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10000032-DS-22

DS

2180-06-27 00:00:00

2180-07-01 10:15:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Percocet Attending: ___. Chief Complaint: abdominal fullness and discomfort Major Surgical or Invasive Procedure: ___ diagnostic paracentesis ___ therapeutic paracentesis History of Present Illness: ___ with HIV on HAART, COPD, HCV cirrhosis complicated by ascites and HE admitted with abdominal distention and pain. She was admitted to ___ for the same symptoms recently and had 3L fluid removed (no SBP) three days ago and felt better. Since discharge, her abdomen has become increasingly distended with pain. This feels similar to prior episodes of ascites. Her diuretics were recently decreased on ___ due to worsening hyponatremia 128 and hyperkalemia 5.1. Patient states she has been compliant with her HIV and diuretic medications but never filled out the lactulose prescription. She states she has had ___ BMs daily at home. She has had some visual hallucinations and forgetfulness. Her appetite has been poor. In the ED, initial vitals were 98.9 88 116/88 18 97% RA. CBC near baseline, INR 1.4, Na 125, Cr 0.6. AST and ALT mildly above baseline 182 and 126 and albumin 2.8. Diagnostic para with 225 WBC, 7% PMN, total protein 0.3. UA with few bact, 6 WBC, mod leuk, neg nitr, but contaminated with 6 epi. CXR clear. RUQ US with no PV thrombus, moderate ascites. She was given ondansetron 4mg IV and morphine 2.5mg IV x1 in the ED. On the floor, she is feeling improved but still has abdominal distention and discomfort. ROS: +Abdominal distention and pain. No black/bloody stools. No ___ pain or swelling. No fevers or chills. Denies chest pain, nausea, vomiting. No dysuria or frequency. Past Medical History: 1. HCV Cirrhosis 2. No history of abnormal Pap smears. 3. She had calcification in her breast, which was removed previously and per patient not, it was benign. 4. For HIV disease, she is being followed by Dr. ___ Dr. ___. 5. COPD 6. Past history of smoking. 7. She also had a skin lesion, which was biopsied and showed skin cancer per patient report and is scheduled for a complete removal of the skin lesion in ___ of this year. 8. She also had another lesion in her forehead with purple discoloration. It was biopsied to exclude the possibility of ___'s sarcoma, the results is pending. 9. A 15 mm hypoechoic lesion on her ultrasound on ___ and is being monitored by an MRI. 10. History of dysplasia of anus in ___. 11. Bipolar affective disorder, currently manic, mild, and PTSD. 12. History of cocaine and heroin use. Social History: ___ Family History: She a total of five siblings, but she is not talking to most of them. She only has one brother that she is in touch with and lives in ___. She is not aware of any known GI or liver disease in her family. Physical Exam: ADMISSION PHYSICAL EXAM: VS: T98.1 105/57 79 20 97RA 44.6kg GENERAL: Thin chronically ill appearing woman in no acute distress HEENT: Sclera anicteric, MMM, no oral lesions HEART: RRR, normal S1 S2, no murmurs LUNGS: Clear, no wheezes, rales, or rhonchi ABD: Significant distention with visible veins, bulging flanks, nontender to palpation, tympanitic on percussion, normal bowel sounds EXT: no ___ edema, 2+ DP and ___ pulses NEURO: alert and oriented, not confused, no asterixis DISCHARGE PE: VS: T 98.4 BP 95/55 (SBP ___ HR 80 RR 18 O2 95RA I/O 240/150 this am GENERAL: Thin chronically ill appearing woman in no acute distress HEENT: Sclera anicteric, MMM, no oral lesions HEART: RRR, normal S1 S2, no murmurs LUNGS: Clear, no wheezes, rales, or rhonchi ABD: Significant distention with visible veins, bulging flanks, nontender to palpation, tympanitic on percussion, normal bowel sounds EXT: no ___ edema, 2+ DP and ___ pulses NEURO: alert and oriented, not confused, no asterixis Pertinent Results: LABS ON ADMISSION: ___ 04:10PM BLOOD ___ ___ Plt ___ ___ 04:10PM BLOOD ___ ___ ___ 04:10PM BLOOD ___ ___ ___ 04:10PM BLOOD ___ ___ ___ 04:10PM BLOOD ___ ___ 04:39PM BLOOD ___ LABS ON DISCHARGE: ___ 05:10AM BLOOD ___ ___ Plt ___ ___ 05:10AM BLOOD ___ ___ ___ 05:10AM BLOOD ___ ___ ___ 05:10AM BLOOD ___ ___ ___ 05:10AM BLOOD ___ MICRO: ___ 10:39 pm URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ___ 7:00 pm PERITONEAL FLUID PERITONEAL FLUID. GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. ___ 7:00 pm PERITONEAL FLUID PERITONEAL FLUID. GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. Diagnositc Para: ___ 07:00PM ASCITES ___ ___ ___ 07:00PM ASCITES ___ IMAGING: ___ CXR- No acute cardiopulmonary abnormality. ___ RUQ US- 1. Extremely coarse and nodular liver echotexture consistent with a history of cirrhosis. 2. Moderate ascites. 3. Patent portal vein. Brief Hospital Course: ___ with HIV on HAART, HCV cirrhosis with ascites and HE, h/o IVDU, COPD, bipolar disorder presents with abdominal discomfort due to ___ ascites. # ASCITES. Now diuretic refractory given last tap was three days ago with 3L removed and she has already built up moderate ascites. Infectious workup negative, with CXR clear, UA contaminated but not grossly positive so will f/u culture, diagnostic para with only 225 WBC, RUQ US with no PV thrombus. Compliant with diuretics but not following low sodium diet or fluid restriction. Dr. ___ discussed possible TIPS in the office but due to lung disease, that was on hold pending further cardiac evaluation. Diuretics were recently decreased due to hyponatremia and hyperkalemia. Held spironolactone for now due to K 5.2 and increased lasix 20 -> 40. No evidence of severe hyponatremia (Na<120) or renal failure Cr>2.0 to stop diuretics at present. Diagnostic paracentesis negative for infection. Ascitic total protein 0.3 so warrants SBP prophylaxis (<1.0) and fortunately already on Bactrim for PCP prophylaxis which would be appropriate for SBP ppx also. Patient did admit to eating pizza and some ___ food prior to admission. She had therapeutic paracentesis with 4.3L removed and received 37.5G albumin IV post procedure. She felt much better with resolution of abdominal discomfort. Patient is scheduled for repeat paracentesis as outpatient on ___. # HEPATIC ENCEPHALOPATHY. History of HE from Hep C cirrhosis. Now with mild encephalopathy (hallucinations and forgetfulness) due to medication noncompliance, but not acutely encephalopathic and without asterixis on exam. Infectious workup negative thus far. Continue lactulose 30mL TID and titrate to 3 BMs daily and continue rifaximin 550mg BID. # HYPONATREMIA. Na 125 on admission, 128 four days ago, and 135 one month ago. Likely due to third spacing from worsening ascites and fluid overload. 1.5L fluid restriction, low salt diet. S/p therapeutic paracentesis with albumin replacement. # CIRRHOSIS, HEPATITIS C. MELD score of 10 and Child's ___ class B on this admission. Now decompensated due to ascites. Hepatitis C genotype IIIB. Dr. ___ starting ___ and ___ with patient in clinic and the insurance process was started by her office. No history of EGD, needs this as outpatient for varices screening. # NUTRITION. Unclear if truly compliant with low salt diet. Poor oral intake. Low albumin 2.8 on admission. Met with nutrition. # COAGULOPATHY. INR 1.4 four days ago. No evidence of active bleeding. Very mild thrombocytopenia with plts 143. # HIV. Most recent CD4 173. On HAART. No established ID provider. Continue Truvada and Isentress, Bactrim DS daily for PCP ___. Needs outpatient ID appointment # COPD. Stable. States she is on intermittent home O2 for comfort at night and with abdominal distentiom. Continued home COPD meds and home O2 as needed **Transitional Issues** - Discontinued spironolactone ___ elevated potassium - Increased furosemide to 40mg daily - Please recheck electrolytes at next visit - Had paracentesis ___ with 4.3 L removed, received 37.5G albumin - Needs outpatient ID provider - ___ needs more frequent paracentesis Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing, SOB 2. ___ (Truvada) 1 TAB PO DAILY 3. Furosemide 20 mg PO DAILY 4. Raltegravir 400 mg PO BID 5. Spironolactone 50 mg PO DAILY 6. Acetaminophen 500 mg PO Q6H:PRN pain,fever 7. Tiotropium Bromide 1 CAP IH DAILY 8. Rifaximin 550 mg PO BID 9. Calcium Carbonate 1250 mg PO BID 10. Lactulose 15 mL PO TID 11. Sulfameth/Trimethoprim DS 1 TAB PO DAILY Discharge Medications: 1. Acetaminophen 500 mg PO Q6H:PRN pain,fever 2. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing, SOB 3. Calcium Carbonate 1250 mg PO BID 4. ___ (Truvada) 1 TAB PO DAILY 5. Furosemide 40 mg PO DAILY 6. Lactulose 15 mL PO TID 7. Raltegravir 400 mg PO BID 8. Rifaximin 550 mg PO BID 9. Sulfameth/Trimethoprim DS 1 TAB PO DAILY 10. Tiotropium Bromide 1 CAP IH DAILY Discharge Disposition: Home Discharge Diagnosis: Primary: diuretic refractory ascites Secondary: HCV cirrhosis, HIV, hyponatremia, COPD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, ___ was a pleasure to take care of you at ___ ___. You were admitted with abdominal fullness and pain from your ascites. You had a diagnostic and therapeutic paracentesis with 4.3 L removed. Your spironolactone was discontinued because your potassium was high. Your lasix was increased to 40mg daily. You are scheduled for another paracentesis on ___ prior to your other appointments that day. Please call tomorrow to find out the time of the paracentesis. Please continue to follow a low sodium diet and fluid restriction. You should call your liver doctor or return to the emergency room if you have abdominal pain, fever, chills, confusion, or other concerning symptoms. Sincerely, Your ___ medical team Followup Instructions: ___

10000117-DS-21

DS

2181-11-15 00:00:00

2181-11-15 15:04:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: omeprazole Attending: ___. Chief Complaint: dysphagia Major Surgical or Invasive Procedure: Upper endoscopy ___ History of Present Illness: ___ w/ anxiety and several years of dysphagia who p/w worsened foreign body sensation. She describes feeling as though food gets stuck in her neck when she eats. She put herself on a pureed diet to address this over the last 10 days. When she has food stuck in the throat, she almost feels as though she cannot breath, but she denies trouble breathing at any other time. She does not have any history of food allergies or skin rashes. In the ED, initial vitals: 97.6 81 148/83 16 100% RA Imaging showed: CXR showed a prominent esophagus Consults: GI was consulted. Pt underwent EGD which showed a normal appearing esophagus. Biopsies were taken. Currently, she endorses anxiety about eating. She would like to try eating here prior to leaving the hospital. Past Medical History: - GERD - Hypercholesterolemia - Kidney stones - Mitral valve prolapse - Uterine fibroids - Osteoporosis - Migraine headaches Social History: ___ Family History: + HTN - father + Dementia - father Physical Exam: ================= ADMISSION/DISCHARGE EXAM ================= VS: 97.9 PO 109 / 71 70 16 97 ra GEN: Thin anxious woman, lying in bed, no acute distress HEENT: Moist MM, anicteric sclerae, NCAT, PERRL, EOMI NECK: Supple without LAD, no JVD PULM: CTABL no w/c/r COR: RRR (+)S1/S2 no m/r/g ABD: Soft, non-tender, non-distended, +BS, no HSM EXTREM: Warm, well-perfused, no ___ edema NEURO: CN II-XII grossly intact, motor function grossly normal, sensation grossly intact Pertinent Results: ============= ADMISSION LABS ============= ___ 08:27AM BLOOD WBC-5.0 RBC-4.82 Hgb-14.9 Hct-44.4 MCV-92 MCH-30.9 MCHC-33.6 RDW-12.1 RDWSD-41.3 Plt ___ ___ 08:27AM BLOOD ___ PTT-28.6 ___ ___ 08:27AM BLOOD Glucose-85 UreaN-8 Creat-0.9 Na-142 K-3.6 Cl-104 HCO3-22 AnGap-20 ___ 08:27AM BLOOD ALT-11 AST-16 LD(LDH)-154 AlkPhos-63 TotBili-1.0 ___ 08:27AM BLOOD Albumin-4.8 ============= IMAGING ============= CXR ___: IMPRESSION: Prominent esophagus on lateral view, without air-fluid level. Given the patient's history and radiographic appearance, barium swallow is indicated either now or electively. NECK X-ray ___: IMPRESSION: Within the limitation of plain radiography, no evidence of prevertebral soft tissue swelling or soft tissue mass in the neck. EGD: ___ Impression: Hiatal hernia Angioectasia in the stomach Angioectasia in the duodenum (biopsy, biopsy) Otherwise normal EGD to third part of the duodenum Recommendations: - no obvious anatomic cause for the patient's symptoms - follow-up biopsy results to rule out eosinophilic esophagitis - follow-up with Dr. ___ if biopsies show eosinophilic esophagitis Brief Hospital Course: Ms. ___ is a ___ with history of GERD who presents with subacute worsening of dysphagia and foreign body sensation. This had worsened to the point where she placed herself on a pureed diet for the last 10 days. She underwent CXR which showed a prominent esophagus but was otherwise normal. She was evaluated by Gastroenterology and underwent an upper endoscopy on ___. This showed a normal appearing esophagus. Biopsies were taken. TRANSITIONAL ISSUES: -f/u biopsies from EGD -if results show eosinophilic esophagitis, follow-up with Dr. ___. ___ for management -pt should undergo barium swallow as an outpatient for further workup of her dysphagia -f/u with ENT as planned #Code: Full (presumed) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Omeprazole 20 mg PO BID Discharge Medications: 1. Omeprazole 20 mg PO BID Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: -dysphagia and foreign body sensation SECONDARY DIAGNOSIS: -GERD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were hospitalized at ___. You came in due to difficulty swallowing. You had an endoscopy to look for any abnormalities in the esophagus. Thankfully, this was normal. They took biopsies, and you will be called with the results. You should have a test called a barium swallow as an outpatient. We wish you all the best! -Your ___ Team Followup Instructions: ___

10000935-DS-19

DS

2187-07-12 00:00:00

2187-07-12 14:01:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Codeine / Bactrim Attending: ___ Chief Complaint: nausea, vomiting, cough Major Surgical or Invasive Procedure: none History of Present Illness: ___ female, with past medical history significant for depression, hyperlipidemia, Hysterectomy, B12 deficiency, back pain, carcinoid, cervical DJD, depression, hyperlipidemia, osteoarthritis, and history of Exploratory laparotomy, lysis of adhesions, and small bowel resection with enteroenterostomy for a high grade SBO ___ who presents with nausea, vomiting, weakness x 2 weeks. She has been uable to tolerate PO liquids, and solids. Had similar presentation ___ for high grade SBO. Denies passing flatus today. However reports having last normal bowel movement this AM, without hematochezia, melena. Also reporting subjective fever (100.0), non productive cough. Denies HA, myalgias. Takes NSAIDS sparingly. Denies alcohol use. Denies sick contacs/ travel or recent consumption of raw foods. Has never had a colonoscopy. . In ED VS were 97.8 120 121/77 20 98% RA Labs were remarkable for lactate 2.8, alk phos 293, HCT 33, WBC 13.9 Imaging: CT abdomen showed mult masses in the liver, consistent with malignancy. CXR also showed multiple nodules EKG: sinus, 112, NA, NI, TWI in III, but largely unchanged from prior Interventions: zofran, tylenol, 2L NS, GI was contacted and they are planning on upper / lower endoscopy for cancer work-up. . Vitals on transfer were 99.2 113 119/47 26 98% Past Medical History: PMH: # high grade SBO ___ s/p exploratory laparotomy, lysis of adhesions, and small bowel resection with enteroenterostomy # carcinoid # hyperlipidemia # vitamin B12 deficiency # cervical DJD # osteoarthritis PSH: s/p R lung resection in ___ at ___ s/p hysterectomy in ___ s/p R arm surgery Social History: ___ Family History: non contributory Physical Exam: On admission VS: 98.9 137/95 117 20 100 RA GENERAL: AOx3, NAD HEENT: MMM. no JVD. neck supple. HEART: Regular tachycardic, S1/S2 heard. no murmurs/gallops/rubs. LUNGS: CTAB, non labored ABDOMEN: soft, tender to palpation in epigastrium. EXT: wwp, no edema. DPs, PTs 2+. SKIN: dry, no rash NEURO/PSYCH: CNs II-XII intact. strength and sensation in U/L extremities grossly intact. gait not assessed. On Discharge: VS: 98.7 118/78 97 20 99RA GENERAL: Patient is sitting in a chair, appears comfortable, A+Ox3, cooperative. HEENT: EOMI, PERRLA, No Pallor or Jaundice, MMM, no JVD, neck supple. HEART: RRR, no m/r/g. LUNGS: CTAB ABDOMEN: obese, soft, mild tenderness on mid +right epigastrium w/o peritoneal signs, no shifting dullness, difficult to appreciate organomegaly. EXT: wwp, no edema, no signs of DVT SKIN: no rash, normal turgor NEURO: no gross deficits PSYCH: appropriate affect, no preceptual disturbances, no SI, normal judgment. Pertinent Results: ___ 03:14PM ___ ___ 12:50PM URINE HOURS-RANDOM ___ 12:50PM URINE UHOLD-HOLD ___ 12:50PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 12:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-TR ___ 12:50PM URINE RBC-2 WBC-2 BACTERIA-NONE YEAST-NONE EPI-2 ___ 09:54AM LACTATE-2.8* ___ 09:45AM GLUCOSE-96 UREA N-7 CREAT-0.5 SODIUM-138 POTASSIUM-3.5 CHLORIDE-100 TOTAL CO2-27 ANION GAP-15 ___ 09:45AM estGFR-Using this ___ 09:45AM ALT(SGPT)-17 AST(SGOT)-46* ALK PHOS-293* TOT BILI-0.5 ___ 09:45AM LIPASE-14 ___ 09:45AM ALBUMIN-3.0* ___ 09:45AM ___ AFP-1.7 ___ 09:45AM WBC-13.9* RBC-3.94* HGB-9.8* HCT-33.0* MCV-84# MCH-25.0*# MCHC-29.9* RDW-16.1* ___ 09:45AM NEUTS-75.2* LYMPHS-17.9* MONOS-5.9 EOS-0.7 BASOS-0.3 ___ 09:45AM PLT COUNT-657*# CT abdomen/pelvis 1. Innumerable hepatic and pulmonary metastases. No obvious primary malignancy is identified on this study. 2. No evidence of small bowel obstruction, ischemic colitis, fluid collection, or perforation. CXR: New nodular opacities within both upper lobes, left greater than right. Findings are compatible with metastases, as was noted in the lung bases on the subsequent CT of the abdomen and pelvis performed later the same day. Brief Hospital Course: ___ Female with PMH significant for depression, hyperlipidemia, Hysterectomy, B12 deficiency, OA, carcinoid, cervical DJD, depression, SBO who presented with nausea, vomiting, weakness x 2 weeks and was found to have multiple liver and lung masses per CT consistent with metastatic cancer of unknown primary. Patient was treated with IV fluids overnight for dehydration. She refused to stay in the hospital for any further work-up or treatment and stated she would rather go home to to think and see to her affairs over the weekend and consider pursuing further work-up as an outpatient. She tolerated oral fluids well w/o vomiting. She remained hemodynamically stable and afebrile throughout her stay. Of note patient has psychiatric history of depressive symptoms and isolation tendencies. She denied any SI/SA or any risk to herself. She has little social supports but does have a good relationship with her driver and friend who came in and was updated by the medical team on the morning of discharge and will be taking her home. She sees a mental health provider at ___ once a month and has a good relationship with her primary care physician. Patient was dischaerged home at her request. Home medications were continued to which we added some symptomatic treatment for her cough with benzonatate and Guaifenesin. We held off on anti-emetics for now as she did not want to stay inhouse to make sure these would be well tolerated (would need to monitor for drug interactions given multiple QTc prolonging and serotonergic medications on her home meds). She was instructed to maintain good hydration and try a soft diet at home if she can not tolerate regular diet. The patient met with SW who provided her with resources for community councelling. Outpatient appointments with oncology, GI and her PCP were set up and her PCP and mental health provider were updated. Her PCP ___ also ___ with her later today by telephone. Medications on Admission: The Preadmission Medication list is accurate and complete 1. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing/SOB 2. BuPROPion 150 mg PO DAILY 3. Gabapentin 300 mg PO TID 4. Ibuprofen 800 mg PO Q8H:PRN pain 5. Sertraline 200 mg PO DAILY 6. Simvastatin 40 mg PO DAILY 7. Tizanidine 4 mg PO BID:PRN muscle spasms/pain 8. traZODONE 100 mg PO HS:PRN sleep 9. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID Discharge Medications: 1. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB 2. BuPROPion 150 mg PO DAILY 3. Gabapentin 300 mg PO TID 4. Sertraline 200 mg PO DAILY 5. Simvastatin 40 mg PO DAILY 6. Tizanidine 4 mg PO BID:PRN muscle spasms/pain 7. traZODONE 100 mg PO HS:PRN sleep 8. Ibuprofen 800 mg PO Q8H:PRN pain 9. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID 10. Benzonatate 100 mg PO TID:PRN cough RX *benzonatate 100 mg 1 capsule(s) by mouth TID: PRN cough Disp #*60 Capsule Refills:*0 11. Guaifenesin ___ mL PO Q6H:PRN cough RX *guaifenesin 100 mg/5 mL ___ ml by mouth Q6H:PRN cough Disp #*1 Bottle Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Liver and Lung Mets of unkown primary Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, ___ were seen in the ED for ongoing cough, nausea and vomiting and had imaging studies which unfortunately showed spots in your liver and lungs which are likely due to wide-spread cancer. ___ were admitted for further work-up and treatment of your symptoms. ___ chose to not have any more work-up in the hospital and wanted to be discharged home as soon as possible. Please make sure ___ keep well hydrated by taking water sips throughout the day. I also prescribed some symptomatic treatment for your nausea and cough. I updated your PCP and ___ and have set up ___ appointments as below. Followup Instructions: ___

10000935-DS-21

DS

2187-10-26 00:00:00

2187-10-27 15:36:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Codeine / Bactrim Attending: ___. Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Percutaneous liver biopsy History of Present Illness: Ms. ___ is a ___ with metastatic cancer of unknown primary (known lesions in lungs and liver) presenting with shortness of breath. She initially presented to ___ in ___ with abdominal pain and failure to thrive. Evaluation at that time included an abdominal CT scan that showed multiple lung and liver metastases. She has yet to undergo definite diagnosis with biopsy, and per recent oncology documentation seems disengaged with care. She was reportedly in her usual state of health until the evening prior to admission, when she developed acute on chronic shortness of breath while at rest. She reported midsternal chest ache associated with this shortness of breath. Pain is exacerbated by direct pressure; nothing seems to alleviate pain. She denied any pleuritic or exertional component to the chest pain or shortness of breath. She feels that symptoms are secondary to her "cancer" and "feels as if the cancer has spread". She reports stable, chronic nonproductive cough, which has been present over the preceding months. She was seen recently in the ED for evaluation of left greater than right lower extremity edema with lower extremity venous ultrasounds negative, without change in edema since since that visit. She denies associated fever, chills, sweats, PND, orthopnea, or positional component to pain. In the ED, initial vital signs were: 98.0 116 100/49 24 99% RA. Labs notable for leukocytosis to 17.9, hematocrit of 32, and lactate of 2.8. Urinalysis was positive, but with 19 epithelial cells. CTA was negative for central pulmonary embolus, focal consolidation, or pleural effusion, though did reveal innumerable pulmonary nodules, as well as enlarged liver with stable metastases. EKG was interpreted as sinus tachycardia and was overall consistent with prior. Ceftriaxone/azithromycin were initiated for possible pneumonia. Vital signs on transfer were as follows: 97.9 107 100/60 22 100% RA. On arrival to the floor, she reports that shortness of breath has improved and that she is chest pain free. Past Medical History: Per OMR: # metastatic cancer of unknown primary # high grade SBO ___ s/p exploratory laparotomy, lysis of adhesions, and small bowel resection with enteroenterostomy # carcinoid # hyperlipidemia # vitamin B12 deficiency # cervical DJD # osteoarthritis s/p R lung resection in ___ at ___ s/p hysterectomy in ___ s/p R arm surgery Social History: ___ Family History: Per OMR: Mother - Died of pancreatic cancer at age ___. Father - Died of ___ disease at age ___. Physical Exam: On admission: VS: 97.9 114/71 105 sinus 18 95%2L GENERAL: non-toxic appearing, speaking in full sentences HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM NECK: supple, no LAD, no JVD CHEST: mild reproducible pain on palp of midsternum; no palpable mass LUNGS: poor aeration but relatively CTA bilat, no r/rh/wh, resp unlabored, no accessory muscle use HEART: clear and audible heart sounds, tachycardiac but regular rhythm, sofy SEM, nl S1-S2 ABDOMEN: normal bowel sounds, soft, mild tenderness to palp throughout and more pronounced in the RUQ, non-distended, no rebound or guarding, palpable liver edge EXTREMITIES: left > right 1+ pitting edema to mid shin, 2+ pulses radial and dp NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact At discharge: VS - Tc 99.7, 116/59, 131, 18, 99% RA GENERAL: obese, NAD, lying in bed comfortably, flat affect and poor eye contact HEENT: NCAT, EOMI, mild scleral icterus, pink conjunctiva, MMM, poor dentition, mild palor of conjunctiva NECK: supple, no LAD CARDIAC: tachycardic but regular, S1/S2, no m/r/g LUNG: CTAB in anterior fields, decreased breath sounds at right base, exam limited secondary to body habitus and mobility, no w/r/r, no accessory muscle use ABDOMEN: obese, ND, +BS, no rebound/guarding, localized area of firmness in mid-upper abdomen and tender to palpation over this area EXTREMITIES: WWP, 2+ DP pulses bilaterally, 1+ pitting edema to torso bilateraly NEURO: no asterixis, moving all four extremities, minimal movement ___ to gravity but distal muscles 4+/5, good hand grip strength today Pertinent Results: On admission: ___ 12:50PM BLOOD WBC-17.9* RBC-3.69* Hgb-9.5* Hct-32.1* MCV-87 MCH-25.8* MCHC-29.7* RDW-19.1* Plt ___ ___ 12:50PM BLOOD Neuts-82.8* Lymphs-11.7* Monos-4.4 Eos-0.7 Baso-0.3 ___ 12:50PM BLOOD ___ PTT-31.2 ___ ___ 12:50PM BLOOD Glucose-97 UreaN-12 Creat-0.6 Na-140 K-2.7* Cl-92* HCO3-31 AnGap-20 ___ 12:50PM BLOOD ALT-17 AST-73* LD(___)-586* CK(CPK)-218* AlkPhos-340* TotBili-2.6* DirBili-1.8* IndBili-0.8 ___ 12:50PM BLOOD CK-MB-1 cTropnT-<0.01 ___ 12:50PM BLOOD Albumin-2.5* Mg-2.2 ___ 12:50PM BLOOD Hapto-307* ___ 05:12PM BLOOD Lactate-2.8* ___ 06:00PM URINE Color-YELLOW Appear-Cloudy Sp ___ ___ 06:00PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-10 Bilirub-SM Urobiln-8* pH-6.0 Leuks-MOD ___ 06:00PM URINE RBC-0 WBC-66* Bacteri-FEW Yeast-NONE Epi-14 ___ 06:00PM URINE CastHy-6* At discharge: ___ 08:30AM BLOOD WBC-16.1* RBC-3.06* Hgb-8.3* Hct-29.2* MCV-95 MCH-27.1 MCHC-28.5* RDW-22.5* Plt ___ ___ 08:30AM BLOOD Glucose-95 UreaN-7 Creat-0.3* Na-143 K-3.5 Cl-110* HCO3-20* AnGap-17 ___ 08:30AM BLOOD Calcium-8.3* Phos-2.4* Mg-1.9 Microbiology: Blood x2 (___): No growth Urine (___): No growth Blood x2 (___): No growth Pathology: Liver biopsy (___): Liver, core needle biopsy (A): Adenocarcinoma, involving the liver (see note). Note: Immunohistochemical stains are performed. The tumor cells are positive for CK20 and CDX-2, and negative for CK7 and TTF-1. These results are consistent with metastasis from a colorectal primary. Imaging: EKG (___): Sinus tachycardia. Low voltage. Diffuse non-specific repolarization abnormalities. Compared to the previous tracing of ___ repolarization abnormalities are slightly more prominent. ___ ___ Portable CXR (___): Innumerable pulmonary metastases. Possible mild pulmonary vascular congestion. Low lung volumes. CTA (___): 1. No central or segmental filling defect in the pulmonary arteries. Evaluation is slightly limited due to suboptimal IV bolus. 2. Innumerable bilateral pulmonary nodules, simas seen on the prior CT study on ___, slightly increased. No focal consolidation or pleural effusion. 3. Enlarged liver with multiple hypodense lesions, with suggestion of increased burden of disease. Right upper quadrant ultrasound (___): Extensive diffuse hepatic metastatic disease. No evidence of biliary duct obstruction. Portable CXR (___): 1. Low lung volumes and mild pulmonary vascular congestion is unchanged. 2. New small right fissural pleural effusion. 3. No new focal opacities to suggest pneumonia. Noncontrast head CT (___): No acute intracranial process. No mass is identified. MRI is more sensitive for evaluation of metastases. Left hip XR (___): No definite lytic lesion; however, an MRI can be performed to evaluate for an osseous lesion if indicated. Portable abdomen (___): Radiographs of the abdomen and pelvis demonstrate a nonobstructed bowel gas pattern. A relative paucity of bowel gas is present in the upper and mid abdomen, likely due to marked enlargement of the liver, displacing bowel loops. Note that the upright view is technically suboptimal, and limits evaluation for free intraperitoneal air. If free intraperitoneal air is suspected clinically, a left lateral decubitus view of the abdomen would be recommended. Brief Hospital Course: Ms. ___ is a ___ with metastatic cancer of unknown primary, including lesions in the liver and lungs, who initially presented with shortness of breath, likely due to worsening intrapulmonary tumor burden, and later underwent percutaneous liver biopsy with pathology consistent with metastatic colon cancer, prompting transfer to the oncology service and eventually discharged home with hospice. Active Issues: (1) Metastatic colon adenocarcinoma: CTA to exclude pulmonary embolus and right upper quadrant ultrasound on admission demonstrated progression of previously recognized metastatic cancer of unknown primary involving the liver and lungs, which had evaded diagnosis in the outpatient setting due to patient reluctance to engage with care. Percutaneous liver biopsy ultimately revealed primary colonic adenocarcinoma. Following discussion with her outpatient oncology providers, she was transferred to the inpatient oncology service for potential trial of FLOX. However, given the patient's very poor functional and nutritional status a goals of care discussion was held with the patient's HCP, ___ and it was decided to focus goals of care of comfort and symptom management and the patient was discharged home with home hospice. (2) Left thigh weakness/spinous tenderness: She was found to have focal left thigh weakness in association with diffuse spinous tenderness of unclear chronicity in the setting of preserved rectal tone without saddle anesthesia. She was noted to be incontinent of urine, but not feces. Given underlying malignancy, there was concern for bony metastases or cord involvement, with alternative consideration given to epidural abscess, prompting transient initiation of empiric antibiotic coverage with vancomycin/cefepim ___ to ___. Despite frequent persuasive efforts, she declined multiple attempts at lumbosacral MRI, including with lorazepam premedication, citing claustrophobia. Neuro exam was monitored and remained stable. (3) Abdominal pain: She experienced intermittent abdominal pain and tenderness without peritoneal signs, concerning for obstruction in the setting of intraabdominal malignancy, particularly given episodes of emesis/hematemesis as below. While multiple KUBs were negative for obstruction, CT abdomen was planned to evaluate for alternative sources of intraabdominal pathology, but she declined on multiple occasions. Pain was controlled with acetaminophen and tramadol as needed. (4) ? Hematemesis: She experienced a single episode of small volume emesis, reportedly approximately 100cc, streaked with blood and found to be guiac positive. Vital signs and hematocrit remained stable. IV pantoprazole was initiated for gastrointestinal prophylaxis, with subsequent discontinuation of PPI given no recurrence and questionable if first episode was true blood vs. red popsicle was eating at time. Esophagogastroduodenoscopy was deferred in the absence of recurrent hematemesis; no prior EGDs were available in OMR. (5) Altered mental status: She was intermittently altered throughout admission, never oriented to more than person and place, with occasional difficulty following simple commands as compared to an uncertain baseline. Infectious work up, including blood and urine cultures and CTA on admission with subsequent CXRs, was unrevealing. Noncontrast head CT was negative for acute intracranial process. Brain MRI for definitive exclusion of metastases could not be obtained due to claustrophobia/MRI aversion as above. ABG on ___ without signs of CO2 retention. History of opiates making patient sleepy per HCP as possible contributing factor and therefore these were discontinued. Hepatic encephalopathy also on differential given metastatic lesions to liver and asterixis on exam. AMS could also be ___ to severe depression. Mental status monitored and remained stable and patient at baseline per HCP on discharge. (6) Shortness of breath: She presented with acute onset shortness of breath without frank hypoxia. CTA on admission was negative for pulmonary embolus, though (subsegmental clot could not be excluded definitively), pleural effusion, or focal infiltrate. EKG and cardiac enzymes were reassuring against acute coronary syndrome. Low voltages on EKG were consistent with prior, hence limited suspicion for pericardial effusion. Shortness of breath resolved over the course of admission without dedicated treatment, with the exception of nebulizers and expectorants as needed. (7) Leukocytosis: White blood cell count was elevated and peaked at 20.6, consistent with recent baseline, likely reflecting underlying malignancy. As noted above, infectious work up including CTA, urine and blood cultures, and CXRs, was unrevealing. She remained afebrile, with the exception of isolated transient fever to 100, with stable vital signs. (8 )Liver function test abnormalities: AST remained elevated ___ to ___, alkaline phosphatase 260s to 380s, and total bilirubin 2.1 to 2.6, likely due to hepatic infiltration of malignancy. Right upper quadrant ultrasound was negative for cholecystitis or obstructive process. The possibility of superimposed intraabdominal process, such as infection, could not be excluded in the setting of abdominal pain with emesis as above, but she declined CT for further evaluation. (9) Elevated lactate: Lactate was found to be 2.7-3.8 throughout admission despite copious IV fluids, likely reflecting compromised hepatic clearance in the setting of malignant infiltration. (10) Sinus tachycardia: She remained persistently tachycardic 100s to 115s throughout admission in the setting of poor PO intake, but incompletely responsive to copious IV fluids. Tachycardia has been present since at least ___. Despite concurrent leukocytosis and elevated lactate, there was no clear infectious source, hence low suspicion for sepsis. Subsegmental pulmonary embolus could not be excluded on the basis of admission CTA, but shortness of breath was short lived, and she was never hypoxic. Hematocrit remained stable without signs of active bleeding, with the exception of transient hematemesis as above. (11) Depression: She appeared depressed with flat affect and seeming anhedonia throughout admission, with underlying depression likely affecting motivation to seek diagnosis and treatment of known malignancy. She denied active suicidal ideation and frequently declined home sertraline, particularly prior to liver biopsy, believing that it was supposed to be held preprocedurally despite explanation to the contrary. She was seen by social work throughout admission. (12) Normocytic anemia: Hematocrit remained stable and consistent with recent baseline at 27 to 33 throughout admission, seemingly due to anemia of chronic disease on the basis of preadmission labs. Vital signs remained stable, with the exception of persistent tachycardia, without signs of active bleeding apart from isolated blood streaked emesis as above. (13) Coagulopathy: INR of 1.2 to 1.8 was felt to reflect synthetic dysfunction in the setting of hepatic infiltration of malignancy, as well as poor oral intake. There were no signs of active bleeding, with the exception of transient hematemesis as above. Transitional Issues: -Patient discharge home with home hospice Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB 2. BuPROPion 150 mg PO DAILY 3. Gabapentin 300 mg PO HS 4. Sertraline 200 mg PO DAILY 5. traZODONE 100 mg PO HS:PRN sleep 6. Ondansetron 4 mg PO Q8H:PRN nausea 7. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 8. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain please hold for sedation, RR<10 9. Enoxaparin Sodium 40 mg SC DAILY Discharge Medications: 1. BuPROPion 150 mg PO DAILY 2. Ondansetron 4 mg PO Q8H:PRN nausea 3. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain RX *tramadol 50 mg 1 tablet(s) by mouth every four (4) hours Disp #*60 Tablet Refills:*0 4. Senna 1 TAB PO BID:PRN constipation RX *sennosides [___] 8.6 mg 1 tablet by mouth twice a day Disp #*60 Tablet Refills:*0 5. Omeprazole 20 mg PO DAILY RX *omeprazole 20 mg 1 capsule,delayed ___ by mouth Daily Disp #*30 Capsule Refills:*0 6. Hospital Bed Bariatric Hospital Bed and Therapeutic Mattress: BariMaxxII 7. Hospice Order Please Screen and Admit to Hospice. 8. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 9. Docusate Sodium 100 mg PO BID 10. Sertraline 200 mg PO DAILY 11. traZODONE 100 mg PO HS:PRN sleep 12. Polyethylene Glycol 17 g PO DAILY:PRN constipation Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: Metastatic colon adenocarcinoma Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: Dear Ms. ___, It was a pleasure taking part in your care during your admission to ___. As you know, you were admitted for shortness of breath, likely due to your underlying cancer, and there was no evidence of pneumonia or blood clot in the blood vessels of your lungs. Your shortness of breath resolved, but you were found to have weakness in your left thigh and abdominal pain. You declined imaging studies for further investigation of these findings. You underwent biopsy of your liver that revealed that the cancer known to affect your liver and lungs originated in your colon (large bowel). You were transferred to the oncology service, but unfortunately chemotherapy would do more harm for you than good. After a long discussion with you and your health care proxy, it was decided that you will go home to be with your family and loved ones. We will also set up hospice services for you so that they can help with any issues that arise while you are at home. Followup Instructions: ___

10000980-DS-20

DS

2188-01-05 00:00:00

2188-01-06 20:49:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo woman with h/o hypertension, hyperlipidemia, diabetes mellitus on insulin therapy, h/o cerebellar-medullary stroke in ___, CKD stage III-IV presenting with fatigue and dyspnea on exertion (DOE) for a few weeks, markedly worse this morning. Over the past few weeks, the patient noted DOE and shortness of breath (SOB) even at rest. She has also felt more tired than usual. She notes no respiratory issues like this before. She cannot walk up stair due to DOE, and feels SOB after only a short distance. She is unsure how long the episodes last, but states that her breathing improves with albuterol which she gets from her husband. She had a bad cough around a month ago, but denies any recent fevers, chills, or night sweats. No chest pain, nausea, or dizziness. Past Medical History: 1. CAD RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: MI in ___ 3. OTHER PAST MEDICAL HISTORY: Hypertension Hyperlipidemia Diabetes mellitus on insulin therapy h/o cerebellar-medullary stroke in ___ CKD stage III-IV PVD Social History: ___ Family History: Denies cardiac family history. Family hx of DM and HTN; otherwise non-contributory. Physical Exam: Admission exam: GENERAL- Oriented x3. Mood, affect appropriate. VS- T= 98.1 BP= 200/103 HR= 65 RR= 26 O2 sat= 100% on RA HEENT- NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK- JVD to angle of mandible CARDIAC- RR, normal S1, S2. No murmurs, rubs or gallops. No thrills, lifts. LUNGS- Kyphosis. Resp were labored, mild exp wheezes bilaterally. ABDOMEN- Soft, non-tender, not distended. Abd aorta not enlarged by palpation. No abdominal bruits. EXTREMITIES- No clubbing, cyanosis or edema. No femoral bruits. SKIN- No stasis dermatitis, ulcers, scars, or xanthomas. NEURO- CNII-XII grossly intact. Strength ___ in LEs and UEs. Diminished sensation along lateral aspect of left leg to light touch Discharge exam: Lungs: CTAB Otherwise unchanged Pertinent Results: Admission Labs ___ 01:18PM BLOOD WBC-6.4# RBC-3.15* Hgb-9.5* Hct-30.1* MCV-96 MCH-30.1 MCHC-31.5 RDW-14.1 Plt ___ ___ 01:18PM BLOOD Glucose-150* UreaN-33* Creat-1.6* Na-144 K-4.8 Cl-111* HCO3-18* AnGap-20 ___ 01:18PM BLOOD CK(CPK)-245* ___ 01:18PM BLOOD cTropnT-0.05* ___ 01:18PM BLOOD CK-MB-6 proBNP-4571* ___ 03:56AM BLOOD Calcium-9.4 Phos-4.9* Mg-2.0 Cholest-230* Pertinent Labs ___ 06:09AM BLOOD WBC-4.3 RBC-3.27* Hgb-9.9* Hct-31.4* MCV-96 MCH-30.4 MCHC-31.6 RDW-14.5 Plt ___ ___ 06:09AM BLOOD Glucose-138* UreaN-31* Creat-1.4* Na-144 K-4.3 Cl-107 HCO3-26 AnGap-15 ___ 06:09AM BLOOD ALT-20 AST-17 ___ 03:56AM BLOOD Triglyc-97 HDL-65 CHOL/HD-3.5 LDLcalc-146* ___ 03:56AM BLOOD %HbA1c-8.1* eAG-186* ___ 01:18PM BLOOD CK(CPK)-245* CK-MB-6 cTropnT-0.05* ___ 08:43PM BLOOD CK(CPK)-198 CK-MB-5 cTropnT-0.03* ___ 03:56AM BLOOD CK(CPK)-173 CK-MB-5 cTropnT-0.04* ___ 06:09AM BLOOD cTropnT-0.01 ___ 01:18PM proBNP-4571* ECG ___ 7:56:06 ___ Baseline artifact. Sinus rhythm. The Q-T interval is 400 milliseconds. Q waves in leads V1-V2 with ST-T wave abnormalities extending to lead V6. Consider prior anterior myocardial infarction. Since the previous tracing of ___ atrial premature beats are not seen. The Q-T interval is shorter. ST-T wave abnormalities are less prominent. CXR ___: PA and lateral views of the chest demonstrate low lung volumes. Tiny bilateral pleural effusions are new since ___. No signs of pneumonia or pulmonary vascular congestion. Heart is top normal in size though this is stable. Aorta is markedly tortuous, unchanged. Aortic arch calcifications are seen. There is no pneumothorax. No focal consolidation. Partially imaged upper abdomen is unremarkable. IMPRESSION: Tiny pleural effusions, new. Otherwise unremarkable. ECHO ___: The left atrium is mildly dilated. The estimated right atrial pressure is ___ mmHg. 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 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 masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. An eccentric, anteriorly directed jet of mild to moderate (___) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. Pulmonary artery hypertension. Mild-moderate mitral regurgitation. Moderate tricuspid regurgitation. Compared with the prior study (images reviewed) of ___, the severity of mitral and tricuspid regurgitation are increased and moderate PA hypertension is now identified. Brief Hospital Course: ___ woman with h/o hypertension, hypelipidemia, diabetes mellitus on insulin, cerebellar-medullary stroke in ___, stage ___ CKD followed by Dr ___ presenting with fatigue and DOE for a few weeks, markedly worse the morning of admission. The patient has known diastolic dysfunction. Of note, she has been noncompliant with her medications at home. On arrival to the floor, she required hydralazine 20 mg to bring down her BP. She has likely had elevated BPs at home for a while, which is contributing to her SOB, CHF exacerbation, and secondary demand myonecrosis (hypertensive urgency) with mildly elevated troponin. # CAD: Although she did not have a classic anginal presentation, patient has several risk factors for acute coronary syndrome. Her only symptom was SOB in the setting of elevated BPs attributed to medication noncompliance at home. Her troponin fell from 0.05 at admission to 0.01 at discharge in the setting of renal dysfunction, but there was not a clear rise and fall to suggest an acute infarction from plaque rupture and thrombosis. She was scheduled for an outpatient stress test to evaluate for evidence of ischemia from flow-limiting CAD. We decreased ASA to 81 mg from 325 mg daily to decrease the risk of bleeding. Her LDL was found to be 146. We wanted to change her from simvastatin to the more potent atorvastatin (and avoid issues with drug-drug interactions), but her insurance would not cover atorvastatin. She was therefore switched to pravastatin 80 mg at discharge. From a cardiac standpoint, we did not feel that Plavix was necessary for CAD, but her neurologist was contacted and wanted Plavix continued. We had to stop metoprolol due to HR in the ___ during admission even off metoprolol. # Pump: Last echo in ___ showed low normal LVEF. Her current presentation was consistent with CHF exacerbation with bilateral pleural effusions, dyspnea, and elevated NT-Pro-BNP. Her TTE showed mild-moderate mitral and moderate tricuspid regurgitation, LVEF 50-55%, and pulmonary hypertension. We changed her HCTZ to Lasix 40 mg PO at discharge. This medication can be uptitrated as needed. # Hypertension: The patient's nephrologist, Dr. ___, agreed with our proposed medication adjustments, but recommended staying away from clonidine. There has been a H/O medication non-adherence. Social work was involved in discharge planning, and ___ will be assisting the patient at home. We added lisinopril 20 mg daily, Lasix 40 mg daily and continued nifedipine 120 mg daily. Her atenolol was stopped due to her renal dysfunction, but her metoprolol had to be stopped due to bradycardia. She should continue on once a day medication dosing to help with compliance. # ? COPD: The patient may have a component of COPD as she was wheezing on admission and responded to albuterol. She was given a prescription for albuterol prn. Transitional Issues: - She will be scheduled for outpt stress stress test - She has follow-up appointments with Dr. ___ and Dr. ___ and both can work on uptitrating her BP meds as needed. - ___ will need to work with patient on medication compliance. Medications on Admission: ATENOLOL - 100 mg Tablet - 1.5 Tablet(s) by mouth once a day CLONIDINE - 0.1 mg/24 hour Patch Weekly - place on shoulder once a week CLOPIDOGREL [PLAVIX] - 75 mg Tablet - 1 Tablet(s) by mouth once a day generic is available preferable, please call Dr ___ an appointment FENOFIBRATE MICRONIZED - 134 mg Capsule - 1 Capsule(s) by mouth once a day HYDROCHLOROTHIAZIDE - 25 mg Tablet - 1 (One) Tablet(s) by mouth once a day NIFEDIPINE [NIFEDIAC CC] - 60 mg Tablet Extended Release - 2 Tablet(s) by mouth once a day NITROGLYCERIN [NITROSTAT] - 0.3 mg Tablet, Sublingual - 1 Tablet(s) sublingually sl as needed for prn chest pain may use 3 doses, 5 minutes apart; if no relief, ED visit RANITIDINE HCL - 300 mg Tablet - 1 Tablet(s) by mouth once a day SIMVASTATIN - 80 mg Tablet - 1 Tablet(s) by mouth at bedtime Medications - OTC ASPIRIN [ENTERIC COATED ASPIRIN] - 325 mg Tablet, Delayed Release (E.C.) - 1 (One) Tablet(s) by mouth once a day INSULIN NPH & REGULAR HUMAN [HUMULIN 70/30] - 100 unit/mL (70-30) Suspension - 30 units at dinner at dinner MULTIVITAMIN - (OTC) - Tablet - 1 Tablet(s) by mouth once a day Discharge Medications: 1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain: may take up to 3 over 15 minutes. Disp:*30 Tablet, Sublingual(s)* Refills:*0* 3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 5. pravastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 7. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. nifedipine 60 mg Tablet Extended Release Sig: Two (2) Tablet Extended Release PO DAILY (Daily). Disp:*30 Tablet Extended Release(s)* Refills:*2* 9. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. insulin NPH & regular human 100 unit/mL (70-30) Insulin Pen Sig: Thirty (30) units Subcutaneous at dinner. Disp:*900 units* Refills:*2* 11. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: ___ puffs Inhalation every ___ hours as needed for shortness of breath or wheezing. Disp:*1 inhaler* Refills:*1* Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: -Hypertension with hypertensive urgency -Myocardial infarction attributed to demand myonecrosis -Acute on chronic left ventricular diastolic heart failure -Chronic kidney disease, stage ___ -Chronic obstructive pulmonary disease -Prior cerebellar-medullary stroke -Hyperlipidemia -Diabetes mellitus requiring insulin therapy -Medication non-adherence 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 shortness of breath. You were found to have elevated blood pressure on admission in the setting of not taking all of your medications regularly. We obtained an echocargiogram of your heart which showed some strain on your heart possibly related to your elevated blood pressures. You will be contacted about an outpatient stress test. This will be completed within the next month. You will be prescribed several new medications as shown below. A visiting nurse ___ come to your home to help with managing your medications. You should dispose of all your home medications and only take the medications shown on this discharge paperwork. Medications: STOP Hydrochlorothiazide STOP Simvastatin STOP Clonidine STOP Atenolol due to low heart rate CHANGE 325mg to 81mg once daily START Lisinopril 20mg once daily START Lasix 40mg once daily START Pravastin 80mg once daily If you experience any chest pain, excessive shortness of breath, or any other symptoms concerning to you, please call or come into the emergency department for further evaluation. Thank you for allowing us at the ___ to participate in your care. Followup Instructions: ___

10000980-DS-21

DS

2189-07-03 00:00:00

2189-07-03 19:50:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: dyspnea Major Surgical or Invasive Procedure: Cardiac catheterization ___ History of Present Illness: This is a ___ M with history of diabetes, diastolic CHF, hypertension, ?CAD, peripheral vascular disease, CKD presenting with ___ days of increasing dyspnea and non-productive cough. She denies fevers, chills, chest pain, nausea, vomiting. Did report feeling somewhat wheezy. Denies leg swelling, has possibly had a 2 lb weight gain. Denies missed medication doses. Does report 2 pillow orthopnea last night. Her husband has also been sick with a cough for the past day or so. She is a non-smoker. She lives at home and has had no recent hospitalizations or courses of antibiotics. In the ED, initial vitals: 97.8 80 132/83 25 97% ra. CXR showed probable RUL PNA. Normal WBC and lactate, Cr at baseline. Troponin 0.09 with normal CK-MB. BNP 2826. She was started on bipap due to tachypnea and increased work of breathing. She was given 40mg IV lasix and started on vancomycin, cefepime and levofloxacin. On transfer, vitals were: 69 141/82 28 100% bipap On arrival to the MICU, patient reports improved breathing on bipap. Review of systems: (+) Per HPI Past Medical History: - hypertension - diabetes - hx CVA (cerebellar-medullary stroke in ___ - CAD (has never been cathed, hx of MI in ___ - peripheral arterial disease- claudication, followed by vascular, managed conservatively - stage IV CKD (baseline 2.5-2.8) - GERD/esophageal rings Social History: ___ Family History: Niece had some sort of cancer. Otherwise, no family history of cancer or early heart disease. Physical Exam: ADMISSION EXAM: General- appears comfortable on BiPap HEENT- PERRL, EOMI Neck- difficult to assess JVP due to habitus and presence of BiPap strap CV- RRR, no gallops Lungs- good air entry. diffuse crackles R>L, rhonchi in RUL. scattered inspiratory wheezing Abdomen- soft, NTND Ext- trace edema, faint peripheral pulses Neuro- A and O x 3, moving all 4 extremities. mildly decreased strength in LLL DISCHARGE EXAM: VS: T98.9 BP144/83 P66 RR18 99RA 76.1kg GENERAL: Laying in bed, sleeping. No acute distress. HEENT: Moist mucous membranes. NECK: Supple, unable to visualize JVP. CARDIAC: Regular rate and rhythm. Normal S1, S2. No S3, S4. ___ systolic murmur. LUNGS: Clear to auscultation bilaterally. No crackles, wheezes, rhonchi. ABDOMEN: +BS, soft, nondistended, nontender to palpation. EXTREMITIES: Warm and well perfused. Pulses 2+. Trace peripheral edema. Pertinent Results: ON ADMISSION: ___ 06:48AM BLOOD WBC-5.3 RBC-2.94* Hgb-9.5* Hct-27.3* MCV-93 MCH-32.4* MCHC-34.9 RDW-13.5 Plt ___ ___ 06:48AM BLOOD Neuts-65.6 ___ Monos-5.2 Eos-2.7 Baso-0.4 ___ 08:03PM BLOOD ___ PTT-69.6* ___ ___ 06:48AM BLOOD Glucose-89 UreaN-37* Creat-2.3* Na-144 K-3.9 Cl-109* HCO3-21* AnGap-18 ___ 06:48AM BLOOD CK-MB-6 proBNP-2826* ___ 06:48AM BLOOD cTropnT-0.09* ___ 12:58PM BLOOD CK-MB-9 cTropnT-0.11* ___ 07:52AM BLOOD Lactate-1.7 ___ 07:40AM URINE Color-Straw Appear-Clear Sp ___ ___ 07:40AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ON DISCHARGE: ___ 09:00AM BLOOD WBC-4.8 RBC-2.53* Hgb-8.0* Hct-23.6* MCV-94 MCH-31.5 MCHC-33.7 RDW-12.9 Plt ___ ___ 09:26AM BLOOD Glucose-121* UreaN-52* Creat-2.2* Na-142 K-4.5 Cl-108 HCO3-24 AnGap-15 ___ 09:26AM BLOOD Calcium-9.9 Phos-4.8* Mg-2.5 CXR: ___ Right upper lobe pneumonia or mass. However, given right hilar fullness, a mass resulting in post-obstructive pneumonia is within the differential. Recommend chest CT with intravenous contrast for further assessment. TTE: ___ The left atrium is elongated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild to moderate regional left ventricular systolic dysfunction with near-akinesis of the inferior, inferolateral and basal lateral segments. The remaining segments contract normally (LVEF = 35-40%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. An eccentric jet of moderate to severe (3+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild to moderate regional left ventricular systolic dysfunction, c/w CAD. Moderate to severe mitral regurgitation. Moderate pulmonary hypertension. Compared with the prior study (images reviewed) of ___, regional LV wall motion abnormalities are new. Severity of mitral regurgitation has increased. CARDIAC CATH: ___ 1. Selective coronary angiography of this right dominant system revealed three vessel coronary artery disease. The LMCA had no obstructive disease. The LAD had a moderate disease in the mid artery and a diagonal branch had an 80% proximal lesion. The Lcx had a 70% proximal lesion. The RCA was totally occluded mid-vessel. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Recommend CABG evaluation CT CHEST: ___ 1. Diffuse confluent ground-glass opacities predominantly in the right upper lobe and right lower lobe most likely represent residual pulmonary edema, localized to the right lung because of direction of jet in mitral regurgitation. 2. Possible pulmonary hypertension. 3. Moderate coronary artery disease. CAROTID US: ___ No evidence of hemodynamically significant internal carotid stenosis on either side. ECHO ___- PCI) There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with inferior and infero-lateral hypokinesis. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The mitral valve leaflets are mildly thickened. An eccentric jet of mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Compared with the prior study (images reviewed) of ___, the LVEF has increased. The degree of MR seen has decreased. Brief Hospital Course: ___ female with ___, HTN, diabetes, CKD presented with increased dyspnea and non-productive cough without fevers or elevated white count, initially admitted to ___ with concern for pneumonia. However, was found to have ST-changes, enzyme leak, new wall motion abnormality consistent with a recent cardiac event and had no evidence of pneumonia (no fevers, wbc, lactate, normal vitals, CXR with likely one sided pulmonary edema from mitral regurgitation). She was seen by cardiology who transferred the patient to cardiology floor. # Acute systolic CHF exacerbation/mitral regurgitation: Likely secondary to ischemic valvular disease resulting in worsening mitral regurgitation. ECHO also with akinetic inferior wall segments, which also supports an ischemic event. Cardiac cath revealed 3 vessel disease. Patient was managed medically with lasix, lisinopril, and metoprolol. Cardiac surgery was consulted for possible CABG and mitral valve repair/replacement. However, given her multiple comorbidities, she is extremely high risk and surgery was deferred. Therefore, the decision was made to revascularize the patient with PCI to see if the patient would regain function of her mitral valve. Patient received a bare metal stent in the LCx and plain old balloon angioplasty in the diagonal artery. Repeat echo showed improvement of her mitral regurgitation. # NSTEMI/CAD: As evidenced by EKG changes and troponin leak. Patient was briefly started on a heparin drip prior to her first cardiac catheterization. As above, cardiac catheterization revealed 3-vessel disease. Patient was initially medically managed with aspirin, plavix, metoprolol, lisinopril, and atorvastatin. As the patient would be too high risk for CABG, patient returned to the cath lab and had a bare metal stent and POBA. She will require plavix for at least 1 month. # Hypertension: Patient remained normotensive. Continued nifedipine at half of her home dose. Continued on lisinopril. She was also started on metoprolol as above for CHF. # Diabetes: Continued home insulin regime. # CKD stage IV: Baseline Cr 2.5-2.8 per renal notes. Currently at baseline. # History of CVA: Continued home aspirin and clopidogrel. # GERD: Continued home ranitidine. TRANSITIONAL ISSUES: * Will need follow up with a cardiologist. Patient will be scheduled to follow up with the first available CMED cardiologist. * Will need plavix for at least one month (day of bare metal stent placement = ___. * Atorvastatin dose increased to 80mg (per pharmacy, her insurance will cover. Her co-pay will be $10/month). * Consider titrating nifedipine dose back to 120mg if still hypertensive. * Please recheck Chem7 at next appointment to evaluate for ___ secondary to dye received during cardiac catheterization. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 30 mg PO DAILY 2. NIFEdipine CR 60 mg PO DAILY 3. Ranitidine 300 mg PO DAILY 4. Pravastatin 80 mg PO DAILY 5. HumuLIN 70/30 (insulin NPH and regular human) 30 units subcutaneous daily 6. Ferrous Sulfate 325 mg PO BID 7. Furosemide 40 mg PO DAILY 8. Multivitamins 1 TAB PO DAILY 9. Nitroglycerin SL 0.3 mg SL PRN chest pain 10. DiphenhydrAMINE 25 mg PO HS:PRN insomnia 11. sevelamer CARBONATE 800 mg PO TID W/MEALS 12. Clopidogrel 75 mg PO DAILY (was not taking regularly) 13. Aspirin 81 mg PO DAILY 14. Vitamin D ___ UNIT PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Clopidogrel 75 mg PO DAILY 3. Furosemide 40 mg PO DAILY 4. Lisinopril 30 mg PO DAILY 5. Multivitamins 1 TAB PO DAILY 6. Ranitidine 300 mg PO DAILY 7. sevelamer CARBONATE 800 mg PO TID W/MEALS 8. Atorvastatin 80 mg PO DAILY RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 9. Metoprolol Succinate XL 25 mg PO DAILY RX *metoprolol succinate 25 mg 1 tablet extended release 24 hr(s) by mouth daily Disp #*30 Tablet Refills:*0 10. DiphenhydrAMINE 25 mg PO HS:PRN insomnia 11. HumuLIN 70/30 (insulin NPH and regular human) 30 units subcutaneous daily 12. Nitroglycerin SL 0.3 mg SL PRN chest pain 13. Vitamin D ___ UNIT PO DAILY 14. NIFEdipine CR 60 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: Severe mitral regurgitation Coronary artery disease 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 caring for you at ___ ___. As you recall, you were admitted for shortness of breath. This was because one of your heart valves was weak, which caused fluid to build up in your lungs. Your heart valve was weak because there was a blockage in one of your heart arteries. You underwent a procedure, called cardiac catheterization, which opened up the blocked arteries. Your valve and heart are pumping much more efficiently now. We are glad you are feeling better. Please weigh yourself every morning, and call your MD if your weight goes up more than 3 lbs over 24 hours. Followup Instructions: ___

10000980-DS-23

DS

2191-04-11 00:00:00

2191-04-11 17:48:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: DVT Major Surgical or Invasive Procedure: EGD History of Present Illness: This is a ___ y/o female with PMHx significant for CAD, HTN, HLD, T2DM, CKD stage IV, PVD (s/p in ___, left superficial femoral artery), presents with lower Left leg numbness and pain since yesterday evening. The numbness started last night in bed. The onset was gradual, and it was associated with pain/cramping over her lateral calf, radiating down into her foot. She has had sx like this before, usually when resting or lying in bed, not with exertion. She denies leg weakness at this time, and is able to walk without assistance. Today the pain and numbness is improved; residual numbness in her lateral calf. Denies hx DVT. Denies spine sx: no trauma, no back pain, no incontinence, no fevers/chills. No numbness elsewhere. Additionally, she denies headache, visual changes, chest pain, chest pressure, chest palpitations, shortness of breath abdominal pain, dysuria, or diarrhea. Past Medical History: - hypertension - diabetes - hx CVA (cerebellar-medullary stroke in ___ - CAD (hx of MI in ___ BMS to circumflex and POBA ___ - peripheral arterial disease- claudication, followed by vascular, managed conservatively - stage IV CKD (baseline 2.1-2.6) - GERD/esophageal rings Social History: ___ Family History: Niece had some sort of cancer. Father died in his ___ due to lung disease. Mother died in her ___ due to an unknown cause. No early CAD or sudden cardiac death. No other known history of cancer. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 97.7, 166/85, 59, 16, 100% on RA. General: Pleasant affect, laying in bed, resting comfortably in NAD. HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: Supple, JVP not elevated. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Minimal bibasilar crackles improved with cough. Abdomen: obese abdomen, soft, non-tender, non-distended, no rebound or guarding. Ext: Warm, well perfused, 1+ pulses, right calf swelling greater than left calf swelling. No calf tenderness to palpation. Thick toenails, dry skin along toes. Hallux valgus. Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation. DISCHARGE PHYSICAL EXAM Vitals: Tmax 99.1 HR ___ BP 97-168/50s-70s RR 18 SpO2 97-100%RA FSG 90-307 General: Pleasant affect, laying in bed, resting comfortably in NAD. HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: Supple, JVP not elevated. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: clear to auscultation in all fields without wheezes or ronchi Abdomen: obese abdomen, soft, non-tender, non-distended, no rebound or guarding. Ext: Warm, well perfused, dopplerable pulses ___ on RLE, dopplerable ___ pulse on LLE, dopplerable DP pulse on LLE, R radial pulse 2+, L radial pulse 1+, mild right calf swelling greater than left calf swelling. No calf tenderness to palpation. No pain to palpation on left dorsal and lateral foot - callous present on left lateral foot. Thick toenails, dry skin along toes. Non-tender indurated cord in left antecubital fossa. Neuro: alert and oriented x 3, CNII-XII intact, ___ RUE, ___ strength LUE, ___ hip flexor strength, ___ dorsi and plantar flexion of bilateral lower extremities (4+/5 on right lower extremity, 4- on LLE), fine touch sensation on extremities bilaterally Pertinent Results: ADMISSION LABS: ___ 02:45PM BLOOD WBC-5.1 RBC-2.50* Hgb-7.7* Hct-23.4* MCV-94 MCH-30.8 MCHC-32.9 RDW-14.7 RDWSD-50.0* Plt ___ ___ 02:45PM BLOOD Neuts-74.4* Lymphs-15.1* Monos-7.7 Eos-2.4 Baso-0.2 Im ___ AbsNeut-3.79 AbsLymp-0.77* AbsMono-0.39 AbsEos-0.12 AbsBaso-0.01 ___ 02:45PM BLOOD ___ PTT-26.1 ___ ___ 02:45PM BLOOD Glucose-107* UreaN-72* Creat-2.9* Na-141 K-4.3 Cl-108 HCO3-21* AnGap-16 ___ 02:45PM BLOOD calTIBC-303 Ferritn-153* TRF-233 PERTINENT LABS/IMAGING: -She received 1U pRBCs on admission on ___ 07:00AM BLOOD WBC-6.0 RBC-2.83* Hgb-8.7* Hct-26.3* MCV-93 MCH-30.7 MCHC-33.1 RDW-14.7 RDWSD-50.2* Plt ___ -She had one large episode of coffee ground emesis- ___ 05:10PM BLOOD WBC-5.6 RBC-2.44* Hgb-7.4* Hct-22.7* MCV-93 MCH-30.3 MCHC-32.6 RDW-14.7 RDWSD-49.8* Plt ___ -She received 500cc NS and 2UpRBCs- ___ 07:45AM BLOOD WBC-5.7 RBC-3.49*# Hgb-10.7*# Hct-32.3* MCV-93 MCH-30.7 MCHC-33.1 RDW-14.9 RDWSD-49.1* Plt ___ ___ bilateral lower extremity doppler U/S IMPRESSION: 1. Deep venous thrombosis in the bilateral posterior tibial veins. 2. 2.0 x 1.3 x 1.8 cm right-sided ___ cyst. EGD ___ Small amount of hematin without evidence of ulceration or active bleeding seen at the GE junction. The stomach is significantly deformed. Diffuse erythema and superficial ulcerations in the stomach consistent with severe gastritis. No active bleeding identified. Medium hiatal hernia Erythema and superficial ulcerations in the duodenal bulb consistent with duodenitis. Otherwise normal EGD to third part of the duodenum ___ Left upper extremity ultrasound IMPRESSION: 1. No evidence of deep vein thrombosis in the left upper extremity. 2. Likely evolving hematoma in the left antecubital fossa. ___ CT head non contrast IMPRESSION: 1. No evidence of acute infarction, hemorrhage, fractures. DISCHARGE LABS: ___ 07:30AM BLOOD WBC-5.8 RBC-2.44* Hgb-7.4* Hct-22.9* MCV-94 MCH-30.3 MCHC-32.3 RDW-14.6 RDWSD-50.2* Plt ___ ___ 07:30AM BLOOD Plt ___ ___ 07:30AM BLOOD Glucose-78 UreaN-45* Creat-1.7* Na-142 K-4.7 Cl-109* HCO3-20* AnGap-18 ___:30AM BLOOD Calcium-9.4 Phos-4.5 Mg-2.0 ___ 07:30AM BLOOD EDTA ___ Brief Hospital Course: Outpatient Providers: ___ with PMHx significant for CAD, HTN, HLD, T2DM, CKD stage IV, PVD (s/p in ___, left superficial femoral artery), presents with lower left leg numbness and pain, found to have bilateral unprovoked DVT. She was treated with a heparin drip and had many bleeding events during her stay: she developed an upper GIB, had an EGD, and was followed by GI during her admission. The heparin drip was stopped and then re-started once her coffee-ground emesis resolved. Her stools were guiac positive, however no active blood was found on rectal exam. GI felt that colonoscopy could be deferred to out patient. Additionally she developed a left arm hematoma. The heparin drip was stopped and then re-started once her hematoma was felt to be stable. She had left radial as well as bilateral lower extremity ___ dopplerable pulses throughout admission. Hematology was consulted after the patient developed a left arm hematoma and the drip was slowly uptitrated as per their recommendations. She was successfully bridged to coumadin with an INR on discharge of 2.0. She was discharged to rehab as per ___ recs. Please see below for a more problem based/detailed summary and transitional issues. = = = = = = = = = = = = = = = = = = ================================================================ ___ y/o female with PMHx significant for CAD, HTN, HLD, T2DM, CKD stage IV, PVD (s/p in ___, left superficial femoral artery), presented with lower Left leg numbness and pain since yesterday evening, with ultrasound bilateral lower extremities showing bilateral posterior tibial veins DVT's. # Unprovoked Bilateral DVTs: No clinical signs of PE on admission or during stay, positive bilateral DVTs on LENIs. Pain and swelling improved on anticoagulation. Patient was bridged with heparin drip to therapeutic warfarin with INR goal ___. Due to continually supratherapeutic PTT > 150 on heparin drip, hematology was consulted and no further workup was deemed necessary. Heparin drip was carefully uptitrated as needed. Clopidogrel was stopped per outpatient cardiologist. Patient will need age-appropriate cancer screening including colonoscopy and mammogram. Patient will follow-up in ___ clinic for anticoagulation management and should continue on warfarin for at least 3 months. # Upper GI bleed: Patient developed 1 episode large coffee ground emesis while on heparin drip with PTT > 150. Received 2U pRBCs. GI consulted and EGD showed gastritis and superficial erosions but no active bleeding. Incidental finding of medium sized hiatal hernia. Stool h. pylori antigen was negative. GI recommended 8 weeks of high dose PPI. # Left antecubital hematoma: Patient developed large left antecubital hematoma in setting of phlebotomy and PTT > 150 on heparin gtt. Heparin gtt held while hematoma improved. Repeat h/h were stable. # Acute on CKD Stage IV: Patient with creatinine of 2.9 on admission with baseline 2.0-2.5. Improved with hydration. Home lasix and lisinopril were initially held. Home lasix restarted on discharge at 20mg daily. # Normocytic Anemia: Patient has normocytic anemia. Rectal exam in ED was guaiac negative. In past treated with aransep as well as EPO. Etiology likely related to underlying CKD, however also must consider slow GI bleed (patient has gastritis/duodenitis on EGD but no evidence of active bleeding. Iron studies were normal. # HFpEF: Home furosemide and Lisinopril were held on admission for ___ followed by GI bleed. Carvedilol and nifedine were held in setting of GIB (see above). Nifedipine was restarted at 30mg bid and lasix was decreased from 40mg to 20mg daily. # CAD: hx of MI in ___ BMS to circumflex and POBA ___. Per discussions with Dr. ___, patient's cardiologist, clopidogrel was held given GI bleed and initiation of warfarin. Lasix initially held as above, but restarted on discharge at 20mg daily. Home ASA, statin, and carvedilol were continued. # HTN: Nifedipine was decreased to 30mg BID from 60mg BID given multiple bleeding episodes and normal blood pressures. Home carvedilol continued. Patient's nifedipine was decreased to 30mg daily given acute bleed and SBPs in the ___ Lasix was decreased from 40 daily to 20 daily. # Diabetes Mellitus: Stable on home 30 units 70/30 insulin at bedtime. TRANSITIONAL ISSUES: - Out patient hypercoaguability work up including screening colonoscopy (last in ___ and mammogram - Patient will need to complete an 8 week course of high dose PPI (started 40mg pantoprazole PO twice daily on ___ with projected end date ___ for upper GI bleed likely from gastritis. - Patient's hypertension medications (Lisinopril and nifedipine) were held due to upper GI bleed. - Patient's furosemide was decreased to 20mg daily - Patient's nifedipine was decreased to 30mg daily given acute bleed and SBPs in the ___ - Patient was started on Coumadin. Clopidogrel was stopped per cardiology. ASA 81mg was continued. - Please address patient's home environment for fall risk given recent "trip" at home and new anticoagulation. - please ensure patient has outpatient anticoagulation follow-up and management upon discharge from rehab Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 40 mg PO DAILY 2. Allopurinol ___ mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. Carvedilol 12.5 mg PO BID 5. Clopidogrel 75 mg PO DAILY 6. Furosemide 40 mg PO DAILY 7. Ranitidine 150 mg PO DAILY:PRN reflux 8. Aspirin 81 mg PO DAILY 9. Multivitamins 1 TAB PO DAILY 10. Vitamin D ___ UNIT PO DAILY 11. NIFEdipine CR 60 mg PO BID 12. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 13. 70/30 30 Units Dinner Discharge Medications: 1. Allopurinol ___ mg PO EVERY OTHER DAY 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. Carvedilol 12.5 mg PO BID 5. 70/30 30 Units Dinner 6. Lisinopril 40 mg PO DAILY 7. Multivitamins 1 TAB PO DAILY 8. NIFEdipine CR 30 mg PO BID 9. Vitamin D ___ UNIT PO DAILY 10. Docusate Sodium 100 mg PO BID 11. Gabapentin 100 mg PO QHS neuropathic pain 12. Pantoprazole 40 mg PO Q12H 13. Senna 8.6 mg PO BID constipation 14. Warfarin 5 mg PO DAILY16 please dose and adjust for INR 15. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 16. Furosemide 20 mg PO DAILY 17. Polyethylene Glycol 17 g PO DAILY 18. Acetaminophen 325-650 mg PO Q6H:PRN pain or fever Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: Deep vein thrombosis (DVT) Secondary: Upper GI bleed L arm hematoma Superficial thrombophlebitis, L antecubital fossa Chronic kidney disease (Stage IV) Peripheral vascular disease Diabetes mellitus type II Coronary artery disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Discharge Instructions: Dear ___, It was a pleasure caring for you at ___. You were admitted for leg swelling and pain. Diagnostic tests were performed and you were diagnosed with deep vein thrombosis, blood clots in your legs. You were treated with blood thinning medications that you will continue at home. You had an episode of upper GI bleeding during your stay for which you are being treated with medication and you underwent an EGD. You developed a left arm hematoma as well during your stay which will resolve on its own over time. For your blood clots, you were started on a new drug called warfarin. You will need to have your blood checked to adjust the dosing. For your upper GI bleed, you were started on Pantoprazole 40mg twice daily. You will continue this drug as an outpatient for at least 8 weeks. Additionally, you will no longer be taking Clopidogrel (Plavix), until you speak with your cardiologist. It was a pleasure taking care you during your hospital stay. Best wishes, Your ___ Care Team Followup Instructions: ___

10000980-DS-24

DS

2191-05-24 00:00:00

2191-05-24 17:29:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: fatigue, anemia Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ year old woman with a past medical history of type-2 DM, hypertension, stage IV CKD, CAD s/p distant MI and bare metal stent, stroke, recent unprovoked DVTs on Coumadin, and recent upper GI bleeding, who was sent to ___ by her physician for anemia (Hgb 6.5). The patient was admitted to ___ in ___ with unprovoked bilateral lower extremity DVTs. She was started on heparin as an inpatient, but anticoagulation was complicated by severely elevated PTT (>150) and upper GI bleed. Endoscopy was notable for significant erythema, superficial ulceration, and gastritis without active bleeding. She was placed on BID PPI prophylaxis. She was eventually bridged to Coumadin for a planned 6 month course. Her INR is managed by her rehab facility, and she is followed by Dr. ___ in ___ clinic. For the last two weeks she has noted increasing fatigue along with shortness of breath, exertional sub-sternal chest pain relieved with rest, and symmetrical lower extremity swelling. During this period she reports that her appetite remained good, and he bowel function was normal. She denies bloody stools or dark stool. On ___ she presented to her PCP office from rehab reporting increasing shortness of breath and fatigue. She was found to have a Hgb of 6.5, with an unconcerning CXR. She was sent to the ___ ED. In the ED, her initial vitals were T: 97.5 P: 60 BP: 156/76 RR: 16 SPO2: 100% RA. Exam was notable for guiac negative stool. Imaging was notable for: "1. Nonocclusive deep vein thrombosis of one of the paired posterior tibial veins bilaterally. The extent of thrombus bilaterally has decreased. No new deep venous thrombosis in either lower extremity. 2. Right complex ___ cyst." The patient was transfused with 2 units of pRBCs, with appropriate increase in Hgb to 9.0. Following transfusion, a repeat CXR was notable for pulmonary edema with bilateral pleural effusions. She was given 20mg PO Lasix and 40mg IV Lasix in the ED. The decision was made to admit the patient for anemia and flash pulmonary edema. On the floor, vitals notable for T: 97.9 BP: 154/75 P: 65 R: 20 O2: 99RA FSBG: 76. She reports no acute complaints, and that her shortness of breath has resolved. She denies chest pain, dizziness, lightheadedness. Past Medical History: - hypertension - diabetes - hx CVA (cerebellar-medullary stroke in ___ - CAD (hx of MI in ___ BMS to circumflex and POBA ___ - peripheral arterial disease- claudication, followed by vascular, managed conservatively - stage IV CKD (baseline 2.1-2.6) - GERD/esophageal rings Social History: ___ Family History: Niece had some sort of cancer. Father died in his ___ due to lung disease. Mother died in her ___ due to an unknown cause. No early CAD or sudden cardiac death. No other known history of cancer. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: 97.9 BP: 154/75 P: 65 R: 20 O2: 99RA FSBG: ___ General: Overweight woman, alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated Lungs: Crackles to the mid-lungs bilaterally CV: Regular rate and rhythm, normal S1 + S2, no murmurs or 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 or cyanosis. 2+ pitting edema in dependent areas to the buttocks Skin: no rashes noted Neuro: ___ strength in deltoids, biceps, triceps, wrist extensors, finger extensors, hip flexors, hamstrings, quadriceps, gastrocs, tibialis anterior, bilaterally. Sensation intact bilaterally. PSYCH: Alert and fully oriented; normal mood and affect. sometimes slow to respond and responding with repetitive answers but otherwise appropriate DISCHARGE PHYSICAL EXAM: VS: T: 97.6 BP: 150s-160s/70s-80s P: 60s-70s RR: 18 SPO2: 100RA General: Overweight woman, alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated Lungs: Clear to auscultation bilaterally CV: Regular rate and rhythm, normal S1 + S2, no murmurs or 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 or cyanosis. 1+ pitting edema in shins bilaterally Skin: no rashes noted Pertinent Results: LABORATORY STUDIES ON ADMISSION ============================================= ___ 12:30PM WBC-4.4 RBC-2.03* HGB-6.5* HCT-20.6* MCV-102*# MCH-32.0 MCHC-31.6* RDW-16.3* RDWSD-59.6* ___ 12:30PM ___ ___ 12:30PM ALBUMIN-4.1 CALCIUM-9.2 PHOSPHATE-4.7* IRON-61 ___ 12:30PM calTIBC-303 FERRITIN-155* TRF-233 ___ 12:30PM UREA N-42* CREAT-2.3* SODIUM-142 POTASSIUM-4.7 CHLORIDE-109* TOTAL CO2-23 ANION GAP-15 ___ 04:50PM LD(___)-247 TOT BILI-0.2 ___ 04:50PM HAPTOGLOB-188 IMAGING: ============================================== LENIs (___) 1. Nonocclusive deep vein thrombosis of one of the paired posterior tibial veins bilaterally. The extent of thrombus bilaterally has decreased. No new deep venous thrombosis in either lower extremity. 2. Right complex ___ cyst. CXR (___): 1. New mild pulmonary edema with persistent small bilateral pleural effusions. 2. Severe cardiomegaly is likely accentuated due to low lung volumes and patient positioning. CXR (___): As compared to ___, the lung volumes have slightly decreased. Signs of mild overinflation and moderate pleural effusions persist. Moderate cardiomegaly. Elongation of the descending aorta. No pneumonia. LABORAROTY STUDIES ON DISCHARGE ============================================== ___ 05:45AM BLOOD WBC-3.4* RBC-2.93* Hgb-8.9* Hct-28.0* MCV-96 MCH-30.4 MCHC-31.8* RDW-17.5* RDWSD-59.7* Plt ___ ___ 05:45AM BLOOD ___ PTT-30.6 ___ ___ 05:45AM BLOOD Glucose-116* UreaN-41* Creat-2.1* Na-144 K-4.0 Cl-108 HCO3-25 AnGap-15 ___ 04:50PM BLOOD LD(LDH)-247 TotBili-0.2 ___ 05:45AM BLOOD Calcium-9.4 Phos-4.7* Mg-1.7 Brief Hospital Course: Ms. ___ is a ___ year old woman with a past medical history of type-2 DM, hypertension, stage IV CKD, CAD s/p distant MI and bare metal stent, stroke, recent unprovoked DVTs on Coumadin, and recent upper GI bleed, who was sent to ___ by her physician for anemia. # Anemia: Patient presented with Hgb of 6.5, down from her recent baseline of ~7.5 since her ___ hospitalization. Upon presentation she had a new macrocytic anemia. Hemolysis labs were negative. She received two units of packed red cells with an appropriate rise in her Hgb to 9.0. Stool was guiac negative, with no reports of dark stool or blood in stool. Her hemoglobin remained stable at this level, there was no overt bleeding, and her stool was guiac negative. After transfusion the patient reported significant improvement in her shortness of breath and fatigue. Given her history of gastritis and diverticulosis, a GI bleed was believed responsible for her anemia. Patient should receive an EGD/colonoscopy as an outpatient. # Acute exacerbation of heart failure with preserved ejection fraction: The patient was also found to be slightly volume overloaded, and was treated with 2x40mg IV Lasix, with good urine output and symptomatic improvement. Her pulmonary edema and peripheral edema resolved with diuresis. CHRONIC ISSUES: # Gastic ulceration: Continued on home pantoprazole BID # Hypertension: Continued on home nifedipine, carvadilol, lisinopril. # Stage IV Chronic Kidney Disease: Creatinine remained at baseline (b/l Cr 2.1-2.6) during admission. TRANSITIONAL ISSUES ====================== --Patient's Anemia is thought to be due to slow GI bleed given history of gastritis and diverticulosis. Please schedule EGD/colonoscopy within the next month --Patient continued on Coumadin for bilateral DVTs; please continue to weigh the risks and benefits of anticoagulation given history of bleed. --Discharge weight: 167.7 # CONTACT: ___ ___ # CODE: full, confirmed Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Allopurinol ___ mg PO EVERY OTHER DAY 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. Carvedilol 12.5 mg PO BID 5. Lisinopril 40 mg PO DAILY 6. Multivitamins 1 TAB PO DAILY 7. NIFEdipine CR 30 mg PO BID 8. Vitamin D ___ UNIT PO DAILY 9. Docusate Sodium 100 mg PO BID 10. Gabapentin 100 mg PO QHS neuropathic pain 11. Pantoprazole 40 mg PO Q12H 12. Senna 8.6 mg PO BID constipation 13. Warfarin 4 mg PO 3X/WEEK (___) 14. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 15. Furosemide 20 mg PO DAILY 16. Polyethylene Glycol 17 g PO DAILY 17. Acetaminophen 325-650 mg PO Q6H:PRN pain or fever 18. Warfarin 3 mg PO 4X/WEEK (___) 19. 70/30 30 Units Dinner Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN pain or fever RX *acetaminophen 325 mg ___ tablet(s) by mouth Q6H:PRN Disp #*120 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 80 mg PO QPM RX *atorvastatin 80 mg 1 tablet(s) by mouth QPM 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. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 6. Gabapentin 100 mg PO QHS neuropathic pain RX *gabapentin 100 mg 1 capsule(s) by mouth at bedtime Disp #*30 Capsule Refills:*0 7. Lisinopril 40 mg PO DAILY RX *lisinopril 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 8. Multivitamins 1 TAB PO DAILY RX *multivitamin 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*0 9. NIFEdipine CR 30 mg PO BID RX *nifedipine 30 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 10. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain RX *nitroglycerin [Nitrostat] 0.3 mg 1 tablet(s) sublingually Q5MIN:PRN Disp #*10 Tablet Refills:*0 11. Pantoprazole 40 mg PO Q12H RX *pantoprazole 40 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*60 Tablet Refills:*0 12. Polyethylene Glycol 17 g PO DAILY RX *polyethylene glycol 3350 17 gram/dose 1 powder(s) by mouth daily Refills:*0 13. Senna 8.6 mg PO BID constipation RX *sennosides [senna] 8.6 mg 1 capsule by mouth twice a day Disp #*60 Capsule Refills:*0 14. Vitamin D ___ UNIT PO DAILY RX *ergocalciferol (vitamin D2) 2,000 unit 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 15. Warfarin 4 mg PO 3X/WEEK (___) RX *warfarin 4 mg 1 tablet(s) by mouth 3X/WEEK Disp #*30 Tablet Refills:*0 16. Warfarin 3 mg PO 4X/WEEK (___) RX *warfarin 3 mg 1 tablet(s) by mouth 4X/WEEK Disp #*30 Tablet Refills:*0 17. Furosemide 20 mg PO DAILY RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 18. Allopurinol ___ mg PO EVERY OTHER DAY RX *allopurinol ___ mg 1 tablet(s) by mouth EVERY OTHER DAY Disp #*30 Tablet Refills:*0 19. 70/30 30 Units Dinner RX *insulin NPH and regular human [Humulin 70/30 KwikPen] 100 unit/mL (70-30) 30 units SC Take 30 Units before DINER Disp #*2 Package Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary diagnosis: Anemia Congestive heart failure exacerbation Secondary diagnosis: Hypertension DMII on insulin Coronary artery disease Stage IV chronic kidney disease Deep vein thrombosis 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 caring for you. You were admitted to the hospital with fatigue, chest pain, and shortness of breath. You were found to have too few red blood cells (anemia). We gave you blood, and your symptoms improved. Additionally, you were found to have too much fluid in your legs and lungs. We treated you with a diuretic, which helped eliminate the fluid. Weigh yourself every morning, call MD if weight goes up more than 3 lbs. Sincerely, Your ___ Team Followup Instructions: ___

10000980-DS-25

DS

2191-07-19 00:00:00

2191-07-22 09:37:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: dyspnea on exertion Major Surgical or Invasive Procedure: None History of Present Illness: ___ with a history of of HTN, CAD s/p DES with ischemic MR and systolic dysfunction, ___ on torsemide, hx of DVT, who presents with 4 days of dyspnea on exertion, leg swelling, and 10 weight gain. Of note, patient was seen in the Heart Failure Clinic with Dr. ___ on ___ where she noted that she has had persistent dyspnea on exertion and PND after a lengthy prior hospitalization for DVT/GIB. At that time she was started on 40mg po torsemide which initially improved her symptoms. Over the holiday she indulged in a high salt diet and developed slow-onset dyspnea on exertion. Denies any medication noncompliance, chest pain, palpitations, palpitations. Describes PND, worsening exercise tolerance (unable to walk >50 feet) and orthopnea. In the ED, patient was found to have 1+ bilateral lower extremity edema, and have bibasilar crackles on exam. Patient underwent CXR, BNP, and was given one dose of IV 40mg Lasix. In the ED initial vitals were: 97.8 73 199/100 18 95% RA. Prior to transfer, vitals were 74 188/95 18 100% RA. Patient's labs were remarkable for sodium 146, Chloride 115, K 5.4, Bicarb 19, BUN 39, Creatinine 2.3. Patient had CK 229, with MB 6, Trop < 0.01. Patient had BNP of 10,180. Patient also had Hgb 8.1, Hct 26.8, Platelet 168, WBC 5.4. Urinalysis still pending upon discharge. EKG: notable for SR 76, with LAD, TWI in the inferior leads which appears unchanged from prior on ___ On the floor she is symptomatically improved since coming to the ED. Past Medical History: - hypertension - diabetes - hx CVA (cerebellar-medullary stroke in ___ - CAD (hx of MI in ___ BMS to circumflex and POBA ___ - peripheral arterial disease- claudication, followed by vascular, managed conservatively - stage IV CKD (baseline 2.1-2.6) - GERD/esophageal rings Social History: ___ Family History: Father died in his ___ due to lung disease. Mother died in her ___ due to an unknown cause. No early CAD or sudden cardiac death. No other known history of cancer. Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS: T=98.0 BP: 168/96 HR=67 RR=16 O2 sat=100% on 2L NC Admission weight 178lbs GENERAL: WDWN, obese, sitting upright in bed, in NAD. AOx3. 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 8cm. CARDIAC: PMI located in ___ intercostal space, midclavicular line. RR, normal S1, S2, +S3. No murmurs/rubs/gallops. No thrills, lifts. LUNGS: Resp were unlabored, no accessory muscle use, dyspneic at the end of a long sentence. Bibasilar crackles ___ up thorax, diffuse wheezing. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: 2+ edema to shins. No femoral bruits. PULSES: Distal pulses palpable and symmetric DISCHARGE PHYSICAL EXAMINATION: VS: T=98.0 BP: 135/72 HR=67 RR=16 O2 sat=100% on RA weight: 74kg GENERAL: WDWN, obese, sitting upright in bed, in NAD. AOx3. 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 7cm. CARDIAC: PMI located in ___ intercostal space, midclavicular line. RR, normal S1, S2, +S3. No murmurs/rubs/gallops. No thrills, lifts. LUNGS: Resp were unlabored, no accessory muscle use. Bibasilar crackles trace, diffuse wheezing. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: dry. No femoral bruits. PULSES: Distal pulses palpable and symmetric Pertinent Results: ADMISSION LABS ___ 11:55AM BLOOD WBC-5.4 RBC-2.63* Hgb-8.1* Hct-26.8* MCV-102*# MCH-30.8 MCHC-30.2* RDW-17.2* RDWSD-64.7* Plt ___ ___ 11:55AM BLOOD Neuts-80.6* Lymphs-11.2* Monos-5.0 Eos-2.4 Baso-0.2 Im ___ AbsNeut-4.38 AbsLymp-0.61* AbsMono-0.27 AbsEos-0.13 AbsBaso-0.01 ___ 12:45PM BLOOD ___ PTT-32.9 ___ ___ 07:30AM BLOOD Ret Aut-2.4* Abs Ret-0.06 ___ 11:55AM BLOOD Glucose-153* UreaN-39* Creat-2.3* Na-146* K-5.4* Cl-115* HCO3-19* AnGap-17 ___ 11:55AM BLOOD CK-MB-6 cTropnT-<0.01 ___ ___ 07:38PM BLOOD CK-MB-6 cTropnT-<0.01 ___ 11:55AM BLOOD Calcium-9.0 Phos-3.9 Mg-1.8 DISCHARGE LABS ===== ___ 07:10AM BLOOD WBC-3.9* RBC-2.81* Hgb-8.6* Hct-26.7* MCV-95 MCH-30.6 MCHC-32.2 RDW-16.0* RDWSD-56.4* Plt ___ ___ 07:10AM BLOOD ___ ___ 07:10AM BLOOD Glucose-100 UreaN-37* Creat-1.9* Na-144 K-3.9 Cl-105 HCO3-29 AnGap-14 ___ 07:10AM BLOOD Calcium-9.5 Phos-4.4 Mg-1.8 IMAGING ===== ___ CXR FINDINGS: There is mild pulmonary edema with superimposed region of more confluent consolidation in the left upper lung. There are possible small bilateral pleural effusions. Moderate cardiomegaly is again seen as well as tortuosity of the descending thoracic aorta. No acute osseous abnormalities. IMPRESSION: Mild pulmonary edema with superimposed left upper lung consolidation, potentially more confluent edema versus superimposed infection. Brief Hospital Course: ___ year-old female with history of hypertension, CAD s/p DES with ischemic MR and systolic dysfunction, ___, hx of DVT, who admitted for CHF exacerbation. # Acute on chronic decompensated heart failure: presented in the setting of high salt diet with dyspnea on exertion, decreased exercise tolerance, ___ edema, crackles on exam, elevated BNP to 10K, 8lbs above dry weight and pulmonary congestion on CXR. Later discovered on pharmacy review that patient had not filled torsemide after last outpatient Cardiology appointment where she was instructed to start taking it. Troponins cycled and negative. On admission, she was placed on a salt and fluid restricted diet. She was diuresed with IV Lasix 80mg for 2 days and then transitioned to po torsemide 40mg with steady weight decline and net negative fluid balance of goal -___ and stable renal function. Electrolytes repleted for goal Mg>2 and K>4. She was continued on home carvedilol 12.5mg BID, atorvastatin 80mg daily and lisinopril 40mg daily for blood pressure control and increased home nifedipine CR from 30 to 60mg BID to achieve goal SBP <140. Discharged with close PCP and ___ to monitor weights and blood pressure control. # Hypertension: She was continued on home carvedilol 12.5mg BID, atorvastatin 80mg daily and lisinopril 40mg daily for blood pressure control and increased home nifedipine CR from 30 to 60mg BID to achieve goal SBP <140. # Positive U/A: patient asymptomatic but with 32WBCs, ___, +bacteria (although 3 epis). Asymptomatic with no fevers/dysuria/malaise. Urine culture negative. # Left upper lung consolidation: infiltrate per Radiology read on admission CXR. No cough, fevers, leukocytosis. Rereviewed with on-call radiologist who favored pulmonary edema with no need for repeat imaging or PNA treatment unless clinically indicated. Monitored without any significant clinical findings. # DVT: anticoagulated on Coumadin goal 2.0-3.0, no signs of thrombus on exam. Daily INR trended and continued on home Coumadin 5mg daily. # Anemia: no signs of external loss, specifically denying any melena. Chronically anemic with baseline ___, presented with Hgb 8. Likely ___ renal disease and ACD however elevated MCV indicates possible reticulocytosis. Altogether low suspicion for GIB so Coumadin was continued. Reticulocytes 2.4 which is inappropriate arguing against acute loss. Trended daily CBC with noted uprising by discharge. # Chronic kidney disease, stage IV- baseline ___, likely ___ HTN and DM. Renally dosed medications and trended Cr with no significant change. # HLD: continued home atorvastatin # DM: held home 25U 70/30. Patient maintained on aspart ISS and glargine qHS with good glycemic control. TRANSITIONAL ISSUES ================== CHF: diuresed with IV lasix, transitioned to po diuretics, discharged home on 40mg po torsemide, to take in the AM and take a banana. Pt complained of unilateral R-sided incomplete hearing loss on day of discharge- was not felt to be related to diuretics but would ___. HTN: increased nifedipine CR to 60mg BID given elevated SBPs. Please f/u at next appointments. Anemia: multiple prior workups showing ACD. Hgb 8s during admission Prior DVT/PE: continued on warfarin, will need continued monitoring DM: stopped home 70/30 while in-house and put on aspart/glargine, discharged on home regimen Discharge weight: 74kg Discharge Cr: 1.9 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 325-650 mg PO Q6H:PRN pain or fever 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. Carvedilol 12.5 mg PO BID 5. Docusate Sodium 100 mg PO BID 6. Gabapentin 100 mg PO QHS neuropathic pain 7. Lisinopril 40 mg PO DAILY 8. Multivitamins 1 TAB PO DAILY 9. NIFEdipine CR 30 mg PO BID 10. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 11. Pantoprazole 40 mg PO Q12H 12. Polyethylene Glycol 17 g PO DAILY 13. Senna 8.6 mg PO BID constipation 14. Vitamin D ___ UNIT PO DAILY 15. Warfarin 5 mg PO DAILY16 16. Allopurinol ___ mg PO EVERY OTHER DAY 17. Torsemide 40 mg PO DAILY 18. HumuLIN 70/30 (insulin NPH and regular human) 100 unit/mL (70-30) subcutaneous 25 units with dinner Discharge Medications: 1. HumuLIN 70/30 (insulin NPH and regular human) 100 unit/mL (70-30) subcutaneous 25 units with dinner 2. Warfarin 5 mg PO DAILY16 3. Vitamin D ___ UNIT PO DAILY 4. Acetaminophen 325-650 mg PO Q6H:PRN pain or fever 5. Allopurinol ___ mg PO EVERY OTHER DAY 6. Aspirin 81 mg PO DAILY 7. Atorvastatin 80 mg PO QPM 8. Docusate Sodium 100 mg PO BID 9. Gabapentin 100 mg PO QHS neuropathic pain 10. Lisinopril 40 mg PO DAILY 11. Multivitamins 1 TAB PO DAILY 12. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 13. Polyethylene Glycol 17 g PO DAILY 14. Senna 8.6 mg PO BID constipation 15. Torsemide 40 mg PO DAILY RX *torsemide 20 mg 2 tablet(s) by mouth once daily Disp #*60 Tablet Refills:*0 16. Pantoprazole 20 mg PO Q12H 17. Carvedilol 25 mg PO BID 18. NIFEdipine CR 60 mg PO BID RX *nifedipine 20 mg 3 capsule(s) by mouth twice daily Disp #*180 Capsule Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnoses: Acute on chronic decompensated congestive Heart Failure Hypertension Secondary Diagnoses: Anemia Diabetes mellitus Prior deep vein thrombosis Chronic Kidney Disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mrs. ___, ___ were admitted to ___ for treatment of your congestive heart failure and hypertension. ___ were given IV diuretics with improvement in your symptoms, labs and exam. We increased one of your blood pressure medications and continued your other home medicines. It was a pleasure taking care of ___ during your stay- we wish ___ all the best! - Your ___ Team Followup Instructions: ___

10001217-DS-4

DS

2157-11-25 00:00:00

2157-11-25 17:26:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: Penicillins Attending: ___ Chief Complaint: Left hand and face numbness, left hand weakness and clumsiness, fever, and headache. Major Surgical or Invasive Procedure: Right parietal craniotomy for abscess incision and drainage. History of Present Illness: Mrs. ___ is a ___ y/o F from ___ with history of MS presents with headaches and left hand clumsiness. Patient states that her headaches first presented on ___ of this week in which she did not think much of, but on ___, developed left hand clumsiness. She states that she had difficulty with grasping objects and using her fingers. She also reported some numbness in the hand. Today, she presented to the ED because she was found to have a temperature of 101.7 in which she took Tylenol and was normothermic after. Once in the ED, patient was seen by neurology who recommended an MRI head. MRI head revealed a R parietal lesion concerning for MS, metastatic disease, or abscess. Neurosurgery was consulted for further evaluation. She reports a mild headache, numbness on the left side of face and difficulty using her left hand. She denies any recent travel outside of ___ and the ___. or ingesting any raw or uncooked meats. She also denies any changes in vision, dysarthria, weakness, nausea, vomitting, diarrhea, cough, or chills. Past Medical History: Multiple sclerosis Social History: ___ Family History: Mother with pancreatic cancer, brother-lung cancer, two sisters with brain cancer. Physical Exam: PHYSICAL EXAM ON ADMISSION: O: T:99 BP:160/102 HR: 81 R: 16 O2Sats: 97% RA Gen: WD/WN, comfortable, NAD. HEENT: atraumatic, normocephalic Pupils: 4-3mm bilaterally EOMs: intact Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: ___ objects at 5 minutes. 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, 4 to 3 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength L FI ___, otherwise full power ___ throughout. No pronator drift Sensation: Intact to light touch PHYSICAL EXAM ON DISCHARGE: T:98.1 BP:133/95 HR: 95 RR: 18 O2Sats: 98% RA Gen: WD/WN, comfortable, NAD. HEENT: atraumatic, normocephalic, with right craniotomy incision. Pupils: 4-3mm bilaterally, EOMs: intact Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: ___ objects at 5 minutes. 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, 4 to 3 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements,tremors. Strength L FI ___, otherwise full power ___ throughout. No pronator drift Sensation: Intact to light touch Pertinent Results: ___ MRI HEAD W/WO CONTRAST IMPRESSION: 1. Ring-enhancing lesion identified in the area of the right precentral sulcus frontal lobe, with associated vasogenic edema, restricted diffusion, possibly consistent with an abscess, other entities cannot be completely ruled out such as metastases or primary brain neoplasm. 2. Multiple FLAIR and T2 hyperintense lesions in the subcortical white matter along the callososeptal region, consistent with known multiple sclerosis disease. ___ MRI HEAD W/ CONTRAST IMPRESSION: Unchanged ring-enhancing lesion identified in the area of the right precentral sulcus of the frontal lobe, with associated vasogenic edema. The differential diagnosis again includes possible abscess, other entities, however, cannot be completely excluded. ___ NON CONTRAST HEAD CT IMPRESSION: 1. Status post right parietal craniotomy with mixed density lesion in the right precentral sulcus and surrounding edema not significantly changed from prior MR of ___ allowing for difference in technique. 2. No acute intracranial hemorrhage or major vascular territorial infarct. 3. Bifrontal subcortical white matter hypodensities compatible with underlying multiple sclerosis. ___ 2:37 am CSF;SPINAL FLUID TUBE #1. 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. Brief Hospital Course: Mrs. ___ presented to the ___ Emergency Department on ___ with left-sided numbness of her hand and face and left hand clumsiness. She was evaluated in the ED and initially believed to have an MS flare and she was evaluted by Neurology service which resulted in the recommendation for an MRI brain. The MRI was read to demonstrate a right parietal lesion concerning for MS, metastatic disease or abscess. She was admitted to Neurosurgery for further evaluation and treatment. On ___, Mrs. ___ was taken to the OR for a right parietal craniotomy with cordisectomy, drainage and irrigation of brain abscess. She tolerated the procedure well. She was taken to PACU to recover then to the ICU. ID recommmend Vancomycin and Meropenem. Gram stain PRELIM: gram negative rods and gram positive cocci in pairs and chains. Post operative head CT showed post operative changes. On post operative exam she had left arm weakness. On ___ the patient continued on vancomycin and Meropenem. WBC was elevated to 19.0 from 15.7 on ___. She was transferred to the floor. Left arm weakness was slightly improved. the patient reported lethargy and left leg weakness. on exam the patient was sleepy but awake. she was oriented to person place and time. right sided strength was ___ and left upper extremity was ___ and left lower extremity was full except for IP which was 5-. A stat NCHCT was performed which was stable. On ___, consent for picc line placement obtained, picc line placed by IV nurse. She will continue with vanco and meropenum IV. Final abcess culture result is still pending. Exam remains stable. On ___ ___ evaluated the patient and found that she continues to have an unsteady gait and would not be safe to go home. They planned to visit her again on ___ for re-evaluation and to perform stair maneuvers with her. The final results on the abcess culture was streptococcus Milleri. New ID recommendations were to discontiniu Vanco and Meropenum, she was started on Ceftriaxone 2 grams and and Flagyl Tid. On ___, patient was re-evaluated by ___ and OT and cleared to be discharged home with the assistance of a cane. They also recommend services while patient is at home. She remained stable on examination. On ___, Mrs. ___ was seen and evaluated, she complained of headache and a non-contrast head CT was ordered. This showed the stable post-operative changes. Home services were established and the patient was discharged. Medications on Admission: Ibuprofen Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN pain RX *acetaminophen 325 mg ___ tablet(s) by mouth every six (6) hours Disp #*112 Tablet Refills:*0 2. CeftriaXONE 2 gm IV Q12H RX *ceftriaxone 2 gram 2 gm IV every twelve (12) hours Disp #*84 Vial Refills:*0 3. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*45 Capsule Refills:*0 4. LeVETiracetam 1000 mg PO BID RX *levetiracetam [Keppra] 1,000 mg 1 tablet(s) by mouth twice a day Disp #*56 Tablet Refills:*0 5. MetRONIDAZOLE (FLagyl) 500 mg PO TID RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth three times a day Disp #*126 Tablet Refills:*0 6. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain RX *oxycodone [Oxecta] 5 mg 1 tablet, oral only(s) by mouth every six (6) hours Disp #*168 Tablet Refills:*0 7. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line flush RX *heparin lock flush (porcine) [heparin lock flush] 10 unit/mL 1 ml IV every eight (8) hours Disp #*126 Vial Refills:*0 8. Sodium Chloride 0.9% Flush 10 mL IV Q8H and PRN, line flush Flush before and after each infusion of antibiotics. RX *sodium chloride 0.9 % [Normal Saline Flush] 0.9 % 10 ml IV q12 Disp #*168 Syringe Refills:*1 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Brain abscess 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: •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 and/or staples 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. •You have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. •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. Followup Instructions: ___

10001338-DS-8

DS

2142-03-02 00:00:00

2142-03-02 16:02:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: ___ Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: Colonoscopy with biopsy ___ History of Present Illness: This patient is a ___ year old female with Hx of sigmoid diverticulitis s/p resection in ___, who complains of RLQ abdominal pain. The patient states that her pain began yesterday afternoon, worsened overnight and causing her to present to the ED around 3AM. She describes it as a "gnawing" pain, nonradiating, constant and ___ intensity. She states this feels similar to her episode of diverticulitis several years ago, only is present on the other side of her abdomen. She denies any fever, nausea, vomiting, SOB, Chest pain, BRBPR. She does endorse subjective feeling of chills. . Prior to the current episode, the patient reports having a "sinus infection" about 3 weeks ago that resolved over one week ago. About 2 weeks ago she also began taking a low dose OCP in order to treate perimenopausal cramping. On the second week she started to have spotting, with intermittent bleeding and LH this past week. She had an episode of diarrhea one week ago ___ morning), that was nonbloody and resolved on its own. Starting on ___ she has had a feeling of "lightheadedness" associated with diaphoresis and nausea. . In the ED, initial VS were: 8 97.2 88 117/64 18 100%. Patient was given morphine 4 mg IV, dilaudid 0.5 mg IV x 6, zofran 4 mg IV, and 3 L NS. She underwent bimanual exam that was reportedly without signs of mass, CMT, or adnexal tenderness. Labs were notable for a leukocytosis of 11, but were otherwise unremarkable. CT abdomen showed normal appendix but thick-walled cecum with appearance of possible mass. Pelvic ultrasound did not show any source of her pain. As she did not have adequate relief with pain medications, she was admitted to the medical service for pain control. . Vitals on transfer were 97.2 68 98/55 18 100%RA . On the floor, patient reported continued ___ pain in the RLQ, along with some mild nausea. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied vomiting, diarrhea, constipation or BRBPR. No dysuria. Denied arthralgias or myalgias. Past Medical History: Hx diverticulitis s/p sigmoid resection ___ Anxiety Allergic rhinitis GERD Eczema Migraine headaches Eustacian tube dysfunction Social History: ___ Family History: Father with hx of colitis, F died lung Ca, Aunt with breast ___, Paternal GM with stomach Ca, Mother with CHF and DM2 Physical Exam: Vitals: T: 97.6 BP: 96/62 P: 68 R:18 O2: 99% on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-distended, bowel sounds present, TTP in RLQ with deep palpation only, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Laboratory Findings: ___ 03:30AM BLOOD WBC-11.3* RBC-3.93* Hgb-12.2 Hct-34.9* MCV-89 MCH-31.0 MCHC-34.8 RDW-12.8 Plt ___ ___ 03:30AM BLOOD Neuts-76.5* ___ Monos-2.8 Eos-1.8 Baso-0.4 ___ 05:26AM BLOOD ___ ___ 03:30AM BLOOD Glucose-123* UreaN-16 Creat-0.8 Na-137 K-4.6 Cl-101 HCO3-25 AnGap-16 ___ 03:30AM BLOOD ALT-16 AST-37 AlkPhos-36 TotBili-0.5 ___ 03:30AM BLOOD Lipase-28 ___ 05:27AM BLOOD Calcium-8.3* Phos-2.0*# Mg-2.0 ___ 03:39AM BLOOD Lactate-0.9 ___ 05:26AM BLOOD WBC-5.4 RBC-3.41* Hgb-10.6* Hct-30.6* MCV-90 MCH-31.1 MCHC-34.7 RDW-12.5 Plt ___ ___ 05:26AM BLOOD Glucose-88 UreaN-5* Creat-0.7 Na-144 K-4.1 Cl-106 HCO3-28 AnGap-14 ___ 03:30AM URINE Color-Straw Appear-Clear Sp ___ ___ 03:30AM URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-MOD ___ 03:30AM URINE RBC-<1 WBC-3 Bacteri-FEW Yeast-NONE Epi-0 Microbiology: URINE CULTURE (Final ___: <10,000 organisms/ml Blood Culture ___: No growth (not final at time of discharge) Imaging: Pelvic U/S ___: FINDINGS: Transabdominally the uterus measures 8.6 x 4.6 x 5.4 cm, and is slightly heterogeneous in appearance with no distinct fibroids seen. Transvaginal exam was performed for better evaluation of the uterus and adnexa. The endometrial stripe measures 5 mm. The left ovary measures 3.5 x 1.6 x 1.8 cm. The right ovary measures 2.9 x 1.4 x 1.7 cm. There is a small echogenic focus within the right ovary measuring 5 x 4 x 4 mm, likely a small hemorrhagic cyst. Both ovaries demonstrate normal arterial and venous waveforms. IMPRESSION: 1. No evidence of ovarian torsion. 2. Small right ovarian hemorrhagic cyst. . CT abd/pelvis w/o contrast ___: Scattered calcified granulomas in the lung bases are stable. There is no new focal pulmonary nodule, consolidation, or effusion. The cardiac apex is within normal limits. Complete evaluation of the intra-abdominal viscera is limited by the non-contrast technique. However, the liver appears homogeneous without focal lesion. No intra- or extra-hepatic biliary ductal dilatation is identified. The gallbladder, spleen, and pancreas appear within normal limits. The adrenal glands are symmetric without focal nodule. The kidneys appear homogeneous without focal lesion or hydronephrosis. The abdominal aorta is non-aneurysmal throughout its visualized course. The second and third portions of the duodenum are equivocally thickened which may be due to underdistension. No small bowel obstruction is identified. The appendix is well visualized and is normal in appearance. There is no free fluid or free air. CT PELVIS WITHOUT INTRAVENOUS CONTRAST ___: Initial images demonstrated a solid mass like abnormality in the cecal tip measuring approximately 3 cm (2:51). As this was potentially concerning for a cecal mass, rescanning of a limited portion of pelvis was performed after passage of oral contrast, confirming the finding and demonstrating a 3 cm mass with thickening of the adjacent cecal wall (601:15). The adjacent appendix is normal and there is no pericecal inflammatory change. The remainder of the colon is normal without evidence of obstruction or inflammation. The surgical anastomosis within the lower midline pelvis appears unremarkable. There is no pelvic free fluid. The uterus and adnexa appear within normal limits. The bladder is markedly distended but is otherwise unremarkable. No pathologically enlarged pelvic or inguinal lymph nodes are identified. OSSEOUS STRUCTURES: No bone destructive lesion or acute fracture is identified. IMPRESSION: 1. Findings consistent with a 3 cm cecal mass and thickening of the cecal tip concerning for neoplasm. Atypical infectious process causing this appearance is felt less likely due to lack of inflammatory stranding. Recommend colonoscopy for further evaluation. 2. Normal appendix, no signs of inflammation. 3. No small or large bowel obstruction. 4. Equivocal thickening of duodenum likely related to underdistention. Colonoscopy ___: Findings: Lumen: Evidence of a previous end to end ___ anastomosis was seen at the sigmoid colon. Protruding Lesions A ulcerated 3 cm mass of malignant appearance was found in the cecum. The scope traversed the lesion. Cold forceps biopsies were performed for histology at the cecum. Excavated Lesions Multiple diverticula with small openings were seen in the descending colon. Impression: Mass in the cecum (biopsy) Diverticulosis of the descending colon Previous end to end ___ anastomosis of the sigmoid colon Otherwise normal colonoscopy to cecum and terminal ileum . PATHOLOGY: DIAGNOSIS: "Cecal mass", mucosal biopsies: Colonic mucosa with focal ischemic change and abundant associated ulceration, exudate, and granulation tissue formation; no carcinoma or dysplasia in these samples. Five levels are examined. Brief Hospital Course: The patient is a ___ year-old female with history significant for diverticulitis s/p sigmoid resection in ___, who presented with abdominal pain and was found to have cecal mass. . # Abdominal pain: Was most likely related to hemorrhagic ovarian cyst. Initially, patient had significant pain that was not relieved with dilaudid. However, over the course of several days her pain resolved on its own and she no longer required any pain medications. Bloodwork and imaging were not suggestive of any intra-abdominal infection. The patient was advised to follow-up with her gynecologist regarding her ovarian cyst, and the need for continued therapy with low dose oral contraceptive. . # Cecal Mass: During the workup of this patient's abdominal pain, a CT of the abdomen and pelvis revealed a 3 cm cecal mass concerning for malignancy. During this hospitalization she underwent colonoscopy with biopsy of the mass. She was instructed to follow-up with her outpatient gastroenterologist regarding the results of this biopsy in one week. The biopsy was negative for malignancy. . # Anxiety - Patient was continued on home regimen of zoloft and ativan. . # Gerd - Patient continued on omeprazole, zantac BID per outpatient regimen. Medications on Admission: -Fish Oil 1,000 mg Cap -Axert 12.5 mg Tab 1 Tablet(s) by mouth at onset of HA may repeat in 2 hour up till 2 a day -Lexapro 10 mg Tab daily -Cholecalciferol (Vitamin D3) 1,000 unit Tab -lorazepam 0.5 mg Tab qd prn -Omeprazole 20 mg Cap, Delayed Release BID -tramadol 50 mg Tab every six (6) hours as needed for pain -oxycodone 5 mg Tab ___ Tablet(s) by mouth qhs prn as needed for pain -Multivitamin Cap -Zantac 150 mg Cap 1 Capsule(s) by mouth twice a day -Fluticasone 50 mcg/Actuation Nasal Spray, Susp 2 sprays(s) intranasally for 7d, then 1 spray qd -Calcium Citrate 1,000 mg Tab -OCPs - Camrasce? started 2 weeks ago Discharge Medications: 1. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY (Daily). 2. Axert 12.5 mg Tablet Sig: One (1) Tablet PO once a day as needed for migraine. 3. escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. cholecalciferol (vitamin D3) 1,000 unit Capsule Sig: One (1) Capsule PO once a day. 5. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for anxiety. 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). 10. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: Two (2) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Cecal Mass Hemorrhagic ovarian cyst Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to the hospital for abdominal pain, which we think was related to a hemorrhagic ovarian cyst. You were treated with analgesics, and your pain resolved. You also had a CAT scan showing a mass in the cecum. You underwent a colonoscopy to biopsy this mass, and you should follow-up with your gastroenterologist. You should also see your gynecologist regarding the need to restart your oral contraceptive. We did not make any changes to your home medications. Followup Instructions: ___

10001401-DS-18

DS

2131-07-02 00:00:00

2131-07-08 09:02:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: UROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Abdominal pain, distention, nausea Major Surgical or Invasive Procedure: Interventional radiology placement of abdominal abscess drain History of Present Illness: ___ F with h/o muscle invasive bladder cancer, returning to the ED POD 15 with abdominal pain, nausea, and distension. She has been obstipated for nearly three days. KUB and CT scan notable for dilated loops, air fluids, and tapering small bowel without an obvious transition point. Labwork notable for ___ and leukocytosis. Concerned for small bowel obstruction or an ileus in presence ___ and leukocytosis she was re-admitted for IVF, bowel rest, NGT decompression. Past Medical History: Hypertension, laparoscopic cholecystectomy, left knee replacement six to ___ years ago, laminectomy of L5-S1 at age ___, two vaginal deliveries. s/p ___: 1. Robot-assisted laparoscopic bilateral pelvic lymph node dissection. 2. Robot-assisted hysterectomy and bilateral oophorectomy for large uterus, greater than 300 grams, with large fibroid. 3. Laparoscopic radical cystectomy and anterior vaginectomy with vaginal reconstruction. Social History: ___ Family History: Negative for bladder CA. Physical Exam: WdWn, NAD, AVSS Abdomen soft, appropriately tender along incision Incision is c/d/I Stoma is well perfused; Urine color is yellow Bilateral lower extremities are warm, dry, well perfused. There is no reported calf pain to deep palpation. Bilateral lower extremities have 2+ pitting edema but no erythema, callor, pain. Pigtail drain has been removed - dressing c/d/i Pertinent Results: ___ 05:58AM BLOOD WBC-9.9 RBC-2.76* Hgb-8.2* Hct-26.2* MCV-95 MCH-29.7 MCHC-31.3* RDW-13.9 RDWSD-47.3* Plt ___ ___ 06:45AM BLOOD WBC-10.3* RBC-2.87* Hgb-8.7* Hct-27.7* MCV-97 MCH-30.3 MCHC-31.4* RDW-14.0 RDWSD-49.4* Plt ___ ___ 05:13AM BLOOD WBC-11.6* RBC-3.27* Hgb-9.8* Hct-31.0* MCV-95 MCH-30.0 MCHC-31.6* RDW-13.6 RDWSD-47.5* Plt ___ ___ 07:06PM BLOOD WBC-22.5*# RBC-3.58* Hgb-10.9* Hct-34.0 MCV-95 MCH-30.4 MCHC-32.1 RDW-13.9 RDWSD-47.9* Plt ___ ___ 07:06PM BLOOD Neuts-89* Bands-1 Lymphs-5* Monos-3* Eos-0 Baso-0 ___ Metas-1* Myelos-0 Hyperse-1* AbsNeut-20.48* AbsLymp-1.13* AbsMono-0.68 AbsEos-0.00* AbsBaso-0.00* ___ 01:04PM BLOOD ___ PTT-30.9 ___ ___ 05:58AM BLOOD Glucose-106* UreaN-26* Creat-0.4 Na-136 K-4.6 Cl-107 HCO3-26 AnGap-8 ___ 06:45AM BLOOD Glucose-114* UreaN-32* Creat-0.4 Na-137 K-4.1 Cl-106 HCO3-25 AnGap-10 ___ 06:00AM BLOOD Glucose-121* UreaN-39* Creat-0.4 Na-140 K-3.6 Cl-107 HCO3-26 AnGap-11 ___ 07:06PM BLOOD Glucose-117* UreaN-60* Creat-1.7*# Na-133 K-5.0 Cl-96 HCO3-21* AnGap-21* ___ 08:30AM BLOOD ALT-20 AST-19 AlkPhos-77 ___ 05:58AM BLOOD Calcium-7.6* Phos-2.8 Mg-2.2 ___ 06:45AM BLOOD Calcium-7.7* Phos-2.4* Mg-2.1 ___ 08:30AM BLOOD Albumin-1.8* Calcium-7.7* Phos-3.5 Mg-2.1 Iron-23* ___ 07:06PM BLOOD Calcium-8.0* Phos-5.5* Mg-2.2 ___ 08:30AM BLOOD calTIBC-116* Ferritn-789* TRF-89* ___ 05:09AM BLOOD Triglyc-106 ___ 08:30AM BLOOD Triglyc-89 ___ 07:06PM BLOOD Lactate-1.5 ___ 03:00PM ASCITES Creat-0.4 Amylase-18 Triglyc-29 Lipase-8 ___ 03:00PM OTHER BODY FLUID Creat-0.5 ___ 7:12 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: CITROBACTER KOSERI. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ CITROBACTER KOSERI | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Aerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE ROD(S). Reported to and read back by ___ ___, @14:35 ON ___. ___ 3:00 pm ABSCESS . PELVIC ASPIRATION. **FINAL REPORT ___ GRAM STAIN (Final ___: 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). WOUND CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Final ___: BACTEROIDES FRAGILIS GROUP. SPARSE GROWTH. BETA LACTAMASE POSITIVE. ___ 10:52 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: Ms. ___ was admitted to Dr. ___ service for management of ileus. Upon admission, a nasogastric tube was placed for decompression. On ___, PICC was placed and TPN started. Blood cultures grew gram negative rods and ceftriaxone was started. On ___, pt started to pass small amount of flatus. ___ CT scan demonstrated improving ileus, but concern for possible urine leak and increased free fluid. On ___, a LLQ drain was placed by interventional radiology. on ___, pt passed clamp trial and NGT was removed. Pt continued to pass flatus and also started to have bowel movements. On ___, pt was advanced to a clear liquid diet. Repeat blood cultures were negative and positive blood culture from admission grew citrobacter. Diet was gradually advanced and ensure added. IV medications were gradually converted to PO and she was re-evaluated by physical therapy for rehabilitative services. She was ambulating with walker assistance and prepared for discharge to her ___ facility (___). TPN was continued up until day before discharge. At time of discharge, she was tolerating regular diet, passing flatus regularly and having bowel movements. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 10 mg PO QPM 2. Levothyroxine Sodium 175 mcg PO DAILY 3. Losartan Potassium 50 mg PO DAILY 4. Acetaminophen 650 mg PO Q6H 5. Docusate Sodium 100 mg PO BID 6. Enoxaparin Sodium 40 mg SC DAILY 7. Nitrofurantoin Monohyd (MacroBID) 100 mg PO DAILY 8. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days Last dose ___ 2. MetroNIDAZOLE 500 mg PO Q6H Duration: 7 Days Last dose ___ 3. Senna 8.6 mg PO BID 4. Acetaminophen 650 mg PO Q6H 5. Atorvastatin 10 mg PO QPM 6. Docusate Sodium 100 mg PO BID 7. Enoxaparin Sodium 40 mg SC DAILY Start: ___, First Dose: Next Routine Administration Time 8. Levothyroxine Sodium 175 mcg PO DAILY 9. LORazepam 0.25 mg PO BID:PRN anxiety 10. Losartan Potassium 50 mg PO DAILY 11. Nitrofurantoin Monohyd (MacroBID) 100 mg PO DAILY 12. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: bladder cancer, post-operative ileus, bacteremia (CITROBACTER KOSERI) and abdominal-pelvic abscess (BACTEROIDES FRAGILIS GROUP) requiring ___ drainage 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 also refer to the instructions provided to you by the Ostomy nurse specialist that details the required care and management of your Urostomy -Resume your pre-admission/home medications except as noted. Always call to inform, review and discuss any medication changes and your post-operative course with your primary care doctor -___ (acetaminophen) and Ibuprofen for pain control. -Ciprofloxacin and Metronidazole are new ANTIBIOTIC medications to treat your infection. Continue for 7 days through ___. -The MAXIMUM dose of Tylenol (ACETAMINOPHEN) is 3 grams (from ALL sources) PER DAY -If you are taking Ibuprofen (Brand names include ___ this should always be taken with food. If you develop stomach pain or note black stool, stop the Ibuprofen. -Please do NOT drive, operate dangerous machinery, or consume alcohol while taking narcotic pain medications. -Do NOT drive and until you are cleared to resume such activities by your PCP or urologist. You may be a passenger -Colace may have 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. -No heavy lifting for 4 weeks (no more than 10 pounds). Do "not" be sedentary. Walk frequently. Light household chores (cooking, folding laundry, washing dishes) are generally “ok” but AGAIN, avoid straining, pulling, twisting (do NOT vacuum). Followup Instructions: ___

10001401-DS-19

DS

2131-08-04 00:00:00

2131-08-04 15:04:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: dyspnea on exertion Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a ___ year old woman s/p robotic radical cystectomy ___ (with ileal conduit creation) with postop course complicated by bacteremia and abscess, LLE DVT (on prophylactic dosing lovenox) who presents with dyspnea on exertion for past 3 days. Briefly, patient was initially admitted to the Urology service from ___ for robotic anterior exenteration with ileal conduit. She was discharged to rehab on prophylactic dosing lovenox for 1 month. She was then readmitted from ___ for ileus requiring NGT decompression, TPN. BCx grew Citrobacter, for which CTX was started. CT showed intra-abdominal, interloop, simple fluid collection and LLQ drain was placed by ___. Patient improved, passing BMs and tolerating PO, and was discharged on cipro/flagyl. She was also discharged on PO Bactrim for presumed UTI, though unclear if she actually took this. During this admission, she was noted to have new bilateral ___ edema. LENIs at the time showed aute deep vein thrombosis of the duplicated mid and distal left femoral veins. She was discharged on Enoxaparin Sodium 40 mg SC daily. She reports that her PCP started PO ___ 20mg daily and since then there has been improvement of the swelling. Per her report, a repeat ___ at the rehab facility (___) was negative for DVT. Patient reports that she recovered well post-operatively and was doing well at her assisted living facility up until a week ago when she began experiencing dyspnea on exertion. She states that she typically is able to ambulate a block before stopping to catch her breath, however in the past week she has been unable to take more than a few steps. She states that it has become increasingly more difficult to ambulate from her bedroom to the bathroom. When visited by the NP her ambulatory saturation was noted to be in the ___ with associated tachycardia to 110, pallor and diaphoresis. She endorses associated leg swelling left worse than right, and she states that her thighs "feel heavy". She denies any associated chest pain, fever, chills, pain with deep inspiration, abdominal pain, rashes, dizziness, lightheadedness. In the ED, initial VS were: 97.7 72 136/93 20 100% Nasal Cannula ED physical exam was recorded as patient resting comfortably with NC, pursed lip breathing, unable to speak in full sentences before becoming short of breath, urostomy pouch in RLQ, stoma pink, 2+ edema to bilateral lower extremities L>R. ED labs were notable for: Hb 9, Hct 29, plt 479, UA: large ___, >182 WBC, many bact 0 epi. Trop neg x1, proBNP normal CTA chest showed: 1. Extensive pulmonary embolism with thrombus seen extending from the right main pulmonary artery into the segmental and subsegmental right upper, middle, and lower lobe pulmonary arteries. No right heart strain identified. 2. Additionally, there are smaller pulmonary emboli seen in the segmental and subsegmental branches of the left upper and lower lobes. 3. Several pulmonary nodules are noted, as noted previously, with the largest appearing spiculated and measuring up to 1 cm in the right middle lobe, suspicious for malignancy on the previous PET-CT. 4. Re- demonstration of 2 left breast nodules for which correlation with mammography and ultrasound is suggested. EKG showed NSR with frequent PAC Patient was given: ___ 20:26 PO/NG Ciprofloxacin HCl 500 mg ___ 20:26 IV Heparin 6600 UNIT ___ 20:26 IV Heparin Transfer VS were: 98.1 77 145/63 20 99% Nasal Cannula When seen on the floor, she reports significant dyspnea with minimal exertion. Denies chest pain, palpitations, lightheadedness. A ten point ROS was conducted and was negative except as above in the HPI. Past Medical History: Hypertension, laparoscopic cholecystectomy, left knee replacement six to ___ years ago, laminectomy of L5-S1 at age ___, two vaginal deliveries. s/p ___: 1. Robot-assisted laparoscopic bilateral pelvic lymph node dissection. 2. Robot-assisted hysterectomy and bilateral oophorectomy for large uterus, greater than 300 grams, with large fibroid. 3. Laparoscopic radical cystectomy and anterior vaginectomy with vaginal reconstruction. Social History: ___ Family History: Negative for bladder CA. Physical Exam: ADMISSION EXAM: Gen: NAD, speaking in 3 word sentences, pursed lip breathing, no accessory muscle use, lying in bed Eyes: EOMI, sclerae anicteric ENT: MMM, OP clear Cardiovasc: RRR, no MRG, full pulses, 1+ edema bilaterally with compression stockings in place, no JVD Resp: normal effort, no accessory muscle use, lungs CTA ___ to anterior auscultation. GI: soft, NT, ND, BS+. Urostomy site does not appear infected MSK: No significant kyphosis. No palpable synovitis. Skin: No visible rash. No jaundice. Neuro: AAOx3. No facial droop. Psych: Full range of affect DISCHARGE EXAM: vitals: 98.3 140/42 90 24 96% 1L Gen: Lying in bed in no apparent distress HEENT: Anicteric, MMM Cardiovascular: RRR normal S1, S2, no right sided heave, ___ systolic murmur Pulmonary: Lung fields clear to auscultation throughout. No crackles or wheezing. GI: Soft, distended, nontender, bowel sounds present, urostomy in place. Extremities: no edema, though left leg appears larger than right leg, warm, well perfused with motor function intact. Her left lower leg is wrapped. Pertinent Results: LABS: ========================== Admission labs: ___ 02:40PM GLUCOSE-101* UREA N-22* CREAT-0.7 SODIUM-136 POTASSIUM-4.1 CHLORIDE-98 TOTAL CO2-22 ANION GAP-20 ___ 02:40PM cTropnT-<0.01 ___ 02:40PM proBNP-567 ___ 02:40PM WBC-7.7 RBC-3.07* HGB-9.0* HCT-29.1* MCV-95 MCH-29.3 MCHC-30.9* RDW-14.9 RDWSD-52.1* ___ 02:40PM PLT COUNT-479* ___ 02:40PM ___ PTT-33.4 ___ Discharge labs: ___ 06:55AM BLOOD WBC-11.0* RBC-2.60* Hgb-7.5* Hct-24.5* MCV-94 MCH-28.8 MCHC-30.6* RDW-14.8 RDWSD-51.4* Plt ___ ___ 06:55AM BLOOD Glucose-99 UreaN-10 Creat-0.5 Na-141 K-4.3 Cl-105 HCO3-26 AnGap-14 ___ 06:55AM BLOOD Calcium-8.2* Phos-3.8 Mg-2.0 ___ 07:15AM BLOOD calTIBC-134* Ferritn-507* TRF-103* ___ 07:15AM BLOOD Iron-18* MICROBIOLOGY ========================== ___ 4:30 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ENTEROCOCCUS SP.. >100,000 CFU/mL. PREDOMINATING ORGANISM INTERPRET RESULTS WITH CAUTION. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ <=2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ 1 S IMAGING ========================== ___ CXR IMPRESSION: Hilar congestion without frank edema. No convincing signs of pneumonia. ___ CTA chest showed: 1. Extensive pulmonary embolism with thrombus seen extending from the right main pulmonary artery into the segmental and subsegmental right upper, middle, and lower lobe pulmonary arteries. No right heart strain identified. 2. Additionally, there are smaller pulmonary emboli seen in the segmental and subsegmental branches of the left upper and lower lobes. 3. Several pulmonary nodules are noted, as noted previously, with the largest appearing spiculated and measuring up to 1 cm in the right middle lobe, suspicious for malignancy on the previous PET-CT. 4. Re- demonstration of 2 left breast nodules for which correlation with mammography and ultrasound is suggested. ___ ___: IMPRESSION: 1. Interval progression of deep vein thrombosis in the left lower extremity, with occlusive thrombus involving the entire femoral vein, previously only involving the mid and distal femoral vein. There is additional nonocclusive thrombus in the deep femoral vein. The left common femoral and popliteal veins are patent. 2. The bilateral calf veins were not visualized due to an overlying dressing. Otherwise no evidence of deep venous thrombosis in the right lower extremity. ___ TTE: Conclusions The left atrium is normal in size. The estimated right atrial pressure is ___ mmHg. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Doppler parameters are most consistent with Grade I (mild) left ventricular diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. Trivial mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. ___ CXR IMPRESSION: Compared to chest radiographs ___ through ___. Heart size top-normal. Lungs grossly clear. No pleural abnormality or evidence of central lymph node enlargement. Brief Hospital Course: Ms. ___ is a ___ woman s/p robotic radical cystectomy ___omplicated by bacteremia and abscess, LLE DVT, currently on daily lovenox who presents with dyspnea on exertion and dyspnea on exertion and found to have large PE and progression of DVT. # PE/DVT: Likely due to undertreatment of known LLE DVT with prophylactic dosing of lovenox. Given underdosing of lovenox, this was not thought to be treatment failure and IVC filter was deferred. She had no signs of right heart strain on imaging, EKG, exam. TTE showed no evidence of right heart strain. She was treated with a heparin gtt, then transitioned to treatment dose lovenox given malignancy associated thrombosis as noted in CLOT trial. She is quite symptomatic and requires oxygen supplementation, though improved during hospitalization. Please wean oxygen as tolerated. # Pulmonary nodules: Known spiculated masses that were noted on CT in ___, concerning for primary lung malignancy vs mets. Current CT showed stable nodules still concerning for malignancy. She was evaluated by the thoracic team who recommended CT biopsy vs. surveillance. Given her current PE/DVT, the family and the patient decided for surveillance at this time. They will follow up with her primary care provider. # Enterococcal UTI She was noted to have rising WBC in the setting of UCX from urostomy growing Enterococcus. Given her rising leukocytosis, we proceeded with treatment. She was started on IV Ampicillin and transitioned to macrobid, based on sensitivies. Leukocytosis improved on antibiotics. She should complete a 7 day course (day 1: ___, day 7: ___. # Normocytic Anemia: No signs of bleeding, or hemolysis. Hb dropped to nadir of 7.3, stable at discharge at 7.5. Iron studies consistent with likely combination iron deficiency anemia and anemia of chronic disease with low iron but elevated ferritin and low TIBC. Would recommend checking again as outpatient and work-up as needed. # ___ swelling: Likley multifactorial including venous insufficiency, as well as known LLE DVT. She responded quite well with compression stockings. # Hx of bladder cancer: s/p ___ TURBT, high-grade TCC, T1 (no muscle identified). Then in ___, pelvic MRI showed bladder mass invasion, perivesical soft tissue, anterior vaginal wall on right (C/W T4 lesion). In ___, underwent robotic TAH-BSO, lap radical cystectomy and anterior vaginectomy with pathology showing pT2b, node and margins negative. No plan for any further therapy at this time per Dr ___. The patient is safe to discharge today, and >30min were spent on discharge day management services. Transitional issues: - She will need follow up chest CT for pulmonary nodules in 3 months (___) - To complete 7 day course for UTI with macrobid (day 7: ___ - Continue oxygen therapy and wean as tolerated to maintain O2 sat > 92% - Please check CBC on ___ to ensure stability of h/h and demonstrate resolution of leukocytosis - HCP: son, Dr. ___ ___ Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Acetaminophen 650 mg PO Q6H 2. Docusate Sodium 100 mg PO BID 3. Enoxaparin Sodium 40 mg SC DAILY Start: ___, First Dose: Next Routine Administration Time 4. Levothyroxine Sodium 175 mcg PO DAILY 5. Atorvastatin 10 mg PO QPM 6. Losartan Potassium 50 mg PO DAILY 7. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate 8. LORazepam 0.25 mg PO BID:PRN anxiety 9. Senna 8.6 mg PO BID Discharge Medications: 1. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H Last day: ___. Enoxaparin Sodium 90 mg SC Q12H Start: Today - ___, First Dose: Next Routine Administration Time 3. LORazepam 0.25 mg PO QHS:PRN insomnia RX *lorazepam 0.5 mg 0.5 (One half) tab by mouth QHS:prn Disp #*3 Tablet Refills:*0 4. Acetaminophen 650 mg PO Q6H 5. Atorvastatin 10 mg PO QPM 6. Docusate Sodium 100 mg PO BID 7. Levothyroxine Sodium 175 mcg PO DAILY 8. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg 1 tablet(s) by mouth Q8H:prn Disp #*3 Tablet Refills:*0 9. Senna 8.6 mg PO BID Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PE 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: Ms. ___ it was a pleasure taking care you during your admission to ___. You were admitted for a clot in your lungs and leg. You were treated with a blood thinner. You will need to continue the blood thinner. You were also treated for a urinary tract infection. For your pulmonary nodules, you should follow up with your primary care doctor. Followup Instructions: ___

