair for more than ~45 minutes without getting up and walking around. Rehabilitation/ Physical Therapy: [MASKED] times a day you should go for a walk for [MASKED] minutes as part of your recovery. You can walk as much as you can tolerate. Cervical Collar / Neck Brace: You need to wear the brace at all times until your follow-up appointment which should be in 2 weeks. You may remove the collar to take a shower. Limit your motion of your neck while the collar is off. Place the collar back on your neck immediately after the shower. Treatments Frequency: Wound Care: Leave the Prevena vacuum dressing on until [MASKED]. After this, place a clean gauze dressing on the wound and keep the wound covered. Change the dressing as needed. Keep the wound covered, clean and dry and do not submerge the wound. If it becomes saturated, replace it with a dry sterile dressing and call the office. Followup Instructions: [MASKED] | [
"M4802",
"G992",
"Z6841",
"M5412",
"E8342",
"I10",
"E785",
"G4733",
"E669",
"E1165",
"Z794",
"Z7984"
] | [
"M4802: Spinal stenosis, cervical region",
"G992: Myelopathy in diseases classified elsewhere",
"Z6841: Body mass index [BMI]40.0-44.9, adult",
"M5412: Radiculopathy, cervical region",
"E8342: Hypomagnesemia",
"I10: Essential (primary) hypertension",
"E785: Hyperlipidemia, unspecified",
"G4733: Obstructive sleep apnea (adult) (pediatric)",
"E669: Obesity, unspecified",
"E1165: Type 2 diabetes mellitus with hyperglycemia",
"Z794: Long term (current) use of insulin",
"Z7984: Long term (current) use of oral hypoglycemic drugs"
] | [
"I10",
"E785",
"G4733",
"E669",
"E1165",
"Z794"
] | [] |
17,617,665 | 26,810,487 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Allergies/ADRs on File\n \nAttending: ___.\n \nChief Complaint:\nhyperglycemia\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nPt is a ___ y.o male with h.o DM2, HTN who was admitted from \nclinic due to concern for poorly controlled diabetes. Per \nreport, pt reportedly non-compliant with diabetic home meds \nincluding lantus and metformin. He presented to urgent care and \nwas found to have ___ 456. He was found to have electrolyte \nabnormalities (low Na and Cl) and was given 2L IVF ___ with \nplan to take increased dose of metformin (1000mg bid) and call \nwith evening finger stick. Last night ___ 300 and he took 60 \nunits lantus. He presented to UC again today with hyperglycemia \nto 456 and reportedly did not take any of his home meds. U/A \nnoted to have 3+blood (appears to be 1+ in records). Outpt team \nfells that diabetes is not being managed sufficiently and \nstarting Humalog would not work without further monitoring and \neducation. He reportedly has has 3 episodes of hyperglycemia \nthis week and there was concern for dehydration. \nPt states that he was taking his lantus and metformin as \ndirected at home. He states that he checks his ___ daily. He \nadmits that because of his work schedule ___ (gets home 1am) \nthat night lantus is problematic and that he cannot remember to \ntake it when he gets home from work. He feels that he would be \nmore compliant if able to take lantus at noon when he wakes up. \nHe is concerned about this admissions interference with his work \nschedule. He states that he has received diabetic teaching and \nnutrition education. \nHe denies fever, chills, CP, sob, cough, ST, abdominal pain, \nn/v/d/c/dysuria, rash, paresthesias or weakness. \n\n10pt ROS reviewed and otherwise negative \n \nPast Medical History:\nmorbid obesity\nHTN\nbipolar disorder \n \nSocial History:\n___\nFamily History:\nboth parents have DM2\n \nPhysical Exam:\nADMISSION EXAM\n\nGEN: well appearing, obese \nvitals:98.0\nPO 141 / 84\nL Sitting 83 20 98 RA ___ 363\nHEENT: ncat eomi anicteric dry MM\nchest: b/l ae no w/c/r\nheart: s1s2 rr no m/r/g\nabd: +bs, soft, NT, ND\next: no c/c/e 2+pulses\nneuro: face symmetric, speech fluent\npsych: calm, cooperative \n\nDISCHARGE EXAM: VSS, unchanged from above\n \nPertinent Results:\n___ clinic labs \n___\nWBC 7.4, Hbg/HCT 13.1/40.9, plt 296 MCV 75.9, eos 3.3%\nchemistries\nna 135, k 4.3, cl 94, co2 25, bun 13, cr 1, gluc 456\nAIC 10.1%\n\nurine alb/cr ratio 1735.8 \nu/a\n1+blood, no suggestion of infection\n\nINPATIENT LABS: \n\n___ 08:40PM URINE COLOR-Straw APPEAR-Clear SP ___\n___ 08:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG \nGLUCOSE-1000 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 \nLEUK-NEG\n___ 06:53PM GLUCOSE-496* UREA N-11 CREAT-1.1 SODIUM-130* \nPOTASSIUM-3.7 CHLORIDE-92* TOTAL CO2-24 ANION GAP-18\n___ 06:53PM estGFR-Using this\n___ 06:53PM CALCIUM-9.5 PHOSPHATE-2.9 MAGNESIUM-1.5*\n___ 06:53PM WBC-7.5 RBC-5.12 HGB-12.8* HCT-37.1* MCV-73* \nMCH-25.0* MCHC-34.5 RDW-13.2 RDWSD-33.6*\n___ 06:53PM PLT COUNT-___ y.o man with h.o DM2, HTN who presents with poorly controlled \ndiabetes.\n\n#type 2 Diabetes, poorly controlled with hyperglycemia. Last AIC \n10.1%. Pt has presented to clinic 3 times this past week with \nhyperglycemia and reports of medication non-compliance. Outpt \nproviders now concerned about his outpt management regimen and \nrisk of dehydration. Pt states his issue is compliance with \ntiming of medications given his work schedule and hours. He was \nseen by the ___ team in the hospital and changed to ___ 80 \nBID from lantus and also continued on an insulin sliding scale. \nHe was also seen by the nutritionist and diabetes educator and \ninstructed to check ___ 3x/day. He was provided with a contact \nnumber to call if ___ >400 or <80\n\n#HTN-continued lisinopril\n\n#bipolar disorder- continued lamictal and olanzapine\n\nMidline placed due to difficult access while hospitalized \nhowever this was dc'd at the time of discharge.\n\n>30 min were spent on dc related activities\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. MetFORMIN (Glucophage) 1000 mg PO BID \n2. Lisinopril 20 mg PO DAILY \n3. OLANZapine 10 mg PO QHS \n4. LamoTRIgine 200 mg PO DAILY \n\n \nDischarge Medications:\n1. Humalog ___ 80 Units Breakfast\nHumalog ___ 80 Units Dinner\nInsulin SC Sliding Scale using HUM Insulin\nRX *insulin lispro protamin-lispro [Humalog Mix ___ KwikPen] \n100 unit/mL (75-25) AS DIR 80 Units before BKFT; 80 Units before \nDINR; Disp #*5 Syringe Refills:*0\nRX *insulin lispro [Humalog KwikPen] 100 unit/mL AS DIR Up to 30 \nUnits QID per sliding scale Disp #*3 Syringe Refills:*0 \n2. LamoTRIgine 200 mg PO DAILY \n3. Lisinopril 20 mg PO DAILY \n4. MetFORMIN (Glucophage) 1000 mg PO BID \n5. OLANZapine 10 mg PO QHS \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nDiabetes, poorly controlled\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr ___,\nYou were admitted to the hospital for high blood sugars. Your \nsugars improved with an increase in insulin dose. It is very \nimportant that you continue to take your insulin and monitor \nyour blood sugars three times a day, before meals, when you \nleave the hospital. Please call the diabetes doctor at the \nnumber provided to you if you have a blood sugar less than 80 or \ngreater than 400. It is very important that you follow up with \nyour primary care doctor and endocrine (diabetes) doctor when \nyou leave the hospital. Please also follow the diabetic diet \ngiven to you while in the hospital. It was a pleasure caring \nfor you while you were in the hospital. \n \nFollowup Instructions:\n___\n"
] | Allergies: No Allergies/ADRs on File Chief Complaint: hyperglycemia Major Surgical or Invasive Procedure: None History of Present Illness: Pt is a [MASKED] y.o male with h.o DM2, HTN who was admitted from clinic due to concern for poorly controlled diabetes. Per report, pt reportedly non-compliant with diabetic home meds including lantus and metformin. He presented to urgent care and was found to have [MASKED] 456. He was found to have electrolyte abnormalities (low Na and Cl) and was given 2L IVF [MASKED] with plan to take increased dose of metformin (1000mg bid) and call with evening finger stick. Last night [MASKED] 300 and he took 60 units lantus. He presented to UC again today with hyperglycemia to 456 and reportedly did not take any of his home meds. U/A noted to have 3+blood (appears to be 1+ in records). Outpt team fells that diabetes is not being managed sufficiently and starting Humalog would not work without further monitoring and education. He reportedly has has 3 episodes of hyperglycemia this week and there was concern for dehydration. Pt states that he was taking his lantus and metformin as directed at home. He states that he checks his [MASKED] daily. He admits that because of his work schedule [MASKED] (gets home 1am) that night lantus is problematic and that he cannot remember to take it when he gets home from work. He feels that he would be more compliant if able to take lantus at noon when he wakes up. He is concerned about this admissions interference with his work schedule. He states that he has received diabetic teaching and nutrition education. He denies fever, chills, CP, sob, cough, ST, abdominal pain, n/v/d/c/dysuria, rash, paresthesias or weakness. 10pt ROS reviewed and otherwise negative Past Medical History: morbid obesity HTN bipolar disorder Social History: [MASKED] Family History: both parents have DM2 Physical Exam: ADMISSION EXAM GEN: well appearing, obese vitals:98.0 PO 141 / 84 L Sitting 83 20 98 RA [MASKED] 363 HEENT: ncat eomi anicteric dry MM chest: b/l ae no w/c/r heart: s1s2 rr no m/r/g abd: +bs, soft, NT, ND ext: no c/c/e 2+pulses neuro: face symmetric, speech fluent psych: calm, cooperative DISCHARGE EXAM: VSS, unchanged from above Pertinent Results: [MASKED] clinic labs [MASKED] WBC 7.4, Hbg/HCT 13.1/40.9, plt 296 MCV 75.9, eos 3.3% chemistries na 135, k 4.3, cl 94, co2 25, bun 13, cr 1, gluc 456 AIC 10.1% urine alb/cr ratio 1735.8 u/a 1+blood, no suggestion of infection INPATIENT LABS: [MASKED] 08:40PM URINE COLOR-Straw APPEAR-Clear SP [MASKED] [MASKED] 08:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-1000 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [MASKED] 06:53PM GLUCOSE-496* UREA N-11 CREAT-1.1 SODIUM-130* POTASSIUM-3.7 CHLORIDE-92* TOTAL CO2-24 ANION GAP-18 [MASKED] 06:53PM estGFR-Using this [MASKED] 06:53PM CALCIUM-9.5 PHOSPHATE-2.9 MAGNESIUM-1.5* [MASKED] 06:53PM WBC-7.5 RBC-5.12 HGB-12.8* HCT-37.1* MCV-73* MCH-25.0* MCHC-34.5 RDW-13.2 RDWSD-33.6* [MASKED] 06:53PM PLT COUNT-[MASKED] y.o man with h.o DM2, HTN who presents with poorly controlled diabetes. #type 2 Diabetes, poorly controlled with hyperglycemia. Last AIC 10.1%. Pt has presented to clinic 3 times this past week with hyperglycemia and reports of medication non-compliance. Outpt providers now concerned about his outpt management regimen and risk of dehydration. Pt states his issue is compliance with timing of medications given his work schedule and hours. He was seen by the [MASKED] team in the hospital and changed to [MASKED] 80 BID from lantus and also continued on an insulin sliding scale. He was also seen by the nutritionist and diabetes educator and instructed to check [MASKED] 3x/day. He was provided with a contact number to call if [MASKED] >400 or <80 #HTN-continued lisinopril #bipolar disorder- continued lamictal and olanzapine Midline placed due to difficult access while hospitalized however this was dc'd at the time of discharge. >30 min were spent on dc related activities Medications on Admission: The Preadmission Medication list is accurate and complete. 1. MetFORMIN (Glucophage) 1000 mg PO BID 2. Lisinopril 20 mg PO DAILY 3. OLANZapine 10 mg PO QHS 4. LamoTRIgine 200 mg PO DAILY Discharge Medications: 1. Humalog [MASKED] 80 Units Breakfast Humalog [MASKED] 80 Units Dinner Insulin SC Sliding Scale using HUM Insulin RX *insulin lispro protamin-lispro [Humalog Mix [MASKED] KwikPen] 100 unit/mL (75-25) AS DIR 80 Units before BKFT; 80 Units before DINR; Disp #*5 Syringe Refills:*0 RX *insulin lispro [Humalog KwikPen] 100 unit/mL AS DIR Up to 30 Units QID per sliding scale Disp #*3 Syringe Refills:*0 2. LamoTRIgine 200 mg PO DAILY 3. Lisinopril 20 mg PO DAILY 4. MetFORMIN (Glucophage) 1000 mg PO BID 5. OLANZapine 10 mg PO QHS Discharge Disposition: Home Discharge Diagnosis: Diabetes, poorly controlled Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr [MASKED], You were admitted to the hospital for high blood sugars. Your sugars improved with an increase in insulin dose. It is very important that you continue to take your insulin and monitor your blood sugars three times a day, before meals, when you leave the hospital. Please call the diabetes doctor at the number provided to you if you have a blood sugar less than 80 or greater than 400. It is very important that you follow up with your primary care doctor and endocrine (diabetes) doctor when you leave the hospital. Please also follow the diabetic diet given to you while in the hospital. It was a pleasure caring for you while you were in the hospital. Followup Instructions: [MASKED] | [
"E1165",
"Z6841",
"I10",
"Z794",
"Z9114",
"E6601",
"F319",
"D509"
] | [
"E1165: Type 2 diabetes mellitus with hyperglycemia",
"Z6841: Body mass index [BMI]40.0-44.9, adult",
"I10: Essential (primary) hypertension",
"Z794: Long term (current) use of insulin",
"Z9114: Patient's other noncompliance with medication regimen",
"E6601: Morbid (severe) obesity due to excess calories",
"F319: Bipolar disorder, unspecified",
"D509: Iron deficiency anemia, unspecified"
] | [
"E1165",
"I10",
"Z794",
"D509"
] | [] |
17,445,690 | 20,765,981 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nchest pain \n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMr. ___ is a ___ w/ PMH of HTN, HLD, Stage IV RCC w/\nhypercalcemia s/p L nephrectomy on ___ transferred from\n___ for pulmonary embolism. He had R-sided chest\npain and shortness of breath, found to have PE. Patient\npresenting after being transferred from ___ for a\nhigh probability VQ scan on heparin drip for PE. Patient states\nthat this morning he woke up with shortness of breath with deep\ninspiration but denies any chest pain, abdominal pain, nausea,\nvomiting. Patient denies any fever, chills but endorses a cough\nfor the last few weeks.\n\nThe patient was admitted ___ for open radical nephrectomy\nand para-aortic lymph node dissection (pT3aN1, margins negative)\nfor large left renal mass and hypercalcemia. Per urology\nconsultation note:\n\"His post-operative course was notable for placement of a right\nsided chest tube intra-operatively due to planned entry of the\npleural cavity to optimize tumor exposure. This was removed on\nPOD1 and his respiratory status remained stable throughout the\ncourse of his hospitalization. The remainder of his post-op\ncourse was relatively uncomplicated and he was discharged in\nstable condition on POD4.\"\n\nIn the ED, initial vitals: \nPain 0 Temp 98.2 HR 81 BP 161/89 RR 16 pO2 97% RA \n \n- Exam notable for: \nGA: Comfortable\nHEENT: No scleral icterus\nCardiovascular: Normal S1, S2, regular rate and rhythm, no\nmurmurs/rubs/gallops, 2+ peripheral pulses bilaterally\nPulmonary: Clear to auscultation bilaterally\nAbdominal: Soft, nontender, nondistended, no masses, fob - brown\nstool\n Lap sites to abdomen and left-sided abdominal incision intact\nwith steristrips, no drainage or s/s infection. \nExtremities: No lower leg edema\nIntegumentary: No rashes noted\n\n- Labs notable for: \nTrop-T <0.01\nCl 109, Bicarb 21, Cr 1.9\nCa 8.3\nproBNP 1757\nH/H 6.8/23.6 (MCV 77), Plt 428\nINR 1.4\n\n- Imaging notable for: \n \n___ CXR\nSmall bilateral pleural effusions. No focal consolidation seen.\n\n- Pt given: \n___ 21:22 IV Heparin ___ 1750 units/hr\n\n- Vitals prior to transfer: \nPain 0 Temp 98.7 HR 77 BP 141/84 RR 16 pO2 96% RA \n\nUpon arrival to the floor, the patient reports the history per\nabove. He describes his new symptoms as R-sided sharp chest pain\nwith inspiration or cough. \n\nREVIEW OF SYSTEMS: \nPositive and negative per HPI. \nAlso endorses pain in LLQ s/p surgery, reduced mobility, chronic\nnonproductive cough for ___ months\nDenies fevers, chills, nausea, constipation, diarrhea, \nhematuria,\nBRBPR, SOB, melena, leg swelling\n \nPast Medical History:\n- HTN\n- HLD\n- Hypercalcemia\n- Anemia\n\n \nSocial History:\n___\nFamily History:\nNo known family history of hematologic\nmalignancy. Mother died today of stroke and lung cancer.\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n======================\nPHYSICAL EXAM: \nVITALS: 98.4 PO 163 / ___ 95 RA \nGeneral: Well-appearing overweight man, lying back in bed, \nAlert,\noriented, no acute distress \nHEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,\nneck supple, JVP not elevated, no JVD, no LAD \nCV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,\ngallops \nLungs: Clear to auscultation bilaterally, no wheezes, rales,\nrhonchi \nAbdomen: Incision along LLQ w/ steri-strips in place, c/d/i,\nSoft, nontender, non-distended, bowel sounds present, no\norganomegaly, no rebound or guarding \nExt: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or\nedema \nSkin: Warm, dry, no rashes or notable lesions. \nNeuro: CNII-XII grossly intact, moving all extremities\nappropriately \n\nDISCHARGE PHYSICAL EXAM:\n======================\n24 HR Data (last updated ___ @ 723)\n Temp: 98.0 (Tm 98.3), BP: 159/84 (129-159/77-95), HR: 74\n(67-86), RR: 16 (___), O2 sat: 96% (96-99), O2 delivery: RA \n\n\nGeneral: Well-appearing overweight man, lying back in bed, \nAlert,\noriented, no acute distress \nHEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,\nneck supple, JVP not elevated, no JVD, no LAD \nCV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,\ngallops \nLungs: Clear to auscultation bilaterally, no wheezes, rales,\nrhonchi \nAbdomen: Incision along LLQ w/ steri-strips in place, c/d/i,\nSoft, nontender, non-distended, bowel sounds present, no\norganomegaly, no rebound or guarding \nExt: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or\nedema \nSkin: Warm, dry, no rashes or notable lesions. \nNeuro: CNII-XII grossly intact, moving all extremities\nappropriately \n\n \nPertinent Results:\nADMISSION LABS:\n==============\n___ 03:20PM WBC-9.6 RBC-3.44* HGB-7.8* HCT-26.5* MCV-77* \nMCH-22.7* MCHC-29.4* RDW-17.3* RDWSD-48.3*\n___ 03:20PM PLT COUNT-453*\n___ 03:20PM PTT-55.7*\n___ 07:51AM GLUCOSE-102* UREA N-12 CREAT-1.9* SODIUM-145 \nPOTASSIUM-3.8 CHLORIDE-110* TOTAL CO2-21* ANION GAP-14\n___ 07:51AM ALBUMIN-2.6* CALCIUM-8.0* PHOSPHATE-3.0 \nMAGNESIUM-1.8\n___ 07:51AM WBC-7.7 RBC-3.16* HGB-7.2* HCT-24.3* MCV-77* \nMCH-22.8* MCHC-29.6* RDW-17.3* RDWSD-48.3*\n___ 07:51AM PLT COUNT-392\n___ 07:51AM ___ PTT-48.2* ___\n___ 07:51AM RET AUT-2.0 ABS RET-0.06\n___ 02:46AM cTropnT-0.01\n___ 02:46AM WBC-7.1 RBC-3.07* HGB-7.0* HCT-23.7* MCV-77* \nMCH-22.8* MCHC-29.5* RDW-17.4* RDWSD-48.6*\n___ 02:46AM PLT COUNT-416*\n___ 12:52AM ___ PTT-40.9* ___\n___ 09:24PM GLUCOSE-94 UREA N-13 CREAT-1.9* SODIUM-144 \nPOTASSIUM-3.6 CHLORIDE-109* TOTAL CO2-21* ANION GAP-14\n___ 09:24PM cTropnT-<0.01\n___ 09:24PM proBNP-1757*\n___ 09:24PM CALCIUM-8.3* PHOSPHATE-2.7 MAGNESIUM-1.9\n___ 09:24PM URINE HOURS-RANDOM\n___ 09:24PM URINE UHOLD-HOLD\n___ 09:24PM WBC-7.8 RBC-3.08* HGB-6.8* HCT-23.6* MCV-77* \nMCH-22.1* MCHC-28.8* RDW-17.4* RDWSD-48.5*\n___ 09:24PM NEUTS-59.2 ___ MONOS-7.4 EOS-5.7 \nBASOS-0.6 IM ___ AbsNeut-4.63 AbsLymp-2.09 AbsMono-0.58 \nAbsEos-0.45 AbsBaso-0.05\n___ 09:24PM PLT COUNT-428*\n___ 09:24PM ___ PTT-35.7 ___\n___ 09:24PM URINE COLOR-Straw APPEAR-Clear SP ___\n___ 09:24PM URINE BLOOD-SM* NITRITE-NEG PROTEIN-30* \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 \nLEUK-NEG\n___ 09:24PM URINE RBC-1 WBC-2 BACTERIA-NONE YEAST-NONE \nEPI-0\n___ 09:24PM URINE HYALINE-1*\n___ 09:24PM URINE MUCOUS-RARE*\n\nIMAGING:\n========\n___ CXR: IMPRESSION: Small bilateral pleural effusions. No \nfocal consolidation seen.\n\n___ LENIs: IMPRESSION: No evidence of deep venous \nthrombosis in the right or left lower extremity veins.\n\n___ TTE: IMPRESSION: Normal biventricular cavity sizes and \nregional/global biventricular systolic function. No valvular \npathology or pathologic flow identified. Indeterminate pulmonary \nartery systolic pressure. EF 57%\n\nMICROBIOLOGY:\n=============\n\nUrine culture ___: No growth final\n\nDISCHARGE LABS:\n===============\n___ 07:10AM BLOOD WBC-8.4 RBC-3.38* Hgb-7.7* Hct-26.3* \nMCV-78* MCH-22.8* MCHC-29.3* RDW-18.1* RDWSD-50.5* Plt ___\n___ 07:10AM BLOOD ___ PTT-77.5* ___\n___ 07:10AM BLOOD Glucose-102* UreaN-10 Creat-1.8* Na-144 \nK-4.1 Cl-108 HCO3-23 AnGap-13\n___ 07:10AM BLOOD Calcium-8.2* Phos-3.2 Mg-1.___ w/ PMH of HTN, HLD, Stage IV RCC w/hypercalcemia s/p L \nnephrectomy on ___ transferred from ___ with \nacute pulmonary embolism.\n\nACUTE/ACTIVE PROBLEMS: \n#Pulmonary embolism, nonsubmassive: \nPatient presented to ___ with right chest pain. He underwent \nV/Q scan with evidence of PE. Given his recent partial \nnephrectomy at ___, he was transferred to ___ for further \nmanagement. His risk factors of increased thrombus formation \ninclude recent surgery and malignancy. LENIs were negative for \nDVT. No troponin bump, BNP elevated but unclear baseline. TTE \nwithout evidence of RV strain. TTE was negative for right heart \ndysfunction. Heparin gtt was continued to bridge to therapeutic \nINR on warfarin. Heparin gtt DC ___. Discharge INR 2.7, \nwarfarin 2.5mg PO daily last dosed ___. Patient remained HD \nstable during hospitalization. \n\nWarfarin dosing:\n___: 5mg INR 1.4\n___: 5mg INR 1.5\n___: 2.5mg INR 2.4\n___: 2.5mg INR 2.7\n\n#Bilateral first toe pain:\nPatient complained on bilateral first toe pain on day of \ndischarge. No warmth or erythema. No history of gout. Pain \nimproved with Tylenol. Plan to discharge with course of Tylenol. \n\n\n#Anemia: hemoglobin on admission 6.8 from 7.5 on ___. Likely \nrelated to RCC and anemia of chronic disease for which he was \ndiagnosed in the past with high ferritin levels. Previously \nnegative for hemolysis. Pt s/p recent surgery but no abdominal \npain or clinical sign to suggest\nhemorrhage in this area. Patient was transfused 1u pRBCs and CBC \nremained stable during rest of hospitalization. Discharge Hgb \n7.7.\n\n#L RCCC Stage IV, s/p L nephrectomy\n# Hypercalcemia \nThe patient was evaluated by urology in the ED and was found to \nnot require urgent urological interventions. Pt with plans to \nfollow up with oncologist re: next steps pending pathology \nresults. Remained stable no interventions or treatments needed. \nCr on discharge 1.8.\n\n# HTN: Initially held antihypertensives. Was able to restart \nhome Metoprolol and amlodipine. Uptitrated amlodipine to 10mg \ndaily. \n\nCHRONIC/STABLE PROBLEMS: \n# HLD: Continued home statin\n\nTRANSITIONAL ISSUES:\n[] New diagnosis of PE: on warfarin with goal INR ___\n[] Will need repeat INR checked on ___ and \nadjust Coumadin accordingly\n[] Consider transitioning in DOAC in next couple of months \npending heme/onc and urology follow up\n[] Consider further evaluation of toe pain if persisting after \ntrial of acetaminophen\n\n#Code status: Full (presumed)\n#Contact\nName of health care proxy: ___ \n___: wife \nPhone number: ___\n\n___ is clinically stable for discharge today. On the \nday of discharge, greater than 30 minutes were spent on the \nplanning, coordination, and communication of discharge. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Atorvastatin 40 mg PO QPM \n2. Metoprolol Succinate XL 50 mg PO DAILY \n3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever \n4. Docusate Sodium 100 mg PO BID \n5. amLODIPine 5 mg PO DAILY \n6. Ferrous Sulfate 325 mg PO EVERY OTHER DAY \n\n \nDischarge Medications:\n1. Warfarin 2.5 mg PO DAILY16 \nRX *warfarin 1 mg 2.5 tablet(s) by mouth daily Disp #*90 Tablet \nRefills:*0 \n2. amLODIPine 10 mg PO DAILY \nRX *amlodipine 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0 \n3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever \n4. Atorvastatin 40 mg PO QPM \n5. Docusate Sodium 100 mg PO BID \n6. Ferrous Sulfate 325 mg PO EVERY OTHER DAY \n7. Metoprolol Succinate XL 50 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS:\n=================\nPulmonary Embolism\n\nSECONDARY DIAGNOSIS:\n===================\nL RCC Stage IV, s/p L nephrectomy with associated hypocalcemia\nAnemia\nHyperlipidemia\nhypertension\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___, \n \nIt was a privilege caring for you at ___. \nPlease see below for more information on your hospitalization. \n \nWHY WERE YOU ADMITTED TO THE HOSPITAL? \n- You had a blood clot in your lung\n \nWHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL? \n- We treated you with blood thiner initially via your IV and we \nthen transitioned you to a PO medication Warfarin (Coumadin) \nwhich you will continue at home\n- You developed toe pain we treated you with Tylenol \n \nWHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? \n- Take all of your medications as prescribed (listed below) \n- Follow up with your doctors as listed below \n- Seek medical attention if you have new or concerning symptoms \nor you develop swelling in your legs, shortness of breath, chest \npain, coughing up blood or palpitations\n\nIt was a pleasure taking part in your care here at ___! \nWe wish you all the best! \n- Your ___ Care Team \n \nFollowup Instructions:\n___\n"
] | Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: chest pain Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is a [MASKED] w/ PMH of HTN, HLD, Stage IV RCC w/ hypercalcemia s/p L nephrectomy on [MASKED] transferred from [MASKED] for pulmonary embolism. He had R-sided chest pain and shortness of breath, found to have PE. Patient presenting after being transferred from [MASKED] for a high probability VQ scan on heparin drip for PE. Patient states that this morning he woke up with shortness of breath with deep inspiration but denies any chest pain, abdominal pain, nausea, vomiting. Patient denies any fever, chills but endorses a cough for the last few weeks. The patient was admitted [MASKED] for open radical nephrectomy and para-aortic lymph node dissection (pT3aN1, margins negative) for large left renal mass and hypercalcemia. Per urology consultation note: "His post-operative course was notable for placement of a right sided chest tube intra-operatively due to planned entry of the pleural cavity to optimize tumor exposure. This was removed on POD1 and his respiratory status remained stable throughout the course of his hospitalization. The remainder of his post-op course was relatively uncomplicated and he was discharged in stable condition on POD4." In the ED, initial vitals: Pain 0 Temp 98.2 HR 81 BP 161/89 RR 16 pO2 97% RA - Exam notable for: GA: Comfortable HEENT: No scleral icterus Cardiovascular: Normal S1, S2, regular rate and rhythm, no murmurs/rubs/gallops, 2+ peripheral pulses bilaterally Pulmonary: Clear to auscultation bilaterally Abdominal: Soft, nontender, nondistended, no masses, fob - brown stool Lap sites to abdomen and left-sided abdominal incision intact with steristrips, no drainage or s/s infection. Extremities: No lower leg edema Integumentary: No rashes noted - Labs notable for: Trop-T <0.01 Cl 109, Bicarb 21, Cr 1.9 Ca 8.3 proBNP 1757 H/H 6.8/23.6 (MCV 77), Plt 428 INR 1.4 - Imaging notable for: [MASKED] CXR Small bilateral pleural effusions. No focal consolidation seen. - Pt given: [MASKED] 21:22 IV Heparin [MASKED] 1750 units/hr - Vitals prior to transfer: Pain 0 Temp 98.7 HR 77 BP 141/84 RR 16 pO2 96% RA Upon arrival to the floor, the patient reports the history per above. He describes his new symptoms as R-sided sharp chest pain with inspiration or cough. REVIEW OF SYSTEMS: Positive and negative per HPI. Also endorses pain in LLQ s/p surgery, reduced mobility, chronic nonproductive cough for [MASKED] months Denies fevers, chills, nausea, constipation, diarrhea, hematuria, BRBPR, SOB, melena, leg swelling Past Medical History: - HTN - HLD - Hypercalcemia - Anemia Social History: [MASKED] Family History: No known family history of hematologic malignancy. Mother died today of stroke and lung cancer. Physical Exam: ADMISSION PHYSICAL EXAM: ====================== PHYSICAL EXAM: VITALS: 98.4 PO 163 / [MASKED] 95 RA General: Well-appearing overweight man, lying back in bed, Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not elevated, no JVD, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Incision along LLQ w/ steri-strips in place, c/d/i, Soft, nontender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: Warm, dry, no rashes or notable lesions. Neuro: CNII-XII grossly intact, moving all extremities appropriately DISCHARGE PHYSICAL EXAM: ====================== 24 HR Data (last updated [MASKED] @ 723) Temp: 98.0 (Tm 98.3), BP: 159/84 (129-159/77-95), HR: 74 (67-86), RR: 16 ([MASKED]), O2 sat: 96% (96-99), O2 delivery: RA General: Well-appearing overweight man, lying back in bed, Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not elevated, no JVD, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Incision along LLQ w/ steri-strips in place, c/d/i, Soft, nontender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: Warm, dry, no rashes or notable lesions. Neuro: CNII-XII grossly intact, moving all extremities appropriately Pertinent Results: ADMISSION LABS: ============== [MASKED] 03:20PM WBC-9.6 RBC-3.44* HGB-7.8* HCT-26.5* MCV-77* MCH-22.7* MCHC-29.4* RDW-17.3* RDWSD-48.3* [MASKED] 03:20PM PLT COUNT-453* [MASKED] 03:20PM PTT-55.7* [MASKED] 07:51AM GLUCOSE-102* UREA N-12 CREAT-1.9* SODIUM-145 POTASSIUM-3.8 CHLORIDE-110* TOTAL CO2-21* ANION GAP-14 [MASKED] 07:51AM ALBUMIN-2.6* CALCIUM-8.0* PHOSPHATE-3.0 MAGNESIUM-1.8 [MASKED] 07:51AM WBC-7.7 RBC-3.16* HGB-7.2* HCT-24.3* MCV-77* MCH-22.8* MCHC-29.6* RDW-17.3* RDWSD-48.3* [MASKED] 07:51AM PLT COUNT-392 [MASKED] 07:51AM [MASKED] PTT-48.2* [MASKED] [MASKED] 07:51AM RET AUT-2.0 ABS RET-0.06 [MASKED] 02:46AM cTropnT-0.01 [MASKED] 02:46AM WBC-7.1 RBC-3.07* HGB-7.0* HCT-23.7* MCV-77* MCH-22.8* MCHC-29.5* RDW-17.4* RDWSD-48.6* [MASKED] 02:46AM PLT COUNT-416* [MASKED] 12:52AM [MASKED] PTT-40.9* [MASKED] [MASKED] 09:24PM GLUCOSE-94 UREA N-13 CREAT-1.9* SODIUM-144 POTASSIUM-3.6 CHLORIDE-109* TOTAL CO2-21* ANION GAP-14 [MASKED] 09:24PM cTropnT-<0.01 [MASKED] 09:24PM proBNP-1757* [MASKED] 09:24PM CALCIUM-8.3* PHOSPHATE-2.7 MAGNESIUM-1.9 [MASKED] 09:24PM URINE HOURS-RANDOM [MASKED] 09:24PM URINE UHOLD-HOLD [MASKED] 09:24PM WBC-7.8 RBC-3.08* HGB-6.8* HCT-23.6* MCV-77* MCH-22.1* MCHC-28.8* RDW-17.4* RDWSD-48.5* [MASKED] 09:24PM NEUTS-59.2 [MASKED] MONOS-7.4 EOS-5.7 BASOS-0.6 IM [MASKED] AbsNeut-4.63 AbsLymp-2.09 AbsMono-0.58 AbsEos-0.45 AbsBaso-0.05 [MASKED] 09:24PM PLT COUNT-428* [MASKED] 09:24PM [MASKED] PTT-35.7 [MASKED] [MASKED] 09:24PM URINE COLOR-Straw APPEAR-Clear SP [MASKED] [MASKED] 09:24PM URINE BLOOD-SM* NITRITE-NEG PROTEIN-30* GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [MASKED] 09:24PM URINE RBC-1 WBC-2 BACTERIA-NONE YEAST-NONE EPI-0 [MASKED] 09:24PM URINE HYALINE-1* [MASKED] 09:24PM URINE MUCOUS-RARE* IMAGING: ======== [MASKED] CXR: IMPRESSION: Small bilateral pleural effusions. No focal consolidation seen. [MASKED] LENIs: IMPRESSION: No evidence of deep venous thrombosis in the right or left lower extremity veins. [MASKED] TTE: IMPRESSION: Normal biventricular cavity sizes and regional/global biventricular systolic function. No valvular pathology or pathologic flow identified. Indeterminate pulmonary artery systolic pressure. EF 57% MICROBIOLOGY: ============= Urine culture [MASKED]: No growth final DISCHARGE LABS: =============== [MASKED] 07:10AM BLOOD WBC-8.4 RBC-3.38* Hgb-7.7* Hct-26.3* MCV-78* MCH-22.8* MCHC-29.3* RDW-18.1* RDWSD-50.5* Plt [MASKED] [MASKED] 07:10AM BLOOD [MASKED] PTT-77.5* [MASKED] [MASKED] 07:10AM BLOOD Glucose-102* UreaN-10 Creat-1.8* Na-144 K-4.1 Cl-108 HCO3-23 AnGap-13 [MASKED] 07:10AM BLOOD Calcium-8.2* Phos-3.2 Mg-1.[MASKED] w/ PMH of HTN, HLD, Stage IV RCC w/hypercalcemia s/p L nephrectomy on [MASKED] transferred from [MASKED] with acute pulmonary embolism. ACUTE/ACTIVE PROBLEMS: #Pulmonary embolism, nonsubmassive: Patient presented to [MASKED] with right chest pain. He underwent V/Q scan with evidence of PE. Given his recent partial nephrectomy at [MASKED], he was transferred to [MASKED] for further management. His risk factors of increased thrombus formation include recent surgery and malignancy. LENIs were negative for DVT. No troponin bump, BNP elevated but unclear baseline. TTE without evidence of RV strain. TTE was negative for right heart dysfunction. Heparin gtt was continued to bridge to therapeutic INR on warfarin. Heparin gtt DC [MASKED]. Discharge INR 2.7, warfarin 2.5mg PO daily last dosed [MASKED]. Patient remained HD stable during hospitalization. Warfarin dosing: [MASKED]: 5mg INR 1.4 [MASKED]: 5mg INR 1.5 [MASKED]: 2.5mg INR 2.4 [MASKED]: 2.5mg INR 2.7 #Bilateral first toe pain: Patient complained on bilateral first toe pain on day of discharge. No warmth or erythema. No history of gout. Pain improved with Tylenol. Plan to discharge with course of Tylenol. #Anemia: hemoglobin on admission 6.8 from 7.5 on [MASKED]. Likely related to RCC and anemia of chronic disease for which he was diagnosed in the past with high ferritin levels. Previously negative for hemolysis. Pt s/p recent surgery but no abdominal pain or clinical sign to suggest hemorrhage in this area. Patient was transfused 1u pRBCs and CBC remained stable during rest of hospitalization. Discharge Hgb 7.7. #L RCCC Stage IV, s/p L nephrectomy # Hypercalcemia The patient was evaluated by urology in the ED and was found to not require urgent urological interventions. Pt with plans to follow up with oncologist re: next steps pending pathology results. Remained stable no interventions or treatments needed. Cr on discharge 1.8. # HTN: Initially held antihypertensives. Was able to restart home Metoprolol and amlodipine. Uptitrated amlodipine to 10mg daily. CHRONIC/STABLE PROBLEMS: # HLD: Continued home statin TRANSITIONAL ISSUES: [] New diagnosis of PE: on warfarin with goal INR [MASKED] [] Will need repeat INR checked on [MASKED] and adjust Coumadin accordingly [] Consider transitioning in DOAC in next couple of months pending heme/onc and urology follow up [] Consider further evaluation of toe pain if persisting after trial of acetaminophen #Code status: Full (presumed) #Contact Name of health care proxy: [MASKED] [MASKED]: wife Phone number: [MASKED] [MASKED] is clinically stable for discharge today. On the day of discharge, greater than 30 minutes were spent on the planning, coordination, and communication of discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 40 mg PO QPM 2. Metoprolol Succinate XL 50 mg PO DAILY 3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 4. Docusate Sodium 100 mg PO BID 5. amLODIPine 5 mg PO DAILY 6. Ferrous Sulfate 325 mg PO EVERY OTHER DAY Discharge Medications: 1. Warfarin 2.5 mg PO DAILY16 RX *warfarin 1 mg 2.5 tablet(s) by mouth daily Disp #*90 Tablet Refills:*0 2. amLODIPine 10 mg PO DAILY RX *amlodipine 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 4. Atorvastatin 40 mg PO QPM 5. Docusate Sodium 100 mg PO BID 6. Ferrous Sulfate 325 mg PO EVERY OTHER DAY 7. Metoprolol Succinate XL 50 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: ================= Pulmonary Embolism SECONDARY DIAGNOSIS: =================== L RCC Stage IV, s/p L nephrectomy with associated hypocalcemia Anemia Hyperlipidemia hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], It was a privilege caring for you at [MASKED]. Please see below for more information on your hospitalization. WHY WERE YOU ADMITTED TO THE HOSPITAL? - You had a blood clot in your lung WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL? - We treated you with blood thiner initially via your IV and we then transitioned you to a PO medication Warfarin (Coumadin) which you will continue at home - You developed toe pain we treated you with Tylenol WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? - Take all of your medications as prescribed (listed below) - Follow up with your doctors as listed below - Seek medical attention if you have new or concerning symptoms or you develop swelling in your legs, shortness of breath, chest pain, coughing up blood or palpitations It was a pleasure taking part in your care here at [MASKED]! We wish you all the best! - Your [MASKED] Care Team Followup Instructions: [MASKED] | [
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"I2699: Other pulmonary embolism without acute cor pulmonale",
"I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease",
"E8351: Hypocalcemia",
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"M79675: Pain in left toe(s)",
"M79674: Pain in right toe(s)",
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10,823,559 | 26,945,936 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: CARDIOTHORACIC\n \nAllergies: \nCeclor\n \nAttending: ___\n \nChief Complaint:\nleft shoulder pain\n\n \nMajor Surgical or Invasive Procedure:\n___\n1. Coronary artery bypass graft x 2. Total arterial\nrevascularization.\n2. Skeletonized left internal mammary artery graft to left\nanterior descending artery.\n3. Left radial artery graft to obtuse marginal artery.\n4. Endoscopy harvesting of the left radial artery.\n\n \nHistory of Present Illness:\n___ year old man who presented with left shoulder pain. ETT \nperformed was abnormal for ischemia during the first stage of \n___ protocol. A cardiac\ncatheterization was performed and he was found to have severe \nmulti-vessel coronary artery disease, including 99% LM disease.\nHe was transferred to ___ for surgical evaluation. Upon\narrival, he is on a Heparin gtt and chest pain free. CT surgery \nwas consulted and surgery was recommended to reduce the pts risk \nof future MI and/or death. \n \nPast Medical History:\nCAD\nType II diabetes\nhypertension\nhyperlipidemia \nDiabetic neuropathy \nAnxiety disorder \n \nSocial History:\n___\nFamily History:\nFamily History: mother with heart disease in her ___\nbrother with PPM\n\n \nPhysical Exam:\nPulse:62 Resp:16 O2 sat: 98%RA\nB/P ___\nHeight: 6'2\" Weight:227#\n\nGeneral:\nSkin: Dry [x] intact [x]\nHEENT: PERRLA [x] EOMI [x]\nNeck: Supple [x] Full ROM [x]\nChest: Lungs clear bilaterally [x]\nHeart: RRR [x] Irregular [] Murmur [] grade ______ \nAbdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds\n+[x]\nExtremities: Warm [x], well-perfused [x] Edema [] _____\nVaricosities: bilateral legs\nNeuro: Grossly intact [x]\nPulses:\nFemoral Right:p Left:p\nDP Right:d Left:d\n___ Right:d Left:d\nRadial Right:p Left:p\n\nCarotid Bruit: Right:- Left:-\nDischarge Exam:\n98.8\nPO 108 / 67 69 18 94 RA \n.\nGeneral: NAD [x] \nNeurological: A/O x3 [x] non-focal [x] \nHEENT: PEERL [] \nCardiovascular: RRR [x] Irregular [] Murmur [] Rub [] \nRespiratory: CTA [x] No resp distress [x]\nGI/Abdomen: Bowel sounds present [x] Soft [x] ND [x] NT [x]\nExtremities: \nRight Upper extremity Warm [] Edema \nLeft Upper extremity Warm [] Edema \nRight Lower extremity Warm [x] Edema trace\nLeft Lower extremity Warm [x] Edema trace\nPulses:\nDP Right: Left:\n___ Right: Left:\nRadial Right: Left:\nSkin/Wounds: Dry [] intact []\nSternal: CDI [x] no erythema or drainage [x]\n Sternum stable [x] Prevena []\nLower extremity: Right [] Left [] CDI []\nUpper extremity: Right [] Left [x] CDI [x]\n\n \nPertinent Results:\nCardiac Catheterization: Date: ___ Place: ___\n99% distal LM\n50% ___ LAD\n100% ___\n50% ___ RCA\nLVEF 60%\nelevated left heart filling pressures \n.\n\n___ 04:22AM BLOOD WBC-7.4 RBC-2.70* Hgb-8.5* Hct-25.9* \nMCV-96 MCH-31.5 MCHC-32.8 RDW-13.2 RDWSD-46.4* Plt ___\n___ 04:46AM BLOOD ___ PTT-23.6* ___\n___ 04:22AM BLOOD Glucose-137* UreaN-17 Creat-1.0 K-4.4\n___ 04:46AM BLOOD Glucose-120* UreaN-14 Creat-1.1 Na-137 \nK-4.4 Cl-99 HCO3-27 AnGap-11\n___ 07:13PM BLOOD ALT-19 AST-15 LD(LDH)-134 AlkPhos-78 \nTotBili-0.3\n___ 04:22AM BLOOD Mg-1.8\n.\nIntra-op TEE ___\nPRE-OPERATIVE STATE: Pre-bypass assessment.\nLeft Atrium ___ Veins: Dilated ___. No spontaneous \necho contrast is seen in the ___.\nEMR 2853-P-IP-OP (O___) Name: ___ MR___: ___ Study \nDate: ___ 13:00:00 p. ___\nRight Atrium (RA)/Interatrial Septum/Inferior Vena Cava (IVC): \nDIlated RA. No spontaneous\necho contrast is seen in the RA/RA appendage. Lipomatous \ninteratrial septum. No atrial septal defect by\n2D/color flow Doppler.\nLeft Ventricle (LV): Normal cavity size. Mild regional systolic \ndysfunction (see schematic).\nRight Ventricle (RV): Normal free wall motion.\nAorta: Normal sinus diameter. Normal ascending diameter. Normal \narch diameter. Normal descending\naorta diameter. No dissection. Simple descending atheroma.\nAortic Valve: Thin/mobile (3) leaflets. No stenosis. No \nregurgitation.\nMitral Valve: Mildly thickened leaflets. Mild [1+] \nregurgitation.\nTricuspid Valve: Normal leaflets. No regurgitation.\nPericardium: No effusion.\nPOST-OP STATE: The post-bypass TEE was performed at 15:37:00. \nSinus rhythm.\nLeft Ventricle: Similar to preoperative findings. Improved \nregional function. Global ejection fraction is\nnormal.\nAorta: Intact. No dissection.\nAortic Valve: No change in aortic valve morphology from \npreoperative state. No change in aortic\nregurgitation.\nMitral Valve: No change in mitral valve morphology from \npreoperative state. No change in valvular\nregurgitation from preoperative state.\nPericardium: No effusion.\nNotification: The surgeon/ proceduralist was notified of the \nfindings at the time of the study.\n.\nTTE ___\nCONCLUSION:\nThe left atrial volume index is moderately increased. The right \natrium is mildly enlarged. There is mild\nsymmetric left ventricular hypertrophy with a normal cavity \nsize. Images are extremely limited, but\nthere is apparent mild regional left ventricular systolic \ndysfunction with septal hypokinesis suggested on\nthe parasternal long-axis views (see schematic) and \npreserved/normal contractility of the remaining\nsegments. Overall left ventricular systolic function is mildly \ndepressed. The visually estimated left\nventricular ejection fraction is 50%. There is no resting left \nventricular outflow tract gradient. The\nright ventricle has mild global free wall hypokinesis. The \naortic sinus is mildly dilated. The aortic arch\ndiameter is normal with a normal descending aorta diameter. The \naortic valve leaflets (?#) appear\nstructurally normal. There is no aortic valve stenosis. There is \ntrace aortic regurgitation. The mitral valve\nleaflets are mildly thickened with no mitral valve prolapse. \nThere is trivial mitral regurgitation. The\npulmonic valve leaflets are normal. The tricuspid valve leaflets \nappear structurally normal. There is\nphysiologic tricuspid regurgitation. The estimated pulmonary \nartery systolic pressure is normal. There is\nno pericardial effusion.\nIMPRESSION: Poor image quality. Probable mild regional left \nventricular systolic dysfunction, c/\nw CAD. If further assessment of LV function is needed, suggest a \ntransesophageal study or a\nrepeat TTE with contrast.\n.\n\n \nBrief Hospital Course:\nPt was admitted ___ and was taken to the operating room on \n___ and underwent CABG x 2 with Dr. ___. Please see \noperative note for full details. Pt tolerated the procedure well \nand was transferred to the CVICU in stable condition for \nrecovery and invasive monitoring. \n \nPt was weaned from sedation, awoke neurologically intact, and \nwas extubated on POD 1. Pt was weaned from inotropic and \nvasopressor support. Beta blocker was initiated and pt was \ndiuresed toward his preoperative weight. Pt remained \nhemodynamically stable and was transferred to the telemetry \nfloor for further recovery. Home Diabetes regimen resumed and \ntitrated. He did have an episode of rapid AFib which converted \nto SR w IV Lopressor and Amiodarone bolus. He will not require \ncoumadin given brevity of AFib. Pt was evaluated by the \nphysical therapy service for assistance with their strength and \nmobility. By the time of discharge on POD 5 pt was ambulating \nfreely, all wounds were healing, and pain was controlled with \noral analgesics. Pt was discharged home in good condition with \nappropriate follow up instructions.\n\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\nAspirin 81 mg PO DAILY \nLipitor 80 mg daily\nFluticasone 50 mcg nasal spray\nGabapentin 800 mg TID\nGlipizide 10 mg daily\nJanuvia 100 mg daily\nLevemir 20 units Q HS\nLisinopril 10 mg daily\nMetformin 1000 mg daily\nZantac 300 mg QHS\nSertraline 150 mg daily\nTerazosin 4 mg daily\nmultivitamin daily\n\n \nDischarge Medications:\n1. Docusate Sodium 100 mg PO BID \nhold for loose stool \nRX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp \n#*60 Tablet Refills:*0 \n2. Furosemide 20 mg PO DAILY Duration: 3 Days \nRX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*3 \nTablet Refills:*0 \n3. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY \nDuration: 6 Months \nRX *isosorbide mononitrate 60 mg 1 tablet(s) by mouth once a day \nDisp #*30 Tablet Refills:*5 \n4. Lidocaine 5% Patch 1 PTCH TD QAM pain \nRX *lidocaine 5 % 1 patch qam Disp #*14 Patch Refills:*0 \n5. Metoprolol Tartrate 25 mg PO TID \nRX *metoprolol tartrate 25 mg 1 tablet(s) by mouth three times a \nday Disp #*90 Tablet Refills:*1 \n6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain: \nmoderate/severe \nRX *oxycodone 5 mg 1 tablet(s) by mouth q4-6h Disp #*60 Tablet \nRefills:*0 \n7. Potassium Chloride 20 mEq PO DAILY Duration: 3 Days \nRX *potassium chloride 20 mEq 1 tablet(s) by mouth once a day \nDisp #*3 Tablet Refills:*0 \n8. Levemir 20 Units Bedtime \n9. Aspirin 81 mg PO DAILY \n10. Atorvastatin 80 mg PO QPM \n11. Fluticasone Propionate NASAL 1 SPRY NU DAILY \n12. Gabapentin 800 mg PO TID \n13. GlipiZIDE 10 mg PO BID \n14. Januvia (SITagliptin) 100 mg oral DAILY \n15. MetFORMIN (Glucophage) 1000 mg PO DAILY \n16. Multivitamins 1 TAB PO DAILY \n17. Ranitidine 300 mg PO QHS \n18. Sertraline 150 mg PO DAILY \n19. Terazosin 4 mg PO QHS \n20. HELD- Lisinopril 10 mg PO DAILY This medication was held. \nDo not restart Lisinopril until directed by Cardiologist or PCP\n\n \n___:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nCAD\nType II diabetes\nhypertension\nhyperlipidemia \nDiabetic neuropathy \nAnxiety disorder \n\n \nDischarge Condition:\nAlert and oriented x3 non-focal \nAmbulating with steady gait\nIncisional pain managed with oxycodone\n\nIncisions: \nSternal - healing well, no erythema or drainage \nLeft Radial artery site c/d/i\nEdema - trace\n\n \nDischarge Instructions:\n Please shower daily including washing incisions gently with \nmild soap, no baths or swimming until cleared by surgeon. Look \nat your incisions daily for redness or drainage\nPlease NO lotions, cream, powder, or ointments to incisions \n Each morning you should weigh yourself and then in the evening \ntake your temperature, these should be written down on the \nchart.\n****call MD if weight goes up more than 3 lbs in 24 hours or 5 \nlbs over 5 days****.\n No driving for approximately one month and while taking \nnarcotics, will be discussed at follow up appointment with \nsurgeon when you will be able to drive \n No lifting more than 10 pounds for 10 weeks\n **Please call cardiac surgery office with any questions or \nconcerns ___. Answering service will contact on call \nperson during off hours**\n\n \nFollowup Instructions:\n___\n"
] | Allergies: Ceclor Chief Complaint: left shoulder pain Major Surgical or Invasive Procedure: [MASKED] 1. Coronary artery bypass graft x 2. Total arterial revascularization. 2. Skeletonized left internal mammary artery graft to left anterior descending artery. 3. Left radial artery graft to obtuse marginal artery. 4. Endoscopy harvesting of the left radial artery. History of Present Illness: [MASKED] year old man who presented with left shoulder pain. ETT performed was abnormal for ischemia during the first stage of [MASKED] protocol. A cardiac catheterization was performed and he was found to have severe multi-vessel coronary artery disease, including 99% LM disease. He was transferred to [MASKED] for surgical evaluation. Upon arrival, he is on a Heparin gtt and chest pain free. CT surgery was consulted and surgery was recommended to reduce the pts risk of future MI and/or death. Past Medical History: CAD Type II diabetes hypertension hyperlipidemia Diabetic neuropathy Anxiety disorder Social History: [MASKED] Family History: Family History: mother with heart disease in her [MASKED] brother with PPM Physical Exam: Pulse:62 Resp:16 O2 sat: 98%RA B/P [MASKED] Height: 6'2" Weight:227# General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade [MASKED] Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds +[x] Extremities: Warm [x], well-perfused [x] Edema [] [MASKED] Varicosities: bilateral legs Neuro: Grossly intact [x] Pulses: Femoral Right:p Left:p DP Right:d Left:d [MASKED] Right:d Left:d Radial Right:p Left:p Carotid Bruit: Right:- Left:- Discharge Exam: 98.8 PO 108 / 67 69 18 94 RA . General: NAD [x] Neurological: A/O x3 [x] non-focal [x] HEENT: PEERL [] Cardiovascular: RRR [x] Irregular [] Murmur [] Rub [] Respiratory: CTA [x] No resp distress [x] GI/Abdomen: Bowel sounds present [x] Soft [x] ND [x] NT [x] Extremities: Right Upper extremity Warm [] Edema Left Upper extremity Warm [] Edema Right Lower extremity Warm [x] Edema trace Left Lower extremity Warm [x] Edema trace Pulses: DP Right: Left: [MASKED] Right: Left: Radial Right: Left: Skin/Wounds: Dry [] intact [] Sternal: CDI [x] no erythema or drainage [x] Sternum stable [x] Prevena [] Lower extremity: Right [] Left [] CDI [] Upper extremity: Right [] Left [x] CDI [x] Pertinent Results: Cardiac Catheterization: Date: [MASKED] Place: [MASKED] 99% distal LM 50% [MASKED] LAD 100% [MASKED] 50% [MASKED] RCA LVEF 60% elevated left heart filling pressures . [MASKED] 04:22AM BLOOD WBC-7.4 RBC-2.70* Hgb-8.5* Hct-25.9* MCV-96 MCH-31.5 MCHC-32.8 RDW-13.2 RDWSD-46.4* Plt [MASKED] [MASKED] 04:46AM BLOOD [MASKED] PTT-23.6* [MASKED] [MASKED] 04:22AM BLOOD Glucose-137* UreaN-17 Creat-1.0 K-4.4 [MASKED] 04:46AM BLOOD Glucose-120* UreaN-14 Creat-1.1 Na-137 K-4.4 Cl-99 HCO3-27 AnGap-11 [MASKED] 07:13PM BLOOD ALT-19 AST-15 LD(LDH)-134 AlkPhos-78 TotBili-0.3 [MASKED] 04:22AM BLOOD Mg-1.8 . Intra-op TEE [MASKED] PRE-OPERATIVE STATE: Pre-bypass assessment. Left Atrium [MASKED] Veins: Dilated [MASKED]. No spontaneous echo contrast is seen in the [MASKED]. EMR 2853-P-IP-OP (O ) Date: [MASKED] 13:00:00 p. [MASKED] Right Atrium (RA)/Interatrial Septum/Inferior Vena Cava (IVC): DIlated RA. No spontaneous echo contrast is seen in the RA/RA appendage. Lipomatous interatrial septum. No atrial septal defect by 2D/color flow Doppler. Left Ventricle (LV): Normal cavity size. Mild regional systolic dysfunction (see schematic). Right Ventricle (RV): Normal free wall motion. Aorta: Normal sinus diameter. Normal ascending diameter. Normal arch diameter. Normal descending aorta diameter. No dissection. Simple descending atheroma. Aortic Valve: Thin/mobile (3) leaflets. No stenosis. No regurgitation. Mitral Valve: Mildly thickened leaflets. Mild [1+] regurgitation. Tricuspid Valve: Normal leaflets. No regurgitation. Pericardium: No effusion. POST-OP STATE: The post-bypass TEE was performed at 15:37:00. Sinus rhythm. Left Ventricle: Similar to preoperative findings. Improved regional function. Global ejection fraction is normal. Aorta: Intact. No dissection. Aortic Valve: No change in aortic valve morphology from preoperative state. No change in aortic regurgitation. Mitral Valve: No change in mitral valve morphology from preoperative state. No change in valvular regurgitation from preoperative state. Pericardium: No effusion. Notification: The surgeon/ proceduralist was notified of the findings at the time of the study. . TTE [MASKED] CONCLUSION: The left atrial volume index is moderately increased. The right atrium is mildly enlarged. There is mild symmetric left ventricular hypertrophy with a normal cavity size. Images are extremely limited, but there is apparent mild regional left ventricular systolic dysfunction with septal hypokinesis suggested on the parasternal long-axis views (see schematic) and preserved/normal contractility of the remaining segments. Overall left ventricular systolic function is mildly depressed. The visually estimated left ventricular ejection fraction is 50%. There is no resting left ventricular outflow tract gradient. The right ventricle has mild global free wall hypokinesis. The aortic sinus is mildly dilated. The aortic arch diameter is normal with a normal descending aorta diameter. The aortic valve leaflets (?#) appear structurally normal. There is no aortic valve stenosis. There is trace aortic regurgitation. The mitral valve leaflets are mildly thickened with no mitral valve prolapse. There is trivial mitral regurgitation. The pulmonic valve leaflets are normal. The tricuspid valve leaflets appear structurally normal. There is physiologic tricuspid regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Poor image quality. Probable mild regional left ventricular systolic dysfunction, c/ w CAD. If further assessment of LV function is needed, suggest a transesophageal study or a repeat TTE with contrast. . Brief Hospital Course: Pt was admitted [MASKED] and was taken to the operating room on [MASKED] and underwent CABG x 2 with Dr. [MASKED]. Please see operative note for full details. Pt tolerated the procedure well and was transferred to the CVICU in stable condition for recovery and invasive monitoring. Pt was weaned from sedation, awoke neurologically intact, and was extubated on POD 1. Pt was weaned from inotropic and vasopressor support. Beta blocker was initiated and pt was diuresed toward his preoperative weight. Pt remained hemodynamically stable and was transferred to the telemetry floor for further recovery. Home Diabetes regimen resumed and titrated. He did have an episode of rapid AFib which converted to SR w IV Lopressor and Amiodarone bolus. He will not require coumadin given brevity of AFib. Pt was evaluated by the physical therapy service for assistance with their strength and mobility. By the time of discharge on POD 5 pt was ambulating freely, all wounds were healing, and pain was controlled with oral analgesics. Pt was discharged home in good condition with appropriate follow up instructions. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. Aspirin 81 mg PO DAILY Lipitor 80 mg daily Fluticasone 50 mcg nasal spray Gabapentin 800 mg TID Glipizide 10 mg daily Januvia 100 mg daily Levemir 20 units Q HS Lisinopril 10 mg daily Metformin 1000 mg daily Zantac 300 mg QHS Sertraline 150 mg daily Terazosin 4 mg daily multivitamin daily Discharge Medications: 1. Docusate Sodium 100 mg PO BID hold for loose stool RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 2. Furosemide 20 mg PO DAILY Duration: 3 Days RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*3 Tablet Refills:*0 3. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY Duration: 6 Months RX *isosorbide mononitrate 60 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*5 4. Lidocaine 5% Patch 1 PTCH TD QAM pain RX *lidocaine 5 % 1 patch qam Disp #*14 Patch Refills:*0 5. Metoprolol Tartrate 25 mg PO TID RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*1 6. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain: moderate/severe RX *oxycodone 5 mg 1 tablet(s) by mouth q4-6h Disp #*60 Tablet Refills:*0 7. Potassium Chloride 20 mEq PO DAILY Duration: 3 Days RX *potassium chloride 20 mEq 1 tablet(s) by mouth once a day Disp #*3 Tablet Refills:*0 8. Levemir 20 Units Bedtime 9. Aspirin 81 mg PO DAILY 10. Atorvastatin 80 mg PO QPM 11. Fluticasone Propionate NASAL 1 SPRY NU DAILY 12. Gabapentin 800 mg PO TID 13. GlipiZIDE 10 mg PO BID 14. Januvia (SITagliptin) 100 mg oral DAILY 15. MetFORMIN (Glucophage) 1000 mg PO DAILY 16. Multivitamins 1 TAB PO DAILY 17. Ranitidine 300 mg PO QHS 18. Sertraline 150 mg PO DAILY 19. Terazosin 4 mg PO QHS 20. HELD- Lisinopril 10 mg PO DAILY This medication was held. Do not restart Lisinopril until directed by Cardiologist or PCP [MASKED]: Home With Service Facility: [MASKED] Discharge Diagnosis: CAD Type II diabetes hypertension hyperlipidemia Diabetic neuropathy Anxiety disorder Discharge Condition: Alert and oriented x3 non-focal Ambulating with steady gait Incisional pain managed with oxycodone Incisions: Sternal - healing well, no erythema or drainage Left Radial artery site c/d/i Edema - trace Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart. ****call MD if weight goes up more than 3 lbs in 24 hours or 5 lbs over 5 days****. No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks **Please call cardiac surgery office with any questions or concerns [MASKED]. Answering service will contact on call person during off hours** Followup Instructions: [MASKED] | [
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"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"D62: Acute posthemorrhagic anemia",
"I2582: Chronic total occlusion of coronary artery",
"Z87891: Personal history of nicotine dependence",
"E1121: Type 2 diabetes mellitus with diabetic nephropathy",
"E1140: Type 2 diabetes mellitus with diabetic neuropathy, unspecified",
"I110: Hypertensive heart disease with heart failure",
"I509: Heart failure, unspecified",
"E7849: Other hyperlipidemia",
"F419: Anxiety disorder, unspecified",
"Z8249: Family history of ischemic heart disease and other diseases of the circulatory system",
"I4891: Unspecified atrial fibrillation",
"Z781: Physical restraint status"
] | [
"I2510",
"D62",
"Z87891",
"I110",
"F419",
"I4891"
] | [] |
16,858,700 | 24,289,554 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nWeakness\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ with PMH recent diagnosis of HIV/AIDS (CD4 10), started on \nARV 3 weeks ago, who presented with severe weakness and fatigue. \n \n He reports that he first initiated his ARVs 3 weeks ago. \nStarted around 2 weeks ago he began noticing what he described \nas severe fatigue. This has progressed since then to the point \nwhere walking to the end of his driveway or stepping into his \nfront door is difficult. He has experienced further weight loss \nin that time from 158 to 150 lb. In terms of his weight loss he \nattributes this mostly to progressive anorexia and has lost most \nof his desire to eat. He feels as if solids no longer go down as \nsmoothly as before but denies any overt dysphagia or feeling of \nfood getting stuck. He has no pain associated with eating. \n He denies any fevers or chills. He does report some drenching \nnight sweats that he first experienced 2 weeks ago. He has not \nhad any night sweats for the past week. He also reports dry \ncough. He feels short of breath with exertion along with fatigue \nbut denies any orthopnea. He also denies chest pain and \ndizziness. \n He has not noticed any blood in his stools or black stools. He \ndenies abdominal pain, nausea/vomiting, constipation, or \ndiarrhea. \n He had a mild sore throat ___ days ago. He had thrush at the \ntime of initial diagnosis but this has since resolved. He has \nnot noticed any swollen glands in his neck or elsewhere. He also \ndenies vision changes, headache, focal weakness, or numbness. \n He presented to the ED after calling the ___ clinic and \nreporting worsening fatigue and weight loss with difficulty \nkeeping food down. He was instructed to present to the ED. \n \n In the ED, initial vital signs were: T 97.0, HR 117, BP 124/78, \n100%RA \n - Exam notable for: per ED: pale conjunctiva, tachycardia, no \nchest pain \n - Labs were notable for WBC 2.6 (8 Bands, 7% ___, Hgb 5.9 \n(7.5 on ___ , AP 454, Alb 2.9, Na 127, Cl 92, HCO3 21, Gluc \n123, Lactate 2.2. \n - Studies performed include Portable CXR which did not reveal \nany acute infection \n - Patient was given: Zosyn + 1L LR \n - Vitals on transfer: 99.1, HR 100, 100/61, 100% \n Upon arrival to the floor, initial vitals were 97.5 103/65 79 \n18 97 ra. Other than his severe fatigue he had no further \ncomplaints. \n \n\n \nPast Medical History:\n 1. Diagnosed ___ with HIV/AIDS, CD4 count of 10 and HIV \nviral load of 524,000 copies per mL \n 2. Weight loss. \n 3. Hypertension and history of recurrent pneumonias. \n 4. He has also had a history of Campylobacter infection in ___ \nand has had an anemia. \n 5. He also has a history of alcohol abuse and gout. \n 6. Hepatitis B core antibody positive \n Past Surgical History: He has had two hernia repairs and wisdom \n \n teeth extraction. \n \nSocial History:\n___\nFamily History:\nnon-contributory \n \nPhysical Exam:\n \nADMISSION PHYSICAL EXAM: \n=========================== \nVital Signs: 97.5 103/65 79 18 97 ra \nGeneral: Alert, oriented, no acute distress but overall \ncachectic and weak appearing \nHEENT: Sclera anicteric, MMM, oropharynx clear without thrush, \nEOMI, PERRL, neck supple, no LAD \nCV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs, \nrubs, gallops \nLungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \nAbdomen: Soft, non-tender, non-distended \nGU: No foley \nExt: Warm, well perfused, no clubbing, cyanosis or edema \nNeuro: CNII-XII intact, ___ strength upper/lower extremities, \ngrossly normal sensation, gait deferred\n\nDISCHARGE PHYSICAL EXAM: \n=========================== \nVS T 98.6 HR 85-100 BP ___ RR ___ SpO2 96-99% RA\nGen: Alert, oriented, NAD but overall cachectic and weak \nappearing \nHEENT: Sclera anicteric, MMM, oropharynx clear without thrush, \nEOMI, PERRL, neck supple, no LAD \nCV: RRR, normal S1 + S2, no murmurs, rubs, gallops \nLungs: CTAB, no wheezes, rales, rhonchi \nAbdomen: Soft, non-tender, non-distended \nGU: No foley \nExt: Clubbing on digits on both hands, warm, well perfused, no \nedema Neuro: CNII-XII intact, ___ strength upper/lower \nextremities, grossly normal sensation, gait deferred. \n \nPertinent Results:\nADMISSION LABS:\n___ 03:08PM BLOOD WBC-2.6* RBC-2.18*# Hgb-5.9* Hct-18.2*# \nMCV-84 MCH-27.1 MCHC-32.4 RDW-19.1* RDWSD-56.7* Plt Ct-78*#\n___ 03:08PM BLOOD Neuts-76* Bands-8* Lymphs-7* Monos-6 \nEos-2 Baso-0 ___ Metas-1* Myelos-0 NRBC-9* AbsNeut-2.18 \nAbsLymp-0.18* AbsMono-0.16* AbsEos-0.05 AbsBaso-0.00*\n___ 03:08PM BLOOD Hypochr-1+ Anisocy-OCCASIONAL Poiklo-1+ \nMacrocy-OCCASIONAL Microcy-OCCASIONAL Polychr-OCCASIONAL \nOvalocy-1+ Tear Dr-1+ Bite-OCCASIONAL\n___ 03:08PM BLOOD Plt Smr-VERY LOW Plt Ct-78*#\n___ 11:28PM BLOOD ___ PTT-30.3 ___\n___ 03:08PM BLOOD Ret Aut-2.5* Abs Ret-0.06\n___ 03:08PM BLOOD Glucose-123* UreaN-27* Creat-0.9 Na-127* \nK-4.6 Cl-92* HCO3-21* AnGap-19\n___ 03:08PM BLOOD ALT-23 AST-14 LD(LDH)-142 AlkPhos-454* \nTotBili-0.7\n___ 03:08PM BLOOD Lipase-24 GGT-97*\n___ 03:08PM BLOOD Albumin-2.9* Calcium-10.3 Phos-4.6* \nMg-1.8 UricAcd-5.5\n___ 03:08PM BLOOD Hapto-302*\n___ 03:08PM BLOOD TSH-3.3\n___ 05:03PM BLOOD Lactate-2.2*\n\nDISCHARGE LABS:\n___ 07:15AM BLOOD WBC-2.0* RBC-2.66* Hgb-7.4* Hct-22.8* \nMCV-86 MCH-27.8 MCHC-32.5 RDW-17.9* RDWSD-54.6* Plt Ct-55*\n___ 07:15AM BLOOD Neuts-72* Bands-9* Lymphs-7* Monos-10 \nEos-0 Baso-0 ___ Myelos-2* NRBC-2* AbsNeut-1.62 \nAbsLymp-0.14* AbsMono-0.20 AbsEos-0.00* AbsBaso-0.00*\n___ 07:15AM BLOOD Plt Smr-VERY LOW Plt Ct-55*\n___ 06:39AM BLOOD ___ PTT-34.2 ___\n___ 07:15AM BLOOD WBC-1.8* Lymph-8* Abs ___ CD3%-71 \nAbs CD3-102* CD4%-12 Abs CD4-17* CD8%-58 Abs CD8-84* \nCD4/CD8-0.21*\n___ 06:39AM BLOOD Glucose-88 UreaN-25* Creat-0.8 Na-128* \nK-4.4 Cl-92* HCO3-26 AnGap-14\n___ 07:15AM BLOOD Calcium-10.2 Phos-3.4 Mg-1.9\n___ 06:39AM BLOOD Ferritn-2914*\n\nIMAGING:\n\nCHEST (PA & LAT) ___:\nIMPRESSION: \n \nNo definite acute cardiopulmonary process.\n\nMICROBIOLOGY:\n\n___ 4:38 pm BLOOD CULTURE\n\n Blood Culture, Routine (Pending): \n\n___ 4:38 pm URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: < 10,000 CFU/mL. \n\n___ 6:35 pm BLOOD CULTURE\n\n Blood Culture, Routine (Pending): \n\n___ 7:15 am BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)\n\n BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. \n\n BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. \n\n\nClose\n___ 7:15 am IMMUNOLOGY\n\n **FINAL REPORT ___\n\nHIV-1 Viral Load/Ultrasensitive (Final ___: \n 350 copies/ml. \nPerformed using the Cobas Ampliprep / Cobas Taqman HIV-1 Test \nv2.0. \nDetection Range: ___ copies/mL. \nThis test is approved for monitoring HIV-1 viral load in known \nHIV-positive patients. It is not approved for diagnosis of acute \nHIV\ninfection. In symptomatic acute HIV infection (acute retroviral \nsyndrome), the viral load is usually very high (>>1000 \ncopies/mL). If acute HIV infection is clinically suspected and \nthere is a detectable but low viral load, please contact the \nlaboratory for interpretation. \nIt is recommended that any NEW positive HIV-1 viral load result, \nin\nthe absence of positive serology, be confirmed by submitting a \nnew sample FOR HIV-1 PCR, in addition to serological testing. \n\n___ 7:03 am Immunology (CMV)\n\n **FINAL REPORT ___\n\n CMV Viral Load (Final ___: \n 1,410 IU/mL. \n Performed by Cobas Ampliprep / Cobas Taqman CMV Test. \n Linear range of quantification: 137 IU/mL - 9,100,000 \nIU/mL. \n Limit of detection 91 IU/mL. \n This test has been verified for use in the ___ patient \npopulation. \n\n___ 7:03 am SEROLOGY/BLOOD CRY ADDED TO ___. \n\n **FINAL REPORT ___\n\n CRYPTOCOCCAL ANTIGEN (Final ___: \n CRYPTOCOCCAL ANTIGEN NOT DETECTED. \n (Reference Range-Negative). \n Test performed by Lateral Flow Assay. \n A negative serum does not rule out localized or \ndisseminated\n cryptococcal infection. \n Appropriate specimens should be sent for culture. \n\n \nBrief Hospital Course:\n___ M with ___ recent diagnosis of HIV/AIDS (CD4 10), started on \nARV 3 weeks ago presenting with severe weakness, fatigue, and \nweight loss now with pancytopenia \n\n# Failure to Thrive/Fatigue: Patient presented with increasing \nweakness, fatigue, and unintentional weight loss (reportedly \n30-lb weight loss in the past six months) associated with \nintermittent night sweats. Patient reports poor appetite. He \ndenies any dysphagia, odynophagia, abdominal pain, or diarrhea. \nDDx includes infection vs poorly controlled HIV vs malignancy. \nHe does not have any risk factors for TB and denies any \nlocalizing symptoms of infection. Clinical presentation not \nconcerning for malabsorptive process. Fatigue probably from \nsymptomatic anemia, Hgb was 5.9 on admission, patient received a \ntotal of 3 units pRBC with improvement in his symptoms. Heme/Onc \nand ID were consulted. Infectious workup notable for EBV and CMV \nviremia, no medical intervention per ID. Patient was evaluated \nby nutrition. He was started on dronabinol for appetite \nstimulation.\n\n# Pancytopenia: Patient previously leukopenic and anemic, \nhowever platelets were previously normal at 166 in ___. With \nregards to his anemia, patient does not appear to be actively \nbleeding and is hemodynamically stable. His reticulocyte \nproduction index (RPI) is about 1% suggesting bone marrow \nsuppression. Hemolysis labs (LDH, haptoglobin, Tbili) not \nsuggestive of hemolysis. With regards to leukopenia, likely due \nto HIV infection. With regards to thrombocytopenia, patient was \nfound to have splenomegaly on recent Abd CT, which may lead to \nplatelet sequestration. Peripheral smear was unremarkable for \nmalignant process. The patient's Bactrim was discontinued and \nreplaced by Atovaquone for PCP ___. Bone marrow biopsy \nwas deferred during hospitalization. CBC was stable at the time \nof discharge. Patient will have close followup with Heme with \nplan for repeat labs next week. \n\n# Hyponatremia: Na 127 on admission. Given poor PO intake, \nlikely hypovolemic hyponatremia. Initially improved with fluids, \nbut Na remained low. Urine Na 94, suggestive if SIADH. He was \ndischarged on a 1.5L fluid restriction.\n\nCHRONIC ISSUES \n\n# HIV/AIDS: CD4 10 at diagnosis, recently initiated on HAART. \n-Continue home emtricitabine-tenofovir (Truvada since Descovy \nnon-formulary), dolutegravir \n\n# Hypertension: Continued home home Losartan \n\nTRANSITIONAL ISSUES:\n-Bactrim discontinued due to bone marrow suppression, replaced \nwith Atovaquone 1500 mg PO PO QDaily\n-Patient discharged on Dronabinol 2.5 mg PO BID for appetite \nstimulation, also nutrition recs for Ensure with meals \n-Patient discharged on 1.5 L fluid restriction for SIADH\n-Patient given prescription for outpatient labs for repeat CBC \nw/diff and Chem 7.\n# CODE: FULL (confirmed with patient) \n# CONTACT: ___ (___)\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Losartan Potassium 100 mg PO DAILY \n2. Dolutegravir 50 mg PO DAILY \n3. emtricitabine-tenofovir alafen 1 TAB PO DAILY \n4. Azithromycin 1200 mg PO 1X/WEEK (TH) \n5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \n\n \nDischarge Medications:\n1. Atovaquone Suspension 1500 mg PO DAILY \nRX *atovaquone 750 mg/5 mL 1500 mg by mouth once a day \nRefills:*3 \n2. Dronabinol 2.5 mg PO BID \nRX *dronabinol 2.5 mg 1 capsule(s) by mouth twice a day Disp \n#*60 Capsule Refills:*1 \n3. Azithromycin 1200 mg PO 1X/WEEK (TH) \n4. Dolutegravir 50 mg PO DAILY \n5. emtricitabine-tenofovir alafen 1 TAB PO DAILY \n6. Losartan Potassium 100 mg PO DAILY \n7.Outpatient Lab Work\nPrescription for Outpatient Labs: ICD-10 Code Pancytopenia \nD61.81. Please draw labs CBC w/ differential, Chem 7. Please \nhave labs done at ___ ___ Floor. \n\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY:\nAnemia\nLeukopenia\nThrombocytopenia\nHuman Immunodeficiency Virus \nHyponatremia\n\nSECONDARY\nHypertension \n\nSECONDARY:\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nIt was a pleasure caring for you at the ___ \n___. As you recall, you were admitted with fatigue \nand weakness. We did test which showed you were anemic, had a \nlow white count and platelets. We gave you blood and your \nsymptoms improved. You felt your low white and red blood cells \nwere due to bone marrow suppression from a medication you were \ntaking called Bactrim, which we discontinued and replaced with a \nmedication called Atovaquone. We did not think you were \nbleeding. You were seen by our nutritionist who recommended \nnutritional supplements and an appetite stimulant called \nDronabinol. Your white blood cells recovered after \ndiscontinuation of Bactrim. Your sodium was also low felt to be \ndue to a condition called syndrome of inappropriate antidiuretic \nhormone (SIADH). We recommend that you restrict your fluid \nintake to 1.5L per day until you have your labs rechecked. We \nwill discharge you with a prescription to have your labs checked \nat ___ ___ floor. Please have \nthese labs done early next week before your planned followup \nappointments. We did not find any infection. Please take your \nmedications as instructed. Please followup with your primary \ncare doctor and other health care providers.\n\nSincerely,\nYour ___ Care Team\n \nFollowup Instructions:\n___\n"
] | Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Weakness Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] with PMH recent diagnosis of HIV/AIDS (CD4 10), started on ARV 3 weeks ago, who presented with severe weakness and fatigue. He reports that he first initiated his ARVs 3 weeks ago. Started around 2 weeks ago he began noticing what he described as severe fatigue. This has progressed since then to the point where walking to the end of his driveway or stepping into his front door is difficult. He has experienced further weight loss in that time from 158 to 150 lb. In terms of his weight loss he attributes this mostly to progressive anorexia and has lost most of his desire to eat. He feels as if solids no longer go down as smoothly as before but denies any overt dysphagia or feeling of food getting stuck. He has no pain associated with eating. He denies any fevers or chills. He does report some drenching night sweats that he first experienced 2 weeks ago. He has not had any night sweats for the past week. He also reports dry cough. He feels short of breath with exertion along with fatigue but denies any orthopnea. He also denies chest pain and dizziness. He has not noticed any blood in his stools or black stools. He denies abdominal pain, nausea/vomiting, constipation, or diarrhea. He had a mild sore throat [MASKED] days ago. He had thrush at the time of initial diagnosis but this has since resolved. He has not noticed any swollen glands in his neck or elsewhere. He also denies vision changes, headache, focal weakness, or numbness. He presented to the ED after calling the [MASKED] clinic and reporting worsening fatigue and weight loss with difficulty keeping food down. He was instructed to present to the ED. In the ED, initial vital signs were: T 97.0, HR 117, BP 124/78, 100%RA - Exam notable for: per ED: pale conjunctiva, tachycardia, no chest pain - Labs were notable for WBC 2.6 (8 Bands, 7% [MASKED], Hgb 5.9 (7.5 on [MASKED] , AP 454, Alb 2.9, Na 127, Cl 92, HCO3 21, Gluc 123, Lactate 2.2. - Studies performed include Portable CXR which did not reveal any acute infection - Patient was given: Zosyn + 1L LR - Vitals on transfer: 99.1, HR 100, 100/61, 100% Upon arrival to the floor, initial vitals were 97.5 103/65 79 18 97 ra. Other than his severe fatigue he had no further complaints. Past Medical History: 1. Diagnosed [MASKED] with HIV/AIDS, CD4 count of 10 and HIV viral load of 524,000 copies per mL 2. Weight loss. 3. Hypertension and history of recurrent pneumonias. 4. He has also had a history of Campylobacter infection in [MASKED] and has had an anemia. 5. He also has a history of alcohol abuse and gout. 6. Hepatitis B core antibody positive Past Surgical History: He has had two hernia repairs and wisdom teeth extraction. Social History: [MASKED] Family History: non-contributory Physical Exam: ADMISSION PHYSICAL EXAM: =========================== Vital Signs: 97.5 103/65 79 18 97 ra General: Alert, oriented, no acute distress but overall cachectic and weak appearing HEENT: Sclera anicteric, MMM, oropharynx clear without thrush, EOMI, PERRL, neck supple, no LAD CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended GU: No foley Ext: Warm, well perfused, no clubbing, cyanosis or edema Neuro: CNII-XII intact, [MASKED] strength upper/lower extremities, grossly normal sensation, gait deferred DISCHARGE PHYSICAL EXAM: =========================== VS T 98.6 HR 85-100 BP [MASKED] RR [MASKED] SpO2 96-99% RA Gen: Alert, oriented, NAD but overall cachectic and weak appearing HEENT: Sclera anicteric, MMM, oropharynx clear without thrush, EOMI, PERRL, neck supple, no LAD CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Lungs: CTAB, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended GU: No foley Ext: Clubbing on digits on both hands, warm, well perfused, no edema Neuro: CNII-XII intact, [MASKED] strength upper/lower extremities, grossly normal sensation, gait deferred. Pertinent Results: ADMISSION LABS: [MASKED] 03:08PM BLOOD WBC-2.6* RBC-2.18*# Hgb-5.9* Hct-18.2*# MCV-84 MCH-27.1 MCHC-32.4 RDW-19.1* RDWSD-56.7* Plt Ct-78*# [MASKED] 03:08PM BLOOD Neuts-76* Bands-8* Lymphs-7* Monos-6 Eos-2 Baso-0 [MASKED] Metas-1* Myelos-0 NRBC-9* AbsNeut-2.18 AbsLymp-0.18* AbsMono-0.16* AbsEos-0.05 AbsBaso-0.00* [MASKED] 03:08PM BLOOD Hypochr-1+ Anisocy-OCCASIONAL Poiklo-1+ Macrocy-OCCASIONAL Microcy-OCCASIONAL Polychr-OCCASIONAL Ovalocy-1+ Tear Dr-1+ Bite-OCCASIONAL [MASKED] 03:08PM BLOOD Plt Smr-VERY LOW Plt Ct-78*# [MASKED] 11:28PM BLOOD [MASKED] PTT-30.3 [MASKED] [MASKED] 03:08PM BLOOD Ret Aut-2.5* Abs Ret-0.06 [MASKED] 03:08PM BLOOD Glucose-123* UreaN-27* Creat-0.9 Na-127* K-4.6 Cl-92* HCO3-21* AnGap-19 [MASKED] 03:08PM BLOOD ALT-23 AST-14 LD(LDH)-142 AlkPhos-454* TotBili-0.7 [MASKED] 03:08PM BLOOD Lipase-24 GGT-97* [MASKED] 03:08PM BLOOD Albumin-2.9* Calcium-10.3 Phos-4.6* Mg-1.8 UricAcd-5.5 [MASKED] 03:08PM BLOOD Hapto-302* [MASKED] 03:08PM BLOOD TSH-3.3 [MASKED] 05:03PM BLOOD Lactate-2.2* DISCHARGE LABS: [MASKED] 07:15AM BLOOD WBC-2.0* RBC-2.66* Hgb-7.4* Hct-22.8* MCV-86 MCH-27.8 MCHC-32.5 RDW-17.9* RDWSD-54.6* Plt Ct-55* [MASKED] 07:15AM BLOOD Neuts-72* Bands-9* Lymphs-7* Monos-10 Eos-0 Baso-0 [MASKED] Myelos-2* NRBC-2* AbsNeut-1.62 AbsLymp-0.14* AbsMono-0.20 AbsEos-0.00* AbsBaso-0.00* [MASKED] 07:15AM BLOOD Plt Smr-VERY LOW Plt Ct-55* [MASKED] 06:39AM BLOOD [MASKED] PTT-34.2 [MASKED] [MASKED] 07:15AM BLOOD WBC-1.8* Lymph-8* Abs [MASKED] CD3%-71 Abs CD3-102* CD4%-12 Abs CD4-17* CD8%-58 Abs CD8-84* CD4/CD8-0.21* [MASKED] 06:39AM BLOOD Glucose-88 UreaN-25* Creat-0.8 Na-128* K-4.4 Cl-92* HCO3-26 AnGap-14 [MASKED] 07:15AM BLOOD Calcium-10.2 Phos-3.4 Mg-1.9 [MASKED] 06:39AM BLOOD Ferritn-2914* IMAGING: CHEST (PA & LAT) [MASKED]: IMPRESSION: No definite acute cardiopulmonary process. MICROBIOLOGY: [MASKED] 4:38 pm BLOOD CULTURE Blood Culture, Routine (Pending): [MASKED] 4:38 pm URINE **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: < 10,000 CFU/mL. [MASKED] 6:35 pm BLOOD CULTURE Blood Culture, Routine (Pending): [MASKED] 7:15 am BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. Close [MASKED] 7:15 am IMMUNOLOGY **FINAL REPORT [MASKED] HIV-1 Viral Load/Ultrasensitive (Final [MASKED]: 350 copies/ml. Performed using the Cobas Ampliprep / Cobas Taqman HIV-1 Test v2.0. Detection Range: [MASKED] copies/mL. This test is approved for monitoring HIV-1 viral load in known HIV-positive patients. It is not approved for diagnosis of acute HIV infection. In symptomatic acute HIV infection (acute retroviral syndrome), the viral load is usually very high (>>1000 copies/mL). If acute HIV infection is clinically suspected and there is a detectable but low viral load, please contact the laboratory for interpretation. It is recommended that any NEW positive HIV-1 viral load result, in the absence of positive serology, be confirmed by submitting a new sample FOR HIV-1 PCR, in addition to serological testing. [MASKED] 7:03 am Immunology (CMV) **FINAL REPORT [MASKED] CMV Viral Load (Final [MASKED]: 1,410 IU/mL. 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 [MASKED] patient population. [MASKED] 7:03 am SEROLOGY/BLOOD CRY ADDED TO [MASKED]. **FINAL REPORT [MASKED] CRYPTOCOCCAL ANTIGEN (Final [MASKED]: CRYPTOCOCCAL ANTIGEN NOT DETECTED. (Reference Range-Negative). Test performed by Lateral Flow Assay. A negative serum does not rule out localized or disseminated cryptococcal infection. Appropriate specimens should be sent for culture. Brief Hospital Course: [MASKED] M with [MASKED] recent diagnosis of HIV/AIDS (CD4 10), started on ARV 3 weeks ago presenting with severe weakness, fatigue, and weight loss now with pancytopenia # Failure to Thrive/Fatigue: Patient presented with increasing weakness, fatigue, and unintentional weight loss (reportedly 30-lb weight loss in the past six months) associated with intermittent night sweats. Patient reports poor appetite. He denies any dysphagia, odynophagia, abdominal pain, or diarrhea. DDx includes infection vs poorly controlled HIV vs malignancy. He does not have any risk factors for TB and denies any localizing symptoms of infection. Clinical presentation not concerning for malabsorptive process. Fatigue probably from symptomatic anemia, Hgb was 5.9 on admission, patient received a total of 3 units pRBC with improvement in his symptoms. Heme/Onc and ID were consulted. Infectious workup notable for EBV and CMV viremia, no medical intervention per ID. Patient was evaluated by nutrition. He was started on dronabinol for appetite stimulation. # Pancytopenia: Patient previously leukopenic and anemic, however platelets were previously normal at 166 in [MASKED]. With regards to his anemia, patient does not appear to be actively bleeding and is hemodynamically stable. His reticulocyte production index (RPI) is about 1% suggesting bone marrow suppression. Hemolysis labs (LDH, haptoglobin, Tbili) not suggestive of hemolysis. With regards to leukopenia, likely due to HIV infection. With regards to thrombocytopenia, patient was found to have splenomegaly on recent Abd CT, which may lead to platelet sequestration. Peripheral smear was unremarkable for malignant process. The patient's Bactrim was discontinued and replaced by Atovaquone for PCP [MASKED]. Bone marrow biopsy was deferred during hospitalization. CBC was stable at the time of discharge. Patient will have close followup with Heme with plan for repeat labs next week. # Hyponatremia: Na 127 on admission. Given poor PO intake, likely hypovolemic hyponatremia. Initially improved with fluids, but Na remained low. Urine Na 94, suggestive if SIADH. He was discharged on a 1.5L fluid restriction. CHRONIC ISSUES # HIV/AIDS: CD4 10 at diagnosis, recently initiated on HAART. -Continue home emtricitabine-tenofovir (Truvada since Descovy non-formulary), dolutegravir # Hypertension: Continued home home Losartan TRANSITIONAL ISSUES: -Bactrim discontinued due to bone marrow suppression, replaced with Atovaquone 1500 mg PO PO QDaily -Patient discharged on Dronabinol 2.5 mg PO BID for appetite stimulation, also nutrition recs for Ensure with meals -Patient discharged on 1.5 L fluid restriction for SIADH -Patient given prescription for outpatient labs for repeat CBC w/diff and Chem 7. # CODE: FULL (confirmed with patient) # CONTACT: [MASKED] ([MASKED]) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Losartan Potassium 100 mg PO DAILY 2. Dolutegravir 50 mg PO DAILY 3. emtricitabine-tenofovir alafen 1 TAB PO DAILY 4. Azithromycin 1200 mg PO 1X/WEEK (TH) 5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY Discharge Medications: 1. Atovaquone Suspension 1500 mg PO DAILY RX *atovaquone 750 mg/5 mL 1500 mg by mouth once a day Refills:*3 2. Dronabinol 2.5 mg PO BID RX *dronabinol 2.5 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*1 3. Azithromycin 1200 mg PO 1X/WEEK (TH) 4. Dolutegravir 50 mg PO DAILY 5. emtricitabine-tenofovir alafen 1 TAB PO DAILY 6. Losartan Potassium 100 mg PO DAILY 7.Outpatient Lab Work Prescription for Outpatient Labs: ICD-10 Code Pancytopenia D61.81. Please draw labs CBC w/ differential, Chem 7. Please have labs done at [MASKED] [MASKED] Floor. Discharge Disposition: Home Discharge Diagnosis: PRIMARY: Anemia Leukopenia Thrombocytopenia Human Immunodeficiency Virus Hyponatremia SECONDARY Hypertension SECONDARY: Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], It was a pleasure caring for you at the [MASKED] [MASKED]. As you recall, you were admitted with fatigue and weakness. We did test which showed you were anemic, had a low white count and platelets. We gave you blood and your symptoms improved. You felt your low white and red blood cells were due to bone marrow suppression from a medication you were taking called Bactrim, which we discontinued and replaced with a medication called Atovaquone. We did not think you were bleeding. You were seen by our nutritionist who recommended nutritional supplements and an appetite stimulant called Dronabinol. Your white blood cells recovered after discontinuation of Bactrim. Your sodium was also low felt to be due to a condition called syndrome of inappropriate antidiuretic hormone (SIADH). We recommend that you restrict your fluid intake to 1.5L per day until you have your labs rechecked. We will discharge you with a prescription to have your labs checked at [MASKED] [MASKED] floor. Please have these labs done early next week before your planned followup appointments. We did not find any infection. Please take your medications as instructed. Please followup with your primary care doctor and other health care providers. Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED] | [
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"B20: Human immunodeficiency virus [HIV] disease",
"R579: Shock, unspecified",
"G92: Toxic encephalopathy",
"E43: Unspecified severe protein-calorie malnutrition",
"D61811: Other drug-induced pancytopenia",
"L89152: Pressure ulcer of sacral region, stage 2",
"E222: Syndrome of inappropriate secretion of antidiuretic hormone",
"D689: Coagulation defect, unspecified",
"R7881: Bacteremia",
"B370: Candidal stomatitis",
"B181: Chronic viral hepatitis B without delta-agent",
"K921: Melena",
"B954: Other streptococcus as the cause of diseases classified elsewhere",
"T370X5A: Adverse effect of sulfonamides, initial encounter",
"Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause",
"E806: Other disorders of bilirubin metabolism",
"E861: Hypovolemia",
"D696: Thrombocytopenia, unspecified",
"R680: Hypothermia, not associated with low environmental temperature",
"E0781: Sick-euthyroid syndrome",
"E860: Dehydration",
"R942: Abnormal results of pulmonary function studies",
"I10: Essential (primary) hypertension",
"E8352: Hypercalcemia",
"K8020: Calculus of gallbladder without cholecystitis without obstruction",
"R627: Adult failure to thrive",
"M270: Developmental disorders of jaws",
"F329: Major depressive disorder, single episode, unspecified",
"Z6823: Body mass index [BMI] 23.0-23.9, adult",
"G629: Polyneuropathy, unspecified",
"R2689: Other abnormalities of gait and mobility",
"Z87891: Personal history of nicotine dependence"
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10,259,430 | 20,410,927 | [
" \nName: ___ ___ No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nTetracycline Analogues / Penicillins / E-Mycin / Amoxicillin\n \nAttending: ___\n \nChief Complaint:\nAbdominal pain\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ y/o female with a history of alcoholic\ncirrhosis, CAD, CVA, COPD, and pancreatitis who presents with\ngeneralized abdominal pain, nausea, and abdominal distension. \n\nPatient was seen in liver clinic this morning for ___. At\nthe appointment, she endorsed abdominal pain and distension. Her\nexam was notable for distended abdomen, tender in the RUQ. \n\nShe was referred to the ED where initial VS were T 98.0, HR 104,\nBP 111/81, RR 18, and O2 99% RA. Exam notable for diffusely\ntender abdomen. Bedside ultrasound without a tappable fluid\ncollection. Labs notable for WBC 7.3, Hgb 11.4 (baseline 13), \nPlt\n167, INR 1.4, Cr 0.8, AG 13, ALT 37, AST 64, Alk phos 115, Tbili\n0.9, Lipase 45, troponin < 0.01, lactate 1.8. UA with 5 WBC, few\nbacteria, small leuks. Blood and urine cultures were drawn. \n\nA CXR showed no acute intrathoracic process. A CTA \nabdomen/pelvis\nshowed no acute intraabdominal abnormality, a cirrhotic liver, \nno\nascites, a 1.9 cm cystic structure in the pancreas tail, and a\nlarge stool burden. EKG was notable for sinus tachycardia. \n\nHepatology was consulted and recommended admission to ET. They\ndid not recommend empiric antibiotics as per ED note. She was\ngiven 500 cc normal saline, morphine 4 mg IV, and Zofran 4 mg \nIV.\n\nUpon arrival to the floor, the patient confirmed the above\nhistory. She adds that this abdominal pain has been intermittent\nfor several months but is acutely worse now. She says it is\nsimilar in quality to the pain during her last admission for\nconstipation. She also endorses nausea without vomiting, low\nappetite, and abdominal distension. She reports her last BM was\nwatery stool yesterday, and her last solid BM was two days ago.\nShe has been taking miralax 4 times per day and lactulose 30 mL\nthree times per day. She denies fevers, chills, and significant\nconfusion. She does endorse increased urinary frequency.\n\n \nPast Medical History:\nEtOH Cirrhosis \ns/p Laparoscopic cholecystectomy ___\nFibromyalgia\nCOPD (chronic obstructive pulmonary disease) (HCC)\nCervical dysplasia\nTobacco dependence\nDrug abuse, episodic use\nHCV (hepatitis C virus)\nAllergic rhinitis\nVitamin D deficiency\nEtOH dependence\nGERD (gastroesophageal reflux disease)\nGeneralized anxiety disorder\nMigraine headache\nCAD (coronary artery disease), possible.\nMacrocytic anemia\nDomestic violence\nLung nodule\nHypopotassemia\nAlcohol withdrawal seizure (HCC)\nHypomagnesemia\nHyponatremia \n \nSocial History:\n___\nFamily History:\nPer scanned document in ___:\nFather deceased with heart disease\nMother with HTN\nBrother, Sister, 2 sons healthy\n1 son died due to overdose\n2 daughters with arthritis\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n=============================================\nVITALS: 98.4, BP 96 / 71, HR 97, RR 18 95 Ra \nGeneral: Alert, oriented x3, appears fatigued \nHEENT: Sclerae anicteric, MMM \nCV: Regular rate and rhythm, normal S1 + S2\nLungs: Clear to auscultation bilaterally, no wheezes, rales,\nrhonchi \nAbdomen: Distended, diffusely tender to palpation, soft \nGU: No foley \nExt: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or\nedema \nSkin: Warm, dry \nNeuro: Normal speech. No asterixis.\n\nDISCHARGE PHYSICAL EXAM:\n=============================================\nVS: 24 HR Data (last updated ___ @ 846)\n Temp: 98.6 (Tm 98.7), BP: 95/61 (93-106/60-72), HR: 82\n(78-87), RR: 18, O2 sat: 95% (94-99), O2 delivery: Ra \nGEN: alert and oriented, in no acute distress\nCV: RRR, no mgr\nLUNGS: CTAB, no wrr\nABD: NABS, soft, nondistended, diffusely mildly tender to deep\npalpation, no rebound/guarding\nEXT: wwp, no edema\nNEURO: alert and oriented, no asterixis\nSKIN: no jaundice, warm, dry\n \nPertinent Results:\nADMISSION LABS:\n=============================================\n___ 09:12PM BLOOD WBC-7.3 RBC-3.46* Hgb-11.4 Hct-33.4* \nMCV-97 MCH-32.9* MCHC-34.1 RDW-15.3 RDWSD-54.4* Plt ___\n___ 09:12PM BLOOD Neuts-52.7 ___ Monos-11.7 Eos-4.4 \nBaso-0.8 Im ___ AbsNeut-3.85 AbsLymp-2.22 AbsMono-0.86* \nAbsEos-0.32 AbsBaso-0.06\n___ 09:12PM BLOOD ___ PTT-32.2 ___\n___ 09:12PM BLOOD Glucose-110* UreaN-13 Creat-0.8 Na-137 \nK-4.4 Cl-102 HCO3-22 AnGap-13\n___ 09:12PM BLOOD ALT-37 AST-64* AlkPhos-115* TotBili-0.9\n___ 09:12PM BLOOD Lipase-45 GGT-77*\n___ 09:12PM BLOOD cTropnT-<0.01\n___ 09:22PM BLOOD Lactate-1.8\n\nDISCHARGE LABS:\n=============================================\n___ 07:25AM BLOOD WBC-7.2 RBC-3.40* Hgb-11.0* Hct-33.0* \nMCV-97 MCH-32.4* MCHC-33.3 RDW-15.5 RDWSD-55.1* Plt ___\n___ 07:25AM BLOOD ___ PTT-33.9 ___\n___ 07:25AM BLOOD Glucose-119* UreaN-11 Creat-0.7 Na-135 \nK-4.0 Cl-102 HCO3-24 AnGap-9*\n___ 07:25AM BLOOD ALT-30 AST-49* LD(LDH)-188 AlkPhos-94 \nTotBili-1.2\n___ 07:30AM BLOOD CK-MB-<1 cTropnT-<0.01\n___ 07:25AM BLOOD Albumin-3.2* Calcium-8.9 Phos-3.5 Mg-2.0\n\nIMAGING:\n=============================================\n\n___ CHEST X-RAY (PA & LAT)\nFINDINGS: \nAP upright and lateral views of the chest provided. There is no \nfocal\nconsolidation, effusion, or pneumothorax. There are no signs of \ncongestion or\nedema. The cardiomediastinal silhouette is normal. Imaged \nosseous structures\nare intact. No free air below the right hemidiaphragm is seen. \nIMPRESSION: \nNo acute intrathoracic process.\n\n___ CTA ABDOMEN & PELVIS\nFINDINGS: \nVASCULAR:\nThere is no abdominal aortic aneurysm. There is mild calcium \nburden in the\nabdominal aorta and great abdominal arteries. There are \nparaesophageal,\nesophageal, perigastric, gastric, gastrohepatic, splenic, and \nmesenteric\nvarices. There is a recanalized paraumbilical vein. There are \nmultiple\nenlarged pelvic veins, a finding which can be seen in pelvic \ncongestion\nsyndrome.\nLOWER CHEST: Minimal atelectasis is noted in the lung bases. \nThere is no\npleural or pericardial effusion.\nABDOMEN:\nHEPATOBILIARY: The liver demonstrates a nodular contour \nsuggestive of\ncirrhotic morphology. There is hypoattenuation of the liver \nthroughout\nsuggestive of hepatic steatosis. There is no evidence of focal \nlesions. There\nis no evidence of intrahepatic biliary dilatation. There is \ndilatation of the\ncommon bile duct measuring up to 1.2 cm likely due to \ncholecystectomy status. \nThe gallbladder is is resected.\nPANCREAS: The pancreas has normal attenuation throughout, \nwithout evidence of\npancreatic ductal dilatation. A lobulated 1.9 x 1.1 cm \nhypoattenuating\nstructure is seen in the pancreatic tail, incompletely \ncharacterized on this\nexam. There is no peripancreatic stranding.\nSPLEEN: The spleen is enlarged measuring 13.5 cm and \ndemonstrates attenuation\nthroughout, without evidence of focal lesions.\nADRENALS: The right and left adrenal glands are normal in size \nand shape.\nURINARY: The kidneys are of normal and symmetric size with \nnormal nephrogram. \nA punctate cortical calcification is seen in the upper pole of \nthe left\nkidney. There is no evidence of stones, focal renal lesions, or\nhydronephrosis. A hypodense lesion in the lower pole of the \nleft kidney is\ncompatible with a simple cyst. There are no urothelial lesions \nin the kidneys\nor ureters. There is no perinephric abnormality.\nGASTROINTESTINAL: Small bowel loops demonstrate normal caliber, \nwall thickness\nand enhancement throughout. Large amount of stool seen within \nthe colon,\notherwise colon and rectum are within normal limits. There is \nno evidence\nabnormal bowel wall enhancement or pneumatosis. There are \nprominent porta\nhepatis lymph nodes measuring up to 0.8 cm, likely reactive. \nThere is\nnonspecific mesenteric stranding, in the right lower quadrant \nand left upper\nquadrant, not significantly changed compared to prior, and \npossibly due to\nmesenteric inflammation or resolving hemorrhage.\nRETROPERITONEUM: There are prominent retroperitoneal lymph nodes \nmeasuring up\nto 1.2 cm, likely reactive.\nPELVIS: The urinary bladder and distal ureters are unremarkable. \n There are\nprominent pelvic lymph nodes which do not meet the CT size \ncriteria for\nlymphadenopathy. No inguinal lymphadenopathy. There is no free \nfluid in the\npelvis.\nREPRODUCTIVE ORGANS: The uterus is unremarkable. No adnexal \nabnormality is\nseen.\nBONES: There is no evidence of worrisome osseous lesions or \nacute fracture. \nMultilevel degenerative changes are seen throughout the \nthoracolumbar spine.\nSOFT TISSUES: An umbilical hernia containing fat is noted.\nIMPRESSION:\n1. No new intra-abdominal abnormality, specifically no evidence \nof bowel\nischemia.\n2. Cirrhotic liver with multiple upper abdominal and mesenteric \nvarices. No\nascites.\n3. Nonspecific mesenteric stranding, in the right lower quadrant \nand left\nupper quadrant, not significantly changed compared to prior, and \npossibly due\nto mesenteric inflammation or resolving hemorrhage.\n4. 1.9 cm cystic structure in the tail the pancreas, likely an \nIPMN, but not\nfully characterized on this exam, recommend nonurgent MRCP for \nfurther\nevaluation.\n5. Large stool burden.\n\nOTHER DIAGNOSTIC TESTS:\n=============================================\n\n___ PHARMACOLOGIC CARDIAC PERFUSION STRESS TEST\nFINDINGS: \nLeft ventricular cavity size is normal.\nRest and stress perfusion images reveal uniform tracer uptake \nthroughout the\nleft ventricular myocardium. \nGated images reveal normal wall motion. \nThe calculated left ventricular ejection fraction is 75%\nNo prior study for comparison.\nIMPRESSION: Normal myocardial perfusion. LV ejection fraction \nof 75%.\nIMPRESSION: No anginal type symptoms or significant ST segment \nchanges.\nAppropriate hemodynamic response to vasodilator stress. \n \nBrief Hospital Course:\nSUMMARY:\n=============================================\nMs. ___ is a ___ y/o female with a history of alcoholic \ncirrhosis, CAD, CVA, COPD, and pancreatitis who presents with \ngeneralized abdominal pain, nausea, and abdominal distension and \nwas found to have large stool burden on CT A/P.\n\nACUTE ISSUES:\n=============================================\n#Acute abdominal pain\n#Chronic IBS\n#Constipation\nThe patient initially presented with abdominal pain and \ndistention. Triple-phase CT large stool burden and cirrhotic \nliver with no ascites. She was started on an aggressive bowel \nregimen including lactulose Q4H, senna BID, polyethylene glycol, \nand bisacodyl PR. She was given oxycodone initially for pain \nwhich was later switched to tramadol. Overnight she did not have \na bowel movement. Thus on HD #2 she was given 1L MoviPrep, after \nwhich she had several large BMs and her abdominal pain improved \nto baseline. She was discharged on a more aggressive bowel \nregimen including double-dose Miralax, Dulcolax, and Mg citrate \nas needed. \n\n#Chest pain\nOn HD #2 the patient admitted to having intermittent chest pain \nfor the past several months, not associated with activity and \nnot always the same type of pain. It occurs throughout the chest \nand extends to the R arm. Given her multiple risk factors \nincluding current smoking, hx of CAD/MI with possible stenting, \nand not on any antiplatelets or statin, the decision was made to \ndo pharmacologic stress testing with pMIBI. The study was \nessentially normal without evidence of ischemia. Additionally, \naspirin 81mg QD and atorvastatin 40mg QD were started (she had \npreviously been on these medications but at some point were \ndiscontinued for unclear reasons). Atorvastatin was started at \nreduced dose given her cirrhosis. Carvedilol was started given \nher history of CAD and likely need for BB. Carvedilol was chosen \nover metoprolol in the setting of cirrhosis and potential \nbenefit in that regard. \n\n#Long QTc\nOn admission ECG the patient was noted to have a QTc of 506 (ECG \nin ___ with QTc 450). The patient was noted to have Zofran \nPRN as a home medication - this was discontinued. Repeat ECG \ncontinued to show prolonged QTc up to 515. She was monitored on \ntelemetry and did not develop any arrhythmias. At discharge she \nwas given a list of medications to avoid and recommended \nCardiology and PCP ___. \n\n#EtOH cirrhosis\nThe patient has a history of alcoholic cirrhosis (Childs C, MELD \n10 on admission). This has been previously complicated by portal \nHTN, recurrent ascites, and hepatic encephalopathy. During her \nhospitalization she was continued on her home medications \nincluding furosemide 60mg QD, spironolactone 100mg QD, rifaximin \n550mg BID, and midodrine 5mg TID. Her lactulose was increased \nfrom 30ml TID at home to 30ml Q4H. Her CT on admission did not \nshow any ascites, thus paracentesis was not performed. She was \ncontinued on a 2g low sodium diet. She did not develop HE during \nthis admission. Her LFTs remained stable. \n\n#Pyuria\nOn admission, the patient was complaining of some urinary \nfrequency. UA was positive for leukocyte esterase. She was \nstarted on CTX 1gm Q24H. However, urine cx came back with mixed \nbacterial flora c/w contamination. The patient reported no \nfurther symptoms. CTX was discontinued after 2 doses. \n\nCHRONIC ISSUES:\n=============================================\n# EtOH use disorder:\nThe patient has a history of alcohol use but reportedly had not \nbeen drinking for the past several months. On admission, AST was \nslightly elevated to 64, ALT 37. She was continued on her home \nmedications of thiamine, folate, and MVI. \n\n# COPD: \nHome albuterol PRN was continued. \n\n# GERD: \nHome omeprazole 40mg QD was continued. \n\n# CVA: \nPt reports history of stroke ___ years ago, no obvious residual \ndeficit. ASA and atorvastatin were started in-house as above. \n\nTRANSITIONAL ISSUES:\n=============================================\n[]Imaging (CT) during this admission shows a likely IPMN, \nrecommend non-urgent MRCP for further evaluation\n[]She will need to continue ___ with Hepatology for her \ncirrhosis. She has seen Dr. ___ in the past. \n[]She will likely need Cardiology ___ as an outpatient \ngiven her hx CAD and chest pain. She should also get a repeat \nECG given her newly prolonged QT, and further evaluation as \nneeded. Will defer to PCP for ___ referral. \n[]She was started on carvedilol and a statin was restarted this \nadmission for hx CAD and cirrhosis. Defer to PCP for \ncontinuation of this medication. \n[]Last screening RUQUS for ___ normal on ___. Needs screening \nQ6months.\n[]New constipation regimen:\n- Lactulose 30mg TID\n- Polyethylene glycol ___ PO BID or more as needed\n- Bisacodyl 10mg daily\n- Magnesium citrate if above regimen fails (no BM for >=1 day or \nabdominal distention)\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Lactulose 30 mL PO TID \n2. Furosemide 60 mg PO DAILY \n3. Polyethylene Glycol 17 g PO BID \n4. Omeprazole 40 mg PO DAILY \n5. Rifaximin 550 mg PO BID \n6. Ondansetron 4 mg PO Q8H:PRN nausea \n7. Thiamine 100 mg PO DAILY \n8. Potassium Chloride 40 mEq PO DAILY \n9. Multivitamins W/minerals 1 TAB PO DAILY \n10. Magnesium Oxide 400 mg PO BID \n11. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/wheezing \n12. Midodrine 5 mg PO TID \n13. Spironolactone 100 mg PO DAILY \n\n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \nRX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0 \n2. Atorvastatin 40 mg PO QPM \nRX *atorvastatin 40 mg 1 tablet(s) by mouth at night Disp #*30 \nTablet Refills:*0 \n3. CARVedilol 3.125 mg PO BID \nRX *carvedilol 3.125 mg 1 tablet(s) by mouth twice daily Disp \n#*60 Tablet Refills:*0 \n4. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily \nDisp #*60 Capsule Refills:*0 \n5. Magnesium Citrate 300 mL PO ONCE Duration: 1 Dose \nRX *magnesium citrate 300 ml by mouth once Refills:*0 \n6. Senna 8.6 mg PO BID \nRX *sennosides [senna] 8.6 mg 1 tab by mouth twice daily Disp \n#*60 Tablet Refills:*0 \n7. Simethicone 40-80 mg PO QID:PRN bloating \nRX *simethicone 40 mg/0.6 mL ___ drops by mouth four times daily \nRefills:*0 \n8. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/wheezing \n9. Furosemide 60 mg PO DAILY \n10. Lactulose 30 mL PO TID \n11. Magnesium Oxide 400 mg PO BID \n12. Midodrine 5 mg PO TID \n13. Multivitamins W/minerals 1 TAB PO DAILY \n14. Omeprazole 40 mg PO DAILY \n15. Polyethylene Glycol 17 g PO BID \n16. Rifaximin 550 mg PO BID \n17. Spironolactone 100 mg PO DAILY \n18. Thiamine 100 mg PO DAILY \n19. HELD- Potassium Chloride 40 mEq PO DAILY This medication \nwas held. Do not restart Potassium Chloride until your doctor \nsays it is needed\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY:\n#Constipation\n\nSECONDARY:\n#Irritable bowel syndrome\n#Coronary artery disease\n#Alcoholic cirrhosis\n#Gastroesophageal reflux disease\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear,\n\nYou were admitted to the hospital because you had abdominal pain \nand constipation. \n\nWHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?\n- You had a CT scan of the belly which showed lots of stool in \nthe bowels. \n- You were given several medications to move the bowels.\n- You had a stress test of the heart which was normal.\n- You improved and were ready to leave the hospital.\n\nWHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?\n- Take all of your medications as prescribed (listed below)\n- Keep your follow up appointments with your doctors\n- Weigh yourself every morning, before you eat or take your \nmedications. Call your doctor if your weight changes by more \nthan 3 pounds\n- Please stick to a low salt diet and monitor your fluid intake\n- If you experience any of the danger signs listed below please \ncall your primary care doctor or come to the emergency \ndepartment immediately.\n\nTake the following constipation medications:\n- Lactulose 30mg three times daily\n- Polyethylene glycol 34g (2 caps) twice daily. Mix well in \n___ oz water and let sit for a few minutes before drinking.\n- Bisacodyl 10mg daily\n\nIf you do not have a bowel movement:\n- Drink 1 bottle of magnesium citrate (buy over the counter at \nany pharmacy)\n\nIt was a pleasure participating in your care. We wish you the \nbest!\n- Your ___ Care Team\n\n \nFollowup Instructions:\n___\n"
] | Allergies: Tetracycline Analogues / Penicillins / E-Mycin / Amoxicillin Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] y/o female with a history of alcoholic cirrhosis, CAD, CVA, COPD, and pancreatitis who presents with generalized abdominal pain, nausea, and abdominal distension. Patient was seen in liver clinic this morning for [MASKED]. At the appointment, she endorsed abdominal pain and distension. Her exam was notable for distended abdomen, tender in the RUQ. She was referred to the ED where initial VS were T 98.0, HR 104, BP 111/81, RR 18, and O2 99% RA. Exam notable for diffusely tender abdomen. Bedside ultrasound without a tappable fluid collection. Labs notable for WBC 7.3, Hgb 11.4 (baseline 13), Plt 167, INR 1.4, Cr 0.8, AG 13, ALT 37, AST 64, Alk phos 115, Tbili 0.9, Lipase 45, troponin < 0.01, lactate 1.8. UA with 5 WBC, few bacteria, small leuks. Blood and urine cultures were drawn. A CXR showed no acute intrathoracic process. A CTA abdomen/pelvis showed no acute intraabdominal abnormality, a cirrhotic liver, no ascites, a 1.9 cm cystic structure in the pancreas tail, and a large stool burden. EKG was notable for sinus tachycardia. Hepatology was consulted and recommended admission to ET. They did not recommend empiric antibiotics as per ED note. She was given 500 cc normal saline, morphine 4 mg IV, and Zofran 4 mg IV. Upon arrival to the floor, the patient confirmed the above history. She adds that this abdominal pain has been intermittent for several months but is acutely worse now. She says it is similar in quality to the pain during her last admission for constipation. She also endorses nausea without vomiting, low appetite, and abdominal distension. She reports her last BM was watery stool yesterday, and her last solid BM was two days ago. She has been taking miralax 4 times per day and lactulose 30 mL three times per day. She denies fevers, chills, and significant confusion. She does endorse increased urinary frequency. Past Medical History: EtOH Cirrhosis s/p Laparoscopic cholecystectomy [MASKED] Fibromyalgia COPD (chronic obstructive pulmonary disease) (HCC) Cervical dysplasia Tobacco dependence Drug abuse, episodic use HCV (hepatitis C virus) Allergic rhinitis Vitamin D deficiency EtOH dependence GERD (gastroesophageal reflux disease) Generalized anxiety disorder Migraine headache CAD (coronary artery disease), possible. Macrocytic anemia Domestic violence Lung nodule Hypopotassemia Alcohol withdrawal seizure (HCC) Hypomagnesemia Hyponatremia Social History: [MASKED] Family History: Per scanned document in [MASKED]: Father deceased with heart disease Mother with HTN Brother, Sister, 2 sons healthy 1 son died due to overdose 2 daughters with arthritis Physical Exam: ADMISSION PHYSICAL EXAM: ============================================= VITALS: 98.4, BP 96 / 71, HR 97, RR 18 95 Ra General: Alert, oriented x3, appears fatigued HEENT: Sclerae anicteric, MMM CV: Regular rate and rhythm, normal S1 + S2 Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Distended, diffusely tender to palpation, soft GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: Warm, dry Neuro: Normal speech. No asterixis. DISCHARGE PHYSICAL EXAM: ============================================= VS: 24 HR Data (last updated [MASKED] @ 846) Temp: 98.6 (Tm 98.7), BP: 95/61 (93-106/60-72), HR: 82 (78-87), RR: 18, O2 sat: 95% (94-99), O2 delivery: Ra GEN: alert and oriented, in no acute distress CV: RRR, no mgr LUNGS: CTAB, no wrr ABD: NABS, soft, nondistended, diffusely mildly tender to deep palpation, no rebound/guarding EXT: wwp, no edema NEURO: alert and oriented, no asterixis SKIN: no jaundice, warm, dry Pertinent Results: ADMISSION LABS: ============================================= [MASKED] 09:12PM BLOOD WBC-7.3 RBC-3.46* Hgb-11.4 Hct-33.4* MCV-97 MCH-32.9* MCHC-34.1 RDW-15.3 RDWSD-54.4* Plt [MASKED] [MASKED] 09:12PM BLOOD Neuts-52.7 [MASKED] Monos-11.7 Eos-4.4 Baso-0.8 Im [MASKED] AbsNeut-3.85 AbsLymp-2.22 AbsMono-0.86* AbsEos-0.32 AbsBaso-0.06 [MASKED] 09:12PM BLOOD [MASKED] PTT-32.2 [MASKED] [MASKED] 09:12PM BLOOD Glucose-110* UreaN-13 Creat-0.8 Na-137 K-4.4 Cl-102 HCO3-22 AnGap-13 [MASKED] 09:12PM BLOOD ALT-37 AST-64* AlkPhos-115* TotBili-0.9 [MASKED] 09:12PM BLOOD Lipase-45 GGT-77* [MASKED] 09:12PM BLOOD cTropnT-<0.01 [MASKED] 09:22PM BLOOD Lactate-1.8 DISCHARGE LABS: ============================================= [MASKED] 07:25AM BLOOD WBC-7.2 RBC-3.40* Hgb-11.0* Hct-33.0* MCV-97 MCH-32.4* MCHC-33.3 RDW-15.5 RDWSD-55.1* Plt [MASKED] [MASKED] 07:25AM BLOOD [MASKED] PTT-33.9 [MASKED] [MASKED] 07:25AM BLOOD Glucose-119* UreaN-11 Creat-0.7 Na-135 K-4.0 Cl-102 HCO3-24 AnGap-9* [MASKED] 07:25AM BLOOD ALT-30 AST-49* LD(LDH)-188 AlkPhos-94 TotBili-1.2 [MASKED] 07:30AM BLOOD CK-MB-<1 cTropnT-<0.01 [MASKED] 07:25AM BLOOD Albumin-3.2* Calcium-8.9 Phos-3.5 Mg-2.0 IMAGING: ============================================= [MASKED] CHEST X-RAY (PA & LAT) FINDINGS: AP upright and lateral views of the chest provided. There is no focal consolidation, effusion, or pneumothorax. There are no signs of congestion or edema. The cardiomediastinal silhouette is normal. Imaged osseous structures are intact. No free air below the right hemidiaphragm is seen. IMPRESSION: No acute intrathoracic process. [MASKED] CTA ABDOMEN & PELVIS FINDINGS: VASCULAR: There is no abdominal aortic aneurysm. There is mild calcium burden in the abdominal aorta and great abdominal arteries. There are paraesophageal, esophageal, perigastric, gastric, gastrohepatic, splenic, and mesenteric varices. There is a recanalized paraumbilical vein. There are multiple enlarged pelvic veins, a finding which can be seen in pelvic congestion syndrome. LOWER CHEST: Minimal atelectasis is noted in the lung bases. There is no pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates a nodular contour suggestive of cirrhotic morphology. There is hypoattenuation of the liver throughout suggestive of hepatic steatosis. There is no evidence of focal lesions. There is no evidence of intrahepatic biliary dilatation. There is dilatation of the common bile duct measuring up to 1.2 cm likely due to cholecystectomy status. The gallbladder is is resected. PANCREAS: The pancreas has normal attenuation throughout, without evidence of pancreatic ductal dilatation. A lobulated 1.9 x 1.1 cm hypoattenuating structure is seen in the pancreatic tail, incompletely characterized on this exam. There is no peripancreatic stranding. SPLEEN: The spleen is enlarged measuring 13.5 cm and demonstrates attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. A punctate cortical calcification is seen in the upper pole of the left kidney. There is no evidence of stones, focal renal lesions, or hydronephrosis. A hypodense lesion in the lower pole of the left kidney is compatible with a simple cyst. There are no urothelial lesions in the kidneys or ureters. There is no perinephric abnormality. GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall thickness and enhancement throughout. Large amount of stool seen within the colon, otherwise colon and rectum are within normal limits. There is no evidence abnormal bowel wall enhancement or pneumatosis. There are prominent porta hepatis lymph nodes measuring up to 0.8 cm, likely reactive. There is nonspecific mesenteric stranding, in the right lower quadrant and left upper quadrant, not significantly changed compared to prior, and possibly due to mesenteric inflammation or resolving hemorrhage. RETROPERITONEUM: There are prominent retroperitoneal lymph nodes measuring up to 1.2 cm, likely reactive. PELVIS: The urinary bladder and distal ureters are unremarkable. There are prominent pelvic lymph nodes which do not meet the CT size criteria for lymphadenopathy. No inguinal lymphadenopathy. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The uterus is unremarkable. No adnexal abnormality is seen. BONES: There is no evidence of worrisome osseous lesions or acute fracture. Multilevel degenerative changes are seen throughout the thoracolumbar spine. SOFT TISSUES: An umbilical hernia containing fat is noted. IMPRESSION: 1. No new intra-abdominal abnormality, specifically no evidence of bowel ischemia. 2. Cirrhotic liver with multiple upper abdominal and mesenteric varices. No ascites. 3. Nonspecific mesenteric stranding, in the right lower quadrant and left upper quadrant, not significantly changed compared to prior, and possibly due to mesenteric inflammation or resolving hemorrhage. 4. 1.9 cm cystic structure in the tail the pancreas, likely an IPMN, but not fully characterized on this exam, recommend nonurgent MRCP for further evaluation. 5. Large stool burden. OTHER DIAGNOSTIC TESTS: ============================================= [MASKED] PHARMACOLOGIC CARDIAC PERFUSION STRESS TEST FINDINGS: Left ventricular cavity size is normal. Rest and stress perfusion images reveal uniform tracer uptake throughout the left ventricular myocardium. Gated images reveal normal wall motion. The calculated left ventricular ejection fraction is 75% No prior study for comparison. IMPRESSION: Normal myocardial perfusion. LV ejection fraction of 75%. IMPRESSION: No anginal type symptoms or significant ST segment changes. Appropriate hemodynamic response to vasodilator stress. Brief Hospital Course: SUMMARY: ============================================= Ms. [MASKED] is a [MASKED] y/o female with a history of alcoholic cirrhosis, CAD, CVA, COPD, and pancreatitis who presents with generalized abdominal pain, nausea, and abdominal distension and was found to have large stool burden on CT A/P. ACUTE ISSUES: ============================================= #Acute abdominal pain #Chronic IBS #Constipation The patient initially presented with abdominal pain and distention. Triple-phase CT large stool burden and cirrhotic liver with no ascites. She was started on an aggressive bowel regimen including lactulose Q4H, senna BID, polyethylene glycol, and bisacodyl PR. She was given oxycodone initially for pain which was later switched to tramadol. Overnight she did not have a bowel movement. Thus on HD #2 she was given 1L MoviPrep, after which she had several large BMs and her abdominal pain improved to baseline. She was discharged on a more aggressive bowel regimen including double-dose Miralax, Dulcolax, and Mg citrate as needed. #Chest pain On HD #2 the patient admitted to having intermittent chest pain for the past several months, not associated with activity and not always the same type of pain. It occurs throughout the chest and extends to the R arm. Given her multiple risk factors including current smoking, hx of CAD/MI with possible stenting, and not on any antiplatelets or statin, the decision was made to do pharmacologic stress testing with pMIBI. The study was essentially normal without evidence of ischemia. Additionally, aspirin 81mg QD and atorvastatin 40mg QD were started (she had previously been on these medications but at some point were discontinued for unclear reasons). Atorvastatin was started at reduced dose given her cirrhosis. Carvedilol was started given her history of CAD and likely need for BB. Carvedilol was chosen over metoprolol in the setting of cirrhosis and potential benefit in that regard. #Long QTc On admission ECG the patient was noted to have a QTc of 506 (ECG in [MASKED] with QTc 450). The patient was noted to have Zofran PRN as a home medication - this was discontinued. Repeat ECG continued to show prolonged QTc up to 515. She was monitored on telemetry and did not develop any arrhythmias. At discharge she was given a list of medications to avoid and recommended Cardiology and PCP [MASKED]. #EtOH cirrhosis The patient has a history of alcoholic cirrhosis (Childs C, MELD 10 on admission). This has been previously complicated by portal HTN, recurrent ascites, and hepatic encephalopathy. During her hospitalization she was continued on her home medications including furosemide 60mg QD, spironolactone 100mg QD, rifaximin 550mg BID, and midodrine 5mg TID. Her lactulose was increased from 30ml TID at home to 30ml Q4H. Her CT on admission did not show any ascites, thus paracentesis was not performed. She was continued on a 2g low sodium diet. She did not develop HE during this admission. Her LFTs remained stable. #Pyuria On admission, the patient was complaining of some urinary frequency. UA was positive for leukocyte esterase. She was started on CTX 1gm Q24H. However, urine cx came back with mixed bacterial flora c/w contamination. The patient reported no further symptoms. CTX was discontinued after 2 doses. CHRONIC ISSUES: ============================================= # EtOH use disorder: The patient has a history of alcohol use but reportedly had not been drinking for the past several months. On admission, AST was slightly elevated to 64, ALT 37. She was continued on her home medications of thiamine, folate, and MVI. # COPD: Home albuterol PRN was continued. # GERD: Home omeprazole 40mg QD was continued. # CVA: Pt reports history of stroke [MASKED] years ago, no obvious residual deficit. ASA and atorvastatin were started in-house as above. TRANSITIONAL ISSUES: ============================================= []Imaging (CT) during this admission shows a likely IPMN, recommend non-urgent MRCP for further evaluation []She will need to continue [MASKED] with Hepatology for her cirrhosis. She has seen Dr. [MASKED] in the past. []She will likely need Cardiology [MASKED] as an outpatient given her hx CAD and chest pain. She should also get a repeat ECG given her newly prolonged QT, and further evaluation as needed. Will defer to PCP for [MASKED] referral. []She was started on carvedilol and a statin was restarted this admission for hx CAD and cirrhosis. Defer to PCP for continuation of this medication. []Last screening RUQUS for [MASKED] normal on [MASKED]. Needs screening Q6months. []New constipation regimen: - Lactulose 30mg TID - Polyethylene glycol [MASKED] PO BID or more as needed - Bisacodyl 10mg daily - Magnesium citrate if above regimen fails (no BM for >=1 day or abdominal distention) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lactulose 30 mL PO TID 2. Furosemide 60 mg PO DAILY 3. Polyethylene Glycol 17 g PO BID 4. Omeprazole 40 mg PO DAILY 5. Rifaximin 550 mg PO BID 6. Ondansetron 4 mg PO Q8H:PRN nausea 7. Thiamine 100 mg PO DAILY 8. Potassium Chloride 40 mEq PO DAILY 9. Multivitamins W/minerals 1 TAB PO DAILY 10. Magnesium Oxide 400 mg PO BID 11. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/wheezing 12. Midodrine 5 mg PO TID 13. Spironolactone 100 mg PO DAILY 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 40 mg PO QPM RX *atorvastatin 40 mg 1 tablet(s) by mouth at night Disp #*30 Tablet Refills:*0 3. CARVedilol 3.125 mg PO BID RX *carvedilol 3.125 mg 1 tablet(s) by mouth twice daily Disp #*60 Tablet Refills:*0 4. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily Disp #*60 Capsule Refills:*0 5. Magnesium Citrate 300 mL PO ONCE Duration: 1 Dose RX *magnesium citrate 300 ml by mouth once Refills:*0 6. Senna 8.6 mg PO BID RX *sennosides [senna] 8.6 mg 1 tab by mouth twice daily Disp #*60 Tablet Refills:*0 7. Simethicone 40-80 mg PO QID:PRN bloating RX *simethicone 40 mg/0.6 mL [MASKED] drops by mouth four times daily Refills:*0 8. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/wheezing 9. Furosemide 60 mg PO DAILY 10. Lactulose 30 mL PO TID 11. Magnesium Oxide 400 mg PO BID 12. Midodrine 5 mg PO TID 13. Multivitamins W/minerals 1 TAB PO DAILY 14. Omeprazole 40 mg PO DAILY 15. Polyethylene Glycol 17 g PO BID 16. Rifaximin 550 mg PO BID 17. Spironolactone 100 mg PO DAILY 18. Thiamine 100 mg PO DAILY 19. HELD- Potassium Chloride 40 mEq PO DAILY This medication was held. Do not restart Potassium Chloride until your doctor says it is needed Discharge Disposition: Home Discharge Diagnosis: PRIMARY: #Constipation SECONDARY: #Irritable bowel syndrome #Coronary artery disease #Alcoholic cirrhosis #Gastroesophageal reflux disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear, You were admitted to the hospital because you had abdominal pain and constipation. WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL? - You had a CT scan of the belly which showed lots of stool in the bowels. - You were given several medications to move the bowels. - You had a stress test of the heart which was normal. - You improved and were ready to leave the hospital. WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? - Take all of your medications as prescribed (listed below) - Keep your follow up appointments with your doctors - Weigh yourself every morning, before you eat or take your medications. Call your doctor if your weight changes by more than 3 pounds - Please stick to a low salt diet and monitor your fluid intake - If you experience any of the danger signs listed below please call your primary care doctor or come to the emergency department immediately. Take the following constipation medications: - Lactulose 30mg three times daily - Polyethylene glycol 34g (2 caps) twice daily. Mix well in [MASKED] oz water and let sit for a few minutes before drinking. - Bisacodyl 10mg daily If you do not have a bowel movement: - Drink 1 bottle of magnesium citrate (buy over the counter at any pharmacy) It was a pleasure participating in your care. We wish you the best! - Your [MASKED] Care Team Followup Instructions: [MASKED] | [
"K5900",
"K589",
"I2510",
"K7030",
"K219",
"J449",
"Z8673",
"R079",
"R9431",
"F1021",
"Z23",
"K766",
"B1920",
"M797",
"E8342",
"E559",
"Z8719",
"F17200",
"I252"
] | [
"K5900: Constipation, unspecified",
"K589: Irritable bowel syndrome without diarrhea",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"K7030: Alcoholic cirrhosis of liver without ascites",
"K219: Gastro-esophageal reflux disease without esophagitis",
"J449: Chronic obstructive pulmonary disease, unspecified",
"Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits",
"R079: Chest pain, unspecified",
"R9431: Abnormal electrocardiogram [ECG] [EKG]",
"F1021: Alcohol dependence, in remission",
"Z23: Encounter for immunization",
"K766: Portal hypertension",
"B1920: Unspecified viral hepatitis C without hepatic coma",
"M797: Fibromyalgia",
"E8342: Hypomagnesemia",
"E559: Vitamin D deficiency, unspecified",
"Z8719: Personal history of other diseases of the digestive system",
"F17200: Nicotine dependence, unspecified, uncomplicated",
"I252: Old myocardial infarction"
] | [
"K5900",
"I2510",
"K219",
"J449",
"Z8673",
"I252"
] | [] |
10,931,598 | 22,273,880 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nMajor Surgical or Invasive Procedure:\nCoronary angiogram (___)\n\nattach\n \nPertinent Results:\nADMISSION LABS:\n==============\n___ 11:15PM BLOOD WBC-4.7 RBC-4.61 Hgb-13.4 Hct-42.0 MCV-91 \nMCH-29.1 MCHC-31.9* RDW-12.1 RDWSD-40.1 Plt ___\n___ 11:15PM BLOOD Neuts-53.2 ___ Monos-7.5 Eos-1.5 \nBaso-0.4 Im ___ AbsNeut-2.47 AbsLymp-1.73 AbsMono-0.35 \nAbsEos-0.07 AbsBaso-0.02\n___ 11:15PM BLOOD Glucose-110* UreaN-18 Creat-0.9 Na-142 \nK-3.8 Cl-102 HCO3-28 AnGap-12\n___ 11:15PM BLOOD CK(CPK)-163\n___ 11:15PM BLOOD CK-MB-3\n___ 11:15PM BLOOD cTropnT-0.09*\n\nDISCHARGE LABS:\n==============\n___ 04:56AM BLOOD WBC-3.4* RBC-4.16 Hgb-12.0 Hct-37.3 \nMCV-90 MCH-28.8 MCHC-32.2 RDW-12.2 RDWSD-39.6 Plt ___\n___ 04:56AM BLOOD Glucose-104* UreaN-17 Creat-0.8 Na-140 \nK-4.4 Cl-104 HCO3-24 AnGap-12\n___ 04:56AM BLOOD Calcium-9.4 Phos-4.7* Mg-2.2\n\nOTHER PERTINENT LABS:\n====================\n___ 05:49PM BLOOD D-Dimer-394\n___ 06:22AM BLOOD cTropnT-0.07*\n___ 11:14PM BLOOD CK-MB-2 cTropnT-0.04*\n___ 05:49PM BLOOD CK-MB-19* cTropnT-0.13*\n___ 03:28AM BLOOD CK-MB-16* MB Indx-8.0* cTropnT-0.32*\n___ 08:35AM BLOOD CK-MB-16* MB Indx-8.5* cTropnT-0.47*\n\nTest Result Reference \nRange/Units\nSED RATE BY MODIFIED 2 < OR = 30 mm/h\n___ \n\nSTUDIES/IMAGING:\n===============\nCXR (___):\n=============\nIMPRESSION: \nNo pneumonia or pulmonary edema. \n\nCTA CORONARY ARTERIES (___):\n===============================\nFINDINGS: \n \nImage Quality: The overall quality of the CT angiographic \nexamination is good and is limited by cardiac motion artifacts. \n \nAGATSTON SCORE: The total (aggregate) calcium score using the AJ \n130 method is 0. Total volume score of 0. ___ of similar \npatients have less coronary artery calcium. \n \nIndividual major vessel AJ 130 scores are: LM: 0; LAD: 0; LCX: \n0; RCA: 0. \n \nCORONARY CTA: Dominance of the coronary artery system: right \nwith normal \norigins and course. The LAD, circumflex, and RCA demonstrate a \ntortuous \ncourse. \n \nLeft Main: The left main is a normal caliber vessel which gives \nrise to the LAD and circumflex arteries. The left main has no \nstenosis with no plaque. \nLeft Anterior Descending Artery: has no stenosis with no plaque. \n\n LAD branches: \n - D1: has no stenosis with no plaque. \n - D2: has no stenosis with no plaque. \n - D2-1: has no stenosis with no plaque. \n - D3: has no stenosis with no plaque. \n \nLeft Circumflex Artery: has no stenosis with no plaque. \n LCX branches: \n - OM1: Too small to characterize. \n - OM2: Too small to characterize. \n - OM3: Too small to characterize. \n \nRight Coronary Artery: has no stenosis with no plaque. \n RCA branches: \n- AM1: To small to characterize. \n- PDA: has no stenosis with no plaque. \n- PDA 2: Has no stenosis with no plaque. \n- PLB: has no stenosis with no plaque. \n- PLB 2: Has no stenosis with no plaque. \n \nCARDIAC MORPHOLOGY: The right atrium is normal. The right \nventricle is \nnormal. The left atrium is normal. The left ventricle is \nnormal. The \npericardium is normal and there is no pericardial effusion. The \naortic valve is tricuspid with normal leaflets. \n \nEXTRACARDIAC FINDINGS: \n \nThere is no mediastinal or hilar lymphadenopathy. \n \nThere is 2 mm nodule in the right lower ___ reflect a \npulmonary nodule versus a small mucous plug (series 2, image \n32). There's mild bibasilar dependent atelectasis. Otherwise, \nthere is no pulmonary mass or consolidation within the limited \nfield of view. There is no central airway or pleural \nabnormality. \n \nLimited images of the upper abdomen are unremarkable. \n \nRegional bones and soft tissues are unremarkable. \n \nIMPRESSION AND RECOMMENDATIONS: This study was considered \ndiagnostic for \nevaluation of the coronary arteries. \n \nNo evidence of coronary artery calcifications. \nCAC Score risk: CAC-DRS 0 (0): very low risk - statin generally \nnot \nrecommended \nCAC-DRS ___ A0/N0 \n(A - risk category based on Agatston score / N - number of \ncoronary arteries containing calcifications) \n \nMildly tortuous course of the coronary arteries without evidence \nof \ndissection. CAD-RADS 0 - No plaque or stenosis. \n \n2 mm nodule in the right lower lobe may reflect a pulmonary \nnodule versus a small mucous plug. Please refer to ___ \ncriteria below for follow-up recommendations: \n \nFor incidentally detected single solid pulmonary nodule smaller \nthan 6 mm, no CT follow-up is recommended in a low-risk patient, \nand an optional CT in 12 months is recommended in a high-risk \npatient. \n \nCAC-DRS 0 (A0) - Agaston score 0: Very low risk (statin \ngenerally not \nrecommended) \nCAC-DRS 1 (A1) - Agaston score between ___: Mildly increased \nrisk (moderate \nintensity statin recommended) \nCAC-DRS 2 (A2) - Agaston score between 100-299: Moderately \nincreased risk \n(moderate to high intensity statin + 81 mg ASA recommended) \nCAC-DRS 3 (A3) - Agaston score between >300: Moderately to \nseverely increased \nrisk (high intensity statin + 81 mg ASA recommended) \n \nCoronary stenoses are reported as maximum percentage diameter \nstenosis and \ngraded using the CAD-RADS classification (___ Cardiovasc \nImaging ___ \nSep;9(9):1099-113). \n \nCAD-RADS 0: 0%, no stenosis \nCAD-RADS 1: ___, minimal stenosis or plaque with no stenosis \nCAD-RADS 2: ___, mild stenosis \nCAD-RADS 3: 50-69%, moderate stenosis \nCAD-RADS 4A: 70-99%, severe stenosis \nCAD-RADS 4B: >50% stenosis of the left main or >=70% stenosis of \nthe left \nanterior descending, the left circumflex, and the right \ncoronary, severe \nstenosis \nCAD-RADS 5: 100%, total occlusion \nCAD-RADS N: Non-diagnostic study, obstructive CAD cannot be \nexcluded \n\nCARDIAC CATH (___):\n=======================\nCoronary Description\nThe left main, left anterior descending, circumflex and right \ncoronary artery have no angiographically significant coronary \nabnormalities. There was severe tortuosity noted throughout.\n\nFindings: No angiographically apparent coronary artery disease.\n\nTTE (___):\n==============\nCONCLUSION:\nThe left atrial volume index is normal. The estimated right \natrial pressure is ___ mmHg. There is normal left ventricular \nwall thickness with a normal cavity size. There is a small area \nof regional left ventricular\nsystolic dysfunction with basal inferior and inferoseptal \nhypokinesis (see schematic). The visually estimated left \nventricular ejection fraction is 50-55%. Left ventricular \ncardiac index is low normal(2.0-2.5 L/min/m2). There is no \nresting left ventricular outflow tract gradient. No ventricular \nseptal defect is seen. Tissue Doppler suggests a normal left \nventricular filling pressure (PCWP less than 12mmHg). Normal \nright ventricular cavity size with low normal free wall motion. \nTricuspid annular\nplane systolic excursion (TAPSE) is depressed. The aortic sinus \ndiameter is normal for gender with a normal ascending aorta \ndiameter for gender. The aortic arch diameter is normal with a \nnormal descending aorta diameter. There is no evidence for an \naortic arch coarctation. The aortic valve leaflets(3) appear \nstructurally normal. There is no aortic valve stenosis. There is \nno aortic regurgitation. The mitral valve leaflets appear \nstructurally normal with leaflet straightening, but no frank \nsystolic prolapse. There is an eccentric, inferolateral directed \njet of mild [1+] mitral regurgitation. Due to the Coanda effect, \nthe severity of mitral regurgitation could be UNDERestimated. \nThe pulmonic valve leaflets are normal. The tricuspid valve \nleaflets appear structurally normal. There is physiologic \ntricuspid regurgitation. The estimated pulmonary artery systolic \npressure is normal. There is a very small pericardial effusion.\n\nIMPRESSION: Low-normal biventricular systolic function in the \nsetting of basal inferior and inferoseptal hypokinesis. Mild \nmitral regurgitation. Normal pulmonary pressure. Very small \npericardial effusion.\n \nBrief Hospital Course:\nHOSPITAL SUMMARY \n================ \n___ with h/o inferoposterolateral STEMI ___ spontaneous RCA \ndissection in ___, who initially presented to ___ \n(___) with chest pain, where her troponin was found to be \nelevated at 0.05. She was loaded w/ 325mg ASA and started on a \nheparin drip, then transferred to ___, where heparin was \ncontinued. Given her history of SCAD, she first underwent a \ncoronary CTA (___), which was negative for CAD or coronary \ndissection. A coronary angiogram was then performed on ___, \nwhich confirmed absence of CAD or SCAD. PE was ruled out with \nnegative D-dimer. TTE (___) was largely unchanged from prior, \napart from a small pericardial effusion. Given the preceding \nunremarkable workup, patient's chest pain and NSTEMI was \npresumed to be ___ myopericarditis vs coronary vasospasm. She \nwas treated with colchicine 0.6mg BID for empiric treatment of \nmyopericarditis, with improvement of her symptoms. A cardiac MRI \nwas planned for ___ as an outpatient to confirm the suspected \ndiagnosis. \n\nTRANSITIONAL ISSUES \n==================== \n#Chest Pain/NSTEMI\n[]Patient is scheduled for a cardiac MRI on ___ to assess for \nevidence of myopericarditis. Please follow-up. \n[]If findings on cardiac MRI are consistent with \nmyopericarditis, then recommend continuing colchicine 0.6mg BID \nfor 3 months (from ___. \n[]If findings on cardiac MRI are not consistent with \nmyopericarditis, then consider initiating amlodipine daily for \nempiric treatment of coronary vasospasm. \n[]We have also recommended that patient take 600mg ibuprofen Q8H \nfor ___ weeks, followed by gradual tapering of the dose by 200 \nto 400mg every ___ weeks. \n\n# CODE: Full code, presumed\n# CONTACT: HCP: ___ (husband), ___ \n\nACTIVE ISSUES: \n=============\n#Chest Pain\n#NSTEMI\n#Hx STEMI ___ SCAD (___) \nPatient presented with chest pain and positive troponin of 0.05 \nat OSH, 0.09 on presentation at ___. He was loaded with ASA \n325mg and started on a heparin gtt at OSH. The heparin gtt was \ncontinued at ___, and she was treated with aspirin 81mg daily. \nContinued home rosuvastatin 5mg QOD. EKG was notable for TWI in \nIII, aVF. Trops initially down-trended (0.09>0.07>0.04), but \nlater up-trended on ___ (0.13>0.32>0.47). CK-MB was also \nelevated (19>16). A coronary CTA was performed (___), which was \nnegative for CAD or dissection. Coronary angiogram was performed \n(___), which confirmed no CAD or dissection. Pt's heparin gtt \nwas discontinued after the coronary angiogram. PE was ruled out \nwith negative D-dimer (394). TTE (___) was largely unchanged \nfrom prior, apart from a small pericardial effusion. Given the \npreceding unremarkable workup, patient's chest pain and NSTEMI \nwas presumed to be ___ myopericarditis vs coronary vasospasm. \nShe was treated with colchicine 0.6mg BID for empiric treatment \nof myopericarditis, with improvement of her symptoms. A cardiac \nMRI was planned for ___ as an outpatient to confirm the \nsuspected diagnosis. \n\nCHRONIC ISSUES: \n==============\n#IBS\n- continued home dicyclomine\n- continued home docusate sodium\n- continued home psyllium\n\n#Anxiety\n- continued home clonazepam PRN\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. DICYCLOMine 10 mg PO TID:PRN IBS abd discomfort \n2. Rosuvastatin Calcium 5 mg PO EVERY OTHER DAY \n3. Aspirin 81 mg PO DAILY \n4. Omeprazole 20 mg PO DAILY \n\n \nDischarge Medications:\n1. Colchicine 0.6 mg PO BID myopericarditis \n2. Ibuprofen 600 mg PO BID \n3. Aspirin 81 mg PO DAILY \n4. DICYCLOMine 10 mg PO TID:PRN IBS abd discomfort \n5. Omeprazole 20 mg PO DAILY \n6. Rosuvastatin Calcium 5 mg PO EVERY OTHER DAY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n=================\nNSTEMI\n\nSECONDARY DIAGNOSES\n===================\nChest pain\nHistory of STEMI ___ spontaneous coronary artery dissection\nIrritable bowel syndrome\nAnxiety\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___, \n\nIt was a pleasure taking care of you at the ___ \n___! \n\nWHY WAS I IN THE HOSPITAL? \n========================== \n- You were admitted because you had chest pain\n\nWHAT HAPPENED IN THE HOSPITAL? \n============================== \n- An imaging study called a coronary CTA was performed to \nvisualize the arteries of your heart. Fortunately, it did not \nshow a blockage (coronary artery disease) or dissection. \n- You also underwent a procedure called a coronary angiogram to \ntake an even closer look at your heart arteries. This also did \nnot show a blockage or dissection. \n- You had a blood test performed, which showed that your chest \npain was not caused by a blood clot in the lungs. \n- You were initially treated with a blood thinner medication \nthrough the IV, called heparin. This was stopped when the \ncoronary angiogram showed that you did not have coronary artery \ndisease. \n- We suspect that your chest pain was caused by an inflammatory \ncondition of the lining of the heart and the heart muscle, \nreferred to as \"myopericarditis.\" You were started on \nanti-inflammatory medications called colchicine and ibuprofen to \ntreat this condition. \n\nWHAT SHOULD I DO WHEN I GO HOME? \n================================ \n- Be sure to take all your medications and attend all of your \nappointments listed below. \n- We have prescribed a new medication for you, called \ncolchicine. We recommend that you take this medication for 3 \nmonths. \n- We also recommend that you take ibuprofen, which you can buy \nover the counter. Please take 600mg every 8 hours for ___ weeks. \nThen, please gradually taper off of ibuprofen by reducing the \ndose by 200 to 400mg every ___ weeks. \n- If you experience new chest pain, please call the heartline at \n___\n\nThank you for allowing us to be involved in your care, we wish \nyou all the best! \nYour ___ Healthcare Team \n\n \nFollowup Instructions:\n___\n"
