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10,000,084 | 23,052,089 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Visual hallucinations
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
___ male with ___ disease, dyslipidemia, and a
history of prostate cancer (s/p prostatectomy) who was referred
to the ED by his neurologist for worsening gait, falls, and
visual hallucinations.
The following history is taken from chart review:
The patient was seen by his neurologist on ___ at which time he
was noted to have visual hallucinations and worsening gait
freezing. For his gait freezing, his mirapex was increased by
0.125 mg every week to a goal dose of 0.75 mg t.i.d. He
successfully up-titrated the medicine to 0.75/0.625/0.625 but
began to have visual hallucinations and confusion so on ___ his
neurologist recommended decreasing the dose to 0.625 TID.
Despite
the changes to his Mirapex, the patient's daughter has noted
progressive gait stiffness and increased difficulty standing.
This has resulted in difficulty with simply getting to the
bathroom leading to episodes of incontinence. A UA performed on
___ was reassuring.
On the day of presentation to the hospital, the patient began to
experience visual hallucinations of a motor cross race in his
backyard. He subsequently had a fall while transferring from the
couch to a chair. His wife was unable to get him off the floor.
The fall was witnessed and there was no head strike. Per the
patient's wife, his gait has acutely worsened over the past 24
hours to the point where he has been unable to ambulate on his
own. The patient's daughter called his neurologist who
recommended presentation to the ED.
In the ED, the patient was afebrile, HRs ___, normotensive, and
SpO2 100% RA. On exam he was noted to have cogwheeling of upper
extremities and decrease ___ strength. Labs were remarkable for a
negative urine and serum tox, Na 132, K 5.8 (hemolyzed and no
EKG
changes), negative troponin, normal LFTs, unremarkable CBC.
Chest
Xray showed no acute process and CTH was reassuring. He was
evaluated by neurology who recommended admission to medicine for
failure to thrive, to continue the patient's home medications,
and complete a toxo-metabolic workup. The patient was given his
home pramipexole and pravastatin before he was admitted.
On arrival to the floor, the patient is comfortable in bed. He
is
not accompanied by family on my interview. He knows that he is
in
the hospital and that it is ___. He is not sure why he is here
and begins to tell me about a party in his house with a motor
cross race in his backyard. When I asked him about his fall, he
mentions that he has not had a fall for ___ years. He denies any
fevers, chills, cough, chest pain, abdominal pain, nausea,
diarrhea, or dysuria.
REVIEW OF SYSTEMS:
==================
Per HPI, otherwise, 10-point review of systems was within normal
limits.
Past Medical History:
___ disease
___ Body Dementia
dyslipidemia
prostate cancer (s/p prostatectomy)
Social History:
___
Family History:
His mother died at age ___ of "old age."
His father died of prostate cancer at ___. He has an older
sister
(age ___ and a younger sister (age ___. He has a younger
brother
(age ___. As noted, he has 2 daughters. There is no family
history of neurologic illness or dementia. There is no family
history of neurodevelopmental mental disorders such as learning
disability or ADHD. There is no family history of psychiatric
problems.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: reviewed in OMR
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
BACK: No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rashes.
NEUROLOGIC: AOx3. CN2-12 intact. cogwheel UE b/l. Increased tone
in LEs, ___ strength b/l ___. Normal sensation.
DISCHARGE PHYSICAL EXAM
======================
24 HR Data (last updated ___ @ 2340)
Temp: 97.7 (Tm 98.4), BP: 130/80 (130-153/80-90), HR: 80
(80-104), RR: 18 (___), O2 sat: 100% (95-100), O2 delivery: Ra
GENERAL: In no acute distress. Talking very quietly.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm.
NEUROLOGIC: AOx3. CN2-12 intact. cogwheel UE b/l. Increased tone
in LEs, ___ strength b/l ___. Normal sensation.
Pertinent Results:
ADMISSION LABS:
===============
___ 10:30PM BLOOD WBC-8.6 RBC-4.03* Hgb-12.8* Hct-38.2*
MCV-95 MCH-31.8 MCHC-33.5 RDW-13.0 RDWSD-45.2 Plt ___
___ 10:30PM BLOOD Neuts-48.1 ___ Monos-15.9*
Eos-2.0 Baso-0.6 Im ___ AbsNeut-4.13 AbsLymp-2.86
AbsMono-1.36* AbsEos-0.17 AbsBaso-0.05
___ 10:30PM BLOOD ___ PTT-23.4* ___
___ 10:30PM BLOOD Glucose-100 UreaN-17 Creat-0.8 Na-132*
K-5.8* Cl-98 HCO3-19* AnGap-15
___ 10:30PM BLOOD ALT-18 AST-38 AlkPhos-39* TotBili-0.4
___ 10:30PM BLOOD Lipase-47
___ 10:30PM BLOOD cTropnT-<0.01
___ 10:30PM BLOOD Albumin-4.0 Calcium-9.9 Phos-3.7 Mg-2.0
___ 10:30PM BLOOD VitB12-570
___ 10:30PM BLOOD TSH-1.4
___ 07:00AM BLOOD Trep Ab-NEG
___ 10:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
IMAGING:
========
___ Imaging CT HEAD W/O CONTRAST
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass.
There is
prominence of the ventricles and sulci suggestive of
involutional changes.
There is no evidence of fracture. The visualized portion of the
remaining
paranasal sinuses and middle ear cavities are clear. The
visualized portion of the orbits are unremarkable apart from
bilateral lens replacements.
IMPRESSION:
1. No acute intracranial abnormality. No hydrocephalus.
___ Imaging CHEST (PA & LAT)
IMPRESSION:
Mild atelectasis in the lung bases without focal consolidation.
Age-indeterminate moderate to severe compression deformity of a
low thoracic vertebral body.
DISCHARGE LABS:
===============
___ 06:21AM BLOOD WBC-7.0 RBC-4.02* Hgb-12.9* Hct-38.1*
MCV-95 MCH-32.1* MCHC-33.9 RDW-12.8 RDWSD-44.4 Plt ___
___ 06:21AM BLOOD Glucose-88 UreaN-10 Creat-0.7 Na-140
K-4.0 Cl-104 HCO3-24 AnGap-12
___ 06:21AM BLOOD Calcium-9.5 Phos-3.2 Mg-1.___ male with ___ disease, dyslipidemia, and a
history of prostate cancer (s/p prostatectomy) who was referred
to the ED by his neurologist for worsening gait, falls, and
visual hallucinations concerning for progression of his
neurologic disorder.
ACUTE/ACTIVE ISSUES:
====================
___ disease
___ Body Dementia
#Visual Hallucinations
The patient appears to have acute on chronic progression of his
___ disease. Unclear if this is disease progression or
underlying medical cause. Continued mirapex, rasagiline, and
rivastigmine. Neurology recommended started Seroquel for his
hallucinations.
He was evaluated by physical therapy who recommended rehab. This
recommendation was discussed with the family who opted for
discharge to home with home physical therapy as this was in line
with the patient's goals of care.
TRANSITIONAL ISSUES:
[] f/u visual hallucination symptoms on Seroquel
[] f/u physical therapy at home
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Rasagiline 1 mg PO DAILY
2. Pramipexole 0.625 mg PO TID
3. rivastigmine 9.5 mg/24 hr transdermal DAILY
4. Pravastatin 40 mg PO QPM
5. Cyanocobalamin Dose is Unknown PO DAILY
6. Loratadine 10 mg PO DAILY
Discharge Medications:
1. QUEtiapine Fumarate 25 mg PO QHS
RX *quetiapine 25 mg 1 tablet(s) by mouth AT NIGHT Disp #*30
Tablet Refills:*0
2. Loratadine 10 mg PO DAILY
3. Pramipexole 0.625 mg PO TID
4. Pravastatin 40 mg PO QPM
5. Rasagiline 1 mg PO DAILY
6. rivastigmine 9.5 mg/24 hr transdermal DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
___ Dementia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Dear Mr. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were sent to the emergency room by your neurologist who
was concerned that you were having visual hallucinations.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were started on a new medication to help treat your
symptoms.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
[
"G3183",
"F0280",
"R441",
"R296",
"E785",
"Z8546"
] |
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Visual hallucinations Major Surgical or Invasive Procedure: N/A History of Present Illness: [MASKED] male with [MASKED] disease, dyslipidemia, and a history of prostate cancer (s/p prostatectomy) who was referred to the ED by his neurologist for worsening gait, falls, and visual hallucinations. The following history is taken from chart review: The patient was seen by his neurologist on [MASKED] at which time he was noted to have visual hallucinations and worsening gait freezing. For his gait freezing, his mirapex was increased by 0.125 mg every week to a goal dose of 0.75 mg t.i.d. He successfully up-titrated the medicine to 0.75/0.625/0.625 but began to have visual hallucinations and confusion so on [MASKED] his neurologist recommended decreasing the dose to 0.625 TID. Despite the changes to his Mirapex, the patient's daughter has noted progressive gait stiffness and increased difficulty standing. This has resulted in difficulty with simply getting to the bathroom leading to episodes of incontinence. A UA performed on [MASKED] was reassuring. On the day of presentation to the hospital, the patient began to experience visual hallucinations of a motor cross race in his backyard. He subsequently had a fall while transferring from the couch to a chair. His wife was unable to get him off the floor. The fall was witnessed and there was no head strike. Per the patient's wife, his gait has acutely worsened over the past 24 hours to the point where he has been unable to ambulate on his own. The patient's daughter called his neurologist who recommended presentation to the ED. In the ED, the patient was afebrile, HRs [MASKED], normotensive, and SpO2 100% RA. On exam he was noted to have cogwheeling of upper extremities and decrease [MASKED] strength. Labs were remarkable for a negative urine and serum tox, Na 132, K 5.8 (hemolyzed and no EKG changes), negative troponin, normal LFTs, unremarkable CBC. Chest Xray showed no acute process and CTH was reassuring. He was evaluated by neurology who recommended admission to medicine for failure to thrive, to continue the patient's home medications, and complete a toxo-metabolic workup. The patient was given his home pramipexole and pravastatin before he was admitted. On arrival to the floor, the patient is comfortable in bed. He is not accompanied by family on my interview. He knows that he is in the hospital and that it is [MASKED]. He is not sure why he is here and begins to tell me about a party in his house with a motor cross race in his backyard. When I asked him about his fall, he mentions that he has not had a fall for [MASKED] years. He denies any fevers, chills, cough, chest pain, abdominal pain, nausea, diarrhea, or dysuria. REVIEW OF SYSTEMS: ================== Per HPI, otherwise, 10-point review of systems was within normal limits. Past Medical History: [MASKED] disease [MASKED] Body Dementia dyslipidemia prostate cancer (s/p prostatectomy) Social History: [MASKED] Family History: His mother died at age [MASKED] of "old age." His father died of prostate cancer at [MASKED]. He has an older sister (age [MASKED] and a younger sister (age [MASKED]. He has a younger brother (age [MASKED]. As noted, he has 2 daughters. There is no family history of neurologic illness or dementia. There is no family history of neurodevelopmental mental disorders such as learning disability or ADHD. There is no family history of psychiatric problems. Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VITALS: reviewed in OMR GENERAL: Alert and interactive. In no acute distress. HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM. NECK: No cervical lymphadenopathy. No JVD. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. BACK: No CVA tenderness. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. Cap refill <2s. No rashes. NEUROLOGIC: AOx3. CN2-12 intact. cogwheel UE b/l. Increased tone in LEs, [MASKED] strength b/l [MASKED]. Normal sensation. DISCHARGE PHYSICAL EXAM ====================== 24 HR Data (last updated [MASKED] @ 2340) Temp: 97.7 (Tm 98.4), BP: 130/80 (130-153/80-90), HR: 80 (80-104), RR: 18 ([MASKED]), O2 sat: 100% (95-100), O2 delivery: Ra GENERAL: In no acute distress. Talking very quietly. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. NEUROLOGIC: AOx3. CN2-12 intact. cogwheel UE b/l. Increased tone in LEs, [MASKED] strength b/l [MASKED]. Normal sensation. Pertinent Results: ADMISSION LABS: =============== [MASKED] 10:30PM BLOOD WBC-8.6 RBC-4.03* Hgb-12.8* Hct-38.2* MCV-95 MCH-31.8 MCHC-33.5 RDW-13.0 RDWSD-45.2 Plt [MASKED] [MASKED] 10:30PM BLOOD Neuts-48.1 [MASKED] Monos-15.9* Eos-2.0 Baso-0.6 Im [MASKED] AbsNeut-4.13 AbsLymp-2.86 AbsMono-1.36* AbsEos-0.17 AbsBaso-0.05 [MASKED] 10:30PM BLOOD [MASKED] PTT-23.4* [MASKED] [MASKED] 10:30PM BLOOD Glucose-100 UreaN-17 Creat-0.8 Na-132* K-5.8* Cl-98 HCO3-19* AnGap-15 [MASKED] 10:30PM BLOOD ALT-18 AST-38 AlkPhos-39* TotBili-0.4 [MASKED] 10:30PM BLOOD Lipase-47 [MASKED] 10:30PM BLOOD cTropnT-<0.01 [MASKED] 10:30PM BLOOD Albumin-4.0 Calcium-9.9 Phos-3.7 Mg-2.0 [MASKED] 10:30PM BLOOD VitB12-570 [MASKED] 10:30PM BLOOD TSH-1.4 [MASKED] 07:00AM BLOOD Trep Ab-NEG [MASKED] 10:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG IMAGING: ======== [MASKED] Imaging CT HEAD W/O CONTRAST FINDINGS: There is no evidence of infarction, hemorrhage, edema, or mass. There is prominence of the ventricles and sulci suggestive of involutional changes. There is no evidence of fracture. The visualized portion of the remaining paranasal sinuses and middle ear cavities are clear. The visualized portion of the orbits are unremarkable apart from bilateral lens replacements. IMPRESSION: 1. No acute intracranial abnormality. No hydrocephalus. [MASKED] Imaging CHEST (PA & LAT) IMPRESSION: Mild atelectasis in the lung bases without focal consolidation. Age-indeterminate moderate to severe compression deformity of a low thoracic vertebral body. DISCHARGE LABS: =============== [MASKED] 06:21AM BLOOD WBC-7.0 RBC-4.02* Hgb-12.9* Hct-38.1* MCV-95 MCH-32.1* MCHC-33.9 RDW-12.8 RDWSD-44.4 Plt [MASKED] [MASKED] 06:21AM BLOOD Glucose-88 UreaN-10 Creat-0.7 Na-140 K-4.0 Cl-104 HCO3-24 AnGap-12 [MASKED] 06:21AM BLOOD Calcium-9.5 Phos-3.2 Mg-1.[MASKED] male with [MASKED] disease, dyslipidemia, and a history of prostate cancer (s/p prostatectomy) who was referred to the ED by his neurologist for worsening gait, falls, and visual hallucinations concerning for progression of his neurologic disorder. ACUTE/ACTIVE ISSUES: ==================== [MASKED] disease [MASKED] Body Dementia #Visual Hallucinations The patient appears to have acute on chronic progression of his [MASKED] disease. Unclear if this is disease progression or underlying medical cause. Continued mirapex, rasagiline, and rivastigmine. Neurology recommended started Seroquel for his hallucinations. He was evaluated by physical therapy who recommended rehab. This recommendation was discussed with the family who opted for discharge to home with home physical therapy as this was in line with the patient's goals of care. TRANSITIONAL ISSUES: [] f/u visual hallucination symptoms on Seroquel [] f/u physical therapy at home Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Rasagiline 1 mg PO DAILY 2. Pramipexole 0.625 mg PO TID 3. rivastigmine 9.5 mg/24 hr transdermal DAILY 4. Pravastatin 40 mg PO QPM 5. Cyanocobalamin Dose is Unknown PO DAILY 6. Loratadine 10 mg PO DAILY Discharge Medications: 1. QUEtiapine Fumarate 25 mg PO QHS RX *quetiapine 25 mg 1 tablet(s) by mouth AT NIGHT Disp #*30 Tablet Refills:*0 2. Loratadine 10 mg PO DAILY 3. Pramipexole 0.625 mg PO TID 4. Pravastatin 40 mg PO QPM 5. Rasagiline 1 mg PO DAILY 6. rivastigmine 9.5 mg/24 hr transdermal DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: [MASKED] Dementia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Discharge Instructions: Dear Mr. [MASKED], It was a privilege caring for you at [MASKED]. WHY WAS I IN THE HOSPITAL? - You were sent to the emergency room by your neurologist who was concerned that you were having visual hallucinations. WHAT HAPPENED TO ME IN THE HOSPITAL? - You were started on a new medication to help treat your symptoms. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Continue to take all your medicines and keep your appointments. We wish you the best! Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]
|
[] |
[
"E785"
] |
[
"G3183: Dementia with Lewy bodies",
"F0280: Dementia in other diseases classified elsewhere without behavioral disturbance",
"R441: Visual hallucinations",
"R296: Repeated falls",
"E785: Hyperlipidemia, unspecified",
"Z8546: Personal history of malignant neoplasm of prostate"
] |
10,000,117 | 22,927,623 |
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:
___
|
[
"R1310",
"R0989",
"K31819",
"K219",
"K449",
"F419",
"I341",
"M810",
"Z87891"
] |
Allergies: omeprazole Chief Complaint: dysphagia Major Surgical or Invasive Procedure: Upper endoscopy [MASKED] History of Present Illness: [MASKED] 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: [MASKED] 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 [MASKED] edema NEURO: CN II-XII grossly intact, motor function grossly normal, sensation grossly intact Pertinent Results: ============= ADMISSION LABS ============= [MASKED] 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 [MASKED] [MASKED] 08:27AM BLOOD [MASKED] PTT-28.6 [MASKED] [MASKED] 08:27AM BLOOD Glucose-85 UreaN-8 Creat-0.9 Na-142 K-3.6 Cl-104 HCO3-22 AnGap-20 [MASKED] 08:27AM BLOOD ALT-11 AST-16 LD(LDH)-154 AlkPhos-63 TotBili-1.0 [MASKED] 08:27AM BLOOD Albumin-4.8 ============= IMAGING ============= CXR [MASKED]: 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 [MASKED]: IMPRESSION: Within the limitation of plain radiography, no evidence of prevertebral soft tissue swelling or soft tissue mass in the neck. EGD: [MASKED] 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. [MASKED] if biopsies show eosinophilic esophagitis Brief Hospital Course: Ms. [MASKED] is a [MASKED] 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 [MASKED]. 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. [MASKED]. [MASKED] 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. [MASKED], You were hospitalized at [MASKED]. 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 [MASKED] Team Followup Instructions: [MASKED]
|
[] |
[
"K219",
"F419",
"Z87891"
] |
[
"R1310: Dysphagia, unspecified",
"R0989: Other specified symptoms and signs involving the circulatory and respiratory systems",
"K31819: Angiodysplasia of stomach and duodenum without bleeding",
"K219: Gastro-esophageal reflux disease without esophagitis",
"K449: Diaphragmatic hernia without obstruction or gangrene",
"F419: Anxiety disorder, unspecified",
"I341: Nonrheumatic mitral (valve) prolapse",
"M810: Age-related osteoporosis without current pathological fracture",
"Z87891: Personal history of nicotine dependence"
] |
10,000,117 | 27,988,844 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
omeprazole / Iodine and Iodide Containing Products /
hallucinogens
Attending: ___.
Chief Complaint:
Left hip pain
Major Surgical or Invasive Procedure:
Status post left CRPP ___, ___
History of Present Illness:
REASON FOR CONSULT: Femur fracture
HPI: ___ female presents with the above fracture s/p mechanical
fall. This morning, pt was walking ___, when dog
pulled on leash. Pt fell on L hip. Immediate pain. ___ ___ with movement. Denies Head strike, LOC or blood thinners.
Denies numbness or weakness in the extremities.
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:
General: Well-appearing female in no acute distress.
Left Lower extremity:
- Skin intact
- No deformity, edema, ecchymosis, erythema, induration
- Soft, non-tender thigh and leg
- Full, painless ROM knee, and ankle
- Fires ___
- SILT S/S/SP/DP/T distributions
- 1+ ___ pulses, 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 left valgus impacted femoral neck fracture and was
admitted to the orthopedic surgery service. The patient was
taken to the operating room on ___ for left closed reduction
and percutaneous pinning of hip, 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 with services 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
weightbearing as tolerated in the left lower extremity, and will
be discharged on Lovenox for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lactaid (lactase) 3,000 unit oral DAILY:PRN
2. Calcium Citrate + D (calcium citrate-vitamin D3) 315-200
mg-unit oral DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
3. Docusate Sodium 100 mg PO BID
4. Enoxaparin Sodium 40 mg SC QHS
RX *enoxaparin 40 mg/0.4 mL 40 mg Subcutaneously Nightly Disp
#*30 Syringe Refills:*0
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth q4 PRN Disp #*25 Tablet
Refills:*0
6. Senna 8.6 mg PO BID
7. Calcium Citrate + D (calcium citrate-vitamin D3) 315-200
mg-unit oral DAILY
8. Lactaid (lactase) 3,000 unit oral DAILY:PRN
9. Multivitamins 1 TAB PO DAILY
10. Vitamin D 400 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Left valgus impacted femoral neck fracture
Discharge Condition:
AVSS
NAD, A&Ox3
LLE: Incision well approximated. Dressing clean and dry. Fires
FHL, ___, TA, GCS. SILT ___ n distributions. 1+ DP
pulse, wwp distally.
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Weightbearing as tolerated left lower extremity
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
Followup Instructions:
___
|
[
"S72012A",
"W010XXA",
"Y93K1",
"Y92480",
"K219",
"E7800",
"I341",
"G43909",
"Z87891",
"Z87442",
"F419",
"M810",
"Z7901"
] |
Allergies: omeprazole / Iodine and Iodide Containing Products / hallucinogens Chief Complaint: Left hip pain Major Surgical or Invasive Procedure: Status post left CRPP [MASKED], [MASKED] History of Present Illness: REASON FOR CONSULT: Femur fracture HPI: [MASKED] female presents with the above fracture s/p mechanical fall. This morning, pt was walking [MASKED], when dog pulled on leash. Pt fell on L hip. Immediate pain. [MASKED] [MASKED] with movement. Denies Head strike, LOC or blood thinners. Denies numbness or weakness in the extremities. Past Medical History: - GERD - Hypercholesterolemia - Kidney stones - Mitral valve prolapse - Uterine fibroids - Osteoporosis - Migraine headaches Social History: [MASKED] Family History: + HTN - father + Dementia - father Physical Exam: General: Well-appearing female in no acute distress. Left Lower extremity: - Skin intact - No deformity, edema, ecchymosis, erythema, induration - Soft, non-tender thigh and leg - Full, painless ROM knee, and ankle - Fires [MASKED] - SILT S/S/SP/DP/T distributions - 1+ [MASKED] pulses, 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 left valgus impacted femoral neck fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on [MASKED] for left closed reduction and percutaneous pinning of hip, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given [MASKED] antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with [MASKED] who determined that discharge to home with services was appropriate. The [MASKED] 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 weightbearing as tolerated in the left lower extremity, and will be discharged on Lovenox for DVT prophylaxis. The patient will follow up with Dr. [MASKED] routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lactaid (lactase) 3,000 unit oral DAILY:PRN 2. Calcium Citrate + D (calcium citrate-vitamin D3) 315-200 mg-unit oral DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever 2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 3. Docusate Sodium 100 mg PO BID 4. Enoxaparin Sodium 40 mg SC QHS RX *enoxaparin 40 mg/0.4 mL 40 mg Subcutaneously Nightly Disp #*30 Syringe Refills:*0 5. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg 1 tablet(s) by mouth q4 PRN Disp #*25 Tablet Refills:*0 6. Senna 8.6 mg PO BID 7. Calcium Citrate + D (calcium citrate-vitamin D3) 315-200 mg-unit oral DAILY 8. Lactaid (lactase) 3,000 unit oral DAILY:PRN 9. Multivitamins 1 TAB PO DAILY 10. Vitamin D 400 UNIT PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Left valgus impacted femoral neck fracture Discharge Condition: AVSS NAD, A&Ox3 LLE: Incision well approximated. Dressing clean and dry. Fires FHL, [MASKED], TA, GCS. SILT [MASKED] n distributions. 1+ DP pulse, wwp distally. Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - Weightbearing as tolerated left lower extremity MEDICATIONS: 1) Take Tylenol [MASKED] every 6 hours around the clock. This is an over the counter medication. 2) Add oxycodone as needed for increased pain. Aim to wean off this medication in 1 week or sooner. This is an example on how to wean down: Take 1 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 Followup Instructions: [MASKED]
|
[] |
[
"K219",
"Z87891",
"F419",
"Z7901"
] |
[
"S72012A: Unspecified intracapsular fracture of left femur, initial encounter for closed fracture",
"W010XXA: Fall on same level from slipping, tripping and stumbling without subsequent striking against object, initial encounter",
"Y93K1: Activity, walking an animal",
"Y92480: Sidewalk as the place of occurrence of the external cause",
"K219: Gastro-esophageal reflux disease without esophagitis",
"E7800: Pure hypercholesterolemia, unspecified",
"I341: Nonrheumatic mitral (valve) prolapse",
"G43909: Migraine, unspecified, not intractable, without status migrainosus",
"Z87891: Personal history of nicotine dependence",
"Z87442: Personal history of urinary calculi",
"F419: Anxiety disorder, unspecified",
"M810: Age-related osteoporosis without current pathological fracture",
"Z7901: Long term (current) use of anticoagulants"
] |
10,000,980 | 20,897,796 |
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:
Patient is a ___ with history of coronary artery disease c/b
ischemic MR ___ DES to LCX ___, TTE ___ with mild regional LV
systolic dysfunction), heart failure with preserved ejection
fraction (LVEF 50% ___, peripheral vascular disease, chronic
kidney disease (stage IV), prior unprovoked DVT c/b severe UGIB
while on AC, HTN, dyslipidemia, and T2DM who presents with
several days of shortness of breath.
Patients says that she first noticed rather acute onset dyspnea
starting ___ when trying to walk up the stairs in her home.
She had to sit down and catch her breath, whereas just days
prior
she was able to mount ___ of stairs without difficulty.
Patient denies any associated chest pain or palpitations. No
dizziness or lightheadedness. Patient further denies any cough,
fevers/chills, or pleuritic chest discomfort. She has not
experienced any symptoms consistent with orthopnea or PND. No
increased ___ swelling, patient notes that she has experienced
this in the past.
Patient takes her weight nearly every day, 7lbs reported weight
gain over the past week (154lbs -> 161lbs), which she attributes
to eating more over the ___. She is currently
taking torsemide 40mg qd, no missed doses. No issues with
abdominal bloating or constipation. No recent travel.
Patient's
husband just recovered from a viral URI.
In the ED, initial VS were: 97.2 90 186/87 22 100% RA
Exam notable for:
Obvious bilateral wheezing.
No overt volume overload.
EKG: NSR (92bpm), normal axis, normal PR/QRS intervals, QTc 479,
q-waves III/aVF, TWIs III/aVF/V3/V6, submm lateral STDs, no
STEs.
Labs showed:
CBC 6.0>9.0/27.8<176 (PMNs 75.2%, MCV 97)
BMP 142/4.8/105/___/2.4/189
Trop <.01
proBNP 4512
VBG 7.33/40
UA: 1.010 SG, pH 6.0, urobilinogen NEG, bilirubin NEG, leuk NEG,
blood NEG, nitrite NEG, protein 100, glucose NEG, ketones NEG,
RBC 1, WBC 1, few bacteria
Imaging showed:
CXR ___
FINDINGS:
Lungs are moderately well-expanded. There is an asymmetric right
lower lung opacity, new from ___. The heart appears mildly
enlarged and there is mild pulmonary vascular congestion. No
pleural effusion or pneumothorax.
IMPRESSION:
Right lower lobe opacity could represent pneumonia in the right
clinical setting, although atelectasis or asymmetric pulmonary
edema could account for this finding. Dedicated PA and lateral
views could be helpful for further assessment.
Consults: NONE
Patient received:
___ 21:45 IH Albuterol 0.083% Neb Soln 1 NEB
___ 22:08 IH Albuterol 0.083% Neb Soln 1 NEB
___ 22:08 IH Ipratropium Bromide Neb 1 NEB
___ 22:47 IH Albuterol 0.083% Neb Soln 1 NEB
___ 22:47 IH Ipratropium Bromide Neb 1 NEB
___ 22:51 IV Azithromycin
___ 22:51 IV CefTRIAXone
___ 22:51 PO PredniSONE 60 mg
___ 22:51 IV Furosemide 80 mg
___ 23:01 IV CefTRIAXone 1 gm
___ 00:13 IV Azithromycin 500 mg
___ 00:23 PO/NG Atorvastatin 80 mg
___ 00:23 PO/NG Carvedilol 25 mg
___ 00:23 PO NIFEdipine (Extended Release) 60 mg
___ 00:23 IH Albuterol 0.083% Neb Soln 1 NEB
___ 00:23 IH Ipratropium Bromide Neb 1 NEB
___ 00:26 PO/NG Gabapentin 100 mg
___ 00:44 SC Insulin 4 Units
Transfer VS were: 98.2 77 141/76 18 100% 2L NC
On arrival to the floor, patient recounts the history as above.
She says that she feels improved after treatment in the ED, no
ongoing SOB.
10-point ROS is otherwise NEGATIVE.
Past Medical History:
Coronary artery disease
Peripheral vascular disease
Type II Diabetes Mellitus c/b diabetic retinopathy
Obesity
Esophageal ring
Hypertension
Dyslipidemia
Bilateral unprovoked posterior tibial DVTs (___) off AC given
severe UGIB
CKD Stage IV iso DM/HTN, secondary hyperparathyroidism
Anemia
Gout
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
==============================
VS: 97.5 162/93 78 16 100RA
GENERAL: Pleasant female appearing younger than her stated age,
taking deep breaths while speaking
HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM.
NECK: JVD 10 CM.
HEART: RRR, S1/S2, no murmurs, gallops, or rubs.
LUNGS: CTAB, no wheezes.
ABDOMEN: Obese abdomen, normoactive BS throughout, nondistended,
nontender in all quadrants, no rebound/guarding, no
hepatosplenomegaly.
EXTREMITIES: No cyanosis, clubbing, or edema.
PULSES: 2+ radial pulses bilaterally.
NEURO: A&Ox3, moving all 4 extremities with purpose.
SKIN: Warm and well perfused, no excoriations or lesions, no
rashes.
==============================
DISCHARGE PHYSICAL EXAM
==============================
VS: Afeb, 144/78, HR 57, 97% RA, RR 12
GEN: Well appearing in NAD
Neck: No JVD appreciated
CV: RRR no m/r/g, no carotid bruits appreciated
PULM: CTAB no wheezes, rales, or crackles. Symmetric expansion
EXT: warm well perfused, no pitting edema
Pertinent Results:
==============================
ADMISSION LABS
==============================
___ 09:37PM BLOOD WBC-6.0 RBC-2.88* Hgb-9.0* Hct-27.8*
MCV-97 MCH-31.3 MCHC-32.4 RDW-15.1 RDWSD-52.0* Plt ___
___ 09:37PM BLOOD Neuts-75.2* Lymphs-17.6* Monos-4.4*
Eos-1.8 Baso-0.3 Im ___ AbsNeut-4.49 AbsLymp-1.05*
AbsMono-0.26 AbsEos-0.11 AbsBaso-0.02
___ 06:40AM BLOOD ___ PTT-25.9 ___
___ 09:37PM BLOOD Glucose-189* UreaN-38* Creat-2.4* Na-142
K-4.8 Cl-105 HCO3-20* AnGap-17
___ 09:37PM BLOOD proBNP-4512*
___ 09:37PM BLOOD cTropnT-<0.01
___ 06:40AM BLOOD CK-MB-6 cTropnT-0.05*
___ 02:01PM BLOOD CK-MB-5 cTropnT-0.04*
___ 09:37PM BLOOD Calcium-9.4 Phos-4.1 Mg-2.3
___ 09:41PM BLOOD ___ pO2-30* pCO2-40 pH-7.33*
calTCO2-22 Base XS--5
==============================
IMAGING
==============================
TTE ___: The left atrial volume index is mildly increased.
The estimated right atrial pressure is ___ mmHg. Left
ventricular wall thicknesses and cavity size are normal. There
is mild regional left ventricular systolic dysfunction with
basal inferoseptal, inferior, inferolateral as well as mid
inferior/inferoseptal wall motion abnormalities. Doppler
parameters are most consistent with Grade II (moderate) left
ventricular diastolic dysfunction. 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. There is no aortic valve stenosis. Trace aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: 1) Mild regional LV systolic dysfunction c/w
prior myocardial infarction in the RCA territory. 2) Grade II
LV diastolic dysfunction.
Compared with the prior study (images reviewed) of ___, LV
sytolic function appears mildly less vigorous. Regional wall
motion abnormalities encompassess slightly greater territory.
CXR PA & LAT ___: No focal consolidation or pulmonary
edema.
BILATERAL LOWER EXTREMITY DOPPLER ULTRASOUND ___:
1. Nonocclusive thrombosis of one of the paired posterior tibial
veins in the bilateral lower extremities which appears grossly
unchanged compared to bilateral lower extremity ultrasound ___. No new deep venous thrombosis in either
extremity.
2. Right ___ cyst measuring up to 1.8 cm across maximal
diameter is
unchanged in size compared to ___.
==============================
MICROBIOLOGY
==============================
URINE CULTURE ___: ENTEROCOCCUS SP.. >100,000 CFU/mL.
BLOOD CULTURE ___: Blood Culture: PENDING
BLOOD CULTURE ___: Blood Culture: PENDING
==============================
DISCHARGE LABS
==============================
___ 05:45AM BLOOD WBC-5.1 RBC-2.57* Hgb-7.9* Hct-24.5*
MCV-95 MCH-30.7 MCHC-32.2 RDW-15.0 RDWSD-51.8* Plt ___
___ 05:45AM BLOOD Glucose-144* UreaN-49* Creat-2.6* Na-147
K-4.0 Cl-105 HCO3-24 AnGap-___ yo F PMH CAD c/b ischemic MR ___ DES to ___ ___, TTE ___
with mild regional LV systolic dysfunction), HFpEF (LVEF 50%
___, PAD, CKD (stage IV), prior DVT c/b severe UGIV on AC,
T2DM presents with subacute SOB, weight gain, c/f acute heart
failure exacerbation. She underwent diuresis with IV Lasix 80
mg, 120mg IV x2 with rapid improvement in subjective dyspnea.
___ showed no acute DVT, CXR without sign of consolidation.
Given her improvement in dyspnea, no supplemental O2
requirement, the patient was discharged w/o medication changes.
# Shortness of breath
# Hypoxia
# acute exacerbation of chronic diastolic heart failure with
preserved LVEF (50%)
Dry weight per pt 154 lbs. Admission weight above baseline, BNP
elevated. Regarding trigger, suspect dietary vs uncontrolled
BP. No EKG changes for ACS, trop negative, repeat TTE showed
mild regional LV systolic dysfunction c/w prior myocardial
infarction in the RCA territory, as well as Grade II LV
diastolic dysfunction and similar to prior ___ TTE. Doubt PNA
given CXR and lack of cough/fever, doubt PE given low Wells'
score 1.5, and stable repeat ___. Underwent diuresis with IV
Lasix 80 mg, 120mg IV x2 with rapid improvement in subjective
dyspnea. Resumed home torsemide 40mg, nifedipine 60mg BID and
carvedilol 25mg BID. Was stable on RA prior to discharge.
# Hypertension - Patient missed her antiHTN medications earlier
day of admission. Continued home carvedilol 25mg BID and
nifedipine 60mg BID with holding parameters. Appears that a
trial of ___ or spironolactone would be limited by
hyperkalemia, so this was deferred.
# Urinary frequency/urge incontinence: occurred in setting of
diuresis, however UCx ordered in ED did grow enterococci, likely
colonization. If symptoms persists would revaluate/treat.
CHRONIC STABLE ISSUES
# Normocytic anemia (recent baseline Hb 9.4 ___ - Hb was at
baseline, no signs of active bleeding. Likely multifactorial,
anemia of chronic disease as well as decreased erythropoiten
production iso CKD.
# Non anion gap metabolic acidosis - Patient has intermittently
had a NAGMA in the past. No recent diarrhea. ___ suspect Type
IV RTA given advanced age and history of T2DM (both of which can
cause hyporeninemia).
# Stage IV Chronic Kidney Disease (baseline Cr 2.3-2.8) - CKD
iso HTN and T2DM, Cr is currently at baseline. Low K/Phos/Na
diet. Continued home calcitriol, avoided nephrotoxins and
renally dosed all medications.