10001667-DS-10

DS

2173-08-24 00:00:00

2173-08-24 15:04:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: slurred speech Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old right-handed woman with hx of Atrial fibrillation on Eliquis (only once daily), hypertension, hyperlipidemia, CHF presents as transfer from OSH after she had acute onset dysarthria and CTA showed possible partial thrombus or stenosis in superior division of L MCA. Transferred here for closer monitoring and possible thrombectomy if her exam acutely worsens. History obtained from patient and daughter at bedside. Patient is an excellent historian. On ___, she had dinner with friends and then returned to her apartment and was fooling around on her computer. Last known well was around 8:00 ___. Then, she had an odd sensation and started throwing her arms around. She went to living room to sit down and tried to read but could not see the words very clearly. Then, two family members were knocking at the door and she had a tough time standing up to open door. She was able to eventually stand up with great difficulty and walked with her walker. She usually walks with a walker because of knee replacement. Finally, got up out of chair with walker and walked to the door to unlock. She noticed problems talking to family members. She had difficulty forming words and pronouncing words. Denies word finding difficulty. She could tell it was slurred like a person who had too much to drink. EMTs asked if she was intoxicated but she was not. She was very aware of her dysarthria and told her daughters that she thinks she's having a stroke. Then, she said she had trouble sitting down but has no idea why she thought that. When she was standing, she was able to walk with walker but she felt unsteady and almost fell. No visual changes. No numbness or tingling. Denies focal weakness; she just had trouble standing up. She was able to unlock her door without issue but she felt shaky. She was brought by EMS to ___ where NIHSS was 1 for slurred speech. There, she felt the same but her symptoms started to improve when she started to be transferred. Paramedics said her speech was improving rapidly en route. Last month, started needing naps. Her hearing is poor at baseline and she normally uses hearing aids. For the past ___ months, she has had ___ nocturia nightly. No dysuria. She has noticed more frequent headaches lately in the past ___ months. Last headache was yesterday. She takes tramadol and acetaminophen up to a couple times a night. She reports headaches at night which wake her up. She denies that the headache is positional; it is the same sitting up or lying down. She has had some gradual weight loss over the past ~12 months; ___ year ago she was almost 140 lbs, and now she is ___ lbs. Her appetite is still good and she enjoys eating but she is less hungry that she used to be. Daughter says that she has had marked decline in memory in past ___ weeks. Over past few years, she has been forgetting plans, times for pickpup, and dinner plans, which has become normal. Over the past ___ weeks, family has noticed dramatic worsening. She doesn't remember which grandkids were coming to visit when she bought the plane tickets herself. She endorses 2 pillow orthopnea. Past Medical History: Divertoculosis Atrial fibrillation on Eliquis CHF Hypercholesterolemia Hypertension Social History: ___ Family History: Father - severe alcoholic, schizophrenia Mother - CHF Brother - stroke, carotid stenosis Physical Exam: ADMISSION EXAM: Vitals: T:97.9 HR: 79 BP: 164/121 RR: 19 SaO2: 94% on RA General: Awake, cooperative elderly woman, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx. Neck: Supple. No nuchal rigidity. Pulmonary: Normal work of breathing. Cardiac: RRR, warm, well-perfused. Abdomen: Soft, non-distended. Extremities: No ___ edema. Skin: ecchymoses in L shin, more extensive on R shin. Neurologic: -Mental Status: Alert, oriented ___. 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. Able to name both high and low frequency objects. Able to read without difficulty. No dysarthria. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial Nerves: II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without nystagmus. Normal saccades. VFF to confrontation. V: Facial sensation intact to light touch and pinprick. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger snapping b/l. Did not bring her hearing aids. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii bilaterally. XII: Tongue protrudes in midline with good excursions. Strength full with tongue-in-cheek testing. -Motor: Normal bulk and tone throughout. No pronator drift. No adventitious movements, such as tremor or asterixis noted. [___] L 5 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 5 -Sensory: No deficits to light touch, pinprick, temperature throughout. Decreased vibratory sense in b/l feet up to ankles. Joint position sense intact in b/l great toes. No extinction to DSS. Romberg absent. -Reflexes: [Bic] [Tri] [___] [Pat] [Ach] L 2+ 2 2 2+ 0 R 2+ 2 2 2+ 0 Plantar response was flexor bilaterally. -Coordination: No intention tremor. No dysmetria on FNF bilaterally. HKS with L heel without dysmetria. Unable to bend R knee due to knee surgery. -Gait: unable to assess as patient needs a walker at baseline DISCHARGE EXAM: 24 HR Data (last updated ___ @ 419) Temp: 97.4 (Tm 98.6), BP: 146/76 (116-155/65-94), HR: 53 (53-86), RR: 17 (___), O2 sat: 96% (92-97), O2 delivery: Ra General: Awake, cooperative elderly woman, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx. Neck: Supple. No nuchal rigidity. Pulmonary: Normal work of breathing. Cardiac: NR, RR, warm, well-perfused. Abdomen: Soft, non-distended. Extremities: No ___ edema. Skin: ecchymoses in L shin, more extensive on R shin. Neurologic: -Mental Status: Alert, oriented to person and situation. Able to relate history without difficulty. Attentive to examiner. Language is fluent with intact comprehension. Normal prosody. There were no paraphasic errors. No dysarthria. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial Nerves: II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to conversation. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii bilaterally. XII: Tongue protrudes in midline with good excursions. -Motor: Normal bulk and tone throughout. No pronator drift. No adventitious movements, such as tremor or asterixis noted. [Delt][Bic][Tri][ECR][FEx][IO][IP][Quad][Ham][TA][Gas] L 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 * * 5 5 *Knee cannot bend after prior surgery -Sensory: No deficits to light touch throughout. -Coordination: No intention tremor. No dysmetria on FNF bilaterally. -Gait: needs a walker at baseline Pertinent Results: ___ 01:50AM BLOOD WBC-7.2 RBC-4.75 Hgb-14.6 Hct-45.5* MCV-96 MCH-30.7 MCHC-32.1 RDW-13.2 RDWSD-46.5* Plt ___ ___ 01:50AM BLOOD Neuts-53.1 ___ Monos-8.2 Eos-1.5 Baso-0.3 Im ___ AbsNeut-3.81 AbsLymp-2.63 AbsMono-0.59 AbsEos-0.11 AbsBaso-0.02 ___ 01:50AM BLOOD ___ PTT-29.7 ___ ___ 01:50AM BLOOD Glucose-97 UreaN-18 Creat-0.7 Na-139 K-4.3 Cl-102 HCO3-26 AnGap-11 ___ 07:35AM BLOOD CK-MB-4 cTropnT-<0.01 ___ 07:35AM BLOOD Calcium-9.3 Phos-3.6 Mg-1.8 Cholest-207* ___ 07:35AM BLOOD Triglyc-62 HDL-69 CHOL/HD-3.0 LDLcalc-126 ___ 10:57AM BLOOD %HbA1c-5.5 eAG-111 ___ 05:22AM BLOOD VitB12-249 ___ 05:22AM BLOOD TSH-5.8* ___ 05:22AM BLOOD Trep Ab-NEG ___ 03:12AM URINE Color-Straw Appear-Clear Sp ___ ___ 03:12AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ OSH CTA head/neck ___ opinion (___) IMPRESSION: 1. Segmental left vertebral artery occlusion of indeterminate chronicity. No evidence of ischemia. 2. Somewhat small caliber attenuated left M2 inferior branch, without evidence of focal occlusion. 3. No acute intracranial abnormality on noncontrast CT head. ___ MRI head w/o contrast IMPRESSION: 1. No acute intracranial abnormality. Specifically, no large territory infarction or hemorrhage. 2. Scattered foci of T2/high-signal intensity in the subcortical and periventricular white matter are nonspecific and may reflect changes due to chronic small vessel disease. ___ TTE IMPRESSION: No structural source of thromboembolism identified (underlying rhythm predisposes to thrombus formation). Preserved left ventricular systolic function in the setting of beat-to-beat variability due to arrhythmia. Mild to moderate mitral and tricuspid regurgitation. Normal pulmonary pressure. Very small pericardial effusion Brief Hospital Course: Ms. ___ is a ___ year old female with AFib on Eliquis, CHF, HLD, HTN who presented w/ sudden onset dysarthria, abnormal arm movements, and poor balance (walker at baseline). NIHSS 1 for slurred speech at OSH. There, a CTA head and neck was completed, and there was concern for left M2 branch attenuation concerning for stenosis or occlusion, and she was subsequently transferred for consideration of thrombectomy but NIHSS 0 on arrival so she was not deemed a candidate. She was admitted to the Neurology stroke service for further evaluation of possible TIA vs stroke. No further symptoms noted during admission. MRI head w/o contrast were without evidence of stroke. Reports recent echocardiogram per outpatient PCP/cardiologist, reported as no acute findings and so this was not repeated. She mentioned concern about worsening memory, but able to perform ADLs w/ meals/cleaning provided by ALF (moved 10 months ago); it appears there has been no acute change. She was taking apixiban 2.5mg once daily (unclear why as this is a BID medication), and so her dose was increased to 2.5mg BID (she was not a candidate for 5mg BID due to her age and weight). She was started on atorvastatin for her hyperlipidemia (LDL 126). EP cardiology was consulted for frequent sinus pauses noted on telemetry that persisted despite holding home atenolol, recommending discontinuing home digoxin and close cardiology ___. Discharged to home w/ ___ & ___ and close PCP ___. #Transient slurred speech and instability, c/f TIA - ___ consult - cleared for home with home services - Started on atorvastatin for HLD and increased home apixaban to therapeutic level - ___ with stroke neurology after discharge Her stroke risk factors include the following: 1) DM: A1c 5.5% 2) Likely chronic segmental left vertebral artery occlusion and somewhat small caliber attenuated left M2 inferior branch 3) Hyperlipidemia: LDL 126 4) Obesity 5) No concern noted for sleep apnea - she does not carry the diagnosis An echocardiogram did not show a PFO on bubble study. AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic Attack 1. Dysphagia screening before any PO intake? (X) Yes, confirmed done - () Not confirmed () No 2. DVT Prophylaxis administered? (X) Yes - () No 3. Antithrombotic therapy administered by end of hospital day 2? (X) Yes - () No 4. LDL documented? (X) Yes (LDL = 126) - () No 5. Intensive statin therapy administered? (simvastatin 80mg, simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin 20mg or 40mg, for LDL > 100) (X) Yes - () No [if LDL if LDL >70, reason not given: [ ] Statin medication allergy [ ] Other reasons documented by physician/advanced practice nurse/physician ___ (physician/APN/PA) or pharmacist [ ] LDL-c less than 70 mg/dL] 6. Smoking cessation counseling given? () Yes - (X) No [reason (X) non-smoker - () unable to participate] 7. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given (verbally or written)? (X) Yes - () No 8. Assessment for rehabilitation or rehab services considered? (X) Yes - () No 9. Discharged on statin therapy? (X) Yes - () No [if LDL >70, reason not given: [ ] Statin medication allergy [ ] Other reasons documented by physician/advanced practice nurse/physician ___ (physician/APN/PA) or pharmacist [ ] LDL-c less than 70 mg/dL 10. Discharged on antithrombotic therapy? (X) Yes [Type: () Antiplatelet - (X) Anticoagulation] - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? (X) Yes - () No - () N/A #Cognitive complaints - B12 249 - one time IM supplementation, then start oral B12 supplementation - Treponemal antibodies negative - consider cognitive neurology referral as outpatient for memory difficulties not appreciated on our examination #Afib #frequent sinus pauses - stopped digoxin, will ___ closely w/ otpt cardiologist (also PCP) - increased to appropriate therapeutic dosing at Eliquis 2.5 mg BID (reduced dose given age and weight <60 kg) #HLD - started atorvastatin #HTN - continue home antihypertensives #elevated troponin (RESOLVED) - Troponin elevated at OSH, negative on admission #elevated TSH - should recheck as otpt w/ PCP ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atenolol 50 mg PO DAILY 2. Apixaban 2.5 mg PO DAILY 3. Losartan Potassium 50 mg PO DAILY 4. Digoxin 0.125 mg PO DAILY 5. LevoFLOXacin 500 mg PO Q24H Discharge Medications: 1. Atorvastatin 40 mg PO QPM RX *atorvastatin 40 mg 1 tablet(s) by mouth once daily at bedtime Disp #*30 Tablet Refills:*5 2. Cyanocobalamin 500 mcg PO DAILY RX *cyanocobalamin (vitamin B-12) 500 mcg 1 tablet(s) by mouth once daily Disp #*30 Tablet Refills:*5 3. Apixaban 2.5 mg PO BID 4. Atenolol 50 mg PO DAILY 5. LevoFLOXacin 500 mg PO Q24H 6. Losartan Potassium 50 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: transient dysarthria not secondary to TIA or stroke Mild Vitamin B12 deficiency Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, You were hospitalized due to symptoms of slurred speech due to concern for an ACUTE ISCHEMIC STROKE, a condition where a blood vessel providing oxygen and nutrients to the brain is blocked by a clot. The brain is the part of your body that controls and directs all the other parts of your body, so damage to the brain from being deprived of its blood supply can result in a variety of symptoms. However, the MRI of your brain did not show evidence of stroke or TIA. Your symptoms could have been related to blood pressure, dehydration, alcohol use, or a combination of these factors. We are changing your medications as follows: Increase apixaban to 2.5mg twice daily Start Vitamin B12 daily supplement Please take your other medications as prescribed. Please follow up with your primary care physician as listed below. You should also follow up with your cardiologist as you were noted to have occasional pauses on cardiac monitoring. If you experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, please pay attention to the sudden onset and persistence of these symptoms: - Sudden partial or complete loss of vision - Sudden loss of the ability to speak words from your mouth - Sudden loss of the ability to understand others speaking to you - Sudden weakness of one side of the body - Sudden drooping of one side of the face - Sudden loss of sensation of one side of the body Sincerely, Your ___ Neurology Team Followup Instructions: ___

10001860-DS-12

DS

2188-03-30 00:00:00

2188-03-29 12:56:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: Sulfa (Sulfonamide Antibiotics) / Penicillins Attending: ___. Chief Complaint: neck pain s/p fall Major Surgical or Invasive Procedure: None on this Admission History of Present Illness: ___ male transferred from outside hospital for evaluation of cervical ___ fracture. Today the patient was attempting to use the bathroom and bent forward and fell hitting the back of his head. There was no loss of consciousness. The patient complains of headache and neck pain. The outside hospital the patient had the head laceration stapled. A CT scan did demonstrate the fracture. The patient denies any numbness, tingling in his arms or legs. No weakness in his arms or legs. Denies any bowel incontinence or bladder retention. No saddle anesthesia. Denies any chest pain, shortness of breath or abdominal pain. Past Medical History: PMH: a. fib, colon ca, htn, copd MED: warfarin, allopurinol, asacol ALL: pcn, sulfa Social History: ___ Family History: NC Physical Exam: C collar in place UEC5C6C7C8T1 (lat arm) (thumb) (mid fing) (sm finger) (med arm) Rintact intact intact intact intact Lintact intact intact intact intact T2-L1 (Trunk) intact ___ L2 L3 L4 L5S1S2 (Groin)(Knee) (Med Calf) (Grt Toe) (Sm Toe) (Post Thigh) Rintactintactintactintact intactintact Lintactintactintactintact intactintact Motor: UEDlt(C5)Bic(C6)WE(C6)Tri(C7)WF(C7)FF(C8)FinAbd(T1) R 5 5 5 5 ___ L 5 5 5 5 ___ ___ Flex(L1) Add(L2) Quad(L3) TA(L4) ___ ___ R ___ 5 5 5 5 L ___ 5 5 5 5 Babinski: negative Clonus: not present Brief Hospital Course: Patient was admitted to the ___ ___ Surgery Service for observation after a C2 fracture. TEDs/pnemoboots were used for postoperative DVT prophylaxis. Diet was advanced as tolerated. The patient was tolerated oral pain medication. Physical therapy was consulted for mobilization OOB to ambulate. He remained hypertensive from 160 - >180. Medicine consult appreciated - felt this was long standing. recommended PRN antihypertensives but cautioned against bringing pressure too low too quickly. 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. Discharge Medications: 1. Acetaminophen 650 mg PO Q4H:PRN pain, temp >100.5, headache 2. Allopurinol ___ mg PO DAILY 3. Mesalamine ___ 400 mg PO TID 4. Metoprolol Tartrate 25 mg PO BID 5. Omeprazole 20 mg PO DAILY 6. Warfarin 1 mg PO DAILY 7. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain 8. Diazepam 2 mg PO Q12H:PRN spasms Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: C2 fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You have undergone the following operation: Anterior Cervical Decompression and Fusion Immediately after the operation: -Activity: You should not lift anything greater than 5 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: o2-3 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. oIsometric Extension Exercise in the collar: 2x/day x ___xercises as instructed. -Swallowing: Difficulty swallowing is not uncommon after this type of surgery. This should resolve over time. Please take small bites and eat slowly. Removing the collar while eating can be helpful – however, please limit your movement of your neck if you remove your collar while eating. -Cervical Collar / Neck Brace: You need to wear the brace at all times until your follow-up appointment which should be in 2 weeks. You may remove the collar to take a shower. Limit your motion of your neck while the collar is off. Place the collar back on your neck immediately after the shower. -Wound Care: Monitor laceration at scalp for drainage/redness. Your PCP may take these staples out. -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 plan ahead. You can either have them mailed to your home or pick them up at the clinic located on ___. We are not allowed to call in narcotic (oxycontin, oxycodone, percocet) prescriptions to the pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. -Follow up: oPlease Call the office ___ and make an appointment with Dr. ___ 2 weeks after the day of your operation if this has not been done already. oAt the 2-week visit we will check your incision, take baseline x rays and answer any questions. oWe will then see you at 6 weeks from the day of the operation. At that time we will most likely obtain Flexion/Extension X-rays and often able to place you in a soft collar which you will wean out of over 1 week. Please call the office if you have a fever>101.5 degrees Fahrenheit, drainage from your wound, or have any questions. Physical Therapy: activity as tolerated C-collar full time for 12 weeks may use ambulatory assistive devices for safety no bending twisting, or lifting >5lbs Treatment Frequency: monitor skin at chin and back of head for breakdown in C-collar Followup Instructions: ___

10001884-DS-30

DS

2130-04-19 00:00:00

2130-04-22 13:31:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: IV Dye, Iodine Containing Contrast Media / Oxycodone / cilostazol / Varenicline Attending: ___. Chief Complaint: Nonexertional Chest pain Major Surgical or Invasive Procedure: none History of Present Illness: This is a ___ year old female with PMHx CAD, PVD and COPD presenting with chest pain. She reports that she woke up at 3 am with substernal pressure like pain which was associated with shortness of breath. She rated the pain a ___ and reports that it lasted for about 5 minutes and resolved spontaneously. She had several more episodes of the same pain lasting about 5 minutes at a time throughout the morning but which were much less severe. She hasn't had an episode of pain since 1 pm. She denies palpitations, lightheadedness, dizziness, nausea, vomiting, diaphoresis. In the ED, initial vitals were: 98.0 50 156/73 20 99% - Labs were significant for: - Na 137 K 3.0 Cl 94 CO2 32 BUN 16 Cr 0.8 - Ca: 10.6 Mg: 1.9 P: 2.9 - WBC 5.9 Hgb 13.6 Hct 41.1 Plt 238 - ___: 10.7 PTT: 28.7 INR: 1.0 - Lactate:2.0 - Trop-T: <0.01 - Imaging revealed: - CXR: No acute cardiopulmonary process - The patient was given: PO Aspirin 243, IH Albuterol 0.083% Neb, IH Ipratropium Bromide Neb, PO Potassium Chloride 40 mEq, 40 mEq Potassium Chloride / 1000 mL NS - Vitals prior to transfer were: 98.1 84 163/118 17 100% RA Upon arrival to the floor, patient denies chest pain, shortness of breath, palpitations, lightheadedness, dizziness. REVIEW OF SYSTEMS: (+) Per HPI Past Medical History: ASTHMA/COPD/Tobacco use, Peripheral Arterial disease s/p recent common iliac stenting, ATRIAL TACHYCARDIA, ATYPICAL CHEST PAIN, CERVICAL RADICULITIS, CERVICAL SPONDYLOSIS, CORONARY ARTERY DISEASE HEADACHE, HIP REPLACEMENT, HYPERLIPIDEMIA, HYPERTENSION, OSTEOARTHRITIS, HERPES ZOSTER, TOBACCO ABUSE, ATRIAL FIBRILLATION ANXIETY,GASTROINTESTINAL BLEEDING, OSTEOARTHRITIS, ATHEROSCLEROTIC CARDIOVASCULAR DISEASE, PERIPHERAL VASCULAR DISEASE, CATARACT SURGERY ___ Surgery: BILATERAL COMMON ILIAC ARTERY STENTING ___ BUNIONECTOMY HIP REPLACEMENT PRIOR CESAREAN SECTION GANGLION CYST Social History: ___ Family History: Mother: ___, HTN Father: ___ CA Brother: CA? Brother: ___ Physical ___: Admission PE: Vitals: 98.4 159/66 91 16 93% RA Wt: 66.2 General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: Supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, ___ systolic murmur heard best at RUSB, no rubs or gallops Lungs: inspiratory and expiratory wheezes, no rales or rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Discharge PE: Vitals: 98.5 ___ 20 ___ 98%RA Weight: 64.5 Weight on admission: 66.2 General: NAD HEENT: Sclera anicteric Neck: JVP not elevated CV: Regular rhythm with frequent skipped beats, normal S1 + S2, ___ systolic murmur heard best at RUSB, no rubs or gallops Lungs: mild expiratory wheezes, diffuse mild rhonchi (pre-nebulizer) Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding Ext: Warm, well perfused, no edema Pertinent Results: Admission Labs: ___ 07:49PM ___ PTT-28.7 ___ ___ 07:05PM LACTATE-2.0 ___ 05:58PM GLUCOSE-103* UREA N-16 CREAT-0.8 SODIUM-137 POTASSIUM-3.0* CHLORIDE-94* TOTAL CO2-32 ANION GAP-14 ___ 05:58PM estGFR-Using this ___ 05:58PM cTropnT-<0.01 ___ 05:58PM CALCIUM-10.6* PHOSPHATE-2.9 MAGNESIUM-1.9 ___ 05:58PM WBC-5.9 RBC-4.62 HGB-13.6 HCT-41.1 MCV-89 MCH-29.4 MCHC-33.1 RDW-14.7 RDWSD-47.1* ___ 05:58PM NEUTS-57.8 ___ MONOS-9.3 EOS-0.3* BASOS-0.2 IM ___ AbsNeut-3.41 AbsLymp-1.88 AbsMono-0.55 AbsEos-0.02* AbsBaso-0.01 ___ 05:58PM PLT COUNT-238 Discharge Labs: ___ 06:20AM BLOOD WBC-6.1 RBC-4.60 Hgb-13.4 Hct-41.2 MCV-90 MCH-29.1 MCHC-32.5 RDW-14.9 RDWSD-47.8* Plt ___ ___ 06:20AM BLOOD Plt ___ ___ 06:20AM BLOOD Glucose-97 UreaN-17 Creat-1.0 Na-134 K-4.2 Cl-96 HCO3-24 AnGap-18 ___ 06:25AM BLOOD ALT-19 AST-22 LD(LDH)-260* AlkPhos-81 TotBili-0.4 ___ 06:20AM BLOOD Calcium-9.7 Phos-3.7 Mg-1.9 Studies: 1. CXR ___: No acute cardiopulmonary process 2. ___: Exercise stress test INTERPRETATION: This ___ year old woman with a history of PAD and LBBB was referred to the lab from the ER following negative serial cardiac markers for evaluation of chest discomfort. The patient was referred for a dipyridamole stress test but due to her theophylline therapy we were not able to proceed. Due to her frequent atrial ectopy we chose not to give her dobutamine but had her walk on the treadmill instead. She exercised for 3 minutes of a modified ___ protocol and stopped due to leg claudication. The estimated peak MET capacity was 2.5 which represents a poor functional capacity for her age. No arm, neck, back or chest discomfort was reported by the patient throughout the study. The ST segments are uninterpretable for ischemia in the setting of the baseline LBBB. The rhythm was sinus with frequent isolated apbs, occasional atrial couplets and a 6 beat run of PSVT. Rare isolated vpbs were also noted. Resting mild systolic hypertension with a pprorpriate increase in BP with exercise and recovery. IMPRESSION: No anginal type symptoms or interpretable ST segments at a high cardiac demand and poor functional capacity. Nuclear report sent separately. 3. ___ CATH: LMCA: short, no CAD. LAD: mild focal origin disease (20%) and mild proximal disease (30%). LCX: minimal luminal irregularities. RCA: 30%. 4. ECG ___: sinus rhythm with multiple PACs, left axis deviation, old LBBB 5. ECG ___: Likely atrial tachycardia. Left bundle-branch block. Compared to the previous tracing atrial tachycardia has replaced sinus rhythm with premature atrial contractions. Left bundle-branch block was previously noted. 6. ECHO ___: Conclusions The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is ___ mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is considerable beat-to-beat variability of the left ventricular ejection fraction due to an irregular rhythm/premature beats. 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 are mildly thickened (?#). There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Physiologic mitral regurgitation is seen (within normal limits). The left ventricular inflow pattern suggests impaired relaxation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Compared with the prior study (images reviewed) of ___, frequent atrial ectopy is seen; biventricular function appears similar. Micro: ___: Bcx pending Brief Hospital Course: Brief Hospital Course =========================================================== ___ PMH of CAD, PVD, and COPD presenting with recurrent non-exertional substernal chest pain. The patient has a history of mild CAD but labs were significant for negative troponins and EKG was without ischemic changes. During her admission, she also developed multiple episodes of atrial tachycardia (AFib vs. Aflutter) and was started on Amiodarone for rate/rhythm control and Rivaroxaban for anticoagulation, and kept on home dose of Diltiazem also for rate control. She did not have any episodes of chest pain during hospitalization, so was discharged once atrial fibrillation/flutter was controlled. She will need to follow up with her primary care doctor regarding vague chest pain which led to admission. Acute Issues: ======================================================== #Atrial Tachycardia: During admission pt had runs of wide complex tachyarrythmia, thought likely supraventricular in origin: rapid Atrial Fibrillation/ Flutter vs. atrial tachycardia, with abberancy (complexes with similar morphology to native LBBB). She was treated with Diltiazem and Amiodarone and had fewer episodes of tachycardia. EP team evaluated patient and recommended anticoagulation and outpatient follow up to consider EP study and possible ablation of Atrial Flutter. Patient was discharged with ___ of Hearts monitor, Amiodarone 200mg twice daily x 1 week followed by 200 mg daily thereafter. Diltiazem continued at home dose. Rivaroxaban added for anticoagulation. As per outpatient cardiologist (Dr. ___, plavix was discontinued in light of addition of Rivaroxaban and interest in avoiding triple therapy in this patient. Pt was given follow up appointments with Drs. ___. She was scheduled to see Dr. ___ EP evaluation in 2 months. #Chest pain: Pt presented with substernal chest pain that occurred at rest and was ruled out for MI with no troponin elevation or significant new ECG changes. Likely her chest pain was related to periods of tachycardia, although while in the hospital the runs of atrial tachycardia did not reproduce chest pain. She did not have any episodes of chest pain during hospitalization, so was discharged once atrial fibrillation/flutter was controlled. She will need to follow up with her primary care doctor regarding vague chest pain which led to admission. #Dry eyes: pt had erythema and pain of R eye, found to have dry eyes per optholmology. Sent out with Artificial tears and erythromycin eye drops. Patient had follow up appointment already scheduled with optholmology and was instructed to attend appointment. Chronic Issues: ============================================================= # COPD Pt appeared to be at baseline respiratory status. She was sent home with her home albuterol neb, albuterol inhaler, Fluticasone nasal spray, fluticasone-salmeterol diskus, tiotropium bromide nebs, and theophylline # PAD: As above, we stopped Clopidogrel as patient is now on Rivaroxaban and wanted to avoid triple therapy as per her cardiologist Dr. ___. Transitional Issues: ============================================================== 1. Patient was discharged on Amiodarone 200 mg po twice daily for one week until ___ and then 200mg po daily thereafter until her EP appointment with Dr. ___ in approximately 2 months. 2. Pt was discharged on Rivaroxaban 20 mg qpm with dinner 3. Pt discharged with outpatient ___ of Hearts monitor with results to be interpreted by Cardiologist. 4. She presented with chest pain but did not have elevated biomarkers or EKG changes concerning for myocardial damage. Moreover, pt remained asymptomatic during periods of supraventricular tachycardia while she was hospitalized. Patient may benefit from outpatient stress test if such symptoms return. 5. On day of discharge, pt had significant R eye pain and redness, was evaluated by Optholmology, who felt that it was just dry eyes, treated with erythromycin drops and artifiical tears. Patient already has appt w/ Opthamology in 5 days which she will need to attend. Full Code Contact: CONTACT: ___ (husband) ___ ___ (daughter) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 325 mg PO Q4H:PRN pain 2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of breath 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 10 mg PO QPM 5. Clopidogrel 75 mg PO DAILY 6. Diltiazem Extended-Release 180 mg PO DAILY 7. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN nasal congestion 8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 9. Hydrochlorothiazide 50 mg PO DAILY 10. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY 11. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE HS 12. Lorazepam 0.5 mg PO QHS:PRN insomnia 13. Multivitamins W/minerals 1 TAB PO DAILY 14. Ranitidine 150 mg PO BID 15. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain 16. Theophylline ER 300 mg PO BID 17. Tiotropium Bromide 1 CAP IH DAILY 18. Guaifenesin-CODEINE Phosphate 5 mL PO Q6H:PRN cough 19. cod liver oil 1,250-135 unit oral BID 20. Calcarb 600 With Vitamin D (calcium carbonate-vitamin D3) 315/200 mg oral daily Discharge Medications: 1. Amiodarone 200 mg PO BID RX *amiodarone 200 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*1 2. Rivaroxaban 20 mg PO DINNER RX *rivaroxaban [Xarelto] 20 mg 1 tablet(s) by mouth qpm Disp #*30 Tablet Refills:*1 3. Acetaminophen 325 mg PO Q4H:PRN pain 4. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of breath 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 10 mg PO QPM 7. Diltiazem Extended-Release 180 mg PO DAILY 8. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN nasal congestion 9. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 10. Guaifenesin-CODEINE Phosphate 5 mL PO Q6H:PRN cough 11. Hydrochlorothiazide 50 mg PO DAILY 12. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY 13. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE HS 14. Lorazepam 0.5 mg PO QHS:PRN insomnia 15. Multivitamins W/minerals 1 TAB PO DAILY 16. Ranitidine 150 mg PO BID 17. Theophylline ER 300 mg PO BID 18. Tiotropium Bromide 1 CAP IH DAILY 19. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain 20. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN eye irritation RX *dextran 70-hypromellose [Artificial Tears] 1 drop OPTH QID:prn Refills:*0 RX *dextran 70-hypromellose [Artificial Tears (PF)] ___ drops eye as needed Disp #*1 Package Refills:*1 21. Erythromycin 0.5% Ophth Oint 0.5 in RIGHT EYE TID RX *erythromycin 5 mg/gram (0.5 %) 0.5 (One half) inch OPTH TID:prn Refills:*0 22. Calcarb 600 With Vitamin D (calcium carbonate-vitamin D3) 315/200 mg oral daily 23. cod liver oil 1,250-135 unit oral BID Discharge Disposition: Home Discharge Diagnosis: Rapid Atrial Fibrillation/Flutter COPD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to ___ due to concerning chest pain symptoms which we think are due to infrequent bursts of a rapid heart rate. Since the rapid rate makes you at increased risk for stroke, you were started on a blood thinning medication called Rivaroxaban which you will need to take every day. Our specialized cardiologists who deal specifically with the electrical rhythm of the heart evaluated you and felt that you would benefit from a medication called amiodarone which was also started. You will need to follow up with them in their clinic regarding this abnormal rhythm. In the meantime, you were outfitted with a Holter monitor to record your heart rate at home. It is very important that you follow up with Dr. ___ your cardiologist. We wish you all the best, Sincerely, Your care team at ___ Followup Instructions: ___

10001884-DS-32

DS

2130-10-12 00:00:00

2130-10-13 22:19:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: IV Dye, Iodine Containing Contrast Media / Oxycodone / cilostazol / Varenicline Attending: ___ Chief Complaint: Dyspnea, Atrial Fibrillation Major Surgical or Invasive Procedure: None History of Present Illness: ___ F with pmhx of COPD (nighttime O2), htn, afib who presents with dyspnea, currently being treated for COPD and admitted for Afib with RVR. The patient went to the ED on ___ and was diagnosed with a COPD flare. She was discharged with a prednisone taper (currently on 60mg) and azithromycin. This AM she initially felt well, then developed dyspnea at rest, worsening with exertion. Her inhalers improved her SOB. She felt that these symptoms were consistent with her COPD. She saw her PCP ___ today in clinic where she was found to be in Afib w/ RVR, rate around 110-120. She has a history of afib. He referred her to the ED for persistent SOB and afib with RVR. She states she been compliant with nebs and steroid/azithro regimen. She denies any ___ edema, orthopnea. She denies recent travel, surgeries. She had an episode of chest tightness this AM that felt like her COPD flares. Denies fevers or coughing or production of sputum, hemomptysis. Past Medical History: ASTHMA/COPD ATYPICAL CHEST PAIN CERVICAL RADICULITIS CERVICAL SPONDYLOSIS CORONARY ARTERY DISEASE HEADACHE HIP REPLACEMENT HYPERLIPIDEMIA HYPERTENSION OSTEOARTHRITIS HERPES ZOSTER ATRIAL FIBRILLATION ANXIETY GASTROINTESTINAL BLEEDING OSTEOARTHRITIS ATHEROSCLEROTIC CARDIOVASCULAR DISEASE PERIPHERAL VASCULAR DISEASE Social History: ___ Family History: Mother: ___, HTN Father: ___ CA Brother: CA? Brother: ___ Physical ___: ADMISSION PHYSICAL EXAM: VS: 98.14 154/74 71 24 98% 2L GENERAL: Well appearing, NAD, no accessory muscle use. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. NECK: No JVD CARDIAC: Irregular rhythm, normal rate. Normal S1, S2. No murmurs/rubs/gallops. LUNGS: Moving air well bilaterally. Trace inspiratory wheezing and louder expiratory wheezing in all lung fields. No crackles/rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. No femoral bruits. DISCHARGE PHYSICAL EXAM: VS: Tm 98.8 Tc 98.4 ___ RA GENERAL: NAD HEENT: NCAT. Sclera anicteric. Conjunctivae noninjected. OM clear. NECK: No JVD CARDIAC: RRR. Normal S1, S2. No murmurs/rubs/gallops. LUNGS: Mildly reduced air movement, significant wheezing bilaterally, +rhonchi, no crackles ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. Pertinent Results: ADMISSION LABS: ___ 03:38PM BLOOD WBC-7.2 RBC-4.06 Hgb-9.4* Hct-31.4* MCV-77* MCH-23.2* MCHC-29.9* RDW-16.9* RDWSD-47.2* Plt ___ ___ 03:38PM BLOOD Neuts-93.8* Lymphs-4.2* Monos-1.3* Eos-0.0* Baso-0.0 Im ___ AbsNeut-6.74*# AbsLymp-0.30* AbsMono-0.09* AbsEos-0.00* AbsBaso-0.00* ___ 03:38PM BLOOD ___ PTT-30.3 ___ ___ 03:38PM BLOOD Glucose-141* UreaN-20 Creat-1.0 Na-133 K-3.8 Cl-93* HCO3-30 AnGap-14 ___ 03:38PM BLOOD Calcium-9.9 Phos-2.8 Mg-2.1 PERTINENT LABS: ___ 03:58PM BLOOD cTropnT-<0.01 ___ 06:50AM BLOOD CK-MB-4 cTropnT-<0.01 ___ 06:50AM BLOOD calTIBC-398 Ferritn-16 TRF-306 ___ 06:50AM BLOOD TSH-4.5* ___ 09:31AM BLOOD ___ pO2-73* pCO2-58* pH-7.35 calTCO2-33* Base XS-3 ___ 07:15AM BLOOD T4, FREE, DIRECT DIALYSIS-Test DISCHARGE LABS: ___ 05:30AM BLOOD WBC-13.2* RBC-3.97 Hgb-9.0* Hct-31.1* MCV-78* MCH-22.7* MCHC-28.9* RDW-17.4* RDWSD-48.7* Plt ___ ___ 05:30AM BLOOD Glucose-85 UreaN-23* Creat-0.9 Na-136 K-3.9 Cl-95* HCO3-30 AnGap-15 ___ 06:30AM BLOOD Calcium-9.7 Phos-3.0 Mg-2.0 IMAGING: ___ Chest X ray: Relative increase in opacity over the lung bases bilaterally felt due to overlying soft tissue rather than consolidation. Lateral view may be helpful for confirmation. ___ Chest X ray: There is hyperinflation. There is no pneumothorax, effusion, consolidation or CHF. There is probable osteopenia. Brief Hospital Course: ___ is a ___ with a history of CAD, PVD, and COPD and history of recurrent chest pain who presented with afib with RVR and COPD exacerbation. ACUTE PROBLEMS: #COPD exacerbation: Ms. ___ had had two recent ED visits for COPD exacerbation, most recently ___ when she was started on prednisone 60 mg. She presented to her PCP's office with worsening dyspnea despite this therapy and was also complaining of nasal congestion, suggesting a viral URI trigger. In clinic she was also noted to be in afib with RVR so was referred to the ED where she was admitted after control of her heart rate (see below). On admission to the floor, she was noted to have wheezing, increased work of breathing, and poor air movement. She was treated with 125 mg solumedrol and maintained on 60 mg PO prednisone daily. Her home theophylline was decreased from 400 mg BID to ___ mg BID due to concerns it was contributing to her tachyarrhythmia. She was placed on ipratropium nebs q6h, albuterol nebs q2h, and fluticasone-salmeterol. Pulmonary was consulted and recommended a trial of diuresis so she received 10 mg IV Lasix as well. Azithromycin was not given due to concerns for QT prolongation with theophylline and amiodarone (QTc was 460). She was started on a 5 day course of ceftriaxone instead, and discharged to finish the course with cefpodoxime. She was discharged with a prednisone taper (10 mg decrease q3d until at 10 mg, then stay at 10 mg until pulm follow up) as well as follow up with pulmonary rehab and a pulmonologist she previously followed with, Dr. ___. She was also discharged on 2L supplemental O2 to be worn at all times. #Atrial fibrillation: Ms. ___ has known atrial fibrillation for which she was on amiodarone and apixaban but was found to have HR in the 120s in her PCP's office, prompting her referral to the ED. Her COPD exacerbation was the likely precipitant, with medications also possibly contributing, particularly theophylline. She was started on a diltiazem gtt in the ED to control her rates than transitioned to diltiazem 90 mg q6h. After arrival to the floor, her rates remained controlled. Her amiodarone and apixaban were continued. Her theophylline was decreased to 200 mg BID from 400 mg BID. #Iron deficiency anemia. Patient was found to have microcytic anemia with low iron and ferritin. She was started on IV iron 125 mg ferric gluconate x4 doses and wasdischarged on PO iron with a bowel regimen. Her H/H was stable throughout the hospitalized; there was no evidence of bleeding. Transitional issues: - patient discharged on prednisone taper: decrease by 10 mg every 3 days until at 10 mg, then keep at 10 mg until seen by pulmonology - patient discharged with plan to follow up with pulmonology and pulmonary rehab. Can call ___ to schedule appointment with pulmonary rehab. - patient discharged on with 2 days of cefpodoxime to complete 5 day course of antibiotics for severe COPD exacerbation - patient discharged with O2 concentrator for continuous home O2 - patient's theophylline decreased from 300 mg BID to ___ mg BID due to her afib with RVR; may want to consider further theophylline wean, and addition of azithromycin (if QTc is decreased as patient also on amiodarone), and/or roflumilast therapy - patient found to be iron deficient, started on IV iron repletion, discharged on PO iron - patient found to have elevated TSH, please follow up free T4 which was pending on discharge - Code: full - Emergency Contact ___ (Husband) ___ Daughter ___: ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Apixaban 5 mg PO BID 3. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of breath 4. Amiodarone 200 mg PO DAILY 5. Atorvastatin 10 mg PO QPM 6. Artificial Tears ___ DROP BOTH EYES PRN irritation 7. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE QHS 8. Diltiazem Extended-Release 180 mg PO BID 9. Fluticasone Propionate NASAL 1 SPRY NU BID 10. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 11. Hydrochlorothiazide 50 mg PO DAILY 12. Isosorbide Mononitrate (Extended Release) 240 mg PO DAILY 13. Lorazepam 0.5 mg PO QHS:PRN insomnia 14. Theophylline ER 300 mg PO BID 15. Ranitidine 300 mg PO DAILY 16. Tiotropium Bromide 1 CAP IH DAILY 17. Multivitamins W/minerals 1 TAB PO DAILY 18. Aspirin 81 mg PO DAILY 19. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID Discharge Medications: 1. Home O2 2 Liters continuous nasal cannula with exertion Diagnosis: chronic obstructive pulmonary disease (J44.9) Length of Needs: ongoing (years) 2. Acetaminophen 650 mg PO Q6H:PRN pain 3. Amiodarone 200 mg PO DAILY 4. Apixaban 5 mg PO BID 5. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN shortness of breath 6. Artificial Tears ___ DROP BOTH EYES PRN irritation 7. Aspirin 81 mg PO DAILY 8. Atorvastatin 10 mg PO QPM 9. Diltiazem Extended-Release 180 mg PO BID 10. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID 11. Fluticasone Propionate NASAL 1 SPRY NU BID 12. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 13. Hydrochlorothiazide 50 mg PO DAILY 14. Isosorbide Mononitrate (Extended Release) 240 mg PO DAILY 15. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE QHS 16. Lorazepam 0.5 mg PO QHS:PRN insomnia 17. Multivitamins W/minerals 1 TAB PO DAILY 18. Ranitidine 300 mg PO DAILY 19. Tiotropium Bromide 1 CAP IH DAILY 20. Theophylline SR 200 mg PO BID RX *theophylline 200 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 21. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 2 Days RX *cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp #*4 Tablet Refills:*0 22. Ferrous Sulfate 325 mg PO DAILY RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 23. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 24. Polyethylene Glycol 17 g PO DAILY RX *polyethylene glycol 3350 17 gram/dose 1 powder(s) by mouth daily Refills:*0 25. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN dyspnea, wheezing RX *ipratropium bromide 0.2 mg/mL (0.02 %) 1 neb INH Every six hours Disp #*30 Nebule Refills:*0 26. PredniSONE 10 mg PO ASDIR 50 mg ___, then 40 mg ___, then 30 mg ___, then 20 mg ___, then 10 mg ongoing Tapered dose - DOWN RX *prednisone 10 mg 1 to 5 tablet(s) by mouth As directed Disp #*50 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary diagnoses: Chronic obstructive pulmonary disease Atrial fibrillation with rapid ventricular response Secondary diagnoses: Hypertension Coronary artery disease Peripheral vascular disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were hospitalized at ___ because you were having difficulty breathing and were found in clinic to have a fast heart rate. Your difficulty breathing was due to your COPD flaring. Your fast heart rate was due to your atrial fibrillation, which is an irregular heart rate that can sometimes cause the heart to beat very quickly. Medications that you were taking, such as theophylline, were likely contributing. Your heart rate was lowered using the same medication that you take at home, diltiazem, given through your IV. Your COPD was likely worsened because of a cold. However, your flare was very serious requiring IV steroids and many inhaled treatments. You should follow up with the lung doctors as ___ as with pulmonary rehab to make sure your lung disease is being treated as well as possible to prevent you from coming into the hospital as often. Please call ___ to schedule an appointment with them. It was a pleasure participating in your care. We wish you all the best in the future. Sincerely, Your ___ team Followup Instructions: ___

10001884-DS-34

DS

2130-11-30 00:00:00

2130-12-01 21:56:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: IV Dye, Iodine Containing Contrast Media / Oxycodone / cilostazol / Varenicline Attending: ___. Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ yo woman with a PMH notable for COPD on home O2(hospitalized ___, multiple recent ED visits), Afib on apixaban, HTN, CAD, and HLD who presents with several days of worsening dyspnea. Patient has had several ED visits for dyspnea and a recent hospitalization for a COPD exacerbation in ___. She has been on steroid therapy with several attempts to taper over the last several months. After her most recent ED visit on ___ she was on placed on 60 mg PO prednisone with a taper down by 10 mg each day. Her SOB worsened with the taper and she was seen on ___ by her PCP who started her on a course of prednisone 30 mg PO to be tapered down by 5 mg every 3 days. With the taper she is currently on prednisone 25 mg QD. She reports that her SOB improved slightly after starting the steroids on ___. However, last night it acutely worsened and she was unable to sleep. She usually uses 3 pillows to sleep but was only comfortable seated upright last night. This morning she increased her oxygen to 3L and felt better. She is usually on 2L NC at home. She reports that for the last several months she has been using two different albuterol inhalers each every ___ hours. She knows that this is more than they are prescribed for but it makes her comfortable. She mostly stays put on the second floor of her home. She states that she can walk to the bathroom without being short of breath, but does not use the stairs unless she has to leave the house because it worsens her breathing. She endorses a cough occasionally productive of ___ sputum. This is consistent with her baseline. She endorses one episode of non-exertional chest pain today that spontaneously resolved. She denies fever, chills, recent sick contacts, and lower extremity edema. In the ED, initial vital signs were: T 98.5 P 80 BP 154/97 R 20 O2 sat 97% NC. - Exam notable for: Diffuse expiratory wheezing, prolonged expiratory phase, left inspiratory crackles, irregularly irregular rhthym, minimal pedal edema - Labs were notable for CBC wnl, proBNP 235, Trop 0.02, chem notable for bicarb 31, AG 13, UA notable for 40 RBCs - Studies performed include CXR with stable mild/moderate cardiomegaly, atelectasis at bases, otherwise clear lung fields - Patient was given Albuterol neb x 1, ipratropium neb x 1, Azithromycin 500 mg PO, Prednisone 25 mg PO Upon arrival to the floor, the patient states that she is doing well. She says that her SOB has improved since this morning and is better than last night when she could not sleep. Review of Systems: (+) per HPI (-) fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: ASTHMA/COPD ATYPICAL CHEST PAIN CERVICAL RADICULITIS CERVICAL SPONDYLOSIS CORONARY ARTERY DISEASE HEADACHE HIP REPLACEMENT HYPERLIPIDEMIA HYPERTENSION OSTEOARTHRITIS HERPES ZOSTER ATRIAL FIBRILLATION ANXIETY GASTROINTESTINAL BLEEDING OSTEOARTHRITIS PERIPHERAL VASCULAR DISEASE (s/p bilateral iliac stents) Social History: ___ Family History: Mother: ___, HTN Father: ___ CA Brother: CA? Brother: ___ Physical ___: ================= ADMISSION EXAM: ================= Vitals- T 98.0 BP 148/70 HR 70 RR 24 O2Sat 96% on 2L NC GENERAL: AOx3, NAD, sitting up in bed HEENT: Normocephalic, atraumatic. Pupils equal, round, and reactive bilaterally, extraocular muscles intact. No conjunctival pallor or injection, sclera anicteric and without injection. Moist mucous membranes, good dentition. Oropharynx is clear. NECK: Supple. JVD not visualized. CARDIAC: Irregularly irregular, ___ systolic murmur best at the LSB, no rubs or gallops. LUNGS: Poor air movement throughout. Mild diffuse inspiratory and expiratory wheezes. No use of accessory muscles of breathing. No rhonchi or rales. BACK: No CVA tenderness ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES: No clubbing or cyanosis. Bilateral pitting edema to the mid shin. Pulses DP/Radial 2+ bilaterally. SKIN: No rash or ulcers NEUROLOGIC: CN2-12 intact. Moves all extremities spontaneously. Normal sensation. ================= DISCHARGE EXAM: ================= Vitals- T 98.7 BP 154/85 HR 77 RR 18 O2Sat 99% on 3L NC GENERAL: AOx3, NAD, sitting up in bed HEENT: NCAT. PERRL. EOMI. Sclera anicteric and not injected. MMM. Oropharynx is clear. NECK: Supple. No LAD. JVP not appreciated at 45 degrees. CARDIAC: Irregularly irregular, normal rate. ___ systolic murmur at the RUSB. No rubs or gallops. LUNGS: Poor air movement throughout all zones of the lungs. No wheezes. No prolonged expiratory phase. No rhonchi or rales. Does typically sit cross legged in the bed with forearms on her legs in a tripod position. BACK: No CVA tenderness. ABDOMEN: +BS, soft, nontender, nondistended EXTREMITIES: Trace pitting edema to the mid shin. 2+ DP pulses bilaterally. No TTP. SKIN: No rash or ulcers. NEUROLOGIC: CN2-12 intact. Moves all extremities spontaneously. Normal sensation. Pertinent Results: ================== ADMISSION LABS: ================== ___ 02:27PM BLOOD WBC-7.4 RBC-4.57 Hgb-12.3 Hct-39.3 MCV-86 MCH-26.9 MCHC-31.3* RDW-23.6* RDWSD-70.9* Plt ___ ___ 02:27PM BLOOD Neuts-86.5* Lymphs-6.1* Monos-6.6 Eos-0.0* Baso-0.0 Im ___ AbsNeut-6.38* AbsLymp-0.45* AbsMono-0.49 AbsEos-0.00* AbsBaso-0.00* ___ 02:27PM BLOOD Glucose-132* UreaN-17 Creat-1.0 Na-137 K-3.7 Cl-93* HCO3-31 AnGap-17 ================== PERTINENT RESULTS: ================== LABS: ================== ___ 12:15AM BLOOD ___ pO2-103 pCO2-49* pH-7.42 calTCO2-33* Base XS-5 === ___ 02:27PM BLOOD cTropnT-0.02* proBNP-235 ___ 09:05PM BLOOD CK-MB-6 cTropnT-<0.01 ___ 07:45AM BLOOD CK-MB-6 cTropnT-0.02* === ___ 07:45AM BLOOD THEOPHYLLINE-17.3 (10.0-20.0) ================== IMAGING: ================== CXR (___): PA and lateral views the chest provided. Biapical pleural parenchymal scarring noted. No focal consolidation concerning for pneumonia. No effusion or pneumothorax. No signs of congestion or edema. Cardiomediastinal silhouette is stable with an unfolded thoracic aorta and top-normal heart size. Bony structures are intact. === CT Chest (___): 1. Moderate upper lobe predominant centrilobular and paraseptal emphysema. 2. New left lower lobe nodule, potentially measuring as large as 6 x 8 mm, warrants close follow-up. Stable to slightly smaller 4 mm right middle lobe nodule. 3. Severe coronary artery calcifications. Aortic valve calcifications. 4. Enlargement of the main and right pulmonary arteries is suggestive of chronic pulmonary arterial hypertension. 5. Fusiform aneurysmal dilatation of the abdominal aorta measuring up to 3.7 cm has progressed compared to prior examination. ================== DISCHARGE LABS: ================== ___ 07:45AM BLOOD WBC-7.8 RBC-4.74 Hgb-12.7 Hct-41.0 MCV-87 MCH-26.8 MCHC-31.0* RDW-23.7* RDWSD-71.7* Plt ___ ___ 07:45AM BLOOD Glucose-94 UreaN-18 Creat-1.0 Na-135 K-3.3 Cl-93* HCO3-31 AnGap-14 ___ 07:45AM BLOOD Calcium-9.8 Phos-2.8 Mg-2.0 Brief Hospital Course: Ms. ___ is a ___ y/o woman with a PMH notable for COPD on home O2 (hospitalized ___, multiple recent ED visits), Afib on apixaban, HTN, CAD, and HLD who presented with dyspnea and orthopnea in the setting of a steroid taper for recent COPD exacerbation. Her dyspnea was thought to be multifactorial due to her severe COPD and with a component of anxiety. The patient was not thought to be having an acute COPD exacerbation. ================ ACTIVE ISSUES: ================ # Dyspnea: Patient was admitted after one night of worsened orthopnea and dyspnea in the setting of a steroid taper from 30 mg to 25 mg. Her dyspnea was thought to be multifactorial due to her severe COPD and with a component of anxiety. The patient was not thought to be having an acute COPD exacerbation. The patient was treated with occasional duonebs and lorazepam 0.5 mg PRN that helped relieve her dyspnea. Pulmonology was consulted. The patient underwent CT that showed emphysema but no evidence of infection such as ___. The patient was initiated on a steroid taper on ___ of prednisone 30 mg for 3 days, then 20 mg for 3 days, then 10 mg until outpatient follow-up. Pulmonology recommended increasing her Advair dose to 500/50, which was done. They also recommended switching from theophylline to roflumilast and initiation of long-term azithromycin therapy provided the patient's QTc was not prolonged; this was deferred to the outpatient setting. Throughout her admission she had O2 sats greater than 95% on 2L NC. She did not desaturate on ambulation. # Anxiety/Insomnia: Patient with a history of anxiety and insomnia, thought to be contributing to her experience of dyspnea. The patient was discharged with lorazepam Q8H as needed for anxiety. The patient would likely benefit from therapy with an SSRI. # Demand Ischemia: Patient with troponin 0.02, <0.01, then 0.02. ECG without acute ischemic changes. # Microscopic hematuria: On admission the patient had a UA with 40 RBCs. Occasional UAs over the last year in OMR with microscopic hematuria. Would recommend repeat UA as an outpatient or work-up for microscopic hematuria. ================ CHRONIC ISSUES: ================ # Smoking: Patient recently quit smoking one month ago. Patient was provided with a nicotine patch 7 mg while in house; could consider continuing as an outpatient if patient endorses cravings. # Atrial fibrillation: Patient continued on diltiazem 240 mg PO BID and apixaban 5 mg BID. # HTN: Patient with a history of hypertension. Blood pressure well-controlled. Continued on isosorbide mononitrate ER 240 mg PO daily and hydrochlorothiazide 50 mg PO daily. # CAD: Cardiac catheterization in ___ without evidence of significant stenosis of coronaries. ECHO on ___ with EF>55% and no regional or global wall motion abnormalities. The patient was continued on aspirin 81 mg daily and atorvastatin 10 mg QPM. =================== TRANSITIONAL ISSUES: =================== #New Medications: -Prednisone 30 mg PO QD through ___, then on ___ mg for 3 days, then on ___ mg until outpatient follow-up -Increased Advair (Fluticasone-Salmeterol) to 500/50 dose -Lorazepam 0.5 mg PO Q8H PRN for anxiety #Follow-up: -Appointment arranged with PCP, ___ ___ -Appointment arranged with Pulmonologist, Dr. ___, ___ #COPD: Patient was seen by pulmonology during admission who had the following recommendations to consider as an outpatient. -Switch to roflumilast from theophylline -Daily azithromycin for treatment of chronic inflammation provided QTc within normal limits. -Patient may benefit from treatment of anxiety with an SSRI, as her anxiety is likely contributing to her experience of dyspnea. -In the future, palliative care consult for consideration of opioid treatment of dyspnea #Microscopic hematuria: Patient had a UA with 40 RBCs on admission -Recommend repeat UA as an outpatient or work-up for microscopic hematuria #Lung nodule: New left lower lobe nodule, potentially measuring as large as 6 x 8 mm, warrants close follow-up. Stable to slightly smaller 4 mm right middle lobe nodule. Follow-up CT in ___ months as per ___ guidelines for evaluation of new left lower lobe pulmonary nodule. #Code Status: Full code #Emergency Contact/HCP: ___ (HUSBAND) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. PredniSONE 5 mg PO DAILY Tapered dose - DOWN 2. Acetaminophen 325 mg PO Q4H:PRN Pain 3. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN Wheezing 4. Tiotropium Bromide 1 CAP IH DAILY 5. Guaifenesin 1 teaspoon PO Q3H:PRN cough 6. Lorazepam 0.5 mg PO QHS vertigo/insomnia 7. Diltiazem Extended-Release 240 mg PO BID 8. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID 9. Docusate Sodium 100 mg PO BID 10. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN allergies 11. Apixaban 5 mg PO BID 12. Ranitidine 300 mg PO DAILY 13. Atorvastatin 10 mg PO QPM 14. Ferrous Sulfate 325 mg PO DAILY 15. Multivitamins 1 TAB PO DAILY 16. Isosorbide Mononitrate (Extended Release) 240 mg PO DAILY 17. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 18. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 19. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315 mg - 200 units oral DAILY 20. Theophylline SR 300 mg PO BID 21. Aspirin 81 mg PO DAILY 22. albuterol sulfate 90 mcg/actuation inhalation Q4H 23. Hydrochlorothiazide 50 mg PO DAILY 24. cod liver oil 1 capsule oral BID Discharge Medications: 1. Acetaminophen 325 mg PO Q4H:PRN Pain 2. Apixaban 5 mg PO BID 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 10 mg PO QPM 5. Diltiazem Extended-Release 240 mg PO BID 6. Docusate Sodium 100 mg PO BID 7. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID 8. Ferrous Sulfate 325 mg PO DAILY 9. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN allergies 10. Hydrochlorothiazide 50 mg PO DAILY 11. Isosorbide Mononitrate (Extended Release) 240 mg PO DAILY 12. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 13. Multivitamins 1 TAB PO DAILY 14. PredniSONE 30 mg PO DAILY RX *prednisone 10 mg 3 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 15. Ranitidine 300 mg PO DAILY 16. Theophylline SR 300 mg PO BID 17. Tiotropium Bromide 1 CAP IH DAILY 18. Guaifenesin 1 teaspoon PO Q3H:PRN cough 19. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN Wheezing 20. cod liver oil 1 capsule oral BID 21. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315 mg - 200 units oral DAILY 22. albuterol sulfate 90 mcg/actuation inhalation Q4H 23. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID RX *fluticasone-salmeterol [Advair Diskus] 500 mcg-50 mcg/dose 1 dose Inhaled Twice a day Disp #*1 Disk Refills:*1 24. Lorazepam 0.5 mg PO Q8H:PRN Anxiety RX *lorazepam [Ativan] 0.5 mg 0.5 (One half) mg by mouth Every 8 hours Disp #*30 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnosis: Chronic obstruction pulmonary disease exacerbation Secondary Diagnoses: Tobacco use disorder Atrial fibrillation Hypertension Anxiety Coronary Artery Disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a privilege taking care of you during your admission to ___. You were admitted to the hospital for shortness of breath and concern that you were having a flare of your COPD. While in the hospital we increased your dose of steroids to help your breathing. You also received several nebulizer treatments that helped your breathing. You were also expressing some anxiety that may have been contributing to your shortness of breath. You were given a medication called Ativan for your anxiety that also seemed to help your breathing. During your admission you were seen by the pulmonary specialists. They recommended a CT scan that showed that you have extensive COPD but did not show any infection. They also suggested increasing the dose of your Advair inhaler, which we did. If you feel short of breath, first please check your oxygen level. If it is less than 90, you can use oxygen and your inhaler. If not, try to wait a few minutes, take a few deep breaths and see if your shortness of breath improves. You can use the medication called Ativan(lorazepam) to help with the shortness of breath(no more than three times a day). If still not improved, you can use one of the inhalers/oxygen. Please follow-up with all your appointments as listed below and continue to take all of your medications as prescribed. If you experience any of the danger signs listed you should call your doctor immediately or go to the Emergency Room. We wish you the best! Sincerely, Your ___ Care Team Followup Instructions: ___

10001884-DS-36

DS

2130-12-24 00:00:00

2130-12-26 17:14:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: IV Dye, Iodine Containing Contrast Media / Oxycodone / cilostazol / Varenicline Attending: ___. Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ with hx COPD on home O2, atrial fibrillation on apixaban, hypertension, CAD, and hyperlipidemia who presented with dyspnea. She has had multiple prior admissions for dyspnea. She was recently discharged on ___ after 3 day inpatient admission for COPD exacerbation. She was discharged on extended prednisone taper with plan for 5d 40mg Prednisone (to finish ___ followed by 10mg taper every 5 days (35mg from ___, 30mg ___, etc...). She initially went to rehab and subsequently went home 2 days prior to admission. Upon arrival at home she subsequently had recrudescence of fatigue, wheezing, dyspnea. She also had increased O2 requirements (up to 3L, using oxygen 24hr instead of during day only). Also with new cough, non-productive. Denies f/c, CP. No n/v, no myalgias. Decreased hearing in right ear with fullness for past 4 days. She was seen by PCP ___ noted to have inspiratory/expiratory wheezes, as well as decreased hearing and bulging TM right ear. She was referred to the ___ ED for further management. In the ED, initial vital signs were: 98.4 74 142/69 16 100%(2L NC) - Labs were notable for: 136 95 17 140 3.5 29 1.0 BNP 254 CBC within normal limits, but with neutrophil predominance UA with 30 protein VBG: pH 7.45, pCO2 43, pO2 59, HCO3 31 Flu PCR negative - Imaging: CXR notable for no acute cardiopulmonary process. - The patient was given: ___ 16:03 IH Albuterol 0.083% Neb Soln 1 NEB ___ 16:03 IH Ipratropium Bromide Neb 1 NEB ___ 17:12 IH Albuterol 0.083% Neb Soln 1 NEB ___ 17:12 IH Ipratropium Bromide Neb 1 NEB ___ 18:12 IH Albuterol 0.083% Neb Soln 1 NEB ___ 18:12 IH Ipratropium Bromide Neb 1 NEB ___ 21:05 IH Albuterol 0.083% Neb Soln 1 NEB ___ 21:05 PO PredniSONE 60 mg ___ 21:05 IV Magnesium Sulfate 2 gm ___ 21:33 IH Albuterol 0.083% Neb Soln 1 NEB Vitals prior to transfer were: 98.8 87 131/83 16 97% (2L) Upon arrival to the floor, she complained of wheezing and SOB, and persistent decreased hearing with fullness in right ear. REVIEW OF SYSTEMS: Per HPI. Denies headache, visual changes, pharyngitis, rhinorrhea, nasal congestion, cough, fevers, chills, sweats, weight loss, dyspnea, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, hematochezia, dysuria, rash, paresthesias, and weakness. Past Medical History: - COPD/Asthma on home 2L O2 - Atypical Chest Pain - Hypertension - Hyperlipidemia - Osteroarthritis - Atrial Fibrillation on Apixaban - Anxiety - Cervical Radiculitis - Cervical Spondylosis - Coronary Artery Disease - Headache - Herpes Zoster - GI Bleeding - Peripheral Vascular Disease s/p bilateral iliac stents - s/p hip replacement Social History: ___ Family History: Mother with asthma and hypertension. Father with colon cancer. Brother with leukemia. Physical Exam: PHYSICAL EXAMINATION ON ADMISSION: ================================== VITALS: 98.1 139/79 78 22 98RA 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 flat. CARDIAC: Normal S1/S2, no murmurs rubs or gallops. PULMONARY: Inspiratory and expiratory wheezes in all lung fields 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. PHYSICAL EXAMINATION ON DISCHARGE: ================================== VITALS: 98.2 130-140/70'S 70-80's 20 98RA 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 flat. CARDIAC: Normal S1/S2, no murmurs rubs or gallops. PULMONARY: Decreased inspiratory and expiratory wheezes in all lung fields 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. Pertinent Results: LABS ON ADMISSION: ================== ___ 04:00PM BLOOD Neuts-92.1* Lymphs-4.5* Monos-2.7* Eos-0.0* Baso-0.0 Im ___ AbsNeut-5.51 AbsLymp-0.27* AbsMono-0.16* AbsEos-0.00* AbsBaso-0.00* ___ 04:00PM BLOOD Plt ___ ___ 04:00PM BLOOD Glucose-140* UreaN-17 Creat-1.0 Na-136 K-3.5 Cl-95* HCO3-29 AnGap-16 ___ 04:00PM BLOOD proBNP-254 ___ 03:58PM BLOOD ___ pO2-59* pCO2-43 pH-7.45 calTCO2-31* Base XS-4 LABS ON DISCHARGE: ================== ___ 08:00AM BLOOD WBC-5.8 RBC-4.37 Hgb-11.9 Hct-38.2 MCV-87 MCH-27.2 MCHC-31.2* RDW-20.4* RDWSD-65.6* Plt ___ ___ 08:00AM BLOOD Plt ___ ___ 08:00AM BLOOD Glucose-156* UreaN-21* Creat-0.9 Na-134 K-3.4 Cl-92* HCO3-30 AnGap-15 ___ 08:00AM BLOOD Calcium-9.7 Phos-3.6 Mg-2.0 STUDIES: ======== CXR ___: No acute cardiopulmonary process EKG: NSR rate 72, QTC 469, LBBB Brief Hospital Course: ___ yo F with history of COPD on home O2, atrial fibrillation on apixaban, hypertension, CAD, hyperlipidemia, and recurrent hospitalization for COPD exacerbation over the last 4 months, who presented with dyspnea consistent with COPD exacerbation, possibly secondary to acute viral URI with concurrent sinusitis / Eustachian tube dysfunction # COPD exacerbation: Patient has been experiencing recurrent COPD exacerbations over the last 4 months. She presented with dyspnea consistent with COPD exacerbation, possibly secondary to acute viral URI with concurrent sinusitis / Eustachian tube dysfunction. We continued home spiriva, theophylline, and advair. We continued her steroid therapy at 30mg prednisone daily with a slow taper (5mg every 2 weeks). We also treated her with levofloxacin (Day ___ with plan for 5-day course given COPD exacerbation with concurrent concern for sinusitis / bulging right tympanic membrane. CHRONIC ISSUES: ================== # Anxiety/Insomnia: We continued home lorazepam. # Atrial Fibrillation: We continued diltiazem for rate control and apixaban for anticoagulation. # Hypertension: We continued home imdur, hydrochlorothiazide, and diltiazem. # CAD: Cardiac catheterization in ___ without evidence of significant stenosis of coronaries. ECHO on ___ with EF > 55% and no regional or global wall motion abnormalities. We continued home aspirin and atorvastatin. # Anemia: We continued home iron supplements. ***TRANSITIONAL ISSUES:*** - Continue levofloxacin with plan for 5-day course (Day ___ end ___ - Patient was started Bactrim PPX (1 tab SS daily) given extended courses of steroids, stop after discontinuation of steroids - Patient was discharged on prednisone 30 mg with plan for taper by 5mg every 2 weeks: Prednisone 30 mg for two weeks (Day 1= ___ end ___ Prednisone 25 mg for two weeks (Day 1= ___ end ___ Prednisone 20 mg for two weeks (Day 1= ___ end ___ etc... # CONTACT: ___ (husband/HCP) ___ # CODE STATUS: Full confirmed Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 325 mg PO Q4H:PRN Pain 2. albuterol sulfate 90 mcg/actuation inhalation Q4H 3. Apixaban 5 mg PO BID 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 10 mg PO QPM 6. Diltiazem Extended-Release 240 mg PO BID 7. Docusate Sodium 100 mg PO BID 8. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID 9. Ferrous Sulfate 325 mg PO DAILY 10. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN allergies 11. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 12. Guaifenesin ___ mL PO Q4H:PRN cough 13. Hydrochlorothiazide 50 mg PO DAILY 14. Isosorbide Mononitrate (Extended Release) 240 mg PO DAILY 15. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 16. Lorazepam 0.5 mg PO Q8H:PRN Insomnia, anxiety, vertigo 17. Multivitamins 1 TAB PO DAILY 18. Ranitidine 300 mg PO DAILY 19. Theophylline SR 300 mg PO BID 20. Tiotropium Bromide 1 CAP IH DAILY 21. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315 mg - 200 units oral DAILY 22. cod liver oil 1 capsule oral BID 23. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN Wheezing 24. PredniSONE 30 mg PO DAILY Tapered dose - DOWN Discharge Medications: 1. Acetaminophen 325 mg PO Q4H:PRN Pain 2. albuterol sulfate 90 mcg/actuation inhalation Q4H 3. Apixaban 5 mg PO BID 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 10 mg PO QPM 6. Diltiazem Extended-Release 240 mg PO BID 7. Docusate Sodium 100 mg PO BID 8. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID 9. Ferrous Sulfate 325 mg PO DAILY 10. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN allergies 11. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 12. Guaifenesin ___ mL PO Q4H:PRN cough 13. Hydrochlorothiazide 50 mg PO DAILY 14. Isosorbide Mononitrate (Extended Release) 240 mg PO DAILY 15. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 16. Lorazepam 0.5 mg PO Q8H:PRN Insomnia, anxiety, vertigo 17. Multivitamins 1 TAB PO DAILY 18. PredniSONE 30 mg PO DAILY Please decrease dose by 5mg every 2 weeks Tapered dose - DOWN RX *prednisone 10 mg 3 tablets(s) by mouth once a day Disp #*45 Dose Pack Refills:*0 19. Ranitidine 300 mg PO DAILY 20. Theophylline SR 300 mg PO BID 21. Tiotropium Bromide 1 CAP IH DAILY 22. Levofloxacin 750 mg PO DAILY Duration: 5 Days RX *levofloxacin 750 mg 1 tablet(s) by mouth once a day Disp #*4 Tablet Refills:*0 23. Sulfameth/Trimethoprim SS 1 TAB PO DAILY prophylaxis for long term steroid use RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 24. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315 mg - 200 units oral DAILY 25. cod liver oil 1 capsule oral BID 26. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN Wheezing Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: COPD exacerbation SECONDARY DIAGNOSES: CAD Hypertension anxiety Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, ___ was a great pleasure taking care of you at ___ ___. You came here because you were experiencing worsening shortness of breath as well as nasal congestion and decreased hearing. Your symptoms are likely related to an upper respiratory tract infection and exacerbation of your COPD. We started you on antibiotics and continued your prednisone. The dose of prednisone will be decreased by 5 mg every two weeks; please take your prednisone as follows: - Prednisone 30 mg for two weeks (Day 1= ___ end ___ - Prednisone 25 mg for two weeks (Day 1= ___ end ___ - Prednisone 20 mg for two weeks (Day 1= ___ end ___ - Discuss with Dr. ___ further taper at f/u Please take all your medications on time and follow up with your doctors as ___. Best regards, Your ___ team Followup Instructions: ___

10002013-DS-10

DS

2162-07-09 00:00:00

2162-07-11 07:26:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: lisinopril Attending: ___. Chief Complaint: Back Pain Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a ___ y/o F with pMHx significant for HTN, GERD, CAD s/p CABG and stenting, IDDM with periperal neuropathy who presents with R flank pain. Per patient, this pain has been going on for the past 3 weeks but has worsened over the past 2 days. It is worsened with coughing and moving. She otherwise denies any dysuria, urinary frequency, abdominal pain, n/v, chest pain, shortness of breath or dizziness. She endorses 4 episodes of diarrhea today. In the ED initial vitals were: 10 98.2 106 167/84 16 99% RA. RR later trended up to 20, HR down to 89. Labs were significant for positive UA (WBC 19), lactate 3.0, WBC 9.4% (70% PMN), AST 53, ALT 16, Lip 70, trop-T < 0.01, Chem hemolyzed but Cr 1.4 (baseline 1.0 in ___, repeat K 3.6. Hyperglycemic to 446, 340 on repeat. CXR showed no acute process. Patient was given 1L NS, 1g CTX, 14 units insulin. Unclear if she received her home long-acting insulin. UCx and BCx's were sent after antibiotics initiated. Vitals prior to transfer were: 3 98.4 89 152/80 20 100% RA. Past Medical History: COPD CAD s/p CABG and stenting Depression DM GERD HTN Migraines Chronic shoulder pain on narcotics OSA Peripheral neuropathy Restless leg Social History: ___ Family History: Mother Unknown ALCOHOL ABUSE pt was ward of state, doesn't know full details of family hx Father ___ ___ HODGKIN'S DISEASE per old records Physical Exam: Admission Physical Exam: Vitals - 98.3 155/88 92 20 99% on RA GENERAL: NAD HEENT: NCAT CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 extremities with purpose BACK: no tenderness to spinal processes, no pain the left side, +CVA tenderness, tenderness to palpation of the R sided paraspinal muscles along entire length of spinal cord Discharge Physical Exam: Vitals: 97.8 107/59 78 18 97/RA General: awake, alert, NAD HEENT: NCAT EOMI MMM grossly normal oropharynx CV: RRR nl S1+S2 no g/r/m no JVD/HJR. Lungs: CTAB no w/r/r, good movement in all fields Abdomen: obese, soft nt/nd normoactive BS Back: ttp along right paraspinal region from sacrum to shoulder. + CVA tenderness. Ext: dry and WWP. no c/c/e Neuro: AAOx3, moving all extrem with purpose, facial movements symmetric, no focal deficits. Skin: no rashes, lesions, excoriations Pertinent Results: CT ABD/PELVIS ___: Noncontrast imaging of the abdomen and pelvis demonstrates a punctate nonobstructing calculus in the right collecting system (02:31). There is no left renal calculus. There is no evidence of ureteral or urinary bladder calculus. There is symmetric renal enhancement and excretion of intravenous contrast. Subcentimeter cortically based hypodensity in the left interpolar region (06:30) is too small to accurately characterize but likely represents renal cyst. There is no evidence of collecting system filling defect. There are segments of the mid to distal ureters are not well opacified, possibly secondary to peristalsis, however there is no evidence of inflammatory change or mass about the ureters. The adrenal glands are unremarkable. Low hepatic attenuation on noncontrast imaging is consistent with hepatic steatosis. There is no evidence of focal hepatic mass. There is no intrahepatic or extrahepatic biliary ductal dilatation. There are numerous gallstones within the gallbladder without evidence of acute cholecystitis. The spleen is not enlarged. There is no pancreatic ductal dilatation or evidence of pancreatic mass. There are no dilated loops of bowel. There is no evidence of bowel wall thickening. There is no intraperitoneal free air or free fluid. There are no enlarged inguinal, iliac chain, retrocrural, or retroperitoneal lymph nodes. Abdominal aorta has a normal course and caliber with moderate atherosclerotic calcification. There is atherosclerotic calcification of the superior mesenteric artery origin. There is no suspicious osseous lesion. IMPRESSION: 1. Tiny nonobstructing right collecting system calculus. 2. Hepatic steatosis. 3. 3 nodular pulmonary densities in the left basilar region measuring up to 8 x 8 mm. These findings may may represent areas of rounded atelectasis, however short-term followup with nonemergent CT chest is recommended. ADMISSION LABS: ___ 08:30PM BLOOD WBC-9.4 RBC-3.95* Hgb-13.3 Hct-37.4 MCV-95 MCH-33.7* MCHC-35.5* RDW-13.5 Plt ___ ___ 08:30PM BLOOD Neuts-70.1* ___ Monos-5.2 Eos-1.6 Baso-0.7 ___ 08:30PM BLOOD Glucose-446* UreaN-18 Creat-1.4* Na-133 K-5.6* Cl-97 HCO3-21* AnGap-21* ___ 08:30PM BLOOD ALT-16 AST-54* AlkPhos-65 TotBili-0.4 ___ 08:30PM BLOOD Albumin-4.1 Calcium-9.1 Phos-3.9 Mg-1.8 ___ 08:30PM BLOOD cTropnT-<0.01 ___ 08:30PM BLOOD Lipase-70* ___ 10:53PM BLOOD ___ pO2-38* pCO2-45 pH-7.37 calTCO2-27 Base XS-0 ___ 10:53PM BLOOD Lactate-3.0* K-3.6 ___ 10:53PM BLOOD O2 Sat-69 ___ 10:40PM URINE Blood-NEG Nitrite-POS Protein-NEG Glucose-1000 Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD ___ 10:40PM URINE RBC-3* WBC-19* Bacteri-FEW Yeast-NONE Epi-1 TransE-<1 ___ 10:40PM URINE Color-Straw Appear-Clear Sp ___ DISHCARGE LABS: ___ 07:00AM BLOOD WBC-7.0 RBC-3.37* Hgb-11.2* Hct-31.8* MCV-94 MCH-33.2* MCHC-35.2* RDW-12.9 Plt ___ ___ 06:23AM BLOOD Neuts-53.5 ___ Monos-5.0 Eos-1.8 Baso-0.6 ___ 07:00AM BLOOD Glucose-254* UreaN-13 Creat-1.0 Na-136 K-3.9 Cl-101 HCO3-24 AnGap-15 ___ 07:00AM BLOOD ALT-14 AST-17 AlkPhos-50 ___ 07:00AM BLOOD Calcium-8.5 Phos-3.5 Mg-1.5* Brief Hospital Course: ___ PMH with HTN, GERD, CAD s/p CABG and stenting, IDDM with R flank pain presumed to musculoskeletal in nature due to negative workup. Incidental UTI / asymptomatic bacturia. ACUTE ISSUES: # UTI / Bacturia: Patient presented without any history of urinary or systemic symptoms, but was started on ceftriaxone in the ED after U/A with ___ positive and 19 WBCs. Antibiotics were taken prior to drawing urinary or blood cultures, and there was no yield. Patient switched to ciprofloxacin and received a three day total antibiotic course. CT scan performed did not have any evidence of pyelonephritis. Antibiotics were discontinued at time of discharge. # Flank Pain: Patient reported 3 weeks of back/flank pain, constant and achy in nature and worsened by movement. Treated with anti-inflammatories with minimal effect. CT scan demonstrated no nephrolithiasis. CXR showed no bony abnormality, but could not totally exclude multiple rib fractures. Patient's pain was well controlled and tolerating PO medications, so she was discharged with PCP following for further workup. # Diabetes / Hyperglycemia: Patient had persistently # IDDM: Last A1C (___) 8.0. Serum glucose initially in the 400s and Chem-7 with gap; however, this was likely ___ lactate and unlikely to be DKA given normal pH on ABG. AM glucose 218. - continue home dose lantus 90 units qPM - per ___ records, is on a very aggressive ISS, will decrease for now and uptitrate as necessary depending on ___ # ___ on CKD: Cr elevated at 1.4 from baseline 1.0. Most likely pre-renal in the setting of infection. Now s/p 2L IVF in the ED and creatinine has corrected to 1.0. Appears euvolemic, maybe slightly up. - consider further workup if no improvement (urine lytes, spinning urine, renal u/s) - renally dose medications for now CHRONIC ISSUES: # HF with pEF/CAD s/p CABG and stents: Was not an active issue whil inpatient. Fluid use was judicious. Metoprolo converted to short acting while in house, isosorbide, aspirin and atorvastatin were continued. Losartan held as below. # HTN: home metoprolol and isosorbide continued, losartan held while inpt as pressures were soft and within normal range. Discharged home off losartan. # Restless leg syndrome: home ropinarole continued # Shoulder pain: oxycodone and tylenol seperately dose while inpatient # COPD: home advair and PRN albuterol nebs were continued # GERD: home pantoprazole continued # Insomnia: home trazodone continued TRANSITIONAL ISSUES: - Losartan held inpatient and at discharge andpatient blood pressures were low-normal. PCP to determine restart. - Patient to follow up with PCP for resolution of UTI and back pain symptoms - Patient should have insulin regiment adjustments for optimal glycemic control - no changes to regimen were made at discharge. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Losartan Potassium 25 mg PO DAILY 2. Metoprolol Succinate XL 200 mg PO DAILY 3. Atorvastatin 80 mg PO HS 4. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY 5. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN pain 6. Ropinirole 0.5 mg PO QPM 7. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN pain 8. Fluticasone Propionate 110mcg 2 PUFF IH BID 9. Pantoprazole 40 mg PO Q12H 10. Aspirin 325 mg PO DAILY 11. albuterol sulfate 90 mcg/actuation inhalation q4hrs wheezing 12. TraZODone 150 mg PO HS 13. Vitamin D 1000 UNIT PO DAILY 14. Levemir Flexpen (insulin detemir) 90 units subcutaneous in the evening 15. HumaLOG KwikPen (insulin lispro) per sliding scale subcutaneous as directed Discharge Medications: 1. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN pain 2. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN pain 3. Metoprolol Succinate XL 200 mg PO DAILY 4. Levemir Flexpen (insulin detemir) 90 units subcutaneous in the evening 5. HumaLOG KwikPen (insulin lispro) 0 SUBCUTANEOUS AS DIRECTED 6. albuterol sulfate 90 mcg/actuation inhalation q4hrs wheezing 7. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth twice a day Disp #*11 Tablet Refills:*0 8. Vitamin D 1000 UNIT PO DAILY 9. TraZODone 150 mg PO HS 10. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY 11. Aspirin 325 mg PO DAILY 12. Atorvastatin 80 mg PO HS 13. Fluticasone Propionate 110mcg 2 PUFF IH BID 14. Pantoprazole 40 mg PO Q12H 15. Ropinirole 0.5 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: UTI Secondary Diagnosis: Back Pain Diabetes Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, ___ were seen in the emergency department for back pain. ___ were admitted to the hospital where ___ were also diagnosed with a urinary tract infection. ___ were treated with antibiotics, IV fluids and pain medication. Due to the concern of your back pain, a CT scan was as performed and it was determined that ___ did not have a kidney stone or an infection. Your diabetes was controlled with an insulin scale while ___ were an inpatient. ___ will be discharged home on antibiotics and intent to follow up with your primary care provider, Dr. ___. Please take all medications as prescribed and keep all scheduled appointments. Weigh yourself every morning, call MD if weight goes up more than 3 lbs. It was a pleasure taking care of ___! Your ___ Care Team Followup Instructions: ___

10002013-DS-13

DS

2166-04-19 00:00:00

2166-04-19 20:22:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: lisinopril Attending: ___. Chief Complaint: Left diabetic foot ulcer Major Surgical or Invasive Procedure: Left partial hallux amputation History of Present Illness: ___ with poorly controlled diabetes (complicated by retinopathy, neuropathy, PAD, foot ulcer L hallux), CAD with ___ s/p CABG, and narcotics agreement, presenting with 3 days subjective fever, chills, increased pain in L great toe. Pt recently had ulcer debrided by podiatry on ___, ulcer had healed to the size of a pin, but within the span of a week enlarged to size of a tennis ball. Presented to ___ urgent care in ___, found to be febrile to ___, given Tylenol, sent to ER and was afebrile and normotensive upon arrival, though sustained tachycardia to low 100s. Podiatry consulted in ER, wound to left medial hallux probes to bone w/ high c/f osteomyelitis. X-rays show bony erosion but no subcutaneous gas. Plan for IV antibiotics and partial amputation of left great toe tomorrow (___). ___ n/v, abd pain, diarrhea, excessive urination, orthostasis, dyspnea, chest pain. In the ED: Initial vital signs were notable for: afebrile, tachycardia to 118, normotensive Exam notable for: PE: warm, slightly diaphoretic CV: RRR, +S1/S2 Resp :lungs clear b/l MSK: erythema involving L big toe, tracking along inferior base. Tenderness tracking along path of great saphenous on L calf. Limited dorsiflexion and plantar flexion. Limited ROM of ankle and toe. Mental Status: A&ox4 Lines & Drains: 20g L hand Labs were notable for: 136 98 26* AGap=20 ------------<266* 4.2 18* 1.6* Lactate elevated: 2.4 Whites elevated: 23.4, neut predominance Studies performed include: Xray Foot Ap,Lat & Obl Left (prelim read): Re-demonstration of ulceration along the medial distal aspect of the great toe and erosion along the medial base of the distal phalanx of the great toe perhaps slightly progressed in the interval. Findings again remain concerning for osteomyelitis and MRI with contrast could be obtained for further assessment. Patient was given: Piperacillin-Tazobactam Vancomycin Consults: Podiatry Vitals on transfer: T100.5, BP 154/80, HR117, RR18, 99 Ra Upon arrival to the floor, patient resting comfortably in bed, complains of chills, which resolve with blankets. Left foot wrapped in gauze dressing, very tender up to midcalf. REVIEW OF SYSTEMS: Complete ROS obtained and is otherwise negative Past Medical History: -COPD -CAD s/p BMS proximal-LAD ___, DES to mid LAD ___, DES to edge ISR of mid LAD DES and stenosis distal to stent ___, DES to OM1 ___, s/p 3 v CABG LIMA-LAD, SVG-OM1, ___ -HFpEF -Depression -DM -GERD -Hypertension -Migraines -Chronic shoulder pain on narcotics -OSA -Peripheral neuropathy -Restless leg Social History: ___ Family History: Patient was ward of the ___, doesn't know full details of family history. Mother with possible alcohol abuse. Father deceased at ___ from Hodgkin's Disease per old records. Physical Exam: ADMISSION EXAM ============== VITALS: T100.5, BP 154/80, HR117, RR18, 99 Ra GENERAL: Alert and interactive. In no acute distress. HEENT: NCAT. MMM. CARDIAC: RRR, no MRG LUNGS: Normal WOB, CTA B/L ABDOMEN: Soft, nontender to deep palpation, nondistended, normoactive bowel sounds. EXTREMITIES: left foot wrapped in gauze dressing, mildly erythematous and very tender up to lower calf, RLE no edema, thready DP pulses NEUROLOGIC: Sensory and motor function grossly intact. DISCHARGE EXAM ============== VS: 98.5, 134 / 75,75, 18, 97% RA General Appearance: Well-groomed, in NAD. HEENT: Atraumatic, normocephalic. Sclera anicteric b/l. MMM. No oropharyngeal lesions. No LAD. Lungs: Equal chest rise. Good air movement. No increased work of breathing. Decreased breath sounds in LLL. Rales in left base. No wheezes or rhonchi. CV: RRR. Normal S1, S2. No murmurs, gallops, or rubs. No carotid bruits b/l. +2 carotid pulses b/l, +2 radial pulses b/l, +1 dorsalis pedis pulse on right, unable to palpate on left due to surgical bandage. Abdomen: Non-distended. Bowel sounds present. Soft, non-tender to palpation throughout. Extremities: No clubbing or cyanosis. Left foot dressing clean today. Erythema and edema around margin of surgical site is improved today. Suture site is clean with no pus. Skin: No rashes or lesions besides surgical site. Neuro: A+O to person, place, and time. CN III-XII grossly intact. Pertinent Results: ADMISSION LABS ============== ___ 05:50PM BLOOD WBC-23.4* RBC-4.01 Hgb-13.3 Hct-37.9 MCV-95 MCH-33.2* MCHC-35.1 RDW-12.0 RDWSD-42.1 Plt ___ ___ 05:50PM BLOOD Neuts-81.4* Lymphs-10.5* Monos-7.1 Eos-0.0* Baso-0.3 Im ___ AbsNeut-19.09* AbsLymp-2.47 AbsMono-1.66* AbsEos-0.00* AbsBaso-0.06 ___ 05:50PM BLOOD Glucose-266* UreaN-26* Creat-1.6* Na-136 K-4.2 Cl-98 HCO3-18* AnGap-20* ___ 05:50PM BLOOD CRP-180.1* ___ 07:45PM BLOOD ___ pO2-22* pCO2-44 pH-7.32* calTCO2-24 Base XS--4 ___ 05:50PM BLOOD Lactate-2.4* ___ 07:40PM URINE Color-Straw Appear-Clear Sp ___ ___ 07:40PM URINE Blood-NEG Nitrite-NEG Protein-TR* Glucose-1000* Ketone-TR* Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM* ___ 07:40PM URINE RBC-4* WBC-7* Bacteri-FEW* Yeast-NONE Epi-1 TransE-<1 ___ 07:40PM URINE Mucous-RARE* PERTINENT INTERVAL LABS ======================= ___ 09:48AM BLOOD ALT-25 AST-29 LD(LDH)-210 AlkPhos-130* TotBili-0.8 DISCHARGE LABS ============== ___ 07:17AM BLOOD WBC-9.9 RBC-3.07* Hgb-9.8* Hct-30.4* MCV-99* MCH-31.9 MCHC-32.2 RDW-12.3 RDWSD-44.2 Plt ___ ___ 07:29AM BLOOD Glucose-109* UreaN-18 Creat-1.2* Na-140 K-4.0 Cl-100 HCO3-25 AnGap-15 ___ 07:29AM BLOOD Calcium-8.8 Phos-4.3 Mg-1.8 ___ 07:29AM BLOOD CRP-44.6* IMAGING ======= LEFT FOOT XRAY (___) IMPRESSION: Re-demonstration of ulceration along the medial distal aspect of the great toe and erosion along the medial base of the distal phalanx of the great toe, the latter of which is perhaps slightly progressed in the interval. Findings again remain concerning for osteomyelitis and MRI with contrast could be obtained for further assessment. NIAS (___) --------------- FINDINGS: On the right side, triphasic Doppler waveforms are seen in the right femoral, popliteal, and dorsalis pedis arteries. Absent waveform in the posterior tibial artery. The right ABI was 1.6, artifactually elevated due to noncompressible vessels. On the left side, triphasic Doppler waveforms are seen at the left femoral and popliteal arteries. Monophasic waveforms are seen in the posterior tibial and dorsalis pedis arteries. The left ABI could not be calculated Pulse volume recordings showed decreased amplitudes at the level the right calf, ankle and metatarsal. IMPRESSION: Significant bilateral tibial arterial insufficiency to the lower extremities at rest, more significant on the right side. CXR (___) -------------- IMPRESSION: Comparison to ___. No relevant change is noted. Alignment of the sternal wires is unremarkable. Mild elongation of the descending aorta. Borderline size of the heart. No pleural effusions. No pneumonia, no pulmonary edema. MRI LEFT FOOT (___) IMPRESSION: 1. Nonenhancing stump soft tissue and the plantar fat pad under the middle phalanges, concerning for devitalized tissue. No evidence of drainable abscess. 2. 4 mm focus of low T1 signal with edema at the most distal cortex of the first metatarsal. This is nonspecific as there was no comparison study and focus of osteomyelitis cannot be excluded. 3. 2 sinus tracts medial to the head of the first metatarsal, status post amputation at the first MTP with postsurgical changes. 4. Dorsal swelling and diffuse skin edema. CXR PICC PLACEMENT (___) IMPRESSION: New right PICC with tip projecting over the junction of the superior vena cava and right atrium. No pneumothorax. Clear lungs. PATHOLOGY ========== SURGICAL TISSUE (___) - Bone with reparative changes, consistent with chronic osteomyelitis. - There is no evidence of acute osteomyelitis. SURGICAL TISSUE (___) 1. LEFT GREAT TOE, EXCISION: - Acute osteomyelitis, focal. - Bone with reparative changes. - Skin and subcutis with ulceration and acute inflammation. - Atherosclerosis, severe. 2. PROXIMAL PHALANX BASE MARGIN, LEFT, EXCISION: - Bone with reparative changes. - There is no evidence of acute osteomyelitis. 3. PROXIMAL PHALANX, LEFT, EXCISION: - Bone with reparative changes. - There is no evidence of acute osteomyelitis. MICROBIOLOGY ============ ___ 10:00 am TISSUE PROXIMAL PHALYNX. GRAM STAIN (Final ___: 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS. Reported to and read back by ___ (___) ON ___ AT 1:20PM. TISSUE (Final ___: STAPH AUREUS COAG +. SPARSE GROWTH. Susceptibility testing performed on culture # ___ ___. ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): __________________________________________________________ ___ 7:00 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 5:38 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 12:34 am BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 11:00 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 12:18 am BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 10:53 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. Brief Hospital Course: ============= SUMMARY ============= ___ yo F with hx of DMII, HTN who presented with diabetic foot ulcer on her left hallux complicated by osteomyelitis. She underwent surgical debridement and partial tissue and bone removal on ___. However the infection persisted, and she underwent left hallux amputation on ___. She was started on IV nafcillin for MSSA infection with plan to continue home infusions of nafcillin until at least ___ ACTIVE ISSUES ============= #Osteomyelitis of left hallux: Due to diabetic ulcer of left hallux. Patient underwent partial left hallux amputation on ___ by podiatry. She was initially placed on IV Vancomycin, Flagyl, and cefepime. Initial surgical cultures came back positive for MSSA, so was changed to IV nafcillin. Patient continued to be afebrile, but her left foot continued to have erythema, edema, pain, and the ulcer was not healing well. There was concern for poor arterial blood flow and therefore underwent noninvasive arterial studies on bilateral lower extremities. The studies showed mild atherosclerotic disease in her left leg and foot, and severe atherosclerotic disease in her right leg and foot. Vascular surgery was consulted for potential intervention, but they felt that no further vascular intervention was warranted prior to podiatric surgery. The patient was brought back to the OR by podiatry on ___ for total left hallux amputation given lack of clinical improvement. Her ___ blood cell count continued to down trend. The pathology report showed clean margins. However, patient was continuing to have pain, and there was increased erythema and swelling around surgical site. An MRI of the left foot was done, which showed devitalization of the surgical flap, some edema, and a hyperintense focal spot at the site of the surgery. There were no signs of abscess or fluid collection. Podiatry team felt patient did not need any acute surgical intervention and will have close follow-up on ___. A PICC line was placed in the right arm ___ with tentative plan to complete a two-week course of IV nafcillin on ___. For the wound, podiatry recommends daily dressing changes to left foot surgical site: Betadine moistened gauze, 4x4 gauze, and kerlix. #Cough: During her stay the patient developed cough that was nonproductive. It was thought to be due to atelectasis after surgery, especially since her rales on exam would clear with coughing. A repeat chest x-ray was negative for any acute cardiopulmonary processes and on comparison to previous chest x-ray during this hospital stay there were no changes. Will restart home Lasix at discharge. #Hypertension: Patient's antihypertensives were held upon admission given that her blood pressures were low with systolic blood pressures in the ___ likely due to sepsis in the setting of her osteomyelitis from her diabetic foot ulcer. After her first debridement, patient's blood pressures increase to 160s-170s so we restarted her losartan and furosemide. However her blood pressure dipped back down again to the ___ systolic and her creatinine bumped up to 1.8 so we discontinued her losartan and furosemide. Her metoprolol was continued with holding parameters, and it was held when her systolic blood pressure was less than 110. Her ___ resolved, and she became hypertensive again, so we restarted her losartan while in the hospital and instructed the patient to restart her Lasix upon discharge from the hospital. #Acute Kidney Injury: Her baseline creatinine is 1.0. It bumped up to 1.8 in the setting of sepsis, restarting her losartan and furosemide, and hypotension. We gave her IV fluids and stopped her losartan and furosemide. Her creatinine continued to improve with these measures and upon discharge it was 1.1-1.2, which is around her baseline. CHRONIC ISSUES ============== #Diabetes Mellitus Type 2: Upon admission, patient was started on 80% of home insulin doses. Her Lantus inpatient dose was 32 units, and her Humalog inpatient dose was 12 units 3 times daily. Patient's blood sugars were hard to control while she was inpatient. Working with the ___ diabetes consult team we adjusted her insulin doses as needed. ___ recommended discharging the patient on 48 units of Toujeo and 18 units of Novolog with meals as well as resuming her Trajenta and Jardiance. #CODE STATUS: Full (presumed) #CONTACT: ___ (grandson's girlfriend) ___ TRANSITIONAL ISSUES =================== [ ] Patient is on oxycodone 5 mg Q8H for her foot pain from the surgery. She was given enough to get her to her PCP appointment, which is ___. Please re-assess pain management. [ ] Osteomyelitis, infected diabetic foot ulcer: Surgical margin from total left hallux amputation on ___ was negative for osteomyelitis. Patient to complete a 2 week course of nafcillin for ongoing soft tissue infection and will follow up with ID prior to completion of antibiotics to ensure resolution. Will be discharged on q4 hour nafcillin to be infused via a pump. Once finished an antibiotic should also have right arm PICC line removed. For the wound, podiatry recommends daily dressing changes to left foot surgical site: Betadine moistened gauze, 4x4 gauze, and kerlix [ ] Diabetes mellitus type 2: Patient's blood sugars were very labile. Given that she came in with a diabetic foot ulcer suggesting that her blood sugars are not well-controlled at home, she needs close follow-up to optimize her diabetic medication regimen. She is being discharged on reduced dose Toujeo and regular home Novolog along with her usual Trajenta and Jardiance with close follow-up with ___ provider on ___, ___ at 1 ___. Please reassess patient's need for Jardiance given history of recurrent AKIs [ ] Cough: Patient developed non-productive cough while in hospital but afebrile, no leukocytosis, CXR no signs of pleural effusion or consolidation. Suspect due to atelectasis in post-op period after foot surgery. Will discharge on incentive spirometer and restarting home Lasix as outpatient. If not improved once back on outpatient Lasix, would consider further workup. [ ] Hypertension: Patient was discharged on her regular home medications. While she was an inpatient, she became hypotensive when we restarted her on all of her antihypertensives. Please follow her blood pressure to ensure that she is on the right regimen. If too low, might consider removing furosemide. [ ] ___: Discharge creatinine 1.2 on ___. Suspect patient will have a slight bump in creatinine after restarting losartan on ___. Patient had weekly labs checked with IV antibiotic infusions. If continues to rise, may be due to nafcillin and would consider switching antibiotic to cefazolin. #CODE STATUS: Full (presumed) #CONTACT: ___ (grandson's girlfriend) ___ >30 minutes spent on complex discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. canagliflozin 100 mg oral DAILY 2. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN angina 3. rOPINIRole 0.5 mg PO QHS restless leg syndrome 4. TraZODone 50 mg PO QHS:PRN insomnia 5. Pantoprazole 40 mg PO BID 6. Gabapentin 400 mg PO QHS:PRN Neuropathic pain 7. Atorvastatin 80 mg PO QPM 8. Fluticasone Propionate 110mcg 2 PUFF IH BID 9. linaGLIPtin 5 mg oral DAILY 10. Losartan Potassium 25 mg PO DAILY 11. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO TID:PRN Pain - Severe 12. Lidocaine 5% Patch 1 PTCH TD QPM 13. Furosemide 20 mg PO DAILY 14. Metoprolol Succinate XL 150 mg PO DAILY 15. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN 16. Aspirin EC 325 mg PO DAILY 17. MetronidAZOLE Topical 1 % Gel 1 Appl TP DAILY Rosacea 18. nystatin 100,000 unit/gram topical DAILY:PRN Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H RX *acetaminophen 500 mg 2 tablet(s) by mouth Every 8 hours for foot pain Disp #*60 Tablet Refills:*0 2. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line RX *bisacodyl 5 mg 2 tablet(s) by mouth Once a day as needed for constipation Disp #*60 Tablet Refills:*0 3. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth Twice a day Disp #*30 Capsule Refills:*0 4. Nafcillin 2 g IV Q4H RX *nafcillin in dextrose iso-osm 2 gram/100 mL 2 g IV Every four hours Disp #*84 Intravenous Bag Refills:*0 5. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Moderate RX *oxycodone 5 mg 1 capsule(s) by mouth Once every 8 hours as needed for severe foot pain. Disp #*15 Capsule Refills:*0 6. Senna 8.6 mg PO BID:PRN Constipation - First Line RX *sennosides [senna] 8.6 mg 1 tablet by mouth Twice a day as needed for constipation Disp #*30 Tablet Refills:*0 7. Novolog 18 Units Breakfast Novolog 18 Units Lunch Novolog 18 Units Dinner 8. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN 9. Aspirin EC 325 mg PO DAILY 10. Atorvastatin 80 mg PO QPM 11. canagliflozin 100 mg oral DAILY 12. Fluticasone Propionate 110mcg 2 PUFF IH BID 13. Furosemide 20 mg PO DAILY 14. Gabapentin 400 mg PO QHS:PRN Neuropathic pain 15. Lidocaine 5% Patch 1 PTCH TD QPM 16. linaGLIPtin 5 mg oral DAILY 17. Losartan Potassium 25 mg PO DAILY 18. Metoprolol Succinate XL 150 mg PO DAILY 19. MetronidAZOLE Topical 1 % Gel 1 Appl TP DAILY Rosacea 20. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN angina 21. nystatin 100,000 unit/gram topical DAILY:PRN 22. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO TID:PRN Pain - Severe 23. Pantoprazole 40 mg PO BID 24. rOPINIRole 0.5 mg PO QHS restless leg syndrome 25. ___ SoloStar U-300 Insulin (insulin glargine) 300 unit/mL (1.5 mL) subcutaneous QHS Inject 48U QHS 26. TraZODone 50 mg PO QHS:PRN insomnia 27.Outpatient Lab Work ICD-10: E11.621 DATE: weekly: draw on ___ and ___ LAB TEST: CBC with differential, BUN, Cr, AST, ALT, Total Bili, ALK PHOS, ESR, CRP PLEASE FAX RESULTS TO: ATTN: ___ CLINIC - FAX: ___ 28.Rolling Walker EQUIPMENT: Rolling Walker DIAGNOSIS: Left hallux amputation ICD-10: ___ PX: Good ___: 13 months Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS ================= Osteomyelitis of left hallux SECONDARY DIAGNOSES =================== Hypertension 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. WHY WAS I ADMITTED TO THE HOSPITAL? You had a diabetic foot ulcer on your left toe that was very infected and had caused an infection in your bone. WHAT WAS DONE WHILE I WAS HERE? Your big left toe was removed because you had a bad bone infection. You were treated with antibiotics to fight the infection and will need to go home on IV antibiotics. WHAT DO I NEED TO DO WHEN I LEAVE? Please continue to take your medications as directed. You will go home with an antibiotic infusion pump and will have a visiting nurse come to your house to teach you how to use it. You will need to administer antibiotics through the pump every 4 hours. We changed your diabetic medication regimen, so please follow along as instructed below and keep close track of your sugars at home. Check your sugars 4 times a day and log the results. Bring the results in with you to your ___ appointment on ___ at 1:00 pm so that they can adjust your medication regimen appropriately. Please follow-up with Dr. ___ team on ___ at 11:00 am. Please follow up with Dr. ___ your antibiotic regimen on ___ at 10:30 am. Please follow-up with Dr. ___ in ___ ___ on ___ at 1:00 pm. Be well, Your ___ Care Team Followup Instructions: ___

10002013-DS-6

DS

2159-12-17 00:00:00

2159-12-21 10:02:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Cardiac catheterization with stenting with drug eluting stent to the left circumflex History of Present Illness: ___ year old woman with diastolic CHF, COPD, DM, HTN, HLD, and CAD (h/o MI in ___ with LAD stenting, repeat stenting with DES in ___ and ___, who presents with chest pain. She has been having chest pain episodes over the past 2 weeks. A tightness located in the ___ her chest that usually occurs with exertion or when lying flat at night, but she has also experienced at rest. It radiates to the left arm, and is relieved with NTG. It is not pleuritic, but is reproducible when she presses over the ___ her chest. Somewhat different from the chest pain that she had prior to her previous PCIs. Associated with dsyspnea and lightheadedness. She came to the ED today after having a more severe episode yesterday. . In the ED initial VS were: 97.5, 67, 127/73, 16, 100%RA. EKG showed SR with non-specific ST and T changes. CXR negative for acute process. Labs notable for negative troponin but Creat 1.7 (was 1.4 in ___ and normal prior to that). She received ASA 325mg. VS prior to transfer were: 97.6, 70, 119/60, 16, 99%RA. . On arrival to the floor, patient is comfortable and denies chest pain. . REVIEW OF SYSTEMS: As noted in HPI. In addition, denies fevers, chills, sweats, presyncope, syncope, cough, PND, orthopnea, leg swelling, abdominal pain, nausea, vomiting, hematemesis, diarrhea, constipation, red or black stools, dysuria, hematuria, myalgias, arthralgias, or rash. No history of DVT or PE. Past Medical History: - CAD: MI in ___ with LAD stenting, repeat stenting with DES in ___ and ___ - Diastolic CHF - DM - HTN - HLD - COPD - Depression - Right shoulder pain (bursitis, rotator cuff injury) Social History: ___ Family History: She was a ward of the ___ and does not know her family. Physical Exam: Admission physical exam: VS: 98, 139/76, 71, 18, 100% RA GENERAL: WDWN woman in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple. JVP not elevated. CARDIAC: RR, normal S1, S2. No m/r/g. No S3 or S4. Pain reproducible with palpation over ___ chest and left breast. LUNGS: Resp unlabored, no accessory muscle use. CTAB. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No edema. WWP. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ DP 2+ ___ 2+ Left: Carotid 2+ Femoral 2+ DP 2+ ___ 2+ . Discharge physical exam: Vitals: Tc 98.1 BP 169/82 (130-169/63-86) HR 71 (70-77) RR 18 O2 Sat 98% RA General: Patient lying in bed in NAD HEENT: EOMI. MMM. Neck: Supple. No JVD appreciated. CV: RRR. No M/R/G Lungs: Clear to auscultation bilaterally. No crackles or wheezes. Nml work of breathing. Abd: Obese. NABS+. Soft. NT/ND. Ext: WWP. 2+ DPs bilaterally. No clubbing, cyanosis, or edema. Pertinent Results: Admission labs: ___ 10:10PM BLOOD WBC-10.9 RBC-3.78* Hgb-12.4 Hct-36.9 MCV-98 MCH-32.7* MCHC-33.6 RDW-12.5 Plt ___ ___ 10:10PM BLOOD Neuts-58.7 ___ Monos-4.6 Eos-1.9 Baso-0.7 ___ 06:05AM BLOOD ___ PTT-27.8 ___ ___ 10:10PM BLOOD Glucose-338* UreaN-32* Creat-1.7* Na-134 K-4.3 Cl-100 HCO3-21* AnGap-17 ___ 10:10PM BLOOD cTropnT-<0.01 Discharge labs: ___ 06:05AM BLOOD WBC-10.1 RBC-3.74* Hgb-12.5 Hct-35.5* MCV-95 MCH-33.5* MCHC-35.2* RDW-12.8 Plt ___ ___ 06:05AM BLOOD Glucose-99 UreaN-29* Creat-1.4* Na-135 K-3.5 Cl-102 HCO3-26 AnGap-11 ___ 06:05AM BLOOD Calcium-9.0 Phos-4.3 Mg-2.0 Cardiac enzymes: ___ 06:05AM BLOOD CK(CPK)-61 ___ 06:05AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 10:10PM BLOOD cTropnT-<0.01 EKG: Sinus rhythm at a rate of 69. Normal axis. The PR interval is prolonged at 204ms (slightly more than prior ekg). Q wave in III. Non-specific ST and T changes. Nuclear Stress Test: INTERPRETATION: The image quality is adequate but limited due to soft tissue and breast attenuation. There is activity adjacent to the heart in the rest and stress images. Left ventricular cavity size is increased. Rest and stress perfusion images reveal a reversible, moderate reduction in photon counts involving the mid and basal inferolateral walls and the distal lateral wall. Gated images reveal normal wall motion. The calculated left ventricular ejection fraction is 52% with an EDV of 107 ml (reprocessed at workstation). IMPRESSION: 1. Reversible, medium sized, moderate severity perfusion defect involving the LCx territory. 2. Increased left ventricular cavity size with normal systolic function. Compared to the prior study of ___, the defect is new. . Cardiac catheterization: COMMENTS: 1. Selective coronary angiography of this right-dominant system demonstrated three-vessel coronary artery disease. The ___ did not have angiographically-apparent flow-limiting stenoses. The LAD had 60% in-stent restenosis at the junction of the old Cypher stent placed in ___ and the new Promus stent placed in ___ the D2 branch was jailed with 60% origin stenosis. The LCx had a 50% stenosis at its origin; there was a 90% stenosis of the OM1 branch. The mid-RCA had a 50% stenosis. 2. Limited resting hemodynamics revealed mild systemic arterial hypertension, with a central aortic pressure of 142/74 mmHg. 3. Successful PTCA and stenting of OM1 with a 3.0x15mm PROMUS stent which was postdilated to 3.5mm. Final angiography revealed no residual stenosis, no angiographically apparent dissection and TIMI III flow (see PTCA comments). FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Successful PTCA and stenting of the OM1 with a DES. . Brief Hospital Course: # Unstable angina: Description of the pain was somewhat atypical for angina in that she experiences in when she lays down and it is also reproducible. However, given her history of CAD status post multiple PCIs and many risk factors, the patient underwent stress test to rule out CAD. Nuclear stress test showed a reversible, medium sized, moderate severity perfusion defect involving the left circumflex territory. In light of these stress test findings, the patient underwent cardiac catheterization. Prior to cardiac catheterization, she was prehydrated given her acute kidney injury. The patient had a drug-eluting stent placed to the obtuse marginal branch. The patient became acutely hypertensive during cardiac catheterization and was started on a nitroglycerin drip (see discussion below). The patient was weaned from this quickly. The patient was continued on aspirin (full-dose), plavix, metoprolol, and imdur. Her home dose of atorvastatin was increased given evidence of coronary artery disease. Serial cardiac enzymes were negative times 3. OUTPATIENT ISSUES: Patient is to continue taking aspirin 325mg and plavix 75mg daily for the next year. Patient will have cardiology follow-up as an outpatient with the ___ ___ ___ group in ___. . # Acute kidney injury: Creatinine currently 1.7, up from 1.4 in ___. Renal function previously was normal. Upon admission, the patient's lisinopril and furosemide were discontinued. Of note, hte patient was started on furosemide approximately ___ months ago, which coincides with the development of the patient's elevated serum creatinine. Serum creatinine was trended through the admission and improved. The patient was restarted on her home lisinopril, though her serum creatinine was noticed to be increasing so was discontinued with instructions to restart this medication after follow-up with her primary care physician. The patient was instructed to have a basic metabolic panel drawn ___. . # Diastolic heart failure: Patient was euvolemic through her admission. Her home lasix was discontinued during this admission given her acute kidney injury. The patient will follow-up with her primary care physician regarding ___ of lasix. OUTPATIENT ISSUES: Outpatient BMP for monitoring of serum creatinine and reinitiation of lasix by the primary care physician. . # Type 2 Diabetes Melltius, insulin dependent: Moderately controlled with last A1c 7.9% in ___. Lantus and sliding scale was continued through the hospitalization. She was discharged home on her home doses of lantus and her home insulin sliding scale. . # Hypertension: Through most of the patient's admission, her blood pressure was well controlled (goal <130/80). She was continued on metoprolol and imdur, though furosemide and lisinopril were discontinued in light of the patient's elevated serum creatinine. However, during the patient's cardiac catheterization, she was noted to have elevated systolic blood pressures and was started on a nitroglycerin drip for control of blood pressures. The patient was weaned from the nitroglycerin drip with in 4 hours after cardiac catheterization. The patient received a dose of lisinopril, but because of rising serum creatinine, the patient's next dose was held. OUTPATIENT ISSUES: Follow-up with primary care physician regarding recent hospitalization and anti-hypertensive regimen in light of elevated serum creatinine. . # Hyperlipidemia: Well controlled with last LDL 50 in ___ (goal LDL<70), though triglycerides mildly elevated. Atorvastatin was increased to 80mg daily given the new CAD lesions. Patient also had a fasting lipid panel that was drawn, which was pending at time of discharge. OUTPATIENT ISSUES: Follow-up of pending fasting lipid panel. . # COPD: Currently asymptomatic. Patient was continue fluticasone and albuterol as needed. Medications on Admission: - Clopidogrel 75 mg daily - Asprin 325 mg daily - Atorvastatin 40 mg daily - Lisinopril 10 mg daily - Metoprolol succinate 100 mg daily - Isosorbide mononitrate 30 mg daily - Furosemide 20 mg daily - Nitroglycerin 0.4 mg SL prn - Glargine insulin 80 units QHS - Lispro insulin sliding scale - Albuterol 90 mcg, 2 puffs Q4-6 hrs prn - Fluticasone 110 mcg, 2 puffs BID - Pantoprazole 40 mg BID - Oxycode-Acetaminophen 5 mg-325 mg Q8h prn pain - Potassium chloride 20 mEq BID - Cholecalciferol 1,000 unit daily - Metronidazole 0.75% lotion for ___ Discharge Medications: 1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 5. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 6. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet Sublingual PRN as needed for chest pain. 7. insulin glargine 100 unit/mL Solution Sig: Eighty (80) units Subcutaneous at bedtime. 8. insulin lispro 100 unit/mL Solution Sig: Sliding scale units of insulin Subcutaneous three times a day: As directed by outpatient provider . 9. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation every ___ hours as needed for SOB, wheezing. 10. fluticasone 110 mcg/actuation Aerosol Sig: Two (2) Puff Inhalation BID (2 times a day). 11. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 12. oxycodone-acetaminophen ___ mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. 13. cholecalciferol (vitamin D3) 1,000 unit Capsule Sig: One (1) Capsule PO once a day. 14. metronidazole 0.75 % Lotion Sig: One (1) application Topical as directed . Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Atypical chest pain Secondary diagnosis: Coronary artery disease Hypertension Hyperlipidemia Type 2 Diabetes Mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure taking care of you during your hospitalization at ___. You were hospitalized with chest pain and had a nuclear stress test that was abnormal. You subsequently had a cardiac catheterization and you were found to have a blockage in the left circumflex coronary artery (one of the heart vessels). Take all medication as instructed. Please note the following medication changes: 1. Stop taking your potassium supplement for now, as your potassium levels were normal in the hospital. 2. Increase your atorvastatin (lipitor) dose from 40mg to 80mg daily. 3. Stop your lisinopril and lasix (furosemide) until otherwise instructed by your primary care physician. You will need repeat bloodwork on ___, which should be sent to your primary care physician, ___. Keep all hospital follow-up appointments. Your up-coming appointments are listed below. Followup Instructions: ___

10002131-DS-16

DS

2128-03-19 00:00:00

2128-03-19 16:38:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Dilantin Kapseal / Zofran (as hydrochloride) Attending: ___. Chief Complaint: Right hip pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ is a ___ y/o F with PMHx CHF, Afib not on anticoagulation, severe advanced Alzheimer's dementia, osteoporosis, HTN, who presents from assisted living facility with R hip pain. The patient has severe dementia, with short term memory loss so is unable to provide history. Much of the history is obtained from multiple family members in the room. She has multiple family members who live close by and are involved intimately in her care. They were called from the assisted living facility this morning when the patient was in ___ right hip pain. This occurred suddenly. No trauma. No reported falls. She was not complaining of other symptoms. She was brought to the ED. Discussing with the patient, she moved into the Assisted living facility in ___ in ___ given worsening of her dementia. She was in her USOH, bowling weekly and very social, until ___ when she developed acute SOB with ambulation prompting admission to ___ where she was noted to be in Afib. She had a week long hospital stay complicated by an ICU course for an allergic reaction to a medication (family thinks Zofran). Since returning from this hospitalization, she has not been back to baseline and has deteriorated. She has spent much of her time wheelchair bound given deconditioning. She has worsening memory function, now with severe short term memory loss. Decreased appetite and PO intake. She was recently seen in ___ clinic by Dr. ___ new diagnosis of CHF. She underwent an TTE at ___ yesterday ___ to evaluate her systolic function. In the ED, initial vitals were: 98.7, 96, 122/48, 20, 96% RA. Exam was significant for: R hip TTP greater trochanter, neg straight leg raise. ___ pulses 2+ LLE 2+ edema, unknown duration Labs were significant for : K 2.8 Cr 0.8 CBC: 13.9/12.5/39.2/168 UA: WBC 22, moderate leuks, negative nitrites Studies: Lower extremity ultrasound: 1. Deep vein thrombosis of the left common femoral vein extending into at least the popliteal vein. Left calf veins were not clearly identified and possibly also occluded. 2. No DVT in the right lower extremity. CXR Bilateral pleural effusions, large on the right and small on the left. No definite focal consolidation identified, although evaluation is limited secondary to these effusions. She was given 80 mEq of K and 60mg Enoxaparin Sodium. Vitals on transfer were: 97.9, 79, 125/53, 18, 100% Nasal Cannula. On the floor, she is resting comfortably in bed. History is obtained as above with family members. She sleeps with 2 pillows at home and has DOE. She has not had a bowel movement in 2 days. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats. denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No dysuria. Denies arthralgias or myalgias. Past Medical History: Hypertension Dementia Osteoporosis Irritable bowel syndrome Macrocytosis of unclear etiology Left ear hearing loss Status post hysterectomy Status post appendectomy Status post ovarian cyst removal Cataract surgery Glaucoma Social History: ___ Family History: Not relevant to the current admission. Physical Exam: ADMISSION EXAM ============== Vital Signs: 98.3, 107/43, 72, 16, 99 2L NC General: AOx1, pleasant, smiling, at baseline per family members at bedside ___: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, soft ___ systolic murmur. Lungs: Moderate inspiratory effort, decreased breath sounds bilaterally at bases L>R. No wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, L>R lower extremity swelling with left leg erythematous and tender to palpation, 2+ pitting edema tender, right lower extremity with e/o chronic venous stasis changes, 1+ pitting edema non tender. Neuro: AOx1, strength ___ upper and lower exteremities, all facial movements in tact, sensation grossly in tact, gait deferred. DISCHARGE EXAM ============== Vitals: T:97.9, 144/59, 72, 20, 93 RA General: AOx1, pleasant, smiling, at baseline per family members at bedside ___: Sclera anicteric, MMM CV: Irregularly irregular, normal S1 + S2, soft ___ systolic murmur. Lungs: Moderate inspiratory effort, decreased breath sounds bilateral bases Ext: Warm, well perfused, 2+ pulses, L>R lower extremity swelling with left leg erythematous and minimal tender to palpation, 2+ pitting edema tender, right lower extremity with e/o chronic venous stasis changes, 1+ pitting edema non tender. Neuro: AOx1 Pertinent Results: ADMISSION LABS ============== ___ 11:35AM URINE RBC-2 WBC-22* BACTERIA-NONE YEAST-NONE EPI-<1 TRANS EPI-<1 ___ 11:35AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-MOD ___ 12:00PM PLT COUNT-168 ___ 12:00PM NEUTS-81.1* LYMPHS-10.8* MONOS-6.7 EOS-0.1* BASOS-0.2 IM ___ AbsNeut-11.29* AbsLymp-1.51 AbsMono-0.94* AbsEos-0.02* AbsBaso-0.03 ___ 12:00PM WBC-13.9* RBC-3.78* HGB-12.5 HCT-39.2 MCV-104* MCH-33.1* MCHC-31.9* RDW-13.6 RDWSD-51.9* ___ 12:00PM CALCIUM-7.8* PHOSPHATE-3.7 MAGNESIUM-1.6 ___ 12:00PM cTropnT-0.03* proBNP-8428* ___ 12:00PM GLUCOSE-118* UREA N-26* CREAT-0.8 SODIUM-144 POTASSIUM-2.8* CHLORIDE-95* TOTAL CO2-38* ANION GAP-14 STUDIES ======= CXR Bilateral pleural effusions, large on the right and small on the left. No definite focal consolidation identified, although evaluation is limited secondary to these effusions. Pelvis Xray There is no acute fracture or dislocation. No focal lytic or sclerotic osseous lesion is seen. There is no radiopaque foreign body. Vascular calcifications are noted. The visualized bowel gas pattern is nonobstructive. IMPRESSION: No acute fracture or dislocation. Lower extremity ultrasound 1. Deep vein thrombosis of the left common femoral vein extending into at least the popliteal vein. Left calf veins were not clearly identified, possibly also occluded. 2. No right DVT. LAST LABS BEFORE DISCHARGE =============================== ___ 06:55AM BLOOD WBC-14.9* RBC-3.51* Hgb-11.5 Hct-36.8 MCV-105* MCH-32.8* MCHC-31.3* RDW-13.8 RDWSD-53.1* Plt ___ ___ 06:55AM BLOOD Glucose-109* UreaN-32* Creat-0.9 Na-144 K-3.7 Cl-96 HCO3-37* AnGap-15 ___ 06:55AM BLOOD Albumin-2.5* Calcium-8.0* Phos-3.2 Mg-1.5* Brief Hospital Course: ___ is a ___ y/o F with PMHx CHF, Afib not on anticoagulation, severe advanced Alzheimer's dementia, osteoporosis, HTN, who presents from assisted living facility with R hip pain, found to have DVT left common femoral vein with volume overload. During a meeting with patient and her family, decision was made to transition care to comfort-directed measures only and to pursue hospice services on discharge. ACTIVE ISSUES ============= # CMO. The team had a family meeting on ___ and decision was made to transition care to CMO and pursue 24 hour hospice services on discharge. Family did not want to pursue active treatments such as Lasix, which would make her uncomfortable given incontinence or shots such as lovenox for treatment of DVT. Home medications metoprolol, donepezil and Memantine were continued for comfort. She was discharged to an ___ ___ facility. OTHER HOSPITAL ISSUES ===================== # DVT. Deep vein thrombosis of the left common femoral vein extending into at least the popliteal vein diagnosed on ultrasound on admission. This was likely acquired in the setting of immobility, as the patient had been restricted to her wheelchair at her assisted living for greater than 1 month due to deconditioning. She was initially started on Lovenox for treatment but this was discontinued in the setting of transition to care to CMO as above. # Acute CHF. Patient was volume overloaded on presentation with pleural effusions. She was diuresed with IV Lasix. Home metoprolol was continued at a decreased dose. In the setting of transition to care to CMO, Lasix was discontinued. She was continued on metoprolol for comfort. She remained on room air without respiratory distress. # Afib. She presented in sinus rhythm, rate controlled on metoprolol. Metoprolol was continued at a decreased dose for comfort. # Hip pain. The right hip pain that she presented with was resolved by the time of admission. Pelvic xray was without fracture. She was treated with Tylenol scheduled for pain control. # Al___ Dementia. She was AOx1 at her baseline per family members. She was continued on Aricept/Namenda. TRANSITIONAL ISSUES =================== - ___ facility to continue writing orders for pain/anxiety/secretions and other symptoms. - Continued metoprolol succinate and Memantine and donepezil on discharge for comfort. Continuation of these medications can be further decided at inpatient hospice. - MOLST form: DNR/DNI, do not re-hospitalize # CODE: DNR/DNI, CMO # CONTACT: HCP ___ (daughter) ___ Primary, secondary ___ (son) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 150 mg PO BID 2. Torsemide 40 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Donepezil 10 mg PO QHS 5. raloxifene 60 mg oral DAILY 6. Multivitamins 1 TAB PO DAILY 7. Namenda XR (MEMAntine) 21 mg oral DAILY 8. Ascorbic Acid ___ mg PO DAILY 9. Calcium Carbonate 1500 mg PO DAILY 10. Vitamin D 1000 UNIT PO DAILY 11. Fish Oil (Omega 3) 1000 mg PO DAILY Discharge Medications: 1. Donepezil 10 mg PO QHS 2. Metoprolol Succinate XL 200 mg PO DAILY 3. Namenda XR (MEMAntine) 21 mg oral DAILY 4. Acetaminophen 1000 mg PO TID 5. Glycopyrrolate 0.1 mg IV Q6H:PRN excess secretions 6. Hyoscyamine 0.125 mg SL QID:PRN excess secretions Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary Diagnosis --------------- Deep Vein Thrombosis Secondary Diagnosis ------------------ Congestive heart failure Atrial fibrillation Constipation Malnutrition Hypertension Alzheimer's dementia 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: Dear ___, It was a pleasure taking care of you during your hospitalization. Briefly, you were hospitalized with right hip pain. We did Xrays of your hip which did not show any fractures. We also found a blood clot in your left leg and noticed that your heart wasn't pumping very efficiently. We talked with you and your family, who shared with us many of your wishes about being hospitalized and the type of care you would like to receive. We decided to focus on your comfort. Because of this, you are being discharged to ___ for hospice care. We wish you and your family the ___, Your ___ Treatment Team Followup Instructions: ___

10002167-DS-10

DS

2166-05-15 00:00:00

2166-05-15 15:36:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: ___ Attending: ___. Chief Complaint: Nausea/Vomiting Major Surgical or Invasive Procedure: Band adjustment History of Present Illness: Ms. ___ is a ___ s/p lap band in ___ who prsents with a 1 week history of nausea, non-bilious non-bloody emesis of undigested food after eating, intolerance to solids/softs, hypersalivation, and moderate post-prandial epigastric discomfort. She denies fever, chills, hematemesis, BRBPR, melena, diarrhea, or sympotoms of dehydration, but was recently evaluated for dizziness in an ED with a diagnosis given of BPPV. Of note, the patient underwent an unfill of her band from 5.8 to 3.8ml on ___ for similar symptoms, the band was subseqently been filled to 4.8 on ___, 5.2 on ___, and most recently to 5.6ml on ___. Past Medical History: PMHx: Hyperlipidemia and with elevated triglyceride, iron deficiency anemia, irritable bowel syndrome, allergic rhinitis, dysmenorrhea, vitamin D deficiency, question of hypothyroidism with elevated TSH level, thalassemia trait, fatty liver and cholelithiasis by ultrasound study. A history of kissing tonsils that was associated with obstructive sleep apnea and gastroesophageal reflux, these have resolved completely after the tonsillectomy in ___. History of polycystic ovary syndrome Social History: ___ Family History: bladder CA; with diabetes, breast neoplasia, colon CA, ovarian CA and sarcoma Physical Exam: VS: Temp: 97.9, HR: 72, BP: 113/64, RR: 16, O2sat: 100% RA GEN: A&O, NAD HEENT: No scleral icterus, MMM CV: RRR PULM: No W/R/C, no increased work of breathing ABD: Soft, nondistended, non-tender to palpation in epigastric region, no rebound or guarding, palpable port Ext: No ___ edema, warm and well perfused Pertinent Results: ___ 12:16AM PLT COUNT-243 ___ 12:16AM NEUTS-46.0 ___ MONOS-6.9 EOS-1.8 BASOS-0.5 IM ___ AbsNeut-4.88 AbsLymp-4.72* AbsMono-0.73 AbsEos-0.19 AbsBaso-0.05 ___ 12:16AM estGFR-Using this ___ 01:02AM URINE MUCOUS-RARE ___ 01:02AM URINE HYALINE-1* ___ 01:02AM URINE RBC-4* WBC-4 BACTERIA-MOD YEAST-NONE EPI-11 ___ 01:02AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-TR ___ 01:02AM URINE COLOR-Yellow APPEAR-Hazy SP ___ ___ 01:02AM URINE UCG-NEGATIVE ___ 01:02AM URINE HOURS-RANDOM ___ 01:02AM URINE HOURS-RANDOM Brief Hospital Course: ___ was admitted from ED on ___ for nausea and vomiting after any po intake. Of note, she has had similar symptomes last year. She was started on IV fluids for rehydration. Her laboratory values were unremarkable on admission and her symptoms gradually improved with anti-emetic medications and IV fluid therapy. She was back to her baseline clinical status after unfilling the band by 1.5cc. Water challenge test was done after band adjustment and was negative for any pain, nausea or vomiting. She was discharged in good condition with instructions to follow up with Dr. ___ ___ after 2. Discharge Medications: 1. Lorazepam 0.5 mg PO BID:PRN anxiety 2. BusPIRone 5 mg PO TID Discharge Disposition: Home Discharge Diagnosis: nausea and vomiting due to tight band Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to ___ for your Nausea and vomiting. Your band was tight enough to cause your nausea and vomiting, 1.5 cc has been taken out from your band in which 2.5cc total left. you subsequently tolerated a water bolus test. You have been deemed fit to be discharged from the hospital. Please return if your nausea becomes untolerable or you start vomiting again. Please continue taking your home medications. Thank you for letting us participate in your healthcare. Followup Instructions: ___