] | Allergies: No Known Allergies / Adverse Drug Reactions Major Surgical or Invasive Procedure: Coronary angiogram ([MASKED]) attach Pertinent Results: ADMISSION LABS: ============== [MASKED] 11:15PM BLOOD WBC-4.7 RBC-4.61 Hgb-13.4 Hct-42.0 MCV-91 MCH-29.1 MCHC-31.9* RDW-12.1 RDWSD-40.1 Plt [MASKED] [MASKED] 11:15PM BLOOD Neuts-53.2 [MASKED] Monos-7.5 Eos-1.5 Baso-0.4 Im [MASKED] AbsNeut-2.47 AbsLymp-1.73 AbsMono-0.35 AbsEos-0.07 AbsBaso-0.02 [MASKED] 11:15PM BLOOD Glucose-110* UreaN-18 Creat-0.9 Na-142 K-3.8 Cl-102 HCO3-28 AnGap-12 [MASKED] 11:15PM BLOOD CK(CPK)-163 [MASKED] 11:15PM BLOOD CK-MB-3 [MASKED] 11:15PM BLOOD cTropnT-0.09* DISCHARGE LABS: ============== [MASKED] 04:56AM BLOOD WBC-3.4* RBC-4.16 Hgb-12.0 Hct-37.3 MCV-90 MCH-28.8 MCHC-32.2 RDW-12.2 RDWSD-39.6 Plt [MASKED] [MASKED] 04:56AM BLOOD Glucose-104* UreaN-17 Creat-0.8 Na-140 K-4.4 Cl-104 HCO3-24 AnGap-12 [MASKED] 04:56AM BLOOD Calcium-9.4 Phos-4.7* Mg-2.2 OTHER PERTINENT LABS: ==================== [MASKED] 05:49PM BLOOD D-Dimer-394 [MASKED] 06:22AM BLOOD cTropnT-0.07* [MASKED] 11:14PM BLOOD CK-MB-2 cTropnT-0.04* [MASKED] 05:49PM BLOOD CK-MB-19* cTropnT-0.13* [MASKED] 03:28AM BLOOD CK-MB-16* MB Indx-8.0* cTropnT-0.32* [MASKED] 08:35AM BLOOD CK-MB-16* MB Indx-8.5* cTropnT-0.47* Test Result Reference Range/Units SED RATE BY MODIFIED 2 < OR = 30 mm/h [MASKED] STUDIES/IMAGING: =============== CXR ([MASKED]): ============= IMPRESSION: No pneumonia or pulmonary edema. CTA CORONARY ARTERIES ([MASKED]): =============================== FINDINGS: Image Quality: The overall quality of the CT angiographic examination is good and is limited by cardiac motion artifacts. AGATSTON SCORE: The total (aggregate) calcium score using the AJ 130 method is 0. Total volume score of 0. [MASKED] of similar patients have less coronary artery calcium. Individual major vessel AJ 130 scores are: LM: 0; LAD: 0; LCX: 0; RCA: 0. CORONARY CTA: Dominance of the coronary artery system: right with normal origins and course. The LAD, circumflex, and RCA demonstrate a tortuous course. Left Main: The left main is a normal caliber vessel which gives rise to the LAD and circumflex arteries. The left main has no stenosis with no plaque. Left Anterior Descending Artery: has no stenosis with no plaque. LAD branches: - D1: has no stenosis with no plaque. - D2: has no stenosis with no plaque. - D2-1: has no stenosis with no plaque. - D3: has no stenosis with no plaque. Left Circumflex Artery: has no stenosis with no plaque. LCX branches: - OM1: Too small to characterize. - OM2: Too small to characterize. - OM3: Too small to characterize. Right Coronary Artery: has no stenosis with no plaque. RCA branches: - AM1: To small to characterize. - PDA: has no stenosis with no plaque. - PDA 2: Has no stenosis with no plaque. - PLB: has no stenosis with no plaque. - PLB 2: Has no stenosis with no plaque. CARDIAC MORPHOLOGY: The right atrium is normal. The right ventricle is normal. The left atrium is normal. The left ventricle is normal. The pericardium is normal and there is no pericardial effusion. The aortic valve is tricuspid with normal leaflets. EXTRACARDIAC FINDINGS: There is no mediastinal or hilar lymphadenopathy. There is 2 mm nodule in the right lower [MASKED] reflect a pulmonary nodule versus a small mucous plug (series 2, image 32). There's mild bibasilar dependent atelectasis. Otherwise, there is no pulmonary mass or consolidation within the limited field of view. There is no central airway or pleural abnormality. Limited images of the upper abdomen are unremarkable. Regional bones and soft tissues are unremarkable. IMPRESSION AND RECOMMENDATIONS: This study was considered diagnostic for evaluation of the coronary arteries. No evidence of coronary artery calcifications. CAC Score risk: CAC-DRS 0 (0): very low risk - statin generally not recommended CAC-DRS [MASKED] A0/N0 (A - risk category based on Agatston score / N - number of coronary arteries containing calcifications) Mildly tortuous course of the coronary arteries without evidence of dissection. CAD-RADS 0 - No plaque or stenosis. 2 mm nodule in the right lower lobe may reflect a pulmonary nodule versus a small mucous plug. Please refer to [MASKED] criteria below for follow-up recommendations: For incidentally detected single solid pulmonary nodule smaller than 6 mm, no CT follow-up is recommended in a low-risk patient, and an optional CT in 12 months is recommended in a high-risk patient. CAC-DRS 0 (A0) - Agaston score 0: Very low risk (statin generally not recommended) CAC-DRS 1 (A1) - Agaston score between [MASKED]: Mildly increased risk (moderate intensity statin recommended) CAC-DRS 2 (A2) - Agaston score between 100-299: Moderately increased risk (moderate to high intensity statin + 81 mg ASA recommended) CAC-DRS 3 (A3) - Agaston score between >300: Moderately to severely increased risk (high intensity statin + 81 mg ASA recommended) Coronary stenoses are reported as maximum percentage diameter stenosis and graded using the CAD-RADS classification ([MASKED] Cardiovasc Imaging [MASKED] Sep;9(9):1099-113). CAD-RADS 0: 0%, no stenosis CAD-RADS 1: [MASKED], minimal stenosis or plaque with no stenosis CAD-RADS 2: [MASKED], mild stenosis CAD-RADS 3: 50-69%, moderate stenosis CAD-RADS 4A: 70-99%, severe stenosis CAD-RADS 4B: >50% stenosis of the left main or >=70% stenosis of the left anterior descending, the left circumflex, and the right coronary, severe stenosis CAD-RADS 5: 100%, total occlusion CAD-RADS N: Non-diagnostic study, obstructive CAD cannot be excluded CARDIAC CATH ([MASKED]): ======================= Coronary Description The left main, left anterior descending, circumflex and right coronary artery have no angiographically significant coronary abnormalities. There was severe tortuosity noted throughout. Findings: No angiographically apparent coronary artery disease. TTE ([MASKED]): ============== CONCLUSION: The left atrial volume index is normal. The estimated right atrial pressure is [MASKED] mmHg. There is normal left ventricular wall thickness with a normal cavity size. There is a small area of regional left ventricular systolic dysfunction with basal inferior and inferoseptal hypokinesis (see schematic). The visually estimated left ventricular ejection fraction is 50-55%. Left ventricular cardiac index is low normal(2.0-2.5 L/min/m2). There is no resting left ventricular outflow tract gradient. No ventricular septal defect is seen. Tissue Doppler suggests a normal left ventricular filling pressure (PCWP less than 12mmHg). Normal right ventricular cavity size with low normal free wall motion. Tricuspid annular plane systolic excursion (TAPSE) is depressed. The aortic sinus diameter is normal for gender with a normal ascending aorta diameter for gender. The aortic arch diameter is normal with a normal descending aorta diameter. There is no evidence for an aortic arch coarctation. The aortic valve leaflets(3) appear structurally normal. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral valve leaflets appear structurally normal with leaflet straightening, but no frank systolic prolapse. There is an eccentric, inferolateral directed jet of mild [1+] mitral regurgitation. Due to the Coanda effect, the severity of mitral regurgitation could be UNDERestimated. The pulmonic valve leaflets are normal. The tricuspid valve leaflets appear structurally normal. There is physiologic tricuspid regurgitation. The estimated pulmonary artery systolic pressure is normal. There is a very small pericardial effusion. IMPRESSION: Low-normal biventricular systolic function in the setting of basal inferior and inferoseptal hypokinesis. Mild mitral regurgitation. Normal pulmonary pressure. Very small pericardial effusion. Brief Hospital Course: HOSPITAL SUMMARY ================ [MASKED] with h/o inferoposterolateral STEMI [MASKED] spontaneous RCA dissection in [MASKED], who initially presented to [MASKED] ([MASKED]) with chest pain, where her troponin was found to be elevated at 0.05. She was loaded w/ 325mg ASA and started on a heparin drip, then transferred to [MASKED], where heparin was continued. Given her history of SCAD, she first underwent a coronary CTA ([MASKED]), which was negative for CAD or coronary dissection. A coronary angiogram was then performed on [MASKED], which confirmed absence of CAD or SCAD. PE was ruled out with negative D-dimer. TTE ([MASKED]) was largely unchanged from prior, apart from a small pericardial effusion. Given the preceding unremarkable workup, patient's chest pain and NSTEMI was presumed to be [MASKED] myopericarditis vs coronary vasospasm. She was treated with colchicine 0.6mg BID for empiric treatment of myopericarditis, with improvement of her symptoms. A cardiac MRI was planned for [MASKED] as an outpatient to confirm the suspected diagnosis. TRANSITIONAL ISSUES ==================== #Chest Pain/NSTEMI []Patient is scheduled for a cardiac MRI on [MASKED] to assess for evidence of myopericarditis. Please follow-up. []If findings on cardiac MRI are consistent with myopericarditis, then recommend continuing colchicine 0.6mg BID for 3 months (from [MASKED]. []If findings on cardiac MRI are not consistent with myopericarditis, then consider initiating amlodipine daily for empiric treatment of coronary vasospasm. []We have also recommended that patient take 600mg ibuprofen Q8H for [MASKED] weeks, followed by gradual tapering of the dose by 200 to 400mg every [MASKED] weeks. # CODE: Full code, presumed # CONTACT: HCP: [MASKED] (husband), [MASKED] ACTIVE ISSUES: ============= #Chest Pain #NSTEMI #Hx STEMI [MASKED] SCAD ([MASKED]) Patient presented with chest pain and positive troponin of 0.05 at OSH, 0.09 on presentation at [MASKED]. He was loaded with ASA 325mg and started on a heparin gtt at OSH. The heparin gtt was continued at [MASKED], and she was treated with aspirin 81mg daily. Continued home rosuvastatin 5mg QOD. EKG was notable for TWI in III, aVF. Trops initially down-trended (0.09>0.07>0.04), but later up-trended on [MASKED] (0.13>0.32>0.47). CK-MB was also elevated (19>16). A coronary CTA was performed ([MASKED]), which was negative for CAD or dissection. Coronary angiogram was performed ([MASKED]), which confirmed no CAD or dissection. Pt's heparin gtt was discontinued after the coronary angiogram. PE was ruled out with negative D-dimer (394). TTE ([MASKED]) was largely unchanged from prior, apart from a small pericardial effusion. Given the preceding unremarkable workup, patient's chest pain and NSTEMI was presumed to be [MASKED] myopericarditis vs coronary vasospasm. She was treated with colchicine 0.6mg BID for empiric treatment of myopericarditis, with improvement of her symptoms. A cardiac MRI was planned for [MASKED] as an outpatient to confirm the suspected diagnosis. CHRONIC ISSUES: ============== #IBS - continued home dicyclomine - continued home docusate sodium - continued home psyllium #Anxiety - continued home clonazepam PRN Medications on Admission: The Preadmission Medication list is accurate and complete. 1. DICYCLOMine 10 mg PO TID:PRN IBS abd discomfort 2. Rosuvastatin Calcium 5 mg PO EVERY OTHER DAY 3. Aspirin 81 mg PO DAILY 4. Omeprazole 20 mg PO DAILY Discharge Medications: 1. Colchicine 0.6 mg PO BID myopericarditis 2. Ibuprofen 600 mg PO BID 3. Aspirin 81 mg PO DAILY 4. DICYCLOMine 10 mg PO TID:PRN IBS abd discomfort 5. Omeprazole 20 mg PO DAILY 6. Rosuvastatin Calcium 5 mg PO EVERY OTHER DAY Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS ================= NSTEMI SECONDARY DIAGNOSES =================== Chest pain History of STEMI [MASKED] spontaneous coronary artery dissection Irritable bowel syndrome Anxiety Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], It was a pleasure taking care of you at the [MASKED] [MASKED]! WHY WAS I IN THE HOSPITAL? ========================== - You were admitted because you had chest pain WHAT HAPPENED IN THE HOSPITAL? ============================== - An imaging study called a coronary CTA was performed to visualize the arteries of your heart. Fortunately, it did not show a blockage (coronary artery disease) or dissection. - You also underwent a procedure called a coronary angiogram to take an even closer look at your heart arteries. This also did not show a blockage or dissection. - You had a blood test performed, which showed that your chest pain was not caused by a blood clot in the lungs. - You were initially treated with a blood thinner medication through the IV, called heparin. This was stopped when the coronary angiogram showed that you did not have coronary artery disease. - We suspect that your chest pain was caused by an inflammatory condition of the lining of the heart and the heart muscle, referred to as "myopericarditis." You were started on anti-inflammatory medications called colchicine and ibuprofen to treat this condition. WHAT SHOULD I DO WHEN I GO HOME? ================================ - Be sure to take all your medications and attend all of your appointments listed below. - We have prescribed a new medication for you, called colchicine. We recommend that you take this medication for 3 months. - We also recommend that you take ibuprofen, which you can buy over the counter. Please take 600mg every 8 hours for [MASKED] weeks. Then, please gradually taper off of ibuprofen by reducing the dose by 200 to 400mg every [MASKED] weeks. - If you experience new chest pain, please call the heartline at [MASKED] Thank you for allowing us to be involved in your care, we wish you all the best! Your [MASKED] Healthcare Team Followup Instructions: [MASKED] | [
"I214",
"I319",
"E785",
"I252",
"Z87891",
"K589",
"F419",
"I2510"
] | [
"I214: Non-ST elevation (NSTEMI) myocardial infarction",
"I319: Disease of pericardium, unspecified",
"E785: Hyperlipidemia, unspecified",
"I252: Old myocardial infarction",
"Z87891: Personal history of nicotine dependence",
"K589: Irritable bowel syndrome without diarrhea",
"F419: Anxiety disorder, unspecified",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris"
] | [
"E785",
"I252",
"Z87891",
"F419",
"I2510"
] | [] |
18,490,502 | 25,281,786 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\n\"Woozy\"\n \nMajor Surgical or Invasive Procedure:\nN/A\n \nHistory of Present Illness:\nPatient presented to his PCP ___ ___ for follow-up from a recent \nstroke and hospital admission from ___. In the office the \npatient was complaining of lightheadedness since his stroke, \nwith increased wooziness when standing up. The patient was found \nto be tachycardic in the office to the 158, and the PCP advised \nthe patient to report to the emergency department. The patient \ndenied chest pain, shortness of breath or exertional symptoms. \n\nOf note, the patient was recently admitted to ___ on ___ with \nnew onset of aphasia, facial asymmetry, weakness in R upper and \nlower extremities, and sensory loss on the right side. On \nadmission CT/CTA showed no intraparenchymal hemorrhage or \nproximal artery occlusion, and the patient received tPA with \ncomplete resolution of his symptoms.\n\n \nPast Medical History:\nHypertension\nGERD\nProstate cancer s/p resection ___ years ago\nCervical spondylosis and radiculopathy\nPrior Stroke\n \nSocial History:\n___\nFamily History:\nPositive for longevity. Mother ___ and living independently. \nindependently. Father died at age ___ of stroke\n \nPhysical Exam:\nADMISSION EXAMINATION\n======================\nVitals: T=98.1 (97.9-98.1) HR= 80 (80-119) BP=122/85 \n(122/85-123/54) RR= 18 O2=98 on RA \nGeneral: Patient pleasant with no complaints, in good spirits\nHEENT: Moist mucous membranes, \nLungs: CTAB, no wheezes, rhonchi\nCV: Irregular rate and rhythm, no M/R/G\nAbdomen: Soft, nontender, nondistended\nExt: Warm and well perfused, trace pitting edema\n\nDISCHARGE EXAMINATION\n======================\nVitals: T=98.1 (97.9-98.1) HR= 80 (80-119) BP=122/85 \n(122/85-123/54) RR= 18 O2=98 on RA \nI/O= 8hr ___ NPO \nWeight: 70.9kg \nTelemetry: Patient in a-flutter, in ___ overnight, at 6am \nrate started to creep up to 100-110s. \nGeneral: Patient feeling well this morning, no complaints, in \ngood spirits this morning\nHEENT: Moist mucous membranes, \nLungs: CTAB, no wheezes, rhonchi\nCV: Irregular rate and rhythm, no M/R/G\nAbdomen: Soft, nontender, nondistended\nExt: Warm and well perfused, trace pitting edema\n \nPertinent Results:\nADMISSION LABS\n===============\n___ 06:00AM BLOOD WBC-8.8 RBC-4.66 Hgb-14.3 Hct-42.9 MCV-92 \nMCH-30.7 MCHC-33.3 RDW-13.3 RDWSD-44.8 Plt ___\n___ 06:00AM BLOOD Plt ___\n___ 06:00AM BLOOD Glucose-91 UreaN-11 Creat-1.0 Na-140 \nK-4.3 Cl-103 HCO3-30 AnGap-11\n___ 06:00AM BLOOD Calcium-9.2 Phos-3.8 Mg-2.3\n\nIMAGING/STUDIES\n==============\n___ CXR\nFINDINGS: \nThe lungs are clear. There is no consolidation, effusion, or \nedema. The \ncardiomediastinal silhouette is within normal limits. No acute \nosseous \nabnormalities. \n\nIMPRESSION: \nNo acute cardiopulmonary process. \n\nMICROBIOLOGY\n==========\n___ 04:45PM URINE Color-Straw Appear-Clear Sp ___\n___ 04:45PM URINE Blood-NEG Nitrite-NEG Protein-NEG \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG\n\nDISCHARGE LABS\n===============\n___ 06:00AM BLOOD WBC-8.8 RBC-4.66 Hgb-14.3 Hct-42.9 MCV-92 \nMCH-30.7 MCHC-33.3 RDW-13.3 RDWSD-44.8 Plt ___\n___ 06:00AM BLOOD Glucose-91 UreaN-11 Creat-1.0 Na-140 \nK-4.3 Cl-103 HCO3-30 AnGap-11\n___ 06:00AM BLOOD Calcium-9.2 Phos-3.8 Mg-2.___RIEF SUMMARY\n============\nMr. ___ is a ___ yr old male with a PMH of HTN, GERD, prostate \ncancer s/p resection (___), cervical spondylosis and \nradiculopathy, and recent stroke/TIA s/p tPA therapy who \npresented from his PCP office with lightheadedness and malaise, \nfound to be tachycardic to the 160s with rapid A flutter with \n4:1 block.\n\nACTIVE ISSUES\n==============\n#Atrial Flutter: When Mr. ___ arrived to the ED he received a \ntotal of 30mg PO Dilt and 25mg IV Dilt, and was well controlled \nwith HRs in the ___. A-flutter etiology unclear given normal TSH \n(3.1 on previous admission, structurally normal heart (TTE on \n___, and no clear infectious causes. He remained \nhemodynamically stable throughout hospitalization, and was \ntransitioned to PO diltiazam 240 mg ER for discharge. The \ndecision was made to start rivaroxaban for anticoagulation given \nhis elevated CHADS VASC score. Neurology was consulted in light \nof his recent stroke and tPA therapy, and anticoagulation \ntherapy was deemed to be safe. The patient was instructed to \nfollow up with Dr. ___ as an outpatient for ablation in \none month. \n\n#Recent Stroke: Patient was recently admitted to ___ on ___ \nwith new onset of stroke, and found to have 2 small subacute \ninfarcts, now s/p tPA therapy. This acute event was initially \nthought to be due to atherosclerosis, and he was started on a \nlow dose statin, in addition to clopidogrel. However, this \nstroke has likely stemmed from paroxysmal a flutter. During his \nhospitalization the patient was continued on Plavix and \natorvastatin as well as rivaroxaban for future stroke \nprophylaxis.\n\n#Leukocytosis: Patient presented with a WBC of 11.3, increased \nfrom 8.3 on recent discharge (___). There were no localizing \nsigns or symptoms of infection, and his WBC improved to 8.8 on \nthe morning of discharge. \n\nCHRONIC ISSUES\n==============\n#HTN: Patient has a history of HTN, and on recent discharge on \n___, his medication regimen was changed from metoprolol to \nlisinopril 5mg daily, as he had poor blood pressure control and \nbradycardia on his previous dose of metoprolol. He was continued \non his home dose of lisinopril during his hospitalization.\n\n#Neck pain: Patient has a history of cervical spondylosis and \nradiculopathy, and pain medications were discontinued on \nprevious admission. During this admission his neck pain was well \ncontrolled with Tylenol. \n\nTRANSITIONAL ISSUES\n=====================\n-The patient will be discharged with ___ of Hearts to monitor \nburden of atrial flutter (to be followed by Dr. ___.\n-Anticoagulation for atrial flutter: Xarelto 20 mg\n-The patient is being discharged on 240 mg Diltiazam ER, in \naddition to his prior dose of 5mg lisinopril. He has been \ninstructed to hold the lisinopril dose should he feel \ndizzy/lightheaded, or if his SBP drops below 100. He will \ncontact his PCP for further management of his medications should \nthis occur.\n\n# CODE: DNR/DNI, will allow cardioversion \n# CONTACT: \nSon: ___: H: ___\nDaughter: ___: ___, Mobile: ___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Omeprazole 20 mg PO DAILY \n2. TraZODone 50 mg PO QHS:PRN Insomnia \n3. Atorvastatin 20 mg PO DAILY \n4. Clopidogrel 75 mg PO DAILY \n5. Lisinopril 5 mg PO DAILY \n6. lutein 20 mg oral DAILY \n\n \nDischarge Medications:\n1. Diltiazem Extended-Release 240 mg PO DAILY \nRX *diltiazem HCl 240 mg 1 capsule(s) by mouth DAILY Disp #*30 \nCapsule Refills:*0 \n2. Rivaroxaban 20 mg PO DINNER \nDaily with the evening meal. \nRX *rivaroxaban [Xarelto] 20 mg 1 tablet(s) by mouth daily Disp \n#*30 Tablet Refills:*0 \n3. Atorvastatin 20 mg PO DAILY \n4. Clopidogrel 75 mg PO DAILY \n5. Lisinopril 5 mg PO DAILY \n6. lutein 20 mg oral DAILY \n7. Omeprazole 20 mg PO DAILY \n8. TraZODone 50 mg PO QHS:PRN Insomnia \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n===================\n# Atrial flutter\n\nSECONDARY DIAGNOSIS\n====================\n# Hypertension\n# History of stroke\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___, \n\nYou were admitted to ___ on ___ from Dr. ___ \nwith where you were found to have an abnormal heart rate. Your \nheart was found to be in atrial flutter. You were brought to the \nED where you received a combination of oral and IV medication to \nlower your heart rate. You were then admitted to the hospital, \nwhere you were started on two new medications. The first is \ndiltiazam, which is a medication to control your heart rate that \nyou will take once a day (first dose tonight). You were also \nstarted on Xarelto, which is a blood thinner to prevent the \nformation of clots which could lead to stroke. Before you were \ndischarged, you also received ___ of Hearts device to monitor \nyour heart rhythms. \n\nPlease take the Xarelto (the blood thinner medication) once a \nday at dinner time with a 500 calorie meal. The second new \nmedication is a 240mg pill of Diltiazam XL, which you will take \nnightly. You will need to take this first dose of Diltiazam \nTONIGHT at 9pm. When you return home you can also take two 325 \nmg regular strength Tylenols every 6 hrs as needed if you \ncontinue to have pain in your neck. \n\nYou will need to follow up with Dr. ___ as an outpatient \nto discuss the option of a procedure to return your heart rate \nto a normal rhythm. You will be contacted regarding this \nappointment.\n\nWhen you return home, if at any time you start to feel dizzy, \nlightheaded, or unwell, please check your blood pressure. If the \nsystolic blood pressure (the higher value), is below 100, please \ndo not take the next dose of Lisinopril medication. Please \ncontact your PCP ___ to discuss what to do with your \nmedications at that time.\n\nWe wish you the best,\nYour ___ Care Team\n \nFollowup Instructions:\n___\n"
] | Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: "Woozy" Major Surgical or Invasive Procedure: N/A History of Present Illness: Patient presented to his PCP [MASKED] [MASKED] for follow-up from a recent stroke and hospital admission from [MASKED]. In the office the patient was complaining of lightheadedness since his stroke, with increased wooziness when standing up. The patient was found to be tachycardic in the office to the 158, and the PCP advised the patient to report to the emergency department. The patient denied chest pain, shortness of breath or exertional symptoms. Of note, the patient was recently admitted to [MASKED] on [MASKED] with new onset of aphasia, facial asymmetry, weakness in R upper and lower extremities, and sensory loss on the right side. On admission CT/CTA showed no intraparenchymal hemorrhage or proximal artery occlusion, and the patient received tPA with complete resolution of his symptoms. Past Medical History: Hypertension GERD Prostate cancer s/p resection [MASKED] years ago Cervical spondylosis and radiculopathy Prior Stroke Social History: [MASKED] Family History: Positive for longevity. Mother [MASKED] and living independently. independently. Father died at age [MASKED] of stroke Physical Exam: ADMISSION EXAMINATION ====================== Vitals: T=98.1 (97.9-98.1) HR= 80 (80-119) BP=122/85 (122/85-123/54) RR= 18 O2=98 on RA General: Patient pleasant with no complaints, in good spirits HEENT: Moist mucous membranes, Lungs: CTAB, no wheezes, rhonchi CV: Irregular rate and rhythm, no M/R/G Abdomen: Soft, nontender, nondistended Ext: Warm and well perfused, trace pitting edema DISCHARGE EXAMINATION ====================== Vitals: T=98.1 (97.9-98.1) HR= 80 (80-119) BP=122/85 (122/85-123/54) RR= 18 O2=98 on RA I/O= 8hr [MASKED] NPO Weight: 70.9kg Telemetry: Patient in a-flutter, in [MASKED] overnight, at 6am rate started to creep up to 100-110s. General: Patient feeling well this morning, no complaints, in good spirits this morning HEENT: Moist mucous membranes, Lungs: CTAB, no wheezes, rhonchi CV: Irregular rate and rhythm, no M/R/G Abdomen: Soft, nontender, nondistended Ext: Warm and well perfused, trace pitting edema Pertinent Results: ADMISSION LABS =============== [MASKED] 06:00AM BLOOD WBC-8.8 RBC-4.66 Hgb-14.3 Hct-42.9 MCV-92 MCH-30.7 MCHC-33.3 RDW-13.3 RDWSD-44.8 Plt [MASKED] [MASKED] 06:00AM BLOOD Plt [MASKED] [MASKED] 06:00AM BLOOD Glucose-91 UreaN-11 Creat-1.0 Na-140 K-4.3 Cl-103 HCO3-30 AnGap-11 [MASKED] 06:00AM BLOOD Calcium-9.2 Phos-3.8 Mg-2.3 IMAGING/STUDIES ============== [MASKED] CXR FINDINGS: The lungs are clear. There is no consolidation, effusion, or edema. The cardiomediastinal silhouette is within normal limits. No acute osseous abnormalities. IMPRESSION: No acute cardiopulmonary process. MICROBIOLOGY ========== [MASKED] 04:45PM URINE Color-Straw Appear-Clear Sp [MASKED] [MASKED] 04:45PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG DISCHARGE LABS =============== [MASKED] 06:00AM BLOOD WBC-8.8 RBC-4.66 Hgb-14.3 Hct-42.9 MCV-92 MCH-30.7 MCHC-33.3 RDW-13.3 RDWSD-44.8 Plt [MASKED] [MASKED] 06:00AM BLOOD Glucose-91 UreaN-11 Creat-1.0 Na-140 K-4.3 Cl-103 HCO3-30 AnGap-11 [MASKED] 06:00AM BLOOD Calcium-9.2 Phos-3.8 Mg-2. RIEF SUMMARY ============ Mr. [MASKED] is a [MASKED] yr old male with a PMH of HTN, GERD, prostate cancer s/p resection ([MASKED]), cervical spondylosis and radiculopathy, and recent stroke/TIA s/p tPA therapy who presented from his PCP office with lightheadedness and malaise, found to be tachycardic to the 160s with rapid A flutter with 4:1 block. ACTIVE ISSUES ============== #Atrial Flutter: When Mr. [MASKED] arrived to the ED he received a total of 30mg PO Dilt and 25mg IV Dilt, and was well controlled with HRs in the [MASKED]. A-flutter etiology unclear given normal TSH (3.1 on previous admission, structurally normal heart (TTE on [MASKED], and no clear infectious causes. He remained hemodynamically stable throughout hospitalization, and was transitioned to PO diltiazam 240 mg ER for discharge. The decision was made to start rivaroxaban for anticoagulation given his elevated CHADS VASC score. Neurology was consulted in light of his recent stroke and tPA therapy, and anticoagulation therapy was deemed to be safe. The patient was instructed to follow up with Dr. [MASKED] as an outpatient for ablation in one month. #Recent Stroke: Patient was recently admitted to [MASKED] on [MASKED] with new onset of stroke, and found to have 2 small subacute infarcts, now s/p tPA therapy. This acute event was initially thought to be due to atherosclerosis, and he was started on a low dose statin, in addition to clopidogrel. However, this stroke has likely stemmed from paroxysmal a flutter. During his hospitalization the patient was continued on Plavix and atorvastatin as well as rivaroxaban for future stroke prophylaxis. #Leukocytosis: Patient presented with a WBC of 11.3, increased from 8.3 on recent discharge ([MASKED]). There were no localizing signs or symptoms of infection, and his WBC improved to 8.8 on the morning of discharge. CHRONIC ISSUES ============== #HTN: Patient has a history of HTN, and on recent discharge on [MASKED], his medication regimen was changed from metoprolol to lisinopril 5mg daily, as he had poor blood pressure control and bradycardia on his previous dose of metoprolol. He was continued on his home dose of lisinopril during his hospitalization. #Neck pain: Patient has a history of cervical spondylosis and radiculopathy, and pain medications were discontinued on previous admission. During this admission his neck pain was well controlled with Tylenol. TRANSITIONAL ISSUES ===================== -The patient will be discharged with [MASKED] of Hearts to monitor burden of atrial flutter (to be followed by Dr. [MASKED]. -Anticoagulation for atrial flutter: Xarelto 20 mg -The patient is being discharged on 240 mg Diltiazam ER, in addition to his prior dose of 5mg lisinopril. He has been instructed to hold the lisinopril dose should he feel dizzy/lightheaded, or if his SBP drops below 100. He will contact his PCP for further management of his medications should this occur. # CODE: DNR/DNI, will allow cardioversion # CONTACT: Son: [MASKED]: H: [MASKED] Daughter: [MASKED]: [MASKED], Mobile: [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Omeprazole 20 mg PO DAILY 2. TraZODone 50 mg PO QHS:PRN Insomnia 3. Atorvastatin 20 mg PO DAILY 4. Clopidogrel 75 mg PO DAILY 5. Lisinopril 5 mg PO DAILY 6. lutein 20 mg oral DAILY Discharge Medications: 1. Diltiazem Extended-Release 240 mg PO DAILY RX *diltiazem HCl 240 mg 1 capsule(s) by mouth DAILY Disp #*30 Capsule Refills:*0 2. Rivaroxaban 20 mg PO DINNER Daily with the evening meal. RX *rivaroxaban [Xarelto] 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. Atorvastatin 20 mg PO DAILY 4. Clopidogrel 75 mg PO DAILY 5. Lisinopril 5 mg PO DAILY 6. lutein 20 mg oral DAILY 7. Omeprazole 20 mg PO DAILY 8. TraZODone 50 mg PO QHS:PRN Insomnia Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS =================== # Atrial flutter SECONDARY DIAGNOSIS ==================== # Hypertension # History of stroke Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], You were admitted to [MASKED] on [MASKED] from Dr. [MASKED] with where you were found to have an abnormal heart rate. Your heart was found to be in atrial flutter. You were brought to the ED where you received a combination of oral and IV medication to lower your heart rate. You were then admitted to the hospital, where you were started on two new medications. The first is diltiazam, which is a medication to control your heart rate that you will take once a day (first dose tonight). You were also started on Xarelto, which is a blood thinner to prevent the formation of clots which could lead to stroke. Before you were discharged, you also received [MASKED] of Hearts device to monitor your heart rhythms. Please take the Xarelto (the blood thinner medication) once a day at dinner time with a 500 calorie meal. The second new medication is a 240mg pill of Diltiazam XL, which you will take nightly. You will need to take this first dose of Diltiazam TONIGHT at 9pm. When you return home you can also take two 325 mg regular strength Tylenols every 6 hrs as needed if you continue to have pain in your neck. You will need to follow up with Dr. [MASKED] as an outpatient to discuss the option of a procedure to return your heart rate to a normal rhythm. You will be contacted regarding this appointment. When you return home, if at any time you start to feel dizzy, lightheaded, or unwell, please check your blood pressure. If the systolic blood pressure (the higher value), is below 100, please do not take the next dose of Lisinopril medication. Please contact your PCP [MASKED] to discuss what to do with your medications at that time. We wish you the best, Your [MASKED] Care Team Followup Instructions: [MASKED] | [
"I4892",
"I10",
"Z8673",
"D72829",
"M4712",
"Z66",
"Z8546",
"Z7902",
"K219",
"G4700"
] | [
"I4892: Unspecified atrial flutter",
"I10: Essential (primary) hypertension",
"Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits",
"D72829: Elevated white blood cell count, unspecified",
"M4712: Other spondylosis with myelopathy, cervical region",
"Z66: Do not resuscitate",
"Z8546: Personal history of malignant neoplasm of prostate",
"Z7902: Long term (current) use of antithrombotics/antiplatelets",
"K219: Gastro-esophageal reflux disease without esophagitis",
"G4700: Insomnia, unspecified"
] | [
"I10",
"Z8673",
"Z66",
"Z7902",
"K219",
"G4700"
] | [] |
11,735,062 | 25,763,436 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: NEUROLOGY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\nright arm weakness, sensory changes\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMr. ___ is an ___ year old with history of atrial fib\non Coumadin who presents to the emergency as a transfer from\n___ after discovery of an intraparenchymal\nhemorrhage. History is obtained from the patient as well as from\nthe CHA records.\n\nHe states he was in his usual state of health when he went to \nbed\nlast night. This morning he awoke at 4:30 to use the bathroom. \nHe\nwas able to urinate without straining or difficulty. He walked\nback to bed without any problem. He went back to sleep and awoke\nat 5:30am. He began to go about his day as normal. However, he\nsoon after noticed that his right arm was tingling. He describes\na diffuse tingling sensation from the shoulder into the finger\ntips of the right arm. He also thinks the arm was somewhat weak.\nHe is not able to describe this in much detail, but he does note\nthat he dropped a pen in his right hand. He was able to get the\nnewspaper and make coffee without much difficulty.\n\nHowever, given the ongoing tingling and weakness, he called ___\nand was brought to CHA. BP on arrival there was 154/73. INR was\n2.7. A CT head revealed a small left frontal intraparenchymal\nhemorrhage. He was given 10mg Vitamin K and transferred to \n___.\n\nAt ___ he says his weakness seems somewhat better. He \ncontinues\nto experience tingling. In the ED he was given Kcentra for\nreversal of INR. \n\nReview of Systems: \nOn neurological review of systems, the patient denies headache,\nconfusion, difficulties producing or comprehending speech, loss\nof vision, blurred vision, diplopia, dysarthria, dysphagia,\nlightheadedness, vertigo, tinnitus or hearing difficulty. No\nbowel or bladder incontinence or retention. Denies difficulty\nwith gait.\n \nOn general review of systems, the patient denies recent fever, \nchills, night sweats, or recent weight changes. Denies cough,\nshortness of breath, chest pain or tightness, palpitations. \nDenies nausea, vomiting, diarrhea, constipation or abdominal\npain. Denies dysuria, or recent change in bowel or bladder\nhabits. Denies arthralgias, myalgias, or rash.\n \n\n \nPast Medical History:\nAtrial fibrillation\nHypertension\nHyperlipidemia\nDiastolic heart failure\nGERD\nDiabetes mellitus\nBPH\n\n \nSocial History:\n___\nFamily History:\nNon-contributory \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n=========================\nVitals: T: 98.4 BP: 135/54 HR: 88 RR: 22 SaO2: 94% RA\nGeneral: Awake, cooperative, NAD.\nHEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in\noropharynx.\nNeck: Supple, no carotid bruits appreciated. No nuchal rigidity.\nPulmonary: Normal work of breathing.\nCardiac: RRR, warm, well-perfused.\nAbdomen: Soft, non-distended.\nExtremities: No ___ edema.\nSkin: No rashes or lesions noted.\n \nNeurologic:\n-Mental Status: Alert, oriented x 3. Able to relate history\nwithout difficulty. Attentive, able to name ___ backward without\ndifficulty. Language is fluent with intact repetition and\ncomprehension. Normal prosody. There were no paraphasic errors.\nAble to name both high and low frequency objects. Able to read\nwithout difficulty. No dysarthria. Able to follow both midline\nand appendicular commands. \n\n-Cranial Nerves:\nII, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without\nnystagmus. Normal saccades. VFF to confrontation. \nV: Facial sensation intact to light touch.\nVII: No facial droop, facial musculature symmetric.\nVIII: Hearing intact to finger-rub bilaterally.\nIX, X: Palate elevates symmetrically.\nXI: ___ strength in trapezii bilaterally.\nXII: Tongue protrudes in midline with good excursions. Strength\nfull with tongue-in-cheek testing.\n\n-Motor: Normal bulk and tone throughout. There is right pronator\ndrift. No adventitious movements, such as tremor or asterixis\nnoted.\n [___]\nL 5- 5 5- 5 5 5 5 5 5 5 5 5\nR 5 5 5 5 5 5 5 5 5 5 5 5\n\n-Sensory: He reports decreased sensation to pinprick throughout\nthe right arm, circumferentially. Otherwise no deficits. No\nextinction to DSS. Romberg absent. \n\n-Reflexes:\n [Bic] [Tri] [___] [Pat] [Ach]\nL 2 2 2 1 1\nR 2 2 2 1 1 \nPlantar response was flexor bilaterally.\n\n-Coordination: No intention tremor. Normal finger-tap\nbilaterally. No dysmetria on FNF or HKS bilaterally.\n\n-Gait: Good initiation. Narrow-based, normal stride and arm\nswing. Able to walk in tandem without difficulty. \n\nDISCHARGE PHYSICAL EXAM\n==========================\nVitals: reviewed in metavision\nGeneral: pleasant and conversant, no acute distress\nHEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in\noropharynx.\nNeck: Supple, no carotid bruits appreciated. No nuchal rigidity.\nPulmonary: Normal work of breathing.\nCardiac: RRR, warm, well-perfused.\nAbdomen: Soft, non-distended.\nExtremities: No ___ edema.\nSkin: No rashes or lesions noted.\n \nNeurologic:\n-Mental Status: Alert, oriented x 3. Able to relate history\nwithout difficulty. Attentive. Language is fluent with intact\nrepetition and comprehension. Normal prosody. There were no\nparaphasic errors. No dysarthria. Able to follow both midline \nand\nappendicular commands. \n\n-Cranial Nerves:\nII, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without\nnystagmus. Normal saccades. VFF to confrontation. \nV: Facial sensation intact to light touch.\nVII: No facial droop, facial musculature symmetric.\nVIII: Hearing intact to finger-rub bilaterally.\nIX, X: Palate elevates symmetrically.\nXI: ___ strength in trapezii bilaterally.\nXII: Tongue protrudes in midline with good excursions. Strength\nfull with tongue-in-cheek testing.\n\n-Motor: Normal bulk and tone throughout. Right forearm minimal\ndownward drift. No adventitious movements, such as tremor or\nasterixis noted.\n [___]\nL 5 5 5 5 5 5 5 5 5 5 5 5\nR 5 5 5 5 5 5 5 5 5 5 5 5\n\n-Sensory: minimal right forearm paresthesias (\"tingling\"), no\nagraphesthesia. No extinction to DSS. Romberg absent. \n\n-Reflexes:\n [Bic] [Tri] [___] [Pat] [Ach]\nL 2 2 2 1 1\nR 2 2 2 1 1 \nPlantar response was flexor bilaterally.\n\n-Coordination: No intention tremor. Normal finger-tap\nbilaterally. No dysmetria on FNF bilaterally.\n\n-Gait: deferred\n\n \nPertinent Results:\nADMISSION LABS\n===============\n___ 11:39AM BLOOD WBC-7.3 RBC-5.17 Hgb-13.1* Hct-41.4 \nMCV-80* MCH-25.3* MCHC-31.6* RDW-14.4 RDWSD-41.9 Plt ___\n___ 11:39AM BLOOD Neuts-64.3 ___ Monos-5.8 Eos-4.1 \nBaso-0.7 Im ___ AbsNeut-4.69 AbsLymp-1.80 AbsMono-0.42 \nAbsEos-0.30 AbsBaso-0.05\n___ 03:08PM BLOOD ___ PTT-29.7 ___\n___ 11:39AM BLOOD Plt ___\n___ 11:39AM BLOOD Glucose-114* UreaN-22* Creat-1.2 Na-142 \nK-4.6 Cl-104 HCO3-23 AnGap-15\n___ 11:39AM BLOOD ALT-17 AST-28 AlkPhos-99 TotBili-0.7\n___ 11:39AM BLOOD Albumin-4.1 Calcium-9.2 Phos-2.7 Mg-1.8\n___ 11:39AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nTricycl-NEG\n\nIMAGING\n=========\nCT HEAD W/O CONTRAST Study Date of ___\nIMPRESSION: \n1. Largely unchanged left frontal intraparenchymal hemorrhage \nwithout \nsignificant mass effect. \n2. No evidence of new hemorrhage or large territorial \ninfarction. \n\nMR HEAD W & W/O CONTRAST Study Date of ___ \nIMPRESSION:\n1. Acute intraparenchymal hemorrhage in the left parietal lobe \nwith mild local edema and no significant midline shift. Due to \nextensive background chronic microvascular changes, the etiology \nis likely hypertensive. Other etiologies such as slow flow \nvascular lesions or small metastatic disease cannot be \ncompletely excluded. Recommend repeat imaging to document \nresolution of bleed. \n2. Periventricular and subcortical area of T2/FLAIR high-signal \nintensity are nonspecific and may reflect chronic \nmicroangiopathic changes. \n3. There is no evidence of abnormal enhancement after contrast \nadministration.\n\nCTA HEAD AND CTA NECK Study Date of ___ \nIMPRESSION: \n1. Subacute 1.8 cm hemorrhagic focus in the high left parietal \nlobe. \n2. Extensive atherosclerotic changes of the intracranial carotid \narteries \nwithout significant stenosis. \n3. Severe attenuation of flow within the left vertebral artery, \nextending from V1-V6, with a diminutive left vertebral artery. \nThis likely represents a chronic atherosclerotic process. \n4. No significant stenosis of the internal carotid arteries, by \nNASCET \ncriteria. \n5. Moderate to severe cervical spondylosis with moderate to \nsevere spinal \ncanal narrowing in the mid to lower cervical spine. Further \nevaluation with an MRI of the cervical spine without contrast \nmay be of benefit. \n\nDISCHARGE LABS\n===============\n___ 06:45AM BLOOD WBC-7.2 RBC-5.08 Hgb-12.9* Hct-41.3 \nMCV-81* MCH-25.4* MCHC-31.2* RDW-14.3 RDWSD-42.2 Plt ___\n___ 06:45AM BLOOD Plt ___\n___ 06:45AM BLOOD Glucose-129* UreaN-20 Creat-1.3* Na-139 \nK-4.5 Cl-102 HCO3-24 AnGap-13\n___ 06:45AM BLOOD Calcium-9.5 Phos-3.0 Mg-2.0\n \nBrief Hospital Course:\nMr ___ is an ___ year old man with atrial fibrillation \non Coumadin who presented with right arm weakness and sensory \nchanges at home. He was found to have a left postcentral gyrus \nintraparenchymal hemorrhage.\n\n#Left postcentral gyrus primary intraparenchymal hemorrhage:\nDeveloped right arm heightened sensation to cold and weakness \nover several hours at home. Initially presented to ___ \n___ where intraparenchymal hemorrhage was \ndiscovered, subsequently transferred to ___ ED. There, NIHSS 2 \n(Sensory, right arm motor), neurologic exam notable for UMN \npattern weakness and sensory deficit in the right arm. Initial \nCT demonstrated small left frontal intraparenchymal hemorrhage, \nMRI with left postcentral gyrus intraparenchymal hemorrhage. He \nnotably had an INR of 2.7 on admission, s/p K repletion. He was \nhypertensive to 150s on presentation which resolved after \nadministration of his home antihypertensives. His exam continued \nto improve throughout admission. At discharge, he had right \nforearm paresthesias (\"tingling\") and agraphasthesia with no \nmotor deficits. Etiology of his bleed most likely primary \nhemorrhage in setting of Coumadin use. Arteriovenous \nmalformation versus cavernous angioma also possible. Angiogram \nwas not pursued to further elucidate, as cavernous malformations \nunlikely to show up on angiogram, and risks of procedure \noutweigh benefits. CTA demonstrated no vascular malformations. \nLow suspicion for amyloid hemorrhage given no microbleeds on \nimaging. Risk factors were checked, notable for: A1C 6.3, LDL \n107. His home Coumadin was held, and he was not discharged on \nany anticoagulation given risk of bleeding. His home \natorvastatin was held and replaced with lovastatin 20 mg three \ntimes per week at discharge, as he reported myalgias with \natorvastatin. \n\n___:\nPeak Cr 1.4, downtrended to 1.3 prior to discharge. Likely in \nsetting of contrast load and prerenal from poor PO intake. Given \nfluid bolus prior to discharge.\n\n#Atrial fibrillation:\nHeld home Coumadin in setting of cerebral bleed as above. \nFractionated home metoprolol.\n\n#HTN:\nContinued home losartan, amlodipine.\n\n#HLD:\nHeld home atorvastatin in setting of cerebral bleed as above, \nalso reports myalgias with use.\n\n#DM:\nHeld home metformin. ISS in-house.\n\n#BPH:\nContinued home tamsulosin.\n\n#GERD:\nContinued home omeprazole.\n\nTRANSITIONAL ISSUES:\n=====================\n[] please check BMP at next PCP visit to monitor ___, Cr 1.4 at \ndischarge\n[] systolic blood pressure goal <150\n[] held Coumadin at discharge in setting of cerebral hemorrhage \n[] discontinued atorvastatin, initiated lovastatin, monitor \ntolerance and development of myalgias\n[] HgA1C: 6.3, continue to titrate home metformin\n[] bilateral calcified pleural plaques found on screening CXR, \ncontinue to monitor\n\nAHA/ASA Core Measures for Intracerebral Hemorrhage \n1. Dysphagia screening before any PO intake? (x) Yes - () No. If \nno, reason why: \n2. DVT Prophylaxis administered? () Yes - (x) No. BLEEDING RISK \nIf no, why not (bleeding risk, hemorrhage, etc.) \n3. Smoking cessation counseling given? () Yes - () No [reason \n(x) non-smoker - () unable to participate] \n4. Stroke education (personal modifiable risk factors, how to \nactivate EMS for stroke, stroke warning signs and symptoms, \nprescribed medications, need for followup) given in written \nform?\n(x) Yes - () No \n5. Assessment for rehabilitation and/or rehab services \nconsidered? (x) Yes - () No. If no, why not? (I.e. patient at \nbaseline functional status) \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Warfarin Dose is Unknown PO DAILY16 \n2. Losartan Potassium 50 mg PO DAILY \n3. Atorvastatin 10 mg PO 3X/WEEK (___) \n4. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY \n5. Tamsulosin 0.8 mg PO QHS \n6. Omeprazole 40 mg PO BID \n7. Furosemide 20 mg PO 4X/WEEK (___) \n8. amLODIPine 10 mg PO DAILY \n9. Metoprolol Succinate XL 100 mg PO DAILY \n\n \nDischarge Medications:\n1. Lovastatin 20 mg oral 3X/WEEK \nRX *lovastatin 20 mg 1 tablet(s) by mouth three times weekly \nDisp #*30 Tablet Refills:*0 \n2. amLODIPine 10 mg PO DAILY \n3. Furosemide 20 mg PO 4X/WEEK (___) \n4. Losartan Potassium 50 mg PO DAILY \n5. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY \n6. Metoprolol Succinate XL 100 mg PO DAILY \n7. Omeprazole 40 mg PO BID \n8. Tamsulosin 0.8 mg PO QHS \n9.Outpatient Occupational Therapy\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nLeft postcentral gyrus primary intraparenchymal hemorrhage\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\n You were hospitalized due to symptoms of right arm weakness and \nchanges in sensation resulting from an ACUTE HEMORRHAGIC STROKE, \na condition where a blood vessel providing oxygen and nutrients \nto the brain leaks blood. The brain is the part of your body \nthat controls and directs all the other parts of your body, so \ndamage to the brain can result in a variety of symptoms.\n\n Stroke can have many different causes, so we assessed you for \nmedical conditions that might raise your risk of having stroke. \nIn order to prevent future strokes, we plan to modify those risk \nfactors. Your risk factors are: \n 1) atrial fibrillation\n 2) high blood pressure\n 3) diabetes\n 4) high cholesterol\n\n We are changing your medications as follows: \n 1) we are stopping your blood thinner (\"Coumadin\") to reduce \nthe risk of future bleeding in your brain\n 2) we are changing your cholesterol lowering medication from \n\"atorvastatin\" to \"lovastatin\", we hope this will cause you less \nmuscle pain\n\n Please take your other medications as prescribed. \n Please follow up with Neurology and your primary care physician \nas listed below.\n\n If you experience any of the symptoms below, please seek \nemergency medical attention by calling Emergency Medical \nServices (dialing 911). In particular, since stroke can recur, \nplease pay attention to the sudden onset and persistence of \nthese symptoms: \n - Sudden partial or complete loss of vision \n - Sudden loss of the ability to speak words from your mouth \n - Sudden loss of the ability to understand others speaking to \nyou \n - Sudden weakness of one side of the body \n - Sudden drooping of one side of the face \n - Sudden loss of sensation of one side of the body\n\n Sincerely, \n Your ___ Neurology Team\n \nFollowup Instructions:\n___\n"
] | Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: right arm weakness, sensory changes Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is an [MASKED] year old with history of atrial fib on Coumadin who presents to the emergency as a transfer from [MASKED] after discovery of an intraparenchymal hemorrhage. History is obtained from the patient as well as from the CHA records. He states he was in his usual state of health when he went to bed last night. This morning he awoke at 4:30 to use the bathroom. He was able to urinate without straining or difficulty. He walked back to bed without any problem. He went back to sleep and awoke at 5:30am. He began to go about his day as normal. However, he soon after noticed that his right arm was tingling. He describes a diffuse tingling sensation from the shoulder into the finger tips of the right arm. He also thinks the arm was somewhat weak. He is not able to describe this in much detail, but he does note that he dropped a pen in his right hand. He was able to get the newspaper and make coffee without much difficulty. However, given the ongoing tingling and weakness, he called [MASKED] and was brought to CHA. BP on arrival there was 154/73. INR was 2.7. A CT head revealed a small left frontal intraparenchymal hemorrhage. He was given 10mg Vitamin K and transferred to [MASKED]. At [MASKED] he says his weakness seems somewhat better. He continues to experience tingling. In the ED he was given Kcentra for reversal of INR. Review of Systems: On neurological review of systems, the patient denies headache, confusion, difficulties producing or comprehending speech, loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. No bowel or bladder incontinence or retention. Denies difficulty with gait. On general review of systems, the patient denies recent fever, chills, night sweats, or recent weight changes. Denies cough, shortness of breath, chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. Denies dysuria, or recent change in bowel or bladder habits. Denies arthralgias, myalgias, or rash. Past Medical History: Atrial fibrillation Hypertension Hyperlipidemia Diastolic heart failure GERD Diabetes mellitus BPH Social History: [MASKED] Family History: Non-contributory Physical Exam: ADMISSION PHYSICAL EXAM ========================= Vitals: T: 98.4 BP: 135/54 HR: 88 RR: 22 SaO2: 94% RA General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx. Neck: Supple, no carotid bruits appreciated. No nuchal rigidity. Pulmonary: Normal work of breathing. Cardiac: RRR, warm, well-perfused. Abdomen: Soft, non-distended. Extremities: No [MASKED] edema. Skin: No rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name [MASKED] backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Able to name both high and low frequency objects. Able to read without difficulty. No dysarthria. Able to follow both midline and appendicular commands. -Cranial Nerves: II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without nystagmus. Normal saccades. VFF to confrontation. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: [MASKED] strength in trapezii bilaterally. XII: Tongue protrudes in midline with good excursions. Strength full with tongue-in-cheek testing. -Motor: Normal bulk and tone throughout. There is right pronator drift. No adventitious movements, such as tremor or asterixis noted. [[MASKED]] L 5- 5 5- 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 5 -Sensory: He reports decreased sensation to pinprick throughout the right arm, circumferentially. Otherwise no deficits. No extinction to DSS. Romberg absent. -Reflexes: [Bic] [Tri] [[MASKED]] [Pat] [Ach] L 2 2 2 1 1 R 2 2 2 1 1 Plantar response was flexor bilaterally. -Coordination: No intention tremor. Normal finger-tap bilaterally. No dysmetria on FNF or HKS bilaterally. -Gait: Good initiation. Narrow-based, normal stride and arm swing. Able to walk in tandem without difficulty. DISCHARGE PHYSICAL EXAM ========================== Vitals: reviewed in metavision General: pleasant and conversant, no acute distress HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx. Neck: Supple, no carotid bruits appreciated. No nuchal rigidity. Pulmonary: Normal work of breathing. Cardiac: RRR, warm, well-perfused. Abdomen: Soft, non-distended. Extremities: No [MASKED] edema. Skin: No rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. No dysarthria. Able to follow both midline and appendicular commands. -Cranial Nerves: II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without nystagmus. Normal saccades. VFF to confrontation. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: [MASKED] strength in trapezii bilaterally. XII: Tongue protrudes in midline with good excursions. Strength full with tongue-in-cheek testing. -Motor: Normal bulk and tone throughout. Right forearm minimal downward drift. No adventitious movements, such as tremor or asterixis noted. [[MASKED]] L 5 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 5 -Sensory: minimal right forearm paresthesias ("tingling"), no agraphesthesia. No extinction to DSS. Romberg absent. -Reflexes: [Bic] [Tri] [[MASKED]] [Pat] [Ach] L 2 2 2 1 1 R 2 2 2 1 1 Plantar response was flexor bilaterally. -Coordination: No intention tremor. Normal finger-tap bilaterally. No dysmetria on FNF bilaterally. -Gait: deferred Pertinent Results: ADMISSION LABS =============== [MASKED] 11:39AM BLOOD WBC-7.3 RBC-5.17 Hgb-13.1* Hct-41.4 MCV-80* MCH-25.3* MCHC-31.6* RDW-14.4 RDWSD-41.9 Plt [MASKED] [MASKED] 11:39AM BLOOD Neuts-64.3 [MASKED] Monos-5.8 Eos-4.1 Baso-0.7 Im [MASKED] AbsNeut-4.69 AbsLymp-1.80 AbsMono-0.42 AbsEos-0.30 AbsBaso-0.05 [MASKED] 03:08PM BLOOD [MASKED] PTT-29.7 [MASKED] [MASKED] 11:39AM BLOOD Plt [MASKED] [MASKED] 11:39AM BLOOD Glucose-114* UreaN-22* Creat-1.2 Na-142 K-4.6 Cl-104 HCO3-23 AnGap-15 [MASKED] 11:39AM BLOOD ALT-17 AST-28 AlkPhos-99 TotBili-0.7 [MASKED] 11:39AM BLOOD Albumin-4.1 Calcium-9.2 Phos-2.7 Mg-1.8 [MASKED] 11:39AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG IMAGING ========= CT HEAD W/O CONTRAST Study Date of [MASKED] IMPRESSION: 1. Largely unchanged left frontal intraparenchymal hemorrhage without significant mass effect. 2. No evidence of new hemorrhage or large territorial infarction. MR HEAD W & W/O CONTRAST Study Date of [MASKED] IMPRESSION: 1. Acute intraparenchymal hemorrhage in the left parietal lobe with mild local edema and no significant midline shift. Due to extensive background chronic microvascular changes, the etiology is likely hypertensive. Other etiologies such as slow flow vascular lesions or small metastatic disease cannot be completely excluded. Recommend repeat imaging to document resolution of bleed. 2. Periventricular and subcortical area of T2/FLAIR high-signal intensity are nonspecific and may reflect chronic microangiopathic changes. 3. There is no evidence of abnormal enhancement after contrast administration. CTA HEAD AND CTA NECK Study Date of [MASKED] IMPRESSION: 1. Subacute 1.8 cm hemorrhagic focus in the high left parietal lobe. 2. Extensive atherosclerotic changes of the intracranial carotid arteries without significant stenosis. 3. Severe attenuation of flow within the left vertebral artery, extending from V1-V6, with a diminutive left vertebral artery. This likely represents a chronic atherosclerotic process. 4. No significant stenosis of the internal carotid arteries, by NASCET criteria. 5. Moderate to severe cervical spondylosis with moderate to severe spinal canal narrowing in the mid to lower cervical spine. Further evaluation with an MRI of the cervical spine without contrast may be of benefit. DISCHARGE LABS =============== [MASKED] 06:45AM BLOOD WBC-7.2 RBC-5.08 Hgb-12.9* Hct-41.3 MCV-81* MCH-25.4* MCHC-31.2* RDW-14.3 RDWSD-42.2 Plt [MASKED] [MASKED] 06:45AM BLOOD Plt [MASKED] [MASKED] 06:45AM BLOOD Glucose-129* UreaN-20 Creat-1.3* Na-139 K-4.5 Cl-102 HCO3-24 AnGap-13 [MASKED] 06:45AM BLOOD Calcium-9.5 Phos-3.0 Mg-2.0 Brief Hospital Course: Mr [MASKED] is an [MASKED] year old man with atrial fibrillation on Coumadin who presented with right arm weakness and sensory changes at home. He was found to have a left postcentral gyrus intraparenchymal hemorrhage. #Left postcentral gyrus primary intraparenchymal hemorrhage: Developed right arm heightened sensation to cold and weakness over several hours at home. Initially presented to [MASKED] [MASKED] where intraparenchymal hemorrhage was discovered, subsequently transferred to [MASKED] ED. There, NIHSS 2 (Sensory, right arm motor), neurologic exam notable for UMN pattern weakness and sensory deficit in the right arm. Initial CT demonstrated small left frontal intraparenchymal hemorrhage, MRI with left postcentral gyrus intraparenchymal hemorrhage. He notably had an INR of 2.7 on admission, s/p K repletion. He was hypertensive to 150s on presentation which resolved after administration of his home antihypertensives. His exam continued to improve throughout admission. At discharge, he had right forearm paresthesias ("tingling") and agraphasthesia with no motor deficits. Etiology of his bleed most likely primary hemorrhage in setting of Coumadin use. Arteriovenous malformation versus cavernous angioma also possible. Angiogram was not pursued to further elucidate, as cavernous malformations unlikely to show up on angiogram, and risks of procedure outweigh benefits. CTA demonstrated no vascular malformations. Low suspicion for amyloid hemorrhage given no microbleeds on imaging. Risk factors were checked, notable for: A1C 6.3, LDL 107. His home Coumadin was held, and he was not discharged on any anticoagulation given risk of bleeding. His home atorvastatin was held and replaced with lovastatin 20 mg three times per week at discharge, as he reported myalgias with atorvastatin. [MASKED]: Peak Cr 1.4, downtrended to 1.3 prior to discharge. Likely in setting of contrast load and prerenal from poor PO intake. Given fluid bolus prior to discharge. #Atrial fibrillation: Held home Coumadin in setting of cerebral bleed as above. Fractionated home metoprolol. #HTN: Continued home losartan, amlodipine. #HLD: Held home atorvastatin in setting of cerebral bleed as above, also reports myalgias with use. #DM: Held home metformin. ISS in-house. #BPH: Continued home tamsulosin. #GERD: Continued home omeprazole. TRANSITIONAL ISSUES: ===================== [] please check BMP at next PCP visit to monitor [MASKED], Cr 1.4 at discharge [] systolic blood pressure goal <150 [] held Coumadin at discharge in setting of cerebral hemorrhage [] discontinued atorvastatin, initiated lovastatin, monitor tolerance and development of myalgias [] HgA1C: 6.3, continue to titrate home metformin [] bilateral calcified pleural plaques found on screening CXR, continue to monitor AHA/ASA Core Measures for Intracerebral Hemorrhage 1. Dysphagia screening before any PO intake? (x) Yes - () No. If no, reason why: 2. DVT Prophylaxis administered? () Yes - (x) No. BLEEDING RISK If no, why not (bleeding risk, hemorrhage, etc.) 3. Smoking cessation counseling given? () Yes - () No [reason (x) non-smoker - () unable to participate] 4. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given in written form? (x) Yes - () No 5. Assessment for rehabilitation and/or rehab services considered? (x) Yes - () No. If no, why not? (I.e. patient at baseline functional status) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Warfarin Dose is Unknown PO DAILY16 2. Losartan Potassium 50 mg PO DAILY 3. Atorvastatin 10 mg PO 3X/WEEK ([MASKED]) 4. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY 5. Tamsulosin 0.8 mg PO QHS 6. Omeprazole 40 mg PO BID 7. Furosemide 20 mg PO 4X/WEEK ([MASKED]) 8. amLODIPine 10 mg PO DAILY 9. Metoprolol Succinate XL 100 mg PO DAILY Discharge Medications: 1. Lovastatin 20 mg oral 3X/WEEK RX *lovastatin 20 mg 1 tablet(s) by mouth three times weekly Disp #*30 Tablet Refills:*0 2. amLODIPine 10 mg PO DAILY 3. Furosemide 20 mg PO 4X/WEEK ([MASKED]) 4. Losartan Potassium 50 mg PO DAILY 5. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY 6. Metoprolol Succinate XL 100 mg PO DAILY 7. Omeprazole 40 mg PO BID 8. Tamsulosin 0.8 mg PO QHS 9.Outpatient Occupational Therapy Discharge Disposition: Home Discharge Diagnosis: Left postcentral gyrus primary intraparenchymal hemorrhage Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], You were hospitalized due to symptoms of right arm weakness and changes in sensation resulting from an ACUTE HEMORRHAGIC STROKE, a condition where a blood vessel providing oxygen and nutrients to the brain leaks blood. The brain is the part of your body that controls and directs all the other parts of your body, so damage to the brain 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: 1) atrial fibrillation 2) high blood pressure 3) diabetes 4) high cholesterol We are changing your medications as follows: 1) we are stopping your blood thinner ("Coumadin") to reduce the risk of future bleeding in your brain 2) we are changing your cholesterol lowering medication from "atorvastatin" to "lovastatin", we hope this will cause you less muscle pain Please take your other medications as prescribed. Please follow up with Neurology and your primary care physician as listed below. If you experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - Sudden partial or complete loss of vision - Sudden loss of the ability to speak words from your mouth - Sudden loss of the ability to understand others speaking to you - Sudden weakness of one side of the body - Sudden drooping of one side of the face - Sudden loss of sensation of one side of the body Sincerely, Your [MASKED] Neurology Team Followup Instructions: [MASKED] | [
"I611",
"N179",
"I5032",
"D6832",
"I110",
"I4891",
"E119",
"G8321",
"R29702",
"N400",
"K219",
"E785",
"Z7901",
"Z87891",
"R202",
"T45515A",
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] | [
"I611: Nontraumatic intracerebral hemorrhage in hemisphere, cortical",
"N179: Acute kidney failure, unspecified",
"I5032: Chronic diastolic (congestive) heart failure",
"D6832: Hemorrhagic disorder due to extrinsic circulating anticoagulants",
"I110: Hypertensive heart disease with heart failure",
"I4891: Unspecified atrial fibrillation",
"E119: Type 2 diabetes mellitus without complications",
"G8321: Monoplegia of upper limb affecting right dominant side",
"R29702: NIHSS score 2",
"N400: Benign prostatic hyperplasia without lower urinary tract symptoms",
"K219: Gastro-esophageal reflux disease without esophagitis",
"E785: Hyperlipidemia, unspecified",
"Z7901: Long term (current) use of anticoagulants",
"Z87891: Personal history of nicotine dependence",
"R202: Paresthesia of skin",
"T45515A: Adverse effect of anticoagulants, initial encounter",
"Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause"
] | [
"N179",
"I5032",
"I110",
"I4891",
"E119",
"N400",
"K219",
"E785",
"Z7901",
"Z87891"
] | [] |
17,065,984 | 22,605,095 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\nPain after ___ drain placement \n \nMajor Surgical or Invasive Procedure:\n___: CT-guided drainage of the pelvic collection\n\n \nHistory of Present Illness:\nPer admission:\n\nMs. ___ is a ___ year old male with a history of IBS and \nalcohol use admitted for diverticulitis with abscess treated \nwith multiple drain placements. Starting ___ approximately he \nhad onset of severe lower abdominal and rectal\npain while on vacation in ___, prompting ER visit there. He \nalso reports low-grade fevers as high as 100.5. CT scan showed \nsigmoid diverticulitis with two fluid collections (1.1 x 2.5cm \ncollection in the left deep pelvis; 3 x 3.8cm collection in \nanterior mesorectum). He was treated with IV antibiotics for 4 \ndays and discharged on oral cipro/flagyl; drainage was discussed \nbut ultimately the collections were thought to not be drainable. \nSince returning to the ___, had persistent pain and was found on \nCT scan to have continued abscesses and had a drain placed on \n___. Discharged from the hospital on ___ in good condition. \n\nAt follow up with Dr ___ patient was doing well and had \nhis drain removed. On ___ the patient had fevers and \nrecurrence of his pain. He had ___ drain placement on ___ and \nwas stricken with pain running through his pelvis to his urethra \nand down his right leg. He was treated by His PCM for the pain \nand had UA/Cx which were negative. Re-evaluated on ___ and \nfound to not be amenable to drain replacement. On ___ the \npatient had the drain pulled at home on some furniture. He was \ntaken to the CT scanner today for replacement of the drain. On \npresentation the drain was malpositioned and there was a \nfistulous tract to the fluid collection 4x3cm. A new drain was \nplaced and frank pus aspirated. After the new drain was placed \nthe patient was in excruciating pain. A repeat scan was \nperformed and found no unusual findings. The patient was \nadmitted for pain control. \n\nOn arrival the patient complains of significant pain, with \nnausea and vomiting. He vomited once in ___ and now vomited once \nmore. He is unable to keep still and feels that he is most \ncomfortable in a fetal position. He has pain with movement RLQ \n>L but all over the abdomen.\n\n \nPast Medical History:\nPMH: \n parotid tumor s/p resection now with recurrence \n possible IBS \n \nPSH: \n lap appendectomy ___, ___ \n parotidectomy (___)\n \nSocial History:\n___\nFamily History:\nFather with diverticulitis. +heart disease\n \nPhysical Exam:\nAdmission Physical Exam:\n\nVS: Temp: 99.4 (Tm 99.4), BP: 123/81, HR: 98, RR: 18, O2 sat: \n98%\nGeneral- well-appearing, Moderate distress \nHEENT- PERRL, EOMI, sclera anicteric, moist mucus membranes \nCardiac- RRR \nChest- no increased WOB, CTAB\nAbdomen- soft, TTP diffusely but more tender in the LLQ. \nSignificant pain to movement of the hips. Rebound L>R and \nvoluntary guarding.\nRectal- normal anoderm, no gross blood, no palpable masses, high \nrectal tone. \nExt- WWP, no edema \n\nDischarge Physical Exam:\n\nVS: 97.6, 117/62, 72, 18, 98%/RA \nGeneral- well-appearing, Moderate distress \nHEENT- PERRL, EOMI, sclera anicteric, moist mucus membranes \nCardiac- RRR \nChest- no increased WOB, CTAB\nAbdomen- soft, tender to palpation in the LLQ, no guarding, \ndrain with feculent output\nExt- WWP, no edema \n \nPertinent Results:\n___ 06:30AM BLOOD WBC-5.6 RBC-3.38* Hgb-9.8* Hct-31.3* \nMCV-93 MCH-29.0 MCHC-31.3* RDW-12.8 RDWSD-43.5 Plt ___\n___ 06:36AM BLOOD WBC-11.2* RBC-4.04* Hgb-11.8* Hct-37.0* \nMCV-92 MCH-29.2 MCHC-31.9* RDW-13.0 RDWSD-43.3 Plt ___\n___ 09:35PM BLOOD WBC-14.9* RBC-4.17* Hgb-12.2* Hct-37.5* \nMCV-90 MCH-29.3 MCHC-32.5 RDW-12.8 RDWSD-42.2 Plt ___\n___ 10:45AM BLOOD ___\n___ 01:25PM BLOOD Glucose-83 UreaN-5* Creat-0.7 Na-144 \nK-4.4 Cl-106 HCO3-27 AnGap-11\n___ 06:30AM BLOOD Glucose-75 UreaN-6 Creat-0.6 Na-143 \nK-3.4* Cl-112* HCO3-22 AnGap-9*\n___ 06:36AM BLOOD Glucose-88 UreaN-8 Creat-0.9 Na-140 K-3.8 \nCl-102 HCO3-25 AnGap-13\n___ 09:35PM BLOOD Glucose-117* UreaN-7 Creat-0.8 Na-138 \nK-3.9 Cl-102 HCO3-24 AnGap-12\n___ 09:35PM BLOOD ALT-14 AST-13 AlkPhos-67 TotBili-0.6\n___ 01:25PM BLOOD Calcium-9.2 Phos-1.9* Mg-2.1\n___ 06:30AM BLOOD Calcium-7.3* Phos-1.7* Mg-1.7\n___ 06:36AM BLOOD Calcium-8.9 Phos-4.2 Mg-2.0\n___ 09:35PM BLOOD Calcium-9.0 Phos-3.4 Mg-1.8\n___ 09:35PM BLOOD CEA-1.5\n___ 09:46PM BLOOD Lactate-0.8\n\nImaging:\n \n\nCT ABD & PELVIS WITH CONTRAST Study Date of ___ 4:55 ___ \nIMPRESSION: \n1. No acute process in the abdomen or pelvis specifically- no \nhematoma or \nbowel perforation. \n2. Appropriately positioned trans-gluteal drainage catheter with \nresolution of the pelvic abscess. \n3. Decompressed fistulous track to the sigmoid colon. Stable \ninflammatory \nchanges in the pelvis. \n4. 2.5 cm hepatic lesion, new since ___, could represent an \nearly hepatic abscess. Further evaluation with ultrasound \nrecommended when feasible. \n\nABDOMEN (SUPINE & ERECT) Study Date of ___ 8:38 ___ \nIMPRESSION: \nNonspecific, nonobstructive bowel gas pattern. No \nintraperitoneal gas. The recently placed drain projects over \nthe low pelvis at midline. \n\nMRI LIVER W&W/O CONTRAST Study Date of ___ 6:41 ___ \nIMPRESSION: \nNo focal liver abnormality or abscess. The previously described \nanomaly at the CT scan has no correlate on this MRI. This is \nlikely due to \nperfusional/focal fat sparing. \n\n \nBrief Hospital Course:\nMr. ___ is a ___ year old male with a history of \ndiverticulitis with failure to respond to antibiotics and \ndevelopment of an abscess. He was admitted after the third drain \nplacement on ___ with acute pain. The patient's pain was \nmanaged with Tylenol and IV dilaudid for breakthrough pain. The \npatient's pain improved on day 1 after drain placement with pain \nmanagement and IV antibiotics. During the drain placement on CT, \na lesion was identified on his liver that was thought to be an \nabscess and radiology suggested ultrasound to better identify \nthe lesion. The patient had an ultrasound that did not identify \na lesion and recommended an MRI. He underwent an MRI on ___, \nhowever, the lesion was not seen and attributed the identified \nlesion on CT scan as perfusional or focal fat sparing. With \nadequate pain control, antibiotics, and no evidence of a lesion \non the liver, the patient was discharged on ___. At the time \nof discharge, the patient was tolerating a regular diet, passing \nflatus, voiding, and ambulating independently. He will follow-up \nin the clinic in ___ weeks. This information was communicated to \nthe patient directly prior to discharge.\n\nPost-Surgical Complications During Inpatient Admission:\n [ ] Post-Operative Ileus resolving w/o NGT\n [ ] Post-Operative Ileus requiring management with NGT\n [ ] UTI\n [ ] Wound Infection\n [ ] Anastomotic Leak\n [ ] Staple Line Bleed\n [ ] Congestive Heart failure\n [ ] ARF\n [ ] Acute Urinary retention, failure to void after Foley D/C'd\n [ ] Acute Urinary Retention requiring discharge with Foley \nCatheter\n [ ] DVT\n [ ] Pneumonia\n [ ] Abscess\n [x] None\n\nSocial Issues Causing a Delay in Discharge:\n [ ] Delay in organization of ___ services\n [ ] Difficulty finding appropriate rehab hospital disposition.\n [ ] Lack of insurance coverage for ___ services\n [ ] Lack of insurance coverage for prescribed medications.\n [ ] Family not agreeable to discharge plan.\n [ ] Patient knowledge deficit related to ileostomy delaying \ndispo\n [x] No social factors contributing in delay of discharge.\n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H \n2. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - \nModerate \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity\nRX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp \n#*20 Tablet Refills:*0 \n3. Sodium Chloride 0.9% Flush ___ mL IV Q8H and PRN, line \nflush \nRX *sodium chloride 0.9 % 0.9 % 10 cc per drain once a day \nRefills:*0 \n4. Sulfameth/Trimethoprim DS 2 TAB PO/NG BID \nRX *sulfamethoxazole-trimethoprim 800 mg-160 mg 2 tablet(s) by \nmouth twice a day Disp #*39 Tablet Refills:*0 \n5. Gabapentin 300 mg PO TID \nRX *gabapentin 100 mg 1 capsule(s) by mouth twice a day Disp \n#*28 Capsule Refills:*0 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nDiverticulitis \nAbscess \nAcute pain with ___ drain placement \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___, \n\nYou were admitted to the ___ \nwith pain after your interventional radiology drain was \nreplaced. During your CT scan in interventional radiology, a \n\"lesion\" was identified. You had both an ultrasound and MRI to \nevaluate the lesion and none were identified. \n\nYour pain is well controlled, your white blood cell count (a \nmarker for infection and initially elevated on presentation) has \nnormalized. You are now ready to be discharged home with your \ndrain and 10 days of oral antibiotics. Follow the instructions \nbelow for drain care. \n\nPlease look at the site every day for signs of infection \n(increased redness or pain, swelling, odor, yellow or bloody \ndischarge, warm to touch, fever). Maintain suction of the bulb. \nNote color, consistency, and amount of fluid in the drain. Call \nthe doctor or nurse practitioner if the amount increases \nsignificantly or changes in character. Flush the drain with 10cc \nof normal saline daily. Be sure to empty the drain frequently. \nRecord the output, if instructed to do so. You may shower; wash \nthe area gently with warm, soapy water. Keep the insertion site \nclean and dry otherwise. Avoid swimming, baths, hot tubs; do not \nsubmerge yourself in water. Make sure to keep the drain attached \nsecurely to your body to prevent pulling or dislocation.\n\nThank you for allowing us to participate in your care, we wish \nyou all the best! \n \nFollowup Instructions:\n___\n"
] | Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Pain after [MASKED] drain placement Major Surgical or Invasive Procedure: [MASKED]: CT-guided drainage of the pelvic collection History of Present Illness: Per admission: Ms. [MASKED] is a [MASKED] year old male with a history of IBS and alcohol use admitted for diverticulitis with abscess treated with multiple drain placements. Starting [MASKED] approximately he had onset of severe lower abdominal and rectal pain while on vacation in [MASKED], prompting ER visit there. He also reports low-grade fevers as high as 100.5. CT scan showed sigmoid diverticulitis with two fluid collections (1.1 x 2.5cm collection in the left deep pelvis; 3 x 3.8cm collection in anterior mesorectum). He was treated with IV antibiotics for 4 days and discharged on oral cipro/flagyl; drainage was discussed but ultimately the collections were thought to not be drainable. Since returning to the [MASKED], had persistent pain and was found on CT scan to have continued abscesses and had a drain placed on [MASKED]. Discharged from the hospital on [MASKED] in good condition. At follow up with Dr [MASKED] patient was doing well and had his drain removed. On [MASKED] the patient had fevers and recurrence of his pain. He had [MASKED] drain placement on [MASKED] and was stricken with pain running through his pelvis to his urethra and down his right leg. He was treated by His PCM for the pain and had UA/Cx which were negative. Re-evaluated on [MASKED] and found to not be amenable to drain replacement. On [MASKED] the patient had the drain pulled at home on some furniture. He was taken to the CT scanner today for replacement of the drain. On presentation the drain was malpositioned and there was a fistulous tract to the fluid collection 4x3cm. A new drain was placed and frank pus aspirated. After the new drain was placed the patient was in excruciating pain. A repeat scan was performed and found no unusual findings. The patient was admitted for pain control. On arrival the patient complains of significant pain, with nausea and vomiting. He vomited once in [MASKED] and now vomited once more. He is unable to keep still and feels that he is most comfortable in a fetal position. He has pain with movement RLQ >L but all over the abdomen. Past Medical History: PMH: parotid tumor s/p resection now with recurrence possible IBS PSH: lap appendectomy [MASKED], [MASKED] parotidectomy ([MASKED]) Social History: [MASKED] Family History: Father with diverticulitis. +heart disease Physical Exam: Admission Physical Exam: VS: Temp: 99.4 (Tm 99.4), BP: 123/81, HR: 98, RR: 18, O2 sat: 98% General- well-appearing, Moderate distress HEENT- PERRL, EOMI, sclera anicteric, moist mucus membranes Cardiac- RRR Chest- no increased WOB, CTAB Abdomen- soft, TTP diffusely but more tender in the LLQ. Significant pain to movement of the hips. Rebound L>R and voluntary guarding. Rectal- normal anoderm, no gross blood, no palpable masses, high rectal tone. Ext- WWP, no edema Discharge Physical Exam: VS: 97.6, 117/62, 72, 18, 98%/RA General- well-appearing, Moderate distress HEENT- PERRL, EOMI, sclera anicteric, moist mucus membranes Cardiac- RRR Chest- no increased WOB, CTAB Abdomen- soft, tender to palpation in the LLQ, no guarding, drain with feculent output Ext- WWP, no edema Pertinent Results: [MASKED] 06:30AM BLOOD WBC-5.6 RBC-3.38* Hgb-9.8* Hct-31.3* MCV-93 MCH-29.0 MCHC-31.3* RDW-12.8 RDWSD-43.5 Plt [MASKED] [MASKED] 06:36AM BLOOD WBC-11.2* RBC-4.04* Hgb-11.8* Hct-37.0* MCV-92 MCH-29.2 MCHC-31.9* RDW-13.0 RDWSD-43.3 Plt [MASKED] [MASKED] 09:35PM BLOOD WBC-14.9* RBC-4.17* Hgb-12.2* Hct-37.5* MCV-90 MCH-29.3 MCHC-32.5 RDW-12.8 RDWSD-42.2 Plt [MASKED] [MASKED] 10:45AM BLOOD [MASKED] [MASKED] 01:25PM BLOOD Glucose-83 UreaN-5* Creat-0.7 Na-144 K-4.4 Cl-106 HCO3-27 AnGap-11 [MASKED] 06:30AM BLOOD Glucose-75 UreaN-6 Creat-0.6 Na-143 K-3.4* Cl-112* HCO3-22 AnGap-9* [MASKED] 06:36AM BLOOD Glucose-88 UreaN-8 Creat-0.9 Na-140 K-3.8 Cl-102 HCO3-25 AnGap-13 [MASKED] 09:35PM BLOOD Glucose-117* UreaN-7 Creat-0.8 Na-138 K-3.9 Cl-102 HCO3-24 AnGap-12 [MASKED] 09:35PM BLOOD ALT-14 AST-13 AlkPhos-67 TotBili-0.6 [MASKED] 01:25PM BLOOD Calcium-9.2 Phos-1.9* Mg-2.1 [MASKED] 06:30AM BLOOD Calcium-7.3* Phos-1.7* Mg-1.7 [MASKED] 06:36AM BLOOD Calcium-8.9 Phos-4.2 Mg-2.0 [MASKED] 09:35PM BLOOD Calcium-9.0 Phos-3.4 Mg-1.8 [MASKED] 09:35PM BLOOD CEA-1.5 [MASKED] 09:46PM BLOOD Lactate-0.8 Imaging: CT ABD & PELVIS WITH CONTRAST Study Date of [MASKED] 4:55 [MASKED] IMPRESSION: 1. No acute process in the abdomen or pelvis specifically- no hematoma or bowel perforation. 2. Appropriately positioned trans-gluteal drainage catheter with resolution of the pelvic abscess. 3. Decompressed fistulous track to the sigmoid colon. Stable inflammatory changes in the pelvis. 4. 2.5 cm hepatic lesion, new since [MASKED], could represent an early hepatic abscess. Further evaluation with ultrasound recommended when feasible. ABDOMEN (SUPINE & ERECT) Study Date of [MASKED] 8:38 [MASKED] IMPRESSION: Nonspecific, nonobstructive bowel gas pattern. No intraperitoneal gas. The recently placed drain projects over the low pelvis at midline. MRI LIVER W&W/O CONTRAST Study Date of [MASKED] 6:41 [MASKED] IMPRESSION: No focal liver abnormality or abscess. The previously described anomaly at the CT scan has no correlate on this MRI. This is likely due to perfusional/focal fat sparing. Brief Hospital Course: Mr. [MASKED] is a [MASKED] year old male with a history of diverticulitis with failure to respond to antibiotics and development of an abscess. He was admitted after the third drain placement on [MASKED] with acute pain. The patient's pain was managed with Tylenol and IV dilaudid for breakthrough pain. The patient's pain improved on day 1 after drain placement with pain management and IV antibiotics. During the drain placement on CT, a lesion was identified on his liver that was thought to be an abscess and radiology suggested ultrasound to better identify the lesion. The patient had an ultrasound that did not identify a lesion and recommended an MRI. He underwent an MRI on [MASKED], however, the lesion was not seen and attributed the identified lesion on CT scan as perfusional or focal fat sparing. With adequate pain control, antibiotics, and no evidence of a lesion on the liver, the patient was discharged on [MASKED]. At the time of discharge, the patient was tolerating a regular diet, passing flatus, voiding, and ambulating independently. He will follow-up in the clinic in [MASKED] weeks. This information was communicated to the patient directly prior to discharge. Post-Surgical Complications During Inpatient Admission: [ ] 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 [ ] Abscess [x] None Social Issues Causing a Delay in Discharge: [ ] Delay in organization of [MASKED] services [ ] Difficulty finding appropriate rehab hospital disposition. [ ] Lack of insurance coverage for [MASKED] services [ ] Lack of insurance coverage for prescribed medications. [ ] Family not agreeable to discharge plan. [ ] Patient knowledge deficit related to ileostomy delaying dispo [x] No social factors contributing in delay of discharge. Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp #*20 Tablet Refills:*0 3. Sodium Chloride 0.9% Flush [MASKED] mL IV Q8H and PRN, line flush RX *sodium chloride 0.9 % 0.9 % 10 cc per drain once a day Refills:*0 4. Sulfameth/Trimethoprim DS 2 TAB PO/NG BID RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 2 tablet(s) by mouth twice a day Disp #*39 Tablet Refills:*0 5. Gabapentin 300 mg PO TID RX *gabapentin 100 mg 1 capsule(s) by mouth twice a day Disp #*28 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Diverticulitis Abscess Acute pain with [MASKED] drain placement Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], You were admitted to the [MASKED] with pain after your interventional radiology drain was replaced. During your CT scan in interventional radiology, a "lesion" was identified. You had both an ultrasound and MRI to evaluate the lesion and none were identified. Your pain is well controlled, your white blood cell count (a marker for infection and initially elevated on presentation) has normalized. You are now ready to be discharged home with your drain and 10 days of oral antibiotics. Follow the instructions below for drain care. Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). Maintain suction of the bulb. Note color, consistency, and amount of fluid in the drain. Call the doctor or nurse practitioner if the amount increases significantly or changes in character. Flush the drain with 10cc of normal saline daily. Be sure to empty the drain frequently. Record the output, if instructed to do so. You may shower; wash the area gently with warm, soapy water. Keep the insertion site clean and dry otherwise. Avoid swimming, baths, hot tubs; do not submerge yourself in water. Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. Thank you for allowing us to participate in your care, we wish you all the best! Followup Instructions: [MASKED] | [
"K5720",
"G8918",
"K589",
"F1290",
"Z7289"
] | [
"K5720: Diverticulitis of large intestine with perforation and abscess without bleeding",
"G8918: Other acute postprocedural pain",
"K589: Irritable bowel syndrome without diarrhea",
"F1290: Cannabis use, unspecified, uncomplicated",
"Z7289: Other problems related to lifestyle"
] | [] | [] |
11,059,274 | 20,179,544 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\nVaginal bleed\n \nMajor Surgical or Invasive Procedure:\nXRT x 10 doses\n \nHistory of Present Illness:\nMs. ___ is a ___ year-old lady with a history of advanced \ngynecologic adenocarcinoma (likely endometrial), bilateral PEs \ns/p IVC and CKD IIIb who presents from rehab with vaginal \nbleeding. \n\nOf note patient got C2 of carboplatin and C1 of taxol 2 weeks \nago, precise date not clear. \n\nMrs. ___ has had intermittent vaginal bleeding for the past \n3 months but for the last 4 days her bleeding has been more \nprofuse and with large clots. She has been feeling lightheaded \nand fatigued. She remembers receiving a blood transfusion \n(unclear amount of units) this week. Her bleeding got worse \nuntil yesterday and has since then decreased in quantity. Given \nongoing bleed, finding of Hb drop from 9.4->7.4 and Plt drop fro \n18->7 she was transferred to the ___ ED. \n\nIn the ED, initial vitals: 111/72 | 114 | 18 | 99% RA \n- Exam notable for: active but scant vaginal bleeding\n- Labs were notable for: \n*CBC:WBC 2.4 NPh 33%, Hb 6.7, Plt 9\n*Chem: Cr 1.5 (1.08 on ___\n*Coag: PTT 19.7 INR 1.0\n-BP transiently dropped to 71/27, HR up to 127\n- Patient was given: ondansetron 4mg iv x1, 2U PRBC, 1U \nPlatelets\n- Consults: Gyn Onc recommended \n\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY: \n# Presumed endometrial adenocarcinoma\ns/p C1 of Carboplatin\n# Recurrent malignant pleural effusion\ns/p ___\n\n-___ MEDICAL HISTORY: \n# Bilateral PEs in ___ s/p lysis, IVC filter on enoxaparin\n# CKD stage III/IV of unclear etiology - ___ admission\n# Chronic Lymphedema\n# HTN\n# Morbid Obesity\n\n \nSocial History:\n___\nFamily History:\nNo history blood clots. 1 Uncle had lung cancer in ___ heavy \nsmoker. \n \nPhysical Exam:\nDischarge\n\nVitals: Afeb 143/76 92 18 100% RA\nGENERAL: Chronically ill-appearing. In no acute distress \nHEENT: Sclera anicteric, pale conjunctiva, dry MM, oropharynx \nclear \nNECK: supple, JVP not elevated, no LAD \nLUNGS: Decreased breath sounds in both bases. R>L. \nPleurx tube CDI. Port in place\nCV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, \ngallops \nABD: soft, non-tender, non-distended, bowel sounds present, no \nrebound tenderness or guarding, no organomegaly \nEXT: Marked edema to groin, erythema, rash on bilateral shins \nand extending medially. not warm. equal bilaterally.\nSKIN: Multiple ecchymotic lesions in chest\nNEURO: Alert, oriented. No gross focal signs. \n \nPertinent Results:\n__________________________________________________________\n___ 7:35 pm MRSA SCREEN Source: Nasal swab. \n\n **FINAL REPORT ___\n\n MRSA SCREEN (Final ___: \n POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS. \n\nIMAGING:\n\nCT NON-CON AB ___:\n \nIMPRESSION: \n \n \n1. No evidence of hematoma in the abdomen or pelvis. \n2. No definite evidence of metastatic disease, though evaluation \nis limited \ngiven the lack of intravenous contrast. \n \nCXR ___:\n \nComparison to ___. Decrease in extent of a \npre-existing pleural \neffusion on the right. The effusion is now limited to the \ncostophrenic sinus. \nOn the left, a pre-existing retrocardiac atelectasis has \nimproved. The \nfeeding tube has been removed. \n\nADMISSION LABS:\n\n___ 11:44PM WBC-2.7* RBC-2.32* HGB-7.4* HCT-21.5* MCV-93 \nMCH-31.9 MCHC-34.4 RDW-15.9* RDWSD-53.1*\n___ 11:44PM PLT COUNT-41*\n___ 09:20AM BLOOD WBC-7.1 RBC-2.79* Hgb-8.9* Hct-26.7* \nMCV-96 MCH-31.9 MCHC-33.3 RDW-16.1* RDWSD-54.8* Plt ___\n___ 05:20AM BLOOD UreaN-20 Creat-1.1 Na-139 K-3.6 Cl-105 \nHCO3-26 AnGap-___ with hx of stage IV endometrial cancer, malignant pleural \neffusions recurrent requiring Pleur-X, PE s/p IVC filter, CKD \nstage III, morbid obesity chronically bed-bound, severe chronic \nlymphedema presenting from ___ rehab with severe vaginal \nbleeding in the setting of severe chemotherapy induced \npancytopenia with platelet count of 7. \n\n1. UTERINE HEMORRHAGE WITH HYPOTENSION: Has endometrial lesion \nthought to be culprit in the setting of severe thrombocytopenia \nto 7 and concurrent lovenox use. Hemodynamics improved with \nblood transfusions. Received 5U prbc's, 2 units of platelets. \nGyn-onc did not recommend any surgical intervention. She began \npelvic radiation with a projected 10 treatment course which \nshould limit further bleeding. Her thrombocytopenia improved and \nher lovenox was held. She had scant bleeding at around a pad a \nday towards the end of her hospitalization with a very stable \nH/H for many days. \n\nIn discussion with patient decision was to hold Lovenox held \nindefinitely. She received anticoagulation since ___ which \nhopefully is adequate to treat that PE. She is obviously at high \nrisk of clot given malignancy and IVC filter, but given poor \nprognosis and bleeding felt risks outweighed benefits. \n\n2. PANCYTOPENIA: Likely chemo-induced by ___. She \nreceived neupogen with recovery of her WBC count. Her platelets \nimproved spontaneously following transfusion. By discharge her \nCBC was normal.\n\n3. STAGE IV PRESUMED ENDOMETRIAL ADENOCARCINOMA / GOALS OF CARE: \nNot amenable to surgical management. Per oncologist Dr. ___, \nshe is not a candidate for further chemotherapy given a very \npoor functional status (essentially bed bound). XRT delivered to \nlimit further uterine hemorrhage. She received 10 doses of XRT, \nlast ___. \n\n4. STASIS CHANGES IN LEGS: She has severe edema bilateral legs \nwith associated stasis changes. given lack of fever, wbc normal, \nbilateral did not treat with antibiotics. \n\n5. CKD stage III baseline creatinine 1.3-1.8:stable\n- avoid nephrotoxins\n\n6. HTN: Holding HCTZ in setting of hypotension, BP is fine \nwithout\nit.\n\n7. Low urine output: Likely related to poor inputs. Cr stable. \nwe pulled long standing foley and there were no high post-void \nresiduals\n\n8. Discharge planning/prognosis: Pt DNR/DNI. Patient recognizes \nher very poor prognosis. Her main goal is to be home for some \nmore time with her daughter/granddaughter for a bit more time. \nher poor functional status and bed-bound\nstatus poses multiple obstacles for her daughter and her family- \nshe would need around the clock care as the family is gone \nthroughout the weekdays. \n\nHer goal is to work with ___ at ___ to regain the ability to walk \nand therefore retrun home with hospice. regaining ability to \nwalk may be a lofty goal\ngiven how long she's been bedbound and it might have to be that \nshe enters hospice at ___. \n\nTRANSITIONAL ISSUES:\n- aggressive ___ with goal of home with hospice. If not \nsuccessful, ? ___ with hospice\n- could consider wrapping legs with ACE to decrease edema and \npotentially improve mobility\n- f/u with oncology set up in case helpful to patient\n- no follow-up with rad onc necessary\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Docusate Sodium 100 mg PO TID \n2. ___ ___ UNIT PO Q6H \n3. Omeprazole 40 mg PO DAILY \n4. Hydrochlorothiazide 25 mg PO DAILY \n5. Potassium Chloride 40 mEq PO DAILY \n6. Scopolamine Patch 1 PTCH TD Q72H \n7. Enoxaparin Sodium 150 mg SC DAILY \n8. Hydrocerin 1 Appl TP BID \n9. Miconazole Powder 2% 1 Appl TP BID \n10. Mupirocin Ointment 2% 1 Appl TP Q24H \n11. Acetaminophen 650 mg PO Q6H:PRN pain \n12. Bisacodyl 10 mg PR QHS:PRN constipation \n13. Guaifenesin-Dextromethorphan 10 mL PO Q4H:PRN cough \n14. LORazepam 0.25 mg PO Q6H:PRN anxiety \n15. Ondansetron 4 mg PO Q8H:PRN nausea \n16. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain \n17. Sarna Lotion 1 Appl TP QID:PRN itching \n18. Senna 17.2 mg PO DAILY:PRN constipation \n19. Sodium Chloride Nasal 2 SPRY NU BID:PRN nasal dryness \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN pain \n2. Bisacodyl 10 mg PR QHS:PRN constipation \n3. Guaifenesin-Dextromethorphan 10 mL PO Q4H:PRN cough \n4. Hydrocerin 1 Appl TP BID \n5. LORazepam 0.25 mg PO Q6H:PRN anxiety \n6. Miconazole Powder 2% 1 Appl TP BID \n7. Omeprazole 40 mg PO DAILY \n8. Ondansetron 4 mg PO Q8H:PRN nausea \n9. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain \n10. Sarna Lotion 1 Appl TP QID:PRN itching \n11. Senna 17.2 mg PO DAILY:PRN constipation \n12. Sodium Chloride Nasal 2 SPRY NU BID:PRN nasal dryness \n13. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n14. Docusate Sodium 100 mg PO TID \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \n___ Diagnosis:\nEndometrial cancer\nPancytopenia due to chemotherapy\n\n \nDischarge Condition:\nMental Status: Confused - sometimes.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nYou were admitted due to severe vaginal bleeding caused by your \nendometrial cancer. You also had very low blood counts as a side \neffect of chemotherapy. You received several blood transfusions \nand were started on radiation treatment to treat the bleeding.\n \nFollowup Instructions:\n___\n"
] | Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Vaginal bleed Major Surgical or Invasive Procedure: XRT x 10 doses History of Present Illness: Ms. [MASKED] is a [MASKED] year-old lady with a history of advanced gynecologic adenocarcinoma (likely endometrial), bilateral PEs s/p IVC and CKD IIIb who presents from rehab with vaginal bleeding. Of note patient got C2 of carboplatin and C1 of taxol 2 weeks ago, precise date not clear. Mrs. [MASKED] has had intermittent vaginal bleeding for the past 3 months but for the last 4 days her bleeding has been more profuse and with large clots. She has been feeling lightheaded and fatigued. She remembers receiving a blood transfusion (unclear amount of units) this week. Her bleeding got worse until yesterday and has since then decreased in quantity. Given ongoing bleed, finding of Hb drop from 9.4->7.4 and Plt drop fro 18->7 she was transferred to the [MASKED] ED. In the ED, initial vitals: 111/72 | 114 | 18 | 99% RA - Exam notable for: active but scant vaginal bleeding - Labs were notable for: *CBC:WBC 2.4 NPh 33%, Hb 6.7, Plt 9 *Chem: Cr 1.5 (1.08 on [MASKED] *Coag: PTT 19.7 INR 1.0 -BP transiently dropped to 71/27, HR up to 127 - Patient was given: ondansetron 4mg iv x1, 2U PRBC, 1U Platelets - Consults: Gyn Onc recommended Past Medical History: PAST ONCOLOGIC HISTORY: # Presumed endometrial adenocarcinoma s/p C1 of Carboplatin # Recurrent malignant pleural effusion s/p [MASKED] -[MASKED] MEDICAL HISTORY: # Bilateral PEs in [MASKED] s/p lysis, IVC filter on enoxaparin # CKD stage III/IV of unclear etiology - [MASKED] admission # Chronic Lymphedema # HTN # Morbid Obesity Social History: [MASKED] Family History: No history blood clots. 1 Uncle had lung cancer in [MASKED] heavy smoker. Physical Exam: Discharge Vitals: Afeb 143/76 92 18 100% RA GENERAL: Chronically ill-appearing. In no acute distress HEENT: Sclera anicteric, pale conjunctiva, dry MM, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: Decreased breath sounds in both bases. R>L. Pleurx tube CDI. Port in place 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: Marked edema to groin, erythema, rash on bilateral shins and extending medially. not warm. equal bilaterally. SKIN: Multiple ecchymotic lesions in chest NEURO: Alert, oriented. No gross focal signs. Pertinent Results: [MASKED] [MASKED] 7:35 pm MRSA SCREEN Source: Nasal swab. **FINAL REPORT [MASKED] MRSA SCREEN (Final [MASKED]: POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS. IMAGING: CT NON-CON AB [MASKED]: IMPRESSION: 1. No evidence of hematoma in the abdomen or pelvis. 2. No definite evidence of metastatic disease, though evaluation is limited given the lack of intravenous contrast. CXR [MASKED]: Comparison to [MASKED]. Decrease in extent of a pre-existing pleural effusion on the right. The effusion is now limited to the costophrenic sinus. On the left, a pre-existing retrocardiac atelectasis has improved. The feeding tube has been removed. ADMISSION LABS: [MASKED] 11:44PM WBC-2.7* RBC-2.32* HGB-7.4* HCT-21.5* MCV-93 MCH-31.9 MCHC-34.4 RDW-15.9* RDWSD-53.1* [MASKED] 11:44PM PLT COUNT-41* [MASKED] 09:20AM BLOOD WBC-7.1 RBC-2.79* Hgb-8.9* Hct-26.7* MCV-96 MCH-31.9 MCHC-33.3 RDW-16.1* RDWSD-54.8* Plt [MASKED] [MASKED] 05:20AM BLOOD UreaN-20 Creat-1.1 Na-139 K-3.6 Cl-105 HCO3-26 AnGap-[MASKED] with hx of stage IV endometrial cancer, malignant pleural effusions recurrent requiring Pleur-X, PE s/p IVC filter, CKD stage III, morbid obesity chronically bed-bound, severe chronic lymphedema presenting from [MASKED] rehab with severe vaginal bleeding in the setting of severe chemotherapy induced pancytopenia with platelet count of 7. 1. UTERINE HEMORRHAGE WITH HYPOTENSION: Has endometrial lesion thought to be culprit in the setting of severe thrombocytopenia to 7 and concurrent lovenox use. Hemodynamics improved with blood transfusions. Received 5U prbc's, 2 units of platelets. Gyn-onc did not recommend any surgical intervention. She began pelvic radiation with a projected 10 treatment course which should limit further bleeding. Her thrombocytopenia improved and her lovenox was held. She had scant bleeding at around a pad a day towards the end of her hospitalization with a very stable H/H for many days. In discussion with patient decision was to hold Lovenox held indefinitely. She received anticoagulation since [MASKED] which hopefully is adequate to treat that PE. She is obviously at high risk of clot given malignancy and IVC filter, but given poor prognosis and bleeding felt risks outweighed benefits. 2. PANCYTOPENIA: Likely chemo-induced by [MASKED]. She received neupogen with recovery of her WBC count. Her platelets improved spontaneously following transfusion. By discharge her CBC was normal. 3. STAGE IV PRESUMED ENDOMETRIAL ADENOCARCINOMA / GOALS OF CARE: Not amenable to surgical management. Per oncologist Dr. [MASKED], she is not a candidate for further chemotherapy given a very poor functional status (essentially bed bound). XRT delivered to limit further uterine hemorrhage. She received 10 doses of XRT, last [MASKED]. 4. STASIS CHANGES IN LEGS: She has severe edema bilateral legs with associated stasis changes. given lack of fever, wbc normal, bilateral did not treat with antibiotics. 5. CKD stage III baseline creatinine 1.3-1.8:stable - avoid nephrotoxins 6. HTN: Holding HCTZ in setting of hypotension, BP is fine without it. 7. Low urine output: Likely related to poor inputs. Cr stable. we pulled long standing foley and there were no high post-void residuals 8. Discharge planning/prognosis: Pt DNR/DNI. Patient recognizes her very poor prognosis. Her main goal is to be home for some more time with her daughter/granddaughter for a bit more time. her poor functional status and bed-bound status poses multiple obstacles for her daughter and her family- she would need around the clock care as the family is gone throughout the weekdays. Her goal is to work with [MASKED] at [MASKED] to regain the ability to walk and therefore retrun home with hospice. regaining ability to walk may be a lofty goal given how long she's been bedbound and it might have to be that she enters hospice at [MASKED]. TRANSITIONAL ISSUES: - aggressive [MASKED] with goal of home with hospice. If not successful, ? [MASKED] with hospice - could consider wrapping legs with ACE to decrease edema and potentially improve mobility - f/u with oncology set up in case helpful to patient - no follow-up with rad onc necessary Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Docusate Sodium 100 mg PO TID 2. [MASKED] [MASKED] UNIT PO Q6H 3. Omeprazole 40 mg PO DAILY 4. Hydrochlorothiazide 25 mg PO DAILY 5. Potassium Chloride 40 mEq PO DAILY 6. Scopolamine Patch 1 PTCH TD Q72H 7. Enoxaparin Sodium 150 mg SC DAILY 8. Hydrocerin 1 Appl TP BID 9. Miconazole Powder 2% 1 Appl TP BID 10. Mupirocin Ointment 2% 1 Appl TP Q24H 11. Acetaminophen 650 mg PO Q6H:PRN pain 12. Bisacodyl 10 mg PR QHS:PRN constipation 13. Guaifenesin-Dextromethorphan 10 mL PO Q4H:PRN cough 14. LORazepam 0.25 mg PO Q6H:PRN anxiety 15. Ondansetron 4 mg PO Q8H:PRN nausea 16. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain 17. Sarna Lotion 1 Appl TP QID:PRN itching 18. Senna 17.2 mg PO DAILY:PRN constipation 19. Sodium Chloride Nasal 2 SPRY NU BID:PRN nasal dryness Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Bisacodyl 10 mg PR QHS:PRN constipation 3. Guaifenesin-Dextromethorphan 10 mL PO Q4H:PRN cough 4. Hydrocerin 1 Appl TP BID 5. LORazepam 0.25 mg PO Q6H:PRN anxiety 6. Miconazole Powder 2% 1 Appl TP BID 7. Omeprazole 40 mg PO DAILY 8. Ondansetron 4 mg PO Q8H:PRN nausea 9. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain 10. Sarna Lotion 1 Appl TP QID:PRN itching 11. Senna 17.2 mg PO DAILY:PRN constipation 12. Sodium Chloride Nasal 2 SPRY NU BID:PRN nasal dryness 13. Polyethylene Glycol 17 g PO DAILY:PRN constipation 14. Docusate Sodium 100 mg PO TID Discharge Disposition: Extended Care Facility: [MASKED] [MASKED] Diagnosis: Endometrial cancer Pancytopenia due to chemotherapy Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted due to severe vaginal bleeding caused by your endometrial cancer. You also had very low blood counts as a side effect of chemotherapy. You received several blood transfusions and were started on radiation treatment to treat the bleeding. Followup Instructions: [MASKED] | [
"C541",
"R571",
"J910",
"I959",
"D61810",
"D6959",
"N183",
"E6601",
"N938",
"T451X5A",
"Y9289",
"Z86711",
"Z7902",
"I129",
"I890",
"Z801",
"I872",
"Z66",
"K219",
"Z6835"
] | [
"C541: Malignant neoplasm of endometrium",
"R571: Hypovolemic shock",
"J910: Malignant pleural effusion",
"I959: Hypotension, unspecified",
"D61810: Antineoplastic chemotherapy induced pancytopenia",
"D6959: Other secondary thrombocytopenia",
"N183: Chronic kidney disease, stage 3 (moderate)",
"E6601: Morbid (severe) obesity due to excess calories",
"N938: Other specified abnormal uterine and vaginal bleeding",
"T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter",
"Y9289: Other specified places as the place of occurrence of the external cause",
"Z86711: Personal history of pulmonary embolism",
"Z7902: Long term (current) use of antithrombotics/antiplatelets",
"I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease",
"I890: Lymphedema, not elsewhere classified",
"Z801: Family history of malignant neoplasm of trachea, bronchus and lung",
"I872: Venous insufficiency (chronic) (peripheral)",
"Z66: Do not resuscitate",
"K219: Gastro-esophageal reflux disease without esophagitis",
"Z6835: Body mass index [BMI] 35.0-35.9, adult"
] | [
"Z7902",
"I129",
"Z66",
"K219"
] | [] |
16,817,333 | 22,898,410 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nAcute appendicitis\n \nMajor Surgical or Invasive Procedure:\nLaparoscopic appendectomy\n\n \nHistory of Present Illness:\n___ Pt presents to ED with mid to right abd pain which started \n___. Pt has move bowels, denies vomiting. Has had chills, \ndenies fevers, but+chills. Denies any no nausea or emesis and \nrefers having loose stools ___ total over 2 days. no sick \ncontacts\n\nROS:\n(+) per HPI\n(-) Denies fevers,night sweats, unexplained weight\nloss, fatigue/malaise/lethargy, changes in appetite, trouble \nwith\nsleep, pruritis, jaundice, rashes, bleeding, easy bruising,\nheadache, dizziness, vertigo, syncope, weakness, paresthesias,\nnausea, vomiting, hematemesis, bloating, cramping, melena, \nBRBPR,\ndysphagia, chest pain, shortness of breath, cough, edema, \nurinary\nfrequency, urgency\n \nPast Medical History:\nPast Medical History: None\n\nPast Surgical History: foot surgery\n\n \nSocial History:\n___\nFamily History:\nFamily History: non contributary\n \nPhysical Exam:\nPhysical Exam on Admission:\nVitals: 98.6 65 125/63 16 97% RA \nGEN: A&O, NAD\nHEENT: No scleral icterus, mucus membranes moist\nCV: RRR, No M/G/R\nPULM: Clear to auscultation b/l, No W/R/R\nABD: Soft, nondistended, tender to palpation on RLQ, + rebound \nnormoactive bowel sounds, no palpable masses\nExt: No ___ edema, ___ warm and well perfused\n\nPhysical Exam on Discharge:\nVitals: 98.8 67 120/65 18 99% RA \nGEN: A&O, NAD\nHEENT: No scleral icterus, mucus membranes moist\nCV: RRR, No M/G/R\nPULM: Clear to auscultation b/l, No W/R/R\nABD: Soft, nondistended, nontender, lap site dressings C/D/I, no \npalpable masses\nExt: No ___ edema, ___ warm and well perfused\n\n \nPertinent Results:\nLaboratory:\n11.9 > 16.0/44.4 < 177 \n\n___: 12.3 PTT: 31.0 INR: 1.1 \n\n136 99 10 \n-------------< 94 \n3.9 22 1.0 \n\nImaging:\n\nCT abdomen & Pelvis: Acute uncomplicated appendicitis.\n\n \nBrief Hospital Course:\nThe patient was admitted to the General Surgical Service on \n___ for evaluation and treatment of abdominal pain. \nAdmission abdominal/pelvic CT revealed acute appendicitis, WBC \nwas elevated at 11.9. The patient underwent laparoscopic \nappendectomy, which went well without complication (reader \nreferred to the Operative Note for details). After a brief, \nuneventful stay in the PACU, the patient arrived on the floor \ntolerating a regular diet, on IV fluids, and PO oxycodone for \npain control. The patient was hemodynamically stable.\n\nWhen tolerating a diet, the patient was continued on oral pain \nmedication with continued good effect. Diet was progressively \nadvanced as tolerated to a regular diet with good tolerability. \nThe patient voided without problem. During this hospitalization, \nthe patient ambulated early and frequently, was adherent with \nrespiratory toilet and incentive spirometry, and actively \nparticipated in the plan of care. The patient received \nsubcutaneous heparin and venodyne boots were used during this \nstay.\n\nAt the time of discharge, the patient was doing well, afebrile \nwith stable vital signs. The patient was tolerating a regular \ndiet, ambulating, voiding without assistance, and pain was well \ncontrolled. The patient was discharged home without services. \nThe patient received discharge teaching and follow-up \ninstructions with understanding verbalized and agreement with \nthe discharge plan.\n\n \nMedications on Admission:\nNone\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild \nRX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by \nmouth every 6 hours Disp #*30 Tablet Refills:*0 \n2. Docusate Sodium 100 mg PO BID \nRX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice \na day Disp #*30 Capsule Refills:*0 \n3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \nRX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours Disp #*20 \nTablet Refills:*0 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nAcute appendicitis\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nYou were admitted to ___ with \nacute appendicitis and underwent laparoscopic appendectomy. You \nare recovering well and are now ready for discharge. Please \nfollow the instructions below to continue your recovery:\n\nLap Appendectomy:\n\nYou were admitted to the hospital with acute appendicitis. You \nwere taken to the operating room and had your appendix removed \nlaparoscopically. You tolerated the procedure well and are now \nbeing discharged home to continue your recovery with the \nfollowing instructions.\n \nPlease follow up in the Acute Care Surgery clinic at the \nappointment listed below.\n \nACTIVITY:\n \no Do not drive until you have stopped taking pain medicine and \nfeel you could respond in an emergency.\no You may climb stairs. \no You may go outside, but avoid traveling long distances until \nyou see your surgeon at your next visit.\no Don't lift more than ___ lbs for 4 weeks. (This is about \nthe weight of a briefcase or a bag of groceries.) This applies \nto lifting children, but they may sit on your lap.\no You may start some light exercise when you feel comfortable.\no You will need to stay out of bathtubs or swimming pools for a \ntime while your incision is healing. Ask your doctor when you \ncan resume tub baths or swimming.\n \nHOW YOU MAY FEEL: \no You may feel weak or \"washed out\" for a couple of weeks. You \nmight want to nap often. Simple tasks may exhaust you.\no You may have a sore throat because of a tube that was in your \nthroat during surgery.\no You might have trouble concentrating or difficulty sleeping. \nYou might feel somewhat depressed.\no You could have a poor appetite for a while. Food may seem \nunappealing.\no All of these feelings and reactions are normal and should go \naway in a short time. If they do not, tell your surgeon.\n \nYOUR INCISION:\no Tomorrow you may shower and remove the gauzes over your \nincisions. Under these dressing you have small plastic bandages \ncalled steri-strips. Do not remove steri-strips for 2 weeks. \n(These are the thin paper strips that might be on your \nincision.) But if they fall off before that that's okay).\no Your incisions may be slightly red around the stitches. This \nis normal.\no You may gently wash away dried material around your incision.\no Avoid direct sun exposure to the incision area.\no Do not use any ointments on the incision unless you were told \notherwise.\no You may see a small amount of clear or light red fluid \nstaining your dressing or clothes. If the staining is severe, \nplease call your surgeon.\no You may shower. As noted above, ask your doctor when you may \nresume tub baths or swimming.\n \nYOUR BOWELS:\no Constipation is a common side effect of narcotic pain \nmedications. If needed, you may take a stool softener (such as \nColace, one capsule) or gentle laxative (such as milk of \nmagnesia, 1 tbs) twice a day. You can get both of these \nmedicines without a prescription.\no If you go 48 hours without a bowel movement, or have pain \nmoving the bowels, call your surgeon. \n \nPAIN MANAGEMENT:\no It is normal to feel some discomfort/pain following abdominal \nsurgery. This pain is often described as \"soreness\". \no Your pain should get better day by day. If you find the pain \nis getting worse instead of better, please contact your surgeon.\no You will receive a prescription for pain medicine to take by \nmouth. It is important to take this medicine as directed. o Do \nnot take it more frequently than prescribed. Do not take more \nmedicine at one time than prescribed.\no Your pain medicine will work better if you take it before your \npain gets too severe.\no Talk with your surgeon about how long you will need to take \nprescription pain medicine. Please don't take any other pain \nmedicine, including non-prescription pain medicine, unless your \nsurgeon has said its okay.\no If you are experiencing no pain, it is okay to skip a dose of \npain medicine.\no Remember to use your \"cough pillow\" for splinting when you \ncough or when you are doing your deep breathing exercises.\nIf you experience any of the following, please contact your \nsurgeon:\n- sharp pain or any severe pain that lasts several hours\n- pain that is getting worse over time\n- pain accompanied by fever of more than 101\n- a drastic change in nature or quality of your pain\n \nMEDICATIONS:\nTake all the medicines you were on before the operation just as \nyou did before, unless you have been told differently.\nIf you have any questions about what medicine to take or not to \ntake, please call your surgeon.\n\n \nFollowup Instructions:\n___\n"
] | Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Acute appendicitis Major Surgical or Invasive Procedure: Laparoscopic appendectomy History of Present Illness: [MASKED] Pt presents to ED with mid to right abd pain which started [MASKED]. Pt has move bowels, denies vomiting. Has had chills, denies fevers, but+chills. Denies any no nausea or emesis and refers having loose stools [MASKED] total over 2 days. no sick contacts ROS: (+) per HPI (-) Denies fevers,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: Past Medical History: None Past Surgical History: foot surgery Social History: [MASKED] Family History: Family History: non contributary Physical Exam: Physical Exam on Admission: Vitals: 98.6 65 125/63 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, tender to palpation on RLQ, + rebound normoactive bowel sounds, no palpable masses Ext: No [MASKED] edema, [MASKED] warm and well perfused Physical Exam on Discharge: Vitals: 98.8 67 120/65 18 99% RA GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, nontender, lap site dressings C/D/I, no palpable masses Ext: No [MASKED] edema, [MASKED] warm and well perfused Pertinent Results: Laboratory: 11.9 > 16.0/44.4 < 177 [MASKED]: 12.3 PTT: 31.0 INR: 1.1 136 99 10 -------------< 94 3.9 22 1.0 Imaging: CT abdomen & Pelvis: Acute uncomplicated appendicitis. Brief Hospital Course: The patient was admitted to the General Surgical Service on [MASKED] for evaluation and treatment of abdominal pain. Admission abdominal/pelvic CT revealed acute appendicitis, WBC was elevated at 11.9. The patient underwent laparoscopic appendectomy, which went well without complication (reader referred to the Operative Note for details). After a brief, uneventful stay in the PACU, the patient arrived on the floor tolerating a regular diet, on IV fluids, and PO oxycodone for pain control. The patient was hemodynamically stable. When tolerating a diet, the patient was continued on oral pain medication with continued good effect. Diet was progressively advanced as tolerated to a regular diet with good tolerability. The patient voided without problem. During this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirometry, and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged home without services. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: None Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by mouth every 6 hours Disp #*30 Tablet Refills:*0 2. 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 3. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours Disp #*20 Tablet 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: Dear Mr. [MASKED], You were admitted to [MASKED] with acute appendicitis and underwent laparoscopic appendectomy. You are recovering well and are now ready for discharge. Please follow the instructions below to continue your recovery: Lap Appendectomy: 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 to continue your recovery with the following instructions. Please follow up in the Acute Care Surgery clinic at the appointment listed below. ACTIVITY: o Do not drive until you have stopped taking pain medicine and feel you could respond in an emergency. o You may climb stairs. o You may go outside, but avoid traveling long distances until you see your surgeon at your next visit. o Don't lift more than [MASKED] lbs for 4 weeks. (This is about the weight of a briefcase or a bag of groceries.) This applies to lifting children, but they may sit on your lap. o You may start some light exercise when you feel comfortable. o You will need to stay out of bathtubs or swimming pools for a time while your incision is healing. Ask your doctor when you can resume tub baths or swimming. HOW YOU MAY FEEL: o You may feel weak or "washed out" for a couple of weeks. You might want to nap often. Simple tasks may exhaust you. o You may have a sore throat because of a tube that was in your throat during surgery. o You might have trouble concentrating or difficulty sleeping. You might feel somewhat depressed. o You could have a poor appetite for a while. Food may seem unappealing. o All of these feelings and reactions are normal and should go away in a short time. If they do not, tell your surgeon. YOUR INCISION: o Tomorrow you may shower and remove the gauzes over your incisions. Under these dressing you have small plastic bandages called steri-strips. Do not remove steri-strips for 2 weeks. (These are the thin paper strips that might be on your incision.) But if they fall off before that that's okay). o Your incisions may be slightly red around the stitches. This is normal. o You may gently wash away dried material around your incision. o Avoid direct sun exposure to the incision area. o Do not use any ointments on the incision unless you were told otherwise. o You may see a small amount of clear or light red fluid staining your dressing or clothes. If the staining is severe, please call your surgeon. o You may shower. As noted above, ask your doctor when you may resume tub baths or swimming. YOUR BOWELS: o Constipation is a common side effect of narcotic pain medications. If needed, you may take a stool softener (such as Colace, one capsule) or gentle laxative (such as milk of magnesia, 1 tbs) twice a day. You can get both of these medicines without a prescription. o If you go 48 hours without a bowel movement, or have pain moving the bowels, call your surgeon. PAIN MANAGEMENT: o It is normal to feel some discomfort/pain following abdominal surgery. This pain is often described as "soreness". o Your pain should get better day by day. If you find the pain is getting worse instead of better, please contact your surgeon. o You will receive a prescription for pain medicine to take by mouth. It is important to take this medicine as directed. o Do not take it more frequently than prescribed. Do not take more medicine at one time than prescribed. o Your pain medicine will work better if you take it before your pain gets too severe. o Talk with your surgeon about how long you will need to take prescription pain medicine. Please don't take any other pain medicine, including non-prescription pain medicine, unless your surgeon has said its okay. o If you are experiencing no pain, it is okay to skip a dose of pain medicine. o Remember to use your "cough pillow" for splinting when you cough or when you are doing your deep breathing exercises. If you experience any of the following, please contact your surgeon: - sharp pain or any severe pain that lasts several hours - pain that is getting worse over time - pain accompanied by fever of more than 101 - a drastic change in nature or quality of your pain MEDICATIONS: Take all the medicines you were on before the operation just as you did before, unless you have been told differently. If you have any questions about what medicine to take or not to take, please call your surgeon. Followup Instructions: [MASKED] | [
"K3580",
"Z23"
] | [
"K3580: Unspecified acute appendicitis",
"Z23: Encounter for immunization"
] | [] | [] |
10,747,475 | 28,720,293 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: NEUROLOGY\n \nAllergies: \nCephalosporins / Sulfa (Sulfonamide Antibiotics) / Penicillins\n \nAttending: ___.\n \nChief Complaint:\nleft facial droop \n \nMajor Surgical or Invasive Procedure:\nnone \n\n \nHistory of Present Illness:\nNeurology Resident Stroke Admission Note \n\n Neurology at bedside for evaluation after code stroke \nactivation\nwithin: 10 minutes\n\n Time/Date the patient was last known well: 11:10 AM on ___\n\n Pre-stroke mRS ___ social history for description): 0\n\nt-PA Administration\n [] Yes - Time given:\n [x] No - Reason t-PA was not given/considered: Low NIHSS\n\nEndovascular intervention: []Yes [x]No\n\n I was present during the CT scanning and reviewed the images\nwithin 20 minutes of their completion.\n\n ___ Stroke Scale - Total [3]\n\n 1a. Level of Consciousness -\n 1b. LOC Questions -\n 1c. LOC Commands -\n 2. Best Gaze -\n 3. Visual Fields -\n 4. Facial Palsy - 1 (left)\n 5a. Motor arm, left -\n 5b. Motor arm, right -\n 6a. Motor leg, left -\n 6b. Motor leg, right -\n 7. Limb Ataxia -\n 8. Sensory - 1 (left leg)\n 9. Language -\n 10. Dysarthria - 1\n 11. Extinction and Neglect -\n\nHPI: \nMr. ___ is a ___ man with a history of liver\ntransplant for hepatitis C cirrhosis and hepatocellular\ncarcinoma, and hypertension, who presents after developing \nsudden\nroom spinning and lightheadedness.\n\nHe states that he was in the ___ for clinic\nappointments. He was getting lunch in the cafeteria, and was\nlast well at 11:10 AM. Then suddenly he developed a sensation \nof\nroom spinning, with lightheadedness, and feeling \"rubbery\" and\nweak all over. His vision was blurry and he felt a \"rash\" in \nhis\nchest. He thought he might feel better if he was able to lie\ndown, so he went to the ___ floor of the far building, where \nhis\nsupport group is located, to lie down. A caseworker who knows\nhim well saw him at approximately noon and noted that he had\nweakness of his left face and slurring of the speech. He was\nbrought to the ED for further evaluation.\n\nCurrently the patient states he feels slightly better, but is\nstill not back to normal.\n\nROS: As per HPI. All other systems negative.\n\n \nPast Medical History:\n1. hepatitis C/alcoholic cirrhosis c/b HCC status post liver\ntransplantation ___, complicated by recurrent hep C\ninfection requiring recent initiation of therapy ___.\n2. Persistent transaminitis attributed to recurrent hep C \nvirus.\n3. Possible latent TB.\n4. History of cellulitis of the left great toe, resolved.\n5. History of MSSA infection with associated line infection.\n6. ORIF R elbow L shoulder, pelvis, ___ PTX after ___ fall.\n7. Alcohol abuse and alcoholic Cirrhosis c/w esophogeal and \ngastric varices with bleeding x1 in ___, encephalopathy \n\n \nSocial History:\n___\nFamily History:\nMother died at age ___ she had hypertension and diabetes. Father \n \nis alive in his ___ with hypertension. He has three sisters in \n\ngood health. No family history of liver disease or liver cancer. \n \n. \n\n \nPhysical Exam:\nAdmission physical exam\n\nVitals: \n98.0 72 138/78 19 97% RA \n General: NAD\n HEENT: NCAT, no oropharyngeal lesions, neck supple\n ___: RRR, no M/R/G, no carotid bruits\n Pulmonary: CTAB, no crackles or wheezes\n Abdomen: Soft, NT, ND, +BS, no guarding\n Extremities: Warm, no edema\n\n Neurologic Examination:\n\n- Mental status: Awake, alert, oriented x 3. Able to relate\nhistory without difficulty. Attentive, able to name ___ backward\nwithout difficulty. Speech is fluent with full sentences, intact\nrepetition, and intact verbal comprehension. Naming intact. No\nparaphasias. Mild dysarthria. Normal prosody. Able to register \n3\nobjects and recall ___ at 5 minutes. No evidence of \nhemineglect.\nAble to follow both midline and appendicular commands.\n\n - Cranial Nerves: PERRL 3->2 brisk. VF full to number counting.\nEOMI, no nystagmus. V1-V3 without deficits to light touch or\npinprick bilaterally. Left nasolabial fold flattening with\nslightly slower activation on the left. Hearing intact to finger\nrub bilaterally. Palate elevation symmetric. SCM/Trapezius\nstrength ___ bilaterally. Tongue midline.\n\n - Motor: Normal bulk and tone. No drift. No tremor or\nasterixis.\n [___]\n L 5 5 5 5 ___ 5 5 5 5 5\n R 5 5 5 5 ___ 5 5 5 5 5 \n \n - Reflexes: \nAreflexic throughout\nPlantar response flexor bilaterally \n\n - Sensory: Left leg decreased fine touch (70% of normal),\ndecreased pinprick (60% of normal), normal proprioception. \nOtherwise, sensation intact. Normal graphesthesia. No\nextinction to DSS.\n\n - Coordination: No dysmetria with finger to nose or heel to \nshin\ntesting bilaterally.\n\n - Gait: Normal initiation. Narrow base. Slightly unsteady but\nno listing to one side.\n\n=\n=\n=\n=\n=\n=\n=\n=\n================================================================\nDischarge physical exam\n\nObjective: \nVitals: Tc 98.2 BP 127/78 (112-139/70-80) HR 64 (59-66) RR 18 \nSpO2 90% RA (90-98RA) \nGeneral: NAD \nHEENT: NCAT, no oropharyngeal lesions, neck supple \n___: Warm, well perfused \nPulmonary: No increased work of breathing on room air \nAbdomen: Soft, ND\nExtremities: Warm, no edema \n\nNeurologic Examination: \nMS: Awake, alert, oriented x3. Able to relate overnight and \nsubjective concerns without difficulty. Language is fluent with \nfull sentences , intact repetition, and intact verbal \ncomprehension. No paraphasias. No dysarthria appreciated on \nrepetition of ___, ___, papa. Normal prosody. No \nleft-right confusion. Able to follow both midline and \nappendicular commands. \n \nCranial Nerves: EOMI, no nystagmus, no diplopia on prolonged \nupgaze. No facial movement asymmetry. Hearing intact. Tongue \nmidline. \n\nMotor - Normal bulk and tone. No fatigability with repetitive \nmuscle movements. \n [Delt] [Bic] [Tri] [ECR] [IP] [FEx] [Ffx] [IO] [TA] \n[Gas]\nL 5 5 5 5 5 5 5 5 5 5 \n \nR 5 5 5 5 5 5 5 5 5 5 \n \n\nSensory - No deficits to light touch appreciated.\n\nCoordination - No dysmetria with finger to nose testing \nbilaterally. Good speed and intact cadence with rapid \nalternating movements. \n\nGait - Normal initiation, narrow base, normal stride length and \narm swing. Negative Romberg- stable without sway. \n\n \nPertinent Results:\nCT brain negative for acute infarct. CTA notable for mild \natherosclerosis in the b/l internal carotid arteries and carotid \nsiphons. \n\nMRI w/o contrast \n1. No acute intracranial abnormality including hemorrhage, \ninfarct, or \nsuggestion of mass. \n2. Trace scattered white matter signal abnormality, nonspecific, \nwhich may \nreflect chronic small vessel ischemic disease. \n3. Minimal paranasal sinus disease, as described. \n\nECHO: No atrial septal defect or patent foramen ovale is seen by \n2D, color Doppler or saline contrast with maneuvers. Moderate \nleft atrial dilation and mild right atrial dilation. Grade I \n(mild) left ventricular diastolic dysfunction. Normal \nbiventricular cavity size and systolic function\n\nLDL 113\nA1c 4.5\nTSH 0.57\nTroponin <0.01\n\n140 104 16\n============<91\n3.7 25 0.9 \n\nCa 8.6 Mg 1.9 P 3.3 \n \n 13.2 \n6.7> ---------< 153\n 40.2\n \nBrief Hospital Course:\nThis is a ___ male with history of HCV cirrhosis and HCC \ns/p liver transplant in ___ and HTN who presented with sudden \nonset vertigo, with reported L facial droop and dysarthria. Exam \nlargely improved with slight dysarthria and L facial droop \n(markedly improved from admission). CT brain negative for acute \ninfarct. CTA notable for mild atherosclerosis in the b/l \ninternal carotid arteries and carotid siphons. MRI findings \nwhich were negative for stroke. Overall presentation of \nremaining subtle left sided findings suspicious of small infarct \nnot seen on MRI vs TIA. At this time etiology is unclear. There \nis no history of cardiac disease nor atrial fibrillation (with \nnone captured while monitored inpatient thus far) to suggest \ncardioembolic source. However will recommend patient undergo a \n___ of Hearts holtor monitor as outpatient. \n\nHospital course by system\n\n# Neuro: \n- F/u stroke risk factors: A1c 4.5, TSH 0.57, ldl 113\n- Started ASA 81 mg daily\n- pcp to begin LDL therapy as outpatient \n- Dr. ___ patient for liver transplant) notified \nregarding potential initiation of LDL therapy in the future \n- ___ consulted, cleared for d/c home\n- Distributed stroke education packet\n\n# ___: \n- Monitored on telemetry, no evidence of afib\n- ___ of Hearts monitor as outpatient \n- Goal SBP <180 and DBP <105 as above \n- Hold home amlodipine for permissive hypertension to facilitate \nincreased cerebral perfusion pressure, restart on ___ \n\n#ID/Tox/Metabolic:\n- UA: likely contaminant \n- CXR: no focal consolidation \n- LFTs within normal limits\n- Continue home everolimus as pt is s/p liver transplant on \nchronic immunosupression\n\n#Endocrine\n- TSH, A1c pending\n- QID FSG with HISS with goal of normoglycemia\n\n#Renal and FEN: \n- Regular diet as passed RN bedside swallow screen \n \n#Ppx: \n- DVT: Pneumoboots, SQH\n- Bowel: Docusate, Senna prn \n- Precautions: Fall \n- Code status: Full \n- Dispo: home \n\nTransitional issues:\n- outpatient ___ of Hearts monitor \n- PCP to monitor LDL and initiate statin therapy\n- hold home amlodipine till ___ to allow for sbp autoregulation \n\n- started on ASA, continue 81mg ASA as outpatient \n\nAHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic \nAttack\n1. Dysphagia screening before any PO intake? (x) Yes, confirmed \ndone - () Not confirmed â () No\n2. DVT Prophylaxis administered? (x) Yes - () No\n3. Antithrombotic therapy administered by end of hospital day 2? \n(x) Yes - () No\n4. LDL documented? (x) Yes (LDL = 113 ) - () No\n5. Intensive statin therapy administered? (simvastatin 80mg, \nsimvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, \nrosuvastatin 20mg or 40mg, for LDL > 100) (x) Yes - () No [if \nLDL >100, reason not given: waiting for approval from liver \ntransplant physicians as patient of everolimus and statins may \ninteract, pcp to initiate treatment as outpatient]\n6. Smoking cessation counseling given? (x) Yes - () No [reason \n() non-smoker - () unable to participate]\n7. Stroke education (personal modifiable risk factors, how to \nactivate EMS for stroke, stroke warning signs and symptoms, \nprescribed medications, need for followup) given (verbally or \nwritten)? (x) Yes - () No\n8. Assessment for rehabilitation or rehab services considered? \n(x) Yes - () No\n9. Discharged on statin therapy? (x) Yes - () No [if LDL >100, \nreason not given: pcp to initiate ]\n10. Discharged on antithrombotic therapy? (x) Yes [Type: (x) \nAntiplatelet - () Anticoagulation] - () No\n11. Discharged on oral anticoagulation for patients with atrial \nfibrillation/flutter? () Yes - () No - (x) N/A\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. BuPROPion (Sustained Release) 200 mg PO BID \n2. amLODIPine 10 mg PO DAILY \n3. Pantoprazole 40 mg PO Q24H \n4. TraZODone 100 mg PO QHS \n\n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \nRX *aspirin [Aspir-81] 81 mg 1 tablet(s) by mouth once a day \nDisp #*30 Tablet Refills:*11 \n2. Atorvastatin 40 mg PO QPM \nRX *atorvastatin 40 mg 1 tablet(s) by mouth qpm Disp #*30 Tablet \nRefills:*11 \n3. Calcium Carbonate 1000 mg PO DAILY \n4. Cetirizine 10 mg PO DAILY \n5. Everolimus 3 mg PO BID \n6. Multivitamins 1 TAB PO DAILY \n7. BuPROPion (Sustained Release) 200 mg PO BID \n8. Pantoprazole 40 mg PO Q24H \n9. TraZODone 100 mg PO QHS \n10. HELD- amLODIPine 10 mg PO DAILY This medication was held. \nDo not restart amLODIPine until ___\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nTIA \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nYou were hospitalized due to symptoms of left facial droop \nresulting from an TRANSIENT ISCHEMIC ATTACK, a condition where a \nblood vessel providing oxygen and nutrients to the brain is \ntemporarily blocked by a clot. The brain is the part of your \nbody that controls and directs all the other parts of your body, \nso damage to the brain from being deprived of its blood supply \ncan result in a variety of symptoms.\nStroke can have many different causes, so we assessed you for \nmedical conditions that might raise your risk of having stroke. \nIn order to prevent future strokes, we plan to modify those risk \nfactors. Your risk factors are:\nHigh lipids \nHigh blood pressure \n\nWe are changing your medications as follows:\nStarted on Aspirin \n\nPlease take your other medications as prescribed.\n\nPlease followup with Neurology and your primary care physician.\nIf you experience any of the symptoms below, please seek \nemergency medical attention by calling Emergency Medical \nServices (dialing 911). In particular, since stroke can recur, \nplease pay attention to the sudden onset and persistence of \nthese symptoms:\n- Sudden partial or complete loss of vision\n- Sudden loss of the ability to speak words from your mouth\n- Sudden loss of the ability to understand others speaking to \nyou\n- Sudden weakness of one side of the body\n- Sudden drooping of one side of the face\n- Sudden loss of sensation of one side of the body\n\nSincerely,\nYour ___ Neurology Team\n \nFollowup Instructions:\n___\n"
] | Allergies: Cephalosporins / Sulfa (Sulfonamide Antibiotics) / Penicillins Chief Complaint: left facial droop Major Surgical or Invasive Procedure: none History of Present Illness: Neurology Resident Stroke Admission Note Neurology at bedside for evaluation after code stroke activation within: 10 minutes Time/Date the patient was last known well: 11:10 AM on [MASKED] Pre-stroke mRS [MASKED] social history for description): 0 t-PA Administration [] Yes - Time given: [x] No - Reason t-PA was not given/considered: Low NIHSS Endovascular intervention: []Yes [x]No I was present during the CT scanning and reviewed the images within 20 minutes of their completion. [MASKED] Stroke Scale - Total [3] 1a. Level of Consciousness - 1b. LOC Questions - 1c. LOC Commands - 2. Best Gaze - 3. Visual Fields - 4. Facial Palsy - 1 (left) 5a. Motor arm, left - 5b. Motor arm, right - 6a. Motor leg, left - 6b. Motor leg, right - 7. Limb Ataxia - 8. Sensory - 1 (left leg) 9. Language - 10. Dysarthria - 1 11. Extinction and Neglect - HPI: Mr. [MASKED] is a [MASKED] man with a history of liver transplant for hepatitis C cirrhosis and hepatocellular carcinoma, and hypertension, who presents after developing sudden room spinning and lightheadedness. He states that he was in the [MASKED] for clinic appointments. He was getting lunch in the cafeteria, and was last well at 11:10 AM. Then suddenly he developed a sensation of room spinning, with lightheadedness, and feeling "rubbery" and weak all over. His vision was blurry and he felt a "rash" in his chest. He thought he might feel better if he was able to lie down, so he went to the [MASKED] floor of the far building, where his support group is located, to lie down. A caseworker who knows him well saw him at approximately noon and noted that he had weakness of his left face and slurring of the speech. He was brought to the ED for further evaluation. Currently the patient states he feels slightly better, but is still not back to normal. ROS: As per HPI. All other systems negative. Past Medical History: 1. hepatitis C/alcoholic cirrhosis c/b HCC status post liver transplantation [MASKED], complicated by recurrent hep C infection requiring recent initiation of therapy [MASKED]. 2. Persistent transaminitis attributed to recurrent hep C virus. 3. Possible latent TB. 4. History of cellulitis of the left great toe, resolved. 5. History of MSSA infection with associated line infection. 6. ORIF R elbow L shoulder, pelvis, [MASKED] PTX after [MASKED] fall. 7. Alcohol abuse and alcoholic Cirrhosis c/w esophogeal and gastric varices with bleeding x1 in [MASKED], encephalopathy Social History: [MASKED] Family History: Mother died at age [MASKED] she had hypertension and diabetes. Father is alive in his [MASKED] with hypertension. He has three sisters in good health. No family history of liver disease or liver cancer. . Physical Exam: Admission physical exam Vitals: 98.0 72 138/78 19 97% RA General: NAD HEENT: NCAT, no oropharyngeal lesions, neck supple [MASKED]: RRR, no M/R/G, no carotid bruits Pulmonary: CTAB, no crackles or wheezes Abdomen: Soft, NT, ND, +BS, no guarding Extremities: Warm, no edema Neurologic Examination: - Mental status: Awake, alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name [MASKED] backward without difficulty. Speech is fluent with full sentences, intact repetition, and intact verbal comprehension. Naming intact. No paraphasias. Mild dysarthria. Normal prosody. Able to register 3 objects and recall [MASKED] at 5 minutes. No evidence of hemineglect. Able to follow both midline and appendicular commands. - Cranial Nerves: PERRL 3->2 brisk. VF full to number counting. EOMI, no nystagmus. V1-V3 without deficits to light touch or pinprick bilaterally. Left nasolabial fold flattening with slightly slower activation on the left. Hearing intact to finger rub bilaterally. Palate elevation symmetric. SCM/Trapezius strength [MASKED] bilaterally. Tongue midline. - Motor: Normal bulk and tone. No drift. No tremor or asterixis. [[MASKED]] L 5 5 5 5 [MASKED] 5 5 5 5 5 R 5 5 5 5 [MASKED] 5 5 5 5 5 - Reflexes: Areflexic throughout Plantar response flexor bilaterally - Sensory: Left leg decreased fine touch (70% of normal), decreased pinprick (60% of normal), normal proprioception. Otherwise, sensation intact. Normal graphesthesia. No extinction to DSS. - Coordination: No dysmetria with finger to nose or heel to shin testing bilaterally. - Gait: Normal initiation. Narrow base. Slightly unsteady but no listing to one side. = = = = = = = = ================================================================ Discharge physical exam Objective: Vitals: Tc 98.2 BP 127/78 (112-139/70-80) HR 64 (59-66) RR 18 SpO2 90% RA (90-98RA) General: NAD HEENT: NCAT, no oropharyngeal lesions, neck supple [MASKED]: Warm, well perfused Pulmonary: No increased work of breathing on room air Abdomen: Soft, ND Extremities: Warm, no edema Neurologic Examination: MS: Awake, alert, oriented x3. Able to relate overnight and subjective concerns without difficulty. Language is fluent with full sentences , intact repetition, and intact verbal comprehension. No paraphasias. No dysarthria appreciated on repetition of [MASKED], [MASKED], papa. Normal prosody. No left-right confusion. Able to follow both midline and appendicular commands. Cranial Nerves: EOMI, no nystagmus, no diplopia on prolonged upgaze. No facial movement asymmetry. Hearing intact. Tongue midline. Motor - Normal bulk and tone. No fatigability with repetitive muscle movements. [Delt] [Bic] [Tri] [ECR] [IP] [FEx] [Ffx] [IO] [TA] [Gas] L 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 Sensory - No deficits to light touch appreciated. 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. Negative Romberg- stable without sway. Pertinent Results: CT brain negative for acute infarct. CTA notable for mild atherosclerosis in the b/l internal carotid arteries and carotid siphons. MRI w/o contrast 1. No acute intracranial abnormality including hemorrhage, infarct, or suggestion of mass. 2. Trace scattered white matter signal abnormality, nonspecific, which may reflect chronic small vessel ischemic disease. 3. Minimal paranasal sinus disease, as described. ECHO: No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. Moderate left atrial dilation and mild right atrial dilation. Grade I (mild) left ventricular diastolic dysfunction. Normal biventricular cavity size and systolic function LDL 113 A1c 4.5 TSH 0.57 Troponin <0.01 140 104 16 ============<91 3.7 25 0.9 Ca 8.6 Mg 1.9 P 3.3 13.2 6.7> ---------< 153 40.2 Brief Hospital Course: This is a [MASKED] male with history of HCV cirrhosis and HCC s/p liver transplant in [MASKED] and HTN who presented with sudden onset vertigo, with reported L facial droop and dysarthria. Exam largely improved with slight dysarthria and L facial droop (markedly improved from admission). CT brain negative for acute infarct. CTA notable for mild atherosclerosis in the b/l internal carotid arteries and carotid siphons. MRI findings which were negative for stroke. Overall presentation of remaining subtle left sided findings suspicious of small infarct not seen on MRI vs TIA. At this time etiology is unclear. There is no history of cardiac disease nor atrial fibrillation (with none captured while monitored inpatient thus far) to suggest cardioembolic source. However will recommend patient undergo a [MASKED] of Hearts holtor monitor as outpatient. Hospital course by system # Neuro: - F/u stroke risk factors: A1c 4.5, TSH 0.57, ldl 113 - Started ASA 81 mg daily - pcp to begin LDL therapy as outpatient - Dr. [MASKED] patient for liver transplant) notified regarding potential initiation of LDL therapy in the future - [MASKED] consulted, cleared for d/c home - Distributed stroke education packet # [MASKED]: - Monitored on telemetry, no evidence of afib - [MASKED] of Hearts monitor as outpatient - Goal SBP <180 and DBP <105 as above - Hold home amlodipine for permissive hypertension to facilitate increased cerebral perfusion pressure, restart on [MASKED] #ID/Tox/Metabolic: - UA: likely contaminant - CXR: no focal consolidation - LFTs within normal limits - Continue home everolimus as pt is s/p liver transplant on chronic immunosupression #Endocrine - TSH, A1c pending - QID FSG with HISS with goal of normoglycemia #Renal and FEN: - Regular diet as passed RN bedside swallow screen #Ppx: - DVT: Pneumoboots, SQH - Bowel: Docusate, Senna prn - Precautions: Fall - Code status: Full - Dispo: home Transitional issues: - outpatient [MASKED] of Hearts monitor - PCP to monitor LDL and initiate statin therapy - hold home amlodipine till [MASKED] to allow for sbp autoregulation - started on ASA, continue 81mg ASA as outpatient AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic Attack 1. Dysphagia screening before any PO intake? (x) Yes, confirmed done - () Not confirmed â () 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 = 113 ) - () No 5. Intensive statin therapy administered? (simvastatin 80mg, simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin 20mg or 40mg, for LDL > 100) (x) Yes - () No [if LDL >100, reason not given: waiting for approval from liver transplant physicians as patient of everolimus and statins may interact, pcp to initiate treatment as outpatient] 6. Smoking cessation counseling given? (x) Yes - () No [reason () non-smoker - () unable to participate] 7. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given (verbally or written)? (x) Yes - () No 8. Assessment for rehabilitation or rehab services considered? (x) Yes - () No 9. Discharged on statin therapy? (x) Yes - () No [if LDL >100, reason not given: pcp to initiate ] 10. Discharged on antithrombotic therapy? (x) Yes [Type: (x) Antiplatelet - () Anticoagulation] - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? () Yes - () No - (x) N/A Medications on Admission: The Preadmission Medication list is accurate and complete. 1. BuPROPion (Sustained Release) 200 mg PO BID 2. amLODIPine 10 mg PO DAILY 3. Pantoprazole 40 mg PO Q24H 4. TraZODone 100 mg PO QHS Discharge Medications: 1. Aspirin 81 mg PO DAILY RX *aspirin [Aspir-81] 81 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*11 2. Atorvastatin 40 mg PO QPM RX *atorvastatin 40 mg 1 tablet(s) by mouth qpm Disp #*30 Tablet Refills:*11 3. Calcium Carbonate 1000 mg PO DAILY 4. Cetirizine 10 mg PO DAILY 5. Everolimus 3 mg PO BID 6. Multivitamins 1 TAB PO DAILY 7. BuPROPion (Sustained Release) 200 mg PO BID 8. Pantoprazole 40 mg PO Q24H 9. TraZODone 100 mg PO QHS 10. HELD- amLODIPine 10 mg PO DAILY This medication was held. Do not restart amLODIPine until [MASKED] Discharge Disposition: Home Discharge Diagnosis: TIA Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], You were hospitalized due to symptoms of left facial droop resulting from an TRANSIENT ISCHEMIC ATTACK, a condition where a blood vessel providing oxygen and nutrients to the brain is temporarily blocked by a clot. The brain is the part of your body that controls and directs all the other parts of your body, so damage to the brain from being deprived of its blood supply can result in a variety of symptoms. Stroke can have many different causes, so we assessed you for medical conditions that might raise your risk of having stroke. In order to prevent future strokes, we plan to modify those risk factors. Your risk factors are: High lipids High blood pressure We are changing your medications as follows: Started on Aspirin Please take your other medications as prescribed. Please followup with Neurology and your primary care physician. If you experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - Sudden partial or complete loss of vision - Sudden loss of the ability to speak words from your mouth - Sudden loss of the ability to understand others speaking to you - Sudden weakness of one side of the body - Sudden drooping of one side of the face - Sudden loss of sensation of one side of the body Sincerely, Your [MASKED] Neurology Team Followup Instructions: [MASKED] | [