# Coronary artery disease ___ DES to LCX ___: troponins were
trended from < 0.01 to 0.05 to 0.04 then stopped. CK-MB was
flat. Patient deneied any chest pain. A TTE showed mild
regional LV systolic dysfunction c/w prior myocardial infarction
in the RCA territory and similar to prior ___ TTE. Continued
home aspirin 81mg qd, home carvedilol 25mg BID with holding
parameters, home atorvastatin 80mg qHS.
# Type II Diabetes Mellitus (last HbA1C 6.4% ___ - Under
excellent control, most recently in the pre-diabetic range.
- Continue home 70/30 sliding scale (___t dinner if
blood sugar over 130, 10 units 90-130, none if blood sugar under
90)
# Dyslipidemia: continued home atorvastatin
# Insomnia: continued home gabapentin
# Gout: continued home allopurinol
==============================
TRANSITIONAL ISSUES
==============================
- Discharge weight: 69.2kg
- Discharge creatinine: 2.6
- Discharge oral diuretic: torsemide 40mg daily
- Transitional issue: consider outpatient epo with renal
- Transitional issue: BP goal of 140/90 per accord or even
130/80 per ACC/AHA ___ guidelines however anticipate difficulty
in adding additional agents iso CKD (limits use of clonidine)
and baseline potassium (would likely limit ___ or
spironolactone)
- TTE showed prior LV hypokinesis, could consider MIBI or
outpatient pharmacological stress test
- had some urinary retention/incontinence while undergoing IV
diuresis would assess for recurrent symptoms at routine
outpatient visits
#CODE: Full (confirmed)
#CONTACT: ___ (husband) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO EVERY OTHER DAY
2. Atorvastatin 80 mg PO QPM
3. Calcitriol 0.5 mcg PO DAILY
4. Carvedilol 25 mg PO BID
5. Gabapentin 100 mg PO QHS
6. NIFEdipine (Extended Release) 60 mg PO BID
7. Torsemide 40 mg PO DAILY
8. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
9. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
10. Aspirin 81 mg PO DAILY
11. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using 70/30 Insulin
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. Allopurinol ___ mg PO EVERY OTHER DAY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Calcitriol 0.5 mcg PO DAILY
6. Carvedilol 25 mg PO BID
7. Gabapentin 100 mg PO QHS
8. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using 70/30 Insulin
9. NIFEdipine (Extended Release) 60 mg PO BID
10. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
11. Torsemide 40 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
- Acute on chronic diastolic congestive heart failure
SECONDARY DIAGNOSES
- Hypertension
- History of prior DVT
- Anemia, NOS
- Chronic Kidney Disease stage IV
- Coronary Artery Disease ___ drug eluting stent
- Diabetes Mellitus Type 2 controlled
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 with shortness of breath and
weight gain. This was likely caused by an exacerbation of your
heart failure possibly from salty foods over the holiday.
While you were in the hospital:
- we gave you IV diuretics to help remove extra fluid
- we checked for pneumonia with a chest x-ray, there was no sign
of a pneumonia
- we checked for signs on new clots in your legs, there was no
new clot
Now that you are going home:
- continue to take all of your medications as prescribed
- monitor your salt intake, this should be no more than 2 grams
every day, ask your doctors for help with this if you do not
know how to keep track of your salt
- continue to weigh yourself every morning, call your doctor if
weight goes up more than 3 lbs.
- follow-up with your primary care doctor regarding your blood
pressure and blood sugar control
It was a pleasure taking care of you!
Your ___ Inpatient Care Team
Followup Instructions:
___
|
[
"I130",
"I5033",
"E872",
"N184",
"E1122",
"N2581",
"I2510",
"E11319",
"D6489",
"E785",
"Z955",
"Z86718",
"I252",
"Z2239",
"G4700",
"M1A9XX0",
"R0902",
"E1151",
"Z794",
"E669",
"Z6831"
] |
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a [MASKED] with history of coronary artery disease c/b ischemic MR [MASKED] DES to LCX [MASKED], TTE [MASKED] with mild regional LV systolic dysfunction), heart failure with preserved ejection fraction (LVEF 50% [MASKED], peripheral vascular disease, chronic kidney disease (stage IV), prior unprovoked DVT c/b severe UGIB while on AC, HTN, dyslipidemia, and T2DM who presents with several days of shortness of breath. Patients says that she first noticed rather acute onset dyspnea starting [MASKED] when trying to walk up the stairs in her home. She had to sit down and catch her breath, whereas just days prior she was able to mount [MASKED] of stairs without difficulty. Patient denies any associated chest pain or palpitations. No dizziness or lightheadedness. Patient further denies any cough, fevers/chills, or pleuritic chest discomfort. She has not experienced any symptoms consistent with orthopnea or PND. No increased [MASKED] swelling, patient notes that she has experienced this in the past. Patient takes her weight nearly every day, 7lbs reported weight gain over the past week (154lbs -> 161lbs), which she attributes to eating more over the [MASKED]. She is currently taking torsemide 40mg qd, no missed doses. No issues with abdominal bloating or constipation. No recent travel. Patient's husband just recovered from a viral URI. In the ED, initial VS were: 97.2 90 186/87 22 100% RA Exam notable for: Obvious bilateral wheezing. No overt volume overload. EKG: NSR (92bpm), normal axis, normal PR/QRS intervals, QTc 479, q-waves III/aVF, TWIs III/aVF/V3/V6, submm lateral STDs, no STEs. Labs showed: CBC 6.0>9.0/27.8<176 (PMNs 75.2%, MCV 97) BMP 142/4.8/105/[MASKED]/2.4/189 Trop <.01 proBNP 4512 VBG 7.33/40 UA: 1.010 SG, pH 6.0, urobilinogen NEG, bilirubin NEG, leuk NEG, blood NEG, nitrite NEG, protein 100, glucose NEG, ketones NEG, RBC 1, WBC 1, few bacteria Imaging showed: CXR [MASKED] FINDINGS: Lungs are moderately well-expanded. There is an asymmetric right lower lung opacity, new from [MASKED]. The heart appears mildly enlarged and there is mild pulmonary vascular congestion. No pleural effusion or pneumothorax. IMPRESSION: Right lower lobe opacity could represent pneumonia in the right clinical setting, although atelectasis or asymmetric pulmonary edema could account for this finding. Dedicated PA and lateral views could be helpful for further assessment. Consults: NONE Patient received: [MASKED] 21:45 IH Albuterol 0.083% Neb Soln 1 NEB [MASKED] 22:08 IH Albuterol 0.083% Neb Soln 1 NEB [MASKED] 22:08 IH Ipratropium Bromide Neb 1 NEB [MASKED] 22:47 IH Albuterol 0.083% Neb Soln 1 NEB [MASKED] 22:47 IH Ipratropium Bromide Neb 1 NEB [MASKED] 22:51 IV Azithromycin [MASKED] 22:51 IV CefTRIAXone [MASKED] 22:51 PO PredniSONE 60 mg [MASKED] 22:51 IV Furosemide 80 mg [MASKED] 23:01 IV CefTRIAXone 1 gm [MASKED] 00:13 IV Azithromycin 500 mg [MASKED] 00:23 PO/NG Atorvastatin 80 mg [MASKED] 00:23 PO/NG Carvedilol 25 mg [MASKED] 00:23 PO NIFEdipine (Extended Release) 60 mg [MASKED] 00:23 IH Albuterol 0.083% Neb Soln 1 NEB [MASKED] 00:23 IH Ipratropium Bromide Neb 1 NEB [MASKED] 00:26 PO/NG Gabapentin 100 mg [MASKED] 00:44 SC Insulin 4 Units Transfer VS were: 98.2 77 141/76 18 100% 2L NC On arrival to the floor, patient recounts the history as above. She says that she feels improved after treatment in the ED, no ongoing SOB. 10-point ROS is otherwise NEGATIVE. Past Medical History: Coronary artery disease Peripheral vascular disease Type II Diabetes Mellitus c/b diabetic retinopathy Obesity Esophageal ring Hypertension Dyslipidemia Bilateral unprovoked posterior tibial DVTs ([MASKED]) off AC given severe UGIB CKD Stage IV iso DM/HTN, secondary hyperparathyroidism Anemia Gout Social History: [MASKED] Family History: Niece had some sort of cancer. Father died in his [MASKED] due to lung disease. Mother died in her [MASKED] due to an unknown cause. No early CAD or sudden cardiac death. No other known history of cancer. Physical Exam: ============================== ADMISSION PHYSICAL EXAM ============================== VS: 97.5 162/93 78 16 100RA GENERAL: Pleasant female appearing younger than her stated age, taking deep breaths while speaking HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM. NECK: JVD 10 CM. HEART: RRR, S1/S2, no murmurs, gallops, or rubs. LUNGS: CTAB, no wheezes. ABDOMEN: Obese abdomen, normoactive BS throughout, nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly. EXTREMITIES: No cyanosis, clubbing, or edema. PULSES: 2+ radial pulses bilaterally. NEURO: A&Ox3, moving all 4 extremities with purpose. SKIN: Warm and well perfused, no excoriations or lesions, no rashes. ============================== DISCHARGE PHYSICAL EXAM ============================== VS: Afeb, 144/78, HR 57, 97% RA, RR 12 GEN: Well appearing in NAD Neck: No JVD appreciated CV: RRR no m/r/g, no carotid bruits appreciated PULM: CTAB no wheezes, rales, or crackles. Symmetric expansion EXT: warm well perfused, no pitting edema Pertinent Results: ============================== ADMISSION LABS ============================== [MASKED] 09:37PM BLOOD WBC-6.0 RBC-2.88* Hgb-9.0* Hct-27.8* MCV-97 MCH-31.3 MCHC-32.4 RDW-15.1 RDWSD-52.0* Plt [MASKED] [MASKED] 09:37PM BLOOD Neuts-75.2* Lymphs-17.6* Monos-4.4* Eos-1.8 Baso-0.3 Im [MASKED] AbsNeut-4.49 AbsLymp-1.05* AbsMono-0.26 AbsEos-0.11 AbsBaso-0.02 [MASKED] 06:40AM BLOOD [MASKED] PTT-25.9 [MASKED] [MASKED] 09:37PM BLOOD Glucose-189* UreaN-38* Creat-2.4* Na-142 K-4.8 Cl-105 HCO3-20* AnGap-17 [MASKED] 09:37PM BLOOD proBNP-4512* [MASKED] 09:37PM BLOOD cTropnT-<0.01 [MASKED] 06:40AM BLOOD CK-MB-6 cTropnT-0.05* [MASKED] 02:01PM BLOOD CK-MB-5 cTropnT-0.04* [MASKED] 09:37PM BLOOD Calcium-9.4 Phos-4.1 Mg-2.3 [MASKED] 09:41PM BLOOD [MASKED] pO2-30* pCO2-40 pH-7.33* calTCO2-22 Base XS--5 ============================== IMAGING ============================== TTE [MASKED]: The left atrial volume index is mildly increased. The estimated right atrial pressure is [MASKED] mmHg. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with basal inferoseptal, inferior, inferolateral as well as mid inferior/inferoseptal wall motion abnormalities. Doppler parameters are most consistent with Grade II (moderate) left ventricular diastolic dysfunction. 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. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: 1) Mild regional LV systolic dysfunction c/w prior myocardial infarction in the RCA territory. 2) Grade II LV diastolic dysfunction. Compared with the prior study (images reviewed) of [MASKED], LV sytolic function appears mildly less vigorous. Regional wall motion abnormalities encompassess slightly greater territory. CXR PA & LAT [MASKED]: No focal consolidation or pulmonary edema. BILATERAL LOWER EXTREMITY DOPPLER ULTRASOUND [MASKED]: 1. Nonocclusive thrombosis of one of the paired posterior tibial veins in the bilateral lower extremities which appears grossly unchanged compared to bilateral lower extremity ultrasound [MASKED]. No new deep venous thrombosis in either extremity. 2. Right [MASKED] cyst measuring up to 1.8 cm across maximal diameter is unchanged in size compared to [MASKED]. ============================== MICROBIOLOGY ============================== URINE CULTURE [MASKED]: ENTEROCOCCUS SP.. >100,000 CFU/mL. BLOOD CULTURE [MASKED]: Blood Culture: PENDING BLOOD CULTURE [MASKED]: Blood Culture: PENDING ============================== DISCHARGE LABS ============================== [MASKED] 05:45AM BLOOD WBC-5.1 RBC-2.57* Hgb-7.9* Hct-24.5* MCV-95 MCH-30.7 MCHC-32.2 RDW-15.0 RDWSD-51.8* Plt [MASKED] [MASKED] 05:45AM BLOOD Glucose-144* UreaN-49* Creat-2.6* Na-147 K-4.0 Cl-105 HCO3-24 AnGap-[MASKED] yo F PMH CAD c/b ischemic MR [MASKED] DES to [MASKED] [MASKED], TTE [MASKED] with mild regional LV systolic dysfunction), HFpEF (LVEF 50% [MASKED], PAD, CKD (stage IV), prior DVT c/b severe UGIV on AC, T2DM presents with subacute SOB, weight gain, c/f acute heart failure exacerbation. She underwent diuresis with IV Lasix 80 mg, 120mg IV x2 with rapid improvement in subjective dyspnea. [MASKED] showed no acute DVT, CXR without sign of consolidation. Given her improvement in dyspnea, no supplemental O2 requirement, the patient was discharged w/o medication changes. # Shortness of breath # Hypoxia # acute exacerbation of chronic diastolic heart failure with preserved LVEF (50%) Dry weight per pt 154 lbs. Admission weight above baseline, BNP elevated. Regarding trigger, suspect dietary vs uncontrolled BP. No EKG changes for ACS, trop negative, repeat TTE showed mild regional LV systolic dysfunction c/w prior myocardial infarction in the RCA territory, as well as Grade II LV diastolic dysfunction and similar to prior [MASKED] TTE. Doubt PNA given CXR and lack of cough/fever, doubt PE given low Wells' score 1.5, and stable repeat [MASKED]. Underwent diuresis with IV Lasix 80 mg, 120mg IV x2 with rapid improvement in subjective dyspnea. Resumed home torsemide 40mg, nifedipine 60mg BID and carvedilol 25mg BID. Was stable on RA prior to discharge. # Hypertension - Patient missed her antiHTN medications earlier day of admission. Continued home carvedilol 25mg BID and nifedipine 60mg BID with holding parameters. Appears that a trial of [MASKED] or spironolactone would be limited by hyperkalemia, so this was deferred. # Urinary frequency/urge incontinence: occurred in setting of diuresis, however UCx ordered in ED did grow enterococci, likely colonization. If symptoms persists would revaluate/treat. CHRONIC STABLE ISSUES # Normocytic anemia (recent baseline Hb 9.4 [MASKED] - Hb was at baseline, no signs of active bleeding. Likely multifactorial, anemia of chronic disease as well as decreased erythropoiten production iso CKD. # Non anion gap metabolic acidosis - Patient has intermittently had a NAGMA in the past. No recent diarrhea. [MASKED] suspect Type IV RTA given advanced age and history of T2DM (both of which can cause hyporeninemia). # Stage IV Chronic Kidney Disease (baseline Cr 2.3-2.8) - CKD iso HTN and T2DM, Cr is currently at baseline. Low K/Phos/Na diet. Continued home calcitriol, avoided nephrotoxins and renally dosed all medications. # Coronary artery disease [MASKED] DES to LCX [MASKED]: troponins were trended from < 0.01 to 0.05 to 0.04 then stopped. CK-MB was flat. Patient deneied any chest pain. A TTE showed mild regional LV systolic dysfunction c/w prior myocardial infarction in the RCA territory and similar to prior [MASKED] TTE. Continued home aspirin 81mg qd, home carvedilol 25mg BID with holding parameters, home atorvastatin 80mg qHS. # Type II Diabetes Mellitus (last HbA1C 6.4% [MASKED] - Under excellent control, most recently in the pre-diabetic range. - Continue home 70/30 sliding scale ( t dinner if blood sugar over 130, 10 units 90-130, none if blood sugar under 90) # Dyslipidemia: continued home atorvastatin # Insomnia: continued home gabapentin # Gout: continued home allopurinol ============================== TRANSITIONAL ISSUES ============================== - Discharge weight: 69.2kg - Discharge creatinine: 2.6 - Discharge oral diuretic: torsemide 40mg daily - Transitional issue: consider outpatient epo with renal - Transitional issue: BP goal of 140/90 per accord or even 130/80 per ACC/AHA [MASKED] guidelines however anticipate difficulty in adding additional agents iso CKD (limits use of clonidine) and baseline potassium (would likely limit [MASKED] or spironolactone) - TTE showed prior LV hypokinesis, could consider MIBI or outpatient pharmacological stress test - had some urinary retention/incontinence while undergoing IV diuresis would assess for recurrent symptoms at routine outpatient visits #CODE: Full (confirmed) #CONTACT: [MASKED] (husband) [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol [MASKED] mg PO EVERY OTHER DAY 2. Atorvastatin 80 mg PO QPM 3. Calcitriol 0.5 mcg PO DAILY 4. Carvedilol 25 mg PO BID 5. Gabapentin 100 mg PO QHS 6. NIFEdipine (Extended Release) 60 mg PO BID 7. Torsemide 40 mg PO DAILY 8. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 9. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild 10. Aspirin 81 mg PO DAILY 11. Insulin SC Sliding Scale Insulin SC Sliding Scale using 70/30 Insulin Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild 2. Allopurinol [MASKED] mg PO EVERY OTHER DAY 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 80 mg PO QPM 5. Calcitriol 0.5 mcg PO DAILY 6. Carvedilol 25 mg PO BID 7. Gabapentin 100 mg PO QHS 8. Insulin SC Sliding Scale Insulin SC Sliding Scale using 70/30 Insulin 9. NIFEdipine (Extended Release) 60 mg PO BID 10. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 11. Torsemide 40 mg PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSIS - Acute on chronic diastolic congestive heart failure SECONDARY DIAGNOSES - Hypertension - History of prior DVT - Anemia, NOS - Chronic Kidney Disease stage IV - Coronary Artery Disease [MASKED] drug eluting stent - Diabetes Mellitus Type 2 controlled Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear [MASKED], You were admitted to the hospital with shortness of breath and weight gain. This was likely caused by an exacerbation of your heart failure possibly from salty foods over the holiday. While you were in the hospital: - we gave you IV diuretics to help remove extra fluid - we checked for pneumonia with a chest x-ray, there was no sign of a pneumonia - we checked for signs on new clots in your legs, there was no new clot Now that you are going home: - continue to take all of your medications as prescribed - monitor your salt intake, this should be no more than 2 grams every day, ask your doctors for help with this if you do not know how to keep track of your salt - continue to weigh yourself every morning, call your doctor if weight goes up more than 3 lbs. - follow-up with your primary care doctor regarding your blood pressure and blood sugar control It was a pleasure taking care of you! Your [MASKED] Inpatient Care Team Followup Instructions: [MASKED]
|
[] |
[
"I130",
"E872",
"E1122",
"I2510",
"E785",
"Z955",
"Z86718",
"I252",
"G4700",
"Z794",
"E669"
] |
[
"I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease",
"I5033: Acute on chronic diastolic (congestive) heart failure",
"E872: Acidosis",
"N184: Chronic kidney disease, stage 4 (severe)",
"E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease",
"N2581: Secondary hyperparathyroidism of renal origin",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema",
"D6489: Other specified anemias",
"E785: Hyperlipidemia, unspecified",
"Z955: Presence of coronary angioplasty implant and graft",
"Z86718: Personal history of other venous thrombosis and embolism",
"I252: Old myocardial infarction",
"Z2239: Carrier of other specified bacterial diseases",
"G4700: Insomnia, unspecified",
"M1A9XX0: Chronic gout, unspecified, without tophus (tophi)",
"R0902: Hypoxemia",
"E1151: Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene",
"Z794: Long term (current) use of insulin",
"E669: Obesity, unspecified",
"Z6831: Body mass index [BMI] 31.0-31.9, adult"
] |
10,000,980 | 25,911,675 |
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:
___
|
[
"D500",
"I5023",
"N184",
"E118",
"K2970",
"Z23",
"K259",
"K5730",
"I2510",
"Z87891",
"I252",
"Z955",
"I129",
"Z794",
"Z8673",
"R0789",
"Z86718",
"R791",
"T45515A",
"I70218",
"K222",
"K219"
] |
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: fatigue, anemia Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] 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 [MASKED] by her physician for anemia (Hgb 6.5). The patient was admitted to [MASKED] in [MASKED] 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. [MASKED] in [MASKED] 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 [MASKED] 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 [MASKED] 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 [MASKED] 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 [MASKED] - CAD (hx of MI in [MASKED] BMS to circumflex and POBA [MASKED] - peripheral arterial disease- claudication, followed by vascular, managed conservatively - stage IV CKD (baseline 2.1-2.6) - GERD/esophageal rings Social History: [MASKED] Family History: Niece had some sort of cancer. Father died in his [MASKED] due to lung disease. Mother died in her [MASKED] 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: [MASKED] 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: [MASKED] 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 ============================================= [MASKED] 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* [MASKED] 12:30PM [MASKED] [MASKED] 12:30PM ALBUMIN-4.1 CALCIUM-9.2 PHOSPHATE-4.7* IRON-61 [MASKED] 12:30PM calTIBC-303 FERRITIN-155* TRF-233 [MASKED] 12:30PM UREA N-42* CREAT-2.3* SODIUM-142 POTASSIUM-4.7 CHLORIDE-109* TOTAL CO2-23 ANION GAP-15 [MASKED] 04:50PM LD([MASKED])-247 TOT BILI-0.2 [MASKED] 04:50PM HAPTOGLOB-188 IMAGING: ============================================== LENIs ([MASKED]) 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 [MASKED] cyst. CXR ([MASKED]): 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 ([MASKED]): As compared to [MASKED], 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 ============================================== [MASKED] 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 [MASKED] [MASKED] 05:45AM BLOOD [MASKED] PTT-30.6 [MASKED] [MASKED] 05:45AM BLOOD Glucose-116* UreaN-41* Creat-2.1* Na-144 K-4.0 Cl-108 HCO3-25 AnGap-15 [MASKED] 04:50PM BLOOD LD(LDH)-247 TotBili-0.2 [MASKED] 05:45AM BLOOD Calcium-9.4 Phos-4.7* Mg-1.7 Brief Hospital Course: Ms. [MASKED] is a [MASKED] 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 [MASKED] by her physician for anemia. # Anemia: Patient presented with Hgb of 6.5, down from her recent baseline of ~7.5 since her [MASKED] 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: [MASKED] [MASKED] # CODE: full, confirmed Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Allopurinol [MASKED] 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 [MASKED] 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 ([MASKED]) 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 ([MASKED]) 19. 70/30 30 Units Dinner Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN pain or fever RX *acetaminophen 325 mg [MASKED] 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 [MASKED] 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 ([MASKED]) RX *warfarin 4 mg 1 tablet(s) by mouth 3X/WEEK Disp #*30 Tablet Refills:*0 16. Warfarin 3 mg PO 4X/WEEK ([MASKED]) 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 [MASKED] mg PO EVERY OTHER DAY RX *allopurinol [MASKED] 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: [MASKED] 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 [MASKED], 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 [MASKED] Team Followup Instructions: [MASKED]
|
[] |
[
"I2510",
"Z87891",
"I252",
"Z955",
"I129",
"Z794",
"Z8673",
"Z86718",
"K219"
] |
[
"D500: Iron deficiency anemia secondary to blood loss (chronic)",
"I5023: Acute on chronic systolic (congestive) heart failure",
"N184: Chronic kidney disease, stage 4 (severe)",
"E118: Type 2 diabetes mellitus with unspecified complications",
"K2970: Gastritis, unspecified, without bleeding",
"Z23: Encounter for immunization",
"K259: Gastric ulcer, unspecified as acute or chronic, without hemorrhage or perforation",
"K5730: Diverticulosis of large intestine without perforation or abscess without bleeding",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"Z87891: Personal history of nicotine dependence",
"I252: Old myocardial infarction",
"Z955: Presence of coronary angioplasty implant and graft",
"I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease",
"Z794: Long term (current) use of insulin",
"Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits",
"R0789: Other chest pain",
"Z86718: Personal history of other venous thrombosis and embolism",
"R791: Abnormal coagulation profile",
"T45515A: Adverse effect of anticoagulants, initial encounter",
"I70218: Atherosclerosis of native arteries of extremities with intermittent claudication, other extremity",
"K222: Esophageal obstruction",
"K219: Gastro-esophageal reflux disease without esophagitis"
] |
10,000,980 | 29,659,838 |
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:
___
|
[
"I5023",
"N184",
"D631",
"E1121",
"Z86718",
"I129",
"Z955",
"I2510",
"Z7901",
"Z794",
"I340",
"I252",
"Z8673",
"Z87891",
"Z91128",
"E785"
] |
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: dyspnea on exertion Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] with a history of of HTN, CAD s/p DES with ischemic MR and systolic dysfunction, [MASKED] 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. [MASKED] on [MASKED] 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 [MASKED] On the floor she is symptomatically improved since coming to the ED. Past Medical History: - hypertension - diabetes - hx CVA (cerebellar-medullary stroke in [MASKED] - CAD (hx of MI in [MASKED] BMS to circumflex and POBA [MASKED] - peripheral arterial disease- claudication, followed by vascular, managed conservatively - stage IV CKD (baseline 2.1-2.6) - GERD/esophageal rings Social History: [MASKED] Family History: Father died in his [MASKED] due to lung disease. Mother died in her [MASKED] 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 [MASKED] 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 [MASKED] 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 [MASKED] 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 [MASKED] 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 [MASKED] [MASKED] 11:55AM BLOOD Neuts-80.6* Lymphs-11.2* Monos-5.0 Eos-2.4 Baso-0.2 Im [MASKED] AbsNeut-4.38 AbsLymp-0.61* AbsMono-0.27 AbsEos-0.13 AbsBaso-0.01 [MASKED] 12:45PM BLOOD [MASKED] PTT-32.9 [MASKED] [MASKED] 07:30AM BLOOD Ret Aut-2.4* Abs Ret-0.06 [MASKED] 11:55AM BLOOD Glucose-153* UreaN-39* Creat-2.3* Na-146* K-5.4* Cl-115* HCO3-19* AnGap-17 [MASKED] 11:55AM BLOOD CK-MB-6 cTropnT-<0.01 [MASKED] [MASKED] 07:38PM BLOOD CK-MB-6 cTropnT-<0.01 [MASKED] 11:55AM BLOOD Calcium-9.0 Phos-3.9 Mg-1.8 DISCHARGE LABS ===== [MASKED] 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 [MASKED] [MASKED] 07:10AM BLOOD [MASKED] [MASKED] 07:10AM BLOOD Glucose-100 UreaN-37* Creat-1.9* Na-144 K-3.9 Cl-105 HCO3-29 AnGap-14 [MASKED] 07:10AM BLOOD Calcium-9.5 Phos-4.4 Mg-1.8 IMAGING ===== [MASKED] 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: [MASKED] year-old female with history of hypertension, CAD s/p DES with ischemic MR and systolic dysfunction, [MASKED], 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, [MASKED] 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 -[MASKED] 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 [MASKED] 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, [MASKED], +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 [MASKED], presented with Hgb 8. Likely [MASKED] 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 [MASKED], likely [MASKED] 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 [MASKED]. 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 [MASKED] UNIT PO DAILY 15. Warfarin 5 mg PO DAILY16 16. Allopurinol [MASKED] 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 [MASKED] UNIT PO DAILY 4. Acetaminophen 325-650 mg PO Q6H:PRN pain or fever 5. Allopurinol [MASKED] 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: [MASKED] 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. [MASKED], [MASKED] were admitted to [MASKED] for treatment of your congestive heart failure and hypertension. [MASKED] 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 [MASKED] during your stay- we wish [MASKED] all the best! - Your [MASKED] Team Followup Instructions: [MASKED]
|
[] |
[
"Z86718",
"I129",
"Z955",
"I2510",
"Z7901",
"Z794",
"I252",
"Z8673",
"Z87891",
"E785"
] |
[
"I5023: Acute on chronic systolic (congestive) heart failure",
"N184: Chronic kidney disease, stage 4 (severe)",
"D631: Anemia in chronic kidney disease",
"E1121: Type 2 diabetes mellitus with diabetic nephropathy",
"Z86718: Personal history of other venous thrombosis and embolism",
"I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease",
"Z955: Presence of coronary angioplasty implant and graft",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"Z7901: Long term (current) use of anticoagulants",
"Z794: Long term (current) use of insulin",
"I340: Nonrheumatic mitral (valve) insufficiency",
"I252: Old myocardial infarction",
"Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits",
"Z87891: Personal history of nicotine dependence",
"Z91128: Patient's intentional underdosing of medication regimen for other reason",
"E785: Hyperlipidemia, unspecified"
] |
10,001,401 | 21,544,441 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Bladder cancer
Major Surgical or Invasive Procedure:
robotic anterior exenteration and open ileal conduit
History of Present Illness:
___ with invasive bladder cancer, pelvic MRI concerning for
invasion into anterior vaginal wall, now s/p robotic anterior
exent (Dr ___ and open ileal conduit (Dr ___.
Past Medical History:
Hypertension, laparoscopic cholecystectomy
six months ago, left knee replacement six to ___ years ago,
laminectomy of L5-S1 at age ___, two vaginal deliveries.
Social History:
___
Family History:
Negative for bladder CA.
Physical Exam:
A&Ox3
Breathing comfortably on RA
WWP
Abd S/ND/appropriate postsurgical tenderness to palpation
Urostomy pink, viable
Pertinent Results:
___ 06:50AM BLOOD WBC-7.6 RBC-3.41* Hgb-10.6* Hct-32.5*
MCV-95 MCH-31.1 MCHC-32.6 RDW-14.4 RDWSD-50.2* Plt ___
___ 06:50AM BLOOD Plt ___
___ 06:45AM BLOOD Glucose-117* UreaN-23* Creat-0.6 Na-136
K-4.4 Cl-104 HCO3-23 AnGap-13
___ 06:45AM BLOOD Calcium-7.9* Phos-3.4 Mg-2.0
Brief Hospital Course:
Ms. ___ was admitted to the Urology service after
undergoing [robotic anterior exenteration with ileal conduit].
No concerning intrao-perative events occurred; please see
dictated operative note for details. Patient received
___ intravenous antibiotic prophylaxis and deep vein
thrombosis prophylaxis with subcutaneous heparin. The
post-operative course was notable for several episodes of emesis
prompting NGT placement on ___. Pt self removed the NGT on ___,
but nausea/emesis resolved thereafter and pt was gradually
advanced to a regular diet with passage of flatus without issue.
With advacement of diet, patient was transitioned from IV pain
medication to oral pain medications. The ostomy nurse
saw the patient for ostomy teaching. At the time of discharge
the wound was healing well with no evidence of erythema,
swelling, or purulent drainage. Her drain was removed. The
ostomy was perfused and patent, and one ureteral stent had
fallen out spontaneously. ___ was consulted and recommended
disposition to rehab. Post-operative follow up appointments
were arranged/discussed and the patient was discharged to rehab
for further recovery.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Heparin 5000 UNIT SC ONCE
Start: in O.R. Holding Area
2. Losartan Potassium 50 mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. Levothyroxine Sodium 175 mcg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Docusate Sodium 100 mg PO BID
take while taking narcotic pain meds
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*50 Capsule Refills:*0
3. Enoxaparin Sodium 40 mg SC DAILY
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 40 mg/0.4 mL 40 mg sc daily Disp #*28 Syringe
Refills:*0
4. Nitrofurantoin Monohyd (MacroBID) 100 mg PO DAILY
take while ureteral stents are in place
RX *nitrofurantoin monohyd/m-cryst [Macrobid] 100 mg 1
capsule(s) by mouth daily Disp #*14 Capsule Refills:*0
5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth q4h prn Disp #*30 Tablet
Refills:*0
6. Atorvastatin 10 mg PO QPM
7. Levothyroxine Sodium 175 mcg PO DAILY
8. Losartan Potassium 50 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Bladder cancer
Discharge Condition:
WdWn, NAD, AVSS
Abdomen soft, appropriately tender along incision
Incision is c/d/I (steris)
Stoma is well perfused; Urine color is yellow
Ureteral stent noted via stoma
JP drain has been removed
Bilateral lower extremities are warm, dry, well perfused. There
is no reported calf pain to deep palpation. No edema or pitting
Discharge Instructions:
-Please also refer to the handout of instructions provided to
you by your Urologist
-Please also refer to the instructions provided to you by the
Ostomy nurse specialist that details the required care and
management of your Urostomy
-You will be sent home with Visiting Nurse ___
services to facilitate your transition to home care 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
-___ you have been prescribed IBUPROFEN, please note that you may
take this in addition to the prescribed NARCOTIC pain
medications and/or tylenol. FIRST, alternate Tylenol
(acetaminophen) and Ibuprofen for pain control.
-REPLACE the Tylenol with the prescribed narcotic if the
narcotic is combined with Tylenol (examples include brand names
___, Tylenol #3 w/ codeine and their generic
equivalents). ALWAYS discuss your medications (especially when
using narcotics or new medications) use with the pharmacist when
you first retrieve your prescription if you have any questions.
Use the narcotic pain medication for break-through pain that is
>4 on the pain scale.
-The MAXIMUM dose of Tylenol (ACETAMINOPHEN) is 4 grams (from
ALL sources) PER DAY and remember that the prescribed narcotic
pain medication may also contain Tylenol (acetaminophen) so this
needs to be considered when monitoring your daily dose and
maximum.
-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.
-You may shower 2 days after surgery, but do not tub bathe,
swim, soak, or scrub incision for 2 weeks
-If you had a drain or skin clips (staples) removed from your
abdomen; bandage strips called steristrips have been applied
to close the wound OR the site was covered with a gauze
dressing. Allow any steristrips/bandage strips to fall off on
their own ___ days). PLEASE REMOVE any "gauze" dressings within
two days of discharge. Steristrips may get wet.
