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10013600-DS-16	10,013,600	20,207,755	DS	16	2172-08-18 00:00:00	2172-08-18 18:40:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Penicillins Attending: ___. Chief Complaint: abd pain, nausea Major Surgical or Invasive Procedure: None History of Present Illness: ___ w/ hx of Afib, CVA on coumadin, prior SBO s/p ex-lap w/ LOA ___ who now p/w abd pain, with questionable partial SBO, passing flatus & loose stools Past Medical History: High Cholesterol Stroke afib on Coumadin CHF Past Surgical History: ___'s lateral R ankle ___ Ex-lap, LOA ___ (___) Cecal polyp removal C-section x2 Family History: non contributory Physical Exam: Vitals: 24 HR Data (last updated ___ @ 021) Temp: 97.5 (Tm 98.5), BP: 118/52 (118-160/52-70), HR: 48 (48-59), RR: 16, O2 sat: 96% (93-96), O2 delivery: RA Fluid Balance (last updated ___ @ 2143) Last 8 hours Total cumulative 124ml IN: Total 124ml, IV Amt Infused 124ml OUT: Total 0ml, Urine Amt 0ml Last 24 hours Total cumulative 124ml IN: Total 124ml, IV Amt Infused 124ml OUT: Total 0ml, Urine Amt 0ml Physical exam: Gen: NAD, AxOx3 Card: RRR, no m/r/g Pulm: no respiratory distress Abd: Soft, non tender, non-distended Ext: No edema, warm well-perfused Pertinent Results: EXAMINATION: CT ABD AND PELVIS WITH CONTRAST FINDINGS: LOWER CHEST: Visualized lung fields are within normal limits. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: Mild cortical thinning bilaterally. Small cortical hypodensities bilaterally are too small to characterize. Otherwise, the kidneys are of normal and symmetric size with normal nephrogram. There is no evidence of focal renal lesions or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: There is a small hiatal hernia. The stomach distended with air and fluid. The duodenum and proximal jejunum are normal in caliber. There is circumferential wall thickening involving a segment of jejunum in the left upper quadrant (series 601, image 39). There are several loops of mildly dilated small bowel with suspected transition points in the left mid abdomen and pelvis (series 2, image 32/58). These loops are distal to the segment of jejunal thickening. There is fecalization in the terminal ileum but the distal bowel is otherwise normal in caliber. There is no pneumoperitoneum, or organized fluid collection. PELVIS: The urinary bladder and distal ureters are unremarkable. There is trace free fluid in the pelvis. REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease is noted. BONES: Multilevel degenerative changes of the lumbar spine with a similar appearance of the compression deformity involving the L2 vertebral body. There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Low-grade small-bowel obstruction with at least ___ssociated short segments of circumferential wall thickening. 2. No pneumoperitoneum or fluid collections. Brief Hospital Course: ___ w/ hx of Afib, CVA on coumadin, prior SBO s/p ex-lap w/ LOA ___ who now p/w abd pain. She was admitted to the ACS service following her CT scan which was concerning for partial small bowel obstruction. She was kept NPO with IV fluids overnight. She did well overnight on HD 1 and continued to pass flatus and have bowel movements. Her abdominal pain resolved and she was given a regular diet which was well tolerated. On the day of discharge the patient was tolerating a regular diet without nausea or emesis, she was passing flatus and having BMs. Her abdominal pain had resolved and she was not nauseated. She was ambulating at her baseline and was deemed medically appropriate for discharge home. She should follow up with her primary care physician and resume all home medications following her discharge from the hospital. Medications on Admission: Lasix 20 mg QD Coumadin (2 mg x 6x weekly, 1 mg 1x weekly) Alprazolam 0.25 mg TID:PRN Simvastatin 80mg Dorzolamide-Timolol eye drops BID Discharge Medications: 1. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID 2. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever 3. ALPRAZolam 0.25 mg PO TID 4. Aspirin 81 mg PO DAILY 5. Atenolol 25 mg PO DAILY 6. FoLIC Acid 1 mg PO DAILY 7. Furosemide 20 mg PO DAILY 8. Simvastatin 40 mg PO QPM 9. Vitamin D 1000 UNIT PO DAILY 10. vits A-C-E-B complx-min-lutein 5,000 unit- 120 mg-60 unit oral unknown 11. ___ MD to order daily dose PO DAILY16 Discharge Disposition: Home Discharge Diagnosis: Small Bowel Obstruction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to ___ evaluation of your abdominal pain and were diagnosed with a small bowel obstruction. You are recovering well and are now ready for discharge. Please follow the instructions below to continue your recovery: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: You experience new chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience a discharge. Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Followup Instructions: ___
10013643-DS-23	10,013,643	27,433,745	DS	23	2200-11-10 00:00:00	2200-11-12 11:44:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Niacin / Bextra / Tessalon / Fosamax / Hydromorphone / NSAIDS / ibuprofen / omeprazole / ranitidine Attending: ___. Chief Complaint: fever, anorexia, generalized weakness, acute on chronic R>L low back pain Major Surgical or Invasive Procedure: none History of Present Illness: ___ h/o vascular dementia, recent admissions ___ for fevers and CP felt to be from PNA and before that an admission in ___ for TAVR c/b heart block requiring pacemaker, presents with fevers and right flank pain. Per report fever up to 101.9 last night. Pain started this morning and described as sharp and radiating to the right upper and lower abdomen and reminds her of the pain she felt during her recent admission for PNA. She took 2 percocet this morning with some relief. Denies HA, myalgias, CP, SOB, cough, nausea, diarrhea or dysuria. She has recently been treated for PNA. She was admited ___ for chest pain and fevers which was felt to be from PNA. She was treated with levofloxacin for 5 days She was also admitted ___ for TAVR c/b complete heart block requiring pacemaker placement and hypotension from femoral bleed after pulling the catheter sheath for which he required blood transfusions. There was also concern pt had acalculous cholecystitis given CT torso from ___ showing significant gallbladder distention, pericholecystic fluid, and adjacent fat stranding, concerning for acute cholecystitis. Pt was not treated with antibiotics and no intervention was done. In addition she developed C dif and was treated with flagyl In the ED, initial vitals: 100.0 76 122/105 20 100% exam: RUQ and RLQ tenderness without rebound or guarding Labs notable for: wbc 13 Ht 33 plat 592, lactate 2.2 LFTs wnl Imaging: CTU (prelim read) showed mildly distended gallbladder without fat stranding improved from prior imaging. CXR Patient was given 1 L NS, levoflox, and her home medications Vitals prior to transfer:98.2 83 122/57 18 98% RA Collateral per husband, ___: ___ appetite and generalized weakness for the last month since her procedure. Also she has had pain in R lower back for the past few days. She has chronic aches and pains in her lower back that she takes percocets for, this pain is similar, not cause has been found. He spoke with PCP ___ after he noted temp 101.4 Wedensday pm (in mouth), so he took her to ED yesterday. No sick contacts. Has ___. Not sure when she finished recent levaquin and flagyl. On arrival to the floor she complains of decreased appetite, generalized weakness, low back pain that is acute on chronic, cough productive of clear sputum for the past few days. No BM x3 days but thinks she has "leaking" from her anus and recently noted a very large anus "big enough to put my hold arm in, but I think it got smaller now". She has been packing it with toilet paper since it is leaking. Denies f/c/s, n/v/d, dysuria. Past Medical History: s/p TAVR and pacemaker placement ___ c/b complete heart block (now with pacer) and hypotension ___ to bleeding at the right femoral artery puncture 1. Hyperlipidemia - borderline 2. Borderline QTC prolongation 3. Chronic back/shoulder/knee pain 4. Depression 6. Gastritis 7. Severe belching 8. DJD 9. Memory loss/possible vascular dementia 10. Hx of Hallucinations - improved with decreased Roxicet dose 11. Osteoarthritis 12. Allergic Rhinitis 13. External/Internal Hemorrhoids 14. Scoliosis 15. s/p right TKR 17. s/p hysterectomy 18. Right Rotator cuff repair 19. Sacroilitis 20. UTI ___ completed course of Cipro 21. MVA ___ 22. Depression Social History: ___ Family History: Mother had CVA in her ___. Father died in his ___. Brother had cancer. She has three brothers, four sisters, four sons and one daughter. She does not know much about her family history, but is not aware of any history of hypertension, hyperlipidemia, early coronary artery disease, or sudden cardiac death Physical Exam: Admission: Vitals: 98.6, 119/45, 74, 20, 96%RA General: AAOx3, comfortable appearing, in NAD HEENT: NCAT, EOMI, PERRL. Sclera anicteric, conjunctiva pink. MMM. OP clear. Neck: supple, no LAD, no JVP elevation Lungs: CTAB, no w/r/r CV: RRR, normal S1 and S2, no m/g/r. Pulsus 4mmHg Abdomen: NABS, soft, nondistended, nontender. No HSM. GU: no foley MS: Tender to deep palpation in R lower back more than L lower back, negative straight leg raise. Calves are tender to deep palpation bilaterally, no palpable cords, no edema/erythema/warmth. No pain to palpation of spine. Ext: WWP. 2+ peripheral pulses. No edema. Neuro: CNs II-XII intact. MAEE. Grossly normal strength and sensation. Rectal visual examination: 5mm rectal skin tag vs. old external hemmorhoid, no rectal prolapse, toilet paper stuffed in underwear which is dry, no stool apparent. DISCHARGE: Vitals: 98.3 117/57 59 18 100RA General: AAOx3, comfortable upright in bed HEENT: NCAT, MMM Neck: supple without LAD Lungs: Generally CTA b/l CV: RRR, normal S1 and S2, no m/g/r Abdomen: Soft, non-tender, non-distended GU: no foley MS: Mild tenderness to deep palpation overlying right flank Ext: No edema Neuro: Cn II-XII grossly intact Pertinent Results: ___ 08:53PM BLOOD WBC-13.1# RBC-3.82 Hgb-10.7* Hct-33.0* MCV-87 MCH-27.9 MCHC-32.3 RDW-15.3 Plt ___ ___ 08:53PM BLOOD Neuts-80.0* Lymphs-12.5* Monos-5.1 Eos-2.2 Baso-0.1 ___ 10:16PM BLOOD ___ PTT-32.1 ___ ___ 08:53PM BLOOD Glucose-170* UreaN-14 Creat-0.6 Na-136 K-4.1 Cl-96 HCO3-27 AnGap-17 ___ 08:53PM BLOOD ALT-13 AST-22 AlkPhos-79 TotBili-0.5 ___ 01:40PM BLOOD ALT-12 AST-21 LD(LDH)-251* CK(CPK)-27* AlkPhos-70 TotBili-0.4 ___ 08:53PM BLOOD Albumin-3.2* ___ 01:40PM BLOOD Albumin-2.8* Calcium-8.4 Phos-3.6 Mg-1.9 ___ 01:40PM BLOOD %HbA1c-5.7 eAG-117 ___ 01:40PM BLOOD CRP-141.7* ___ 09:04PM BLOOD Lactate-2.2* ___ 02:04PM BLOOD Lactate-1.7 ___ 01:40PM BLOOD SED RATE-Test Discharge Labs: ___ 06:00AM BLOOD WBC-7.7 RBC-3.43* Hgb-10.0* Hct-29.8* MCV-87 MCH-29.1 MCHC-33.5 RDW-15.6* Plt ___ ___ 06:00AM BLOOD Neuts-59.8 ___ Monos-6.0 Eos-6.3* Baso-0.3 CXR 1. PREVIOUS MILD PULMONARY EDEMA RESOLVED. 2. Small bilateral pleural effusions CT Urogram 1. No evidence of renal, ureteral, or bladder calculi. 2. No evidence of acute cholecystitis. 3. Small bilateral pleural effusions left greater than right and small pericardial effusion, overall mildly increased from ___. Brief Hospital Course: ___ h/o vascular dementia, recent admissions ___ for fevers and CP felt to be from PNA and before that an admission in ___ for TAVR c/b heart block requiring pacemaker c/b c. diff, presents with report of fever, elevated inflammatory markers, malaise/anorexia and acute on chronic low back pain. #Fever, generalized weakness, anorexia. One fever reported at home to 101.4 2 days prior to admission per husband. No documented fevers while here. In ED WBC 13, lactate 2.2, HDS. WBC normalized. UA clean, CXR clean. Had recent course of levaquin for pneumonia, now only with mild cough and clear sputum; PNA seems unlikely. CTU (originally ordered for ? flank pain in ED) unrevealing except pericardial effusion; present since her TAVR, but appears to be possibly increasing on current CT. No severe or positional CP, EKG is v-paced, ECHO ___ without worsened effusion, but still would consider pericarditis given no other obvious cause for fever and systemic inflammation and enlarging effusion on CT (although this can be over-read). CK currently low, no myositis. PMR still on the ddx given elevated ESR/CRP and tender proximal/girdle muscles. Adrenal insuff unlikely, no hypotension, weight loss, eosinophilia but could consider if nothing else turns up. Recent TSH normal. Anemia could be contributing to weakness, but is not severe. Patient will follow up with PCP, ___. #Acute on chronic low back pain. Per husband and patient she gets many aches and pains including low back pain similar to what she has now, usually responds to percocets at home. Since her surgery she has had decreased energy and has been more sedentary, this may be contributing to her musculoskeletal low back pain. No evidence that this is pyelo, renal calculi, or neurologic. CK low, not myositis. She is a difficult historian, but on exam was tender throughout the pelvic girdle, in this clinical setting this raises concern for PMR as above, and would consider rheumatology evaluation as an outpatient. #AS s/p TAVR c/b CHB with PPM. Continued ASA/plavix. Per Dr. ___ will call ___ to overbook in clinic next ___, patient will call Dr. ___ phone to touch base. Repeat ECHO if Dr. ___ it is indicated. #Anemia. Has been anemic since ___ after TAVR likely ___ blood loss, received 4u RBC's that admission, and additional 1u RBC ___ during last admission. Hgb currently 10.7 up from 8's suggesting appropriate response to recent transfusion, and likely hemoconcentrated now. Recent iron studies show replete iron stores and likely low available iron in setting of inflammation. B12 not current but has been normal in the past. Recent haptoglobin high. Retic index recently low, marrow likely suppressed in setting of inflammation. Complains of hemmorhoids requiring surgery, but currently no symptoms. Stable HCT while here. #Hyperglycemia, no known dx of DM. A1C 5.7. Current glucoses 160's-170's, perhaps ___ stress response/inflammation. #HTN. Held home hctz while here. Chronic/inactive issues: #HLD -cont statin #Depression -cont citalopram, gabapentin #Dementia -cont donepezil Transitional Issues: -as above given elevated inflammatory markers without source of infection, anemia of inflammation, pelvic girdle pain, likely reactive thrombocytosis, would consider polymyalgia rheumatica and rheumatologic evaluation. Doubt that pericardial effusion is responsible for all of her symptoms, but she will see Dr. ___ week and get an ECHO if he feels it will be helpful. Would also consider adrenal insufficiency if no other cause for her symptoms is identified. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO QPM 3. Citalopram 30 mg PO DAILY 4. Clopidogrel 75 mg PO DAILY 5. Donepezil 10 mg PO QHS 6. Gabapentin 300 mg PO DAILY 7. Hydrochlorothiazide 12.5 mg PO DAILY 8. Polyethylene Glycol 17 g PO DAILY 9. Vitamin D 1000 UNIT PO DAILY 10. Multivitamins 1 TAB PO DAILY 11. calcium carbonate-vitamin D3 500-100 mg-unit oral daily 12. Oxycodone-Acetaminophen (5mg-325mg) 2 TAB PO Q6H:PRN pain Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO QPM 3. Citalopram 30 mg PO DAILY 4. Clopidogrel 75 mg PO DAILY 5. Donepezil 10 mg PO QHS 6. Gabapentin 300 mg PO DAILY 7. Multivitamins 1 TAB PO DAILY 8. Oxycodone-Acetaminophen (5mg-325mg) 2 TAB PO Q6H:PRN pain 9. Polyethylene Glycol 17 g PO DAILY 10. Vitamin D 1000 UNIT PO DAILY 11. calcium carbonate-vitamin D3 500-100 mg-unit oral daily 12. Hydrochlorothiazide 12.5 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary: - Fever - Right lower back pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital because you had a fever, generalized weakness, pain in your lower back, and lack of appetite. We did not find a cause for your symptoms, and we did not find a source of infection. While here you did not have any fevers. You should follow up with your primary care doctor and with Dr. ___. Weigh yourself every morning, call MD if weight goes up more than 3 lbs. Followup Instructions: ___
10013724-DS-18	10,013,724	28,766,875	DS	18	2180-07-18 00:00:00	2180-07-18 13:52:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ ___ Complaint: Abdominal pain, constipation and large bowel obstruction Major Surgical or Invasive Procedure: Laparotomy and total colonic resection with proximal proctectomy with end ileostomy. History of Present Illness: ___ MEDICINE ATTENDING ADMISSION NOTE . . ___ Time: 0256 . _ ________________________________________________________________ PCP: Name: ___ ___: ___ Address: ___ Phone: ___ Fax: ___ CC: ___ pain and constipation _ ________________________________________________________________ HPI: The patient is a ___ year old male with h/o BPAD self treated with marijuana, who has never had a colonoscopy who presents with abdominal distension, abdominal pain and decreased stool output -> no stool output x 10 days. This was initially thought to represent constpation, for which meds were attempted without improvement. He reports that in the past ___ days he has not stooled, and may not have had flatus. He was sent for CT scan yesterday, where he was told that he had new colon ca. He was referred to the ED given the finding of bowel obstruction on imaging. . In ER: (Triage Vitals: 3 \|98.4 \|113 \|135/92 \|20 \|98% RA ) Meds Given: None Fluids given: 1L NS Radiology Studies: abdominal CT/consults called- GI-ERCP for placement of sigmoid stent and ACS . REVIEW OF SYSTEMS: CONSTITUTIONAL: As per HPI- denies fevers or chills and he has had a 20 lb intentional weight loss over the past year HEENT: [X] All normal RESPIRATORY: [+] cough which he states is secondary to the air in the ED being dry CARDIAC: [X] All normal GI: As per HPI GU: [X] All normal SKIN: [X] All normal MUSCULOSKELETAL: [X] All normal NEURO: [X] All normal ENDOCRINE: [X] All normal HEME/LYMPH: [X] All normal PSYCH: [X] All normal All other systems negative except as noted above Past Medical History: PMH: Varicose veins ? Bipolar affective disorder PSH: Microphlebectomy Social History: ___ Family History: Father died of metastatic melanoma at age ___. Mother is alive and lives independently at age ___. Physical Exam: Vitals: T 97.7 P 88 BP 148/79 RR 20 SaO2 97% on RA GEN: NAD, chronically ill appearing who appears older than his stated age HEENT: ncat anicteric MMM CV: s1s2 rr no m/r/g RESP: b/l ae no w/c/r ABD: no bowel sounds, distended, soft-> firm, with no rebound. Mild tenderness with deep palpation throughout. EXTR:? increased LLE edema compared to R DERM: no rash NEURO: face symmetric speech fluent PSYCH: calm, cooperative At discharge: NAD RRR EWOB Ab soft, slightly tender, ostomy pink, output WNL, surgical incisions clean dry and intact Neuro grossly intact Pertinent Results: ___ 09:01PM LACTATE-1.6 ___ 08:50PM GLUCOSE-89 UREA N-16 CREAT-0.9 SODIUM-138 POTASSIUM-5.4* CHLORIDE-99 TOTAL CO2-23 ANION GAP-21* ___ 08:50PM estGFR-Using this ___ 08:50PM CALCIUM-9.0 PHOSPHATE-4.0 MAGNESIUM-2.4 ___ 08:50PM WBC-10.9* RBC-4.74 HGB-13.8 HCT-42.1 MCV-89 MCH-29.1 MCHC-32.8 RDW-13.9 RDWSD-44.9 ___ 08:50PM NEUTS-64.3 ___ MONOS-8.5 EOS-0.1* BASOS-0.5 IM ___ AbsNeut-6.99* AbsLymp-2.82 AbsMono-0.92* AbsEos-0.01* AbsBaso-0.05 ___ 08:50PM PLT COUNT-427* ============================ ADMISSION ABDOMINAL CT SCAN: Large bowel obstruction - Narrowing/collapse of the large bowel lumen in at the site of focal apple core wall thickening in the region of the distal sigmoid/rectum junction which may correspond to the known colon cancer resulting in proximal large bowel dilation with stool. No free air or evidence of pneumatosis. Wall enhancement is normal. No evidence of lymphadenopathy. 2. 8-mm right adrenal nodule of uncertain etiology. This could be further evaluated with MR or CT with adrenal protocol. ================================================= ___ ABDOMINAL CT SCAN IN ATRIUS Obstructing mass in the rectosigmoid with large and small bowel dilatation proximally. Adjacent involvement of the pararectal soft tissues. Enlarged right pararectal lymph node and mild free fluid in the pelvis. Small right pleural effusion. 1 cm indeterminate nodule in the right adrenal. On discharge: ___ 07:20AM BLOOD WBC-8.2 RBC-3.09* Hgb-8.9* Hct-28.2* MCV-91 MCH-28.8 MCHC-31.6* RDW-14.1 RDWSD-47.3* Plt ___ ___ 07:20AM BLOOD Plt ___ ___ 06:40AM BLOOD Glucose-88 UreaN-12 Creat-0.6 Na-140 K-3.4 Cl-105 HCO3-25 AnGap-13 ___ 06:40AM BLOOD Calcium-8.2* Phos-2.5* Mg-2.1 ___ 07:20AM BLOOD calTIBC-160* TRF-123* Brief Hospital Course: ___ presented to pre-op holding at ___ on ___ for a proctocolectomy w/ end ilesotomy. 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. On ___, he was bolused 1L of fluid for low urine output. On ___, his foley was discontinued. On ___, he was tolerating PO and voided independently. On ___, his malecot was discontinued, was started on a regular diet, and was started on loperamide for high ostomy output. On ___, he received ostomy teaching. On ___, his loperamide was increased for high ostomy output. He also received ostomy teaching. Neuro: The patient was alert and oriented throughout hospitalization; pain was initially managed with a PCA. Pain was very well controlled. The patient was then transitioned to oral pain medication once tolerating a diet. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout hospitalization. GI/GU/FEN: The patient was initially kept NPO. The patient had emesis that later resolved. She was then advanced to clears then to a regular diet, which was tolerated. 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. Prophylaxis: The patient received subcutaneous heparin and ___ dyne boots were used during this stay and was encouraged to get up and ambulate as early as possible. On ___, 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 ___ weeks. This information was communicated to the patient directly prior to discharge. Include in Brief Hospital Course for Every Patient and check of boxes that apply: 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 ___ services [ ] Difficulty finding appropriate rehabilitation hospital disposition. [ ] Lack of insurance coverage for ___ services [ ] Lack of insurance coverage for prescribed medications. [ ] Family not agreeable to discharge plan. [ X] Patient knowledge deficit related to ileostomy delaying discharge. [ ] No social factors contributing in delay of discharge. 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 Q8H:PRN pain Do not take over 3000 mg per day RX acetaminophen 500 mg 2 tablet(s) by mouth every eight (8) hours Disp #50 Tablet Refills:0 2. LOPERamide 2 mg PO TID ostomy output please continue to monitor ileostomy output RX loperamide 2 mg 1 tablet by mouth three times a day Disp #100 Tablet Refills:0 3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain do not drink alcohol or drive a car while taking this medication RX oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #25 Tablet Refills:0 4. Nicotine Patch 14 mg TD DAILY please take until ___, and then taper to lower dose patch RX nicotine 14 mg/24 hour 1 patch daily Disp #10 Patch Refills:0 5. Nicotine Patch 7 mg TD DAILY Duration: 14 Days please take for two weeks after finishing 14mg patch RX nicotine 7 mg/24 hour 1 patch daily Disp #14 Patch Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Large bowel resections secondary to upper rectal cancer with impending perforation. Discharge Condition: Activity Status: Ambulatory - Independent. Level of Consciousness: Alert and interactive. Mental Status: Clear and coherent. Discharge Instructions: ___ were admitted to the hospital after a proctocolectomy with end ilesotomy. ___ have recovered from this procedure well and ___ are now ready to return home. Samples from your colon were taken and this tissue has been sent to the pathology department for analysis. ___ will receive these pathology results at your follow-up appointment. If there is an urgent need for the surgeon to contact ___ regarding these results they will contact ___ before this time. ___ have tolerated a regular diet, are passing gas and your pain is controlled with pain medications by mouth. ___ may return home to finish your recovery. Please monitor your bowel function closely. ___ may or may not have had a bowel movement prior to your discharge which is acceptable, however it is important that ___ have a bowel movement in the next ___ days. After anesthesia it is not uncommon for patients to have some decrease in bowel function but ___ should not have prolonged constipation. Some loose stool and passing of small amounts of dark, old appearing blood are expected. However, if ___ notice that ___ are passing bright red blood with bowel movements or having loose stool without improvement please call the office or go to the emergency room if the symptoms are severe. If ___ are taking narcotic pain medications there is a risk that ___ will have some constipation. Please take an over the counter stool softener such as Colace, and if the symptoms do not improve call the office. If ___ have any of the following symptoms please call the office for advice or go to the emergency room if severe: increasing abdominal distension, increasing abdominal pain, nausea, vomiting, inability to tolerate food or liquids, prolonged loose stool, or extended constipation. ___ have ___ 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 ___ 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 ___ develop any of these symptoms or a fever. ___ may go to the emergency room if your symptoms are severe. ___ 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. ___ will be prescribed narcotic pain medication. This medication should be taken when ___ have pain and as needed as written on the bottle. This is not a standing medication. ___ should continue to take Tylenol for pain around the clock and ___ can also take Advil. Please do not take more than 3000mg of Tylenol in 14 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. Thank ___ for allowing us to participate in your care! Our hope is that ___ will have a quick return to your life and usual activities. Good luck! ___ 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. ___ must measure your ileostomy output for the next few weeks. The output from the stoma should not be more than 1200cc or less than 500cc. If ___ find that your output has become too much or too little, please call the office for advice. The office nurse or nurse practitioner can recommend medications to increase or slow the ileostomy output. Keep yourself well hydrated, if ___ notice your ileostomy output increasing, take in more electrolyte drink such as Gatorade. Please monitor yourself for signs and symptoms of dehydration including: dizziness (especially upon standing), weakness, dry mouth, headache, or fatigue. If ___ notice these symptoms please call the office or return to the emergency room for evaluation if these symptoms are severe. ___ may eat a regular diet with your new ileostomy. However it is a good idea to avoid fatty or spicy foods and follow diet suggestions made to ___ by the ostomy nurses. Please monitor the appearance of the ostomy and stoma and care for it as instructed by the wound/ostomy nurses. ___ stoma (intestine that protrudes outside of your abdomen) should be beefy red or pink, it may ooze small amounts of blood at times when touched and this should subside with time. The skin around the ostomy site should be kept clean and intact. Monitor the skin around the stoma for bulging or signs of infection listed above. Please care for the ostomy as ___ have been instructed by the wound/ostomy nurses. ___ will be able to make an appointment with the ostomy nurse in the clinic 7 days after surgery. ___ will have a visiting nurse at home for the next few weeks helping to monitor your ostomy until ___ are comfortable caring for it on your own. Followup Instructions: ___
10013866-DS-9	10,013,866	27,131,607	DS	9	2127-05-02 00:00:00	2127-05-02 20:12:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: left distal tibia and proximal fibular fracture Major Surgical or Invasive Procedure: Tibia ORIF with intramedullary nail History of Present Illness: This is a ___ year-old man in her USOH until yesterday afternoon when he sustained a syncope and sustained a torsional fall from standing. He was transferred from an ___ with a splint in place. He denies headstrike and LOC. He also denies, neck or chest pain. He presented to ___ ED with films demonstrating a distal tibia shaft fracture as well as a fibula fracture. Past Medical History: PMH: none PSH: L patellar tendon repair with anterior incision extending to tibial tubercle Social History: ___ Family History: NC Physical Exam: On Admission: A&O x 3 Calm and comfortable ___ Pelvis stable to AP and lateral compression. RLE skin clean and intact Tenderness over L tibia and obvious deformity however no erythema, edema, induration or ecchymosis. There is a small abrasion over anterior aspect of Thighs and leg compartments soft No pain with passive motion Saphenous, Sural, Deep peroneal, Superficial peroneal SILT ___ ___ TA Peroneals Fire 1+ ___ and DP pulses On Discharge: A+Ox3, calm/comfortable RLE skin clean and intact Dressing c/d/i, incision healing well No pain with passive motion Saphenous, Sural, Deep peroneal, Superficial peroneal SILT ___ ___ TA Peroneals Fire 2+ ___ and DP pulses Pertinent Results: XR Tibia/Fibula ___: FINDINGS: ___ spot fluoroscopic images of the left tibia were submitted for archival in order to document lateral fixation plate and screw placement across a comminuted distal tibial fracture. For further details, please refer to the operative note. Total operative fluoroscopic time was 141.2 seconds. Brief Hospital Course: On ___ the patient was admitted to the ortho trauma service and noted to have a closed, distal spiral tibial shaft fracture which was reduced and splinted without signs of compartment syndrome or neurovascular compromised. On ___ the patient underwent ORIF intramedullary rod fixation of left tibia fracture. On ___ the patient continued to recover well from surgery. His dressings were changed on post-op day 2 the incision was noted to be healing well. He was discharged home on lovenox for DVT prophylaxis with instructions to follow-up with Dr. ___ in clinic. Discharge Medications: 1. Aspirin 325 mg PO DAILY 2. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain RX oxycodone 5 mg ___ tablet(s) by mouth every 3 hours Disp #140 Tablet Refills:0 RX oxycodone 5 mg ___ tablet(s) by mouth every 3 hours Disp #140 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: fracture left tibia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take aspirin 325mg daily for 2 weeks/until your follow-up appointment WOUND CARE: - You can get the wound wet/take a shower starting 3 days after your surgery. You may wash gently with soap and water, and pat the incision dry after showering. - No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - No dressing is needed if wound continues to be non-draining. ACTIVITY AND WEIGHT BEARING: touch-down weight bearing LLE Followup Instructions: ___
10014354-DS-10	10,014,354	22,741,225	DS	10	2146-10-12 00:00:00	2146-10-13 14:26:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: Penicillins Attending: ___ Chief Complaint: left leg weakness and numbness s/p tPA Major Surgical or Invasive Procedure: IV tPA prior to admission History of Present Illness: Mr. ___ is a ___ yo man with CLL, DM, HTN, HLD and right subcortical stroke in ___ who presents s/p tPA from OSH for left leg numbness and weakness. Today he went into the bedroom to put on pajamas at 4:45 pm. When he sat down, his left leg went numb. When he stood up to pull up his pants, he almost fell to the left. He sat down and called ___. He was taken to ___, where he was given tPA at 6:51 pm. Since receiving tPA, he feels that his symptoms are unchanged. In ___, he had left face/arm/leg paresis and numbness due to stroke. He recovered with the exception of Left thigh weakness, though he was still able to move his leg. He walks with a cane. This leg weakness/numbness today felt similar to his previous stroke. He has chronic right shoulder pain. On neuro ROS, the pt denies headache, loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. No bowel or bladder incontinence or retention. On general review of systems, the pt denies recent fever or chills. No night sweats or recent weight loss or gain. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: CLL PPM for bradycardia Stroke in ___ HTN HLD DM Social History: ___ Family History: - no cancer or stroke Physical Exam: ============================== ADMISSION EXAM: Vitals: 98.2 63 118/49 16 97% RA General: Awake, cooperative, NAD. HEENT: NC/AT, MMM Neck: Supple, no nuchal rigidity. Pulmonary: CTABL Cardiac: RRR, no murmurs Abdomen: soft, nontender, nondistended Extremities: mild edema, pulses palpated Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history 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. Speech was not dysarthric. Able to follow both midline and appendicular commands. Attentive, able to name ___ backward without difficulty. There was no evidence of neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm, both directly and consentually; brisk bilaterally. VFF to confrontation. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch in all distributions VII: No facial droop, facial musculature symmetric and ___ strength in upper and lower distributions, bilaterally VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, paratonia throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L ___ ___ 5 0 0 0 4- 5 3 R ___ ___ ___ 5 5 5 5 -DTRs: Bi Tri ___ Pat Ach L 2 1 1 0 0 R 2 1 1 0 0 - Plantar response was extensor bilaterally. - Pectoralis Jerk was absent, and Crossed Adductors are absent. -Sensory: Left thigh and calf decreased FT and pin, normal sensation in left foot. Mildly decreased proprioception bilaterally. -Coordination: Mild intention tremor on L FNF. No dysmetria on FNF. Normal R HKS. -Gait: not tested. ============================== DISCHARGE EXAM: -Mental Status: Alert, oriented x 3. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt. was able to name both high and low frequency objects. Speech was not dysarthric. Able to follow both midline and appendicular commands. Attentive with no evidence of neglect. -Cranial Nerves: PERRL, EOMI without nystagmus, no facial asymmetry , palate elevates symmetrically and tongue in midline -Motor: Full strength in the UE. IP Quad Ham TA ___ ___ L 4+ ___ 4+ 4 R 4+ ___ 5 5 -DTRs: Bi Tri ___ Pat Ach L 2 2 1 0 0 R 2 2 1 0 0 -Sensory: Left leg mild decrease sensation to light touch , no dermatomal pattern. ============================== Pertinent Results: ADMISSION LABS: ___ WBC-74.2* RBC-3.36* Hgb-9.2* Hct-30.0* Plt ___ Neuts-7* Bands-0 Lymphs-90* Monos-2* Eos-1 Baso-0 Atyps-0 ___ Myelos-0 AbsNeut-5.19 AbsLymp-66.78* AbsMono-1.48* AbsEos-0.74* AbsBaso-0.00* ___ PTT-32.5 ___ Glucose-214* UreaN-14 Creat-1.2 Na-137 K-4.0 Cl-100 HCO3-23 AnGap-18 ALT-14 AST-28 AlkPhos-32* TotBili-0.2 Calcium-8.8 Phos-3.9 Mg-1.8 cTropnT-<0.01 STox: negative UTox: +opioids UA: bland Stroke Risk Factors: Cholest-100 Triglyc-230* HDL-24 CHOL/HD-4.2 LDLcalc-30 %HbA1c-7.4* eAG-166* TSH-20* T3-PND Free T4-PND Imaging: CTA Head/Neck ___ IMPRESSION: 1. Patent circle of ___. 2. Patent vasculature in the neck with no evidence of internal carotid artery stenosis by NASCET criteria. 3. No acute intracranial abnormality. 4. At least moderate spinal canal stenosis at C2-C3 and C3-C4 secondary to ossifications of the posterior longitudinal ligaments. CT Head ___ post-tPA: no hemorrhagic transformation or evolving infarct noted Echocardiogram: The left atrium is normal in size. The estimated right atrial pressure is ___ mmHg. Agitated saline injected at rest but suboptimal image quality precludes adequate visualization of bubbles. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). There is no ventricular septal defect. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Bubble study at rest performed but inadequate to exclude a PFO/ASD due to very suboptimal image quality. Mild symmetric left ventricular hypertrophy with preserved regional and global systolic function (contrast used for better endocardial definition). Mild aortic regurgitation. Mild pulmonary artery systolic hypertension. Brief Hospital Course: Mr. ___ presented to OSH with acute onset left leg numbness and weakness. He received IV tPA and was transferred to ___ for monitoring. # NEURO At ___, he was found to have proximal>distal weakness of the left lower extremity with some improvement in his sensory deficit. His lower extremity exam had some functional overlay and was variable from day to day. He was monitored in the ICU for 24 hours without change in his examination and there was no evidence hemorrhagic transformation on his CT head. The etiology of his symptoms remained unclear. CTA head and neck was difficult to interpret given timing of contrast, possibly with a cutoff in R ACA territory, but there was no evidence of evolving infarct within the limits of CT on repeat scan. An echo was done, but was of poor quality. His stroke risk factors were assessed and include: 1) dyslipidemia, 2) IDDM, 3) HTN, 4) Obesity. Lipid panel revealed low LDL and HDL and elevated triglycerides with a high triglyceride to LDL ratio. Diabetes management is discussed below. His blood pressure was in good control ranging between 130-160's/50's-70's. His home aspirin was restarted and his simvastatin and fenofibrates were continued. No meds were changed. # HEME/ONC His outpatient oncologist recommended holding is ibrutinib for 24 hours after tPA due to elevated bleeding risk. This will be restarted as outpatient. # THYROID He was continued on his home levothyroxine. His thyroid function tests were notable for an elevated TSH at 30 T3-93. # DIABETES His A1c was elevated at 7.4% and his metformin was initially held after contrast. He was maintained on insulin glargine and sliding scale. His ___ were elevated and that was the result of giving him 50 ___ at bedtime when he typically has it twice a day. At discharge, his diabetes regimen was restarted as per his home regimen given that his blood glucose was well controlled ___ that regiment and this was confirmed with ___ Diabetes consult team. # MUSKULOSKELETAL He complained of Left shoulder pain with a remote hx of trauma, we had a shoulder X-ray that was negative and pain was well controlled on Ibuprofen and Vicodin which he sues at home Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amlodipine 5 mg PO DAILY 2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID 3. Divalproex (EXTended Release) 500 mg PO QAM 4. Divalproex (EXTended Release) 750 mg PO QPM 5. Fenofibrate 150 mg PO DAILY 6. Fluoxetine 10 mg PO DAILY 7. Furosemide 20 mg PO DAILY 8. Gabapentin 200 mg PO TID 9. Hydrocodone-Acetaminophen (5mg-325mg) 1 TAB PO TID:PRN pain 10. ibrutinib 420 mg oral DAILY 11. Glargine 50 Units Breakfast Glargine 50 Units Bedtime 12. Levothyroxine Sodium 50 mcg PO DAILY 13. Losartan Potassium 50 mg PO DAILY 14. MetFORMIN (Glucophage) 1000 mg PO BID 15. RISperidone 0.5 mg PO DAILY 16. Simvastatin 20 mg PO QPM 17. ZIPRASidone Hydrochloride 40 mg PO BID 18. Aspirin EC 81 mg PO DAILY 19. Calcium Carbonate 1000 mg PO DAILY 20. Vitamin D3 (cholecalciferol (vitamin D3)) 400 unit oral DAILY 21. Senna 8.6 mg PO BID:PRN cosntipation 22. TraZODone 300 mg PO QHS Discharge Medications: 1. Aspirin EC 81 mg PO DAILY 2. Divalproex (EXTended Release) 500 mg PO QAM 3. Divalproex (EXTended Release) 750 mg PO QPM 4. Fenofibrate 150 mg PO DAILY 5. Gabapentin 200 mg PO TID 6. Hydrocodone-Acetaminophen (5mg-325mg) 1 TAB PO TID:PRN pain 7. Levothyroxine Sodium 50 mcg PO DAILY 8. RISperidone 0.5 mg PO DAILY 9. Senna 8.6 mg PO BID:PRN cosntipation 10. Simvastatin 20 mg PO QPM 11. ZIPRASidone Hydrochloride 40 mg PO BID 12. Amlodipine 5 mg PO DAILY 13. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID 14. Calcium Carbonate 1000 mg PO DAILY 15. Furosemide 20 mg PO DAILY 16. ibrutinib 420 mg oral DAILY 17. Losartan Potassium 50 mg PO DAILY 18. MetFORMIN (Glucophage) 1000 mg PO BID 19. Vitamin D3 (cholecalciferol (vitamin D3)) 400 unit oral DAILY 20. Fluoxetine 10 mg PO DAILY 21. Glargine 50 Units Breakfast Glargine 50 Units Bedtime 22. TraZODone 300 mg PO QHS Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: left leg weakness Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. ___, You were admitted to ___ after being treated with a blood thinning intravenous medication called tPA for concerns of an acute stroke as you presented with worsening left leg weakness and numbness. We found no stroke on repeated brain imaging, the weakness and numbness has been improving. You also complained of left shoulder pain for which we obtained an x-ray and that was normal. You should continue your home medications. Followup Instructions: ___
10014354-DS-12	10,014,354	27,494,880	DS	12	2147-06-04 00:00:00	2147-06-04 16:26:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / codeine / acetaminophen / oxycodone Attending: ___ Chief Complaint: Chest pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo M with CLL on ibrutinib, HTN, T2DM, SSS s/p PPM (A-paced, LRL appears ~50), hx of AF on Xarelto, CAD s/p ___ LHC with DES (? x2) placed in mid-LAD, now presenting with constant ___ chest pain on left radiating down arm. Chest pain is described as a central substernal chest "pressure", like a "fist into the chest". Patient did not have nitroglycerin at home. Chest pain was precipitated by him walking his dog at around ___ on ___. Pain was accompanied by shortness of breath. Reports he feels worse than the chest pain that brought him in with the LAD occlusion. Received ASA 325mg via EMS. Given 2 nitro by EMS as well with some improvement in his chest pain. EMS stated he had one episode ___ beat run of NSVT in ambulance. In the ED, initial vitals: T 97.9, HR 62, BP 145/63, 16, 95%RA - Later vitals in the ED notable for bradycardia (with intermittent A-pacing dependency) between 50-65. - Exam notable for: RRR, no murmurs, clear lungs, trace edema - Labs notable for: Trop <.01 x2, Na 128, WBC 11.9, Hgb 8.9 (9.9) - Imaging notable for: unremarkable CXR - Patient given: ASA 325 by EMS ___ 00:23 IV HYDROmorphone (Dilaudid) .5 mg ___ 01:38 IV HYDROmorphone (Dilaudid) .5 mg ___ 03:24 PO/NG Gabapentin 300 mg ___ 03:24 PO/NG TraZODone 300 mg ___ 03:24 IV Heparin Started 1000 ___ 03:24 IV DRIP Nitroglycerin (0.35-3.5 mcg/kg/min ordered) Started 0.35 mcg/kg/min ___ 05:19 IV DRIP Nitroglycerin Stopped - Unscheduled ___ 06:16 IV Heparin Confirmed No Change in Rate, rate continued at 1000 units/hr ___ 08:44 PO Divalproex (EXTended Release) 250 mg ___ 08:44 IV Heparin Stopped (5h ___ ___ 09:24 IV HYDROmorphone (Dilaudid) .5 mg - Vitals prior to transfer: 98.0 50 119/56 12 100% RA On arrival to the floor, pt reports chest pain ___ from ___ with dilaudid .5 adm in ED 45 minutes ago. Denies associated sx, n/v, headache, shortness of breath, palpitations. Reports feeling well after stent, no pain or shortness of breath until ___. Pain has persisted since onset with only slight relief from nitro or dilaudid. Past Medical History: CLL PPM for bradycardia Stroke in ___ HTN HLD DM Social History: ___ Family History: - no cancer or stroke Physical Exam: Vitals: 97.6 175/34 55 16 96RA BP re-check 120/70 General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, neck supple, JVP not elevated Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Bradycardic, regular, normal S1 + S2, II/VI systolic murmur best heard Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, no cyanosis, 1+ edema to mid-shins Skin: Without rashes or lesions Neuro: A&Ox3. Grossly intact. Pertinent Results: ___ 11:05PM BLOOD WBC-11.9* RBC-3.25* Hgb-8.9* Hct-27.1* MCV-83 MCH-27.4 MCHC-32.8 RDW-14.2 RDWSD-42.9 Plt ___ ___ 11:05PM BLOOD Neuts-45.0 ___ Monos-7.0 Eos-1.4 Baso-0.5 Im ___ AbsNeut-5.36 AbsLymp-5.41* AbsMono-0.83* AbsEos-0.17 AbsBaso-0.06 ___ 11:05PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+ Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Ovalocy-1+ Tear ___ ___ 11:05PM BLOOD ___ PTT-38.7* ___ ___ 11:05PM BLOOD Glucose-122* UreaN-9 Creat-0.9 Na-128* K-3.9 Cl-91* HCO3-23 AnGap-18 ___ 11:05PM BLOOD ALT-17 AST-18 AlkPhos-45 TotBili-<0.2 ___ 11:05PM BLOOD Lipase-62* ___ 06:32AM BLOOD cTropnT-<0.01 ___ 11:05PM BLOOD cTropnT-<0.01 ___ 06:32AM BLOOD CK-MB-3 ___ 11:05PM BLOOD Albumin-3.6 Calcium-8.9 Phos-4.6* Mg-1.6 ___ 11:05PM BLOOD Osmolal-263* Brief Hospital Course: ___ with CLL, HTN, HLD, T2DM, CAD s/p stenting to LAD on ___, presenting with ___ chest pain concerning for unstable angina. # Chest Pain / Hx CAD: Clinical history is concerning for ACS. S/p 2x DES to the LAD on ___ for a 70% stenosis. Patient was reportedly out walking when the pain started and he clearly describes ___ chest pressure like a "fist into his chest". Partially responsive to nitro gtt and dilaudid, but also reproducible on exam. Heparin gtt started initially, but cardiology consultant recommended discontinuation. Recent cath with single vessel disease now s/p PCI. No biomarker elevation or EKG change to raise concern for stent thrombosis. Patient has no untreated disease to cause ischemic symptoms. No indication to re-cath. Reproducible pain points toward non-cardiac etiology. Discussion with outpatient provider indicates pain contract and possible history of drug-seeking behavior. He was given home medications, re-assured about the non-cardiac nature of his chest pain and discharged home. # SSS s/p Pacemaker: A-paced in ___ this admission. Normotensive at this rate off nitro gtt. # H/o AFib: - continued home xeralto # Hypertension: - continued home metoprolol and losartan # CLL: - Patient should continue ibrutinib at home # T2DM: - Home insulin continued and metformin held while inpatient. No changes to home regimen on discharge # Depression & Cognitive Impairment: - Continued home ziprasidone, fluoxetine and divalproex CHRONIC ISSUES # Hyperlipidemia: Continue atorvastatin 80mg QHS # Depression: Continue high dose trazodone which is his home medication. # Hypothyroidism: Continue home levothyroxine. # R Hip Pain due to bursitis: Has required Vicodin BID as well as gabapentin and Depakote. CORE MEASURES # CODE STATUS: Presumed Full # CONTACT: ___ (___) Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO QPM 3. Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE Q8H 4. Cyanocobalamin 1000 mcg PO DAILY 5. Divalproex (EXTended Release) 500 mg PO BID 6. Divalproex (EXTended Release) 250 mg PO QHS 7. FLUoxetine 30 mg PO DAILY 8. Furosemide 20 mg PO DAILY 9. Gabapentin 300 mg PO TID 10. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO BID 11. Levothyroxine Sodium 50 mcg PO DAILY 12. Losartan Potassium 50 mg PO DAILY 13. Magnesium Oxide 400 mg PO BID 14. Metoprolol Tartrate 12.5 mg PO BID 15. Pantoprazole 40 mg PO Q24H 16. Senna 17.2 mg PO BID:PRN constipation 17. TraZODone 300 mg PO QHS 18. MetFORMIN (Glucophage) 1000 mg PO BID 19. Fenofibrate 150 mg PO DAILY 20. dextrose-maltodextrin 10 gram/11.5 gram oral DAILY:PRN 21. Capsaicin 0.025% 1 Appl TP QID shoulder pain 22. albuterol sulfate 2.5 mg /3 mL (0.083 %) inhalation QID:PRN 23. Multivitamins 2 TAB PO DAILY 24. Vitamin D ___ UNIT PO EVERY MONTH 25. ZIPRASidone Hydrochloride 40 mg PO BID 26. ibrutinib 420 mg oral DAILY 27. Sodium Chloride Nasal ___ SPRY NU QID:PRN congestion 28. Clopidogrel 75 mg PO DAILY 29. Rivaroxaban 10 mg PO DAILY 30. Glargine 56 Units Breakfast Glargine 56 Units Bedtime Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. albuterol sulfate 2.5 mg /3 mL (0.083 %) inhalation QID:PRN 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE Q8H 5. Capsaicin 0.025% 1 Appl TP QID shoulder pain 6. Clopidogrel 75 mg PO DAILY 7. Cyanocobalamin 1000 mcg PO DAILY 8. dextrose-maltodextrin 10 gram/11.5 gram oral DAILY:PRN 9. Divalproex (EXTended Release) 500 mg PO BID 10. Divalproex (EXTended Release) 250 mg PO QHS 11. Fenofibrate 150 mg PO DAILY 12. FLUoxetine 30 mg PO DAILY 13. Furosemide 20 mg PO DAILY 14. Gabapentin 300 mg PO TID 15. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO BID 16. ibrutinib 420 mg oral DAILY 17. Glargine 56 Units Breakfast Glargine 56 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 18. Levothyroxine Sodium 50 mcg PO DAILY 19. Losartan Potassium 50 mg PO DAILY 20. Magnesium Oxide 400 mg PO BID 21. MetFORMIN (Glucophage) 1000 mg PO BID 22. Metoprolol Tartrate 12.5 mg PO BID 23. Multivitamins 2 TAB PO DAILY 24. Pantoprazole 40 mg PO Q24H 25. Rivaroxaban 10 mg PO DAILY 26. Senna 17.2 mg PO BID:PRN constipation 27. Sodium Chloride Nasal ___ SPRY NU QID:PRN congestion 28. TraZODone 300 mg PO QHS 29. Vitamin D ___ UNIT PO EVERY MONTH 30. ZIPRASidone Hydrochloride 40 mg PO BID Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: Atypical chest 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: Dear Mr. ___, You came to ___ because you were having chest pain. We evaluated you very carefully and determined that you were not having a heart attack and that your pain is very likely not coming from your heart. Your symptoms are probably coming from your ribs and the muscles of your chest. We recommend Tylenol and your home pain medication for this. You can follow up with your usual doctor to see if there is anything else that can be done to help this pain. Best wishes, Your ___ Care Team Followup Instructions: ___
10014354-DS-14	10,014,354	26,013,492	DS	14	2147-11-16 00:00:00	2147-11-16 20:23:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / erythromycin base Attending: ___. Chief Complaint: Fall, weakness, fatigue Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ year-old gentleman with history of CAD s/p DES, SSS s/p PPM, pAF on rivaroxaban in addition to Rai III CLL on ibrutinib and Stage IIIA NSGCT s/p radical orchiectomy and now on C2D7 of EP who presents with generalized weakness, a fall and abdominal discomfort. Mr. ___ was in his usual state of health until 2 days prior to admission when he began having generalized fatigue and malaise that has progressively worsened since then. On the day of admission he was walking back to the bathroom and felt his legs give out falling forward on his knees and hands. He denies loss of consciousness, dizziness/lightheadedness, head strike. He is having some vague upper gastrointestinal upset over the past 2 days along with some intermittent dyspnea. He denies having nausea/vomiting, diarrhea or constipation. He has not had chest discomfort, palpitations, pleuritic chest pain. He has been able to tolerate POs. ED initial vitals were 97.3 80 138/78 18 99% RA Prior to transfer vitals were 98.5 82 142/78 18 100% RA Exam in the ED showed : "pale gentleman, without acute distress. breathing comfortably on room air, shallow respirations bilaterally, without ronchi or wheezing, no murmurs, power port to R SCV, without overlying erythema, drainage, tenderness, abd: soft, no RUQ tenderness. nontender extremities: no swelling, no tenderness to palpation bilaterally neuro: a+ox3." ED work-up were significant for: -CBC: WBC: 52.2* HGB: 8.8. Plt Count: 289. Neuts%: 76. -Chemistry: Na: 137. K: 3.8. Cl: 100. CO2: 25. BUN: 26. Creat: 1.3. Ca: 8.3. Mg: 2.0. PO4: 3.3. -Lactate:1.8 -Coags: INR: 1.0. PTT: 29.1. -LFTs: ALT: 20. AST: 17. Alk Phos: 77. Total Bili: <0.2. -Lipase: 159 -Cards: EKG non-ischemic, TnT<0.01 -UA: WBC 1, RBC 1, Prot 100, Glu 100 -CXR: no acute process Patient was given: AlOH/simethicone 30mL, viscous lidocaine 2% 10mL, ondansetron 4mg IV x1, NS @ 150mL/h On arrival to the floor, patient reports concern about his elevated lipase and white blood cell count, he thinks his cancer may have extended to his pancreas and that his CLL has worsened for being off the ibrutinib. He continues to feel tired, the nausea he felt in the emergency room has improved with ondansetron. He is afraid that his kidneys are failing and he would not like to be on dialysis. Past Medical History: PAST ONCOLOGIC HISTORY: -___: Lymphocytosis incidentally found during a psychiatric hospitalization. -___: CT scan showed a slightly enlarged spleen at 14.5 cm and no adenopathy. -___: He met with Dr. ___ in ___ at ___. WBC was 15.0 with 49.6% lymphocytes, Hgb 11.9, and platelets 260,000. Flow cytometry was consistent with CLL, and B-cell gene rearrangement confirmed clonality. CLL FISH panel showed a p53 mutation. He was asymptomatic at the time of diagnosis and followed with Dr. ___. -WBC gradually uptrended to 22.7 in ___, 37.3 in ___, 51.3 in ___, and 50.4 on ___. Hgb has decreased slightly to 10.9 and Hct 34.4 with platelets 234,000 on the ___ labs. -___: Hematology care transitioned to Dr. ___ after Dr. ___. He also started having nightly sweats. -___: CT Chest without lymphadenopathy or other notable findings. -___: Initial ___ Hematology evaluation for second opinion. WBC 50.7, Hgb 10.5, Hct 33.2, Plt 226. Peripheral blood flow cytometry and cytogenetics confirmed CLL with TP53 deletion. -___: CT Abdomen/Pelvis without lymphadenopathy or other notable findings. -___: Started ibrutinib 420 mg daily. -___: Ibrutinib held for vitreous bleed -___: Ibrutinib restarted -___: Per OSH records, underwent scrotal U/S showing heterogeneous left testicle, prominent rete testis on right. -___: Presented to his outpatient hematologist, Dr. ___ a painful swollen left testicle (swelling over ~8 months, worsening pain). This had been evaluated on ___ with an ultrasound that did not demonstrate torsion but did show heterogeneous morphology of the left testicle. HCG was positive. Referred to Dr. ___. -___: ibrutinib held for surgery -___: Underwent left radical orchiectomy. Pathology revealed 3.9 cm malignant mixed germ cell tumor of the testis, 95% embryonal carcinoma, 2% teratoma, 2% yolk sac tumor, 1% choriocarcinoma, invading hilar statin ___ vaginalis, with lymphatic vascular invasion and metastatic tumor nodules in the spermatic cord. pT2NxS1 (although no post-orch levels, beta hCG 64 on ___, up from 21 on ___ AFP 3, LDH normal). -___: CT torso showing new 8 mm nodule in the left lower lobe, and comparison with CT ___. Left para-aortic lymphadenopathy up to 2.8 cm and a 3.5 cm fluid collection in the left inguinal region/scrotum, felt to be likely postsurgical. -___: C1D1 EP -___: C2D1 EP PAST MEDICAL HISTORY: -Sick sinus syndrome s/p PPM ___ Revo DDD, MRI-compatible, ___ -CAD s/p DES to mid-LAD in ___. Preserved LVEF in ___. -Stroke ___ -Diabetes mellitus type II on insulin -Hypertension -Hyperlipidemia -Morbid obesitys/p Gastric bypass surgery ___ -Obstructive sleep apnea - not on CPAP -Pancreatitis ___ related to alcohol -s/p Cholecystectomy -Hypothyroidism -Osteoarthritis -s/p Bilateral shoulder surgery, chronic pain -Major depression with psychotic features (vs schizoaffective disorder per patient) (Dr. ___ name unknown, affiliated with ___ ___) -Anxiety -Conversion disorder -Benign paroxysmal positional vertigo -Glaucoma, cataract (Dr. ___ at ___) Social History: ___ Family History: No cancer or stroke Physical Exam: ADMISSION PHYSICAL EXAM: VS: 99.0 PO 171 / 79 79 20 97 RA GENERAL: Chronically-ill appearing gentleman, in emotional distress lying in bed. HEENT: Anicteric, PERLL, Mucous membranes dry, OP clear. CARDIAC: Regular rate and rhythm, normal heart sounds, no murmurs, rubs or gallops. JVP 1cm above clavicle. LUNG: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi. ABD: Non-distended, bowel sounds increased in frequency and volume but normal tone, soft, non-tender, no guarding, no palpable masses, no organomegaly. EXT: Warm, well perfused. No lower extremity edema. No erythema or tenderness. NEURO: A&Ox3, good attention and linear thought, CN II-XII intact. Strength full throughout. Sensation to light touch intact. PSYCH: Anxious mood and affect. SKIN: No significant rashes. DISCHARGE PHYSICAL EXAM: Vitals: 98.2 150 / 76 77 18 99 RA GENERAL: Chronically-ill appearing gentleman, sitting up in chair eating breakfast HEENT: Anicteric sclera, PERLL, MMM, OP clear. CARDIAC: Regular rate and rhythm, normal heart sounds, no murmurs, rubs or gallops. LUNG: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi. ABD: Non-distended, soft, non-tender, no guarding, no palpable masses, no organomegaly. EXT: Warm, well perfused. Trace to 1+ lower extremity edema bilaterally. No erythema or tenderness. NEURO: A&Ox3, good attention and linear thought, CN II-XII intact. Strength full throughout. Sensation to light touch intact. PSYCH: calm and cooperative. SKIN: No significant rashes. Pertinent Results: ============== ADMISSION LABS ============== ___ 07:00PM BLOOD WBC-52.2# RBC-3.31* Hgb-8.8* Hct-26.8* MCV-81* MCH-26.6 MCHC-32.8 RDW-17.9* RDWSD-47.8* Plt ___ ___ 07:00PM BLOOD Neuts-76* Bands-0 ___ Monos-1* Eos-1 Baso-0 ___ Myelos-0 NRBC-1* AbsNeut-39.67* AbsLymp-11.48* AbsMono-0.52 AbsEos-0.52 AbsBaso-0.00* ___ 07:00PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+ Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Tear Dr-1+ Acantho-1+ ___ 07:00PM BLOOD ___ PTT-29.1 ___ ___ 07:00PM BLOOD Glucose-158* UreaN-26* Creat-1.3* Na-137 K-3.8 Cl-100 HCO3-25 AnGap-16 ___ 07:00PM BLOOD ALT-20 AST-17 AlkPhos-77 TotBili-<0.2 ___ 07:00PM BLOOD Lipase-159* ___ 07:00PM BLOOD Albumin-3.8 Calcium-8.3* Phos-3.3 Mg-2.0 ___ 05:11AM BLOOD TSH-4.0 ___ 07:00PM BLOOD Lactate-1.8 ============== MICROBIOLOGY ============== ___ 10:30 pm Rapid Respiratory Viral Screen & Culture Source: Nasopharyngeal swab. Respiratory Viral Culture (Pending): Respiratory Viral Antigen Screen (Final ___: Negative for Respiratory Viral Antigen. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Refer to respiratory viral culture and/or Influenza PCR (results listed under "OTHER" tab) for further information.. =============== IMAGING/STUDIES =============== ___ CXR IMPRESSION: No acute cardiopulmonary process. ============== DISCHARGE LABS ============== ___ 05:30AM BLOOD WBC-30.3* RBC-3.20* Hgb-8.3* Hct-26.2* MCV-82 MCH-25.9* MCHC-31.7* RDW-17.7* RDWSD-48.7* Plt ___ ___ 05:30AM BLOOD Glucose-104* UreaN-17 Creat-0.8 Na-138 K-4.8 Cl-104 HCO3-25 AnGap-14 ___ 05:30AM BLOOD Calcium-8.5 Phos-2.8 Mg-1.7 Brief Hospital Course: Mr. ___ is a ___ year-old gentleman with history of CAD s/p DES, SSS s/p PPM, pAF on rivaroxaban in addition to Rai III CLL on ibrutinib (currently on hold) and Stage IIIA NSGCT s/p radical orchiectomy and now s/p initiation of cycle 2 (___) of Cisplatin/Etoposide who presents with generalized weakness, poor PO intake, a fall and abdominal discomfort. #Weakness: #Hypovolemia: #Acute Kidney Injury: Weakness and fatigue are similar to what he experienced for a week during his first cycle of chemotherapy. Volume depleted on admission due to poor PO intake and ongoing use of furosemide. Cr elevated to 1.3 on admission, was given 1 L IVF with improvement in Cr to 0.9. Flu swab negative, respiratory viral panel negative for Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV; viral culture pending at the time of discharge. Held furosemide and losartan during this admission, but will resume on discharge. #S/P Fall: Suspect that fall was due to orthostatic factors, owing to volume depletion. Low suspicion for arrhythmia. No suspicion for ACS or seizure. No secondary injuries on exam. Patient was ambulatory in the hospital and did not need ___ evaluation. #Epigastric discomfort #Nausea #Hyperlipasemia: Patient had significant upper GI upset and nausea after previous cycle of chemotherapy so likely attributable to chemotherapy. Mildly elevated lipase very unlikely to represent pancreatitis given absence of significant abdominal pain or tenderness. Contributing factors for hyperlipasemia in this patient are furosemide, renal failure, valproate, narcotics, RYGB. Continued Ondansetron, and added prochlorperazine and Ativan. Continued home pantoprazole and added sucralfate. Lipase trended down. Pt's diet was advanced without issue. #Stage IIIA Non-seminoma testicular cancer #Leukocytosis with Neutrophilia: With low risk features. Has completed C2 ___ C2D1) of cisplatin/etoposide. Received pegfilgrastim on ___ which explains his leukocytosis with neutrophilia. Did not receive any chemotherapy while in-house. #Rai Stage III Chronic Lymphocytic Leukemia: Lymphocytosis to 11.48 on differential up from 3.39 on ___. Likely reactive and not reflecting recurrence or acceleration of CLL. Did not receive ibrutinib while inpatient, as this is being held while he is on chemo for his testicular cancer. #Coronary artery disease #Chronic diastolic heart failure #History of CVA: No symptoms suggestive of acute ischemia during this admission. EKG non-ischemic and initial TnT<0.01. No acute neurologic symptoms. Unclear why on atypical dose of 243mg of ASA but no evidence supporting this especially while anticoagulated and on clopidogrel with a history of vitreal bleed, so treated with ASA 81. Continued home Plavix, atorva, metoprolol. Held home furosemide while inpatient #Paroxysmal Atrial Fibrillation #Sick Sinus Syndrome: Currently in sinus rhythm. Warrants continuation of anticoagulation given CHADSVaSC 6 (NNT 12). Continued dose reduced rivaroxaban 10mg with dinner. PPM active in DDD mode. #Type 2 Diabetes Mellitus c/b nephropathy: Last A1c 7.4%. Held metformin in setting of ___. Continued home glargine 56sc bid. Humalog sliding scale. #Depressive Disorder with Psychotic features #Anxiety: Appropriately anxious affect while hospitalized, no positive or negative psychotic symptoms. Continued home psychiatric medications. #Chronic back and shoulder pain: Not exacerbated. Continued acetaminophen-hydrocodone tid prn. =================== TRANSITIONAL ISSUES =================== -Respiratory viral culture pending at the time of discharge. -He has been on triple anticoagulation with aspirin, clopidogrel, and rivaroxaban. Ibrutinib adds additional bleeding risk (though he is not currently on this). Patient will follow-up with his cardiologist for discussion of continuing clopidogrel (for LAD stent placed in ___. -Nausea: added Compazine during this admission. ___ benefit from addition of Ativan or olanzapine to his anti-emetic regimen for the next round of chemotherapy #CODE: Full Code, presumed. Not addressed in setting of marked anxiety. No urgency given clinical stability. #EMERGENCY CONTACT / HCP: ___ (son) Phone number: ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 500 mg PO Q8H:PRN Headache 2. Aspirin 243 mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. Clopidogrel 75 mg PO DAILY 5. Metoprolol Tartrate 12.5 mg PO BID 6. Divalproex (EXTended Release) 500 mg PO BID 7. Divalproex (EXTended Release) 250 mg PO QPM 8. Docusate Sodium 100 mg PO BID constipation 9. FLUoxetine 20 mg PO DAILY 10. Furosemide 20 mg PO DAILY 11. Gabapentin 300 mg PO TID 12. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN Pain - Moderate 13. Levothyroxine Sodium 25 mcg PO DAILY 14. Losartan Potassium 50 mg PO DAILY 15. Magnesium Oxide 400 mg PO BID 16. melatonin 2.5 mg oral QHS:PRN 17. MetFORMIN (Glucophage) 1000 mg PO BID 18. Pantoprazole 40 mg PO Q24H 19. Rivaroxaban 10 mg PO DAILY 20. Senna 8.6 mg PO DAILY constipation 21. Glargine 56 Units Breakfast Glargine 56 Units Bedtime 22. TraZODone 300 mg PO QHS Discharge Medications: 1. Prochlorperazine 10 mg PO Q6H:PRN nausea RX prochlorperazine maleate 10 mg 1 tablet(s) by mouth q6h:prn Disp #30 Tablet Refills:0 2. Sucralfate 1 gm PO TID:PRN upset stomach with meals RX sucralfate 1 gram/10 mL 10 mL by mouth TID:PRN Refills:*0 3. Acetaminophen 500 mg PO Q8H:PRN Headache 4. Aspirin 243 mg PO DAILY 5. Atorvastatin 80 mg PO QPM 6. Clopidogrel 75 mg PO DAILY 7. Divalproex (EXTended Release) 500 mg PO BID 8. Divalproex (EXTended Release) 250 mg PO QPM 9. Docusate Sodium 100 mg PO BID constipation 10. FLUoxetine 20 mg PO DAILY 11. Furosemide 20 mg PO DAILY 12. Gabapentin 300 mg PO TID 13. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN Pain - Moderate 14. Glargine 56 Units Breakfast Glargine 56 Units Bedtime 15. Levothyroxine Sodium 25 mcg PO DAILY 16. Losartan Potassium 50 mg PO DAILY 17. Magnesium Oxide 400 mg PO BID 18. melatonin 2.5 mg oral QHS:PRN 19. MetFORMIN (Glucophage) 1000 mg PO BID 20. Metoprolol Tartrate 12.5 mg PO BID 21. Pantoprazole 40 mg PO Q24H 22. Rivaroxaban 10 mg PO DAILY 23. Senna 8.6 mg PO DAILY constipation 24. TraZODone 300 mg PO QHS Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSES Volume depletion Acute Kidney Injury Testicular Cancer Secondary diagnoses: Chronic lymphocytic leukemia Coronary artery disease Diabetes mellitus type 2 Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you at ___. WHY DID YOU COME TO THE HOSPITAL? You were feeling weak and tired, and you had a fall at home. This was likely due to dehydration. WHAT HAPPENED WHILE YOU WERE HERE? We treated you with IV fluids, and started some new medicines for nausea. WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL? Please continue to take all of your medications as directed, and follow up with all of your doctors. Again, it was a pleasure taking care of you! Sincerely, Your ___ Team Followup Instructions: ___
10014354-DS-22	10,014,354	24,980,601	DS	22	2150-02-08 00:00:00	2150-02-08 14:17:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / erythromycin base / cheeses soft, ___, cottage, cream cheese Attending: ___. Chief Complaint: L sided weakness and numbness in face, arm, leg Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ man with CLL on Venclexta, hx testicular cancer, diabetes, hypertension, hyperlipidemia, obesity, right subcortical stroke in ___ with residual left leg weakness (ambulates with a cane), remote BPV, sick sinus syndrome status post pacemaker, depression with psychotic features, presenting with vertigo, near falls, vision changes. He describes near-constant vertigo, worse with position changes, and several near syncopal events, starting ___ morning ___. Symptoms initially improved that evening, but when he woke up on ___ felt significantly worse. He had no associated nausea or vomiting, but was taking reduced p.o. (water only minimal food) due to concern that he would become nauseous and be at risk for falling while going to the bathroom. On ___, he called the on-call physician for his insurance, and was advised to go to the ED to be evaluated; however, he did not, because he had just put in a freestyle ___ monitor and was worried that they would take it out if he needed a scan (he paid for this out of pocket). He did however call his wife, from whom he is separated, and went to stay with her. Due to continuing symptoms on ___, he went to ___ urgent care. His vitals were unremarkable, and his exam was notable for almost falling off of his chair with extraocular movement check. His finger-nose-finger was notable for past pointing bilaterally, and he had binocular double vision. He was sent to the ___ ED by ambulance for further work-up. He reports that While getting into the ambulance from ___, he developed left arm and leg weakness and numbness. On arrival to the emergency room a rapid response was called due to concern for stroke. He had hypoglycemia to 50. A an amp of dextrose, after his blood sugar improved to 126 and left arm weakness and numbness improved, however, his leg still is "paralyzed". CT head was negative for an acute bleed; CTA head and neck had no thrombus. Labs notable for: WBC 8.9, hemoglobin 10.7, platelets 198 INR 1.6, ___ 17.2, PTT 46.3 BUN 21; hold blood: Sodium 138, K3.6, chloride 103, bicarb 25, creatinine 1.1 Troponin negative, lactate 1.6 AST 42, ALT 38, alk phos 107, T bili 0.3, albumin 4.2 Negative serum tox for ASA, ethanol, acetaminophen, TCA. ___ Imaging notable for negative CTA head and CT brain perfusion scan, copied below, wet read. The patient was given: -1 amp dextrose -Hydrocodone-acetaminophen ___ p.o. x2, which she reports was ineffective Vitals prior to transfer: Heart rate 73, blood pressure 136/65, respiratory rate 16, satting 98% on room air, glucose 124. Upon arrival to the floor, the patient confirms the above history. He additionally describes some dyspnea on exertion that has been long-standing and which he attributes to his wife's ___ smoke. A complete REVIEW OF SYSTEMS was negative except for as noted in the HPI. Specifically, he denies lightheadedness, headache, chest pain, palpitations, abdominal pain, constipation, dysuria, rash, joint pain. Of note, in ___ and ___ he had an external work-up for left arm weakness concerning for possible TIAs, unrevealing for an embolic disorders. Past Medical History: PAST ONCOLOGIC HISTORY: CLL (17p-) and Stage IIIA Mixed germ cell tumor of the testis - ___ Lymphocytosis incidentally found during a psychiatric hospitalization. - ___ CT scan showed a slightly enlarged spleen at 14.5 cm and no adenopathy. - ___ He met with Dr. ___ in ___ at ___. WBC was 15.0 with 49.6% lymphocytes, Hgb 11.9, and platelets 260,000. Flow cytometry was consistent with CLL, and B-cell gene rearrangement confirmed clonality. CLL FISH panel showed a p53 mutation. He was asymptomatic at the time of diagnosis and followed with Dr. ___. - WBC gradually uptrended to 22.7 in ___, 37.3 in ___, 51.3 in ___, and 50.4 on ___. Hgb has decreased slightly to 10.9 and Hct 34.4 with platelets 234,000 on the ___ labs. - ___ Hematology care transitioned to Dr. ___ after Dr. ___. He also started having nightly sweats. - ___ CT Chest without lymphadenopathy or other notable findings. - ___ Initial ___ Hematology evaluation for second opinion. WBC 50.7, Hgb 10.5, Hct 33.2, Plt 226. Peripheral blood flow cytometry and cytogenetics confirmed CLL with TP53 deletion. - ___ CT Abdomen/Pelvis without lymphadenopathy or other notable findings. - ___ Started ibrutinib 420 mg daily. - ___ Ibrutinib held for vitreous bleed - ___ Ibrutinib restarted - ___ Per OSH records, underwent scrotal U/S showing heterogeneous left testicle, prominent rete testis on right. - ___ Presented to his outpatient hematologist, Dr. ___ a painful swollen left testicle (swelling over ~8 months, worsening pain). This had been evaluated on ___ with an ultrasound that did not demonstrate torsion but did show heterogeneous morphology of the left testicle. HCG was positive. Referred to Dr. ___. - ___ Underwent left radical orchiectomy. Pathology revealed 3.9 cm malignant mixed germ cell tumor of the testis, 95% embryonal carcinoma, 2% teratoma, 2% yolk sac tumor, 1% choriocarcinoma, invading hilar statin ___ vaginalis, with lymphatic vascular invasion and metastatic tumor nodules in the spermatic cord. pT2NxS1 (although no post-orch levels, beta hCG 64 on ___, up from 21 on ___ AFP 3, LDH normal). - ___ CT torso showing new 8 mm nodule in the left lower lobe, and comparison with CT ___. Left para-aortic lymphadenopathy up to 2.8 cm and a 3.5 cm fluid collection in the left inguinal region/scrotum, felt to be likely postsurgical. - ___ C1D1 EP - ___ C2D1 EP (delayed 1 week after nasal infection - ___ Admitted for weakness, fall - ___ Admitted for parainfluenza pneumonia, symptomatic anemia, palpitations, developed nausea/vomiting in hospital - ___ C3D1 EP (delayed 1 week, added palonosetron) - ___ C4D1 EP - ___ CT torso with significant decrease in size of the previously seen left para-aortic lymph node which now measures 6 mm, previously 28 mm. Otherwise no LAD. - ___ Restarted ibrutinib for recurrent CLL (night sweats, lymphocytosis) PAST MEDICAL HISTORY: - Sick sinus syndrome s/p PPM ___ Revo DDD, MRI-compatible, ___ - CAD s/p DES to mid-LAD (___) - Stroke ___ (with recovering motor function, though still with some left thigh sensory decrease) - Type II DM (on insulin) - Hypertension - Hyperlipidemia - Morbid Obesity status post gastric bypass surgery ___ - OSA (not on CPAP) - Pancreatitis secondary to alcohol (___) - Cholecystectomy - Hypothyroidism - Osteoarthritis - Bilateral shoulder surgery, chronic pain right shoulder - Major depression with psychotic features - Anxiety - Conversion Disorder - Benign Paroxysmal Positional Vertigo - Glaucoma Social History: ___ Family History: No known history of malignancies. Physical Exam: ADMISSION PHYSICAL EXAM ======================= VS: 98.2, pulse 57/83, heart rate 69, respiratory rate 20, satting 99% on room air GENERAL: Obese man, sitting comfortably in bed, fully conversant, HEENT: Pupils 2 mm, reactive to light; no scleral icterus; moist mucous membranes without any lesions. NECK: no lymphadenopathy CV: Regular rate and rhythm without murmurs PULM: Clear to auscultation bilaterally with good air movement throughout and no adventitious sounds ABD: Obese, nondistended, nontender; cannot assess organomegaly; several ecchymoses at insulin sites EXT: Warm, well-perfused, 1+ pitting edema to knees bilaterally SKIN: No concerning rashes or lesions NEURO: Alert, oriented, telling cogent history, no speech abnormalities. Cranial nerves: - Left homonymous hemianopia on visual field testing. Did not assess blink to threat. - UNABLE to do left lateral gaze with either eye when asked. - Symmetric V1 through V3 sensation bilaterally, symmetric eyes squeeze, bite, puffed cheeks. - Hearing normal, hearing aids in place - Tongue midline, no palate deviation - Shrug symmetric Strength: Moving left arm against gravity; 4+ out of 5 strength in all muscle groups compared to 5 out of 5 on the right. Unable to lift left leg against gravity on command. Sensation of upper extremities symmetric. Reports absent sensation to light touch in all fields of the left leg compared to right; does not feel pinprick on the left leg. Trouble following command for finger-nose-finger, but no obvious dysmetria. PSYCH: slightly odd affect, but overall appropriate. ACCESS: Port DISCHARGE PHYSICAL EXAM ======================= PHYSICAL EXAM: 24 HR Data (last updated ___ @ 721) Temp: Pt. refused Vitals. (Tm 98.2), BP: 124/73 (105-151/57-73), HR: 78 (69-78), RR: 16 (___), O2 sat: 98% (97-99), O2 delivery: Ra, Wt: 296.2 lb/134.36 kg GENERAL: Obese man, sitting comfortably in chair, conversant NEURO: Alert, with fluent speech; EOMI; no scleral icterus; moist mucous membranes without any lesions. Symmetric smile. Pronator drift on L with eyes closed. ___ UE strength and sensation. ___ motor at hip, ___ motor elsewhere + no sensation at LLE; ___ motor, + sensation RLE. Was observed to walk from bathroom later in the morning, stable but slow gait. NECK: no lymphadenopathy, no subclav LAD CV: Regular rate and rhythm, distant heart sounds PULM: Clear to auscultation bilaterally with good air movement, distant ABD: Obese, nondistended, nontender, excoriations on R side EXT: Warm, well-perfused, 2+ ___ edema to mid-shin SKIN: No concerning rashes or lesions PSYCH: linear thought, mood anxious ACCESS: Port Pertinent Results: ADMISSION LABS ============== ___ 03:20PM BLOOD WBC-8.9 RBC-4.01* Hgb-10.7* Hct-34.8* MCV-87 MCH-26.7 MCHC-30.7* RDW-15.0 RDWSD-47.3* Plt ___ ___ 03:20PM BLOOD Neuts-44.9 ___ Monos-10.0 Eos-1.2 Baso-0.3 Im ___ AbsNeut-4.01 AbsLymp-3.86* AbsMono-0.89* AbsEos-0.11 AbsBaso-0.03 ___ 03:20PM BLOOD ___ PTT-46.3* ___ ___ 03:20PM BLOOD UreaN-21* ___ 03:20PM BLOOD ALT-38 AST-42* AlkPhos-107 TotBili-0.3 ___ 03:20PM BLOOD cTropnT-<0.01 ___ 03:20PM BLOOD Albumin-4.2 ___ 01:00AM BLOOD VitB12-513 ___ 01:00AM BLOOD TSH-28* ___ 01:00AM BLOOD Free T4-0.7* ___ 03:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG ___ 03:23PM BLOOD Glucose-50* Lactate-1.6 Creat-1.1 Na-138 K-3.6 Cl-103 calHCO3-25 PERTINENT IMAGING AND MICRO =========================== 1. Head CT: No evidence for acute intracranial hemorrhage or acute major vascular territorial infarction. 2. CT perfusion: 6 ml area of T-max > 6 seconds and mismatch project over the left periatrial white matter and left lateral ventricle, possibly an artifact. If clinically indicated, MRI would be more sensitive for the detection of acute infarct. 3. CTA: No carotid stenosis by NASCET criteria. Atherosclerosis of intracranial carotid and intracranial vertebral arteries without flow-limiting stenosis. 4. Ossification of the posterior longitudinal ligament in the upper cervical spine narrows the spinal canal, as seen on the prior cervical spine CT from ___. MRI Head w wo Contrast 1. No evidence of infarction, hemorrhage, mass, or edema. DISCHARGE LABS ============== ___ 12:00AM BLOOD WBC-9.6 RBC-3.62* Hgb-9.7* Hct-31.3* MCV-87 MCH-26.8 MCHC-31.0* RDW-15.1 RDWSD-47.3* Plt ___ ___ 12:00AM BLOOD Glucose-181* UreaN-22* Creat-1.2 Na-138 K-3.9 Cl-101 HCO3-21* AnGap-16 ___ 12:00AM BLOOD ALT-32 AST-39 LD(LDH)-229 AlkPhos-94 TotBili-0.3 ___ 12:00AM BLOOD Calcium-9.1 Phos-3.4 Mg-2.0 UricAcd-7.5* Brief Hospital Course: Mr. ___ is a ___ man with high risk CLL on venetoclax, insulin-dependent type 2 diabetes, history of left sided cerebrovascular accident, depression with psychotic features, reported history of conversion disorder, hypothyroidism, hypertension, who was admitted with left-sided weakness and diminished sensation in the setting of hypoglycemia and 3 days of vertigo. CT head negative, CTA head and neck with no thrombus on admission. MRI Brain performed without acute findings. His symptoms gradually resolved over the course of his stay and he was discharged with outpatient ___. TRANSITIONAL ISSUES ================== [ ] Follow up hypothyroidism. Levothyroxine dose increase ___ from 75mcg to 100mcg, after lab findings of elevated TSH (28) and low free T4 (0.7). Needs repeat TSH/FT4 in ___ weeks [ ] Follow up on neurological symptoms. His L sided weakness and sensory deficits had resolved by time of discharge [ ] F/u blood glucose, he was discharged on his home ___ ___ at meals with ISS per ___ [ ] For his MRI, his freestyle ___ was removed. He may require replacement as an outpatient. [ ] Follow up re: BPPV symptoms. [ ] Follow up re: L forearm-hand peripheral neuropathy, alleviated by capsaicin cream. He was continued on gabapentin 600mg BID as an inpatient. [ ] Follow up on joint/tailbone pain, exacerbated by poor weather. [ ] Follow up uric acid level. He was given 1 dose of allopurinol at discharge after his AM labs showed uric acid 7.5. Will need repeat level at next appointment. [] Discharge weight 296lbs (134Kg), increased throughout hospitalization. Follow up weight, consider increasing dose of daily Lasix if needed ACUTE ISSUES ============ #L sided weakness, numbness #L homonymous hemianopsia #H/o prior CVA Presented with left-sided weakness and diminished sensation. No acute stroke was seen on CT/CTA imaging, despite what would be a large territory infarct given profound ipsilateral facial and upper and lower extremity symptoms. Neurology was consulted and had low suspicion for new event. Hypoglycemia was considered, as this can cause recrudescence of stroke symptoms; however, his symptoms persisted even with correction of blood sugar. B12 and TSH/T4 were also obtained; he was noted to be somewhat hypothyroid, even with medications, and we increased his dosage from 75mcg to 100mcg. He was placed on telemetry; no events were noted. With approval from our EP team and his outpatient cardiologist, an MRI brain was performed, with read notable for no evidence of infarction, hemorrhage, mass, or edema. He continued to work with our ___ team. His symptoms gradually resolved throughout his stay, with full upper extremity strength at discharge and waxing/waning ability to walk on his LLE. There was low concern for an acute stroke or TIA; the primary team, neurology, and psychiatry found that his presentation is most consistent with functional neurologic disorder, with possible recrudescence of stroke symptoms given hypoglycemia and low thyroid. He should follow up as an outpatient for further management of symptoms. #Hypoglycemia in setting of Insulin-dependent Type 2 Diabetes Mellitus His A1c in ___ was 8.7%. His home insulin regimen is 70/30, 100 units 3 times daily. He was reportedly taking in much less p.o. in the setting of his persistent vertigo, which may explain his hypoglycemia. No symptoms of other common causes of hypoglycemia, eg infection or adrenal insufficiency, were found. No insulin was given on admission, and he was started on 50% of his dose the next morning. ___ was consulted and his insulin regimen was adjusted per their recommendations. His home metformin was held but restarted on discharge. His discharge regimen was home ___ ___ at meals with ISS per ___. #Anxiety Psychiatry was consulted regarding his increasing anxiety, and were also made aware of his ongoing symptoms, potentially contributing to his anxiety. He was given lorazepam prn for acute anxiety events. #Diabetic neuropathy He noted exacerbation of L sided neuropathy from fingers to mid forearm. He was given capsaicin cream prn to good effect, and did not note further symptoms throughout the rest of his stay. He also continued on his home gabapentin. #BPPV He noted worsening vertigo the day prior to discharge, similar but reduced in intensity as compared to previous events. He noted that he had been given meclizine prior to good effect. He stated that he felt okay to move around, with the main symptom being that he saw double if something was held close to his face. He was given meclizine. He was able to ambulate without issues at time of discharge. CHRONIC ISSUES ============== #Depression He was continued on home ziprasidone. #CLL He brought in his venetoclax from home, and was continued on his regimen. He was given allopurinol on discharge given a slight increase in uric acid levels. #HTN Continued on home losartan and metoprolol. He was also continued on home furosemide with furosemide prn for ___ edema and increase weight. He should follow up as an outpatient for weight check and possible uptitration of Lasix. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 2. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild/Fever 3. Losartan Potassium 50 mg PO DAILY 4. Magnesium Oxide 400 mg PO BID 5. Gabapentin 600 mg PO BID 6. Colchicine 0.6 mg PO DAILY 7. Venetoclax 400 mg PO DAILY 8. Lidocaine 5% Patch 3 PTCH TD QAM 9. HydrOXYzine 10 mg PO Q6H:PRN anxiety 10. ZIPRASidone Hydrochloride 40 mg PO BID 11. Metoprolol Succinate XL 150 mg PO DAILY 12. Docusate Sodium 100 mg PO BID 13. Senna 8.6 mg PO BID:PRN Constipation - First Line 14. Triamcinolone Acetonide 0.1% Cream 1 Appl TP DAILY 15. Rivaroxaban 20 mg PO DAILY 16. Carbamide Peroxide 6.5% ___ DROP BOTH EARS DAILY 17. Fenofibrate 54 mg PO DAILY 18. Atorvastatin 40 mg PO QPM 19. Furosemide 20 mg PO DAILY 20. Acyclovir 400 mg PO Q8H 21. melatonin 6 mg oral qhs 22. Nystatin-Triamcinolone Cream 1 Appl TP BID 23. Sucralfate 1 gm PO BID 24. Pantoprazole 40 mg PO Q24H 25. Aspirin 325 mg PO DAILY 26. Levothyroxine Sodium 75 mcg PO DAILY 27. ___ 100 Units Breakfast ___ 100 Units Lunch ___ 100 Units DinnerMax Dose Override Reason: home regimen 28. Topiramate (Topamax) 50 mg PO DAILY Discharge Medications: 1. Capsaicin 0.025% 1 Appl TP TID:PRN neuropathy 2. Levothyroxine Sodium 100 mcg PO DAILY RX levothyroxine [Euthyrox] 100 mcg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:*0 3. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild/Fever 4. Acyclovir 400 mg PO Q8H 5. Aspirin 325 mg PO DAILY 6. Atorvastatin 40 mg PO QPM 7. Carbamide Peroxide 6.5% ___ DROP BOTH EARS DAILY 8. Colchicine 0.6 mg PO DAILY 9. Docusate Sodium 100 mg PO BID 10. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 11. Fenofibrate 54 mg PO DAILY 12. Furosemide 20 mg PO DAILY 13. Gabapentin 600 mg PO BID 14. HydrOXYzine 10 mg PO Q6H:PRN anxiety 15. ___ 100 Units Breakfast ___ 100 Units Lunch ___ 100 Units DinnerMax Dose Override Reason: home regimen 16. Lidocaine 5% Patch 3 PTCH TD QAM 17. Losartan Potassium 50 mg PO DAILY 18. Magnesium Oxide 400 mg PO BID 19. melatonin 6 mg oral qhs 20. Metoprolol Succinate XL 150 mg PO DAILY 21. Nystatin-Triamcinolone Cream 1 Appl TP BID 22. Pantoprazole 40 mg PO Q24H 23. Rivaroxaban 20 mg PO DAILY 24. Senna 8.6 mg PO BID:PRN Constipation - First Line 25. Sucralfate 1 gm PO BID 26. Topiramate (Topamax) 50 mg PO DAILY 27. Triamcinolone Acetonide 0.1% Cream 1 Appl TP DAILY 28. Venetoclax 400 mg PO DAILY 29. ZIPRASidone Hydrochloride 40 mg PO BID Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS ================= Neuropathy Weakness/numbness SECONDARY DIAGNOSIS =================== Hypoglycemia in the setting of Insulin-dependent type 2 diabetes Insomnia Depression Chronic lymphocytic leukemia Benign paroxysmal positional vertigo Hypertension Hypothyroidism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. ___, It was a privilege to care for you at ___. WHY WAS I IN THE HOSPITAL? You noted that your left arm, leg, and face were paralyzed. You also noted that you weren't able to appreciate sensation on the left side of your face and your left arm and leg. WHAT HAPPENED TO ME IN THE HOSPITAL? - You received CT scans and an MRI of your brain; in other words, we took pictures of your head. These pictures did not show an acute reason for your weakness and loss of sensation, which was reassuring. Your symptoms resolved over the course of your stay, and you worked with our physical therapists to help with the symptoms. - We gave you a cream to treat the neuropathy you endorsed in your left forearm. - We gave you more Lasix medication to help with the swelling in your lower legs. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? Continue to take all your medicines and keep your appointments. - Continue taking your insulin as you were prior to the hospitalization, you should check your blood sugar at least 4 times a day - Your levothyroxine (synthroid) dose was increased, you will need repeat labs in ___ weeks to monitor levels We wish you the ___. Sincerely, Your ___ Team Followup Instructions: ___
10014354-DS-23	10,014,354	29,757,856	DS	23	2150-04-15 00:00:00	2150-04-15 18:26:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / erythromycin base / cheeses soft, ___, cottage, cream cheese Attending: ___. Chief Complaint: Epigastric Pain Major Surgical or Invasive Procedure: Endoscopy (___) History of Present Illness: Mr. ___ is a ___ man with CLL on venetoclax, hx testicular cancer, IDDM, hypertension, hyperlipidemia, obesity, right subcortical stroke in ___ with residual left leg weakness (ambulates with a cane), sick sinus syndrome status post pacemaker, depression with psychotic features, presenting with sudden onset of epigastric abdominal pain. Patient states he ate dinner at 4:30PM yesterday evening, and an hour later at 5:30pm, he began experiencing epigastric pain. Described pain as sharp and stabbing, 9.5/10. Reported associated nausea, but no emesis. States pain radiated "straight to my back". Denies any alleviating or exacerbating factors. Did not try to take any medications, and instead called an ambulance to bring him to the hospital. Stated he had never felt this pain before. Reportedly had a history of GERD and takes a PPI daily. When asked if this pain resembled his reflux symptoms, he states it's hard to say as he very rarely has reflux symptoms on this regimen. Denies any diarrhea, constipation, obstipation, dysuria, foul smelling urine, hematochezia, melena. Reports last BM the day prior to admission which was normal. No history of gallstones. In the ED, initial vitals: 75 \| 180/74 \| 18 \| 98% RA. Labs significant for WBC 10.6, Plts 149, Hgb 10.0. Na 133, BUN 21, Glu 391. AST 42, ALT 57. T bili 0.2. AP 115, lipase 25, trop <0.01 x2, Lactate 2.0. UA with glucose, but no signs of infection. EKG with sinus tachycardia, no acute ischemic changes, QTc 505. Patient underwent CTA abd/pelvis ___ which showed (prelim) no acute intra-abdominal process. Specifically, no evidence of mesenteric ischemia. Patient got IV morphine 4mg x2, Maalox, foamotidine, viscous lidocaine. Patient admitted to oncology for additional management. On arrival to floors, patient confirms history as above and states his pain improved after getting IV morphine in the ED, now down to a ___. Past Medical History: PAST ONCOLOGIC HISTORY: -___: found to have CLL incidentally on labs performed during psych admission. - Followed for several years until ___ when he noted night sweats and progressive fatigue. - Ibrutinib ___. Complicated by multiple bleeding events Including retinal bleed. Ibrutinib was held, lymph node. Ibrutinib was restarted, c/b GI and pericardial bleeding - Ventoclax initiated ___ PAST MEDICAL HISTORY: -Non-seminoma testicular GCT sp 4 cycles EP ___ -Chronic lymphocytic leukemia as above. -Sick sinus syndrome s/p PPM ___ Revo DDD, MRI-compatible, ___. -CAD s/p DES to mid-LAD in ___ -Cerebrovascular accident (___) with residual left weakness. -Diabetes mellitus type II on insulin -pAF on xarelto -Hypertension. -Hyperlipidemia. -Morbid obesity. -Obstructive sleep apnea - not on CPAP. -Pancreatitis. -Hypothyroidism. -Peripheral neuropathy. -Chronic pain. -Osteoarthritis. -Major depression with psychotic features (vs schizoaffective disorder per patient). -Anxiety. -Conversion disorder. -Benign paroxysmal positional vertigo. -Glaucoma. -s/p Cholecystectomy. -s/p Bilateral shoulder surgery. -s/p Gastric bypass surgery ___. Social History: ___ Family History: Father and mother with cardiovascular disease; mother died of unknown malignancy. Physical Exam: ADMISSION PHYSICAL EXAM: ========================= Vitals: 24 HR Data (last updated ___ @ 428) Temp: 97.6 (Tm 97.6), BP: 137/75, HR: 71, O2 sat: 97%, O2 delivery: RA, Wt: 287.5 lb/130.41 kg GENERAL: Sitting in chair comfortably, eyes closed intermittently throughout interview, NAD, obese HEENT: Clear OP without lesions or thrush EYES: PERRL, anicteric NECK: supple, no JVD RESP: No increased WOB, no wheezing, rhonchi or crackles ___: RRR, no murmurs/rubs/gallops GI: obese, soft, distended. tympanic to percussion over epigastrum. When asked if palpation over epigastrum causes pain during gentle palpation, patient says yes and jumps. However, when palpating the same region without asking if he's tender, patient without pain. No rebound or guarding. EXT: RLE edema 2+, trace pedal edema in LLE, warm. SKIN: dry, no obvious rashes NEURO: alert though closes eyes throughout interview. Responds in short ___ word answers. PERRL, EOMI. ACCESS: POC DISCHARGE PHYSICAL EXAM: ========================= Vitals: 24 HR Data (last updated ___ @ 428) Temp: 98, 126/77, 71, 20, 98% RA GENERAL: Sitting in chair comfortably, pleasant, conversant HEENT: Clear OP without lesions or thrush EYES: PERRL, anicteric NECK: supple, no JVD RESP: No increased WOB, no wheezing, rhonchi or crackles ___: RRR, no murmurs/rubs/gallops GI: obese, soft, distended. Non tender to palpation EXT: RLE edema 2+, trace pedal edema in LLE, warm. SKIN: dry, no obvious rashes NEURO: AOx3, answering questions appropriately. ACCESS: POC Pertinent Results: ADMISSION LABS: =============== ___ 10:23PM BLOOD WBC-10.6* RBC-3.93* Hgb-10.0* Hct-32.8* MCV-84 MCH-25.4* MCHC-30.5* RDW-15.7* RDWSD-47.3* Plt ___ ___ 10:23PM BLOOD Neuts-45 ___ Monos-3* Eos-0* Baso-0 AbsNeut-4.77 AbsLymp-5.51* AbsMono-0.32 AbsEos-0.00* AbsBaso-0.00* ___ 04:48AM BLOOD ___ PTT-33.6 ___ ___ 10:23PM BLOOD Glucose-391* UreaN-17 Creat-1.0 Na-133* K-4.3 Cl-98 HCO3-21* AnGap-14 ___ 10:23PM BLOOD ALT-57* AST-42* AlkPhos-115 TotBili-0.2 ___ 10:23PM BLOOD Albumin-3.7 UricAcd-7.0 ___ 10:23PM BLOOD Lipase-25 ___ 10:23PM BLOOD cTropnT-<0.01 ___ 11:33PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-1000* Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG RELEVANT INTERVAL LABS: ======================= ___ 05:21AM BLOOD Glucose-332* UreaN-28* Creat-1.5* Na-141 K-4.4 Cl-103 HCO3-22 AnGap-16 ___ 05:32AM BLOOD ALT-41* AST-44* LD(___)-409* AlkPhos-98 Amylase-24 TotBili-0.2 ___ 05:32AM BLOOD Calcium-8.5 Phos-3.2 Mg-2.4 UricAcd-9.2* ___ 05:21AM BLOOD VitB12-551 Folate-14 ___ 05:21AM BLOOD 25VitD-13* DISCHARGE LABS: =============== ___ 05:08AM BLOOD WBC-8.7 RBC-3.76* Hgb-9.6* Hct-31.8* MCV-85 MCH-25.5* MCHC-30.2* RDW-15.9* RDWSD-48.7* Plt ___ ___ 05:08AM BLOOD Neuts-40 ___ Monos-10 Eos-1 Baso-0 AbsNeut-3.48 AbsLymp-4.26* AbsMono-0.87* AbsEos-0.09 AbsBaso-0.00* ___ 04:51AM BLOOD Hypochr-2+* Anisocy-1+* Poiklo-2+* Microcy-1+* Polychr-1+* Spheroc-2+* Ovalocy-2+* Schisto-1+* Tear Dr-1+* RBC Mor-SLIDE REVI ___ 05:08AM BLOOD ___ PTT-41.7* ___ ___ 05:08AM BLOOD Glucose-108* UreaN-18 Creat-1.1 Na-143 K-4.0 Cl-109* HCO3-20* AnGap-14 ___ 05:08AM BLOOD ALT-34 AST-42* LD(___)-247 AlkPhos-91 TotBili-0.3 ___ 05:08AM BLOOD Calcium-9.1 Phos-3.6 Mg-2.3 UricAcd-7.6* IMAGING: ======== CTA A/P (___): No acute intra-abdominal process. Specifically, no evidence of mesenteric ischemia. The appendix is not visualized, however, there are no secondary signs to suggest appendicitis. EGD (___): Normal mucosa of esophagus. ___ fistula with mild erythema and food debris. Esophageal hiatal hernia. Healing ulcer of proximal jejunum. EKG: A-paced, V sensed, mod critera for LVH PATHOLOGY: ========== Gastric pouch, biopsy: -Corpus type mucosa within normal limits. Brief Hospital Course: BRIEF HOSPITAL COURSE ================================= Mr. ___ is a ___ gentleman w/ history of CLL (on venetoclax), depression with psychotic features, GERD, single remote episode of pancreatitis, IDDM, CAD s/p PCI, roux-en-y gastric bypass & cholecystectomy, & hypothyroidism who presented with acute onset, severe epigastric pain. CTA A/P, lab work & cardiac workup were all unrevealing. Mr. ___ was evaluated by GI and underwent EGD, which revealed a healing jejunal ulcer as well as a ___ fistula. His home PPI was made BID and Mr. ___ was provided with low dose oxycodone prn for pain management. Course was complicated by periods of lethargy and delirium. His levothyroxine was titrated up as his recent TSH was elevated and concern this was contributing to his lethargy. Mr. ___ was also seen by psychiatry, who assisted in medication adjustments. Over the course of his hospitalization, Mr. ___ mental status waxed and waned, likely due to his underlying medical issues and medication titration, however at discharge his mental status was back to baseline and clear. Course was further complicated by ___, that was deemed contrast induced nephropathy. Mr. ___ was seen by renal, and upon discharge his Cr was 1.1. Mr. ___ was followed by ___ throughout his hospitalization for assistance in managing his IDDM. TRANSITIONAL ISSUES: ================================= ___: [] please continue to follow Mr. ___ for his IDDM PCP: [] please check a repeat TSH on ___ and titrate his levothyroxine dose accordingly. he is being discharged on levothyroxine 125mcg daily. GI: [] please follow-up with Mr. ___ after he completes 8 weeks of BID PPI therapy to ensure resolution of epigastric abdominal pain. at that point in time please continue him on daily PPI. PSYCHIATRY: [] please continue to titrate Mr. ___ medications BARIATRIC SURGERY: [] please follow-up with Mr. ___ regarding the ___ fistula that was found on ___ EGD OTHER ISSUES: - Discharge Hemoglobin: 9.6 - Discharge Cr: 1.1 - Discharge weight: 290.78lbs # CODE: Full presumed # CONTACT: Son ___ (___) is his primary proxy, wife (separated) is his alternate ACTIVE PROBLEMS: ====================== # Contrast Induced Nephropathy Mr. ___ with ___, seen by renal and deemed likely ___ contrast induced nephropathy. We held his colchicine, losartan, and furosemide. We renally dosed his medications. However these were resumed on discharge as his renal function recovered. Cr on discharge of 1.1. #Epigastric Abd Pain #Jejunal Ulcer Suspect abd pain ___ healing jejunal ulcer seen on EGD ___. CTA A/P with no concerning findings at this time for infectious, ischemic, or pancreatic etiologies. ECG & trop unremarkable for ACS. Initiated on BID PPI for ___ontinued home mag ox & sucralfate. Provided low dose oxycodone intermittently for pain relief. He should follow up with GI as an outpatient. #Lethargy #AMA Request Unclear etiology but possibly polypharmacy vs. other TME vs. hypothyroidism vs. delirium. Waxing & waning disorientation most c/f superimposed delirium. TSH persistently elevated therefore possible that poorly managed hypothyroidism contributing. Seen by psychiatry, who recommended stopping ziprasidone & amitriptyline & decreasing his gabapentin. Agreed to discharge with home ___. # Insulin-dependent type 2 diabetes: Complicated by peripheral neuropathy. A1c 8.7% in ___ Home insulin regimen is 70/30, 100 units 3 times daily. Followed by ___ & held metformin while inpatient. Will be discharged on regimen of 70/30 insulin, 70 units at breakfast, 60 units at lunch, and 55 units at dinner. Resume metformin at home. #Hx Roux-en-y ___ fistula Fistula seen by EGD ___. Bariatric surgery favor no surgical intervention at current time. GI also favors deferring EGD clipping as unlikely contributing to current presentation. Vitamin studies wnl. Added thiamine supplementation. TI: follow up with Dr. ___ after discharge # Elevated LFTs Mild elevations. Has had intermittently elevated LFTs in past. Likely drug induced liver injury, but unclear precipitant. These resolved upon discharge. # Normocytic Anemia: # Thrombocytopenia: Appears stable. Recent Fe studies indicate ___. Possibly r/t hx gastric bypass vs. colon cancer. Last c-scope ___ w/ tubular adenoma & serrated adenoma. GI at that time rec ___ f/up screen w/ stool based testing d/t difficulty w/ GI prep. TI: colon cancer screening #Hx Depression w/ psychotic features Seen by psychiatry. D/c ziprasidone & amitriptyline per above. Continued escitalopram, risperidone, and topirimate. Decreased dose of gabapentin. #Hypothyroidism Recent TSH elevated at 17 & fT4 low at 0.7. Unclear dose of levothyroxine at home, but increased to 125mcg per day, per ___ recs. TI: repeat TSH 6weeks (___) #Hyperuricemia #Hx of Gout Held home colchicine in s/o renal injury. Initiated allopurinol ___ daily. Home meds were resumed at time of discharge. CHRONIC ISSUES: ================ ___ swelling Per pt at baseline. Held furosemide in s/o renal injury. #CLL Stable. Patient continued on home venetoclax & acyclovir ppx. #Chronic Back Pain Stable. Continued lidocaine patches. #Skin Care Hx xerosis. Possibly ___ hypothyroid. Nystatin & triamcinolone creams. #CAD s/p PCI #CVA w/ residual left sided weakness #HTN ECG & trops w/o e/o ACS. Continued ASA, atorvastatin, metop succ. Held home losartan ___ renal injury. Resumed upon discharge. #HLD #Hypertriglyceridemia ___ cholesterol 334, ___ 1475, HDL 24, LDL 151. Continued home atorvastatin & fenofibrate. #pAF Rate controlled (metop suc) & on OAC (rivaroxaban) #Hx Gout Nothing acute. Held home colchicine ___ renal injury. Started renally dosed allopurinol. d/c planning > 30 min Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q8H 2. Atorvastatin 40 mg PO QPM 3. Fenofibrate 54 mg PO DAILY 4. Furosemide 20 mg PO DAILY 5. Gabapentin 300 mg PO BID 6. Levothyroxine Sodium 100 mcg PO DAILY 7. Lidocaine 5% Patch 3 PTCH TD QAM 8. Losartan Potassium 50 mg PO DAILY 9. Pantoprazole 40 mg PO Q24H 10. Rivaroxaban 20 mg PO DAILY 11. Senna 8.6 mg PO BID:PRN Constipation - First Line 12. Sucralfate 1 gm PO BID 13. Topiramate (Topamax) 50 mg PO DAILY 14. Triamcinolone Acetonide 0.1% Cream 1 Appl TP DAILY 15. Carbamide Peroxide 6.5% ___ DROP BOTH EARS DAILY 16. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 17. HydrOXYzine 10 mg PO Q6H:PRN anxiety 18. Magnesium Oxide 400 mg PO BID 19. melatonin 6 mg oral qhs 20. Metoprolol Succinate XL 150 mg PO DAILY 21. Nystatin-Triamcinolone Cream 1 Appl TP BID 22. Venetoclax 400 mg PO DAILY 23. Docusate Sodium 100 mg PO BID 24. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild/Fever 25. Aspirin 81 mg PO DAILY 26. Colchicine 0.6 mg PO DAILY 27. Amitriptyline 10 mg PO QHS 28. Escitalopram Oxalate 20 mg PO DAILY 29. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY 30. ___ 100 Units Breakfast ___ 100 Units Lunch ___ 100 Units BedtimeMax Dose Override Reason: as per ___ 31. RisperiDONE 3 mg PO DAILY 32. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate Discharge Medications: 1. Allopurinol ___ mg PO DAILY RX allopurinol ___ mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 2. Gabapentin 100 mg PO TID RX gabapentin 100 mg 1 capsule(s) by mouth three times a day Disp #90 Capsule Refills:0 3. ___ 70 Units Breakfast ___ 50 Units Lunch ___ 30 Units Dinner Insulin SC Sliding Scale using HUM InsulinMax Dose Override Reason: home regimen 4. Levothyroxine Sodium 125 mcg PO DAILY RX levothyroxine [Euthyrox] 125 mcg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 5. Lidocaine 5% Patch 3 PTCH TD QPM 6. OxyCODONE (Immediate Release) 2.5 mg PO Q6H:PRN Pain - Moderate 7. Pantoprazole 40 mg PO Q12H RX pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:1 8. RisperiDONE 3 mg PO QHS 9. Rivaroxaban 20 mg PO DINNER 10. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild/Fever 11. Acyclovir 400 mg PO Q8H 12. Aspirin 81 mg PO DAILY 13. Atorvastatin 40 mg PO QPM 14. Carbamide Peroxide 6.5% ___ DROP BOTH EARS DAILY 15. Colchicine 0.6 mg PO DAILY 16. Docusate Sodium 100 mg PO BID 17. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 18. Escitalopram Oxalate 20 mg PO DAILY 19. Fenofibrate 54 mg PO DAILY 20. Furosemide 20 mg PO DAILY 21. HydrOXYzine 10 mg PO Q6H:PRN anxiety 22. Losartan Potassium 50 mg PO DAILY 23. Magnesium Oxide 400 mg PO BID 24. melatonin 6 mg oral qhs 25. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY Do Not Crush 26. Metoprolol Succinate XL 150 mg PO DAILY 27. Nystatin-Triamcinolone Cream 1 Appl TP BID 28. Senna 8.6 mg PO BID:PRN Constipation - First Line 29. Sucralfate 1 gm PO BID 30. Topiramate (Topamax) 50 mg PO DAILY 31. Triamcinolone Acetonide 0.1% Cream 1 Appl TP DAILY 32. Venetoclax 400 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: Jejunal Ulcer Secondary: ___ fistula Lethargy Hypothyroidism Insulin dependent diabetes mellitus Delirium Contrast induced nephropathy Depression with psychotic features, in remission Hyperuricemia Elevated LFTs 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, It was a pleasure taking part in your care here at ___! Why was I admitted to the hospital? - You were admitted for abdominal pain What was done for me while I was in the hospital? - We took pictures of your abdomen to determine what was causing your abdominal pain - We used a camera to look into your stomach (endoscopy) and saw a healing ulcer in your small intestine - We gave you pain medications & anti-acid medications to treat the ulcer - We had diabetes doctors ___ help manage your blood sugars - We had psychiatrists see you to help manage your medications - We had the kidney doctors ___ because your kidney levels were high What should I do when I leave the hospital? - please note that your acid reducing medication (Pantoprazole) should be taken twice a day for the next 8 weeks. - please check your blood sugars before meals and at bedtime everyday, and bring a log of your readings to your next doctors ___. - Take all of your medications as prescribed - Follow-up with all of your physicians as directed Sincerely, Your ___ Care Team Followup Instructions: ___
10014378-DS-19	10,014,378	22,267,781	DS	19	2181-07-23 00:00:00	2181-07-23 18:17:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Penicillins / fluconazole / Strawberry Attending: ___. Chief Complaint: Wheezing, Shortness of Breath Major Surgical or Invasive Procedure: None History of Present Illness: This is an ___ female with a history of asthma, CHF and hypertension presenting to the emergency department for productive cough of yellow sputum and increased wheezing since ___. The patient also states that ___ night she woke up with chills. She has not had another episode of chills. The patient is already on a Z-Pak ___ chronically. The patient called her PCP and was prescribed steroids on ___. The patient has been taking her inhaler and nebulizers every 4 hours and her pro-air 2 times a day. The patient states she is still wheezing and coughing. The patient states her voice has become raspy. The patient has not measured any fevers at home, her p.o. appetite has been okay, no chest pain, no nausea, no vomiting, no, no history of blood clots, no history of DVT, no hemoptysis. The patient states she is not having any more trouble than normal laying flat. She has not noticed increased swelling in her legs. Initial VS: T 97.1, HR 82, BP 121/60, RR 16 98% RA Exam: Respiratory: Mild respiratory distress, no accessory muscle use, equal chest rise, wheezes in all fields with good air movement throughout. CV: RRR with S1 and S2. No S3, S4, murmurs, heaves, thrills, rubs appreciated. (-) JVD. Trace peripheral edema. Radial and Pedal pulses 2+ bilaterally. Pertinent labs/imaging studies: CXR: Low lung volumes. No acute cardiopulmonary abnormality. CBC: WNL Patient received: Duonebs x3, methylpred 125, mag sulfate On arrival to the floor, she confirms the above story. No sick contacts at home, 2 days of increased wheezing, some SOB that is now improved, but mostly just concerned about the wheezing. No fevers or chills, a mild headache. No abdominal, nausea, vomiting, diarrhea, or constipation. Past Medical History: - Asthma - Hypertension - GERD Social History: ___ Family History: Mother & maternal grandmother with stroke. Father and daughter with cancer. Grandmother with CAD/PVD. Physical Exam: ADMISSION ========= Vitals: Temp: 98.3 PO BP: 108/70 HR: 94 RR: 18 O2 sat: 100% O2 delivery: RA General: Alert and oriented x3, no acute distress HEENT: NC/AT, MMM, EOMI Neck: Supple, non-tender Lungs: Diffuse wheezing bilaterally, good air movement, no crackles or consolidations CV: RRR, no murmurs, rubs, or gallops GI: Soft, non-tender and non-distended, BS+ Ext: Warm and well perfused, non-edematous Neuro: Alert and oriented x3, CNII-XII grossly intact, no focal neurologic deficit. DISCHARGE ========= Vitals: Temp: 98.1 (Tm 98.1), BP: 115/64 (115-134/63-77), HR: 74 (74-89), RR: 20 (___), O2 sat: 96%, O2 delivery: Ra General: Alert and oriented x3, no acute distress HEENT: NC/AT, MMM, EOMI Neck: Supple, non-tender Lungs: Diffuse wheezing bilaterally, good air movement, no crackles or consolidations CV: RRR, no murmurs, rubs, or gallops GI: Soft, non-tender and non-distended, BS+ Ext: Warm and well perfused, non-edematous Neuro: Alert and oriented x3, CNII-XII grossly intact, no focal neurologic deficit. Pertinent Results: ADMISSION ========= ___ 02:25PM GLUCOSE-142* UREA N-20 CREAT-1.0 SODIUM-139 POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-25 ANION GAP-10 ___ 02:25PM estGFR-Using this ___ 02:25PM cTropnT-<0.01 proBNP-447 ___ 11:33AM VoidSpec-SPECIMEN R ___ 11:33AM WBC-9.0 RBC-4.52 HGB-12.7 HCT-40.0 MCV-89 MCH-28.1 MCHC-31.8* RDW-16.3* RDWSD-52.3* ___ 11:33AM NEUTS-85.9* LYMPHS-7.7* MONOS-5.5 EOS-0.3* BASOS-0.2 IM ___ AbsNeut-7.71* AbsLymp-0.69* AbsMono-0.49 AbsEos-0.03* AbsBaso-0.02 ___ 11:33AM PLT COUNT-298 DISCHARGE ========= ___ 07:45AM BLOOD WBC-6.5 RBC-4.42 Hgb-12.2 Hct-38.7 MCV-88 MCH-27.6 MCHC-31.5* RDW-15.7* RDWSD-50.5* Plt ___ ___ 07:45AM BLOOD Glucose-117* UreaN-21* Creat-0.9 Na-139 K-4.2 Cl-102 HCO3-26 AnGap-11 IMAGING ======= ___ CXR: Heart size is top-normal. The mediastinal and hilar contours are unremarkable apart from minimal tortuosity of the thoracic aorta and mild atherosclerotic calcifications at the aortic knob. The pulmonary vasculature is normal. Lung volumes are low, but the lungs are clear. No pleural effusion or pneumothorax is seen. There are no acute osseous abnormalities. IMPRESSION: Low lung volumes. No acute cardiopulmonary abnormality. Brief Hospital Course: This is an ___ year old female with past medical history of asthma, GERD, recently diagnosed fungal laryngitis, admitted ___ with acute asthma exacerbation, treated with steroids with slow improvement, able to be discharged home on prednisone taper with outpatient follow up. # Moderate persistent asthma with acute exacerbation Patient with PFTs with evidence of asthma but no obstructive disease, also undergoing workup with ENT with recent laryngoscopy showing fungal laryngitis, who presented with several days of increased wheezing. CXR reassuring no pneumonia. She was treated with IV solumedrol 125MG in the ED and then transitioned to PO prednisone 60MG on admission with standing and prn nebulizers, as well as her home asthma/allergy medications. Unclear trigger for her symptoms. Over 72 hours patient slowly improved back to baseline, was able to ambulate without symptoms and peakflow returned to baseline (she reported baseline as 300-350). Per discussion with outpatient pulmonologist, discharged with prednisone taper and planned PCP, ___, and ENT follow up for ongoing treatment and workup of her recurrent respiratory issues. # Fungal laryngitis Recently diagnosed by ENT 2 weeks ago, unclear how/if this may relate to her chronic respiratory symptom burden. Continued on nystatin with plan for previously scheduled close ENT follow-up. #GERD: Continued home omeprazole and ranitidine #HTN: Continued home triamterene-HCTZ, amlodipine TRANSITIONAL ISSUES # Emergency contact: ___ (___) ___ # Code: Full with limited trial of life sustaining measures > 30 minutes spent on discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheeze 3. Montelukast 10 mg PO DAILY 4. Omeprazole 20 mg PO BID 5. ZyrTEC (cetirizine) 10 mg Oral qd 6. Dyazide (triamterene-hydrochlorothiazid) 37.5-25 mg oral DAILY 7. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation BID 8. amLODIPine 2.5 mg PO DAILY 9. Albuterol Inhaler 1 PUFF IH Q4H:PRN wheeze 10. Calcium Carbonate 500 mg PO DAILY 11. Vitamin D 1000 UNIT PO DAILY 12. Fluticasone Propionate NASAL 1 SPRY NU BID 13. Nystatin Oral Suspension 5 mL PO QID 14. Azithromycin 250 mg PO 3X/WEEK (___) 15. Ranitidine 150 mg PO BID Discharge Medications: 1. PredniSONE 40 mg PO DAILY Duration: 2 Doses Start: Today - ___, First Dose: Next Routine Administration Time This is dose # 1 of 3 tapered doses RX prednisone 10 mg 4 tablet(s) by mouth once a day Disp #14 Tablet Refills:*0 2. PredniSONE 20 mg PO DAILY Duration: 2 Doses Start: After 40 mg DAILY tapered dose This is dose # 2 of 3 tapered doses 3. PredniSONE 10 mg PO DAILY Duration: 2 Doses Start: After 20 mg DAILY tapered dose This is dose # 3 of 3 tapered doses 4. Albuterol Inhaler 1 PUFF IH Q4H:PRN wheeze 5. amLODIPine 2.5 mg PO DAILY 6. Aspirin 81 mg PO DAILY 7. Azithromycin 250 mg PO 3X/WEEK (___) 8. Calcium Carbonate 500 mg PO DAILY 9. Dyazide (triamterene-hydrochlorothiazid) 37.5-25 mg oral DAILY 10. Fluticasone Propionate NASAL 1 SPRY NU BID 11. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheeze 12. Montelukast 10 mg PO DAILY 13. Nystatin Oral Suspension 5 mL PO QID 14. Omeprazole 20 mg PO BID 15. Ranitidine 150 mg PO BID 16. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation BID 17. Vitamin D 1000 UNIT PO DAILY 18. ZyrTEC (cetirizine) 10 mg Oral qd Discharge Disposition: Home Discharge Diagnosis: PRIMARY ======= Asthma SECONDARY ========= Gastroesophageal Reflux Disease Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure caring for you at ___ ___. WHY WAS I IN THE HOSPITAL? - You were wheezing and short of breath. WHAT HAPPENED TO ME IN THE HOSPITAL? - You got IV and oral steroids and nebulizer treatments to improve your breathing. - You felt better and continued to have good oxygen levels without needing extra oxygen so you were discharged home. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - You should complete your prednisone taper and follow up with your pulmonologist and ENT doctor regarding ongoing workup surrounding your asthma and cough. We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___
10014449-DS-11	10,014,449	23,164,170	DS	11	2174-05-29 00:00:00	2174-05-30 12:52:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: morphine Attending: ___. Chief Complaint: OSH transfer for RUE DVT Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ with PMH of Breast CA s/p mastectomy, colon CA s/p XRT and total colectomy, AFib on coumadin, ___ with EF 30%< HLD, and obesity transferred from ___ ___ for management of R arm swelling and discomfort. Regarding relevant history, patient was recently admitted to ___ ___ for vaginal bleeding and s/p fall in the setting of therapeutic INR of 3. Through work-up for vaginal bleeding conducted and including cystoscopy, colonoscopy, and CT A/P (patient is s/p hysterectomy) that were unrevealing, making atrophic vagina from prior XRT the most likely etiology. In this setting, the patient's warfarin was held and she was recommended estrogen cream (but never took it). During this admission, patient had a PICC line placed ___ for IV access, lab draws, and medication administration that was removed on ___ prior to discharge. Approximately 1 week after discharge, patient and daughter followed up with PCP ___. She was told to restart coumadin approximately 1 week after this appointment, so she has been back ___ coumadin for ___ weeks. In this setting, patient's vaginal bleeding has recurred. She was recommended an estrogen ring, but declined. Per the patient's daughter, the patient developed some R finger swelling starting a week or so ago that was initially attributed to her arthritis. She then developed increasing hand swelling, for which she presented to PCP's urgent care office and was prescribed Keflex ___ for presumed cellulitis. Given that the pain persisted/worsened, the patient subsequently presented to ___. ED physician there was concerned for blood clot given lack of evidence for infection (no fevers or leukocytosis), and because of their hospital's inability to obtain an U/S over the weekend, patient was transferred to ___ for further management. Upon arrival to ___ ED, initial VS 98.2 90 120/80 18 98%. Labs notable for K 3.1, Cr 1.5, INR 2.6. R UENI notable for "non-occlusive thrombus in the right mid cephalic vein which also has the PICC line/venous line. Clot does not extend to the axillary vein." Per OSH ED reports, line in RUE was actually an IV. This was removed and replaced with LEJ peripheral IV. Given concern for clot in the setting of therapeutic INR, patient is being admitted to Medicine for further management. VS prior to transfer 98.5 84 sBP 130 16 96% RA. Upon arrival to the floor, VS Afebrile 106/65 88 16 100%RA. Patient is unable to recollect much of prior hospitalization and recent medical management. She complains of continued RUE pain, but otherwise denies fevers, chills, chest pain, SOB beyond usual DOE, abdominal pain, N/V/D. Past Medical History: Rectal CA s/p total colectomy Left breast CA s/p radical mastectomy AFib on coumadin s/p pacemaker ICD CAD c/b MI CHF EF 30% CKD Stage IV HLD OSA noncompliant with CPAP Intertrigo Post-menopausal vaginal bleeding Social History: ___ Family History: Noncontributory Physical Exam: ADMISSION PHYSICAL EXAM ======================= Vitals: Afebrile 106/65 88 16 100RA General: Obese elderly lady, lying in bed shivering/tremulous, but in NAD HEENT: NC/AT, PERRL, EOMI, oropharynx clear, MMM Neck: Supple CV: Distand heart sounds Lungs: CTAB anteriorly Abdomen: Obese, soft, NT/ND, no rebound/guarding, unable to appreciate GU: No foley Ext: RUE with tense swelling up through mid-forearm, overlying erythema over R hand and fingers (outlines), unable to flex fingers. Chronic lymphedema of LUE from mastectomy. Neuro: CN II-XII intact, moving all extremities spontaneously. Sensation (light touch) intact in R hand and foreharm. DISCHARGE PHYSICAL EXAM ======================= Vitals: AF 97.8 140/79 94 18 98%RA General: Obese elderly lady, lying in bed shivering/tremulous, but in NAD HEENT: NC/AT, PERRL, EOMI, oropharynx clear, MMM Neck: Supple CV: Distand heart sounds Lungs: CTAB anteriorly Abdomen: Obese, soft, NT/ND, no rebound/guarding, unable to appreciate GU: No foley Ext: RUE with improved/less tense swelling up through mid-forearm, overlying erythema over R hand and fingers (outlines), unable to flex fingers. Chronic lymphedema of LUE from mastectomy. Neuro: CN II-XII intact, moving all extremities spontaneously. Sensation (light touch) intact in R hand and foreharm. Pertinent Results: ADMISSION LABS =============== ___ 05:20AM BLOOD WBC-9.7 RBC-3.79* Hgb-11.8* Hct-36.1 MCV-95 MCH-31.1 MCHC-32.6 RDW-15.0 Plt ___ ___ 05:20AM BLOOD Neuts-79.6* Lymphs-11.8* Monos-8.1 Eos-0.2 Baso-0.4 ___ 05:20AM BLOOD ___ PTT-38.4* ___ ___ 05:20AM BLOOD Glucose-122* UreaN-29* Creat-1.5* Na-141 K-3.1* Cl-103 HCO3-24 AnGap-17 ___ 05:20AM BLOOD Calcium-8.6 Phos-4.0 Mg-2.0 DISCHARGE LABS ============== ___ 03:40AM BLOOD WBC-9.2 RBC-3.75* Hgb-11.4* Hct-35.9* MCV-96 MCH-30.4 MCHC-31.7 RDW-14.9 Plt ___ ___ 03:40AM BLOOD ___ ___ 03:40AM BLOOD Glucose-126* UreaN-32* Creat-1.4* Na-140 K-4.0 Cl-102 HCO3-29 AnGap-13 ___ 03:40AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.2 REPORTS ======= ___ UNILAT UP EXT VEINS US RIGHT: The left subclavian vein cannot be visualized for comparison. There is normal flow and respiratory variation in the right subclavian vein. The right internal jugular and axillary veins are patent and compressible with transducer pressure. The right brachial and basilic veins are patent and compressible with transducer pressure and show normal color flow. There is a partially occlusive non-compressible thrombus in the cephalic vein which also contains an echogenic focus consistent with a PICC or venous catheter, or the cast of a PICC in thrombus that has been removed (resident caring for patient states PICC has been removed and replaced with peripheral IV). Thrombus does not extend to the axillary veins. IMPRESSION: Non-occlusive thrombus in the right cephalic vein. Clot does not extend to the axillary vein. Brief Hospital Course: ___ woman with a history of breast canacer s/p mastectomy, colon cancer s/p radiation and total colectomy, post-menopausal vaginal bleeding x2 months, atrial fibrillation on coumadin, chronic systolic heart failure with EF 30%, hyperlipidema, and obesity transferred from ___ for management of right upper extremity swelling. # Right cephalic vein thombosis/Superficial thrombophlebitis: Patient presented with right upper extremity swelling, erythema, pain with ultrasound showing clot in the right cephalic vein not extending extending into axillary vein. For this superficial thrombophlebitis, patient was managed supportively with Tylenol, elevation, and hot compresses with improvement in pain and swelling prior to discharge. # Atrial fibrillation s/p pacemaker ICD: CHADS2 score ___ (age, CHF). Therapeutic INR on admission, patient was continued on her home dose of coumadin 2.5mg daily per her ___ clinic. Patient's heart rate remained well-controlled in the 80-90s during thsi admission on her home metoprolol. # Post-menopausal vaginal bleeding: Thorough work-up at ___ ___ ___ including cystoscopy, colonoscopy, and abdomen/pelvis CT that were negative. Patient is status post hysterectomy so no evaluation of uterus was required. As such, the etiology of her vaginal bleeding was thoughout secondary to vaginal atrophy in the setting if being post-menopausal and receiving radiation for colon cancer. Patient was recommended estrogen vaginal cream and well as vaginal ring, both of which she declined. In the setting of restarting coumadin, vaginal bleeding recurred and during this admission she reported using ___ pads/day. During this admission, patient was amenable to trying vaginal estrogen after education that hormone would not be systemic and should not cause facial growth. She was administered a dose vaginal conjugated estrogen 1g during this admission with improvement in vaginal bleeding. She agreed to start the vaginal estrogen ring already prescribed for her upon returning home. ___ was arranged to help ensure proper application. # Chronic systolic heart failure: The patient remained without evidence of decompensatied heart failure during this admission. She was continued on her home furosemide 80mg BID. Potassium supplementation was initiated in the setting of hypokalemia discovered on labs. # Coronary artery disease: Remained stable, continued on his home aspirin 81mg daily. # Hyperlipidemia: Remained stable, continued on home atorvastatin 20mg daily. ================================= TRANSITIONAL ISSUES ================================= - Patient/family agreed/preferred to use estrogen vaginal ring already prescribed by outpatient provider. Advised to apply and continue per outpatient provider's instructions. - STARTED on Tylenol for R upper extremity pain - STARTED KCl 20meq daily supplementation given diuretic regimen and hypokalemia on admission - CONTINUED on home coumadin. INR remained therapeutic during this hopistalization. Patient should maintain regular INR checks. - STARTED on home physical therapy - Patient instructed to call PCP office for appointment ___ weeks after discharge (contact information provided). Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Aspirin 81 mg PO DAILY 2. Warfarin Dose is Unknown PO Frequency is Unknown 3. Nitroglycerin SL 0.4 mg SL PRN chest pain 4. Atorvastatin 20 mg PO DAILY 5. Ferrous Sulfate 325 mg PO BID 6. Ranitidine 150 mg PO BID 7. Furosemide 80 mg PO BID 8. Vitamin D ___ UNIT PO DAILY 9. Metoprolol Succinate XL 50 mg PO DAILY 10. Cyanocobalamin Dose is Unknown PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 20 mg PO DAILY 3. Ferrous Sulfate 325 mg PO BID 4. Furosemide 80 mg PO BID 5. Metoprolol Succinate XL 50 mg PO DAILY 6. Ranitidine 150 mg PO BID 7. Vitamin D ___ UNIT PO DAILY 8. Warfarin 2.5 mg PO DAILY16 9. Acetaminophen 1000 mg PO Q8H:PRN pain RX acetaminophen 500 mg 2 tablet(s) by mouth Every 8 hours as needed for pain Disp #24 Tablet Refills:0 10. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours RX potassium chloride 20 mEq 1 packet(s) by mouth daily on days that you take Lasix Disp #14 Packet Refills:0 11. Nitroglycerin SL 0.4 mg SL PRN chest pain 12. Cyanocobalamin 1000 mcg PO DAILY 13. estradiol 2 mg vaginal Unknown Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY Right upper extremity superficial thrombophlebitis Post-menopausal vaginal bleeding Atrial fibrillation SECONDARY Chronic systolic heart failure Coronary artery disease Hyperlipidemia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you during this hospitalization. You were admitted to to ___ ___ for right hand swelling due to a blood clot in one of the veins in your arms. This was likely due to the prior IV you had in your right arm when you were admitted to to ___ ___ in ___. You were treated with Tylenol and hot packs with improvement in your hand swelling and pain. You should continue these treatments at home. You were continued on your home coumadin to prevent strokes in the setting of your abnormal heart rhythm. Because of your vaginal bleeding, you agreed to use the vaginal estrogen ring already prescribed for your vaginal bleeding. Please follow your primary care doctor's instructions on how to apply this ring. Your blood counts were monitored and remained stable during this hospitalization. Our physical therapy team saw you, and felt that you would benefit for additional physical therapy at home. You are now safe to leave the hospital. It is very important that you schedule a follow-up appointment with your PCP ___ ___ weeks of leaving the hospital. Please take all your medications as prescribed. Followup Instructions: ___
10014610-DS-32	10,014,610	23,859,571	DS	32	2174-01-06 00:00:00	2174-01-13 15:30:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: Vancocin / Zosyn / ceftriaxone / Meropenem / Tigecycline / amoxicillin-pot clavulanate / Gentamicin Attending: ___ Chief Complaint: L hand weakness Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is a ___ year old ___ man with a history of severe aortic insufficiency with left ventricular dilatation s/p Bentall with CABGx3 on ___, discharged ___, b/l TKA with R chronic knee infection, presents with 2 days of L hand weakness and progressive L hand sensory loss. He notes that he woke with these symptoms 2 days prior to his ED visit ___ AM) feeling like he couldn't write with his L hand. He had numbness in his L fingers at the time (from tip to where they meet the palm, both dorsal and palmar surfaces) that he feels has gradually progressed circumferentially up his L arm since then. He presents to the ED today concerned about he gradual sensory loss. No pain, tingling, pins/needles. No speech slurring or word finding difficulty. No other focal neurologic symptoms. Ambulating at his baseline with a walker. On neuro ROS, notable for the above. Otherwise, the pt denies headache, loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal weakness, numbness, parasthesiae except as above. No bowel or bladder incontinence or retention. Denies difficulty with gait. On general review of systems, the pt denies recent fever or chills. No night sweats or recent weight loss or gain. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: PMH: HTN, Glaucoma, b/l TKA ___ and ___ L TKA c/b polymicrobial infection - currently on suppressive Moxifloxacin/Fluconazole PSxH: -___ - Bentall Procedure with 27 mm Medetronic root valve and coronary artery bypass grafting x 3 (Ao valve, root, ascAo graft replacement with coronary artery reimplantation onto graft): left internal mammary artery to left anterior descending artery; saphenous vein graft to obtuse marginal branch; saphenous vein graft to posterolateral branch -___ - Bilateral laminectomy L1-L5 with proximal foraminotomies -b/l TKA ___ and ___ Social History: ___ Family History: There is no family history of strokes or significant heart disease per patient Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T:97.7 P:89 R: 18 BP:110/64 SaO2:100% RA General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted Neck: Supple Pulmonary: Regular respirations Cardiac: RRR Abdomen: soft Skin: Midline sternotomy c/d/I, ___ scarring (R>L) from TKA. Neurologic: -Mental Status: Alert, oriented to BI, name, and ___ (thought ___ or ___. Able to relate history without difficulty. Named ___ through ___ only. Language is fluent with intact repetition and comprehension. Poor prosody. There were no paraphasic errors. Pt was able to name both high and low frequency objects. Speech was not dysarthric but was hypophonic. Able to follow both midline and appendicular commands. Pt was able to register 3 objects and recall ___ at 5 minutes (despite category and choice cues). -Cranial Nerves: I: Olfaction not tested. II: PERRL 4 to 2mm and brisk. VFF to confrontation. III, IV, VI: EOMI without nystagmus. No diplopia. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. L hand with pronation and finger curl. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ ___- 5 5 5 5 5 5 5 R 5 ___ ___ * 5 5 5 5 5 5 Abductor pollicis longus, extensor pollicus longus 4- Opponens pollicis 4+ Flexor carpi ulnaris 5- patient notes he is unable to lift this since his R knee infection -Sensory: Diminished pinprick, light touch, temperature sensation worst at L fingers and then gradually improving up to shoulders. Patient notes light touch is worst at the palmar and dorsal services of all of his fingers. On pinprick testing, mildly worse on ___ and ___ digit palmar surfaces, but diffusely diminished primarily across hand palmar surface and dorsal aspect of digits ___. No propriception deficits in L fingers. No deficits to light touch, pinprick, cold sensation, proprioception throughout otherwise. -DTRs: Bi Tri ___ Pat Ach L 2 2 2 0 0 R 2 2 2 0 0 Plantar response was flexor bilaterally. -Coordination: No intention tremor on R, FNF limited on L. -Gait: Patient asked to defer as walker was not readily available (patient uses walker to ambulate at home) ==================================================== DISCHARGE PHYSICAL EXAM: L finger extensors 4-, L finger flexors 5-. L IO 4-. L hand > forearm > arm diminished sensation to pinprick/cold/light touch (but intact to proprioception). Pertinent Results: ADMISSION LABS: ___ 08:53PM BLOOD WBC-8.3 RBC-3.04 Hgb-8.6* Hct-27.8* MCV-91 MCH-28.3 MCHC-30.9* RDW-14.6 RDWSD-48.8* Plt ___ ___ 08:53PM BLOOD Neuts-69.0 Lymphs-9.9* Monos-8.7 Eos-9.7* Baso-1.9* Im ___ AbsNeut-5.71# AbsLymp-0.82* AbsMono-0.72 AbsEos-0.80* AbsBaso-0.16* ___ 06:00AM BLOOD ___ PTT-28.5 ___ ___ 08:53PM BLOOD Glucose-95 UreaN-26* Creat-1.5* Na-135 K-3.7 Cl-99 HCO3-23 AnGap-17 ___ 08:53PM BLOOD ALT-31 AST-43* AlkPhos-82 TotBili-0.3 ___ 06:00AM BLOOD GGT-32 ___ 06:00AM BLOOD CK-MB-2 cTropnT-0.03* ___ 08:53PM BLOOD Calcium-8.9 Phos-3.5 Mg-1.8 ___ 06:00AM BLOOD Triglyc-68 HDL-32 CHOL/HD-3.3 LDLcalc-58 ___ 08:53PM BLOOD TSH-1.3 ___ 06:00AM BLOOD CRP-52.6* ___ 08:53PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG IMAGING: CXR ___: No acute cardiopulmonary process. No focal consolidation to suggest pneumonia. CT HEAD ___: No acute intracranial abnormality including no acute intracranial hemorrhage. Note that MR is more sensitive for the detection of early stroke. MRI C-SPINE ___: 1. No evidence of bony or ligamentous injury. 2. Moderate spinal stenosis at C3-4 and C5-6 levels. Spinal fusion at C4-5 level. 3. Mild extrinsic indentation on the spinal cord by disc bulging and thickening of the ligaments at C3-4 and C5-6 levels without abnormal increased signal within the spinal cord. 4. Foraminal changes as described above. MRI/A BRAIN ___: Subacute appearing infarcts in the left periatrial white matter. No definite acute infarct. Chronic left-sided watershed frontoparietal infarcts. Mild changes of small vessel disease. No significant abnormalities are seen on MRA of the head and neck. DISCHARGE LABS: ___ 07:07AM BLOOD WBC-6.8 RBC-3.17* Hgb-8.6* Hct-28.0* MCV-88 MCH-27.1 MCHC-30.7* RDW-14.4 RDWSD-46.3 Plt ___ ___ 07:07AM BLOOD Plt ___ ___ 07:07AM BLOOD Glucose-107* UreaN-17 Creat-1.1 Na-138 K-3.5 Cl-102 HCO3-28 AnGap-12 ___ 07:07AM BLOOD Calcium-9.0 Phos-3.0 Mg-1.6 Brief Hospital Course: ___ is a ___ year old ___ man with a history of severe aortic insufficiency with left ventricular dilatation s/p Bentall with CABGx3 on ___, discharged ___, history of lumbar stenosis s/p L1-L5 laminectomies, presents with 2 days of L hand weakness and progressive L hand sensory loss. CT/A, MRI brain negative for acute stroke. MRI brain DID show a small subacute stroke in the left posterior periventricular white matter which may have been related to his prior cardiac intervention, although it is impossible to tell. There were also tiny chronic left parietal cortical infarcts that do no correlate with symptoms. MRA was normal. MRI C-spine with diffuse mild degenerative changes, C4-5 and C5-6 discs that abut the cord and mild neural foraminal narrowing at C6 and C7 bilaterally. Though the disease appears diffuse on MRI, clinically the etiology of symptoms most consistent with C7 radiculopathy. ==================== TRANSITIONAL ISSUES: ==================== -soft collar at night -outpatient OT as needed -no need for surgery referral -continue home aspirin for stroke prevention -neurology follow-up to be arranged 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. Fluconazole 100 mg PO Q24H 4. Metoprolol Tartrate 50 mg PO Q8H 5. Moxifloxacin 400 mg Other DAILY 6. Pravastatin 20 mg PO QPM 7. Tamsulosin 0.4 mg PO QHS 8. Sarna Lotion 1 Appl TP QID:PRN itching 9. DiphenhydrAMINE 25 mg PO Q6H:PRN itching Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Docusate Sodium 100 mg PO BID 3. Fluconazole 100 mg PO Q24H 4. Metoprolol Tartrate 50 mg PO Q8H 5. Pravastatin 20 mg PO QPM 6. Sarna Lotion 1 Appl TP QID:PRN itching 7. Tamsulosin 0.4 mg PO QHS 8. DiphenhydrAMINE 25 mg PO Q6H:PRN itching 9. Moxifloxacin 400 mg OTHER DAILY Discharge Disposition: Home Discharge Diagnosis: subacute left parietal lobe stroke C7 radiculopathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to the hospital with left sided arm numbness and mild hand weakness. We have imaged your brain and vessels with CT/CTA and MRI which did not show evidence of an acute stroke. However, we did find evidence of 1 small subacute stroke (at least ___ weeks old) and very small older chronic strokes on the left side of your brain which are not the cause of your symptoms. We imaged your spinal cord at the level of your neck which showed chronic disc disease that abut the spinal cord. We believe your symptoms are coming from a mild impingement of one of the nerve roots coming from your neck, known as "C7 RADICULOPATHY." This does not need to be treated with surgery, but you may benefit from outpatient occupational therapy. You should continue on your baby aspirin for stroke prevention. You may also wear a soft collar at night to help keep your neck in alignment. You can buy this from any pharmacy. You should follow-up with stroke neurology as an outpatient. It was a pleasure taking care of you, Your ___ Neurologists Instructions: 1. Please continue to take all your medications as directed. 2. Please follow up with your primary care doctor. 3. Please call with any questions. Followup Instructions: ___