10002221-DS-11

DS

2204-07-06 00:00:00

2204-07-06 16:19:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Codeine / Augmentin / Topamax Attending: ___. Chief Complaint: RLE pain and swelling Major Surgical or Invasive Procedure: Ultrasound guided steroid injection of the right trochanteric bursa (right hip) History of Present Illness: This is a ___ woman with a history of breast cancer with BRCA1 gene mutation, COPD, cerebral aneurysm, sleep apnea, depression, hyperlipidemia, antiphospholipid syndrome with hx DVT/PE ___ ago on warfarin who presents for evaluation of severe right lower extremity pain. She was just admitted to the hospital for lumpectomy (infiltrating ductal carcinoma of left breast) and sentinel lymph node biopsy on ___, complicated by hematoma status post evacuation on ___. Prior to these procedures, she had severe right lower extremity pain similar to today and underwent a DVT ultrasound on ___ which was negative. Her anticoagulation was held in the hospital due to the hematoma, and she had DVT prophylaxis with pneumoboots. During her postoperative hematoma her anticoagulation was held. She did not have extremity pain during her time in the hospital. However, upon returning home, she developed severe pain which she describes as cramps in her mid calf on the right. She also has pain that intermittently occurs in the right thigh which she describes as spasms. She has not had numbness, tingling, or weakness on that side. She was seen in breast clinic today where she complained of this pain, and was referred to the ED for further evaluation. She initially triggered as a pulseless extremity because of nonpalpable pulses in the right foot. She has been taking Tylenol as well as tramadol with minimal pain relief. Of note, she resumed her warfarin without any enoxaparin bridge this past ___. She has been wearing compression stockings and elevating her leg in an attempt to relieve the pain. In the ED, initial vitals: T 98.7 HR 85 BP 175/77 RR 20 O2 Sat 98% RA - Exam notable for: Right lower extremity with dopplerable pulses, palpable pulses in the left lower extremity. The right lower extremity is warm. There is tenderness to palpation of the right calf. Tenderness to palpation of the right thigh. - Labs notable for: Chem panel: Unremarkable with Cr 0.8 CK 67 CBC: WBC 5.6, Hgb 10.8 with MCV 93, Plt 264 Coags: ___ 14.8, PTT 28.2, INR 1.4 Lactate 1.1 UA: Mod Leuk, few bacteria - Imaging notable for: RLE Ultrasound ___ Right calf veins not visualized. Otherwise, no evidence of deep venous thrombosis in the right lower extremity veins. CT Lower Extremity Right ___ Unremarkable contrast enhanced CT of the right calf with a two vessel runoff to the foot. The veins of the lower extremity are not opacified therefore cannot be assessed for patency. Consider repeat ultrasound to more fully evaluate. No focal collection or obvious muscular abnormality identified by CT. - Pt given: IV Morphine 4mg IV APAP 1g IV NS IV Dilaudid 5 mg total (1mg x 5) Warfarin 7.5mg Atorvastatin 40mg Omeprazole 20mg Surgery was consulted: Recommend vascular surgery consult for possible dvt with history of multiple vein stripping procedures and DVTs. Also recommend admission to medicine for pain control. Vascular surgery was consulted: There is no clear vascular etiology for her pain. - Vitals prior to transfer: T 98.3 HR 83 BP 140/55 RR 20 O2 Sat 100% RA Upon arrival to the floor, the patient reports the pain is ___. She reports again that this pain is similar to the pain she had on ___ but even then an ultrasound showed no DVT. She is able to move her toes but has pain with lifting her leg. She has never had this kind of pain before, even with the vein stripping that she had in the past (age ___. She has no chest pain or shortness of breath. She has had no recent travel or trauma to her leg. Past Medical History: Dyslipidemia, Varicose veins (R>L) s/p ligation, COPD, OSA (+CPap), recent URI (received course of Zithromax), bilateral PEs (___), antiphospholipid antibody syndrome (on lifelong anticoagulation), T2DM (last A1C 6.2 on ___, cerebral aneurysm (followed by Dr. ___, unchanged), GERD, diverticulosis, h/o colon polyps, depression, s/p right CMC joint arthroplasty, b/l rotator cuff repair, excision right ___ digit mass, CCY w/stone & pancreatic duct exploration (___), hysterectomy, tonsillectomy Social History: ___ Family History: Mother ___ ___ OVARIAN CANCER dx age ___ Father ___ ___ BRAIN CANCER PGM OVARIAN CANCER Aunt OVARIAN CANCER paternal aunt in ___ MGM ENDOMETRIAL CANCER MGF PROSTATE CANCER Brother ___ ___ KIDNEY CANCER RENAL FAILURE CONGESTIVE HEART FAILURE DIABETES MELLITUS TOBACCO ABUSE ALCOHOL ABUSE Sister ___ ___ OVARIAN CANCER dx age ___ Brother ___ THROAT CANCER dx age ___, died in ___ Sister BRCA1 MUTATION, BREAST CANCER Daughter Living ___ ABNORMAL PAP SMEAR ___ SUBSTANCE ABUSE Son Died ___ SUBSTANCE ABUSE ___ - heroin overdose on ___. Physical Exam: ADMISSION EXAM: ================== VITALS: T 97.9 BP 125 / 80 HR 82 RR 16 O2 Sat 94 RA General: Alert, oriented, no acute distress HEENT: MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not elevated Chest: L breast incisions well healed. S/p L axilla surgical drain removal. CV: Regular rate and rhythm, normal S1 + S2, no murmurs Lungs: Clear to auscultation bilaterally, no wheezes or crackles Abdomen: Soft, non-tender, non-distended, bowel sounds present Ext: Warm, well perfused, right lower extremity is tender to palpation and movement limited by pain. Swelling of RLE > LLE. Palpable 2+ ___ pulses bilaterally. Skin: Warm, dry, varicose veins noted in lower extremities. Neuro: CNII-XII intact, grossly normal strength and sensation and symmetric bilaterally DISCHARGE EXAM: ================ VITALS: Temp: 98.2 (Tm 98.9), BP: 133/74 (127-147/72-83), HR: 76 (76-91), RR: 18, O2 sat: 99% (90-99), O2 delivery: Ra General: Alert, oriented, no acute distress HEENT: MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not elevated Chest: L breast incisions well healed. S/p L axilla surgical drain removal. CV: RRR, no murmurs Lungs: Clear Abdomen: Soft, non-tender, non-distended, bowel sounds present Ext: Warm, well perfused. No asymmetric swelling. Minimally tender to palpation along the right trochanteric bursa and minimally tender to palpation along the right tibia. Normal ROM though pain elicited with knee flexion; improves with leg raise and extension. Palpable 2+ ___ pulses bilaterally. Skin: varicose veins noted in lower extremities. Neuro: lower extremity sensation is equal on both sides to light touch. Normal bilateral lower extremity strength. Negative babinsky. Ambulating in hallway independently though it precipitates right tibial pain Pertinent Results: ADMISSION LABS: ================ ___ 12:00PM BLOOD WBC-5.6 RBC-3.48* Hgb-10.8* Hct-32.3* MCV-93 MCH-31.0 MCHC-33.4 RDW-14.7 RDWSD-48.6* Plt ___ ___ 12:00PM BLOOD Neuts-73.6* ___ Monos-4.9* Eos-0.9* Baso-0.7 Im ___ AbsNeut-4.09 AbsLymp-1.08* AbsMono-0.27 AbsEos-0.05 AbsBaso-0.04 ___ 12:00PM BLOOD ___ PTT-28.2 ___ ___ 12:00PM BLOOD Glucose-107* UreaN-7 Creat-0.8 Na-139 K-4.0 Cl-100 HCO3-26 AnGap-13 ___ 05:40AM BLOOD Calcium-8.6 Phos-4.8* Mg-2.2 Iron-36 ___ 05:40AM BLOOD calTIBC-291 VitB12-331 Ferritn-50 TRF-224 ___ 07:15AM BLOOD 25VitD-45 ___ 12:25PM BLOOD Lactate-1.1 DISCHARGE LABS: ================ ___ 04:41AM BLOOD WBC-5.6 RBC-3.36* Hgb-10.1* Hct-31.1* MCV-93 MCH-30.1 MCHC-32.5 RDW-14.5 RDWSD-48.7* Plt ___ ___ 04:41AM BLOOD ___ ___ 04:41AM BLOOD Glucose-132* UreaN-15 Creat-0.7 Na-140 K-5.0 Cl-103 HCO3-26 AnGap-11 ___ 04:41AM BLOOD Calcium-9.2 Phos-4.0 Mg-2.4 IMAGING: =================== Unilat lower extremity vein- R ___ Right calf veins not visualized. Otherwise, no evidence of deep venous thrombosis in the right lower extremity veins. CT RLE ___ Unremarkable contrast enhanced CT of the right calf with a two vessel runoff to the foot. The veins of the lower extremity are not opacified therefore cannot be assessed for patency. Consider repeat ultrasound to more fully evaluate. No focal collection or obvious muscular abnormality identified by CT ___: 1.. Uneventful ultrasound-guided injection of long-acting anesthetic and steroid into theright greater trochanteric bursa. 2. Prior injection, small amount of fluid in the right greater trochanteric bursa and dystrophic calcification within the bursal space. Findings raise suspicion for chronic trochanteric bursitis. Brief Hospital Course: SUMMARY: ================== Ms. ___ is a ___ with a PMH significant for antiphospholipid syndrome with DVTs and PEs on Coumadin, recent L-sided breast cancer s/p lumpectomy, who presented to the ED with acute on chronic right lower extremity and right hip pain, making it difficult to ambulate. Right lower extremity U/S and CT did not reveal a DVT though calf veins were not well visualized. ACTIVE ISSUES: ================== # Right trochanteric bursitis # Right anterior lower leg pain # Right sided varicose veins Pt endorsed >4mths of pain in RLE that became acutely worse over the last few wks. Her initial exam was most consistent with severe trochanteric bursitis on the right. She also has some focal pain along the right tibia which she felt was most consistent with pain from her varicose veins. The XRs of her tibia/fibula and right hip were without obvious pathology. There are no concerning neurologic symptoms to suggest a radiculopathy, no weakness or numbness though she may have some degree of chronic sciatica. Mildly decreased patellar reflex on the right as compared to left may have been in the setting of pain and guarding; strength was normal bilaterally as was her sensation. She underwent U/S guided steroid injection of her trochanteric bursa w/ significant improvement in symptoms; ___ stated that there was some fluid near the bursa, suggestive of acute on chronic trochanteric bursitis. Her anterior shin pain improved with initiation of gabapentin and lidocaine patch in addition to her home tylenol and an increase in the frequency of her home tramadol (q8h PRN to q4h PRN). Pt was not given her home hydromorphone PRN, though she did require one dose of 0.5 mg IV hydromorphone following her injection in the setting of an acute pain episode. She was discharged with Tramadol 50mg x15 tablets given increased requirement. By discharge, she was able ambulate and was felt safe for discharge home with a cane per ___ evaluation. Pt was eager to leave and will reach out to her vascular surgeon for an appointment early in the new year for treatment of her painful varicose veins. # Iron deficiency anemia: Anemia is new since ___. Normocytic. Downtrended overnight to 8.9 from 10.8. No concern for active bleeding. Per iron studies, she is iron deficient with a ferritin of 50. She endorses fatigue and restless leg syndrome. Etiology is unclear, though it may be related to the recent left breast hematoma of her breast (unlikely though the timing fits). Prior EGD with gastritis (___) for which she is on a BID PPI; prior colonoscopy ___ with findings that may be suggestive of celiac disease, though ttg at that time was normal with a normal IgA. She also had two polyps biopsied and were normal. On this admission, a vitamin D level was obtained to assess for evidence of malabsorption iso daily supplementation: level was 45. She was given ferric gluconate IV x1 on ___. TTG was repeated and pending at discharge. CHRONIC ISSUES: =================== # History of DVT/PE on warfarin: # Antiphospholipid antibody syndrome: # Subtherapeutic INR: Lupus anticoagulant positive in ___. She has been taking her home dose of warfarin (5 mg ___ and 7.5 mg other days). Her warfarin was held last ___ iso hematoma and she was not bridged with Lovenox upon reinitiation. INR on this admission was subtherapeutic at 1.4. Bridged during this hospitalization with Lovenox for goal INR ___. She was given an increased dose of warfarin, 7.5 mg daily while in house. INR at discharge was 1.9, with plan to continue home warfarin regimen. Patient will get repeat INR on ___. # Vitamin D deficiency: pt takes 2,000 U vitamin D daily. Repeat level IS 45 which suggests against malabsorption to account for her iron deficiency. TRANSITIONAL ISSUES: ==================== Code status: Full, presumed HCP: ___, granddaughter - ___. - Right trochanteric bursitis: [] Consider repeat injection [] Consider physical therapy - Right anterior leg pain [] discharged on gabapentin 600 mg three times daily [] discharged with tramadol 50mg, home regimen is Q8hrs and required Q4hrs during hospitalization. Will give two day supply of increased dose. Plan to see PCP next week. [] Consider outpatient MRI of the lumbar spine for chronic pain [] Consider EMG [] Vascular surgery follow up as outpt for treatment of painful veins - Iron deficiency anemia: [] Consider repeat IV iron infusion [] F/u pending TTG [] Consider further work up (though may be related to left breast hematoma) - History of DVT/PE, antiphospholipid antibody syndrome, subtherapeutic INR: [] F/u ___ clinic on ___. Patient can continue home Warfarin regimen Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 40 mg PO QPM 2. Docusate Sodium 100 mg PO BID 3. Omeprazole 20 mg PO BID 4. Senna 8.6 mg PO HS 5. Sertraline 150 mg PO DAILY 6. TraZODone 50 mg PO QHS:PRN sleep 7. TraMADol 50 mg PO Q8H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity 8. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First Line 9. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q4H:PRN 10. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever 11. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN cough, wheeze 12. Vitamin D ___ UNIT PO DAILY 13. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES QID 14. Furosemide 20 mg PO DAILY:PRN Leg swelling 15. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain - Severe 16. Warfarin 7.5 mg PO 2X/WEEK (___) 17. Warfarin 5 mg PO 5X/WEEK (___) Discharge Medications: 1. Gabapentin 600 mg PO TID RX *gabapentin 600 mg 1 tablet(s) by mouth three times daily Disp #*90 Tablet Refills:*0 2. Lidocaine 5% Patch 1 PTCH TD QAM right hip RX *lidocaine 5 % Apply ___ patches daily Disp #*12 Patch Refills:*0 3. TraMADol 50 mg PO Q6H:PRN Pain - Moderate RX *tramadol 50 mg 1 tablet(s) by mouth Every six hours as needed Disp #*15 Tablet Refills:*0 4. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever 5. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN cough, wheeze 6. Atorvastatin 40 mg PO QPM 7. Docusate Sodium 100 mg PO BID 8. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES QID 9. Furosemide 20 mg PO DAILY:PRN Leg swelling 10. Omeprazole 20 mg PO BID 11. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First Line 12. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q4H:PRN 13. Senna 8.6 mg PO HS 14. Sertraline 150 mg PO DAILY 15. TraZODone 50 mg PO QHS:PRN sleep 16. Vitamin D ___ UNIT PO DAILY 17. Warfarin 5 mg PO 2X/WEEK (___) 18. Warfarin 7.5 mg PO 5X/WEEK (___) Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY: ================= Right trochanteric bursitis Right anterior leg pain Right sided varicose veins SECONDARY: ================= Iron deficiency anemia History of DVT/PE on warfarin Antiphospholipid antibody syndrome Subtherapeutic INR Vitamin D deficiency 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 ___, You were admitted because you were having a lot of leg pain, making it difficult to walk. In the hospital, we gave you a steroid injection near your right thigh for a condition called, Trochanteric Bursitis. We also gave you a medication called Gabapentin to help with your leg pain lower down. We also started you on a medication called Lovenox in order to bridge you back to your warfarin - currently, your warfarin dose is 7.5 mg daily and your INR was 1.9 at discharge (goal ___. Finally, you received 1 dose of intravenous iron because you are iron deficient which may be why you are more fatigued than usual. When you go home, please take your medications as prescribed and make an appointment with your primary care doctor. We do not know what exactly is causing the lower leg pain, so you may want to talk to your doctor about having an MRI of your spine. You can also ask your doctor about prescribing a medication called DICLOFENAC GEL, also called VOLTAREN. This is essentially Motrin or Advil in a topical form and may help your pain. Additionally, please talk to your doctor about why you may be iron deficient. It was a pleasure taking part in your care. We wish you all the best with your health. Sincerely, The team at ___ Followup Instructions: ___

10002348-DS-13

DS

2112-12-10 00:00:00

2112-12-10 16:52:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Headaches Major Surgical or Invasive Procedure: ___ - Suboccipital craniotomy for resection of cerebellar lesion History of Present Illness: ___ is a ___ female with hx cerebral aneurysm clipping in ___ who presents from OSH with left cerebellar hypodensity concerning for underlying lesion. Patient reports that three weeks ago she started having headaches, which is abnormal for her. She describes the headaches to be global and resolve with Tylenol, but at the worst was an ___. She also reports having difficulty walking, which also started about three weeks ago. She describes her walking as "staggering side to side." She denies any vision changes, nausea, vomiting, confusion, or word finding difficulty. She saw her eye doctor this morning for routine visit, who referred her to the ED for evaluation of these symptoms. OSH CT showed an area of hypodensity in the left cerebellum, concerning for underlying lesion. She was subsequently transferred to ___. Of note, patient reports her aneurysm clip is not MRI compatible. Past Medical History: - ___ - Hypertension - S/p aneurysm clipping ___ at ___ by Dr. ___ Social History: ___ Family History: No known history of stroke, cancer, aneurysm. Physical Exam: ON ADMISSION: O: T: 97.9 BP: 130/62 HR: 64 R 16 O2Sats 98% RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils: L ___, R ___ 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: Left pupil 5-4mm, right 4-3mm, both equally reactive to light. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. 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. Slight left upward drift Sensation: Intact to light touch Coordination: normal on finger-nose-finger and heel to shin ====================================================== ON DISCHARGE: Exam: Opens eyes: [x]Spontaneous [ ]To voice [ ]To noxious Orientation: [x]Person [x]Place [x]Time Follows commands: [ ]Simple [x]Complex [ ]None Pupils: Right 4-3mm Left 5-4mm - chronic EOM: [ ]Full [x]Restricted - chronic, most prominent left lateral Face Symmetric: [x]Yes [ ]NoTongue Midline: [x]Yes [ ]No Pronator Drift: [ ]Yes [x]No Speech Fluent: [x]Yes [ ]No Comprehension Intact: [x]Yes [ ]No Motor: TrapDeltoid BicepTricepGrip Right 5 5 5 5 5 Left 5 5 5 5 5 IPQuadHamATEHLGast Right5 5 5 5 5 5 Left5 5 5 5 5 5 [x]Sensation intact to light touch Pertinent Results: Please see OMR for pertinent lab and imaging results. Brief Hospital Course: #Brain lesion Patient was found to have cerebellar hypodensity on NCHCT from OSH. CT w/wo contrast was obtained while in the ED at ___ which was concerning for underlying mass lesion and hydrocephalus. (Of note, she was unable to get MRI due to reportedly having a non-compatible aneurysm clip that was placed in ___ at ___. Patient was admitted to the ___ for close monitoring and surgical planning. She was started on dexamethasone 4mg Q6hr for mass effect. CT torso was obtained which showed two lung nodules, see below for more information. Neuro and radiation oncology were consulted. Plan was made for surgical resection of the lesion. On ___, it was determined that her aneurysm clip was MRI compatible and she was able to have a MRI Brain for surgical planning. She went to the OR the evening of ___ for a suboccipital craniotomy for resection of her cerebellar lesion. Postoperatively she was monitored in Neuro ICU, where she remained neurologically and hemodynamically stable. She was transferred to the ___ on POD#2 and made floor status. Her Dexamethasone was ordered to taper down to a maintenance dose of 2mg BID over the course of one week. Her pathology finalized as small cell lung carcinoma. #Lung lesions CT torso was obtained which showed two lung nodules, one in the left paramedian abutting the aortic arch and the other in the right upper lobe. Pulmonary was consulted and stated that no further intervention was indicated until final pathology was back. Heme-Onc was also consulted, and made recommendations that no further lung imaging or separate lung biopsy was needed. Both Pulmonary and Heme-Onc stated that staging and treatment could be determined based on the tissue pathology from resection of the brain lesion. Her final pathology came back as small cell lung carcinoma. She will follow-up with the thoracic oncologist on ___. #Steroid-induced hyperglycemia Throughout her admission, the patient intermittently required sliding scale Insulin for elevated blood sugars while on Dexamethasone. She was evaluated by the ___ inpatient team on ___, who decided that she did not need to go home on Insulin. They recommended discharging her with a glucometer so that she could check her blood sugars daily with a goal blood sugar less than 200. She was advised to record her readings and follow-up with her PCP and ___. #Bradycardia She was due to transfer out to the ___ on POD1, however was kept in the ICU for asymptomatic bradycardia to the ___. She remained asymptomatic, and her heartrate improved with fluids, and administration of her levothyroxine. She intermittently dipped to the ___, however remained asymptomatic. #Bell's palsy The patient was resumed on her home Valacyclovir and Prenisolone gtts. #Urinary urgency On POD 2, the patient complained of urinary urgency and increased frequency. U/A was negative and culture was negative. Her symptoms had resolved at the time of discharge. #Dispo The patient was evaluated by ___ and OT who cleared her for home with services. She was discharged on ___ in stable condition. She will follow up in ___ on ___. Medications on Admission: - ASA 81mg - Alendronate 70mg weekly - Vitamin D3 ___ units daily - Levothyroxine 88mcg daily - Lisinopril 20mg daily Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 2. Bisacodyl 10 mg PO/PR DAILY 3. Dexamethasone 3 mg PO Q8H Duration: 6 Doses start ___: 3tabsq8hrs x2, 2tabsq8hrs x6, 2tabsq12hrs maintenance dose. This is dose # 2 of 3 tapered doses RX *dexamethasone 1 mg 3 tablet(s) by mouth every eight (8) hours Disp #*120 Tablet Refills:*1 4. Docusate Sodium 100 mg PO BID 5. Famotidine 20 mg PO Q24H RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*1 6. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First Line 7. Senna 17.2 mg PO HS 8. Levothyroxine Sodium 88 mcg PO DAILY 9. Lisinopril 20 mg PO DAILY 10. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE QID 11. ValACYclovir 1000 mg PO Q8H 12. Vitamin D ___ UNIT PO DAILY 13. HELD- Alendronate Sodium 70 mg PO 1X/WEEK (___) This medication was held. Do not restart Alendronate Sodium until POD ___ - ___ 14. HELD- Aspirin 81 mg PO DAILY This medication was held. Do not restart Aspirin until POD 14 - ___ ___ glucometer ___ Freestyle glucometer. Check blood sugars ___ hours after a starchy meal. Record numbers and show to your Oncologist. ___ test strips #50. Check blood sugars QD. 3 refills. ___ Lancets #50. Check blood sugars QD. 3 refills. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Brain tumor Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid. Discharge Instructions: Surgery: - You underwent surgery to remove a brain lesion from your brain. - A sample of tissue from the lesion in your brain was sent to pathology for testing. - Please keep your incision dry until your sutures are removed. - You may shower at this time but keep your incision dry. - It is best to keep your incision open to air but it is ok to cover it when outside. - Call your surgeon if there are any signs of infection like redness, fever, or drainage. Activity: - We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. - You make take leisurely walks and slowly increase your activity at your own pace once you are symptom free at rest. ___ try to do too much all at once. - No driving while taking any narcotic or sedating medication. - If you experienced a seizure while admitted, you are NOT allowed to drive by law. - No contact sports until cleared by your neurosurgeon. You should avoid contact sports for 6 months. Medications: - Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. We held your Aspirin 81mg daily. You are cleared to resume this medication on POD 14 (___). - We held your home Alendronate during this admission. You are cleared to resume this medication on POD 14 (___). - You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. - You were started on Dexamethasone, a steroid that treats intracranial swelling. This Dexamethasone is being tapered down to a maintenance dose of 2mg BID. Please take this medication as prescribed. - While admitted, you had elevated blood glucose levels that needed to be treated by Insulin. You should continue to check your blood sugars daily at home with the prescribed glucometer. You visiting nurse should teach you how to use this device at home. Please record your blood sugars and follow-up with your PCP and ___ regarding the results. Your goal blood sugar is less than 200. What You ___ Experience: - You may experience headaches and incisional pain. - You may also experience some post-operative swelling around your face and eyes. This is normal after surgery and most noticeable on the second and third day of surgery. You apply ice or a cool or warm washcloth to your eyes to help with the swelling. The swelling will be its worse in the morning after laying flat from sleeping but decrease when up. - You may experience soreness with chewing. This is normal from the surgery and will improve with time. Softer foods may be easier during this time. - Feeling more tired or restlessness is also common. - Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. If you are taking narcotics (prescription pain medications), try an over-the-counter stool softener. When to Call Your Doctor at ___ for: - Severe pain, swelling, redness or drainage from the incision site. - Fever greater than 101.5 degrees Fahrenheit - Nausea and/or vomiting - Extreme sleepiness and not being able to stay awake - Severe headaches not relieved by pain relievers - Seizures - Any new problems with your vision or ability to speak - Weakness or changes in sensation in your face, arms, or leg Call ___ and go to the nearest Emergency Room if you experience any of the following: - Sudden numbness or weakness in the face, arm, or leg - Sudden confusion or trouble speaking or understanding - Sudden trouble walking, dizziness, or loss of balance or coordination - Sudden severe headaches with no known reason Followup Instructions: ___

10002428-DS-16

DS

2156-04-29 00:00:00

2156-04-30 22:51:00

Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Diarrhea - Transfer to MICU for Hypoxia Major Surgical or Invasive Procedure: ___ line placement Right pigtail pleural catheter placement History of Present Illness: Pt is an ___ year-old female with h/o Sjogren's syndrome, IBS, who presents with diarrhea and fever. Patietn starting having non-bloody, watery diarreha approximately three weeks ago. This has been persistent since that time. For the past several days, she has been experiencing crampy b/l lower quadrant abdominal pain and distension. Today she developed subjective fever and rigors at home. Denies nausea, vomiting, dysuria. Decreased appetite over same time course. In the ED, initial vs were: 98.5 125 111/63 22 100%. Patient AAOx3. Subsequently febrile to 101.0. Exam remarkable for mild discomfort to palpation in RLQ/LLQ. Labs notable for WBC 20.2 with 93.6% PMNs (no bands), Na 127, lactate 2.2, normal LFTs. UA showed 5 hyaline casts, no mucus/WBC/RBC etc. BCx and UCx drawn. CT ___ with contrast showed pancolitis without perforation or obstruction, intrahepatic biliary duct dilatation and prominent CBD, right lung base consolidation. CXR showed bibasilar opacities +/- pulm edema and multiple dilated small bowel loops. Patient given 2L NS, 2L LR, IV Cipro, IV Flagyl and Tylenol. Patient was initially admitted to medicine floor, but developed hypoxia while in ED and had new 5L O2 requirement. She had a repeat CXR showing possible pneumonia vs. pulmonary edema. She received ceftriaxone for possible pneumonia and was transferred to MICU. . On arrival to the MICU, patient appears uncomfortable and is rigoring. She reports crampy abdominal pain in her lower abdomen, fevers, and rigors. She continues to have diarrhea, but no nausea or vomiting. Mild cough productive of white sputum. Of note, patient last received antibiotics in ___ (azithromycin for CAP). . Review of systems: (+) Per HPI (-) Denies night sweats. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes Past Medical History: Anemia Borderline cholesterol C. Diff Heart Murmur Hypertension Hypothyroidism Mitral Regurgitation Osteoporosis Pneumonia Sinusitis ___ Social History: ___ Family History: Long history of hypertension in her family. She does report that her father's family has a history of multiple cancers. She has a grandfather with a history of stomach cancer and an uncle with a history of throat cancer. She denies any history of colon cancers. Father had stroke. No family h/o MI. Mother had a heart valve replaced (pt not sure which one). Physical Exam: Admission Exam: General: Alert, oriented, rigoring, appears uncomfortable HEENT: Sclera anicteric, dry mucus membranes, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Tachy, S1, S2, II/VI holosystolic murmur at apex Lungs: Diffuse rhonchi, no wheezes Abdomen: +BP, Firm, distended, tender to palpation in right and left lower quadrant, no rebound/guarding GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, moving all extremities Discharge exam - unchanged from above, except as below: General: tired but arousable to voice, appropriate CV: RRR, ___ systolic murmur at the apex Lungs: Slightly decreased breath sounds at the lung bases, right pigtail catheter in place Abd: Hypoactive BS, soft, non-tender, mildly distended Extr: 2+ edema to the thigh bilaterally Pertinent Results: Admission Labs: ___ 10:20AM BLOOD WBC-20.2*# RBC-3.76* Hgb-11.6* Hct-36.1 MCV-96 MCH-30.9 MCHC-32.3 RDW-12.8 Plt ___ ___ 10:20AM BLOOD Neuts-93.6* Lymphs-3.6* Monos-2.4 Eos-0.1 Baso-0.2 ___ 07:24PM BLOOD ___ PTT-26.9 ___ ___ 10:20AM BLOOD Glucose-121* UreaN-15 Creat-1.1 Na-127* K-4.3 Cl-89* HCO3-25 AnGap-17 ___ 10:20AM BLOOD ALT-26 AST-30 AlkPhos-78 TotBili-0.5 ___ 10:20AM BLOOD Lipase-21 ___ 07:24PM BLOOD Calcium-7.4* Phos-2.2* Mg-1.4* ___ 10:20AM BLOOD Albumin-4.1 ___ 10:29AM BLOOD Lactate-2.2* Discharge Labs: ___ 07:30AM BLOOD WBC-7.1 RBC-3.11* Hgb-9.3* Hct-30.3* MCV-97 MCH-29.9 MCHC-30.7* RDW-14.0 Plt ___ ___ 07:30AM BLOOD Glucose-122* UreaN-20 Creat-0.3* Na-133 K-4.0 Cl-92* HCO3-39* AnGap-6* Micro: Stool Culture (___): C. difficile DNA amplification assay (Final ___: Reported to and read back by ___ --CC7D-- @ 09:40 ___. CLOSTRIDIUM DIFFICILE. Positive for toxigenic C. difficile by the Illumigene DNA amplification. (Reference Range-Negative). FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. ___ 12:50 pm Mini-BAL **FINAL REPORT ___ GRAM STAIN (Final ___: 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final ___: NO GROWTH, <1000 CFU/ml. ___ 10:42 am PLEURAL FLUID PLEURAL FLUID. GRAM STAIN (Final ___: 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. Legionella Urinary Antigen (___): NEG FOR LEGIONELLA SEROGROUP 1 AG Urine Culture: negative or yeast in multiple cultures Blood Cultures: NGTD or negative in multiple cultures Imaging: CT Abd/Plevis with Contrast (___): IMPRESSION: 1. Diffuse colonic mucosal hyperenhancement and bowel wall thickening is consistent with pancolitis. 2. Ground-glass opacities within the right middle and right lower lobes compatible with acute infection and/or aspiration. Possible mild pulmonary edema. 3. Intrahepatic biliary ductal dilatation and prominence of the common bile and pancreatic ducts could be better characterized with non-emergent MRCP. CXR (___): IMPRESSION: 1. Bibasilar opacities would be consistent with pneumonia and/or aspiration in the right clinical setting. Likely some component of pulmonary edema given the interstitial thickening. 2. Multiple dilated loops of small bowel may represent ileus or obstruction. Dedicated abdominal radiograph may be performed for better characterization. ECHO (___): Left ventricular wall thicknesses are normal. Left ventricular systolic function is hyperdynamic (EF>75%). There is a mild resting left ventricular outflow tract obstruction. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. The mitral valve leaflets are mildly thickened. There is severe mitral annular calcification. There is moderate functional mitral stenosis (mean gradient XXmmHg) due to mitral annular calcification. Mild to moderate (___) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of ___, mitral regurgitation is now less prominent. The mitral inflow gradient is similar (although not reported in the previous report). AXR (___): There is no subdiaphragmatic free air. There are multiple distended loops of bowel, most likely representing both colon and small bowel. Findings are most consistent with an ileus. Air-fluid levels are seen on the left lateral decubitus view. IMPRESSION: Dilated colon and small bowel consistent with ileus. Head CT (___): IMPRESSION: No acute intracranial process. ECHO (___): The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. Left ventricular systolic function is hyperdynamic (EF 80%). Right ventricular chamber size and free wall motion are normal. There is mild aortic valve stenosis (valve area 1.6 cm2). Due to the technically suboptimal nature of this study, LVOT obstruction cannot be excluded with certainty. The mitral valve leaflets are mildly thickened. There is severe mitral annular calcification (cannot exclude posterior leaflet MVP). Moderate (2+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is no pericardial effusion. Repeat CT Abd/Pelvis (___): IMPRESSION: Interval increase in bilateral pleural effusions, and in abdominal ascites. The colon remains dilated and ahaustral, in keeping with C. difficile colitis. CXR (___): There is a Dobbhoff tube whose distal tip is in the body of the stomach. There are bilateral pleural effusions. There is a right-sided pleural-based catheter. There is no pneumothoraces or signs for overt pulmonary edema. Overall, these findings are stable since prior study from ___. Brief Hospital Course: Pt is an ___ year-old woman with history of Sjogren's syndrome and IBS presenting with fevers, diarrhea, tachycardia, hypotension, leukocytosis, hypoxia, found to have pancolitis and pneumonia. # Septic Shock due to Cdiff Colitis: On admission meet criteria for sepsis given fever, tachycardia, leukocytosis and likely source being colitis. BP remained low and patient remained mildly tachycardic for next ___ requiring aggressive IVF (roughly 20L in first 72hrs). Initially started on IV flagyl/PO vanco emperically for possible Cdiff as well as levofloxacin over concern for PNA. Bcx, Ucx unrevealing. Stool for Cdiff ultimately positive and levofloxacin changed to CTX/Azithro. PCP (Dr. ___ visited and said that pt always has CXR infiltrate so abx for CTX/Azithro for pneumonia stopped after pt had received total of 3 days PNA treatment. Lactate and WBC count trended up in first 48hrs and patient developed ileus on abdominal imaging with worsening distension. GI and Gen Surg followed and pt kept NPO initially, but ultimately illness turned around with just Abx and IVF. By time of ICU call-out, BP had stabilized without requiring fluids and abdominal exam was improving with downtrending WBC. Came back to ICU on ___ due to respiratory distress and hypoxia. Also had to be started back on pressors, initially phenylephrine but then this was stopped as extremities were cold and mottled. Pressors changed to Norepinephrine and mottling of ext quickly resolved. SVO2 and ECHO not consistent with cardiogenic shock and EKG/Trops were negative. ID saw in consult and recommended starting Tigecycline to help cover Cdiff which she completed an 8 day course of. Abdominal exam improved and ileus resolved. Doboff was placed on ___ and tube feeds were started due poor ability to keep with with nutritional requirements. Metronidazole d/c'd on ___. Plan to continue Vancomycin 500mg PO Q6 for a total of 2 weeks after all other antibiotics were stopped (last day ___. # Hypoxia: No breathing issues at baseline but developed hypoxia requiring 5L NC while in ED so was admitted to the ICU. Initial concern for RLL PNA on CXR and received 3 days of Abx as noted above until PCP informed MICU team that infiltrate had been present for some time. Thought that hypoxia developed in setting of aggressive fluids in patient with significant mitral regurg (got 4L in ED and then aggressive IVF in first 72hrs) and the development of pleural effusions. Had started diuresis by MICU callout on ___ but then after couple days on floor, triggered for hypoxia and increased work of breathing on ___. Found to have significant worsening of R pleural effusion and development of L pleural effusion. Required intubation for respiratory state on ___. Cardiac w/u showed no cardiogenic component and when spiked fever on ___ started on empiric HCAP coverage after mini-BAL was performed. Interventional pulmonary (IP) consulted on ___ and performed right sided thoracentesis with pigtail placement. ID saw on ___ and recommended stopping Vanco/cefepime as unclear if actual pneumonia and starting Tigecycline as would cover many HCAP organisms and also treat Cdiff. Mini-BAL and pleural fluid with negative cultures. Started diuresis again on ___ as she was weaned off pressors and extubated. She was weaned off all oxygen at the time of discharge and right pigtail still draining 400-700cc per day, will follow-up with IP after discharge. She will require ongoing diuresis given her significant volume overload, she responds well to ___ IV Lasix and had been ___ negative in the days leading up to discharge. # Altered Mental Status: In setting of trigger for hypoxia and MICU transfer on ___, there was concern that she was less responsive with concern for focal defecits. Stat head CT without evidence of stroke or bleed. Neuro was consulted and said nothing to do and deficits resolved over next ___. EEG initially ordered but then canceled after discussion with neuro. Rest of ICU stay had intermittent delerium in the evenings requiring some doses of Olanzapine. Delerium had improved by time of ICU callout but still with some sundowning. # Hyponatremia: Patient with Na of 127 in ED. Likely hypovolemic hyponatremia in setting of diarrhea/poor PO intake. Could also be SIADH given pneumonia, pain. Upon review of old labs, patient often hyponatremic as outpatient as well. Urine lytes confusing in setting of shock as urine Na elevated in ___ so some question of sodium wasting renal injury. Hyponatremia started to resolve as overall condition improved and did not re-develop even in setting of ___ ICU readmission for hypoxia. # ___: Patient with creatinine of 1.1 at admission up from recent baseline of 0.7 - 0.8. Likely pre-renal etiology in setting of infection, diarrhea, poor PO intake. Trended up slightly to 1.3 after a few days likely with mild ATN in setting of persistent boarderline hypotension. Lisinopril was held while in ICU for this and hypotension. Cr trended back down to roughly 0.5 and stayed there for rest of hospitalization even in setting of second ICU readmission. --Inactive issues-- # Hypothyroidism: Continued levothyroxine 50 mcg daily # Hypertension: Due to hypotension with sepsis, lisinopril was held. BP remained well controlled and this will continue to be held at discharge. # GERD: Omeprazole stopped when Cdiff came back positive. For time was put on H2 blocker for GI prophylaxis but this stopped again when delerious and started feeeding. # Code: Full (confirmed with patient, son-in-law) # Transitional issues -Right pigtail pleural catheter in place at discharge, she will follow-up with interventional pulmonary after discharge. Tube can be removed when output is <200cc per day. -Will need ongoing diuresis given large volume of fluids she received in the ICU this admission, she responds well to Lasix 10mg IV. Goal ___ negative as BP tolerates. -Will continue on high dose PO vancomycin through ___ (___fter other abx stopped) -She should continue tube feeds until taking adequate PO, would benefit from ongoing nutrition evaluation Medications on Admission: fluticasone 50 mcg 1 - 2 nasal sprays BID PRN allergies levothyroxine 50 mcg daily lisinopril 10 mg daily tiotropum bromide 18 mcg daily Calcium multivitamin omeprazole 20 mg daily acetaminophen PRN pain Discharge Medications: 1. fluticasone 50 mcg/actuation Spray, Suspension Sig: ___ puffs Nasal twice a day as needed for allergies. 2. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. acetaminophen 325 mg Tablet Sig: ___ Tablets PO every four (4) hours as needed for pain. 4. polyvinyl alcohol 1.4 % Drops Sig: One (1) drop Ophthalmic every four (4) hours as needed for dry eyes. 5. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush. 6. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection twice a day. 7. insulin lispro 100 unit/mL Solution Sig: sliding scale units Subcutaneous three times a day: Sliding scale: 150-200 - 2 units; 201-250 - 4 units; 251-300 - 6 units; 301-350 - 8 units; 351-400 - 10 units; over 400 - 10 units and call MD. 8. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed for rash. 9. ondansetron HCl 2 mg/mL Solution Sig: Four (4) mg Intravenous every eight (8) hours as needed for nausea. 10. olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for anxiety/insomnia. 11. olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for anxiety. 12. vancomycin 250 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours) for 12 days: Continue through ___. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary diagnoses: Clostridium difficile colitis and sepsis Pleural effusion with pigtail catheter placed 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: Dear Ms. ___, It was a pleasure taking care of you during your admission to ___ for abdominal pain. You were found to have an infection called C. diff. This was treated with antibiotics which you will continue after discharge. You also had shortness of breath and were found to have a large collection of fluid around your right lung and a catheter was placed to drain this fluid. This catheter will remain in place when you go to rehab and you will follow-up with the lung doctors after ___. The following changes have been made to your medications: STOP lisinopril STOP omeprazole STOP tiotropium START Zofran 4mg IV START vancomycin 500mg by mouth every 6 hours through ___ START olanzapine 2.5mg twice daily as needed for anxiety Followup Instructions: ___

10002428-DS-17

DS

2156-05-03 00:00:00

2156-05-04 20:25:00

Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Shortness of breath, altered mental status Major Surgical or Invasive Procedure: None History of Present Illness: Patient is an ___ year-old patient with history of Sjogren's syndrome, moderate MR, recent hospitalization for sepsis secondary to c. diff colitis complicated by hypercarbic respiratory failure requiring intubation, who is presenting from ___ with worsening dyspnea for one day. Patient was discharged from ___ yesterday (___) following hospitalization for c. diff colitis. Patient had ABG at ___, which was 7.___. Her vitals on transfer were 97.9 99 24 113/68 92% 2L. She reports shortness of breath associated with the cough. She denies chest pain. She denies nausea or vomiting. She denies abdominal pain. In the ED, initial vitals are 100.2 95 99/47 28 100% 4L nc. Exam was notable for tachypnea with respiratory rates in the ___. While in ED, blood pressure dipped to ___, but improved on it's own. Given the tachypnea, cough, and dyspnea, there was concern for pneumonia. Patient received vancomycin and levofloxacin. CXR appeared improved from most recent CXR. Patiwnt was started on BIPAP. Patient underwent CTA to evaluate for PE prior to leaving ED. On transfer vitals are, HR 93, BP 109/45, O2 sat 100% on BIPAP. On arrival to the MICU, patient is wearing BiPAP, but wants it removed and does not want any other supplemental oxygen. She denies pain. She denies cough or shortness of breath. Review of systems: Unable to obtain, patient wearing BiPAP and is delerious. Past Medical History: Anemia Borderline cholesterol C. Diff Flatulence Health Maintenance Heart Murmur Hypertension Hypothyroidism Mitral Regurgitation Osteoporosis Pneumonia Sinusitis ___ Social History: ___ Family History: Long history of hypertension in her family. She does report that her father's family has a history of multiple cancers. She has a grandfather with a history of stomach cancer and an uncle with a history of throat cancer. She denies any history of colon cancers. Father had stroke. No family h/o MI. Mother had a heart valve replaced (pt not sure which one). Physical Exam: Exam upon admission: General: Awake, interactive, but delerious. Not oriented to place or time, calling out, trying to get out of bed. Cachetic, frail, elderly female. HEENT: Sclera anicteric, dry mucus membranes. Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, II/VI systolic murmur at apex. Lungs: Dull at bases bilaterally, breathing comfortably, no accessory muscle use. Abdomen: soft, distended, non-tender, no rebound/guarding. bowel sounds present. Flexiseal draining watery stool with blood in it. GU: foley in place foley Ext: warm, 1+ DP pulses, Diffuse edema Neuro: CNII-XII intact, disoriented, inattentive Discharge exam - unchanged from above, except as below: General: Awake, sleepy but arousable to voice, NAD GU: Foley removed Neuro: A&Ox2 (name and date), MS has been waxing/waning, no focal defecits Pertinent Results: Labs upon admission: ___ 07:30AM BLOOD WBC-7.1 RBC-3.11* Hgb-9.3* Hct-30.3* MCV-97 MCH-29.9 MCHC-30.7* RDW-14.0 Plt ___ ___ 07:10PM BLOOD Neuts-68.2 ___ Monos-6.6 Eos-2.4 Baso-1.0 ___ 07:30AM BLOOD Glucose-122* UreaN-20 Creat-0.3* Na-133 K-4.0 Cl-92* HCO3-39* AnGap-6* ___ 07:10PM BLOOD ALT-32 AST-40 AlkPhos-129* TotBili-0.2 ___ 07:10PM BLOOD cTropnT-0.01 ___ 07:30AM BLOOD Calcium-7.8* Phos-2.4* Mg-1.9 ___ 11:05PM BLOOD Type-ART Temp-36.7 Tidal V-300 PEEP-5 FiO2-50 pO2-133* pCO2-78* pH-7.37 calTCO2-47* Base XS-15 Intubat-NOT INTUBA ___ 07:16PM BLOOD Lactate-1.5 Discharge labs: ___ 06:30AM BLOOD WBC-4.9 RBC-2.67* Hgb-8.2* Hct-26.4* MCV-99* MCH-30.8 MCHC-31.2 RDW-15.0 Plt ___ ___ 06:30AM BLOOD Glucose-113* UreaN-6 Creat-0.3* Na-136 K-3.5 Cl-95* HCO3-37* AnGap-8 Micro: -BCx x2 (NGTD) -UCx ___ - Yeast, no bacterial growth -Midline tip - NGTD -C. diff PCR - neg Imaging: ___: CXR: IMPRESSION: No significant interval change with bilateral pleural effusions with right pigtail catheter in the lower chest. Possible small right apical pneumothorax. ___: CT-A IMPRESSION: 1. No evidence of pulmonary embolism. 2. Bilateral pleural effusions, small to moderate on the left, decreased since the most recent prior examination and trace on the right, markedly decreased compared to ___ with pigtail catheter noted in place on the right. 3. Ascites. Brief Hospital Course: ___ year old woman, recently hospitalized for C. Difficile sepsis and shock, re-admitted to ___ from ___ with altered mental status, tachypnea and a mild respiratory acidosis. #Hypoxia/hypercarbia: She initially required BiPAP and was admitted to the MICU for monitoring of her respiratory status. She was able to be weaned from BiPAP on ICU day 2 and remained on 2L NC at the time of discharge. Cause of her respiratory symptoms is unclear, but may be due to hypoventilation from somnolence related to oversedation with Zyprexa. Zyprexa was held at the time of discharge. CTA Chest was negative for PE and showed no clear evidence of pneumonia. She was initially started on HCAP antibiotics with vanc/cefepime which were stopped on HD 4 prior to discharge given that all cultures were negative and there was no consolidation on imaging. # Delirium: Likely multifactorial, but thought to be related to oversedation from Zyprexa. There was no evidence of infection and antibiotics were quickly stopped as described above. UA was dirty, but UCx was negative x2 (grew only yeast) and she had no urinary symptoms. Most of her mental status changes were probably related to her sedationg medications and hypercarbia at admission, which improved with BiPAP and holding her antipsychotics. # C Diff Colitis: Recently admitted for C. diff colitis with sepsis. Repeat C Diff PCR was negative during this hospitalization. She continued to have high volume stool output and Flexiseal is in place for skin ulceration. ID was curbsided regarding vanco course given that she received a few days of HCAP antibotics and her PO vanco was changed to 125mg q6h for 7 days after stopping IV vanc/cefepime (D7 will be ___. Flexiseal in place at discharge. # Anemia: Patient with guaiac positive stools this admission, new from past admission. Felt to be secondary to sloughing and mucosal oozing secondary to C diff. Normal lactate on admission and benign abdominal exam. Hct has been variable recently, but fairly stable, although still markedly below her baseline of low to mid ___. # Bilateral pleural effusions: Noted to have bilateral pleural effusions last hospitalization in setting of massive fluid resuscitation, right pleural pigtail catheter removed this admission in the MICU. She is still volume overloaded on exam, but her bicarb remained elevated, and she was not given any further diuresis. The elevated bicarb is also be partially due to compensation from her respiratory acidosis. # Volume overload: She has some diastolic dysfunction and has 2+ MR on ___. She continues to appear total body overloaded, likely in setting of volume resuscitation on prior admission for sepsis, but with contraction alkalosis currently, so further diuresis was held as above. Consider further diuresis once hypercarbia improves and bicarb trends down. # Hypothyroidism: Continued on levothyroxine 50 mcg daily # Hypertension: Patient was previously on lisinopril which was held since last admission in setting of sepsis and relative hypotension. She remained normotensive # GERD: Patient previously on omeprazole last hospitalization, which was stopped after C. diff came back positive, and she was transitioned to H2 blocker for GI prophylaxis but this was stopped again when she became delirious last hospitalization. She remains off H2 blocker at discharge because of concern that it may be contributing to her AMS. # Code status this admission: FULL # Transitional issues: -Foley was removed ___ and she has not voided as of discharge, may need Foley replaced if she is unable to void -Would restart diuresis when bicarb trends down -Continue PO vanco 125mg q6h through ___ -Please follow Hct daily given melanotic stools, should resolve as her C. diff resolves -Midline removed ___ -Pigtail catheter removed this admission -F/u pending BCx, catheter tip cx Medications on Admission: Medications at ___: fluticasone 50 mcg nasal spray ___ puffs BID PRN levothyroxine 50 mcg dialy acetaminophen 650 mg Q4H PRN pain polyvinyl alcohol 1.4% drops every 4H PRN dry eyes heparin line flush Humalog insulin sliding scale Miconazole nitrate 2% powder, 1 application TID PRN rash ondansetron 4 mg IV Q8H PRN nausea Olanzapine 2.5 mg PO daily and qHS PRN anxiety/insomnia Vancomycin 500 mg Q6H planned through ___ Discharge Medications: 1. fluticasone 50 mcg/actuation Spray, Suspension Sig: ___ puffs Nasal twice a day as needed for allergies. 2. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. acetaminophen 325 mg Tablet Sig: ___ Tablets PO every four (4) hours as needed for fever or pain. 4. polyvinyl alcohol 1.4 % Drops Sig: One (1) drop Ophthalmic every four (4) hours as needed for dry eyes. 5. insulin lispro 100 unit/mL Solution Sig: Sliding scale units Subcutaneous three times a day: 150-200 - 2 units; 201-250 - 4 units; 251-300 - 6 units; 301-350 - 8 units; 351-400 - 10 units; over 400 - 10 units and call MD. 6. miconazole nitrate 2 % Powder Sig: One (1) application Topical three times a day as needed for rash. 7. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 7 days: Last dose on ___. 8. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection three times a day. 9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation every four (4) hours as needed for shortness of breath or wheezing. 10. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation every six (6) hours as needed for shortness of breath or wheezing. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary diagnoses: Altered mental status Hypoxia Secondary diagnoses: Clostridium difficule 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: Dear Ms. ___, It was a pleasure taking care of you during your admission to ___ for hypoxia/hypercarbia and altered mental status. Your mental status improved once we stopped your Zyprexa and your breathing improved. We looked for an infection but were not able to find a clear source. You received a few days of antibiotics while your cultures were pending. You will continue PO vanco for an additional 7 days. The following changes were made to your medications: CHANGE vancomycin 125mg by mouth every 6 hours for 7 days (last dose ___ START albuterol neb every 4 hours as needed for SOB/wheezing START ipratropium neb every 6 hours as needed for SOB/wheezing STOP Zyprexa Followup Instructions: ___

10002428-DS-18

DS

2156-05-22 00:00:00

2156-05-23 13:10:00

Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: meropenem Attending: ___ ___ Complaint: Hypercarbic Respiratory Failure Major Surgical or Invasive Procedure: Mechanical Intubation, Arterial -Line, Central Venous Access Line History of Present Illness: This is an ___ year old woman, recently hospitalized for C. Difficile sepsis and shock, complicated by readmission hypoxia/hypercarbia (___) who presents with respiratory distress and respiratory failure. . The patient had reportedly been doing well ___ rehab until today when she was noted to have an altered (depressed) mental status, tachypnea, and dyspnea. EMS was called who found the patient ___ extremis, intubation was attempted x2 and failed. A ___ airway was placed and the patient was transported to ___ emergency department. There were no reports of increased coughing or stooling from ___. . The patient has had a complicated medical course ___ the past month - . ___ brief, the patient was initially discharge on ___ after a 14 hosptilazation for c.diff colitis complicated by sepsis and hypercarbic respiratory failure requiring intubation. On the day following discharge from that admission, the patient was noted to be complaining of worsening SOB and ABG at ___ was 7.4/___. She was re-admitted to ___ on ___ to the MICU and intially reuqired biPAP for HD1-2. Her oxygen requirement on d/c was 2L NC. The etiology of her hypercarbic respiratory failure was felt to be ___ hypoventilation from somnolence related to oversedation with zyprexa which was held on discharge. A CTA chest was negative for PE and showed no clear evidence of pneumonia. She was initially started on HCAP antibiotics with vanc/cefepime which were stopped on HD 4 prior to discharge given that all cultures were negative and there was no consolidation on imaging. . ___ the ED, initial VS were: HR: 82 BP: 94 systolic Resp: No spontaneous respirations O(2)Sat: 100; Initial labs demonstrated hct 22.0, wbc 16.0, creatinine 0.3, BIN 18, lipase 148 and lactate 0.9. A cxr demonstrated bilateral pleural effusions with R>L. A UA demonstrated large leuks, positive nitrites and 104 wbc. Due respiratory failure the patient was intubated. . An initial ABG was 7.___/128 which was 7.___/395 post intubation. The patient was given vancomycin and cefepime for coverage of both a urinary and pulmonary source. Post intubation her BP dropped to the ___. She was started on levophed and phenylephrine through her existing PICC line. Given her altered mental status on arrival, a head CT was performed which showed no acute findings. Vitals on transfer were: 36.3 66 118 107/58 99%. . Vent settings were: fio2 60% RR 18 Vt 400 peep 5. Sedation with midazolam and fentanyl. She was transferred on levophed alone w/ MAPs> 70. . On arrival to the MICU, vitals were: 36.2 106/58 77 18 (vented) 100% on 40% FiO2. The patient was on a levophed drip, was not sedated, was unresponsive to verbal and painful stimuli, was thought to have a brief episode of decerebrate posturing with the upper extremities. . Review of systems: Unable to Obtain Past Medical History: Anemia Borderline cholesterol Recurrent C. Diff Flatulence Heart Murmur Hypertension Hypothyroidism Mitral Regurgitation Osteoporosis Pneumonia Sinusitis Sjogren Social History: ___ Family History: Long history of hypertension ___ her family. Father's family has a history of multiple cancers. She has a grandfather with a history of stomach cancer and an uncle with a history of throat cancer. No history of colon cancers. Father had stroke. No family h/o MI. Mother had a heart valve replaced. Physical Exam: ADMISSION PHYSICAL EXAM: 36.2 106/58 77 18 (vented) 100% on 40% FiO2 General: Intubated, unresponsive, pale, very thin HEENT: Sclera anicteric, MMM, oropharynx clear, pupils constricted and sluggish b/l; there is a dobhoff and an NGT present Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, there is a ___ SEM best heard over the LSB. There is a midline catheter present ___ the R arm Lungs: Bilateral crackles R > L, no spontaneous respirations; there is an ETT ___ place. Abdomen: soft, non-distended, bowel sounds present, no organomegaly GU: Foley present; there is a candidal rash ___ the groin area, there is powder c/w miconazole powder present over the same distribution Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Unable to fully evaluate due to unresponsiveness. The patient has 1+ DTRs bilaterally ___ all extremities; decerebration briefly noted ___ the upper extremities. . DISCHARGE PHYSICAL EXAM: **** Pertinent Results: ADMISSION LABS: ___ 11:43AM BLOOD WBC-16.0* RBC-2.84* Hgb-8.4* Hct-29.0* MCV-102* MCH-29.7 MCHC-29.1* RDW-16.4* Plt ___ ___ 11:43AM BLOOD ___ PTT-38.4* ___ ___ 11:43AM BLOOD ___ 02:46AM BLOOD Glucose-96 UreaN-12 Creat-0.4 Na-135 K-3.1* Cl-107 HCO3-23 AnGap-8 ___ 11:43AM BLOOD CK(CPK)-28* ___ 11:43AM BLOOD Lipase-148* ___ 11:43AM BLOOD CK-MB-6 cTropnT-0.02* ___ 02:46AM BLOOD Calcium-8.1* Phos-3.2 Mg-1.8 Iron-17* ___ 02:46AM BLOOD calTIBC-222* VitB12-726 Folate-15.3 Ferritn-101 TRF-171* ___ 11:43AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 11:44AM BLOOD pO2-128* pCO2-70* pH-7.22* calTCO2-30 Base XS-0 Comment-GREEN TOP ___ 11:44AM BLOOD Glucose-132* Lactate-0.9 Na-130* K-3.6 Cl-98 ___ 11:44AM BLOOD Hgb-8.8* calcHCT-26 O2 Sat-96 COHgb-3 MetHgb-0 ___ 12:30PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 12:30PM URINE Blood-MOD Nitrite-POS Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG ___ 12:30PM URINE RBC-18* WBC-104* Bacteri-MOD Yeast-NONE Epi-0 TransE-2 ___ 12:30PM URINE CastHy-3* ___ 12:30PM URINE CastHy-3* ___ 12:30PM URINE Mucous-RARE DISCHARGE LABS: **** MICROBIOLOGY: -Urine culture (___): PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed ___ MCG/ML AMIKACIN-------------- <=2 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CIPROFLOXACIN--------- 2 I GENTAMICIN------------ =>16 R MEROPENEM------------- 1 S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ 8 I -Blood culture (___): LACTOBACILLUS SPECIES. Isolated from only one set ___ the previous five days. SENSITIVITIES: MIC expressed ___ MCG/ML AMPICILLIN------------ 1 S GENTAMICIN------------ 2 S PENICILLIN G---------- 0.5 S -Sputum culture ___, endotracheal source): GRAM STAIN: >25 PMNs and <10 epithelial cells/100X field. 2+ ___ per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND SINGLY. RESPIRATORY CULTURE (Final ___: MODERATE GROWTH Commensal Respiratory Flora. YEAST. SPARSE GROWTH. LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. -Urine culture ___, foley): YEAST. 10,000-100,000 ORGANISMS/ML. -Blood culture ___, final): NEGATIVE -Blood culture ___, final): NEGATIVE -Blood culture ___, pending): NO GROWTH TO DATE AP CHEST X-RAY (___): 1. Bilateral pleural effusion, right greater than left. Underlying consolidation cannot be completely excluded. 2. Endotracheal tube terminates 1.8 cm above the carina. Recommend repositioning. 3. NG tube terminates ___ stomach with sidehole ___ distal esophagus. 3. Right PICC terminates ___ the axilla. CT HEAD WITHOUT CONTRAST (___): There is no evidence of hemorrhage, edema, infarction, or mass effect. The ventricles and sulci are prominent, suggesting age-related involutional changes or atrophy. Periventricular white matter hypodensities are compatible with chronic small vessel ischemic disease. Basal cisterns appear patent, and there is preservation of gray-white matter differentiation. No fracture is identified. There is fluid within the nasal cavity, likely secondary to intubated state. Atherosclerotic mural calcifications of the internal carotid arteries are present. The visualized paranasal sinuses, mastoid air cells, and middle ear cavities are otherwise clear. Bilateral ocular lenses have been replaced. IMPRESSION: No intracranial hemorrhage or mass effect. TTE (___): The left atrium is normal ___ size. There is mild (non-obstructive) focal hypertrophy of the basal septum. The left ventricular cavity size is normal. Left ventricular systolic function is hyperdynamic (EF = 75%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is severe mitral annular calcification. Moderate (2+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study dated ___ (images reviewed), findings are similar. AP UPRIGHT CHEST X-RAY (___): Compared to the most recent study, there is improvement ___ the mild pulmonary edema and decrease ___ the small left pleural effusion. Moderate right pleural effusion and bibasilar atelectasis are stable. AP UPRIGHT CHEST X-RAY (___): Cardiac size is normal. Lines and tubes are ___ the standard position. Large right and moderate left pleural effusions are grossly unchanged allowing the differences ___ positioning of the patient. Right upper lobe opacity has improved consistent with improving atelectasis. Pleural effusions are associated with atelectasis, larger on the right side. There is mild vascular congestion. Brief Hospital Course: HOSPITAL COURSE: This is an ___ year old woman, recently hospitalized for C. Difficile sepsis and shock, complicated by readmission hypoxia/hypercarbia (___) p/w hypercarbic respiratory failure and urinary tract infection. . # Hypercarbic Respiratory Failure: Etiology likely multifactorial, primarily respiratory muscle weakness and pulm edema with pleural effusions as noted on admission x-ray (has history of 2+ mitral regurg). She remained intubated for most of her MICU stay due to pulmonary edema and respiratory muscle weakness with a poor negative inspiratory force (NIF). Her NIF gradually improved with optimization of her nutrition and supportive care. Her pulmonary edema was addressed with aggressive diuresis with IV and PO Lasix boluses (responds well to Lasix 10mg IV). With treatment of these issues, she was able to be successfully extubated to nasal cannula on ___. She was started on Lisinopril 5mg daily for afterload reduction ___ setting of her 2+ MR which may have been causing the pulmonary edema. She may require further PRN doses of Lasix at rehab; if so would try Lasix 20mg PO PRN. Consider increasing lisinopril to 10mg for better afterload reduction pressure tolerating. . # Pseudomonas UTI: Patient grew out Pseudomonas sensitive to everything but Gentamicin on ___ urine culture. She was initially started on double coverage with Cipro/Cefepime while cultures pending, then narrowed to Cefepime alone, then broadened to Meropenam per ID recs. There was concern that Meropenam caused a drug rash so she was then switched to IV Zosyn. She completed Zosyn course on ___, received total of 10 days antibiotics for complicated UTI. . # RASH: pt noted to have red macular rash on extremities after starting meropenam, initially presumed to be meropenam drug rash so meropenam was stopped. However this was later believed to be more consistent with contact dermatitis vs. eczema. Triamcinolone cream was started and rash improved. . # C Diff Colitis: Patient was recently admitted for C. diff colitis with sepsis. Repeat C Diff PCR was negative during last hospitalization. She completed her PO vancomycin course on ___. Her PO vancomycin was continued during hospitalization because of concurrent treatment with broad-spectrum antibiotics (zosyn) for pseudomonas UTI. Her zosyn was completed on ___, should continued PO vanco until ___. . # Anemia: Patient with guaiac positive stools during last admission, new from past admission. Hct stable ___ high ___ throughout hospitalization; she did receive one unit pRBC for colloid pressure support. . # Hypothyroidism: Continued on levothyroxine 50 mcg daily. . # GERD: Patient previously on omeprazole last hospitalization, which was stopped after C. diff came back positive, and she was transitioned to H2 blocker for GI prophylaxis which was held ___ setting of delirium. Famotidine was restarted at 20mg BID once she was no longer delirious. # EKG Changes: Patient had lateral STE and mildly elevated troponin x3 (CK/MB flat)on admission, felt likely due to blunt injury ___ compressions ___ ED vs. demand ischemia. . # A-line: patient had femoral A-line placed ___ ED ___ setting of her hypotension. This was discontinued ___ ICU and replaced with PICC. She had one set of BCx which grew Lactobacillus, likely skin contaminant. Other surveillance cx negative. . TRANSITIONAL ISSUES: - Code: Full - Labs: She should have a daily chem 7 for phos repletions and while being diuresed - Nutrition: Tube Feeds + soft diet and thin liqiuds Medications on Admission: 1. fluticasone 50 mcg/actuation Spray, Suspension ___ puffs BID 2. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY 3. acetaminophen 325 mg Tablet Sig: ___ Tablets q4hr prn 4. polyvinyl alcohol 1.4 % Drops 1every four (4) hours prn 5. insulin lispro 100 unit/mL Solution SS TID Sliding scale units Subcutaneous three times a day: 150-200 - 2 units; 201-250 - 4 units; 251-300 - 6 units; 301-350 - 8 units; 351-400 - 10 units; over 400 - 10 units and call MD. 6. miconazole nitrate 2 % Powder 1 TID prn rash 7. vancomycin 125 mg Capsule 1 PO Q6H for 7 days 8. heparin (porcine) 5,000 unit/mL Solution 5000 (5000) TID 9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution 1 q4hr prn SOB 10. ipratropium bromide 0.02 % Solution 1 q6hr prn SOB Discharge Medications: 1. Vancomycin Oral Liquid ___ mg PO Q6H Duration: 12 Days Last day = ___ 2. Fluticasone Propionate 110mcg 2 PUFF IH BID 3. Levothyroxine Sodium 50 mcg PO DAILY 4. Triamcinolone Acetonide 0.025% Cream 1 Appl TP BID pls apply thin layer to rash 5. Miconazole Powder 2% 1 Appl TP TID to groin rash 6. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using lispro Insulin 7. Lisinopril 5 mg PO DAILY HOLD for SBP<100 8. Famotidine 20 mg PO Q12H 9. Heparin 5000 UNIT SC TID 10. polyvinyl alcohol *NF* 1.4 % ___ q4 hours PRN dry eyes 11. Docusate Sodium (Liquid) 100 mg PO BID 12. Furosemide 20 mg PO DAILY as needed for volume overload, please check electrolytes 13. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze 14. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheeze Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: ACUTE ISSUES: 1. Hypercarbic respiratory failure 2. Sepsis due to urinary source 3. Recurrent C. difficile colitis CHRONIC ISSUES: 1. Hypothyroidism 2. Chronic anemia 3. Mitral regurgitation 4. Osteoporosis 5. Sjogren syndrome Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. ___, It was a pleasure participating ___ your care at ___ ___. You were admitted to the hospital with respiratory failure requiring intubation and mechanical ventilation. This was likely due to a combination of severe weakness caused by chronic illness, pleural effusions and pulmonary edema (fluid ___ the lungs). You were also found to have a urinary tract infection causing sepsis (bloodstream infection), which likely also contributed to your respiratory failure. You were treated with antibiotics, your symptoms and breathing improved, and you were successfully extubated on ___. You will be discharged to rehab where you will receive intensive physical therapy and your nutrition will be optimized to help you continue regaining strength. . When you are discharged from rehab, you will need to follow up with your primary care doctor ___. . We made the following changes to your medications: 1. STARTED famotidine 20mg by mouth twice daily for heartburn 2. STARTED triamcinolone acetonide 0.025% cream three times daily for rash 3. RESTARTED lisinopril 5mg by mouth daily for high blood pressure and heart failure 4. STARTED docusate (Colace) 100mg by mouth twice daily for constipation 5. CONTINUED vancomycin oral liquid ___ by mouth every 6 hours (last day = ___ 6. START lasix po 20mg daily prn volume overload Followup Instructions: ___

10002428-DS-19

DS

2157-07-18 00:00:00

2157-07-18 16:39:00

Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: meropenem Attending: ___. Chief Complaint: left hip pain Major Surgical or Invasive Procedure: Closed reduction and percutaneous pinning, left femoral neck fracture History of Present Illness: This is a ___ yo woman in her USOH until the day of presentation when she sustained a mechanical fall onto her left lower extremity with immediate pain, inability to ambulate. The patient denies LOC, premonitory symptoms and ROS is otherwise at baseline. Past Medical History: Anemia Borderline cholesterol Recurrent C. Diff Flatulence Heart Murmur Hypertension Hypothyroidism Mitral Regurgitation Osteoporosis Pneumonia Sinusitis Sjo___ Social History: ___ Family History: Long history of hypertension in her family. Father's family has a history of multiple cancers. She has a grandfather with a history of stomach cancer and an uncle with a history of throat cancer. No history of colon cancers. Father had stroke. No family h/o MI. Mother had a heart valve replaced. Physical Exam: On admission: Pelvis stable to AP and lateral compression. BLE skin clean and intact LLE Shortened and externally rotated, painful with internal or external rotation of the hip. Thighs and leg compartments soft Saphenous, Sural, Deep peroneal, Superficial peroneal SILT ___ FHS ___ TA Peroneals Fire 1+ ___ and DP pulses Knee stable to varus and valgus stress. Negative anterior, posterior drawer signs. On discharge: NAD, A+Ox3 INcision: dressing changed ___ - c/d/i Neurovascularly intact, strenght intact, SILT s/s/dp/sp/t distributions WWP, 2+ DP pulse Pertinent Results: Hip XR ___: IMPRESSION: Impacted left subcapital femoral neck fracture. Brief Hospital Course: On ___ the pt was admitted to the ortho trauma service and found to have a valgus impacted left femoral neck hip fracture, for which she underwent closed reduction and percutaneous pinning, left femoral neck fracture by Dr. ___ On ___ the patient was noted to be recovering well from surgery. She became hypotensive with physical therapy, which normalized after stopping exercise. On ___ the patient continued to do well. She was seen by physical therapy and cleared for discharge to a rehab facility. SOcial work saw pt for her difficulty coping with decreased mobility. Her labs showed sodium level of 130, unchanged from ___ and similar to 132 on admission. She was given instructions to f/u with Dr. ___ in clinic in 2 weeks, and will be on lovenox subq 40 mg daily in the interim. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 75 mcg PO DAILY 2. Lisinopril 5 mg PO DAILY 3. MethylPHENIDATE (Ritalin) 2.5 mg PO BID 4. mirtazapine 30 mg Oral QHS Discharge Medications: 1. Levothyroxine Sodium 75 mcg PO DAILY 2. Lisinopril 5 mg PO DAILY 3. MethylPHENIDATE (Ritalin) 2.5 mg PO BID 4. mirtazapine 30 mg Oral QHS 5. Acetaminophen 1000 mg PO TID 6. Aluminum-Magnesium Hydrox.-Simethicone ___ ml PO QID:PRN Dyspepsia 7. Artificial Tears ___ DROP BOTH EYES PRN dry eyes 8. Biotene Dry Mouth Rinse (saliva substitution combo no.8) 1 application Mucous Membrane q2hr 9. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 10. Calcium Carbonate 1250 mg PO TID 11. Docusate Sodium 100 mg PO BID 12. Enoxaparin Sodium 40 mg SC DAILY DVT prophylaxis Duration: 14 Days Start: ___, First Dose: Next Routine Administration Time RX *enoxaparin 40 mg/0.4 mL 40 mg subq daily Disp #*14 Syringe Refills:*0 13. Milk of Magnesia 30 ml PO BID:PRN Dyspepsia 14. Multivitamins 1 CAP PO DAILY 15. OxycoDONE (Immediate Release) 2.5 mg PO Q6H:PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every four hours Disp #*60 Tablet Refills:*0 16. Pantoprazole 40 mg PO Q24H 17. Senna 2 TAB PO HS 18. Vitamin D 800 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: left femoral neck fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take lovenox 40mg daily for 2 weeks WOUND CARE: - 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 Physical Therapy: Touch-down weight bearing LLE Treatments Frequency: 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. Followup Instructions: ___

10002430-DS-5

DS

2125-09-30 00:00:00

2125-10-02 10:47:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Corgard / Vasotec Attending: ___ Chief Complaint: leg edema Major Surgical or Invasive Procedure: None History of Present Illness: HISTORY OF PRESENTING ILLNESS: Mr. ___ is an ___ year old gentleman with history of CAD (s/p 3V CABG ___, LM PCI ___, pulmonary HTN, AFib on anticoagulation, ___ (EF 50%) who presents with volume overload and new found RV dilation on office echocardiogram. Patient reports he has had 10 days of waking up feeling nervous and jittery. He also endorses weight gain, and new onset lower extremity swelling. He has not had chest pain, palpitations, orthopnea, or PND. He has not had any fevers, cough, recent travel, medication non compliance, increased salty food intake. He also has not had dyspnea on exertion and rides 4 miles per day on a stationary bike and does 6 minutes of weight lifting. He presented to Dr. ___ today for evaluation. There he had a TTE that showed new RV dilation and was referred to the ___ ED for further evaluation with concern for pulmonary embolism. In the ED, initial vitals were: T98. HR 70, BP 166/65, RR 16, 100% RA. Exam in ED notable for bilateral pitting edema to knees. Labs notable for mild hyponatremia, Cr 1.1. ALT/AST mildly elevated at 81/64. WBC 4, Hgb 11.3, INR 1.3. DDimer <150. UA unremarkable. CXR with mild cardiomegaly but no evidence of consolidation or pulmonary edema. CTA was negative for PE, showed severe emphysema and dilated pulmonary artery. Patient received 20 mg IV Lasix with significant urine output per patient. He was then admitted to the heart failure service for acute heart failure exacerbation and further workup of RV dilation. Vitals on transfer: Afebrile, HR 66, BP 129/54, RR 19, 95%RA. On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. Cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope or presyncope. Past Medical History: Past Medical History: BILATERAL MODERATE CAROTID DISEASE CONGESTIVE HEART FAILURE CORONARY ARTERY DISEASE GASTROESOPHAGEAL REFLUX HYPERTENSION SEVERE EMPHYSEMA PULMONARY HYPERTENSION RIGHT BUNDLE BRANCH BLOCK BENIGN PROSTATIC HYPERTROPHY HYPERLIPIDEMIA PAROXYSMAL ATRIAL FIBRILLATION H/O HISTIOPLASMOSIS Past Surgical History: CARDIOVERSION ___ RIGHT LOWER LOBE LOBECTOMY ___ CORONARY BYPASS SURGERY ___ Social History: ___ Family History: Non-contributory Physical Exam: ADMISSION Vitals: 98 159/62 16 98% on RA weight 143 lbs (bed scale) General: very pleasant older gentleman lying in bed speaking in full sentences in NAD HEENT: PERRL, EOMI, no scleral icterus, oropharynx clear Neck: supple, JVP at 6cm, no adenopathy CV: regular rate and rhythm, normal S1, physiologic split S2, ___ systolic murmur at LLSB. No rubs or gallops. Lungs: CTAB, no crackles, wheezes, or rhonchi Abdomen: soft, non distended, non tender to deep palpation, +BS GU: no CVA tenderness, no foley Extr: warm, well perfused, 2+ pulses in radial and DP, 2+ edema in bilateral lower extremities to knees Neuro: aoxo3, CN2-12 grossly intact, moving all 4 extremities without deficit, stable gait Skin: warm, well perfused, dry, no rashes or lesions DISCHARGE Vitals: 98.3 100-121/49-59 54-62 18 96RA Tele: no tele Last 8 hours I/O: ___ Last 24 hours I/O: 1200/3150 Weight on admission: 64.3 Today's weight: 63.1 General: elderly, NAD Neck: JVP at base of clavicle when 90 degrees Lungs: CTAB no crackles CV: RRR, split S2 Abdomen: slightly obese, soft, NTND, NABS Ext: no edema Pertinent Results: ADMISSION ___ 04:02PM BLOOD WBC-4.0 RBC-4.32* Hgb-11.3* Hct-35.1* MCV-81* MCH-26.2 MCHC-32.2 RDW-16.3* RDWSD-48.3* Plt ___ ___ 04:02PM BLOOD ___ PTT-35.8 ___ ___ 04:02PM BLOOD Glucose-93 UreaN-17 Creat-1.1 Na-131* K-3.8 Cl-93* HCO3-27 AnGap-15 ___ 04:02PM BLOOD ALT-81* AST-64* AlkPhos-89 TotBili-0.7 ___ 04:02PM BLOOD CK-MB-3 cTropnT-<0.01 proBNP-1284* ___ 04:02PM BLOOD Albumin-4.2 Calcium-9.7 Mg-2.2 ___ 04:34PM BLOOD D-Dimer-<150 ___ 04:02PM BLOOD TSH-3.0 DISCHARGE ___ 04:04AM BLOOD WBC-6.5# RBC-4.57* Hgb-12.2* Hct-36.8* MCV-81* MCH-26.7 MCHC-33.2 RDW-16.4* RDWSD-47.8* Plt ___ ___ 04:04AM BLOOD ___ PTT-34.1 ___ ___ 04:04AM BLOOD Glucose-113* UreaN-32* Creat-1.4* Na-133 K-3.9 Cl-94* HCO3-26 AnGap-17 ___ 04:04AM BLOOD ALT-79* AST-57* AlkPhos-83 TotBili-0.6 ___ 04:04AM BLOOD Calcium-10.0 Phos-4.4 Mg-2.0 ECHO ___ The left atrium is moderately dilated. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with hypokinesis of the mid-anterior and mid-distal inferior wall. The estimated cardiac index is normal (>=2.5L/min/m2). Doppler parameters are indeterminate for left ventricular diastolic function. The right ventricular cavity is mildly dilated with depressed free wall contractility (RV free wall is not well seen). The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. The pulmonic valve leaflets are thickened. There is no pericardial effusion. IMPRESSION: Mild regional left ventricular dysfunction c/w multivessel CAD, with overall mildly depressed global systolic function. Mildly dilated right ventricle with depressed free wall systolic function. Moderate tricuspid regurgitation with moderate pulmonary hypertension. Brief Hospital Course: Mr. ___ is an ___ year old gentleman with history of CAD (s/p CABG and PCI), pAF, PAH, diastolic CHF who presents with weight gain, leg swelling and new evidence of right ventricle dilation concerning for acute on chronic heart failure exacerbation. #Acute on Chronic Diastolic Heart Failure Exacerbation: with component of RV failure by report of OSH echo. Likely primary process is lung disease causing elevated RV pressures and subsequent poor filling of LV. He diuresed quite well with 20 IV Lasix which is consistent with RV failure. Started on torsemide 10 daily but this is likely too aggressive. We obtained an echo but read PND at time of discharge. We sent him home on a diuretic regimen on torsemide 5 mg daily (and discontinued home triamterene-HCTZ). Close follow up with Dr. ___ ensured. #Elevated Transaminases: Patient with mildly elevated AST and ALT. Most likely etiologies in this patient include amiodarone toxicity and congestive hepatopathy. Encouraged outpatient trending. #Pulmonary disease: patient with extensive emphysema on CTA though patient has no history of smoking. As this may be driving R heart failure, Dr. ___ requested pulmonology consult prior to discharge but patient was insistent on leaving. Instead scheduled outpatient appointment. #Atrial Fibrillation: Continue home amiodarone 200mg daily, Apixaban 5mg BID #CAD: Continue ASA 81mg, rosuvastatin 40mg qHS #HTN: continue home losartan 25mg qD. TRANSITIONAL ISSUES [] New medication: Torsemide 5 mg daily [] Discontinued triamterene/HCTZ in favor of above [] LFTs mild elevated in house; consider possible discontinuing/changing amiodarone [] Please check LFT's and Creatinine at follow up appointment as these were elevated while hospitalized [] Follow up appointment with cardiology, Dr. ___ [] Follow up appointment with pulmonology [] Follow up appointment with PCP ***Discharge weight 63.1 kg*** Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amiodarone 200 mg PO DAILY 2. Apixaban 5 mg PO BID 3. Aspirin 81 mg PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Losartan Potassium 25 mg PO DAILY 6. Omeprazole 10 mg PO DAILY 7. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY 8. Senna 17.2 mg PO HS 9. Align (bifidobacterium infantis) 4 mg oral DAILY 10. coenzyme Q10 100 mg oral DAILY 11. Rosuvastatin Calcium 40 mg PO QPM 12. Vitamin D 1000 UNIT PO DAILY 13. Tamsulosin 0.4 mg PO QHS Discharge Medications: 1. Amiodarone 200 mg PO DAILY 2. Apixaban 5 mg PO BID 3. Aspirin 81 mg PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Losartan Potassium 25 mg PO DAILY 6. Rosuvastatin Calcium 40 mg PO QPM 7. Senna 17.2 mg PO HS RX *sennosides [senna] 8.6 mg 1 capsule by mouth once a day Disp #*30 Capsule Refills:*0 8. Vitamin D 1000 UNIT PO DAILY 9. Torsemide 5 mg PO DAILY RX *torsemide 5 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 10. Align (bifidobacterium infantis) 4 mg oral DAILY 11. coenzyme Q10 100 mg oral DAILY 12. Omeprazole 10 mg PO DAILY 13. Tamsulosin 0.4 mg PO QHS Discharge Disposition: Home Discharge Diagnosis: Primary: Acute on chronic diastolic congestive heart failure Cor pulmonale Secondary: Pulmonary hypertension Paroxysmal atrial fibrillation Hyponatremia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were hospitalized for progressive leg swelling over the past week and a half. We started you on a new medication here that should help prevent this from happening. Of note, Dr. ___ was concerned about a clot in your lungs, but our scans showed NO clot. With this news, you were discharged home with PCP and cardiology follow up. Please continue to take your torsemide in order to maintain your weight. Please weight yourself everyday and call your cardiologist if you weight changes by three pounds. You also have "pulmonary hypertension," which may be due to your underlying lung disease. Amiodarone can also cause lung changes and we recommend following up with the lung doctors as ___ outpatient to see if this may be contributing. It was a pleasure taking care of you! Your ___ team Followup Instructions: ___

10002557-DS-6

DS

2152-11-17 00:00:00

2152-11-17 17:47:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Ciprofloxacin Hcl Attending: ___. Chief Complaint: RUQ and epigastric pain Major Surgical or Invasive Procedure: Laparoscopic cholecystectomy. History of Present Illness: ___ is an ___ year old female who presents with a one day history of RUQ and epigastric pain. The pain has been intermittent and associated with nausea. She reports that the pain is somewhat improved now, but not completely alleviated. She denies any emesis. She denies any fevers or chills. She has had a couple episodes of pain that was similar in the past. She continues to have flatus and bowel movements. She has not had any po intake since the pain began, so she is not sure if the pain is increased with po intake. She reports decreased appetite today. Last po intake was this morning. Past Medical History: PMH: Multinodular goiter, Osteopenia, GERD, Gallbladder stone disease, Breast Cancer, chronic constipation, chronic migraines PSH: Right mastectomy, partial thyroidectomy x2, appendectomy Social History: ___ Family History: Unknown Physical Exam: Admission PE: VS: 97.9 64 137/84 16 96% RA Gen: no acute distress, alert, responsive Pulm: unlabored breathing CV: regular rate and rhythm Abd: soft, mildly tender in the epigastric region and the RUQ, non-distended, no rebound, no gaurding, negative ___ sign Ext: warm and well perfused Discharge PE: VS: Temp: 98.9, HR: 64, BP: 128/61, RR: 18, O2: 95% RA General: A+Ox3, NAD, MAE. CV: RRR Resp: CTA b/l Abdomen: soft, non-distended, mildly tender to palpation Skin: abd lap sites w/ dsgs c/d/i Extremeties: no edema Pertinent Results: ___ 08:10PM URINE HOURS-RANDOM ___ 08:10PM URINE HOURS-RANDOM ___ 08:10PM URINE UHOLD-HOLD ___ 08:10PM URINE GR HOLD-HOLD ___ 08:10PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 08:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-SM ___ 08:10PM URINE RBC-<1 WBC-1 BACTERIA-NONE YEAST-NONE EPI-0 ___ 08:10PM URINE MUCOUS-RARE ___ 07:45PM GLUCOSE-90 UREA N-19 CREAT-0.7 SODIUM-140 POTASSIUM-3.5 CHLORIDE-104 TOTAL CO2-27 ANION GAP-13 ___ 07:45PM estGFR-Using this ___ 07:45PM ALT(SGPT)-106* AST(SGOT)-309* ALK PHOS-140* TOT BILI-0.7 ___ 07:45PM LIPASE-36 ___ 07:45PM ALBUMIN-4.1 ___ 07:45PM WBC-8.8 RBC-3.83* HGB-11.6* HCT-33.9* MCV-89 MCH-30.4 MCHC-34.4 RDW-14.5 ___ 07:45PM NEUTS-82.6* LYMPHS-12.5* MONOS-4.8 EOS-0.1 BASOS-0.1 ___ 07:45PM PLT COUNT-169 Imaging: ___: Ultrasound: Porcelain gallbladder with calcification of the wall of the gallbladder, similar to previous. Stable dilatation of the common bile duct. ___: CXR: No evidence of acute cardiopulmonary disease. ___: Hida Scan: Findings are consistent with acute cholecystitis ___: Intraoperative Cholangiogram Contrast is seen opacifying the remaining biliary system, without filling defect. Brief Hospital Course: The patient was admitted to the General Surgical Service on ___ for evaluation and treatment of abdominal pain. Admission abdominal ultra-sound showed calcification of the wall of the gallbladder as well as stable dilatation of the common bile duct. Next she had a hida scan which was positive for acute cholecystitis. On ___, the patient underwent laparoscopic cholecystectomy with an introperative cholangiogram, which went well without complication (reader referred to the Operative Note for details). After a brief, uneventful stay in the PACU, the patient arrived on the floor tolerating a clear liquid diet, on IV fluids, and po pain medicine for pain control. The patient was hemodynamically stable. Pain was well controlled. Diet was progressively advanced as tolerated to a regular diet with good tolerability. The patient voided without problem. During this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirometry, and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. On POD2, pt was noted to have saturated RUQ lap site dsgs with ongoing oozing, requiring a bedside cauderization which the patient tolerated well. Post-cauderization, good hemostasis was achieved. 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 and her family received discharge teaching and follow-up instructions with the use of an interpreter and the patient verbalized understanding and agreement with the discharge plan. She has a follow-up appointment scheduled in 2 weeks in the ___ clinic. Medications on Admission: amlodipine 10 mg', atorvastatin 40 mg', Fioricet 50 mg-325 mg-40 mg'', Premarin 0.625 mg/gram vaginal cream, hydrochlorothiazide 25 mg', lorazepam 0.5 mg', metoprolol succinate ER 50 mg', omeprazole 20 mg', tramadol 50 mg'', valsartan 320 mg', zolpidem 5mg', aspirin 81 mg', Vit D Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H do NOT exceed more than 3gm in 24 hours. RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8) hours Disp #*40 Tablet Refills:*0 2. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN headache 3. Amlodipine 10 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 40 mg PO QPM 6. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*20 Capsule Refills:*0 7. Lorazepam 0.5 mg PO QHS:PRN insomnia 8. Metoprolol Succinate XL 50 mg PO DAILY 9. Omeprazole 20 mg PO DAILY 10. OxycoDONE (Immediate Release) 2.5-10 mg PO Q4H:PRN Pain please do NOT drive while taking this medication. RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*25 Tablet Refills:*0 11. Polyethylene Glycol 17 g PO DAILY:PRN Constipation 12. Senna 8.6 mg PO BID:PRN constipation please hold for loose stools 13. TraMADOL (Ultram) 50 mg PO BID:PRN pain 14. Valsartan 320 mg PO DAILY 15. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia Discharge Disposition: Home Discharge Diagnosis: 1. Cholelithiasis 2. Chronic cholecystitis. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to the hospital with acute cholecystitis. You were taken to the operating room and had your gallbladder removed laparoscopically. You tolerated the procedure well and are now being discharged home to continue your recovery with the following instructions. Please follow up in the Acute Care Surgery clinic at the appointment listed below. ACTIVITY: o Do not drive until you have stopped taking pain medicine and feel you could respond in an emergency. o You may climb stairs. o You may go outside, but avoid traveling long distances until you see your surgeon at your next visit. o Don't lift more than ___ lbs for 4 weeks. (This is about the weight of a briefcase or a bag of groceries.) This applies to lifting children, but they may sit on your lap. o You may start some light exercise when you feel comfortable. o You will need to stay out of bathtubs or swimming pools for a time while your incision is healing. Ask your doctor when you can resume tub baths or swimming. HOW YOU MAY FEEL: o You may feel weak or "washed out" for a couple of weeks. You might want to nap often. Simple tasks may exhaust you. o You may have a sore throat because of a tube that was in your throat during surgery. o You might have trouble concentrating or difficulty sleeping. You might feel somewhat depressed. o You could have a poor appetite for a while. Food may seem unappealing. o All of these feelings and reactions are normal and should go away in a short time. If they do not, tell your surgeon. YOUR INCISION: o Tomorrow you may shower and remove the gauzes over your incisions. Under these dressing you have small plastic bandages called steri-strips. Do not remove steri-strips for 2 weeks. (These are the thin paper strips that might be on your incision.) But if they fall off before that that's okay). o Your incisions may be slightly red around the stitches. This is normal. o You may gently wash away dried material around your incision. o Avoid direct sun exposure to the incision area. o Do not use any ointments on the incision unless you were told otherwise. o You may see a small amount of clear or light red fluid staining your dressing or clothes. If the staining is severe, please call your surgeon. o You may shower. As noted above, ask your doctor when you may resume tub baths or swimming. YOUR BOWELS: o Constipation is a common side effect of narcotic pain medications. If needed, you may take a stool softener (such as Colace, one capsule) or gentle laxative (such as milk of magnesia, 1 tbs) twice a day. You can get both of these medicines without a prescription. o If you go 48 hours without a bowel movement, or have pain moving the bowels, call your surgeon. PAIN MANAGEMENT: o It is normal to feel some discomfort/pain following abdominal surgery. This pain is often described as "soreness". o Your pain should get better day by day. If you find the pain is getting worse instead of better, please contact your surgeon. o You will receive a prescription for pain medicine to take by mouth. It is important to take this medicine as directed. o Do not take it more frequently than prescribed. Do not take more medicine at one time than prescribed. o Your pain medicine will work better if you take it before your pain gets too severe. o Talk with your surgeon about how long you will need to take prescription pain medicine. Please don't take any other pain medicine, including non-prescription pain medicine, unless your surgeon has said its okay. o If you are experiencing no pain, it is okay to skip a dose of pain medicine. o Remember to use your "cough pillow" for splinting when you cough or when you are doing your deep breathing exercises. If you experience any of the following, please contact your surgeon: - sharp pain or any severe pain that lasts several hours - pain that is getting worse over time - pain accompanied by fever of more than 101 - a drastic change in nature or quality of your pain MEDICATIONS: Take all the medicines you were on before the operation just as you did before, unless you have been told differently. If you have any questions about what medicine to take or not to take, please call your surgeon. Followup Instructions: ___

10002559-DS-7

DS

2179-06-07 00:00:00

2179-06-11 09:04:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: fever Major Surgical or Invasive Procedure: Lumbar puncture History of Present Illness: Mr ___ is a ___ male presents with 1 day general malaise, fever, altered mental status Per patient notes one day of chills, sore throat, dry cough and intermittent headache. He was later brought in by ambulance after being noted by his roommates to be altered. While being assessed by EMS patient was tachycardic to 160. Upon arrival to ED patient was disoriented to time and place. VS: 102.7 136 117/62 18 100% 4L. He underwent LP due to concern for meningitis. LP revealed protein 24 glucose 61. UA negative. CXR wnl. Urine/blood tox screen negative. Patient received 4L IVF, CTX 2gm, 4mg IV ativan pre-treatment for LP. VS prior to transfer: 99.9 119 94/44 18 98%. On arrival to the floor, patient is sleeping but arousable; oriented x3 but intermittently confused. Reports mild HA, sore throat, fever, dry cough, sweats, chills. No recent travel. No known sick contacts. No recent sexual activity. No genital ulcers/lesions. No skin rashes. Lives with 4roommates. Denies recent exposures, ingestions. Last EtOH use on ___ night. Past Medical History: None Social History: ___ Family History: Father: HTN, pre-DM No psych history Physical Exam: ADMISSION PHYSICAL EXAM: VS: 98.2 110/52 113regular 18 97%RA GENERAL: Sleeping but arousable, NAD, mildly diaphoretic HEENT: NC/AT, PERRLA, EOMI, no nystagmus, sclerae anicteric, MMM NECK: supple, no appreciable LAD LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART: tacycardiac, no MRG, nl S1-S2 ABDOMEN: thin, NABS, soft/NT/ND, no masses or HSM, no rebound/guarding SKIN: no obvious rashes, petechiae EXTREMITIES: WWP, no edema bilaterally in lower extremities, no erythema, induration, or evidence of injury or infection NEURO: A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, no clonus, no rigidity, unsteady gait. DISCHARGE PHYSICAL EXAM: VS: 98.3, 112/70, 91, 18, 100%RA GENERAL: awake, NAD HEENT: NC/AT, sclerae anicteric, MMM, red/swollen bilat tonsils without evidence of exudate NECK: supple, no neck stiffness LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART: RRR, no MRG, nl S1-S2 ABDOMEN: thin, NABS, soft/NT/ND, no masses or HSM, no rebound/guarding SKIN: no obvious rashes, petechiae EXTREMITIES: WWP, no edema bilaterally in lower extremities, no erythema, induration, or evidence of injury or infection NEURO: A&Ox3, CNs II-XII grossly intact, gait normal, no focal deficits Pertinent Results: ADMISSION LABS: ___ 12:00AM GLUCOSE-104* UREA N-14 CREAT-0.8 SODIUM-136 POTASSIUM-3.4 CHLORIDE-99 TOTAL CO2-20* ANION GAP-20 ___ 12:12AM LACTATE-2.1* ___ 12:00AM ALT(SGPT)-25 AST(SGOT)-26 LD(LDH)-187 CK(CPK)-89 ALK PHOS-78 TOT BILI-1.0 ___ 12:00AM CALCIUM-10.4* PHOSPHATE-0.8* MAGNESIUM-1.7 ___ 12:00AM TSH-2.3 ___ 12:00AM WBC-13.6* RBC-5.02 HGB-15.2 HCT-43.8 MCV-87 MCH-30.2 MCHC-34.7 RDW-12.3 ___ 12:00AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG MICRO: - ___ 1:17 am CSF;SPINAL FLUID Source: LP. **FINAL REPORT ___ GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final ___: NO GROWTH. - ___ 1:15 pm SEROLOGY/BLOOD **FINAL REPORT ___ RAPID PLASMA REAGIN TEST (Final ___: NONREACTIVE. Reference Range: Non-Reactive. - ___ 1:15 pm SEROLOGY/BLOOD **FINAL REPORT ___ LYME SEROLOGY (Final ___: NO ANTIBODY TO B. BURGDORFERI DETECTED BY EIA. Reference Range: No antibody detected. Negative results do not rule out B. burgdorferi infection. Patients in early stages of infection or on antibiotic therapy may not produce detectable levels of antibody. Patients with clinical history and/or symptoms suggestive of lyme disease should be retested in ___ weeks. - ___ 5:22 am Rapid Respiratory Viral Screen & Culture Source: Nasopharyngeal swab. **FINAL REPORT ___ Respiratory Viral Culture (Final ___: No respiratory viruses isolated. Culture screened for Adenovirus, Influenza A & B, Parainfluenza type 1,2 & 3, and Respiratory Syncytial Virus.. Detection of viruses other than those listed above will only be performed on specific request. Please call Virology at ___ within 1 week if additional testing is needed. Respiratory Viral Antigen Screen (Final ___: Negative for Respiratory Viral Antigen. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Refer to respiratory viral culture for further information. - Herpes Simplex Virus PCR Specimen Source CSF Result Negative - Test (Serum) Result Reference Range/Units HSV 1 IGG TYPE SPECIFIC AB 3.61 H index HSV 2 IGG TYPE SPECIFIC AB <0.90 index Index Interpretation <0.90 Negative 0.90-1.10 Equivocal >1.10 Positive ___ 01:15PM BLOOD HIV Ab-NEGATIVE Brief Hospital Course: ___ male presents with 1 day general malaise, fever; found to be altered, febrile and tachycardic in the ED. # Altered Mental Status: Was noted to have confusion when at home with roommates, who called EMS given their concern. There was no history of ingestion, and tox screen was negtaive. Blood culture showed no growth, and influenza swab was negative as well. He was noted to be febrile, raising concern for possible meningitis/encephalitis. LP did not show any evidence of infection, and culture results were negative. All other infectious processes which were tested (HIV, RPR, lyme, CSF HSV) were also negative, but arborovirus is still pending at this time. His mental status returned to baseline shortly after he was admitted. # Throat Pain: Complained of throat pain with swallowing. Noted to have erythematous, slightly enlarged tonsils without evidence of exudates. Swab was negative for Strep. He was treated with 7 days of augmentin empirically. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN fever, pain 2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*14 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary: Fever, acute encephalopathy, pharyngitis Secondary: None Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you at ___ ___. You were admitted for evaluation of your acute confusion and fever. While you were here you had a lumbar puncture and blood work to check for evidence of an infection. You were treated with antibiotics, and your symptoms improved. None of the tests which were run show any evidence of infection around your brain or in your blood. The antibiotics were stopped, and you continued to do well. The exact cause of your acute confusion and fever is unknown. Followup Instructions: ___

10002930-DS-10

DS

2196-04-17 00:00:00

2196-04-18 00:09:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Hypoglycemia, Alcohol intoxication, Suicidality Major Surgical or Invasive Procedure: None History of Present Illness: ___ is a ___ F with a history of HCV, HIV, and multiple prior admissions for suicidal ideation who presented to the ___ ED this morning after being found down, somnolent and was ultimately found to have an EtOH level of 117 and initial FSBG 42. She was being observed in the ED but hypoglycemia did not readily improve. She is being transferred to the MICU for close monitoring and treatment of refractory hypoglyemia. Per the patient she reports trying to drink "as much as possible" to try and kill herself. She is not sure if she took anything else. She does not recall any other details about last evening. In the ED, initial vitals were 98.0 84 110/65 12 100% RA In the ED, she received: - 4 amps of dextrose - Started on D5 NS gtt - Diazepam 10mg PO @ 10:45a - Octreotide 100mcg - Folic acid 1mg IV x 1 - Thiamine 100mg IV x 1 - Multivitamin Labs/imaging were significant for: - Urine tox: positive for cocaine and benzodiazepines - Serum tox: positive for benzodiazepines, EtOH level of 117 - VBG ___ with AG = 18, lactate 3 - CT head without acute intracranial abnormality on prelim read Vitals prior to transfer were T 95.6 HR 89 BP 106/65 RR 16 SpO2 100% On arrival to the MICU, the patient reports no current complaints. Review of systems: (+) Per HPI, headache Past Medical History: PAST MEDICAL HISTORY: - HIV (dx ___: Previously on ARV - Hepatitis C: Diagnosed ___, genotype 1 - Truamatic brain injury (1980s) - pt reports she was "assaulted" and subsequently received 300 stitches, was hospitalized x 2wks, and underwent rehab at ___ she denies LOC or persistent deficits but receives SSDI for this injury PSYCHIATRIC HISTORY: (per OMR) Dx/Sxs- Per pt, depression, panic attacks, polysubstance (ETOH, crack, heroin) abuse/dependence. Hospitalizations- Per pt, multiple hospitalizations at ___ (last, ___ and ___ (last, 5+ yrs ago). Per OMR, multiple (>20) detox admissions. No record of treatment at ___ in Partners system. SA/SIB- Per pt, OD on Ultram "probably to hurt [her]self" ___ ago) Psychiatrist- None Therapist- None Medication Trials- Amitriptyline Social History: ___ Family History: Denies h/o psychiatric illness, suicide attempts, addictions. Physical Exam: ADMISSION EXAM: Vitals- Tmax: 37.3 °C (99.2 °F) Tcurrent: 37.3 °C (99.2 °F) HR: 89 (87 - 89) bpm BP: 104/51(62) {104/51(62) - 133/70(80)} mmHg RR: 14 (14 - 20) insp/min SpO2: 100% Heart rhythm: SR (Sinus Rhythm) General- Well appearing, no apparent distress HEENT- Tattoo on right neck. Pupils 4mm, reactive. Neck- No JVD CV- RRR, III/VI SEM heard best at ___ Lungs- CTAB Abdomen- Soft, nontender. Specifically no tenderness of RUQ. No stigmata of chronic liver disease. GU- No foley Ext- Warm, well perfused. No edema. Neuro- CN II-XII grossly intact. No tremor. DISCHARGE PHYSICAL EXAM Vitals: T98.3 HR83 BP106/73 RR18 100%RA General- Well appearing, no apparent distress HEENT- Tattoo on right neck. Pupils 4mm, reactive. Neck- No JVD CV- RRR, III/VI SEM heard best at ___ Lungs- CTAB Abdomen- Soft, nontender. Specifically no tenderness of RUQ. No stigmata of chronic liver disease. GU- No foley Ext- Warm, well perfused. No edema. Neuro- CN II-XII grossly intact. No tremor. Pertinent Results: ADMISSION LABS: ___ 03:36AM BLOOD WBC-2.4* RBC-3.64* Hgb-7.7* Hct-27.6* MCV-76* MCH-21.1* MCHC-27.8* RDW-18.5* Plt ___ ___ 03:36AM BLOOD Glucose-107* UreaN-15 Creat-0.6 Na-136 K-3.4 Cl-107 HCO3-21* AnGap-11 ___ 07:35AM BLOOD ALT-49* AST-105* CK(CPK)-224* AlkPhos-69 TotBili-0.2 ___ 03:36AM BLOOD Calcium-7.8* Phos-2.6*# Mg-1.8 ___ 07:35AM BLOOD Osmolal-321* ___ 07:35AM BLOOD ASA-NEG ___ Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG ___ 09:05AM BLOOD ___ Temp-36.7 pO2-47* pCO2-36 pH-7.26* calTCO2-17* Base XS--9 Intubat-NOT INTUBA ___ 11:10AM BLOOD Glucose-51* Lactate-2.1* HeaD CT: IMPRESSION: 1. No acute intracranial abnormality. 2. Prominence of the posterior nasopharyngeal soft tissues is seen and correlation with direct visualization is recommended. 3. Encephalomalacia in the left parietal lobe with overlying bony defect, possibly from prior trauma. DISCHARGE LABS ___ 03:36AM BLOOD WBC-2.4* RBC-3.64* Hgb-7.7* Hct-27.6* MCV-76* MCH-21.1* MCHC-27.8* RDW-18.5* Plt ___ ___ 06:35AM BLOOD Glucose-97 UreaN-15 Creat-0.5 Na-139 K-3.7 Cl-109* HCO3-23 AnGap-11 ___ 07:35AM BLOOD ALT-49* AST-105* CK(CPK)-224* AlkPhos-69 TotBili-0.2 ___ 06:35AM BLOOD Calcium-8.2* Phos-2.7 Mg-1.4* Brief Hospital Course: ___ F with HCV, HIV presenting after being found down with +EtOH, cocaine, benzodiazepines and transferred to the MICU for hypoglycemia, now resolving. 1) HYPOGLYCEMIA: Suspect related to poor PO intake. Hypoglycemia resolved with eating and patient has remained euglycemic for the remainder of her hospital stay. 2) SUICIDALITY: Patient has had prior admissions to psychiatry for SI and has active SI currently. On ___. Psych was following in house. 1:1 sitter at all times. Patient transferred to ___ for active suicidality. 3) ETOH WITHDRAWAL: No active etoh withdrawal during hospital stay. CIWA scale but not scoring. 4) HEPATITIS C INFECTION: Chronic. Elevated transaminases currently, but in classic 2:1 pattern for EtOH and given recent ingestion history, this is more likely the explanation. - Follow-up as outpatient issue 5) HIV: Will bear in mind as transitional issue to consider re-initiating ARVs CODE STATUS: Unable to assess given active suicidality # Transitional issues - New murmur work up - chronic leukopenia - reinitiating HIV treatment and consideration for initiation of HCV treatment - Nystagmus work-up as outpatient Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. Bisacodyl 10 mg PO DAILY:PRN constipation 2. Docusate Sodium 100 mg PO BID 3. FoLIC Acid 1 mg PO DAILY 4. Multivitamins W/minerals 1 TAB PO DAILY 5. Polyethylene Glycol 17 g PO 1X Duration: 1 Dose 6. Senna 8.6 mg PO BID:PRN Constipation 7. Thiamine 100 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary diagnosis: hypoglycemia secondary to poor po intake, suicidal ideation, severe depression Discharge Condition: Flat affect, active suicidal ideation Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure to take care of you at ___. You were admitted to the ICU for low blood sugars that you had when you arrived. You have not had any further blood sugars since. They were probably caused by not eating enough while drinking excessive alcohol. You were transferred back to the general floor and monitored. You continue to have suicidal thoughts and will therefore be going to ___ when you leave ___. We wish you all the best in your recovery. Your ___ tem. Followup Instructions: ___

10002930-DS-12

DS

2198-04-22 00:00:00

2198-04-22 18:23:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: alcohol intoxication Major Surgical or Invasive Procedure: none History of Present Illness: ___ y/o ___ homeless F with PMH of TBI, HIV+, HCV, polysubstance abuse (alcohol, crack cocaine, and heroin), unspecified mood disorder (MDD with psychotic features vs. substance-induced mood disorder), and chronic AH who presented from ___ station via EMS with complaint of multiple head strikes found to have EtOH intoxication and SI admitted to MICU for EtOH withdrawal and CIWA monitoring. Patient is noted to be a poor historian; however she reports she hit her head "multiple" times today ___ falling asleep. Of note, she reports active EtOH use and states her last drink was at 1200 on ___. She is unsure if she used other drugs/medications. In addition, she reports concern that she is having auditory hallucinations with the voices increasing in frequency. In addition, patient reports active SI although she does not have a plan. In the ED, initial vitals: 98.2 88 150/98 16 100% RA. During time in ED, patient became febrile to 101; a urinalysis/urine cx, CXR, and blood cultures were sent. - Exam notable for: pleasant patient with poor hygiene/dress, tangential and appearing to respond to internal stimuli, neuro intact, no clear HEENT trauma, mild upper thoracic tenderness, (+) tongue fasiculation - Labs were notable for: 2.9>9.9/33.6<168 Na 140 K 3.5 Cl 103 HCO3 24 BUN 15 Cr 0.6 Gluc 111 AGap=17 ALT 77 AST 196 AP 98 Tbili 0.6 Alb 3.9 Serum EtOH 21 Serum ASA, Acetmnphn, ___, Tricyc Negative Lactate 1.0 U/A with ketones, 6 WBCs, few bacteria, negative leuks, negative nitrites - Imaging showed: NCHCT (___): 1. No acute intracranial abnormality. 2. Stable left parietal encephalomalacia. CXR (___): No acute cardiopulmonary abnormality or fracture. - Patient was given: 40mg diazepam 100mg thiamine MVI 1mg folic acid 30mg ketorolac 2L NS 1gm Tylenol - Psychiatry was consulted who felt patient was disorganized and endorsing AH and SI (no plan). Per their recommendations, patient was placed on a ___ with a 1:1 sitter with admission to medicine for EtOH withdrawal On arrival to the MICU, she was sleeping comfortably. Would open eyes to voice and answer questions, but was overall very sleepy. Denies pain. Cannot articulate when last drink was, says "yesterday." Denies taking anything else. Past Medical History: Per Dr. ___ (___), confirmed with patient and updated as relevant: - HIV - Hepatitis C - H/o head injury (Per Deac 4 DC summary ___: "pt reports she was "assaulted" and subsequently received 300 stitches, was hospitalized x 2wks, and underwent rehab at ___ she denies LOC or persistent deficits but receives SSDI for this injury" Social History: Per Dr. ___ (___), confirmed with patient and updated as relevant: "The patient reports that she was born and raised in ___ and that her parents were separated while she was growing up. She states that she lives with her grandmother her whole life until ___ years ago when her mother died and that she has been living in the ___ since. She states that she has 2 daughters (age ___ and ___, named ___ and ___ who are both enrolled at ___ and that she also has 2 grandchildren. Denies contact with parents, whom she reports are not supportive. " On today's interview patient reports no contact with her family, reports having 3 living children (2 daughters and 1 son) and 1 dead son. She has no contact with her children. She did not wish to elaborate further. Confirms living at ___. Family History: Unknown (pt refused to answer in past) Physical Exam: ADMISSION PHYSICAL EXAM: =========================== Vitals: 98.2 103 138/77 22 99% ra GEN: lying in bed, somnolent, but wakes to voice, NAD HEENT: no scleral icterus, PERRL, mmm, nl OP NECK: supple, no JVD CV: tachycardic, regular rhythm, II/VI systolic murmur PULM: nl wob on ra, LCAB, no wheezes or crackles ABD: soft, mild distension, normal bs, nontender EXT: warm, trace bilateral edema, 2+ DP pulses SKIN: no rashes or visible track marks NEURO: sleepy, oriented to person, didn't answer re place or time, answering questions then falls asleep, moving all 4 extremities ACCESS: PIV DISCHARGE PHYSICAL EXAM: =========================== stable vital signs lying comfortably in bed. bilateral knee ecchymosis. Pertinent Results: ADMISSION LABS: =========================== ___ 03:27PM BLOOD WBC-2.9* RBC-3.81* Hgb-9.9* Hct-33.6* MCV-88 MCH-26.0 MCHC-29.5* RDW-17.9* RDWSD-56.8* Plt ___ ___ 03:27PM BLOOD Neuts-74.0* ___ Monos-4.5* Eos-0.7* Baso-0.3 AbsNeut-2.16 AbsLymp-0.60* AbsMono-0.13* AbsEos-0.02* AbsBaso-0.01 ___ 03:27PM BLOOD Glucose-111* UreaN-15 Creat-0.6 Na-140 K-3.5 Cl-103 HCO3-24 AnGap-17 ___ 03:27PM BLOOD ALT-77* AST-196* AlkPhos-98 TotBili-0.6 ___ 03:27PM BLOOD Albumin-3.9 ___ 03:27PM BLOOD Osmolal-295 ___ 03:27PM BLOOD ASA-NEG Ethanol-21* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG MICRO: =========================== -Blood cx pending -Urine cx pending IMAGING/STUDIES: =========================== -NCHCT (___): 1. No acute intracranial abnormality. 2. Stable left parietal encephalomalacia. -CXR (___): No acute cardiopulmonary abnormality or fracture. DISCHARGE LABS: =========================== Brief Hospital Course: ___ y/o ___ homeless F with PMHx of TBI, HIV+, HCV, polysubstance abuse (alcohol, crack cocaine, and heroin), unspecified mood disorder (MDD with psychotic features vs. substance-induced mood disorder), and chronic AH who presented from ___ station via EMS with complaint of multiple head strikes found to have EtOH intoxication and SI admitted to MICU for EtOH withdrawal and CIWA monitoring, now stabilized and transferred to the floor, now medically stable for discharge to psychiatric facility ACTIVE ISSUES: ======================== # EtOH intoxication/withdrawal: on phenobarbital withdrawal protocol. Last drink ___. Patient was loaded with phenobarbital, which may continue if the accepting psychiatric facility is okay with administering, however there is no contraindication to discontinuing. -Phenobarb protocol while inpatient, stopped at discharge -Continued MVI, thiamine, folate -Hydroxyzine PRN for additional agitation -seen by psychiatry and social work - appreciated. # Suicidal ideation: patient repeatedly stating "I have suicidal thoughts" and "I'm depressed," though is unable to fully elaborate. Psychiatry saw the patient and had the following recommendations: -Patient meets ___ criteria for involuntary admission, may not leave AMA, should continue 1:1 observation. -Would hold on any psychiatric medications given acute alcohol withdrawal. -If chemical restraint necessary, please call psychiatry for specific recs. Please be aware that patient has cited "jaw locking" with Haldol administration in the past, thus would consider alternative antipsychotic. - seen by psychiatry - recommended inpatient psychiatric placement, and transferred to deac 4. # FEVER: Patient febrile to 101 in the ED. No localizing signs of symptoms of infection. Suspect that this was likely related to acute ingestion, however given her murmur which has not been documented previously, obtained TTE which showed no evidence of vegetation or endocarditis. # Psychosis: suspect this is part of underlying psych disorder and not necessarily alcoholic hallucinosis. Will defer to psychiatry. -Appreciate Psychiatry recs CHRONIC STABLE ISSUES: ======================== # HIV: not on HAART, started Bactrim for PCP prophylaxis given last CD4 count was <200, will send repeat CD4 count on ___ if still inpatient. Patient was previously not taking her HAART medications, will defer to outpatient. # HCV: not on active treatment - Monitor LFTs, as above Transitioanl issues: Should see PCP re HIV and HCV once psychiatrically stabilized. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Amitriptyline 25 mg PO QHS 2. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID 3. Sulfameth/Trimethoprim DS 1 TAB PO DAILY (not taking) 4. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY (not taking) 5. Darunavir 600 mg PO BID (not taking) 6. RiTONAvir 100 mg PO DAILY (not taking) Discharge Medications: 1. Sulfameth/Trimethoprim DS 1 TAB PO DAILY 2. FoLIC Acid 1 mg PO DAILY 3. Thiamine 100 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Polysubstance abuse Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to ___ for evaluation of numerous falls, alcohol and substance abuse. While you were here you were briefly in the intensive care unit where you were started on phenobarbital to help you withdrawal from alcohol and prevent delirium tremens. You also disclosed that you were not taking any of your HIV medications. You were started on Bactrim as prophylaxis for opportunistic infections, and should follow up with your outpatient providers regarding restarting your HIV medications and for evaluation of your hepatitis C. You were deemed medically stable for discharge to a psychiatric facility. Followup Instructions: ___

10003019-DS-19

DS

2174-10-25 00:00:00

2174-10-25 13:21:00

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Oxycodone / Ragweed Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: ___ Exploratory Laparotomy, ___ History of Present Illness: ___ year old male with history to intestinal sarcoidosis s/p Ex.laparoscopy, right colectomy ___ (___), ITP s/p open splenectomy, and inguinal hernia repair complaining of new abdominal pain that started last night and has now progressed to ___ with 1 episode of foot particulate emesis. He denies fevers and chills. He has never had an episode like this before. He reports he urinated this am without difficulty. It is difficult for him to breath this am. He also has new bilateral shoulder pain with breathing. Past Medical History: 1. Sarcoidosis, dx skin bx: intestinal & pulmonary involvement, recurrent iritis 2. Inflammatory bowel disease; s/p ileo-hemicolectomy ___, path +sarcoid 3. GERD. 4. Hyperlipidemia 5 OSA on CPAP 6. Asthma. 7. Osteoarthritis. 8. Fractured pelvis, ___ s/p fall. 9. BPH, status post prostatectomy. 10. Depression. 11. History of ITP, status post splenectomy in ___. 12. Hard of hearing and wears hearing aid. Past Surgical History: 1. s/p Ex Lap, R hemicolectomy, ileocecal colostomy for evaluation ileocecal mass. 2. Arthroscopic surgery of both knees. 3. Shoulder surgery. 4. Hernia repair. Social History: ___ Family History: Mother: ___, cardiac disease. Father: diverticulosis, peptic ulcer disease, died at age ___. Maternal grandfather: ___ cancer. Two siblings, living and healthy. Physical Exam: Physical Exam upon admission: Vitals:Temp 97.8, HR 87, BP 119/83, RR 26, 99% Room air GEN: A&O x3, uncomfortable with movement of stretcher HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Firm abdomen with diffuse peritonitis. Well healed open splenectomy, laparscopic right colectomy, and right inguinal hernia repair incisions. Ext: No ___ edema, ___ warm and well perfused Physical Exam upon discharge: VS: 98.1, 72, 152/83, 18, 98%/RA Gen: NAD, ambulating in room Heent: EOMI, MMM Cardiac: Normal S1, S1. RRR Pulm: Lungs CTAB No Abdomen: Soft/nontender/nondistended staples OTA Ext: + pedal pulses, no CCE Neuro: AAOx3, normal mentation. Pertinent Results: ___ 05:21AM BLOOD WBC-6.3 RBC-3.17* Hgb-8.4* Hct-27.2* MCV-86 MCH-26.4* MCHC-30.7* RDW-22.4* Plt ___ ___ 05:26AM BLOOD WBC-8.0 RBC-3.34* Hgb-9.0* Hct-28.5* MCV-85 MCH-26.9* MCHC-31.5 RDW-22.7* Plt ___ ___ 05:47AM BLOOD WBC-9.8 RBC-3.62* Hgb-9.7* Hct-31.4* MCV-87 MCH-26.8* MCHC-30.8* RDW-22.7* Plt ___ ___ 10:35AM BLOOD WBC-9.8 RBC-4.27* Hgb-11.4* Hct-37.1* MCV-87 MCH-26.8* MCHC-30.8* RDW-22.8* Plt ___ ___ 10:35AM BLOOD Neuts-81* Bands-0 Lymphs-12* Monos-3 Eos-3 Baso-0 Atyps-1* ___ Myelos-0 NRBC-1* ___ 05:21AM BLOOD Glucose-140* UreaN-18 Creat-0.8 Na-138 K-3.6 Cl-103 HCO3-27 AnGap-12 ___ 05:26AM BLOOD Glucose-143* UreaN-18 Creat-0.9 Na-135 K-4.1 Cl-103 HCO3-24 AnGap-12 ___ 05:47AM BLOOD Glucose-84 UreaN-24* Creat-0.8 Na-137 K-4.7 Cl-105 HCO3-23 AnGap-14 ___ 10:35AM BLOOD Glucose-105* UreaN-34* Creat-1.0 Na-140 K-3.8 Cl-105 HCO3-27 AnGap-12 ___ 10:35AM BLOOD ALT-80* AST-54* AlkPhos-290* TotBili-0.5 ___ 05:21AM BLOOD Calcium-8.2* Phos-2.9 Mg-1.9 ___ 05:26AM BLOOD Calcium-8.1* Phos-2.9 Mg-2.0 ___ 05:47AM BLOOD Calcium-8.0* Phos-4.0 Mg-1.7 ___ 10:35AM BLOOD Albumin-3.8 Calcium-9.3 Phos-2.6* Mg-1.9 ___ 10:42AM BLOOD Lactate-2.0 ___ Radiology CHEST (PORTABLE AP) IMPRESSION: 1. Pneumoperitoneum. 2. Widening of the vascular pedicle may be related to low lung volumes and intravascular volume status. Brief Hospital Course: This is a ___ year old male with history to intestinal sarcoidosis s/p right colectomy ___ (___), ITP s/p open splenectomy, and inguinal hernia repair who presented to ___ complaining of new abdominal pain and emesis. The patient was admitted to the Acute Care Surgery service. A Chest Xray demonstrated "Free air is present underneath both hemidiaphragms". He was taken to the operating room on ___ for exploratory laparatomy, which revealed that the patient had a perforated duodenal ulcer. Please see operative report for full details. The patient was transferred to the surgical floor post-operatively in stable condition. A nasogastric tube was placed and the patient was kept NPO on POD 1. He received intravenous dosing of his home medications. He also was started on a proton pump inhibitor that he will continue taking after his discharge. The patient's nasogastric tube was discontinued on POD 2, however he was kept NPO. His abdominal pain was well controlled with a Morphine PCA. He did not complain of any nausea or vomiting at this time. On POD 3, the patient was advanced to a regular diet and was passing flatus. He was restarted on his previous home medications and was receiving an oral pain regimen. The patient was also started on a proton pump inhibitor to prevent ulcers in the future and was instructed never to take NSAIDS. He was evaluated by physical therapy; they recommended that the patient have a ___ home safety evaluation and that he was cleared to go home. On the day of discharge, the patient's vital signs were stable and he remained afebrile. He was tolerating a regular diet. His staples were open to air without any signs of erythema or drainage. They are due to come out ___. He will have scheduled followup in the ___. Medications on Admission: Prednisone 40' Alendronate 70' Azathioprine 50', Ergocalciferol 1 capsule/week Fluoxetine 40' Vicodin ___, simvastatin 20' Bactrim 400/80' Discharge Medications: 1. Docusate Sodium 100 mg PO BID 2. PredniSONE 40 mg PO DAILY 3. Alendronate Sodium 70 mg PO QMON 4. Azathioprine 50 mg PO DAILY 5. Simvastatin 20 mg PO DAILY 6. Fluoxetine 40 mg PO DAILY 7. Amoxicillin-Clavulanic Acid ___ mg PO Q12H RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth twice a day Disp #*2 Tablet Refills:*0 8. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills:*0 9. Omeprazole 20 mg PO BID RX *omeprazole 20 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Perforated Duodenal Ulcer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to ___ after you experienced an ducodenal ulcer perforation. You were taken to the operating room on ___ for exploration and placement of ___ patch. Post-operatively, you received a 5 day course of antibiotics. Upon discharge, you were tolerating a regular diet and your pain was well controlled on an oral pain regimen. You will be discharged with followup in the ___ in ___ weeks. DO NOT TAKE ANY NSAIDS: ie Ibuprofen, Aleve, Advil, Naproxen, Aspirin, Motrin 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: ___

10003019-DS-23

DS

2175-11-02 00:00:00

2175-11-02 22:33:00

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Ragweed / morphine / Percocet Attending: ___. Chief Complaint: pre-syncope Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old male with hx of systemic sarcoidosis and Hodgkins lymphoma p/w pre-syncopal episode. Pt was receiving chemo on day of admission (lying flat) when he suddenly felt nauseated. He sat up at the edge of his bed but was unable to stay in seated position d/t dizzines and lay back into bed. Pt said he did not feel like himself and is unable to say whether he went fully unconscious. Wife was present and did not witness any shaking movement, though did report he was confused and not acting like himself. Pt does admit to feeling confused when he woke up. He denies any preceding chest pain, HPs, dyspnea. No other associated sxs. . In the ED: AF/VSS. Neuro saw pt and recommended MRI brain and EEG. CT head negative for acute changes. Labs notabel for WBC 71, hct 28 plt 190. CEs neg. chem 10 notable only for cr 1.3. Pt admitted to OMED. . On the floor pt reports being asymptomatic and feeling well. ROS is as above. Otherwise complete ROS negative. Past Medical History: 1. Sarcoidosis, dx skin bx: intestinal & pulmonary involvement, recurrent iritis 2. Inflammatory bowel disease; s/p ileo-hemicolectomy ___, path +sarcoid 3. GERD. 4. Hyperlipidemia 5 OSA on CPAP 6. Asthma. 7. Osteoarthritis. 8. Fractured pelvis, ___ s/p fall. 9. BPH, status post prostatectomy. 10. Depression. 11. History of ITP, status post splenectomy in ___. 12. Hard of hearing and wears hearing aid. Past Surgical History: 1. s/p Ex Lap, R hemicolectomy, ileocecal colostomy for evaluation ileocecal mass. 2. Arthroscopic surgery of both knees. 3. Shoulder surgery. 4. Hernia repair. Social History: ___ Family History: Mother: ___, cardiac disease. Father: diverticulosis, peptic ulcer disease, died at age ___. Maternal grandfather: ___ cancer. Two siblings, living and healthy. Physical Exam: ADMISSION EXAM: t97.8 134/66 82 20 95%ra NAD eomi, perrl neck supple no ___ chest clear rrr abd benign ext w/wp neuro: cn ___ intact, strength/sensation intact, DTRs intact, cerebellar signs neg skin: no rash DISCHARGE EXAM: VITALS - T 97.7, 138/72, 74, 20, 97% RA, Wt 146.6kg Telemetry: No events overnight General: Pleasant, conversant, elderly gentleman, NAD HEENT: PERRL, sclera anicteric, MMM, no mucositis Neck: Supple, no JVD, no LAD CV: RRR, nl S1/S2, no m/r/g Lungs: CTAB, no w/r/r Abdomen: NABS, flat, soft, NTTP, no HSM GU: No Foley Ext: WWP, no ___ edema, no rashes Neuro: No slurred speech, no facial droop, moving all extremities equally Pertinent Results: ADMISSION LABS: ___ 12:55PM UREA N-28* CREAT-1.3* SODIUM-141 POTASSIUM-3.8 CHLORIDE-106 TOTAL CO2-23 ANION GAP-16 ___ 12:55PM ALT(SGPT)-40 AST(SGOT)-58* ALK PHOS-304* TOT BILI-0.3 ___ 12:55PM TOT PROT-5.4* ALBUMIN-3.4* GLOBULIN-2.0 CALCIUM-9.0 PHOSPHATE-3.3 MAGNESIUM-1.7 URIC ACID-8.9* ___ 12:55PM WBC-71.0*# RBC-2.86* HGB-9.0* HCT-28.4* MCV-99* MCH-31.4 MCHC-31.6 RDW-22.8* ___ 12:55PM NEUTS-71* BANDS-8* LYMPHS-1* MONOS-2 EOS-0 BASOS-0 ATYPS-1* METAS-6* MYELOS-8* PROMYELO-2* NUC RBCS-27* OTHER-1* ___ 12:55PM HYPOCHROM-3+ ANISOCYT-3+ POIKILOCY-1+ MACROCYT-3+ MICROCYT-OCCASIONAL POLYCHROM-1+ OVALOCYT-1+ TARGET-OCCASIONAL SCHISTOCY-1+ HOW-JOL-1+ PAPPENHEI-1+ ENVELOP-OCCASIONAL ___ 12:55PM PLT SMR-NORMAL PLT COUNT-190 PERTINENT LABS: ___ 12:55PM BLOOD CK-MB-2 cTropnT-<0.01 ___ 03:03AM BLOOD CK-MB-2 cTropnT-<0.01 DISCHARGE LABS: ___ 12:39AM BLOOD WBC-30.8*# RBC-2.35* Hgb-7.1* Hct-22.7* MCV-97 MCH-30.4 MCHC-31.5 RDW-23.7* Plt ___ ___ 12:39AM BLOOD Neuts-96* Bands-1 Lymphs-1* Monos-1* Eos-0 Baso-0 ___ Metas-1* Myelos-0 NRBC-5* ___ 12:39AM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-1+ Macrocy-1+ Microcy-1+ Polychr-1+ Ovalocy-1+ Schisto-1+ Stipple-OCCASIONAL How-Jol-1+ Pappenh-1+ ___ 12:39AM BLOOD Plt Smr-LOW Plt ___ ___ 12:39AM BLOOD Glucose-171* UreaN-30* Creat-0.9 Na-135 K-4.0 Cl-105 HCO3-23 AnGap-11 ___ 12:39AM BLOOD ALT-41* AST-56* LD(LDH)-1672* AlkPhos-229* TotBili-0.4 ___ 12:39AM BLOOD Albumin-2.8* Calcium-8.1* Phos-3.8 Mg-1.7 UricAcd-7.3* IMAGING: CT HEAD ___: 1. No evidence of acute intracranial process. No focal enhancement or pachymeningeal enhancement identified, although the study is suboptimal for assessment of neurosarcoidosis. If there is further clinical concern, a contrast-enhanced brain MRI should be performed. 2. Air-fluid levels in the sphenoid sinuses compatible with acute inflammatory sinus disease. CXR ___: Allowing for differences in technique and projection, there has been little interval change in the appearance of the chest since the previous radiograph, with no new focal areas of consolidation to suggest the presence of pneumonia. Multifocal linear areas of scarring appear unchanged, previously attributed to sarcoidosis. Band-like opacity at periphery of left lung base has slightly worsened and is attributed to localize atelectasis. MR EXAMINATION OF BRAIN WITHOUT AND WITH CONTRAST, MRA OF THE HEAD WITHOUT CONTRAST, MRA OF THE NECK WITH CONTRAST, ___ 1. No acute intracranial abnormality. 2. Progressive multifocal T2-hyperintensities in bihemispheric and central pontine white matter, which may represent sequelae of chronic small vessel ischemic disease, neurosarcoidosis, or a combination of the two. 3. No pathologic parenchymal, leptomeningeal or dural enhancement to suggest active inflammation related to neurosarcoidosis. 4. Unremarkable cranial and cervical MRA, with no significant mural irregularity, flow-limiting stenosis or evidence of dissection. 5. Inflammatory disease involving, particularly the sphenoid air cells, with likely layering fluid, suggesting an acute component; this should be correlated clinically, as there is also a small amount of layering fluid in the nasopharynx and fluid-opacification of scattered mastoid air cells, which may relate to protracted supine positioning. Brief Hospital Course: Mr. ___ is a ___ M with stage IV Hodgkin's Lymphoma C2D3 (on ___ of ABVD, as well as h/o systemic sarcoid on prednisone, here after altered mental status/pre-syncope during dacarbazine infusion ___. # Altered Mental Status/Pre-Syncope: Differential diagnosis on admission included allergic reaction, stroke, seizure, and cardiogenic syncope. The patient has a history of presumed neurosarcoid making an intracranial process more likely. Seizure less likely given no tonic-clonic movements and no post-ictal confusion. Neurology was consulted in the ED. Head CT negative for acute process. Head and neck MRI/MRA was checked on ___ and showed progressive multifocal T2 hyperintensity in bihemispheric and central pontine white matter; could represent small vessel ischemic disease and/or neurosarcoidosis. There was no pathologic enhancement to suggest active inflammation due to neurosarcoidosis. The MRA of head and neck was unremarkable. An EEG was checked but results were pending at the time of discharge. The patient ruled out for cardiac ischemia/infarction with a normal EKG and negative cardiac enzymes. He was monitored on telemetry for 24 hours without event. Overall, it's unclear what caused the pre-syncope and altered mental status. The patient's cognitive function rapidly returned to normal even prior to admission and remained stable throughout hospitalization. He will be admitted to the hospital for all future cycles of chemotherapy for closer monitoring. # Stage IV Hodgkin's Lymphoma: Admitted on cycle 2 day 1 of ABVD. Did not get full dose of decarbazine on ___ due to pre-syncope. He received the remainder of the decarbazine dose on ___. He was continued on prophylaxis with fluconazole 400 mg PO/NG Q24H, Acyclovir 400 mg PO/NG Q8H, Sulfameth/Trimethoprim SS 1 TAB PO/NG DAILY. The patient will start Neupogen and Cipro on ___. He was started on allopurinol due to elevated uric acid. # Systemic Sarcoidosis: Involves skin, gut, eyes, lungs, and presumed neurosarcoid. On prednisone daily. He was continued on prednisone 25mg daily. # Depression: Stable. Continued on fluoxetine 40mg daily # Obstructive Sleep Apnea. Compliant with home CPAP, which was continued during hospitalization. # History of AVNRT. This was transient during prior hospitalization and likely related to sepsis. At that time, cardiology recommended conservative treatment with beta blockers, since invasive ablation contraindicated in this immunosuppressed pt. The patient was continued on metoprolol, but switched to short acting metoprolol tartrate 12.5mg BID while hospitalized. TRANSITIONAL ISSUES: -EEG results pending at discharge -Patient will be admitted to the hospital for future chemotherapy -Will start Neupogen and Cipro ___. -New Rx for allopurinol Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Acyclovir 400 mg PO Q8H 2. Fluconazole 400 mg PO Q24H 3. Fluoxetine 40 mg PO DAILY 4. Fluticasone Propionate 110mcg 2 PUFF IH BID 5. Omeprazole 40 mg PO BID 6. Ondansetron 8 mg PO Q8H:PRN n/v 7. PredniSONE 25 mg PO DAILY 8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 9. Metoprolol Succinate XL 25 mg PO DAILY 10. Prochlorperazine 10 mg PO Q6H:PRN n/v Discharge Medications: 1. Acyclovir 400 mg PO Q8H 2. Fluconazole 400 mg PO Q24H 3. Fluoxetine 40 mg PO DAILY 4. Fluticasone Propionate 110mcg 2 PUFF IH BID 5. Omeprazole 40 mg PO BID 6. Ondansetron 8 mg PO Q8H:PRN n/v 7. PredniSONE 25 mg PO DAILY 8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 9. Vitamin D 50,000 UNIT PO 1X/WEEK (WE) 10. Allopurinol ___ mg PO DAILY RX *allopurinol ___ mg one tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 11. Metoprolol Succinate XL 25 mg PO DAILY 12. Prochlorperazine 10 mg PO Q6H:PRN n/v 13. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY: -Pre-syncope during chemotherapy administration, unknown etiology SECONDARY: -Stage IV Hodgkin's Lymphoma -Systemic sarcoidosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure to care for you at ___. You were admitted after having a period of confusion and near-loss of consciousness while getting chemotherapy. A CT scan of your brain was normal. The MRI showed small lesions scattered throughout your brain that may be related to sarcoid, but could also be related to low blood flow in the tiniest blood vessels in your brain (a common finding as people age). The MRI did not show active inflammation in your brain from sarcoid, nor did it show a stroke- good news! An EEG was checked to look for seizure activity and the result is still pending. We also monitored your heart function. Blood tests and an EKG did not reveal a heart attack. The electrical activity of your heart was normal over 24 hours of monitoring. Overall, it's unclear why you experienced near-loss of consciousness and confusion with the chemotherapy. Dr. ___ ___ that you be admitted to the hospital for all future administrations of chemotherapy to be cautious and allow for closer monitoring. After returning home, please start Neupogen and Ciprofloxacin on ___. Followup Instructions: ___