-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:
___
|
[
"C675",
"I10",
"D259",
"Z87891",
"E785",
"E890"
] |
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Bladder cancer Major Surgical or Invasive Procedure: robotic anterior exenteration and open ileal conduit History of Present Illness: [MASKED] with invasive bladder cancer, pelvic MRI concerning for invasion into anterior vaginal wall, now s/p robotic anterior exent (Dr [MASKED] and open ileal conduit (Dr [MASKED]. Past Medical History: Hypertension, laparoscopic cholecystectomy six months ago, left knee replacement six to [MASKED] years ago, laminectomy of L5-S1 at age [MASKED], two vaginal deliveries. Social History: [MASKED] Family History: Negative for bladder CA. Physical Exam: A&Ox3 Breathing comfortably on RA WWP Abd S/ND/appropriate postsurgical tenderness to palpation Urostomy pink, viable Pertinent Results: [MASKED] 06:50AM BLOOD WBC-7.6 RBC-3.41* Hgb-10.6* Hct-32.5* MCV-95 MCH-31.1 MCHC-32.6 RDW-14.4 RDWSD-50.2* Plt [MASKED] [MASKED] 06:50AM BLOOD Plt [MASKED] [MASKED] 06:45AM BLOOD Glucose-117* UreaN-23* Creat-0.6 Na-136 K-4.4 Cl-104 HCO3-23 AnGap-13 [MASKED] 06:45AM BLOOD Calcium-7.9* Phos-3.4 Mg-2.0 Brief Hospital Course: Ms. [MASKED] was admitted to the Urology service after undergoing [robotic anterior exenteration with ileal conduit]. No concerning intrao-perative events occurred; please see dictated operative note for details. Patient received [MASKED] intravenous antibiotic prophylaxis and deep vein thrombosis prophylaxis with subcutaneous heparin. The post-operative course was notable for several episodes of emesis prompting NGT placement on [MASKED]. Pt self removed the NGT on [MASKED], but nausea/emesis resolved thereafter and pt was gradually advanced to a regular diet with passage of flatus without issue. With advacement of diet, patient was transitioned from IV pain medication to oral pain medications. The ostomy nurse saw the patient for ostomy teaching. At the time of discharge the wound was healing well with no evidence of erythema, swelling, or purulent drainage. Her drain was removed. The ostomy was perfused and patent, and one ureteral stent had fallen out spontaneously. [MASKED] was consulted and recommended disposition to rehab. Post-operative follow up appointments were arranged/discussed and the patient was discharged to rehab for further recovery. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Heparin 5000 UNIT SC ONCE Start: in O.R. Holding Area 2. Losartan Potassium 50 mg PO DAILY 3. Atorvastatin 10 mg PO QPM 4. Levothyroxine Sodium 175 mcg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. Docusate Sodium 100 mg PO BID take while taking narcotic pain meds RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*50 Capsule Refills:*0 3. Enoxaparin Sodium 40 mg SC DAILY Start: [MASKED], First Dose: Next Routine Administration Time RX *enoxaparin 40 mg/0.4 mL 40 mg sc daily Disp #*28 Syringe Refills:*0 4. Nitrofurantoin Monohyd (MacroBID) 100 mg PO DAILY take while ureteral stents are in place RX *nitrofurantoin monohyd/m-cryst [Macrobid] 100 mg 1 capsule(s) by mouth daily Disp #*14 Capsule Refills:*0 5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg 1 tablet(s) by mouth q4h prn Disp #*30 Tablet Refills:*0 6. Atorvastatin 10 mg PO QPM 7. Levothyroxine Sodium 175 mcg PO DAILY 8. Losartan Potassium 50 mg PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Bladder cancer Discharge Condition: WdWn, NAD, AVSS Abdomen soft, appropriately tender along incision Incision is c/d/I (steris) Stoma is well perfused; Urine color is yellow Ureteral stent noted via stoma JP drain has been removed Bilateral lower extremities are warm, dry, well perfused. There is no reported calf pain to deep palpation. No edema or pitting Discharge Instructions: -Please also refer to the handout of instructions provided to you by your Urologist -Please also refer to the instructions provided to you by the Ostomy nurse specialist that details the required care and management of your Urostomy -You will be sent home with Visiting Nurse [MASKED] services to facilitate your transition to home care 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 -[MASKED] you have been prescribed IBUPROFEN, please note that you may take this in addition to the prescribed NARCOTIC pain medications and/or tylenol. FIRST, alternate Tylenol (acetaminophen) and Ibuprofen for pain control. -REPLACE the Tylenol with the prescribed narcotic if the narcotic is combined with Tylenol (examples include brand names [MASKED], Tylenol #3 w/ codeine and their generic equivalents). ALWAYS discuss your medications (especially when using narcotics or new medications) use with the pharmacist when you first retrieve your prescription if you have any questions. Use the narcotic pain medication for break-through pain that is >4 on the pain scale. -The MAXIMUM dose of Tylenol (ACETAMINOPHEN) is 4 grams (from ALL sources) PER DAY and remember that the prescribed narcotic pain medication may also contain Tylenol (acetaminophen) so this needs to be considered when monitoring your daily dose and maximum. -If you are taking Ibuprofen (Brand names include [MASKED] 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. -You may shower 2 days after surgery, but do not tub bathe, swim, soak, or scrub incision for 2 weeks -If you had a drain or skin clips (staples) removed from your abdomen; bandage strips called steristrips have been applied to close the wound OR the site was covered with a gauze dressing. Allow any steristrips/bandage strips to fall off on their own [MASKED] days). PLEASE REMOVE any "gauze" dressings within two days of discharge. Steristrips may get wet. -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: [MASKED]
|
[] |
[
"I10",
"Z87891",
"E785"
] |
[
"C675: Malignant neoplasm of bladder neck",
"I10: Essential (primary) hypertension",
"D259: Leiomyoma of uterus, unspecified",
"Z87891: Personal history of nicotine dependence",
"E785: Hyperlipidemia, unspecified",
"E890: Postprocedural hypothyroidism"
] |
10,001,401 | 24,818,636 |
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:
___
|
[
"I2699",
"I82412",
"N390",
"I471",
"I10",
"I872",
"R918",
"B952",
"E039",
"E785",
"E876",
"E8342",
"G4700",
"K5900",
"Z66",
"N63",
"D509",
"D638",
"Z7901",
"Z8551",
"Z906",
"Z87891",
"Z96652"
] |
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: dyspnea on exertion Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a [MASKED] year old woman s/p robotic radical cystectomy [MASKED] (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 [MASKED] for robotic anterior exenteration with ileal conduit. She was discharged to rehab on prophylactic dosing lovenox for 1 month. She was then readmitted from [MASKED] 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 [MASKED]. 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 [MASKED] 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 [MASKED] 20mg daily and since then there has been improvement of the swelling. Per her report, a repeat [MASKED] at the rehab facility ([MASKED]) 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 [MASKED] 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 [MASKED], >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: [MASKED] 20:26 PO/NG Ciprofloxacin HCl 500 mg [MASKED] 20:26 IV Heparin 6600 UNIT [MASKED] 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 [MASKED] years ago, laminectomy of L5-S1 at age [MASKED], two vaginal deliveries. s/p [MASKED]: 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: [MASKED] 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 [MASKED] 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, [MASKED] 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: [MASKED] 02:40PM GLUCOSE-101* UREA N-22* CREAT-0.7 SODIUM-136 POTASSIUM-4.1 CHLORIDE-98 TOTAL CO2-22 ANION GAP-20 [MASKED] 02:40PM cTropnT-<0.01 [MASKED] 02:40PM proBNP-567 [MASKED] 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* [MASKED] 02:40PM PLT COUNT-479* [MASKED] 02:40PM [MASKED] PTT-33.4 [MASKED] Discharge labs: [MASKED] 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 [MASKED] [MASKED] 06:55AM BLOOD Glucose-99 UreaN-10 Creat-0.5 Na-141 K-4.3 Cl-105 HCO3-26 AnGap-14 [MASKED] 06:55AM BLOOD Calcium-8.2* Phos-3.8 Mg-2.0 [MASKED] 07:15AM BLOOD calTIBC-134* Ferritn-507* TRF-103* [MASKED] 07:15AM BLOOD Iron-18* MICROBIOLOGY ========================== [MASKED] 4:30 pm URINE **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: 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 [MASKED] ENTEROCOCCUS SP. | AMPICILLIN------------ <=2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ 1 S IMAGING ========================== [MASKED] CXR IMPRESSION: Hilar congestion without frank edema. No convincing signs of pneumonia. [MASKED] 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. [MASKED] [MASKED]: 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. [MASKED] TTE: Conclusions The left atrium is normal in size. The estimated right atrial pressure is [MASKED] 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. [MASKED] CXR IMPRESSION: Compared to chest radiographs [MASKED] through [MASKED]. Heart size top-normal. Lungs grossly clear. No pleural abnormality or evidence of central lymph node enlargement. Brief Hospital Course: Ms. [MASKED] is a [MASKED] 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 [MASKED], 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: [MASKED], day 7: [MASKED]. # 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. # [MASKED] 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 [MASKED] TURBT, high-grade TCC, T1 (no muscle identified). Then in [MASKED], pelvic MRI showed bladder mass invasion, perivesical soft tissue, anterior vaginal wall on right (C/W T4 lesion). In [MASKED], 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 [MASKED]. 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 ([MASKED]) - To complete 7 day course for UTI with macrobid (day 7: [MASKED] - Continue oxygen therapy and wean as tolerated to maintain O2 sat > 92% - Please check CBC on [MASKED] to ensure stability of h/h and demonstrate resolution of leukocytosis - HCP: son, Dr. [MASKED] [MASKED] 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: [MASKED], 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: [MASKED]. Enoxaparin Sodium 90 mg SC Q12H Start: Today - [MASKED], 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: [MASKED] 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. [MASKED] it was a pleasure taking care you during your admission to [MASKED]. 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: [MASKED]
|
[] |
[
"N390",
"I10",
"E039",
"E785",
"G4700",
"K5900",
"Z66",
"D509",
"Z7901",
"Z87891"
] |
[
"I2699: Other pulmonary embolism without acute cor pulmonale",
"I82412: Acute embolism and thrombosis of left femoral vein",
"N390: Urinary tract infection, site not specified",
"I471: Supraventricular tachycardia",
"I10: Essential (primary) hypertension",
"I872: Venous insufficiency (chronic) (peripheral)",
"R918: Other nonspecific abnormal finding of lung field",
"B952: Enterococcus as the cause of diseases classified elsewhere",
"E039: Hypothyroidism, unspecified",
"E785: Hyperlipidemia, unspecified",
"E876: Hypokalemia",
"E8342: Hypomagnesemia",
"G4700: Insomnia, unspecified",
"K5900: Constipation, unspecified",
"Z66: Do not resuscitate",
"N63: Unspecified lump in breast",
"D509: Iron deficiency anemia, unspecified",
"D638: Anemia in other chronic diseases classified elsewhere",
"Z7901: Long term (current) use of anticoagulants",
"Z8551: Personal history of malignant neoplasm of bladder",
"Z906: Acquired absence of other parts of urinary tract",
"Z87891: Personal history of nicotine dependence",
"Z96652: Presence of left artificial knee joint"
] |
10,001,401 | 26,840,593 |
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:
___
|
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"T814XXA",
"K651",
"N179",
"I82412",
"C679",
"I10",
"B966",
"R7881",
"Y838",
"Y9289",
"F17210",
"Z436",
"Z90710",
"D72829",
"Z96652"
] |
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Abdominal pain, distention, nausea Major Surgical or Invasive Procedure: Interventional radiology placement of abdominal abscess drain History of Present Illness: [MASKED] 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 [MASKED] and leukocytosis. Concerned for small bowel obstruction or an ileus in presence [MASKED] and leukocytosis she was re-admitted for IVF, bowel rest, NGT decompression. Past Medical History: Hypertension, laparoscopic cholecystectomy, left knee replacement six to [MASKED] years ago, laminectomy of L5-S1 at age [MASKED], two vaginal deliveries. s/p [MASKED]: 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: [MASKED] 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: [MASKED] 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 [MASKED] [MASKED] 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 [MASKED] [MASKED] 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 [MASKED] [MASKED] 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 [MASKED] [MASKED] 07:06PM BLOOD Neuts-89* Bands-1 Lymphs-5* Monos-3* Eos-0 Baso-0 [MASKED] Metas-1* Myelos-0 Hyperse-1* AbsNeut-20.48* AbsLymp-1.13* AbsMono-0.68 AbsEos-0.00* AbsBaso-0.00* [MASKED] 01:04PM BLOOD [MASKED] PTT-30.9 [MASKED] [MASKED] 05:58AM BLOOD Glucose-106* UreaN-26* Creat-0.4 Na-136 K-4.6 Cl-107 HCO3-26 AnGap-8 [MASKED] 06:45AM BLOOD Glucose-114* UreaN-32* Creat-0.4 Na-137 K-4.1 Cl-106 HCO3-25 AnGap-10 [MASKED] 06:00AM BLOOD Glucose-121* UreaN-39* Creat-0.4 Na-140 K-3.6 Cl-107 HCO3-26 AnGap-11 [MASKED] 07:06PM BLOOD Glucose-117* UreaN-60* Creat-1.7*# Na-133 K-5.0 Cl-96 HCO3-21* AnGap-21* [MASKED] 08:30AM BLOOD ALT-20 AST-19 AlkPhos-77 [MASKED] 05:58AM BLOOD Calcium-7.6* Phos-2.8 Mg-2.2 [MASKED] 06:45AM BLOOD Calcium-7.7* Phos-2.4* Mg-2.1 [MASKED] 08:30AM BLOOD Albumin-1.8* Calcium-7.7* Phos-3.5 Mg-2.1 Iron-23* [MASKED] 07:06PM BLOOD Calcium-8.0* Phos-5.5* Mg-2.2 [MASKED] 08:30AM BLOOD calTIBC-116* Ferritn-789* TRF-89* [MASKED] 05:09AM BLOOD Triglyc-106 [MASKED] 08:30AM BLOOD Triglyc-89 [MASKED] 07:06PM BLOOD Lactate-1.5 [MASKED] 03:00PM ASCITES Creat-0.4 Amylase-18 Triglyc-29 Lipase-8 [MASKED] 03:00PM OTHER BODY FLUID Creat-0.5 [MASKED] 7:12 pm BLOOD CULTURE **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: CITROBACTER KOSERI. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] 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 [MASKED]: GRAM NEGATIVE ROD(S). Reported to and read back by [MASKED] [MASKED], @14:35 ON [MASKED]. [MASKED] 3:00 pm ABSCESS . PELVIC ASPIRATION. **FINAL REPORT [MASKED] GRAM STAIN (Final [MASKED]: 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). WOUND CULTURE (Final [MASKED]: NO GROWTH. ANAEROBIC CULTURE (Final [MASKED]: BACTEROIDES FRAGILIS GROUP. SPARSE GROWTH. BETA LACTAMASE POSITIVE. [MASKED] 10:52 am STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT [MASKED] C. difficile DNA amplification assay (Final [MASKED]: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). Brief Hospital Course: Ms. [MASKED] was admitted to Dr. [MASKED] service for management of ileus. Upon admission, a nasogastric tube was placed for decompression. On [MASKED], PICC was placed and TPN started. Blood cultures grew gram negative rods and ceftriaxone was started. On [MASKED], pt started to pass small amount of flatus. [MASKED] CT scan demonstrated improving ileus, but concern for possible urine leak and increased free fluid. On [MASKED], a LLQ drain was placed by interventional radiology. on [MASKED], pt passed clamp trial and NGT was removed. Pt continued to pass flatus and also started to have bowel movements. On [MASKED], 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 [MASKED] facility ([MASKED]). 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 [MASKED] 2. MetroNIDAZOLE 500 mg PO Q6H Duration: 7 Days Last dose [MASKED] 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: [MASKED], 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: [MASKED] Discharge Diagnosis: bladder cancer, post-operative ileus, bacteremia (CITROBACTER KOSERI) and abdominal-pelvic abscess (BACTEROIDES FRAGILIS GROUP) requiring [MASKED] 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 -[MASKED] (acetaminophen) and Ibuprofen for pain control. -Ciprofloxacin and Metronidazole are new ANTIBIOTIC medications to treat your infection. Continue for 7 days through [MASKED]. -The MAXIMUM dose of Tylenol (ACETAMINOPHEN) is 3 grams (from ALL sources) PER DAY -If you are taking Ibuprofen (Brand names include [MASKED] 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: [MASKED]
|
[] |
[
"N179",
"I10",
"F17210"
] |
[
"T814XXA: Infection following a procedure",
"K651: Peritoneal abscess",
"N179: Acute kidney failure, unspecified",
"I82412: Acute embolism and thrombosis of left femoral vein",
"C679: Malignant neoplasm of bladder, unspecified",
"I10: Essential (primary) hypertension",
"B966: Bacteroides fragilis [B. fragilis] as the cause of diseases classified elsewhere",
"R7881: Bacteremia",
"Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure",
"Y9289: Other specified places as the place of occurrence of the external cause",
"F17210: Nicotine dependence, cigarettes, uncomplicated",
"Z436: Encounter for attention to other artificial openings of urinary tract",
"Z90710: Acquired absence of both cervix and uterus",
"D72829: Elevated white blood cell count, unspecified",
"Z96652: Presence of left artificial knee joint"
] |
10,001,401 | 27,012,892 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fevers and chills
Major Surgical or Invasive Procedure:
___ -- stent exchange
History of Present Illness:
Ms. ___ is a ___ female with the past
medical history notable for history of bladder cancer status
post
robotic TAH-BSO, lap radical cystectomy with ileal loop
diversion
and anterior vaginectomy in ___ complicated by abdominal
fluid requiring placement of drainage catheters, further
complicated by a severe bilateral hydronephrosis requiring
bilateral urostomy tube placement and then ultimately ureteral
stent placements with improvement who presented to the hospital
for routine stent exchange and cystoscopy. The patient
underwent
an uncomplicated procedure but then postoperatively in the PACU
she developed a fever to 102.4 and was tachycardic 105 and as
such was felt to need admission for treatment of sepsis. At
that
time she was given ampicillin and gentamicin given her history
of
drug resistant organisms. She reported at that time she was
feeling feverish and chills with nausea and vomiting x1. She
received IV fluids and her IV antibiotics and her symptoms
improved. She was admitted to the medical service for further
evaluation and management
On the floor the patient reports that she continues to have
persistent chills. She feels slightly nauseous. She denies any
abdominal pain. She otherwise reports that she is feeling
better
than she did immediately postprocedural but is still
significantly off of her baseline. She reports that she has a
history of urinary tract infections and was most recently on
ciprofloxacin and ___. She reports that she was on
this medication for 7-day course. No ___ acute complaints.
Past Medical History:
- Hypertension
- s/p lap chole
- s/p left knee replacement
- s/p laminectomy of L5-S1 at age ___
- Bladder Cancer high grade TCC, T1 diagnosed in ___, then
___ pelvic MRI w/invasion into bladder wall, perivesical
soft tissue and anterior vaginal wall c/w T4 staging
- s/p hysterectomy and bilateral oophorectomy for large uterus
w/fibroid, s/p laparascopic b/l pelvic lymph node resection, s/p
radical cystectomy and anterior vaginectomy with vaginal
reconstruction with ileal conduit creation ___, course
complicated by bacteremia and development of intra-abdominal
fluid collection, no s/p drain placement by ___ ___
- h/o LLE DVT and PE no longer on anticoagulation.
Social History:
___
Family History:
Negative for bladder CA.
Physical Exam:
ADMISSION EXAM:
VITALS: ___ 2227 Temp: 99.3 PO BP: 119/54 HR: 80 RR: 16 O2
sat: 98% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: ___
GENERAL: Alert and in no apparent distress, facial twitches
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation, foley
catheter in place
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:
AVSS, ambulating comfortably at baseline. Urostomy bag in place
with no surround erythema or pain.
Pertinent Results:
LABORATORY RESULTS:
___ 05:30AM BLOOD WBC-16.5* RBC-3.23* Hgb-9.8* Hct-31.8*
MCV-99* MCH-30.3 MCHC-30.8* RDW-14.5 RDWSD-52.3* Plt ___
___ 06:09AM BLOOD WBC-14.1* RBC-3.39* Hgb-10.2* Hct-33.2*
MCV-98 MCH-30.1 MCHC-30.7* RDW-14.6 RDWSD-52.7* Plt ___
___ 06:10AM BLOOD WBC-10.0 RBC-3.55* Hgb-10.5* Hct-33.6*
MCV-95 MCH-29.6 MCHC-31.3* RDW-14.1 RDWSD-49.9* Plt ___
___ 05:30AM BLOOD Glucose-115* UreaN-34* Creat-1.6* Na-142
K-4.2 Cl-106 HCO3-22 AnGap-14
___ 06:10AM BLOOD Glucose-99 UreaN-29* Creat-1.3* Na-141
K-3.8 Cl-104 HCO3-23 AnGap-14
___ 05:30AM BLOOD Calcium-8.1* Phos-3.4 Mg-1.8
MICROBIOLOGY:
___ 3:00 pm URINE Site: CYSTOSCOPY RIGHT KIDNEY
WASH.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ENTEROCOCCUS FAECIUM. >10,000 CFU/ML.
___ (___) REQUESTS SUSCEPTIBILITY TESTING
___.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. 1,000 - 10,000
CFU/ML.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). 1,000 - 10,000
CFU/ML.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECIUM
|
AMPICILLIN------------ 8 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 2 S
Blood cultures NGTD
Brief Hospital Course:
Ms. ___ was admitted with sepsis from a urinary tract
infection after her stent exchange. She was placed empirically
on vancomycin and cefepime (narrowed to vanc/ceftriaxone on
HD#1), because of her history of resistant organisms. She
rapidly improved. Her urine grew E. faecium, sensitive to
ampicillin. Therefore, a PICC line was placed, and she will
complete two weeks total of ampicillin for a complicated urinary
tract infection (additional day days). She will follow up with
Dr. ___ as an outpatient. She will stop her prophylactic TMP
while on ampicillin, but then resume after finishing her course.
- ampicillin 500 mg TID x 9 additional days
- restart TMP 100 mg daily for ppx after antibiotic course
- follow up with Dr. ___
___ problems addressed this hospitalization:
1. ___. Ms. ___ initially had an ___, likely prerenal from
her sepsis. She received IV fluids and antibiotics as above, and
her creatinine down-trended. Losartan was initially held, but
restarted on discharge.
2. Hyperlipidemia: continued atorvastatin 10 mg daily
3. Hypothyroidism: continue levothyroxine 175 mcg daily
> 30 minutes spent on discharge activities.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Atorvastatin 10 mg PO QPM
3. Cyanocobalamin 1000 mcg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Levothyroxine Sodium 175 mcg PO DAILY
6. LORazepam 0.5 mg PO Q12H:PRN anxiety
7. Losartan Potassium 50 mg PO BID
8. Multivitamins 1 TAB PO DAILY
9. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
10. Trimethoprim 100 mg PO Q24H
Discharge Medications:
1. Ampicillin 500 mg IV Q8H
RX *ampicillin sodium 500 mg 500 mg IV Every eight hours Disp
#*15 Vial Refills:*0
RX *ampicillin sodium 500 mg 500 mg IV Every eight hours Disp
#*27 Vial Refills:*0
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
3. Atorvastatin 10 mg PO QPM
4. Cyanocobalamin 1000 mcg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Levothyroxine Sodium 175 mcg PO DAILY
7. LORazepam 0.5 mg PO Q12H:PRN anxiety
8. Losartan Potassium 50 mg PO BID
9. Multivitamins 1 TAB PO DAILY
10. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
11. HELD- Trimethoprim 100 mg PO Q24H This medication was held.
Do not restart Trimethoprim until after you finish your
ampicillin.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Complicated E. faecium UTI
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after you developed fevers and
chills after you developed fevers and chills from your stent
exchange. Your urine grew the enterococcus species -- the source
of your infection. Because it was enterococcus, a PICC line was
placed and you will finish a total 14-day course of IV
ampicillin.
You also had kidney injury, likely from infection, that resolved
with antibiotics and fluids. It was a pleasure taking care of
you!
Followup Instructions:
___
|
[
"T8140XA",
"A4181",
"R6520",
"N179",
"N1330",
"N12",
"T8144XA",
"Z936",
"I10",
"E785",
"E039",
"Z87891",
"Z8551",
"Z86718",
"Y848",
"Y92239"
] |
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Fevers and chills Major Surgical or Invasive Procedure: [MASKED] -- stent exchange History of Present Illness: Ms. [MASKED] is a [MASKED] female with the past medical history notable for history of bladder cancer status post robotic TAH-BSO, lap radical cystectomy with ileal loop diversion and anterior vaginectomy in [MASKED] complicated by abdominal fluid requiring placement of drainage catheters, further complicated by a severe bilateral hydronephrosis requiring bilateral urostomy tube placement and then ultimately ureteral stent placements with improvement who presented to the hospital for routine stent exchange and cystoscopy. The patient underwent an uncomplicated procedure but then postoperatively in the PACU she developed a fever to 102.4 and was tachycardic 105 and as such was felt to need admission for treatment of sepsis. At that time she was given ampicillin and gentamicin given her history of drug resistant organisms. She reported at that time she was feeling feverish and chills with nausea and vomiting x1. She received IV fluids and her IV antibiotics and her symptoms improved. She was admitted to the medical service for further evaluation and management On the floor the patient reports that she continues to have persistent chills. She feels slightly nauseous. She denies any abdominal pain. She otherwise reports that she is feeling better than she did immediately postprocedural but is still significantly off of her baseline. She reports that she has a history of urinary tract infections and was most recently on ciprofloxacin and [MASKED]. She reports that she was on this medication for 7-day course. No [MASKED] acute complaints. Past Medical History: - Hypertension - s/p lap chole - s/p left knee replacement - s/p laminectomy of L5-S1 at age [MASKED] - Bladder Cancer high grade TCC, T1 diagnosed in [MASKED], then [MASKED] pelvic MRI w/invasion into bladder wall, perivesical soft tissue and anterior vaginal wall c/w T4 staging - s/p hysterectomy and bilateral oophorectomy for large uterus w/fibroid, s/p laparascopic b/l pelvic lymph node resection, s/p radical cystectomy and anterior vaginectomy with vaginal reconstruction with ileal conduit creation [MASKED], course complicated by bacteremia and development of intra-abdominal fluid collection, no s/p drain placement by [MASKED] [MASKED] - h/o LLE DVT and PE no longer on anticoagulation. Social History: [MASKED] Family History: Negative for bladder CA. Physical Exam: ADMISSION EXAM: VITALS: [MASKED] 2227 Temp: 99.3 PO BP: 119/54 HR: 80 RR: 16 O2 sat: 98% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: [MASKED] GENERAL: Alert and in no apparent distress, facial twitches EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. No HSM GU: No suprapubic fullness or tenderness to palpation, foley catheter in place 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: AVSS, ambulating comfortably at baseline. Urostomy bag in place with no surround erythema or pain. Pertinent Results: LABORATORY RESULTS: [MASKED] 05:30AM BLOOD WBC-16.5* RBC-3.23* Hgb-9.8* Hct-31.8* MCV-99* MCH-30.3 MCHC-30.8* RDW-14.5 RDWSD-52.3* Plt [MASKED] [MASKED] 06:09AM BLOOD WBC-14.1* RBC-3.39* Hgb-10.2* Hct-33.2* MCV-98 MCH-30.1 MCHC-30.7* RDW-14.6 RDWSD-52.7* Plt [MASKED] [MASKED] 06:10AM BLOOD WBC-10.0 RBC-3.55* Hgb-10.5* Hct-33.6* MCV-95 MCH-29.6 MCHC-31.3* RDW-14.1 RDWSD-49.9* Plt [MASKED] [MASKED] 05:30AM BLOOD Glucose-115* UreaN-34* Creat-1.6* Na-142 K-4.2 Cl-106 HCO3-22 AnGap-14 [MASKED] 06:10AM BLOOD Glucose-99 UreaN-29* Creat-1.3* Na-141 K-3.8 Cl-104 HCO3-23 AnGap-14 [MASKED] 05:30AM BLOOD Calcium-8.1* Phos-3.4 Mg-1.8 MICROBIOLOGY: [MASKED] 3:00 pm URINE Site: CYSTOSCOPY RIGHT KIDNEY WASH. **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: ENTEROCOCCUS FAECIUM. >10,000 CFU/ML. [MASKED] ([MASKED]) REQUESTS SUSCEPTIBILITY TESTING [MASKED]. STAPHYLOCOCCUS, COAGULASE NEGATIVE. 1,000 - 10,000 CFU/ML. CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). 1,000 - 10,000 CFU/ML. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] ENTEROCOCCUS FAECIUM | AMPICILLIN------------ 8 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- =>16 R VANCOMYCIN------------ 2 S Blood cultures NGTD Brief Hospital Course: Ms. [MASKED] was admitted with sepsis from a urinary tract infection after her stent exchange. She was placed empirically on vancomycin and cefepime (narrowed to vanc/ceftriaxone on HD#1), because of her history of resistant organisms. She rapidly improved. Her urine grew E. faecium, sensitive to ampicillin. Therefore, a PICC line was placed, and she will complete two weeks total of ampicillin for a complicated urinary tract infection (additional day days). She will follow up with Dr. [MASKED] as an outpatient. She will stop her prophylactic TMP while on ampicillin, but then resume after finishing her course. - ampicillin 500 mg TID x 9 additional days - restart TMP 100 mg daily for ppx after antibiotic course - follow up with Dr. [MASKED] [MASKED] problems addressed this hospitalization: 1. [MASKED]. Ms. [MASKED] initially had an [MASKED], likely prerenal from her sepsis. She received IV fluids and antibiotics as above, and her creatinine down-trended. Losartan was initially held, but restarted on discharge. 2. Hyperlipidemia: continued atorvastatin 10 mg daily 3. Hypothyroidism: continue levothyroxine 175 mcg daily > 30 minutes spent on discharge activities. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 2. Atorvastatin 10 mg PO QPM 3. Cyanocobalamin 1000 mcg PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Levothyroxine Sodium 175 mcg PO DAILY 6. LORazepam 0.5 mg PO Q12H:PRN anxiety 7. Losartan Potassium 50 mg PO BID 8. Multivitamins 1 TAB PO DAILY 9. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First Line 10. Trimethoprim 100 mg PO Q24H Discharge Medications: 1. Ampicillin 500 mg IV Q8H RX *ampicillin sodium 500 mg 500 mg IV Every eight hours Disp #*15 Vial Refills:*0 RX *ampicillin sodium 500 mg 500 mg IV Every eight hours Disp #*27 Vial Refills:*0 2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 3. Atorvastatin 10 mg PO QPM 4. Cyanocobalamin 1000 mcg PO DAILY 5. Docusate Sodium 100 mg PO BID 6. Levothyroxine Sodium 175 mcg PO DAILY 7. LORazepam 0.5 mg PO Q12H:PRN anxiety 8. Losartan Potassium 50 mg PO BID 9. Multivitamins 1 TAB PO DAILY 10. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First Line 11. HELD- Trimethoprim 100 mg PO Q24H This medication was held. Do not restart Trimethoprim until after you finish your ampicillin. Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Complicated E. faecium UTI Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital after you developed fevers and chills after you developed fevers and chills from your stent exchange. Your urine grew the enterococcus species -- the source of your infection. Because it was enterococcus, a PICC line was placed and you will finish a total 14-day course of IV ampicillin. You also had kidney injury, likely from infection, that resolved with antibiotics and fluids. It was a pleasure taking care of you! Followup Instructions: [MASKED]
|
[] |
[
"N179",
"I10",
"E785",
"E039",
"Z87891",
"Z86718"
] |
[
"T8140XA: Infection following a procedure, unspecified, initial encounter",
"A4181: Sepsis due to Enterococcus",
"R6520: Severe sepsis without septic shock",
"N179: Acute kidney failure, unspecified",
"N1330: Unspecified hydronephrosis",
"N12: Tubulo-interstitial nephritis, not specified as acute or chronic",
"T8144XA: Sepsis following a procedure, initial encounter",
"Z936: Other artificial openings of urinary tract status",
"I10: Essential (primary) hypertension",
"E785: Hyperlipidemia, unspecified",
"E039: Hypothyroidism, unspecified",
"Z87891: Personal history of nicotine dependence",
"Z8551: Personal history of malignant neoplasm of bladder",
"Z86718: Personal history of other venous thrombosis and embolism",
"Y848: Other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure",
"Y92239: Unspecified place in hospital as the place of occurrence of the external cause"
] |
10,001,401 | 27,060,146 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
subjective fevers, lethargy, and bloody drain output
Major Surgical or Invasive Procedure:
___: For the large pelvic fluid collections, CT-guided
repositioning of existing drain and placement of an additional
drain.
___: Removal of more recently placed drain
History of Present Illness:
Ms. ___ is an ___ with PMH of hypertension and bladder
cancer (high grade invasive urothelial carcinoma pT2b) s/p
TAH/BSO, radical cystectomy w/ileal conduit c/b intra-abdominal
infection and pelvic fluid collection s/p ___ guided drain
placement ___ who presents with 2 days of generalized
malaise and 1 day of fevers.
Patient underwent ___ guided JP drain placement for
intra-abdominal fluid collection and infection, thought to be
complicated of recent TAH/BSO, radical cystectomy and pelvic
lymph node biopsy. This procedure was done on ___. Over the
past 2 days she had noticed generalized malaise and 1 day of
fever w/rigors to Tmax 101.5 at home. She notes that the
drainage from her intra-abdominal drain is darker, but her
urostomy output has been unchanged. She notes some associated
mild LLQ pain. She denies diarrhea, BRBPR, rash, cough,
headache, neck stiffness. She presented initially to OSH, where
she was evaluated with BCx and drain culture and was started on
zosyn and vancomycin and given 650mg acetaminophen. She was
transferred to ___ for further management.
Past Medical History:
- Hypertension
- s/p lap chole
- s/p left knee replacement
- s/p laminectomy of L5-S1 at age ___
- Bladder Cancer high grade TCC, T1 diagnosed in ___, then
___ pelvic MRI w/invasion into bladder wall, perivesical
soft tissue and anterior vaginal wall c/w T4 staging
- s/p hysterectomy and bilateral oophorectomy for large uterus
w/fibroid, s/p laparascopic b/l pelvic lymph node resection, s/p
radical cystectomy and anterior vaginectomy with vaginal
reconstruction with ileal conduit creation ___, course
complicated by bacteremia and development of intra-abdominal
fluid collection, no s/p drain placement by ___ ___
- h/o LLE DVT and PE on lovenox
Social History:
___
Family History:
Negative for bladder CA.
Physical Exam:
ADMISSION EXAM:
===============
Vital Signs: 100.9 PO 130 / 54 L Lying 80 24 95 RA
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear
CV: RRR, normal S1 S2, systolic murmur RUBS, no rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
+ileal conduit drain in RLQ, with pigtail drain in LLQ draining
dark/sang fluid
GU: No foley
Ext: Warm, well perfused, 1+ nonpitting edema LLE
Neuro: CN2-12 grossly intact, moving all extremities
spontaneously
DISCHARGE EXAM:
===============
Vital signs: 98.3 134/64 71 20 96 RA
General: AxO x3
HEENT: Sclera anicteric
Neck: supple
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi on anterior auscultation
CV: Regular rate and rhythm, normal S1 + S2, III/VI SEM
Abdomen: +BS, ileal conduit draining clear yellow urine. Has
one LLQ drain in place draining serosanguinous fluid.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
ADMISSION LABS:
===============
___ 07:10PM BLOOD WBC-19.4*# RBC-2.53* Hgb-6.9* Hct-22.9*
MCV-91 MCH-27.3 MCHC-30.1* RDW-15.1 RDWSD-49.5* Plt ___
___ 07:10PM BLOOD Neuts-81.4* Lymphs-9.4* Monos-7.4
Eos-0.0* Baso-0.1 Im ___ AbsNeut-15.77*# AbsLymp-1.81
AbsMono-1.43* AbsEos-0.00* AbsBaso-0.02
___ 07:10PM BLOOD ___ PTT-33.4 ___
___ 07:10PM BLOOD Ret Aut-2.9* Abs Ret-0.07
___ 07:10PM BLOOD Glucose-118* UreaN-25* Creat-1.1 Na-133
K-5.0 Cl-97 HCO3-23 AnGap-18
___ 07:10PM BLOOD ALT-9 AST-9 AlkPhos-56 TotBili-0.3
___ 07:10PM BLOOD Lipase-9
___ 07:10PM BLOOD Albumin-2.5* Iron-6*
___ 07:10PM BLOOD calTIBC-170* Hapto-518* Ferritn-489*
TRF-131*
___ 07:13PM BLOOD Lactate-1.0
DISCHARGE LABS:
===============
___ 06:00AM BLOOD WBC-6.9 RBC-2.92* Hgb-8.3* Hct-26.8*
MCV-92 MCH-28.4 MCHC-31.0* RDW-15.4 RDWSD-52.4* Plt ___
___ 06:00AM BLOOD ___ PTT-31.2 ___
___ 06:00AM BLOOD Plt ___
___ 06:00AM BLOOD Glucose-86 UreaN-8 Creat-0.8 Na-143 K-3.6
Cl-106 HCO3-25 AnGap-16
___ 06:00AM BLOOD Calcium-7.5* Phos-3.7 Mg-2.3
MICROBIOLOGY:
=============
Blood cultures x3 pending
___ 4:35 pm pelvic aspiration
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
PERTINENT IMAGING:
==================
CT ABD&PEL W/ CONTRAST
___
1. Interval decrease in size of the right hemipelvis fluid
collection (7.0 x 6.5 x 11.3 cm, previously 10.0 x 12.7 x 14.8
cm) with the anterior approach pigtail catheter unchanged in
position. The pigtail is again located partly within the
collection and partly outside its wall.
2. Interval increase in size of the left pelvic fluid
collection, now
measuring 14.7 x 16.2 x 23.3 cm (previously 13.6 x 13.9 x 23.0
cm). Increased peripheral enhancement may suggest superimposed
infection.
3. No new fluid collection identified.
CTA ABD & PELVIS
___
1. Decrease in size of right lower quadrant fluid collection
that has
percutaneous drain within it, with areas of high attenuation on
noncontrast exam consistent with blood products, and associated
hyperemia which is likely inflammatory, but without evidence of
contrast extravasation.
2. There is large stable fluid collection in the low left
abdomen, pelvis with mild linear peripheral enhancement,
infection cannot be excluded.
3. There is severe left, and moderate to severe right
hydroureteronephrosis, with delayed left nephrogram, stable from
today. Mass effect about anastomosis between distal ureters and
neobladder has resolved all since ___, and while
hydronephrosis may be from residual edema, if this does not
resolve, alternative etiologies including stenosis, tumor
infiltration should be excluded.
4. Tiny hepatic lesion segment ___, attention to this area on
subsequent
followups recommended.
CT INTERVENTIONAL PROCEDURE
___
1. Complete collapse the patient has recently drained left
lower quadrant
collection. The catheter from this collection was removed.
2. Near complete collapse of the patient is originally drained
collection in the mid pelvis, with pigtail catheter in place.
3. Left lower quadrant and deep pelvic collections as above.
These findings were discussed with the team. Given the
patient's improving clinical status, the decision was made to
pursue no further collection drainage at this time.