10014610-DS-34	10,014,610	20,579,647	DS	34	2174-06-07 00:00:00	2174-06-07 14:46:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Vancocin / Zosyn / ceftriaxone / Meropenem / Tigecycline / amoxicillin-pot clavulanate / Gentamicin Attending: ___ Chief Complaint: knee pain Major Surgical or Invasive Procedure: ORIF, washout, debridement History of Present Illness: ___ with PMH of ___ year old man with a history of severe aortic insufficiency with left ventricular dilatation s/p Bentall with CABGx3 on ___, b/l TKA with R chronic knee infection on moxifloxacin and fluconazole who presents with acute onset R knee pain. Patient started feeling knee pain overnight on ___. Patient was woken up in the middle of the night by the pain. Pain was ___. Tried to get up out of bed, but was unable to get out of bed or put weight on it. Noticed joint swelling. Pain is worse today. Hurts when moves or puts weight on it. No other joints joints. No fevers, chills, shortness of breath. No fevers, chills, SOB. No dysuria, hematuria. Feels pain and numbness. In review of recent surgical history, patient had TURP on ___ that was uneventful. He also states that he had a dental procedure in the last month for replacement of his dentures. He was given prophylactic antibiotics prior to the procedure. In review of his R chronic knee infection: He received his initial knee replacement in ___, but developed acutely septic right TKA later in the month. In the next few months, knee cultures grew proteus and staph species; he was treated with several operations including a liner exchange. He was eventually revised to remove his entire prosthesis in ___, at which time a GMRS prothesis was placed. He was last admitted to ___ on ___ and received 8 staged irrigation and debridements with VAC changes and eventual use of an antibiotic spacer before final reconstruction on ___. Early cultures of his wound from ___ grew E. coli, Enterococcus sp., Bacteroides, and ___ parapsilosis. However, later wound cultures and gram stains from ___ were negative. After his latest reconstruction with rectus free flap and skin graft on ___, he was maintained on piperacillin-tazobactam and rifampin. In the ED, initial vitals were: T 98.6 HR 94 BP 116/67 16 100% RA Exam notable for R knee warmth and tenderness to palpation. Swelling difficult to assess given post-operative anatomy. ROM limited due to pain. Sensation intact bilaterally. Statis dermatitis changes present b/l. Labs notable for WBC 16, Cr 1.6 (bl 1.0), CRP 101 (last 52 in ___ Imaging notable for -Renal u/s w no hydronephrosis -R knee XR: hardware loosening of the tibial component that is chronic but increased posterior and varus angulation. Extensive overlying soft tissue swelling, no definite superimposed osseous fracture. Ortho was consulted and recommended: admit for pain control, ___ consult, continue suppressive abx, follow up in clinmic w Dr. ___ week. Recommend further w/u of elevated Cr and WBC. Patient was given: 1g Tylenol, 2L IVF, 5 mg po oxycodone Decision was made to admit for ___ and leukocytosis Vitals prior to transfer: T 98.6 BP 139/75 RR 16 100% RA On the floor, pt reports feeling chills and minimal pain in R knee Past Medical History: PMH: HTN, Glaucoma, b/l TKA ___ and ___ L TKA c/b polymicrobial infection - currently on suppressive Moxifloxacin/Fluconazole PSxH: -___ - Bentall Procedure with 27 mm Medetronic root valve and coronary artery bypass grafting x 3 (Ao valve, root, ascAo graft replacement with coronary artery reimplantation onto graft): left internal mammary artery to left anterior descending artery; saphenous vein graft to obtuse marginal branch; saphenous vein graft to posterolateral branch -___ - Bilateral laminectomy L1-L5 with proximal foraminotomies -b/l TKA ___ and ___ Social History: ___ Family History: There is no family history of strokes or significant heart disease per patient Physical Exam: Discharge Physical Exam: ======================== Vital Signs: afeb 120/64 69 18 98% RA General: Alert, oriented, NAD HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not elevated CV: RRR, I/VI systolic murmur best at LSB, normal S1 + S2, + sternotomy Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding . Abdominal scar noted GU: No foley Ext: multiple scars, brace, staples C/D/I, wound imtact Neuro: CNII-XII intact, ___ strength upper/lower extremities ___ limited by pain). 1+ DPs bilaterally Pertinent Results: Admission Labs: =============== ___ 01:25PM BLOOD WBC-16.5# RBC-4.66 Hgb-10.3 Hct-35.4* MCV-76* MCH-22.1* MCHC-29.1* RDW-17.3* RDWSD-47.8* Plt ___ ___ 05:15AM BLOOD ___ ___ 01:25PM BLOOD Glucose-128* UreaN-23* Creat-1.6* Na-136 K-4.3 Cl-99 HCO3-23 AnGap-18 ___ 05:15AM BLOOD ALT-21 AST-21 LD(LDH)-188 AlkPhos-80 TotBili-0.4 ___ 10:45AM BLOOD CK(CPK)-143 ___ 05:15AM BLOOD Albumin-3.5 Calcium-8.5 Phos-3.0 Mg-1.8 ___ 01:25PM BLOOD CRP-101.1* ___ 05:15AM BLOOD CRP-261.3* ___ 01:25PM BLOOD Lactate-1.9 Discharge labs: ++++++++++++++++++ ___ 05:50AM BLOOD WBC-10.0 RBC-2.91* Hgb-7.7* Hct-24.0* MCV-83 MCH-26.5 MCHC-32.1 RDW-18.0* RDWSD-54.4* Plt ___ ___ 05:24AM BLOOD UreaN-15 Creat-1.2 Na-135 K-3.9 Cl-103 HCO3-24 AnGap-12 ___ 05:24AM BLOOD CK(CPK)-262 ___ 06:40AM BLOOD Phos-3.4 Mg-1.9 ___ 05:49AM BLOOD CRP-278.2* Imaging: ======== ___ Xray Knee: Hardware loosening of the tibial component was also present in ___ but there is increased posterior and varus angulation. Extensive overlying soft tissue swelling. No definite superimposed osseous fracture. ___ Renal US: 1. No hydronephrosis. 2. Debris in the bladder, and possible 4 mm bladder stone. 3. Postvoid bladder volume measured 429 cc. ___ CXR: No radiographic evidence of acute cardiopulmonary disease. Microbiology: ============= ___ 1:25 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: ENTEROCOCCUS FAECALIS. FINAL SENSITIVITIES. BETA LACTAMASE NEGATIVE. HIGH LEVEL GENTAMICIN SCREEN: Resistant to 500 mcg/ml of gentamicin. Screen predicts NO synergy with penicillins or vancomycin. Consult ID for treatment options. HIGH LEVEL STREPTOMYCIN SCREEN: Susceptible to 1000mcg/ml of streptomycin. Screen predicts possible synergy with selected penicillins or vancomycin. Consult ID for details.. Daptomycin MIC: 0.50 MCG/ML (SENSITIVE). Daptomycin Sensitivity testing performed by Etest. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS FAECALIS \| AMPICILLIN------------ <=2 S DAPTOMYCIN------------ S PENICILLIN G---------- 2 S VANCOMYCIN------------ 1 S Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN PAIRS AND CHAINS. Reported to and read back by ___ ___, @08:10 ON ___. Anaerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN PAIRS AND CHAINS. Brief Hospital Course: ___ yo man with complicated PMH including AI/CAD s/p CABG, h/o bilateral TKAs c/b infection on chronic suppressive antibiotics who presented with R knee pain and ___, found to have high grade enterococcal bacteremia and septic arthritis. # R knee pain s/p TKR, and h/o R knee prosthetic joint infection: presented with acute knee pain with a warm and red joint. CRP was > 200. He was also found to have high grade enterococcal bacteremia. He was started on daptomycin given multiple antibiotic allergies and continued on chronic suppressive antibiotics (levofloxacin rather than moxifloxacin, then back to moxifloxacin on recommendation of ID team due to better coverage of his previously grown bacteroides). He underwent ___ guided arthrocentesis on ___ which was significant for WBC count of 12,000 (on antibiotic therapy X 2 days) with 90% PMNs. Culture later grew enterococcus. He was evaluated by orthopedic surgery, who recommended placement of an antibiotic spacer. This was placed on ___, with repeat I&D and ORIF ___. Intra op cultures grew enterococcus as well. Final ID regimen. "Now that the prosthesis is explanted, our plan is to treat with 6 weeks for all bacteria previously found in the knee, inc dapto ~6mg/kg for VSE (but pcn allergic) BSI & septic arthritis s/p explantation, fluc for ___, and moxifloxacin for GNR & anaerobes. This was intended as curative, "mop up" therapy. Consideration for d/c abx if no concern persistent infxn at the end of the course. We also Rx'd treating 14days Bactrim for new E coli in urine culture, esp as pt had recent TURP." Final ortho plan to be discussed at follow-up. Please do not remove sutures until follow-up as wound closure was tenuous. Daily dressing changes by RN. Long term plan unclear. Hope is that if infection is effectively cleared than there is a possibility of a new knee implant. However, given the long term nature of the infection, loss of viable bone, that eventually he may need an above the knee amputation. # blood loss anemia: had 1L blood loss after procedure on ___, requiring 3U PRBCs, IVF, FFP. Remained intubated prophylactically and admitted to ICU, but did quite well and was quickly extubated and returned to medical floor. He then had a very slow drop in hgb through ___. There was a reticulocytosis, but insufficient. We attributed this to blood draws and anemia of chronic disease (infection). We transfused 1 uni on ___ without incident. # Bacteremia: blood cultures from ___ and ___ positive for enterococcus. He remained hemodynamically stable without signs of shock. He was started on daptomycin. Given his history of aortic valve replacement there was high suspicion for endocarditis. As above he was also found to have septic arthritis. TTE and TEE both unrevealing for endocarditis. antibiotics as above. # femur fracture: noted post op, Went for ORIF ___ # UTI: UA with pyuria, urine culture grew E. coli. Per ID guidance he was started on nitrofurantoin BID given his multiple antibiotic allergies, but when ___ was resolved this was switched to Bactrim for planned prolonged course. # ___: mild ___ on admission, resolved with IVF. Likely pre-renal. CHRONIC ISSUES #CAD/AI s/p CABG, Bentall procedure (___): continued metoprolol, asa 81 (these were held briefly after blood loss) but restarted. #HTN: held home lisinopril 5 mg in s/o ongoing infection and lower bp. #BPH s/p TURP ___: pt recently passed voiding trial in ___ at outpatient urology follow up. Patient reports no longer taking tamsulosin at home. # Multiple drug allergies: patient has previously seen allergy but no plans for desensitization per patient/daughter. Would consider going forward. Transitional Issues: - may benefit from antibiotic desensitization - Bactrim through ___ for complex UTI - please follow Hgb, he refused a transfusion on ___ because of slow drift down in hgb which we are attributing to frequent blood draws and anemia of chronic disease. - Outpatient labs weekly - please keep sutures in until f/u ortho appointment. closure was tenuous. - Blood pressure meds were decreased or dropped during hospitalization. If BP rises at rehab, can re-add lisinopril 5mg and increase metoprolol to 150 total. - we have continued LMWH to prevent DVT given his relative immobility and the explant of knee. would recommend until completion of antibiotics though usual course is 3 weeks - he can return to his home if there is sufficient social support. his goal is to be able to transfer to wheelchair to commode to bed. ___, his daughter, is involved in care and may move in with him at discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Fluconazole 100 mg PO Q24H 2. Metoprolol Tartrate 50 mg PO TID 3. Pravastatin 20 mg PO QPM 4. Docusate Sodium 100 mg PO BID 5. Aspirin 81 mg PO DAILY 6. Lisinopril 5 mg PO DAILY 7. Moxifloxacin 400 mg Other DAILY 8. Lumigan (bimatoprost) 0.01 % ophthalmic QHS Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: prosthetic joint infection bacteremia acute kidney injury urinary tract infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. ___, It was a pleasure caring for you. You were admitted because you had a fever, which we believe was caused by bacteria in your knee and blood. This got better with antibiotics and the removal of your prosthetic joint. You also got blood after your operation because of how much you lost as well as another transfusion when your blood count was low. You received fluids for a mild kidney injury which has resolved. Followup Instructions: ___
10014651-DS-6	10,014,651	24,341,393	DS	6	2139-06-11 00:00:00	2139-06-11 21:20:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: oxycodone / Omnipaque / adhesive tape Attending: ___. Chief Complaint: Cough Major Surgical or Invasive Procedure: None History of Present Illness: ___ with a history of mixed ischemic/non-ischemic HFrEF (EF ___, type II diabetes mellitus, HTN, HLD, and CKD, who presented to the ED with dyspnea on exertion and cough. Patient reports she discontinued torsemide in ___ per the recommendation of her outpatient cardiologist. Since then, he has developed progressive shortness of breath on exertion. Currently she feels short of breath after climbing only four steps, needing to stop to take a breath. Associated chronic dry cough, which has worsened over the past few weeks. Denies chest pain, on exertion or at rest, palpitations, light-headedness, dizziness, orthopnea, or PND. However, she does report a "gurgling" sound in her chest when she lies down. With regards to her weight, she has gained ~20lbs since ___ (currently ~240lbs from dry weight ~220lbs). Otherwise denies any other symptoms. She tries to adhere to a low salt diet but unfortunately has not been compliant in recent weeks as her husband passed away on ___ 10 in early ___ and was hospitalized for one month prior to this. She has understandably felt very low since then. In the ED, initial vital signs were notable for; Temp 97.4 HR 102 BP 163/90 RR 20 SaO2 99% RA Examination was notable for; 2+ pitting edema, JVP elevated at 90 degrees, clear lungs bilaterally Labs were notable for; WBC 10.3 Hgb 12.8 Plt 279 Na 139 K 5.1 Cl 102 HCO3 24 BUN 19 Cr 1.0 Plt 261 ALT 20 AST 15 ALP 79 LDH 268 Tbili 0.5 Alb 4.1 Trop-T <0.01 NT-proBNP 1832 Lactate 1.4 Urine studies notable for negative leuks, negative nitrites, 0 WBC, and no bacteria. CXR demonstrated low lung volumes without focal consolidation or pulmonar edema. EKG with rate of 103bpm, sinus rhythm, leftward axis, IVCD with left bundaloid appearance, prolonged QTc, intra-atrial conduction delay, poor R wave progression, Q wave in III, non-specific ST-T abnormalities, similar to prior. Patient was given; - IV furosemide 40mg Vital signs on transfer notable for; Upon arrival to the floor, patient repeats the above story. Reports significant urine output since she received IV furosemide in the ED earlier today. Happy her weight is already 4lbs less since she received furosemide. Currently denies chest pain, shortness of breath, palpitations, light-headedness, or dizziness. Past Medical History: - Mixed ischemic/non-ischemic cardiomyopathy/HFrEF (EF ___ - CAD (60% mid LAD, 30% mid LCx, 50% mid RCA, 90% RPDA) - Mitral/Tricuspid regurgitation, likely functional - Type II diabetes mellitus - HTN - HLD - CKD - GERD - Right TKR - Right rotator cuff tear - Total abdominal hysterectomy Social History: ___ Family History: Mother with history of MI at age ___, valve replacement and remote colorectal cancer. Father died secondary to MI at age ___. Sister with arrhythmia (possibly AF) and multiple stents. Paternal grandmother with an "enlarged heart". Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: Temp 98.9 BP 163/72 HR 81 RR 18SaO2 96% RA GENERAL: sitting comfortably in bed, no distress HEENT: AT/NC, no conjunctival pallor, anicteric sclera, MMM NECK: supple, non-tender, JVP ~15cm at 90 degrees CV: RRR, S1 and S2 normal, no murmurs/rubs/gallops RESP: CTAB, no wheezes/crackles ___: soft, non-tender, obese, BS normoactive EXTREMITIES: warm, well perfused, 2+ lower extremity edema NEURO: A/O x3, grossly intact DISCHARGE PHYSICAL EXAM: ======================== VS: 24 HR Data (last updated ___ @ 541) Temp: 98.3 (Tm 100.0), BP: 93/58 (93-129/58-78), HR: 90 (79-109), RR: 18 (___), O2 sat: 98% (95-98), O2 delivery: RA GENERAL: sitting comfortably in bed, no distress HEENT: AT/NC, anicteric sclera, MMM NECK: supple, JVP 8-9 cm CV: RRR, S1 and S2 normal, no murmurs/rubs/gallops RESP: CTAB ___: soft, non-tender, obese EXTREMITIES: warm, well perfused, no ___ edema NEURO: alert, grossly intact Pertinent Results: ADMISSION LABS: =============== ___ 05:03PM BLOOD WBC-10.3* RBC-4.41 Hgb-12.8 Hct-39.2 MCV-89 MCH-29.0 MCHC-32.7 RDW-13.7 RDWSD-44.6 Plt ___ ___ 05:03PM BLOOD Neuts-58.7 ___ Monos-5.5 Eos-2.4 Baso-0.6 Im ___ AbsNeut-6.03 AbsLymp-3.31 AbsMono-0.57 AbsEos-0.25 AbsBaso-0.06 ___ 05:03PM BLOOD Glucose-261* UreaN-19 Creat-1.0 Na-139 K-5.1 Cl-102 HCO3-24 AnGap-13 ___ 05:03PM BLOOD ALT-20 AST-15 LD(LDH)-268* AlkPhos-79 TotBili-0.5 ___ 05:03PM BLOOD cTropnT-<0.01 ___ 05:03PM BLOOD proBNP-1832* ___ 05:03PM BLOOD Albumin-4.1 Calcium-9.6 Phos-3.3 Mg-1.7 ___ 05:03PM BLOOD TSH-1.1 ___ 05:08PM BLOOD Lactate-1.4 ___ 05:43PM URINE Color-Yellow Appear-Clear Sp ___ ___ 05:43PM URINE Blood-NEG Nitrite-NEG Protein-TR* Glucose-1000* Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 05:43PM URINE RBC-1 WBC-0 Bacteri-NONE Yeast-NONE Epi-<1 INTERVAL LABS: ============== ___ 08:21AM BLOOD %HbA1c-9.2* eAG-217* ___ 08:06AM BLOOD Triglyc-275* HDL-56 CHOL/HD-5.2 LDLcalc-181* DISCHARGE LABS: =============== ___ 07:42AM BLOOD WBC-10.0 RBC-4.26 Hgb-12.5 Hct-38.4 MCV-90 MCH-29.3 MCHC-32.6 RDW-14.0 RDWSD-46.0 Plt ___ ___ 07:42AM BLOOD Glucose-164* UreaN-41* Creat-1.5* Na-138 K-4.2 Cl-97 HCO3-28 AnGap-13 ___ 07:42AM BLOOD Calcium-9.5 Phos-5.4* Mg-1.8 MICROBIOLOGY: ============= None IMAGING AND REPORTS: ==================== CHEST (PA & LAT) ___ FINDINGS: There are low lung volumes. No focal consolidation, pleural effusion, evidence of pneumothorax is seen. Cardiac silhouette size is likely accentuated by low lung volumes and appears borderline to mildly enlarged. Mediastinal contours are unremarkable. No pulmonary edema is seen. IMPRESSION: Low lung volumes without focal consolidation. TRANSTHORACIC ECHO REPORT ___ CONCLUSION: The left atrial volume index is normal. The estimated right atrial pressure is ___ mmHg. There is normal left ventricular wall thickness with a normal cavity size. There is SEVERE global left ventricular hypokinesis and relative preservation of apical function. No thrombus or mass is seen in the left ventricle. Quantitative biplane left ventricular ejection fraction is 13 %. Left ventricular cardiac index is depressed (less than 2.0 L/min/m2). There is no resting left ventricular outflow tract gradient. No ventricular septal defect is seen. Tissue Doppler suggests an increased left ventricular filling pressure (PCWP greater than 18 mmHg). Normal right ventricular cavity size with normal free wall motion. Tricuspid annular plane systolic excursion (TAPSE) is normal. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. The aortic arch diameter is normal. 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 are mildly thickened. There is an eccentric, inferolateral directed jet of mild to moderate [___] mitral regurgitation. Due to the Coanda effect, the severity of mitral regurgitation could be UNDERestimated. The tricuspid valve leaflets appear structurally normal. There is trivial tricuspid regurgitation. The pulmonary artery systolic pressure could not be estimated. There is a trivial pericardial effusion. IMPRESSION: Suboptimal image quality. Top normal left ventricular cavity size with severe global hypokinesis in a pattern most c/w a non-ischemic cardiomyopathy. Mild-moderate mitral regurgitation. Compared with the prior TTE (images reviewed) of ___ , the left ventricular ejection fraction is further reduced. Brief Hospital Course: ___ with a history of mixed ischemic/non-ischemic HFrEF (EF ___, type II diabetes mellitus, HTN, HLD, and CKD, who presented to the ED with dyspnea on exertion and cough, in the setting of decompensated heart failure. ==================== ACUTE/ACTIVE ISSUES: ==================== #Acute on chronic HFrEF (EF 25%-30%). Patient presents with one month of weight gain, progressive dyspnea on exertion, and worsening chronic cough, in the setting of stopping torsemide in ___. Prior to this date, the patient had experienced a recovery in her EF to 45-50%. She has also reported stopping her ___ and ___ statin in the ___. Volume overload was felt to have occurred in the setting of diuretic discontinuation as well as dietary indiscretion given the recent passing of her husband earlier this month. BNP on arrival was felt to be elevated at 1832. Repeat TTE on this admission once again showed reduced EF, felt to be similar on imaging to her TTE from ___ (EF ___. She received IV Lasix with improvement in her symptoms before being transitioned to Torsemide 40 mg daily on discharge. She has also been started on Entresto and restarted her on her home Metoprolol. #CAD #Hyperlipidemia. Patient reports discontinuation of atorvastatin due to muscle cramps. She was continued on home ASA and started on Rosuvastatin. #Type 2 diabetes mellitus. Patient with poorly controlled Diabetes found to have glucosuria on UA. A1c 9.2%. ___ was consulted while she was hospitalized with optimization of her insulin regimen and addition of Metformin. She also met with a heart failure nutritionist given recent dietary indiscretion as described above. #Chronic cough. Patient has a history of chronic cough, likely worsened in the setting of hypervolemia. She follows with pulmonology here. PFTs have been unremarkable. ====================== CHRONIC/STABLE ISSUES: ====================== #Depression. Continued home sertraline. Her husband recently passed away but she declined social work consult. She was noted to have excellent family support. #GERD. Continued ranitidine. ==================== TRANSITIONAL ISSUES: ==================== Discharge weight: 105 kg (231.48 lb) Discharge creatinine: 1.5 Heart Failure Medications - Torsemide 40 mg daily - Entresto ___ mg) 1 tab BID - Metoprolol Succcinate XL 75mg daily [] Follow-up with pulmonology as outpatient for chronic cough. [] Plan for patient to follow-up with ___ Endocrinology in the short term given recent adjustments made to her insulin regimen and poorly controlled Diabetes [] Will need repeat electrolytes on ___ to be followed by her cardiologist Dr. ___. [] ___ CRT if no improvement in EF with medical therapy. [] Consider Vascepa if triglycerides continue to remain elevated in the future. #CODE STATUS: Full code #CONTACT: ___, sister, ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 75 mg PO DAILY 2. Sertraline 100 mg PO DAILY 3. Ranitidine 150 mg PO BID 4. Glargine 25 Units Breakfast Glargine 25 Units Bedtime 5. Aspirin 81 mg PO DAILY 6. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. MetFORMIN (Glucophage) 500 mg PO BID RX metformin 500 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:2 2. Rosuvastatin Calcium 20 mg PO QPM RX rosuvastatin 20 mg 1 tablet(s) by mouth qPM Disp #30 Tablet Refills:2 3. Sacubitril-Valsartan (24mg-26mg) 1 TAB PO BID RX sacubitril-valsartan [Entresto] 24 mg-26 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:2 4. Torsemide 40 mg PO DAILY RX torsemide 20 mg 2 tablet(s) by mouth daily Disp #60 Tablet Refills:2 5. Glargine 28 Units Breakfast Glargine 28 Units Bedtime Humalog 12 Units Breakfast Humalog 12 Units Lunch Humalog 12 Units Dinner Insulin SC Sliding Scale using HUM Insulin 6. Aspirin 81 mg PO DAILY 7. Metoprolol Succinate XL 75 mg PO DAILY 8. Multivitamins 1 TAB PO DAILY 9. Ranitidine 150 mg PO BID 10. Sertraline 100 mg PO DAILY 11.Outpatient Lab Work Dx: Acute systolic (congestive) heart failure I50.21 Please obtain chem-10 on ___ Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES ================== Acute on chronic heart failure with reduced ejection fraction Coronary artery disease Hyperlipidemia Type 2 diabetes mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you at ___ ___. WHY WAS I ADMITTED TO THE HOSPITAL? - You were admitted to the hospital for shortness of breath and weight gain. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? - You were given medications (diuretics) to remove fluid from your body. - Imaging of your heart showed decreased heart pumping function. You were started on medications to help improve your heart function and reduce your cardiac risk. - You were found to have elevated blood sugars, so your diabetes regimen was adjusted and you were started on an additional medication (metformin) to help control your blood sugar. WHAT SHOULD I DO WHEN I GO HOME? - You should continue to take your medications as prescribed. - You should attend the appointments listed below. - Weigh yourself every morning, call your doctor if your weight goes up more than 3 lbs. - Seek medical attention if you have new or concerning symptoms or you develop swelling in your legs, abdominal distention, or shortness of breath at night. - Your discharge weight: 105 kg (231.48 lb). You should use this as your baseline after you leave the hospital. We wish you the best! Your ___ Care Team Followup Instructions: ___
10014652-DS-13	10,014,652	24,754,012	DS	13	2148-03-23 00:00:00	2148-03-23 09:07:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: Penicillins Attending: ___. Chief Complaint: left ___ digit MCP dislocation Major Surgical or Invasive Procedure: Open reduction of left ___ digit dislocation at MCP Joint History of Present Illness: ___ y/o p/w irreducible dorsal dislocation of SF MPJ. Pt. now s/p open reduction of MCP fracture. Pt being admitted O/N for monitoring. Past Medical History: PMH: HTN DMT2 - no insulin required diverticulosis hemrrhoids . PSH: TAH - for "benign tumor" Partial L colectomy ___ for acute GI bleed Breast Bx -benign L wrist surgery - "cyst" Central back area infected "cyst" s/p I&D Social History: ___ Family History: sister- h/o diverticulosis, GI bleeding, no surgeries required Physical Exam: GEN - Alert, oriented, no acute distress HEENT - NCAT, MMM, EOMI, sclera anicteric, OC/OP clear NECK - supple, no JVD, no LAD PULM - CTAB, CV - RRR, ABD - soft, NT/ND, normoactive bowel sounds, no guarding or rebound EXT - WWP, no c/c/e, 2+ pulses palpable bilaterally MSK- splint in place, no paresthesias, sensation intouch to light touch, warm well perfused. Motion limited by splint application SKIN - no ulcers or lesions Brief Hospital Course: The patient was admitted to the plastic surgery service on ___ and had a open reduction of left ___ digit MCP dislocation. The patient tolerated the procedure well. . Neuro: Post-operatively, the patient was transitioned to oral pain medications and tolerated it well . . CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. . Pulmonary: The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. . GI/GU: Post-operatively, the patient was given IV fluids until tolerating oral intake. Intake and output were closely monitored. . Prophylaxis: The patient received subcutaneous heparin during this stay, and was encouraged to get up and ambulate as early as possible. . At the time of discharge on POD#1, the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled Discharge Medications: 1. Atenolol 50 mg PO DAILY 2. GlyBURIDE 5 mg PO DAILY 3. Hydrochlorothiazide 25 mg PO DAILY 4. Prazosin 2 mg PO BID 5. Acetaminophen w/Codeine ___ TAB PO Q4H:PRN pain Discharge Disposition: Home Discharge Diagnosis: left ___ digit dislocation at MCP joint with volar plate interposition Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: keep hand in splint until follow up on ___. Do not change dressing NWB left upper extremity Keep splint dry OK to shower tomorrow please resume all home medication take pain medication as indicated Followup Instructions: ___
10014670-DS-14	10,014,670	24,563,254	DS	14	2187-05-11 00:00:00	2187-05-11 14:22:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: aspirin / Levaquin Attending: ___. Chief Complaint: S/P fall back onto head Major Surgical or Invasive Procedure: N/A History of Present Illness: ___ F presents with C1 fracture s/p mechanical fall. She thinks she fell backwards onto the back of her head but is unsure. She was able to get up and walk around prior to presenting to ___ ___, where she was found to have the above fracture, placed in a C-collar and transferred here for further management. She denies neck pain, numbness, weakness, difficulty swallowing, or bowel or bladder incontinence. Past Medical History: A-fib on Coumadin Stroke - cerebral thrombosis, no cerebral infarct, no residual Tachycardia-bradycardia syndrome Hypertension Pacemaker Spinal stenosis Compression fracture of thoracic vertebra, non-traumatic Sensorineural hearing loss, bilateral Otorrhea of right ear Anemia Recurrent UTI Constipation, chronic Social History: Alcohol: yes. Tobacco: never. Illicit drug use: never. Physical Exam: Admission Physical Exam- Vitals: 98.7 72 160/93 16 98% RA General: Well-appearing female in no acute distress. Spine exam: Non-tender over cervical, thoracic, or lumbar spine. Motor: Delt Bic Tri WrE FFl FE IO IP glut Quad Ham TA Gastroc L 5 ___ ___ 5 5 5 5 5 5 R 5 ___ ___ 5 5 5 5 5 5 Sensory: Sensory UE C5 (Ax) R nl, L nl C6 (MC) R nl, L nl C7 (Mid finger) R nl, L nl C8 (MACN) R nl, L nl T1 (MBCN) R nl, L nl T2-L2 Trunk R nl, L nl Sensory ___ L2 (Groin): R nl, L nl L3 (Leg) R nl, L nl L4 (Knee) R nl, L nl L5 (Grt Toe): R nl, L nl S1 (Sm toe): R nl, L nl S2 (Post Thigh): R nl, L nl DTRs: Bi Tri ___ Pat Ach L 2 2 2 2 2 R 2 2 2 2 2 ___: negative Vascular Radial: L2+, R2+ DPR: L2+, R2+ Pertinent Results: ___ 07:50PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG MRI ___ 1. C1 fracture better evaluated on CT cervical spine from the same day. Associated prevertebral soft tissue edema at this level. 2. Moderate spinal canal stenosis at the C5-6 level, related to disc bulge. ___ 09:53AM BLOOD WBC-8.3 RBC-3.55* Hgb-11.6 Hct-35.6 MCV-100* MCH-32.7* MCHC-32.6 RDW-14.0 RDWSD-51.0* Plt ___ ___ 09:53AM BLOOD Plt ___ ___ 09:53AM BLOOD ___ PTT-36.8* ___ ___ 09:53AM BLOOD Glucose-135* UreaN-16 Creat-0.8 Na-132* K-4.4 Cl-97 HCO3-23 AnGap-16 ___ 09:53AM BLOOD Calcium-8.8 Phos-3.4 Mg-2.2 Brief Hospital Course: Patient was admitted to the ___ Spine Surgery Service after being worked up by the Emergency Room. An MRI of her cervical spine on ___ revealed: 1.C1 fracture better evaluated on CT cervical spine from the same day. Associated prevertebral soft tissue edema at this level. 2.Moderate spinal canal stenosis at the C5-6 level, related to disc bulge. The patient will need to wear a cervical collar for at least 6 weeks. TEDs/pnemoboots were used for DVT prophylaxis. Pain was controlled with Tylenol. Diet was advanced as tolerated. Physical therapy and Occupational Therapy Services were consulted for mobilization OOB to ambulate. Hospital course was otherwise unremarkable. On the day of discharge the patient was afebrile with stable vital signs, comfortable on oral pain control and tolerating a regular diet. Medications on Admission: Digoxin Donepezil Duloxetine Memantine Metoprolol Omeprazole Quetiapine Warfarin Discharge Medications: 1. Digoxin 0.125 mg PO DAILY 2. Donepezil 10 mg PO QHS 3. Duloxetine 30 mg PO DAILY 4. Memantine 5 mg PO DAILY 5. Metoprolol Succinate XL 100 mg PO DAILY 6. Omeprazole 20 mg PO BID 7. Warfarin 5 mg PO DAILY16 8. Bisacodyl 10 mg PO/PR DAILY constipation 9. Docusate Sodium 100 mg PO BID 10. Polyethylene Glycol 17 g PO BID constipation 11. Senna 8.6 mg PO BID 12. QUEtiapine Fumarate 25 mg PO BID 13. Acetaminophen 650 mg PO TID pain Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: C1 Fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Cervical Fracture You have sustained a Cervical Fracture of the C1 Vertebrae 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: ___ times a day you should go for a walk for ___ minutes as part of your recovery. You can walk as much as you can tolerate. Cervical Collar / Neck Brace: You need to wear the brace at all times for at least 6 weeks. You may remove the collar for hygiene. Limit your motion of your neck while the collar is off. Place the collar back on your neck immediately after you wash up. You should resume taking your normal home medications. You have also been given Additional Medications to control your pain. . Please allow 72 hours for refill of narcotic prescriptions, so please plan ahead. You can either have them mailed to your home or pick them up at the clinic located on ___ 2. We are not allowed to call in 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 discharge if this has not been done already. At the 2-week visit we will check your neck, take baseline x rays and answer any questions. We will then see you at 6 weeks from the day of dishcharge from the hospital. 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 any questions. Physical Therapy: C-Collar X 6 weeks -Weight bearing as tolerated -No lifting >10 lbs -No significant bending/twisting Treatments Frequency: N/A skin checks underneath collar R shoulder abrasion: may apply xeroform or adaptic with dry gauze and paper tape Followup Instructions: ___
10014765-DS-9	10,014,765	26,650,343	DS	9	2198-11-23 00:00:00	2198-11-23 17:08:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Midazolam / latex Attending: ___. Chief Complaint: Right sided chest pain and worsening SOB Major Surgical or Invasive Procedure: Chest tube placement History of Present Illness: Mr ___ is a ___ y/o M with relevant PMH of A. fib on Coumadin, Sick Sinus syndrome w/ pacemaker, 2-vessel CABG, who presents with R-sided chest pain and worsening SOB. In the first week of ___, the patient developed R-sided pain over the course of a few days. There was intermittent mild non-productive cough. He describes the right-sided chest pain as non-radiating, sharp and worse when lying down on either side. He is able to point to his lateral right-side as the focal point of pain. After a few days of these symptoms, he was seen at ___ on ___ and following CXR indicated R medial lobe consolidation he was then started on 5-day course of azithromycin (___). However, the chest pain then persisted. He then had a business trip to ___ during which he noticed worsening SOB. SOB was worsened with lying flat. He stated that sleeping became a problem d/t pain and required sleeping upright. Though SOB was not affected by exertion. Notably he denied fever, chills, night sweats and weight changes. Additionally, patient noted that a couple of weeks ago he accidently doubled up on his warfarin one day. But he was sure he had not recently doubled up on any dosing. On ROS he endorsed feeling bloated and have intermittent loose stools but denied diarrhea. He has some difficulty initiating urination and notes a weak stream which is not new. He denied HA, acute vision/hearing changes, dysphagia, facial flushing, nausea, vomiting, dysuria and rashes or other skin changes. He denied any travel to TB endemic countries, or exposure to prison or homeless populations. In the ED: Initial vital signs were notable for: 97.1 \| HR 61 \| BP 125/73 \| RR 18 at 98% on RA Exam notable for: Decreased right lower breath sounds. Distended abdomen but nontender to palpation. 1+ pitting edema on bilateral lower extremity. Labs were notable for: WBC 9.7; Hgb 14.1; Hct 43.4; Plt 250 ___ 47.4; PTT 42.2; INR 4.4 Ma 140; K 4.7; Cl 102; Bicarb 24; BUN 21; Cr 1.2; Glu 143 Lactate 1.3 Trop <0.01 X2 Flu A/B Neg ProBNP 585 UA: Color Yellow; Appear Clear; SpecGr 1.025; pH 5.5; Urobil Neg; Bili Neg; Leuk Neg; Bld Neg; Nitr Neg; Prot Tr; Glu Neg; Ket Neg; RBC 2; WBC 2; Bact None; Yeast None; Epi 0 Studies performed include: ECG notable for Afib, T-wave inversion in V2-6 and borderline LVH; Repeat ECG unchanged Bedside ultrasound of abdomen, FAST exam does not show any fluid or ascites. Visualization of right-sided pleural effusion. CHEST (PA & LAT) Large right pleural effusion with significant compressive atelectasis of the right mid and lower lobes. Please refer to subsequent CT for further details. CTA CHEST 1. No pulmonary embolism or acute aortic process. 2. Large right pleural effusion with significant collapse of the right lung. 3. Relative hypodense mass seen within the collapsed right lower lobe raises potential concern for malignancy or pneumonia. Consider thoracentesis with cytology. 4. Sclerotic focus with the T6 vertebra - attention on followup advised. Patient was given: Morphine 2mg IV Consults: None Vitals on transfer: HR 91 \| BP 106/86 \| RR 18 at 94% on RA Upon arrival to the floor, patient noted that his pain was better controlled since being given morphine. He stated he felt a little bloated which was unchanged. Otherwise, he had no acute changes in his symptoms since presenting to the ED. Past Medical History: Afib Sick Sinus syndrome s/p pacemaker placement (___) CAD s/p 2-vessel CABG w/ ___ graft (___) HTN Parathyroidectomy (___) for Hypercalcemia; 1 gland removed Social History: ___ Family History: He stated he has family history of heart problems and diabetes though no known history of cancer. Physical Exam: Admission Exam: =============== VITALS: Temp: 97.7 PO BP: 152/82 L Lying HR: 98 RR: 20 O2 sat: 94% O2 delivery: Ra GENERAL: Alert and interactive. Lying upright in bed NAD. Pleasant. HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without injection. MMM. No cervical LAD or masses. CARDIAC: Irregularly irregular. Normal S1/S2. No murmurs/rubs/gallops. LUNGS: Decreased breath sounds on right side up ___ of his total lung field. Otherwise no wheezes/crackles/rhonchi ABDOMEN: Mild distension. +BS. Soft, non-tender, no HSM or masses palpated. EXTREMITIES: Trace edema bilaterally. Pulses DP/Radial 2+ bilaterally. Well-healed old surgical scar on R medial lower leg. SKIN: Warm. Cap refill <2s. No rash. Some cherry hemangiomas diffuse across body NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal sensation. Gait is normal. AOx3. Discharge Exam: ================ 97.9 PO 114 / 76 77 18 ___ppearing, comfortable in NAD, interactive, lying in bed MMM, OP clear without lesions Irregular HR, no murmurs appreciated Slight decrease in breath sounds at right base, otherwise clear lungs Abdomen soft, nontender, nondistended No peripheral edema, 2+ pulses distally No rashes, bandage over chest tube site Moving all extremities Pertinent Results: Admission Labs: ================ ___ 10:33AM BLOOD WBC-9.7 RBC-4.65 Hgb-14.1 Hct-43.4 MCV-93 MCH-30.3 MCHC-32.5 RDW-13.2 RDWSD-44.8 Plt ___ ___ 10:33AM BLOOD Neuts-69.4 Lymphs-18.8* Monos-10.3 Eos-0.9* Baso-0.4 Im ___ AbsNeut-6.72* AbsLymp-1.82 AbsMono-1.00* AbsEos-0.09 AbsBaso-0.04 ___ 10:33AM BLOOD ___ PTT-42.2* ___ ___ 10:33AM BLOOD Glucose-143* UreaN-21* Creat-1.2 Na-140 K-4.7 Cl-102 HCO3-24 AnGap-14 ___ 10:33AM BLOOD ALT-18 AST-29 LD(LDH)-370* AlkPhos-89 TotBili-0.8 ___ 10:33AM BLOOD proBNP-585 ___ 10:33AM BLOOD cTropnT-<0.01 ___ 01:20PM BLOOD cTropnT-<0.01 ___ 10:33AM BLOOD Albumin-3.8 Calcium-9.2 Phos-3.5 Mg-1.8 Discharge/Interval Labs: ======================== ___ 07:10AM BLOOD WBC-7.7 RBC-4.21* Hgb-12.9* Hct-38.4* MCV-91 MCH-30.6 MCHC-33.6 RDW-13.2 RDWSD-43.1 Plt ___ ___ 07:00AM BLOOD Glucose-148* UreaN-36* Creat-1.4* Na-135 K-5.0 Cl-100 HCO3-25 AnGap-10 ___ 07:10AM BLOOD ___ PTT-25.8 ___ ___ 07:00AM BLOOD Calcium-8.4 Phos-3.1 Mg-1.9 ___ 07:00AM BLOOD CEA-0.9 PSA-1.7 AFP-1.5 ___ 07:10AM BLOOD CA ___ -PND Imaging: ========= CHEST (PA & LAT) on admission Large right pleural effusion with significant compressive atelectasis of the right mid and lower lobes. Please refer to subsequent CT for further details. CTA CHEST 1. No pulmonary embolism or acute aortic process. 2. Large right pleural effusion with significant collapse of the right lung. 3. Relative hypodense mass seen within the collapsed right lower lobe raises potential concern for malignancy or pneumonia. Consider thoracentesis with cytology. 4. Sclerotic focus with the T6 vertebra - attention on followup advised. CT Chest w/o Contrast ___: 1. Interval reexpansion of the right lung status post chest tube placement, with scattered areas of ground glass opacity in the right lung likely representing reexpansion pulmonary edema. 2. A small right pneumothorax, which was not visualized on prior chest radiographs, and a small residual right pleural effusion. 3. Areas of residual opacity primarily in the right middle lobe and right lower lobe are favored to represent atelectasis, however underlying pneumonia or a small mass cannot be entirely excluded. 4. Unchanged calcified aneurysm of the splenic artery. 5. Nonspecific 5 mm hypodensities in the liver, which can be further evaluated with MRI Abdomen with contrast. CXR Portable ___: 1. Interval worsening of large right mid and lower lung opacities likely representing a combination of pleural effusion and atelectasis. However, a superimposed infectious process or mass cannot be excluded. 2. Small right apical pneumothorax. CT Abdomen/pelvis with contrast ___: 1. No evidence of primary malignancy or metastatic disease in the abdomen or pelvis. 2. Cholelithiasis without evidence cholecystitis. 3. Partially visualized loculated right pleural effusion. Pleural fluid cytology ___: Consistent with metastatic adenocarcinoma. Brief Hospital Course: Mr ___ is a ___ y/o M with relevant PMH of A. fib on Coumadin, Sick Sinus syndrome w/ pacemaker, 2-vessel CABG, who presented with R-sided chest pain and worsening SOB found to have malignant pleural effusion with concern for lung primary. ACUTE ISSUES: ============= #Pleural Effusion with Right Lung Collapse #Adenocarcinoma of Unknown primary Patient previously treated with Z-pack on ___ with no impact on symptoms. CTA chest demonstrated large R-sided effusion with significant lung collapse and hypodense mass as well as sclerotic features on T6 vertebrae. IP placed chest tube w 1.5L drainage. cytology showed adenocarcinoma with immunostaining that was not c/w a lung primary. CT Chest did not clearly demonstrate a large mass. CT A/P showed no evidence of mass lesion. Heme-onc was consulted and felt this was most likely pulmonary in origin. They are working to arrange outpatient ___ in the Thoracic ___ clinic for this week. #Hypotension Likely hypovolemic in the setting of large volume pleural effusion drainage. No fevers or leukocytosis to suggest infection. Small pneumothorax but no e/o tension pneumo. Improved with 1L LR and holding home lisinopril. Lisinopril was held at discharge. CHRONIC ISSUES: =============== #Afib #Sick Sinus syndrome s/p pacemaker placement (___) CHADS-VASC score of 5. He presented w/ supratherapeutic INR though no indication of bleeding. Held home warfarin periprocedurally and did not bridge. Continued home verapamil. At discharge, Mr. ___ was started on lovenox given malignancy and likelihood of procedures in the near future for ongoing diagnosis. #Suprathereuptic INR - Resolved Unclear cause of elevated INR. ___ be due to recent azithro. s/p vit K po 5 mg, and 1U FFP normalized. #CAD s/p 2-vessel CABG w/ LIMA graft (___) Continued home atorvastatin #HTN Held home Lisinopril 40 mg given mild hypotension this admission. TRANSITIONAL ISSUES ==================== [ ] Please ensure that patient follows up with thoracic oncology [ ] Tumor markers sent prior to d/c have not resulted at time of discharge. [ ] Please restart lisinopril as indicated [ ] Please discuss ongoing anticoagulation plan with patient pending further work-up of malignancy (lovenox vs return to warfarin or DOAC) [ ]Please repeat Creatinine within one week to ensure stability given contrast exposure ___ and initiation of lovenox #CODE: Full (code) #CONTACT: ___ (son, physician at ___ ___ [x]>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. Verapamil SR 120 mg PO Q24H 2. Warfarin 5 mg PO DAILY16 3. Lisinopril 40 mg PO DAILY 4. Atorvastatin 40 mg PO QPM 5. Finasteride 5 mg PO DAILY 6. Aspirin 81 mg PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever RX acetaminophen 500 mg 2 tablet(s) by mouth every 8 hours Disp #80 Tablet Refills:0 2. Enoxaparin Sodium 100 mg SC BID RX enoxaparin 100 mg/mL 100 mg SC twice a day Disp #30 Syringe Refills:0 3. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line RX polyethylene glycol 3350 17 gram 1 powder(s) by mouth daily Disp #14 Packet Refills:0 4. TraMADol 50 mg PO Q6H:PRN Pain - Moderate RX tramadol 50 mg 1 tablet(s) by mouth every 6 hours Disp #10 Tablet Refills:0 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 40 mg PO QPM 7. Finasteride 5 mg PO DAILY 8. Verapamil SR 120 mg PO Q24H 9. HELD- Lisinopril 40 mg PO DAILY This medication was held. Do not restart Lisinopril until told to restart by your PCP ___: Home Discharge Diagnosis: Malignant pleural effusion ___ Adenocarcinoma of possible lung origin Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you during your stay at ___. WHY WAS I HERE? - You were having pain and trouble breathing WHAT WAS DONE WHILE I WAS HERE? - You had a chest tube place and fluid drained out - The fluid showed cells that are adenocarcinoma - You had a CT scan of your chest, abdomen and pelvis which did not find a tumor - You were seen by oncology who recommended ___ in their clinic for ongoing work-up WHAT SHOULD I DO WHEN I GO HOME? - You should schedule a follow up appointment with your PCP after discharge MEDICATION CHANGES -Stop warfarin -Start lovenox -Start Tylenol -Start Miralax -Start tramadol It was a pleasure taking care of you, Your ___ Care Team Followup Instructions: ___
10014790-DS-4	10,014,790	25,010,346	DS	4	2171-11-11 00:00:00	2171-11-11 19:59:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: LLQ pain Major Surgical or Invasive Procedure: Flexible sigmoidoscopy History of Present Illness: ___ y/o GO lady w/ recent dx of IBD likely ___ (on prednisone PO) presenting to ED w/ LLQ pain and bloody diarrhea. Pt reports waking up this morning at 0500 AM w/ mid abdominal pain quickly localizing to LLQ. Reports this is the most pain she has ever felt. Endorsed some dysuria and L flank pain. Pt had multiple episodes of vomiting in the AM that were non-bloody and "green/bilious". She also reports ___ episodes of diarrhea mixed w/ blood, which is baseline for her in the setting of internal hemorrhoids and recent IBD dx. In terms of her ___ dx, pt reports gradual change in bowel movements this past year. After seeing multiple providers, she eventually had uncomplicated colonoscopy on ___. Histology confirmed colitis in the ascending/descending colon, sigmoid and rectum w/ normal mucosa in specimens from TI ulcerated nodules. No report of granulomata or dysplasia. Pt received dx of ___ and initiated on 40 mg pred on ___ reporting good compliance since. Given less than ideal symptom control ___ episodes of diarrhea daily), prednisone increased to 60 mg on ___ by outpt GI. Also started hydrocortisone enema performed x1 on ___ ___. In the ED, initial vitals: T 97.5 HR 72 BP 156/87 RR18 O2sat 100%RA - Exam notable for: no CMT/adnexal tenderness, diffuse TTP, +IUD strings - Labs notable for: - CRP 4.3 (___) - Urine UCG NEG - UA bland - serum lytes, CBC, LFTs WNL - Imaging notable for: - CT abd & pelv w/ con: - Rectosigmoid inflammation suggestive of IBD - ?IUD migration (to the R) - ?mild L hydronephrosis (no ureteral stone but study w/ con) - Sig flex: PENDING - Pt given: - 1L NS IV - 4 mg morphine IV - Acetaminophen 1000 mg PO - Fleet enema saline (sig flex prep) Pt underwent uncomplicated sig flex, per verbal sign out (pending full report) notable for friable mucosal tissue/inflammation extending up to descending colon suggestive of IBD flare. Pt was evaluated on the floor after return from sig flex. She reported severe nausea and LLQ pain improved only in the setting of pain medication. She confirmed the above admission history. Was informed about upcoming OB/GYN exam and pelvic U/S as well as about pain medication limitations (no opioids, NSAIDs). She confirmed full code status and named boyfriend ___ (___) as emergency contact. REVIEW OF SYSTEMS: General: no weight loss, fevers, sweats. Eyes: no vision changes. ENT: no odynophagia, dysphagia, neck stiffness. Cardiac: no chest pain, palpitations, orthopnea. Resp: no shortness of breath or cough. GI: +nausea, vomiting, diarrhea GU: + dysuria Neuro: no unilateral weakness, numbness, headache. MSK: no myalgia or arthralgia. Heme: no bleeding or easy bruising. Lymph: no swollen lymph nodes. Integumentary: no new skin rashes or lesions. Psych: no mood changes Past Medical History: - Migraines - IBD (___) - Angular cheilitis Social History: ___ Family History: Reports that grandmother had ___ disease. Physical Exam: ADMISSION PHYSICAL EXAM (___): ================================ VITALS: T 98.3 PO, BP 141/85 R lying, HR 64, RR 18, O2sat 100%RA General: A&Ox3, lying in bed in pain w/ nausea HEENT: Sclerae anicteric, MMM, neck supple, JVP not elevated, no LAD CV: RRR, normal S1 + S2, no murmurs/rubs/gallops Lungs: Clear to auscultation anteriorly, no wheezes/rales/rhonchi Abdomen: bowel sounds present x4, diffuse TTP increased in LLQ, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing/cyanosis/edema Skin: Warm, dry, no rashes or notable lesions. Neuro: A&Ox3, moving all extremities w/ purpose DISCHARGE PHYSICAL EXAM (___): ================================ Vitals: 98.1 \| 104/65 \| 53 \| 16 \| 97 RA General: A&Ox3, no acute distress, resting in bed HEENT: Sclerae anicteric, MMM, neck supple, JVP not elevated, no LAD CV: RRR, normal S1 + S2, no murmurs/rubs/gallops Lungs: Clear to auscultation bilaterally, no wheezes/rales/rhonchi Abdomen: +BS, non TTP. No rebound, guarding. GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing/cyanosis/edema Skin: Heme crusted ulcer at the R preauricular Lymph nodes: Faintly palpable, mobile, nontender, R inferior precervical LN. Neuro: A&Ox3, CN2-12 intact, moving all extremities w/ purpose Pertinent Results: ADMISSION LABS: ============== ___ 11:17AM LACTATE-1.2 ___ 08:11AM GLUCOSE-94 UREA N-15 CREAT-0.8 SODIUM-144 POTASSIUM-3.5 CHLORIDE-102 TOTAL CO2-27 ANION GAP-15 ___ 08:11AM estGFR-Using this ___ 08:11AM ALT(SGPT)-13 AST(SGOT)-14 ALK PHOS-52 TOT BILI-0.2 ___ 08:11AM LIPASE-60 ___ 08:11AM ALBUMIN-4.3 ___ 08:11AM CRP-4.3 ___ 08:11AM WBC-8.4 RBC-4.48 HGB-12.1 HCT-38.4 MCV-86 MCH-27.0 MCHC-31.5* RDW-12.7 RDWSD-39.2 ___ 08:11AM NEUTS-59.8 ___ MONOS-15.4* EOS-0.0* BASOS-0.4 IM ___ AbsNeut-5.05 AbsLymp-1.93 AbsMono-1.30* AbsEos-0.00* AbsBaso-0.03 ___ 08:11AM PLT COUNT-389 ___ 07:47AM URINE HOURS-RANDOM ___ 07:47AM URINE UCG-NEGATIVE ___ 07:47AM URINE COLOR-Straw APPEAR-Cloudy* SP ___ ___ 07:47AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-10* BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG NOTABLE LABS: ============= CRP ___: 4.3 ___: 161.0 ___: 58.6 ___: 33.2 ___: 12.3 ___: ALT 52 AST 41 Alk Phos 53 TBili 0.4 HIV Ab: Neg HAV Ab: Neg HBsAg: Neg HBsAb: Pos HBcAb: Neg HCV Ab: Neg PPD (___): Neg DISCHARGE LABS: =============== Na 143 K 5.6 Cl 99 HCO3 29 BUN 13 Cr 0.6 WBC 12.5 Hgb 13.3 Hct 41.6 Plt 347 CRP 5.2 MICRO: ====== Stool O+P (___): NO OVA AND PARASITES SEEN. MODERATE RBC'S. MANY POLYMORPHONUCLEAR LEUKOCYTES. UCx (___): No growth Fecal culture (___): No salmonella, shigella, campylobacter, vibrio, yersinia, e. coli 0157:H7 C. Diff (___): Negative IMAGING: ======== CT Abdomen and Pelvis w/ contrast (___): IMPRESSION: 1. Hyperemia of the rectosigmoid and mild wall thickening concerning for flare of inflammatory bowel disease. 2. An IUD is seen extending just beyond the borders of the myometrium in the pelvis, to the right of midline. 3. Bilateral duplicated collecting systems and ureters. The inferior moiety of the duplicated renal collecting system demonstrates delayed excretion of contrast and mild hydronephrosis. The mid to distal left inferior ureter is not well assessed, but no definite ureteral stone is seen. Other sources of obstruction cannot be excluded. Correlate with history of vesicoureteral reflux. If this has not been previously evaluated, recommend outpatient urology ___. 4. Periportal edema, which can be seen in the setting of aggressive hydration. Pelvic US (___): FINDINGS: The uterus is anteverted and measures 7.4 x 2.7 x 4.2 cm. The endometrium is homogenous and measures 2 mm. As seen on same-day CT, the IUD extends past the borders of the myometrium. A small portion of the IUD appears to be in the endometrium. The ovaries are normal. There is a small amount of free fluid. IMPRESSION: 1. As seen on same-day CT, the IUD extends past the borders of the myometrium. A small portion of the IUD appears to be in the endometrial canal 2. Small amount of free fluid. MR ___ (___): IMPRESSION: Mucosal hyperenhancement of the distal sigmoid colon and rectum with surrounding inflammatory changes in the mesorectal fat and reactive lymph nodes. The findings are compatible with proctocolitis, for which inflammatory bowel disease is a consideration given the clinical history. MR ___ w/ and w/o contrast (___): IMPRESSION: 1. No evidence of perianal fistula, sinus tract or abscess. 2. Again seen is mucosal hyperenhancement of the distal sigmoid colon and rectum with surrounding inflammatory changes in the mesorectal fat and reactive lymph nodes. 3. Again seen is a malpositioned intrauterine device likely perforating the uterus as previously reported. PATH: ===== GI Mucosal Biopsies on Flex-Sigmoidoscopy (___): PATHOLOGIC DIAGNOSIS: 1 A. Sigmoid colon: Active colitis, moderate-see note. 2 A. Rectum: Active colitis, moderate-see note. Note. Granulomas or dysplasia not identified; stains for CMV are negative (control satisfactory). Brief Hospital Course: ___ G0 with recently diagnosed IBD, believed to be ___, poorly controlled on PO prednisone, who presented with LLQ pain and bloody diarrhea with CT and flex sig consistent with IBD flare with negative infectious work-up currently on IV solumedrol c/b rash c/f VZV reactivation, discharged on initiation of infliximab for improved IBD control. Brief hospital course by problem below. ACTIVE ISSUES: ============= # IBD flare: IBD confirmed on CLS with biopsy (___). Began pred 40mg QD on ___. Uptitrated to pred 60mg QD on ___ with hydrocortisone enema ___ I the setting of persistent disease. Presented to ___ in setting of continued disease activity on ___ with severe LLQ pain, bloody diarrhea, and non-bloody emesis. Imaging (MRE, CT Abd/Pelvis, endoscopy) consistent with moderate-to-severe ___ flare with no evidence of perianal infection (abscess, fistula). Low suspicion for colonic perf s/p colonoscopy (no free air), pregnancy (negative test in ED), PID (given no CMT on ED exam or sxs) or trauma. C diff and stool cx negative. CRP downtrended appropriately over hospitalization. GI was consulted for treatment recommendations. For pain, pt was treated with IV tylenol to mild effect. NSAIDs and opioids were contraindicated iso IBD flare. For her IBD, pt was treated with IV solumedrol 20mg (___). She was also started on infliximab on ___ after negative PPD, negative hepatitis A/B/C serologies, and s/p 24h valacyclovir treatment for presumptive VZV reactivation. Patient was tolerating a low residue diet with no pain on discharge, denying loose bowel movement. CRP peaked at 161 on ___. CRP on discharge 5.2. Discharge on PO prednisone 40mg with plan to taper by patient's GI. Second infliximab infusion on ___. # Hyperkalemia: On ___, the patient was found to have a K of 6.0 on routine AM labs. However, on re-check without fluids or other intervention and requesting no tourniquet, the patient's K normalized, suggesting pseudohyperkalemia. Notably, had a normal EKG and denied weakness, palpitations, lightheadedness. On ___, the patient had a K of 5.6, again felt likely to be secondary to pseudohyperkalemia. The patient has been counseled regarding this finding and of clinical signs for which she should seek medical attention. Will suggest re-check at outpatient provider with close ___. # Mild elevated transaminasemia: Elevated ALT to 52 and AST to 41 on ___ screening labs. Mild elevation felt potentially secondary to initiation of valacyclovir for VZV reactivation. Downtrending on AM labs today. Will request recheck on close ___. # IUD malposition: During CT AP w contrast, the patient was found to have incidental finding of malpositioned IUD with myometrial invasion. OB/GYN was consulted, who recommended pelvic ultrasound, which was consistent. Per OB/GYN, no need for emergent removal, and the patient was scheduled for outpatient ___ on ___ at 9:45AM Chief resident clinic, ___ 8 at ___. # Hydronephrosis: On abdominal/pelvic CT with contrast, incidental hydronephrosis was found. Per discussion with radiology, did not appear consistent with obstructive uropathy secondary to nephrolithiasis. No urinary complaints during hospitalization with normal renal function and bland UA. ___ have passed a stone, but no residual evidence. Cr remained stable over hospitalization. Patient advised to seek medical care and/or ultrasound if develops urinary symptoms, flank pain, or nausea or if hydronephrosis persists. #Pain Control: During admission, opioids and NSAIDs were avoided. Pain adequately controlled on IV/PO acetaminophen. TRANSITIONAL ISSUES =================== [ ] Pt has an IUD which has invaded into the myometrium of her uterus and should be removed. An outpatient appointment with OB/GYN has been scheduled on ___ at 9:45AM Chief resident clinic, ___ 8 at ___.. [ ] Pt has mild L-sided hydronephrosis found on CT scan which radiology feels is not related to a renal stone causing obstruction. Other causes of obstruction are possible. Pt should have ultrasound in future to re-evaluate and further workup should be considered if hydronephrosis is persistently present. [ ] Continue PO prednisone 40mg until ___. Second infliximab infusion on ___ for which patient will receive instructions from GI primary. [ ] Consider DEXA scan for ankylosing spondylitis eval as an outpatient and prior to starting biologics [ ] Patient found to be HAV Ab negative. Please consider HAV Vaccination. [ ] Patient with likely pseudohyperkalemia with AM labs of 6.0, which normalized on re-check. Please check K on ___ during GI ___ with Dr ___. [ ] Patient with incidental elevated transaminasemia, likely in the setting of valacyclovir initiation. Downtrending on discharge. Please check LFTs on ___ during GI ___ with Dr ___. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. PredniSONE 60 mg PO DAILY 2. Hydrocortisone Acetate 10% Foam 1 Appl PR TID Discharge Medications: 1. PredniSONE 40 mg PO (___) 2. Hydrocortisone Acetate 10% Foam 1 Appl PR TID 3. Infliximab infusion #2 (___) 4. Valacyclovir 1000mg TID (until ___ Discharge Disposition: Home Discharge Diagnosis: Primary: IBD flare, VZV reactivation, IUD malposition, hydronephrosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, WHY WERE YOU ADMITTED? - You were admitted for increased abdominal pains and bloody stool. WHAT WAS DONE FOR YOU WHILE YOU WERE IN THE HOSPITAL? - We consulted our GI service, who recommended a plan for your treatment, which you received. - We performed a lower GI endoscopy, which showed active inflammatory bowel disease (IBD) and was negative for other acute causes of your abdominal pain. - We performed tests that showed no evidence of infection - We screened you for tuberculosis and hepatitis A, B, and C, all of which were negative, prior to beginning a new medication called infliximab. - We gave you IV steroids, which eventually helped, but introduced infliximab to achieve better control of your IBD. - We imaged your abdomen and pelvis, which incidentally showed that your IUD was incorrectly positioned. - We asked our OB/GYN service to see you for the IUD, who felt there was no need to remove it emergently. They arranged an appointment for you to have your IUD removed as an outpatient as below. -We found that you had elevated potassium levels, which we believe was due to the way in which your blood was drawn. When we re-checked it, it was normal. -We found a small increase in your liver enzymes, that began to normalize. This may be secondary to your new medication, of which you have 4 more days. We will ask your GI doctor to re-check. WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL? - Please take all of 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 physician or come to the emergency department immediately It was a pleasure caring for you here at ___. Best Wishes, Your ___ Care Team Followup Instructions: ___
10014991-DS-12	10,014,991	24,216,569	DS	12	2131-06-28 00:00:00	2131-06-29 14:02:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: lisinopril / Percocet / Zestril / Duricef Attending: ___. Chief Complaint: bilateral hand pain, left shoulder pain, left rib pain. Major Surgical or Invasive Procedure: ___: Irrigation of laceration. 3 cm superficial laceration closed in 1 layer with 12 sutures of 5.0 size Ethilon suture material with good approximation History of Present Illness: Ms. ___ is a ___ who presents following mechanical fall down 12 steps at ___ ___. She reports that she only remembers parts of the fall, and vaguely remembers climbing to the top of the stairs and returning to bed where she was found by her granddaughter at 0400 with blood on her hands. She does not recall if she had headstrike or LOC. She was taken by her granddaughter to the ___ where she underwent CT scan of her head/Cspine and XR of her UE and left shoulder. Identified injuries at the time of transfer to ___ include left clavicle fracture, multiple left rib fractures, and multiple bilateral hand fractures. Got TDaP and Morphine @ OSH. Past Medical History: Past Medical History: HTN HLD Traumatic dislocated shoulder Past Surgical History: B/l hip replacements L foot neuroma excision Open cholecystectomy -___ yrs ago Social History: ___ Family History: NC Physical Exam: Admission Physical Exam: Temp: 98.0 HR: 83 BP: 129/80 Resp: 18 O(2)Sat: 98 Constitutional: Comfortable HEENT: Normocephalic, atraumatic no C-spine tenderness Chest: left chest wall tenderness to palpation Cardiovascular: Regular Rate and Rhythm Abdominal: Soft Pelvic: stable pelvis GU/Flank: No costovertebral angle tenderness Extr/Back: no midline spine tenderness, bilateral wrist splints in place with ecchymosis Skin: abrasions over the right thumb with ecchymosis Neuro: GCS 15 Psych: Normal mood Discharge Physical Exam: VS:97.9 PO 145/75 68 18 97 RA HEENT: no deformity. PERRL. EOMI. Neck supple, trachea midline. mucus membranes pink/ moist CV: RRR Pulm: Clear to auscultation bilaterally Abd: Soft, non-tender, non-distended. Active bowel sounds x 4 quadrants. Ext: Warm and dry. Ecchymotic left great toe. Ecchymotic bilateral hands. Bilateral hands in cast. Left great toe ecchymosis. Neuro: A&O x3. Follows and moves all equal and strong. Speech is clear and fluent. Pertinent Results: Imaging: ___ FAST negative Obtained at OSH ___: CT cspine/head negative except for parietal scalp hematoma. CXR: Left ___ rib fx Left clavicle xrays: Comminuted fracture of the left mid clavicle. Fracture of the lateral portion of the left ___ and 3rd rib. Right hand xray: Fracture at the base of the second and possibly third metacarpal bone. Moderate to severe osteopenia. Left hand xray: Intra-articular fracture at the base of the first metacarpal. Left humerus/forearm: negative ___ CT chest/abd/pelvis: 1. Acute left clavicular and left third through fifth rib fractures. 2. Small left pneumothorax. 3. Luminal irregularity and focal hypodensity in the left external jugular vein, likely representing mural injury with nonocclusive thrombus secondary to the adjacent left clavicular fracture. No active extravasation. 4. Biliary ductal dilatation, potentially due to post cholecystectomy state. ___ Left toe: No great toe fracture or dislocation. Scattered mild degenerative changes midfoot, forefoot. ___ 05:25AM BLOOD WBC-5.7 RBC-3.34* Hgb-10.5* Hct-32.3* MCV-97 MCH-31.4 MCHC-32.5 RDW-12.3 RDWSD-43.5 Plt ___ ___ 05:25AM BLOOD Plt ___ ___ 05:25AM BLOOD ___ PTT-25.1 ___ ___ 09:45AM BLOOD Glucose-76 UreaN-11 Creat-0.6 Na-135 K-3.4 Cl-100 HCO3-23 AnGap-15 ___ 05:25AM BLOOD Glucose-119* UreaN-12 Creat-0.5 Na-140 K-3.6 Cl-105 HCO3-24 AnGap-15 ___ 05:25AM BLOOD ALT-15 AST-21 AlkPhos-49 Amylase-41 TotBili-1.0 ___ 05:25AM BLOOD Calcium-8.3* Phos-2.7 Mg-2.0 Brief Hospital Course: Ms. ___ is a ___ yo F who was admitted to the Acute Care Trauma Surgery service on ___ after a fall. She was transferred from an outside hospital and found to have a left clavicle fracture, left sided rib fractures ___, small left pneumothorax, left intra-articular fracture at the base of the first metacarpal, and right base of the second and probably third metacarpal bone. There was an incidental finding of a biliary ductal dilatation. She was hemodynamically stable and admitted to the surgical floor for further management. Orthopedic surgery was consulted for the left clavicle fracture recommended non-operative management and outpatient follow up. Hand surgery was consulted for the bilateral hand fractures and placed spica splints. The laceration was washed out and repaired with sutures. The right had will be managed non-operatively and the left hand will be surgically fixated as an outpatient. She had an MRCP to further evaluate biliary ductal which showed no choledocholithiasis or periampullary mass. She was seen and evaluated by occupational and physical therapy who recommended discharge to a rehabilitation facility. The patient had adequate pain control with oral medication regimen. 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: Atenolol 50mg daily Losartan 50mg daily Pravastatin 10 mg PO QPM Discharge Medications: 1. Acetaminophen 650 mg PO TID 2. Docusate Sodium 100 mg PO BID:PRN constipation Hold for loose stool 3. Milk of Magnesia 30 mL PO Q8H:PRN constipation as needed 4. TraMADol 25 mg PO Q4H:PRN pain Take lowest effective dose. 5. Atenolol 50 mg PO DAILY 6. Losartan Potassium 50 mg PO DAILY 7. Pravastatin 10 mg PO QPM Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: Left ___ rib fractures Comminuted fracture of the left mid clavicle Right side fracture at the base of the second and possibly third metacarpal bone. Left intra-articular fracture at the base of the first metacarpal. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, You were admitted to the Acute Care Trauma Surgery Service on ___ after a fall. You were found to have bilateral hand fractures, a left clavicle fractures, and left sided rib fractures ___. There was an incidental finding of biliary duct dilation seen on CT scan. You had an MRI to further evaluate this change which was a normal. You were seen by the hand surgeon for your hand fractures. They recommend that you wear your splints. Your rehabilitation center will be notified with the appointment time for surgery on ___ ___. You were seen by the orthopedic team who recommended a sling for comfort for your clavicle fracture with gentle range of motion. You were seen and evaluated by physical and occupational therapy who recommend discharge to rehabilitation. You are now doing better, tolerating a regular diet, and pain is better controlled. You are now ready to be discharged to rehab to continue your recovery. Please note the following discharge instructions: Rib Fractures: * Your injury caused Left sided rib fractures which can cause severe pain and subsequently cause you to take shallow breaths because of the pain. Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: You experience new chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience a discharge. Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Continue to be non-weight bearing on both hands until further notice from your hand surgeon. Avoid driving or operating heavy machinery while taking pain medications. You should take your pain medication as directed to stay ahead of the pain otherwise you won't be able to take deep breaths. If the pain medication is too sedating take half the dose and notify your physician. * Pneumonia is a complication of rib fractures. In order to decrease your risk you must use your incentive spirometer 4 times every hour while awake. This will help expand the small airways in your lungs and assist in coughing up secretions that pool in the lungs. * You will be more comfortable if you use a cough pillow to hold against your chest and guard your rib cage while coughing and deep breathing. * Symptomatic relief with ice packs or heating pads for short periods may ease the pain. * Narcotic pain medication can cause constipation therefore you should take a stool softener twice daily and increase your fluid and fiber intake if possible. * Do NOT smoke * If your doctor allows, non-steroidal ___ drugs are very effective in controlling pain ( ie, Ibuprofen, Motrin, Advil, Aleve, Naprosyn) but they have their own set of side effects so make sure your doctor approves. * Return to the Emergency Room right away for any acute shortness of breath, increased pain or crackling sensation around your ribs (crepitus). Followup Instructions: ___
10015487-DS-10	10,015,487	28,610,978	DS	10	2173-05-04 00:00:00	2173-05-08 19:50:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: E-Mycin / azithromycin Attending: ___. Chief Complaint: intoxication, SOB Major Surgical or Invasive Procedure: none History of Present Illness: ___ with a PMH of HIV for which he is taking antiretrovirals presents with alcohol intoxication and shortness of breath. He states that he does not remember why he came to the hospital. He was at ___ last night when he was invovled in an altercation. He states that in all, he probably drank about a liter of alcohol last night. He was brought to the ED by the police. The patient initially presented to the emergency department last night with alcohol intoxication and slept it off in the waiting room, however, in the ED he later noted difficulty breathing and was additionally reporting pleuritic CP. In the ED, initial vitals were: 96.3 63 117/74 15 97% Labs significant for WBC 6.2, lactate 1.4, troponin 0.2 and 0.18. CXR showed LLL opacity. He was given 325mg ASA and 750mg levofloxacin. Cardiology was consulted given elevated troponin. They felt that his chest pain was atypical for cardiac etiology with admit to medicine for serial troponin, TTE. On the floor, patient states that he feels stuffed up. He notes that he is "feeling like he's drowning". He states that he has been feeling like this for more than one year. He also states that he has been hospitalized about 6 times in the past year at ___, and ___ for pneumonia. He has a cough for the past year as well, which is occasionally productive of white/yellow sputum. + chills, but no fevers. No weight loss. He also notes pain in his shoulders, knees, and ankle. He reports his last CD4 count was approximately 500 back in ___. He states that he remembers to take his anti-retrovirals most days. He was diagnosed with HIV in ___. Review of systems: (+) Per HPI He denies any fever, chills, abdominal pain, nausea, vomiting, bowel or bladder changes. Past Medical History: HIV - diagnosed ___. Per patient last CD4 count was approximately 500 in ___ Chronic back pain allergic rhinitis per OMR: depression with report of SI, polysubstance use disorder, alcohol dependence, PTSD, and ADHD Social History: ___ Family History: - M: liver cancer, liver transplant - DM in multiple family members - Grandfather's twin brothers completed joint suicide - Grandfather's sister and her husband also completed suicide - Many other suicides in relatives - Diffuse psychiatric and substance use problems Physical Exam: ADMISSION PHYSICAL EXAM: ================= Vitals: T:98.1 BP:127/83 P:99 R:20 O2:98 General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated at 90 degress, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: no rash Neuro: AOx3. no asterixis DISCHARGE PHYSICAL EXAM: ================== Vitals: T:97.7 BP:130/96 P:70 R:20 O2:97/RA CIWA ___ General: Alert, oriented, no acute distress. sitting up in chair HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: no rash Neuro: AOx3. Pertinent Results: ADMISSION LABS: =========== ___ 08:20AM BLOOD WBC-6.2 RBC-4.50* Hgb-14.4 Hct-41.6 MCV-92# MCH-31.9 MCHC-34.5 RDW-14.2 Plt ___ ___ 08:20AM BLOOD WBC-6.2 Lymph-37 Abs ___ CD3%-83 Abs CD3-1893* CD4%-50 Abs CD4-1152* CD8%-32 Abs CD8-731* CD4/CD8-1.6 ___ 08:20AM BLOOD Glucose-109* UreaN-9 Creat-0.6 Na-144 K-4.0 Cl-107 HCO3-25 AnGap-16 ___ 02:35PM BLOOD ALT-82* AST-106* CK(CPK)-546* TotBili-0.3 ___ 08:15AM BLOOD Calcium-9.2 Phos-3.2 Mg-2.1 ___ 08:31AM BLOOD Lactate-1.4 CARDIAC LABS: ========== ___ 08:20AM BLOOD cTropnT-0.20* ___ 02:35PM BLOOD CK-MB-36* MB Indx-6.6* ___ 02:35PM BLOOD cTropnT-0.18* ___ 07:11AM BLOOD proBNP-55 STUDIES: ===== CXR ___: Subtle left lower lobe opacity could reflect pneumonia in the appropriate clinical setting. TTE ___: Normal study. Normal biventricular cavity sizes with preserved regional and global biventricular systolic function. No structural heart disease or pathologic flow identified. DISCHARGE LABS: =========== ___ 07:20AM BLOOD WBC-4.5 RBC-4.81 Hgb-14.8 Hct-44.2 MCV-92 MCH-30.8 MCHC-33.6 RDW-14.2 Plt ___ ___ 07:20AM BLOOD Glucose-96 UreaN-8 Creat-0.5 Na-139 K-4.2 Cl-103 HCO3-25 AnGap-15 ___ 08:15AM BLOOD ALT-62* AST-69* AlkPhos-84 TotBili-0.8 ___ 07:20AM BLOOD Calcium-9.1 Phos-3.5 Mg-2.0 Brief Hospital Course: Mr. ___ is ___ with a h/o HIV on ART, EtOH use, and no known cardiac history who presented with etoh intoxication and and dyspnea. Initial work up was notable for an elevated troponin to 0.2 and q waves in leads III, AvF on ECG. His troponin downtrended and he never promoted any chest pain. An echo was normal without any findings suggestive of prior infarction. Additionally, no echographic evidence of pulm hypertension. Etiology of elevated trop is unclear but may have been related to myositis as pt promotes recent URI symptoms. While he continued to promote dyspnea, he was never hypoxemic, afebrile, and lung exam was normal. An area of increased opacification on CXR was felt to be atelectasis. TRANSITIONAL ISSUES: =============== -Consider outpatient stress testings given risk factors and elevated trop with uncertain etiology -Consider PFTS if dyspnea fails to improve - CODE: full confirmed - CONTACT: mother (___) ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 5 mg PO DAILY 2. Cetirizine 10 mg PO DAILY 3. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY 4. Fluticasone Propionate NASAL 1 SPRY NU DAILY 5. Dolutegravir 50 mg PO DAILY 6. Qvar (beclomethasone dipropionate) 80 mcg/actuation inhalation BID 7. Albuterol Inhaler 1 PUFF IH Q4H:PRN SOB 8. Polymyxin B -Trimethoprim Ophth Soln 1 DROP BOTH EYES QID 9. BuPROPion 150 mg PO BID Discharge Medications: 1. Albuterol Inhaler 1 PUFF IH Q4H:PRN SOB 2. BuPROPion 150 mg PO BID 3. Cetirizine 10 mg PO DAILY 4. Dolutegravir 50 mg PO DAILY 5. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY 6. Fluticasone Propionate NASAL 1 SPRY NU DAILY 7. Lisinopril 5 mg PO DAILY 8. Polymyxin B -Trimethoprim Ophth Soln 1 DROP BOTH EYES QID 9. FoLIC Acid 1 mg PO DAILY RX folic acid 1 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:3 10. Multivitamins W/minerals 1 TAB PO DAILY This is a new medication to treat your nutrition deficiency RX multivitamin,tx-minerals [Multi-Vitamin HP/Minerals] 1 capsule(s) by mouth daily Disp #30 Capsule Refills:3 11. Thiamine 100 mg PO DAILY RX thiamine HCl 100 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:*3 12. Qvar (beclomethasone dipropionate) 80 mcg/actuation inhalation BID Discharge Disposition: Home Discharge Diagnosis: Primary: EtOH withdrawal Myocarditis Secondary: HIV Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to ___ with concern for difficulty breathing and a possible mini heart attack. Fortunately, we did not find evidence of a pneumonia. We do NOT think that you had a heart attack. Rather, we think that your abnormal blood values were due to a viral infection, which also caused the blood work abnormalities. To be sure, we did an ultrasound of your heart which was normal. It is important that you stop drinking alcohol. It has been a pleasure taking care of you and we wish you all the best, Your ___ Care Team Followup Instructions: ___
10015701-DS-13	10,015,701	25,619,291	DS	13	2133-08-04 00:00:00	2133-08-07 15:53:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Malaise Major Surgical or Invasive Procedure: Bone marrow biopsy History of Present Illness: ___ presenting to the ED w/ weakness, fatigue, exertional shortness of breath and weight loss. Patient was in her USOH until ___ whewn she notes "Bronchitis" started - describes this as severe cough with productive sputum, rhinorrhea, malaise, no fevers/chills. Did have flu vaccine this season. Never a smoker. Patient was evaluated by PCP who rx ___ without much improvement. Also tried cough codeine which also did not help her cough. As symptoms persisted patient noticed more pallor of skin, poor appetitie and weight loss (1llbs since ___ so went to see PCP in ___. PCP noticed ___ mass and labwork that concerned him, encouraged patient to be admitted for further evaluation. Currently notes that her most bothersome symptoms are general weakness and lack of appetite. As opposed to a high activity level the patient notes that she may stay in bed for many hours a day. Has not noticed rashes, no specific joint swelling or ache besides usual knee pain. Does note "night sweats" but apparently she uses many blankets during sleep and this is not new. Did note some episodes of intermittent diarrhea, none now, no BRBPR, no hematochezia. Does note some early satiety and poor appetite, no pain on swallowing food or liquids. No nausea/emesis. No hematuria. no easy bruising, no unusual bleeding. Has not noticed swelling of legs but does endorse some SOB for the last several months, but mostly if she walks long distances. No PND, no orthopnea, no chest pain. Labs at ___ showed ___ 10.2/Hct 31.8, retic count of 3.76(H), ESR 77, Fe 31 (L), Trasnferrin Saturation 10 (L), CRP 4(H), B12 normal. In the ED: patient was not in any distress, hemodynamics were stable. T 98.6, 120/66, 85, 97% RA. While in ED did endorse some SOB and DDimer was ___, Labs also revealed LDH of 359. EKG showed NSR, poor R Wave progression and Q Waves in III, aVF. CTA and CT abd/pelvis was ordered and patient sent to floor. . On the floor vitals were unchanged from ED (afebrile, normotensive, not tachycardic). Patient denies focal pain, endorses malaise as noted earlier, and notes a dry cough. Past Medical History: - Osteoporosis - Hypothyroidism - HLD Social History: ___ Family History: - CA: Pancreatic CA in Sister (died at age ___, Breast CA in daughter (survivor currently in her ___ - Father died of MI at ___ - Mother died of MI at ___ - One brother in good health Physical Exam: Vitals - 98.2, 130/74, 80, 98RA General - Very pleasant ___ female in NAD, sharp, alert, fully oriented and looks younger than chronological age. HEENT - Sclera anicteric but with some conjunctival pallor, MMM, oropharynx without lesions Neck - supple, JVP not elevated, no anterior chain adenopathy appreciated, no supraclavicular adenopathy appreciated Lungs - Clear to auscultation bilaterally, no wheezes, rales, ronchi CV - Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen - Scaphoid, ___ with what seems like enlargement of the spleen but not obvious. Non tender throughout, not distended, no rebound and no guarding. Bowel sounds present GU - no foley Ext - Cap refill normal, Pulses 2+ of DP and radial, no clubbing, B/L Calf without tenderness and no cords Neuro - CNs2-12 intact with a midline tongue, no facial droop, EOMI, strength ___ of upper and lower ext. Gait not assessed. Access - PIV EKG: Sinus, Rate ___, Poor R Wave progression, Q waves in III, aVF, no T Wave, ST changes . DISCHARGE: Vitals - 98.9/99.1, 105/64, 72, 97RA General - Elderly female anxious, fully alert and awake this morning, comfortable but had difficulty sleeping after thinking about bone marrow biopsy. HEENT - Sclera anicteric with some conjunctival pallor, MMM, oropharynx without lesions Neck - supple, no changes from yesterday Lungs - Clear to auscultation bilaterally, no wheezes, rales, ronchi CV - unchanged ___ mid systolic ejection murmur at RUSB, Regular rhythm, normal S1 + S2, rate in the ___ Abdomen - Scaphoid, spleen palpated again in the same location and about the same size. From below umbilicus to ___. Non tender throughout, not distended, no rebound and no guarding. Bowel sounds present GU - no foley Ext - Cap refill normal, Pulses 2+ of DP and radial, no clubbing, B/L Calf without tenderness and no cords Neuro - No changes from yesterday with CNs2-12 intact, midline tongue, no facial droop, EOMI, speech fluent without scanning Access - PIV Pertinent Results: ADMISSION: Labs: - Hct 33.9 (MCV 89, RDW 16.8) - Wbc 6.1 (34 N, 56 L, 3 Atyp, 1 Plas) - PLT 117 - Chem 7 normal - Coags normal - LDH 359 - DDimer ___ - Hapto < 5 . Microbiology: - none Imaging: - Colonoscopy ___ --> 2 Polyps (one with hyperplastic changes other normal) - CT Torse and Abdomen: NO PULM EMBOLISM - CXR: normal ========================== DISCHARGE: - Iron studies Iron: 32, calTIBC: 291, Ferritn: 128, TRF: 224 - CMV VL NEG - HIV Ab NEG - Uric acid 7.0 - Parasite smear NEG - UPEP Neg - BMBx pending ___ 07:30AM BLOOD WBC-6.4 RBC-3.65* Hgb-10.3* Hct-32.4* MCV-89 MCH-28.3 MCHC-31.9 RDW-16.8* Plt ___ ___ 07:30AM BLOOD Neuts-36* Bands-0 Lymphs-54* Monos-7 Eos-0 Baso-0 Atyps-3* ___ Myelos-0 ___ 07:30AM BLOOD Hypochr-1+ Anisocy-NORMAL Poiklo-2+ Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-1+ Burr-OCCASIONAL Tear Dr-1+ Bite-OCCASIONAL Ellipto-OCCASIONAL ___ 07:30AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE ___ 07:00AM BLOOD PEP-NO SPECIFI IgG-835 IgA-56* IgM-71 ___ 07:10AM BLOOD HIV Ab-NEGATIVE ___ 07:30AM BLOOD HCV Ab-NEGATIVE Brief Hospital Course: ___ yo female with several month history of malaise now with Anemia, Thrombocytopenia, massive splenomegaly, elevated DDimer, low hapto and elevated LDH. . # Splenic Marginal Zone Lymphoma - Patient presented with FTT with Massive Splenomegaly, Low Hapto, elev LDH, Thrombocytopenia, Anemia, Positive Direct Coombs, atypical Lymphocytes - Patient's presentation was in the setting of URI she experienced ___, however, given further evidence noted in her labs, we pursued a malignancy work up. Moreover, a Spleen of 24cm is atypical for viral infections. Hematology was consulted after atypical cells were seen in periphery. Patient was never in any acute distress and her vitals remained stable. Her symptoms of malaise and cough improved during her stay. Her symptom of early satiety, likely related to the massive spleen, did not resolve fully. She remained in the hospital to have a Bone marrow biopsy. The preliminary results, as described verbally by the HemeOnc fellow showed "Splenic Marginal Zone Lymphoma". On the last day of the patient's stay, we discussed these results with first the patient's daughters. At the time of our discussion we presumed a diagnosis of MZL. Family and patient were made aware that the final results will not be back until ___, the day of her appointment with Dr. ___. The family insisted not to use the term "Cancer" with the patient, and we respected this wish. The hematology fellow did describe the findings and how she can be treated with Rituximab. The prognosis of ___ years as a median number was given to the family, if indeed this is the final diagnosis. The family was very thankful and understanding. They were anxiously awaiting the appointment on ___. At discharge, final results were pending, as were Hepatitis serologies. . . TRANSITIONAL: - Hematology f/u on ___ - Outstanding data will be followed by outpatient HemeOnc physician to make ultimate diagnosis, prognosis, and plan (Bone Marrow Biopsy) - Viral serologies were pending at discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Influenza Virus Vaccine 0.5 mL IM NOW X1 Follow Influenza Protocol Document administration in POE 2. Levothyroxine Sodium 100 mcg PO DAILY 3. Vitamin D 400 UNIT PO DAILY 4. Multivitamins W/minerals 1 TAB PO DAILY 5. Calcium Carbonate 1000 mg PO DAILY Discharge Medications: 1. Levothyroxine Sodium 100 mcg PO DAILY 2. Multivitamins W/minerals 1 TAB PO DAILY 3. Vitamin D 400 UNIT PO DAILY 4. Albuterol Inhaler 2 PUFF IH Q6H:PRN cough RX albuterol sulfate [ProAir HFA] 90 mcg 2 puffs inhaled four times a day Disp #1 Inhaler Refills:0 5. Benzonatate 100 mg PO TID:PRN cough RX benzonatate 200 mg 1 capsule(s) by mouth three times a day Disp #15 Capsule Refills:0 6. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #15 Capsule Refills:*0 7. Calcium Carbonate 1000 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY: - Splenic Marginal Cell Lymphoma - Massive Splenomegaly SECONDARY - Hypothyroidism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. ___, It was a pleasure taking care of you at ___. You were admitted for lethargy and an abdominal mass. It was found that you had significant splenomegaly and concerning lab abnormalities. You were seen by Hematology specialists who performed a bone marrow biopsy. Although the final results are not back, the preliminary findings suggests a Splenic Marginal Cell Lymphoma. This does not need to be treated during this hospitalization, and instead, you will have the hematology doctors ___ the ___ as an outpatient. You have a scheduled hematology appointmet at the time/office found below. Please make sure to follow up with physicians as noted below. Followup Instructions: ___
10015785-DS-16	10,015,785	23,058,424	DS	16	2150-05-13 00:00:00	2150-05-13 17:09:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Codeine Attending: ___. Chief Complaint: syncope Major Surgical or Invasive Procedure: None History of Present Illness: ___ w/ PMH advanced Alzheimer's, chronic HCV, autoimmune hepatitis presents following witnessed period of 15min unresponsiveness and myoclonic jerking. Pt had returned from PCP with niece this morning, had gone to toilet, niece found her sitting with her eyes rolled back followed by steady-beat jerking of all extremities. Unknown whether incontinent, but pt's mental status post-incident was below baseline per niece. No head strike. No prior history of seizures. No current URI, pre-event N/V, diarrhea, change in fluid intake. Pt's niece endorses long-term cough. In the ED, initial exam notable for: PE: 98.9, 85, 144/55, 20, 97%/RA, FSG 213 Gen: AOx2, no insight into acute presentation, in no apparent pain HEENT: NC/AT, slight anisocoria ___ cataracts), CN2-12 intact on exam, EOMI, MMM Cards: RRR, no m/r/g Resp: CTAB, no adventitious sounds Abd: NT/ND, no rebound or guarding, no masses or HSM Ext: WWP, trace periph edema at lower shins - Labs were significant for creat 1.3 (Baseline 0.9) - Imaging revealed CT head without contrast that showed 3.5 x 3.0 x 2.8 cm hyperdense mass centered in the anterior interhemispheric fissure, significantly increased in size since ___ - The patient was given 1L NS and 5mg IV metop Neurology was consulted and recommended monitoring on telemetry with 24h EEG and f/u with MRI brain with contrast HCP states she does not want surgery involved in care. Of note, initial EKG in sinus rhythm and repeat EKG in afib. Discussed with neurology, given new onset afib, would like patient admitted to medicine overnight for telemetry and further monitoring with neurology following. Vitals prior to transfer were: Today 19:03 0 92 150/77 20 99% RA Upon arrival to the floor, the patient was without complaint. REVIEW OF SYSTEMS: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Past Medical History: - Alzheimer's; ADL impaired in preparing food, remembering to bathe, recalling faces. Lives at home but with extensive ___ and family support. - HCV, chronic, low viral load (last in OMR ___, 15 million copies) - Autoimmune hepatitis - HTN Social History: ___ Family History: Unable to obtain from patient secondary to memory deficits Physical Exam: ADMISSION PHYSICAL EXAM: ======================== Vitals: Tm ___, Tc 100.7F, BP 159/61, HR 86, R 22, SpO2 97%/RA, 69.1 kg General: alert, pleasant, comfortable, in no distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: Supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, ? possible diastolic murmur, difficult to appreciate over breathing Lungs: faint bibasilar crackles Abdomen: Soft, non-tender, non-distended, bowel sounds present Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: oriented to name, hospital (___), but not to date, face symmetric, tongue protrudes midline, cheek puff & eye squeeze strong & equal, ___ upper extremity extension/flexion, gait not assessed DISCHARGE PHYSICAL EXAM: ======================== Vitals: 98.3 130-170/60-70 60-70 18 94% RA General: alert, pleasant, comfortable, in no distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL, EEG electrodes in place Neck: Supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, ? possible diastolic murmur, difficult to appreciate over breathing Lungs: faint bibasilar crackles Abdomen: Soft, non-tender, non-distended, bowel sounds present Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: oriented to name, hospital (but says ___, but not to date, face symmetric, tongue protrudes midline, cheek puff & eye squeeze strong & equal, ___ upper extremity extension/flexion, gait not assessed Pertinent Results: PERTINENT LABS: =============== ___ 06:57AM BLOOD WBC-12.2# RBC-4.51 Hgb-12.8 Hct-40.3 MCV-89 MCH-28.4 MCHC-31.8 RDW-14.6 RDWSD-47.4* Plt ___ ___ 03:16PM BLOOD Neuts-81.0* Lymphs-12.5* Monos-5.7 Eos-0.1* Baso-0.2 Im ___ AbsNeut-6.53* AbsLymp-1.01* AbsMono-0.46 AbsEos-0.01* AbsBaso-0.02 ___ 09:57AM BLOOD WBC-8.4 RBC-4.69 Hgb-13.3 Hct-41.7 MCV-89 MCH-28.4 MCHC-31.9* RDW-14.6 RDWSD-46.6* Plt ___ ___ 03:16PM BLOOD Glucose-143* UreaN-21* Creat-1.3* Na-138 K-4.5 Cl-99 HCO3-25 AnGap-19 ___ 09:57AM BLOOD Glucose-143* UreaN-17 Creat-0.9 Na-137 K-3.4 Cl-101 HCO3-23 AnGap-16 ___ 03:16PM BLOOD ALT-16 AST-26 CK(CPK)-58 AlkPhos-57 TotBili-0.4 ___ 03:16PM BLOOD cTropnT-<0.01 ___ 03:16PM BLOOD Albumin-4.3 Calcium-9.9 Phos-3.2 Mg-2.5 ___ 03:16PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 03:22PM BLOOD Lactate-3.1* ___ 10:24AM BLOOD Lactate-1.8 ___ 04:43PM URINE Color-Yellow Appear-Clear Sp ___ ___ 04:43PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 04:43PM URINE RBC-1 WBC-<1 Bacteri-FEW Yeast-NONE Epi-<1 ___ 04:43PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG PERTINENT IMAGING: ================== MRI ___: IMPRESSION: 1. Significant interval increase size of an extra-axial frontal lobe parafalcine lesion, compatible with a meningioma. Given the rapid growth in size am prominent peripheral FLAIR hyperintense signal, this could represent an atypical meningioma. 2. The lesion abuts the superior sagittal sinus without evidence of invasion. 3. No additional lesions are identified. ECG ___: TRACING #4 Sinus arrhythmia. Compared to tracing #3 atrial and ventricular premature beats are now not seen. T waves are probably improved. Otherwise, no change. Intervals Axes Rate PR QRS QT QTc (___) P QRS T 76 186 96 422 450 63 -49 48 ECG ___: TRACING #3 Sinus rhythm with atrial and ventricular premature beats. Compared to the previous tracing of ___ the rate is now slower. There is less artifact. There is now more prominent T wave flattening in the precordial leads. Intervals Axes Rate PR QRS QT QTc (___) P QRS T 79 196 96 400 433 53 -45 51 ECG ___: TRACING #2 Baseline artifact. Probably sinus tachycardia with atrial premature beats and a single ventricular premature beat. Left anterior fascicular block. Consider voltage for left ventricular hypertrophy in leads I and III. Compared to the previous tracing heart rate is increased. Atrial premature beats and ventricular premature beats are new. Clinical correlation is suggested. Intervals Axes Rate PR QRS QT QTc (___) P QRS T 118 171 93 ___ 44 -61 88 ECG ___: TRACING #1 Sinus rhythm. Left axis deviation. Consider left anterior fascicular block. Late R wave progression may be related to left anterior fascicular block. T wave abnormalities. No previous tracing available for comparison. Intervals Axes Rate PR QRS QT QTc (___) P QRS T 81 182 92 374 410 46 -51 20 EEG ___: IMPRESSION: This is an abnormal continuous video EEG study as it showed the presence of continuous background disorganization over the left hemisphere together with continuous focal mixed frequency slowing in the left posterior quadrant. These findings are indicative of focal cerebral dysfunction which is non-specific but may be due to a structural lesion in broadly distributed over the left temporal/occipital regions. There were no epileptiform discharges or electrographic seizures. There were no pushbutton activations. CT Head ___: IMPRESSION: 1. Moderately motion limited exam. 2. No acute intracranial hemorrhage or large vascular territorial infarction. 3. 3.5 x 3.0 x 2.8 cm hyperdense mass centered in the anterior interhemispheric fissure, significantly increased in size since ___. MRI is recommended for further evaluation. 4. Chronic small vessel ischemic disease. PERTINENT MICRO: ================ ___ 4:43 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ___: Blood culture pending Brief Hospital Course: ___ with a PMH of severe Alzheimer's, HCV infection and history of autoimmune hepatitis, who presented with an unresponspive episode/syncope, concerning for seizure given appearance of large brain mass on head CT, now with MRI concerning for atypical meningioma. ACTIVE ISSUES: ============== # Atypical meningioma: Patient presented with an episode of syncope that most likely represented seizure given brain mass on MRI (per niece, did not actually occur on the toilet, episode occurred while patient seated at dinner table, making vasovagal syncope less likely). Cardiogenic causes also less likely, given her atrial fibrillation has been stable without any rate control agents (unclear if this is new). No evidence of infection as predisposing factor. Patient was not orthostatic after 2L IVF. She did not have further syncopal or presyncopal symptoms. MRI brain was performed that revealed a 3 cm mass in the interhemispheric fissue with characteristics suggestive of an atypical meningioma. ___ discussed with niece; patient would not want surgical intervention. She was started Keppra 500 mg PO BID for seizure prophylaxis and discharged with outpatient neuro follow-up. # A. fib: Paroxysmal, newly discovered in ED on this admission. CHADSVASC score 4, so anticoagulation would be warranted; however, decision was made not to anticoagulate given age, risk of fall, and intracranial lesion. Location makes saggital sinus vulnerable to compression, increasing risk for venous bleed. Niece in agreement with decision. # Fever, leukocytosis: Patient with new T 101 and WBC count of 12 on admission, resolved today. Infectious ROS entirely negative, and lab work up unrevealing (UA clear, LFTs NWL, CXR clear). It is possible that she aspirated during her syncopal event. # ___: Cr 1.3 on admission, returned to her baseline of 0.9 with hydration. Most likely prerenal given presence of hyaline casts and resolution with IVF. CHRONIC ISSUES: =============== # Autoimmune hepatitis The patient was continued on her home prednisone # Hypertension The patient was continued on her home nifedipine # Alzheimer's dementia The patient's mental status remained at her baseline throughout this hospitalization. She was Continued on her home donepezil and memantine. # CODE STATUS: DNR, DNI (confirmed) # CONTACT: ___ ___ TRANSITIONAL ISSUES: ==================== - Patient with a ~3 cm mass arising from the intrahemispheric fissue with imaging appearance consistent with an atypical meningioma. In goals of care discussion with the patient's niece, surgical management was deferred. She was started on Keppra 500 mg PO BID for seizure prophylaxis and will follow-up with her neurologist as an outpatient - Patient diagnosed with new atrial fibrillation on this admission. She did not require any standing nodal agents for rate control. Regarding anticoagulation, it would be indicated given her high CHADS2-VASC score; however, given the location of her atypical meningioma, advanced dementia, and limited life expectancy, anticoagulation was deferred. She was continued on her home aspirin 81 mg PO QD. - If she has uncontrolled heart rates in the future, consider starting a low-dose long-acting beta blocker, such as Metoprolol succinate 12.5-25 mg PO QD. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. PredniSONE 5 mg PO DAILY 2. Memantine 21 mg PO DAILY 3. NIFEdipine CR 30 mg PO DAILY 4. Multivitamins W/minerals 1 TAB PO DAILY 5. Donepezil 10 mg PO QHS 6. Aspirin 81 mg PO DAILY 7. Vitamin E 400 UNIT PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Donepezil 10 mg PO QHS 3. Memantine 21 mg PO DAILY 4. Multivitamins W/minerals 1 TAB PO DAILY 5. NIFEdipine CR 30 mg PO DAILY 6. PredniSONE 5 mg PO DAILY 7. Vitamin E 400 UNIT PO DAILY 8. LeVETiracetam 500 mg PO BID Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: Seizure, atypical meningioma, atrial fibrillation Secondary: Alzheimer's dementia, hepatitis C virus infection, hypertension, autoimmune hepatitis Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, It was our pleasure caring for you at ___ ___. You were admitted to the hospital after having what was most likely a seizure. We did a scan of your head and found a benign tumor called an atypical meningioma. This may increase your risk for seizure, so we are starting you on an antiseizure medication called Keppra, which you will continue to take twice daily. This benign tumor does not require any surgery to remove or chemotherapy. While you were here, you also had evidence of a fast, abnormal heart rhythm called atrial fibrillation. This can increase the risk of stroke; however, the risks of giving you a blood thinner to decrease the risk of stroke probably outweigh the benefits, so in discussion with your neurologists, we opted not to start you on anticoagulation. Your neurologist can re-evaluate this decision as an outpatient in case you or your neice would like to revisit this issue. Thank you for allowing us to participate in your care. Followup Instructions: ___
10015785-DS-17	10,015,785	23,958,054	DS	17	2150-12-09 00:00:00	2150-12-09 14:50:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Codeine Attending: ___. Chief Complaint: RLE pain Major Surgical or Invasive Procedure: IVF filter placement ___ History of Present Illness: Ms. ___ is a ___ PMHx advanced Alzheimer's dementia, chronic HCV, autoimmune hepatitis, and AFib who presents from her SNF for RLE DVT. Per report from her SNF, the patient had been complaining of RLE pain. LENIs showed DVT after which the patient was transferred to ___. In the ED, initial VS 98.1, 84, 142/65, 16, 98% RA. Initial labs were unremarkable. CXR here showed no evidence of PNA. UA was grossly positive and the patient was given IV ceftriaxone, Lovenox 70 mg x 1 prior to transfer. Of note, the patient was most recently discharged from ___ in ___ for seizure activity and was found to have a 3 cm atypical meningioma. Per ___ discussion with the patient's niece, surgical intervention was deferred. Her course at the time was also notable for new paroxysmal AFib; given her CHADSVASC score of 4, anticoagulation was warranted. However, given her age, risk of fall, and her new intracranial lesion (high risk for venous bleed), anticoagulation was deferred. From further collateral information obtained from her SNF (Vero Health and Rehab of Mattapan) this evening, it is unclear why the patient was not started on anticoagulation for DVT treatment and why the patient was transferred to ___ for further evaluation. The ED attempted to reach out to the family re: utility of IVC filter placement in this setting, but was unable to contact the family. Upon arrival to the floor, the patient denies any chest pain or SOB. She has had a cough x 2 weeks; she has had no fevers. She is AOx2 to self and place (at baseline). She denies any dysuria, urinary incontinence or increased urinary frequency. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight gain. Denies sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies vomiting, diarrhea, constipation. No recent change in bladder habits. No dysuria. Denies arthralgias or myalgias. Past Medical History: - Alzheimer's; ADL impaired in preparing food, remembering to bathe, recalling faces. Lives at home but with extensive ___ and family support. - HCV, chronic, low viral load (last in OMR ___, 15 million copies) - Autoimmune hepatitis - HTN - atypical meningioma Social History: ___ Family History: Unable to obtain from patient as patient with memory deficits Physical Exam: ADMISSION PHYSICAL EXAM ======================= Vital Signs: 98.7, 178/81, 80, 18, 99% on RA General: Alert, elderly female, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no appreciable m/r/g Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, obese, distended, nontender, bowel sounds present. No suprapubic tenderness. GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or pitting edema of BLE. TTP of RLE calf. Neuro: alert, oriented to name and place (knows she is in hospital, but unable to say which one), face symmetric, able to move all extremities Psych: normal affect and appropriately interactive Derm: no rash or lesions Pertinent Results: ADMISSION LABS ============== ___ 11:00PM GLUCOSE-94 UREA N-10 CREAT-0.8 SODIUM-141 POTASSIUM-4.7 CHLORIDE-102 TOTAL CO2-26 ANION GAP-18 ___ 11:00PM LACTATE-1.5 ___ 11:00PM WBC-7.6 RBC-4.63 HGB-12.8 HCT-41.0 MCV-89 MCH-27.6 MCHC-31.2* RDW-14.5 RDWSD-46.3 ___ 11:00PM NEUTS-56.1 ___ MONOS-10.4 EOS-1.6 BASOS-0.4 IM ___ AbsNeut-4.28 AbsLymp-2.37 AbsMono-0.79 AbsEos-0.12 AbsBaso-0.03 ___ 11:00PM PLT COUNT-178 ___ 11:00PM ___ PTT-32.0 ___ ___ 10:00PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 10:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-7.0 LEUK-LG ___ 10:00PM URINE RBC-2 WBC-21* BACTERIA-FEW YEAST-NONE EPI-<1 IMAGING/STUDIES =============== ___ CXR No evidence of pneumonia. OSH ___: RLE DVT FINDINGS: 1. Patent normal sized, non-duplicated IVC with single bilateral renal veins and no evidence of a clot. 2. Successful deployment of an infra-renal permanent infrarenal IVC filter. IMPRESSION: Successful deployment of permanent infrarenal IVC filter. Brief Hospital Course: Ms. ___ is a ___ PMHx advanced Alzheimer's dementia, chronic HCV, autoimmune hepatitis, and AFib who presents from her SNF for RLE DVT. # DVT. Diagnosed by LENIs at ___. Patient started on Lovenox in ED for anticoagulation. However, given intracranial lesion which is higher risk for bleeding, will discuss utility of IVC filter placement with HCP. After discussion with HCP ___ ___, decision made to place IVC filter and NOT anti coagulate given the patient's high risk for bleeding. She went for uncomplicated IVC filter placement on ___. She will not be anti coagulated going forward. # Asymptomatic bacteriuria: UA was positive and she was initially given antibiotics. However, there was no report of any symptoms to suggest UTI. Thus antibiotics were stopped. # Atypical meningioma. Recently seen on brain MRI in ___. Patient at the time was placed on Keppra for seizure prophylaxis. It is high risk for bleeding and that is partly why IVC filter placement was decided - Continued Keppra 500 mg BID # A. fib. Recent diagnosis of paroxysmal AFib. Despite CHADSVASC score of 4 warranting anticoagulation, systemic anticoagulation deferred due to age, risk of fall, and atypical meningioma at high risk for bleeding. - No rate-control # Autoimmune hepatitis. - Continued home prednisone # Hypertension. Stable. - Continued home nifedipine # Alzheimer's dementia. At baseline. - Continued home donepezil and memantine # CODE STATUS: DNR, DNI (confirmed by SNF, MOLST form completed # CONTACT: ___ ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Donepezil 10 mg PO QHS 3. Memantine 21 mg PO DAILY 4. Multivitamins W/minerals 1 TAB PO DAILY 5. NIFEdipine CR 30 mg PO DAILY 6. PredniSONE 5 mg PO DAILY 7. Vitamin E 400 UNIT PO DAILY 8. LevETIRAcetam 500 mg PO BID Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Donepezil 10 mg PO QHS 3. LevETIRAcetam 500 mg PO BID 4. Memantine 21 mg PO DAILY 5. Multivitamins W/minerals 1 TAB PO DAILY 6. NIFEdipine CR 30 mg PO DAILY 7. PredniSONE 5 mg PO DAILY 8. Vitamin E 400 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Acute RLE DVT Alzheimer's dementia Autoimmune hepatitis HCV Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Patient admitted for evaluation of acute RLE DVT. Due to high bleeding risk, IVC filter was placed and patient will not be anti coagulated. Please resume all previous medications Followup Instructions: ___
10015860-DS-13	10,015,860	28,236,161	DS	13	2187-09-19 00:00:00	2187-09-19 13:01:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: PODIATRY Allergies: Penicillins Attending: ___ Chief Complaint: right foot ulcer Major Surgical or Invasive Procedure: None History of Present Illness: ___ y/o DM M with a hx of presents hypertension and hypercholesteremia, who is well known to the podiatry service presents with a right plantar forefoot ulcer. He is a patient of Dr. ___ originally missed his appointment today and wanted to have his foot evaluated before the infection worsened. He presented today in athletic running shoes. Past Medical History: DM Type II Hypertension Hypercholesterolemia . PSH: Appendectomy Social History: ___ Family History: Father ___ - Type II Mother Cancer - ___ Hyperlipidemia Physical Exam: VSS, afebrile Gen: NAD, AAOx3, pleasant CV: RRR Pulm: CTAB Abd: soft, NT/ND RLE: DP and ___ pulses palpable. CFT brisk to all digits. Skin temp warm to warm proximal to distal. Ulcer encompassing plantar aspect of foot along metatarsal head level, most notably at ___ MPJ. Minimal surrounding erythema and edema. Does not probe deeply or track to the level of bone. No exudate. No fluctance. Gross sensation diminished. Pertinent Results: ___ 06:30AM BLOOD WBC-10.2 RBC-3.62* Hgb-10.0* Hct-29.8* MCV-82 MCH-27.5 MCHC-33.4 RDW-12.5 Plt ___ ___ 03:45PM BLOOD WBC-13.1* RBC-4.19* Hgb-11.5* Hct-34.9* MCV-83 MCH-27.5 MCHC-33.0 RDW-12.7 Plt ___ ___ 03:45PM BLOOD Neuts-72.5* ___ Monos-6.3 Eos-1.7 Baso-0.7 ___ 06:30AM BLOOD Plt ___ ___ 03:45PM BLOOD Plt ___ ___ 06:30AM BLOOD Glucose-120* UreaN-25* Creat-1.5* Na-137 K-4.5 Cl-100 HCO3-28 AnGap-14 ___ 03:45PM BLOOD Glucose-316* UreaN-26* Creat-1.6* Na-132* K-4.2 Cl-96 HCO3-26 AnGap-14 ___ 06:30AM BLOOD Calcium-8.9 Phos-4.6* Mg-1.9 ___ 07:00AM BLOOD Vanco-19.9 ___ 06:30AM BLOOD Vanco-11.5 ___ 03:45PM BLOOD HoldBLu-HOLD ___ 03:50PM BLOOD Lactate-1.0 ___: R FXR: IMPRESSION: Plantar soft tissue ulcer at the level of the metatarsal heads with no radiographic evidence for osteomyelitis or soft tissue gas. ___: RLE US: IMPRESSION: No evidence of deep vein thrombosis in the right lower extremity. Brief Hospital Course: Mr. ___ presented to the Emergency Department at ___ after missing a scheduled appointment with Dr. ___ concern that his infection was worsening. He was admitted on ___ for a right foot infection. During his stay, he received IV antibiotics to fight the cellulitis and xrays were obtained and showed no osteomyelitis. The wound was lightly debrided at the bedside during his stay and he was fitted for a bivalve cast by an orthotech. He was given strict instructions on touch down weight bearing to the heel using a walker or crutches. Physical therapy worked with him while in the hospital and cleared him for home with such. Prior to discharge his vital signs were stable and neurovascular status intact. He understood all of his discharge instructions and is to follow up with Dr. ___ in approximately 1 week. Medications on Admission: omeprazole ec 20", simvastatin 40 qhs, glyburide 5', lisinopril 5', sildenafil 100 prn Discharge Medications: 1. Clindamycin 150 mg PO Q6H RX clindamycin HCl 150 mg 1 capsule(s) by mouth every six (6) hours Disp #40 Capsule Refills:*0 2. Aspirin 81 mg PO DAILY 3. Atenolol 25 mg PO DAILY 4. Glargine 40 Units Breakfast Insulin SC Sliding Scale using REG Insulin 5. Lisinopril 5 mg PO DAILY 6. Omeprazole 20 mg PO BID 7. Simvastatin 40 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: right foot ulcer 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: Please follow these guidelines unless your physician has specifically instructed you otherwise. Please call our office nurse if you have any questions. Dial 911 if you have any medical emergency. ACTIVITY: There are restrictions on activity. On your right side you are TOUCH DOWN WEIGHT BEARING TO THE HEEL IN A BIVALVE CAST AND CRUTCHES/WALKER for ___ weeks. You should keep this site elevated when ever possible (above the level of the heart!) Physical therapy worked with you in the hospital and gave instructions on weight bearing: please follow these accordingly. No driving until cleared by your Surgeon. PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS: Redness in or drainage from your leg wound(s). New pain, numbness or discoloration of your foot or toes. Watch for signs and symptoms of infection. These are: a fever greater than 101 degrees, chills, increased redness, or pus draining from the incision site. If you experience any of these or bleeding at the incision site, CALL THE DOCTOR. Exercise: Limit strenuous activity for 6 weeks. No heavy lifting greater than 20 pounds for the next ___ days. Try to keep leg elevated when able. BATHING/SHOWERING: You may shower immediately upon coming home, but you must keep your dressing CLEAN, DRY and INTACT. You can use a shower bag taped around your ankle/leg or hang your foot/leg outside of the bathtub. WOUND CARE: You will be getting every other day dressing changes by a visiting nurse with betadine paint to the ulceration and a dry sterile dressing. You may cleanse the foot with peroxide. Once the dressing is in place, avoid getting it wet. MEDICATIONS: Unless told otherwise you should resume taking all of the medications you were taking before surgery. You will be given a new prescription for infection which will be taken every 6 hours. CAUTIONS: NO SMOKING! We know you've heard this before, but it really is an important step to your recovery. Smoking causes narrowing of your blood vessels which in turn decreases circulation. If you smoke you will need to stop as soon as possible. Ask your nurse or doctor for information on smoking cessation. If a follow up appointment was not made prior to your discharge, please call the office on the first working day after your discharge from the hospital to schedule a follow-up visit. This should be scheduled on the calendar for seven to fourteen days after discharge. Normal office hours are ___ through ___. PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR QUESTIONS THAT MIGHT ARISE. Followup Instructions: ___
10015860-DS-16	10,015,860	20,854,119	DS	16	2188-08-12 00:00:00	2188-08-13 13:38:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: Right foot infection Major Surgical or Invasive Procedure: - Incision and drainage (___) - Right UE PICC line placement (___) History of Present Illness: ___ yo man with hx HTN and DM who presents with a diabetic foot ulcer. For the past week, he has been maintained on clindamycin for a R foot ulcer but the ulcer has worsened and become more painful and his blood glucose has ranged above 400. He has been fatigued and has noted chills. He was seen ___ clinic today and was found to have a WBC of 15.6 and a HR of 130. He was referred to the ED for evaluation for sepsis. ___ the ED intial vitals were: ___ 99%. Spiked to 102.5 - Labs were significant for WBC of 17.7 with 90% PMNs, Na of 126, Cr of 2.1, glucose ___ 500s. Lactate 1.4. - Blood cultures, wound culture drawn - Foot xray pending - Podiatry consulted - r. plantar foot I&D at bedside revealed copious purulent drainage. Plan for OR likely on ___. - Patient was given vanc, cipro, flagyl, 1g tylenol, 10 mg oxycodone, and 40 units of lantus Vitals prior to transfer were: 100.1 94 132/82 17 98% RA On the floor, he has no further complaints. Review of Systems: (+) per HPI (-) 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: - DM Type II with neuropathy - Hypertension - Hypercholesterolemia - Obesity - CKD, stage ___ - s/p Appendectomy Social History: ___ Family History: -Father with diabetes -Mother with colon cancer Physical Exam: PHYSICAL EXAM ON ADMISSION: ============================================= Vitals- 98.0 112/66 88 18 100% RA General- comfortable ___ NAD HEENT- sclera anicteric. MMM Neck- supple, no cervical lymphadenopathy Lungs- clear to ausculatation CV- RRR Abdomen- +BS. soft. NT/ND GU- no foley Ext- ___ pulses palpable ___ RLE. ___ edema ___ RLE. Ulceration under ___ digit with prurulent drainage, foul odor with dressing c/d/i. Neuro- A&Ox3. moving all extremities. diminished sensation over ___ toe bilaterally consist with neuropathy. PHYSICAL EXAM ON DISCHARGE: ============================================= VS: 98.1 89 109/69 18 98%RA General: Awake, alert, ___ no distress. HEENT: Pupils equal, round, minimally reactive to light. No scleral icterus. MMM. No oral lesions. Neck: Supple. No LAD. CV: Regular rate, regular rhythm. No murmur appreciated. Lungs: CTA b/l. Abdomen: BS+. Soft, nontender, mildly distended. No masses or HSM appreciated. GU: Deferred. No foley. Ext: Right ___ with 1+ pitting edema to mid shin, stable from previous exams. Right foot with dry, scaly skin. Foot wrapped ___ ACE wrap, wound with stiches at base of ___ metatarsal clean and dry. Wound above stitches (plantar aspect of ___ toe) is open and a bit mushy, with granulation tissue vs purulence? Left ___ with no edema. Neuro: AOx3. CN2-12 grossly intact. No focal deficits. Pertinent Results: LABS: ======================================== ___ 08:50PM BLOOD WBC-17.7# RBC-3.76 Hgb-10.6* Hct-30.9* MCV-82 MCH-28.3 MCHC-34.5 RDW-13.2 Plt ___ ___ 08:50PM BLOOD Neuts-90.0* Lymphs-4.9* Monos-4.6 Eos-0.2 Baso-0.3 ___ 06:57AM BLOOD ___ PTT-26.8 ___ ___ 06:57AM BLOOD ESR-115* ___ 08:50PM BLOOD Glucose-523* UreaN-32* Creat-2.1* Na-126* K-5.1 Cl-91* HCO3-23 AnGap-17 ___ 06:57AM BLOOD Calcium-7.8* Phos-3.8 Mg-1.6 ___ 06:57AM BLOOD CRP-175.4* ___ 09:00PM BLOOD Lactate-1.4 ___ 06:40AM BLOOD WBC-14.2* RBC-3.60* Hgb-9.3* Hct-29.5* MCV-82 MCH-25.9* MCHC-31.5 RDW-13.7 Plt ___ ___ 06:40AM BLOOD Glucose-117* UreaN-24* Creat-1.7* Na-137 K-4.8 Cl-102 HCO3-25 AnGap-15 ___ 06:40AM BLOOD Calcium-8.9 Phos-4.0 Mg-1.6 ___ 8:52 pm BLOOD CULTURE #1. FINAL REPORT ___ Blood Culture, Routine (Final ___: BETA STREPTOCOCCUS GROUP G. Anaerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI ___ PAIRS AND CHAINS. Reported to and read back by ___ ___ ___ 1420. ___ 10:00 pm BLOOD CULTURE FINAL REPORT ___ Blood Culture, Routine (Final ___: ANAEROBIC GRAM POSITIVE COCCUS(I). (formerly Peptostreptococcus species). Isolated from only one set ___ the previous five days. NO FURTHER WORKUP WILL BE PERFORMED. Anaerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI ___ PAIRS AND CLUSTERS. Reported to and read back by ___ ___ ___ 1020. ___ 10:30 pm SWAB Source: R foot wcx. FINAL REPORT ___ GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND ___ CLUSTERS. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). WOUND CULTURE (Final ___: 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 BELOW, THEY ARE NOT PRESENT ___ this culture.. BETA STREPTOCOCCUS GROUP G. MODERATE GROWTH. BETA STREPTOCOCCUS GROUP B. SPARSE GROWTH. STAPH AUREUS COAG +. SPARSE GROWTH. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN-------------<=0.25 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. ___ 4:55 pm BLOOD CULTURE FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 7:10 pm BLOOD CULTURE FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 6:29 am BLOOD CULTURE FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 10:12 am BLOOD CULTURE SET#2. FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 7:55 am TISSUE Site: BONE RIGHT FOOT BONE. FINAL REPORT ___ GRAM STAIN (Final ___: 3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND CHAINS. 2+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). TISSUE (Final ___: 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 BELOW, THEY ARE NOT PRESENT ___ this culture.. BETA STREPTOCOCCUS GROUP G. MODERATE GROWTH. IDENTIFICATION PERFORMED ON CULTURE # ___ ___. BETA STREPTOCOCCUS GROUP B. Isolated from broth media only, INDICATING VERY LOW NUMBERS OF ORGANISMS. ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. IMAGING: ======================================== -FOOT AP,LAT & OBL RIGHT Study Date of ___: IMPRESSION: 1. Acute fracture of the head of the ___ metatarsal, with lateral displacement. 2. Diffuse demineralization of the bones, with significant overlying soft tissue swelling raises concern for possible osteomyelitis. -FOOT AP,LAT & OBL RIGHT PORT Study Date of ___: FINDINGS: Comparison is made to the prior radiographs from ___ and ___. Patient has undergone resection of the majority of the distal fourth metatarsal as well as of the fourth proximal phalanx. There remains some soft tissue swelling and gas consistent with the recent surgery and this is stable. There are postoperative changes involving the fifth ray, which are stable. There is a large os peronei adjacent to the cuboid. Spurs about the calcaneal tuberosity are present. On the lateral view, there is a plantar soft tissue ulcer seen adjacent to the metatarsal heads. -TTE (Complete) Done ___ at 9:41:11 AM: Conclusions The left atrium is normal ___ size. Color-flow imaging of the interatrial septum raises the suspicion of an atrial septal defect, but this could not be confirmed on the basis of this study. The estimated right atrial pressure is ___ mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Doppler parameters are indeterminate for left ventricular diastolic function. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. IMPRESSION: No valvular vegetations or abscess identified. Preserved regional and global biventricular systolic function. -CHEST PORT. LINE PLACEMENTStudy Date of ___: IMPRESSION: Right-sided PIC line ends ___ the right atrium and should be pulled back 3-4 cm for positioning ___ the distal SVC. -Note Date: ___ Signed by ___, R.N. on ___ at 10:31 am Affiliation: ___ Picc pulled back 4 cm to place tip ___ lower SVC per Dr ___ ___ radiology. Wire removed on insertion Brief Hospital Course: PRIMARY REASON FOR HOSPITALIZATION: =================================================== ___ y/o male with PMHx of poorly controlled DM2 (HbA1c ___ was 13.6), HTN, HLD presented with infected diabetic foot ulcer and sepsis. ACTIVE ISSUES: =================================================== # Diabetic foot ulcer: Patient presented with a chronic foot ulcer of his right foot. He had been seen ___ clinic earlier that day and labs drawn were significant for a leukocytosis; he was thus sent to the ED for evaluation. ___ the ED initial vitals were: ___ 99%. He spiked a fever to 102.5. Labs were significant for WBC of 17.7 with 90% PMNs, Na of 126, Cr of 2.1, glucose ___ 500s. Lactate 1.4. He was placed on vanc/cipro/flagyl. Podiatry performed bedside I&D on ___. Blood cultures grew group B strep, group G strep. These also grew out of wound cultures; MSSA also grew out of the wound. He was taken back to the OR for further I&D on ___ and ___. Surface ECHO was performed and negative for any mass or vegetation. WBC trended down, though did have slight uptrend prior to discharge (14.2 on day of discharge). He was hemodynamically stable throughout his stay. He was discharged on ertapenem 1g q24hrs at home, to be taken for another 6-weeks, with stop date of ___. # Type 2 diabetes: uncontrolled, last HbA1c was 13.6 (___). Patient was placed on his home medication which was Lantus 40units qAM. Initially his FSBGs were high, requiring large amounts of sliding scale correction at mealtimes. However as his infection was controlled, his FSBGs were less that 200. Given that not much adjustment was made to his insulin from home, yet his sugars were much better controlled than his HbA1c suggested, it was thought that his dietary discretion at home may be playing a significant role. He was seen by nutrition for diet education. He will follow-up with his PCP for further titration of his insulin regimen. Given drug interaction, his preadmission simvastain was stopped and he was placed on atorvastatin 20mg daily. He was continued on his ASA 81mg daily. # Acute on chronic kidney injury - Cr on admission up to 2.1 from baseline ~1.4-1.6. Likely due to hypovolemia from sepsis as has improved with IVFs and ABx. At discharge his Cr was 1.7. # HTN: Prior to admission the patient was maintained on atenolol and lisinopril. His antihypertensives were intitially held due to severe infection. He was eventually placed back on lisinopril and uptitrated to 10mg daily. Additionally he was started on amlodipine 5mg daily. His atenolol was held given his CKD. His BPs were maintained at SBP 120-130s on this regimen. # Anemia: Review of records show baseline Hbg of around 10. Labs from ___ consistent with chronic inflammation, which is likely still the case given his chronic ulcers and current osteomyelitis. Hbg remained stable at ___ during this hospitalization. TRANSITIONAL ISSUES: =================================================== - Lisinopril was increased from 5mg to 10mg daily. - Atenolol was stopped. - Amlodipine was started at 5mg daily. - Simvastatin was changed to atorvastatin 20mg daily (given interaction between simvastatin and amlodipine). - He was discharged on 40units Lantus qAM. He will need to monitor his FSBGs and likely need insulin adjustment as an outpatient based on his dietary pattern. - Discharged on Ertapenem 1g q24hrs, with stop date of ___. All questions regarding outpatient parenteral antibiotics should be directed to the Infectious Disease RNs at ___. - Needs weekly lab draw (CBC with differential, BUN/Cr, AST/ALT, Alk Phos, Total bili, ESR/CRP). Results should be faxed to Infectious Disease RNs at ___. - Weight-bearing to right heel. - Wound needs daily dressing change. Betadine wash, with dry ___ and ___ wrap. - Right PICC line placed ___. This can be removed once treatment is completed. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Omeprazole 20 mg PO DAILY:PRN gerd 2. Simvastatin 40 mg PO QPM 3. Lisinopril 5 mg PO DAILY 4. Sildenafil 100 mg PO DAILY:PRN sexual activity 5. Clindamycin 150 mg PO Q6H 6. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain 7. Atenolol 25 mg PO DAILY 8. Glargine 40 Units Breakfast 9. Aspirin 81 mg PO DAILY Discharge Medications: 1. ertapenem 1 gram injection q24hrs Stop date ___ RX ertapenem [Invanz] 1 gram 1 gram IV q24hrs Disp #39 Gram Refills:0 2. Outpatient Lab Work Please draw weekly CBC with differential, BUN/Cr, AST/ALT, Alk Phos, Total bili, ESR/CRP. All laboratory results should be faxed to the ___ R.N.s at ___ ICD9: 730.0 3. Aspirin 81 mg PO DAILY 4. Glargine 40 Units Breakfast 5. Lisinopril 10 mg PO DAILY 6. Acetaminophen 325-650 mg PO Q6H:PRN pain, fever 7. Amlodipine 5 mg PO DAILY RX amlodipine 5 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 8. Atorvastatin 20 mg PO DAILY RX atorvastatin 20 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 9. Docusate Sodium 100 mg PO BID RX docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #60 Capsule Refills:0 10. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain RX oxycodone 5 mg 1 tablet(s) by mouth q6hrs Disp #10 Tablet Refills:*0 11. Omeprazole 20 mg PO DAILY:PRN gerd 12. Sildenafil 100 mg PO DAILY:PRN sexual activity 13. ertapenem 1 gram injection once Duration: 1 Dose Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Right foot diabetic foot ulcer Osteomyelitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure to care for you here at ___ ___. You were admitted on ___ for a serious right foot infection. Because the infection invloved your bone, you were placed on IV antibiotics and were taken to the operating room to remove infected tissue. You will continue IV antibiotics at home for 6-weeks, with a stop date of ___. You will continue to be seen as an outpatient by the Infectious Disease Department. Your blood pressure medications were changed. Please see below for medication changes. Controlling your diabetes will be a very important part of your recovery and important means to prevent future foot infections. We urge you to pay close attention to your diet and work with your Primary Care Physician to control your blood sugar. It was great to meet you. We wish you all the best. -Your ___ Team Followup Instructions: ___