10003400-DS-15

DS

2136-12-15 00:00:00

2136-12-16 07:31:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: afib with rvr Major Surgical or Invasive Procedure: None History of Present Illness: Mrs ___ is a ___ with obesity, atrial fibrillation on coumadin, CKD III (recent baseline 0.88-1.1), UPJ obstruction s/p stent placement ___ c/b persistent Klebsiella bacteruria, chronic multiple myeloma, and adenocarcinoma of anal canal dx ___ who presents with atrial fibrillation with rapid ventricular response. Pt was seen by PCP ___, ___, for pre-op visit re: cystoscopy and right ureteral stent exchange. She presented with complaints of fatigue, inability to stand due to pain in legs, and bilateral leg swelling. Metoprolol had been hold at nursing home due to intermittent hypotension. EKG in office showed AF with RVR in 140s and she was sent to the ED. In the ED, initial VS were 98.3 157 115/81 18 Exam significant for Labs significant for Cr 1.2, (baseline .9), phos 1.7, WBC 3.8, Hb 9.6, INR of 6.5, and troponin of 0.02. Imaging significant for normal CXR. Initially received 5 mg IV metoprolol tartrate, 50 mg metoprolol tartrate PO, and 1L NS. Due to persistent tachycardia to the 130s, she received an additional 5 mg IV metoprolol x2 then diltiazem 10 mg IV. Transfer VS were 98.6 ___ 16 100% RA. On arrival to the floor, patient reports that she has been feeling tired, lightheaded and dizzy for several weeks. She has also had bilateral leg pain both at rest and exacerbated with weight bearing. She has also had decreased PO intake and describes dry mouth. She also describes dysuria, but no frequency or flank pain. She denies fevers and night sweats, but admits to feeling cold. REVIEW OF SYSTEMS: Denies fever, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, or hematuria. All other 10-system review negative in detail Past Medical History: Hypertension Atrial fibrillation on coumadin Obesity Myeloma Osteoarthritis of right knee UPJ obstruction s/p stent placement ___ c/b persistent Klebsiella bacteruria Anal adenocarcinoma (dx ___ without evidence of metastatic dz ? Perirectal cyst drainage in ___ Social History: ___ Family History: Her parents died in their ___ or ___ of "old age." Her parents and multiple siblings have hypertension. There is no family history of significant arrhythmia or premature coronary disease. Physical Exam: ADMISSION EXAM: VS: 98.9 112 18 112/61 100RA Tele: irreg irreg 100s GENERAL: NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclerae, pink conjunctivae, patent nares, poor dentition, dry oral mucosa NECK: nontender supple neck, no LAD, no JVD CARDIAC: irregulary irregularm no murmurs, gallops, or rubs. no carotid bruits LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly, no CVA tenderness EXTREMITIES: No cyanosis or clubbing; Diffuse anasarca, BLE > BLE. 2+ pitting edema in BLE to knee. Bilateral knees edematous, but non erythematous. PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact (with the exception of mild left side of mouth droop). Strength: RUE flexor/extensors ___ LUE rlexor/extensors ___ RLE knee extensor ___ LLE knee extensor ___ Unable to elicit bilateral patellar reflexes; Downward babinkski bilat SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE EXAM: VS Tm 98 18 ___ 100RA Tele: irreg 100s, excursions to 130s IO: 24h 1140/inc + 5 BMs (small) GENERAL: NAD HEENT: AT/NC, EOMI, anicteric sclerae, pink conjunctivae, patent nares, poor dentition NECK: nontender supple neck, no LAD, no JVD CHEST: right-sided portacath accessed, bandage c/d/i, no induration/ttp CARDIAC: irregulary irregular, no murmurs, gallops, or rubs. no carotid bruits LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: No cyanosis or clubbing; Diffuse anasarca, BLE > BUE. 2+ pitting edema in BLE to knee, improved since admission. Bilateral knees edematous, but non erythematous. PULSES: 2+ DP pulses bilaterally Pertinent Results: ADMISSION LABS: --------------- ___ 01:30PM BLOOD WBC-3.8*# RBC-3.39* Hgb-9.6* Hct-29.4* MCV-87 MCH-28.3 MCHC-32.6 RDW-19.4* Plt ___ ___ 01:30PM BLOOD Neuts-77.1* Lymphs-14.1* Monos-8.4 Eos-0.4 Baso-0.1 ___ 01:30PM BLOOD ___ PTT-35.9 ___ ___ 01:30PM BLOOD Glucose-105* UreaN-18 Creat-1.2* Na-137 K-4.1 Cl-100 HCO3-23 AnGap-18 ___ 01:30PM BLOOD cTropnT-0.02* ___ 01:30PM BLOOD Albumin-3.0* Calcium-8.1* Phos-1.7* Mg-1.9 ___ 01:56PM BLOOD Lactate-2.6* PERTINENT LABS: --------------- ___ 01:30PM BLOOD CK(CPK)-77 ___ 09:10PM BLOOD cTropnT-0.01 ___ 04:46AM BLOOD Cortsol-30.5* ___ 09:24PM BLOOD Lactate-1.2 ___ 10:59PM URINE Color-DkAmb Appear-Cloudy Sp ___ ___ 10:59PM URINE Blood-MOD Nitrite-NEG Protein-600 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG ___ 10:59PM URINE RBC-67* WBC->182* Bacteri-MANY Yeast-MOD Epi-7 ___ 10:33AM URINE Color-Yellow Appear-Cloudy Sp ___ ___ 10:33AM URINE Blood-MOD Nitrite-NEG Protein-600 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG ___ 10:33AM URINE RBC-46* WBC->182* Bacteri-MOD Yeast-FEW Epi-25 MICROBIOLOGY: ------------- BLOOD CULTURE ___: Negative URINE CULTURE ___: YEAST ___, org/ml URINE CULTURE ___: YEAST ___, org/ml STOOL C. DIF TOXIN ___: POSITIVE URINE CULTURE ___: YEAST ___, org/ml DISCHARGE LABS: --------------- ___ 05:55AM BLOOD WBC-3.5* RBC-2.81* Hgb-8.1* Hct-24.6* MCV-88 MCH-28.7 MCHC-32.7 RDW-19.8* Plt ___ ___ 05:55AM BLOOD Glucose-159* UreaN-21* Creat-0.9 Na-138 K-4.1 Cl-109* HCO3-22 AnGap-11 ___ 05:55AM BLOOD Calcium-7.7* Phos-2.7 Mg-2.0 STUDIES: -------- ___ CXR: IMPRESSION: No acute cardiopulmonary abnormality. Brief Hospital Course: ___ PMHx obesity, atrial fibrillation on coumadin, CKD III (baseline 1.4) and chronic multiple myeloma and adenocarcinoma of anal canal (dx'ed ___ presenting for AFib with RVR. ACUTE ISSUES: ------------- # Atrial fibrillation with RVR: Pt presented initially with RVR in the 140s. Most likely in the setting of B-blocker and CCB being held due to hypotension. C. diff infection (see below) most likely contributing to hypotension. Pt received IV metoprolol and IV diltiazem in ED and was started on PO metoprolol/diltiazem on floor. She was also fluid resuscitated. Patient discharged with control of afib with RVR with PO metop and diltiazem at home doses. INR was supratherapeutic and coumadin was held (see below). # Hypotension: Per nursing home, she had intermittent hypotension requiring discontinuation of her metoprolol and diltiazem. Most likely secondary to decreased PO intake/loose stools from C.diff infection. Adrenal insufficiency secondary to chronic steroid use in the setting of infection was ruled out with AM cortisol (30). # Funguria, bacteruria: Pt initially reported dysuria and UA x2 showed large leuks/bacteria/yeast. Despite being contaminated, due to symptoms of dysuria, she was initially treated with IV CTX. Urine cultures eventually grew only yeast, prompting discontinuation of CTX. She was no longer symptomatic at this time, and she had no CVA tenderness or systemic symptoms of infection. She had a foley place initially for urine output monitoring, however, this was removed. Funguria will be treated with fluconazole for total 7 days of therapy. # C.difficile infection: Although no recent history of antibiotics, patient immunosuppressed and at rehabilitation facility. She was initially started on PO metronidazole on ___, but this was changed to PO vanc, given that she is immunosuppresed and falls into the severe category. ___, ___. # Coagulopathy: INR on admission was 6.5. Most likely secondary to decreased PO ntake and exacerbated antibiotics. No active signs of bleeding. Once INR reached 7.8, she was given 2.5 mg PO vitamin K. She received additional 2.5 mg PO vitamin K on ___. Coumadin was held on discharge. # Acute on chronic CKD (stage 3): Cr 1.2 (baseline 0.8-1.1). Most likely secondary to decreased PO intake and decreased cardiac output from afib with RVR. Creatinine improved with IVF. # Lower extremity edema: Multi-factorial. Most likely venous stasis vs diastolic heart failure, especially in the setting of afib with RVR, vs hypoalbuminemia. Pa/lateral film in ED showed no cardiomegaly or pulmonary vascualar congestion to suggest decompensated systolic heart failure. Pt on furosemide at home. Albumin was 3.0. Furosemide held on admission due to ___. Edema was managed with pneumatic boots. Furosemide was restarted at 40 mg on discharge. # UPJ obstruction s/p stent placement ___ c/b persistent Klebsiella bacteruria: Pt scheduled for stent replacement soon. She had no CVA tenderness on exam and creatinine was stable after IVF. Pt was scheduled to have stent replaced on ___, but procedure was cancelled due to supratherapeutic INR. Per Urology, pt's INR needs to be <3.0 and she will need this procedure in the next ___ months. # Troponinemia: Most likely strain from RVR vs decreased clearance in the setting of ___. Peaked at 0.02 before downtrending. # Hyperlactatemia: Lactate 2.6 on admission. Most likely secondary to dehydration versus ineffective cardiac output from RVR. Peaked at 2.6 before downtrending. CHRONIC ISSUES: --------------- # Weakness: She had generalized total body weakness, with the lower extremities worse than upper extremities. Also with the left ___ greater than right ___. No documented previous CVA to which asymmetry can be attributed. Most likely deconditioning and myopathy from dexamethasone, versus myositis or cerebrovascular event, both thought unlikely. CK was within normal limits. ___ worked with patient and she was discharged back to rehab. # Leg pain: Most likely osteoarthritis. She does not have diabetes to suggest neuropathy. She continued home oxycodone 10 mg qHS. # Pancytopenia: Patient with stable neutropenia, anemia, thrombocytopenia improved from prior, thought to be secondary to lenalidomide as well as anemia of chronic disease. # Anal adenocarcinoma: Diagnosed recently in ___. T2N0M0. Staging scans showed local disease without suspicious regional LAD, and no distant mets. Baseline CEA 20. Has plans for colorectal surgeon Dr. ___ diverting ostomy. S/p port placement in ___. Plans for chemo/radiation. Updated oncologist. # Anorectal pain: Her bowel regimen included docusate, colace and miralax, as well as being advised to increase and regulate her fiber intake. She was also given nitroglycerin 0.02% cream, 2% lidocaine ointment, Tuck's ointment and perineum care recommendations from wound care nursing. Bowel regimen was held in the setting of loose stools. # IgG myeloma: Patient with longstanding IgG MM, followed by ___ Oncology for which she is on lenolidamide days ___ of 28 days and dexamethasone 1x/week on weeks when she takes lenolidamide. The patient completed her last 3 weeks of Revlamid ___. Also received Zometa ___. Lenolidamide/dexamethasone was held during admission due to infection. TRANSITIONAL ISSUES: -------------------- - C.diff infection, Severe: Needs PO vancomycin 125mg PO QID until ___ for total 14 day treatment course. - Funguria: Three urine cultures grew >100,000 cfu/ml of yeast. She was started on fluconazole treatment, per her Urologist. D1 = ___, D7 = ___. - Ureteral stent replacement: Was scheduled for replacement on ___, but cancelled due to supratherapeutic INR. Her stent can be replaced when her INR is therapeutic (2.0 - 3.0). When therapeutic, please call her Urologist Dr. ___ to schedule a stent replacement. She will also see him on ___. - Supratherapeutic INR: Will need daily INR checks to follow INR until therapeutic so Coumadin may be restarted. If uptrending x72hours, consider 2.5mg PO vitamin K (in the absence of normal gut flora due to C. diff infection). - Diastolic heart failure: Patient restarted on lower dose of furosemide 40 mg. Uptitrate as necessary based on volume status and kidney function. - Myeloma: Revlamid/dexamethasone held during admission and on discharge. Please call her Oncologist Dr. ___ to discuss restarting on ___. - Rectal adenocarcinoma: Stool softeners should be held until frequency and consistency of BM normalizes. # Emergency Contact/HCP: ___ (son) ___ and ___ (son) ___ # CODE: FULL, confirmed Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Docusate Sodium 100 mg PO BID 2. Polyethylene Glycol 17 g PO DAILY 3. Metamucil (psyllium;<br>psyllium husk;<br>psyllium husk (with sugar);<br>psyllium seed (sugar)) 3.4 gram/12 gram oral Daily 4. Senna 8.6 mg PO BID 5. Diltiazem Extended-Release 120 mg PO DAILY 6. Furosemide 80 mg PO DAILY 7. Metoprolol Tartrate 100 mg PO TID 8. Potassium Chloride 20 mEq PO DAILY 9. Vitamin D 1000 UNIT PO DAILY 10. Lenalidomide 15 mg PO DAILY 11. Dexamethasone 20 mg PO ASDIR 12. Warfarin 3 mg PO DAILY16 Discharge Medications: 1. Diltiazem Extended-Release 120 mg PO DAILY 2. Furosemide 40 mg PO DAILY 3. Metoprolol Tartrate 100 mg PO TID Hold for HR<55 or SBP<90 4. Vitamin D 1000 UNIT PO DAILY 5. Fluconazole 200 mg PO Q24H Duration: 7 Days Last day = ___ 6. Vancomycin Oral Liquid ___ mg PO Q6H Day 14 = ___ 7. Docusate Sodium 100 mg PO BID Hold for loose stools 8. Metamucil (psyllium;<br>psyllium husk;<br>psyllium husk (with sugar);<br>psyllium seed (sugar)) 3.4 gram/12 gram oral Daily Hold for loose stools. 9. Polyethylene Glycol 17 g PO DAILY Hold for loose stools 10. Potassium Chloride 20 mEq PO DAILY 11. Senna 8.6 mg PO BID Hold for loose stools. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary diagnoses: -atrial fibrillation with rapid ventricular response -c.difficile infection, severe Secondary diagnoses: -multiple myeloma -rectal adenocarcinoma -pancytopenia 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 ___, ___ was a pleasure taking care of you at the ___ ___. You were admitted for a fast heart rate. We treated this with intravenous medications, and then restarted your home medications. You were also found to have an infection of your colon called C.difficile. You will need to continue antibiotics by mouth for this. Your INR (measure of how thin your blood is from warfarin) is still elevated. Your rehab will measure this and restart warfarin when appropriate. Please remember to weigh yourself every morning, and speak to your MD if your weight rises by more than 3lbs. On behalf of your ___ team, We wish you a speedy recovery! Followup Instructions: ___

10003400-DS-16

DS

2137-01-03 00:00:00

2137-01-04 22:47:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: ALTERED MENTAL STATUS Major Surgical or Invasive Procedure: NONE History of Present Illness: Ms. ___ is a ___ year-old woman a ___ significant for AFib on coumadin, UPJ obstruction s/p stent placement in ___ c/b chronic Klebsiella bacturia, IgG myeloma on lenolidamide, and recently diagnosed adenocarcinoma of the anal canal who presents with altered mental status. Of note, patient is currently unable to relay any of her medical information (only response to questions is "I don't know"). As such, much of medical information is obtained from medical records. Per ED note, the patient was brought in from ___. Her family reports that that she has had AMS for the last ___ days. to the point that she does not recognize her family members and does not know where she is. Upon arrival to ___ ED, initial VS 97.7 91 111/68 16 100%. Labs notable for Chem-7 wnl, P2.0, LFTS wnl, Alb 2.8, CBC with pancytopenia 2.8>9.1<140, coags with INR 3.6. UA positive with large leuk, neg nitrites, 137 WBC, few bacteria. CXR without cardiopulmonary process. Pateint was administered 500cc LR, ceftriaxone 1g x1. She is now admitted to medicine for further management. Vitals prior to transfer 98 88 140/80 18 100% RA. On the floor, initial VS 97.7 110/57 72 18 98%RA. The patient in lying in bed NAD but her only response to questions are "I don't know." Past Medical History: Hypertension Atrial fibrillation on coumadin Obesity Myeloma Osteoarthritis of right knee UPJ obstruction s/p stent placement ___ c/b persistent Klebsiella bacteruria Anal adenocarcinoma (dx ___ ? Perirectal cyst drainage in 1980s Social History: ___ Family History: Her parents died in their ___ or ___ of "old age." Her parents and multiple siblings have hypertension. Sibling with Alzheimer's disease. No family history of significant arrhythmia or premature coronary disease. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 97.7 110/57 72 18 98%RA GENERAL: Elderly woman, lying in bed, NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM NECK: nontender supple neck, no LAD, no JVD CARDIAC: Irregularly irregular, +S1/S2, no murmurs, gallops, or rubs LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly. Anus with friable mucosa. EXTREMITIES: 2 piting edema up through shins bilaterally, no cyanosis or clubbing PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII and motor grossly intact intact SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAM: Vitals: 99.0 (99.0) 119/71 (100-120/50-80) 85 (60-90) 18 100%RA I/O: 1140/inc Weight: 86.7 kg GENERAL: elderly woman lying in bed in NAD. HEENT: AT/NC, EOMI, PERRL, anicteric sclera CARDIAC: irregularly irregular, +S1/S2, no murmurs LUNG: CTAB, no wheezes, mild crackles, breathing comfortably ABDOMEN: non-distended, +BS, non-tender in all quadrants, no rebound/guarding EXTREMITIES: 2+ piting edema to shins bilaterally NEURO: CN II-XII grossly intact, AA+O X 3. did not know day of the week. uncooperative with other cognitive questions SKIN: warm and well perfused, no rashes Pertinent Results: ADMISSION LABS ============================= ___ 05:30PM WBC-2.8* RBC-3.31* HGB-9.1* HCT-28.6* MCV-87 MCH-27.4 MCHC-31.6 RDW-20.8* ___ 05:30PM NEUTS-71.7* LYMPHS-17.9* MONOS-8.5 EOS-1.6 BASOS-0.2 ___ 05:30PM PLT COUNT-140* ___ 05:30PM ___ PTT-35.1 ___ ___ 05:30PM ALT(SGPT)-16 AST(SGOT)-20 ALK PHOS-83 TOT BILI-0.6 ___ 05:30PM LIPASE-24 ___ 05:30PM GLUCOSE-99 UREA N-6 CREAT-0.6 SODIUM-141 POTASSIUM-3.3 CHLORIDE-104 TOTAL CO2-31 ANION GAP-9 ___ 04:40PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-LG ___ 04:40PM URINE RBC-12* WBC-137* BACTERIA-FEW YEAST-NONE EPI-1 PERTINANT LABS ============================== ___ 05:01AM BLOOD ___ ___ 05:47AM BLOOD ___ PTT-33.4 ___ ___ 05:47AM BLOOD VitB12-471 ___ 05:47AM BLOOD TSH-2.6 DISCHARGE LABS ============================== ___ 05:19AM BLOOD WBC-3.1* RBC-2.90* Hgb-8.1* Hct-25.4* MCV-88 MCH-28.1 MCHC-32.0 RDW-20.5* Plt ___ ___ 05:19AM BLOOD ___ PTT-35.6 ___ ___ 05:19AM BLOOD Glucose-95 UreaN-5* Creat-0.6 Na-142 K-3.6 Cl-108 HCO3-27 AnGap-11 ___ 05:19AM BLOOD Calcium-7.8* Phos-1.8* Mg-1.9 IMAGING ============================== CXR (___): No evidence of acute cardiopulmonary disease. Head CT w/o contrast (___): 1. No acute intracranial abnormality. 2. Please note MRI of the brain is more sensitive for the evaluation of acute infarct. 3. Atrophy and probable small vessel ischemic changes as described. 4. 15 mm right posterior neck probable dermal inclusion cyst as described. Recommend clinical correlation and correlation with direct examination. MICROBIOLOGY ============================== URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. BLOOD CULTURE x 2: NGTD Brief Hospital Course: ___ with AFib on coumadin, UPJ obstruction s/p stent placement in ___ c/b chronic Klebsiella bacturia, IgG myeloma on lenolidamide, and recently diagnosed adenocarcinoma of the anal canal who presents with altered mental status. # Subacute congitive decline: Patient presenting from assisted living facility with several days of progressive AMS. On admission was A+O X 1 without focal deficits but quickly improved to orientation x3. Differential included infectious etiology (ie UTI), mild dementia per family report or subacute hemorrhage given supratherapeutic INRs. NCHCT obtained on ___ and showed no acute intracranial abnormality. Initially covered with ABX for possible to be UTI (see below) but ABX stopped with urine culture unrevealing. TSH and B12 WNL. Given hx of rectal adenocarcinoma, considered potential brain metastasis, however with no localizing symptoms and low burden malignancy so head MRI was deferred. Please arrange neurocognitive work-up to exclude dementia vs depression/pseudodementia as outpatient given mental status largely notable for apathy and pt being withdrawn with relatively good attention and orientation which makes an acute encephalopathy less likely. . # Pyuria: Patient has a history of chronic Klebsiella bacteriuria as a complication of UPJ obstruction s/p stent placement in ___. Seen previously by ID who recommended not treating unless symptoms. Given that she presented with altered mental status, she was started on ceftriaxone. However, urine culture on ___ returned with mixed flora and CTX stopped. . # Anal adenocarcinoma: Diagnosed recently in ___. T2N0M0. Staging scans showed local disease without suspicious regional LAD, and no distant mets. Baseline CEA 20. Has plans for colorectal surgeon Dr. ___ diverting ostomy. Home bowel regimen of metamucil, senna, colace was continued. . # AFib: CHADS = 2. Patient was rate-controlled during hospitalization. INR 3.6 on admission. Home warfarin was held given supratherapeutic INR. Rate-control agents with home diltiazem and metoprolol was also continued. Warfarin restarted at lower dose on ___. . # Hypertension: Normotensive. Home BB/CCB and furosemide were continued. . # CKD Stage 3: Baseline Cr 0.8-1.1, currently 0.6. . # IgG Myeloma: Patient with longstanding IgG MM, followed by ___ Oncology. . TRANSITIONAL ISSUES: ======================== -will benefit from neurocognitive evaluation to further elucidate possibility of dementia -would also assess for pseudodementia/depression with psychiatry evaluation -will need to discuss with outpatient oncologist re: Revalmid therapy -pt requires motivation from staff for participation in ___ activities. Please promote OOB to chair for all meals and encourage PO intake. -f/u with colorectal surgeon (Dr. ___ for mgmt of anal adenocarcinoma -full code -contact ___ (son) ___ and ___ (son) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Diltiazem Extended-Release 120 mg PO DAILY 2. Furosemide 40 mg PO DAILY 3. Metoprolol Tartrate 100 mg PO TID 4. Vitamin D 1000 UNIT PO DAILY 5. Docusate Sodium 100 mg PO BID 6. Metamucil (psyllium;<br>psyllium husk;<br>psyllium husk (with sugar);<br>psyllium seed (sugar)) 3.4 gram/12 gram oral Daily 7. Polyethylene Glycol 17 g PO DAILY 8. Potassium Chloride 20 mEq PO DAILY 9. Senna 8.6 mg PO BID Discharge Medications: 1. Diltiazem Extended-Release 120 mg PO DAILY 2. Docusate Sodium 100 mg PO BID 3. Furosemide 40 mg PO DAILY 4. Metamucil (psyllium;<br>psyllium husk;<br>psyllium husk (with sugar);<br>psyllium seed (sugar)) 3.4 gram/12 gram oral Daily 5. Metoprolol Tartrate 100 mg PO TID Hold for HR<55 or SBP<90 6. Polyethylene Glycol 17 g PO DAILY 7. Senna 8.6 mg PO BID 8. Vitamin D 1000 UNIT PO DAILY 9. Warfarin 1 mg PO DAILY16 10. Potassium Chloride 20 mEq PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary Diagnosis: Subacute Encephalopathy Secondary Diagnosis: Atrial Fibrillation, Anal Adenocarcinoma, Hypertension, CKD Stage 3 Discharge Condition: Mental Status: Clear and Coherent. Level of Consciousness: Alert and interactive - usually. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you at ___. You were admitted for confusion. You were initially put on antibiotics, but your urine culture did not how infection and these medications were stopped. Other tests including blood tests and a CAT scan of your brain were reassuring. Your mental status remained at baseline throughout your hospitalization and you will need further testing as an outpatient to further define your cognition. Please follow-up with the appointments listed below and take your medications as instructed below. Best wishes, Your ___ Team Followup Instructions: ___

10003502-DS-9

DS

2169-08-28 00:00:00

2169-08-29 15:43:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: nifedipine / Amitriptyline / Prilosec OTC / Terazosin / Amlodipine / Atenolol / Oxybutynin / Hydrochlorothiazide / spironolactone / furosemide Attending: ___. Chief Complaint: Fall, bradycardia. Major Surgical or Invasive Procedure: None. History of Present Illness: ___ YO F w/ PMH significant for CAD, mild AS, afib/flutter on dabigatran, HFpEF, HTN, HLD, chronic hyponatremia, who presents after a fall at her nursing home. Pt unable to provide history, but per nursing home and OSH notes, in early AM on ___, pt fell and was discovered by nursing home RN. RN at that time noted that pt was confused and lethargic. HR at that time per report was in the ___. EMS was activated and pt brought to OSH ER. En route, EMS report indicates that heart rates were labile, but there are no EKG strips and unclear if pt received any cardiac medications. At OSH ER, pt's EKG revealed bradycardia to 20 with ventricular escape and no signs of atrial activity. The pt was then given 1 mg of atropine with no effect and then transcutaneously paced for 1 hour. She was then noted to have HRs in the ___ and atrial activity. She was then transferred to ___ for possible PPM. Here at ___, noted to be intermittently lethargic and poorly responsive. CT head and neck negative. EP was consulted for possible PPM and initially recommended admission to ___, deferred PPM for the time being. She continued to be intermittently bradycardic to the ___ in the ED, but given that she has a history of previous bradycardia and has been asymptomatic with her episodes, she was felt to be stable for the floor. However, after this she had increasing respiratory distress requiring a NRB. Due to this she was admitted to the CCU. Received Lasix 60mg IV x1. Of note, pt's HCP reports that she had been more altered over the last week in the setting of higher doses of seroquel that the nursing home had started for increased agitation. In the ED initial vitals were: 98.3, HR 90, 142/73, 18, 93% RA EKG: Labs/studies notable for: Na 140, K 4.6, Cl 98 HCO3 35 BUN 58 Cr 1.2 glu 125, WBC 7 Hct 34.8 AST 219 ALT 178 Trop 0.05 ___: 14.8 PTT: 42.4 INR: 1.4 AGap=12 BNP 2900 Lactate 1.5. ABG: ___ On arrival to the CCU: Awake but not answering questions. Pt does not speak ___, per report. On NRB. Past Medical History: 1. CARDIAC RISK FACTORS - Hypertension - Dyslipidemia 2. CARDIAC HISTORY - CAD (100% LAD occlusion). MI ___ year ago. Unclear history of PCI. - Afib/flutter on dabigatran - Mild aortic stenosis 3. OTHER PAST MEDICAL HISTORY - Chronic hyponatremia - Dementia Social History: ___ Family History: Mother deceased at ___ yo from breast cancer. Father deceased at ___ yo. Son deceased at ___ yo from heart attack. Physical Exam: ADMISSION PHYSICAL EXAM: VS: T 97.6 BP 132/103 HR 80 RR 21 O2 SAT 100% NRB GENERAL: Ill appearing. Not answering questions. HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. Conjunctiva were pink. No pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple. JVP unable to assess due to restlessness. CARDIAC: PMI located in ___ intercostal space, midclavicular line. Irregularly irregular. Normal S1, S2. II/VI systolic murmur at R sternal border. LUNGS: No chest wall deformities or tenderness. Tachypneic but withoug increased work of breathing. Faint crackles. ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No splenomegaly. EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. SKIN: No significant skin lesions or rashes. PULSES: Distal pulses palpable and symmetric. DISCHARGE PHYSICAL VS: T 97.6 BP 144/75 HR 54 RR 22 O2 SAT 92% 2 L NC GENERAL: Skinny, somewhat anxious. Oriented to self only. HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. Conjunctiva were pink. No pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple. JVP unable to assess due to restlessness. CARDIAC: PMI located in ___ intercostal space, midclavicular line. Irregularly irregular. Normal S1, S2. II/VI systolic murmur at R sternal border. LUNGS: No chest wall deformities or tenderness. Tachypneic no signs respiratory distress. Lungs clear to auscultation bilaterally. ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No splenomegaly. EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. SKIN: No significant skin lesions or rashes. PULSES: Distal pulses palpable and symmetric. Pertinent Results: ADMISSION LABS: ___ 12:45PM BLOOD WBC-10.0 RBC-3.55* Hgb-10.5* Hct-34.8 MCV-98 MCH-29.6 MCHC-30.2* RDW-13.1 RDWSD-46.9* Plt ___ ___ 12:45PM BLOOD Neuts-87.3* Lymphs-5.0* Monos-7.0 Eos-0.0* Baso-0.2 Im ___ AbsNeut-8.76* AbsLymp-0.50* AbsMono-0.70 AbsEos-0.00* AbsBaso-0.02 ___ 12:45PM BLOOD ___ PTT-42.4* ___ ___ 12:45PM BLOOD Glucose-125* UreaN-58* Creat-1.2* Na-140 K-4.6 Cl-98 HCO3-35* AnGap-12 ___ 12:45PM BLOOD proBNP-2915* ___ 12:45PM BLOOD cTropnT-0.05* ___ 05:51AM BLOOD CK-MB-9 cTropnT-0.13* ___ 05:51AM BLOOD Calcium-10.1 Phos-4.6* Mg-2.5 ___ 08:10PM BLOOD ___ pO2-23* pCO2-79* pH-7.29* calTCO2-40* Base XS-6 ___ 12:52PM BLOOD Lactate-1.5 PERTINENT RESULTS: ___ 12:45PM BLOOD cTropnT-0.05* ___ 05:51AM BLOOD CK-MB-9 cTropnT-0.13* ___ 12:52PM BLOOD Lactate-1.5 ___ 11:47PM BLOOD Lactate-1.0 ___ 06:04AM BLOOD Lactate-2.9* DISCHARGE LABS: ___ 05:51AM BLOOD WBC-7.8 RBC-3.90 Hgb-11.3 Hct-37.7 MCV-97 MCH-29.0 MCHC-30.0* RDW-13.2 RDWSD-46.2 Plt ___ ___ 05:51AM BLOOD ___ PTT-36.7* ___ ___ 05:51AM BLOOD Glucose-89 UreaN-56* Creat-1.2* Na-141 K-4.1 Cl-97 HCO3-31 AnGap-17 ___ 05:51AM BLOOD CK-MB-9 cTropnT-0.13* IMAGING: CHEST XRAY ___: Large right and moderate left pleural effusions and severe bibasilar atelectasis are unchanged. Cardiac silhouette is obscured. No pneumothorax. Pulmonary edema is mild, obscured radiographically by overlying abnormalities. MICROBIOLOGY: None. Brief Hospital Course: Ms. ___ is ___ year old female with a past medical history significant for CAD, mild AS, afib/flutter on dabigatran, HTN, HLD, chronic hyponatremia, who presented to ___ on transfer from OSH after a fall and headstrike when subsequently found to be bradycardic to the ___. She was transferred here externally paced and was seen by our EP physicians. After discussion with patient's healthcare proxy, it was decided not to purse pacemaker placement and to withdraw external pacemaker. She initially became profoundly bradycardic from ___ beats per minute but stabilized to the ___ overnight. She was made DNR/DNI/DNH and sent back to senior living facility hemodynamically stable. Of note CT head at outside facility was negative. TRANSITIONAL ISSUES ==================== - Per discussion with patient's sister, ___, patient was made DNH in addition to her DNR/DNI. She will need a new MOLST signed by her sister and the doctors at ___ ___ - She will also need a palliative care consult with possible escalation to hospice care as needed. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Artificial Tears ___ DROP BOTH EYES BID 2. Aspirin 81 mg PO DAILY 3. Dabigatran Etexilate 75 mg PO BID 4. Vitamin D ___ UNIT PO EVERY 3 WEEKS 5. Escitalopram Oxalate 15 mg PO DAILY 6. Losartan Potassium 37.5 mg PO DAILY 7. QUEtiapine Fumarate 12.5 mg PO QHS 8. Senna 17.2 mg PO QHS 9. Sodium Chloride Nasal ___ SPRY NU BID:PRN congestion 10. Torsemide 60 mg PO DAILY 11. OxyCODONE (Immediate Release) 2.5 mg PO QAM 12. LORazepam 0.5 mg PO Q6H:PRN anxiety 13. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Artificial Tears ___ DROP BOTH EYES BID 3. Dabigatran Etexilate 75 mg PO BID 4. Escitalopram Oxalate 15 mg PO DAILY 5. LORazepam 0.5 mg PO Q6H:PRN anxiety 6. Losartan Potassium 37.5 mg PO DAILY 7. OxyCODONE (Immediate Release) 2.5 mg PO QAM 8. QUEtiapine Fumarate 12.5 mg PO QHS 9. Senna 17.2 mg PO QHS 10. Sodium Chloride Nasal ___ SPRY NU BID:PRN congestion 11. Torsemide 60 mg PO DAILY 12. Vitamin D ___ UNIT PO EVERY 3 WEEKS Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Bradycardia 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 a pleasure taking care of you at ___. Why was I here? - You originally went to another hospital because you fell and hit your head. - You were found to have a very slow heart rate and transferred here to ___ for further management What was done while I was in the hospital? - A CT scan of your head and neck at the outside hospital was done and was normal. - You were transferred here with an external pacemaker to bring your heart rate up but we eventually decided to withdraw this device. - You were seen by our electrophysiologists, who did not decided to put in a pacemaker at this time. What should I do when I get home? - Take your old medications as prescribed. All the best, Your ___ team Followup Instructions: ___

10003637-DS-18

DS

2146-01-26 00:00:00

2146-01-26 15:18:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: lisinopril Attending: ___. Chief Complaint: perianal fistula and abscess Major Surgical or Invasive Procedure: Examination under anesthesia, incision and drainage of abscess, placement of Malecot drain History of Present Illness: ___ with PMH significant for fistula in ano with rectal abscess s/p 3 OR drainages, CAD, CHF, hx of stroke and ___ s/p CABG & pacemaker who presents with rectal pain. The patient states that he has been having worsening rectal pain for the past week. Patient first noticed pain on ___ and described as mild. He did his typical routine of warm shower which in the past has worked for rectal pain with mild abscess. On ___ he was admitted to ___ with cough c/w pulmonary edema and was treated with lasix. He was discharged on ___ with continuing worsening rectal pain. On presentation, he describes his pain as ___, with warm baths helping the pain. He had taken no medications to improve his pain. He felt a palpable mass on his inner right buttock and feels it has gotten larger. He had been bedridden with pain for several days. His last bowel movement was the morning of presentation. His last urine output was also that morning. He endorsed trouble passing stool and urine since this morning (even if he were to try he is unable). He endorsed that all 3 times he has required OR intervention, he has had these same set of symptoms. He denied fever, chills, abdominal pain, nausea, vomitting, diarrhea, constipation, bloody bowel movements, or blood from his rectal mass. In the ED, his temp max was 99.5. Lactate is 2.1. WBC 15.8 and H/H is 10.3/32.3. Past Medical History: Illness: HTN, HLD, CAD c/b MI s/p PCI/stent (___), Hx perirectal abscess s/p I&D (___) ___: I&D perirectal abscess (___), EUA, ___ placement (___) Medications: ASA 81', metoprolol succinate ER 25' Allergies: NKDA Social History: ___ Family History: Noncontributory Physical Exam: Discharge PE: VS: AVSS Gen: well appearing male, NAD HEENT: no lymphadenopathy, moist mucous membranes Lungs: CTAB Heart: rrr Abd: soft, nt, nd Incisions: cdi Extremities: wwp Pertinent Results: ___ 11:43PM ___ PTT-32.4 ___ ___ 05:30PM URINE HOURS-RANDOM ___ 05:30PM URINE GR HOLD-HOLD ___ 05:30PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 05:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 05:30PM URINE RBC-0 WBC-1 BACTERIA-NONE YEAST-NONE EPI-0 ___ 05:30PM URINE HYALINE-1* ___ 05:30PM URINE MUCOUS-RARE ___ 01:02PM LACTATE-2.1* ___ 11:30AM GLUCOSE-103* UREA N-37* CREAT-1.6* SODIUM-135 POTASSIUM-4.1 CHLORIDE-96 TOTAL CO2-22 ANION GAP-21* ___ 11:30AM estGFR-Using this ___ 11:30AM WBC-15.8*# RBC-3.37* HGB-10.3* HCT-32.3* MCV-96 MCH-30.6 MCHC-31.9* RDW-14.7 RDWSD-52.4* ___ 11:30AM NEUTS-78.2* LYMPHS-9.6* MONOS-11.3 EOS-0.3* BASOS-0.2 IM ___ AbsNeut-12.33* AbsLymp-1.51 AbsMono-1.79* AbsEos-0.05 AbsBaso-0.03 ___ 11:30AM PLT COUNT-183 Brief Hospital Course: Patient was taken to the OR on ___ for an examination under anesthesia, drainage of abscess, and placement of Malecot drain for perianal fistula and abscess. He tolerated the procedure well and was transferred to the floor with no issue. Neuro: Pain was well controlled on oxycodone 5 mg q6 hours. CV: Vital signs were routinely monitored during the patient's length of stay. Pulm: The patient was encouraged to ambulate, sit and get out of bed, use the incentive spirometer, and had oxygen saturation levels monitored as indicated. GI: The patient was initially kept NPO after the procedure. The patient was later advanced to and tolerated a regular diet at time of discharge. GU: Patient had a Foley catheter that was removed at time of discharge. Urine output was monitored as indicated. At time of discharge, the patient was voiding without difficulty. ID: The patient's vital signs were monitored for signs of infection and fever. The patient was started on/continued on antibiotics as indicated. Heme: The patient had blood levels checked post operatively during the hospital course to monitor for signs of bleeding. The patient had vital signs, including heart rate and blood pressure, monitored throughout the hospital stay. On ___, 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 the clinic in ___ weeks. This information was communicated to the patient directly prior to discharge. Medications on Admission: ATORVASTATIN - atorvastatin 80 mg tablet. 1 tablet(s) by mouth once a day CARVEDILOL - carvedilol 12.5 mg tablet. 1 tablet(s) by mouth twice a day - (Prescribed by Other Provider) DIGOXIN - digoxin 125 mcg tablet. 1 tablet(s) by mouth daily - (Prescribed by Other Provider) LOSARTAN - losartan 25 mg tablet. 1 tablet(s) by mouth daily - (Prescribed by Other Provider) SPIRONOLACTONE - spironolactone 25 mg tablet. 1 tablet(s) by mouth daily - (Prescribed by Other Provider) TORSEMIDE - torsemide 20 mg tablet. 2 tablet(s) by mouth daily - (Prescribed by Other Provider) WARFARIN [COUMADIN] - Coumadin 5 mg tablet. 1 tablet(s) by mouth daily x 5 days per week, 3mg on M and F - (Prescribed by Other Provider) Medications - OTC ASPIRIN [ASPIR-81] - Aspir-81 81 mg tablet,delayed release. 1 tablet(s) by mouth once a day - (Prescribed by Other Provider) IRON - Dosage uncertain - (Prescribed by Other Provider) (Not Taking as Prescribed) Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. sodium chloride 0.9 % 0.9 % mallencot drain irrigation BID RX *sodium chloride [Saline Wound Wash] 0.9 % please irrigate rectal mallenot drain with 60cc of sterile normal saline twice a day Refills:*3 3. Tamsulosin 0.4 mg PO QHS please take for 10 days RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*10 Capsule Refills:*0 4. Atorvastatin 80 mg PO QPM 5. Carvedilol 12.5 mg PO BID 6. Digoxin 0.125 mg PO DAILY 7. Losartan Potassium 25 mg PO DAILY 8. Spironolactone 25 mg PO DAILY 9. Torsemide 20 mg PO DAILY 10. Warfarin 6 mg PO 1X/WEEK (FR) 11. Warfarin 4 mg PO 6X/WEEK (___) Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Perianal fistula and abscess Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to the ___ on ___ for a perianal fistula with abscess. You underwent an examination under anesthesia with incision and drainage and placement of a drain. You have recovered from the procedure well and are ready to return home. You were seen by cardiology while you were here prior to your surgery. They recommended that you have close follow up with your cardiologist once you are discharged from the hospital. You required diuresis with Lasix several times during your hospital stay with good improvement in your shortness of breath. Please ensure that you make an appointment with both your PCP and your cardiologist once you are discharged for management of your diuretic regimen. The drain placed in your abscess site should remain until you follow up with Dr. ___ in his clinic. You will receive ___ to help you flush the drain twice daily. Followup Instructions: ___

10003637-DS-19

DS

2146-02-19 00:00:00

2146-02-21 02:29:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: lisinopril Attending: ___. Chief Complaint: Hypotension Major Surgical or Invasive Procedure: None History of Present Illness: ___ hx of ischemic cardiomyopathy sent from ___ clinic when his BP was noted to be systolic ___. Patient reports that at 9am his vision was a little blurry and he felt diffusely weak and tired, the subjective feelings completely resolved prior to admission. He states he had been taking his blood pressure medication regularly and drinking only about one small bottle of water daily. He reports over the last year his blood pressure has been regularly with systolic in the ___. He denies fevers or recent illness. Had perirectal abscess drained in ___, site looked well at evaluation today in clinic. No chest pain, palpitations, or cough. No abd pain/n/v/d/urinary symptoms. In the ED, initial vitals were: HR 82 BP79/42 RR16 SaO298% RA Exam notable for Labs notable for BNP 5890, Cr 2.8, WBC 13.4 Imaging notable for ___ CXR: No acute cardiopulmonary abnormality. Patient was given: 500 cc IVF Decision was made to admit for hypotension and ___ Vitals prior to transfer: HR 73 BP101/57 RR20 SaO2 100% RA On the floor, Patient was resting comfortably in bed and asymptomatic. ROS: (+) Per HPI (-) Denies fever, chills, night sweats. 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: *Cards: HTN, HLD, CAD c/b MI s/p PCI/stent and CABG, CHF with reduced EF (LVEF 27%), Single lead ICD pacemaker *Neuro: L MCA ischemic stroke *GI: Perirectal abscess s/p I&D (___), Anal fistula, s/p EUA, ___ placement Social History: ___ Family History: Noncontributory Physical Exam: ADMISSION EXAM: Vital Signs: T97.9 PO, BP97/50, HR60 RR16 SaO2: 100% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation DISCHARGE EXAM: Vital Signs: Tmax 98.2 T97.4 BP 102/67 HR 71 RR 18 O2 100%RA General: No acute distress HEENT: Sclera anicteric, conjunctiva without injection. PERRLA. Oropharynx clear with MMM. Neck supple, no JVP elevation. Lungs: Clear to auscultation bilaterally with no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops. Left-sided AICD. Abdomen: Soft, non-tender, non-distended. Bowel sounds present with no renal bruits. No rebound tenderness or guarding, no organomegaly, no pulsatile mass. Ext: Warm, well perfused with no cyanosis of the toes or fingers. No calf tenderness or edema. Skin: Without rashes or lesions on gross exam. Tattoos over the forearm bilaterally. Neuro: Alert and oriented. Face symmetric. Speech is fluent and logical with no evidence of dysarthria. Moves all extremities purposefully. Pertinent Results: ADMISSION LABS: ___ 02:05PM WBC-13.4*# RBC-4.11*# HGB-12.1*# HCT-35.6*# MCV-87 MCH-29.4 MCHC-34.0 RDW-14.0 RDWSD-43.9 ___ 02:05PM NEUTS-72.3* LYMPHS-13.0* MONOS-12.7 EOS-1.2 BASOS-0.4 IM ___ AbsNeut-9.68* AbsLymp-1.74 AbsMono-1.70* AbsEos-0.16 AbsBaso-0.05 ___ 02:05PM PLT COUNT-223 ___ 02:21PM ___ PTT-34.1 ___ ___ 02:05PM GLUCOSE-143* UREA N-78* CREAT-2.8*# SODIUM-133 POTASSIUM-3.7 CHLORIDE-89* TOTAL CO2-23 ANION GAP-25* ___ 02:05PM CALCIUM-10.4* PHOSPHATE-4.6* MAGNESIUM-2.4 ___ 02:05PM CK(CPK)-59 ___ 02:05PM cTropnT-0.04* ___ 02:05PM CK-MB-2 proBNP-5890* ___ 07:30PM URINE HOURS-RANDOM ___ 07:30PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 07:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG ___ 07:30PM URINE RBC-<1 WBC-2 BACTERIA-FEW YEAST-NONE EPI-0 ___:30PM URINE MUCOUS-RARE ___ 07:30PM URINE HYALINE-13* DISCHARGE LABS: ___ 07:35AM BLOOD WBC-7.7 RBC-3.84* Hgb-11.3* Hct-33.8* MCV-88 MCH-29.4 MCHC-33.4 RDW-14.1 RDWSD-44.8 Plt ___ ___ 07:35AM BLOOD Plt ___ ___ 07:35AM BLOOD ___ PTT-34.7 ___ ___ 07:35AM BLOOD Glucose-105* UreaN-91* Creat-2.6* Na-134 K-3.5 Cl-91* HCO3-25 AnGap-22* ___ 03:14PM BLOOD Glucose-96 UreaN-84* Creat-1.8* Na-134 K-3.4 Cl-95* HCO3-22 AnGap-20 ___ 07:35AM BLOOD CK-MB-4 cTropnT-0.03* ___ 07:35AM BLOOD Calcium-9.6 Phos-5.1* Mg-2.6 ___ 03:14PM BLOOD Digoxin-0.2* DIAGNOSTICS: ECHO (CHA ___ CONCLUSIONS 1. LV ejection fraction is 27%. 2. The apical portion of the anterior wall and the LV apex are akinetic. 3. The left atrium is mildly dilated. 4. There is mild-to-moderate mitral regurgitation. 5. Estimated RV systolic pressure is moderately elevated at 55 mmHg. 6. Compared to the previous echo of ___, there is no significant change. CXR ___ FINDINGS: Patient is status post median sternotomy and CABG. Left-sided AICD is noted with single lead terminating in the right ventricle. Heart size is normal. Mediastinal and hilar contours are normal. Lungs are clear. No pleural effusion or pneumothorax. No acute osseous abnormalities are detected. IMPRESSION: No acute cardiopulmonary abnormality. Brief Hospital Course: ___ M with h/o ischemic cardiomyopathy (s/p PCI/stent, CABG, ICD pacemaker) c/b systolic CHF (LVEF 27%), L MCA stroke, and perirectal abscess who presents with hypotension and new ___ in the setting fluid restriction while taking multiple diuretics and anti-hypertensives. #Hypotension: Pt presented with a baseline SBP in ___ over past year, was fluid restricting given history of pulmonary edema, presented with SBP in 60-70s in ED. After 500cc fluid bolus, SBP returned to baseline and pt was asymptomatic. Patient was not orthostatic. Bolused additional 1L NS. Hypotension seemed likely attributable to self fluid restriction in the setting of multiple diuretic and anti-hypertensive medications. Losartan, Spironolactone, Carvedilol and Torsemide were held on discharge. Patient was instructed to schedule primary care to have follow-up of his laboratory values. ___: Rise in pt's Cr to 2.8 from baseline of 1.1 with associated BUN/Cr >20. UA was unremarkable. Pt was maintaining UOP, w/ no history to suggest post-renal obstruction. Elevated pro-BNP suggestive of ventricular overload c/w history of ischemic cardiomyopathy, possible cardiorenal contribution to ___. Overall findings were pre-renal ___, likely ___ decreased effective circulating volume in the setting of hypotension and fluid restriction in pt with underlying ischemic cardiomyopathy. He responded well to 1.5L IVFs, with a creatinine of 1.8 at time of discharge. He was instructed to improve his PO intake to 1.5L per day (has hx of CHF exacerbations). Antihypertensives were held at time of discharge. #Hyperphosphatemia: Phos to 5.1 on ___. Likely ___ renal insufficiency. He was given a low phosphate diet for one day. #Normocytic Anemia: H/H down to 11.3/33.8 on ___ AM. Had low suspicion for hemolysis or acute blood loss. Was thought to be likely dilutional after fluids and was consistent with pt's normal range. RESOLVED ISSUES: #Leukocytosis: Patient presented with transient leukocytosis, which downtrended to wnl ___ AM, likely ___ acute stress reaction. CXR/UA was not concerning for infection. Further infectious workup was not pursued. CHRONIC ISSUES: #Ischemic Cardiomyopathy: s/p L ICD placement. No evidence of volume overload on exam ___. Losartan, Spironolactone, Torsemide, Carvedilol in were held in the setting of hypotension and ___, and also held on discharge. #Hypertension: Losartan, Spironolactone, Torsemide, Carvedilol were held as above. #Hyperlipidemia: atorvastatin was continued without issue. #History of MCA stroke: continued home warfarin without issue. TRANSITIONAL ISSUES: -patient was instructed to drink 1.5 L of fluid per day -patient's home antihypertensives were held at time of discharge. -patient was instructed to follow-up with his PCP within one week -patient may benefit from a repeat Na, K, Cl, bicarb, BUN, Cr at time of follow-up -consideration of when to restart home antihypertensives can be considered at follow-up. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Warfarin 4 mg PO DAILY16 3. Atorvastatin 80 mg PO QPM 4. Carvedilol 12.5 mg PO BID 5. Digoxin 0.125 mg PO DAILY 6. Ferrous Sulfate uncertain mg PO DAILY 7. Losartan Potassium 25 mg PO DAILY 8. Spironolactone 25 mg PO DAILY 9. Torsemide 20 mg PO BID Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO QPM 3. Digoxin 0.125 mg PO DAILY 4. Ferrous Sulfate uncertain mg PO DAILY 5. Warfarin 4 mg PO DAILY16 6. HELD- Carvedilol 12.5 mg PO BID This medication was held. Do not restart Carvedilol until following up with your primary care doctor 7. HELD- Losartan Potassium 25 mg PO DAILY This medication was held. Do not restart Losartan Potassium until following up with your primary care doctor 8. HELD- Spironolactone 25 mg PO DAILY This medication was held. Do not restart Spironolactone until following up with your primary care doctor 9. HELD- Torsemide 20 mg PO BID This medication was held. Do not restart Torsemide until following up with your primary care doctor Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS ------------------- Hypotension ___ Secondary Diagnosis Congestive Heart Failure 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 when it was discovered that you had low blood pressures and evidence of kidney injury after having reduced fluid intake while still taking your antihypertensives. You were evaluated with bloodwork and imaging, and given intravenous fluids. Your blood pressure medications were held and we have not restarted these on discharge from the hospital. Please follow-up with your primary care doctor with ___ visit in the next week before resuming your home antihypertensives. Please continue to drink 1.5L of fluids per day. It was a pleasure to be involved with your care! -___ Team Followup Instructions: ___

10003731-DS-2

DS

2146-11-19 00:00:00

2146-12-04 16:13:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Bactrim / Doxycycline / Sulfa(Sulfonamide Antibiotics) Attending: ___. Chief Complaint: cellulitis Major Surgical or Invasive Procedure: needle aspiration of subcutaneous hematoma History of Present Illness: ___ with A. fib on rivaroxaban, hypertension, and venous stasis presents with 7 days of increasing erythema on the left leg. One week ago, patient was walking down stairs and struck her left shin on a metal plant holder. Two days ago she noticed some erythema in her lower left leg and went to an urgent care and was placed on clindamycin. Over the last couple days the erythema had increased and she was seen by her PCP on ___ and again on ___. At that time, erythema was noted to expand beyond the marked edges, and she was advised to be admitted for IV antibiotics, but she declined. On the day of presentation, patient's erythema extended even further which prompted her to come to the emergency department. Patient denies any fevers, chest pain, shortness of breath, nausea or vomiting. There has not been any purulent drainage from the leg. In the ED intial vitals were: T 98.3 HR 88 BP 157/86 RR 16 Sat 99%. Labs were significant for lactate of 2, K of 3.4, Cr 1.1, BUN 21, INR 1.3, PTT 40. Patient was given tylenol and IV vancomycin 1 gram x1. Blood cultured were drawn and pending. On the floor, patient states that her leg pain is improved and she has no other acute complaints at this time. Review of Systems: (+) per HPI. 10-point ROS conducted and otherwise negative. Past Medical History: venous insufficiency in lower extremities Paroxysmal a-fib on rivaroxaban for anticoagulation CKD w/ baseline creatinine 1.2 - eGFR 45-50 HTN obesity Depression GERD HSV rosacea sleep disorder PCOS H. pylori by EGD biopsy in ___ Social History: ___ Family History: Sister: DVTs Father: a-fib. CVA Mother: vascular disease Physical Exam: On Admission: Vitals - 98.2 160/80 76 18 97%RA GENERAL: NAD. Well-appearing. Very pleasant. HEENT: AT/NC, EOMI, PERRL CARDIAC: irregularly irregular rhythma, ___ SEM heard best at LUSB LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, nontender in all quadrants, obese PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact. No focal deficits SKIN: Large area of erythema extending across left anterior shin and ___ surface of left foot. Area of erythema is extending beyond previously marked lines. This area is warm to touch and tender to palpation. No areas of fluctuance or purulence. No calf tenderness. Right leg w/o any significant skin changes. On Discharge: 97.5 142/84 70 18 100%RA GENERAL: NAD. Well-appearing. HEENT: AT/NC CARDIAC: rrr, no murmurs LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, nontender in all quadrants, obese PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact. No focal deficits SKIN: erythema improving w/in pen marks. Small fluid collection ant shin Pertinent Results: On Admission: ___ 08:40AM GLUCOSE-102* UREA N-15 CREAT-0.9 SODIUM-144 POTASSIUM-3.6 CHLORIDE-101 TOTAL CO2-32 ANION GAP-15 ___ 08:40AM WBC-6.8 RBC-4.48 HGB-14.2 HCT-42.0 MCV-94 MCH-31.6 MCHC-33.7 RDW-12.4 ___ 08:40AM PLT COUNT-279 ___ 08:40AM ___ PTT-38.4* ___ ___ 09:00PM LACTATE-2.0 ___ 08:46PM GLUCOSE-133* UREA N-21* CREAT-1.1 SODIUM-140 POTASSIUM-3.4 CHLORIDE-99 TOTAL CO2-31 ANION GAP-13 ___ 08:46PM WBC-8.7 RBC-4.51 HGB-14.1 HCT-43.6 MCV-97 MCH-31.2 MCHC-32.3 RDW-13.0 ___ 08:46PM NEUTS-69.8 ___ MONOS-4.7 EOS-1.6 BASOS-1.2 ___ 08:46PM PLT COUNT-317 ___ 08:46PM ___ PTT-40.0* ___ On Discharge: ___ 08:15AM BLOOD WBC-5.6 RBC-4.40 Hgb-14.4 Hct-42.3 MCV-96 MCH-32.6* MCHC-34.0 RDW-12.6 Plt ___ ___ 08:15AM BLOOD Glucose-114* UreaN-13 Creat-0.8 Na-143 K-4.1 Cl-106 HCO3-27 AnGap-14 Imaging: lower extremity ultrasound ___: 1. No evidence of deep venous thrombosis in the left lower extremity veins. 2. Subcutaneous edema in the area of redness in the mid to distal left shin. Microbiology: Left Shin Fluid Aspiration ___ 1:57 pm SWAB Source: left shin ABSCESS. **FINAL REPORT ___ GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. WOUND CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Final ___: NO GROWTH. Blood Culture ___ x 2: no growth Brief Hospital Course: Ms. ___ is a ___ year old woman with A. fib on rivaroxaban, hypertension, and venous stasis who presented with left leg cellulitis that had not improved on PO clindamycin, admitted for IV antibiotics. ACTIVE ISSUE: # Cellulitis: She presented with a large area of erythema extending across her left anterior shin and ___ surface of left foot. The area of erythema extended beyond previously marked lines. It was warm to the touch and tender to palpation. She had one area of fluctuance noted on her anterior shin which was aspirated and found to be a hematoma; fluid culture of the aspirated fluid was negative for growth. DVT was ruled out with ultrasound. She was treated with vancomycin and her symptoms and erythema improved. Given her multiple medication allergies and previous failure on clindamycin, she was discharged on linezolid to complete treatment of her cellulitis outpatient. CHRONIC/INACTIVE ISSUES: # Paroxysmal Afib: continued metoprolol and rivaroxaban. Rate controlled. # HTN: continued home losartan, metoprolol, and HCTZ # Depression/sleep disorder: continued aderral, lamotrigine and risperidone TRANSITIONAL ISSUES: - Code: Full (confirmed with patient) - Emergency Contact: HCP ___ (friend) ___. Alternative: ___ (brother) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Adderall XR (dextroamphetamine-amphetamine) 40 mg oral daily 2. Hydrochlorothiazide 25 mg PO DAILY 3. LaMOTrigine 300 mg PO HS 4. Losartan Potassium 50 mg PO DAILY 5. Metoprolol Tartrate 25 mg PO BID 6. Rivaroxaban 20 mg PO DAILY 7. Acetaminophen 325-650 mg PO Q6H:PRN pain 8. Multivitamins 1 TAB PO DAILY 9. Docusate Sodium 100 mg PO BID Discharge Medications: 1. Linezolid ___ mg PO Q12H Duration: 10 Days RX *linezolid [Zyvox] 600 mg 1 tablet(s) by mouth twice a day Disp #*20 Tablet Refills:*0 2. Acetaminophen 325-650 mg PO Q6H:PRN pain 3. Docusate Sodium 100 mg PO BID 4. Hydrochlorothiazide 25 mg PO DAILY 5. LaMOTrigine 300 mg PO HS 6. Losartan Potassium 50 mg PO DAILY 7. Metoprolol Tartrate 25 mg PO BID 8. Multivitamins 1 TAB PO DAILY 9. Rivaroxaban 20 mg PO DAILY 10. Adderall XR (dextroamphetamine-amphetamine) 40 mg ORAL DAILY Discharge Disposition: Home Discharge Diagnosis: 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 meeting you during your hospitalization at ___. You were admitted with cellulitis for IV antibiotics. Your infection improved with IV vancomycin. You will be discharged on linezolid to continue to treat the infection. While taking this antibiotic, you will need to follow a low tyramine diet. Please take your medication as prescribed and follow up with your doctor. Sincerely, Your ___ Team Followup Instructions: ___

10004322-DS-23

DS

2135-02-12 00:00:00

2135-02-13 19:55:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: None History of Present Illness: ___ is a ___ year old male with history of schizophrenia with most recent ED visit ___, COPD, DM, mechanical falls most recently in ___ and s/p negative syncope workup in ___, history of urinary retention s/p indwelling foley in ___, admission in ___ for sepsis from pneumonia, presenting with complaints of fever and altered mental status. ___ presented to the ED from his group home after reportedly being febrile yesterday. The group home care staff changed his foley yesterday and noted that he his mental status was altered this morning. Seen in ___ on ___ by Dr. ___ for evaluation of need for chronic foley which was placed in late ___ after ___ presented to the ED after a fall and was found to be in ___ (prior to this, he had no problems voiding) and have obstructive uropathy. Noted to have a hypersensitive bladder with normal compliance, terminal detrusor overactivity, no obstruction, and was able to empty bladder completely despite over activity. The plan was to leave the foley catheter out and monitor PVRs ___ times daily with foley re-insertion if PVR>400-450cc and to continue tamsulosin. In the ED, initial vital signs were: T99.1 HR112 BP91/58 RR16 SaO2 95% on RA - Exam notable for: lethargy, arousable only to pain, oriented x1 - Labs were notable for: 1) Chem 10 - 134|94|28 ---------<159 4.2|20|1.5 2) CBC - 27.3>10.5/32.5<376 Diff - 85.6%, 4.5%, Monos 8.7% 3) LFTs - ALP 167 (ALT 5, AST 14, Tbili 0.5, Alb 3.8) 4) U/A - hazy appearance with large leuks (WBC>182), small amount of blood (RBC>10), Few bacteria, Negative Nitrites, 30 Proteins 5) FluAPCR and FluBPCR - negative 6) Lactate - 1.6 7) Blood cx - pnd 8) Urine cx - pnd - Studies performed include: 1) CT C-spine w/o contrast: No acute fracture or malalignment of the cervical spine. 2) NCHCT: No acute intracranial process 3) CXR: No acute cardiopulmonary process. No focal consolidation to suggest pneumonia. - Patient was given: 1) IV NS 2) Ceftriaxone 2 gm - Vitals on transfer: ___, 99.2F, HR111(106-113), BP135/67 (91-135/55-67), RR25 (___), SaO2 100% on RA Upon arrival to the floor, the patient was somnolent but arousable, oriented to name only. History could not be completed as patient could not answer questions. REVIEW OF SYSTEMS: (+) per HPI (-) chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: 1. Paranoid schizophrenia, well-controlled on Clozaril - Previous auditory and visual hallucinations, none "for awhile" per patient 2. Mechanical falls with negative syncope workup (___) 3. T2DM (last HbA1c 7.1 in ___ 4. COPD (last FEV1 unknown) 5. GERD/Reflux Esophagitis 6. CAD 7. HTN 8. Hyperlipidemia Social History: ___ Family History: Unknown to patient Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: 98.9, 109bpm, BP129/66, RR18, SaO2 96% on RA GENERAL: A&Ox1 (name only), somnolent, responsive to voice and gentle touch but quickly falls asleep, unable to answer questions comprehensibly HEENT: Normocephalic, atraumatic. Pupils equal (3mm), round, and unreactive bilaterally. No conjunctival pallor or injection, sclera anicteric and without injection. Moist mucous membranes, good dentition. Oropharynx is clear. NECK: Thyroid is normal in size and texture, no nodules. No cervical lymphadenopathy. CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops. No JVD. LUNGS: Clear to auscultation bilaterally w/appropriate breath sounds appreciated in all fields. No wheezes, rhonchi or rales. BACK: Skin. no spinous process tenderness. no CVA tenderness. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants though difficult to assess given patient's altered sensorium. Tympanic to percussion. No organomegaly. well-healed mid-line incision measuring ___ inches EXTREMITIES: No clubbing, cyanosis, or edema, no sign of atrophy/hypertrophy. Pulses DP/Radial 2+ bilaterally. SKIN: No evidence of ulcers, rash or lesions suspicious for malignancy NEUROLOGIC: could not complete due to lack of patient cooperation DISCHARGE PHYSICAL EXAM: ======================== VS: 98.0PO, Tmax 98.1, 156/79 (149-156/79-87), 83 (71-85), 18, SaO2 95% on RA GENERAL: A&Ox2 (name and place), able to engage in conversation and keep eyes open HEENT: Normocephalic, atraumatic. Pupils equal (3mm), round, and unreactive bilaterally. No conjunctival pallor or injection, sclera anicteric and without injection. Moist mucous membranes, good dentition. Oropharynx is clear. NECK: Thyroid is normal in size and texture, no nodules. No cervical lymphadenopathy. CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops. No JVD. LUNGS: Clear to auscultation bilaterally w/appropriate breath sounds appreciated in all fields. No wheezes, rhonchi or rales. BACK: Skin. no spinous process tenderness. no CVA tenderness. ABDOMEN: Normal bowels sounds, soft, non-tender/non-distended. Tympanic to percussion. No organomegaly. well-healed mid-line incision measuring ___ inches EXTREMITIES: No clubbing, cyanosis, or edema, no sign of atrophy/hypertrophy. Pulses DP/Radial 2+ bilaterally. SKIN: No evidence of ulcers, rash or lesions suspicious for malignancy NEUROLOGIC: could not complete due to lack of patient cooperation Pertinent Results: ADMISSION LABS: =============== ___ 12:54PM PLT SMR-NORMAL PLT COUNT-376 ___ 12:54PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL ___ 12:54PM NEUTS-85.6* LYMPHS-4.5* MONOS-8.7 EOS-0.0* BASOS-0.2 IM ___ AbsNeut-23.37*# AbsLymp-1.23 AbsMono-2.36* AbsEos-0.00* AbsBaso-0.05 ___ 12:54PM WBC-27.3*# RBC-3.75* HGB-10.5* HCT-32.5* MCV-87 MCH-28.0 MCHC-32.3 RDW-14.2 RDWSD-44.6 ___ 12:54PM ALBUMIN-3.8 ___ 12:54PM ALT(SGPT)-5 AST(SGOT)-14 ALK PHOS-167* TOT BILI-0.5 ___ 12:54PM estGFR-Using this ___ 12:54PM GLUCOSE-159* UREA N-28* CREAT-1.5* SODIUM-134 POTASSIUM-4.2 CHLORIDE-94* TOTAL CO2-20* ANION GAP-24* ___ 01:19PM LACTATE-1.6 ___ 01:53PM OTHER BODY FLUID FluAPCR-NEGATIVE FluBPCR-NEGATIVE ___ 03:00PM URINE MUCOUS-RARE ___ 03:00PM URINE HYALINE-4* ___ 03:00PM URINE RBC-10* WBC->182* BACTERIA-FEW YEAST-NONE EPI-<1 ___ 03:00PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-LG ___ 03:00PM URINE COLOR-Yellow APPEAR-Hazy SP ___ ___ 03:00PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG oxycodn-NEG ___ 03:00PM URINE UHOLD-HOLD ___ 03:00PM URINE HOURS-RANDOM ___ 09:32PM PLT COUNT-334 ___ 09:32PM WBC-19.8* RBC-3.39* HGB-9.4* HCT-29.7* MCV-88 MCH-27.7 MCHC-31.6* RDW-14.5 RDWSD-46.8* ___ 09:32PM GLUCOSE-123* UREA N-24* CREAT-1.2 SODIUM-139 POTASSIUM-3.7 CHLORIDE-101 TOTAL CO2-21* ANION GAP-21* DISCHARGE/PERTINENT LABS: ========================= ___ 07:05AM BLOOD WBC-8.9 RBC-3.32* Hgb-9.2* Hct-27.7* MCV-83 MCH-27.7 MCHC-33.2 RDW-13.9 RDWSD-42.4 Plt ___ ___ 07:05AM BLOOD Glucose-118* UreaN-6 Creat-0.6 Na-140 K-3.5 Cl-101 HCO3-24 AnGap-19 ___ 07:00AM BLOOD ___ PTT-35.2 ___ ___ 07:00AM BLOOD ALT-6 AST-14 LD(LDH)-176 AlkPhos-127 TotBili-0.4 ___ 07:05AM BLOOD Calcium-8.5 Phos-2.5* Mg-1.7 MICROBIOLOGY: ============== ___ 3:00 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: ESCHERICHIA COLI. 10,000-100,000 CFU/mL. Fosfomycin Susceptibility testing requested by ___. ___ ___ (___) ON ___. FOSFOMYCIN = 24MM = SUSCEPTIBLE. FOSFOMYCIN sensitivity testing performed by ___ ___. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMIKACIN-------------- 8 S AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S TOBRAMYCIN------------ =>16 R TRIMETHOPRIM/SULFA---- =>16 R IMAGING: ======== ___ Imaging ABDOMEN (SUPINE & ERECT) Nonobstructive bowel gas pattern in the stomach, small bowel and colon. No evidence of pneumoperitoneum. ___ Imaging CHEST (SINGLE VIEW) No acute cardiopulmonary process. No focal consolidation to suggest pneumonia. ___-SPINE W/O CONTRAST No acute fracture or malalignment of the cervical spine. ___ Imaging CT HEAD W/O CONTRAST No acute intracranial process. Brief Hospital Course: Mr. ___ is a ___ man with history of paranoid schizophrenia, COPD, Type 2 DM, urinary retention s/p indwelling foley catheter placement in ___, who presented from his group home with report of 1 day of fever prior to admission and altered mental status on the day of presentation to the ED (___). # Altered mental status/catheter associated urinary tract infection: Patient hemodynamically stable on admission, but drowsy and not oriented. Afebrile, but WBC count of 27. Urinalysis consistent with infection in the setting of indwelling foley catheter. Head and neck imaging without acute abnormalities. He was without headaches, photophobia, or neck stiffness to suggest meningoencephalitis. Patient initially started on ceftriaxone; however, urine culture revealed ESBL E. coli resistant to ceftriaxone. Patient switched to meropenem, which he received from ___ to ___. Patient was switched to fosfomycin (1 dose) on discharge to complete a full antibiotic course. Foley catheter was replaced. # Acute kidney injury: Patient also noted to have acute kidney injury with Cr 1.5, likely prerenal in etiology, that resolved with IV fluids. Cr on discharge 1.0. # Paranoid schizophrenia: Patient's clozapine was held on admission, given altered mental status. He was seen by the psychiatry service for assistance with management. Clozapine was resumed at the suggestion of psychiatry at 100mg PO QHS, with plan for outpatient uptitration by primary psychiatrist. # Normocytic anemia: He was found to have Hgb of 8.8-10.5 as compared to most recent baseline of 11.8. He was without signs of overt bleeding. There was low suspicion for hemolysis in the setting of normal TBili and lack of schistocytes on manual smear. # Abdominal pain: He experienced transient abdominal pain with benign abdomen, possibly related to urinary tract infection, though not specifically suprapubic. KUB was without signs of obstruction or perforation. Abdominal pain resolved prior to discharge. # T2DM He received long-acting insulin with sliding scale as needed. Home metformin was held throughout admission and resumed at discharge. # COPD Home fluticasone and tiotropium inhaler were held throughout admission and resumed at discharge. # GERD/Reflux esophagitis He received omeprazole in place of home ranitidine in the inpatient setting. # CAD Home ASA was continued. # Hyperlipidemia Home gemfibrozil was held throughout admission and resumed at discharge. # Orthostatic hypotension Home fludrocortisone was continued. TRANSITIONAL ISSUES: ==================== # Patient's clozapine was stopped on admission and restarted at 100mg PO QHS by recommendation from psychiatry. Patient should follow up with outpatient psychiatrist for uptitration. # Patient was found to have anemia with Hgb of 9.2. He should have a follow-up CBC with differential within 1 week and should be worked-up for iron-deficiency or other causes anemia if not improved; downtrending monocyte count, likely elevated on admission in the setting of infection, also should be ensured. # Follow-up of coagulation studies to ensure downtrending INR (elevated to 1.4 on this admission likely in the setting of infection and poor PO intake, without overt signs of DIC) also advised. # Patient found to have 10 RBC on urinalysis on this admission, likely in the setting of urinary tract infection; please assess for resolution of hematuria following resolution of urinary tract infection, though may be confounded if ongoing foley catheter needed. # Patient should follow up with urology for foley catheter care and to assess whether ongoing foley catheter is needed. Appointment was made for ___. # CODE: Full # CONTACT: ___ (___) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Fludrocortisone Acetate 0.1 mg PO DAILY hypotension 2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 3. Aspirin 81 mg PO DAILY 4. Clozapine 200 mg PO BID 5. Clozapine 75 mg PO QHS 6. Docusate Sodium 100 mg PO BID 7. Fluticasone Propionate 110mcg 2 PUFF IH BID 8. Gemfibrozil 600 mg PO BID 9. Levemir (insulin detemir) 32 units subcutaneous BREAKFAST 10. MetFORMIN (Glucophage) 1000 mg PO BID 11. Ranitidine 150 mg PO BID 12. Tiotropium Bromide 1 CAP IH DAILY Discharge Medications: 1. Clozapine 100 mg PO QHS 2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 3. Aspirin 81 mg PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Fludrocortisone Acetate 0.1 mg PO DAILY hypotension 6. Fluticasone Propionate 110mcg 2 PUFF IH BID 7. Gemfibrozil 600 mg PO BID 8. Levemir (insulin detemir) 32 units subcutaneous BREAKFAST 9. MetFORMIN (Glucophage) 1000 mg PO BID 10. Ranitidine 150 mg PO BID 11. Tiotropium Bromide 1 CAP IH DAILY 12. HELD- Clozapine 200 mg PO BID This medication was held. Do not restart Clozapine until until you see your psychiatrist Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSES: ================== Toxic Metabolic Encephalopathy Catheter-associated UTI Acute Kidney Injury SECONDARY DIAGNOSES: ==================== Paranoid Schizophrenia Type 2 Diabetes COPD Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you. You were admitted to the ___ because you were confused and had a fever. You were found to have a urinary tract infection and you were started on IV antibiotics and your mental status improved significantly. Your Clozaril was also stopped and restarted at a lower dose because of your confusion. You should follow-up with your PCP and outpatient psychiatrist within ___ weeks of discharge. Wishing you a speedy recovery, ___ Care Team Followup Instructions: ___

10004606-DS-21

DS

2159-03-22 00:00:00

2159-03-29 12:54:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Weakness Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ female with past medical history notable for hypertension, prior small intestinal bleed (sounds like distal upper AVM), recent hospitalization for seizures in the setting of gallstone pancreatitis status post cholecystectomy who was discharged on ___ who presents to the hospital with several days of weakness. She reports that initially following discharge she was feeling well. She reports that after several days at home she started to feel increasingly fatigued. She reports that she felt similar to when she was bleeding in ___ and required the upper GI which found a likely AVM. She reports the records from that hospitalization or at ___ in ___. She reports that at that time her bowel movements were normal. She reports that on the evening prior to admission she developed diarrhea with black stools. She reports that this is the exact same happened last time she had the upper GI bleed. She reports that she continue to feel further fatigue. She touch base with her primary care doctor who referred her into the emergency department for further evaluation. She also reports that while at home she had a decreased appetite. Per her daughter she started to look increasingly pale. She became lightheaded and dizzy in the shower on several occasions. She also reports that she had urinary symptoms from around the time she got home. She reports that over the last 6 days she has had increased lower abdominal pain, burning on urination, pressure. She reports that she feels like it got so bad she decreased her p.o. intake to reduce the amount that she would have to urinate. She also reports that she had some blood in the urine. In the emergency department she was seen and evaluated. Her initial vital signs were unremarkable. She was afebrile with a heart rate of 81, blood pressure 157/94, respiratory rate of 18. Her H&H was notable for 11.3/35.3 which is up from her discharge hemoglobin and hematocrit of 8.7/26.8. She had a UA that was checked which unfortunately contained 9 epithelial cells. It did have positive nitrates, large leukocyte esterase, greater than 184 white blood cells as well as few bacteria. She received 1 g of IV ceftriaxone, 2 L of normal saline, and was admitted to the medical service for further evaluation and management. She was also evaluated by the surgery service while in the emergency department he felt like if she had anything was likely a slow GI bleed and would not require acute surgical intervention and would recommend admission to medicine for a GI workup. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: Gallstone pancreatitis status post cholecystectomy ___ Seizures in the setting of the above gallstone pancreatitis Hypertension due to renal artery stenosis, difficult to control Prior history of upper GI bleed from a likely AVM Prior history of DVT no longer on anticoagulation Social History: ___ Family History: ___ and found to be not relevant to this illness/reason for hospitalization. She specifically denies any family history of seizures or strokes. Physical Exam: ADMISSION EXAM -------------- VITALS: 98.4 PO 147 / 72 60 18 100 RA GENERAL: Alert and in no apparent distress, laying in bed EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, tender to palpation over the suprapubic region. Laparoscopic cholecystectomy incisions healing well. Bowel sounds present. No HSM. No CVA tenderness GU: No suprapubic fullness but significant tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: pleasant, appropriate affect DISCHARGE EXAM -------------- VS: Reviewed GENERAL: Alert and in no apparent distress, laying in bed EYES: Anicteric, pupils equally round CV: Heart regular, no murmur. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, tender to palpation over the suprapubic region. Laparoscopic cholecystectomy incisions healing well. Bowel sounds present. GU: No suprapubic fullness but significant tenderness to palpation PSYCH: pleasant, appropriate affect Pertinent Results: ADMISSION LABS -------------- ___ 03:46PM BLOOD WBC-10.6*# RBC-3.78*# Hgb-11.5# Hct-35.3# MCV-93 MCH-30.4 MCHC-32.6 RDW-14.0 RDWSD-47.6* Plt ___ ___ 03:46PM BLOOD Neuts-71.9* Lymphs-17.5* Monos-6.9 Eos-2.6 Baso-0.7 Im ___ AbsNeut-7.65* AbsLymp-1.86 AbsMono-0.73 AbsEos-0.28 AbsBaso-0.07 ___ 02:22PM BLOOD Glucose-108* UreaN-12 Creat-1.0 Na-145 K-4.8 Cl-104 HCO3-24 AnGap-17 ___ 02:22PM BLOOD ALT-18 AST-17 AlkPhos-121* TotBili-0.5 MICROBIOLOGY ------------ ___ 4:55 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE IDENTIFICATION. PREDOMINATING ORGANISM. INTERPRET RESULTS WITH CAUTION. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S DISCHARGE LABS -------------- ___ 08:10AM BLOOD WBC-5.6 RBC-2.92* Hgb-8.9* Hct-27.2* MCV-93 MCH-30.5 MCHC-32.7 RDW-13.3 RDWSD-45.4 Plt ___ ___ 08:10AM BLOOD Glucose-101* UreaN-11 Creat-1.0 Na-142 K-4.6 Cl-101 HCO3-30 AnGap-11 ___ 07:10AM BLOOD ALT-16 AST-17 AlkPhos-91 TotBili-0.4 ___ 07:45AM BLOOD Calcium-9.7 Phos-3.8 Mg-1.7 ___ 03:46PM BLOOD calTIBC-411 Ferritn-___-___ ___ 02:35PM BLOOD Lactate-1.8 KUB: IMPRESSION: Normal bowel gas pattern. Brief Hospital Course: ___ female with past medical history notable for hypertension, prior small intestinal bleed (sounds like distal upper AVM), recent hospitalization for seizures in the setting of gallstone pancreatitis status post cholecystectomy who was discharged on ___ who presents to the hospital with several days of weakness. # Possible upper GI bleed # Gastritis: Patient reported several episodes of black stools, but none during admission. Hemoglobin downtrended over the course of admission. Awaiting records from ___ in ___. GI following patient, but did not plan on EGD/colonoscopy. H. pylori antigen was sent. She was placed on PO pantoprazole, as well as home famotidine and simethicone, given complaints of indigestion, as well as antiemetics. # Urinary tract infection: Patient reported approximately five days of urinary tract symptoms with pain on urination, burning on urination, and suprapubic fullness. Pan-sensitive E.coli on urine specimen, placed on ceftriaxone and switched to ciprofloxacin for 7-day course. She was also placed on three day course of pyridium. # Weakness: suspect related to UTI and possible slow GI bleed, see above. ___ consulted. She progressed and was able to be discharged home. #Constipation Patient noted to constipated likely ___ to opioids and decreased mobility. KUB without obstruction. She received bowel regimen. She had a bowel movement prior to discharge. # HTN due to # RAS: Patient has renal artery stenosis as documented on her prior admission. She has difficult to control blood pressures. She was stabilized on a regimen during her prior hospitalization. Continued home antihypertensive regimen of amlodipine, labetalol, lisinopril. # Seizure Disorder: Patient had generalized tonic-clonic seizure during her prior hospitalization in the setting of her gallstone pancreatitis. She was seen by neurology during her prior hospitalization and is now on antiseizure medication with outpatient follow-up. She was continued on her home Keppra. # GERD: continued on home famotidine and added PO pantoprazole. I updated her son and daughter with the plan of care. TRANSITIONS OF CARE ------------------- # Follow-up: patient will follow up with her PCP. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY hypertension 2. Atorvastatin 40 mg PO QPM 3. LevETIRAcetam 1500 mg PO Q12H 4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 5. Lisinopril 40 mg PO DAILY 6. Famotidine 20 mg PO BID 7. Aspirin 81 mg PO DAILY 8. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Severe 9. Labetalol 400 mg PO BID Hypertension Discharge Medications: 1. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*30 Capsule Refills:*0 2. Ondansetron 4 mg PO Q8H RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours Disp #*30 Tablet Refills:*0 3. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Severe RX *oxycodone 5 mg 1 capsule(s) by mouth every eight (8) hours Disp #*6 Capsule Refills:*0 4. Pantoprazole 40 mg PO Q12H RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 5. Polyethylene Glycol 17 g PO DAILY RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by mouth once a day Disp #*30 Packet Refills:*0 6. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 7. amLODIPine 10 mg PO DAILY hypertension 8. Aspirin 81 mg PO DAILY 9. Atorvastatin 40 mg PO QPM 10. Famotidine 20 mg PO BID 11. Labetalol 400 mg PO BID Hypertension 12. LevETIRAcetam 1500 mg PO Q12H 13. Lisinopril 40 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Urinary tract infection Gastritis/peptic ulcer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure caring for you during your recent admission at ___. You came for further evaluation of weakness, pain when urinating and black stools. It is important that you continue to take your medications as prescribed and follow up with the appointments listed below. Please follow up with your PCP ___. Please arrange to have you labs checked. Good luck! Followup Instructions: ___

10004606-DS-23

DS

2159-09-22 00:00:00

2159-09-22 19:16:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Presyncope, Fall Major Surgical or Invasive Procedure: EGD ___ Capsule endoscopy ___ Colonoscopy ___ History of Present Illness: ___ with history of CVA, seizures, upper GI AVM's with chronic anemia, HTN, presents after presyncopal fall. On ___ she was at home and went to linen closet to grab something. Then felt presyncopal, dizzy, warm feeling, and fell backwards, hitting her head first against a bedroom door which gave way, and then against the floor. No LOC. Daughter came to her aid. She did not want to go to the hospital. The next day she went to ___. CT head and CT C-spine negative for acute bleed or fracture. Today she went to her GI appointment and was referred to ___. Last ___ she reported a seizure episode where her arms were shaking and she was in a daze. This lasted for a few minutes. Consistent with prior seizures episodes. In the ___, initial VS were: - 98.3 77 147/45 19 100% RA - Exam: diffuse mild abd tenderness, scant brown stool in rectal vault +guaiac, - Labs: Hgb 7.4, Creatinine 1.1, Lactate 1.3, urine WBC 35, lg leuk, hazy, few bac - Imaging: CXR clear. CT A/P no acute process. On interview she reports acute on chronic "soreness" in neck, back, hips, for which she takes oxycodone at home. Otherwise no acute complaints. REVIEW OF SYSTEMS: +tinnitus; all other positives per HPI otherwise 10 point ROS reviewed and negative except as per HPI Past Medical History: - Hypertension - Renal Artery Stenosis - Seizures - CVA - Gallstone pancreatitis - Iron deficiency anemia - AVM's in stomach and duodenum - Lumbar radiculopathy - Chronic opioid use, with pain contract - Hypothyroidism - Hyperlipidemia - COPD - Neuropathic pain - GERD - DVT Social History: ___ Family History: Mother had dementia. Father had asbestosis and mesothelioma. Physical Exam: ADMISSION PHYSICAL ================== VS: 98.3 130 / 55 58 18 99 ra GENERAL: NAD HEENT: PERRL, EOMI, no nystagmus, tongue moist NECK: +L carotid bruit HEART: RRR, S1, S2, no murmurs LUNGS: LCAB ABDOMEN: s, lower abdominal tenderness GU: suprapubic tenderness EXTREMITIES: no edema NEURO: A&Ox3, moving all 4 extremities with purpose, RLE weakness DISCHARGE PHYSICAL ================== ___ ___ Temp: 97.9 PO BP: 162/62 HR: 56 RR: 18 O2 sat: 97% O2 delivery: Ra GENERAL: NAD, sitting in bed NECK: +bilateral carotid bruits HEART: RRR, S1, S2, no murmurs PULM: CTABL ABDOMEN: soft, mildly distended without tenderness, +BS EXTREMITIES: warm, 1+ ___ pulses bilaterally, no edema NEURO: A&Ox3, no facial asymmetry, moving all 4 extremities with purpose Pertinent Results: ADMISSION LABS ============== ___ 05:50PM BLOOD WBC-5.5 RBC-2.49* Hgb-7.4* Hct-22.3* MCV-90 MCH-29.7 MCHC-33.2 RDW-15.3 RDWSD-50.4* Plt ___ ___ 05:50PM BLOOD Neuts-47.5 ___ Monos-8.9 Eos-7.5* Baso-0.5 Im ___ AbsNeut-2.60 AbsLymp-1.94 AbsMono-0.49 AbsEos-0.41 AbsBaso-0.03 ___ 05:50PM BLOOD ___ PTT-34.2 ___ ___ 05:50PM BLOOD Glucose-101* UreaN-12 Creat-1.1 Na-138 K-4.2 Cl-99 HCO3-24 AnGap-15 ___ 05:50PM BLOOD ALT-14 AST-13 AlkPhos-43 TotBili-0.3 ___ 05:50PM BLOOD Lipase-22 ___ 05:50PM BLOOD proBNP-78 ___ 05:50PM BLOOD cTropnT-<0.01 ___ 05:50PM BLOOD Albumin-4.8 Calcium-9.6 Phos-3.7 Mg-1.8 PERTINENT INTERVAL LABS ======================= ___ 09:10AM BLOOD Calcium-9.4 Phos-4.1 Mg-1.8 Iron-16* ___ 09:10AM BLOOD calTIBC-382 VitB12-318 Folate-14 Ferritn-14 TRF-294 ___ 06:48AM BLOOD TSH-3.6 ___ 06:48AM BLOOD Free T4-0.9* DISCHARGE LABS ============== ___ 05:35AM BLOOD WBC-5.0 RBC-3.62* Hgb-10.7* Hct-34.0 MCV-94 MCH-29.6 MCHC-31.5* RDW-15.5 RDWSD-53.1* Plt ___ ___ 05:35AM BLOOD Glucose-91 UreaN-20 Creat-1.1 Na-144 K-4.5 Cl-104 HCO3-24 AnGap-16 ___ 05:35AM BLOOD Calcium-9.6 Phos-5.0* Mg-2.0 MICROBIOLOGY ============ Urine Culture ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION IMAGING AND STUDIES =================== ___ CXR AP upright and lateral views of the chest provided. There is no focal consolidation, effusion, or pneumothorax. The cardiomediastinal silhouette is normal. Imaged osseous structures are intact. No free air below the right hemidiaphragm is seen. ___ CT ABD/PEVLIS W CON 1. Colonic diverticulosis without evidence of diverticulitis. No signs of colitis or bowel obstruction. Normal appendix. 2. Status post cholecystectomy with stable mild prominence of the intrahepatic and extrahepatic biliary tree. 3. Extensive aortoiliac atherosclerotic calcification with stents in the bilateral external iliac arteries which appear patent. 4. Atrophic right kidney. 5. Trace free pelvic fluid, nonspecific. ___ ECHO (TTE) The left atrial volume index is normal. The estimated right atrial pressure is ___ mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no left ventricular outflow obstruction at rest or with Valsalva. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Normal biventricular cavity size and global/regional systolic function. No pathological valvular flow identified. No structural cause for syncope identified. ___ CAROTID ULTRASOUND Moderate-to-marked predominantly heterogeneous soft plaque within the bilateral carotid arteries most profound within the mid ICAs, right greater than left, resulting in hemodynamically significant stenosis estimated to be 80-99% bilaterally. ___ EGD Mucosa suggestive of ___ Esophagus Erosion in pylorus Angioectasias in stomach and second part of duodenum (Thermal Therapy applied) Capsule released in duodenum ___ COLONOSCOPY Aborted due to high residue material ___ pMIBI FINDINGS: There was soft tissue attenuation. Left ventricular cavity size is within normal limits. Rest and stress perfusion images reveal uniform tracer uptake throughout the left ventricular myocardium. Gated images reveal normal wall motion. The calculated left ventricular ejection fraction is 71%. IMPRESSION: 1. No evidence of myocardial perfusion defect. 2. Normal left ventricular cavity size with normal systolic function. ___ KUB Endoscopy capsule in the proximal descending colon. ___ KUB Endoscopy pill capsule has migrated since ___, now possibly in the sigmoid colon. Brief Hospital Course: ___ with history of CVA, seizures, upper GI AVM's with chronic anemia, HTN, peripheral vasculopathy, who presented after presyncopal fall. ACUTE ISSUES ============ # Acute on Chronic Blood Loss Anemia # Upper GI Bleed Presented with ongoing intermittent melena and known gastric and duodenal AVMs per prior EGD's s/p single balloon enteroscopy with APC to small bowel AVMs. Stool guaiac positive in ___. Required 2u pRBCs during her hospitalization. EGD showed several duodenal/gastric AVMs that were cauterized, as well as likely ___ esophagus. Patient was iron deficient and was given 2 125mg IV infusions of ferric gluconate. Patient was continued on PPI prophylaxis. # Seizures Patient reported that her last seizure 1 week prior to admission and involved extremity shaking and AMS that lasted several minutes, consistent with previous episodes. Neurology was consulted for optimization of her AEDs. EEG was performed and the patient was continued on Keppra with plans for outpatient followup in neurology clinic. She had no seizures in house. # Severe, Bilateral Carotid Artery Stenosis Carotid US done as part of pre-syncope work-up revealed severe bilateral carotid artery stenosis (80-99%). She was seen by vascular surgery in house, who recommended no urgent treatment. This could certainly contribute to pre-syncope, however vascular surgery will followup with patient for CEA consideration. # Presyncope Presented 4 days after presyncopal episode at home with fall and head trauma. CT head and c-spine were negative at OSH. Signs and symptoms not consistent with prior seizures. Initial ddx included CNS process (TIA, carotid stenosis), cardiac (had old RBBB on EKG, and new LBBB on this admission), orthostasis (had previously documented orthostatic hypotension), vasovagal event, peripheral vertigo (has tinnitus), or symptomatic anemia. # Concern for Cardiac Conduction Disease Noted patient has HRs usually in ___, even when standing and lightheaded. There was concern that she was not adequately augmenting her cardiac output with exertion due to conduction disease and this blunted response was contributing to her pre-syncope. Also noted to initially have RBBB on EKG, but then LBBB on EKG done later in the same day (in ___ on presentation). Unusual and concerning for conduction disease, so cardiology was consulted and beta-blocker (home med) was held. pMIBI revealed no overt ischemia and ambulatory telemetry revealed that patients heart rates increased to ___. Cardiology felt that this was an appropriate response and the patient did not require further electrophysiologic evaluation during this hospitalization. # Hypertension Patient has history of hypertension (renal artery stenosis) with orthostatic hypotension. Antihypertensives were held in the setting of GI bleed but were restarted once her GI bleed was addressed. She was continued on home doses of blood pressure medications and was also started on chlorthalidone 12.5mg daily for better control. # Chronic Back and Neck Pain Has narcotics contract w PCP for oxycodone 5mg BID since ___. Review of MassPMP indicates pt also prescribed vicodin in OSH ___ three days prior to presentation. Likely that pain is exacerbated by recent fall, so increased pain regimen while in-house. CHRONIC ISSUES ============== # Neuropathic pain: continued gabapentin 300mg TID. # GERD: continued PPI and famotidine. # Chronic nausea: continued ondansetron PRN. TRANSITIONAL ISSUES =================== []Ensure passage of capsule, on discharge KUB ___ noted to be in sigmoid colon/rectum. Consider repeat KUB to assess if concerned. Per GI, very unlikely to cause obstruction once in colon. []Labetalol/Beta-Blockade: Recommend avoiding all beta-blockade given heart rates in the ___. Patient's labetalol was discontinued to avoid negative chronotrope effect []Chlorthalidone: titrate dose as needed for adequate blood pressure control []ASA 81: discharged on ASA 81 given stroke risk in the setting of severe carotid disease, if GI bleed recurs, risk/benefit should be discussed with patient (okay to hold per inpatient cardiology recommendations but neurology would recommend continuing) []Atorvastatin: increased to 80mg (although less data in secondary prevention) due to severe vascular disease ___ esophagus: Noted on EGD. Will have follow up endoscopy with plan for biopsy in ___ []Labs: Repeat CBC at clinic visit to ensure stability, discharge Hgb 9.9 []Vascular Followup: Has appointment with Dr. ___ ___ for CEA evaluation []Neurology Followup: Has appointment for further management of anti-seizure medications # Contact/HCP: ___ (daughter) ___ # Code status: Full, presumed Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY hypertension 2. Atorvastatin 40 mg PO QPM 3. LevETIRAcetam 1500 mg PO Q12H 4. Lisinopril 40 mg PO DAILY 5. Simethicone 40-80 mg PO QID:PRN abd pain 6. Famotidine 20 mg PO BID 7. Ondansetron 4 mg PO Q8H:PRN nausea 8. Pantoprazole 40 mg PO Q12H 9. Aspirin 81 mg PO DAILY 10. Ferrous Sulfate 325 mg PO BID 11. Ascorbic Acid ___ mg PO BID 12. OxyCODONE (Immediate Release) 5 mg PO Q12H:PRN BREAKTHROUGH PAIN 13. Labetalol 200 mg PO BID 14. Gabapentin 300 mg PO TID The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY hypertension 2. Atorvastatin 40 mg PO QPM 3. LevETIRAcetam 1500 mg PO Q12H 4. Lisinopril 40 mg PO DAILY 5. Simethicone 40-80 mg PO QID:PRN abd pain 6. Famotidine 20 mg PO BID 7. Ondansetron 4 mg PO Q8H:PRN nausea 8. Pantoprazole 40 mg PO Q12H 9. Aspirin 81 mg PO DAILY 10. Ferrous Sulfate 325 mg PO BID 11. Ascorbic Acid ___ mg PO BID 12. OxyCODONE (Immediate Release) 5 mg PO Q12H:PRN BREAKTHROUGH PAIN 13. Labetalol 200 mg PO BID 14. Gabapentin 300 mg PO TID Discharge Medications: 1. Bisacodyl 10 mg PO/PR DAILY:PRN constipation RX *bisacodyl 5 mg 2 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 2. Chlorthalidone 12.5 mg PO DAILY RX *chlorthalidone 25 mg 0.5 (One half) tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. Docusate Sodium 100 mg PO BID constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily Disp #*30 Capsule Refills:*0 4. Multivitamins W/minerals 1 TAB PO DAILY RX *multivitamin,tx-minerals 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 5. Polyethylene Glycol 17 g PO DAILY constipation RX *polyethylene glycol 3350 [PEG___] 17 gram/dose 17 g by mouth daily Refills:*0 6. Senna 8.6 mg PO BID RX *sennosides [senna] 8.6 mg 1 by mouth twice a day Disp #*30 Tablet Refills:*0 7. Atorvastatin 80 mg PO QPM RX *atorvastatin 80 mg 1 tablet(s) by mouth at nightime Disp #*30 Tablet Refills:*0 8. amLODIPine 10 mg PO DAILY hypertension 9. Ascorbic Acid ___ mg PO BID 10. Aspirin 81 mg PO DAILY 11. Famotidine 20 mg PO BID 12. Ferrous Sulfate 325 mg PO BID 13. Gabapentin 300 mg PO TID 14. LevETIRAcetam 1500 mg PO Q12H 15. Lisinopril 40 mg PO DAILY 16. Ondansetron 4 mg PO Q8H:PRN nausea 17. OxyCODONE (Immediate Release) 5 mg PO Q12H:PRN BREAKTHROUGH PAIN 18. Pantoprazole 40 mg PO Q12H 19. Simethicone 40-80 mg PO QID:PRN abd pain 20.Rolling Walker Please provide rolling walker. Dx: Seizure Disorder (ICD-9: 780.39) Prognosis: Good ___: 13 Months Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnoses ================= Acute on chronic upper GI bleed Severe, bilateral coronary artery stenosis Seizure disorder Orthostatic hypotension Secondary Diagnoses =================== Bipolar Disorder Hepatitis B Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, ___ was a pleasure taking care of you in the hospital. WHY DID YOU COME TO THE HOSPITAL? -You felt lightheaded and suffered a fall WHAT HAPPENED TO YOU DURING YOUR HOSPITAL STAY? -You were given blood to increase your blood counts -Your bloody bowel movements were evaluated and treated by the gastroenterologists -You were evaluated for seizures by the neurologists and was started on a medication to prevent seizures -You were found to have severe blockages in both arteries supplying blood to brain and need to follow-up with the vascular surgeons in vascular surgery clinic to discuss surgical correction of these blockages -Your heart was evaluated by the cardiologists who do not recommend any further testing at this time WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL? –please take all of your medications as prescribed, details below –Please keep all of your appointments as scheduled -Please keep track of whether you have passed the capsule in your bowel movement. If you have not passed the capsule in 2 days since discharge, you should be seen in clinic by your PCP. Please call your PCP right away if you have any symptoms such as constipation, vomiting, anorexia, and if you are not passing any gas. We wish you the very best! Your ___ Care Team Followup Instructions: ___

10004648-DS-13

DS

2135-12-08 00:00:00

2135-12-08 15:48:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: presumed ectopic pregnancy Major Surgical or Invasive Procedure: none History of Present Illness: ___ G1 with LMP ___ with presumed ectopic (never seen on ultrasound) presents to ED with severe abdominal pain after treatment with MTX on ___. She was having some mild abdominal pain responsive to Tylenol but this morning her pain became ___ and unresponsive to Tylenol. She describes the pain as located across her low abdomen, left > right. It was "unbearable" and she had trouble walking although wasn't lightheaded, just overwhelmed with pain. In the ambulance ride, she received 50mcg fentanyl and 4mg zofran IV. Her pain is now ___. She also notes vaginal bleeding, ~3 pads per day. No clots. ___ TVUS (prelim): Focal thickening of the endometrium, portion with vascular flow -> consistent with ongoing SAB. Cystic structure in left ovary most likely corpus luteum. Past Medical History: PGynHx: Notes severe dysmenorrhea, normally takes Aleve. Previously on OCPs. PMHx: denies PSHx: denies Social History: ___ Family History: NC Physical Exam: VS on arrival: 97.4 58 106/55 100% RA General: NAD Cardiac: RRR Pulm: CTA Abdomen: Soft, no focal tenderness with NO rebound or guarding. +BS Bimanual: Mildly enlarged AV uterus without tenderness or CMT. Some left adnexal fullness without discrete tenderness (pt notes diffuse "tenderness") Ext: NT, NE Labs: HCG 1845 CBC 7.8>41.7<221 Blood type O+ Pertinent Results: ___ 11:57AM BLOOD WBC-7.8# RBC-4.77 Hgb-13.3 Hct-41.7 MCV-88 MCH-27.9 MCHC-31.9 RDW-14.0 Plt ___ ___ 11:57AM BLOOD ___ PTT-28.0 ___ ___ 11:57AM BLOOD Glucose-87 UreaN-11 Creat-0.8 Na-136 K-4.4 Cl-105 HCO3-25 AnGap-10 ___ 11:57AM BLOOD Mg-2.0 ___ 11:57AM BLOOD HCG-1845 Brief Hospital Course: Ms. ___ is a ___ year old G1 with LMP at end of ___ and a presumed ectopic who presents with severe abdominal pain after methotrexate administration. On arrival in the ED, she was hemodynamically stable with a hematocrit of 41 and benign abdominal exam. Ultrasound showed a small amount of material in the lower uterine segment, no adenxal masses or free fluid. She was admitted for observation in the absence of any signs of ruptured ectopic. She did well overnight, only requiring tylenol for analgesia. She remained hemodynamically stable without change in abdominal exam. She was discharged to home on HD 2 in good condition. Medications on Admission: none Discharge Medications: 1. Percocet 7.5-325 mg Tablet Sig: ___ Tablets PO every ___ hours. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: PRESUMED ECTOPIC PREGNANCY Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. ___, You were admitted with abdominal pain in the setting of suspected ectopic pregnancy. This was thought to be due to either ongoing miscarriage or aborting tubal ectopic. There was no evidence of a ruptured ectopic pregnancy. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * nausea/vomiting where you are unable to keep down fluids/food or your medication Followup Instructions: ___

10004719-DS-15

DS

2183-09-03 00:00:00

2183-09-03 18:25:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Percocet Attending: ___. Chief Complaint: Right leg/foot pain Major Surgical or Invasive Procedure: ___ Right lower extremity angiogram, angioJet mechanical thrombectomy of occluded bypass graft, balloon angioplasty of outflow stenosis. ___ Right lower extremity angiogram, angioJet mechanical thrombectomy of occluded bypass graft, balloon angioplasty of outflow stenosis. History of Present Illness: ___ w Rt AK pop to ___ bypass with NRGSV for a thrombosed popliteal aneurysm in ___ present with worsening new onset right foot claudication. Past Medical History: PMH: DVT R pop v (___), asthma, Rt pop artery thrombus with negative hypercoagulable workup PSH: Rt AK pop to ___ bypass with NRGSV ___ Physical Exam: Physical Exam: Alert and oriented x 3 VS:BP 104/54 HR 72 RR 16 Resp: Lungs clear Abd: Soft, non tender Ext: Pulses: palp throughout. Feet warm, well perfused. No open areas Left groin puncture site: Dressing clean dry and intact. Soft, no hematoma or ecchymosis. Pertinent Results: ___ 05:45AM BLOOD WBC-9.0 RBC-3.91 Hgb-11.5 Hct-34.2 MCV-88 MCH-29.4 MCHC-33.6 RDW-12.9 RDWSD-40.8 Plt ___ ___ 05:45AM BLOOD Plt ___ ___ 05:45AM BLOOD Glucose-108* UreaN-10 Creat-0.8 Na-141 K-3.7 Cl-107 HCO3-26 AnGap-12 ___ 05:45AM BLOOD Calcium-9.2 Phos-3.1 Mg-2.0 Arterial Duplex: Findings. Doppler evaluation was performed of both lower extremity arterial systems at rest. On the right the tibial waveforms are monophasic and there is no audible Waveforms are flat. The left all waveforms are triphasic. The ankle-brachial index is 1.3. Impression severe ischemia right lower extremity Brief Hospital Course: ___ sp Rt AK pop to ___ bypass with NRGSV ___ for arterial thrombosis presents with worsening right leg pain that occurred over predictable distances and acute change over past 24 hours with fullness in her right leg. Her motor and sensation are intact with no signs of limb threat. A heparin infusion was started. Arterial duplex showed occluded right popliteal to posterior tibial artery bypass. She was taken to the OR for right lower extremity angiogram, angioJet mechanical thrombectomy of occluded bypass graft, balloon angioplasty of outflow stenosis. A tpa catheter was left in place overnight. She return the next day for right lower extremity angiogram, angioJet mechanical thrombectomy of occluded bypass graft and balloon angioplasty of outflow stenosis. At that session, we were able to remove residual thrombus in the native right popliteal artery and bypass with good outflow to the foot via the anterior tibial, and peroneal arteries. At this point she was pain free with a palpable graft AT and DP pulse. The next morning, we discontinued the heparin infusion and started xarelto. She was ambulatory ad lib, voiding qs and tolerating a regular diet. She was discharged to home. We will see her again in followup in one month with surveillance duplex. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Clobetasol Propionate 0.05% Soln 1 Appl TP BID 2. Fluocinolone Acetonide 0.01% Solution 1 Appl TP Q24H PRN 3. metroNIDAZOLE 0.75 topical BID 4. ALPRAZolam 0.5 mg PO TID:PRN anxiety 5. Lovastatin 10 mg ORAL DAILY 6. Montelukast 10 mg PO DAILY 7. Fluticasone-Salmeterol Diskus (500/50) 2 INH IH DAILY 8. Pantoprazole 40 mg PO Q24H 9. Aspirin 81 mg PO DAILY 10. Loratadine 10 mg PO BID Discharge Medications: 1. Rivaroxaban 15 mg PO/NG BID FOR THE NEXT 3 WEEKS ONLY. RX *rivaroxaban [___] 15 mg 1 tablet(s) by mouth twice daily Disp #*42 Tablet Refills:*0 2. Clopidogrel 75 mg PO DAILY For the next ___ days. RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. metroNIDAZOLE 0.75 topical BID 4. Fluocinolone Acetonide 0.01% Solution 1 Appl TP Q24H PRN 5. Clobetasol Propionate 0.05% Soln 1 Appl TP BID 6. ALPRAZolam 0.5 mg PO TID:PRN anxiety 7. Aspirin 81 mg PO DAILY 8. Fluticasone-Salmeterol Diskus (500/50) 2 INH IH DAILY 9. Loratadine 10 mg PO BID 10. Montelukast 10 mg PO DAILY 11. Pantoprazole 40 mg PO Q24H 12. Rivaroxaban 20 mg PO DAILY Start ___ after loading dose of 15 mg twice daily. RX *rivaroxaban [___] 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*3 13. Lovastatin 10 mg ORAL DAILY Discharge Disposition: Home Discharge Diagnosis: Peripheral Arterial Disease Right Posterior Tibial Deep Vein Thrombosis 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 to the hospital with right leg pain that we found was secondary to a blockage in your bypass graft. We also noted a clot in a vein in your calf. We did a peripheral angiogram to open up the graft with special catheter and balloons. To do the procedure, a small puncture was made in one of your arteries. The puncture site heals on its own: there are no stitches to remove. You tolerated the procedure well and are now ready to be discharged from the hospital. Please follow the recommendations below to ensure a speedy and uneventful recovery. Peripheral Angiography Puncture Site Care For one week: •Do not take a tub bath, go swimming or use a Jacuzzi or hot tub. •Use only mild soap and water to gently clean the area around the puncture site. •Gently pat the puncture site dry after showering. •Do not use powders, lotions, or ointments in the area of the puncture site. You may remove the bandage and shower the day after the procedure. You may leave the bandage off. You may have a small bruise around the puncture site. This is normal and will go away one-two weeks. Activity For the first 48 hours: •Do not drive for 48 hours after the procedure For the first week: •Do not lift, push , pull or carry anything heavier than 10 pounds •Do not do any exercises or activity that causes you to hold your breath or bear down with abdominal muscles. Take care not to put strain on your abdominal muscles when coughing, sneezing, or moving your bowels. After one week: •You may go back to all your regular activities, including sexual activity. We suggest you begin your exercise program at half of your usual routine for the first few days. You may then gradually work back to your full routine. Medications: Before you leave the hospital, you will be given a list of all the medicine you should take at home. If a medication that you normally take is not on the list or a medication that you do not take is on the list please discuss it with the team! Followup Instructions: ___

10004749-DS-21

DS

2129-03-22 00:00:00

2129-03-27 15:54:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: abdominal pain and diarrhea Major Surgical or Invasive Procedure: none History of Present Illness: The patient is a ___ year old female with a history of GERD and prior C.diff infecion ___ years ago who presents with right lower quadrant abdominal pain. . She reports that the pain started when she awoke this morning. It is localized to the mid abdomen with radiation to the RLQ. She had some associated nausea without vomiting. The abdominal pain very similar to the pain with her previous C.diff colitis. She presented to her ___ clinic, where there was concern for appendicitis. She was also given Acetaminophen 975 mg PO. . After arriving in the ED, she began to have diarrhea, about ___ episodes. The pain was briefly relieved with defecation. She was incontinent of stool at times. There was no bright red blood per rectum or melena. She has felt slightly feverish, but did not check her temperature. Her appetite has been poor today. She denies any vaginal bleeding or discharge. . Prior to this morning, she was feeling at her baseline without any symptoms. She denies any recent antibiotics. Last week, she was on a cruise to ___. She did not have any diarrhea or GI symptoms on the trip. She did not drink any unbottled water or local food. . Initial vitals in ED triage were T 99.7, HR 110, BP 145/84, RR 16, and SpO2 98% on RA. Exam was notable to RLQ tenderness. Pelvic exam showed no CMT or adnexal tenderness. Her CBC was notable for WBC 17.6 with N 86.4%. Her chemistry panel showed Cr 0.7, K 3.4, bicarb 21, and anion gap 14. LFTs were unremarkable except for Lipase 61. UCG was negative and UA appeared contaminated with WBC 6 and few bacteria, but Epi 18. CT abd/pelvis showed several loops of small bowel in the right lower quadrant and pelvis with wall edema, minimal surrounding fat stranding, and trace free fluid. The appendix was minimally hyperemic but only 5-6 mm in diameter, and unlikely to represent acute appendicitis. . She was given NS ___ ml IV. Stool samples were sent for C.diff and bacterial culture. Antibiotics were held pending culture results. She received Morphine x3 and Dilaudid 0.5 mg IV x2. She continued to have abdominal pain and was admitted to medicine for pain control and further workup of her enteritis. . Vitals prior to floor transfer were T 99.2, HR 89, BP 119/74, RR 14, and SPO2 99% on RA. On reaching the floor, she reported continued abdominal pain in the periumbilical area with radiation to the RLQ. She reported baseline loose stool, but that the current diarrhea is abnormal for her. . REVIEW OF SYSTEMS: (+) Per HPI. Mild sore throat and hoarse voice, which she thinks is from not drinking anything in the ED. Some slight chills and mild fatigue. Recent sunburn while on cruise. (-) No fevers. No weight loss. No headache, rhinorrhea, or nasal congestion. No vertigo, presyncope, syncope, vision changes, hearing changes, focal weakness, or paresthesias. No chest pain, pressure, palpitations, SOB, cough, or hemoptysis. No dysphagia or odynophagia. No melena or BRBPR. No hematuria, dysuria, frequency, urgency, incontinence, or discharge. No back, neck, joint, or muscle pain. No rashes or concerning skin lesions. No easy bleeding or bruising. No depression or anxiety. Review of systems was otherwise negative. Past Medical History: # Asthma -- mild intermittent, rare Albuterol use # Chronic Sinusitis -- improved after ENT surgery ___ years ago # GERD -- high dose Omeprazole # C.diff Colitis (___) # Migraines -- few per year # Overweight Social History: ___ Family History: No famil history of inflammatory bowel disease or GI malignancy. # Mother: Healthy # Father: Died at age ___ from asthma exacerbation # Siblings: Brother who is well Physical Exam: ADMISSION: VS: T 98.7, BP 132/81, HR 98, RR 16, SpO2 97% on RA, Wt 153 lbs, Ht 62 in Gen: Young female in NAD. Oriented x3. Pleasant, bright affect. HEENT: Sclera anicteric. PERRL, EOMI. MMM, OP benign. Neck: JVP not elevated. No concerning cervical lymphadenopathy. CV: RRR with normal S1, S2. No M/R/G. Chest: Respiration unlabored, no accessory muscle use. CTAB without crackles, wheezes or rhonchi. Abd: Active bowel sounds. Soft, ND. No organomegaly or masses. Tender to palpation in RLQ and periumbilical area. Some rebound tenderness, minimal voluntary guarding. Ext: WWP. Digital cap refill <2 sec. No C/C/E. Distal pulses intact radial 2+, DP 2+, ___ 2+. Skin: No rashes or lesions noted in area of discomfort. Neuro: CN II-XII grossly intact. Moving all four limbs. Normal speech. DISCHARGE: VS: 97.9 115/60 88 18 99%RA Gen: Young female in NAD. Oriented x3. Pleasant, bright affect. HEENT: Sclera anicteric. MM moist, OP benign. Neck: JVP not elevated. No concerning cervical lymphadenopathy. CV: RRR with normal S1, S2. No M/R/G. Chest: Respiration unlabored, no accessory muscle use. CTAB without crackles, wheezes, or rhonchi. Abd: Active bowel sounds. Soft, ND. No organomegaly or masses. Tender to palpation in RLQ and periumbilical area but improved from yesterday. no rebound or guarding. psoas, obturatory, and ___ signs negative Ext: WWP. Digital cap refill <2 sec. No C/C/E. Distal pulses intact radial 2+, DP 2+, ___ 2+. Skin: No rashes or lesions noted in area of discomfort. Neuro: CN II-XII grossly intact. Moving all four limbs. Normal speech. Pertinent Results: ADMISSION; ___ 06:10PM BLOOD WBC-17.6*# RBC-4.55# Hgb-14.0 Hct-42.2 MCV-93 MCH-30.9 MCHC-33.3 RDW-12.7 Plt ___ ___ 06:10PM BLOOD Neuts-86.4* Lymphs-8.4* Monos-4.2 Eos-0.5 Baso-0.5 ___ 06:10PM BLOOD Plt ___ ___ 08:10AM BLOOD ___ PTT-27.2 ___ ___ 06:10PM BLOOD Glucose-88 UreaN-16 Creat-0.7 Na-139 K-3.4 Cl-104 HCO3-21* AnGap-17 ___ 06:10PM BLOOD ALT-19 AST-21 AlkPhos-60 TotBili-0.4 ___ 06:10PM BLOOD Albumin-4.6 Calcium-9.5 Phos-2.9 Mg-1.9 OTHER PERTINENT: ___ 08:10AM BLOOD WBC-7.3# RBC-4.04* Hgb-12.4 Hct-38.1 MCV-94 MCH-30.8 MCHC-32.6 RDW-13.0 Plt ___ ___ 08:10AM BLOOD Glucose-90 UreaN-14 Creat-0.6 Na-141 K-4.1 Cl-111* HCO3-20* AnGap-14 ___ 08:10AM BLOOD Calcium-8.6 Phos-2.4* Mg-1.8 ___ 05:04PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 05:04PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-MOD ___ 05:04PM URINE RBC-1 WBC-6* Bacteri-FEW Yeast-NONE Epi-18 MICRO: ___ 5:04 pm STOOL CONSISTENCY: WATERY Source: Stool. **FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final ___: NO OVA AND PARASITES SEEN. This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA FOUND. DISCHARGE: ___ 07:59AM BLOOD WBC-8.7 RBC-3.89* Hgb-12.1 Hct-36.4 MCV-94 MCH-31.1 MCHC-33.3 RDW-12.9 Plt ___ ___ 07:59AM BLOOD Glucose-93 UreaN-5* Creat-0.7 Na-138 K-4.2 Cl-108 HCO3-22 AnGap-12 ___ 07:59AM BLOOD Calcium-8.9 Phos-2.7 Mg-2.0 IMAGING: ___ CT ABD/PELVIS: IMPRESSION: 1. Enteritis involving several loops of small bowel located in the right lower quadrant of the abdomen and within the pelvis. Differential diagnosis includes infectious, inflammatory, and ischemic etiology. 2. The appendix is 5-6 mm in diameter, and given the diffuse inflammatory findings, appendicitis is not likely the cause of the patient's symptoms. ___ CXR: FINDINGS: The lung volumes are normal. No pleural effusions. No parenchymal abnormalities. Normal size of the cardiac silhouette. Brief Hospital Course: The patient is a ___ year old female with a history of GERD and prior C.diff infecion ___ years ago who presents with right lower quadrant abdominal pain and watery diarrhea. ACTIVE ISSUES: # Enteritis/Abdominal Pain: Most likely represents a viral enteritis given her associated URI symptoms of voice hoarseness and sinus congestion, though her recent cruise to ___ raises traveler's diarrhea as also possible but unlikely due to late presentation. Appendicitis was considered very unlikely based on imaging and prominence of diarrhea. Fortunately C-diff PCR is negative. Campylobacter and otther stool studies also negative. IBD very unlikely given the acute presentation and lack of alarm or systemic symptoms. She receivedI IV fluids, bismuth, and an empiric 3-day course of po ciprofloxacin. Her pain was managed with tylenol, opioids, and dicyclomine for cramping. She was tolerating a light diet prior to time of discharge. # Leukocytosis: Resolved after IV fluids overnight after admission. She had elevated WBC 17.6 with N 86.4% on admission. Most likely this is multifactorial from enteritis along with hypovolemia and hemoconcentration. Resolved with fluids alone without any initial empiric antibiotic coverage. CHRONIC ISSUES: # GERD: She takes Omeprazole 40 mg PO BID for GERD symptoms. Given her Cdiff history, tapering her PPI as an outpatient would be reasonable to consider. Continued Omeprazole 40 mg PO BID for now # Anxiety: Continued home fluoxetine. TRANSITIONAL ISSUES: - consider tapering omeprazole as outpatient if able given history of c-diiff Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Omeprazole 40 mg PO BID 2. Albuterol Inhaler ___ PUFF IH Q4-6H:PRN SOB 3. Fluoxetine 20 mg PO DAILY 4. Lorazepam 0.5-1 mg PO BID:PRN anxiety 5. acetaminophn-isometh-dichloral *NF* 325-65-100 mg Oral Q1H:PRN migraine up to maximum of 5 tabs in 12 hours 6. Microgestin Fe ___ (28) *NF* (norethindrone-e.estradiol-iron) 1.5-30 mg-mcg Oral DAILY Discharge Medications: 1. Fluoxetine 20 mg PO DAILY 2. Microgestin Fe ___ (28) *NF* (norethindrone-e.estradiol-iron) 1.5-30 mg-mcg Oral DAILY 3. Omeprazole 40 mg PO BID 4. Acetaminophen 1000 mg PO Q8H 5. DiCYCLOmine 20 mg PO QID RX *dicyclomine 20 mg 1 tablet(s) by mouth four times a day Disp #*10 Tablet Refills:*0 6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain do not take if drowsy or driving. Take only if pain persists despite taking acetaminophen. RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*15 Tablet Refills:*0 7. Albuterol Inhaler ___ PUFF IH Q4-6H:PRN SOB 8. Lorazepam 0.5-1 mg PO BID:PRN anxiety 9. Ondansetron 4 mg PO Q8H:PRN nausea RX *ondansetron 4 mg 1 tablet,disintegrating(s) by mouth every eight (8) hours Disp #*10 Tablet Refills:*0 10. Ciprofloxacin HCl 500 mg PO Q12H Duration: 3 Doses take through end of ___ RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*3 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: gastroenteritis 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 the ___ ___. You were admitted with diarrhea and abdominal pain. We treated you with antibiotics, fluids and pain medications, and your symptoms improved. You were able to eat and drink by the time of discharge. You will need to continue treatment with antibiotics for a further 1 day. We also gave you medications to contorl pain and cramping. Please followup with your primary care practitioner. Followup Instructions: ___

10005024-DS-4

DS

2138-04-19 00:00:00

2138-04-19 13:18:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: -Flexible sigmoidoscopy ___ -Colonic stent placement ___ History of Present Illness: Mr. ___ is a ___ with history of HCV, etOH use, and hypertension who presents upon transfer from ___ with abdominal pain and found to have likely metastatic colon cancer on CT imaging. The patient reports that he has had dark, liquid bowel movements for the past several weeks. He also reports crampy lower abdominal pain for the past several days which has been worsening. His symptoms have been associated with weight loss; the patient reports 40-lbs over just a few weeks. Lately, the patient has also noticed some lightheadedness with rising with unsteadiness while walking. At ___, the patient was noted to have a hematocrit of 34% and sodium of 118. A CT abdomen showed a rectosigmoid mass with likely metastases to the liver and lungs. Given concern for a RLL infiltrate, he was given antibiotics for a community-acquired pneumonia. Upon transfer to ___ ED, he was found to have a further reduced hematocrit after IV fluids. Past Medical History: Hypertension Alcohol dependence Hepatitis C infection Social History: ___ Family History: Mother without significant illnesses. Father with heart condition. Physical Exam: ADMISSION: Vitals: 97.4 134/95 104 22 71.2kg General: Disheveled appearing, drowsy. No acute distress. HEENT: Sclera anicteric. Pale conjunctiva. Pupils equal and reactive to light. Poor dentition. Oropharynx clear. Dry mucous membranes. NECK: Supple. Heart: Tachycardic. Regular rate and rhythm. Normal S1, S2. No murmurs. Lungs: Decreased breath sounds at the bases bilaterally. No wheezes, crackles, or rhonchi. Abdomen: +BS, soft, nondistended. Tender to palpation diffusely. +Hepatomegaly. Genitourinary: No foley. Extremities: Warm and well perfused. Pulses 2+. No peripheral edema. DISCHARGE: Vitals: none GENERAL: Pale appearing not moving. Not arousable to sternal rub HEENT: No pupilary or corneal reflex. Pale conjunctiva CARDIAC: no heart sounds PULMONARY: No breath sounds EXTREMITIES: Cool, no pulses. NEURO: no corneal, pupilary, gag reflexes. No withdrawal to painful stimulus. Pertinent Results: ADMISSION LABS: ============== ___ 01:30AM BLOOD WBC-8.0 RBC-3.83* Hgb-10.8* Hct-31.0* MCV-81* MCH-28.1 MCHC-34.7 RDW-15.3 Plt ___ ___ 06:19AM BLOOD ___ PTT-30.5 ___ ___ 01:30AM BLOOD Glucose-93 UreaN-7 Creat-0.4* Na-123* K-3.5 Cl-90* HCO3-19* AnGap-18 ___ 01:30AM BLOOD ALT-30 AST-64* AlkPhos-364* TotBili-0.7 ___ 01:30AM BLOOD Albumin-3.1* Calcium-8.2* Phos-2.6* Mg-1.9 IMAGING: ======== CT ABD PLV w/oral Contrast (___) IMPRESSION: 1. Interval (since ___ placement of a colonic stent, 2. Circumscribed 10.4 x 7.4mm anterior pelvic fluid collection containing small locules of gas, likely an abscess from sigmoid tumor perforation. This is amenable to drainage. 2a. Moderate/large amount of free air, and small amount of free fluid within the peritoneum. 3. Extensive lymphadenopathy in the retroperitoneum and porta hepatis, which results in narrowing of the origin of the left renal vein. Encasement of the splenic vein-SMV confluence and bilateral renal arteries is also demonstrated, without significant intraluminal narrowing in these vessels. Normally enhancing kidneys on today's study. 4. Innumerable hepatic metastases. 5. Innumerable pulmonary metastases, lungs only partially imaged. 6. Moderately-sized bilateral non-hemorrhagic pleural effusions. ___ Flexible sigmoidoscopy A circumferential mass was encountered at the rectosigmoid junction around 15 cm from the anal verge highly suspcious for primary colorectal cancer. The colonoscope was unable to traverse the stricture which was estimated at around 9mm in diameter.The mass was very friable. (biopsy) Otherwise normal sigmoidoscopy to distal sigmoid colon. Sigmoidoscopy ___: Contents: Solid green stool was found in the rectum. No fresh or old blood was noted. A metal stent was found in the rectum. There is mild tumor ingrowth into the mid-portion of the stent. This area is friable with some bleeding from passage of the endoscope - likely source of bleeding. Impression: Stent in the rectum Stool in the rectum Otherwise normal sigmoidoscopy to splenic flexure Recommendations: Stool softners and laxatives as d/w inpatient team. Oral iron CXR ___: IMPRESSION: There is no clear radiographic change over the past 11 days. Bilateral pleural effusions moderate on the right small on the left and callus pulmonary nodules are unchanged. Extent of central adenopathy is better revealed by the chest CT scan. Confluent opacification at the base of the right lung is probably atelectasis, pleural mild pneumonia is difficult to exclude. In all other locations there no findings that would raise the possibility of pneumonia. ___ ___: FINDINGS: There is normal compressibility, flow and augmentation of the bilateral common femoral, proximal, mid, distal femoral, and popliteal veins. Normal color flow and compressibility are demonstrated in the posterior tibial and peroneal veins. There is normal respiratory variation in the common femoral veins bilaterally. No evidence of medial popliteal fossa (___) cyst. IMPRESSION: No evidence of deep venous thrombosis in the bilaterallower extremity veins. EKG ___: Narrow complex tachycardia. Probably sinus tachycardia. Compared to the previous tracing of ___ the rate has increased. CXR ___: FINDINGS: Numerous nodular opacities compatible the patient's metastatic disease are again appreciated. In addition, there is worsening pulmonary edema as well as a worsening right lower lobe infiltrate which could represent pneumonia in the correct clinical setting. A right pleural effusion is also increased in size. IMPRESSION: Worsening combination of pleural effusion, pulmonary edema and possibly pneumonia particularly in the right lower lobe. CTA CHEST W/ CONTRAST ___: IMPRESSION: 1. Partially limited evaluation of the subsegmental pulmonary arteries, however no evidence of central, lobar, or segmental pulmonary embolism. 2. Since ___, increase in size and number of innumerable pulmonary metastases, as well as enlargement of bilateral pleural effusions, large on the right and moderate on the left. 3. Partially imaged upper abdomen demonstrates diffuse intrahepatic metastasis and considerable upper abdominal lymphadenopathy. KUB ___: IMPRESSION: 1. Rectal stent overlying the sacrum. 2. No bowel obstruction. 3. Likely interval decrease of small right pleural effusion. CT ABDOMEN PELVIS W/ CONTRAST ___: IMPRESSION: 1. Interval (since ___ placement of a colonic stent, 2. Circumscribed 10.4 x 7.4mm anterior pelvic fluid collection containing small locules of gas, likely an abscess from sigmoid tumor perforation. This is amenable to drainage. 2a. Moderate/large amount of free air, and small amount of free fluid within the peritoneum. 3. Extensive lymphadenopathy in the retroperitoneum and porta hepatis, which results in narrowing of the origin of the left renal vein. Encasement of the splenic vein-SMV confluence and bilateral renal arteries is also demonstrated, without significant intraluminal narrowing in these vessels. Normally enhancing kidneys on today's study. 4. Innumerable hepatic metastases. 5. Innumerable pulmonary metastases, lungs only partially imaged. 6. Moderately-sized bilateral non-hemorrhagic pleural effusions PATHOLOGY: ========== ___ GI mucosa PATHOLOGIC DIAGNOSIS: Sigmoid mass biopsy: Adenocarcinoma, low grade Brief Hospital Course: Mr. ___ was a ___ with history of HCV and EtOH abuse who presented with abdominal pain and melena with imaging concerning for metastatic colon cancer. ACUTE ISSUES: ============= # Metastatic colon cancer: Patient presented with weight loss for several months with anemia and abdominal pain. Patient without prior preventative health care. Imaging from outside hospital demonstrated rectosigmoid mass with metastases to the liver and lungs. Patient underwent flexible sigmoidoscopy with biopsy demonstrating adenocarcinoma. Given near complete obstruction Advanced Endoscopy placed a palliative stent. He developed diffuse abdominal pain on ___ CT abd showed colonic stent perforation. He was not deemed a surgical candidate due to his widely metastatic disease. He wished to become CMO/DNR/DNI, and expired peacefully on ___. Family was notified and declined autopsy. # Abdominal Stent Perforation: Experienced diffuse abdominal pain on ___, CT abdomen showed perforation ___ stent. He was not felt to be a good surgical candidate due to metastatic cancer and poor functional status. He wished to become CMO. Vancomycin, Ceftriaxone, and Metronidazole were prescribed to improve his abdominal pain and discomfort. # Hyponatremia, chronic: Patient presented with sodium of 118 at outside hospital The patient was given IV fluids until stable sodium level reached at 127. SIADH was thought to be a significant component of his hyponatremia, given his extensive metastatic disease to his lungs. # Septicemia: Met sepsis criteria on ___. Thought to be due to either hospital-associated pneumonia or GI translocation in the setting of stent perforation. He was treated with antibiotics until his family was able to visit, then discontinued. # Hospital-Associated Pneumonia: He developed increased sputum production and shortness of breath, and a chest x-ray was suggestive of right lower lobe pneumonia. He was treated with vancomycin and ceftriaxone. CHRONIC ISSUES: =============== # Microcytic anemia: Patient found to have anemia with MCV 79. Iron studies demonstrated anemia of chronic disease and also likely iron deficient in setting of chronic bleeding from GI malignancy. He was started on iron supplementation. # Transaminitis: Likely secondary to metastatic liver involvement vs. EtOH use given elevated AST:ALT ratio. # Alcohol abuse: Patient reports chronic use of alcohol, multiple beers and at least two shots of brandy daily. Has continued to drink despite lack of appetite prior to hospitalization. During his admission, he had no evidence of withdrawal. # Melena: Patient had melena after stent placement. Sigmoidoscopy on ___ showed tumor infiltration into the stent with friable, bleeding tissue, which was the likely source of his bleeding. # Hypertension: Held home lisinopril in the setting of low blood pressures. # Hepatitis C: untreated. Medications on Admission: none Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Primary: ======= Metastatic colon (adenocarcinoma) cancer Colonic perforation Hospital associated pneumonia Septicemia Secondary: ========== Anemia Hypertension Hyponatremia Hepatitis C Discharge Condition: expired Discharge Instructions: Dear loved ones of Mr. ___, It was as pleasure taking part in his care during your hospitalization at ___. He wastransferred from ___ ___ after a CT scan was concerning for colon cancer. A biopsy revealed colon cancer with metastases to his liver and his lung. He had a stent placed in his colon to relieve his abdominal pain. He wasseen by the Oncologists who felt he was not a candidate for chemotherapy given his weakness/poor functional status. Over his hospitalization he had pneumonia, which was treated with antibiotics. He developed worsening abdominal pain and was found to have a perforated colon from the stent that was placed. It was a pleasure taking part in his care! Followup Instructions: ___

10005308-DS-20

DS

2178-04-20 00:00:00

2178-04-20 14:00:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: right ankle fracture dislocation Major Surgical or Invasive Procedure: right ankle surgical fixation History of Present Illness: ___ healthy female who sustained a right ankle injury following a mechanical slip and fall down stairs. She states she was packing to fly home tomorrow morning when she was going to load up her suitcase down stairs, slipped on the last step, twisting and injuring her ankle. Denied head strike or loss of consciousness. She is not currently on anticoagulation. She denies any numbness or paresthesias in the right foot. She denies any previous injury to the right ankle. Notably she is currently in town visiting her son. She lives in ___ currently. She is here with her husband and son. Past Medical History: none Social History: ___ Family History: noncontributory Physical Exam: Right lower exam -splint c/d/I -grossly moves exposed toes -silt in exposed toes -toes WWP 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 ankle fracture dislocation and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for open reduction internal fixation of right ankle 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 nonweightbearing in the right lower extremity in a splint, and will be discharged on Lovenox for DVT prophylaxis. The patient will follow up with Dr. ___ routine. Alternatively, since she is from ___ she may choose to follow-up with an orthopedic provider ___. She was instructed to follow-up in 2 weeks. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Medications on Admission: none Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H 2. Docusate Sodium 100 mg PO BID 3. Enoxaparin Sodium 40 mg SC QHS RX *enoxaparin 40 mg/0.4 mL ___t bedtime Disp #*28 Syringe Refills:*0 4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain don't drink or drive while taking RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours PRN Disp #*30 Tablet Refills:*0 5. Senna 8.6 mg PO BID Discharge Disposition: Home Discharge Diagnosis: right ankle 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: 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: -Nonweightbearing right lower extremity in splint MEDICATIONS: 1) Take Tylenol ___ every 6 hours around the clock. This is an over the counter medication. 2) Add oxycodone as needed for increased pain. Aim to wean off this medication in 1 week or sooner. This is an example on how to wean down: Take 1 tablet every 3 hours as needed x 1 day, then 1 tablet every 4 hours as needed x 1 day, then 1 tablet every 6 hours as needed x 1 day, then 1 tablet every 8 hours as needed x 2 days, then 1 tablet every 12 hours as needed x 1 day, then 1 tablet every before bedtime as needed x 1 day. Then continue with Tylenol for pain. 3) Do not stop the Tylenol until you are off of the narcotic medication. 4) Per state regulations, we are limited in the amount of narcotics we can prescribe. If you require more, you must contact the office to set up an appointment because we cannot refill this type of pain medication over the phone. 5) Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and continue following the bowel regimen as stated on your medication prescription list. These meds (senna, colace, miralax) are over the counter and may be obtained at any pharmacy. 6) Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. 7) Please take all medications as prescribed by your physicians at discharge. 8) Continue all home medications unless specifically instructed to stop by your surgeon. ANTICOAGULATION: - Please take Lovenox 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. DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever ___ 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns THIS PATIENT IS EXPECTED TO REQUIRE ___ DAYS OF REHAB Followup Instructions: ___