4. Severe bilateral hydronephrosis, as on prior examinations.
RECOMMENDATION: Given persistence of severe hydronephrosis,
percutaneous
nephrostomy tubes should be considered.
Brief Hospital Course:
BRIEF SUMMARY:
==============
___ year old women with a history of bladder cancer s/p
cystectomy, hysterectomy, and BSO now with ileal conduit, whose
post operative course has been complicated by DVT/PE, ileus, and
pelvic fluid collections w/ one LLQ drain presented with
subjective fevers, lethargy, and bloody drain output. She was
found to have worsening anemia and was given 2 units of pRBC
with appropriate increase in hemoglobin noted. She was also
found on CT imaging to have an interval increase in size of a
left abdominal fluid collection. Decision was made to place a
drain per ID. Fluid was sent and revealed: negative cultures,
negative malignant cells, no evidence of lymphatic or urinary
fluid. This new drain was subsequently removed per ___ as fluid
collection was completely drained. The prior drain was still
draining serosanguinous fluid and was kept in but repositioned.
ID was consulted for the fevers, leukocytosis and fluid
collections and was deemed to need antibiotics and tranisitioned
from broad spectrum to IV ertapenem at discharge. Will require
multiple follow ups and imaging as specified in the transitional
issues.
ACUTE ISSUES:
=============
#Pelvic fluid collections: patient arrived with one anterior
drain putting out serosanguinous fluid. CT abdomen/pelvis
revealed enlarging left fluid collection, and decision was made
to place a drain per ___. The fluid was negative for malignant
cells. The fluid had Cr 1 and triglycerides <9 suggesting that
fluid collection is neither urine nor lymphatic fluid. Fluid
culture was negative for bacteria. On interval imaging, the new
enlarging fluid collection had completely collapsed and the
drain was removed. As for the other fluid collection that
already had a drain putting out serosanguinous fluid, it
continued to drain serosanguinous fluid but at a lower rate than
prior to admission. The drain was left in place as the fluid
collection on imaging had not completely collapsed. BID - N
cultures for the aforementioned fluid collection came back
positive for MSSA but per ID, does not reflect rue
intra-abdominal infection. Given that patient had a fever at OSH
and a leukocytosis, she was placed on broad spectrum antibiotics
with vanc, ceftaz and flagyl. This was tapered per ID team to IV
zosyn. On discharge, ID recommended ertapenem for approximately
4 weeks with final length of treatment to be determined by fluid
collection changes on repeat imaging on outpatient basis. Mrs.
___ remained afebrile, and leukocytosis resolved.
#Pulmonary embolism: Likely developed in the setting of being
diagnosed with a post-op DVT. She was placed on lovenox. She
was transitioned to heparin ggt as she needed ___ procedures and
was transitioned back to lovenox but at a lower dose per weight
dosing to 70mg q12H upon discharge.
#Acute renal injury: SCr has been steadily rising from a
baseline of around 0.04-0.06 in ___ to 1.1, likely
___ obstructed uropathy ___ large pelbic fluid collections. ___
resolved over the course of her hospital stay with final Cr 0.8.
#Hydronephrosis: bilateral and worsening on interval imaging
from prior studies. Given patient's age, adequate urinary
output, adequate creatinine clearance, and no significant
electrolyte abnormalities, patient likely would not
significantly benefit from intervention at this time. Per
urology consult, deemed stable for discharge and recommended
outpatient urology followup.
#Anemia: likely a combination of anemia of chronic inflammation
and acute blood loss ___ to anterior abdominal drain showing
serosanguinous fluid. Labs not consistent with hemolysis.
Received 2 units of pRBC with appropriate response. Patient was
discharged with Hgb of 8.3 per hem/onc recommendation for
threshold Hgb>8 as patient feels and functionally performs
better with higher blood counts.
#Hypokalemia: was hypokalemic and was repleted with oral KCl
PRN.
CHRONIC ISSUES:
===============
#Invasive high-grade urothelial carcinoma, involving the deep
muscularis propria
S/p cystectomy, hysterectomy, and BSO now with ileal conduit,
whose post operative course has been complicated by DVT/PE,
ileus, and pelvic fluid collections. Patient stating that there
is no plan for chemo and radiation, her PET scan does show
concerning foci of metastatic disease in the lung and
peritoneum. Per patient's son, Mrs. ___ has seen a doctor
to work up the lung mass. Will need ongoing discussion with
outpatient hem/onc regarding how to best manage concerning
lesions.
#Breast mass ___ mammogram showing BI-RADS 5, Solid mass
in the 3 o'clock left breast with features of a highly
suspicious for malignancy. Per patient's son, she has seen a
doctor for evaluating the new breast mass. Would recommend
ongoing discussion with aforementioned doctor and outpatient
hem/onc about plan to manage.
# HLD: continued atorvastatin without changes. Consider
evaluation regarding stopping atorvastatin on outpatient basis
# Hypothyroidism: continued levothyroxine without changes.
#HCP: Dr. ___ (son, ___ physician) ___
#Code status: full code (confirmed with patient on ___
TRANSITIONAL ISSUES:
====================
[ ] Will need infectious disease follow up. If ID has not
contacted Mrs ___ by ___, she should call ___
to set up an appointment. The ID appointment needs to be AFTER
her CT abdomen/pelvis has already been done
[ ] Assure that Mrs ___ has her CT abdomen & pelvis with
contrast in the week of ___
[ ] She should get weekly lab draws of the following: CBC with
differential, BUN, Cr, AST, ALT, TB, ALK PHOS. ALL LAB REQUESTS
SHOULD BE ANNOTATED WITH: **ATTN: ___ CLINIC - FAX:
___
[ ] If possible, please give ertapenem at night-time so it does
not interfere with her daily activities. Tentatively, she will
be receiving ertapenem for ___ weeks but with final treatment
length determined by the infectious disease team.
[ ] Will need ongoing discussion with outpatient PCP and hem/onc
regarding how to manage new breast lesion and lung/peritoneum
lesions.
[ ] Reevaluate need for atorvastatin
[ ] Will need outpatient follow up with urology, Dr. ___
his team regarding worsening hydronephrosis
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H
2. Atorvastatin 10 mg PO QPM
3. Enoxaparin Sodium 90 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
4. Levothyroxine Sodium 175 mcg PO DAILY
5. LORazepam 0.25-0.5 mg PO DAILY:PRN anxiety
Discharge Medications:
1. Ertapenem Sodium 1 g IV 1X Duration: 1 Dose
please give ertapenem daily, preferably at nighttime to not
interfere with her daily activities
2. Milk of Magnesia 30 mL PO Q6H:PRN constipation
3. Enoxaparin Sodium 70 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
4. Acetaminophen 650 mg PO Q6H
5. Atorvastatin 10 mg PO QPM
6. Levothyroxine Sodium 175 mcg PO DAILY
7. LORazepam 0.25-0.5 mg PO DAILY:PRN anxiety
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis: Pelvic fluid collection infection, ___, acute
blood loss anemia
Secondary diagnosis: acute renal failure, acute on chronic
anemia, recent pulmonary embolism, invasive high-grade
urothelial carcinoma, left breast mass (BIRADS 5),
hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
___ did you come to the hospital?
- You were feeling tired and your drain output was bloody.
What happened at the hospital?
- A CT scan showed very large fluid collections in your pelvis
- The radiologists placed another drain and removed it once it
appeared that the large fluid collection was gone
- You were given a blood transfusion
- We placed a PICC (a long IV) so that you can receive
antibiotics after you get discharged from the hospital
What needs to happen when you leave the hospital?
- Please continue seeing the doctors that are ___ your
lung and breast lesions and follow their recommendations.
- Continue taking Lovenox every day to treat the blood clot in
your lung.
- If the infectious disease doctor has not contacted you by ___, please call the following number to set up an appointment:
___.
- Please make sure you have a repeat CT scan done BEFORE your
appointment with the infectious disease doctor
- You will be getting IV antibiotics for several weeks. The
infectious disease doctor ___ determine how long you will need
to be on it.
It was a pleasure taking care of you.
Your ___ team
Followup Instructions:
___
|
[
"T814XXA",
"A419",
"K651",
"N179",
"N1330",
"D62",
"I2782",
"N138",
"C679",
"I10",
"E785",
"E039",
"K439",
"K435",
"E876",
"Y838",
"Y929",
"Z96652",
"Z86718",
"N63",
"Z7901",
"Z87891"
] |
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: subjective fevers, lethargy, and bloody drain output Major Surgical or Invasive Procedure: [MASKED]: For the large pelvic fluid collections, CT-guided repositioning of existing drain and placement of an additional drain. [MASKED]: Removal of more recently placed drain History of Present Illness: Ms. [MASKED] is an [MASKED] with PMH of hypertension and bladder cancer (high grade invasive urothelial carcinoma pT2b) s/p TAH/BSO, radical cystectomy w/ileal conduit c/b intra-abdominal infection and pelvic fluid collection s/p [MASKED] guided drain placement [MASKED] who presents with 2 days of generalized malaise and 1 day of fevers. Patient underwent [MASKED] guided JP drain placement for intra-abdominal fluid collection and infection, thought to be complicated of recent TAH/BSO, radical cystectomy and pelvic lymph node biopsy. This procedure was done on [MASKED]. Over the past 2 days she had noticed generalized malaise and 1 day of fever w/rigors to Tmax 101.5 at home. She notes that the drainage from her intra-abdominal drain is darker, but her urostomy output has been unchanged. She notes some associated mild LLQ pain. She denies diarrhea, BRBPR, rash, cough, headache, neck stiffness. She presented initially to OSH, where she was evaluated with BCx and drain culture and was started on zosyn and vancomycin and given 650mg acetaminophen. She was transferred to [MASKED] for further management. Past Medical History: - Hypertension - s/p lap chole - s/p left knee replacement - s/p laminectomy of L5-S1 at age [MASKED] - Bladder Cancer high grade TCC, T1 diagnosed in [MASKED], then [MASKED] pelvic MRI w/invasion into bladder wall, perivesical soft tissue and anterior vaginal wall c/w T4 staging - s/p hysterectomy and bilateral oophorectomy for large uterus w/fibroid, s/p laparascopic b/l pelvic lymph node resection, s/p radical cystectomy and anterior vaginectomy with vaginal reconstruction with ileal conduit creation [MASKED], course complicated by bacteremia and development of intra-abdominal fluid collection, no s/p drain placement by [MASKED] [MASKED] - h/o LLE DVT and PE on lovenox Social History: [MASKED] Family History: Negative for bladder CA. Physical Exam: ADMISSION EXAM: =============== Vital Signs: 100.9 PO 130 / 54 L Lying 80 24 95 RA General: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear CV: RRR, normal S1 S2, systolic murmur RUBS, no rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, +ileal conduit drain in RLQ, with pigtail drain in LLQ draining dark/sang fluid GU: No foley Ext: Warm, well perfused, 1+ nonpitting edema LLE Neuro: CN2-12 grossly intact, moving all extremities spontaneously DISCHARGE EXAM: =============== Vital signs: 98.3 134/64 71 20 96 RA General: AxO x3 HEENT: Sclera anicteric Neck: supple Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi on anterior auscultation CV: Regular rate and rhythm, normal S1 + S2, III/VI SEM Abdomen: +BS, ileal conduit draining clear yellow urine. Has one LLQ drain in place draining serosanguinous fluid. Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: ADMISSION LABS: =============== [MASKED] 07:10PM BLOOD WBC-19.4*# RBC-2.53* Hgb-6.9* Hct-22.9* MCV-91 MCH-27.3 MCHC-30.1* RDW-15.1 RDWSD-49.5* Plt [MASKED] [MASKED] 07:10PM BLOOD Neuts-81.4* Lymphs-9.4* Monos-7.4 Eos-0.0* Baso-0.1 Im [MASKED] AbsNeut-15.77*# AbsLymp-1.81 AbsMono-1.43* AbsEos-0.00* AbsBaso-0.02 [MASKED] 07:10PM BLOOD [MASKED] PTT-33.4 [MASKED] [MASKED] 07:10PM BLOOD Ret Aut-2.9* Abs Ret-0.07 [MASKED] 07:10PM BLOOD Glucose-118* UreaN-25* Creat-1.1 Na-133 K-5.0 Cl-97 HCO3-23 AnGap-18 [MASKED] 07:10PM BLOOD ALT-9 AST-9 AlkPhos-56 TotBili-0.3 [MASKED] 07:10PM BLOOD Lipase-9 [MASKED] 07:10PM BLOOD Albumin-2.5* Iron-6* [MASKED] 07:10PM BLOOD calTIBC-170* Hapto-518* Ferritn-489* TRF-131* [MASKED] 07:13PM BLOOD Lactate-1.0 DISCHARGE LABS: =============== [MASKED] 06:00AM BLOOD WBC-6.9 RBC-2.92* Hgb-8.3* Hct-26.8* MCV-92 MCH-28.4 MCHC-31.0* RDW-15.4 RDWSD-52.4* Plt [MASKED] [MASKED] 06:00AM BLOOD [MASKED] PTT-31.2 [MASKED] [MASKED] 06:00AM BLOOD Plt [MASKED] [MASKED] 06:00AM BLOOD Glucose-86 UreaN-8 Creat-0.8 Na-143 K-3.6 Cl-106 HCO3-25 AnGap-16 [MASKED] 06:00AM BLOOD Calcium-7.5* Phos-3.7 Mg-2.3 MICROBIOLOGY: ============= Blood cultures x3 pending [MASKED] 4:35 pm pelvic aspiration GRAM STAIN (Final [MASKED]: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [MASKED]: NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. PERTINENT IMAGING: ================== CT ABD&PEL W/ CONTRAST [MASKED] 1. Interval decrease in size of the right hemipelvis fluid collection (7.0 x 6.5 x 11.3 cm, previously 10.0 x 12.7 x 14.8 cm) with the anterior approach pigtail catheter unchanged in position. The pigtail is again located partly within the collection and partly outside its wall. 2. Interval increase in size of the left pelvic fluid collection, now measuring 14.7 x 16.2 x 23.3 cm (previously 13.6 x 13.9 x 23.0 cm). Increased peripheral enhancement may suggest superimposed infection. 3. No new fluid collection identified. CTA ABD & PELVIS [MASKED] 1. Decrease in size of right lower quadrant fluid collection that has percutaneous drain within it, with areas of high attenuation on noncontrast exam consistent with blood products, and associated hyperemia which is likely inflammatory, but without evidence of contrast extravasation. 2. There is large stable fluid collection in the low left abdomen, pelvis with mild linear peripheral enhancement, infection cannot be excluded. 3. There is severe left, and moderate to severe right hydroureteronephrosis, with delayed left nephrogram, stable from today. Mass effect about anastomosis between distal ureters and neobladder has resolved all since [MASKED], and while hydronephrosis may be from residual edema, if this does not resolve, alternative etiologies including stenosis, tumor infiltration should be excluded. 4. Tiny hepatic lesion segment [MASKED], attention to this area on subsequent followups recommended. CT INTERVENTIONAL PROCEDURE [MASKED] 1. Complete collapse the patient has recently drained left lower quadrant collection. The catheter from this collection was removed. 2. Near complete collapse of the patient is originally drained collection in the mid pelvis, with pigtail catheter in place. 3. Left lower quadrant and deep pelvic collections as above. These findings were discussed with the team. Given the patient's improving clinical status, the decision was made to pursue no further collection drainage at this time. 4. Severe bilateral hydronephrosis, as on prior examinations. RECOMMENDATION: Given persistence of severe hydronephrosis, percutaneous nephrostomy tubes should be considered. Brief Hospital Course: BRIEF SUMMARY: ============== [MASKED] year old women with a history of bladder cancer s/p cystectomy, hysterectomy, and BSO now with ileal conduit, whose post operative course has been complicated by DVT/PE, ileus, and pelvic fluid collections w/ one LLQ drain presented with subjective fevers, lethargy, and bloody drain output. She was found to have worsening anemia and was given 2 units of pRBC with appropriate increase in hemoglobin noted. She was also found on CT imaging to have an interval increase in size of a left abdominal fluid collection. Decision was made to place a drain per ID. Fluid was sent and revealed: negative cultures, negative malignant cells, no evidence of lymphatic or urinary fluid. This new drain was subsequently removed per [MASKED] as fluid collection was completely drained. The prior drain was still draining serosanguinous fluid and was kept in but repositioned. ID was consulted for the fevers, leukocytosis and fluid collections and was deemed to need antibiotics and tranisitioned from broad spectrum to IV ertapenem at discharge. Will require multiple follow ups and imaging as specified in the transitional issues. ACUTE ISSUES: ============= #Pelvic fluid collections: patient arrived with one anterior drain putting out serosanguinous fluid. CT abdomen/pelvis revealed enlarging left fluid collection, and decision was made to place a drain per [MASKED]. The fluid was negative for malignant cells. The fluid had Cr 1 and triglycerides <9 suggesting that fluid collection is neither urine nor lymphatic fluid. Fluid culture was negative for bacteria. On interval imaging, the new enlarging fluid collection had completely collapsed and the drain was removed. As for the other fluid collection that already had a drain putting out serosanguinous fluid, it continued to drain serosanguinous fluid but at a lower rate than prior to admission. The drain was left in place as the fluid collection on imaging had not completely collapsed. BID - N cultures for the aforementioned fluid collection came back positive for MSSA but per ID, does not reflect rue intra-abdominal infection. Given that patient had a fever at OSH and a leukocytosis, she was placed on broad spectrum antibiotics with vanc, ceftaz and flagyl. This was tapered per ID team to IV zosyn. On discharge, ID recommended ertapenem for approximately 4 weeks with final length of treatment to be determined by fluid collection changes on repeat imaging on outpatient basis. Mrs. [MASKED] remained afebrile, and leukocytosis resolved. #Pulmonary embolism: Likely developed in the setting of being diagnosed with a post-op DVT. She was placed on lovenox. She was transitioned to heparin ggt as she needed [MASKED] procedures and was transitioned back to lovenox but at a lower dose per weight dosing to 70mg q12H upon discharge. #Acute renal injury: SCr has been steadily rising from a baseline of around 0.04-0.06 in [MASKED] to 1.1, likely [MASKED] obstructed uropathy [MASKED] large pelbic fluid collections. [MASKED] resolved over the course of her hospital stay with final Cr 0.8. #Hydronephrosis: bilateral and worsening on interval imaging from prior studies. Given patient's age, adequate urinary output, adequate creatinine clearance, and no significant electrolyte abnormalities, patient likely would not significantly benefit from intervention at this time. Per urology consult, deemed stable for discharge and recommended outpatient urology followup. #Anemia: likely a combination of anemia of chronic inflammation and acute blood loss [MASKED] to anterior abdominal drain showing serosanguinous fluid. Labs not consistent with hemolysis. Received 2 units of pRBC with appropriate response. Patient was discharged with Hgb of 8.3 per hem/onc recommendation for threshold Hgb>8 as patient feels and functionally performs better with higher blood counts. #Hypokalemia: was hypokalemic and was repleted with oral KCl PRN. CHRONIC ISSUES: =============== #Invasive high-grade urothelial carcinoma, involving the deep muscularis propria S/p cystectomy, hysterectomy, and BSO now with ileal conduit, whose post operative course has been complicated by DVT/PE, ileus, and pelvic fluid collections. Patient stating that there is no plan for chemo and radiation, her PET scan does show concerning foci of metastatic disease in the lung and peritoneum. Per patient's son, Mrs. [MASKED] has seen a doctor to work up the lung mass. Will need ongoing discussion with outpatient hem/onc regarding how to best manage concerning lesions. #Breast mass [MASKED] mammogram showing BI-RADS 5, Solid mass in the 3 o'clock left breast with features of a highly suspicious for malignancy. Per patient's son, she has seen a doctor for evaluating the new breast mass. Would recommend ongoing discussion with aforementioned doctor and outpatient hem/onc about plan to manage. # HLD: continued atorvastatin without changes. Consider evaluation regarding stopping atorvastatin on outpatient basis # Hypothyroidism: continued levothyroxine without changes. #HCP: Dr. [MASKED] (son, [MASKED] physician) [MASKED] #Code status: full code (confirmed with patient on [MASKED] TRANSITIONAL ISSUES: ==================== [ ] Will need infectious disease follow up. If ID has not contacted Mrs [MASKED] by [MASKED], she should call [MASKED] to set up an appointment. The ID appointment needs to be AFTER her CT abdomen/pelvis has already been done [ ] Assure that Mrs [MASKED] has her CT abdomen & pelvis with contrast in the week of [MASKED] [ ] She should get weekly lab draws of the following: CBC with differential, BUN, Cr, AST, ALT, TB, ALK PHOS. ALL LAB REQUESTS SHOULD BE ANNOTATED WITH: **ATTN: [MASKED] CLINIC - FAX: [MASKED] [ ] If possible, please give ertapenem at night-time so it does not interfere with her daily activities. Tentatively, she will be receiving ertapenem for [MASKED] weeks but with final treatment length determined by the infectious disease team. [ ] Will need ongoing discussion with outpatient PCP and hem/onc regarding how to manage new breast lesion and lung/peritoneum lesions. [ ] Reevaluate need for atorvastatin [ ] Will need outpatient follow up with urology, Dr. [MASKED] his team regarding worsening hydronephrosis Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H 2. Atorvastatin 10 mg PO QPM 3. Enoxaparin Sodium 90 mg SC Q12H Start: [MASKED], First Dose: Next Routine Administration Time 4. Levothyroxine Sodium 175 mcg PO DAILY 5. LORazepam 0.25-0.5 mg PO DAILY:PRN anxiety Discharge Medications: 1. Ertapenem Sodium 1 g IV 1X Duration: 1 Dose please give ertapenem daily, preferably at nighttime to not interfere with her daily activities 2. Milk of Magnesia 30 mL PO Q6H:PRN constipation 3. Enoxaparin Sodium 70 mg SC Q12H Start: Today - [MASKED], First Dose: Next Routine Administration Time 4. Acetaminophen 650 mg PO Q6H 5. Atorvastatin 10 mg PO QPM 6. Levothyroxine Sodium 175 mcg PO DAILY 7. LORazepam 0.25-0.5 mg PO DAILY:PRN anxiety Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Primary diagnosis: Pelvic fluid collection infection, [MASKED], acute blood loss anemia Secondary diagnosis: acute renal failure, acute on chronic anemia, recent pulmonary embolism, invasive high-grade urothelial carcinoma, left breast mass (BIRADS 5), hypothyroidism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear [MASKED], [MASKED] did you come to the hospital? - You were feeling tired and your drain output was bloody. What happened at the hospital? - A CT scan showed very large fluid collections in your pelvis - The radiologists placed another drain and removed it once it appeared that the large fluid collection was gone - You were given a blood transfusion - We placed a PICC (a long IV) so that you can receive antibiotics after you get discharged from the hospital What needs to happen when you leave the hospital? - Please continue seeing the doctors that are [MASKED] your lung and breast lesions and follow their recommendations. - Continue taking Lovenox every day to treat the blood clot in your lung. - If the infectious disease doctor has not contacted you by [MASKED], please call the following number to set up an appointment: [MASKED]. - Please make sure you have a repeat CT scan done BEFORE your appointment with the infectious disease doctor - You will be getting IV antibiotics for several weeks. The infectious disease doctor [MASKED] determine how long you will need to be on it. It was a pleasure taking care of you. Your [MASKED] team Followup Instructions: [MASKED]
|
[] |
[
"N179",
"D62",
"I10",
"E785",
"E039",
"Y929",
"Z86718",
"Z7901",
"Z87891"
] |
[
"T814XXA: Infection following a procedure",
"A419: Sepsis, unspecified organism",
"K651: Peritoneal abscess",
"N179: Acute kidney failure, unspecified",
"N1330: Unspecified hydronephrosis",
"D62: Acute posthemorrhagic anemia",
"I2782: Chronic pulmonary embolism",
"N138: Other obstructive and reflux uropathy",
"C679: Malignant neoplasm of bladder, unspecified",
"I10: Essential (primary) hypertension",
"E785: Hyperlipidemia, unspecified",
"E039: Hypothyroidism, unspecified",
"K439: Ventral hernia without obstruction or gangrene",
"K435: Parastomal hernia without obstruction or gangrene",
"E876: Hypokalemia",
"Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure",
"Y929: Unspecified place or not applicable",
"Z96652: Presence of left artificial knee joint",
"Z86718: Personal history of other venous thrombosis and embolism",
"N63: Unspecified lump in breast",
"Z7901: Long term (current) use of anticoagulants",
"Z87891: Personal history of nicotine dependence"
] |
10,001,401 | 28,058,085 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hematuria, weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o female with h/o PE (on lovenox), bladder cancer s/p
Robotic TAH-BSO, lap radical cystectomy with ileal loop
diversion and anterior vaginectomy in ___ c/b abdominal
fluid requiring placement of drainage catheters. Recent
abdominal imaging noted worsening of her bilateral severe
hydronephrosis and her Cr was noted to have risen from 0.8 to
1.3(outside lab value). Patient recently underwent bilateral
nephrostomy tube placement by ___ on ___.
She first started feeling weak during ___ yesterday doing the
exercises. Had palpitations with ambulation. Has tightness in
chest with ambulating since yesterday. Felt light headed with
ambulation. SNF noticed increased hematuria with R bag darker
than L bag since yesterday. Her Urostomy (placed in ___
also positive for hematuria. She was transferred to ___ ED for
further management.
In the ED, initial vitals were:
Temp. 98.1, HR 72, BP 139/56, RR 16, 99% RA
- Labs notable for:
WBC 5.9, Hg 8.1, platelets 374. Na 140, K 4.3, Cl 103, biacrb
22, BUN 29, Cr 1.0
UA from bilateral nephrostomy tubes with > 100 WBC, moderate
leukocytes, and large blood.
- Imaging was notable for:
CT abd/pelvis w/o contrast:
Interval placement of bilateral percutaneous nephroureterostomy
tubes with resolved hydroureteronephrosis. No RP hematoma.
- Patient was given:
LR
Upon arrival to the floor, patient reports that she noticed
shortness of breath today with walking in conjunction with
bloody output from her ostomy tubes. She notes that the output
from her nephrostomy tubes was pink tinged when she left the
hospital 2 days ago. She also endorses associated chest
tightness but no pain or pressure. She denies cough, fever,
chills, abdominal pain, or diarrhea. She notes that she has an
ostomy and nephroureterostomy without sensation of dysuria.
Patient notes feeling dizzy and lightheaded previously though is
currently asymptomatic.
Past Medical History:
- Hypertension
- s/p lap chole
- s/p left knee replacement
- s/p laminectomy of L5-S1 at age ___
- Bladder Cancer high grade TCC, T1 diagnosed in ___, then
___ pelvic MRI w/invasion into bladder wall, perivesical
soft tissue and anterior vaginal wall c/w T4 staging
- s/p hysterectomy and bilateral oophorectomy for large uterus
w/fibroid, s/p laparascopic b/l pelvic lymph node resection, s/p
radical cystectomy and anterior vaginectomy with vaginal
reconstruction with ileal conduit creation ___, course
complicated by bacteremia and development of intra-abdominal
fluid collection, no s/p drain placement by ___ ___
- h/o LLE DVT and PE on lovenox
Social History:
___
Family History:
Negative for bladder CA.
Physical Exam:
=========================
ADMISSION PHYSICAL EXAM:
=========================
VITAL SIGNS: Temp. 98.1 PO BP 158 / 66 HR 72 RR 18 Spo2 95 RA
GENERAL: well-appearing elderly woman in no acute distress
CARDIAC: RRR, no murmurs
LUNGS: clear to auscultation bilaterally
ABDOMEN: soft, non-tender to palpation, normal bowel sounds.
Ostomy draining brown stool. Nephroureterostomy draining dark
red bloody urine. Bilateral nephrostomy tubes draining blood
urine.
EXTREMITIES: No edema, warm and well-perfused.
=========================
DISCHARGE PHYSICAL EXAM:
=========================
VS - 98.3 PO 139/67 71 18 94 RA
GENERAL: well-appearing elderly woman in no acute distress
CARDIAC: RRR, no murmurs
LUNGS: clear to auscultation bilaterally
ABDOMEN: soft, non-tender to palpation, normal bowel sounds.
Nephroureterostomy draining dark red bloody urine. Bilateral
nephrostomy tubes capped.
EXTREMITIES: No edema, warm and well-perfused
Pertinent Results:
================
ADMISSION LABS
================
___ 05:20PM BLOOD WBC-5.9 RBC-2.90* Hgb-8.1* Hct-26.6*
MCV-92 MCH-27.9 MCHC-30.5* RDW-15.4 RDWSD-51.2* Plt ___
___ 05:48AM BLOOD WBC-4.6 RBC-2.46* Hgb-7.0* Hct-22.6*
MCV-92 MCH-28.5 MCHC-31.0* RDW-15.3 RDWSD-51.7* Plt ___
___ 05:20PM BLOOD Neuts-56.3 ___ Monos-12.6 Eos-1.5
Baso-0.3 Im ___ AbsNeut-3.29# AbsLymp-1.69 AbsMono-0.74
AbsEos-0.09 AbsBaso-0.02
___ 05:20PM BLOOD Glucose-101* UreaN-29* Creat-1.0 Na-140
K-4.3 Cl-103 HCO3-22 AnGap-19
=================
IMAGING/STUDIES
=================
___ CT Abd/Pel w/o Contrast:
IMPRESSION:
1. Interval placement of bilateral percutaneous
nephroureterostomy tubes with resolved hydroureteronephrosis.
No RP hematoma.
2. Partially imaged nodular opacity in the right middle lobe
which can be
further assessed on a nonemergent dedicated CT chest.
___ CXR
AP portable upright view of the chest. Right upper extremity
access PICC
line is seen with its tip in the upper SVC. Overlying EKG leads
are present. Lungs are clear. Cardiomediastinal silhouette is
stable. Bony structures are intact.
==============
MICROBIOLOGY
==============
___ 6:35 pm URINE LEFT NEPHROSTOMY TUBE.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
================
DISCHARGE LABS
================
___ 05:08AM BLOOD WBC-5.4 RBC-2.86* Hgb-8.2* Hct-26.5*
MCV-93 MCH-28.7 MCHC-30.9* RDW-15.3 RDWSD-51.8* Plt ___
___ 05:08AM BLOOD Glucose-94 UreaN-29* Creat-0.9 Na-143
K-4.0 Cl-106 HCO3-26 AnGap-15
___ 05:08AM BLOOD Calcium-8.8 Phos-5.2* Mg-2.1
Brief Hospital Course:
Ms. ___ is an ___ year old woman with history of provoked
DVT/PE (on lovenox), bladder cancer s/p Robotic TAH-BSO, lap
radical cystectomy with ileal loop diversion and anterior
vaginectomy in ___ c/b abdominal fluid requiring
placement of drainage catheters, and recent hydronephrosis
requiring placement of bilateral PCN tubes on ___, presenting
from rehab with hematuria and weakness.
On arrival, pt had evidence of frank hematuria in her urostomy
bag and PCN tubes. Her hemoglobin was initially 8.1, which
subsequently dropped to 7.0 Her lovenox was held, and she was
transfused with 1 U PRBC with an appropriate hemoglobin bump to
8.2. Hematuria was likely caused by recent instrumentation in
the setting of anticoagulation. Her hematuria improved, as did
her dizziness/weakness. ___ was consulted and recommending
capping her PCN tubes. After discussion with the patient's
hematologist, it was decided to stop her lovenox treatment given
that her DVT/PE were provoked in the setting of her recovery
from surgery, and that she had received almost 6 months of
treatment.
Secondary Issues:
# Asymptomatic bacteruria: Patient with asymptomatic bacteruria
in setting of recent procedural manipulation. She was afebrile
and without leukocytosis, so treatment with antibiotics was
deferred.
# Hyperlipidemia: continued atorvastatin 10 mg daily
# Hypothyroidism: continue levothyroxine 175 mcg daily
===================
TRANSITIONAL ISSUES
===================
Medication Changes: Lovenox stopped
[ ] CT Abdomen/Pelvis showed partially imaged nodular opacity in
the right middle lobe which can be further assessed on a
nonemergent dedicated CT chest.
[ ] Pt's PCN tubes were capped per ___ recommendation during her
hospitalization; she was discharged with scheduled followup to
decide on long term management
[ ] If pt develops hematuria and/or lightheadedness or other
symptoms of anemia, a CBC should be rechecked to assess for
bleeding
[ ] Hemoglobin/Hematocrit on discharge: 8.2/26.5
# CODE: presumed full
# CONTACT: ___ (MD) ___ (cell)
___ (home)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 10 mg PO QPM
2. Enoxaparin Sodium 70 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
3. Levothyroxine Sodium 175 mcg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Probiotic-Digestive Enzymes (L. acidophilus-dig ___ 5)
___ mg oral daily
Discharge Medications:
1. Atorvastatin 10 mg PO QPM
2. Levothyroxine Sodium 175 mcg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Probiotic-Digestive Enzymes (L. acidophilus-dig ___ 5)
___ mg oral daily
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnoses: Hematuria, anemia
Secondary Diagnoses: Bladder cancer, hydronephrosis,
hypothyroidism, DVT/PE
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___.
WHY DID YOU COME TO THE HOSPITAL?
You noticed blood in your urine, and you were feeling
weak/lightheaded.
WHAT HAPPENED WHILE YOU WERE HERE?
We did not give you your blood thinner medication (Lovenox), and
we gave you a unit of blood. The blood in your urine cleared up.
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
Along with your oncologist Dr. ___ have decided that you
no longer need to take any Lovenox. You should continue to
follow up with your doctors, and take all of your medications as
prescribed. Your followup appointments are listed below.