10015860-DS-21	10,015,860	25,103,777	DS	21	2192-08-06 00:00:00	2192-08-07 07:56:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / metformin Attending: ___. Chief Complaint: Bacteremia Major Surgical or Invasive Procedure: Removal of tunneled HD line ___ Placement of tunneled HD line ___ TEE ___ History of Present Illness: ___ w/ PMH DM, HTN, ESRD on dialysis MWF via left IJ tunnel line presents with fever and tachycardia. Patient stated that he did not feel well on ___, was found to have fever, did not go for HD. had peripheral blood cultures drawn in rehab at that time. H went to HD unit for catch up session yesterday (___), was noted to be tachycardia with low grade temp(100.2), was able to complete HD treatment with 1.6L UF. Blood culture turned out positive today, patient was then sent to ED for further management. Per ED, all blood cultures grew MRSA; gram stain with GPCs and GPRs. Patient was seen in ED, feels ok, denied any chills, no cough or shortness of breath, no nausea/vomiting, stated that he still makes a good amount of urine, denied any diarrhea and endorses chronic constipation that is not bothersome. Per chart, he was discharged from the hospital (___) for right foot necrotizing fasciitis requiring amputation of ___ toe on ___ followed by additional debridement on ___, initiated HD during that admission on ___ with left IJ tunnel line placement. In the ED, initial vitals: T 100.0 HR 103 BP 138/84 RR 18 O2 97% RA - Exam notable for: redness at insertion of port site on anterior chest without tenderness - Labs notable for: Chemistry: 133/5.8//90/26//42/5.9<132 AG 17 Whole blood K: 5.2 CBC 11.6>11.3/34.6>89 Lactate 1.1 - Imaging notable for: CXR ___: Large bore dual lumen left-sided central venous catheter terminates at the cavoatrial junction/proximal right atrium. Cardiac mediastinal silhouettes are unremarkable. No pleural effusion, focal consolidation, evidence of pneumothorax is seen. - Renal-Dialysis was consulted who recommended: 1. No indication for HD today 2. Start Vancomycin 3. ___ consult for port removal 4. Holding on replacing HD catheter for now 5. Dose vancomycin by level - Pt given: 1gm IV vancomycin - Vitals prior to transfer: HR 95 BP 128/68 RR 16 O2 98% RA On the floor, pt endorses the above history Past Medical History: ESRD stage 5 DM HTN Chronic anemia History of Septic R Hip ___ R foot ulcer s/p ___ metatarsal resection (___), s/p ___ metatarsal removal (___) Social History: ___ Family History: Mother with colon cancer and hyperlipidemia. Father with type 2 DM. Physical Exam: ============= ON ADMISSION ============= VITALS: ___ 1724 Temp: 97.7 PO BP: 181/105 R Lying HR: 109 RR: 18 O2 sat: 98% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: ___ GENERAL: AOx3, NAD HEENT: Normocephalic, atraumatic. PERRLA, EOMI, MMM, top and bottom dentures in place NECK: No cervical LAD CARDIAC: Borderline tachycardia, nl rhythm, nl s1/s2, no mrg LUNGS: non labored respirations, CTAB ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES: No clubbing, cyanosis, or edema. Skin is quite dry and flaky. He has purple marker on his right lower extremity from his surgery in ___. His right ___ toe is amputated, area is non erythematous or swollen. 2+DP pulses SKIN: Right upper chest s/p port removal with surrounding erythematous nodules (?), non tender or edematous NEUROLOGIC: CN2-12 intact. ___ strength throughout. ============ DISHCARGE EXAM ============ VITALS: ___ 0448 Temp: 97.4 PO BP: 124/67 HR: 95 RR: 18 O2 sat: 98% O2 delivery: Ra GENERAL: AOx3, NAD HEENT: Normocephalic, atraumatic. PERRLA, EOMI, MMM, top and bottom dentures in place CARDIAC: nl rhythm, nl s1/s2, no mrg LUNGS: non labored respirations, CTAB ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES: No clubbing, cyanosis, or edema. Skin is quite dry and flaky. His right ___ toe is amputated, area is non erythematous or swollen. 2+DP pulses SKIN: Right upper chest s/p port removal with surrounding erythematous nodules (?), non tender or edematous NEUROLOGIC: No gross motor/coordination abnormalities SKIN: Site of previous tunnel line c/d/I no pus. Pertinent Results: =================== LABS ON ADMISSION =================== ___ 12:45PM BLOOD WBC-11.6* RBC-3.89# Hgb-11.3# Hct-34.6# MCV-89 MCH-29.0 MCHC-32.7 RDW-13.1 RDWSD-42.3 Plt ___ ___ 12:45PM BLOOD Neuts-66.1 Lymphs-14.2 Monos-17.1* Eos-1.4 Baso-0.8 Im ___ AbsNeut-7.70# AbsLymp-1.65 AbsMono-1.99 AbsEos-0.16 AbsBaso-0.09* ___ 12:45PM BLOOD Plt ___ ___ 12:45PM BLOOD Glucose-132* UreaN-42* Creat-5.9# Na-133 K-5.8* Cl-90* HCO3-26 AnGap-17 ======= MICRO ======= ___ URINE CULTURE (Final ___: < 10,000 CFU/mL. ___ BLOOD CULTURE Blood Culture, Routine (Pending): ___ BLOOD CULTURE Blood Culture, Routine (Pending): ___ BLOOD CULTURE Blood Culture, Routine (Pending): ___ Blood Culture, Routine (Pending): ___ Blood Culture, Routine (Pending): ___ Blood Culture, Routine (Pending): ___ Blood Culture, Routine (Pending): ___ 12:45 pm BLOOD CULTURE #1. Blood Culture, Routine (Preliminary): STAPH AUREUS COAG +. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus, yeast or other fungi. FINAL SENSITIVITIES. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. RIFAMPIN should not be used alone for therapy. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN---------- 1 I GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 4 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=0.5 S Anaerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. ___ 12:45 pm BLOOD CULTURE #2. *FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ============ IMAGING ============ TEE ___ Good image quality. A ?moderate in size (will measure for final report) echodensity with mobile components is seen on the LVOT side of the non-coronary cusp of the aortic valve consistent with a vegetation. Trace aortic regurgitation. No abscesses appreciated. Dynamic interatrial septum. Simple atheroma ascending aorta and aortic arch. A ?moderate in size (will measure for final report) echodensity with mobile components is seen on the LVOT side of the non-coronary cusp of the aortic valve consistent with a vegetation. Trace aortic regurgitation. No abscesses appreciated. Dynamic interatrial septum. Simple atheroma ascending aorta and aortic arch. Tunneled Dialysis Line Placement ___ IMPRESSION: Successful placement of a 27cm tip-to-cuff length tunneled dialysis line. The tip of the catheter terminates in the right atrium. The catheter is ready for use. TTE ___ Left Ventricle - Ejection Fraction: 56% The left atrium is mildly elongated. Left ventricular wall thicknesses and cavity size are normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is low normal (biplane LVEF 56%). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is a very small pericardial effusion. IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes with low normal global left ventricular systolic function. Mild mitral regurgitation. No discrete vegetation/abscess identified. Compared with the prior study (images reviewed) of ___, the findings are similar Dialysis Catheter Removal ___ The procedure was performed at bedside. The Left chest tunneled line site was cleaned and draped in standard sterile fashion. 1% lidocaine was administered around the tube track. The cuff was loosened with a bent forceps. The catheter was removed with gentle traction while manual pressure was held at the venotomy site. Hemostasis was achieved after 5 min of manual pressure. A clean sterile dressing was applied. The patient tolerated the procedure well. There were no immediate postprocedural complications. FINDINGS: Expected appearance after tunneled line removal. IMPRESSION: Successful removal of a left chest tunneled line DISCHARGE LABS =============== ___ 06:25AM BLOOD WBC-10.0 RBC-3.53 Hgb-10.3* Hct-30.7* MCV-87 MCH-29.2 MCHC-33.6 RDW-13.2 RDWSD-41.4 Plt ___ ___ 06:25AM BLOOD Plt ___ ___ 06:25AM BLOOD Glucose-98 UreaN-42* Creat-4.8# K-4.7 Cl-95 HCO3-25 AnGap-18 ___ 06:25AM BLOOD Calcium-9.0 Phos-6.3* Mg-1.9 ___ 06:25AM BLOOD Vanco-17.4 Brief Hospital Course: ___ is a ___ with DMII c/b ESRD on HD MWF p/w 2 days of fevers and positive blood cultures with MRSA, now s/p HD port removal and identification of aortic valve vegetation. # MRSA BACTEREMIA LIKELY DUE TO LINE INFECTION # MRSA ENDOCARDITIS OF AORTIC VALVE Patient presented from his ___ facility on ___ after episode of fevers, rigors, found to have high grade MRSA bacteremia (positive culture at rehab ___ 1 of 4 cultures on ___ with MRSA). Likely etiology is line sepsis from infected tunneled HD catheter and this was removed on ___. TTE was done which was suboptimal quality but did not show any vegetations. TEE on ___ndocarditis with mod vegetation on AV cusp. No paravalvular abscess seen. Repeat surveillance blood cultures were negative. New tunneled hemodialysis line was placed ___. Plan is to treat with 6 weeks of vancomycin dosed with HD through ___. Will follow-up in ___ clinic. #ESRD on HD MWF #Hyperkalemia Patient was initiated on HD during his last hospitalization ___. Renal failure is secondary to diabetic nephropathy. Still makes urine. He was given a line holiday and missed dialysis session on ___ and ___. CMP checked daily, hyperK+ and hypervolemia treated with insulin/dextrose and 100 mg Lasix and insulin/dextrose PRN. HD tunneled line was replaced on ___. He was kept on strict low K+ diet, strict ___ mL fluid restriction and continued on home nephro caps, calcitriol, calcium carbonate and Vitamin D. Last dialysis session on ___. His home Lisinopril was held and then restarted on discharge. #s/p right toe amputation Healing well, no signs of infection. Podiatry curbsided and had a very low suspicion for infection, but recommened x-ray to ensure no signs of osteo, though patient declined. CRP ~11. #DIABETES MELLITUS II Previously followed by ___. Most recent A1C 6.6%. Continued home glargine and Humalog SS. #HYPERTENSION SBP 140-150s. Continued on Lisinopril on discharge. #HLD: Continued on atorvastatin 20mg QHS and ASA 81mg daily #ANEMIA Hb 11.3, bl ___. Unclear why higher than usual, maybe some component of hemoconcentration in setting of fever and bacteremia. Iron studies from ___ suggestive of anemia of chronic inflammation; B12 normal. Anemia likely due to ESRD. EPO 10,000units q14 days per renal recs. TRANSITIONAL ISSUES =================== - Continue vancomycin with hemodialysis sessions (end date ___ for a total of 6 weeks. - Weekly CBC/diff, vanc levels at least every other week, and CRP every ___ weeks, and surveillance blood cultures at the end of his course. PLEASE DRAW DURING HD SESSIONS, ALL LAB RESULTS SHOULD BE SENT TO: ATTN: ___ CLINIC - FAX: ___ - ___ clinic follow-up, likely surveillance culture after abx Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 5 mg PO DAILY 2. LORazepam 0.5 mg PO PRE DIALYSIS 3. Epoetin ___ ___ UNIT IV Q14 DAYS 4. Atorvastatin 20 mg PO QPM 5. Furosemide 20 mg PO DAILY 6. TraMADol 50 mg PO UNKNOWN, PRN Pain - Moderate 7. Polyethylene Glycol 17 g PO Frequency is Unknown 8. Calcium Carbonate 500 mg PO TID 9. Aspirin 81 mg PO DAILY 10. Calcitriol 0.25 mcg PO DAILY 11. Vitamin D ___ UNIT PO DAILY 12. Glargine 8 Units Bedtime Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Nephrocaps 1 CAP PO DAILY RX B complex with C#20-folic acid [Nephrocaps] 1 mg 1 capsule(s) by mouth daily Disp #30 Capsule Refills:0 2. Vancomycin 1000 mg IV WITH HD RX vancomycin 1 gram 1 g IV with HD Disp #15 Vial Refills:0 3. Glargine 8 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 4. Polyethylene Glycol 17 g PO DAILY:PRN constipation 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 20 mg PO QPM 7. Calcitriol 0.25 mcg PO DAILY 8. Calcium Carbonate 500 mg PO TID 9. Epoetin ___ ___ UNIT IV Q14 DAYS 10. Furosemide 20 mg PO DAILY 11. Lisinopril 5 mg PO DAILY 12. LORazepam 0.5 mg PO PRE DIALYSIS RX lorazepam 0.5 mg 1 tablet by mouth predialysis Disp #2 Tablet Refills:*0 13. Vitamin D ___ UNIT PO DAILY 14.Outpatient Lab Work Weekly CBC/diff, vanc levels at least every other week, and CRP every ___ weeks, and surveillance blood cultures at the end of his course. Please draw with HD, ALL LAB RESULTS SHOULD BE SENT TO: ATTN: ___ CLINIC - FAX: ___. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: MRSA Bacteremia ESRD on HD Hyperkalemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to ___ with fevers. You had bacteria in your blood and were treated with intravenous antibiotics. We suspected the source of this infection to be from your hemodialysis line which was removed. We replaced your hemodialysis line. You underwent echocardiograms of your heart which found a bacteria in one of your heart valves. You will need antibiotics for several weeks with your hemodialysis sessions. It was a pleasure caring for you. Wishing you the best, Your ___ Team Followup Instructions: ___
10015860-DS-22	10,015,860	26,352,758	DS	22	2192-09-28 00:00:00	2192-09-28 16:41:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: Penicillins / metformin / Naprosyn Attending: ___. Chief Complaint: Comminuted left intertrochanteric fracture Major Surgical or Invasive Procedure: Left short TFN ___, KRod) History of Present Illness: HPI: ___ PMHx ESRD (b/l Cr variable, >5 last admission) on HD MWF w/ access via tunneled Left IJ, DM w/ peripheral neuropathy, HTN, PVD s/p multiple Right toe amputations, and recent admission for MRSA bacteremia/AV endocarditis s/p 6 weeks IV Vanc (completed ___ presents from rehab s/p fall from standing with Left hip pain. He states he felt a "crunch" when he hit the ground. He endorses head strike, but reports no LOC. He has no new N/T/P in his BLE (baseline peripheral neuropathy). He states that for the past several years he has been ambulating with a walker given his Right foot status (multiple toe amps). His HCP is his brother ___: ___. He denies chest pain, SOB, or abdominal pain. He is alert and oriented to situation, place, and date. He states he last ate yesterday ___ (dinner)> Past Medical History: ESRD stage 5 DM HTN Chronic anemia History of Septic R Hip ___ R foot ulcer s/p ___ metatarsal resection (___), s/p ___ metatarsal removal (___) Social History: ___ Family History: Mother with colon cancer and hyperlipidemia. Father with type 2 DM. Physical Exam: On discharge: General: well-appearing, breathing comfortably CV: pink and well perfused Abd: soft, non-tender, non-distended LLE: Incision well approximated. Dressing clean and dry. Fires FHL, ___, TA, GCS. SILT ___ n distributions. Toes WWP distally. Pertinent Results: ___ 11:19PM BLOOD WBC-7.8 RBC-3.51* Hgb-10.0* Hct-30.2* MCV-86 MCH-28.5 MCHC-33.1 RDW-14.6 RDWSD-45.1 Plt ___ ___ 11:19PM BLOOD Glucose-148* UreaN-27* Creat-3.8* Na-137 K-4.3 Cl-93* HCO3-31 AnGap-13 Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have fracture of the left hip and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for ORIF with short TFN, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. After the procedure 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 renal diet and oral medications. The patient was given ___ antibiotics (IV Vanc given penicillin allergy) and anticoagulation (___ 5000U BID given ESRD). The patient's home medications were continued throughout this hospitalization. Nephrology was consulted given need for HD. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is weight bearing as tolerated in the left lower extremity, and will be discharged on ___ 5000U BID for DVT prophylaxis. The patient will follow up with Dr. ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Lisinopril 5 mg PO DAILY 2. Atorvastatin 20 mg PO QPM 3. Aspirin 81 mg PO DAILY 4. LORazepam 0.5 mg PO DAILY:PRN anxiety 5. Glargine 8 Units Bedtime 6. melatonin 5 mg oral QPM Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Comminuted Left intertrochanteric fracture Discharge Condition: AVSS NAD Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). LLE: Incision well approximated. Dressing clean and dry. Fires FHL, ___, TA, GCS. SILT ___ n distributions. Toes WWP distally. Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - weight bearing as tolerated in left lower extremity MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take SQH 5000U twice a day for 4 weeks WOUND CARE: - Your incision is covered with a dry dressing. Please change the dressing daily. If there is no drainage, you may leave your incision open to the air. If you are continuing to have drainage, you may place a dry dressing over the incision as needed. - 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. THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB Physical Therapy: weight bearing as tolerated in 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: ___
10015860-DS-23	10,015,860	28,196,804	DS	23	2193-11-27 00:00:00	2193-11-29 20:26:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / metformin / Naprosyn Attending: ___. Chief Complaint: ? cellulitis Major Surgical or Invasive Procedure: Fistulogram with ___ on ___. History of Present Illness: ___ yo male with ESRD on HD, IDDM and history of left brachiocephalic vein occlusion ___ s/p stenting who presents from Presentation Rehab on recommendation from his outpatient nephrologist with left arm redness and swelling of entire left arm c/f restenosis of brachiocephalic vein and overlying cellulitis. His left arm swelling and redness has been worsening over past 2 weeks. He has noted the arm has become more painful over the last ___ days. He is unable to provide a history of the pattern of spread for the erythema. He was evaluated by transplant nephrology in clinic today who noted c/f restenosis of left brachiocephalic vein stent. They were also concerned for cellulitis and therefore deferred fistulogram and angioplasty. Dr. ___ a low suspicion for graft infection and no systematic signs of infection. They recommended arm elevation, exercise, antibiotic treatment and then proceeding with a fistulogram/angioplasty prior to discharge if edema does not resolve with treatment of cellulitis. Regarding his current AV graft, it was placed in left upper extremity on on ___. He has required 2 procedures since graft creation for arm swelling. His first procedure was in ___ and at that time a significant stenosis at the venous anastomosis was also angioplastied and stented. The second procedure was in ___, and involved recanalization of a brachiocephalic occlusion and stenting of the brachiocephalic. - In the ED, initial vitals were: T 97.1 HR 77 BP 154/76 RR 18 SPO2 99% RA - Exam was notable for: LUE with +thrill, arm edematous to axilla with erythema and induration of forearm, neurovascularly intact, dorsal forearm ulcer with surrounding erythema RLE with ulcer and s/p 1 toe amputation without erythema/warmth/induration - Labs were notable for: WBC: 7.7, Hgb 13.1, Na: 135, K 5.4, Cl: 93, BUN: 28, BUN 35, Cr 4.5 Ag: 14 - Studies were notable for: Left Upper Extremity Venous U/S: IMPRESSION: No evidence of deep vein thrombosis in the left upper extremity. - The patient was given: Vancomycin ___ @ 1700 -Transplant Surgery was consulted Staffed with Dr. ___. Recommend admission to medicine for antibiotics. ___ may consider fistulogram if swelling does not improve with elevation and antibiotics. Transplant surgery will follow along as inpatient. On arrival to the floor, patient is without complaints. he confimrs the above story. Past Medical History: ESRD stage 5 on HD with L AV fistula DM HTN Chronic anemia History of Septic R Hip ___ R foot ulcer s/p ___ metatarsal resection (___), s/p ___ metatarsal removal (___) L brachiocephalic vein occlusion and stenting Social History: ___ Family History: Mother with colon cancer and hyperlipidemia. Father with type 2 DM. Physical Exam: ADMISSION PHYSICAL EXAM: ====================== VITALS: T 97.6 BP 184 / 10 HR 84 RR 18O2: 96Ra GENERAL: Alert and interactive. In no acute distress. HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM. NECK: No cervical lymphadenopathy. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. BACK: No CVA tenderness. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES: Left arm with pitting edema from hand to shoulder. Arm is warm with dark red/purple blanchable erythema worst on medial aspect of upper arm. 2+ radial artery pulses bilaterally. Sensation intact in left arm. Right foot with superficial ulceration over lateral aspect near base of ___ toe. SKIN: Warm. Cap refill <2s. NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs spontaneously. ___ grip strenght, ___ hip flexor strenght.. Normal sensation. DISCHARGE PHYSICAL EXAM: ====================== 24 HR Data (last updated ___ @ 814) Temp: 97.7 (Tm 97.8), BP: 154/86 (146-169/79-88), HR: 72 (69-75), RR: 18, O2 sat: 98% (96-98), O2 delivery: Ra GENERAL: Alert and interactive. In no acute distress. HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM. 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. EXTREMITIES: Left arm with pitting edema from hand to shoulder. Arm is warm with light red blanchable erythema worst on medial aspect of upper arm. 2+ radial artery pulses bilaterally. Sensation intact in left arm. Right foot with superficial ulceration over lateral aspect near base of ___ toe. SKIN: Warm. Cap refill <2s. NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs spontaneously. ___ grip strength, ___ hip flexor strength. Normal sensation. Pertinent Results: ADMISSION LABS: ============= ___ 01:50PM WBC-7.7 RBC-4.75 HGB-13.1* HCT-43.6 MCV-92 MCH-27.6 MCHC-30.0* RDW-17.1* RDWSD-57.8* ___ 01:50PM NEUTS-61.4 ___ MONOS-11.6 EOS-2.0 BASOS-0.8 IM ___ AbsNeut-4.73 AbsLymp-1.82 AbsMono-0.89* AbsEos-0.15 AbsBaso-0.06 ___ 01:50PM GLUCOSE-109* UREA N-35* CREAT-4.5* SODIUM-135 POTASSIUM-7.5* CHLORIDE-93* TOTAL CO2-28 ANION GAP-14 ___ 01:56PM LACTATE-1.1 K+-5.4 MICROBIO: ======== negative blood culture IMAGING: ======= UNILAT UP EXT VEINS US LEFTStudy Date of ___ 5:50 ___ No evidence of deep vein thrombosis in the left upper extremity. ___. Left upper extremity AV fistulagram. 2. Axillary, subclavian and super vena cava venography. 3. Balloon angioplasty of the occluded brachiocephalic stent. 4. Balloon angioplasty of the small amount of clot proximal to the brachiocephalic stent. 1. Complete occlusion of the brachiocephalic vein stent with severe central collaterals. 2. Restoration of flow after balloon angioplasty. DISCHARGE LABS: ============= ___ 06:10AM BLOOD WBC-7.2 RBC-4.39* Hgb-12.0* Hct-39.9* MCV-91 MCH-27.3 MCHC-30.1* RDW-16.6* RDWSD-55.8* Plt ___ ___ 06:10AM BLOOD Glucose-61* UreaN-53* Creat-6.4# Na-137 K-5.4 Cl-92 HCO3-23 AnGap-22* ___ 06:10AM BLOOD Calcium-10.0 Phos-3.7 Mg-2.0 Brief Hospital Course: Mr. ___ is a ___ with IDDM, ESRD on HD MWF, and and history of left brachiocephalic vein occlusion ___ s/p stenting who presents with ___ weeks of left arm swelling and 1.5 weeks of erythema due to venous congestion/stenosis vs cellulitis. TRANSITIONAL ISSUES: ================== []Please continue IV Vancomycin with HD to complete 7 day course, last day of administration on ___. ACUTE/ACTIVE ISSUES: ==================== #Left arm edema with concern for Left brachiocephalic vein stent restenosis and cellulitis. Arm swelling is concerning for restenosis of left brachiocephalic vein occlusion which was noted on fistulogram in ___ and s/p stenting. Patient was evaluated by interventional radiology and transplant surgery, underwent fistulogram with ___ on ___ with balloon angioplasty of brachiocephalic vein stent. Given erythema and edema patient was also treated with IV Vancomycin with HD. Plan for a 7 day course (___). #ESRD on HD ___ Pt currently with AV fistula for only access. Transplant surgery reports it is ok to use AV fistula as it is functioning now. Continued nephrocaps, sevelemer, Vitamin D, calcium acetate. #Hypertension: Elevated BP on admission. Continued home metoprolol tartrate 50mg BID and lisinopril 5mg CHRONIC/STABLE ISSUES: ====================== #Insulin Dependent Diabetes: Continue lantus 8 units at night and ISS. #Primary Prevention: Continue aspirin 81mg #HLD: Continue home atorvastatin #Anxiety: Continue home fluoxetine and home lorazepam 0.5mg 1 tablet by mouth 3x weekly pre dialysis. #GERD: Continue pantoprazole 40mg # CODE: full confirmed # CONTACT: ___ (HCP, Brother) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 5 mg PO DAILY 2. LORazepam 0.5 mg PO THREE TIMES WEEKLY 3. Metoprolol Tartrate 50 mg PO BID 4. Atorvastatin 20 mg PO QPM 5. Calcium Acetate 1334 mg PO TID W/MEALS 6. FLUoxetine 20 mg PO DAILY 7. Glargine 8 Units Bedtime 8. Pantoprazole 40 mg PO Q24H 9. sevelamer CARBONATE 2400 mg PO TID W/MEALS 10. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line 11. Nepro Carb Steady (nut.tx.imp.renal fxn,lac-reduc) 0.08 gram-1.8 kcal/mL oral BID 12. Glucagon Emergency Kit (human) (glucagon (human recombinant)) 1 mg injection ONCE:PRN hypoglycemia 13. Aspirin 81 mg PO DAILY 14. Nephrocaps 1 CAP PO DAILY 15. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 16. Vitamin D ___ UNIT PO DAILY 17. melatonin 5 mg oral DAILY 18. Senna 8.6 mg PO QHS 19. ProMod Protein (protein supplement) 30 ml oral BID Discharge Medications: 1. Sarna Lotion 1 Appl TP TID 2. ___ MD to order daily dose IV HD PROTOCOL Sliding Scale Start: ___, First Dose: Next Routine Administration Time 3. Glargine 8 Units Bedtime 4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 20 mg PO QPM 7. Calcium Acetate 1334 mg PO TID W/MEALS 8. FLUoxetine 20 mg PO DAILY 9. Glucagon Emergency Kit (human) (glucagon (human recombinant)) 1 mg injection ONCE:PRN hypoglycemia 10. Lisinopril 5 mg PO DAILY 11. LORazepam 0.5 mg PO THREE TIMES WEEKLY 12. melatonin 5 mg oral DAILY 13. Metoprolol Tartrate 50 mg PO BID 14. Nephrocaps 1 CAP PO DAILY 15. Nepro Carb Steady (nut.tx.imp.renal fxn,lac-reduc) 0.08 gram-1.8 kcal/mL oral BID 16. Pantoprazole 40 mg PO Q24H 17. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line 18. ProMod Protein (protein supplement) 30 ml oral BID 19. Senna 8.6 mg PO QHS 20. sevelamer CARBONATE 2400 mg PO TID W/MEALS 21. Vitamin D ___ UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary Diagnosis Thrombosis due to vascular prosthetic devices, implants and grafts Secondary diagnosis End Stage Renal Disease Type 2 Diabetes Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ====================== DISCHARGE INSTRUCTIONS ====================== Dear Mr ___, It was a privilege caring for you at ___. WHY WAS I IN THE HOSPITAL? - You were admitted to the hospital because your left arm was very swollen WHAT HAPPENED TO ME IN THE HOSPITAL? - In the hospital you continued your normal dialysis schedule - We gave you IV antibiotics in case your arm was infected - We performed a procedure to allow better blood flow in the veins in your arm WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Continue to take all your medicines and keep your appointments. We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___
10016084-DS-4	10,016,084	23,267,624	DS	4	2155-12-09 00:00:00	2155-12-09 15:09:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: L foot and ankle pain Major Surgical or Invasive Procedure: -Left ankle arthrocentesis -C5-T1 laminectomy with abscess drainage -Left ankle/foot I&D with bone biopsy -Peripheral inserted central catheter placement and removal -Left ankle/foot repeat wash out History of Present Illness: ___ w/ PMH significant for MGUS, CKD, DM, HTN, and gout, in his usual state of health until ___, when he noticed left foot swelling and pain with taking a step, which worsened to the point of not being able to walk. In the ED, initial vitals 101 65 97/57 18 96% RA ED physicians felt ___ unable to amb and not functioning at baseline ___ L foot pain. Able to indep and safely transfer to w/c and propel w/c therefore safe for d/c to home c home ___ and rental w/c ordered. However, informed following eval by CM that Pt may be admitted therefore, rental w/c order cancelled. If Pt is d/c to home, re-order will be needed, company currently closed. Please contact covering ___ in AM if this is necessary. Pt was diagnosed w/ gout of right MCP and big toe, put on a steroid taper, and admitted for placement because he can't walk, lives alone, and can't get food. Vitals on transfer: ___ Upon arrival to the floor: vitals were 100.0F, 119/63, 87, 16, 94RA. Pt thought his walking pain was due to gout, which Pt was only recently diagnosed w/ ___ months prior based on serum uric acid levels alone (no joint was ever aspirated), mainly affecting the right ___ mcp joint. Pt states that his hand has actually felt fine over the last two days as he as started a prednisone taper (currently 50mg po daily), but his foot pain has been getting worse, to the point where he can no longer walk around. Pt does not have any history of blood clots and has generally been active around the house. No recent travel, no immobilization. He has noticed unilateral left lower extremity swelling. No sob, no dyspnea, no pleuritic chest pain, reports occasional cough. States that he has lost 17 lbs unintentionally over the last 2 months and occasionally had drenching night sweats, which he attributed to hypoglycemia. ROS: reports mild fever, chills, night sweats as per hpi, denies headache, vision changes, rhinorrhea, congestion, sore throat. Reports occasional cough, but no shortness of breath, no chest pain, no abdominal pain, no nausea, vomiting, diarrhea, or constipation, no BRBPR, melena, hematochezia, dysuria, or hematuria. Past Medical History: (per ___ notes): KIDNEY DISEASE - CHRONIC STAGE IV (SEVERE, EGFR ___ ML/MIN) - had been evaluated for fistula at ___ but did not follow through DM W RENAL COMPLIC - last HGBA1C 6.8% (___) HYPERTENSION - ESSENTIAL, UNSPEC HYPERLIPIDEMIA MUSCLE WEAKNESS - EMG in ___ with generalized mixed axonal demyelinating polyneuropathy; also evidence of LS polyradiculopathy involving both legs residual mild right sided weakness, cane only with lots of ___ ESOPHAGITIS, UNSPEC (on PPI) ENDOCARDITIS (___, ___ MGUS, Kappa light chain disease Obesity h/o stroke with residual right sided weakness h/o periph neuropathy PSH: Hernia repair, drainage of paraspinal abscess Social History: ___ Family History: Diabetes - Type II Maternal Aunt Other [Other] Mother Comment: alzheimer's cancer - lung[Other] Father cancer - pancreas[Other] Sister Physical Exam: Admission- VS - 100.0F, 119/63, 87, 16, 94RA GENERAL - well-appearing man in NAD, comfortable, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no JVD LUNGS - reduced breath sounds to midlung on R, egophony to midlung on right, otherwise clear to auscultation bilaterally HEART - RRR, no MRG, nl S1-S2 ABDOMEN - soft, non-tender, no masses, normal bowel sounds EXTREMITIES - left lower extremity warm and tender to palpation, edematous from toes to mid calf. Tender to palpation of left calf. No palpable cords, but pain in calf w/ dorsiflexion of left foot. Full range of motion of all left toes and ankle. No tenderness to palpation of L foot or toe joints. No edema or tenderness to palpation on R lower extremity, 2+ dp pulses. LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout. Discharge Vitals: Tc/m 98.398.7 BP 146/71 (135-148) HR 86(84-99) R 18O2 Sat 94% RA ___ 120 (60-153) General: Patient lying in bed in NAD. Pleasant and interactive and in NAD HEENT: EOMI. PERRL. MMM. CV: RRR. +systolic murmur c/w prior Lungs: CTA bilaterally. No crackles or wheezes. Nml work of breathing. decreased breath sounds on right c/w prior. Abdomen: NABS+. Soft. NT/ND. Ext: Warm. No pitting edema of the ___ bilaterally. L foot covered in bandage which is c/d/i. Large ecchymoses of LUE Neuro: AAOx3, LUE 3+/5 with left finger extention (pt able to move fingers but can not fully extend; similar with yesterday), ___ wrist extentions, ___ flexors/deltoid, RUE ___ strength, LLE/RLE ___ strength. sensation intact throughout. Skin: Ecchymoses over triceps b/l within marked outlines. Pertinent Results: Admission- ___ 11:33AM BLOOD WBC-7.3 RBC-3.20* Hgb-9.5* Hct-29.2* MCV-92 MCH-29.7 MCHC-32.4 RDW-13.8 Plt ___ ___ 11:33AM BLOOD Neuts-76* Bands-0 Lymphs-12* Monos-11 Eos-1 Baso-0 ___ Myelos-0 ___ 05:40AM BLOOD ___ PTT-23.2* ___ ___ 11:33AM BLOOD Glucose-167* UreaN-91* Creat-5.0* Na-139 K-4.0 Cl-96 HCO3-28 AnGap-19 ___ 11:33AM BLOOD Albumin-3.4* Calcium-10.6* Phos-2.4* Mg-2.0 UricAcd-13.5* ___ 04:35AM BLOOD calTIBC-155* Ferritn-651* TRF-119* ___ 04:35AM BLOOD PTH-60 ___ 04:35AM BLOOD 25VitD-28* ___ 05:40AM BLOOD PEP-ABNORMAL B IgG-1098 IgA-298 IgM-36* IFE-MONOCLONAL Discharge- ___ 06:52AM BLOOD WBC-11.8* RBC-2.54* Hgb-7.1* Hct-22.5* MCV-89 MCH-27.9 MCHC-31.5 RDW-16.0* Plt ___ ___ 06:52AM BLOOD Glucose-182* UreaN-72* Creat-4.4* Na-134 K-5.0 Cl-101 HCO3-20* AnGap-18 ___ 06:52AM BLOOD ALT-38 AST-85* AlkPhos-159* TotBili-0.5 ___ 06:52AM BLOOD Calcium-8.4 Phos-4.6* Mg-2.1Microbiology- Pathology- -Bone, left foot, biopsy (___): Acute osteomyelitis. Studies- -UNILAT LOWER EXT VEINS LEFT (___): No evidence of deep venous thrombosis of the left lower extremity. Left peroneal veins were not visualized. -ANKLE (AP, MORTISE & LAT) AND FOOT, LEFT (___): Moderate degenerative changes throughout the hindfoot and mid foot. No acute fracture. -MR ANKLE ___ CONTRAST LEFT (___): 1. Likely tophaceous gouty deposit at lateral aspect foot tarsometatarsal level with associated osseous erosive changes, detailed above. 2. Muscular edema in plantar musculature, flexor hallucis longus and peroneus brevis may reflect sequela of diabetic neuropathy. 3. Moderate subcutaneous soft tissue edematous changes at the dorsal lateral ankle and foot. Correlate clinically to exclude the possibility of cellulitis. No definite findings to suggest abscess formation. 4. Early degenerative changes seen at the tibiotalar joint and throughout the midfoot, likely representing early Charcot neuro-osteoarthropathic changes. 5. Longitudinal tear of distal peroneus brevis tendon extending towards attachment to base of fifth metatarsal. 6. Mild tendinosis of peroneus longus at level of and inferior to lateral malleolus. 7. Tenosynovitis of medial and lateral ankle tendons, detailed above. 8. Old osseous avulsion injury at medial malleolus. 9. Sinus tarsi edema which can be seen in sinus tarsi syndrome. -TTE (___): The left atrium is mildly dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. -TEE (___): No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. -MR CERVICAL SPINE ___ CONTRAST (___): Extremely limited examination due to patient motion, lack of gadolinium contrast and axial images. There is a questionable lesion with high signal intensity at the level of C7 on the left, with possible soft tissue edema in the interspinous process, epidural or intrdural lesions cannot be completely excluded, please consider repeating this examination under conscious sedation for further characterization. MRI ___ IMPRESSION: 1. Interval debridement at the dorsal lateral aspect of the foot. 2. Extensive erosive disease with characteristic features of gout, not significantly changed. 3. Limited examination, stopped early due to patient discomfort. Reimaging may be performed when the patient is better able to tolerate the exam. CXR PICC Placement IMPRESSION: Right PICC line tip in the distal SVC Brief Hospital Course: ___ M w/ PMH significant for MGUS, CKD, DM, HTN, and gout, initially presented with left lower extremity swelling and pain thought to be gout, found to have MSSA bacteremia and septic arthritis, fungemia (C albicans) and s/p I&D and wash out of left foot, epidural abscess evacuation, and C5-T1 laminectomy. . # Bacteremia (MSSA) The patient reported have nightsweats at home and spiked a fever to ___ the evening of admission. Subsequently, the patient was found to have positive blood cultures growing MSSA. He was initially start on vancomycin, which was then transitioned to daptomycin given his changing renal function. He underwent a TTE, followed by a TEE which were both negative for endocarditis. His last positive bacterial blood culture was from ___. He is to have weekly safety labs including CK while he is receiving daptomycin. Given his osteomyelitis and epidural abscess (see below) he is to remain on daptomycin for 6 weeks following his last foot wash out (___). Daptomycin 760 mg IV Q48H x6 weeks ___ to finish on ___ unless otherwise specified by outpatient Infectious Disease follow up. . # Fungemia (C albicans) The patient was noted to be growing ___ albicans from a blood culture dated ___. He was started on micafungin and surveillance fungal blood cultures were sent and subsequently returned negative. An ophthalmic evaluation did not reveal evidence of fungal endophthalmitis. He was transitioned to fluconazole po, which he is to take for a total of a 2 week course starting from the date of his first negative blood culture; completing on ___. # C7 Epidural abscess In the evening of ___, patient reported that his LUE felt weak. On exam, he was noted to have significant weakness with extension of his LUE, including triceps, wrist and fingers. An MR of the Cspine was concerning for an epidural abscess at C7. He was taken to the OR on ___ for C5-T1 laminectomy and epidural abscess drainage and he tolerated the procedure well. The abscess fluid that was drained also grew MSSA. His anticoagulation was transiently held (48 hours) while the surgical drain was in place. The drain was d/c without incident. The patient denied subsequent neck pain and his LUE weakness slowly began to improve. He continues to have difficulties with left finger (digit ___ extension and weakness particuarly with tricep extension. Flexion of the LUE and grip strength remain relatively preserved. Orthopedics will follow up patient as an outpatient though appointments have not been scheduled yet. Orthopedics contacted morning of discharge and will schedule an outpatient appointment. . # Osteomyelitis After the patient's bedside aspiration by podatry, he was taken to the OR for an I&D and bone biopsy. The patient's bone biopsy began growing MSSA as well and the pathology was consistent with acute osteomyelitis. The patient went for subsequent wash out of the wound, and cultures continued to grow MSSA. As above, he is to continue on daptomycin for at least six weeks following his last foot wash out, last dose is to be ___ unless otherwise directed. He is to remain non-weight bearing on his left lower extremity until follow up appointment by podiatry. Again, Podiatry is scheduling appointment though follow up visit has not been made by discharge time. The patient is also to remain with wound vac set at settings in Page I and to be changed Q3 days. This should remain in place until specified by Podiatry. # Gout The patient had previously been diagnosed with gout based on symptoms and elevated uric acid level. He presented with an erythematous and tender right ___ metacarpal head and an erythematous, swollen diffusely tender left ankle. He underwent a left ankle arthrocentesis by rheumatology, the analysis of which was significant for 12,500 WBCs and monosodium urate crystals c/w gout. No microorganisms were noted on gram stain and the initial fluid culture was negative. The patient underwent a subsequent aspiration of a fluid collection on the lateral aspect of his left foot by podiatry, which revealed MSSA in additional to multiple monosodium urate crystals. He had been started on prednisone by his PCP even prior to admission. This was continued as an inpatient and tapered down given his concurrent infection and as his pain improved. His last dose of prednisone is to be ___. He was not started on uric acid lowering therapy during this admission as he was in an acute flair of his gout. He is to follow up with rheumatology in 4 weeks. # Anemia: Chronically anemic likely related to anemia of chronic disease and chronic kidney disease causing poor EPO production. On day of discharge his Hct level was 22.5. There was no active sources of bleeding or hemolysis and his hct should be monitored while he is in an ___ facility to monitor for stability of Hct. He did not require transfusion during this admission. # Chronic Kidney Disease, Stage 4 The underlying etiology of his CKD was felt to be secondary to his DM. His kidney function was carefully monitored and all medications were renally dosed. He was monitored with the assistance of the nephrology team in order to preserve his current kidney function. Regardless, the patient should follow up with his outpatient nephrologist for follow up when his is discharged. # Monoclonal gammopathy of undetermined significance The patient's initial compliants of unintentional weight loss associated with night sweats and subjective fevers was concerning for malignancy. A repeat SPEP was sent and as per report from his primary oncologist, was consistent with prior. # Insulin dependant diabetes mellitus The patients blood sugars were carefully monitored given the concern for early Charcot joint and changing doses of prednisone therapy. His insulin therapy was down titrated when he had an episode of am hypoglycemia. The patient reported feeling well at the time, but did experience some dizziness. With downtitration of Prednisone dosing the patient required less insulin. Lantus was discontinued and his blood sugars were controlled with Humalog Insulin Sliding Scale. He should remain on HISS while at ___. If his blood sugars remain uncontrolled then he should be restarted on Lantus based on the daily requirement of Humalog. # Hypertension The patient's home antihypertensives were initially held given his bacteremia and the concern that his infection may worsen. He remained hemodynamically stable throughout his hospital stay. As his clinic status improved, his antihypertensives were restarted. Although toresemide has been discontinued and he was given metoprolol in place of his atenolol given his CKD. His hypertension remains not at goal <130/80 but were not titrated further. Would defer to outpatient Nephrologist regarding next steps in management of his hypertension. . # Right elevated hemidiaphragm: Noted in his prior medical chart, dating back to at least ___. The etiology is not entirely clear although it was felt to be stable and there were no interventions during this hospitalization. . # Transaminitis: Elevated but stable without rise in T.Bili or INR. This is likely the result of Fluonazole for Fungemia and will likely resolve after completion of course. Should follow AST/ALT/T.Bili closely ================================================ TRANSITIONS OF CARE: . -ID: Patient to continue on fluconazole for until ___. He will be on daptomycin until ___. He is to have weekly safety labs on ___ (CBC, BMP, LFTs, CPK, ESR, and CRP), fax results to ___. -Podiatry: The patient is to remain nonweight bearing on his left lower extremity until directed by podiatry. The would vac is also to remain in place at all times, settings defined by Page I. It should be changed Q3 days and remain in place until directed by Podiatry. - Orthopedics: Patient should follow up with Orthopedics. They will be contacting patient for a follow up appointment, if a follow up appointment is not scheduled the week of discharge then one should be made for patient, - Diabetes: His insulin regimen has been adjusted and his blood glucose should be carefully monitored in care further dose adjustments are required. He is being discharged without Lantus ad covered only with Humalog. If his blood sugars are uncontrolled Lantus should be restarted - Rheumatology: Patient is to remain on prednisone 5 mg daily until ___. He will follow up with Rheum in 4 weeks time - Please closely monitor hgb/hct - Please monitor AST/ALT and T.Bili while patient is on Fluconazole, he has had some transaminitis which is likely from antifungal therapy, LFTs have been stable but elevated - CODE: FULL CODE - COMMUNICATION: SISTER ___ on ___: -Prednisone 10 mg Oral Tablet Take ___ tablet(s) daily on consecutive days. Take in AM w/ food -Rosuvastatin (CRESTOR) 20 mg Oral Tablet take 1 tablet by mouth at bedtime -Insulin Glargine (LANTUS) 100 unit/mL Subcutaneous Solution inject 40 units under the skin daily AS DIRECTED -Calcitriol 0.25 mcg Oral Capsule take 1 capsule EVERY OTHER DAY -Amlodipine 10 mg Oral Tablet Take 1 tablet daily -Torsemide 20 mg Oral Tablet TAKE 1 TABLET TWICE A DAY -Insulin Lispro (HUMALOG) 100 unit/mL Subcutaneous Solution use ___ units with brunch and 22 units with dinner -Omeprazole Magnesium (PRILOSEC OTC) 20 mg Oral Tablet, Delayed Release (E.C.) TAKE 1 TABLET 30 minutes before the first meal of the day -Calcium Carbonate (TUMS) 200 mg calcium (500 mg) Oral Tablet, Chewable Take 1 Tums at breakfast and 2 Tums for dinner time -Atenolol 50 mg Oral Tablet Take 1 tablet daily -Ferrous Sulfate 325 mg (65 mg iron) Oral Tablet 1 tablet twice daily -Aspirin 81 mg Oral Tablet Take 1 tablet daily. Available over the counter. -Docosahexanoic Acid-EPA (FISH OIL) 120-180 mg Oral Capsule Aim for 1000mg omega-3 (EPA + DHA) per day -Multivitamin Oral Capsule Take 1 capsule daily; available over the counter Discharge Medications: 1. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Last dose: ___. 2. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO twice a day. 6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. oxycodone 10 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO Q12H (every 12 hours): Do not drive or drink alcohol while taking this medication. 11. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 12. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) Powder in Packet PO BID (2 times a day) as needed for constipation. 13. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 14. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 15. fluconazole 100 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours): Last dose: ___. 16. daptomycin 500 mg Recon Soln Sig: Seven Hundred Sixty (760) mg Intravenous Q48H (every 48 hours): Last dose: ___. ___. insulin lispro 100 unit/mL Solution Sig: Two (2) unit Subcutaneous QACHS: As directed by insulin sliding scale. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: -Bacteremia (MSSA) -Osteomyelitis (MSSA) -Epidural abscess (MSSA) -Fungemia (C. albicans) Secondary: -Polyarticular gout -Insulin dependent diabetes mellitus -Chronic kidney 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 Mr. ___, It was a pleasure taking part in your care during this hospitalization. You came to the hospital because you had severe left lower leg and foot pain. You were evaluated by rheumatology who felt that at least part of this pain was due to gout. You also were found to have an infection in your blood stream. You were evaluated by podiatry who helped drain a fluid collection and found that the infection had spread to part of your bone. You will need antibiotics for about 6 weeks to help fully clear this infection. You also developed weakness of your left arm, and MRI of your spine revealed another abscess near your spine cord. This was drained and the strength in your arm began to improve. The physical therapist feel that you will benefit from additional therapy at a rehabilitation facility. You will also be able to receive you antibiotics there. I was wonderful meeting you and we wish you a speedy recovery. We have made the following changes to your medications: -START: Daptomycin, an antibiotic until ___. -START: Fluconazole, an anti-fungal until ___ -START: Metoprolol, this is for your blood pressure, it takes the place of Atenolol, which you should stop. -STOP: Torsemide -DECREASE: Prednisone to 5 mg daily, your last dose should be ___. -Your blood sugars were very well controlled so you should STOP Lantus for now and only use Humalog sliding scale to control your blood sugars -STOP: Calcitriol and calcium carbonate. -START: Calcium acetate Please continue to take your other medications as previously prescribed. It is also important to follow up with your primary care doctor and nephrologist (kidney doctor) when you leave rehab. You should also carefully note the appointments listed below which are with the rheumatologist (joint and gout doctor) and podiatrist (foot doctor). * ORTHO * Followup Instructions: ___
10016367-DS-22	10,016,367	26,107,656	DS	22	2135-04-02 00:00:00	2135-04-02 20:15:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / ibuprofen / Novocain / lovastatin Attending: ___ Chief Complaint: Palpitations Major Surgical or Invasive Procedure: None History of Present Illness: ___ PMH of AVNRT, HTN who presents w/ palpitations, SOB which had resolved prior to arrival to ED, and was admitted to ___ for workup. Pt noted that she has episodes of palpitations frequently, sometimes as much as 1x wk, and had a holter in ___ which did not show any e/o AVNRT. Diltiazem then switched to metoprolol/verapamil in ___ and pt felt that symptoms were greatly improved. However, over the last few weeks have had much longer lasting episodes, sometimes up to hours in duration. Pt called outpt cardiologist last ___ who rec'd 40mg verapamil to be taken prn in addition to TID dosing. Pt followed such intructions to good effect. Yesterday, pt had episode that lasted 4 hours from 4:30pm to 8:30pm, despite taking 40mg verapamil at 5:30pm. It then recurred at 9:30pm so pt took another 40mg verapamil and called EMS. She denied any preceeding ACS symptoms, but endorsed SOB during episode of palpitations. Pt routinely checks her pulse during such episodes, and noted that HR feels fast/regular, w/ occasional pauses. On ROS, pt denied any infectious symptoms (cough, fever, chills), or heart failure symptoms (orthopnea, wt gain). In the ED, initial VS were: 68 123/68 20 94% RA. Pt was not tachycardic in ED. Labs were significant for normal WBC/CHEM/UA/Trop. Pt was not given any medication and was admitted to ___ for further evaluation. Overnight, pt reports doing well. She still has occasional palpitations. Otherwise, no CP, light-headedness or SOB. Past Medical History: 1. Episodic cardiac arrhythmia 2. Hypertension 3. Hypercholesterolemia 4. Elevated calcium level (measured at 10.2 1 month ago) 5. Irritable bowel syndrome (periodic diarrhea) 6. Back pain 7. s/p ORIF L bimalleolar ankle francture (___) 8. osteoporosis Social History: ___ Family History: Patient's Father: coronary artery disease (died at age ___ Patient's Mother: heart valve dysfunction (specifics unknown) Patient's Daughter: parathyroid gland removed Physical Exam: On Admission: Vitals - T97.5, BP 159/75 P58, R20, O297RA GENERAL: NAD, sitting in bed, pleasant HEENT: MMM, supple neck CV: RRR no m/r/g, normal S1/S2 LUNGS: CTA b/l, no wheezes/rales/rhonchi ABD: Soft, NT, ND, normoactive BS EXT: Warm, well perfused, no edema NEURO: fluent speech, AOx3, no focal deficits At Discharge: VS: 97.5/97.5; 151-159/55-75; 53-58; 20; 95-97% RA GENERAL: WDWN F in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple with no JVD. CARDIAC: PMI located in ___ intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominal bruits. EXTREMITIES: Trace pitting edema in ___, R>L. No cyanosis or clubbing. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Radial 2+ DP 2+ ___ 2+ Left: Radial 2+ DP 2+ ___ 2+ Pertinent Results: On Admission: ___ 11:36PM BLOOD WBC-7.5 RBC-4.31 Hgb-14.0 Hct-39.3 MCV-91 MCH-32.5* MCHC-35.7* RDW-14.4 Plt ___ ___ 11:36PM BLOOD Neuts-57.3 ___ Monos-6.7 Eos-1.8 Baso-0.4 ___ 11:36PM BLOOD Plt ___ ___ 11:36PM BLOOD Glucose-122* UreaN-15 Creat-0.8 Na-140 K-4.3 Cl-101 HCO3-25 AnGap-18 ___ 11:36PM BLOOD cTropnT-<0.01 On Discharge: ___ 10:34AM BLOOD WBC-4.8 RBC-3.99* Hgb-12.6 Hct-36.8 MCV-92 MCH-31.5 MCHC-34.2 RDW-13.9 Plt ___ ___ 10:34AM BLOOD Glucose-114* UreaN-13 Creat-0.8 Na-141 K-3.8 Cl-100 HCO3-32 AnGap-13 ___ 10:34AM BLOOD cTropnT-<0.01 ___ 10:34AM BLOOD Calcium-9.6 Phos-3.2 Mg-2.1 STUDIES: ___ CXR: IMPRESSION: No acute cardiopulmonary process. Brief Hospital Course: ___ PMH of AVNRT, HTN who presents w/ palpitations, SOB which had resolved prior to arrival to ED. Pt was monitored on telemetry overnight and had two short runs of narrow complex tachycardia. She was discharged with a plan to follow up with her primary cardiologist and consider possible EP study and ablation of AVNRT. No medication changes were made. Transitional Issues: -Follow up with primary cardiologist -Consider electrophysiology evaluation to consider possible EP study and ablation Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lorazepam 0.5 mg PO DAILY:PRN anxiety 2. Metoprolol Succinate XL 75 mg PO DAILY 3. Verapamil 40 mg PO Q8H 4. Aspirin 81 mg PO DAILY 5. Pravastatin 20 mg PO QPM Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Lorazepam 0.5 mg PO DAILY:PRN anxiety 3. Metoprolol Succinate XL 75 mg PO DAILY 4. Pravastatin 20 mg PO QPM 5. Verapamil 40 mg PO Q8H Discharge Disposition: Home Discharge Diagnosis: Primary: Narrow complex tachycardia Secondary: Hypertension Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___ were admitted to ___ because of palpitations. ___ were observed overnight, and we did not see anything concerning while monitoring your heart. ___ should continue taking your home medications as prescribed. ___ should also follow up with your primary cardiologist and ___ should talk with her about the possibility of getting a study to look more closely at your heart rhythm and to possibly "ablate" . It was a pleasure to help care for ___ during this hospitalization, and we wish ___ all the best in the future. Sincerely, Your ___ Team Followup Instructions: ___
10016367-DS-23	10,016,367	23,401,924	DS	23	2137-12-12 00:00:00	2137-12-12 18:07:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / ibuprofen / Novocain / lovastatin / pravastatin / procaine Attending: ___. Chief Complaint: Weakness/Syncope Major Surgical or Invasive Procedure: None History of Present Illness: ___ with a background history of paroxysmal SVT/AVNRT, HTN, HLD, osteoporosis and OA, presenting from her assisted living facility following an episode of possible unresponsiveness, with associated weakness and nausea. Patient awoke this morning with palpitations ("sensation of heart beating fast"), which was consistent with prior episodes of SVT. Checked her pulse with her monitor and found her heart rate to be 147. Has a supply of verapamil 40mg tablets for which she was informed to take one if she experienced symptoms as above. Took one tablet of same, with resolution of her palpitations about one hour post. However, did report associated nausea and general weakness, which she has experienced on past occasions post verapamil. Subsequently felt light-headed when leaning forward and getting dressed, so activated her life alert, before "blacking out". Was found mildly unresponsive, sitting on her toilet, by assisted living facility team, which resolved without intervention. No indication if event was associated with limb jerking, but no evidence of tongue biting or incontinence. No duration for loss of consciousness, but patient had come to on arrival. Does report difficulty speaking immediately post event, but associates this with a feeling of severe generalized fatigue, rather than an inability to speak. Otherwise continued to have generalized fatigue, but no focal neurological deficits, headache, or confusion. EMS on arrival noted a systolic BP in low 100s, when she is normally mildly hypertensive at baseline. In the ED, initial vital signs were; Temp 98.7 HR 50 BP 106/56 RR 18 SaO2 98% RA Examination was notable for a pale appearing lady, but otherwise with no abnormal findings. Labs included; WBC 6.7 Hgb 14.5 Plt 246 BUN 17 Cr 1.1 Na 140 K 4.7 Cl 98 HCO3 24 Troponin <0.01 Urinalysis bland CXR demonstrated a subtle opacity within the left lung base, which could be secondary to atelectasis, however a superimposed infectious process can not be excluded. CT head without evidence of acute large territorial infarction or hemorrhage, or calvarial fracture. CT cervical spine demonstrated no evidence of acute traumatic fracture or traumatic malalignment. Initial EKG at rate of 57, sinus rhythm with normal axis, normal PR interval and QTc of 455, poor R wave progression but otherwise no ischemic changes. Repeat EKG at rate of 55, sinus rhythm with normal axis, normal PR interval and QTc of 500. poor R wave progression but otherwise no ischemic changes. Patient was given 500ml NS in ED. Vitals on transfer were; Temp 98 HR 62 BP 149/67 RR 20 SaO2 95% RA Upon arrival to the floor, the patient reports continued fatigue and nausea, but symptoms are much improved from earlier today. Denies chest pain or shortness of breath throughout day, before, during and after the above events. Also does not report fevers, productive cough, lower urinary tract symptoms or abdominal pain. Patient was in her usual state of health prior to this morning, eating and drinking without issue. Unsure if dehydrated, but feels it is unlikely as she drinks large amounts of water. Review of systems as per HPI, except for chronic intermittent diarrhea/constipation associated with IBS. Otherwise negative. Past Medical History: 1. Episodic cardiac arrhythmia, paroxysmal SVT/AVNRT 2. Hypertension 3. Hypercholesterolemia 4. Elevated calcium level (measured at 10.2 1 month ago) 5. Irritable bowel syndrome (periodic diarrhea) 6. Back pain 7. s/p ORIF L bimalleolar ankle francture (___) 8. osteoporosis 9. osteoarthritis 10. Amiodarone induced hypothyroidism Social History: ___ Family History: Patient's Father: coronary artery disease (died at age ___ Patient's Mother: heart valve dysfunction (specifics unknown) Patient's Daughter: parathyroid gland removed Physical Exam: =========================== EXAM ON ADMISSION =========================== VS: Temp 98.2 BP 184/78 HR 62 RR 18 SaO2 98% RA GENERAL: pleasant appearing lady with no acute distress HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, no conjunctival pallor, MMM NECK: supple, non-tender, no LAD, JVP flat CV: bradycardic, regular rhythm, S1/S2 normal, no murmurs/rubs/gallops RESP: CTAB, no wheeze/crackles, breathing comfortably without use of accessory muscles of respiration ___: soft, non-tender, no distention, BS normoactive EXTREMITIES: moving all four extremities with purpose, no lower extremity edema SKIN: no rashes/lesions NEURO: A/O x3, CN II-XII intact, strength ___ in all extremities, sensation intact =========================== EXAM ON ADMISSION =========================== VS: T 98.3, HR 56, BP 148/76, RR 18, 93% Ra GENERAL: sitting up in bed, well-appearing, NAD HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, no conjunctival pallor, MMM NECK: supple, non-tender, no LAD, JVP flat CV: bradycardic, regular rhythm, S1/S2 normal, no murmurs/rubs/gallops RESP: CTAB, no wheeze/crackles, breathing comfortably without use of accessory muscles of respiration ___: normal bowel sounds, soft, non-tender, no distention EXTREMITIES: no lower extremity edema SKIN: no rashes/lesions NEURO: A/O x3, CN II-XII grossly intact, strength ___ in all extremities, sensation to touch intact in upper and lower extremities. Pertinent Results: ============================= LABS ON ADMISSION ============================= ___ 10:50AM BLOOD WBC-6.7 RBC-4.41 Hgb-14.5 Hct-41.9 MCV-95 MCH-32.9* MCHC-34.6 RDW-12.9 RDWSD-44.5 Plt ___ ___ 10:50AM BLOOD Neuts-69.7 ___ Monos-7.5 Eos-0.6* Baso-0.4 Im ___ AbsNeut-4.64 AbsLymp-1.43 AbsMono-0.50 AbsEos-0.04 AbsBaso-0.03 ___ 10:50AM BLOOD Glucose-112* UreaN-17 Creat-1.1 Na-140 K-4.7 Cl-98 HCO3-24 AnGap-18 ___ 06:25AM BLOOD Calcium-9.5 Phos-3.5 Mg-2.1 ============================= LABS ON DISCHARGE ============================= ___ 10:50AM BLOOD WBC-6.7 RBC-4.41 Hgb-14.5 Hct-41.9 MCV-95 MCH-32.9* MCHC-34.6 RDW-12.9 RDWSD-44.5 Plt ___ ___ 10:50AM BLOOD Glucose-112* UreaN-17 Creat-1.1 Na-140 K-4.7 Cl-98 HCO3-24 AnGap-18 ___ 06:25AM BLOOD Calcium-9.5 Phos-3.5 Mg-2.1 ___ 06:25AM BLOOD TSH-8.2* ___ 06:25AM BLOOD T4-6.0 ============================= MICROBIOLOGY ============================= ___ urine culture - negative ============================= IMAGING ============================= ___ CXR Subtle opacity within the left lung base could be secondary to atelectasis however a superimposed infectious process cannot be excluded. ___ CT HEAD NON CONTRAST No evidence of acute large territorial infarction or hemorrhage. No evidence of calvarial fracture. ___ CT C-SPINE No evidence of acute traumatic fracture or traumatic malalignment. Unchanged degenerative disease as described above. Brief Hospital Course: Information for Outpatient Providers: ___ with a background history of paroxysmal SVT/AVNRT, HTN, HLD, osteoporosis and OA, presenting from her assisted living facility following an episode of possible unresponsiveness, with associated weakness and nausea. ======================== ACUTE ISSUES ADDRESSED ======================== # Presyncope Patient presented following an episode of presyncope at assisted living facility. Preceded by an episode of tachycardia to 147 earlier in AM with subsequent verapamil 40mg taken. She was found to have negative trops and unchanged EKG from prior. No signs of infection with normal white count, no fever, and no pyuria. No dyspnea to suggest PE, and no risk factors. EKG did show bradycardia to ___ and patient was initially orthostatic. She was admitted to the hospital and monitored on telemetry, again showing sinus bradycardia. Her amiodarone and amlodipine were held overnight, but restarted the following morning. A repeat EKG was again unchanged. She worked with the ___ team, who found that she was not orthostatic and recommended home ___. Given that vital signs and labs remained stable, she was discharged on her home medications with cardiology followup. She was instructed to take an extra dose of amiodarone rather than verapamil should she again experience palpitations. ========================== CHRONIC ISSUES ADDRESSED ========================== # Hypothyroidism - Continued home levothyroxine 50mcg daily. TSH was elevated at 8.2, but T4 normal at 6. # HTN - Amlodipine initially held on admission, restarted given stable blood pressures. ========================== TRANSITIONAL ISSUES ========================== [] Patient instructed to take extra dose of amiodarone rather than verapamil should she experience another episode of AVNRT [] Discharged with cardiology follow up pending [] Discharged with home ___ and ___ #CODE STATUS: Full, with limited trial of life-saving measures #CONTACT: ___, ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amiodarone 100 mg PO DAILY 2. amLODIPine 2.5 mg PO DAILY 3. Levothyroxine Sodium 50 mcg PO DAILY 4. LORazepam 0.5 mg PO DAILY:PRN Anxiety 5. Verapamil 40 mg PO ___ TABLETS DAILY:PRN Palpitations 6. Aspirin 81 mg PO DAILY 7. ipratropium bromide 0.03 % nasal Two sprays in each nostril BID Discharge Medications: 1. Amiodarone 100 mg PO DAILY 2. amLODIPine 2.5 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. ipratropium bromide 0.03 % nasal Two sprays in each nostril BID 5. Levothyroxine Sodium 50 mcg PO DAILY 6. LORazepam 0.5 mg PO DAILY:PRN Anxiety 7. HELD- Verapamil 40 mg PO ___ TABLETS DAILY:PRN Palpitations This medication was held. Do not restart Verapamil until you speak with your cardiologist Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnosis: # Syncope # Tachycardic episode Secondary Diagnosis: # Hypothyroidism # Paroxysmal SVT/AVNRT # 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. ___, It was a pleasure to be a part of your care team at ___ ___. You were admitted to the hospital after you experienced palpitations and then felt faint after taking verapamil. We are not exactly sure why this happened - it may have been because of the verapamil on top of the amiodarone. We did blood tests, which all looked fine. You were monitored overnight, and since you were feeling better were able to be discharged home. We spoke with Dr. ___ suggests that if this happens again you could take an extra amiodarone pill instead of the verapamil as this may prevent this from happening. We have also scheduled you an appointment to see her. Please see below for your medications and appointments. Again, it was very nice to meet you, and we wish you the best. Sincerely, Your ___ Care Team Followup Instructions: ___
10016742-DS-17	10,016,742	28,506,150	DS	17	2178-07-16 00:00:00	2178-07-17 16:02:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Zosyn Attending: ___. Chief Complaint: Decreased level of consciousness Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ yo female with history of ALS, ventilator dependence with tracheostomy and PEG, history of seizure disorder, nonverbal but interactive at baseline, who presents with concern for non-convulsive status epilepticus after being found unresponsive. Ms ___ was recently admitted to the ___ ICU from ___ to ___ for ventilator associated pneumonia. For this prior admission, she was undergoing trach exchange at her facility but had became briefly apneic (question of whether vent was attached at the time); she was bagged and brought to ___ where she was responsive to painful stimuli only. CXR was performed which showed diffuse PNA. She received CTX and azithromycin and transferred to ___ ICU. At ___, she was changed to vanc/zosyn due to concern for VAP. Hospital course was complicated by AIN, with creatinine rising from 0.3 to 1.0, and peripheral eosinophilia and FeNa>2, thought to be due to Zosyn. Sputum cultures were positive for 2 strains of pseudomonas with variable resistance patterns. Her antibiotic regimen was therefore changed to vanc/cefepime, planned for 15 days, to end ___ via right PICC; vanc was discontinued prior to discharge. Tracheostomy tube was changed on ___ from Portex 7 to Portex soft-seal cuff (15mm connector), inner diameter 7.0, outer diameter 10.5. She was also found to have an E.coli UTI, treated with cefepime. Cardiology was consulted for NSTEMI, as troponins were increasing to 0.14 at peak with EKG showing STE in precordial leads, II, III. She was treated medically with 48 hours of heparin IV, aspirin 325 mg, high dose statin, and metoprolol. She was clear and coherent, alert and interactive, and bedbound when she was discharged on ___. On ___, patient was at her facility, found with decreased responsiveness, reacting only to loud voice or sternal rub. BP was noted to be 146/96, FSBG 238. She was transferred to ___ ___, where she was intermittently reactive to physical stimuli only, occasionally looking around but mostly lying still with eyes closed. At ___, there was concern for sepsis with BP 80/60; she was afebrile without hypoxemia. Her eyes were closed and she would not follow commands or respond to painful stimuli. Labs notable for negative troponin, lactate 1.2, WBC 12.8, K 5.4, Creat 0.6. EKG showed diffuse J-point elevation, PR depression in II, V3-V6. Head CT showed no acute infarct, intracranial hemorrhage, or mass. CXR showed mild persistent RLL consolidation with partial obscuring of right hemidiaphragm, although improved since CXR during last ___ admission. Her hypotension was treated with 2L normal saline. She was evaluated by neurology who recommended transfer to ___ for monitoring for subclinical status epilepticus with EEG. In the ED, initial vitals: T 96.8, BP 147/89, HR 98, RR 16, 100% SPO2 While in the ED her BP dropped to 78/43, and subsequently improved with doses of lorazepam. She was continued on full ventilator support with CMV, VT 350, RR 20, PEEP 5, FIO2 30% (Same settings from rehab). On exam in the ED she was noted to be following commands (moving eyes, nodding), but unable to move extremities. However she had several events with rightward eye deviation, minor mouth twitching, and unresponsiveness, and was hypotensive to the ___ systolic. These episodes were treated with lorazepam, and afterwards her BP improved but she was not following commands, not answering questions, not blinking to threat, only grimacing to sternal rub. Labs demonstrated --WBC 13 (67.4% PMNs, 5.6% eosinophils), Hgb 10.8, Plt 545 --INR 1.2, PTT 33.2 --Na 145, K 4.8, Bicab 29, creat 0.6, BUN 39 --troponin 0.16, CKMB 5 --lactate 1.1 --ALT 21, AST 17, Alk phos 112, Tbili 0.2, Alb 3.6, lipase 40 --UA with moderate leuks, prot 30, WBC 30, few bacteria She was treated with aspirin 600mg PR, lorazepam 4mg IV total, and loaded with keppra 1000mg. Also received dose of vancomycin 1000mg IV. On arrival to the MICU, she continues to be unresponsive, with leftward eye deviation. Initially normotensive with BP 140s, subsequently decreased to 80-90s. Past Medical History: Amyotrophic lateral sclerosis - followed at ___ DM ?frontal lobe dementia ?schizoaffective d/o Social History: ___ Family History: Unable to obtain Physical Exam: ADMISSION PHYSICAL EXAM =========================== GENERAL: unresponsive HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD. Tracheostomy tube in place. No drainage or bleeding from trach site. Small amount of granulation tissue on inferior margin of tracheostomy stoma. LUNGS: Clear to auscultation bilaterally anteriorly, no wheezes, rales, rhonchi. Ventilated on CMV TV 350, RR 20, fio2 30%, PEEP 5. No tracheal secretions. CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, no reaction to deep palpation, non-distended, bowel sounds present. LUQ PEG tube site C/D/I no erythema, discharge, or bleeding. GU: foley in place draining clear yellow urine EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. MSK: diffuse muscle wasting in extremities, bilateral temples. No joint swelling, or erythema. SKIN: warm and dry, no defects or rashes NEURO: unresponsive. No reaction to sternal rub. Pupils round, 2mm, sluggishly reactive. Eyes currently midline though on initial assessment were deviated up and to the left. Not moving extremities. No tremor. Normal tone. No clonus. No response to painful stimuli in extremities. DISCHARGE PHYSICAL EXAM =========================== Gen: awake, alert, tracheostomy in place CV: regular rate, normal rhythm Lungs: decreased effort, slight rhonchi, no increased WOB or respiratory distress GI: soft, non-tender, non-distended, G-tube in place Neuro: flaccid upper extremities with interosseous muscle wasting, moves lower extremities with purpose Ext: warm and well-perfused Pertinent Results: ADMISSION LABS ================= ___ 05:00AM BLOOD WBC-13.0* RBC-4.03 Hgb-10.8* Hct-35.1 MCV-87 MCH-26.8 MCHC-30.8* RDW-14.3 RDWSD-45.3 Plt ___ ___ 05:00AM BLOOD Neuts-67.4 Lymphs-18.9* Monos-6.8 Eos-5.6 Baso-0.8 Im ___ AbsNeut-8.79* AbsLymp-2.46 AbsMono-0.89* AbsEos-0.73* AbsBaso-0.10* ___ 05:00AM BLOOD ___ PTT-33.2 ___ ___ 05:00AM BLOOD Glucose-94 UreaN-39* Creat-0.6 Na-145 K-4.8 Cl-108 HCO3-29 AnGap-13 ___ 05:00AM BLOOD ALT-21 AST-17 CK(CPK)-77 AlkPhos-112* TotBili-0.2 ___ 05:00AM BLOOD Lipase-40 ___ 05:00AM BLOOD CK-MB-5 ___ 05:00AM BLOOD cTropnT-0.16* ___ 05:00AM BLOOD Albumin-3.6 Calcium-9.7 Phos-2.9 Mg-2.1 ___ 05:04AM BLOOD Lactate-1.1 TROPONIN TREND ___ 05:00AM BLOOD cTropnT-0.16* ___ 12:02PM BLOOD CK-MB-5 cTropnT-0.31* ___ 06:15PM BLOOD CK-MB-6 cTropnT-0.21* MICROBIOLOGY ___ BCx - pending ___ UCx - yeast ___ Sputum ___ 8:30 pm SPUTUM Source: Endotracheal. GRAM STAIN (Final ___: >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Preliminary): GRAM NEGATIVE ROD(S). MODERATE GROWTH. GRAM NEGATIVE ROD #2. MODERATE GROWTH. GRAM NEGATIVE ROD #3. MODERATE GROWTH. ___ 12:30 pm BRONCHIAL WASHINGS GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Preliminary): Further incubation required to determine the presence or absence of commensal respiratory flora. GRAM NEGATIVE ROD(S). OF THREE COLONIAL MORPHOLOGIES. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ___ - BCx pending ___ - BCx pending IMAGING ___ CXR IMPRESSION: In comparison with the study ___, there is little interval change. Tracheostomy tube remains in place, as does the right subclavian PICC line. Again there is opacification of the right base with obscuration of the hemidiaphragm. Although this could represent volume loss in the right lower lobe with associated pleural effusion, in the appropriate clinical setting superimposed pneumonia would have to be considered. Probable atelectatic changes at the left base. ___ TTE 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%). The estimated cardiac index is normal (>=2.5L/min/m2). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be estimated. There is a small circumferential pericardial effusion without echocardiographic signs of tamponade. IMPRESSION: Suboptimal image quality. Mild symmetric left ventricular hypertrophy with preserved regional and global biventricular systolic function. Small circumferential pericardial effusion without echocardiographic evidence for hemodynamic compromise. ___ CXR IMPRESSION: Heart size and mediastinum are stable. Right PICC line tip terminates at the level of superior SVC. Heart size and mediastinum are stable. Tracheostomy is in unchanged position. No interval development of of new consolidations is seen except for persistent right basal opacity which most likely represents a combination of atelectasis and infection. There is small amount of pleural effusion bilaterally. DISCHARGE LABS ___ 03:23AM BLOOD WBC-9.0 RBC-3.29* Hgb-8.8* Hct-27.3* MCV-83 MCH-26.7 MCHC-32.2 RDW-14.3 RDWSD-43.3 Plt ___ ___ 03:23AM BLOOD Neuts-57.7 ___ Monos-5.8 Eos-6.3 Baso-1.0 Im ___ AbsNeut-5.19# AbsLymp-2.61 AbsMono-0.52 AbsEos-0.57* AbsBaso-0.09* ___ 03:23AM BLOOD ___ PTT-36.3 ___ ___ 03:23AM BLOOD Glucose-117* UreaN-13 Creat-0.5 Na-139 K-4.0 Cl-104 HCO3-24 AnGap-15 ___ 03:23AM BLOOD Calcium-9.4 Phos-3.7 Mg-1.9 ___ 03:48AM BLOOD calTIBC-226* Hapto-200 Ferritn-279* TRF-174* Brief Hospital Course: Ms. ___ is a ___ year old female with ALS s/p trach and PEG with recent admission for technical trach issues complicated by VAP and type II NSTEMI who presented to ___ with decreased mental status, found to have episodes of mucous plugging. # Altered mental status: During last admission, had similar brief episodes of unresponsiveness that resolved without intervention. Now presents with multiple episodes of unresponsiveness, and right then leftward eye deviation. Associated hypotension improved with lorazepam, and documentation also indicates that she became more responsive, with eyes open, following simple commands, prior to becoming unresponsive again. Per Neurology consult, these episodes are concerning for complex partial seizures, vs non-convulsive status epilepticus. Ultimately, etiology was unclear, though she has two known infections being treated with cefepime, including UTI and PNA. CT head unremarkable. EEG was performed which showed no epileptiform activity. She was switched to ceftazidime for antibiotic coverage out of concern for altered mental status/seizures from cefepime. However, given the lack of correlate on EEG and the alternate explanation (ie respiratory distress due to mucous plugging), it is likely that her episodes both prior to and during admission were NOT seizures. She was continued on levetiracetam 750mg PO BID. # ECG changes and troponin elevation: Patient with history of recent NSTEMI, managed medically. On this admission, she had fluctuating EKG changes including intermittent PR depressions, and ___ ST segment changes, which appear most consistent with J-point elevation. Cardiology was consulted, who recommended TTE and trending of cardiac markers. She was found to have preserved EF with small pericardial effusion and EKGs c/w pericarditis. No further treatment was recommended as the diffuse ECG changes were transient and not associated with a particular coronary distribution. Her troponins trended downward and she had no complaints of chest pain. She was continued on ASA, high-dose atorvastatin and metoprolol. # Ventilator-associated pneumonia: Diagnosed during last admission with leukocytosis, fever, RLL infiltrate, treated with cefepime for planned 15 day course, to end ___. CXR at ___ ___ shows mild persistent RLL infiltrate. She is having minimal tracheal secretions now, mild leukocytosis, and no reported fevers or hypoxemia on 30% FIO2. ___ not need to complete full 15 day treatment # Acute hypoxic respiratory distress: Her hospital course was notable for acute hypoxemic event due to mucous plugging. On ___, the patient became acutely hypoxic down into the 40's following a change in position. She was taken off the ventilator and bad masked given coinciding decreases in tidal volume. Emergent bronchoscopy was performed which revealed severe mucus plugging worse in the RLL. This plugging was relieved and patient's oxygen saturations came back up to high 90's. During this episode was observed to have extensor posturing and roving eye movements, however neurology evaluated clinical findings along with EEG and determined that they were not seizures. During the event patient was hypertensive with SBP up to 240's, fentanyl and versed bolus for sedation was given, as well as 10 mg IV labetalol. Pressures continued to be elevated throughout the afternoon and metoprolol was doubled from 6.25 Q6 to 12.5 Q6. To assist with the clearance of her secretions, she was placed on the Mechanical Insufflator Exsufflator machine, which significantly assisted improved her cough. She should use this every eight hours and also as needed. # Chronic respiratory failure: Mechanically ventilated, does not require sedation. She was continued on prior vent settings: CMV, TV 350, RR 20, FIO2 30% but with an increase in PEEP from 5 to 8. # Diabetes mellitus: continued home lantus and insulin sliding scale. # HTN: was started on metoprolol 12.5mg PO Q6hrs. Would recommend continued monitoring of BP and titration of regimen at facility. TRANSITIONAL ISSUES ===================== - Please use MIE every eight hours and as needed for cough - Please continue ceftazidime through ___ (treating ventilator associated pneumonia from previous admission) - Please continue to monitor her BP and titrate regimen as necessary. # Communication: HCP: Legal Guardian ___: ___ # Code: Full, per legal guardian Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Docusate Sodium (Liquid) 100 mg PO DAILY 2. Ferrous Sulfate (Liquid) 300 mg PO DAILY 3. LevETIRAcetam 750 mg PO BID 4. QUEtiapine Fumarate 37.5 mg PO DAILY 5. QUEtiapine Fumarate 75 mg PO QHS 6. Sertraline 150 mg PO DAILY 7. Aspirin 81 mg PO DAILY 8. Atorvastatin 80 mg PO QPM 9. CefePIME 1 g IV Q12H 10. Metoprolol Tartrate 6.25 mg PO Q6H 11. Glucerna (nut.tx.gluc.intol,lac-free,soy;<br>nut.tx.glucose intolerance,soy) ORAL DAILY 12. GuaiFENesin ___ mL PO Q4H 13. LORazepam 0.5 mg PO Q8H 14. Omeprazole 40 mg PO DAILY 15. QUEtiapine Fumarate 12.5 mg PO DAILY:PRN agitation 16. Miconazole Powder 2% 1 Appl TP BID:PRN irritation of PEG 17. Glargine 10 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 18. Polyethylene Glycol 17 g PO/NG DAILY:PRN constipation Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO QPM 3. Ferrous Sulfate (Liquid) 300 mg PO DAILY 4. GuaiFENesin ___ mL PO Q4H 5. Glargine 10 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 6. Metoprolol Tartrate 12.5 mg PO Q6H 7. Polyethylene Glycol 17 g PO DAILY:PRN constipation 8. QUEtiapine Fumarate 12.5 mg PO DAILY:PRN agitation 9. Sertraline 150 mg PO DAILY 10. CefTAZidime 1 g IV Q8H 11. Omeprazole 40 mg PO DAILY 12. Docusate Sodium (Liquid) 100 mg PO DAILY 13. Glucerna (nut.tx.gluc.intol,lac-free,soy;<br>nut.tx.glucose intolerance,soy) ORAL DAILY 14. LevETIRAcetam 750 mg PO BID 15. Miconazole Powder 2% 1 Appl TP BID:PRN irritation of PEG 16. QUEtiapine Fumarate 75 mg PO QHS:PRN insomnia, agitation 17. LORazepam 0.5 mg PO Q8H Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS =================== Altered mental status Hypoxic respiratory distress SECONDARY DIAGNOSIES ======================= Ventilator-associated pneumonia ECG changes ALS Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you during your hospital stay at ___. You were admitted after you were confused and less responsive than normal. The Neurologists evaluated you and discovered that you are not having any seizures. You can continue the same Keppra as before. We also asked the Cardiologists to see you because of your history of a recent heart attack and some changes on your EKG. They felt that you were not having a new heart issue and did not recommend any new treatment. During your hospital stay, you had a brief episode of getting some mucous and sputum caught in your airway that caused you to lose consciousness. We were able to suck the mucous out with a bronchoscopy. From now, we recommend that you something called the MIE or Cough Assist to help you bring up secretions so as to prevent this from happening again. We are discharging you back to your facility where they can finish your antibiotic treatment for pneumonia and provide you with the Cough Assist as well. We wish you the best! - Your ___ Care Team Followup Instructions: ___
10017393-DS-6	10,017,393	21,985,481	DS	6	2179-07-23 00:00:00	2179-07-23 15:00:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: latex / Augmentin Attending: ___ Chief Complaint: Petechiae, purpura, lower extremity swelling, ankle tenderness (predominantly R side) Major Surgical or Invasive Procedure: Skin biopsy ___ History of Present Illness: In brief, Dr. ___ is a ___ yo general pediatrician at ___ ___ with a complicated ophtho hx (spontaneous retinal tear several years ago) p/w bilateral lower extremity palpable purpura, transaminitis, and microscopic hematuria beginning 7 days after starting Augmentin for suspected sialolithiasis of the R submandibular gland. On ___, pt initially presented to urgent care with 1 day of painful swelling below the right of midline mandible of the jaw. She was rxed empirically with Augmentin (875mg PO BID x 10d). On ___, she followed up w/ ENT, who suspected sialolithiasis (on their exam R SMG enlarged, TTP, mobile) and ordered CT Neck but pt never actually had imaging done. On ___, she presented to urgent care again w/ improvement in R submandibular pain and swelling, but had low grade fever, and a painful purpuric rash most prominently on the R shin. During this time, she did not have any chills, night sweats, weight loss, shortness of breath, chest discomfort, abdominal pain, diarrhea, headaches, vision changes, or changes to her urine. Per recs of on-call rheumatology, Augmentin was stopped and she was transferred to ___ ED for further evaluation. In the ED, her initial vitals were 98.8, HR 111, BP 97/75, RR 16, 99% RA. Her exam was notable for: Palpable purpura with areas of petechiae and confluence on RLE, extending from the R ankle to R knee; LLE less involved No rash on abdomen, back, buttocks, face/head/neck/extremities Left ankle equisitely tender Labs notable for: WBC 8.1 (85% polys) INR 1.2 BUN/SCr ___ RBCs in urine) AST/ALT 156/126 AlkPhos 112 LDH 365 Fibrinogen 574 D-dimer 1355 Lactate 1.1 Imaging notable for: CXR - No acute cardiopulmonary process. Pt given: ___ 16:54 PO Doxycycline Hyclate 100 mg ___ 16:54 IV Ketorolac 30 mg Vitals prior to transfer: 98.5 92 135/80 17 99% RA On the floor, pt reported pain and swelling of her R > L legs; she felt that the R ankle was particular tender, with the greatest pain located just inferior to the right lateral malleolus. Her skin findings were somewhat painful as well. She was otherwise comfortable and well appearing. Of note, patient denied any recent travel, hikes in the woods, sexual contacts (has been many years), drug use, or animal exposures. Given her job as ___, she does have sick contacts. Her routine cancer screening is up to date. Her family history is notable in that her mother had ___ syndrome and breast cancer and her father had pancreatic cancer - otherwise there is no other family history of autoimmune disease or cancer. REVIEW OF SYSTEMS: +low grade fever +dry eyes +dry cough (the cough is long-standing and tends to flare up during this time of year) Past Medical History: -Retinal tear R eye -GERD -Asthma/allergies Social History: ___ Family History: Father - HTN, DM, glaucoma, pancreatic cancer Mother - ___ cancer, ___, died from CVD Twin sister - healthy Physical ___: ADMISSION PHYSICAL EXAM: ====================== Vital Signs: 98.2 119/70 96 18 96%RA General: Alert, oriented, no acute distress HEENT: right ptosis (chronic), right eye minimally reactive, oral mucosa notable for bilateral erythematous lesions in the area of the opening of the parotid duct, Neck: Fullness in the right submandibular area Lymph nodes: no cervical, suplraclavicular, axillary, inguinal lymphadenopathy CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended Skin: right leg more swollen than left, right leg with confluent palpable purpura with scattered petechiae tracking up inner thihg. Left leg with tender raised nodules and petechiae. Images in OMR. Ext: Warm, well perfused, 2+ pulses Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. DISCHARGE PHYSICAL EXAM: ====================== Vitals: 97.8 PO 128 / 88 R Sitting 83 18 98 Ra General: Alert, oriented, no acute distress HEENT: right ptosis (chronic). There are erythematous lesions near the entrances of the parotid ducts bilaterally. Neck: Fullness in the right submandibular area Lymph nodes: no cervical lymphadenopathy CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Lungs: CTAB Abdomen: Soft, non-tender, non-distended Skin: R leg with confluent palpable purpura with scattered petechiae tracking up inner thigh. R leg more swollen than left. R ankle swollen and tender. Left leg with ___ tender raised nodules and petechiae. L thigh with new streaks of petchiae and purpura extending to buttocks. Ext: Warm, well perfused. Neuro: Grossly normal motor function and sensation Pertinent Results: ADMISSION LABS: ============== ___ 05:30PM BLOOD WBC-8.1 RBC-4.09 Hgb-12.4 Hct-37.5 MCV-92 MCH-30.3 MCHC-33.1 RDW-12.5 RDWSD-42.0 Plt ___ ___ 05:30PM BLOOD Neuts-85.0* Lymphs-6.4* Monos-5.2 Eos-3.1 Baso-0.1 Im ___ AbsNeut-6.85* AbsLymp-0.52* AbsMono-0.42 AbsEos-0.25 AbsBaso-0.01 ___ 05:30PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Envelop-OCCASIONAL ___ 05:30PM BLOOD ___ PTT-30.7 ___ ___ 05:30PM BLOOD ___ ___ 05:30PM BLOOD Glucose-121* UreaN-8 Creat-0.8 Na-139 K-3.5 Cl-100 HCO3-23 AnGap-20 ___ 05:30PM BLOOD ALT-126* AST-156* LD(LDH)-365* CK(CPK)-109 AlkPhos-112* TotBili-0.4 ___ 05:30PM BLOOD cTropnT-<0.01 ___ 05:30PM BLOOD Albumin-4.1 ___ 05:30PM BLOOD D-Dimer-1355* ___ 05:30PM BLOOD HBsAg-Negative HBsAb-Positive HBcAb-Negative ___ 05:30PM BLOOD ANCA-NEGATIVE B ___ 05:30PM BLOOD ___ CRP-61.6* ___ 05:30PM BLOOD IgG-969 IgA-163 IgM-59 ___ 05:30PM BLOOD C3-165 C4-51* ___ 05:30PM BLOOD HCV Ab-Negative ___ 05:36PM BLOOD Lactate-1.1 ___ 09:30PM BLOOD SED RATE-Test-36* DISCHARGE LABS: ============== ___ 06:40AM BLOOD WBC-6.9 RBC-3.69* Hgb-11.3 Hct-34.9 MCV-95 MCH-30.6 MCHC-32.4 RDW-12.7 RDWSD-44.3 Plt ___ ___ 06:40AM BLOOD Glucose-81 UreaN-15 Creat-0.7 Na-143 K-4.2 Cl-106 HCO3-27 AnGap-14 ___ 06:40AM BLOOD ALT-120* AST-53* LD(LDH)-258* AlkPhos-121* TotBili-0.2 ___ 06:40AM BLOOD Calcium-9.1 Phos-4.0 Mg-2.3 OTHER PERTINENT LABS: ===================== ___ 03:20PM BLOOD Cryoglb-PND ___ 05:30PM BLOOD D-Dimer-1355* ___ 05:30PM BLOOD HBsAg-Negative HBsAb-Positive HBcAb-Negative ___ 05:30PM BLOOD ANCA-NEGATIVE B ___ 05:30PM BLOOD ___ CRP-61.6* ___ 03:20PM BLOOD PEP-NO SPECIFI ___ FreeLam-26.3 Fr K/L-0.72 ___ 05:30PM BLOOD IgG-969 IgA-163 IgM-59 ___ 05:30PM BLOOD C3-165 C4-51* ___ 05:30PM BLOOD HCV Ab-Negative ___ 09:30PM BLOOD SED RATE-Test ___ 05:30PM BLOOD RO & ___ MICROBIOLOGY: ============= Urine culture negative 2x blood cultures pending IMAGING: ======== Chest: Frontal (PA) and lateral views, X-ray COMPARISON: None. FINDINGS: No focal consolidation is seen. There is no pleural effusion or pneumothorax. The cardiac and mediastinal silhouettes are unremarkable. No pulmonary edema is seen. IMPRESSION: No acute cardiopulmonary process. If clinical concern persists for small pulmonary nodules, chest CT is more sensitive. Brief Hospital Course: Dr. ___ is a ___ year old woman w/ h/o spontaneous retinal tear admitted w/ palpable purpura in bilateral lower extremities and right ankle swelling in the setting of Augmentin (which she started for suspected sialolithiasis and submandibular gland infection), found to have leukocytoclastic vasculitis and improved with cessation of Augmentin and initiation of prednisone. ACTIVE ISSUES: ============= #Leukocytoclastic vasculitis (LCV): Patient presented with palpable purpura of the bilateral lower extremities with right ankle swelling. Labs notable for transaminitis and microscopic hematuria. Seen by dermatology and rheumatology and underwent skin biopsy with pathology confirming leukocytoclastic vasculitis (LCV). The recent history of Augmentin usage and infection is consistent with LCV. Her Augmentin was held and she was started on prednisone to which she improved. At the time of discharge, she was having resolving transaminitis, resolved microscopic hematuria, and improved ankle right pain and lower right leg swelling, although still noticing new petechiae, which can be seen in LCV despite withdrawal of offending stimulus. Continued on prednisone 20mg daily on discharge with a plan to decrease to 15mg daily after one week and follow up with rheumatology and dermatology. #Right submandibular gland swelling: Patient initially presented to an outside urgent care clinic on ___ with right submandibular gland swelling and tenderness, started empirically on Augmentin, and initially thought to have sialolithiasis with concurrent infection, which is plausible given that patient's symptoms improved with Augmentin therapy. However, given the family history of ___ and the patient's joint symptoms on her admission to ___, there was concern that her initial jaw tenderness could have been part of a broader rheumatological process and a rheumatological workup was done. At the time of discharge, her workup was notable for negative ___, negative ANCA, and negative Sjogren antibodies, and the patient's right submandibular gland swelling and tenderness had improved significantly and she was otherwise stable. She will need to follow up with ENT after discharge, and consider possible CT scan. CHRONIC ISSUES: ============== #Retinal tear: Continued home eye drops TRANSITIONAL ISSUES: ================== 1.) Patient should have sutures removed on ___ from her biopsy site. 2.) If pruritus develops, dermatology recommended triamcinolone 0.1% ointment BID to affected areas - use up to two weeks per month. 3.) Patient's malignancy screening should be clarified to ensure that she is up to date 4.) Pt needs to follow up with ENT for management of the right submandibular gland swelling. Consider outpatient CT neck per ENT. 5.) Pt needs to continue prednisone 20mg daily and then decrease to 15mg daily after one week until follow up with outpatient rheumatology. 6.) Augmentin added to the allergy list. It is unclear whether patient can be exposed to penicillins in the future; can consider outpatient allergy referral 7.) Pt needs to have repeat LFTs as an outpatient. Consider further workup if not resolved # CONTACT: Sister/HCP ___ ___ # CODE STATUS: Full (presumed) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE 1 TIMES PER DAY, ALTERNATING WITH 2 TIMES PER DAY 2. Dorzolamide 2% Ophth. Soln. 1 DROP RIGHT EYE TID 3. brimonidine 0.2 % ophthalmic BID 4. Fexofenadine 180 mg PO DAILY:PRN allergies 5. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath Discharge Medications: 1. PredniSONE 20 mg PO DAILY Take 20mg daily for 7 days, then decrease to 15mg daily RX prednisone 10 mg 2 tablet(s) by mouth Daily Disp #40 Tablet Refills:*0 2. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath 3. brimonidine 0.2 % ophthalmic BID 4. Dorzolamide 2% Ophth. Soln. 1 DROP RIGHT EYE TID 5. Fexofenadine 180 mg PO DAILY:PRN allergies 6. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE 1 TIMES PER DAY, ALTERNATING WITH 2 TIMES PER DAY Discharge Disposition: Home Discharge Diagnosis: Primary: Leukocytoclastic vasculitis secondary to Augmentin usage and infection Secondary: Sialolithiasis 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 Dr. ___, ___ was a pleasure taking care of you during your hospital stay at ___. You were hospitalized for the onset of petechiae, purpura, lower leg swelling, and ankle tenderness, predominantly on your right lower leg, in the setting of 7 days of Augmentin usage. Upon admission, you were found to have signs of mild injury to your liver and kidney. You were found to have a leukocytoclastic vasculitis and your symptoms managed with cessation of Augmentin and initiation of prednisone, to which you responded well. On discharge, it is important for you to continue applying vaseline to your biopsy site with a change in the bandaid daily. Continue to wrap the leg and elevate it to facilitate resolution of the edema. If the rash worsens or becomes more bothersome, please page dermatology at ___ during business hours or call ___ and request pager ___ after hours. Please continue to take your home medications as prescribed. In particular, you should take 20 mg of prednisone daily for 1 week from discharge, after which you should take 15 mg of prednisone daily until you have your follow-up rheumatology appointment. For management of your pain, ibuprofen or tylenol are acceptable but do not exceed 2 g tylenol daily given your recent transaminitis. Take Care, Your ___ Team. Followup Instructions: ___
10017764-DS-5	10,017,764	28,307,589	DS	5	2123-07-04 00:00:00	2123-07-04 17:58:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: UROLOGY Allergies: Gentamicin Attending: ___. Chief Complaint: Fever Major Surgical or Invasive Procedure: None this admission, however, recent procedure ___: Cystoscopy, left retrograde pyelogram, left ureteroscopy, left laser lithotripsy and basket extraction of stone, and left ureteral stent exchange. History of Present Illness: ___ with h/o nephrolithiasis s/p L laser litho, stent placement today c/b post-op urinary retention requiring foley placement returning to the ED with fevers at home. In the ED patient with temp of 100.9 with chills. She was given 1gm ceftriaxone and admitted to urology for observation. Patient states that foley was draining well at home, although renal US in the ED demonstrated a partially full bladder. Thus, she was admitted for IV antibiotics and observation. Past Medical History: PMH: -Nephrolithiasis -Hypertension -Type II Diabetes Mellitus -Hyperlipidemia Allergies: Gentamicin PSH: Emergent left ureteral stent placement Left ureteroscopy, laser lithotripsy, basket extraction, stent exchange Social History: ___ Family History: Non-contributory Physical Exam: Afeb, VSS Wd Obese female ___ speaking, NAD Unlabored breathing Soft abdomen, nttp, no CVAT Stent string fastened onto pubic area Ext WWP, no edema Pertinent Results: ___ 06:40AM BLOOD WBC-8.8 RBC-3.62* Hgb-10.4* Hct-32.0* MCV-88 MCH-28.6 MCHC-32.4 RDW-15.1 Plt ___ ___ 08:05AM BLOOD WBC-15.6* RBC-4.12* Hgb-11.7* Hct-36.4 MCV-88 MCH-28.3 MCHC-32.0 RDW-15.1 Plt ___ ___ 09:40PM BLOOD WBC-14.1# RBC-3.99 Hgb-11.4* Hct-34.6* MCV-87 MCH-28.7 MCHC-33.0 RDW-15.1 Plt ___ ___ 09:40PM BLOOD Neuts-90.5* Lymphs-5.0* Monos-2.9 Eos-1.2 Baso-0.4 ___ 06:40AM BLOOD Glucose-127* UreaN-17 Creat-1.5* Na-143 K-3.9 Cl-105 HCO3-27 AnGap-15 ___ 09:40PM BLOOD Glucose-201* UreaN-22* Creat-1.5* Na-140 K-4.3 Cl-104 HCO3-25 AnGap-15 Urine: GENERAL URINE ___ ___ ___ YellowHazy1.009 DIPSTICK U R I N A L Y S ISBloodNitriteProteinGlucoseKetoneBilirubUrobilnpHLeuks ___ 21:36 LGNEG100NEGNEGNEGNEG5.5LG MICROSCOPIC URINE EXAMINATIONRBCWBCBacteriYeastEpiTransERenalEp ___ 21:36 >182>182FEWNONE0 Urine culture: *FINAL REPORT ___ URINE CULTURE (Final ___: <10,000 organisms/ml. Brief Hospital Course: The pateint was admitted to Urology service for fevers after being recently discharged earlier that day from an outpatient procedure - left ureteroscopy, laser lithotripsy, basket removal, and stent exchange. No concerning intraoperative events occurred; please see dictated operative note for details. She received intravenous fluids and antibiotics (Ceftriaxone). On POD2, the Foley was removed after active voiding trial and post void residuals were checked. She was tolerating a regular diet, ambulating without difficulty. On POD3, her urine culture revealed <10,000 organisms. She was afebrile with stable vital signs. She was discharged home with 7 days of ciprofloxacin, and instructed to follow up with Dr. ___ stent removal in 3 days. Her creatinine was 1.5, and she was instructed to hold her metformin, unless her surgars are greater than 200. She was instructed to eat a diabetic diet, and to check her sugars regularly. She will follow up with her PCP office early this week. Medications on Admission: Metformin Amlodipine 10 mg PO DAILY Atenolol 50 mg PO DAILY Atorvastatin 20 mg PO DAILY Tamsulosin 0.4 mg PO DAILY Hydrocodone-Acetaminophen (5mg-500mg) 1 TAB PO Q6H:PRN pain Metformin 1000 bid Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain,fever 2. Amlodipine 10 mg PO DAILY 3. Atenolol 50 mg PO DAILY 4. Atorvastatin 20 mg PO DAILY 5. Tamsulosin 0.4 mg PO DAILY 6. Hydrocodone-Acetaminophen (5mg-500mg) 1 TAB PO Q6H:PRN pain 7. Ciprofloxacin HCl 500 mg PO Q12H RX ciprofloxacin 500 mg 1 tablet(s) by mouth every twelve (12) hours Disp #14 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: ADMISSION DIAGNOSIS: Post-operative fever PREOPERATIVE DIAGNOSES: Proximal left ureteral calculus approximately 8 mm in size, acute-on-chronic renal insufficiency, status post emergent ureteral stent placement. POSTOPERATIVE DIAGNOSES: 1 cm renal calculus. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: -You can expect to see occasional blood in your urine and to possibly experience some urgency and frequency over the next month; this may be related to the passage of stone fragments or the indwelling ureteral stent (if there is one). -The kidney stone may or may not have been removed AND/or there may fragments/others still in the process of passing. -You may experience some pain associated with spasm of your ureter.; This is normal. Take the narcotic pain medication as prescribed if additional pain relief is needed. -Ureteral stents MUST be removed or exchanged and therefore it is IMPERATIVE that you follow-up as directed. -Do not lift anything heavier than a phone book (10 pounds) -You may continue to periodically see small amounts of blood in your urine--this is normal and will gradually improve -Resume all of your pre-admission medications, except HOLD aspirin until you see your urologist in follow-up AND your foley has been removed (if not already done) -You may or may not have passed all your stones ****Ureteral stent -You MAY be discharged home with a medication called PYRIDIUM that will help with the "burning" pain you may experience when voiding. This medication may turn your urine bright orange. -Colace has been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication. Discontinue if loose stool or diarrhea develops. Colace is a stool softener, NOT a laxative, and available over the counter. The generic name is DOCUSATE SODIUM. It is recommended that you use this medication. -Do not eat constipating foods for ___ weeks, drink plenty of fluids to keep hydrated -No vigorous physical activity or sports for 4 weeks and if there is a Foley catheter is in place. -Tylenol should be your first line pain medication, a narcotic pain medication has been prescribed for breakthrough pain >4. Replace Tylenol with narcotic pain medication. -Max daily Tylenol (acetaminophen) dose is 4 grams from ALL sources, note that narcotic pain medication also contains Tylenol -Do not drive or drink alcohol while taking narcotics and do not operate dangerous machinery. Also, if the Foley catheter and Leg Bag are in place--Do NOT drive (you may be a passenger). Followup Instructions: ___
10018081-DS-15	10,018,081	21,027,282	DS	15	2134-01-12 00:00:00	2134-01-12 06:06:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: morphine / Lipitor Attending: ___. Chief Complaint: porto-venous and mesenteric venous gas; ischemic bowel; sepsis Major Surgical or Invasive Procedure: ___ exploratory laparotomy, extended right colectomy, left in discontinuity ___ Abdominal closure, end ileostomy, long ___ ___ PEG History of Present Illness: ___, poor historian, transferred from ___ after CT obtained today returned with extensive portal and mesenteric venous gas, pneumatosis and concerns for bowel ischemia. Pt with 3 days of abdominal cramping with diarrhea x 3 days. Reported to ___ today where initial evaluation was performed. Minimally resuscitated per records. He reports feeling dehydrated, weakened, and now with nausea. Foley placed in OSH. Denies any fevers or dysuria. Past Medical History: PMH: CAD, CHF, afib on coum, HL, HTN PSH: appy, GB, R colectomy with colostomy, takedown Social History: ___ Family History: NC Physical Exam: 97.8 86 120/58 18 96%RA NAD, alert, mumbles some comprehensible words but certainly not oriented Irregularly irregular No resp distress Abd soft, obese, NT, ND, PEG in place, ostomy functional, incision dry and approximated Ext wwp x4 Pertinent Results: ___ 01:45PM BLOOD WBC-9.4 RBC-5.65 Hgb-18.4* Hct-55.2* MCV-98 MCH-32.6* MCHC-33.4 RDW-14.1 Plt ___ ___ 01:43AM BLOOD WBC-4.6 RBC-4.34* Hgb-14.3 Hct-42.3 MCV-97 MCH-33.0* MCHC-33.9 RDW-14.1 Plt ___ ___ 02:17AM BLOOD WBC-17.1# RBC-3.61 Hgb-11.5* Hct-35.8* MCV-99* MCH-31.9 MCHC-32.2 RDW-14.0 Plt ___ ___ 01:56AM BLOOD WBC-23.0* RBC-3.57* Hgb-11.5* Hct-35.9* MCV-101* MCH-32.4* MCHC-32.1 RDW-13.9 Plt ___ ___ 06:55AM BLOOD WBC-9.6 RBC-2.93* Hgb-9.6* Hct-29.5* MCV-101* MCH-32.9* MCHC-32.7 RDW-13.3 Plt ___ ___ 04:55AM BLOOD WBC-11.9* RBC-2.90* Hgb-9.3* Hct-28.9* MCV-100* MCH-32.0 MCHC-32.1 RDW-13.4 Plt ___ ___ 01:45PM BLOOD ___ PTT-37.1* ___ ___ 01:51PM BLOOD ___ PTT-61.5* ___ ___ 10:30AM BLOOD ___ PTT-47.3* ___ ___ 04:55AM BLOOD ___ ___ 01:45PM BLOOD Glucose-150* UreaN-58* Creat-6.2* Na-140 K-3.4 Cl-98 HCO3-11* AnGap-34* ___ 09:04PM BLOOD Glucose-152* UreaN-52* Creat-4.8* Na-135 K-3.1* Cl-105 HCO3-16* AnGap-17 ___ 01:43AM BLOOD Glucose-118* UreaN-53* Creat-4.9* Na-136 K-3.7 Cl-103 HCO3-15* AnGap-22* ___ 12:36AM BLOOD Glucose-97 UreaN-61* Creat-4.6* Na-132* K-4.1 Cl-101 HCO3-18* AnGap-17 ___ 02:13AM BLOOD Glucose-93 UreaN-67* Creat-4.1* Na-128* K-3.5 Cl-100 HCO3-18* AnGap-14 ___ 02:12AM BLOOD Glucose-83 UreaN-65* Creat-3.8* Na-137 K-3.3 Cl-107 HCO3-19* AnGap-14 ___ 02:03AM BLOOD Glucose-90 UreaN-65* Creat-3.3* Na-141 K-3.8 Cl-111* HCO3-21* AnGap-13 ___ 02:09AM BLOOD Glucose-112* UreaN-74* Creat-3.1* Na-145 K-4.3 Cl-114* HCO3-22 AnGap-13 ___ 02:17AM BLOOD Glucose-106* UreaN-80* Creat-2.8* Na-151* K-4.6 Cl-113* HCO3-25 AnGap-18 ___ 01:59AM BLOOD Glucose-164* UreaN-84* Creat-2.6* Na-150* K-4.2 Cl-113* HCO3-26 AnGap-15 ___ 01:56AM BLOOD Glucose-140* UreaN-92* Creat-2.7* Na-146* K-4.9 Cl-110* HCO3-26 AnGap-15 ___ 02:12AM BLOOD Glucose-103* UreaN-107* Creat-3.2* Na-141 K-5.3* Cl-101 HCO3-25 AnGap-20 ___ 04:19AM BLOOD Glucose-111* UreaN-123* Creat-3.7* Na-147* K-4.8 Cl-103 HCO3-28 AnGap-21* ___ 12:22AM BLOOD Glucose-128* UreaN-132* Creat-3.6* Na-147* K-4.7 Cl-100 HCO3-30 AnGap-22* ___ 02:07AM BLOOD Glucose-116* UreaN-124* Creat-3.3* Na-142 K-3.9 Cl-97 HCO3-30 AnGap-19 ___ 01:45AM BLOOD Glucose-110* UreaN-109* Creat-2.7* Na-138 K-4.2 Cl-95* HCO3-29 AnGap-18 ___ 06:55AM BLOOD Glucose-112* UreaN-93* Creat-2.2* Na-140 K-4.3 Cl-100 HCO3-31 AnGap-13 ___ 09:30AM BLOOD Glucose-122* UreaN-74* Creat-2.1* Na-146* K-4.3 Cl-104 HCO3-28 AnGap-18 ___ 05:20AM BLOOD Glucose-125* UreaN-68* Creat-2.0* Na-142 K-4.3 Cl-103 HCO3-29 AnGap-14 ___ 05:45AM BLOOD Glucose-119* UreaN-73* Creat-2.0* Na-145 K-4.5 Cl-103 HCO3-27 AnGap-20 ___ 05:30AM BLOOD Glucose-131* UreaN-81* Creat-2.3* Na-146* K-4.3 Cl-106 HCO3-26 AnGap-18 ___ 05:30AM BLOOD Glucose-128* UreaN-91* Creat-2.8* Na-143 K-4.4 Cl-102 HCO3-27 AnGap-18 ___ 05:50AM BLOOD Glucose-129* UreaN-97* Creat-3.2* Na-141 K-4.8 Cl-99 HCO3-26 AnGap-21* ___ 04:55AM BLOOD Glucose-83 UreaN-93* Creat-2.8* Na-143 K-4.9 Cl-104 HCO3-26 AnGap-18 ___ 05:20AM BLOOD Glucose-86 UreaN-75* Creat-2.3* Na-146* K-4.2 Cl-107 HCO3-27 AnGap-16 ___ 04:55AM BLOOD Glucose-133* UreaN-60* Creat-1.9* Na-145 K-4.0 Cl-107 HCO3-27 AnGap-15 ___ 01:45PM BLOOD ALT-36 AST-28 AlkPhos-83 TotBili-0.5 ___ 06:11AM BLOOD ALT-14 AST-37 AlkPhos-33* TotBili-2.1* ___ 10:07PM BLOOD ALT-17 AST-26 AlkPhos-107 TotBili-2.8* ___ 10:00PM BLOOD CK(CPK)-202 ___ 05:10AM BLOOD CK(CPK)-236 ___ 01:00PM BLOOD CK(CPK)-187 ___ 01:45PM BLOOD Lipase-27 ___ 01:45PM BLOOD cTropnT-0.05* ___ 01:51PM BLOOD CK-MB-9 cTropnT-<0.01 ___ 09:20PM BLOOD CK-MB-8 cTropnT-<0.01 ___ 10:00PM BLOOD CK-MB-2 cTropnT-0.10* ___ 05:10AM BLOOD CK-MB-2 ___ 01:00PM BLOOD CK-MB-3 ___ 01:45PM BLOOD Albumin-4.4 Calcium-9.2 Phos-6.8* Mg-1.9 ___ 09:04PM BLOOD Calcium-7.9* Phos-4.3 Mg-2.5 ___ 04:55AM BLOOD Calcium-8.9 Phos-3.5 Mg-1.7 ___ 09:04PM URINE Color-AMBER Appear-Cloudy Sp ___ ___ 09:04PM URINE Blood-LG Nitrite-NEG Protein-100 Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG ___ 09:04PM URINE RBC->182* WBC-159* Bacteri-MOD Yeast-NONE Epi-0 TransE-1 ___ 09:04PM URINE CastGr-8* CastHy-32* ___ 09:04PM URINE Mucous-OCC ___ 09:04PM URINE Hours-RANDOM Creat-111 Na-19 K-52 Cl-14 ___ 04:10PM URINE Color-Yellow Appear-Clear Sp ___ ___ 04:10PM URINE Blood-MOD Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG ___ 04:10PM URINE RBC-29* WBC-3 Bacteri-FEW Yeast-NONE Epi-<1 ___ 04:10PM URINE CastHy-1* ___ 04:10PM URINE Mucous-RARE ___ 02:03AM URINE Hours-RANDOM UreaN-670 Creat-61 Na-21 K-20 Cl-27 ___ 10:13PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 10:13PM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG ___ 10:13PM URINE RBC-7* WBC-4 Bacteri-NONE Yeast-NONE Epi-0 ___ 10:13PM URINE CastHy-4* ___ 10:13PM URINE Mucous-RARE ___ 10:13PM URINE Hours-RANDOM UreaN-771 Creat-118 Na-10 K-80 Cl-11 ___ 01:30PM URINE Color-Yellow Appear-Clear Sp ___ ___ 01:30PM URINE Blood-TR Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 01:30PM URINE Mucous-RARE The following cultures were all negative: Blood culture: ___ Urine culture: ___ C.diff: ___ CT ABDOMEN W/O CONTRAST Study Date of ___ 1:14 ___ Extensive mesenteric venous gas and portal venous gas is concerning for a large territory of ischemic bowel. Ischemic bowel appears grossly in the distribution of the SMA. The SMA calcifications are only mild. Patency of the SMA cannot be assessed without intravenous contrast. CT HEAD W/O CONTRAST Study Date of ___ 10:___vidence of acute intracranial process. Chronic changes as described above. MRI would be more sensitive for brainstem ischemia. CT ABD & PELVIS W/O CONTRAST Study Date of ___ 4:09 ___ 1. Status post right colectomy and diverting ileostomy with no evidence of fluid collection or abscess formation. 2. Small bowel and sigmoid diverticulosis, no evidence of acute diverticulitis. 3. Left abdominal wall defect containing multiple loops of small bowel without evidence of bowel strangulation, likely secondary to diastasis of the rectus abdominis muscles versus herniation. CT CHEST W/O CONTRAST Study Date of ___ 4:23 ___ 1. Mild opacification at the lung bases, is most likely atelectasis. Endobronchial material is either retained secretions or recent aspiration. None of the contrast agent filling the stomach is present in the tracheobronchial tree. 2. Asbestos-related pleural plaques. No evidence of intrathoracic malignancy. 3. Mild-to-moderate emphysema. 4. Moderate cardiomegaly. No pulmonary edema. CT ABD & PELVIS W/O CONTRAST Study Date of ___ 10:56 ___ Postoperative changes from previous ileostomy and right hemicolectomy without evidence of obstruction or extraluminal fluid collection to suggest abscess. Marked bladder distention. Consideration of Foley catheter placement is recommended if there is a history of urinary retention. MR HEAD W/O CONTRAST Study Date of ___ 2:56 ___ No acute infarction. No evidence for other acute intracranial abnormalities. Brief Hospital Course: ___ INR 2.3, d/c hep gtt, MS slightly improved, nystatin for (early) ___ ___ tube feeding resumed, heparin drip ___ OR for PEG ___ Foley placed for overflow incontinence ___ every other staple removed. self d/c'd ___ - replaced & bridled ___ dobhoff replaced, dc'd foley, desat to 90 ___ Increase O2 req day, less responsive on ___ exam, more somnolent ___ ABG, CXR, EKG, serial cardiac enzymes ordered Mr. ___ was admitted to the Acute Care Surgery service at ___ on ___ with pneumatosis and portal/mesenteric venous gas, sepsis, and acute renal failure. He was promptly taken to the operating room for an exploratory laparotomy and right colectomy for ischemia. For further details of the procedure, please see the operative report. The patient was left in discontinuity and brought to the intensive care unit for resuscitation. On ___, the pt returned to the operating room for an end ileostomy and abdominal closure. He then returned intubated to the intensive care unit where his hypotension, arrhythmias (runs of vtach, trigeminy), renal failure, and altered mental status were managed. Finally, on ___, the patient was extubated. On ___, a CT scan was obtained given the patient's leukocytosis but did not show any abscesses. On ___, Nephrology was consulted regarding the patient's persistent renal failure, which they felt was prerenal. The following day, the patient was started on 1:1 replacement of his ileostomy output with lactated ringers and immodium was started. On ___ the patient's diet was advanced to purees after he was cleared by speech and swallow. He was started on erythromycin for improved motility. The following day, on ___, the patient was transferred to the floor. That same day, Speech recommended the patient be made NPO for concern of aspiration. He was given tube feeds via a dobhoff catheter. On ___, the patient was taken back to the operating room for placement of a percutaneous gastrostomy tube. While on the floor, the patient's foley was removed and then replaced for urinary retention. His dobhoff was self d/c'd and replaced twice. His mental status waxed and waned although was peristently poor. He was bridged back to coumadin with a heparin drip. His creatinine and BUN slowly drifted down. On ___, the patient's mental status was notably improved. He answered some questions appropriately and spoke some comprehensible words. He was screened and accepted at a rehab facility where he will continue his recovery. Medications on Admission: Crestor 20' Lasix 40' Lisinopril 40' KCl 20 meq daily MVI Norvasc Coumadin 5qpm ___ 2.5qpm Th Discharge Medications: 1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain 2. Furosemide 40 mg PO DAILY 3. LOPERamide 2 mg PO QID:PRN administer for high ostomy output 4. Nystatin Oral Suspension 5 mL PO QID Duration: 3 Days 5. Opium Tincture 5 DROP PO Q8H 6. Rosuvastatin Calcium 20 mg PO DAILY ___ MD to order daily dose PO DAILY16 Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: ischemic colitis sepsis acute renal failure altered mental status Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You came to the hospital with abdominal pain and had a CT scan which showed insufficient blood flow to your large bowel. You were taken to the operating room for exploration and had your right colon removed. Two days later, your abdomen was re-explored, an ileostomy was made, and your abdomen was closed. Due to your altered mental status causing your to be unable to eat, you later had a feeding tube placed. Your ileostomy has been working and you are tolerating tube feeds. Your mental status has been improving and your swallowing ability should be evaluated next week. Please follow up in ___ clinic. ACTIVITY: Don't lift more than ___ lbs for ___ weeks. (This is about the weight of a briefcase or a bag of groceries.) This applies to lifting children, but they may sit on your lap. You will need to stay out of bathtubs or swimming pools for a time while your incision is healing. Ask your doctor when you can resume tub baths or swimming. HOW YOU MAY FEEL: You may feel weak or "washed out" for 6 weeks. You might want to nap often. Simple tasks may exhaust you. You might have trouble concentrating or difficulty sleeping. You might feel somewhat depressed. You could have a poor appetite for a while. Food may seem unappealing. All of these feelings and reactions are normal and should go away in a short time. If they do not, tell your surgeon. YOUR INCISION: You may gently wash away dried material around your incision. It is normal to feel a firm ridge along the incision. This will go away. Avoid direct sun exposure to the incision area. Do not use any ointments on the incision unless you were told otherwise. You may see a small amount of clear or light red fluid staining your dressing or clothes. If the staining is severe, please call your surgeon. You may shower. As noted above, ask your doctor when you may resume tub baths or swimming. Ove the next ___ months, your incision will fade and become less prominent. Monitoring Ostomy output/Prevention of Dehydration: Keep well hydrated. Replace fluid loss from ostomy daily. Avoid only drinking plain water. Include Gatorade and/or other vitamin drinks to replace fluid. Try to maintain ostomy output between 1000mL to 1500mL per day. *If Ostomy output >1 liter, take 4mg of Imodium, repeat 2mg with each episode of loose stool. Do not exceed 16mg/24 hours. PAIN MANAGEMENT: You may take tylenol as needed for pain. If you experience any of the folloiwng, please contact your surgeon: - sharp pain or any severe pain that lasts several hours - pain that is getting worse over time - pain accompanied by fever of more than 101 - a drastic change in nature or quality of your pain MEDICATIONS: Take all the medicines you were on before the operation just as you did before, unless you have been told differently. In some cases you will have a prescription for antibiotics or other medication. If you have any questions about what medicine to take or not to take, please call your surgeon. DANGER SIGNS: Please call your surgeon if you develop: - worsening abdominal pain - sharp or severe pain that lasts several hours - temperature of 101 degrees or higher - severe diarrhea - vomiting - redness around the incision that is spreading - increased swelling around the incision - excessive bruising around the incision - cloudy fluid coming from the wound - bright red blood or foul smelling discharge coming from the wound - an increase in drainage from the wound Followup Instructions: ___
10018081-DS-17	10,018,081	23,983,182	DS	17	2134-08-23 00:00:00	2134-08-27 20:22:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: morphine / Lipitor Attending: ___. Chief Complaint: feculent drainage from abdominal wound Major Surgical or Invasive Procedure: ___: ___ line placed ___ ___ drain placement x2 ___: VAC dressing placed History of Present Illness: ___ year old gentleman recently discharged from the ACS service ___ s/p end ileostomy takedown ileocolic anastomosis ___ (from original hartmanns for ischemic bowel ___ presents back from rehab with concern of feculent drainage from his abdominal wound. Postoperative course was complicated by postop ileus, incidental upper GI bleed on POD3 with urgent EGD showing severe esophagitis with a 1cm ulcer at the pylorus as well as small ulcers in the proximal duodenum without any areas of active bleeding. His symptoms resolved with stable Hcts. His abdominal incision also had superficial skin dehiscence which was managed with a wound vac. Patient was discharged to rehab on POD10 tolerating a regular diet and well healing wound. Patient reports he has been feeling well in rehab and was ready to go home until yesterday during a wound vac change the rehab staff noticed green, feculent drainage from the middle of his abdominal wound. Patient reports he has been eating well with normal BMs and denies any change in output from his wound vac with meals. He denies any fevers, chills, nausea, vomiting, abdominal pain or any other GI symptoms. Past Medical History: PMH: CAD, CHF, afib on coum, HL, HTN PSH: appy, GB, R colectomy with colostomy, takedown Social History: ___ Family History: NC Physical Exam: Physical Exam: upon admission ___: 97.8 79 134/76 18 97%RA GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, nontender, large mid abdominal wound open down to facia with some granulation tissue in periphery, prolene sutures visible, focal area of bilious drainage in the superior portion of the wound, no obvious bowel wall visible, nontender, no rebound or guarding Ext: No ___ edema, ___ warm and well perfused Physical examination upon dishcarge: ___: general: resting in bed, skin warm and dry, color pink vital signs: t=98.5, hr=64, bp=135/68, rr=17, oxygen sat. 97% room air CV: irreg, ns1, s2, -s3, -s4, + Grade ___ systolic murmur ___ ICS, left sternal border LUNGS: fine crackles bases bil ABDOMEN: soft, bulging left side abdomen, VAC dressing midline, ___ drain right side abd, dark maroon drainage SKIN: intact EXT: no pedal edema bil. NEURO: follows commands, oriented to person, disoreinted to time and place LINES: left antecubital PICC line, peripheral line right hand Pertinent Results: ___ 09:17AM BLOOD WBC-9.1 RBC-2.95* Hgb-8.9* Hct-29.1* MCV-99* MCH-30.1 MCHC-30.6* RDW-16.1* Plt ___ ___ 04:55AM BLOOD WBC-7.5 RBC-2.60* Hgb-7.8* Hct-25.8* MCV-99* MCH-30.1 MCHC-30.4* RDW-15.9* Plt ___ ___ 03:56AM BLOOD WBC-7.6 RBC-2.48* Hgb-7.5* Hct-24.6* MCV-99* MCH-30.1 MCHC-30.3* RDW-15.7* Plt ___ ___ 04:52PM BLOOD WBC-12.6* RBC-2.76* Hgb-8.4* Hct-27.3* MCV-99* MCH-30.4 MCHC-30.7* RDW-15.7* Plt ___ ___ 04:52PM BLOOD Neuts-82.9* Lymphs-10.7* Monos-5.0 Eos-1.1 Baso-0.2 ___ 09:17AM BLOOD Plt ___ ___ 03:56AM BLOOD ___ PTT-30.7 ___ ___ 09:17AM BLOOD Glucose-119* UreaN-24* Creat-0.8 Na-139 K-4.2 Cl-108 HCO3-26 AnGap-9 ___ 04:55AM BLOOD Glucose-108* UreaN-23* Creat-0.8 Na-141 K-4.4 Cl-110* HCO3-23 AnGap-12 ___ 01:00PM BLOOD CK(CPK)-22* ___ 04:52PM BLOOD ALT-12 AST-18 AlkPhos-104 TotBili-0.4 ___ 04:55AM BLOOD proBNP-1053* ___ 09:17AM BLOOD Calcium-8.6 Phos-2.3* Mg-1.8 ___ 04:55AM BLOOD VitB12-324 Folate-11.1 ___ 03:56AM BLOOD Ferritn-1240* ___ 03:56AM BLOOD Triglyc-67 ___ 03:56AM BLOOD TSH-3.2 ___: chest x-ray: IMPRESSION: PICC line terminating in the lower superior vena cava. No evidence of acute disease. ___: cat scan of abdomen and pelvis: Extensive intra-abdominal abscesses, some with high attenuation content suggesting enteric content, as described above including around the anastomosis and in the deep pelvis. Ileocolic anastomosis is directly underneath the open wound. ___: ___ drainage: Technically successful percutaneous drainage of 2 right pelvic fluid collections with CT guidance. 8 ___ pigtail drains are left position with within each pocket. ___: EKG: Atrial fibrillation with ventricular bigeminy. Conducted complexes have left axis deviation, intraventricular conduction delay, and left bundle-branch block type pattern. Compared to the previous tracing the rate is now slower. There is less artifact and that tracing probably showed atrial fibrillation as well. Clinical correlation is suggested. ___: chest x-ray: Left PICC line tip is at the level of mid SVC. Cardiomegaly and mediastinum are unchanged. Right basal opacity has slightly progressed. Left retrocardiac atelectasis is unchanged. Upper zone re- distribution of the vasculature is unchanged ___: EKG: Atrial fibrillation with ventricular bigeminy. Left anterior fascicular block with left bundle-branch block. Intraventricular conduction delay. Compared to the previous tracing of ___ findings are similar. However, ventricular ectopy is more frequent. ___ 9:14 am STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Reported to and read back by ___. ___ ___, ___, 2:25PM. CLOSTRIDIUM DIFFICILE. Positive for toxigenic C. difficile by the Illumigene DNA amplification. (Reference Range-Negative). Time Taken Not Noted Log-In Date/Time: ___ 4:39 pm ABSCESS FINAL REPORT ___ GRAM STAIN (Final ___: 3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 3+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S). WOUND CULTURE (Final ___: ESCHERICHIA COLI. HEAVY GROWTH. Cefepime sensitivity testing confirmed by ___. PROTEUS MIRABILIS. MODERATE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| PROTEUS MIRABILIS \| \| AMIKACIN-------------- 8 S AMPICILLIN------------ =>32 R =>32 R AMPICILLIN/SULBACTAM-- =>32 R =>32 R CEFAZOLIN------------- =>64 R 16 R CEFEPIME-------------- 2 S <=1 S CEFTAZIDIME----------- 16 R <=1 S CEFTRIAXONE----------- =>64 R <=1 S CIPROFLOXACIN--------- =>4 R <=0.25 S GENTAMICIN------------ =>16 R <=1 S MEROPENEM-------------<=0.25 S <=0.25 S PIPERACILLIN/TAZO----- 8 S <=4 S TOBRAMYCIN------------ =>16 R <=1 S TRIMETHOPRIM/SULFA---- =>16 R =>16 R ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. Brief Hospital Course: Mr ___ was admitted to the hospital after takedown of his end ileostomy with ileocolic anastomosis on ___. His course was complicated by a upper GIB. An EGD was done that revealed severe esophagitis with a 1cm ulcer at the pylorus as well as small ulcers in the proximal duodenum without any areas of active bleeding. The patient was monitored in the intensive care unit where he received 2 units of blood. Shortly after this, the patient was reported to have a wound separation, the staples were removed and the wound was debrided. A VAC dressing was placed on ___ to promote wound healing. The patient stabilized and was discharged to a rehabilitation facility on ___. Mr. ___ was re-admitted to the hospital on ___ from the ___ facility after he was noted to have green, feculent drainage from the middle of his abdominal wound. Prior to this, he was reported to be doing well and was preparing for discharge home. Upon admission to the hospital, he was made NPO, given intravenous fluids, and underwent imaging. He was reported to have extensive intra-abdominal abscesses as well as an enteroatmospheric fistula through his open midline incisional wound. He was taken to ___ where he underwent placement of 2 percutaneous drainage catheters into the right pelvic fluid collections under CT guidance. Cultures from the wound were reported to be growing E.coli and proteus. The patient was started on a course a 2 week course of meropenum. At the time of his admission, he was having diarrhea and a stool specimen was sent for c.diff which returned positive. The patient was started on a course of flagyl. Throughout his hospital course the patient's vital signs were closely monitored and his electrolytes repleted. To maintain his nutritional status, he resumed TPN. Because of his NPO status, his anticoagulation was changed from coumadin to lovenox. On HD #1, the patient was reported to have premature ventricular beats and runs of ventricular ectopy. His hemodynamic status remained stable. His electroyltes were repleted. Despite this, he ectopy continued and a cardiology consult was called. The patient was started on intravenous metoprolol and enalapril. Over the next ___ hours, his ectopy resolved. Throughout his hospitalization, the patient has experienced bouts of confusion, but re-orients easily to time and place. In preparation for discharge, the patient was evaluated by physical therapy and recommendations were made for discharge to a rehabilitation center where the patient could be provided with cardiac monitoring, TPN support, and wound care management. The patient was discharged on HD # 6 in stable condition. An appointment for follow-up was made with the acute care service and the Cardiology service. Medications on Admission: crestor 20, lasix 40, lisinopril 40, KCl 20 meq Daily, MVI, norvasc, coum 5qpm ___ Coumadin* 2.5qpm Th, iron Discharge Medications: 1. Acetaminophen IV 1000 mg IV Q6H:PRN pain, fever 2. Enoxaparin Sodium 40 mg SC DAILY Start: Today - ___, First Dose: Next Routine Administration Time 3. Meropenem 500 mg IV Q6H last dose ___. Metoprolol Tartrate 5 mg IV Q6H hold for systolic blood pressure <90, hr<60 5. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H last dose ___ 6. Ondansetron 4 mg IV Q8H:PRN nausea 7. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush 8. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line flush 9. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line flush 10. Enalaprilat 1.25 mg IV Q6H hold for systolic blood pressure <100 Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: EC fistula intra-abdominal abscesses premature ventricular contractions Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were re-admitted to the hospital from the rehabilation center after you noted feculent drainage from abdominal wound. You underwent a cat scan and you were found to have many abdominal abscesses and a fistula. You had 2 drains placed in the fluid collections. You were started on antibiotics to cover the bacteria which was growing in the abscesses. To help the fistula to close and the wound to heal, you had a vac dressing placed. During your hospital course, you were noted to have several premature ventricular beats. THe cardiololgy service was consulted and recommendations made for medication to help control them. Your vital signs have been stable. You are now preparing for discharge to a rehabilation facililty where you will be on IV nutrition to help the bowel heal. Followup Instructions: ___
10018297-DS-12	10,018,297	20,306,868	DS	12	2115-02-06 00:00:00	2115-02-06 18:39:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: right acetabular fracture Major Surgical or Invasive Procedure: None History of Present Illness: HPI: ___ male presents with right hip pain. Patient was biking at about 3 pm today, got into an accident, went over the handlebars. He reports head strike while wearing helmet, no loss of consciousness. No head, neck, or back pain. Right hip pain with difficulty walking. He limped back home and was taken to urgent care where he underwent x-rays showing acetabular fracture. He was transferred to ___ for further care. Past Medical History: None Social History: ___ Family History: Non-contributory. Physical Exam: Exam on discharge: Right lower extremity: - Skin intact - No deformity, erythema, edema, induration or ecchymosis - Soft, non-tender thigh and leg - Full, painless AROM/PROM of hip, knee, and ankle - ___ fire - SILT SPN/DPN/TN/saphenous/sural distributions - 1+ ___ pulses, foot warm and well-perfused Pertinent Results: ___ 06:33PM WBC-10.9 RBC-4.83 HGB-14.6 HCT-41.7 MCV-86 MCH-30.1 MCHC-34.9 RDW-13.2 Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have a right acetabular fracture and was admitted to the orthopedic surgery service. The patient was given a trial of non-operative management and worked with physical therapy. Repeat XRs were performed after mobilization with ___. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to home was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is TDWB in the right lower extremity. The patient will follow up with Dr. ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Medications on Admission: None Discharge Medications: 1. Acetaminophen 650 mg PO Q6H Do not exceed 4g/day. 2. Diazepam 5 mg PO Q6H:PRN muscle spasm Do not drink alcohol, drive, or use heavy machinery while taking. 3. Docusate Sodium 100 mg PO BID 4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain Do not drink alcohol, drive, or use heavy machinery while taking. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Right acetabular fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for an Orthopaedic injury. It is normal to feel tired or "washed out", 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 weight bearing right lower extremity MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take lovenox 40mg daily for 2 weeks DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever > 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns Followup Instructions: ___