10005606-DS-17

DS

2143-12-16 00:00:00

2143-12-16 09:33:00

Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: neck fracture Major Surgical or Invasive Procedure: ___ C5/6 corpectomy, C4-C7 ACDF ___ C2-T2 posterior cervical fusion, C4-6 cervical laminectomy History of Present Illness: ___ year-old male who presents s/p intoxicated fall from ___ story balcony. He denies LOC, but sustained a laceration to his face. He complaining of neck, chest and right shoulder pain. CT of the cervical spine demonstrated comminuted C5-C7 fractures, T2 superior endplate fracture. He also sustained a sternal fracture. He denies numbness, tingling, weakness, or loss of bowel or bladder function. Past Medical History: ETOH abuse Social History: ___ Family History: NC Physical Exam: PHYSICAL EXAMINATION: General: laceration/abrasions to face, Alert and interacting, but appears intoxicated nl resp effort RRR Sensory: UE C5 C6 C7 C8 T1 (lat arm) (thumb) (mid fing) (sm finger) (med arm) R SILT SILT SILT SILT SILT L SILT SILT SILT SILT SILT T2-L1 (Trunk) SILT ___ L2 L3 L4 L5 S1 S2 (Groin) (Knee) (Med Calf) (Grt Toe) (Sm Toe) (Post Thigh) R SILT SILT SILT SILT SILT SILT L SILT SILT SILT SILT SILT SILT Motor: UE Dlt(C5) Bic(C6) WE(C6) Tri(C7) WF(C7) FF(C8)FinAbd(T1) R 5 5 5 5 5 5 5 L 5 5 5 5 5 5 5 ___ Flex(L1) Add(L2) Quad(L3) TA(L4) ___ ___ R 5 5 5 5 5 5 5 L 5 5 5 5 5 5 5 Reflexes Bic(C4-5) BR(C5-6) Tri(C6-7) Pat(L3-4) Ach(L5-S1) R 2 2 2 2 2 L 2 2 2 2 2 ___: Negative Babinski: Downgoing Clonus: No beats Postop: gen: awake, pleasant, Dressings with staining skin: warm and dry, incision are intact ___: normal breathing abd: soft, nt extr: no c/c/e Neurologic: Motor Strength: Delt Bi Tri BR WF/WE HI Right 5 5 5 5 5 5 Left 4+ 4+ 4- 4 4 4 IP Quad Ham TA Gas ___ Right 5 5 5 5 5 5 Left 5 5 5 5 5 5 Sensation: dyesthesia bilateral C7/C8 distribution Pertinent Results: Trauma Pelvis XR ___ IMPRESSION: 1. No acute cardiopulmonary process. No obvious rib fractures. 2. No fracture or dislocation involving the ___, hips, and partially imaged femurs. ___ C/A/P CT IMPRESSION: 1. Comminuted and displaced sternal fracture with surrounding hematoma and underlying pulmonary contusion in the right middle lobe. 2. Subtle focal irregularity of the superior T12 vertebral body with subtle superior endplate depression, suspicious for T12 compression fracture. 3. No additional acute fracture is identified. 4. Small amount of hyperdense material between the right kidney and psoas muscle most likely representing hematoma without active extravasation. Adjacent ureter appears patent but with short-segment luminal narrowing. Close follow-up is recommended. 5. No additional traumatic organ injury in the chest, abdomen, or pelvis. Ct c-spine ___ 1. Multiple mildly displaced comminuted fractures through the C5, C6, and C7 vertebral bodies as described above, with traumatic kyphotic angulation at C5-C6 and extension into the spinal canal with fractures involving the C4, C5, C6 spinous processes, lamina and multiple levels, and right C5-C6 facet joint and possibly right C6-C7 facet joint. Additional acute anterosuperior endplate fracture of T2 is also noted. 2. Extensive prevertebral edema from C2-C3 through T1-T2. CT head ___ 1. Large scalp hematoma over the vertex with skin laceration. No underlying calvarial fracture. No evidence of acute intracranial hemorrhage. CT Head angiogram ___ 1. Patent intracranial and cervical vasculature without high-grade stenosis, occlusion, or dissection. 2. Numerous known comminuted fractures involving the mid to lower cervical spine are better delineated on the separately reported CT cervical spine examination. 3. For description of the intracranial parenchymal findings please see the separate CT head examination performed earlier on the same day. Cervical spine MRI ___ . Redemonstrated acute to subacute compression deformities of the C5, C6 and C7 vertebral bodies with associated unchanged traumatic kyphotic deformity at C5-C6. There is also evidence of acute to subacute compression deformities of the superior endplates of the T2 and T3 vertebral bodies with minimal loss of vertebral body height. 2. Redemonstrated multilevel mildly displaced cervical spine fractures extending from C4 through C7, better described on the recent CT cervical spine study. 3. Evidence of increased interspinous interval and ligamentum flavum disruption at C4-C5 with findings suspicious for CSF leak at this level. 4. Extensive edema of the posterior paraspinal musculature extending from C2 through T1. 5. Unchanged traumatic kyphotic angulation at C5-C6. 6. Moderate prevertebral edema is likely trauma related. 7. Degenerative changes of the cervical spine most significant at C5-C6 where superimposed traumatic kyphotic deformity results in mild spinal canal narrowing and flattening of the ventral cord without evidence of abnormal cord signal. pCXR ___ In comparison with the study of ___, the bilateral layering pleural effusions are no longer seen. However, this appearance could merely reflect a more upright position of the patient. No pneumonia, vascular congestion, or other abnormality. Cervical fusion device is again seen. Brief Hospital Course: Patient was admitted to Orthopedic Spine Service on ___ in the trauma ICU for further management. He underwent the above stated procedure on ___ and ___. Patient tolerated the procedures well without complication. Please review dictated operative report for details. Patient remained intubated postoperative for respiratory failure and delirium tremens. He was started on folate/thiamine IV and phenobarb for agitation and DTs. His neuro exam was monitored closely. His ICU course is as follows: ___- paresthesias in bilateral thumbs, consented to remain intubated x2d for procedures if needed > to OR for ACDF EBL 2.2L ___, 2u pRBC, 4u FFP remained intubated (easy with ___, lactate downtrending. plan for OR likely ___. started phenobarb load postop. BPs with MAPS in ___, UOP trending down > gave albumin bolus, expect Hct to continue slow downtrend for now but holding off on blood. ___- Neuro exam improved, only mild numbness in left ___ digit. Hct stable 23.7->24. Sedation increased and phenobarb rescue dosed for agitation/tremors. Hypercarbic on ASV with increased sedation. Switched to CMV but hypoxic with paO2 75-> PEEP increased to 8. CXR without congestion or consolidation. TTE: LVEF 74%. Grade I (mild) left ventricular diastolic dysfunction. ___: pt intermittently agitated, will write midaz PRN; pt to go to the OR today for posterior fusion, EBL 3.5 L, 6U PRBC, 2U Plts, 1U FFP; post op Hct 28, pt HDS and has to be flat for CSF leak. Pt anemic preop, got 1UPRBC. ankle XR showed ankle sprain, can immobilize if uncomfortable/consult ortho. ___: Og tube replaced. stays flat for 24h, until ___ on ___. wean propofol, add precedex. repeat CBC is 8.8/26.4. per spine, SQH restarted. concern for ? CSF leak on the blanket, ortho spine consulted- discussed with ___. will monitor. does not think it is csf leak. ___: Pt extubated in the AM, doing well from resp standpoint, good O2 sat on RA. NGT out, A-line out, +gas, -BM, Still agitated on precedex, being weaned off. HLIV, foley still in, Neurochecks Q4H, lactulose added to bowel regimen, worked with ___: recommending rehab ___: pt continues on dex intermittently, was interactive and appropriate with friend today. will continue to monitor for agitation ___: febrile with leukocytosis. plan is for fever workup with Cdiff, UA, Blood culture, CXR. gabapentin TID. speech and swallow consult. plan to transfer to spine, no longer has ICU needs. He was transferred to floor in stable condition on ___. During the patient's course ___ were used for postoperative DVT prophylaxis. Diet was advanced as tolerated. Foley was removed in routine fashion and patient voided without incident. Hemovac was removed in routine fashion once the output per 8 hours became minimal. He was complicated by diarrhea on ___ and CDIFF was sent. On ___, patient + for CDIFF and was started on flagyl po for 10 days. His diarrhea improved as of ___. Neurologically he had dysesthesia and numbness. He had LUE weakness secondary to spinal cord injury and jumped facet. Physical therapy and Occupational therapy were consulted for mobilization OOB to ambulate and ADL's. Now, Day of Discharge, patient is afebrile, VSS, and neuro stable s/p SCI. He had LUE weakness and bilateral ulnar weaknessPatient tolerated a good oral diet and pain was controlled on oral pain medications. Patient ambulated without issues. Patient's wound is clean, dry and intact. Patient is set for discharge to home in stable condition. Medications on Admission: none Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H RX *acetaminophen 650 mg ___ tablet(s) by mouth every eight (8) hours Disp #*120 Tablet Refills:*0 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 3. FoLIC Acid 1 mg PO DAILY RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. Gabapentin 300 mg PO Q8H RX *gabapentin 300 mg 1 capsule(s) by mouth every eight (8) hours Disp #*90 Capsule Refills:*1 5. MetroNIDAZOLE 500 mg PO Q8H Duration: 7 Days RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth three times a day Disp #*21 Tablet Refills:*0 6. OxycoDONE Liquid 5 mg PO Q3H:PRN Pain - Moderate RX *oxycodone 5 mg 1 tab by mouth Q4-6h Disp #*40 Tablet Refills:*0 7. Thiamine 100 mg PO DAILY RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: c5 fx C6 fx jumped facet fx CSF leak Delirium Tremens D-diff colitis spinal cord injury respiratory failure alcohol abuse respiratory failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent with Hard collar on at all times Discharge Instructions: ACDF: You have undergone the following operation: Anterior Cervical Decompression and Fusion. 1.When you are discharged from the hospital and settled at home/rehab, if you do not have an appointment, please call to schedule two appointments: 1.a wound check visit for 8 -14 days after surgery 2.a post-operative visit with your surgeon for ___ weeks after surgery. 1.You can reach the office at ___ and ask to speak with staff to schedule or confirm your appointments. Wound Care •If not already done in the hospital, remove the incision dressing on day 2 after surgery. Keep the incision dry for the first two days after surgery. •There will often be small white strips of tape over the incision (steri-strips). These should be left alone and may get wet in the shower on day 3. •Starting on the third day, you should be washing your incision DAILY. While holding the head and neck still, gently clean the incision and surrounding area with mild soap and water, rinse and then pat dry. •Do not put any lotion, ointments, alcohol, or peroxide on the incision. •If you have a multi-level fusion and require a hard cervical collar, this may be removed for showering, and often sleeping and eating. The collar will typically be removed at the week 4 visit. •You may remove the compression stockings when you leave the hospital •Have someone look at the incision daily for 2 weeks. Call the surgeon’s office if you notice any of the following: ___ redness along the length of the incision ___ swelling of the area around your incision ___ from the incision ___ of your extremities greater than before surgery ___ of bowel or bladder control ___ of severe headache ___ swelling or calf tenderness ___ above 101.5 •At your wound check visit, the Nurse Practitioner or ___ ___, will check your wound and remove any sutures or staples or steri-strips. •Do not soak or immerse your incision in water for 1 month. For example, no tub baths, swimming pools or jacuzzi. Medications • You will be given prescriptions for pain medications and stool softeners upon discharge from the hospital. •Pain medications should be taken as prescribed by your surgeon or nurse practitioner/ physician ___. You are allowed to gradually reduce the number of pills you take when the pain begins to subside. •If you are taking more than the recommended dose, please contact the office to discuss this with a practitioner ___ medication may need to be increased or changed). •Constipation: Pain medications (narcotics) may cause constipation (difficulty having a bowel movement). It is important to be aware of your bowel habits so you ___ develop severe constipation. Call the office if this occurs for more than 3 days or if you have stomach pain. •Most prescription pain medications cannot be called into the pharmacy for renewal. The following are 2 options you may explore to obtain a renewal of your narcotic medications: 1.Call the office ___ days before your prescription runs out and speak with our office staff about mailing a prescription to your home/pharmacy. (Prescriptions will not be sent by Fed Ex/UPS) 2.Call the office 24 hours in advance and speak with office staff about coming into the office to pick up a prescription. •If you continue to require medications, you may be referred to a pain management specialist or your medical doctor for ongoing management of your pain medications. •Avoid NSAIDS for 12 weeks post-operative. These medications include, but are not limited to the following: •Non-Steroidal Anti-Inflammatory Agents: Advil, Aleve, Cataflam, Clinoril, Diclofenac, Dolobid, Feldene, Ibuprofen, Indocin, Medipren, Motrin, Nalfon, Naprosyn, Nuprin, Relafen, Rufen, Tolectin, Toradol, Trilisate, Voltarin Activity Guidelines •If you have a multi-level cervical fusion, you will be asked to wear a hard cervical collar. This is typically removed at week 4 after surgery. You may not drive while wearing the collar. •You may remove your cervical collar for eating, sleeping, and when showering. •Avoid strenuous activity, bending, pushing, or reaching overhead. For example, you should not vacuum, do large loads of laundry, walk the dog, wash the car, etc. until your follow-up visit with your surgeon. •Avoid heavy lifting. Do not lift anything over ___ pounds for the first few weeks that you are home from the hospital. •Increase your activities a little each day. Walking is a form of exercise. Exercise should not cause pain. Limit yourself to things that you can do comfortably and plan rest periods throughout the day. •You are not unless you are not taking narcotic medication and are not required to wear a collar. You may ride in a car for short distances and avoid sitting in one position for too long. •You may resume sexual activity ___ weeks after surgery, avoiding stress on the neck and shoulders. Physical Therapy •Outpatient Physical Therapy (if appropriate) will not begin until after your post-operative visit with your surgeon. A prescription is needed for formal outpatient therapy. •You may be given simple stretching exercises or a prescription for formal outpatient physical therapy, based on what your needs are after surgery. Blood Clots in the Leg 1.It is not uncommon for patients who recently had surgery to develop blood clots in leg veins. •Symptoms include low-grade fever, and/or redness, swelling, tenderness, and/or an aching/cramping pain in your calf. •You should call your doctor immediately if you have these symptoms. •To prevent blood clots in legs, try walking and/or pumping ankles several times during the day. •If the blood clot breaks free from the leg vein, it can travel to the lungs and cause severe breathing difficulty and/or chest pain. If you experience this, call ___ immediately. Questions •Any questions may be directed to your surgeon or nurse practitioner/ physician ___. 1.During normal business hours (8:30am- 5:00pm), you can call our office directly at ___. If no one picks up, please leave a message and someone will get back to you. •If you are calling with an urgent medical issue, please go to nearest emergency room (i.e. pain unrelieved with medications, wound breakdown/infection, or new neurological symptoms). Rigid Collar Instructions •How to put collar on: ___ collar is labeled front and back with arrows indicating top and bottom. ___ the back section on your neck first. Apply the front section placing your chin in the chin rest. ___ securing the Velcro, make sure the front overlaps the back section. This allows more Velcro to be exposed giving the collar a more secure fit. ___ the collar as tight as you can while remaining comfortable. The tighter it is worn, the more immobilization of your spine is obtained and the less likely you will move your neck. •Care for/during use: ___ alert to pressures under your chin. Some pressure is necessary but do not allow a blister or pressure sore to develop. ___ provide comfort, you should wear the collar liners provided between the brace and your chin to absorb perspiration and lessen irritation. We recommend that these liners be hand washed. ___ collar can be washed with mild soap and water, then dried with a towel and/or hair dryer on the lowest setting. Hand washing is recommended. Posterior Cervical Fusion You have undergone the following operation: Posterior Cervical Decompression and Fusion Immediately after the operation: • Activity:You should not lift anything greater than 10 lbs for 2 weeks.You will be more comfortable if you do not sit in a car or chair for more than~45 minutes without getting up and walking around. • Rehabilitation/ Physical ___ times a day you should go for a walk for ___ minutes as part of your recovery.You can walk as much as you can tolerate.Limit any kind of lifting. • Cervical Collar / Neck Brace:You need to wear the brace at all times until your follow-up appointment which should be in 2 weeks.You may remove the collar to take a shower.Limit your motion of your neck while the collar is off.Place the collar back on your neck immediately after the shower. • Wound Care:Remove the dressing in 2 days.If the incision is draining cover it with a new sterile dressing.If it is dry then you can leave the incision open to the air.Once the incision is completely dry (usually ___ days after the operation) you may take a shower.Do not soak the incision in a bath or pool.If the incision starts draining at anytime after surgery,do not get the incision wet.Call the office at that time.If you have an incision on your hip please follow the same instructions in terms of wound care. • 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 operation if this has not been done already. ___ At the 2-week visit we will check your incision, take baseline x rays and answer any questions. Please call the office if you have a fever>101.5 degrees Fahrenheit,drainage from your wound,or have any questions. Followup Instructions: ___

10005749-DS-17

DS

2145-09-14 00:00:00

2145-09-16 20:38:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: High blood sugars, labs showing acute on chronic kidney injury Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ with a h/o renal transplant, CHF, AFib on Coumadin, DM who presented to the ED on ___ with hyperglycemia (600s) and worsening kidney function on routine tests at PCP. On ___, her blood glucose was 665, and her Hgb A1c was found to be 12.7. Her creatinine was 2.1, up from 1.4 in ___ (most recent value). Had been taking her home Glipizide as prescribed. She had been urinating frequently and had a cold a few days prior to admission, but otherwise had no symptomatic complaints. Past Medical History: ATRIAL FIBRILLATION CHRONIC KIDNEY DISEASE DIABETES TYPE II HYPERLIPIDEMIA HYPERTENSION GALLSTONE PANCREATITIS S/P SPHINCTEROTOMY S/P RENAL TRANSPANT SYSTOLIC CONGESTIVE HEART FAILURE EF ___ SHINGLES - FOREHEAD DIABETES MELLITUS MITRAL REGURGITATION URINARY TRACT INFECTION RENAL TRANSPLANT ___ BILATERAL NEPHRECTOMIES ___ SPHINCTEROTOMY BREAST AUGMENTATION Social History: ___ Family History: Sister RENAL TRANSPLANT Daughter POLYCYSTIC KIDNEYS Physical Exam: PHYSICAL EXAM upon admission: Vitals: 97.4 PO, 160 / 55, 71, 20, 97 Ra Intake: 480, outs not recorded General: alert, oriented, no acute distress HEENT: sclera anicteric, slightly dry mucus membranes, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Irregularly irregular rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNs2-12 intact, motor function grossly normal PHYSICAL EXAM upon discharge: Vitals: 97.4 PO, 160 / 55, 71, 20, 97 Ra Intake: 480, outs not recorded General: alert, oriented, no acute distress HEENT: sclera anicteric, slightly dry mucus membranes, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Irregularly irregular rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNs2-12 intact, motor function grossly normal Pertinent Results: LABS UPON ADMISSION ___ 05:42PM BLOOD UreaN-46* Creat-2.1* Na-127* K-4.0 Cl-86* HCO3-22 AnGap-23* ___ 05:42PM BLOOD Glucose-665* ___ 05:42PM BLOOD WBC-7.9 RBC-3.54* Hgb-9.8* Hct-29.1* MCV-82 MCH-27.7 MCHC-33.7 RDW-14.1 RDWSD-41.6 Plt ___ ___ 05:42PM BLOOD %HbA1c-12.7* eAG-318* ___ 12:15PM BLOOD Glucose-548* UreaN-47* Creat-1.9* Na-122* K-3.8 Cl-85* HCO3-21* AnGap-20 ___ 12:15PM BLOOD WBC-11.2* RBC-3.64* Hgb-10.1* Hct-30.0* MCV-82 MCH-27.7 MCHC-33.7 RDW-14.1 RDWSD-41.8 Plt ___ ___ 12:15PM BLOOD Neuts-90.2* Lymphs-6.1* Monos-2.1* Eos-0.2* Baso-0.2 Im ___ AbsNeut-10.14* AbsLymp-0.68* AbsMono-0.24 AbsEos-0.02* AbsBaso-0.02 LABS UPON DISCHARGE: ___ 11:19AM BLOOD Glucose-221* UreaN-42* Creat-1.8* Na-130* K-3.1* Cl-91* HCO3-22 AnGap-20 ___ 05:56PM BLOOD Glucose-356* UreaN-43* Creat-1.9* Na-126* K-4.0 Cl-89* HCO3-23 AnGap-18 ___ 11:19AM BLOOD WBC-11.4* RBC-3.64* Hgb-10.1* Hct-30.1* MCV-83 MCH-27.7 MCHC-33.6 RDW-14.1 RDWSD-41.7 Plt ___ ___ 11:19AM BLOOD ___ PTT-35.5 ___ IMAGING: RENAL US ___ IMPRESSION: 1. Patent renal transplant vasculature. 2. Borderline to minimally elevated intrarenal resistive indices measuring up to 0.79 in the interpolar region. CXR ___ IMPRESSION: Persistent small left and trace right pleural effusions and cardiomegaly. No pulmonary edema. Brief Hospital Course: ___ with a history of renal transplant, CHF, AFib on Coumadin, DM who was admitted on ___ after she was found to have hyperglycemia (600s) and worsening renal function on routine lab tests at PCP (Cr 2.1 on ___, up from most recent 1.4 on ___. # Hyperglycemia / T2DM: Pt presented with significant hyperglycemia with ___ and elevated serum osms (but not meeting criteria for HHS). Treated with insulin in ED and developed low K. Given her significantly elevated glucose and HbA1c, the patient requires insulin therapy for glucose control. ___ was consulted and recommended the following regimen: NPH 10 Units fixed dose in the morning and Humalog sliding scale at meals (see discharge paperwork for scale). Her electrolyte abnormalities resolved with repletion and intravenous fluids. Her home glipizide was held. # Acute on chronic kidney disease s/p renal transplant: She presented with Cr 2.1, though her Cr has been baseline 1.2-1.3 for many years. Her acute presentation is likely due to hypovolemia in setting of hyperglycemia and gradual decline in kidney function. She was given intravenous fluids, and her creatinine was followed closely. Her Lasix and Losartan were held during admission due to her dehydration and ___. Her home cyclosporine, prednisone, and MMF were continued. Cr was not back to baseline upon discharge. Losartan and Lasix held at discharge. # UTI: She was also found to have a urinalysis suggestive of UTI, culture pending. This infection likely developed in setting of acute on chronic hyperglycemia. Endorsed urinary sx. She was treated with ceftriaxone 1g IV once daily and transitioned to cefpoxodime 500mg twice a day for a 7 day course (last dose ___. Urine cultures were pending at the time of discharge. #Extensive discussions were had with patient and husband regarding discharge plan. We requested that the patient stay overnight given the elevated Cr, pending urine cultures, electrolyte abnormalities, and need for additional fluid repletion and patient education. Patient insisted on discharge and agreed to help ensure very close follow-up. CHRONIC: # A-fib Continued home warfarin at 0.5 and 1mg alternating (note was just changed on ___ per ___ clinic because INR was high. Continued diltiazem, metoprolol and digoxin. # CHF ECHO ___ with normal regional/global systolic function. Mild-to-moderate mitral regurgitation. Moderate pulmonary hypertension. EF >55%. Per hx and exam, she was volume down. Lasix was held. # Anxiety Continued home lorazepam # HTN Losartan held in setting of ___. Furosemide held in setting of ___. # HLD Continued home atorvastatin and zetia. **TRANSITIONAL ISSUES** NEW MEDICATIONS: Insulin NPH 10 units at breakfast Insulin sliding scale Humalog (see discharge medications) Cefpodoxime 100 mg PO BID, end date ___ STOPPED MEDICATIONS: Glipizide Furosemide (Lasix) Losartan -Pt needs close f/u with PCP, ___, and ___. PCP is ___. Discussed with patient and family -Pt should have repeat labs on ___, chem 10 and INR. If her creatinine is improved and she does not appear hypovolemic, please restart her losartan and furosemide. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. PredniSONE 5 mg PO DAILY 2. Losartan Potassium 25 mg PO DAILY 3. LORazepam 0.5 mg PO QHS:PRN anxiety 4. Metoprolol Succinate XL 100 mg PO BID 5. Diltiazem Extended-Release 120 mg PO DAILY 6. Ezetimibe 10 mg PO DAILY 7. Warfarin 1 mg PO EVERY OTHER DAY 8. Atorvastatin 10 mg PO QPM 9. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H 10. Mycophenolate Mofetil 250 mg PO BID 11. Ferrous Sulfate 325 mg PO EVERY OTHER DAY 12. Furosemide 60 mg PO BID 13. Multivitamins 1 TAB PO DAILY 14. GlipiZIDE XL 5 mg PO DAILY 15. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral DAILY 16. Warfarin 0.5 mg PO EVERY OTHER DAY Discharge Medications: 1. Cefpodoxime Proxetil 100 mg PO Q12H Duration: 10 Days RX *cefpodoxime 100 mg 1 tablet(s) by mouth twice per day Disp #*18 Tablet Refills:*0 2. NPH 10 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 3. Atorvastatin 10 mg PO QPM 4. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral DAILY 5. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H 6. Diltiazem Extended-Release 120 mg PO DAILY 7. Ezetimibe 10 mg PO DAILY 8. Ferrous Sulfate 325 mg PO EVERY OTHER DAY 9. LORazepam 0.5 mg PO QHS:PRN anxiety 10. Metoprolol Succinate XL 100 mg PO BID 11. Multivitamins 1 TAB PO DAILY 12. Mycophenolate Mofetil 250 mg PO BID 13. PredniSONE 5 mg PO DAILY 14. Warfarin 1 mg PO EVERY OTHER DAY 15. Warfarin 0.5 mg PO EVERY OTHER DAY 16. HELD- Furosemide 60 mg PO BID This medication was held. Do not restart Furosemide until you see your PCP or your kidney doctor 17. HELD- Losartan Potassium 25 mg PO DAILY This medication was held. Do not restart Losartan Potassium until you see your PCP or kidney doctor 18.Outpatient Lab Work Chem 10, ___ fax to: ___, MD ___, MD ___ Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: HYPERGLYCEMIA Acute kidney injury on chronic kidney injury Complicated urinary tract infection Hyponatremia Hypokalemia SECONDARY DIAGNOSIS: Atrial fibrillation Renal transplant Congestive heart failure Anxiety Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You came to the hospital because you had very high blood sugar and bloodwork showing that your kidneys were not working as well. While you were in the hospital, you were given insulin and intravenous fluids. Your Lasix and Losartan medications were held because you were very dehydrated. Your electrolyte levels were abnormal, which were repleted. You were also found to have a urinary tract infection, which was treated with antibiotics. Since your blood sugars were so high, it is very important that you take insulin every day, as prescribed. When you leave the hospital, you will also need to continue taking antibiotics (cefpodoxime 100 mg PO twice per day for 10 days) with last dose on ___. NEW MEDICATIONS: Insulin NPH 10 units at breakfast Insulin sliding scale Humalog (see discharge medications)(we have provided you with a chart that) Cefpodoxime 100 mg PO twice a day through ___ STOPPED MEDICATIONS: Glipizide Furosemide (Lasix) Losartan MAKE AN APPOINTMENT WITH YOUR NEPHROLOGIST FOR WITHIN ONE WEEK - Dr. ___ AN APPOINTMENT WITH YOUR PRIMARY CARE DOCTOR - Call ___ PLEASE ATTEND YOUR ___ APPOINTMENT Please get your labs checked next ___. It was a pleasure taking care of you. Your ___ Team Followup Instructions: ___

10005858-DS-13

DS

2172-07-20 00:00:00

2172-07-20 09:13:00

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: Aspirin / Adhesive Tape / Percocet / Erythromycin Base / Bee Sting Kit / adhesive bandage / Caffeine Attending: ___. Chief Complaint: Left leg weakness with multiple falls Major Surgical or Invasive Procedure: Lumbar laminectomy L2-5 with L3-5 fusion History of Present Illness: ___ with pmhx of chronic LBP ___ steroid injections), sp bl TKR, cerebral aneurysm sp clipping, hypothyroidism (sp L hemithyroidectomy), sp ccy, sp tonsillectomy, sp TAH (fibroids), sp R oopheretomy), sp appy, sp CTS release who presents with LBP and "knee buckling". Pt underwent massage on ___, and on ___ (4d ago), developed severe, sharp, sudden onset LBP in area of lower lumbar spine, radiating to left side of lower back. She had another massage last night and subsequently developed feeling of weakness in ___. She also reports numbness on medial aspect of LLE. Due to these sx she has had ___ falls (no head strike, no LOC) during the past day. She was referred by her PCP. In the ED, initial vs were: 97 75 161/76 18 97%. Pt had MRI spine which showed no acute changes. Patient seen by orthopedics who recommended outapatient evaluation for steroid injections, since patient did not want surgery. Labs were unremarkable. Patient was given tramadol, and dexamethasone. She was seen by ___ and case management who felt that she was unable to ambulate and would need further evaluation prior to placement in a rehab facility. Past Medical History: 1. Hypertension 2. Hypothyroidism, status post partial thyroidectomy for multinodular goiter 3. Arthritis 4. Spinal stenosis 5. Chronic low back pain 6. Mitral valve prolapse 7. Irritable bowel syndrome 8. Cerebral Aneurysm Social History: ___ Family History: Positive for breast cancer in the patient's mother. Brother and father both status post CABG. Brother with type ___ diabetes. Physical Exam: Vitals: 98.6, 144/77, 72, 22, 97RA General: Alert, obese, oriented, tearful about impending surgery HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Distant heart sounds, Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, obese, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: ttp in lumbar spine and R flank, R leg, some numbness in medial L shin Pertinent Results: ___ 06:38PM BLOOD WBC-11.0 RBC-5.13 Hgb-14.0 Hct-44.8 MCV-87 MCH-27.3 MCHC-31.2 RDW-13.8 Plt ___ ___ 06:38PM BLOOD Neuts-69.3 ___ Monos-6.3 Eos-1.9 Baso-1.0 ___ 05:55AM BLOOD ___ PTT-28.6 ___ ___ 06:38PM BLOOD Glucose-91 UreaN-20 Creat-0.9 Na-142 K-3.8 Cl-102 HCO3-33* AnGap-11 ___ 05:55AM BLOOD Calcium-9.3 Phos-4.0 Mg-2.2 IMAGING: MRI L spine No signficant change since the prior study. Severe degenerative changes with grade 1 anterolisthesis of L3-L4 and severe spinal stenosis and neural foraminal narrowing at that level. Clumbing of the nerve roots is also stable, likely arachnoiditis. At L4-L5 stable grade 1 anterolisthesis with clumping of nerve roots, moderate canal stenosis and neural foraminal stenosis. No fractures. LUMBO SACRAL X RAY: Marked multilevel degenerative changes with no definite evidence of new malalignment or fracture. If there is high clinical concern for fracture, CT of the lumbar spine could be obtained. If there are worsening neurological symptoms, MR of the lumbar spine could be obtained. ___ discussed with ___ at 10:30 a.m. on ___, at the time of discovery. B/L KNEE X RAY: IMPRESSION: Bilateral knee arthroplasties without evidence of hardware failure or fracture. HIP/FEMUR X RAY: No acute fracture or traumatic malalignment. Moderate degenerative changes. Brief Hospital Course: Ms. ___ is a ___ yo F with a history of spinal stenosis, chronic lower back pain, HTN, hypothyroidism presenting with worsening lower back pain, found to have severe spinal stenosis now s/p L2-L5 fusion laminectomy with Dr. ___. #Lower Back Pain: Came to ED with pain that was consistent with patient's prior lower back pain. Ortho spine was consulted in the ED and felt that although surgical intervention was possible, patient initially refused. They therefore recommended pain control, patient received steroids in the ED, and was admitted for pain control and placement with rehab facility. However, the patient changed her mind and Dr. ___ was able to take Ms. ___ to the OR for the procedure. She did not require pain control with anything on the medicine floor and refused narcotics based on the side effect of nightmares. #HTN: History of hypertension, elevated to 140s on admission, however patient is not currently on any antihypretensive regimen #Hypothyroidism: History of multinodular goiter, currently stable. Synthroid 50mcg daily was continued. Ms. ___ was taken to the OR for a lumbar laminectomy and fusion L2-5. She tolerated the procedure well and was able to work with ___. She was discharged in good condition and will follow up with Dr. ___ in 10 days. Medications on Admission: LEVOTHYROXINE [LEVOXYL] - Levoxyl 50 mcg tablet. 1 Tablet(s) by mouth once a day MODAFINIL - modafinil 100 mg tablet. 1 Tablet(s) by mouth qam and one at lunch NITROFURANTOIN MONOHYD/M-CRYST [MACROBID] - Macrobid ___ mg capsule. 1 capsule(s) by mouth twice daily x 7 days PRAMIPEXOLE - pramipexole 0.25 mg tablet. 1 tablet(s) by mouth three times a day SEQUENTIAL COMPRESSION STOCKINGS - . thigh high daily SOLIFENACIN [VESICARE] - Vesicare 5 mg tablet. 1 tablet(s) by mouth once a day SULINDAC - Dosage uncertain - (Prescribed by Other Provider) TRAZODONE - trazodone 100 mg tablet. 2 (Two) Tablet(s) by mouth at bedtime VENLAFAXINE - venlafaxine 100 mg tablet. 2 Tablet(s) by mouth at bedtime Medications - OTC B COMPLEX-VITAMIN C-FOLIC ACID - Dosage uncertain - (OTC) CALCIUM CITRATE-VITAMIN D3 [CITRACAL + D] - Citracal + D 315 mg-200 unit tablet. 2 Tablet(s) by mouth twice daily CHOLECALCIFEROL (VITAMIN D3) - cholecalciferol (vitamin D3) 1,000 unit capsule. 1 Capsule(s) by mouth daily - (Prescribed by Other Provider) FERROUS GLUCONATE [FERGON] - Dosage uncertain - (Prescribed by Other Provider) LACTOBACILLUS ACIDOPHILUS [PROBIOTIC] - Dosage uncertain - (Prescribed by Other Provider) LYSINE [L-LYSINE] - L-Lysine 500 mg capsule. 1 Capsule(s) by mouth twice daily - (OTC) MAGNESIUM - Dosage uncertain - (Prescribed by Other Provider: PCP) MULTIVITAMIN - multivitamin tablet. 1 Tablet(s) by mouth DAILY (Daily) - (Prescribed by Other Provider) Discharge Medications: 1. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every four (4) hours Disp #*100 Tablet Refills:*0 2. Levothyroxine Sodium 50 mcg PO DAILY 3. TraZODone 100 mg PO HS:PRN insomnia 4. Venlafaxine 200 mg PO HS Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Lumbar stenosis L2-5 Discharge Condition: Good Discharge Instructions: You have undergone the following operation: Lumbar laminectomy and fusion Immediately after the operation: -Activity: You should not lift anything greater than 10 lbs for 2 weeks. You will be more comfortable if you do not sit or stand more than ~45 minutes without getting up and walking around. -Rehabilitation/ Physical Therapy: o2-3 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. oLimit any kind of lifting. -Diet: Eat a normal healthy diet. You may have some constipation after surgery. You have been given medication to help with this issue. -Brace: You have been given a brace. This brace is to be worn for comfort when you are walking. You may take it off when sitting in a chair or while lying in bed. -Wound Care: Remove the dressing in 2 days. If the incision is draining cover it with a new sterile dressing. If it is dry then you can leave the incision open to the air. Once the incision is completely dry (usually ___ days after the operation) you may take a shower. Do not soak the incision in a bath or pool. If the incision starts draining at anytime after surgery, do not get the incision wet. Cover it with a sterile dressing. Call the office. -You should resume taking your normal home medications. No NSAIDs. -You have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so please plan ahead. You can either have them mailed to your home or pick them up at the clinic located on ___. We are not allowed to call in or fax narcotic prescriptions (oxycontin, oxycodone, percocet) to your pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. Please call the office if you have a fever>101.5 degrees Fahrenheit and/or drainage from your wound. Physical Therapy: As tolerated Treatment Frequency: Please continue to change the dressing daily Followup Instructions: ___

10005858-DS-14

DS

2172-08-17 00:00:00

2172-08-17 09:34:00

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: Aspirin / Adhesive Tape / Percocet / Erythromycin Base / Bee Sting Kit / adhesive bandage / Caffeine Attending: ___. Chief Complaint: Wound infection Major Surgical or Invasive Procedure: Washout of lumbar incision History of Present Illness: ___ with pmhx of chronic LBP ___ steroid injections), sp bl TKR, cerebral aneurysm sp clipping, hypothyroidism (sp L hemithyroidectomy), sp ccy, sp tonsillectomy, sp TAH (fibroids), sp R oopheretomy), sp appy, sp CTS release with recent lumbar laminectomy L2-5 with L3-5 fusion on ___ by Dr. ___ presents with fever. Patient states that for the past two days she has had worsening pain and redness at her operative site. She denies any new lower extremity weakness, parasthesias or anesthesia. She does endorse occasional urinary incontinence she attributes to difficulty reaching commode in time. Denies fecal incontinence, saddle anesthesia. Denies CP, dyspnea, cough, abd pain, dysuria. Past Medical History: 1. Hypertension 2. Hypothyroidism, status post partial thyroidectomy for multinodular goiter 3. Arthritis 4. Spinal stenosis 5. Chronic low back pain 6. Mitral valve prolapse 7. Irritable bowel syndrome 8. Cerebral Aneurysm Social History: ___ Family History: Positive for breast cancer in the patient's mother. Brother and father both status post CABG. Brother with type ___ diabetes. Physical Exam: In general, the patient is a Vitals: T 102.7dF Hr 93 BP 127/77 RR 18 SpO2 96% RA Spine exam: Wound: Midline lumbar spine wound from L1-L5 has surrounding blanching erthema and induration, no clear fluctuance. No discharge. Vascular Radial: L2+, R2+ DPR: L2+, R2+ Motor- Delt Bic Tri WrE FFl FE IO IP glut Quad Ham TA Gastroc L ___ 5 R ___ 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 R ___ 2 2 Plantar response was extensor bilaterally. ___: neg Babinski: downgoing Clonus: none Perianal sensation: intact Rectal tone: intact Pertinent Results: ___ 06:50PM BLOOD WBC-11.5* RBC-3.75* Hgb-10.3* Hct-32.9* MCV-88 MCH-27.4 MCHC-31.3 RDW-14.4 Plt ___ ___ 10:10AM BLOOD WBC-13.3* RBC-3.54* Hgb-9.9* Hct-31.4* MCV-89 MCH-28.0 MCHC-31.6 RDW-14.2 Plt ___ ___ 03:27PM BLOOD WBC-14.2* RBC-4.03* Hgb-10.9* Hct-35.0* MCV-87 MCH-27.0 MCHC-31.1 RDW-14.2 Plt ___ ___ 03:27PM BLOOD Neuts-82.2* Lymphs-11.1* Monos-5.9 Eos-0.4 Baso-0.3 ___ 06:50PM BLOOD ESR-128* ___ 03:27PM BLOOD ESR-92* ___ 06:50PM BLOOD Glucose-100 UreaN-13 Creat-0.8 Na-145 K-4.5 Cl-99 HCO3-31 AnGap-20 ___ 10:10AM BLOOD Glucose-134* UreaN-17 Creat-0.8 Na-139 K-4.2 Cl-102 HCO3-28 AnGap-13 ___ 03:27PM BLOOD Glucose-102* UreaN-17 Creat-0.8 Na-139 K-4.3 Cl-98 HCO3-29 AnGap-16 ___ 09:55AM BLOOD Vanco-15.2 ___ 08:45PM BLOOD Genta-4.0* Vanco-14.0 Brief Hospital Course: Ms. ___ underwent a washout of her posterior lumbar incision. She had a PICC line placed and will receive 10 weeks of IV vancomycin. She will follow up with both the ___ clinic and Dr. ___. Medications on Admission: Trazodone Venlafaxine Pramipexole Synthroid Discharge Medications: 1. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line flush 2. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every four (4) hours Disp #*100 Tablet Refills:*0 3. Levothyroxine Sodium 50 mcg PO DAILY 4. pramipexole 0.25 mg oral TID restless leg 5. TraZODone 100 mg PO HS:PRN insomnia 6. Venlafaxine 200 mg PO QHS 7. Vancomycin 1000 mg IV Q 12H X 10 weeks Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Lumbar incision infection Discharge Condition: Good Discharge Instructions: You have undergone the following operation: Washout lumbar incision Immediately after the operation: -Activity: You should not lift anything greater than 10 lbs for 2 weeks. You will be more comfortable if you do not sit or stand more than ~45 minutes without getting up and walking around. -Rehabilitation/ Physical Therapy: o2-3 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. oLimit any kind of lifting. -Diet: Eat a normal healthy diet. You may have some constipation after surgery. You have been given medication to help with this issue. -Wound Care: Remove the dressing in 2 days. If the incision is draining cover it with a new sterile dressing. If it is dry then you can leave the incision open to the air. Once the incision is completely dry (usually ___ days after the operation) you may take a shower. Do not soak the incision in a bath or pool. If the incision starts draining at anytime after surgery, do not get the incision wet. Cover it with a sterile dressing. Call the office. -You should resume taking your normal home medications. No NSAIDs. -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 or fax narcotic prescriptions (oxycontin, oxycodone, percocet) to your pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. Please call the office if you have a fever>101.5 degrees Fahrenheit and/or drainage from your wound. Physical Therapy: Activity as tolerated Treatments Frequency: Please continue to change the dressing daily Followup Instructions: ___

10005866-DS-16

DS

2149-02-14 00:00:00

2149-02-16 09:59:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Tylenol / Neurontin Attending: ___ Chief Complaint: RUQ abdominal pain, vomiting, diarrhea Major Surgical or Invasive Procedure: -diagnostic para ___ History of Present Illness: Mr ___ is a ___ year old man with cirrhosis (EtOH/HCV untreated, genotype 3)Child Class C, complicated by esophageal varices, ascites, and encephalopathy, chronic abdominal pain and multiple prior abdominal surgeries, presenting with 3 days of more severe RUQ pain, vomiting, and diarrhea. After a several month stay in rehab in ___ following his last ___ hospitalization in ___, the patient has been doing well at home. In his usual state of health, he has chronic RUQ abdominal pain, and is followed by his PCP and hepatologist; patient states that his pain has been attributed to possibly scar tissue from his several abdominal surgeries. He was previously on fentanyl patch for this but is now on oxycodone 10mg QID. ___ checked ___. Last filled oxycodone 10mg 30 day supply (120 pills) ___. He has Child's class C cirrhosis but overall his ascites and hepatic encephalopathy are well controlled with Lasix/spironolactone and lactulose. Prior paracentesis was "Several years ago." He developed his present symptoms 3 days ago, with the subacute onset of worsening RUQ pain (stabbing, constant with waves of more severe pain, worse with vomiting, no change with eating/position/movement). For the past 3 days he has also had ___ episodes per day of vomiting (clear/yellow fluid, no blood or coffee-ground emesis), and has been unable to tolerate food, or fluids, and thinks he has also vomited pills (although has been trying to stay compliant with his regimen). He has also been having multiple episodes per day of watery/yellow fluid diarrhea (no blood or melena). His ROS is positive for chills/sweats, and fatigue. His abdominal distention is moderate but stable. But he denies fevers, myalgia/arthralgias, HA, URI symptoms, visual complaint, chest pain/pressure, dyspnea, cough, rash, bruising, lower extremity edema. No recent travel, sick contacts, or recent raw/uncooked/spoiled food. He presented to the ED for further evaluation. In the ED, initial vitals were: Temp. 98.0, HR 82, BP 157/82, RR 22, 100% RA - Exam notable for: RUQ tenderness to palpitation, abdomen distended but soft --Bedside abdominal ultrasound showed small volume of ascites without a pocket amenable to paracentesis. - Labs notable for: --WBC 5.4, Hgb 14.0, plt 181 --Na 130, K 4.8, HCO3 15, creatinine 0.8, glucose 144, BUN 9 --ALT 32, AST 127, alk phos 145, Tbili 4.7, albumin 2.8 --lactate 2.6, repeat lactate 1.7 --INR 1.4, PTT 38.7 - Imaging was notable for: CT abdomen ___: 1. Cirrhosis with evidence of portal hypertension with moderate volume ascites partially loculated in the right upper quadrant, extensive portosystemic varices. ***Partially occlusive thrombus in the main portal vein. *** 2. Small bowel distention without obstruction may reflect ileus. Mild thickening of the proximal colon may reflect portal colopathy. 3. Trace right pleural effusion with chronic appearing atelectasis in the right lower lung. 4. Extensive atherosclerotic disease of the aorta. Liver US ___: 1. There is a new nonocclusive thrombus within the main portal vein with extension into the left and right portal vein branches. There is normal hepatopetal flow within the main portable vein and evidence of sluggish flow within the left and right portal vein branches. 2. Large volume ascites. 3. Worsening splenomegaly measuring 13.7 cm today, previously measuring 12 cm ___. 4. New 1.6 cm focus within the right hepatic lobe is incompletely characterized. Follow-up MR for further evaluation is recommended. - Patient was given: --morphine 4mg IV x2 --ondansetron 4mg IV --1L normal saline --started on heparin drip Upon arrival to the floor, patient reports continued abdominal pain in the RUQ, and being very thirsty and a little hungry. REVIEW OF SYSTEMS: (+) Per HPI (-) 10 point ROS reviewed and negative unless stated above in HPI Past Medical History: - Hepatitis C (genotype 3) - Cirrhosis, Child's Class C due EtOH and HCV d/b hepatic encephalopathy, portal hypertension with ascites and esophageal varices, portal hypertensive gastropathy - Gastric & Duodenal ulcers - Insomnia - Umbilical hernia - Sacral osteoarthritis Past Surgical History: - Umbilical hernia repair (___) -SBO requiring Ex lap & repair of ruptured umbilical hernia with lysis of adhesions (___) - Abdominal Hematoma evacuation (___) - Abdominal incision opened, wound vac placed (___) Social History: ___ Family History: Sister and brother both with "collapsed lungs." No family history of liver disease. Physical Exam: ADMISSION PHYSICAL EXAM: ============================== VITAL SIGNS: BP 115 / 77 hr 64 RR18 SPO2 98 Ra GENERAL: chronically ill appearing man, resting in bed in moderate discomfort. Able to move around in bed without obvious increase in pain. Alert, fully conversant, very pleasant. HEENT: NCAT. Dry oral mucosa. No scleral icterus. Conjunctivae white. No JVD. NECK: full ROM, no masses CARDIAC: RRR, no murmurs, no lower extremity edema LUNGS: CTAB, unlabored breathing on ambient air ABDOMEN: moderately distended, but soft. Moderately tender in RUQ. Umbilical hernia site intact, non-tender. Dull to percussion, no fluid wave. Normal bowel sounds. Collateral vessels faintly visible in abdominal wall EXTREMITIES: warm, no edema. No asterixis NEUROLOGIC: alert, fully oriented. CN exam normal. Strength/sensation intact. Gait not tested. No asterixis or tremor. SKIN: no rashes, no jaundice DISCHARGE PHYSICAL EXAM: ============================== VS: 98.1 PO 106 / 68 R Lying 68 18 96 Ra GENERAL: chronically ill appearing man, resting in bed in moderate discomfort. HEENT: NCAT. MMM. No scleral icterus CARDIAC: RRR, no murmurs, no lower extremity edema LUNGS: CTAB, unlabored breathing on ambient air ABDOMEN: moderately distended, but soft. Moderately tender in RUQ. Umbilical hernia site intact, non-tender. Normal bowel sounds. Collateral vessels faintly visible in abdominal wall EXTREMITIES: warm, no edema. No asterixis NEUROLOGIC: alert, fully oriented. CN exam normal. Strength/sensation intact. Gait not tested. No asterixis or tremor. SKIN: no rashes, no jaundice Pertinent Results: ADMISSION LABS: ========================== ___ 09:36AM BLOOD WBC-5.4 RBC-3.97* Hgb-14.0 Hct-42.2 MCV-106* MCH-35.3* MCHC-33.2 RDW-14.2 RDWSD-56.4* Plt ___ ___ 09:36AM BLOOD Neuts-65.3 ___ Monos-10.4 Eos-1.9 Baso-1.7* Im ___ AbsNeut-3.51 AbsLymp-1.08* AbsMono-0.56 AbsEos-0.10 AbsBaso-0.09* ___ 11:21AM BLOOD ___ PTT-38.7* ___ ___ 09:36AM BLOOD Glucose-144* UreaN-9 Creat-0.8 Na-130* K-4.8 Cl-101 HCO3-15* AnGap-19 ___ 09:36AM BLOOD ALT-32 AST-127* AlkPhos-145* TotBili-4.7* ___ 09:36AM BLOOD Albumin-2.8* ___ 05:00AM BLOOD Calcium-7.7* Phos-2.9 Mg-1.4* ___ 09:44AM BLOOD Lactate-2.6* DISCHARGE LABS: ========================== ___ 04:46AM BLOOD WBC-5.1 RBC-3.46* Hgb-12.3* Hct-37.0* MCV-107* MCH-35.5* MCHC-33.2 RDW-14.2 RDWSD-55.5* Plt ___ ___ 04:46AM BLOOD ___ PTT-36.8* ___ ___ 04:46AM BLOOD Glucose-93 UreaN-9 Creat-0.9 Na-133 K-4.2 Cl-99 HCO3-26 AnGap-12 ___ 04:46AM BLOOD ALT-21 AST-63* AlkPhos-159* TotBili-2.3* ___ 04:46AM BLOOD Albumin-2.4* Calcium-8.0* Phos-3.6 Mg-1.6 PERTINENT RESULTS: ========================== ___ 01:55PM ASCITES TNC-64* RBC-650* Polys-1* Lymphs-48* Monos-6* Mesothe-2* Macroph-43* Other-0 ___ 01:55PM ASCITES TotPro-1.7 Glucose-103 LD(LDH)-104 Albumin-0.7 Cholest-19 ___ 08:58PM STOOL NoroGI-NEGATIVE NoroGII-NEGATIVE MICROBIOLOGY: ========================== ___ 1:55 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES PERITONEAL FLUID. Fluid Culture in Bottles (Preliminary): NO GROWTH. ___ 1:48 pm PERITONEAL FLUID PERITONEAL FLUID. **FINAL REPORT ___ GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count. IMAGING: ========================== ___ IMPRESSION: 1. Cirrhosis with new partially occlusive thrombus within the main portal vein. 2. Large volume ascites. 3. Worsening splenomegaly measuring 13.7 cm today, previously measuring 12 cm ___. 4. New 1.6 cm focus within the right hepatic lobe is incompletely characterized. Follow-up MR for further evaluation is recommended. ___ IMPRESSION: Tiny right pleural effusion, otherwise unremarkable exam. ___ IMPRESSION: 1. Cirrhosis with evidence of portal hypertension with moderate volume ascites partially loculated in the right upper quadrant, extensive portosystemic varices. Partially occlusive thrombus in the main portal vein. 2. Small bowel distention without obstruction may reflect ileus. Mild thickening of the proximal colon may reflect portal colopathy. 3. Trace right pleural effusion with chronic appearing atelectasis in the right lower lung. 4. Extensive atherosclerotic disease of the aorta. Brief Hospital Course: ___ year old man with cirrhosis (EtOH/HCV untreated, genotype 3) Child Class C, complicated by esophageal varices, ascites, and encephalopathy, chronic abdominal pain and multiple prior abdominal surgeries, presenting with 3 days of acute on chronic RUQ pain, vomiting, and diarrhea likely ___ viral gastroenteritis. C.diff negative, norovorius negative. Diagnostic para w/ no e/o SBP. Stool Cx pending at time of discharge. Patient was given IV fluids with spontaneous resolution (though persistent chronic RUQ pain). Hospital course complicated by new non-occlusive PVT, lactate slightly elevated on initial presentation normalized with IVF less c/f ischemia. Outpatient hepatologist (Dr. ___ was contacted who recommended against anticoagulation given non-occlusive, and concerns with patient compliance. Otherwise no changes to home medications. ====================== ACUTE ISSUES ====================== #Abdominal pain, vomiting, diarrhea: presented with 3 days of acute on chronic RUQ pain, vomiting, and diarrhea likely ___ viral gastroenteritis. C.diff negative, norovorius negative. Diagnostic para w/ no e/o SBP. Stool Cx pending at time of discharge. Patient was given IV fluids with spontaneous resolution (though persistent chronic RUQ pain). Of note RUQ U/S and CT A/P w/ e/o non-occlusive PVT, though unlikely explanation for presentation as non-occlusive w/ down-trending lactate. #Partially occlusive portal vein thrombosis: iso decompensated cirrhosis; RUQ ultrasound and CT abdomen with contrast demonstrated partially occlusive portal vein thrombus, new since ___ ultrasound. Lactate slightly elevated on initial presentation normalized with IVF less c/f ischemia. Outpatient hepatologist (Dr. ___ was contacted who recommended against anticoagulation given non-occlusive, and concerns with patient compliance. #Hyponatremia : Admitted w/ serum sodium 130. Per history, multiple days of low fluid intake, diarrhea, vomiting, while continuing to take diuretics suggested he was intravascularly depleted. Resolved s/p 1L IVF, and resolution of gastroenteritis w/ improved PO intake. Home diuretics restarted upon discharge. #Cirrhosis: Child's Class C, complicated by ascites, hepatic encephalopathy, prior SBP, esophageal varices. -volume: home Lasix/spironolactone initially held iso n/v/d, resumed upon discharge. -hepatic encephalopathy - cont home lactulose after resolution of diarrhea -SBP ppx - cont home Bactrim -esophageal varices - last EGD in ___ no evidence of bleeding on this presentation; Transitional Issues: ========================== -On RUQ U/S: There is a 1.6 cm echogenic focus within the mid right hepatic lobe, peripherally, for which follow-up MR for further evaluation is recommended. -Patient w/ new non-occlusive PVT. Would recommend f/u CT in 3 months to eval for progression of PVT thrombus. -Stool cultures pending at time of discharge, please follow up # CODE: full # CONTACT: sister/HCP ___ ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Furosemide 20 mg PO DAILY 2. Lactulose 30 mL PO TID 3. Spironolactone 50 mg PO DAILY 4. Famotidine 20 mg PO Q12H 5. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN Pain - Moderate 6. Multivitamins 1 TAB PO DAILY 7. Potassium Chloride 10 mEq PO DAILY 8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 9. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral DAILY 10. Polyethylene Glycol 17 g PO DAILY:PRN constipation Discharge Medications: 1. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral DAILY 2. Famotidine 20 mg PO Q12H 3. Furosemide 20 mg PO DAILY 4. Lactulose 30 mL PO TID 5. Multivitamins 1 TAB PO DAILY 6. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN Pain - Moderate RX *oxycodone 10 mg 1 tablet(s) by mouth every six (6) hours Disp #*8 Tablet Refills:*0 7. Polyethylene Glycol 17 g PO DAILY:PRN constipation 8. Potassium Chloride 10 mEq PO DAILY Hold for K > 9. Spironolactone 50 mg PO DAILY 10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: ======================= -viral gastroenteritis Secondary Diagnosis: ====================== -ETOH/HCV Cirrhosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr ___, It was a pleasure being involved in your care. Why you were here: -You came in for nausea/vomiting/diarrhea. What we did while you were here : -We gave you some fluids through your IV because you were dehydrated. We believe that you had a viral illness, which cleared on its own. -We also took some fluid out of your abdomen to make sure you were not having an infection, and this was negative for any infection. Your next steps: -please take all your medications as indicated below -please keep all of your appointments We wish you well, Your ___ Care Team Followup Instructions: ___

10006029-DS-16

DS

2169-10-05 00:00:00

2169-10-06 14:02:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: ___ Attending: ___. Chief Complaint: Fatigue Major Surgical or Invasive Procedure: ___: ERCP and EUS History of Present Illness: Mr. ___ is a ___ male with IDDM, HTN, BPH, and clear cell RCC s/p radical L nephrectomy (___) metastatic to the lungs, mediastinum, and hilum currently on chemotherapy (experimental trial; on sunitinib), with recent admission (___) for biliary stricture s/p ERCP with plastic stent placement (CBD brushing cytology non-diagnostic) and non-occlusive portal vein thrombus started on enoxaparin who presented to the ED with fever, jaundice, and confusion. The CBD brushing cytology from his prior admission was non-diagnostic. His imaging was reviewed at multidisciplinary pancreas conference and no mass lesion was visualized in the head of the pancreas but there was some peripancreatic stranding around the head of the pancreas noted. There was some concern for a potential primary pancreatobiliary tumor (rather than rare RCC metastasis to pancreas), so he was planned for a repeat ERCP and EUS in ___ weeks (planned for the week of ___ off sunatinib). He last followed up in ___ clinic with Dr. ___ on ___. He was complaining of a week of increased fatigue, nausea, and poor PO intake. His sunatinib was held due to concern for side effects. Over the past week since then, he has had worsening jaundice and fatigue. Last night, he developed chills, restlessness, mild confusion, and fevers to 101, which prompted his wife to bring him to ___. He was transferred from there to the ___ ED. Right now, he feels ok, just a little tired. He feels like his thinking is foggy. No fevers/chills since he presented to the hospital. No nausea, vomiting, abdominal pain. He has had loose stools, which he associates with the sunatinib. No bloody, black, or ___ stools. His urine has been "tea colored." He has had poor appetite. No chest pain, shortness of breath, or palpitations. ED COURSE: VS: Tmax 98.6, HR ___, BP 100s-110s/60s, RR 16, SpO2 98-100% on RA Labs: WBC 3.4, AST/ALT 71/97, AP 214, Tbili 7.6, lipase 148, lactate 1.4 Exam: jaundiced, abdomen benign, guaiac negative brown stool Imaging: RUQ US: persistent left intrahepatic biliary dilation, persistent GB sludge Interventions: None ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: PAST ONCOLOGIC HISTORY (per OMR): -___: presented with acute onset of gross hematuria accompanied with some mild flank pain. During his workup, he was found to have a 4.8 cm mass on a CAT scan dated ___, specifically the scan describes a left renal mass with internal enhancement measuring 4.1 x 4.8 cm in size in the mid and upper pole of the left kidney. Also described was the fat-containing left inguinal hernia and left perinephric stranding. There was no adenopathy or other suspicious lesions. There is also an old sclerotic right ilial lesion and left sacral lesion. -___: underwent a laparoscopic hand assisted radical right nephrectomy by Dr. ___ pathology showed a renal cell carcinoma, clear cell type, ___ grade II/IV measuring 4 cm extending but not invading through the renal capsule or Gerota's fascia margins were questionably positive at the renal vein and otherwise negative. On review of pathology here at ___, the margins are described as negative including the renal vein margin. A background of global glomerulosclerosis is described. Overall, this was a T3bNxMx lesion. Postoperative imaging on ___ which was a CT torso showed no evidence of recurrent or metastatic disease. -___: CT chest showed interval increase in prominence of mediastinal lymph nodes and minimal interval increase in multiple b/l pulmonary nodules, concerning for progression -___: Fine needle aspirate of 11R and 11L lymph nodes, which was consistent with metastatic RCC -___: CT Torso - mediastinal and hilar nodes and pulmonary lesions increased in size. No definite intra-abdominal sites of disease -___: C1D1 ___, randomized to sunitinib -___: Multiple grade ___ adverse events including thrombocytopenia (grade 2; platelet 52,000), leukopenia (grade 2; WBC 2.9), elevated lipase (grade 1), elevated amylase (grade 1; elevated at baseline), elevated ALT (grade 1), and hypothyroidism (grade 1). Mild symptoms with treatment. Continued sunitinib at 50mg daily per protocol. -___: CT Torso: Response of mediastinal lymphadenopathy, bilateral hilar lymphadenopathy, and numerous parenchymal metastases. Stable disease by RECIST (decrease 19.1% from baseline). -___: Sunitinib reduced to 37.5 mg daily due to erythematous rash and blistering on palms and sole of right foot. -___: CT Torso: Decrease in pulmonary and mediastinal lesions. Stable disease by RECIST 1.1 (decrease 22.5% from baseline). -___: CT Torso: Partial response by RECIST 1.1 (decrease 39.8% from baseline). -___: CT Torso: Partial response by RECIST 1.1 (decrease 46.3% from baseline). -___: CT Torso: Partial response by RECIST 1.1 (decrease 40.3% from baseline). -___: CT Torso: Partial response by RECIST 1.1 (decrease 42.6% from baseline). -___: CT Torso: Partial response by RECIST 1.1 (decrease 47.7% from baseline). -___: CT torso: Ongoing partial response comments: No significant change compared to prior scan. No new lesions. -___: CT Torso: PR by RECIST 1.1 -___: CT Torso: PR by RECIST 1.1: -54.22% change from baseline and -10.29% change from last scan. -___: CT Torso: partial response: -57.79% from baseline, -7.79% from nadir -___: CT Torso shows continued partial response, no significant change compared to prior PAST MEDICAL HISTORY (per OMR): 1. Clear cell kidney cancer as above. 2. Benign prostatic hypertrophy. 3. Diabetes mellitus. 4. Hypertension. 5. Hyperlipidemia. 6. History of anxiety. Social History: ___ Family History: Colorectal cancer - mother ___ cancer - sister (dx at age ___ Liver cancer - brother ___ cell leukemia - brother ___ - father Physical ___: ADMISSION EXAM: VITALS: T 97.6, HR 68, BP 115/76, RR 16, SpO2 98% on RA ___: Alert, NAD, breathing room air comfortably EYES: Icteric sclera, PERRL ENT: MMM, sublingual jaundice, OP clear CV: NR/RR, no m/r/g RESP: CTAB, no wheezes, crackles, or rhonchi GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. No HSM. MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: Jaundiced NEURO: Alert, oriented to hospital, city, date; able to recite the days of the week backwards, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs PSYCH: pleasant, appropriate affect DISCHARGE EXAM: T 97.9, HR 70, BP 143/79, RR 18, SpO2 97% on RA ___: Alert, NAD, breathing room air comfortably EYES: Icteric sclera ENT: MMM, OP clear CV: NR/RR, no m/r/g RESP: CTAB, no wheezes, crackles, or rhonchi GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: Jaundiced (but improved) NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs PSYCH: pleasant, appropriate affect Pertinent Results: ADMISSION LABS: ___ 05:43AM BLOOD WBC-3.4* RBC-2.48* Hgb-8.4* Hct-24.9* MCV-100* MCH-33.9* MCHC-33.7 RDW-16.8* RDWSD-61.6* Plt ___ ___ 05:43AM BLOOD Glucose-95 UreaN-24* Creat-1.5* Na-138 K-4.4 Cl-106 HCO3-18* AnGap-14 ___ 05:55AM BLOOD Albumin-2.5* Calcium-8.1* Phos-3.5 Mg-1.9 Iron-18* ___ 05:43AM BLOOD Albumin-2.8* ___ 05:55AM BLOOD calTIBC-160* Hapto-230* Ferritn-990* TRF-123* ___ 05:43AM BLOOD ALT-97* AST-71* AlkPhos-214* TotBili-7.6* DirBili-5.6* IndBili-2.0 MICRO: BCx ___: NGTD Blood culture (___): STREPTOCOCCUS ANGINOSUS (___) GROUP | CEFTRIAXONE----------- 0.5 S CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.12 S PENICILLIN G----------<=0.06 S VANCOMYCIN------------ 0.5 S PATHOLOGY/CYTOLOGY: Biliary mass biopsy (___): Minute fragment of highly atypical cells with sclerotic stroma consistent with adenocarcinoma Common bile duct stricture brushings (___): POSITIVE FOR MALIGNANT CELLS. - Adenocarcinoma. IMAGING: RUQ US (___): IMPRESSION: 1. Persistent mild left intrahepatic biliary dilation in presence of a partially visualized CBD stent raises concern for stent malfunction. Compared to the prior ultrasound, the degree of intrahepatic biliary dilation has not changed significantly. 2. Persistent gallbladder sludge. ERCP ___: removal of the old stent and placement of a new stent over a 2cm malignant-appearing stricture of the distal CBD. Cytology brushings were sampled. EUS ___: 1.8 x 1.1 cm ill-defined hypoechoic area around the distal CBD. FNB was performed x3 CT torso ___: IMPRESSION: Non obstructive pneumonia, left upper lobe. Minimal residual pulmonary edema and pleural effusions attributable to heart failure. Atherosclerotic coronary calcification. Left PICC line ends just above the superior cavoatrial junction. IMPRESSION: 1. No evidence of local recurrence or metastatic disease in the abdomen and pelvis. 2. Mild intrahepatic and extrahepatic biliary ductal dilatation, with CBD stent in place. 3. Known nonocclusive main portal vein thrombus appears increased in size, though difficult to directly compare to MR due to differences in imaging technique. ERCP ___: Biliary plastic stent removed with a snare. A metal stent was placed over 2cm long malignant appearing stricture in the distal CBD. TTE ___: IMPRESSION: Adequate image quality. Mild symmetric left ventricular hypertrophy with normal cavity size and regional/global left ventricular systolic function. No 2D echocardiographic evidence for endocarditis. If clinically suggested, the absence of a discrete vegetation on echocardiography does not exclude the diagnosis of endocarditis. Brief Hospital Course: SUMMARY/ASSESSMENT: Mr. ___ is a ___ male with IDDM, HTN, BPH, and metastatic clear cell RCC s/p radical L nephrectomy (___) on chemotherapy (sunitinib), with recent admission (___) for biliary stricture s/p ERCP with plastic stent placement (CBD brushing cytology non-diagnostic) and non-occlusive portal vein thrombus started on enoxaparin who presented to the ED with fever, jaundice, and confusion, found to have persistent intrahepatic biliary dilation and gallbladder sludge on ___ US s/p ERCP x2 with placement of plastic, then metal biliary stent and EUS with pathology from FNB of CBD mass consistent with new pancreatobiliary adenocardinoma. ACUTE/ACTIVE PROBLEMS: # Cholangitis # Strep spp. (likely Enterococcus) bacteremia # Adenocarcinoma pancreaticobiliary origin He presented with fever, jaundice, and mental status changes. RUQ US also showed persistent left intrahepatic biliary dilation and gallbladder sludge despite the presence of CBD stent, suggesting that the stent was non-functioning/occluded or there was some other source of obstruction. The CBD brushing cytology from his prior ERCP was non-diagnostic. He had no apparent mass in the head of the pancreas on imaging but there remained some concern for a primary pancreatobiliary tumor so he was planned to have a repeat ERCP and EUS the week he was admitted. Blood culture at ___ is growing Strep spp. He was treated with Unasyn for cholangitis as well as Strep bacteremia. BCx here grew Strep anginosus. He had an ERCP on ___ with removal of the old stent and placement of a new stent over a 2cm malignant-appearing stricture of the distal CBD. Cytology brushings were sampled. EUS was completed on which they visualized a 1.8 x 1.1 cm ill-defined hypoechoic area around the distal CBD. FNB was performed x3. Pathology was consistent with adenocarcinoma. After the plastic stent placement, his LFTs did not improve and bilirubin continued to rise. A repeat ERCP was done on ___ with removal of the plastic stent and placement of a metal stent. After this, his LFTs started to improve. His Unasyn was changed to ceftriaxone and metronidazole for ease of dosing to complete a 2 week course ___ - ___. A PICC was placed prior to discharge. TTE did not show evidence of endocarditis. # ___ on CKD Cr peaked at 1.8 from baseline 1.2. Most likely this was prerenal in the setting of cholangitis. It improved after ERCP, antibiotics, and fluid resuscitation. # PVT He was found to have a non-occlusive portal vein thrombus on MRCP during his recent hospital admission and was started on enoxaparin. HIs home enoxaparin was initially held for ERCP, then resumed. # Macrocytic anemia Macrocytic anemia is chronic. Baseline H/H appears to be ___, so he is lower than baseline. He had no signs of bleeding. Recent TSH, folate, B12, ferritin, and TIBC were wnl. Bilirubin is predominantly direct, so less likely hemolysis. Other hemolysis labs were not consistent with hemolysis. Acute on chronic anemia is perhaps ___ bone marrow suppression from sepsis. He was given 1 unit pRBCs for Hgb 7.6. # Metastatic clear cell RCC on chemotherapy He is followed at ___ by Dr. ___. He was diagnosed in ___ in workup of gross hematuria and flank pain. He underwent a laparoscopic radical right nephrectomy in ___. He was found to have metastases to the lungs, mediastinal lymph nodes, and hilar lymph nodes in ___. In ___ he was enrolled in an experimental trial and started on sunatinib. His most recent CT showed clinical response. He is currently in his regularly scheduled two weeks off on sunatinib. He had a surveillance CT on ___ which showed no evidence of local recurrence of metastatic disease in the abdomen/pelvis. # LUL pneumonia He was found to have LUL opacity on CT chest ordered for surveillance. He was also complaining of cough. He was on Unasyn while inpatient, then transitioned to ceftriaxone and metronidazole for 2 weeks total, which should cover him for pneumonia. # HTN Initially his home atenolol dose was halved due to concern for cholangitis/impending sepsis. His home amlodipine 10 mg and lisinopril 40 mg daily were also initially held. These were resumed prior to or at discharge. # Insulin-dependent DM type II At home he takes glargine 16 units qhs if his FSBG is <170 and he takes 18 units qhs if his FBSG is >170. While inpatient, he was given glaring 8 units qhs as he was not taking much PO as well as lispro SSI. CHRONIC/STABLE PROBLEMS: # Hypothyroidism - continued home levothyroxine # Depression and anxiety - continued home fluoxetine; held home cariprazine as it is non-formulary Mr. ___ is clinically stable for discharge. The total time spent today on discharge planning, counseling and coordination of care was greater than 30 minutes. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Enoxaparin Sodium 120 mg SC DAILY Start: ___, First Dose: Next Routine Administration Time 2. amLODIPine 10 mg PO DAILY 3. Ascorbic Acid ___ mg PO DAILY 4. Atenolol 100 mg PO DAILY 5. cariprazine 1.5 mg oral DAILY 6. FLUoxetine 20 mg PO DAILY 7. Gabapentin 100 mg PO BID 8. GlipiZIDE 2.5 mg PO BID 9. Glargine 16 Units Bedtime 10. Levothyroxine Sodium 100 mcg PO DAILY 11. Lisinopril 40 mg PO DAILY 12. LORazepam 0.5 mg PO DAILY:PRN anxiety 13. Omeprazole 20 mg PO DAILY 14. Ondansetron 4 mg PO Q8H:PRN nausea 15. Prochlorperazine 5 mg PO Q8H:PRN nausea 16. Tamsulosin 0.4 mg PO QHS 17. Vitamin D 5000 UNIT PO DAILY 18. Multivitamins 1 TAB PO DAILY 19. Fenofibrate 48 mg PO DAILY Discharge Medications: 1. CefTRIAXone 2 gm IV Q24H RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 gm IV once a day Disp #*9 Intravenous Bag Refills:*0 2. MetroNIDAZOLE 500 mg PO Q8H RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #*27 Tablet Refills:*0 3. Glargine 16 Units Bedtime 4. amLODIPine 10 mg PO DAILY 5. Ascorbic Acid ___ mg PO DAILY 6. Atenolol 100 mg PO DAILY 7. cariprazine 1.5 mg oral DAILY 8. Enoxaparin Sodium 120 mg SC DAILY Start: ___, First Dose: Next Routine Administration Time 9. Fenofibrate 48 mg PO DAILY 10. FLUoxetine 20 mg PO DAILY 11. Gabapentin 100 mg PO BID 12. GlipiZIDE 2.5 mg PO BID 13. Levothyroxine Sodium 100 mcg PO DAILY 14. Lisinopril 40 mg PO DAILY 15. LORazepam 0.5 mg PO DAILY:PRN anxiety 16. Multivitamins 1 TAB PO DAILY 17. Omeprazole 20 mg PO DAILY 18. Ondansetron 4 mg PO Q8H:PRN nausea 19. Prochlorperazine 5 mg PO Q8H:PRN nausea 20. Tamsulosin 0.4 mg PO QHS 21. Vitamin D 5000 UNIT PO DAILY Discharge Disposition: Home With Service Facility: ___ ___ Diagnosis: Cholangitis Bacteremia Adenocarcinoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to the hospital after you were found to have a blockage of your bile ducts causing a serious infection called cholangitis. You were also found to have bacteria in your blood stream. You underwent an ERCP with a plastic stent placed. After the procedure your bilirubin continued to rise and you underwent a second ERCP to place a metal stent. For your serious infection you were started on IV antibiotics and will need to continue this for two weeks. This blockage in the bile duct was caused by a stricture. Samples of the stricture were taken and found to be cancer (adenocarcinoma). You were seen by the oncology team and have follow up with them in a few days to talk about treatment options. It was a pleasure caring for you, Your ___ Team Followup Instructions: ___

10006269-DS-16

DS

2124-07-05 00:00:00

2124-07-06 07:25:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Major Surgical or Invasive Procedure: EGD Colonoscopy Biopsy during colonoscopy Lumbar puncture attach Pertinent Results: ADMISSION LABS: ___ 11:00AM WBC-10.0 RBC-4.66 HGB-8.4* HCT-30.9* MCV-66* MCH-18.0* MCHC-27.2* RDW-20.1* RDWSD-45.3 ___ 11:00AM NEUTS-85.1* LYMPHS-6.6* MONOS-7.7 EOS-0.0* BASOS-0.2 IM ___ AbsNeut-8.47* AbsLymp-0.66* AbsMono-0.77 AbsEos-0.00* AbsBaso-0.02 ___ 11:00AM PLT COUNT-225 ___ 11:00AM GLUCOSE-111* UREA N-15 CREAT-1.0 SODIUM-128* POTASSIUM-4.6 CHLORIDE-95* TOTAL CO2-18* ANION GAP-15 ___ 11:00AM ALT(SGPT)-13 AST(SGOT)-20 ALK PHOS-80 TOT BILI-1.0 ___ 11:00AM ALBUMIN-4.9 ___ 07:20AM BLOOD Hypochr-1+* Anisocy-1+* Macrocy-1+* Microcy-1+* Polychr-1+* Tear Dr-1+* RBC Mor-SLIDE REVI ___ 11:42AM BLOOD Ret Aut-3.1* Abs Ret-0.13* ___ 07:20AM BLOOD calTIBC-371 VitB12-293 Folate-8 Ferritn-5.6* TRF-285 ___ 11:42AM BLOOD Hapto-208* ___ 07:20AM BLOOD TSH-1.1 ___ 07:20AM BLOOD 25VitD-17* ___ 03:30AM BLOOD IgA-162 ___ 03:40PM CEREBROSPINAL FLUID (CSF) TNC-146* RBC-7* POLYS-1 ___ MONOS-12 BASOS-1 OTHER-0 ___ 03:40PM CEREBROSPINAL FLUID (CSF) TNC-141* RBC-2 POLYS-1 ___ MONOS-3 OTHER-0 ___ 03:40PM CEREBROSPINAL FLUID (CSF) PROTEIN-100* GLUCOSE-57 ___ 11:00AM Lyme Ab-NEG ___ 04:45PM BLOOD Trep Ab-NEG ___ 07:20AM BLOOD HIV Ab-NEG ___ 03:05PM BLOOD Parst S-NEGATIVE MICRO: ___ 3:40 pm CSF;SPINAL FLUID Site: LUMBAR PUNCTURE TUBE #3. GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: NO GROWTH. HSV CSF HSV2 + low positive IMAGING: CT head w/o acute intracranial process Discharge Labs: ___ 06:00AM BLOOD WBC-5.6 RBC-3.79* Hgb-7.2* Hct-27.1* MCV-72* MCH-19.0* MCHC-26.6* RDW-22.1* RDWSD-56.4* Plt ___ ___ 06:00AM BLOOD Glucose-80 UreaN-12 Creat-0.8 Na-143 K-3.9 Cl-111* HCO3-21* AnGap-11 ___ 06:00AM BLOOD Calcium-8.2* Phos-4.5 Mg-1.7 ___ 05:45AM BLOOD Hapto-126 ___ 07:20AM BLOOD TSH-1.1 ___ 05:50AM BLOOD CEA-1.9 ___ 03:30AM BLOOD IgA-162 Colonoscopy: Circumferential mass of malignant appearance was found in the distal rectum completely encircling the rectal verge. There were local ulcerations in the 12 o'clock position. Multiple cold forceps biopsies were performed for histology in the rectal mass. EGD: Normal erythema in the whole esophagus. Erythema in the antrum with gastritis. Erythema in the duodenum compatible with duodenitis. Brief Hospital Course: Hospital Medicine Attending Progress Note Time patient seen and examined today HPI on Admission: Mr. ___ is a ___ male with a PMHX of partial aortic dissection, HTN, who presents w/ HA & fever x2d concerning for meningitis. Patient reports that 3 days ago, he developed malaise and terrible headache: constant, dull, diffuse. The following day, headache was relenting ___ pain. Also had fever of 102 and took tylenol/ibuprofen without relief of symptoms. He reports nausea and decreased PO intake. Denies vision changes, sensitivity to light, syncope, URI sx, chest pain, shortness of breath, abd pain, diarrhea/constipation, sick contacts. Has mild neck stiffness as well. He lives in ___, does a lot of yardwork. Has had exposure to ticks, mosquitoes, but none he memorably recalls recently. No recent travel hx. No rash. He was feeling entirely well prior to onset of these symptoms. Given terrible headache and fever, he presented to the ED. Hospital Course to Date: The pt was admitted for acute onset headache and fever. LP showed a cell count of 141 with lymphocytic predominance and elevated protein to 100. He was initially started on bacterial meningitis coverage, then narrowed to acyclovir based on negative CSF stain and cultures. Doxycycline was added to cover potential lyme meningitis. The pt's CSF came back positive for HSV PCR. Per ID recommendations from ___: "Would recommend continuing on Acyclovir for now but when safe for discharge can change to Valtrex 1 gram po three times per day to complete 14 day course. In setting of only low positive HSV 2 PCR and extensive outdoor activity would also complete 14 day course of doxycycline even though lyme is less likely." The pt improved dramatically. His headache resolved. Throughout his hospitalization, he had no confusion or neurologic deficits. He was transitioned to oral acyclovir the day before discharge and discharged on PO acyclovir + PO doxycycline for a total 14 day course. Of note, the pt was incidentally found to have an abnormally low Hb on admission. He required 1u PRBC transfusion ___. He denies any known bleeding. GI was consulted and recommended EGD + colonoscopy, performed ___. EGD showed diffuse erythema of the mucosa with no bleeding noted in the antrum, consistent with gastritis. Colonoscopy showed a circumferential mass of malignant appearance in the distal rectum completely encircling the rectal verge. There were local ulcerations in the 12:00 position. Colorectal surgery was consulted. They recommended follow up at the colorectal cancer clinic. Follow up was arranged prior to discharge and the pt was aware of the diagnosis and need for follow up. The clinic and colorectal surgery asked for a baseline CEA which was normal. They asked for a staging MRI pelvis which did not show any spread of the presumed cancer. Pathology was sent by GI. Initial pathology showed superficial fragments of tubulovillous adenoma. This was pending at the time of discharge, though initial reports had shown the same diagnosis, so the pt was instructed to follow up with GI. The GI phone number was shared with the patient and he was instructed to call them directly if he did not hear from the clinic within 24 hours. The pt received a total of 2u PRBCs this hospitalization. Hb was 7.2 on the morning of discharge and the pt received 1u PRBCs (the second unit this stay) on the day of discharge after the Hb of 7.2 in order to ensure that his Hb did not drop below 7.0 at home. Close follow up was arranged prior to discharge. The pt had no active bleeding at the time of discharge. Return to ER precautions such as dizziness and increased bleeding were reviewed with the patient. The pt's BP meds were held on admission but restarted prior to discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. TraZODone 50 mg PO QHS:PRN insomnia 2. Citalopram 20 mg PO DAILY 3. Lisinopril 20 mg PO DAILY 4. Metoprolol Succinate XL 50 mg PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever 2. Doxycycline Hyclate 100 mg PO Q12H RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day Disp #*12 Capsule Refills:*0 3. Pantoprazole 40 mg PO DAILY RX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 4. ValACYclovir 1000 mg PO TID RX *valacyclovir [Valtrex] 1,000 mg 1 tablet(s) by mouth three times a day Disp #*18 Tablet Refills:*0 5. Citalopram 20 mg PO DAILY 6. Lisinopril 20 mg PO DAILY 7. Metoprolol Succinate XL 50 mg PO DAILY 8. TraZODone 50 mg PO QHS:PRN insomnia Discharge Disposition: Home Discharge Diagnosis: Viral meningitis ___ HSV Iron deficiency anemia Rectal cancer Discharge Condition: Stable for outpatient follow up Discharge Instructions: Dear ___, You came to the hospital with severe headache and fevers. You were found to have a viral meningitis with testing showing herpes simplex virus to be the cause. Please continue taking Valtrex and doxycycline until ___ to treat this infection. When you were in the hospital, you were found to have iron deficiency anemia. You were seen by the Gastroenterologists. You underwent an EGD and a colonoscopy. The EGD showed a little stomach irritation. Avoid ibuprofen, higher dose aspirin, and naproxen. Take pantoprazole to help with the irritation. There was no cancer found in the stomach. The colonoscopy showed a rectal cancer. Please follow up as instructed with gastroenterology for a better pathology sample and with the multi-disciplinary colorectal cancer team as instructed. Your appointment with the multi-disciplinary team has already been set up. Call the ___ clinic to set up an appointment with them, in order for them to get a better sample of the tumor. This is needed for the pathologists and oncologists. If you do not hear from the office within 48 hours, call them at: ___. We wish you the best in your recovery. -- Your medical team Followup Instructions: ___

10006431-DS-22

DS

2128-03-07 00:00:00

2128-03-16 02:26:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: latex Attending: ___. Chief Complaint: diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a pleasant ___ w/ HTN, DL, congenital deafness, and recently diagnosed borderline resectable pancreatic head adenocarcinoma, on neoadjuvant C1D21 Folfirinox who presents for diarrhea for two days. She had ERCP with stent placement done yesterday. No complications with that. She reports multiple episodes of watery brown non-bloody diarrhea for the past two days. She reports not eating or drinking as much over the past several months. Also some nausea on and off over the same time period. She reports mild gas pain but denies abdominal pain and vomiting. In ED, initial vitals were Temp 97.7, HR 91, BP 102/65, RR 15, O2 sat 98% RA. She received 1L NS. CXR was negative for infection. Vitals prior to transfer were Temp 98.1, HR 77, BP 106/66, RR 16, O2 sat 100% RA. On arrival to the floor, she reports that she is feeling well. She denies fevers/chills, headache, dizziness/lightheadedness, shortness of breath, cough, chest pain, palpitations, abdominal pain, vomiting, constipation, dysuria, and rashes. Past Medical History: HTN congenital deafness GERD Goiter Social History: ___ Family History: Father passed away from complications of gangrenous colitis. Mother with T2DM. Sister with colon CA. Sister deceased, ___. Physical Exam: ADMISSION PHYSICAL EXAM: VS: Temp 97.3, BP 125/89, HR 69, RR 18, O2 sat 100% RA. GENERAL: Pleasant woman, in no distress, lying in bed comfortably. HEENT: Anicteric, PERLL, OP clear. CARDIAC: RRR, normal s1/s2, no m/r/g. LUNG: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi. ABD: Normal bowel sounds, soft, nontender, nondistended, no hepatomegaly, no splenomegaly. EXT: Warm, well perfused, no lower extremity edema, erythema or tenderness. NEURO: Alert, oriented, good attention and linear thought, CN II-XII intact. Strength full throughout. SKIN: No significant rashes. Brief Hospital Course: ___ is a pleasant ___ w/ HTN, DL, congenital deafness, and recently diagnosed borderline resectable pancreatic head adenocarcinoma, on neoadjuvant C1D21 Folfirinox who presents for diarrhea for two days. Diarrhea- She has 2 loose watery diarrhea everyday mostly at AM. Her stool c diff was negative. She was started on Imodium and the dose was titrated up to 4mg TID but she still continued to have loose watery diarrhea. Her diarrhea is most likely from Irinotecan. She was also started on peptobismol to help her diarrhea Elevated Lipase- She had a mild elevation of lipase levels but this is likely from her having a ERCP on the day prior to admission. She does not have any epigastric abdominal pain or lipase levels high enough to suspect pancreatitis. Her blood and urine cultures were negative during this admission. She was discharged home in a stable condition. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 20 mg PO DAILY 2. Omeprazole 20 mg PO DAILY 3. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 4. LORazepam 0.5 mg PO BID:PRN anxiety,nausea 5. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting 6. TraMADol 50-100 mg PO Q6H:PRN Pain - Moderate 7. Dexamethasone 4 mg PO BID Discharge Medications: 1. Bismuth Subsalicylate 30 mL PO TID ___ cause black discoloration of stool RX *bismuth subsalicylate [Bismatrol] 525 mg/15 mL 15 ml by mouth three times daily Refills:*0 2. LOPERamide 4 mg PO Q8H RX *loperamide 2 mg 2 tablets by mouth three times daily Disp #*50 Capsule Refills:*1 3. Dexamethasone 4 mg PO BID take for 2 days after chemotherapy 4. Lisinopril 20 mg PO DAILY 5. LORazepam 0.5 mg PO BID:PRN anxiety,nausea RX *lorazepam 0.5 mg 1 tablet by mouth twice daily Disp #*30 Tablet Refills:*1 6. Omeprazole 20 mg PO DAILY 7. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 8. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting 9. TraMADol 50-100 mg PO Q6H:PRN Pain - Moderate Discharge Disposition: Home Discharge Diagnosis: Diarrhea-likely from Irinotecan. Pancreatic cancer Discharge Condition: stable alert and oriented to time place and person independent ambulation Discharge Instructions: Dear ___, It was a pleasure taking care of you. You were admitted since you developed loose stools. We found out that you had no infections causing the diarrhea. It is likely a adverse reaction from chemotherapy agent. Please take Imodium and Peptobismol as directed until your diarrhea is controlled. Please follow up for your appointment with ___ on ___. Sincerely, ___ MD Followup Instructions: ___

10006431-DS-23

DS

2128-03-30 00:00:00

2128-03-30 16:30:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: latex Attending: ___. Chief Complaint: Nausea/vomting, diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ female with with HTN, DL, congenital deafness, and borderline resectable pancreatic head adenocarcinoma on neoadjuvant C2D12 Folfirinox who presents with nausea/vomiting, diarrhea, and inability to tolerate POs. Patient reports continued diarrhea as well as nausea/vomiting that has not been controlled with home medications. She was seen in clinic on ___ where she noted diarrhea for one week and was given immodium, Zofran, and 1L NS. She had been taking Pepto Bismal. Stool studies were ordered however patient unable to give a sample and attempted to be done at outside facility but not processed. She continued to have diarrhea and poor PO intake due to nausea and poor appetite. She tried immodium without significant improvement. She wants to stop chemo due to the side effects. Of note, she was recently admitted ___ to ___ with diarrhea. Stool studies were negative. She was started on immodium and pepto bismal. On arrival to the ED, initial vitals were 97.9 80 118/71 16 100% RA. Labs were notable for WBC 3.0, H/H 13.0/39.8, Plt 248, Na 134, K 3.5, BUN/Cr ___, LFTs wnl, INR 1.2, and UA bland. CT abdomen was negative for acute process. Patient was given Zofran 4mg IV x 2 and 1L Ns at 100 cc/hr. Vitals prior to transfer were 98.0 99 117/90 18 99% RA. On arrival to the floor, patient reports that she is feeling better. She is able to drink without nausea. She denies fevers/chills, headache, dizziness/lightheadedness, vision changes, weakness/numbness, shortness of breath, cough, chest pain, palpitations, and dysuria. Past Medical History: PAST ONCOLOGIC HISTORY: ___ has a history of hypertension, congenital deafness, and GERD, and presented in early ___ to ___ with painless jaundice. At the time, she also noted several weeks of nausea, vomiting, postprandial abdominal pain and a 20-pound weight loss. She was referred to ___ where she underwent ERCP. This study identified a stricture in the common bile duct due to external compression. Brushings were atypical. Her CA ___ was elevated at 180 U/mL. She underwent endoscopic ultrasound ___. This study identified a 1.8 x 1.6 cm pancreatic head mass without vascular involvement. Biopsy by ___ showed adenocarcinoma. CT angiogram also showed a 1.6 x 1.4 x 1.4 cm pancreatic head mass with stranding but no definite involvement at the SMA and SMV. There was no evidence of distant metastases. Ms. ___ was diagnosed with borderline resectable PDA and initiated chemotherapy with neoadjuvant FOLFIRINOX ___. C1D15 dose reduced for N/V/D. She underwent biliary stent change and was then hospitalized ___ with persistent diarrhea and leukocytosis. PAST MEDICAL HISTORY: 1. Hypertension 2. Congenital deafness 3. GERD 4. Goiter 5. History of nephrolithiasis 6. Hypercholesterolemia 7. Status post C-section x 2 Social History: ___ Family History: The patient's father died of an MI at ___ years. Her mother died with type 2 diabetes mellitus. A sister died with colon cancer at ___ years. Another sister died of ___ disease. She has two sons without health concerns. Physical Exam: ADMISSION PHYSICAL EXAM: VS: Temp 97.2, BP 154/84, HR 99, RR 18, O2 sat 98% RA. ___: Pleasant woman, in no distress, lying in bed comfortably. HEENT: Anicteric, PERLL, OP clear. CARDIAC: RRR, normal s1/s2, no m/r/g. LUNG: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi. ABD: Normal bowel sounds, soft, nontender, nondistended, no hepatomegaly, no splenomegaly. EXT: Warm, well perfused, no lower extremity edema, erythema or tenderness. NEURO: Alert, oriented, good attention and linear thought, CN II-XII intact. Strength full throughout. SKIN: No significant rashes. Discharge PE: 97.7 142 / 80 82 18 97 RA ___: Well appearing, lying in bed in NAD Eyes: PERLL, EOMI, sclera anicteric ENT: MMM, oropharynx clear without exudate or lesions Respiratory: CTAB without crackles, wheeze, rhonchi, though breath sounds reduced at bases. Cardiovascular: RRR, normal S1 and S2, no murmurs, rubs or gallops Gastrointestinal: Soft, nontender, nondistended, +BS, no masses or HSM Extremities: Warm and well perfused, no peripheral edema Skin: warm, no rashes/no jaundice/no skin ulcerations noted Neurological: Alert and oriented x3 Pertinent Results: ADMISSION LABS: ___ 10:35AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 10:35AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 10:35AM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE EPI-1 ___ 04:29AM GLUCOSE-103* UREA N-10 CREAT-0.5 SODIUM-134 POTASSIUM-3.5 CHLORIDE-99 TOTAL CO2-20* ANION GAP-19 ___ 04:29AM ALT(SGPT)-29 AST(SGOT)-22 ALK PHOS-60 TOT BILI-0.4 ___ 04:29AM LIPASE-33 ___ 04:29AM ALBUMIN-3.0* CALCIUM-8.1* PHOSPHATE-2.3* MAGNESIUM-1.6 ___ 04:29AM WBC-3.0*# RBC-4.66 HGB-13.0 HCT-39.8 MCV-85 MCH-27.9 MCHC-32.7 RDW-15.0 RDWSD-45.9 ___ 04:29AM NEUTS-41 BANDS-3 ___ MONOS-21* EOS-2 BASOS-0 ATYPS-1* ___ MYELOS-0 AbsNeut-1.32* AbsLymp-0.99* AbsMono-0.63 AbsEos-0.06 AbsBaso-0.00* ___ 04:29AM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-3+ MACROCYT-NORMAL MICROCYT-2+ POLYCHROM-NORMAL OVALOCYT-1+ SCHISTOCY-OCCASIONAL BURR-3+ TEARDROP-OCCASIONAL ___ 04:29AM ___ PTT-22.7* ___ DISCHARGE LABS: ___ 06:17AM BLOOD WBC-7.6 RBC-4.35 Hgb-12.0 Hct-36.5 MCV-84 MCH-27.6 MCHC-32.9 RDW-15.4 RDWSD-46.3 Plt ___ ___ 06:17AM BLOOD Glucose-94 UreaN-8 Creat-0.4 Na-137 K-4.0 Cl-99 HCO3-29 AnGap-13 ___ 06:17AM BLOOD Calcium-8.9 Phos-3.4 Mg-1.7 MICRO: URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ___ C diff, stool studies negative IMAGING: ___ CXR IMPRESSION: In comparison with the study of ___, there is little interval change. The cardiac silhouette remains within normal limits with no evidence of vascular congestion or acute focal pneumonia. There is blunting of the left costophrenic angle on the lateral view, suggesting small interval pleural effusion. The right Port-A-Cath again extends to the lower SVC. ___ CT A/P IMPRESSION: 1. No evidence of acute intra-abdominal process. 2. Pancreatic head hypodensity is unchanged and associated peripancreatic soft tissue density is less conspicuous, potentially due to interval improvement or differences in technique. 3. Left pelvic vein engorgement and left gonadal vein enlargement are nonspecific findings but may be seen in the setting of pelvic congestion syndrome. Brief Hospital Course: ___ female with with HTN, congenital deafness, and borderline resectable pancreatic head adenocarcinoma on neoadjuvant C2D12 Folfirinox who presents with nausea/vomiting, diarrhea, and inability to tolerate POs. # Diarrhea/Nausea/Vomiting: Most likely due to side effects of FOLFIRINOX. Abdominal CT without acute process and exam benign. Similar symptoms in past after chemotherapy. Less likely infection especially given negative stool studies. C. diff negative so after consultation with outpatient oncologist, treated with typical antidiarrheal regimen of loperamide and lomotil with resolution of diarrhea. Beginning to improve, mildly increased PO intake but solid foods still limited. Diarrhea largely resolved. After discussion with patient and outpatient oncologist was started on Decadron 2 mg PO daily to help improve appetite/reduce nausea in order to allow adequate PO intake for safe discharge. - Continue 2mg dexamethasone daily, likely will stop after 7 day course if continued improvement - Continue anti-emetic regimen - Continue PPI #Cough: Having cough intermittently productive of yellow sputum. Lung exam reassuring, CXR shows no evidence of pneumonia, afebrile without leukocytosis. -Monitor off antibiotics, if symptoms worsening consider repeat chest imaging -Cont IS -Encourage ambulation # Pancreatic Cancer/neutropenia: s/p FOLFIRINOX cycle 2 on ___. GI sx likely ___ further plans for administration of this drug. Neutropenic with ANC ___, likely ___ recent chemotx, no fevers to date, WBC now improved with ANC >2800. Will follow with Dr. ___. - Continue tramadol for pain # HTN: - Lisinopril was held initially, restarted on discharge # Anxiety: She reports having anxiety about leaving the hospital as after multiple recent discharges she quickly went to a local ED. She was counseled extensively that she had made gradual improvement and there was no further treatment recommended in the hospital at this time. -Consider outpatient social work or palliative care referral to help with anxiety and symptom management. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. LORazepam 0.5 mg PO BID:PRN anxiety,nausea 2. Omeprazole 20 mg PO DAILY 3. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 4. TraMADol 50-100 mg PO Q6H:PRN Pain - Moderate 5. Bismuth Subsalicylate 30 mL PO TID:PRN diarrhea/nausea/abdominal pain 6. LOPERamide 4 mg PO TID:PRN diarrhea 7. Dexamethasone 4 mg PO BID 8. Lisinopril 20 mg PO DAILY 9. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting 10. ___ ___ UNIT PO QID Discharge Medications: 1. Docusate Sodium 100 mg PO BID:PRN constipation RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 2. Senna 8.6 mg PO BID:PRN constipation RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp #*60 Tablet Refills:*0 3. Dexamethasone 2 mg PO DAILY Duration: 7 Days RX *dexamethasone 2 mg 1 tablet(s) by mouth once a day Disp #*7 Tablet Refills:*0 4. Bismuth Subsalicylate 30 mL PO TID:PRN diarrhea/nausea/abdominal pain 5. Lisinopril 20 mg PO DAILY 6. LOPERamide 4 mg PO TID:PRN diarrhea 7. LORazepam 0.5 mg PO BID:PRN anxiety,nausea 8. ___ ___ UNIT PO QID 9. Omeprazole 20 mg PO DAILY 10. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 11. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting 12. TraMADol 50-100 mg PO Q6H:PRN Pain - Moderate Discharge Disposition: Home With Service Facility: ___ ___ Diagnosis: Primary: Chemotherapy-related nausea Secondary: Pancreatic adenocarcinoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to ___ for nausea/vomiting/diarrhea and inability to tolerate food after your recent chemotherapy. You were given medicine which resolved your diarrhea and helped with nausea. Since you continued to have difficulty eating, you were started on a course of steroids. Please follow up with your oncologist to determine your ongoing chemotherapy plans. It was a pleasure caring for you, Your ___ Healthcare Team Followup Instructions: ___

10006457-DS-13

DS

2147-12-17 00:00:00

2147-12-17 14:34:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Morphine Sulfate / Codeine / Dilaudid (PF) Attending: ___. Chief Complaint: Dizziness, fatigue, and possible syncopal episode x 2 weeks. Major Surgical or Invasive Procedure: Carotid endarterectomy (CEA) History of Present Illness: ___ is a ___ right handed woman with PMH of HTN, HL, DM II c/b peripheral neuropathy, current smoking, an episode of pericarditis, family history of early MI, and poor previous medical care (has not seen a physician in over ___ years), who initially presented with HTN (SBP 190-210) and nonspecific symptoms of postural lightheadedness, bilateral hand numbness and tingling, left retro-orbital headaches, some transient visual blurring, and a possible syncopal episode. Past Medical History: PmHX: DMII - ___ years, complicated with neuropathy and retinopathy. pericarditis HTN Hyperlipidemia abd pain, s/p x-lap ___, unrevealing; appendectomy ETT ___ with small anterior defect (likely artifact). EF 73%. Nephrolithiasis ALL: Codeine, morphine, dilaudid - all cause nausea, vomiting, itching Social History: ___ Family History: No family history of neurologic disease including stroke, seizures, movement disorders, demyelinating diseases, or migraines. # Mother: ___ # Father: Fatal MI at age ___. # Siblings: Three sisters and one brother, all well. Physical Exam: PER OMR on ___ T 98.8 BP 115/74 (110-150s) HR 79 RR 18 O2 100% RA Blood glucose ranging from 200-252 General: Awake, cooperative, NAD. HEENT: NC/AT Neck: Supple, soft bruit in left neck, high by the angle of jaw. Pulmonary: CTABL Cardiac: RRR, III/VI murmur in mitral area Abdomen: soft, nontender, nondistended Extremities: no edema, warm to palpation Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented to self, ___ and ___. -Cranial Nerves: I: Olfaction not tested. II: PERRL briskly, L>R by <1mm. VFF to confrontation. III, IV, VI: Some difficulty with smooth pursuit but EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: R NLF, symmetric activation 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. Mild atrophy of small muscles of hand/feet. +R pronator drift. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ ___ 4+ 5 4+ 5 5 4 4 R 4+ 5 4+ ___ 4+ 4+ 5 4 5 5 4 4 -Sensory: No deficits to light touch throughout. Decreased vibration at the toes bilaterally. Decreased pinprick to just below the knees bilaterally. Decreased proprioception at the toes > fingers. -DTRs: Bi Tri ___ Pat Ach L 1 1 1 1 0 R 1 1 1 1 0 Plantar response was tonically extensor. -Coordination: Mild dysmetria on FNF on R, worse when eyes closed ?related to proprioceptive loss. Somewhat slow/clumsier on R hand with finger tapping and rapid alternating movement. -Gait: +Romberg. Somewhat unsteady gait but not broad based. Pertinent Results: ADMISSION LABS ___ 07:53PM BLOOD WBC-8.5 RBC-4.82 Hgb-14.7 Hct-42.0 MCV-87 MCH-30.5 MCHC-35.1* RDW-12.3 Plt ___ ___ 07:53PM BLOOD Neuts-63.0 ___ Monos-3.9 Eos-2.1 Baso-1.1 ___ 06:10AM BLOOD ___ PTT-29.5 ___ ___ 07:53PM BLOOD Glucose-152* UreaN-17 Creat-0.8 Na-138 K-3.7 Cl-98 HCO3-28 AnGap-16 PERTINENT LABS ___ 07:53PM BLOOD ALT-19 AST-24 CK(CPK)-212* AlkPhos-81 TotBili-1.1 ___ 07:53PM BLOOD Calcium-9.9 Phos-3.3 Mg-1.6 ___ 07:53PM BLOOD Lipase-53 ___ 07:53PM BLOOD CK-MB-5 cTropnT-<0.01 ___ 06:10AM BLOOD CK-MB-3 cTropnT-<0.01 ___ 06:10AM BLOOD VitB12-PND ___ 06:10AM BLOOD %HbA1c-9.3* eAG-220* ___ 06:10AM BLOOD Triglyc-PND HDL-PND LDLmeas-PND DISCHARGE LABS WBC RBC Hgb Hct MCV MCH MCHC RDW Plt ___ 9.6 4.13* 12.3 35.7* 87 29.7 34.3 12.6 256 Glucose UreaN Creat Na K Cl HCO3 AnGap ___ 05:15 173 9 0.6 138 3.9 ___ Calcium Phos Mg ___ 8.6 3.9 2.0 MICRO __________________________________________________________ ___ 6:10 am SEROLOGY/BLOOD CHEM # ___ ___. RAPID PLASMA REAGIN TEST (Pending): NON-REACTIVE __________________________________________________________ ___ 9:00 pm URINE 802S. URINE CULTURE (Pending): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. __________________________________________________________ ___ 8:32 pm BLOOD CULTURE Blood Culture, Routine (Pending): NO GROWTH. __________________________________________________________ ___ 7:53 pm BLOOD CULTURE Blood Culture, Routine (Pending): NO GROWTH. STUDIES ___: CTA NECK W&W/OC & RECONS IMPRESSION: Increase in size of hypodensities in the left basal ganglia and left frontal lobe compared to the previous MR, which could represent evolution of the infarct; however, new infarcts are also possible. Consider MRI to evaluate for acute or progressive infarct if clinically indicated. The left common carotid artery is widely patent status post endarterectomy. Patent right carotid arterie, vertebral arteries and major branches. ___: MR HEAD W/O CONTRAST IMPRESSION: Multiple, predominantly left infarctions as above, with interval increase in the size of infarctions seen previously, as well as multiple new foci of infarction, including a right paramedian focus. A small amount of interval susceptibility artifact in the confluent left frontal infarction suggests minimal interval intracranial blood. ___: MR HEAD W/O CONTRAST IMPRESSION: Redemonstration of numerous bilateral cerebral foci of abnormally slow diffusion consistent with infarction, overall unchanged from the most recent comparison. A small amount of left frontal hypointensity on gradient-echo imaging suggesting blood products seen on the most recent examination is no longer apparent. Brief Hospital Course: ___ woman h/o HTN, DMII c/b neuropathy and retinopathy, daily tobacco abuse, alcohol dependence, presented with postural lightheadedness, visual obscurations, bilateral hand tingling and numbness. She also had fluctuating inattentiveness. Was initially admitted to medicine, but MRI showed scattered punctate left hemisphere deep ___ infarctions as well as one in the splenium of the CC. MRA shows what looks like critical stenosis of the left carotid bifurcation ___: - Patient presented to ED with dizziness and subtle left-sided weakness with high BP (194/95). In the ED, she remained quite hypertensive (SBP 190-210), and all parts of neurological examination were normal except for a mild distal symmetric peripheral neuropathy in a stocking distribution. Overnight, her blood pressures were improved, remaining in the 130-140s, with blood sugars in the 200-250 range. She spiked one low grade fever to 100.2 while in house, but this spontaneously resolved. On my examination, she had a delayed reaction time and was quite indifferent and dysprosodic. There was a paucity of emotionality and facial expressions. She had no aphasia or dysarthria, and followed commands well. There was no neglect. The remainder of the examination was unremarkable. ___: With the nonspecific findings on examination, the patient was admitted to the medicine service for a presumed hypertensive emergency. She was started on a baby aspirin. An MRI was recommended, and identified multiple small areas of restricted diffusion in the left hemisphere and splenium all consistent with a shower of emboli from a proximal embolic source. An MRA done at that time showed the presence of a stenosed left carotid bifurcation. Labs showed hyperglycemia and an elevated A1c to 9.3, consistent with poorly controlled DM. Her lipid panel returned showing an elevated TC (277), elevated LDL (169) and normal HDL(46). Her UA showed a urinary tract infection, and so she was started on ceftriaxone. Upon discovery of the stroke, the patient has been transferred to the neurology stroke service for continued work up and care. Echo on ___ showed: IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved regional and global biventricular systolic function (LVEF >55%). No valvular pathology or pathologic flow identified. No structural cardiac cause of syncope identified. Carotid Duplex on ___ showed: IMPRESSION: Significant stenosis at the origin of the left internal carotid artery, estimated between 80 and 99%. On the right, there is also significant stenosis at the origin of the ICA, with estimated 40-59% narrowing. ___: In light of discovering significant stenosis at the origin of the left internal carotid artery, estimated between 80 and 99%, urgent vascular surgery consult was initiated and heparin gtt was started (goal 50-70, PTT q6h). - Will stop ASA 325mg daily while on heparin drip - HOB down and allow BP autoregulation. - Continue atorvastatin 40mg daily - Supportive care with insulin sliding scale, PRN tylenol, CIWA scale, nicotine patch, etc. - Continue ceftriaxone for UTI - ___ consult - Placed SW consults in light of poor previous medical care, new diagnosis. The patient underwent emergent left CEA on ___ (see operative note for details). The patient tolerated the procedure well, was extubated in the OR and was taken to the recovery room in stable condition. Overnight on ___, the patient experienced confusion and weakness of the right upper extremity; anisocria was seen on examination. Neurology was consulted who recommended avoidance of hypotension with goal SBP 120-160, continue aspirin/statin and repeat MRI of head to look for additional infarcts. A CTA of the head and neck was performed on ___ that showed increase in size of hypodensities in the left basal ganglia and left frontal lobe compared to the previous MR with possibility of new infarcts. This was followed by a MR1 Head that confirmed the presence of multiple, predominantly left infarctions as above, with interval increase in the size of infarctions, as well as multiple new foci of infarction, including a right paramedian focus. There was also concern for a left frontal hypointensity on gradient-echo imaging suggesting blood products. The next day on ___ the patient complained of headache so Neurology was consulted again who recommended obtaining a repeat CT brain to document stability of the left frontal lobe petechial hemorrhage. The patient's aspirin and SQH were held and an MRI Head w/o contrast was performed on ___. The repeat MRI confirmed resolution of hemorrhage seen the previous day. That same day the patient underwent a speech/swallowing evaluation the next day following which her diet was progressed. ___ were on board throughout the ___ hospital stay. On ___, the patient's motor function appeared to be stable (barring some fluctuation due to difficulty with cooperating) and there was improvement in speech so the goal was to achieve normotension with a SBP <150, avoid hypotension, continue aspirin/statin, re-start heparin SQ TID for DVT prophylaxis, diabetic diet/heart healthy diet, and insulin sliding scale for goal normoglycemia. ___ was consulted, given the patient's uncontrolled blood sugar levels and HBA1C of 9%, following which she was started on oral hyperglycemics and Humalog sliding scale. Over ___, the patient has continued to make excellent progress. Her medical issues are well under control and after soliciting re-evaluation from Neurology and ___ ___ she was deemed stable for discharge to an acute rehab facility of her family's choice in ___. There the patient will continue to receive extensive ___ and speech therapy and will follow up with Vascualr Surgery, Neurology and ___ ___ in the coming weeks. Medications on Admission: None. Discharge Medications: 1. Senna 1 TAB PO BID:PRN constipation 2. Acetaminophen 1000 mg PO Q6H:PRN pain 3. Aspirin EC 325 mg PO DAILY 4. Atorvastatin 80 mg PO DAILY RX *atorvastatin 80 mg 1 tablet(s) by mouth once a day Disp #*60 Tablet Refills:*1 5. Heparin 5000 UNIT SC TID 6. Metoprolol Tartrate 12.5 mg PO TID RX *metoprolol tartrate 25 mg Half tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1 7. GlipiZIDE 5 mg PO DAILY RX *glipizide 5 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 8. MetFORMIN (Glucophage) 1000 mg PO BID RX *metformin [Glucophage] 1,000 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*1 9. Insulin SC Sliding Scale Fingerstick QID Insulin SC Sliding Scale using HUM Insulin RX *insulin lispro [Humalog] 100 unit/mL As per attached schedule Up to 10 Units QID per sliding scale Disp #*2 Cartridge Refills:*0 10. Nicotine Patch 7 mg TD DAILY 11. Docusate Sodium 100 mg PO BID:PRN constipation 12. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN headache Duration: 1 Weeks RX *butalbital-acetaminophen-caff [Fioricet] 50 mg-325 mg-40 mg ___ tablet(s) by mouth three times a day Disp #*30 Tablet Refills:*0 Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Left-sided carotid stenosis s/p Left Carotid Endarterectomy (___) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires supervision because of some motor weakness on the right upper extremity. Discharge Instructions: Please monitor your blood glucose levels frequently and alter insulin dose according to the attached Insulin Sliding Scale guidleines. WHAT TO EXPECT: 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 surgeon’s 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 MEDICATION: •Take all of your medications as prescribed in your discharge ACTIVITIES: •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 CALL THE OFFICE FOR: ___ •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: ___

10006513-DS-13

DS

2125-05-07 00:00:00

2125-05-09 13:11:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: UROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: nephrolithiasis, acute kidney injury Major Surgical or Invasive Procedure: Cystoscopy, left ureteral stent placement. History of Present Illness: ___ yo diabetic male, found to have at least 2 separate left ureteral stones, 4 mm at left UVJ and 6 mm at proximal ureter. His UA is unremarkable and he is without fevers. His creatinine is elevated to 1.4 on arrival and 1.5 on recheck after fluids. Discussed this with the patient, and ultimately recommended cystoscopy and placement of left ureteral stent for decompression given his elevated creatinine. Past Medical History: Problems (Last Verified - None on file): DIABETES TYPE II NEPHROLITHIASIS Surgical History (Last Verified - None on file): No Surgical History currently on file. Social History: ___ Family History: No Family History currently on file. Physical Exam: WdWn male, NAD, AVSS Interactive, cooperative Abdomen soft, Nt/Nd Lower extremities w/out edema or pitting and no report of calf pain Pertinent Results: ___ 10:36PM BLOOD WBC-10.1* RBC-5.54 Hgb-14.2 Hct-44.0 MCV-79* MCH-25.6* MCHC-32.3 RDW-12.9 RDWSD-36.7 Plt ___ ___ 10:36PM BLOOD Neuts-64.3 ___ Monos-6.9 Eos-2.9 Baso-0.4 Im ___ AbsNeut-6.50* AbsLymp-2.49 AbsMono-0.70 AbsEos-0.29 AbsBaso-0.04 ___ 06:28AM BLOOD Glucose-193* UreaN-13 Creat-1.4* Na-143 K-4.9 Cl-107 HCO3-24 AnGap-12 ___ 05:39AM BLOOD Glucose-91 UreaN-15 Creat-1.5* Na-139 K-4.8 Cl-102 HCO3-24 AnGap-13 ___ 10:36PM BLOOD Glucose-260* UreaN-18 Creat-1.4* Na-135 K-4.6 Cl-99 HCO3-18* AnGap-18 ___ 10:36PM BLOOD ALT-23 AST-14 AlkPhos-93 TotBili-0.2 ___ 06:28AM BLOOD Calcium-8.8 Mg-2.0 ___ 10:36PM BLOOD Albumin-4.0 ___ 03:16AM BLOOD Lactate-1.6 ___ 12:35AM URINE Color-Yellow Appear-Clear Sp ___ ___ 12:35AM URINE Blood-SM* Nitrite-NEG Protein-TR* Glucose-1000* Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 12:35AM URINE RBC-14* WBC-3 Bacteri-FEW* Yeast-NONE Epi-<1 ___ 12:35AM URINE Mucous-RARE* ___ 01:05PM OTHER BODY FLUID STONE ANALYSIS-PND ___ 12:35 am URINE **FINAL REPORT ___ URINE CULTURE (Final ___: ESCHERICHIA COLI. 10,000-100,000 CFU/mL. PRESUMPTIVE IDENTIFICATION. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ 4 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Brief Hospital Course: Mr. ___ is known to Dr. ___ previous treatment of uric acid renal stones. He has had ___ days of vomiting and left flank pain and came to the emergency room last night. CT scan revealed proximal and distal left ureteral stones. His creatinine was elevated from baseline of ___. Based on his constellation of symptoms and the acute kidney injury, we decided to bring him to the operating room today for left ureteral stent placement. He was taken urgently for obstructing left ureteral stones with acute kidney injury and underwent cystoscopy, left ureteral stent placement. He tolerated the procedure well and recovered in the PACU before transfer to the general surgical floor. See the dictated operative note for full details. Overnight, the patient was hydrated with intravenous fluids and received appropriate perioperative prophylactic antibiotics. Intravenous fluids and Flomax were given to help facilitate passage of stones but toradol was held given his acute kidney injury. On POD1 his creatinine bumped to 1.6 from 1.4. At discharge on POD1, patient’s pain was controlled with oral pain medications, tolerating regular diet, ambulating without assistance, and voiding without difficulty. He was explicitly advised to follow up for future procedures to include ureteral stent removal/exchange, definitive stone management. He was discharged with antibiotics and sodium bicarb tablets and advised to have a recheck of his lab work in ___ days after discharge. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. MetFORMIN (Glucophage) 1000 mg PO BID 2. GlipiZIDE 20 mg PO DAILY 3. Januvia (SITagliptin) 100 mg oral DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Cephalexin 250 mg PO Q6H Duration: 7 Days RX *cephalexin 250 mg ONE tablet(s) by mouth Q6hrs Disp #*28 Tablet Refills:*0 3. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg ONE capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg ONE tablet(s) by mouth Q4hrs Disp #*10 Tablet Refills:*0 5. Pravastatin 80 mg PO DAILY 6. Sodium Bicarbonate 650 mg PO TID RX *sodium bicarbonate 650 mg ONE tablet(s) by mouth three times a day Disp #*28 Tablet Refills:*0 7. Tamsulosin 0.4 mg PO QHS RX *tamsulosin 0.4 mg ONE capsule(s) by mouth DAILY Disp #*30 Capsule Refills:*0 8. amLODIPine 10 mg PO DAILY 9. Aspirin 81 mg PO DAILY 10. GlipiZIDE 20 mg PO DAILY 11. Januvia (SITagliptin) 100 mg oral DAILY 12. MetFORMIN (Glucophage) 1000 mg PO BID 13.Outpatient Lab Work Please have repeat lab work (Chem 7) through your PCP ___ ___ days after discharge (to check your kidney function). Call to arrange when you get home today. Discharge Disposition: Home Discharge Diagnosis: nephrolithiasis; Obstructing left ureteral stones acute kidney injury urinary tract infection (E.Coli) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: -You can expect to see occasional blood in your urine and to possibly experience some urgency and frequency over the next month; this may be related to the passage of stone fragments or the indwelling ureteral stent. -The kidney stone may or may not have been removed AND/or there may fragments/others still in the process of passing. -You may experience some pain associated with spasm of your ureter.; This is normal. Take the narcotic pain medication as prescribed if additional pain relief is needed. -Ureteral stents MUST be removed or exchanged and therefore it is IMPERATIVE that you follow-up as directed. -Do not lift anything heavier than a phone book (10 pounds) -You may continue to periodically see small amounts of blood in your urine--this is normal and will gradually improve -Resume your pre-admission/home medications EXCEPT as noted. You should ALWAYS call to inform, review and discuss any medication changes and your post-operative course with your primary care doctor. -For pain control, try TYLENOL FIRST, then ibuprofen, and then take the narcotic pain medication as prescribed if additional pain relief is needed. -You may be given “prescriptions” for a stool softener and/or a gentle laxative. These are over-the-counter medications that may be “health care spending account reimbursable.” -Colace (docusate sodium) may have been prescribed to avoid post-surgical constipation or constipation related to use of narcotic pain medications. Discontinue if loose stool or diarrhea develops. Colace is a stool-softener, NOT a laxative. -Senokot (or any gentle laxative) may have been prescribed to further minimize your risk of constipation. -Do not eat constipating foods for ___ weeks, drink plenty of fluids to keep hydrated Followup Instructions: ___

10006692-DS-5

DS

2165-05-13 00:00:00

2165-05-14 07:35:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: CHIEF COMPLAINT: Headache, RLE cellulitis Major Surgical or Invasive Procedure: None History of Present Illness: HISTORY OF PRESENT ILLNESS: Pt is a ___ year old ___ speaking M w/ PMH of CAD s/p CABG, HTN and HLD presenting to the ED with hypertension recorded at home, found to have RLE cellulitis. Per pt, on the day prior to admission, he began to experience RLE leg pain that was described as more discomfort. This was followed one hour later by an acute onset of headache, chills, shivering/shaking and felt feverish. Pt felt warm to the touch but Temp taken at home was not elevated. Pt took Excedrin at the time of symptom onset, checked his BP at home which showed a reading of 211/110. Pt took 2 doses of Captopril 25mg tablets, and came into the ___ ED for further evaluation. Of note, pt reports that he has had well controlled BP on a beta blocker (trade name: ___ 25mg x1 a day, a Bblocker not available in the US), with baseline BPs in the 120s/50s per home readings. Pt had been fasting for ___ in the day-light hours, but of note, he has been fasting for ___ but states he has been taking his BP meds, as well as his Aspirin 81mg and Lipitor 40mg. In the ED, initial vitals were: 97.7 98 ___ - Labs were significant for Labs were significant for initial Wbc of 9.6 which increased to 17.8 (initial Diff 93.2%N), low Phos at 1.4, low Mg of 1.5 but otherwise normal Mg and lactate of 1.6. Pt received ___, CT head, and Chest CXR were negative for acute process. - The patient was given 500NS bolus, 125ml/hr maintenance. Cefazolin, Vanc, Ceftriaxone, Tylenol and , IV Mag, IV Phos + 3 packets NeutraPhos, Potassium Chloride 40 mEq - EKG was notable for 1mm STD V3-V4 and TWI when BP was in 200's systolic. First trop neg and second value .02. Repeat ECG after control of BP shows sub-1mm STD in V3-V4. Trop resolved. - Cards was consulted who believed patient had demand ischemia in setting of febrile cellulitis and hypertensive emergency which resolved. They had no suspicion of plaque rupture and no need for anticoagulation. While in the ED he spiked to T100.5 HR 81 BP 103/50 RR 24 SpO2 96% RA. Pt continued to improve on IV Abx therapy, with vitals prior to transfer T 97.8 HR 73 BP 106/53 RR 24 SpO2 97% RA. Upon arrival to the floor, pt was afebrile with stable VS: T99.4, HR 68 BP 124/59 RR 18 and Spo2 of 99% on RA. Pt was comfortable sitting in bed, with no pain in the LLE, resolution of his headache symptoms and no chills or shakes. Pt did endorse feeling subjectively warm, and endorsed 2x episodes of diarrhea. REVIEW OF SYSTEMS: (+) Per HPI (-) Denies recent weight loss or gain. Denies 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: HLD HTN CAD s/p CABG Social History: ___ Family History: Denies family history of CAD Physical Exam: PHYSICAL EXAM: Vitals: VS: T99.4, HR 68 BP 124/59 RR 18 and Spo2 of 99% on RA General: Alert, oriented, sitting upright in bed, in no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: Supple, JVP not elevated, no LAD CV: Systolic murmur, regular rate and rhythm, audible S1 S2 Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. Full ROM of RLE at knee and ankle. Skin: Warm, smooth, erythematous area extending from ankle to upper calf just below knee. Area marked. Warm to touch, with minimal tenderness to palpation Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. Pertinent Results: Admission ========== ___ 05:10PM GLUCOSE-106* UREA N-15 CREAT-1.0 SODIUM-134 POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-20* ANION GAP-16 ___ 05:10PM CALCIUM-8.7 PHOSPHATE-3.2# MAGNESIUM-2.0 ___ 01:00PM cTropnT-<0.01 ___ 06:45AM cTropnT-0.02* ___ 10:30AM ALT(SGPT)-28 AST(SGOT)-30 LD(LDH)-146 CK(CPK)-50 ALK PHOS-47 TOT BILI-2.4* DIR BILI-0.2 INDIR BIL-2.2 ___ 10:30AM WBC-17.8*# RBC-4.95 HGB-14.4 HCT-41.6 MCV-84 MCH-29.1 MCHC-34.6 RDW-12.9 RDWSD-39.2 ___ 01:09AM URINE HOURS-RANDOM ___ 01:09AM URINE UHOLD-HOLD ___ 01:09AM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 01:09AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG Discharge =========== ___ 07:17AM BLOOD Glucose-94 UreaN-12 Creat-0.9 Na-135 K-3.8 Cl-102 HCO3-22 AnGap-15 ___ 07:17AM BLOOD Calcium-8.4 Phos-1.5*# Mg-1.8 ___ 07:17AM BLOOD ALT-28 AST-37 AlkPhos-49 TotBili-1.4 ___ 07:17AM BLOOD WBC-11.9* RBC-4.73 Hgb-13.9 Hct-40.0 MCV-85 MCH-29.4 MCHC-34.8 RDW-13.2 RDWSD-40.7 Plt ___ Imaging ========== Chest Xray ___ IMPRESSION: No acute cardiopulmonary abnormality. CT Head ___ IMPRESSION: Mild involutional change. No evidence of hemorrhage. ___ ___ IMPRESSION: No evidence of deep venous thrombosis in the right lower extremity veins. The peroneal veins are not visualized. Brief Hospital Course: This is a ___ year old ___ male recently immigrated to ___ with past medical history of CAD s/p CABG presenting ___ with headache, chills, and subjective fever in setting of fasting for ___, as well as hypertension on check at home, in ED found to have RLE cellulitis and hypertensive emergency (SBP 211mmHg with EKG changes concerning for demand ischemia), with quick normalization of blood pressures on oral regimen (and normalization of EKG changes), treated with antibiotics with significant improvement, discharged home with scheduled appointment to establish care at ___. # Acute Cellulitis right leg: patient presented after acute onset of RLE pain, swelling and progressively worsening erythema; exam consistent with acute cellulitis; otherwise notable for leukocytosis WBC 17.9, afebrile. He was started on Cefazolin 2G IV Q8H with rapid improvement, receding from the area marked in the ED, WBC downtrending to 11.9. He was transitioned to PO Cephalexin 2GM Q8H prior to discharge with an expected ___nding on ___. # Malignant Hypertensive / Accelerated Hypertension - patient admitted with SBP 211mmHg; during that time he had nonspecific ST/Twave changes noted and troponin peaking at 0.02. His blood pressures rapidly improved with oral metoprolol. Repeat EKG improved, troponins downtrended. Underlying etiology felt to relate to possible missed doses of home antihypertensive. On day of discharge BP ranged 110s-120s/60s-70s. Patient on nabivolol from ___ (not available here), declined transition to blood pressure agent sold here, but willing to discuss when establishing with PCP. # Hyponatremia / Hypokalemia / Hypophosphatemia / Hypomagnesemia - Na of 132, K of 3.4, Phos 1.0 and Mg 1.5 on presentation, all thought to related to insensible losses from infection as well as ongoing fasting during ___. He was repleted with improvement. Counseled patient that due to his acute illness, team advised against additional fasting which could pose a risk to his health. #CAD s/p 3 vessel CABG - as above, he had evidence of cardiac strain in setting of hypertension that resolved with blood pressure control; while inpatient he was given metoprolol (as nabivolol is not available here), home Aspirin and Atorvastatin. See above re: blood pressure management medications. Transitional ------------- - In setting of fasting for ___, he was noted to have some electrolyte deficiencies - he was counseled that, given his illness, would avoid fasting - To complete a 10 day course of antibiotics end date ___ - Noted to have mild thrombocytopenia during this admission, stable; could consider outpatient workup Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 40 mg PO QPM 2. nebivolol 25 ng oral DAILY 3. Aspirin 81 mg PO DAILY Discharge Medications: 1. Atorvastatin 40 mg PO QPM 2. Acetaminophen 325-650 mg PO Q6H:PRN fever RX *acetaminophen 500 mg 1 tablet(s) by mouth every 6 hours Disp #*20 Tablet Refills:*0 3. Cephalexin 500 mg PO Q6H RX *cephalexin 500 mg 1 tablet(s) by mouth every 6 hours Disp #*33 Tablet Refills:*0 4. Aspirin 81 mg PO DAILY 5. nebivolol 25 ng oral DAILY Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis Cellulitis Hypertensive emergency Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. ___, It was our pleasure caring for you in ___ ___. You came to the hospital because you were feeling unwell and had high blood pressure. You were found to have a skin infection and we gave you antibiotics and you improved. Your blood pressure improved as well. You were doing better so you were able to go home. Followup Instructions: ___