Again, it was a pleasure taking care of you!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
[
"N99820",
"E43",
"R310",
"N131",
"D62",
"R8271",
"E039",
"E785",
"N9989",
"I10",
"Z86718",
"Z936",
"Z7902",
"Z86711",
"Z87891",
"Z6822",
"Z8551",
"Z96652",
"Y848",
"Y833",
"Y929"
] |
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Hematuria, weakness Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] y/o female with h/o PE (on lovenox), bladder cancer s/p Robotic TAH-BSO, lap radical cystectomy with ileal loop diversion and anterior vaginectomy in [MASKED] c/b abdominal fluid requiring placement of drainage catheters. Recent abdominal imaging noted worsening of her bilateral severe hydronephrosis and her Cr was noted to have risen from 0.8 to 1.3(outside lab value). Patient recently underwent bilateral nephrostomy tube placement by [MASKED] on [MASKED]. She first started feeling weak during [MASKED] yesterday doing the exercises. Had palpitations with ambulation. Has tightness in chest with ambulating since yesterday. Felt light headed with ambulation. SNF noticed increased hematuria with R bag darker than L bag since yesterday. Her Urostomy (placed in [MASKED] also positive for hematuria. She was transferred to [MASKED] ED for further management. In the ED, initial vitals were: Temp. 98.1, HR 72, BP 139/56, RR 16, 99% RA - Labs notable for: WBC 5.9, Hg 8.1, platelets 374. Na 140, K 4.3, Cl 103, biacrb 22, BUN 29, Cr 1.0 UA from bilateral nephrostomy tubes with > 100 WBC, moderate leukocytes, and large blood. - Imaging was notable for: CT abd/pelvis w/o contrast: Interval placement of bilateral percutaneous nephroureterostomy tubes with resolved hydroureteronephrosis. No RP hematoma. - Patient was given: LR Upon arrival to the floor, patient reports that she noticed shortness of breath today with walking in conjunction with bloody output from her ostomy tubes. She notes that the output from her nephrostomy tubes was pink tinged when she left the hospital 2 days ago. She also endorses associated chest tightness but no pain or pressure. She denies cough, fever, chills, abdominal pain, or diarrhea. She notes that she has an ostomy and nephroureterostomy without sensation of dysuria. Patient notes feeling dizzy and lightheaded previously though is currently asymptomatic. Past Medical History: - Hypertension - s/p lap chole - s/p left knee replacement - s/p laminectomy of L5-S1 at age [MASKED] - Bladder Cancer high grade TCC, T1 diagnosed in [MASKED], then [MASKED] pelvic MRI w/invasion into bladder wall, perivesical soft tissue and anterior vaginal wall c/w T4 staging - s/p hysterectomy and bilateral oophorectomy for large uterus w/fibroid, s/p laparascopic b/l pelvic lymph node resection, s/p radical cystectomy and anterior vaginectomy with vaginal reconstruction with ileal conduit creation [MASKED], course complicated by bacteremia and development of intra-abdominal fluid collection, no s/p drain placement by [MASKED] [MASKED] - h/o LLE DVT and PE on lovenox Social History: [MASKED] Family History: Negative for bladder CA. Physical Exam: ========================= ADMISSION PHYSICAL EXAM: ========================= VITAL SIGNS: Temp. 98.1 PO BP 158 / 66 HR 72 RR 18 Spo2 95 RA GENERAL: well-appearing elderly woman in no acute distress CARDIAC: RRR, no murmurs LUNGS: clear to auscultation bilaterally ABDOMEN: soft, non-tender to palpation, normal bowel sounds. Ostomy draining brown stool. Nephroureterostomy draining dark red bloody urine. Bilateral nephrostomy tubes draining blood urine. EXTREMITIES: No edema, warm and well-perfused. ========================= DISCHARGE PHYSICAL EXAM: ========================= VS - 98.3 PO 139/67 71 18 94 RA GENERAL: well-appearing elderly woman in no acute distress CARDIAC: RRR, no murmurs LUNGS: clear to auscultation bilaterally ABDOMEN: soft, non-tender to palpation, normal bowel sounds. Nephroureterostomy draining dark red bloody urine. Bilateral nephrostomy tubes capped. EXTREMITIES: No edema, warm and well-perfused Pertinent Results: ================ ADMISSION LABS ================ [MASKED] 05:20PM BLOOD WBC-5.9 RBC-2.90* Hgb-8.1* Hct-26.6* MCV-92 MCH-27.9 MCHC-30.5* RDW-15.4 RDWSD-51.2* Plt [MASKED] [MASKED] 05:48AM BLOOD WBC-4.6 RBC-2.46* Hgb-7.0* Hct-22.6* MCV-92 MCH-28.5 MCHC-31.0* RDW-15.3 RDWSD-51.7* Plt [MASKED] [MASKED] 05:20PM BLOOD Neuts-56.3 [MASKED] Monos-12.6 Eos-1.5 Baso-0.3 Im [MASKED] AbsNeut-3.29# AbsLymp-1.69 AbsMono-0.74 AbsEos-0.09 AbsBaso-0.02 [MASKED] 05:20PM BLOOD Glucose-101* UreaN-29* Creat-1.0 Na-140 K-4.3 Cl-103 HCO3-22 AnGap-19 ================= IMAGING/STUDIES ================= [MASKED] CT Abd/Pel w/o Contrast: IMPRESSION: 1. Interval placement of bilateral percutaneous nephroureterostomy tubes with resolved hydroureteronephrosis. No RP hematoma. 2. Partially imaged nodular opacity in the right middle lobe which can be further assessed on a nonemergent dedicated CT chest. [MASKED] CXR AP portable upright view of the chest. Right upper extremity access PICC line is seen with its tip in the upper SVC. Overlying EKG leads are present. Lungs are clear. Cardiomediastinal silhouette is stable. Bony structures are intact. ============== MICROBIOLOGY ============== [MASKED] 6:35 pm URINE LEFT NEPHROSTOMY TUBE. **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: NO GROWTH. ================ DISCHARGE LABS ================ [MASKED] 05:08AM BLOOD WBC-5.4 RBC-2.86* Hgb-8.2* Hct-26.5* MCV-93 MCH-28.7 MCHC-30.9* RDW-15.3 RDWSD-51.8* Plt [MASKED] [MASKED] 05:08AM BLOOD Glucose-94 UreaN-29* Creat-0.9 Na-143 K-4.0 Cl-106 HCO3-26 AnGap-15 [MASKED] 05:08AM BLOOD Calcium-8.8 Phos-5.2* Mg-2.1 Brief Hospital Course: Ms. [MASKED] is an [MASKED] year old woman with history of provoked DVT/PE (on lovenox), bladder cancer s/p Robotic TAH-BSO, lap radical cystectomy with ileal loop diversion and anterior vaginectomy in [MASKED] c/b abdominal fluid requiring placement of drainage catheters, and recent hydronephrosis requiring placement of bilateral PCN tubes on [MASKED], presenting from rehab with hematuria and weakness. On arrival, pt had evidence of frank hematuria in her urostomy bag and PCN tubes. Her hemoglobin was initially 8.1, which subsequently dropped to 7.0 Her lovenox was held, and she was transfused with 1 U PRBC with an appropriate hemoglobin bump to 8.2. Hematuria was likely caused by recent instrumentation in the setting of anticoagulation. Her hematuria improved, as did her dizziness/weakness. [MASKED] was consulted and recommending capping her PCN tubes. After discussion with the patient's hematologist, it was decided to stop her lovenox treatment given that her DVT/PE were provoked in the setting of her recovery from surgery, and that she had received almost 6 months of treatment. Secondary Issues: # Asymptomatic bacteruria: Patient with asymptomatic bacteruria in setting of recent procedural manipulation. She was afebrile and without leukocytosis, so treatment with antibiotics was deferred. # Hyperlipidemia: continued atorvastatin 10 mg daily # Hypothyroidism: continue levothyroxine 175 mcg daily =================== TRANSITIONAL ISSUES =================== Medication Changes: Lovenox stopped [ ] CT Abdomen/Pelvis showed partially imaged nodular opacity in the right middle lobe which can be further assessed on a nonemergent dedicated CT chest. [ ] Pt's PCN tubes were capped per [MASKED] recommendation during her hospitalization; she was discharged with scheduled followup to decide on long term management [ ] If pt develops hematuria and/or lightheadedness or other symptoms of anemia, a CBC should be rechecked to assess for bleeding [ ] Hemoglobin/Hematocrit on discharge: 8.2/26.5 # CODE: presumed full # CONTACT: [MASKED] (MD) [MASKED] (cell) [MASKED] (home) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 10 mg PO QPM 2. Enoxaparin Sodium 70 mg SC Q12H Start: [MASKED], First Dose: Next Routine Administration Time 3. Levothyroxine Sodium 175 mcg PO DAILY 4. Multivitamins 1 TAB PO DAILY 5. Probiotic-Digestive Enzymes (L. acidophilus-dig [MASKED] 5) [MASKED] mg oral daily Discharge Medications: 1. Atorvastatin 10 mg PO QPM 2. Levothyroxine Sodium 175 mcg PO DAILY 3. Multivitamins 1 TAB PO DAILY 4. Probiotic-Digestive Enzymes (L. acidophilus-dig [MASKED] 5) [MASKED] mg oral daily Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Primary Diagnoses: Hematuria, anemia Secondary Diagnoses: Bladder cancer, hydronephrosis, hypothyroidism, DVT/PE Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], It was a pleasure taking care of you at [MASKED]. WHY DID YOU COME TO THE HOSPITAL? You noticed blood in your urine, and you were feeling weak/lightheaded. WHAT HAPPENED WHILE YOU WERE HERE? We did not give you your blood thinner medication (Lovenox), and we gave you a unit of blood. The blood in your urine cleared up. WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL? Along with your oncologist Dr. [MASKED] have decided that you no longer need to take any Lovenox. You should continue to follow up with your doctors, and take all of your medications as prescribed. Your followup appointments are listed below. Again, it was a pleasure taking care of you! Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]
|
[] |
[
"D62",
"E039",
"E785",
"I10",
"Z86718",
"Z7902",
"Z87891",
"Y929"
] |
[
"N99820: Postprocedural hemorrhage of a genitourinary system organ or structure following a genitourinary system procedure",
"E43: Unspecified severe protein-calorie malnutrition",
"R310: Gross hematuria",
"N131: Hydronephrosis with ureteral stricture, not elsewhere classified",
"D62: Acute posthemorrhagic anemia",
"R8271: Bacteriuria",
"E039: Hypothyroidism, unspecified",
"E785: Hyperlipidemia, unspecified",
"N9989: Other postprocedural complications and disorders of genitourinary system",
"I10: Essential (primary) hypertension",
"Z86718: Personal history of other venous thrombosis and embolism",
"Z936: Other artificial openings of urinary tract status",
"Z7902: Long term (current) use of antithrombotics/antiplatelets",
"Z86711: Personal history of pulmonary embolism",
"Z87891: Personal history of nicotine dependence",
"Z6822: Body mass index [BMI] 22.0-22.9, adult",
"Z8551: Personal history of malignant neoplasm of bladder",
"Z96652: Presence of left artificial knee joint",
"Y848: Other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure",
"Y833: Surgical operation with formation of external stoma as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure",
"Y929: Unspecified place or not applicable"
] |
10,001,667 | 22,672,901 |
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:
___
|
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"E538",
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"I4891",
"Z7902",
"I110",
"E7849",
"K5790",
"Z87891",
"R946",
"I455",
"R413"
] |
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: slurred speech Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] 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 [MASKED], 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 [MASKED]. 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 [MASKED] 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 [MASKED] months, she has had [MASKED] nocturia nightly. No dysuria. She has noticed more frequent headaches lately in the past [MASKED] 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; [MASKED] year ago she was almost 140 lbs, and now she is [MASKED] 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 [MASKED] weeks. Over past few years, she has been forgetting plans, times for pickpup, and dinner plans, which has become normal. Over the past [MASKED] 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: [MASKED] 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 [MASKED] edema. Skin: ecchymoses in L shin, more extensive on R shin. Neurologic: -Mental Status: Alert, oriented [MASKED]. Able to relate history without difficulty. Attentive, able to name [MASKED] backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Able to name both high and low frequency objects. Able to read without difficulty. No dysarthria. Able to follow both midline and appendicular commands. 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: [MASKED] strength in trapezii bilaterally. XII: Tongue protrudes in midline with good excursions. Strength full with tongue-in-cheek testing. -Motor: Normal bulk and tone throughout. No pronator drift. No adventitious movements, such as tremor or asterixis noted. [[MASKED]] L 5 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 5 -Sensory: 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] [[MASKED]] [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 [MASKED] @ 419) Temp: 97.4 (Tm 98.6), BP: 146/76 (116-155/65-94), HR: 53 (53-86), RR: 17 ([MASKED]), 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 [MASKED] 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: [MASKED] 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: [MASKED] 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 [MASKED] [MASKED] 01:50AM BLOOD Neuts-53.1 [MASKED] Monos-8.2 Eos-1.5 Baso-0.3 Im [MASKED] AbsNeut-3.81 AbsLymp-2.63 AbsMono-0.59 AbsEos-0.11 AbsBaso-0.02 [MASKED] 01:50AM BLOOD [MASKED] PTT-29.7 [MASKED] [MASKED] 01:50AM BLOOD Glucose-97 UreaN-18 Creat-0.7 Na-139 K-4.3 Cl-102 HCO3-26 AnGap-11 [MASKED] 07:35AM BLOOD CK-MB-4 cTropnT-<0.01 [MASKED] 07:35AM BLOOD Calcium-9.3 Phos-3.6 Mg-1.8 Cholest-207* [MASKED] 07:35AM BLOOD Triglyc-62 HDL-69 CHOL/HD-3.0 LDLcalc-126 [MASKED] 10:57AM BLOOD %HbA1c-5.5 eAG-111 [MASKED] 05:22AM BLOOD VitB12-249 [MASKED] 05:22AM BLOOD TSH-5.8* [MASKED] 05:22AM BLOOD Trep Ab-NEG [MASKED] 03:12AM URINE Color-Straw Appear-Clear Sp [MASKED] [MASKED] 03:12AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [MASKED] OSH CTA head/neck [MASKED] opinion ([MASKED]) 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. [MASKED] 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. [MASKED] 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. [MASKED] is a [MASKED] 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 [MASKED]. Discharged to home w/ [MASKED] & [MASKED] and close PCP [MASKED]. #Transient slurred speech and instability, c/f TIA - [MASKED] consult - cleared for home with home services - Started on atorvastatin for HLD and increased home apixaban to therapeutic level - [MASKED] 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 [MASKED] (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 [MASKED] (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 [MASKED] 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 [MASKED] 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: [MASKED] 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. [MASKED], 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 [MASKED] Neurology Team Followup Instructions: [MASKED]
|
[] |
[
"Z66",
"I4891",
"Z7902",
"I110",
"Z87891"
] |
[
"R471: Dysarthria and anarthria",
"I5030: Unspecified diastolic (congestive) heart failure",
"E538: Deficiency of other specified B group vitamins",
"Z66: Do not resuscitate",
"I4891: Unspecified atrial fibrillation",
"Z7902: Long term (current) use of antithrombotics/antiplatelets",
"I110: Hypertensive heart disease with heart failure",
"E7849: Other hyperlipidemia",
"K5790: Diverticulosis of intestine, part unspecified, without perforation or abscess without bleeding",
"Z87891: Personal history of nicotine dependence",
"R946: Abnormal results of thyroid function studies",
"I455: Other specified heart block",
"R413: Other amnesia"
] |
10,001,884 | 24,746,267 |
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,
with recurrent hospitalizations for COPD exacerbations, 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...).
On the evening prior to presentation, patient experienced
worsening shortness of breath, nonproductive cough and wheezing
c/w prior COPD exacerbations. She reported taking inhalers as
directed, without relief. The patient reported that this is
almost identical to her last presentation. She also felt that
she was taking too many medications and does not wish to
continue to take prednisone. The patient was also noted to have
increased O2 requirement and she was referred to the ___ ED
for further management. Of note, please see prior admission note
for details regarding prior admission.
In the ED, initial vital signs were: 88 143/105 26 94% RA. Labs
were notable for normal BNP and a creatinine of 1.2. Patient was
given azithromycin and duoneb. Patient was scheduled to have
methylpred but did not have it administered until arrival to the
floor.
Upon arrival to the floor, she complained of wheezing and SOB.
She otherwise felt well. She agreed to take the methyprednisone
but does not wish to take prednisone any more.
REVIEW OF SYSTEMS: Per HPI. Denies headache, visual changes,
pharyngitis, fevers, chills, sweats, weight loss, 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: 97.3 159/91 75 16 94% on 2L
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: Mild 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: 98.6 127-150/50-60 70-90'S 16 98% on 3L
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: Minimally decreased bilateral air entry, no 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:
==================
___ 06:15PM BLOOD WBC-7.7 RBC-4.92 Hgb-13.5 Hct-42.4 MCV-86
MCH-27.4 MCHC-31.8* RDW-19.6* RDWSD-61.2* Plt ___
___ 06:15PM BLOOD Neuts-87.4* Lymphs-5.7* Monos-6.1
Eos-0.0* Baso-0.1 Im ___ AbsNeut-6.72* AbsLymp-0.44*
AbsMono-0.47 AbsEos-0.00* AbsBaso-0.01
___ 06:15PM BLOOD ___ PTT-29.6 ___
___ 06:15PM BLOOD Plt ___
___ 06:15PM BLOOD Glucose-122* UreaN-21* Creat-1.2* Na-136
K-3.4 Cl-92* HCO3-31 AnGap-16
___ 06:15PM BLOOD ALT-52* AST-34 AlkPhos-69 TotBili-0.3
___ 06:15PM BLOOD Lipase-28
___ 06:15PM BLOOD cTropnT-<0.01 proBNP-325
___ 06:15PM BLOOD Albumin-4.2
LABS ON DISHCHARGE:
===================
___ 06:40AM BLOOD WBC-10.3* RBC-4.20 Hgb-11.8 Hct-37.0
MCV-88 MCH-28.1 MCHC-31.9* RDW-19.9* RDWSD-65.1* Plt ___
___ 06:40AM BLOOD Plt ___
___ 06:40AM BLOOD Glucose-112* UreaN-18 Creat-0.9 Na-137
K-3.6 Cl-96 HCO3-28 AnGap-17
___ 06:40AM BLOOD Calcium-9.5 Phos-2.6* Mg-2.1
IMAGING:
========
___ CXR:
No acute cardiopulmonary process.
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 and increased wheezing secondary to
severe COPD.
#Recurrent COPD exacerbation: Patient presented with increased
dyspnea and diffuse wheezing, likely secondary to COPD
exacerbation. She has a history of multiple recurrent COPD
hospitalizations. According to Pulmonary, patient has severe
COPD based on her obstructive deficits on PFTs as well as her
severe symptoms even at rest, as well as her more frequent
exacerbations and is likely approaching end-stage disease. We
continued Advair 500/50 BID, Spiriva, standing nebulizers, and
theophylline. Pulmonary recommended additional budesonide
inhalers to allow reduction of PO prednisone dose. Prednisone
dose was increased back to 40mg (where patient was better) with
a plan for slow wean by 5mg every 2 weeks. Also, patient was
started on chronic azithromycin for chronic anti-inflammation;
after discussion with Dr. ___ was agreed to stop
azithromycin on discharge due to inability to monitor QT the
week after discharge, with plan to restart azithromycin once Dr.
___ is able to see the patient. Patient did not want to go to
pulmonary rehab. She was seen by Palliative Care who recommended
initiation of morphine liquid suspension as needed for shortness
of breath.
# Acute kidney injury: Creatinine was slightly elevated to 1.2
from a baseline of 1.0. She likely had poor PO intake.
Creatinine on discharge was 0.9.
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 ___ showed no evidence of
significant stenosis of coronaries. ECHO on ___ showed 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 Advair 500/50 BID, Spiriva, and theophylline
- Make sure patient receives standing nebulizers
- Added additional budesonide inhalers to allow reduction of PO
prednisone dose
- Start chronic azithromycin for chronic anti-inflammation.
(Patient was started on azithromycin in the hospital and QTc on
___ was 472 ms. ___ discussion with Dr. ___ was agreed
to stop azithromycin on discharge due to inability to monitor QT
the week after discharge, with the plan to restart azithromycin
once Dr. ___ is able to see the patient.)
- Would recommend audiology testing at some point while patient
is on chronic azithromycin
- Continue supplemental oxygen for comfort
- Follow up with Dr. ___ discharge
- Continue Bactrim PPX (1 tab SS daily) given extended courses
of steroids
- Patient was discharged on prednisone 40 mg with plan for taper
by 5mg every 2 weeks:
Prednisone 40 mg for two weeks (Day 1= ___ end
___
Prednisone 35 mg for two weeks (Day 1= ___ end
___
Prednisone 30 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. PredniSONE 30 mg PO DAILY
Tapered dose - DOWN
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
23. Sulfameth/Trimethoprim SS 1 TAB PO DAILY prophylaxis for
long term steroid use
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 Medications:
1. Acetaminophen 325 mg PO Q4H:PRN Pain
2. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315 mg -
200 units oral DAILY
3. Tiotropium Bromide 1 CAP IH DAILY
4. Theophylline SR 300 mg PO BID
5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY prophylaxis for long
term steroid use
6. Ranitidine 300 mg PO DAILY
7. PredniSONE 40 mg PO DAILY
8. Lorazepam 0.5 mg PO Q8H:PRN Insomnia, anxiety, vertigo
9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
10. Isosorbide Mononitrate (Extended Release) 240 mg PO DAILY
11. Ipratropium Bromide Neb 1 NEB IH Q6H Wheezing
12. Hydrochlorothiazide 50 mg PO DAILY
13. Guaifenesin ___ mL PO Q4H:PRN cough
14. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
15. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN allergies
16. Ferrous Sulfate 325 mg PO DAILY
17. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID
18. albuterol sulfate 90 mcg/actuation inhalation Q4H
19. Apixaban 5 mg PO BID
20. Aspirin 81 mg PO DAILY
21. Atorvastatin 10 mg PO QPM
22. Diltiazem Extended-Release 240 mg PO BID
23. Docusate Sodium 100 mg PO BID
24. Sodium Chloride Nasal ___ SPRY NU QID:PRN nasal discomfort
RX *sodium chloride 0.65 % ___ spray QID nasal congestion Disp
#*1 Spray Refills:*0
25. Morphine Sulfate (Oral Solution) 2 mg/mL 5 mg PO Q4H:PRN
shortness of breath
RX *morphine 10 mg/5 mL 2.5 mL by mouth every four (4) hours
Disp ___ Milliliter Milliliter Refills:*0
26. Budesonide Nasal Inhaler 180 mcg Other DAILY
RX *budesonide [Pulmicort Flexhaler] 180 mcg/actuation (160 mcg
delivered) 1 puff INH DAILY Disp #*1 Inhaler Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Severe COPD
SECONDARY DIAGNOSES:
CAD
Hypertension
Atrial fibrillation
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 to the hospital because you
were experiencing worsening shortness of breath. Pulmonary team
saw you and reviewed your condition, and your symptoms are
thought to be related to severe COPD. We did some changes in
your medications and increased the dose of prednisone. The
Palliative Care team was consulted and started you on morphine
liquid suspension to help with your breathing symptoms.
Please take all your medications on time and follow up with your
doctors as ___.
Best regards,
Your ___ team
Followup Instructions:
___
|
[
"J441",
"N179",
"Z9981",
"I4891",
"D649",
"I10",
"E785",
"G5622",
"I2510",
"M1990",
"Z96649",
"Z87891",
"J45909",
"F419",
"G4700",
"R040",
"I739"
] |
Allergies: IV Dye, Iodine Containing Contrast Media / Oxycodone / cilostazol / Varenicline Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] with hx COPD on home O2, atrial fibrillation on apixaban, hypertension, CAD, and hyperlipidemia, with recurrent hospitalizations for COPD exacerbations, who presented with dyspnea. She has had multiple prior admissions for dyspnea. She was recently discharged on [MASKED] after 3 day inpatient admission for COPD exacerbation. She was discharged on extended prednisone taper with plan for 5d 40mg Prednisone (to finish [MASKED] followed by 10mg taper every 5 days (35mg from [MASKED], 30mg [MASKED], etc...). On the evening prior to presentation, patient experienced worsening shortness of breath, nonproductive cough and wheezing c/w prior COPD exacerbations. She reported taking inhalers as directed, without relief. The patient reported that this is almost identical to her last presentation. She also felt that she was taking too many medications and does not wish to continue to take prednisone. The patient was also noted to have increased O2 requirement and she was referred to the [MASKED] ED for further management. Of note, please see prior admission note for details regarding prior admission. In the ED, initial vital signs were: 88 143/105 26 94% RA. Labs were notable for normal BNP and a creatinine of 1.2. Patient was given azithromycin and duoneb. Patient was scheduled to have methylpred but did not have it administered until arrival to the floor. Upon arrival to the floor, she complained of wheezing and SOB. She otherwise felt well. She agreed to take the methyprednisone but does not wish to take prednisone any more. REVIEW OF SYSTEMS: Per HPI. Denies headache, visual changes, pharyngitis, fevers, chills, sweats, weight loss, 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: [MASKED] Family History: Mother with asthma and hypertension. Father with colon cancer. Brother with leukemia. Physical Exam: PHYSICAL EXAMINATION ON ADMISSION: ================================== VITALS: 97.3 159/91 75 16 94% on 2L 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: Mild 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 [MASKED] throughout. PHYSICAL EXAMINATION ON DISCHARGE: ================================== VITALS: 98.6 127-150/50-60 70-90'S 16 98% on 3L 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: Minimally decreased bilateral air entry, no 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 [MASKED] throughout. Pertinent Results: LABS ON ADMISSION: ================== [MASKED] 06:15PM BLOOD WBC-7.7 RBC-4.92 Hgb-13.5 Hct-42.4 MCV-86 MCH-27.4 MCHC-31.8* RDW-19.6* RDWSD-61.2* Plt [MASKED] [MASKED] 06:15PM BLOOD Neuts-87.4* Lymphs-5.7* Monos-6.1 Eos-0.0* Baso-0.1 Im [MASKED] AbsNeut-6.72* AbsLymp-0.44* AbsMono-0.47 AbsEos-0.00* AbsBaso-0.01 [MASKED] 06:15PM BLOOD [MASKED] PTT-29.6 [MASKED] [MASKED] 06:15PM BLOOD Plt [MASKED] [MASKED] 06:15PM BLOOD Glucose-122* UreaN-21* Creat-1.2* Na-136 K-3.4 Cl-92* HCO3-31 AnGap-16 [MASKED] 06:15PM BLOOD ALT-52* AST-34 AlkPhos-69 TotBili-0.3 [MASKED] 06:15PM BLOOD Lipase-28 [MASKED] 06:15PM BLOOD cTropnT-<0.01 proBNP-325 [MASKED] 06:15PM BLOOD Albumin-4.2 LABS ON DISHCHARGE: =================== [MASKED] 06:40AM BLOOD WBC-10.3* RBC-4.20 Hgb-11.8 Hct-37.0 MCV-88 MCH-28.1 MCHC-31.9* RDW-19.9* RDWSD-65.1* Plt [MASKED] [MASKED] 06:40AM BLOOD Plt [MASKED] [MASKED] 06:40AM BLOOD Glucose-112* UreaN-18 Creat-0.9 Na-137 K-3.6 Cl-96 HCO3-28 AnGap-17 [MASKED] 06:40AM BLOOD Calcium-9.5 Phos-2.6* Mg-2.1 IMAGING: ======== [MASKED] CXR: No acute cardiopulmonary process. Brief Hospital Course: [MASKED] 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 and increased wheezing secondary to severe COPD. #Recurrent COPD exacerbation: Patient presented with increased dyspnea and diffuse wheezing, likely secondary to COPD exacerbation. She has a history of multiple recurrent COPD hospitalizations. According to Pulmonary, patient has severe COPD based on her obstructive deficits on PFTs as well as her severe symptoms even at rest, as well as her more frequent exacerbations and is likely approaching end-stage disease. We continued Advair 500/50 BID, Spiriva, standing nebulizers, and theophylline. Pulmonary recommended additional budesonide inhalers to allow reduction of PO prednisone dose. Prednisone dose was increased back to 40mg (where patient was better) with a plan for slow wean by 5mg every 2 weeks. Also, patient was started on chronic azithromycin for chronic anti-inflammation; after discussion with Dr. [MASKED] was agreed to stop azithromycin on discharge due to inability to monitor QT the week after discharge, with plan to restart azithromycin once Dr. [MASKED] is able to see the patient. Patient did not want to go to pulmonary rehab. She was seen by Palliative Care who recommended initiation of morphine liquid suspension as needed for shortness of breath. # Acute kidney injury: Creatinine was slightly elevated to 1.2 from a baseline of 1.0. She likely had poor PO intake. Creatinine on discharge was 0.9. 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 [MASKED] showed no evidence of significant stenosis of coronaries. ECHO on [MASKED] showed 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 Advair 500/50 BID, Spiriva, and theophylline - Make sure patient receives standing nebulizers - Added additional budesonide inhalers to allow reduction of PO prednisone dose - Start chronic azithromycin for chronic anti-inflammation. (Patient was started on azithromycin in the hospital and QTc on [MASKED] was 472 ms. [MASKED] discussion with Dr. [MASKED] was agreed to stop azithromycin on discharge due to inability to monitor QT the week after discharge, with the plan to restart azithromycin once Dr. [MASKED] is able to see the patient.) - Would recommend audiology testing at some point while patient is on chronic azithromycin - Continue supplemental oxygen for comfort - Follow up with Dr. [MASKED] discharge - Continue Bactrim PPX (1 tab SS daily) given extended courses of steroids - Patient was discharged on prednisone 40 mg with plan for taper by 5mg every 2 weeks: Prednisone 40 mg for two weeks (Day 1= [MASKED] end [MASKED] Prednisone 35 mg for two weeks (Day 1= [MASKED] end [MASKED] Prednisone 30 mg for two weeks (Day 1= [MASKED] end [MASKED] etc... # CONTACT: [MASKED] (husband/HCP) [MASKED] # 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 [MASKED] 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 Tapered dose - DOWN 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 23. Sulfameth/Trimethoprim SS 1 TAB PO DAILY prophylaxis for long term steroid use 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 Medications: 1. Acetaminophen 325 mg PO Q4H:PRN Pain 2. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315 mg - 200 units oral DAILY 3. Tiotropium Bromide 1 CAP IH DAILY 4. Theophylline SR 300 mg PO BID 5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY prophylaxis for long term steroid use 6. Ranitidine 300 mg PO DAILY 7. PredniSONE 40 mg PO DAILY 8. Lorazepam 0.5 mg PO Q8H:PRN Insomnia, anxiety, vertigo 9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 10. Isosorbide Mononitrate (Extended Release) 240 mg PO DAILY 11. Ipratropium Bromide Neb 1 NEB IH Q6H Wheezing 12. Hydrochlorothiazide 50 mg PO DAILY 13. Guaifenesin [MASKED] mL PO Q4H:PRN cough 14. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 15. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN allergies 16. Ferrous Sulfate 325 mg PO DAILY 17. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID 18. albuterol sulfate 90 mcg/actuation inhalation Q4H 19. Apixaban 5 mg PO BID 20. Aspirin 81 mg PO DAILY 21. Atorvastatin 10 mg PO QPM 22. Diltiazem Extended-Release 240 mg PO BID 23. Docusate Sodium 100 mg PO BID 24. Sodium Chloride Nasal [MASKED] SPRY NU QID:PRN nasal discomfort RX *sodium chloride 0.65 % [MASKED] spray QID nasal congestion Disp #*1 Spray Refills:*0 25. Morphine Sulfate (Oral Solution) 2 mg/mL 5 mg PO Q4H:PRN shortness of breath RX *morphine 10 mg/5 mL 2.5 mL by mouth every four (4) hours Disp [MASKED] Milliliter Milliliter Refills:*0 26. Budesonide Nasal Inhaler 180 mcg Other DAILY RX *budesonide [Pulmicort Flexhaler] 180 mcg/actuation (160 mcg delivered) 1 puff INH DAILY Disp #*1 Inhaler Refills:*0 Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSIS: Severe COPD SECONDARY DIAGNOSES: CAD Hypertension Atrial fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear [MASKED], [MASKED] was a great pleasure taking care of you at [MASKED] [MASKED]. You came to the hospital because you were experiencing worsening shortness of breath. Pulmonary team saw you and reviewed your condition, and your symptoms are thought to be related to severe COPD. We did some changes in your medications and increased the dose of prednisone. The Palliative Care team was consulted and started you on morphine liquid suspension to help with your breathing symptoms. Please take all your medications on time and follow up with your doctors as [MASKED]. Best regards, Your [MASKED] team Followup Instructions: [MASKED]
|
[] |
[
"N179",
"I4891",
"D649",
"I10",
"E785",
"I2510",
"Z87891",
"J45909",
"F419",
"G4700"
] |
[
"J441: Chronic obstructive pulmonary disease with (acute) exacerbation",
"N179: Acute kidney failure, unspecified",
"Z9981: Dependence on supplemental oxygen",
"I4891: Unspecified atrial fibrillation",
"D649: Anemia, unspecified",
"I10: Essential (primary) hypertension",
"E785: Hyperlipidemia, unspecified",
"G5622: Lesion of ulnar nerve, left upper limb",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"M1990: Unspecified osteoarthritis, unspecified site",
"Z96649: Presence of unspecified artificial hip joint",
"Z87891: Personal history of nicotine dependence",
"J45909: Unspecified asthma, uncomplicated",
"F419: Anxiety disorder, unspecified",
"G4700: Insomnia, unspecified",
"R040: Epistaxis",
"I739: Peripheral vascular disease, unspecified"
] |
10,001,884 | 24,962,904 |
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:
N/A
History of Present Illness:
Ms. ___ is a ___ female with history of
COPD on home O2, atrial fibrillation on apixaban, hypertension,
CAD, and hyperlipidemia who presents with shortness of breath,
cough, and wheezing for one day.
The patient reports shortness of breath, increased cough
productive of ___ red-flected sputum, and wheezing since
yesterday evening. She has been using albuterol IH more
frequently (___) with ipratropium nebs every 4 hours with
minimal relief. She had to increase her O2 flow up to 4L without
significant improvement. She was currently taking 10mg of
prednisone. She has also been taking tiotropium IH,
theophylline, advair IH at home as prescribed. She denies sick
contacts. She quit smoking approximately 1 month ago.
She reports an episode of chest pain in waiting room while
sitting down, non-exertional, resolved after 2 minutes. She
denies fever/chills, abdominal pain, nausea/vomiting,
palpitations, and diaphoresis.
She was recently admitted from ___ to ___ for dyspnea that
was thought to be secondary to steroid taper for recent COPD
exacerbation with a component of anxiety (not an acute COPD
exacerbation) and was treated with steroids and duonebs but no
antibiotics. She had a CT that showed emphysema but no evidence
of infection such as ___. Pulmonary was consulted and
recommended increasing her Advair dose to 500/50 (which was
done) and switching from theophylline to
roflumilast and initiation of long-term azithromycin therapy
(which was deferred for outpatient follow-up) She 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.
In the ED, initial vital signs were: 97.6 67 132/82 22 97% 4L.
Exam was notable for limited air movement with wheezing
bilaterally. Labs were notable for WBC 7.1, H/H 12.8/41.1, Plt
233, Na 133, K 3.6, BUN/Cr ___, trop < 0.01, BNP 181, lactate
1.5, VBG 7.43/___. Imaging with CXR showed mild basilar
atelectasis without definite focal consolidation. The patient
was given Duonebs and solumedrol 125mg IV. Vitals prior to
transfer were:
Upon arrival to the floor, she reports her breathing is
improved.
REVIEW OF SYSTEMS: Per HPI. Denies headache, visual changes,
pharyngitis, rhinorrhea, nasal congestion, fevers, chills,
sweats, weight loss, 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:
ADMISSION PHYSICAL EXAM:
==========================
VITALS: Temp 97.3, HR 76, O2 sat 160/80, RR 20, O2 sat 94% 4L
GENERAL: AOx3, speaking in full sentences, NAD, resting in bed
comfortably.
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: Expiratory wheezes throughout with poor air movement.
ABDOMEN: +BS, soft, nontender, and nondistended.
EXTREMITIES: Warm and well-perfused. No edema. 2+ DP pulses
bilaterally.
NEUROLOGIC: A&Ox3, CNII-XII intact, strength and sensation
grossly intact bilaterally.
DISCHARGE PHYSICAL EXAM:
===========================
VITALS: Tm 99.1, 146/69 (143-159/69-77), 94, 22, 94-95%% 2L
GENERAL: speaking in full sentences, NAD, resting in bed
comfortably.
CARDIAC: rrr, normal rate. ___ systolic murmur at the RUSB
LUNGS: +mild wheezes throughout
ABDOMEN: +BS, soft, nontender, and nondistended.
EXTREMITIES: Warm and well-perfused. 1+ b/l ___ edema.
NEUROLOGIC: grossly nonfocal, aaox3
Pertinent Results:
ADMISSION LABS:
=========================
___ 05:54PM BLOOD WBC-7.1 RBC-4.74 Hgb-12.8 Hct-41.1 MCV-87
MCH-27.0 MCHC-31.1* RDW-22.6* RDWSD-69.0* Plt ___
___ 05:54PM BLOOD Neuts-81.8* Lymphs-9.6* Monos-7.6
Eos-0.3* Baso-0.1 Im ___ AbsNeut-5.82 AbsLymp-0.68*
AbsMono-0.54 AbsEos-0.02* AbsBaso-0.01
___ 06:35AM BLOOD Calcium-9.9 Phos-4.1 Mg-2.0
___ 05:54PM BLOOD ___ pO2-52* pCO2-49* pH-7.43
calTCO2-34* Base XS-6
___ 05:54PM BLOOD Lactate-1.5
___ 05:54PM BLOOD proBNP-181
___ 05:54PM BLOOD cTropnT-<0.01
STUDIES:
=========================
+ CXR (___): Mild basilar atelectasis without definite focal
consolidation.
+ EKG: Sinus rhythm at 69, left bundle branch block, no acute ST
or T wave changes.
DISCHARGE LABS:
=========================
___ 06:38AM BLOOD WBC-14.4*# RBC-4.34 Hgb-11.8 Hct-37.6
MCV-87 MCH-27.2 MCHC-31.4* RDW-22.5* RDWSD-69.4* Plt ___
___ 06:38AM BLOOD Glucose-113* UreaN-18 Creat-0.8 Na-137
K-3.1(repleted)* Cl-94* HCO3-31 AnGap-15
Brief Hospital Course:
Ms. ___ is a ___ female with history of
COPD on home O2, atrial fibrillation on apixaban, hypertension,
CAD, and hyperlipidemia who presents with shortness of breath,
cough, and wheezing for one day. Pt recently DC'd from hospital
for dyspnea, treated only w/nebs and steroids as not thought ___
true COPD exacerbation, c/f anxiety component. Pt re-admitted
w/similar Sx, thought ___ COPD exacerbation, received nebs,
steroids, azithromycin. Pt's wheezing, cough, SOB improved
shortly after admission, O2 titrated down & satting well on 2L
in mid-90s which is baseline. Evaluated by ___, recommended DC to
pulmonary rehab, pt was agreeable.