10018297-DS-13	10,018,297	25,480,562	DS	13	2119-05-04 00:00:00	2119-05-04 21:52:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Left distal humerus fracture Major Surgical or Invasive Procedure: Open Reduction Internal Fixation of Left Distal Humerus Fractures by Dr. ___ on ___ History of Present Illness: ___ male with no significant past medical history presenting after a bicycle accident. Patient was riding his bike when he braked too hard. Patient fell onto his left side. Patient was wearing a helmet. No loss of consciousness. Patient was able to ambulate afterwards. Patient presents with significant left elbow pain and swelling. Patient has no significant past medical or surgical history. He is not on any blood thinners. Past Medical History: None Social History: ___ Family History: Non-contributory. Physical Exam: AVSS NAD, A&Ox3 RUE: posterior slab in place, clean and dry. Fires EPL/FPL/DIO. SILT radial/median/ulnar n distributions. 1+ radial pulse, wwp distally. Pertinent Results: ___ 06:08AM BLOOD WBC-7.7 RBC-3.85* Hgb-11.2* Hct-35.7* MCV-93 MCH-29.1 MCHC-31.4* RDW-12.9 RDWSD-43.7 Plt ___ ___ 05:17AM BLOOD Neuts-61.6 ___ Monos-7.8 Eos-0.9* Baso-0.5 Im ___ AbsNeut-3.38 AbsLymp-1.59 AbsMono-0.43 AbsEos-0.05 AbsBaso-0.03 ___ 06:08AM BLOOD Plt ___ ___ 06:08AM BLOOD ___ PTT-30.9 ___ ___ 06:08AM BLOOD Glucose-93 UreaN-8 Creat-0.8 Na-140 K-4.2 Cl-101 HCO___ AnGap-12 ___ 06:08AM BLOOD Calcium-9.1 Phos-3.4 Mg-1.8 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 humerus fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for L humerus open reduction and internal fixation, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given ___ antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to home was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, dressings were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is non-weight bearing in the left upper extremity, range of motion as tolerated at shoulder/wrist/digits, and will be discharged on aspirin for DVT prophylaxis. The patient will follow up with Dr. ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Discharge Medications: 1. Acetaminophen 500 mg PO Q4H 2. Aspirin 325 mg PO DAILY 3. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 4. Docusate Sodium 100 mg PO BID 5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain 6. Senna 8.6 mg PO BID Discharge Disposition: Home Discharge Diagnosis: Distal Humerus Fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - NWB LUE in posterior slab, ROMAT at shoulder/wrist/digits etc MEDICATIONS: 1) Take Tylenol ___ every 6 hours around the clock. This is an over the counter medication. 2) Add Oxycodone as needed for increased pain. Aim to wean off this medication in 1 week or sooner. This is an example on how to wean down: Take 1 tablet every 3 hours as needed x 1 day, then 1 tablet every 4 hours as needed x 1 day, then 1 tablet every 6 hours as needed x 1 day, then 1 tablet every 8 hours as needed x 2 days, then 1 tablet every 12 hours as needed x 1 day, then 1 tablet every before bedtime as needed x 1 day. Then continue with Tylenol for pain. 3) Do not stop the Tylenol until you are off of the narcotic medication. 4) Per state regulations, we are limited in the amount of narcotics we can prescribe. If you require more, you must contact the office to set up an appointment because we cannot refill this type of pain medication over the phone. 5) Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and continue following the bowel regimen as stated on your medication prescription list. These meds (senna, colace, miralax) are over the counter and may be obtained at any pharmacy. 6) Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. 7) Please take all medications as prescribed by your physicians at discharge. 8) Continue all home medications unless specifically instructed to stop by your surgeon. ANTICOAGULATION: - Please take Aspirin 325mg for VTE ppx x 3 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. - 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 FOLLOW UP: Please follow up with your Orthopaedic Surgeon, Dr. ___. You will have follow up with ___, NP in the Orthopaedic Trauma Clinic 14 days post-operation for evaluation. Call ___ to schedule appointment upon discharge. Please follow up with your primary care doctor regarding this admission within ___ weeks and for any new medications/refills. Physical Therapy: Activity: Activity: Activity as tolerated Left upper extremity: Non weight bearing Encourage turn, cough and deep breathe q2h when awake 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 after POD3. 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. Please remain in the splint until follow-up appointment. Please keep your splint dry. If you have concerns regarding your splint, please call the clinic at the number provided. Followup Instructions: ___
10018328-DS-14	10,018,328	26,706,939	DS	14	2154-02-09 00:00:00	2154-02-10 15:42:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: Syncope and fall Major Surgical or Invasive Procedure: none History of Present Illness: Ms ___ is a ___ year old female, with past medical history significant for left breast cancer (with +LN) s/p chemoXRT s/p lumpectomy, who suffered a fall. Her story is as follows: She was in her usual state of health at the ___ when she had an acute onset of "light-headedness". From her recollection, this is the sole symptom surrounding the event: no nausea, visual changes, tinitis, vertigo, diaphoresis, tremors, palpitations, etc. As a result, she fell with head strike. She does endorse some antegrade amnesia and unable to recall exactly what happened immediately following the event. GCS was 15 on scene and currently. She states that she is sore diffusely, without any localized area of pain. No weakness, numbness or tinling. Imaging was performed at ___ where she presented which showed left sided ___ rib fractures (nondisplaced), T3 compression fracture; head and spine imaging were atraumatic. EKG shows LVH and cardiac enzyme was negative. She was transferred to ___ for trauma evaluation as well as neurosurgery evaluation. Past Medical History: Left breast cancer with mets to LN s/p chemoXRT Hypertension Hyperlipidemia Social History: ___ Family History: No family history of aneurisms. Physical Exam: Admission Physical Exam: VITAL SIGNS: 98.0 130/40 60 18 95%RA GENERAL: AAOx3 NAD HEENT: Head lac and ecchymosis, EOMI, PERRLA, No scleral icterus, mucosa moist, no LAD CARDIOVASCULAR: R/R/R, S1/S2, NO M/R/G CAROTIDS: 2+, No bruits or JVD PULMONARY: CTA ___, No crackles or rhonchi GASTROINTESTINAL: S/NT/ND. No guarding, rebound, or peritoneal signs. +BSx4 EXT/MS/SKIN: No C/C/E; Feet warm. Good perfusion. Back TTP thoracic spine; No step offs. Hip stable. NEUROLOGICAL: Reflexes, strength, and sensation grossly intact CNII-XII: WNL DISCHARGE PHYSICAL EXAM: Vitals - Orthostatics: 118/53 sitting, 115/51 laying, 124/66 standing. General: well appearing, NAD HEENT: MMM, EOMI, PERRL Neck: no JVD, no LAD CV: rrr, no m/r/g Lungs: CTAB, breathing comfortably Abdomen: soft, nontender, nondistended, no HSM appreciated GU: deferred Ext: warm and well perfused, pulses, no edema MSK: Slightly tender to palpation over the left lower ribs laterally Neuro: CN ___ intact, strength ___ in all extremities, sensation grossly intact, A&Ox3 Pertinent Results: ADMISSION LABS: ___ 05:35PM BLOOD WBC-16.5* RBC-4.57 Hgb-13.5 Hct-41.3 MCV-90 MCH-29.5 MCHC-32.7 RDW-13.0 RDWSD-42.6 Plt ___ ___ 05:35PM BLOOD Neuts-89.3* Lymphs-6.5* Monos-3.0* Eos-0.1* Baso-0.2 Im ___ AbsNeut-14.76* AbsLymp-1.07* AbsMono-0.50 AbsEos-0.01* AbsBaso-0.04 ___ 05:35PM BLOOD Plt Smr-NORMAL Plt ___ ___ 05:07AM BLOOD ___ PTT-26.6 ___ ___ 05:35PM BLOOD Glucose-121* UreaN-11 Creat-0.8 Na-137 K-4.2 Cl-101 HCO3-19* AnGap-21* ___ 05:07AM BLOOD Calcium-8.8 Phos-2.7 Mg-1.8 MICRO: ___: UA with 70WBC, +NIT, Lg LEUK ___: Urine culture consistent with contamination IMAGING: ___ IMAGING: T-Spine: 1. Moderate T3 and mild T2 compression fractures. 2. Chronic severe compression fracture of T5 with focal kyphosis. MRI C&T SPINE: 1. Acute anterior and posterior vertebral body fracture of the T3 with 4 mm retropulsion of the posterior vertebral body, moderately narrowing the vertebral canal at the level. Possible posterior ligamentous complex disruption at T3-4. No subluxation or rotation. 2. Moderate amount of prevertebral swelling spanning from T2-8 with likely disruption of the anterior longitudinal ligament at T7-8. 3. Mild acute compression fracture at T2. 4. Severe chronic compression fracture at T5. 5. Cholelithiasis without evidence of cholecystitis. 6. Bilateral renal simple cysts. ___ Imaging: MRI Head w&w/o contrast: 1. 2.5 X 1.5 cm aneurysm possibly arising from the left posterior communicating artery origin of the left internal carotid artery with at the carotid canal. Angiogram or CTA with 3D reconstruction is recommended for further evaluation of the aneurysm. CTA Head/Neck: 1. 2.4 x 1.5 cm left internal carotid aneurysm arising at the bifercation of the posterior communicating artery. The neck of the artery measuring up to 5 mm. 2. Air locule within the head likely from venous injection. 3. Posterior head laceration s/p skin stapling. 4. Patent circle of ___ and its major tributaries. Final read pending 3D reconstructions. OSH studies: Pan CT showing new T3 compression fx, 3 non displaced L rib fx, old T5 fx, CT head also showing likely lipoma and a 4 x 1.6 x 1.3 cm mass in L temporal lobe, likely extra-axial in location. TTE ___: The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. DISCHARGE LABS: ___ 06:10AM BLOOD WBC-11.1* RBC-3.92 Hgb-11.4 Hct-34.2 MCV-87 MCH-29.1 MCHC-33.3 RDW-13.2 RDWSD-41.2 Plt ___ ___ 06:10AM BLOOD Plt ___ ___ 06:10AM BLOOD Glucose-121* UreaN-13 Creat-0.7 Na-136 K-3.7 Cl-100 HCO3-23 AnGap-17 ___ 06:10AM BLOOD Calcium-8.8 Phos-2.7 Mg-2.1 Brief Hospital Course: The patient is an ___ year-old female with a history of breast cancer status-post lumpectomy, hypertension, and hyperlipidemia who presented to ___ for syncope and fall with multiple vertebral fractures. She was transferred to ___, where she was found to have a urinary tract infection as well as an internal carotid artery aneurism. Her UTI was treated with Ciprofloxacin. She was briefly placed in a soft collar for musculoskeletal injuries, and neurosurgery recommended outpatient follow-up for her aneurism. She was discharged in stable condition on an increased dose of amlodipine to manage hypertension in the setting of internal carotid aneurysm. ACUTE ISSUES: # Syncope: The patient experienced syncope of unclear etiology. She had an EKG and troponin that were normal, no findings on telemetry, non-orthostatic vitals, a normal neurologic examination, and had no witnessed seizure activity during hospitalization. The patient had no further episodes of syncope during hospitalization. She also had an echocardiogram which was normal. Therefor syncope was likely in the setting of orthostasis vs vasovagal. # Left internal carotid aneurysm: This aneurism was discovered on Head CT and followed up with CTA. The patient had no focal neurologic deficits. Neurosurgery was consulted and recommended outpatient follow-up. She should follow up with neurosurgery. It was thought unlikely that this was a cause of her syncope. # Fall resulting in fractures of T2, T3, T5, and left ribs ___: The patient was seen and evaluated by acute care surgery as well as orthopedic spine service. She was briefly placed in a soft collar, which was subsequently removed. She should follow up in the orthopedic spine clinic. # Urinary Tract Infection: The patient was found to have leukocytosis and urinalysis suggestive of urinary tract infection in the absence of symptoms. She was started on Ciprofloxacin, which she should continue until ___. # Hypokalemia: RESOLVED. This was likely in the setting of decreased PO intake surrounding the patient's fall. CHRONIC ISSUES: # Hypertension: The patient had pressures consistently above 140 systolic in the setting of internal carotid artery aneurism. She was discharged on an increased dose of amlodipine, now 10mg daily (from 5mg previously). She was continued on enalapril, atenolol, and aspirin. # Insomnia: Continued home zolpidem. TRANSITIONAL ISSUES: # Syncope: Please follow up with orthostatic vitals monitoring as outpatient. # ICA Aneurysm: Patient to follow up with neurosurgery as outpatient next week to determine plan for intervention. # Orthopedic Spine Clinic: Patient to follow up with orthopedic spine clinic for newly diagnosed vertebral and rib fractures. Patient to also continue physical therapy as outpatient. # UTI: Patient to complete therapy with ciprofloxacin until ___. # Hypokalemia: Please repeat CBC, and electrolytes upon follow-up. # Hypertension: Amlodopine increased to 10 mg daily to have SBP < 140 given new diagnosis of internal carotid artery aneurism. Please continue to monitor cardiopulmonary assessment, and adjust regimen as needed. CODE: Full, with limited trial of life-sustaining treatment. Recommend continued discussion about code status with family. EMERGENCY CONTACT HCP: ___ Relationship: DAUGHTER Phone: ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 5 mg PO DAILY 2. Enalapril Maleate 40 mg PO DAILY 3. Atenolol 50 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia 6. Vitamin D 1000 UNIT PO DAILY Discharge Medications: 1. amLODIPine 10 mg PO DAILY RX amlodipine 10 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 2. Aspirin 81 mg PO DAILY 3. Atenolol 50 mg PO DAILY 4. Enalapril Maleate 40 mg PO DAILY 5. Vitamin D 1000 UNIT PO DAILY 6. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia 7. Ciprofloxacin HCl 250 mg PO Q12H RX ciprofloxacin HCl 250 mg 1 tablet(s) by mouth twice daily Disp #8 Tablet Refills:0 8. Roller Please dispense 1 rolling walker Diagnosis: R53.1 Leg Weakness. Prognosis: Good Length of Need: 13 months Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnoses: Vertebral fracture of T2,3, and 5. Internal cardotid artery aneurism, Hypokalemia, Syncope, Urinary tract infection Secondary Diagnoses: Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. ___, You were admitted to ___ because you passed out and fell. We found that you broke some bones in your back as well as some ribs on your left side. We put you in a neck collar for several days and made sure you were not in too much pain. While you were here, we found out that you had a urinary tract infection and we started you on antibiotics. We also found on an image of your brain that you have an aneurism, and for this we arranged a follow-up appointment for you with neurosurgery. When you leave, remember to take all of your medications as directed. Please follow up with your primary care doctor as well as with our neurosurgeons for your brain aneurism. Thank you for allowing us to care for you here, Your ___ care team Followup Instructions: ___
10018423-DS-18	10,018,423	29,366,372	DS	18	2167-05-11 00:00:00	2167-05-11 13:38:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: chest pain Major Surgical or Invasive Procedure: ___ 1. Urgent coronary artery bypass graft x3, left internal mammary artery to left anterior descending artery, right internal mammary artery to distal right coronary artery, and saphenous vein graft to obtuse marginal artery. 2. Endoscopic harvesting of the long saphenous vein. ___ Cardiac catheterization History of Present Illness: ___ year old male with a cardiac risk factor history of HTN (not compliant with meds), dyslipidemia, obesity, and FH of premature CAD presenting with intermittent exertional chest pain of 5 days duration. 5 days PTA, he was in a fire and pulling out a hose when he suddenly felt a ___ squeezing sensation in his chest which radiated to his neck and jaw. He also had associated SOB. Upon leaving work and on his way back to the fire house he had chest pain again and was seen at the ___ ED and had a normal EKG and negative troponins x2. A stress test was suggested to further characterize but pt decided to leave the hospital. He went to see his PCP yesterday who suggested he come back to the ED for coronary angiography. Throughout the weekend, pt has noted some SOB, lightheadedness and intermittent chest pain sometimes occurring with rest. The pain is less severe than it was on ___, however it is a ___ "poking" pain, made worse with exertion and better with rest. At baseline, he does significant exercise for his work. Neither changes in position nor palpation make it better or worse. He denies pleuritic chest pain. He has previously experienced GERD and reports that this pain is different than his reflux sx. He denies any orthopnea or nocturnal dyspnea. His ROS is pan-negative except as mentioned above, though he does endorse some fatigue over the past month that is not associated with weight loss, fevers, or night sweats. In ___, pt had a stress test at ___, which noted horizontal/downsloping ST depressions in II/III/avF and V6. On the perfusion images, there was a small area of decreased perfusion in the ___ region, was going to get a cath but due to scheduling difficulties, did not. Was seen one time by a cardiologist (___) who started him on atorvastatin and aspirin which he discontinued. In the ED initial vitals were: Pain 3, T97.9, HR84, BP 135/84, RR 16 97% RA EKG: NSR w/ nonspecific T wave inversion in III, <1mm STE in I c/w prior on ___ Labs/studies notable for: Trop negative, UA bacteria but neg ___, WBC 7.6, Hgb 14.4, Cr 0.7 Patient was given: ASA 325mg, atorvastatin 40 mg., acetaminophen for pain Vitals on transfer: pain 3, T97.7, HR93, BP139/82, RR27, 97% RA On the floor, continues to have chest pain 3 out of 10. Past Medical History: GERD Hyperlipidemia Hypertension Obesity Social History: ___ Family History: Mother: deceased CAD (___), DM, CJD Father: Alive w/ CAD (___), DM Brother: high cholesterol MGM: 85 MI MGF: 77 MI PGF: 80 ?MI Sister: ___ MI Physical Exam: On admission: PHYSICAL EXAM: GENERAL: WDWN male in NAD. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple with no visible JVD CARDIAC: RRR, normal S1, S2. No murmurs/rubs/gallops. No thrills, lifts. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND w/o rebound/garuding. EXTREMITIES: No c/c/e. Moving all extremities No femoral bruits. NEURO: AOx3, CNII-XII intact. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Distal pulses palpable and symmetric LABS: see below MICRO: see below EKG: Nonspecific TWI in III and <1mm STE in I o/w NSR, normal axis and intervals w/ late R wave transition Discharge physcial exam Vital signs: temp 98.1, HR 82 SBP 135/76 RA 94% Dischareg wgt: 109.8 kg preop 109.8 Neuro: non focal A&O x 3 Resp:diminished bases CV: S1 s2 no JVD GI: abd soft + BS +BM GU: voiding clear yellow urine Ext: trace lower ext edema Sternal incision and right EVH healing no erythema or drainage Pertinent Results: ___ TTE PREBYPASS: Normal LV systolic function, with LVEF>55% and no segmental wall motion abnormalities. Normal valves. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. No clot seen in the ___. Normal coronary sinus. Intact interatrial septum. POSTBYPASS: LVEF>55%. No disection seen following removal of the aortic cannula. No new wall motion abnormalities following chest closure. Otherwise unchanged. ___ PA&Lat Stable postoperative mediastinal widening. Small bilateral effusions are unchanged. Bibasilar atelectasis is improved. ___ 04:59AM BLOOD WBC-7.5 RBC-3.21* Hgb-8.3* Hct-26.4* MCV-82 MCH-25.9* MCHC-31.4* RDW-14.5 RDWSD-42.3 Plt ___ ___ 05:20PM BLOOD WBC-7.6 RBC-5.61 Hgb-14.4 Hct-44.5 MCV-79* MCH-25.7* MCHC-32.4 RDW-12.8 RDWSD-36.5 Plt ___ ___ 11:06AM BLOOD ___ PTT-150* ___ ___ 04:59AM BLOOD UreaN-17 Creat-0.8 Na-135 K-4.4 Cl-97 ___ 05:20PM BLOOD Glucose-98 UreaN-20 Creat-0.7 Na-136 K-4.3 Cl-102 HCO3-27 AnGap-11 ___ 01:27AM BLOOD PTT-72.9* ___ 05:20PM BLOOD VitB12-423 ___ 09:10AM BLOOD %HbA1c-5.9 eAG-123 ___ 08:11AM BLOOD Triglyc-384* HDL-35 CHOL/HD-7.0 LDLcalc-134* Brief Hospital Course: Presented with chest pain and underwent cardiac catheterization that revealed significant coronary artery disease. Cardiac surgery was consulted and he underwent preoperative workup. On ___ was taken to the operating room for coronary artery bypass graft surgery. Please see operative report for further surgical details. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. He required vasoactive medications for blood pressure management that were weaned off post operative day one. Early in the morning on post operative day one he was weaned from sedation, awoke neurologically intact and was extubated without complications. He was started on betablocker and diuretic, continued to progress and later that day was transferred to the floor. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. He was postoperatively anemic, likely due to volume resuscitation, and he deferred transfusion. However on post operative day five he was feeling symptomatic on ambulation with increased fatigue and lightheadedness. He was transfused one unit of packed red blood cells, with resolution. He continued to improve and was ready for discharge home with services on post operative day six. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN SOB 2. Omeprazole 20 mg PO DAILY 3. Atorvastatin 40 mg PO QPM Of note, pt reports not taking any of these medications despite having prescriptions Discharge Medications: 1. Atorvastatin 80 mg PO QPM RX atorvastatin 80 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:1 2. Aspirin EC 81 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain RX tramadol [Ultram] 50 mg 1 tablet(s) by mouth every four (4) hours Disp #40 Tablet Refills:0 5. Ibuprofen 600 mg PO Q8H:PRN pain take with food 6. Furosemide 40 mg PO DAILY Duration: 5 Days RX furosemide 40 mg 1 tablet(s) by mouth once a day Disp #5 Tablet Refills:0 7. Guaifenesin ER 600 mg PO Q12H RX guaifenesin 600 mg 1 tablet(s) by mouth twice a day Disp #14 Tablet Refills:0 8. albuterol sulfate 90 mcg/actuation INHALATION Q4H:PRN SOB 9. Omeprazole 20 mg PO DAILY 10. Polyethylene Glycol 17 g PO DAILY hold for loose stools 11. Metoprolol Tartrate 50 mg PO BID RX metoprolol tartrate [Lopressor] 50 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:1 12. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain RX hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth q3h Disp #80 Tablet Refills:0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Coronary artery disease s/p revascularization Anemia acute blood loss Secondary Diagnosis Hypertension Hyperlipidemia Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with dilaudid, tylenol, ultram Sternal Incision - healing well, no erythema or drainage Right leg incision- healing well, no erythema or drainage Edema trace edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions 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 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 with any questions or concerns ___ Please call cardiac surgery office with any questions or concerns ___. Answering service will contact on call person during off hours* Followup Instructions: ___
10018501-DS-9	10,018,501	28,479,513	DS	9	2141-08-05 00:00:00	2141-08-05 14:58:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: s/p MVC Major Surgical or Invasive Procedure: None History of Present Illness: ___ restrained driver in high speed MVC. GCS 15 at scene and self extricated. Went to OSH where initial imaging showed concern for right sided frontal/parietal SDH. He was transferred for neurosurgery evaluation. En route further review of his imaging showed a lumbar spine retropulsion injury. He arrive in our ED GCS 15, moving all extremities, with no focal deficits. The ED had checked rectal tone which was intact with no gross blood. Past Medical History: HTN, GERD, Gout, cataracts bilateral (done at ___, history of skin CA, appendectomy, right CEA Social History: ___ Family History: NC Physical Exam: On Admission: 98.3 72 160/67 20 96% ra NAD, PERRL, A+Ox3, CN intact RRR CTAB abd soft, NT mild bilateral edema, large bony changes bilateral olecranon related to gout motor and sensation intact, ___ 4+/5 bilaterally related to pain but otherwise ___ throughout On Discharge: A&O x3, neuro intact. Has tophus gouty deposits in elbows bilaterally. Pertinent Results: CT Head ___: 1. Stable small right subdural hematoma along the right frontal temporal region. No mass-effect or shift of midline structures. 2. No additional hemorrhage. CT Chest ___: No acute intrathoracic injury. Left posterior eleventh rib fracture is chronic. CT Abdomen/Pelvis ___: 1. L2 burst fracture with 5 mm of retropulsion and 2 column involvement. 2. Nondisplaced fracture through L1 anterior osteophyte at inferior endplate. Single column involvement. 3. Small calcified gallstones without evidence of acute cholecystitis. 4. Diffuse colonic diverticulosis without evidence of acute diverticulitis. 5. Left bladder diverticulum. CT Head ___: Stable size and morphology of tiny right frontotemporal extra-axial hematoma. MRI Lumbar Spine: ___ Preliminary Report: 1. Fracture through the L2 vertebral body causing moderate vertebral body height loss. Marrow edema extends into the bilateral L2 pedicles. There is mild retropulsion. 2. Additional bony defects of the inferior L3 and superior L4 endplates, either small fractures or Schmorl's nodes. There is increased T2/STIR signal within the L3-4 intervertebral disc that may be traumatic. Brief Hospital Course: Patient was admitted to the ICU from the ED for frequent neurologic checks. He remained stable overnight on ___ into ___. On morning rounds on ___ he was neurologically intact and remained on flat bedrest with logroll precautions. A TLSO brace was ordered and measured. He also underwent a repeat CT scan of the head to evalaute for interval change which showed stable right sided SDH. He was deemed fit for transfer to the floor while awaiting MRI of the L-Spine and transfer orders were written. In ___ afternoon he began developing signs of alcohol withdrawl and was placed on a phenobarb withdrawl scale. He remained in the ICU for initiation of the protocol. On ___ BP was better controlled with PO medications. He was transferred to the floor. On ___ Patinet reamined stable. Repeat K and Mag was repleted. He was hypertensive to 180s which was resolved with 20mg hydralazine. His brace arrived and he was evaluate by ___. On ___ ___ recommended that the patient be evaluated by OT. On ___ the patient was transferred out of the step-down unit. On ___ the patient was seen and evaluated and was neurologically satable. He was offered a bed at rehab which was accepted and he was discharged to rehab on the afternoon of ___. Prior to discharge all questions were answered and he was given instructions for followup. Medications on Admission: atenolol 25', lasnix 40', amlodipine 2.5', glucoasmine 1500', omeprazole 20', tamsulosin 0.4', travatan Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN pain 2. Amlodipine 2.5 mg PO DAILY 3. Atenolol 25 mg PO DAILY 4. Docusate Sodium (Liquid) 100 mg PO DAILY:PRN constipation 5. Heparin 5000 UNIT SC TID 6. HydrALAzine ___ mg IV Q6H:PRN SBP>160 7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 8. Omeprazole 20 mg PO DAILY 9. Sarna Lotion 1 Appl TP QID:PRN itching 10. Tamsulosin 0.4 mg PO QHS Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: L2 fracture Right Subdural hematoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Activity You must wear your brace at all times when out of bed. You may apply your brace sitting at the edge of the bed. You do not need to sleep with it on. You must wear your brace while showering. We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. You make take leisurely walks and slowly increase your activity at your own pace. ___ try to do too much all at once. No driving while taking any narcotic or sedating medication. No contact sports until cleared by your neurosurgeon. Medications Please do NOT take any blood thinning medication (Aspirin, Plavix, Coumadin) until cleared by the neurosurgeon. You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. Do NOT take any NSAIDs like Motrin, Ibuprofen, or Advil until cleared by your neurosurgeon. It is important to increase fluid intake while taking pain medications. We also recommend a stool softener like Colace. Pain medications can cause constipation. What You ___ Experience: You may have difficulty paying attention, concentrating, and remembering new information. Emotional and/or behavioral difficulties are common. Feeling more tired, restlessness, irritability, and mood swings are also common. Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. If you are taking narcotics (prescription pain medications), try an over-the-counter stool softener. When to Call Your Doctor at ___ for: Fever greater than 101.5 degrees Fahrenheit Nausea and/or vomiting Extreme sleepiness and not being able to stay awake Severe headaches not relieved by pain relievers Seizures Any new problems with your vision or ability to speak Weakness or changes in sensation in your face, arms, or leg Call ___ and go to the nearest Emergency Room if you experience any of the following: Sudden numbness or weakness in the face, arm, or leg Sudden confusion or trouble speaking or understanding Sudden trouble walking, dizziness, or loss of balance or coordination Sudden severe headaches with no known reason Followup Instructions: ___
10018684-DS-7	10,018,684	26,649,049	DS	7	2118-09-20 00:00:00	2118-09-22 16:37:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: RLE edema, incidental tachycardia Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ with hx asthma, OSA, and morbid obesity now presenting with tachycardia and ___ swelling. He presented to ___ clinic on ___ with RLE swelling for the last month. He also complained of pain on the medial aspect of the R ankle, with intermittent tightness, swelling and mild pain on the calf. He had been taking ibuprofen 800mg for pain. No recent injury or trauma, though he did have an ankle injury from an accident 5 months ago. In the PCP's office, he was noted to have tachycardia with heart rate 142. Last recorded clinic HR 70 in ___. No palpitations, chest pain, SOB. Denied ingestions other than coffee and energy drinks. who presented from clinic with one month of right lower extremity pain, dyspnea, and ___ swelling. He reports that these symptoms have been present for the past several weeks. He denies chest pain, fevers, cough, abdominal pain. He does get short of breath with exertion but this does appear stable. In the ED, initial vitals: 98.0 140 121/85 18 100% RA -Labs were significant for: - Na 138 K 4.3 Cl 102 CO2 27 BUN 12 Cr 1.0 - WBC 7.4 Hgb 12.1 Hct 38.3 Plt 343 - TSH 1.2 - D dimer 2217 - proBNP 811 - Trop < 0.01 - UA: protein 30 - EKG: atrial tachycardia, RBBB -Imaging notable for ___ with no DVT, CXR with possible central pulmonary vascular engorgement, CTA with motion artifact but no large PE. CT abd/pelvis showed no central DVT. -In the ED, he received: Acetaminophen 1000 mg, IVF 1000 mL NS x 2, IV Metoprolol Tartrate 5 mg x 3, PO Metoprolol Tartrate 25 mg, IV Morphine Sulfate 4 mg -Vitals prior to transfer: 131 100/63 17 97% RA On arrival to floor, patient endorses no acute complaints. No chest pain, no SOB. Denies palpitations. He reports that leg swelling has been ongoing for months but has been worse over the last 2 weeks. ROS: As per HPI, otherwise negative Past Medical History: ASTHMA SLEEP APNEA VARICOSE VEINS OBESITY - MORBID Social History: ___ Family History: Brother ___ - Type II; Hypertension Mother ___ - Type II Physical Exam: ADMISSION EXAM VS: 98.1 145/95 120 20 97RA GEN: Alert, sitting in bed, no acute distress HEENT: Moist MM, anicteric sclerae, no conjunctival pallor NECK: Supple without LAD. JVP not appreciated. PULM: Generally CTA b/l without wheeze or rhonchi COR: RRR (+)S1/S2 no m/r/g ABD: Soft, non-tender, non-distended EXTREM: Warm, well-perfused, R>L 2+ lower extremity edema. Bilateral varicose veins. NEURO: CN II-XII grossly intact, motor function grossly normal DISCHARGE EXAM VS: 98.1 99.8 130-140/90s ___ 20 100CPAP GEN: NAD, lying in bed HEENT: anicteric sclerae, no conjunctival pallor NECK: Supple. JVP unable to be assessed given body habitus PULM: CPAP on, CTAB COR: tachycardic, mostly regular occasional aberration, (+)S1/S2 no m/r/g ABD: obese abdomen, soft, NTND; several tattoos, nontender reducible umbilical hernia EXTREM: Warm, well-perfused, 1+ pitting edema around bilateral ankles; trace up ___ shins. Bilateral varicose veins. NEURO: not assessed Pertinent Results: ADMISSION LABS ============== ___ 09:45PM BLOOD WBC-7.4 RBC-4.35* Hgb-12.1* Hct-38.3* MCV-88 MCH-27.8 MCHC-31.6* RDW-14.5 RDWSD-46.3 Plt ___ ___ 09:45PM BLOOD Neuts-62.6 ___ Monos-7.4 Eos-1.9 Baso-0.7 Im ___ AbsNeut-4.63 AbsLymp-2.00 AbsMono-0.55 AbsEos-0.14 AbsBaso-0.05 ___ 09:45PM BLOOD Glucose-91 UreaN-12 Creat-1.0 Na-138 K-4.3 Cl-102 HCO3-27 AnGap-13 ___ 09:45PM BLOOD proBNP-811* ___ 09:45PM BLOOD cTropnT-<0.01 ___ 09:45PM BLOOD D-Dimer-2217* ___ 09:45PM BLOOD TSH-1.2 ___ 03:50AM URINE Color-Yellow Appear-Clear Sp ___ ___ 03:50AM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 03:50AM URINE RBC-<1 WBC-0 Bacteri-NONE Yeast-NONE Epi-<1 ___ 03:50AM URINE Hours-RANDOM Creat-216.9 TotProt-19 Prot/Cr-0.1 DISCHARGE LABS ============== ___ 06:20AM BLOOD WBC-7.5 RBC-4.20* Hgb-11.6* Hct-37.0* MCV-88 MCH-27.6 MCHC-31.4* RDW-14.4 RDWSD-45.8 Plt ___ ___ 06:20AM BLOOD Plt ___ ___ 06:20AM BLOOD ___ PTT-37.0* ___ ___ 06:20AM BLOOD Glucose-93 UreaN-17 Creat-1.1 Na-135 K-4.6 Cl-99 HCO3-30 AnGap-11 ___ 06:20AM BLOOD ALT-25 AST-23 LD(LDH)-234 AlkPhos-60 TotBili-0.5 ___ 06:20AM BLOOD Albumin-3.5 Calcium-8.8 Phos-4.2 Mg-2.1 STUDIES/IMAGING =============== ___ Cardiovascular ECHO: Very poor quality images. The right heart was completely nonvisualized. The left atrium is mildly dilated. The estimated right atrial pressure is at least 15 mmHg. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF = 65%). There is considerable beat-to-beat variability of the left ventricular ejection fraction due to an irregular rhythm. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve is not well seen. There is no aortic valve stenosis. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. ___ Cardiovascular ECG: Atrial flutter with variable A-V conduction delay. Right bundle-branch block. Left anterior fascicular block. Compared to the previous tracing of ___ the rhythm is more clearly atrial flutter with variable block today, although I suspect that the prior ECG also represents atrial flutter with 2:1 A-V conduction as it is more difficult to appreciate due to the more rapid rate. Clinical correlation is suggested. ___BD & PELVIS W & W/O: No central or peripheral DVT identified although examination is moderately limited by body habitus and evaluation of the pelvis is also limited by streak artifact from residual contrast in the bladder. ___ Imaging CTA CHEST: 1. Limited exam. No evidence of central pulmonary embolism. Evaluation of the segmental and subsegmental pulmonary arteries is limited by respiratory motion. 2. 4 mm left upper lobe pulmonary nodule. 3. Borderline enlarged mediastinal lymph nodes may be reactive. Correlate with clinical symptoms ___ Imaging UNILAT LOWER EXT VEINS: No evidence of deep venous thrombosis in the right lower extremity veins. ___ Imaging CHEST (PORTABLE AP): Suboptimal study due to underpenetration presumed secondary to patient body habitus. Enlarged cardiomediastinal silhouette. Possible underlying mediastinal lipomatosis. Possible central pulmonary vascular engorgement. ___ Cardiovascular ECG: Probable sinus tachycardia. Right bundle-branch block. Possible prior inferior wall myocardial infarction. No previous tracing available for comparison. Brief Hospital Course: This is a ___ year old male with past medical history of OSA, morbid obesity admitted ___ w new atrial flutter, status post initiation and uptitration of rate control agents, started on rivaroxaban for anticoagulation, seen by cardiology and recommended for outpatient cardioversion, able to be discharged home. # Atrial flutter: On admission, HR up to 130-140s. Refractory to multiple metop IV pushes and PO 25 metop in ED. Negative trops x2. TSH WNL. ___, CTA negative for DVT despite elevated d-dimer. No changes with carotid massage or vasalva, still persistent despite increasing doses of dilt. TTE results as aforementioned. Patient eventually stabilized with dilt 240mg BID, metop succinate 200mg BID with HR in 80-90s and SBPs 120-130s. Patient was initially started on apixiban, then switched to rivaroxaban given limited data of apixiban in obese patients. Given high risk for anesthesia and TEE plus DCCV, it was decided patient would undergo potential DCCV at a later date. In addition to the aforementioned recommendations, Atrius cardiology also recommended starting Lasix 20mg QD and aldactone 25mg QD which patient tolerated well. # Acute diastolic CHF - Patient admitted with reports of worsening ___ edema. Patient underwent TTE and was seen by ___ cardiology for above---they felt that this was most likely acute diastolic CHF and recommended initiation of Lasix and aldactone. Would consider rechecking electrolytes within 2 weeks of discharge. # OSA: Continued on CPAP at night. Counseled on importance of weight loss. Met with nutritionist for further discussions of healthy lifestyle changes to help risk reduction in heart disease and modification of other risk factors. Transitional Issues: - CTA Chest ___ showed: "4 mm left upper lobe pulmonary nodule. Borderline enlarged mediastinal lymph nodes may be reactive. Correlate with clinical symptoms. RECOMMENDATION(S): Per ___ guidelines for ___ of pulmonary nodules, if no risk factors for malignancy, no followup is recommended. If risk factors, recommend followup CT in ___ year." - QTc was ~ 460ms during this admission; would avoid Qtc prolonging agents if possible; can consider rechecking in the future - Please check Chem-10 at PCP ___ for ___ and K+ assessment since he has been started on diuretics; please also check INR (1.7 at discharge for unclear reasons) - Dr. ___ arrange to see this patient in ___ weeks for ___ and to discuss cardioversion - Contact: ___, wife, ___ - Full Code Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ibuprofen 800 mg PO Q12H:PRN pain 2. Methocarbamol 500 mg PO Q6H:PRN muscle cramps Discharge Medications: 1. Rivaroxaban 20 mg PO DINNER RX rivaroxaban [Xarelto] 20 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 2. Diltiazem Extended-Release 120 mg PO Q12H RX diltiazem HCl 120 mg 1 capsule(s) by mouth every twelve (12) hours Disp #60 Capsule Refills:0 3. Furosemide 20 mg PO DAILY RX furosemide 20 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 4. Metoprolol Succinate XL 200 mg PO Q12H RX metoprolol succinate 200 mg 1 tablet(s) by mouth every twelve (12) hours Disp #60 Tablet Refills:0 5. Spironolactone 25 mg PO DAILY RX spironolactone 25 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: - Atrial flutter - Acute diastolic CHF - Obstructive sleep apnea - morbid obesity Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to the ___ after being found to have an abnormally fast heart rate. Electrocardiogram (or EKG) of your heart showed that your heart was in a rhythm called atrial flutter. You were given medications to help slow down your heart; these medications are Diltiazem and Metoprolol. You were also started on a blood thinner called Xarelto (rivaroxaban); this is to prevent blood clots from forming in your heart and causing a stroke, which is sometimes a complication associated with the irregular rhythm. Please do not discontinue any of these medications until instructed to do so by a cardiologist. You were also started on two medications to help reduce the swelling in your legs. Your doctors ___ to come in for blood work from time to time to assess your electrolytes. Finally, you were seen by nutrition for dietary education. You had liver enzymes that were normal. It was a pleasure taking part in your care, Your ___ Team Followup Instructions: ___
10018845-DS-16	10,018,845	21,101,111	DS	16	2184-10-11 00:00:00	2184-10-11 14:50:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Slurred speech. Major Surgical or Invasive Procedure: Two left burr holes and evacuation of subdural hematoma on ___. History of Present Illness: ___ y/o M hx CAD, HTN, HLD and stage V CKD on ASA 81 presents with word finding difficulty and lethargy over the past ___ weeks. Pt and family states that he has fallen twice that they can recall in that time frame and also few more times within the past year, last fall 2 days before presentation. Pt denies any LOC during these falls. Pt denies numbness weakness, nausea and vomiting, blurred vision, double vision, dizziness. Past Medical History: HTN Hyperlipidemia BPH- pt is ? s/p TURP (pt could not recall details) . Past Surgical Hx: R total knee replacement Social History: ___ Family History: NC Physical Exam: PHYSICAL EXAMINATION ON ADMISSION: O: T:98.0 BP: 132/79 HR: 71 RR:22 O2Sats:100% Gen: WD/WN, comfortable, NAD. HEENT: normocephalic, atraumatic Neck: Supple. Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. frequent problems with word finding. Difficulty naming low frequency objects. mild dysarthria with frequent paraphasic errors. Cranial Nerves: I: Not tested. II: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. Visual fields not tested. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Mild right facial droop. sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power ___ throughout. No pronator drift Sensation: Intact to light touch bilaterally. Toes downgoing bilaterally. Coordination: normal on finger-nose-finger, rapid alternatinng movements. PHYSCIAL EXAMINATION ON DISCHARGE: Alert and oriented x3. Speech clear. Comprehension intact. CN II-XII grossly intact. Motor examination full strength throughout all four extremities. Incisions: Closed with nylon sutures. Clean, dry and intact without edema, erythema or discharge. Pertinent Results: CT Head: ___ Large left holohemispheric chronic SDH with subacute components, maximal thickness of 2.4cm with 1cm midline shift. CT Head: ___ Status post evacuation of left subdural collection with air and fluid now occupying the left subdural space. Although overall the midline shift has mildly decreased, there is a focal area of increased mass effect of the left frontal lobe caused by pneumocephalus. CT Head: ___ 1. Stable postoperative changes after evacuation of left subdural hematoma including a large amount of pneumocephalus. 2. No new hemorrhage. 3. Stable mass effect including 7 mm of subfalcine herniation. Brief Hospital Course: The patient was admitted to the ICU for close monitoring on the day of presentation, ___. She received a loading dose of Dilantin and was continued on Dilantin three times daily. On ___, the patient was taken to the operating room and underwent burr holes on the left for evacuation of the subdural hematoma. A post-operative head CT was obtained and showed post-operative changes and was negative for active hemorrhage. On ___, the patient remained neurologically stable. Subcutaneous Heparin was started for DVT prophylaxis. It was determined he would be transferred to the floor and evaluated by ___ and OT for dispo planning. On ___, the patient's urine culture was negative for growth and the IV Ceftriaxone was discontinued. A Head CT was obtained and was stable. He was evaluated by ___ who recommended discharge to rehabilitation. The case management team are screening him for facilities. On ___, the patient continued with urinary incontinence, which is his baseline. It was determined he would be discharged to rehabilitation later today. Medications on Admission: Asa 81 mg PO daily Doxazosin 8mg PO daily, Simvastatin 40mg PO daily Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN pain; fever Do not exceed greater than 4g Acetaminophen in a 24-hour period. 2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 3. Docusate Sodium 100 mg PO BID 4. Doxazosin 8 mg PO HS 5. Heparin 5000 UNIT SC TID 6. HydrALAzine ___ mg IV Q6H:PRN SBP >160 Goal SBP <160. 7. Ondansetron 4 mg IV Q8H:PRN nausea; vomiting 8. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain Hold for sedation, drowsiness or RR <12. 9. Senna 8.6 mg PO BID:PRN constipation 10. Simvastatin 40 mg PO DAILY 11. LeVETiracetam 500 mg PO BID Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Chronic Subdural Hematoma Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Craniotomy for Hemorrhage: Have a friend/family member check your incision daily for signs of infection. Take your pain medicine as prescribed. Exercise should be limited to walking; no lifting, straining, or excessive bending. Your wound was closed with sutures. You may wash your hair only after sutures have been removed. You may shower before this time using a shower cap to cover your head. Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. If you were on a medication such as Coumadin (Warfarin), or Plavix (clopidogrel), or Aspirin, prior to your injury, you may not resume this medication until cleared by the outpatient neurosurgery office. You have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow-up with laboratory blood drawing in one week. This can be drawn at your PCPs office, but please have the results faxed to ___. You have been discharged on Keppra, an anti-seizure medication. Take this medication as directed. Clearance to drive and return to work will be addressed at your post-operative office visit. Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: New onset of tremors or seizures. Any confusion or change in mental status. Any numbness, tingling, weakness in your extremities. Pain or headache that is continually increasing, or not relieved by pain medication. Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. Fever greater than or equal to 101.5° F. Followup Instructions: ___
10018852-DS-17	10,018,852	23,361,965	DS	17	2119-07-01 00:00:00	2119-07-01 20:05:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ ___ Complaint: Nausea, emesis and abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ year-old male with past medical history of ulcerative colitis s/p laparoscopic proctocolectomy, ileal pouch anal anastomosis with diverting loop ileostomy (___) with subsequent takedown (___) by Dr ___, presenting to the ED on ___ with a 24-hour history of persistent nausea and emesis. Patient states that he has not had a bowel movement or passed any gas since ___ hours ago (normally multiple bowel movements per day). He endorses persistent nausea and bilious emesis since waking up this morning, as well as moderate, pressure-like, abdominal pain, that he has been having intermittently for the past few months. He denies fever, chills, or bright red blood per rectum. Of note, patient stated that in the recent past, he has developed symptoms of "partial obstruction" where he feels constipated, distended, and nauseated. These episodes occur approximately once a month and last for about ___ hours before spontaneously resolving. Also, for the past few months, he had been experiencing occasional rectal and lower abdominal pain, especially when going to the bathroom at night, with some feeling of tightness in the rectum. On his last visit to his gastroenterologist two weeks ago (Dr ___, a possible explanation given to his symptoms was that of pouchitis, for which purpose a ___ had been arranged. Past Medical History: PMH: Ulcerative colitis PSH: ___- Laparoscopic proctocolectomy and mobilization of splenic flexure, ileal pouch anal anastomosis with diverting loop ileostomy. Social History: ___ Family History: He has 2 maternal cousins with underlying inflammatory bowel disease. He has one twin brother and one sister who are in good health. Maternal GF pancreatic cancer 56. Maternal GM breast post menopausal age ___. Paternal GF ? lung ca. Physical Exam: Vitals: VSS on discharge GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, nontender, no rebound or guarding, normoactive bowel sounds, no palpable masses DRE: normal tone, no gross or occult blood Ext: No ___ edema, ___ warm and well perfused Pertinent Results: ___ 09:40PM WBC-11.4* RBC-4.99 HGB-14.5 HCT-43.6 MCV-87 MCH-28.9 MCHC-33.1 RDW-14.7 ___ 09:40PM NEUTS-84.1* LYMPHS-5.6* MONOS-9.9 EOS-0.2 BASOS-0.2 ___ 09:40PM PLT COUNT-208 ___ 01:59PM LACTATE-1.6 ___ 01:49PM LACTATE-1.6 ___ 01:09PM ___ PTT-24.3* ___ ___ 12:50PM GLUCOSE-102* UREA N-14 CREAT-0.9 SODIUM-141 POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-27 ANION GAP-16 ___ 12:50PM estGFR-Using this ___ 12:50PM ALT(SGPT)-22 AST(SGOT)-20 ALK PHOS-86 TOT BILI-0.7 ___ 12:50PM LIPASE-18 ___ 12:50PM ALBUMIN-5.3* ___ 12:50PM WBC-16.4# RBC-5.68# HGB-16.5# HCT-49.6# MCV-87 MCH-29.0 MCHC-33.2 RDW-14.6 ___ 12:50PM NEUTS-89.3 LYMPHS-3.9* MONOS-6.3 EOS-0.3 BASOS-0.3 ___ 12:50PM PLT COUNT-230 Brief Hospital Course: Mr ___ presented to the ED on ___ with nausea, emesis and abdominal pain. Given his history of ulcerative colitis s/p laparoscopic proctocolectomy, ileal pouch anal anastomosis with diverting loop ileostomy (___) with subsequent takedown (___) by Dr ___ was admitted to the floor for conservative management of SBO. CT scan confirmed SBO with transition point at proximal pelvic anastomosis. In the ED he was made NPO, had an NGT placed and was maintained on IV fluids. After a brief and uneventful stay in the ED, the patient was transferred to the floor for further management. Neuro: The patient received IV pain control with good effect. Narcotic medications were avoided. 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: The patient was made NPO, had an NGT placed and received IV fluids. On HD#2 the patient passed gas and had BMs. The NGT was subsequently clamped with 0 residual output. GI was consulted; as per their recommendations the patient would be discharged on a low-residue diet and would follow up with his gastroenterologist Dr. ___ to determine the underlying cause of his condition (stricture versus inflammation). Diet was advanced which was initially well tolerated. For the rest of his stay, patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. Electrolytes were routinely followed, and repleted when necessary. GU:The patient voided without difficulty throughout his hospital stay. ID: The patient's white blood count and fever curves were closely watched for signs of infection. On admission his WBC was 16.4 which when repeated went down to 11.4. On ___, the patient was discharged to home. At discharge, he was tolerating a regular diet, passing flatus, stooling, voiding, and ambulating independently. He will follow-up in clinic. This information was communicated to the patient directly prior to discharge with verbalized understanding and agreement. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. LOPERamide 2 mg PO BID 2. Psyllium Wafer 1 WAF PO BID 3. Tamsulosin 0.4 mg PO HS 4. Ferrous Sulfate 325 mg PO BID Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain do not take more than 3000mg of tylenol in 24 hours Discharge Disposition: Home Discharge Diagnosis: small bowel obstruction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital for a small bowel obstruction. You were given bowel rest and intravenous fluids and a nasogastric tube was placed in your stomach to decompress your bowels. Your obstruction has subsequently resolved after conservative management. 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. You should keep your appointment with Dr. ___ your ___ tomorrow. Please follow the instructions given to you by his office for the bowel prep. After this procedure, Dr. ___ also study the pouch. Please monitor your bowel function closely. 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 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. 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: ___
10018862-DS-19	10,018,862	21,851,498	DS	19	2148-12-08 00:00:00	2148-12-10 16:25:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: clindamycin / naproxen / Sulfa (Sulfonamide Antibiotics) / E-Mycin Attending: ___ Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: EGD ___ History of Present Illness: Ms. ___ is a very pleasant ___ yo female with PMHx NIDDM and Child's A Cirrhosis (previously complicated by variceal bleed s/p banding) who presents today with 1 week of abdominal pain. Ms. ___ first presented to ___ 1 week ago with abdominal pain. She describes a "dull," constant, recurrent upper abdominal pain that is present throughout the day. Changing position somewhat worsens the pain in her belly and Tylenol "helps take the edge off." She notes no relation to PO intake and has been able to tolerate PO, though notes some nausea. She also notes "burning" substernal chest pain yesterday that lasted for ~ 20 minutes and then subsided. She presented to ___ in ___ with the above complaints, was there for 5 days and told she had "inflammation of the pancreas." She eventually left against medical advice because she felt that staff there was rude to her. Her pain persisted on her departure and she presented to ___ ED for further diagnosis and management. Past Medical History: -NIDDM -Prior obesity -Cirrhosis -Variceal bleed ___: At ___ presented with coffee ground emesis and melena and was found to have grade II varices, banded x3. Also with gastric erosion noted with contact bleeding that required clipping per report. No description of high risk stigmatata or active bleeding, no biopsies taken. -Chronic back pain after a fall ___ years ago. Is on disability and ambulates with a walker. -? CAD: She was seen at ___ several months ago with chest pain and underwent exercise stress test. She was told she has "angina" and was given PRN nitro. -Asthma -Anxiety -GERD -Prior obesity -Osteporosis -Gout Past Surgical History -Appendectomy -Hysterectomy -c/s x3 Social History: ___ Family History: Mother: heart attackx3 Father: stroke Brother who died secondary to alcohol cirrhosis Brother with ___ cancer Daughter thinks she may have fatty liver disease Physical Exam: ADMISSION PHYSICAL EXAM: VS: Temp 98.2 BP 116/70 HR 84 RR 20 SaO2 97%Ra GENERAL: Well-appearing woman in NAD. AAOx3, pleasant and conversational. Able to recite days of week forwards and backwards without issue 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. Tender ___ depression noted over right 10th rib. ABDOMEN: Redundant skin folds. Soft, non-distended, no discernible bulging flanks or fluid wave noted. Tenderness with voluntary guarding in epigastrium. No hepatomegaly appreciated. EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ DP pulses bilaterally NEURO: Moving all 4 extremities with purpose. No asterixis. SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAM: VS: 98.4 104 / 70 73 18 97 Ra GENERAL: Lying in bed, appears comfortable and relatively well. HEENT: poor dentition, thin hair. No scleral icterus Cardiac: Normal S1 and S2. Pulmonary: Clear to auscultation without rales, rhonchi, wheezing or diminished breath sounds. Abdomen: soft, mildly tender to palpation of abdomen in the epigastric area. Neuro: Alert and oriented x3. No gross focal deficits. No asterixis. Skin: no rashes Pertinent Results: ADMISSION LABS =============== ___ 08:36PM BLOOD WBC-4.7 RBC-4.29 Hgb-12.1 Hct-38.4 MCV-90 MCH-28.2 MCHC-31.5* RDW-17.8* RDWSD-58.3* Plt ___ ___ 08:36PM BLOOD Neuts-55.8 ___ Monos-9.0 Eos-3.0 Baso-0.6 Im ___ AbsNeut-2.61 AbsLymp-1.47 AbsMono-0.42 AbsEos-0.14 AbsBaso-0.03 ___ 08:36PM BLOOD Plt ___ ___ 08:36PM BLOOD Glucose-197* UreaN-5* Creat-0.6 Na-143 K-4.2 Cl-105 HCO3-22 AnGap-16 INTERVAL LABS ============== ___ 01:40PM BLOOD ALT-17 AST-44* AlkPhos-84 TotBili-0.7 ___ 01:40PM BLOOD Lipase-66* ___ 01:40PM BLOOD Albumin-2.9* ___ 06:35AM BLOOD Albumin-2.6* Calcium-8.4 Phos-3.8 Mg-1.5* ___ 06:28AM BLOOD CK-MB-2 cTropnT-<0.01 IMAGING ======= CT A/P ___ IMPRESSION: 1. The liver has a nodular border. The spleen is enlarged. Gastric varices are evident. There is a small amount of ascites. Findings are most compatible with cirrhosis and portal hypertension. 2. Sub cm right renal lesions which are too small for accurate characterization but statistically likely represent tiny cysts. 3. Diverticulosis. ___ ___ IMPRESSION: 1. Cirrhotic liver morphology with sequela of portal hypertension including splenomegaly and intra-abdominal varices. 2. No suspicious focal hepatic lesion. 3. No evidence of pancreatitis. DISCHARGE LABS ============== ___ 06:09AM BLOOD WBC-3.8* RBC-3.92 Hgb-11.4 Hct-34.7 MCV-89 MCH-29.1 MCHC-32.9 RDW-17.3* RDWSD-55.6* Plt ___ ___ 06:09AM BLOOD Plt ___ ___ 06:28AM BLOOD ___ PTT-34.8 ___ ___ 06:09AM BLOOD Glucose-133* UreaN-8 Creat-0.6 Na-142 K-4.4 Cl-105 HCO3-26 AnGap-11 ___ 06:09AM BLOOD ALT-13 AST-28 AlkPhos-87 TotBili-0.5 ___ 06:09AM BLOOD Albumin-2.9* Calcium-8.7 Phos-3.4 Mg-1.9 Brief Hospital Course: Ms. ___ is a ___ year old woman with likely NASH Childs B cirrhosis c/b ascites and esophageal variceal bleeding, who presents with acute abdominal pain with negative workup thus far, except portal gastropathy. #Acute abdominal Pain: Patient presents with an episode of acute abdominal pain. These episodes have been occurring frequently, with multiple hospitalizations. Testing prior to this admission thus far had been unrevealing (multiple CTs abdomen/pelvis, CTAs of chest, and a stress test to rule out cardiac etiology). Low suspicion for gyn pathology given hysterectomy ___ years ago. EGD was done and revealed evidence of portal gastropathy and varices, but no ulcers. MRCP showed no evidence biliary pathology. Unlikely pancreatitis (looks extremely well and CT/MRCP not supportive). Unlikely that pain could be due to metformin side effect. Patient treated supportively with Maalox and PPI. Amitryptiline was started at night for pain control in case there was a component of nerve involvement. She will need follow up with GI on discharge for monitoring, further evaluation, and pain management. #NASH Cirrhosis: Patient with Child's B cirrhosis, no biopsy proven diagnosis but likely NASH given her history of obesity and metabolic syndrome with HTN and T2DM. She presented with volume overload, with edema, mild ascites and varices. She had ascites on imaging, not previously seen on prior workup, however there was no pocket to tap. She had not been taking her home spironolactone and Lasix for a month prior to admission. Started on home spironolactone and double Lasix dose to BID dosing. Edema improved and she was discharged with home Lasix dosing. EGD with evidence of varices as above. #?CAD: Patient with recent history of "angina". Stress test was performed ___ negative, therefore this is not a fair diagnosis. Troponin negative at OSH and on this admission on ___. # GERD: Continued Omeprazole 20 mg PO DAILY. Maalox given for symptomatic relief. # DM II: Home metformin was held on admission. Patient was given ISS. Transitional issues: ================================= [ ] Patient was not taking Lasix or spironolactone at home. Please follow up volume status, blood pressure, and chemistry panel at follow up appointment and adjust dosing as appropriate. [ ] Continue to work up abdominal pain as outpatient [ ] PCP and GI follow up [ ] Consider referral to pain clinic for chronic abdominal pain of unknown etiology. [ ] Needs HBV vaccine series. [ ] Discharge weight: 145.94 lb [ ] Discharge Cr: 0.6 NEW MEDS: - Amitriptyline 25 mg PO/NG QHS - Acetaminophen 1000 mg PO/NG Q8H - Lidocaine 5% Patch 1 PTCH TD QAM - Maalox/Diphenhydramine/Lidocaine 15 mL PO TID RESTARTED MEDS (wasn't taking for 1 month): - Furosemide 20 mg PO/NG DAILY - Spironolactone 50 mg PO/NG BID #CONTACT: ___ Phone number: ___ #CODE: Full (confirmed) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. MetFORMIN (Glucophage) 1000 mg PO BID 2. Ferrous Sulfate 325 mg PO DAILY 3. Furosemide 20 mg PO DAILY 4. Spironolactone 50 mg PO BID 5. Omeprazole 20 mg PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H RX acetaminophen 500 mg 2 tablet(s) by mouth every 8 hours Disp #84 Tablet Refills:0 2. Amitriptyline 25 mg PO QHS RX amitriptyline 25 mg 1 tablet(s) by mouth every night before bed Disp #28 Tablet Refills:0 3. Maalox/Diphenhydramine/Lidocaine 15 mL PO TID abdominal pain RX calcium carbonate-simethicone [Antacid Anti-Gas (ca ___ 1,000 mg-60 mg 15 mL by mouth three times a day Disp #2 Bottle Refills:0 4. Ferrous Sulfate 325 mg PO DAILY 5. Furosemide 20 mg PO DAILY RX furosemide 20 mg 1 tablet(s) by mouth daily Disp #28 Tablet Refills:0 6. MetFORMIN (Glucophage) 1000 mg PO BID 7. Omeprazole 20 mg PO DAILY 8. Spironolactone 50 mg PO BID RX spironolactone 50 mg 1 tablet(s) by mouth two times a day Disp #56 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS Idiopathic Acute Abdominal Pain SECONDARY DIAGNOSES NASH Cirrhosis GERD Diabetes Mellitus Type II Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure taking part in your care here at ___! Why was I admitted to the hospital? ====================================== -You were admitted for belly pain. What happened to me in the hospital? ====================================== -A "CT Scan" of your belly was done, which did not show any signs of intestinal obstruction or infection. It did show cirrhosis of your liver. -An endoscopy was done to look at your esophagus, stomach, and intestines. No ulcers were seen. No bleeding was seen. There were signs of dilated veins in your esophagus, which are called varices. -An MRI of your liver was done, which showed a normal pancreas, and liver cirrhosis. What should I do when I leave the hospital? ====================================== -Please take all of your medicines as prescribed. -Please follow up with a GI doctor, as listed in the appointments below. -Please follow up with your new PCP, as listed in the appointments below. -You will need labs at your next appointment. -Please do NOT smoke or drink alcohol. -Please try to avoid fatty/fried foods. You should avoid eating right before bedtime. When should I come back to the hospital? ====================================== -You should come back to the hospital if you have worsening abdominal pain, fevers. Sincerely, Your ___ Treatment Team Followup Instructions: ___
10018862-DS-25	10,018,862	29,501,040	DS	25	2149-06-24 00:00:00	2149-06-25 05:51:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: clindamycin / naproxen / Sulfa (Sulfonamide Antibiotics) / E-Mycin / ibuprofen Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ year old woman with a h/o HTN, NIDDM, ___ cirrhosis ___ class A), complicated by ascites and esophageal variceal bleeding in ___, s/p banding x 3, with recent admission for esophageal stricture s/p dilation on ___ who presented with abdominal pain. Patient was recently admitted ___ for abdominal pain. A CT on admission revealed short segment colitis but no hepatobiliary pathology, ascites, or gastric abnormalities to explain her symptoms. She was discharged with a course of cipro and flagyl. She also reports another admission to ___, discharged ___ with an "infection in her ___ She was discharged on Augmentin but has been unable to take any of her medications due to nausea and pain. She reports feeling weak and tired and is having trouble walking. She is having sharp, diffuse abdominal pain worse on the left side. It is constant but fluctuates in intensity. Her last bowel movement was this morning and she reports it was "all water." She reports some occasional nausea. She denies fever, chest pain, SOB, cough, vomiting, BRBPR, melena, or dysuria. Past Medical History: -NIDDM -Cirrhosis, ___ class A -Variceal bleed ___: At ___ presented with coffee ground emesis and melena and was found to have grade II varices, banded x3. Also with gastric erosion noted with contact bleeding that required clipping per report. No description of high risk stigmatata or active bleeding, no biopsies taken. -Chronic back pain after a fall ___ years ago. Is on disability and ambulates with a walker. -? CAD: She was seen at ___ with chest pain and underwent exercise stress test. She was told she has "angina" and was given PRN nitro. -Asthma -Anxiety -GERD -Prior obesity -Osteoporosis -Gout -Appendectomy -Hysterectomy -c/s x3 Social History: ___ Family History: Mother: heart attackx3 Father: stroke Brother who died secondary to alcohol cirrhosis Brother with ___ cancer Daughter thinks she may have fatty liver disease Physical Exam: ADMISSION PHYSICAL EXAM: VS: reviewed in OMR GEN: NAD, interactive, alert HEENT: MMM, poor dentition with decaying bottom teeth & several missing teeth, Sclera anicteric, EOM, PERRL Resp: breathing comfortably on room air, clear to auscultation bilaterally CV: regular rate and rhythm ___ systolic murmur best heard at left upper sternal border GI: non-distended, bowel sounds present, mildly tender to palpation in epigastrium, tender to deep palpation in LLQ otherwise abdomen soft and nontender, no rebound tenderness or guarding, liver not palpated, no splenomegaly appreciated. MSK: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: no rashes, no palmar erythema, no spider angiomata, non tender nodule in left palm Neuro: A&Ox3, moving extremities w/ purpose Pertinent Results: ADMISSION LABS ================== ___ 01:30PM BLOOD WBC-4.0 RBC-3.62* Hgb-11.0* Hct-31.8* MCV-88 MCH-30.4 MCHC-34.6 RDW-13.4 RDWSD-43.4 Plt ___ ___ 01:30PM BLOOD Neuts-59.3 ___ Monos-10.3 Eos-0.5* Baso-0.3 Im ___ AbsNeut-2.38 AbsLymp-1.17* AbsMono-0.41 AbsEos-0.02* AbsBaso-0.01 ___ 01:30PM BLOOD Plt ___ ___ 01:30PM BLOOD Glucose-129* UreaN-7 Creat-0.7 Na-141 K-3.8 Cl-108 HCO3-18* AnGap-15 ___ 01:30PM BLOOD estGFR-Using this ___ 01:30PM BLOOD ALT-12 AST-26 AlkPhos-69 TotBili-0.8 ___ 01:30PM BLOOD Lipase-59 ___ 01:30PM BLOOD Albumin-3.0* ___ 01:53PM BLOOD Lactate-2.8* DISCHARGE LABS ================== ___ 05:20AM BLOOD WBC-3.0* RBC-3.28* Hgb-9.8* Hct-29.4* MCV-90 MCH-29.9 MCHC-33.3 RDW-13.8 RDWSD-45.2 Plt ___ ___ 05:20AM BLOOD Plt ___ ___ 05:20AM BLOOD ___ PTT-31.9 ___ ___ 05:20AM BLOOD Glucose-88 UreaN-8 Creat-0.7 Na-143 K-3.7 Cl-111* HCO3-21* AnGap-11 ___ 05:20AM BLOOD ALT-10 AST-22 LD(LDH)-144 AlkPhos-60 TotBili-0.4 ___ 05:20AM BLOOD cTropnT-<0.01 ___ 05:20AM BLOOD Albumin-2.6* Calcium-7.9* Phos-3.8 Mg-1.5* IMAGING ================= ___ CT ABD/PELVIS IMPRESSION: 1. Sigmoid diverticulosis with essentially complete resolution of previously noted pericolonic fat stranding and hyperenhancement of the sigmoid ___. No evidence of acute intra-abdominal or intrapelvic process to explain the patient's current symptoms. 2. Cirrhotic liver with splenomegaly. Brief Hospital Course: ___ year old woman with a h/o HTN, NIDDM, ___ ___ class A), complicated by ascites and esophageal variceal bleeding in ___, s/p banding x 3, with recent admission for esophageal stricture s/p dilation on ___ who presented with recurrent abdominal pain. She left prior to the day team's formal evaluation against medical advise. ACUTE ISSUES: ============= #Acute on chronic abdominal pain: Multiple hospital visits for this complaint with most recent discharge on ___ from Sturdy hosptial. Prior CT showing evidence of short-segment colitis as a potential etiology treated with cipro and flagyl. Recent OSH admission also with persistent colitis as per patient, discharged on Augmentin. CT A/P on this admission without any abnormalities to explain the patient's symptoms. No fevers, leukocytosis to indicate infectious process. Most likely etiology likely an acute exacerbation of patient's gastroparesis vs. residual pain from prior bout of colitis. During an earlier admission started on reglan with only minimal improvement in symptoms as per patient. Low suspicion for ACS given unremarkable EKG. On the morning of ___, prior to the patient's evaluation, she refused Tylenol for pain and then asked to leave against medical advise as she "didn't want to sit in the hospital in pain when she could just do it at home." She was counseled on the risk of leaving prior to full examination, including worsening infection or missing a severe issue with her bowels. She voice understanding of these concerns and able to repeat them back. She continued to insist on leaving. She called her daughter for a ride. Overall low suspicion with initial work-up for life-threatening condition. She was continued on home hyoscyamine 0.125 mg, metoclopramide 5 mg PO/NG BID, simethicone 40-80 mg PO/NG QID:PRN abd pain, omeprazole 40mg BID and augmentin. Her reglan was held due to long QTc and no repeat EKG to verify. #___ Cirrhosis: Childs A, history of ascites, and esophageal variceal bleeding ___ s/p banding x3. No prior history of HE. No evidence of decompensation on examination on admission. Hepatology did not suspect underlying cirrhosis as a cause #Gap acidosis: lactate elevated, also likely ketosis ___ starvation. S/p 1L NS in the ED. She left against medical advise prior to further work up and evaluation CHRONIC ISSUES: =============== #NIDDM: held home metformin and start ISS #Back pain/Chronic lumbar and cervical pain: Previously on opioid contract at ___ but has not been filled since ___. ___ shows recent filled Rx for oxycodone from >6 providers in last 6 months so discontinued narcotics during prior admission. Narcotics were not used for pain control while in house. # Type 2 Diabetes mellitus Last A1c 7.1% on ___. On metformin 500 mg BID at home, though this had been discontinued during previous sturdy admission to avoid stomach upset. # GERD - omeprazole 40 mg PO BID TRANSITIONAL ISSUES ======================= [] Left against medical advice [] Should try to attend previously scheduled GI appointment with Dr. ___ colonoscopy [] Encouraged to schedule and attend PCP ___ [] On future admissions, would check ___ prior to prescribing narcotic medications #CODE: Full (presumed) #CONTACT: ___ ___, ___daughter) ___ Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing 2. Hyoscyamine 0.125 mg SL QID 3. Metoclopramide 5 mg PO BID 4. Omeprazole 40 mg PO BID 5. Sucralfate 1 gm PO QID 6. Multivitamins 1 TAB PO DAILY 7. MetFORMIN (Glucophage) 500 mg PO BID 8. Furosemide 20 mg PO DAILY 9. Emetrol (phosphorated carbohydrate) 15 mL oral QACHS PRN 10. Simethicone 40-80 mg PO QID:PRN abd pain 11. Senna 8.6 mg PO BID 12. Polyethylene Glycol 17 g PO DAILY:PRN constipation 13. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing 2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H 3. Emetrol (phosphorated carbohydrate) 15 mL oral QACHS PRN 4. Furosemide 20 mg PO DAILY 5. Hyoscyamine 0.125 mg SL QID 6. Multivitamins 1 TAB PO DAILY 7. Omeprazole 40 mg PO BID 8. Polyethylene Glycol 17 g PO DAILY:PRN constipation 9. Senna 8.6 mg PO BID 10. Simethicone 40-80 mg PO QID:PRN abd pain 11. Sucralfate 1 gm PO QID 12. HELD- MetFORMIN (Glucophage) 500 mg PO BID This medication was held. Do not restart MetFORMIN (Glucophage) until you follow-up with your PCP 13. HELD- Metoclopramide 5 mg PO BID This medication was held. Do not restart Metoclopramide until you see your PCP ___: Home Discharge Diagnosis: Primary =========== Abdominal pain Secondary =========== Cirrhosis NIDDM Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were here because you were having abdominal pain. While you were here, you had an imaging study of your stomach called a CT scan which showed improvement in the inflammation in your ___. Unfortunately, you left against medical advice before we were able to evaluate your abdominal pain. We had a detailed conversation about the risks of leaving AMA. You verbalized understanding and wished to leave anyway When you leave, please continue your previously prescribed antibiotics. If you are not able to eat or drink, please come back to the ER. Please attend your previously scheduled GI appointment with Dr. ___. We wish you the best of luck. Your ___ Care Team Followup Instructions: ___
10019003-DS-17	10,019,003	27,525,946	DS	17	2153-04-20 00:00:00	2153-04-25 20:27:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Wellbutrin / sertraline Attending: ___. Chief Complaint: GI Bleed Major Surgical or Invasive Procedure: Endoscopy ___ embolization History of Present Illness: Ms. ___ is a ___ old woman with a past medical history of metabolic syndrome, COPD, HTN, HLD, breast cancer (T1N0M0, ER+/PR+, HER2-) s/p lumpectomy and adjuvant XRT, and more recently dx undifferentiated myeloproliferative disorder, atypical CML versus CNL. She was recently admitted to ___ FICU and OMED after episode of diarrhea and rash felt to be medication related possibly allopurinol. She developed dysuria and presented to ___ w/ leukocytosis 100K. She was transferred to ___ ED then FICU for sepsis requiring vasopressors. Smear reviewed by heme did not show any blasts thus hyperleukocytosis felt to be a leukamoid response to infection rather than transformation. Hydroxyurea was stopped due to concern for drug rash and she started jakafi ___. Regarding sepsis she was treated with cipro/flagyl for Klebsiella UTI (Cx+ ___ at BI remained negative. BP stabilized and she was transferred to floor but course then complicated by melena requiring 5u pRBCs s/p EGD ___ showing duodenal ulcer treated w/ thermal therapy. started on PPI. DC Hct 27 She also had hypoxia felt to be volume overload which improved with diuresis and ___ w/ Cr peak a 4.4 felt be prerenal from sepsis, lisinopril was held and Cr improved. Since discharge, still feeling fatigue but had normal BMs x2 days. ___ at midnight had 1 episode of melena, for which she presented to ___ overnight ___. Labs there notable for Hct 25.1 and Cr 0.9. had another episode melena today at 3am. She was discharged w/ plan to present to ___ ED. Initial VS ___ ED 13:12 0 99.1 96 114/66 17 96% RA ___ ED pt received pantoprazole IV and Ativan PO She denies any abdominal pain, fever/chills, lightheadedness, weakness, DOE, chest pain. Only taking clear liquids since she left ___ as instructed, prior to that was eating regular meals. No nausea, vomiting. no other bleeding. Past Medical History: PAST ONCOLOGIC HISTORY: per OMR She was found to have leukocytosis to 38,000 at a pre-operative check for a retinal defect ___ ___. Repeat testing performed on ___ revealed a similar WBC with immature myeloid forms, promyelocytes, myelocytes, metamyelocytes, bands and hypersegmented neutrophils. ___ comparison, a CBC from ___ showed a WBC of 10,000 (no diff) with normal hemoglobin and platelet count. On an MRCP ___ ___, she was incidentally found to have splenomegaly to 15 cm. Given this constellation there was a concern for CP-CML and she therefore underwent testing for BCR-ABL and JAK2 mutation on ___ - both of which returned NEGATIVE. She underwent bone marrow aspiration and biopsy on ___ which showed a markedly hypercellular marrow with myeloid predominant trilineage hematopoiesis and increased megakaryocytes suspicious for a myeloid neoplasm. Mild reticulin staining. IPT showed a nonspecific T cell dominant lymphoid profile. MDS-FISH negative. Normal female karyotype. Mutational testing for SETBP1 and CSF3R were negative. Due to suspected atypical CML vs. CNL and the increased WBC to 80,000 ___ ___, she was started on hydroxyurea 500 mg QD and allopurinol on ___, with a goal to bridge her to ruxolitinib treatment. Notably, she had a significant response with WBC reduction from 80,000 to 40,000 within one week. Past Medical History: Myeloproliferative disorder Hypertension Diabetes mellitus type 2 COPD Hypothyroidism Hypercholesterolemia Depression ___ breast cancer s/p lumpectomy and adjuvant radiation Social History: ___ Family History: Mother died at ___ from cardiac disease. Father died at ___ from CAD, had h/o CVA at ___. Sister died of CAD ___ ___. No significant family history of malignancy. Physical Exam: VS: 97.5, 124/69, 86, 18, 95% RA GEN: NAD HEENT: MMM. Neck supple. Cards: RR S1/S2 normal. Pulm: CTAB no crackles or wheezes Abd: Soft, NT, no rebound/guarding Extremities: no edema. Skin: no rashes or bruising Neuro: AOx3, no focal deficits. Pertinent Results: ADMISSION LABS: =============== ___ 03:40PM BLOOD WBC-57.1* RBC-2.38* Hgb-7.2* Hct-23.7* MCV-100* MCH-30.3 MCHC-30.4* RDW-19.4* RDWSD-67.7* Plt ___ ___ 03:40PM BLOOD Neuts-72* Bands-5 Lymphs-7* Monos-2* Eos-3 Baso-0 ___ Metas-4* Myelos-5* Promyel-2* Other-0 AbsNeut-43.97* AbsLymp-4.00* AbsMono-1.14* AbsEos-1.71* AbsBaso-0.00* ___ 03:40PM BLOOD Hypochr-2+ Anisocy-3+ Poiklo-3+ Macrocy-OCCASIONAL Microcy-3+ Polychr-1+ Schisto-1+ Stipple-OCCASIONAL Tear Dr-2+ How-Jol-OCCASIONAL ___ 03:40PM BLOOD Glucose-91 UreaN-23* Creat-0.9 Na-143 K-4.3 Cl-109* HCO3-27 AnGap-11 ___ 04:34PM BLOOD Type-ART Rates-/___ Tidal V-550 PEEP-5 FiO2-40 pO2-87 pCO2-37 pH-7.39 calTCO2-23 Base XS--1 Intubat-INTUBATED MICROBIOLOGY: ============= Blood cultures: ___ x 2 no growth Urine culture ___ no growth Sputum Culture FINAL REPORT ___ GRAM STAIN (Final ___: >25 PMNs and <10 epithelial cells/100X field. 2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND CLUSTERS. SMEAR REVIEWED; RESULTS CONFIRMED. ___ 6:04 am SEROLOGY/BLOOD Source: Line-picc. FINAL REPORT ___ HELICOBACTER PYLORI ANTIBODY TEST (Final ___: NEGATIVE BY EIA. (Reference Range-Negative). DISCHARGE LABS: =============== ___ 07:00AM BLOOD WBC-64.8* RBC-3.15* Hgb-9.5* Hct-30.4* MCV-97 MCH-30.2 MCHC-31.3* RDW-19.9* RDWSD-67.1* Plt ___ ___ 07:00AM BLOOD Glucose-80 UreaN-5* Creat-0.7 Na-144 K-4.1 Cl-107 HCO3-27 AnGap-14 ___ 07:00AM BLOOD Mg-1.9 IMAGING: ======== Portable CXR ___: 1. The tip of the ETT is seen 2.8 cm above the carina. No pneumothorax 2. Increased left lower lung opacities are concerning for aspiration. Portable CXR ___: ET tube tip is 5 cm above the carinal. NG tube tip is ___ the stomach. There is interval improvement of left basal atelectasis but still there is a persistent left perihilar opacities that might represent residua of aspiration or developing pneumonia. Reassessment of the patient ___ ___ hr is recommended. Mild vascular enlargement is not excluded. Portable CXR ___: Left perihilar consolidation is unchanged. Retrocardiac atelectasis have improved. Vascular congestion is stable. There is no evident pneumothorax. Small left pleural effusion is unchanged. Cardiomediastinal contours are stable. Left PICC tip is ___ the lower SVC Mesenteric arteriogram ___: Successful coil and gel foam embolization of the right gastroepiploic artery and the gastroduodenal artery, with good angiographic result, showing embolization of multiple small vessels that were seen coursing to the area of the known duodenal ulcer. Portable CXR ___ Cardiomediastinal contours are unchanged. Left perihilar and left lower lobe consolidations are unchanged. Mild vascular congestion has improved. Left PICC tip is ___ the lower SVC. There is no evident pneumothorax. Small left effusion is unchanged. Brief Hospital Course: ___ yr old female with undifferentiated myeloproliferative disorder (?atypical CML, extensive testing inc BCR-ABL, Jak2 negative) who was admitted with recurrent upper GI bleed ___ setting of recent duodenal ulcer with an aspiration event requiring intubation. Recurrent Upper GI bleed from Duodenal Ulcer - The patient first underwent and EGD with endoclip and thermal therapy but continued to bleed to then underwent a gastroepiploic embolization by ___. She did require multiple blood transfusions. Her hemoglobin then stabilized. She will continue on a PPI. H.pylori was checked and was negative. Respiratory failure - The patient did have respiratory failure requiring intubation during her EGD and was then transferred to the ICU. She was treated for an aspiration pneumonia with vanc, cefepime, and flagyl. She was later extubated and transferred to the floor. Flagyl was stopped. She then completed a course of vanc and cefepime on ___. Myeloproliferative disorder - Her home ___ was stopped given bleeding after discussion was held with her primary oncologist. Prior to discharge she was re-started on hydrea which she was been on previously per her primary oncologist. She will follow up with oncology as an outpatient. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Escitalopram Oxalate 5 mg PO DAILY 3. Levothyroxine Sodium 75 mcg PO DAILY 4. Simvastatin 10 mg PO 3X/WEEK (___) 5. Tiotropium Bromide 1 CAP IH DAILY 6. Pantoprazole 40 mg PO Q12H 7. Vitamin D ___ UNIT PO DAILY 8. Probiotic Blend (___) 2 million cell-50 mg oral DAILY 9. Multivitamins 1 TAB PO DAILY 10. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY 11. Calcium 500 + D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -200 unit oral QHS 12. ValACYclovir 1000 mg PO Q12H 13. Fish Oil (Omega 3) 1000 mg PO HOME DOSE 14. Jakafi (ruxolitinib) 10 mg oral daily Discharge Medications: 1. Escitalopram Oxalate 5 mg PO DAILY 2. Levothyroxine Sodium 75 mcg PO DAILY 3. Simvastatin 10 mg PO 3X/WEEK (___) 4. Tiotropium Bromide 1 CAP IH DAILY 5. Calcium 500 + D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -200 unit oral QHS 6. Fish Oil (Omega 3) 1000 mg PO HOME DOSE 7. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY 8. Multivitamins 1 TAB PO DAILY 9. Pantoprazole 40 mg PO Q12H 10. Probiotic Blend (___) 2 million cell-50 mg oral DAILY 11. ValACYclovir 1000 mg PO Q12H 12. Vitamin D ___ UNIT PO DAILY 13. Hydroxyurea 500 mg PO DAILY RX hydroxyurea 500 mg 1 capsule(s) by mouth Daily Disp #30 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Leukemia Pneumonia GI Bleed/Ulcer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with a GI bleed from the ulcer that was seen on your last admission. You had an EGD but it continued to bleed so you then had an embolization done by ___ which stopped the bleeding. You also developed a pneumonia which you were treated with antibiotics with. Your jakafi was stopped and you were restarted on hydrea. Followup Instructions: ___
10019061-DS-3	10,019,061	20,965,201	DS	3	2178-03-04 00:00:00	2178-03-04 14:44:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Code stroke right leg weakmess Major Surgical or Invasive Procedure: Left carotid endarterectomy ___ History of Present Illness: ___ year-old right-handed male, past history significant for CAD, s/p CABG, s/p pacemaker, ESRD(not on dialysis) who presents with right leg weakmess. The patient was in his usual state of health and going about his daily routine. He took a nap at noon. Upon awakening he noted that he was stuck on the couch and he could not move his right leg. He used his arms to pull himself near the phone. He then fell off the couch and hit his head. He denies loss of consciousness. He then called ___. He was taken to ___ where a CT scan was performed that showed no acute process. He was then transferred to ___ for further evaluation. BP on arrival was 150/60. He denies any recent illness. On ___ review of systems, the pt denies recent fever or chills. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: PMH: CAD HTN Hyperlipidemia Recently dx T3 N0 posterior right posterior pharyngeal wall/base of tongue ca s/p chemo and XRT last in past few weeks. S/P PEG ESRD not on dialysis has left B-C fistula AAA h/o bladder CA PSH: PEG tube insertion CABG Previous R CEA Partial cystectomy Tonsillectomy Social History: ___ Family History: Unknown as per the patient. Physical Exam: Admission Physical Exam: ___: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt. was able to name both high and low frequency objects. Speech was not dysarthric. Able to follow both midline and appendicular commands. -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. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. Subtle right pronator drift. Tremor noted bilaterally Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ ___ 5 5 5 5 5 5 R 5 5- 5- ___ 5 4+ 5 4+ 4+ 4+ 4+ -Sensory:Decreased distinction on double simultaneous stilulation on the lower extremity. -DTRs: Bi Tri ___ Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Right toe is upgoing. Left toe is down. -Coordination: Some tremor on FNF bilaterally. FNF is slower on the right versus the left, but no ataxia or dysmetria. -Gait: deferred. . . Neurology transfer examination: No evidence of aphasia or other mental status abnormalities. CN examination reveals mild dysarthria slight right face asymmetry and reduced gag bilaterally (likely chronic from esophageal ca surgery and XRT) without clear facial asymmetry. On limb exam patient has a right leg>arm hemiparesis with slight decreased sensation in right leg to light touch and pinprick, slight reflex asymmetry with right extensor plantar. Discharge Physical Exam: Vital Signs: 97.9/97.3 72 138/53 15 97/3L 106 ___: Patient appears well and in no immediate distress. He is alert and oriented x3 HEENT: L sided neck incision that is clean, dry and intact with mild bruising ___: Normal heart rate and rhythm Respiratory: LBCTA Abdominal: soft, nontender, nondistended, with normal bowel sounds Extremities: Motor function bilaterally intact with some persistent but improving right-sided weakness, ___ strength of ___ and ___, no peripheral edema, all pulses palpable Pertinent Results: Laboratory investigations: Admission labs: ___ 07:10PM BLOOD WBC-8.8 RBC-3.85* Hgb-10.6* Hct-33.4* MCV-87 MCH-27.5 MCHC-31.7 RDW-15.8* Plt ___ ___ 07:10PM BLOOD ___ PTT-32.3 ___ ___ 07:10PM BLOOD UreaN-102* ___ 07:10PM BLOOD Creat-3.8* ___ 04:25AM BLOOD Glucose-103* UreaN-99* Creat-3.5* Na-137 K-4.0 Cl-96 HCO3-28 AnGap-17 . Other pertinent labs: ___ 12:02AM BLOOD CK(CPK)-41* ___ 04:25AM BLOOD ALT-18 AST-22 CK(CPK)-39* AlkPhos-93 TotBili-0.2 ___ 08:55AM BLOOD CK(CPK)-43* ___ 04:20AM BLOOD Calcium-10.1 Phos-4.7* Mg-2.8* ___ 04:25AM BLOOD VitB12-1249* Folate-GREATER TH ___ 04:25AM BLOOD %HbA1c-5.6 eAG-114 ___ 04:25AM BLOOD Albumin-4.1 Cholest-117 ___ 04:25AM BLOOD Triglyc-140 HDL-39 CHOL/HD-3.0 LDLcalc-50 ___ 04:25AM BLOOD TSH-5.7* . Urine: ___ 07:27PM URINE Color-Straw Appear-Clear Sp ___ ___ 07:27PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 07:27PM URINE RBC-<1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0 ___ 07:27PM URINE CastHy-1* ___ 07:27PM URINE Mucous-RARE . . Microbiology: ___ 4:25 am SEROLOGY/BLOOD **FINAL REPORT ___ RAPID PLASMA REAGIN TEST (Final ___: NONREACTIVE. Reference Range: Non-Reactive. . . Radiology: CT HEAD W/O CONTRAST Study Date of ___ 8:09 AM FINDINGS: There is a hypoattenuating region in the posterior left frontal lobe along the falx with loss of gray-white matter differentiation extending to the cortex, not seen on the outside study performed 17 hours earlier, consistent with an evolving partial left ACA territory infarct. No hemorrhagic transformation is detected, and there is no mass effect or shift of normally midline structures. Small scattered hypodensities in the right subcortical and periventricular region are also seen on the outside study, consistent with age-indeterminate infarcts. Diffuse periventricular white matter hypodensity is consistent with sequela of chronic microvascular ischemic disease. The ventricles and sulci are prominent with prominent temporal horns of the lateral ventricles consistent with brain atrophy and medial temporal lobe atrophy. Atherosclerotic calcifications of the bilateral carotid siphons are noted. There is no evidence of intracranial hemorrhage. The visualized paranasal sinuses, middle ear cavities, and mastoid air cells are clear bilaterally. The bony calvaria are intact. IMPRESSION: 1. Evolving partial left ACA territorial infarct from ___ without hemorrhagic transformation. 2. Hypoattenuating foci in the right periventricular region are consistent with age-indeterminate infarcts. If clinically indicated, MRI is recommended for determination of chronicity. 3. Mild brain atrophy with medial temporal lobe atrophy and evidence of chronic microvascular ischemic disease. . CHEST (PORTABLE AP) Study Date of ___ 8:27 AM FINDINGS: Patchy linear opacities at the right base most likely represent atelectasis. There is no definite focal consolidation or pleural effusion or pneumothorax. Cardiomediastinal silhouette is stable with dense calcifications at the thoracic aorta. There is a right chest wall pacemaker with leads terminating in the right atrium and right ventricle. A fracture of the left fourth posterior rib is likely not acute. IMPRESSION: Linear opacities at the right base are likely atelectasis. No definite aspiration or focal consolidation. . Carotid U/S ___ Prelim read: normal right system and 70-79% L ICA stenosis with high resistance in the left vertebral suggesting distal stenosis/occlusion . . Cardiology: TTE (Complete) Done ___ at 3:40:10 ___ FINAL Conclusions The left atrium is elongated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). The estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is borderline pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Brief Hospital Course: ___ year-old right-handed male with a past history significant for CAD, s/p CABG, arrhythmia s/p pacemaker, ESRD (not on dialysis), previous R CEA and recently dx T3 N0 posterior right posterior pharyngeal wall/base of tongue ca s/p chemo and XRT last in past few weeks s/p PEG ___ dysphagia who presented with acute onset right leg weakness on waking. Patient was initially transferred to ___ where a CT scan was performed that showed no acute process. He was then transferred to ___ for further evaluation. Patient was admitted on ___ to the stroke neurology srvice and transferred to vascular surgery on ___. On examination, there is no evidence of aphasia or other mental status abnormalities. Has a left carotid bruit (possibly secondary to left B-C fistula) and CN examination reveals mild dysarthria with slight right face asymmetry and reduced gag bilaterally (likely chronic from esophageal ca surgery and XRT). On limb exam patient has a right leg>arm hemiparesis with some possibly ataxic component (also has intention tremor on left) with decreased sensation in right leg to light touch and pinprick and slight reflex asymmetry with right extensor plantar. Repeat CT head showed a clear left ACA infarct and small vessel disease. Carotid u/s revealed a normal right system and 70-79% L ICA stenosis with high resistance in the left vertebral suggesting distal stenosis/occlusion. TTE showed mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function EF>55% and borderline pulmonary HTN. Patient was monitored on telemetry and patient was paced and no events noted. Patient was treated with HISS to maintain normoglycemia. Stroke risk factors were assessed and TSH 5.7, fasting lipid panel Chol 117 TGCs 140 HDL 39 LDL 50, HbA1c was 5.6%. Additional labs revealed RPR, 12, foB12 and folate which were normal. Anti-hypertensives were reduced to allow auto-regulation initially. Simvastatin was increased to 40mg and patent was initially changed from aspirin to clopidogrel and latterly this was stopped and patient was treated with IV heparin with a goal PTT of 50-70 given likely embolic aetiology. The most likely likely source of embolism is from a symptomatic significant left ICA stenosis. Given significant left ICA stenosis, vascular surgery were consulted. Although imaging with CTA would have been ideal, given his tenuous renal function this was deferred. Patient had a L CEA on ___ and was transferred to the vascular surgery service. The patient was admitted to the vascular surgery service on ___ after undergoing a left carotid endarterectomy. There were no complications during the procedure and he tolerated it well. He was initially mildly lethargic and not moving right extremities immediately post op. However, after spending some time waking up in the PACU he became more alert and oriented and was slowly regaining function of right side. He was transferred to the VICU in stable condition. Neuro: The patient received tylenol with good effect and adequate pain control. By the afternoon of POD 1, he was moving his right extremities against gravity and with slightly more strength than pre-op. He was neurologically and cognitively intact throughout. CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout this hospitalization. GI/GU/FEN: Post operatively, the patient was made NPO with IVF. After POD 1 morning labs were stable, he was slowly advanced to his previous diet after first passing a bedside swallow evaluation and then a more formal evaluation by the Speech & Swallow team. He was restarted on his tube feeds and advanced to nectar thick liquids and ground solids by the time of discharge, which was tolerated well. The patient's intake and output were closely monitored, and IVF were adjusted when necessary. The patient's electrolytes were routinely followed during this hospitalization, and repleted when necessary. ID: The patient's white blood count and fever curves were closely watched for signs of infection. He remained afebrile throughout. Endocrine: The patient's blood sugar was monitored throughout this stay; insulin dosing was adjusted accordingly. Hematology: The patient's complete blood count was examined routinely; no transfusions were required during this stay. Prophylaxis: The patient received subcutaneous heparin during this stay, and was encouraged to get up and ambulate as early as possible. At the time of discharge on POD 2, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, moving all 4 extremities, voiding without assistance, and pain was well controlled. Medications on Admission: Simvastatin 20 mg Daily ASA 81 mg Daily Amlodipine 10 mg Daily Carvedilol 25 mg TID Lasix 40 mg Daily Omeprazole 20 mg Daily. Iron 65 mg BID Fluconazole 100 mg Daily. Isosorbide 30 mg Daily. Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever. 2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 9. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 10. Iron (ferrous sulfate) 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Left symptomatic carotid stenosis 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 ___ because you had a stroke. You were found to have significant occlusion of your left carotid artery that may have been the cause of your stroke. Therefore, you underwent surgery to remove the blockage in your artery. You have done well in the post-operative period and are now ready to continue your recovery in a rehabilitation facility with the following instructions: What to expect when you go home: 1. Surgical Incision: It is normal to have some swelling and feel a firm ridge along the incision Your incision may be slightly red and raised, it may feel irritated from the staples 2. You may have a sore throat and/or mild hoarseness Try warm tea, throat lozenges or cool/cold beverages 3. You may have a mild headache, especially on the side of your surgery Try ibuprofen, acetaminophen, or your discharge pain medication If headache worsens, is associated with visual changes or lasts longer than 2 hours- call vascular surgeons office 4. It is normal to feel tired, this will last for ___ weeks You should get up out of bed every day and gradually increase your activity each day You may walk and you may go up and down stairs Increase your activities as you can tolerate- do not do too much right away! 5. It is normal to have a decreased appetite, your appetite will return with time You will probably lose your taste for food and lose some weight Eat small frequent meals It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: No driving until post-op visit and you are no longer taking pain medications No excessive head turning, lifting, pushing or pulling (greater than 5 lbs) until your post op visit You may shower (no direct spray on incision, let the soapy water run over incision, rinse and pat dry) Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed Take all the medications you were taking before surgery, unless otherwise directed Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: Changes in vision (loss of vision, blurring, double vision, half vision) Slurring of speech or difficulty finding correct words to use Severe headache or worsening headache not controlled by pain medication A sudden change in the ability to move or use your arm or leg or the ability to feel your arm or leg Trouble swallowing, breathing, or talking Temperature greater than 101.5F for 24 hours Bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions Followup Instructions: ___
10019517-DS-19	10,019,517	22,863,073	DS	19	2160-05-27 00:00:00	2160-05-27 13:52:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: fall Major Surgical or Invasive Procedure: none History of Present Illness: ___ year old female with past medical history of follicular lymphoma in CR and recurrent UTI presenting with fall and 2 days of fatigue. She is very active normally, yesterday during practice for a play she felt very fatigued and not herself. She has been going to the bathroom more frequently than usual, denies dysuria. Early this morning she woke up to urinate and felt very lightheaded, tried walking back to the bed and fell down to the ground, hit the back of her head, denies losing consciousness. Brought to ED, head and neck CT, CXR unremarkable. U/A was mildly positive, she was given IV cipro. Past Medical History: 1. Follicular lymphoma in CR s/p bendamustine and rituxamab 2. Lumbar spinal stenosis status post XLIF (extreme lateral interbody fusion). 3. Cervical spinal stenosis. 4. Recurrent urinary tract infections with chronic cystitis. 5. Hypertension. 6. History of breast cancer requiring a lumpectomy, chemotherapy and radiation 7. History of migraine headaches. 8. History of right upper extremity "nerve damage" following a surgical procedure of the right shoulder 9. History of left shoulder shingles. 10. Moderate aortic regurgitation and aortic root dilatation with an EF of 60%. Social History: ___ Family History: Migraines in mother and daughter. Unknown cancer in paternal grandparents. Physical Exam: Admission Physical Exam: T: 97.3 HR 77 BP 146/76 RR 18 100% RA Gen: NAD, resting comfortably in bed HEENT: EOMI, PERRLA, MMM, OP clear CV: RRR nl s1s2 no m/r/g Resp: CTAB no w/r/r Abd: Soft, NT, ND +BS Ext: no c/c/e Neuro: CN II-XII intact, ___ strength throughout Discharge Physical Exam: T: 97.8 HR 73 BP 149/78 RR 20 99% RA Gen: NAD, resting comfortably in bed HEENT: EOMI, PERRLA, MMM, OP clear CV: RRR nl s1s2 no m/r/g Resp: CTAB no w/r/r Abd: Soft, NT, ND +BS Ext: no c/c/e Neuro: CN II-XII intact, ___ strength throughout Pertinent Results: ___ 06:00AM URINE BLOOD-NEG NITRITE-POS PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-MOD ___ 06:00AM URINE RBC-0 WBC-7* BACTERIA-MANY YEAST-NONE EPI-0 TRANS EPI-<1 ___ 03:00AM GLUCOSE-110* UREA N-17 CREAT-0.8 SODIUM-134 POTASSIUM-4.6 CHLORIDE-97 TOTAL CO2-20* ANION GAP-22* ___ 03:00AM ALT(SGPT)-26 AST(SGOT)-45* ALK PHOS-58 TOT BILI-0.3 ___ 03:00AM LIPASE-57 ___ 03:00AM ALBUMIN-4.9 CALCIUM-10.2 PHOSPHATE-3.3 MAGNESIUM-1.8 ___ 03:00AM WBC-13.8# RBC-4.81 HGB-15.7 HCT-44.9 MCV-93 MCH-32.7 MCHC-35.1* RDW-13.5 CT head: IMPRESSION: Atrophy. No evidence of fracture, hemorrhage or infarction. CT C-spine: IMPRESSION: 1. No evidence of fracture. 2. Severe degenerative changes, mildly progressed since ___. 3. 9mm right thyroid nodule increased in size from prior, a non emergent thyroid ultrasound can be obtained if clinically indicated. 4. Enlarged descending thoracic aorta measuring up to 3.4 cm. ECG: sinus rhythm RBBB, no ST-T wave abnormalities, no change from prior Brief Hospital Course: ___ year old female with past medical history of follicular lymphoma in CR and recurrent UTI presenting with fall and 2 days of fatigue. 1. UTI: Mildly positive urinalysis with increased urinary frequency. No history of resistent infections. -Continue PO cipro for 3 day course. -Urine culture pending on discharge, will call if growing resistant organism. 2. Fall: Likely due to infection and dehydration, no concerning findings on ECG, no loss of consciousness. CT head and C-spine showing no acute abnormlities. ___ was consulted and she was able to ambulate using rolling walker without dizziness or significant difficulties. Home ___ was recommended. 3. Migraines: Continue Tylenol 4. FEN/PPX: regular diet, heparin SC, ___ protocol DNR/DNI HCP: ___ (daughter) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 1000 mg PO Q8H 2. cranberry extract unknown oral daily 3. Multivitamins W/minerals 1 TAB PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Ciprofloxacin HCl 500 mg PO Q12H RX ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice a day Disp #4 Tablet Refills:*0 3. cranberry extract 1 tablet ORAL DAILY 4. Multivitamins W/minerals 1 TAB PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: 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: You were admitted after a fall and found to have a urinary tract infection and dehydration. You were started on ciprofloxacin for the infection. You were given IV fluids for the dehydration. Followup Instructions: ___
10020187-DS-4	10,020,187	24,104,168	DS	4	2169-01-24 00:00:00	2169-01-24 13:00:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Subarachnoid hemorrhage Major Surgical or Invasive Procedure: ___: diagnostic cerebral angiogram (positive for p.comm aneurysm) ___: angiogram for coiling of pComm aneurysm History of Present Illness: ___ y/o ___ female transferred from OSH with WHOL and imaging showing SAH. She experienced a sudden onset WHOL at 7:30PM this evening while at a funeral. She headache was localized to the top of her head and at the base of her skull. She also noted a transient episode of hearing loss when the headache started. Her hearing has returned to normal. The headache continued and she was taken to ___ ___ for further evaluation. She underwent a CT without contrast at the CHA which showed a subarachnoid hemorrhage in the left sylvian fissure and basilar cisterns. She was transferred to ___ for further evaluation. The patient continues with complaints of a headache which is located at the top of her head and at the base of her skull. She also reports bilateral lower facial, jaw, and tongue numbness and tingling which has improved since the onset of the headache. She denies numbness, tingling, pain, and weakness of the upper and lower extremities bilaterally. However, she does endorse chest pain within the upper portion of the left arm. She denies SOB, nausea, vomiting, fever, chills, diplopia, dizziness, blurred vision, or speech-language difficulties. Past Medical History: HTN Hyperlipidemia Depression Arthritis H Pylori Colon polyp Bilateral osteoarthritis of the knees s/p right total knee replacement Colon polyp Gastritis ___ esophagus Social History: ___ Family History: No family history of neurologic diease or aneurysms. Physical Exam: On Discharge: ___ speaking, limited ___ A&Ox3 PERRL Face symmetric No drift MAE ___ strength Pertinent Results: CTA HEAD W&W/O C & RECONS Study Date of ___ 2:25 AM IMPRESSION: 1. 3-mm aneurysm is seen directed laterally at the origin of the left posterior communicating artery and a 2 mm aneurysm is seen directed medially at the origin of left posterior communicating artery. 2. Diminutive left vertebral artery with ___ termination. Dominant right vertebral artery. Otherwise, the posterior circulation is unremarkable. 3. No significant interval change in the extent of the subarachnoid hemorrhage, compared to the prior exam from ___. Probable bi-frontal small subdural hematomas (3;17). 4. Hypoplastic left transverse sinus, likely congenital. The remainder the dural venous sinuses are patent. INTRACRANIAL COILING Study Date of ___ 2:25 ___ IMPRESSION: 1. Successful coiling of a left PCOM artery aneurysm compatible with ___ and ___ grade CTA HEAD W&W/O C & RECONS Study Date of ___ 8:55 ___ CT head: No definite subarachnoid blood identified. No new hemorrhage. CTA head: There is no definite evidence of vasospasm of the circle of ___ although of the left MCA is possibly slightly more narrow and irregular compared to study from ___. CT neck: The a neck vessels are patent without stenosis, occlusion, or dissection Brief Hospital Course: ___ year old female who experienced a sudden onset WHOL while at a funeral. She reported headache which was localized to the top of her head and at the base of her skull. She also noted a transient episode of hearing loss when the headache started. She was taken to an OSH where imaging demonstrated subarachnoid hemorrhage in the left sylvian fissure and basilar cisterns. #___: On arrival to ___ a CT/CTA was performed and demonstrated a 3-mm aneurysm on the posterior communicating artery and a 2 mm aneurysm medially at the origin of left posterior communicating artery. She was started on Keppra and Nimodipine. She underwent a diagnostic angiogram which confirmed the PCOMM aneursm. The patient was taken back to the angio suite on ___ for a coiling of the aneurysm. She tolerated the procedure well and was transferred back to the NICU for postop care. She developed slight R pronator drift postop which improved. She was transferred to ___ on POD #1. TCDs were completed on ___ and were negative for vasospasm, howevever limited due to poor bone window. She remained stable and was transferred to the floor on ___. She was continued on Nimodipine and IVF. CTA was done for vasospasm watch on ___ which did not demonstrate vasospasm. She was evaluated by physical therapy and was cleared for safe discharge to home. On day of discharge (___) Patient was neurologically stable and discharged to home with services in good condition. She was set up for home ___ and ___ services. Family confirmed they would provide home supervision for the first few days after discharge. She was given prescription to continue her 21 day course of Nimodipine for vasospasm prevention. Medications on Admission: Unknown. Discharge Medications: 1. Acetaminophen-Caff-Butalbital 1 TAB PO Q4H:PRN Pain - Severe Do not exceed >4g of acetaminophen in 24 hours including from other sources RX butalbital-acetaminophen-caff 50 mg-325 mg-40 mg 1 tablet(s) by mouth Q4-6H PRN headache Disp #90 Tablet Refills:0 2. Aspirin 81 mg PO DAILY RX aspirin 81 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:12 3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation RX bisacodyl 5 mg 2 tablet(s) by mouth daily PRN constipation Disp #60 Tablet Refills:0 4. LevETIRAcetam 500 mg PO BID RX levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:3 5. NiMODipine 60 mg PO Q4H RX nimodipine 30 mg 2 capsule(s) by mouth every four (4) hours Disp #144 Capsule Refills:0 6. Omeprazole 20 mg PO DAILY RX omeprazole 20 mg 1 capsule(s) by mouth daily Disp #30 Capsule Refills:3 7. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate RX oxycodone 5 mg 1 tablet(s) by mouth Q4-6H PRN pain Disp #30 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Subarachnoid Hemorrhage Posterior Communicating Artery Aneurysm Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Surgery/ Procedures: You had a cerebral angiogram to coil the aneurysm. You may experience some mild tenderness and bruising at the puncture site (groin). Activity We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. You make take leisurely walks and slowly increase your activity at your own pace. ___ try to do too much all at once. You make take a shower. No driving while taking any narcotic or sedating medication. If you experienced a seizure while admitted, you must refrain from driving. Medications Resume your normal medications and begin new medications as directed. You have been discharged on a medication called Nimodipine. This medication is used to help prevent cerebral vasospasm (narrowing of blood vessels in the brain). You have been discharged on Keppra (Levetiracetam). This medication helps to prevent seizures. Please continue this medication until follow-up. It is important that you take this medication consistently and on time. You have been discharged on a medication to lower your cholesterol levels. We recommend that you continue this medication indefinitely. You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. What You ___ Experience: Mild to moderate headaches that last several days to a few weeks. Difficulty with short term memory. Fatigue is very normal Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. If you are taking narcotics (prescription pain medications), try an over-the-counter stool softener. When to Call Your Doctor at ___ for: Severe pain, swelling, redness or drainage from the incision site or puncture site. Fever greater than 101.5 degrees Fahrenheit Constipation Blood in your stool or urine Nausea and/or vomiting Extreme sleepiness and not being able to stay awake Severe headaches not relieved by pain relievers Seizures Any new problems with your vision or ability to speak Weakness or changes in sensation in your face, arms, or leg Call ___ and go to the nearest Emergency Room if you experience any of the following: Sudden numbness or weakness in the face, arm, or leg Sudden confusion or trouble speaking or understanding Sudden trouble walking, dizziness, or loss of balance or coordination Sudden severe headaches with no known reason Followup Instructions: ___
10020218-DS-16	10,020,218	22,515,625	DS	16	2177-05-09 00:00:00	2177-05-09 14:43:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: Bactrim / morphine / shellfish derived Attending: ___. Chief Complaint: Headache Major Surgical or Invasive Procedure: ___: Left occipital Shunt revision History of Present Illness: Ms. ___ is a ___ year old female with VP shunt placed at age ___ by Dr. ___ at ___ for hydrocephalus in the setting of premature birth; she was last seen in followup in ___. She presents today with headache for the past 2 weeks which have worsened over the past 2 days. She contacted Dr. ___ ___ who referred her to the ED. ___ revealed developing hydrocephalus. Past Medical History: Premature birth VP shunt placed age ___ Cholecystectomy ___ Social History: ___ Family History: NC Physical Exam: ON ADMISSION ============ PHYSICAL EXAM: O: T: 98.1 BP: 108/74 HR: 66 R: 18 O2Sats: 100% RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils: PERRL EOMs Full The left occipital shunt valve is palpable; no recoil is noted. Neck: Supple. Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 5mm to 3mm bilaterally. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power ___ throughout. No pronator drift ON DISCHARGE ============ Gen: WD/WN, comfortable, NAD. HEENT: Pupils: PERRL EOMs Full Neck: Supple. Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 5mm to 3mm bilaterally. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power ___ throughout. No pronator drift Skin: Left occipital shunt site well approximated with sutures Abdominal incision with steri strips and minimal serosanguinous drainage Pertinent Results: Please see OMR for pertinent labs & imaging Brief Hospital Course: On ___, Ms. ___ presented to the ED with worsening headaches. #Hydrocephalus The patient underwent NCHCT which was concerning for worsening hydrocephalus; prior MRI from ___ was obtained for comparison which did show increased ventriculomegaly. Shunt series and CT abdomen were performed which did not show any abnormalities. Shunt tap was attempted but failed due to low pressure. She was admitted for close monitoring. On ___, she went to the OR with Dr. ___ shunt revision which was routine. Shunt was set to 1.5. Postoperative head CT demonstrated decreased ventricular size and expected postoperative changes. On POD2 pt had poor pain control with pain in the neck along the tunneled catheter site. Valium and lidocaine patches were added to her pain regimen with some improvement. At the time of discharge patient was ambulating independently, voiding spontaneously, tolerating a regular diet, afebrile with stable vital signs. Pain was well controlled with oral medications. Medications on Admission: None Discharge Medications: 1. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN Headache Do not exceed 6 tablets/day RX butalbital-acetaminophen-caff 50 mg-325 mg-40 mg ___ tablet(s) PO Q6H PRN Disp #24 Tablet Refills:0 2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 3. Diazepam 2 mg PO Q8H:PRN muscle stiffness/ spasm RX diazepam 2 mg 1 tab by mouth Q8H PRN Disp #24 Tablet Refills:0 4. Docusate Sodium 100 mg PO BID 5. Lidocaine 5% Patch 1 PTCH TD QAM RX lidocaine 5 % 1 patch daily Disp #15 Patch Refills:0 6. Ondansetron 4 mg PO Q8H:PRN nausea Duration: 1 Dose RX ondansetron HCl 4 mg 1 tablet(s) by mouth Q8H PRN Disp #24 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: Hydrocephalus VP shunt malfunction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ventriculoperitoneal Shunt Surgery You had a VP shunt replaced for hydrocephalus. Your incisions should be kept dry until sutures are removed. The steri strips on your abdomen will fall off on their own, do not pull them off. Your shunt is a ___ Strata Valve which is programmable. This will need to be readjusted after all MRIs or exposure to large magnets. Your shunt is programmed to 1.5.. It is best to keep your incision open to air but it is ok to cover it when outside. Call your surgeon if there are any signs of infection like redness, fever, or drainage. Activity We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. You make take leisurely walks and slowly increase your activity at your own pace once you are symptom free at rest. ___ try to do too much all at once. No driving while taking any narcotic or sedating medication. If you experienced a seizure while admitted, you are NOT allowed to drive by law. No contact sports until cleared by your neurosurgeon. You should avoid contact sports for 6 months. Medications Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. What You ___ Experience: Headache or pain along your incision. Some neck tenderness along the shunt tubing. Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. If you are taking narcotics (prescription pain medications), try an over-the-counter stool softener. When to Call Your Doctor at ___ for: Severe pain, swelling, redness or drainage from the incision site. Fever greater than 101.5 degrees Fahrenheit Nausea and/or vomiting Extreme sleepiness and not being able to stay awake Severe headaches not relieved by pain relievers Seizures Any new problems with your vision or ability to speak Weakness or changes in sensation in your face, arms, or leg Call ___ and go to the nearest Emergency Room if you experience any of the following: Sudden numbness or weakness in the face, arm, or leg Sudden confusion or trouble speaking or understanding Sudden trouble walking, dizziness, or loss of balance or coordination Sudden severe headaches with no known reason Followup Instructions: ___
10020852-DS-21	10,020,852	23,905,070	DS	21	2177-05-25 00:00:00	2177-05-25 22:16:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Bactrim Attending: ___. Chief Complaint: cough, SOB Major Surgical or Invasive Procedure: Broncoscopy- ___ History of Present Illness: Ms. ___ is a ___ female with the past medical history of tobacco use, THC vaping, exercise induced asthma and DVT/PE (one in ___ and another in ___ post-surgery immobilization) who presents with worsening cough and SOB x 1 week. Initially started having the cough in ___ and presented to PCP where she got abx and inhaled steroids and felt somewhat better. She was in ___ for most of ___ until ___ and was feeling improved during that time. Since ___, her cough started to worsen, sometimes productive with yellow/green sputum. Now over the past week, she has started to have significant SOB that is preventing her from performing her daily activities. It is mostly exertional even when she walks to bathroom. She denies orthopnea, PND. She says she has required frequent albuterol inhalers w/o improvement. She has hx of PE but says these symptoms are different, and she has been compliant with her xarelto. She takes Tylenol daily for frequent aches and pains. Currently she is having a HA in the middle of her forehead. Tylenol has not helped. She has a hx of frequent pseudophed use for sinus headaches but she hasn't used it for a month. Doesn't have rhinorrhea or congestion but does have some pain when pressing on her nose. She denies any ill contacts. She also endorses a history of daily vaping for several years. In the ED, she was afebrile, HR in ___, SBP 140s-200s, RR ___, and ranged from being on 4L O2 (presumably for comfort) and then on RA. Labs in ED were concerning for leukocytosis with WBC 17.6 and increased eosinophils. She was given frequent nebs, iv steroids, and a dose of rocephin/azithromycin. Pt reports improvement following this treatment. Imaging in ED: CXR: No focal consolidation, pleural effusion, or evidence of pneumothorax is seen. The cardiac and mediastinal silhouettes are stable. CTA chest: 1. No evidence of pulmonary embolism or aortic abnormality. 2. Scattered bilateral ground-glass opacities may be due to aspiration pneumonitis versus atypical pneumonia versus less likely pulmonary edema. 3. Scattered areas of bronchiectasis and bronchial wall thickening, suggestive of small airways disease. 4. 10 mm solid nodule at the left lung base. Recommendation as below. For incidentally detected single solid pulmonary nodule bigger than 8mm, a follow-up CT in 3 months, a PET-CT, or tissue sampling is recommended. On review of systems patient denies Fever, chills, vision changes, hearing changes, Sore throat, rhinorrhea, congestion, Back pain, extremity pain, extremity swelling, Dysuria, Hematuria, Urinary urgency, urinary frequency, abdominal Pain, Nausea, Vomiting, Diarrhea or constipation falls, dizziness. +productive cough, +dyspnea on exertion, +headache, +Night sweats (x1 week). EKG: sinus tachycardia Past Medical History: - Hx of PE/DVT in ___ in setting of post-surgery - asthma - PCOS c/b menorrhagia - Depression - Anxiety - Fatty liver - Borderline personality disorder - gastroparesis, bacterial overgrowth, and pelvic floor - dyssynergy - GERD - Ankle fracture s/p surgery x2 with pins - Finger surgery ___ - C. diff infection ___ (hospital-acquired) Social History: ___ Family History: Dad died of a brain aneurysm. No history of VTE in any family member. Physical Exam: ============================ PHYSICAL EXAM ON ADMISSION ============================ VITALS: Afebrile and vital signs stable (see eFlowsheet). On 4 L NC for comfort. GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate. No sinus tenderness. CV: Heart regular, tachycardic, no murmur, no S3, no S4. RESP: Bilateral wheezing present L>R. 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 PSYCH: pleasant, appropriate affect ============================ PHYSICAL EXAM ON DISCHARGE ============================ Vitals:97.5 BP: 146 / 99 HR:93 R:16 95 Ra GENERAL: Alert and in no apparent distress, obese EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate. CV: RRR, no murmur, no S3, no S4. No ___. RESP: Clear b/l on auscultation. Breathing is non-labored, speaking in full sentences. GI: deferred GU: deferred MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: healed scars on lower legs. NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs PSYCH: pleasant, appropriate affect Pertinent Results: ========================= LABS ON ADMISSION ========================= ___ 05:24PM BLOOD WBC-17.8* RBC-4.76 Hgb-16.7* Hct-48.7* MCV-102* MCH-35.1* MCHC-34.3 RDW-13.5 RDWSD-50.9* Plt ___ ___ 05:24PM BLOOD Neuts-32.4* Lymphs-11.6* Monos-4.2* Eos-51.0* Baso-0.6 Im ___ AbsNeut-5.78 AbsLymp-2.06 AbsMono-0.75 AbsEos-9.10* AbsBaso-0.10* ___ 05:24PM BLOOD Glucose-102* UreaN-5* Creat-0.9 Na-142 K-4.7 Cl-102 HCO3-24 AnGap-16 ========================= PERTINENT INTERVAL LABS ========================= ___ 06:40AM BLOOD ANCA-POSITIVE- Protienase 3Ab positive, MCO negative ___ 06:40AM BLOOD IgG-1369 IgA-300 IgM-348 COCCIDIOIDES ANTIBODIES TO TP AND F ANTIGENS, ID Test Result Reference Range/Units AB TO TP ANTIGEN (IGM) NEGATIVE AB TO F ANTIGEN (IGG) NEGATIVE ASPERGILLUS ANTIBODY Test Result Reference Range/Units ASPERGILLUS ___ AB Negative Negative ASPERGILLUS FUMIGATUS AB Negative Negative Interpretive Criteria: Negative: Antibody not detected Positive: Antibody detected A positive result is represented by 1 or more precipitin bands, and may indicate fungus ball, allergic bronchopulmonary aspergillosis (ABA) or invasive aspergillosis. Generally, the appearance of ___ bands indicates either fungus ball or ABA. Test Result Reference Range/Units ASPERGILLUS FLAVUS AB Negative Negative IGE Test Result Reference Range/Units IMMUNOGLOBULIN E 1282 H <OR=114 ___ RAST Testing- see report in OMR ========================= LABS ON DISCHARGE ========================= ___ 06:15AM BLOOD WBC-7.4 RBC-4.08 Hgb-14.1 Hct-41.1 MCV-101* MCH-34.6* MCHC-34.3 RDW-13.0 RDWSD-47.8* Plt ___ ___ 06:15AM BLOOD Glucose-81 UreaN-11 Creat-0.7 Na-143 K-3.6 Cl-103 HCO3-26 AnGap-14 ___ 06:40AM BLOOD ALT-33 AST-34 AlkPhos-47 TotBili-0.2 ___ 06:15AM BLOOD Calcium-9.1 Phos-5.3* Mg-1.9 ========================= MICROBIOLOGY ========================= - ___ blood cultures x2 - negative - ___ Rapid Respiratory Viral Screen & Culture -negatve - ___ bronchoalveolar lavage GRAM STAIN (Final ___: 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS AND IN SHORT CHAINS. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN CLUSTERS. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count, if applicable. RESPIRATORY CULTURE (Final ___: ___ CFU/mL Commensal Respiratory Flora. STAPH AUREUS COAG +. 10,000-100,000 CFU/mL. 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. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. RIFAMPIN should not be used alone for therapy. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 1 S OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S POTASSIUM HYDROXIDE PREPARATION (Final ___: NO FUNGAL ELEMENTS SEEN. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): - ___ Rapid Respiratory Viral Screen & Culture - Negative/Inadecuate ========================= IMAGING/STUDIES ========================= ## ___ Chest xray (Pa and Lat): - IMPRESSION: No acute cardiopulmonary process. ## ___ CTA chest: IMPRESSION: 1. No evidence of pulmonary embolism or aortic abnormality. 2. Scattered bilateral ground-glass opacities may be due to aspiration pneumonitis versus atypical pneumonia versus less likely pulmonary edema. 3. Scattered areas of bronchiectasis and bronchial wall thickening, suggestive of small airways disease. 4. 10 mm solid nodule at the left lung base. Recommendation as below. RECOMMENDATION(S): For incidentally detected single solid pulmonary nodule bigger than 8mm, a follow-up CT in 3 months, a PET-CT, or tissue sampling is recommended. ## ___ Bronchoscopy Report: Findings: - Secretions: Quantity: moderate; Color: white; Consistency: thick. Patient had thickened secretions plugging numerous airways bilaterally (Lingula, LLL, RUL, RML, RLL). These were difficult to remove and formed an airway cast (see images above). - A bronchoalveolar lavage with 120 ml of saline was performed in the right middle lobe bronchus. Frothy return with some plugs was obtained. Total of 35cc was returned. - Summary: Airways showed thick sticky mucus diffusely and BAL was performed with good return. Impressions: - secretions - airway obstruction. Plan: - follow up microbiology - follow up cytology ## ___ Chest x-ray (AP) IMPRESSION: 1. No pneumothorax status post bronchoscopy. 2. Mild pulmonary edema. ## ___ CT Sinus IMPRESSION: Moderate paranasal sinus opacification without air-fluid levels, hyperostosis, or bone destruction to suggest upper respiratory manifestations of granulomatosis with polyangiitis. Brief Hospital Course: Ms. ___ is a ___ female with the past medical history of tobacco use, THC vaping, exercise induced asthma and DVT/PE (one in ___ and another in ___ post-surgery immobilization) who presents with worsening cough and SOB x 1 week. #Eosinophilic Granulomatosis with Polyangitis #Pneumonia #?Asthma Exacerbation The patient presented with worsening cough and shortness of breath. CT scan on admission showed multifocal pneumonia. The differential for the patient's presentation included EGPA vs AEP vs Vaping related lung disease, with less likely APBA or Coccidioides. The patient was also noted to have a significant peripheral eosinophilia. She was initially started on Ceftraixone/azithromycin for treatment of CAP. Which was transitioned to Vancomycin when sputum from BAL was +for MRSA- she was ultimately transitioned to clindamycin to complete a 5 day course of antibiotics. Following bronchoscopy, the patient was started on Prednisone 60mg daily, She had a CT sinus which did not show evidence of EGPA. She was also evaluated by dermatology who found no skin lesions to biopsy. Ultimately, the patient's ANCA (PR3 antibodies) returned positive. In addition she was found to have a significantly elevated IgE. The combination of ANCA positivity, eosinophilia, lung findings are consistent with EGPA. The patient was discharged on Prednisone 40mg daily to continue until close pulmonary follow up. She was continued on a PPI and started on atovaquone for PJP ppx. She was also started on Advair. ECG was without significant abnormalities. The patient will need an echocardiogram as an outpatient to asses for cardiac involvement of EGPA. The patient had significant improvement in her symptoms prior to discharge. #Hypertension The patient was noted to have significantly elevated blood pressures. She was started on HCTZ which was uptitrated to 50mg Daily and then amiodarone was added. Blood pressures not optimally controlled on discharge. Will likely require additional titration #Vulvovaginal candidiasis: - Patient was given Fluconazole x2 CHRONIC/STABLE PROBLEMS: #DVT/PE: on xarelto at home, no PE seen on CTA -continued home Xarelto 20 QD #Tobacco use: The patient was counseled on smoking cessation. She expressed interest in Chantix and was provided a prescription on discharge. #Mood disorder: The patient was continued on her home medications while hospitalized. She has follow up scheduled with her psychiatrist the week after discharge. Transitional issues: - Please arrange outpatient echocardiogram - Continue to monitor blood pressure, may require additional medications - Discharged on Chantix for smoking cessation- Would continue to encourage smoking cessation - Patient has follow up scheduled with pulmonary, can consider referral to rheumatology as outpatient Code: Full Patient seen and examined on day of discharge. >30 minutes on discharge activities. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Rivaroxaban 20 mg PO DAILY 2. CloniDINE 0.2 mg PO DAILY 3. Mirtazapine 45 mg PO HS 4. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q4-6H:PRN sob, wheezing 5. LORazepam 1 mg PO DAILY:PRN anxiety 6. LaMICtal XR (lamoTRIgine) 300 mg oral QHS 7. Omeprazole 20 mg PO DAILY 8. Gabapentin 300 mg PO TID 9. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line 10. BuPROPion XL (Once Daily) 450 mg PO DAILY 11. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID:PRN rash 12. Mirena (levonorgestrel) 20 mcg/24 hours ___ yrs) 52 mg injection ___ 13. Fluticasone Propionate 110mcg 2 PUFF IH BID 14. BusPIRone 15 mg PO BID Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever 2. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB 3. amLODIPine 5 mg PO DAILY RX amlodipine 5 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 4. Atovaquone Suspension 1500 mg PO DAILY RX atovaquone [Mepron] 750 mg/5 mL 10 ml by mouth once a day Refills:0 5. Calcium 500 + D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -200 unit oral DAILY 6. Chantix (varenicline) 0.5 mg oral DAILY Days ___ BID Days ___ BID for 11 weeks RX varenicline [Chantix Starting Month Box] 0.5 mg (11)-1 mg (42) 1 tablet(s) by mouth as dir Disp #1 Dose Pack Refills:0 7. Clindamycin 300 mg PO/NG Q6H RX clindamycin HCl [Cleocin HCl] 300 mg 1 capsule(s) by mouth Q6hrs Disp #8 Capsule Refills:0 8. Fluticasone Propionate NASAL 2 SPRY NU BID RX fluticasone propionate 50 mcg/actuation 2 SPRAY NAS twice a day Disp #1 Spray Refills:0 9. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID RX fluticasone propion-salmeterol [Advair Diskus] 250 mcg-50 mcg/dose 2 puff INH twice a day Disp #1 Disk Refills:0 10. Hydrochlorothiazide 50 mg PO DAILY RX hydrochlorothiazide 50 mg 50 mg by mouth once a day Disp #30 Tablet Refills:0 11. PredniSONE 40 mg PO DAILY RX prednisone 20 mg 2 tablet(s) by mouth once a day Disp #60 Tablet Refills:*0 12. Gabapentin 300 mg PO QID 13. BuPROPion XL (Once Daily) 450 mg PO DAILY 14. BusPIRone 15 mg PO BID 15. CloniDINE 0.2 mg PO DAILY 16. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line 17. LaMICtal XR (lamoTRIgine) 300 mg oral QHS 18. LORazepam 1 mg PO DAILY:PRN anxiety 19. Mirena (levonorgestrel) 20 mcg/24 hours ___ yrs) 52 mg injection ___ 20. Mirtazapine 45 mg PO HS 21. Omeprazole 20 mg PO DAILY 22. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q4-6H:PRN sob, wheezing 23. Rivaroxaban 20 mg PO DAILY 24. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID:PRN rash Discharge Disposition: Home Discharge Diagnosis: Eosinophilic granulomatosis with polyangitis Hypertension Pneumonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. ___, It was a pleasure taking care of you during your admission to ___. You were evaluated for shortness of breath. You were seen by the pulmonary team and had a CAT scan and a bronchoscopy in addition to a number of lab tests. You were treated for pneumonia with antibiotics while you were hospitalized. The results of your studies indicate you likely have Eosinophilic Granulomatosis with Polyangitis (EGPA). You were started on steroids which will treat this condition. You have also been given new inhalers to help your breathing. It is important that you stop smoking and vaping. You were started on Chantix to help with this. While you take steroids, you should take a medication to protect your stomach and calcium with vitamin D to protect your bones. You have also been started on an antibiotic to prevent an infection while you are on steroids. You were found to have high blood pressure during your hospitalization. You have been started on new blood pressure medications. It is important that you follow up with your PCP and with the pulmonary team on discharge. Your primary care doctor ___ refer you for an echocardiogram. We wish you the best, Your ___ Care team Followup Instructions: ___