10007058-DS-2

DS

2167-11-11 00:00:00

2167-11-12 11:39:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Chest pain Major Surgical or Invasive Procedure: ___ - Percutaneous coronary intervention with thrombectomy and no stent History of Present Illness: Mr. ___ is a healthy ___ year-old male who presented with back pain and chest pain following a crossfit work-out and was found to have a dissection of the abdominal aorta in addition to new q waves on EKG and a mildly elevated troponin. The patient reports that he had a strenuous work-out the morning of admission. At home, shortly following the work-out, he experienced acute onset back pain across his back below the clavicle. This was associated with a cold sweat. The pain did not subside and when the patient tried to climb his stairs at home, he felt extremely week and thus presented to the ___ at ___. Upon presentation his back pain began to subside but he did begin to experience some mild central chest pain. At the ___, he was hemodynamically stable. An EKG was obtained which demonstrated new inferior q waves and a troponin was measured at 0.04. A CTA was obtained which demonstrated an abdominal aortic dissection of the infrarenal aorta. He was therefore transferred to ___ for further care. Here CT repeated – still no ascending dissection. Overnight echocardiogram poor quality, no obvious WMA. This morning’s echo showed slight inferior HK. Cardiac biomarkers rising and pt noted to have Q waves with slight STEs inferiorly. He went to cath and was found to have a RCA lesion. He had a thrombectomy with no stent and has a 50% residual distal RCA stenosis. Admitted to the CCU for further monitoring. Vitals on transfer were: T 98.2, HR 63, BP 123/71, RR 21, 99% RA. On the floor, patient reports that he feels "great" with no chest pain, back pain, shoulder pain or SOB. Only complaint is of mild lower abdominal dull pain. Past Medical History: PCP ___ ___ EKG with first-degree heart block sinus bradycardia, pt is asymptomatic, no further actions GERD L4/L5 microdiscectomy Otherwise healthy Social History: ___ Family History: Father: angioplasty, afib Mother: afib ___ grandfather may have had MI Otherwise mainly history of cancer (lung) No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: T 98.2, HR 63, BP 123/71, RR 21, 99% RA Gen: Pleasant gentleman, NAD HEENT: MMM NECK: no JVP elevation CV: RRR, no murmurs, rubs, gallops LUNGS: CTAB, no wheezes ABD: soft, +BS, mild tenderness in mid lower quadrant EXT: warm, well-perfused, +pulses SKIN: warm, dry, no rashes or lesions NEURO: A&Ox3, CNII-XII grossly intact DISCHARGE PHYSICAL EXAM: ======================== VS: T 98.2, HR 60-70s, BP 120s/70s, RR ___, 97-99% RA Gen: Pleasant gentleman, NAD HEENT: MMM NECK: no JVP elevation CV: RRR, no murmurs, rubs, gallops LUNGS: CTAB, no wheezes ABD: soft, +BS, mild tenderness in mid lower quadrant EXT: warm, well-perfused, +pulses SKIN: warm, dry, no rashes or lesions NEURO: A&Ox3, CNII-XII grossly intact Pertinent Results: Admission Labs: =============== ___ 06:15PM BLOOD WBC-11.3* RBC-4.61 Hgb-13.4* Hct-40.5 MCV-88 MCH-29.1 MCHC-33.1 RDW-12.9 RDWSD-41.2 Plt ___ ___ 06:15PM BLOOD Neuts-76.8* Lymphs-15.5* Monos-7.2 Eos-0.0* Baso-0.2 Im ___ AbsNeut-8.67* AbsLymp-1.75 AbsMono-0.81* AbsEos-0.00* AbsBaso-0.02 ___ 06:15PM BLOOD ___ PTT-27.9 ___ ___ 06:15PM BLOOD Glucose-99 UreaN-15 Creat-1.0 Na-137 K-4.1 Cl-102 HCO3-27 AnGap-12 ___ 12:19AM BLOOD CK(CPK)-2278* ___ 06:15PM BLOOD CK-MB-52* ___ 12:19AM BLOOD Calcium-8.8 Phos-2.9 Mg-2.0 Discharge Labs: =============== ___ 06:40AM BLOOD WBC-6.1 RBC-4.14* Hgb-11.9* Hct-37.3* MCV-90 MCH-28.7 MCHC-31.9* RDW-12.8 RDWSD-42.0 Plt ___ ___ 06:40AM BLOOD ___ PTT-28.4 ___ ___ 06:40AM BLOOD Glucose-92 UreaN-13 Creat-0.9 Na-138 K-4.1 Cl-101 HCO3-26 AnGap-15 ___ 10:45AM BLOOD CK(CPK)-713* ___ 06:40AM BLOOD Calcium-9.3 Phos-4.3 Mg-2.0 ___ 04:55AM BLOOD %HbA1c-5.2 eAG-103 ___ 11:26AM BLOOD Triglyc-627* HDL-65 CHOL/HD-2.6 LDLmeas-73 ___ 04:24AM BLOOD CRP-2.8 Troponin Trend: =============== ___ 06:15PM BLOOD cTropnT-0.21* ___ 12:19AM BLOOD CK-MB-157* MB Indx-6.9* cTropnT-0.70* ___ 03:58AM BLOOD CK-MB-178* MB Indx-7.3* cTropnT-1.37* ___ 09:58AM BLOOD CK-MB-171* MB Indx-6.7* cTropnT-1.82* ___ 04:24AM BLOOD cTropnT-2.77* ___ 11:26AM BLOOD CK-MB-3 cTropnT-<0.01 CK Trend: ========= ___ 12:19AM BLOOD CK(CPK)-2278* ___ 03:58AM BLOOD CK(CPK)-2432* ___ 09:58AM BLOOD CK(CPK)-2562* ___ 11:26AM BLOOD CK(CPK)-74 Micro: ======= RPR: Imaging: ========= CTA ___: 1. Infrarenal abdominal aortic aneurysm as detailed above originating at the level of the ___ and extending into the proximal right common iliac artery. No significant change compared to recent CT. 2. Normal thoracic aorta without dissection. CXR ___: Lungs are fully expanded and clear. Cardiomediastinal and hilar silhouettes and pleural surfaces are normal. EKG (___): NSR, nl axis, no ST changes TTE (___): The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. An aortic dissection cannot be excluded. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. CARDIAC CATH (___): RCA occluded with thrombus in mid- to distal-vessel. LAD and circumflex free of disease. Brief Hospital Course: ___ y/o previously healthy gentleman presenting with a type B aortic dissection complicated by an NSTEMI in the context of a cross-fit workout. # CORONARIES: 50% distal RCA occlusion, LAD and circumflex clean # PUMP: EF > 55% # RHYTHM: normal #) TYPE B AORTIC DISSECTION: Mr. ___ is a healthy ___ year-old male who presented with back pain and chest pain following a crossfit work-out and was found to have a dissection of the abdominal aorta. The dissection was located just beneath the takeoff of the ___, and terminating at the proximal most aspect of the right common iliac artery. Although he is a male he has no other clear risk factors, including HTN, age, CAD, vasculitis, bicuspid aortic valve, family history, h/o AVR, or cocaine use. We continued tight BP control - SBP<140 with IV/PO BB. He had no evidence on exam or imaging of end-organ or lower extremity ischemia. Therefore, the is no indication for emergent vascular surgery intervention. He will need f/u imaging in 6 months and will follow up with ___. His ESR and CRP were within normal limits and his RPR was not reactive. #) ACUTE CORONARY SYNDROME: He went to cath and was found to have a RCA lesion. He had a thrombectomy with no stent and has a 50% residual distal RCA stenosis. Admitted to the CCU for further monitoring after thrombectomy and we continued heparin 24h after procedure (starting it 4 hours after procedure). The patient is a Killip Class I indicating 6% mortality based on an updated study in JAMA performed at ___ and ___ published in ___. We continued aspirin 81mg daily, ticagrelor 90 BID, atorvastatin 10mg daily. TRANSITIONAL ISSUES: ========================= [] f/u aortic imaging in 6 months Medications on Admission: None. Discharge Medications: 1. TiCAGRELOR 90 mg PO BID RX *ticagrelor [BRILINTA] 90 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*6 2. Atorvastatin 80 mg PO QPM RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*6 3. Aspirin EC 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*6 4. Metoprolol Succinate XL 12.5 mg PO DAILY RX *metoprolol succinate 25 mg 0.5 (One half) tablet(s) by mouth daily Disp #*30 Tablet Refills:*6 5. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain RX *nitroglycerin 0.4 mg 1 tablet(s) sublingually q5min Disp #*15 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: - TYPE B AORTIC DISSECTION - ACUTE CORONARY SYNDROME Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You came to the hospital because you were having chest pain. We found that you were having a heart attack and we broke down a clot from one of your hearts blood vessels to treat that. Other imaging found that the wall of your large blood vessel, the aorta had formed a slit called a dissection. The vascular surgeons and did not think you needed to have a surgical repair at this time. It will be very important for you to keep good control of your blood pressure, and follow-up with the vascular surgeons, your PCP, and your new cardiologist (Drs. ___ and ___. Should you have any chest pain, please use the nitroglycerin pills we have prescribed for you. Take up to three pills, spaced 5 minutes apart. If the pain does not go away after this, call ___. If your pain does go away, call either Dr. ___ Dr. ___ an appointment. Finally, we have started you on several new medications because of your heart attack. These are very important, and must be taken every day. They are: 1) Ticagrelor (Brillinta) 90 mg twice a day. This will be continued for at least 3 months, and potentially as long as 9 months. The duration of this will be decided in follow-up appointments with Dr. ___ 2) Aspirin 81 mg daily, likely for the forseeable future 3) Metoprolol succinate 12.5 mg daily, on an ongoing basis 4) Atorvastatin 80 mg daily, on an ongoing basis It was a pleasure taking care of you! Your ___ Team Followup Instructions: ___

10007134-DS-16

DS

2140-05-24 00:00:00

2140-05-24 15:23:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Allergies/ADRs on File Attending: ___ Chief Complaint: Left chest pain Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ year old man who was sleeping lying on a driveway and was run over by backing out car, causing 3 left ribs fracture. Past Medical History: DM (not treated) ? head aneurysm ___ years ago, seen in ___ Social History: ___ Family History: non-contributory Physical Exam: PHYSISCAL EXAM ON ADIMSSION (___) Constitutional: Comfortable, intoxicated HEENT: Pupils equal, round and reactive to light, Normocephalic, atraumatic Ccollar in place Chest: Clear to auscultation, diffuse tenderness, L crepitus Cardiovascular: Regular Rate and Rhythm Abdominal: Soft, Nontender Extr/Back: No cyanosis, clubbing or edema Skin: abrasions to anterior chest wall Neuro: GCS 14 ( -1 for spont eye opening), otherwise intact Psych: Normal mood PHYSISCAL EXAM ON DISCHARGE (___) Constitutional: Comfortable, AAOX3 HEENT: Pupils equal, round and reactive to light, normocephalic Chest: Clear to auscultation, mild diffuse tenderness on anterior chest wall Cardiovascular: Regular Rate and Rhythm, no m/r/g Abdominal: Soft, Nontender, non-distended, no organomegaly Extr/Back: No cyanosis, clubbing or edema Skin: abrasions to anterior chest wall Neuro: GCS 15, strength ___ Psych: Normal mood Pertinent Results: LAB RESULTS ___ 08:45AM BLOOD WBC-7.6 RBC-4.12* Hgb-13.3* Hct-40.4 MCV-98 MCH-32.3* MCHC-32.9 RDW-15.5 RDWSD-55.6* Plt ___ ___ 06:02AM BLOOD WBC-7.9 RBC-4.02* Hgb-13.1* Hct-38.1* MCV-95 MCH-32.6* MCHC-34.4 RDW-14.7 RDWSD-51.2* Plt ___ ___ 08:47AM BLOOD WBC-7.2 RBC-4.13* Hgb-13.3* Hct-39.5* MCV-96 MCH-32.2* MCHC-33.7 RDW-14.8 RDWSD-51.8* Plt ___ ___ 05:35AM BLOOD WBC-7.8 RBC-3.99* Hgb-12.9* Hct-38.7* MCV-97 MCH-32.3* MCHC-33.3 RDW-14.6 RDWSD-52.1* Plt ___ ___ 05:35AM BLOOD Plt ___ ___ 08:47AM BLOOD Plt ___ ___ 08:45AM BLOOD Plt ___ ___ 05:35AM BLOOD Glucose-159* UreaN-5* Creat-0.6 Na-132* K-3.5 Cl-94* HCO3-26 AnGap-16 ___ 08:47AM BLOOD Glucose-126* UreaN-8 Creat-0.7 Na-130* K-3.9 Cl-91* HCO3-22 AnGap-21* ___ 06:02AM BLOOD Glucose-149* UreaN-8 Creat-0.6 Na-132* K-3.7 Cl-92* HCO3-26 AnGap-18 ___ 05:35AM BLOOD Calcium-8.8 Phos-2.6* Mg-1.8 ___ 08:47AM BLOOD Calcium-8.9 Phos-1.2* Mg-2.0 ___ 08:45AM BLOOD Calcium-8.8 Phos-3.8 Mg-1.8 IMAGING CXR (___) IMPRESSION: Small amount of subcutaneous emphysema along the mid left lateral chest wall with concern for nondisplaced fracture of the left sixth and seventh ribs. CT pending CT SPINE (___) 1. No acute traumatic abnormality. 2. Severe paraseptal emphysema. 3. Small left thyroid nodule could be further evaluate dedicated ultrasound, if clinically indicated. CT HEAD (___) IMPRESSION: 1. Left lamina papyracea probable chronic fracture. 2. No intracranial hemorrhage. CT TORSO (___) IMPRESSION: 1. Small left pneumothorax with adjacent anterolateral left fifth through seventh rib fractures and small amount of adjacent subcutaneous emphysema. 2. Small foci of cortical regularity in the anterior right ribs may reflect a nutrient foramen. If pain is present in this location, however, subtle nondisplaced fractures could be considered. 3. Severe paraseptal emphysema with a significant component of centrilobular emphysema. 4. Scattered calcified pulmonary granulomas likely reflect prior granulomatous infection. CXR (___) IMPRESSION: Small left pneumothorax, more fully assessed by recent CT. CXR (___) IMPRESSION: Resolution of pneumothorax. Unchanged left sixth and seventh rib fractures. No other acute cardiopulmonary process. Brief Hospital Course: The patient presented to Emergency Department on ___. Upon arrival to ED the patient was evaluated for anterior chest pain. Several imaging studies were done including CXR, CT scan of Torson, spine and head showing only left ___ ribs fracture and a small apical pneumothorax which did not need placement of a chest tube. He was admitted to the floor for pain control. Neuro: The patient was alert and oriented throughout hospitalization; pain was initially managed with a dilaudid PCA and then transitioned to oral oxycodone, ketorolac and a lidocaine patch. 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: Patient was always on a regular diet and with bathroom privileges. 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. At the time of discharge, the patient was doing well, afebrile and hemodynamically stable. The patient was tolerating a diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: None Discharge Medications: OxyCODONE (Immediate Release) ___ mg PO/NG Q3H:PRN Pain - Moderate Lidocaine 5% Patch 1 PTCH TD QAM Ketorolac 30 mg IV Q8H Docusate Sodium 100 mg PO/NG BID Discharge Disposition: Home Discharge Diagnosis: Left ___ rib fracture Left small apical pneumothorax Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to ___ for rib fractures and were treated conservatively. You are recovering well and are now ready for discharge. Please follow the instructions below to continue your recovery: * Your injury caused 3 rib fractures which can cause severe pain and subsequently cause you to take shallow breaths because of the pain. * 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: ___

10007174-DS-11

DS

2164-03-04 00:00:00

2164-03-06 14:08:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) / vancomycin / levofloxacin / acyclovir / Lipitor / lisinopril / amlodipine Attending: ___. Chief Complaint: abdominal pain and diarrhea Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is a ___ year old man with history of DVT and PE on coumadin, T2DM, HTN, large smoking history, Crohn's, multiple SBOs and abdominal surgeries who presents with right side abdominal pain and diarrhea. 2 weeks prior to admission Mr. ___ was in his usual state of health when he began experiencing watery diarrhea ___ times per day which consisted mostly of water with small pieces of stool as well as what he describes as "rectal pain" and diffuse pain across his entire abdomen. His watery diarrhea continued when 4 days prior to admission he began noticing bright red blood on the toilet tissue and occasional blood mixed in with his stool. 2 days prior to admission, Mr. ___ developed sharp episodic non-radiating right side abdominal pain which came every ___ minutes then gradually dissipated. Of note, he admits to experiencing nightsweats, increased satiety, increased belching and increased flatulence for the past 2 weeks, and 50lb weight loss over the past year. He also notes one episode of hematuria 2 weeks ago with the onset of his symptoms, rhinorrhea, and increased urinary frequency of late which is consistent with his past UTIs. He denies any fever, chills, vomiting, sick contacts, recent travel, change in diet, change in his pain with eating, dysuria, shortness of breath, or chest pain. Also of note, Mr. ___ had 7 sessile polyps removed during colonoscopy on ___, and was found to have multiple colonic diverticula at this time. On ___ multiple biopsies were taken without any evidence of colitis. In the ED, initial vitals were: 98.7 74 145/99 18 100% ED Labs: significant for INR 2.6, lipase 108, CRP 2.1, positive UA ED Studies: CT Abdomen and pelvis with contrast - showed no acute intraabdominal process, small bowel containing hernia adjacing to surgical scarring in the RLQ without evidence of obstruction UA - Lg leuk, 68 WBC, few bacteria, trace protein ED Course: The patient was given morphine 5mg x1 and zofran 4mg x1. He was admitted for further workup of abdmominal pain and bloody diarrhea. Vitals prior to transfer were: 98.9 69 125/66 17 100% RA. Upon transfer, Mr. ___ continued to complain of R sided abdominal pain. Past Medical History: -Diabetes mellitus with renal manifestation -Hyperlipidemia -Colon adenomas -Hypertension, essential, benign -PANIC DISORDER W/O AGORAPHOBIA -DEPRESSIVE DISORDER -Pulmonary nodule/lesion, solitary -Crohn's disease -NEUROPATHY, UNSPEC -History of pulmonary embolism -Coronary artery disease -History of obesity -COPD, moderate -___ disease -CKD (chronic kidney disease) stage 1, GFR 90 ml/min or greater -PUD c/b perforation, s/p laparotomy, colostomy and reversal -multiple hernia surgeries -open cholecystectomy Social History: ___ Family History: No family GI history Father - had emphysema Mother - had CAD, PVD, and RA Sister - had TTP Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T 97.8 BP 112/58 HR 58 RR 18 Sat 96%RA Wt 74.7kg General: Alert, oriented, no acute distress HEENT: Sclera anicteric, PERRL, MMM, oropharynx clear of erythema and exudate Neck: supple, no LAD or masses. Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-distended, Moderately tender at border between RUQ and RLQ. Bowel sounds present in all quadrants, no rebound tenderness or guarding. Multiple large ~1cm external hemorrhoids and erythema on rectal exam. Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: Dry. Normal texure and temperature. Few echymmoses on right wrist. Neuro: CN II-XII intact. Full ___ strength in UE and ___ bilaterally. Sensation to light touch grossly intact in face, UE, and ___ bilaterally. DISCHARGE PHYSICAL EXAM: Vitals: Tm 98.5 Tc 98.3 BP 127/60 (106-130/45-60) HR 68 (55-68) RR 20 Sat 98%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, PERRL, MMM, oropharynx clear of erythema and exudate Neck: supple, no LAD or masses. Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-distended, Moderately tender at border between RUQ and RLQ. Bowel sounds present in all quadrants, no rebound tenderness or guarding. Multiple large ~1cm external hemorrhoids and erythema on rectal exam. Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: Dry. Normal texure and temperature. Few echymmoses on right wrist. Neuro: CN II-XII intact. Full ___ strength in UE and ___ bilaterally. Sensation to light touch grossly intact in face, UE, and ___ bilaterally. Pertinent Results: ADMISSION LABS ___ 04:20PM GLUCOSE-91 UREA N-13 CREAT-0.9 SODIUM-142 POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-26 ANION GAP-16 ___ 04:20PM WBC-9.8 RBC-5.31 HGB-11.2* HCT-37.9* MCV-71* MCH-21.1* MCHC-29.6* RDW-18.4* RDWSD-44.9 ___ 04:20PM PLT COUNT-231 ___ 04:20PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 04:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-LG ___ 04:20PM URINE RBC-0 WBC-68* BACTERIA-FEW YEAST-NONE EPI-1 MICROBIOLOGY ___ Blood cx pending Urine culture ___ 4:39 pm URINE Site: NOT SPECIFIED ADDED TO CHEM ___. **FINAL REPORT ___ URINE CULTURE (Final ___: ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S DISCHARGE LABS ___ 05:43AM BLOOD WBC-6.5 RBC-4.80 Hgb-10.1* Hct-34.2* MCV-71* MCH-21.0* MCHC-29.5* RDW-18.0* RDWSD-44.7 Plt ___ ___ 05:43AM BLOOD ___ PTT-38.6* ___ ___ 05:43AM BLOOD Glucose-112* UreaN-9 Creat-0.9 Na-142 K-4.0 Cl-106 HCO3-27 AnGap-13 ___ 05:43AM BLOOD Calcium-8.8 Phos-3.4 Mg-1.8 Brief Hospital Course: Mr. ___ is a ___ year old man with history of DVT and PE on coumadin, T2DM, HTN, large smoking history, Crohn's, multiple SBOs and abdominal surgeries who presented with right side abdominal pain and diarrhea. #Abdominal pain and diarrhea/brbpr: Likely secondary to external hemorrhoids and infectious enteritis. Mr. ___ reported sharp episodic non-radiating right side abdominal pain which came every ___ minutes then gradually dissipated before returning again. He had one loose, non-bloody bowel movement while in the ED but had no diarrhea during his hospitalization despite reporting a two week history of watery, non-bloody bowel movements ___ times per day which became tinged with blood 4 days prior to admission. CRP was wnl, CT A/P showed a hernia containing bowel but was negative for fat stranding, mesenteric lymphadenopathy, and bowel obstruction. Rectal exam revealed multiple large external hemorrhoids. He was given Tylenol for pain and tolerated a clear liquids diet. He was started on a topical hydrocortisone BID for external hemorrhoids. He was evaluated by the surgical team given his hx of multiple abdominal surgeries and hernia, however no surgical intervention was advised. #Complicated Urinary Tract Infection: On admission Mr. ___ reported increased urinary frequency consistent with past UTIs. UA done in the ED was positive, so he was started on a 7 day course of Ceftriaxone 1g IV in the ED, and completed ___ days of the course during his hospital stay. Urine culture grew pan-sensitive E. coli. He was switched to PO Cefpodoxime for continuation of the remaining 5 days of this antibiotic course upon discharge. Given his history of multiple UTIs, Mr. ___ complicated UTI was believed to be secondary to urinary tract structural abnormality vs. prostatic enlargement. #Microcytic Anemia: Mr. ___ had low H/H with low MCV in the ED that persisted throughout his hospital stay. Iron studies showed iron deficiency anemia. He was started on Ferrous gluconate 324mg daily. His microcytic anemia was believed to be secondary to chronic bleeding from hemorrhoids vs. nutritional deficiency. Slow bleeding from occult GI malignancy is also possible. #Hypomagnesemia: On admission Mr. ___ was found to have low magnesium. He was given Magnesium Oxide, after which his magnesium level normalized. This hypomagnesemia was believed to be secondary to diarrhea in the setting of infectious enteritis vs. colitis. #Weight loss/Fe deficiency anemia: Mr. ___ reported unintentional 50lb weight loss over the past year. PSA sent on admission was within normal limits. Serum TSH level was sent as further workup of his weight loss, and will be followed up after discharge. Further workup for malignancy should be considered in the outpatient setting. #T2DM: Mr. ___ was started on Humalog sliding scale upon admission. His blood glucose remained stable throughout the admission. He will be restarted on his diabetes regimen of Glipizide and Metformin upon discharge. #History of PE and DVT: Mr. ___ was continued on his home dose of warfarin during his hospitalization and his INR remained therapeutic. He should continue this warfarin dosage after discharge, with periodic f/u by PCP to test INR. #Coronary artery disease: Mr. ___ was continued on his home dosages of ASA and Rosuvastatin during this hospitalization given his history of coronary artery disease. #Peptic Ulcer Disease: Continued on his home dosage of Omeprazole during this hospitalization given his history of peptic ulcer disease. #HTN: Continued on his home dosage of Metoprolol tartrate for HTN during this hospitalization with good blood pressure control. #HLD: Continued on his home dosage of Rosuvastatin during this hospitalization. #Insomnia: Continued on his home dosage of Trazodone for insomnia during this hospitalization. #Panic Disorder with Agoraphobia: Continued on his home dosage of Lorazepam PRN for panic disorder during this hospitalization. He did not require any administrations of the Lorazepam during his stay. ==================== TRANSITIONAL ISSUES: ==================== -Continue topical hydrocortisone 0.2% ointment for one week only given risk for thinning of skin with prolonged steroid use. -Continue Cefpodoxime 400mg PO BID to be started on ___ and continue until ___ (Day ___. -Follow-up urine culture sensitivities -Continue Ferrous gluconate 324mg PO q24h for iron deficiency anemia and consider further w/u for etiology. Consider w/u of malignancy in the setting of iron deficiency anemia, night sweats, and weight loss. -Followup TSH after discharge and notify PCP for further workup if necessary. #CODE STATUS: Full code. #CONTACT: ___ (niece) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Omeprazole 20 mg PO BID 2. MetFORMIN (Glucophage) 1000 mg PO BID 3. GlipiZIDE 10 mg PO DAILY 4. Losartan Potassium 50 mg PO DAILY 5. Metoprolol Tartrate 25 mg PO DAILY 6. Aspirin 81 mg PO DAILY 7. Warfarin 3 mg PO DAILY16 8. Rosuvastatin Calcium 20 mg PO QPM 9. TraZODone 100 mg PO DAILY 10. Lorazepam 1 mg PO Q6H:PRN anxiety Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Lorazepam 1 mg PO Q6H:PRN anxiety 3. Losartan Potassium 50 mg PO DAILY 4. Metoprolol Tartrate 25 mg PO DAILY 5. Omeprazole 20 mg PO BID 6. Rosuvastatin Calcium 20 mg PO QPM 7. Warfarin 3 mg PO DAILY16 8. Acetaminophen 1000 mg PO Q8H:PRN abdominal pain RX *acetaminophen [Pain Reliever] 500 mg 2 capsule(s) by mouth every 8 hours Disp #*30 Capsule Refills:*0 9. Cefpodoxime Proxetil 400 mg PO Q12H Last dose should be administered ___ RX *cefpodoxime 200 mg 2 tablet(s) by mouth twice daily Disp #*20 Tablet Refills:*0 10. GlipiZIDE 10 mg PO DAILY 11. MetFORMIN (Glucophage) 1000 mg PO BID 12. TraZODone 100 mg PO DAILY 13. Ferrous GLUCONATE 324 mg PO DAILY RX *ferrous gluconate 324 mg (37.5 mg iron) 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 14. Outpatient Lab Work ICD9: V12.51 Please check INR ___. Please fax results to: ___, RN - ___ Please fax results to ___ Discharge Disposition: Home Discharge Diagnosis: Diarrhea Bleeding Hemorrhoids Discharge Condition: Stable Discharge Instructions: Dear Mr. ___, You were admitted to ___ because you had a 2 week course of diarrhea, abdominal pain and nausea. A CT Scan of your abdomen showed a hernia but showed no signs of a small bowel obstruction. We performed a rectal exam and identified multiple external hemorrhoids which likely caused the bleeding you noticed recently with your diarrhea. You were also found to have a urinary tract infection for which we gave you antibiotics that you will continue to take (by mouth) for another 4 days through ___. You were also found to have iron deficiency, for which you will take an iron supplement daily. You should continue to take the Tylenol that we prescribed for your abdominal pain until it resolves, and should apply the hydrocortisone cream for one week we prescribed for your hemorrhoids as needed. Lastly, we recommend that you eat a diet high in fiber to prevent future development or worsening of your hemorrhoids. It is very important that you follow up with your primary care physician and take your medications as prescribed. Please have your INR checked on ___. We wish you the best! Sincerely, Your ___ medical team Followup Instructions: ___

10007795-DS-16

DS

2136-08-11 00:00:00

2136-08-11 16:50:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: ciprofloxacin / fluconazole Attending: ___. Chief Complaint: Elevated WBC, malaise Major Surgical or Invasive Procedure: None History of Present Illness: ___ with ETOH hepatitis and pancreatitis episode ___ with prolonged hospitalization at ___ c/b PNA, sepsis, respiratory failure, and pancreatic pseudocyst s/p endoscopic cystogastrostomy ___ and ___ drainage of R flank collection ___ c/b infection of pseudocyst (___), ___ fungemia, & severe necrotizing pancreatitis s/p laparoscopic drainage and debridement ___, on home tube feeds and outpatient micafungin therapy, now presents at the behest of her outpatient caregiver due to an elevated WBC to 18 on routine outpatient labs. She does endorse some malaise, myalgias, and mild SOB for the past ___s a change in character of her drain output from a purulent yellowish color to a purulent brown/tan color, however drain quantity has remained unchanged at about 40cc per day. Has had some non-radiating LLQ pain around her ostomy for the past couple weeks that is dull and not exacerbated by palpation or tube feeds (via dobhoff) and has been stable, but she does feel that oral intake occasionally makes this pain increase. Denies nausea or emesis and continues to pass stool and gas from her ostomy, has lost ___ lbs over the past month. She continues to have intermittent low-grade fevers at home, but no fevers of 101 or higher, no chills or sweats. RUE ___ site is cared for by home RN's and the cap is changed weekly, last changed today, and she has not noticed any swelling or redness or drainage from this site. No pain with urination, urinary frequency, or discharge. No dizziness, lightheadedness, chest pain, cough. Surgery is now consulted regarding her elevated WBC and generalized malaise. Past Medical History: Per ___ and ___ discharge summary ___. Hypertension. Hypercholesterolemia. Diabetes ___ pancreatitis. Metabolic toxic encephalopathy Depression. Diverticulitis s/p sigmoid resection and end colostomy unable to be reversed b/c severe scarring and fibrosis. Anemia of chronic disease. Breast Ca s/p bl mastectomy and chemotherapy ___ years ago. ETOH abuse. Bowel obstruction. Pancreatic pseudocyst. s/p appendectomy for ruptured appendix. s/p laparoscopy - pelvic pain r/o endomitriosis Social History: ___ Family History: Cancer Physical Exam: Discharge physical exam: Vital signs afebrile and stable Gen: Alert and oriented, no acute distress CV: RRR Pulm: No respiratory distress Abdomen: Soft, non-distended, mildly tender, ostomy with foul smelling brown stool, R flank drainage with small amount of brown liquid Extremities: warm and well perfused Pertinent Results: ___ 09:20PM URINE COLOR-Yellow APPEAR-Hazy SP ___ ___ 09:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-5.0 LEUK-LG ___ 09:20PM URINE RBC-7* WBC-50* BACTERIA-FEW YEAST-NONE EPI-11 TRANS EPI-<1 ___ 09:20PM URINE MUCOUS-MANY ___ 05:20PM GLUCOSE-107* UREA N-12 CREAT-0.5 SODIUM-137 POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-22 ANION GAP-19 ___ 05:20PM estGFR-Using this ___ 05:20PM ALT(SGPT)-28 AST(SGOT)-22 ALK PHOS-129* TOT BILI-0.3 ___ 05:20PM LIPASE-11 ___ 05:20PM ALBUMIN-4.3 ___ 05:20PM WBC-20.4*# RBC-4.78 HGB-13.2 HCT-40.1 MCV-84 MCH-27.6 MCHC-32.8 RDW-15.6* ___ 05:20PM NEUTS-82.5* LYMPHS-9.3* MONOS-6.8 EOS-1.1 BASOS-0.4 ___ 05:20PM PLT COUNT-295 US from ___: Nonocclusive thrombus extending from the right subclavian vein into the axillary and central portion of the basilic vein. There is no DVT in the distal basilic vein, cephalic vein or paired brachial veins. Brief Hospital Course: Ms. ___ was admitted on ___ after being found to have an elevated WBC in combination with malaise and some abdominal pain. She was pan-cultured on admission. Her blood cultures revealed negative cultures in those drawn from peripheral IV's, however in the blood culture from the PICC, viridans strep, coag-neg staph, and micrococcus grew. Her clostridium difficile PCR test at the same time was positive. The infectious disease service was then consulted. They recommended that she be on IV vancomycin for 14 days for her gram positive bacteremia and po vancomycin for 2 months. They planned to follow her in clinic to gradually wean the dose of po vanc. On HOD1, she did note some blood from her R flank drain however this never occurred again during her hospitalization. On ___, IV nurse attempted to place a R sided PICC line however follow chest xray revealed it was curled up in the arm. She then went to interventional radiology for placement of a PICC on ___. The radiology placement was unsuccessful and it prompted for RUE US. US revealed right subclavian vein thrombosis. Patient was started on SC Lovenox. Her antibiotics were changed to Linezolid per ID. Also per ID, her micafungin was stopped on ___. During her hospitalization, her WBC was trended and was normalized at the time of her discharge. Her electrolytes were also monitored and repleted as necessary. At the time of discharge, she was voiding, ambulatory, and mentating well. Her ostomy output was brown and foul smelling. The output from the drain on the R flank was decreasing in quantity and mostly liquid brown. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Duloxetine 60 mg PO DAILY 2. Gabapentin 300 mg PO TID 3. Gemfibrozil 600 mg PO BID 4. HYDROmorphone (Dilaudid) 8 mg PO Q3H:PRN pain 5. Pancrelipase 5000 2 CAP PO TID W/MEALS 6. Lorazepam 1 mg PO Q8H:PRN anxiety 7. Micafungin 100 mg IV Q24H 8. Pantoprazole 40 mg PO Q24H 9. Tamoxifen Citrate 20 mg PO DAILY 10. Docusate Sodium 100 mg PO BID 11. Milk of Magnesia 30 mL PO HS:PRN constipation 12. Multivitamins 1 TAB PO DAILY 13. Senna 2 TAB PO HS:PRN constipation Discharge Medications: 1. Docusate Sodium 100 mg PO BID 2. Duloxetine 60 mg PO DAILY 3. Gabapentin 300 mg PO TID 4. Gemfibrozil 600 mg PO BID 5. HYDROmorphone (Dilaudid) 8 mg PO Q3H:PRN pain 6. Lorazepam 1 mg PO Q8H:PRN anxiety 7. Micafungin 100 mg IV Q24H 8. Milk of Magnesia 30 mL PO Q6H:PRN constipation 9. Multivitamins 1 TAB PO DAILY 10. Pancrelipase 5000 2 CAP PO TID W/MEALS 11. Pantoprazole 40 mg PO Q12H 12. Senna 1 TAB PO BID:PRN constipation 13. Tamoxifen Citrate 20 mg PO DAILY 14. Vancomycin Oral Liquid ___ mg PO Q6H Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: 1. Clostridium difficile colitis 2. Gram positive bacteremia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: General Discharge Instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Drain Care: *Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). *Note color, consistency, and amount of fluid in the drain. ___ the doctor, ___, or ___ nurse if the amount increases significantly or changes in character. *Be sure to empty the drain frequently. Record the output, if instructed to do so. *You may shower; wash the area gently with warm, soapy water. *Keep the insertion site clean and dry otherwise. *Avoid swimming, baths, hot tubs; do not submerge yourself in water. *Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. PICC Line: *Please monitor the site regularly, and ___ your MD, nurse practitioner, or ___ Nurse if you notice redness, swelling, tenderness or pain, drainage or bleeding at the insertion site. * ___ your MD or proceed to the Emergency Room immediately if the PICC Line tubing becomes damaged or punctured, or if the line is pulled out partially or completely. DO NOT USE THE PICC LINE IN THESE CIRCUMSTANCES.Please keep the dressing clean and dry. Contact your ___ Nurse if the dressing comes undone or is significantly soiled for further instructions. What to watch out for when you have a Dobhoff Feeding Tube: 1. Blocked tube: If the tube won't flush, try using 15 mL carbonated cola or warm water. If it still will not flush, ___ your nurse or doctor. Always be sure to flush the tube with at least 60 mL water after giving medicine or feedings. 2.Vomiting: ___ doctor if vomiting persists. Vomiting causes the loss of body fluids, salts and nutrients. *Give the feeding in an upright position. *Try smaller, more frequent feedings. Be sure the total amount for the day is the same though. *Infection may cause vomiting. Clean and rinse equipment well between feedings. *Do not let formula in the feeding bag hang longer than 6 hours unrefrigerated. After the formula can is opened, it should be stored in refrigerator until used. 3. Diarrhea: *This is frequent loose, watery stools. *Can be caused by: giving too much feeding at once or running it too quickly, decreased fiber in diet, impacted stool or infection. Some medicines also cause diarrhea. *Avoid hanging formula for longer than 6 hours. *Give more water after each feeding to replace water lost in diarrhea. ___ doctor if diarrhea does not stop after ___ days. 4. Dehydration: *Due to diarrhea, vomiting, fever, sweating. (Loss of water and fluids) *Signs include: decreased or concentrated (dark) urine, crying with no tears, dry skin, fatigue, irritability, dizziness, dry mouth, weight loss, or headache. *Give more water after each feeding to replace the water lost. ___ your doctor. 5. Constipation: ___ be caused by too little fiber in diet, not enough water or side effects of some medicines. *Take extra fruit juice or water between feedings. *If constipation becomes chronic, ___ the doctor. 6. Gas, bloating or cramping: Be sure there is no air in the tubing before attaching the feeding tube. 7.Tube is out of place: If the tube is no longer in your stomach, tape it down and ___ your doctor or home health nurse. Do not use the tube. You will need to have a new tube placed. 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. Followup Instructions: ___

10007795-DS-17

DS

2136-09-24 00:00:00

2136-09-24 11:54:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: ciprofloxacin / fluconazole Attending: ___. Chief Complaint: dehydration, abdominal pain, and tachycardia Major Surgical or Invasive Procedure: none History of Present Illness: Ms ___ is a ___ with ETOH hepatitis and pancreatitis on ___ with a prolonged hospitalization at ___ c/b PNA, sepsis, respiratory failure, and pancreatic pseudocyst, s/p endoscopic cystogastrostomy ___ and ___ drainage of R flank collection ___ c/b infection of pseudocyst ___ fungemia, & severe necrotizing pancreatitis s/p laparoscopic drainage and debridement ___. She was most recently readmitted to ___ on ___ for increased WBCs and malaise, and a work up was notable for blood cultures from her PICC which grew viridans strep, coag-neg staph, and micrococcus grew and clostridium difficile PCR test at the same time was positive. She was treated with Vancomycin and transitioned to Linezolid and started on Micafungin per ID recomendations. She was ultimately discharged to a rehab on ___ in stable condition. Since discharge, the patient has been doing well, went from rehab to home two weeks prior to presenting and has been tolerating a regular diet. One week prior to presentation, however, she noticed a sharp burning pain at the site of her RLQ drain that she reported was ___ in severity and has persisted. She also noted that during this time, her RLQ drain, which had been working its way out over the past few weeks, had withdrawn back into her wound. Over the past few days, her RLQ pain has persisted and radiates across her epigastrum and along her back and increases to ___ in severity. Given the persistent abdominal and back pain, she presented to clinic today for evaluation. In addition to pain, she endorses poor po intake, dark urine, and feeling dehdraded. She denies emesis or fevers during this time, but does endorse having some nausea and night sweats. She also reports feeling depressed and is upset that she continues to return to the hospital. Past Medical History: Per ___ and ___ discharge summary ___. Hypertension. Hypercholesterolemia. Diabetes ___ pancreatitis. Metabolic toxic encephalopathy Depression. Diverticulitis s/p sigmoid resection and end colostomy unable to be reversed b/c severe scarring and fibrosis. Anemia of chronic disease. Breast Ca s/p bl mastectomy and chemotherapy ___ years ago. ETOH abuse. Bowel obstruction. Pancreatic pseudocyst. s/p appendectomy for ruptured appendix. s/p laparoscopy - pelvic pain r/o endomitriosis Social History: ___ Family History: Cancer Physical Exam: Pertinent Results: ___ 09:15PM URINE HOURS-RANDOM ___ 09:15PM URINE UCG-NEGATIVE ___ 09:15PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 09:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-MOD ___ 09:15PM URINE RBC-4* WBC-14* BACTERIA-FEW YEAST-NONE EPI-4 TRANS EPI-<1 ___ 09:15PM URINE MUCOUS-RARE ___ 06:36PM LACTATE-1.1 ___ 06:30PM GLUCOSE-78 UREA N-13 CREAT-0.5 SODIUM-136 POTASSIUM-3.8 CHLORIDE-99 TOTAL CO2-26 ANION GAP-15 ___ 06:30PM estGFR-Using this ___ 06:30PM ALT(SGPT)-12 AST(SGOT)-14 ALK PHOS-116* TOT BILI-0.2 ___ 06:30PM LIPASE-14 ___ 06:30PM ALBUMIN-4.2 CALCIUM-9.8 PHOSPHATE-3.3 MAGNESIUM-1.8 ___ 06:30PM WBC-14.6*# RBC-4.97# HGB-13.7# HCT-42.3# MCV-85 MCH-27.6 MCHC-32.3 RDW-14.2 ___ 06:30PM NEUTS-81.4* LYMPHS-11.5* MONOS-4.3 EOS-2.2 BASOS-0.5 ___ 06:30PM PLT COUNT-285 ___ 06:30PM ___ PTT-31.8 ___ Brief Hospital Course: The patient was admitted to the General Surgical Service on ___ from clinic where she had presented with left abdominal pain and tachycardia. Her drain had been removed in clinic and silver nitrate was applied due to some bloody drainage at the site. On admission, she was made NPO, put on IV pain medication, and received IV fluid hydration. CT scan of her abdomen showed an interval decrease in size of a prior peripancreatic fluid collection with question of superinfection of the collection. CT also showed question of a new splenic infarct, a high density in the subcutaneous tissue of the right posterolateral drain tract (which was correlated with the application of silver nitrate at that site), and a destructive appearing right iliac lucency concerning for a metastatic focus (given history of breast cancer). Infectious work up was done that was unremarkable - chest x-ray showed mild atelectasis and urinalaysis was negative. Her labs were also within normal limits with no leukocytosis. On HD2, the patient showed improvement in her abdominal pain and was advanced to a regular diet, which she tolerated well with no nausea and vomiting. Her home medications were restarted, and she was transitioned to PO pain control. Her wound remained covered, and her ostomy was viable. 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. We discussed with her the CT finding of possible metastatic disease for which she was follow up with oncology. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Gabapentin 300 mg PO TID 2. Duloxetine 60 mg PO DAILY 3. Gemfibrozil 600 mg PO BID 4. Pancrelipase 5000 3 CAP PO TID W/MEALS 5. Lorazepam 1 mg PO Q8H:PRN anxiety 6. Pantoprazole 40 mg PO Q24H 7. Pregabalin 50 mg PO TID 8. Tamoxifen Citrate 20 mg PO DAILY 9. Docusate Sodium 100 mg PO BID 10. Senna 1 TAB PO BID:PRN constipation 11. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 2. Duloxetine 60 mg PO DAILY 3. Gabapentin 300 mg PO TID 4. Gemfibrozil 600 mg PO BID 5. Lorazepam 1 mg PO Q8H:PRN anxiety 6. Multivitamins 1 TAB PO DAILY 7. Pancrelipase 5000 3 CAP PO TID W/MEALS 8. Pantoprazole 40 mg PO Q24H 9. Senna 1 TAB PO BID:PRN constipation 10. Tamoxifen Citrate 20 mg PO DAILY 11. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain RX *hydromorphone 4 mg ___ tablet(s) by mouth every four (4) hours Disp #*60 Tablet Refills:*0 12. Pregabalin 50 mg PO TID Discharge Disposition: Home Discharge Diagnosis: Dehydration Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call your doctor or nurse practitioner if you experience the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain is not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. . General Discharge Instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Incision Care: *Please 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. *Please change your dressing to your right abdomen wound daily and as needed with dry gauze Followup Instructions: ___

10007920-DS-20

DS

2136-08-30 00:00:00

2136-09-05 12:44:00

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / Abacavir Attending: ___. Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: NONE History of Present Illness: Mr. ___ is a ___ with a history of HIV (last CD4 1236 ___ who was found to have gait instability and ?AMS by visiting nurse. RN reports that patient had missed appointment, and per protocol, case worker visited patient. Noted that patient was unsteady on his feet, had difficulty concentrating and following directions, could not sign a document they had brought for him. They note a recent decline in his self-care over the past few months, and that he has appeared more disheveled. He is continuing to drink and it is unclear the extent to which he is currently drinking. They were concerned about overmedication and requested that he go to the hospital. In the ED, VS: Temp: 97.8 HR: 64 BP: 115/78 Resp: 20 O(2)Sat: 100 Normal. He was comfortable, and exam was notable for mildly surged speech and lethargy. Tox screen positive for methadone and benzodiazopenes. On admission to the floor, he reports that he was brought to the hospital because his pills were missing and he was concerned about the effects of BZD withdrawal because he is a substance abuse counselor. He repeatedly brought up his concerns that he has no way to organize his pills. He also says that he is in the hospital because of worsening back pain over the past week around his thoracic region that is exacerbated by walking and is in the region around the spine. He is able to walk in his building but after walking a few yards outdoords is he becomes hunched over. He also says that he has been feeling confused over the past week, losing track of what he is doing or where he is. ROS: Denies any headache, CP, dyspnea, abdominal pain, f/c/n/v/d. Dizzy with standing, longstanding attributed to meds. Denies HI, SI. Past Medical History: - HIV - schizoaffective disorder - Alcoholism - psoriasis - hypertension - Hepatitis B, resolved per patient report Social History: ___ Family History: Mother: died of MI in ___ Father: died of ___ at 100. Physical Exam: VS: 98.3 164/98 67 20 100/RA Gen: Slightly disheveled man in NAD. HEENT: Anicteric sclerae. MMM. 2mm wart on tip of tongue, noted on previous exams. Yellow-brown rough-appearing plaque on posterior tongue. Pulm: CTAB, no w/r/r Abdomen: Soft, NTND. + BS Back: No vertebral tenderness. Parapinal tenderness R > L. Neuro: Alert, oriented to ___ at ___. PERRL. EOMI. Biceps, triceps, deltoid strength intact. Hip flexor, hamstring, gastroc, tib anterior strength intact. Left patellar reflex difficult to elicit. R s/p repair. Achilles reflexes 1+ bilaterally. Exam on discharge: VS: 98.1 104/67 67 18 97/RA Gen: Slightly disheveled man in NAD. HEENT: Anicteric sclerae. Slightly dry MM. 2mm wart on tip of tongue, noted on previous exams. Red rough-appearing plaque on posterior tongue. Pulm: CTAB, no w/r/r Cor: RRR, no m/r/g Abdomen: Soft, NTND. + BS Neuro: Alert, oriented to conversation. Finger-nose-finger: slow, but no dysmetria. Heel-shin - slow but no dysmetria. Difficulty understanding instructions for assessing repetitive movements. Mild orbiting of right around left. Intact proprioception of big toe bilaterally. Romberg: Strongly positive. Stable while standing, very unsteady with closing eyes. Gait is wide-based, slight drift to right while walking, but walked ___ yards without assistance. Pertinent Results: ___ 02:50PM BLOOD WBC-9.7# RBC-4.06* Hgb-12.7* Hct-38.1* MCV-94 MCH-31.4 MCHC-33.4 RDW-14.1 Plt ___ ___ 06:00AM BLOOD WBC-8.4 RBC-3.73* Hgb-11.8* Hct-35.2* MCV-94 MCH-31.6 MCHC-33.5 RDW-14.2 Plt ___ ___ 07:24AM BLOOD WBC-6.3 ___ 02:50PM BLOOD ___ PTT-29.2 ___ ___ 02:50PM BLOOD Glucose-93 UreaN-17 Creat-1.3* Na-144 K-3.0* Cl-114* HCO3-19* AnGap-14 ___ 07:24AM BLOOD Glucose-127* UreaN-15 Creat-0.9 Na-144 K-3.3 Cl-117* HCO3-19* AnGap-11 ___ 06:00AM BLOOD ALT-15 AST-24 AlkPhos-62 TotBili-0.5 ___ 07:24AM BLOOD Calcium-8.1* Phos-2.2* Mg-1.7 ___ 07:24AM BLOOD TSH-PND ___ 02:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG ___ 03:01PM BLOOD ___ pO2-28* pCO2-39 pH-7.30* calTCO2-20* Base XS--7 ___ 04:20PM URINE bnzodzp-POS barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-POS ___ 04:20PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 04:20PM URINE RBC-<1 WBC-1 Bacteri-NONE Yeast-NONE Epi-<1 Blood cultures (sent ___: No growth to date Urine cx: <10,000 colonies CXR (___) FINDINGS: PA and lateral views of the chest are compared to previous exam from ___. As on prior, there are low lung volumes. There are calcified pulmonary nodules seen in the right upper lung stable dating back to ___. The lungs are clear of consolidation, effusion or pneumothorax. Cardiomediastinal silhouette is unchanged as are the osseous and soft tissue structures. IMPRESSION: No acute cardiopulmonary process. Head CT (___): FINDINGS: There is no evidence of hemorrhage, edema, mass effect, or large territorial infarction. The ventricles and sulci are normal in size and caliber. The basal cisterns appear patent and there is preservation of gray-white matter differentiation. No fracture is identified. The visualized paranasal sinuses, middle ear cavities, and mastoid air cells are clear. IMPRESSION: No intracranial hemorrhage or mass effect. EKG (___): Sinus rhythm at lower limits of normal rate. Left axis deviation. Intraventricular conduction delay. ST-T wave abnormalities. Since the previous tracing of ___, the rate is slower. Axis is less leftward Brief Hospital Course: Mr. ___ is a ___ with a history of well-controlled HIV, schizoaffective disorder, EtOH abuse, polysubstance abuse, who was sent to the ED by his case manager and RN with concern for AMS and gait instability secondary to overmedication and not taking medications as prescribed. He was lethargic and dysarthric on presentation to the ED, but became increasingly lucid during his admission. His gait instabilities improved significantly over the course of his admission. Active issues: # ALTERED MENTAL STATUS Mr. ___ was brought to the hospital with poor attention and lethargy. Tox screen positive for benzos and methadone. He has a complicated psychiatric history and is on several psychiatric medications; per case manager, he manages his medications poorly and they are all mixed together where he stores them in his apartment. His medications as written prior to admission were fluoxetine 60mg daily, seroquel 200mg qHS (patient reported 300mg), bupropion (patient reported 300mg bid), and Valium (not recorded in our LMR, but verified by ___ RN - patient reports 10mg tid). Mr. ___ was oriented to time and place. Reported frequent confusion and lapses of memory. Further mental status assessment notable for deficits in attention and memory. He had intact registration and recall and was able interpret metaphors. He received Seroquel 200mg daily, fluoxetine 60mg daily, bupropion XR 150mg daily while in the hospital. Given his history of alcohol abuse and AMS, he received Valium 5mg once on the night of admission, and then Valium was discontinued and he was observed for signs of withdrawal. He reported insomnia on the night of admission, but reported sleeping well on the second night. He became increasingly alert over the course of the admission, and was aroused from sleep more easily. His dysarthria improved considerably with his improving alertness. # GAIT INSTABILITY Mr. ___ reports multiple falls in recent weeks, and his gait was markedly unstable at the time of his presentation, with considerable drift to the left. On the morning of his discharge, he had a slightly wide-based gait and slight unsteadiness on Romberg; discharge to ___ rehab was considered. He was not dizzy and had no dysmetria, nystagmus on exam. His gait continued to improve over the course of the day, and on repeat evaluation, he was deemed safe to return to activity with home ___. These gait difficulties may reflect a combined effect of overmedication and electrolyte abnormalities, in the context of neuropathy secondary to alcohol abuse. B12 was low-normal and given his symptoms we gave him a 1g dose IM. TSH and folate were within normal limits. # ELECTROLYTE ABNORMALITIES Deficiencies of potassium, bicarb, calcium, magnesium, and phosphate were noted on metabolic panel; these were not present in labs as recent as ___, but were trending in this direction in ___. The cause of these abnormalities is unclear, but could reflect a combination of chronic alcohol use and drug-induced Fanconi syndrome from tenofovir. These deficiencies were repleted, but will warrant repeat evaluation. # SUBSTANCE ABUSE Patient denied any current drug use, and reported one drink every other day, but prior use fifth/day one year ago per patient report. He denies any other substance abuse. Blood alcohol on presentation was less than assay. He received folate, thiamine, MVI. He reports last abusing substances over ___ years ago. He received 5mg Valium on the night of admission. Valium was then discontinued and he was observed for signs of withdrawal. His urine tox screen on presentation was positive for methadone. Denies any current drug use, including methadone or heroin use. Methadone assay is highly specific, but false positive results have been reported for patients taking Seroquel, so we sent urine sample for GC/MS confirmation, which is pending. #BACK PAIN - patient complained of back pain that seemed primarily musculoskeletal in origin. Responded well to ibuprofen 600mg q6h prn. Inactive issues: #HIV - well controlled, last CD4 > 1200 and VL < assay on ___ - Continued home ARV #Psoriasis - continued home clobetasol #Nausea - continued metoclopramide 5mg ___ TAB q8h prn nausea, not required #Diarrhea - continued diphenoxylate-atropine 2.5mg-0.025mg 1 TAB prn diarrhea, not required #GERD - continued home omeprazole Transitional issues: # Psychiatric medications: Inpatient psychiatry recommended against use of Valium in a patient with substance abuse history and active alcohol use. His mental staus improved without Valium and he did not request Valium after the night of his admission. His Valium should be discontinued as an outpatient. Further adjustments to his psychiatric medications may be required. # Medications: Continued concern for disorganized medications reported by RN, case manager. Patient will benefit from home health aide for managing meds (currently being set up by case manager) and/or pre-packaged medications such as those offered by Medicines on Time. # Pending lab tests: Urine methadone GC/MS # Electrolytes: Repleted while admitted, but etiology still not clear; possibly Fanconi syndrome secondary to tenofovir. Will require repeat lytes as outpatient. Medications on Admission: Preadmissions medications listed are incomplete and require futher investigation. Information was obtained from PatientwebOMR. 1. Atenolol 50 mg PO DAILY 2. BuPROPion (Sustained Release) 150 mg PO QAM 3. Clobetasol Propionate 0.05% Soln 1 Appl TP DAILY 4. Diphenoxylate-Atropine 1 TAB PO Q6H:PRN diarrhea 5. ATRIPLA *NF* (efavirenz-emtricitabin-tenofov) ___ mg Oral qHS 6. Fluoxetine 60 mg PO DAILY 7. Ibuprofen 800 mg PO Q6H:PRN pain 8. Metoclopramide 5 mg PO Q8H:PRN nausea 9. Pantoprazole 40 mg PO Q24H 10. Quetiapine Fumarate 200 mg PO HS 11. Diazepam 10 mg PO Q 8H 10mg per patient report. Have attempted to contact Dr. ___ at ___ to verify correct dose. Discharge Medications: 1. Atenolol 50 mg PO DAILY 2. Clobetasol Propionate 0.05% Soln 1 Appl TP DAILY 3. Diphenoxylate-Atropine 1 TAB PO Q6H:PRN diarrhea RX *diphenoxylate-atropine 2.5 mg-0.025 mg 1 Tablet(s) by mouth every six (6) hours Disp #*120 Tablet Refills:*5 4. Fluoxetine 60 mg PO DAILY 5. Metoclopramide 5 mg PO Q8H:PRN nausea RX *metoclopramide 5 mg 1 tablet by mouth three times a day Disp #*90 Tablet Refills:*5 6. Quetiapine Fumarate 200 mg PO HS 7. ATRIPLA *NF* (efavirenz-emtricitabin-tenofov) ___ mg Oral qHS 8. FoLIC Acid 1 mg PO DAILY RX *folic acid 1 mg 1 Tablet(s) by mouth daily Disp #*30 Tablet Refills:*11 9. Multivitamins 1 TAB PO DAILY RX *multivitamin 1 Tablet(s) by mouth daily Disp #*30 Tablet Refills:*11 10. Thiamine 100 mg PO DAILY RX *thiamine HCl 100 mg 1 Tablet(s) by mouth daily Disp #*30 Tablet Refills:*11 11. Ibuprofen 600 mg PO Q8H:PRN back pain RX *ibuprofen 600 mg 1 Tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*5 12. BuPROPion (Sustained Release) 300 mg PO QHS 13. Omeprazole 40 mg PO DAILY 14. Cyanocobalamin 1000 mcg IM/SC DAILY Duration: 6 Days RX *cyanocobalamin (vitamin B-12) 1,000 mcg/mL Inject Subcutaneously or Intramuscularly daily Disp #*6 Syringe Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary diagnosis: Pharmacologic/metabolic encephalopathy Secondary diagnosis: Peripheral neuropathy 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 ___ after your nurse and case worker were concerned that you were confused. You were also concerned about back pain and difficulty walking, and told us that you had several falls over the past few weeks. While you were admitted, you became less confused and you were walking more comfortably. We believe some of these changes may be due to an effect of your medicaitons, and are concerned that you might have taken a medication at a higher dose than prescribed by accident. We also think these symptoms were made worse with Valium, and you should not take Valium anymore. We think it is a very good idea for you to have someone help with you with organizing your medications. We also noticed some changes in several chemicals that are normally in your blood. Some of these changes may be caused by medicines you are taking at home, and others can be the result of drinking alcohol. We corrected the changes while you were in the hospital, but you should speak with Dr. ___ making any changes in your medication. Your trouble with walking is likely caused by poor sensation in your legs. This loss in sensation in your legs can be caused by drinking alcohol. If you continue drinking alcohol, this damage can become worse. It is also very dangerous to drink alcohol while taking Valium. We recommend that you stop drinking alcohol. You should follow up with your psychiatrist, Dr. ___, ___ you have completed rehab about the correct doses of your medications and to see if any of your medications could be adjusted to lower the chance you may become confused. Changes in medications: 1. STOP Valium - you should not take Valium until you speak with your psychiatrist 2. START Vitamin B12 - Cyanocobalamin Injections daily for 6 days 3. START Thiamine daily 4. START Folate daily 5. START Mulivitamin daily No other changes were made in your medications. It was a pleasure participating in your care at ___. Followup Instructions: ___

10007928-DS-2

DS

2129-04-11 00:00:00

2129-04-14 16:42:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfa(Sulfonamide Antibiotics) / Sulfa(Sulfonamide Antibiotics) Attending: ___. Chief Complaint: hematemesis Major Surgical or Invasive Procedure: EGD History of Present Illness: ___ year old woman with no PMH presents with 5 days of abdominal pain and nausea, and one day of nausea/hematemesis. . 5 days ago patient experienced ___ loose non bloody bowel movements per day, assocaiated with mild intermittent lower abdominal pain. Three days ago, she noted shaking and felt hot and sweaty, thought she hd a temperature, but did not have a thermometer. This evening around 7:00 pm she became acutely nauseous and vomiting with BRB. With her second emesis, she vomited > 1 cup BRB. She then had 4 more episodes of hematemesis, < 1 cup. . Denies dizziness, lightheadedness, syncope, chest pain. No recent travel or food experiementation. She does note a tick bite to her right thigh about 1 week ago. She removed it promptly, and did not have any rash. . On arrival to the ED VS were 97.1 98 102/59 15 99% RA. NGT was placed, removed mild BRB and coffee grounds, cleared after 500cc lavage. Guaiac negative brown stool. Hct 40. Called GI, thought likely ___ tear, would consider endoscopy in am. Started on pantoprazole bolus + drip, 2 18g PIVs placed. Given 2L NS. Admitted to ICU for UGIB. . On arrival to the MICU, she feels shaky, but nausea is improved since arrival. Past Medical History: None Social History: ___ Family History: Father with type ___ DM and bladder cancer, mother with lung cancer. Physical Exam: ADMISSION EXAM: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact . DISCHARGE EXAM: VS: 98.0, 100-110/60-76, 73-86, 18, 95% on 4L Gen: Well-appearing, alert, and communicative HEENT: MMM Lungs: Minimal crackles anteriorly R>L. Heart: RRR, no murmuirs, no rubs Abd: Soft, nontender, nondistended Ext: Trace pedal edema, edema of right hand, clubbing of fingers. No further rashon legs Pertinent Results: ADMISSION LABS: ___ 09:30PM BLOOD WBC-15.6* RBC-4.54 Hgb-13.8 Hct-40.6 MCV-89 MCH-30.3 MCHC-33.9 RDW-11.8 Plt ___ ___ 09:30PM BLOOD Neuts-87.7* Lymphs-6.1* Monos-5.6 Eos-0.4 Baso-0.2 ___ 09:30PM BLOOD ___ PTT-29.8 ___ ___ 09:30PM BLOOD Glucose-126* UreaN-17 Creat-0.9 Na-128* K-3.6 Cl-89* HCO3-25 AnGap-18 ___ 09:30PM BLOOD ALT-59* AST-51* AlkPhos-68 TotBili-0.6 . DISCHARGE LABS: ___ 01:30PM BLOOD WBC-8.3 RBC-4.09* Hgb-12.1 Hct-38.0 MCV-93 MCH-29.6 MCHC-31.9 RDW-12.9 Plt ___ ___ 06:15AM BLOOD Neuts-79.3* Lymphs-15.4* Monos-4.7 Eos-0.1 Baso-0.5 ___ 04:25AM BLOOD Hypochr-1+ Anisocy-OCCASIONAL Poiklo-OCCASIONAL Macrocy-OCCASIONAL Microcy-OCCASIONAL Polychr-OCCASIONAL ___ 05:15PM BLOOD Parst S-NEGATIVE ___ 01:30PM BLOOD Glucose-94 UreaN-10 Creat-0.6 Na-138 K-4.5 Cl-103 HCO3-27 AnGap-13 ___ 06:15AM BLOOD ALT-49* AST-59* AlkPhos-63 TotBili-0.4 . MICROBIOLOGY: ___ Urine culture: mixed flora ___ Blood culture: no growth to date ___ Influenza A/B nasopharyngeal swab: negative ___ Lyme serology: pending ___ H. pylori Ab: negative ___ Urine Legionella Ag: negative ___ Blood culture: no growth to date ___ Blood culture: no growth to date ___ Blood culture (mycolytic): no growth to date ___ Stool culture/C. diff: pending . IMAGING: ___ CXR: The lung apices are not depicted. NG tube ends in the gastric antrum in appropriate position. The lungs are clear, the cardiomediastinal silhouette and hila are normal. There is no pleural effusion and no pneumothorax. Partially visualized abdomen shows normal bowel gas pattern. EGD ___: Esophagitis in the lower third of the esophagus Small hiatal hernia Friability and erythema in the antrum and stomach body compatible with gastritis Ulcer in the pylorus Ulcers in the duodenal bulb Otherwise normal EGD to third part of the duodenum Recommendations: Prilosec 40mg BID Advance diet as tolerated. Avoid NSAIDs. Serial hcts. Active type and cross. GI bleeding is unlikely the cause of the patient's current hypotensive episodes and warrents further investigation for a possible infectious cause. Given the clear history of NSAID use, follow up egd is not required but would check a h pylori serology and treat if positive. Would need a test of cure 4 weeks post h pylori serology as well. . ___ CTA chest: 1. No PE. 2. Mild pulmonary edema. 3. Upper lobe peribronchovascular airspace filling could be edema or a manifestation of more severe airspace abnormality in the lower lungs, mostly consolidation, partially atelectasis, due to aspiration, multifocal pneumonia, or less likely hemorrhage. In the setting of a recent transfusions, transfusion reaction may be contributory. 4. Esophageal wall thickening, with diffuse infiltration of the mediastinal fat which may reflect inflammatory change or confluent lymphadenopathy, though the progression from normal mediastinal contours on ___ favors a rapidly evolving inflammatory process. There is no finding to suggest esophageal perforation. . ___ CXR: As compared to the previous radiograph, there is a massive increase in extent and severity of multifocal pneumonia. The resulting very widespread parenchymal opacities are more extensive on the right than on the left and show multiple air bronchograms. In addition, retrocardiac atelectasis has newly appeared, and there is a small right pleural effusion. The opacities are better displayed on the CTA examination, performed yesterday at 9:41 p.m. Moderate cardiomegaly. Brief Hospital Course: ___ year old woman with no known medical history who presented with subjective fevers, abdominal pain, and hematemesis and developed hypoxic respiratory failure. Clinical picture likely consistent with an initial gastroenteritis with emesis likely leading to aspiration pneumonia and hematemesis. # Hematemesis: EGD revealed mild esophagitis, a non-bleeding 7mm ulcer in the pylorus, and several superficial non-bleeding ulcers ranging in size from 3mm to 5mm in the duodenal bulb. This was likely due to aspirin use and recurrent emesis. H. pylori antibody is negative. Her HCT continued to rise and she was transitioned from a pantoprazole gtt to pantoprazole 40mg PO Q12h. # Hypoxemic Respiratory Failure: Patient developed fevers and new hypoxia on ___. She was empirically treated for pneumonia with ceftriaxone. CT chest showed likely multifocal pneumonia which was possible due to aspiration. Given these findings, antibiotics were broadened to vanc/levo/flagyl and ID was consulted. The vanc was discontinued on ___ and the patient was discharged with PO levo and flagyl for likely aspiration pneumonia. Her pulmonary status improved significantly during hosptialization and she was satting 100% on RA at discharge. # Volume overload: the patient received over 12L of IV fluids in the ICU in the setting of hypotension (BP 80/40s with fever, mottled legs, likely sepsis with pulmonary source). After pt stabalized, she was gently diuresed. # Diarrhea/Abdominal Pain: Likely viral gastroenteritis as this resolved during the hospitalization. Stool cultures, including C diff, were negative. # Tick Bite: Recent tick bite removed quickly. Lyme serologies were negative and smear was negative for babesiosis although ANAPLASMA PHAGOCYTOPHILUM was negative. . # Transaminitis: Very mild transaminitis (50s). No RUQ pain, no hyperbilirubinemia. Likely related to viral gastroenteritis/acute infectious process. Transitional issues/INcidental radiographic findings. -Pt will require primary care follow up: has not seen a PCP ___ ___ years. Would follow LFT's as well. -Pt has recently decided to stop smoking. Outpatient support should be provided to support this goal. -Pt still mildly volume overload at discharge. She was mobilizing and self-diuresing effectively and will follow up with PCP closely to see if she would benefit from lasix. -___ WAS NOTED TO HAVE ESOPHAGEAL WALL THICKENING ON CT WITH CONFLUENT LYMPHADENOPATHY THAT FAVORED AN INFLAMMATORY PROCESS. This will likely require further work up Medications on Admission: None Discharge Medications: 1. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H Duration: 6 Days RX *metronidazole 500 mg Every 8 hours Disp #*18 Tablet Refills:*0 2. Pantoprazole 40 mg PO Q12H RX *pantoprazole 40 mg twice a day Disp #*60 Tablet Refills:*2 3. Levofloxacin 750 mg PO DAILY RX *Levaquin 750 mg daily Disp #*6 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Pneumonia- multifocal Ulcers of the stomach and duodenum (upper small intestine). Diarrhea Gastroenteritis Pulmonary Edema Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were treated in the hospital for pneumonia and vomitting up of blood clots that likely developed because of vomitting, diarrhea, and fevers (possibly due to a stomach flu) as well as high doses of aspirin that worsened your stomach and small intestine ulcers. It is important that you complete the course of antibiotics for treatment of your pneumonia. Please take Levofloxacin 750 mg by mouth daily and metronidazole 500 mg by mouth every 8 hours for six more days. As you know, you were given many liters of fluids through your veins while you were in the intensive care unit because you were so sick. You will continue to urinate out this fluid within the next several days. Because you vomitted blood, we took a look at your esophagus, stomach, and upper small intestines with a camera. We saw that you have an ulcer in your stomach and several ulcers of your upper small intestine. To help treat your ulcers, it is important that you start to take Prilosec (omeprazole) 40mg twice a day. It is also important that you avoid all non-steroidal anti-inflammatory drugs, including ibuprofen, alleve, and aspirin. You may take tylenol. You developed new diarrhea in the hospital. This is most likely likely due to antibiotics and should resolve as your gut flora return. You can take yogurt or lactobacillus supplements to accelerate this process. If your diarrhea gets worse or you develop any fevers, please see your doctor. Finally, it is important that you begin to see a primary care doctor regularly. Please follow-up regarding this hospitalization with ___ NP (see appointment below). At that time, you will also be set up with a primary care doctor. We have made the following changes to your medications: START Levofloxacin 750 mg by mouth daily and metronidazole 500 mg by mouth every 8 hours for six more days. START Pantoprazole 40mg by mouth twice a day Followup Instructions: ___

10009021-DS-18

DS

2132-04-13 00:00:00

2132-04-13 17:18:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: lip and chin mass Major Surgical or Invasive Procedure: Biopsy of right chin mass ___ History of Present Illness: Mr. ___ is a ___ gentleman followed at ___ with a history of HIV (on HAART; ___ CD4+: 136, CD4%: 5, VL: <75) and hepatitis C who present for management of R chin lesion. Lesion first developed about three months ago and initially looked like a small pimple; it has enlarged more rapidly over the past two months and it is painful, draining yellow fluid. Patient has taken multiple courses of antibiotics and antivirals, including treatment-dose TMP-SMX and Valtrex without improvement. On ___, patient was seen in the ___, where he was told lesion did not look viral but could be skin cancer. On ___, patient was seen in the ___ ___ where his lesion was I&D's. He was started on Keflex and treatment-dose TMP-SMX and referred to Dermatology. He was seen by ___ Dermatology on ___, where the lesion was biopsied. On ___, micro grew MRSA and patient was started on minocycline and vicodin for pain control. Biopsy also showed epidermal necrosis with multinucleated keratinocytes consistent with HSV infection. Fungal culture is still pending. In the ___, initial VS were 99.0 82 123/74 18 100%. Exam showed a 3 x 5 cm yellow crusted lesion extending from the R lip to the R chin without involvement of mucous membranes. Labs were notable for normal electrolytes, normal WBC. The patient was seen by plastic surgery who recommeded admission to medicine for IV antibiotics and raised concern that this rapidly growing lesion could represent malignancy. Received vancomycin 1 gram and was admitted to the medicine service for futher management. On arrival to the floor, vital signs were 98.2 118/74 79 16 99 RA, 78.9 kg. Patient denies fevers, chills, nausea, vomiting, abdominal pain, night sweats, weight loss. There is no family history of skin cancer; patient has a history of anal condyloma/AIN1 but no malignancy. No history of excessive sun exposure. Review of Systems: per HPI. Also specifically denies mouth pain, gum pain, dysphagia, difficulty swallowing. Past Medical History: - Dizziness - HIV - Hepatitis C - HSV - HPV - Hypertension - Rectal mass: anal condylomata, surgically removed ___ (AIN I, low-grade dysplasia) - Shoulder pain - Abnormal LFT's - Anemia - Tinea cruris - Diarrhea - Hip pain (bilateral): previously on narcotics contract - DJD right hip - R hip labral tear, chronic - Dysplastic hips - Knee derangement - Hyperlipidemia - Hypertension - Tobacco use - Presbyopia - Polysubstace abuse (cocaine, crystal meth, MJ) - Depression Social History: ___ Family History: Includes breast, lung cancer. No skin cancers. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals- 98.2 118/74 79 16 99 RA General- Alert, oriented, no acute distress HEENT- Sclera anicteric, MMM with minimal white exudate on bilateral buccal mucosa but no erythema or lesions in mouth. 2cm x 2.5 cm hypertrophic lesion on R lower ___ border of lip with satellite 1 x 1 cm lesion on R chin draining serosanguinous fluis, portions ulcerated, tender to palpation. Does not extend into mucosa. Neck- Supple, JVP not elevated, submandibular 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 or edema Neuro- CNs2-12 intact, A+O x 3 DISCHARGE PHYSICAL EXAM: Vitals- Tm98.9 ___ 98-99%RA General- Alert, oriented, no acute distress HEENT- Dressing clean, no drainage noted. 2cm x 2 cm fungating yellow lesion on R lower ___ border of lip with satellite lesion 0.8, biopsied. Minimal exudate. Does not extend into mucosa. 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 GU- no foley Ext- warm, well perfused, no edema Pertinent Results: Admission Labs ___ 04:50PM BLOOD WBC-4.2 RBC-5.16 Hgb-12.9* Hct-41.1 MCV-80* MCH-25.0* MCHC-31.3 RDW-15.4 Plt ___ ___ 04:50PM BLOOD Neuts-44.7* ___ Monos-5.5 Eos-7.9* Baso-0.7 ___ 04:50PM BLOOD Glucose-73 UreaN-11 Creat-0.9 Na-139 K-4.0 Cl-103 HCO3-27 AnGap-13 ___ 08:05AM BLOOD ALT-83* AST-48* AlkPhos-56 TotBili-0.4 ___ 08:05AM BLOOD Calcium-9.2 Phos-4.0 Mg-1.9 ___ 04:50PM BLOOD Neuts-44.7* ___ Monos-5.5 Eos-7.9* Baso-0.7 Pertinent Labs ___ 08:22AM BLOOD WBC-4.7 Lymph-41 Abs ___ CD3%-84 Abs CD3-1610 CD4%-6 Abs CD4-119* CD8%-74 Abs CD8-1417* CD4/CD8-0.1* ___ 08:05AM BLOOD ALT-83* AST-48* AlkPhos-56 TotBili-0.4 ___ 06:02AM BLOOD ALT-125* AST-80* AlkPhos-49 TotBili-1.2 ___ 06:04AM BLOOD ALT-113* AST-66* AlkPhos-51 TotBili-1.4 ___ 06:02AM BLOOD Vanco-4.5* Discharge Labs ___ 06:04AM BLOOD WBC-6.0 RBC-4.30* Hgb-10.8* Hct-34.4* MCV-80* MCH-25.1* MCHC-31.4 RDW-16.0* Plt ___ ___ 06:04AM BLOOD Glucose-110* UreaN-11 Creat-1.0 Na-140 K-3.7 Cl-105 HCO3-28 AnGap-11 ___ 06:04AM BLOOD Calcium-9.6 Phos-5.0* Mg-1.7 __________________________________________________________ Time Taken Not Noted Log-In Date/Time: ___ 4:29 pm SKIN SCRAPINGS **FINAL REPORT ___ VIRAL CULTURE: R/O HERPES SIMPLEX VIRUS (Final ___: HERPES SIMPLEX VIRUS TYPE 2. CONFIRMED BY MONOCLONAL FLUORESCENT ANTIBODY.. VARICELLA-ZOSTER CULTURE (Final ___: NO FURTHER WORK UP. Refer to Herpes simplex viral culture for further information. __________________________________________________________ ___ 8:22 am IMMUNOLOGY **FINAL REPORT ___ HIV-1 Viral Load/Ultrasensitive (Final ___: 34 copies/ml. Performed using the Cobas Ampliprep / Cobas Taqman HIV-1 Test v2.0. Detection Range: ___ copies/mL. This test is approved for monitoring HIV-1 viral load in known HIV-positive patients. It is not approved for diagnosis of acute HIV infection. In symptomatic acute HIV infection (acute retroviral syndrome), the viral load is usually very high (>>1000 copies/mL). If acute HIV infection is clinically suspected and there is a detectable but low viral load, please contact the laboratory for interpretation. It is recommended that any NEW positive HIV-1 viral load result, in the absence of positive serology, be confirmed by submitting a new sample FOR HIV-1 PCR, in addition to serological testing. __________________________________________________________ ___ 8:15 am BLOOD CULTURE #2. Blood Culture, Routine (Pending): __________________________________________________________ ___ 8:05 am BLOOD CULTURE #1. Blood Culture, Routine (Pending): __________________________________________________________ ___ 4:50 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ PICC LINE INSERTION In comparison with the earlier study of this date, the PICC line has been re-directed with the tip in the region of the mid portion of the SVC. ___ Skin biopsy right chin mass: PENDING Brief Hospital Course: ___ M with HIV (on HAART; ___ CD4+: 136, CD4%: 5, VL: <75) and recently diagnosed hepatitis C with a R lip/chin lesion rapidly increasing in size, positive for MRSA and resistant to acyclovir, bactrim, keflex, minocycline. Patient with HIV (CD4 119, VL 34 on this admission) on HAART presented with rapidly enlarging lip/chin lesion/mass over past three months, resistant to bactrim, acyclovir, keflex. It was positive for MRSA without improvement on minocycline. He was admitted for IV vanc, and evaluated by derm and ID and felt to be HSV (possibly verrucous HSV per derm) vs malignancy with MRSA superinfection. He was treated with IV vanc and initially high-dose acyclovir then switched to foscarnet per ID and derm consult recs. Viral culture of lesion was positive for HSV-2. Biopsy of the satellite newer lesion is pending at discharge. A PICC line was placed for IV abx with home ___. He is to continue foscarnet for ___ weeks (exact duration to be determined on outpatient followup) with 500cc normal saline infusion prior to each foscarnet infusion. Electrolytes and renal function to be checked twice weekly while on foscarnet. Vancomycin was increased from 1g Q12H dosing to 1750mg Q12H due to low vanc trough. He is to continue vancomycin through ___ with trough to be checked on ___. Follow up with PCP ___, and ___ clinic were scheduled at discharge. # HIV Infection: Checked with CD4 count ___. Continued on atazanavir, ritonavir, abacavir-lamivudine, Bactrim ppx. # Hepatitis C: Recently diagnosed with LFTs elevated, which were stable/downtrending at discharge. Previously referred to Dr. ___ with no appointments made. He will follow up with ___ clinic for current lip/chin lesion and will subsequently be scheduled for followup for his hepatitis C. CHRONIC ISSUES: # Hip Pain: Bilateral, chronic. managed on tramadol, naproxen and tylenol. # Substance Abuse: History of cocaine and crystal meth abuse (reports none in past 4 months). Uses MJ for pain. Patient should continue counseling at Adcare (1hr x 2d/week) at discharge. # HTN - Continued amlodipine, losartan, HCTZ # Cardiac prophylaxis - Continued aspirin 81 mg daily TRANSITIONAL ISSUES: **Continue foscarnet for ___ weeks (exact duration to be determined on outpatient followup). Please monitor electrolytes twice weekly while on foscarnet. Should have 500cc normal saline infusion prior to each foscarnet infusion. **Continue vancomycin through ___. Trough to be checked ___. **Elevated LFTs which were stable/down trending at discharge. **Pending at discharge: pathology from biopsy of right lip/chin. **Ordered for chem panel, LFTs and vanc trough on ___. **Patient needs to schedule a visit with ID for hepatitis C; has ___ clinic f/u for now regarding current lip/chin lesion on ___. **Biopsy sutures can be removed at derm appointment ___. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atazanavir 300 mg PO DAILY 2. RiTONAvir 100 mg PO DAILY 3. abacavir-lamivudine 600-300 mg oral daily 4. Minocycline 100 mg PO Q12H 5. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain 6. Sulfameth/Trimethoprim DS 1 TAB PO DAILY 7. Naproxen 500 mg PO Q12H 8. Acetaminophen 1000 mg PO Q6H:PRN pain 9. Amlodipine 5 mg PO DAILY 10. losartan-hydrochlorothiazide 50-12.5 mg oral daily 11. Aspirin 81 mg PO DAILY 12. Cialis (tadalafil) 10 mg oral 1 hour prior to sexual activity as needed 13. Docusate Sodium 100 mg PO BID:PRN constipation 14. Senna 1 TAB PO HS Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN pain 2. Amlodipine 5 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Atazanavir 300 mg PO DAILY 5. Docusate Sodium 100 mg PO BID:PRN constipation 6. Naproxen 500 mg PO Q12H 7. RiTONAvir 100 mg PO DAILY 8. abacavir-lamivudine 600-300 mg oral daily 9. losartan-hydrochlorothiazide 50-12.5 mg oral daily 10. Cialis (tadalafil) 10 mg oral 1 hour prior to sexual activity as needed 11. Foscarnet Sodium 4500 mg IV Q12H RX *foscarnet 24 mg/mL 4500 mg IV q12 h Disp ___ Milligram Refills:*0 12. IV fluids Normal Saline (0.9%) 500ml to be given with each Foscarnet infusion. Dispense- quantity sufficient for 3 week course of foscarnet 13. Sulfameth/Trimethoprim DS 1 TAB PO DAILY 14. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain 15. Senna 1 TAB PO HS 16. Vancomycin 1750 mg IV Q 12H RX *vancomycin 750 mg 750 mg IV every twelve hours Disp #*9 Vial Refills:*0 RX *vancomycin 1 gram 1 gram IV every twelve hours Disp #*9 Vial Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Herpes simplex virus infection Methicillin resistant staphylococcus aureus Human immunodeficiency virus with acquired immune deficiency syndrome Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted for IV treatment of your lip and chin ulcer/mass. You were evaluated by dermatology and infectious disease, and your ulcer/mass was thought to be a herpes lesion with a bacterial (MRSA) infection. The mass was biopsied and sent for pathology, which is still pending. You were treated for MRSA with vancomycin, and HSV was treated at first with acyclovir, then switched to foscarnet. You will continue vancomycin through ___ and foscarnet for ___ weeks (exact duration to be determined at outpatient visit). You will need frequent laboratory monitoring of your kidney function while on the foscarnet. Please go to the ___ clinic lab on ___ between ___ AM (before your morning vancomycin infusion) for your lab draw. It was a pleasure caring for you. Sincerely, Your ___ Care Team Followup Instructions: ___

10009049-DS-16

DS

2174-05-31 00:00:00

2174-06-03 15:00:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: Chest pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old male with hx remote paroxysmal afib presenting as transfer from OSH with c/o cough, n/diarrhea, and chest pain. Patient reports onset of cough/congestion 4d ago. Cough productive of green sputum. Had progressive fatigue, and yesterday had 6 episodes watery diarrhea with nonbloody emesis x1. Denies fevers/chills although did not take temp at home, no recent travel or sick contacts Yesterday evening then developed sharp left sided chest pain, left sided, ___, also involving left shoulder. Pain lasted about 10mins and went away on its own, denies associated aggravating or releiving factors. He presented to ___ where initial EKG showed STE in I, avL. Patient received nitro/morphine x1 with improvement in chest pain, however became bradycardic to the ___ with SBP 73/44, received 0.5mg atropine. Also received ASA 325, ceftriaxone, lovenox ___, toradol and 1L IVF. Plan was for PCI but this was aborted after reviewing subsequent EKGs. Also ceftriaxone x1 and 2L IVF. Trop/MB neg x2, WBC @ 15.3 with 52% bands. He was transferred to our ED for further eval. In the ED, initial vitals: 99 87 126/68 18 96% 3L, Tm 104.9. Iniital labs notable for chem-7 with bicarb 21, Bun/Cr ___ (baseline 1.0). CBC with plt 134, INR 1.3, lactate 2.5. trop neg, LFTs WNL. Patient was given tylenol, vanc/levofloxacin, oseltamivir and toradol x1, and 2L IVF. CXR was done with evidence of bibasilar opacities concerning for rapidly developing pneumonia vs. alveolar hemorrhage. On arrival to the MICU, patient has no complaints. Says he is feeling a little better. Denies dyspnea, chest pain, abdominal pain, no further episodes emesis or diarrhea since yesterday. Denies hemoptysis. Past Medical History: Low back pain Disc disorder of lumbar region PROSTATITIS, UNSPEC H/O SCC left forehead ___ Atopic Dermatitis paroxysmal atrial fibrillation - noticed on ETT in ___, asymptomatic Social History: ___ Family History: Unknown/adopted Physical Exam: Admission Physical Exam: ======================== Vitals- T: 98.4 BP: 106/64 hr 87 94% 4L General- awake, alert, NAD HEENT- EOMI, PERRLA, OMM no lesions Neck- supple JVP mildly elevated at 30deg to under mandible CV- RRR, split s2 more prominent during inhalation, no murmurs Lungs- rhonchi bilaterally with fair air movement, + egophany LLB Abdomen- mildly distended/hypertympanic, no r/g/r, +BS GU- no foley Ext- WWP no c/c/e Neuro- CN II-XII intact, strength ___ in UE and ___ b/l Dishcarge Physical Exam: ========================= Vitals - 97.9, 126/88, HR 72, 18, 97% on RA General- awake, alert, NAD HEENT- EOMI, PERRLA, OMM no lesions Neck- supple JVP mildly elevated at 30deg to under mandible CV- RRR, split s2 more prominent during inhalation, no murmurs Lungs- CTAB, improved egophany LLB Abdomen- mildly distended/hypertympanic, no r/g/r, +BS GU- no foley Ext- WWP no c/c/e Neuro- CN II-XII intact, strength ___ in UE and ___ b/l Pertinent Results: ADMISSION LABS =============== ___ 05:05AM BLOOD WBC-6.8 RBC-4.95 Hgb-15.3 Hct-46.1 MCV-93 MCH-30.9 MCHC-33.2 RDW-12.5 Plt ___ ___ 05:05AM BLOOD ___ PTT-36.9* ___ ___ 05:05AM BLOOD Glucose-127* UreaN-26* Creat-1.4* Na-137 K-4.0 Cl-101 HCO3-21* AnGap-19 ___ 05:05AM BLOOD Albumin-3.9 ___ 05:25AM BLOOD Lactate-2.5* DISCHARGE LABS =============== ___ 05:40AM BLOOD WBC-8.4 RBC-3.55* Hgb-11.0* Hct-32.9* MCV-93 MCH-30.9 MCHC-33.4 RDW-12.9 Plt ___ ___ 05:40AM BLOOD Glucose-91 UreaN-10 Creat-0.9 Na-145 K-3.4 Cl-106 HCO3-27 AnGap-15 ___ 05:40AM BLOOD Calcium-7.4* Phos-3.3# Mg-1.9 IMAGING ======= TTE: Normal global and regional biventricular systolic function. No diastolic dysfunction, pulmonary hypertension or pathologic valvular abnormality seen. No pericardial effusion. CXR: Short interval development of bibasilar opacities, which are concerning for a rapidly developing pneumonia versus alveolar hemorrhage. CT CHEST W/CONTRAST (___): 1. Bilateral pleural effusions, moderate on the left side without evidence of empyema. 2. Multifocal airspace disease which is predominant at the lung bases and is likely in keeping with multifocal pneumonia. Multiple mediastinal and hilar reactive lymph nodes are noted. 3. Incidental finding of a 6 mm non-obstructing stone in the upper pole of the left kidney. Brief Hospital Course: BRIEF SUMMARY STATEMENT: Mr. ___ is a ___ year old male with no significant medical history presenting as transfer from OSH with c/o cough, n/d/diarrhea, and chest pain found to have fever and hypoxia. On further work-up, pt. was found to have a multifocal pneumonia. Culture data was unrevealing. Pt. was placed on antibiotics and continued to improve. His O2 requirement resolved and he was discharged with close follow-up. ACTIVE ISSUES ============= # Sepsis and Community Acquired Pneumonia: Mr. ___ presented with tachycardia, temp to 104, and multifocal opacities seen on CXR. He was started on ceftriaxone and levofloxacin in accordance to ___ guidelines for community acquired pneumonia. Respiratory viral panel negative, legionella negative, strep pneumo antigen negative, and cultures were unrevealing. Pt. grew GPCs in clusters in blood ___ bottles) which raised concern for possible MRSA bacteremia from MRSA pneumonia. Pt. has negative MRSA swab and without known MRSA risk factors. TTE was negative for evidence of endocarditis and surveillance blood cultures were negative. Oxygen requirement had resolved by day 2 of admission and he was transferred to the floor. He was transitioned to levofloxacin to complete his course of antibiotics. # Chest Pain: Pt. complained of left sided sharp chest pain made worse with coughing and deep breathing. Most likely pleuritic chest pain from underlying inflammatory pleuritis from pneumonia. Cardiac enzymes neg x2 making cardiac ischemia less likely. No ischemic changes or other notable changes seen on ECG. TTE done on ___ and was grossly normal with LVEF 60-65%. # Abdominal Distension: Initially, pt. presented with diarrhea, CDiff negative. Continued to complain of abdominal distension. KUB showed multiple air filled loops of bowel without air fluid levels consistent with possible ileus. Pt. continued to complain of minimal flatus, abdominal distension made worse with consuming POs, and minimal BMs. Slowly, he began to tolerate PO intake. At time of discharge, pt. was tolerating full liquids without issue. He was encouraged to advance his diet as tolerated. # Anemia: Patient with downtrending Hct throughout this admission. Initial and repeat DIC labs returned negative. Most likely etiology ___ bone marrow suppression due to acute illness with possible suppression ___ medication effect. No signs of active bleeding. # ___: Pt. with evidence ___ on admission. Likely pre-renal etiology in the setting of pneumonia and sepsis. With IVF, pt's creatinine returned to baseline and ___ resolved. CHRONIC ISSUES ============== # BPH: Stable. Continued on flomax TRANSITIONAL ISSUES =================== # Antibiotics: Pt. should continue levofloxacin for an additional 4 days to complete a 10 day course. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN pain 2. Docusate Sodium 200 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 3. Guaifenesin ___ mL PO Q6H:PRN cough RX *guaifenesin 100 mg/5 mL 5 mL by mouth every 6 hours Disp #*1 Bottle Refills:*0 4. Levofloxacin 750 mg PO DAILY RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*4 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary: Pneumonia Secondary: Ileus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr ___, It was a pleasure taking care of you during your stay at ___. You were admitted after you were diagnosed with pneumonia. We started you on antibiotics and you improved. You also had issues with moving your bowels which resolved with conervative measures. Please continue a full liquid diet at home (soups, jello, shakes) and advance to regular diet slowly as tolerated. ___ MDs Followup Instructions: ___

10009203-DS-9

DS

2201-08-14 00:00:00

2201-08-16 13:02:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: bloody bowel movement Major Surgical or Invasive Procedure: none History of Present Illness: ___ smoker w/ history of hyperlipidemia, BPH, GERD, DJD, osteoarthritis, and colon polyps presents today with one bloody BM, fever in AM and abdominal pain. Pt's last ___ was in ___ at which point he had some polyps that were benign. The patient woke up in the morning in his usual state of health. He went to work after eating a muffin and drinking a coffee. While at work, he experienced a band of pain along his abdomen, lasting for 45 minutes and was drenched in sweat. Had large blood BM at 11 AM (blood covered stool). Since then has had ___ belly pain in lower quadrants in a horizontal band. In the ED, initial vs at 14:22 were pain 6 t 98.6 64 133/78 16 99%. He was ound to have elevated WBC (19.2). CT shows colitis, patient given 0.5 mg IV dilaudid, 400mg IV cipro. Transfer VS 98.1po 59 16 126/81 100% RA ___. On arrival to the floor, patient reports continued abdominal pain, but is comfortable. He also reports continuing smoking and having a rash along his right axila. He denies any recent antibiotics, travel, changes in his diet, or sick contacts. REVIEW OF SYSTEMS: Recent headache over the weekend, twice, which is new for him.. Denies fever, chills, night sweats, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, constipation, melena, dysuria, hematuria. All other 10-system review negative in detail. Past Medical History: 1. Status post appendectomy. 2. Status post sebaceous cyst excision. 3. Status post arthroscopy, left knee. 4. Status post arthroscopy, right knee. Social History: ___ Family History: Positive for lung cancer, CAD, hypertension, and diabetes. No history of crohn disease or ulceraive colitis. Physical Exam: Admission: VS 98.7, 146/89, 56, 18, 98% GEN Alert, oriented, no acute distress HEENT NCAT MMM EOMI sclera anicteric, OP clear NECK supple, no JVD, no LAD PULM Good aeration, CTAB no wheezes, rales, ronchi CV RRR normal S1/S2, no mrg ABD soft tender along left lower quadrant. ND normoactive bowel sounds, no hsm EXT WWP 2+ pulses palpable bilaterally, no c/c/e NEURO CNs2-12 intact, motor function grossly normal SKIN small erythematous papular rash under right axila. Discharge: VS 98.4, 122/80, 65, 18, 96%RA GEN Alert, oriented, no acute distress HEENT NCAT MMM EOMI sclera anicteric, OP clear NECK supple, no JVD, no LAD PULM Good aeration, CTAB no wheezes, rales, ronchi CV RRR normal S1/S2, no mrg ABD soft, mildly tender with soft and deep palpation in LLQ, no masses EXT WWP 2+ pulses palpable bilaterally, no c/c/e NEURO CNs2-12 intact, motor function grossly normal SKIN small erythematous papular rash under right axila. Pertinent Results: Admission: ___ 02:32PM NEUTS-91.6* LYMPHS-5.7* MONOS-2.6 EOS-0 BASOS-0.1 ___ 02:32PM WBC-19.2*# RBC-5.14 HGB-15.6 HCT-46.2 MCV-90 MCH-30.4 MCHC-33.8 RDW-13.1 ___ 02:32PM LIPASE-51 ___ 02:32PM PLT COUNT-346 ___ 02:32PM ALT(SGPT)-30 AST(SGOT)-29 LD(LDH)-187 ALK PHOS-73 TOT BILI-0.5 ___ 02:32PM LIPASE-51 ___ 02:32PM GLUCOSE-120* UREA N-14 CREAT-0.7 SODIUM-137 POTASSIUM-4.5 CHLORIDE-103 TOTAL CO2-27 ANION GAP-12 ___ 02:40PM LACTATE-1.1 ___ 07:52PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 07:52PM URINE COLOR-Yellow APPEAR-Clear SP ___ Discharge: ___ 07:00AM BLOOD WBC-12.2* RBC-4.90 Hgb-14.3 Hct-43.5 MCV-89 MCH-29.2 MCHC-32.9 RDW-12.6 Plt ___ ___ 07:00AM BLOOD Plt ___ ___ 07:00AM BLOOD Glucose-95 UreaN-13 Creat-0.7 Na-138 K-4.1 Cl-106 HCO3-25 AnGap-11 ___ 07:00AM BLOOD Calcium-9.0 Phos-3.1 Mg-2.2 Micro: ___ 9:00 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). FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO FOUND. FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA FOUND. FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___: NO E.COLI 0157:H7 FOUND. ___ 2:52 pm BLOOD CULTURE Blood Culture, Routine (Pending): ___BD & PELVIS WITH CO IMPRESSION: 1. Acute colitis involving the descending and sigmoid colon. Etiologies include infectious, inflammatory and less likely ischemic. 2. Enlarged prostate, correlate with PSA. 3. Bilateral small indeterminate adrenal nodules. 4. Mild compression of T11 and T12 vertebral bodies. Cardiovascular Report ECG Study Date of ___ 3:26:28 ___ Sinus rhythm. Normal tracing. No previous tracing available for comparison. Brief Hospital Course: # Colitis: Patient presented with one bloody bowel movement associated with crampy abdominal pain. CT showing acute colitis of descending colon. Differential diagnosis includes infectious (bacterial, viral, parasitic), ischemic, and inflammatory. Ischemic possible given high white count, acute nature and smoking history, however normal lactate. EKG with normal sinus rhythm. Infectious possible with high white count, however patient was afebrile and did not describe diarrhea or vomiting. Further, patient had no travel history, sick contacts or concerning food ingestion. First presentation of inflammatory bowel disease is possible, however less likely given acute nature and disease of only descending colon. Diverticuli seen on previous colonoscopy, however elevated white count and pain is not consistent with diverticular bleeding. The patient was started on ciprofloxacin for possible infectious etiology and given IV fluids. Gastroenterology was consulted due to concern for ischemic etiology. Stool studes were sent and were negative for salmonella, shigella, campylobacter, vibrio and yersinia. C. difficile testing was not done as sample was unsuitable for testing (solid). GI recommended discontinuing ciprofloxacin and outpatient follow up given resolving symptoms with stable hemodynamics and recent colonoscopy. The patient was scheduled for outpatient follow up with gastroenterology. Chronic Issues: # T11/ T12 vetebral compression: Compression seen on CT scan. Patient has no current back pain with normal neurological exam. # Enlarged prostate: BPH, mildly symptomatic with stable PSA, and a relatively recent prostate biopsy, which was negative for malignancy. Patient continued on finasteride and Flomax as prescribed. Transitional Issues: -follow up with GI for possible endoscopy as outpatient -follow up with PCP -___ cultures pending Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. Finasteride 5 mg PO DAILY 2. Tamsulosin 0.4 mg PO HS Hold for SBP<100 Discharge Medications: 1. Finasteride 5 mg PO DAILY 2. Tamsulosin 0.4 mg PO HS Hold for SBP<100 Discharge Disposition: Home Discharge Diagnosis: Primary: colitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. ___, It was a pleasure taking care of you at ___ ___. You were admitted with an episode bloody bowel movement. CT scan showed colitis, which may have be infectious. You were seen by gastroenterology and will follow up with Dr. ___ in clinic. Medication changes: none Followup Instructions: ___

10009614-DS-9

DS

2188-09-19 00:00:00

2188-09-21 17:27:00

Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Morphine Attending: ___ Chief Complaint: RUQ abdominal pain Major Surgical or Invasive Procedure: ERCP with sphincterotomy ___ laparoscopic cholecystectomy ___ History of Present Illness: ___ s/p C-section ___ presents to the ___ ER after experiencing an acute onset of RUQ pain after eating last night. Patient states she ate a steak dinner yesterday evening and approximately one hour after had an acute onset of sharp, severe RUQ pain. The pain was constant and associated with nausea but no vomiting. She went an OSH hospital where her pain resolved with pain medication and was told to follow up with her PCP. After returning home she had two more episodes of pain which resolved within an hour. She also reports having another episode of pain 2 weeks ago in a similar location, but less severe which resolved after an hour. She denies fevers, vomiting, BRBPR or melena. Past Medical History: - Hairy cell leukemia (now status post 1 cycle Cladribine) - History of diabetes mellitus, untreated /diet controlled . - S/p knee and ankle surgeries x ___ - S/p appendectomy Social History: ___ Family History: Her mother is ___ and has thyroid disease and elevated cholesterol. Her father is ___ and has coronary artery disease and hemochromatosis. Her brother is ___ and well. She has one paternal uncle who died in his ___ from an asbestos-related cancer. No other family members have cancers or blood disorders. Physical Exam: Physical Exam: Vitals: T 97.8 P 80 BP 130/90 RR 16 O2 100% 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, negative ___ sign no rebound or guarding, normoactive bowel sounds, no palpable masses Ext: No ___ edema, ___ warm and well perfused Pertinent Results: ___ WBC-6.4 RBC-3.96* HGB-11.7* HCT-35.0* MCV-89 MCH-29.7 MCHC-33.6 RDW-13.3 ___ ALT-366* AST-396* AlkPhos-173* Amylase-39 TotBili-2.6* DirBili-1.4* IndBili-1.2 ___ ALT-342* AST-206* AlkPhos-166* Amylase-34 TotBili-3.2* ___ ALT-249* AST-101* AlkPhos-170* TotBili-1.5 ___ ALT-158* AST-49* AlkPhos-144* TotBili-1.0 ___ Lipase-29 RUQ (___) 1. Slightly distended gallbladder, but no evidence of cholecystitis or cholelithiasis. 2. Echogenic liver consistent with fatty infiltration; other forms of liver disease, including more significant hepatic fibrosis or cirrhosis cannot be excluded on the basis of this examination. 3. Mildly enlarged spleen measuring 13.2 cm. ERCP ___ The major papilla was bulging proximal to the opening. There appeared to be two openings to the biliary orifice consistent with a possible fistula. A sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. There was no bleeding. The intrahepatics were normal. The CBD was around 7 mm. There was a distal CBD filling defect. The stone was extracted successfully using a 9-12 mm stone extraction balloon. An occlusion cholangiogram after the bile duct sweeps showed no filling defects. There was excellent flow of bile and contrast. Brief Hospital Course: The patient was admitted to the ___ service on ___ for right upper quadrant pain on elevated LFTs suggestive of choledocolithiasis. She was made NPO and started on maintainence IVFs. Her abdominal pain was well controlled on the floor. Her follow-up LFTs on HD#2 revealed an uptrending t-bili from admission (2.6->3.2). Interventional GI was consulted and the patient underwent successfully ERCP removal of a CBD stone with sphincterotomy on ___. The patient did not exhibit complications from the ERCP and her abdominal pain improved significantly following the procedure as well. On HD#3, the patient's LFTs downtrended, most notable for a t-bili of 1.5 (from 3.2), along with a decrease in her transaminitis. Given the patient's clinical improvement and downtrending LFTs, the decision was made to proceed to laparoscopic cholecystectomy, which was performed on ___. The procedure was without complication. The patient's diet was advanced on POD#1, and she was tolerating a regular diet upon discharge. She was instructed to follow-up in the ___ clinic in 2 weeks. Medications on Admission: none Discharge Medications: 1. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain RX *Endocet 5 mg-325 mg ___ Tablet(s) by mouth every four (4) hours Disp #*20 Tablet Refills:*0 2. Docusate Sodium 100 mg PO BID RX *Colace 100 mg 1 Capsule(s) by mouth twice a day Disp #*14 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: choledocolithiasis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the acute care surgery service with choledocolithiasis (a gallstone in you common bile duct). The gallstone was removed by a procedure called an ERCP. You then underwent a laparoscopic cholecystectomy to remove your gallbladder without complication. Below are instructions to follow post-operatively: Please resume all regular home medications unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. 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: ___

10009657-DS-3

DS

2139-05-16 00:00:00

2139-05-16 13:17:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: perirectal abscess Major Surgical or Invasive Procedure: Exam under anesthesia Incision and drainage of complex ___ abscess History of Present Illness: Ms. ___ is a ___ woman who underwent incision and drainage of a perirectal abscess approximately ___ years ago. She now presents with recurrent perirectal abscess and on a CAT scan that was obtained in the emergency room before surgery consult; the patient was found to have a horseshoe type of perirectal abscess extending from the patient's left side and around the rectum on the dorsal aspect. The patient was then taken to the OR for examination under anesthesia and incision and drainage of the perirectal abscess. Past Medical History: PMH: Depression, anxiety, perineal/perianal condylomata PSH: Microscopically-assisted biopsy and transanal laser destruction of anal, perineal, vulvar, and vaginal condylomata ___ Social History: ___ Family History: Non-contributory. Physical Exam: Discharge Physical Exam VS: 98.9 73 115/76 18 100%ra Gen: alert and oriented x3 NAD CV: RRR Pulm: CTAB Abd: Soft NT ND Rectal: opened abscess cavity with some purulent drainage, packed loosely with plain packing material Pertinent Results: ___ 04:21PM LACTATE-0.9 ___ 02:25PM WBC-19.1*# RBC-3.82* HGB-11.7* HCT-36.0 MCV-94 MCH-30.6 MCHC-32.5 RDW-11.9 ___ 04:45AM BLOOD WBC-13.7* RBC-3.59* Hgb-11.2* Hct-33.4* MCV-93 MCH-31.1 MCHC-33.5 RDW-11.6 Plt ___ Brief Hospital Course: Ms. ___ has a history of prior perirectal abscesses, and presented to the ED with symptoms of a recurrent abscess. She was taken to the OR for incision and drainage of this large horseshoe type abscess; for full details please see the dictated operative summary. She tolerated the procedure well; a shortened chest tube was left in the cavity to allow for irrigation overnight. She was brought back to the floor in good condition. She was advanced to a regular diet and pain was controlled on oral medications. She ambulated and voided appropriately. She remained on cipro/flagyl for the duration of her hospital course. Prior to discharge, the tube was removed from the cavity and a loose packing was placed. She will remove the packing in one day and follow up with Dr. ___ in clinic later this week. She is discharged home in good condition on hospital day 2, POD#1. Medications on Admission: lamictal 100', dicyclomine 10' Discharge Medications: 1. lamotrigine 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 4. dicyclomine 10 mg Capsule Sig: One (1) Capsule PO once a day. 5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: ___ abscess Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the colorectal surgery service after drainage of a complex ___ abscess. You have done well postoperatively and you are now ready to go home. You will have a small wick inside the abscess. This should be removed tomorrow. After it is removed, please start taking ___ baths daily and after bowel movements. Continue to take pain medication as needed and also take stool softeners to prevent constipation. Followup Instructions: ___

10009657-DS-4

DS

2139-05-27 00:00:00

2139-05-27 22:10:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: N/V/D Major Surgical or Invasive Procedure: none History of Present Illness: ___ woman whose PMH includes laser ablation for perianal condylomata and subsequent hx of complex ischiorectal abscess requiring operative drainage, s/p resection of perianal abscess ___, p/w n/v/d since this AM. Pt reports that the diarrhea is watery, emesis is nonbilious, non-bloody. Denies f/c. Denies cp/sob/ha. Pt reports that she initially had onset of abdominal pain shortly before diarrhea. Reports no rectal pain.She felt very well on the day of presentation and only after participating in cleaning day did she experienced gradual -> severe abdominal pain/supra-pelvic burning -> nausea -> emesis and diarrhea. Earlier outbreak of norovirus at her school where she works but none recently. No clear sick contacts. No foreign travel. No strange foods. No vaginal discharge or bleeding. On examination in the ED, moderate abdominal ttp below the umbilicus with rebound. Per rectum, purulent-appearing mucoid discharge which is occult positive. In ER: (Triage Vitals:9 96.9 77 101/54 16 100% RA ) Meds Given: ___ 14:15 Ondansetron 2mg/mL-2mL 1 ___ ___ 15:38 Ondansetron 2mg/mL-2mL 1 ___ ___ 15:50 Readi-Cat 2 (Barium Sulfate 2% Suspension) 450 mL Bottle 2 ___ ___ 16:15 Morphine 5 mg Vial [class 2] Radiology Studies: abdominal CT PAIN SCALE: ___ ________________________________________________________________ REVIEW OF SYSTEMS: CONSTITUTIONAL: [] All Normal [ -] Fever [- ] Chills [ ] Sweats [ ] Fatigue [ ] Malaise [ ]Anorexia [ ]Night sweats [ -] _____ lbs. weight loss/gain over _____ months Eyes [X] All Normal [ ] Blurred vision [ ] Loss of vision [] Diplopia [ ] Photophobia ENT [x] WNL [ ] Dry mouth [ ] Oral ulcers [ ] Bleeding gums [ ] Sore throat [] Sinus pain [ ] Epistaxis [ ] Tinnitus [ ] Decreased hearing [ ] Other: RESPIRATORY: [X] All Normal [ ] Shortness of breath [ ] Dyspnea on exertion [ ] Can't walk 2 flights [ ] Cough [ ] Wheeze [ ] Purulent sputum [ ] Hemoptysis [ ]Pleuritic pain [ ] Other: CARDIAC: [X] All Normal [ ] Palpitations [ ] Edema [ ] PND [ ] Orthopnea [ ] Chest Pain [ ] Dyspnea on exertion [ ] Other: GI: [] All Normal [ +] Nausea [+] Vomiting [+] Abd pain [] Abdominal swelling [+] Diarrhea [ ] Constipation [ ] Hematemesis [- ] Blood in stool [ ] Melena [ ] Dysphagia: [ ] Solids [ ] Liquids [ ] Odynophagia [ ] Anorexia [ ] Reflux [ ] Other: GU: [X] All Normal [ ] Dysuria [ ] Incontinence or retention [ ] Frequency [ ] Hematuria []Discharge []Menorrhagia SKIN: [X] All Normal [ ] Rash [ ] Pruritus MS: [X] All Normal [ ] Joint pain [ ] Jt swelling [ ] Back pain [ ] Bony pain NEURO: [X] All Normal [ ] Headache [ ] Visual changes [ ] Sensory change [ ]Confusion [ ]Numbness of extremities [ ] Seizures [ ] Weakness [ ] Dizziness/Lightheaded [ ]Vertigo [ ] Headache ENDOCRINE: [X] All Normal [ ] Skin changes [ ] Hair changes [ ] Heat or cold intolerance [ ] loss of energy HEME/LYMPH: [] All Normal [+] Easy bruising- chronic [ ] Easy bleeding [ ] Adenopathy PSYCH: [X] All Normal [ ] Mood change []Suicidal Ideation [ ] Other: ALLERGY: [- ]Medication allergies [ ] Seasonal allergies [X]all other systems negative except as noted above Past Medical History: PMH: Depression, anxiety, perineal/perianal condylomata PSH: # Microscopically-assisted biopsy and transanal laser destruction of anal, perineal, vulvar, and vaginal condylomata ___ # perirectal abscess drainage in ___ # perirectal abscess drainage ___ Social History: ___ Family History: Maternal grandmother with skin cancer. Paternal aunt with breast cancer. Physical Exam: 1. VS T = 98.9 P = 73 BP = 127/76 RR = 18 O2Sat on _100% on RA GENERAL: Well appearing very pleasant female. Nourishment: good Grooming: good Mentation 2. Eyes: [X] WNL EOMI without nystagmus, Conjunctiva: clear/injection/exudates/icteric 3. ENT [X] WNL [X] Moist [] Endentulous [] Ulcers [] Erythema [] JVD ____ cm [] Dry [] Poor dentition [] Thrush [] Swelling [] Exudate 4. Cardiovascular [X] WNL [X] Regular [] Tachy [X] S1 [X] S2 [] Systolic Murmur /6, Location: [] Irregular []Brady []S3 [] S4 [] Diastolic Murmur /6, Location: [X] Edema RLE None [] Bruit(s), Location: [X] Edema LLE None [] PMI [] Vascular access [X] Peripheral [] Central site: 5. Respiratory [ ] [X] CTA bilaterally [ ] Rales [ ] Diminshed [] Comfortable [ ] Rhonchi [ ] Dullness [ ] Percussion WNL [ ] Wheeze [] Egophony 6. Gastrointestinal [ ] WNL Soft, non tender all quadrants. She reports that her abdomen was tender when examined in the ED but now it is much improved. Rectum: site of ___ abscess drainage non-tender and without erythema 7. Musculoskeletal-Extremities [] WNL [ ] Tone WNL [x ]Upper extremity strength ___ and symmetrical [ ]Other: [ ] Bulk WNL [X] Lower extremity strength ___ and symmetrica [ ] Other: [] Normal gait []No cyanosis [ ] No clubbing [] No joint swelling 8. Neurological [X] WNL [X ] Alert and Oriented x 3 [ ] Romberg: Positive/Negative [ ] CN II-XII intact [ ] Normal attention [ ] FNF/HTS WNL [] Sensation WNL [ ] Delirious/confused [ ] Asterixis Present/Absent [ ] Position sense WNL [ ] Demented [ ] No pronator drift [] Fluent speech 9. Integument [] WNL Warm and dry with multiple tatooes 10. Psychiatric [X] WNL [X] Appropriate [] Flat affect [] Anxious [] Manic [] Intoxicated [] Pleasant [] Depressed [] Agitated [] Psychotic [] Combative 11. Hematologic/Lymphatic [ X] WNL [X] No cervical ___ [] No axillary ___ [] No supraclavicular ___ [] No inguinal ___ [] Thyroid WNL TRACH: []present [X]none PEG: []present [X]none [ ]site C/D/I COLOSTOMY: :[]present [X]none [ ]site C/D/I Pertinent Results: ___ 04:00PM URINE HOURS-RANDOM ___ 04:00PM URINE UCG-NEGATIVE ___ 04:00PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 04:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG ___ 04:00PM URINE RBC-1 WBC-2 BACTERIA-FEW YEAST-NONE EPI-4 ___ 04:00PM URINE MUCOUS-MANY ___ 02:29PM LACTATE-3.3* ___ 02:15PM GLUCOSE-113* UREA N-12 CREAT-0.9 SODIUM-136 POTASSIUM-3.7 CHLORIDE-100 TOTAL CO2-23 ANION GAP-17 ___ 02:15PM estGFR-Using this ___ 02:15PM ALT(SGPT)-31 AST(SGOT)-29 ALK PHOS-73 TOT BILI-0.3 ___ 02:15PM LIPASE-88* ___ 02:15PM ALBUMIN-4.9 CALCIUM-9.8 PHOSPHATE-3.6 MAGNESIUM-1.7 ___ 02:15PM WBC-37.1*# RBC-4.99# HGB-15.3# HCT-46.8# MCV-94 MCH-30.6 MCHC-32.6 RDW-12.5 ___ 02:15PM NEUTS-92.4* LYMPHS-4.5* MONOS-2.4 EOS-0.5 BASOS-0.2 ___ 02:15PM PLT COUNT-482*# -------------- Brief Hospital Course: The patient is a lovely ___ year old female with h/o perirectal abscess x ___ s/p drainage of a perirectal abscess now presenting with abdominal pain, nausea, vomiting, diarrhea. # viral gastroenteritis, likely Norovirus: Clinically stable, quickly improved, able to tolerate po and advance to regular diet within 12 hours of admission. Leukocytosis much improved. No indication for antibiotics. # perirectal abscess: no acute issues, s/p drainage on ___ # IBS: stable, continued dicyclomine . # ovarian cyst: noted on CT scan; obtained pelvic US to further evaluate. It showed simple right ovarian cyst measuring up to 5.2 cm in maximum dimension. Ultrasound followup in one year is recommended. # depression/ anxiety: stable, continued lamictal Medications on Admission: dicyclomine 10 mg Capsule 1 (One) Capsule(s) by mouth four times a day take before each meal and at bedtime ___ lamotrigine [Lamictal] 100 mg Tablet 1 (One) Tablet(s) by mouth once a day (Prescribed by Other Provider) ___ Discharge Medications: 1. lamotrigine 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. dicyclomine 10 mg Capsule Sig: One (1) Capsule PO four times a day: before meals and at bedtime. Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: viral gastroenteritis Secondary diagnoses: pelvic cyst, needs f/u IBS depression/ anxiety Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: See below. We made no changes in your outpatient medications. Followup Instructions: ___

10010058-DS-12

DS

2145-10-03 00:00:00

2145-10-03 17:41:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: acute encephalopathy Major Surgical or Invasive Procedure: none History of Present Illness: Mr ___ is a ___ year-old male with a past medical history of hyperlipidemia, CAD, anterior MI, ischemic cardiomyopathy with LVEF 35%, mild- moderate MR, CKD, and AF with CHB s/p BiVICD implant, here with failure to thrive, lightheadedness, and mild confusion. History is very limited due to patient being deaf and confused. Pt is also ___ speaking however does seem to understand some ___ and is able to read ___ when I write down questions. I was also unable to reach family members by phone. Per ED records, pt has had poor PO intake for weeks, however in the past week it has decreased even more and he has had bilious small amounts of vomit in the AMs. Denies fevers, chills, sweats, cough, shortness of breath. Endorses incontinence x about 1 week. Patient's daughter also endorses mild confusion. In the ED, patient was able to recognize daughters and knows his own name, however was unsure what date it was - which is not his baseline. In the ED, initial vitals were: 98.6 60 96/51 16 100% RA. Labs were notable for trop of 0.15--)0.13-->>0.11, LDH 373, Na 130, creatinine 3.4, bland UA, plts 48. CT head showed no acute process, CXR was nl. Pt was given 2 L NS. On the floor, pt states that he is tired but is unable to answer any other questions, I think due to a combination of confusion and difficulty hearing. When I write my questions on paper, he reads the first part however then becomes confused. He states he is not on any pain. Provides phone numbers for his granddaughter however one of them is not a valid number. Review of systems: unable to obtain due to confusion and HOH Past Medical History: (per chart, unable to confirm with patient): hypertension hyperlipidemia AFib CAD CHF hearing loss CORONARY ARTERY DISEASE GOUT HYPERLIPIDEMIA MEMORY LOSS PACEMAKER CHRONIC KIDNEY DISEASE HYPERTENSION ISCHEMIC CARDIOMYOPATHY Social History: ___ Family History: unknown Physical Exam: 97.8 116 / 56 60 16 99 Ra Constitutional: Alert, confused, NAD EYES: Sclera anicteric, EOMI, PERRL ENT: MMD, oropharynx clear, Neck: Supple, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Respiratory: Clear to auscultation bilaterally, no wheezes, rales, rhonchi GI: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley EXT: Warm, well perfused, no CCE NEURO: unable to assess, responds to questioning but answers are unclear, moves all extermities, CNS grossly intact SKIN: no rashes or lesions Pertinent Results: ___ 06:30PM LD(LDH)-373* TOT BILI-0.6 ___ 06:30PM cTropnT-0.11* ___ 06:30PM CK-MB-6 cTropnT-0.13* ___ 06:30PM HAPTOGLOB-241* ___ 02:14PM ___ PTT-34.6 ___ ___ 01:30PM URINE HOURS-RANDOM ___ 01:30PM URINE UHOLD-HOLD ___ 01:30PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 01:30PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 01:30PM URINE RBC-4* WBC-<1 BACTERIA-FEW YEAST-NONE EPI-0 ___ 01:30PM URINE AMORPH-RARE ___ 01:30PM URINE MUCOUS-RARE ___ 12:45PM GLUCOSE-99 UREA N-140* CREAT-3.4*# SODIUM-130* POTASSIUM-4.1 CHLORIDE-96 TOTAL CO2-13* ANION GAP-25* ___ 12:45PM estGFR-Using this ___ 12:45PM ALT(SGPT)-29 AST(SGOT)-44* CK(CPK)-248 ALK PHOS-71 TOT BILI-0.6 ___ 12:45PM LIPASE-132* ___ 12:45PM cTropnT-0.15* ___ 12:45PM CK-MB-6 ___ 12:45PM ALBUMIN-4.1 ___ 12:45PM WBC-7.2 RBC-3.78* HGB-11.3* HCT-32.3* MCV-85# MCH-29.9 MCHC-35.0 RDW-15.1 RDWSD-46.9* ___ 12:45PM NEUTS-74.0* LYMPHS-8.5* MONOS-16.3* EOS-0.4* BASOS-0.1 IM ___ AbsNeut-5.33 AbsLymp-0.61* AbsMono-1.17* AbsEos-0.03* AbsBaso-0.01 ___ 12:45PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-2+ MACROCYT-OCCASIONAL MICROCYT-1+ POLYCHROM-OCCASIONAL OVALOCYT-1+ SCHISTOCY-OCCASIONAL BURR-1+ ELLIPTOCY-OCCASIONAL ___ 12:45PM PLT COUNT-48*# ___ 12:45PM RET AUT-1.0 ABS RET-0.04 MICRO: urine cxs pending STUDIES: CT head: No acute intracranial process. CXR: no acute process EKG: paced rhythm with underlying afib, TWI in V1, V2, LVH, LAD ___ 06:25AM BLOOD WBC-5.7 RBC-3.40* Hgb-10.2* Hct-28.6* MCV-84 MCH-30.0 MCHC-35.7 RDW-15.1 RDWSD-46.4* Plt Ct-47* ___ 06:25AM BLOOD Plt Ct-47* ___ 06:25AM BLOOD ___ ___ 06:25AM BLOOD Glucose-137* UreaN-110* Creat-3.0* Na-137 K-3.2* Cl-106 HCO3-12* AnGap-20 ___ 06:30PM BLOOD cTropnT-0.11* ___ 06:30PM BLOOD CK-MB-6 cTropnT-0.13* ___ 12:45PM BLOOD cTropnT-0.15* ___ 06:25AM BLOOD TSH-1.3 ___ 06:25AM BLOOD calTIBC-241* VitB12-862 Folate->20 Ferritn-706* TRF-185* ___ 06:30PM BLOOD Hapto-241* ___ 06:25AM BLOOD Digoxin-1.6 ___ 06:25AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 06:25AM BLOOD COPPER (SERUM)-PND C IMPRESSION: 1. Fusiform and saccular aneurysmal dilatation of the infrarenal abdominal aorta measuring up to 3.9 cm extending into both common iliac arteries and the right external iliac artery. Linear areas of calcification within the aneurysm sac at the level of the third portion of the duodenum is suspicious for dissection which is limited in the absence of intravenous contrast. The aneurysm sac exerts mass effect on the third portion of the duodenum which is decompressed. There is no upstream dilatation of the duodenum to suggest obstruction. The distance between the anterior aspect of the aortic aneurysm to the anterior wall peritoneal is approximately 1.5 cm. 2. Colonic diverticulosis without CT evidence of acute diverticulitis. 3. Cholelithiasis without CT evidence of acute cholecystitis. 4. Asymmetric sclerosis and narrowing of the right SI joint likely reflecting prior sacroiliitis. 5. Mild-to-moderate cardiomegaly with at least right and possibly biatrial enlargement. Stable size of a known left ventricular aneurysm with increased interval calcifications since ___. 6. Two 2 mm pulmonary micro nodules in the right lung base. In a patient with no known risk factors for lung cancer, these are presumed to be benign and no follow-up is recommended. In a patient with risk factors for lung cancer, ___ year follow-up is recommended. T abdomen/pelvis: Brief Hospital Course: ___ y.o male with h.o HL, CAD, MI, ___ with EF 35%, CKD, afib with CHF s/p biVICD who presented with weight loss, inability to tolerate PO, confusion, weakness found to have acidosis and ___ on CKD. #weight loss #inability to tolerate PO #nausea with vomiting #severe protein calorie malnutrition Symptoms are concerning for underlying malignancy. Pt with signs of dehydration and weight loss. No apparent prior w/u for these symptoms and pt has yet to see PCP. Unknown if prior colonoscopy. CT scan without revealing cause. Nutrition consulted and pt given IVF. However, pt and family after much discussion with ___ ___ present and again with pt's PCP on speaker phone, pt and family elected to leave AMA accepting risks of dehydration, malnutrition, undiagnosed illness, cancer, electrolyte abn, worsening renal function, risk of falls and injury due to weakness. Pt advised to f/u with PCP ___. #acute encephalopathy-likely due to metabolic derangements. Head CT without acute process. Tox screen neg. TSH, LFts, b12/folate WNL. IVF given. Held mirtazapine. ___ on CKD, baseline appears to be Cr 2.4-2.5. Likely prerenal due to above. Pt given some IVF. #thrombocytopenia-b12/folate WNL. Iron studies c/w ACD. Haptoglobin elevated, less likely hemolysis. Outpt f/u given AMA discharge. #anemia-most likely AOCD. Outpt f/u given AMA discharge. #hyponatremia-improved #AGMA-likely due to ___. Lactate WNL. Outpt f /u given AMA discharge. #HTN, HL, afib, CAD, chronic systolic CHF -continued home meds (BB, statin, held dig and eliquis given tpenia. Currently hypovolemic. #gout-no e/o acute flare. Continue appropriately dosed allopurinol. HOld colchicine given CKD. Pt was never able to see ___ as he left AMA before consult. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO DAILY 2. Apixaban 2.5 mg PO BID 3. Colchicine 0.6 mg PO TID:PRN joint pain 4. Digoxin 0.25 mg PO DAILY 5. ipratropium bromide 0.03 % nasal Other 6. Metoprolol Succinate XL 50 mg PO DAILY 7. Mirtazapine 30 mg PO QHS 8. Rosuvastatin Calcium 20 mg PO QPM 9. Aspirin 81 mg PO DAILY 10. Loratadine 10 mg PO DAILY Discharge Medications: 1. Allopurinol ___ mg PO EVERY OTHER DAY 2. ipratropium bromide 0.03 % nasal Other 3. Loratadine 10 mg PO DAILY 4. Metoprolol Succinate XL 50 mg PO DAILY 5. Rosuvastatin Calcium 20 mg PO QPM 6. HELD- Apixaban 2.5 mg PO BID This medication was held. Do not restart Apixaban until you discuss with your doctor due to your low platlet count 7. HELD- Aspirin 81 mg PO DAILY This medication was held. Do not restart Aspirin until you discuss with your doctor due to your low platelet count 8. HELD- Colchicine 0.6 mg PO TID:PRN joint pain This medication was held. Do not restart Colchicine until you discuss with your doctor 9. HELD- Digoxin 0.25 mg PO DAILY This medication was held. Do not restart Digoxin until you discuss with your doctor 10. HELD- Mirtazapine 30 mg PO QHS This medication was held. Do not restart Mirtazapine until you discuss with your doctor Discharge Disposition: Home Discharge Diagnosis: weakness dehydration nausea with vomiting weight loss 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: You were admitted for monitoring and further work up of weight loss, nausea, vomiting, dehydration, kidney failure and weakness. For this, you had lab testing and were given IV fluids and had a CT scan. Due to the unexplained dehydration and weight loss as well as weakness, renal failure, electrolyte abnormalities, and concern for falls and fractures due to weakness we recommended that you stay inpatient for further work up and monitoring but you declined. Risks of leaving against medical advice include infection, worsened renal failure, electrolyte abnormalities, undiagnosed cancer and including death. We recommend that you see your PCP ___ for ongoing care. Weigh yourself every morning, call MD if weight goes up more than 3 lbs. Followup Instructions: ___

10010058-DS-13

DS

2147-01-06 00:00:00

2147-01-07 18:42:00

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: N/A History of Present Illness: Mr. ___ is a ___ year old male with past medical history significant for ischemic cardiomyopathy with LVEF 35%, coronary artery disease ___ silent anterior MI of indeterminate age (presumed to be years ago), permanent AF w/ CHB ___ BiV-ICD implant, mild-moderate MR, CKD, hyperlipidemia who presents to the emergency department today with complaint of chest and epigastric pain. Pain occurred in middle of night and awoke patient from his sleep. Pain is associated with nausea, dyspnea, and diaphoresis. Denies any pain similar to this in the past. Denies any pain in his back, fevers, chills, or emesis. In the ED initial vitals were: T 96.7, HR 57, BP 99/57, RR 18, SpO2 99% RA Past Medical History: (per chart, unable to confirm with patient): hypertension hyperlipidemia AFib CAD CHF hearing loss CORONARY ARTERY DISEASE GOUT HYPERLIPIDEMIA MEMORY LOSS PACEMAKER CHRONIC KIDNEY DISEASE HYPERTENSION ISCHEMIC CARDIOMYOPATHY Social History: ___ Family History: Noncontributory to patient's presentation Physical Exam: Admission ___ Temp: 97.7 PO BP: 108/67 R Lying HR: 60 RR: 16 O2 sat: 96% O2 delivery: 2LNC GENERAL: lying in bed, interactive but hard of hearing. HEENT: PERRL. EOMI. No pallor or cyanosis of the oral mucosa. NECK: Supple. JVP 14-15cm CARDIAC: Normal S1, S2. No murmurs, rubs, or gallops. LUNGS: Bibasilar crackles and dullness at bases. ABDOMEN: Soft, non-tender, non-distended. EXTREMITIES: 1+ bilateral edema. WWP. PULSES: 2+ peripheral pulses. Discharge ___ 0710 Temp: 97.5 PO BP: 115/61 R Lying HR: 60 RR: 16 O2 sat: 100% O2 delivery: Ra ___ Total Intake: 1570ml PO Amt: 1570ml ___ Total Output: 650ml Urine Amt: 650ml GENERAL: NAD HEENT: PERRL. MMM. NECK: JVP noted at the clavicle with patient at 30 degrees CARDIAC: Normal S1, S2. Grade ___ systolic murmur LUNGS: Clear to auscultation bilaterally EXTREMITIES: No ___ edema noted. Warm and well perfused. PULSES: 2+ peripheral pulses. Pertinent Results: Admission ___ 04:05AM BLOOD WBC-7.3 RBC-3.39* Hgb-10.4* Hct-31.8* MCV-94 MCH-30.7 MCHC-32.7 RDW-14.5 RDWSD-49.7* Plt ___ ___ 04:05AM BLOOD Neuts-73.4* Lymphs-14.6* Monos-9.6 Eos-1.6 Baso-0.4 Im ___ AbsNeut-5.36 AbsLymp-1.07* AbsMono-0.70 AbsEos-0.12 AbsBaso-0.03 ___ 04:05AM BLOOD ___ PTT-39.0* ___ ___ 04:05AM BLOOD Glucose-118* UreaN-34* Creat-1.8* Na-137 K-4.5 Cl-102 HCO3-20* AnGap-15 ___ 04:05AM BLOOD ALT-34 AST-48* CK(CPK)-153 AlkPhos-59 TotBili-0.6 ___ 04:05AM BLOOD CK-MB-6 ___ ___ 04:05AM BLOOD Albumin-4.0 Calcium-8.8 Phos-3.2 ___ 04:05AM BLOOD D-Dimer-2200* ___ 07:40AM BLOOD TSH-2.2 ___ 07:30AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-POS* ___ 07:50AM BLOOD HBV VL-NOT DETECT ___ 07:30AM BLOOD HCV Ab-NEG Discharge ___ 07:50AM BLOOD WBC-6.2 RBC-3.24* Hgb-10.2* Hct-31.4* MCV-97 MCH-31.5 MCHC-32.5 RDW-15.6* RDWSD-55.2* Plt ___ ___ 07:50AM BLOOD Neuts-67.8 Lymphs-16.0* Monos-11.3 Eos-3.9 Baso-0.2 Im ___ AbsNeut-4.21 AbsLymp-0.99* AbsMono-0.70 AbsEos-0.24 AbsBaso-0.01 ___ 07:50AM BLOOD Plt ___ ___ 07:50AM BLOOD Glucose-92 UreaN-68* Creat-2.5* Na-140 K-5.8* Cl-100 HCO3-27 AnGap-13 ___ 07:50AM BLOOD ALT-86* AST-63* LD(LDH)-285* AlkPhos-68 TotBili-0.5 ___ 06:50AM BLOOD ___ ___ 07:50AM BLOOD Calcium-9.1 Phos-5.4* Mg-2.7* ___ 06:17AM BLOOD Hapto-154 Studies ___ RUQ US 1. Cholelithiasis. 2. Mild gallbladder wall edema is significantly improved compared to recent CT from ___. No other evidence of cholecystitis. ___ ECHO The left atrial volume index is SEVERELY increased. The right atrium is moderately enlarged. The estimated right atrial pressure is >15mmHg. There is normal left ventricular wall thickness with a moderately increased/dilated cavity. The apex is aneurysmal. A left ventricular thrombus/mass cannot be excluded. Overall left ventricular systolic function is severely depressed secondary to akinesis of the anterior septum and apex with focal apical dyskinesis, severe hypokinesis with focal basal akinesis of the inferior septum and inferior free wall, and hypokinesis of the anterior ftree wall and lateral wall. Quantitative biplane left ventricular ejection fraction is 27 %. The right ventricular free wall is hypertrophied. Dilated right ventricular cavity with low normal free wall motion. Intrinsic right ventricular systolic function is likely lower due to the severity of tricuspid regurgitation. The aortic sinus diameter is normal for gender with mildly dilated ascending aorta. The aortic arch diameter is normal. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. There is moderate [2+] aortic regurgitation. The mitral valve leaflets are mildly thickened with no mitral valve prolapse. There is moderate to severe [3+] mitral regurgitation. The tricuspid valve leaflets appear structurally normal. There is moderate to severe [3+] tricuspid regurgitation. Due to acoustic shadowing, the severity of tricuspid regurgitation may be UNDERestimated. There is mild-moderate pulmonary artery systolic hypetension. In the setting of at least moderate to severe tricuspid regurgitation, the pulmonary artery systolic pressure may be UNDERestimated. There is no pericardial effusion. A left pleural effusion is present. Compared with the prior TTE ___, left ventricular ejection fraction is further reduced, with increased mitral and tricuspid regurgitation. EMR ___ CTA 1. 7 mm penetrating plaque in the distal portion of the aortic arch, without prior imaging for 2 studies acuity. A short-segment focal dissection in the mid aortic arch, appears chronic. 2. Signs of heart failure with cardiomegaly, pulmonary edema, bilateral pleural effusions greater on the right, as well as gallbladder-wall edema. 3. Infrarenal aortic aneurysm and left common iliac aneurysm. Please note that the prior study was done without IV contrast however based on wall calcifications in overall diameter it is grossly unchanged. Brief Hospital Course: Mr. ___ is a ___ year old male with PMH significant for ischemic cardiomyopathy (LVEF 27% on ___ ECHO), CAD ___ silent anterior MI of indeterminate age), permanent AF w/ CHB ___ BiV-ICD implant (on apixaban), CKD, hyperlipidemia who presented for chest/epigastric pain. He was found to have elevated troponins and decompensated heart failure. He was medically treated for NSTEMI with heparin drip and continuation of home medications including aspirin, statin, and beta blocker. He was diuresed with Lasix drip. He was also managed for ___ during this time, which was improving at time of discharge. While inpatient he had a reaction to likely hydralazine that resulted in a morbilliform drug rash. The drug was discontinued and his rash improved. Corresponding to that rash he had elevated LFTs that were downtrending by time of admission. He was found to have isolated hepatitis B antibody. # CORONARIES: CAD ___ silent anterior MI # PUMP: HFrEF (EF 35%) # RHYTHM: permanent AF and CHB ___ BiV-ICD ACTIVE ISSUES: ============== #Acute decompensated HFrEF (EF 35%) #Ischemic Cardiomyopathy #LBBB ___ CRT-D The patient presented with clinical evidence of volume overload with rales, elevated JVP, mild pulmonary edema on CXR, and congestive gallbladder and ascending colon on CT. BNP >50000. Diuresed on a Lasix drip at 10cc/hr. - Admission weight 51 kg, discharge dry weight 45.4 kg - Preload: 10 mg furosemide daily - Afterload: Imdur 90 mg daily (previous intolerance to ACE + he has hyperkalemia) - Neurohormonal blockade: metoprolol 50 mg XL - Digoxin was discontinued w/ supratherapeutic level, worsening renal failure, and stable cardiac function after diuresis #NSTEMI #CAD with prior silent MI Initial trop elevated with peak to 2.60, without clear new ECG changes. Unclear if initial presentation was Type 1 NSTEMI versus demand in the setting of severe decompensated CHF. He received 48 hour heparin drip, aspirin, and rosuvastatin. After discussion with the patient and family, it was determined that he did not desire any invasive intervention such as cardiac catheterization. He will continue on aspirin, rosuvastatin 20 mg, and metoprolol succinate 50 mg qD at home. ___ on CKD Baseline appears to be ___ and was at baseline at presentation, but increased to a peak of 3.4 with diuresis. It was not clear the etiology of his ___, but possibly prerenal in the setting of his low flow state. No urinalysis sediment evidence of ATN. No post-renal obstruction. Renal function was improving at the time of discharge, with creatinine down to 2.5. We did suspend apixaban for some time, but it was restarted once renal function improved. #Hyperkalemia Persistently hyperkalemic during the admission. Likely a combination of both diet and acute renal failure. Patient was found to have pile of bananas in his room. He likes eating them because they are soft. Patient and patient's family education on low potassium foods. He was not discharged on any potassium elevating agents at the time of discharge. His levels will need to be followed closely as ___ outpatient. # Transaminitis Mild transaminitis of unclear etiology. Initially thought to be due to vascular congestion, but has remained elevated even after diuresis. RUQ without evidence for cholecystitis. Possibly hypersensitivity to hydralazine, as LFTs increased after drug was introduced. Was also Hep B core Ig positive without Ag or Ab positive, which is nonspecific. LFTs were downtrending at time of discharge. Hepatitis B viral load pending at time of discharge. He should receive a fibroscan to follow up for possible cirrhosis secondary to possible chronic disease. # Morbilliform Drug Eruption Patient with erythematous itchy macular rash that started on back and thighs and since spread to abdomen anteriorly. Derm consulted, believes to be drug eruption, but unclear which drug. Patient started on hydralazine, furosemide, isosorbide mononitrite at the same time. Hydralazine was held at is was believed to be likely culprit, and rash improved. He was started on 14 day course of betamethasone steroid cream, per derm. #Ulceration of aortic arch #Aortic dissection Found on CT in ED. Cardiac surgery was consulted and recommended medical management with blood pressure control with systolic blood pressures < 120 mmHg. This should be continued as ___ outpatient. # Anemia Stable between ___ without any further acute drops. No evidence for hemolysis or active bleeding at this time. CHRONIC ISSUES: =============== #AF ___ BiV-ICD: Patient continued home metoprolol, as above, and will be able to continue apixaban for anticoagulation. He has a BiV-ICD in place. Transitional Issues: ==================== [ ] Persistent hyperkalemia while inpatient, please follow at next appointment (lab slip provided on discharge). [ ] Patient with elevated transaminases during admission. Improving on discharge. Please follow with repeat LFTs at PCP ___ [ ] Follow up hepatitis B viral load (to r/o active Hep B infection). Currently pending in OMR. [ ] Due to prior hepatitis B infection, patient may benefit from fibroscan. [ ] Follow weights to ensure proper diuretic dose on furosemide 10 mg qD [ ] Follow blood pressures to ensure adequate afterload reduction (ideally systolic < 120 mmHg), previously intolerant to ACE inhibitors (and hyperkalemic) thus not initiated on discharge [ ] Discuss with patient whether or not to inactivate ICD given DNR/DNI code status Cr: 2.5 Wt: 45.4 kg CODE STATUS: DNR/DNI CONTACT: ___ Relationship: Daughter Phone number: ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO DAILY 2. Metoprolol Succinate XL 50 mg PO DAILY 3. Rosuvastatin Calcium 20 mg PO QPM 4. ipratropium bromide 0.03 % nasal Other 5. Loratadine 10 mg PO DAILY 6. Mirtazapine 45 mg PO QHS 7. Digoxin 0.25 mg PO DAILY 8. Colchicine 0.6 mg PO TID:PRN joint pain 9. Apixaban 2.5 mg PO BID 10. Aspirin 81 mg PO DAILY Discharge Medications: 1. Betamethasone Dipro 0.05% Oint 1 Appl TP BID RX *betamethasone dipropionate 0.05 % Apply to affected areas (not on face, groin, axilla) twice a day Refills:*0 2. Furosemide 10 mg PO DAILY RX *furosemide 20 mg 0.5 (One half) tablet(s) by mouth once a day Disp #*15 Tablet Refills:*3 3. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY RX *isosorbide mononitrate 30 mg 3 tablet(s) by mouth once a day Disp #*90 Tablet Refills:*3 4. Multivitamins W/minerals 1 TAB PO DAILY RX *multivitamin,tx-minerals [Multi-Vitamin HP/Minerals] 1 capsule(s) by mouth once a day Disp #*30 Capsule Refills:*12 5. Allopurinol ___ mg PO DAILY RX *allopurinol ___ mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 6. Apixaban 2.5 mg PO BID RX *apixaban [Eliquis] 2.5 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 7. Aspirin 81 mg PO DAILY RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 8. ipratropium bromide 0.03 % nasal Other RX *ipratropium bromide 21 mcg (0.03 %) 1 spray nasal once a day Disp #*1 Spray Refills:*0 9. Loratadine 10 mg PO DAILY RX *loratadine [Claritin] 10 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 10. Metoprolol Succinate XL 50 mg PO DAILY RX *metoprolol succinate 50 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 11. Mirtazapine 45 mg PO QHS RX *mirtazapine 45 mg 1 tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*0 12. Rosuvastatin Calcium 20 mg PO QPM RX *rosuvastatin 20 mg 1 tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*0 13.Outpatient Lab Work ICD 10 N17.9: acute kidney injury R74.0 transaminitis Please obtain CMP, lytes, and LFTs (ALT/ALT/LDH/TBili/Albumin) and provide to outpatient PCP ___ ___ Fax ___. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: Acute Decompensated Systolic Heart Failure Non-ST Elevation MI Secondary: Acute Kidney Injury Transaminitis Hyperkalemia Atrial fibrillation 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 ___ because you had a small heart attack. You had extra fluid that caused weight gain. This is called heart failure. While you were here we gave you a medication to help you urinate more and remove fluid. What to do when you go home: * Please weigh yourself every daily. Do this in the morning after you go to the bathroom and before you get dressed. * If your weight goes up by more than 3 lbs in 1 day or more than 5 lbs in 3 days, please call your heart doctor or your primary care doctor and alert them to this change. * We have made changes to your medication list, so please make sure to take your medications as listed below * You will also need to have close follow up with your heart doctor and your primary care doctor. It was a pleasure to take care of you. We wish you the best with your health! Your ___ Cardiac Care Team Followup Instructions: ___