ACTIVE ISSUES
=================
# Shortness of Breath: Patient with history of COPD and recent
admission for dyspnea in the setting of steroid taper. Her
symptoms on presentation were consistent with severe COPD given
diffuse wheezing and poor air movement. She likely had an
exacerbation in the setting of a decrease in her steroids. There
may also be a component of anxiety. She underwent CT last
admission that was negative for infections such as ___. She was
continued on home spiriva, theophylline, advair. She was started
on standing duonebs q6h and albuterol q2h prn and prednisone was
started at 40mg daily with slow taper. She was also given
azithromycin to complete 5 day course. She had improvement in
her wheezing and returned to baseline O2 requirement after 48
hours. She was seen by ___ who felt that she would benefit from
discharge to inpatient pulmonary rehabilitation program. On DC
to ___ rehab, recommended continued Prendisone 40mg
daily for 1x week with slow taper by 5mg every 5 days. ___ also
consider starting bactrim ppx with extended duration of steroids
if unable to wean less than 20mg qd. Will also f/u as outpatient
with pulm.
CHRONIC ISSUES:
==================
# Anxiety/Insomnia: Continued home lorazepam. Consider starting
SRRI as an outpatient.
# Atrial Fibrillation: Continued dilt for rate control and
apixaban for anticoagulation.
# Hypertension: 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.
Continued home aspirin and atorvastatin.
# Anemia: Continued home iron supplements.
TRANSITIONAL ISSUES:
==========================
[] For pt's continued COPD exacerbations, recommend finishing 5d
course of Azithromycin, 250mg qd until ___
[] Recommend extended prednisone taper for pt, 5d 40mg
Prednisone (to finish ___ followed by 10mg taper every 5 days
(35mg from ___, 30mg ___, etc...).
[] Would consider PCP prophylaxis with ___ if unable to wean
prednisone to less than 20mg daily.
[] Pt's SOB may have an anxiety component, may benefit from
starting SSRI in addition to home benzos already prescribed
# CONTACT: Full Code
# CODE STATUS: ___ (husband/HCP) ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
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 10 mg PO DAILY
15. Ranitidine 300 mg PO DAILY
16. Theophylline SR 300 mg PO BID
17. Tiotropium Bromide 1 CAP IH DAILY
18. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN Wheezing
19. cod liver oil 1 capsule oral BID
20. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315 mg -
200 units oral DAILY
21. albuterol sulfate 90 mcg/actuation inhalation Q4H
22. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
23. Lorazepam 0.5 mg PO Q8H:PRN Anxiety
24. Guaifenesin ___ mL PO Q4H:PRN cough
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 Anxiety
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. Nicotine Patch 7 mg TD DAILY
25. Azithromycin 250 mg PO Q24H Duration: 4 Doses
please take until ___. PredniSONE 40 mg PO DAILY Duration: 5 Days
40mg until ___
Tapered dose - DOWN
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
PRIMARY:
COPD Exacerbation
SECONDARY:
Afib
Anxiety
HTN
CAD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ after you developed
shortness of breath and wheezing at home shortly after your last
discharge. You were treated for a COPD exacerbation and your
breathing quickly got better. Our physical therapists evaluated
you and recommended that you have a short stay at Pulmonary
___ before going home to improve your breathing.
We wish you all the best at rehab and send our condolences to
your family on your recent loss.
It was truly a pleasure taking care of you.
Your ___ Team
Followup Instructions:
___
|
[
"J441",
"Z9981",
"I4891",
"J45909",
"Z7901",
"I10",
"I2510",
"E785",
"M1990",
"F419",
"I739",
"G4700",
"D649",
"Z96649",
"Z87891"
] |
Allergies: IV Dye, Iodine Containing Contrast Media / Oxycodone / cilostazol / Varenicline Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: N/A History of Present Illness: Ms. [MASKED] is a [MASKED] female with history of COPD on home O2, atrial fibrillation on apixaban, hypertension, CAD, and hyperlipidemia who presents with shortness of breath, cough, and wheezing for one day. The patient reports shortness of breath, increased cough productive of [MASKED] red-flected sputum, and wheezing since yesterday evening. She has been using albuterol IH more frequently ([MASKED]) with ipratropium nebs every 4 hours with minimal relief. She had to increase her O2 flow up to 4L without significant improvement. She was currently taking 10mg of prednisone. She has also been taking tiotropium IH, theophylline, advair IH at home as prescribed. She denies sick contacts. She quit smoking approximately 1 month ago. She reports an episode of chest pain in waiting room while sitting down, non-exertional, resolved after 2 minutes. She denies fever/chills, abdominal pain, nausea/vomiting, palpitations, and diaphoresis. She was recently admitted from [MASKED] to [MASKED] for dyspnea that was thought to be secondary to steroid taper for recent COPD exacerbation with a component of anxiety (not an acute COPD exacerbation) and was treated with steroids and duonebs but no antibiotics. She had a CT that showed emphysema but no evidence of infection such as [MASKED]. Pulmonary was consulted and recommended increasing her Advair dose to 500/50 (which was done) and switching from theophylline to roflumilast and initiation of long-term azithromycin therapy (which was deferred for outpatient follow-up) She was initiated on a steroid taper on [MASKED] of prednisone 30 mg for 3 days, then 20 mg for 3 days, then 10 mg until outpatient follow-up. In the ED, initial vital signs were: 97.6 67 132/82 22 97% 4L. Exam was notable for limited air movement with wheezing bilaterally. Labs were notable for WBC 7.1, H/H 12.8/41.1, Plt 233, Na 133, K 3.6, BUN/Cr [MASKED], trop < 0.01, BNP 181, lactate 1.5, VBG 7.43/[MASKED]. Imaging with CXR showed mild basilar atelectasis without definite focal consolidation. The patient was given Duonebs and solumedrol 125mg IV. Vitals prior to transfer were: Upon arrival to the floor, she reports her breathing is improved. REVIEW OF SYSTEMS: Per HPI. Denies headache, visual changes, pharyngitis, rhinorrhea, nasal congestion, fevers, chills, sweats, weight loss, 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: [MASKED] Family History: Mother with asthma and hypertension. Father with colon cancer. Brother with leukemia. Physical Exam: ADMISSION PHYSICAL EXAM: ========================== VITALS: Temp 97.3, HR 76, O2 sat 160/80, RR 20, O2 sat 94% 4L GENERAL: AOx3, speaking in full sentences, NAD, resting in bed comfortably. 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. [MASKED] systolic murmur at the RUSB. No rubs or gallops. LUNGS: Expiratory wheezes throughout with poor air movement. ABDOMEN: +BS, soft, nontender, and nondistended. EXTREMITIES: Warm and well-perfused. No edema. 2+ DP pulses bilaterally. NEUROLOGIC: A&Ox3, CNII-XII intact, strength and sensation grossly intact bilaterally. DISCHARGE PHYSICAL EXAM: =========================== VITALS: Tm 99.1, 146/69 (143-159/69-77), 94, 22, 94-95%% 2L GENERAL: speaking in full sentences, NAD, resting in bed comfortably. CARDIAC: rrr, normal rate. [MASKED] systolic murmur at the RUSB LUNGS: +mild wheezes throughout ABDOMEN: +BS, soft, nontender, and nondistended. EXTREMITIES: Warm and well-perfused. 1+ b/l [MASKED] edema. NEUROLOGIC: grossly nonfocal, aaox3 Pertinent Results: ADMISSION LABS: ========================= [MASKED] 05:54PM BLOOD WBC-7.1 RBC-4.74 Hgb-12.8 Hct-41.1 MCV-87 MCH-27.0 MCHC-31.1* RDW-22.6* RDWSD-69.0* Plt [MASKED] [MASKED] 05:54PM BLOOD Neuts-81.8* Lymphs-9.6* Monos-7.6 Eos-0.3* Baso-0.1 Im [MASKED] AbsNeut-5.82 AbsLymp-0.68* AbsMono-0.54 AbsEos-0.02* AbsBaso-0.01 [MASKED] 06:35AM BLOOD Calcium-9.9 Phos-4.1 Mg-2.0 [MASKED] 05:54PM BLOOD [MASKED] pO2-52* pCO2-49* pH-7.43 calTCO2-34* Base XS-6 [MASKED] 05:54PM BLOOD Lactate-1.5 [MASKED] 05:54PM BLOOD proBNP-181 [MASKED] 05:54PM BLOOD cTropnT-<0.01 STUDIES: ========================= + CXR ([MASKED]): Mild basilar atelectasis without definite focal consolidation. + EKG: Sinus rhythm at 69, left bundle branch block, no acute ST or T wave changes. DISCHARGE LABS: ========================= [MASKED] 06:38AM BLOOD WBC-14.4*# RBC-4.34 Hgb-11.8 Hct-37.6 MCV-87 MCH-27.2 MCHC-31.4* RDW-22.5* RDWSD-69.4* Plt [MASKED] [MASKED] 06:38AM BLOOD Glucose-113* UreaN-18 Creat-0.8 Na-137 K-3.1(repleted)* Cl-94* HCO3-31 AnGap-15 Brief Hospital Course: Ms. [MASKED] is a [MASKED] female with history of COPD on home O2, atrial fibrillation on apixaban, hypertension, CAD, and hyperlipidemia who presents with shortness of breath, cough, and wheezing for one day. Pt recently DC'd from hospital for dyspnea, treated only w/nebs and steroids as not thought [MASKED] true COPD exacerbation, c/f anxiety component. Pt re-admitted w/similar Sx, thought [MASKED] COPD exacerbation, received nebs, steroids, azithromycin. Pt's wheezing, cough, SOB improved shortly after admission, O2 titrated down & satting well on 2L in mid-90s which is baseline. Evaluated by [MASKED], recommended DC to pulmonary rehab, pt was agreeable. ACTIVE ISSUES ================= # Shortness of Breath: Patient with history of COPD and recent admission for dyspnea in the setting of steroid taper. Her symptoms on presentation were consistent with severe COPD given diffuse wheezing and poor air movement. She likely had an exacerbation in the setting of a decrease in her steroids. There may also be a component of anxiety. She underwent CT last admission that was negative for infections such as [MASKED]. She was continued on home spiriva, theophylline, advair. She was started on standing duonebs q6h and albuterol q2h prn and prednisone was started at 40mg daily with slow taper. She was also given azithromycin to complete 5 day course. She had improvement in her wheezing and returned to baseline O2 requirement after 48 hours. She was seen by [MASKED] who felt that she would benefit from discharge to inpatient pulmonary rehabilitation program. On DC to [MASKED] rehab, recommended continued Prendisone 40mg daily for 1x week with slow taper by 5mg every 5 days. [MASKED] also consider starting bactrim ppx with extended duration of steroids if unable to wean less than 20mg qd. Will also f/u as outpatient with pulm. CHRONIC ISSUES: ================== # Anxiety/Insomnia: Continued home lorazepam. Consider starting SRRI as an outpatient. # Atrial Fibrillation: Continued dilt for rate control and apixaban for anticoagulation. # Hypertension: Continued home imdur, hydrochlorothiazide, and diltiazem. # CAD: Cardiac catheterization in [MASKED] without evidence of significant stenosis of coronaries. ECHO on [MASKED] with EF > 55% and no regional or global wall motion abnormalities. Continued home aspirin and atorvastatin. # Anemia: Continued home iron supplements. TRANSITIONAL ISSUES: ========================== [] For pt's continued COPD exacerbations, recommend finishing 5d course of Azithromycin, 250mg qd until [MASKED] [] Recommend extended prednisone taper for pt, 5d 40mg Prednisone (to finish [MASKED] followed by 10mg taper every 5 days (35mg from [MASKED], 30mg [MASKED], etc...). [] Would consider PCP prophylaxis with [MASKED] if unable to wean prednisone to less than 20mg daily. [] Pt's SOB may have an anxiety component, may benefit from starting SSRI in addition to home benzos already prescribed # CONTACT: Full Code # CODE STATUS: [MASKED] (husband/HCP) [MASKED] [MASKED] on Admission: The Preadmission Medication list is accurate and complete. 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 10 mg PO DAILY 15. Ranitidine 300 mg PO DAILY 16. Theophylline SR 300 mg PO BID 17. Tiotropium Bromide 1 CAP IH DAILY 18. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN Wheezing 19. cod liver oil 1 capsule oral BID 20. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315 mg - 200 units oral DAILY 21. albuterol sulfate 90 mcg/actuation inhalation Q4H 22. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 23. Lorazepam 0.5 mg PO Q8H:PRN Anxiety 24. Guaifenesin [MASKED] mL PO Q4H:PRN cough 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 [MASKED] 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 Anxiety 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. Nicotine Patch 7 mg TD DAILY 25. Azithromycin 250 mg PO Q24H Duration: 4 Doses please take until [MASKED]. PredniSONE 40 mg PO DAILY Duration: 5 Days 40mg until [MASKED] Tapered dose - DOWN Discharge Disposition: Extended Care Facility: [MASKED] [MASKED] Diagnosis: PRIMARY: COPD Exacerbation SECONDARY: Afib Anxiety HTN CAD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [MASKED], You were admitted to [MASKED] after you developed shortness of breath and wheezing at home shortly after your last discharge. You were treated for a COPD exacerbation and your breathing quickly got better. Our physical therapists evaluated you and recommended that you have a short stay at Pulmonary [MASKED] before going home to improve your breathing. We wish you all the best at rehab and send our condolences to your family on your recent loss. It was truly a pleasure taking care of you. Your [MASKED] Team Followup Instructions: [MASKED]
|
[] |
[
"I4891",
"J45909",
"Z7901",
"I10",
"I2510",
"E785",
"F419",
"G4700",
"D649",
"Z87891"
] |
[
"J441: Chronic obstructive pulmonary disease with (acute) exacerbation",
"Z9981: Dependence on supplemental oxygen",
"I4891: Unspecified atrial fibrillation",
"J45909: Unspecified asthma, uncomplicated",
"Z7901: Long term (current) use of anticoagulants",
"I10: Essential (primary) hypertension",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"E785: Hyperlipidemia, unspecified",
"M1990: Unspecified osteoarthritis, unspecified site",
"F419: Anxiety disorder, unspecified",
"I739: Peripheral vascular disease, unspecified",
"G4700: Insomnia, unspecified",
"D649: Anemia, unspecified",
"Z96649: Presence of unspecified artificial hip joint",
"Z87891: Personal history of nicotine dependence"
] |
10,001,884 | 26,184,834 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
IV Dye, Iodine Containing Contrast Media / Oxycodone /
cilostazol / Varenicline
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Intubation & Mechanical Ventilation (Extubated)
Temporary Pacer Placement
CVL Insertion
History of Present Illness:
___ with COPD who has been admitted 9 times since ___ for
dyspnea, CAD, atrial fibrillation on apixaban who presented with
shortness of breath since being discharged on ___. She was
discharged home with services.
Mrs. ___ has significant COPD, with recent PFTs on ___
showing severely reduced FEV1 and moderately reduced FEV1/FVC.
She was generally feeling better since discharged on ___,
continuing her prednisone (at 40mg today) until the day prior to
presentation. She subsequently began to become short of breath,
especially with exertion, and developed a cough productive of
brown sputum. No fever, chills, nausea, vomiting, diarrhea. She
sleeps with three pillows laying on her side, which is stable.
Her secondary concern is that she is having trouble walking due
to pain in her R-hip to R-thigh with weight bearing. This was
new. No falls or trauma. No loss of sensation, numbness,
weakness, urinary or fecal incontinence or difficulty urinating.
In the ED, initial vital signs were: 99.0 80 116/66 24 98% Nasal
Cannula
- Exam was notable for: diffuse ronchi worst in the RLL,
tripoding
- Labs were notable for: flu swab negative, WBC 7.5 with left
shift, CBC otherwise WNL, BNP 425, lactate 3.0, U/A cloudy with
30 protein but otherwise negative, BUN/Cr ___
- Imaging: CXR with mild bibasilar atelectasis, though ED
physicians concerned for pneumonia on lateral view
- The patient was given: 1g Vancomycin, 2g cefepime, 500 mg PO
azithromycin, 1 duoneb, 20 mg prednisone (total 60 mg that day)
- Consults: none
Vitals prior to transfer were: 98.2 87 148/76 18 92% RA
Upon arrival to the floor, Mrs. ___ stated her breathing
was slightly better, but she continued to have shortness of
breath. She felt as though her ears are clogged up, and this was
her as well. She stated she has been taking all her medications
as prescribed.
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: 98.4 140/83 77 22 94% RA
GENERAL: breathing somewhat heavily with audible wheeze
HEENT - no pallor or icterus, no oropharyngeal lesion, no sinus
tenderness
NECK: Supple, JVP flat
CARDIAC: RRR, unable to appreciate any m/r/g due to breathing
PULMONARY: diffuse wheezes and ronchi
ABDOMEN: NT/ND, +BS
EXTREMITIES: 1+ lower extremity edema up shins, patient is
sitting ___ style and I do not appreciate tenderness at the R
hip
SKIN: Without rash.
NEUROLOGIC: A&Ox3, moving all extremities with purpose
PHYSICAL EXAMINATION ON DISCHARGE:
==================================
HR and RR went to zero on continuous telemetry. Patient did not
respond to vocal or tactile stimuli. Pupils were non-reactive to
light. She had no heart or lung sounds for > 1 minute on
auscultation. She was pronounced dead at 0515. Family was
notified, they had previously declined an autopsy.
Pertinent Results:
LABS ON ADMISSION:
==================
___ 04:38PM BLOOD WBC-7.5 RBC-4.39 Hgb-12.3 Hct-38.6 MCV-88
MCH-28.0 MCHC-31.9* RDW-18.0* RDWSD-56.9* Plt ___
___ 04:38PM BLOOD Neuts-92.1* Lymphs-3.9* Monos-3.5*
Eos-0.0* Baso-0.0 Im ___ AbsNeut-6.91* AbsLymp-0.29*
AbsMono-0.26 AbsEos-0.00* AbsBaso-0.00*
___ 04:38PM BLOOD Plt ___
___ 04:38PM BLOOD Glucose-143* UreaN-20 Creat-1.1 Na-135
K-3.5 Cl-91* HCO3-29 AnGap-19
___ 04:38PM BLOOD ALT-50* AST-41* AlkPhos-73 TotBili-0.3
___ 04:38PM BLOOD proBNP-425
___ 04:38PM BLOOD Albumin-4.4 Calcium-10.3 Phos-3.6 Mg-2.0
___ 10:40AM BLOOD ___ pO2-130* pCO2-41 pH-7.42
calTCO2-28 Base XS-2 Comment-GREEN TOP
___ 04:44PM BLOOD Lactate-3.0*
LABS ON DISCHARGE:
==================
___ 04:15AM BLOOD WBC-13.4* RBC-2.42* Hgb-7.0* Hct-22.9*
MCV-95 MCH-28.9 MCHC-30.6* RDW-17.5* RDWSD-56.8* Plt ___
___ 04:15AM BLOOD Glucose-94 UreaN-15 Creat-0.6 Na-138
K-4.2 Cl-97 HCO3-37* AnGap-8
___ 04:15AM BLOOD Calcium-8.3* Phos-3.0 Mg-2.0
SELECT IMAGING:
===============
___ CXR:
COMPARISON: ___
FINDINGS:
Heart size is mildly enlarged. There is mild unfolding of the
thoracic aorta. Cardiomediastinal silhouette and hilar contours
are otherwise unremarkable. There is mild bibasilar atelectasis.
Lungs are otherwise clear. Pleural surfaces are clear without
effusion or pneumothorax. Focus of air seen under the right
hemidiaphragm, likely represents colonic interposition.
IMPRESSION:No acute cardiopulmonary abnormality.
___ RUE U/S:
IMPRESSION: 4 cm acute deep vein thrombosis noted within the
mid right brachial vein as detailed above.
___ CXR:
IMPRESSION: The endotracheal tube tip is 6 cm above the carina.
Nasogastric tube tip is beyond the GE junction and off the edge
of the film. A left central line is present in the tip is in
the mid SVC. A pacemaker is noted on the right in the lead
projects over the right ventricle. There is probable scarring
in both lung apices. There are no new areas of consolidation.
There is upper zone redistribution and cardiomegaly suggesting
pulmonary venous hypertension. There is no pneumothorax.
Brief Hospital Course:
___ hx severe COPD, AFib, CAD, HTN, HLD, recent hospitalizations
for recurrent COPD exacerbations over the last several months,
who presented with dyspnea and increased wheezing secondary to
severe COPD.
She was treated for her COPD with nebulizers and steroids, but
continued to decline eventually suffering a PEA arrest thought
due to hypoxemia requiring endotracheal intubation and
mechanical ventilation. A temporary pacemaker was placed for
periods of bradycardia that may also have contributed to her PEA
arrest (versus being a manifestation of severe hypoxemia/severe
hypercarbia preceding her arrest). She made a cognitive recovery
but was unable to be successfully weaned from her ventilator.
She had capacity and was able to make it understand that she did
not wish: continued intubation & mechanical ventilation;
re-intubation and mechanical ventilation once extubated; or,
positive non-invasive pressure ventilation. After extensive
discussions with her and her family, she was transitioned to
DNR/DNI and comfort-oriented care. She was extubated to spend
quality time with her family before passing from respiratory
failure on the morning of ___ at 0515. Autopsy was declined
by family.
She was incidentally found to have a RUE DVT that was treated
with heparin gtt (which was also used for anticoagulation for
her atrial fibrillation; she was temporarily transitioned to
argatroban for concern of HIT, but PF4 antibodies returned at
very low OD, making this diagnosis unlikely). She was also
treated for an acute sinusitis with Augmentin during her
hospital stay.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325 mg PO Q4H:PRN Pain
2. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315 mg -
200 units oral DAILY
3. Tiotropium Bromide 1 CAP IH DAILY
4. Theophylline SR 300 mg PO BID
5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY prophylaxis for long
term steroid use
6. Ranitidine 300 mg PO DAILY
7. PredniSONE 40 mg PO DAILY
8. Lorazepam 0.5 mg PO Q8H:PRN Insomnia, anxiety, vertigo
9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
10. Isosorbide Mononitrate (Extended Release) 240 mg PO DAILY
11. Ipratropium Bromide Neb 1 NEB IH Q6H Wheezing
12. Hydrochlorothiazide 50 mg PO DAILY
13. Guaifenesin ___ mL PO Q4H:PRN cough
14. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
15. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN allergies
16. Ferrous Sulfate 325 mg PO DAILY
17. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID
18. albuterol sulfate 90 mcg/actuation inhalation Q4H
19. Apixaban 5 mg PO BID
20. Aspirin 81 mg PO DAILY
21. Atorvastatin 10 mg PO QPM
22. Diltiazem Extended-Release 240 mg PO BID
23. Docusate Sodium 100 mg PO BID
24. Sodium Chloride Nasal ___ SPRY NU QID:PRN nasal discomfort
25. Morphine Sulfate (Oral Solution) 2 mg/mL 5 mg PO Q4H:PRN
shortness of breath
26. Budesonide Nasal Inhaler 180 mcg Other DAILY
Discharge Medications:
None.
Discharge Disposition:
Expired
Discharge Diagnosis:
PRIMARY DIAGNOSES:
s/p PEA Arrest
Respiratory Failure
COPD
Sinusitis
RUE DVT
SECONDARY DIAGNOSES:
Atrial fibrillation
Hypertension
CAD
Discharge Condition:
Deceased.
Discharge Instructions:
N/A
Followup Instructions:
___
|
[
"J441",
"K7200",
"R579",
"J9602",
"J9601",
"I442",
"I82621",
"I4891",
"D696",
"I469",
"I10",
"E785",
"Z7901",
"M47892",
"I7389",
"I2510",
"Z87891",
"Z96641",
"J0190",
"F419",
"G4700",
"R609",
"D509",
"R509",
"M1990",
"Y92239",
"Z7952",
"Z825",
"Z781",
"Z515",
"Z66",
"Z9981",
"J45909",
"I447",
"M7981",
"T45515A"
] |
Allergies: IV Dye, Iodine Containing Contrast Media / Oxycodone / cilostazol / Varenicline Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Intubation & Mechanical Ventilation (Extubated) Temporary Pacer Placement CVL Insertion History of Present Illness: [MASKED] with COPD who has been admitted 9 times since [MASKED] for dyspnea, CAD, atrial fibrillation on apixaban who presented with shortness of breath since being discharged on [MASKED]. She was discharged home with services. Mrs. [MASKED] has significant COPD, with recent PFTs on [MASKED] showing severely reduced FEV1 and moderately reduced FEV1/FVC. She was generally feeling better since discharged on [MASKED], continuing her prednisone (at 40mg today) until the day prior to presentation. She subsequently began to become short of breath, especially with exertion, and developed a cough productive of brown sputum. No fever, chills, nausea, vomiting, diarrhea. She sleeps with three pillows laying on her side, which is stable. Her secondary concern is that she is having trouble walking due to pain in her R-hip to R-thigh with weight bearing. This was new. No falls or trauma. No loss of sensation, numbness, weakness, urinary or fecal incontinence or difficulty urinating. In the ED, initial vital signs were: 99.0 80 116/66 24 98% Nasal Cannula - Exam was notable for: diffuse ronchi worst in the RLL, tripoding - Labs were notable for: flu swab negative, WBC 7.5 with left shift, CBC otherwise WNL, BNP 425, lactate 3.0, U/A cloudy with 30 protein but otherwise negative, BUN/Cr [MASKED] - Imaging: CXR with mild bibasilar atelectasis, though ED physicians concerned for pneumonia on lateral view - The patient was given: 1g Vancomycin, 2g cefepime, 500 mg PO azithromycin, 1 duoneb, 20 mg prednisone (total 60 mg that day) - Consults: none Vitals prior to transfer were: 98.2 87 148/76 18 92% RA Upon arrival to the floor, Mrs. [MASKED] stated her breathing was slightly better, but she continued to have shortness of breath. She felt as though her ears are clogged up, and this was her as well. She stated she has been taking all her medications as prescribed. 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: [MASKED] Family History: Mother with asthma and hypertension. Father with colon cancer. Brother with leukemia. Physical Exam: PHYSICAL EXAMINATION ON ADMISSION: ================================== VITALS: 98.4 140/83 77 22 94% RA GENERAL: breathing somewhat heavily with audible wheeze HEENT - no pallor or icterus, no oropharyngeal lesion, no sinus tenderness NECK: Supple, JVP flat CARDIAC: RRR, unable to appreciate any m/r/g due to breathing PULMONARY: diffuse wheezes and ronchi ABDOMEN: NT/ND, +BS EXTREMITIES: 1+ lower extremity edema up shins, patient is sitting [MASKED] style and I do not appreciate tenderness at the R hip SKIN: Without rash. NEUROLOGIC: A&Ox3, moving all extremities with purpose PHYSICAL EXAMINATION ON DISCHARGE: ================================== HR and RR went to zero on continuous telemetry. Patient did not respond to vocal or tactile stimuli. Pupils were non-reactive to light. She had no heart or lung sounds for > 1 minute on auscultation. She was pronounced dead at 0515. Family was notified, they had previously declined an autopsy. Pertinent Results: LABS ON ADMISSION: ================== [MASKED] 04:38PM BLOOD WBC-7.5 RBC-4.39 Hgb-12.3 Hct-38.6 MCV-88 MCH-28.0 MCHC-31.9* RDW-18.0* RDWSD-56.9* Plt [MASKED] [MASKED] 04:38PM BLOOD Neuts-92.1* Lymphs-3.9* Monos-3.5* Eos-0.0* Baso-0.0 Im [MASKED] AbsNeut-6.91* AbsLymp-0.29* AbsMono-0.26 AbsEos-0.00* AbsBaso-0.00* [MASKED] 04:38PM BLOOD Plt [MASKED] [MASKED] 04:38PM BLOOD Glucose-143* UreaN-20 Creat-1.1 Na-135 K-3.5 Cl-91* HCO3-29 AnGap-19 [MASKED] 04:38PM BLOOD ALT-50* AST-41* AlkPhos-73 TotBili-0.3 [MASKED] 04:38PM BLOOD proBNP-425 [MASKED] 04:38PM BLOOD Albumin-4.4 Calcium-10.3 Phos-3.6 Mg-2.0 [MASKED] 10:40AM BLOOD [MASKED] pO2-130* pCO2-41 pH-7.42 calTCO2-28 Base XS-2 Comment-GREEN TOP [MASKED] 04:44PM BLOOD Lactate-3.0* LABS ON DISCHARGE: ================== [MASKED] 04:15AM BLOOD WBC-13.4* RBC-2.42* Hgb-7.0* Hct-22.9* MCV-95 MCH-28.9 MCHC-30.6* RDW-17.5* RDWSD-56.8* Plt [MASKED] [MASKED] 04:15AM BLOOD Glucose-94 UreaN-15 Creat-0.6 Na-138 K-4.2 Cl-97 HCO3-37* AnGap-8 [MASKED] 04:15AM BLOOD Calcium-8.3* Phos-3.0 Mg-2.0 SELECT IMAGING: =============== [MASKED] CXR: COMPARISON: [MASKED] FINDINGS: Heart size is mildly enlarged. There is mild unfolding of the thoracic aorta. Cardiomediastinal silhouette and hilar contours are otherwise unremarkable. There is mild bibasilar atelectasis. Lungs are otherwise clear. Pleural surfaces are clear without effusion or pneumothorax. Focus of air seen under the right hemidiaphragm, likely represents colonic interposition. IMPRESSION:No acute cardiopulmonary abnormality. [MASKED] RUE U/S: IMPRESSION: 4 cm acute deep vein thrombosis noted within the mid right brachial vein as detailed above. [MASKED] CXR: IMPRESSION: The endotracheal tube tip is 6 cm above the carina. Nasogastric tube tip is beyond the GE junction and off the edge of the film. A left central line is present in the tip is in the mid SVC. A pacemaker is noted on the right in the lead projects over the right ventricle. There is probable scarring in both lung apices. There are no new areas of consolidation. There is upper zone redistribution and cardiomegaly suggesting pulmonary venous hypertension. There is no pneumothorax. Brief Hospital Course: [MASKED] hx severe COPD, AFib, CAD, HTN, HLD, recent hospitalizations for recurrent COPD exacerbations over the last several months, who presented with dyspnea and increased wheezing secondary to severe COPD. She was treated for her COPD with nebulizers and steroids, but continued to decline eventually suffering a PEA arrest thought due to hypoxemia requiring endotracheal intubation and mechanical ventilation. A temporary pacemaker was placed for periods of bradycardia that may also have contributed to her PEA arrest (versus being a manifestation of severe hypoxemia/severe hypercarbia preceding her arrest). She made a cognitive recovery but was unable to be successfully weaned from her ventilator. She had capacity and was able to make it understand that she did not wish: continued intubation & mechanical ventilation; re-intubation and mechanical ventilation once extubated; or, positive non-invasive pressure ventilation. After extensive discussions with her and her family, she was transitioned to DNR/DNI and comfort-oriented care. She was extubated to spend quality time with her family before passing from respiratory failure on the morning of [MASKED] at 0515. Autopsy was declined by family. She was incidentally found to have a RUE DVT that was treated with heparin gtt (which was also used for anticoagulation for her atrial fibrillation; she was temporarily transitioned to argatroban for concern of HIT, but PF4 antibodies returned at very low OD, making this diagnosis unlikely). She was also treated for an acute sinusitis with Augmentin during her hospital stay. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 325 mg PO Q4H:PRN Pain 2. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315 mg - 200 units oral DAILY 3. Tiotropium Bromide 1 CAP IH DAILY 4. Theophylline SR 300 mg PO BID 5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY prophylaxis for long term steroid use 6. Ranitidine 300 mg PO DAILY 7. PredniSONE 40 mg PO DAILY 8. Lorazepam 0.5 mg PO Q8H:PRN Insomnia, anxiety, vertigo 9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 10. Isosorbide Mononitrate (Extended Release) 240 mg PO DAILY 11. Ipratropium Bromide Neb 1 NEB IH Q6H Wheezing 12. Hydrochlorothiazide 50 mg PO DAILY 13. Guaifenesin [MASKED] mL PO Q4H:PRN cough 14. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 15. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN allergies 16. Ferrous Sulfate 325 mg PO DAILY 17. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID 18. albuterol sulfate 90 mcg/actuation inhalation Q4H 19. Apixaban 5 mg PO BID 20. Aspirin 81 mg PO DAILY 21. Atorvastatin 10 mg PO QPM 22. Diltiazem Extended-Release 240 mg PO BID 23. Docusate Sodium 100 mg PO BID 24. Sodium Chloride Nasal [MASKED] SPRY NU QID:PRN nasal discomfort 25. Morphine Sulfate (Oral Solution) 2 mg/mL 5 mg PO Q4H:PRN shortness of breath 26. Budesonide Nasal Inhaler 180 mcg Other DAILY Discharge Medications: None. Discharge Disposition: Expired Discharge Diagnosis: PRIMARY DIAGNOSES: s/p PEA Arrest Respiratory Failure COPD Sinusitis RUE DVT SECONDARY DIAGNOSES: Atrial fibrillation Hypertension CAD Discharge Condition: Deceased. Discharge Instructions: N/A Followup Instructions: [MASKED]
|
[] |
[
"J9601",
"I4891",
"D696",
"I10",
"E785",
"Z7901",
"I2510",
"Z87891",
"F419",
"G4700",
"D509",
"Z515",
"Z66",
"J45909"
] |
[
"J441: Chronic obstructive pulmonary disease with (acute) exacerbation",
"K7200: Acute and subacute hepatic failure without coma",
"R579: Shock, unspecified",
"J9602: Acute respiratory failure with hypercapnia",
"J9601: Acute respiratory failure with hypoxia",
"I442: Atrioventricular block, complete",
"I82621: Acute embolism and thrombosis of deep veins of right upper extremity",
"I4891: Unspecified atrial fibrillation",
"D696: Thrombocytopenia, unspecified",
"I469: Cardiac arrest, cause unspecified",
"I10: Essential (primary) hypertension",
"E785: Hyperlipidemia, unspecified",
"Z7901: Long term (current) use of anticoagulants",
"M47892: Other spondylosis, cervical region",
"I7389: Other specified peripheral vascular diseases",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"Z87891: Personal history of nicotine dependence",
"Z96641: Presence of right artificial hip joint",
"J0190: Acute sinusitis, unspecified",
"F419: Anxiety disorder, unspecified",
"G4700: Insomnia, unspecified",
"R609: Edema, unspecified",
"D509: Iron deficiency anemia, unspecified",
"R509: Fever, unspecified",
"M1990: Unspecified osteoarthritis, unspecified site",
"Y92239: Unspecified place in hospital as the place of occurrence of the external cause",
"Z7952: Long term (current) use of systemic steroids",
"Z825: Family history of asthma and other chronic lower respiratory diseases",
"Z781: Physical restraint status",
"Z515: Encounter for palliative care",
"Z66: Do not resuscitate",
"Z9981: Dependence on supplemental oxygen",
"J45909: Unspecified asthma, uncomplicated",
"I447: Left bundle-branch block, unspecified",
"M7981: Nontraumatic hematoma of soft tissue",
"T45515A: Adverse effect of anticoagulants, initial encounter"
] |
10,001,884 | 26,202,981 |
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:
Anemia, Melena, SOB
Major Surgical or Invasive Procedure:
Upper endoscopy ___
History of Present Illness:
___ yo female with history of Afib on Xarelto, COPD, HTN, PAD who
presents for abnormal labs. She noted dark, tarry, stool on
___ and presented to PCP ___ ___, where H/H was noted
to be 8.8/28.6 from prior 11.___.6 (baseline Hct about 38). She
has also been experiencing bright red blood with wiping, she
believes from her hemorrhoids. PCP called pt who agreed to come
to ED. She had colonoscopy in ___ with showed a benign polyp,
internal hemorrhoids, and diverticulosis. Her last BM was ___,
was reportedly "regular." She currently complains of increased
exertional fatigue and has been feeling more SOB than her
baseline. Over the last 6 months she has noticed she becomes
increasingly out of breath, walking or climbing stairs. She
becomes SOB after 6 stairs or less than 1 block, requiring her
to stop, and at times use albuterol inhaler. She used to use her
only use her inhaler ___ times per day, now she uses it over
four times a day and nebulizers twice a day.
She denies any fevers, chills, nausea/vomit, diarrhea, dysuria,
rash, unintentional weight loss.
In the ED, initial vitals: 0 98 64 149/85 20 98% RA
Labs significant for:
WBC 5.0 HGB 8.8 HCT 28.4( Last baseline of 11.___/34.6 in
___ MCV PLT 240
___ 16.7 INR 1.5 PTT 38.8
Chem 7 was normal
She was given albuterol nebs and started on IV normal saline
On transfer, vitals were: T:98.4 BP: 152/60 P:68 R:18 18
O2:97%RA
On arrival to the floor patient was stable and in good spirits.
She notes that she had some blood per rectum on her underwear.