10020944-DS-13	10,020,944	29,974,575	DS	13	2131-03-13 00:00:00	2131-03-13 17:42:00	Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: ciprofloxacin Attending: ___. Chief Complaint: Respiratory failure, hypotension Major Surgical or Invasive Procedure: Intubation Bronchoscopy PICC placement Central Line Placement History of Present Illness: Mr. ___ is a ___ with a PMHx of COPD, cutaneous TCL, rectosigmoid adenocarcinoma (sp radiation and chemotherapy), h/o PE, chronic osteomyelitis, alcoholic neuropathy (cb urethral stricture with chronic foley), recent hospitalization at ___ for Cardiac arrest, recent ESBL UTI, who presented with altered mental status and is transferred to the ICU for respiratory failure and hypotension. Pt's past medical history (including recent events) is not entirely available. Per ___ notes, pt completed a prednisone taper on ___ and recently had treatment with meropenem (per ED verbal report) for UTI. Pt has had a decreased level of consciousness for the past ___s SOB and hypoxia. He was placed on NRB for 24hrs at NH with improvement ___ BP. He was transferred to ___ for further management. Per pt's son, pt was recently switched from ativan to klonopin, and this corresponded to new onset lethargy and irritability/delerium. ___ the ED, initial vitals: T 98 P 75 BP 154/67 R 24 O2 Sat 91% on NRB. Pt was noted to be obtunded, with an ETCO2 ___ the 40 range. He was intubated (etomidate/rocurinium/7.5tube) on arrival with immediate improvement of ETCO2 to ___. Labs were remarkable for WBC 13.5, TnT 0.03, Cr 1.6 (baseline 1.3-1.7), P 6, K 7.8, pH 7.05/123/78 (immediately prior to intubation). He received vancomycin, meropenem, albuterol, tylenol, fentanyl, versed and was started on neorepinephrine for BP support (IJ placed). EKG showed SR at 69bpm, with STD ___ V1-3. On arrival to the MICU, pt was intubated and sedated. He was withdrawing to painful stimuli. At baseline, pt moves around ___ motorized wheelchair and is cognitavely intact. He underwent bronchoscopy (copious purulent secretions), EEG (prelim no e/o seizure) and arterial line placement. He also underwent placement of foley catheter by urology. Past Medical History: - Rectosigmoid Ca sp LAR ___ ___, XRT and chemo - Cutaneous T-cell lymphoma (sp UVB and Ontak and DFCI) - EtOH cirrhosis - Chronic osteomyelitis (on doxycycline) - Zoster meningoencephalitis (C2 distribution) - Urethral stricture followed at ___ - RUL pulmonary nodule - HTN - Baseline Cr 1.3-1.4 - Gait disorder - ___ SBO ___ ___ course cb respiratory failure requiring tracheostomy - ___ UGIB - ___ PE ___ ___, sp 6mo Coumadin - ___ Hepatitis - ___ hyperkalemia ___ setting of renal failure - sp ventral hgernia repair ___ - sp appendectomy - sp adenoidectomy - sp L ankle ORIF - sp deviated septum rpair at ___ Social History: ___ Family History: Mother - CAD Father - DM Uncle - MI at ___ Physical Exam: ADMISSION PHYSICAL EXAM ====================================== GENERAL: Ill-appearing, pale male, intubated, sedated HEENT: Proptosis, constricted pupils bl NECK: Supple, JVP not elevated, no LAD LUNGS: Profound rhonchi, R>>L; decreased breath sounds on R; crackles at bases bl; no wheezing 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: Cool, mottled, 1+ pulses, no clubbing or edema NEURO: R face deviation (possibly ___ ETT placement); withdrawing extremities to pain; intermittent rhythmic protrusions of tongue DISCHARGE PHYSICAL EXAM: ==================================== Tm98.3, BP 100-125/44-59, P60-82, R18-20, O294-97@3L General: Sitting ___ bed, AOx3, less coarse voice, full affect HEENT: MMM, OP clear CV: RRR no m/r/g Lungs: Anterior exam only given habitus and inability to roll over. R lung w/ decreased breath sounds ___ lower ___ of lung, clear at apex. L lung CTA b/l anteriorly. No incr WOB. Regular rate Abd: Soft, ND, NT, Obese, normoactive BS, no rebound/guarding Ext: Warm, dry, no peripheral edema, atrophied muscle tone, able to lift off of bed Pertinent Results: ADMISSION LABS: ================================================== ___ 01:30PM BLOOD WBC-13.5* RBC-4.85 Hgb-13.2* Hct-44.9 MCV-93 MCH-27.2 MCHC-29.3* RDW-15.6* Plt ___ ___ 01:30PM BLOOD Neuts-83.1* Lymphs-12.4* Monos-3.7 Eos-0.2 Baso-0.5 ___ 01:44PM BLOOD ___ PTT-33.9 ___ ___ 01:30PM BLOOD Glucose-146* UreaN-35* Creat-1.6* Na-136 K-7.7* Cl-99 HCO3-27 AnGap-18 ___ 01:30PM BLOOD ALT-26 AST-36 AlkPhos-168* TotBili-0.3 ___ 01:30PM BLOOD cTropnT-0.03* ___ 06:00PM BLOOD CK-MB-4 cTropnT-0.02* ___ 04:16AM BLOOD CK-MB-2 cTropnT-0.05* ___ 01:30PM BLOOD Albumin-4.2 Calcium-9.5 Phos-6.0* Mg-1.8 ___ 01:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 06:00PM BLOOD TSH-0.72 ___ 11:47AM BLOOD Ammonia-14 ___ 01:43PM BLOOD ___ pO2-78* pCO2-123* pH-7.05* calTCO2-36* Base XS-0 ___ 03:15PM BLOOD ___ pO2-56* pCO2-70* pH-7.17* calTCO2-27 Base XS--4 ___ 03:18PM BLOOD Comment-GREEN TOP ___ 12:35AM BLOOD Type-ART pO2-101 pCO2-38 pH-7.44 calTCO2-27 Base XS-1 ___ 01:43PM BLOOD Lactate-1.3 K-7.8* ___ 12:35AM BLOOD Lactate-1.1 K-4.7 DISCHARGE LABS: =========================================== ___ 05:27AM BLOOD WBC-7.9 RBC-3.84* Hgb-10.3* Hct-33.6* MCV-87 MCH-26.7* MCHC-30.5* RDW-15.6* Plt ___ ___ 03:19AM BLOOD Neuts-68.7 ___ Monos-8.0 Eos-3.7 Baso-0.4 ___ 05:27AM BLOOD ___ PTT-42.8* ___ ___ 05:27AM BLOOD Glucose-109* UreaN-23* Creat-1.7* Na-138 K-3.8 Cl-96 HCO3-33* AnGap-13 ___ 04:16AM BLOOD ALT-15 AST-21 AlkPhos-105 TotBili-0.4 ___ 05:27AM BLOOD Calcium-9.2 Phos-3.2 Mg-1.8 EEG: This is an abnormal routine EEG due to the presence of a slow and disorganized background throughout the recording with intermixed generalized slowing and brief periods of voltage attenuation. These findings are indicative of a moderate to severe diffuse encephalopathy which implies widespread cerebral dysfunction but is non-specific as to etiology. No focal or epileptiform features were noted at any time. Episodes of repeated mouth and tongue movements seen on video were not associated with any change on EEG. MRI HEAD ___: MRI Head: There is no evidence of slow diffusion to suggest acute infarct. There is no hemorrhage, intracranial mass, mass effect, or midline shift. There is mild prominence of the ventricles and sulci, consistent with generalized cerebral volume loss. There are multiple patchy and confluent foci of FLAIR hyperintensity within the subcortical, deep and periventricular white matter, most likely related to severe chronic microvascular ischemic disease. The ___ the pons also demonstrates T2/FLAIR hyperintensity, most likely related to chronic infarct and/or microvascular ischemic disease. Intracranial flow voids are maintained. There is mild mucosal thickening of the paranasal sinuses. There is opacification of of the right greater than left mastoid air cells. The orbits and soft tissues are grossly unremarkable. Partially visualized orogastric and endotracheal tubes are noted with fluid layering ___ the nasopharynx. MRA Head: There is adequate flow related related enhancement of the bilateral internal carotid, middle cerebral, anterior cerebral, vertebral, basilar and posterior cerebral arteries. The distal left M1 and proximal M2 segments demonstrate mildly decreased flow, compared to the right, which may be artifactual. Distal MCA branches demonstrate adequate flow related enhancement bilaterally. The anterior communicating artery is well visualized. The vertebral arteries are codominant. The right posterior communicating artery is well visualized. The left posterior communicating artery is diminutive. No evidence of new aneurysm, stenosis or dissection. No evidence of vascular malformation. MRA Neck: There is a left-sided aortic arch with conventional origin of the major arch branches. There is mild narrowing at the origin of the left internal carotid artery. Otherwise, there is adequate contrast related enhancement of the common carotid, internal carotid and vertebral arteries. There is no evidence of occlusion, stenosis or dissection. There is no significant stenosis of the internal carotid arteries by NASCET criteria. IMPRESSION: 1. No evidence of acute intracranial process. 2. Multiple patchy and confluent regions of FLAIR hyperintensity within the white matter are most likely sequela of severe chronic microvascular ischemic disease. T2/FLAIR hyperintensity at the ___ the pons there is likely related to chronic infarct and/or chronic microvascular ischemic disease. 3. No evidence of high-grade narrowing within the intracranial vasculature. No aneurysm or occlusion identified. 4. Mild narrowing at the origin of the left internal carotid artery. Otherwise no evidence of significant stenosis, occlusion or dissection. No significant stenosis of the internal carotid arteries by NASCET criteria. CTA CHEST ___: IMPRESSION: 1. Near complete collapse of the right lung secondary to secretions/mucus within the right mainstem bronchus. The substantial volume loss has resulted ___ shift of the mediastinum to the right. Bronchoscopy recommended. 2. No pulmonary embolus. 3. Enlargement of the main pulmonary artery is compatible with underlying pulmonary hypertension. 4. Mediastinal lymphadenopathy of indeterminate etiology. ECHO ___: Suboptimal image quality.The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is preserved (LVEF>50%). There is no ventricular septal defect. The right ventricular free wall is hypertrophied. The right ventricular cavity is markedly dilated with moderate global free wall hypokinesis. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. MRA HEAD/NECK ___: IMPRESSION: 1. No evidence of acute intracranial process. 2. Multiple patchy and confluent regions of FLAIR hyperintensity within the white matter are most likely sequela of severe chronic microvascular ischemic disease. T2/FLAIR hyperintensity at the ___ the pons there is likely related to chronic infarct and/or chronic microvascular ischemic disease. 3. No evidence of high-grade narrowing within the intracranial vasculature. No aneurysm or occlusion identified. 4. Mild narrowing at the origin of the left internal carotid artery. Otherwise no evidence of significant stenosis, occlusion or dissection. No significant stenosis of the internal carotid arteries by NASCET criteria. PORTABLE CXR ___: IMPRESSION: Continued right lower lobe collapse. Interval extubation and enteric tube removal. Improvement ___ pulmonary edema. PORTABLE CXR ___: Unchanged left PICC. Aeration of the right lung is essentially unchanged. Right lower lobe consolidation which may represent pneumonia, aspiration, or atelectasis, is unchanged. Cardiomediastinal contours are stable. RUQ U/S ___: FINDINGS: Study is limited by poor acoustic penetration; however, the liver does not show focal lesions. The gallbladder contains multiple shadowing stones measuring up to 2 cm. There is no gallbladder wall thickening or pericholecystic fluid. The gallbladder is distended. There is no intra- or extra-hepatic biliary dilatation and the common bile duct measures 3 mm. The spleen measures 11.3 cm ___ length. There is no ascites. IMPRESSION: Distended gallbladder with gallstones. If there is concern for acute cholecystitis, HIDA scan can be performed. PERTINENT MICRO: ========================================== ___ 6:00 pm SPUTUM Source: Endotracheal. FINAL REPORT ___ GRAM STAIN (Final ___: >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND CLUSTERS. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): BUDDING YEAST. RESPIRATORY CULTURE (Final ___: SPARSE GROWTH Commensal Respiratory Flora. KLEBSIELLA PNEUMONIAE. SPARSE GROWTH. Cefepime AND Piperacillin/Tazobactam sensitivity testing performed by ___. YEAST. SPARSE GROWTH. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE \| AMIKACIN-------------- <=2 S AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- I CEFTAZIDIME----------- 16 R CEFTRIAXONE----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ 8 I TRIMETHOPRIM/SULFA---- =>16 R ___ 5:41 pm SWAB Source: Stool. FINAL REPORT ___ R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (Final ___: ENTEROCOCCUS SP.. Sensitivity testing performed by Etest. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ ENTEROCOCCUS SP. \| VANCOMYCIN------------ >256 R ___ 1:00 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). Brief Hospital Course: BRIEF HOSPITAL COURSE: ========================================== ___ with a PMHx of COPD, cutaneous TCL, rectosigmoid adenocarcinoma (sp radiation and chemotherapy), h/o PE, chronic osteomyelitis, alcoholic neuropathy, hypospadia (cb urethral stricture with chronic foley), recent hospitalization at ___ for Cardiac arrest, recent ESBL UTI, who presented with altered mental status from nursing home, was intubated for hypercarbia respiratory failure ___ PNA) and transferred to ICU for pressor support given hypotension who was successfully extubated and weaned off of pressors, who was transferred out of the MICU on ___, who was s/p 10d course of Zosyn, w/ improved O2 saturations via nasal cannula, but profound deconditioning ___ hospitalization ACTIVE ISSUES: ========================================== #Septic Shock: On admission lactate elevated and pt was hypotensive, but responsive to levophed. Intubation appeared to have precipitated hypotension, possibly ___ setting of pHTN (suggested on CTA). Cardiogenic shock was also on the differential given question of ischemic changes on EKG. Trops however were stable at ~0.04 and CK-MB remained flat. Neurogenic shock unlikely despite initial question of seizures given no seizure activity on EEG and no acute process on CT head. Patient was fluid resuscitated and treated with antibiotics allowing him to clinically improve and be weaned from pressors. # Respiratory Failure/PNA: Pt presented with hypoxemic, hypercarbic respiratory failure. No evidence of PE on CTA; ACS ruled out. Lung process thought likely septic pneumonia complicated by COPD, although no evidence of COPD exacerbation on vent (see below). CT chest revealed near-complete collapse of entire right lung secondary to mucus plugging of the R mainstem bronchus, as well as enlarged pulmonary artery consistent with pHTN, pointing to other contributors to respiratory failure. On follow-up bronchoscopy, copius purulent secretions were suctioned from the R lung; Multi lobar collapse possibly secondary to severe PNA vs. malignancy (there is a note of RUL lung mass ___ record). Pt was started on vancomycin/zosyn/azithromycin. Sputum cultures X2 grew klebsiella sensitive to zosyn and MRSA screen was negative therefor pt was narrowed to zosyn monotherapy. Pt was maintained on the vent and treated with nebulizers, and initially failed to improve: he was difficult to sedate, becoming alternatively apneic and unresponsive and agitated on fent/versed. On ___ he self-extubated but immediately became hypopneic and sedated and required ventilatory support with a bag-valve mask until he could be reintubated. Gradually his respiratory status improved, and by ___ he was weaned to pressure support. Discussions had been underway regarding trach, which patient had undergone ___ the past. The decision was made that since he was on minimal vent settings, he would be given a trial of extubation, but given his volatile respiratory status the team would be ready to reintubate quickly if extubation was unsuccessful, with a plan for trach/peg the following day. Pt was extubated successfully on ___, with no respiratory decompensation. By ___ he was alert and oriented, breathing comfortably, and was transferred to the floor. Thereafter, he maintained O2 saturations via nasal cannula, while finishing course of IV ABX for PNA (Klebsiella sensitive to Zosyn). Pt finished 10 day course of Zosyn on ___. CXR on ___ showed no interval improvement since ___, w/ unchanged RLL opacification. ___ speaking w/ pulm consult service, it was thought that pt would likely need time to recover fxn of that lobe. Accordingly, he was given outpatient pulmonary f/u appt to have such issue re-addressed, as well as pHTN evaluated, and lung nodule re-imaged. # AMS/Delerium: On admission, pt presented ___ acute confusional state, thought likely to be ___ toxic metabolic encephalopathy. No evidence of seizure on EEG. CT head and MRA head both without acute processes. Pt was intermittently agitated and nearly-obtunded on sedation for ventilation, and was started on seroquel QHS. He was successfully extubated on ___, and became alert and oriented within 24 hours. He remained AOx3 thereafter without incident. # Hyperkalemia: Pt presented with a K+ of 7.7, not hemolyzed. He had presented on multiple prior occasions with hyperkalemia of unclear etiology. Differential included RTA vs. ___. No e/o rhabdo, CK normal. No peaked Ts on EKG. Pt given kayexelate, Insulin+D5W, and his K resolved and remained stable thereafter. # ST Depressions: On admission, pt had ST depressions on EKG ___ V1-V3 concerning for ischemia; no prior EKG available for comparison. However his trop and ___ remained flat. TTE showed EF >50%, severe pulmonary hypertension but no evidence of focal wall motion abnormality or systolic dysfunction. # COPD: Status of pt's COPD not clear. No evidence of exacerbation at present. Low auto-PEEP and nearly normal peak pressures on vent. Investigation into OSH records revealed pt does not have a pulmonologist and appears not to have undergone pulmonary function testing; COPD was a presumed diagnosis given difficulty weaning from vent ___ the past. Pt was continued on tiotropium/albuterol nebs; however steroids for COPD exacerbation were not initiated. Prior to discharge, pt was restarted on outpatient regimen of Advair and Tiotropium. Since Ipratropium seemed to be a redundant medication, it was discontinued on discharge. Pt was given outpatient pulmonary f/u appt to have PFTs done, regimen evaluated, pHTN evaluated, and lung nodule re-imaged. #Pulmonary HTN: Given findings on TTE and CTA, severe pHTN was thought to represent the patient's primary chronic respiratory issue rather than COPD. Etiology of pHTN likely chronic OSA given pt's habitus. Thus, it was felt that pt could benefit from and R heart catheterization ___ future. Accordingly, he was provided with a pulmonary f/u appt where such test can be scheduled. #Guiac +, Maroon Streaked Stool ___ the ICU, pt was noted to have guiac positive stool, not on anticoagulation, but Hct remained stable throughout. On admission to the medicine floor, nurses noted that pt had maroon colored blood swirled into soft brown stool. Pt had hx of rectosigmoid ca s/p XRT/Chemo so could possible represent anastamotic issues, radiation proctitis, recurrent malignancy or more likely gastritis, or gastric ulcer from critical illness and intubation. Pt was without elevated coags or abnormalities ___ platelets. His Hct was trended and remained stable. He was continued on a PPI and did not require blood transfusions. However, he will need outpatient gastroenterology follow up to have colonoscopy/endoscopy evaluation. # Hypothyroidsim: Levothyroxine continued. # ___ on CKD: Cr baseline is 1.4, of unknown etiology. Increased to max of 2.3 on ___, likely ___ aggressive diuresis given elevated bicarb and dry MM on exam. Pt given 250cc boluses, and lasix held thereafter, causing Cr to downtrend to baseline prior to discharge. # HTN: Pt hypotensive on arrival, antihypertensives held. Occasionally would become hypertensive to 160s when agitated on the vent, but required no interventions. By time of discharge, pt was restarted on home dose metoprolol XL. TRANSITIONAL ISSUES: =============================================== 1. Pt was given outpatient pulmonary f/u appt to have PFTs done, COPD regimen evaluated, pHTN evaluated, lung nodule re-imaged, and for discussion of possible therapy w/ intention to re-expand chronically collapsed right lower lobe of lung 2. Pt had a R lung nodule identified w/ mediastinal lymphadenopathy on CT scan and it is recommended that he have repeat CT Chest as outpatient after pneumonia clears to better characterize lesion. 3. Pt needs outpatient follow up with Urology for hypospadia 4. Pt should follow up with ___ provider for general health care maintenance 5. Pt would benefit from continued physical/occupational therapy to recover from profound deconditioning 6. Pt was found to have Guiac positive stool, thought to be ___ gastritis, but will need to be evaluated as an outpatient by gastroenterologist with endoscopy and colonoscopy. 7. Pt may benefit from speech and swallow re-evaluation # Communication: Patient; Son ___ ___ # Code: Full CODE Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 975 mg PO Q8H:PRN pain 2. Senna 8.6 mg PO DAILY:PRN constipation 3. Omeprazole 40 mg PO DAILY 4. Multivitamins 1 TAB PO DAILY 5. Bisacodyl 10 mg PO DAILY:PRN constipation 6. Albuterol Inhaler 4 PUFF IH Q4H:PRN SOB 7. Tiotropium Bromide 1 CAP IH DAILY 8. Doxycycline Hyclate 100 mg PO Q12H 9. Metoprolol Succinate XL 75 mg PO DAILY 10. Vitamin D ___ UNIT PO BID 11. Vitamin E 400 UNIT PO DAILY 12. Artificial Tears ___ DROP BOTH EYES PRN dry eyes 13. Levothyroxine Sodium 75 mcg PO DAILY 14. Ipratropium Bromide MDI 2 PUFF IH BID 15. Nystatin-Triamcinolone Cream 1 Appl TP BID:PRN rash 16. Simethicone 40 mg PO TID:PRN gas 17. Pregabalin 75 mg PO TID 18. Mirtazapine 7.5 mg PO HS 19. ClonazePAM 0.25 mg PO BID 20. Fluticasone Propionate NASAL 1 SPRY NU DAILY 21. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 22. Guaifenesin ___ mL PO Q6H:PRN cough Discharge Medications: 1. Albuterol Inhaler 4 PUFF IH Q4H:PRN SOB 2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes 3. Bisacodyl 10 mg PO DAILY:PRN constipation 4. ClonazePAM 0.25 mg PO BID 5. Fluticasone Propionate NASAL 1 SPRY NU DAILY 6. Levothyroxine Sodium 75 mcg PO DAILY 7. Metoprolol Succinate XL 75 mg PO DAILY 8. Mirtazapine 7.5 mg PO HS 9. Multivitamins 1 TAB PO DAILY 10. Omeprazole 40 mg PO DAILY 11. Pregabalin 75 mg PO TID 12. Senna 8.6 mg PO DAILY:PRN constipation 13. Simethicone 40 mg PO TID:PRN gas do not take at same time as thyroid medication 14. Tiotropium Bromide 1 CAP IH DAILY 15. Vitamin D ___ UNIT PO BID 16. Vitamin E 400 UNIT PO DAILY 17. Acetaminophen 975 mg PO Q8H:PRN pain 18. Nystatin-Triamcinolone Cream 1 Appl TP BID:PRN rash 19. Doxycycline Hyclate 100 mg PO Q12H 20. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 21. Guaifenesin ___ mL PO Q6H:PRN cough Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Hypercarbic Respiratory Failure Health Care Acquired Pneumonia c/b Septic Shock ___ on CKD COPD GI Bleed Pulmonary Hypertension Hypothyroidism Discharge Condition: Discharge Condition: Stable Mental Status: AOx3 (baseline) Ambulatory Status: Bed Bound requiring assistance w/ most ADLs Discharge Instructions: Mr. ___, It was a pleasure taking care of you while you were hospitalized at ___. As you know, you were admitted for concern that your breathing had worsened and you were found to have a pneumonia that required intubation and a prolonged stay ___ our intensive care unit. Fortunately, you improved markedly thereafter and finished your course of antibiotics. You will likely require oxygen supplementation for some time and will need to be evaluated by a pulmonologist after discharge. Additionally, there are a number of other medical issues that you need to have follow up appointments for evaluation. Please see the attached sheet for full details. We wish you a speedy recovery!!! Followup Instructions: ___
10021395-DS-21	10,021,395	24,726,474	DS	21	2132-12-20 00:00:00	2132-12-21 05:54:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: amitriptyline / Cholestyramine / Dicloxacillin / diltiazem / niacin / amlodipine Attending: ___. Chief Complaint: Dizziness Major Surgical or Invasive Procedure: None History of Present Illness: ___ F with medical history notable for severe AS s/p TAVR (___), resistant hypertension, PMR on chronic prednisone, and cryptogenic stroke (___), who presented with dizziness and hypertension. Per patient, she was feeling well until x1 day prior to admission when she developed sensation of dizziness and feeling "flushed" while eating lunch. She described dizziness as feeling lightheaded, does not feel that things are spinning around her. She reports the episodes of dizziness were similar to her prior episodes for which she has been hospitalized for 8 times. She does not feel that the episodes are correlated with her blood pressure. Due to persistence of her symptoms, she presented to the ED for further evaluation. She denied headache, lightheadedness, vision changes, hearing changes, CP/palp, dyspnea, nausea/vomiting, dysuria, abdominal pain, change in ___ edema. Of note, she was seen by her PCP ___ ___ and her valsartan was increased from 160mg to 320mg due to ongoing hypertension. She was also recently treated for LLE cellulitis vs venous stasis changes with course of augmentin ___. In the ED: -Initial VS: 97.8 74 162/86 18 100% RA -Work-up notable for labs with stable hyponatremia, NCHCT and CXR negative for acute process, orthostatics negative x2 -She received: ___ 19:45 PO CloNIDine .1 mg ___ ___ 19:45 PO/NG HydrALAZINE 25 mg ___ ___ 19:45 PO Acetaminophen 650 mg ___ ___ 19:52 PO/NG Simvastatin 20 mg ___ ___ 20:00 PO/NG PredniSONE ___ Not Given ___ 08:37 PO CloNIDine .1 mg ___ ___ 08:37 PO/NG Aspirin 81 mg ___ ___ 08:37 PO/NG Clopidogrel 75 mg ___ ___ 08:37 PO/NG HydrALAZINE 25 mg ___ ___ 09:20 PO/NG Ascorbic Acid ___ mg ___ ___ 09:20 PO/NG Vitamin D 1000 UNIT ___ ___ 09:20 PO/NG PredniSONE 2 mg ___ ___ 12:59 PO/NG Valsartan 320 mg -Consults: ___ recommended home with ___ when medically cleared -VS on transfer: 98.2 56 161/84 14 99% RA Decision was made to admit for ongoing management of worsening lightheadedness with standing, increasing hypertension. On arrival, patient reports her dizziness has been constant since noon yesterday. She came to the ED because her symptoms have lasted longer than her usual episodes of dizziness. She feels lightheaded, does not feel things are spinning. Her symptoms are significantly improved when she lies flat. She does report some pain in her lower extremities, which she attributes to Nifedipine which has been stopped. She was also treated with Augmentin for cellulitis. She currently denies fevers, chills, chest pain, shortness of breath, nausea, vomiting, abdominal pain, dysuria, diarrhea, constipation, leg swelling. Past Medical History: Subacute L temporal and R occipital infarcts (cryptogenic stroke ___ H pylori infection HTN Dyslipidemia Severe aortic stenosis s/p TAVR PMR Temporal arteritis SIADH Hyponatremia Spinal stenosis Osteopenia Macular degeneration Cataracts Leukopenia Iron def anemia Deviated septum Social History: ___ Family History: Reviewed and found to be not relevant to this illness/reason for hospitalization. Physical Exam: DISCHARGE: 24 HR Data (last updated ___ @ 1544) Temp: 97.9 (Tm 98.7), BP: 181/93 (135-201/68-110), HR: 51 (45-59), RR: 16 (___), O2 sat: 99% (96-99), O2 delivery: RA, Wt: 107.8 lb/48.9 kg General: well appearing female sitting comfortably Neck: No JVD. No LAD Lungs: CTAB CV: Regular rate and rhythm, normal S1 and S2. ___ systolic murmur at apex. Flow murmur heard at RUSB GI: Bowel sounds present, nontender to palpation, no organomegally noted Ext: No lower extremity edema, erythematous skin changes over LLE, lower extremities TTP. Neuro: No focal neurologic deficits. Pertinent Results: LABS: ___ 03:40PM WBC-3.4* RBC-3.71* HGB-11.5 HCT-34.1 MCV-92 MCH-31.0 MCHC-33.7 RDW-13.8 RDWSD-46.3 ___ 03:40PM ___ PTT-27.7 ___ ___ 03:40PM CK-MB-3 cTropnT-<0.01 ___ 03:40PM GLUCOSE-100 UREA N-24* CREAT-0.7 SODIUM-134* POTASSIUM-4.6 CHLORIDE-97 TOTAL CO2-23 ANION GAP-14 IMAGING: -NCHCT ___: IMPRESSION: No acute intracranial process. -CXR ___: IMPRESSION: No acute cardiopulmonary process. Brief Hospital Course: ___ F with medical history notable for severe AS s/p TAVR (___), resistant hypertension, PMR on chronic prednisone, and cryptogenic stroke (___), who presented with dizziness and hypertension. Etiology of recurrent dizziness unclear - possibly due to recent medication change (increased valsartan) vs decreased po intake vs hypertension. # Hypertensive urgency: # Resistant hypertension Patient with long-standing resistant hypertension complicated by large variability in BPs and associated dizziness. Etiology thought to be due to secondary hyporeninism and adrenal adenoma as well as 60% right renal artery stenosis resulting in resistant hypertension. She has been trialed on multiple medications in the past. Due to AM hypertension, her valsartan was changed from daily to BID dosing at increased dose. She was continued on clonidine and hydralazine. # Dizziness: Patient with recurrent dizziness, with work-up notable for negative NCHCT, negative orthostatics. On previous admission, work-up including CTA H/N, TTE negative for acute process. Etiology thought to be due to recent medication titration, possibly poor po intake, and deconditioning. Orthostatics were negative on multiple checks. She was able to ambulate without difficulty prior to discharge. # Chronic neutropenia: Received heme work-up in past, thought to be benign. At baseline -Continue to trend # Severe AS s/p TAVR: Most recent TTE (___) notable for well-seated valve. -Continue ASA and Plavix # PMR: -Continue home prednisone # HLD: -Continue simvastatin # Venous stasis dermatitis: -Continue compression stockings, elevation TRANSITIONAL ISSUES: [] Recommend close monitoring of BPs and medication titration as appropriate [] Consider transition to clonidine patch # Emergency contact: Name of health care proxy: ___ Phone number: ___ Comments: home ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. CloNIDine 0.2 mg PO BID 3. Clopidogrel 75 mg PO DAILY 4. Multivitamins W/minerals 1 TAB PO DAILY 5. Simvastatin 20 mg PO QPM 6. Ascorbic Acid ___ mg PO DAILY 7. Calcium 500 + D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -200 unit oral DAILY 8. Fish Oil (Omega 3) 1000 mg PO DAILY 9. PredniSONE 2 mg PO DAILY 10. Valsartan 320 mg PO DAILY 11. Senna 17.2 mg PO QHS:PRN Constipation - First Line 12. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second Line 13. HydrALAZINE 25 mg PO TID Discharge Medications: 1. Valsartan 160 mg PO BID RX valsartan 160 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:*0 2. Ascorbic Acid ___ mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Calcium 500 + D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -200 unit oral DAILY 5. CloNIDine 0.2 mg PO BID 6. Clopidogrel 75 mg PO DAILY 7. Fish Oil (Omega 3) 1000 mg PO DAILY 8. HydrALAZINE 25 mg PO TID 9. Multivitamins W/minerals 1 TAB PO DAILY 10. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second Line 11. PredniSONE 2 mg PO DAILY 12. Senna 17.2 mg PO QHS:PRN Constipation - First Line 13. Simvastatin 20 mg PO QPM Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY: Hypertensive urgency Dizziness Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, WHY WAS I ADMITTED TO THE HOSPITAL? You were dizzy and your blood pressure was high WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? We monitored your blood pressure closely We checked for causes of your dizziness, including infection, a stroke, dehydration - all work-up was unrevealing You met with the physical therapy team who felt you were walking around well WHAT SHOULD I DO WHEN I GO HOME? Please take your medications as prescribed Move slowly from sit to stand to monitor for lightheadedness Thank you for letting us be a part of your care! Your ___ Team Followup Instructions: ___
10021487-DS-22	10,021,487	26,321,862	DS	22	2117-02-05 00:00:00	2117-02-05 17:40:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Penicillins Attending: ___. Chief Complaint: Necrotic liver lesion post trauma Major Surgical or Invasive Procedure: ___ CT Guided Placement of Percutaneous transhepatic drains ___: Replacement of pigtail drain History of Present Illness: ___ s/p MVC on ___ and was transferred ___ from an OSH with multiple injuries. On admission for the trauma he was found to have an acute abdomen and was hypotensive so he was taken emergently to the operating room where he was found to have an avulsion ___ the small bowel requiring resection and a multiple liver lacerations, which were packed, and debridement of liver fragments. He was then brought to the ICU and urgently brought back ___ for ex-lap where 750 cc of fresh blood was found. It was thought that the bleeding was stopped and a small liver biopsy was taken. Post operatively patient was brought to the ICU and was re-scanned on ___ and found to have large necrotic liver lesion, right posterior. On ___ ___ drain was placed. Patient was put on levo for MSSA that grew out of BAL and flagyl for B.frag that grew out of drain ___ liver lesion. Antibiotics were completed on ___ and pt was disharged on ___. Since that time he has been having intermittent fevers every ___ day up to 101.7 as max ___ the evening that resolve 1 hour after getting tylenol. On ___ he noted new brown milky drainage from the catheter site and again had a temperature to 101.5. On ___ he developed ___ abdominal pain at the drain site and ___ the RUQ. when he called the ___ office he was instructed to come to the ED. He reports that he is passing gas and moving his bowels normally. ___ the ED his abdominal pain began to resolve. He got a CT scan that shwoed similar size to necrotic liver lesion as seen on CT scan from ___. Past Medical History: s/p Left ankle ORIF s/p removal of adenoids Social History: ___ Family History: Noncontributory Physical Exam: 98.8 106 110/69 16 97 RA Gen: A+Ox3 CV: RRR S1 S2 Lungs: CTA B/L Abd: soft, mild tenderness most at drain site on rt lateral abdomen and RUQ, no R/G Extr: no edema Imaging: ___: CT torso: No change ___ the size of a 10.1 x 8.0 x 15.1 cm segment VI and VII hepatic Preliminary Reportabscess with a drain noted ___ appropriate position. ___ CXR: No significant change with stable right pleural effusion with basilar atelectasis and air-fluid level ___ the right upper quadrant compatible with known right hepatic lobe collection. Pertinent Results: ___ 07:00PM BLOOD WBC-6.9 RBC-3.20* Hgb-8.4* Hct-27.5* MCV-86 MCH-26.2* MCHC-30.5* RDW-15.8* Plt ___ ___ 06:25AM BLOOD WBC-10.6# RBC-3.20* Hgb-8.3* Hct-27.6* MCV-86 MCH-26.0* MCHC-30.2* RDW-17.4* Plt ___ ___ 06:25AM BLOOD ___ PTT-30.5 ___ ___ 07:00PM BLOOD ___ PTT-28.5 ___ ___ 07:00PM BLOOD Glucose-91 UreaN-4* Creat-0.4* Na-130* K-4.1 Cl-93* HCO3-29 AnGap-12 ___ 06:25AM BLOOD Glucose-108* UreaN-3* Creat-0.4* Na-133 K-3.9 Cl-97 HCO3-29 AnGap-11 ___ 07:00PM BLOOD ALT-11 AST-17 LD(LDH)-143 AlkPhos-85 TotBili-0.7 ___ 06:25AM BLOOD ALT-7 AST-15 AlkPhos-63 TotBili-0.5 ___ 09:05PM BLOOD Vanco-7.0* ___ 2:52 am PERITONEAL FLUID FINAL REPORT ___ GRAM STAIN (Final ___: THIS IS A CORRECTED REPORT ___. CORRECTIONS Reported to and read back by ___ ___ 13:00. 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND CHAINS. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). PREVIOUSLY REPORTED AS ___. 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND CHAINS. Reported to and read back by ___. ___ ON ___ AT 0600. FLUID CULTURE (Final ___: SENSITIVITIES REQUESTED BY ___. STREPTOCOCCUS ANGINOSUS (___) GROUP. HEAVY GROWTH. ___. ___ ___ REQUESTED SENSITIVITIES TO LEVOFLOXACIN. Sensitivity testing performed by Sensititre. SENSITIVE TO CLINDAMYCIN MIC <=0.12MCG/ML. ___ ALBICANS. SPARSE GROWTH. SENSITIVE TO Fluconazole , sensitivity testing performed by ___ ___. This test has not been FDA approved but has been verified following Clinical and Laboratory Standards Institute guidelines by ___ Clinical ___ Laboratory.. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ STREPTOCOCCUS ANGINOSUS (___) GROUP \| CLINDAMYCIN----------- S ERYTHROMYCIN----------<=0.25 S LEVOFLOXACIN---------- 0.5 S PENICILLIN G----------<=0.06 S VANCOMYCIN------------ <=1 S ANAEROBIC CULTURE (Final ___: PREVOTELLA SPECIES. HEAVY GROWTH. BETA LACTAMASE POSITIVE. BACTEROIDES FRAGILIS GROUP. SPARSE GROWTH. BETA LACTAMASE POSITIVE. ___ 4:30 pm ABSCESS Source: liver abscess. FINAL REPORT ___ GRAM STAIN (Final ___: 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND CHAINS. Reported to and read back by ___ ON ___ @955 ___. SMEAR REVIEWED; RESULTS CONFIRMED. FLUID CULTURE (Final ___: STREPTOCOCCUS ANGINOSUS (___) GROUP. SPARSE GROWTH. ANAEROBIC CULTURE (Final ___: PREVOTELLA SPECIES. MODERATE GROWTH. BETA LACTAMASE NEGATIVE. BACTEROIDES FRAGILIS GROUP. SPARSE GROWTH. BETA LACTAMASE POSITIVE. ___ Blood cultures, negative ___ and ___, Blood cultures pending Brief Hospital Course: ___ s/p MVC with multiple injuries including liver lacerations with necrotic liver lesion and adjoining collection that has not been resolving. He was admitted to the ___ for further management. IV Unasyn and Flagyl were started on ___. He was pan-cultured. CXR demonstrated right pleural effusion and air-fluid level ___ the RUQ compatible with known right hepatic lobe collection which was stable from previous CXR. An abdominal CT scan was done which showed no change ___ the size of a large complex hepatic collection with unchanged position of pigtail drain. (liver segment VI and VII 10.1 x 8.0 x 15.0 cm complex collection containing nondependent air and complex fluid extending along the inferior edge of the liver along the lateral conal fascia with a small drain within the fluid collection). Drain outputs averaged 150-190cc/day of beige thick drainage. Fluid from this drain were sent to micro. Culture isolated pan sensitive Strep anginosus ___. On ___, he underwent CT guided exchange over wire of an 8 ___ catheter positioned within the most inferior anterior aspect of a right hepatic lobe abscess. A new 8 ___ drainage catheter was placed into the more superior portion of the hepatic abscess. New drain fluid output was sent for culture. Postop procedure he spiked a temperature of 102. IV Vancomycin was added to his regimen. Outputs from the new drain averaged ___ cc/day. Fluconazole was added on ___. New drain cultures isolated sparse streptococcus anginosus (___). Anaerobic culture isolated moderate growth of Prevotella, beta lactamase negative, and sparse growth Bacteroides fragilis, beta lactamase positive. The original catheter required repair by radiology for a cracked piece at the adapter. Two days later, the new drain (more medial/inferior drain) had dislodged approximately 1.5cm necessitating exchange over wire on ___. Vital signs remained stable. The drains were flushed with 10ml of saline bid. ID was consulted and recommended IV antibiotics for ___ weeks for optimal coverage. However, the patient is from N.H. and does not have insurance, therefore an oral antibiotic regimen was recommended which consisted of Levaquin 750 mg QD, Flagyl 500 mg tid and Fluconazole 400 mg daily for 6 weeks with f/u CT and ID follow up. Scripts for 6 week course of these antibiotics were provided. ___ addition, applications for free or reduced drug supply from each pharmaceutical company for fluc/Flagyl and Levo were completed. He was also given scripts for 5 day supplies for antibiotics pending delivery of drugs to Dr. ___ for patient to pick up at f/u visit on ___. Medications on Admission: HYDROMORPHONE 2, CALCIUM, CHOLECALCIFEROL (VITAMIN D3), DOCUSATE SODIUM, MVI Discharge Medications: 1. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H Duration: 6 Weeks RX metronidazole 500 mg 1 tablet(s) by mouth q8 Disp #126 Tablet Refills:0 2. Levofloxacin 750 mg PO Q24H Duration: 6 Weeks RX levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #42 Tablet Refills:0 3. Fluconazole 400 mg PO Q24H Duration: 6 Weeks RX fluconazole 200 mg 2 tablet(s) by mouth once a day Disp #84 Tablet Refills:0 4. Docusate Sodium 100 mg PO TID 5. Acetaminophen 325-650 mg PO Q6H:PRN fever/pain 6. Vitamin D 400 UNIT PO DAILY 7. Calcium Carbonate 500 mg PO TID 8. HYDROmorphone (Dilaudid) 4 mg PO Q4H:PRN pain RX hydromorphone 4 mg 1 tablet(s) by mouth every four (4) hours Disp #42 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: Hepatic necrotic abscess s/p ___ drainage and placment of 2 hepatic drains 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 care of your hepatic necrotic abscess. While you were ___ the hospital, your previous drain was upsized and another superior drain was placed. You will need to care for your drains by flushing with 10cc three times a day. You may shower with your drains but do not scrub or swim. You may wear regular clothing but avoid tugging/pulling. Please call if you have fevers, chills, rigors, pain, redness around the site, increased output, change ___ the color or consitency or signs of drain blockage. Followup Instructions: ___
10021487-DS-25	10,021,487	27,112,038	DS	25	2117-10-29 00:00:00	2117-10-29 14:14:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Penicillins Attending: ___. Chief Complaint: Fevers, abdominal pain Major Surgical or Invasive Procedure: Abdominal abscess pigtail drain ___ History of Present Illness: ___ who was involved ___ a MVC requiring ex-lap, ileocecectomy c/b hemoperitoneum requiring takeback < 24 hours. Eventually this patient presented with a suspect enteric fistula and liver abscess which then the transplant surgical service did an ex-lap, drainage of abscess and ileocolectomy with ileocolonic anastamosis. During this last hospitalization, his abscess was polymicrobial and recieved V/C/F. Eventually his antibiotics were switched over to Augmentin on discharge. He was last seen approximately on ___ at which time a CT of the abdomen revealed a marked improvement ___ the abscess cavity with a residual fluid collection measuring 6.7 x 3.5 cm. His last remaining drain was removed at that time as it was only putting out 5 cc/day of serous fluid. Per ID, given the persistance of this collection, the decision was to continue augmentin for 2 more weeks, which it appears the patient did not do. Was doing well since then. No complaints. Good PO intake. 2 days ago developed abdominal pain, felt a "mass" where previous JP drain sites were. No N/V, +flatus. This AM developed fever of 101. Took some advil and tylenol and called ___ and was informed to come to ED for further eval. Patient currently denies any other symptoms other than RUQ abdominal pain. Of note patient has been slowly tapering off pain medications since last year. Past Medical History: MVC with liver lacs leading to necrotic liver lesion PSH: Exploratory laparotomy, washout of hemoperitoneum, debridement of laceration of the liver, ileocecectomy, ileocolostomy. s/p Left ankle ORIF s/p removal of adenoids ___: 1. Exploratory laparotomy and lysis of adhesions. 2. Debridement of liver. 3. Ileocolectomy with ileocolonic anastomosis Social History: ___ Family History: Noncontributory Physical Exam: PE: 96.7 114 119/93 14 96% RA NAD, A+OX3 no scleral icterus RRR CTAB Soft, TTP RUQ mainly over JP site. Mass felt with bowel noises likely overlying bowel versus fluid collection. No cellulitis. No peritoneal signs. MIdline scar well healed no hernias felt. no flank pain b/l no c/c/e Labs: CBC: 12.5 (86N)/44.4/198 Chem: ___ LFT: 151/96/291/1.1 ___ - ___ Coag: 12.5/33.8/1.2 Lactate: 1.0 Pertinent Results: ___ 04:00PM BLOOD WBC-12.5# RBC-5.05 Hgb-14.3 Hct-44.4 MCV-88 MCH-28.4 MCHC-32.2 RDW-14.5 Plt ___ ___ 05:40AM BLOOD WBC-5.5# RBC-4.65 Hgb-13.4 Hct-40.5 MCV-87 MCH-28.8 MCHC-33.1 RDW-14.4 Plt ___ ___ 06:30AM BLOOD ___ PTT-29.2 ___ ___ 04:00PM BLOOD Glucose-106* UreaN-14 Creat-0.7 Na-136 K-4.2 Cl-100 HCO3-26 AnGap-14 ___ 05:40AM BLOOD Glucose-87 UreaN-14 Creat-0.7 Na-140 K-4.4 Cl-102 HCO3-30 AnGap-12 ___ 04:00PM BLOOD ALT-151* AST-96* AlkPhos-291* TotBili-1.1 ___ 05:40AM BLOOD ALT-65* AST-32 AlkPhos-198* TotBili-0.3 ___ Blood cultures: negative to date, unfinalized ___ rectal swab VRE negative ___ 10:00 am ABSCESS HEPATIC ABSCESS. GRAM STAIN (Final ___: 3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS, CHAINS, AND CLUSTERS. 2+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S). 2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S). WOUND CULTURE (Preliminary): 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 BELOW, THEY ARE NOT PRESENT ___ this culture.. WORK UP PER ___ ___. CITROBACTER FREUNDII COMPLEX. SPARSE GROWTH. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. ESCHERICHIA COLI. SPARSE GROWTH. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ CITROBACTER FREUNDII COMPLEX \| ESCHERICHIA COLI \| \| AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CIPROFLOXACIN---------<=0.25 S <=0.25 S GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S PIPERACILLIN/TAZO----- <=4 S <=4 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S ANAEROBIC CULTURE (Preliminary): RESULTS PENDING. Brief Hospital Course: ___ w h/o MVC ex-lap, ileocecetomy developed liver abscess and enteric fistula s/p debridement and ileocolectomy. Patient had large fluid collection before drain was pulled presented with fevers, elevated LFT and new onset abdominal pain near fluid collection, worrisome for infected fluid collection and/or new liver abscess. Other ddx included cholecystitis and abscess near ileocolonic anastamosis. He was pan cultured and started on IV Vanco, Cipro and Flagyl. CT Abd/Pelvis with PO and IV contrast was done showing 7.5 x 3.5 x 13.3 cm (TV x AP x CC) subhepatic collection extending up to the anterolateral abdominal wall ___ the region of the prior drain. The previous perihepatic collection located more posteriorly was nearly resolved with a small amount of residual fluid remaining. On ___ he had a temperature spike to 102. He then underwent CT-guided placement of an 8 ___ catheter inside right mid abdomen abscess. There was no communication of the adjacent bowel was demonstrated. Drainage was from collection was sent to microbiology. Drain output was purulent. He remained afebrile with wbc decreasing to 5.5 from 12. Drain output averaged 40cc/d then decreased to 20cc/d. Drain was flushed with saline and flush came out of drain insertion site. Drain output decreased to scant output. Micro isolated pansensitive Citrobacter and E. coli. ID was consulted and recommended oral Cipro 500mg bid and Flagyl 500mg tid for 2 weeks then f/u CT. Instructions for drain care were provided. Drain flushes were stopped. He felt well and was discharged to home. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. OxycoDONE (Immediate Release) 7.5 mg PO Q6H:PRN pain 2. Acetaminophen ___ mg PO Q8H:PRN pain maximum 3 grams daily 3. Docusate Sodium 100 mg PO BID 4. Senna 1 TAB PO BID:PRN constipation 5. Milk of Magnesia 30 mL PO PRN constipation 6. Calcium Carbonate 500 mg PO TID 7. Vitamin D 400 UNIT PO DAILY 8. Multivitamins 1 TAB PO DAILY 9. Ibuprofen 600 mg PO Q8H:PRN pain Discharge Medications: 1. Docusate Sodium 100 mg PO BID 2. Multivitamins 1 TAB PO DAILY 3. Senna 1 TAB PO BID:PRN constipation 4. Vitamin D 400 UNIT PO DAILY 5. Acetaminophen ___ mg PO Q8H:PRN pain 6. Milk of Magnesia 30 mL PO PRN constipation 7. Ibuprofen 600 mg PO Q8H:PRN pain 8. Ciprofloxacin HCl 500 mg PO Q12H RX ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp #28 Tablet Refills:0 9. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H RX metronidazole 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #42 Tablet Refills:0 10. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain your PCP ___ write script Discharge Disposition: Home Discharge Diagnosis: Right mid intra-abdominal abscess (citrobacter and Ecoli isolated) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call Dr ___ office at ___ if you experience fever (temperature of 101 or greater), chills, increased abdominal pain, the drainage from the abdominal drain changes ___ appearance, develops a foul odor, becomes bloody, increases significantly or stops completely, you develop nausea, vomiting or diarrhea. Please drain and record the drainage from the abdominal drain twice daily and as needed. Keep a copy of the output amounts and bring this record with you to the office for appointments. Do not flush catheter at this time unless instructed to flush. Change the dressing around the drain site daily. Do not tuck dressings under the tubing. Report any drainage or bleeding and if the tube appears dislodged. You may shower, allow water to run over the site and pat area dry. Do not rub, apply lotions or powders or allow the drain to hang freely at any time. Please continue antibiotics as ordered No heavy lifting No driving if taking narcotic pain medication and avoid all alcoholic beverages Followup Instructions: ___
10021621-DS-6	10,021,621	29,271,862	DS	6	2169-03-13 00:00:00	2169-03-13 16:03:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: ___, overall healthy with R radius fracture secondary to gun shot wound Major Surgical or Invasive Procedure: Irrigation and debridement and ORIF of R radius fracture History of Present Illness: Patient is an otherwise healthy RHD ___ with no sig PMH who presents s/p GSW to R forearm at approximately 1:15AM on ___. He was outside a bar in ___ when he reports he was shot by an unknown person. He noted immediate pain and bleeding in his right upper extremity, no other sites of pain or injury.. He was brought to ___ and received 1g Ancef and TDAP. He was placed into a volar resting splint. X-rays demonstrated a comminuted midshaft radius fracture consistent with ballistic injury. He was subsequently transferred to ___ for definitive care. On evaluation in the emergency department the patient reports sensation to all of his fingers although notes difficulty moving. He has no other sites of pain. He noted immediate bleeding after the injury, but it has since stabilized since being placed into a splint at the outside hospital. He denies chest pain, shortness of breath, abdominal pain. Review of systems is otherwise Past Medical History: Denies Social History: ___ Family History: Non contributory Physical Exam: Vitals: ___ Temp: 98.7 PO BP: 131/75 L Lying HR: 74 RR: 18 O2 sat: 98% O2 delivery: Ra General: Resting in bed with arm elevated MSK: RUE - forearm in a sugar tong splint, c/d/i - soft and compressible forearm compartments - appropriately tender, but no pain out of proportion and just appropriate surgical pain with passive movement of his fingers that actually improves with continued movement - SILT R/M/U distributions. -Able to adduct and abduct fingers, flexes at MCP, PIP and DIP on all digits, makes ok sign, thumbs up and crosses fingers. - Fires EPL, FHL, DIO fire Pertinent Results: ___ 09:52AM BLOOD WBC-12.9* RBC-4.67 Hgb-13.9 Hct-39.8* MCV-85 MCH-29.8 MCHC-34.9 RDW-13.1 RDWSD-40.3 Plt ___ Brief Hospital Course: Patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have a fracture in his right radius secondary to gunshot wound and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for irrigation and debridement and open reduction internal fixation of right radius fracture, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given ___ antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to home was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is non weightbearing in the right upper extremity, and will be discharged on aspirin 325 mg for DVT prophylaxis. The patient will follow up with Dr. ___ in 2 weeks at the orthopedic trauma clinic. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Medications on Admission: None Discharge Medications: 1. Acetaminophen 650 mg PO 5X/DAY RX acetaminophen 325 mg 650 mg by mouth four times a day Disp #100 Capsule Refills:0 2. Aspirin 325 mg PO DAILY Duration: 28 Days RX aspirin ___ Aspirin] 325 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 3. Docusate Sodium 100 mg PO BID 4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate RX oxycodone 5 mg 1 to 2 tablet(s) by mouth every four (4) hours as needed Disp #50 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: Gunshot wound to right forearm with highly comminuted radial shaft fracture with radial artery laceration Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: -Non weight bearing right upper extremity MEDICATIONS: 1) Take Tylenol ___ every 6 hours around the clock. This is an over the counter medication. 2) Add ** as needed for increased pain. Aim to wean off this medication in 1 week or sooner. This is an example on how to wean down: Take 1 tablet every 3 hours as needed x 1 day, then 1 tablet every 4 hours as needed x 1 day, then 1 tablet every 6 hours as needed x 1 day, then 1 tablet every 8 hours as needed x 2 days, then 1 tablet every 12 hours as needed x 1 day, then 1 tablet every before bedtime as needed x 1 day. Then continue with Tylenol for pain. 3) Do not stop the Tylenol until you are off of the narcotic medication. 4) Per state regulations, we are limited in the amount of narcotics we can prescribe. If you require more, you must contact the office to set up an appointment because we cannot refill this type of pain medication over the phone. 5) Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and continue following the bowel regimen as stated on your medication prescription list. These meds (senna, colace, miralax) are over the counter and may be obtained at any pharmacy. 6) Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. 7) Please take all medications as prescribed by your physicians at discharge. 8) Continue all home medications unless specifically instructed to stop by your surgeon. ANTICOAGULATION: - Please take <<<<<>>>> 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. - If you have a splint in place, splint must be left on until follow up appointment unless otherwise instructed. Do NOT get splint wet. Followup Instructions: ___
10021704-DS-12	10,021,704	29,777,036	DS	12	2132-04-02 00:00:00	2132-04-03 07:04:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: codeine Attending: ___. Chief Complaint: dyspnea Major Surgical or Invasive Procedure: Bronchoscopy ___ History of Present Illness: Mr. ___ is a ___ man with a history of CAD s/p 3 MI's & 5 stents on dual antiplatelet therapy (aspirin & brilinta), T2DM, asthma, and left rotator cuff repair on ___, complicated by pneumonia requiring ICU stay & intubation who was discharged 9 days ago, now presenting as a transfer from ___ with malaise, fatigue, worsening of baseline chronic dry cough. Of note patient also endorses BRBPR times approximately ___ weeks. He never felt back to baseline after being discharged from ___. He has gotten progressively more fatigued over the past week, with worsening dyspnea on exertion and cough. He has had poor PO intake during this time. No fevers, but occasional chills. His physical therapist evaluated him today & recommended he come to the ED for evaluation. At ___, chest x-ray showed probable pneumonia. Patient was sent having already been given Zosyn, Levoquin, vancomycin, 1 L normal saline, negative tropes, blood cultures ×2. Patient received a DRE at ___, positive guaiac and positive internal hemorrhoid. - ___ the ED, initial VS were: 98 68 107/64 20 99% RA - Exam notable for: Rales ___ bilateral bases, no DtP, no accessory mm. use Rectal exam with guaiac pos stool and presence of internal hemorrhoid - Labs showed: Lactate 1.3. WBC 8.6, 74% PMN's without bands - Imaging showed: CXR PA & Lat Extensive multi lobar interstitial opacities with background ground-glass opacities bilaterally with volume loss, suggestive of infectious or inflammatory etiology. Correlate with outside hospital course ___ prior disease and consider sputum culture. - Patient received: Zosyn, Levoquin, Vancomycin, 1 L normal saline all at ___ - Transfer VS were: 98.2 59 117/63 15 98% 3L NC On arrival to the floor, patient reports fatigue. He continues to have a dry cough. He has no dyspnea at rest or with talking, but dyspnea with minor exertion. Past Medical History: - recent left rotator cuff surgery c/b PNA requiring intubation - HTN - HLD - Obesity - CAD s/p MI and PCI ___ ___ with bare metal stent ___ left anterior descending artery -GERD -Asthma -Tobacco Use -Congenital single kidney -Diverticulitis and Partial Colectomy ___ -Memory Loss -Anxiety -Psoriasis-not on steroids currently Social History: ___ Family History: Father: deceased ___, ___ with mets, MI Mother: deceased ___, multiple myeloma, CHF, COPD, and DM Sister: ___ cancer (unknown type) ___: Murdered ___, ___ (?OD) ___, sis-OD, meds, and EtOH ___ Children: 1 daughter, ___, healthy Physical Exam: ADMISSION PHYSICAL: GENERAL: lying ___ bed, nontoxic, NAD HEENT: AT/NC, EOMI, anicteric sclera, pink conjunctiva, MMM NECK: supple, no LAD, no JVD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: normal work of breathing on 4L O2 without use of accessory muscles, no crackles or wheezes appreciated, good air movement ABDOMEN: nondistended, nontender ___ all quadrants, no rebound/guarding EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, moving all 4 extremities with purpose SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL: PHYSICAL EXAM: Vitals: 97.4 BP127/81 HR71 RR21 94% 2L General: AOx3, well appearing, no acute distress HEENT: Sclera anicteric, dry mucous membranes. Lungs: Scattered inspiratory crackles CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present Ext: Warm, well perfused, no edema. Left arm ___ sling. Neuro: Grossly normal Pertinent Results: ADMISSION LABS: ___ 09:30PM BLOOD WBC-8.6 RBC-3.45# Hgb-10.5# Hct-33.1# MCV-96 MCH-30.4 MCHC-31.7 RDW-13.2 RDWSD-46.8* Plt ___ ___ 05:05AM BLOOD WBC-8.9 RBC-3.40* Hgb-10.3* Hct-32.3* MCV-95 MCH-30.3 MCHC-31.9* RDW-13.1 RDWSD-45.3 Plt ___ ___ 09:30PM BLOOD Glucose-84 UreaN-12 Creat-1.0 Na-143 K-3.6 Cl-104 HCO3-25 AnGap-14 ___ 05:05AM BLOOD Glucose-116* UreaN-10 Creat-1.0 Na-141 K-4.1 Cl-102 HCO3-26 AnGap-13 ___ 05:00PM BLOOD CK(CPK)-41* ___ 05:05AM BLOOD Calcium-8.8 Phos-2.4* Mg-1.6 ___ 06:40AM BLOOD Calcium-8.9 Phos-2.9 Mg-1.6 PERTINENT LABS AND IMAGING Scleroderma Antibody negative Anti-RNP negative Pneumonitis Hypersensitivity Profile negative Anti CCP negative Anit-JO1 negative Aldolase negative MICRO: ___ 8:53 am BRONCHOALVEOLAR LAVAGE RIGHT MIDDLE LOBE. GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND CLUSTERS. RESPIRATORY CULTURE (Final ___: 10,000-100,000 CFU/mL Commensal Respiratory Flora. LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. Immunofluorescent test for Pneumocystis jirovecii (carinii) (Final ___: NEGATIVE for Pneumocystis jirovecii (carinii). Less than 2 ml received. INTERPRET NEGATIVE CULTURE RESULTS WITH CAUTION. FUNGAL CULTURE (Preliminary): NOCARDIA CULTURE (Preliminary): ACID FAST SMEAR (Preliminary): ACID FAST CULTURE (Preliminary): ___ 10:00 am MRSA SCREEN Source: Nasal swab. FINAL REPORT ___ MRSA SCREEN (Final ___: No MRSA isolated. ___ 8:13 am STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Reported to and read back by ___ ___ ___ 340PM. CLOSTRIDIUM DIFFICILE. Positive for toxigenic C difficile by the Cepheid nucleic amplification assay. ___ 8:53 am Rapid Respiratory Viral Screen & Culture RIGHT MIDDLE LOBE. Respiratory Viral Culture (Preliminary): Respiratory Viral Antigen Screen (Final ___: Negative for Respiratory Viral Antigen. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Refer to respiratory viral culture and/or Influenza PCR (results listed under "OTHER" tab) for further information.. IMAGING: CXR ___: Extensive multi lobar interstitial opacities with background ground-glass opacities bilaterally with volume loss, suggestive of infectious or inflammatory etiology. Correlate with outside hospital course ___ prior disease and sputum culture. CT CHEST ___: 1. PARENCHYMA: No air trapping noted. Again seen is mild centrilobular emphysema, unchanged since prior. ___ comparison to ___ there are multiple new subpleural interstitial opacities with associated honeycombing and more confluent components involving the lower lobes and lingula.. 2. AIRWAYS: Diffuse bronchial wall thickening predominantly involving the upper and central airways is unchanged, consistent with small airways disease. The airways are otherwise patent to the subsegmental level. There is mild central and right lower lobe traction bronchiectasis (302:133). No evidence of tracheobronchiomalacia on expiratory phase. 3. VESSELS: Thoracic aorta and main pulmonary artery are normal ___ caliber. CHEST CAGE: No focal lytic or blastic lesions worrisome for malignancy. No acute fracture. IMPRESSION: 1. Findings suspicious for idiopathic pulmonary fibrosis. 2. Mild centrilobular emphysema. 3. Small airways disease. CXR ___: IMPRESSION: ___ comparison with the study of ___, there has been substantial clearing of the diffuse interstitial disease involving both lungs. However, there still is a substantial residual of interstitial fibrosis. No evidence of acute focal consolidation. DISCHARGE ___ 06:05AM BLOOD WBC-17.1* RBC-4.03* Hgb-12.3* Hct-38.4* MCV-95 MCH-30.5 MCHC-32.0 RDW-13.4 RDWSD-46.8* Plt ___ ___ 06:05AM BLOOD Glucose-176* UreaN-26* Creat-1.1 Na-139 K-4.7 Cl-98 HCO3-29 AnGap-12 ___ 05:05AM BLOOD CRP-96.8* Brief Hospital Course: This is a ___ year old male with past medical history of CAD with prior VT arrest, diabetes type 2, recent diagnosis of interstitial lung disease, admitted ___ with progressively worsening hypoxia thought to be possible cryptogenic organizing pneumonia, course complicated by Cdiff colitis, treated with antibiotics for cdiff and steroids for COP, with improving stool output and respiratory status, able to be discharged home with oxygen ACUTE Issues Addressed: ========================= # Acute Hypoxemic Respiratory Failure # Crypotgenic organizing pneumonia # COPD Patient with recent history notable for post-operative respiratory failure at ___ initially attributed to bacterial pneumonia after an extensive workup, who presented to ___ 9 days following his discharge with worsening dyspnea, cough and hypoxia, with cross-sectional imaging with increased GGOs and reticular opacities suggestive of interval progression of an interstitial process. Workup from ___ was reviewed and pulmonary service was consulted. Bronchoscopy with BAL was performed ___ without evidence of infection. Imaging was felt to be consistent with cryptogenic organizing pneumonia. Once infection was ruled out (and his cdiff was controlled as below), patient was placed on high dose steroids with subsequent slow response over ensuing 7 days. Discharged patient on prednisone, as well as Bactrim and PPI prophylaxis. Continued home Spiriva and Advair. Discharged home on 2L O2. #C Diff Colitis Course complicated by loose stools with positive C Diff PCR assay. Infection was thought to be due to recent antibiotics course following surgery. Patient was started on PO Vancomycin with improvement. Discharged to complete PO vancomycin course. # Type 2 diabetes Metformin was initially held while he was acutely ill, then restarted. Would follow-up outpatient blood sugars to ensure continued control while on steroids. #CAD s/p stenting # History of Ventricular tachycardia Patient continued on home aspirin, brilinta and atorvastatin. Amiodarone was stopped due to concerns for pulmonary toxicity. Patient should follow up with cardiologist regarding discontinuation of amiodarone. #HTN Patient continued home Ramipril. #GERD: Continued home Omeprazole 20 mg PO BID #ANXIETY: Continue home Diazepam 5 mg PO QID:PRN anxiety TRANSITIONAL ISSUES: ================================== [ ]Medications stopped: amiodarone; would consider alternate antiarrhythmic [ ]Medications started: Prednisone 60 mg daily, Bactrim DS daily, Calcium and Vitamin D, PO vancomycin 125mg q6H (through ___ [ ] Pt should continue on Prednisone 60 mg daily until directed to change dosing as per pulmonary team [ ] Per ___ pulmonary service request, would consider outpatient DEXA scan [ ] ___ pulmonary follow-up is being scheduled Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 50 mg PO DAILY 2. Ramipril 5 mg PO DAILY 3. Omeprazole 20 mg PO BID 4. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY 5. Tudorza Pressair (aclidinium bromide) 400 mcg/actuation inhalation DAILY 6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 7. Diazepam 5 mg PO Q6H:PRN anxiety 8. TiCAGRELOR 60 mg PO BID 9. Aspirin 81 mg PO DAILY 10. Atorvastatin 80 mg PO QPM 11. Amiodarone 200 mg PO DAILY Discharge Medications: 1. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath RX albuterol sulfate [Proventil HFA] 90 mcg ___ PUFFs INH q6hr:PRN Disp #1 Inhaler Refills:5 2. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500 mg(1,250mg) -125 unit oral DAILY RX calcium carbonate-vitamin D3 [Calcium 500 + D] 500 mg calcium (1,250 mg)-400 unit 1 tablet(s) by mouth daily Disp #30 Tablet Refills:5 3. PredniSONE 60 mg PO DAILY RX prednisone 20 mg 3 tablet(s) by mouth daily Disp #90 Tablet Refills:1 4. 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 5. Vancomycin Oral Liquid ___ mg PO Q6H RX vancomycin 125 mg/2.5 mL 2.5 mL by mouth every six (6) hours Disp #24 Applicatorful Refills:*0 6. Aspirin 81 mg PO DAILY 7. Atorvastatin 80 mg PO QPM 8. Diazepam 5 mg PO Q6H:PRN anxiety 9. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 10. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY 11. Metoprolol Succinate XL 50 mg PO DAILY 12. Omeprazole 20 mg PO BID 13. Ramipril 5 mg PO DAILY 14. TiCAGRELOR 60 mg PO BID 15. Tudorza Pressair (aclidinium bromide) 400 mcg/actuation inhalation DAILY 16.equipment Rolling walker DX: hypoxemic respiratory failure PX: good ___: 3months 17.Pulmonary Rehab ICD.10: ___ Cryptogenic organizing pneumonia Evaluate and treat Discharge Disposition: Home With Service Facility: ___ ___: # Acute hypoxic respiratory failure secondary to Cryptogenic organizing pneumonia # Cdiff Colitis # Coronary Artery Disease s/p stenting # Hypertension # Gastroesphageal reflux # Anxiety Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure to care for you at ___ ___! Why was I admitted to the hospital? -You were admitted to the hospital because you were having trouble breathing at home. What was done for me while I was ___ the hospital? -Our pulmonary team evaluated you. -We took an image of your chest which showed scarring of your lungs -We completed a procedure called a bronchoscopy which gave us a sample of what is ___ your lungs. -You were started on a medication called prednisone to treat the inflammation ___ your lungs and improved over the course of your hospital stay. -We stopped your amiodarone because it may affect your lungs -You had an infection ___ your stool from a bacteria called C. Difficile, which should be continued for a total of 14 days. -We placed you on an antibiotic, Bactrim, to protect your lungs against a lung infection while you are on high dose steroids. -You should continue to take Calcium and Vitamin D to help keep your bones strong while taking steroids. What should I do when I leave the hospital? -Do not take Amiodarone -Continue on your Prednisone 60 mg daily -Continue taking your other medications as prescribed (see below) We wish you the best! Your ___ treatment team Followup Instructions: ___
10021927-DS-24	10,021,927	25,202,388	DS	24	2177-12-23 00:00:00	2177-12-24 21:50:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Doxycycline / Levofloxacin / Lisinopril Attending: ___. Chief Complaint: Dysphagia, electrolyte abnormalities Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ year-old woman with HTN, GERD/gastritis, ___ esophagus, and ___ esophageal manometry showing spasms in 20% the esophagus who presented to ___ on ___ with 1 month of decreased PO intake and dysphagia of solids. The patient describes around 1 month of dysphagia of solid foods, but has continued to take oral fluids well (diet has mostly been soup and broth). Specifically, she feels that this all started after having magnesium citrate for colonoscopy, after which she developed nausea, bloating, gas pain. This has also been associated with some dizziness but she denies chest pain or palpitations. She was seen by her primary GI doctor, ___. ___ recommended referred her to ED for expedited GI evaluation as he thought patient was failing at home. In the ED, initial vitals 0 96.9 81 ___ 100%. Labs notable for electrolyte abnormalities of Na 122, K 2.8, Cl 78, Mg 1.3 but otherwise normal BUN/Cr ___. CBC was within patient's baseline, LFTs and lipase wnl. Lactate became elevated to 2.5-->4 in ED, which then downtrended to 2.8 with IVF (total 6L in ED). In ED, exam was notable for diffuse abdominal pain, for which CT Abd was conducted and negative for infection or ischemia. Patient was administered Vanc/Zosyn for ?infection though she remained without fever. GI consult was called, and they agreed to see the patient as an inpatient. Central RIJ line was attempted and failed x 2, and the patient was admitted to MICU for further resuscitation and management. Past Medical History: PAST MEDICAL HISTORY: Hypertension Hyperlipidemia Depression Hyponatremia/SIADH of unclear etiology S/p surgery for bowel obstruction Cerebellar syndrome with positional dizziness History of colon adenoma Tobacco abuse (quit ___ H/o Alcohol abuse (last drink ___ yr ago) Urinary incontinence Right hip pain ___ esophagus Fibroids Right kidney lesion surveillance with serial MRIs PAST SURGICAL HISTORY: Back surgery for ruptured disc SBO x2 (___) Sigmoid resection for repair of rectal prolapse perineorrhaphy s/p B/L upper lid blepharoplasty (___) s/p TAH BSO for fibroid uterus (age ___ Social History: ___ Family History: Mother ___ ___ CERVICAL CANCER ___ Father ___ ___ OBESITY, STROKE Brother Living ___ DIABETES TYPE II Sister ___ ___ BREAST CANCER Niece ___ ___ OVARIAN CANCER Physical Exam: ADMISSION PHYSICAL EXAM: General- elderly female, NAD HEENT- EOMI, PERRLA, OP clear Neck- soft, supple CV- nl s1 + s2, rrr Lungs- ctab Abdomen- tenderness to deep palpation, BS+ve, no peritoneal signs GU- deferred Ext- warm well perfused Neuro- grossly intact DISCHARGE PHYSICAL EXAM: VS: 98.1 119/58 75 18 98%RA General: Elderly female sitting in bed, conversant, NAD HEENT: EOMI, PERRLA, OP clear Neck: Soft, supple, pain at RIJ attempt sites CV: RRR, + S1/S2 Lungs: CTAB Abdomen: Tenderness to deep palpation, +BS, no gaurding/rebound Ext: WWP, DP 2+, trace/1+ edema Neuro: grossly intact Pertinent Results: ADMISSION LABS: ___ 09:35PM BLOOD WBC-6.5 RBC-3.87* Hgb-12.2 Hct-35.3* MCV-91 MCH-31.6 MCHC-34.6 RDW-13.1 Plt ___ ___ 10:30PM BLOOD ___ PTT-32.9 ___ ___ 09:35PM BLOOD Glucose-104* UreaN-2* Creat-0.6 Na-122* K-2.8* Cl-78* HCO3-32 AnGap-15 ___ 01:15AM BLOOD Na-125* K-2.7* Cl-85* ___ 07:36AM BLOOD Glucose-102* UreaN-2* Creat-0.5 Na-135 K-4.1 Cl-104 HCO3-25 AnGap-10 ___ 09:35PM BLOOD Albumin-3.5 Calcium-8.7 Phos-3.2 Mg-1.3* ___ 07:36AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEGATIVE Tricycl-NEG ___ 10:31PM BLOOD Lactate-2.5* ___ 01:24AM BLOOD Lactate-4.0* ___ 01:51AM BLOOD Lactate-3.6* ___ 04:43AM BLOOD Lactate-2.8* ___ 01:18PM BLOOD Lactate-2.9* PERTINENT LABS: ___ 07:36AM BLOOD WBC-3.7* RBC-3.34* Hgb-10.5* Hct-31.2* MCV-93 MCH-31.4 MCHC-33.6 RDW-13.1 Plt ___ ___ 07:36AM BLOOD Glucose-102* UreaN-2* Creat-0.5 Na-135 K-4.1 Cl-104 HCO3-25 AnGap-10 ___ 07:36AM BLOOD Calcium-6.8* Phos-1.4* Mg-1.6 ___ 07:36AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEGATIVE Tricycl-NEG ___ 07:40AM BLOOD WBC-4.7 RBC-3.27* Hgb-10.3* Hct-30.6* MCV-94 MCH-31.4 MCHC-33.5 RDW-13.5 Plt ___ ___ 07:40AM BLOOD Glucose-94 UreaN-2* Creat-0.4 Na-132* K-4.1 Cl-103 HCO3-24 AnGap-9 ___ 07:40AM BLOOD Calcium-7.7* Phos-2.9 Mg-2.3 DISCHARGE LABS: ___ 07:45AM BLOOD WBC-4.4 RBC-3.25* Hgb-10.2* Hct-30.6* MCV-94 MCH-31.3 MCHC-33.3 RDW-13.6 Plt ___ ___ 07:45AM BLOOD Glucose-99 UreaN-3* Creat-0.4 Na-133 K-4.3 Cl-100 HCO3-25 AnGap-12 ___ 07:45AM BLOOD Calcium-8.1* Phos-3.3 Mg-1.7 Iron-61 ___ 07:45AM BLOOD calTIBC-144* Ferritn-222* TRF-111* REPORTS: ___ VIDEO OROPHARYNGEAL SWALLOW 1. Trace penetration with nectar which cleared spontaneously. No aspiration. 2. No upper esophageal sphincter dysfunction. ___ UGI SGL CONTRAST W/ KUB 1. Small hiatal hernia. 2. Mild reflux. 3. No stricture within the esophagus with free passage of a 13 mm barium tablet to stomach. 4. Mild esophageal dysmotility with tertiary contractions. ___ CHEST (PORTABLE AP) AP portable single-view chest x-ray of the chest shows reduced lung volume and new mild vascular engorgement. Left lung base is not fully assessable, because obscured by midly enlarged heart. Aorta is elongated. There is no pleural effusion or pneumothorax. n dominal arterial vasculature. No evidence of mesenteric ischemia. 2. Nonspecific fat stranding in the retroperitoneum may be due to mild third spacing in the setting of congestive heart failure. 3. Cholelithiasis 4. Unchanged size of a 7-mm right renal solid lesion. MRI followup continues to be recommended as per report from MR abdomen on ___. ___ ECG Baseline artifact. Sinus rhythm. Prolonged A-V conduction. Probable left anterior hemiblock. Diminished QRS voltage. Delayed R wave progression. Compared to the previous tracing of ___ findings are probably similar. TRACING #1 MICROBIOLOGY: ___ MRSA Screen - No MRSA isolated. ___ Blood Cx x2 - Pending Brief Hospital Course: ___ with a longstanding history of GERD/gastritis, ___, HTN recent esophageal manometry this ___ showing occasional esophageal dysmotility in 20% of the esophagus who presented with dysphagia of solids and was found to have several impaired electrolyte levels. # Dysphagia: The patient has a long-standing history of GERD, ___ esophagus, and recent diagnosis of 20% esophageal dysmotility on manometry. She was referred to ___ by her outpatient GI doctor, ___ expedited workup of her dysphagia for solids (good liquid intake). Nutrition saw and noted patient was able to tolerate supplements. The GI consult team saw the patient and recommended a barium swallow study that showed mild esophageal dysmotility and mild reflux. She also underwent a video swallow that revealed no upper esophageal sphincter dysfunction despite very mild narrowing at the sphincter, felt highly unlikely to be the cause of her symptoms. A zinc level was sent to assess zinc deficiency as a source of her dysphagia - this was pending at the time of discharge. The patient was started on diltiazem for her esophageal spasms. Of note, atenolol and amlodipine were held, and simvastatin was switched to atorvastatin given the interaction between simvastatin and diltiazem. At the time of discharge, the patient was able to tolerate soft solids and liquids. She was scheduled ___ with her outpatient gastroenterologist and PCP to assess effect of diltiazem and/or restart prior antihypertensive medications. # Electrolyte abnormalities: The patient has has chronic hyponatremia per report and records but was found on presentation to have hypomagnesemia, hypokalemia, hypochloremia, and hypophosphatemia in the setting of decreased PO intake for 1 month. Given her elevated lactate on admission that decreased in response to fluids, the etiology was thought most likely due poor PO intake. It was also felt that the patient's furosemide contributed and/or precipitated her current electrolyte abnormalities and her prior admission in ___. The patient was advised not take lasix but the patient was insistent upon restarting her lasix. In total, the patient received 10 L of fluid in the ___ ED and MICU as well as electrolyte supplementation with significant improvement in electrolytes. Monitoring included EKG that was without U-waves or ischemic changes. She was transferred to the medical floor, where electrolyte supplementation and maintenance IV fluids were continued. At the time of discharge, the patient's electrolytes were all within normal limits except for a slightly low calcium level (8.1). The patient was scheduled for PCP ___ with electrolyte check a week after discharge. # Hypotension: The patient presented with hypotension to sBP ___ thought most likely due hypovolemia in the setting of poor PO intake due to dysphagia. She remained without signs of shock, bleeding, or infection. INACTIVE ISSUES: # History bowel obstruction: The patient was monitored and continued to pass both gas and stool during this admission. # HLD: The patient's home simvastatin 20mg was converted to atorvastatin 20mg daily when diltiazem was started, given concern of rhabdomyolysis from simvastatin and diltiazem in combination. # Insomnia: The patient was continued on her home trazadone 50mg without complications. # ___ swelling: The patient takes furosemide at home. Given that this like contributed or preipitated her electrolyte abnormalities, the patient was encouarged to stop furosemide. However, he felt adamant about resuming this. She will need an electrolyte check at her PCP appointment on ___. =========================== TRANSITIONAL ISSUES: =========================== MEDICATION CHANGES - Diltiazem 30mg QID was STARTED for esophageal spasms - Atenolol was STOPPED because diltiazem was started - Amlodipine was STOPPED because diltiazem was started - Simvastatin was STOPPEd because it interacts with diltiazem, and atorvastatin was STARTED instead. - If her diltiazem is not helping her symptoms, it would be reasonable to restart her home antihypertensive regimen. - Patient was cautioned to stop the diltiazem if she experiences dizziness or lightheadedness. - The patient was encouraged to STOP her Lasix given concern that it is source of her electrolyte abnormalities, but she was adamant about continuing this medication. She will likely continue despite our strong warning against it. OTHER ISSUES - Patient has a pending Zinc level. Low zinc can also cause many electrolyte disturbances consistent with her picture, so she should be repleted if this level is low and worked up for causes of low zinc (possibly simple low dietary intake given her eating issues). - The patient remained Full Code during this hospitalization Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amlodipine 2.5 mg PO DAILY 2. Atenolol 50 mg PO DAILY 3. Multivitamins 1 TAB PO DAILY 4. Oxybutynin 5 mg PO BID 5. Simvastatin 20 mg PO DAILY 6. traZODONE 50 mg PO HS:PRN insomnia 7. Furosemide 20 mg PO DAILY 8. esomeprazole magnesium 40 mg oral qd 9. Ranitidine 75 mg PO BID Discharge Medications: 1. Multivitamins 1 TAB PO DAILY 2. Oxybutynin 5 mg PO BID 3. traZODONE 50 mg PO HS:PRN insomnia 4. FoLIC Acid 1 mg PO DAILY RX folic acid 1 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 5. esomeprazole magnesium 40 mg oral qd 6. Atorvastatin 20 mg PO DAILY RX atorvastatin 20 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 7. Ranitidine 75 mg PO BID 8. Furosemide 20 mg PO DAILY 9. Diltiazem 30 mg PO QID Hold for dizziness, low blood pressure RX diltiazem HCl 30 mg 1 tablet(s) by mouth four times a day Disp #120 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES: Electrolyte abnormalities Esophageal Dysmotility SECONDARY DIAGNOSES: Gastroesophageal reflux ___ esophagus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure to take care of you during this hospitalization. You were admitted to ___ ___ for difficulty eating solid food, which you report you have had for several years. You were also found to have several electrolyte abnormalities, likely from your lasix. You were administered intravenous fluids and admitted to the medical ICU where your electrolyte abnormalities were further corrected with fluids and supplements. When your electrolyte abnormalities improved, you were transferred to the medical floor. The Gastroenterology team saw you and recommended that you undergo a "barium swallow" test that showed mild esophageal dysmotlity and mild reflux. You had a test call a "video swallow" that showed very mild narrowing at the upper esophagus that was felt highly unlikely cause of your symptoms. You were also started a medication called diltiazem to treat your esophageal spasms. This should take the place of your other blood pressure medications for now; you will follow up with Dr. ___ if she feels you are not benefiting from the diltiazem, she may switch you back to your prior regimen. Also, we switched your simvastatin to atorvastatin as simvastatin interacts with diltiazem. If you experience dizziness or lightheadedness, you should stop taking this medication. You felt strongly that you wanted to restart lasix. We recommend that you not restart your lasix because it very likely precipitated your electrolyte abnormalities during this admission and your prior admission in ___. You were also noted to have a mild phlebitis in your left arm, where your IV was. We recommend warm compresses for this; it should resolve shortly. A low dose of an NSAID such as ibuprofen can also help if you can tolerate this medication. You also noted a very mild rash on your right elbow as well, which was felt to be due to dry skin versus a mild eczema; you can use emollients on this and it should resolve. If it worsens, see your PCP. You have scheduled ___ with your PCP and GI doctors. ___ follow up with your doctors and take ___ your medications as prescribed. Followup Instructions: ___
10021927-DS-25	10,021,927	23,373,975	DS	25	2178-01-19 00:00:00	2178-01-22 14:29:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Doxycycline / Levofloxacin / Lisinopril Attending: ___. Chief Complaint: ___ Major Surgical or Invasive Procedure: none History of Present Illness: ___ with a longstanding history of GERD/gastritis, ___, HTN, esophageal dysmotility in 20% of the esophagus who presents with dysphagia of solids and was found to have several impaired electrolyte levels. Patient was recently admitted in ___ at ___ for the same reasons. She had a follow up visit with her PCP (___) who upon routine lab screening noted that the patient had an elevated Cr with electrolyte abnormalities. The patient was asymptomatic at the time. 1 Dysphagia: The patient has a long-standing history of GERD, ___ esophagus, and recent diagnosis of 20% esophageal dysmotility on manometry. In recent admit: She was referred to ___ by her outpatient GI doctor, ___ expedited workup of her dysphagia for solids (good liquid intake). Nutrition saw and noted patient was able to tolerate supplements. The GI consult team saw the patient and recommended a barium swallow study that showed mild esophageal dysmotility and mild reflux. She also underwent a video swallow that revealed no upper esophageal sphincter dysfunction despite very mild narrowing at the sphincter, felt highly unlikely to be the cause of her symptoms. A zinc level was sent to assess zinc deficiency as a source of her dysphagia - which is low. The patient was started on diltiazem for her esophageal spasms. Of note, atenolol and amlodipine were held, and simvastatin was switched to atorvastatin given the interaction between simvastatin and diltiazem. At the time of discharge, the patient was able to tolerate soft solids and liquids. In the ED intial vitals were: 97.0 82 117/64 18 100%. Pt found to be hyponatremic, hypokalemic, hypomagnesemic. Pt received 1L NS, IV K and IV mag along with Zofran. Vitals on transfer: 98.3 83 ___ 96% RA On the floor patient was upset regarding wait time in the ED but otherwise without complaints. Past Medical History: PAST MEDICAL HISTORY: Hypertension Hyperlipidemia Depression Hyponatremia/SIADH of unclear etiology S/p surgery for bowel obstruction Cerebellar syndrome with positional dizziness History of colon adenoma Tobacco abuse (quit ___ H/o Alcohol abuse (last drink ___ yr ago) Urinary incontinence Right hip pain ___ esophagus Fibroids Right kidney lesion surveillance with serial MRIs PAST SURGICAL HISTORY: Back surgery for ruptured disc SBO x2 (___) Sigmoid resection for repair of rectal prolapse perineorrhaphy s/p B/L upper lid blepharoplasty (___) s/p TAH BSO for fibroid uterus (age ___ Social History: ___ Family History: Mother ___ ___ CERVICAL CANCER ___ Father ___ ___ OBESITY, STROKE Brother Living ___ DIABETES TYPE II Sister ___ ___ BREAST CANCER Niece ___ ___ OVARIAN CANCER Physical Exam: ADMISSION PHYSICAL EXAM Vitals- 97.7 113/66 83 18 99RA General- Alert, oriented, no acute distress HEENT- Sclera anicteric, dry MM, oropharynx clear Neck- supple, JVP not elevated, no LAD Lungs- Clear to auscultation bilaterally, no wheezes, rales, ronchi CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen- soft, 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, 1+ foot edema Neuro- motor function grossly normal . DISCHARGE PHYSICAL EXAM Vitals- 98.4 144/90 92 18 97RA General- Alert, oriented, no acute distress HEENT- Sclera anicteric, dry MM, oropharynx clear Lungs- CTAB CV- RRR, normal S1 + S2, no murmurs, rubs, gallops Abdomen- Soft, mildly tender diffusely worst in lower quadrants, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU- no foley Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis, 1+ foot edema Neuro- motor function grossly normal Pertinent Results: ADMISSION LABS ___ 10:40AM BLOOD WBC-5.3 RBC-3.61* Hgb-11.3* Hct-34.6* MCV-96 MCH-31.3 MCHC-32.6 RDW-15.8* Plt ___ ___ 10:40AM BLOOD UreaN-14 Creat-2.8# Na-128 K-3.0* Cl-86* HCO3-31 AnGap-14 ___ 01:43PM BLOOD Calcium-8.7 Phos-3.2 Mg-1.2* ___ 08:05AM BLOOD Triglyc-85 HDL-38 CHOL/HD-2.7 LDLcalc-47 ___ 01:43PM BLOOD Osmolal-260* ___ 01:43PM BLOOD TSH-0.70 ___ 01:54PM BLOOD Lactate-2.6* DISCHARGE LABS ___ 08:25AM BLOOD WBC-6.3 RBC-2.86* Hgb-8.9* Hct-27.4* MCV-96 MCH-31.2 MCHC-32.6 RDW-15.9* Plt ___ ___ 08:25AM BLOOD Glucose-85 UreaN-10 Creat-1.2* Na-132* K-3.7 Cl-98 HCO3-27 AnGap-11 ___ 08:25AM BLOOD Calcium-8.5 Phos-5.0* Mg-1.3* Brief Hospital Course: ___ with a longstanding history of GERD/gastritis, ___, HTN recent esophageal manometry this ___ showing occasional esophageal dysmotility in 20% of the esophagus who presented with dysphagia of solids and was found to have several impaired electrolyte levels and acute kidney injury. # Dysphagia: The patient has a long-standing history of GERD, ___ esophagus, and recent diagnosis of 20% esophageal dysmotility on manometry. Barium swallow study showed mild esophageal dysmotility and mild reflux. She also underwent a video swallow that revealed no upper esophageal sphincter dysfunction despite very mild narrowing at the sphincter, felt highly unlikely to be the cause of her symptoms. Zinc level low so on zinc supplementation. Neurology evaluated the patient, and does not think there is neurologic contribution to dysphagia, recommended outpatient follow-up for cerebellar process. Psychiatry also evaluated the patient, and did not think there was any particular pathology but did think patient had poor coping with her dysphagia. Nutritionist also evaluated the patient adn created a concreate list of foods/liquids that patient can tolerate while providing adequate calorie and nutrition intake. PCP follow up was arranged for the patient with recommendation for nutrition referral as an outpatient. # Acute Kidney Injury: baseline 0.5-0.6 (likely from malnourishment) but up to 2.7 on admission. The acute kidney injury is likely secondary to volume depletion given history of poor PO intake and use of furosemide, as well as possible ATN from prolonged dehydration. Pt was resuscitated with fluid. Microscopic examination of urine was normal. Her creatinine decreased to 1.2 with continuous PO encouragement, this new value may be reflective for patien'ts new baseline. #Electrolyte disturbances: hyponatremia (baseline 130), low potassium, magnesium, chloride consistent with severely poor PO intake. also may have contribution from lasix. EKG was without significant abnormalities. Electrolyte abnormalities resolved after fluid resuscitation as well as electrolyte repletion. Pt was instructed to take multivitamins with minerals to maintain magnesium levels. CHRONIC ISSUES ISSUES: # Insomnia: The patient was continued on her home trazadone 50mg without complications. # ___ swelling: The patient takes furosemide at home. Given that this like contributed or preipitated her electrolyte abnormalities, the patient was encouarged to stop furosemide. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Oxybutynin 5 mg PO BID 2. Diltiazem Extended-Release 180 mg PO DAILY 3. Furosemide 10 mg PO DAILY 4. Multivitamins 1 TAB PO DAILY 5. esomeprazole magnesium 40 mg oral bid 6. Zinc Sulfate 50 mg PO DAILY 7. TraZODone 50 mg PO HS:PRN insomnia 8. FoLIC Acid 1 mg PO DAILY 9. Ranitidine 75 mg PO BID Discharge Medications: 1. Diltiazem Extended-Release 180 mg PO DAILY 2. FoLIC Acid 1 mg PO DAILY 3. Multivitamins 1 TAB PO DAILY 4. Oxybutynin 5 mg PO BID 5. Ranitidine 75 mg PO BID 6. TraZODone 50 mg PO HS:PRN insomnia 7. Zinc Sulfate 50 mg PO DAILY 8. Docusate Sodium 100 mg PO BID RX docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #60 Capsule Refills:2 9. Senna 1 TAB PO BID constipation RX sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp #60 Tablet Refills:1 10. esomeprazole magnesium 40 mg oral bid 11. Magnesium Oxide 400 mg PO DAILY RX magnesium oxide 400 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:*1 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Acute Kidney Injury Secondary Diagnosis: Dysphagia, dysthymia with superimposed adjustment disorder in the setting of recent stressors and medical issues Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted because you have been eating poorly at home and your kidney has been functioning less well than before. You were seen by nutritionists, neurologist and psychiatrist during this stay, and we are glad to see that we have come up with a plan to help you eat better at home. You will continued to be followed by your primary care doctor and we have asked your primary care doctor to provide referral to a nutritionist Followup Instructions: ___
10021930-DS-13	10,021,930	20,480,646	DS	13	2177-01-14 00:00:00	2177-01-15 07:20:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: gold injections / Lipitor Attending: ___. Chief Complaint: Back pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo male with history of hypertension, rheumatoid arthritis, chronic low back pain, renal cell carcinoma s/p mets to lumbar spine, sacrum, R iliac wing s/p XRT chemo (sutent) admitted with worsened LBP. At baseline, apparently, Mr. ___ has chronic LBP but able to perform ADLs, ambulate in the house and climb stairs. He presented to ___ clinic last week with c/o mucositis, perirectal skindown, nausea as a result of the sutent. The sutent was stopped and given decadron. He was reportedly doing fine until over the past ___ days noted progressive worsening LBP described as lower, radiating to bil buttocks and legs. Denies weakness, loss of sensation, bowel/bladder incontinence. Yesterday, pain was severe and not relieved by oxycodone. Could not get up from the supine position and thus went to ___. There, they could not do a L-spine MRI to further eval and thus he was transferred to the ___ ED for further eval. MRI T-spine/L-spine showed stable L spine disease but progression of T-spine mets. He was given 2 percocets and ativan with good effect. No iv opiates were given. Presently describes pain as "mild". ROS: per HPI, denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. A 10 pt review of sxs was otherwise negative. Past Medical History: # HTN # hyperchol # GERD # OA # Bil hip and knee replacements # RA ___ yrs # gout and pseudogout for ___ years # bilateral essential tremors. # anxiety # h/o ___ DVT ___ s/p MVA ONCOLOGIC HISTORY: - ___ - lumbar MRI done due to worsening LBP (hx OA, lumbar stenosis with chronic back pain) revealing hyperintense foci at L3, L4, L5 as well as within the right aspect of the sacrum and bilateral ilium suggestive of malignancy. - ___ - abdominal revealed a 2.9 cm area of enhancement in the upper left kidney. - ___ - lumbar spine CT revealed a destructive lesion in the transverse processes of L5 and lytic lesions involving the right iliac wing, right sacrum, L2 and L4. A 2.9 cm mass was seen in the left kidney consistent with renal cell carcinoma. - -___ - CT-guided biopsy of the right ilium demonstrated metastatic adenocarcinoma. The tumor cells were negative for PSA and positive for CD10 and cytokeratin cocktail; vimentin stains difficult to interpret. -___ - completed 10 fractions of XRT to the spine and pelvis. -___ - renal biopsy revealing an undifferentiated tumor, most consistent with a collecting duct origin. -___ signed consent for sutent vs everolimus trial, but withdrew consent on ___ began sunitinib 50 mg daily four weeks on/two weeks off schedule. Therapy held for GI side effects and restarted 2 weeks on/1 week off. Hospitalized with ARF, hypotension and dehydration at end of ___ restarted sunitinib 37.5 mg daily two weeks on/one week off. -___ torso CT stable. -___ lumbar MRI shows severe canal stenosis at L2 due to retropulsion of epidural tumor and nerve root enhancement. Progression at T11 also noted. Social History: ___ Family History: Positive for hypertension, mother with question of lung tumor. No history of renal cell carcinoma. Father deceased with history of CAD and perforated bowel. Physical Exam: ADMISSION EXAM: Vital Signs: 97.9 126/84 76 18 94% on RA glucose: . GEN: NAD, lying in bed, A&Ox3, pleasant, interactive, mod obese EYES: PERRL, EOMI, conjunctiva clear, anicteric ENT: moist mucous membranes, no exudates NECK: supple CV: RRR s1s2 nl, no m/r/g PULM: CTA, no r/r/w GI: normal BS, NT/ND, no HSM BACK: mild focal tenderness in lumbar spine EXT: warm, no c/c/e SKIN: no rashes NEURO: alert, oriented x 3, answers ? appropriately, follows commands, non focal PSYCH: appropriate ACCESS: PIV FOLEY: absent DISCHARGE EXAM: Vital Signs: Tm/Tc 98.1/98.1 BP 122.53 P 65 R 18 Sat 95% on RA I/O: 2180/___ . GEN: NAD, sitting in bed, A&Ox3, pleasant, interactive, mod obese EYES: PERRL, EOMI, conjunctiva clear, anicteric ENT: moist mucous membranes, no exudates NECK: supple CV: RRR s1s2 nl, no m/r/g PULM: CTA, no r/r/w GI: normal BS, NT/ND, no HSM BACK: mild focal tenderness in lumbar spine, TLSO brace in place EXT: warm, no c/c/e SKIN: no rashes NEURO: alert, oriented x 3, answers ? appropriately, follows commands, non focal, ___ strength in all muscle groups in all extremities PSYCH: appropriate ACCESS: PIV FOLEY: absent Pertinent Results: ADMISSION LABS -------------- ___ 04:30PM BLOOD WBC-2.7* RBC-2.86* Hgb-10.4* Hct-32.3* MCV-113* MCH-36.3* MCHC-32.1 RDW-16.1* Plt ___ ___ 04:30PM BLOOD Glucose-89 UreaN-18 Creat-0.9 Na-141 K-4.2 Cl-101 HCO3-32 AnGap-12 ___ 04:30PM BLOOD Calcium-8.8 Phos-2.8 Mg-1.4* DISCHARGE LABS -------------- ___ 07:45AM BLOOD WBC-3.6* RBC-2.56* Hgb-9.3* Hct-28.4* MCV-111* MCH-36.1* MCHC-32.6 RDW-16.7* Plt ___ ___ 07:45AM BLOOD Glucose-128* UreaN-37* Creat-1.0 Na-139 K-4.6 Cl-102 HCO3-27 AnGap-15 ___ 07:45AM BLOOD Calcium-9.3 Phos-3.1 Mg-1.7 IMAGING ------- MRI T,L-spine (___): Compared with the prior thoracic spine MRI of ___, there is further collapse of the T2 pathologic fracture with likely epidural extension of metastatic disease. Also, metastatic lesion within the T7 vertebral body has increased in size. There is new enhancing anterior and posterior epidural metastatic disease from T10 through L1 levels. There is stable extensive metastatic disease within the lumbar spine and pelvis as described above. The study and the report were reviewed by the staff radiologist. Brief Hospital Course: ___ yo man history of hypertension, rheumatoid arthritis, chronic low back pain, renal cell carcinoma s/p metastases to lumbar spine, sacrum, right iliac wing s/p XRT and chemotherapy (sutent) admitted with worsened low back pain. ACTIVE ISSUES ------------- # Low back pain: Mr. ___ was admitted with acute on chronic low back pain. He has known extensive renal cell carcinoma metastases to lumbar spine, T2, and T7. MRI on this admission showed steady progression of the thoracic mets, particularly with T2 collapse and epidural extension. Given concern for T2 vertebra stability, neurosurgery was consulted and recommended that he have a full TLS (Somi) brace at all times while upright. He, however, is not required to wear the brace when lying down at HOB <30 degs. The T2 compression fracture is high enough that significant neck movement is prohibited. The brace is designed to restrict neck movement - and thus precludes Mr. ___ from driving. With his interests in driving and his collection of multiple cars/trucks, this news was naturally quite distressing to Mr. ___. Social Work was consulted to provide some coping. It was communicated to Mr. ___ that it is unlikely that he will be able to drive ever again. He would not be able to drive with the brace because of neck restrictions; he would not be able to drive without it because the risk of paralysis with T2 vertebra instability; and patient is already at significant risk with the high doses of opiates and pain medications. During this stay, here, there was no cauda equina symptoms. Pain was controlled with dexamethasone, Butrans patch, tramadol, NSAIDs, cyclobenzaprine, oxycodone PRN. The Butrans patch was doubled to 20 ug/hr to provide stronger baseline relief of the pain. ___ evaluated the patient and felt he was stable for discharge but would benefit from home physical therapy. Training on the placement on removal of the brace was provided to the patient and his wife. The ___ was contacted with paperwork stating that the patient is not medically safe to drive. The patient refused to sign this paperwork. # Renal cell carcinoma: s/p XRT and chemotherapy (Sutent). Mr. ___ has been off the Sutent due to significant mucositis and nausea. There has been near complete resolution of these symptoms. There is some residual sacral wounds and wound consult made the following recommendations: Mepilex to back blisters to protect from friction from straps, Criticaid clear to perianal fissures Qshifts or pRN, pressure redistribution measures, limit sit time to 1 hour at a time. He will follow with Dr. ___ to determine what chemo to initiate as an outpt # Anemia: Mr. ___ has had decrease in Hct but no clear evidence of bleed. There was no GI bleed noted and blood pressure was stable. Hematocrit was followed serially. # Hiccups: patient was started on a trial of chlorpromazine 25mg TID x 7 days, which he will continue upon discharge INACTIVE ISSUES --------------- # Hypertension: stable, patient was continued on atenolol and hydrochlorthiazide. # GERD: patient was continued on home omeprazole. # Anxiety: no anxiolytics were provided while patient was admitted. . TRANSITIONS OF CARE ------------------- # Follow-up: patient will follow up with Oncology on discharge, for an appointment to be arranged after discharge. He will be discharged with a Somi brace and wheelchair. He should have a full TLS (Somi) brace on at all times while upright. He, however, is not required to wear the brace when lying down at HOB <30 degrees. The T2 compression fracture is high enough that significant neck movement is prohibited. He will get home physical therapy. # Code status: patient is confirmed full code. # Contact: Wife ___ ___ ___ on Admission: - ATENOLOL 25 mg daily - Butrans 10 mcg/hour Transderm Patch. 10 mg patch once weekly - COLCHICINE 0.6 mg tablet. 1 tablet daily - CYCLOBENZAPRINE 10 mg tablet QHS PRN restless legs - DEXAMETHASONE 4 mg BID - HYDROCHLOROTHIAZIDE 25 mg daily - LORAZEPAM 0.5 mg PRN - OMEPRAZOLE ___ 20 mg Daily - ONDANSETRON HCL Dosage uncertain - OXYCODONE ___ mg q4h PRN pain - PROCHLORPERAZINE MALEATE ___ mg QID PRN nausea - SUNITINIB [SUTENT] 12.5 mg 3 capsule mouth daily x 2 weeks, then 1 week off. - TRAMADOL - tramadol 150 mg daily - ASPIRIN 325 mg daily - NAPROXEN SODIUM [ALEVE] 220 mg PRN - TROLAMINE SALICYLATE [ASPERCREME] - Dosage uncertain - (OTC) Discharge Medications: 1. Butrans NF (buprenorphine) 10 mcg/hour Transdermal Q1Week pain RX buprenorphine [Butrans] 10 mcg/hour 1 patch once a week Disp #4 Each Refills:0 2. Aspirin 325 mg PO DAILY 3. Atenolol 25 mg PO DAILY 4. Colchicine 0.6 mg PO DAILY 5. Cyclobenzaprine 10 mg PO HS:PRN restless legs 6. Dexamethasone 4 mg PO Q12H 7. Hydrochlorothiazide 25 mg PO DAILY 8. Lorazepam 0.5 mg PO Q4H:PRN anxiety 9. Naproxen 250 mg PO Q8H:PRN pain Research Pharmacy Approval Required* Research protocol ___ 10. Omeprazole 20 mg PO DAILY Research Pharmacy Approval Required Research protocol ___ 11. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain Research Pharmacy Approval Required Research protocol ___ 12. TraMADOL (Ultram) 50 mg PO Q8H Research Pharmacy Approval Required Research protocol ___ 13. Ondansetron 4 mg PO Q8H:PRN nausea 14. Prochlorperazine ___ mg PO Q6H:PRN nausea 15. Citalopram 20 mg PO DAILY RX citalopram [Celexa] 20 mg 1 tablet(s) by mouth daily Disp #14 Tablet Refills:0 16. Senna 1 TAB PO BID:PRN constipation RX sennosides [senna] 8.6 mg 1 tab by mouth daily Disp #10 Tablet Refills:0 17. Bisacodyl 10 mg PO/PR DAILY:PRN constipation RX bisacodyl 5 mg ___ tablet,delayed release (___) by mouth daily Disp #14 Tablet Refills:0 18. ChlorproMAZINE 25 mg PO TID hiccups Duration: 5 Days RX chlorpromazine 25 mg 1 tablet(s) by mouth three times a day Disp #15 Tablet Refills:0 19. wheelchair NF 1 Miscellaneous daily RX wheelchair Use one wheelchair daily Disp #1 Each Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Back pain Collapsed T2 with spinal instability Metastatic renal cell cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure looking after you, Mr. ___. As you know, you were admitted with increased pain in the back. MRI of the spine showed progression of the cancer involvement of the T2 and T7 vertebrae. The T2 vertebra (below the neck), in particular, was collapsed and revealed extension of the break into the spinal canal. It is for this reason, that you should have the brace in place while you are upright. This can be removed when you are lying down flat with the head below 30 degrees from horizontal. You have verbalized that you understand the risks and potential consequences, namely paralysis, that can occur from not wearing the brace. Because of the limitations with the neck brace, you should not drive for risk of getting into an accident. Driving without the brace is equally dangerous, as the T2 vertebra may press on the spinal cord and lead to paralysis - and thus a risk for yourself and others. The ___ ___ has been contacted and your license is no longer active and you are not permitted by law to be driving. Please follow up with Dr. ___ about the next steps for your treatment. Followup Instructions: ___
10021938-DS-19	10,021,938	23,112,364	DS	19	2181-10-14 00:00:00	2181-10-16 12:23:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: lisinopril Attending: ___ ___ Complaint: Chief Complaint: tachycardia, hypertension, nausea, tremors Reason for MICU transfer: uremia and hyperkalemia needing urgent HD Major Surgical or Invasive Procedure: None History of Present Illness: ___ is a ___ M with h/o ESRD on Mo/Th HD and HTN who presents with confusion, shakiness and hypertension in setting of missing HD two days ago, found to be uremic with hyperkalemia on labs and admitted to ICU for urgent HD. Pt normally receives dialysis twice weekly on ___ and ___. This ___ he reports he missed dialysis because he "just forgot". After this, he was noted to become more confused at his assisted living facility. He does remember this but doesn't recall many details of past few days. He denies any other symptoms like fever, chills, cough, dysuria, nausea/vomiting, diarrhea, constipation. Today at his assisted living facility he was found to be confused and shaky/tremulous, hypertensive and complaining of nausea. He was sent to ED for evaluation. Of note, pt recently presented to ___ ED on ___ from his facility for similar symptoms of confusion, hypertension and shaking after awaking from a nap. Had received dialysis earlier in the day during which he complained of nausea and was tachycardic. Labs at that time showed K 4.6, BUN 49, Cr 7.7 NCHCT showed extensive white matter hypodensities which may be due to chronic small vessel disease and lacunar infarcts, but also consider multi-infarct dementia in appropriate clinical setting. Plan was for further toxic-metabolic workup of his confusion, but pt refused further care. Psychiatry was consulted and noted impaired word-list recall but overall felt he had capacity to make decision to leave ED. In the ED, initial vitals: 99.8 110 178/85 18 93% 2L NC. On exam had bibasilar crackles, tremors, asterixis and was oriented x1 only. Labs notable for K 7.4, HCO3 18, BUN 107, Cr 15.0, AG 29. WBC 13.9 (85.7% PMNs). EKG showed mildly peaked T waves, <1mm ST depressions in lateral leads. CXR showed cardiomegaly, no pulmonary edema. Pt received calcium gluconate, insulin + dextrose, albuterol and kayexelate. Potassium downtrended from 7.4 to 6.1 in the ED. Was seen by nephrology who recommended urgent dialysis against low-K bath, likely to be repeated in late morning or afternoon. He was admitted to the ICU for urgent HD and lab monitoring. He became agitated, refused care and attempted to leave ED, security was called and pt deemed unable to leave given acutely altered mental status, no capacity to refuse care. Received Diazepam 10mg PO once. On transfer, vitals were: 98.9 77 168/74 20 100% RA. On arrival to the MICU, vitals are 88, 171/92, 99% RA. Patient had large liquid bowel movement on arrival. He is currently asymptomatic. Review of systems: positive per HPI, otherwise negative. Past Medical History: - ESRD ___ HTN, on Mo/Th HD for ___ year, has L AF fistula - HTN - Hyperlipidemia - H/O EtOH abuse (sober ___ year) Social History: ___ Family History: Noncontributory Physical Exam: ADMISSION PHYSICAL EXAM: Vitals- 88, 171/92, 99% RA General- pleasant older M in NAD, unable to provide detailed history but generally oriented and cooperative. HEENT- NC/AT, MMM Neck- supple, no JVD CV- RRR S1 S2 no R/M/G Lungs- bibasilar crackles. Abdomen- SNTND +BS no HSM/masses GU- No foley Ext- Bruit and palpable thrill over L AV fistula Neuro- Unable to provide detailed history but generally oriented and cooperative. Oriented to person, date, states he is in "dialysis" but does not know hospital. Inattentive on days of week backward, stops at ___. Cranial nerves grossly intact. +Asterixis. DISCHARGE PHYSICAL EXAM: Pertinent Results: ADMISSION LABS: - WBC-13.9# RBC-4.56 Hgb-12.3* Hct-39.6* MCV-87 MCH-27.1 MCHC-31.1 RDW-16.1* Plt ___ - Neuts-85.7* Lymphs-7.9* Monos-5.1 Eos-0.8 Baso-0.5 - Glucose-122* UreaN-107* Creat-15.0# Na-137 K-7.4 Cl-92* HCO3-18* AnGap-34* - Calcium-8.3* Phos-7.9* Mg-4.1* - ALT-7 AST-5 LD(LDH)-196 AlkPhos-55 TotBili-0.4 - Serum Tox: ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG MICROBIOLOGY: - Hepatitis serologies (___): * EKG (___): Sinus rhythm with borderline first degree A-V conduction delay. Non-specific intraventricular conduction delay. Poor R wave progression. Peaked T waves in leads V2-V3 could be due to hyperkalemia. Prolonged QTc interval. Compared to the previous tracing of ___ the precordial T waves are taller and more peaked and the QTc interval is slightly longer and the P-R interval is longer which all could be consistent with hyperkalemia. The lateral ST-T wave abnormalities in leads V4-V6 are less pronounced. AP CXR (___): 1. Mild cardiomegaly with mild interstitial pulmonary edema. 2. 15-mm nodular opacity superior to the right costophrenic angle, possibly a calcified pulmonary nodule. Further assessment with conventional radiographs should be performed once the patient's fluid status has normalized. 3. Bulbous appearance of the right hilus should be reassessed on the same conventional radiographs as recommended in impression point #2. PA/LAT CXR (___): * Brief Hospital Course: ___ is a ___ M with h/o ESRD on Mo/Th HD and HTN who presents with confusion, shakiness and hypertension in setting of missing HD two days ago, found to be uremic with hyperkalemia on labs and admitted to ICU for urgent HD. # UREMIC ENCEPHALOPATHY: Presented with confusion, shakiness and hypertension in setting of missing HD two days PTA. Exam notable for confusion and asterixis which cleared with hemodialysis. His encephalopathy was likely due to uremia from missing dialysis. This is also likely acute on chronic picture, as prior head CT showed significant small vessel disease and lacunar strokes which suggest probable underlying vascular dementia. He has history of EtOH abuse but insists he has been sober for one year. His mental status improved back to baseline with hemodialysis. # UREMIA, HYPERKALEMIA: Pt has ESRD on bi-weekly dialysis. He skipped his ___ HD session and thus presented with uremia with anion gap acidosis and hyperkalemia to 7.6 with peaked T waves. His hyperkalemia improved with medications in the ED (calcium gluconate, insulin, albuterol and kayexelate) and subsequent HD. He received urgent HD session on arrival to ICU at 4am, and was dialyzed again in the afternoon. Had his routine HD session on HD #2 (___) during hospitalization as well. His home cinacalcet, calcium carbonate and nephrocaps were continued. # HYPERTENSION: Arrived hypertensive to SBP 180s. Received hydral 10mg x2 and labetalol 50mg x1, then his home nifedipine was restarted. With these medications and receipt of HD, his SBP improved to 120s. He also had mild pulmonary edema in setting of HTN and renal failure on admission. Improved with dialysis and home torsemide. # POOR MEDICAL COMPLIANCE: Pt has poor insight into his medical problems and per his home nurse practitioner, has missed multiple dialysis sessions over the past year. He currently resides at an assisted living facility but probably needs higher level of care (e.g. SNF). Social work and case management were involved and counseled patient about this, but he is competent to make his own decisions and he refused to go to ___. Will receive daily ___ visits at home. # ?NODULE ON CXR: Chest x-ray showed question of RLL nodular opacity. Repeat AP/lateral CXR showed interval resolution of this finding, probable engorged vessel. ==================== TRANSITIONS OF CARE: # Communication: Patient, friend ___ (___) # Code: Full (confirmed) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Epoetin Alfa 10,000 units SC PER HD 2. Cinacalcet 30 mg PO DAILY 3. NIFEdipine CR 30 mg PO DAILY 4. Metoprolol Succinate XL 150 mg PO DAILY 5. Nephrocaps 1 CAP PO DAILY 6. Famotidine 20 mg PO BID 7. Calcium Acetate 667 mg PO TID W/MEALS 8. Ondansetron 4 mg PO Q8H:PRN Nausea 9. Calcium Carbonate 1000 mg PO QID:PRN Dyspepsia 10. Bisacodyl ___AILY:PRN constipation 11. Acetaminophen 325-650 mg PO Q6H:PRN Pain or Fever 12. Torsemide 100 mg PO DAILY Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain or Fever 2. Bisacodyl ___AILY:PRN constipation 3. Calcium Acetate 1334 mg PO TID W/MEALS RX calcium acetate 667 mg 2 capsule(s) by mouth TID With Meals Disp #100 Tablet Refills:*0 4. Calcium Carbonate 1000 mg PO QID:PRN Dyspepsia 5. Cinacalcet 30 mg PO DAILY 6. Famotidine 20 mg PO DAILY 7. Metoprolol Succinate XL 150 mg PO DAILY 8. Nephrocaps 1 CAP PO DAILY 9. NIFEdipine CR 30 mg PO DAILY 10. Ondansetron 4 mg PO Q8H:PRN Nausea 11. Torsemide 100 mg PO DAILY 12. Epoetin Alfa 10,000 units SC PER HD Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Active: - ESRD on Dialysis Chronic: - HTN - HLD Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr ___, It was a pleasure treating you during this admission. You were admitted to ___ ICU for urgent dialysis. You received a dialysis session and your kidney numbers and confusion improved. We wanted you to stay overnight for another dialysis session but you declined and elected to be discharged home instead. Followup Instructions: ___
10022037-DS-22	10,022,037	29,052,432	DS	22	2169-02-08 00:00:00	2169-02-08 17:12:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Tetanus & Diphtheria Tox,Adult Attending: ___. Chief Complaint: left sided abdominal pain, dysphagia, weight loss Major Surgical or Invasive Procedure: ___ EGD History of Present Illness: ___ yo M with PMH notable for HCV cirrhoisis s/p OLT (___), history of DM2, migraine headaches, CKD (baseline Cr 1.5) and nephrolithiasis presenting with decreased PO intake, weight loss 139->126, chronic vomiting and LUQ pain. The patient reports ongoing GI issues since switching to liquid methadone in ___. His main complaints include LUQ pain, and vomiting w/o nausea. These symptoms worsened after ___. The pain is ___ intensity, constant, w/o radiation and not specifically associated with food intake. Morphine in the ED slighly decreased the pain. His vomiting occurs either immediately after attempting to swallow food or is delayed by 2 hours. There is no blood in the vomit, and as of late the volume has been very low due to poor PO. He also says that he often things get "caught in my throat and make me gag". He feels he has lost significant weight (about 15 lbs), but unsure of the amount. He also describes worsening ___ edema over past month. He denies fevers, chills, chest pain, SOB, and bloody emesis. He was seen by his PCP on the day of admission who was concerned about multiple medical issues and social issues with care, malnutrition and medication noncompliance. The patient has been unable to make numerous appointments this year to due lack of transporation. His sister previously provided transportation but has moved away.He has difficulty w/ mobility and falls so public transportation is not an option. The patient describes difficulty with taking his methadone. Per an OMR note: Since the preparation was changed from the "orange wafer" to "the white pill or red liquid". He left his methadone program for this reason and now gets it on the street "when I have the money". He has been taking anywhere from 40-60 mg daily. Finally, he reports constant pain, ___ in his R hip. He says that the L hip (s/p THR) is much better and he wishes he could have had the same thing done to the R side. In the ED intial vitals were: 98.2, 70, 163/98, 18, 98% - Labs were significant for WBC 6.0, H/H ___, plt 209, Na 145, K 4.9, Cl 102, HCO 28, BUN 14, Cr 1.6, glucose 86, AG 15, and normal LFTs with an albumin of 4.1 - UA largely unremarkable except for trace protein, trace ketones and few bacteria - Patient was given IVFs with D5 + K and IV morphine - Hepatology and transplant surgery were consulted in the ED and recommended medical admission Vitals prior to transfer were: 60, 152/60, 14, 98% RA On the floor the patient denies nausea however continued to complain of LUQ pain (___). He experienced wretching in the room w/ associated tremulousness. He reports chronic constipation. Past Medical History: AVN of the hip Asthma Migraine HA HCV cirrhosis s/p OLT (___) Chronic Back pain Radiculopathy History of IVDU Chronic kidney disease (baseline Cr 1.5) Nephrolithiasis PAST SURGICAL HISTORY: Cadaveric liver transplantation, piggy-back technique (___) Left cystoscopy and left stent placement (___) Primary repair of right distal biceps tendon rupture (___) Left percutaneous lithotripsy (___) Press fit left bipolar hip hemiarthroplasty (___) Right hip unipolar hemiarthroplasty (___) Removal of foreign body from the left foot (___) Social History: Long-standing history of depressive symptoms starting when one of his son's was murdered by four gunshots on the street in ___ in ___. He reports his wife cheating on him and divorcing him in ___ because of his impotence. . Tobacco: denies history of smoking Alcohol: denies alcohol use/abuse IV: history of heroine abuse, sober ___ years . The patient has been unable to make numerous appointments this year to due lack of transporation. His sister previously provided transportation but has moved away. He has difficulty w/ mobility and falls so public transportation is not an option. . The patient describes difficulty with taking his methadone. Per an OMR note: Since the preparation was changed from the "orange wafer" to "the white pill or red liquid". He left his methadone program for this reason and now gets it on the street "when I have the money". He has been taking anywhere from 40-60 mg daily. Family History: M: stroke, pacemaker, alcohol abuse F: alcohol and tobacco use Sisters: 3, healthy Brother: chronic back pain Physical Exam: Admission Exam: Vitals- 98.3 171/78 70 16 99%RA General- malnourished older gentleman in NAD HEENT- PERRL, nose clear, OP w/o lesions Neck- thin, no LAD, JVP at clavicle Lungs- soft breath sounds bilaterally, no appreciable W/W/R CV- soft heart tones, no M/R/G appreciated Abdomen- well healed scar, mild distenstion, mild tenderness in left upper and left lower quadrants, no rebound/guarding Ext- WWP, no clubbing/cyanosis, trace bilateral lower extremity edema Neuro- AAOx3, CNII-XII intact, ___ upper and lower extremity strength bilaterally Psych- depressed affect, poor eye contact, interactive during conversation . Discharge Exam: Vitals- 98.8 158/79 71 18 100%RA General- malnourished older gentleman in NAD, poor historian HEENT- PERRL, OP w/o lesions, no oral candidiasis, no halitosis Neck- thin, no LAD, JVP at clavicle Lungs- CTAB, no appreciable W/W/R CV- RRR, no M/R/G appreciated Abdomen- well healed scar, mild distenstion, mild tenderness in left upper and left lower quadrants, no rebound/guarding Ext- WWP, no clubbing/cyanosis, trace bilateral lower extremity edema Neuro- AAOx3, CNII-XII intact, ___ upper and lower extremity strength bilaterally, sensation intact to light touch throughout Psych- depressed affect, poor eye contact, vague in communication Pertinent Results: Admission Labs: ___ 04:39PM BLOOD WBC-6.0 RBC-4.72 Hgb-13.0* Hct-41.7 MCV-88 MCH-27.5 MCHC-31.2 RDW-14.8 Plt ___ ___ 04:39PM BLOOD Neuts-58.2 ___ Monos-7.4 Eos-0.5 Baso-0.5 ___ 04:39PM BLOOD ___ PTT-30.5 ___ ___ 04:39PM BLOOD Glucose-89 UreaN-14 Creat-1.6* Na-145 K-4.9 Cl-102 HCO3-28 AnGap-20 ___ 04:39PM BLOOD ALT-16 AST-30 LD(LDH)-210 AlkPhos-83 TotBili-0.5 ___ 04:39PM BLOOD Albumin-4.1 ___ 08:42PM BLOOD rapmycn-6.6 ___ 06:58AM BLOOD HIV Ab-PND ___ 04:23PM URINE Color-Yellow Appear-Clear Sp ___ ___ 04:23PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG ___ 04:23PM URINE RBC-<1 WBC-1 Bacteri-FEW Yeast-NONE Epi-<1 ___ Esophageal Brushings: Time Taken Not Noted Log-In Date/Time: ___ 3:55 pm FLUID,OTHER Site: ESOPHAGUS ESOPHAGUS BRUSHINGS, FUNGAL STAIN TO R/O ___ ESOPHAGITIS. GRAM STAIN (Pending): FLUID CULTURE (Pending): ANAEROBIC CULTURE (Pending): FUNGAL CULTURE (Pending): ___ Discharge Labs: ___ 06:58AM BLOOD WBC-6.1 RBC-4.76 Hgb-12.9* Hct-42.2 MCV-89 MCH-27.1 MCHC-30.7* RDW-14.9 Plt ___ ___ 06:58AM BLOOD ___ PTT-30.8 ___ ___ 06:58AM BLOOD Glucose-106* UreaN-8 Creat-1.4* Na-143 K-4.4 Cl-104 HCO3-27 AnGap-16 ___ 06:58AM BLOOD ALT-20 AST-44* LD(LDH)-294* AlkPhos-83 TotBili-0.6 ___ 06:58AM BLOOD Calcium-9.5 Phos-2.6* Mg-1.5* HIV screen: ___ 06:58AM BLOOD HIV Ab-PND Imaging: ___ CXR: Frontal and lateral views of the chest were obtained. No focal consolidation, pleural effusion, or evidence of pneumothorax is seen. The cardiac and mediastinal silhouettes are stable and unremarkable. IMPRESSION: No acute cardiopulmonary process. ___ CT ABD & PELVIS WITH CONTRAST: 1. Significant atrophy and cortical thinning in the left kidney with mild dilation of the collecting system, and delayed contrast excretion. This appearance is essentially unchanged from the prior MRI in ___. 2. Mild nonspecific colonic wall thickening at the junction of the sigmoid colon and descending colon, likely due to underdistension. 3. Status post a liver transplant with mild central intrahepatic biliary duct prominence, unchanged from the prior MRI. It otherwise is normal in appearance. 4. Normal spleen. ___ EGD Impression: Diverticulum in the upper third of the esophagus Small white plaque in the middle third of the esophagus and lower third of the esophagus Otherwise normal EGD to third part of the duodenum Brief Hospital Course: ___ yo M with PMH notable for HCV cirrhoisis s/p OLT (___), CKD (baseline Cr 1.5) and nephrolithiasis presenting with dysphagia, poor PO intake, emesis and weight loss. #DYSPHAGIA/EMESIS/LUQ PAIN/POOR PO: The timeline of the patient's symptoms is somewhat unclear based on his history, but seems to be over the last 2 months. His more concerning symptom is dysphagia which is present with solids>liquids with associated weight loss of 15pounds (albumin of note was normal, 4.1). No evidence of malignancy seen on CXR or CT abd/pelvis scan. He was started on Ensure supplements. He denied odynophagia. He has not experienced any coughing after swallow or other symptoms consistent with aspiration and while here he underwent a bedside speech and swallow which he passed. A CT abd pelvis performed in the ED provided no clear reason for his functional complaints or left sided abdominal pain, though stool was noted in colon and patient had not had a bowel movement in >1week, so his LUQ abdominal pain was attributed to constipation (likely due to chronic methadone use) and he was started on an aggressive bowel regimen. He had a bowel movement on the morning of discharge. GI saw patient for nausea, dysphagia and weight loss and he underwent an EGD under MAC anesthesia which showed an esophageal diverticulum (nonintervenable) and several small white plaques of which brushings were taken and were pending on discharge. GI will follow up these brushings to rule out ___ or other treatable process. HIV was checked and pending on discharge. Patient's nausea was managed with Zofran. He did not have emesis and did eat well. . #DEPRESSION: The patient has multiple social stressors and poor support system. He does not currently have a therapist or pharmacologic treatment for depression. He denies any thoughts of hurting himself or others. Social work was consulted and patient was set up with a social worker to visit him in the home and assess his need for further supports. . #CKD: Creatinine at baseline (1.5). . #HCV CIRRHOSIS S/P OLT: The patient appears to be doing well from this standpoint. A liver biopsy in ___ showed no evidence of rejection, Grade 2 inflammation and Stage 1 fibrosis. Transaminases and synthetic function preserved. The patient reports compliance with Rapamune, level 6.6. Continued on rapamune and Bactrim ppx. #H/O IVDU: Sober x ___ years. He is no longer enrolled at the ___ clinic and acquires methadone on the stree. He reports taking methadone 40-60 mg PO daily. Given methadone 40mg daily during admission. #AVASCULAR NECROSIS: S/p bilateral hip surgery. The patient uses a cane to ambulate. He reports some recent falls do to instability. Patient was set up with ___ and outpatient ___. #HISTORY OF DMII: Most recent A1C 5.8. Not managed with insulin. TRANSITIONAL ISSUES # Code: FULL - consider SSRI treatment for depression - There was concern that patient may be failing at home (question of malnourishment, though Albumin was 4.1), carnation instant breakfast was recommended and patient was discharged with ___ for nursing, ___ and social work. - PCP ___ of ongoing issues on ___. - GI will follow up esophageal brushings with patient - HIV pending on discharge Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB 2. Atorvastatin 10 mg PO DAILY 3. fenofibrate 54 mg oral daily 4. Methadone 40 mg PO DAILY 5. Metoprolol Tartrate 100 mg PO BID 6. Sirolimus 0.5 mg PO DAILY 7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB 2. Atorvastatin 10 mg PO DAILY 3. Methadone 40 mg PO DAILY 4. Sirolimus 0.5 mg PO DAILY 5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 6. Bisacodyl ___AILY RX bisacodyl 10 mg 1 suppository(s) rectally daily Disp #30 Suppository Refills:0 7. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #60 Capsule Refills:0 8. Polyethylene Glycol 17 g PO DAILY RX polyethylene glycol 3350 17 gram 1 packet by mouth daily Disp #30 Packet Refills:0 9. Senna 8.6 mg PO BID RX sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp #60 Tablet Refills:0 10. Ondansetron 4 mg PO Q8H:PRN nausea RX ondansetron HCl 4 mg 1 tablet(s) by mouth Q8hours Disp #60 Tablet Refills:0 11. Metoprolol Succinate XL 200 mg PO DAILY RX metoprolol succinate 200 mg 1 tablet extended release 24 hr(s) by mouth daily Disp #30 Tablet Refills:0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnosis: dysphagia, esophageal diverticulum Seconadry Diagnosis: Weight loss, NOS Avascular necrosis of the hip Asthma Hepatitis C cirrhosis s/p OLT (___) Back pain Radiculopathy Chronic kidney disease (baseline Cr 1.5) Nephrolithiasis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted with trouble swallowing, nausea, and weight loss. The speech and swallow therapists evaluated you at the bedside and felt you were safe to eat regular food and liquids. We started you on ensure supplements to make sure you were getting adequate nutrition and calories to keep you well. Please continue to drink ensure or carnation instant breakfast supplements ___ a day. The gastroenterology specialists performed an upper endoscopy which showed a small pocket in your esophagus that could be causing your symptoms of feeling like food is getting stuck in your chest. Unfortunately there is no intervention for this. Try to keep a food diary and avoid the foods that cause these symptoms. They also noted small white areas in your esophagus which they took a sample of during the procedure. The gastroenterologists will call you with the results of this and determine if you need any treatment. We think your abdominal pain is related to your constipation, caused by your methadone use. Please take the stool softners every day as prescribed. You are being discharged with home physical therapy for your musculoskeletal complaints, and social work to ensure you have all the resources you need to do well at home. You have very close follow up with Dr. ___ ___, which you should keep to continue the evaluation and work up of your various symptoms. Followup Instructions: ___