10010231-DS-28

DS

2118-05-09 00:00:00

2118-05-09 18:40:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: febrile neutropenia Major Surgical or Invasive Procedure: POC removal ___ History of Present Illness: HPI: ___ with history of AML on HiDAC C4D13 presenting to the ED with fever and submandibular swelling. The patient reports he had a small "bump" under his chin for over a week. This morning he awoke and found the bump had dramatically enlarged, became tender to touch, and he developed fevers. He then presented to the hospital. He denies CP, SOB, N/V/D, abdominal pain. In the ED: VS: T 102.9 | HR120 | BP 137/87 | 20 | 100% RA His evam was notable for: Small pustule on R scalp, palpable fluctuant 3cm diameter ? abscess in submandibular region. Labs Notable for WBC 0.1, HGB of 8.4 and plt of 14. Also sodium of 131. He was given: 13:22 IVF NS 14:19 PO Acetaminophen 1000 mg 14:37 IV Vancomycin 16:21 IV CefePIME 2 g On the floor, he arrived in stable condition, still febrile and confirmed the above story Past Medical History: Past Medical History: Other than his malignancy, he has no medical conditions. Past Onc History: Initial presentation of AML on ___ to ___, transferred to ___ for Leukocyotosis with blastsand Bone marrow confirmed. Bone marrow biopsy confirmed acute myeloid leukemia, t(8;21), RUNX1/RUNX1T1 rearrangement. Patient was started on 7+3 on ___. Day 14 bone marrow with aplasia but persistent t(8;21) in 40% of cells per karyotype and RUNX1/RUNX1T1 rearrangement in 16% per FISH. Decision was made not to re-induce. Day 21 bone marrow on ___ was with no morphologic or cytogenetic evidence of residual disease. Treatment History: - ___: 7+3 - ___: BMB with ___ - ___: C1D1 HiDAC - ___: C2D1 HiDAC - ___: C3D1 HiDAC - ___: C4D1 HiDAC Social History: ___ Family History: Both mother and father died of old age. He denies any family history of malignancy or blood disorders. Physical Exam: Admission Physical Exam: Vitals: 98.8 | PO 130/69 | 87 | 18 | 100% RA Gen: Pleasant, calm HEENT: No conjunctival pallor. No icterus. MMM. OP clear. NECK: 2cm fluctuant nodule in left submandibular region with small central lesion. No JVP appreciated. LYMPH: No cervical or supraclav LAD CV: Normocardic, regular. Normal S1,S2. No MRG. LUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi. ABD: NABS. Soft, NT, ND. EXT: WWP. No ___ edema. SKIN: No rashes/lesions, petechiae/purpura ecchymoses other than noted above NEURO: A&Ox3. LINES: Left Portacath heparin dependent Discharge Physical Exam: VS: TC 97.7 ___ 94-99%RA Gen: pleasant & conversant, NAD. HEENT: No conjunctival pallor. No icterus. MMM. OP clear. NECK: submandibular swelling and erythema resolved. No fluctuance or tenderness appreciated. CV: Normocardic, regular. Normal S1/S2. No MRG. LUNGS: No increased WOB. CTAB. ABD: +BS, soft, NT/ND EXT: WWP. No ___ edema. SKIN: Except as described above. No other petechiae/purpura ecchymoses. NEURO: A&Ox3, grossly non-focal Pertinent Results: ADMISSION LABS: ___ 09:00AM BLOOD WBC-0.2*# RBC-2.51* Hgb-8.5* Hct-24.4* MCV-97 MCH-33.9* MCHC-34.8 RDW-15.9* RDWSD-56.5* Plt Ct-10*# ___ 09:00AM BLOOD Neuts-23* Bands-0 Lymphs-75* Monos-0 Eos-1 Baso-1 ___ Myelos-0 AbsNeut-0.05* AbsLymp-0.15* AbsMono-0.00* AbsEos-0.00* AbsBaso-0.00* ___ 09:00AM BLOOD UreaN-14 Creat-0.7 Na-134 K-4.0 Cl-101 HCO3-24 AnGap-13 ___ 09:00AM BLOOD ALT-99* AST-41* AlkPhos-85 TotBili-0.4 ___ 09:00AM BLOOD Calcium-9.0 Phos-2.7 Mg-1.9 Microbiology: ___ 1:15 pm BLOOD CULTURE positive x2 **FINAL REPORT ___ Blood Culture, Routine (Final ___: STAPH AUREUS COAG +. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML ________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN-------------<=0.25 S TRIMETHOPRIM/SULFA---- <=0.5 S Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN CLUSTERS. Reported to and read back by ___ ___ (___), @11:10 ON ___. IMAGING: ___ CT Neck IMPRESSION: 1. There are a few prominent, though nonenlarged, cervical lymph nodes. 1 of which may correspond to the clinical area of concern, but is not pathologically enlarged or necrotic. No mass or abscess is identified. 2. Mild, nonspecific soft tissue stranding in the subcutaneous tissues inferior to the chin. 3. Moderate mucosal thickening in the left maxillary sinus. ___ CT Neck IMPRESSION: 1. Left greater than right submental subcutaneous edema, consistent with known cellulitis in this area, demonstrates mild progression compared to 3 days earlier on ___. No free fluid or abscess. 2. Multiple small right upper lobe lung nodules measuring up to 5 mm are new compared ___. In the setting of bacteremia, these may represent septic emboli. Atypical infection may also be considered as the patient is neutropenic (Nocardia, etc). 3. Moderate polypoid mucosal thickening in the left maxillary sinus with occlusion of the left ostiomeatal unit and a mucous retention cyst in the right maxillary sinus, similar to prior. Given the small periapical lucency involving ___ 14 or 15, as detailed above, please correlate clinically whether there may be odontogenic etiology of sinus disease. ___ CT Chest IMPRESSION: 1. Numerous bilateral pulmonary nodules appear increased in number at least in the upper lobes since the prior neck CT and favor infectious etiology, likely fungal in the setting of febrile neutropenia. Correlate with clinical assessment. If the patient's symptoms persist despite treatment, consider repeat Chest CT in ___ weeks to reevaluate. 2. Anemia. 3. Minimal colonic diverticulosis. ___ US Neck IMPRESSION: 1. No drainable fluid collection. No abnormal lymph nodes. 2. Mild skin thickening and subcutaneous edema of the submental area, consistent with patient's known cellulitis. ___ MANDIBLE PANOREX IMPRESSION: No periapical lucency. ___ LIVER U/S IMPRESSION: Echogenic liver consistent with steatosis. Other forms of liver disease including steatohepatitis, hepatic fibrosis, or cirrhosis cannot be excluded on this examination. Unchanged from prior. CT CHEST ___ IMPRESSION: Multiple scattered pulmonary nodules are minimally decreased in size as compared to chest CT ___. No new pulmonary nodules identified. DISCHARGE LABS: ___ 08:15AM BLOOD WBC-2.8* RBC-2.80* Hgb-9.4* Hct-28.3* MCV-101* MCH-33.6* MCHC-33.2 RDW-20.9* RDWSD-76.9* Plt ___ ___ 08:15AM BLOOD Neuts-42.9 ___ Monos-25.9* Eos-0.4* Baso-0.7 NRBC-1.4* Im ___ AbsNeut-1.21* AbsLymp-0.83* AbsMono-0.73 AbsEos-0.01* AbsBaso-0.02 ___ 08:15AM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-1+ Macrocy-1+ Microcy-NORMAL Polychr-1+ Ovalocy-1+ Schisto-1+ Tear Dr-1+ ___ 08:15AM BLOOD Plt Smr-NORMAL Plt ___ ___ 08:15AM BLOOD Glucose-103* UreaN-6 Creat-0.8 Na-140 K-4.2 Cl-103 HCO3-28 AnGap-13 ___ 08:15AM BLOOD ALT-51* AST-58* LD(LDH)-204 AlkPhos-82 TotBili-0.3 ___ 08:15AM BLOOD Albumin-3.8 Calcium-9.0 Phos-3.9 Mg-2.1 ___ 08:15AM BLOOD Brief Hospital Course: ASSESSMENT/PLAN: Mr. ___ is a ___ year old male with AML s/p C4 of HiDAC (___) who presents with febrile neutropenia found to have MSSA bacteremia and new pulmonary nodules. C4D38 ___ #Febrile Neutropenia: #MSSA bacteremia: Likely source is skin and soft tissue infection from an ingrown hair/folliculitis. MSSA growing from first set of blood cultures on ___, was on vancomycin and meropenem but narrowed to cefazolin x 4 week course from POC removal (___). Patient has completed mandatory 2 weeks course of IV ABX with cefazolin in-house with NTD surveillance cultures. However, given concern for medical contraindication for central line access to provide intravenous antibiotics at home, we recommend changing from cefazolin to linezolid PO as there is no better alternative for patient. Patient transitioned to linezolid on ___ and will continue until ___ -surveillance cultures have been negative to date as above. -CT Neck negative for abscess -TTE no significant findings -ID consulted, recs appreciated--felt more comfortable tx as endovascular infection for extended course, per ___ team will treat 4 week course from POC removal (___) - Chest CT concerning for fungal infection, see below - F/U panorex for abscess - negative - F/U b-glucan/galactomannan - negative on ___, see below for repeat on ___ #Lung Nodules: concerning for fungal infection, found incidentally on neck CT that were new and worsening on repeat imaging. Patient was switched from fluconazole to posaconazole on ___ given these findings. However, due to elevated LFTs, discontinued posaconazole (___) which was thought to be the likely culprit as well as ciprofloxacin. Per ID, patient will require repeat CT chest in 4 weeks to monitor nodules but may obtain earlier per primary oncologist. Repeat CT chest on ___ showed multiple scattered pulmonary nodules that are minimally decreased in size as compared to chest CT ___. Although no new pulmonary nodules were identified, patient now has elevated BD glucan and given his AML, he is at a high risk for fungal PNA so initiated on voriconazole (d1: ___ with plan to follow up radiographically as above. He will likely need a 6WK course. -Beta glucan 61 on ___ (was negative on ___ -Asp galactomannan negative on ___ #Transaminitis: (improving). Thought to be secondary to medication-effect (posaconazole likely culprit which was discontinued on ___. Liver ultrasound on ___ showed echogenic liver consistent with steatosis. Other forms of liver disease including steatohepatitis, hepatic fibrosis, or cirrhosis cannot be excluded on this examination. Hep serologies were unremarkable on ___. Re-consulted ID on ___ in light of worsening transaminitis to consider switch from cefazolin to vancomycin. ID thinks that his transaminitis is potentially from posaconazole which has been discontinued, as above, and would not expect his LFTs to plateau until ___ days after discontinuing the offending agent. We will continue to monitor and trend LFTs closely particularly given initiation of voriconaozle. #AML on HiDAC: s/p 4C of HIDAC. Patient counts now recovered, continue with Acyclovir 400mg BID prophylactically. #Pancytopenia: now recovered although noted some mild downtrending of his WBC and ANC, etiology most likely secondary to chemotherapy. He had a positive hemoocult test on ___ and ___. Repeat CBC/COAGS stable. Coombs negative. Will need GI consult for further work-up -stopped filgrastim ___ -Singulair 10mg daily for history or mild urticarial reaction to plts transfusions #ACCESS: POC removed. No access. #CODE: Presumed Full #Contact: ___ #DISPO: Discharged ___. RTC next week on ___ or ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q12H 2. Pantoprazole 40 mg PO Q24H 3. Simethicone 40-80 mg PO QID:PRN gas pains 4. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES TID 5. Ciprofloxacin HCl 500 mg PO Q12H 6. Fluconazole 400 mg PO Q24H 7. Montelukast 10 mg PO DAILY Discharge Medications: 1. Linezolid ___ mg PO Q12H you will continue this medication until ___ RX *linezolid ___ mg 1 tablet(s) by mouth twice a day Disp #*30 Tablet Refills:*0 2. Voriconazole 200 mg PO Q12H 3. Acyclovir 400 mg PO Q12H 4. Montelukast 10 mg PO DAILY 5. Pantoprazole 40 mg PO Q24H 6. Simethicone 40-80 mg PO QID:PRN gas pains Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Febrile Neutrapenia MSSA Bacteremia Peripheral Pulmonary Nodules Secondary Diagnosis: AML Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. ___, You were admitted due to fever when your blood counts were very low. You were found to have a blood infection and you were treated with IV antibiotics. Your fever has now resolved so we transitioned you to an oral regimen of antibiotics with plan of completing on ___. Please refer below for your appointment with Dr. ___ ___ was a pleasure taking care of you. Sincerely Your ___ TEAM Followup Instructions: ___

10010393-DS-5

DS

2136-07-02 00:00:00

2136-07-02 21:27:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Topamax / Reglan Attending: ___. Chief Complaint: Urinary retention, pain at intrathecal pump catheter site Major Surgical or Invasive Procedure: None History of Present Illness: This is a ___ year old woman with history of pudendal neuralgia s/p intrathecal pump placement in ___ and with ongoing narcotic use, hypothyroidism and history of an arrhythmia who presents with pain at the site of her intrathecal pain pump catheter and urinary retention, transferred from ___ for rule-out of cord compression. Patient has had several years of pain so disabling that she "has not been able to get out of bed for ___ years." She trialed many different pain regimens (see pain management notes from this institution) and ultimately was seen by a pain management physician in ___ for placement of an intrathecal pain pump in ___. Since then, she has been able to get out of bed on at least two occasions, though her pain is only moderately improved. This week she developed new back pain at the site of the pump's insertion and urinary retention. Also with one episode of fecal incontinence in the setting of new nausea, vomiting X ___ yesterday and multiple episodes of watery diarrhea over the past week. No other incontinence during this time. No fevers, chills, chest pain, shortness of breath, melena, BRBPR. Given the pain at the insertion site, she presented to ___ ___ where she was reportedly neurologically stable and a CT with IV contrast was unremarkable. She was bladder scanned there for 800 cc urine, Foley was placed and she put out 1200cc urine. Required 4mg IV dilaudid for pain control. She was then transferred to ___ to rule out cord compression given pain and new urinary retention. Upon arrival to the floor, she complains the light is bothering her eyes. She also details the history above. REVIEW OF SYSTEMS: Per HPI. Denies headache, visual changes, cough, fevers, chills, dyspnea, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, dysuria, rash and weakness. Past Medical History: HYPOTHYROIDISM ARRHYTHMIA PUDENDAL IMPINGEMENT SYNDROME s/p INTRATHECAL PUMP PLACEMENT SOMATIZATION DISORDER Social History: ___ Family History: No cardiac or cancer history in either parent. Mother and sister with depression. Physical Exam: ADMISSION PHYSICAL EXAM: VITALS: 97.9F 113/68 76 18 96% on RA GENERAL: no acute distress, lying in bed HEENT: NC/AT, no scleral icterus, PERRLA, EOMI NECK: supple CARDIAC: RRR, normal S1/S2, no murmurs PULMONARY: clear to auscultation bilaterally ABDOMEN: normal bowel sounds, soft, non-tender, non-distended EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or edema. Mild tenderness to palpation over lumbar incision site where pump catheter is. NEUROLOGIC: A&Ox3, CN II-XII grossly normal, strength normal and symmetric in the bilateral UE and ___ DISCHARGE PHYSICAL EXAM: VITALS: 98.3F 116/85 77 18 97% on RA GENERAL: no acute distress, lying in bed HEENT: NC/AT, no scleral icterus, PERRLA, EOMI NECK: supple CARDIAC: RRR, normal S1/S2, no murmurs PULMONARY: clear to auscultation bilaterally ABDOMEN: normal bowel sounds, soft, non-tender, non-distended EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or edema NEUROLOGIC: A&Ox3, CN II-XII grossly normal, strength normal and symmetric in the bilateral UE and ___ Pertinent Results: ADMISSION LABS: ___ 12:20AM BLOOD WBC-3.2* RBC-3.84* Hgb-11.5 Hct-33.4* MCV-87 MCH-29.9 MCHC-34.4 RDW-12.2 RDWSD-38.7 Plt ___ ___ 12:20AM BLOOD Neuts-28.9* Lymphs-56.1* Monos-12.5 Eos-1.6 Baso-0.9 AbsNeut-0.93* AbsLymp-1.80 AbsMono-0.40 AbsEos-0.05 AbsBaso-0.03 ___ 12:20AM BLOOD Glucose-96 UreaN-10 Creat-0.7 Na-142 K-3.9 Cl-107 HCO3-27 AnGap-12 ___ 12:20AM BLOOD CK(CPK)-80 ___ 12:49AM URINE Type-RANDOM Color-Yellow Appear-Clear Sp ___ ___ 12:49AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-1 pH-6.5 Leuks-NEG ___ 12:49AM URINE RBC-4* WBC-1 Bacteri-FEW Yeast-NONE Epi-0 ___ 12:49AM URINE Mucous-RARE ___ 12:14PM STOOL NoroGI-NEGATIVE NoroGII-NEGATIVE DISCHARGE LABS: ___ 05:52AM BLOOD WBC-2.7* RBC-3.65* Hgb-10.9* Hct-31.7* MCV-87 MCH-29.9 MCHC-34.4 RDW-12.2 RDWSD-38.8 Plt ___ MICROBIOLOGY: **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. **FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO FOUND. FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA FOUND. FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___: NO E.COLI 0157:H7 FOUND. ECG Study Date of ___ 7:51:52 AM Clinical indication for EKG: ___.___ - QT interval for medication monitoring Sinus rhythm. Normal tracing. Read by: ___. Intervals Axes Rate PR QRS QT QTc (___) P QRS T 83 ___ 426 54 63 55 IMAGING: SECOND OPINION READ OF CT (___) L-SPINE FINDINGS: There is normal alignment of the lumbar spine. Mild ligamentum flavum thickening is seen at L3-4, L4-5 and L5-S1. No significant spinal canal or neural foraminal stenosis is seen. There is no acute fracture or malalignment. There is an intrathecal catheter which courses from the pump, which is not visualized, through the left subcutaneous soft tissues of the back, between the L2-3 spinous process and into the thecal sac. Two linear hyperdensities are noted within the soft tissues at the level of the L3 spinous process, consistent with surgical sutures. Minimal stranding is noted within the posterior soft tissues, at the level of the L3 spinous process, likely secondary to postsurgical changes. No fluid collection or soft tissue mass is identified along the course of the catheter. The catheter extends from the through the T11- L2 spinal canal. No discontinuity is noted in the visualized catheter. A fluid-filled distended bladder is seen. Multiple sub cm hypodensities are noted in the kidneys, which are too small to characterize and likely represent simple cysts. IMPRESSION: 1. Minimal soft tissue stranding in the posterior soft tissues of the back, at the L2-3 level, consistent with postsurgical changes. No fluid collection or abscess identified along the course of the visualized catheter. Brief Hospital Course: ___ with chronic pudendal impingement syndrome s/p intrathecal pump for ziconotide infusion who was admitted for acute urinary retention and pain at intrathecal pump catheter site. #Acute urinary retention - Timing seems to coincide with recent increase in ziconotide dose on ___. ___ Pain service was consulted and recommended decreasing the ziconotide dose 20%, to previous dose. However, ___ Pain service only has equipment for ___ pumps and were not able to interrogate or adjust the Flowonix Prometra pump, which the patient has. Administrative approval was obtained for Pentec, the company who manages patient's pump in the outpatient setting, to provide services as inpatient. Given delay in ability of pump service agency to provide adjustment in the inpatient setting, patient was discharged with Foley catheter with plan for decrease in ziconotide dose as an outpatient, followed by Foley removal and voiding trial. #Acute pain over intrathecal pump catheter site - Developed over the ___ weeks prior to admission. CT L spine revealed no signs of infection. However, where catheter bends and overlaps the L2 spinous process is quite superficial and had some mild surrounding inflammatory stranding of the soft tissue. Per ___ Pain Service, this inflammation could be causing the pain. Pressure on the site over time from supine position (patient spends most of her time in bed due to debilitating pain) could explain the timing of the pain 6 months after pump was placed. The pain was partially relieved by lidocaine patches. Patient was discharged with lidocaine ointment and Voltaren gel. Dr. ___ at the ___ in ___, who placed the pump, was contacted by phone on ___ regarding this issue, and did not feel the catheter was causing the pain but was willing to see the patient in followup. He recommended that the patient find a local pain specialist in ___ who could manage the pump and the ziconotide but was unable to provide a referral to a specific specialist. ___ Pain was also unable to provide this referral as the Flowonix brand of intrathecal pumps is essentially never used in the ___ of ___. Patient will contact the vendor to request a referral to an appropriate local provider. #Chronic low back pain and pelvic pain: Patient has been debilitated by this pain for several years despite multiple procedures. Her current narcotics are managed by Dr. ___ ___ in ___ and her pump is managed by Dr. ___ ___ in ___. She was continued on her home pain regimen, which was confirmed per phone conversation with Dr. ___ on ___, with the exception of substituting regular release hydromorphone for her extended release hydromorphone due to it being non-formulary at ___. #Orthostatic hypotension: Pt had been having loose stools and decreased PO intake, likely due to a viral gastroenteritis. She was also on higher doses of hydromorphone at the beginning of the hospitalization for acute on chronic pain. The orthostasis resolved with IV fluids, weaning of narcotics, and improvement in her gastroenteritis. Stool studies were negative for infectious source. CHRONIC ISSUES: #HYPOTHYROIDISM: Continued levothyroxine. #HX OF HTN/CARDIAC ARRHYTHMIA: Continued home Verapamil. #PSYCH: Continued home medications. TRANSITIONAL ISSUES: - Patient will require routine Foley care - Voiding trial to be performed after intrathecal ziconotide dose is decreased by 20%. If no void within 8 hours, seek urgent medical attention. - Patient will require ongoing followup with pain specialist and evaluation of intrathecal pump catheter incision site. - Patient had mild leukopenia (WBC 2.8) and anemia (Hgb ___ that was stable during this admission. Consider outpatient workup. - Consider routine periodic monitoring of CK levels while patient is on ziconotide. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. HYDROmorphone (Dilaudid) 4 mg PO Q8H:PRN PAIN 2. LORazepam 1 mg PO Q4H:PRN anxiety 3. Methadone 5 mg PO TID 4. DULoxetine 60 mg PO BID 5. Pregabalin ___ mg PO DAILY 6. NexIUM (esomeprazole magnesium) 40 mg oral DAILY 7. Levothyroxine Sodium 137 mcg PO DAILY 8. Vitamin D ___ UNIT PO 1X/WEEK (WE) 9. BusPIRone 15 mg PO TID 10. Lidocaine 5% Ointment 1 Appl TP ONCE ASDIR 11. Tizanidine 2 mg PO TID 12. TraZODone 150 mg PO QHS:PRN insomnia 13. Verapamil SR 120 mg PO Q24H 14. Polyethylene Glycol 17 g PO DAILY 15. Ranitidine 300 mg PO QHS 16. Ondansetron 4 mg PO Q8H:PRN nausea 17. Dilaudid (HYDROmorphone) 16 mg oral QAM 18. ziconotide 8.01 mcg/day injection INFUSION Discharge Medications: 1. BusPIRone 15 mg PO TID 2. HYDROmorphone (Dilaudid) 4 mg PO Q8H:PRN PAIN 3. Levothyroxine Sodium 137 mcg PO DAILY 4. LORazepam 1 mg PO Q4H:PRN anxiety 5. Methadone 5 mg PO TID 6. Ondansetron 4 mg PO Q8H:PRN nausea 7. Polyethylene Glycol 17 g PO DAILY 8. Pregabalin ___ mg PO DAILY 9. Ranitidine 300 mg PO QHS 10. Tizanidine 2 mg PO TID 11. TraZODone 150 mg PO QHS:PRN insomnia 12. Verapamil SR 120 mg PO Q24H Do not take this medication if your systolic blood pressure in the morning is below 100. 13. DULoxetine 60 mg PO BID 14. Lidocaine 5% Ointment 1 Appl TP ONCE ASDIR 15. NexIUM (esomeprazole magnesium) 40 mg oral DAILY 16. Vitamin D ___ UNIT PO 1X/WEEK (WE) 17. HYDROmorphone (Dilaudid) (HYDROmorphone) 16 mg ORAL QAM 18. Voltaren (diclofenac sodium) 1 % topical QID:PRN pain RX *diclofenac sodium [Voltaren] 1 % Apply to painful site of lower back 4 times per day Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSES: Acute urinary retention Acute viral gastroenteritis SECONDARY DIAGNOSES: Postsurgical pain of incision site Chronic pudendal impingement syndrome Hypothyroidism Unspecified cardiac arrhythmia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to ___ for urinary retention and pain over your intrathecal pump catheter incision site. We believe the urinary retention was due to the recent increase in the ziconotide dose running through your pump. We were able to get administrative approval for the company who adjusts your pump settings to come provide their services in the inpatient setting, however they are able to visit you in your home to adjust the settings sooner. You will have additional nursing services to care for your new Foley catheter. Once your ziconotide dose is decreased, the Foley catheter should be removed to allow a trial of urination. If you are still unable to urinate, you should return to the hospital immediately. Our radiologists and pain specialists reviewed the CT images of your lumbar spine and we believe that the pain you are experiencing is due to the superficial placement of the pump catheter, which has some mild inflammatory changes around it. Please continue lidocaine ointment or patches and Voltaren gel to relieve the pain in that area until you can see a pain specialist who can manage this type of intrathecal pump. It was a pleasure taking care of you. Best wishes, Your ___ Care Team Followup Instructions: ___

10010440-DS-5

DS

2173-08-19 00:00:00

2173-08-19 14:33:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: CODE CORD: Leg weakness, known T12 lesion Major Surgical or Invasive Procedure: 1. Anterior arthrodesis T11-L1. 2. Application interbody cage T11-L1. 3. Biopsy of T12 vertebral body. 4. Posterior arthrodesis T10-L2. 5. Posterolateral posterior instrumentation T10-L2 segmental. 6. Open treatment fracture dislocation from metastatic disease and destruction of the T12 vertebral body. 7. Laminectomy of partial L1, all of T12, and the inferior aspect of T11. 8. Application of allograft. ANESTHESIA: General endotracheal. History of Present Illness: History obtain largely from Daughter in law and PCP, ___ (___) History of Present Illness: This is a ___ yo ___ female with a history of a ___ secondary to an aneurysm with residual aphasia, HTN, and hyperlipidemia and recent work-up initiated for multiple myeloma who presents with leg weakness and multiple falls. Per the patient's daughter in law on ___ the patient had a bad fall at home where she lives with her son and daughter in law. She was down for 4 hours. She reported to her PCP that her "legs gave out". She was seen at ___ where she had plain films and a head CT that were normal. She received 6 weeks of home ___ and was doing fairly well. When that concluded though, she began a slow decline. She has had decreased appetite, a rapid 30 lbs weight loss and a few more falls. She complains of back pain and it is unclear whether pain or weakness has been the cause of her falls. She also became incontinent of urine, but not stool. Ultimately, 2 weeks ago when she could not even walk two steps she went back to the ED where Xrays were negative. She went to rehab. A CT was not done. At the nursing home rehab she continued to have pain and weakness with not much improvement. Last night the patient was much more quiet than usual. This AM she woke upset and in a lot of pain. She was screaming and refusing to take her medications. The daughter encouraged the rehab nursing home to send her to the ED. At the ___ ED she received a spine CT that revealed, "Findings consistent with multiple myeloma involving multiple levels and an associated mass arising from T12 extending into the canal and compressing the thecal sac significantly." Of note the patient can not have an MRI due to the aneurysm clips. A left toes fracture was also found on plain films. The patient was sent to ___ for further evaluation and treatment. In the ED now the patient is in some mild pain, but reports feeling ok. Of note a year ago the patient began a w/u for multiple myeloma. She had a biopsy done of the T12 lytic lesion that was inconclusive. She then had a bone marrow biopsy that revealed pre Kappa light chains, but no conclusive evidence of multiple myeloma. Review of systems: (+) Per HPI (-) Denies recent weight gain. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel habits. No dysuria. Denies arthralgias. Ten point review of systems is otherwise negative. On neuro ROS, No HA, visual aura. No loss of vision, lightheadedness, vertigo, diplopia, dizziness, dysarthria, dysphagia, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Weakness of ___. No numbness, parasthesiae. Bladder incontinence, but no bowel incontinence. Gait problems. Past Medical History: SAH, s/p b/l Aneurysm clipping. With frontal craniotomy. Residual aphasia. HTN Hyperlipidemia Right knee replacement VP shunt Social History: ___ Family History: Multiple family members, particularly cousins with brain aneurysms requiring clipping, some of who had strokes. No history of cancer in the family. Physical Exam: Vitals: T 98.2, HR 90, BP 106/72, RR 18, O2 99 % RA General: Awake, cooperative, in NAD. Obese. HEENT: NC/AT, no sclera icterus noted, MMM, no lesions noted in oropharynx Neck: Supple. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted. No carotid bruits Abdomen: soft, NT/ND Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented to place, person, and year with choices (difficult exam as the patient's motor aphasia prevents answers to multiple questions). Naming impaired, perseverative. Follows commands, but again requires some mimicking to reliably follow. Per PCP and daughter in law this is her cognitive baseline. -Cranial Nerves: I: Olfaction not tested. II: PERRL 2.5 b/l, sluggishly reactive. Visual fields are difficult to assess reliably. Appears to be some impairment in peripheral fields. 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. 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. No tremor or other adventitious movements. No asterixis noted. Nml finger tapping. Delt Bic Tri FFl FE IO IP Quad Ham TA ___ L 5 5 ___ 5 4- 4 ___- 3 R 5 5 ___ 5 2 4 4- 2 5- 5- -Sensory: Intact and symmetric sensation to light touch, temp and pinprick, although patient has some trouble understanding the questions. Normal rectal tone. - DTRs: Bi Tri ___ Pat Ach L 2 2 2 1 2 R 2 2 2 0* 2 Plantar response was extensor b/l. * Knee replacement -Coordination: No dysmetria on FNF. -Gait: Not assessed. Unable to sit or stand unassisted. Pertinent Results: ___ PATHOLOGY report from surgical resection (PRELIM): Bone, T12 vertebra, lytic lesion; Bone and fibrous tissue with dense plasma cell infiltrate, consistent with plasma cell dyscrasia, see note. ___ ANKLE (AP, LAT & OBLIQU) FINAL There are moderate degenerative changes of the tibiotalar joint with narrowing and subchondral sclerosis. There is evidence of prior avulsive injury arising off the medial malleolus and likely the lateral malleolus as well. There is chronic deformity of the lateral malleolus. No acute fracture is identified. There is calcaneal enthesopathy. Soft tissue swelling is noted. IMPRESSION: Moderate tibiotalar joint degenerative change. No acute fracture appreciated. ___ CT HEAD IMPRESSION: 1. No acute intracranial hemorrhage status post right craniotomy and aneurysm clipping. 2. Hyperdensity of the left posterior cerebral hemisphere not corresponding to vascular territory could conceivably represent retained contrast related to the patient's recent myelogram. Attention on followup is recommended. 3. Stable bifrontal encephalomalacia. 4. Unchanged position of a right parietal ventriculostomy catheter. ___ TECHNIQUE: Thoracolumbar spine, five views. FINDINGS: The patient is status post posterior fusion from T10 through L2 with a T12 corpectomy including placement of a vertical fusion spacer. Moderate-to-severe degenerative changes are incompletely characterized, but suspected, along the facet joints along the mid through lower lumbar spine. Small anterior osteophytes are present along the lower thoracic spine. There is no evidence for hardware loosening. A PICC line terminates in the upper right atrium. A ventriculoperitoneal shunt is also noted. IMPRESSION: Unremarkable post-operative appearance. ___ MRI SPINE IMPRESSION: Status post T12 corpectomy and T10-L2 fusion. Posterior and right-sided intraspinal fluid collection communicates through the laminectomy defect and causes anterior and left lateral displacement of the thecal sac. This leads to severe encroachment on the distal spinal cord. There are no findings to suggest tumor in this location. The signal intensity characteristics are typical of simple fluid, rather than hemorrhage. ___ 05:14AM BLOOD WBC-22.1* RBC-3.39* Hgb-10.2* Hct-30.8* MCV-91 MCH-30.2 MCHC-33.3 RDW-17.6* Plt ___ ___ 12:06PM BLOOD Neuts-83.9* Lymphs-8.5* Monos-7.3 Eos-0.2 Baso-0.1 ___ 05:14AM BLOOD Plt ___ ___ 06:45AM BLOOD ___ PTT-30.2 ___ ___ 05:49AM BLOOD Glucose-113* UreaN-27* Creat-0.9 Na-138 K-6.6* (HEMOLYZED FROM PICC - falsely elevated) Cl-106 HCO3-28 AnGap-11 ___ 04:10AM BLOOD ALT-16 AST-29 LD(LDH)-425* AlkPhos-60 TotBili-0.3 DirBili-0.1 IndBili-0.2 ___ 04:10AM BLOOD Hapto-422* ___ 9:01 pm URINE Source: Catheter. **FINAL REPORT ___ URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Brief Hospital Course: ___ w/ h/o of stroke ___ years ago with baseline of expressive aphasia and RLE weakness, although family claims that she can fully comprehend. Pt was found to have T12 mass concerning for malignancy in ___, however bx of mass and BM was inconclusive. She was asymptomatic at that time and family decided not to persue further work-up. Pt now p/w with a 2.5 month h/o of progressive weakness and recurrent falls unresponsive to ___, and weight loss from 250-->225. Pt had CT at OSH which demonstrated expanding lesion at T12 and was subsequently given 10mg IV dexamethasone and transfered to ___ for further management. Patient arrived on the floor afebrile and hemodynamically stable. Immediate neurology and neurosurgery consults were obtained. Her hospitalization course is as follows: # T12 lesion: Patient has profound lower extremity weakness bilaterally, some of which is baseline from her previous CVA. Her right sided neuro exam is notable for hyperreflexia and clonus which is likely left over from her distant stroke. She was continued on dexamethasone and ISS while on the high dose steroids. The patient was also given a TLSO brace for ambulation (although initially in too much pain to ambulate), and the head of her bed was kept at <45 degrees. She received a pre-op myelogram, consistent with an expanding T12 lesion from prior imaging. She was subsequently taken for decompression surgery by Ortho-Spine Team (s/p T10-L2 fusion, T12 Corpectomy) and transferred to the Ortho-Spine service for post-op management for two days. When she returned to the medicine service on POD2, the patient was unable to move her lower extremities bilaterally. Ortho-spine service indicated that the patient required additional pain control. After consult with Neuro-Onc, the patient was transitioned from dexamethasone 10mg Q8 hours to dexamethasone 4mg BID on POD4. She was transferred to the Neurology service for better management of her leg weakness. It was felt this was likely due to post-op pain and inability for her to express her pain level due to her aphasia. Her medications were titrated and she did better on a higher dose fentanyl patch with immediate release morphine and tylenol for breaththrough pain. Subsequently her leg movements improved on better pain control. She will require XRT for her other bony lesions, and will need to follow up in ___ clinic after XRT (to be arranged by XRT). # FED/GI: Patient was found to initially have very mild hypercalcemia on admission. She was NPO for procedure and started on maintenence fluids overnight however did not require agressive IVF. At the time of surgery, her hypercalcemia resolved. She was advanced to a dysphagia diet post-operatively and did well on that for the rest of her course. Electrolytes were stable with the exception of potassium which kept returning falsely elevated from hemolosis when drawn off her PICC. # Foot Fracture: The patient was found to have R foot fracture involving the base of the fifth proximal phalanx with extension to the fifth MTP joint. This was consistent with repeat imaging at ___. Her L foot and ankles were also imaged because the pt was complaining of additional pain, however, films did not reveal any additional acute fractures. The feet were vascularly intact. Orthopedics recommended a hard sole boot for when the patient became ambulatory, otherwise, no intervention necessary. # Pain: Patient was found in extreme pain when transfered back to medicine service on POD2. Unclear of origin as patient has difficulty communicating due to her aphasia. Patient's pain was controlled with standing acetaminophen, oxycodone, oxycontin, fentanyl patch and dilaudid IV PRN. The pain team was also consulted to help manage her pain. She was able to come off the oxycontin on a higher dose of fentanyl patch, and had PO ___ oxycodone and tylenol for break through pain. # Encephalopathy: On POD2, there was noted an increase in aphasia, and confusion, which was difficult to assess given baseline communication issues. HCHCT for acute bleed was negative. The Pt was afebrile and infectious work-up including UA was neg. Urine Ctx and blood ctx were negaitve for occult infection. Her mental status improved with better pain control. She got a little worse on ___ and was subsequently found to have a new UTI (E Coli), which improved after treating with first ceftriaxone and then Bactrim when sensitivies returned pan-sensitive. # Hct Drop: The patient Hct dropped from 32 on POD1-->22 on POD2, Hemavac drained only 185cc, pt responded appropriately to 2U PRBC. Unclear where bleed is. Patients Hct subsequent remained stable after transfusion. A T&L MRI revealed: "Posterior and right-sided intraspinal fluid collection communicates through the laminectomy defect and causes anterior and left lateral displacement of the thecal sac. This leads to severe encroachment on the distal spinal cord. There are no findings to suggest tumor in this location. The signal intensity characteristics are typical of simple fluid, rather than hemorrhage." Her Hct remained stable and the ultimate source of her Hct drop was never identified but felt to be possibly due to post-op hemolysis. The fluid collection was discussed with ortho spine service who felt it could be conservatively watched for now (likely just post-surgical changes). # History of Stroke: The patient was continued on home dose of aggrenox until the time of her surgery. When the patient was transfered back to Medicine on POD2, the aggrenox was held. It was restarted on ___ at the consent of orthopedics team. # HTN: The patient was continued on home dose of losartan, diltiazem and atenolol # HLD: The patient was continued on her home dose of pravastatin # ID: UTI discovered ___eveloped foul smelling urine and WBC bumped to 22 (but this was felt to partially be due to her dexamethasone as well). Treated with first Ceftriaxone, then Bactrim, and culture grew out pan-sensitive E Coli. # Access: Pt had a PICC line placed and confirmed in good position early on in her hopspitalization. Due to initial concerns with dysphagia and patient frequently spitting out her meds, we decided to keep her steroids IV to ensure she received this crucial medication post-operatively. Once she has started radiation therapy, however, the PICC may come out and the IV steroids may be converted to the PO form. Medications on Admission: Lasix 20 qd Pravastatin 80 qD Allopurinol ___ qD Colchicine PRN Aggrenox 25 BID Cozaar 50 qD Atenolol 25 BID Discharge Medications: 1. Atenolol 25 mg PO DAILY 2. Diltiazem Extended-Release 240 mg PO DAILY 3. Furosemide 20 mg PO DAILY 4. Losartan Potassium 50 mg PO DAILY 5. Pravastatin 80 mg PO DAILY 6. Acetaminophen 650 mg PO Q6H:PRN pain 7. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 8. Docusate Sodium 100 mg PO BID 9. Fentanyl Patch 50 mcg/h TD Q72H RX *fentanyl 50 mcg/hour place one patch on skin change every 72 hours Disp #*10 Transdermal Patch Refills:*0 10. Heparin 5000 UNIT SC TID 11. Heparin Flush (10 units/ml) 2 mL IV PRN line flush 12. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using REG Insulin 13. OxycoDONE (Immediate Release) 10 mg PO Q4H RX *oxycodone 10 mg 1 tablet(s) by mouth every 4 hours Disp #*120 Tablet Refills:*0 14. Polyethylene Glycol 17 g PO DAILY 15. Ranitidine 150 mg PO BID 16. Senna 1 TAB PO BID 17. Dipyridamole-Aspirin 1 CAP PO BID 18. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 2 Days 19. Allopurinol ___ mg PO DAILY 20. Dexamethasone 4 mg IV Q24H (may switch over to PO once radiation therapy starts) Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary diagnosis: T12 destruction spinal lesion - resected Secondary diagnosis: Post-surgical leg weakness, likely related to pain and deconditioning Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair - advance per ___ recs. TLSO brace to be worn with any and all attempts at ambulation. Discharge Instructions: You were admitted for surgery to remove a lesion in your thoracic spine, and then was transferred to the Neurology service for leg weakness after the surgery. This did get better with pain control and supportive care, and we did not find any othe reason for your new leg weakness. You likely have a condition called multiple myeloma. This will require radiation therapy for treatment, which have set up for you (see below). Followup Instructions: ___

10010440-DS-7

DS

2173-10-27 00:00:00

2173-10-27 21:06:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: altered mental status Major Surgical or Invasive Procedure: none History of Present Illness: Ms ___ is a ___ yo female patient with history of cognitive impairment after ruptured cerebral aneurysm, recent diagnosis of MM undergoing radiation treatment to lytic lesion to T12 vertebra who presents from her facility with altered mental status after she refused radiation treatment today. Per report, pt became increasingly agitated at her nursing home facility this afternoon, refused to go to radiation treatment so she was sectioned and sent to the ED for evaluation. On arrival the the ED, vitals were 97.7 65 133/67 18 100%. She was unable to say why she was in the emergency department. She denied any symptoms, including no chest pain, abdominal pain. No shortness of breath, cough, bladder or bowel symptoms. Her labs were notable for WBC 11.1, hct 32.5, cr 0.4, normal lytes. She had a UA with 10 WBC, no bacteria, small leuks, neg nit so she was given 1 dose of levaquin. Patient's daughter-in-law reports a more subacute decline in mental status, beginning most notably after her surgery in ___. She states that pt has been more agitated and confused since that surgery, though her symptoms have definitely worsened over the past few weeks to the point that her facility is having difficulty controlling her. Daughter-in-law has been told that pt's agitation is intermittently attributed to UTI, pneumonia, etc but she is frustrated that she does not feel that pt has improved at all despite treatment of multiple infections. In the past week, the patient has become physical with nursing staff. The daughter-in-law reports that pt has been hallucinating, seeing people and hearing voices over the past several weeks to months. Documentation from facility notes increasing paranoia. Psych was consulted at the facility and has been adjusting her seroquel dosing. It also appears that pt was treated for UTI recently with meropenem, last dose ___ with repeat culture from ___ at her facility negative. With regards to her MM, she has a long history of plasma cell disorder dating back to ___. Her evaluation at the time included bone marrow biopsy which showed ___ plasma cell, suboptimal core. FISH staining was negative for cytogenetic abnormalities, and since she had no other evidence of MM (no anemia, renal failure or hypercalcemia), she was managed with serial measurements of monoclonal proteins. However, in ___, pt suffered a fall and has been steadily declining since then with significant weight loss (at least 30 pounds), back pain, and urinary incontinence. She eventually had imaging that showed cord compression at the T12 level so she was transferred to ___ in ___, evaluated by neurology, neuro-onc and spine surgery and underwent T12 extracavitary corpectomy. Pathology showed plasma cells. MRI of C, T, L spine at the time also commented on marked heterogenous signal intensity which may be consistent with diffuse involvement of myeloma. Her post-op course was complicated by wound dehiscence necessitating surgical debridement and closure at the beginning of ___. Past Medical History: SAH, s/p b/l Aneurysm clipping. With frontal craniotomy. Residual aphasia. HTN Hyperlipidemia Right knee replacement VP shunt Multiple myeloma T12 extracavitary corpectomy for removal of tumor ___ Social History: ___ Family History: Multiple family members, particularly cousins with brain aneurysms requiring clipping, some of who had strokes. No history of cancer in the family. Physical Exam: ADMISSION PHYSICAL: Vitals- 97.6 144/79 69 20 100% RA General- Alert, no acute distress, interactive HEENT- Sclera anicteric, MMM, 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, palpable nodules on abdomen, likely due to heparin injections GU- no foley Ext- warm, well perfused, 2+ pulses, trace edema Neuro- pt unable to reliably follow commands, CN grossly intact, able to move all extremities antigravity except RLE (horizontal movement), A&O x 1 Skin: scattered echymoses on right arm and over abdomen, back with well healing surgical wound, no surrounding redness or drainage, no fluctuance, small area of ulceration on right coccyx, as well as superficial ulceration on buttocks bilaterally DISCHARGE PHYSICAL: Vitals- T 98 BP 120s/60s HR ___ RR 18 sat 100% RA General- Alert and more calm this AM. HEENT- Sclera anicteric. MMM. Neck- supple 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. multiple ecchymoses. GU- foley draining yellow urine Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- CNs2-12 grossly intact, moving all extremities symmetrically. AO to self only. Unable to follow commands or participate in full neuro exam. More calm this AM and responding appropriately to some questions. Skin - scattered echymoses on right arm and over abdomen, back with well healing surgical wound, no surrounding redness or drainage, no fluctuance, small area of ulceration on right coccyx, as well as superficial ulceration on buttocks bilaterally Pertinent Results: ADMISSION LABS: ___ 09:20PM BLOOD WBC-11.1* RBC-3.35* Hgb-10.5* Hct-32.5* MCV-97 MCH-31.4 MCHC-32.4 RDW-16.9* Plt ___ ___ 09:20PM BLOOD Neuts-70.9* ___ Monos-5.4 Eos-0.1 Baso-0.4 ___ 09:20PM BLOOD Glucose-79 UreaN-21* Creat-0.4 Na-138 K-4.7 Cl-106 HCO3-23 AnGap-14 ___ 07:20AM BLOOD ALT-18 AST-21 LD(LDH)-434* AlkPhos-51 TotBili-0.2 ___ 09:20PM BLOOD Calcium-8.8 Phos-2.8 Mg-1.9 ___ 09:20PM BLOOD VitB12-948* Folate-14.1 ___ 09:20PM BLOOD TSH-1.5 ___ 09:31PM BLOOD Lactate-1.8 ___ 07:20AM BLOOD PEP-AWAITING F IgG-625* IgA-372 IgM-37* IFE-PND MICRO: URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. PROTEUS MIRABILIS. QUANTITATION NOT AVAILABLE. PRESUMPTIVE IDENTIFICATION. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | PROTEUS MIRABILIS | | AMPICILLIN------------ =>32 R <=2 S AMPICILLIN/SULBACTAM-- =>32 R <=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 NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S <=4 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- =>16 R <=1 S CT HEAD ___: IMPRESSION: No acute intracranial process. No change from prior. CXR ___: Left basilar opacity potentially atelectasis given low ___ ___ ng volumes however infection cannot be excluded. MRI BRAIN ___: A localizer sequence was obtained. Two attempts at sagittal T1-weighted images were made, both degraded by patient's motion. The exam was subsequently discontinued because the patient was trying to climb off the table. No diagnostic information was obtained. Brief Hospital Course: ___ yo female with complicated past medical history who presents with subacute to acute altered mental status. . # encephalopathy: Per conversation with HCP, pt has not been herself since surgery in ___, though admittedly has gotten progressively worse since then and is now exhibiting aggressive behaviors at her facility, also concern for visual and auditory hallucinations, along with paranoia. Pt has had multiple medication changes recently, i.e. uptitrated seroquel, on and off antibiotics, also on narcotic pain medications. Pt also on steroids, which can cause AMS/psychosis. HCP also concerned that pt is depressed, which can certainly present as AMS in elderly. Neurology and psychiatry were consulted and both agreed encephalopathy likely ___ delirium and/or progression of underlying dementia +/- depression. CT negative for any acute processes. Given unlikely CNS infection or acute intracranial process given symptoms and time course held on LP and MRI. CXR negative. TSH, B12, folate all within normal limits. Oncology consulted and did not think CNS involvement of myeloma was likely (CNS myeloma extremely rare, especially in pt like Ms. ___ with limited disease burden). Per recommendations from neurology and psychiatry, we held her narcotics, increased seroquel to 25mg BID + 100mg qhs, and started her on citalopram 10mg daily. With permission from oncology and radiation oncology, we also initiated a decadron taper. Pt improved greatly with these measures. # UTI: Urine cx showed > 100,000 E coli sensitive to cipro and ceftriaxone, but not to bactrim. UCx also with unclear # of CFU of proteus. Attempted ceftriaxone IV, but pt would not tolerate IV. Now giving ceftriaxone IM. Chose to avoid cipro as this can worsen her encephalopathy. Pt to complete 5d course of CTX for complicated UTI to end on ___ # multiple myeloma: Pt received ___ tx of XRT today (___). Plan for 2 additional treatments, which have been scheduled. Pt will f/u with Dr. ___ in oncology re: initiation of chemotherapy. Family is aware that someone will need to accompany pt to appt with Dr. ___ to consent for chemo. # hyperglycemia: Secondary to decadron. Well controlled on sliding scale insulin with BG 115-175. # HTN: continued atenolol, diltiazem, losartan # HLD: continued statin # h/o CVA: continued aggrenox Transitional issues - UTI: on ceftriaxone IM as she could not tolerate maintaining an IV. E coli resistant to bactrim, sensitive to cipro but we avoided cipro as it could precipitate worsening encephalopathy. Pt should receive final dose ceftriaxone 1g IM in 2.1ml normal saline on ___ - encephalopathy: Increased quetiapine to 25mg BID during the day and 100mg qhs. Started pt on citalopram 10mg on ___. This can be increased to 20mg in one week. - multiple myeloma: Steroid taper. Pt received 3mg of decadron on ___ and will go to 2mg on ___. Dr ___ (___) should manage further tapering and management of decadron. Pt received ___ of 5 radiation treatments today (___). She should follow up with radiation oncology for remaining 2 treatments. She should also follow up with Dr. ___ at ___ listed below for initiation of chemotherapy. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atenolol 25 mg PO DAILY 2. Diltiazem Extended-Release 180 mg PO DAILY 3. Vitamin D 1000 UNIT PO BID 4. Multivitamins 1 TAB PO DAILY 5. Calcium Carbonate 500 mg PO BID 6. Heparin 5000 UNIT SC TID 7. Senna 2 TAB PO BID 8. Losartan Potassium 50 mg PO DAILY 9. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain 10. Polyethylene Glycol 17 g PO DAILY 11. Omeprazole 20 mg PO BID 12. Ferrous Sulfate 325 mg PO DAILY 13. Acetaminophen 650 mg PO Q6H:PRN pain or fever 14. Allopurinol ___ mg PO DAILY 15. Atorvastatin 20 mg PO DAILY 16. Dexamethasone 4 mg PO DAILY 17. Dipyridamole-Aspirin 1 CAP PO BID 18. OxycoDONE (Immediate Release) 5 mg PO BID 19. Ascorbic Acid ___ mg PO BID 20. Zinc Sulfate 220 mg PO DAILY 21. QUEtiapine Fumarate 50 mg PO QHS 22. QUEtiapine Fumarate 25 mg PO DAILY 23. Ondansetron 4 mg PO Q6H:PRN N/V 24. TraZODone 25 mg PO Q6H:PRN agitation 25. QUEtiapine Fumarate 25 mg PO TID:PRN agitation 26. HumaLOG (insulin lispro) 100 unit/mL Subcutaneous qACHS 27. TraZODone 25 mg PO HS 28. Acetaminophen 975 mg PO Q8H Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H Please transition to PRN when pain better controlled. 2. Allopurinol ___ mg PO DAILY 3. Ascorbic Acid ___ mg PO BID 4. Atenolol 25 mg PO DAILY hold for SBP < 100, HR < 55 5. Calcium Carbonate 500 mg PO BID 6. Diltiazem Extended-Release 180 mg PO DAILY hold if SBP < 100, HR < 55 7. Dipyridamole-Aspirin 1 CAP PO BID 8. Ferrous Sulfate 325 mg PO DAILY 9. Heparin 5000 UNIT SC TID 10. Losartan Potassium 50 mg PO DAILY hold for SBP < 100 11. Multivitamins 1 TAB PO DAILY 12. Omeprazole 20 mg PO BID 13. Polyethylene Glycol 17 g PO DAILY Hold for loose stool. 14. QUEtiapine Fumarate 100 mg PO QHS hold if sedated 15. QUEtiapine Fumarate 25 mg PO BID please give about 6 hours apart during the day as pt should receive 100mg qhs. hold if sedated 16. Senna 2 TAB PO BID Hold for loose stool. 17. Vitamin D 1000 UNIT PO BID 18. Zinc Sulfate 220 mg PO DAILY 19. CeftriaXONE 1 g IM DAILY please dilute in 2.1ml normal saline or 1% lidocaine if available. last dose should be given ___. Citalopram 10 mg PO DAILY Please uptitrate to 20mg daily if tolerated in 1wk (___) 21. Ondansetron 4 mg PO Q6H:PRN N/V 22. Atorvastatin 20 mg PO DAILY 23. Dexamethasone 2 mg PO DAILY Further management per Dr. ___. 24. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using REG Insulin Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary diagnosis: encephalopathy, urinary tract infection Secondary diagnoses: multiple myeloma hyperglycemia Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: Ms. ___, It was a pleasure taking care of you at ___. You were admitted for altered mental status and agitation. A CT head showed no evidence of a stroke or other acute changes. We attempted to obtain an MRI of the brain but you were not able to tolerate this. Neurology, oncology and psychiatry were consulted and all felt that your current mental status is either due to delirium (temporary confusion that is reversible) or a natural progression of your dementia. Delirium may be caused by steroids, recurrent urinary tract infections, or medication changes. As such, we began to taper your steroids. We also increased your dose of quetiapine and started you on anti-depressant called citalopram. For your multiple myeloma, please follow up with Dr. ___ at the appointment listed below for chemotherapy. You should be contacted at ___ House regarding completion of your radiation therapy. Followup Instructions: ___

10010920-DS-10

DS

2150-10-06 00:00:00

2150-10-07 20:55:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: All allergies / adverse drug reactions previously recorded have been deleted Attending: ___. Chief Complaint: rash, leg swelling Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ with no significant PMH who presents with rash and leg swelling. He is visiting from ___ and is Portugeuse speaking only. He got Tdap and MMR vaccines on ___ prior to coming to the ___ for a visit. Just prior to leaving ___, he noticed a rash on his neck that was pruritic and erythematous. He thought it was irritation from the hot weather and came to the ___ during the week of ___. The rash was progressing, so he went to ___ urgent care on ___. At that time, there was concern for viral xanthem and he was referred to dermatology. He saw Dr. ___ on ___ and due to concern for syphilis vs. measles-like syndrome, RPR was sent as was measles, mumps and rubella serology. Fluocinonide cream was prescribed for the leg swelling. Pt presented to the ED due to concern for worsening leg swelling. Echo ws negative for an acute cardiomyopathy. UA showed trace protein. Patient was admitted for further workup and for transaminitis. In the ED, initial vitals: 100.8 97 158/89 18 99% - Exam notable for: erythematous rash on neck, chest and groin - Labs notable for: ALT 126, AST 182, RPR + 1:64. Lactate 2.2 On arrival to the floor, pt reports no discomfort. Rash is nonpainful. Denies rhinorrhea, corrhyza or mucosal lesions. ROS: 11 point ROS is positive per HPI otherwise negative. Past Medical History: GERD Social History: ___ Family History: NC Physical Exam: ADMMISSION: =========== Vitals- 98.6 87 137/86 16 97% RA General- Alert, oriented, no acute distress HEENT- Sclerae anicteric, MMM, oropharynx clear Neck- supple, JVP not elevated, no LAD Lungs- CTAB no wheezes, rales, rhonchi CV- RRR, Nl S1, S2, No MRG Abdomen- soft, NT/ND bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- CNs2-12 intact, motor function grossly normal SKIN: erythematous papules on neck, behind ears, over scalp, chest and groin. Few scattered papules on back. One crusted lesion on R neck. DISCHARGE: ========== Vitals- 99.5, 98.7, 118/59, 93, 16, 99%RA General- Alert, oriented, no acute distress HEENT- Sclerae anicteric, MMM, oropharynx clear Neck- supple, JVP not elevated Lungs- CTAB no wheezes, rales, rhonchi CV- RRR, Nl S1, S2, No MRG Abdomen- soft, NT/ND bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- CNs2-12 intact, motor function grossly normal SKIN: erythematous papules on neck, behind ears, over scalp, chest and groin. Few scattered papules on back. One crusted lesion on R neck. Pertinent Results: ADMISSION: ========== ___ 02:45PM ALT(SGPT)-116* AST(SGOT)-96* LD(LDH)-206 ALK PHOS-96 TOT BILI-0.4 ___ 03:40AM URINE HOURS-RANDOM ___ 03:40AM URINE HOURS-RANDOM ___ 03:40AM URINE UHOLD-HOLD ___ 03:40AM URINE GR HOLD-HOLD ___ 03:40AM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 03:40AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG ___ 03:40AM URINE RBC-1 WBC-<1 BACTERIA-NONE YEAST-NONE EPI-<1 ___ 03:40AM URINE MUCOUS-RARE ___ 02:44AM LACTATE-2.2* K+-4.1 ___ 02:00AM GLUCOSE-116* UREA N-11 CREAT-0.8 SODIUM-131* POTASSIUM-7.3* CHLORIDE-98 TOTAL CO2-23 ANION GAP-17 ___ 02:00AM estGFR-Using this ___ 02:00AM ALT(SGPT)-126* AST(SGOT)-182* ALK PHOS-93 TOT BILI-0.3 ___ 02:00AM LIPASE-37 ___ 02:00AM proBNP-99* ___ 02:00AM TOT PROT-7.7 ALBUMIN-3.9 GLOBULIN-3.8 CALCIUM-9.5 PHOSPHATE-4.6* MAGNESIUM-2.0 ___ 02:00AM CRP-41.1* ___ 02:00AM WBC-10.0 RBC-4.37* HGB-13.4* HCT-41.1 MCV-94 MCH-30.7 MCHC-32.7 RDW-14.4 ___ 02:00AM NEUTS-73.4* LYMPHS-14.8* MONOS-5.6 EOS-5.4* BASOS-0.8 ___ 02:00AM PLT COUNT-315 DISCHARGE: ========== ___ 06:15AM BLOOD WBC-14.2* RBC-4.47* Hgb-13.7* Hct-41.7 MCV-93 MCH-30.6 MCHC-32.8 RDW-14.3 Plt ___ ___ 06:15AM BLOOD Glucose-101* UreaN-9 Creat-0.8 Na-137 K-4.3 Cl-101 HCO3-29 AnGap-11 ___ 06:15AM BLOOD ALT-108* AST-72* LD(LDH)-192 AlkPhos-105 TotBili-0.6 ___ 06:15AM BLOOD Calcium-8.8 Phos-4.5 Mg-1.9 ___ 02:00AM BLOOD HCV Ab-NEGATIVE ___ 04:45PM BLOOD HIV Ab-NEGATIVE ___ 02:00AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE ___ 10:03 am SEROLOGY/BLOOD RPR w/check for Prozone (Final ___: REACTIVE. Reference Range: Non-Reactive. QUANTITATIVE RPR (Final ___: REACTIVE AT A TITER OF 1:64. Reference Range: Non-Reactive. TREPONEMAL ANTIBODY TEST (Preliminary): SENT TO STATE. IMAGING: ======== ___ CXR FINDINGS: The lungs are well inflated and clear. The cardiomediastinal silhouette, hila contours, and pleural surfaces are normal. There is no pleural effusion or pneumothorax. IMPRESSION: No evidence of acute cardiopulmonary process. Brief Hospital Course: Mr. ___ is a ___ with no significant PMH who presents with rash and leg swelling. # Syphilis, leg swelling: In the setting of transaminitis, positive RPR, concerning for secondary syphilis. Leg swelling has unclear relation but began in this setting. He was treated with a test dose of penicillin 500mg on ___ and tolerated this without difficulty. He received 2.4 million units of penicillin IM on the morning of ___, was observed for several hours and then discharged home. FTA-abs are still pending at the ___ lab at the time of discharge. # Tachycardia: Had episode of tachycardia to 150s while ambulating, asymptomatic. Received 1 L NS with resolution. # GERD: continued omeprazole TRANSITIONAL ISSUES: -will be returning to ___, but will need follow up to ensure resolution of symptoms Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Omeprazole 20 mg PO DAILY 2. Fluocinonide 0.05% Cream 1 Appl TP BID Discharge Medications: 1. Fluocinonide 0.05% Cream 1 Appl TP BID 2. Omeprazole 20 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary: secondary syphilis Secondary: GERD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you during your hospitalization at ___. You were admitted with a rash and leg swelling. Your rash was found to be caused by syphilis infection. You were given a test dose of penicillin and treated with a full dose once you tolerated the test. Your leg swelling is of uncertain cause, but may be related to the syphilis. You should follow up with your doctor in ___. Make sure to use condoms when having sex as this will protect you against syphilis and other infections. Wishing you the best, Your ___ Care Team Followup Instructions: ___

10010997-DS-9

DS

2139-05-02 00:00:00

2139-05-07 15:37:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: R IF pain Major Surgical or Invasive Procedure: PROCEDURE: Irrigation, washout and debridement right index finger distal interphalangeal joint. History of Present Illness: ___ year-old right-hand dominant nurse at ___ with severe RA on methotrexate who underwent excision of distal right IF mass just proximal to eponychial fold concerning for mucus cyst on ___ at ___. She noted some drainage from the incision starting in the past ___, she had worsening pain therefore went to ___ earlier today where they cultured purulent discharge and GPCs in clusters and pairs were observed on gram stain, gave vancomycin and zosyn, and was superficially washed out and digital block performed for pain control. She was transferred to ___ for further management. She denies fevers or chills, only increasing pain, drainage, and swelling of the digit. Past Medical History: RA Social History: ___ Family History: non contributory Physical Exam: *** Pertinent Results: ___ 02:26PM WBC-8.9 RBC-3.94 HGB-12.5 HCT-37.7 MCV-96 MCH-31.7 MCHC-33.2 RDW-13.1 RDWSD-45.1 Brief Hospital Course: This is a delightful ___ female nurse ___ ___ who is on immunosuppressants for rheumatoid arthritis. She underwent excision of a draining mucous cyst by Dr. ___ ___ unfortunately she developed an infection at the surgical site. She was admitted to the hospital yesterday and underwent bedside I&D x2. The patient was formally admitted to hand service for ongoing observation as well as IV antibiotic treatment. She was placed on vancomycin and Unasyn. Her cultures from the OSH grew pan sensitive enterococcus and MSSA (resistant to b lactams) she was discharged on levofloxacin. She will follow up with Dr. ___ in clinic as scheduled. Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Levofloxacin Discharge Disposition: Home Discharge Diagnosis: R IF wound infection Discharge Condition: AVSS, AOx3 Discharge Instructions: You were admitted to the ED with a wound infection. Please follow this instructions for postoperative care: 1. Soak your wound four times daily in warm soapy water. After this, replace the dressing. 2. Take your antibiotics as prescribed 3. Only take narcotic pain medications for sever pain and do not drive while taking these medications Followup Instructions: ___

10011126-DS-22

DS

2155-11-24 00:00:00

2155-11-30 14:40:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Iodine-Iodine Containing Attending: ___. Chief Complaint: Fever Major Surgical or Invasive Procedure: none History of Present Illness: ___ with history of prostate cancer (s/p chemo on Thurday), recent aortic valve Enterococcus faecalis endocarditis, and chronic uteral stent with intermittent hematuria who presents with fevers. He underwent his first dose of chemo on ___ (___) as treatment of his prostate cancer. He was in his ususal state of health until last night, at which point he developed chills and sweats. He has also had some worsening abdominal pain. He denies any chest pain, cough, or shortness of breath. In the ___, initial vs were: 100.6 130 138/64 16 98% RA. Labs were remarkable for a very dirty UA and a lactate of 2.9. CT ABD/PEL showed moderate-severe left hydronephrosis despite left sided ureteral stent placement, as well as obstructing bladder mass at the UVJ junction on that side as well, and some stranding surrounding that left kidney. CXR normal. He was seen by urology while in the ___, who recommended admission to medicine for antibiotics and possible stent removal/exchange. ID was also consulted, and agreed with this plan. Of note, on admission to the ___ he triggered for tachycardia to the 130s. He was given 2L NS bolus, and his heart rate normalized. Additionally, he was started on vanc/cefepime, and given tylenol for fever. On the floor, he denies any fevers, chills, but had experienced these earlier today. He does endorse intermittent hematuria and dysuria, but none since two days ago. His highest fever today was 101.1. Past Medical History: CAD with single coronary artery stent around ___ HTN H/O atrial fibrillation developed during his recent hospitalization Osteoarthritis Hyprelipidemia DVT RUE hemoptysis on Coumadin peptic ulcer disease nephrolithiasis inguinal hernia repair Social History: ___ Family History: Mother: died of MI Father: lung cancer and diabetes, nephrolithiasis Physical Exam: ADMISSION PHYSICAL EXAM: Vitals:99.3, 117/76, 84, 20, 99%RA pain ___ General: NAD, pleasant HEENT: NC/AT, MMM Neck: supple CV: RRR, no M/R/G Lungs: CTAB Abdomen: +BS, soft/non-tender/non-distended. No rebound or guarding, no palpable masses GU: condom cath in place Neuro: A+Ox3, CN ___ grossly intact Skin: no rashes DISCHARGE PHYSICAL EXAM: *** *** *** Pertinent Results: ADMISSION LABS: ___ 10:50AM URINE BLOOD-LG NITRITE-POS PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-6.0 LEUK-LG ___ 10:38AM LACTATE-2.9* ___ 10:30AM GLUCOSE-161* UREA N-17 CREAT-0.8 SODIUM-139 POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-19* ANION GAP-24* ___ 10:30AM ALT(SGPT)-17 AST(SGOT)-39 ALK PHOS-184* TOT BILI-0.5 ___ 10:30AM LIPASE-21 ___ 10:30AM ALBUMIN-4.2 ___ 10:30AM WBC-6.5 RBC-3.64* HGB-11.4* HCT-32.0* MCV-88 MCH-31.2 MCHC-35.6* RDW-14.0 IMAGING: - CXR (___): IMPRESSION: No acute cardiopulmonary process. - CT ABD/PEL (___): Brief Hospital Course: ___ with history of prostate cancer (s/p chemo on ___ at OSH), recent aortic valve Enterococcus faecalis endocarditis, and chronic ureteral stent with intermittent hematuria who presents with fevers, likely pyelonephritis and now with Neutropenia. # Pyelonephritis/Sepsis from Urinary source: Resolved. Initially septic with UA indicative of UTI.Risk factors for pyelonephritis include chronic incontinence from prior TURP, bladder mass causing obstruction and hydronephrosis. Complicating matters is a left ureteral Double J stent, which will likely need to be removed and/or replaced. All culture data is negative so far (urine with mixed flora). Patient is currently neutropenic, however, has been afebrile and was not admitted with neutropenia and so will not treat as neutropenic fever . Vancomycin and Cefepime discontinued ___ and now on ciprofloxacin monotherapy which he was discharged on to complete 14 day course. . # Neutropenia: Related to recent chemotherapy, currently C1D7 and so likely reached nadir and now uptrending. He is afebrile and doing well with PO Cipro to cover Pyelonephritis. Received neupogen ___, will receive dose on ___ at ___. - Neupogen 480mcg SC x5days (___) #Back Pain: likely combination of chronic back pain. received oxycodone x1, already receiving lidocaine patch, will add tramadol. -lidocaine patch -tramadol -consider muscle relaxant, already on lorazepam qhs # Prostate Cancer: Pt has now undergone first cycle of chemo on ___. He had previously been trialed on Zytiga, but failed this, as his PSA rose substantially despite therapy. Per the patient, on last check on ___ his PSA was 100 (had previously been ___. At this time he was started on chemo. Discussed case with outpatient Oncologist Dr. ___ and ___ on ___. # Prostate Cancer: Pt has a history of locally invasive prostate cancer with bladder mets, and has now undergone first cycle of chemo on ___. He had previously been trialed on Zytiga, but failed this, as his PSA rose substantially despite therapy. Per the patient, on last check on ___ his PSA was 100 (had previously been ___. CHRONIC ISSUES: # HTN: Continued lisinopril, metoprolol # A-fib: Rate well controlled. CHADS 2 score of 1. Continued aspirin, metoprolol. # CAD: Continue aspirin, metoprolol. # GERD: His home medication nexium is not on formulary, so he was treated with omeprazole instead. # Anxiety: Continued ativan home regimen. TRANSITIONAL ISSUES: -Pt should receive neupogen from his ___ provider -___ with outpatient PCP -___. diff assay was negative, patient notified over phone Medications on Admission: The Preadmission Medication list is accurate and complete. 1. clotrimazole *NF* 1 % Topical TID Apply to affected hands and foot 2. Lotrisone *NF* (clotrimazole-betamethasone) ___ % Topical QHS Apply to affected areas 3. NexIUM *NF* (esomeprazole magnesium) 20 mg Oral daily 4. Hydrocortisone Cream 1% 1 Appl TP BID apply to affected areas 5. Lisinopril 10 mg PO DAILY please hold for SBP<90 6. Lorazepam 0.5 mg PO QPM Please give at 1600. Please hold for RR<12 or sedation. 7. Lorazepam 2 mg PO HS Please give at 2355. Please hold for RR<12 or sedation 8. Metoprolol Succinate XL 100 mg PO DAILY Please hold for SBP<90, HR <60 9. Aspirin 325 mg PO DAILY 10. Docusate Sodium 100 mg PO BID please hold for loose stools 11. Lactinex *NF* (lactobacillus acidoph & bulgar) 1 million cell Oral TID 12. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Aspirin 325 mg PO DAILY 2. Lisinopril 10 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Lorazepam 0.5 mg PO QPM 5. Lorazepam 2 mg PO HS 6. Metoprolol Succinate XL 100 mg PO DAILY 7. Multivitamins 1 TAB PO DAILY 8. Ciprofloxacin HCl 500 mg PO Q12H Duration: 10 Days Last dose on ___ RX *ciprofloxacin 500 mg 1 tablet(s) by mouth q12 Disp #*20 Tablet Refills:*0 9. Lidocaine 5% Patch 1 PTCH TD DAILY RX *lidocaine 5 % (700 mg/patch) apply 1 patch to affected areas daily Disp #*10 Unit Refills:*0 10. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills:*0 11. clotrimazole *NF* 1 % Topical TID 12. Hydrocortisone Cream 1% 1 Appl TP BID 13. Lactinex *NF* (lactobacillus acidoph & bulgar) 1 million cell Oral TID 14. Lotrisone *NF* (clotrimazole-betamethasone) ___ % Topical QHS 15. NexIUM *NF* (esomeprazole magnesium) 20 mg Oral daily Discharge Disposition: Home Discharge Diagnosis: Primary: Urosepsis, pyelonephritis Secondary: prostate cancer, hypertension, atrial fibrillation, anxiety, gastroesophageal reflux disorder, hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you at ___ ___. You were admitted for evaluaion of your fevers. While you were here you were found to have an infection in your urine, which extended up to your left kidney. You were treated with antibiotics, and you improved. Additionally, you were seen by urology, who felt that your ureteral stent should be removed once you finish antibiotics. Your white blood cell count dropped so we started you on a medication called Neupogen. We spoke with Dr. ___ will see you in her clinic on ___ to receive your 4th dose of neupogen. Please continue to take antibiotics until ___. Please call your PCP or return to the hospital if you develop worsening abdominal pain, fevers, or bloody bowel movements. Followup Instructions: ___

10011126-DS-23

DS

2156-02-26 00:00:00

2156-03-07 20:37:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Iodine-Iodine Containing / Percocet / Statins-Hmg-Coa Reductase Inhibitors Attending: ___ Chief Complaint: nausea Major Surgical or Invasive Procedure: none History of Present Illness: ___ man whose PMH includes HTN, HL, CAD, atrial fibrillation, anxiety, GERD, low back pain, aortic valve endocarditis ___, and metastatic prostate cancer s/p brachytherapy, TURP, & ongoing chemotherapy (last dose ___, followed at ___, recently discharged (___) from ___ on levofloxacin for atypical pneumonia. Developed N/V over ___s dysuria, chronic urinary incontinence unchanged. Found to be hypotensive at BID-N. Labs notable for bandemia 15% & hypocalcemia, transferred here for further mgmt. CXR neg, UA showed UTI. Treating empirically with CTX pending urine cx. N/V improved with antiemetics so he tried clear liquids and tolerated well. He was hungry and wanted full liquids, which he also tried but later vomited. No abd pain or diarrhea but reports heartburn, notes he did not get his Nexium today. Quite anxious about his condition, worried about losing more weight. Has been ambulating comfortably, chronic back pain at baseline. Past Medical History: CAD with single coronary artery stent around ___ HTN H/O atrial fibrillation developed during his recent hospitalization Osteoarthritis Hyprelipidemia DVT RUE hemoptysis on Coumadin peptic ulcer disease nephrolithiasis inguinal hernia repair Social History: ___ Family History: Mother: died of MI Father: lung cancer and diabetes, nephrolithiasis Physical Exam: Admit: EXAM: VS afeb 112/66 ___ 100% RA GEN: NAD, well-appearing EYES: conjunctiva clear anicteric ENT: moist mucous membranes, few sm white plaques on buccal mucosa NECK: supple CV: RRR s1s2 II/VI SEM PULM: CTA GI: normal BS, ND, soft, nontender GU: erythematous patchy rash along shaft of penis EXT: warm, no ___ edema NEURO: alert, oriented x 3, answers ? appropriately, follows commands PSYCH: appropriate, pleasant ACCESS: PIV FOLEY: none DC XAM: VS afeb 104/62, 70, 95% RA GEN: NAD, well-appearing EYES: conjunctiva clear anicteric ENT: moist mucous membranes, few sm white plaques on buccal mucosa NECK: supple CV: RRR s1s2 II/VI SEM PULM: CTA GI: normal BS, ND, soft, nontender GU: erythematous patchy rash along shaft of penis with ulcerated lesion on foreskin over glans EXT: warm, no ___ edema NEURO: alert, oriented x 3, answers ? appropriately, follows commands PSYCH: appropriate, pleasant ACCESS: PIV FOLEY: none Pertinent Results: WBC RBC Hgb Hct MCV MCH MCHC RDW Plt ___ 06:40 3.5* 2.88* 8.6* 25.3* 88 30.0 34.2 15.8 29* ___ 06:50 3.1* 2.81* 8.6* 24.8* 88 30.6 34.6 16.1 32* ___ 10:30 4.6 2.84* 8.8* 25.5* 90 31.0 34.5 16.4* 38 UreaN Creat Na K Cl HCO3 AnGap ___ 06:50 8 0.4* 137 4.2 ___ ___ 10:30 15 0.5 138 3.7 ___ ___ 10:30AM BLOOD ALT-23 AST-39 LD(LDH)-706* AlkPhos-1621* TotBili-0.6 ___ 05:20AM URINE RBC-16* WBC-87* Bacteri-FEW Yeast-NONE Epi-1 TransE-<1 ___ CULTURE (Final ___: STAPHYLOCOCCUS, COAGULASE NEGATIVE. >100,000 ORGANISMS/ML.. COAG NEG STAPH does NOT require contact precautions, regardless of resistance. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE | GENTAMICIN------------ 8 I LEVOFLOXACIN---------- =>8 R NITROFURANTOIN-------- <=16 S OXACILLIN------------- =>4 R TETRACYCLINE---------- <=1 S VANCOMYCIN------------ 2 S RUQ US MPRESSION: 1. Multiple scattered isoechoic hepatic lesions, the largest in the right lobe measuring 2.0 cm, suspicious for metastases. Further evaluation with contrast-enhanced MR or multiphasic CTA is recommended. 2. Splenomegaly. 3. Unremarkable gallbladder without stones. 4. No evidence of abdominal aortic aneurysm. Brief Hospital Course: ___ was hypovolemic and nauseated in the context of a UTI for which culture grew S. Epi. He did well with ceftriaxone and was transitioned to cefpodoxime on discharge. He has macerated penis rash with some ulceration that needs careful skin care. We started miconazole for fungal superinfection and monitored his ability for self-care which was appropriate. We did attempt a foley to maintain a dry area however this was difficult and swiwftly aborted - it may reflect obstructive disease. As discussed previously, he does have liver metastases which is a new finding. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. NexIUM (esomeprazole magnesium) 40 mg Oral Daily 2. Lisinopril 10 mg PO DAILY 3. MethylPHENIDATE (Ritalin) 5 mg PO BID 4. Polyethylene Glycol 17 g PO DAILY 5. pramipexole 0.125 mg Oral QHS 6. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L.acidophilus-Bif. animalis;<br>L.rhamn ___ acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus combination no.4;<br>lactobacillus combo no.11) Dose is Unknown Oral BID 7. Senna 2 TAB PO BID 8. Multivitamins 1 TAB PO DAILY 9. TraZODone 50 mg PO HS:PRN insomnia 10. Acetaminophen 500 mg PO BID 11. Bisacodyl ___AILY:PRN constipation 12. Docusate Sodium 200 mg PO BID 13. Gabapentin 300 mg PO BID 14. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN pain 15. Metoprolol Tartrate 12.5 mg PO BID 16. Metoclopramide 10 mg PO TID 17. Morphine SR (MS ___ ___ mg PO Q8H pain 18. Citalopram 20 mg PO DAILY 19. Lorazepam 1 mg PO Q6H:PRN anxiety 20. OxycoDONE (Immediate Release) 10 mg PO Q3H:PRN pain Discharge Medications: 1. Acetaminophen 500 mg PO BID 2. Bisacodyl ___AILY:PRN constipation 3. Citalopram 20 mg PO DAILY 4. Docusate Sodium 200 mg PO BID 5. Gabapentin 300 mg PO BID 6. Lidocaine 5% Patch 2 PTCH TD DAILY:PRN pain 7. Lorazepam 1 mg PO Q6H:PRN anxiety 8. MethylPHENIDATE (Ritalin) 5 mg PO BID 9. Metoclopramide 10 mg PO TID 10. Metoprolol Tartrate 12.5 mg PO BID 11. Morphine SR (MS ___ ___ mg PO Q8H pain 12. pramipexole 0.125 mg Oral QHS 13. Senna 2 TAB PO BID 14. TraZODone 50 mg PO HS:PRN insomnia 15. Miconazole Powder 2% 1 Appl TP TID RX *miconazole nitrate [Miconazorb AF] 2 % Apply to penis three times a day Disp #*1 Unit Refills:*0 16. Nystatin Oral Suspension 5 mL PO QID RX *nystatin 100,000 unit/mL 5 mL by mouth four times a day Disp #*1 Unit Refills:*0 17. Lisinopril 10 mg PO DAILY 18. NexIUM (esomeprazole magnesium) 40 mg ORAL DAILY 19. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L.acidophilus-Bif. animalis;<br>L.rhamn ___ acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus combination no.4;<br>lactobacillus combo no.11) 0 unknown ORAL BID 20. Ondansetron 8 mg PO Q8H:PRN nausea RX *ondansetron [ZOFRAN ODT] 8 mg 1 tablet,disintegrating(s) by mouth q8 Disp #*45 Tablet Refills:*0 21. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 10 Days RX *cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp #*20 Tablet Refills:*0 22. Multivitamins 1 TAB PO DAILY 23. OxycoDONE (Immediate Release) 10 mg PO Q3H:PRN pain 24. Polyethylene Glycol 17 g PO DAILY 25. Phenazopyridine 100 mg PO TID Duration: 3 Days RX *phenazopyridine 100 mg 1 tablet(s) by mouth three times a day Disp #*9 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: # urinary tract infection # chemotherapy-induced nausea/vomiting # hypovolemia Secondary diagnoses: # prostate cancer with metastases to bone and probably liver # candidal rash # Penis ulcer # chemotherapy-induced thrombocytopenia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. ___, you were admitted with a urinary tract infection. You fared well with antibiotics. Nausea improved over the hospitalization and was somewhat worse in the setting of reflux. You have a penis rash with some ulceration that will need careful skin care - keep as clean dry as possible and use the new powder. Please resume all your previous medications. New medication: Cefpodoxime - continue until completed : Miconazole powder, apply to penis as directed : Zofran - use for nausea as needed : Nystatin swish - for thrush : Pyridium - for urinary burning Followup Instructions: ___

10011189-DS-12

DS

2188-02-26 00:00:00

2188-02-26 17:51:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Syncope, Visual Changes, Tinnitus Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo M ___ M with history of ?TIA, HTN, HLD, who presents with episodes of altered consciousness. Occurred ___ in the morning while sitting, he describes feeling out-of-body in that his perception was "off," and then his vision in both eyes narrowed circumferentially and then expanded. He sat down in a chair, and continued to have series of about 6 brief episodes of this. He then loses memory of what happened. Per sister, her other brother witnessed this and stated he was not speaking but remained sitting up without fall or convulsions, loss of bowel or bladder function. Directly prior to these episodes he could hear a "whooshing sound" in his ear. He recovered quickly from the events without any weakness numbness or balance issues. He does say his chest felt "tight" prior to the episodes. He did have palpitations, lightheadedness, chest pain, shortness of breath. He reports they also occurred about 4 months ago, and again 6 months prior to that. They did occur in the setting of poor PO intake and possibly taking an extra dose of his Amlodipine. There was no clear positional component to his symptoms. He denies melena, hematochezia. He does have a history of "ulcers" diagnosed 6 weeks ago in ___. He had an EGD there. He does not recall being told if he had H. pylori. He was put on several medications, he believes antibiotics for a total of 3 weeks to which he was compliant. also reports he intermittently notices blood on his toilet paper and that a lump extrudes at times when he strains when having bowel movements. He recently moved to ___ from ___ within the last two weeks. He is living with his sister. He used to drink heavily but has not had alcohol in "many years." He denies other drug use. He denies fevers, chills, nausea, diaphoresis, any recent cough, abdominal pain, shortness of breath. He denies dyspnea on exertion. In the ED, initial VS were: 98.1 67 115/70 19 100% RA Imaging showed: NCTH with no acute intracranial abnormality CXR wnl Neuro were consulted and recommended to admit to medicine for syncopal/cardiac work-up On arrival to the floor, patient reports he is feeling well. He is concerned that he had a small amount of blood on the toilet paper when having a bowel movement upon arrvial. He is very worried about this. He does strain when having bowel movements. Past Medical History: ? PUD Psoriasis HTN HLD ? TIA ? CAD ? "arrhythmia" Social History: ___ Family History: mother- uterine cancer father- kidney cancer maternal grandmother kidney cancer no family history of strokes or seizure Physical Exam: EXAM ON ADMISSION ====================== tele sinus, rates ___ VS: 96.4 AdultAxillary 91 / 58 60 18 94 Ra GENERAL: NAD, laying comfortably in bed. barrel-chested HEENT: AT/NC, EOMI, PERRL,pink conjunctiva, MMM NECK: no JVD HEART: Distant heart sounds, RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly Rectal: deferred per patient EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, CNII-XII, strength, sensation grossly intact SKIN: warm and well perfused, no excoriations. hyperpigmented patches to back. EXAM ON DISCHARGE =========================== Vitals: 98.0, 130/76, hr 64, RR 17, 97 Ra Telemetry: sinus with rates 50-60's General: Alert, oriented, no acute distress, well appearing HEENT: Sclerae anicteric, MMM, oropharynx clear Neck: supple, no LAD Lungs: normal WOB on room air CV: RRR, no murmur, no gallop Abdomen: soft, NT/ND Ext: warm, no edema Neuro: Moving all extremities. Able to walk the halls with a normal gait. Skin: No rash or lesion Pertinent Results: ADMISSION LABS ========================= ___ 03:14PM BLOOD WBC-6.3 RBC-4.38* Hgb-13.2* Hct-39.8* MCV-91 MCH-30.1 MCHC-33.2 RDW-12.3 RDWSD-40.7 Plt ___ ___ 03:14PM BLOOD Glucose-101* UreaN-13 Creat-0.7 Na-142 K-4.2 Cl-106 HCO3-20* AnGap-16 ___ 04:28PM BLOOD ___ PTT-31.1 ___ ___ 03:14PM BLOOD cTropnT-<0.01 ___ 05:28AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 03:14PM BLOOD CK(CPK)-102 ___ 05:28AM BLOOD ALT-27 AST-21 AlkPhos-96 TotBili-0.6 ___ 05:28AM BLOOD Calcium-8.7 Phos-4.6* Mg-2.3 ___ 03:14PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 04:34PM BLOOD Lactate-0.8 ___ 04:45PM URINE Blood-TR* Nitrite-NEG Protein-NEG Glucose-NEG Ketone-10* Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 04:50PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG DISCHARGE LABS =========================== ___ 05:12AM BLOOD WBC-5.5 RBC-4.40* Hgb-13.2* Hct-40.8 MCV-93 MCH-30.0 MCHC-32.4 RDW-12.3 RDWSD-42.5 Plt ___ ___ 05:12AM BLOOD Glucose-104* UreaN-16 Creat-0.8 Na-140 K-4.6 Cl-103 HCO3-27 AnGap-10 ___ 05:12AM BLOOD Calcium-9.1 Phos-4.4 Mg-2.3 Iron-115 MICROBIOLOGY =========================== ___ 4:45 pm URINE URINE CULTURE (Preliminary): GRAM POSITIVE BACTERIA. 10,000-100,000 CFU/mL REPORTS =========================== CTA Head and Neck ___ Right MCA aneurysm measuring 5 x 4 x 3 mm. The aneurysm has a slightly lobulated/irregular appearance. No significant ICA stenosis by NASCET criteria. There is poor opacification of the left vertebral artery at its origin, this may be secondary to its tortuous origin or be related stenosis. Rest of the vertebral arteries and basilar artery are widely patent with no significant stenosis. Lobular/tubular structure just posterior to the suprasternal notch which seems to connect to the left brachiocephalic vein which most likely represents an anomalous venous structure. However correlation with neck ultrasound is advised. NCCT Head ___ No acute intracranial abnormality. CXR ___ No acute cardiopulmonary abnormality. EEG ___ This is a normal awake and asleep EEG with no epileptiform discharges or features. EKG ___ Sinus Bradycardia Brief Hospital Course: ___ from ___, reported hx of possible CAD, possible hx of TIA, possible hx of "arrhythmia," HTN, HLD, who presented to the ED with transient episode of alteration in consciousness, visual changes, and tinnitus. He reports episodes of symptoms similar to this occurring about 6 months ago, and again a few months before that, while in ___. No etiology had previously been identified. On arrival to the floor, orhostatics were positive. He received IV fluid and Amlodipine was stopped. Even after stopping Amlodipine, blood pressures remained low-normal, so it was discontinued. He had a workup for this while in house, including telemetry monitoring (no tachy- or bradyarrthymia was seen), CT of the Head, EEG, and EKG, all of which were normal or unremarkable. Neurology was consulted in the Emergency Room, and recommended a CTA of the Head and Neck. This was negative for acute pathology in the posterior circulation to explain his presenting symptoms, but did show an incidental Right MCA aneurysm measuring 5 x 4 x 3 mm. He had no further symptoms or episodes while in house, and was feeling well on the day of discharge. Ultimately, given the lack of other etiology identified, his symptoms were felt to most likely be due to orthostatic hypotension in the setting of Amlodipine, but he will need further monitoring as an outpatient for recurrence of symptoms and consideration of further workup. CHRONIC ISSUES ======================== # HLD - Atorva 20mg daily # HTN - holding amlodipine given hypotension and positive orthostatics, as above # CAD (per report) - Aspirin 81mg # GERD - omeprazole 40mg daily TRANSITIONAL ISSUES ======================== [ ] NO HEALTH INSURANCE at the time of discharge. Patient is having ongoing discussions with the Financial Department at ___ for arranging insurance. Once insurance arranged, he will be contacted by ___ Health Care Associates and see Dr. ___ ___ in clinic [ ] have STOPPED Amlodipine given orthostatic hypotension on admission and normal BP's without it [ ] incidental Right MCA aneurysm measuring 5x4x3mm found on CTA of Head and Neck [ ] mild normocytic anemia with normal iron studies, B12, Folate. Follow up as outpatient. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 20 mg PO QPM 2. Aspirin 81 mg PO DAILY 3. amLODIPine 5 mg PO DAILY 4. Omeprazole 40 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 20 mg PO QPM 3. Omeprazole 40 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Syncope - likely from antihypertensive medication Incidental finding of R MCA Aneurysm Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. ___, It was a pleasure meeting you at ___. You were admitted to our hospital after developing dizziness, passing out, visual symptoms, and ear ringing. We did multiple tests. We found that your blood pressure was low, and for this we gave you IV fluids and stopped your Amlodipine. The EEG of the brain did not show any seizures. Your Head CT did not show anything to explain your symptoms. It did show a finding of an aneurysm in one of the arteries of your brain. This was NOT what was causing your symptoms, but you will need to follow up on this as an outpatient to for further monitoring. Please stop your Amlodipine, and continue your other medications. It was a pleasure, we wish you the best, ___ Medicine Team Followup Instructions: ___

10011427-DS-20

DS

2136-04-08 00:00:00

2136-04-09 18:12:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: optiflux dialyzer / lisinopril Attending: ___ Chief Complaint: Dislodged HD line Encephalopathy Sepsis Major Surgical or Invasive Procedure: ___ CVL Insertion Note History of Present Illness: HISTORY OF PRESENTING ILLNESS: =========================== Ms. ___ is a ___ year old F w/ EtOH cirrhosis complicated by hepatic encephalopathy, recurrent ascites with weekly large volume paracentesis, and hepatorenal syndrome on TuThSa HD who was transferred from ___ for a dislodged central line and imaging showing free air in the peritoneal space. She presented there after waking up with blood in her bed overnight. CXR showed air in her peritoneum. Her HD line was found to be dislodge and was removed. She was given vancomycin and cefepime and transferred to ___ for further evaluation. Of note, she was recently admitted to BI for altered mental status. It was felt that she had hepatic encephalopathy. Infectious workup was negative. She was started on lactulose and rifaximin with improvement in her mental status. She was also diagnosed with gout in her R ___ DIP and started on a prednisone taper. It was recommended that she go to rehab, but was discharge home with ___ on ___. In the ED, vitals were notable for hypotension with BPs in ___. Exam was notable for an unwell-appearing woman with bibasilar crackles, bilateral lower extremity edema, an abdominal fluid wave, asterixis, and disorientation. Labs were notable for hypotatremia, anemia, thrombocytopenia, and coagulopathy. CXR was normal. CT abd/pelvis showed "The air appears to communicates with an umbilical defect. No portal venous gas or pneumatosis to suggest bowel ischemia. In the setting of recent paracentesis and lack of convincing evidence of bowel ischemia, the pneumoperitoneum could be secondary to the paracentesis and less likely from bowel perforation. No acute processes." She was started on Zosyn and Flagyl. Transplant Surgery was consulted who had low suspicion for intraabdominal process. Hepatology recommended treatment with antibiotics, lactulose, and rifaxmin. They also recommended diagnostic paracentesis, which was not performed as there was reportedly no tappable pocket. Upon arrival to the floor, she feels well. She denies any fevers, chills, night sweats, headaches, N/V, diarrhea, black or red stools, abdominal pain, chest pain, easy bleeding, or confusion. She is unsure of her home medications. Past Medical History: - CV: HLD, HTN - GI: Esophageal stricture, GERD, Childs B EtOH Cirrhosis (MELD-Na 15) decompensated by encephalopathy, ascites - MSK: arthritis Past Surgical History - Appendectomy Social History: ___ Family History: - No family history of liver disease - Father had a cancer of unknown origin - Mother is in her ___ - No family history of liver disease - Father had a cancer of unknown origin - Mother is in her ___ Physical Exam: VS: 97.___ GENERAL: Chronically ill-appearing woman laying in bed. Alert and interactive in no acute distress HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM CHEST: HD line site C/D/I with line removed HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: soft, mild distention, non-tender, normoactive bowel sounds, +fluid wave EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ DP and radial pulses bilaterally NEURO: Alert and oriented to place, year, date; states month is ___. CN II-XII intact. Moving all 4 extremities with purpose, no asterixis SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ADMISSION Labs: ___ 09:05PM BLOOD WBC-10.8* RBC-2.51* Hgb-8.7* Hct-27.0* MCV-108* MCH-34.7* MCHC-32.2 RDW-20.1* RDWSD-79.3* Plt Ct-52* ___ 09:05PM BLOOD ___ PTT-30.4 ___ ___ 09:05PM BLOOD Glucose-133* UreaN-72* Creat-4.6*# Na-129* K-4.0 Cl-95* HCO3-16* AnGap-18 ___ 09:05PM BLOOD ALT-28 AST-33 AlkPhos-112* TotBili-1.5 ___ 09:05PM BLOOD Albumin-3.0* ___ 05:24AM BLOOD calTIBC-222* Ferritn-262* TRF-171* DISCHARGE Labs: ___ 06:13AM BLOOD WBC-5.8 RBC-2.68* Hgb-8.8* Hct-28.1* MCV-105* MCH-32.8* MCHC-31.3* RDW-23.2* RDWSD-88.3* Plt Ct-58* ___ 02:24AM BLOOD Neuts-83.4* Lymphs-9.0* Monos-6.7 Eos-0.0* Baso-0.2 NRBC-0.7* AbsNeut-3.35 AbsLymp-0.36* AbsMono-0.27 AbsEos-0.00* AbsBaso-0.01 ___ 06:13AM BLOOD Glucose-134* UreaN-35* Creat-4.5*# Na-135 K-3.9 Cl-96 HCO___ AnGap-16 MICROBIOLOGY: ___ 10:51 am BLOOD CULTURE Source: Venipuncture. **FINAL REPORT ___ Blood Culture, Routine (Final ___: ENTEROCOCCUS FAECIUM. Identification and susceptibility testing performed on culture # ___ (___). Aerobic Bottle Gram Stain (Final ___: Reported to and read back by ___. ___ ON ___ AT 0540. GRAM POSITIVE COCCI IN PAIRS AND CHAINS. Anaerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN PAIRS AND CHAINS. ___ 10:51 am BLOOD CULTURE Source: Line-tlcl. **FINAL REPORT ___ Blood Culture, Routine (Final ___: ENTEROCOCCUS FAECIUM. FINAL SENSITIVITIES. Daptomycin MIC OF 2 MCG/ML test result performed by Etest. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS FAECIUM | AMPICILLIN------------ =>32 R DAPTOMYCIN------------ S LINEZOLID------------- 2 S PENICILLIN G---------- =>64 R VANCOMYCIN------------ =>32 R HD Line Report ___: FINDINGS: Patent left internal jugular vein. Final fluoroscopic image showing catheter with tip terminating in the right atrium. INDICATION: ___ year old woman with etoh cirrhosis HRS on line holiday for vre bacteremia, needs ___ dialysis on ___, can she get line on ___ AM, thank you // can she get tunneled line in am of ___ for pm dialysis on ___, thanks FLUOROSCOPY TIME AND DOSE: 2:01 min, 7.7 mGy PROCEDURE: PROCEDURE DETAILS: Following the explanation of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the patient. The patient was then brought to the angiography suite and placed supine on the exam table. A pre-procedure time-out was performed per ___ protocol. The left upper chest was prepped and draped in the usual sterile fashion. Under continuous ultrasound guidance, the patent left internal jugular vein was compressible and accessed using a micropuncture needle. Permanent ultrasound images were obtained before and after intravenous access, which confirmed vein patency. Subsequently a Nitinol wire was passed into the right atrium using fluoroscopic guidance. The needle was exchanged for a micropuncture sheath. The Nitinol wire was removed and a short Amplatz wire was advanced to make appropriate measurements for catheter length. The wire was then passed distally into the IVC. Next, attention was turned towards creation of a tunnel over the upper anterior chest wall. After instilling superficial and deeper local anesthesia using lidocaine mixed with epinephrine, a small skin incision was made at the tunnel entry site. A 23cm tip-to-cuff length catheter was selected. The catheter was tunneled from the entry site towards the venotomy site from where it was brought out using a tunneling device. The venotomy tract was dilated using the introducer of the peel-away sheath supplied. Following this, the peel-away sheath was placed over the ___ wire through which the catheter was threaded into the right side of the heart with the tip in the right atrium. The sheath was then peeled away. The catheter was sutured in place with 0 silk sutures. Steri-strips were also used to close the venotomy incision site. Final spot fluoroscopic image demonstrating good alignment of the catheter and no kinking. The tip is in the right atrium. The catheter was flushed and both lumens were capped. Sterile dressings were applied. The patient tolerated the procedure well. FINDINGS: Patent left internal jugular vein. Final fluoroscopic image showing catheter with tip terminating in the right atrium. IMPRESSION: Successful placement of a 23cm tip-to-cuff length tunneled dialysis line. The tip of the catheter terminates in the right atrium. The catheter is ready for use. Brief Hospital Course: Ms. ___ is a ___ y/o female with a history of ETOH cirrhosis c/b HE, recurrent ascites with weekly large and hepatorenal syndrome on HD (___), undergoing transplant work up, who was transferred from ___ on ___ for a dislodged HD line that was removed, hospital course c/b encephalopathy, VRE bacteremia and concern for endocarditis. Patient was admitted to ___, at which time she was started on daptomycin. Repeat blood cultures were obtained, and the last positive blood culture was on ___ growing enterococcus that was resistant to vancomycin. The patient continued on IV therapy, and she was clinically improving, denying any fevers, chills, chest pain, palpitations, and throughout her hospitalization had no stigmata of endocarditis. The source of the infection was likely due to her HD line. ID was consulted, and the recommendations included continuing daptomycin, removing her HD line, and getting a TEE to determine the course of antibiotic therapy. The patient had her HD line removed, was on a line holiday, with replacement of her HD line 48 hours after removal. Patient had no issues with removal, blood cultures were persistently negative, and her TEE did not show any evidence of endocarditis. She was stable throughout her time in the hospital. The patient had initially NG tube placement, but prior to discharge given intolerance of NG tube the patient and care team elected to remove the NG tube. The patient tolerated oral feedings well, with the caveat that her nutrition will have to be closely monitored. Patient was discharged after her dialysis on ___, needing 2 additional doses of daptomycin for her VRE bacteremia. TI: VRE Bacteremia []last 2 dapto doses on ___ and ___ after HD Cirrhosis/transplant w/u []will need q6month HCC screening [] please schedule pt to have eval for fistula [] Continue to assess nutritional status and p.o. intake. Patient briefly on NG tube while in hospital. Patient did not want NG tube as outpatient. PCP: [] recheck vitamin d levels ACUTE ISSUES: ============== #Septic shock #VRE bacteremia, stable The patient was admitted with septic shock with VRE bacteremia with 4 out of 4 blood cultures positive, requiring norepinephrine/vasopressin. Patient was hemodynamically stable, and transferred to the floor. Her last blood culture was positive on ___ growing enterococcus resistant to vancomycin sensitive to daptomycin. The source of the infection was likely line infection although diarrheal illness was initially considered. TTE was initially performed with a possible vegetation, although later TEE was reassuring for no signs of endocarditis. ID was consulted this hospitalization and provided recommendations for infection management. She had a line holiday for her HD line, with replacement of her HD line on ___, for which she continue daptomycin with dialysis. Her CK levels were unremarkable. The patient was maintained on Midodrine. She was scheduled to complete 2 weeks of daptomycin treatment, with the last 2 courses to be infused via her midline as an outpatient. #Dislodged HD catheter #ESRD on ___ HD #Hepatorenal syndrome The patient had HD line placed upon arrival to the ICU, was stable on hemodialysis. She was maintained on midodrine, continued hemodialysis through her tunneled HD line, and was continued on her home Nephrocaps and sevelamer. #Encephalopathy, resolved The patient's encephalopathy was likely multifactorial although there was a large component from her VRE bacteremia. Encephalopathy improved with antibiotics and lactulose, the patient was awake and alert oriented x3 and did not have any asterixis on exam. Her mental status was stable over the course of his hospitalization. #ETOH Cirrhosis C/b HE, recurrent ascites with weekly large and hepatorenal syndrome on HD (___), undergoing transplant work up. MELD 27, Childs Class B. Currently decompensated by ascites. - V: Moderate ascites on exam. paracetensis on ___ removed 4.3 liters of fluid - I: VRE treatment as above, otherwise no new infections - B: No signs of acute bleeding, continued pantoprazole - E: None on exam. Continued rifaximin and lactulose - S: will need q6month ___ screening #Acute on chronic macrocytic anemia Baseline Hgb ___, downtrended <7 requiring 1u pRBC. OSH EGD in ___ showed no varices. No evidence of active bleeding. Likely multifactorial from chronic illness and cirrhosis. - Trended CBC - Continued home pantoprazole - Maintained active T&S - Transfused for Hgb <7 or HD instability #Concern for pneumoperitoneum Seen on outside hospital CXR. CT shows improvement in free air and tracking to umbilical deficit. Per Surgery and Radiology, most likely secondary to recent paracentesis. Abdominal exam has remained benign throughout her hospitalization. - Trended abdominal exam #Malnutrition - Nutrition consulted -The patient was initially on tube feeds while she was on the floor, she was tolerating p.o. intake well and her NG tube was DC'd the night prior to her discharge. The patient tolerated dinner and breakfast well. CHRONIC ISSUES: ================ #Thrombocytopenia Likely ___ underlying cirrhosis. # Vitamin D deficiency - Continued vitamin D supplements - Recheck vitamin D level as outpatient CORE MEASURES: # FEN: No IVF, replenish electrolytes, regular diet # PPX: Subcutaneous heparin (hold for plt <50), lactulose # ACCESS: PIV, HD line # CODE: Full code # CONTACT: ___ (Husband) ___ # DISPO: ET pending abx plan, TEE, line holiday Medications on Admission: 1. Vitamin B Complex w/C 1 TAB PO DAILY 2. FoLIC Acid 1 mg PO DAILY 3. Lactulose 30 mL PO TID 4. Midodrine 30 mg PO TID 5. Mirtazapine 15 mg PO DAILY 6. PredniSONE 10 mg PO DAILY 7. rifAXIMin 550 mg PO BID 8. sevelamer CARBONATE 800 mg PO TID W/MEALS 9. Thiamine 100 mg PO DAILY 10. Vitamin D ___ UNIT PO 1X/WEEK (___) 11. Simvastatin 20 mg PO QPM Discharge Medications: 1. Daptomycin 350 mg IV QTUTHUR (___) RX *daptomycin 350 mg 350 mg IV on ___ and ___ Disp #*2 Vial Refills:*0 2. Midodrine 25 mg PO Q6H 3. FoLIC Acid 1 mg PO DAILY 4. Lactulose 30 mL PO TID 5. Mirtazapine 15 mg PO DAILY 6. rifAXIMin 550 mg PO BID 7. sevelamer CARBONATE 800 mg PO TID W/MEALS 8. Simvastatin 20 mg PO QPM 9. Thiamine 100 mg PO DAILY 10. Vitamin B Complex w/C 1 TAB PO DAILY 11. Vitamin D ___ UNIT PO 1X/WEEK (___) Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: VRE bacteremia Dislodged HD catheter Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, You were admitted to the hospital because your dialysis line was dislodged, and you were found to have a bacterial infection. While you were in the hospital, you had IV antibiotics started, and your blood cultures eventually showed that there was no bacterial growth and you started to feel better. You also had a paracentesis performed to take fluid from your belly. WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? - You must never drink alcohol, and you should try to keep your liver as healthy as possible. See below for all our recommended strategies. - Please enroll in AA and work with your primary care doctor to determine the best strategy to help you stay sober - Take all of your medications as prescribed (listed below) - Keep your follow up appointments with your doctors - Weigh yourself every morning, before you eat or take your medications. Call your doctor if your weight changes by more than 3 pounds - Please stick to a low salt diet and monitor your fluid intake - If you experience any of the danger signs listed below please call your primary care doctor or come to the emergency department immediately. It was a pleasure participating in your care. Best wishes to you and your family. - Your ___ Care Team Followup Instructions: ___

10011466-DS-18

DS

2191-08-30 00:00:00

2191-08-31 20:49:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: morphine Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: This patient is a ___ year old male who complains of RIGHT SIDED ABDOMINAL PAIN. Patient presents with 2 days of right lower quadrant pain. Patient states noticed it while walking. Patient's noticed intermittent pain worsens. Patient had no relief with Pepto-Bismol. Patient denies fevers or chills. Patient reports some anorexia. Past Medical History: none Social History: ___ Family History: NC Physical Exam: PHYSICAL EXAMINATION: upon admission: ___ Temp: 97.8 HR: 90 BP: 124/86 Resp: 14 O(2)Sat: 100 Constitutional: Comfortable HEENT: Normocephalic, atraumatic Oropharynx within normal limits Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Right lower quadrant pain without Rovsing sign GU/Flank: No costovertebral angle tenderness Extr/Back: No cyanosis, clubbing or edema Skin: No rash, Warm and dry Neuro: Speech fluent Pertinent Results: ___ 06:10AM BLOOD WBC-8.9 RBC-5.59 Hgb-12.5* Hct-42.0 MCV-75* MCH-22.4* MCHC-29.8* RDW-14.2 Plt ___ ___ 10:43PM BLOOD WBC-6.6 RBC-5.71 Hgb-12.9* Hct-42.3 MCV-74* MCH-22.7* MCHC-30.6* RDW-14.3 Plt ___ ___ 06:10AM BLOOD Plt ___ ___ 10:43PM BLOOD Glucose-99 UreaN-13 Creat-1.0 Na-137 K-4.0 Cl-103 HCO3-22 AnGap-16 ___: US of appendix: ReportFINDINGS: Non-visualization of a normal or abnormal appendix. Several loops Preliminary Reportof peristalsing bowel are noted. ___: cat scan of abdomen and pelvis: Appendix demonstrates dilation of the midportion to 8 mm with tapering distally. No adjacent fat stranding, but air is not seen distal to the focal dilation. Acute appendicitis is improbable with these findings. Brief Hospital Course: The patient was admitted to the hospital with abdominal pain. Upon admission, he was made NPO, given intravenous fluids and underwent imaging. Cat scan imaging showed a large appendix with a maximum diameter of 8 mm and a small amount of fat stranding. The patient underwent serial abdominal examinations and his white blood cell count was closely monitored. As the patient's abdominal pain resolved, he was introduced to clear liquids and advanced to a regular diet. There was no recurrence of pain, nausea or vomiting. The patient's vital signs remained stable and he was afebrile. The patient was discharged home on HD #1 in stable condition. An appointment for follow-up was made with his primary care provider. Medications on Admission: none Discharge Medications: none Discharge Disposition: Home Discharge Diagnosis: abdominal pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital with right sided abdominal pain. You were placed on bowel rest. Your abdominal pain has slowly resolved. You are now 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. * Please resume all regular home medications and take any new meds as ordered. Followup Instructions: ___

10011668-DS-28

DS

2141-04-20 00:00:00

2141-04-20 21:36:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: lisinopril Attending: ___. Major Surgical or Invasive Procedure: Cardiac Catheterization ___ TEE ___ attach Pertinent Results: ADMISSION LABS ============== ___ 05:04PM BLOOD WBC-6.1 RBC-4.03 Hgb-12.3 Hct-38.0 MCV-94 MCH-30.5 MCHC-32.4 RDW-13.6 RDWSD-46.5* Plt ___ ___ 05:04PM BLOOD Neuts-62.5 ___ Monos-5.7 Eos-3.1 Baso-1.0 Im ___ AbsNeut-3.80 AbsLymp-1.64 AbsMono-0.35 AbsEos-0.19 AbsBaso-0.06 ___ 05:04PM BLOOD ___ PTT-36.0 ___ ___ 05:04PM BLOOD Glucose-84 UreaN-12 Creat-0.6 Na-141 K-5.0 Cl-104 HCO3-24 AnGap-13 ___ 10:07PM BLOOD ALT-16 AST-33 AlkPhos-99 TotBili-2.3* DirBili-0.4* IndBili-1.9 ___ 05:14AM BLOOD Calcium-9.4 Phos-4.7* Mg-1.7 OTHER PERTINENT LABS ==================== ___ 05:14AM BLOOD ___ ___ 05:42AM BLOOD ___ PTT-150* ___ ___ 04:55AM BLOOD ___ PTT-62.0* ___ ___ 05:03AM BLOOD ___ PTT-45.4* ___ ___ 05:05PM BLOOD ___ ___ 05:50AM BLOOD ___ PTT-105.1* ___ ___ 05:10AM BLOOD ___ ___ 05:14AM BLOOD LD(LDH)-452* ___ 05:04PM BLOOD cTropnT-0.19* ___ 08:29PM BLOOD CK-MB-9 cTropnT-0.25* ___ 10:07PM BLOOD CK-MB-7 cTropnT-0.29* ___ 05:14AM BLOOD CK-MB-5 cTropnT-0.16* ___ 05:19PM BLOOD CK-MB-3 cTropnT-0.06* ___ 05:14AM BLOOD Hapto-<10* ___ 05:42AM BLOOD CRP-4.0 ___ 06:16AM BLOOD SED RATE-Test DISCHARGE LABS =============== ___ 05:10AM BLOOD WBC-3.8* RBC-3.76* Hgb-11.6 Hct-36.0 MCV-96 MCH-30.9 MCHC-32.2 RDW-13.9 RDWSD-48.8* Plt ___ ___ 05:10AM BLOOD ___ ___ 05:10AM BLOOD Glucose-100 UreaN-19 Creat-0.8 Na-138 K-4.9 Cl-103 HCO3-24 AnGap-11 ___ 05:10AM BLOOD Calcium-9.3 Phos-3.5 Mg-1.9 MICRO ===== ___ 7:33 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. IMAGING ======= ___ CXR Moderate pulmonary vascular congestion/edema. More focal nodular opacity at the right lung base could be due to volume overload, but pulmonary nodule or consolidation is not excluded. Recommend repeat chest radiographs after diuresis. ___ TTE TTE ___. Probable large thrombus on the left atrial aspect of the bileaflet mitral valve adjacent to the posterior annulus with no significant mitral regurgitation and normal transvalvular gradients. Moderate global left ventricular hypokinesis. ___ TEE Normally functioning mechanical mitral prosthesis. No thrombus/mass. The interatrial septum is intact, but may have had prior repair or chairi attachments to the right atrial side of the septum (see clips ___. ___ Cardiac Cath No angiographically apparent coronary artery disease. Normal left-side filling pressures. Brief Hospital Course: TRANSITIONAL ISSUES =================== [ ] Discharge Weight: 71.9kg [ ] Discharge INR 2.6 [ ] Please repeat lab to check INR this week by ___, given lab script. [ ] Patient presented with atypical chest pain and NSTEMI, underwent LHC which showed no lesions. Her chest pain is quite atypical so she was trialed on GI cocktails and pain medications with little effect. She was ultimately trialed on Isurdil which strangely resolved her chest pain. She was discharged on Imdur. [ ] Patient presented with subtherapeutic INR. She was bridged with heparin and ultimately resumed her home warfarin regimen. INR seems to be labile as an outpatient. Please continue to monitor INR closely. [ ] Patient with TTE showing reduced EF 35-40% down from 60% in ___. She presented with fluid overload requiring IV diuresis. She was not transitioned to PO diuretics as she was euvolemic and not net positive without its addition. Advised patient to weigh herself daily. Please follow weights as patient may need addition of PO Lasix as an outpatient. BRIEF HOSPITAL COURSE ====================== Ms. ___ is a ___ woman with a history of mechanical mitral valve replacement(on Coumadin) in ___ rheumatic disease c/b MSSA endocarditis in ___, HTN, HLD, non-ischemic CM w/ EF 45%, and long-standing history of atypical chest pain, who presents with recurrent chest pain, also with evidence of volume overload and elevated troponins. In terms of chest pain, patient ultimately underwent LHC on ___ showing no lesions. She continued to have chest pain despite GI cocktail and pain regimen. She was trialed on Isurdil which actually resolved her pain. In terms of fluid overload, patient was treated with IV diuresis and discharged in euvolemic condition. In addition, patient's course was complicated by subtherapeutic INR and concern for mitral valve thrombus, however, TEE showed no thrombus and she was bridged with heparin to goal INR on discharge. CORONARIES: ___ clean coronaries/ ___ with clean coronaries. PUMP: EF 35-40% as of ___ RHYTHM: NSR =============== ACTIVE ISSUES: =============== #NSTEMI #Atypical Chest pain Patient has a longstanding history of atypical chest pain for which she has undergone previous work-up including diagnostic LHC in ___ showing clean coronaries and no obstructive CAD. Her ___ stress test revealed a poor exercise tolerance, resting hypertension, and a blunted blood pressure response, as well as a decrease in her heart rate (90s to ___ but no ischemic ECG changes or wall motion abnormalities were appreciated. Her current symptoms are consistent with prior presentations. EKG does show similar STD in lateral leads and TWI in V4-V6 which are stable compared to prior EKGs. However, the big difference is that she had significantly elevated troponins on admission trending up to 0.25 and since downtrending. Initially, this was thought to be possibly a type II MI iso decompensated heart failure but unusually high troponins and normal renal function. It was less likely a type I NSTEMI given such clean coronaries on LHC in ___. Now with TTE showing global hypokinesis, decreased EF to 35-40%. Therefore, patient underwent repeat LHC on ___ given continuing ___ chest pain which again showed no angiographically apparent coronary artery disease and normal left-side filling pressures. Patient failed GI cocktails and typical pain regimens. Therefore, she was trialed on Isurdil 10mg TID which did relieve her pain. This could represent microvascular changes given her history of rheumatic heart disease, however is still atypical. Will discharge on Imdur given its success and tolerance. #Heart Failure with Reduced Ejection Fraction (35-40%) #Hypoxemia Patient had a most recent EF of 45%, although repeat TTE in ___ stress echo showing recovered EF of 60%. Echo this admission showed EF of 35-40%. CXR showed moderate pulmonary vascular congestion also with BNP ___. Possible trigger was dietary indiscretion given high salt diet. Patient received IV diuresis. She was not transitioned to a standing oral regimen as she was improved to baseline euvolemic, not reaccumulating fluid off diuretics. Patient continued on home losartan and metoprolol. Patient euvolemic and saturating well on room air upon discharge. Weight on discharge 71.9kg. Please continue to monitor weights and volume exam. ___ need addition of loop diuretic in future. #History of Mitral Valve Replacement #Indirect Hyperbilirubinemia Patient has a mechanical bileaflet mitral valve replacement secondary to rheumatic mitral stenosis ___, later complicated by Staph aureus endocarditis ___ TR. Patient presented subtherapeutic on coumadin, INR 1.6 (goal 2.5-3.5). She has been subtherapeutic recently as an outpatient as well. Patient with positive hemolysis labs. TTE showed concern for MV thrombus, but TEE shows confirmed no thrombus. She was bridged with heparin until her INR was therapeutic and she was discharged on her home regimen. Please ensure INRs are checked regularly and warfarin dosing is titrated accordingly. ================ CHRONIC ISSUES: ================ #HLD Patient continued on home atorvastatin 80mg PO QPM #Depression Patient continued on home celexa 20mg PO QD. Please monitor QTc as was elevated at start of admission. QTc on discharge 449. # CODE STATUS: Full Code # CONTACT: Name of health care proxy: ___ Relationship: boyfriend Phone number: ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Warfarin 4 mg PO 6X/WEEK (___) 2. Warfarin 6 mg PO 1X/WEEK (___) 3. Atorvastatin 80 mg PO QPM 4. Metoprolol Succinate XL 300 mg PO DAILY 5. Losartan Potassium 50 mg PO DAILY 6. Citalopram 20 mg PO DAILY Discharge Medications: 1. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY RX *isosorbide mononitrate 30 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 2. Atorvastatin 80 mg PO QPM 3. Citalopram 20 mg PO DAILY 4. Losartan Potassium 50 mg PO DAILY 5. Metoprolol Succinate XL 300 mg PO DAILY 6. Warfarin 4 mg PO 6X/WEEK (___) 7. Warfarin 6 mg PO 1X/WEEK (___) 8.Outpatient Lab Work Z95.2 lab: INR when: any day between ___. Please fax results to ___ attn: ___ ___, MD Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES ================= Atypical Chest Pain Acute on Chronic Heart Failure with Reduced Ejection Fraction SECONDARY DIAGNOSES =================== Subtherapeutic INR with mechanical heart valve 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 privilege caring for you at ___. WHY WAS I IN THE HOSPITAL? - You had chest pain WHAT HAPPENED TO ME IN THE HOSPITAL? - You had imaging of your heart. - You were given medications for your chest pain - You had a procedure to look at your valve replacement better which was normal - You had a procedure to look at the blood vessels of your heart which was normal WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? -Please continue to take all of your medications and follow-up with your appointments as listed below. -Please weigh yourself every morning. Call your doctor if you gain more than 3 lbs in one day. We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___

10011938-DS-19

DS

2132-01-30 00:00:00

2132-01-31 16:46:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Seizure Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a ___ right-handed woman with a history of complex partial seizures was brought to the ED by EMS due to concern for seizure at home. She reports that her father passed away 2 weeks ago after a fairly lengthy illness. This is caused her a great deal of stress and other social difficulties. Since that time she has been having several episodes per day, which are of a new semiology for her. She describes these as follows: A feeling of swelling and numbness of the tongue, which is accompanied by difficulty forming words. She feels that she is able to think of the words she wants to say but is unable to get her mouth to produce them. She is able to understand people if they did speak to her. She feels quite certain that the tongue numbness/swelling as well as the difficulty speaking come on at the same time. Episodes last between 1 and 2 minutes, after which she is completely back to normal. Her husband has apparently seen his episodes, and there is no associated abnormal eye movements, oral or facial automatism, or abnormal movement of the limbs. She has had the episodes while seated, and has been able to maintain her posture; she is unsure if she is ever had them while standing. These episodes have been happening between 5 and 10 times per day for the last 2 weeks. She is unable to identify any particular triggers, and feels that they come on randomly. These episodes actually started at rehab, where she has been for the last several days after she tripped and fell and sustained a left ankle injury at home. Other than this, there have not been any recent changes to her medical status. She is not certain of the medicine she takes, but denies any changes in the doses or frequency of her antiseizure medications. Her medications are currently administered by visiting nurse. She reports that she was not sleeping very well at rehab, but denies any significant loss of sleep. She also denies any recent infections fevers, etc. Today, her visiting nurse apparently noted her to have one or more of these episodes, and recommended she be brought to the ED for evaluation. Regarding her seizure history, she has been followed by Dr. ___ quite some time. Seizure started in the ___. Her typical semiology consists of a visual aura of flashing lights, followed by a head deviation to the right lasting a minute or so. This is been followed by a postictal cry as well as difficulty speaking for several minutes. Apparently, there also sometimes strange behaviors such as starting to make a pot of coffee. She has never had a generalized seizure. Prior medications include Dilantin, which was stopped for unclear reasons. She is currently on a regimen of levetiracetam, phenobarbital, and lamotrigine which she reports she tolerates well. She feels like her last seizure was around ___ years ago. On neurologic review of systems, the patient denies headache, lightheadedness, or confusion. Denies loss of vision, blurred vision, diplopia, vertigo, tinnitus, hearing difficulty, dysarthria, or dysphagia. Denies focal muscle weakness, numbness, parasthesia. Denies loss of sensation. Denies 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: - COPD - Epilepsy, complex-partial; followed by Dr. ___ seizures characterized by head turn to the right with impaired ability to speak but maintains awareness; this lasts for ___ minutes, followed by emotional crying, and then headache and nausea. Last seizure was > ___ years ago. - AVM, Left frontal, s/p Proton beam radiation at ___ in ___ and again ___ - PCom aneurysm s/p clipping at ___ in ___ - HLD - Lumbar disc herniation, presented with left sciatic pain but none recently - Anemia (iron deficiency) - Eosinophilia Social History: ___ Family History: No family history of neurologic disease. Both parents had COPD. Father had colon cancer. Physical Exam: Admission Physical Examination: Vitals: T: 98.2 p: 79 R: 18 BP: 137/66 SaO2: 94% room air General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Breathing comfortably on room air Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND. Extremities: No ___ edema. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Spells WORLD backward as DLOW. 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 follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial Nerves: II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without nystagmus. Normal saccades. 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 IP Quad Ham TA Gastroc L 5- ___ ___- 5 5 5 5 R 5- ___ ___- 5 5 5 5 -Sensory: There is a circumferential, length dependent loss of pinprick and temperature sensation below the upper shin. No extinction to DSS. -DTRs: Bi Tri ___ Pat Ach L 1 1 1 0 0 R 1 1 1 0 0 Plantar response was mute bilaterally. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on finger to nose bilaterally. -Gait: Not tested ================================================= Discharge Physical Exam: 24 HR Data (last updated ___ @ 500) Temp: 97.3 (Tm 98.3), BP: 166/75 (119-166/72-80), HR: 64 (64-74), RR: 18 (___), O2 sat: 94% (94-97), O2 delivery: 2 L General: elderly woman lying comfortably in recliner, NAD HEENT: NC/AT, EEG leads in place Cardiac: warm, well-perfused Pulmonary: no increased work of breathing Abdomen: soft, ND Extremities: wwp, CAM boot on LLE Skin: no rashes or lesions noted. Neurologic: - Mental status: Awake, alert, oriented to self, ___, date. Able to relate history without difficulty. Attentive to interview. Speech is fluent with full sentences, intact repetition, and intact verbal comprehension. Naming intact. No paraphasias. No dysarthria. Normal prosody. No evidence of hemineglect. No left-right confusion. Able to follow both midline and appendicular commands. - Cranial Nerves: PERRL 4->2 brisk. EOMI, no nystagmus. V1-V3 without deficits to light touch bilaterally. No facial movement asymmetry. Hearing intact to voice. Trapezius strength ___ bilaterally. Tongue midline. - Motor: Normal bulk and tone. No drift. No tremor or asterixis. [Delt] [Bic] [Tri] [ECR] [FEx] [IP] [Quad] [Ham] [TA] [Gas] L 5 5 5 5 5 5 5 5 * * R 5 5 4- 5 5 5 5 5 3+ 5 L wrapped in dressing in CAM boot - Sensory: No deficits to light touch bilaterally. - Reflexes: deferred - Coordination: No dysmetria with finger to nose testing bilaterally. - Gait: unable to assess Pertinent Results: Admission Labs: ___ 05:59PM BLOOD WBC-9.8 RBC-3.65* Hgb-10.7* Hct-34.1 MCV-93 MCH-29.3 MCHC-31.4* RDW-13.9 RDWSD-47.3* Plt ___ ___ 05:59PM BLOOD Neuts-65.5 Lymphs-16.4* Monos-5.9 Eos-11.2* Baso-0.7 Im ___ AbsNeut-6.40* AbsLymp-1.61 AbsMono-0.58 AbsEos-1.10* AbsBaso-0.07 ___ 06:45PM BLOOD ___ PTT-28.4 ___ ___ 05:59PM BLOOD Glucose-87 UreaN-24* Creat-1.4* Na-139 K-4.8 Cl-100 HCO3-24 AnGap-15 ___ 05:59PM BLOOD ALT-6 AST-7 AlkPhos-160* TotBili-0.3 ___ 05:59PM BLOOD Calcium-9.5 Phos-4.3 Mg-2.0 Discharge Labs: ___ 06:00AM BLOOD WBC-9.9 RBC-3.23* Hgb-9.3* Hct-30.3* MCV-94 MCH-28.8 MCHC-30.7* RDW-13.4 RDWSD-46.5* Plt ___ ___ 06:00AM BLOOD ___ PTT-27.9 ___ ___ 09:39AM BLOOD Glucose-90 UreaN-32* Creat-1.3* Na-142 K-5.4 Cl-104 HCO3-25 AnGap-13 ___ 09:39AM BLOOD Calcium-9.4 Phos-4.6* Mg-2.1 ___ 06:05AM BLOOD calTIBC-218* Ferritn-76 TRF-168* ___ 05:59PM BLOOD Phenoba-26.0 CXR AP Lat ___: FINDINGS: No focal consolidation is seen. There is minimal basilar atelectasis. Left upper hemithorax scarring is noted. There is mild pulmonary vascular congestion. No pleural effusion or pneumothorax is seen. Cardiac silhouette as mildly enlarged. There is mild prominence the main pulmonary artery, would suggest a component of underlying pulmonary hypertension. IMPRESSION: Mild pulmonary vascular congestion. Mild prominence of the main pulmonary artery suggest component of underlying pulmonary hypertension. CTA Head Neck ___: IMPRESSION: 1. No evidence of acute infarction or intracranial hemorrhage. 2. Stable large left frontal AVM with arterial feeders from the left MCA and venous drainage into the superior sagittal sinus. 3. Approximately 20% stenosis by NASCET criteria of the proximal bilateral internal carotid arteries. 4. Mild-to-moderate multifocal atherosclerotic calcifications of the head and neck vasculature with no evidence of occlusion. TIB/FIB (AP AND LAT) LEFT ___: IMPRESSION: Diffuse osteopenia is noted. There is a healing subacute spiral fracture through the distal tibial metadiaphysis, which demonstrates fibroosseous bridging and callus formation. There is a healed fracture through the distal fibular diaphysis. Multiple well corticated ossific densities inferior to the medial malleolus most likely represent sequela from remote trauma. There are mild degenerative changes of the medial patellofemoral compartment and tibiotalar joint. FOOT AP,LAT & OBL LEFT PORT ___: FINDINGS: Diffuse osteopenia is noted. No acute fracture or dislocation is seen. There are sclerotic changes along the second, third and fourth metatarsal necks, which most likely represent subacute/chronic fractures. Mild degenerative changes are seen in the hindfoot and midfoot. There is a small plantar calcaneal spur. There is a small skin defect along the posterior aspect of the calcaneus. There is no adjacent cortical erosion, focal osteopenia or periosteal reaction. IMPRESSION: 1. Small skin defect along the posterior aspect of the calcaneus. No radiographic evidence of osteomyelitis. If there is high clinical concern for osteomyelitis, further evaluation may be performed with MRI with contrast or nuclear medicine bone scan. 2. Sclerotic changes along the second, third and fourth metatarsal necks, which most likely represent subacute/chronic fractures. 3. Please see separate report from concurrently performed radiographs of the left tibia and fibula for additional findings. Brief Hospital Course: Ms. ___ is a ___ woman with a history of epilepsy, was well controlled on levetiracetam/lamotrigine/phenobarbital who presented with new onset of episodes of tongue numbness/swelling sensation, as well as aphasia. EEG shows multiple left frontal brief seizures ___ long. Patient may be having breakthrough seizures due to UTI and soft tissue infections. She also has a L heel ulcer and a R groin abscess s/p I&D by ACS. #Epilepsy -cvEEG monitoring showed numerous of electrographic seizures daily (>80-90). Did not improve on addition of Ativan bridge, vimpat, klonopin. However, there was decrease in clinical seizures on fycompa 6mg such that there were no further clinical events x24 hours prior to discharge. - Continued home AEDs (LEV 1000mg BID, PHB 97.2mg BID, LTG 200mg TID) - vimpat 250mg BID (started ___ - ineffective - weaned off. - trialed ativan bridge which was not improving EEG, so it was stopped after 2 days - stopped klonopin on ___ after short, ineffective trial - prednisone 60 mg on ___, 40 mg on ___, 20 mg ___. Back to home dose of 5 mg daily on ___. per outpatient epileptologist, Dr. ___ - started Fycompa at 2 mg QHS and uptitrated to 6 mg QHS. Plan to increase to 8mg QHS in 1 week as outpatient. #R groin abscess- with purulent drainage - consulted ACS; s/p I+D - doxycycline and Keflex on ___ to complete 10 day course - BID wet to dry dressing changes per ACS #Heel ulcer, R buttock ulcer - wound care consulted - podiatry consulted - please see wound recs #multiple L tibia/fibula fractures, subacute in ___ - x-ray shows multiple subacute healing fractures - spoke with patient's outpatient ortho, Dr. ___ - weight bearing as tolerated if CAM boot in place with walker per OP ortho - ___ consulted; recommended rehab #UTI - urine culture grew E. coli resistent to cipro and ampicillin. sensitive to cephalosporins - s/p ceftriaxone x1 in ED - macrobid stopped; covered by Keflex and doxy for ulcers - repeat UA negative #Gross hematuria - painless, 2 episodes - UA negative for blood, 1 RBC - recommended outpatient follow-up with Urology Chronic Issues: #HTN - Lisinopril 10 mg held. BPs mostly 120s-140s. Please restart as appropriate. =========================================== Transitional Issues: [] f/u on healing of R groin ulcers/abscesses, R buttock ulcer, L heel ulcer. [] Continue daily/BID wound dressing changes [] antibiotics through ___ unless continuing concern for infection [] increase Fycompa to 8 mg QHS on ___ [] follow-up in 1 week with ___ RN [] follow up with Dr. ___ surgeon) within 2 weeks of discharge. [] follow up with urology for painless hematuria within 1 month [] monitor blood pressure and restart home lisinopril 10 mg as appropriate. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. sevelamer CARBONATE 800 mg PO TID W/MEALS 2. PredniSONE 5 mg PO DAILY 3. Famotidine 20 mg PO DAILY 4. Albuterol Inhaler 2 PUFF IH Q4H:PRN Shortness of Breath 5. LevETIRAcetam 1000 mg PO BID 6. LamoTRIgine 200 mg PO TID 7. PHENObarbital 97.2 mg PO BID 8. LORazepam 1 mg PO DAILY:PRN anxiety 9. Ferrous Sulfate 325 mg PO BID 10. HydrOXYzine 25 mg PO Q6H:PRN anxiety 11. Lisinopril 10 mg PO DAILY 12. Gabapentin 400 mg PO TID 13. budesonide-formoterol 160-4.5 mcg/actuation inhalation BID Discharge Medications: 1. Cephalexin 500 mg PO QID RX *cephalexin 500 mg 1 capsule(s) by mouth four times a day Disp #*9 Capsule Refills:*0 2. Collagenase Ointment 1 Appl TP DAILY 3. Doxycycline Hyclate 100 mg PO BID RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day Disp #*5 Tablet Refills:*0 4. Fycompa (perampanel) 6 mg oral QHS RX *perampanel [Fycompa] 6 mg 1 tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*0 RX *perampanel [Fycompa] 8 mg 1 tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*3 5. Polyethylene Glycol 17 g PO DAILY 6. Pramipexole 0.125 mg PO QHS 7. Sarna Lotion 1 Appl TP DAILY:PRN itching 8. Gabapentin 100 mg PO TID:PRN pain 9. Albuterol Inhaler 2 PUFF IH Q4H:PRN Shortness of Breath 10. budesonide-formoterol 160-4.5 mcg/actuation inhalation BID 11. Famotidine 20 mg PO DAILY 12. Ferrous Sulfate 325 mg PO BID 13. HydrOXYzine 25 mg PO Q6H:PRN anxiety 14. LamoTRIgine 200 mg PO TID 15. LevETIRAcetam 1000 mg PO BID 16. PHENObarbital 97.2 mg PO BID 17. PredniSONE 5 mg PO DAILY 18. sevelamer CARBONATE 800 mg PO TID W/MEALS 19. HELD- Lisinopril 10 mg PO DAILY This medication was held. Do not restart Lisinopril until necessary for high blood pressure. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Seizure disorder Secondary diagnoses: Urinary tract infection Right groin abscess Left heel ulcer COPD Left tibia/fibular fractures 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 ___ due to new episodes of tongue heaviness and difficulty speaking. You were monitored on EEG, which showed that these episodes are seizures. In addition, you had dozens of subclinical seizures each day, which you do not notice. We think you are having more seizures due to infections. You were found to have a urinary tract infection which has been treated with antibiotics. You also had ulcers on your left heel and your right buttock. An abscess was found in your right groin which needed to be lanced and drained by the surgery team. You were treated for 7 days with antibiotics called Keflex and Doxycycline. Take your medications as prescribed. You were started on an additional anti-seizure medication: Fycompa (perampanel) 6 mg at bedtime. On ___, increase to 8 mg at bedtime. You are being treated on antibiotics through ___. Keep taking cephalexin 500 mg four times a day. Stop after ___. Keep taking doxycycline 100 mg twice a day. Stop after ___. Your Lisinopril 10 mg daily was held temporarily while in the hospital. Please see your PCP about whether you should restart it for your blood pressure. Continue all your other medications as prescribed. Follow up with your PCP ___ ___ weeks of discharge. You had a couple episodes of painless blood in your urine. This may be completely benign but there is a possibility that sometimes it is an early sign of bladder or kidney cancer. You should see your PCP or ___ urologist within the next month to follow up on blood in your urine. Follow up with your orthopedic surgeon (Dr. ___ in 2 weeks. He suggests calling his office to make an appointment. Follow up with your neurologist within 2 months. Thank you for the opportunity to care for you. Sincerely, The ___ Neurology Team Followup Instructions: ___