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 PHYSICAL EXAM:
Vitals: T:98.4 BP: 152/60 P:68 R:18 18 O2:97%RA
GENERAL: Well nourished, well appearing AA female, sitting up in
bed Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally though decreased air
movement. No no wheezes, rales, rhonchi
CV: Irregularly irregular rate and rhythm, normal S1 S2, ___
systolic murmur heard best at RUSB, no rubs or gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
Rectum: No obvious hemorrhoids
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: clear
NEURO: No gross deficits.
DISCHARGE PHYSICAL EXAM:
Vitals: T: 98.2, BP: 146-152/67-78, P:57-60, ___, O2:97%RA
GENERAL: Well nourished, well appearing, sitting up in bed, NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Scattered wheezes bilaterally but no resp distress
CV: Irregularly irregular rate and rhythm, normal S1 S2, ___
systolic murmur heard best at RUSB, no rubs or gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: clear
NEURO: No gross deficits.
Pertinent Results:
ADMISSION LABS:
================
___ 12:28PM BLOOD WBC-5.0 RBC-3.28* Hgb-8.8* Hct-28.4*
MCV-87 MCH-26.8 MCHC-31.0* RDW-16.1* RDWSD-50.4* Plt ___
___ 02:28PM BLOOD ___ PTT-38.8* ___
___ 12:28PM BLOOD Glucose-96 UreaN-18 Creat-1.0 Na-137
K-3.6 Cl-98 HCO3-28 AnGap-15
PERTINENT FINDINGS:
====================
EGD negative for evidence of bleeding
DISCHARGE LABS:
================
___ 06:35AM BLOOD WBC-4.7 RBC-3.38* Hgb-9.1* Hct-29.1*
MCV-86 MCH-26.9 MCHC-31.3* RDW-16.1* RDWSD-50.5* Plt ___
___ 06:35AM BLOOD ___ PTT-37.1* ___
___ 06:35AM BLOOD Glucose-99 UreaN-8 Creat-0.9 Na-137
K-3.2* Cl-98 HCO3-30 AnGap-12
___ 06:35AM BLOOD Calcium-9.5 Phos-3.3 Mg-2.___ PMH of CAD, PVD, and COPD and history of recurrent chest
pain present with drop in HCT and progressive SOB.
ACTIVE PROBLEMS
#GI Bleed: Presented to PCP with melena and wiping BRBPR. CBC
was taken and Hgb found to drop from 11.3->8.8. Two large bore
IVs were placed, started on IV PPI, and she was type and
screened. Vitals remained stable, so patient was continued on
home rivaroxaban. She was evaluated by GI who recommended upper
GI endoscopy, which showed no evidence of bleeding. She remained
hemodynamically stable throughout the admission. Hgb 9.1 on day
of discharge. She was discharged home on both her Xarelto and
ASA.
#SOB: Long standing history of smoking and COPD. Progressive
exertional dyspnea despite use of Spiriva, advair, fluticasone
nasal spray, theophylline, and albuterol nebulizers. Has
increased rescue inhaler use. Etiology unclear, does not appear
to be infectious given chronicity. Most likely is progression of
underlying COPD. PFT's were obtained while in-house. Smoking
cessation was also discussed. Will need continued outpatient f/u
re: her COPD.
CHRONIC PROBLEMS
#Afib: Continued home amiodarone and diltiazem. Continued
rivaroxaban for anticoagulation, as discussed above.
#HTN: Stable, continued on home diltiazem, Imdur, HCTZ
#Anxiety/insomnia: stable, continued home lorazepam QHS PRN for
insomnia/anxiety.
#Dry eyes: History of glaucoma. Continued home latanoprost
ophthalmic drops.
#PAD: Stable, continued on home atorvastatin, s/p iliac stent.
OK to continue aspirin as well.
TRANSITIONAL ISSUES:
- Should consider outpatient colonoscopy to potentially identify
any source of lower GI Bleed.
- Given stable hemoglobin/hematocrit while inpatient as well as
no evidence of bleeding on EGD, her Xarelto and Aspirin were
continued on discharge
- Was treated with IV PPI while inpatient, but given no evidence
of active bleeding, was discharged on home Ranitidine 300mg PO
daily
- Continue to encourage smoking cessation
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Rivaroxaban 20 mg PO QPM
2. Acetaminophen 325 mg PO Q6H:PRN pain
3. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 10 mg PO QPM
6. Diltiazem Extended-Release 180 mg PO BID
7. Fluticasone Propionate NASAL 2 SPRY NU BID nasal congestion
8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
9. Hydrochlorothiazide 50 mg PO DAILY
10. Isosorbide Mononitrate (Extended Release) 240 mg PO DAILY
11. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE QHS
12. Lorazepam 0.5 mg PO QHS:PRN insomnia
13. Multivitamins W/minerals 1 TAB PO DAILY
14. Ranitidine 300 mg PO DAILY
15. Theophylline ER 300 mg PO BID
16. Tiotropium Bromide 1 CAP IH BID
17. TraMADOL (Ultram) 50 mg PO BID pain
18. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN
irritation
19. Amiodarone 200 mg PO DAILY
Discharge Medications:
1. Acetaminophen 325 mg PO Q6H:PRN pain
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
3. Amiodarone 200 mg PO DAILY
4. Atorvastatin 10 mg PO QPM
5. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN
irritation
6. Diltiazem Extended-Release 180 mg PO BID
7. Fluticasone Propionate NASAL 2 SPRY NU BID nasal congestion
8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
9. Hydrochlorothiazide 50 mg PO DAILY
10. Isosorbide Mononitrate (Extended Release) 240 mg PO DAILY
11. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE QHS
12. Lorazepam 0.5 mg PO QHS:PRN insomnia
13. Rivaroxaban 20 mg PO QPM
14. Theophylline ER 300 mg PO BID
15. Ranitidine 300 mg PO DAILY
16. TraMADOL (Ultram) 50 mg PO BID pain
17. Tiotropium Bromide 1 CAP IH BID
18. Multivitamins W/minerals 1 TAB PO DAILY
19. Aspirin 81 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- Anemia
Secondary:
- Afib
- CAD
- HTN
- COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You were admitted to ___ due to
a decrease in blood count on laboratory testing. Because we were
concerned for a bleed in your GI tract, you underwent an upper
endoscopy. Fortunately, this did not show any evidence of
bleeding. Your blood counts remained stable while in the
hospital. You were discharged with plan for outpatient follow up
with GI for colonoscopy in the future. Pulmonary function
testing was done as well while you were here. You will also
follow up with Dr. ___ in his clinic.
It was a pleasure taking care of your at ___. If you have any
questions about the care you received, please do not hesitate to
ask.
Sincerely,
Your Inpatient ___ Care Team
Followup Instructions:
___
|
[
"K921",
"D62",
"I4891",
"J449",
"I10",
"F17210",
"D649",
"I2510",
"F419",
"E785",
"I739",
"M47892",
"R0602",
"G4700",
"H409",
"K449",
"K2970",
"Z7982",
"Z7901",
"Z96649"
] |
Allergies: IV Dye, Iodine Containing Contrast Media / Oxycodone / cilostazol / Varenicline Chief Complaint: Anemia, Melena, SOB Major Surgical or Invasive Procedure: Upper endoscopy [MASKED] History of Present Illness: [MASKED] yo female with history of Afib on Xarelto, COPD, HTN, PAD who presents for abnormal labs. She noted dark, tarry, stool on [MASKED] and presented to PCP [MASKED] [MASKED], where H/H was noted to be 8.8/28.6 from prior 11.[MASKED].6 (baseline Hct about 38). She has also been experiencing bright red blood with wiping, she believes from her hemorrhoids. PCP called pt who agreed to come to ED. She had colonoscopy in [MASKED] with showed a benign polyp, internal hemorrhoids, and diverticulosis. Her last BM was [MASKED], was reportedly "regular." She currently complains of increased exertional fatigue and has been feeling more SOB than her baseline. Over the last 6 months she has noticed she becomes increasingly out of breath, walking or climbing stairs. She becomes SOB after 6 stairs or less than 1 block, requiring her to stop, and at times use albuterol inhaler. She used to use her only use her inhaler [MASKED] times per day, now she uses it over four times a day and nebulizers twice a day. She denies any fevers, chills, nausea/vomit, diarrhea, dysuria, rash, unintentional weight loss. In the ED, initial vitals: 0 98 64 149/85 20 98% RA Labs significant for: WBC 5.0 HGB 8.8 HCT 28.4( Last baseline of 11.[MASKED]/34.6 in [MASKED] MCV PLT 240 [MASKED] 16.7 INR 1.5 PTT 38.8 Chem 7 was normal She was given albuterol nebs and started on IV normal saline On transfer, vitals were: T:98.4 BP: 152/60 P:68 R:18 18 O2:97%RA On arrival to the floor patient was stable and in good spirits. She notes that she had some blood per rectum on her underwear. 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 [MASKED] Surgery: BILATERAL COMMON ILIAC ARTERY STENTING [MASKED] BUNIONECTOMY HIP REPLACEMENT PRIOR CESAREAN SECTION GANGLION CYST Social History: [MASKED] Family History: Mother: [MASKED], HTN Father: [MASKED] CA Brother: CA? Brother: [MASKED] Physical [MASKED]: ADMISSION PHYSICAL EXAM: Vitals: T:98.4 BP: 152/60 P:68 R:18 18 O2:97%RA GENERAL: Well nourished, well appearing AA female, sitting up in bed Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: Clear to auscultation bilaterally though decreased air movement. No no wheezes, rales, rhonchi CV: Irregularly irregular rate and rhythm, normal S1 S2, [MASKED] systolic murmur heard best at RUSB, no rubs or gallops ABD: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Rectum: No obvious hemorrhoids EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: clear NEURO: No gross deficits. DISCHARGE PHYSICAL EXAM: Vitals: T: 98.2, BP: 146-152/67-78, P:57-60, [MASKED], O2:97%RA GENERAL: Well nourished, well appearing, sitting up in bed, NAD HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: Scattered wheezes bilaterally but no resp distress CV: Irregularly irregular rate and rhythm, normal S1 S2, [MASKED] systolic murmur heard best at RUSB, no rubs or gallops ABD: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: clear NEURO: No gross deficits. Pertinent Results: ADMISSION LABS: ================ [MASKED] 12:28PM BLOOD WBC-5.0 RBC-3.28* Hgb-8.8* Hct-28.4* MCV-87 MCH-26.8 MCHC-31.0* RDW-16.1* RDWSD-50.4* Plt [MASKED] [MASKED] 02:28PM BLOOD [MASKED] PTT-38.8* [MASKED] [MASKED] 12:28PM BLOOD Glucose-96 UreaN-18 Creat-1.0 Na-137 K-3.6 Cl-98 HCO3-28 AnGap-15 PERTINENT FINDINGS: ==================== EGD negative for evidence of bleeding DISCHARGE LABS: ================ [MASKED] 06:35AM BLOOD WBC-4.7 RBC-3.38* Hgb-9.1* Hct-29.1* MCV-86 MCH-26.9 MCHC-31.3* RDW-16.1* RDWSD-50.5* Plt [MASKED] [MASKED] 06:35AM BLOOD [MASKED] PTT-37.1* [MASKED] [MASKED] 06:35AM BLOOD Glucose-99 UreaN-8 Creat-0.9 Na-137 K-3.2* Cl-98 HCO3-30 AnGap-12 [MASKED] 06:35AM BLOOD Calcium-9.5 Phos-3.3 Mg-2.[MASKED] PMH of CAD, PVD, and COPD and history of recurrent chest pain present with drop in HCT and progressive SOB. ACTIVE PROBLEMS #GI Bleed: Presented to PCP with melena and wiping BRBPR. CBC was taken and Hgb found to drop from 11.3->8.8. Two large bore IVs were placed, started on IV PPI, and she was type and screened. Vitals remained stable, so patient was continued on home rivaroxaban. She was evaluated by GI who recommended upper GI endoscopy, which showed no evidence of bleeding. She remained hemodynamically stable throughout the admission. Hgb 9.1 on day of discharge. She was discharged home on both her Xarelto and ASA. #SOB: Long standing history of smoking and COPD. Progressive exertional dyspnea despite use of Spiriva, advair, fluticasone nasal spray, theophylline, and albuterol nebulizers. Has increased rescue inhaler use. Etiology unclear, does not appear to be infectious given chronicity. Most likely is progression of underlying COPD. PFT's were obtained while in-house. Smoking cessation was also discussed. Will need continued outpatient f/u re: her COPD. CHRONIC PROBLEMS #Afib: Continued home amiodarone and diltiazem. Continued rivaroxaban for anticoagulation, as discussed above. #HTN: Stable, continued on home diltiazem, Imdur, HCTZ #Anxiety/insomnia: stable, continued home lorazepam QHS PRN for insomnia/anxiety. #Dry eyes: History of glaucoma. Continued home latanoprost ophthalmic drops. #PAD: Stable, continued on home atorvastatin, s/p iliac stent. OK to continue aspirin as well. TRANSITIONAL ISSUES: - Should consider outpatient colonoscopy to potentially identify any source of lower GI Bleed. - Given stable hemoglobin/hematocrit while inpatient as well as no evidence of bleeding on EGD, her Xarelto and Aspirin were continued on discharge - Was treated with IV PPI while inpatient, but given no evidence of active bleeding, was discharged on home Ranitidine 300mg PO daily - Continue to encourage smoking cessation Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Rivaroxaban 20 mg PO QPM 2. Acetaminophen 325 mg PO Q6H:PRN pain 3. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 10 mg PO QPM 6. Diltiazem Extended-Release 180 mg PO BID 7. Fluticasone Propionate NASAL 2 SPRY NU BID nasal congestion 8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 9. Hydrochlorothiazide 50 mg PO DAILY 10. Isosorbide Mononitrate (Extended Release) 240 mg PO DAILY 11. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE QHS 12. Lorazepam 0.5 mg PO QHS:PRN insomnia 13. Multivitamins W/minerals 1 TAB PO DAILY 14. Ranitidine 300 mg PO DAILY 15. Theophylline ER 300 mg PO BID 16. Tiotropium Bromide 1 CAP IH BID 17. TraMADOL (Ultram) 50 mg PO BID pain 18. Artificial Tears Preserv. Free [MASKED] DROP BOTH EYES PRN irritation 19. Amiodarone 200 mg PO DAILY Discharge Medications: 1. Acetaminophen 325 mg PO Q6H:PRN pain 2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB 3. Amiodarone 200 mg PO DAILY 4. Atorvastatin 10 mg PO QPM 5. Artificial Tears Preserv. Free [MASKED] DROP BOTH EYES PRN irritation 6. Diltiazem Extended-Release 180 mg PO BID 7. Fluticasone Propionate NASAL 2 SPRY NU BID nasal congestion 8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 9. Hydrochlorothiazide 50 mg PO DAILY 10. Isosorbide Mononitrate (Extended Release) 240 mg PO DAILY 11. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE QHS 12. Lorazepam 0.5 mg PO QHS:PRN insomnia 13. Rivaroxaban 20 mg PO QPM 14. Theophylline ER 300 mg PO BID 15. Ranitidine 300 mg PO DAILY 16. TraMADOL (Ultram) 50 mg PO BID pain 17. Tiotropium Bromide 1 CAP IH BID 18. Multivitamins W/minerals 1 TAB PO DAILY 19. Aspirin 81 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary: - Anemia Secondary: - Afib - CAD - HTN - COPD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [MASKED], You were admitted to [MASKED] due to a decrease in blood count on laboratory testing. Because we were concerned for a bleed in your GI tract, you underwent an upper endoscopy. Fortunately, this did not show any evidence of bleeding. Your blood counts remained stable while in the hospital. You were discharged with plan for outpatient follow up with GI for colonoscopy in the future. Pulmonary function testing was done as well while you were here. You will also follow up with Dr. [MASKED] in his clinic. It was a pleasure taking care of your at [MASKED]. If you have any questions about the care you received, please do not hesitate to ask. Sincerely, Your Inpatient [MASKED] Care Team Followup Instructions: [MASKED]
|
[] |
[
"D62",
"I4891",
"J449",
"I10",
"F17210",
"D649",
"I2510",
"F419",
"E785",
"G4700",
"Z7901"
] |
[
"K921: Melena",
"D62: Acute posthemorrhagic anemia",
"I4891: Unspecified atrial fibrillation",
"J449: Chronic obstructive pulmonary disease, unspecified",
"I10: Essential (primary) hypertension",
"F17210: Nicotine dependence, cigarettes, uncomplicated",
"D649: Anemia, unspecified",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"F419: Anxiety disorder, unspecified",
"E785: Hyperlipidemia, unspecified",
"I739: Peripheral vascular disease, unspecified",
"M47892: Other spondylosis, cervical region",
"R0602: Shortness of breath",
"G4700: Insomnia, unspecified",
"H409: Unspecified glaucoma",
"K449: Diaphragmatic hernia without obstruction or gangrene",
"K2970: Gastritis, unspecified, without bleeding",
"Z7982: Long term (current) use of aspirin",
"Z7901: Long term (current) use of anticoagulants",
"Z96649: Presence of unspecified artificial hip joint"
] |
10,001,884 | 27,507,515 |
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:
___
|
[
"J441",
"J45909",
"H6991",
"F419",
"G4700",
"I4891",
"Z7901",
"I10",
"I2510",
"D649",
"E785",
"Z87891",
"Z006"
] |
Allergies: IV Dye, Iodine Containing Contrast Media / Oxycodone / cilostazol / Varenicline Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] 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 [MASKED] after 3 day inpatient admission for COPD exacerbation. She was discharged on extended prednisone taper with plan for 5d 40mg Prednisone (to finish [MASKED] followed by 10mg taper every 5 days (35mg from [MASKED], 30mg [MASKED], 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 [MASKED] noted to have inspiratory/expiratory wheezes, as well as decreased hearing and bulging TM right ear. She was referred to the [MASKED] 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: [MASKED] 16:03 IH Albuterol 0.083% Neb Soln 1 NEB [MASKED] 16:03 IH Ipratropium Bromide Neb 1 NEB [MASKED] 17:12 IH Albuterol 0.083% Neb Soln 1 NEB [MASKED] 17:12 IH Ipratropium Bromide Neb 1 NEB [MASKED] 18:12 IH Albuterol 0.083% Neb Soln 1 NEB [MASKED] 18:12 IH Ipratropium Bromide Neb 1 NEB [MASKED] 21:05 IH Albuterol 0.083% Neb Soln 1 NEB [MASKED] 21:05 PO PredniSONE 60 mg [MASKED] 21:05 IV Magnesium Sulfate 2 gm [MASKED] 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: [MASKED] 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 [MASKED] 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 [MASKED] throughout. Pertinent Results: LABS ON ADMISSION: ================== [MASKED] 04:00PM BLOOD Neuts-92.1* Lymphs-4.5* Monos-2.7* Eos-0.0* Baso-0.0 Im [MASKED] AbsNeut-5.51 AbsLymp-0.27* AbsMono-0.16* AbsEos-0.00* AbsBaso-0.00* [MASKED] 04:00PM BLOOD Plt [MASKED] [MASKED] 04:00PM BLOOD Glucose-140* UreaN-17 Creat-1.0 Na-136 K-3.5 Cl-95* HCO3-29 AnGap-16 [MASKED] 04:00PM BLOOD proBNP-254 [MASKED] 03:58PM BLOOD [MASKED] pO2-59* pCO2-43 pH-7.45 calTCO2-31* Base XS-4 LABS ON DISCHARGE: ================== [MASKED] 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 [MASKED] [MASKED] 08:00AM BLOOD Plt [MASKED] [MASKED] 08:00AM BLOOD Glucose-156* UreaN-21* Creat-0.9 Na-134 K-3.4 Cl-92* HCO3-30 AnGap-15 [MASKED] 08:00AM BLOOD Calcium-9.7 Phos-3.6 Mg-2.0 STUDIES: ======== CXR [MASKED]: No acute cardiopulmonary process EKG: NSR rate 72, QTC 469, LBBB Brief Hospital Course: [MASKED] 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 [MASKED] 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 [MASKED] without evidence of significant stenosis of coronaries. ECHO on [MASKED] 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 [MASKED] end [MASKED] - 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= [MASKED] end [MASKED] Prednisone 25 mg for two weeks (Day 1= [MASKED] end [MASKED] Prednisone 20 mg for two weeks (Day 1= [MASKED] end [MASKED] etc... # CONTACT: [MASKED] (husband/HCP) [MASKED] # 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 [MASKED] 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 [MASKED] 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: [MASKED] 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 [MASKED], [MASKED] was a great pleasure taking care of you at [MASKED] [MASKED]. 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= [MASKED] end [MASKED] - Prednisone 25 mg for two weeks (Day 1= [MASKED] end [MASKED] - Prednisone 20 mg for two weeks (Day 1= [MASKED] end [MASKED] - Discuss with Dr. [MASKED] further taper at f/u Please take all your medications on time and follow up with your doctors as [MASKED]. Best regards, Your [MASKED] team Followup Instructions: [MASKED]
|
[] |
[
"J45909",
"F419",
"G4700",
"I4891",
"Z7901",
"I10",
"I2510",
"D649",
"E785",
"Z87891"
] |
[
"J441: Chronic obstructive pulmonary disease with (acute) exacerbation",
"J45909: Unspecified asthma, uncomplicated",
"H6991: Unspecified Eustachian tube disorder, right ear",
"F419: Anxiety disorder, unspecified",
"G4700: Insomnia, unspecified",
"I4891: Unspecified atrial fibrillation",
"Z7901: Long term (current) use of anticoagulants",
"I10: Essential (primary) hypertension",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"D649: Anemia, unspecified",
"E785: Hyperlipidemia, unspecified",
"Z87891: Personal history of nicotine dependence",
"Z006: Encounter for examination for normal comparison and control in clinical research program"
] |
10,001,884 | 28,475,784 |
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:
cough, dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: ___ year old female with history of COPD (on home O2), HTN,
Afib admitted with dyspnea and cough.
Pt states inc dyspnea since this am, also one episode of
retrosternal chest pressure lasting 2minuts on way to ED. No cp
currently. on home O2. no fevers/chills or abd sx.
Patient was recently admitted from ___ with COPD flare
and afib with RVR. She could not receive azithromycin due to
concern for QTc prolongation and so was treated with
ceftriaxone/cefpodoxime. She was treated with 60mg PO prednisone
and discharged with a prednisone taper of 10 mg decrease q3d
until at 10 mg, then stay at 10 mg until pulm follow up. She was
also counseled to do pulmonary rehab and follow up with Dr.
___. She was discharged on 2L supplemental O2 to be worn at
all times. He theophylline was decreased from 300 mg BID to ___
mg BID due to her afib with RVR.
She was also seen in the ED on ___ and ___ due to dyspnea
which was felt to be a continuation of her COPD flare in the
setting of patient not taking her home medications. She was
given nebulizers and improved. She was DCed home with ___ for
assistance with medications. She declined pulmonary rehab
facility disposition.
In the ED, initial vitals:
- Exam notable for: diffuse insp/esp wheezing, dry oropharynx
- Labs notable for: nl WBC. Trop X1 neg. EKG in sinus.
- Imaging notable for: CXR no acute process.
- Pt given: duoneb X 3. methylpred 125mg. Aspirin 325mg, 1L NS,
and azithromycin 500mg. Peak flow 150, baseline per pt. Symptoms
overall improved after nebs.
- Vitals prior to transfer: 98.2 76 138/72 20 97NC.
On arrival to the floor, pt reports feeling much improved and
minimal wheezing.
ROS:
No fevers, chills, night sweats, or weight changes. No changes
in vision or hearing, no changes in balance. No cough, no
shortness of breath, no dyspnea on exertion. No chest pain or
palpitations. No nausea or vomiting. No diarrhea or
constipation. No dysuria or hematuria. No hematochezia, no
melena. No numbness or weakness, no focal deficits.
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
Vitals: 99 142/80 77 20 95/2L
General: Alert, oriented, no acute distress, appears very calm
and can talk in full sentences
HEENT: Sclerae anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: scattered wheezing
CV: II/VI RUSB systolic murmur, Nl S1, S2, No MRG
Abdomen: soft, NT/ND bowel sounds present, no rebound tenderness
or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis, 2+
edema b/l
Neuro: CN2-12 intact, no focal deficits
Vitals: 98.5 122/69(130-150) 76(70s) 18 100/2L
General: Alert, oriented, no acute distress, appears very calm
and can talk in full sentences
HEENT: Sclerae anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: scattered wheezing
CV: II/VI RUSB systolic murmur, Nl S1, S2, No MRG
Abdomen: soft, NT/ND bowel sounds present, no rebound tenderness
or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis, 2+
edema b/l
Neuro: CN2-12 intact, no focal deficits
Pertinent Results:
Admission
___ 01:46PM BLOOD WBC-8.3 RBC-4.52 Hgb-10.8* Hct-36.2
MCV-80* MCH-23.9* MCHC-29.8* RDW-21.6* RDWSD-52.4* Plt ___
___ 01:46PM BLOOD Neuts-93.4* Lymphs-4.0* Monos-1.8*
Eos-0.1* Baso-0.1 Im ___ AbsNeut-7.77* AbsLymp-0.33*
AbsMono-0.15* AbsEos-0.01* AbsBaso-0.01
___ 01:46PM BLOOD ___ PTT-31.9 ___
___ 01:46PM BLOOD Glucose-121* UreaN-19 Creat-1.1 Na-134
K-3.7 Cl-91* HCO3-31 AnGap-16
___ 01:46PM BLOOD cTropnT-<0.01
___ 01:46PM BLOOD Calcium-10.1 Phos-2.7 Mg-2.1
___ 01:58PM BLOOD Lactate-1.6
DISCHARGE
___ 05:52AM BLOOD WBC-14.1*# RBC-3.81* Hgb-9.4* Hct-30.8*
MCV-81* MCH-24.7* MCHC-30.5* RDW-22.5* RDWSD-58.1* Plt ___
___ 05:52AM BLOOD Glucose-107* UreaN-26* Creat-0.9 Na-136
K-3.5 Cl-94* HCO3-35* AnGap-11
CXR ___
IMPRESSION:
No acute cardiopulmonary process.
Brief Hospital Course:
___ year old female with history of COPD (on home O2), HTN, Afib
admitted with dyspnea and cough.
# COPD exacerbation: Presenting with cough, significant
wheezing and poor air movement initially consistent with COPD
exacerbation. No PNA on CXR. No ischemic EKG changes. Symptoms
improved with duonebs, prednisone and doxycycline. Evaluated by
___ and discharged to rehab facility for physical strengthening
and respiratory rehab. Discharged on home COPD meds and steroid
taper and abx course.
# pAfib: currently rate well controlled. on apixaban
- continued diltiazam
- continued apixaban
- continued amiodarone
# Anemia: Fe def anemia on recent admission, discharged on Fe,
continued iron supplement
# CAD: continue aspirin, atorvastatin
# Constipation: continue home bowel reg
# Anxiety: continued home meds
TRANSITIONAL
- Discharged on steroid taper with maintenance dose of 10mg
daily until she sees PCP
* Take ___-
- Doxycycline 100mg BID to ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Amiodarone 200 mg PO DAILY
3. Apixaban 5 mg PO BID
4. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN SOB
5. Artificial Tears ___ DROP BOTH EYES PRN irritation
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 10 mg PO QPM
8. Diltiazem Extended-Release 180 mg PO BID
9. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID
10. Fluticasone Propionate NASAL 1 SPRY NU BID
11. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
12. Hydrochlorothiazide 50 mg PO DAILY
13. Isosorbide Mononitrate (Extended Release) 240 mg PO DAILY
14. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE QHS
15. Lorazepam 0.5 mg PO QHS:PRN insomnia
16. Multivitamins W/minerals 1 TAB PO DAILY
17. Ranitidine 300 mg PO DAILY
18. Tiotropium Bromide 1 CAP IH DAILY
19. Theophylline SR 200 mg PO BID
20. Ferrous Sulfate 325 mg PO DAILY
21. Docusate Sodium 100 mg PO BID
22. Polyethylene Glycol 17 g PO DAILY
23. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB
24. PredniSONE 30 mg PO DAILY
Start: ___, First Dose: Next Routine Administration Time
This is dose # 1 of 2 tapered doses
25. PredniSONE 20 mg PO DAILY
Start: After 30 mg DAILY tapered dose
This is dose # 2 of 2 tapered doses
26. PredniSONE 10 mg PO DAILY
Start: After last tapered dose completes
This is the maintenance dose to follow the last tapered dose
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Amiodarone 200 mg PO DAILY
3. Apixaban 5 mg PO BID
4. Artificial Tears ___ DROP BOTH EYES PRN irritation
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 10 mg PO QPM
7. Diltiazem Extended-Release 180 mg PO BID
8. Docusate Sodium 100 mg PO BID
9. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID
10. Ferrous Sulfate 325 mg PO DAILY
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. Polyethylene Glycol 17 g PO DAILY
19. Ranitidine 300 mg PO DAILY
20. Theophylline SR 200 mg PO BID
21. Tiotropium Bromide 1 CAP IH DAILY
22. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
23. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB
24. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN SOB
25. Doxycycline Hyclate 100 mg PO Q12H Duration: 2 Days
to end ___
26. PredniSONE 10 mg PO ASDIR
Take ___-
Tapered dose - DOWN
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary
COPD exacerbation
Secondary
CORONARY ARTERY DISEASE
HYPERLIPIDEMIA
HYPERTENSION
OSTEOARTHRITIS
ATRIAL FIBRILLATION
ANXIETY
GASTROINTESTINAL BLEEDING
OSTEOARTHRITIS
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
___ were admitted with exacerbation of your COPD. We gave
___ some treatments and ___ improved. ___ were evaluated by the
physical therapy team who recommended a rehab stay for
strengthening and improve your breathing. Please take your
medications as prescribed and follow up with your providers.