10022373-DS-4	10,022,373	22,567,635	DS	4	2150-03-01 00:00:00	2150-03-01 14:39:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: codeine / curry leaf tree / morphine / Penicillins Attending: ___ Chief Complaint: Syncope Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ lady with a PMH significant for pancreatic who presents with syncope. Patient reports that on the morning of admission she developed dizziness after standing up to go to the bathroom. She told her friend she was about to pass out, and she was lowered to the floor. Patient then remember waking up as the EMT's were loading her on her stretcher. Her friend reported that she passed out a second time, and did not report any seizure like activity. Patient denies tongue biting, head strike, or loss of bowel or bladder continence. The EMTs reported that she was hypotensive on seen and gave her fluids in the field and placed her in R ___. In the ED, initial VS were T 97.0, HR 79, BP 87/62, RR 18, O2 96% on RA. Patient was given 2LNS and BP's improved to 100's/60's. Initial labs were notable for nl chem 7, WBC 71.1K, HCT 33.1, PLT 145, trop negative x1, ALP 171 otherwise nl LFT's. UA unremarkable, lactate 1.9. CT a/p redemonstrated known pancreatic mass with no acute process. CXR showed no acute process. Patient was given 1g IV vancomycin and admitted to oncology for further management. On arrival to the floor, patient reports chronic ___ abdominal pain, similar to her prior pain. She also has a chronic productive cough. She has no other acute complaints. She did have an episode of 'explosive' diarrhea on ___ prior to admission. No bowel movements since then. She denies fevers or chills. No headache. No dysphagia. She has mild odynophagia from some OP ulcers. No CP or palpiatiations. No SOB or pleuritic pain. No nausea or vomiting. 1 episode of diarrhea, as above. No personal or family history of DVT. No recent travel. No leg pain or swelling. She did receive neulasta on ___. Remainder of ROS is unremarkable. Past Medical History: PAST ONCOLOGIC HISTORY: - ___: Evaluated by PCP ___ ?umbilical hernia and GI distress. On exam, there was no mass that was able to be palpated, so an ultrasound was recommended. - ___: The ultrasound showed a 2.9 x 2.3 cm solid well-circumscribed mass in the posterior abdomen versus retroperitoneum versus pancreatic head with adjacent adenopathy. She then underwent an abdominal CT on ___ which demonstrated a 2.8 cm mass in the pancreas uncinate process suspicious for carcinoma. - ___: She underwent an endoscopic ultrasound showed a 30 x 30 mm ill-defined mass in the head of the pancreas. The mass was hypoechoic and heterogeneous in texture. The borders were irregular and poorly defined. Both an FNA and FNB were performed, but unfortunately they were nondiagnostic withscant parenchymal sampling, stromal fibrosis and atypical ductal cells seen. The initial ultrasound showed that the celiac artery takeoff and superior mesenteric artery takeoff were not invaded by the mass. The mass also did not seem to involve the portal vein or a portosplenic confluence; however, it was in close proximity to the SMV, though there was an intact interface noted at all levels. - ___: She returned for a second endoscopic ultrasound on ___ and this time pathology from this biopsy showed pancreatic ductal adenocarcinoma, moderately differentiated. Cytology was also suspicious for malignancy. - ___: She saw Dr. ___ and ___ recommended neoadjuvant chemotherapy and CyberKnife. - ___: C1D1 FOLFIRINOX - ___: C2D1 FOLFIRINOX - ___: C3D1 FOLFIRINOX PAST MEDICAL HISTORY: - Chronic low back pain, - Bipolar disorder, - PTSD, - Anxiety and panic disorder - Hyperthyroidism s/p surgery - Hypothyroidism - GERD, - Irritable bowel syndrome, - Osteoporosis, - Palpitations - Prior myocarditis s/p appendectomy, s/p thyroidectomy, s/p total abdominal hysterectomy in ___ due to abnormal vaginal bleeding, s/p C-section x 4, s/p bladder suspension s/p tonsillectomy and adenoidectomy. Social History: ___ Family History: Her birth mother had breast cancer at an unknown age. Her sister, ___, was diagnosed with breast cancer at age ___. She has two maternal uncles who died of colon cancer, one in his ___ and one in his ___. She has a maternal aunt who had ovarian cancer in her ___ and her maternal grandmother also had breast cancer. She states that she has met with a genetic counselor in the past and was told that she was at high risk for ovarian cancer, but does not remember any blood work being done. When they did her hysterectomy, they also took out her ovaries. Physical Exam: ADMISSION PHYSICAL EXAM: VS: T 97.9 HR 84 BP 107/66 RR 19 SAT 99% O2 on RA GENERAL: Pleasant, lying in bed comfortably HEENT: Anicteric sclerae, PERLL, EOMI, OP clear, No LAD CARDIAC: Regular rate and rhythm, faint S1S2, 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, TTP RUQ, no ___ sign, nondistended, no hepatomegaly, no splenomegaly EXT: Warm, well perfused, no lower extremity edema PULSES: 2+ radial pulses, 2+ ___ pulses, 2+ DP pulses NEURO: Alert, oriented, CN II-XII intact, motor and sensory function grossly intact, FTN intact SKIN: No significant rashes Discharge Physical Exam: VS: 97.6 108/57 74 13 100% RA GENERAL: Pleasant, lying in bed comfortably HEENT: Anicteric sclerae, PERLL, EOMI, OP clear, No LAD CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops LUNG: Appears in no respiratory distress, clear to auscultation bilaterally ABD: Normal bowel sounds, soft, TTP RUQ, nondistended, no hepatomegaly, no splenomegaly EXT: Warm, well perfused, no lower extremity edema NEURO: Alert, oriented, motor and sensory function grossly intact Pertinent Results: ADMISSION LABS: ___ 12:50PM BLOOD WBC-71.1# RBC-3.48 Hgb-11.0* Hct-33.1* MCV-95 MCH-31.6 MCHC-33.2 RDW-16.6* RDWSD-57.2* Plt ___ ___ 12:50PM BLOOD Neuts-90* Bands-1 Lymphs-7* Monos-2* Eos-0 Baso-0 ___ Myelos-0 AbsNeut-64.70* AbsLymp-4.98* AbsMono-1.42* AbsEos-0.00* AbsBaso-0.00* ___ 12:50PM BLOOD Plt Smr-LOW Plt ___ ___ 12:50PM BLOOD ___ PTT-22.3* ___ ___ 12:50PM BLOOD Glucose-75 UreaN-20 Creat-1.0 Na-137 K-3.4 Cl-98 HCO3-25 AnGap-17 ___ 12:50PM BLOOD ALT-21 AST-20 AlkPhos-171* TotBili-0.2 ___ 12:50PM BLOOD cTropnT-<0.01 ___ 01:05AM BLOOD CK-MB-1 cTropnT-<0.01 ___ 12:50PM BLOOD Albumin-4.2 Calcium-9.2 Phos-4.2 Mg-2.3 ___ 12:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 01:01PM BLOOD Lactate-1.9 DISCHARGE LABS: ___ 01:05AM BLOOD WBC-61.6* RBC-3.27* Hgb-10.4* Hct-30.9* MCV-95 MCH-31.8 MCHC-33.7 RDW-16.5* RDWSD-56.8* Plt ___ ___ 01:05AM BLOOD Glucose-74 UreaN-13 Creat-0.6 Na-138 K-3.7 Cl-103 HCO3-24 AnGap-15 ___ 01:05AM BLOOD ALT-16 AST-17 LD(LDH)-261* AlkPhos-167* TotBili-<0.2 ___ 01:05AM BLOOD Calcium-8.2* Phos-3.3 Mg-2.3 STUDIES: ___ Imaging CHEST (PA & LAT) No acute cardiopulmonary process. ___ Imaging CTA ABD & PELVIS Mass centered in the uncinate process of the pancreas which is unchanged from exam 8 days prior. No evidence of acute intra-abdominal process EKG: NSR at 79. LAD with LAFB. Anterior qwave. No concerning ST changes. Compared to ___ EKG at ___ is similar. MICRO: - Blood and urine cultures pending - Cdiff negative Brief Hospital Course: ___ woman with PMH significant for bipolar disorder, anxiety, chronic pain, hypothyroidism and pancreatic cancer currently on FOLFIRINOX (Cycle 3 Day 1: ___ who presented with syncope. # Syncope: Patient with orthostasis at home and hypotensive on arrival to ED. She had signs of dehydration (elevated urine specific gravity, fluid responsiveness). She received 3L IVF with improvement of her symptoms. Laboratory workup only significant for leukocytosis in setting of recently receiving neulasta. On many sedating medications at home, but no new medication changes. Infectious workup negative: negative UA, CXR, abd/pelvis CT. No N/V/Diarrhea. EKG w/o ischemic changes and negative troponins x2. Her primary oncologist was emailed; she may need IV fluids after chemotherapy in the future to prevent dehydration. She was discharged home with PCP and oncology follow up. # Leukocytosis: Likely due to recent neulasta. No signs of infection. Initially started on flagyl due to concerns for possible diarrheal infection, but stopped before discharge given negative C.diff and normal bowel movements during admission. CHRONIC ISSUES: # Abdominal pain: Chronic, due to pancreatic cancer. Continued on her home oxycontin and oxycodone. # Pancreatic cancer: Currently C3 FOLFIRINOX with planned stereotactic body radiotherapy with hope to become surgical candidate. She will follow up with her outpatient oncologist. # Hx of bipolar disorder, anxiety: Continued home medications of Abilify, lamotrigine, clonazepam, trazodone. # Hypothyroidism: Continued home levothyroxine # Hyperlipidemia: Continued home atorvastatin TRANSITIONAL ISSUES: - Blood and urine cx pending at discharge - ___ benefit from IV fluids after chemotherapy to prevent dehydration Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB 2. ARIPiprazole 10 mg PO DAILY 3. Atorvastatin 20 mg PO QPM 4. ClonazePAM 1 mg PO TID:PRN anxiety 5. Cyclobenzaprine 10 mg PO TID:PRN back pain 6. Dexilant (dexlansoprazole) 60 mg oral DAILY 7. LamoTRIgine 100 mg PO QAM 8. LamoTRIgine 200 mg PO QHS 9. Levothyroxine Sodium 137 mcg PO DAILY 10. Levothyroxine Sodium 75 mcg PO 1X/WEEK (___) 11. Levothyroxine Sodium 137 mcg PO 1X/WEEK (SA) 12. Ondansetron 8 mg PO Q8H:PRN nausea 13. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN pain 14. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H 15. Pregabalin 200 mg PO TID 16. Ranitidine 150 mg PO BID 17. TraZODone 300 mg PO QHS:PRN insomnia 18. Docusate Sodium 100 mg PO BID Discharge Medications: 1. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB 2. ARIPiprazole 10 mg PO DAILY 3. Atorvastatin 20 mg PO QPM 4. ClonazePAM 1 mg PO TID:PRN anxiety 5. Cyclobenzaprine 10 mg PO TID:PRN back pain 6. Docusate Sodium 100 mg PO BID 7. LamoTRIgine 100 mg PO QAM 8. LamoTRIgine 200 mg PO QHS 9. Levothyroxine Sodium 137 mcg PO DAILY 10. Levothyroxine Sodium 75 mcg PO 1X/WEEK (___) 11. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN pain 12. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H 13. Pregabalin 200 mg PO TID 14. Ranitidine 150 mg PO BID 15. TraZODone 300 mg PO QHS:PRN insomnia 16. Dexilant (dexlansoprazole) 60 mg oral DAILY 17. Levothyroxine Sodium 137 mcg PO 1X/WEEK (SA) 18. Ondansetron 8 mg PO Q8H:PRN nausea Discharge Disposition: Home Discharge Diagnosis: PRIMARY: Syncope ___ dehydration SECONDARY: Chronic low back pain Bipolar disorder Anxiety Hypothyroidism GERD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you during your stay. You were admitted after you fainted at home. Your blood pressure was low on admission and you had signs of dehydration. You were given IV fluids with improvement of your symptoms. Infectious workup was negative and heart monitoring was also unrevealing. Try to eat and drink well at home. You may need IV fluids after your chemotherapy in the future. Please follow up with your PCP and oncologist after discharge. We wish you the best! Your ___ care team Followup Instructions: ___
10022373-DS-5	10,022,373	27,450,651	DS	5	2150-06-06 00:00:00	2150-06-06 14:50:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: codeine / curry leaf tree / morphine / Penicillins Attending: ___. Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: Celiac Plexus Block ___. History of Present Illness: Ms. ___ is a pleasant undomiciled ___ with multiple anxiety disorders and locally advanced pancreatic cancer, currently on neoadjuvant FOLFIRINOX, last administered C515 on ___, today C5D26) who is p/w two weeks of uncontrollable nausea/vomiting/abd pain. She states her symptoms started w/ nausea and severe abdominal pain (around her epigastric area and RUQ area) just prior to her ___ cycle of chemo. Pain did not radiaate, was constant, spikes, and had no alleviating or provoking factors. She was admitted to ___ on sat where she had a CT which revealed a pancreatic mass of 20 x 16 mm (previously in our records 27 x ___. She was managed conservatively with IVF, zofran, and her symptoms improved per the d/c summary. She was maintained on a soft diet which she tolerated well. Pt notes that her symptoms never improved and after leaving the hospital, she presented to our ED. She denied any F/C, no vomiting. + nausea. No BM in several days but just had one on admission and described it as formed. Has some chest tightness and sob from chronic bronchitis but no current change from baseline. She notes food does not alleviate nor provoke her symptoms. ___? Old records: ___ 11.2, Alk phos 168 ___ showed No definite acute abdominal process, lung nodules, pancreatic mass; LLE US No DVT She last saw Dr. ___ on ___ at which point she had reported syncope a few days prior, this seemed like an isolated incident, EKG was stable from prior apparently. She has been staying at a ___. ___ ED COURSE: T 97.9 HR 96 BP 112/70 RR 19 98%RA BP as low as 88/64. Got 1L IVF. Also given total 3mg IV dilaudid. Given total 8mg IV Zofran and 40 meq potassium. Labs with K 3.1 otherwise chem reassuring except alk phos 231. Hct 30, WBC 15, plts 107. Lipase 17. Admitted for decreased po intake, pain and nausea. REVIEW OF SYSTEMS: 10 point ROS negative except for what is mentioned above Past Medical History: PAST ONCOLOGIC HISTORY: PER OMR - ___: Evaluated by PCP ___ ?umbilical hernia and GI distress. On exam, there was no mass that was able to be palpated, so an ultrasound was recommended. - ___: The ultrasound showed a 2.9 x 2.3 cm solid well-circumscribed mass in the posterior abdomen versus retroperitoneum versus pancreatic head with adjacent adenopathy. She then underwent an abdominal CT on ___ which demonstrated a 2.8 cm mass in the pancreas uncinate process suspicious for carcinoma. - ___: She underwent an endoscopic ultrasound showed a 30 x 30 mm ill-defined mass in the head of the pancreas. The mass was hypoechoic and heterogeneous in texture. The borders were irregular and poorly defined. Both an FNA and FNB were performed, but unfortunately they were nondiagnostic withscant parenchymal sampling, stromal fibrosis and atypical ductal cells seen. The initial ultrasound showed that the celiac artery takeoff and superior mesenteric artery takeoff were not invaded by the mass. The mass also did not seem to involve the portal vein or a portosplenic confluence; however, it was in close proximity to the SMV, though there was an intact interface noted at all levels. - ___: She returned for a second endoscopic ultrasound on ___ and this time pathology from this biopsy showed pancreatic ductal adenocarcinoma, moderately differentiated. Cytology was also suspicious for malignancy. - ___: She saw Dr. ___ and ___ recommended neoadjuvant chemotherapy and CyberKnife. - ___: C1D1 FOLFIRINOX - ___: C2D1 FOLFIRINOX - ___: C3D1 FOLFIRINOX PAST MEDICAL HISTORY: PER OMR - Chronic low back pain, - Bipolar disorder, - PTSD, - Anxiety and panic disorder - Hyperthyroidism s/p surgery - Hypothyroidism - GERD, - Irritable bowel syndrome, - Osteoporosis, - Palpitations - Prior myocarditis Social History: ___ Family History: Her birth mother had breast cancer at an unknown age. Her sister, ___, was diagnosed with breast cancer at age ___. She has two maternal uncles who died of colon cancer, one in his ___ and one in his ___. She has a maternal aunt who had ovarian cancer in her ___ and her maternal grandmother also had breast cancer. She states that she has met with a genetic counselor in the past and was told that she was at high risk for ovarian cancer, but does not remember any blood work being done. When they did her hysterectomy, they also took out her ovaries. Physical Exam: ADMISSIOn PHYSICAL EXAM: VITAL SIGNS: ___ 68 101/61 18 98% RA General: NAD HEENT: MMM, no OP lesions, no cervical, supraclavicular, or axillary adenopathy, no thyromegaly CV: RR, NL S1S2 no S3S4 MRG PULM: CTAB GI: BS+, soft, + TTP to deep palpation epigastric and RUQ area, no masses or hepatosplenomegaly LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal adenopathy SKIN: No rashes or skin breakdown NEURO: Grossly intact DISCHARGE EXAM: VITAL SIGNS: T 99.0 BP 104/58 HR 75 RR 18 O2 93%RA General: Pleasant woman, sitting up in bed, NAD CV: RR, NL S1S2 PULM: Nonlabored appearing on RA. CTAB GI: Soft, mildly tender in epigastrium, non tender in RLQ and LLQ, no ___ sign, NABS. Nondistended. LIMBS: No ___ NEURO: Alert and oriented, no focal deficits. Pertinent Results: PERTINENT IMAGING: ___ Imaging CTA ABD & PELVIS 1. No evidence of acute intra-abdominal process. 2. Unchanged appearance of hypo attenuating uncinate process pancreatic mass with encasement of an early branch of the SMA. No abnormal bowel wall enhancement or pneumatosis. 3. Right lower lobe areas of ___ opacity suggesting either aspiration or early infection. ___ Imaging GASTRIC EMPTYING STUDY FINDINGS: Residual tracer activity in the stomach is as follows: At 45 mins 99% of the ingested activity remains in the stomach At 2 hours 93% of the ingested activity remains in the stomach At 3 hours 86% of the ingested activity remains in the stomach At 4 hours 77% of the ingested activity remains in the stomach The emptying curve demonstrates a plateau for the first 45 minutes followed by markedly slow emptying for the remainder of the exam. No reflux to the esophagus. IMPRESSION: Markedly abnormal gastric emptying study with the majority of activity remaining in the stomach. ___ Imaging CHEST (PA & LAT) The cardiomediastinal silhouette is normal. The hila are normal. There is a large region of heterogeneous opacity extending from the mid lower to upper lung zone likely representing pneumonia. No pleural abnormalities. No pneumothorax. The visualized bones and soft tissues are normal. The right port is in satisfactory position. ___BD & PELVIS WITH CO 1. No significant interval changes in an uncinate process pancreatic lesion encasing and occluding an early branch of the SMA. No abnormal wall enhancement noted. 2. Significant amount of residual dense oral contrast in the rectum and sigmoid colon since last study raises concern for barium impaction. 3. Persistent ___ nodules in the right lower and right middle lobes are likely due to aspiration. 4. Unchanged 5 mm left lower lobe lung nodule should be reassessed at the time of the follow-up. ___ Imaging CHEST (PORTABLE AP) Compared to chest radiographs ___ and ___. Heterogeneous peribronchial opacification in the right lung has improved consistent with decreasing pneumonia. Left lung clear. No pleural abnormality. Normal cardiomediastinal silhouette. Right transjugular central venous infusion catheter ends in the low SVC. ADMISSION BLOOD WORK: ___ 12:50PM BLOOD WBC-15.2* RBC-3.14* Hgb-10.0* Hct-30.2* MCV-96 MCH-31.8 MCHC-33.1 RDW-18.8* RDWSD-66.1* Plt ___ ___ 05:05AM BLOOD ___ PTT-28.0 ___ ___ 12:50PM BLOOD Glucose-94 UreaN-7 Creat-0.8 Na-138 K-3.1* Cl-98 HCO3-26 AnGap-17 ___ 12:50PM BLOOD ALT-16 AST-20 AlkPhos-231* TotBili-0.2 ___ 12:50PM BLOOD Lipase-17 ___ 05:32AM BLOOD Albumin-3.6 Calcium-8.6 Phos-3.5 Mg-1.9 ___ 09:33AM BLOOD Lactate-2.9* DISCHARGE BLOOD WORK: ___ 05:49AM BLOOD WBC-7.6 RBC-2.78* Hgb-8.4* Hct-26.8* MCV-96 MCH-30.2 MCHC-31.3* RDW-17.9* RDWSD-62.9* Plt ___ ___ 05:49AM BLOOD Glucose-76 UreaN-8 Creat-0.7 Na-137 K-4.6 Cl-101 HCO3-27 AnGap-14 ___ 04:34PM BLOOD ALT-24 AST-27 CK(CPK)-108 AlkPhos-259* TotBili-0.2 ___ 05:49AM BLOOD Calcium-8.7 Phos-5.7* Mg-2.5 ___ 12:05AM BLOOD Lactate-1.3 MICRO: ___ BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT ___ URINE URINE CULTURE-FINAL INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT All negative to date Brief Hospital Course: PRINCIPLE REASON FOR ADMISSION: ___ w/ locally advanced pancreatic cancer (s/p XRT, on FOLFIRINOX f/b neulasta), upcoming whipple scheduled ___, who p/w 2 weeks of persistent nausea and abdominal pain. ACUTE PROBLEMS: # Nausea/Vomiting/Abdominal Pain # Gastroparesis # Fever Etiology initially thought related to chemo (given symptoms started shortly after FOLFIRNOX prior to admission). CT scan unremarkable. Initially improved with Ativan, Zofran, Zyprexa. Underwent celiac nerve block on ___. Symptoms recurred on ___, the day of most recent FOLFIRINOX chemotherapy. That same day, also had a markedly positive gastric emptying study. She was started on metoclopramide on ___ and erythromycin on ___ with good response. Erythromycin was discontinued on ___nd prevent tachyphlyaxis. Of note, her Abilify was discontinued as it interacts with the metoclopramide. Other interventions included increasing home oxycontin to 20mg twice daily, fosprepitent with chemotherapy D1, added Creon to meals, added bid PPI in place of H2 blocker, and increased bowel regimen. Despite this, patient continued to have significant nausea and vomiting with meals. Patient developed a fever on ___, and CT abdomen/pelvis on ___ revealed oral barium impaction. Patient underwent enema that night with output of ___ barium contrast and solid stool. Patient's nausea and vomiting improved significantly, but continued to have marked abdominal pain. She did not have another bowel movement for the next two days, aso underwent additional enema on ___, again with good output. Shortly following second enema, patient did develop feelings of presyncope and SBP's in the low 80's. Infectious and cardiac workup was unremarkable, and patient responded quite well to 1.5L NS. Etiology thought due to hypovolemia and vagal stimulation from enema. By day of discharge, patient felt well without nausea or vomiting, and significant improvement in her chronic abdominal pain, which was well controlled with oral pain medications. Notably, fever on ___ thought due to aspiration, as it resolved quickly without sigficant leukocytosis or antibiotics and resolving infiltrate on repeat CXR. # Pancreatic Cancer Locally advanced and has demonstrated a favorable response to neoadjuvant chemotherapy. Plan to continue chemo when n/v and abdominal pain improve and patient plans for ___ on ___. C6D1 Folfirinox was given on ___ with neulasta on ___. C6D15 FOLFIRINOX was held, and after discussion with patient's primary oncologist, she will not undergo additional chemotherapy. She will follow up with her outpatient oncologist and with her surgeon, Dr. ___, in preparation for Whipple surgery at the end of this month. # Depression/Anxiety Symptoms were largely stable during admisison. Abilify was stopped due to interaction with metoclopramide. Patient should follow up with her outpatient psychiatry providers. We continued her trazodone, pregabalin, lamotrigine, and clonazepam. QTC was monitored weekly, last was 400msec ___. (on admit QTC was 420msec) # Hypokalemia: Likely due to N/V and chemotherapy. Resolved w/ repletion. CHRONIC PROBLEMS # Borderline Macrocytic Anemia: stable, ___ antineoplastic therapy # Thrombocytopenia: stable, ___ antineoplastic therapy, improved # GERD: Switched to bid omeprazole, and tums prn # Hypothyroid: Continued levothyroxine TRANSITIONAL ISSUES: - Maintain aggressive bowel regimen to prevent constipation/obstipation - Monitor QTc intermittently while on standing metoclopramide, would suggest doing this every ___ for the next ___ weeks - Adjust pain medications as needed - Follow up with surgery on ___ for planning of Whipple s/p neoadjuvant FOLFIRINOX - Ensure follow up with her outpatient psychiatry providers ___ rehab stay is less than 30 days at this time. Greater than 30 minutes were spent in planning and execution of this discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB 2. ARIPiprazole 1 mg PO DAILY 3. Atorvastatin 20 mg PO QPM 4. ClonazePAM 1 mg PO TID anxiety 5. Cyclobenzaprine 10 mg PO TID:PRN back pain 6. Docusate Sodium 100 mg PO BID 7. LamoTRIgine 100 mg PO QAM 8. LamoTRIgine 200 mg PO QHS 9. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN pain 10. Pregabalin 200 mg PO TID 11. Ranitidine 150 mg PO BID 12. TraZODone 300 mg PO QHS insomnia 13. Ondansetron 8 mg PO Q8H:PRN nausea Discharge Medications: 1. Calcium Carbonate 500 mg PO QID:PRN heartburn RX calcium carbonate 500 mg calcium (1,250 mg) 1 tablet(s) by mouth four times a day Disp #28 Tablet Refills:0 2. Creon 12 1 CAP PO QIDWMHS RX lipase-protease-amylase [Creon] 12,000 unit-38,000 unit-60,000 unit 1 capsule(s) by mouth three times a day Disp #90 Capsule Refills:0 3. LORazepam 0.5 mg PO TID RX lorazepam 0.5 mg 1 tab by mouth three times a day Disp #21 Tablet Refills:0 4. Metoclopramide 10 mg PO QIDACHS RX metoclopramide HCl 10 mg 1 tab by mouth three times a day Disp #90 Tablet Refills:0 5. OLANZapine (Disintegrating Tablet) 5 mg PO DAILY RX olanzapine 5 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 6. Omeprazole 40 mg PO BID RX omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #60 Capsule Refills:0 7. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H RX oxycodone [OxyContin] 20 mg 1 tablet(s) by mouth twice a day Disp #14 Tablet Refills:0 8. Polyethylene Glycol 17 g PO DAILY RX polyethylene glycol 3350 [Miralax] 17 gram/dose 1 powder(s) by mouth daily Refills:0 9. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain RX oxycodone 5 mg ___ capsule(s) by mouth q4 hours Disp #84 Capsule Refills:0 10. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB RX albuterol sulfate [ProAir HFA] 90 mcg 1 puff IH q4 hours Disp #1 Inhaler Refills:0 11. Atorvastatin 20 mg PO QPM RX atorvastatin 20 mg 1 tablet(s) by mouth at bedtime Disp #30 Tablet Refills:0 12. ClonazePAM 1 mg PO TID anxiety RX clonazepam 1 mg 1 tablet(s) by mouth three times a day Disp #21 Tablet Refills:0 13. Cyclobenzaprine 10 mg PO TID:PRN back pain RX cyclobenzaprine 10 mg 1 tablet(s) by mouth three times a day Disp #21 Tablet Refills:0 14. Docusate Sodium 100 mg PO BID RX docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #60 Capsule Refills:0 15. LamoTRIgine 100 mg PO QAM RX lamotrigine 100 mg 1 tablet(s) by mouth qam Disp #30 Tablet Refills:0 16. LamoTRIgine 200 mg PO QHS RX lamotrigine 200 mg 1 tablet(s) by mouth at bedtime Disp #30 Tablet Refills:0 17. Levothyroxine Sodium 137 mcg PO 5X/WEEK (___) RX levothyroxine 137 mcg ___ tablet(s) by mouth daily Disp #60 Tablet Refills:0 18. Levothyroxine Sodium 274 mcg PO 1X/WEEK (SA) 19. Levothyroxine Sodium 205.5 mcg PO 1X/WEEK (___) 20. Ondansetron 8 mg PO Q8H:PRN nausea RX ondansetron 8 mg 1 tablet(s) by mouth q8 hours Disp #84 Tablet Refills:0 21. Pregabalin 200 mg PO TID RX pregabalin [Lyrica] 200 mg 1 capsule(s) by mouth three times a day Disp #84 Capsule Refills:0 22. TraZODone 300 mg PO QHS insomnia RX trazodone 300 mg 1 tablet(s) by mouth at bedtime Disp #30 Tablet Refills:*0 Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: Pancreatic Cancer Abdominal pain Gastroparesis Fecal impaction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted for nausea and vomiting. This was likely from a combination of as side effect of your chemotherapy, gastroparesis (slow emptying of the stomach), and impaction of oral barium. We started you on several medications to help improve your symptoms of gastroparesis, and we gave you two enemas to help clear out the impaction. Afterward, your symptoms significantly improved. You received your last dose of chemotherapy on ___ (we held the ___ dose). You will follow up with your primary care doctor and with Dr. ___ as below before meeting with Dr. ___ on ___ in preparation for your surgery late this month. Sincerely, Your ___ Care Team Followup Instructions: ___
10022500-DS-14	10,022,500	28,659,510	DS	14	2140-11-22 00:00:00	2140-11-24 14:14:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: Lower GI Bleed Major Surgical or Invasive Procedure: ___ Flexible Sigmoidoscopy (x2) History of Present Illness: Mr. ___ is a ___ year old man with a history of CAD s/p CABG x3 in ___, aortic stenosis s/p aortic valve replacement, HTN, CKD III, pulmonary sarcoidosis, and GERD who is presenting with hematochezia. The patient was in his usual health prior to presenting on ___ for a routine screening colonoscopy. He had a 1 cm polyp removed via endoscopic mucosal resection (EMR). Once he returned at home after the procedure, he had 4 episodes of bright red blood covering his stool and in the toilet bowl, without rectal pain or dark stools. He had not had bloody stools beforehand. He called the GI office who recommended that he go to the nearest ED. He was then transferred from an ED in ___ to ___. He had no associated symptoms of lightheadedness, vision changes, syncope, head strike, chest pain, palpitations, or abdominal pain. In the ED, the patient's vitals were stable. His exam was notable for bright red blood in the rectal vault, but was otherwise normal. Labs including CBC had a Hgb 15.7, Chem-10 with Cr 1.5 (baseline). GI was consulted and performed a flexible sigmoidoscopy on ___ which showed bleeding from the polyp removal site. He received epinephrine injection and 3 endoclips with adequate hemostasis. Postprocedurally, he developed crampy abdominal pain with distension. An abdominal X-Ray showed nonobstructive bowel gas pattern with an overall paucity of bowel gas. Due to his unrelenting pain, he had a repeat flex sig which didn't identify perforation or repeat bleeding. Air was suctioned out, after which his symptoms improved. On repeat CBC, H/H with 1.1 HgB drop from 15.8 to 14.7 and new leukocytosis to 12. On arrival to the floor, the patient is having dinner and feels well. He is pain free and has not had any bloody BM over the last 24h. He reminds me that he's a Jehovah's witness and would not receive blood products should he need them. Past Medical History: CAD, s/p CABG x3 in ___ Aortic stenosis s/p bioprosthetic aortic valve replacement HTN CKD-III Pulmonary sarcoidosis GERD Social History: ___ Family History: Extensive history of heart disease in his immediate family, no history of cancer, particularly colon cancer. Physical Exam: ADMISSION ========= VITALS: T 98.3, BP 126/78, HR 96, RR 18, O2 sat95% Ra GEN: In NAD. HEENT: PERRL, moist mucous membranes, oropharynx clear without exudates. NECK: No JVD, no cervical lymphadenopathy. CV: RRR, no murmurs/gallops/rubs. PULM: CTAB, no wheezing/crackles/rhonchi. ABD: Soft, non tender, non distended. EXTREM: No ___ edema. Pulses +2 ___P, ___ bilaterally. SKIN: No rashes. NEURO: A&Ox3, CN II-XII intact, motor and sensation grossly intact. DISCHARGE ========= 24 HR Data (last updated ___ @ 13:52) ___ 1107 Temp: 98.3 PO BP: 109/67 L Lying HR: 72 RR: 18 O2 sat: 97% O2 delivery: Ra GEN: NAD. HEENT: PERRL, no conjunctival pallor, MMM, oropharynx clear without exudates. NECK: No JVD, no cervical lymphadenopathy. CV: RRR, no murmurs/gallops/rubs. PULM: CTAB, no wheezing/crackles/rhonchi. ABD: Soft, non tender, non distended. Slight TTP in RLQ, RUQ, and epigastric region. EXTREM: No ___ edema. Pulses +2 ___P, ___ bilaterally. SKIN: No rashes. NEURO: A&Ox3, CN II-XII intact, motor and sensation grossly intact. Pertinent Results: ADMISSION ========= ___ 04:21AM WBC-8.8 RBC-5.03 HGB-15.7 HCT-47.5 MCV-94 MCH-31.2 MCHC-33.1 RDW-13.1 RDWSD-44.6 ___ 04:21AM NEUTS-62.3 ___ MONOS-10.0 EOS-0.8* BASOS-0.5 IM ___ AbsNeut-5.49 AbsLymp-2.26 AbsMono-0.88* AbsEos-0.07 AbsBaso-0.04 ___ 04:21AM GLUCOSE-101* UREA N-17 CREAT-1.5* SODIUM-143 POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-26 ANION GAP-13 ___ 04:21AM CALCIUM-9.3 PHOSPHATE-3.9 MAGNESIUM-1.7 ___ 02:48PM WBC-12.4* RBC-4.71 HGB-14.8 HCT-44.6 MCV-95 MCH-31.4 MCHC-33.2 RDW-13.0 RDWSD-45.1 ___ 02:48PM NEUTS-83.0* LYMPHS-8.1* MONOS-8.2 EOS-0.1* BASOS-0.2 IM ___ AbsNeut-10.27* AbsLymp-1.00* AbsMono-1.02* AbsEos-0.01* AbsBaso-0.03 DISCHARGE ========= ___ 07:47AM BLOOD WBC-8.8 RBC-4.58* Hgb-14.4 Hct-43.8 MCV-96 MCH-31.4 MCHC-32.9 RDW-13.0 RDWSD-45.5 Plt ___ ___ 01:08PM BLOOD WBC-8.8 RBC-4.64 Hgb-14.5 Hct-44.1 MCV-95 MCH-31.3 MCHC-32.9 RDW-12.9 RDWSD-44.6 Plt ___ IMAGING ======= ___ Sigmoidoscopy: A single oozing ulcer was found at the site of the previous EMR polypectomy (at 20cm). 3mL of ___ epi were injected and 3 endoclips placed for hemostasis. Brief Hospital Course: ___ w/ PMH CAD (s/p CABG ___, AS s/p aortic valve replacement, HTN, CKD III, pulmonary sarcoidosis, and GERD p/w hematochezia following screening colonoscopy, underwent flexible sigmoidoscopy with epipherine injection and 3 endoclips with adequate hemostasis. He remained hemodynamically stable with a stable Hgb and tolerated PO well with BMs with some dried blood but no fresh blood. ACUTE ISSUES ============ #Hematochezia #Abdominal pain Patient originally presented with hematochezia following routine colonoscopy with polypectomy on ___, and is now s/p flexible sigmoidoscopy with successful hemostasis. His vital signs remained stable and he had no signs or symptoms of significant volume loss. His H/H were stable. Of note, the patient is ___'s witness and doesn't accept blood transfusion. #Leukocytosis Patient with leukocytosis to 12.4 while in ED. He has been afebrile without evidence of active infection on exam, likely reactive secondary to blood loss and endoscopy. CHRONIC/STABLE ISSUES ===================== #CAD, s/p CABG x3 in ___ - Continued home metoprolol. Aspirin held while inpatient. #HTN - Continued home amlodipine, spironolactone #Pulmonary sarcoidosis - Continued home prednisone #CKD-III - Cr at baseline (1.5) this admission TRANSITIONAL ISSUES =================== Discharge Cr. 1.5 Discharge Hgb: 14.5 [] Please obtain repeat CBC within one week to ensure stability and continue to monitor for signs of bleeding. If stable, recommend restarting aspirin. [] No specific GI follow up needed outside of screening recommendations pending pathology report. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. PredniSONE 5 mg PO EVERY OTHER DAY 2. ChlordiazePOXIDE 25 mg PO Q8H:PRN Anxiety 3. Metoprolol Succinate XL 50 mg PO DAILY 4. amLODIPine 10 mg PO DAILY 5. Spironolactone 25 mg PO BID 6. Aspirin 81 mg PO DAILY 7. Vitamin D 1000 UNIT PO DAILY Discharge Medications: 1. amLODIPine 10 mg PO DAILY 2. ChlordiazePOXIDE 25 mg PO Q8H:PRN Anxiety 3. Metoprolol Succinate XL 50 mg PO DAILY 4. PredniSONE 5 mg PO EVERY OTHER DAY 5. Spironolactone 25 mg PO BID 6. Vitamin D 1000 UNIT PO DAILY 7. HELD- Aspirin 81 mg PO DAILY This medication was held. Do not restart Aspirin until told by your PCP or cardiologist ___ Disposition: Home Discharge Diagnosis: Primary: Lower GI bleed from polypectomy site Secondary: Coronary Artery Disease Hypertension Chronic Kidney Disease Stage III Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a privilege caring for you at ___. WHY WAS I IN THE HOSPITAL? - You had blood in your stool, which was found to be caused by the site of your polyp removal during your colonoscopy. WHAT HAPPENED TO ME IN THE HOSPITAL? - The GI team went in an placed clips and injected medication to control the bleeding from in your colon. - You were watched carefully and had stable blood pressure, heart rate, and blood counts. - You had bowel movements with some dried blood in them but no fresh blood. This is to be expected. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - If you have another episode where you are filling the toilet bowl with fresh blood, please go to the emergency room. - We recommend that you hold off on taking your aspirin for a short time. Please discuss with your PCP or cardiologist about restarting your aspirin at your follow up appointment. - Continue to take all your medicines and keep your appointments. We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___
10023117-DS-18	10,023,117	24,244,087	DS	18	2174-06-12 00:00:00	2174-06-12 17:17:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Clozaril / Tegretol / Benadryl Attending: ___ Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: ___ presents to ED from ___ with PMH of paronoid schizophrena with chronic non-infarct related systolic heart failure and cardiomyopathy LVEF 15%, ___ CRT with surgical epicardial lead placement who presents for dyspnea and weakness. Pt reports mild increased shortness of breath with exertion over past week. Pt reports that last night he had an episode of weakness in his legs, which prevented him from being able to move. Denies any increase in weight and instead reports weight loss. No reports of increased orthopnea. Pt reports symptoms are much improved, but was transferred to ___ since his care is primarily here. He had a RUQ US performed at OSH that was reported wnl. Of note, last visit with Dr. ___ on ___ who increased his home torsemide to 200mg. Of note, his clinical exam was never reported to be significantly overloaded but had his medications increased. Not a transplant candidate due to neuropsych co-morbidities. In the ED, initial vitals were: 97.7 79 100/58 20 99% ra. Initial labs were remarkable for WBC 15.5, Hgb 10.5, plts 295, N76.3%, ALT 277, AST 283, AP88, Tbili2.2, Trop <0.01, Na 132, Cr 3.2 (baseline ) Lactate 2. On arrival to the floor, pt without specific complaint except mild SOB. No reports of increased ___. No f/c/s/n/v. No abdominal pain. Reports that he has been urinating with torsemide though reports occasionally with difficulties urinating. Does not believe he has issues with complete emptying. Reports complicance with meds and diet. REVIEW OF SYSTEMS Per HPI Denies fevers, chills, URI like symptoms, n/v/d, abdominal pain, dysuria, hematuria, lower extremity swelling Cardiac review of systems is notable for absence of chest pain, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. Chronic systolic heart failure and cardiomyopathy dating back to ___ with LVEF ___ 2. Pacemaker with ICD, since ___ not BiV pacing due to chest wall stimulation. 3. Paranoid schizophrenia. 4. Depression. 5. Hypertension. 6. Hyperlipidemia. 7. Renal cancer with tumor extraction in ___. 8. GERD/ Barretts esophagus. 9. Complete teeth extraction. 10. Mild anemia. Social History: ___ Family History: Premature coronary artery disease Paternal & Maternal grandfathers had heart dz Physical Exam: ADMISSION PHYSICAL EXAM ======================== VS- 97.6 115/81 87 18 97/RA 78.6 kg (admission) GENERAL: Alert in NAD. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. NECK- Supple with JVD at 12cm however exam difficult due to body habitus, significant carotid pulsations and TR CARDIAC- RRR. Grade II/VI holosystolic murmur best heard at the apex. LUNGS- CBAT, unlabored, no wheezes, rhonchi, or crackles ABDOMEN- Soft, obese, NT/ND. +BS EXTREMITIES- No c/c/e Psych: No SI/HI. At times, remarks on paranoias. No active audiatory, visual hallucinations DISCHARGE PHYSICAL EXAM ======================== VS: 97.8 ___ 87-107/59-71 18 98% RA Admission wt: 78.6kg Discharge Wt.73.1 kg GENERAL: WDWN male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple with JVP not visible at 90 deg CARDIAC: RRR, normal S1, S2. ___ holosystolic murmur head best at apex. No r/g. LUNGS: Resp were unlabored, no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. NBS. EXTREMITIES: No pedal edema. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: 2+ DP bilat Pertinent Results: ADMISSION LABS ============== ___ 07:43PM BLOOD WBC-15.5# RBC-5.12 Hgb-10.5# Hct-36.2* MCV-71# MCH-20.5# MCHC-29.0* RDW-23.4* RDWSD-55.4* Plt ___ ___ 07:43PM BLOOD Neuts-76.3* Lymphs-14.5* Monos-8.3 Eos-0.1* Baso-0.2 NRBC-0.7* Im ___ AbsNeut-11.85* AbsLymp-2.25 AbsMono-1.29* AbsEos-0.01* AbsBaso-0.03 ___ 07:52PM BLOOD ___ PTT-28.7 ___ ___ 07:43PM BLOOD Ret Aut-3.2* Abs Ret-0.17* ___ 07:43PM BLOOD Glucose-91 UreaN-75* Creat-3.2# Na-132 K-4.8 Cl-95* HCO3-24 AnGap-18 ___ 07:43PM BLOOD ALT-277* AST-283* LD(LDH)-442* CK(CPK)-114 AlkPhos-88 TotBili-2.2* ___ 07:43PM BLOOD Lipase-47 ___ 07:43PM BLOOD CK-MB-4 cTropnT-<0.01 ___ ___ 07:43PM BLOOD Albumin-3.9 Iron-13* ___ 07:43PM BLOOD calTIBC-455 VitB12-1702* Folate-GREATER TH Ferritn-23* TRF-350 ___ 06:02AM BLOOD TSH-2.0 ___ 07:43PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE IgM HAV-NEGATIVE ___ 06:02AM BLOOD HIV Ab-NEGATIVE ___ 07:43PM BLOOD HCV Ab-NEGATIVE ___ 07:52PM BLOOD Lactate-2.0 ___ 06:06AM URINE Color-Straw Appear-Clear Sp ___ ___ 06:06AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 06:06AM URINE Hours-RANDOM UreaN-338 Creat-35 Na-36 K-33 Cl-45 DISCHARGE AND PERTINENT LABS ============================= ___ 04:50AM BLOOD WBC-10.3* RBC-5.72 Hgb-11.7* Hct-41.2 MCV-72* MCH-20.5* MCHC-28.4* RDW-24.4* RDWSD-59.7* Plt ___ ___ 04:50AM BLOOD ___ PTT-39.8* ___ ___ 04:50AM BLOOD Glucose-78 UreaN-39* Creat-1.6* Na-142 K-3.7 Cl-101 HCO3-27 AnGap-18 ___ 04:50AM BLOOD ALT-123* AST-44* LD(LDH)-284* AlkPhos-89 TotBili-1.4 ___ 04:50AM BLOOD Calcium-9.5 Phos-4.2 Mg-2.0 MICROBIOLOGY ============= ___ 7:43 pm BLOOD CULTURE Blood Culture, Routine (Pending): IMAGING ======== ___ ECHOCARDIOGRAM - TTE Conclusions The left atrium is moderately dilated. The right atrium is moderately dilated. The estimated right atrial pressure is ___ mmHg. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is severely dilated. There is severe global left ventricular hypokinesis (LVEF = ___ %). The estimated cardiac index is depressed (<2.0L/min/m2). No masses or thrombi are seen in the left ventricle. The right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. The mitral valve leaflets do not fully coapt. Severe (4+) mitral regurgitation is seen. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of ___, the right ventricle is dilated with greater tricuspid regurgitation and higher estimated pulmonary arterial pressure. The appearance of the left ventricle is similar. ___ ECG Ventricular paced rhythm. Compared to the previous tracing no change. ___ CXR FINDINGS: Left-sided AICD device is noted with leads terminating in the regions of the right atrium, right ventricle and coronary sinus, unchanged. Severe cardiomegaly is again noted. Mediastinal and hilar contours are unchanged. No pulmonary edema is demonstrated. No focal consolidation, pleural effusion or pneumothorax is present. Atelectasis is noted in both lung bases. There are no acute osseous abnormalities. IMPRESSION: Severe cardiomegaly without congestive heart failure or pneumonia. Brief Hospital Course: ___ y/o M with heart failure with reduced ejection fraction(EF ___, nonischemic dilated cardiomyopathy, attributed to an anti-psychotic medication, mild pulmonary hypertension, ___ MR and TR, and CKD with baseline ___ creatinine, and ICD who presented with weakness and dyspnea. # Acute on Chronic Decompensated Heart Failure Upon arrival patient appeared hypervolemic based on JVP exam, the rest of the exam was not remarkable for hypervolemia (minimal pedal edema, lungs without major crackles). BNP was elevated to 30k from baseline 15k. He also had leukocytosis, transaminitis, and ___ on CKD. Patient was diuresed with IV lasix 200mg BID boluses with net fluid loss daily. After diuresis, patient's lab abnormalities improved and he returned to baselinine renal function, leukocytosis resolved and liver enzymes were downtrending. A repeat cardiac echo showed a LVEF ___ and compared to echo from ___ the right ventricle is dilated with greater tricuspid regurgitation and higher estimated pulmonary arterial pressure. Patient was started on hydralazine for afterload reduction given heart failure. EP was consulted to check for arrhythmias that could have precipitated exacerbation of CHF, but nothing substantial was found. Of note, patient's ICD is no longer BiV paced since ___ given chest wall stimulation. Also in ___ LV lead could not be replaced d/t anatomic structure. Upon discharge patient was on 100 mg torsemide daily with a return to baseline of his symptoms. He occasionally had short runs of asymptomatic non-sustained ventricular tachycardia. Discharge weight: 73.1kg. #Mitral Regurgiation/TR - severe MR and mod/sev TR. Will benefit from afterload reduction. Started on hydralazine 10mg TID in addition to isordil. # Transaminitis ALT/AST to 300s with mild elevation of Tbili to 2.2 on admission. Normal RUQ U/S reported at OSH without evidence of obstruction. Mild liver heterogenetity. Trace ascites. Coagulopathy initially with INR of 1.1 at discharge. Most likely congestive hepatopathy that improved with diuresis. Labwork for hepatitis A,B,C and HIV was negative. #Leukocytosis on presentation. Infectious work-up was negative. Resolved with diuresis. Most likely cause was CHF exacerbation. # Acute on chronic kidney disease Significantly elevated from prior baseline 1.7-2.2. Creatinine 3.2 on admission. Most likely a reflection of cardiorenal process with CHF exacerbation. Resolved with diuresis with Cr 1.6 at discharge. Of note, has only R kidney per abdominal US though patient does not remember. Had RCC of the other kidney. UA with urine lytes unremarkable. #Fe Deficiency Anemia. TIBC borderline normal/high. Low Iron, low ferritin. Most likely iron def anemia. B12 high.Patient was anemic on admission and iron studies were consistent with iron deficiency. His iron was repleted with iron gluconate. #Schizophrenia - was well controlled on home medications during hospitalization. TRANSITIONAL ISSUES =================== #Discharge weight: 73.1kg #Patient is Hepatitis B surface antibody negative - consider vaccination as an outpatient. #Transaminitis - f/u to check for resolution. Most likely cause was congestive hepatopathy from CHF. If not resolved consider further workup. #Iron deficiency anemia - check for improving hemoglobin and further iron administration/work-up if not improving. Make sure patient is up to date on colon cancer screening. #started on hydralazine for afterload reduction. Monitor for signs/symptoms of hypotension at follow up. #Not on an ___ d/t history of hypotension. Consider restarting if blood pressures permit in the future Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO DAILY 2. Zolpidem Tartrate 10 mg PO QHS:PRN Insomnia 3. OLANZapine 10 mg PO QHS 4. ALPRAZolam 0.5 mg PO BID 5. Metoprolol Succinate XL 100 mg PO DAILY 6. Digoxin 0.125 mg PO DAILY 7. Atorvastatin 10 mg PO QPM 8. Torsemide 200 mg PO DAILY 9. Spironolactone 12.5 mg PO DAILY 10. Multivitamins 1 TAB PO DAILY 11. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 12. Vitamin C (ascorbate Ca-multivit-min;<br>ascorbate calcium;<br>ascorbic acid;<br>vit c-ascorbate Ca-ascorb sod) Dose is Unknown oral DAILY 13. Omeprazole 20 mg PO DAILY 14. Potassium Chloride 20 mEq PO BID 15. Aspirin 81 mg PO DAILY 16. Vitamin D 1000 UNIT PO DAILY 17. Fish Oil (Omega 3) 1000 mg PO BID Discharge Medications: 1. Allopurinol ___ mg PO DAILY 2. ALPRAZolam 0.5 mg PO BID 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 10 mg PO QPM 5. Digoxin 0.125 mg PO DAILY 6. Fish Oil (Omega 3) 1000 mg PO BID 7. Multivitamins 1 TAB PO DAILY 8. OLANZapine 10 mg PO QHS 9. Omeprazole 20 mg PO DAILY 10. Spironolactone 12.5 mg PO DAILY 11. Torsemide 100 mg PO DAILY RX torsemide 100 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 12. Vitamin D 1000 UNIT PO DAILY 13. Zolpidem Tartrate 10 mg PO QHS:PRN Insomnia 14. HydrALAzine 10 mg PO Q8H RX hydralazine 10 mg 1 tablet(s) by mouth Every 8 hours Disp #90 Tablet Refills:0 15. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 16. Metoprolol Succinate XL 100 mg PO DAILY RX metoprolol succinate 100 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:*0 17. Potassium Chloride 20 mEq PO BID Hold for K > 18. Ascorbic Acid (ascorbate Ca-multivit-min;<br>ascorbate calcium;<br>ascorbic acid;<br>vit c-ascorbate Ca-ascorb sod) 1 pill ORAL DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES ================= #Acute on Chronic Decompensated Heart Failure with reduced ejection fraction #Acute on chronic kidney disease #Transaminitis SECONDARY DIAGNOSES =================== #Iron Deficiency Anemia #Mitral Regurgiation/Tricuspid Regurgitation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure meeting you and taking care of you while you were at the ___. You were admitted to us after worsening shortness of breath. In the hospital it was determined that you had too much fluid retention in your body from the heart failure causing your symptoms of shortness of breath. You were given medicine to help you urinate the extra fluid. Before discharge you were given tosemide which is a diuretic (water pill) to help you maintain your fluid balance. In addition you were started on a medicine called hydralazine which lowers blood pressure and can help with some symptoms of your heart failure. It is important to continue eating low sodium foods when you are at home and to restriciting yourself to 2 liters of fluids per day. You need to call and schedule a follow up with your primary care physician. You already have a follow up scheduled with your cardioligist, Dr. ___. You should weigh yourself every morning, and call your MD if weight goes up more than 3 lbs in a 24 hour period. We wish you the best of health, Your ___ Care Team Followup Instructions: ___
10023239-DS-18	10,023,239	29,295,881	DS	18	2137-06-22 00:00:00	2137-06-22 16:31:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Nausea, vomiting, hyperglycemia Major Surgical or Invasive Procedure: None History of Present Illness: ___ F h/o DMI p/w nausea, vomiting and hyperglycemia. Pt was in her usual state of health until yesterday morning when she developed the sudden onset of nausea and vomiting. Her last episode of emesis was about noon today. She estimates about six episodes of emesis. No food stayed down; when she tried to eat, vomitus looked like food, otherwise it was watery. No blood or black color in vomitus. No abdominal pain. Last BM last night, brown, normal appearing. Pt also reports chills, alternating hot/cold, took temp yesterday AM and it was normal. She was very thirsty yesterday at noon, also thirsty today. Has produced a little more urine than usual but not a lot. Also endorses blurry vision all day today, which has improved since coming to ED. Has soreness of b/l leg muscles yesterday and this AM but the legs are "fine" now. C/o generalized weakness and palpitations with walking short distances. Had dizziness/lightheadedness but none currently. No weight change. No focal weakness or paresthesias. She had a blood sugar of ___ yesterday AM and BG went as low as ___. She gave herself some extra doses of subcutaneous insulin, approx 15 units altogether, in efforts to get her sugars under better control. She does not usually take extra insulin beyond her pump but she was concerned her pump was not working due to possible kink, and she tried changing the tubing. Of note, she denies shortness of breath, cough, chest pain. In the ED, initial VS: 97.9 130 118/70 16 95% RA. Labs notable for sugar 348, bicarb 11, Cr 1.3, AG 24, WBC 19.5. CXR showed possible RML PNA. Pt received regular insulin 6 units/hr, azithro, CTX and 2L NS with 40mEq K. Review of systems: Gen: +chills, alternating hot/cold, took tempt yesterday AM and it was normal. No weight change. HEENT: +blurry vision as per HPI. No rhinorrhea. +sore throat which pt attributes to mouth dryness. Pulm: No SOB, no cough. CV: No CP, +palpitations walking short distances, +dizziness/lightheadedness as per HPI. GI: As per HPI. GU: No dysuria. MSK: B/l leg muscle soreness yesterday and this AM. Fine now. Heme/lymph: No abnormal bruising/bleeding/LAD. Neuro: +generalized weakness, no focal weakness, no paresthesias. Endo: As per HPI. Past Medical History: DMI, diagnosed at age ___. Hospitalized at time of diagnosis but no other DM-related hospitalizations, no prior episodes of DKA. Has insulin pump managed by ___. Checks blood sugars herself QID. Blood sugars usually run 100-250. No known neuropathy, nephropathy or eye problems. Epilepsy, last seizure ___ years ago Hypothyroidism Hypercholesterolemia Anxiety Social History: ___ Family History: None Physical Exam: ADMISSION PHYSICAL EXAM: Vitals- 114 110/73 100% RA bed weight 68.8kg General: Awake, alert, oriented, no acute distress HEENT: Sclera anicteric, dry MM Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Tachycardic, regular rhythm, no murmurs, rubs, gallops Abdomen: Soft, NT, ND. Ext: WWP, no edema Neuro: Face symmetric, speech fluent, able to turn to left side in bed without assistance. DISCHARGE PHYSICAL EXAM: General: Awake, alert, oriented, no acute distress HEENT: Sclera anicteric, MMM Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, no m/g/r Abdomen: Soft, NT, ND. Ext: WWP, no edema Neuro: Face symmetric, speech fluent. Pertinent Results: ADMISSION LABS: ___ 03:20PM PLT COUNT-358# ___ 03:20PM NEUTS-89.4* LYMPHS-4.9* MONOS-5.4 EOS-0.1 BASOS-0.2 ___ 03:20PM WBC-19.5# RBC-4.84 HGB-15.4 HCT-46.1 MCV-95# MCH-31.8 MCHC-33.5 RDW-12.6 ___ 03:20PM ALBUMIN-5.6 ___ 03:20PM LIPASE-16 ___ 03:20PM ALT(SGPT)-27 AST(SGOT)-24 ALK PHOS-85 TOT BILI-0.3 ___ 03:20PM GLUCOSE-348* UREA N-28* CREAT-1.3* SODIUM-135 POTASSIUM-4.7 CHLORIDE-100 TOTAL CO2-11* ANION GAP-29* ___ 03:48PM O2 SAT-73 ___ 03:48PM GLUCOSE-338* LACTATE-2.5* ___ 03:48PM ___ PO2-41* PCO2-31* PH-7.11* TOTAL CO2-10* BASE XS--19 DISCHARGE LABS: ___ 03:00AM BLOOD WBC-6.2 RBC-3.76* Hgb-12.0 Hct-33.9* MCV-90 MCH-31.9 MCHC-35.4* RDW-12.6 Plt ___ ___ 03:00AM BLOOD Plt ___ ___ 03:00AM BLOOD Glucose-269* UreaN-12 Creat-0.6 Na-135 K-3.9 Cl-100 HCO3-22 AnGap-17 ___ 03:00AM BLOOD Calcium-8.6 Phos-3.3# Mg-2.0 MICRO: Blood cultures ___: Pending IMAGING: CXR PA/lateral ___ There is subtle right basilar opacity and lack of visualization of the right heart border. There is minimal increased density projecting over the cardiac sillouette on the lateral view. Elsewhere, the lungs are clear. The cardiomediastinal silhouette is normal. No acute osseous abnormality is identified. IMPRESSION: Loss of the right heart border with subtle increased right lower lung opacity which could represent right middle lobe pneumonia. Brief Hospital Course: ___ F h/o DMI diagnosed at age ___ with no prior h/o DKA, hypothyroidism, epilepsy, HLD, anxiety who presents with nausea, vomiting and hyperglycemia. ACTIVE ISSUES #) Hyperglycemia: Likely DKA given blood sugars elevated to the 300s and h/o DMI, with evidence of ketonuria. Precipitant unclear; most likely due to malfunctioning pump. Other possible precipitants included infection such as viral gastroenteritis or pneumonia. Initial AG was 24. She was treated with insulin drip and her gap closed. She was transitioned to BID Lantus and Humalog sliding scale insulin. She was seen by ___ who provided recommendations for insulin titration. She was also seen by a diabetes nurse educator who provided recommendations to transition the patient back onto her pump prior to discharge. She was transiently hyperglycemic on the night prior to discharge, as expected given her transition from glargine and humalog injections back onto her pump and received a correction bolus. She is discharged home with ketone strips and will follow up in the ___ clinic 2 days after discharge on ___. #) Leukocytosis: Differential diagnosis included infection versus hemoconcentration. Infection could be viral gastroenteritis based on abrupt onset of nausea and vomiting (though these symptoms could be a manifestation of DKA rather than precipitant). CXR revealed impressive obscuration of right heart border, which may represent aspiration pneumonia versus pneumonitis in the setting of nausea/vomiting. She did not have SOB or cough to suggest typical or atypical PNA. She did not have dysuria to suggest UTI. Considered influenza given reported myalgias, generalized weakness and subjective fever, though patients illness began with abrupt onset GI distress making flu less likely. Leukocytosis may be a reflection of hemoconcentration to some extent given elevated albumin and Hgb/Hct approaching upper range of normal with significant decrease in all cell lines after receiving IVF fluids. She was started on azithro/CTX for five-day course and then transitioned to azithro monotherapy. CHRONIC ISSUES #) Hypothyroidism: Continued home levothyroxine. #) Epilepsy: Continued home lamotrigine. #) HLD: Continued home simvastatin. #) Anxiety: Continued home alprazolam. Continued home fluoxetine. TRANSITIONAL ISSUES * Patient will follow up with ___ on ___ to adjust insulin pump Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 75 mcg PO 6X/WEEK (___) 2. Ibuprofen Dose is Unknown PO Frequency is Unknown 3. ALPRAZolam 0.5 mg PO DAILY:PRN anxiety 4. Fluoxetine 80 mg PO DAILY 5. LaMOTrigine 200 mg PO BID 6. Simvastatin 40 mg PO DAILY 7. Insulin Pump SC (Self Administering Medication) Target glucose: Unclear Discharge Medications: 1. ALPRAZolam 0.5 mg PO DAILY:PRN anxiety 2. Fluoxetine 80 mg PO DAILY 3. Insulin Pump SC (Self Administering Medication)Insulin Aspart (Novolog) (non-formulary) Basal rate minimum: 1.0 units/hr Basal rate maximum: 1.4 units/hr Bolus minimum: 0.1 units Bolus maximum: 20 units Target glucose: ___ Fingersticks: QAC and HS MD acknowledges patient competent MD has ordered ___ consult MD has completed competency 4. LaMOTrigine 200 mg PO BID 5. Levothyroxine Sodium 75 mcg PO 6X/WEEK (___) 6. Simvastatin 40 mg PO DAILY 7. Ibuprofen 0 mg PO Frequency is Unknown 8. Azithromycin 250 mg PO Q24H RX azithromycin 250 mg 1 tablet(s) by mouth daily Disp #2 Tablet Refills:0 9. Ketone Urine Test (acetone (urine) test) miscellaneous PRN RX acetone (urine) test 1 strip PRN Disp #1 Package Refills:0 Discharge Disposition: Home Discharge Diagnosis: Diabetic ketoacidosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure taking part in your care at ___ ___. As you know, you came to the hospital with nausea and vomiting. You were found to have diabetic ketoacidosis. You received intravenous insulin and your blood work improved. You were transitioned to subcutaneous insulin. You were seen by ___ consultants and observed using your insulin pump overnight. Please drink plenty of water to remain well hydrated. In the future, if you are feeling ill and/or your blood sugars are elevated despite taking insulin, use the prescribed ketose strips to test your urine for ketones. Seek medical attention immediately if you are feeling unwell and your urine tests positive for ketones. Please be sure to follow up closely with ___ after discharge. Followup Instructions: ___
10023239-DS-19	10,023,239	21,759,936	DS	19	2140-10-08 00:00:00	2140-10-09 18:20:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Weakness, abdominal pain, SOB Major Surgical or Invasive Procedure: ___ Flexibile bronchoscopy with endobronchial ultrasound (EBUS)with transbronchial needle aspiration History of Present Illness: Ms. ___ is a ___ year old female with a history of IDDM, currently being worked up for pulmonary sarcoidosis, who presents as a transfer from ___ with concern for DKA. Patient has an insulin pump which she states stopped working for a few hours on ___. She subsequently changed the pump and found her FSBG to be significantly elevated. She then presented to ___ for further evaluation. FSBG at ___ was found to be in the 400s with anion gap of 20. She received 2 L of LR, 1 L normal saline, but no insulin prior to transfer to ___ (as she is set to undergo bronchoscopy with IP for sarcoid workup on ___. She had one episode of NBNB emesis at the OSH. She reports dyspnea on exertion and intermittent dry cough which she states has been ongoing and thought to be associated with this probable diagnosis of sarcoidosis. She denies nausea, abdominal pain, diarrhea, cough, dysuria, hematuria, or recent fevers. On presentation to ___ ED, initial vital signs show: 97.8 115 92/42 20 99% RA with FSBG of 424. Labs were significant for: VBG 7.___/11, K 5.6, Na 126 (corrected 133), HCO3 9, AG 20, trop < 0.01, lactate 2.6, WBC 12.1. CXR showed: Bilateral hilar adenopathy, better seen on recent chest CT, can be seen in sarcoidosis but lymphoma and other neoplastic etiologies cannot be excluded. Medications received: 2L NS, insulin gtt at 6 units/hr Patient was then admitted to the ___ for DKA. Past Medical History: DMI, diagnosed at age ___. Hospitalized at time of diagnosis but no other DM-related hospitalizations, no prior episodes of DKA. Has insulin pump managed by ___. Checks blood sugars herself QID. Blood sugars usually run 100-250. No known neuropathy, nephropathy or eye problems. Epilepsy, last seizure ___ years ago Hypothyroidism Hypercholesterolemia Anxiety Social History: ___ Family History: Non-contributory to patient's current admission. Physical Exam: Admission Physical Exam VITALS: T 97.9 BP 139/58 P ___ RR 23 98%RA GENERAL: NAD, AAOx3 HEENT: Bilateral parotid enlargement, non-tender. Sclera anicteric, oropharynx clear NECK: supple, no cervical LAD LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Tachycardic, normal S1 S2, no murmurs, rubs, gallops ABD: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: Mild erythema on bilateral shins around ankles NEURO: Moves all extremities with purpose, no focal deficit ACCESS: PIV DISCHARGE PHYSICAL EXAM: VITALS: 97.9 PO 125 / 79 92 18 96 1L NC-RA GENERAL: young woman in NAD, AAOx3, speaking in full sentences. Comfortable appearing. HEENT: Bilateral parotid enlargement, non-tender. Sclera anicteric, oropharynx clear. MMM NECK: supple, no cervical LAD CHEST: rales in b/l lower loabes and ___, no wheezes or rhonchi. no accessory muscle use. EWOB. improved aearation at bases compared to yesterday. CV: RRR, nl S1/S2, no murmurs, rubs, gallops ABD: soft, NT/ND NABS, no HSM, no r/g. EXT: WWP, 2+ pulses, no clubbing, cyanosis or edema SKIN: Mild erythema on bilateral shins around ankles. RLQ pmp insertion site without erythema, induration, or nodules. NEURO: Non-focal Pertinent Results: ADMISSION LABS ___ 07:04AM BLOOD WBC-12.1# RBC-4.42 Hgb-12.3 Hct-37.2 MCV-84 MCH-27.8 MCHC-33.1 RDW-12.2 RDWSD-37.3 Plt ___ ___ 07:04AM BLOOD Neuts-87.5 Lymphs-6.4* Monos-5.1 Eos-0.0* Baso-0.4 Im ___ AbsNeut-10.59# AbsLymp-0.78 AbsMono-0.62 AbsEos-0.00* AbsBaso-0.05 ___ 07:04AM BLOOD Glucose-528* UreaN-24* Creat-1.1 Na-126* K-5.6* Cl-97 HCO3-9* AnGap-20* ___ 07:04AM BLOOD cTropnT-<0.01 ___ 07:04AM BLOOD Albumin-3.6 Calcium-9.8 Phos-4.7* Mg-1.7 ___ 07:15AM BLOOD ___ pO2-47* pCO2-28* pH-7.18* calTCO2-11* Base XS--16 ___ 07:15AM BLOOD Lactate-2.6* K-5.6* INTERVAL LABS ___ 03:10AM BLOOD WBC-9.7 RBC-3.82* Hgb-11.0* Hct-31.2* MCV-82 MCH-28.8 MCHC-35.3 RDW-13.2 RDWSD-39.3 Plt ___ ___ 10:50AM BLOOD Glucose-105* UreaN-4* Creat-0.6 Na-132* K-3.6 Cl-100 HCO3-17* AnGap-15 ___ 03:10AM BLOOD Calcium-8.1* Phos-1.8* Mg-1.5* ___ 10:54AM BLOOD ___ pO2-77* pCO2-23* pH-7.46* calTCO2-17* Base XS--4 MICROBIOLOGY BAL.LAD Bx STAPH AUREUS COAG +. RARE GROWTH. . BETA STREPTOCOCCUS GROUP B. SPARSE GROWTH. VIRIDANS STREPTOCOCCI. RARE GROWTH. GRAM POSITIVE RODS. RARE GROWTH. STAPH AUREUS COAG + \| CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S MIXED BACTERIAL FLORA. STAPH AUREUS COAG +. RARE GROWTH. BETA STREPTOCOCCUS GROUP B. SPARSE GROWTH. VIRIDANS STREPTOCOCCI. RARE GROWTH. GRAM POSITIVE RODS. RARE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN------------- 0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S ___ Urine: GRAM POSITIVE BACTERIA. 10,000-100,000 CFU/mL. Alpha hemolytic colonies consistent with alpha streptococcus or Lactobacillus sp. CXR ___ moderate to severe parenchymal opacities, predominantly within the mid to lower right lung with air bronchograms appears grossly unchanged compared to the prior exam. Small right pleural effusion is persistent. The cardiomediastinal silhouette otherwise appears unchanged. The visualized osseous structures are unremarkable. There is no evidence of a pneumothorax. IMPRESSION: Overall, stable appearance of the moderate to severe parenchymal opacities within the right lung compared to the prior exam from ___. ___ CXR: There is only minimal decrease in extent and severity of the severe bilateral parenchymal opacities. The multiple pre-existing rounded consolidations in the lung parenchyma are stable. No evidence of pneumothorax. No pleural effusions. ___ CXR: New alveolar airspace opacity when compared to the previous study. Hemorrhage as well as other etiologies should be considered in this patient who is status post lung biopsy. Bilateral hilar adenopathy. ___ CXR: Bilateral hilar adenopathy, better seen on recent chest CT, can be seen in sarcoidosis but lymphoma and other neoplastic etiologies cannot be excluded. DISCHARGE LABS: ___ 06:50AM BLOOD WBC-5.3 RBC-3.52* Hgb-10.0* Hct-29.4* MCV-84 MCH-28.4 MCHC-34.0 RDW-12.6 RDWSD-38.2 Plt ___ ___ 06:50AM BLOOD Glucose-132* UreaN-4* Creat-0.7 Na-135 K-3.8 Cl-94* HCO3-26 AnGap-15 ___ 06:50AM BLOOD Calcium-8.9 Phos-4.7* Mg-1.5* Brief Hospital Course: # DKA. # Type 1 DM, poorly controlled (recent A1c 10%). Patient initially presented with weakness, abdominal pain, SOB, found to have FSBG of 424 and initial VBG of ___ and was admitted for DKA. Most likely etiology is insulin pump malfunction as per patient's history. Patient was started on insulin drip of 6 units/hr, received IVF per protocol with aggressive K repletion. Once anion gap was closed, patient was started on SQ insulin with insulin pump with ___ following. Transitioned to the floor, where basal insulin rate was titrated down for some low episodes. Discharged with intent to follow-up with PCP and ___. Patient was informed that she should she be started on steroids as an outpatient, she should contact ___ immediately to change her insulin. # Evaluation for Sarcoidosis. Seen in pulmonary clinic at beginning of ___ with clinical presentation, imaging, markedly elevated ACE level concerning for sarcoidosis. Transferred from ___ to ___ as she is set to undergo biopsy with IP and Dr. ___ on ___. Patient underwent bronchoscopy with endobronchial US and transbronchial needle aspiration on ___ with mediastinal lymph node biopsy, with post-procedural issues as below. Biopsy was pending at time of discharge. # Post-Bronch PNA: After procedure, patient developed a 3L O2 requirement with fevers and dyspnea. CXR with new infiltrates bilaterally. This persisted for 3 days post-bronch, longer than would be expected for BAL cause. ID was consulted to eval for true pneumonia, after bronchial washing/biopsy grew MSSA. Started initially on vancomycin, later changed to a 7 day course of augmentin. CHRONIC ISSUES # Seizure disorder: Seizure-free for ___ years per PCP ___. Continued Lamictal 200 mg BID # Anxiety: Continued Citalopram and alprazolam # Hypothyroidism: Cont Levothyroxine 75 mcg 6x/week TRANSITIONAL ISSUES - New medication: Augmentin 875/125mg BID (final day ___ ___ - Biopsy results from EBUS are pending at time of discharge - Patient's basal insulin rate titrated down this admission for low blood sugars. - If steroids are prescribed as an outpatient for her underlying connective tissue disorder, she will need URGENT follow-up with ___ to account for effect on glycemic control. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. LamoTRIgine 200 mg PO BID 2. Citalopram 20 mg PO DAILY 3. ALPRAZolam 0.5 mg PO QID:PRN anxiety 4. Levothyroxine Sodium 75 mcg PO 6X/WEEK (___) 5. Insulin Pump SC (Self Administering Medication)Insulin Lispro (Humalog) Target glucose: 80-180 Discharge Medications: 1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H RX amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth twice a day Disp #11 Tablet Refills:*0 2. Insulin Pump SC (Self Administering Medication)Insulin Lispro (Humalog) Target glucose: 80-180 3. ALPRAZolam 0.5 mg PO QID:PRN anxiety 4. Escitalopram Oxalate 20 mg PO DAILY 5. LamoTRIgine 200 mg PO BID 6. Levothyroxine Sodium 75 mcg PO 6X/WEEK (___) 7.INsulin pump settings basal rates: MN 0.9 3am: 0.85 7a 1.1 12p 1.25 6p: 1 Continue ___ ratios mn 1:15 6a 1:12 5p 1:10 9p 1:15 Continue sensitivity mn 100 6a 80 9p 100 Continue targets: ___ MN 160 7 AM 140 10 ___ 160 Discharge Disposition: Home Discharge Diagnosis: Diabetic Ketoacidosis Acute Hypoxic Respiratory Failure Pneumonia Sarcoidosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, ___ were admitted to the hospital because ___ were found to have DKA after a pump malfunction at home. This was treated and your condition improved. ___ also underwent a bronchoscopy for a lymph node biosy while hospitalized. Afterwards, ___ developed lower oxygen levels and fevers; ___ were treated for a pneumonia and your condition improved. ___ will be discharged to complete a course of antibiotics (Augmentin). The results of your biopsy are pending now, at the time of your discharge. ___ will be contacted with the results of the biopsy in the near future. ___ will need to follow-up with your PCP ___ ___ weeks of discharge. If ___ are started on steroids for the treatment of possible sarcoidosis, ___ will need to contact the ___ (Dr ___ for an appointment as soon as possible given its effects on blood sugar control. Please take all medications as prescribed and keep all scheduled doctor's appointments. Seek medical attention if ___ develop a worsening or recurrence of the same symptoms that originally brought ___ to the hospital, experience any of the warning signs listed below, or have any other symptoms that concern ___. It was a pleasure taking care of ___! Your ___ Care Team Followup Instructions: ___
10023486-DS-6	10,023,486	20,530,186	DS	6	2151-07-12 00:00:00	2151-07-25 14:56:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Lamictal / Cipro Attending: ___. Chief Complaint: fevers Major Surgical or Invasive Procedure: None History of Present Illness: Pt.is a ___ year old male with history of HTN, HLD, myelofibrosis,G6PD deficiency who had previously been admitted following a ground level fall causing a left renal retroperitoneal hematoma s/p two attempts at ___ embolization and finally an exploratory laparotomy with left nephrectomy and hematoma evacuation. Of note, ___ hospital course was complicated by new consent a-fib(now on Coumadin) and potential withdrawal from ruxolitinib-pt.'s myleofibrosis medication. Pt.'s was later discharged with scheduled appointment ___ with notable improvement however with mild drainage from his lower midline wound. Pt. was scheduled for follow up abdominal CT this upcoming ___. Today, patient presented to ___ ED after recently being discharged from rehab yesterday. His wife stated he became increasingly altered with associated weakness this morning and became concerned. Upon arrival to the ED pt. was noted to be febrile to 104, lethargic, but oriented. He complains of very mild abdominal tenderness. He denies n/v, SOB, chest pain. Past Medical History: Past Medical History: -Myleofibrosis, HTN, HLD, AF Past Surgical History: ___: Left mid kidney selective arterial embolization. ___: Repeat left mid kidney selective arterial coil embolization Social History: ___ Family History: NC Physical Exam: Admission Physical Exam: Physical Exam: Vitals:T:100 and 104 on recheck(rectal), BP:115/59/RR:18. 99% on RA GEN: A&Ox3,malaise, warm to touch, sick in appearance HEENT: No scleral icterus, mucus membranes moist CV: RRR, normal S1 an S2 PULM: Clear to auscultation b/l, no increased work of breathing ABD: Soft, nondistended, mild tenderness around JP site, purulent drainage from midline wound(grey/yellow in appearance, no purulent drainage expressed from JP drain site-serous output, normoactive bowel sounds, no palpable masses Ext: No ___ edema, ___ warm and well perfused Discharge Physical Exam: VS: 97.6, 116/77, 67, 18, 97 Ra Gen: A&O x3, sitting up in chair CV: HR irregular, rate controlled Pulm: LS diminished at bases Abd: soft, Mildly TTP around midline incision. Incision with opening at inferior section, scant drainage, no erythema. JP has been removed. Ext: thick lower extremities. no pitting edema. Pertinent Results: ___ 06:50AM BLOOD WBC-5.1 RBC-3.33* Hgb-9.4* Hct-31.4* MCV-94 MCH-28.2 MCHC-29.9* RDW-20.8* RDWSD-72.0* Plt ___ ___ 06:54AM BLOOD WBC-5.7 RBC-3.14* Hgb-8.7* Hct-29.3* MCV-93 MCH-27.7 MCHC-29.7* RDW-20.9* RDWSD-71.5* Plt ___ ___ 06:34AM BLOOD WBC-5.9 RBC-3.19* Hgb-8.8* Hct-29.3* MCV-92 MCH-27.6 MCHC-30.0* RDW-20.6* RDWSD-69.8* Plt ___ ___ 11:56PM BLOOD Hct-30.3* ___ 03:30PM BLOOD WBC-7.3 RBC-3.72* Hgb-10.5* Hct-34.0* MCV-91 MCH-28.2 MCHC-30.9* RDW-20.9* RDWSD-69.0* Plt ___ ___ 06:50AM BLOOD Glucose-89 UreaN-22* Creat-1.7* Na-147 K-4.1 Cl-103 HCO3-33* AnGap-11 ___ 06:54AM BLOOD Glucose-95 UreaN-23* Creat-1.8* Na-146 K-4.2 Cl-104 HCO3-32 AnGap-10 ___ 06:34AM BLOOD Glucose-117* UreaN-25* Creat-1.6* Na-144 K-3.7 Cl-102 HCO3-32 AnGap-10 ___ 03:30PM BLOOD Glucose-124* UreaN-27* Creat-1.4* Na-141 K-4.6 Cl-98 HCO3-31 AnGap-12 ___ 06:50AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.0 ___ 06:54AM BLOOD Calcium-8.1* Phos-3.5 Mg-2.4 ___ 06:34AM BLOOD Calcium-8.1* Phos-3.9 Mg-1.7 ___ ___ M ___ ___ Microbiology Lab Results ___ 4:00 pm URINE URINE CULTURE (Preliminary): PROTEUS MIRABILIS. >100,000 CFU/mL. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PROTEUS MIRABILIS \| AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- 16 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Imaging: CT Abdomen/Pelvis 1. No fluid collection is noted along the course of the left anterior approach drain terminating adjacent to the spleen in the left mid abdomen. The tip of the drain does not terminate in a fluid collection. No substantial subcutaneous changes are noted along its course. 2. Hematoma in the left nephrectomy bed contains area of increased density measuring up to 53 in ___ suggestive of areas of more acute hemorrhage, but difficult to compare as there are no postoperative images. 3. Air and soft tissue edema is noted along the tract of the surgical scar along the mid abdomen, consistent with recent intervention Brief Hospital Course: ___ year old male with history of HTN, HLD, myelofibrosis,G6PD deficiency who had previously been admitted following a ground level fall causing a left renal retroperitoneal hematoma s/p two attempts at ___ embolization and finally an exploratory laparotomy with left nephrectomy and hematoma evacuation, admitted to the Acute Care Surgery service with fevers to 104 and lethargy. CT abdomen pelvis notable for hematoma in the left nephrectomy bed but no other fluid collections. The JP drain was removed. The surgical wound had recently been opened up in clinic and drained, was currently packed lightly with wet to dry gauze. Interventional radiology was consulted for the hematoma but they felt it was too loculated and dense to drain. The patient was started on IV antibiotics. Fever work-up also revealed a positive urinalysis with culture growing proteus mirabilis, sensitive to ciprofloxacin. Wound swab with moderate staph aureas coag+. Creatinine was noted to be rising, FeUrea 41% consistent with intrinsic process. Lasix was held. The patient was hemodynamically stable and was afebrile during the hospital stay. Antibiotics were narrowed based on culture sensitivities. Coumadin was restarted. Physical therapy worked with the patient and he was cleared for discharge home with ___ for INR monitoring and wound care. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating with a walker, voiding without assistance, moving his bowels, and pain was well controlled. The patient was discharged home with ___ services. The patient and his wife received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. He was sent with a prescription to complete a course of ciprofloxacin. He was instructed to closely monitor INR while taking cipro. He would follow-up in ___ clinic and with his PCP. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Allopurinol ___ mg PO DAILY 2. Atenolol 50 mg PO DAILY 3. Furosemide 40 mg PO DAILY 4. Lidocaine 5% Patch 1 PTCH TD QAM 5. OXcarbazepine 150 mg PO BID 6. Pregabalin 150 mg PO TID 7. Tizanidine 4 mg PO Q8H:PRN muscle spasms 8. Fluticasone Propionate NASAL 2 SPRY NU DAILY 9. Jakafi (ruxolitinib) 5 mg oral BID 10. Docusate Sodium 100 mg PO BID 11. Multivitamins 1 TAB PO DAILY 12. Senna 8.6 mg PO BID:PRN Constipation - First Line 13. Warfarin 7.5 mg PO DAILY16 14. Lactulose 15 mL PO BID Discharge Medications: 1. Baclofen 10 mg PO TID:PRN Muscle Spasms RX baclofen 10 mg 1 tablet(s) by mouth three times a day Disp #20 Tablet Refills:0 2. Ciprofloxacin HCl 500 mg PO Q12H RX ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve (12) hours Disp #11 Tablet Refills:0 3. Herb-Lax 1 TAB PO QID:PRN 4. Morphine SR (MS ___ 15 mg PO Q12H 5. Warfarin 5 mg PO DAILY16 6. Allopurinol ___ mg PO DAILY 7. Atenolol 50 mg PO DAILY 8. Docusate Sodium 100 mg PO BID 9. Fluticasone Propionate NASAL 2 SPRY NU DAILY 10. Furosemide 40 mg PO DAILY 11. Jakafi (ruxolitinib) 5 mg oral BID 12. Lactulose 15 mL PO BID 13. Lidocaine 5% Patch 1 PTCH TD QAM 14. Multivitamins 1 TAB PO DAILY 15. OXcarbazepine 150 mg PO BID 16. Pregabalin 150 mg PO TID 17. Senna 8.6 mg PO BID:PRN Constipation - First Line 18. Tizanidine 4 mg PO Q8H:PRN muscle spasms Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Urinary tract infection Hematoma in the left nephrectomy bed Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to ___ with fevers. A CT scan was done which showed a hematoma around the left nephrectomy site. Interventional Radiology evaluated this but felt it was too coagulated to drain. Your urine came back positive for an infection, so you have begun a course of antibiotics to treat this. This antibiotic can elevate your INR so you will need close monitoring of your INR and adjustments to the dose of coumadin as needed. You are now doing better and have been cleared by Physical Therapy for discharge home. Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: You experience new chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience a discharge. Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. Avoid swimming and baths until your follow-up appointment. You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry Followup Instructions: ___
10023708-DS-19	10,023,708	28,410,180	DS	19	2144-08-31 00:00:00	2144-09-01 22:46:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Codeine / Darvon / aspirin Attending: ___. Chief Complaint: Nausea, vomiting Major Surgical or Invasive Procedure: None History of Present Illness: ___ y/o F with HTN, HLD, T2DM presents with diaphoresis, nausea, vomiting x1 day. Patient reports sudden onset of nausea and dry-heaving while sitting at her desk at work this morning around 11AM associated with diaphoresis. Although she felt orange juice and chocolate cake may have irritated her stomach, the episode occurred ___ hours after she ate breakfast. She denied frank vomiting, but did say she tasted OJ in her mouth. She has had breakfast with milk, cereal, OJ around 8AM. Nausea was associated with diaphoresis, weakness, and lightheadedness. She had some water and then was brought into the ED. Patient has been feeling unwell with generalized weakness and fatigue for ___ days. She denied any SOB, cough, chest pain, pleuritic chest pain, abdominal pain, dysuria, urinary urgency, symptoms of orthostasis, pre-syncope, diarrhea, headache, sick contacts. She does report ~ 20 lb weight loss since ___, after she started on metformin. She is not sure if the weight loss is from loss of appetite but has recently changed her diet. She also reports loss of appetite for the last 4 months due to recent illnesses. She states that she has routine health maintenance and has recent colonoscopy, mammography, and pap smear in ___, all of which are negative. Of note, pt had similar episodes in ___ and ___. In first episode, pt was given fluids, underwent stress test, which was negative and was found to bradycardic, attributed at that time to her beta blocker (which she no longer takes). In ___, she was discharged from ED without intervention. She also had norovirus with N/V/D x3 days in ___. In the ED, initial VS ___ 78 139/79 16 96%. EKG was obtained, no evidence of ischemia, troponin negative. RUQ was negative and CT abdomen obtained, showing no GI pathology but a lesion on the left adnexa, suspicious for malignancy. IVF were given and Vancomycin and Zosyn were given for presumed intra-abdominal infection despite negative CT Currently, pt reports no symptoms, back to baseline except feeling very hungry. ROS: Denies fever, chills, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: - HTN - HLD - T2DM - h/o colon adenoma and hyperplastic polyp - h/o basal cell carcinoma, nose ___ - remote h/o cholecystectomy Social History: ___ Family History: - sister with DM - cousin with breast CA - GF with leukemia Physical Exam: Admission exam: VS - Temp 97.9F, RR 18, O2-sat 97% RA Orthostatics: Supine: 84, 124/68; Sitting: 76, 120/72; Standing: 103, 110/66 GENERAL - well-appearing woman in NAD, comfortable, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, dry MM, OP clear NECK - supple, no thyromegaly, JVP 8 cm, no carotid bruits LUNGS - CTA bilat, no r/rh/wh, good air movement, respiration unlabored, no accessory muscle use HEART - RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout, cerebellar exam intact, gait deferred Discharge exam: VS - Temp 98.2F, RR 18 , O2-sat 95% RA Orthostatics: Supine: 80, 142/52; Sitting: 84, 146/56; Standing: 77, 147/51 Gait steady otherwise, exam is unchanged from admission Pertinent Results: Admission labs: ___ 12:40PM BLOOD WBC-19.1# RBC-5.20 Hgb-14.3 Hct-41.4 MCV-80 MCH-27.4 MCHC-34.5 RDW-13.4 Plt ___ ___ 12:40PM BLOOD Neuts-63.6 ___ Monos-2.9 Eos-1.3 Baso-0.7 ___ 01:18PM BLOOD ___ PTT-26.7 ___ ___ 12:40PM BLOOD Glucose-159* UreaN-19 Creat-0.9 Na-140 K-4.4 Cl-99 HCO3-26 AnGap-19 ___ 12:40PM BLOOD ALT-20 AST-18 AlkPhos-154* TotBili-0.4 ___ 12:40PM BLOOD Lipase-12 ___ 12:40PM BLOOD cTropnT-<0.01 Discharge labs: ___ 01:32AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 12:40PM BLOOD Iron-73 ___ 12:40PM BLOOD calTIBC-393 Ferritn-90 TRF-302 ___ 12:47PM BLOOD Lactate-5.7* ___ 05:00PM BLOOD Lactate-1.7 ___ 07:20AM BLOOD WBC-14.5* RBC-4.74 Hgb-12.9 Hct-37.3 MCV-79* MCH-27.2 MCHC-34.6 RDW-13.6 Plt ___ ___ 07:20AM BLOOD Neuts-77.8* Lymphs-17.7* Monos-2.9 Eos-0.9 Baso-0.6 ___ 07:20AM BLOOD Glucose-115* UreaN-12 Creat-0.7 Na-141 K-3.6 Cl-103 HCO3-29 AnGap-13 ___ 07:20AM BLOOD Calcium-9.0 Phos-3.6 Mg-1.7 Microbiology: Urine culture ___ negative Blood culture ___ no growth by ___ Imaging: ___ ECG: Sinus rhythm. Mild Q-T interval prolongation. Borderline low limb lead voltage. Early R wave progression. Since the previous tracing of ___ Q-T interval is longer and T waves are probably improved. ___ CXR: FINDINGS: A round retrocardiac opacity with an air fluid level abutting the left paravertebral stripe is a hiatal hernia. No other focal opacities are noted. Cardiomnediastinal and hilar contours are unremarkable. No pleural effusion or pneumothorax. IMPRESSION: Hiatal hernia. Otherwise, unremarkable chest radiographic examination. ___ CTA abdomen: IMPRESSION: 1. No evidence of bowel ischemia. 2. Left adnexal heterogeneously enhancing solid mass, concerning for malignancy. Further assessment by the pelvic ultrasound exams is recommended. 3. Moderate hiatal hernia. 4. Small pericardial effusion. 5. Extensive calcified atherosclerotic disease of the aorta without associated aneurysmal changes. ___: Transvaginal pelvic ultrasound: In the left adnexa is a 3.7 x 3.9 x 3.1 cm solid, heterogeneous, vascular mass concerning for malignancy. The borders are somewhat irregular. There is no cystic component. The uterus is unremarkable and measures 6.5 x 3.1 x 3.5 cm. The right adnexa is unremarkable without large mass. There is no ascites. IMPRESSION: 3.9 cm solid vascular mass in the left adnexa is concerning for malignancy. Brief Hospital Course: ___ yo F with HTN, HLD, T2DM who presents with episode of diaphoresis, nausea, and weakness. # Lightheadedness/Nausea/Vomiting. Two similar episodes in the past that resolved once spontaneously and once with IVF. Work-up in the past include negative stress test, normal EKG, and normal cardiac biomarkers. Previous episode thought to be associated with vasovagal. This episode also not due to ACS given atypical presentation, no ischemic changes on EKG and negative cardiac enzymes x2. Patient also denied chest pain. Food poisoning or gastroenteritis also unlikely in the absence of diarrhea or abdominal pain, and her symptoms were different from presentation of norovirus in ___. In the setting of newly found adnexal mass, weight loss, and ? early satiety, a paraneoplastic gastroparesis is a possible. Most likely, however, pt was dehydrated as she admits to minimal water intake, had lactate of 5.7 that improved to 1.7 with IVF, and symptoms also resolved after receiving 2.5L IVF. In addition, patient was orthostatic on admission by heart rate, further pointing to volume depletion. She was no longer orthostatic by the time of discharge. # Ovarian lesion. Pt found to have lesion on left adnexa on CT abd/pelvis. Follow up transvaginal ultrasound also concerning for malignancy. Patient asymptomatic. Patient was told that ultrasound was not finalized at the time of discharge, but malignancy was on the differential. Plan to have patient follow up with PCP ___ 3 days for further workup and appropriate referrals. # Leukocytosis. Unclear etiology. Patient has baseline high WBC in the ___. Initially elevated WBC to 19 with normal differential and no atypical cells. Patient has been afebrile and has no localizing signs to suggest an infectious process. ___ also be secondary to a possible paraneoplastic syndrome secondary to ovarian malignancy, however, presence of malignancy is not confirmed. No new medications as potential cause. Heme malignancy unlikely given normal Hct and platelet and normal differential. This was likely partially due to hemoconcentration as all cell lines trended down after IVF. WBC on discharge was 14.5. # HTN. Orthostatic by heart rate but not blood pressure on admission. Initially held amilodipine and HCTZ. Patient slightly hypertensive on morning of the day of discharge, BP 140/70s. Restarted amlodipine, but held HCTZ in the setting of its likely contributing to volume depletion. # HLD. Continued home does simvastatin. # T2DM. Pt takes Metformin at home, reports that she is moderately well-controlled, improving more recently. Last hemoglobin A1C 7.5 in ___, down from 7.9 prior. Held Metformin and placed on HISS in the hospital in case of imaging with contrast. Restarted home does metformin at the time of discharge. # Transitional issues: Code status- full - Follow up- with PCP, ___ 3 days of discharge - L. adenexal mass- high concern for malignancy, but patient currently asymptomatic. She will need expedited outpatient workup - Follow up leukocytosis as outpatient - Follow up final blood culture results Medications on Admission: - amlodipine 10 mg daily - HCTZ 12.5 mg daily - lorazepam 0.5 mg qHS prn - metformin 500 mg BID - simvastatin 20 mg daily Discharge Medications: 1. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 2. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 3. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 4. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: DEHYDRATION OVARIAN MASS Secondary Diagnosis: HYPERTENSION DIABETES Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure participating in your care at ___. You were admitted to the ___ from ___ to ___ for nausea, vomiting, sweats, and weakness. Your symptoms were most likely due to dehydration. Your EKG and cardiac enzymes showed that you did NOT have a heart attack. You were given IV fluids, which helped to resolve your symptoms. During your workup, you underwent a CT scan of your abdomen and pelvis, which showed a mass in your left ovary. You also underwent a pelvic ultrasound for further evaluation. The result is not finalized at the time of your discharge. You will need to follow up with your primary care physician (see below) for the final result. The following changes were made to your medications: STOPPED Hydrochlorothiazide (HCTZ) 12.5 mg daily (this is likely contributing to your dehydration) Followup Instructions: ___
10023948-DS-8	10,023,948	24,863,234	DS	8	2135-07-21 00:00:00	2135-07-21 09:02:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: Penicillins Attending: ___ Chief Complaint: right hip dislocation s/p failed closed reduction on ___ Major Surgical or Invasive Procedure: right THR explant, antibiotic spacer placement ___, ___ History of Present Illness: ___ year old female with right THA (___) s/p multiple dislocations +revisions, s/p failed closed reduction on ___, now s/p right THA explant, abx spacer on ___. Past Medical History: HTN, depression, bilateral total hip arthroplasty, status post multiple revisions since ___ on right hip Social History: ___ 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 mild old drainage distal aspect * Thigh full but soft * No calf tenderness * ___ strength * SILT, NVI distally * Toes warm Pertinent Results: ___ 05:25AM BLOOD WBC-6.6 RBC-3.41* Hgb-10.1* Hct-30.2* MCV-89 MCH-29.6 MCHC-33.4 RDW-14.5 RDWSD-46.9* Plt ___ ___ 05:32AM BLOOD WBC-6.5 RBC-3.32* Hgb-9.8* Hct-29.1* MCV-88 MCH-29.5 MCHC-33.7 RDW-14.9 RDWSD-48.3* Plt ___ ___ 06:44AM BLOOD WBC-6.1 RBC-3.37* Hgb-10.2* Hct-30.4* MCV-90 MCH-30.3 MCHC-33.6 RDW-15.4 RDWSD-51.4* Plt ___ ___ 07:20PM BLOOD Hgb-9.7* Hct-28.7* ___ 07:15AM BLOOD Hgb-8.3* Hct-24.6* ___ 06:10AM BLOOD WBC-6.1 RBC-2.91* Hgb-9.0* Hct-26.9* MCV-92 MCH-30.9 MCHC-33.5 RDW-14.8 RDWSD-50.0* Plt ___ ___ 08:25PM BLOOD WBC-13.8* RBC-3.71* Hgb-11.4 Hct-33.7* MCV-91 MCH-30.7 MCHC-33.8 RDW-14.6 RDWSD-48.5* Plt ___ ___ 06:10PM BLOOD WBC-9.6 RBC-4.03 Hgb-12.5 Hct-36.5 MCV-91 MCH-31.0 MCHC-34.2 RDW-14.9 RDWSD-49.5* Plt ___ ___ 08:25PM BLOOD Neuts-88.2* Lymphs-6.8* Monos-3.7* Eos-0.2* Baso-0.4 Im ___ AbsNeut-12.16* AbsLymp-0.94* AbsMono-0.51 AbsEos-0.03* AbsBaso-0.06 ___ 06:10PM BLOOD Neuts-73.4* Lymphs-17.0* Monos-7.9 Eos-0.7* Baso-0.5 Im ___ AbsNeut-7.01* AbsLymp-1.63 AbsMono-0.76 AbsEos-0.07 AbsBaso-0.05 ___ 08:25PM BLOOD ___ PTT-28.6 ___ ___ 06:10PM BLOOD ___ PTT-30.5 ___ ___ 05:32AM BLOOD Creat-0.4 ___ 06:44AM BLOOD Creat-0.5 ___ 06:10AM BLOOD Glucose-92 UreaN-9 Creat-0.4 Na-137 K-4.2 Cl-101 HCO3-24 AnGap-12 ___ 06:10PM BLOOD Glucose-91 UreaN-15 Creat-0.5 Na-134* K-4.3 Cl-98 HCO3-19* AnGap-17 ___ 05:32AM BLOOD Mg-2.1 ___ 06:44AM BLOOD Mg-1.9 ___ 07:15AM BLOOD Mg-1.7 ___ 06:10AM BLOOD Calcium-7.8* Phos-3.7 Mg-1.5* ___ 09:07AM BLOOD CRP-87.5* ___ 05:32AM BLOOD Vanco-10.6 ___ 05:45PM BLOOD ___ pO2-78* pCO2-45 pH-7.30* calTCO2-23 Base XS--3 ___ 05:45PM BLOOD Glucose-74 Lactate-1.1 Na-136 K-3.4* Cl-107 ___ 05:45PM BLOOD Hgb-10.3* calcHCT-31 O2 Sat-91 ___ 06:25PM URINE Color-Straw Appear-Clear Sp ___ ___ 06:25PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG ___ 11:00AM JOINT FLUID TNC-827* ___ Polys-57* ___ Macro-11 ___ 11:00AM JOINT FLUID TNC-9056* HCT,Fl-20.0* Polys-99* ___ ___ 11:00AM JOINT FLUID Crystal-NONE Brief Hospital Course: The patient was admitted to the orthopedic surgery service after being admitted through the ED. A closed reduction was attempted in the OR the following day and was unsuccessful. She was eventually 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 lost one-liter and received 3.3 liters of fluid and 2 units of blood intra-operatively. POD #1, Infectious Disease was consulted for antibiotic management. OR cultures showed no growth to date. ID recommended continuing Ancef and obtaining a right knee x-ray due to a past knee replacement. Patient was started on daily Vitamin D supplement to prevent vitamin D defieciency. Magnesium of 1.5 was repleted. Foley was discontinued and the patient was able to void independently. Patient was orthostatic with physical therapy and was given 500ml fluid bolus. POD #2, hematocrit was 24.6 and patient was transfused 2 units pRBCS. Post-transfusion hct was 28.7. Right knee x-ray results unable to rule out hardware loosening. Due to ongoing knee swelling and warmth, a right knee aspiration under ___ was obtained. OR cultures showed coag negative staph. ID recommended continuing IV Ancef and starting IV Vanco 1g every 12 hours. POD #3, hct was 30.4. Joint aspiration results showed WBC 827, RBC > 152k, polys 57, no crystals. ID recommended discontinuation of IV Ancef and continuing Vancomycin. Tizanidine was added for c/o muscle spasms. Urinalysis was obtained for c/o urinary urgency/frequency, which results were negative. Urine cultures showed PICC line was placed. POD #4, vancomycin trough was low at 10.6 and dose was increased to 1250mg every 12 hours. Joint aspiration cultures showed NGTD. Final OPAT recommended to continue Vancomycin 1250mg every 12 hours. POD #5, knee aspiration cultures continued to show no growth to date. Final urine cultures were negative. Otherwise, pain was controlled with a combination of IV and oral pain medications. The patient received Lovenox daily for DVT prophylaxis . 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 TOUCH DOWN weight bearing on the operative extremity. No hip precautions. Walker or two crutches at all times. Ms. ___ is discharged to rehab in stable condition. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. etodolac 400 mg oral BID 2. FLUoxetine 20 mg PO DAILY 3. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Moderate 4. lisinopril-hydrochlorothiazide ___ mg oral DAILY 5. Gabapentin 600 mg PO TID 6. Gabapentin 300 mg PO QHS Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Docusate Sodium 100 mg PO BID 3. Enoxaparin Sodium 40 mg SC QPM 4. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN Pain - Moderate 5. Senna 17.2 mg PO BID 6. Vancomycin 1250 mg IV Q 12H Start Date: ___ Projected End Date: ___ 7. Vitamin D 1000 UNIT PO DAILY 8. FLUoxetine 20 mg PO DAILY 9. Gabapentin 600 mg PO TID 10. Gabapentin 300 mg PO QHS 11. lisinopril-hydrochlorothiazide ___ mg oral DAILY 12. HELD- etodolac 400 mg oral BID This medication was held. Do not restart etodolac until you've been cleared by your surgeon Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: right hip dislocation s/p failed closed reduction 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. 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 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. 10. ___ (once at home): Home ___, dressing changes as instructed, and wound checks. 11. ACTIVITY: TOUCH DOWN weight bearing with walker or 2 crutches. No hip precautions. Wean assistive device as able. No strenuous exercise or heavy lifting until follow up appointment. Mobilize frequently. 12. ___ CARE: Per protocol 13. WEEKLY LABS: draw on ___ and send result to ___ clinic at ___: - CBC/DIFF - CHEM 7 - LFTS - ESR/CRP - Vancomycin trough All questions regarding outpatient parenteral antibiotics should be directed to the ___ R.N.s at ___ or to the on-call ID fellow when the clinic is closed.** Physical Therapy: TDWB RLE No hip precautions Assistive device at all times 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 Followup Instructions: ___
10024012-DS-22	10,024,012	23,111,013	DS	22	2134-08-17 00:00:00	2134-08-18 11:24:00	Name: ___ Unit ___: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Codeine / ACE Inhibitors Attending: ___. Chief Complaint: This is a ___ year old woman with atrial fibrillation on coumadin and metoprolol, AS s/p AVR with bioprosthetic valve on ___, ascending aortic aneurysm, HTN, HLD, who presents as transfer for R femur neck fracture. She was with her husband at the ___ when she fell. She reports she was accompanying him to an appointment when she tripped over some carpeting. She did not hit her head, ___ LOC. She had NCHCT which revealed on bleed and plain films which revealed R femur neck fracture. She was seen by orthopedics in the ED who will surgically repair in AM. She is admitted to medicine for new O2 requirement. In the ED, initial vitals: T 97.4 HR65 BP174/84 RR18 92% RA - Exam notable for: ___ systolic murmur heard best at ULSB, ___ equal lengths, ___ strength in feet and ankles, able to internall and externally rotate at hip bilaterally" - Labs notable for: INR: 1.7 WBC 12.4 - Imaging notable for: CTA chest: 1. ___ evidence of pulmonary embolism or aortic abnormality. 2. Mild interstitial edema. 3. Multiple subpleural rule opacities throughout the lungs with the largest measures 1.3 x 1.0 cm in the right upper lobe, which may be infectious/inflammatory. Follow-up chest CT in 3 months is recommended to assess resolution. 4. T8 deformity of indeterminate chronicity, although ___ definite surrounding hematoma or fracture line identified. CXR: IMPRESSION: 1. Large retrocardiac opacity likely represents known large hiatal hernia. 2. ___ gross signs for pneumonia or edema. R hip plain films IMPRESSION: Right femoral neck fracture better assessed on outside hospital radiographs performed on same date. ___ additional fracture is seen. - Pt given: ___ 18:56 IV Ondansetron 4 mg ___ 21:13 IVF LR 250 mL/hr - Vitals prior to transfer: T 74 BP 170/86 RR 18 94% 3L NC On the floor, she feels quite well. She is tired. She has ___ pain. She is not dyspneic despite her O2 requirement. She has ___ chest pain or heart palpitations. ROS is otherwise negative. Major Surgical or Invasive Procedure: ___: Percutaneous pinning of right femoral neck fracture History of Present Illness: This is a ___ year old woman with atrial fibrillation on coumadin and metoprolol, AS s/p AVR with bioprosthetic valve on ___, ascending aortic aneurysm, HTN, HLD, who presents as transfer for R femur neck fracture. She was with her husband at the ___ when she fell. She reports she was accompanying him to an appointment when she tripped over some carpeting. She did not hit her head, ___ LOC. She had NCHCT which revealed on bleed and plain films which revealed R femur neck fracture. She was seen by orthopedics in the ED who will surgically repair in AM. She is admitted to medicine for new O2 requirement. In the ED, initial vitals: T 97.4 HR65 BP174/84 RR18 92% RA - Exam notable for: ___ systolic murmur heard best at ULSB, ___ equal lengths, ___ strength in feet and ankles, able to internall and externally rotate at hip bilaterally" - Labs notable for: INR: 1.7 WBC 12.4 - Imaging notable for: CTA chest: 1. ___ evidence of pulmonary embolism or aortic abnormality. 2. Mild interstitial edema. 3. Multiple subpleural rule opacities throughout the lungs with the largest measures 1.3 x 1.0 cm in the right upper lobe, which may be infectious/inflammatory. Follow-up chest CT in 3 months is recommended to assess resolution. 4. T8 deformity of indeterminate chronicity, although ___ definite surrounding hematoma or fracture line identified. CXR: IMPRESSION: 1. Large retrocardiac opacity likely represents known large hiatal hernia. 2. ___ gross signs for pneumonia or edema. R hip plain films IMPRESSION: Right femoral neck fracture better assessed on outside hospital radiographs performed on same date. ___ additional fracture is seen. - Pt given: ___ 18:56 IV Ondansetron 4 mg ___ 21:13 IVF LR 250 mL/hr - Vitals prior to transfer: T 74 BP 170/86 RR 18 94% 3L NC On the floor, she feels quite well. She is tired. She has ___ pain. She is not dyspneic despite her O2 requirement. She has ___ chest pain or heart palpitations. ROS is otherwise negative. Past Medical History: 1. Aortic stenosis, status post AVR with a bioprosthetic valve ___ 2. Ascending aortic aneurysm 3. Hypertension 4. Hypercholesterolemia 5. Iron deficiency anemia: thought to be from blood loss from a hiatal hernia. 6. s/p bilateral cataracts 7. Hearing loss 8. Osteoporosis Social History: ___ Family History: Mother - CHF, HTN, hearing loss Father - CHF MGM - colon cancer Physical Exam: ADMISSION PHYSICAL EXAM: ============================ VITALS: ___ 0128 Temp: 98.2 PO BP: 144/86 L Lying HR: 95 RR: 17 O2 sat: 95% O2 delivery: 2L General: Pleasant, alert, oriented, ___ acute distress, very hard of hearing HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not elevated, ___ LAD CV: Irregular, normal S1 + S2, low pitched systolic murmur across precordium Lungs: diminished ___ bases with crackles in mid lung fields Abdomen: Soft, non-tender, non-distended, bowel sounds present, ___ organomegaly, ___ rebound or guarding GU: ___ foley Ext: Warm, well perfused, 2+ pulses, ___ clubbing, cyanosis or edema. There is ___ bruising or TTP over R hip or knee. Legs are equal in length. ___ internal or external rotation. Skin: Warm, dry, ___ rashes or notable lesions. Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally. DISCHARGE PHYSICAL EXAM: ============================ VS: ___ 0126 Temp: 98.4 Axillary BP: 132/69 L Lying HR: 82 RR: 20 O2 sat: 91% O2 delivery: RA PHYSICAL EXAM: General: Pleasant, alert, ___ acute distress, very hard of hearing, JVP not elevated, ___ LAD CV: Irregular, normal S1 + S2, low pitched systolic murmur across precordium Lungs: CTAB Abdomen: Soft, non-tender, non-distended, bowel sounds present Ext: Warm, well perfused, ___ clubbing, cyanosis or edema. Dressing on R hip looks c/d/I. Mild TTP over R hip. Legs are equal in length. ___ internal or external rotation. Skin: Warm, dry, ___ rashes or notable lesions. Neuro: AOx1 (to name only). ___ Results: ADMISSION LABS ========================= ___ 07:45PM ___ PO2-19* PCO2-51* PH-7.35 TOTAL CO2-29 BASE XS-0 ___ 07:45PM LACTATE-2.0 ___ 07:45PM O2 SAT-22 ___ 07:38PM GLUCOSE-149* UREA N-20 CREAT-0.7 SODIUM-143 POTASSIUM-3.7 CHLORIDE-101 TOTAL CO2-27 ANION GAP-15 ___ 07:38PM cTropnT-<0.01 ___ 07:38PM WBC-12.4* RBC-4.26 HGB-12.5 HCT-39.9 MCV-94 MCH-29.3 MCHC-31.3* RDW-15.6* RDWSD-53.1* ___:38PM NEUTS-81.0* LYMPHS-10.7* MONOS-7.2 EOS-0.3* BASOS-0.2 IM ___ AbsNeut-10.01* AbsLymp-1.32 AbsMono-0.89* AbsEos-0.04 AbsBaso-0.02 ___ 07:38PM PLT COUNT-234 ___ 05:50PM GLUCOSE-105* UREA N-21* CREAT-0.8 SODIUM-143 POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-25 ANION GAP-16 ___ 05:50PM estGFR-Using this ___ 05:50PM WBC-10.8* RBC-4.23 HGB-12.4 HCT-39.5 MCV-93 MCH-29.3 MCHC-31.4* RDW-15.5 RDWSD-52.8* ___ 05:50PM NEUTS-81.6* LYMPHS-11.4* MONOS-5.5 EOS-0.7* BASOS-0.1 IM ___ AbsNeut-8.78* AbsLymp-1.23 AbsMono-0.59 AbsEos-0.08 AbsBaso-0.01 ___ 05:50PM PLT COUNT-234 ___ 05:50PM ___ PTT-30.2 ___ DISCHARGE LABS =============================== ___ 07:10AM BLOOD WBC-7.0 RBC-3.14* Hgb-9.3* Hct-28.9* MCV-92 MCH-29.6 MCHC-32.2 RDW-15.3 RDWSD-51.8* Plt ___ ___ 07:10AM BLOOD Plt ___ ___ 07:10AM BLOOD Glucose-119* UreaN-19 Creat-0.8 Na-141 K-4.3 Cl-102 HCO3-26 AnGap-13 ___ 07:10AM BLOOD Calcium-8.0* Phos-2.7 Mg-1.8 Brief Hospital Course: PATIENT SUMMARY: =========================== Ms. ___ is a ___ year old woman with atrial fibrillation on Coumadin and metoprolol, aortic stenosis s/p AVR with bioprosthetic valve on ___, ascending aortic aneurysm, HTN, HLD, who presents as transfer for R femur neck fracture now s/p closed reduction and percutaneous pinning course complicated by hypoactive delirium. ACTIVE ISSUES: =========================== #R impacted femur neck fracture - Initially presented status post fall, found to have right femoral neck fracture on XR. Was evaluated by orthopedic surgery underwent right hip closed reduction and percutaneous pinning on ___. She had minimal pain post-op and received tyelnol for pain control. She was started on Vit D supplementation at 1000u daily. Please consider initiating bisphosphonate in ___ weeks as an outpatient. While she remained sub-therpaeutic on warfarin for atrial fibrillation, was also started on lovenox 40 SC QD for DVT prophylxais. At rehab once therapeutic on warfarin can discontinue lovenox. Dressing to remain intact until follow-up in 2 weeks with orthopedics unless saturated. #Hypoxemic respiratory failure Initially with 2L O2 requirement thought to be secondary to IV fluids received during early admission. Patient was afebrile, ___ leukocytosis and CXR with ___ signs of pneumonia. Patient was diuresed with intermittent IV lasix. We were able to wean her off oxygen prior to discharge. At this point hypoxemia thought to be primarily related to atelectasis post-op. Was encouraged to use incentive spirometry. #Atrial fibrillation CHADSVASC = 4 (age, sex and HTN)- Maintained on metoprolol succinate 50 mg daily at home for rate control and warfarin and warfarin 2mg daily. Was initiallyon heparin prior to surgery, was re-started on warfarin 2mg daily. INR on discharge was 1.4 so 5mg administered on day of discharge given remains subtherapeutic. Please discontinue lovenox once warfarin is therapeutic (goal INR ___. #Hypoactive delirium Patient had waxing and weaning mentation. She was also alert and oriented x1 (to name only). She is also very hard of hearing. Infectious work-up was sent. CXR with ___ consolidation, UA was bland and ___ other localizing symptoms. This was felt to be hospital/post-op hypoactive delirium. Delirium precautions were put in place. #Recurrent falls Pt with listed history of gait disorder listed in chart, has recurrent falls (including one in ___ which resulted in head lac requiring staples). She remains on AC for atrial fibrillation. She reports using a walker. She denies pre-syncope or LOC during these events. ___ to continue working with patient and discharge to rehab. #Urinary retention - Issues with intermittent urinary retention requiring straight cath x1. Continue to monitor at rehab. CHRONIC/STABLE ISSUES ============================= #HTN - Patient was continued on home metoprolol 50XL daily, however home valsartan was initially held ___ was not continued on discharge given she remained normotensive off of this. #HLD: continued home statin #AS s/p AVR #TR, MR ___ specific therapy. Mild to moderate MR and moderate TR. #TRANSITIONAL ISSUES: ============================== [ ] NEW/CHANGED MEDICATIONS - Started vitamin D 1000 U QD - Started lovenox 40mg SC QD while sub-therapeutic post operatively - Held valsartan 320mg PO QD given normotensive off of this [ ] Received warfarin 2mg QD ___ and 5mg on ___. Discharge INR 1.4. Continue with daily dosing until INR therapeutic ___ [ ] Continue lovenox 40mg SC QD until INR therapeutic [ ] Multiple subpleural rule opacities throughout the lungs with the largest measures 1.3 x 1.0 cm in the right upper lobe, which may be infectious/inflammatory. Follow-up chest CT in 3 months is recommended to assess resolution. #CONTACT: Name of health care proxy: Dr ___ Relationship: Son Phone number: ___ #Code Status: Full, presumed Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Simvastatin 40 mg PO DAILY 2. Metoprolol Succinate XL 50 mg PO DAILY 3. Valsartan 320 mg PO DAILY 4. Omeprazole 20 mg PO DAILY 5. Warfarin 2 mg PO DAILY16 Discharge Medications: 1. Enoxaparin Sodium 40 mg SC DAILY 2. Vitamin D 1000 UNIT PO DAILY 3. ___ MD to order daily dose PO DAILY16 4. Metoprolol Succinate XL 50 mg PO DAILY 5. Omeprazole 20 mg PO DAILY 6. Simvastatin 40 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary diagnosis -R hip fracture Secondary diagnosis -Hypoxemic respiratory failure -A fib -Hypoactive delirium -Hypertension -Hyperlipidemia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. ___, It was a pleasure caring for you at ___. Why did you come to the hospital? -You came to the hospital because you fell and broke your right hip. What did you receive in the hospital? -While you were in the hospital, you went to the operating room to fix the hip fracture with the orthopedic surgeous. -You also had some trouble breathing requiring oxygen by nasal cannula. We think this is due to the fact that you are taking shallow breaths. Please continue using the incentive spirometry to open up your lungs. We also want you to continue working with physical therapy while at rehab What should you do once you leave the hospital? - Continue to take all of your medications as prescribed - Follow-up with your scheduled appointments as listed below We wish you all the best! Your ___ Care Team Followup Instructions: ___
10024331-DS-33	10,024,331	26,698,935	DS	33	2144-03-01 00:00:00	2144-03-01 18:17:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / Persantine / Allopurinol And Derivatives / Dobutamine Attending: ___ Chief Complaint: chest pain Major Surgical or Invasive Procedure: PCI with placement of 1 DES in the L circumflex History of Present Illness: ___ year old man with complicated PMH notable for CAD s/p multiple PCIs (BMS X 2 and brachytherapy to LAD; ___ 2 to LCx, BMS and DES to RCA), systolic CHF with LVEF of 20%, paroxysmal atrial fibrillation on Pradaxa, diabetes mellitus, hyperlipidemia, hypertension, prostate cancer, radiation proctitis, ___ Disease, CKD, left hip hemiarthroplasty ___, who presents with worsening left sided chest pain at rest over the past few weeks. Apparently he had an echo done on ___ that showed new global hypokinesis and a decrease in his EF from 35 to 20% from ___. He was scheduled for direct admission to cath lab on ___, but revealed to his cardiologist that he had been having unstable angina for the past several weeks and he was advised to come to the ED. He has had trouble staying euvolemic and his diuretics have recently changed from lasix to torsemide 20mg. In the ED, initial VS were 97.2 90 105/51 18 97% RA. Initial troponin was <0.01, Cr elevated to 1.6 from 1.1 prior. DDimer elevated. ECG showed NSR w/o ischemia. A CXR was unremarkable. Guiac (-). A CTA was deferred given ___ and possible need for cath. On arrival to the floor, he reports that he has not had any chest pain at all today and denies feeling short of breath or experiencing DOE, orthopnea or PND. He is mostly complaining of shooting knee pain secondary to his sciatica. Past Medical History: 1. CAD RISK FACTORS: (+)Diabetes, (+)Dyslipidemia, (+)Hypertension 2. CARDIAC HISTORY: - Coronary artery disease s/p multiple PCI (BMS X 2 and brachytherapy to LAD; ___ 2 to LCx, BMS and DES to RCA) with history of stent thrombosis after discontinuation of aspirin and Plavix with last cath in ___ - Systolic congestive heart failure with last echo in ___ demonstrating moderate regional LV systolic dysfunction with inferior and inferolateral hypokinesis (overall LVEF of 35%) - Paroxysmal atrial fibrillation -CABG: None. -PERCUTANEOUS CORONARY INTERVENTIONS: As above. -PACING/ICD: None. 3. OTHER PAST MEDICAL HISTORY: - Cholelithiasis with gallstones causing biliary obstruction, s/p ERCP and sphincterotomy ___ - Radiation proctitis ___, and ___, s/p argon laser treatment - Prostate cancer, T3b N0 M0, ___ 4+3 stage III - ___ Disease - Migraine and cluster headaches - Gout - CKD with baseline creatinine of ___ - Right Hip replacement x 3 with subsequent dislocations - Left hip hemiarthroplasty on ___ - Osteoarthritis of bilateral knees - Chronic anemia - S/p tonsillectomy at age Social History: ___ Family History: Father had MI at age ___, DM, HTN. Brother with CAD s/p CABG at a young age. Mother with cancer, unknown type. Physical Exam: VITALS: 97.7KG 97.7F, 113/63, ___, 18, ___ GENERAL: having uncontrollable automatisms of bilaterally arms, emotionally labile, NAD HEENT: PERRL, EOMI NECK: no carotid bruits, JVP 10 cm LUNGS: CTAB HEART: RRR, normal S1 S2, no MRG ABDOMEN: Soft, NT, NABS, no organomegaly EXTREMITIES: 2+ pitting edema ___ way up thighs, venous stasis NEUROLOGIC: A+OX3 DISCHARGE PHYSICAL EXAM OBJECTIVE: VS: Tmax 98.2 BP ___ PR 20 O2sat 98% ra I/O: ___ GENERAL: NAD, makes appropriate jokes HEENT: EOMI, MMM LUNGS: CTAB HEART: normal rate, regular rhythm, normal S1 S2, no MRG ABDOMEN: Soft, NT, NABS, no organomegaly EXTREMITIES: 1+ pitting edema, warm NEUROLOGIC: A+OX3 Pertinent Results: ___ 12:57PM CK(CPK)-171 ___ 12:57PM CK-MB-3 cTropnT-<0.01 ___ 05:20AM GLUCOSE-141* UREA N-33* CREAT-1.4* SODIUM-142 POTASSIUM-3.5 CHLORIDE-98 TOTAL CO2-38* ANION GAP-10 ___ 05:20AM CK(CPK)-157 ___ 05:20AM CK-MB-3 cTropnT-<0.01 ___ 05:20AM CALCIUM-9.1 PHOSPHATE-3.9 MAGNESIUM-2.3 ___ 05:20AM WBC-5.5 RBC-3.66* HGB-11.1* HCT-35.4* MCV-97 MCH-30.3 MCHC-31.3 RDW-13.2 ___ 05:20AM PLT COUNT-147* ___ 05:20AM ___ PTT-45.4* ___ ___ 10:24PM ___ PTT-49.1* ___ ___ 08:30PM GLUCOSE-142* UREA N-36* CREAT-1.6* SODIUM-141 POTASSIUM-3.9 CHLORIDE-97 TOTAL CO2-36* ANION GAP-12 ___ 08:30PM estGFR-Using this ___ 08:30PM CK(CPK)-207 ___ 08:30PM cTropnT-0.01 ___ 08:30PM CK-MB-3 ___ 08:30PM D-DIMER-959* ___ 08:30PM D-DIMER-959* ___ 08:30PM NEUTS-74.9* LYMPHS-12.9* MONOS-9.4 EOS-2.1 BASOS-0.7 ___ 08:30PM PLT COUNT-162 The patient had 1 run of 7 beats of V tach on tele monitoring during admission. In response, Metoprolol dose was increased. PTT 51.2, Cr 1.4 on ___ LENIs: No DVT CXR: No acute cardiopulmonary process. Brief Hospital Course: ___ year old man with complicated PMH notable for CAD s/p multiple PCIs (BMS X 2 and brachytherapy to LAD; ___ 2 to LCx, BMS and DES to RCA), systolic CHF with LVEF of 20%, paroxysmal atrial fibrillation on Pradaxa, diabetes mellitus, presents with one week chest pain at rest concerning for unstable angina. # Unstable angina - Chest pain concerning for UA in the setting of significant CAD and worsening EF with global ischemia. 2 sets of troponins negative with flat MBs. Given concern for unstable angina, the patient underwent cateterization, with placement of 1 DES in the L circumflex. The patient was restarted on plavix, and told that he needs to remain on this medication for life given his history of stent re-thrombosis. The patient's dabigitran was held for several days before and after the cath, with heparin ggt given as replacement. He was restarted on dabigitran and heparin DCed before discharge. He was continued on home ASA. Metoprolol dose was increased to 50 daily given a run of 7 beats of Vtach on tele monitoring and overall poor EF and CAD. Atorvastatin dose was increased to 80. The patient was discharged with PCP and cardiology follow up, with recommendation for possible holter monitor in future, repeat Echo in ___ weeks, and consideration for EP referral for possible placement of ICD given low EF. # systolic CHF: Lungs were clear and the patient was satting well on room air. Drop in EF was concerning for new ischemic changes, and helped prompt cath. Torsemide was continued. Metoprolol was increased. Lisinopril was started. The patient remained stable. # ___ - Cr rose initially, could be ___ changing diuretics. Got precath hydration and did well with cath. On DC Cr was 1.4 # atrial fibrillation: Patient with history of pAF, on pradaxa and metoprolol for rate control. Patient was monitored on tele. # parkinsons - continue carbidopa-levodopa, selegine # diabetes - ISS while in house # sciatica and hip pain: intermittent pain, currently controlled with oxycodone. During hospital stay the patient was in pain from him but rarely took oxycodone. He was reassured that he could take oxycodone for pain and discharged with a small supply of oxycodone to use as needed as he was having significant pain. Transitional Issues - The patient was discharged with PCP and cardiology follow up, with recommendation for possible holter monitor in future, repeat Echo in ___ weeks, and consideration for EP referral for possible placement of ICD given low EF. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. Atorvastatin 40 mg PO DAILY 2. Carbidopa-Levodopa (___) 1 TAB PO Q4H 3. Colchicine 0.6 mg PO DAILY 4. Cyclobenzaprine 10 mg PO TID:PRN back pain 5. Dabigatran Etexilate 150 mg PO BID 6. GlipiZIDE XL 2.5 mg PO BID 7. Metoprolol Succinate XL 25 mg PO DAILY 8. Nitroglycerin SL 0.4 mg SL PRN chest pain 9. Selegiline HCl 5 mg PO QD 10. Torsemide 20 mg PO BID 11. Aspirin 81 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO DAILY RX atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:6 3. Carbidopa-Levodopa (___) 1 TAB PO Q4H 4. Dabigatran Etexilate 150 mg PO BID 5. Metoprolol Succinate XL 50 mg PO DAILY RX metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:6 6. Nitroglycerin SL 0.4 mg SL PRN chest pain 7. Selegiline HCl 5 mg PO QD 8. Torsemide 20 mg PO BID 9. Clopidogrel 75 mg PO DAILY RX clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:6 10. Lisinopril 2.5 mg PO DAILY Please hold for SBP < 100 RX lisinopril 2.5 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:6 11. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN Pain RX oxycodone 5 mg 1 tablet(s) by mouth q6h prn hip pain Disp #20 Tablet Refills:*0 12. Colchicine 0.6 mg PO DAILY 13. Cyclobenzaprine 10 mg PO TID:PRN back pain 14. GlipiZIDE XL 2.5 mg PO BID Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: coronary artery disease systolic CHF Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you at ___. You were admitted for chest pain, and a cardiac catheterization was done, and a drug eluting stent was placed in your L circumflex artery. On telemetry monitoring your heart had 7 beats of Vtach once, so your metoprolol dose was increased. Please follow up with your cardiologist soon. They may recommend an outpatient Holter monitor test. We recommend repeating your echocardiogram in ___ weeks after discharge. If your ejection fraction remains low at that time, you should get a referral to EP to discuss possible ICD placement. Weigh yourself every morning, call MD if weight goes up more than 3 lbs. It is important that you take all your medications as prescribed and keep all your follow up appointments. Followup Instructions: ___
10024913-DS-21	10,024,913	27,207,228	DS	21	2164-07-27 00:00:00	2164-07-29 16:59:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Angina Major Surgical or Invasive Procedure: Cardiac catheterization ___ History of Present Illness: Mr. ___ is a pleasant ___ year old AA male with a past medical history of 3VD (poor CABG candidate), peripheral vascular disease, type 2 diabetes, dyslipidemia, hypertension, vascular dementia, presenting with left sided chest pain s/p rotoablation, and 3 BMS to proximal and mid LAD. The patient was recently hospitalized (d/c'd ___ as a transfer patient from ___ for chest pain. At ___ had nuclear stress showing reversible anterior-apical and lateral-apical ischemia. He was transferred to ___ and CT surgery believed pt not acceptable CABG candidate based on his performance status. Cardiac catherization was not performed. He was discharged on metoprolol and ranolazine. The chest pain came on while the patient was laying in bed on day prior to admission, with associated shortness of breath and diaphoresis. His wife gave him a full dose aspirin and SL nitroglyercin x 2, which improved his symptoms. The wife called EMS and he was transferred to ___. Pt admitted to ___ and consented for PCI which was done today. Cath study showed heavily calcified with ostial 90% lesion and diffuse 70-80% stenoses in the mid and distal vessel more severe than ___. Underwent rotoablation of LAD and 3BMS to ___ LAD. Procedure complicated by low BPs to ___ and IABP placed with dopamine and levophed gtt. Upon arrival to CCU, pt's vitals SBP 120-130s, HR ___ while on levo 0.1 and dopamine 5. Pt saturating well on 2L NC and mentating at baseline. Pt demented and confused where he had difficulty lying flat in bed while IABP in place. Pt required immobilizers to keep both legs straight and also Posey chest restraint to maintain supine position. Pt was redirectable and A&Ox1 which is his baseline. He does not complain of CP/SOB. Past Medical History: 1. CARDIAC RISK FACTORS: (+)Diabetes, (+)Dyslipidemia, (+)HTN 2. CARDIAC HISTORY: known 3 vessel CAD (LAD, D2, LCx, RCA) -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: no history of interventions -PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: Dementia (likely multi-infarct) Depression Latent tuberculosis (on INH and B6 until ___ Erectile dysfunction Gastroesophageal reflux disease Chronic back pain Hearing loss H/o falls Chronic Renal Insufficency- ___ to DM2 and HTN Benign distal esophageal stricture S/p left carotid stent S/p groin stent S/p left nephrectomy for benign kidney tumor S/p left rotator cuff repair Social History: ___ Family History: His brother had a heart attack @ 80. There is no family history of premature coronary artery disease or sudden death. Physical Exam: ADMISSION EXAM VS- T= 97.3 BP= 154/86 HR= 68 RR= 20 O2 sat= 100% RA GENERAL- NAD. Oriented x1 (not oriented to time or place, but knows it is ___. Mood, affect appropriate. HEENT- NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK- Supple with JVP of 6 cm. No carotid bruits. CARDIAC- PMI located in ___ intercostal space. RRR, normal S1, physiologically split S2 with promient P2. ___ holosytolic murmur at apex. No r/g. No thrills, lifts. No S3 or S4. LUNGS- No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN- Soft, NT. Mild distension. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES- No c/c/e. No femoral bruits. SKIN- No stasis dermatitis, ulcers, scars, or xanthomas. PULSES- Right: Carotid 2+ Femoral 1+ Popliteal 1+ DP 0+ ___ 0+ radial 2+ Left: Carotid 2+ Femoral 1+ Popliteal 1+ DP 0+ ___ 0+ radial 2+ DISCHARGE EXAM Vitals 97.7 151/81 77 20 98%RA Gen: No acute distress. Sleeping peacefully in hospital bed. Oriented to person, but thinks he is at home, and unable to tell what year it is. HEENT: NCAT. EOMI. MMM. No LAD Neck: JVP ~5-7cm. supple CV: RRR. NS1&S2. NMRG. Resp: CTAB. Good air flow. No rales, rhonchi, or wheeze GI: BS+4. S/NT/ND Ext: No c/c/e SKin: NO evidence of dermatitis, rash, or ulcer Pertinent Results: ADMISSION LABS ___ 02:45AM BLOOD WBC-4.8 RBC-3.37* Hgb-10.2* Hct-32.3* MCV-96 MCH-30.4 MCHC-31.7 RDW-12.5 Plt ___ ___ 02:45AM BLOOD Neuts-54.6 ___ Monos-9.1 Eos-4.7* Baso-0.3 ___ 03:24AM BLOOD ___ PTT-30.9 ___ ___ 02:45AM BLOOD Glucose-466* UreaN-30* Creat-1.6* Na-132* K-5.4* Cl-99 HCO3-25 AnGap-13 ___ 11:00AM BLOOD Calcium-8.9 Phos-2.8 Mg-1.7 CARDIAC ENZYME TREND ___ 02:45AM BLOOD cTropnT-<0.01 ___ 11:00AM BLOOD CK(CPK)-168 ___ 11:00AM BLOOD CK-MB-4 cTropnT-<0.01 ___ 08:50PM BLOOD CK(CPK)-373* ___ 08:50PM BLOOD CK-MB-29* MB Indx-7.8* cTropnT-0.25* ___ 03:24AM BLOOD CK(CPK)-583* ___ 03:24AM BLOOD CK-MB-44* MB Indx-7.5* cTropnT-0.57* ___ 08:30AM BLOOD CK(CPK)-704* ___ 08:30AM BLOOD CK-MB-45* MB Indx-6.4* cTropnT-0.68* DISCHARGE LABS ___ 08:55AM BLOOD WBC-5.8 RBC-3.61* Hgb-11.0* Hct-33.5* MCV-93 MCH-30.6 MCHC-33.0 RDW-12.7 Plt ___ ___ 07:16AM BLOOD Glucose-156* UreaN-21* Creat-1.1 Na-140 K-4.1 Cl-104 HCO3-28 AnGap-12 ___ 07:16AM BLOOD Calcium-9.3 Phos-3.4 Mg-1.7 ECG Study Date of ___ 2:15:48 AM Sinus rhythm with diffuse non-specific repolarization abnormalities. Compared to the previous tracing of ___ there is no diagnostic change. CHEST (PA & LAT) Study Date of ___ 4:17 AM Low lung volumes and likely bibasilar atelectasis. No definite evidence of acute cardiopulmonary process. CARDIAC CATHETERIZATION ___: Final Report Pending: Coronary angiography: Right dominant LMCA: Distal 30% LAD: Heavily calcified with ostial 90% lesion and diffuse 70-80% stenoses in the mid and distal vessel more severe than ___. Calcified 90% stenosis in a 2.0 mm diagonal. LCX: Proximal 90% calcified in retroflexed vessel with 70% stenosis into OM1 RCA: Severe diffuse disease with 80-90% stenoses throughout vessel and left to right collaterals from the ___ Brief Hospital Course: Primary Reason for Admission: Mr. ___ is a ___ gentleman with HTN, HLD, DM2, 3 vessel CAD (poor CABG candidate), PVD, and dementia who presented with angina and underwent cardiac catheterization with BMS x3 to LAD. His course was complicated by post-procedural hypotension requiring pressors, IABP placement, and CCU transfer. He stabilized quickly, was transferred back to the Cardiology floor, and was discharged to rehab. . #. CAD: s/p BMS x3 and rotoablation to LAD. He presented with worsening/unstable angina despite medical therapy with ranolazine (he has not tolerated nitrates in the past). On ___ had PCI that revealed heavily calcified LAD with ostial 90% lesion and diffuse 70-80% stenoses in the mid and distal vessel more severe than ___. Underwent rotoablation of LAD and 3BMS to ___ LAD. Procedure was complicated by low BPs to ___ and IABP placed with dopamine and levophed gtt. He was transferred to the CCU where the IABP and pressors were able to be weaned off in <12 hours. He was able to be transferred back to the Cardiology floor where his blood pressures remained stable and he was slowly restarted on his home. He continues on lifelong ASA daily and will need Clopidogrel for at least 1 month. He continues on a statin, beta blocker, ACEi, Ranolazine. His ACEi was decreased from home dose as his BP only able to tolerate lower doses. He will follow up with Dr ___ in Cardiology after discharge; he may benefit from a repeat TTE as an outpatient. . #. Hypertension: Well controlled; he did have hypotension post-cath. SBP mostly ~110 but post-cath he did have the transient hypotension requiring pressors and IABP (see above). Note that his hypotension was likely due to ischemia from distal showering of plaque during cardiac cath (especially given that his cardiac enzymes increased afterwards). In the CCU his anti-hypertensives were held but upon transfer to the Cardiology floor these were able to be added back. His Lisinopril dose was changed to 20mg daily. His Metoprolol was continued at his home dose. . #. Dementia: With delirium post-cath. Likely chronic vascular dementia. At home he is alert but only oriented x1-2, intermittently confused, but after cardiac cath he was very agitated, confused, and combative requiring restraints and reorientation. This resolved by the next morning. He continues on home Seroquel, Memantine, and Galantamine. . #. Urinary retention: resolved. After cardiac catheterization he had urinary retention requiring foley placement; this was likely due to sedating medications he had received. He passed a voiding trial and was subsequently able to urinate without complication. . #. DM2: stable. In house, he was covered with SSI Humalog. He can continue his oral hypoglycemics upon discharge. . #. Dyslipidemia: stable. Lipid profile (___): TC-183, Trig-54, HDL-57, LDL 115->68->88. He was changed from Simvastatin to Atorvastatin and upon discharge will continue on Atorvastatin. . INACTIVE ISSUES . #. Latent TB: on treatment. CXR with pleural plaques. No evidence of cavitary disease. No cough. He continues on INH and pyridoxine. . #. GERD: stable. He continues on Ranitidine. . #. Depression: stable. He continues on Citalopram. . TRANSITIONAL ISSUES . # Please titrate BP meds as needed. At home he was on lisinopril 40mg daily and toprol xL 25mg daily #. Code status: Full code #. Emergency contact: ___ (wife): ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Simvastatin 40 mg PO DAILY 2. Ranitidine 150 mg PO DAILY 3. Quetiapine Fumarate 25 mg PO BID 4. Pyridoxine 50 mg PO DAILY 5. Memantine 10 mg PO BID 6. Lisinopril 40 mg PO DAILY 7. Isoniazid ___ mg PO DAILY 8. galantamine NF 16 mg Oral once daily extended release 9. Citalopram 40 mg PO DAILY 10. Aspirin 81 mg PO DAILY 11. Acetaminophen 500 mg PO TID:PRN pain 12. ranolazine NF 500 mg ORAL BID Reason for Ordering: Unable to tolerate imdur, would like to medically optimize. Attg cardiologist recommends. 13. Clopidogrel 75 mg PO DAILY 14. Combigan NF (brimonidine-timolol) 0.2-0.5 % ___ BID gluacoma 15. GlipiZIDE 10 mg PO BID 16. MetFORMIN (Glucophage) 1000 mg PO BID 17. Nitroglycerin SL 0.4 mg SL PRN chest pain 18. Pioglitazone 45 mg PO DAILY 19. Metoprolol Succinate XL 25 mg PO DAILY Discharge Medications: 1. Acetaminophen 500 mg PO TID:PRN pain 2. Aspirin 81 mg PO DAILY 3. Citalopram 40 mg PO DAILY 4. Clopidogrel 75 mg PO DAILY 5. Isoniazid ___ mg PO DAILY 6. Memantine 10 mg PO BID 7. Nitroglycerin SL 0.4 mg SL PRN chest pain 8. Pyridoxine 50 mg PO DAILY 9. Quetiapine Fumarate 25 mg PO BID 10. Ranitidine 150 mg PO DAILY 11. ranolazine NF 1000 mg ORAL QAM Reason for Ordering: Wish to maintain preadmission medication while hospitalized, as there is no acceptable substitute drug product available on formulary. 12. ranolazine NF 500 mg ORAL QPM Reason for Ordering: Wish to maintain preadmission medication while hospitalized, as there is no acceptable substitute drug product available on formulary. 13. Combigan NF (brimonidine-timolol) 0.2-0.5 % ___ BID gluacoma 14. GlipiZIDE 20 mg PO BID 15. MetFORMIN (Glucophage) 1000 mg PO BID 16. Metoprolol Succinate XL 25 mg PO DAILY 17. Pioglitazone 45 mg PO DAILY 18. galantamine NF 16 mg Oral once daily extended release 19. Lisinopril 20 mg PO DAILY 20. Atorvastatin 80 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Stable angina Coronary artery disease Diabetes Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure to take care of you at ___ ___. You were admitted for chest pain which was determined to be the result of your advanced coronary artery diease. A cardiac catheterization was performed on ___ and three bare metal stents were placed. Your procedure was complicated by low blood pressure which required the use of special pressure-supporting medicines and transfer to the cardiac intensive care unit. You quickly regained your blood pressure and were transferred back to the cardiology service. On the floor, your blood pressure was stable, and we were able to restart your home medications. These medications were restarted at lower doses, and will likely need to be increased by your cardiologist. You were chest pain free when you left the hospital. You will need to stay on plavix until instructed to stop by a Cardiologist. The following changes were made to your medications: START atorvastatin 80mg daily STOP simvastatin 40mg daily DECREASE Lisinopril from 40mg to 20mg daily DECREASE Toprol XL from 50mg daily to 25mg daily Followup Instructions: ___
10024982-DS-19	10,024,982	24,190,442	DS	19	2203-09-18 00:00:00	2203-09-19 08:05:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Zoloft Attending: ___. Chief Complaint: Chest pain Major Surgical or Invasive Procedure: none History of Present Illness: Dr. ___ is a ___ Surgeon at ___ with past medical history notable for coronary artery disease CAD s/p CABG and several PCI's since then (most recent balloon angioplasty SVG-OM ___ who presents with ___ days of chest pain. Exam in the ED notable for bilateral lower extremity edema. ECG showed V-pacing at 59 bpm, intermittent ectopy, Sgarbossa negative. POCUS TTE showed EF 50%, no apparent RWMA. In the ED initial vitals were: Temp. 97.9, HR 60, BP 159/67, RR 22, 100% RA ECG showed V-pacing at 59 bpm, intermittent ectopy, Sgarbossa negative. POCUS TTE showed EF 50%, no apparent wall motion abnormality Labs/studies notable for: WBC 7.1, Hg 8.7, Hct 30.7, platelets 205, MCV 74. Chemistry notable for Na 148, K 4.2, Cl 109, Bicarb 27, BUN 32, Cr 1.1, glucose 111. Trop < 0.01, MB 3, CK 74, Pro-BNP 2323, INR 1.4. CXR showed small right pleural effusion with patchy bibasilar airspace opacities, possibly atelectasis though infection is not excluded. Mild pulmonary vascular congestion. Patient was given: 243 mg aspirin, 0.4 mg nitro, 4000 unit heparin. Evaluated by Cardiology consult who recommended: Treatment as unstable angina with initiation of heparin gtt without bolus (already on apixaban.) Recommendation to hold apixaban, make NPO after midnight. Recommendation for nuclear stress test in AM. If chest pain overnight start sublingual nitro or nitro gtt and consider cardiac cath at that time. Vitals on transfer: HR 69, BP 143/98, RR 19, 100% RA On the floor, Dr. ___ that he has had ongoing chest pressure in his mid-chest for ___ days both with exertion and at rest. The pressure also radiates to his left wrist with associated numbness/tingling. He denies any associated dyspnea, diaphoresis, feeling lightheaded or dizziness. He notes that his chest pressure has improved with nitroglycerin. He is currently chest pain free. He does endorse a few episodes of vomiting without diarrhea, abdominal pain, or fevers unrelated to his chest pressure over the last few days. Of note, he has not taken his eliquis the past 2 days as he has planned injection on ___ for chronic back pain. Past Medical History: ANGINA PECTORIS --post CABG ___ and post multiple stents/PTCA ATRIAL FIBRILLATION BENIGN PROSTATIC HYPERTROPHY GASTROESOPHAGEAL REFLUX OSTEOARTHRITIS PACEMAKER CHRONIC OBSTRUCTIVE PULMONARY DISEASE BACK AND NECK PAIN TURP Knee surgery Social History: ___ Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: ADMISSION EXAM VS: T= 98.7 BP= 139/80 HR=108, manual recheck 70's RR= 16 O2 sat= 100% RA GENERAL: In NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple without JVD CARDIAC: Normal S1, S2. No murmurs/rubs/gallops. No thrills, lifts. CHEST: raised erythematous papule (stable from baseline), well-healed surgical scar LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Lipoma on right lower quadrant. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Distal pulses palpable and symmetric DISCHARGE EXAM VS - Temp 98.7, HR 56-108, BP 131-150/71-94, RR ___, 99-100% RA Tele: Paced, occ PVC's General: NAD, A+Ox3, pleasant, laying down in bed HEENT: Sclera anicteric, oropharynx clear Neck: No JVD CV: RRR, no murmurs, normal PMI Lungs: Clear bilaterally Abdomen: NTND, +BS Ext: Warm and well perfused, no ___ edema Neuro: Grossly normal Pertinent Results: ADMISSION LABS ___ 06:06PM BLOOD WBC-7.1 RBC-4.16* Hgb-8.7* Hct-30.7* MCV-74* MCH-20.9* MCHC-28.3* RDW-17.5* RDWSD-46.3 Plt ___ ___ 08:04PM BLOOD ___ PTT-33.2 ___ ___ 06:06PM BLOOD Neuts-60.1 ___ Monos-14.9* Eos-3.1 Baso-0.3 Im ___ AbsNeut-4.25 AbsLymp-1.50 AbsMono-1.05* AbsEos-0.22 AbsBaso-0.02 ___ 06:06PM BLOOD Glucose-111* UreaN-32* Creat-1.1 Na-148* K-4.2 Cl-109* HCO3-27 AnGap-16 ___ 06:06PM BLOOD CK-MB-3 proBNP-2323* ___ 06:06PM BLOOD cTropnT-<0.01 ___ 01:25AM BLOOD CK-MB-3 cTropnT-<0.01 ___ 06:00AM BLOOD CK-MB-3 cTropnT-0.01 ___ 06:06PM BLOOD Calcium-8.6 Phos-3.4 Mg-2.2 DISCHARGE LABS ___ 06:00AM BLOOD WBC-8.5 RBC-4.34* Hgb-9.0* Hct-32.0* MCV-74* MCH-20.7* MCHC-28.1* RDW-17.7* RDWSD-46.9* Plt ___ ___ 06:00AM BLOOD ___ PTT-64.6* ___ ___ 06:00AM BLOOD Glucose-88 UreaN-30* Creat-1.2 Na-143 K-3.8 Cl-105 HCO3-27 AnGap-15 ___ 06:00AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.2 REPORTS PHARMACOLOGIC STRESS TEST ___. Normal myocardial perfusion. 2. Increased left ventricular cavity size with mild global systolic dysfunction. Compared with prior study of ___, the prior apical defect is no longer present, left ventricular cavity size has increased, and systolic function has decreased. CXR ___ Small right pleural effusion with patchy bibasilar airspace opacities, possibly atelectasis though infection is not excluded. Mild pulmonary vascular congestion. Brief Hospital Course: ___ y/o M Cardiac Surgeon with a h/o CAD s/p CABG and PCI's, A-Fib, PPM, COPD, GERD, presenting with several days of chest pain concerning for unstable angina. ACTIVE ISSUES # Chest pain: Presented with ___t rest, relieved by nitro. Given his significant cardiac history there was concern for unstable angina. He was started on a heparin drip and given full dose ASA on arrival, and his home apixaban was held. He was chest pain free after admission. There were no ischemic EKG changes. Troponin and CK-MB were negative x3. Stress MIBI was done, showing normal perfusion, and a decrease in systolic function (to 40%) vs his prior study. He was discharged home with plan for an outpatient catheterization in 5 days. Home Imdur was increased from 60mg daily to 120mg daily. Continued home metoprolol succinate 25mg daily, ASA 81mg, and Atorvastatin 40mg daily. CHRONIC ISSUES # H/o A-Fib: s/p pacemaker for Tachy-Brady. Takes apixaban for anticoag as outpatient, but this has been held in anticipation of a pain injection procedure on ___. Heparin drip was used for anticoag while inpatient. # COPD: Lung exam unremarkable. Normal RR and O2 sats. Continued home Symbicort BID, tiotropium, albuterol inhaler PRN # Anemia: Microcytic, stable during this admission, stable vs prior labs earlier this year. Prior workup c/w Iron Deficiency. # Back/neck pain: Continued home Duloxetine 30mg daily, Hydrocodone-Acetaminophen PRN # GERD: Pantoprazole 40mg daily # Hypothyroidism: Levothyroxine 75 mcg daily TRANSITIONAL ISSUES # Imdur increased from 60 mg daily to 120 mg daily at discharge # Will follow up with Dr. ___ likely receive an angiogram in 5 days. Request was sent and timing being finalized with Dr. ___. # Apixiban held on discharge, as it had been held prior to admission, in anticipation of upcoming back procedure on ___ it will also be held in anticipation of upcoming angiogram, to be determined by Dr. ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler ___ PUFF IH BID PRN SOB 2. Apixaban 5 mg PO BID 3. Atorvastatin 40 mg PO QPM 4. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation inhalation BID 5. Duloxetine 30 mg PO DAILY 6. Isosorbide Mononitrate 60 mg PO DAILY 7. Levothyroxine Sodium 75 mcg PO DAILY 8. Metoprolol Succinate XL 25 mg PO DAILY 9. Endocet (oxyCODONE-acetaminophen) ___ mg oral Q6 PRN pain 10. Pantoprazole 40 mg PO Q24H 11. Tiotropium Bromide 1 CAP IH DAILY 12. Aspirin 81 mg PO DAILY 13. Nitromist (nitroglycerin) 400 mcg/spray translingual ___ sprays Q5 minutes PRN chest pain Discharge Medications: 1. Albuterol Inhaler ___ PUFF IH BID PRN SOB 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. Duloxetine 30 mg PO DAILY 5. Levothyroxine Sodium 75 mcg PO DAILY 6. Metoprolol Succinate XL 25 mg PO DAILY 7. Nitromist (nitroglycerin) 400 mcg/spray translingual ___ sprays Q5 minutes PRN chest pain 8. Pantoprazole 40 mg PO Q24H 9. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation inhalation BID 10. Tiotropium Bromide 1 CAP IH DAILY 11. Endocet (oxyCODONE-acetaminophen) ___ mg oral Q6 PRN pain 12. Isosorbide Mononitrate 60 mg PO BID Discharge Disposition: Home Discharge Diagnosis: Primary: ========== Unstable angina Secondary: ============ coronary artery disease atrial fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Dr. ___, ___ was a pleasure participating in your care at ___. You were admitted to our hospital because of chest pain. We checked your troponins, which we negative three times, ruling out a heart attack. A pharmacologic cardiac perfusion study showed normal perfusion and a mild decrease in systolic function. Dr. ___ ___ about these results, and will follow-up with you as an outpatient. He may recommend an angiogram. We wish you all the best, Your ___ Care Team Followup Instructions: ___