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"Z944: Liver transplant status",
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"R471: Dysarthria and anarthria",
"Z8505: Personal history of malignant neoplasm of liver",
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"Z87891: Personal history of nicotine dependence",
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12,916,556 | 28,877,678 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: CARDIOTHORACIC\n \nAllergies: \nTylenol / acetaminophen\n \nAttending: ___.\n \nChief Complaint:\nhemoptysis/right pneumothorax\n \nMajor Surgical or Invasive Procedure:\nremoval of chest tube\n\n \nHistory of Present Illness:\nThis is a case of ___ year old male patient presenting to ___\nas transfer from ___ Family with R pneumothorax s/p chest tube\nplacement at ___. Pt had CT guided right upper lobe biopsy 4 \ndays\nago for lung nodules. Since then pt has been having intermittent\nhemoptysis with cough (measuring as tea spoon) and SOB with DOE.\nThe blood has been increasing in amount over the last 2 days\nuntil he went to OSH today where he was found to have 50% ptx\nthus he got the chest tube placed. He denies any \nnausea/vomiting,\nchest pain, fever/chills, weight loss, and no other complaints.\n \nPast Medical History:\nBRAIN ANEURYSM \nTOBACCO ABUSE \nBACK PAIN \nNECK PAIN \nR HEAD PAIN \nR FACIAL NUMBNES \nFACIAL PAIN \nFATIGUE \nLUNG NODULES \n\nPSH:\n___: R Craniotomy for clipping of ACOMM aneurysm \n___: Diagnostic cerebral angiogram \ncorrective foot surgery at ___ yrs old\n \nSocial History:\n___\nFamily History:\nNC\n \nPhysical Exam:\nAdmit PE:\nTemp:98.4 HR:86 BP:120/76 RR:18 O2 Sat:96%RA\nGENERAL \n[x] WN/WD [x] NAD [x] AAO [ ] abnormal findings:\n\nHEENT \n[x] NC/AT [x] EOMI [x] PERRL/A [x] Anicteric\n[x] OP/NP mucosa normal [x] Tongue midline\n[x] Palate symmetric [x] Neck supple/NT/without mass\n[x] Trachea midline [x] Thyroid nl size/contour\n[ ] Abnormal findings:\n\nRESPIRATORY \n[x] CTA/P [x] Excursion normal [x] No fremitus\n[x] No egophony [x] No spine/CVAT\n[ ] Abnormal findings: Right Chest Tube in place \n\nCARDIOVASCULAR \n[x] RRR [x] No m/r/g [x] No JVD [x] PMI nl [x] No edema\n[x] Peripheral pulses nl [x] No abd/carotid bruit\n[ ] Abnormal findings:\n\nGI \n[x] Soft [x] NT [x] ND [x] No mass/HSM [x] No hernia\n[ ] Abnormal findings:\n\nGU [x] Deferred \n[ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE\n[ ] Abnormal findings:\n\nNEURO \n[x] Strength intact/symmetric [x] Sensation intact/ symmetric\n[x] Reflexes nl [x] No facial asymmetry [x] Cognition intact\n[x] Cranial nerves intact [ ] Abnormal findings:\n\nMS \n \n[x] No clubbing [x] No cyanosis [x] No edema [x] Gait nl\n[x] No tenderness [x] Tone/align/ROM nl [x] Palpation nl\n[x] Nails nl [ ] Abnormal findings:\n\nDischarge PE:\nVitals: Temp 99.2 PO, BP 109/46, HR 94, RR 20, O2sat 96% RA \nGen: A&O, NAD, resting comfortable in bed, ambulatory for \nseveral days including previously with chest tube now removed\nCV: RRR\nPulm: no increased WOB, CTAB, chest tube site on right upper \nlateral chest is clean and dry, closed, no drainage, erythema, \nor induration\nAbd: soft, NT/ND\nExt: WWP, no CCE\n \nPertinent Results:\nCHEST (PA & LAT) Study Date of ___ 9:22 AM:\nThe tiny right apical pneumothorax seen previously has resolved. \n \nCardiomediastinal silhouette is within normal limits. There has \nbeen improved aeration at the left base however there remains \nsome atelectasis. No definite consolidation are seen. \n\n \nBrief Hospital Course:\nMr. ___ is a ___ year-old male who underwent CT guided right \nupper lobe biopsy on ___ for lung nodules (RUL, 18G core, per \nprocedural note - parenchymal bleeding noted). He subsequently \nhad persistent intermittent hemoptysis (non-massive - 35-50cc \nper day) and gradual worsening of SOB and DOE. He initially \npresented to OSH ED and was found to have a right pneumothorax. \nA right chest tube was placed and the patient as transferred to \n___ for further management ___. IP was consulted for \nbronchoscopy given the patient's hemoptysis. However, flexible \nbronchoscopy was deferred given rapid improvement/resolution of \nhemoptysis without intervention. The patients chest tube was \ninitially kept to WS and chest films reveal interval resolution \nof his small apical pneumothorax. His chest tube was clamped \nfor 6 hours without interval development of expanding \npneumothorax. His chest tube was removed ___ and post-up films \ndemonstrated tiny right apical pneumothorax with subsequent \nresolution the morning of ___. The patient was discharged home \nin stable condition with clinic follow-up and CXR scheduled for \n___.\n \nMedications on Admission:\nBACLOFEN - baclofen 10 mg tablet. 1 tablet(s) by mouth one in \nthe\nam, one at 2P and 2 at bedtime - (Prescribed by Other Provider)\nGABAPENTIN [NEURONTIN] - Neurontin 600 mg tablet. 1 tablet(s) by\nmouth three times per day - (Prescribed by Other Provider)\nOXYCODONE - oxycodone 10 mg tablet. 1 tablet(s) by mouth three\ntimes a day as needed for pain - (Prescribed by Other Provider)\nPREGABALIN [LYRICA] - Lyrica 150 mg capsule. capsule(s) by mouth\ntwice a day - (Prescribed by Other Provider) (Not Taking as\nPrescribed: pt states no longer taking) \n \nDischarge Medications:\n1. Baclofen 10 mg PO TID \n2. Docusate Sodium 100 mg PO TID \nRX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day \nDisp #*20 Capsule Refills:*0\n3. Gabapentin 600 mg PO TID \n4. Pregabalin 150 mg PO BID \n5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain \ndo not drive or drink alcohol while taking this medication \nRX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours \nDisp #*20 Tablet Refills:*0\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nright pneumothorax\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\n* You were admitted to the hospital for pneumothorax and you've \nrecovered well. You are now ready for discharge.\n* Continue to use your incentive spirometer 10 times an hour \nwhile awake.\n* Your chest tube dressing may be removed in 48 hours. If it \nstarts to drain, cover it with a clean dry dressing and change \nit as needed to keep site clean and dry.\n* You will continue to need pain medication once you are home \nbut you can wean it over a few weeks as the discomfort resolves. \n Make sure that you have regular bowel movements while on \nnarcotic pain medications as they are constipating which can \ncause more problems. Use a stool softener or gentle laxative to \nstay regular.\n* No driving while taking narcotic pain medication. \n* Continue to stay well hydrated and eat well to heal your \nincision\n* Shower daily. Wash incision with mild soap & water, rinse, pat \ndry\n* No tub bathing, swimming or hot tubs until incision healed\n* No lotions or creams to incision site\n* Walk ___ times a day and gradually increase your activity as \nyou can tolerate.\n\nCall Dr. ___ ___ if you \nexperience:\n-Fevers > 101 or chills\n-Increased shortness of breath, chest pain or any other symptoms \nthat concern you.\n \nFollowup Instructions:\n___\n"
] | Allergies: Tylenol / acetaminophen Chief Complaint: hemoptysis/right pneumothorax Major Surgical or Invasive Procedure: removal of chest tube History of Present Illness: This is a case of [MASKED] year old male patient presenting to [MASKED] as transfer from [MASKED] Family with R pneumothorax s/p chest tube placement at [MASKED]. Pt had CT guided right upper lobe biopsy 4 days ago for lung nodules. Since then pt has been having intermittent hemoptysis with cough (measuring as tea spoon) and SOB with DOE. The blood has been increasing in amount over the last 2 days until he went to OSH today where he was found to have 50% ptx thus he got the chest tube placed. He denies any nausea/vomiting, chest pain, fever/chills, weight loss, and no other complaints. Past Medical History: BRAIN ANEURYSM TOBACCO ABUSE BACK PAIN NECK PAIN R HEAD PAIN R FACIAL NUMBNES FACIAL PAIN FATIGUE LUNG NODULES PSH: [MASKED]: R Craniotomy for clipping of ACOMM aneurysm [MASKED]: Diagnostic cerebral angiogram corrective foot surgery at [MASKED] yrs old Social History: [MASKED] Family History: NC Physical Exam: Admit PE: Temp:98.4 HR:86 BP:120/76 RR:18 O2 Sat:96%RA GENERAL [x] WN/WD [x] NAD [x] AAO [ ] abnormal findings: HEENT [x] NC/AT [x] EOMI [x] PERRL/A [x] Anicteric [x] OP/NP mucosa normal [x] Tongue midline [x] Palate symmetric [x] Neck supple/NT/without mass [x] Trachea midline [x] Thyroid nl size/contour [ ] Abnormal findings: RESPIRATORY [x] CTA/P [x] Excursion normal [x] No fremitus [x] No egophony [x] No spine/CVAT [ ] Abnormal findings: Right Chest Tube in place CARDIOVASCULAR [x] RRR [x] No m/r/g [x] No JVD [x] PMI nl [x] No edema [x] Peripheral pulses nl [x] No abd/carotid bruit [ ] Abnormal findings: GI [x] Soft [x] NT [x] ND [x] No mass/HSM [x] No hernia [ ] Abnormal findings: GU [x] Deferred [ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE [ ] Abnormal findings: NEURO [x] Strength intact/symmetric [x] Sensation intact/ symmetric [x] Reflexes nl [x] No facial asymmetry [x] Cognition intact [x] Cranial nerves intact [ ] Abnormal findings: MS [x] No clubbing [x] No cyanosis [x] No edema [x] Gait nl [x] No tenderness [x] Tone/align/ROM nl [x] Palpation nl [x] Nails nl [ ] Abnormal findings: Discharge PE: Vitals: Temp 99.2 PO, BP 109/46, HR 94, RR 20, O2sat 96% RA Gen: A&O, NAD, resting comfortable in bed, ambulatory for several days including previously with chest tube now removed CV: RRR Pulm: no increased WOB, CTAB, chest tube site on right upper lateral chest is clean and dry, closed, no drainage, erythema, or induration Abd: soft, NT/ND Ext: WWP, no CCE Pertinent Results: CHEST (PA & LAT) Study Date of [MASKED] 9:22 AM: The tiny right apical pneumothorax seen previously has resolved. Cardiomediastinal silhouette is within normal limits. There has been improved aeration at the left base however there remains some atelectasis. No definite consolidation are seen. Brief Hospital Course: Mr. [MASKED] is a [MASKED] year-old male who underwent CT guided right upper lobe biopsy on [MASKED] for lung nodules (RUL, 18G core, per procedural note - parenchymal bleeding noted). He subsequently had persistent intermittent hemoptysis (non-massive - 35-50cc per day) and gradual worsening of SOB and DOE. He initially presented to OSH ED and was found to have a right pneumothorax. A right chest tube was placed and the patient as transferred to [MASKED] for further management [MASKED]. IP was consulted for bronchoscopy given the patient's hemoptysis. However, flexible bronchoscopy was deferred given rapid improvement/resolution of hemoptysis without intervention. The patients chest tube was initially kept to WS and chest films reveal interval resolution of his small apical pneumothorax. His chest tube was clamped for 6 hours without interval development of expanding pneumothorax. His chest tube was removed [MASKED] and post-up films demonstrated tiny right apical pneumothorax with subsequent resolution the morning of [MASKED]. The patient was discharged home in stable condition with clinic follow-up and CXR scheduled for [MASKED]. Medications on Admission: BACLOFEN - baclofen 10 mg tablet. 1 tablet(s) by mouth one in the am, one at 2P and 2 at bedtime - (Prescribed by Other Provider) GABAPENTIN [NEURONTIN] - Neurontin 600 mg tablet. 1 tablet(s) by mouth three times per day - (Prescribed by Other Provider) OXYCODONE - oxycodone 10 mg tablet. 1 tablet(s) by mouth three times a day as needed for pain - (Prescribed by Other Provider) PREGABALIN [LYRICA] - Lyrica 150 mg capsule. capsule(s) by mouth twice a day - (Prescribed by Other Provider) (Not Taking as Prescribed: pt states no longer taking) Discharge Medications: 1. Baclofen 10 mg PO TID 2. Docusate Sodium 100 mg PO TID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*20 Capsule Refills:*0 3. Gabapentin 600 mg PO TID 4. Pregabalin 150 mg PO BID 5. OxycoDONE (Immediate Release) [MASKED] mg PO Q4H:PRN pain do not drive or drink alcohol while taking this medication RX *oxycodone 5 mg [MASKED] tablet(s) by mouth every four (4) hours Disp #*20 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: right pneumothorax Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: * You were admitted to the hospital for pneumothorax and you've recovered well. You are now ready for discharge. * Continue to use your incentive spirometer 10 times an hour while awake. * Your chest tube dressing may be removed in 48 hours. If it starts to drain, cover it with a clean dry dressing and change it as needed to keep site clean and dry. * You will continue to need pain medication once you are home but you can wean it over a few weeks as the discomfort resolves. Make sure that you have regular bowel movements while on narcotic pain medications as they are constipating which can cause more problems. Use a stool softener or gentle laxative to stay regular. * No driving while taking narcotic pain medication. * Continue to stay well hydrated and eat well to heal your incision * Shower daily. Wash incision with mild soap & water, rinse, pat dry * No tub bathing, swimming or hot tubs until incision healed * No lotions or creams to incision site * Walk [MASKED] times a day and gradually increase your activity as you can tolerate. Call Dr. [MASKED] [MASKED] if you experience: -Fevers > 101 or chills -Increased shortness of breath, chest pain or any other symptoms that concern you. Followup Instructions: [MASKED] | [
"J95811",
"R042",
"F17210",
"Y848",
"R918"
] | [
"J95811: Postprocedural pneumothorax",
"R042: Hemoptysis",
"F17210: Nicotine dependence, cigarettes, uncomplicated",
"Y848: Other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure",
"R918: Other nonspecific abnormal finding of lung field"
] | [
"F17210"
] | [] |
12,764,151 | 21,141,063 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: OBSTETRICS/GYNECOLOGY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\nright flank pain\n \nMajor Surgical or Invasive Procedure:\nnone\n \nHistory of Present Illness:\nHPI: Pt is a ___ G1 at ___ who presents to triage for \nfurther\nevaluation of R flank and R abd pain. Pt states the pain started\n6 days ago in her back. Its been a constant pain that has been\nsteady, not getting better or worse. States the pain in her back\nis worse than her abdomen. Denies fevers/chills. Denies dysuria,\nbut does have increased urinary frequency. States she's had\nintermittent nausea/vomiting, which is not unusual for her \nduring\npregnancy. Reports distant hx of prior UTI ___ years ago) and\nreports hx of \"cysts on kidney.\"\n\nPt seen in ___ ED on ___ and was started on po Keflex for +UA.\nPt reports no improvement in her pain. She was seen back at ___\ntoday and it was recommended she present to triage given\npersistent R flank pain and concern for pyelonephritis. WBC at\n___ today was 12.8, and per verbal report from BI microbiology\nto ___ staff, her urine cx growing GNR, likely EColi.\n\nat ___: 11.0\n 12.8 > ---- < 155\n 32\n\nUCx pending\n\nPNC:\n___ ___\n*)Labs: O+, HbsAg-,CF-,HIV-,GC/CT-,RPRnr,VI\n*)sickle cell trait\n*)nl ERA\n\nObHx: G1\nGynHx: hx Chlamydia (___), neg GC/CT (___). hx ruptured\novarian cyst ___\n\nMeds: PNV\nNKDA, allergic to fruit drinks (hives)\n\n \nPast Medical History:\nneg\n \nSocial History:\n___\nFamily History:\nnon contrib \n \nPhysical Exam:\nExam\nGen: well appearing, NAD\nVS: T 98.6, HR 81, BP 103/59, RR 18, O2 100% RA\nAbd: soft, nondistended. +RLQ tenderness, slight rebound\ntenderness. +R CVAT\nU/S: +FH (150)\n\n \nPertinent Results:\n___ 03:55AM URINE HOURS-RANDOM\n___ 03:55AM URINE UCG-POSITIVE*\n___ 03:55AM URINE COLOR-Straw APPEAR-Clear SP ___\n___ 03:55AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR* \nGLUCOSE-NEG KETONE-10* BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 \nLEUK-LG\n___ 03:55AM URINE RBC-1 WBC-54* BACTERIA-FEW* YEAST-NONE \nEPI-3\n___ 03:55AM URINE MUCOUS-RARE*\n___ culture e coli; ___ pending discharge\n \nBrief Hospital Course:\nStarted on IV ceftriaxone and oral pain meds\n\nhd # 2 pain somewhat improved\npt remains afeb\nurine culture pend\n \nMedications on Admission:\npnv\n \nDischarge Medications:\nmacrobid ___ bid x 7d then qd for prophylaxis\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\npyelonephritis\n \nDischarge Condition:\nstable\n \nDischarge Instructions:\ncall for fever chills worsening pain bleeding or leaking\n \nFollowup Instructions:\n___\n"
] | Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: right flank pain Major Surgical or Invasive Procedure: none History of Present Illness: HPI: Pt is a [MASKED] G1 at [MASKED] who presents to triage for further evaluation of R flank and R abd pain. Pt states the pain started 6 days ago in her back. Its been a constant pain that has been steady, not getting better or worse. States the pain in her back is worse than her abdomen. Denies fevers/chills. Denies dysuria, but does have increased urinary frequency. States she's had intermittent nausea/vomiting, which is not unusual for her during pregnancy. Reports distant hx of prior UTI [MASKED] years ago) and reports hx of "cysts on kidney." Pt seen in [MASKED] ED on [MASKED] and was started on po Keflex for +UA. Pt reports no improvement in her pain. She was seen back at [MASKED] today and it was recommended she present to triage given persistent R flank pain and concern for pyelonephritis. WBC at [MASKED] today was 12.8, and per verbal report from BI microbiology to [MASKED] staff, her urine cx growing GNR, likely EColi. at [MASKED]: 11.0 12.8 > ---- < 155 32 UCx pending PNC: [MASKED] [MASKED] *)Labs: O+, HbsAg-,CF-,HIV-,GC/CT-,RPRnr,VI *)sickle cell trait *)nl ERA ObHx: G1 GynHx: hx Chlamydia ([MASKED]), neg GC/CT ([MASKED]). hx ruptured ovarian cyst [MASKED] Meds: PNV NKDA, allergic to fruit drinks (hives) Past Medical History: neg Social History: [MASKED] Family History: non contrib Physical Exam: Exam Gen: well appearing, NAD VS: T 98.6, HR 81, BP 103/59, RR 18, O2 100% RA Abd: soft, nondistended. +RLQ tenderness, slight rebound tenderness. +R CVAT U/S: +FH (150) Pertinent Results: [MASKED] 03:55AM URINE HOURS-RANDOM [MASKED] 03:55AM URINE UCG-POSITIVE* [MASKED] 03:55AM URINE COLOR-Straw APPEAR-Clear SP [MASKED] [MASKED] 03:55AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR* GLUCOSE-NEG KETONE-10* BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-LG [MASKED] 03:55AM URINE RBC-1 WBC-54* BACTERIA-FEW* YEAST-NONE EPI-3 [MASKED] 03:55AM URINE MUCOUS-RARE* [MASKED] culture e coli; [MASKED] pending discharge Brief Hospital Course: Started on IV ceftriaxone and oral pain meds hd # 2 pain somewhat improved pt remains afeb urine culture pend Medications on Admission: pnv Discharge Medications: macrobid [MASKED] bid x 7d then qd for prophylaxis Discharge Disposition: Home Discharge Diagnosis: pyelonephritis Discharge Condition: stable Discharge Instructions: call for fever chills worsening pain bleeding or leaking Followup Instructions: [MASKED] | [
"O2301",
"N281",
"O9989",
"B9620",
"O99011",
"D573",
"Z3A13"
] | [
"O2301: Infections of kidney in pregnancy, first trimester",
"N281: Cyst of kidney, acquired",
"O9989: Other specified diseases and conditions complicating pregnancy, childbirth and the puerperium",
"B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere",
"O99011: Anemia complicating pregnancy, first trimester",
"D573: Sickle-cell trait",
"Z3A13: 13 weeks gestation of pregnancy"
] | [] | [] |
12,331,210 | 21,080,557 | [
" \nName: ___ Unit ___: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: CARDIOTHORACIC\n \nAllergies: \nindomethacin\n \nAttending: ___.\n \nChief Complaint:\nAsymptomatic \n \nMajor Surgical or Invasive Procedure:\n___: AVR (25mm ___ \n\n \nHistory of Present Illness:\n___ year old male with known aortic stenosis for roughly ___ year. \nHe is followed closely with serial echocardiograms which have \nshown progression of his aortic valve disease. His most recent \nechocardiogram in ___ showed severe aortic stenosis. \nOverall, He's been feeling well. He has ___ chest pain,\nsob, dizziness, palpitations, syncope, orthopnea, PND or new \nneuro symptoms. Recent cardiac cath showed only minimal cad in \nthe rca (20%) with normal arteries otherwise. His valve area \ncame out to be 0.7cm2. Surgery was recommended and he wishes to \nproceed.\n\n \nPast Medical History:\nAortic Stenosis\nLow back pain \nGout \nHyperlipidemia \nInsomnia \nFatty tumor \nHDL deficiency \nClass 1 obesity without serious comorbidity with body mass index\n(BMI) of 32.0 to 32.9 in adult \nBenign prostatic hyperplasia with Elevated PSA \n\n \nSocial History:\n___\nFamily History:\nBrother Alive CAD/PVD \nFather ___ ? myocardial infarction \nMother ___ pancreatic cancer \n\n \nPhysical Exam:\n130/74,95,96% on RA\nHeight: 70\" Weight: 228lb\n\nGeneral: WDWN in NAD\nSkin: Warm, Dry and intact. ___ lesions or rashes. \nHEENT: NCAT, PERRL, sclera anicteric, OP benign. Full dentures. \nNeck: Supple [X] Full ROM [X] ___ JVD\nChest: Lungs clear bilaterally [X]\nHeart: RRR, Nl S1-S2, III/VI SEM best heard at RUSB \nAbdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds\n+[X]\nExtremities: Warm [X], well-perfused [X] ___ Edema\nVaricosities: None [X]\nNeuro: Grossly intact [X]\nPulses:\nFemoral Right:2 Left:2\nDP Right:2 Left:2\n___ Right:2 Left:2\nRadial Right:2 Left:2\n\nCarotid Bruit: Transmitted vs. bruit R>L\n\nDischarge Exam:\n98.1\nPO 115 / 73\nL Lying 73 18 95 Ra \n.\nGeneral: NAD [x] \nNeurological: A/O x3 [x] Moves all extremities non-focal\nCardiovascular: RRR [x] \nRespiratory: CTA [x] ___ resp distress [x] \nGI/Abdomen: Bowel sounds present [x] Soft [x] ND [x] NT [x]\nExtremities: \nRight Upper extremity Warm [x] Edema none \nLeft Upper extremity Warm [x] Edema none\nRight Lower extremity Warm [x] Edema none\nLeft Lower extremity Warm [x] Edema none\nSkin/Wounds: Dry [x] intact [x]\nSternal: CDI [x] ___ erythema or drainage [x]\n Sternum stable [x] Prevena []\n\n \nPertinent Results:\nEchocardiogram ___\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Prominent \nEustachian valve (normal variant). \nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and \nregional/global systolic function (LVEF>55%). \nRIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic \nfunction. \nAORTA: Mildly dilated ascending aorta. Normal aortic arch \ndiameter. Mildly dilated descending aorta. \nAORTIC VALVE: Bicuspid aortic valve. Severely thickened/deformed \naortic valve leaflets. Severe AS (area <1.0cm2). Trace AR. \nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. ___ \nMS. \n___ VALVE: Normal tricuspid valve leaflets with trivial \nTR. ___ TS. \nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. \n___ PS. Physiologic PR. \nPERICARDIUM: ___ pericardial effusion. \n\nConclusions \nPre-Bypass\nThere is mild symmetric left ventricular hypertrophy with normal \ncavity size and regional/global systolic function (LVEF>55%). \nThe right ventricular cavity is mildly dilated with normal free \nwall contractility. The ascending aorta is mildly dilated. The \ndescending thoracic aorta is mildly dilated. The aortic valve is \nbicuspid with fusion of the left and right coronary cusps. The \naortic valve leaflets are severely thickened/deformed. There is \nsevere aortic valve stenosis (valve area <1.0cm2). Trace aortic \nregurgitation is seen. The mitral valve appears structurally \nnormal with trivial mitral regurgitation. There is ___ \npericardial effusion. \n\nPost-Bypass\n The patient is in an atrially-paced rhythm and receiving a \nnicardipine infusion. \n 1. A well-seated bioprosthetic valve is visualized in the \naortic position. There is normal leaflet opening. There is ___ \nparavalvular regurgitation. Under varying hemodynamic \nconditions, peak gradient across the valve ranges rom ___ \nmmHg, and mean gradient from ___ mmHg.\n 2. Left ventricular function remains preserved. There are ___ \nregional wall motion abnormalities.\n 3. Right ventricular function remains preserved.\n 4. Remaining valvular function is unchanged.\n 5. The visualized portions of the thoracic aorta are intact \nfollowing decannulation.\n 6. There is ___ pericardial effusion.\n The patient should have follow-up surveillance of the dilated \nascending aorta given history of bicuspid aortic valve. \n\nCXR: ___\nStable mild cardiomegaly. Stable platelike \natelectasis at the left lung basis. ___ pulmonary edema. ___ \npleural \neffusions. ___ pneumonia. Correct position of the right \ninternal jugular vein catheter. Stable correct alignment of the \nsternal wires. \n\nLabs:\nAdmission:\n___ WBC-18.2* RBC-3.80* Hgb-11.7* Hct-33.5* MCV-88 MCH-30.8 \nMCHC-34.9 RDW-12.4 RDWSD-40.1 Plt ___\n___ Neuts-81.9* Lymphs-10.7* Monos-5.6 Eos-0.8* Baso-0.2 Im \n___ AbsNeut-14.88* AbsLymp-1.95 AbsMono-1.02* AbsEos-0.14 \nAbsBaso-0.04\n___ ___ PTT-27.7 ___\n___ UreaN-12 Creat-0.8 Cl-107 HCO3-24 AnGap-8*\n___ Calcium-7.8* Phos-2.1* Mg-1.9\n.\nDischarge\n\n___ 04:17AM BLOOD WBC-11.0* RBC-3.79* Hgb-11.6* Hct-33.6* \nMCV-89 MCH-30.6 MCHC-34.5 RDW-12.5 RDWSD-40.7 Plt ___\n___ 10:08AM BLOOD WBC-18.2* RBC-3.80* Hgb-11.7* Hct-33.5* \nMCV-88 MCH-30.8 MCHC-34.9 RDW-12.4 RDWSD-40.1 Plt ___\n___ 02:02AM BLOOD ___ PTT-26.6 ___\n___ 05:48AM BLOOD UreaN-14 Creat-0.8 K-4.0\n___ 03:52AM BLOOD Glucose-130* UreaN-15 Creat-0.9 Na-133* \nK-4.5 Cl-96 HCO3-26 AnGap-11\n \nBrief Hospital Course:\nThe patient was brought to the Operating Room on ___ where \nthe patient underwent AVR (25mm ___. Overall the \npatient tolerated the procedure well and post-operatively was \ntransferred to the CVICU in stable condition for recovery and \ninvasive monitoring. \nPOD 1 found the patient extubated, alert and oriented and \nbreathing comfortably. The patient was neurologically intact \nand hemodynamically stable. Beta blocker was initiated and the \npatient was gently diuresed toward the preoperative weight. The \npatient was transferred to the telemetry floor for further \nrecovery. Chest tubes and pacing wires were discontinued \nwithout complication. POD ___trial fibrillation and \nconverted to sinus rhythm with IV metoprolol and an amiodarone \nbolus. He was started on a 1 month course of PO amiodarone to \nmaintain sinus rhythm. He will not require anti-coagulation. \nThe patient was evaluated by the Physical Therapy service for \nassistance with strength and mobility. By the time of discharge \non POD 4 the patient was ambulating freely, the wound was \nhealing and pain was controlled with oral analgesics. The \npatient was discharged home in good condition with appropriate \nfollow up instructions.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. ALPRAZolam 0.5 mg PO QHS:PRN anxiety \n2. Lovastatin 20 mg oral DAILY \n3. Aspirin 81 mg PO DAILY \n4. Naproxen 500 mg PO Q12H:PRN Pain - Mild \n5. Multivitamins 1 TAB PO DAILY \n\n \nDischarge Medications:\n1. Amiodarone 400 mg PO BID \n___ bid x 7 days, then 400mg daily x 7 days, then 200mg daily \nRX *amiodarone 200 mg 1 tablet(s) by mouth twice a day Disp #*58 \nTablet Refills:*0 \n2. Docusate Sodium 100 mg PO BID \nRX *docusate sodium [Stool Softener] 100 mg 1 tablet(s) by mouth \ntwice a day Disp #*60 Tablet Refills:*0 \n3. Furosemide 20 mg PO DAILY Duration: 5 Days \nRX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*5 Tablet \nRefills:*0 \n4. Metoprolol Tartrate 25 mg PO TID \nRX *metoprolol tartrate 25 mg 1 tablet(s) by mouth three times a \nday Disp #*90 Tablet Refills:*1 \n5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain: \nmoderate/severe \nRX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours \nDisp #*60 Tablet Refills:*0 \n6. Potassium Chloride 20 mEq PO DAILY Duration: 5 Days \nRX *potassium chloride 20 mEq 1 tablet(s) by mouth daily Disp \n#*5 Tablet Refills:*0 \n7. Ramelteon 8 mg PO QHS:PRN insomnia \nShould be given 30 minutes before bedtime \nRX *ramelteon [Rozerem] 8 mg 1 tablet(s) by mouth at bedtime \nDisp #*20 Tablet Refills:*0 \n8. Ranitidine 150 mg PO BID \nRX *ranitidine HCl 150 mg 1 tablet(s) by mouth twice a day Disp \n#*60 Tablet Refills:*0 \n9. Atorvastatin 20 mg PO QPM \nRX *atorvastatin 20 mg 1 tablet(s) by mouth qpm Disp #*30 Tablet \nRefills:*1 \n10. ALPRAZolam 0.5 mg PO QHS:PRN anxiety \n11. Aspirin 81 mg PO DAILY \n12. Multivitamins 1 TAB PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nAortic Stenosis s/p AVR (25mm ___ \nPostoperative Atrial Fibrillation\n\nSecondary Diagnosis\nLow back pain\nGout\nHyperlipidemia \nInsomnia\nFatty tumor\nBenign prostatic hyperplasia w/ Elevated PSA \n\n \nDischarge Condition:\nAlert and oriented x3, non-focal\nAmbulating, gait steady\nSternal pain managed with oral analgesics\nSternal Incision - healing well, ___ erythema or drainage\nEdema- none\n\n \nDischarge Instructions:\nPlease shower daily -wash incisions gently with mild soap, ___ \nbaths or swimming, look at your incisions daily\n Please - ___ lotion, cream, powder or ointment to incisions\n Each morning you should weigh yourself and then in the evening \ntake your temperature, these should be written down on the chart\n ___ driving for approximately one month and while taking \nnarcotics\n\nClearance to drive will be discussed at follow up appointment \nwith surgeon\n ___ lifting more than 10 pounds for 10 weeks\nEncourage full shoulder range of motion, unless otherwise \nspecified\n \n**Please call cardiac surgery office with any questions or \nconcerns ___. Answering service will contact on call \nperson during off hours**\n \nFollowup Instructions:\n___\n"
] | Allergies: indomethacin Chief Complaint: Asymptomatic Major Surgical or Invasive Procedure: [MASKED]: AVR (25mm [MASKED] History of Present Illness: [MASKED] year old male with known aortic stenosis for roughly [MASKED] year. He is followed closely with serial echocardiograms which have shown progression of his aortic valve disease. His most recent echocardiogram in [MASKED] showed severe aortic stenosis. Overall, He's been feeling well. He has [MASKED] chest pain, sob, dizziness, palpitations, syncope, orthopnea, PND or new neuro symptoms. Recent cardiac cath showed only minimal cad in the rca (20%) with normal arteries otherwise. His valve area came out to be 0.7cm2. Surgery was recommended and he wishes to proceed. Past Medical History: Aortic Stenosis Low back pain Gout Hyperlipidemia Insomnia Fatty tumor HDL deficiency Class 1 obesity without serious comorbidity with body mass index (BMI) of 32.0 to 32.9 in adult Benign prostatic hyperplasia with Elevated PSA Social History: [MASKED] Family History: Brother Alive CAD/PVD Father [MASKED] ? myocardial infarction Mother [MASKED] pancreatic cancer Physical Exam: 130/74,95,96% on RA Height: 70" Weight: 228lb General: WDWN in NAD Skin: Warm, Dry and intact. [MASKED] lesions or rashes. HEENT: NCAT, PERRL, sclera anicteric, OP benign. Full dentures. Neck: Supple [X] Full ROM [X] [MASKED] JVD Chest: Lungs clear bilaterally [X] Heart: RRR, Nl S1-S2, III/VI SEM best heard at RUSB Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds +[X] Extremities: Warm [X], well-perfused [X] [MASKED] Edema Varicosities: None [X] Neuro: Grossly intact [X] Pulses: Femoral Right:2 Left:2 DP Right:2 Left:2 [MASKED] Right:2 Left:2 Radial Right:2 Left:2 Carotid Bruit: Transmitted vs. bruit R>L Discharge Exam: 98.1 PO 115 / 73 L Lying 73 18 95 Ra . General: NAD [x] Neurological: A/O x3 [x] Moves all extremities non-focal Cardiovascular: RRR [x] Respiratory: CTA [x] [MASKED] resp distress [x] GI/Abdomen: Bowel sounds present [x] Soft [x] ND [x] NT [x] Extremities: Right Upper extremity Warm [x] Edema none Left Upper extremity Warm [x] Edema none Right Lower extremity Warm [x] Edema none Left Lower extremity Warm [x] Edema none Skin/Wounds: Dry [x] intact [x] Sternal: CDI [x] [MASKED] erythema or drainage [x] Sternum stable [x] Prevena [] Pertinent Results: Echocardiogram [MASKED] RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Prominent Eustachian valve (normal variant). LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global systolic function (LVEF>55%). RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic function. AORTA: Mildly dilated ascending aorta. Normal aortic arch diameter. Mildly dilated descending aorta. AORTIC VALVE: Bicuspid aortic valve. Severely thickened/deformed aortic valve leaflets. Severe AS (area <1.0cm2). Trace AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. [MASKED] MS. [MASKED] VALVE: Normal tricuspid valve leaflets with trivial TR. [MASKED] TS. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. [MASKED] PS. Physiologic PR. PERICARDIUM: [MASKED] pericardial effusion. Conclusions Pre-Bypass There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). The right ventricular cavity is mildly dilated with normal free wall contractility. The ascending aorta is mildly dilated. The descending thoracic aorta is mildly dilated. The aortic valve is bicuspid with fusion of the left and right coronary cusps. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (valve area <1.0cm2). Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is [MASKED] pericardial effusion. Post-Bypass The patient is in an atrially-paced rhythm and receiving a nicardipine infusion. 1. A well-seated bioprosthetic valve is visualized in the aortic position. There is normal leaflet opening. There is [MASKED] paravalvular regurgitation. Under varying hemodynamic conditions, peak gradient across the valve ranges rom [MASKED] mmHg, and mean gradient from [MASKED] mmHg. 2. Left ventricular function remains preserved. There are [MASKED] regional wall motion abnormalities. 3. Right ventricular function remains preserved. 4. Remaining valvular function is unchanged. 5. The visualized portions of the thoracic aorta are intact following decannulation. 6. There is [MASKED] pericardial effusion. The patient should have follow-up surveillance of the dilated ascending aorta given history of bicuspid aortic valve. CXR: [MASKED] Stable mild cardiomegaly. Stable platelike atelectasis at the left lung basis. [MASKED] pulmonary edema. [MASKED] pleural effusions. [MASKED] pneumonia. Correct position of the right internal jugular vein catheter. Stable correct alignment of the sternal wires. Labs: Admission: [MASKED] WBC-18.2* RBC-3.80* Hgb-11.7* Hct-33.5* MCV-88 MCH-30.8 MCHC-34.9 RDW-12.4 RDWSD-40.1 Plt [MASKED] [MASKED] Neuts-81.9* Lymphs-10.7* Monos-5.6 Eos-0.8* Baso-0.2 Im [MASKED] AbsNeut-14.88* AbsLymp-1.95 AbsMono-1.02* AbsEos-0.14 AbsBaso-0.04 [MASKED] [MASKED] PTT-27.7 [MASKED] [MASKED] UreaN-12 Creat-0.8 Cl-107 HCO3-24 AnGap-8* [MASKED] Calcium-7.8* Phos-2.1* Mg-1.9 . Discharge [MASKED] 04:17AM BLOOD WBC-11.0* RBC-3.79* Hgb-11.6* Hct-33.6* MCV-89 MCH-30.6 MCHC-34.5 RDW-12.5 RDWSD-40.7 Plt [MASKED] [MASKED] 10:08AM BLOOD WBC-18.2* RBC-3.80* Hgb-11.7* Hct-33.5* MCV-88 MCH-30.8 MCHC-34.9 RDW-12.4 RDWSD-40.1 Plt [MASKED] [MASKED] 02:02AM BLOOD [MASKED] PTT-26.6 [MASKED] [MASKED] 05:48AM BLOOD UreaN-14 Creat-0.8 K-4.0 [MASKED] 03:52AM BLOOD Glucose-130* UreaN-15 Creat-0.9 Na-133* K-4.5 Cl-96 HCO3-26 AnGap-11 Brief Hospital Course: The patient was brought to the Operating Room on [MASKED] where the patient underwent AVR (25mm [MASKED]. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. POD trial fibrillation and converted to sinus rhythm with IV metoprolol and an amiodarone bolus. He was started on a 1 month course of PO amiodarone to maintain sinus rhythm. He will not require anti-coagulation. The patient was evaluated by the Physical Therapy service for assistance with strength and mobility. By the time of discharge on POD 4 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged home in good condition with appropriate follow up instructions. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ALPRAZolam 0.5 mg PO QHS:PRN anxiety 2. Lovastatin 20 mg oral DAILY 3. Aspirin 81 mg PO DAILY 4. Naproxen 500 mg PO Q12H:PRN Pain - Mild 5. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Amiodarone 400 mg PO BID [MASKED] bid x 7 days, then 400mg daily x 7 days, then 200mg daily RX *amiodarone 200 mg 1 tablet(s) by mouth twice a day Disp #*58 Tablet Refills:*0 2. Docusate Sodium 100 mg PO BID RX *docusate sodium [Stool Softener] 100 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 3. Furosemide 20 mg PO DAILY Duration: 5 Days RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*5 Tablet Refills:*0 4. Metoprolol Tartrate 25 mg PO TID RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*1 5. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain: moderate/severe RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*60 Tablet Refills:*0 6. Potassium Chloride 20 mEq PO DAILY Duration: 5 Days RX *potassium chloride 20 mEq 1 tablet(s) by mouth daily Disp #*5 Tablet Refills:*0 7. Ramelteon 8 mg PO QHS:PRN insomnia Should be given 30 minutes before bedtime RX *ramelteon [Rozerem] 8 mg 1 tablet(s) by mouth at bedtime Disp #*20 Tablet Refills:*0 8. Ranitidine 150 mg PO BID RX *ranitidine HCl 150 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 9. Atorvastatin 20 mg PO QPM RX *atorvastatin 20 mg 1 tablet(s) by mouth qpm Disp #*30 Tablet Refills:*1 10. ALPRAZolam 0.5 mg PO QHS:PRN anxiety 11. Aspirin 81 mg PO DAILY 12. Multivitamins 1 TAB PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Aortic Stenosis s/p AVR (25mm [MASKED] Postoperative Atrial Fibrillation Secondary Diagnosis Low back pain Gout Hyperlipidemia Insomnia Fatty tumor Benign prostatic hyperplasia w/ Elevated PSA Discharge Condition: Alert and oriented x3, non-focal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, [MASKED] erythema or drainage Edema- none Discharge Instructions: Please shower daily -wash incisions gently with mild soap, [MASKED] baths or swimming, look at your incisions daily Please - [MASKED] lotion, cream, powder or ointment to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart [MASKED] driving for approximately one month and while taking narcotics Clearance to drive will be discussed at follow up appointment with surgeon [MASKED] lifting more than 10 pounds for 10 weeks Encourage full shoulder range of motion, unless otherwise specified **Please call cardiac surgery office with any questions or concerns [MASKED]. Answering service will contact on call person during off hours** Followup Instructions: [MASKED] | [
"I350",
"I97190",
"D62",
"I4891",
"I2510",
"M545",
"E786",
"E669",
"Z6832",
"N400",
"R9720",
"G4700",
"Z87891",
"Z8249",
"M109",
"Y831",
"Y713",
"Y92239"
] | [
"I350: Nonrheumatic aortic (valve) stenosis",
"I97190: Other postprocedural cardiac functional disturbances following cardiac surgery",
"D62: Acute posthemorrhagic anemia",
"I4891: Unspecified atrial fibrillation",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"M545: Low back pain",
"E786: Lipoprotein deficiency",
"E669: Obesity, unspecified",
"Z6832: Body mass index [BMI] 32.0-32.9, adult",
"N400: Benign prostatic hyperplasia without lower urinary tract symptoms",
"R9720: Elevated prostate specific antigen [PSA]",
"G4700: Insomnia, unspecified",
"Z87891: Personal history of nicotine dependence",
"Z8249: Family history of ischemic heart disease and other diseases of the circulatory system",
"M109: Gout, unspecified",
"Y831: Surgical operation with implant of artificial internal device as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure",
"Y713: Surgical instruments, materials and cardiovascular devices (including sutures) associated with adverse incidents",
"Y92239: Unspecified place in hospital as the place of occurrence of the external cause"
] | [
"D62",
"I4891",
"I2510",
"E669",
"N400",
"G4700",
"Z87891",
"M109"
] | [] |
17,993,079 | 28,539,226 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nMacrolide Antibiotics\n \nAttending: ___\n \nChief Complaint:\nAbdominal Pain \n \nMajor Surgical or Invasive Procedure:\nPercutaneous cholecystostomy (___)\n\n \nHistory of Present Illness:\nMr. ___ is an ___ with a past medical history of native aortic\nvalve endocarditis in ___ status post aortic valve replacement\n(bovine in ___ AI), with subsequent prosthetic valve MSSA\nendocarditis in ___ c/b L sided strokes status post \nrepeat\nAVR replacement and CABG x1 due to abscess cavity blocking\nnon-coronary sinus, dual-chamber PPM, CKD, hypertension, hx of\nsevere C. diff presenting with RUQ abdominal pain x2 days. \n\nThe patient was admitted to ___ in ___ for fevers and\nhypotension. He had strep pneumoniae in his ___ blood\ncultures (sensitive to penicillins) and was de-escalated to\ncefazolin then ceftriaxone. He had a TEE that showed an aortic\nroot abscess but was too high risk for surgery per ___ cardiac\nsurgery as well as second opinion by ___. \n\nRepeat TEE 1 week post discharge showed unchanged abscess. He \nwas\neventually switched to Keflex ___ TID in ___. Given that\nsurgery is not an option for him, referral for palliative care\nhas been made, but patient has not yet been to appointment. \n\nThe patient has had pain in his abdomen in his right upper\nquadrant pain for the past two days. ___ he presented to\n___ with pain and tenderness around the g tube site (was\nremoved last ___. CT scan reported showed cholecystitis\nbut clinically this did not fit and given improvement in pain, \nhe\nwas discharged. He ate a spicy meal on ___ night and then\ndeveloped pain in his RUQ. He returned to the ___ on ___\nafter some vomiting. He was then transferred to ___ for \nfurther\nevaluation of cholecystitis.\n\nIn the ___, \n- Initial VS: 97.2 80 138/78 18 96% RA \n- Exam notable for: \nGEN: No acute distress\nRESP: lungs clear\nABD: tender in RUQ, no fluid wave, Gtube site with healing\ngranuloma and no surrounding erythema or discharge\n- Labs notable for: \nCBC: WBC 9.0, hgb 10.3, plt 258\nINR 2.1 \nChem: Na 139, K 5.1, bicarb 16, BUN 31, Cr 1.8\nLFTs and lipase: WNL \n\nUA:\nLarge leuks, negative nitrites, >182 WBC, few bacteria 0 epis\nBld cx x2 pending \n\n- Imaging: \n___ A/P w/o contrast ___\nCholelithiasis with GB wall thickening and pericholecystic \nedema.\nNo biliary ductal dilation. \n\n- Meds: \nIV Morphine Sulfate 4 mg \nPO Acetaminophen 650 mg \nIV Ampicillin-Sulbactam 3 g \n\n- Consults: \nSurgery who recommended ___ consult for percutaneous cholecystomy \n\n\n___ who will perform perc chole ___\n\n- Vitals prior to transfer: 97.8 80 124/78 18 100% \n \nOn arrival to the floor, he is reporting sharp pain constant\nrated a ___ in his RUQ. He denies current nausea. He feels\nsomewhat hungry. There is no fevers, chills. He last had a\nbowel movement on the day of removal of the gtube a few days\nprior. The pain around his gtube removal has resolved\ncompletely. He denies dysuria, urinary habit changes, \nhematuria.\n\nREVIEW OF SYSTEMS: \nA complete 10-point review of systems was performed and was\nnegative less otherwise noted in the HPI. \n\n \nPast Medical History:\n- Native aortic valve endocarditis in ___ status post aortic \nvalve replacement (bovine in ___ AI), with subsequent \nprosthetic valve MSSA endocarditis in ___ c/b L sided \nstrokes status post repeat AVR replacement and CABG x1 due to \nabscess cavity blocking non-coronary sinus\n - dual-chamber PPM \n - Chronic Kidney Disease Cr 1.8-2.2 \n - HLD \n - HTN \n - Hx DVT \n - h/o C. difficile diarrhea x2\n - Peripheral neuropathy \n - Spinal stenosis \n - Migraine \n - Depression/Anxiety \n - Nuclear sclerotic cataract of left eye \n - Central retinal vein occlusion \n - Glaucoma \n - Malignant melanoma \n - BPH \n - Hematuria \n - Anemia \n - Thrombocytopenia \n\n \nSocial History:\n___\nFamily History:\nNon-contributory as it relates to patients current presentation\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \n========================\nVS: 97.4 135 / 83 80 16 98 Ra \nGENERAL: Pleasant, lying in bed comfortably \nHEENT: EOMI PERRL anicteric sclera\nCARDIAC: RRR unable to appreciate murmurs/gallops, distant heart\nsounds\nLUNG: Appears in no respiratory distress, poor inspiratory \neffort\nlimited by pain\nABD: gtube site appears well appearing, covered by clean white\ndry dressing; RUQ pain on palpation, no rebound or guarding, \nsoft\nabdomen, normoactive BS\nEXT: Warm, well perfused, no lower extremity edema \nPULSES: 2+ radial pulses, 2+ ___ pulses\nNEURO: Alert, oriented, CN II-XII intact, motor and sensory\nfunction grossly intact \n\nDISCHARGE PHYSICAL EXAM:\n========================\nVS: Temp: 97.3 (Tm 97.9), BP: 115/68 (103-115/61-71), HR: 80\n(80-90), RR: 18 (___), O2 sat: 97% (96-97), O2 delivery: Ra\n\n24 hour PTBD drain output: 210ml\n\nGENERAL: NAD\nHEENT: AT/NC, anicteric sclera, MMM\nCV: RRR, S1/S2, no m/r/g\nPULM: LCTAB, breathing comfortably without use of accessory\nmuscles\nGI: Abdomen soft, nondistended, mildly tender to palpation in \nRUQ\nat drain site, no rebound/guarding, dressings c/d/i, no\necchymosis or hematoma at PTBD site, drain putting out\ngreen/bilious material with less visible black sediment than\npreviously\nNEURO: Alert, moving all 4 extremities with purpose, face\nsymmetric\nDERM: WWP, unchanged multiple excoriations on upper and\nlower extremities, improved scaly dermatitis on lower \nextremities\nbilaterally\n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 03:14PM BLOOD WBC-9.0 RBC-3.37* Hgb-10.3* Hct-32.5* \nMCV-96 MCH-30.6 MCHC-31.7* RDW-14.7 RDWSD-52.1* Plt ___\n___ 03:14PM BLOOD Neuts-70.9 Lymphs-10.7* Monos-13.4* \nEos-4.0 Baso-0.7 Im ___ AbsNeut-6.34* AbsLymp-0.96* \nAbsMono-1.20* AbsEos-0.36 AbsBaso-0.06\n___ 03:14PM BLOOD ___ PTT-41.0* ___\n___ 03:14PM BLOOD Glucose-94 UreaN-31* Creat-1.8* Na-139 \nK-5.1 Cl-111* HCO3-16* AnGap-12\n___ 03:14PM BLOOD ALT-20 AST-36 AlkPhos-107 TotBili-0.3\n___ 03:14PM BLOOD Lipase-16\n___ 03:14PM BLOOD Albumin-2.8* Calcium-8.1* Phos-4.0 Mg-1.8\n\n___ 02:35PM URINE Color-Yellow Appear-Hazy* Sp ___\n___ 02:35PM URINE Blood-SM* Nitrite-NEG Protein-300* \nGlucose-TR* Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG*\n___ 02:35PM URINE RBC-4* WBC->182* Bacteri-FEW* Yeast-NONE \nEpi-0\n___ 02:35PM URINE Mucous-RARE*\n\nPERTINENT LABS/MICRO/IMAGING:\n============================\n___ 07:20AM BLOOD %HbA1c-5.4 eAG-108\n\nMICRO:\n----------\n___ 2:35 pm URINE\n URINE CULTURE (Final ___: < 10,000 CFU/mL.\n\n___ 3:11 pm BLOOD CULTURE\n Blood Culture, Routine (Final ___: NO GROWTH. \n\n___ 6:14 pm BLOOD CULTURE\n Blood Culture, Routine (Final ___: NO GROWTH. \n\n___ 2:30 pm FLUID,OTHER\n GRAM STAIN (Final ___: \n NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. \n NO MICROORGANISMS SEEN. \n FLUID CULTURE (Final ___: NO GROWTH. \n ANAEROBIC CULTURE (Final ___: NO GROWTH.\n\nIMAGING:\n-------------\n___ Perc Chole ___:\nSuccessful ultrasound-guided placement of ___ pigtail \ncatheter into the\ngallbladder. A sample was sent for microbiology evaluation.\n\nRUQUS ___:\n1. The gallbladder and percutaneous cholecystostomy tube are \nsuboptimally\nvisualized, due to bowel gas and artifact.\n2. Trace perihepatic ascites.\n\nCARDIAC PERFUSION PHARMStudy Date of ___ \nSUMMARY FROM THE EXERCISE LAB:\nFor pharmacologic stress 0.4 mg of regadenoson (0.08 mg/ml) was \ninfused\nintravenously over 20 seconds followed by a saline flush.\n \nFINDINGS: Left ventricular cavity size is normal.\n \nRest and stress perfusion images reveal a mild-to-moderate \nreversible inferior\nand inferolateral wall defect.\n \nGated images reveal normal wall motion.\n \nThe calculated left ventricular ejection fraction is 46%.\n \nIMPRESSION: 1. Mild-to-moderate reversible inferior and \ninferolateral wall\ndefect. \n2. Mild septal hypokinesis. Left ventricular ejection fraction \nis 46%. \n\nCardiovascular ReportStressStudy Date of ___ \nINTERPRETATION: This ___ y.o. man with h/o HTN, CKD, and \nendocarditis;\ns/p AVR in ___ and again in ___ with CABG X1 with aortic root \nabcess\nand PPM was referred to the lab for evaluation prior to \nnon-cardiac\nsurgery. The patient was administered 0.4 mg of Regadenoson IV \nbolus\nover 20 seconds. No chest, neck, back, or arm discomforts were \nreported\nby the patient throughout the study. There were no significant \nST\nsegment changes throughout the study. The rhythm was sinus with \none APB\nand rare, isolated VPBs. Transient LBBB was noted immediately \npost\ninfusion. Appropriate hemodynamic response to the infusion. \nPost-MIBI,\nthe patient was administered 60 mg of IV Caffeine.\n \nIMPRESSION: No anginal type symptoms or ischemic EKG changes. \nNuclear\nreport sent separately.\n\nDISCHARGE LABS:\n===============\n___ 08:35AM BLOOD WBC-8.5 RBC-3.64* Hgb-11.2* Hct-35.2* \nMCV-97 MCH-30.8 MCHC-31.8* RDW-14.4 RDWSD-50.4* Plt ___\n___ 08:35AM BLOOD ___ PTT-45.3* ___\n___ 08:35AM BLOOD Glucose-101* UreaN-47* Creat-2.6* Na-142 \nK-4.8 Cl-111* HCO3-17* AnGap-14\n___ 08:35AM BLOOD Calcium-8.9 Phos-4.5 Mg-2.___ with h/o endocarditis s/p AVR replacementx2 with CABG c/b \ninoperable aortic root abscess among other issues who presents \nwith three days of RUQ pain and CT findings concerning for \ncholelithiasis and acute cholecystitis.\n\n====================\nACTIVE/ACUTE ISSUES:\n====================\n# Cholecystitis\n# Cholelithiasis\nMr. ___ presented with three days of RUQ pain, exacerbated by \ndeep inspiration and meals, with a prominent ___ sign and \nCT imaging supporting the diagnosis of cholelithiasis and \npossible cholecystitis. Mild clinical presentation and absence \nof leukocytosis and fever may have been related to long-term \nKeflex use for aortic root abscess control. Patient was felt to \nbe a risky surgical candidate given his inoperable aortic root \nabscess. ___ percutaneous cholecystostomy was done \ninstead, which relieved his RUQ tenderness and pain associated \nwith meals, however his pain triggered by inspiration still \nremained and was ultimately felt to be due to a combination of \nconstipation and diaphragmatic irritation from the drain. \nInitially received IV Unasyn, which was discontinued upon \nachieving source control and home suppressive Keflex restarted. \nDrain to be removed by ___ as outpatient once output falls below \n10cc/day for 2 consecutive days. Risk stratified by cardiology \nand ID this admission in case of need for future \ncholecystectomy, patient's cardiac condition is not a \ncontraindication. Started on aspirin 81mg QD, home statin \nswitched for the more efficacious rosuvastatin. Will follow-up \nwith cardiology and general surgery.\n\n# Constipation\nOSH abdominal x-ray showed high stool burden. Likely contributed \nto his RUQ pain as once he had a large BM with the aid of an \nenema, his pain triggered by deep inspiration improved \nsignificantly.\n\n# Pyuria\nPatient with UA notable for large leuk esterase, >182 WBC and \nfew bacteria, which would be suspicious for UTI, though in the \nabsence of symptoms, negative urine culture, and GI infection as \nabove, most likely sterile pyuria associated with intraabdominal \ninflammation. \n\n# Acute on CKD\nBaseline Cr 1.8-2.2. ___ peaked at 2.8, rare eosinophils seen in \nurine, consistent with likely AIN from prior IV Unasyn. \nCreatinine 2.6 on day of discharge.\n\n# CAD status post CABG (SVG-LIMA)\nUnderwent cardiac risk stratification with P-MIBI this \nadmission, while surgical intervention was being considered, \nwith mild-to-moderate reversible inferior and inferolateral wall \ndefect. Cardiology were consulted; recommended medical \nmanagement given poor baseline functional status. Started \naspirin 81mg daily and transitioned to rosuvastatin 40mg daily, \nin addition to continuing metoprolol succinate 25mg daily. Will \nneed to follow-up with outpatient cardiologist. \n\n======================\nCHRONIC/STABLE ISSUES:\n======================\n# Afib, goal INR ___, CHADS2 4\nContinued home metoprolol succinate 25mg daily, home warfarin \n3mg daily initially held for ___ procedure as above, restarted \nafterwards without bridge as CHADS2 score is 4. Discharge INR \n2.4.\n\n# History of native and prosthetic valve endocarditis\n# Aortic root abscess near non-coronary sinus\nOn indefinite antibiotic suppression. Home Keflex initially \nswitched to IV Unasyn to also cover GI infection as above, \nfollowing source control with placement of percutaneous \ncholecysostomy was switched back to Kelfex.\n\n# Hx of seizure event\nContinued levetiracetam 250mg BID.\n\n# HLD\nTransitioned to rosuvastatin 40mg daily as above.\n\n====================\nTRANSITIONAL ISSUES:\n====================\nDischarge creatinine: 2.6\nDischarge INR: 2.4\n\nNew Medications:\n- Aspirin 81mg QD\n- Rosuvastatin 40mg QHS\n- Polyethylene glycol 17g daily\n\nDiscontinued Medications:\n- Pravastatin 40mg QPM\n\n[ ] BILIARY COLIC: follow-up with general surgery as outpatient \nto determine suitability for cholecystectomy; if continued \nsymptoms without intervention planned, consider initiation of \nursodiol\n[ ] PERC CHOLE: drain to remain in place until output <10cc for \ntwo consecutive days\n[ ] ___ on CKD: patient should have repeat Chem-7 within one \nweek of discharge\n[ ] CAD: if symptomatic, discussion should be had with patient \nre: benefit of coronary angiogram\n[ ] Patient's cardiac condition/chronic infection is not a \ncontraindication for non-open heart surgeries\n\n=============================================\n# CONTACT: HCP: ___ - ___\n# CODE: Full \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. coenzyme Q10 100 mg oral DAILY \n2. Docusate Sodium 100 mg PO DAILY \n3. LevETIRAcetam 250 mg PO BID \n4. Warfarin ___ mg PO DAILY \n5. Metoprolol Succinate XL 25 mg PO DAILY \n6. Pravastatin 40 mg PO QPM \n7. Cephalexin 500 mg PO Q8H \n8. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever \n9. B-Complex (vitamin B complex) 100 mg oral DAILY \n\n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \nRX *aspirin 81 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet \nRefills:*0 \n2. Polyethylene Glycol 17 g PO DAILY \nRX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by \nmouth Daily Disp #*24 Packet Refills:*0 \n3. Rosuvastatin Calcium 40 mg PO QPM \nRX *rosuvastatin 40 mg 1 tablet(s) by mouth QPM Disp #*30 Tablet \nRefills:*0 \n4. Warfarin 3 mg PO DAILY16 \nRX *warfarin 3 mg AS DIR tablet(s) by mouth Daily Disp #*10 \nTablet Refills:*0 \n5. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever \n6. B-Complex (vitamin B complex) 100 mg oral DAILY \n7. Cephalexin 500 mg PO Q8H \n8. coenzyme Q10 100 mg oral DAILY \n9. Docusate Sodium 100 mg PO DAILY \n10. LevETIRAcetam 250 mg PO BID \n11. Metoprolol Succinate XL 25 mg PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nCholelithiasis/Possible cholecystitis\n\n \nDischarge Condition:\nActivity Status: Bedbound.\nLevel of Consciousness: Alert and interactive.\nMental Status: Clear and coherent.\n\n \nDischarge Instructions:\nDear ___,\n\nIt was a pleasure taking care of you at ___.\n\nWhy you were in the hospital\n- You were having abdominal pain.\n\nWhat was done for you in the hospital\n- We suspected the pain was coming from your gallbladder and ___ \ninserted a drain into it to decompress and relieve the pressure \ninside.\n- You were also constipated, so were given medication to help \nrelieve your constipation.\n- You had a stress test which showed an area concerning for a \nblocked blood vessel in your heart for which our cardiology \ndoctors saw ___ \n \nWhat you should do after you leave the hospital\n- Please take your medications as detailed in the discharge \npapers. If you have questions about which medications to take, \nplease contact your regular doctor to discuss.\n- Please follow-up with your outpatient providers as arranged \n- Please monitor for worsening symptoms. If you do not feel like \nyou are getting better or have any other concerns, please call \nyour doctor to discuss or return to the emergency room.\n\nDrain Care:\n- Please look at the site every day for signs of infection \n(increased redness or pain, swelling, odor, yellow or bloody \ndischarge, warm to touch, fever).\n- Note color, consistency, and amount of fluid in the drain. \nCall the doctor, ___, or ___ nurse if the amount \nincreases significantly or changes in character.\n- Be sure to empty the drain bag or bulb frequently. Record the \noutput daily.\n- You may shower; wash the area gently with warm, soapy water.\n- Keep the insertion site clean and dry otherwise.\n- Avoid swimming, baths, hot tubs; do not submerge yourself in \nwater.\n- If you develop worsening abdominal pain, fevers or chills \nplease call Interventional Radiology at ___ at ___ \nand page ___.\n- When the drainage total is LESS THAN 10/ml for 2 days in a \nrow, please have the ___ call Interventional Radiology at ___ \nat ___ and page ___. This is the Radiology fellow on \ncall who can assist you.\n\nWe wish you the best!\n\nYour ___ Care Team\n \nFollowup Instructions:\n___\n"