10012206-DS-11

DS

2127-07-14 00:00:00

2127-07-14 15:26:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: floctafenine Attending: ___. Chief Complaint: Acute pancreatitis Major Surgical or Invasive Procedure: ___: Laparoscopic cholecystectomy Laparoscopic cholecystectomy - Dr. ___ ___ History of Present Illness: Pt.is ___ y/o male with hx of hypertriglyceridemia, HTN, OSA, DMII, neuropathy, essential tremor, and prior diagnosis of acute pancreatitis 3 weeks ago at ___ in ___ after experience abdominal pain, nausea/vomiting, and several episodes of loose stools ___. CT at that time was notable for mild acute pancreatitis/duodenitis, a high density fluid collection posterior to the pancreatic tail, and a small nonocclusive filling defect in SMV suspicious for thrombus. Patient underwent IVF resuscitation and with an ___ hospital course and was subsequently discharged home. Since discharge pt. states he as been unable to tolerate Po intake eating solid food once in the past 10 days. While traveling for a funeral the past couple of day his emesis, abdominal pain, and diarrhea have intensified culminating in evaluation at ___ where CT findings were again notable for edema and inflammation around the pancreas, fluid collection in both the tail(5.7x3.1cm) and head(2.9x2.2cm) of the pancreas, as well fluid extending down the right abdomen. On presentation, pt is not in acute distress, persistently hypotensive 80-90 systolic despite receiving 3L at the OSH endorsing continued abdominal pain, dry mouth, diarrhea, a frustrating lack of PO intake. Pt denies nausea/vomiting today, chest pain, LOC, prior MI, melena, or headache. Past Medical History: Past Medical History: -DMII -HTN -HLD -Acute Pancreatitis -Neuropathy -OSA -Essential Tremor Past Surgical History: -Spinal Stimulator Placement -C-spine Fusion Social History: ___ Family History: Non-contributory Physical Exam: Admission Physical Exam: Vitals:98.5 PO 142 / 90 R Lying 92 18 98 RA GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: hypotensive, regular rhythm PULM: Clear to auscultation b/l, No wheezin ABD: Soft,obese, nondistended, mild epigastric tenderness, no rebound or guarding, normoactive bowel sounds, Ext: No ___ edema, ___ warm and well perfused Discharge Physical Exam: VS: 97.5 PO 141 / 83 104 20 97 RA Gen: NAD, AxOx3 Card: RRR, no m/r/g Pulm: CTAB, no respiratory distress Abd: Soft, non-tender, non-distended, normal bs. NJT in place Wounds: c/d/i Ext: No edema, warm well-perfused Pertinent Results: IMAGING: ___: DUPLEX DOPP ABD/PEL PORT: 1. Patent hepatic vasculature. 2. Limited evaluation of the splenic vein and superior mesenteric vein. The visualized portions of the splenic and superior mesenteric veins appear patent. 3. Diffusely echogenic liver suggestive of a degenerative cyst or intrinsic liver disease. 4. Heterogeneous collections adjacent to the spleen as on the prior CT, likely sequela of known pancreatitis. 5. Cholelithiasis, without evidence of acute cholecystitis. ___: CTA Abdomen/Pelvis: 1. Multiple peripancreatic collections are unchanged from recent prior. 2. Nonocclusive thrombus in the splenic vein. A second order jejunal branch of the SMV is narrowed however remains patent. ___: Upper Endoscopic Ultrasound: -Normal mucosa in the whole esophagus -Normal mucosa in the whole stomach -Multiple shallow nonbleeding clean-based ulcers in the examined duodenum, expected in setting of acute pancreatitis -EUS: markedly edematous and distorted pancreatic parenchyma in setting of acute pancreatitis. Several acute pancreatic and peripancreatic fluid collections identified. The CBD could not be assessed due to distorted in anatomy in setting of acute pancreatitis. -Nasojejunal tube placed at the end of the procedure. ___: Portable Abdominal x-ray: There is a nasojejunal tube which terminates in the expected region of the proximal jejunum in the left hemiabdomen. There are no abnormally dilated loops of large or small bowel. There is no free intraperitoneal air, although evaluation is limited by supine technique. A spinal cord stimulator device projects over the right side of the abdomen. No acute osseous abnormalities are identified. ___: CT Interventional Radiology Procedure: 1. Sample 1: 3 cc of milky fluid was aspirated from the right paracolic gutter collection. 2. Sample 2: 5 cc of straw-colored, blood tinged fluid was aspirated from the peripancreatic collection. IMPRESSION: Technically successful CT-guided aspiration of the collections as described above. LABS: ___ 03:14AM LACTATE-0.7 ___ 02:59AM GLUCOSE-108* UREA N-35* CREAT-1.5* SODIUM-132* POTASSIUM-3.8 CHLORIDE-95* TOTAL CO2-23 ANION GAP-14 ___ 02:59AM ALT(SGPT)-12 AST(SGOT)-14 LD(LDH)-150 ALK PHOS-50 TOT BILI-0.2 ___ 02:59AM LIPASE-150* ___ 02:59AM ALBUMIN-3.5 CALCIUM-8.7 PHOSPHATE-3.1 MAGNESIUM-1.5* ___ 02:59AM TRIGLYCER-412* ___ 02:59AM WBC-15.2* RBC-3.53* HGB-10.3* HCT-31.6* MCV-90 MCH-29.2 MCHC-32.6 RDW-15.2 RDWSD-50.1* ___ 02:59AM NEUTS-83* LYMPHS-15* MONOS-1* EOS-1 BASOS-0 AbsNeut-12.62* AbsLymp-2.28 AbsMono-0.15* AbsEos-0.15 AbsBaso-0.00* ___ 02:59AM HYPOCHROM-1+* ANISOCYT-1+* MACROCYT-1+* ___ 02:59AM PLT SMR-HIGH* PLT COUNT-587* ___ 02:59AM ___ PTT-27.7 ___ ___ 08:50PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 08:50PM URINE BLOOD-TR* NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG ___ 08:50PM URINE RBC-6* WBC-1 BACTERIA-NONE YEAST-NONE EPI-0 ___ 08:50PM URINE HYALINE-5* ___ 08:49PM LACTATE-1.0 ___ 08:39PM GLUCOSE-100 UREA N-39* CREAT-1.7* SODIUM-131* POTASSIUM-4.0 CHLORIDE-95* TOTAL CO2-21* ANION GAP-15 ___ 08:39PM ALT(SGPT)-12 AST(SGOT)-16 ALK PHOS-52 TOT BILI-0.2 ___ 08:39PM LIPASE-168* ___ 08:39PM ALBUMIN-3.6 ___ 08:39PM WBC-17.5* RBC-3.53* HGB-10.4* HCT-31.2* MCV-88 MCH-29.5 MCHC-33.3 RDW-15.3 RDWSD-49.2* ___ 08:39PM NEUTS-68 ___ MONOS-3* EOS-3 BASOS-0 MYELOS-1* AbsNeut-11.90* AbsLymp-4.38* AbsMono-0.53 AbsEos-0.53 AbsBaso-0.00* ___ 08:39PM RBCM-WITHIN NOR ___ 08:39PM RBCM-WITHIN NOR Brief Hospital Course: Mr. ___ is a ___ y/o male with hx of hypertriglyceridemia, HTN, OSA, DMII, neuropathy, essential tremor, and recent diagnosis of acute pancreatitis at ___ in ___ after experiencing abdominal pain, nausea/vomiting, and several episodes of loose stools ___. He was discharged from ___ and then later presented at ___ in ___ with abdominal pain and emesis. CT findings at ___ were again notable for edema and inflammation around the pancreas, fluid collection in both the tail(5.7x3.1cm) and head(2.9x2.2cm) of the pancreas, as well fluid extending down the right abdomen. The patient was transferred to ___ in hypovolemic shock and was admitted to the Acute Care Surgery service on ___. Blood culture from ___ grew staphylococcus coagulase negative and he was started on vancomycin. Repeat blood cultures were sent which were negative and vancomycin was discontinued. The patient was transferred to the ICU and was made NPO with IVF for hydration. Gastroenterology was consulted for endoscopy. Abdominal ultrasound revealed gallstones and his pancreatitis was thought to be due to gallstone pancreatitis. On ___, CTA was done to evaluate for SMV thrombus and a nonocclusive thrombus was seen in the splenic vein. The patient was started on a heparin drip which was later transitioned to warfarin with lovenox bridging. On ___, the patient went for upper endoscopy with Gastroenterology which revealed multiple shallow nonbleeding clean-based ulcers in the examined duodenum, a markedly edematous and distorted pancreatic parenchyma in the setting of acute pancreatitis, several acute pancreatic and peripancreatic fluid collections. The CBD could not be assessed due to distorted anatomy in the setting of acute pancreatitis. A nasojejunal tube was placed so that the patient could receive tube feedings. Tube feeds were initiated on ___ which the patient tolerated. Tube feeds were later changed from continuous to cycled. On ___, the patient was taken to the operating room where he underwent laparoscopic cholecystectomy. This procedure went well (reader, please refer to operative note for details). After remaining hemodynamically stable in the PACU, the patient was transferred to the surgical floor. Pain was managed with a hydromorphone PCA initially. On POD #2, the PCA was d/c'd and oxycodone and acetaminophen were prescribed. The patient continued on tube feeds which he tolerated. Given that the patient lives in ___, follow-up care appointments were arranged in his home state. Please see discharge worksheet for further details. INR check ___ ___. All other INR check with primary care doctor in ___ Dr. ___. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating Tube feeds, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged home with ___ services for tube feeds. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. atenolol-chlorthalidone 50-25 mg oral DAILY 2. DULoxetine 60 mg PO DAILY 3. Fenofibrate 145 mg PO DAILY 4. Gabapentin 600 mg PO TID 5. Lisinopril 10 mg PO DAILY 6. MetFORMIN XR (Glucophage XR) 1000 mg PO BID 7. Nortriptyline 25 mg PO QHS 8. PrimiDONE 50 mg PO TID 9. Aspirin 81 mg PO DAILY Discharge Medications: 1. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*30 Capsule Refills:*0 2. Enoxaparin Sodium 90 mg SC Q12H RX *enoxaparin 100 mg/mL 90 mg sc every twelve (12) hours Disp #*30 Syringe Refills:*0 3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate RX *oxycodone [Oxaydo] 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*6 Tablet Refills:*0 4. Warfarin 5 mg PO ONCE Duration: 1 Dose RX *warfarin [Coumadin] 5 mg 1 tablet(s) by mouth once a day Disp #*8 Tablet Refills:*0 5. atenolol-chlorthalidone 50-25 mg oral DAILY 6. DULoxetine 60 mg PO DAILY 7. Fenofibrate 145 mg PO DAILY 8. Gabapentin 600 mg PO TID 9. Lisinopril 10 mg PO DAILY 10. MetFORMIN XR (Glucophage XR) 1000 mg PO BID 11. Nortriptyline 25 mg PO QHS 12. PrimiDONE 50 mg PO TID Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: -Non-occlusive thrombus in the splenic vein- 3 months Lovenox and Warfarin -___ fluid collections- negative gram stain on aspiration -Cholelithaisis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___ ___ were admitted to ___ and underwent laparoscopic cholecystectomy. During your hospitalization ___ also had the interventional radiology team aspirate a sample of the ___ fluid collections seen on the CT scan. These cultures were negative. ___ are recovering well and are now ready for discharge. Please follow the instructions below to continue your recovery: *****ANTICOAGULATION: ___ have a partial splenic thrombus seen on the CT scan. ___ are on a Lovenox bridge until your INR is goal ___. ___ also need to take Warfarin for 3 months. Follow up with primary care doctor ___ in ___ . Your PCPC will monitor your anticoagulation in the office for INR checks .Avoid changes in diet with foods rich in Vit.K (broccoli, spinach, cauliflower & ___ sprouts) ****Your health records were sent to Dr. ___ ___ surgery clinic (___) )office at the Medical ___. ___ is Dr. ___ assistant. The office will review your record then contact ___ in the next ___ days to be assigned to Dr. ___ another surgeon for your post operative appointment(s). ___ can call ___ if ___ have any questions. This arrangement was coordinated on your behalf due to preference to follow up in ___. ***VISITING NURSES*** ___ will have ___ services for 1 week in ___ for nutrition feeding education and supplies. This company will connect ___ with ___ services in ___ if still needed. ******FOLLOW UPS: 1) Primary care doctor- INR blood test goal INR (___), blood sugar and medication reconciliation . Please go to your primary care doctor ___. 2) ___- post operative check from laparoscopic cholecystectomy and splenic vein thrombus 3) ___ ___ at 3:30pm- post operative and a one time INR check. Your primary care doctor will be following all additional INR checks. Please go the ___ blood lab before your clinic appointment to have labs drawn. Clinic number ___. ACTIVITY: o Do not drive until ___ have stopped taking pain medicine and feel ___ could respond in an emergency. o ___ may climb stairs. o ___ may go outside, but avoid traveling long distances until ___ see your surgeon at your next visit. o Don't lift more than ___ lbs for 4 weeks. (This is about the weight of a briefcase or a bag of groceries.) This applies to lifting children, but they may sit on your lap. o ___ may start some light exercise when ___ feel comfortable. o ___ will need to stay out of bathtubs or swimming pools for a time while your incision is healing. Ask your doctor when ___ can resume tub baths or swimming. HOW ___ MAY FEEL: o ___ may feel weak or "washed out" for a couple of weeks. ___ might want to nap often. Simple tasks may exhaust ___. o ___ may have a sore throat because of a tube that was in your throat during surgery. o ___ might have trouble concentrating or difficulty sleeping. ___ might feel somewhat depressed. o ___ could have a poor appetite for a while. Food may seem unappealing. o All of these feelings and reactions are normal and should go away in a short time. If they do not, tell your surgeon. YOUR INCISION: o Tomorrow ___ may shower and remove the gauzes over your incisions. o Your incisions may be slightly red around the stitches. This is normal. o ___ may gently wash away dried material around your incision. o Avoid direct sun exposure to the incision area. o Do not use any ointments on the incision unless ___ were told otherwise. o ___ may see a small amount of clear or light red fluid staining your dressing or clothes. If the staining is severe, please call your surgeon. o ___ may shower. As noted above, ask your doctor when ___ may resume tub baths or swimming. YOUR BOWELS: o Constipation is a common side effect of narcotic pain medications. If needed, ___ may take a stool softener (such as Colace, one capsule) or gentle laxative (such as milk of magnesia, 1 tbs) twice a day. ___ can get both of these medicines without a prescription. o If ___ go 48 hours without a bowel movement, or have pain moving the bowels, call your surgeon. PAIN MANAGEMENT: o It is normal to feel some discomfort/pain following abdominal surgery. This pain is often described as "soreness". o Your pain should get better day by day. If ___ find the pain is getting worse instead of better, please contact your surgeon. o ___ will receive a prescription for pain medicine to take by mouth. It is important to take this medicine as directed. o Do not take it more frequently than prescribed. Do not take more medicine at one time than prescribed. o Your pain medicine will work better if ___ take it before your pain gets too severe. o Talk with your surgeon about how long ___ will need to take prescription pain medicine. Please don't take any other pain medicine, including non-prescription pain medicine, unless your surgeon has said its okay. o If ___ are experiencing no pain, it is okay to skip a dose of pain medicine. o Remember to use your "cough pillow" for splinting when ___ cough or when ___ are doing your deep breathing exercises. If ___ experience any of the following, please contact your surgeon: - sharp pain or any severe pain that lasts several hours - pain that is getting worse over time - pain accompanied by fever of more than 101 - a drastic change in nature or quality of your pain MEDICATIONS: Take all the medicines ___ were on before the operation just as ___ did before, unless ___ have been told differently. If ___ have any questions about what medicine to take or not to take, please call your surgeon. Followup Instructions: ___

10012688-DS-17

DS

2179-10-22 00:00:00

2179-10-22 17:15:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: shellfish derived Attending: ___ Chief Complaint: dizziness, gait unsteadiness Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ year old woman with history of chronic left ear pulsatile tinnitus of unclear etiology and GERD who presents with 1 day history of dizziness and gait unsteadiness, for whom neurology is consulted due to question of posterior circulation etiology. History provided by patient. Ms. ___ reports she was in her usual state of health until 4 ___ yesterday. At that time, she got out of her car on the way home from work, and felt significant dizziness. Reports that this started suddenly. She describes her dizziness as a combination of feeling disequilibrium, off-balance, and with some room spinning sensation. She reported that when she tried to walk, it felt like she "drank 20 beers." She struggled walking back into the house, but eventually was able to do so, and immediately went to lie down the couch. She right on the couch and rested for 1 hour, and then felt back to her baseline. Last night, she spent most of the night with her father who was hospitalized at ___ and felt fine. During that time she was able to ambulate without any symptoms. The patient woke up this morning feeling in her usual state of health. She got to ___ at 10 AM for a tour of the stadium, and felt fine walking around the park. She had a breakfast sandwich and 2 beers with breakfast. Shortly after the game started at 1 ___, she went to the bathroom. After standing for a few minutes after using the restroom, while washing her hands, she felt the dizziness come back. Dizziness was similar to yesterday, described as a combination of disequilibrium, gait unsteadiness, with some room spinning component. It was more severe than usual. She sat down and put her head in her hands, covering her eyes. She felt significantly nauseous but did not vomit. She sat in the chair but that it did not help. There was no difference or change positions. She tried to stand up, but was swaying back and forth, not in any particular direction, and unable to take steps. EMS was called and she was transferred to ___ emergency department for further evaluation. On the emergency department evaluation, vitals were notable for elevated blood pressures with systolic blood pressures 180s-190s. Shortly after being in triage, she took a 20 minute nap and felt some transient improvement, but by 5:30 ___, symptoms resumed. Currently, patient reports low-grade dizziness and room spinning vertigo. When she sits upright or tries to walk, it becomes unbearable. She cannot ambulate unless she has significant assistance, which is far from her baseline. Her blood pressures continue to be elevated to 170s-180s. Of note, the patient has baseline, chronic left ear pulsatile tinnitus. She reports her left ear always feels blocked. This has been worked up in the past with MRI head and MRA's, which she reports been overall unrevealing. She believes that over the last day, this left ear sensation has been somewhat more prominent than usual. She otherwise denies any new symptoms, including denying focal weakness, sensory changes, visual changes, difficulties understanding or expressing speech. Prior to the above, the only change to her routine is that she has had significant stress recently due to her father being ill with pneumonia. She stayed up late last night overnight in the hospital caring for him. She otherwise denies any recent illnesses, denies fevers/chills, denies any new or missed medications. On neuro ROS, the pt reports dizziness and gait unsteadiness. Denies headache, loss of vision, blurred vision, diplopia, dysarthria, dysphagia. Denies difficulties producing or comprehending speech. Denies focal weakness, numbness, parasthesiae. No bowel or bladder incontinence or retention. On general review of systems, the pt reports nausea. 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 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: -Chronic pulsatile tinnitus of the left ear -GERD Social History: ___ Family History: Denies any family history of stroke or neurologic conditions Physical Exam: ADMISSION PHYSICAL EXAM ========================= Vitals: 97.3F, heart rate ___, blood pressure 178-191/94-109, RR 18, O2 94% RA Orthostatic vital signs in ED: Supine HR 74, BP 181/104 Sitting HR 81, BP 178/109 Standing HR 73, BP 180/108 General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, No nuchal rigidity Pulmonary: Normal work of breathing Cardiac: RRR, warm, well-perfused Abdomen: soft, non-distended Extremities: No ___ edema. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name ___ backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt was able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial Nerves: II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without nystagmus. No skew. Head impulse test indeterminate. Normal saccades. VFF to confrontation. Visual acuity ___ bilaterally. V: Facial sensation intact to light touch. VII: Mild left nasolabial fold flattening at rest, symmetric upon activation. Obtained previous license photos and photos from phone; difficult to appreciate if this was present previously. Symmetric smile after hearing a joke. Symmetric forehead wrinkle and eyeclosure. Facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii bilaterally. XII: Tongue protrudes in midline with good excursions. Strength full with tongue-in-cheek testing. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FE IP Quad Ham TA ___ ___ L 5 ___ ___ 5 5 5 5 R 5 ___ ___ 5 5 5 5 -Sensory: No deficits to light touch, pinprick, proprioception throughout. No extinction to DSS. -DTRs: Bi Tri ___ Pat Ach L 3 2+ 2+ 3 2+ R 3 2+ 2+ 3 2+ Pectoralis jerks and crossed adductors present b/l Plantar response was flexor bilaterally. -Coordination: When attempting to sit up, there appears to be truncal ataxia, more prominent upon standing. No intention tremor. Normal finger-tap bilaterally. No dysmetria on FNF or HKS bilaterally. No overshoot on cerebellar mirroring. -Gait: Stands without assistance, but sways back and forth with a wide base at rest. Falls backward when attempting to do Unteberger testing. Requires one person assistance to ambulate. Gait is wide-based, normal stride and arm swing. Cannot walk in tandem. DISCHARGE PHYSICAL EXAM ========================== General: no acute distress HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx, Tympanic membranes with no infection or effusion. Neck: Supple, No nuchal rigidity Pulmonary: Normal work of breathing Cardiac: RRR, warm, well-perfused Abdomen: soft, non-distended Extremities: no cyanosis, clubbing, edema. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt was able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial Nerves: II, III, IV, VI: PERRL 3 to 2mm and brisk. R gaze nystagmus. No skew. Head impulse test indeterminate. Normal saccades. VFF to confrontation. V: Facial sensation intact to light touch. VII: No nasolabial fold flattening. Smile symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii bilaterally. XII: Tongue protrudes in midline with good excursions. Strength full with tongue-in-cheek testing. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FE IP Quad Ham TA ___ ___ L 5 ___ ___ 5 5 5 5 R 5 ___ ___ 5 5 5 5 -Sensory: No deficits to light touch, pinprick, proprioception throughout. No extinction to DSS. -DTRs: Bi Tri ___ Pat Ach L 3 2+ 2+ 3 2+ R 3 2+ 2+ 3 2+ Pectoralis jerks and crossed adductors present b/l Plantar response was flexor bilaterally. -Coordination: When attempting to sit up, there appears to be truncal ataxia, more prominent upon standing. No intention tremor. Normal finger-tap bilaterally. No dysmetria on FNF or HKS bilaterally. No overshoot on cerebellar mirroring. -Gait: Stands without assistance, veers to left with eyes closed. Requires one person assistance to ambulate. Pertinent Results: ADMISSION LABS =============== ___ 05:00PM BLOOD WBC-10.6* RBC-4.45 Hgb-13.7 Hct-40.7 MCV-92 MCH-30.8 MCHC-33.7 RDW-12.8 RDWSD-41.7 Plt ___ ___ 05:00PM BLOOD Neuts-76.7* Lymphs-17.6* Monos-4.7* Eos-0.3* Baso-0.4 Im ___ AbsNeut-8.11* AbsLymp-1.86 AbsMono-0.50 AbsEos-0.03* AbsBaso-0.04 ___ 05:00PM BLOOD Plt ___ ___ 05:00PM BLOOD Glucose-114* UreaN-10 Creat-0.6 Na-142 K-4.3 Cl-105 HCO3-21* AnGap-16 ___ 05:00PM BLOOD ALT-18 AST-21 AlkPhos-97 TotBili-0.3 ___ 05:00PM BLOOD Lipase-29 ___ 05:00PM BLOOD cTropnT-<0.01 ___ 05:00PM BLOOD Albumin-4.5 Cholest-243* ___ 05:00PM BLOOD Triglyc-312* HDL-47 CHOL/HD-5.2 LDLcalc-134* ___ 05:00PM BLOOD TSH-2.8 ___ 05:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG DISCHARGE LABS ================= ___ 04:25AM BLOOD WBC-7.0 RBC-4.01 Hgb-12.3 Hct-37.0 MCV-92 MCH-30.7 MCHC-33.2 RDW-12.7 RDWSD-43.3 Plt ___ ___ 04:25AM BLOOD Neuts-40.8 ___ Monos-7.8 Eos-3.4 Baso-0.3 Im ___ AbsNeut-2.87 AbsLymp-3.34 AbsMono-0.55 AbsEos-0.24 AbsBaso-0.02 ___ 04:25AM BLOOD Plt ___ ___ 04:25AM BLOOD ___ PTT-27.3 ___ ___ 04:25AM BLOOD Glucose-92 UreaN-11 Creat-0.7 Na-144 K-4.1 Cl-108 HCO3-25 AnGap-11 ___ 04:25AM BLOOD Calcium-9.1 Phos-3.4 Mg-2.0 IMAGING =========== CT HEAD W/O CONTRAST Study Date of ___ FINDINGS: There is no evidence of acute large territorial infarction, hemorrhage, edema,or mass effect. The ventricles and sulci are normal in size and configuration.There is no evidence of fracture. Minimal mucosal thickening is seen within the right sphenoid sinus posteriorly. The visualized portion of the remaining paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: No acute intracranial abnormality. MR HEAD W/O CONTRAST Study Date of ___ FINDINGS: There is no evidence of hemorrhage, edema, masses, mass effect, midline shift or infarction. The ventricles and sulci are normal in caliber and configuration. Normal flow voids are demonstrated bilaterally. IMPRESSION: 1. Normal brain MRI. Brief Hospital Course: Ms. ___ is a ___ year old woman with history of chronic left ear pulsatile tinnitus of unclear etiology and GERD who presented with 1 day history of dizziness and gait unsteadiness. She was ruled out for acute stroke. #Vestibulopathy of unclear etiology: Initially presented with intermittent dizziness, described as a combination of dysequilibrium, gait unsteadiness and room spinning over one day. Her dizziness was positional and worse with standing, she was unable to ambulate independently which is a change from her baseline. She also developed new left ear "fullness". Initial exam notable for unremarkable HINTS exam, however did have truncal ataxia. Interval repeat examination was notable for persistent gait unsteadiness (veered to left), and right beating nystagmus on right gaze. Tympanic membranes had no evidence of infection or effusion. Head CT and MRI with no evidence of stroke. Etiology of her symptoms is unclear, has mixed features. Peripheral vestibulopathy possible, lower suspicion for vestibular neuritis (no preceding viral symptoms, nausea, or vomiting), BPPV (negative ___, Menieres (late age of onset). Stroke risk factors were checked: LDL 134, A1C 5.9. Initiated atorvastatin 40 mg daily. At the time of discharge, patient felt subjectively better although still required some assistance with walking. ___ recommended discharge home with ___ rehab. TRANSITIONAL ISSUES: ===================== [] A1C 5.9, prediabetic range, continue to monitor and consider metformin initiation [] LDL 134, started atorvastatin 40 mg daily [] noted to be hypertensive throughout admission (in ED SBP 180s-190s, on floor 140-160s/60-70s), consider addition of antihypertensive [] please perform outpatient audiogram, consider VNG pending audiogram results and evolution of symptoms (Scheduled for ENT) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Omeprazole 40 mg PO DAILY 2. Cetirizine 10 mg PO DAILY Discharge Medications: 1. Atorvastatin 40 mg PO QPM RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 2. Cetirizine 10 mg PO DAILY 3. Omeprazole 40 mg PO DAILY 4.Outpatient Physical Therapy ___ rehab ICD-10: H81.90 Discharge Disposition: Home Discharge Diagnosis: #Vestibulopathy of unclear etiology Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, It was a pleasure to care for you at the ___ ___. You came to the hospital because you developed dizziness, ear fullness, and unsteadiness when walking at home. These symptoms were concerning for a stroke. We performed blood tests and imaging of your brain and determined that you did not have a stroke. We also performed examinations of your ears and found no abnormalities. We believe your symptoms are related to a problem in your inner ears, which is an area of your body that controls balance. It is safe for you to return home. ENT also evaluated you and recommended you follow up in their clinic on ___ at ___:30 AM for a hearing test. While in the hospital, we found that your cholesterol levels were high and we started you on a medication to lower your cholesterol ("atorvastatin"). You will also have ___ rehab" sessions which will help you regain and improve your balance. Please continue to take your medications as prescribed and to ___ with your doctors as ___. We wish you all the best, Your ___ care team Followup Instructions: ___

10012853-DS-9

DS

2176-06-08 00:00:00

2176-06-15 14:25:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: generalized weakness Major Surgical or Invasive Procedure: None History of Present Illness: Mrs. ___ is a ___ y/o woman with a PMH of atrial fibrillation on warfarin, PE, CKD III, PVD, HTN, T2DM, neurogenic bladder and multinodular goiter, who was referred by her PCP for generalized weakness and decreased appetite. Per the daughter, ___, for the past three days the patient has been feeling nauseated and clear, watery NBNB vomiting ___. Normal BM today. The patient has not been eating or drinking, has required her daughter to help her walk to the bathroom, and has not been able to sit up due to weakness. Denies shortness of breath, chest pain, abdominal pain, blood in stool or urine. Of note, the patient was started on methimazole 1 week ago for hyperthyroidism. She also had a CT scan on ___ for lung nodules, with a slightly increased size of the right lower lob nodule of 6 mm (previously 5 mm). Remainder of nodules unchaged from prior study in ___, but all nodules have gradually increased from ___. In ___, she also had a pneumonia, for which she was in a rehab facility for a week. In the ED, initial vitals were: T 98.1F P 77 BP 100/43 RR 18 98% Labs were notable for: Trop-T <0.01. Na 137, K 3.5, Cl 98, HCO3 28, BUN 33, Cr 1.5, Gluc 107, Ca 8.9, Mg 1.8, P 4.4, ALT 33, AST 33, AP 125, Tbili 0.5, Alb 3.1. WBC of 9.1, H/H of 10.2/33.4 Plt 419. INR of 2.6. ProBNP 1144. UA notable for small leuks, moderate blood, positive nitrites, >300 protein, RBC 15, WBC 98, few bacteria. Thyroid studies were pending. Patient was given: ___ 18:22 IV CeftriaXONE 1 gm On the floor, Ms. ___ reported that she has not been "feeling right" since ___, when she had her catheter changed; she endorsed increased dysuria and urinary frequency. Denies hematuria. Has also had light headedness, with no syncope or falls. Denied fevers, chills, chest pain, shortness of breath, abdominal pain, diarrhea, BRBPR, melena, hematochezia, and constipation. Last BM was yesterday, with one well-formed stool. Now she reports that she is feeling considerably better. Past Medical History: - T2DM (HbA1c 6.1% in ___, diet controlled) - HLD - CKD III - PVD - OA - iron deficiency anemia - paroxysmal atrial fibrillation - pulmonary embolism - stroke - diverticulosis - goiter (nontoxic multinodular) - AAA (3.3 cm in ___, no further eval) - cholelithiasis - obesity - lung nodules (as above) - neurogenic bladder - prolonged QT Social History: ___ Family History: Mother, aunt, and uncle all had CHF, unknown cause; no known hx of CAD in her family. Daughter with heart arrhythmia on amiodarone Physical Exam: ======================= ADMISSION PHYSICAL EXAM ======================= Vitals: T 97.4F BP 128/39 P 65 RR 18 O2 96%RA General: Alert, oriented, pleasant woman in NAD. HEENT: PERRL; EOMs intact. MMM, OP clear. Anicteric sclera. Neck: Supple; large, palpable goiter; non-tender. No JVD. CV: RRR, III/VI systolic murmur best heard over LUSB. No rubs or gallops. Normal S1/S2. Pulm: CTA b/l; no wheezes, rhonchi, or rales. Abd: Soft, non-tender, non-distended, NABS; no organomegaly. GU: Suprapubic catheter in place, draining dark urine. Ext: Warm, well-perfused. 2+ pulses; trace edema. No clubbing or cyanosis. Neuro: A&Ox3. Preserved strength in upper and lower extremities and distal sensation intact to light touch, gait deferred. ======================= DISCHARGE PHYSICAL EXAM ======================= Vitals: 98.7 145/55 56 18 95% RA General: Alert, oriented, pleasant woman in NAD. HEENT: PERRL; EOMs intact. MMM, OP clear. Anicteric sclera. Neck: Supple; large, palpable goiter; non-tender. No JVD. CV: RRR, III/VI systolic murmur best heard over LUSB. No rubs or gallops. Normal S1/S2. Pulm: CTA b/l; no wheezes, rhonchi, or rales. Abd: Soft, non-tender, non-distended, NABS; no organomegaly. GU: Suprapubic catheter in place, draining dark urine. Ext: Warm, well-perfused. 2+ pulses; trace edema. No clubbing or cyanosis. Neuro: A&Ox3. CNII-XII grossly intact, moving all extremities spontaneously, gait deferred. Pertinent Results: ============== ADMISSION LABS ============== ___ 04:00PM BLOOD WBC-9.1 RBC-4.24 Hgb-10.2* Hct-33.4* MCV-79* MCH-24.1* MCHC-30.5* RDW-17.4* RDWSD-49.2* Plt ___ ___ 04:00PM BLOOD Neuts-77.7* Lymphs-8.3* Monos-12.8 Eos-0.2* Baso-0.4 Im ___ AbsNeut-7.07* AbsLymp-0.75* AbsMono-1.16* AbsEos-0.02* AbsBaso-0.04 ___ 04:00PM BLOOD Glucose-107* UreaN-33* Creat-1.5* Na-137 K-3.5 Cl-98 HCO3-28 AnGap-15 ___ 04:00PM BLOOD ALT-33 AST-33 AlkPhos-125* TotBili-0.5 ___ 04:00PM BLOOD cTropnT-<0.01 ___ 04:00PM BLOOD proBNP-1144* ___ 04:00PM BLOOD Albumin-3.1* Calcium-8.9 Phos-4.4 Mg-1.8 ___ 04:00PM BLOOD TSH-<0.02* ___ 04:00PM BLOOD T3-92 Free T4-1.8* ___ 04:08PM BLOOD Lactate-1.4 ___ 04:00PM BLOOD TSH-<0.02* ___ 04:00PM BLOOD T3-92 Free T4-1.8* ============== DISCHARGE LABS ============== ___ 06:20AM BLOOD WBC-5.6 RBC-3.83* Hgb-9.3* Hct-29.9* MCV-78* MCH-24.3* MCHC-31.1* RDW-17.5* RDWSD-49.1* Plt ___ ___ 06:20AM BLOOD ___ PTT-36.6* ___ ___ 06:20AM BLOOD Glucose-82 UreaN-20 Creat-0.8 Na-141 K-4.0 Cl-104 HCO3-25 AnGap-16 =============== IMAGING/STUDIES =============== CHEST (PA & LAT) (___) IMPRESSION: Hyperinflated lungs. Mild pulmonary vascular congestion. No focal consolidation. ============ MICROBIOLOGY ============ ___________________________________________________________ ___ 10:33 pm URINE Source: Suprapubic. URINE CULTURE (Preliminary): GRAM NEGATIVE ROD(S). >100,000 ORGANISMS/ML.. __________________________________________________________ ___ 4:00 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. Brief Hospital Course: Mrs. ___ is a ___ y/o woman with a PMH of atrial fibrillation on warfarin and amiodarone, PE, CKD III, PVD, HTN, T2DM, and multinodular goiter recently started on methimazole, who was referred by her PCP for generalized weakness and decreased appetite, who presented with symptoms and UA consistent with UTI, no leukocytosis and no fever. ============ ACUTE ISSUES ============ #Complicated UTI. She had no fever or leukocytosis, and endorsed symptoms of urinary urgency and frequency, in the setting of suprapubic catheter for neurogenic bladder. She history of Pseudomonas (pan-sensitive) and Klebsiella UTIs in the past, with no CVA tenderness to suggest pyelonephritis. We avoided ciprofloxacin owing to history of prolonged QT. There was no evidence of pneumonia on plain film. She was treated with one dose of ceftriaxone in the ED, and then was monitored off antibiotics. Her urine culture grew GNRs, but this was thought to represent colonization. She did well off of antibiotics and was discharged without any further antibiotic treatment. # Toxic multinodular goiter. Mrs. ___ was recently started on methimazole 10 mg on ___. TSH 0.02 on ___ and she had a palpable, painless goiter. Methimazole was held on admission but was restarted in the setting of thyroid studies showing suppressed TSH. # ___ on CKD, stage III. The was thought to be pre-renal in the setting of poor PO intake, and her creatinine improved from 1.5 to 1.1 with the administration of fluids. # Generalized weakness. Her weakness had improved on admission and was thought to represent infection vs. thyroid dysfunction in the setting of starting methimazole. There was no evidence of neurogenic or cardiovascular dysfunction. No syncope or loss of consciousness. We opted to pursue UTI treatment, encouragement of PO intake, and maintenance fluids as above. ============== CHRONIC ISSUES ============== # Neurogenic bladder. Suprapubic catheter, secondary to diabetic nephropathy, with Foley change by urology approximately once per month with annual cystoscopy. # Tobacco use. Nicotine patch was offered but declined. # T2DM. Diet-controlled. A1c of 6.1% in ___. # Paroxysmal atrial fibrillation. In normal sinus rhythm. Warfarin and amiodarone were continued. # Hypertension. Home lisinopril, amlodipine and HCTZ were continued. # Hyperlipidemia. Home atorvastatin and aspirin were continued # Iron deficiency anemia. Home ferrous sulfate 325 mg was continued. =================== TRANSITIONAL ISSUES =================== # Anticoagulation. Next INR should be drawn on ___. Managed by Dr. ___ at ___. # CODE: FULL # CONTACT: ___ ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Warfarin 1 mg PO 3X/WEEK (___) 2. Atorvastatin 40 mg PO QPM 3. Lisinopril 30 mg PO DAILY 4. Hydrochlorothiazide 25 mg PO DAILY 5. Amiodarone 200 mg PO DAILY 6. Amlodipine 5 mg PO DAILY 7. Ferrous Sulfate 325 mg PO DAILY 8. Multivitamins 1 TAB PO DAILY 9. Calcium Carbonate 500 mg PO DAILY 10. Aspirin 81 mg PO DAILY 11. Methimazole 10 mg PO DAILY 12. Warfarin 2 mg PO 4X/WEEK (___) Discharge Medications: 1. Amiodarone 200 mg PO DAILY 2. Amlodipine 5 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 40 mg PO QPM 5. Calcium Carbonate 500 mg PO DAILY 6. Ferrous Sulfate 325 mg PO DAILY 7. Hydrochlorothiazide 25 mg PO DAILY 8. Lisinopril 30 mg PO DAILY 9. Multivitamins 1 TAB PO DAILY 10. Warfarin 1 mg PO 3X/WEEK (___) 11. Warfarin 2 mg PO 4X/WEEK (___) 12. Methimazole 10 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: ================= PRIMARY DIAGNOSES ================= - urinary tract infection - toxic multinodular goiter - acute kidney injury =================== SECONDARY DIAGNOSES =================== - neurogenic bladder - tobacco use - type 2 diabetes mellitus - paroxysmal atrial fibrillation - hypertension - hyperlipidemia - iron deficiency anemia ================= PRIMARY DIAGNOSES ================= - urinary tract infection - toxic multinodular goiter - acute kidney injury =================== SECONDARY DIAGNOSES =================== - neurogenic bladder - tobacco use - type 2 diabetes mellitus - paroxysmal atrial fibrillation - hypertension - hyperlipidemia - iron deficiency anemia 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 ___ ___. You were admitted for weakness and concern for a urinary tract infection. You were initially treated with antibiotics, but because our suspicion that you had a urinary tract infection was low since you didn't have a fever and your bloodwork did not show signs of infection, we decided to discontinue antibiotics and to observe you for 24 hours. During that time, you continued to feel well, so we felt it was safe to send you home. Please take all of your discharge medications as prescribed. We recommend that you make a follow-up appointment with someone from your primary care physician's practice this week to make sure you are still doing okay. We wish you all the very best! Warmly, Your ___ Team Followup Instructions: ___

10013015-DS-4

DS

2121-08-12 00:00:00

2121-08-12 18:19:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Complete Heart Block Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is an ___ female with history of A. fib on Coumadin, chronic kidney disease, COPD on 2L O2, severe pulmonary hypertension who is presenting as a transfer from ___ ___ for concern for 3rd degree heart block. The patient was recently admitted to ___ in ___ for syncope. She was walking through a store to buy medications for her constipation and she became lightheaded, weak, and she fell to the floor and hit her head. She endorsed epigastric pain prior to event but no other prodrome of diaphoresis, nausea, or tunnel vision. The event was thought to be due to pulmonary HTN from chronic COPD as her TTE showed elevated PA pressures as well as a possible orthostatic component. She was given gentle fluids and her Lasix was held but resumed at a decreased dose prior to discharge. She was also given prednisone 30mg PO daily, levaquin 250mg daily, and started on albuterol nebulizers. She was discharged on 2L NC with plan to get outpatient PFTs. She states that she has not been the same since discharge. She used to be able to walk her dog around the block multiple times but in the past month, she has been so short of breath she has not been able to walk her dog at all. The most activity she is able to perform is chores around the house. She has noticed lower extremity swelling but no orthopnea, PND, nausea, or vomiting. She does not weigh herself as she does not have a scale but she does not think she has gained weight. She manages all of her medications on her own and does not think she missed any doses. The patient was cooking dinner for herself the night prior to admission when she developed a sharp chest pressure in the left side of her chest. The pain progressed so she called EMS. She denied any palpitations, shortness of breath, nausea, or vomiting. The pain lasted about one hour. When EMTs arrived, she was bradycardic to the ___. On arrival to ___, her blood pressure was 82/39 with a heart rate of ___. EKG was concerning for complete heart block. She had minimal response to atropine so was started on transvenous pacing without capture. She was then given pushes of epinepherine then started on an epinepherine drip. Her lowest blood pressure was 70/40. Labs were notable for a creatinine of 3.1, potassium of 6.2, ph on the VBG of 7.10 with a pCO2 of 34 and a bicarbonate of 10. She was then given IVF boluses and started on a bicarbonate drip. She was also given 1 amp of calcium gluconate and 3mg of glucagon given concern for AV nodal blockage overdose. The patient was transferred to ___ for further management of complete heart block. Blood pressure was 90/40 on transfer and she was placed on epinepherine and norepinephrine. In the ED, epinephrine and norepinephrine were weaned off and she was placed on dopamine 2.5 mcg/kg/min. In the ED, - Initial vitals were: 97.3 66 100/58 12 96% 3L NC - Exam notable for: None documented - Labs notable for: WBC of 27.6, hgb of 8.5, plt of 338 Na of 141, K of 5.9, Cl of 115, HCO3 of 13, BUN 46, Cr of 2.8 ALT of 21, AST of 51, ALP of 89, Tbili of 0.4 VBG with ___ lactate of 1.9 - Studies notable for: CXR with Apparent opacities projecting over the right lower lung may partially be due to costochondral calcifications but cannot exclude possible lung parenchymal opacities. - Patient was given: IV DRIP DOPamine 2.5 mcg/kg/min 500 cc IVF IV Calcium Gluconate 1 gm On arrival to the CCU, the patient endorses shortness of breath mildly improved from prior. She denies any chest pain, nausea, vomiting, palpitations, dysuria, urgency, frequency, or diarrhea. She has been eating and drinking normally over the past few days. In speaking with renal this morning, they recommended 1L of Nabicarb for his acidosis. Past Medical History: Cardiac History: - type 2 diabetes - hypertension - dyslipidemia - atrial fibrillation - HFpEF Other PMH: - CKD stage III - COPD Social History: ___ Family History: FATHER, ___ Cause: CVA (cerebral vascular accident). MOTHER, ___ Cause: Colon cancer. DAUGHTER, ___, Age ___ Cause: Diabetes mellitus. SON, ___, Age ___ Cause: ___ syndrome. SON, ___, Age ___ Cause: Hydrocephalus. Physical Exam: ADMISSION EXAM =============== VS: Reviewed in Metavision GENERAL: Well developed, well nourished in NAD. Oriented x3. Mood, affect appropriate. HEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI. NECK: Supple. JVP at 11 cm at 90 degrees. CARDIAC: Normal rate, regular rhythm. No murmurs, rubs, or gallops. LUNGS: No chest wall deformities or tenderness. scattered wheezes throughout both lung fields ABDOMEN: Soft, non-tender, non-distended. No palpable hepatomegaly or splenomegaly. EXTREMITIES: Warm, well perfused. 2+ pitting edema of both lower extremities bilaterally SKIN: No significant lesions or rashes. PULSES: Distal pulses palpable and symmetric. DISCHARGE EXAM ================ 24 HR Data (last updated ___ @ 516) Temp: 97.6 (Tm 98.0), BP: 149/70 (109-149/43-70), HR: 83 (___), RR: 20 (___), O2 sat: 90% (84-93), O2 delivery: 3L, Wt: 168.21 lb/76.3 kg GENERAL: Well developed, well nourished in NAD. Oriented x3. Mood, affect appropriate. CARDIAC: RRR. No murmurs, rubs, or gallops. LUNGS: Decreased breath sounds. No wheezing, no increased WOB or use of accessory muscles ABDOMEN: Soft, NTND. No palpable hepatomegaly or splenomegaly. EXTREMITIES: 1+ pitting edema of both lower extremities bilaterally to mid shin. PULSES: Distal pulses palpable and symmetric. NEURO: Alert, conversant, no gross focal deficits Pertinent Results: ADMISSION LABS ================ ___ 11:59PM BLOOD WBC-27.6* RBC-3.71* Hgb-8.5* Hct-30.3* MCV-82 MCH-22.9* MCHC-28.1* RDW-21.0* RDWSD-59.8* Plt ___ ___ 11:59PM BLOOD Neuts-85.5* Lymphs-6.9* Monos-6.2 Eos-0.0* Baso-0.3 NRBC-0.3* Im ___ AbsNeut-23.60* AbsLymp-1.90 AbsMono-1.72* AbsEos-0.01* AbsBaso-0.08 ___ 11:59PM BLOOD ___ PTT-27.4 ___ ___ 11:59PM BLOOD ALT-21 AST-51* CK(CPK)-67 AlkPhos-89 TotBili-0.4 ___ 11:59PM BLOOD Albumin-3.4* INTERVAL LABS =============== ___ 12:05AM BLOOD ___ pO2-72* pCO2-36 pH-7.16* calTCO2-14* Base XS--15 Comment-GREEN TOP ___ 07:46AM BLOOD ___ pO2-133* pCO2-37 pH-7.37 calTCO2-22 Base XS--3 Comment-GREEN TOP ___ 05:37AM BLOOD Cortsol-15.3 ___ 11:59PM BLOOD TSH-2.1 ___ 05:55AM BLOOD calTIBC-300 Ferritn-31 TRF-231 ___ 11:59PM BLOOD cTropnT-<0.01 ___ 05:37AM BLOOD CK-MB-3 cTropnT-<0.01 MICROBIOLOGY ============= ___ 12:05 am BLOOD CULTURE Blood Culture, Routine (Preliminary): STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. ___ BLOOD CULTURE NO GROWTH ___ URINE CULTURE NO GROWTH - FINAL MRSA SWAB - PENDING ___ BLOOD CULTURE NO GROWTH TO DATE (PENDING) ___ BLOOD CULTURE NO GROWTH TO DATE (PENDING) IMAGING ========== TTE (___) The left atrial volume index is normal. The right atrium is mildly enlarged. There is no evidence for an atrial septal defect by 2D/color Doppler. The estimated right atrial pressure is ___ mmHg. There is normal leftventricular wall thickness with a normal cavity size. There is normal regional and global left ventricular systolic function. Quantitative biplane left ventricular ejection fraction is 73 %. Left ventricular cardiac index is depressed (less than 2.0 L/min/m2). There is no resting left ventricular outflow tract gradient. Diastolic parameters are indeterminate. Mildly dilated right ventricular cavity with moderate global free wall hypokinesis. Tricuspid annular plane systolic excursion (TAPSE) is depressed. There is abnormal interventricular septal motion c/w right ventricular pressure and volume overload. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. The aortic arch diameter is normal with a normal descending aorta diameter. The aortic valve leaflets (3) appear structurally normal. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral valve leaflets appear structurally normal with no mitral valve prolapse. There is trivial mitral regurgitation. The pulmonic valve leaflets are not well seen. The tricuspid valve leaflets appear structurally normal. There is moderate [2+] tricuspid regurgitation. There is moderate to severe pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Moderate to severe pulmonary artery systolic hypertension. Right ventricular cavity dilation with free wall hypokinesis. Moderate tricuspid regurgitation. RENAL U.S. Study Date of ___ 6:20 ___ 1. Atrophic kidneys bilaterally. No hydronephrosis. 2. Small right pleural effusion. CXR (___) Heart size is top-normal. Mediastinum is stable. Right basal opacities are minimal and unchanged, unlikely to represent infectious process but attention on the subsequent radiographs is recommended to this area. No pleural effusion or pneumothorax is seen ___: CT chest w/o contrast: 1. No evidence of interstitial lung disease. 2. Moderate upper lobe predominant centrilobular emphysema. 3. Small bilateral pleural effusions with minor associated atelectasis. '' 4. Coronary calcification. 5. Cholelithiasis without evidence of acute cholecystitis. 6. Few small lung nodules measuring up to at most 4 mm. These are very likely benign, but noting emphysema may be appropriate to consider follow-up chest CT for surveillance in ___ year. RECOMMENDATION(S): Follow-up chest CT is recommended for surveillance of very small, probably benign, lung nodules in ___ year.3. ___: RUQUS with duplex 1. Patent hepatic vasculature. No evidence for portal vein thrombosis 2. Loss of diastolic flow in the main hepatic artery is likely secondary to hepatic congestion. 3. Cholelithiasis without cholecystitis. 4. Small right pleural effusion. V/Q Scan: FINDINGS: Ventilation images demonstrate irregular tracer distribution in both lung fields. Perfusion images demonstrate irregular tracer uptake in both lung fields, worse on the left compared to the right. All perfusion images are matched but less apparent than the defects noted on ventilation imaging. Chest x-ray shows bibasilar infiltrates and pulmonary congestion. IMPRESSION: Ventilation images more apparent than perfusion images, most consistent with COPD/airways disease. No clear evidence of pulmonary thromboembolism. DISCHARGE LABS =============== ___ 06:19AM BLOOD WBC-9.8 RBC-3.47* Hgb-8.1* Hct-28.6* MCV-82 MCH-23.3* MCHC-28.3* RDW-22.3* RDWSD-65.3* Plt ___ ___ 06:19AM BLOOD ___ ___ 06:19AM BLOOD Plt ___ ___ 06:19AM BLOOD Glucose-80 UreaN-44* Creat-1.7* Na-139 K-4.7 Cl-107 HCO3-22 AnGap-10 ___ 06:10AM BLOOD ALT-12 AST-17 LD(LDH)-242 AlkPhos-100 TotBili-0.4 ___ 06:00AM BLOOD ___ ___ 05:37AM BLOOD CK-MB-3 cTropnT-<0.01 ___ 06:19AM BLOOD Calcium-9.0 Phos-3.3 Mg-2.1 ___ 05:55AM BLOOD calTIBC-300 Ferritn-31 TRF-231 ___ 06:47AM BLOOD ANCA-PND ___ 06:47AM BLOOD RheuFac-<10 ___ Cntromr-NEGATIVE ___ 06:47AM BLOOD C3-110 C4-23 ___ 06:47AM BLOOD HIV Ab-NEG ___ 05:55AM BLOOD Vanco-13.6 Brief Hospital Course: Ms. ___ is an ___ female with history of A. fib on Coumadin, chronic kidney disease, COPD on 2L O2, severe pulmonary hypertension who is presenting as a transfer from ___ ___ for bradycardia likely due to metabolic disturbances in the setting ___ from right sided heart failure/HFpEF, thought related to new severe pulmonary hypertension. Discharge Cr: 1.7 Discharge Weight: 168.21 lb (76.3 kg) Discharge Diuretic: Furosemide 10 mg daily Discharge Hgb: 8.1 ACUTE ISSUES: ============= #Bradycardia The patient presented with bradycardia in the setting of electrolyte disturbance and acidosis as transfer from ___ ___. Reportedly at the OSH her ECG was concerning for possible atrial fibrillation w/ complete heart block and both atropine and transcutaneous pacing were attempted prior to transfer. Of note, on arrival to ___ she was noted to be in atrial fibrillation w/ slow ventricular response and rates ___. Sequence of causality is unclear: ie, if patient was bradycardic leading to decreased renal perfusion and thus an acidosis or if patient was acidotic due to renal failure (or other cause) leading to bradycardia. However, given lack of other end organ damage, more likely the latter. Her troponins were negative so unlikely to be ischemic in etiology. She is on high doses of metoprolol and Diltiazem at home and denies taking more medications than prescribed. On arrival, the pt was briefly on a dopamine drip. In this setting, her metoprolol and dilitiazem were held and her metoprolol was slowly reintroduced. Her Bradycardia resolved. #Pulmonary Hypertension The patient had evidence of volume overload with elevated JVP and lower extremity edema consistent with right sided heart failure exacerbation. However with diuresis, the patient became orthostatic. RHC showed severe pulmonary hypertension. Likely group III iso oxygen dependent COPD but evaluation for other causes was recommended by pulmonary. Group I work up included ___, ANCA, CCP, anti-centromere pending at time of discharge, C3: 110, C4: 23, RF: <10, anti-RNP: negative, HIV: negative. She is s/p RUQUS with doppler for portopulmonary HTN: No evidence of porto-pulmonary HTN. Group III work up: was unable to acquire full PFTs - (spirometry, DLCO, lung volumes), has appointment on ___. A Non con CT chest: demonstrated emphysema. Regarding group IV workup, a VQ scan was performed without evidence of PE. #HFpEF Patient with new diagnosis of HFpEF with evidence of right-sided HF likely secondary to COPD given elevated RV pressures on her TTE, right axis deviation/low limb lead voltage on her EKG. She is chronically on 3L but had an increased oxygen requirement intitially. She was initially diuresed with IV Lasix but this was ultimately held given mild ___. TTE this admission notable for RV dilation w free wall hypokinesis. She was diuresed with IV Lasix transitioned to torsemide. Held ACEi in the setting of ___. Received metoprolol as above, continued to hold diltiazem. Imdur was discontinued given absence of angina. Continued with IV Lasix lead to orthostatic hypotension and RHC was done to evaluate for volume overload. PCWP was normal at 10 and CI was normal at 2.82. PA pressure was ___ (47) consistent for severe pulmonary hypertension as above. At discharge, diuretic was her home dose of furosemide 10mg PO. #Atrial Fibrillation CHADS2VASC of 5 on warfarin. INR supratherapeutic on admission, initially held diltiazem and metoprolol iso of bradycardia. High doses of AV nodal blocking agents suggest that she has difficult to control rates. She had intermittent bouts of AF w/ RVR to 150s while her nodal agents were being held. We restarted her metoprolol and uptitrated to metoprolol tartrate 25mg q6H (her home dose of metop) and consolidated to 100mg succinate prior to discharge. Anticoagulation was continued with warfarin 3 mg after correction of coagulopathy. #Coagulopathy On arrival pt's INR was supratherapeutic to 6.0 with prolonged PTT and decreasing platelets. Possibly in the setting of congestive hepatopathy vs. due to changes in her PO intake prior to arrival. She was given PO vitamin K for three days, w/ normalization of her INR. Fibrinogen normal, blood smear showed 1+ schistocytes. Warfarin was restarted as above. #Iron Deficiency Anemia Pt w/ Hgb ___ this admission. Required intermittent pRBC. Her iron studies are consistent w/ Fe deficiency anemia (Ferritin 31, TIBC 300, Fe 17). Stool guaiac positive, but brown. Likely slow lower GI bleed iso supratherapeutic INR. INR reversed with vitamin K and Hgb stabilized. She should undergo EGD and a colonoscopy as an outpatient, but had adamantly refused inpatient evaluation. She received IV iron repletion x3 days. #Non-Anion Gap Metabolic Acidosis: Patient with non anion gap metabolic acidosis with respiratory acidosis. Bicarbonate is chronically around 18 but ph was 7.16 on presentation. Non anion gap metabolic acidosis likely due to renal failure from worsening heart failure or injury due to hypotensive event. She required small quantities of bicarb initially before her pH normalized. Renal was consulted while she was inpatient and improved without intervention. ___ on CKD: Patient has been seen by nephrologist with workup notable for negative spep, upep. Baseline creatinine in ___ ~1.5. Give exertional dyspnea, lower extremity dyspnea, and volume overload, likely pre-renal from decreased effective circulatory volume. Cr was 2.8 on admission and improved initially with diuresis. Diuresis was restarted with increase in Cr. on discharge Cr was 1.7. #Positive blood cultures #Leukocytosis #Possible Cellulitis She was briefly on vancomycin for possible GPC bactermia, but given speciation as CoNS only in one bottle, suspect this may have been contaminant. She had a full infectious workup which was negative and we transitioned her to Keflex to complete a 5 day course for cellulitis (___). CHRONIC ISSUES: =============== #Diabetes mellitus: on levemir 10U SQ qhs so switched to glargine 10mg qhs with sliding scale insulin while inpatient. #COPD: Baseline 3L of home O2 with extensive smoking history. Continued Advair. #gout: continued allopurinol, dose reduced to every other day in setting of worsening renal function. #CODE: DNR/okay to intubate #CONTACT/HCP: ___ ___ (son) TRANSITIONAL ISSUES ===================== [] Recommend performance of Full PFTs - spirometry, DLCO, lung volumes, which are scheduled at ___ on ___. [] Recommend follow up with a pulmonologist (she preferred to see a provider closer to home as outpatient follow up in ___ will be challenging for her to keep.) If possible outpatient follow-up should involve a local Pulmonologist (at ___) and PH specialist at ___. She has had relatively extensive pulmonary hypertension workup however still needs PFTs. We have scheduled an appointment for her on ___ at ___ with a pulmonary hypertension specialist. [] Recommend referral to a cardiologist given her bradycardia with heart block on admission and further titration of nodal blockers. [] Few small lung nodules measuring up to at most 4 mm. These are very likely benign, but noting emphysema may be appropriate to consider follow-up chest CT for surveillance in ___ year. [] Pt w/ iron deficiency anemia this admission w/ Hgb ___. Her stool was guaic positive, but pt did not have any BRBPR or melena, so suspecting slow ooze. She was repleted with IV iron. Consider EGD/Colonscopy as an outpatient. [] Consider transition from colesevelam to a statin. [] Consider continuing iron repletion as an outpatient. [] Diuretic management: she was discharged on lasix 10mg PO with notable lower extremity edema, further attempts at diuresis were made during her hospital course with worsening of her kidney function, absent of resolution of her edema and orthostasis. [] INR management: She was supratherapeutic with INR of 6 on admission please continue to monitor INR closely on discharge. She was ultimately continued on her home dose of 3 mg daily. [] Reduced allopurinol to every other day dosing due to decreased CrCl, if Cr improves can consider increasing dose. [] Monitor BP. Stopped ACE because she was normotensive at rest and intermittently orthostatic. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of breath 2. fosinopril 10 mg oral DAILY 3. levemir 10 Units Bedtime 4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 5. WelChol (colesevelam) 1875 mg oral BID 6. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 7. Omeprazole 40 mg PO DAILY 8. Allopurinol ___ mg PO DAILY 9. Metoprolol Succinate XL 100 mg PO DAILY 10. Diltiazem Extended-Release 240 mg PO DAILY 11. Warfarin 3 mg PO DAILY16 12. Vitamin D 1000 UNIT PO DAILY 13. Aspirin 81 mg PO DAILY 14. Furosemide 10 mg PO DAILY Discharge Medications: 1. Allopurinol ___ mg PO EVERY OTHER DAY RX *allopurinol ___ mg 1 tablet(s) by mouth every other day Disp #*15 Tablet Refills:*0 2. levemir 10 Units Bedtime 3. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of breath 4. Aspirin 81 mg PO DAILY 5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 6. Furosemide 10 mg PO DAILY 7. Metoprolol Succinate XL 100 mg PO DAILY 8. Omeprazole 40 mg PO DAILY 9. Vitamin D 1000 UNIT PO DAILY 10. Warfarin 3 mg PO DAILY16 11. WelChol (___) 1875 mg oral BID Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: ================== Bradycardia Pulmonary hypertension SECONDARY DIAGNOSIS: ==================== Atrial fibrillation Anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, Thank you for allowing us to participate in your care. WHY WAS I ADMITTED TO THE HOSPITAL? - Your heart rates were extremely slow. WHAT DID YOU DO FOR ME WHILE I WAS HERE? - Your heart rates were monitored closely. - We slowly restarted some your medications to control your heart rates. - You were treated with antibiotics for a possible skin infection. - Your blood was too thin, so we held a few doses of your blood thinner until it normalized. - You had a right heart catheterization which showed severe pulmonary hypertension so you were seen by lung doctors . After you leave: ================ - Please take your medications as prescribed. - Please attend any outpatient follow-up appointments you have upcoming. - Your primary care doctor ___ refer you to a local pulmonologist. We would also recommend that you follow up with a pulmonary hypertension specialist here at ___. We have made an appointment for you (see below) and there are pulmonary function tests scheduled for the same day. If you feel that you do not want to keep this appointment, please call the clinic to cancel. - Please work with your primary care provider to monitor your warfarin level or INR closely, if the level is too high it can cause bleeding. If it is too low, it can increase your risk of a stroke. - Please ask your primary care doctor to assist you in finding a pulmonologist close to your home. They can help further evaluate the causes of your shortness of breath. It was a pleasure participating in your care! We wish you the very best! Sincerely, Your ___ HealthCare Team Followup Instructions: ___

10013310-DS-17

DS

2153-07-21 00:00:00

2153-07-21 18:10:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Celebrex / Excedrin Migraine / Fluzone / glyburide / ibuprofen / metformin / tizanidine Attending: ___ Chief Complaint: Right-sided weakness, aphasia Major Surgical or Invasive Procedure: Mechanical thrombectomy PEG History of Present Illness: ___ is a ___ woman ___ speaking with a history of diabetes, dilated cardiomyopathy, hypertension, hyperlipidemia who presented initially to an outside hospital with acute onset right-sided weakness and aphasia. And most of it is provided by EMS run sheets as well as the history is limited, outside hospital records. Patient was otherwise last known well at 0835 this a.m. when she was talking on the phone with a relative. She got off the phone at that time. Unclear how she was discovered, however she was noted to have right-sided weakness right facial droop, and a aphasia. She was initially taken to an outside hospital. Initial ___ stroke scale was 27 for the findings as above. She was given TPA at 1005, after CT confirmed no hemorrhage. Initial blood pressures were less than 110. She was subsequently transferred to ___ for consideration for endovascular clot retrieval. Per daughter, the patient lives alone without assistance. Past Medical History: 1. CARDIAC RISK FACTORS - Diabetes - Hypertension - Dyslipidemia 2. CARDIAC HISTORY -Nonischemic cardiomyopathy (LVEF ___ 3. OTHER PAST MEDICAL HISTORY -Chronic low back pain Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Physical Exam: ADMISSION EXAMINATION: ====================== General: Drowsy but awakens to voice HEENT: NCAT, no oropharyngeal lesions, neck supple ___: RRR, no M/R/G Pulmonary: CTAB, no crackles or wheezes Abdomen: Soft, NT, ND, +BS, no guarding Extremities: Warm, no edema Neurologic Examination: - Mental status: Eyes open to voice. Does not follow commands. no spontaneous speech output - Cranial Nerves: PERRL 3->2 brisk. There is significant left gaze deviation but the patient is able to cross her eyes to the right. There is right facial droop. Visual fields difficult to assess, no significant blink to threat on either side. - Sensorimotor: Left upper extremity is antigravity for at least 10 seconds. Left lower extremity briskly withdraws to noxious but does not clearly give good antigravity effort. Right lower extremity withdraws slightly against gravity to noxious. Right upper extremity slightly withdraws off of the bed to noxious. - Reflexes: Plantar response flexor bilaterally - Coordination/gait deferred DISCHARGE PHYSICAL EXAMINATION: =============================== GENERAL: Elderly female sitting in chair, NAD. HEAD: NC/AT. Leftward gaze preference. NECK: Supple. CARDIAC: RRR, S1S2 w/o m/r/g. RESPIRATORY: Normal effort, CTABL. ABODMEN: Soft, NT, +BS. EXTREMITIES: Warm, non-pitting edema of feet and lower shins, intact pulses. NEUROLOGIC: Moves limbs spontaneously. Pertinent Results: ADMISSION LABS: =============== Labs: ___ 06:35AM BLOOD WBC:12.2* RBC:4.23 Hgb:10.0* Hct:33.3* MCV:79* MCH:23.6* MCHC:30.0* RDW:18.8* RDWSD:52.8* Plt Ct:282 ___ 06:35AM BLOOD Glucose:319* UreaN:47* Creat:1.2* Na:156* K:4.0 Cl:113* HCO3:27 AnGap:16 ___ 06:35AM BLOOD Calcium:8.7 Phos:2.1* Mg:2.8* ___ 02:12PM BLOOD Type:ART pO2:81* pCO2:35 pH:7.49* calTCO2:27 Base XS:3 Intubat:NOT INTUBA ___ 01:28PM TSH-2.6 ___ 01:28PM %HbA1c-8.6* eAG-200* ___ 01:28PM TRIGLYCER-151* HDL CHOL-42 CHOL/HDL-2.5 LDL(CALC)-35 DISCHARGE LABS: =============== ___ 06:33AM BLOOD WBC-6.9 RBC-4.36 Hgb-9.6* Hct-33.3* MCV-76* MCH-22.0* MCHC-28.8* RDW-20.3* RDWSD-54.4* Plt ___ ___ 06:33AM BLOOD Glucose-322* UreaN-36* Creat-1.0 Na-138 K-4.7 Cl-93* HCO3-29 AnGap-16 MICROBIOLOGY: ============= ___ URINE URINE CULTURE-FINAL NEG ___ BLOOD CULTURE Blood Culture, Routine-FINAL NEG URINE (___) BETA STREPTOCOCCUS GROUP B. 10,000-100,000 CFU/mL. IMAGING: ======== CHEST XRAY (___) Left lower lobe atelectasis has improved substantially. Small bilateral pleural effusions are smaller. Moderate to severe cardiomegaly and pulmonary vascular engorgement have both improved. No pulmonary edema. No pneumothorax. Compared to previous chest radiographs TTE (___) Mild to moderately dilated left ventricle with severe global hypokinesis. No intracardiac thrombi identified (cardiac MRI may be more specific for left ventricular thrombi and TEE for left atrial appendage thrombus if this would change clinical management). Severe mitral regurgitation. At least moderate tricuspid regurgitation. Moderate to severe pulmonary hypertension. MR HEAD W/O CONTRAST (___) 1. Acute infarction involving the left MCA territory, ASPECTS of 1. There is involvement of the left occipital lobe. Evidence of cortical micro hemorrhage on gradient images only within the parietal, occipital, and temporal lobe. No evidence of parenchymal hematoma 2. Chronic small right frontal lobe infarct. LIVER OR GALLBLADDER US (___) Unremarkable abdominal ultrasound. CHEST (PORTABLE ___ Moderate cardiomegaly is chronic. Large heart obscures the left lower lobe where there is at least some atelectasis. Lateral view would be helpful to decide if there is pneumonia, and to assess pleural effusions probably small to moderate on both sides. No pulmonary edema. Pulmonary vasculature mildly engorged. ___ UNILAT LOWER EXT VEINS IMPRESSION: No evidence of deep venous thrombosis in the left lower extremity veins. ___ CXR IMPRESSION: Small bilateral pleural effusions and mild pulmonary edema. ___ ___ IMPRESSION: Stable distribution of infarcts, with large left MCA late subacute to chronic infarct, with areas of predominant cortical mineralization, with possible smaller components of cortical microhemorrhage, and interval volume loss. There is no gyral expansion or edema. There is no parenchymal hematoma Brief Hospital Course: BRIEF SUMMARY: ============== Ms. ___ is a ___ ___ speaking woman with a history notable for IDDM, HTN, HLD, recent MI s/p stent (___), and HFrEF (EF=20%)transferred from ___ after presenting with right-sided weakness and altered mental status (LKW ___ am ___. t-PA administered at OSH at 10:05 AM prior to transfer to ___. On arrival to ___ angiogram revealed occlusion of the left MCA at the M2 bifurcation, followed by mechanical thrombectomy with TICI 2b reperfusion of the left MCA territory after 3 passes at 11:00 AM. Following admission to Neuro ICU, exam was notable for somnolence and bradypnea, prompting NCHCT that revealed diffuse left MCA hyperdensity likely related to contrast administration. Follow-up MRI 24 hours after t-PA administration revealed microhemorrhages within the infarct bed affecting the parietal, occipital, and temporal lobes. Given patient's recent MI s/p DES, dual antiplatelets were subsequently resumed. ICU course otherwise notable for period of sinus tachycardia, ascribed to beta blocker withdrawal effect and somewhat improved on resuming home metoprolol dose, as well as pulmonary edema which responded to IV furosemide. She was transferred to the floor. Floor course complicated by aspiration PNA requiring antibiotic treatment & hyperglycemia requiring frequent adjustments in insulin regimen. PEG placed ___ for long-term nutrition. TRANSITIONAL ISSUES: =================== [ ] CRITICAL TO DO: Please follow this insulin regimen, as patient has been prone to significant hyperglycemia: [ ] NPH 60U given at 7PM (NEEDS TO BE GIVEN EXACTLY 1 HOUR BEFORE TUBE FEEDS ARE GIVEN) [ ] Sliding scale at breakfast, lunch, dinner, and before bedtime as written. [ ] Fasting sugar should be checked before each meal & sliding scale insulin should be administered based on this sugar value. [ ] If fasting sugar is > 400 or < 70 please call the MD on call to review insulin regimen. [ ] If tube feeds are held, start D10 at same rate of tube feeds [ } CRITICAL FOLLOW-UP: Needs ongoing titration of insulin regimen. Please arrange follow up with her endocrinologist Dr. ___ who is her primary endocrinologist for many years (daughter will arrange appointment). Pt used to be on Victoza in the past and per daughter she had achieved good glycemic control on that. Victoza is an outapatient treatment to consider if her hyperglycemia cannot be controlled despite titration of insulin doses. [ ] Diuretic regimen: torsemide 40mg BID, D/C Weight: 65.1 kg, 143.52 lb on standing scale. Please weigh daily and call MD if change in weight by 3 lbs. [ ] CAD regimen: aspirin 81mg daily, clopidogrel 75mg daily, rosuvastatin 40mg daily, isosorbide dinitrate 10mg 3x/day, metoprolol succinate 150mg daily [ ] D/C diet: pureed solids w/ nectar pre-thickened liquids & aspiration precautions [ ] Tube feeds as written Continuous tubefeeding: Start ___ Glucerna 1.5 Cal; Full strength Tube Type: Percutaneous gastrostomy (PEG); Placement confirmed. Starting rate: 90 ml/hr; Do not advance rate Goal rate: 90 ml/hr Cycle?: Yes Cycle start: ___ Cycle end: 0800 Residual Check: Q4H Hold feeding for residual >= : 200ml Flush w/ 30 mL water Per standard Free water amount: 50 mL; Free water frequency: Q6H ISSUES ADDRESSED: ================= # Left MCA stroke: MRI: "Acute infarction involving the left MCA territory. There is involvement of the left occipital lobe. Evidence of cortical microhemorrhage on gradient images only within the parietal, occipital, and temporal lobe. No evidence of parenchymal hematoma. Chronic small right frontal lobe infarct." Received t-PA administration & mechanical thrombectomy. Suffered residual deficits and required daily work w/ ___ & OT. Has Neurology f/u ___. # Aspiration PNA c/b sepsis, resolved: # Recurrent aspiration: ___ placed for TF. PEG ___. On medical floor, febrile w/ leukocytosis. Initial concern for UTI, started on empiric amp-sulb ___. CXR suspicious for aspiration PNA, switched to vancomycin and ceftriaxone. Ceftriaxone changed to ceftazidime ___, course was completed on ___. Repeat aspiration PNA w/ diet advancement required further treatment w/ ceftazadime for course completed ___. No further PNA or anti-infectives since that time. On d/c, PEG in place, diet on d/c pureed solids w/ nectar pre-thickened liquids & aspiration precautions w/ plans to advance as tolerated at rehab. # IDDM: Hospital course complicated by hyperglycemia and difficult control given intermittent tube feeds & NPO status. ___ followed. # HFrEF, last EF 20% ___: Home diuretic is torsemide 20mg BID, she suffered fluid overload when on ICU service & required IV diuretics. Maintained on furosemide 40mg PO QD until appeared overloaded on exam w/ lower extremity edema ___. Weight noted to be 10-lb increased from ___ (no weights charted in between). She was diuresed w/ furosemide 40mg IV (___) w/ adequate response but creatinine increased to 1.2 on ___ (from baseline 0.9). Diuresis was held ___ given creatinine increase to 1.2, creatinine remained @ 1.2 by ___, gave gentle hydration w/ improvement in creatinine to 1.0 ___. -Preload: D/c diuretic torsemide 40mg BID, d/c weight 65.1 kg, 143.52 lb. -Afterload: Did not initiate b/c of previous attempts w/ hyperkalemia. -NHBK: Was on metoprolol tartrate 25mg Q6H, increased to metoprolol tartrate 37.5mg PO Q6H given ST, plan to continue w/ metoprolol succinate 150mg daily on d/c. -Inotropy: None. # CAD s/p recent RCA STEMI with DES: Continued DAPT + statin + BB & isosorbide dinitrate. # Normocytic anemia: Stable, monitored H/H, did not require transfusions. # Glaucoma: Continued home eye drops. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspart 10 Units Breakfast Aspart 10 Units Lunch Aspart 10 Units Dinner Glargine 20 Units Bedtime 2. Torsemide 20 mg PO BID 3. Vitamin D 1000 UNIT PO DAILY 4. Aspirin EC 81 mg PO DAILY 5. Rosuvastatin Calcium 40 mg PO QPM 6. Isosorbide Dinitrate 10 mg PO TID 7. Clopidogrel 75 mg PO DAILY 8. Gabapentin 600 mg PO TID 9. Omeprazole 40 mg PO BID 10. Metoprolol Succinate XL 75 mg PO DAILY 11. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 12. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID 13. Tizanidine 2 mg PO Q8H:PRN muscle spasm 14. liraglutide 0.6 mg/0.1 mL (18 mg/3 mL) subcutaneous DAILY 15. Lidocaine 5% Patch 3 PTCH TD QAM 16. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID Discharge Medications: 1. Metoprolol Tartrate 150 mg PO DAILY 2. Multivitamins W/minerals Liquid 15 mL PO DAILY 3. NPH 60 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 4. Metoprolol Succinate XL 150 mg PO DAILY 5. Aspirin EC 81 mg PO DAILY 6. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID 7. Clopidogrel 75 mg PO DAILY 8. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID 9. Isosorbide Dinitrate 10 mg PO TID 10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 11. Rosuvastatin Calcium 40 mg PO QPM 12. Torsemide 40 mg PO BID 13. Vitamin D 1000 UNIT PO DAILY 14. HELD- Omeprazole 40 mg PO BID This medication was held. Do not restart Omeprazole until until directed by your phsyician. 15. HELD- Tizanidine 2 mg PO Q8H:PRN muscle spasm This medication was held. Do not restart Tizanidine until directed by your physician. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSES Left MCA Stroke ___ Acquired Pneumonia Insulin Dependent Diabetes Coronary Artery Disease, s/p STEMI with DES Acute on Chronic Systolic Heart Failure Acute on Chronic Kidney Disease SECONDARY DIAGNOSES Chronic systolic heart failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. ___ and family, It was a pleasure to care for you at the ___ ___. WHY WERE YOU ADMITTED: -You had weakness on the right side of your body and trouble speaking. WHAT HAPPENED WHEN YOU WERE HERE: -We found you had a stroke. We gave you medication to dissolve the clot and you had a procedure to remove it too. -You had an infection in your lungs that we treated with antibiotics. -We put a feeding tube in your stomach because we found you were unable to swallow food safely. WHAT SHOULD YOU DO WHEN YOU LEAVE: -Please take all of your medications as below. -Please make sure to follow up with your cardiologist for ongoing monitoring of your heart at the appointment listed below. -Please weigh yourself or have someone weigh you every morning on a standing scale. If your weight changes by 3 pounds then call your doctor because this might mean you are gaining too much fluid in your body. -If you notice worsening shortness of breath, chest pain, leg swelling, dizziness, or any other symptoms that concern you please let us know right away. We wish you the best! Your ___ Care Team Followup Instructions: ___

10013502-DS-19

DS

2159-01-02 00:00:00

2159-01-03 10:38:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Foot ulcer pain and fever. Major Surgical or Invasive Procedure: ___ line placement. History of Present Illness: Mr. ___ is a ___ male with DMII, Afib on coumadin (cardioverted in ___, HTN, and obesity here with fevers and diabetic foot ulcer. Patient noted this ulcer on the plantar aspect of his right foot two weeks ago after he pulled off some dead skin in that area. He has no feeling in either foot but has noted increase pain over his baseline. He went to his podiatrist (Dr. ___ at ___ 3 days prior to admission for some bothersome ulcers on L toe when podiatrist noted this wound and some associated red streaks extending up the foot. He debrided the wound and started patient on Augmentin. Wound culture reportedly sent at that time to patient's PCP at ___. The night prior to admission, patient woke up with fever to 101 and has been feeling generally unwell since debridement. The wound had been draining some yellow pus. In the ER, initial vitals 7 97.6 108 133/78 18 95% RA. Labs notable for WBC 12.7 (66%N), ESR 23, CRP 7.5, lactate and Chem 7 normal. Foot XR showed no clear evidence of osteo. Blood cultures were sent and he received vanc and unasyn. Currently, patient has mild bilateral foot pain related to his neuropathy. REVIEW OF SYSTEMS: (+) Per HPI dry cough, chronic abdominal pain and diarrhea (-) Denies weight change, Denies headache, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies vomiting. Denies dysuria, frequency, or urgency. Past Medical History: Neuropathy Insomnia Hypercholesteremia Hypertension DM (diabetes mellitus) type II Atrial fibrillation s/p cardioversion ___ Social History: ___ Family History: Mother had a large MI at age ___ and died from cancer/heart failure at age ___. Uncle had an MI in his late ___. Father's hx unknown. Physical Exam: EXAM ON ADMISSION: VS: 97.8 124/68 92 18 96%RA 147.7kg GENERAL: well appearing obese man in NAD HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM NECK: supple, no LAD, no JVD LUNGS: +scattered wheezes bilat, no rales, resp unlabored, no accessory muscle use HEART: RRR, no MRG, nl S1-S2 ABDOMEN: normal bowel sounds, soft, non-distended, no rebound or guarding, no masses, mild ttp over upper abdomen b/l EXTREMITIES: no edema, 2+ pulses pt dp though cooler toes on R than L, numb feet b/l, 2cm in diameter shallow clean-based round ulcer on plantar surface of R foot w/some faint red streaking to dorsal surface of foot, two bandaged toes on L EXAM ON DISCHARGE: VS: 97.6 140/83 ___ 97%RA ___ 185 GENERAL: well appearing obese man in NAD HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM NECK: supple, no LAD, no JVD LUNGS: clear to auscultation bilaterally, no rales, resp unlabored, no accessory muscle use HEART: regular, no MRG, nl S1-S2 ABDOMEN: normal bowel sounds, obese, non-distended, no rebound or guarding, no masses EXTREMITIES: no edema, 2+ pulses pt dp though cooler toes on R than L, numb feet b/l, 2cm in diameter shallow clean-based round ulcer on plantar surface of R foot w/no erythematous streaking, previous marks of streaking to dorsal surface of foot now resolved, L toe lesions without erythema or purulence Pertinent Results: Labs on Admission: ___ 06:05PM BLOOD WBC-12.7* RBC-5.03 Hgb-15.2 Hct-44.8 MCV-89 MCH-30.3 MCHC-34.0 RDW-12.6 Plt ___ ___ 06:05PM BLOOD Neuts-66.6 ___ Monos-5.5 Eos-1.5 Baso-0.7 ___ 06:05PM BLOOD ESR-23* ___ 06:05PM BLOOD Glucose-86 UreaN-19 Creat-1.1 Na-141 K-3.8 Cl-104 HCO3-25 AnGap-16 ___ 06:22PM BLOOD Lactate-1.6 ___ 08:10AM BLOOD Calcium-8.9 Phos-3.4 Mg-1.3* ___ 08:10AM BLOOD ALT-26 AST-27 AlkPhos-78 TotBili-0.5 ___ 08:10AM BLOOD ___ PTT-42.0* ___ Labs on Discharge: ___ 02:35AM BLOOD WBC-6.2 RBC-4.59* Hgb-13.9* Hct-41.1 MCV-90 MCH-30.3 MCHC-33.9 RDW-12.3 Plt ___ ___ 02:35AM BLOOD ___ PTT-38.9* ___ ___ 02:35AM BLOOD Glucose-187* UreaN-10 Creat-0.9 Na-137 K-4.6 Cl-100 HCO3-27 AnGap-15 ___ 02:35AM BLOOD Calcium-9.2 Phos-3.2 Mg-1.7 ___ 02:35AM BLOOD Vanco-10.5 ___ Blood cultures pending. XR FOOT AP,LAT & OBL RIGHT Study Date of ___: Soft tissue ulcer along the plantar and lateral aspect of the foot at the level of the midshaft of the metatarsals. No subcutaneous gas or definite radiographic evidence for osteomyelitis. Please note that MRI or bone scan is a more sensitive exam for the detection of osteomyelitis. CXR ___: Low lung volumes, no pleural effusions. No parenchymal abnormality, in particular no evidence of pneumonia. Borderline size of the cardiac silhouette without pulmonary edema. No hilar or mediastinal abnormalities. Brief Hospital Course: ___ with DMII c/b neuropathy here with a foot ulcer and fever. . # Neuropathic Foot ulcer: Despite debridement by podiatry and oral antibiotics as an outpatient, patient developed fever and cellulitis concerning for resistant organism. Wound culture from OSH shows only skin flora ___ strep, diptherioids) but the patient reports a history of MRSA ulcer infection. Wound had some lymphangitic spread on admission but resolved with vanc/unasyn, now on vanc/augmentin. Low levels of inflammatory markers (see results) and foot XR without e/o osteomyelitis make this unlikely. Patient has good pulses. Podiatry recommended wet to dry betadine dressings and f/u with outpatient podiatry provider. Has been afebrile throughout admission. Has PICC for continued vanc/augmentin to complete total ___s outpatient. Vanc trough 10.5 (therapeutic). . # Afib: Missed coumadin dose ___ night of admission; INR ___ -> ___ -> ___, below goal INR of ___. Was cardioverted in ___, regular rate and rhythm on exam. Continued coumadin and beta blocker. Patient will follow up in ___ clinic ___ to follow-up INR. . # Abdominal pain: Mild on admission and seemed resolved during admission. On last admission, pt was felt to have diverticulitis but current pain is located in the mid-epigastrium so differential more likely to include gastritis, GERD, gastroparesis, gallstones. Per patient he also has associated chronic diarrhea. LFTs/lipase unremarkable ___. . # DM2: continued home insulin regimen and restarted metformin on day prior to discharge. HgbA1c 8.5. # HL: continued statin. # HTN: continued BB, ACEi. . ## Transitional Issues ## 1. pending studies at discharge - blood cx's drawn ___, no growth to date, final pending 2. complete course of antibiotics for cellulitis with IV Vancomycin and PO Augmentin for total 7 day course (___) 3. f/u with outpt podiatrist for 5 metatarsal base resection 4. f/u with ___ for INR monitoring and Coumadin adjustment. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 20 mg PO DAILY 2. Glargine 56 Units Breakfast Glargine 30 Units Bedtime Humalog 18 Units Breakfast Humalog 18 Units Lunch Humalog 18 Units Dinner 3. Metoprolol Tartrate 100 mg PO BID HOLD for SBP < 100, HR < 60 4. Warfarin 8.75 mg PO 2X/WEEK (MO,FR) 5. Lisinopril 10 mg PO DAILY HOLD for SBP < 100 6. MetFORMIN (Glucophage) 1000 mg PO BID 7. oxyCODONE-acetaminophen *NF* ___ mg ORAL Q6H severe pain 8. Vitamin D 800 UNIT PO DAILY 9. Warfarin 10 mg PO 5X/WEEK (___) 10. Clonazepam 1 mg PO QHS:PRN insomnia Discharge Medications: 1. Atorvastatin 20 mg PO DAILY 2. Clonazepam 1 mg PO QHS:PRN insomnia 3. Glargine 56 Units Breakfast Glargine 30 Units Bedtime Humalog 18 Units Breakfast Humalog 18 Units Lunch Humalog 18 Units Dinner 4. Lisinopril 10 mg PO DAILY 5. Metoprolol Tartrate 100 mg PO BID 6. Vitamin D 800 UNIT PO DAILY 7. Warfarin 8.75 mg PO 2X/WEEK (MO,FR) 8. Warfarin 10 mg PO 5X/WEEK (___) 9. oxyCODONE-acetaminophen *NF* ___ mg ORAL Q6H severe pain 10. MetFORMIN (Glucophage) 1000 mg PO BID 11. Vancomycin 1500 mg IV Q 12H RX *vancomycin 750 mg 1500 mg(s) IV every twelve (12) hours Disp #*20 Vial Refills:*0 12. Amoxicillin-Clavulanic Acid ___ mg PO Q12H RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*10 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnosis: Neuropathic Diabetic Foot Ulcer c/b cellulitis Seconadry Diagnosis: Atrial Fibrillation s/p Cardioversion HTN Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you at ___. You were admitted for treatment of cellulitis complicating an ulcer on your right foot. You were started on antibiotics to treat this infection. Your infection appears markedly improved and you are now safe to return home. You missed your ___ evening warfarin dose. Your INR was 1.6 (below your goal of ___ for two days (on ___ and ___. Please follow up in ___ clinic and have your INR checked again on ___, they are aware and will be expecting you. We made the following changes to your medication: Please START Vancomycin Please CONTINUE Augmentin Followup Instructions: ___

10013502-DS-21

DS

2161-05-16 00:00:00

2161-05-16 13:55:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Right lower extremity stump infection. Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ man with history signficiant for diabetes and neuropathy with right BKA who now presents with purulent wound on stump. BKA was performed ___ due to diabetic foot infection and was well-healed and he was ambulating with a prosthesis. First noticed stump swelling ___, went to ___ ED on ___ and was admitted for cellulitis, treated with IV abx and discharged ___ on Bactrim. Went to wound clinic at ___ ___ and was admitted for I&D at the bedside and antibiotics, discharged ___. Wound was treated with wicks and dry dressings. Again seen at ___ wound ___ ___ and admitted ___ at ___, no surgical intervention, again discharged on Bactrim. He has since been seen twice at ___ for followup assessment and wound care. Inciting incident is unclear, although patient thinks it may be due to a new carbon fiber prosthesis he has been using since shortly before his problems began. Past Medical History: PMH: - Neuropathy - Insomnia - Hypercholesteremia - Hypertension - Type II diabetes mellitus with neurological manifestations - Chronic pain syndrome - Pain medication agreement - Adenomatous colon polyp - S/P R BKA (below knee amputation) unilateral - Diabetic ulcer of left foot - MRSA cellulitis - 1 episode of Afib resolved with cardioversion PSH: - R BKA - I&D of wound above R BKA at bedside - L shoulder surgery - Open appendectomy (pediatric) - Tonsillectomy (pediatric) Physical Exam: Physical Exam: Alert and oriented x 3 VS:BP 144/80 HR 82 RR 16 Resp: Lungs clear Abd: Soft, non tender Ext: Pulses: Left Femoral palp, DP palp ,___ palp Right Femoral palp, Right anterior stump wound: 8 cm length x 1 cm maximal width x superficial depth. Wound bed pink with no slough or necrosis. Periwound area is red but no surrounding erythema. Pertinent Results: CT Right lower extremity Thick periosteal reaction about the distal tibia and fibula amputation site. No cortical erosion or aggressive appearing periosteal reaction. If there is concern for osteomyelitis, MRI can be performed. Soft tissue edema and fluid. About the amputation site without absent soft tissue abscess. ___ 07:15AM BLOOD WBC-5.9 RBC-4.25* Hgb-12.1* Hct-36.5* MCV-86 MCH-28.5 MCHC-33.2 RDW-12.8 RDWSD-39.5 Plt ___ ___ 07:05AM BLOOD Glucose-207* UreaN-10 Creat-1.0 Na-139 K-4.5 Cl-100 HCO3-28 AnGap-16 ___ 07:05AM BLOOD Calcium-9.4 Phos-3.8 Mg-1.8 ___ 07:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Brief Hospital Course: Mr. ___ is a ___ man with history signficiant for diabetes and neuropathy with right BKA who now presents from PCP office with purulent wound on stump. BKA was performed ___ due to diabetic foot infection and was well-healed and he was ambulating with a prosthesis. First noticed stump swelling ___, went to ___ ED on ___ and was admitted for cellulitis, treated with IV abx and discharged ___ on Bactrim. Since that time, he has had 2 admissions of short course IV antibiotics with return of cellulitis when transitioned to an appropriate oral coverage for his cultured MRSA at an OSH. Of note MRI at OSH was negative for osteo andour CT showed no fluid/abscess at the site. He was treated initially with IV vanco/cipro and flagyl and the drainage and erythema quickly resolved. We open the wound at the bedsite to facility drainage and wound packing but the wound is superficial and does not tract. On the day prior to discharge, we transitioned to oral clinda and augmentin with no return of the erythema. We are concerned that the proximity of the bone to the wound as seen on CT may be problematic for prothesetic use. We plan to follow him closely as an outpatient. He is discharged to a friends house having declined to go to ___ transtional care house. Medications on Admission: - Percocet, ___, 1 tab Q4H PRN - Oxybutynin ER 5' - Gabapentin 900 mg TID - Metformin 1,000'' - Aspirin 81' - Vitamin D3 1,000u' - Atorvastatin 20' - Lisinopril 20' - Metoprolol tartrate 100'' - Insulin Glargine 64 Units subcutaneously daily - Insulin Aspart (NOVOLOG FLEXPEN) sliding scale Discharge Medications: 1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 20 mg PO QPM 4. Clindamycin 450 mg PO Q6H 5. Gabapentin 900 mg PO TID 6. Glargine 64 Units Bedtime Humalog 18 Units Breakfast Humalog 18 Units Lunch Humalog 18 Units Dinner Insulin SC Sliding Scale using HUM Insulin 7. MetFORMIN (Glucophage) 1000 mg PO BID 8. Metoprolol Tartrate 100 mg PO BID 9. Lisinopril 20 mg PO DAILY 10. Vitamin D 1000 UNIT PO DAILY 11. Oxybutynin 5 mg PO BID 12. Docusate Sodium 100 mg PO BID HOLD FOR LOOSE STOOLS 13. Senna 8.6 mg PO BID:PRN constipation 14. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain not to exceed 8 tabs/day. Discharge Disposition: Home Facility: ___ Discharge Diagnosis: Right lower extremity stump infection. Discharge Condition: Mental Status: Clear and coherent. Activity Status: Out of Bed with assistance to chair or wheelchair. Level of Consciousness: Alert and interactive. Discharge Instructions: Mr. ___, You were admitted to the hospital with an right lower extrmity stump wound with surrounding redness and infected appearing drainage. Although there was no fever or other signs of infection like elevated white blood cell count, we admitted you to the hospital as this has been a reoccuring problem despite oral antibiotics. You were started on IV antibiotics which stopped the drainage and redness. We need a CT scan that showed no pockets of fluid or infection. We then opened the area at the skin to allow drainage and packing of the wound. You were transitioned to oral antibiotics on the day prior to discharge with little change in the appearance of your wound. We will now follow you now very closely as an outpatient in the clinic. Followup Instructions: ___

10013569-DS-10

DS

2167-12-25 00:00:00

2167-12-25 16:07:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Percocet / Morphine / Codeine / Demerol / Iodine-Iodine Containing Attending: ___. Chief Complaint: dyspnea Major Surgical or Invasive Procedure: R thoracentesis Right heart cath x2 Swan placement and removal x2 PICC line placement and removal History of Present Illness: ___ w/ PMH significant for CHF (LVEF 30% in ___, ESRD s/p renal transplant in ___, type 1 diabetes, CAD, hld, and recent admission at ___ for CHF and possible RLL pneumonia, d/c on ___, recent admission to ___ for CHF exacerbation, now representing with dyspnea, hypoxia, concern for CHF exacerbation. A summary of recent medical history is as follow: on ___ she presented to ___ in ___ for CHF exacerbation (BNP of 8265). Diuresis was limited due to change in cr from 1.4 to 2.0 after several days of diuretics. OSH report Pt was 100.7 kg on admission on ___ kg on discharge on ___. She was discharged on torsemide 40mg po bid (was on furosemide 120mg po qam and 80mg po qpm) and spironolactone 25mg po bid (new). At home she has had worsening dyspnea despite taking medications as prescribed. She reports increasing edema, dyspnea, orthopnea. Pt denies fevers, chest pain, cough, any myalgias. On admission ___ pt found to have BNP 10902, CXR suggestive of volume overload w/ R pleural effusion. She was diuresed with lasix 80mg IV for a few doses and then discharged on PO torsemide 60mg qam and 40mg qpm with plans to follow-up ___ outpt cardiologist for TTE showing worsening EF (30->25%). Pt now complaining that ___ night she started having SOB, wheezing, and suprapubic pressure. She used nebs which helped but did not completely resolve the pain. ___ came yesterday and wanted to send the pt to her PCP, however she became very dyspneic and fatigued, couldn't move her arms. The husband called ___ and she was taken to ___ where the pt had a u/a which was clean, BNP 12449. Unclear from paperwork what was done for her there. She was transferred to ___ ED. The pt was transferred to ___ and initial vitals in the ED were 98.0 80 127/85 20 98% 2L. Labs revealed a K of 5.7, BUN/Cr 44/1.4, trop 0.02 and a BNP 11008. Her CXR prelim read was significant for large right sided pleural effusion. She was given furosemide 80 mg IV x1 but urine output was not recorded due to difficulties measuring urine. On the floor: 97.5 152/90 88 20 98%RA. The pt states she is improved but not back to baseline. Pt denies medication non-adherence, inc fluid intake or dietary indiscretion. REVIEW OF SYSTEMS: (+) per HPI (-) fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, nausea, vomiting, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: -CAD s/p CABG ___, s/p coronary angiography in ___ showing native 3VD but patent vv grafts (2) and patent LIMA-LAD. T -systolic CHF w/ EF 35-45% in ___ -pacemaker implanted, unclear type -chronic kidney disease s/p transplant ___ -HTN -hyperlipidemia -PVD s/p b/l BKAs -type 1 diabetes -osteoporosis -Peripheral neuropathy Social History: ___ Family History: -DM on mother's side. Physical Exam: On Admission: VS: 97.5 152/90 88 20 98%RA GENERAL: Hypervolemic, somewhat flat affect, setting in chair HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM NECK: supple, obese LUNGS: R sided decreased breathsounds, no wheezes HEART: RRR, no MRG, nl S1-S2 ABDOMEN: firm, nontender, mildly distended, edematous EXTREMITIES: bilateral BKA NEURO: awake, A&Ox3, CNs II-XII grossly intact, moving all extremities On Discharge: VS: Temp: 98.4/97.6 HR: 74-84, RR: 20, BP: 118-145/63-73, O2 sat: 100% RA I/O: 24h: 1140/2150 8h: 300/100, BM x2 Wt: 83.9 Tele: a paced ___: ___ Gen: A&Ox3, pleasant, in NAD HEENT: MM dry. OP clear. EOMI NECK: Supple, No LAD. JVP difficult to assess CV: RRR, no murmurs LUNGS: air exchange symmetric, CTAB ABD: NABS. Soft, NT, ND. EXT: B/l BKA, trace thigh edema, trace left hand edema Pertinent Results: Admission labs: ___ 12:30AM BLOOD WBC-8.6 RBC-5.16 Hgb-13.2 Hct-44.7 MCV-87 MCH-25.5* MCHC-29.4* RDW-15.9* Plt ___ ___ 12:30AM BLOOD Glucose-278* UreaN-44* Creat-1.4* Na-141 K-5.7* Cl-98 HCO3-28 AnGap-21* ___ 12:40AM BLOOD CK(CPK)-29 ___ 12:30AM BLOOD ___ ___ 07:45AM BLOOD Calcium-9.4 Phos-4.9* Mg-2.2 ___ 05:55AM BLOOD tacroFK-2.8* Other Relevant Labs: ___ 12:30AM BLOOD ___ ___ 12:30AM BLOOD cTropnT-0.02* ___ 07:45AM BLOOD CK-MB-5 cTropnT-0.01 ___ 05:55AM BLOOD ___ ___ 12:40AM BLOOD CK-MB-2 cTropnT-0.08* ___ 05:00AM BLOOD CK-MB-2 cTropnT-0.06* ___ 02:27PM BLOOD CK-MB-6 cTropnT-0.29* ___ 11:47PM BLOOD CK-MB-12* cTropnT-0.56* ___ 05:47AM BLOOD CK-MB-13* MB Indx-15.3* cTropnT-0.72* ___ 01:00PM BLOOD CK-MB-10 MB Indx-16.4* cTropnT-0.73* ___ 12:12AM BLOOD CK-MB-6 cTropnT-0.72* ___ 02:27PM BLOOD TSH-2.8 ___ 05:55AM BLOOD Anti-Tg-LESS THAN Thyrogl-21 ___ 03:30AM BLOOD ___ ___ 05:45PM BLOOD RheuFac-11 ___ 06:00AM BLOOD Digoxin-0.6* Discharge Labs: ___ 06:20AM BLOOD WBC-6.1 RBC-4.16* Hgb-10.8* Hct-34.1* MCV-82 MCH-25.9* MCHC-31.6 RDW-17.2* Plt ___ ___ 06:20AM BLOOD Glucose-332* UreaN-102* Creat-2.2* Na-133 K-3.6 Cl-92* HCO3-25 AnGap-20 ___ 06:20AM BLOOD Calcium-9.6 Phos-4.6* Mg-2.1 >> Imaging: ___ CXR: IMPRESSION: Enlarging right pleural effusion without pulmonary edema. Recommend obtaining PA and lateral chest radiograph. ___ Pleural fluid cytology: NEGATIVE FOR MALIGNANT CELLS. ___ Renal Transplant Ultrasound: IMPRESSION: Again the RIs are elevated compared to the previous examination with diminshed diastolic flow. As well, there is increased peak systolic velocity within the main renal artery. CXR ___ IMPRESSION: 1. A left-sided pacemaker remains in place. A right subclavian PICC line is unchanged. The right internal jugular Swan-___ catheter continues to be in the right pulmonary artery with the tip somewhat distal and a pullback of 3-4 cm has been previously conveyed to the house staff on ___ by Dr. ___, but the position remains unchanged. The heart remains stably enlarged. There has been some interval improvement in but there is persistent mild pulmonary edema. No pneumothorax is seen. No focal airspace consolidation is seen to suggest pneumonia. There is likely a layering right effusion with patchy streaky right basilar opacities likely reflectiing compressive atelectasis. ___: CARDIAC CATHETERIZATION: COMMENTS: 1. Resting hemodynamics revealed elevated left and right-sided filling pressures. The RA pressure was elevated at a mean of 30 mmHg. The mean PA pressure was elevated at 46 mmHg. The wedge pressure was 30 mmHg. 2. The pulmonary artery oxygen saturation was low at 26%. 3. Cardiac index was 1.27 L/min/m2 FINAL DIAGNOSIS: 1. Severe pulmonary hypertension. 2. Marked elevation of the RA and PCW pressures. 3. Markedly reduced cardiac index. 4. Elevated PVR. ___: ABD US: No ascites. ___: RENAL TRANSPLANT US: 1. Elevated intrarenal artery resistive indices, unchanged from ___, with diminished or no diastolic flow. Increased peak systolic velocity in the main renal artery, also unchanged. 2. Tiny right perinephric fluid is new from ___. ___ ___ BILATERAL: No evidence of bilateral lower extremity DVT. ___: CARDIAC CATHETERIZATION COMMENTS: 1. Selective resting hemodynamics revealed markedly elevated left sided filling pressure with mean PCWP 32mmHg. Severe pulmonary hypertension with mean PA 55mmHg and PASP 85mmHg. Cardiac output was low normal while on milrinone and dopamine infusions with arterial oxygenation obtained from pulse oximeter and assumped oxygen consumption. FINAL DIAGNOSIS: 1. Markedly elevated left sided filling pressures. 2. Severe pulmonary hypertension (predominantly secondary to left sided pressures). 3. Low normal cardiac output while on milrinone and dobutamine infusions. >> Micro: BCX ___: neg ___ 3:58 pm URINE Source: Catheter. URINE CULTURE (Final ___: GRAM POSITIVE COCCUS(COCCI). ~5000/ML. ___ 1:33 pm PLEURAL FLUID PRO BNP. GRAM STAIN (Final ___: 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Final ___: NO GROWTH. ___ 5:54 pm URINE Source: ___. URINE CULTURE (Final ___: ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ <=2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- =>16 R VANCOMYCIN------------ 1 S . ___ 5:20 pm URINE Source: ___. URINE CULTURE (Final ___: ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML.. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # ___ (___). . ___ 9:45 pm Rapid Respiratory Viral Screen & Culture Source: Nasopharyngeal swab. Respiratory Viral Culture (Final ___: No respiratory viruses isolated. Culture screened for Adenovirus, Influenza A & B, Parainfluenza type 1,2 & 3, and Respiratory Syncytial Virus..Detection of viruses other than those listed above will only be performed on specific request. Please call Virology at ___ within 1 week if additional testing is needed. Respiratory Viral Antigen Screen (Final ___: Negative for Respiratory Viral Antigen. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Refer to respiratory viral culture for further information. ___ 11:32 pm URINE Source: ___. URINE CULTURE (Final ___: KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 32 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S UCX ___: negative ___ 6:00 pm CATHETER TIP-IV Source: right PICC . WOUND CULTURE (Preliminary): No significant growth. Brief Hospital Course: ___ woman w/ PMH significant for CHF (LVEF 30% in ___, ESRD s/p renal transplant in ___, type 1 diabetes, CAD, hld, and recent admission at OSH for CHF and possible RLL pneumonia, d/c on ___, recent admission ___ for the CHF exacerbation, and presenting to ___ with worsening SOB and hypervolemia. # Acute on chronic systolic CHF: Pt presented with dyspnea likely flash pulmonary edema with unclear precipitant. Dyspnea exacerbated by R pleural effusion. Symptoms improved with diuresis, and with R thoracentesis with 1150cc fluid removed ___ have potential component of undiagnosed OSA she had worsening hypoxia at night. Patient was initially aggressively diuresed with IV lasix. However, patient developed fever and hypotension on ___, so diuresis was discontinued (both lasix and spironolactone). Patient remained very volume overloaded on physical exam, and her creatinine worsened. The heart failure service was consulted, she received right heart catheterization ___, which showed depressed cardiac index (1.2-1.9) and elevated biventricular pressures as well as elevated PA pressure, and she and was transferred to the CCU further management with a swan in place. In the CCU, she was started on milrinone and dopamine for inotropic support, and lasix drip for diuresis. Her CI improved to > 2, however on ___ she was found unresponsive in PEA after returning from the commode. She has ROSC after 1 min of CPR, and then had evidence off unstable A.fib/SVT. Dopamine and lasix were held temporarily, and were restarted once she spontaneously converted to sinus rhythm. The episode was attributed to vasovagal response and amiodarone was subsequently discontinued without recurrence of atrial fibrillation. She also received Metolazone 5mg BID to augment diuresis; also acetazolamide. Her beta blocker, ACE-I, and spironolactone were held in the setting of hypotension. Pulmonary was consulted for evaluation of lung disease and pulmonary hypertension and recommended above treatment and outpatient PFTs. Dopamine weaned ___, lasix gtt weaned and transitioned to PO torsemide ___, milrinone also weaned. Called out ___. Coreg had been restarted. Digoxin started ___ for inotropy. Her last CVP prior to removal of central line was 10. Her creatinine subsequently rose to >3 on the floor on PO torsemide so RHC repeated ___ which demonstrated markedly elevated left sided filling pressures, severe pulmonary hypertension, and low normal cardiac output while on milrinone and dopamine infusions. She was transferred back the CCU where she was continued on dopamine, milrinone and lasix drips with ___ again in place. Coreg discontinued and not restarted. Pt diuresed for multiple days on this regimen and then milrinone gtt was weaned. Swan was again discontinued and lasix gtt stopped and transionted to PO torsemide. Pt called out to the floor and dopamine subsequently weaned and discontinued. Pt's creatinine remained stable off inotropic support. I/Os remained even. When milrinone weaned off, hydralazine was uptitrated for afterload reduction. Imdur continued at 60. As dopamine weaned, hydral uptitrated further and Imdur subsequently uptitrated as well. Spironolactone subsequently restarted. Prior to ___ CCU transfer, Palliative care was consulted due to difficulty managing pt's heart failure as it seemed pt may be inotrope dependent in order to support renal functinon. Pt had multiple meetings with the palliative care team to discuss such topics and plan for future as prognosis relatively poor. # Acute on chronic renal failure: Patient is s/p renal transplant. Cr baseline 1.3-1.5. Pt with fluctuating renal function during long hospital course. Initial ___ prior to ___ CCU transfer (Cr up to 3.4) thought ___ cardiogenic hypoperfusion vs. infection/poor PO intake vs ATN in setting of hypotension. Transplant US (___) showed increased resistive index in the renal artery. FEUrea 18.3%, suggesting etiology was pre-renal. She was treated with milrinone, dopamine, furosemide, and Metolazone to augment urine output. Her ACE-I was held in the setting of ___. She was continued on mycophenolate mofetil and her tacrolimus was continued at goal trough of ___ initially. Pt's renal function improved on inotropic support and with lasix gtt. Cr improved to 1.8-2. Cr again rose to 3.2 on PO torsemide and pt subsequently returned on CCU on inotropic support. Cr improved to 2 range and was maintained as this level after wean of inotropes. At the time of discharge, her Cr was 2.2. Tacro levels were monitored through the admission at the direction of Transplant Nephrology. Prior to discharge Transplant Nephrology recommended increasing the dose of tacrolimus. The patient will have tacro levels drawn by ___ after discharge. # UTIs: Pt with fever and hypotension on ___, started on vanc/cefepime. Found to have ucx +enterococcus (___). CXR unchanged from prior. Bcx without growth. No diarrhea to raise concern for cdiff. +Myalgias concerning for flu, but DFA was negative for influenza. Pt initially started on vanc/cefepime, but when urine culture came back she was started on ampicillin for 7 day course for complicated UTI until ___. The patient developed an additional pansensitive Klebsiella UTI during this hospitalization. She was initially treated with ceftriaxone and later switched to cefpodixime (___). # Hyponatremia, resolved: Pt with intermitent hyponatremia, hypervolemic in nature from CHF. Pt s/p tolvaptan ___. On day of discharge Na was 133. # New AFib, resolved prior to discharge: She was found to have afib with RVR after her brief PEA on ___, and converted spontaneously to sinus rhythm. She was treated with amiodarone (loading IV, converted to PO load), which was subsequently discontinued after no recurrent episodes of afib. She was also started on a heparin bridge to coumadin, which also discontinued after no recurrent episodes of afib. # Hypertension: During this hospital stay lisinopril was held due to ___. Carvedilol was held in the setting of hypotension and inotrope use. Imdur and Hydralazine were used for afterload reduction and the patient was normotensive on these medications. # Type 1 Diabetes: Highly variable insulin regimen. Pt uses ___ levemir qhs plus tid sliding scale. Was getting 70 U levemir at OSH but pt states this was causing severe hypoglycemia. Due to persistent poor glycemic control per patient's dictated regimen, ___ was consulted, and recommended BID Lantus and humalog insulin sliding scale. Pt's insulin regimen generally changed on a daily basis per ___ recommendations. Although there were attempts to control FSG with BID lantus dosing the patient was eventually transition to levemir (her home medication) along with ISS prior to discharge. # Pulmonary Hypertension: Pulmonary consulted during CCU stay and have no further recs. Recommend PFT's as outpatient. # CAD s/p CABG: Continued home pravastatin, aspirin 81 daily. # Back pain, chronic: Continued home tramadol. Added lidoderm patch for better control of pain. # GERD: Continued home pantoprazole. # Neuropathy: Home dose of gabapentin was uptitrated during this admission. TRANSITIONAL ISSUES: # CODE: Full, confirmed # CONTACT: husband ___ ___. # Dry Weight 73kg - Please perform follow-up PFTs as outpatient to further evaluated pulmonary HTN - Please consider sleep study given evidence of night-time hypoxia Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Carvedilol 12.5 mg PO BID hold for sbp < 90 or HR < 60 3. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY hold for sbp < 90 4. Mycophenolate Mofetil 500 mg PO QAM 5. Mycophenolate Mofetil 1000 mg PO QPM 6. Pantoprazole 40 mg PO Q12H 7. Pravastatin 80 mg PO DAILY 8. Spironolactone 25 mg PO BID hold for sbp < 90 9. Tacrolimus 0.5 mg PO Q12H 10. TraMADOL (Ultram) 50 mg PO QHS: PRN back pain 11. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 12. Gabapentin 1200 mg PO HS 13. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN sob/wheeze 14. calcium carbonate-vitamin D3 *NF* 500 mg(1,250mg) -400 unit Oral daily 15. Vitamin D 50,000 UNIT PO MONTHLY Discharge Medications: 1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN sob/wheeze 2. Aspirin 81 mg PO DAILY 3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 4. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY RX *isosorbide mononitrate 30 mg three tablet(s) by mouth daily Disp #*90 Tablet Refills:*2 5. Mycophenolate Mofetil 500 mg PO QAM 6. Mycophenolate Mofetil 1000 mg PO QPM 7. Pantoprazole 40 mg PO Q12H 8. Pravastatin 80 mg PO DAILY 9. Spironolactone 25 mg PO DAILY 10. TraMADOL (Ultram) 50 mg PO QHS: PRN back pain 11. Acetaminophen 1000 mg PO TID 12. Digoxin 0.0625 mg PO DAILY RX *digoxin 125 mcg 0.5 (One half) tablet(s) by mouth daily Disp #*15 Tablet Refills:*2 13. HydrALAzine 50 mg PO Q8H RX *hydralazine 50 mg one tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*2 14. Metolazone 5 mg PO BID RX *metolazone 5 mg one tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*2 15. Torsemide 60 mg PO BID RX *torsemide [Demadex] 20 mg three tablet(s) by mouth twice a day Disp #*180 Tablet Refills:*2 16. calcium carbonate-vitamin D3 *NF* 500 mg(1,250mg) -400 unit Oral daily 17. Vitamin D 50,000 UNIT PO MONTHLY 18. Gabapentin 300 mg PO HS RX *gabapentin 300 mg one capsule(s) by mouth hs Disp #*30 Capsule Refills:*2 19. Tacrolimus 2 mg PO Q12H RX *tacrolimus 1 mg two capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*2 20. Levemir 60 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 21. Potassium Chloride 20 mEq PO DAILY RX *potassium chloride 20 mEq one tablet by mouth daily Disp #*30 Tablet Refills:*2 22. Outpatient Lab Work Please check chem-7 and tacrolimus level twice weekly with results to Dr. ___ at Phone: ___ and Fax: ___ and Dr. ___ at ___ fax and ___ fax. ICD 9: 585.6 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Acute on chronic systolic heart failure Acute on Chronic kidney injury Diabetes Mellitus type 1 End Stage renal disease s/p transplant Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure taking care of ___ at ___. ___ had an acute exacerbation of your heart failure and needed dopamine, milrinone and lasix intravenously to remove the extra fluid. Your weight at discharge is 170 pounds. Weigh yourself every morning, call Dr. ___ weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. ___ heart stopped beating and ___ were transferred back to the ICU, there was evidence of a heart rhythm called atrial fibrillation and a medicine called amiodarone was started but then stopped. ___ have not had further episodes of atrial fibrillation. Your kidney function worsened because of your heart but is now improving. ___ will need to have your tacromilus level checked twice a week with results to Dr. ___ at ___. Followup Instructions: ___

10013569-DS-9

DS

2167-11-14 00:00:00

2167-11-17 18:36:00

Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Percocet / Morphine / Codeine / Demerol / Iodine-Iodine Containing Attending: ___ Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: none History of Present Illness: ___ w/ PMH significant for CHF (LVEF 30% in ___, ESRD s/p renal transplant in ___, type 1 diabetes, CAD, hld, and recent admission at OSH for CHF and possible RLL pneumonia, d/c on ___, now presenting to ___ with worsening SOB. Pt reports that she had been feeling dyspneic since ___. She initially went to OSH ED and was diagnosed with acute bronchitis, prescribed steroids and nebulizer, which helped her symptoms. Pt feels that ever since then, she started to gain weight and become more edematous. She finally went to another OSH ___ ___ in ___) on ___, where she was treated for CHF exacerbation based on her BNP of 8265. Per discharge summary, her diuresis was limited by acute renal insufficiency w/ increase in Cr from baseline 1.4 to 2.0 after several days of diuretics. OSH report Pt was 100.7 kg on admission on ___ kg on discharge on ___. Pt was also noted to have significant stool in abdomen w/out evidence of obstruction, moderate R pleural effusion, and anasarca. Pt was given bowel regimen and also treated with azithromycin for 3 days and cefpodoxime 5 days on discharge (assuming they were started 2 days prior to discharge, but no mention in DC summary). She was also discharged on torsemide 40mg po bid (was on furosemide 120mg po qam and 80mg po qpm) and spironolactone 25mg po bid (new). Pt states that since she has been at home, her dyspnea has worsened. States that she has been taking her medications as prescribed by feels more edematous and dyspneic, with worsening orthopnea. Pt denies fevers, chest pain, cough, any myalgias. In the ED, initial vitals were 97.9 78 134/71 32 100% EKG showed v-paced rhythm at 73, difficult to compare to prior since that was sinus rhythm, but diffuse T wave inversions were also present at that time. BNP 10902, Troponin mildly elevated to 0.09 but no chest pain symptoms and CK-MB flat. Other labs benign and UA was bland. CXR suggestive of volume overload w/ R pleural effusion. Pt was given nitroglycerin 0.4mg w/ some improvement in dyspnea. Pt was also given aspirin 325 and renal consult was called. Pt was previously admitted for CHF exacerbations in the past, and per renal consult, Pt had a foley placed and was given furosemide 40mg iv x 1 w/ admission to ET service for further management. On arrival to the floor: 97.3, 145/79, 76, 20, 96% 2L nc. Wt 100kg bed. Pt states that she feels that her breathing is improved. Denies fever, cough, myalgias, rhinorrhea. States that she was taking all her medications as previously prescribed. Denies sick contacts, though she was recently hospitalized. ROS: per HPI, denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: -CAD s/p CABG ___, s/p coronary angiography in ___ showing native 3VD but patent vv grafts (2) and patent LIMA-LAD. T -systolic CHF w/ EF 35-45% in ___ -pacemaker implanted, unclear type -chronic kidney disease s/p transplant ___ -HTN -hyperlipidemia -PVD s/p b/l BKAs -type 1 diabetes -osteoporosis -Peripheral neuropathy Social History: ___ Family History: -DM on mother's side. Physical Exam: Admission: 97.3, 145/79, 76, 20, 96% 2L nc. Wt 100kg bed. GENERAL: obese woman sleeping in mild respiratory distress HEENT: Sclera icteric. PERRL, EOMI. Clear oropharynx NECK: Supple, JVP difficult to discern CARDIAC: RRR, normal S1, S2, no m/r/g LUNGS: reduced breath sounds in R > L bases, bibasilar inspiratory crackles, no wheezes ABDOMEN: normal bowel sounds, obese, distended, Soft, non-tender to palpation, no masses. 1+ pitting edema EXTREMITIES: 2+ pitting edema in bilateral upper extremities to elbows. Lower extremities s/p bilateral BKA. 2+ pitting edema to abdomen. NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout Discharge VS 98.3 131/70 75 20 96%RA GENERAL: A&Ox3, NAD, bilateral BKAs with prostheses HEENT: Sclera icteric. PERRL, EOMI. Clear oropharynx NECK: Supple, JVP difficult to discern CARDIAC: RRR, normal S1, S2, no m/r/g LUNGS: reduced breath sounds in R > L bases, no wheezes ABDOMEN: normal bowel sounds, obese, distended, Soft, non-tender to palpation, no masses. 1+ pitting edema EXTREMITIES: 2+ pitting edema in bilateral upper extremities to elbows. Lower extremities s/p bilateral BKA. 2+ pitting edema to abdomen. NEURO - awake, A&Ox3, moving all extremities Pertinent Results: ___ 07:30PM BLOOD WBC-8.3 RBC-4.78 Hgb-12.6 Hct-40.2 MCV-84 MCH-26.4* MCHC-31.4 RDW-15.7* Plt ___ ___ 06:55AM BLOOD WBC-7.0 RBC-4.71 Hgb-12.3 Hct-41.1 MCV-87 MCH-26.0* MCHC-29.8* RDW-15.8* Plt ___ ___ 07:30PM BLOOD Glucose-221* UreaN-61* Creat-1.5* Na-138 K-4.9 Cl-98 HCO3-23 AnGap-22* ___ 06:55AM BLOOD Glucose-46* UreaN-59* Creat-1.5* Na-142 K-4.3 Cl-100 HCO3-28 AnGap-18 ___ 07:30PM BLOOD ALT-17 AST-20 CK(CPK)-43 AlkPhos-65 TotBili-0.4 ___ 07:30PM BLOOD CK-MB-3 ___ ___ 07:30PM BLOOD cTropnT-0.09* ___ 07:20AM BLOOD CK-MB-3 cTropnT-0.08* ___ 06:45AM BLOOD tacroFK-3.3* ___ 06:40AM BLOOD tacroFK-5.7 ___ 07:30PM BLOOD Lactate-1.4 ___ ECG: Atrial sensing and ventricular pacing which has replaced regularly conducted beats. Clinical correlation is suggested. ___ CXR: IMPRESSION: Enlarged cardiac silhouette and engorged pulmonary hila with pulmonary vascular congestion may be due to CHF. Right lower hemithorax opacity could be due to pleural effusions with overlying atelectasis and/or consolidation, elevation of the right hemidiaphragm. If patient able, dedicated PA and lateral views would be helpful for further evaluation. ___ TTE: There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. Overall left ventricular systolic function is severely depressed (LVEF = 25 %). The right ventricular free wall thickness is normal. The right ventricular cavity is dilated with depressed free wall contractility. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. Significant pulmonic regurgitation is seen. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of ___, left ventricular contractile function is further impaired. Brief Hospital Course: ___ w/ PMH significant for CHF (LVEF 30% in ___, ESRD s/p renal transplant in ___, type 1 diabetes, CAD, hld, and recent admission at OSH for CHF and possible RLL pneumonia, d/c on ___, now presenting to ___ with worsening SOB and hypervolemia. ___ Exacerbation: The pt presented with worsening dyspnea, hypoxia, and weight gain. Most likely due to CHF exacerbation given elevated BNP, known CHF w/ history of exacerbations, clinical appearence of hypervolemia, and improvement with diuresis. The pt seems to have had difficulty with volume status since a prednisone taper in ___ for bronchitis. Pt was recently discharged from OSH on torsemide 40mg po bid plus spironolactone 25mg po bid, though previously taking furosemide 120mg po qam and 80mg po qpm. This is unlikely to be sufficient diuresis and may explain her repeat CHF exacerbation. The pt was treated initially with a few doses of lasix 80mg IV with significant output, and then transitioned to torsemide 60mg qam and 40mg qpm. The pt was successfully weaned from O2 and edema decreased, though still present at discharge. Repeat TTE showed worsening LVEF from 30% previously to 25%, without current ACS. Pt scheduled for f/u with outpt cardiology and home ___ to help with daily weights. # Dyspnea: mainly due to sCHF exacerbation as above. Pt also with some episodes of wheezing and mild hypoxia improved with albuterol nebs. Started on advair (which pt has taken in the past) and continued on home albuterol nebs. # s/p renal transplant: Cr is close to baseline (1.3-1.5). Prot/cr ratio 0.1. UA bland. No evidence of infection, obstruction, or rejection. Hypervolemia most likely cardiac in origin. Continued MMF 500mg po qam and 1000mg po qpm and tacrolimius 0.5mg po q12h. Tacro level 3.3 and 5.7 (goal ___. # Dysuria: Pt with pain at meatus, in the setting of foley in place, possibly worse with urination. U/a with blood but without e/o infection. Pain likely ___ trauma from foley. # Hypertension: normotensive. Lisinopril has been held due to ___. Continued home carvedilol, isosorbide mononitrate # Diabetes: highly variable insulin regimen. States ___ U levemir qhs plus tid sliding scale based on carb counting. During admission, treated with 30U glargine qhs (levemir is non-formulary) and humalog sliding scale adjusted per pt carb counting. . # h/o CAD s/p CABG: continued home pravastatin, aspirin 81 daily # Back pain, chronic: continued home tramadol # GERD: continued home pantoprazole # neuropathy: continued home gabapentin, of note, pt taking 2400mg qhs at home, agreed to decrease to 1200mg qhs. Transitional issues: # ___ at home, pt refused ___ rehab, which was recommended by ___ # ___ to check weekly BMP, tacro levels # Pt to f/u with outpt cardiologist re: decreased EF Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Carvedilol 12.5 mg PO BID hold for sbp < 90 or HR < 60 2. Vitamin D 50,000 UNIT PO MONTHLY 3. Torsemide 40 mg PO BID hold for sbp < 90 4. Gabapentin 2400 mg PO HS 5. Levemir 30 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY Start: In am hold for sbp < 90 7. Mycophenolate Mofetil 500 mg PO QAM Start: In am 8. Mycophenolate Mofetil 1000 mg PO QPM 9. Pantoprazole 40 mg PO Q12H 10. Spironolactone 25 mg PO BID hold for sbp < 90 11. Pravastatin 80 mg PO DAILY Start: In am 12. Tacrolimus 0.5 mg PO Q12H 13. Aspirin 81 mg PO DAILY Start: In am 14. calcium carbonate-vitamin D3 *NF* 500 mg(1,250mg) -400 unit Oral daily 15. TraMADOL (Ultram) 50 mg PO QHS: PRN back pain 16. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN sob/wheeze Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Carvedilol 12.5 mg PO BID hold for sbp < 90 or HR < 60 3. Levemir 30 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 4. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY hold for sbp < 90 5. Mycophenolate Mofetil 500 mg PO QAM 6. Mycophenolate Mofetil 1000 mg PO QPM 7. Pantoprazole 40 mg PO Q12H 8. Pravastatin 80 mg PO DAILY 9. Spironolactone 25 mg PO BID hold for sbp < 90 10. Tacrolimus 0.5 mg PO Q12H 11. Torsemide 60 mg PO QAM RX *torsemide 20 mg 3 tablet(s) by mouth qAM Disp #*90 Tablet Refills:*0 12. Torsemide 40 mg PO QPM RX *torsemide 20 mg 2 tablet(s) by mouth qpm Disp #*60 Tablet Refills:*0 13. TraMADOL (Ultram) 50 mg PO QHS: PRN back pain 14. calcium carbonate-vitamin D3 *NF* 500 mg(1,250mg) -400 unit Oral daily 15. Vitamin D 50,000 UNIT PO MONTHLY 16. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID RX *fluticasone-salmeterol [Advair Diskus] 250 mcg-50 mcg/Dose 1 disk INH twice a day Disp #*1 Inhaler Refills:*0 17. Gabapentin 1200 mg PO HS 18. Outpatient Lab Work On ___ Check basic metabolic panel, tacrolimus . Please fax results to ___ Attn Dr ___ 19. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN sob/wheeze Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: CHF exacerbation 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 ___, It was a pleasure participating in your care. You were admitted because of worsening shortness of breath and found to have to have retained too much fluid. You were given IV diuretics to help decrease this fluid and then restarted on oral diuretics. You also had some shortness of breath with wheezing that improved with nebulizers. Physical therapy evaluated you and felt you would benefit from ___ rehab. However you opted to return home with ___. Weigh yourself every morning, call MD if weight goes up more than 3 lbs. Followup Instructions: ___