10025647-DS-28	10,025,647	28,326,162	DS	28	2180-09-13 00:00:00	2180-09-13 18:34:00	Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Morphine / Asacol Attending: ___. Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: ___ M with history of systolic heart failure (EF 30%), CAD (sp CABG ___, MI x2)sp ___ BiV (___), A fib/A flutter, HTN, cardiac arrest with subsequent ICD placement (___), catheter ablation after sustained monomorphic VT (___), presenting with progressively worsening shortness of breath x 4 weeks. He admits to PND and orthopnea. He states he is compliant with medications, does not endorse any obvious dietary indiscretion although he says he does eat salty crackers on occasion. In the ED yesterday, initial vitals were 70 149/64 98% Labs and imaging significant for Na 129, K 3.5, Cr 1.0, Dig level 0.4, MG 1.5. BNP 12,141. Trop 0.02. HCT 36, WBC 7, PLT 223. INR 6.1, PTT 42. Pt initialy admitted to ED observation and given lasix 40mg IV x1. Patient given Mag sulfate 2, lasix 40mg IV, oxycodone-tylenol, KCl 40, docusate, digoxin 0.125mg, amio 200mg, lisinopril 5mg, sertraline 50mg, metoprolol 50mg, spironolactone 25mg. Held his home HCTZ and coumadin. Pt did well last night. This AM labs were fine but pt desated with ambulation. Pt had continued desat to 91% with ambulation. Vitals on transfer were 97.7 70 123/77 18 99% On arrival to the floor, patient is comfortable, no chest pain, talking in complete sentences. Pt states he used to walk up and down the fence outside his apartment until reaching DOE. Now he walks to bathroom and feels SOB. Past Medical History: 1. CARDIAC RISK FACTORS: +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: -CABG: CABG ___ -PACING/ICD: Bi V device ___ 3. OTHER PAST MEDICAL HISTORY: LV dysfunction Hypertension Systolic heart failure Atrial fibrillation on Coumadin, last dose pre procedure Coumadin ___ (Not bridged with Lovenox as per Dr. ___. Atrial tachycardia s/p MI, CABG s/p cardiac arrest hyperlipidemia s/p VT ablation ___ mechanical fall s/p hip replacement ___ years ago walks with a walker Ulcerative colitis Social History: ___ Family History: Father had a "leaky valve." Mother had hypertension, stroke. Physical Exam: Admission exam: VS- 97.8, 154/76, 77, 20, 94%2L GENERAL- NAD. Oriented x3. Mood, affect appropriate. HEENT- NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK- Supple with JVP of 9 cm. CARDIAC- PMI located in ___ intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. LUNGS- crackles bilateral bases L>R ABDOMEN- Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: no pedal edema PULSES- 2+ radial bilat Discharge exam: 97.5, 145/70, 71, 18, 99%2l Gen: nad, comfortable, A+Ox3 Cardiac: JVP around 7 Pulm: no crackles on lung exam today Abd: soft, nt Ext: no pedal edema Pertinent Results: ___ 07:55PM cTropnT-0.03* ___ 10:02AM cTropnT-0.02* ___ 10:02AM ___ ___ CXR: IMPRESSION: Interval development of pulmonary edema with bilateral pleural effusions, left greater than right ___ CXR pending but from our team read: it looks markedly improved, resolved edema Brief Hospital Course: ___ with history of systolic heart failure (EF 30%), CAD (sp CABG 1198, MI x2)sp ___ BiV (___), A fib/A flutter, HTN, cardiac arrest with subsequent ICD placement (___), catheter ablation after sustained monomorphic VT (___), presenting with progressively worsening shortness of breath x 3 weeks, pulmonary edema, consistent with acute on chronic systolic heart failure. # Acute on chronic systolic heart failure: Baseline EF 30%. Unclear trigger, possible dietary indiscretion or chronic intermittent ischemia. No EKG changes, troponin only mildly elevated but likely secondary to heart faillure. ICD device was interrogated and no episodes of ventricular arrythmias or tachycardias. He spends most of his time in A fib/A flutter. He was diuresed with Lasix 40g IV with good response. At time of discharge pt was felt to be euvolemic. Discharge weight 71 Kg. He was discharged on Lasix 20mg PO daily. # CAD: sp CABG in ___. Denied any chest pain. EKG unremarkable for acute ST /T wave changes. Trop 0.03. Continued his home regimen of aspirin 81, metop succ 50mg. Started lisinopril 5mg. # A fib/A flutter: Interrogation of device showed he is in A fib/flutter 100% of the time. Continued his home metoprolol, digoxin, and amiodarone. Of note, pt had elevated INR 6 on admission. Coumadin was held. On day of discharge, INR 2.7 and he was resumed on home coumadin 1mg daily. #HTN: BP elevated in 150s. Per PCP, preference to have pt in 120-150s as he has history of hypotension and falls in the past. His HCTZ was discontinued. Instead he was given lasix 20mg daily (to keep fluid off), continued his home spironolactone, lisinopril, metoprolol. BP range ___ on this regimen. #HLD: Continued home atorva 40. #Depression: Continued home sertraline 25mg. # CODE- DNR/DNI # EMERGENCY CONTACT- wife ___ PENDING: -Final CXR read from ___. Prelim read from team: improved/resolved pulm edema. Transitional Issues: -Starting lasix 20mg daily, needs lytes check outpatient -INR 2.7 at discharge -has chronic right hip pain. Will follow with rheumatology outpatient. Seen by ortho in the past and had trochanteric bursa injection. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amiodarone 200 mg PO DAILY 2. Atorvastatin 40 mg PO DAILY 3. Digoxin 0.0625 mg PO EVERY OTHER DAY 4. Metoprolol Succinate XL 50 mg PO DAILY hold SBP<90, HR<55 5. Nitroglycerin SL 0.3 mg SL PRN chest pain 6. Sertraline 25 mg PO DAILY 7. Spironolactone 25 mg PO DAILY hold sbp<100 8. Warfarin 1 mg PO DAILY16 9. Hydrochlorothiazide 25 mg PO DAILY Discharge Medications: 1. Amiodarone 200 mg PO DAILY 2. Atorvastatin 40 mg PO DAILY 3. Digoxin 0.0625 mg PO EVERY OTHER DAY 4. Metoprolol Succinate XL 50 mg PO DAILY hold SBP<90, HR<55 5. Nitroglycerin SL 0.3 mg SL PRN chest pain 6. Sertraline 25 mg PO DAILY 7. Spironolactone 25 mg PO DAILY hold sbp<100 8. Warfarin 1 mg PO DAILY16 9. Lisinopril 5 mg PO DAILY This is a new medicine for your blood pressure RX lisinopril 5 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:1 10. Furosemide 20 mg PO DAILY RX furosemide 20 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:1 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Acute on chronic systolic heart failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: It was a pleasure providing care for you during this hospitalization. You were admitted to the hospital for shortness of breath. You were found to have some fluid in your lungs that is likely from fluid back-up from the heart. You were given a medicine called lasix to make you urinate out the fluid. Your breathing improved. Medication changes: START: lasix 20mg daily- this will prevent fluid from backing up in your lungs. Weigh yourself every morning, call MD if weight goes up more than 3 lbs. Please make sure to get in touch with the doctors that manage your coumadin. You should get your INR checked again in 1 week. We have also arranged for you to see a Rheumatologist to discuss your hip pain. You will see them on ___ at 11am. Please see appointment dates and time below for Rheumatology (for your hip), Cardiologist (for your heart), and Dr ___ ___ this appointment you should make sure you have your electrolytes checked after starting this medicine called Lasix). Followup Instructions: ___
10025647-DS-29	10,025,647	20,302,361	DS	29	2180-11-21 00:00:00	2180-11-21 14:21:00	Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Morphine / Asacol Attending: ___ Chief Complaint: syncope Major Surgical or Invasive Procedure: none History of Present Illness: ___ year old male with history CHF + AICD, presenting with several days of cough accompanied by multiple near-syncopal episodes with sensation of AICD firing. The first was at 2am; he awoke from sleep feeling dizzy and then the AICD fired. This happened again at 5am and 5:30am, so he came to the hospital. The patient had mild rhinorrhea with dry cough, and was prophylactically put on Tamiflu by his daughter. While in triage the patient had a brief syncopal episode lasting approximately ___ seconds accompanied by some jerking motions. He reports he did not feel like the AICD had gone off at this time. Patient denies fever, chills, nausea, dysuria, diarrhea. He also denies chest pain and headache. He does reports worsening fatigue with exertion (minimal walking and ___ sessions) over the past ___ weeks. He also reprots occassional post-tussive emesis, as frequent as every other day. He's had a cough for the past ___ months, productive of white sputum. He denies shortness of breath, except when lying down flat (2 pillow orthopnea, which has not worsened recently). He reports his baseline weight used to be 175-180 lbs, but is now ___ lbs. He was 154 lbs when he left rehab a month ago, but reports he has lost weight since then and is now ___ lbs. On the other hand, he was told by his wife that he has gained fluid weight recently. In the ED, initial vitals were 97.8 73 162/72 18 100%. Exam was significant for faint crackles in the left lower lung field. ECG showed ventricular paced rhythm at 72 bpm, consistent with prior ECG and no sign of new ischemia or arrhythmia. Labs showed INR of 2.7. Lactate was 2.5. Patient received ceftriaxone, azithromycin, and oseltamivir for possible flu. He was given 40 mg IV furosemide x 1. Blood culture x 2 were sent. Vitals upon transfer were 97.3 70 143/58 26 100%. On review of systems, s/he denies any prior history of stroke, TIA, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, hemoptysis, black stools or red stools. S/he denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. He does report a hx of DVT x 2 in separate legs and separated by time both several years ago. He has had decreased appetite for several months. All of the other review of systems were negative. Past Medical History: 1. CARDIAC RISK FACTORS: +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: Systolic congestive heart failure Coronary artery disease Atrial fibrillation Atrial tachycardia s/p Cardiac arrest s/p VT ablation ___ -CABG: CABG ___ -PACING/ICD: Bi V device ___ 3. OTHER PAST MEDICAL HISTORY: DVT x 2 in separate legs and separated by time both several years ago Ulcerative colitis s/p Total hip replacement TB s/p lung surgery ___ Social History: ___ Family History: Father had a "leaky valve." Mother had hypertension, stroke. Physical Exam: ADMISSION: VS: 98.0, 142/75, 71, 24, 96% RA WT: 67 kg (147.7 lbs) GENERAL: Frail, slightly cachectic M in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple with JVP of 7 cm. CARDIAC: RR, normal S1, S2. No m/r/g. LUNGS: Resp were unlabored, no accessory muscle use. Crackles ___ way up on right and ___ way up on left. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. SKIN: No stasis dermatitis, ulcers, scars. . VS: 98.7/98.6, 112/57-143/78, 68-70, 20, 96% RA WT: 66.3kg; admission 67 kg (147.7 lbs) Is/Os: 1L net negative yesterday GENERAL: Frail, slightly cachectic M in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple without JVD. CARDIAC: RR, normal S1, S2. No m/r/g. LUNGS: Resp were unlabored, no accessory muscle use. Crackles ___ way up on both sides. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. SKIN: No stasis dermatitis, ulcers, scars. Pertinent Results: LABS: ___ 08:55AM BLOOD WBC-8.3 RBC-4.38* Hgb-12.7* Hct-39.4* MCV-90 MCH-28.9 MCHC-32.2 RDW-15.2 Plt ___ ___ 08:55AM BLOOD Neuts-79.2* Lymphs-15.9* Monos-3.0 Eos-1.7 Baso-0.3 ___ 06:40AM BLOOD WBC-8.0 RBC-4.28* Hgb-12.1* Hct-38.0* MCV-89 MCH-28.3 MCHC-31.8 RDW-15.2 Plt ___ ___ 08:55AM BLOOD ___ PTT-40.0* ___ ___ 07:20AM BLOOD ___ PTT-39.2* ___ ___ 09:00AM BLOOD ___ PTT-42.1* ___ ___ 04:15PM BLOOD ___ ___ 06:40AM BLOOD ___ PTT-42.8* ___ ___ 08:55AM BLOOD Glucose-146* UreaN-27* Creat-0.9 Na-139 K-3.4 Cl-100 HCO3-27 AnGap-15 ___ 03:25PM BLOOD Glucose-122* UreaN-28* Creat-1.0 Na-135 K-5.4* Cl-97 HCO3-28 AnGap-15 ___ 06:15AM BLOOD Glucose-90 UreaN-30* Creat-1.1 Na-134 K-4.8 Cl-96 HCO3-29 AnGap-14 ___ 06:40AM BLOOD Glucose-90 UreaN-33* Creat-1.1 Na-133 K-4.5 Cl-94* HCO3-33* AnGap-11 ___ 08:55AM BLOOD ALT-78* AST-116* LD(LDH)-186 AlkPhos-89 TotBili-0.8 ___ 08:55AM BLOOD Albumin-3.3* ___ 04:45PM BLOOD Calcium-8.3* Phos-3.0 Mg-1.5* ___ 06:40AM BLOOD Calcium-8.5 Phos-3.9 Mg-2.1 ___ 08:55AM BLOOD Digoxin-0.5* ___ 09:13AM BLOOD Lactate-2.5* ___ 11:50AM URINE Color-Yellow Appear-Clear Sp ___ ___ 11:50AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG . MICRO: ___ Influenza A/B by ___ DIRECT INFLUENZA A ANTIGEN TEST-FINAL negative; DIRECT INFLUENZA B ANTIGEN TEST-FINAL negative ___ URINE URINE CULTURE-FINAL no growth ___ BLOOD CULTURE Blood Culture, Routine-PENDING ___ BLOOD CULTURE Blood Culture, Routine-PENDING . EKG ___: A-V sequentially paced rhythm with capture. Baseline artifact. Compared to the previous tracing of ___ the rhythm is now A-V sequential pacing. Rate PR QRS QT/QTc P QRS T 72 ___ 52 -57 107 . CXR ___: FINDINGS: Unchanged mediastinal and hilar borders. Heart size demonstrates stable cardiomegaly. Multifocal opacifications throughout both lungs and may represent atypical infectious process with a less likely consideration given to pulmonary edema; there is relative absence of central pulmonary vessel prominence. No pleural effusion or pneumothorax is evident. Redemonstration of pacemaker including abandoned leads in the right atrium, right ventricle and left ventricle epicardial location, unchanged. IMPRESSION: Multifocal opacification throughout both lungs, possibly representing atypical infectious process, with a less likely consideration given to pulmonary edema. Brief Hospital Course: ___ w/ hx systolic CHF with AICD p/w several days of cough and 1 day of multiple near-syncopal episodes with sensation of AICD firing. In the ED, he had several more episodes of near-syncope and at least 1 episode of syncope. His device was interrogated, and he had had 8 episodes of VT w/ 2 AICD fires. His amiodarone was increased from 200mg daily to 200mg BID. He had no further episodes of pre-syncope, syncope, VT, or AICD firing. Syncope was very likely due to VT. Patient was found to have pneumonia on CXR and was thought to have some pulmonary edema from acute on chronic systolic heart failure as well. The patient was diuresed with IV Lasix 40mg ___ times/day and then transitioned to PO Lasix 40mg daily. His admission weight was 67kg, and his discharge weight was 66.3kg. Pneumonia was treated with azithromycin (for 5 days) and ceftriaxone (to be transitioned to cefpodoxime for 7 days total). He was influenza negative by DFA. He should have an outpatient CXR to ensure resolution of the PNA. INR became supratherapeutic in the setting of antibiotic therapy. His warfarin was held on ___ and ___, and should be restarted at 0.5mg daily when his INR is 3.0 or lower. Transitional Issues for Rehab Facility: - Patient is confirmed DNR/DNI. - Patient should have daily cardiopulmonary assessment and assessment of weight and fluid status; he may need adjustment of furosemide dose according to fluid starus. - Patient should initially have daily INR checks; warfarin can be restarted at 0.5mg daily when INR is between 2 and 3 (further adjustments in dosing can be made based on INR once warfarin is restarted). - Azithromycin should be continued through ___, and cefpodoxime should be continued through ___. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amiodarone 200 mg PO DAILY 2. Atorvastatin 40 mg PO DAILY 3. Digoxin 0.0625 mg PO EVERY OTHER DAY 4. Metoprolol Succinate XL 50 mg PO DAILY hold SBP<90, HR<55 5. Nitroglycerin SL 0.3 mg SL PRN chest pain 6. Sertraline 25 mg PO DAILY 7. Spironolactone 25 mg PO DAILY hold sbp<100 8. Warfarin 1 mg PO DAILY16 9. Lisinopril 5 mg PO DAILY This is a new medicine for your blood pressure 10. Furosemide 20 mg PO DAILY Discharge Medications: 1. Amiodarone 200 mg PO BID 2. Atorvastatin 40 mg PO DAILY 3. Digoxin 0.0625 mg PO EVERY OTHER DAY 4. Furosemide 40 mg PO DAILY 5. Lisinopril 5 mg PO DAILY 6. Nitroglycerin SL 0.3 mg SL PRN chest pain 7. Sertraline 25 mg PO DAILY 8. Spironolactone 25 mg PO DAILY hold sbp<100 9. Azithromycin 250 mg PO Q24H Duration: 1 Days last day of 5-day course is ___. Cefpodoxime Proxetil 400 mg PO Q12H last day of 7-day course is ___ 11. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN sob, wheezing 12. Metoprolol Succinate XL 50 mg PO DAILY hold SBP<90, HR<55 13. Multivitamins W/minerals 1 TAB PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: ventricular tachycardia acute on chronic systolic heart failure community-acquired pneumonia syncope atrial fibrillation 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: Dear Mr. ___, You were admitted to the hosptial with pre-syncope (lightheadedness) and syncope (fainting). These symptoms were likely due to ventricular tachycardia (VT), an abnormal heart rhythm. Your AICD (pacemaker/defibrillator) indicated you did have several episodes of VT prior to admission, and your defibrillator fired twice to get you out of this rhythm. Your dose of amiodarone (a medication that can help prevent VT) was increased. You had no further episodes of VT during this admission. You were also found to have a pneumonia and some heart failure. The pneumonia was treated with antibiotics. Please continue to take the antibiotics as prescribed. The heart failure was treated with IV Lasix (a diuretic) and then oral Lasix (also known as furosemide). Weigh yourself every morning, and call your physician if your weight goes up more than 3 lbs. Thank you for allowing us to take part in your care. Followup Instructions: ___
10025647-DS-30	10,025,647	20,807,698	DS	30	2181-05-14 00:00:00	2181-05-14 17:21:00	Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Morphine / Asacol Attending: ___. Chief Complaint: "I couldn't get up" Major Surgical or Invasive Procedure: None History of Present Illness: ___ with history of ___ MIs with pacer/defib and on Coumadin for history of multiple DVTs presents with weakness. He was laying in bed and found that he had had a BM in the bed which he has had in the past. His wife walked him into the bathroom to clean him up. While standing in the bathroom, he felt weak and said he needed to slump to the floor. His wife caught him and was careful to make sure he didn't hit his head. He laid down on the floor and his wife called ___. He had SOB associated with the weakness and vomiting once while on the ground. He then just felt weak and couldn't get up so they called EMS. In the ED, initial vs were: ___ 97.6 90 128/59 20 100% 2L. ED exam sig for lungs with crackles at the bases, worse on the left rectal exam was heme negative. ED drew blood cultures, ua, urine culture, troponin, CXR c/w left atelectasis vs pleural effusion, CT head and CT c spine w/o concerning findings. He also received 10mg PO Vit. K/ Labs were remarkable for initial lactate 3.2, after 1L NS was 1.3. Patient was given 10 mg po vitamin K for an INR of 9, as well as 1L NS as noted above. On the floor he notes he is very thirsty and hoping for some water. He notes SOB has been on and off, but feels better with oxygen. He has not had decreased intake, but did not eat supper - this AM ate eggs, toast, ham, for lunch had a baloney and cheese. Doesn't eat any greens. Review of sytems: (+) Per HPI (-) denies cp and sob, no fever or chills per pt, no n/v/d, no leg swelling, no weight gain, productive cough that has been going on for a couple of weeks Past Medical History: Dyslipidemia Hypertension Systolic congestive heart failure Coronary artery disease Atrial fibrillation Atrial tachycardia S/p Cardiac arrest S/p VT ablation ___ CABG ___ Bi V device ___ DVT x 2 in separate legs and separated by time both several years ago Ulcerative colitis S/p Total hip replacement TB s/p lung surgery ___ Social History: ___ Family History: Father had a "leaky valve." Mother had hypertension, stroke. Physical Exam: ADMISSION EXAM: Vitals: 98.0 - 128/___ - ___ - ___, 98 on 2L wt 66.2kg 6'2" General: pleasant gentleman, interactive, spritely HEENT: nc/at mm dry/parched sclera anicteric Lungs: crackles to mid left lung, crackles R lower lobe w/o egophony CV: regular rate and rhythm Abdomen: soft, non tender Ext: no peripheral edema Skin: no rashes Neuro: alert, oriented x3, knows president, speech fluent, linear, appropriate, moves all 4 extremities against resistance DISCHARGE EXAM: Vitals - 97.8 131/59 69 20 99/RA General - Alert&oriented x3, no acute distress HEENT - Sclera anicteric, MMM dry, oropharynx clear Neck - Supple, JVP not elevated, no LAD Lungs - Clear to auscultation bilaterally, no wheezes, rales, ronchi CV - Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops, ICD evident underneath the skin Abdomen - soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU - no foley SKIN - significant ecchymoses on arms Ext - 2+ pulses, no clubbing, cyanosis or edema Neuro - CNs2-12 intact, motor function grossly normal Pertinent Results: ADMISSION LABS: ___ 06:22PM BLOOD WBC-8.5 RBC-3.81* Hgb-11.4* Hct-35.7* MCV-94 MCH-29.9 MCHC-31.9 RDW-15.4 Plt ___ ___ 06:22PM BLOOD Neuts-75.6* ___ Monos-4.5 Eos-0.8 Baso-1.0 ___ 06:22PM BLOOD ___ PTT-54.1* ___ ___ 06:22PM BLOOD Glucose-118* UreaN-30* Creat-1.4* Na-139 K-3.9 Cl-101 HCO3-22 AnGap-20 ___ 06:22PM BLOOD cTropnT-0.03* ___ 08:00AM BLOOD CK-MB-2 cTropnT-0.04* ___ 06:22PM BLOOD Calcium-8.3* Phos-3.6 Mg-1.8 ___ 06:22PM BLOOD Digoxin-0.8* ___ 06:22PM BLOOD TSH-2.9 ___ 06:22PM BLOOD HBcAb-NEGATIVE ___ 06:31PM BLOOD Lactate-3.2* ___ 10:30PM BLOOD Lactate-1.3 DISCHARGE LABS: ___ 07:00AM BLOOD WBC-6.9 RBC-3.56* Hgb-10.6* Hct-32.8* MCV-92 MCH-29.8 MCHC-32.3 RDW-15.4 Plt ___ ___ 11:10AM BLOOD ___ PTT-41.5* ___ ___ 07:00AM BLOOD Glucose-86 UreaN-27* Creat-1.3* Na-140 K-4.4 Cl-105 HCO3-29 AnGap-10 ___ 07:00AM BLOOD Calcium-8.1* Phos-2.5* Mg-1.9 CT HEAD ___ FINDINGS: There is no hemorrhage, edema, mass effect or acute vascular territorial infarct. Prominent ventricles and sulci are suggestive of age-related involutional change. Diffuse periventricular, subcortical and deep white matter hypodensity is compatible with chronic small vessel ischemic disease. The basal cisterns are patent and there is preservation of gray-white matter differentiation. No fracture is identified. Mucosal wall thickening is noted in the left frontal sinus. The remainder of the paranasal sinuses, mastoid air cells and middle ear cavities are clear. Globes are intact. IMPRESSION: No acute intracranial abnormality. CT NECK ___ FINDINGS: The osseous structures are grossly demineralized. No fracture or malalignment is identified. The prevertebral soft tissues are unremarkable. There are multilevel multifactorial degenerative changes of the cervical spine with prominent anterior and posterior osteophytes particularly at the level of C5/C6 which mildly indents the ventral thecal sac. Multilevel disc space narrowing is most severe at the C5/C6. Multilevel facet joint and uncovertebral hypertrophic changes mildly narrow the neural foramina. A calcification is again noted in the right thyroid lobe. The thyroid is otherwise unremarkable. The trachea is midline. The imaged lung apices are clear. Left-sided pacer leads are partially imaged. IMPRESSION: No acute fracture or malalignment. CXR ___ FINDINGS: Frontal and lateral views of the chest were obtained. Triple lead left-sided pacemaker is again seen with leads similar in position. There is elevation of the left hemidiaphragm and slight blunting of the left costophrenic angle which may be due to a small pleural effusion with overlying atelectasis. Calcifications project over the left mid lung. No right pleural Effusion is seen. The right lung is clear. IMPRESSION: Left base opacity may be due to combination of pleural effusion And atelectasis. Brief Hospital Course: ___ year old gentleman with history of systolic HF/CAD with AICD, afib on warfarin, presenting with an episode of weakness/pre-syncope and supratherapeutic INR. * Active Diagnoses * # Weakness/Pre-Syncope: Atraumatic fall with no evidence of bleed or fracture on CT head or spine. Given history of diarrhea, vomiting while on the floor, mild ___ (baseline Cr of 1.0), and new furosemide therapy, orthostatic hypotension was considered on presentation. The patient was noted to be orthostatic on admission. IV fluids were given judiciously because of his history of severe HF with depressed EF ___, last echo ___. No evidence of arrhythmia on ICD interrogation by EP. No evidence of acute MI with unremarkable trops x2 and ECG at baseline. The patient was monitored on tele with no events. Digoxin level 0.8 ng/mL. Furosemide, spironolactone and lisinopril were initially held and restarted at discharge. His dose of furosemide was decreased to 10mg daily. The patient most likely experienced hypovolemia from decreased PO intake leading to hypovolemia and his weakness/pre-syncope. Pt sent to ___ rehabilitation per ___. # Supratherapeutic INR: The patient is on warfarin for his h/o a.fib. Warfarin was initially held. He received got 10mg PO vitamin K in the ED . He normally is on 1mg of warfarin daily. The patient reports notes no change in dosing or diet recently. Diarrhea and decreased PO intake likely lead to his supratherpeutic INR. The patient was restarted on warfarin on ___ with plan to re-check his INR upon discharge. * Chronic Diagnoses * # Chronic systolic heart failure s/p ICD placement: Baseline EF 30%-35%, last echo ___. The patient has an ICD. The patient's spironolactone, lisinopril and furosemide were initially held due to orthostasis, but subsequently restarted. Metoprolol and digoxin were continued. Digoxin level on admission 0.8. The patient has cardiology follow up scheduled. # Coronary artery disease: S/p CABG in 1990s. Denied any chest pain. EKG unremarkable for acute ST /T wave changes. Trop 0.03 and 0.04. The patient was continued on aspirin 81mg daily and metoprolol XL 50mg daily. Lisinopril was restarted at discharge after discontinuation in the setting of orthostatic hypotension. # A fib/A flutter: Telemetry showed sequential AP-VP. No episode of RVR. The patient was continued on metoprolol, digoxin and amiodarone. INR was initially supratherapeutic at 9.0. Corrected with 10mg PO vitamin K. Warfarin was restarted at 1mg per day on ___. # Hypertension: Orthostatic on admission. BP medications were held, and subsequently restarted. # Pleural effusion vs atelectasis on CXR: Not impressive. Shows possibly elevated right hemidiaphragm which appears irregular, consistent with either atelectasis or pleural effusion, but does not appear significantly changed from before. He has no history of malignancy, no evidence of PE currently, does note that he may have had pneumonia a few months prior, but unlikely to be complicated parapneumonic effusion. # Hyperlipidemia: Stable. The patient was continued on atorvastatin 40mg daily. # Depression: Stable. The patient was continued on sertraline 25mg daily. # Incidental finding of thyroid calcifications: "A calcification is noted in the right thyroid lobe. The thyroid is otherwise unremarkable." This issue will need f/u as an outpatient. TRANSITIONAL ISSUES ******************* 1. Calcification in R thyroid lobe on ct cspine 2. Draw INR on ___, adjust warfarin dose as necessary 3. Monitor daily weights, edema and respiratory status for titration of furosemide 4. Draw Chem 7 on ___ to monitor renal function and potassium given diuretic therapy 5. Battery of ICD is approaching ERI, so cardiology told patient to go to device clinic for evaluation. Appointment setup. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 2.5 mg PO DAILY please hold for SBP<100 2. Metoprolol Succinate XL 50 mg PO DAILY please hold for SBP<100, HR<60 3. Digoxin 0.0625 mg PO EVERY OTHER DAY 4. Docusate Sodium 100 mg PO DAILY 5. Amiodarone 200 mg PO BID 6. Warfarin 1 mg PO DAILY16 7. Atorvastatin 40 mg PO HS 8. Furosemide 20 mg PO DAILY please hold for SBP<100 9. Spironolactone 25 mg PO DAILY please hold for SBP<100 10. Nitroglycerin SL 0.4 mg SL PRN chest pain 11. Acetaminophen w/Codeine 1 TAB PO Q4H:PRN pain 12. Sertraline 25 mg PO DAILY Discharge Medications: 1. Amiodarone 200 mg PO BID 2. Atorvastatin 40 mg PO HS 3. Digoxin 0.0625 mg PO EVERY OTHER DAY 4. Docusate Sodium 100 mg PO DAILY 5. Furosemide 10 mg PO DAILY 6. Lisinopril 2.5 mg PO DAILY 7. Metoprolol Succinate XL 50 mg PO DAILY 8. Sertraline 25 mg PO DAILY 9. Spironolactone 25 mg PO DAILY 10. Warfarin 1 mg PO DAILY16 11. Nitroglycerin SL 0.4 mg SL PRN chest pain 12. Acetaminophen w/Codeine 1 TAB PO Q6H:PRN pain Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Orthostatic Hypotension Supratherapeutic INR Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Hi Mr. ___, You came into the hospital because you were dehydrated (orthostatic hypotension) after having diarrhea and vomiting causing you to feel weak and slump to the ground. The diarrhea and vomiting was likely caused by something you ate or a virus and has since resolved while you were here. For your low blood pressures, we gave you a little fluid with improvement. Please stay well-hydrated but limit to less than 2 liters per day given your history of heart failure. Please follow-up with your cardiologist within 1 week after leaving the hospital. Weigh yourself every morning, call MD if weight goes up more than 3 lbs. Please note the following changes to your medications: -decreased furosemide to 10mg daily -decreased acetaminophen w/ codeine to every 6 hours as needed Followup Instructions: ___
10025747-DS-20	10,025,747	28,292,012	DS	20	2182-12-19 00:00:00	2182-12-19 21:20:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Fentanyl / Zantac / Flagyl / Entocort EC / Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: Flex sigmoidoscopy History of Present Illness: HISTORY OF PRESENT ILLNESS: ___ female patient with a history of ___ disease (restarted on Humira ___ for new flare) who came to the ED for abdominal pain since the morning of ___ concerning for acute-on-chronic ___ flare, found to have colitis on CT and leukocytosis to 27, and admitted for workup and IV antibiotics. Per her report, she was diagnosed with "hemorrhagic ___ in her ___ and nothing initially could control the bleeding; she required a partial resection. She eventually went into a ___ admission, developing abdominal pain and cramping in ___. She was initially diagnosed with diverticulitis but on CT scan was found to have colitis. She had a 5 day admission to ___ at this time, for abdominal pain and symptomatic hypotension. At the end of ___ she underwent a colonoscopy which showed chronic severely active colitis with ulceration, which was negative for CMV. She was started on Humira the beginning of ___. The morning of admission, she woke up feeling lightheaded and was dizzy on standing and "knew that her blood pressure was low. "She also had cramping abdominal pain. Her last bowel movement was 2 days prior to admission and was a formed stool. She has been unable to tolerate p.o. for the past several days. She has had some nausea and reflux as well, these are more chronic symptoms for. She feels fatigued and weak. In the ED, initial VS were 96.0 110 51/37 1893% nasal cannula. She triggered for hypotension and was given first 1L NS with improvement to 112/70. She received: -1 L normal saline at ___ -1 g vancomycin at 1500 -4.5g pip-tazo at 1500 -1g APAP PO at 1640 Subsequent pressures were ___ prompting the additional NS mentioned above. Past Medical History: - ___ on Humira - reflux with dysphagia - hiatal hernia - diverticulitis - bronchiectasis - positive hepatitis C antibody with a negative HCV RNA - history of a sleep disorder - pruritus - fibroid uterus - Sjogren's syndrome (clinical; negative autoantibody testing) - interstitial cystitis - fibromyalgia and chronic ___ Social History: ___ Family History: Grandmother and several great aunts had ___ disease. Father with type 2 diabetes. Brother passed away from AML in his ___. Physical Exam: Admission Physical Exam ================ VS: 97.8 \| 153/72 \| 97 \| 20 \| 91%Ra GENERAL: NAD, thin but not cachectic, appears elderly and mildly diaphoretic but nontoxic. HEENT: PERRL, dry mucous membranes NECK: full rom, no LAD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: well-healed RLQ scar. Minimally distended. Tender to palpation throughout, worse in LLQ. No rebound/guarding. Hyperactive bowel sounds. Typmpanic to percussion. EXTREMITIES: WWP, no cyanosis, clubbing, or edema PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, face grossly symmetric, no dysarthria. Moving all 4 extremities with purpose SKIN: no excoriations or lesions, no rashes Discharge Physical Exam ================ PHYSICAL EXAM: VS: 98.0 PO 137 / 81 nL Lying 76 RR 16 O292 Ra GENERAL: NAD, awake, alert HEENT: AT/NC, EOMI, PERRL, anicteric sclera, cracked lips, MMM HEART: RRR, normal S1/S2, no murmurs, gallops, or rubs LUNGS: clear to auscultation, no increased work of breathing, no crackles ABDOMEN: soft, ND NT, no rebound/guarding, midline scar from remote surgery, normoactive/hypoactive bowel sounds, improved EXTREMITIES: no edema NEURO: A&Ox3, ambulating normal SKIN: warm and well perfused Pertinent Results: Admission Labs =========== ___ 02:30PM BLOOD WBC-27.9# RBC-4.12 Hgb-12.3 Hct-38.8 MCV-94 MCH-29.9 MCHC-31.7 RDW-13.4 RDWSD-46.4* Plt ___ ___ 02:30PM BLOOD Neuts-85.5* Lymphs-8.1* Monos-5.0 Eos-0.3* Baso-0.5 Im ___ AbsNeut-23.82* AbsLymp-2.26 AbsMono-1.39* AbsEos-0.07 AbsBaso-0.14* ___ 02:30PM BLOOD Plt ___ ___ 02:30PM BLOOD Glucose-163* UreaN-15 Creat-1.2* Na-139 K-3.7 Cl-103 HCO3-16* AnGap-24* ___ 02:30PM BLOOD ALT-15 AST-23 AlkPhos-97 TotBili-0.5 ___ 02:30PM BLOOD Albumin-3.8 ___ 02:30PM BLOOD CRP-0.7 ___ 03:10PM BLOOD ___ pO2-27* pCO2-43 pH-7.26* calTCO2-20* Base XS--8 ___ 03:10PM BLOOD Lactate-4.1* ___ 06:45AM BLOOD CRP-46.1* ___ 02:30PM BLOOD CRP-0.7 Discharge Labs =========== ___ 07:40AM BLOOD WBC-22.7* RBC-4.05 Hgb-11.9 Hct-37.1 MCV-92 MCH-29.4 MCHC-32.1 RDW-14.4 RDWSD-48.2* Plt ___ ___ 07:40AM BLOOD Plt ___ ___ 07:40AM BLOOD Glucose-98 UreaN-17 Creat-0.5 Na-141 K-4.1 Cl-99 HCO3-28 AnGap-14 ___ 07:20AM BLOOD ALT-19 AST-14 AlkPhos-77 TotBili-0.3 ___ 07:40AM BLOOD Calcium-9.7 Phos-3.5 Mg-2.0 ___ 07:25AM BLOOD VitB12-224* Folate-6 ___ 07:25AM BLOOD CRP-3.3 Microbiology ========= ___ STOOLC. difficile DNA amplification assay- negative ___ URINE URINE CULTURE negative ___ BLOOD CULTUREBlood Culture negative ___ BLOOD CULTUREBlood Culture negative ___ STOOLFECAL CULTURE- Negative ___ CULTURE negative ___ CULTURE Negative ___ CULTURE Negative Imaging ========= ___- Lung CTA 1. No pulmonary embolism or acute aortic abnormality. 2. Acute on chronic ___ flare with thickened hyperemic transverse and descending colon. No definite bowel obstruction. 3. Large left upper pole renal cyst with septations may be further assessed with non-emergent renal ultrasound. 4. Fibroid uterus. 5. Two lung nodules measuring up to 5 mm along the left fissure. ___- CXR Cardiac silhouette size is normal. Mediastinal and hilar contours are unremarkable. The pulmonary vasculature is not engorged. Elevation of the right hemidiaphragm is of indeterminate chronicity. Patchy opacities within the lung bases likely reflect areas of atelectasis. No pleural effusion or focal consolidation is noted. There are no acute osseous abnormalities. No subdiaphragmatic free air is present. ___ Colonic and small bowel dilatation likely ileus, consider cross-sectional imaging if there is concern for obstruction. ___ Chest Xray Left basal peribronchial opacification is improved slightly. Right hemidiaphragm remains severely elevated and is responsible for new right middle lobe atelectasis. Upper lungs are clear. Heart size is normal. Pleural effusions small if any. No pneumothorax. ___ Abd Xray No significant change in bowel distention from the exam done two days ago. No free air demonstrated. ___- Echo The left atrium is normal in size. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Left ventricular systolic function is hyperdynamic (EF = 75%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). The right ventricular free wall thickness is normal. Right ventricular chamber size is normal with normal free wall contractility. 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. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The left ventricular inflow pattern suggests impaired relaxation. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. ___ CXR No significant interval change since the prior chest radiograph. No evidence of pulmonary edema. ___- CT abd/pelvis 1. No evidence of intra-abdominal abscess. 2. Interval increased conspicuity of right hepatic lobe wedge-shaped perfusion abnormality likely representing evolving infarct. 3. Moderate colonic stool, consider constipation. 4. Mildly increased size of left renal cyst with thin enhancing septations measuring 8.5 cm, previously measured 5.1 cm. 5. Additional findings as above. ___- Liver MRI Previously seen abnormality at dome of the liver is not visualized on MRI. The liver enhances homogeneously and there is no evidence of focal mass or infarction Brief Hospital Course: Brief Hospital Course: ___ female patient with a history of ___ disease (restarted on ___ ___ for new flare) who came to the ED for abdominal pain since the morning of ___ concerning for acute-on-chronic ___ flare, found to have colitis on CT and leukocytosis to 27, and admitted for workup and IV antibiotics. GI was consulted and followed the patient throughout the hospitalization. It was believed the abdominal pain came about secondary to constipation and abdominal distention. The patient was given an aggressive bowel regimen, which helped the symptoms which we believe were secondary to a previous botox injection for pelvic floor disfunction. The patient also received her second loading dose of Humira while in the hospital and was started on a course of steroids (initially IV to PO prednisone). Her abdominal pain and distension continued to improve and was at baseline at discharge. Throughout the hospitalization, the patient also had continued hypoxia, which was something she had experienced at a recent hospitalization at ___, but without any clear reason. The patient required ___ of oxygen for the first half of her stay to remain in the low ___ on her O2 stat and would desat into the high ___ and low ___ during ambulation. Outside records could not be gathered regarding any hypoxia. It was believe this was caused by a raised right hemidiaphragm causing low lung volumes, atlectosis from laying in bed, and blunting secondary to abdominal pain. The patient was also found to have a pneumonia (CAP) which was treated for 5 days with levaquin. Ultimately, once the patient began ambulating and her abdominal pain improved she was able to come of all O2 without difficulty and did not require home oxygen. The patient was also found to have leukocytosis on admission which reached a nadir of 10 during the middle of the hospitalization when the patient felt well, however began to rise without a clear cause. The WBC went up to 23.9 and stabilized around this value, and although the patient had been started on steroids, was a suspicious rise in the context of her clinical picture. A blood smear was obtained which showed inflammation, B12 deficiency, and some questionable MDS type cells. The patients B12 was found to be low at 224, but an MMA was not obtained as it an outpatient lab. To evaluate for other potential causes of leukocytosis, a CT abdomin/pelvis was done to evaluate for potential abscess/occult infection, and revealed a wedge-shaped infarct in a peripheral region of her liver. To further classify this and to look for any local process which could have contributed, a MRI liver was done which did not demonstrate the lesion and heme/onc did not recommend anticoagulation. The patient was discharged home in stable condition. ======================= TRANSITIONAL ISSUES: ======================= []Check CBC in 1 week to evaluate improving leukocytosis. If continues to be elevated, consider heme/onc referral for possible bone marrow biopsy for MDS ___ []Vitamin B12 was deficient. Will replete B12 and folate. Consider follow-up with methylmalonic acid and/or homocysteine levels []Patient had severe constipation and on numerous anticholinergeric medications. Can consider modifying her regimen. []Cholestyramine was held due to constipation. Can consider restarting if diarrhea reoccurs. []Patient's blood pressure had dizziness when taking lisinopril. This was held during hospitalization and not restarted on d/c. Can consider restarting as outpatient. MEDICATIONS: - New Meds: Prednisone 50mg daily, tapering 10mg weekly (on ___ until 30mg daily - Stopped Meds: Sodium Chloride tablets, lisinopril - Changed Meds: None Incidental findings: #RENAL CYST: Large left upper pole renal cyst on CT ___, again on CT abd/ pelvis with septations. Will need follow up in ___ year with renal ultrasound #PULM NODULES: 5 mm left fissural nodule and 4 mm RML nodule on CT ___. For incidentally detected multiple solid pulmonary nodules <6mm, no CT follow-up is recommended in a low-risk patient. Optional CT follow-up in 12 months is recommended in a high-risk patient. Can consider f/u CT in 12 months # CONTACT: ___ ___ # CODE: Full Code ACTIVE: #COLITIS #CROHNS: Abdominal pain was consistent with acute-on-chronic Crohns flare. Ruled out infectious colitis w/ neg C.diff and stool cultures. KUB demonstrated dilated colon with potential ileus. Was given a strong bowel regimen, started on steroids, and patient had Humira ___ loading dose on (___). A flex sig ___ unremarkable to sigmoid, though unable to visualize much due to poor prep. GI followed closely and recommended tapering steroids weekly by 10mg starting on ___, eventually continuing at 30mg PO daily until follow-up with ___ ___ in outpatient. #LEUKOCYTOSIS: Wedge-shaped low attentuation found on CT A/P ___ which was suspicious for a liver infarct. Was originally thought to be cause of leukocytosis, however was not redemonstrated on MRI. At discharge, the ___ is 22.3. Will follow-up with PCP ___ 1 week and consider heme/onc referral for further evaluation, possible bone marrow biopsy, and consideration of MDS. #CONSTIPATION: Improving bowel function on bowel regimen (daily suppositories, Colace, senna). Constipation ___ rectal sphincter dysfunction from hx of Botox injections for pelvic floor dysfunction. Also precipitated by inflammation from active Crohns flare. On numerous medications which can contribute, but did not want to change regimen at this time. Her cholestyramine was held during hospitalization. #HYPOXIA: Resolving, O2sat in low ___ on RA throughout hospitalization. Hypoxia likely secondary to splinting, atelectasis, and poor lung expansion, precipitated by PNA and completed a 5-day levo. Unclear hx of preload failure but TTE ___ without shunt or evidence of right heart strain. VBG appropriate on ___. CT negative for PE on admission. Pulm consult ___ suggesting atelectasis as cause, appreciate recs. Patient was recommended to follow-up outpatient with pulmonologist Dr. ___ at ___ and sleep doctor at ___. #B12 DEFICIENCY: B12 low at 224. No hyper segmentation seen on smear. Currently asymptomatic with no GI or neuro sxs. Heme/onc recommended to get an MMA and start B12 injections. These were not done in house as it is a send out lab. CHRONIC: #HYPERTENSION: - Home lisinopril was held. #POTS: Has episodes of dizziness a/w abdominal pain. - Holding home salt tablets, can continue outpatient #SJOGREN'S, #VAGINAL DRYNESS, #PELVIC FLOOR DYSFUNCTION, #MISC - Home eye drops - Home vaginal diazepam BID - Home doxepin HS - Hold home fluconazole unless having symptomatic yeast infection - Home pregabalin TID - Home prevalite - Home carisoprodol Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ondansetron ___ mg PO Q8H:PRN nausea 2. Humira (adalimumab) unknown subcutaneous unknown 3. Pantoprazole 40 mg PO Q24H 4. carisoprodol 350 mg oral TID:PRN 5. Doxepin HCl 50 mg PO HS 6. Lisinopril 5 mg PO DAILY 7. Prevalite (cholestyramine-aspartame) 4 gram oral BID 8. Diazepam 20 mg PO Q12H pelvic floor dysfunction 9. Dronabinol 2.5 mg PO BID-TID:PRN nausea 10. Sodium Chloride Dose is Unknown PO TID 11. Pregabalin 200 mg PO TID 12. Fluconazole 200 mg PO Q24H Discharge Medications: 1. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry eyes 2. Bisacodyl ___AILY 3. Cyanocobalamin 100 mcg IM/SC DAILY Duration: 7 Days RX cyanocobalamin (vitamin B-12) [Vitamin B-12] 1,000 mcg/mL 1000 mcg IM weekly Disp #3 Vial Refills:0 4. Docusate Sodium 100 mg PO BID 5. FoLIC Acid 1 mg PO DAILY 6. PredniSONE 50 mg PO DAILY RX prednisone 10 mg 5 tablet(s) by mouth daily Disp #75 Tablet Refills:0 7. Senna 8.6 mg PO BID:PRN constipation 8. Sucralfate 1 gm PO QID:PRN stomach pain 9. Humira (adalimumab) 40 mg subcutaneous 1X/WEEK (___) 10. carisoprodol 350 mg oral TID:PRN 11. Diazepam 20 mg PO Q12H pelvic floor dysfunction 12. Doxepin HCl 50 mg PO HS 13. Dronabinol 2.5 mg PO BID-TID:PRN nausea 14. Fluconazole 200 mg PO Q24H 15. Ondansetron ___ mg PO Q8H:PRN nausea 16. Pantoprazole 40 mg PO Q24H 17. Pregabalin 200 mg PO TID 18. HELD- Lisinopril 5 mg PO DAILY This medication was held. Do not restart Lisinopril until you see your PCP. 19. HELD- Prevalite (cholestyramine-aspartame) 4 gram oral BID This medication was held. Do not restart Prevalite until you talk to your PCP or GI doctor because you were constipated in the hospital. 20. HELD- Sodium Chloride Dose is Unknown PO TID This medication was held. Do not restart Sodium Chloride until you talk to your PCP . Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary ___ Flare Secondary Pneumonia Vitamin B12 deficiency Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You came to ___ because you were having abdominal pain and bloating in your stomach. You were found to have a flare of your ___ Disease and a pneumonia. You were given antibiotics for your infections and started on steroids. The gastrointestinal (GI) team came to see you and you got your second loading dose of Humira. You were having low oxygen numbers and were found to have a pneumonia and were treated with antibiotics. You were seen by a hematologist, a doctor who is an expert in blood problems, who found you had low vitamin B12. You also had a CT scan, which showed a possible area of low blood flow in your liver, but another imaging test, an MRI, was done to help us look at this and did not find anything abnormal. Please see the instructions for what to do after leaving the hospital. -You should continue your prednisone 50 mg until ___ and then decrease your dose by 10mg every ___ until you are taking 30mg a day and follow-up with Dr. ___. - You should follow-up with you PCP ___ on ___ - You should start weekly Humira administration on ___, with the next dose ___ - You should take your B12 shot once a week - You should talk to your GI doctor about your cholestyramine - You should talk to your PCP about your sodium chloride pills It was a pleasure participating in your care. We wish you the best! Sincerely, Your ___ Care Team Followup Instructions: ___
10025791-DS-20	10,025,791	25,012,487	DS	20	2170-11-16 00:00:00	2170-11-16 21:53:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Chest pain Major Surgical or Invasive Procedure: ___: Cardiac catheterization via right radial artery History of Present Illness: ___ with history of alcohol and tobacco abuse who presented to PCP for routine physical on ___ after being lost to follow up for several years, complaining of chest discomfort, so was referred for outpatient stress test. EKG showed TWIs (no baseline available), and echo showed EF ___ with severe hypokinesis of the apex and basal inferoseptum, so he was transferred to ___ for further work up. He states that over the past year he has been having episodes of chest discomfort associated with L arm tingling lasting ___ minutes, about 2 episodes a month, usually occuring at rest and self resolving. He has also noticed dyspnea with exertion, mostly noticed when yelling at his crews at work. He denies PND, orthopnea, or leg edema, palpitations, diaphoresis, lightheadedness. In the ED, initial vitals were T98.3F, HR 80, BP 150/102, RR 18 98% RA. On exam he appeared euvolemic, but BNP elevated to 800, troponins negative. He was admitted to the cardiology service for catheterization. Vitals prior to transfer were T97.8 HR 92 BP 150/93 RR22 96%. On arrival to the floor vitals ___, BP 152/105, HR 99, RR 18, 98% RA. He endorses the history above, denies current chest pain. On ROS he denies fevers, chills, cough, weight loss, myalgias, sore throat, rhinorrhea, nausea, vomiting, diarrhea, dysuria, hematuria, blood in stools, difficulty swallowing. He does report 2 occasions over the past year of coughing fits where he then found himself on the floor after losing consciousness, no neuro deficits before or after these episodes, he doesn't know how long he was down for, most recent was about a month ago. Past Medical History: 1. CARDIAC RISK FACTORS: -Diabetes, -Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: none 3. OTHER PAST MEDICAL HISTORY: anal fistula elevated LFTs tobacco abuse EtOH abuse Social History: ___ Family History: Father with EtOH abuse and esophageal cancer, mother still alive Physical Exam: ADMISSION PHYSICAL EXAMINATION: ___, BP 152/105, HR 99, RR 18, 98% RA GENERAL: overweight man in NAD. Oriented x3. Mood, affect appropriate. HEENT: face flushed, NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no pallor or cyanosis of the oral mucosa. No xanthelasma. OP clear, good dentition NECK: Supple with difficult to assess JVP CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Respirations unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominal bruits. EXTREMITIES: No peripheral edema SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: 2+ carotids, radials, DPs NEURO: CN II-XII intact and symmetric, strength ___ in BUE and BLE, LT intact and symmetric DISCHARGE PHYSICAL EXAMINATION: VS:97.6F, BP 113/82, HR 83, RR 18, 96% RA Weight 80.9kg GENERAL: overweight man in NAD. Oriented x3. Mood, affect appropriate. HEENT: face flushed, NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no pallor or cyanosis of the oral mucosa. No xanthelasma. OP clear, good dentition NECK: Supple with difficult to assess JVP CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Respirations unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominal bruits. EXTREMITIES: No peripheral edema, R radial without SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: 2+ carotids, radials, DPs Pertinent Results: ADMISSION LABS: ___ 01:05PM BLOOD WBC-8.5 RBC-5.19 Hgb-15.0 Hct-45.4 MCV-87 MCH-29.0 MCHC-33.1 RDW-12.8 Plt ___ ___ 01:05PM BLOOD Neuts-68.5 ___ Monos-4.3 Eos-0.8 Baso-1.3 ___ 01:45PM BLOOD ___ ___ 01:05PM BLOOD Glucose-93 UreaN-11 Creat-0.8 Na-142 K-4.0 Cl-102 HCO3-27 AnGap-17 PERTINENT LABS: ___ 01:05PM BLOOD cTropnT-<0.01 ___ 07:10AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 01:05PM BLOOD ALT-15 AST-17 AlkPhos-69 TotBili-0.8 ___ 01:05PM BLOOD proBNP-801* ___ 07:10AM BLOOD HIV Ab-NEGATIVE DISCHARGE LABS: ___ 07:10AM BLOOD WBC-7.5 RBC-4.92 Hgb-15.0 Hct-42.8 MCV-87 MCH-30.4 MCHC-34.9 RDW-12.8 Plt ___ ___ 07:10AM BLOOD Glucose-106* UreaN-16 Creat-0.8 Na-140 K-4.5 Cl-101 HCO3-29 AnGap-15 IMAGING: CXR ___ FINDINGS: Frontal and lateral views of the chest. The lungs are clear of consolidation, effusion, or pulmonary vascular congestion. The cardiac silhouette slightly enlarged and the aorta is tortuous. No acute osseous abnormality detected. IMPRESSION: No acute cardiopulmonary process. Note evidence of congestive failure. Cath ___ Selective coronary angiography of this co dominant system demonstrated no angiographically apparent flow limiting stenoses. The LMCA, LAD, LCx and RCA were all normal and patent. Limited resting hemodynamics revealed low normal central aortic pressure and normal LVEDP of 10mmHg. FINAL DIAGNOSIS: 1. Coronary arteries are normal. 2. Normal LVEDP. Brief Hospital Course: ___ man with history of alcohol and tobacco abuse who presented to PCP with episodes of mild chest discomfort, found to have concerning EKG changes and severely depressed EF on echo, admitted for further work up, found to have non-ischemic cardiomyopathy. # Chronic congestive heart failure with systolic dysfunction: New diagnosis. Presented with chest discomfort, found to have T-wave inversions (no baseline available) and severely depressed EF at ___, admitted for further work up. Troponins were negative, BNP was elevated but patient was euvolemic on exam as well as on hemodynamics during cardiac catheterization. Cardiac cath revealed clean coronaries, making ischemic disease unlikely etiology, HIV Ab neg, no viral symptoms to invoke viral cardiomyopathy. Most likely cause is alcoholic cardiomyopathy. Started metoprolol, lisinopril, discharged on carvdilol with plan for close follow up. Encouraged patient to observe 1.5L fluid and 2g Na restrictions. # Hyperlipidemia: LDL on ___ was 130. Encouraged lifestyle modification to lower cardiac risk. # Alcohol abuse: no history of withdrawal but at least 1 pint rum/day with last drink 10pm night prior to admission. Did not require lorazepam on ___ protocol, scores were ___. Social work did not have a chance to see patient prior to discharge. Alcohol cessation was strongly encouraged to patient, risks of continuing to drink were discussed with him. # Tobacco abuse: Patient declined nicotine replacement therapy. Encouraged cessation. TRANSITIONAL ISSUES - Will need re-enforcement for low salt diet, fluid restriction, and daily weights - Weight at discharge 80.9kg - Encourage smoking and alcohol cessation - New medications: Carvedilol and lisinopril - Code Status: full, Mother ___ is intended HCP ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. FoLIC Acid 1 mg PO DAILY RX folic acid 1 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 2. Lisinopril 10 mg PO DAILY RX lisinopril 10 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 3. Thiamine 100 mg PO DAILY RX thiamine HCl 100 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 4. Carvedilol 6.25 mg PO BID RX carvedilol 6.25 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary: suspected alcoholic cardiomyopathy; chronic systolic congestive heart failure Secondary: alcohol abuse, hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, You were admitted to ___ after presenting to your primary care doctor with episodes of chest discomfort. An ultrasound of the heart (echocardiogram) showed that your heart does not pump as hard as it should, a condition called "systolic heart failure". A procedure called an cardiac catheterization was performed to look at the blood vessels that supply the heart, as blockages to these arteries can cause this condition. Your cardiac catheterization showed clean blood vessels, which leads us to believe your systolic heart failure may be due to your heavy alcohol use. We have started you on several medications to protect your heart and help it beat stronger, but the most important thing you can do for this condition is to stop drinking alcohol. Please ask your primary care doctor about resources to help you do this. Continuing to drink could be dangerous to your health and even fatal Drinking too much alcohol also puts you at risk for vitamin deficiences, so we recommend that you start taking folate and thiamine, two vitamins now included in your medication list. Your heart condition puts you at risk for having excess fluid build up in your lungs and legs. Please weigh yourself every morning and call your doctor if your weight increases by more than 3 pounds in 5 days. You should also keep a low sodium diet (less than 2g or 2000mg per day) and try to drink only 1.5L or 50 ounces of fluids a day. Followup Instructions: ___
10025981-DS-12	10,025,981	20,580,099	DS	12	2150-02-15 00:00:00	2150-02-15 14:56:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: aspirin / Penicillins / latex / eggs Attending: ___. Chief Complaint: Right leg pain, r/o compartment syndrome Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ ___ yo F with past medical history significant for RLE DVT, polyarthralgias who is ___ s/p right TKA (Dr. ___, who presents from OSH with acute onset of pain out of proportion and parathesias of her RLE. Patient states that she had expected pain immediate postoperatively however, her pain acutely worsened over last 24h. Of note, she recently transitioned from lovenox back to her home xarelto. Past Medical History: Past Medical History: Noninflammatory polyarthralgia with myalgias, morbid obesity, currently calculated a BMI 42, hiatal hernia, right-sided sciatica, right knee arthritis, right leg traumatic-induced DVT, migraine headaches, complex regional pain syndrome, asthma, bilateral carpal tunnel syndrome, GERD and vertigo. Past Surgical History: In ___, right knee arthroscopic medial meniscectomy at ___, ___, ___. She has also had endometrial ablation, right shoulder arthroscopy, tubal ligation, cholecystectomy and appendectomy. MEDICATIONS: Advair Diskus, butalbital, APAP caffeine, gabapentin 300 mg twice a day, glucosamine chondroitin, loratadine 10 mg daily, multivitamins, omeprazole 20 mg daily, tramadol 50 mg p.r.n. and zolpidem 10 mg daily. Allergies: Aspirin, latex and penicillin. Social History: ___ Family History: ___ Physical Exam: ADMISSION PHYSICAL EXAM Right upper extremity: - Skin intact - No deformity, erythema, edema, induration or ecchymosis - Soft, non-tender arm and forearm - Full, painless AROM/PROM of shoulder, elbow, wrist, and digits - EPL/FPL/DIO (index) fire - SILT axillary/radial/median/ulnar nerve distributions - 2+ radial pulse Left upper extremity: - Skin intact - No deformity, erythema, edema, induration or ecchymosis - Soft, non-tender arm and forearm - Full, painless AROM/PROM of shoulder, elbow, wrist, and digits - EPL/FPL/DIO (index) fire - SILT axillary/radial/median/ulnar nerve distributions - 2+ radial pulse Right lower extremity: - Incision intact with some dried bloody drainage. - Swelling about knee, lower leg and foot, with areas of ecchymosis - exquisite tenderness to pROM of great toe and ankle - ___ fire - SGILT but diminiahed in SPN/DPN/TN/saph/sural distribution - foot WWP Left lower extremity: - Skin intact - No deformity, erythema, edema, induration or ecchymosis - Soft, non-tender thigh and leg - Full, painless AROM/PROM of hip, knee, and ankle - ___ fire - SILT SPN/DPN/TN/saphenous/sural distributions - 1+ ___ pulses, foot warm and well-perfused DISCHARGE PHYSICAL EXAM: Comfortable, NAD RLE with minimal pain Right lower extremity: - Incision intact with some dried bloody drainage. - Swelling about knee, lower leg and foot, with areas of ecchymosis - No tenderness to pROM of great toe and ankle - ___ fire - SILT in all distributions - foot WWP Pertinent Results: ___ 06:30PM WBC-8.8 RBC-2.88* HGB-8.0* HCT-25.5* MCV-89 MCH-27.8 MCHC-31.4* RDW-13.2 RDWSD-41.5 ___ 06:41PM LACTATE-1.2 ___ 06:30PM ___ PTT-39.7* ___ Brief Hospital Course: ___ year old female who presents to ___ with acute onset of pain and parathesia to RLE after recent R TKA. On exam, she does have significant pain w/ passive range of motion, but sensation is diminished but intact at currently. Concern for compartment syndrome is high. Recommendations: - NPO - please obtain RLE U/S - serial compartment checks - please hold narcotics for now. - final recommendations pending serial examinations Please see attending addendum for final recommendations. The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have acute onset of pain and parathesia to RLE after recent R TKA. On exam, she did have significant pain w/ passive range of motion, but sensation was diminished but intact at currently. Concern for compartment syndrome was high, ___ compartment pressures checked with range ___ (DBP 68). Patient was admitted to the orthopedic surgery service for serial exams and observation, pain control. Pain improved over a period of observation. Patient tolerated ___ without issue, and was ambulatory with minimal pain. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is WBAT in the right lower extremity, and will be discharged on lovenox 40mg QPM for DVT prophylaxis. The patient will follow up with Dr. ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Medications on Admission: ACLIDINIUM BROMIDE [___] - ___ Pressair 400 mcg/actuation breath activated. 1 puff twice a day - (Prescribed by Other Provider) ALBUTEROL SULFATE [VENTOLIN HFA] - Ventolin HFA 90 mcg/actuation aerosol inhaler. 2 puffs twice a day as needed for shortness of breath or wheezing - (Prescribed by Other Provider) BUDESONIDE-FORMOTEROL [SYMBICORT] - Symbicort 160 mcg-4.5 mcg/actuation HFA aerosol inhaler. 2 puffs twice a day - (Prescribed by Other Provider) BUTALBITAL-ACETAMINOPHEN - butalbital-acetaminophen 50 mg-325 mg tablet. 1 tablet(s) by mouth as needed for pain, headaches - (Prescribed by Other Provider) DRONABINOL - dronabinol 5 mg capsule. 1 capsule(s) by mouth twice a day - (Prescribed by Other Provider) GABAPENTIN - gabapentin 800 mg tablet. 1 tablet(s) by mouth four times a day - (Prescribed by Other Provider) IBUPROFEN - ibuprofen 800 mg tablet. 1 tablet(s) by mouth every eight (8) hours as needed for pain OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. 1 capsule(s) by mouth once a day am - (Prescribed by Other Provider) OXYCODONE - oxycodone 5 mg tablet. ___ tablet(s) by mouth every four (4) hours as needed for pain RIVAROXABAN [XARELTO] - Xarelto 20 mg tablet. 1 tablet(s) by mouth daily - (Prescribed by Other Provider: ___ TRAMADOL - tramadol 50 mg tablet. 1 tablet(s) by mouth three times a day - (Prescribed by Other Provider) Discharge Medications: As above Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Right Leg Pain Discharge Condition: Stable, Improved Discharge Instructions: 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 40mg everyday for three (3) weeks to help prevent deep vein thrombosis (blood clots). You should resume the rivaroxaban after completing the 3 week course of Lovenox. 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 your follow-up appointment in two weeks. 10. ___ (once at home): Home ___, dressing changes as instructed, wound checks. 11. ACTIVITY: Keep the Right leg elevated as much as possible Weight bearing as tolerated on the operative extremity. Mobilize. ROM as tolerated. No strenuous exercise or heavy lifting until follow up appointment. Physical Therapy: WBAT Mobilize frequently Treatments Frequency: DSD daily prn drainage Ice and elevate *Staples will be removed at your first post-operative visit in three(3)weeks Followup Instructions: ___
10026246-DS-21	10,026,246	27,069,095	DS	21	2138-03-05 00:00:00	2138-03-05 21:46:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: Back Pain Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a ___ year old male with a history of HTN, hypothyroidism, and a distant history of bladder CA who presented as a transfer from OSH with an L1 burst fracture with 4mm retropulsion. The patient reports that he fell from standing yesterday hitting his back on a chair. The patient states that he was walking to the stairs to go up to bed when he slipped and fell. No chest pain, palpitations, dizziness or lightheadedness prior to the fall, and had not just stood up from seated position. He was able to pull himself up after the fall, but had severe back pain. He denied bowel or bladder incontinence, had no post ictal state, and had no LOC. On presentation to the ___, he denied numbness/tingling, weakness or incontinence. The patient takes no anticoagulants and no aspirin. He had a CT head non-contrast which was negative, a CT neck which was negative, and a CT L spine which showed an L1 burst fracture with retropulsion. At this point, the patient was transferred to ___ for a neurosurgical evaluation. In the ___ he had an MRI which showed an L1 vertebral body with 4 mm posterior fragment retropulsion. The retropulsed fragment mildly narrows the central canal. There is mild neural foraminal narrowing on the left at T12-L1. Spine evaluated the pt and recommended TLSO brace at all times, pain control and follow up in 1 month in the ___ clinic. At 5 a.m. in the ___, he began experiencing relatively acute onset of sharp mid abdominal pain and distention. This occurred shortly after eating a large pack ___ crackers and drinking multiple milk cartons. His last bowel movement was the day prior to admission, and it was completely normal. He had no vomiting, and was still passing gas. He was found to be focally exquisitely tender in his periumbilical area, and thus he had a CT abdomen and pelvis which showed cholelithiasis with gallbladder distension and apparent mild intrahepatic biliary ductal dilation raising potential concern for choledocholithiasis/cholangitis, with a RUQ redemonstrating these findings with some concern for Mirizzi syndrome. He was given a dose of Ciprofloxacin and Flagyl. Surgery was consulted given these findings, however in the setting of an exam which did not correlate with these findings as well as normal LFTs, this was thought to be an incidental findings which did not explain the patient's sudden onset abdominal pain. The patient's pain resolved with a large bowel movement in the ___. The patient's UA showed large leukocytes, negative nitrites, and the patient's abdominal pain was thought to be secondary to an underlying UTI. He was given a dose of Ceftriaxone in the ___. Past Medical History: Dementia HTN Hypothyroidism BPH Bladder cancer Social History: ___ Family History: Father: ___, ___ Physical Exam: ==================== Admission Physical ==================== VITALS: 97.7PO 174 / 54L Lying 81 18 97 Ra GENERAL: Alert and interactive. In no acute distress, lying comfortably in bed, in TLSO brace HEENT: Normocephalic, atraumatic. Pupils equal, round, and reactive bilaterally, extraocular muscles intact. Sclera anicteric and without injection. NECK: No cervical lymphadenopathy. No JVD. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally w/appropriate breath sounds appreciated in all fields. No wheezes, rhonchi or rales. No increased work of breathing. BACK: TLSO brace in place. Tenderness to palpation over midline lower back, no notable step off. No CVA tenderness. ABDOMEN: Normal bowels sounds, non distended. Very mildly tender to deep palpation of RLQ, but otherwise non-tender. No tenderness in right upper quadrant with a negative ___ sign. EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. NEUROLOGIC: CN2-12 intact. ___ strength throughout, including ___ strength in bilateral lower extremities in all proximal and distal muscle groups. Normal sensation. ===================== Discharge Physical ===================== VITALS: 98.0 PO 122 / 47 L Lying 77 20 95 Ra GENERAL: Alert and interactive. In no acute distress, lying comfortably in bed HEENT: Normocephalic, atraumatic. Surgical pupils b/l, OS 1mm, OD 3mm. Sclera anicteric and without injection. NECK: No cervical lymphadenopathy. No JVD. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Faint bibasilar crackles, otherwise CTA, No increased work of breathing. BACK: not wearing brace, mild TTP over the lower right flank, 2 crops of vesicles on L side L3 or L4 dermatome with erythematous base concerning for Zoster ABDOMEN: Normal bowels sounds, non distended, non-tender. EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DPs 2+ bilaterally. NEUROLOGIC: CN2-12 intact grossly, normal gait. Normal strength and sensation grossly Normal. AOx3, at b/l mental status per family. Pertinent Results: ADMISSION LABS ================ ___ 06:48PM BLOOD WBC-5.7 RBC-3.91* Hgb-11.6* Hct-33.5* MCV-86 MCH-29.7 MCHC-34.6 RDW-13.4 RDWSD-41.2 Plt ___ ___ 06:48PM BLOOD Neuts-62.7 ___ Monos-8.9 Eos-7.7* Baso-0.3 Im ___ AbsNeut-3.59 AbsLymp-1.15* AbsMono-0.51 AbsEos-0.44 AbsBaso-0.02 ___ 06:48PM BLOOD ___ PTT-27.6 ___ ___ 06:48PM BLOOD Glucose-98 UreaN-33* Creat-2.2* Na-139 K-4.3 Cl-100 HCO3-23 AnGap-16 ___ 12:55PM BLOOD ALT-24 AST-35 CK(CPK)-96 AlkPhos-90 TotBili-0.5 ___ 06:48PM BLOOD cTropnT-<0.01 ___ 12:55PM BLOOD Lipase-35 INTERVAL LABS ============== ___ 07:37AM BLOOD Calcium-8.4 Phos-3.4 Mg-1.6 Iron-11* ___ 07:37AM BLOOD calTIBC-220* Ferritn-104 TRF-169* ___ 07:35AM BLOOD VitB12-818 URINE LABS ============= ___ 07:51AM URINE Color-Yellow Appear-Clear Sp ___ ___ 07:51AM URINE Blood-NEG Nitrite-NEG Protein-30* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG ___ 07:51AM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-1 ___ 09:59PM URINE Color-Straw Appear-Clear Sp ___ ___ 09:59PM URINE Blood-NEG Nitrite-NEG Protein-TR* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG* ___ 09:59PM URINE RBC-<1 WBC-80* Bacteri-FEW* Yeast-NONE Epi-<1 TransE-<1 ___ 10:12AM URINE Hours-RANDOM Creat-179 Na-42 ___ 10:12AM URINE Osmolal-584 ___ 09:55PM URINE Hours-RANDOM UreaN-726 Creat-117 Na-100 ___ 09:55PM URINE Osmolal-644 DISCHARGE LABS =============== ___ 07:21AM BLOOD WBC-11.6* RBC-3.45* Hgb-10.2* Hct-30.4* MCV-88 MCH-29.6 MCHC-33.6 RDW-13.6 RDWSD-43.5 Plt ___ ___ 08:20AM BLOOD Glucose-95 UreaN-31* Creat-2.0* Na-139 K-4.3 Cl-97 HCO3-27 AnGap-15 ___ 08:20AM BLOOD Calcium-9.2 Phos-3.3 Mg-1.8 MICROBIOLOGY ============== ___ 9:59 pm URINE FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ___ 7:51 am URINE Source: ___. FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ___ BLOOD CULTURE: no growth ___ BLOOD CULTURE: no growth ___ BLOOD CULTURE: pending ___ BLOOD CULTURE: pending ___ 2:06 pm DIRECT ANTIGEN TEST FOR VARICELLA-ZOSTER VIRUS SKIN TEST. DIRECT ANTIGEN TEST FOR VARICELLA-ZOSTER VIRUS (Pending): IMAGING =========== Hip XRay ___ No evidence of acute fracture or dislocation is seen. The pubic symphysis and sacroiliac joints are intact. Mild degenerative changes are seen at the hip joints bilaterally. Vascular calcifications are seen. MRI Spine ___ 1. Moderate to severe, acute L1 vertebral body burst fracture with bony retropulsion which combines with background spondylosis to result in mild canal narrowing. No spinal cord compression is identified. 2. Subacute appearing, probable Schmorl's node involving the superior endplate of L5 with approximately 50% loss of height. 3. Background spondylosis of the lumbar spine at multiple levels, as detailed above. Findings are most notable at L4-L5 with moderate canal narrowing. 4. Foraminal narrowing as described above. 5. Diffusely heterogeneous bone marrow signal, a nonspecific finding which can be seen with osteopenia.. CT Abdomen Pelvis, with contrast ___ 1. Cholelithiasis with gallbladder distension and apparent mild intrahepatic biliary ductal dilation raises potential concern for choledocholithiasis/cholangitis. Please correlate clinically. 2. L1 burst fracture with 4 mm posterior fragment retropulsion, better assessed on MR lumbar spine performed ___. 3. Extensive atherosclerotic calcifications with a small aneurysm of infrarenal abdominal aorta measuring up to 3.0 x 2.4 cm. 4. Right inguinal hernia containing a portion of the urinary bladder, uncomplicated. 5. Calcified pleural plaques the lung bases likely reflect prior asbestos exposure. Liver/Gallbladder U/S ___ Cholelithiasis with gallbladder distension and dilation of the intrahepatic biliary tree with normal caliber CBD. Findings raise potential concern for Mirizzi syndrome. Brief Hospital Course: Mr. ___ is a ___ year old male with a history of HTN, dementia, hypothyroidism, and a distant history of bladder CA who presented as a transfer from OSH with an L1 burst fracture with 4mm retropulsion after a fall, with toxic metabolic encephalopathy likely ___ UTI, dehydration, and abdominal pain likely ___ constipation. Acute Issues ============= #UTI #Leukocytosis #Fever: Pt presented with increased urinary frequency, but this has been chronic over the past ___ years. His daughter states that she noticed him having to go more often as recently as ___. No recent change in urination, has no burning, frequency or urgency. Noted incidentally on CT A/P to have a small segment of bladder entrapped in right inguinal hernia that could be a stasis nidus for ongoing infection, though upon discussion with urology, they declined intervention, given that he is ___. DRE was negative for prostatitis. Post void residuals at 180cc, confirmed with urology that is appropriate and he is not retaining pathologically. Febrile to 100.8 initially with WBC spike to 21K, downtrended on Ceftriaxone (D1 = ___, then transitioned to cefpodoxime. Urine cultures did not reveal a source, ___ was contaminated, ___ negative already on antibiotics, but given his clinical improvement on ceftriaxone, he will complete a 7d course (end ___. #L1 burst facture s/p fall: #Presumed osteoporosis L1 spinal fracture with 4mm retropulsion. Pt seen by neurosurgery and recommended TLSO brace at all times while OOB for next month with follow up in the ___ clinic ___, will likely need X-rays beforehand. ___ and OT evaluation cleared him to be discharged home after ___ sessions each. He is not to drive while wearing TLSO brace (see below). Fracture i/s/o fall raises concern for osteoporosis, would consider empiric treatment with bisphosphonate outpatient. DC'd with home ___, family agreeable for ___ supervision. #Dementia: #Toxic metabolic encephalopathy ___ UTI According to his daughter, ___, his mental state has been slowly deteriorating as recently as last fall, but began to decline precipitously in ___ after he contracted pneumonia. Since then he has been frequently confused and disoriented. He lives alone and cares for himself, including driving himself. His daughter came in to see him several times and confirmed that he at his baseline mental status. His disorientation and confusion seemed to improve after starting antibiotics for UTI, so likely had some encephalopathy in addition to baseline dementia. He was AOx3 and able to complete ___ backwards for most of his hospital stay. His daughter expressed ongoing concern with his ability to care for himself at home, but stated that he is too stubborn to accept input from his family and continues to drive and live alone. ___ evaluated him and deemed him safe for discharge home with 24h care while he is wearing the brace given that he was forgetful of putting it on while still in bed. Mr. ___ was receptive to staying with his daughter. Mr. ___ daughter completed a health care proxy form, which is in his chart. He is DNR/DNI per MOLST, copy of which was placed in chart. #Family concern over patient driving Daughter noted concern for patient still being on the road. ___ eval deemed not safe to drive while wearing TLSO brace. Patient counseled regarding this. Social work coordinated Request for Medical Evaluation to DMV but family changed their mind and would like to readdress this issue in ___ when driver's license up for renewal. This was discussed w PCP. Recommend referring patient to Drive Wise program. ___ on CKD: According to patient charts, baseline Cr 2.2, with increase to from 2.8 ___, most likely I/s/o poor PO intake. Mr. ___ was given 1L of fluid, encouraged PO intake, and diuretics were held, and Cr slowly recovered back down to baseline. Discharge Cr 2.0. #Abd pain: #Constipation: #R inguinal hernia Pt developed short episode of severe abdominal pain with PO intake in ___. CT A and P concerning for gallstones with some obstruction of the CBD and resultant intrahepatic bile duct dilatation, concerning for Mirizzi syndrome. Surgery evaluated in ___ and thought symptoms not consistent with biliary pathology, particularly in the setting of normal LFTs. Got one dose of Cipro/Flagyl however did not continue. Pt endorsed improvement of pain with bowel movement, and states that felt constipated prior. Optimized bowel regimen. Subsequently, pain continued, but localized much more the RLQ, and clinically thought to be most likely due to his inguinal hernia. #Bradycardia: ___ worked with patient in the ___ and noted bradycardia to ___ at that time. Given this as well as patient's unclear cause for fall, some concern for intermittent heart block with exercise which would raise concern for nodal disease. No further bradycardia noted on Telemetry however noted to have occasional PVCs and bigeminy. #Fall: Most likely mechanical based on story. No clear evidence of orthostasis or vagal symptoms. Low concern for sz given no post ictal state. Only concern is bradycardia, so monitored on tele as above. ___ consult recommended discharge to home with home ___. #Vesicular Rash: Patient noted to have 2 small crops of vesicles on approximately L3 or L4 dermatome with erythematous base, concerning for Shingles. Started empiric 7 day course of Acyclovir ___, to end ___. DFA was done to confirm diagnosis, results pending at discharge. #Iron deficiency anemia: Noted to be mildly anemic with transferrin saturation 5%, indicative of iron deficiency. Recommend oral iron supplement, concentrated 65mg daily (equivalent of 325) in attempt to prevent constipation. CHRONIC/STABLE: =============== #HTN: Briefly held home diuretics for ___, restarted on discharge. #Hypothyroid: Continued home synthroid #BPH: Continued home tamsulosin Transitional Issues: ==================== [ ] Neurosurgery followup scheduled ___, should wear brace when OOB until then. Family agreeable to ___ supervision until that time, will get home ___ and ___ care as well. [ ] Recommend referring patient to Drive Wise program. [ ] Fracture i/s/o fall raises concern for osteoporosis, would consider empiric treatment with bisphosphonate outpatient. [ ] Cefpodoxime for UTI through ___ to finish 7d course [ ] DNR/DNI per MOLST, copy placed in chart [ ] Pt given short course oxycodone 2.5mg & Lido TD for back pain [ ] Pt started on Miralax and PRN Lactulose for constipation [ ] Started 7 day course of Acyclovir for Shingles ___, end date ___, DFA was done to confirm diagnosis, results pending at discharge. [ ] Family states they will obtain a shower chair for patient to use until cleared by NSGY. [ ] Please recheck iron studies in ___ weeks on iron supplementation #CODE: DNR/DNI per MOLST #CONTACT: HCP: Son (___) ___ Daughter ___ ___ H: ___ C: ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Meclizine 25 mg PO Q8H:PRN Nausea 2. Levothyroxine Sodium 100 mcg PO DAILY 3. Omeprazole 20 mg PO DAILY 4. Tamsulosin 0.4 mg PO QHS 5. Betaxolol Ophth Susp 0.25% 1 DROP BOTH EYES BID 6. Hydrochlorothiazide 25 mg PO DAILY 7. Triamterene 50 mg PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO TID Do not take more than 4 pills per day. 2. Acyclovir 800 mg PO Q8H end after ___ RX acyclovir 800 mg 1 tablet(s) by mouth three times a day Disp #20 Tablet Refills:0 3. Cefpodoxime Proxetil 200 mg PO Q24H Duration: 3 Doses RX cefpodoxime 200 mg 1 tablet(s) by mouth once a day Disp #1 Tablet Refills:0 4. Ferrous Sulfate 65 mg PO DAILY 5. Lactulose 30 mL PO DAILY:PRN constipation RX lactulose 10 gram/15 mL (15 mL) 15 mL by mouth daily:PRN Disp #1 Package Refills:0 6. Lidocaine 5% Patch 1 PTCH TD QAM RX lidocaine 5 % apply to back pain QAM Disp #30 Patch Refills:0 7. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN pain RX oxycodone 5 mg 0.5 (One half) tablet(s) by mouth q8h:prn Disp #8 Tablet Refills:0 8. Polyethylene Glycol 17 g PO DAILY Constipation RX polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by mouth once a day Disp #24 Packet Refills:0 9. Betaxolol Ophth Susp 0.25% 1 DROP BOTH EYES BID 10. Hydrochlorothiazide 25 mg PO DAILY 11. Levothyroxine Sodium 100 mcg PO DAILY 12. Omeprazole 20 mg PO DAILY 13. Tamsulosin 0.4 mg PO QHS 14. Triamterene 50 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnoses: L1 burst fracture R flank pain ___ fall History of fall Toxic metabolic encephalopathy ___ Urinary Tract Infection Constipation R inguinal hernia Episode of Bradycardia, PVCs, Bigeminy ___ on CKD ___ dehydration Herpes Zoster Infection (local) Iron deficiency anemia Secondary Diagnoses: CKD HTN Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were initially transferred to the ___ from another hospital because a picture of your back showed that the pain in your back you were feeling was from a fracture in one of the bones in your lower spine (L1 burst fracture). While you were here, we imaged your back and found that you had broken a bone in your lower back (L1 burst fracture) when you fell, and that was causing your pain. The spine doctors ___ and ___ you a brace to wear, all the time when you are not sleeping, for 1 month. You will see Dr. ___ to see how your back is doing. While you were in the hospital you also had some pain in your stomach and a small fever, which was likely because of an infection in your urinary tract. We gave you some antibiotics to take, which you should continue to take after you leave (until ___ in order to treat the infection. You had some spots on your back that look like Shingles, so you need to take medicine for it for the next 7 days. When you leave the hospital, please call Dr. ___ at the number listed below to see if you need X-rays of your back before your appointment. Please wear your back brace every day until then, all day when you aren't in bed. Please continue to take all your medication, including your antibiotics. It is very important that you do not DRIVE AT ALL until you ___ Wise program and are cleared from your neurosurgeon to take the brace off. Driving with the brace puts other people on the road in danger and puts you in danger. It was a pleasure caring for you and we wish you the best. Your ___ Team Followup Instructions: ___
10026255-DS-7	10,026,255	20,437,651	DS	7	2200-09-29 00:00:00	2200-10-05 23:03:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Fall, shortness of breath Major Surgical or Invasive Procedure: ___ Right pigtail History of Present Illness: ___ man w/PMH of COPD (last FEV1/FVC in ___: 53%), HCV, HBV and posttraumatic seizure disorder since ___, admitted by ___ ortho on ___ s/p ?mechanical fall 4d PTA with R-sided rib fx c/b PTX s/p pigtail placement and reexpansion of lung, transferred to medicine on ___ for further management of dyspnea in the setting of presumed CAP on 10d course of levaquin. He first noticed increasing shortness of breath and productive cough over last ___ days, with nightly episodes of dizziness, which he relates to his antiepileptic medications. Consequently, he has been titrating his AEDs on his own at home based on side effects. Four days PTA, he said he felt dizzy after taking his medications, and tripped and fell into his sink. He hit his right chest into the sink with significant force and had instant pain. Pain has worsened over 4 days with worsening SOB and ongoing productive cough. No other painful areas, no LOC, no headstrike, no other complaints. Patient encouraged to be evaluated by his family. Went to PCP found to be hypoxic and sent to ED. Upon arrival patient satting 81-85% on room air, found to have moderate sized PTX on CXR with associated right sided rib fractures ___. Patient in mild-modest respiratory distress requiring non-rebreather, patient leaning forward and uncomfortable with productive cough and audible wheezes. Other vitals and labs essentially normal. Prior to transfer, he was on a shovel mask at 6L on ___ cannula on ___ -> on 2L of oxygen since ___ with desats to ___ with ambulation. He was treated with Levofloxacin for presumed PNA started on ___, as well as duonebs q6 and tramadol for pain. He did not receive lasix because the Ortho/trauma team did not feel this was related to CHF exacerbation in any way, nor did the patient look volume overloaded to them. Pigtail placement on ___, removed on ___, and cleared from trauma standpoint on transfer. Recent sick contact, wife with URI. Currently, continues to have significant dyspnea with O2 requirement of 1.5-2L NC. Anxious to return home on ___, patient refuses to go to rehab. Denies any F/C/N/V. Past Medical History: HTN HPL Seizure disorder: partial motor with secondary generalization, s/p MVA in ___, originally diagnosed in ___. No seizures since before ___ (patient changes doses of meds based on side effect of dizziness) HCV (last VL: ___ 2.6x10^6) HBV h/o IVDU (past heroin use, about ___ years ago) s/p meningitis in ___ (?strep malei), also found to have demand ischemia with troponin leak (started on lopressor) h/o ataxia, likely secondary to being on AED. MRI in ___ for acute pathology s/p cervical spine surgery in ___ for "bone spurs" that caused nerve damage to RUE/RLE Social History: ___ Family History: N/C Physical Exam: Physical Exam upon admission: 99.4, 90, 153/73, 20, 86 RA, 963L plus non-rebreather normocephalic, atraumatic increased work of breathing, diaphoretic airways tight bilaterally with audible wheezes, decreased breath sounds on right tenderness overlying right anterolateral chest wall to palpation, no obvious deformity or overlying ecchymoses regular rate and rhythm no murmurs abdomen soft nontender nondistended no obvious extremity trauma, dry scaly rash on bilateral lower extremities Discharge Exam: VS: 97.2 128/78 61 20 94% RA GENERAL: Mildly dyspneic, sitting upright, tripoding HEENT: NCAT, sclerae anicteric, dry MM NECK: no JVD HEART: RRR, nl S1-S2 LUNGS: Diffuse expiratory wheezes throughout, bibasilar crackles (L>R). Pigtail site well-healed. ABDOMEN: soft, NT/ND EXTREMITIES: Pitting edema 2+ up to knees (R>L) SKIN: scattered petechiae on R LLE NEURO: ___, CNII-XII grossly intact, unsteady gait. Pertinent Results: ___ 07:40PM BLOOD WBC-7.7 RBC-4.70 Hgb-15.5 Hct-46.4 MCV-99* MCH-32.9* MCHC-33.4 RDW-13.0 Plt ___ ___ 07:40PM BLOOD Neuts-71.5* Lymphs-17.9* Monos-8.3 Eos-1.6 Baso-0.8 ___ 08:09PM BLOOD ___ PTT-26.9 ___ ___ 07:40PM BLOOD Glucose-113* UreaN-24* Creat-0.7 Na-144 K-4.2 Cl-101 HCO3-32 AnGap-15 ___ 06:55PM BLOOD CK(CPK)-159 ___ 10:35AM BLOOD CK(CPK)-183 ___ 03:58AM BLOOD CK(CPK)-214 ___ 07:40PM BLOOD ALT-87* AST-69* AlkPhos-98 TotBili-0.7 ___ 10:35AM BLOOD CK-MB-5 ___ 07:40PM BLOOD Albumin-4.5 ___ 04:13AM BLOOD ___ pO2-139* pCO2-56* pH-7.34* calTCO2-32* Base XS-3 Comment-GREEN TOP ___ CXR: Cardiomediastinal and hilar contours unchanged from ___. No focal consolidation, pleural effusion or pneumothorax. Bilateral basilar atelectasis unchanged from ___. Right lower rib fractures again noted. IMPRESSION: No focal consolidation. Unchanged bilateral basal atelectasis. CTA CHEST IMPRESSION: 1. No evidence of PE or aortic injury. 2. Emphysema and resolution of previously described pneumothorax, with worsening left lower lobe consolidation. 3. Stable right-sided minimally displaced rib fractures as described above. Liver Ultrasound IMPRESSION: Mildly coarsened echotexture of the liver is nonspecific, but could be seen in the setting of early fibrosis. No focal liver lesions identified. Brief Hospital Course: ___ man w/PMH of COPD (last FEV1/FVC in ___: 53%), HCV, HBV and posttraumatic seizure disorder since ___ admitted to the orthopedic service on ___ s/p fall with R-sided rib fractures and PTX. He had a chest tube placed and was monitored for lung reexpansion. #S/p fall - Pt presented to the ED 4 days out from fall with R sided rib fractures ___, moderate sized R pneumothorax. Pig tail was placed in the ED and pt admitted to the surgical service. His pneumothorax improved and pig tail was pulled on HD4 with out any issues. The cause for his fall is unknown, it may have been a mechanical vs. seizure-related fall as he said he was attempting to self-wean himself off his antiepileptic medications. # Hypoxia - Increased O2 requirement from 2L->3L NC. Speaking in short phrases with significant SOB. Pt was found still found to be hypoxic upon arrival to the medicine service, which was thought to be due to PE vs. COPD vs pneumonia. After he was transferred to our service, we obtained a CTA to rule out PE. The CT did not show a PE and confirmed the fact that his COPD was very severe, and it was thought that his baseline O2 sat were likely 88-92% at home. He had been placed on antibiotics for possible pneumonia prior to transfer to medicine; he was treated with Levofloxacin for presumed PNA started on ___, as well as duonebs q6 and tramadol for pain. On ___, per CXR, it appeared his PNA had cleared. Though he may have had a PNA, his hypoxia is most likely attributable to acute COPD exacerbation in the setting of recent URI and recent fall c/b PTX w/pigtail d/c ___. Improved from admission, but still persistently hypoxic with supplemental O2 requirement. We gave him albuterol and ipratroprium nebulizer treatments, prednisone 60 mg daily for a 5 day course, supplemental O2, and encouraged use of incentive spirometry to help improve his respiratory status. He clinically appeared improved, but was O2 dependent and required home O2. Patient is s/p fall c/b R-PTX now s/p pigtail placement with gradual improvement of respiratory status. Likely multifactorial in the setting of URI ?CAP completed a 5d course of levaquin, COPD with 56py smoking history, and recent fall c/b R-PTX. Prior to transfer, he was on a shovel mask at 6L on ___ cannula on ___ -> on 2L of oxygen since ___ with desats to ___ with ambulation. He did not receive lasix because the Ortho/trauma team did not feel this was related to CHF exacerbation in any way, nor did the patient look volume overloaded to them. Patient refused to go to rehab. His oxygen requirement improved during the hospitalization. We had him evaluated for home O2, and he was discharged on 2L O2. #PNA - He had been placed on antibiotics for possible pneumonia prior to transfer to medicine; he was treated with Levofloxacin for presumed PNA that was started on ___, as well as duonebs q6 and tramadol for pain. On ___, per CXR, it appeared his PNA had cleared. CT on ___ reporting increased LLL consolidation and positive sputum culture ___ worrisome for HCAP. On ___, he began to produce yellow sputum but clinically did not appear to be worse. CT chest ___ revealed increased LLL consolidation compared to CT chest ___, with interval CXR on ___ revealing the absence of any focal consolidation, suggesting his initial CAP may have cleared. There was some bibasilar consolidation on CT ___ that appeared to have resolved after starting levaquin, as CXR on ___ reported absence of any focal consolidation. This newly increased LLL consolidation is worrisome for HCAP, particularly given sputum cx ___ revealing GPC in clusters. However, he clinically does not appear sick, afebrile, no elevated WBC, and has even had decreased O2 requirement today (down to 1.5L). Given concern for HCAP, he was given one dose on ___ of vancomycin 1000mg IV Q12H (day 1: ___, Cefepime 2g IV Q12H (day 1: ___. Given that he clinically appeared to be doing better and expressed the desire to return home, we discontinued his antibiotics, and requested that he return to the hospital should his symptoms worsen. We recommended that he follow-up with his PCP for ___ repeat CXR in ___ weeks to ensure that the pneumonia had clear and that this was not a postobstructive pneumonia. # PTX ___ rib fx: Resolved prior to transfer to medicine, s/p removal of pigtail. For persistent pain around the fracture site, we continued him on dilaudid PO Q3H, tramadol, tylenol PRN pain. # Afib with RVR: He triggered for afib with RVR while on the orthopedic service. He was in sinus on arrival to the medicine service, and his afib had resolved. # Seizure history: Posttraumatic seizure disorder s/p MVA in ___, originally diagnosed in ___. Controlled with lamictal at home. No seizures since before ___. We recommended that he see a neurologist as an outpatient or return to the Epilepsy clinic at ___ for further management of this AEDs. # HCV: h/o IVDU. VL in ___ 2.6 x10^6. Not on treatment. # HTN: He was normotensive while hospitalized and we held his antihypertensives. # HLD: We continued his statin while inpatient. Transitional Issues: 1. Outpatient PFTs 2. Neurology - management of anti-epileptics Medications on Admission: The Preadmission Medication list is accurate and complete. 1. LaMOTrigine 50 mg PO BID 2. Carbamazepine 500 mg PO DAILY 3. Metoprolol Succinate XL 25 mg PO DAILY 4. Amlodipine 10 mg PO DAILY 5. Atorvastatin 10 mg PO DAILY 6. Aspirin 81 mg PO DAILY 7. Albuterol Inhaler 2 PUFF IH BID Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H 2. Carbamazepine 300 mg PO QAM 3. Carbamazepine 500 mg PO QPM 4. Levofloxacin 750 mg PO DAILY 5. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain 6. Atorvastatin 10 mg PO DAILY 7. Aspirin 81 mg PO DAILY 8. Ibuprofen 600 mg PO Q8H 9. LaMOTrigine 150 mg PO QAM 10. LaMOTrigine 300 mg PO QPM 11. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Pneumonia, COPD flare Secondary Diagnosis: fall with right rib fractures ___ and right-sided pneumothorax Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. ___, It was a pleasure participating in your care at ___ ___. You were admitted after you had a fall with the following injuries: right sided ___ rib fractures and a right pneumothorax. You had a chest tube placed with resolution of your pneumothorax. You also developed a pneumonia and received a course of antibiotics, along with nebulizers and inhalers to treat your COPD exacerbation. On the day of discharge, your oxygen saturations were improved, but physical therapy recommended that you go home with supplemental oxygen. We also would like you to follow-up with a pulmonologist after discharge to further manage your shortness of breath and COPD. Please discuss about this with your primary care physician. Please see attached for appointments. Sincerely, Your ___ Care Team Followup Instructions: ___
10026263-DS-10	10,026,263	26,565,360	DS	10	2139-11-29 00:00:00	2139-12-01 14:14:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: seasonal Attending: ___ Chief Complaint: Lightheadedness Major Surgical or Invasive Procedure: Cardiac catheterization History of Present Illness: ___ with h/o CAD s/p stents x2 in ___, on ASA + Plavix, who presents with one week of lightheadedness, fatigue, right shoulder pain, and shortness of breath (SOB). He reports that the fatigue/SOB occurs after 1 flight of stairs, which is abnormal for him. He also had symptoms with lifting boxes at work. In regards to the shoulder discomfort, he describes it as a "hollow feeling" in his right shoulder without frank pain, with some extension into the right arm. His symptoms improve with SL nitro. There is no particular pattern with exertion, but sometimes it wakes him up at night. He also reports some intermittent epigastric pain which he reports is how his prior MI presented, but currently not associated with activity. He denies any peripheral edema. He has had sclerotherapy recently for ganglion cyst in his leg and held Plavix about 1 month ago for that. In the ED, initial vitals were T 97.6 HR 78 BP 125/70 RR 16 SaO2 99% on RA. Labs and imaging significant for normal CBC, Chem 10, and troponin. EKG: NSR at 67 bpm with Q waves in III and aVF, similar to baseline. Vitals on transfer were T 98.2 BP 160/87 HR 87 RR 18 SaO2 98% on RA. On arrival to the floor, patient reports some epigastric discomfort and right arm discomfort similar to before. REVIEW OF SYSTEMS: On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. Cardiac review of systems is as above. Past Medical History: 1. CAD RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: 2 drug eluting stents: proximal and mid LAD (___) -PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: -cluster headache (no terrible headaches for years) -Left leg tibial/fibula ganglion cyst -BPH Social History: ___ Family History: No family history of cancer, arrhythmia, cardiomyopathies, or sudden cardiac death. His uncle and cousin died of MIs in their ___. Physical Exam: Admission: GENERAL: WDWN in NAD.Oriented x3. Mood, affect appropriate. VS: T 98.2 BP 160/87 HR 87 RR 18 SaO2 98% on RA HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple without elevation of JVP cm. CARDIAC: RRR, no murmurs, rubs or gallops. LUNGS: CTAB ABDOMEN: Soft, non-tender, not distended. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No clubbing, cyanosis or edema. 2+ ___ pulses NEURO: CN II-XII grossly intact, moving all extremeties, sensation grossly normal. Gait not tested. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Discharge Vitals: T 97.6 BP 140/90 HR 75 RR 18 SaO2 100% on RA NECK: Supple without elevation of JVP cm. CARDIAC: RRR; no murmurs, rubs or gallops. LUNGS: CTAB EXTREMITIES: No clubbing, cyanosis or edema. 2+ ___ pulses Pertinent Results: ___ 12:00PM WBC-4.7 RBC-4.58* HGB-14.6 HCT-44.2 MCV-97 MCH-31.8 MCHC-32.9 RDW-13.8 ___ 12:00PM NEUTS-62.6 ___ MONOS-6.2 EOS-4.3* BASOS-0.5 ___ 12:00PM PLT COUNT-184 ___ 12:00PM ___ PTT-28.6 ___ ___ 05:57AM WBC-4.9 RBC-4.55* Hgb-14.2 Hct-43.5 MCV-96 MCH-31.3 MCHC-32.7 RDW-13.6 Plt ___ ___ 12:00PM GLUCOSE-93 UREA N-21* CREAT-0.9 SODIUM-140 ___ 05:57AM Glucose-95 UreaN-17 Creat-0.9 Na-140 K-4.6 Cl-103 ___ 05:57AM Calcium-9.3 Phos-3.2 Mg-2.2 HCO3-28 AnGap-14 ___ 12:00PM cTropnT-<0.01 ___ 06:50PM CK(CPK)-80 CK-MB-3 cTropnT-<0.01 ___ 05:57AM CK(CPK)-81 CK-MB-2 cTropnT-<0.01 ECG ___ 11:05:56 AM Sinus rhythm. Prior inferior myocardial infarction. Compared to the previous tracing of ___ no diagnostic interim change. CHEST (PA & LAT) ___ 2:10 ___ The cardiomediastinal, pleural and pulmonary structures are unremarkable. There is no pleural effusion or pneumothorax. No focal airspace consolidation is seen to suggest pneumonia. Heart size is normal. There are mild degenerative changes of thoracic spine, with anterior osteophytosis. Cardiac catheterization ___ 1. Selective coronary angiography of this left dominant system demonstrated no angiographically apparent, flow-limiting coronary artery disease. The LMCA was normal in appearence. The LAD stents were widely patent with no significant flowing limiting lesions. The dominant LCx had no significant lesions. The RCA was small, non-dominant with no significant luminal narrowing. 2. Limited resting hemodynamics revealed normal left ventricular filling pressures, with an LVEDP of 5mmHg. The was no transvalvular gradient to suggest aortic stenosis. The was normal systemic blood pressure, with a central aortic pressure of 113/72 mmHg. Brief Hospital Course: ___ yo man with history of CAD s/p drug-eluting stenting of proximal and mid LAD in ___, now presenting with right arm discomfort, epigastric pain, fatigue, and shortness of breath with exertion. # Arm discomfort, fatigue, dyspnea: Symptoms were concerning for unstable angina given new onset over past week, though symptoms were predominantly on exertion and resolve with rest. Of note, he does have some epigastric discomfort which is a similar presentation to his prior MI. However, troponins were negative and EKG unchanged. Coronary angiography revealed no flow-limiting lesions and in particular no in-stent restenosis or thrombosis. Unclear what was causing his shortness of breath with right arm discomfort, but small vessel ischemia or diastolic dysfunction could not be excluded; he was already on dual anti-platelet therapy, ACE-I, and a calcium channel blocker. We continued his Plavix (although not clear he needs this ___ years S/P DES). Atorvastatin was begun to avoid drug-drug interactions with simvastatin. He would also benefit from a beta-blocker for post-infarct secondary prevention given prior NSTEMI in ___, but we deferred substitution of his veramapil for a beta-blocker to his outpatient cardiologist. # Hypertension: continued on ACE-I and verapamil # BPH: Continued on alfuzosin # CODE: full # EMERGENCY CONTACT: wife ___ number: ___ Cell phone: ___ Transitions of care: -follow up with outpatient cardiology. Medications on Admission: alfuzosin 10 mg po daily Plavix 75 mg daily cyclobenzaprine 10 mg TID PRN lisinopril 5 mg daily ranitidine 300 mg po daily simvastatin 80 mg po daily verapamil 240 mg ER daily aspirin 325 mg daily MVI Omega 3/vitamin E Discharge Medications: 1. alfuzosin 10 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO daily (). 2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO three times a day as needed for muscle spasm. 4. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. ranitidine HCl 300 mg Tablet Sig: One (1) Tablet PO once a day. 6. verapamil 240 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO once a day. 7. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Omega 3 Oral 10. vitamin E Oral 11. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Chest pain without biomarker evidence of myonecrosis Coronary artery disease with prior myocardial infarction Hypertension Benign prostatic hypertrophy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure participating in your care at ___. You were admitted to the hospital for chest pain. Cardiac catheterization was re-assuring that there was no blockage in your coronary arteries. REGARDING YOUR MEDICATIONS... Medications STARTED that you should continue: atorvastatin Medications STOPPED this admission: simvastatin Medication DOSES CHANGED that you should follow: NONE Otherwise, it is very important that you take all of your usual home medications as directed in your discharge paperwork. Please followup with your primary care physician ___ ___ days regarding the course of this hospitalization. Followup Instructions: ___
10026263-DS-11	10,026,263	24,619,264	DS	11	2140-09-29 00:00:00	2140-09-30 10:31:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: seasonal Attending: ___. Chief Complaint: left inguinal hernia Major Surgical or Invasive Procedure: ___ Left Incarcerated recurrent Inguinal Hernia Repair History of Present Illness: ___ with history of L inguinal hernia repair presented with sudden onset of painful left groin buldge. Patient awoke with bulge in left groin and constant pain. Denies vomiting, some nausea, fevers/chills. Last BM was 2 days prior. Last flatus was yesterday. Denies sense of abdominal bloating. Past Medical History: 1. CAD RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: 2 drug eluting stents: proximal and mid LAD (___) -PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: -cluster headache (no terrible headaches for years) -Left leg tibial/fibula ganglion cyst -BPH PSH 1. History of Left sided inguinal herniorraphy with mesh (___ ___ 2. Coronary stent placement 3. Left leg cyst excision Social History: ___ Family History: No family history of cancer, arrhythmia, cardiomyopathies, or sudden cardiac death. His uncle and cousin died of MIs in their ___. Physical Exam: Vitals: 98 82 136/64 17 98%ra Gen: no acute distress, alert and oriented, well appearing Abd: hernia repair site in left inguinal region with dressing c/d/i, mild tenderness to palpation; abdomen nondistended, nontender, no rebound or guarding Cardio: regular rate and rhythm Pulm: nonlabored breathing, clear to ascultation Ext: nonedematous, noncyanotic Pertinent Results: ___ 10:15AM BLOOD WBC-6.6 RBC-4.30* Hgb-13.8* Hct-42.4 MCV-99* MCH-32.2* MCHC-32.6 RDW-13.9 Plt ___ ___ 10:15AM BLOOD Neuts-72.8* Lymphs-17.5* Monos-6.0 Eos-3.2 Baso-0.5 ___ 10:15AM BLOOD ___ PTT-29.4 ___ ___ 10:15AM BLOOD Glucose-98 UreaN-22* Creat-0.7 Na-136 K-4.4 Cl-103 HCO3-25 AnGap-12 CT ABD & PELVIS WITH CONTRAST Study Date of ___ Abdomen: The lung bases demonstrate minimal dependent atelectasis. No pleural or pericardial effusion is seen. A subcentimeter hypodensity in segment 4A of the liver likely represents a cyst. Calcification is again seen in the spleen. An accessory spleen is noted. The gallbladder, pancreas, adrenal glands, stomach, and small bowel are within normal limits. Bilateral renal hypodensities most likely represent cysts; the largest arises from the lower pole of the right kidney and measures 4.4 x 3.8 cm. Neither kidney demonstrates hydronephrosis. Colonic diverticula do not demonstrate evidence for acute inflammation. There is no free intraperitoneal air or ascites. Major intra-abdominal vasculature appears patent and normal in caliber with dense calcified and non-calcified aortic atherosclerotic plaque. Pelvis: The prostate, seminal vesicles, and rectum demonstrate no acute abnormalities. The bladder is distended with layering contrast. No free fluid is seen in the pelvis. Fat containing right inguinal hernia is seen. No left inguinal hernia is seen. No concerning lytic or sclerotic osseous lesions are detected. IMPRESSION: No CT evidence for acute intra-abdominal or pelvic process or incarcerated hernia. Brief Hospital Course: The patient was admitted on ___ under the acute care surgery service for management of an incarcerated left inguinal hernia. Initial CT scan report said there was no hernia, but the clinical suspicion was high for an incarcerated inguinal hernia so he was taken to the operating room for open left inguinal hernia repair. Please see operative report for details of this procedure. He tolerated the procedure well and was extubated upon completion. He was subsequently taken to the PACU for recovery. He was transferred to the surgical floor hemodynamically stable. His vital signs were routinely monitored and he remained afebrile and hemodynamically stable. He was initially given IV fluids postoperatively, which were discontinued when he was tolerating PO's. His diet was subsequently advanced and he tolerated it well. On ___ the patient's pain was under control; he was tolerating a regular diet and functioning independently so he was discharged home. At the time of discharge the patient understood the recommendation for follow up and instructions for no heavy lifting for minimum of 6 weeks after the surgery. Medications on Admission: 1. Verapamil 2. Plavix 75 daily 3. Lisinopril 4. Simvastatin 40 Discharge Medications: 1. Acetaminophen 650 mg PO Q8H RX acetaminophen 650 mg 1 tablet(s) by mouth q8hrs Disp #60 Tablet Refills:2 2. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain do not drive or use alcohol while taking this medicaiton RX oxycodone 5 mg 1 tablet(s) by mouth q4hrs prn Disp #40 Tablet Refills:0 3. Verapamil SR 240 mg PO Q24H 4. Clopidogrel 75 mg PO DAILY 5. Lisinopril 5 mg PO DAILY 6. Simvastatin 40 mg PO DAILY 7. Docusate Sodium 100 mg PO BID RX docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #60 Capsule Refills:2 Discharge Disposition: Home Discharge Diagnosis: left inguinal hernia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were seen and evaluated by the Acute Care Surgery Service at ___ for your left inguinal hernia. We took you to the operating room and repaired the hernia. You are now in better condition and are safe to return home and continue your recovery there. You will need to avoid heavy lifting for at least 6 weeks. You will have some pain and swelling at the surgical site, but these will improve with time. Please take the pain medication as prescribed; also take the stool softener while taking narcotic pain medications to prevent constipation. You will need to follow up with us in clinic in 2 weeks so we can monitor your recovery. You can take off your dressing on ___, ___. Until then, do not get the area wet (take a sponge bath if necessary). After taking the bandage off you can shower, allowing warm water to run over the wound but do not scrub the wound; pat dry with a clean towel; leave the steristrips (white bandages) in place; these will fall off on their own (or you can remove them ___ days after your surgery). Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: You experience new chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience a discharge. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. Avoid swimming and baths until your follow-up appointment. You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. If you have staples, they will be removed at your follow-up appointment. If you have steri-strips, they will fall off on their own. Please remove any remaining strips ___ days after surgery. Followup Instructions: ___
10026404-DS-16	10,026,404	21,375,571	DS	16	2125-10-04 00:00:00	2125-10-05 10:50:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: High blood pressure Major Surgical or Invasive Procedure: None History of Present Illness: ___ ___-speaking man w/ PMH of HTN who presents the emergency room for evaluation of high blood pressure. Patient was in usual state of health and was asymptomatic but decided to go to his PCP's office for routine care because he hadn't seen a doctor for years, and was found to have BP: 260/150 left arm, 248/140 right arm. He was asymptomatic. He was previously on 4 antihypertensives but stopped these medications in ___ because he says he felt fine without them, which is the last time he saw a doctor. He reports a mild headache that started earlier, was not sudden in onset, and has gotten better since this morning. He has not had consistent headaches prior to this one. Denies vision changes, blurry vision, chest pain or shortness of breath, nausea, vomiting, difficulties urinating, lightheadedness, both recently and in the past. His PCP then sent him to the ED. In the ED, initial vital signs were: 99.1; 74; 216/130; 20; 99% RA. - Labs were notable for: Cr 1.1, WBC 11.1, ALT/AST 46/53, AP 99, TB 0.6, BNP 731 Trop negative x2 - Imaging: CXR showed "enlarged cardiomediastinal silhouette. Mild pulmonary vascular congestion. Subtle right base opacity most likely relates to vascular congestion although underlying infection is difficult to exclude." CT head showed "No acute intracranial process. Possible subtle ectasia of the distal left vertebral artery and proximal basilar artery." - The patient was given: ___ 19:05 IV Labetalol 5 mg ___ 21:09 IV Labetalol 5 mg ___ 21:59 PO/NG Labetalol 100 mg ___ 01:07 PO Aspirin 324 mg Vitals prior to transfer were: 98.2 63 174/113 21 97%RA Upon arrival to the floor, patient reports ongoing headache which is frontal and not associated with change in vision or other neurologic complaints. Continues to deny other symptoms as mentioned above. Past Medical History: Hypertension Social History: ___ Family History: Negative for known cancers, CAD, DM. Mom with HTN, alive. Father died in his ___ of unknown causes. Physical Exam: ADMISSION ========= VITALS - afebrile ___ 100RA GENERAL - pleasant, well-appearing, in no apparent distress HEENT - normocephalic, atraumatic, no conjunctival pallor or scleral icterus, PERRLA, EOMI, OP clear NECK - supple, no LAD, no thyromegaly, JVP not elevated CARDIAC - regular rate & rhythm, 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 EXTREMITIES - warm, well-perfused, no cyanosis, clubbing or edema SKIN - without rash NEUROLOGIC - A&Ox3, CN II-XII grossly normal, normal sensation, with strength ___ throughout. No pronator drift, cerebellar function intact. Gait assessment deferred PSYCHIATRIC - listen & responds to questions appropriately, pleasant DISCHARGE ========= GENERAL - pleasant, well-appearing, in no apparent distress HEENT - normocephalic, atraumatic, no conjunctival pallor or scleral icterus, PERRLA, EOMI, OP clear NECK - supple, no LAD, no thyromegaly, JVP not elevated CARDIAC - regular rate & rhythm, 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 EXTREMITIES - warm, well-perfused, no cyanosis, clubbing or edema SKIN - without rash NEUROLOGIC - A&Ox3, CN II-XII grossly normal, strength and sensation grossly intact. PSYCHIATRIC - listen & responds to questions appropriately, pleasant Pertinent Results: ADMISSION ========= ___ 06:55PM BLOOD WBC-11.1* RBC-5.16 Hgb-14.4 Hct-44.4 MCV-86 MCH-27.9 MCHC-32.4 RDW-14.2 RDWSD-43.8 Plt ___ ___ 06:55PM BLOOD Neuts-67.8 ___ Monos-9.0 Eos-1.0 Baso-0.5 Im ___ AbsNeut-7.53* AbsLymp-2.38 AbsMono-1.00* AbsEos-0.11 AbsBaso-0.06 ___ 06:55PM BLOOD ___ PTT-32.5 ___ ___ 06:55PM BLOOD Glucose-165* UreaN-23* Creat-1.1 Na-139 K-3.4 Cl-101 HCO3-27 AnGap-14 ___ 06:55PM BLOOD ALT-46* AST-53* AlkPhos-99 TotBili-0.6 ___ 06:55PM BLOOD proBNP-731* ___ 06:55PM BLOOD cTropnT-<0.01 ___ 12:21AM BLOOD cTropnT-<0.01 ___ 06:55PM BLOOD Albumin-4.0 Calcium-9.2 Phos-3.4 Mg-1.8 PERTINENT ========= ___ 07:05AM BLOOD ALT-29 AST-24 LD(LDH)-247 AlkPhos-99 TotBili-0.9 ___ 06:55PM BLOOD Lipase-24 ___ 07:05AM BLOOD Albumin-4.1 Calcium-9.5 Phos-3.9 Mg-2.1 Cholest-224* ___ 07:05AM BLOOD %HbA1c-5.9 eAG-123 ___ 07:05AM BLOOD Triglyc-154* HDL-49 CHOL/HD-4.6 LDLcalc-144* ___ 07:05AM BLOOD TSH-1.2 DISCHARGE ========= ___ 06:40AM BLOOD WBC-9.1 RBC-5.82 Hgb-16.1 Hct-49.9 MCV-86 MCH-27.7 MCHC-32.3 RDW-14.6 RDWSD-44.8 Plt ___ ___ 06:40AM BLOOD Glucose-116* UreaN-29* Creat-1.2 Na-137 K-4.0 Cl-98 HCO3-25 AnGap-18 ___ 06:40AM BLOOD Calcium-9.8 Phos-4.4 Mg-1.9 IMAGING ======= ___ CXR PA/L: Enlarged cardiomediastinal silhouette. Mild pulmonary vascular congestion. Subtle right base opacity most likely relates to vascular congestion although underlying infection is difficult to exclude. ___ NCHCT: No acute intracranial process. Possible subtle ectasia of the distal left vertebral artery and proximal basilar artery. EKG: NSR @ 69 bpm, normal axis, incomplete RBBB, LVH w/ secondary repolarization abnormalities, LAE ___ Renal artery Doppler: No evidence of renal artery stenosis in the left kidney and likely no stenosis in the right kidney however the Doppler examination is somewhat limited due to the patient's limited ability to hold his breath. ___ TTE: The left atrial volume index is moderately increased. The estimated right atrial pressure is ___ mmHg. There is severe symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed (Quantitative (biplane) LVEF = 46%) secondary to mild global hypokinesis with slightly worse function of the basal-mid inferior and inferoseptal walls. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The right ventricular free wall is hypertrophied. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. There is a very small pericardial effusion. There are no echocardiographic signs of tamponade. IMPRESSION: Severe concentric left ventricular hypertrophy with mildly depressed global and regional systolic dysfunction and increased filling pressure. Mild mitral regurgitation. Mild pulmonary artery systolic hypertension. Mild dilatation of the ascending aorta and arch. Very small pericardial effusion. Findings are suggestive of hypertensive myopathy (with possible underlying CAD), although an infiltrative process cannot be excluded. Brief Hospital Course: ___ Portugese-speaking man w/ PMH of HTN who presents the emergency room for evaluation of high blood pressure. #Hypertensive urgency: Patient presenting with BP of 260/150 at his PCP ___. Asymptomatic other than a headache, without signs/symptoms of end organ damage. BNP mildly elevated without prior comparison, EKG w/ LVH, trop neg x 2, Cr at baseline. Renal artery Doppler with no evidence of renal artery stenosis. He was previously on a 4-drug regimen of hctz, lisinopril, nifedipine, and metoprolol. Labetalol was initiated in the ED with resultant bradycardia to ___. Started on chlorthalidone 25mg daily, amlodipine 10mg daily, lisinopril 20mg daily, and carvedilol 12.5mg BID with improvement in blood pressures. #Cardiovascular disease risk Patient at increased risk for cardiovascular disease given longstanding poorly controlled hypertension. Significant LVH noted on EKG. EF 45% with significant LVH and wall motion abnormalities seen on TTE. ASCVD risk 16% based on TC of 224, HDL 49. ___ 154. HbA1c 5.9%. Started on ASA 81 daily, Atorvastatin 40mg daily. #Transaminitis: Mild elevation, AST:ALT ~1:1. Initially thought to be due to NASH given obesity (BMI 31.5). Last viral serologies from ___ showed hep A immunity, otherwise unremarkable. Hepatitis serologies sent, which were negative. Transaminitis resolved on repeat labs, suggesting it may have been to mild hepatic ischemia in the setting of hypertension. Transitional Issues =================== -Continue to monitor BP and adjust blood pressure medications -Patient started on lisinopril, should have lytes checked at follow up appointment -He needs outpatient work up for CAD given focal wall motion abnormalities on TTE -Continue counseling on importance of medication compliance -Continue ASA/statin; continue to monitor cholesterol and consider titration to high intensity statin if inadequate response to moderate intensity. # CONTACT: Wife, ___, ___ or ___ # CODE STATUS: Full code (confirmed) Medications on Admission: None Discharge Medications: 1. Amlodipine 10 mg PO DAILY Please take in the EVENING RX amlodipine 10 mg 1 tablet(s) by mouth daily in the evening Disp #30 Tablet Refills:0 2. Aspirin 81 mg PO DAILY RX aspirin 81 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 3. Atorvastatin 40 mg PO QPM RX atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 4. Carvedilol 12.5 mg PO BID RX carvedilol 12.5 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 5. Chlorthalidone 25 mg PO DAILY please take in the MORNING RX chlorthalidone 25 mg 1 tablet(s) by mouth daily in the morning Disp #30 Tablet Refills:0 6. Lisinopril 20 mg PO DAILY please take in the EVENING RX lisinopril 20 mg 1 tablet(s) by mouth daily in the evening Disp #1 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY Hypertensive urgency SECONDARY Congestive Heart Failure Hyperlipidemia Pre-diabetes Cardiovascular disease risk Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, Thank you for choosing to receive your care at ___. You were admitted for a very high blood pressure, in the setting of stopping taking your blood pressure medications several years ago. We restarted your blood pressure medications, with good improvement in your pressures. We also did an ultrasound study of your heart, which showed that the high blood pressure has decreased its efficiency. You had blood tests for cholesterol and diabetes, which showed high cholesterol and risk for diabetes; you should try to minimize sugary and fatty foods and limit carbohydrates in your diet moving forward. You were prescribed 6 new medications here in the hospital, which you should take moving forward. You should also follow up with your primary care provider at the appointment listed below. Moving forward, you should exercise caution when standing up quickly because your body is used to the higher pressures; it will eventually adjust, so that you don't become dizzy when you stand. We wish you the best with your ongoing recovery. Sincerely, your ___ care team Followup Instructions: ___
10026406-DS-11	10,026,406	25,260,176	DS	11	2129-01-05 00:00:00	2129-01-05 14:34:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Assault/EtOH withdrawal Major Surgical or Invasive Procedure: none History of Present Illness: ___ with past medical history of ETOH withdrawal and seizure who presents after an assault early on AM of admission. In the ED, he reported that someone attempted to get money from him for marijuana at which point he was assualted. In the ED, initial VS were 98.0 105 153/77 20 98% RA. Labs notable for clean UA (no bloodwork sent). CT head showed small posterior subgaleal hematoma but no intracranial bleed. CT sinus/mandible showed communited fracture of nasal bone through nasal septum. CT C-spine showed possible avulsion injury of superior endplate of C5, no compression Fx or retropulsion. C-spine flex-ex was normal; CT abdomen-pelvis showed no acute abdominal process. Neurosurgery evaluated the patient and felt no evaluation was necessary. The patient was initially comfortable but became tremulous, tachycardic, and c/o HA, suspicious for EtOH withdrawal. Patient received 5 mg Diazepam CIWA Q2H; this was insufficient, so he was escalated to 20 mg Q1H for a brief period in the ED. This controlled his withdrawal symptoms and he was noted to be drowsy but arousable thereafter. He was switched to Q2H Diazepam and admitted. He also received thiamine, folate, Ibuprofen, and Zofran. VS on transfer were 85 113/76 19 97%. On arrival to the floor, patient reports that he has a bad headache and feels shaky. His last drink was early this AM (before 6 AM). He drank particularly heavily overnight, reporting ___ beers and "lots" of whisky shots. He normally drinks one 6-pack of beers and several shots every day or every other day. Past Medical History: ETOH ABUSE ETOH WITHDRAWAL COMPLICATED BY SURGERY GERD Social History: ___ Family History: Reports that all his family is deceased, denies significant medical history. Physical Exam: ADMISSION PHYSICAL EXAM: VS - 97.5 88 18 143/84 96 RA General: Mildly uncomfortable, but non-toxic appearing, well-nourished HEENT: Contusions over glabella, ecchymosis over left eyelid. PERRLA, EOMI. Oropharynx clear. Poor dentition Neck: Soft supple, full ROM. No TTP of cervical vertebrae CV: RRR. S1 and S2. No m/r/g Lungs: No increased WOB. CTAB Abdomen: + BS. Soft, non-distended. Mild TTP of RUQ. Negative ___ sign. No peritoneal signs. GU: Deferred Ext: Warm, well-perfused without cyanosis, clubbing or edema Neuro: Cn2-12 grossly intact, AAOx3, moves all extremities to commands Skin: Contusions as per HEENT DISCHARGE PHYSICAL EXAM: Pertinent Results: ADMISSION LABS: ___ 01:55AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 01:55AM URINE COLOR-Straw APPEAR-Clear SP ___ PERTINENT LABS: DISCHARGE LABS: IMAGING: ___ NON-CON HEAD CT:IMPRESSION: Small posterior subgaleal hematoma. No fracture. Otherwise normal head CT. No intracranial hemorrhage. ___ CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST IMPRESSION: Deformity of the nasal bone and anterior septum due to fracture of undetermined age. No additional fracture. No soft tissue hematoma. ___ CT C-SPINE W/O CONTRAST IMPRESSION: Bony oaaicle near superior endplate of C5 indicating avulsion injury of undetermined age. No compression fracture. No retropulsion. ___ C-SPINE FLEX AND EXT ONLY 2 VIEWS IMPRESSION: Preliminary Report1. 3 mm ossific fragment inferior to C4 vertebral body, better assessed on CT Preliminary Report2 hr prior. Preliminary Report2. No abnormal vertebral movement on flexion and extension views. Preliminary Report3. For details on C7 and the dens please refer to CT cervical spine. ___ CT ABD & PELVIS W/O CON IMPRESSION: 1. Hepatic steatosis. 2. No acute lower thoracic or lumbar vertebral fracture. 3. Largely distended, normal-appearing bladder. 4. No acute intra-abdominal pathology. No free fluid. Brief Hospital Course: ___ with history of EtOH abuse, ETOH withdrawal with seizures who presents after an assault for management of EtOH withdrawal. ___- transferred to the ICU for persistent symptoms despite q2H diazepam on CIWA. He is almost 48hrs after last drink which is usual window to experience withdrawal, and given chronic use and hx he is at high risk for withdrawal seizure. Slurring words likely from benzo intoxication on floor. RR 12 as of ___. -d/c CIWA, IV phenobarb protocol started -Check phenobarb level #EtOH Abuse: Patient with history of ETOH withdrawal and seizures. Patient spaced to Q2H diazepam in ED. Reports he started drinking after his mother died in ___, and expresses interest in quitting. - Start 100 mg thiamine, 1 mg folic acid daily, multivitamin - Social work consult #trauma S/p assault: Imaging in ED revealed a subgaleal hematoma but no intracranial bleed, communited fracture of nasal bone through nasal septum, and possible avulsion injury of superior endplate of C5. was evaluated by neurosurgery who recommend no further intervention. ENT recommends outpatient follow up for nasal fracture Neurosurgery consulted, do not recommend further intervention. - Pain control with acetaminophen/ibuprofen - Per ENT, can follow up as outpatient in clinic for nasal fracture ___ - Per neurosurgery, no need for followup or repeat imaging #Isolated elevated PTT (59.1). INR 1.0. Unclear etiology - needs confirmation. - Recheck labs - If sustained consider putting on Pneumoboots prophylaxis #RUQ tenderness: Most likely ___ trauma from altercation. CT abd/pelvis without acute pathology. LFTs mildly elevated consistent with acute alcohol use. -CTM, pain control per below #GERD: continue home omeprazole TRANSITIONAL ISSUE: ====================== - F/u ENT as outpatient Medications on Admission: OMEPRAZOLE 20 MG DAILY Discharge Disposition: Home Discharge Diagnosis: Alcohol withdrawal Broken nose (nasal spetum fracture) Alcohol abuse Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr ___, You were admitted to the ICU for alcohol withdrawal. You were treated with medications to prevent like-threatening complications of alcohol withdrawal. We recommended you stay in the hospital longer for close monitoring and evaluation by social work for help with your alcohol abuse. You understood the risks of leaving the hospital at this time were severe, and included seizure, injury, and DEATH. You expressed an understanding in this, and decided to leave AGAINST MEDICAL ADVICE. Please return to the hospital if you experience seizures or other medical complications (SEE BELOW). Followup Instructions: ___