] | Allergies: Macrolide Antibiotics Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: Percutaneous cholecystostomy ([MASKED]) History of Present Illness: Mr. [MASKED] is an [MASKED] with a past medical history of native aortic valve endocarditis in [MASKED] status post aortic valve replacement (bovine in [MASKED] AI), with subsequent prosthetic valve MSSA endocarditis in [MASKED] c/b L sided strokes status post repeat AVR replacement and CABG x1 due to abscess cavity blocking non-coronary sinus, dual-chamber PPM, CKD, hypertension, hx of severe C. diff presenting with RUQ abdominal pain x2 days. The patient was admitted to [MASKED] in [MASKED] for fevers and hypotension. He had strep pneumoniae in his [MASKED] blood cultures (sensitive to penicillins) and was de-escalated to cefazolin then ceftriaxone. He had a TEE that showed an aortic root abscess but was too high risk for surgery per [MASKED] cardiac surgery as well as second opinion by [MASKED]. Repeat TEE 1 week post discharge showed unchanged abscess. He was eventually switched to Keflex [MASKED] TID in [MASKED]. Given that surgery is not an option for him, referral for palliative care has been made, but patient has not yet been to appointment. The patient has had pain in his abdomen in his right upper quadrant pain for the past two days. [MASKED] he presented to [MASKED] with pain and tenderness around the g tube site (was removed last [MASKED]. CT scan reported showed cholecystitis but clinically this did not fit and given improvement in pain, he was discharged. He ate a spicy meal on [MASKED] night and then developed pain in his RUQ. He returned to the [MASKED] on [MASKED] after some vomiting. He was then transferred to [MASKED] for further evaluation of cholecystitis. In the [MASKED], - Initial VS: 97.2 80 138/78 18 96% RA - Exam notable for: GEN: No acute distress RESP: lungs clear ABD: tender in RUQ, no fluid wave, Gtube site with healing granuloma and no surrounding erythema or discharge - Labs notable for: CBC: WBC 9.0, hgb 10.3, plt 258 INR 2.1 Chem: Na 139, K 5.1, bicarb 16, BUN 31, Cr 1.8 LFTs and lipase: WNL UA: Large leuks, negative nitrites, >182 WBC, few bacteria 0 epis Bld cx x2 pending - Imaging: [MASKED] A/P w/o contrast [MASKED] Cholelithiasis with GB wall thickening and pericholecystic edema. No biliary ductal dilation. - Meds: IV Morphine Sulfate 4 mg PO Acetaminophen 650 mg IV Ampicillin-Sulbactam 3 g - Consults: Surgery who recommended [MASKED] consult for percutaneous cholecystomy [MASKED] who will perform perc chole [MASKED] - Vitals prior to transfer: 97.8 80 124/78 18 100% On arrival to the floor, he is reporting sharp pain constant rated a [MASKED] in his RUQ. He denies current nausea. He feels somewhat hungry. There is no fevers, chills. He last had a bowel movement on the day of removal of the gtube a few days prior. The pain around his gtube removal has resolved completely. He denies dysuria, urinary habit changes, hematuria. REVIEW OF SYSTEMS: A complete 10-point review of systems was performed and was negative less otherwise noted in the HPI. Past Medical History: - Native aortic valve endocarditis in [MASKED] status post aortic valve replacement (bovine in [MASKED] AI), with subsequent prosthetic valve MSSA endocarditis in [MASKED] c/b L sided strokes status post repeat AVR replacement and CABG x1 due to abscess cavity blocking non-coronary sinus - dual-chamber PPM - Chronic Kidney Disease Cr 1.8-2.2 - HLD - HTN - Hx DVT - h/o C. difficile diarrhea x2 - Peripheral neuropathy - Spinal stenosis - Migraine - Depression/Anxiety - Nuclear sclerotic cataract of left eye - Central retinal vein occlusion - Glaucoma - Malignant melanoma - BPH - Hematuria - Anemia - Thrombocytopenia Social History: [MASKED] Family History: Non-contributory as it relates to patients current presentation Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: 97.4 135 / 83 80 16 98 Ra GENERAL: Pleasant, lying in bed comfortably HEENT: EOMI PERRL anicteric sclera CARDIAC: RRR unable to appreciate murmurs/gallops, distant heart sounds LUNG: Appears in no respiratory distress, poor inspiratory effort limited by pain ABD: gtube site appears well appearing, covered by clean white dry dressing; RUQ pain on palpation, no rebound or guarding, soft abdomen, normoactive BS EXT: Warm, well perfused, no lower extremity edema PULSES: 2+ radial pulses, 2+ [MASKED] pulses NEURO: Alert, oriented, CN II-XII intact, motor and sensory function grossly intact DISCHARGE PHYSICAL EXAM: ======================== VS: Temp: 97.3 (Tm 97.9), BP: 115/68 (103-115/61-71), HR: 80 (80-90), RR: 18 ([MASKED]), O2 sat: 97% (96-97), O2 delivery: Ra 24 hour PTBD drain output: 210ml GENERAL: NAD HEENT: AT/NC, anicteric sclera, MMM CV: RRR, S1/S2, no m/r/g PULM: LCTAB, breathing comfortably without use of accessory muscles GI: Abdomen soft, nondistended, mildly tender to palpation in RUQ at drain site, no rebound/guarding, dressings c/d/i, no ecchymosis or hematoma at PTBD site, drain putting out green/bilious material with less visible black sediment than previously NEURO: Alert, moving all 4 extremities with purpose, face symmetric DERM: WWP, unchanged multiple excoriations on upper and lower extremities, improved scaly dermatitis on lower extremities bilaterally Pertinent Results: ADMISSION LABS: =============== [MASKED] 03:14PM BLOOD WBC-9.0 RBC-3.37* Hgb-10.3* Hct-32.5* MCV-96 MCH-30.6 MCHC-31.7* RDW-14.7 RDWSD-52.1* Plt [MASKED] [MASKED] 03:14PM BLOOD Neuts-70.9 Lymphs-10.7* Monos-13.4* Eos-4.0 Baso-0.7 Im [MASKED] AbsNeut-6.34* AbsLymp-0.96* AbsMono-1.20* AbsEos-0.36 AbsBaso-0.06 [MASKED] 03:14PM BLOOD [MASKED] PTT-41.0* [MASKED] [MASKED] 03:14PM BLOOD Glucose-94 UreaN-31* Creat-1.8* Na-139 K-5.1 Cl-111* HCO3-16* AnGap-12 [MASKED] 03:14PM BLOOD ALT-20 AST-36 AlkPhos-107 TotBili-0.3 [MASKED] 03:14PM BLOOD Lipase-16 [MASKED] 03:14PM BLOOD Albumin-2.8* Calcium-8.1* Phos-4.0 Mg-1.8 [MASKED] 02:35PM URINE Color-Yellow Appear-Hazy* Sp [MASKED] [MASKED] 02:35PM URINE Blood-SM* Nitrite-NEG Protein-300* Glucose-TR* Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG* [MASKED] 02:35PM URINE RBC-4* WBC->182* Bacteri-FEW* Yeast-NONE Epi-0 [MASKED] 02:35PM URINE Mucous-RARE* PERTINENT LABS/MICRO/IMAGING: ============================ [MASKED] 07:20AM BLOOD %HbA1c-5.4 eAG-108 MICRO: ---------- [MASKED] 2:35 pm URINE URINE CULTURE (Final [MASKED]: < 10,000 CFU/mL. [MASKED] 3:11 pm BLOOD CULTURE Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] 6:14 pm BLOOD CULTURE Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] 2:30 pm FLUID,OTHER GRAM STAIN (Final [MASKED]: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [MASKED]: NO GROWTH. ANAEROBIC CULTURE (Final [MASKED]: NO GROWTH. IMAGING: ------------- [MASKED] Perc Chole [MASKED]: Successful ultrasound-guided placement of [MASKED] pigtail catheter into the gallbladder. A sample was sent for microbiology evaluation. RUQUS [MASKED]: 1. The gallbladder and percutaneous cholecystostomy tube are suboptimally visualized, due to bowel gas and artifact. 2. Trace perihepatic ascites. CARDIAC PERFUSION PHARMStudy Date of [MASKED] SUMMARY FROM THE EXERCISE LAB: For pharmacologic stress 0.4 mg of regadenoson (0.08 mg/ml) was infused intravenously over 20 seconds followed by a saline flush. FINDINGS: Left ventricular cavity size is normal. Rest and stress perfusion images reveal a mild-to-moderate reversible inferior and inferolateral wall defect. Gated images reveal normal wall motion. The calculated left ventricular ejection fraction is 46%. IMPRESSION: 1. Mild-to-moderate reversible inferior and inferolateral wall defect. 2. Mild septal hypokinesis. Left ventricular ejection fraction is 46%. Cardiovascular ReportStressStudy Date of [MASKED] INTERPRETATION: This [MASKED] y.o. man with h/o HTN, CKD, and endocarditis; s/p AVR in [MASKED] and again in [MASKED] with CABG X1 with aortic root abcess and PPM was referred to the lab for evaluation prior to non-cardiac surgery. The patient was administered 0.4 mg of Regadenoson IV bolus over 20 seconds. No chest, neck, back, or arm discomforts were reported by the patient throughout the study. There were no significant ST segment changes throughout the study. The rhythm was sinus with one APB and rare, isolated VPBs. Transient LBBB was noted immediately post infusion. Appropriate hemodynamic response to the infusion. Post-MIBI, the patient was administered 60 mg of IV Caffeine. IMPRESSION: No anginal type symptoms or ischemic EKG changes. Nuclear report sent separately. DISCHARGE LABS: =============== [MASKED] 08:35AM BLOOD WBC-8.5 RBC-3.64* Hgb-11.2* Hct-35.2* MCV-97 MCH-30.8 MCHC-31.8* RDW-14.4 RDWSD-50.4* Plt [MASKED] [MASKED] 08:35AM BLOOD [MASKED] PTT-45.3* [MASKED] [MASKED] 08:35AM BLOOD Glucose-101* UreaN-47* Creat-2.6* Na-142 K-4.8 Cl-111* HCO3-17* AnGap-14 [MASKED] 08:35AM BLOOD Calcium-8.9 Phos-4.5 Mg-2.[MASKED] with h/o endocarditis s/p AVR replacementx2 with CABG c/b inoperable aortic root abscess among other issues who presents with three days of RUQ pain and CT findings concerning for cholelithiasis and acute cholecystitis. ==================== ACTIVE/ACUTE ISSUES: ==================== # Cholecystitis # Cholelithiasis Mr. [MASKED] presented with three days of RUQ pain, exacerbated by deep inspiration and meals, with a prominent [MASKED] sign and CT imaging supporting the diagnosis of cholelithiasis and possible cholecystitis. Mild clinical presentation and absence of leukocytosis and fever may have been related to long-term Keflex use for aortic root abscess control. Patient was felt to be a risky surgical candidate given his inoperable aortic root abscess. [MASKED] percutaneous cholecystostomy was done instead, which relieved his RUQ tenderness and pain associated with meals, however his pain triggered by inspiration still remained and was ultimately felt to be due to a combination of constipation and diaphragmatic irritation from the drain. Initially received IV Unasyn, which was discontinued upon achieving source control and home suppressive Keflex restarted. Drain to be removed by [MASKED] as outpatient once output falls below 10cc/day for 2 consecutive days. Risk stratified by cardiology and ID this admission in case of need for future cholecystectomy, patient's cardiac condition is not a contraindication. Started on aspirin 81mg QD, home statin switched for the more efficacious rosuvastatin. Will follow-up with cardiology and general surgery. # Constipation OSH abdominal x-ray showed high stool burden. Likely contributed to his RUQ pain as once he had a large BM with the aid of an enema, his pain triggered by deep inspiration improved significantly. # Pyuria Patient with UA notable for large leuk esterase, >182 WBC and few bacteria, which would be suspicious for UTI, though in the absence of symptoms, negative urine culture, and GI infection as above, most likely sterile pyuria associated with intraabdominal inflammation. # Acute on CKD Baseline Cr 1.8-2.2. [MASKED] peaked at 2.8, rare eosinophils seen in urine, consistent with likely AIN from prior IV Unasyn. Creatinine 2.6 on day of discharge. # CAD status post CABG (SVG-LIMA) Underwent cardiac risk stratification with P-MIBI this admission, while surgical intervention was being considered, with mild-to-moderate reversible inferior and inferolateral wall defect. Cardiology were consulted; recommended medical management given poor baseline functional status. Started aspirin 81mg daily and transitioned to rosuvastatin 40mg daily, in addition to continuing metoprolol succinate 25mg daily. Will need to follow-up with outpatient cardiologist. ====================== CHRONIC/STABLE ISSUES: ====================== # Afib, goal INR [MASKED], CHADS2 4 Continued home metoprolol succinate 25mg daily, home warfarin 3mg daily initially held for [MASKED] procedure as above, restarted afterwards without bridge as CHADS2 score is 4. Discharge INR 2.4. # History of native and prosthetic valve endocarditis # Aortic root abscess near non-coronary sinus On indefinite antibiotic suppression. Home Keflex initially switched to IV Unasyn to also cover GI infection as above, following source control with placement of percutaneous cholecysostomy was switched back to Kelfex. # Hx of seizure event Continued levetiracetam 250mg BID. # HLD Transitioned to rosuvastatin 40mg daily as above. ==================== TRANSITIONAL ISSUES: ==================== Discharge creatinine: 2.6 Discharge INR: 2.4 New Medications: - Aspirin 81mg QD - Rosuvastatin 40mg QHS - Polyethylene glycol 17g daily Discontinued Medications: - Pravastatin 40mg QPM [ ] BILIARY COLIC: follow-up with general surgery as outpatient to determine suitability for cholecystectomy; if continued symptoms without intervention planned, consider initiation of ursodiol [ ] PERC CHOLE: drain to remain in place until output <10cc for two consecutive days [ ] [MASKED] on CKD: patient should have repeat Chem-7 within one week of discharge [ ] CAD: if symptomatic, discussion should be had with patient re: benefit of coronary angiogram [ ] Patient's cardiac condition/chronic infection is not a contraindication for non-open heart surgeries ============================================= # CONTACT: HCP: [MASKED] - [MASKED] # CODE: Full Medications on Admission: The Preadmission Medication list is accurate and complete. 1. coenzyme Q10 100 mg oral DAILY 2. Docusate Sodium 100 mg PO DAILY 3. LevETIRAcetam 250 mg PO BID 4. Warfarin [MASKED] mg PO DAILY 5. Metoprolol Succinate XL 25 mg PO DAILY 6. Pravastatin 40 mg PO QPM 7. Cephalexin 500 mg PO Q8H 8. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever 9. B-Complex (vitamin B complex) 100 mg oral DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 2. Polyethylene Glycol 17 g PO DAILY RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by mouth Daily Disp #*24 Packet Refills:*0 3. Rosuvastatin Calcium 40 mg PO QPM RX *rosuvastatin 40 mg 1 tablet(s) by mouth QPM Disp #*30 Tablet Refills:*0 4. Warfarin 3 mg PO DAILY16 RX *warfarin 3 mg AS DIR tablet(s) by mouth Daily Disp #*10 Tablet Refills:*0 5. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever 6. B-Complex (vitamin B complex) 100 mg oral DAILY 7. Cephalexin 500 mg PO Q8H 8. coenzyme Q10 100 mg oral DAILY 9. Docusate Sodium 100 mg PO DAILY 10. LevETIRAcetam 250 mg PO BID 11. Metoprolol Succinate XL 25 mg PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Cholelithiasis/Possible cholecystitis Discharge Condition: Activity Status: Bedbound. Level of Consciousness: Alert and interactive. Mental Status: Clear and coherent. Discharge Instructions: Dear [MASKED], It was a pleasure taking care of you at [MASKED]. Why you were in the hospital - You were having abdominal pain. What was done for you in the hospital - We suspected the pain was coming from your gallbladder and [MASKED] inserted a drain into it to decompress and relieve the pressure inside. - You were also constipated, so were given medication to help relieve your constipation. - You had a stress test which showed an area concerning for a blocked blood vessel in your heart for which our cardiology doctors saw [MASKED] What you should do after you leave the hospital - Please take your medications as detailed in the discharge papers. If you have questions about which medications to take, please contact your regular doctor to discuss. - Please follow-up with your outpatient providers as arranged - Please monitor for worsening symptoms. If you do not feel like you are getting better or have any other concerns, please call your doctor to discuss or return to the emergency room. Drain Care: - Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). - Note color, consistency, and amount of fluid in the drain. Call the doctor, [MASKED], or [MASKED] nurse if the amount increases significantly or changes in character. - Be sure to empty the drain bag or bulb frequently. Record the output daily. - You may shower; wash the area gently with warm, soapy water. - Keep the insertion site clean and dry otherwise. - Avoid swimming, baths, hot tubs; do not submerge yourself in water. - If you develop worsening abdominal pain, fevers or chills please call Interventional Radiology at [MASKED] at [MASKED] and page [MASKED]. - When the drainage total is LESS THAN 10/ml for 2 days in a row, please have the [MASKED] call Interventional Radiology at [MASKED] at [MASKED] and page [MASKED]. This is the Radiology fellow on call who can assist you. We wish you the best! Your [MASKED] Care Team Followup Instructions: [MASKED] | [
"K8000",
"N179",
"K5900",
"I129",
"N189",
"I2510",
"I4891",
"E785",
"N400",
"G629",
"I7789",
"D631",
"Z8619",
"Z951",
"Z87891",
"Z8673",
"Z86718",
"Z953",
"Z950"
] | [
"K8000: Calculus of gallbladder with acute cholecystitis without obstruction",
"N179: Acute kidney failure, unspecified",
"K5900: Constipation, unspecified",
"I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease",
"N189: Chronic kidney disease, unspecified",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"I4891: Unspecified atrial fibrillation",
"E785: Hyperlipidemia, unspecified",
"N400: Benign prostatic hyperplasia without lower urinary tract symptoms",
"G629: Polyneuropathy, unspecified",
"I7789: Other specified disorders of arteries and arterioles",
"D631: Anemia in chronic kidney disease",
"Z8619: Personal history of other infectious and parasitic diseases",
"Z951: Presence of aortocoronary bypass graft",
"Z87891: Personal history of nicotine dependence",
"Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits",
"Z86718: Personal history of other venous thrombosis and embolism",
"Z953: Presence of xenogenic heart valve",
"Z950: Presence of cardiac pacemaker"
] | [
"N179",
"K5900",
"I129",
"N189",
"I2510",
"I4891",
"E785",
"N400",
"Z951",
"Z87891",
"Z8673",
"Z86718"
] | [] |
19,367,303 | 22,518,358 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nFluorescein / Percocet\n \nAttending: ___.\n \nChief Complaint:\nDizziness\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ year old woman with history of HTN, DM, TIA, and vertigo who \npresents with dizziness and vertigo for past 3 days.\n\nThe patient reports having been diagnosed with vertigo ___ years \nago and it has been an ongoing problem that acutely worsened \nover the past 3 days. She states it gets worse with moving her \nhead. She reports feeling dizzy and wobbly on her feet. \n\nShe denies headache, changes in her vision, new weakness or \nnumbness. No recent preceding viral illness, cough, shortness of \nbreath, sinus pain, tinnitus or ear pain. She does report \nincreased urinary frequency and chronic diarrhea. She has not \nhad any other lower urinary tract symptoms. The diarrhea she \nreports has been ongoing for over a year. She was recently \nstopped metformin however the diarrhea has persisted. \n\nOf note she was admitted to the neuro service in ___ with TIA.\n\nIn the ED, initial vitals: 98.1 HR 76 BP 147/69 RR 18 SpO2 100% \nRA \n\nExam Notable for: Tired-appearing in NAD, Positive ___ Hall \nPike, dizziness worsened with maneuver and patient with \nhorizontal nystagmus, CN II-XII grossly intact. Normal UE and ___ \nstrength and sensation bilaterally. Normal cerebellar function. \nNormal gait (with help).\n\nLabs were significant for: WBC of 10.6, Cr of 1.6 improved to \n1.4, BUN 48. UA concerning for Lg leuks, Tr Protein, 300 Gluc, \n85WBC, Many bacteria and moderate yeast. 1 EPI and 4 casts. \n\nPatient was given: \n___ 23:30 IVF 1000 mL NS 250 mL/hr \n___ 23:30 IV Lorazepam 2 mg \n___ 02:45 IV CeftriaXONE 2 gm \n___ 03:19 IVF 1000 mL \n___ 03:19 IV Magnesium Sulfate 2 gm \n___ 04:13 IV Magnesium Sulfate 2 gm \n\nThere was concern for UTI. Patient was given CTX. \nNeurology was consulted and her exam was concerning for acute \ncerebellar signs but may be confounded by Ativan. Recommended \northostatics, hydration. Admission to medicine. \n\nOn the floor, patient arrived and continued to report dizziness. \nThe room isn't spinning but she feels dizzy. Worse when she sits \nup. No nausea, vomiting, chest pain, SOB, abdominal pain. No \ndysuria, incontinence. Reports urinary frequency and chronic \ndiarrhea. \n\nROS: As per HPI. All other ROS negative. \n\n \nPast Medical History:\nDM\nHTN\nHyperlipidemia\nDiabetic Retinopathy and Neuropathy\nTIA in ___\nDegenerative disc and joint Disease of Lumbar Spine\nTobacco Abuse\n \nSocial History:\n___\nFamily History:\nFather- CAD, ___\nMother- Heart failure, ___, HTN\nSister- ___\n \nPhysical ___:\nADMISSION PHYSICAL EXAM: \nVS: 97.9 150/64 65 18 99%RA \nGEN: Alert, lying in bed, no acute distress \nHEENT: MMM, anicteric sclera, no conjunctival pallor \nNECK: Supple without LAD \nPULM: Clear, no wheeze, rales, or rhonchi \nCOR: RRR, normal S1/S2, no murmurs \nABD: Soft, NT ND, normal BS \nEXTREM: Warm, no edema \nNEURO: CN2-12 intact with normal sensation on face bilaterally. \nnormal sensation in strength in upper and lower extremities. \nUnable to replicate + ___ hall pike on my examination\n\nDISCHARGE PHYSICAL EXAM: \nVS:98.3 119/59 (130-180/60-80) 64 18 100%RA\nGEN: Alert, lying in bed, no acute distress \nHEENT: MMM\nPULM: Clear, no wheeze, rales, or rhonchi \nCOR: RRR, normal S1/S2, no murmurs \nABD: Soft, NT ND, normal BS \nEXTREM: no edema \nNEURO: CN2-12 intact with normal sensation on face bilaterally. \nnormal sensation in strength in upper and lower extremities. \n \nPertinent Results:\nADMISSION LABS\n==============\n___ 11:50PM BLOOD WBC-10.6* RBC-4.09 Hgb-12.5 Hct-36.9 \nMCV-90 MCH-30.6 MCHC-33.9 RDW-13.0 RDWSD-42.2 Plt ___\n___ 11:50PM BLOOD Neuts-62.5 ___ Monos-6.6 Eos-2.0 \nBaso-0.8 Im ___ AbsNeut-6.66* AbsLymp-2.94 AbsMono-0.70 \nAbsEos-0.21 AbsBaso-0.08\n___ 11:50PM BLOOD Plt ___\n___ 11:50PM BLOOD Glucose-192* UreaN-48* Creat-1.6* Na-139 \nK-4.3 Cl-100 HCO3-26 AnGap-17\n___ 05:47AM BLOOD Cholest-240*\n___ 08:55AM BLOOD Calcium-9.6 Phos-4.0 Mg-1.9\n___ 01:00AM URINE Color-Yellow Appear-Hazy Sp ___\n___ 01:00AM URINE Blood-NEG Nitrite-NEG Protein-TR \nGlucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG\n___ 01:00AM URINE RBC-0 WBC-85* Bacteri-MANY Yeast-MOD \nEpi-1\n___ 01:00AM URINE CastHy-4*\n\nPERTINENT LABS\n==============\n___ 05:47AM BLOOD WBC-11.2* RBC-4.28 Hgb-12.7 Hct-39.2 \nMCV-92 MCH-29.7 MCHC-32.4 RDW-12.8 RDWSD-42.6 Plt ___\n___ 08:55AM BLOOD WBC-8.7 RBC-4.15 Hgb-12.5 Hct-38.4 MCV-93 \nMCH-30.1 MCHC-32.6 RDW-12.8 RDWSD-43.5 Plt ___\n___ 05:47AM BLOOD Glucose-264* UreaN-41* Creat-1.2* Na-139 \nK-4.1 Cl-104 HCO3-25 AnGap-14\n___ 06:04AM BLOOD Glucose-103* UreaN-23* Creat-0.9 Na-137 \nK-5.0 Cl-106 HCO3-16* AnGap-20\n___ 05:47AM BLOOD %HbA1c-10.4* eAG-252*\n___ 05:47AM BLOOD Triglyc-251* HDL-54 CHOL/HD-4.4 \nLDLcalc-136*\n___ 08:55AM BLOOD TSH-1.2\n\nDISCHARGE LABS\n===============\n___ 09:30AM BLOOD WBC-9.1 RBC-4.16 Hgb-12.7 Hct-39.7 MCV-95 \nMCH-30.5 MCHC-32.0 RDW-13.1 RDWSD-45.2 Plt ___\n___ 09:30AM BLOOD Neuts-59.1 ___ Monos-7.3 Eos-5.3 \nBaso-1.0 Im ___ AbsNeut-5.36 AbsLymp-2.45 AbsMono-0.66 \nAbsEos-0.48 AbsBaso-0.09*\n___ 09:30AM BLOOD Glucose-233* UreaN-21* Creat-1.0 Na-138 \nK-4.8 Cl-105 HCO3-20* AnGap-18\n\nMICRO\n===============\n___ 1:00 am URINE Site: NOT SPECIFIED\n CHEM S# ___ ___ UCU ADDED 03.03. \n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. \n PRESUMPTIVE IDENTIFICATION. \n Cefazolin interpretative criteria are based on a dosage \nregimen of\n 2g every 8h. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n ESCHERICHIA COLI\n | \nAMPICILLIN------------ =>32 R\nAMPICILLIN/SULBACTAM-- 16 I\nCEFAZOLIN------------- <=4 S\nCEFEPIME-------------- <=1 S\nCEFTAZIDIME----------- <=1 S\nCEFTRIAXONE----------- <=1 S\nCIPROFLOXACIN--------- =>4 R\nGENTAMICIN------------ <=1 S\nMEROPENEM-------------<=0.25 S\nNITROFURANTOIN-------- <=16 S\nPIPERACILLIN/TAZO----- 8 S\nTOBRAMYCIN------------ <=1 S\nTRIMETHOPRIM/SULFA---- <=1 S\n\nIMAGING\n============\n\n___ HEAD W & W/O CONTRAS\n\nFINDINGS: \n \nPlease note the study is mildly degraded by motion.\n \nThere is a punctate focus of slow diffusion in the right middle \ncerebellar\npeduncle. There is no evidence of hemorrhage, edema, masses, \nmass effect, or\nmidline shift. There is prominence of the ventricles and sulci \nsuggestive\ninvolutional changes. There are multiple stable periventricular \nsubcortical\nT2/FLAIR hyperintensities, greatest in the right periventricular \nwhite matter.\nThere is no abnormal enhancement after contrast administration. \nA right\nfrontal developmental venous anomaly is seen.\n \nThe major vascular flow voids are preserved. The orbits and \nmastoid air cells\nare normal. Minimal mucosal thickening in the ethmoid sinuses \nseen.\n \nIMPRESSION:\n \n \n1. Grossly stable white matter signal abnormality, which is a \nnonspecific\nfinding and may be secondary to chronic microvascular ischemic \nchanges,\nmigraines, demyelination, or chronic infection/inflammation.\n2. Punctate focus of low diffusion in the middle right \ncerebellar peduncle,\nmost consistent with an acute infarction.\n3. No evidence for intracranial metastatic disease.\n\n___\nLEFT ATRIUM: Normal LA size. \n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. \n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and \nregional/global systolic function (LVEF>55%). Mild resting LVOT \ngradient. \n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion. \n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch \nlevels. No 2D or Doppler evidence of distal arch coarctation. \n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. \n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. \n\n___ VALVE: Normal tricuspid valve leaflets with trivial \nTR. Normal PA systolic pressure. \n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. \nNo PS. Physiologic PR. \n\nPERICARDIUM: No pericardial effusion. There is an anterior space \nwhich most likely represents a fat pad, though a loculated \nanterior pericardial effusion cannot be excluded.\nConclusions\nThe left atrium is normal in size. There is mild symmetric left \nventricular hypertrophy with normal cavity size and \nregional/global systolic function (LVEF>55%). Right ventricular \nchamber size and free wall motion are normal. The diameters of \naorta at the sinus, ascending and arch levels are normal. The \naortic valve leaflets (3) appear structurally normal with good \nleaflet excursion and no aortic stenosis or aortic \nregurgitation. The mitral valve appears structurally normal with \ntrivial mitral regurgitation. The estimated pulmonary artery \nsystolic pressure is normal. There is no pericardial effusion. \nThere is an anterior space which most likely represents a \nprominent fat pad. \n\nIMPRESSION: No intracardiac source of thromboembolism \nidentified. Mild symmetric left ventricular hypertrophy with \npreserved biventricular systolic function. Mild resting LVOT \nobstruction in the setting of vigorous systolic function. No \nclinically significant valvular disease. Normal pulmonary artery \nsystolic pressure. \n\n___ HEAD & CTA NECK\n\nFINDINGS: \n \nCT HEAD WITHOUT CONTRAST:\nThere is no evidence of hemorrhage, edema, or mass. The small \nright\ncerebellar peduncle infarct is not well visualized on this study \ngiven the\nsize. The ventricles and sulci are normal in size and \nconfiguration.\n \nThe visualized portion of the paranasal sinuses, mastoid air \ncells, and middle\near cavities are clear. The visualized portion of the orbits are \nunremarkable.\n \nCTA HEAD: There is atherosclerotic calcification and \nirregularity of the\ncavernous internal carotid arteries.\nOtherwise, the vessels of the circle of ___ and their \nprincipal\nintracranial branches appear normal without stenosis, occlusion \nor aneurysm\nformation. The dural venous sinuses are patent.\n \nCTA NECK: Atherosclerotic calcification of the aortic arch and \nbranch vessels\nis seen. There is a common origin between the brachiocephalic \nand left\ncarotid artery. Otherwise, the carotid and vertebral arteries \nand their major\nbranches appear normal with no evidence of stenosis or \nocclusion. There is no\nevidence of internal carotid stenosis by NASCET criteria.\n \nOTHER:\nThere is a 0.5 cm right upper lobe lung nodule, series 7, image \n29 The\nvisualized portion of the thyroid gland is within normal limits. \nThere is no\nlymphadenopathy by CT size criteria. Mild degenerative changes \nof the\ncervical spine are seen.\n \nIMPRESSION:\n \n1. No evidence of acute intracranial hemorrhage.\n2. No evidence of aneurysm greater than 3 mm, dissection or \nvascular\nmalformation, or significant luminal narrowing.\n3. A 0.5 cm right upper lobe lung nodule. Recommend a \ncompletion CT chest for\nfurther evaluation.\n \n\n \nBrief Hospital Course:\n___ woman with history of remote Left Insular Infarct, \nHypertension, Hyperlipidemia, Diabetes Mellitus II, Smoking and \nBPPV who presented with 3 days of dizziness. Dizziness likely \nmultifactorial with BPPV, orthostatic hypotension and acute \ninfarct all playing a role in her symptoms. \n\n#BPPV- Neurology was consulted and diagnosed her with BPPV \n(given rotation nystagmus on exam). She was treated with \nmeclizine which was uptitrated to 25mg TID. \n\n#Orthostatic Hypotension- patient treated with IV fluids. She \nmay have a component of autonomic dysfunction given her poorly \ncontrolled diabetes. \n\n#R middle cerebellar peduncle acute stroke - neurology was \nconsulted and recommended further work up of her acute \ndizziness. She had an MRI that showed acute infarct in her R \ncerebellar peduncle which may be causing some of her symptoms. \nShe had echo which was negative for thrombus and CTA head and \nneck that showed no stenosis. Patient was found to have \nhyperlipidemia and elevated hemoglobin A1C. She will need \nfurther titration as an outpatient. Her statin dose was \nincreased. She was counseled on the importance of smoking \ncessation and dietary control.\n\n#Smoking cessation- patient counseled and given nicotine patch \non discharge. \n\n#Acute Kidney Injury - likely prerenal in setting of diarrhea. \nPatient improved with IVF. HCTZ and lisinopril were held. \n\n#Pyuria- positive UA, only symptom she reports is urinary \nfrequency that had resolved during her admission. Patient with \nno recent sexual history to be concerned for gonorrhea or \nchlamydia. She was initially treated with 3 days of ceftriaxone. \nThis was discontinued as the patient was asymptomatic. Post \ndischarge Urine culture grew >100,000 ecoli. \n\n#Chronic diarrhea- unclear etiology has been ongoing for months. \nStools described as malabsobitive. Patient will need further \nwork up as an outpatient. TTG-IGA and Giardia DFA were pending \non discharge. \n\n#Diabetes - patient noted to have hemoglobin A1C of 10.4. \n___ was consulted and recommended current humalog 75/25, \nhowever they suggested moving her evening humalog to dinner \ninstead of at bed time. Patient will need further titration as \nan outpatient. \n\n#Neuropathy- continued on gabapentin\n\n#Hypertension - patient continued on Metoprolol Succinate XL \n200 mg PO DAILY and Diltiazem Extended-Release 180 mg PO DAILY. \nInitially lisnopril and HCTZ were held. She was restarted on a \nlisinopril dose of 10mg daily given her lightheadedness. HCTZ \nwas discontinued as it may be leading to her \ndehydration/orthostasis. \n\nTRANSITIONAL ISSUES\n=======================\n- smoking cessation counseling- given nicotine patch on \ndischarge\n- exercise and nutrition counseling \n- lisinopril HCTZ combination discontinued- switched to \nlisinopril 10mg qNoon(give orthostatic hypotension and ___\n- patient to stager BP medications to prevent sudden drops in \nblood pressures\n- outpatient ___ for dizziness\n- meclizine TID PRN for dizziness\n- discuss MOLST form as per patients wishes\n- follow up urine culture - patient with asymptomatic pyuria on \nadmission\n- CTA head and neck with 0.5cm lung mass, will need dedicated CT \nscan of the lungs\n# CODE STATUS: Full \n# CONTACT: ___ (daughter) ___ Necna ___ \n___\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Atorvastatin 20 mg PO QPM \n2. Gabapentin 800 mg PO QHS \n3. lisinopril-hydrochlorothiazide 40mg-25mg oral DAILY \n4. Metoprolol Succinate XL 200 mg PO DAILY \n5. Diltiazem Extended-Release 180 mg PO DAILY \n6. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob \n7. Humalog ___ 60 Units Breakfast\nHumalog ___ 70 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin\n\n \nDischarge Medications:\n1. Gabapentin 800 mg PO QHS \n2. Humalog ___ 60 Units Breakfast\nHumalog ___ 70 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin\n3. Metoprolol Succinate XL 200 mg PO QAM \nPlease take this medication in the morning \n4. Diltiazem Extended-Release 180 mg PO QAM \n5. Aspirin 81 mg PO DAILY \nRX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0\n6. Lisinopril 10 mg PO NOON \nRX *lisinopril 10 mg 1 tablet(s) by mouth at noon daily Disp \n#*30 Tablet Refills:*0\n7. Meclizine 25 mg PO Q8H:PRN dizziness \nRX *meclizine 25 mg 1 tablet(s) by mouth three times a day Disp \n#*30 Tablet Refills:*0\n8. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob \n9. Nicotine Patch 14 mg TD DAILY \nRX *nicotine 14 mg/24 hour Please apply 1 patch daaily Disp #*14 \nPatch Refills:*0\n10. Outpatient Physical Therapy\nICD10 BPPV 81.10- Outpatient physical therapy \nProgression of VOR X1 / X2 exercises, Habituation exercises\nBalance training Frequency/Duration: ___ for 1 week \n\n11. Equipment\nI6___.54 Cerebellar Infarction - please provide patient with \nbedside commode. As patient is fall risk \n12. Equipment\nI63.54 Cerebellar Infarction - Prognosis: good. Duration 13 \nmonths. Please provide patient with walker, as patient is fall \nrisk. \n13. Atorvastatin 80 mg PO QPM \nRX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*0\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY: BPPPV, Acute Right Cerebellar Peduncle Infarct\nSECONDARYL: HTN, HLD, DM\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nIt was a pleasure taking care of you at the ___ \n___. You were admitted for dizziness. You \nwere evaluated by the neurology team and you were found to have \nbenign paroxysmal positional vertigo. You also had testing and \nimaging of your brain and were found to have a small stroke on \nMRI that could also be causing some of your symptoms. You will \nneed to follow up with your doctors as ___. \n\nWe encourage you to quit smoking and have provided you with \nnicotine patches. Please continue to take your medications as \nprescribed.\n\nSincerely,\n\nYour ___ team\n \nFollowup Instructions:\n___\n"
] | Allergies: Fluorescein / Percocet Chief Complaint: Dizziness Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] year old woman with history of HTN, DM, TIA, and vertigo who presents with dizziness and vertigo for past 3 days. The patient reports having been diagnosed with vertigo [MASKED] years ago and it has been an ongoing problem that acutely worsened over the past 3 days. She states it gets worse with moving her head. She reports feeling dizzy and wobbly on her feet. She denies headache, changes in her vision, new weakness or numbness. No recent preceding viral illness, cough, shortness of breath, sinus pain, tinnitus or ear pain. She does report increased urinary frequency and chronic diarrhea. She has not had any other lower urinary tract symptoms. The diarrhea she reports has been ongoing for over a year. She was recently stopped metformin however the diarrhea has persisted. Of note she was admitted to the neuro service in [MASKED] with TIA. In the ED, initial vitals: 98.1 HR 76 BP 147/69 RR 18 SpO2 100% RA Exam Notable for: Tired-appearing in NAD, Positive [MASKED] Hall Pike, dizziness worsened with maneuver and patient with horizontal nystagmus, CN II-XII grossly intact. Normal UE and [MASKED] strength and sensation bilaterally. Normal cerebellar function. Normal gait (with help). Labs were significant for: WBC of 10.6, Cr of 1.6 improved to 1.4, BUN 48. UA concerning for Lg leuks, Tr Protein, 300 Gluc, 85WBC, Many bacteria and moderate yeast. 1 EPI and 4 casts. Patient was given: [MASKED] 23:30 IVF 1000 mL NS 250 mL/hr [MASKED] 23:30 IV Lorazepam 2 mg [MASKED] 02:45 IV CeftriaXONE 2 gm [MASKED] 03:19 IVF 1000 mL [MASKED] 03:19 IV Magnesium Sulfate 2 gm [MASKED] 04:13 IV Magnesium Sulfate 2 gm There was concern for UTI. Patient was given CTX. Neurology was consulted and her exam was concerning for acute cerebellar signs but may be confounded by Ativan. Recommended orthostatics, hydration. Admission to medicine. On the floor, patient arrived and continued to report dizziness. The room isn't spinning but she feels dizzy. Worse when she sits up. No nausea, vomiting, chest pain, SOB, abdominal pain. No dysuria, incontinence. Reports urinary frequency and chronic diarrhea. ROS: As per HPI. All other ROS negative. Past Medical History: DM HTN Hyperlipidemia Diabetic Retinopathy and Neuropathy TIA in [MASKED] Degenerative disc and joint Disease of Lumbar Spine Tobacco Abuse Social History: [MASKED] Family History: Father- CAD, [MASKED] Mother- Heart failure, [MASKED], HTN Sister- [MASKED] Physical [MASKED]: ADMISSION PHYSICAL EXAM: VS: 97.9 150/64 65 18 99%RA GEN: Alert, lying in bed, no acute distress HEENT: MMM, anicteric sclera, no conjunctival pallor NECK: Supple without LAD PULM: Clear, no wheeze, rales, or rhonchi COR: RRR, normal S1/S2, no murmurs ABD: Soft, NT ND, normal BS EXTREM: Warm, no edema NEURO: CN2-12 intact with normal sensation on face bilaterally. normal sensation in strength in upper and lower extremities. Unable to replicate + [MASKED] hall pike on my examination DISCHARGE PHYSICAL EXAM: VS:98.3 119/59 (130-180/60-80) 64 18 100%RA GEN: Alert, lying in bed, no acute distress HEENT: MMM PULM: Clear, no wheeze, rales, or rhonchi COR: RRR, normal S1/S2, no murmurs ABD: Soft, NT ND, normal BS EXTREM: no edema NEURO: CN2-12 intact with normal sensation on face bilaterally. normal sensation in strength in upper and lower extremities. Pertinent Results: ADMISSION LABS ============== [MASKED] 11:50PM BLOOD WBC-10.6* RBC-4.09 Hgb-12.5 Hct-36.9 MCV-90 MCH-30.6 MCHC-33.9 RDW-13.0 RDWSD-42.2 Plt [MASKED] [MASKED] 11:50PM BLOOD Neuts-62.5 [MASKED] Monos-6.6 Eos-2.0 Baso-0.8 Im [MASKED] AbsNeut-6.66* AbsLymp-2.94 AbsMono-0.70 AbsEos-0.21 AbsBaso-0.08 [MASKED] 11:50PM BLOOD Plt [MASKED] [MASKED] 11:50PM BLOOD Glucose-192* UreaN-48* Creat-1.6* Na-139 K-4.3 Cl-100 HCO3-26 AnGap-17 [MASKED] 05:47AM BLOOD Cholest-240* [MASKED] 08:55AM BLOOD Calcium-9.6 Phos-4.0 Mg-1.9 [MASKED] 01:00AM URINE Color-Yellow Appear-Hazy Sp [MASKED] [MASKED] 01:00AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG [MASKED] 01:00AM URINE RBC-0 WBC-85* Bacteri-MANY Yeast-MOD Epi-1 [MASKED] 01:00AM URINE CastHy-4* PERTINENT LABS ============== [MASKED] 05:47AM BLOOD WBC-11.2* RBC-4.28 Hgb-12.7 Hct-39.2 MCV-92 MCH-29.7 MCHC-32.4 RDW-12.8 RDWSD-42.6 Plt [MASKED] [MASKED] 08:55AM BLOOD WBC-8.7 RBC-4.15 Hgb-12.5 Hct-38.4 MCV-93 MCH-30.1 MCHC-32.6 RDW-12.8 RDWSD-43.5 Plt [MASKED] [MASKED] 05:47AM BLOOD Glucose-264* UreaN-41* Creat-1.2* Na-139 K-4.1 Cl-104 HCO3-25 AnGap-14 [MASKED] 06:04AM BLOOD Glucose-103* UreaN-23* Creat-0.9 Na-137 K-5.0 Cl-106 HCO3-16* AnGap-20 [MASKED] 05:47AM BLOOD %HbA1c-10.4* eAG-252* [MASKED] 05:47AM BLOOD Triglyc-251* HDL-54 CHOL/HD-4.4 LDLcalc-136* [MASKED] 08:55AM BLOOD TSH-1.2 DISCHARGE LABS =============== [MASKED] 09:30AM BLOOD WBC-9.1 RBC-4.16 Hgb-12.7 Hct-39.7 MCV-95 MCH-30.5 MCHC-32.0 RDW-13.1 RDWSD-45.2 Plt [MASKED] [MASKED] 09:30AM BLOOD Neuts-59.1 [MASKED] Monos-7.3 Eos-5.3 Baso-1.0 Im [MASKED] AbsNeut-5.36 AbsLymp-2.45 AbsMono-0.66 AbsEos-0.48 AbsBaso-0.09* [MASKED] 09:30AM BLOOD Glucose-233* UreaN-21* Creat-1.0 Na-138 K-4.8 Cl-105 HCO3-20* AnGap-18 MICRO =============== [MASKED] 1:00 am URINE Site: NOT SPECIFIED CHEM S# [MASKED] [MASKED] UCU ADDED 03.03. **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: 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 [MASKED] ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S IMAGING ============ [MASKED] HEAD W & W/O CONTRAS FINDINGS: Please note the study is mildly degraded by motion. There is a punctate focus of slow diffusion in the right middle cerebellar peduncle. There is no evidence of hemorrhage, edema, masses, mass effect, or midline shift. There is prominence of the ventricles and sulci suggestive involutional changes. There are multiple stable periventricular subcortical T2/FLAIR hyperintensities, greatest in the right periventricular white matter. There is no abnormal enhancement after contrast administration. A right frontal developmental venous anomaly is seen. The major vascular flow voids are preserved. The orbits and mastoid air cells are normal. Minimal mucosal thickening in the ethmoid sinuses seen. IMPRESSION: 1. Grossly stable white matter signal abnormality, which is a nonspecific finding and may be secondary to chronic microvascular ischemic changes, migraines, demyelination, or chronic infection/inflammation. 2. Punctate focus of low diffusion in the middle right cerebellar peduncle, most consistent with an acute infarction. 3. No evidence for intracranial metastatic disease. [MASKED] LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global systolic function (LVEF>55%). Mild resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal diameter of aorta at the sinus, ascending and arch levels. No 2D or Doppler evidence of distal arch coarctation. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. [MASKED] VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS. Physiologic PR. PERICARDIUM: No pericardial effusion. There is an anterior space which most likely represents a fat pad, though a loculated anterior pericardial effusion cannot be excluded. Conclusions The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: No intracardiac source of thromboembolism identified. Mild symmetric left ventricular hypertrophy with preserved biventricular systolic function. Mild resting LVOT obstruction in the setting of vigorous systolic function. No clinically significant valvular disease. Normal pulmonary artery systolic pressure. [MASKED] HEAD & CTA NECK FINDINGS: CT HEAD WITHOUT CONTRAST: There is no evidence of hemorrhage, edema, or mass. The small right cerebellar peduncle infarct is not well visualized on this study given the size. The ventricles and sulci are normal in size and configuration. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. CTA HEAD: There is atherosclerotic calcification and irregularity of the cavernous internal carotid arteries. Otherwise, the vessels of the circle of [MASKED] and their principal intracranial branches appear normal without stenosis, occlusion or aneurysm formation. The dural venous sinuses are patent. CTA NECK: Atherosclerotic calcification of the aortic arch and branch vessels is seen. There is a common origin between the brachiocephalic and left carotid artery. Otherwise, the carotid and vertebral arteries and their major branches appear normal with no evidence of stenosis or occlusion. There is no evidence of internal carotid stenosis by NASCET criteria. OTHER: There is a 0.5 cm right upper lobe lung nodule, series 7, image 29 The visualized portion of the thyroid gland is within normal limits. There is no lymphadenopathy by CT size criteria. Mild degenerative changes of the cervical spine are seen. IMPRESSION: 1. No evidence of acute intracranial hemorrhage. 2. No evidence of aneurysm greater than 3 mm, dissection or vascular malformation, or significant luminal narrowing. 3. A 0.5 cm right upper lobe lung nodule. Recommend a completion CT chest for further evaluation. Brief Hospital Course: [MASKED] woman with history of remote Left Insular Infarct, Hypertension, Hyperlipidemia, Diabetes Mellitus II, Smoking and BPPV who presented with 3 days of dizziness. Dizziness likely multifactorial with BPPV, orthostatic hypotension and acute infarct all playing a role in her symptoms. #BPPV- Neurology was consulted and diagnosed her with BPPV (given rotation nystagmus on exam). She was treated with meclizine which was uptitrated to 25mg TID. #Orthostatic Hypotension- patient treated with IV fluids. She may have a component of autonomic dysfunction given her poorly controlled diabetes. #R middle cerebellar peduncle acute stroke - neurology was consulted and recommended further work up of her acute dizziness. She had an MRI that showed acute infarct in her R cerebellar peduncle which may be causing some of her symptoms. She had echo which was negative for thrombus and CTA head and neck that showed no stenosis. Patient was found to have hyperlipidemia and elevated hemoglobin A1C. She will need further titration as an outpatient. Her statin dose was increased. She was counseled on the importance of smoking cessation and dietary control. #Smoking cessation- patient counseled and given nicotine patch on discharge. #Acute Kidney Injury - likely prerenal in setting of diarrhea. Patient improved with IVF. HCTZ and lisinopril were held. #Pyuria- positive UA, only symptom she reports is urinary frequency that had resolved during her admission. Patient with no recent sexual history to be concerned for gonorrhea or chlamydia. She was initially treated with 3 days of ceftriaxone. This was discontinued as the patient was asymptomatic. Post discharge Urine culture grew >100,000 ecoli. #Chronic diarrhea- unclear etiology has been ongoing for months. Stools described as malabsobitive. Patient will need further work up as an outpatient. TTG-IGA and Giardia DFA were pending on discharge. #Diabetes - patient noted to have hemoglobin A1C of 10.4. [MASKED] was consulted and recommended current humalog 75/25, however they suggested moving her evening humalog to dinner instead of at bed time. Patient will need further titration as an outpatient. #Neuropathy- continued on gabapentin #Hypertension - patient continued on Metoprolol Succinate XL 200 mg PO DAILY and Diltiazem Extended-Release 180 mg PO DAILY. Initially lisnopril and HCTZ were held. She was restarted on a lisinopril dose of 10mg daily given her lightheadedness. HCTZ was discontinued as it may be leading to her dehydration/orthostasis. TRANSITIONAL ISSUES ======================= - smoking cessation counseling- given nicotine patch on discharge - exercise and nutrition counseling - lisinopril HCTZ combination discontinued- switched to lisinopril 10mg qNoon(give orthostatic hypotension and [MASKED] - patient to stager BP medications to prevent sudden drops in blood pressures - outpatient [MASKED] for dizziness - meclizine TID PRN for dizziness - discuss MOLST form as per patients wishes - follow up urine culture - patient with asymptomatic pyuria on admission - CTA head and neck with 0.5cm lung mass, will need dedicated CT scan of the lungs # CODE STATUS: Full # CONTACT: [MASKED] (daughter) [MASKED] Necna [MASKED] [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 20 mg PO QPM 2. Gabapentin 800 mg PO QHS 3. lisinopril-hydrochlorothiazide 40mg-25mg oral DAILY 4. Metoprolol Succinate XL 200 mg PO DAILY 5. Diltiazem Extended-Release 180 mg PO DAILY 6. Albuterol Inhaler [MASKED] PUFF IH Q6H:PRN sob 7. Humalog [MASKED] 60 Units Breakfast Humalog [MASKED] 70 Units Bedtime Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Gabapentin 800 mg PO QHS 2. Humalog [MASKED] 60 Units Breakfast Humalog [MASKED] 70 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 3. Metoprolol Succinate XL 200 mg PO QAM Please take this medication in the morning 4. Diltiazem Extended-Release 180 mg PO QAM 5. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 6. Lisinopril 10 mg PO NOON RX *lisinopril 10 mg 1 tablet(s) by mouth at noon daily Disp #*30 Tablet Refills:*0 7. Meclizine 25 mg PO Q8H:PRN dizziness RX *meclizine 25 mg 1 tablet(s) by mouth three times a day Disp #*30 Tablet Refills:*0 8. Albuterol Inhaler [MASKED] PUFF IH Q6H:PRN sob 9. Nicotine Patch 14 mg TD DAILY RX *nicotine 14 mg/24 hour Please apply 1 patch daaily Disp #*14 Patch Refills:*0 10. Outpatient Physical Therapy ICD10 BPPV 81.10- Outpatient physical therapy Progression of VOR X1 / X2 exercises, Habituation exercises Balance training Frequency/Duration: [MASKED] for 1 week 11. Equipment I6 .54 Cerebellar Infarction - please provide patient with bedside commode. As patient is fall risk 12. Equipment I63.54 Cerebellar Infarction - Prognosis: good. Duration 13 months. Please provide patient with walker, as patient is fall risk. 13. Atorvastatin 80 mg PO QPM RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY: BPPPV, Acute Right Cerebellar Peduncle Infarct SECONDARYL: HTN, HLD, DM 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. [MASKED], It was a pleasure taking care of you at the [MASKED] [MASKED]. You were admitted for dizziness. You were evaluated by the neurology team and you were found to have benign paroxysmal positional vertigo. You also had testing and imaging of your brain and were found to have a small stroke on MRI that could also be causing some of your symptoms. You will need to follow up with your doctors as [MASKED]. We encourage you to quit smoking and have provided you with nicotine patches. Please continue to take your medications as prescribed. Sincerely, Your [MASKED] team Followup Instructions: [MASKED] | [
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"N179: Acute kidney failure, unspecified",
"E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease",
"E1140: Type 2 diabetes mellitus with diabetic neuropathy, unspecified",
"Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits",
"H8110: Benign paroxysmal vertigo, unspecified ear",
"E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema",
"I951: Orthostatic hypotension",
"R270: Ataxia, unspecified",
"R197: Diarrhea, unspecified",
"M5136: Other intervertebral disc degeneration, lumbar region",
"N181: Chronic kidney disease, stage 1",
"I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease",
"E1165: Type 2 diabetes mellitus with hyperglycemia",
"E669: Obesity, unspecified",
"F17210: Nicotine dependence, cigarettes, uncomplicated",
"Z794: Long term (current) use of insulin",
"G901: Familial dysautonomia [Riley-Day]",
"Z6836: Body mass index [BMI] 36.0-36.9, adult",
"R8290: Unspecified abnormal findings in urine",
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19,232,595 | 20,339,185 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nPenicillins / Ibuprofen / Codeine / sucralfate\n \nAttending: ___.\n \nChief Complaint:\nAbdominal pain\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ old woman with a history of a \nroux-en-Y gastric bypass ___, Dr. ___ c/b need for ex-lap \nfor revision of the J-J anastomosis for a leak, and who has \nsubsequently had a history of chronic abdominal pain. She \npresents to the ED with acute onset abdominal pain with no\nprecipitating factors around 3:45PM on ___. This was sharp, \nconstant, and located mainly in the lower quadrants. She states \nthat earlier in the day while at work, she was nauseated, but \nafter coming home she experienced pain, and increased nausea, as \nwell as one episode of vomiting (regurgitated food). She had a \nnormal bowel movement at this time without blood, mucous, or \nabnormal coloring. She has not passed gas since this time. She \ndoes have some subjective fevers and chills, although she did \nnot take her temperature at home.\nOf note she had a previous admission in ___ with \nsimilar symptoms, during which she underwent an EGD showing \nshallow ulcerations at the GJ anastomosis and was discharged on \na PPI and Carafate. She was non-compliant with the Carafate \nbecause she thinks it caused her to have leg edema and continues \nto smoke. She has not had a repeat EGD since this time.\nUpon evaluation in the ED, her pain was mostly controlled by \nnarcotics and her nausea by anti-emetics, so she appeared quite \ncomfortable. \n \nPast Medical History:\nPMH: Dyslipidemia, GERD, PUD, colonic polyps, B-12 deficiency, \npetit mal seizures in childhood\n.\nPSHx: laparoscopic RNYGB ___, Ex-lap/revision of jejunostomy \n___\n \nSocial History:\n___\nFamily History:\n- thyroid cancer\n- HTN, DM, CAD\n \nPhysical Exam:\nVS T 98 P 66 BP 102/67 RR 18 02 99%RA\n\nConstitutional: No acute distress\nNeuro: Alert and oriented\nCardiac: Regular rate and rhythm\nResp: Clear to auscultation, bilaterally\nAbdomen: Soft, non-tender, non-distended, no rebound tenderness \nor guarding\nExt: No lower extremity edema, bilaterally\n \nPertinent Results:\nLABS:\n___ 05:00PM BLOOD WBC-4.1# RBC-3.54* Hgb-10.0* Hct-30.9* \nMCV-87 MCH-28.2 MCHC-32.4 RDW-14.2 RDWSD-45.2 Plt ___\n___ 06:55PM BLOOD Neuts-89.1* Lymphs-6.0* Monos-4.1* \nEos-0.2* Baso-0.2 Im ___ AbsNeut-15.05*# AbsLymp-1.01* \nAbsMono-0.70 AbsEos-0.04 AbsBaso-0.04\n___ 05:00PM BLOOD Glucose-83 UreaN-8 Creat-0.6 Na-135 K-3.5 \nCl-103 HCO3-24 AnGap-12\n___ 06:55PM BLOOD Glucose-88 UreaN-10 Creat-0.6 Na-138 \nK-4.6 Cl-104 HCO3-22 AnGap-17\n___ 05:00PM BLOOD Calcium-7.6* Phos-4.3 Mg-1.8\n___ 07:01PM BLOOD Lactate-1.0\n\nIMAGING:\n___:\nUGI SGL CONTRAST W/ KUB\nIMPRESSION: \nNo evidence of leak or obstruction. \n\n___:\nIMPRESSION: \nCT ABD & PELVIS WITH CONTRAST \nIncreased distention/dilation of the small bowel at the JJ \nanastomosis filled with fecalized material, however note is made \nof oral contrast passing distally to this point, with eventual \ngradual tapering of small bowel loops. Small bowel is \ndecompressed distally. Although there is no high-grade \nobstruction, findings suggest some degree of partial \nobstruction, potentially functional. No high-grade mechanical \nobstruction at the level of the JJ anastomosis. \n\n \n\n \nBrief Hospital Course:\nThe patient presented to Emergency Department on ___ \nwith complaints of abdominal pain. Given presentation, the \npatient underwent an abdominal/pelvic CT scan was obtained and \nnot suggestive of high-grade bowel obstruction but did show \nlarge volumes of stool; a 2.4 cm left adnexal and 12mm cystic \nfocus at the right adnexa were noted.\nNeuro: The patient was alert and oriented throughout \nhospitalization; pain was initially managed with intravenous \nmorphine and acetaminophen. The patient's pain had \nsignificantly improved at the time of discharge.\nCV: The patient remained stable from a cardiovascular \nstandpoint; vital signs were routinely monitored.\nPulmonary: The patient remained stable from a pulmonary \nstandpoint; vital signs were routinely monitored. \nGI/GU/FEN: The patient was initially kept NPO and treated with \nintravenous pantoprazole and po sucralfate. Her diet was \ngradually advanced and which was well tolerated. Patient's \nintake and output were closely monitored; patient had an \naggressive bowel regimen with several bowel movements during the \nadmission.\nGYN: The patient was evaluated by the GYN service due to adnexal \ncysts noted on CT scan. GYN felt that cysts were physiological \nand not a source of the patient's pain.\nID: The patient's fever curves were closely watched for signs of \ninfection, of which there were none.\nHEME: The patient's blood counts were closely watched for signs \nof bleeding, of which there were none.\nAt the time of discharge, the patient was doing well, afebrile \nand hemodynamically stable. The patient was tolerating a diet, \nambulating, voiding without assistance, and pain was well \ncontrolled. The patient received discharge teaching and \nfollow-up instructions with understanding verbalized and \nagreement with the discharge plan including an outpatient \nendoscopy with push enteroscopy; specific emphasis and education \nregarding smoking cessation was reviewed with the patient on \nseveral occasions by both the surgical team and nursing staff.\n\n \nDischarge Medications:\n1. ___ Biotin (biotin) 10,000 mcg oral ASDIR \n2. Multivitamins W/minerals 1 TAB PO BID \n3. Omeprazole 40 mg PO BID \nRX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*60 \nCapsule Refills:*3 \n4. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n5. Sucralfate 1 gm PO QID \nRX *sucralfate [Carafate] 1 gram 1 tablet(s) by mouth four times \na day Disp #*120 Tablet Refills:*3 \n6. Cyanocobalamin 1000 mcg IM/SC MONTHLY \n7. EPINEPHrine (EpiPEN) 0.3 mg IM ASDIR \n8. Ferrous GLUCONATE 324 mg PO DAILY \n9. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nAbdominal pain\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear ___, \n\n___ were admitted to the bariatric surgery service with \nabdominal pain. ___ had a workup including a CT scan of your \nabdomen and a small bowel follow through which did provide \nexplanation for your pain. However, given that your pain has \nsignificantly improved withh antiacids and sucralfate it is \nlikely that ___ have a recurrent marginal ulcer. ___ will need \nto have an endoscopy, which has been scheduled for ___. ___ are \nnow preparing for discharge home with the following \ninstructions:\n\nPlease call your doctor or nurse practitioner or return to the \nEmergency Department for any of the following:\n___ experience new chest pain, pressure, squeezing or \ntightness.\n*New or worsening cough, shortness of breath, or wheeze.\n*If ___ are vomiting and cannot keep down fluids or your \nmedications.\n___ are getting dehydrated due to continued vomiting, diarrhea, \nor other reasons. Signs of dehydration include dry mouth, rapid \nheartbeat, or feeling dizzy or faint when standing.\n___ see blood or dark/black material when ___ vomit or have a \nbowel movement.\n___ experience burning when ___ urinate, have blood in your \nurine, or experience a discharge.\n*Your pain in not improving within ___ hours or is not gone \nwithin 24 hours. Call or return immediately if your pain is \ngetting worse or changes location or moving to your chest or \nback.\n___ have shaking chills, or fever greater than 101.5 degrees \nFahrenheit or 38 degrees Celsius.\n*Any change in your symptoms, or any new symptoms that concern \n___.\n\nPlease resume all regular home medications, unless specifically \nadvised not to take a particular medication. Also, please take \nany new medications as prescribed.\n\nIt was a pleasure taking care of ___,\nYour surgical team \n \nFollowup Instructions:\n___\n"
] | Allergies: Penicillins / Ibuprofen / Codeine / sucralfate Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] old woman with a history of a roux-en-Y gastric bypass [MASKED], Dr. [MASKED] c/b need for ex-lap for revision of the J-J anastomosis for a leak, and who has subsequently had a history of chronic abdominal pain. She presents to the ED with acute onset abdominal pain with no precipitating factors around 3:45PM on [MASKED]. This was sharp, constant, and located mainly in the lower quadrants. She states that earlier in the day while at work, she was nauseated, but after coming home she experienced pain, and increased nausea, as well as one episode of vomiting (regurgitated food). She had a normal bowel movement at this time without blood, mucous, or abnormal coloring. She has not passed gas since this time. She does have some subjective fevers and chills, although she did not take her temperature at home. Of note she had a previous admission in [MASKED] with similar symptoms, during which she underwent an EGD showing shallow ulcerations at the GJ anastomosis and was discharged on a PPI and Carafate. She was non-compliant with the Carafate because she thinks it caused her to have leg edema and continues to smoke. She has not had a repeat EGD since this time. Upon evaluation in the ED, her pain was mostly controlled by narcotics and her nausea by anti-emetics, so she appeared quite comfortable. Past Medical History: PMH: Dyslipidemia, GERD, PUD, colonic polyps, B-12 deficiency, petit mal seizures in childhood . PSHx: laparoscopic RNYGB [MASKED], Ex-lap/revision of jejunostomy [MASKED] Social History: [MASKED] Family History: - thyroid cancer - HTN, DM, CAD Physical Exam: VS T 98 P 66 BP 102/67 RR 18 02 99%RA Constitutional: No acute distress Neuro: Alert and oriented Cardiac: Regular rate and rhythm Resp: Clear to auscultation, bilaterally Abdomen: Soft, non-tender, non-distended, no rebound tenderness or guarding Ext: No lower extremity edema, bilaterally Pertinent Results: LABS: [MASKED] 05:00PM BLOOD WBC-4.1# RBC-3.54* Hgb-10.0* Hct-30.9* MCV-87 MCH-28.2 MCHC-32.4 RDW-14.2 RDWSD-45.2 Plt [MASKED] [MASKED] 06:55PM BLOOD Neuts-89.1* Lymphs-6.0* Monos-4.1* Eos-0.2* Baso-0.2 Im [MASKED] AbsNeut-15.05*# AbsLymp-1.01* AbsMono-0.70 AbsEos-0.04 AbsBaso-0.04 [MASKED] 05:00PM BLOOD Glucose-83 UreaN-8 Creat-0.6 Na-135 K-3.5 Cl-103 HCO3-24 AnGap-12 [MASKED] 06:55PM BLOOD Glucose-88 UreaN-10 Creat-0.6 Na-138 K-4.6 Cl-104 HCO3-22 AnGap-17 [MASKED] 05:00PM BLOOD Calcium-7.6* Phos-4.3 Mg-1.8 [MASKED] 07:01PM BLOOD Lactate-1.0 IMAGING: [MASKED]: UGI SGL CONTRAST W/ KUB IMPRESSION: No evidence of leak or obstruction. [MASKED]: IMPRESSION: CT ABD & PELVIS WITH CONTRAST Increased distention/dilation of the small bowel at the JJ anastomosis filled with fecalized material, however note is made of oral contrast passing distally to this point, with eventual gradual tapering of small bowel loops. Small bowel is decompressed distally. Although there is no high-grade obstruction, findings suggest some degree of partial obstruction, potentially functional. No high-grade mechanical obstruction at the level of the JJ anastomosis. Brief Hospital Course: The patient presented to Emergency Department on [MASKED] with complaints of abdominal pain. Given presentation, the patient underwent an abdominal/pelvic CT scan was obtained and not suggestive of high-grade bowel obstruction but did show large volumes of stool; a 2.4 cm left adnexal and 12mm cystic focus at the right adnexa were noted. Neuro: The patient was alert and oriented throughout hospitalization; pain was initially managed with intravenous morphine and acetaminophen. The patient's pain had significantly improved at the time of discharge. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. GI/GU/FEN: The patient was initially kept NPO and treated with intravenous pantoprazole and po sucralfate. Her diet was gradually advanced and which was well tolerated. Patient's intake and output were closely monitored; patient had an aggressive bowel regimen with several bowel movements during the admission. GYN: The patient was evaluated by the GYN service due to adnexal cysts noted on CT scan. GYN felt that cysts were physiological and not a source of the patient's pain. ID: The patient's fever curves were closely watched for signs of infection, of which there were none. HEME: The patient's blood counts were closely watched for signs of bleeding, of which there were none. 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 including an outpatient endoscopy with push enteroscopy; specific emphasis and education regarding smoking cessation was reviewed with the patient on several occasions by both the surgical team and nursing staff. Discharge Medications: 1. [MASKED] Biotin (biotin) 10,000 mcg oral ASDIR 2. Multivitamins W/minerals 1 TAB PO BID 3. Omeprazole 40 mg PO BID RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*3 4. Polyethylene Glycol 17 g PO DAILY:PRN constipation 5. Sucralfate 1 gm PO QID RX *sucralfate [Carafate] 1 gram 1 tablet(s) by mouth four times a day Disp #*120 Tablet Refills:*3 6. Cyanocobalamin 1000 mcg IM/SC MONTHLY 7. EPINEPHrine (EpiPEN) 0.3 mg IM ASDIR 8. Ferrous GLUCONATE 324 mg PO DAILY 9. Vitamin D [MASKED] UNIT PO DAILY 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 [MASKED], [MASKED] were admitted to the bariatric surgery service with abdominal pain. [MASKED] had a workup including a CT scan of your abdomen and a small bowel follow through which did provide explanation for your pain. However, given that your pain has significantly improved withh antiacids and sucralfate it is likely that [MASKED] have a recurrent marginal ulcer. [MASKED] will need to have an endoscopy, which has been scheduled for [MASKED]. [MASKED] are now preparing for discharge home with the following instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: [MASKED] experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If [MASKED] are vomiting and cannot keep down fluids or your medications. [MASKED] 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. [MASKED] see blood or dark/black material when [MASKED] vomit or have a bowel movement. [MASKED] experience burning when [MASKED] urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within [MASKED] 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. [MASKED] 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 [MASKED]. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. It was a pleasure taking care of [MASKED], Your surgical team Followup Instructions: [MASKED] | [
"R109",
"K219",
"N83202",
"N83201",
"K5641",
"F17210",
"E538",
"Z9884"
] | [
"R109: Unspecified abdominal pain",
"K219: Gastro-esophageal reflux disease without esophagitis",
"N83202: Unspecified ovarian cyst, left side",
"N83201: Unspecified ovarian cyst, right side",
"K5641: Fecal impaction",
"F17210: Nicotine dependence, cigarettes, uncomplicated",
"E538: Deficiency of other specified B group vitamins",
"Z9884: Bariatric surgery status"
] | [
"K219",
"F17210"
] | [] |
11,839,480 | 20,431,162 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\npainful, erythematous ___ \n\n \nMajor Surgical or Invasive Procedure:\nnone\n \nHistory of Present Illness:\nThis is an ___ with hx of afib on xarelto, recurrent\nnon-melanoma SC who presents with ___ pain and skin breakdown. He\nreports on ___ he went to see his dermatologist for his ___ skin\nlesions and was prescribed 5 different creams that he has been\napplying to his ___ since that time. He reports about 10 days\nlater he developed burning in b/l legs. He tried to reach his\ndermatologist but was unable to decided to cut back on his cream\nuse. Given ongoing symptoms he decied around ___ to stop using\nthe creams all together. He notes since that time he has had\nongoing burning in his b/l. He decided to come in because he\nnoticed non-purulent drainage coming from his legs yesterday. He\ndenies any fevers/chills, N/V, CP, SOB, abdominal pain, \ndiarrhea,\ndysuria. He does endorse constipation. He initially presented to\n___ but was transferred to ___ for vascular\nsurgery eval.\n In the ED vitals were 97.4; HR 110-140s; BP 128/90; RR \n18;\nO2 95% RA. Labs notable for creatinine to 2.7 (baseline appears\nto be around 1.5-1.8), bicarb of 15, AG of 21. Lactate was 1.3.\nBlood and urine cultures were obtained. In the ED he was given \nNS\nx2L, vancomycin 1.5gm IV, lisinopril 10mg, and oxycodone 5mg PO\nx1. He was seen by vascular surgery in the ED and felt not to\nhave vascular problem. He was admitted to medicine for concern\nfor cellulitis.\n\nROS: Pertinent positives and negatives as noted in the HPI. All\nother systems were reviewed and are negative. \n\n \nPast Medical History:\nafib on xarelto\nCKD III (baseline creatinine around 1.5)\nrecurrent non-melanoma skin cancer\nakinitic keratosis\nBPH\nHTN\nGout\n \nSocial History:\n___\nFamily History:\nReviewed and found to be not relevant to this\nillness/reason for hospitalization.\n \nPhysical Exam:\nVITALS before discharge: Afebrile and vital signs stable 97.6\nPO 127 / 86 97 17 97 RA \nGENERAL: Alert and in no apparent distress\nEYES: Anicteric, pupils equally round, EOMI, right eye with\nprominent blood vessels but improved at discharge \nENT: Ears and nose without visible erythema, masses, or trauma. \nOropharynx without visible lesion, erythema or exudate\nCV: irregularly irregular, no murmur appreciated\nRESP: Lungs clear to auscultation with good air movement\nbilaterally. Breathing is non-labored\nGI: Abdomen hard, non-distended, non-tender to palpation,\numbilical hernia reducible. Bowel sounds present. No HSM\nGU: No suprapubic fullness or tenderness to palpation\nMSK: Neck supple, moves all extremities, 1+ b/l foot edema, TTP\nfrom ankles to knees b/l\nSKIN: b/l ___ erythema with desquamating ulcerating lesions,\nnumerous non-blanchable lesions\nNEURO: Alert, oriented, face symmetric, gaze conjugate with \nEOMI,\nspeech fluent, moves all limbs, sensation to light touch grossly\nintact throughout\nPSYCH: pleasant, appropriate affect\n \nPertinent Results:\n___ 06:22AM BLOOD TSH-1.2\n___ 04:32AM BLOOD Lactate-1.3\n___ 07:50AM BLOOD WBC-6.9 RBC-3.97* Hgb-13.0* Hct-40.2 \nMCV-101* MCH-32.7* MCHC-32.3 RDW-14.0 RDWSD-52.7* Plt ___\n___ 07:50AM BLOOD Plt ___\n___ 07:50AM BLOOD Creat-1.3* Na-146 K-4.7 HCO3-21* AnGap-14\n___ 09:00AM BLOOD ALT-16 AST-26 AlkPhos-60 TotBili-0.5\n___ 01:07PM BLOOD Ammonia-<10\n \nBrief Hospital Course:\nThis is an ___ with hx of afib on xarelto,\nCKD, NMSC recently started on 5 cream regimen coming in with\nworsening pain, erythema, and discharge in his skin, hospital\ncourse complicated by ___, encephalopathy, and A fib with RVR. \n\n#Encephalopathy - delirium for about 3 days with severe \nrestlessness may be secondary to being in the hospital v. EtOH \nwithdrawal, since his family reports that he has 3 martinis a \nnight (more\nthan one as he reported)\n- Consult Geriatrics \n- Thiamine 500mg PO daily ___\n- Delirium precautions\n- Normal TSH, no evidence of UTI\n- Resolved with supportive treatment \n\n#Non-melanoma skin cancer (___) \n___ rash- He presents with worsening b/l ___ pain, erythema and\ndischarge. There was initial concern for celluliltis or super\ninfection, but neither Dermatology nor ID thought that this was\nthe issue. He was initially on Vancomycin, but this was \nstopped.\n\n- Continue Triamcinolone \n\n#CKD stage III\n___- He has known CKD with baseline creatinine around 1.9 as\ndrawn by his PCP ___ few days prior to admission. Elevated to 2.7\non admission secondary to poor PO intake most likely. \n- LR improved back to baseline (1.3 on ___\n- renally dose medications\n- Lisinopril held on discharge since BP readings were always on \nthe low side \n\n#Afib w/RVR- He has known afib. CHADS2VASC elevated at 3. He is\nanticoagulated with xarelto. He is not on any rate controlling\nagents. Noted to be in afib w/RVR in the ED with rates 110-140s.\n- Xarelto initially held secondary to ___, resumed at discharge\n- started Lopressor ___ BID and uptitrated down to 12.5 BID for \nlow BP. HR ___ before discharge \n\n#herpes opthamic- He reports having been diagnosed with herpes \nin\nthe right eye about 8 months and confirmed recently by\nopthamology. He notes he has been on acyclovir since then\n- c/w acyclovir 400mg daily\n- started on antibiotics ointment erythromycin for suspected \nbacterial infection\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Allopurinol ___ mg PO DAILY \n2. Calcipotriene 0.005% Cream 1 Appl TP BID \n3. Hydrocortisone ___. Cream 0.2% 1 Appl TP BID \n4. imiquimod 5 % topical BID \n5. Lisinopril 10 mg PO DAILY \n6. Rivaroxaban 15 mg PO DAILY \n7. Tretinoin 0.025% Cream 1 Appl TP QHS \n8. Acyclovir 400 mg PO DAILY \n9. Tamsulosin 0.4 mg PO QHS \n\n \nDischarge Medications:\n1. Acetaminophen 325-650 mg PO Q4H:PRN Pain \n2. Erythromycin 0.5% Ophth Oint 0.5 in RIGHT EYE TID Duration: \n3 Weeks \n3. Metoprolol Tartrate 12.5 mg PO BID \n4. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First \nLine \n5. Senna 8.6 mg PO BID:PRN Constipation - Second Line \n6. Thiamine 100 mg PO DAILY \nRX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a \nday Disp #*60 Tablet Refills:*0 \n7. Acyclovir 400 mg PO DAILY \n8. Allopurinol ___ mg PO DAILY \n9. Calcipotriene 0.005% Cream 1 Appl TP BID \n10. Hydrocortisone ___. Cream 0.2% 1 Appl TP BID \n11. imiquimod 5 % topical BID \n12. Rivaroxaban 15 mg PO DAILY \n13. Tamsulosin 0.4 mg PO QHS \n14. Tretinoin 0.025% Cream 1 Appl TP QHS \n15. HELD- Lisinopril 10 mg PO DAILY This medication was held. \nDo not restart Lisinopril until blood pressure has been \nlow.Don't take until instructed otherwise by primary care doctor\n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\n___\nA fib with RVR\nEncephalopathy/delirium \nIrritant dermatitis \n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - one assist.\n \nDischarge Instructions:\nYou were admitted to the hospital with itchiness in your leg, \nand there was concern that it may have an infection. You were \nseen by both the dermatologists and infection doctors, and they \ndid not think you had an infection. While you were here, your \nkidneys were not working as strongly, your heart rate was high \nwith A fib, and you were very restless. The kidney injury \nresolved, and the restlessness may have been the result of being \nin the hospital and medications side effects. \nWe wish you the best in your recovery, \nYour ___ team \n \nFollowup Instructions:\n___\n"
] | Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: painful, erythematous [MASKED] Major Surgical or Invasive Procedure: none History of Present Illness: This is an [MASKED] with hx of afib on xarelto, recurrent non-melanoma SC who presents with [MASKED] pain and skin breakdown. He reports on [MASKED] he went to see his dermatologist for his [MASKED] skin lesions and was prescribed 5 different creams that he has been applying to his [MASKED] since that time. He reports about 10 days later he developed burning in b/l legs. He tried to reach his dermatologist but was unable to decided to cut back on his cream use. Given ongoing symptoms he decied around [MASKED] to stop using the creams all together. He notes since that time he has had ongoing burning in his b/l. He decided to come in because he noticed non-purulent drainage coming from his legs yesterday. He denies any fevers/chills, N/V, CP, SOB, abdominal pain, diarrhea, dysuria. He does endorse constipation. He initially presented to [MASKED] but was transferred to [MASKED] for vascular surgery eval. In the ED vitals were 97.4; HR 110-140s; BP 128/90; RR 18; O2 95% RA. Labs notable for creatinine to 2.7 (baseline appears to be around 1.5-1.8), bicarb of 15, AG of 21. Lactate was 1.3. Blood and urine cultures were obtained. In the ED he was given NS x2L, vancomycin 1.5gm IV, lisinopril 10mg, and oxycodone 5mg PO x1. He was seen by vascular surgery in the ED and felt not to have vascular problem. He was admitted to medicine for concern for cellulitis. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: afib on xarelto CKD III (baseline creatinine around 1.5) recurrent non-melanoma skin cancer akinitic keratosis BPH HTN Gout Social History: [MASKED] Family History: Reviewed and found to be not relevant to this illness/reason for hospitalization. Physical Exam: VITALS before discharge: Afebrile and vital signs stable 97.6 PO 127 / 86 97 17 97 RA GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round, EOMI, right eye with prominent blood vessels but improved at discharge ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: irregularly irregular, no murmur appreciated RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen hard, non-distended, non-tender to palpation, umbilical hernia reducible. Bowel sounds present. No HSM GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, 1+ b/l foot edema, TTP from ankles to knees b/l SKIN: b/l [MASKED] erythema with desquamating ulcerating lesions, numerous non-blanchable lesions NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: pleasant, appropriate affect Pertinent Results: [MASKED] 06:22AM BLOOD TSH-1.2 [MASKED] 04:32AM BLOOD Lactate-1.3 [MASKED] 07:50AM BLOOD WBC-6.9 RBC-3.97* Hgb-13.0* Hct-40.2 MCV-101* MCH-32.7* MCHC-32.3 RDW-14.0 RDWSD-52.7* Plt [MASKED] [MASKED] 07:50AM BLOOD Plt [MASKED] [MASKED] 07:50AM BLOOD Creat-1.3* Na-146 K-4.7 HCO3-21* AnGap-14 [MASKED] 09:00AM BLOOD ALT-16 AST-26 AlkPhos-60 TotBili-0.5 [MASKED] 01:07PM BLOOD Ammonia-<10 Brief Hospital Course: This is an [MASKED] with hx of afib on xarelto, CKD, NMSC recently started on 5 cream regimen coming in with worsening pain, erythema, and discharge in his skin, hospital course complicated by [MASKED], encephalopathy, and A fib with RVR. #Encephalopathy - delirium for about 3 days with severe restlessness may be secondary to being in the hospital v. EtOH withdrawal, since his family reports that he has 3 martinis a night (more than one as he reported) - Consult Geriatrics - Thiamine 500mg PO daily [MASKED] - Delirium precautions - Normal TSH, no evidence of UTI - Resolved with supportive treatment #Non-melanoma skin cancer ([MASKED]) [MASKED] rash- He presents with worsening b/l [MASKED] pain, erythema and discharge. There was initial concern for celluliltis or super infection, but neither Dermatology nor ID thought that this was the issue. He was initially on Vancomycin, but this was stopped. - Continue Triamcinolone #CKD stage III [MASKED]- He has known CKD with baseline creatinine around 1.9 as drawn by his PCP [MASKED] few days prior to admission. Elevated to 2.7 on admission secondary to poor PO intake most likely. - LR improved back to baseline (1.3 on [MASKED] - renally dose medications - Lisinopril held on discharge since BP readings were always on the low side #Afib w/RVR- He has known afib. CHADS2VASC elevated at 3. He is anticoagulated with xarelto. He is not on any rate controlling agents. Noted to be in afib w/RVR in the ED with rates 110-140s. - Xarelto initially held secondary to [MASKED], resumed at discharge - started Lopressor [MASKED] BID and uptitrated down to 12.5 BID for low BP. HR [MASKED] before discharge #herpes opthamic- He reports having been diagnosed with herpes in the right eye about 8 months and confirmed recently by opthamology. He notes he has been on acyclovir since then - c/w acyclovir 400mg daily - started on antibiotics ointment erythromycin for suspected bacterial infection Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol [MASKED] mg PO DAILY 2. Calcipotriene 0.005% Cream 1 Appl TP BID 3. Hydrocortisone [MASKED]. Cream 0.2% 1 Appl TP BID 4. imiquimod 5 % topical BID 5. Lisinopril 10 mg PO DAILY 6. Rivaroxaban 15 mg PO DAILY 7. Tretinoin 0.025% Cream 1 Appl TP QHS 8. Acyclovir 400 mg PO DAILY 9. Tamsulosin 0.4 mg PO QHS Discharge Medications: 1. Acetaminophen 325-650 mg PO Q4H:PRN Pain 2. Erythromycin 0.5% Ophth Oint 0.5 in RIGHT EYE TID Duration: 3 Weeks 3. Metoprolol Tartrate 12.5 mg PO BID 4. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First Line 5. Senna 8.6 mg PO BID:PRN Constipation - Second Line 6. Thiamine 100 mg PO DAILY RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a day Disp #*60 Tablet Refills:*0 7. Acyclovir 400 mg PO DAILY 8. Allopurinol [MASKED] mg PO DAILY 9. Calcipotriene 0.005% Cream 1 Appl TP BID 10. Hydrocortisone [MASKED]. Cream 0.2% 1 Appl TP BID 11. imiquimod 5 % topical BID 12. Rivaroxaban 15 mg PO DAILY 13. Tamsulosin 0.4 mg PO QHS 14. Tretinoin 0.025% Cream 1 Appl TP QHS 15. HELD- Lisinopril 10 mg PO DAILY This medication was held. Do not restart Lisinopril until blood pressure has been low.Don't take until instructed otherwise by primary care doctor Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: [MASKED] A fib with RVR Encephalopathy/delirium Irritant dermatitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - one assist. Discharge Instructions: You were admitted to the hospital with itchiness in your leg, and there was concern that it may have an infection. You were seen by both the dermatologists and infection doctors, and they did not think you had an infection. While you were here, your kidneys were not working as strongly, your heart rate was high with A fib, and you were very restless. The kidney injury resolved, and the restlessness may have been the result of being in the hospital and medications side effects. We wish you the best in your recovery, Your [MASKED] team Followup Instructions: [MASKED] | [
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"Z7902",
"I129",
"N183",
"N400",
"Z87891",
"T50995A"
] | [
"N179: Acute kidney failure, unspecified",
"G9340: Encephalopathy, unspecified",
"B0230: Zoster ocular disease, unspecified",
"I4891: Unspecified atrial fibrillation",
"L309: Dermatitis, unspecified",
"Z7902: Long term (current) use of antithrombotics/antiplatelets",
"I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease",
"N183: Chronic kidney disease, stage 3 (moderate)",
"N400: Benign prostatic hyperplasia without lower urinary tract symptoms",
"Z87891: Personal history of nicotine dependence",
"T50995A: Adverse effect of other drugs, medicaments and biological substances, initial encounter"
] | [
"N179",
"I4891",
"Z7902",
"I129",
"N400",
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] | [] |
16,336,118 | 29,474,349 | [
" \nName: ___ ___ No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nBactrim / Erythromycin Base / Sulfa (Sulfonamide Antibiotics)\n \nAttending: ___.\n \nChief Complaint:\nDiarrhea, emesis, small bowel obstruction\n \nMajor Surgical or Invasive Procedure:\n___: Cystoscopy with stent placement\n.\n___: EUS with FNA\n.\n___: EUS with FNA\n.\n___: Exploratory laparotomy, liver biopsy, \ngastrojejunostomy.\n.\n___: Abdominal wall closure. \n \nHistory of Present Illness:\nHPI: ___ with hx of htn, asthma, vertigo, depression, gastric\nulcer presenting with weakness and diarrhea. Pt was diagnosed\nwith recurrent gastric ulcer on ___, was started on PPI, and\nhad repeat EGD on ___ which demonstrated healed ulcer. She\ndeveloped profuse, nonbloody diarrhea post procedure, described\nas BM q30 minutes, with occasional urge fecal incontinence. She\ndescribes stool as loose, brown, without hematochezia or melena.\nOn ___, she describes being hunched over in the bathroom\ntrying to clean the floor when she slumped over and fell to the\nground, without LOC or head strike. She endorses generalized\nweakness and chills, as well as dull R sided chest pain,\nnonpleuritic, which preceded the fall. She denies SOB, cough,\nN/V, dysuria. Last BM was ___. She has had continued urine\noutput without notable change in frequency or quantity.\n\nOf note, pt underwent EGD on ___ with Dr ___\nrevealed recurrent gastric ulcer. At that time, she was also\nnoted to have erythema, congestion, erosion compatible with \nacute\ngastritis. At that time, she was prescribed omeprazole 40 mg PO\nBID and ranitidine 300 mg qHS. She underwent repeat EGD \n___,\nwhere congestion and erythema were noted in the \"whole stomach,\"\nwith previously noted ulcer now healed.\n\nIn the ___ ED:\nVS 98.3, 81, 193/77, 99% RA\nExam notable for:\n\"Appears fatigued, non-toxic\nRRR, no murmur\nCTA bilaterally, faint expiratory wheezes\nNo tenderness with anterior or lateral chest compression\nAbdomen soft, diffusely tender with no localization, active \nbowel\nsounds\nSkin warm and dry\"\nLabs notable for WBC 6.8, Hb 10.1, plt 289, K 2.9, BUN 21, Cr \n1.9\n\nImaging:\nCXR unremarkable\n\nReceived:\nIVF\nKCl 40 meq\n\nOn arrival to the floor, pt reports feeling generalized \nweakness.\nShe denies headache, chest pain, visual changes. \n\nROS: 10 point review of system reviewed and negative except as\notherwise described in HPI\n\n \nPast Medical History:\nPMH, per prior notes, confirmed with pt:\nHypertension\nPerforated gastric ulcer s/p ex lap with oversew of perforated\ngastric ulcer, abdominal washout ___\nAsthma\nInternal hemorrhoids\nVertigo\nDepression\nRecurrent falls\n \nSocial History:\n___\nFamily History:\nFamily History, per prior notes: \nfather - deceased ___ at young age\nmother - deceased of pancreatic cancer at age ___\nbrother - healthy\n\n \nPhysical ___:\nPrior To Discharge:\nVS: 98.5, 93, 113/68, 18, 94%c RA\nGEN: Somnolent, but easy arousal, NAD\nHEENT: NC/AT, PERRL, EOMI, no scleral icterus\nCV: RRR\nPULM: CTAB\nABD: Midline incision open to air with steri strips and c//di. \nSmall palpable amount of fluid underneath of incision line, \nwithout any leak or drainage. No erythema or any other signs of \ninfection. Abdomen slightly distended, soft.\nEXTR: Warm, no c/c/e\n.\n \n \nPertinent Results:\nRADIOLOGY:\n\n___ RENAL US:\nIMPRESSION: \n1. Bilateral moderate-severe hydronephrosis without obstructing \nlesion or \nstone identified. The bladder is decompressed, with small \nintrapelvic \nascites. \n\n___ CT ABD:\nIMPRESSION: \n1. Ill-defined infiltrative masslike soft tissue density \ncentered in the right central mesentery and retroperitoneum in \nthe region of prior inflammatory changes in ___. Consider \nsclerosing mesenteritis or retroperitoneal fibrosis, with \nmalignancy not excluded. Recommend dedicated MRI of the abdomen \nfor further evaluation. \n2. There appears to be involvement of the soft tissue lesion \nwith the \ndescending duodenum, proximal right ureter, inferior head of the \npancreatitis, IVC and central mesenteric vasculature with \npossible partial obstructive signs. This may be a cause of the \nright hydronephrosis and proximal right hydroureter. \n3. There is also moderate left hydronephrosis and hydroureter, \nwhich may also be related to this soft tissue lesion although \nthe fat planes appear preserved at the level of the lesion. . \n4. Diffuse intraperitoneal stranding and small to moderate \nfree-fluid in the pelvis, most prominent in the left lower \nquadrant and pelvis where there is sigmoid diverticular disease. \n This could represent an acute inflammatory process such as \nsigmoid diverticulitis. A focal culprit diverticulum is not \nidentified on this study, but there is some limitation due to \nabsence of contrast. A colonic Mass lesion is not excluded \ngiven the colonic wall thickening. Consider further evaluation \nwith colonoscopy if not recently performed. \n\n___ CT ABD/PEL:\nIMPRESSION: \n1. Infiltrating right retroperitoneal mass involves the \npancreatic head and ___ and ___ portions of the duodenum. \nInvolvement of the pancreatic head along with dilation of the \npancreatic and common bile ducts raises concern for primary \npancreatic malignancy. However, retroperitoneal fibrosis is \nalso a differential consideration given involvement of the \nureters (especially on the left). \n2. New bilateral nephroureteral stents with interval resolution \nof right \nhydronephrosis and unchanged moderate left hydronephrosis. \nDelayed imaging demonstrates contrast within the urinary bladder \nand adjacent to both stents, likely indicating stent patency. \n3. Diffuse mesenteric fat stranding of uncertain etiology. \n4. Incidentally noted 3 mm focus of enhancement in the left \nbreast could \npossibly correspond to a benign asymmetry described on the \nscreening mammogram performed in ___. \n\n___ CTA PANCREAS:\nIMPRESSION: \n1. Similar appearance of the ill-defined retroperitoneal soft \ntissue which \nsurrounds second and third portions of the duodenum, contacts \nthe uncinate \nprocess of the pancreas, contacts the proximal right ureter, and \nencases the distal SMA and mesenteric branches, unchanged \ncompared to CT from ___. Differential again \nincludes retroperitoneal fibrosis or malignancy. \n2. Occlusion of the SMV from the level of the portal confluence, \nunchanged \nfrom prior. \n3. Appropriately positioned bilateral double-J stents. No \nhydronephrosis. \n4. Consolidative and ground-glass opacities in the right lower \nlobe, new since ___, concerning for infection or \naspiration. Worsened band like consolidative opacities in the \nleft lower lobe, which could represent atelectasis, though \nsuperimposed infection is not excluded. Trace left pleural \neffusion, decreased from prior. \n\n___ CXR:\nIMPRESSION: \nRight PICC terminating in the right atrium approximately 3 cm \ndistal to the cavoatrial junction. \n\nRECENT LABS:\n\n___ 04:28AM BLOOD WBC-11.0* RBC-2.52* Hgb-7.5* Hct-23.4* \nMCV-93 MCH-29.8 MCHC-32.1 RDW-15.7* RDWSD-53.2* Plt ___\n___ 07:42AM BLOOD Glucose-108* UreaN-32* Creat-0.8 Na-134* \nK-4.6 Cl-98 HCO3-24 AnGap-12\n___ 03:04AM BLOOD ALT-26 AST-21 LD(LDH)-130 AlkPhos-99 \nTotBili-0.3\n___ 07:42AM BLOOD Calcium-9.7 Phos-4.0 Mg-1.8\n___ 08:25PM BLOOD calTIBC-211* Ferritn-220* TRF-162*\n___ 06:35AM BLOOD CEA-3.1\n\nMICROBIOLOGY:\n___ 1:49 pm URINE Source: ___. \n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n Culture workup discontinued. Further incubation showed \ncontamination\n with mixed skin/genital flora. Clinical significance of \nisolate(s)\n uncertain. Interpret with caution. \n ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE \nIDENTIFICATION. \n Cefazolin interpretative criteria are based on a dosage \nregimen of\n 2g every 8h. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n ESCHERICHIA COLI\n | \nAMPICILLIN------------ 4 S\nAMPICILLIN/SULBACTAM-- <=2 S\nCEFAZOLIN------------- <=4 S\nCEFEPIME-------------- <=1 S\nCEFTAZIDIME----------- <=1 S\nCEFTRIAXONE----------- <=1 S\nCIPROFLOXACIN---------<=0.25 S\nGENTAMICIN------------ <=1 S\nMEROPENEM-------------<=0.25 S\nNITROFURANTOIN-------- <=16 S\nPIPERACILLIN/TAZO----- <=4 S\nTOBRAMYCIN------------ <=1 S\nTRIMETHOPRIM/SULFA---- <=1 S\n\n \nBrief Hospital Course:\n___ with PMH of hypertension, gastric ulcer presenting with \nweakness and diarrhea which developed after EGD found to have \n___ now with hydronephrosis and imaging concerning for \nretroperitonal fibrosis versus pancreatic mass.\n\n# Abdominal Mass- concern for retroperitoneal fibrosis versus \nmalignancy\nCT scan to look for cause of hydronephrosis was grossly abnormal \nwith concern for sclerosing mesenteritis or retroperitoneal \nfibrosis with malignancy/lymphoma on differential. CT with \ncontrast more consistent with pancreatic mass. GI fellow \ndiscussed with radiology who recommended EUS with biopsy as the \nnext step. Patient underwent EUS with biopsy x2 which was \nnon-diagnostic. \nExtensive serologic testing notable for elevated chromogranin \nand gastrin levels. ___ also positive \nExtensive add'l workup including ANCA, TTG IgA, stool studies, \nVIP were otherwise negative. Oncology was consulted to \ndetermine if there are other modalities other than surgical \nbiopsy to arrive at a diagnosis but also recommended biopsy. \nThe patient underwent an open biopsy
\n\n#Acute duodenal obstruction/Gastric outlet obstruction\nOn ___ noted to have increased obstructive symptoms. KUB c/w \nduodenal obstruction. CRS consulted and NGT placed with \ndecompression and improvement in symptoms. The patient was \nstarted on TPN for nutrition. Surgery was consulted as noted \nabove and the patient had a surgical bipass...\n\n#Acute renal failure\n#Hydronephrosis\n#Hypernatremia\n#Hypokalemia\nPatient presented with acute renal failure due to obstructive \nuropathy. She was evaluated by urology and underwent bilateral \nureteral stent placement. Following placement of stents the \npatient's creatinine improved and trended down to 1.1. Patient \ncontinues to have some hematuria. She will need outpatient \nfollow-up with urology in ___ weeks with renal ultrasound prior \nto follow-up. Repeat CAT scan showed hydronephrosis have \nresolved.\n\n# Anemia: Hb 8.7 in the setting of fluids, normocytic, with \nnormal RDW. Was previously WNL at 12.4 on ___. Iron \nstudies support anemia of chronic inflammation- in addition to \nlow retic cout. no evidence of active bleeding\n\n# Hypertension: Asymptomatic hypertension. Likely remains ___ \nin the setting of holding her ACE inhibitor. Unclear if any \nrelation to intrabdominal process. Blood pressure improved \nsignificantly on current regimen of labetalol 400 mg TID and \naddion of amlodipine 5 mg p.o. daily\n\n# Hx of PUD: Continued on home pantoprazole 40 mg PO BID\n\n# Depression: Continued home sertraline\n\n# Insomnia: Continued home trazodone\n\nAt the time of discharge, the patient was doing well, afebrile \nwith stable vital signs. The patient was tolerating regular \ndiet and cycling TPN, ambulating with walker, voiding without \nassistance, and pain was well controlled. The patient received \ndischarge teaching and follow-up instructions with understanding \nverbalized and agreement with the discharge plan. \n\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. TraZODone 100 mg PO QHS:PRN insomnia \n2. Moexipril 15 mg PO BID \n3. Labetalol 200 mg PO BID \n4. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation \nQ4H:PRN \n5. Pantoprazole 40 mg PO Q12H \n6. Sertraline 100 mg PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO TID \n2. Cefpodoxime Proxetil 200 mg PO Q12H \n___ last day for this medication \n3. Docusate Sodium 100 mg PO BID \n4. Dronabinol 2.5 mg PO BID \n5. Lidocaine 5% Patch 1 PTCH TD QAM \n6. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line \n \n7. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - Second \nLine \n8. Senna 8.6 mg PO BID \n9. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line \nflush \n10. TraMADol 25 mg PO Q6H:PRN pain \nRX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every four \n(4) hours Disp #*30 Tablet Refills:*0 \n11. Sertraline 50 mg PO DAILY \n12. TraZODone 50 mg PO QHS insomnia \n13. Labetalol 200 mg PO BID \n14. Moexipril 15 mg PO BID \n15. Pantoprazole 40 mg PO Q12H \n16. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation \nQ4H:PRN sob \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\n1. Metastatic adenocarcinoma\n2. Gastric outlet obstruction \n3. Acute kidney injury secondary to bilateral hydronephrosis \n4. Fascial wound dehiscence \n5. Urinary tract infection \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nMs. ___,\nYou were admitted at ___ for evaluation of nausea and \nvomiting. Abdominal CT scan revealed large retroperitoneal mass, \nwhich compress your small bowels. Endoscopic biopsies were \ninconclusive. You were transferred to the surgery service for \nopen biopsy. On ___ you underwent laparoscopy, liver biopsy \nand palliative gastrojejunostomy. Unfortunately you biopsy \ndemonstrated metastatic adenocarcinoma. Your post operative \ncourse was complicated by wound dehiscence, which required \nsurgical repair, and post operative ileus, which required NGT \nfor decompression. You were provided with TPN for nutrition \nduring your hospital stay. You are now safe to return home to \ncomplete your recovery with the following instructions:\n.\nPlease ___ Dr. ___ office at ___ if you have any \nquestions or concerns.\n.\nPlease ___ your doctor or nurse practitioner if you experience \nthe following:\n*You experience new chest pain, pressure, squeezing or \ntightness.\n*New or worsening cough, shortness of breath, or wheeze.\n*If you are vomiting and cannot keep down fluids or your \nmedications.\n*You are getting dehydrated due to continued vomiting, diarrhea, \nor other reasons. Signs of dehydration include dry mouth, rapid \nheartbeat, or feeling dizzy or faint when standing.\n*You see blood or dark/black material when you vomit or have a \nbowel movement.\n*You experience burning when you urinate, have blood in your \nurine, or experience a discharge.\n*Your pain is not improving within ___ hours or is not gone \nwithin 24 hours. ___ or return immediately if your pain is \ngetting worse or changes location or moving to your chest or \nback.\n*You have shaking chills, or fever greater than 101.5 degrees \nFahrenheit or 38 degrees Celsius.\n*Any change in your symptoms, or any new symptoms that concern \nyou.\n .\nGeneral Discharge Instructions:\nPlease resume all regular home medications , unless specifically \nadvised not to take a particular medication. Also, please take \nany new medications as prescribed.\nPlease get plenty of rest, continue to ambulate several times \nper day, and drink adequate amounts of fluids. Avoid lifting \nweights greater than ___ lbs until you follow-up with your \nsurgeon, who will instruct you further regarding activity \nrestrictions.\nAvoid driving or operating heavy machinery while taking pain \nmedications.\nPlease follow-up with your surgeon and Primary Care Provider \n(PCP) as advised.\n.\nIncision Care:\n*Please ___ your doctor or nurse practitioner if you have \nincreased pain, swelling, redness, or drainage from the incision \nsite.\n*Avoid swimming and baths until your follow-up appointment.\n*You may shower, and wash surgical incisions with a mild soap \nand warm water. Gently pat the area dry.\n*If you have staples, they will be removed at your follow-up \nappointment.\n*If you have steri-strips, they will fall off on their own. \nPlease remove any remaining strips ___ days after surgery.\n.\nPICC Line:\n\n*Please monitor the site regularly, and ___ your MD, nurse \npractitioner, or ___ Nurse if you notice redness, swelling, \ntenderness or pain, drainage or bleeding at the insertion site.\n * ___ your MD or proceed to the Emergency Room immediately if \nthe PICC Line tubing becomes damaged or punctured, or if the \nline is pulled out partially or completely. DO NOT USE THE PICC \nLINE IN THESE CIRCUMSTANCES.Please keep the dressing clean and \ndry. Contact your ___ Nurse if the dressing comes undone or is \nsignificantly soiled for further instructions. \n \nFollowup Instructions:\n___\n"
] | Allergies: Bactrim / Erythromycin Base / Sulfa (Sulfonamide Antibiotics) Chief Complaint: Diarrhea, emesis, small bowel obstruction Major Surgical or Invasive Procedure: [MASKED]: Cystoscopy with stent placement . [MASKED]: EUS with FNA . [MASKED]: EUS with FNA . [MASKED]: Exploratory laparotomy, liver biopsy, gastrojejunostomy. . [MASKED]: Abdominal wall closure. History of Present Illness: HPI: [MASKED] with hx of htn, asthma, vertigo, depression, gastric ulcer presenting with weakness and diarrhea. Pt was diagnosed with recurrent gastric ulcer on [MASKED], was started on PPI, and had repeat EGD on [MASKED] which demonstrated healed ulcer. She developed profuse, nonbloody diarrhea post procedure, described as BM q30 minutes, with occasional urge fecal incontinence. She describes stool as loose, brown, without hematochezia or melena. On [MASKED], she describes being hunched over in the bathroom trying to clean the floor when she slumped over and fell to the ground, without LOC or head strike. She endorses generalized weakness and chills, as well as dull R sided chest pain, nonpleuritic, which preceded the fall. She denies SOB, cough, N/V, dysuria. Last BM was [MASKED]. She has had continued urine output without notable change in frequency or quantity. Of note, pt underwent EGD on [MASKED] with Dr [MASKED] revealed recurrent gastric ulcer. At that time, she was also noted to have erythema, congestion, erosion compatible with acute gastritis. At that time, she was prescribed omeprazole 40 mg PO BID and ranitidine 300 mg qHS. She underwent repeat EGD [MASKED], where congestion and erythema were noted in the "whole stomach," with previously noted ulcer now healed. In the [MASKED] ED: VS 98.3, 81, 193/77, 99% RA Exam notable for: "Appears fatigued, non-toxic RRR, no murmur CTA bilaterally, faint expiratory wheezes No tenderness with anterior or lateral chest compression Abdomen soft, diffusely tender with no localization, active bowel sounds Skin warm and dry" Labs notable for WBC 6.8, Hb 10.1, plt 289, K 2.9, BUN 21, Cr 1.9 Imaging: CXR unremarkable Received: IVF KCl 40 meq On arrival to the floor, pt reports feeling generalized weakness. She denies headache, chest pain, visual changes. ROS: 10 point review of system reviewed and negative except as otherwise described in HPI Past Medical History: PMH, per prior notes, confirmed with pt: Hypertension Perforated gastric ulcer s/p ex lap with oversew of perforated gastric ulcer, abdominal washout [MASKED] Asthma Internal hemorrhoids Vertigo Depression Recurrent falls Social History: [MASKED] Family History: Family History, per prior notes: father - deceased [MASKED] at young age mother - deceased of pancreatic cancer at age [MASKED] brother - healthy Physical [MASKED]: Prior To Discharge: VS: 98.5, 93, 113/68, 18, 94%c RA GEN: Somnolent, but easy arousal, NAD HEENT: NC/AT, PERRL, EOMI, no scleral icterus CV: RRR PULM: CTAB ABD: Midline incision open to air with steri strips and c//di. Small palpable amount of fluid underneath of incision line, without any leak or drainage. No erythema or any other signs of infection. Abdomen slightly distended, soft. EXTR: Warm, no c/c/e . Pertinent Results: RADIOLOGY: [MASKED] RENAL US: IMPRESSION: 1. Bilateral moderate-severe hydronephrosis without obstructing lesion or stone identified. The bladder is decompressed, with small intrapelvic ascites. [MASKED] CT ABD: IMPRESSION: 1. Ill-defined infiltrative masslike soft tissue density centered in the right central mesentery and retroperitoneum in the region of prior inflammatory changes in [MASKED]. Consider sclerosing mesenteritis or retroperitoneal fibrosis, with malignancy not excluded. Recommend dedicated MRI of the abdomen for further evaluation. 2. There appears to be involvement of the soft tissue lesion with the descending duodenum, proximal right ureter, inferior head of the pancreatitis, IVC and central mesenteric vasculature with possible partial obstructive signs. This may be a cause of the right hydronephrosis and proximal right hydroureter. 3. There is also moderate left hydronephrosis and hydroureter, which may also be related to this soft tissue lesion although the fat planes appear preserved at the level of the lesion. . 4. Diffuse intraperitoneal stranding and small to moderate free-fluid in the pelvis, most prominent in the left lower quadrant and pelvis where there is sigmoid diverticular disease. This could represent an acute inflammatory process such as sigmoid diverticulitis. A focal culprit diverticulum is not identified on this study, but there is some limitation due to absence of contrast. A colonic Mass lesion is not excluded given the colonic wall thickening. Consider further evaluation with colonoscopy if not recently performed. [MASKED] CT ABD/PEL: IMPRESSION: 1. Infiltrating right retroperitoneal mass involves the pancreatic head and [MASKED] and [MASKED] portions of the duodenum. Involvement of the pancreatic head along with dilation of the pancreatic and common bile ducts raises concern for primary pancreatic malignancy. However, retroperitoneal fibrosis is also a differential consideration given involvement of the ureters (especially on the left). 2. New bilateral nephroureteral stents with interval resolution of right hydronephrosis and unchanged moderate left hydronephrosis. Delayed imaging demonstrates contrast within the urinary bladder and adjacent to both stents, likely indicating stent patency. 3. Diffuse mesenteric fat stranding of uncertain etiology. 4. Incidentally noted 3 mm focus of enhancement in the left breast could possibly correspond to a benign asymmetry described on the screening mammogram performed in [MASKED]. [MASKED] CTA PANCREAS: IMPRESSION: 1. Similar appearance of the ill-defined retroperitoneal soft tissue which surrounds second and third portions of the duodenum, contacts the uncinate process of the pancreas, contacts the proximal right ureter, and encases the distal SMA and mesenteric branches, unchanged compared to CT from [MASKED]. Differential again includes retroperitoneal fibrosis or malignancy. 2. Occlusion of the SMV from the level of the portal confluence, unchanged from prior. 3. Appropriately positioned bilateral double-J stents. No hydronephrosis. 4. Consolidative and ground-glass opacities in the right lower lobe, new since [MASKED], concerning for infection or aspiration. Worsened band like consolidative opacities in the left lower lobe, which could represent atelectasis, though superimposed infection is not excluded. Trace left pleural effusion, decreased from prior. [MASKED] CXR: IMPRESSION: Right PICC terminating in the right atrium approximately 3 cm distal to the cavoatrial junction. RECENT LABS: [MASKED] 04:28AM BLOOD WBC-11.0* RBC-2.52* Hgb-7.5* Hct-23.4* MCV-93 MCH-29.8 MCHC-32.1 RDW-15.7* RDWSD-53.2* Plt [MASKED] [MASKED] 07:42AM BLOOD Glucose-108* UreaN-32* Creat-0.8 Na-134* K-4.6 Cl-98 HCO3-24 AnGap-12 [MASKED] 03:04AM BLOOD ALT-26 AST-21 LD(LDH)-130 AlkPhos-99 TotBili-0.3 [MASKED] 07:42AM BLOOD Calcium-9.7 Phos-4.0 Mg-1.8 [MASKED] 08:25PM BLOOD calTIBC-211* Ferritn-220* TRF-162* [MASKED] 06:35AM BLOOD CEA-3.1 MICROBIOLOGY: [MASKED] 1:49 pm URINE Source: [MASKED]. **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: Culture workup discontinued. Further incubation showed contamination with mixed skin/genital flora. Clinical significance of isolate(s) uncertain. Interpret with caution. 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 [MASKED] ESCHERICHIA COLI | AMPICILLIN------------ 4 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Brief Hospital Course: [MASKED] with PMH of hypertension, gastric ulcer presenting with weakness and diarrhea which developed after EGD found to have [MASKED] now with hydronephrosis and imaging concerning for retroperitonal fibrosis versus pancreatic mass. # Abdominal Mass- concern for retroperitoneal fibrosis versus malignancy CT scan to look for cause of hydronephrosis was grossly abnormal with concern for sclerosing mesenteritis or retroperitoneal fibrosis with malignancy/lymphoma on differential. CT with contrast more consistent with pancreatic mass. GI fellow discussed with radiology who recommended EUS with biopsy as the next step. Patient underwent EUS with biopsy x2 which was non-diagnostic. Extensive serologic testing notable for elevated chromogranin and gastrin levels. [MASKED] also positive Extensive add'l workup including ANCA, TTG IgA, stool studies, VIP were otherwise negative. Oncology was consulted to determine if there are other modalities other than surgical biopsy to arrive at a diagnosis but also recommended biopsy. The patient underwent an open biopsy #Acute duodenal obstruction/Gastric outlet obstruction On [MASKED] noted to have increased obstructive symptoms. KUB c/w duodenal obstruction. CRS consulted and NGT placed with decompression and improvement in symptoms. The patient was started on TPN for nutrition. Surgery was consulted as noted above and the patient had a surgical bipass... #Acute renal failure #Hydronephrosis #Hypernatremia #Hypokalemia Patient presented with acute renal failure due to obstructive uropathy. She was evaluated by urology and underwent bilateral ureteral stent placement. Following placement of stents the patient's creatinine improved and trended down to 1.1. Patient continues to have some hematuria. She will need outpatient follow-up with urology in [MASKED] weeks with renal ultrasound prior to follow-up. Repeat CAT scan showed hydronephrosis have resolved. # Anemia: Hb 8.7 in the setting of fluids, normocytic, with normal RDW. Was previously WNL at 12.4 on [MASKED]. Iron studies support anemia of chronic inflammation- in addition to low retic cout. no evidence of active bleeding # Hypertension: Asymptomatic hypertension. Likely remains [MASKED] in the setting of holding her ACE inhibitor. Unclear if any relation to intrabdominal process. Blood pressure improved significantly on current regimen of labetalol 400 mg TID and addion of amlodipine 5 mg p.o. daily # Hx of PUD: Continued on home pantoprazole 40 mg PO BID # Depression: Continued home sertraline # Insomnia: Continued home trazodone At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating regular diet and cycling TPN, ambulating with walker, 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. TraZODone 100 mg PO QHS:PRN insomnia 2. Moexipril 15 mg PO BID 3. Labetalol 200 mg PO BID 4. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q4H:PRN 5. Pantoprazole 40 mg PO Q12H 6. Sertraline 100 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO TID 2. Cefpodoxime Proxetil 200 mg PO Q12H [MASKED] last day for this medication 3. Docusate Sodium 100 mg PO BID 4. Dronabinol 2.5 mg PO BID 5. Lidocaine 5% Patch 1 PTCH TD QAM 6. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line 7. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - Second Line 8. Senna 8.6 mg PO BID 9. Sodium Chloride 0.9% Flush [MASKED] mL IV DAILY and PRN, line flush 10. TraMADol 25 mg PO Q6H:PRN pain RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills:*0 11. Sertraline 50 mg PO DAILY 12. TraZODone 50 mg PO QHS insomnia 13. Labetalol 200 mg PO BID 14. Moexipril 15 mg PO BID 15. Pantoprazole 40 mg PO Q12H 16. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q4H:PRN sob Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: 1. Metastatic adenocarcinoma 2. Gastric outlet obstruction 3. Acute kidney injury secondary to bilateral hydronephrosis 4. Fascial wound dehiscence 5. Urinary tract infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Ms. [MASKED], You were admitted at [MASKED] for evaluation of nausea and vomiting. Abdominal CT scan revealed large retroperitoneal mass, which compress your small bowels. Endoscopic biopsies were inconclusive. You were transferred to the surgery service for open biopsy. On [MASKED] you underwent laparoscopy, liver biopsy and palliative gastrojejunostomy. Unfortunately you biopsy demonstrated metastatic adenocarcinoma. Your post operative course was complicated by wound dehiscence, which required surgical repair, and post operative ileus, which required NGT for decompression. You were provided with TPN for nutrition during your hospital stay. You are now safe to return home to complete your recovery with the following instructions: . Please [MASKED] Dr. [MASKED] office at [MASKED] if you have any questions or concerns. . Please [MASKED] your doctor or nurse practitioner if you experience the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain is not improving within [MASKED] hours or is not gone within 24 hours. [MASKED] or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. . General Discharge Instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [MASKED] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. . Incision Care: *Please [MASKED] 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 [MASKED] days after surgery. . PICC Line: *Please monitor the site regularly, and [MASKED] your MD, nurse practitioner, or [MASKED] Nurse if you notice redness, swelling, tenderness or pain, drainage or bleeding at the insertion site. * [MASKED] your MD or proceed to the Emergency Room immediately if the PICC Line tubing becomes damaged or punctured, or if the line is pulled out partially or completely. DO NOT USE THE PICC LINE IN THESE CIRCUMSTANCES.Please keep the dressing clean and dry. Contact your [MASKED] Nurse if the dressing comes undone or is significantly soiled for further instructions. Followup Instructions: [MASKED] | [
"C250",
"C787",
"C786",
"N131",
"K311",
"E870",
"T8132XA",
"N179",
"E46",
"K9189",
"K567",
"N390",
"F05",
"I10",
"J45909",
"F329",
"R42",
"E876",
"Z87891",
"Z9181",
"D649",
"E8342",
"Y836",
"Y92230",
"R197",
"G4700",
"Z66",
"Z781",
"B9620"
] | [
"C250: Malignant neoplasm of head of pancreas",
"C787: Secondary malignant neoplasm of liver and intrahepatic bile duct",
"C786: Secondary malignant neoplasm of retroperitoneum and peritoneum",
"N131: Hydronephrosis with ureteral stricture, not elsewhere classified",
"K311: Adult hypertrophic pyloric stenosis",
"E870: Hyperosmolality and hypernatremia",
"T8132XA: Disruption of internal operation (surgical) wound, not elsewhere classified, initial encounter",
"N179: Acute kidney failure, unspecified",
"E46: Unspecified protein-calorie malnutrition",
"K9189: Other postprocedural complications and disorders of digestive system",
"K567: Ileus, unspecified",
"N390: Urinary tract infection, site not specified",
"F05: Delirium due to known physiological condition",
"I10: Essential (primary) hypertension",
"J45909: Unspecified asthma, uncomplicated",
"F329: Major depressive disorder, single episode, unspecified",
"R42: Dizziness and giddiness",
"E876: Hypokalemia",
"Z87891: Personal history of nicotine dependence",
"Z9181: History of falling",
"D649: Anemia, unspecified",
"E8342: Hypomagnesemia",
"Y836: Removal of other organ (partial) (total) as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure",
"Y92230: Patient room in hospital as the place of occurrence of the external cause",
"R197: Diarrhea, unspecified",
"G4700: Insomnia, unspecified",
"Z66: Do not resuscitate",
"Z781: Physical restraint status",
"B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere"
] | [
"N179",
"N390",
"I10",
"J45909",
"F329",
"Z87891",
"D649",
"Y92230",
"G4700",
"Z66"
] | [] |
16,916,476 | 20,355,547 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nPrograf / Augmentin / doxycycline\n \nAttending: ___\n \nMajor Surgical or Invasive Procedure:\nERCP\n\nattach\n \nPertinent Results:\nADMISSION LABS\n=============\n___ 12:36PM BLOOD WBC-7.4 RBC-4.58* Hgb-12.7* Hct-38.9* \nMCV-85 MCH-27.7 MCHC-32.6 RDW-12.6 RDWSD-38.9 Plt ___\n___ 05:15AM BLOOD WBC-4.6 RBC-4.01* Hgb-11.1* Hct-33.9* \nMCV-85 MCH-27.7 MCHC-32.7 RDW-12.6 RDWSD-38.5 Plt ___\n___ 05:15AM BLOOD Neuts-62.8 ___ Monos-13.2* \nEos-1.1 Baso-0.0 Im ___ AbsNeut-2.90 AbsLymp-1.04* \nAbsMono-0.61 AbsEos-0.05 AbsBaso-0.00*\n___ 05:15AM BLOOD Plt ___\n___ 05:15AM BLOOD ___ PTT-31.6 ___\n___ 05:15AM BLOOD Glucose-95 UreaN-11 Creat-0.7 Na-140 \nK-3.8 Cl-102 HCO3-26 AnGap-12\n___ 12:36PM BLOOD ALT-77* AST-110* AlkPhos-183* TotBili-0.6\n___ 05:15AM BLOOD ALT-61* AST-79* LD(LDH)-188 AlkPhos-145* \nTotBili-0.5\n___ 05:15AM BLOOD Albumin-2.7* Calcium-8.9 Phos-3.6 Mg-1.8\n___ 05:15AM BLOOD rapmycn-9.0\n___ 05:10PM BLOOD Lactate-1.2\n\n___ 03:00PM URINE Color-Yellow Appear-CLEAR Sp ___\n___ 03:00PM URINE Blood-NEG Nitrite-NEG Protein-100* \nGlucose-NEG Ketone-TR* Bilirub-NEG Urobiln-NORMAL pH-6.5 \nLeuks-NEG\n___ 03:00PM URINE RBC-1 WBC-2 Bacteri-NONE Yeast-NONE Epi-0\n___ 07:50AM STOOL CDIFPCR-NEG\n\nDISCHARGE LABS\n==============\n\n___ 05:02AM BLOOD WBC-4.2 RBC-3.97* Hgb-11.0* Hct-33.1* \nMCV-83 MCH-27.7 MCHC-33.2 RDW-12.8 RDWSD-39.1 Plt ___\n___ 05:02AM BLOOD Plt ___\n___ 05:02AM BLOOD Glucose-96 UreaN-8 Creat-0.6 Na-141 K-4.1 \nCl-106 HCO3-25 AnGap-10\n___ 05:02AM BLOOD ALT-54* AST-69* AlkPhos-120 TotBili-0.3\n___ 05:02AM BLOOD Calcium-8.7 Phos-3.0 Mg-1.___RIEF HOSPITAL COURSE \n================================= \n___ year old male with past medical history of renal transplant \nfor polycystic kidney disease in ___, multiple episodes of \ncholedocholithiasis status post ERCP x3, Caroli's disease \npresenting with abnormal liver enzymes and fevers with concern \nfor recurrent cholangitis. CXR, urinalysis, blood cultures, and \nurine cultures were negative. Stool cultures were sent, and he \nwas negative for C diff and Norovirus. Hepatitis serologies, \nurine Legionella, CMV, and EBV were negative. An MRCP was \nconcerning for cholangitis and cholecystitis, so he had an ERCP \nwhich removed some biliary sludge but no stones. He was treated \nwith IV ceftriaxone and Flagyl, which helped his fevers. He had \na CT C/A/P that was negative for signs of malignancy despite \nnightly fevers and recent 19 lb weight loss.\n\nTRANSITIONAL ISSUES: \n================================= \n[ ] Follow up stool culture and studies and treat any positive \nresults\n[ ] Follow up duodenal aspirates from ERCP\n[ ] Follow up sirolimus levels since dosing was changed to 1mg \n___, Mo, We, Fr and 0.5mg ___, Th, ___\n[ ] Bactrim was discontinued per Renal transplant \nrecommendations as his transplant was over ___ years ago\n[ ] Colonoscopy as he has not had age-appropriate screening\n\nFOLLOW-UP \n- Follow up: stool cultures, duodenal aspirates\n- Tests required after discharge: colonoscopy\n- Incidental findings: none\n\nOTHER ISSUES: \n- Discharge Hemoglobin: *** \n- Discharge Cr: *** \n- Discharge weight: *** \n\n#CODE: Full (presumed)\n#CONTACT: ___, wife, ___\n\nACUTE ISSUES:\n================\n#Fever\n#Diarrhea\nPatient reports a one month history of fevers and chronic \ndiarrhea that acutely worsened over the same time period. Exam \nshowed normal cardiopulmonary and no abdominal pain, negative \n___ sign, no stigmata of endocarditis. No evidence of \ninfiltrate on CXR, UA without evidence of infection. Urine and \nblood cultures were negative. Stool culture was negative for \nSalmonella, Shigella, ova and parasites; cryptosporidium, \nmicrosporidium, cyclospora, EHEC, giardia, vibrio were pending. \nC diff, Norovirus were negative. CMV, EBV negative. Hepatitis \nserologies negative. Urine Legionella negative. MRCP showed \nsigns of cholangitis vs cholecystitis. CT C/A/P showed no \nevidence of malignancy, redemonstrated signs of cholecystitis. \nERCP ___ removed sludge, found no stones, and did not use dye \nto reduce risk of post-op infection. Infectious Disease and \nHepatology were consulted and offered recommendations throughout \nhospitalization. He was treated empirically with IV ceftriaxone \nand flagyl x 5 days and switched to oral cefpodoxime and flagyl \nto finish a 7 day course given patient desiring discharge \ninstead of waiting to finish IV antibiotics as inpatient. \nWeekend antibiotic infusions could not be set up.\n\n#Elevated Transaminase\nALT, AST slightly elevated above baseline in the setting of new \nonset fever but was ultimately thought to be consistent with his \nknown ___'s Disease after infectious workup was completed as \nabove. \n\n#History of Recurrent Cholangitis\n#___'s Disease\nPatient has a known history of recurrent cholangitis with last \nepisode ___. RUQ US on presentation with evidence of \nintrahepatic intraductal stones measuring up to 1.3 cm. \nAbdominal exam was always negative for pain or ___ sign. \nDue to signs of cholangitis on MRCP, ERCP was performed and \npatient was treated with ceftriaxone and Flagyl as above. \nContinued home ursodiol and resumed suppressive antibiotics on \ndischarge\n\n#Back Pain, resolved \nPatient reported history of back pain and symptoms exertional \nsymptoms. He reported previous xrays were normal. As he had no \npain during admission, we did not repeat films.\n\n#Abnormal Weight loss\nPatient reports 19 lb weight loss over past 6 weeks although in \nsetting of significant dietary restriction. Pt reports he has \nnever had colonoscopy. MRCP and CT C/A/P this admission without \nlesions concerning for malignancy. Nutrition was consulted. \nDiarrhea was worked up as above.\n\n#S/p cadaveric kidney transplant ___\nRenal Ultrasound on admission without abnormality and renal \nfunction at baseline. Continued home immunosuppressive regimen \nwith sirolimus, MMF and Bactrim prophylaxis. Sirolimus levels \nwere monitored every other day, and dosing was changed to \nsirolimus 1mg ___, Mo, We, Fr and 0.5mg ___, Th, ___ per Renal \nTransplant recs. \n\n# Coagulopathy\nINR was elevated to 1.4 on admission, likely in setting of \nnutritional deficiency, so he was given po vitamin K.\n\n# Normocytic Anemia\nAt baseline, no evidence of bleeding.\n\nCHRONIC ISSUES:\n===============\n#Hypertension\nContinued home Metoprolol\n\n#Hyperlipidemia\nContinued home pravastatin\n\n#Anxiety\nContinued home At___\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Allopurinol ___ mg PO DAILY \n2. LORazepam 0.5 mg PO BID:PRN anxiety \n3. Metoprolol Tartrate 12.5 mg PO BID \n4. Mycophenolate Mofetil 500 mg PO BID \n5. Pravastatin 40 mg PO QPM \n6. Sirolimus 1 mg PO 5X/WEEK (___) \n7. Sirolimus 0.5 mg PO 2X/WEEK (___) \n8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \n9. Ursodiol 500 mg PO BID \n10. Multivitamins W/minerals 1 TAB PO DAILY \n11. Ciprofloxacin HCl 500 mg PO Q12H \n12. Omeprazole 20 mg PO DAILY \n13. Cetirizine 5 mg PO DAILY \n\n \nDischarge Medications:\n1. Cefpodoxime Proxetil 200 mg PO Q12H \n2. MetroNIDAZOLE 500 mg PO TID \n3. Sirolimus 1 mg PO 4XWEEK (___) \nDaily dose to be administered at 6am \n4. Sirolimus 0.5 mg PO 3XWEEK (___) \nDaily dose to be administered at 6am \n5. Allopurinol ___ mg PO DAILY \n6. Cetirizine 5 mg PO DAILY \n7. LORazepam 0.5 mg PO BID:PRN anxiety \n8. Metoprolol Tartrate 12.5 mg PO BID \n9. Multivitamins W/minerals 1 TAB PO DAILY \n10. Mycophenolate Mofetil 500 mg PO BID \n11. Omeprazole 20 mg PO DAILY \n12. Pravastatin 40 mg PO QPM \n13. Ursodiol 500 mg PO BID \n14. HELD- Ciprofloxacin HCl 500 mg PO Q12H This medication was \nheld. Do not restart Ciprofloxacin HCl until you have finished \nyour cefpodoxime and flagyl\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS \n================ \nCHOLANGITIS \n \nSECONDARY DIAGNOSES \n=================== \nCHOLECYSTITIS \nCAROLI'S DISEASE \n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nIt was a privilege taking care of you at ___ \n___. \n\nWHY WAS I ADMITTED TO THE HOSPITAL?\n===================================\n- You were having fevers and had elevated liver enzymes. \n\nWHAT HAPPENED WHILE I WAS IN THE HOSPITAL?\n==========================================\n- Your blood, urine, and stool were tested for signs of \ninfection.\n- You had an MRCP that showed signs of an infection in your \nbiliary system.\n- You had an ERCP to remove sludge from the biliary system.\n- You received IV antibiotics.\n\nWHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?\n============================================ \n- Please continue to take all your medications and follow up \nwith your doctors at your ___ appointments. \n\nWe wish you all the best!\n\nSincerely, \nYour ___ Care Team \n \nFollowup Instructions:\n___\n"
] | Allergies: Prograf / Augmentin / doxycycline Major Surgical or Invasive Procedure: ERCP attach Pertinent Results: ADMISSION LABS ============= [MASKED] 12:36PM BLOOD WBC-7.4 RBC-4.58* Hgb-12.7* Hct-38.9* MCV-85 MCH-27.7 MCHC-32.6 RDW-12.6 RDWSD-38.9 Plt [MASKED] [MASKED] 05:15AM BLOOD WBC-4.6 RBC-4.01* Hgb-11.1* Hct-33.9* MCV-85 MCH-27.7 MCHC-32.7 RDW-12.6 RDWSD-38.5 Plt [MASKED] [MASKED] 05:15AM BLOOD Neuts-62.8 [MASKED] Monos-13.2* Eos-1.1 Baso-0.0 Im [MASKED] AbsNeut-2.90 AbsLymp-1.04* AbsMono-0.61 AbsEos-0.05 AbsBaso-0.00* [MASKED] 05:15AM BLOOD Plt [MASKED] [MASKED] 05:15AM BLOOD [MASKED] PTT-31.6 [MASKED] [MASKED] 05:15AM BLOOD Glucose-95 UreaN-11 Creat-0.7 Na-140 K-3.8 Cl-102 HCO3-26 AnGap-12 [MASKED] 12:36PM BLOOD ALT-77* AST-110* AlkPhos-183* TotBili-0.6 [MASKED] 05:15AM BLOOD ALT-61* AST-79* LD(LDH)-188 AlkPhos-145* TotBili-0.5 [MASKED] 05:15AM BLOOD Albumin-2.7* Calcium-8.9 Phos-3.6 Mg-1.8 [MASKED] 05:15AM BLOOD rapmycn-9.0 [MASKED] 05:10PM BLOOD Lactate-1.2 [MASKED] 03:00PM URINE Color-Yellow Appear-CLEAR Sp [MASKED] [MASKED] 03:00PM URINE Blood-NEG Nitrite-NEG Protein-100* Glucose-NEG Ketone-TR* Bilirub-NEG Urobiln-NORMAL pH-6.5 Leuks-NEG [MASKED] 03:00PM URINE RBC-1 WBC-2 Bacteri-NONE Yeast-NONE Epi-0 [MASKED] 07:50AM STOOL CDIFPCR-NEG DISCHARGE LABS ============== [MASKED] 05:02AM BLOOD WBC-4.2 RBC-3.97* Hgb-11.0* Hct-33.1* MCV-83 MCH-27.7 MCHC-33.2 RDW-12.8 RDWSD-39.1 Plt [MASKED] [MASKED] 05:02AM BLOOD Plt [MASKED] [MASKED] 05:02AM BLOOD Glucose-96 UreaN-8 Creat-0.6 Na-141 K-4.1 Cl-106 HCO3-25 AnGap-10 [MASKED] 05:02AM BLOOD ALT-54* AST-69* AlkPhos-120 TotBili-0.3 [MASKED] 05:02AM BLOOD Calcium-8.7 Phos-3.0 Mg-1. RIEF HOSPITAL COURSE ================================= [MASKED] year old male with past medical history of renal transplant for polycystic kidney disease in [MASKED], multiple episodes of choledocholithiasis status post ERCP x3, Caroli's disease presenting with abnormal liver enzymes and fevers with concern for recurrent cholangitis. CXR, urinalysis, blood cultures, and urine cultures were negative. Stool cultures were sent, and he was negative for C diff and Norovirus. Hepatitis serologies, urine Legionella, CMV, and EBV were negative. An MRCP was concerning for cholangitis and cholecystitis, so he had an ERCP which removed some biliary sludge but no stones. He was treated with IV ceftriaxone and Flagyl, which helped his fevers. He had a CT C/A/P that was negative for signs of malignancy despite nightly fevers and recent 19 lb weight loss. TRANSITIONAL ISSUES: ================================= [ ] Follow up stool culture and studies and treat any positive results [ ] Follow up duodenal aspirates from ERCP [ ] Follow up sirolimus levels since dosing was changed to 1mg [MASKED], Mo, We, Fr and 0.5mg [MASKED], Th, [MASKED] [ ] Bactrim was discontinued per Renal transplant recommendations as his transplant was over [MASKED] years ago [ ] Colonoscopy as he has not had age-appropriate screening FOLLOW-UP - Follow up: stool cultures, duodenal aspirates - Tests required after discharge: colonoscopy - Incidental findings: none OTHER ISSUES: - Discharge Hemoglobin: *** - Discharge Cr: *** - Discharge weight: *** #CODE: Full (presumed) #CONTACT: [MASKED], wife, [MASKED] ACUTE ISSUES: ================ #Fever #Diarrhea Patient reports a one month history of fevers and chronic diarrhea that acutely worsened over the same time period. Exam showed normal cardiopulmonary and no abdominal pain, negative [MASKED] sign, no stigmata of endocarditis. No evidence of infiltrate on CXR, UA without evidence of infection. Urine and blood cultures were negative. Stool culture was negative for Salmonella, Shigella, ova and parasites; cryptosporidium, microsporidium, cyclospora, EHEC, giardia, vibrio were pending. C diff, Norovirus were negative. CMV, EBV negative. Hepatitis serologies negative. Urine Legionella negative. MRCP showed signs of cholangitis vs cholecystitis. CT C/A/P showed no evidence of malignancy, redemonstrated signs of cholecystitis. ERCP [MASKED] removed sludge, found no stones, and did not use dye to reduce risk of post-op infection. Infectious Disease and Hepatology were consulted and offered recommendations throughout hospitalization. He was treated empirically with IV ceftriaxone and flagyl x 5 days and switched to oral cefpodoxime and flagyl to finish a 7 day course given patient desiring discharge instead of waiting to finish IV antibiotics as inpatient. Weekend antibiotic infusions could not be set up. #Elevated Transaminase ALT, AST slightly elevated above baseline in the setting of new onset fever but was ultimately thought to be consistent with his known [MASKED]'s Disease after infectious workup was completed as above. #History of Recurrent Cholangitis #[MASKED]'s Disease Patient has a known history of recurrent cholangitis with last episode [MASKED]. RUQ US on presentation with evidence of intrahepatic intraductal stones measuring up to 1.3 cm. Abdominal exam was always negative for pain or [MASKED] sign. Due to signs of cholangitis on MRCP, ERCP was performed and patient was treated with ceftriaxone and Flagyl as above. Continued home ursodiol and resumed suppressive antibiotics on discharge #Back Pain, resolved Patient reported history of back pain and symptoms exertional symptoms. He reported previous xrays were normal. As he had no pain during admission, we did not repeat films. #Abnormal Weight loss Patient reports 19 lb weight loss over past 6 weeks although in setting of significant dietary restriction. Pt reports he has never had colonoscopy. MRCP and CT C/A/P this admission without lesions concerning for malignancy. Nutrition was consulted. Diarrhea was worked up as above. #S/p cadaveric kidney transplant [MASKED] Renal Ultrasound on admission without abnormality and renal function at baseline. Continued home immunosuppressive regimen with sirolimus, MMF and Bactrim prophylaxis. Sirolimus levels were monitored every other day, and dosing was changed to sirolimus 1mg [MASKED], Mo, We, Fr and 0.5mg [MASKED], Th, [MASKED] per Renal Transplant recs. # Coagulopathy INR was elevated to 1.4 on admission, likely in setting of nutritional deficiency, so he was given po vitamin K. # Normocytic Anemia At baseline, no evidence of bleeding. CHRONIC ISSUES: =============== #Hypertension Continued home Metoprolol #Hyperlipidemia Continued home pravastatin #Anxiety Continued home At Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol [MASKED] mg PO DAILY 2. LORazepam 0.5 mg PO BID:PRN anxiety 3. Metoprolol Tartrate 12.5 mg PO BID 4. Mycophenolate Mofetil 500 mg PO BID 5. Pravastatin 40 mg PO QPM 6. Sirolimus 1 mg PO 5X/WEEK ([MASKED]) 7. Sirolimus 0.5 mg PO 2X/WEEK ([MASKED]) 8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 9. Ursodiol 500 mg PO BID 10. Multivitamins W/minerals 1 TAB PO DAILY 11. Ciprofloxacin HCl 500 mg PO Q12H 12. Omeprazole 20 mg PO DAILY 13. Cetirizine 5 mg PO DAILY Discharge Medications: 1. Cefpodoxime Proxetil 200 mg PO Q12H 2. MetroNIDAZOLE 500 mg PO TID 3. Sirolimus 1 mg PO 4XWEEK ([MASKED]) Daily dose to be administered at 6am 4. Sirolimus 0.5 mg PO 3XWEEK ([MASKED]) Daily dose to be administered at 6am 5. Allopurinol [MASKED] mg PO DAILY 6. Cetirizine 5 mg PO DAILY 7. LORazepam 0.5 mg PO BID:PRN anxiety 8. Metoprolol Tartrate 12.5 mg PO BID 9. Multivitamins W/minerals 1 TAB PO DAILY 10. Mycophenolate Mofetil 500 mg PO BID 11. Omeprazole 20 mg PO DAILY 12. Pravastatin 40 mg PO QPM 13. Ursodiol 500 mg PO BID 14. HELD- Ciprofloxacin HCl 500 mg PO Q12H This medication was held. Do not restart Ciprofloxacin HCl until you have finished your cefpodoxime and flagyl Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS ================ CHOLANGITIS SECONDARY DIAGNOSES =================== CHOLECYSTITIS CAROLI'S DISEASE Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], It was a privilege taking care of you at [MASKED] [MASKED]. WHY WAS I ADMITTED TO THE HOSPITAL? =================================== - You were having fevers and had elevated liver enzymes. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? ========================================== - Your blood, urine, and stool were tested for signs of infection. - You had an MRCP that showed signs of an infection in your biliary system. - You had an ERCP to remove sludge from the biliary system. - You received IV antibiotics. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? ============================================ - Please continue to take all your medications and follow up with your doctors at your [MASKED] appointments. We wish you all the best! Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED] | [
"K8309",
"E43",
"Q445",
"Z940",
"Q613",
"Q453",
"N2581",
"D684",
"I10",
"E785",
"M109",
"M818",
"Q0700",
"D649",
"F419",
"K529",
"R509",
"M549",
"R61",
"Z6823"
] | [
"K8309: Other cholangitis",
"E43: Unspecified severe protein-calorie malnutrition",
"Q445: Other congenital malformations of bile ducts",
"Z940: Kidney transplant status",
"Q613: Polycystic kidney, unspecified",
"Q453: Other congenital malformations of pancreas and pancreatic duct",
"N2581: Secondary hyperparathyroidism of renal origin",
"D684: Acquired coagulation factor deficiency",
"I10: Essential (primary) hypertension",
"E785: Hyperlipidemia, unspecified",
"M109: Gout, unspecified",
"M818: Other osteoporosis without current pathological fracture",
"Q0700: Arnold-Chiari syndrome without spina bifida or hydrocephalus",
"D649: Anemia, unspecified",
"F419: Anxiety disorder, unspecified",
"K529: Noninfective gastroenteritis and colitis, unspecified",
"R509: Fever, unspecified",
"M549: Dorsalgia, unspecified",
"R61: Generalized hyperhidrosis",
"Z6823: Body mass index [BMI] 23.0-23.9, adult"
] | [
"I10",
"E785",
"M109",
"D649",
"F419"
] | [] |
16,405,695 | 21,871,056 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: ORTHOPAEDICS\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nLeft leg pain\n \nMajor Surgical or Invasive Procedure:\n___ retrograde femoral intramedullary nail\n\n \nHistory of Present Illness:\n___ year-old female with a PMHx significant for hypertension, \nhyperlipidemia, anxiety, depression, bipolar disorder, reported \nhistory of bilateral avascular necrosis of the hips who presents \nto the hospital with left knee pain after mechanical slip and \nfall on a wet bathroom floor. The patient denies any preceding \nlightheadedness, dizziness, chest pains, palpitations, \ndifficulty breathing. She denies head strike or loss of \nconsciousness. She was taken by EMS to an outside hospital and \nthen transferred for ___ for \nfurther management. Patient denies numbness, tingling, \nweakness, or other injuries. \n\n \nPast Medical History:\nHypertension\nHyperlipidemia\nAnxiety\nDepression\nBipolar disorder\nReported history of bilateral avascular necrosis of the hips\nReported history of ulcerative colitis\n \nSocial History:\n___\nFamily History:\nNon-contributory\n \nPhysical Exam:\nOn Admission: \n\nSkin intact, clean, no wounds\nLeft lower extremity held in flexion at the knee and external \nrotation\nTTP over the distal femur \nAll compartments of the thigh and leg soft and compressible \n___ fire\n+SILT SPN/DPN/TN/saphenous/sural distributions\n___ pulses, foot warm and well-perfused\n\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n================================================================\n\nOn Discharge:\n\n \nBrief Hospital Course:\nThe patient presented to the emergency department and was \nevaluated by the orthopedic surgery team. The patient was found \nto have a left distal femur fracture and was admitted to the \northopedic surgery service. The patient was taken to the \noperating room on ___ for left retrograde intramedullary \nfemoral nail, which the patient tolerated well. For full details \nof the procedure please see the separately dictated operative \nreport. The patient was taken from the OR to the PACU in stable \ncondition and after satisfactory recovery from anesthesia was \ntransferred to the floor. The patient was initially given IV \nfluids and IV pain medications, and progressed to a regular diet \nand oral medications by POD#1. The patient was given \n___ antibiotics and anticoagulation per routine. The \npatient's appropriate home medications were continued throughout \nthis hospitalization. The patient worked with ___ who determined \nthat discharge to rehab was appropriate. We expect that her \nrehab stay will be <30d. The patient's had several episodes of \northostatic hypotension while working with the ___ team which \nresolved with lying flat. She did receive one unit of packed red \nblood cells, which she tolerated well. \n\nAt the time of discharge the patient's pain was well controlled \nwith oral medications, incisions were clean/dry/intact, and the \npatient was voiding/moving bowels spontaneously. The patient is \ntouch down weight bearing in the left lower extremity, and will \nbe discharged on enoxaparin for DVT prophylaxis. The patient \nwill follow up with Dr. ___ routine. A thorough \ndiscussion was had with the patient regarding the diagnosis and \nexpected post-discharge course including reasons to call the \noffice or return to the hospital, and all questions were \nanswered. The patient was also given written instructions \nconcerning precautionary instructions and the appropriate \nfollow-up care. The patient expressed readiness for discharge.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Simvastatin 40 mg PO QPM \n2. Gabapentin 800 mg PO TID \n3. LORazepam 1.5 mg PO DAILY:PRN anxiety \n4. QUEtiapine extended-release 800 mg PO QHS \n5. FLUoxetine 40 mg PO DAILY \n6. Pantoprazole 40 mg PO Q12H \n7. carisoprodol 350 mg oral Q8H:PRN \n8. Levothyroxine Sodium 100 mcg PO DAILY \n9. Metoprolol Succinate XL 200 mg PO DAILY \n10. Montelukast 10 mg PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 975 mg PO Q6H \nDo not take more than 4000mg total, daily \n2. Docusate Sodium 100 mg PO BID \nPlease take while you are using your oxycodone \n3. Enoxaparin Sodium 40 mg SC QHS \n4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain \nDo not drink or drive on this med. Beware sedation. \nRX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp \n#*30 Tablet Refills:*0 \n5. FLUoxetine 40 mg PO DAILY \n6. Gabapentin 800 mg PO TID \n7. Levothyroxine Sodium 100 mcg PO DAILY \n8. LORazepam 1.5 mg PO DAILY:PRN anxiety \n9. Metoprolol Succinate XL 200 mg PO DAILY \n10. Montelukast 10 mg PO DAILY \n11. Pantoprazole 40 mg PO Q12H \n12. QUEtiapine extended-release 800 mg PO QHS \n13. Simvastatin 40 mg PO QPM \n14. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia \n15. HELD- carisoprodol 350 mg oral Q8H:PRN This medication was \nheld. Do not restart carisoprodol until stopping your narcotic \npain medications\n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \n___ Diagnosis:\nLeft distal femur fracture\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Out of Bed with assistance to chair or \nwheelchair.\n\n \nDischarge Instructions:\nINSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:\n\n- You were in the hospital for orthopedic surgery. It is normal \nto feel tired or \"washed out\" after surgery, and this feeling \nshould improve over the first few days to week. \n- Resume your regular activities as tolerated, but please follow \nyour weight bearing precautions strictly at all times.\n\nACTIVITY AND WEIGHT BEARING:\n-Touchdown weightbearing in the left lower extremity.\n\nMEDICATIONS:\n 1) Take Tylenol ___ every 6 hours around the clock. This is \nan over the counter medication.\n 2) Add oxycodone as needed for increased pain. Aim to wean \noff this medication in 1 week or sooner. This is an example on \nhow to wean down:\nTake 1 dose every 3 hours as needed x 1 day,\nthen 1 dose every 4 hours as needed x 1 day,\nthen 1 dose every 6 hours as needed x 1 day,\nthen 1 dose dose every 8 hours as needed x 2 days, \nthen 1 dose every 12 hours as needed x 1 day,\nthen 1 dose every before bedtime as needed x 1 day. \nThen continue with Tylenol for pain.\n 3) Do not stop the Tylenol until you are off of the narcotic \nmedication.\n 4) Per state regulations, we are limited in the amount of \nnarcotics we can prescribe. If you require more, you must \ncontact the office to set up an appointment because we cannot \nrefill this type of pain medication over the phone. \n 5) Narcotic pain relievers can cause constipation, so you \nshould drink eight 8oz glasses of water daily and continue \nfollowing the bowel regimen as stated on your medication \nprescription list. These meds (senna, colace, miralax) are over \nthe counter and may be obtained at any pharmacy.\n 6) Do not drink alcohol, drive a motor vehicle, or operate \nmachinery while taking narcotic pain relievers.\n 7) Please take all medications as prescribed by your \nphysicians at discharge.\n 8) Continue all home medications unless specifically \ninstructed to stop by your surgeon.\n \nANTICOAGULATION:\n- Please take 40 mg of enoxaparin subcutaneously daily for 4 \nweeks\n\nWOUND CARE:\n- You may shower. No baths or swimming for at least 4 weeks.\n- Any stitches or staples that need to be removed will be taken \nout at your 2-week follow up appointment.\n- Incision may be left open to air unless actively draining. If \ndraining, you may apply a gauze dressing secured with paper \ntape.\n\nDANGER SIGNS:\nPlease call your PCP or surgeon's office and/or return to the \nemergency department if you experience any of the following:\n- Increasing pain that is not controlled with pain medications\n- Increasing redness, swelling, drainage, or other concerning \nchanges in your incision\n- Persistent or increasing numbness, tingling, or loss of \nsensation\n- Fever > 101.4\n- Shaking chills\n- Chest pain\n- Shortness of breath\n- Nausea or vomiting with an inability to keep food, liquid, \nmedications down\n- Any other medical concerns\n\nPhysical Therapy:\nMs. ___ is to be touchdown weightbearing in the left lower \nextremity.\nTreatments Frequency:\nAny staples or superficial sutures you have are to remain in \nplace for at least 2 weeks postoperatively. Incision may be \nleft open to air unless actively draining. If draining, you may \napply a gauze dressing secured with paper tape. You may shower \nand allow water to run over the wound, but please refrain from \nbathing for at least 4 weeks postoperatively.\n\n \nFollowup Instructions:\n___\n"
] | Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Left leg pain Major Surgical or Invasive Procedure: [MASKED] retrograde femoral intramedullary nail History of Present Illness: [MASKED] year-old female with a PMHx significant for hypertension, hyperlipidemia, anxiety, depression, bipolar disorder, reported history of bilateral avascular necrosis of the hips who presents to the hospital with left knee pain after mechanical slip and fall on a wet bathroom floor. The patient denies any preceding lightheadedness, dizziness, chest pains, palpitations, difficulty breathing. She denies head strike or loss of consciousness. She was taken by EMS to an outside hospital and then transferred for [MASKED] for further management. Patient denies numbness, tingling, weakness, or other injuries. Past Medical History: Hypertension Hyperlipidemia Anxiety Depression Bipolar disorder Reported history of bilateral avascular necrosis of the hips Reported history of ulcerative colitis Social History: [MASKED] Family History: Non-contributory Physical Exam: On Admission: Skin intact, clean, no wounds Left lower extremity held in flexion at the knee and external rotation TTP over the distal femur All compartments of the thigh and leg soft and compressible [MASKED] fire +SILT SPN/DPN/TN/saphenous/sural distributions [MASKED] pulses, foot warm and well-perfused = = = = = = = = = = = = = = = ================================================================ On Discharge: Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have a left distal femur fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on [MASKED] for left retrograde intramedullary femoral nail, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given [MASKED] antibiotics and anticoagulation per routine. The patient's appropriate home medications were continued throughout this hospitalization. The patient worked with [MASKED] who determined that discharge to rehab was appropriate. We expect that her rehab stay will be <30d. The patient's had several episodes of orthostatic hypotension while working with the [MASKED] team which resolved with lying flat. She did receive one unit of packed red blood cells, which she tolerated well. 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 touch down weight bearing in the left lower extremity, and will be discharged on enoxaparin for DVT prophylaxis. The patient will follow up with Dr. [MASKED] routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Simvastatin 40 mg PO QPM 2. Gabapentin 800 mg PO TID 3. LORazepam 1.5 mg PO DAILY:PRN anxiety 4. QUEtiapine extended-release 800 mg PO QHS 5. FLUoxetine 40 mg PO DAILY 6. Pantoprazole 40 mg PO Q12H 7. carisoprodol 350 mg oral Q8H:PRN 8. Levothyroxine Sodium 100 mcg PO DAILY 9. Metoprolol Succinate XL 200 mg PO DAILY 10. Montelukast 10 mg PO DAILY Discharge Medications: 1. Acetaminophen 975 mg PO Q6H Do not take more than 4000mg total, daily 2. Docusate Sodium 100 mg PO BID Please take while you are using your oxycodone 3. Enoxaparin Sodium 40 mg SC QHS 4. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain Do not drink or drive on this med. Beware sedation. RX *oxycodone 5 mg [MASKED] tablet(s) by mouth every 4 hours Disp #*30 Tablet Refills:*0 5. FLUoxetine 40 mg PO DAILY 6. Gabapentin 800 mg PO TID 7. Levothyroxine Sodium 100 mcg PO DAILY 8. LORazepam 1.5 mg PO DAILY:PRN anxiety 9. Metoprolol Succinate XL 200 mg PO DAILY 10. Montelukast 10 mg PO DAILY 11. Pantoprazole 40 mg PO Q12H 12. QUEtiapine extended-release 800 mg PO QHS 13. Simvastatin 40 mg PO QPM 14. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia 15. HELD- carisoprodol 350 mg oral Q8H:PRN This medication was held. Do not restart carisoprodol until stopping your narcotic pain medications Discharge Disposition: Extended Care Facility: [MASKED] [MASKED] Diagnosis: Left distal femur fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: -Touchdown weightbearing in the left lower extremity. MEDICATIONS: 1) Take Tylenol [MASKED] every 6 hours around the clock. This is an over the counter medication. 2) Add oxycodone as needed for increased pain. Aim to wean off this medication in 1 week or sooner. This is an example on how to wean down: Take 1 dose every 3 hours as needed x 1 day, then 1 dose every 4 hours as needed x 1 day, then 1 dose every 6 hours as needed x 1 day, then 1 dose dose every 8 hours as needed x 2 days, then 1 dose every 12 hours as needed x 1 day, then 1 dose every before bedtime as needed x 1 day. Then continue with Tylenol for pain. 3) Do not stop the Tylenol until you are off of the narcotic medication. 4) Per state regulations, we are limited in the amount of narcotics we can prescribe. If you require more, you must contact the office to set up an appointment because we cannot refill this type of pain medication over the phone. 5) Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and continue following the bowel regimen as stated on your medication prescription list. These meds (senna, colace, miralax) are over the counter and may be obtained at any pharmacy. 6) Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. 7) Please take all medications as prescribed by your physicians at discharge. 8) Continue all home medications unless specifically instructed to stop by your surgeon. ANTICOAGULATION: - Please take 40 mg of enoxaparin subcutaneously daily for 4 weeks WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - Incision may be left open to air unless actively draining. If draining, you may apply a gauze dressing secured with paper tape. DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever > 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns Physical Therapy: Ms. [MASKED] is to be touchdown weightbearing in the left lower extremity. Treatments Frequency: Any staples or superficial sutures you have are to remain in place for at least 2 weeks postoperatively. Incision may be left open to air unless actively draining. If draining, you may apply a gauze dressing secured with paper tape. You may shower and allow water to run over the wound, but please refrain from bathing for at least 4 weeks postoperatively. Followup Instructions: [MASKED] | [
"S72402A",
"D62",
"W010XXA",
"I10",
"E785",
"F418",
"F319",
"I951",
"K219"
] | [
"S72402A: Unspecified fracture of lower end of left femur, initial encounter for closed fracture",
"D62: Acute posthemorrhagic anemia",
"W010XXA: Fall on same level from slipping, tripping and stumbling without subsequent striking against object, initial encounter",
"I10: Essential (primary) hypertension",
"E785: Hyperlipidemia, unspecified",
"F418: Other specified anxiety disorders",
"F319: Bipolar disorder, unspecified",
"I951: Orthostatic hypotension",
"K219: Gastro-esophageal reflux disease without esophagitis"
] | [
"D62",
"I10",
"E785",
"K219"
] | [] |
17,952,547 | 21,663,927 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nPhenergan Plain / Compazine / Reglan / Haldol / citalopram\n \nAttending: ___\n \nChief Complaint:\nNausea, vomiting and abdominal pain\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ MEDICINE ATTENDING ADMISSION NOTE .\n.\nDate: ___\nTime: ___\n_\n________________________________________________________________\n\nPCP: Dr. ___\nCC: nausea/vomiting and abdominal pain\nPatient's goals for admission:\n1. Break the cycle of recurrent admissions\n2. Leave with a plan of how to remain compliant on reglan qid\n3. Get \"more on top\" of my diabetes\n. \n_\n________________________________________________________________\nHPI: \n___ with T1DM since age ___ with last HgbA1C = 8.7% (___) and \nlongstanding history of severe gastroparesis and colonic \ninertia secondary to narcotic bowel from chronic narcotic use \nfor management of chronic abdominal pain. She is status post \nplacement of a neuroenteric gastric stimulator in ___, with \nfrequent admissions, now presenting with nausea/vomiting and \nabdominal pain.\n.\nLast seen in GI in ___ where the plan was for a EGD with \nbotox injections and return to a \"blenderized\" diet so that \nthere would be better coordination with the availability of \ninsulin with her digested food. She underwent EGD with botox \ninjections in ___. She thinks that since then her sx worsened \nafter that. She tried glucerna shakes as advised but this seemed \nto make her sx worse. She thinks that she had a good month in \n___ when ___ days at the end of ___ and then two other \ntimes in ___ which was good for her which occurred when she \nstopped the glucerna and then started solid foods. She felt very \nwell. Her gastroparesis flares can occur without a clear trigger \nunless triggered by anxiety. She cannot keep a food log since it \ntriggers her binging her eating disorder. No correlation with \nhigh blood sugars. She feels that she has had multiple problems \nsince her pacemaker put in ___ years ago. \nShe is very frustrated. No relief with taking Zofran at the \nfirst sign of sx. \n.\nShe has recurrent admissions for nausea/vomiting and abdominal \npain, with care plan established by PCP ___ note from \n___. Recent history was notable for admission to ___ \nfrom ___, during which she improved with symptomatic \nmanagement for nausea/vomiting/pain. Two weeks ago, she was \nadmitted to ___ for pancreatitis and improved with \nsymptomatic management as well.\n.\nFor the last week, she has had worsening \nnausea/vomiting/abdominal pain. Symptoms are more acute in the \nmornings. She has presented to ___ 3 times over the last \n3 days, and has been treated symptomatically with IVF, Ativan, \nBenadryl, Reglan and IV Dilaudid. She presented again to \n___ this morning, and symptoms persisted after the above \ninterventions (also received 1L NS). She was therefore \ntransferred to ___ per her care plan for further evaluation. \nLast emesis was at BID-P at 1130 which was undigested food. Non- \nbloody and non-bilious emesis. \n.\nShe has been in her slump with her DM. Her meter has been \nbroken. She has been doing water aerobics with her sister. Her \nBS were in 300s-500 for the past two weeks after a cortisone \ninjection in her shoulder. She has taking her long acting \ninsulin daily but does more catch up doses of insulin rather \nthan anticipatory doses.\n.\nHer diabetologist Dr. ___ will leave ___ soon and she has \nseen him since she was ___. \n\nIn terms of her diet, she eats the same things and sticks to a \nbland diet. \nIn ER: (Triage Vitals:10 |97.2 |66 |142/71 |16 |99% RA ) \nMeds/IVF Given:\n___ 16:42 IV HYDROmorphone (Dilaudid) 1 mg White,Roxane P \n \n___ 16:42 IV DiphenhydrAMINE 25 mg White,Roxane P \n___ 16:42 IVF 40 mEq Potassium Chloride / 1000 mL NS \nWhite,Roxane P Started 250 mL/hr \n___ 19:09 PO/NG Warfarin 5 mg White,Roxane P \n___ 19:32 IV HYDROmorphone (Dilaudid) 1 mg \n___ \n___ 19:32 IV Metoclopramide 5 mg ___ \n\nRadiology Studies: None\nconsults called: None\n.\n\nPAIN ___ - oK level for her, her normal is ___ REVIEW OF \nSYSTEMS:\n CONSTITUTIONAL: No weight loss, she has re-gained the 4lhs \nthat she lost\n HEENT: [+] chronic diabetic retinopathy but no acute changes\n RESPIRATORY: [X] All normal\n CARDIAC: [X] All normal\n GI: As per HPI and no diarrhea\n GU: [X] All normal\n SKIN: [+] acne on her forehead\n MUSCULOSKELETAL: [X] All normal\n NEURO: [X] All normal\n ENDOCRINE: [X] All normal\n HEME/LYMPH: [+] easy/bruising since on Coumadin. \n PSYCH: [X] All normal\n\nAll other systems negative except as noted above\n \nPast Medical History:\nDMI since age ___\nHTN\nFibromyalgia dx'd Dr. ___ ___\nGenital herpes x years\ndysmenorrhea\ncarpal tunnel syndrome\nhypercholesterolemia\nGastroparesis wi placement gastric pacemaker ___\nGastric emptying study: ___ - IMPRESSION: Severe \ngastroparesis, with no significant interval change from \nprior study performed on ___ \ns/p eye surgery for diabetic retinopathy\nMRSA carrier\npain consult at ___ in past \nHistory of eating disorder, anxiety\n\n \nSocial History:\n___\nFamily History:\nFather with DM 2 who died at age ___. Mother with ___ who \npassed away at ___. Brother with diabetes. Sister with ___ \nwho has a brain tumor. Maternal uncle and maternal grandmother \ndied of MI's at age ___.\n \nPhysical Exam:\nVitals: T 98.2 P 88 BP 153/84 RR 18 SaO2 99% on RA \n CONS: NAD, comfortable appearing \n HEENT: ncat anicteric MMM \n CV: s1s2 rr no m/r/g \n RESP: b/l ae no w/c/r \n GI: +bs, soft, + b/l upper quadrant tenderness with palpation, \nno rebound or guarding\nWell healed midline scar from gastric pacemaker placement \n back: \n MSK:no c/c/e 2+pulses \n SKIN: no rash \n NEURO: face symmetric speech fluent \n PSYCH: calm, cooperative \nLAD: No cervical LAD\nCHEST: L POC cath, c/d/i\n\nDischarge Exam: \nVitals: 98 130/72 85 16 100%RA\nConsitutional: NAD, lying in bed comfortably, speaking full \nsentences \nEyes: EOMI, sclerae anicteric \nENT: MMM, OP clear\nCardiovasc: RRR, no MRG, no edema \nResp: normal effort, no accessory muscle use, lungs CTA ___, no \nwheezes, rales, rhonchi\nGI: well healed ab scars, nontender, mild distension, BS+\nMSK: No significant kyphosis. No palpable synovitis.\nSkin: No visible rash. No jaundice.\nNeuro: AAOx3. CNs II-XII intact. MAEE.\nPsych: Full range of affect\nGU: no foley, otherwise deferred\n \nPertinent Results:\n___ 04:37PM GLUCOSE-181* UREA N-12 CREAT-0.8 SODIUM-137 \nPOTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-24 ANION GAP-12\n\n___ 04:37PM CALCIUM-8.7 PHOSPHATE-2.4*# MAGNESIUM-1.9\n___ 04:37PM CALCIUM-8.7 PHOSPHATE-2.4*# MAGNESIUM-1.9\n___ 04:37PM PLT COUNT-219\n___ 04:37PM ___ PTT-31.6 ___\n=============================================\nABDOMINAL CT AT ___ ___\nIMPRESSION:\nNo acute abdominal pelvic process is identified.\nThe patient is status post cholecystectomy with stable intra and\nextrahepatic biliary dilatation.\nThere are some air-fluid levels within the small bowel loops but \nno\nbowel wall thickening or evidence of obstruction is identified.\nThere are several cysts within the pelvis which may be ovarian \nin\norigin measuring up to 4.2 cm.\n\n___ 05:18AM BLOOD WBC-3.6* RBC-3.64* Hgb-11.2 Hct-35.0 \nMCV-96 MCH-30.8 MCHC-32.0 RDW-14.9 RDWSD-52.7* Plt ___\n___ 05:18AM BLOOD ___\n___ 05:18AM BLOOD Glucose-138* UreaN-4* Creat-0.8 Na-139 \nK-3.9 Cl-104 HCO3-26 AnGap-13\n___ 05:18AM BLOOD Calcium-9.0 Phos-3.7 Mg-1.9\n___ 04:18AM BLOOD %HbA1c-8.9* eAG-209*\n \nBrief Hospital Course:\nMs. ___ is a ___ year old woman with long standing DM type I c/b \nsevere gastroparesis (s/p gastric pacemaker ___, followed by \nDr. ___ with frequent ___ visits in\npast year), recently admitted to ___ for questionable \npancreatitis (lipse 200) who presented with n/v/abdominal pain, \nc/w previous gastroparesis flares; transferred from ___ \nfor further management. \n\nGastroparesis flare is likely secondary to poor glycemic control \nin the setting of a recent corticosteroid injection for frozen \nshoulder, multiple stressors leading to poor glycemic control. \n\n#Acute on chronic gastroparesis: Last seen by ___ ___ \nwhere plan was for an EGD with botox injections and return to a \n\"blenderized\" diet so that there would be better coordination \nwith the availability of insulin with her digested food. She had \nEGD with botox in ___, though felt this was not helpful. \nTried glucerna shakes alone for a long time but did not help. \nLater, tried switching to her own \"bland diet\" which she thinks \nhelped and had fewer ___ visits since doing this since ___ \nor so (this also coincided with her botox injections so \nunclear). Per recent ___ d/c summary pt last had a an \nEGD on ___ which showed erosive esophagitis, ruled out \n___ esophagitis, mild gastritis ruled out H. pylori. \nEsophageal biopsies were consistent with acute and chronic \ninflammation. When seen by Dr. ___ was concerned about \npossible autoimmune pancreatitis. However, presentation on this \nadmission not consistent with pancreatitis, lipase negative. Dr. \n___ of admission. \n- reglan increased to 5mg QID without dystonia or tardive \ndyskinesia, and patient repidly improved, tolerating regular \ndiet and was motivated to go home\n- counseled her on signs and symptoms of TD/dystonia and \ninstructed her to call outpatient providers immediately should \nthis recur\n- bowel regimen augmented, counseled on avoidance of \nconstipation, especially if requiring home morphine use (no \nprescriptions given upon discharge)\n- f/u with PCP, GI\n\n#DM type I, poorly controlled with complications of retinopathy \nand gastroparesis. This has been difficult to control probably \nsecondary to recent corticosteroid injection. A1c 8.9, discussed \nwith patient importance of glycemic control for management of \ngastroparesis. ___ consulted during admission. \n- ___ 21u qlunch (home dose ___ 26u qAM) decreased to due \npoor PO intake \n- ___ follow up arranged for ___, expecting to increase \nToujeo dose with improved PO \n- Patient admits she let her DM \"slide\", but feels motivated to \nget it back under control \n\n#History of DVT (neck/upper extremity): ___ dx with R \nubclavian, R axilary and R innominate ,and R IJ veins. Portocath \nin place, and INR subtherapeutic on admission in setting of \nemesis, poor PO, inability to tolerate meds. Bridged while \ninpatient with Lovenox, restarted on warfarin 5mg and instructed \nto continue 5mg daily until follow up with ___, \nwho were emailed prior to discharge. \n- she will present on ___ for repeat INR as she will be in the \narea for ___ appt\n\n#Depression/anxiety: Continued home dulaxetine, home Xanax, home \nTopamax and tolerated them well once tolerating PO. Significant \nstressors at this time with her chronic illness, sister with \nGBM, two of her outpatient providers departing. SW consulted for \nsupport. \n\n#Cognitive retraining/mild reported deficit: Evaluated by OT \nwhile inpatient, who recommended outpatient OT with PCP follow \nup and discussion. \n\n#HTN: continued lisinopril\n\n#History of Iron deficiency anemia: CBC stable, defer restarting \nto outpatient setting. \n\n#Neuropathy: continued Gabapentin 600 mg PO BID \n\n#HLD: continued home simva 40mg qpm\n\n#Med rec: continues home vitamin D, Valacyclovir 500mg q12h\n.\nMedically stable. \n>30 minutes spent on discharge day services, counseling and \ncoordination of care. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. ALPRAZolam 0.5 mg PO BID:PRN anxiety \n2. Ascorbic Acid ___ mg PO DAILY \n3. Aspirin 81 mg PO DAILY \n4. DULoxetine 30 mg PO DAILY \n5. Ferrous GLUCONATE 324 mg PO DAILY \n6. Gabapentin 600 mg PO BID \n7. Metoclopramide 5 mg PO BID W/MEALS PRN nausea \n8. Morphine SR (MS ___ 15 mg PO Q12H \n9. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n10. Simvastatin 40 mg PO QPM \n11. Topiramate (Topamax) 75 mg PO QHS \n12. Vitamin D 800 UNIT PO DAILY \n13. ValACYclovir 500 mg PO Q12H \n14. biotin 800 mcg ORAL DAILY \n15. Morphine Sulfate ___ 15 mg PO BID:PRN pain \n16. Lisinopril 5 mg PO DAILY \n17. Warfarin 5 mg PO DAILY16 \n18. Acetaminophen 650 mg PR Q6H:PRN pain, nausea \n19. Toujeo 26 Units Breakfast\nInsulin SC Sliding Scale using HUM Insulin\n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PR Q6H:PRN pain, nausea \n2. ALPRAZolam 0.5 mg PO BID:PRN anxiety \n3. Ascorbic Acid ___ mg PO DAILY \n4. Aspirin 81 mg PO DAILY \n5. DULoxetine 30 mg PO DAILY \n6. Ferrous GLUCONATE 324 mg PO DAILY \n7. Gabapentin 600 mg PO BID \n8. Toujeo 21 Units Lunch\nInsulin SC Sliding Scale using HUM Insulin\n9. Lisinopril 5 mg PO DAILY \n10. Morphine SR (MS ___ 15 mg PO Q12H \n11. Morphine Sulfate ___ 15 mg PO BID:PRN pain \n12. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n13. Simvastatin 40 mg PO QPM \n14. Topiramate (Topamax) 75 mg PO QHS \n15. Vitamin D 800 UNIT PO DAILY \n16. Warfarin 5 mg PO DAILY16 \n17. Metoclopramide 5 mg PO QIDACHS nausea \n18. ValACYclovir 500 mg PO Q12H \n19. biotin 800 mcg ORAL DAILY \n20. Senna 8.6 mg PO BID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nGastroparesis flare\nDMI, uncontrolled with complications\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___, \n\nYou were admitted to the hospital with a gastroparesis flare. \nYour sugars were uncontrolled but your insulin was adjusted and \nactually DECREASED while you are recovering from this flare. \nYour reglan was increased and it helped your symptoms. It is \nvery important to get better control of your blood sugars to \nhelp prevent worsening gastroparesis. \n\nYou are being discharged on 21 unit of long-acting insulin, but \nthis will probably be increased once you are consistently eating \nbetter. \n\nPlease make sure to make an appointment at ___ within one \nweek. \n\nYou were also seen by occupational therapy, who recommended that \nyou discuss with your PCP outpatient occupation therapy. Please \nmake sure to follow up with Dr. ___ Dr. ___. \n\nWe wish you all the best. \n \nFollowup Instructions:\n___\n"
] | Allergies: Phenergan Plain / Compazine / Reglan / Haldol / citalopram Chief Complaint: Nausea, vomiting and abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] MEDICINE ATTENDING ADMISSION NOTE . . Date: [MASKED] Time: [MASKED] [MASKED] PCP: Dr. [MASKED] CC: nausea/vomiting and abdominal pain Patient's goals for admission: 1. Break the cycle of recurrent admissions 2. Leave with a plan of how to remain compliant on reglan qid 3. Get "more on top" of my diabetes . [MASKED] HPI: [MASKED] with T1DM since age [MASKED] with last HgbA1C = 8.7% ([MASKED]) and longstanding history of severe gastroparesis and colonic inertia secondary to narcotic bowel from chronic narcotic use for management of chronic abdominal pain. She is status post placement of a neuroenteric gastric stimulator in [MASKED], with frequent admissions, now presenting with nausea/vomiting and abdominal pain. . Last seen in GI in [MASKED] where the plan was for a EGD with botox injections and return to a "blenderized" diet so that there would be better coordination with the availability of insulin with her digested food. She underwent EGD with botox injections in [MASKED]. She thinks that since then her sx worsened after that. She tried glucerna shakes as advised but this seemed to make her sx worse. She thinks that she had a good month in [MASKED] when [MASKED] days at the end of [MASKED] and then two other times in [MASKED] which was good for her which occurred when she stopped the glucerna and then started solid foods. She felt very well. Her gastroparesis flares can occur without a clear trigger unless triggered by anxiety. She cannot keep a food log since it triggers her binging her eating disorder. No correlation with high blood sugars. She feels that she has had multiple problems since her pacemaker put in [MASKED] years ago. She is very frustrated. No relief with taking Zofran at the first sign of sx. . She has recurrent admissions for nausea/vomiting and abdominal pain, with care plan established by PCP [MASKED] note from [MASKED]. Recent history was notable for admission to [MASKED] from [MASKED], during which she improved with symptomatic management for nausea/vomiting/pain. Two weeks ago, she was admitted to [MASKED] for pancreatitis and improved with symptomatic management as well. . For the last week, she has had worsening nausea/vomiting/abdominal pain. Symptoms are more acute in the mornings. She has presented to [MASKED] 3 times over the last 3 days, and has been treated symptomatically with IVF, Ativan, Benadryl, Reglan and IV Dilaudid. She presented again to [MASKED] this morning, and symptoms persisted after the above interventions (also received 1L NS). She was therefore transferred to [MASKED] per her care plan for further evaluation. Last emesis was at BID-P at 1130 which was undigested food. Non- bloody and non-bilious emesis. . She has been in her slump with her DM. Her meter has been broken. She has been doing water aerobics with her sister. Her BS were in 300s-500 for the past two weeks after a cortisone injection in her shoulder. She has taking her long acting insulin daily but does more catch up doses of insulin rather than anticipatory doses. . Her diabetologist Dr. [MASKED] will leave [MASKED] soon and she has seen him since she was [MASKED]. In terms of her diet, she eats the same things and sticks to a bland diet. In ER: (Triage Vitals:10 |97.2 |66 |142/71 |16 |99% RA ) Meds/IVF Given: [MASKED] 16:42 IV HYDROmorphone (Dilaudid) 1 mg White,Roxane P [MASKED] 16:42 IV DiphenhydrAMINE 25 mg White,Roxane P [MASKED] 16:42 IVF 40 mEq Potassium Chloride / 1000 mL NS White,Roxane P Started 250 mL/hr [MASKED] 19:09 PO/NG Warfarin 5 mg White,Roxane P [MASKED] 19:32 IV HYDROmorphone (Dilaudid) 1 mg [MASKED] [MASKED] 19:32 IV Metoclopramide 5 mg [MASKED] Radiology Studies: None consults called: None . PAIN [MASKED] - oK level for her, her normal is [MASKED] REVIEW OF SYSTEMS: CONSTITUTIONAL: No weight loss, she has re-gained the 4lhs that she lost HEENT: [+] chronic diabetic retinopathy but no acute changes RESPIRATORY: [X] All normal CARDIAC: [X] All normal GI: As per HPI and no diarrhea GU: [X] All normal SKIN: [+] acne on her forehead MUSCULOSKELETAL: [X] All normal NEURO: [X] All normal ENDOCRINE: [X] All normal HEME/LYMPH: [+] easy/bruising since on Coumadin. PSYCH: [X] All normal All other systems negative except as noted above Past Medical History: DMI since age [MASKED] HTN Fibromyalgia dx'd Dr. [MASKED] [MASKED] Genital herpes x years dysmenorrhea carpal tunnel syndrome hypercholesterolemia Gastroparesis wi placement gastric pacemaker [MASKED] Gastric emptying study: [MASKED] - IMPRESSION: Severe gastroparesis, with no significant interval change from prior study performed on [MASKED] s/p eye surgery for diabetic retinopathy MRSA carrier pain consult at [MASKED] in past History of eating disorder, anxiety Social History: [MASKED] Family History: Father with DM 2 who died at age [MASKED]. Mother with [MASKED] who passed away at [MASKED]. Brother with diabetes. Sister with [MASKED] who has a brain tumor. Maternal uncle and maternal grandmother died of MI's at age [MASKED]. Physical Exam: Vitals: T 98.2 P 88 BP 153/84 RR 18 SaO2 99% on RA CONS: NAD, comfortable appearing HEENT: ncat anicteric MMM CV: s1s2 rr no m/r/g RESP: b/l ae no w/c/r GI: +bs, soft, + b/l upper quadrant tenderness with palpation, no rebound or guarding Well healed midline scar from gastric pacemaker placement back: MSK:no c/c/e 2+pulses SKIN: no rash NEURO: face symmetric speech fluent PSYCH: calm, cooperative LAD: No cervical LAD CHEST: L POC cath, c/d/i Discharge Exam: Vitals: 98 130/72 85 16 100%RA Consitutional: NAD, lying in bed comfortably, speaking full sentences Eyes: EOMI, sclerae anicteric ENT: MMM, OP clear Cardiovasc: RRR, no MRG, no edema Resp: normal effort, no accessory muscle use, lungs CTA [MASKED], no wheezes, rales, rhonchi GI: well healed ab scars, nontender, mild distension, BS+ MSK: No significant kyphosis. No palpable synovitis. Skin: No visible rash. No jaundice. Neuro: AAOx3. CNs II-XII intact. MAEE. Psych: Full range of affect GU: no foley, otherwise deferred Pertinent Results: [MASKED] 04:37PM GLUCOSE-181* UREA N-12 CREAT-0.8 SODIUM-137 POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-24 ANION GAP-12 [MASKED] 04:37PM CALCIUM-8.7 PHOSPHATE-2.4*# MAGNESIUM-1.9 [MASKED] 04:37PM CALCIUM-8.7 PHOSPHATE-2.4*# MAGNESIUM-1.9 [MASKED] 04:37PM PLT COUNT-219 [MASKED] 04:37PM [MASKED] PTT-31.6 [MASKED] ============================================= ABDOMINAL CT AT [MASKED] [MASKED] IMPRESSION: No acute abdominal pelvic process is identified. The patient is status post cholecystectomy with stable intra and extrahepatic biliary dilatation. There are some air-fluid levels within the small bowel loops but no bowel wall thickening or evidence of obstruction is identified. There are several cysts within the pelvis which may be ovarian in origin measuring up to 4.2 cm. [MASKED] 05:18AM BLOOD WBC-3.6* RBC-3.64* Hgb-11.2 Hct-35.0 MCV-96 MCH-30.8 MCHC-32.0 RDW-14.9 RDWSD-52.7* Plt [MASKED] [MASKED] 05:18AM BLOOD [MASKED] [MASKED] 05:18AM BLOOD Glucose-138* UreaN-4* Creat-0.8 Na-139 K-3.9 Cl-104 HCO3-26 AnGap-13 [MASKED] 05:18AM BLOOD Calcium-9.0 Phos-3.7 Mg-1.9 [MASKED] 04:18AM BLOOD %HbA1c-8.9* eAG-209* Brief Hospital Course: Ms. [MASKED] is a [MASKED] year old woman with long standing DM type I c/b severe gastroparesis (s/p gastric pacemaker [MASKED], followed by Dr. [MASKED] with frequent [MASKED] visits in past year), recently admitted to [MASKED] for questionable pancreatitis (lipse 200) who presented with n/v/abdominal pain, c/w previous gastroparesis flares; transferred from [MASKED] for further management. Gastroparesis flare is likely secondary to poor glycemic control in the setting of a recent corticosteroid injection for frozen shoulder, multiple stressors leading to poor glycemic control. #Acute on chronic gastroparesis: Last seen by [MASKED] [MASKED] where plan was for an EGD with botox injections and return to a "blenderized" diet so that there would be better coordination with the availability of insulin with her digested food. She had EGD with botox in [MASKED], though felt this was not helpful. Tried glucerna shakes alone for a long time but did not help. Later, tried switching to her own "bland diet" which she thinks helped and had fewer [MASKED] visits since doing this since [MASKED] or so (this also coincided with her botox injections so unclear). Per recent [MASKED] d/c summary pt last had a an EGD on [MASKED] which showed erosive esophagitis, ruled out [MASKED] esophagitis, mild gastritis ruled out H. pylori. Esophageal biopsies were consistent with acute and chronic inflammation. When seen by Dr. [MASKED] was concerned about possible autoimmune pancreatitis. However, presentation on this admission not consistent with pancreatitis, lipase negative. Dr. [MASKED] of admission. - reglan increased to 5mg QID without dystonia or tardive dyskinesia, and patient repidly improved, tolerating regular diet and was motivated to go home - counseled her on signs and symptoms of TD/dystonia and instructed her to call outpatient providers immediately should this recur - bowel regimen augmented, counseled on avoidance of constipation, especially if requiring home morphine use (no prescriptions given upon discharge) - f/u with PCP, GI #DM type I, poorly controlled with complications of retinopathy and gastroparesis. This has been difficult to control probably secondary to recent corticosteroid injection. A1c 8.9, discussed with patient importance of glycemic control for management of gastroparesis. [MASKED] consulted during admission. - [MASKED] 21u qlunch (home dose [MASKED] 26u qAM) decreased to due poor PO intake - [MASKED] follow up arranged for [MASKED], expecting to increase Toujeo dose with improved PO - Patient admits she let her DM "slide", but feels motivated to get it back under control #History of DVT (neck/upper extremity): [MASKED] dx with R ubclavian, R axilary and R innominate ,and R IJ veins. Portocath in place, and INR subtherapeutic on admission in setting of emesis, poor PO, inability to tolerate meds. Bridged while inpatient with Lovenox, restarted on warfarin 5mg and instructed to continue 5mg daily until follow up with [MASKED], who were emailed prior to discharge. - she will present on [MASKED] for repeat INR as she will be in the area for [MASKED] appt #Depression/anxiety: Continued home dulaxetine, home Xanax, home Topamax and tolerated them well once tolerating PO. Significant stressors at this time with her chronic illness, sister with GBM, two of her outpatient providers departing. SW consulted for support. #Cognitive retraining/mild reported deficit: Evaluated by OT while inpatient, who recommended outpatient OT with PCP follow up and discussion. #HTN: continued lisinopril #History of Iron deficiency anemia: CBC stable, defer restarting to outpatient setting. #Neuropathy: continued Gabapentin 600 mg PO BID #HLD: continued home simva 40mg qpm #Med rec: continues home vitamin D, Valacyclovir 500mg q12h . Medically stable. >30 minutes spent on discharge day services, counseling and coordination of care. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ALPRAZolam 0.5 mg PO BID:PRN anxiety 2. Ascorbic Acid [MASKED] mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. DULoxetine 30 mg PO DAILY 5. Ferrous GLUCONATE 324 mg PO DAILY 6. Gabapentin 600 mg PO BID 7. Metoclopramide 5 mg PO BID W/MEALS PRN nausea 8. Morphine SR (MS [MASKED] 15 mg PO Q12H 9. Polyethylene Glycol 17 g PO DAILY:PRN constipation 10. Simvastatin 40 mg PO QPM 11. Topiramate (Topamax) 75 mg PO QHS 12. Vitamin D 800 UNIT PO DAILY 13. ValACYclovir 500 mg PO Q12H 14. biotin 800 mcg ORAL DAILY 15. Morphine Sulfate [MASKED] 15 mg PO BID:PRN pain 16. Lisinopril 5 mg PO DAILY 17. Warfarin 5 mg PO DAILY16 18. Acetaminophen 650 mg PR Q6H:PRN pain, nausea 19. Toujeo 26 Units Breakfast Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Acetaminophen 650 mg PR Q6H:PRN pain, nausea 2. ALPRAZolam 0.5 mg PO BID:PRN anxiety 3. Ascorbic Acid [MASKED] mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. DULoxetine 30 mg PO DAILY 6. Ferrous GLUCONATE 324 mg PO DAILY 7. Gabapentin 600 mg PO BID 8. Toujeo 21 Units Lunch Insulin SC Sliding Scale using HUM Insulin 9. Lisinopril 5 mg PO DAILY 10. Morphine SR (MS [MASKED] 15 mg PO Q12H 11. Morphine Sulfate [MASKED] 15 mg PO BID:PRN pain 12. Polyethylene Glycol 17 g PO DAILY:PRN constipation 13. Simvastatin 40 mg PO QPM 14. Topiramate (Topamax) 75 mg PO QHS 15. Vitamin D 800 UNIT PO DAILY 16. Warfarin 5 mg PO DAILY16 17. Metoclopramide 5 mg PO QIDACHS nausea 18. ValACYclovir 500 mg PO Q12H 19. biotin 800 mcg ORAL DAILY 20. Senna 8.6 mg PO BID Discharge Disposition: Home Discharge Diagnosis: Gastroparesis flare DMI, uncontrolled with complications Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You were admitted to the hospital with a gastroparesis flare. Your sugars were uncontrolled but your insulin was adjusted and actually DECREASED while you are recovering from this flare. Your reglan was increased and it helped your symptoms. It is very important to get better control of your blood sugars to help prevent worsening gastroparesis. You are being discharged on 21 unit of long-acting insulin, but this will probably be increased once you are consistently eating better. Please make sure to make an appointment at [MASKED] within one week. You were also seen by occupational therapy, who recommended that you discuss with your PCP outpatient occupation therapy. Please make sure to follow up with Dr. [MASKED] Dr. [MASKED]. We wish you all the best. Followup Instructions: [MASKED] | [
"E1043",
"D6832",
"E10319",
"Z794",
"K3184",
"F419",
"F329",
"I10",
"M797",
"T45515A",
"Y92009",
"G3184",
"D509",
"Z86718",
"Z7901",
"Z9689"
] | [
"E1043: Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy",
"D6832: Hemorrhagic disorder due to extrinsic circulating anticoagulants",
"E10319: Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema",
"Z794: Long term (current) use of insulin",
"K3184: Gastroparesis",
"F419: Anxiety disorder, unspecified",
"F329: Major depressive disorder, single episode, unspecified",
"I10: Essential (primary) hypertension",
"M797: Fibromyalgia",
"T45515A: Adverse effect of anticoagulants, initial encounter",
"Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause",
"G3184: Mild cognitive impairment, so stated",
"D509: Iron deficiency anemia, unspecified",
"Z86718: Personal history of other venous thrombosis and embolism",
"Z7901: Long term (current) use of anticoagulants",
"Z9689: Presence of other specified functional implants"
] | [
"Z794",
"F419",
"F329",
"I10",
"D509",
"Z86718",
"Z7901"
] | [] |
15,723,637 | 26,665,385 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nErythromycin Base\n \nAttending: ___.\n \nChief Complaint:\nchest pain\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\nMs. ___ is a ___ female with a PMH of obesity,\npast smoking, DM2 (not on insulin), asthma, depression, GERD and\nother issues who presented to the ED with chest pain. She\nreports that her symptoms were overall very similar to an \nepisode\nshe experienced in ___. She was in her usual state of health\nbut began feeling nauseated yesterday evening; she did not eat\ndinner due to this. She also felt diffusely itchy and took a\ndose of children's Benadryl, which helped with the itch and\nhelped her go to sleep; however, she awoke around 3 am with\nnausea/vomiting, several episodes of watery diarrhea, and chest\npressure that she described as central and feeling like someone\nwas sitting on her chest. She has not had fever, chills,\nabdominal pain, dysuria, weakness, or any other issues recently\nprior to this. \n\nIn the ED, initial VS were 98.3 120 93/65 22 92% 4L NC. Exam \nwas\nnotable only for tachycardia and TTP in the epigastrium. Labs\nwere notable for WBC of 8.0 without neutrophilia, Hgb 14.4\n(baseline ___, plts 549, MCV 81, BUN/Cr ___ (baseline Cr\n0.7-1.0), Ca ___ w/ Albumin 4.1, lipase WNL, LFTs WNL, K 7.1\n(grossly hemolyzed) -> 5.3 on recheck; Na 128 -> 131, Mg 1.5,\nTroponin negative x1, HCO3 17 -> 16 with anion gap of 15 -> 16,\npH 7.32 / pCO2 40, uHCG negative, UA with 30 protein, 1000\nglucose, and trace ketones. Serum glucose 435 -> 399, influenza\nPCR negative. CT A/p with cholelithiasis but no acute findings,\nCXR without evidence of pneumonia, EKG with RBBB seen previously\nbut no ST-segment or T-wave changes when compared with prior. \nBedside TTE in the ED was without evidence of R-heart strain. \nBlood and urine cultures were collected; the patient received 1L\nLR and 1L NS, as well as vancomycin 1g / pip/tazo, Insulin 16\nunits SubQ, bupropion, omeprazole, nebulizers and was admitted. \nVS prior to transfer were 110 136/56 16 100% RA (she was weaned\nrapidly to room air); FSBG prior to transfer was 260. \n\nOn arrival to the floor, the patient reported feeling much\nbetter, with the exception of feeling very hungry. Her chest\npain has resolved and currently she only has mild dizziness. \n\nROS: A 10-point review of systems was performed and was negative\nwith the exception of those systems noted in the HPI. \n\n \nPast Medical History:\nDEPRESSION \nDIABETES, TYPE II \nHYPERLIPIDEMIA \nOBESITY \nTHROMBOCYTOSIS \nPNEUMONIA \nASTHMA \nENDOMETRIOSIS \nGASTROESOPHAGEAL REFLUX \nH/O TOBACCO ABUSE \nH/O HEART MURMUR \n \nSocial History:\n___\nFamily History:\nBreast cancer in mother\n \nPhysical ___:\nADMISSION\nVITALS: 98.3 PO 100 / 70 119 16 98 RA \nGENERAL: Alert and in no apparent distress, eating dinner\nEYES: Anicteric, pupils equally round\nENT: Ears and nose without visible erythema, masses, or trauma. \nOropharynx without visible lesion, erythema or exudate\nCV: Heart regular, no murmur, no S3, no S4. No JVD.\nRESP: Lungs clear to auscultation with good air movement\nbilaterally. Breathing is non-labored\nGI: Abdomen soft, non-distended, non-tender to palpation. Bowel\nsounds present\nGU: No suprapubic fullness or tenderness to palpation\nMSK: Neck supple, moves all extremities, strength grossly full\nand symmetric bilaterally in all limbs\nSKIN: No rashes or ulcerations noted\nNEURO: Alert, oriented, face symmetric, gaze conjugate with \nEOMI,\nspeech fluent, moves all limbs, sensation to light touch grossly\nintact throughout\nPSYCH: pleasant, appropriate affect\n\nDISCHARGE\n97.9 PO 108 / 70 R Lying 96 20 98 Ra \nGENERAL: Alert and in no apparent distress, eating dinner\nEYES: Anicteric, pupils equally round\nENT: Ears and nose without visible erythema, masses, or trauma. \nOropharynx without visible lesion, erythema or exudate\nCV: Heart regular, no murmur, no S3, no S4. No JVD.\nRESP: Lungs clear to auscultation with good air movement\nbilaterally. Breathing is non-labored\nGI: Abdomen soft, non-distended, non-tender to palpation. Bowel\nsounds present\nGU: No suprapubic fullness or tenderness to palpation\nMSK: Neck supple, moves all extremities, strength grossly full\nand symmetric bilaterally in all limbs\nSKIN: No rashes or ulcerations noted\nNEURO: Alert, oriented, face symmetric, gaze conjugate with \nEOMI,\nspeech fluent, moves all limbs, sensation to light touch grossly\nintact throughout\nPSYCH: pleasant, appropriate affect\n \nPertinent Results:\nADMISSION\n\n___ 05:40AM BLOOD WBC-8.0 RBC-5.50* Hgb-14.4 Hct-44.4 \nMCV-81* MCH-26.2 MCHC-32.4 RDW-13.7 RDWSD-39.8 Plt ___\n___ 05:40AM BLOOD Neuts-64.2 ___ Monos-2.8* \nEos-0.1* Baso-0.1 Im ___ AbsNeut-5.14 AbsLymp-2.59 \nAbsMono-0.22 AbsEos-0.01* AbsBaso-0.01\n___ 05:40AM BLOOD Glucose-435* UreaN-12 Creat-1.2* Na-128* \nK-7.1* Cl-96 HCO3-17* AnGap-15\n___ 05:40AM BLOOD ALT-11 AST-29 CK(CPK)-122 AlkPhos-92 \nTotBili-0.3\n___ 05:40AM BLOOD CK-MB-1 proBNP-69\n___ 05:40AM BLOOD cTropnT-<0.01\n___ 07:10AM BLOOD cTropnT-<0.01 proBNP-15\n___ 05:40AM BLOOD Albumin-4.1 Calcium-10.4* Phos-3.6 Mg-1.8\n___ 05:47AM BLOOD %HbA1c-7.9* eAG-180*\n___ 06:37AM BLOOD ___ pO2-46* pCO2-40 pH-7.32* \ncalTCO2-22 Base XS--5\n___ 06:37AM BLOOD K-5.3*\n\nDISCHARGE\n\n___ 05:47AM BLOOD WBC-6.7 RBC-4.02 Hgb-10.2* Hct-32.9* \nMCV-82 MCH-25.4* MCHC-31.0* RDW-14.0 RDWSD-41.4 Plt ___\n___ 05:47AM BLOOD Glucose-171* UreaN-10 Creat-0.8 Na-139 \nK-4.5 Cl-104 HCO3-25 AnGap-10\n___ 05:47AM BLOOD ALT-8 AST-10 LD(LDH)-166 AlkPhos-73 \nTotBili-0.2\n___ 07:10AM BLOOD cTropnT-<0.01 proBNP-15\n___ 05:47AM BLOOD Calcium-9.2 Phos-3.3 Mg-1.9\n___ 05:47AM BLOOD %HbA1c-7.9* eAG-180*\n\nIMAGING\nCXR ___\nNo acute findings\n\nCT abd/pel w/ pelvis ___\n1. No acute findings in the abdomen or pelvis. \n2. Cholelithiasis. \n\n \nBrief Hospital Course:\n# Hyperglycemia\n# Metabolic acidosis with ketonuria\nThe patient's presentation with hyperglycemia most likely \nreflects poorly controlled DM2, +/- mild starvation \nketoacidosis, rather than frank DKA or HHS. While the patient \ndoes have evidence of hyperosmolarity (evinced by her mild \nhyponatremia),\nher anion gap is not markedly elevated, and as she is volume \ndepleted and has not eaten since the day before admission, \nstarvation ketoacidosis seems like a more likely explanation \nthan DKA/HHS in a patient not previously on insulin. \nInterestingly HA1C is 7.9 (7.8 ___, however, so she doesn't \nseem to be significantly poorly controlled or significantly more \nso than prior. ___ was consulted and she initially received \n10U qHS overnight, but given her A1C, will discharge on home \nmetformin and glipizide (in exchange for home glyburide for \nlower hypoglycemic risk.) She was seen for diabetic education \nprior to discharge.\n\n# Hyperkalemia\nRelatively mild, likely reflects relative insulin deficiency. No \nEKG changes. 4.5 on discharge.\n\n# Chest pressure\n# Diarrhea, nausea, vomiting\n# Diffuse pruritis\nThe patient has no changes from prior on her EKG and now had 2 \nnegative troponins. Her symptoms had completed resolved by the \nmorning after admission. She most recently had a stress test \nperformed 6 months ago which showed no evidence of inducible \nischemia and no wall motion abnormalities on echo. The \nsignificance of her symptoms is unclear but seem less likely to \nbe due to ischemia. Symptomatic hypoglycemia is one possibility \n(and her hyperglycemia on presentation was rebound), though \nunusual to have pruritus with it. Stress/panic attack also \nconsidered although again the pruritis seems unusual. It's also \npossible that she has some allergen in her environment that she \nis unaware of, which was also considered in her last admission \nwith a similar presentation. Given this is the second \npresentation, allergy follow up was scheduled for her on \ndischarged. Continued home statin and ASA.\n\n# Sinus tachycardia, resolved\n# Acute hypoxemic respiratory failure, resolved\nEtiology of her tachycardia is unclear, but multiple possible \ncontributors including hypovolemia and pain. Acute PE is \nunlikely given rapid resolution of hypoxemia. Aspiration event \nfrom vomiting seems most likely. Further, she has had multiple\ninstances of tachycardia from the 100-130s documented as an \noutpatient, so this may be a chronic abnormality for her. She \nwas stable with normal vital signs the day after admission.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. BuPROPion 200 mg PO BID \n2. Omeprazole 20 mg PO BID \n3. GlyBURIDE 5 mg PO DAILY \n4. MetFORMIN XR (Glucophage XR) 1000 mg PO BID \n5. Aspirin 81 mg PO DAILY \n6. Rosuvastatin Calcium 5 mg PO QPM \n\n \nDischarge Medications:\n1. GlipiZIDE XL 5 mg PO DAILY \nRX *glipizide 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*4 \n2. Aspirin 81 mg PO DAILY \n3. BuPROPion 200 mg PO BID \n4. MetFORMIN XR (Glucophage XR) 1000 mg PO BID \nDo Not Crush \n5. Omeprazole 20 mg PO BID \n6. Rosuvastatin Calcium 5 mg PO QPM \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nChest tightness \nShortness of breath\nDiabetes mellitus\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\nYou were admitted to the hospital with chest tightness, \ndifficulty breathing and itchiness. We found that fortunately \nyou were not having heart problems to account for these \nsymptoms. It is still not entirely clear what caused them, but \nit may be due in part to hypoglycemia, stress/anxiety, and/or \nyet-unidentified allergens in your environment. An allergy \nappointment has been scheduled for you to help evaluate for any \npotential allergies.\n\nFor your diabetes management, we changed glyburide to glipizide \nto try to reduce hypoglycemic episodes. Please make sure to not \ngo too long without eating at least a snack so as to avoid the \nblood sugar going too low too.\n\nIt was a pleasure taking care of you!\n\nSincerely,\nYour ___ team\n \nFollowup Instructions:\n___\n"
] | Allergies: Erythromycin Base Chief Complaint: chest pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] female with a PMH of obesity, past smoking, DM2 (not on insulin), asthma, depression, GERD and other issues who presented to the ED with chest pain. She reports that her symptoms were overall very similar to an episode she experienced in [MASKED]. She was in her usual state of health but began feeling nauseated yesterday evening; she did not eat dinner due to this. She also felt diffusely itchy and took a dose of children's Benadryl, which helped with the itch and helped her go to sleep; however, she awoke around 3 am with nausea/vomiting, several episodes of watery diarrhea, and chest pressure that she described as central and feeling like someone was sitting on her chest. She has not had fever, chills, abdominal pain, dysuria, weakness, or any other issues recently prior to this. In the ED, initial VS were 98.3 120 93/65 22 92% 4L NC. Exam was notable only for tachycardia and TTP in the epigastrium. Labs were notable for WBC of 8.0 without neutrophilia, Hgb 14.4 (baseline [MASKED], plts 549, MCV 81, BUN/Cr [MASKED] (baseline Cr 0.7-1.0), Ca [MASKED] w/ Albumin 4.1, lipase WNL, LFTs WNL, K 7.1 (grossly hemolyzed) -> 5.3 on recheck; Na 128 -> 131, Mg 1.5, Troponin negative x1, HCO3 17 -> 16 with anion gap of 15 -> 16, pH 7.32 / pCO2 40, uHCG negative, UA with 30 protein, 1000 glucose, and trace ketones. Serum glucose 435 -> 399, influenza PCR negative. CT A/p with cholelithiasis but no acute findings, CXR without evidence of pneumonia, EKG with RBBB seen previously but no ST-segment or T-wave changes when compared with prior. Bedside TTE in the ED was without evidence of R-heart strain. Blood and urine cultures were collected; the patient received 1L LR and 1L NS, as well as vancomycin 1g / pip/tazo, Insulin 16 units SubQ, bupropion, omeprazole, nebulizers and was admitted. VS prior to transfer were 110 136/56 16 100% RA (she was weaned rapidly to room air); FSBG prior to transfer was 260. On arrival to the floor, the patient reported feeling much better, with the exception of feeling very hungry. Her chest pain has resolved and currently she only has mild dizziness. ROS: A 10-point review of systems was performed and was negative with the exception of those systems noted in the HPI. Past Medical History: DEPRESSION DIABETES, TYPE II HYPERLIPIDEMIA OBESITY THROMBOCYTOSIS PNEUMONIA ASTHMA ENDOMETRIOSIS GASTROESOPHAGEAL REFLUX H/O TOBACCO ABUSE H/O HEART MURMUR Social History: [MASKED] Family History: Breast cancer in mother Physical [MASKED]: ADMISSION VITALS: 98.3 PO 100 / 70 119 16 98 RA GENERAL: Alert and in no apparent distress, eating dinner EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: pleasant, appropriate affect DISCHARGE 97.9 PO 108 / 70 R Lying 96 20 98 Ra GENERAL: Alert and in no apparent distress, eating dinner EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: pleasant, appropriate affect Pertinent Results: ADMISSION [MASKED] 05:40AM BLOOD WBC-8.0 RBC-5.50* Hgb-14.4 Hct-44.4 MCV-81* MCH-26.2 MCHC-32.4 RDW-13.7 RDWSD-39.8 Plt [MASKED] [MASKED] 05:40AM BLOOD Neuts-64.2 [MASKED] Monos-2.8* Eos-0.1* Baso-0.1 Im [MASKED] AbsNeut-5.14 AbsLymp-2.59 AbsMono-0.22 AbsEos-0.01* AbsBaso-0.01 [MASKED] 05:40AM BLOOD Glucose-435* UreaN-12 Creat-1.2* Na-128* K-7.1* Cl-96 HCO3-17* AnGap-15 [MASKED] 05:40AM BLOOD ALT-11 AST-29 CK(CPK)-122 AlkPhos-92 TotBili-0.3 [MASKED] 05:40AM BLOOD CK-MB-1 proBNP-69 [MASKED] 05:40AM BLOOD cTropnT-<0.01 [MASKED] 07:10AM BLOOD cTropnT-<0.01 proBNP-15 [MASKED] 05:40AM BLOOD Albumin-4.1 Calcium-10.4* Phos-3.6 Mg-1.8 [MASKED] 05:47AM BLOOD %HbA1c-7.9* eAG-180* [MASKED] 06:37AM BLOOD [MASKED] pO2-46* pCO2-40 pH-7.32* calTCO2-22 Base XS--5 [MASKED] 06:37AM BLOOD K-5.3* DISCHARGE [MASKED] 05:47AM BLOOD WBC-6.7 RBC-4.02 Hgb-10.2* Hct-32.9* MCV-82 MCH-25.4* MCHC-31.0* RDW-14.0 RDWSD-41.4 Plt [MASKED] [MASKED] 05:47AM BLOOD Glucose-171* UreaN-10 Creat-0.8 Na-139 K-4.5 Cl-104 HCO3-25 AnGap-10 [MASKED] 05:47AM BLOOD ALT-8 AST-10 LD(LDH)-166 AlkPhos-73 TotBili-0.2 [MASKED] 07:10AM BLOOD cTropnT-<0.01 proBNP-15 [MASKED] 05:47AM BLOOD Calcium-9.2 Phos-3.3 Mg-1.9 [MASKED] 05:47AM BLOOD %HbA1c-7.9* eAG-180* IMAGING CXR [MASKED] No acute findings CT abd/pel w/ pelvis [MASKED] 1. No acute findings in the abdomen or pelvis. 2. Cholelithiasis. Brief Hospital Course: # Hyperglycemia # Metabolic acidosis with ketonuria The patient's presentation with hyperglycemia most likely reflects poorly controlled DM2, +/- mild starvation ketoacidosis, rather than frank DKA or HHS. While the patient does have evidence of hyperosmolarity (evinced by her mild hyponatremia), her anion gap is not markedly elevated, and as she is volume depleted and has not eaten since the day before admission, starvation ketoacidosis seems like a more likely explanation than DKA/HHS in a patient not previously on insulin. Interestingly HA1C is 7.9 (7.8 [MASKED], however, so she doesn't seem to be significantly poorly controlled or significantly more so than prior. [MASKED] was consulted and she initially received 10U qHS overnight, but given her A1C, will discharge on home metformin and glipizide (in exchange for home glyburide for lower hypoglycemic risk.) She was seen for diabetic education prior to discharge. # Hyperkalemia Relatively mild, likely reflects relative insulin deficiency. No EKG changes. 4.5 on discharge. # Chest pressure # Diarrhea, nausea, vomiting # Diffuse pruritis The patient has no changes from prior on her EKG and now had 2 negative troponins. Her symptoms had completed resolved by the morning after admission. She most recently had a stress test performed 6 months ago which showed no evidence of inducible ischemia and no wall motion abnormalities on echo. The significance of her symptoms is unclear but seem less likely to be due to ischemia. Symptomatic hypoglycemia is one possibility (and her hyperglycemia on presentation was rebound), though unusual to have pruritus with it. Stress/panic attack also considered although again the pruritis seems unusual. It's also possible that she has some allergen in her environment that she is unaware of, which was also considered in her last admission with a similar presentation. Given this is the second presentation, allergy follow up was scheduled for her on discharged. Continued home statin and ASA. # Sinus tachycardia, resolved # Acute hypoxemic respiratory failure, resolved Etiology of her tachycardia is unclear, but multiple possible contributors including hypovolemia and pain. Acute PE is unlikely given rapid resolution of hypoxemia. Aspiration event from vomiting seems most likely. Further, she has had multiple instances of tachycardia from the 100-130s documented as an outpatient, so this may be a chronic abnormality for her. She was stable with normal vital signs the day after admission. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. BuPROPion 200 mg PO BID 2. Omeprazole 20 mg PO BID 3. GlyBURIDE 5 mg PO DAILY 4. MetFORMIN XR (Glucophage XR) 1000 mg PO BID 5. Aspirin 81 mg PO DAILY 6. Rosuvastatin Calcium 5 mg PO QPM Discharge Medications: 1. GlipiZIDE XL 5 mg PO DAILY RX *glipizide 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*4 2. Aspirin 81 mg PO DAILY 3. BuPROPion 200 mg PO BID 4. MetFORMIN XR (Glucophage XR) 1000 mg PO BID Do Not Crush 5. Omeprazole 20 mg PO BID 6. Rosuvastatin Calcium 5 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: Chest tightness Shortness of breath Diabetes mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You were admitted to the hospital with chest tightness, difficulty breathing and itchiness. We found that fortunately you were not having heart problems to account for these symptoms. It is still not entirely clear what caused them, but it may be due in part to hypoglycemia, stress/anxiety, and/or yet-unidentified allergens in your environment. An allergy appointment has been scheduled for you to help evaluate for any potential allergies. For your diabetes management, we changed glyburide to glipizide to try to reduce hypoglycemic episodes. Please make sure to not go too long without eating at least a snack so as to avoid the blood sugar going too low too. It was a pleasure taking care of you! Sincerely, Your [MASKED] team Followup Instructions: [MASKED] | [
"R079",
"E1165",
"E872",
"R824",
"L299",
"R0902",
"R0602",
"J45909",
"E785",
"R42",
"R531",
"K529",
"R197",
"R112",
"E7800",
"E875",
"R000",
"F329",
"E669",
"Z6841",
"Z87891",
"K219",
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"Z803"
] | [
"R079: Chest pain, unspecified",
"E1165: Type 2 diabetes mellitus with hyperglycemia",
"E872: Acidosis",
"R824: Acetonuria",
"L299: Pruritus, unspecified",
"R0902: Hypoxemia",
"R0602: Shortness of breath",
"J45909: Unspecified asthma, uncomplicated",
"E785: Hyperlipidemia, unspecified",
"R42: Dizziness and giddiness",
"R531: Weakness",
"K529: Noninfective gastroenteritis and colitis, unspecified",
"R197: Diarrhea, unspecified",
"R112: Nausea with vomiting, unspecified",
"E7800: Pure hypercholesterolemia, unspecified",
"E875: Hyperkalemia",
"R000: Tachycardia, unspecified",
"F329: Major depressive disorder, single episode, unspecified",
"E669: Obesity, unspecified",
"Z6841: Body mass index [BMI]40.0-44.9, adult",
"Z87891: Personal history of nicotine dependence",
"K219: Gastro-esophageal reflux disease without esophagitis",
"D473: Essential (hemorrhagic) thrombocythemia",
"N809: Endometriosis, unspecified",
"Z803: Family history of malignant neoplasm of breast"
] | [
"E1165",
"E872",
"J45909",
"E785",
"F329",
"E669",
"Z87891",
"K219"
] | [] |
11,058,554 | 28,818,695 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: OTOLARYNGOLOGY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nfloor of mouth cancer\n \nMajor Surgical or Invasive Procedure:\ns/p composite resection of floor of mouth, bilateral neck\ndissection, tracheotomy, posterior leg (med sural artery) \nreconstruction\n\n \nHistory of Present Illness:\nPatient reports blister under tongue since ___. + \ndysphagia, no odynophagia, no lumps in neck, no bleeding, no \nvoice change.\n___- biopsy oral mucosa, left floor of mouth lesion: \ninvasive\nsquamous cell carcinoma, P16 immunostains are negative.\n___- CT neck: No abnormal enhancement, mass or\nlymphadenopathy.\n___- CT chest: Small pulmonary nodules, undetermined. \nAttention on follow-up. No suspicious lymphadenopathy or osseous \nlesions. Moderate cardiomegaly with enlarged left atrium and \nventricle. Mild pulmonary emphysema and bronchial inflammation \nwhich are smoking related changes. \n \nPast Medical History:\nhypertension, cirrhosis, chronic hepatitis B\n \nSocial History:\n___\nFamily History:\nNoncontributory \n \nPhysical Exam:\nGEN: No acute distress\nResp: Unlabored breathing\n___: Hemodynamically stable\nHEENT: Intraoral flap with good color and turgor, Doppler \nbiphasic. Neck incisions clean, dry and intact.\nExt: Leg dressing clean, dry and intact.\nNeuro: Alert and oriented\n\n \nPertinent Results:\n___ 06:10AM BLOOD WBC-8.3 RBC-4.43* Hgb-8.8* Hct-28.7* \nMCV-65* MCH-19.9* MCHC-30.7* RDW-16.1* RDWSD-36.0 Plt ___\n___ 10:17AM BLOOD WBC-8.7 RBC-4.35* Hgb-8.7* Hct-27.9* \nMCV-64* MCH-20.0* MCHC-31.2* RDW-15.9* RDWSD-35.8 Plt ___\n___ 01:42PM BLOOD WBC-7.4 RBC-4.35* Hgb-8.7* Hct-28.0* \nMCV-64* MCH-20.0* MCHC-31.1* RDW-15.9* RDWSD-35.8 Plt ___\n___ 06:10AM BLOOD Plt Smr-NORMAL Plt ___\n___ 10:17AM BLOOD Plt ___\n___ 01:42PM BLOOD Plt ___\n___ 06:10AM BLOOD Glucose-135* UreaN-11 Creat-0.7 Na-141 \nK-4.4 Cl-105 HCO3-23 AnGap-13\n___ 10:17AM BLOOD Glucose-106* UreaN-13 Creat-0.8 Na-144 \nK-4.7 Cl-106 HCO3-28 AnGap-10\n___ 01:42PM BLOOD Glucose-203* UreaN-13 Creat-0.8 Na-143 \nK-4.4 Cl-106 HCO3-26 AnGap-11\n___ 06:10AM BLOOD Calcium-8.8 Phos-3.5 Mg-1.8\n___ 10:17AM BLOOD Albumin-3.6 Calcium-8.7\n___ 01:42PM BLOOD Calcium-8.3* Phos-2.1* Mg-1.9\n \nBrief Hospital Course:\nThe patient was admitted to the Otolaryngology-Head and Neck \nSurgery Service after composite resection of floor of mouth, \nbilateral neck dissection, tracheotomy, and posterior leg (med \nsural artery) reconstruction buy plastic surgery. Please see the \nseparately dictated operative note for details of procedure. \nThere were no significant intraoperative complications. \nPost-operatively, patient underwent an ___ hospital \ncourse.\n\nENT: The patient had a composite floor of mouth tumor resection \nwith posterior leg free flap for reconstruction. Patient \nunderwent 72 hours of Q1Hr flap checks in the ICU, his Doppler \npulse remained robust throughout. Neck drains were sequentially \ndiscontinued once they met drain criteria. Patients trach was \ndownsized to a Portex 6 cuffless on POD#5. Patient subsequently \nunderwent a capping trial that the patient tolerated and was \ntherefore decannulated. \n\nNeuro: Patient received parenteral and then enteral narcotics as \nneeded for pain control via his NG tube. The patient was at \nbaseline neurologic status. Patient is to continue his pain \nregimen and wean narcotics as tolerated. \n\nCV: Patient was on home medications throughout the hospital \nstay. Vitals were monitored while the patient was hospitalized. \nPatient's vitals were within normal limits on discharge. \n\nPulm: Patient was breathing comfortably on RA at the time of \ndischarge.\n\nGI: Patient was NPO postoperatively and received all medications \nand nutrition through NG tube. Patient had a swallow study \npostoperatively on *****. Patient was subsequently started on \n***** diet. Pt tolerated PO intake well and NGT was therefore \ndiscontinued. \n\nRenal/GU: Patient was on IVF as needed with electrolytes \nrepleted prn. \n\nHeme: Pt was on ___ and compression boots for DVT prophylaxis. \nPatient is to continue ASA 325mg QD for the free flap.\n\nID: The patient was on perioperative antibiotics and remained \nafebrile otherwise. \n\nEndocrine: The patients blood glucose was checked and was well \ncontrolled throughout the hospital stay.\n\nPhysical therapy: Patient was seen by physical therapy who \nrecommend continued ___, including arm exercises for the donor \narm site.\n\nOverall the patient had an uneventful recovery and is being \ndischarged to home in stable condition.\n\nAt time of discharge, the patient was in stable condition, \nambulating and voiding independently, and with adequate pain \ncontrol. The patient was given instructions to follow-up in \nclinic as scheduled. Patient was given detailed discharge \ninstructions outlining wound care, activity, diet, follow-up and \nthe appropriate medication scripts.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Metoprolol Succinate XL 25 mg PO DAILY \n2. Tenofovir Disoproxil (Viread) 300 mg PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nT2N0M0 squamous cell carcinoma left floor of mouth \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDivision of Otolaryngology Head and Neck Surgery\nPost-Operative Instructions \nFree Tissue Transplant\n\nACTIVITY\nGo home and rest today.\nYou need to avoid strenuous activity for 2 weeks\nDo NOT lift any weight greater than 10 lbs for 2 weeks.\nMake sure you exercise your shoulders and arms gently to keep \nthem from getting stiff\nIt is important for you to walk to improve any swelling in \nyour legs.\n\nFLUIDS & DIET\nStart with liquids and, if tolerated, you can eat normal \nfoods.\n\nMEDICATIONS\nTake pain medication as prescribed.\nResume other medications as prescribed except any aspirin or \naspirin containing products unless cleared by your surgeon.\n\nCARE OF PROCEDURE SITE\nSome swelling of the neck incision and graft donor site is \nexpected.\nYou may note some bloody looking drainage from the region \nwhere the plastic drain was removed for up to 5 days.\nApply antibiotic ointment to your incisions twice a day for 7 \ndays after surgery, then use Vaseline only.\nKeep incision dry for 7 days from date of surgery. You may be \nable to take a bath from your shoulders down as long as the \nincision stays dry.\nIf there are any crusts/clots on your wound you may gently \nclean them with a Q-tip and Half strength hydrogen peroxide \n(10cc water + 10cc peroxide) as needed. Do not be too vigorous \nor your stitches or staples may break\nThe staples/stitches will be removed on your first \npost-operative visit (usually in ___ days).\nIf a skin graft was taken from your thigh then there is a \ndressing over this that will fall off over the next few weeks. \nJust trim the edges as it separates from your skin. If it is \nitchy then apply a liberal coating of Vaseline twice a day over \nthis site\nIf a graft was taken from your arm or leg then cover this site \nwith Vaseline twice a day and apply a clean gauze dressing over \nit. \nWHEN TO CALL YOUR DOCTOR\nExcessive redness of your incision site\nFever greater than 101 degrees Fahrenheit\nSudden excessive swelling of incision site\n\nFor questions or problems, please call ___ to speak \nto the clinic nurse during clinic hours.\n\nAfter hours, or on weekends, dial ___ and ask the \noperator to page the Otolaryngology resident on-call.\n \nFollowup Instructions:\n___\n"
] | Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: floor of mouth cancer Major Surgical or Invasive Procedure: s/p composite resection of floor of mouth, bilateral neck dissection, tracheotomy, posterior leg (med sural artery) reconstruction History of Present Illness: Patient reports blister under tongue since [MASKED]. + dysphagia, no odynophagia, no lumps in neck, no bleeding, no voice change. [MASKED]- biopsy oral mucosa, left floor of mouth lesion: invasive squamous cell carcinoma, P16 immunostains are negative. [MASKED]- CT neck: No abnormal enhancement, mass or lymphadenopathy. [MASKED]- CT chest: Small pulmonary nodules, undetermined. Attention on follow-up. No suspicious lymphadenopathy or osseous lesions. Moderate cardiomegaly with enlarged left atrium and ventricle. Mild pulmonary emphysema and bronchial inflammation which are smoking related changes. Past Medical History: hypertension, cirrhosis, chronic hepatitis B Social History: [MASKED] Family History: Noncontributory Physical Exam: GEN: No acute distress Resp: Unlabored breathing [MASKED]: Hemodynamically stable HEENT: Intraoral flap with good color and turgor, Doppler biphasic. Neck incisions clean, dry and intact. Ext: Leg dressing clean, dry and intact. Neuro: Alert and oriented Pertinent Results: [MASKED] 06:10AM BLOOD WBC-8.3 RBC-4.43* Hgb-8.8* Hct-28.7* MCV-65* MCH-19.9* MCHC-30.7* RDW-16.1* RDWSD-36.0 Plt [MASKED] [MASKED] 10:17AM BLOOD WBC-8.7 RBC-4.35* Hgb-8.7* Hct-27.9* MCV-64* MCH-20.0* MCHC-31.2* RDW-15.9* RDWSD-35.8 Plt [MASKED] [MASKED] 01:42PM BLOOD WBC-7.4 RBC-4.35* Hgb-8.7* Hct-28.0* MCV-64* MCH-20.0* MCHC-31.1* RDW-15.9* RDWSD-35.8 Plt [MASKED] [MASKED] 06:10AM BLOOD Plt Smr-NORMAL Plt [MASKED] [MASKED] 10:17AM BLOOD Plt [MASKED] [MASKED] 01:42PM BLOOD Plt [MASKED] [MASKED] 06:10AM BLOOD Glucose-135* UreaN-11 Creat-0.7 Na-141 K-4.4 Cl-105 HCO3-23 AnGap-13 [MASKED] 10:17AM BLOOD Glucose-106* UreaN-13 Creat-0.8 Na-144 K-4.7 Cl-106 HCO3-28 AnGap-10 [MASKED] 01:42PM BLOOD Glucose-203* UreaN-13 Creat-0.8 Na-143 K-4.4 Cl-106 HCO3-26 AnGap-11 [MASKED] 06:10AM BLOOD Calcium-8.8 Phos-3.5 Mg-1.8 [MASKED] 10:17AM BLOOD Albumin-3.6 Calcium-8.7 [MASKED] 01:42PM BLOOD Calcium-8.3* Phos-2.1* Mg-1.9 Brief Hospital Course: The patient was admitted to the Otolaryngology-Head and Neck Surgery Service after composite resection of floor of mouth, bilateral neck dissection, tracheotomy, and posterior leg (med sural artery) reconstruction buy plastic surgery. Please see the separately dictated operative note for details of procedure. There were no significant intraoperative complications. Post-operatively, patient underwent an [MASKED] hospital course. ENT: The patient had a composite floor of mouth tumor resection with posterior leg free flap for reconstruction. Patient underwent 72 hours of Q1Hr flap checks in the ICU, his Doppler pulse remained robust throughout. Neck drains were sequentially discontinued once they met drain criteria. Patients trach was downsized to a Portex 6 cuffless on POD#5. Patient subsequently underwent a capping trial that the patient tolerated and was therefore decannulated. Neuro: Patient received parenteral and then enteral narcotics as needed for pain control via his NG tube. The patient was at baseline neurologic status. Patient is to continue his pain regimen and wean narcotics as tolerated. CV: Patient was on home medications throughout the hospital stay. Vitals were monitored while the patient was hospitalized. Patient's vitals were within normal limits on discharge. Pulm: Patient was breathing comfortably on RA at the time of discharge. GI: Patient was NPO postoperatively and received all medications and nutrition through NG tube. Patient had a swallow study postoperatively on *****. Patient was subsequently started on ***** diet. Pt tolerated PO intake well and NGT was therefore discontinued. Renal/GU: Patient was on IVF as needed with electrolytes repleted prn. Heme: Pt was on [MASKED] and compression boots for DVT prophylaxis. Patient is to continue ASA 325mg QD for the free flap. ID: The patient was on perioperative antibiotics and remained afebrile otherwise. Endocrine: The patients blood glucose was checked and was well controlled throughout the hospital stay. Physical therapy: Patient was seen by physical therapy who recommend continued [MASKED], including arm exercises for the donor arm site. Overall the patient had an uneventful recovery and is being discharged to home in stable condition. At time of discharge, the patient was in stable condition, ambulating and voiding independently, and with adequate pain control. The patient was given instructions to follow-up in clinic as scheduled. Patient was given detailed discharge instructions outlining wound care, activity, diet, follow-up and the appropriate medication scripts. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 25 mg PO DAILY 2. Tenofovir Disoproxil (Viread) 300 mg PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: T2N0M0 squamous cell carcinoma left floor of mouth Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Division of Otolaryngology Head and Neck Surgery Post-Operative Instructions Free Tissue Transplant ACTIVITY Go home and rest today. You need to avoid strenuous activity for 2 weeks Do NOT lift any weight greater than 10 lbs for 2 weeks. Make sure you exercise your shoulders and arms gently to keep them from getting stiff It is important for you to walk to improve any swelling in your legs. FLUIDS & DIET Start with liquids and, if tolerated, you can eat normal foods. MEDICATIONS Take pain medication as prescribed. Resume other medications as prescribed except any aspirin or aspirin containing products unless cleared by your surgeon. CARE OF PROCEDURE SITE Some swelling of the neck incision and graft donor site is expected. You may note some bloody looking drainage from the region where the plastic drain was removed for up to 5 days. Apply antibiotic ointment to your incisions twice a day for 7 days after surgery, then use Vaseline only. Keep incision dry for 7 days from date of surgery. You may be able to take a bath from your shoulders down as long as the incision stays dry. If there are any crusts/clots on your wound you may gently clean them with a Q-tip and Half strength hydrogen peroxide (10cc water + 10cc peroxide) as needed. Do not be too vigorous or your stitches or staples may break The staples/stitches will be removed on your first post-operative visit (usually in [MASKED] days). If a skin graft was taken from your thigh then there is a dressing over this that will fall off over the next few weeks. Just trim the edges as it separates from your skin. If it is itchy then apply a liberal coating of Vaseline twice a day over this site If a graft was taken from your arm or leg then cover this site with Vaseline twice a day and apply a clean gauze dressing over it. WHEN TO CALL YOUR DOCTOR Excessive redness of your incision site Fever greater than 101 degrees Fahrenheit Sudden excessive swelling of incision site For questions or problems, please call [MASKED] to speak to the clinic nurse during clinic hours. After hours, or on weekends, dial [MASKED] and ask the operator to page the Otolaryngology resident on-call. Followup Instructions: [MASKED] | [
"C048",
"C7989",
"B181",
"I10",
"K7460",
"R1319",
"R339",
"Z87891"
] | [
"C048: Malignant neoplasm of overlapping sites of floor of mouth",
"C7989: Secondary malignant neoplasm of other specified sites",
"B181: Chronic viral hepatitis B without delta-agent",
"I10: Essential (primary) hypertension",
"K7460: Unspecified cirrhosis of liver",
"R1319: Other dysphagia",
"R339: Retention of urine, unspecified",
"Z87891: Personal history of nicotine dependence"
] | [
"I10",
"Z87891"
] | [] |
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