10026479-DS-13	10,026,479	21,649,207	DS	13	2189-02-11 00:00:00	2189-02-11 12:26:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: ___ R hemi-colectomy History of Present Illness: HPI: ___ with reported history of redundant colon and conservatively-managed sigmoid volvulus presents with acute onset abdominal pain and nausea. Ms ___ awoke at 0200 this morning with sharp low abdominal pain that came in waves. She developed nausea and chills and had one episode of non-bloody diarrhea. She presented to the ___ ED where she proceeded to have an episode of nonbloody, nonbilious emesis. CT A/P revealed cecal volvulus, for which a surgical consult is requested. Upon interviewing Ms ___, she reports her pain to now be constant and located in the RLQ. She endorses nausea but denies any further emesis. She additionally denies fevers, hematemesis, hematochezia. She has not passed flatus since the onset of her pain. Past Medical History: Past Medical History: 1. Reports hx of sigmoid volvulus treated conservatively with bowel rest/NGT. 2. Hx chronic abdominal discomfort followed by ___ gastroenterologist. Pt reports numerous tests performed without definite etiology. 3. Depression 4. Essential tremor 5. Hx b/l varicose veins Social History: ___ Family History: NC Physical Exam: Physical Exam: upon admission ___: Vitals: T 97.7, Hr 85, BP 166/83, RR 18, O2Sat 100% RA GEN: Thin woman in NAD. Alert and oriented. HEENT: No scleral icterus. Mucus membranes dry. CV: RRR PULM: Clear to auscultation b/l ABD: Soft, minimally distended. Tender RLQ and infraumbilical area. Prominence over LUQ which is nontender. No R/G. Ext: Warm without edema. Pertinent Results: ___ 05:30AM BLOOD WBC-7.0 RBC-3.92* Hgb-11.2* Hct-34.6* MCV-88 MCH-28.5 MCHC-32.3 RDW-13.6 Plt ___ ___ 05:25AM BLOOD WBC-8.3 RBC-4.59 Hgb-12.7 Hct-40.3 MCV-88 MCH-27.6 MCHC-31.5 RDW-13.3 Plt ___ ___ 05:25AM BLOOD Neuts-86.0* Lymphs-10.9* Monos-2.4 Eos-0.3 Baso-0.4 ___ 05:30AM BLOOD Plt ___ ___ 05:25AM BLOOD Plt ___ ___ 05:25AM BLOOD Glucose-113* UreaN-6 Creat-0.8 Na-140 K-3.6 Cl-103 HCO3-30 AnGap-11 ___ 06:30AM BLOOD Glucose-121* UreaN-6 Creat-0.7 Na-139 K-3.7 Cl-101 HCO3-32 AnGap-10 ___ 05:25AM BLOOD Calcium-9.1 Phos-2.9 Mg-1.8 ___ 06:30AM BLOOD Calcium-8.8 Phos-2.4* Mg-1.8 EKG: ___: Sinus rhythm. Left bundle-branch block. Non-specific septal T wave changes. No previous tracing available for comparison. Tracing #1 EKG: ___: Sinus rhythm. Left bundle-branch block. Compared to tracing #1 no change. TRACING #2 ___: cat scan of abdomen and pelvis: IMPRESSION: 1. Cecal volvulus with closed loop obstruction. 2. Multiple hypodensities within the liver, the largest of which are compatible with cysts. Others are too small to characterize but are statistically likely to represent cysts. ___: x-ray of the abdomen: IMPRESSION: Ileus or early obstruction. Followup is recommended. Brief Hospital Course: ___ year old female admitted to the acute care service with abdominal pain and nausea. Upon admission, she was made NPO, given intravenous fluids, and underwent a cat scan of the abdomen which showed a cecal volvulus. She was placed on intravenous antibiotics. On HD #1, she was taken to the operating room where she underwent a right colectomy with primary anastomosis. Her operative course was stable with minimal blood loss. She was extubated after the procedure and monitored in the recovery room. Her post-operative course has been stable. Her surgical pain was controlled with intravenous analgesia. She was started on sips on POD # 1 and her pain regimen was converted to oral analgesia. Her bowel function was slow to return and she underwent an x-ray of the abdomen which showed a ileus vs obstruction. She was given a dose of methynaltrexone. On POD #5, she began passing flatus and her diet was advanced. She resumed her home meds. Her vital signs are stable and she is afebile. She is tolerating a regular diet. Her white blood cell count is 7.0 with a hematocrit of 35. She has been ambulating. She is preparing for discharge home with follow-up in the acute care clinic for staple removal. She has also been advised to follow up with her primary care physician to further evaluate the finding of left bundle ___ block on recent EKG. Medications on Admission: ___: Citalopram 10; Clonazepam 0.5 HS Discharge Medications: 1. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 2. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 3. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain: may cause drowsiness, avoid driving while on this medication. Disp:30 Tablet(s) Refills:0 6. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Discharge Disposition: Home Discharge Diagnosis: sigmoid volvulus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hosptial with abdominal pain. You had a cat scan of your abdomen done which showed a twising of the colon. This can lead to a bowel obstruction. You were taken to the operating room where you had a segment of your colon removed. You have made a nice recovery and you are ready for discharge home with the following instructions: Please call your doctor or return to the emergency room if you have any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in 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 have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. Activity: No heavy lifting of items ___ pounds for 6 weeks. You may resume moderate exercise at your discretion, no abdominal exercises. Wound Care: You may shower, no tub baths or swimming. If there is clear drainage from your incisions, cover with clean, dry gauze. You will need to follow-up in the acute care clinic for removal of your staples. Followup Instructions: ___
10026658-DS-20	10,026,658	27,625,088	DS	20	2142-03-29 00:00:00	2142-03-29 20:37:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is a ___ year old gentleman with ahistory of diverticulosis seen on prior colonoscopies whopresents with 3 weeks of low abdominal pain and profusenon-bloody diarrhea. He saw his PCP who dismissed his symptoms. He and his wife were en route to ___ and had a layover in ___ when his diarrhea and abdominal pain became worse. They ended up staying the night in a hotel in ___ where he spent the entire night in the bathroom having severe abdominal pain, profuse diarrhea, and diaphoresis. The next morning, he caught the first flight back to ___ and came directly to the ___ ED. His most recent colonoscopy was in ___. He was told he had diverticuli and some polyps were biopsied. Past Medical History: diverticulitis, BPH, OA, GERD, colonic adenomas, HPL Social History: ___ Family History: NC Physical Exam: EXAM: upon admission: ___ VS - 97.7 73 143/92 18 99% RA GEN - NAD, awake/alert, cooperative & pleasant HEENT - NCAT, EOMI, dry mucous membranes, no scleral icterus ___ - RRR PULM - CTAB ABD - soft, nondistended, mild suprapubic tenderness to palpation without evidence of rebound or guarding EXTREM - warm, well-perfused; no peripheral edema Physical examination upon discharge: ___: vital signs: t=97.7, hr=59, bp=116/61, rr=18, 98% room air CV: ns1, s2, -s3, -s4 LUNGS: diminished bases bil ABDOMEN: soft, hypoactive BS, mild tenderness left lower quadrant, no rebound EXT: no calf tenderness bil., no pedal edema bil NEURO: alert and oriented x 3, speech clear Pertinent Results: ___ 06:06PM BLOOD WBC-5.8 RBC-4.36* Hgb-14.0 Hct-41.5 MCV-95 MCH-32.1* MCHC-33.7 RDW-15.5 Plt ___ ___ 12:41PM BLOOD WBC-6.5 RBC-4.35* Hgb-13.9* Hct-40.6 MCV-93 MCH-32.1* MCHC-34.3 RDW-15.3 Plt ___ ___ 12:41PM BLOOD Neuts-56.5 ___ Monos-5.7 Eos-5.0* Baso-0.6 ___ 09:00AM BLOOD Plt ___ ___ 09:00AM BLOOD Glucose-85 UreaN-13 Creat-1.4* Na-140 K-4.1 Cl-104 HCO3-26 AnGap-14 ___ 06:06PM BLOOD Glucose-81 UreaN-12 Creat-1.4* Na-139 K-3.9 Cl-101 HCO3-26 AnGap-16 ___ 12:41PM BLOOD Glucose-96 UreaN-16 Creat-1.4* Na-137 K-4.3 Cl-100 HCO3-27 AnGap-14 ___ 12:41PM BLOOD ALT-33 AST-35 AlkPhos-54 TotBili-0.7 ___ 09:00AM BLOOD Calcium-8.6 Phos-2.6* Mg-2.2 ___: cat scan of abdomen and pelvis: Small amount of ascites in the lower pelvis which is abnormal but not specific. Given clinical concern for diverticulitis the possibility could be considered when it is noted that the fluid resides near as diverticula at the rectosigmoid junction. 2. Fatty infiltration of the liver. 3. Findings consistent with mesenteric panniculitis. 4. Moderate atherosclerotic change, including mild aortic ectasia. Follow-up ultrasound is suggested to reassess in one year. /___ 9:12 am STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. *FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). Brief Hospital Course: The patient was admitted to the hospital with a 3 week course of abdominal pain. Upon admission, he was made NPO, given intravenous fluids, and underwent imaging. Cat scan imaging showed moderate to severe sigmoid diverticulosis. The patient was placed on bowel rest and placed on intravenous ciprofloxacin and flagyl. He resumed a clear liquid diet on HD #3, but reported increased burning sensation in his abdomen. He was again placed on bowel rest with resolution of his abdominal pain. He resumed clear liquids on HD #4, and advanced to a regular diet. His white blood cell count remained normal, along with a negative c.diff. The patient was ambulating without difficulty. On HD #6, the patient was discharged home in stable condition. He was instructed to complete a 10 day course of ciprofloxacin and flagyl. His vital signs upon discharge were stable and he was afebrile. He was voiding without difficulty and moving his bowels. Follow-up appointments were made with the acute care service and with his primary care provider. Moderate atherosclerotic change, including mild aortic ectasia were reported on the abdominal cat scan. Follow-up ultrasound was suggested to reassess in one year. Both the patient and his wife were informed of these findings and a copy of the cat scan report was provided. Medications on Admission: doxazosin (unknown dose), gemfibrozil 600', omeprazole 20', flonase 50 prn Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q12H last dose ___ RX ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth every twelve (12) hours Disp #12 Tablet Refills:0 2. Doxazosin 2 mg PO HS 3. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H last dose ___ RX metronidazole 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #18 Tablet Refills:0 4. Omeprazole 20 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: sigmoid diverticulosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital with abdominal pain and diarrhea. You underwent a cat scan of the abdomen which showed diverticulosis. You were placed on bowel rest. Your abdominal pain has resolved and you are preparing for discharge home with the following instructions: Please call your doctor or return to the emergency room if you have any of the following: You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in 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 have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. Followup Instructions: ___
10026950-DS-12	10,026,950	28,254,249	DS	12	2133-03-19 00:00:00	2133-03-19 17:53:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Prednisone / Cortisone / Penicillins / Demerol / Valium / Feldene Attending: ___ Chief Complaint: SOB Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ with a history of dementia and prostate cancer who was transfered from ___ with elevated troponin. History is unclear as patient cannot provide a history, but per nursing home report, the patient was found on the floor after sitting down complaining of shortness of breath. He was brought to ___ where he was given an aspirin in route. EKG showed new right bundle branch block. Troponin was elevated at 1.12. Chest x-ray showed concern of early developing pneumonia or CHF. The patient was given Levaquin and 10 mg of Lasix and then transfered to the ___ ED for cardiology evaluation. On arrival to ___, the patient denied any pain or shortness of breath. He was noted to have hematuria, which he's had in the past in the setting of prostate cancer (treatment). Hematuria started again recently in the past few weeks. He was treated with ciprofloxacin ___ in case hematuria was due to UTI. . A month ago the patient developed lower extremity edema, put on Lasix, then taken off for unclear reasons. . In the ___ ED, initial vitals were 98.3, 80, 112/64, 20, 98% 2L. EKG showed RBBB. Labs were notable for troponin of 1.12. Creatinine was 1.6 (unclear baseline). HCT of 30. Chest X-ray showed mild pulmonary edema. . Currently, patient is on the floor and denies pain, discomfort, or SOB. (He appears able to understand and answer simple yes/no questions.) . ROS: unable to obtain Past Medical History: - hx prostate cancer (recently stopped ?hormonal therapy) - hx bladder CA - hospitalization a month ago for a skin condition, stopped prednisone due to confusion and hyperglycemia - chronic kidney disease stage III - Factor V Leiden, no hx thrombotic events Social History: ___ Family History: Son has Factor V Leiden deficiency Physical Exam: ADMISSION EXAM: VS - 98.6, 118/64, 74, 24, 96% on RA GENERAL - NAD, lying in bed, appears comfortable, oriented to person only; has dried blood on his hands, Foley in place with red urine HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, not able to clearly visualize JVP, no carotid bruits LUNGS - decreased breath sounds at the bases bilaterally; bilateral crackles at the bases HEART - PMI non-displaced, RRR, ___ systolic murmur, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c, 2+ pitting edema B/L to knees, 1+ DP on the right, no palpable DP on the left SKIN - numerous excoriations and scabs on the skin LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout . DISCHARGE EXAM: VS - 98.0, 136/70, 72, 22, 97% on RA, FSBG 150-265 GENERAL - NAD, lying in bed, appears comfortable, oriented to person only; no Foley in place LUNGS - clear to auscultation HEART - PMI non-displaced, RRR, ___ systolic murmur, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - scant pitting edema (pneumoboots in place); moderate pre-sacral edema and moderate scrotal edema SKIN - numerous excoriations and scabs on the skin NEURO - awake, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout Pertinent Results: ADMISSION LABS: ___ 11:25AM BLOOD WBC-8.1 RBC-3.25# Hgb-9.4 Hct-29.5* MCV-91# MCH-28.8# MCHC-31.8 RDW-15.9* Plt ___ ___ 11:25AM BLOOD Neuts-86.9* Lymphs-6.6* Monos-4.8 Eos-1.5 Baso-0.2 ___ 11:25AM BLOOD Glucose-149* UreaN-38* Creat-1.6* Na-138 K-4.9 Cl-108 HCO3-21* AnGap-14 ___ 11:25AM BLOOD ALT-39 AST-51* LD(LDH)-295* CK(CPK)-117 AlkPhos-126 TotBili-0.3 ___ 11:25AM BLOOD CK-MB-6 ___ 11:25AM BLOOD cTropnT-1.12* ___ 11:25AM BLOOD Albumin-3.7 ___ 07:15AM BLOOD Calcium-8.9 Phos-3.8 Mg-2.0 . CBC/HCT TREND: ___ 07:45PM BLOOD Hct-26.1* ___ 07:15AM BLOOD WBC-8.8 RBC-3.14* Hgb-9.1* Hct-28.1* MCV-90 MCH-29.0 MCHC-32.4 RDW-16.0* Plt ___ ___ 03:15PM BLOOD Hct-25.5* ___ 07:30AM BLOOD WBC-6.7 RBC-3.79* Hgb-11.1* Hct-33.5# MCV-88 MCH-29.4 MCHC-33.2 RDW-16.8 Plt ___ ___ 07:55AM BLOOD WBC-7.0 RBC-3.83* Hgb-11.4* Hct-34.3* MCV-90 MCH-29.8 MCHC-33.2 RDW-16.4* Plt ___ . CHEM/CR TREND: ___ 07:15AM BLOOD Glucose-114* UreaN-42* Creat-1.9* Na-139 K-4.5 Cl-108 HCO3-18* AnGap-18 ___ 03:15PM BLOOD Glucose-198* UreaN-46* Creat-2.2* Na-139 K-4.7 Cl-108 HCO3-22 AnGap-14 ___ 07:30AM BLOOD Glucose-91 UreaN-44* Creat-1.9* Na-141 K-4.5 Cl-111* HCO3-19* AnGap-16 ___ 07:55AM BLOOD Glucose-136* UreaN-49* Creat-1.7* Na-142 K-4.6 Cl-111* HCO3-21* AnGap-15 ___ 07:55AM BLOOD Calcium-8.4 Phos-3.4 Mg-2.0 . CARD ENZYME TREND: ___ 07:45PM BLOOD CK-MB-5 cTropnT-1.17* ___ 07:15AM BLOOD CK-MB-6 cTropnT-1.47* ___ 03:15PM BLOOD CK-MB-5 cTropnT-1.55* ___ 07:30AM BLOOD CK-MB-4 cTropnT-1.32* ___ 04:35PM BLOOD CK-MB-4 cTropnT-1.37* ___ 07:55AM BLOOD CK-MB-4 cTropnT-1.14* . CHEST X-RAY, TWO VIEWS, ___ HISTORY: ___ male with elevated troponins and shortness of breath. FINDINGS: AP and lateral views of the chest are compared to study performed at ___ from earlier the same day. There has been interval development of indistinct pulmonary vascular markings. Small- to moderate-sized bilateral pleural effusions are more clearly delineated on the current exam. The lung volumes are seen. Cardiac silhouette is prominent, likely accentuated due to AP technique and low inspiratory effort. Osseous and soft tissue structures are unremarkable. IMPRESSION: Findings suggestive of congestive failure and moderate bilateral effusions. . PORTABLE CHEST X-RAY OF ___. COMPARISON: Radiograph ___. FINDINGS: Persistent cardiomegaly with improved pulmonary vascular congestion but persistent moderate right and small left pleural effusion with adjacent basilar atelectasis and/or consolidation. Diffuse haziness in upper abdomen suggest the possibility of ascites. . RENAL U/S ___: INDICATION: Assess for hydronephrosis and clot burden in the bladder. COMPARISONS: CT abdomen and pelvis from ___. RENAL ULTRASOUND: Assessment of the kidneys is somewhat limited due to body habitus and overlying bowel gas. The right kidney measures 9.5 cm. The left kidney was not as well seen, measuring 9.6 cm. No definite hydronephrosis is seen bilaterally. The bladder is decompressed with a Foley catheter with a 4.4 x 3.8 cm avascular lesion within the bladder. IMPRESSION: No definite hydronephrosis on this limited study with 4.4-cm avascular echogenbic lesion in the bladder. This could reflect clot given the history though a mass is not excluded. Consider contrast enhanced CT or direct visualization. . B/L LENIs ___: INDICATION: ___ male with new right bundle-branch block, concern for PE, but unable to get CTA. Assess for DVT. COMPARISONS: None. Grayscale and color Doppler sonographic evaluation was performed of the bilateral lower extremities. Normal compressibility and flow was seen in the bilateral common femoral, superficial femoral, popliteal, peroneal, and posterior tibial veins without evidence of DVT. Mild left sided subcutaneous edema noted. IMPRESSION: No lower extremity DVT. . Echo ___: The left atrium is mildly dilated. The left atrium is elongated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). There is no ventricular septal defect. The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. The diameters of aorta at the sinus, ascending and arch levels are normal. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are moderately thickened. Significant aortic stenosis is present (not quantified). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate (___) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is a small pericardial effusion. The effusion appears circumferential. There are no echocardiographic signs of tamponade. IMPRESSION: Suboptimal image quality. Preserved left ventricular global systolic function with moderate, symmetric LVH. Aortic stenosis is present but unable to quantify. Mild to moderate MR. ___ RV is mildly dilated and hypokinetic. Small, circumferential pericardial effusion with no echocardiographic signs of tamponade. Brief Hospital Course: ___ with hx dementia, prostate CA, and bladder CA who presents with recent hx hematuria, recent ___ edema, and shortness of breath. He was found to have RBBB and ST changes, edema on CXR, and evidence of right heart strain on ECHO. He was thought to have (1) worsening heart failure due to NSTEMI vs. demand ischemia vs. acute PE and (2) hematuria of undetermined cause. . # ACUTE SYSTOLIC HEART FAILURE: Patient presented with ___ edema and pulm edema on CXR and on exam (and recent subacute edema), consistent with heart failure. Differential for the cause of heart failures includes acute MI and acute PE. No known liver disease, but does have chronic renal insufficiency at baseline. Initially we diuresed the patient with IV Lasix, which improved his exam but worsened his renal function to a creatinine of 2.2. His blood pressures overall were not suggestive of cardiogenic shock, but he did have occassional systolic BPs below 90. The patient might have a component of preload dependence as his pressures improved with IVF and PRBC ___, and his heart failure did not appear dramatically worse. However, on ___, he was noted to have severe scrotal and moderate pre-sacral edema. Lasix was restarted without worsening renal function (creatinine of 1.7 on discharge, which appears to be his baseline). He is being discharged on 20mg PO Lasix daily and will have electrolyte and creatinine lab follow up and monitoring at the rehab facility. . # POSSIBLE PULMONARY EMBOLISM: Patient presented with shortness of breath, RBBB, tachypnea to ___ ___nd troponin leak. While these symptoms might be c/w other etiologies such as heart failure and myocardial ischemia/infarction, they were also very concerning for PE. In terms of PE risk, patient has factor V Leiden but no hx clot. PE strongly considered in pt with right heart strain, elevated troponins, signs of right heart failure more than left heart failure. Has renal failure so unlikely to tolerate CTA. V/Q scan unlikely to be useful given the underlying pulmonary edema. LENIs were negative. The medical team had a long conversation with the family about goals of care and about the possible PE in particular. The family understood that their father might have a PE and that the PE could kill him if untreated. However, anticoagulating the patient with heparin (and later with warfarin) would have worsened his hematuria. Given his age, fall risk, and the goals of care, we recommended not treating the patient. The family understood the situation and the risks and did not want to pursue CTA or empiric anticoagulation. The patient did receive heparin subQ. . # NSTEMI / DEMAND ISCHEMIA: Patient presented with troponin leak (peaked at 1.55) and ST changes difficult to interpret in the setting of RBBB, which was found to be pre-existing at least since ___. Catheterization not c/w patient's goals of care. Heparin gtt also not in line with goals of care and would risk worsening hematuria. We treated the patient with aspirin 325mg daily, atorvastatin 80mg daily, and metoprolol 12.5mg QID (he was eventually transitioned to metoprolol XL 25mg, a lower total dose due to heart rates in the ___ when getting 50mg total daily). On ___, we tranfused 2 units blood for dropping HCT (to 25.5) and active GU bleeding in the setting of NSTEMI/demand ischemia. The patient denied chest pain, and his troponin trended down. . # HEMATURIA: ___ be due to prostate CA or treatment or bladder CA or treatment. Renal U/S did reveal a lesion in the bladder (clot vs. mass). Urology was consulted, and they recommended putting in a large-bore Foley to tamponade possible prostatic bleeding and to start finasteride 5mg daily. Finasteride was started. A ___ catheter was placed, but was removed ___ when he appeared to be obstructed. He continued to pass blood and clots in his urine until ___ when the urine was clear. He did have to be straight cathed on ___ for obstruction, and we continued to monitor him with bladder scans. As above, he was transfused on ___. We spoke with radiation oncology about the possibility of palliative radiation to stop bleeding. They would need to do preferably a cystoscopy (family did not want to pursue this due to risk of anesthesia in their father) or a CT w/ contrast (which we and the family did not want to pursue given the kidney disease). CT without contrast might localize source of bleeding enough to plan pelvic XRT. Son wanted to consider pursuing this if bleeding worsened and after meeting with urology for outpatient follow up. After transfusion on ___, HCT remained stable around ~33. . # ___ (on CHRONIC KIDNEY DISEASE STAGE III): Chronic kidney disease likely from DMII, unknown baseline, but appears to be in range of 1.6-1.8 base on records from ___. Patient presented with creatinine of 1.6, which increased to 2.2 with aggressive diuresis. Acute injury likely from prerenal (acute heart failure vs. over-diuresis) vs. obstruction (CA/mass vs. clot). Obstruction was thought to be less likely given no obvious hydro on renal u/s. Most likely prerenal is setting of over-diuresis. Creatinine stabilized in range of ~1.7-1.8. . # DMII: On oral hypoglycemics at home. Patient was put on insulin sliding scale while here. . # GOALS OF CARE: Patient was DNR/DNI at baseline. On ___, the medicine team, along with palliative care, met with the son/POA/HCP ___ and the pt's daughter ___ to discuss goals of care. We agreed not to further pursue diagnosis or treatment of PE, given the patient's c/i to IV contrast and given that we would not want to treat him right now because of his stable respiratory status, his GU bleeding, and his high fall risk. ___ and ___ are sure that they would like their father to go back to ___, the ___, and not to go to a nursing home/SNF, or if he has to go, to go only temporarily. We discussed the option of "do not hospitalize," but the family did not seem ready to make that decision. We did, however, discuss hospice, and the son spoke to case management to see if the patient meets criteria. I spoke with the son again ___ about goals of care. In addition to reviewing what we talked about at the family meeting on the day prior, we also talked about the option of "allowing natural death" and not transfusing blood if he were to have increased bleeding from his GU tract. Son expressed that to him and his sister, this would feel too much like "pulling the plug." They are not ready to have their father be "do not hospitalize" or "allow natural death," but they are aware that these options exist for the future. Case management spoke to the family about hospice, and they would like to continue exploring this as an option for the future. . TRANSITIONAL ISSUES: - Patient's family would like to get their father back to ___ (assisted living) as soon as possible, but understands he will have to go to a SNF first. - Patient's family may consider do not hospitalize (___) and/or hospice in the future. - Urology follow-up is scheduled for early ___. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. GlipiZIDE XL 20 mg PO DAILY Start: In am 2. Pioglitazone 30 mg PO DAILY Start: In am 3. Valsartan 160 mg PO DAILY Start: In am 4. Docusate Sodium 100 mg PO DAILY Start: In am 5. Donepezil 10 mg PO DAILY at dinner time 6. Memantine 10 mg PO BID one at breakfast, one at dinner time 7. Risperidone 0.25 mg PO DAILY at dinner time 8. Aspirin 81 mg PO HS Discharge Medications: 1. Aspirin 325 mg PO DAILY 2. Docusate Sodium 100 mg PO QAM 3. Donepezil 10 mg PO DAILY at dinner time 4. Memantine 10 mg PO BID one at breakfast, one at dinner time 5. Atorvastatin 80 mg PO DAILY 6. Finasteride 5 mg PO DAILY 7. Heparin 5000 UNIT SC TID 8. Metoprolol Succinate XL 25 mg PO DAILY 9. Senna 2 TAB PO BID:PRN constipation 10. GlipiZIDE XL 20 mg PO DAILY 11. Pioglitazone 30 mg PO DAILY 12. Furosemide 20 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: - NSTEMI Secondary diagnoses: - hematuria secondary to suspected recurrent prostate vs bladder ca - acute blood loss anemia - dementia - hypertension - DM type II - CKD stage III Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair; ambulatory with assistance or aid (walker or cane). Discharge Instructions: Dear Mr. ___, You were admitted to the hospital with shortness of breath. You had fluid in your lungs, which may have contributed to the shortness of breath. This fluid in your lungs may have been due to a heart attack, heart failure, a blood clot in your lungs, or a combination of these issues. It is very likely that you had a blood clot in your lungs, but we did not do the CT test to confirm this, given that it would likely further harm your kidneys. We also did not treat you for this blood clot, given that the treatment would increase your risk of having blood in your urine and increase the risk of you dying from a bleed in your gastrointestinal tract or head, especially if you were to fall. Your family agreed with this plan. We gave you Lasix (a diuretic) to decrease the fluid around your lungs. After we did this, your breathing improved. For your heart, we gave you aspirin (an increased dose compared to what you used to take), metoprolol (a beta-blocker, which decreases the work that your heart has does when pumping blood), and atorvastatin (which decreases cholesterol plaque formation in your arteries). You also had blood in your urine, which may have been coming from your prostate or your bladder. We transfused you with red blood cells in order to increase your red blood cell level. The bleeding stabilized. Please follow up with urology at the appointment time listed below. Thank you for allowing us to take part in your care. Followup Instructions: ___
10027407-DS-2	10,027,407	21,216,166	DS	2	2188-03-25 00:00:00	2188-03-25 15:26:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Abdominal pain, small bowel obstruction Major Surgical or Invasive Procedure: NONE History of Present Illness: Mr. ___ is a ___ year old male with history of Crohn's disease s/p ileocectomy w/ ileostomy and subsequent reversal who has had multiple episodes (>10) of small bowel obstruction who presents with 1 day of crampy abdominal pain consistent w/ previous episodes of SBO. He states he was at a ___ game when he first began to feel the crampy abdominal pain, which worsened by early morning so he came to the ED. He reports he was dehydrated and eating peanuts at the time, but otherwise, leafy green vegetables can sometimes bring out an episode of SBO. They have all been managed conservatively in the past, and an NG tube was used only once. He currently reports improved pain, no fever, chills, chest pain, shortness of breath, headache, dizziness, blood per rectum or dysuria. He last passed gas and had a small BM yesterday evening, but reports none since. Past Medical History: Past Medical History: - Crohn's disease - Hypertension - Obstructive sleep apnea - Gout - Hyperlipidemia ________________________________________________________________ Past Surgical History: - Appendiceal abscess s/p ileocectomy, ileostomy placement (___) - Ileostomy reversal (___) - Repair of abdominal wall diastasis/weakness (___) ________________________________________________________________ Social History: ___ Family History: No family history of inflammatory bowel disease or colon cancer. Physical Exam: ON ADMISSION Vitals: Afebrile, vital signs stable GEN: Alert and oriented, no acute distress, conversant and interactive. HEENT: Sclerae anicteric, mucous membranes moist, oropharynx is clear. NECK: Trachea is midline, thyroid unremarkable, no palpable cervical lymphadenopathy, no visible JVD. CV: Regular rate and rhythm, no audible murmurs. PULM/CHEST: Clear to auscultation bilaterally, respirations are unlabored on room air. ABD: Soft, non distended, mildly tender to palpation diffusely in lower quadrants. No guarding or rebound tenderness. Ext: No lower extremity edema, distal extremities feel warm and appear well-perfused. ON DISCHARGE: VS: T 97.7, HR 58, BP 138/72, RR 18, SaO2 98% RA GEN: No acute distress, alert and cooperative CV: RRR PULM: Easy work of breathing ABD: Soft, nontender, nondistended EXT: Warm, well perfused. Pertinent Results: ___ 03:00AM BLOOD WBC-8.6 RBC-5.00 Hgb-15.4 Hct-45.1 MCV-90 MCH-30.8 MCHC-34.1 RDW-12.3 RDWSD-40.5 Plt ___ ___ 03:00AM BLOOD Neuts-80.2* Lymphs-11.9* Monos-7.3 Eos-0.1* Baso-0.3 Im ___ AbsNeut-6.92* AbsLymp-1.03* AbsMono-0.63 AbsEos-0.01* AbsBaso-0.03 ___ 05:30AM BLOOD Glucose-117* UreaN-8 Creat-0.9 Na-136 K-3.8 Cl-103 HCO3-25 AnGap-12 ___ 03:00AM BLOOD Glucose-126* UreaN-15 Creat-1.0 Na-135 K-4.0 Cl-98 HCO3-25 AnGap-16 ___ 05:30AM BLOOD Calcium-8.2* Phos-2.5* Mg-1.8 ___ KUB: IMPRESSION: Nonspecific bowel gas pattern with paucity of small bowel gas, though no specific plain radiographic evidence for obstruction. If SBO remains of clinical concern, followup imaging should be considered. ___ CT A/P: IMPRESSION: Mild distention of mid jejunum up to 3 cm with slight surrounding free fluid and two proximal and distal transition points. This could be seen in setting of partial or early small bowel obstruction or possibly enteritis, and is not suggestive of a high-grade obstruction. Brief Hospital Course: Mr. ___ is a ___ year old gentleman with long history of previous small bowel obstructions after ileocectomy, ileostomy, and then reversal. He presented with 1 day of abdominal pain associated with nausea and minimal bowel function. CT findings on arrival to ___ were consistent with small bowel obstruction. He was admitted to ___ ___ monitoring and IV fluids. Overnight, he reports he began to pass flatus and had several bowel movements. His diet was advanced, and he reports his abdominal pain had resolved. He was deemed ready for discharge. He expressed understanding of the plan. We recommended that he follow-up with his gastroenterologist or surgeon if his symptoms are becoming more frequent as this may indicate need for intervention. Medications on Admission: - Sulfasalazine - Atorvastatin - Benicar - Allopurinol - Vitamin B12 - Folic acid - Probiotic - Imodium Discharge Medications: Please resume your medications at home at their usual doses. There are no changes or additions to your medications at home. Discharge Disposition: Home Discharge Diagnosis: Small bowel obstruction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to ___ after experiencing small bowel obstruction associated with abdominal pain and some nausea for 1 day. Overnight, you began passing flatus and having bowel movements, suggesting that your obstruction is not relieved. You have now also tolerated a diet without abdominal pain and are ready to be discharged. Please continue to stay hydrated and monitor your diet. Return to the ED if you have fever, chills, worsening abdominal pain, or are not having bowel movements or passing flatus for several days. Given your history of previous small bowel obstructions, you should continue to follow-up closely with your gastroenterologist as well as surgeon. You may need a surgical repair of the anastomosis where there appears to be a stricture if your small bowel obstructions are becoming more frequent. Thank you for allowing us to participate in your care Followup Instructions: ___
10027557-DS-8	10,027,557	28,332,555	DS	8	2136-02-08 00:00:00	2136-02-08 16:12:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: moxifloxacin Attending: ___. Chief Complaint: Confusion Major Surgical or Invasive Procedure: None History of Present Illness: ___ w/ hx of metastatic hepatocellular carcinoma, decompensated cirrhosis, possible SBP on ciprofloxacin presents from palliative care appointment with altered mental status, fatigue. Per patient's daughter, she was doing relatively well until 6 days prior to admission when she developed fatigue and lethargy, seeming "not there". She had a paracentesis 5 days ago for this new lethargy and culture grew Escherichia coli for which she was started on ciprofloxacin yesterday (received one dose). Patient was then taken to see palliative care today for scheduled follow-up and was noted to be ill appearing with thready pulse and slow to respond and was sent to the ED for further evaluation. Patient's family remained in palliative care appointment with Dr. ___ discussion was reiterated about goal for comfort/alertness with hope to get patient home to be with her cat prior to death. Ok with hospitalizations and medical treatment with goal to get patient home but would not be interested in life sustaining treatments or major procedures. Per Palliative Care note prior to admission: "The goal is to do everything we can to help Mrs. ___ feel as well as she can, focusing on helping her be more alert and present and minimize any discomfort. Her daughter ___ recognizes that the time is short and very much wants to her mom to be home with her cat (named ___) at the end. In the immediate term, she wants to do whatever might help her Mom recover, as in past, she was treated with antibiotics and lactulose and the patient improved. - Family, ___ and ___ (who are health care proxies for ___, are both clear that goal is to help 'buff her up' while in the hospital and then to get her home for her final stretch. We addressed specifics. Patient is NOT interested in life-sustaining therapy. Patient is DNR/DNI." In the ED, initial vitals: 97.8 66 143/70 16 99% ra. Labs were done and notable for normal WBC count 9.3 with 88% polys, Na 128, Cr 1.4, ALT/AST 159/172, Tbili 8.2, Alb 1.8. Lactate 3.3. Urine without evidence of infection. Urine and blood cultures sent, CXR without evidence of infection. Patient denies chest pain, SOB, nausea or vomiting. Patient received ceftriaxone 2g IV in ED prior to transfer to the floor. Vitals on transfer: 60 135/56 16 100% RA. On arrival to the floor, vitals 97.7 122/51 59 22 100%RA. Patient lethargic, intermittently interactive but slow to respond, denying pain or other symptoms. Review of sytems: Per HPI, unable to complete full ROS given mental status but daughter denied recent fevers, chills, did have some recent dry heaving. Past Medical History: -Cirrhosis, presumed due to EtOH; been sober for ___ c/b ascites, HCC -HCC s/p surgical resection at ___ on ___. Pathology did not show malignancy in the lesion; however, a metastatic foci of HCC was identified at the falciform ligament. She was referred to ___ at ___, and CT ___ showed a 3.8 cm lesion in the left liver consistent with HCC and associated tumor thrombus in the portal vein. Also notable was a 2-mm lung nodule. Started on sorafenib ___. The dose was initially reduced to 200mg Q12hour due to toxicity. Given rising AFP, she increased back to 400mg BID ___ now being held since ___ -"Irritable bowel" per patient -History of depression/anxiety -GERD -Status post tubal ligation -Status post appendectomy Social History: ___ Family History: The patient's mother died with diabetes mellitus. Her maternal grandmother also had diabetes mellitus and stroke. A maternal aunt was treated for liver cancer, unclear if this is primary or secondary. Physical Exam: ADMISSION PHYSICAL: ==================== Vitals: 97.7 122/51 59 22 100%RA General: Lying in bed on side, difficulty turning, answering questions slowly, repeating words/answers HEENT: Sclera grossly icteric, MM very dry, oropharynx clear, cachectic appearing Neck: Thin, JVP not elevated Lungs: Coarse breath sounds anteriorly but clear to auscultation bilaterally posteriorly without wheezes, rales, rhonchi CV: Bradycardic with regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, moderately tender throughout with palpable liver in RUQ, no rebound, well healed mid-line incision Ext: Warm, well perfused, 2+ pitting edema along majority of legs, anasarcic Skin: dry, bruises over right, jaundiced Neuro: Oriented to self and place not to date. Unable to do days of week forward. Full strength in lower extremities bilaterally, possible left right sided weakness at arm. DISCHARGE PHYSICAL: ==================== Vitals: 97.8 150/70 80 20 95%RA General: Lying in bed on side, awake, answering questions slowly, oriented to self, place as ___, not to date HEENT: Sclera icteric, MM moist, oropharynx clear, cachectic appearing Neck: Thin, JVP not elevated Lungs: Clear to ausculatation bilaterally with upper airway wheeze noted anteriorly CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, moderately distended with mild ttp throughout. Ext: Warm, well perfused, 1+ edema to midcalf bilaterally 2+ Skin: dry, bruises over chest, jaundiced Neuro: Oriented to self and hospital (___) not to date or name of place. No asterixis. Pertinent Results: ADMISSION LABS: ================ ___ 11:21AM BLOOD WBC-9.3 RBC-4.59 Hgb-15.2 Hct-46.0 MCV-100* MCH-33.1* MCHC-33.0 RDW-18.5* Plt ___ ___ 11:21AM BLOOD Neuts-88.5* Lymphs-8.3* Monos-2.5 Eos-0.3 Baso-0.3 ___ 11:21AM BLOOD ___ PTT-32.3 ___ ___ 11:21AM BLOOD Glucose-131* UreaN-48* Creat-1.4* Na-128* K-4.3 Cl-95* HCO3-22 AnGap-15 ___ 11:21AM BLOOD ALT-159* AST-172* AlkPhos-165* TotBili-8.2* DirBili-4.2* IndBili-4.0 ___ 11:21AM BLOOD Albumin-1.8* Calcium-8.2* Phos-3.8 Mg-2.2 ___ 11:40AM BLOOD Lactate-3.3* INTERIM LABS: =================== ___ 08:25AM BLOOD WBC-6.8 RBC-2.94# Hgb-10.0# Hct-30.3# MCV-103 MCH-34.1* MCHC-33.1 RDW-19.3* Plt ___ ___ 04:00PM BLOOD ___ PTT-116.6* ___ ___ 04:00PM BLOOD Fibrino-57* ___ 07:45AM BLOOD ___ 08:25AM BLOOD Glucose-87 UreaN-55* Creat-1.5* Na-139 K-3.8 Cl-99 HCO3-26 AnGap-18 ___ 08:25AM BLOOD ALT-85* AST-106* AlkPhos-79 TotBili-9.1* DirBili-3.8* IndBili-5.3 ___ 11:21AM BLOOD Lipase-52 ___ 08:43AM BLOOD Lactate-2.3* CULTURES: =========== Urine Culture ___: Negative Blood Cultures ___: NGTD DISCHARGE LABS: =================== ___ 07:45AM BLOOD WBC-6.4 RBC-3.21* Hgb-10.4* Hct-33.4* MCV-104* MCH-32.5* MCHC-31.1 RDW-19.0* Plt ___ ___ 07:45AM BLOOD ___ PTT-54.2* ___ ___ 07:45AM BLOOD Glucose-132* UreaN-48* Creat-1.3* Na-139 K-3.4 Cl-101 HCO3-28 AnGap-13 ___ 07:45AM BLOOD ALT-107* AST-125* LD(LDH)-468* AlkPhos-91 TotBili-10.1* ___ 07:45AM BLOOD Albumin-3.6 Calcium-9.2 Phos-2.6* Mg-2.5 IMAGING: ========= Chest PA/Lat ___: No acute cardiopulmonary process. CT Head w/o Contrast ___: No acute abnormalities are seen. No hemorrhage identified. Small vessel disease. The metastatic disease is concerned, coronal post enhanced CT or MRI can help further assessment if indicated. Brief Hospital Course: ___ with decompensated cirrhosis, hepatocellular carcinoma and recently diagnosed SBP admitted with altered mental status, fatigue and ___ complicated by hematocrit drop and worsening coagulopathy ultimately with plan to focus on comfort and avoid invasive procedures. # Goals of Care: Long discussion with patient's health care proxys on ___ (please see OMR note for full discussion) during which time patient's son and daughter were informed of patient's poor prognosis given progressive worsening over last several weeks to months coupled with acute decompensation in liver function and encephalopathy. In this setting, family made clear that patient's wishes would be to focus on getting her home and comfortable. Code status transitioned toward CMO with no escalation of care or invasive procedures per family. On further discussion with patient's family, decision made to stop lab draws. However, would be comfortable with palliative paracentesis for comfort. Hospice services arranged for including home hospital bed for transfer home with hospice. # Altered Mental Status: Patient admitted with altered mental status most consistent with hepatic encephalopathy likely due to SBP and worsening liver failure. Given concern for weakness in right arm on admission, non-contrast head CT performed ___ without evidence of bleed. Encephalopathy treated with frequent lactulose and home rifaximin with some improvement in mental status though still only oriented x1-2 at discharge. SBP treated with ceftriaxone transitioned to ciprofloxacin prior to discharge with plan for 500mg BID until ___ then transition to 500mg daily on ___. Patient continued on lactulose q8h at discharge. Blood cultures pending at discharge. #Hepatic Failure/HCC: Patient with worsening liver function on admission with grossly elevated bili (mixed direct and indirect) and moderately elevated LFTs. Per liver, thought to be end stage cirrhosis complicated by worsening HCC in setting of known portal vein thrombosis. No further treatment indicated for hepatic failure and HCC as above. Patient had had recent paracentesis. Abdominal exam notable for significant ascites but soft at discharge and no paracentesis pursued this admission. Patient continued on lactulose and rifaximin as above. Nadalol continued for ppx against esophageal bleeds. Lasix and spironolactone restarted at low doses prior to discharge. # Acute Kidney Injury: Patient with new onset of renal failure on admission with creatinine of 1.4 up from 0.7. FeUrea of 27% suggesting pre-renal etiology. No significant improvement with albumin for SBP. Most likely related to hepatorenal syndrome in setting of patient's worsening liver failure. Home diuretics initially held however in setting of transition to comfort focus, decision made to restart low dose lasix and spironolactone given ongoing ascites. #SBP: As evidenced by positive para culture on ___ complicated by hepatic encephalopathy prompting transfer to ED. Patient initially treated with ceftriaxone 2g daily and transitioned to ciprofloxacin ___ BID, plan to transition to ciprofloxacin 500mg daily starting ___ for SBP prophylaxis. Patient continued on home rifaximin and lactulose for encephalopathy. # Coagulopathy: Patient with baseline elevated INR and poor synthetic function of liver. Bump in coags to INR of 3.1 with low fibrinogen and FDPs concerning for DIC vs bleeding with hct drop to 30 from 45. Labs stable on ___. No evidence of bleeding and decision made to transition patient to ___ care therefore no further work-up pursued on this admission. # Anemia: Patient with 15 point hct drop from 45 on admission to 30 on HD2. No evidence of bleeding. Concern for intraabdominal bleed vs hemolysis. Stable on repeat ___ and ___ and given transition in goals, no further work-up pursued. # Hyponatremia: Patient admitted with hyponatremia to 129 likely related to hepatorenal syndrome. Improved to normal with albumin treatment for SBP. # Chronic Pain: Related to hepatocellular carcinoma and chronic bone pain. No significant pain during hospitalization. Consider morphine/dilaudid as needed for pain at home. # CODE: DNR/DNI, no escalation of care # CONTACT: ___, Daughter P) ___ -- Transitional Issues: -If patient develops worsening ascites with very tense abdomen, could consider paracentesis done as outpatient for palliation of symptoms per family discussion -Patient's family clear that she would like to be home at the end of life, no further hospitalizations -Follow-up blood cultures sent ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Megestrol Acetate 400 mg PO DAILY 2. Rifaximin 550 mg PO BID 3. Ciprofloxacin HCl 250 mg PO Q24H 4. DiCYCLOmine 10 mg PO BID 5. Fluoxetine 20 mg PO DAILY 6. Furosemide 30 mg PO DAILY 7. Magnesium Oxide 400 mg PO DAILY 8. Nadolol 20 mg PO DAILY 9. Omeprazole 20 mg PO DAILY 10. Spironolactone 50 mg PO DAILY 11. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain 12. Lactulose 15 mL PO BID Discharge Medications: 1. 1 Hospital Bed with Mattress ___ ___ ___ Duration: Lifetime 2. Ciprofloxacin HCl 500 mg PO Q12H RX ciprofloxacin 500 mg 1 tablet(s) by mouth BID then Daily Disp #30 Tablet Refills:0 3. Fluoxetine 20 mg PO DAILY 4. Furosemide 20 mg PO DAILY RX furosemide 20 mg 1 tablet(s) by mouth Daily Disp #30 Tablet Refills:0 5. Lactulose 30 mL PO Q8H Please titrate to ___ bowel movements per day until thinking clearly RX lactulose 20 gram/30 mL 1 packet by mouth every eight (8) hours Disp #45 Packet Refills:0 6. Nadolol 20 mg PO DAILY 7. Omeprazole 20 mg PO DAILY 8. Rifaximin 550 mg PO BID 9. Spironolactone 25 mg PO DAILY RX spironolactone 25 mg 1 tablet(s) by mouth Daily Disp #30 Tablet Refills:0 10. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain 11. Megestrol Acetate 400 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnosis: 1. Hepatic Encephalopathy 2. Spontaneous bacterial peritonitis 3. Liver Failure 4. Hepatorenal syndrome 5. Coagulopathy Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. ___, You were admitted to the hospital with confusion. You were found to have worsening liver failure, an infection in your abdomen and kidney injury. Your confusion and worsening liver failure likely represent progression of your cancer and cirrhosis. On further discussion with your primary doctors and family, the decision was made to enroll in home hospice in order to make you most comfortable. Your ___ and hospice nurses ___ help manage your pain and discomfort at home. It was a pleasure taking care of you, Your ___ Team Followup Instructions: ___
10027602-DS-8	10,027,602	28,166,872	DS	8	2201-11-20 00:00:00	2201-11-20 13:26:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: Prednisone / Latex / Lactose / Mirapex / doxycycline Attending: ___. Chief Complaint: Intraventricular hemorrhage Major Surgical or Invasive Procedure: ___ R EVD placed ___ Angio- dural av fistula ___ Angio for embolization Post Meningeal Branch ___ Replacement of R EVD ___ Embolization of Dural AV fistula ___ PEG insertion History of Present Illness: This is a ___ year old female found down by her roommate in the bathroom on the ground with emesis. Roommate stated that the patient may have taken some Percocet. EMS called and patient taken to ___. Upon arrival patient was obtunded, received Narcan with no improvement and was intubated for airway protection and underwent a head CT which revealed a hemorrhage. Past Medical History: ADHD Cholecystectomy appendectomy c-section partial face lift Social History: ___ Family History: Non-contributory Physical Exam: On the day of admission: PHYSICAL EXAM: O: T: BP: 139 / 94 HR:89 R 18 O2Sats 100 CMV Gen: Intubated and sedated w propofol HEENT: No visible sign of trauma Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft Extrem: Warm and well-perfused. Neuro: Mental status: Intubated, +/- weak eye opening Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light 7mm to 5mm bilaterally. Motor: Moves lower extremities spontaneously, flex to nox bilateral upper extremities. Upon discharge: Awake, alert, oriented to self, ___. Intermittently following simple commands. PERRL. No facial droop. Moves all extremities with good strength. Unable to assess individual motor groups due to lack of cooperation. Pertinent Results: ___ CTA: Intraventricular and subarachnoid hemorrhage is unchanged. CT vessels no evidence of vascular occlusion, stenosis, dissection, or abnormal vascular structures or aneurysm greater than 3 mm in size. This report is provided without 3D and curved reformats. When these images are available, and if additional information is obtained, then an addendum may be given to this report. ___ CT head s/p EVD placement: 1. Right frontal approach ventriculostomy catheter in appropriate position with interval decrease in the lateral ventricle sizes. No evidence of new hemorrhage. 2. Stable multi-compartment intracranial hemorrhage. ___ CT Head: Diffuse intraventricular hemorrhage. Increase in ventricular size particularly of the temporal horns slightly compared with the previous CT of ___. EEG ___ This EEG telemetry is abnormal for generalized background slowing and rhythmic delta activity are indicative of global cerebral dysfunction and consistent with a mild moderate encephalopathy of nonspecific etiology. The pushbutton events have no overt electrographic correlate. Of note, the more rhythmic bifrontal activity, sometimes with sharper features, may correspond to periods when propofol was reduced, but this is not known for certain. Results of this study were relayed to the primary caregivers in real time. MRA BRAIN W/O CONTRAST ___ 1. Diffuse intraventricular hemorrhage, unchanged in configuration from prior CT examinations. There is ventriculomegaly, unchanged from exam of ___ but significantly increased since exam of ___. 2. There are foci of slow diffusion involving the left frontal medial cortex as well as along the white matter of the posterior horn of the left lateral ventricle, likely representing late acute to subacute infarcts. CAROTID/CEREBRAL ARTERIOGRAM ___ 1. Evolution and decrease in extent of intraventricular hemorrhage. No new area of hemorrhage or recent infarct is seen. Significant interval decrease in ventricular dilation. 2. Stable location of right ventriculostomy catheter with tip terminating in the foramen of ___. 3. Resolving posterior falcine subdural hematoma. Head CT: ___ 1. Interval placement of new right ventriculostomy catheter which terminates in the body of the right lateral ventricle. 2. No interval change in resolving posterior falcine subdural hematoma or known evolving intraventricular hemorrhage. CEREBRAL EMBO ___ 1. ___ type 3 dural AV fistula now continuing to be fed from distal PCA branches that feed into an early draining vein that drains into the straight sinus. Previously, this has been drained by middle meningeal branches and Onyx embolization, has occluded the middle meningeal on the right with no longer filling of the fistula from these vessels. 2. No evidence of thromboembolic complications CT HEAD W/O CONTRAST ___ Intraventricular hemorrhage and a small posterior falcine subdural hematoma are stable from the prior exam. No evidence of new hemorrhage or acute territorial infarction. PORTABLE HEAD CT W/O CONTRAST ___ IMPRESSION: 1. Decreased ventricular caliber status the prior study. 2. No new evidence of infarction or new hemorrhage. Continued evolution of prior known intraventricular hemorrhage and subdural hematoma. ___ CXR A nasogastric tube terminates within the stomach. The heart size is normal. The hilar and mediastinal contours are within normal limits. Mild atherosclerotic calcifications are seen within the aortic arch. There is no pneumothorax, focal consolidation, or pleural effusion. ___ Non-contrast head CT: 1. No evidence for acute intracranial injury. 2. Small amount of blood in the occipital horns of lateral ventricles has decreased since ___. Small amount of residual subdural blood may be present along the posterior falx. 3. The ventricles have slightly increased in size compared to ___, s/p interim removal of the right ventriculostomy catheter. ___ Non-contrast Cervical spine CT 1. No fracture or acute subluxation. 2. Multilevel degenerative disease. 3. Mixed solid/ ground-glass spiculated lesion in the apical left upper lobe, highly concerning for malignancy. If this has not been previously worked up elsewhere, PET-CT and surgical consultation should be considered. 4. 8 mm left lobe thyroid nodule, which should be further assessed by ultrasound if not previously performed elsewhere. ___ CXR No fractures or acute cardiopulmonary abnormalities.If clinical symptoms persist, dedicated rib series is recommended due to higher sensitivity of that technique. ___ CT chest with contrast Spiculated left apical semi-solid lesion concerning for lung malignancy. ___ CT abdomen and pelvis 1. No evidence of metastatic disease in the abdomen or pelvis 2. 1.7 x 1.8 cm left adnexal cystic structure. If patient is to receive followup CT abdomen and pelvis examinations, this finding may be re-evaluated in ___ year. If patient will not have CT abdomen and pelvis performed in ___ year, pelvic ultrasound examination is recommended in ___ year to re-evaluate left adnexa. 3. Trace amounts of intraperitoneal free air likely related to recent gastrostomy tube placement. 4. 2- 3 mm hypodensities in the pancreatic head likely represent small IPMN. 5. Please see separate dictation for dedicated CT chest report. ___ 06:20AM BLOOD WBC-20.2* RBC-3.69* Hgb-11.4* Hct-33.9* MCV-92 MCH-30.9 MCHC-33.7 RDW-15.1 Plt ___ ___ 06:09AM BLOOD WBC-14.2* RBC-3.86* Hgb-11.6* Hct-36.2 MCV-94 MCH-30.1 MCHC-32.2 RDW-15.3 Plt ___ ___ 06:42AM BLOOD WBC-10.4 RBC-3.97* Hgb-11.9* Hct-35.7* MCV-90 MCH-29.9 MCHC-33.2 RDW-14.8 Plt ___ ___ 10:46AM BLOOD WBC-11.6* RBC-3.70* Hgb-11.2* Hct-33.8* MCV-91 MCH-30.3 MCHC-33.2 RDW-14.9 Plt ___ ___ 01:14AM BLOOD WBC-12.6* RBC-3.51* Hgb-10.5* Hct-31.8* MCV-91 MCH-30.0 MCHC-33.2 RDW-14.8 Plt ___ ___ 02:24AM BLOOD WBC-13.2* RBC-3.11* Hgb-9.5* Hct-27.7* MCV-89 MCH-30.5 MCHC-34.2 RDW-14.1 Plt ___ ___ 01:04AM BLOOD WBC-13.2* RBC-3.07* Hgb-9.2* Hct-27.2* MCV-89 MCH-29.9 MCHC-33.7 RDW-14.0 Plt ___ ___ 02:07AM BLOOD WBC-13.4* RBC-3.36* Hgb-10.2* Hct-29.7* MCV-89 MCH-30.3 MCHC-34.2 RDW-13.8 Plt ___ ___ 02:38AM BLOOD WBC-12.1* RBC-3.23* Hgb-9.7* Hct-29.0* MCV-90 MCH-30.0 MCHC-33.5 RDW-14.2 Plt ___ ___ 02:03AM BLOOD WBC-15.4* RBC-3.73* Hgb-11.2* Hct-33.2* MCV-89 MCH-30.1 MCHC-33.8 RDW-14.1 Plt ___ ___ 11:30AM BLOOD Neuts-92.7* Lymphs-2.4* Monos-4.2 Eos-0.7 Baso-0.1 ___ 06:09AM BLOOD ___ PTT-25.5 ___ ___ 06:09AM BLOOD Glucose-143* UreaN-21* Creat-0.6 Na-133 K-4.4 Cl-97 HCO3-27 AnGap-13 ___ 06:42AM BLOOD Glucose-150* UreaN-14 Creat-0.6 Na-134 K-3.9 Cl-95* HCO3-26 AnGap-17 ___ 02:07AM BLOOD Glucose-145* UreaN-14 Creat-0.6 Na-136 K-3.5 Cl-101 HCO3-23 AnGap-16 ___ 01:14AM BLOOD Glucose-122* UreaN-11 Creat-0.5 Na-136 K-3.7 Cl-101 HCO3-26 AnGap-13 ___ 02:24AM BLOOD Glucose-115* UreaN-7 Creat-0.5 Na-139 K-3.8 Cl-102 HCO3-27 AnGap-14 ___ 06:09AM BLOOD Calcium-9.8 Phos-4.6* Mg-2.6 ___ 06:42AM BLOOD Calcium-9.5 Phos-3.8 Mg-2.4 ___ 02:07AM BLOOD Calcium-8.5 Phos-3.0 Mg-2.2 ___ 01:14AM BLOOD Calcium-8.8 Phos-2.6* Mg-2.2 ___ 02:24AM BLOOD Calcium-8.3* Phos-2.9 Mg-2.4 Brief Hospital Course: Ms. ___ was transferred to ___ for neurosurgical evaluation. She was admitted to the Neurosurgical ICU and a right frontal EVD was placed. A CTA was done that showed no evidence of a vascular lesion. She remained stable overnight into ___. On morning rounds on ___ she was noted to be following commands with all 4 extremities, as well as opening her eyes to voice. Her ICPs remained less than 20, her EVD remained at 15, and she was awaiting an MRI for prognostication. Her son was consented for a diagnostic cerebral angiogram and she was pre-oped for it with plan for it to be done on ___. Later in the day she had a loss of 25cc of CSF during positioning for a procedure which was aborted and EVD leveled appropriately. Later on she was noticed to have horizontal nystagmus and some LUE twitching. She received ativan with good effect. Neurology was consulted and EEG was started. Her keppra was increased to 1000mg BID. She was noted to be posturing intermittently and a STAT CT was obtained which was stable. Later in the evening her exam improved and she was localizing with her uppers and withdrawing her lowers. On ___ she was awaiting MRI and angiogram. Her exam remained stable and per neurology her Keppra was increased to 1500mg BID. On ___, she was unchanged on exam. She awaits angiogram. On ___, she was stable. On ___, she was taken to angiogram for partial embolization of the posterior meningeal branch. Post operatively, she was not moving her BUE to noxious, BLE w/d to noxious and EO to stimuli. Her EVD remains at 15. On ___, on examination, patient spontaneous with LUE and extending RUE. BLE w/d briskly to noxious stimuli. She was made NPO in preparation for angiogram on ___. EVD was raised to 20 in attempts to wean. On ___, the patient was febrile, cultures were sent and patient was given Tylenol. CSF was also sent and showed no growth at this time. Her exam was poor and EVD output was very low, a stat head CT was done which showed that the EVD catheter was placed in the correct position and the IVH was redistributed. A clamp trial was attempted and her ICP elevated to 38 and drain was opened. No output was seen from the EVD and the EVD was replaced. Repeat head CT showed good position of EVD. On ___, the patient's examination improved. Her EVD was left open at 20 and ICPs were within the normal range. The EVD drained briskly throughout the day. She will undergo an angiogram tomorrow. She was extubated in the afternoon but became stridorous and required re-intubation. On ___, the patient's neurologic examination remained stable. She spiked fevers to 102 overnight. Her EVD remained open at 20 and her ICPs were all within normal limits. Her urine was positive for Enterococcus and her antibiotic regimen was changed to Ampicillin. She underwent a BAL and the cultures remain pending at this time. The patient was taken back to the angio suite for further embolization of her Dural AV Fistula and collateral vessels were noted. It was determined further intervention will be necessary in the near future. On ___, the patient was extubated and EVD was clamped. On ___, the patients neurologic status has improved, external ventricular drain remained clamped. The patient was slightly confused, and repeat head CT suggests slightly larger ventricles On ___, the patient was alert, neurological exam was improved. A repeat non contrast head CT was stable. The patient's external ventricular drain was removed, and a sample of CSF fluid was sent for culture routinely. The patient was mobilized out of bed to the chair. The daughters were updated at the bedside by the neurosurgical team. On ___, the patient was alert, eyes open to voice, EOMs grossly intact, patient localizes bilateral upper extremities, and withdraws BLE to pain, patient non verbal. The patient was called out to the step down unit, awaiting a bed. ___/ OT evaluated the patient and recommended rehab. Speech therapy consult was placed to evaluate the patients swallow mechanism. The patient completed a course of ampicillin for UTI today. Foley catheter was changed today. Mrs. ___ was transferred to the step-down unit on ___. Both physical and occupational therapy were consulted and recommended discharge to a rehabilitation facility. The patient was found to have a urinary tract infection and was started on a course of ampicillin. Her Foley catheter was changed. Between ___ and ___, Mrs. ___ continued to recover well. Because the patient was unable to swallow and therefore, had a PEG inserted by ACS on ___. Tube feeds were started the following day. On the early morning of ___, the patient sustained an unwitnessed fall out of bed. A non-contrast head CT was obtained and showed no acute intracranial process. A non-contrast C-spine CT was also obtained and showed no acute fracture or subluxation. Incidentally, however, that exam showed a concerning lesion in the apex of the left upper lung. As a result, a CT torso was obtained to assess for any possible metastatic disease. Mrs. ___ was discharged to a rehabilitation facility on ___. She was afebrile, hemodynamically and neurologically stable. Her course of vancomycin used to treat MRSA pneumonia was completed (7 day course). Her CXR showed no infiltrates and the patient was afebrile for at least 72 hours. Per discharge instructions, the patient should follow up with Dr. ___ service in approximately one month. At that time, planning will be discussed for surgical resection of her dural AV fistula. Medications on Admission: Per OMR: Medications - Prescription ALBUTEROL SULFATE - albuterol sulfate HFA 90 mcg/actuation aerosol inhaler. 2 puffs inhaled q4-6 hr as needed for wheeze, shortness of breath BUDESONIDE [PULMICORT FLEXHALER] - Pulmicort Flexhaler 90 mcg/actuation breath activated. 1 inh(s) inhaled twice a day ESTRADIOL [VAGIFEM] - Vagifem 10 mcg vaginal tablet. as directed - (Prescribed by Other Provider) ESTROGEN-PROGESTERONE-TESTOSTERONE CREAM - Dosage uncertain - (Prescribed by Other Provider) FLUTICASONE - fluticasone 50 mcg/actuation nasal spray,suspension. 2 sprays in each nostril once a day - (Not Taking as Prescribed) METHYLPHENIDATE - methylphenidate 5 mg tablet. 1 Tablet(s) by mouth up to three times a day with some food No to be taken after 5 ___ Medications - OTC CHLORPHENIRAMINE MALEATE - chlorpheniramine ER 12 mg tablet,extended release. 1 tablet(s) by mouth twice a day MULTIVITAMIN - Dosage uncertain - (OTC) PSEUDOEPHEDRINE HCL [LONG ACTING NASAL DECONG (PSE)] - Long Acting Nasal Decongestant (PSE) 120 mg tablet,extended release. 1 tablet(s) by mouth twice a day SODIUM BICARBONATE - Dosage uncertain - (OTC) VIT B COMP-C-FA-IRON-VIT E [VITAMIN B COMPLEX] - Dosage uncertain - (OTC) VITAMIN B12-FOLIC ACID - Dosage uncertain - (OTC) Discharge Medications: 1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN fever 2. Bisacodyl 10 mg PO/PR DAILY 3. Docusate Sodium 100 mg PO BID 4. Heparin 5000 UNIT SC TID 5. LeVETiracetam 1500 mg PO BID 6. Senna 8.6 mg PO BID Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Dural AV fistula Hydrocephalus Respiratory failure Altered mental status Pneumonia Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair. Discharge Instructions: Medications: Take Aspirin 325mg (enteric coated) once daily. Take Plavix (Clopidogrel) 75mg once daily. Continue all other medications you were taking before surgery, unless otherwise directed You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort. What activities you can and cannot do: When you go home, you may walk and go up and down stairs. You may shower (let the soapy water run over groin incision, rinse and pat dry) Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal). After 1 week, you may resume sexual activity. After 1 week, gradually increase your activities and distance walked as you can tolerate. No driving until you are no longer taking pain medications What to report to office: Changes in vision (loss of vision, blurring, double vision, half vision) Slurring of speech or difficulty finding correct words to use Severe headache or worsening headache not controlled by pain medication A sudden change in the ability to move or use your arm or leg or the ability to feel your arm or leg Trouble swallowing, breathing, or talking Numbness, coldness or pain in lower extremities Temperature greater than 101.5F for 24 hours New or increased drainage from incision or white, yellow or green drainage from incisions Bleeding from groin puncture site *SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site) Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call our office. If bleeding does not stop, call ___ for transfer to closest Emergency Room! Followup Instructions: ___
10027957-DS-21	10,027,957	28,485,516	DS	21	2172-09-02 00:00:00	2172-09-04 11:27:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: Pepcid / Sulfasalazine / metronidazole / azathioprine / Remicade / Ceftin Attending: ___ Chief Complaint: Seizure Major Surgical or Invasive Procedure: History of Present Illness: EU Critical ___ is a ___ woman with Crohn's Disease and HTN who presents after an event concerning for seizure. Two hours prior to admission, she called her significant other and was mumbling. He says that it sounded like she were drinking because she kept mumbling and was not making sense. He told her that he would talk to her later. She was apparently coming home from school. Very stressed out, has a paper due tomorrow and if she does not pass an exam, she will not be able to graduate. She was standing at the kitchen sink, roommate came in the room and noticed that she was odd and staring into space and not talking. Roommate came in 3 different times to check on her, and after the third time, the roommate heard a thud. She had fallen at the sink and a glass fell from her hand. Her extremities were extended and shaking, and her whole body was turning to the left side. Her eyes were open and "rolled back." Mother thought episode lasted ___ seconds, but others say less than 1 min. EMS called, and pt had another episode that lasted 1min when they arrived. All episodes self resolved and did not require medication. Blood glucose in the 180s. SBP in 110s with HR in ___ and pin point pupils. She was brought to ___. No tongue biting, unclear if there were any incontinence. Never had episodes like this before. Of note, this would be her third Christmas in the hospital per mother. Pt is not back at baseline. Past Medical History: (per chart, confirmed with pt): CROHN'S DISEASE currently on methotrexate every other week -h/o Remicade infusion reaction --hospitalized ___, Rx cyclosporine and steroids ALLERGIC RHINITIS Occ bronchitis HYPERTENSION diet controlled diabetes LACTOSE INTOLERANCE on lactate POSITIVE PPD, treated with INH x 6 months and ? rifaximin for 9 m in ___, no longer on tx ARTHRITIS knees, ankle and L shoulder, currently receiving ___ hypertension Hx iron def anemia on folic acid x2-3, has not yet gotten iron infusion -HAs on tylenol Social History: ___ Family History: (per chart, confirmed with pt and updated): -No family history of Crohn's. -HTN -breast CA Physical Exam: Admission Exam: Vitals: HR: 113 BP: 119/76 RR: 24 SaO2: 97% RA General: NAD HEENT: NCAT, cervical collar in place ___: RRR, no m/r/g Pulmonary: CTAB, no crackles or wheezes Abdomen: Soft, NT, ND, +BS, no guarding Extremities: Warm, no edema Neurologic Examination: - Mental status: Awake, alert, oriented to self, ___ and Women's and ___ (when asked year, says it is ___. Unable to relate history, inattentive. Follows simple commands. Speech is fluent with short sentences, intact repetition. Naming intact to high frequency objects. No paraphasias. Perseverates. No dysarthria. - Cranial Nerves: PERRL 3->2 brisk. VF full to number counting. EOMI, no nystagmus. V1-V3 without deficits to light touch bilaterally. No facial movement asymmetry. Hearing intact to finger rub bilaterally. Palate elevation symmetric. SCM/Trapezius strength ___ bilaterally. Tongue midline. - Motor: Normal bulk and tone. No drift. No asterixis. Mild postural tremor in LUE. [Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas] [C5] [C5] [C7] [C6] [T1] [L2] [L3] [L5] [L4] [S1] L 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 - Reflexes: [Bic] [Tri] [___] [Quad] [Gastroc] L 3+ 3+ 3+ 3+ 2 R 3+ 3+ 3+ 3+ 2 Plantar response flexor bilaterally. Pectoralis jerk and cross adductors present bilaterally. 2 beats of clonus bilaterally. - Sensory: No deficits to light touch throughout - Coordination: No dysmetria with finger to nose testing bilaterally. - Gait: deferred Discharge Exam Pertinent Results: ___ 06:13AM ___ COMMENTS-GREEN TOP ___ 06:13AM LACTATE-2.0 ___ 05:45AM GLUCOSE-118* UREA N-13 CREAT-0.9 SODIUM-140 POTASSIUM-3.7 CHLORIDE-101 TOTAL CO2-27 ANION GAP-16 ___ 05:45AM estGFR-Using this ___ 05:45AM CALCIUM-9.2 PHOSPHATE-3.5 MAGNESIUM-1.8 ___ 05:45AM WBC-12.6* RBC-3.75* HGB-9.9* HCT-31.1* MCV-83 MCH-26.4 MCHC-31.8* RDW-17.0* RDWSD-51.3* ___ 05:45AM PLT COUNT-350 ___ 11:05PM URINE HOURS-RANDOM ___ 11:05PM URINE HOURS-RANDOM ___ 11:05PM URINE UCG-NEGATIVE ___ 11:05PM URINE GR HOLD-HOLD ___ 11:05PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG ___ 11:05PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 11:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG ___ 11:05PM URINE RBC-1 WBC-1 BACTERIA-FEW YEAST-NONE EPI-1 ___ 11:05PM URINE HYALINE-1* ___ 11:05PM URINE MUCOUS-RARE ___ 10:20PM LACTATE-14.7* ___ 10:08PM GLUCOSE-184* UREA N-13 CREAT-1.1 SODIUM-138 POTASSIUM-3.8 CHLORIDE-95* TOTAL CO2-14* ANION GAP-33* ___ 10:08PM estGFR-Using this ___ 10:08PM ALT(SGPT)-9 AST(SGOT)-19 ALK PHOS-93 TOT BILI-<0.2 ___ 10:08PM ALBUMIN-4.1 CALCIUM-9.7 PHOSPHATE-5.3* MAGNESIUM-2.0 ___ 10:08PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 10:08PM WBC-13.9* RBC-4.10 HGB-10.8* HCT-35.7 MCV-87 MCH-26.3 MCHC-30.3* RDW-17.1* RDWSD-54.0* ___ 10:08PM NEUTS-62.5 ___ MONOS-5.5 EOS-1.5 BASOS-0.4 IM ___ AbsNeut-8.71* AbsLymp-4.08* AbsMono-0.77 AbsEos-0.21 AbsBaso-0.06 ___ 10:08PM PLT COUNT-395 EEG ___ IMPRESSION: This is an abnormal EEG as it demonstrates the presence of a single electrographic seizure (without obvious clinical correlate) originating from left frontotemporal regions, consistent with an active focus of cortical irritability in this region. In addition, there are abundant left frontally predominant sharp waves presenting as continuous runs of slow periodic discharges (0.2-0.3Hz) primarily during sleep, confirming local cortical irritability. There are no other abnormalities noted in her record during wakefulness or sleep. There are three accidental pushbutton activations. MRI/MRV ___ IMPRESSION: 1. Slightly irregular area of dural based enhancement in the anterior interhemispheric fissure adjacent to the left straight gyrus measuring up to 18 x 9 mm with adjacent edema of the left straight/orbital gyri, as described, favored to represent infection, particularly given adjacent mild bony irregularity of the fovea ethmoidalis, possibly fungal in this patient with a history of Crohn's disease with immunosuppression. Dural inflammatory pseudotumor would be the next most likely etiology. Meningioma is considered unlikely, though possible. 2. Minimal areas of white matter signal abnormality in a configuration most suggestive of chronic small vessel ischemic disease. 3. No dural venous sinus thrombosis. 4. Mild paranasal sinus opacification, as described. Brief Hospital Course: ___ is a ___ right-handed woman with past medical history significant for Crohn's disease who presents after 2 events concerning for seizures. She was started on cvEEG and one electrographic seizure was captured on EEG overnight. She was also noted to have a left orbital frontal hypodensity on her CT scan. She was started on seizure prophylaxis with 1000mg of Keppra BID. She underwent a MRI/MRV to better characterize the left sided frontal hypodensity in addition to ruling out other possible focal pathology including a sinus venous thrombosis -which she would be at increased risk for given her Crohn's disease. MRI/MRV showed dural based enhancement and edema of the left straight/orbital gyri concerning for infectious process. ENT and neurosurgery were consulted. ENT exam did not reveal any abnormalities. The decision was made to repeat her imaging in 2 weeks before we proceeding with a biopsy. Of note, the patient was noted to have a cystic lesion in her kidney which should be followed up with ultrasound in ___ year. She was also noted to have a PFO, pulmonary hypertension and 2 pulmonary aneurysms which should be addressed in pulmonary and cardiology clinic (we were unable to arrange these follow ups do to the holiday weekend). Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. diclofenac sodium 1 % topical BID:PRN 3. Fluticasone Propionate NASAL 1 SPRY NU BID 4. FoLIC Acid 1 mg PO DAILY 5. Hydrochlorothiazide 25 mg PO DAILY 6. lidocaine 5 % topical BID:PRN 7. Methotrexate 15 mg SC 1X/WEEK (___) (0.6ml SC once weekly by visiting nurse) 8. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO BID:PRN Pain - Moderate 9. Polyethylene Glycol 17 g PO DAILY:PRN constipation 10. TraMADol 50 mg PO TID:PRN Pain - Moderate 11. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild 12. Calcium Carbonate 500 mg PO DAILY:PRN heartburn 13. Cetirizine 10 mg PO DAILY 14. Glycerin Supps 1 SUPP PR PRN constipation 15. Lactaid (lactase) 3,000 unit oral DAILY:PRN 16. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L. acidophilus-L. rhamnosus;<br>L.acidophilus-Bif. animalis;<br>L.rhamn ___ acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus combination no.4;<br>lactobacillus combo no.11) 15 billion cell oral DAILY Discharge Medications: 1. LevETIRAcetam 1000 mg PO BID RX levetiracetam [Keppra] 1,000 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:*3 2. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild 3. amLODIPine 10 mg PO DAILY 4. Calcium Carbonate 500 mg PO DAILY:PRN heartburn 5. Cetirizine 10 mg PO DAILY 6. diclofenac sodium 1 apl topical BID:PRN rash 7. Fluticasone Propionate NASAL 1 SPRY NU BID 8. FoLIC Acid 1 mg PO DAILY 9. Glycerin Supps 1 SUPP PR PRN constipation 10. Hydrochlorothiazide 25 mg PO DAILY 11. Lactaid (lactase) 3,000 unit oral DAILY:PRN 12. lidocaine 5 % topical BID:PRN 13. Methotrexate 15 mg SC 1X/WEEK (___) (0.6ml SC once weekly by visiting nurse) 14. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO BID:PRN Pain - Moderate 15. Polyethylene Glycol 17 g PO DAILY:PRN constipation 16. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L. acidophilus-L. rhamnosus;<br>L.acidophilus-Bif. animalis;<br>L.rhamn ___ acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus combination no.4;<br>lactobacillus combo no.11) 15 billion cell oral DAILY 17. TraMADol 50 mg PO TID:PRN Pain - Moderate Discharge Disposition: Home Discharge Diagnosis: Seizures Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___ were admitted to ___ for evaluation of episodes that were concerning for seizures. ___ were placed on cvEEG overnight and we captured an electrographic seizure. ___ were started on keppra 1000 mg twice a day. ___ also underwent MRI/MRV of your brain and it showed and area of inflammation in an area of your brain which was likely the cause of your seizures. Please discuss with your primary care doctor the need to set up pulmonary and cardiology follow up appointments Please continue to take your medications as described. ___ have follow up appointments scheduled as below. It was a pleasure taking care of ___. Best, Your ___ Team! Followup Instructions: ___
10027957-DS-22	10,027,957	25,485,223	DS	22	2173-02-26 00:00:00	2173-02-26 17:07:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Pepcid / Sulfasalazine / metronidazole / azathioprine / Remicade / Ceftin Attending: ___. Chief Complaint: vision loss Major Surgical or Invasive Procedure: none History of Present Illness: ___ with Crohn's on MTX, newly Dx'd seizures with brain masses of unknown significance and recent ED visit for L orbital cellulitis presents with sudden onset of monocular vision loss. 2 weeks ag,o the patient was seen in the ED for 1 week of progressive blurry vision. Her eye exam demonstrated increased intraocular pressure and mild proptosis. CT orbit showed fat stranding and she was discharged on clindamycin for orbital cellulitis. The patient had been doing well and awoke this AM with left eye vision loss. Patient states she is able to see some in the periphery of her left eye. She has pain with extraoccular movements. She went to see her eye doctor who did a dilated exam and sent her to ___ for further eval. The patient had been having occasional subjective fevers, last fever 3 days ago. No chest pain or dyspnea. No neck pain. No difficulty swallowing. She was seen by ophtho in the ED: "The ophthalmic exam is normal aside from a previously noted APD in the left eye. The MRI orbits/brain demonstrates what appears to be a left perineuritis. There are no clinical signs of orbital cellulitis, aside from mild proptosis of the left globe. Optic perineuritis is often associated with inflammatory conditions (ie orbital pseudotumor, sarcoid) and is treated with steroids, often times with improvement in vision. The problem is the prior concern that the previously noted brain lesion is an indolent infection, such as fungus. Given this concern, I think the benefit of improved vision with steroids is overruled by the potentially fatal complication of unmasking the potential fungal infection in the brain with steroids." Neurology agreed with ___ evaluation. Seen by ENT as well to eval for mucor. They did a fiberoptic exam, which was reassuring. Also seen by neurosurgery, who felt that benefit from steroids outweighed risk of infection. Decision was made to start steroids. In the ED, initial VS were 0 96.8 83 140/79 18 100% RA . Exam notable for: NAD +left sided proptosis. Pain with EOM of left eye. Pupils dilated Fundoscopic: blurred disc L eye. No erythema RRR no MRG CTAB Visual acuity (patient does not have glasses with her): OD: ___ OS: N/A Occular Pressure (per outpatient eye doctor today ___ 16 L 18) CN III-12 intact Labs showed: WBC 11.8, Hgb 9.1, Hematuria Imaging showed: MRI ORBIT: There is minimal increased signal and enhancement within the retro bulbar fat on the left (series 11, image 8 and series 13 image 7), which given differences in modality is similar compared to the prior CT. In addition, there is increased enhancement of the left orbital nerve compared to the right (series 14, image 8). The left orbital nerve may be slightly expanded compared to the right. Again, these findings likely represent postseptal orbital cellulitis as suggested on the prior CT. No acute abnormalities within the visualized brain parenchyma. Mild paranasal sinus disease is re-demonstrated. Please refer to the final report for full details. Received: Percocet, vanc, levoquin, Benadryl Transfer VS were 79 134/82 16 100% RA Neurology, ophthalmology, ENT, and Neurosurgery were consulted On arrival to the floor, patient confirms the above story. She clarifies that she was previously having fevers (unmeasured, may be hot flashes) but none today or yesterday. She also states her vision improved to baseline after clinda but then when she awoke on day of presentation suddenly had central vision loss. She currently denies F/C, N/V, SOB, Cp/dizzy, abd pain (had some R-sided tenderness earlier), constipation/diarrhea. Endorses continued central vision loss. She had some itching earlier with Percocet that resolved with Benadryl. Vaginal bleeding is minimal. Past Medical History: (per chart, confirmed with pt): CROHN'S DISEASE currently on methotrexate every other week -h/o Remicade infusion reaction --hospitalized ___, Rx cyclosporine and steroids ALLERGIC RHINITIS Occ bronchitis HYPERTENSION diet controlled diabetes LACTOSE INTOLERANCE on lactate POSITIVE PPD, treated with INH x 6 months and ? rifaximin for 9 m in ___, no longer on tx ARTHRITIS knees, ankle and L shoulder, currently receiving ___ hypertension Hx iron def anemia on folic acid x2-3, has not yet gotten iron infusion -HAs on tylenol Social History: ___ Family History: (per chart, confirmed with pt and updated): -No family history of Crohn's. -HTN -breast CA Physical Exam: Admission Physical Exam: ======================= VS: 98.2 PO 138 / 81 87 97 GENERAL: NAD, pleasant HEENT: AT/NC, EOMI w/ tenderness on L, L proptosis, mild periorbital swelling NECK: supple, no LAD, no thyroid nodules palpated HEART: RRR, + murmur LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, nontender in all quadrants, no rebound/guarding EXTREMITIES: no cyanosis, clubbing, or edema NEURO: A&Ox3, moving all 4 extremities with purpose SKIN: warm and well perfused, no excoriations or lesions, no rashes Discharge Physical Exam: ======================= Vitals: 98.4 139/83 87 16 99% RA GENERAL: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear NECK: Supple, JVP not elevated, no LAD RESP: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops ABD: soft. GU: no foley EXT: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema NEURO: visual field testing improved almost resolved, proptosis on left resolving Pertinent Results: Admission Labs: ============== ___ 04:00PM BLOOD WBC-11.8* RBC-3.50# Hgb-9.1# Hct-29.7# MCV-85 MCH-26.0 MCHC-30.6 RDW-16.2* RDWSD-49.8* Plt ___ ___ 04:00PM BLOOD Neuts-77.9* Lymphs-16.6* Monos-4.2* Eos-0.7* Baso-0.3 Im ___ AbsNeut-9.18* AbsLymp-1.95 AbsMono-0.50 AbsEos-0.08 AbsBaso-0.03 ___ 04:00PM BLOOD Plt ___ ___ 04:00PM BLOOD ___ PTT-27.4 ___ ___ 04:00PM BLOOD Glucose-106* UreaN-10 Creat-0.8 Na-141 K-3.8 Cl-105 HCO3-24 AnGap-16 Micro: ===== Lyme pending HIV pending Imaging: ======== MRI brain with orbits: 1. Diffuse enhancement surrounding the left optic nerve with adjacent retrobulbar fat stranding. These findings are suggestive of perineuritis, with differential considerations including inflammatory process such as sarcoid. Postseptal cellulitis is considered less likely. 2. Paranasal sinus disease, as above. 3. Additional chronic findings as described above. Discharge Labs: =============== ___ 08:45AM BLOOD WBC-13.1* RBC-3.10* Hgb-8.2* Hct-26.2* MCV-85 MCH-26.5 MCHC-31.3* RDW-16.3* RDWSD-50.5* Plt ___ ___ 05:30AM BLOOD Glucose-116* UreaN-16 Creat-0.8 Na-143 K-4.1 Cl-110* HCO3-24 AnGap-13 Brief Hospital Course: Ms. ___ is a ___ yo woman with Crohn's disease on methotrexate and recently diagnosed seizure disorder as well abnormal MRI brain findings who presented with vision loss and MRI findings of perineuritis. She was seen by the neurology, neurosurgery, ENT, and ophthalmology in the ED. She was also seen by the infectious disease doctors. ___, her symptoms were thought to be due to either perineuritis from an inflammatory process vs. partially treated post septal cellulitis. She improved with steroids and antibiotics. Steroid course to be determined by ophthalmology team. # Vision loss # Perineuritis: Most likely etiology is inflammatory process vs. infectious. Opthomology recommended steroids 60 mg daily with taper to be determined as outpatient; ID was consulted and felt comfortable with steroids but also recommend unasyn while in house and then augmentin x 2 weeks on discharge out of concern for partially treated pre-septal cellulitis. ID felt there was lower index of suspicion for fungal disease to explain current presentation. B-glucan, galactomanan, HIV, and Lyme were ordered and pending at time of discharge. Patient's vision was much improved at time of discharge. She will follow with optho (scheduled prior to discharge) this week and ID will contact her for a follow-up appointment. #Nasal mucosa management: ENT was consulted in the ED and recommended the following, which she received in house. An ENT appointment was not made at discharge, but the patient was called and given the number to follow with ENT as an outpatient. - Saline nasal spray ___ - Flonase 2 sprays each nostril BID - Afrin 2 sprays TID for 3 days following saline rises # Crohn's: Patient reported that she had not been taking methotrexate at home because she was worried about the cancer risk and equates the methotrexate with her new brain lesions. Her gastroenterologist asked that her methotrexate be restarted, which was recommended to the patient. However, there is an interaction between augmentin and methotrexate so it was recommended that she hold the methotrexate until she complete her antibiotic course. # Anemia # Vaginal bleeding: Stbale throughout stay. On morning of discharge had a drop in H/H but on repeat H/H was back to baseline suggesting a lab error. She was continued on MEDROXYPROGESTERONE ACETATE 10 TABS BID through ___ Chronic Issues: =============== #Hx of Cribiform plate mass: F/u imaging with improvement. - neurosurgery f/u as outpatient # Leptomeningeal enhancement: New, noted on MRI ___. culture reported final report on ___, was also negative. Serum RPR tox antibody were negative. ID discussed with patient the importance of biopsy for definitive diagnosis but she declined. # HTN: Well controlled. - Continued dilt # Seizure disorder: - Continued keppra Transitional Issues: =================== - abx: augmentin through ___ - steroid course to be determined by optho, if patient is on steroids > 4 weeks, would initiate her on Bactrim prophylaxis - Methotrexate was restarted per GI recs, but patient was unwilling to take it, would recommend discussing with her outpatient gastroenterologist - However, should hold methotrexate while on augmentin - should schedule ID follow-up (pending at time of discharge) - pending labs: B-glucan, galactomannan, Lyme titer, and HIV Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB, wheeze 2. azelastine 0.15 % (205.5 mcg) nasal BID 3. Voltaren (diclofenac sodium) 1 % topical Q6H:PRN pain 4. Diltiazem Extended-Release 240 mg PO DAILY 5. Fluticasone Propionate NASAL 1 SPRY NU DAILY 6. FoLIC Acid 1 mg PO DAILY 7. LevETIRAcetam 1000 mg PO BID 8. Lidocaine 5% Ointment 1 Appl TP BID 9. Methotrexate 15 mg SC 1X/WEEK (WE) 10. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO BID:PRN Pain - Severe 11. Polyethylene Glycol 17 g PO DAILY:PRN contstipation 12. TraMADol 50 mg PO TID:PRN Pain - Severe 13. MedroxyPROGESTERone Acetate 10 mg PO BID 14. Beano (alpha-d-galactosidase) 150 unit oral ASDIR 15. Calcium Carbonate 300 mg PO PRN indigestion 16. Cetirizine 10 mg PO DAILY 17. DiphenhydrAMINE 25 mg PO QHS:PRN allergy Discharge Medications: 1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 13 Days RX amoxicillin-pot clavulanate [Augmentin] 875 mg-125 mg 1 daily by mouth twice a day Disp #26 Tablet Refills:0 2. PredniSONE 60 mg PO DAILY RX prednisone 20 mg 3 tablet(s) by mouth daily Disp #30 Tablet Refills:0 3. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB, wheeze 4. azelastine 0.15 % (205.5 mcg) nasal BID 5. Beano (alpha-d-galactosidase) 150 unit oral ASDIR 6. Calcium Carbonate 300 mg PO PRN indigestion 7. Cetirizine 10 mg PO DAILY 8. Diclofenac Sodium ___ ___ sodium) 1 % topical Q6H:PRN pain 9. Diltiazem Extended-Release 240 mg PO DAILY 10. DiphenhydrAMINE 25 mg PO QHS:PRN allergy 11. Fluticasone Propionate NASAL 1 SPRY NU DAILY 12. FoLIC Acid 1 mg PO DAILY 13. LevETIRAcetam 1000 mg PO BID 14. Lidocaine 5% Ointment 1 Appl TP BID 15. MedroxyPROGESTERone Acetate 10 mg PO BID 16. Methotrexate 15 mg SC 1X/WEEK (WE) 17. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO BID:PRN Pain - Severe 18. Polyethylene Glycol 17 g PO DAILY:PRN contstipation 19. TraMADol 50 mg PO TID:PRN Pain - Severe Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary diagnosis: perineuritis post septal cellulitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you at ___. Why was I here? - You had blurred vision. - You were seen by many different doctors and ___ got steroids and antibiotics. - You got better. What should I do when I get home? - It is very important to take all your medicines everyday. - If you do not want to take your methotrexate, please let Dr. ___. Followup Instructions: ___
10027957-DS-23	10,027,957	29,592,503	DS	23	2173-03-10 00:00:00	2173-03-11 01:35:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: Pepcid / Sulfasalazine / metronidazole / azathioprine / Remicade / Ceftin Attending: ___. Chief Complaint: Positive IgM serum lyme Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ year-old woman with a history of Crohn's disease on methotrexate, with recent admission to BI acute onset left eye vision loss found to have an abnormal MRI consistent with left perioptic neuritis which has improved and she now returns with a positive lyme IgM. Ms. ___ reports a history of blurred vision and pain in her left eye which was present for the past month. She presented to the ED three weeks ago with left eye pain and was found to have left eye proptosis on exam. CT showed fat stranding around the eye and she was given a diagnosis of orbital cellulitis and started on Clindamycin which improved the blurry vision. On ___, she awoke with vision loss in the left eye and presented to ___ ED. Initial neurologic exam showed L eye proptosis and APD with a loss of vision in the right hemifield of the left eye. She then underwent MRI brain and orbits which showed diffuse enhancement of the optic nerve sheath on the left consistent with left perioptic neuritis. Neurology was consulted who recommended ID involvement. She was treated initially with Vancomycin and Cipro and then narrowed to Augmentin. She also began Prednisone 60mg daily on ___. She reports improvement in her vision since starting Prednisone. She followed up with Dr. ___ in neuro-ophthalmology most recently in clinic on ___. Visual acuity was documented initially as only to hand movements in the left eye and then ___ after steroids. Etiology was thought to be secondary an underlying autoimmune etiology, though work-up thus far has been negative. She had routine follow-up with her PCP, who sent off lyme which turned out to be positive on ___. She was referred back to the ED to be worked up for possible CNS lyme. On my visit, in the past week since she has been discharged, she states that her vision is now back to baseline. Her pain with extraocular movements has resolved. She denies headache. She did note that 2 days prior she had blurry vision for about 1 hour but then improved to baseline. She states her plan for prednisone and antibiotics were extended for an additional 3 weeks. She is very concerned about how she may have obtained lying. She denies exposure to wounds or tick bites. She denies rashes. She is wondering whether her cat was the reason for her exposure but her cat is a house cat. Since discharge her only complaint is her chronic knee and ankle pain which she has previously attributed to Crohn's. Of note, she was admitted to the neurology service in ___ with events concerning for seizure and was found to have: left frontal seizures with secondary generalization, left frontal FLAIR hyperintensity, anterior skullbase dural enhancement, discontinuity of the ethmoid plate on the left, no clear sinus mass, all new from ___ MRI. LP was notable for 6 wbc, protein 50, normal glucose. Etiology was unknown and given her clinical stability, patient deferred biopsy. She was treated with Keppra 1g BID for her seizures and they have been well controlled since then. ROS notable for chronic joint pains, but no tick bites or rashes. She does note indigestion that improved with baking soda as well as initial nausea when taking prednisone. Past Medical History: (per chart, confirmed with pt): CROHN'S DISEASE currently on methotrexate every other week -h/o Remicade infusion reaction --hospitalized ___, Rx cyclosporine and steroids ALLERGIC RHINITIS Occ bronchitis HYPERTENSION diet controlled diabetes LACTOSE INTOLERANCE on lactate POSITIVE PPD, treated with INH x 6 months and ? rifaximin for 9 m in ___, no longer on tx ARTHRITIS knees, ankle and L shoulder, currently receiving ___ hypertension Hx iron def anemia on folic acid x2-3, has not yet gotten iron infusion -HAs on tylenol Social History: ___ Family History: (per chart, confirmed with pt and updated): -No family history of Crohn's. -HTN -breast CA Physical Exam: Admission Physical Exam: Vitals: T: 99.1 P: 87 R: 16 BP: 137/80 SaO2: 100% RA General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits. Pulmonary: CTABL. No R/R/W Cardiac: RRR, nl. S1S2, no M/R/G Abdomen: soft, NT/ND, +BS, no masses or organomegaly noted. 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 ___ 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. Able to follow both midline and appendicular commands. Pt was able to register 3 objects and recall ___ at 5 minutes. There was no evidence of apraxia or neglect. -Cranial Nerves: II, III, IV, VI: Left eye proptosis. PERRL 3 to 2mm and brisk. EOMI without nystagmus. VFF to confrontation. No red desaturation. Unable to visualize fundi bilaterally. V: Facial sensation intact to light touch. VII: L eye proptosis. No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ ___ 5 5 5 5 5 5 5 R 5 ___ ___ 5 5 5 5 5 5 5 -Sensory: No deficits to light touch, pinprick, cold sensation, vibratory sense, proprioception throughout. No extinction to DSS. -DTRs: Bi Tri ___ Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response was flexor 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. Romberg absent. Discharge Physical Exam: Vitals: T: 97.9 P: 82 R: ___ BP: 147-161/83 SaO2: 100% RA General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits. Pulmonary: CTABL. No R/R/W Cardiac: RRR, nl. S1S2, no M/R/G Abdomen: soft, NT/ND, +BS, no masses or organomegaly noted. 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 ___ 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. Able to follow both midline and appendicular commands. Pt was able to register 3 objects and recall ___ at 5 minutes. There was no evidence of apraxia or neglect. -Cranial Nerves: II, III, IV, VI: Left eye proptosis. PERRL 3 to 2mm and brisk. EOMI without nystagmus. VFF to confrontation. No red desaturation. Unable to visualize fundi bilaterally. V: Facial sensation intact to light touch. VII: L eye proptosis. No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ ___ 5 5 5 5 5 5 5 R 5 ___ ___ 5 5 5 5 5 5 5 -Sensory: No deficits to light touch, pinprick, cold sensation, vibratory sense, proprioception throughout. No extinction to DSS. -DTRs: Bi Tri ___ Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response was flexor bilaterally. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. -Gait: deferred Pertinent Results: ___ 12:35PM BLOOD WBC-14.5* RBC-3.38* Hgb-8.7* Hct-28.2* MCV-83 MCH-25.7* MCHC-30.9* RDW-17.4* RDWSD-52.9* Plt ___ ___ 08:00AM BLOOD WBC-19.3* RBC-3.29* Hgb-8.3* Hct-27.4* MCV-83 MCH-25.2* MCHC-30.3* RDW-17.3* RDWSD-52.1* Plt ___ ___ 12:35PM BLOOD Neuts-91.7* Lymphs-6.4* Monos-1.0* Eos-0.0* Baso-0.1 Im ___ AbsNeut-13.31* AbsLymp-0.93* AbsMono-0.14* AbsEos-0.00* AbsBaso-0.01 ___ 12:35PM BLOOD ___ PTT-23.6* ___ ___ 05:25AM BLOOD ___ PTT-22.0* ___ ___ 12:35PM BLOOD Glucose-160* UreaN-17 Creat-0.8 Na-142 K-4.2 Cl-106 HCO3-23 AnGap-17 ___ 08:00AM BLOOD Glucose-82 UreaN-12 Creat-0.8 Na-145 K-3.8 Cl-107 HCO3-19* AnGap-23* ___ 12:35PM BLOOD ALT-16 AST-13 AlkPhos-78 TotBili-0.2 ___ 12:35PM BLOOD Albumin-4.2 Calcium-8.8 Phos-3.5 Mg-2.0 ___ 08:00AM BLOOD Calcium-8.7 Phos-3.6 Mg-1.9 ___ 12:15PM URINE Color-Straw Appear-Clear Sp ___ ___ 12:15PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 09:08AM CEREBROSPINAL FLUID (CSF) TNC-3 RBC-5 Polys-4 ___ ___ 09:08AM CEREBROSPINAL FLUID (CSF) TotProt-33 Glucose-71 ___ 09:08AM CEREBROSPINAL FLUID (CSF) BORRELIA BURGDORFERI ANTIBODY INDEX FOR CNS INFECTION-PND ___ 09:08AM CEREBROSPINAL FLUID (CSF) ANGIOTENSIN 1 CONVERTING ENZYME-PND ___ 09:08AM CEREBROSPINAL FLUID (CSF) CSF HOLD-Test ___ 9:08 am CSF;SPINAL FLUID Source: LP #3. CSF cytology: pending GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Preliminary): NO GROWTH. ___ 5:25 am Blood (LYME) Lyme IgG (Pending): Lyme IgM (Pending): ___ 12:35 pm BLOOD CULTURE Blood Culture, Routine (Pending): ___ 12:15 pm URINE Site: CLEAN CATCH **FINAL REPORT ___ URINE CULTURE (Final ___: < 10,000 CFU/mL MRI brain and orbits: 1. Interval decrease in left perioptic enhancement and retro-orbital fat stranding suggestive of perineuritis. 2. Stable to decreased enhancement along the interhemispheric fissure and the inferior left orbital gyrus. 3. No evidence of infarction or new abnormal enhancement. CXR: neg Brief Hospital Course: Ms. ___ is a ___ year-old woman with a history of Crohn's disease on methotrexate, with left perioptic neuritis and leptomeningial enhcancement seen on prior neuroimaging that responded to steroids/Augmentin (she had refused biopsy in past admissions). Symptomatically, she is much improved since starting the steroids and her visual acuity is ___ bilaterally with residual left eye proptosis only. She was admitted to Neurology as her serum IgM came back positive for Lyme. Unclear if perioptic neuritis related to lyme or due to other pathology such as inflammatory vs neoplastic. Completed LP on ___ and sent csf for further testing such as csf Lyme/cytology/ACE. CSF studies notable for notable for 3 whites, 5 rbc, normal protein and glucose. Cytology pending serum and CSF/repeat Serum lyme pending at time of discharge. An MRI brain/orbits showed no interval change. We also recommended biopsy to further evaluate and assess her underlying brain lesions, however patient declined. Patient wanted to be discharged and stated she will return if she requires IV antibiotics. # Neurology: 1) Perioptic neuritis - Lumbar Puncture performed ___: Cell Count wbc 3 rbc 3, Protein nl, Glucose nl, ___, Lyme, cytology - Continued current antibiotics (Augmentin) - continued Prednisone 60mg daily x 3 weeks 2) Lyme IgM positive - if csf lyme positive then start IV ceft (will need desensitization, and PICC line) - if repeat serum lyme positive then start doxycycline - ID Consulted, f/u outpatient 3) Seizures: - continued Keppra # CV: HTN - continued Diltiazam # Pulm: - continued albuterol prn # GI: Crohns - held Methotrexate as there is an interaction with Augmentin # Heme: anemia ___ menorrhagia - H/H trended - continued Medroxyprogesterone Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB, wheeze 2. Diltiazem Extended-Release 240 mg PO DAILY 3. FoLIC Acid 1 mg PO DAILY 4. LevETIRAcetam 1000 mg PO BID 5. Lidocaine 5% Ointment 1 Appl TP BID 6. MedroxyPROGESTERone Acetate 10 mg PO BID 7. Methotrexate 15 mg SC 1X/WEEK (WE) 8. Polyethylene Glycol 17 g PO DAILY:PRN contstipation 9. PredniSONE 60 mg PO DAILY 10. azelastine 0.15 % (205.5 mcg) nasal BID 11. Beano (alpha-d-galactosidase) 150 unit oral ASDIR 12. Calcium Carbonate 300 mg PO PRN indigestion 13. Cetirizine 10 mg PO DAILY 14. DiphenhydrAMINE 25 mg PO QHS:PRN allergy 15. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO BID:PRN Pain - Severe 16. TraMADol 50 mg PO TID:PRN Pain - Severe 17. Amoxicillin-Clavulanic Acid ___ mg PO Q12H 18. Diclofenac Sodium ___ ___ sodium) 1 % topical Q6H:PRN pain Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB, wheeze 2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 21 Days 3. Atovaquone Suspension 1500 mg PO DAILY 4. azelastine 0.15 % (205.5 mcg) nasal BID 5. Beano (alpha-d-galactosidase) 150 unit oral ASDIR 6. Calcium Carbonate 300 mg PO PRN indigestion 7. Cetirizine 10 mg PO DAILY 8. Diclofenac Sodium ___ ___ sodium) 1 % topical Q6H:PRN pain 9. Diltiazem Extended-Release 240 mg PO DAILY 10. DiphenhydrAMINE 25 mg PO QHS:PRN allergy 11. FoLIC Acid 1 mg PO DAILY 12. LevETIRAcetam 1000 mg PO BID 13. Lidocaine 5% Ointment 1 Appl TP BID 14. MedroxyPROGESTERone Acetate 10 mg PO BID 15. Methotrexate 15 mg SC 1X/WEEK (WE) 16. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO BID:PRN Pain - Severe 17. Polyethylene Glycol 17 g PO DAILY:PRN contstipation 18. PredniSONE 60 mg PO DAILY 19. TraMADol 50 mg PO TID:PRN Pain - Severe Discharge Disposition: Home Discharge Diagnosis: Inflammatory process Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to ___ with a positive lyme blood test. Given concern that this may be related to you underlying unknown neurologic diagnosis, a lumbar puncture was recommended to evaluate for lyme in the nervous system. Additionally, a lumbar puncture was recommended to further work-up the lesions in your brain, specifically to look for evidence of cancer cells, results of which are pending, but so far the preliminary tests are benign. You were seen by the ID doctors, and your lyme testing in the blood was repeated and lyme was tested in your spinal fluid and the results are pending. If the spinal fluid returns positive, we will have you come back to the hospital to start IV antibiotics. You should continue on Prednisone and Augmentin to treat the inflammation around the optic nerve and follow-up with ophtho and neurology. Please be sure to return to the hospital should we find positive test results. It was a pleasure taking care of you, Your ___ Neurologists Followup Instructions: ___
10028480-DS-17	10,028,480	25,485,913	DS	17	2195-04-05 00:00:00	2195-04-07 22:45:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Morphine / Indocin / Nafcillin Attending: ___. Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a ___ year old AA woman with a PMH significant for HTN, HLD, T2DM, HFrEF (LVEF 25% ___, stage 3 CKD, AFib on warfarin, OSA on CPAP, who presented to the ___ ED with SOB, lower extremity edema, and chest pain. Pt reports worsening since ___ of usual upper, lower back pain and chest pain. She came to pain clinic on day of admission for her chronic back pain where they referred her to ED for her dyspnea. Dyspnea has been worsening over the last week, worse with exertion. Over the last 2 weeks, has been eating salty foods (fried chicken, fast food) because her refrigerator broke. Usually adheres to a healthy diet with home cooked meals with very little added salt. CP is her usual angina by location and character (stabbing, left of sternum), occurs both at rest and on exertion. Does not radiate. Nitro gives complete relief, last taken x2 at 6am on ___. She has had this same chest pain ___ times per week over "many years". Notably, she has UTI with urine cultures positive for E. Coli (___), currently on cefpodoxime 200 mg BID prescribed by her gynecologist which she began ___. She is incontinent at baseline. Denies dysuria, increased frequency, increased urinary urgency, fevers, chills, nausea, vomiting, diarrhea. Past Medical History: Infarct-related Systolic CHF (EF 25% ___ Type 2 IDDM HTN CAD (cath at ___ in ___ showing "small vessel disease", cardiac cath in ___ showing single vessel disease no intervention) Atrial fibrillation CKD, stage 3 OSA on CPAP Gout Non-Hodgkin's lymphoma Multinodular Goiter Glaucoma Chronic Low Back Pain s/p lumbar decompression surgery Osteoporosis Urinary incontinence s/p TAH and BSO s/p bilateral knee replacements s/p bilateral eye surgery Social History: ___ Family History: Diabetes; Grandmother died of MI at ___. Father: MI in ___, Mother: died before her ___ of "heart condition that was undiagnosed" Physical Exam: ADMISSION PHYSICAL EXAM: ====================== GENERAL: Short of breath at rest, difficulty carrying conversation, appears tired, pleasant HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple with distended neck veins, no JVP CARDIAC: Irregularly irregular, no rubs murmurs or gallops. LUNGS: Clear to auscultation bilaterally, no wheezes or crackles. ABDOMEN: Soft, NTND. No HSM or tenderness. Bowel sounds present EXTREMITIES: 1+ pitting edema to shins bilaterally, no cyanosis or clubbing SKIN: No rashes, bilateral linear knee scars from knee replacement surgery PULSES: 2+ Distal pulses palpable and symmetric DISCHARGE PHYSICAL EXAM: ======================= VITALS: T 97.9 PO BP 99/65 Lying HR 99 RR 18 ___ WEIGHT: ADMISSION 94.2 kg 207.67 lb TODAY: 89.9 kg (standing) Is/Os: 24H 480 cc/250 cc; since midnight 280/520 cc GENERAL: Obese, resting in bed comfortably with nebs, no acute distress NECK: Supple, JVP unassessable given AFib CARDIAC: Irregularly irregular, S4 and I/VI systolic murmur loudest at apex. No rubs. LUNGS: Clear to auscultation bilaterally, no wheezes, rhonchi or rales. ABDOMEN: Soft, NTND, obese. GU: No foley in place. No suprapubic tenderness. EXTREMITIES: no edema, cyanosis, clubbing. SKIN: No rashes, bilateral linear knee scars from knee replacement surgery PULSES: 2+ Distal pulses palpable and symmetric Pertinent Results: ADMISSION LABS: ============= ___ 10:40AM BLOOD WBC-7.4 RBC-3.60* Hgb-10.5* Hct-34.7 MCV-96 MCH-29.2 MCHC-30.3* RDW-17.2* RDWSD-58.4* Plt ___ ___ 10:40AM BLOOD Neuts-62.6 ___ Monos-11.7 Eos-0.4* Baso-0.5 NRBC-0.4* Im ___ AbsNeut-4.60# AbsLymp-1.77 AbsMono-0.86* AbsEos-0.03* AbsBaso-0.04 ___ 10:40AM BLOOD ___ PTT-39.3* ___ ___ 10:40AM BLOOD Glucose-203* UreaN-60* Creat-2.3* Na-138 K-5.1 Cl-101 HCO3-21* AnGap-16 ___ 10:40AM BLOOD CK-MB-5 cTropnT-0.02* proBNP-7265* ___ 10:40AM BLOOD Calcium-9.0 Phos-5.5* Mg-2.3 ___ 10:49AM BLOOD Lactate-2.2* DISCHARGE LABS: ============== ___ 07:30AM BLOOD WBC-6.6 RBC-3.40* Hgb-9.5* Hct-32.3* MCV-95 MCH-27.9 MCHC-29.4* RDW-16.4* RDWSD-56.8* Plt ___ ___ 07:30AM BLOOD ___ ___ 07:10AM BLOOD Glucose-101* UreaN-63* Creat-1.8* Na-148* K-3.8 Cl-103 HCO3-29 AnGap-16 ___ 07:10AM BLOOD Calcium-9.0 Phos-4.4 Mg-2.1 DIAGNOSTIC STUDIES: ================== CXR (___): FINDINGS: The heart is enlarged, stable. The trachea is midline. There is mild pulmonary edema, unchanged when allowing for differences in technique. Mild degenerative changes are seen in the spine. IMPRESSION: Mild pulmonary edema. Cardiomegaly. CXR (___): FINDINGS: Cardiac silhouette size remains mildly enlarged. Mediastinal and hilar contours are unremarkable. Lung volumes remain low. Mild pulmonary edema appears new in the interval. No focal consolidation, pleural effusion, or pneumothorax is seen. There are mild degenerative changes seen in the thoracic spine. Mild pulmonary edema, new in the interval. Brief Hospital Course: Ms. ___ is an ___ year old woman with a PMH of HFrEF (25% ___, HTN, HLD, Type 2 DM, stage 3 CKD, Afib on warfarin, OSA on CPAP, who presented with SOB, lower extremity edema, and chest tightness, found to have acute on chronic heart failure exacerbation secondary to high salt diet at home over last 2 weeks. Problems addressed during this hospitalization are listed below: ACTIVE ISSUES: ================================= # Acute on Chronic Heart Failure with Reduced Ejection Fraction(EF 25% ___: Patient presented with elevated BNP (7265), worsening shortness of breath, volume overloaded on physical exam and CXR. Etiology most likely diet-related, as patient reported eating high salt diet over the last 2 weeks (fridge at home broke). Patient compliant with home medications (lives with her son who monitors medications), no significant concern for missed MI as trop negative on admission. Was diuresed with 40-80 IV Lasix as needed, then transitioned to torsemide 80 mg PO BID (previously discharged in ___ on torsemide 40 daily). Her hydralazine was also decreased to 10 in order to make room to increase her isosorbide mononitrate (XR) to 60 mg QD to alleviate her non-exertional chest pain below. She also had her metoprolol succinate XL increased from 50 mg daily to 200 mg daily. # Coronary Artery Disease: Non-exertional chest pain is chronic issue that occurs ___ times per week over many years. Presented with chest tightness. Trops elevated on admission (0.02-->0.04-->0.03), but MB flat, likely related to CKD. Cath at ___ in ___ showed "small vessel disease", repeat cardiac cath in ___ showed single vessel disease without any intervention. Had one episode of CP this admission, relieved with 2 SL nitros, no EKG changes, trops <0.01. Continue aspirin 81 mg, atorvastatin 40 mg, SL nitro as needed, and isosorbide mononitrate 60 mg (increased from prior discharge) as described above. # UTI # Urge incontinence Patient has a history of urge incontinence for approx. ___ year. Made appt to see OBGYN in ___, planned urodynamic study on ___ but was aborted given a urinalysis showed + nitrates and over 100 WBCs. Patient incontinent at home and mostly using adult diapers, tried intermittent cath briefly. Asymptomatic throughout admission; foley was placed to monitor ins and outs. Urine was notably hazy. Urine culture from ___ grew pansensitive E. coli. Completed course of cefpodoxime 200 mg BID (___) prescribed by outpatient gynecologist. Will need follow up with obgyn again. Sent home with another course of cefpodoxime 200 mg BID (___) given a positive UA. # ___: Admission Cr 2.3, values ranged from 1.7-2.6 throughout hospital course (baseline Cr 1.9), Most likely etiology reduced renal perfusion and increased venous pressure from CHF exacerbation. CHRONIC/STABLE ISSUES: ================================= # Chronic Low Back Pain: Present throughout admission, remained at baseline. Continued home Gabapentin 100 mg PO TID, home Lidocaine 5% patch PRN. Given oxycodone 5 mg PO Q4H PRN. Held home oxycodone acetaminophen 7.5-325 mg oral TID. # Type 2 IDDM: Morning sugars 40-60s before breakfast, patient confirms that this happens at home too. Optimized with glargine 34 units at bedtime and ISS. Will need follow-up with endocrinologist as outpatient. # HTN: Continued metoprolol, hydralazine, and isosorbide mononitrate. Changes to dosing as above. # Permanent Atrial Fib w/ RVR: Continued metoprolol as above and home warfarin 7.5 decreased to 3.5 mg QD due to supratherapeutic INRs on admission (peak INR 3.8). # OSA on CPAP: Continued CPAP at night. #Normocytic Anemia: Remained stable (9.4-10.5). #Gout: Held home allopurinol ___ BID. >30 minutes spent on discharge planning/coordination of care. TRANSITIONAL ISSUES: ==================== - Please see changes and additions to medications. - Patient requires follow-up with the heart failure nurse practitioner at the cardiac direct access unit on ___. - Please check basic metabolic panel (potassium, creatinine) within 1 week, as home torsemide dose increased from 40 to 80 mg BID on discharge. - Please check INR and ensure patient compliant and therapeutic with new warfarin dose of 3.5 mg daily. - Patient was started on cefpodoxime for a urinary tract infection (Last ___. - Patient need to have a urodynamic study performed. This was previously deferred given a UTI. Please re-check urinalysis for evidence of UTI prior to obgyn appt on ___. - Her hydralazine was decreased to 10mg TID to increase the Imdur to 60mg daily for better anti-anginal therapy. - Patient requires follow-up with ___ with her endocrinologist Dr. ___ within 2 weeks of discharge to adjust home insulin regimen. - Consider switching from warfarin to rivaroxaban/apixaban (renal dosing), given very low TTR on warfarin. - CODE STATUS: Full code (confirmed) - CONTACT: ___ (daughter) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 40 mg PO QPM 3. Cyanocobalamin 1000 mcg PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Gabapentin 100 mg PO TID 6. HydrALAZINE 20 mg PO Q8H 7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 8. Metoprolol Succinate XL 50 mg PO DAILY 9. oxyCODONE-acetaminophen 7.5-325 mg oral TID 10. Pantoprazole 40 mg PO Q24H 11. Senna 17.2 mg PO BID 12. Vitamin D 1000 UNIT PO DAILY 13. HumaLOG KwikPen (insulin lispro) 100 unit/mL subcutaneous per sliding scale 14. Levemir FlexTouch (insulin detemir) 100 unit/mL (3 mL) subcutaneous 34 units in the morning, 14 units in the evening 15. Torsemide 40 mg PO QAM 16. Warfarin 3.5 mg PO DAILY16 17. Allopurinol ___ mg PO BID 18. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain Discharge Medications: 1. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 3 Days RX cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp #5 Tablet Refills:0 RX cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp #6 Tablet Refills:0 2. HydrALAZINE 10 mg PO Q8H RX hydralazine 10 mg 1 (One) tablet(s) by mouth every eight (8) hours Disp #90 Tablet Refills:0 3. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY RX isosorbide mononitrate 60 mg 1 (One) tablet(s) by mouth once a day Disp #30 Tablet Refills:0 4. Metoprolol Succinate XL 200 mg PO DAILY RX metoprolol succinate 200 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 5. Torsemide 80 mg PO BID RX torsemide 20 mg 4 tablet(s) by mouth twice a day Disp #240 Tablet Refills:0 6. Allopurinol ___ mg PO BID 7. Aspirin 81 mg PO DAILY 8. Atorvastatin 40 mg PO QPM 9. Cyanocobalamin 1000 mcg PO DAILY 10. Docusate Sodium 100 mg PO BID 11. Gabapentin 100 mg PO TID 12. HumaLOG KwikPen (insulin lispro) 100 unit/mL subcutaneous per sliding scale 13. Levemir FlexTouch (insulin detemir) 100 unit/mL (3 mL) subcutaneous 34 units in the morning, 14 units in the evening 14. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 15. oxyCODONE-acetaminophen 7.5-325 mg oral TID 16. Pantoprazole 40 mg PO Q24H 17. Senna 17.2 mg PO BID 18. Vitamin D 1000 UNIT PO DAILY 19. Warfarin 3.5 mg PO DAILY16 20.Hospital Bed Hospital Bed Length: ___ years Diagnosis: Chronic diastolic (congestive) heart failure (I50.32) Limited mobility, severe shortness of breath on exertion 21.Oxygen Oxygen Therapy Length: ___ years Portable O2 tank and concentrator unit Diagnosis: I50.32 Chronic diastolic (congestive) heart failure Severe shortness of breath on exertion and desaturation to <88% 22.Outpatient Lab Work ICD9: 428.3 Please check: Chem 10, INR on ___. Please fax results to ___, MD : ___ Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnosis: ================== Acute on chronic heart failure with reduced ejection fraction Acute on chronic Kidney Injury Secondary Diagnosis: ==================== Coronary Artery Disease Hypertension Hyperlipidemia Type 2 diabetes mellitus Stage 3 Chronic kidney disease Atrial fibrillation Obstructive Sleep Apnea Urinary tract infection Gout Chronic back pain Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - requires assistance or aid Discharge Instructions: Dear Ms. ___, It was a pleasure to care for you at the ___ ___. Why was I admitted to the hospital? - You came to the hospital because you were having shortness of breath and swelling in your legs. - You were found to have extra fluid in your body. We believe this happened because you ate a high salt diet for several weeks before coming to the hospital, and this worsened your heart failure. What happened while I was admitted? - We treated you with medication to remove this extra fluid from your body. Your shortness of breath and swelling improved with this medication. - You developed some chest pain in the hospital, which was similar to the chest pain you often experience at home. We monitored this with blood tests and EKGs, which evaluate the electrical activity of the heart. - We also continued to treat you with antibiotics for a urinary tract infection that you had before you came to the hospital. What should I do when I go home? - Please follow up with your primary care doctor and our heart failure clinic as listed below. - Please maintain a low salt diet (salt causes your body to retain fluid, which makes you short of breath). - Please continue to take your antibiotic (cefpodoxime) for the urinary tract infection for the next 3 days. (Last ___ - Please weigh yourself in the morning everyday. Call your primary care doctor or the heart failure clinic if your weight increases by more than 3 lbs over ___ days. We wish you all the ___, -Your ___ cardiology team Followup Instructions: ___
10028683-DS-3	10,028,683	23,978,212	DS	3	2170-03-16 00:00:00	2170-03-20 09:47:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Beta-Blockers (Beta-Adrenergic Blocking Agts) Attending: ___ Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: Laparoscopic evacuation of blood clot, cauterization of surgical sites, hysteroscopy and dilation and curettage. History of Present Illness: ___ yo G2P2 presents post-op day 3 after laparoscopic salpingectomies with severe abdominal pain. Past Medical History: OBHx G2P2-0-0-2. GYN HX: Menarche age ___. - Irregular menses with menometrorrhagia ___ bleeding episodes per month) with heavy flow. LMP ___. - last PAP (___): neg SIL, +LR HPV, -HR HPV. - s/p Essure HSC permanent sterilization in ___, now s/p LSC removal on ___ - Denies history of any STDs. PMHx: endometriosis, asthma, migraines, chronic constipation, B12 defcy, AUB, recurrent vag candidiasis PSHx: ___, laparoscopy ?fulguration of endometriosis at ___ in ___ and ___, Essure ___, laparoscopic excision of endometriosis ___, b/l salpingectomies as noted Social History: ___ Family History: NC Physical Exam: on presentation: 98.6 63 109/52 16 100RA Appears uncomfortable, speaking in short sentences and bracing herself against gurney RRR CTAB Abd soft, mildly distended, diffusely TTP, mild rebound, no guarding, incisions c/d/i, no erythema Ext WWP, no edema Pelvic copious dark blood in vault, unable to visualize cervix, small anteverted uterus but difficult to examine given severe abdominal tenderness, no adnexal masses Labs 6.7 > 31.8 < 234 PMNs 62.5 no bands INR 1.0 PTT 26.9 ___ 10.8 143 \| 105 \| 8 ---------------< 101 3.5 \| 26 \| 0.___bd/pel w contrast Wet read: 1. Moderate blood within the pelvis. No evidence of extravasation of contrast. 2. No evidence of uterine rupture, although ultrasound is more sensitive for the detection of uterine rupture. 3. No evidence of bowel obstruction or ileus. Pertinent Results: hematocrit: pre-op Hct 42 -> 31 -> 28 -> 24 -> 29 -> ___ prior to discharge Brief Hospital Course: Ms. ___ was readmitted 3 days after laparoscopic bilateral salpingectomies with severe abdominal pain, vaginal bleeding, evidence of hemoperitoneum and falling hematocrit. She was urgently taken back to OR for diagnostic laparoscopy. All surgical sites were noted to be hemostatic but there was 500cc of hemoperitoneum. This was evacuated and surgical sites reinforced. Given no signficiant source identified, she also underwent hysteroscopy (findings: normal cavity) and D&C. Differential diagnosis includes uterine bleeding (menorrhagia) with retrograde flow through cornual surgical sites or resolved surgical bleeding with similar cornual communication and transvaginal passage. She was observed overnight and hematocrit was stable. She was discharged to home in good condition. Medications on Admission: albuterol, fluticasone, ibuprofen, reglan, zofran, percocet, valtrex, colace Discharge Medications: home meds plus: 1. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain Do not drive while taking this medication. RX hydromorphone 2 mg 1 tablet(s) by mouth every four (4) hours Disp #25 Tablet Refills:0 2. Acetaminophen ___ mg PO Q6H:PRN pain Do not take more than 4000mg in one day. RX acetaminophen 500 mg 1 to 2 tablet(s) by mouth every six (6) hours Disp #40 Tablet Refills:2 3. Docusate Sodium 100 mg PO BID Take while using dilaudid to prevent constipation. RX docusate sodium 100 mg 1 capsule(s) by mouth BOD Disp #60 Capsule Refills:2 Discharge Disposition: Home Discharge Diagnosis: hemoperitoneum Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: Take your medications as prescribed. * Do not 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 2 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 bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. Followup Instructions: ___
10029038-DS-2	10,029,038	20,484,353	DS	2	2154-08-29 00:00:00	2154-09-01 14:42:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: headache and arm contraction Major Surgical or Invasive Procedure: none History of Present Illness: The pt is a ___ previously healthy man with a 2 month history of intermittent headaches and R thumb "cramps" who presents tonight after an episode of R arm dystonic posturing in the setting of a headache. He reports that he has had intermittent "brain freeze" headaches over the last few months. They are dull, holocephalic, not too severe, and typically improve with advil or on their own. Over the same period of time he has had ___ episodes of R thumb "cramps," usually in association with a headache. He says that his R thumb will suddenly start to be pulled over toward his pinky finger in a painful, forcible way. This will last ___ minutes and then resolve, and his thumb and lateral hand will feel sore afterward like a muscle cramp. He reports intermittent R sided neck pain as well but is unsure if this correlates with these other symptoms. Looking back he says these did usually seem to occur along with a headache but he didn't think too much of it until yesterday when he had a more dramatic episode. He was at work yesterday evening and developed a mild, typical headache. It had lasted about 20 minutes and he was thinking of taking something for it when his R thumb again began to cramp up. Over the next ___ seconds this then spread to involve his whole R arm. The rest of his fingers first became painfully contorted as well, then his wrist flexed, followed by forced flexion of his arm all the way up to his shoulder, and then painful contraction of his shoulder and neck muscles as well. He said he felt like he could not control his arm at all. He tried with his left hand to open up his hand and bend his arm back down but was unable. The whole episode lasted about 30 seconds, and he says by the time it had spread up to his neck his hand was beginning to relax. Shortly thereafter his whole arm relaxed and returned to normal. There was no weakness in his arm afterward and it felt sore but he was able to use it normally. There was no shaking of the arm during this, and no involvement of any of his other extremities. He remained alert and lucid and able to think and speak clearly throughout this. He called his PCP who recommended that he come into the ED. In addition, he reports occasional severe headaches which are different from the ones described above and wake him from sleep in the early morning. He works as a ___ from 4pm to 2:30am and usually goes to sleep around 3:30am. Over the last several months he has been woken from sleep by very severe headaches a few hours after going to bed around 5 or 6am. The headaches are constant, sharp pain, holocephalic but mostly bitemporal, without any throbbing or photophobia. There are no other associated symptoms. He often cannot go back to sleep so gets up and takes some advil. The headaches can last up to ___ hours. There is no positional component to them, and he can often go back to sleep after they resolve. These tend to happen about once a month, and they seem to cluster together somewhat. He will often get two in one week and then won't have any more for ___ months. He most recently had two of these last week. He denies any history of exertional headaches or headaches during intercourse. He works out quite strenuously on the elliptical machine and never gets headaches during this. He presented to ___ after this episode earlier. Basic labwork was normal (other than K 3.3). A CT head was initially thought be normal but was subsequently reviewed by neuroradiology and there was some concern for hyperdensity of the venous sinuses as well as the intracranial arteries. He was therefore transferred to ___ for neurologic evaluation and further management. Currently he is feeling well with a mild frontal HA and some residual soreness in his R arm but no other complaints. On further history he and his wife reports a few other odd symptoms over the last several months to year. He reports episodes of memory lapses for which he went to see his PCP last fall. He says at times he will be walking or doing something and suddenly will realize time has gone by and he isn't sure what happened. His wife also reports that he has a tendency to fall asleep without warning at any time of the day. They will be sitting and talking and she will look away for a minute and then look back and he will be fast asleep. He is often difficult to arouse and will sometimes sleep for an hour after this. He will then wake up and ask what happened, not realizing he had fallen asleep. On neuro ROS, the pt denies changes in vision, lightheadedness, difficulty speaking, focal weakness, numbness, parasthesiae. No bowel or bladder incontinence or retention. Denies difficulty with gait. On general review of systems, the pt denies recent fever or chills. 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. Past Medical History: Severe dental abscess ___ years ago, became almost septic and was in the hospital for 2 weeks No other hospitalizations or surgeries, otherwise healthy Social History: ___ Family History: Does not know much about family history but reports some heart disease and a paternal uncle with a stroke. No other known history of neurologic disorders. Physical Exam: Physical Exam: Vitals: 98.1 74 118/86 14 98% RA General: Awake, pleasant and cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity. Full range of motion. +Tenderness to palpation over R paraspinal muscles. Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally Skin: no rashes or lesions noted Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name ___ backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Speech was not dysarthric. Able to follow both midline and appendicular commands. The pt had good knowledge of current events. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 4 to 2mm and brisk. VFF to confrontation. Funduscopic exam revealed no papilledema, exudates, or hemorrhages. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ ___ 5 5 5 5 5 5 5 R 5 ___ ___ 5 5 5 5 5 5 5 -Sensory: Reports decreased sensation to pinprick over ulnar surface of R forearm extending into ___ and ___ digits of R hand. No tingling on palpation over ulnar groove. Sensation otherwise intact to light touch and pinprick throughout. Proprioception intact in b/l great toes. -DTRs: Bi Tri ___ Pat Ach L 2 2 2 1 1 R 2 2 2 1 1 Strong withdrawal to plantar stimulation b/l but toes appeared to be down on R, up on L. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. -Gait: Good initiation. Narrow-based, normal stride and arm swing. Slight unsteadiness with a few stumbles on tandem gait. Romberg absent. Pertinent Results: ___ 03:35AM WBC-5.4 RBC-5.52 HGB-17.1 HCT-50.1 MCV-91 MCH-31.0 MCHC-34.1 RDW-12.6 ___ 11:54AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG ___ 03:35AM CALCIUM-9.9 PHOSPHATE-3.5 MAGNESIUM-2.4 Non-Contrast Head CT ___ at ___: Initial concern for abnormal signal on the venous sinuses. However, final read was read as normal with no acute processes. CXR ___: Normal radiographic study of the chest. Brief Hospital Course: Mr ___ is ___ previously healthy man who presented with a 2 month history of intermittent headaches and R thumb "cramps" followed by an episode of R hand and arm dystonic posturing on ___ in the setting of a headache. He also reported a slightly longer history of less frequent, more severe headaches which wake him from sleep in the early morning. His first headache type is somewhat nonspecific, and with the report of R arm dystonic posturing and occasional neck pain raises the possibility of cervical spine disease. This episode did not sound consistent with seizure. His headaches also do not sound typical of vasculitis, given the lack of an exertion component and no focal neurologic symptoms. However he does report taking an "energy complex" exercise supplement; the ingredients of this are currently unknown but there have been reports of vasculitis in patients taking similar supplements. Finally, his neurologic exam was overall unrevealing However, at the outside hospital there was a concern for a potential vascular abnormality on CT and he was admitted to ___ stroke service for an MRI/A/V head and neck in the morning. Since admission he did not re-experience any further headache or dystonic posturing. Upon re-examining the head CT by the stroke team it was determined to be normal, and there was no evidence of mass lesion or edema. Therefore, the MRI/A/V head and neck was cancelled and it was felt that he was safe for discharge and follow up as an outpatient. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Vitamin B Complex 1 CAP PO DAILY 2. Ibuprofen 400 mg PO Q8H:PRN headache Discharge Medications: 1. Ibuprofen 400 mg PO Q8H:PRN headache 2. Vitamin B Complex 1 CAP PO DAILY Discharge Disposition: Home Discharge Diagnosis: headache with right arm contraction episode Discharge Condition: -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.Speech was not dysarthric. Able to follow both midline and appendicular commands. The pt had good knowledge of current events. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 4 to 2mm and brisk. VFF to confrontation. Funduscopic exam revealed no papilledema, exudates, or hemorrhages. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ ___ 5 5 5 5 5 5 5 R 5 ___ ___ 5 5 5 5 5 5 5 -DTRs: Bi Tri ___ Pat Ach L 2 2 2 1 1 R 2 2 2 1 1 Toes appeared to be down on R, and equivicol on the L. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. -Gait: Good initiation. Narrow-based, normal stride and arm swing. Discharge Instructions: Mr. ___, You were admitted on ___ after being transferred from ___ for your headache and right arm contraction episode. Your brain was scanned at ___ and there was concern there might be some abnormalities, but on closer inspection it was considered normal. If this happens again with worsening symptoms please seek medical attention. Please follow up with a neurologist, ___, on ___. Followup Instructions: ___

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