Sincerely,
___ medical team
Followup Instructions:
___
|
[
"J441",
"I4892",
"Z9981",
"I480",
"J45998",
"Z87891",
"I2510",
"Z96649",
"I10",
"E785",
"D509",
"I739",
"F419",
"K5900",
"M1990",
"Z825",
"Z8249",
"Z7901"
] |
Allergies: IV Dye, Iodine Containing Contrast Media / Oxycodone / cilostazol / Varenicline Chief Complaint: cough, dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: HPI: [MASKED] year old female with history of COPD (on home O2), HTN, Afib admitted with dyspnea and cough. Pt states inc dyspnea since this am, also one episode of retrosternal chest pressure lasting 2minuts on way to ED. No cp currently. on home O2. no fevers/chills or abd sx. Patient was recently admitted from [MASKED] with COPD flare and afib with RVR. She could not receive azithromycin due to concern for QTc prolongation and so was treated with ceftriaxone/cefpodoxime. She was treated with 60mg PO prednisone and discharged with a prednisone taper of 10 mg decrease q3d until at 10 mg, then stay at 10 mg until pulm follow up. She was also counseled to do pulmonary rehab and follow up with Dr. [MASKED]. She was discharged on 2L supplemental O2 to be worn at all times. He theophylline was decreased from 300 mg BID to [MASKED] mg BID due to her afib with RVR. She was also seen in the ED on [MASKED] and [MASKED] due to dyspnea which was felt to be a continuation of her COPD flare in the setting of patient not taking her home medications. She was given nebulizers and improved. She was DCed home with [MASKED] for assistance with medications. She declined pulmonary rehab facility disposition. In the ED, initial vitals: - Exam notable for: diffuse insp/esp wheezing, dry oropharynx - Labs notable for: nl WBC. Trop X1 neg. EKG in sinus. - Imaging notable for: CXR no acute process. - Pt given: duoneb X 3. methylpred 125mg. Aspirin 325mg, 1L NS, and azithromycin 500mg. Peak flow 150, baseline per pt. Symptoms overall improved after nebs. - Vitals prior to transfer: 98.2 76 138/72 20 97NC. On arrival to the floor, pt reports feeling much improved and minimal wheezing. ROS: No fevers, chills, night sweats, or weight changes. No changes in vision or hearing, no changes in balance. No cough, no shortness of breath, no dyspnea on exertion. No chest pain or palpitations. No nausea or vomiting. No diarrhea or constipation. No dysuria or hematuria. No hematochezia, no melena. No numbness or weakness, no focal deficits. 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: [MASKED] Family History: Mother: [MASKED], HTN Father: [MASKED] CA Brother: CA? Brother: [MASKED] Physical [MASKED]: Admission Vitals: 99 142/80 77 20 95/2L General: Alert, oriented, no acute distress, appears very calm and can talk in full sentences HEENT: Sclerae anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: scattered wheezing CV: II/VI RUSB systolic murmur, Nl S1, S2, No MRG Abdomen: soft, NT/ND bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis, 2+ edema b/l Neuro: CN2-12 intact, no focal deficits Vitals: 98.5 122/69(130-150) 76(70s) 18 100/2L General: Alert, oriented, no acute distress, appears very calm and can talk in full sentences HEENT: Sclerae anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: scattered wheezing CV: II/VI RUSB systolic murmur, Nl S1, S2, No MRG Abdomen: soft, NT/ND bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis, 2+ edema b/l Neuro: CN2-12 intact, no focal deficits Pertinent Results: Admission [MASKED] 01:46PM BLOOD WBC-8.3 RBC-4.52 Hgb-10.8* Hct-36.2 MCV-80* MCH-23.9* MCHC-29.8* RDW-21.6* RDWSD-52.4* Plt [MASKED] [MASKED] 01:46PM BLOOD Neuts-93.4* Lymphs-4.0* Monos-1.8* Eos-0.1* Baso-0.1 Im [MASKED] AbsNeut-7.77* AbsLymp-0.33* AbsMono-0.15* AbsEos-0.01* AbsBaso-0.01 [MASKED] 01:46PM BLOOD [MASKED] PTT-31.9 [MASKED] [MASKED] 01:46PM BLOOD Glucose-121* UreaN-19 Creat-1.1 Na-134 K-3.7 Cl-91* HCO3-31 AnGap-16 [MASKED] 01:46PM BLOOD cTropnT-<0.01 [MASKED] 01:46PM BLOOD Calcium-10.1 Phos-2.7 Mg-2.1 [MASKED] 01:58PM BLOOD Lactate-1.6 DISCHARGE [MASKED] 05:52AM BLOOD WBC-14.1*# RBC-3.81* Hgb-9.4* Hct-30.8* MCV-81* MCH-24.7* MCHC-30.5* RDW-22.5* RDWSD-58.1* Plt [MASKED] [MASKED] 05:52AM BLOOD Glucose-107* UreaN-26* Creat-0.9 Na-136 K-3.5 Cl-94* HCO3-35* AnGap-11 CXR [MASKED] IMPRESSION: No acute cardiopulmonary process. Brief Hospital Course: [MASKED] year old female with history of COPD (on home O2), HTN, Afib admitted with dyspnea and cough. # COPD exacerbation: Presenting with cough, significant wheezing and poor air movement initially consistent with COPD exacerbation. No PNA on CXR. No ischemic EKG changes. Symptoms improved with duonebs, prednisone and doxycycline. Evaluated by [MASKED] and discharged to rehab facility for physical strengthening and respiratory rehab. Discharged on home COPD meds and steroid taper and abx course. # pAfib: currently rate well controlled. on apixaban - continued diltiazam - continued apixaban - continued amiodarone # Anemia: Fe def anemia on recent admission, discharged on Fe, continued iron supplement # CAD: continue aspirin, atorvastatin # Constipation: continue home bowel reg # Anxiety: continued home meds TRANSITIONAL - Discharged on steroid taper with maintenance dose of 10mg daily until she sees PCP * Take [MASKED]- - Doxycycline 100mg BID to [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Amiodarone 200 mg PO DAILY 3. Apixaban 5 mg PO BID 4. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN SOB 5. Artificial Tears [MASKED] DROP BOTH EYES PRN irritation 6. Aspirin 81 mg PO DAILY 7. Atorvastatin 10 mg PO QPM 8. Diltiazem Extended-Release 180 mg PO BID 9. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID 10. Fluticasone Propionate NASAL 1 SPRY NU BID 11. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 12. Hydrochlorothiazide 50 mg PO DAILY 13. Isosorbide Mononitrate (Extended Release) 240 mg PO DAILY 14. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE QHS 15. Lorazepam 0.5 mg PO QHS:PRN insomnia 16. Multivitamins W/minerals 1 TAB PO DAILY 17. Ranitidine 300 mg PO DAILY 18. Tiotropium Bromide 1 CAP IH DAILY 19. Theophylline SR 200 mg PO BID 20. Ferrous Sulfate 325 mg PO DAILY 21. Docusate Sodium 100 mg PO BID 22. Polyethylene Glycol 17 g PO DAILY 23. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB 24. PredniSONE 30 mg PO DAILY Start: [MASKED], First Dose: Next Routine Administration Time This is dose # 1 of 2 tapered doses 25. PredniSONE 20 mg PO DAILY Start: After 30 mg DAILY tapered dose This is dose # 2 of 2 tapered doses 26. PredniSONE 10 mg PO DAILY Start: After last tapered dose completes This is the maintenance dose to follow the last tapered dose Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Amiodarone 200 mg PO DAILY 3. Apixaban 5 mg PO BID 4. Artificial Tears [MASKED] DROP BOTH EYES PRN irritation 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 10 mg PO QPM 7. Diltiazem Extended-Release 180 mg PO BID 8. Docusate Sodium 100 mg PO BID 9. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID 10. Ferrous Sulfate 325 mg PO DAILY 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. Polyethylene Glycol 17 g PO DAILY 19. Ranitidine 300 mg PO DAILY 20. Theophylline SR 200 mg PO BID 21. Tiotropium Bromide 1 CAP IH DAILY 22. Albuterol Inhaler [MASKED] PUFF IH Q6H:PRN SOB 23. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB 24. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN SOB 25. Doxycycline Hyclate 100 mg PO Q12H Duration: 2 Days to end [MASKED] 26. PredniSONE 10 mg PO ASDIR Take [MASKED]- Tapered dose - DOWN Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Primary COPD exacerbation Secondary CORONARY ARTERY DISEASE HYPERLIPIDEMIA HYPERTENSION OSTEOARTHRITIS ATRIAL FIBRILLATION ANXIETY GASTROINTESTINAL BLEEDING OSTEOARTHRITIS Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear [MASKED], [MASKED] were admitted with exacerbation of your COPD. We gave [MASKED] some treatments and [MASKED] improved. [MASKED] were evaluated by the physical therapy team who recommended a rehab stay for strengthening and improve your breathing. Please take your medications as prescribed and follow up with your providers. Sincerely, [MASKED] medical team Followup Instructions: [MASKED]
|
[] |
[
"I480",
"Z87891",
"I2510",
"I10",
"E785",
"D509",
"F419",
"K5900",
"Z7901"
] |
[
"J441: Chronic obstructive pulmonary disease with (acute) exacerbation",
"I4892: Unspecified atrial flutter",
"Z9981: Dependence on supplemental oxygen",
"I480: Paroxysmal atrial fibrillation",
"J45998: Other asthma",
"Z87891: Personal history of nicotine dependence",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"Z96649: Presence of unspecified artificial hip joint",
"I10: Essential (primary) hypertension",
"E785: Hyperlipidemia, unspecified",
"D509: Iron deficiency anemia, unspecified",
"I739: Peripheral vascular disease, unspecified",
"F419: Anxiety disorder, unspecified",
"K5900: Constipation, unspecified",
"M1990: Unspecified osteoarthritis, unspecified site",
"Z825: Family history of asthma and other chronic lower respiratory diseases",
"Z8249: Family history of ischemic heart disease and other diseases of the circulatory system",
"Z7901: Long term (current) use of anticoagulants"
] |
10,001,884 | 28,664,981 |
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:
___
|
[
"J441",
"I4892",
"I248",
"J45909",
"Z87891",
"I4891",
"F419",
"G4700",
"E780",
"I2510",
"E876",
"R312",
"I739",
"Z7952",
"Z9981"
] |
Allergies: IV Dye, Iodine Containing Contrast Media / Oxycodone / cilostazol / Varenicline Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] yo woman with a PMH notable for COPD on home O2(hospitalized [MASKED], 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 [MASKED]. She has been on steroid therapy with several attempts to taper over the last several months. After her most recent ED visit on [MASKED] 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 [MASKED] 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 [MASKED]. 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 [MASKED] 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 [MASKED] 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: [MASKED] Family History: Mother: [MASKED], HTN Father: [MASKED] CA Brother: CA? Brother: [MASKED] Physical [MASKED]: ================= 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, [MASKED] 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. [MASKED] 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: ================== [MASKED] 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 [MASKED] [MASKED] 02:27PM BLOOD Neuts-86.5* Lymphs-6.1* Monos-6.6 Eos-0.0* Baso-0.0 Im [MASKED] AbsNeut-6.38* AbsLymp-0.45* AbsMono-0.49 AbsEos-0.00* AbsBaso-0.00* [MASKED] 02:27PM BLOOD Glucose-132* UreaN-17 Creat-1.0 Na-137 K-3.7 Cl-93* HCO3-31 AnGap-17 ================== PERTINENT RESULTS: ================== LABS: ================== [MASKED] 12:15AM BLOOD [MASKED] pO2-103 pCO2-49* pH-7.42 calTCO2-33* Base XS-5 === [MASKED] 02:27PM BLOOD cTropnT-0.02* proBNP-235 [MASKED] 09:05PM BLOOD CK-MB-6 cTropnT-<0.01 [MASKED] 07:45AM BLOOD CK-MB-6 cTropnT-0.02* === [MASKED] 07:45AM BLOOD THEOPHYLLINE-17.3 (10.0-20.0) ================== IMAGING: ================== CXR ([MASKED]): 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 ([MASKED]): 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: ================== [MASKED] 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 [MASKED] [MASKED] 07:45AM BLOOD Glucose-94 UreaN-18 Creat-1.0 Na-135 K-3.3 Cl-93* HCO3-31 AnGap-14 [MASKED] 07:45AM BLOOD Calcium-9.8 Phos-2.8 Mg-2.0 Brief Hospital Course: Ms. [MASKED] is a [MASKED] y/o woman with a PMH notable for COPD on home O2 (hospitalized [MASKED], 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 [MASKED]. The patient was initiated on a steroid taper on [MASKED] 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 [MASKED] without evidence of significant stenosis of coronaries. ECHO on [MASKED] 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 [MASKED], then on [MASKED] mg for 3 days, then on [MASKED] 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, [MASKED] [MASKED] -Appointment arranged with Pulmonologist, Dr. [MASKED], [MASKED] #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 [MASKED] months as per [MASKED] guidelines for evaluation of new left lower lobe pulmonary nodule. #Code Status: Full code #Emergency Contact/HCP: [MASKED] (HUSBAND) [MASKED] 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: [MASKED] 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. [MASKED], It was a privilege taking care of you during your admission to [MASKED]. 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 [MASKED] Care Team Followup Instructions: [MASKED]
|
[] |
[
"J45909",
"Z87891",
"I4891",
"F419",
"G4700",
"I2510"
] |
[
"J441: Chronic obstructive pulmonary disease with (acute) exacerbation",
"I4892: Unspecified atrial flutter",
"I248: Other forms of acute ischemic heart disease",
"J45909: Unspecified asthma, uncomplicated",
"Z87891: Personal history of nicotine dependence",
"I4891: Unspecified atrial fibrillation",
"F419: Anxiety disorder, unspecified",
"G4700: Insomnia, unspecified",
"E780: Pure hypercholesterolemia",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"E876: Hypokalemia",
"R312: Other microscopic hematuria",
"I739: Peripheral vascular disease, unspecified",
"Z7952: Long term (current) use of systemic steroids",
"Z9981: Dependence on supplemental oxygen"
] |
10,001,884 | 29,678,536 |
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:
___
|
[
"I4891",
"J441",
"Z9981",
"Z7901",
"I10",
"E785",
"F419",
"I739",
"I2510",
"Z87891",
"D509",
"R079",
"G4700",
"H409"
] |
Allergies: IV Dye, Iodine Containing Contrast Media / Oxycodone / cilostazol / Varenicline Chief Complaint: Dyspnea, Atrial Fibrillation Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] 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 [MASKED] 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 [MASKED] 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 [MASKED] 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: [MASKED] Family History: Mother: [MASKED], HTN Father: [MASKED] CA Brother: CA? Brother: [MASKED] Physical [MASKED]: 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 [MASKED] 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: [MASKED] 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 [MASKED] [MASKED] 03:38PM BLOOD Neuts-93.8* Lymphs-4.2* Monos-1.3* Eos-0.0* Baso-0.0 Im [MASKED] AbsNeut-6.74*# AbsLymp-0.30* AbsMono-0.09* AbsEos-0.00* AbsBaso-0.00* [MASKED] 03:38PM BLOOD [MASKED] PTT-30.3 [MASKED] [MASKED] 03:38PM BLOOD Glucose-141* UreaN-20 Creat-1.0 Na-133 K-3.8 Cl-93* HCO3-30 AnGap-14 [MASKED] 03:38PM BLOOD Calcium-9.9 Phos-2.8 Mg-2.1 PERTINENT LABS: [MASKED] 03:58PM BLOOD cTropnT-<0.01 [MASKED] 06:50AM BLOOD CK-MB-4 cTropnT-<0.01 [MASKED] 06:50AM BLOOD calTIBC-398 Ferritn-16 TRF-306 [MASKED] 06:50AM BLOOD TSH-4.5* [MASKED] 09:31AM BLOOD [MASKED] pO2-73* pCO2-58* pH-7.35 calTCO2-33* Base XS-3 [MASKED] 07:15AM BLOOD T4, FREE, DIRECT DIALYSIS-Test DISCHARGE LABS: [MASKED] 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 [MASKED] [MASKED] 05:30AM BLOOD Glucose-85 UreaN-23* Creat-0.9 Na-136 K-3.9 Cl-95* HCO3-30 AnGap-15 [MASKED] 06:30AM BLOOD Calcium-9.7 Phos-3.0 Mg-2.0 IMAGING: [MASKED] 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. [MASKED] Chest X ray: There is hyperinflation. There is no pneumothorax, effusion, consolidation or CHF. There is probable osteopenia. Brief Hospital Course: [MASKED] is a [MASKED] 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. [MASKED] had had two recent ED visits for COPD exacerbation, most recently [MASKED] 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 [MASKED] 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. [MASKED]. She was also discharged on 2L supplemental O2 to be worn at all times. #Atrial fibrillation: Ms. [MASKED] 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 [MASKED] 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 [MASKED] 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 [MASKED] (Husband) [MASKED] Daughter [MASKED]: [MASKED] [MASKED] 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 [MASKED] 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 [MASKED] 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 [MASKED], then 40 mg [MASKED], then 30 mg [MASKED], then 20 mg [MASKED], 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: [MASKED] 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. [MASKED], You were hospitalized at [MASKED] 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 [MASKED] 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 [MASKED] 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 [MASKED] team Followup Instructions: [MASKED]
|
[] |
[
"I4891",
"Z7901",
"I10",
"E785",
"F419",
"I2510",
"Z87891",
"D509",
"G4700"
] |
[
"I4891: Unspecified atrial fibrillation",
"J441: Chronic obstructive pulmonary disease with (acute) exacerbation",
"Z9981: Dependence on supplemental oxygen",
"Z7901: Long term (current) use of anticoagulants",
"I10: Essential (primary) hypertension",
"E785: Hyperlipidemia, unspecified",
"F419: Anxiety disorder, unspecified",
"I739: Peripheral vascular disease, unspecified",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"Z87891: Personal history of nicotine dependence",
"D509: Iron deficiency anemia, unspecified",
"R079: Chest pain, unspecified",
"G4700: Insomnia, unspecified",
"H409: Unspecified glaucoma"
] |
10,001,919 | 29,897,682 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Locally advanced gastric carcinoma
Major Surgical or Invasive Procedure:
Cystoscopy for foley catheter placement; Laparoscopy with
biopsy; Gastroscopy
History of Present Illness:
Mr. ___ is a ___ year old male with locally advanced gastric
cancer (stage II [T3N2]) who arrives to ___ for
curative-intent surgical resection after completion of induction
chemotherapy.
He was started on neoadjuvant chemotherapy with FLOT4 on
___. Overall he tolerated the chemotherapy well without any
significant side effects. However, last
month he developed right upper extremity edema and was noted to
have a thrombosis in the R SVC. He was started on Lovenox 1
mg/kg
BID, which he is compliant with. Denies any fever, nausea,
emesis, chills, weight loss, melena, hematochezia or hematuria.
He comes after recent repeat staging (___) with torso CT
scan demonstrating no evidence of disease. He is now now taken
to the operating room for minimally invasive and possibly open
radical distal gastrectomy with lymphadenectomy. The risks
and benefits of surgery have been described with the patient
in detail and are documented by Dr. ___ in a separate
note.
Past Medical History:
Past Medical History: Prostate cancer, Thyroid nodule,
Hypothyroid, GERD mild, Diverticulosis on colonoscopy ___
anemia iron def. anemia which resolved and no workup
Past Surgical History: Prostate cancer external beam ___,
Achilles tendon repair ___, Shattered right tibia and fibula,
Tonsillectomy age ___.
Social History:
___
Family History:
Father died at ___ from Lymphoma. Mother died at ___ with type II
DM, Dementia.
Physical Exam:
VS: 24 HR Data (last updated ___ @ 1118)
Temp: 98.1 (Tm 98.9), BP: 116/73 (108-118/59-77), HR: 79
(77-86), RR: 18 (___), O2 sat: 99% (97-99), O2 delivery: Ra
GEN: A&Ox3, NAD, resting comfortably
HEENT: NCAT, EOMI, sclera anicteric
CV: RRR
PULM: no respiratory distress
ABD: soft, NT, ND, no rebound or guarding
EXT: warm, well-perfused, no edema
PSYCH: normal insight, memory, and mood
WOUND(S): Incision c/d/i
Brief Hospital Course:
Mr. ___ is a ___ year old Male who presented on ___ for
a planned minimally invasive and possibly open radical distal
gastrectomy with lymphadenectomy for locally advanced gastric
carcinoma after chemotherapy. After placement of the Right upper
quadrant port, insufflation revealed the right upper quadrant
port to be penetrating the omentum. It appeared to miss the
transverse mesocolon as well as the colon itself. During the
surgery, there were visually obvious peritoneal deposits on all
peritoneal surfaces in all four quadrants, which demonstrated
undetected carcinomatosis, poorly -differentiated adenocarcinoma
involving the peritoneum. For this reason, the procedure was
then aborted. Post-operatively the patient was taken to the PACU
until stable and then transferred to the wards until stable to
go home.
#NEURO: The patient was alert and oriented throughout
hospitalization; pain was initially managed with dilaudid PCA
which he was not using and then transitioned to tramadol which
he got only one dose. Pain was very well controlled.
#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: Before the procedure started, OR nurse was unable to
pass Foley after attempt with standard and coude type. PA
___, with usual sterile technique, re-attempted foley
placement after 10cc urojet application with ___ and ___
coude-type catheters but was also unable to get passed the
prostate. Urology was consulted and they performed a flexible
cystoscope demonstrating a normal urethra. Using a flexible
guidewire, cystoscope was advanced into the bladder. The scope
was withdrawn and a ___ council was advanced over the wire,
passed the prostate and into the bladder. The patient was
discharged with the Foley in place with instructions to
follow-up with urology as outpatient in 5 to 7 days for a
voiding trial. No antibiotics were administered. The patient was
tolerating a regular diet prior to discharge.
#ID: The patient's fever curves were closely watched for signs
of infection, of which there were none.
#HEME: Patient received BID SQH for DVT prophylaxis, in addition
to encouraging early ambulation and Venodyne compression
devices. On POD1 the patient was restarted on his home
enoxaparin before discharge.
#TRANSITIONAL ISSUES
--------------------
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating diet as
above per oral, ambulating, and pain was well controlled. The
patient was discharged home with the Foley catheter with
appropriate teaching for care. The patient received discharge
teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.
Medications on Admission:
Medications - Prescription
BIO-THROID - Bio-Throid . 65 mg. once a day - (Prescribed by
Other Provider)
ENOXAPARIN - enoxaparin 120 mg/0.8 mL subcutaneous syringe. 120
mg SC daily
OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. 1
capsule(s) by mouth twice daily
UBIQUINOL - ubiquinol . (100 mg) 2 tabs mouth twice a day -
(Prescribed by Other Provider)
Medications - OTC
FERROUS SULFATE - ferrous sulfate 325 mg (65 mg iron) tablet. 1
tablet(s) by mouth twice a day - (Prescribed by Other Provider)
LACTOBACILLUS COMBINATION NO.4 [PROBIOTIC] - Dosage uncertain -
(Prescribed by Other Provider; daily)
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
2. Docusate Sodium 100 mg PO BID
3. Senna 8.6 mg PO BID:PRN Constipation - First Line
4. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
This medication is a low dose narcotic and may cause
constipation.
RX *tramadol 50 mg 1 (One) tablet(s) by mouth every six (6)
hours Disp #*20 Tablet Refills:*0
5. Enoxaparin Sodium 120 mg SC DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Metastatic gastric cancer (stage IV [T3N2M1])
Urethral stricture
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 here at ___
___. You were admitted to our hospital for
gastric cancer. You had an attempted Robot-assisted laparoscopic
partial gastrectomy and gastroscopy on ___ without
complications. You tolerated the procedure well and are
ambulating, stooling, tolerating a regular diet, and your pain
is controlled by pain medications by mouth. You are now ready to
be discharged to home. Please follow the recommendations below
to ensure a speedy and uneventful recovery.
ACTIVITY:
- Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
- You may climb stairs. You should continue to walk several
times a day.
- You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
- You may start some light exercise when you feel comfortable.
Slowly increase your activity back to your baseline as
tolerated.
- Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
- No heavy lifting (10 pounds or more) until cleared by your
surgeon, usually about 6 weeks.
- You may resume sexual activity unless your doctor has told you
otherwise.
HOW YOU MAY FEEL:
- You may feel weak or "washed out" for 6 weeks. You might want
to nap often. Simple tasks may exhaust you.
- You may have a sore throat because of a tube that was in your
throat during the surgery.
YOUR BOWELS:
- Constipation is a common side effect of narcotic pain medicine
such as oxycodone. If needed, you may take a stool softener
(such as Colace, one capsule) or gentle laxative (such as milk
of magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
- If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
- After some operations, diarrhea can occur. If you get
diarrhea, don't take anti-diarrhea medicines. Drink plenty of
fluids and see if it goes away. If it does not go away, or is
severe and you feel ill, please call your surgeon.
PAIN MANAGEMENT:
- You are being discharged with a prescription for **oxycodone
for pain control. You may take Tylenol as directed, not to
exceed 3500mg in 24 hours. Take regularly for a few days after
surgery but you may skip a dose or increase time between doses
if you are not having pain until you no longer need it. You may
take the oxycodone for moderate and severe pain not controlled
by the Tylenol. You may take a stool softener while on narcotics
to help prevent the constipation that they may cause. Slowly
wean off these medications as tolerated.
- Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- chest pain, pressure, squeezing, or tightness
- cough, shortness of breath, wheezing
- pain that is getting worse over time or pain with fever
- shaking chills, fever of more than 101
- a drastic change in nature or quality of your pain
- nausea and vomiting, inability to tolerate fluids, food, or
your medications
- if you are getting dehydrated (dry mouth, rapid heart beat,
feeling dizzy or faint especially while standing)
-any change in your symptoms or any symptoms that concern you
Additional:
*- pain that is getting worse over time, or going to your chest
or back
*- urinary: burning or blood in your urine or the inability to
urinate
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.
WOUND CARE:
- dressing removal:
- You may remove your dressings tomorrow ___ and shower that
same day with any bandage strips that may be covering your
wound. Do not scrub and do not soak or swim, and pat the
incision dry. If you have steri strips, they will fall off by
themselves in ___ weeks. If any are still on in two weeks and
the edges are curling up, you may carefully peel them off.
Do not take baths, soak, or swim for 6 weeks after surgery
unless told otherwise by your surgical team.
-Notify your surgeon is you notice abnormal (foul smelling,
bloody, pus, etc) or increased drainage from your incision site,
opening of your incision, or increased pain or bruising. Watch
for signs of infection such as redness, streaking of your skin,
swelling, increased pain, or increased drainage.
Please call with any questions or concerns. Thank you for
allowing us to participate in your care. We hope you have a
quick return to your usual life and activities.
Home with ___:
You had a Foley catheter in your bladder placed by urology on
the day of your surgery after difficulty trying to place it.
You will keep the catheter until your appointment with Urology
in 5 days (please call the number below to schedule your
appointment), who will decide if you need it longer or attempt
to remove it and see if you are able to void.
Empty the bag as needed and as shown to you by nursing staff.
You will be given a leg bag before your discharge, that you may
use for short trips. This is a smaller bag that straps to your
leg, to take home and wear if you are traveling outside your
home. This holds a smaller amount than the bag you have now, so
it needs to be emptied more often. Some people find it easier to
use the larger bad when they are at home or carry it with them.
-- Your ___ Care Team
Followup Instructions:
___
|
[
"C169",
"C786",
"I82621",
"K9171",
"Y838",
"Y92234",
"N359",
"E039",
"K219",
"Z7901",
"Z8546"
] |
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Locally advanced gastric carcinoma Major Surgical or Invasive Procedure: Cystoscopy for foley catheter placement; Laparoscopy with biopsy; Gastroscopy History of Present Illness: Mr. [MASKED] is a [MASKED] year old male with locally advanced gastric cancer (stage II [T3N2]) who arrives to [MASKED] for curative-intent surgical resection after completion of induction chemotherapy. He was started on neoadjuvant chemotherapy with FLOT4 on [MASKED]. Overall he tolerated the chemotherapy well without any significant side effects. However, last month he developed right upper extremity edema and was noted to have a thrombosis in the R SVC. He was started on Lovenox 1 mg/kg BID, which he is compliant with. Denies any fever, nausea, emesis, chills, weight loss, melena, hematochezia or hematuria. He comes after recent repeat staging ([MASKED]) with torso CT scan demonstrating no evidence of disease. He is now now taken to the operating room for minimally invasive and possibly open radical distal gastrectomy with lymphadenectomy. The risks and benefits of surgery have been described with the patient in detail and are documented by Dr. [MASKED] in a separate note. Past Medical History: Past Medical History: Prostate cancer, Thyroid nodule, Hypothyroid, GERD mild, Diverticulosis on colonoscopy [MASKED] anemia iron def. anemia which resolved and no workup Past Surgical History: Prostate cancer external beam [MASKED], Achilles tendon repair [MASKED], Shattered right tibia and fibula, Tonsillectomy age [MASKED]. Social History: [MASKED] Family History: Father died at [MASKED] from Lymphoma. Mother died at [MASKED] with type II DM, Dementia. Physical Exam: VS: 24 HR Data (last updated [MASKED] @ 1118) Temp: 98.1 (Tm 98.9), BP: 116/73 (108-118/59-77), HR: 79 (77-86), RR: 18 ([MASKED]), O2 sat: 99% (97-99), O2 delivery: Ra GEN: A&Ox3, NAD, resting comfortably HEENT: NCAT, EOMI, sclera anicteric CV: RRR PULM: no respiratory distress ABD: soft, NT, ND, no rebound or guarding EXT: warm, well-perfused, no edema PSYCH: normal insight, memory, and mood WOUND(S): Incision c/d/i Brief Hospital Course: Mr. [MASKED] is a [MASKED] year old Male who presented on [MASKED] for a planned minimally invasive and possibly open radical distal gastrectomy with lymphadenectomy for locally advanced gastric carcinoma after chemotherapy. After placement of the Right upper quadrant port, insufflation revealed the right upper quadrant port to be penetrating the omentum. It appeared to miss the transverse mesocolon as well as the colon itself. During the surgery, there were visually obvious peritoneal deposits on all peritoneal surfaces in all four quadrants, which demonstrated undetected carcinomatosis, poorly -differentiated adenocarcinoma involving the peritoneum. For this reason, the procedure was then aborted. Post-operatively the patient was taken to the PACU until stable and then transferred to the wards until stable to go home. #NEURO: The patient was alert and oriented throughout hospitalization; pain was initially managed with dilaudid PCA which he was not using and then transitioned to tramadol which he got only one dose. Pain was very well controlled. #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: Before the procedure started, OR nurse was unable to pass Foley after attempt with standard and coude type. PA [MASKED], with usual sterile technique, re-attempted foley placement after 10cc urojet application with [MASKED] and [MASKED] coude-type catheters but was also unable to get passed the prostate. Urology was consulted and they performed a flexible cystoscope demonstrating a normal urethra. Using a flexible guidewire, cystoscope was advanced into the bladder. The scope was withdrawn and a [MASKED] council was advanced over the wire, passed the prostate and into the bladder. The patient was discharged with the Foley in place with instructions to follow-up with urology as outpatient in 5 to 7 days for a voiding trial. No antibiotics were administered. The patient was tolerating a regular diet prior to discharge. #ID: The patient's fever curves were closely watched for signs of infection, of which there were none. #HEME: Patient received BID SQH for DVT prophylaxis, in addition to encouraging early ambulation and Venodyne compression devices. On POD1 the patient was restarted on his home enoxaparin before discharge. #TRANSITIONAL ISSUES -------------------- At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating diet as above per oral, ambulating, and pain was well controlled. The patient was discharged home with the Foley catheter with appropriate teaching for care. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: Medications - Prescription BIO-THROID - Bio-Throid . 65 mg. once a day - (Prescribed by Other Provider) ENOXAPARIN - enoxaparin 120 mg/0.8 mL subcutaneous syringe. 120 mg SC daily OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. 1 capsule(s) by mouth twice daily UBIQUINOL - ubiquinol . (100 mg) 2 tabs mouth twice a day - (Prescribed by Other Provider) Medications - OTC FERROUS SULFATE - ferrous sulfate 325 mg (65 mg iron) tablet. 1 tablet(s) by mouth twice a day - (Prescribed by Other Provider) LACTOBACILLUS COMBINATION NO.4 [PROBIOTIC] - Dosage uncertain - (Prescribed by Other Provider; daily) Discharge Medications: 1. Acetaminophen 1000 mg PO TID 2. Docusate Sodium 100 mg PO BID 3. Senna 8.6 mg PO BID:PRN Constipation - First Line 4. TraMADol 50 mg PO Q6H:PRN Pain - Moderate This medication is a low dose narcotic and may cause constipation. RX *tramadol 50 mg 1 (One) tablet(s) by mouth every six (6) hours Disp #*20 Tablet Refills:*0 5. Enoxaparin Sodium 120 mg SC DAILY Discharge Disposition: Home Discharge Diagnosis: Metastatic gastric cancer (stage IV [T3N2M1]) Urethral stricture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], It was a pleasure taking care of you here at [MASKED] [MASKED]. You were admitted to our hospital for gastric cancer. You had an attempted Robot-assisted laparoscopic partial gastrectomy and gastroscopy on [MASKED] without complications. You tolerated the procedure well and are ambulating, stooling, tolerating a regular diet, and your pain is controlled by pain medications by mouth. You are now ready to be discharged to home. Please follow the recommendations below to ensure a speedy and uneventful recovery. ACTIVITY: - Do not drive until you have stopped taking pain medicine and feel you could respond in an emergency. - You may climb stairs. You should continue to walk several times a day. - You may go outside, but avoid traveling long distances until you see your surgeon at your next visit. - You may start some light exercise when you feel comfortable. Slowly increase your activity back to your baseline as tolerated. - Heavy exercise may be started after 6 weeks, but use common sense and go slowly at first. - No heavy lifting (10 pounds or more) until cleared by your surgeon, usually about 6 weeks. - You may resume sexual activity unless your doctor has told you otherwise. HOW YOU MAY FEEL: - You may feel weak or "washed out" for 6 weeks. You might want to nap often. Simple tasks may exhaust you. - You may have a sore throat because of a tube that was in your throat during the surgery. YOUR BOWELS: - Constipation is a common side effect of narcotic pain medicine such as oxycodone. If needed, you may take a stool softener (such as Colace, one capsule) or gentle laxative (such as milk of magnesia, 1 tbs) twice a day. You can get both of these medicines without a prescription. - If you go 48 hours without a bowel movement, or have pain moving the bowels, call your surgeon. - After some operations, diarrhea can occur. If you get diarrhea, don't take anti-diarrhea medicines. Drink plenty of fluids and see if it goes away. If it does not go away, or is severe and you feel ill, please call your surgeon. PAIN MANAGEMENT: - You are being discharged with a prescription for **oxycodone for pain control. You may take Tylenol as directed, not to exceed 3500mg in 24 hours. Take regularly for a few days after surgery but you may skip a dose or increase time between doses if you are not having pain until you no longer need it. You may take the oxycodone for moderate and severe pain not controlled by the Tylenol. You may take a stool softener while on narcotics to help prevent the constipation that they may cause. Slowly wean off these medications as tolerated. - Your pain should get better day by day. If you find the pain is getting worse instead of better, please contact your surgeon. If you experience any of the following, please contact your surgeon: - sharp pain or any severe pain that lasts several hours - chest pain, pressure, squeezing, or tightness - cough, shortness of breath, wheezing - pain that is getting worse over time or pain with fever - shaking chills, fever of more than 101 - a drastic change in nature or quality of your pain - nausea and vomiting, inability to tolerate fluids, food, or your medications - if you are getting dehydrated (dry mouth, rapid heart beat, feeling dizzy or faint especially while standing) -any change in your symptoms or any symptoms that concern you Additional: *- pain that is getting worse over time, or going to your chest or back *- urinary: burning or blood in your urine or the inability to urinate 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. WOUND CARE: - dressing removal: - You may remove your dressings tomorrow [MASKED] and shower that same day with any bandage strips that may be covering your wound. Do not scrub and do not soak or swim, and pat the incision dry. If you have steri strips, they will fall off by themselves in [MASKED] weeks. If any are still on in two weeks and the edges are curling up, you may carefully peel them off. Do not take baths, soak, or swim for 6 weeks after surgery unless told otherwise by your surgical team. -Notify your surgeon is you notice abnormal (foul smelling, bloody, pus, etc) or increased drainage from your incision site, opening of your incision, or increased pain or bruising. Watch for signs of infection such as redness, streaking of your skin, swelling, increased pain, or increased drainage. Please call with any questions or concerns. Thank you for allowing us to participate in your care. We hope you have a quick return to your usual life and activities. Home with [MASKED]: You had a Foley catheter in your bladder placed by urology on the day of your surgery after difficulty trying to place it. You will keep the catheter until your appointment with Urology in 5 days (please call the number below to schedule your appointment), who will decide if you need it longer or attempt to remove it and see if you are able to void. Empty the bag as needed and as shown to you by nursing staff. You will be given a leg bag before your discharge, that you may use for short trips. This is a smaller bag that straps to your leg, to take home and wear if you are traveling outside your home. This holds a smaller amount than the bag you have now, so it needs to be emptied more often. Some people find it easier to use the larger bad when they are at home or carry it with them. -- Your [MASKED] Care Team Followup Instructions: [MASKED]
|
[] |
[
"E039",
"K219",
"Z7901"
] |
[
"C169: Malignant neoplasm of stomach, unspecified",
"C786: Secondary malignant neoplasm of retroperitoneum and peritoneum",
"I82621: Acute embolism and thrombosis of deep veins of right upper extremity",
"K9171: Accidental puncture and laceration of a digestive system organ or structure during a digestive system procedure",
"Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure",
"Y92234: Operating room of hospital as the place of occurrence of the external cause",
"N359: Urethral stricture, unspecified",
"E039: Hypothyroidism, unspecified",
"K219: Gastro-esophageal reflux disease without esophagitis",
"Z7901: Long term (current) use of anticoagulants",
"Z8546: Personal history of malignant neoplasm of prostate"
] |
10,002,013 | 21,763,296 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac cath (___)
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 state, 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
==============
GENERAL:NAD AOx3 Pleasant woman.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no
pallor or cyanosis of the oral mucosa
NECK: Supple with no JVD
CARDIAC: RRR normal S1/S2. No thrills, lifts.
LUNGS: CTAB. No crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No ___ edema
PULSES: ___ and DP palpable on the right side. Did not take
bandage down for exam as podiatry had just dressed.
DISCHARGE EXAM
==============
VITALS: ___ 0412 Temp: 97.8 PO BP: 105/67 R Lying HR: 71
RR: 18 O2 sat: 97% O2 delivery: Ra
GENERAL:NAD AOx3 Pleasant woman.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no
pallor or cyanosis of the oral mucosa
NECK: Supple with no JVD
CARDIAC: RRR normal S1/S2. No thrills, lifts.
LUNGS: CTAB. No crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND.
EXTREMITIES: No ___ edema
PULSES: ___ and DP palpable on the right side. Did not take
bandage down for exam as podiatry had just dressed.
Per podiatry exam (___) [See attached picture on OMR]
___ pulses palpable b/l. CFT <3 sec to digits
bilaterally. There is a L hallux wound present at the medial
aspect of the toe at the level of the IPJ. Wound has eschar over
top of the base w/ surrounding hyperkeratotic skin and
surrounding erythema. There is no malodor or proximal streaking
present. Once the wound was debrided and the eschar was
deroofed,
there is fibrotic skin at the base of the wound. It does not
probe deep to bone. 2cc of purulent drainage was expressed from
wound. Wound is extremely TTP. Gross sensation is intact to b/l
lower extremities. MMT ___ to all ___ muscle groups crossing the
ankle jt. No gross deformities noted.
Pertinent Results:
ADMISSION LABS
==============
___ 12:50AM BLOOD WBC-12.7* RBC-4.34 Hgb-14.4 Hct-41.7
MCV-96 MCH-33.2* MCHC-34.5 RDW-11.8 RDWSD-41.3 Plt ___
___ 12:50AM BLOOD Glucose-318* UreaN-21* Creat-1.1 Na-134*
K-4.2 Cl-92* HCO3-19* AnGap-23*
___ 12:50AM BLOOD cTropnT-<0.01
___ 06:00AM BLOOD cTropnT-<0.01
___ 11:40AM BLOOD cTropnT-<0.01
___ 05:20PM BLOOD CK-MB-1 cTropnT-<0.01
___ 05:20PM BLOOD Albumin-3.5 Calcium-8.6 Phos-3.6 Mg-1.8
___ 05:20PM BLOOD %HbA1c-12.0* eAG-298*
___ 12:50AM BLOOD CRP-36.4*
___ 12:50AM BLOOD ASA-NEG Acetmnp-NEG Tricycl-NEG
STUDIES
=======
___ Coronary Angiogram
Coronary Anatomy
Dominance: Right
* Left Main Coronary Artery
The LMCA is.
* Left Anterior Descending
The LAD has diffuse 60% in-stent restenosis with patent LIMA to
distal vessel.
The ___ Diagonal is small and diffusely diseased.
* Circumflex
The Circumflex is occluded after a small OM1. There is a patent
SVG to OM2.
* Right Coronary Artery
The RCA has focal mid 50% stenosis.
SVG to OM patent.
LIMA to LAD patent.
Intra-procedural Complications: None
Impressions:
1. three vessel CAD.
2. Patent SVG to OM and LIMA to LAD.
Recommendations
1. Medical therapy.
Pharmacological MIBI ___
IMPRESSION:
1. Reversible, medium sized, moderate severity perfusion defect
involving the
LAD territory.
2. Normal left ventricular cavity size and systolic function.
Compared to the prior study of ___, the perfusion defect
is new.
ECHO ___
LEFT ATRIUM: Normal LA volume index.
LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
regional/global systolic function (biplane LVEF>55%). Doppler
parameters are most consistent with normal LV diastolic
function.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
Paradoxic septal motion consistent with prior cardiac surgery.
AORTA: Normal diameter of aorta at the sinus, ascending and arch
levels.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
___ mitral valve supporting structures. No MS.
___ VALVE: Normal tricuspid valve leaflets with trivial
TR. Normal PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
Conclusions
The left atrial volume index is normal. Normal left ventricular
wall thickness, cavity size, and regional/global systolic
function (biplane LVEF = 63 %). Doppler parameters are most
consistent with normal left ventricular diastolic function.
Right ventricular chamber size and free wall motion are normal.
The diameters of aorta at the sinus, ascending and arch levels
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis or
aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION:
1) Normal biventricular regional/global systolic function.
Compared with the prior study (images reviewed) of ___,
no clinically significant change noted
DISCHARGE LABS
==============
___ 06:10AM BLOOD WBC-7.7 RBC-3.53* Hgb-11.6 Hct-33.8*
MCV-96 MCH-32.9* MCHC-34.3 RDW-11.7 RDWSD-40.6 Plt ___
___ 06:10AM BLOOD Glucose-245* UreaN-12 Creat-1.0 Na-140
K-4.3 Cl-101 HCO3-25 AnGap-14
___ 02:45AM BLOOD ALT-14 AST-17 AlkPhos-50 TotBili-0.4
___ 06:10AM BLOOD Calcium-8.0* Phos-2.6* Mg-1.___ year old female with 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 ___, s/p 3 v CABG LIMA-LAD,
SVG-OM1, SVG-D1(occluded) ___, HFpEF, IDDM, HTN who
presented with several days atypical chest pain both with
exertion and at rest, with mild T wave deepening but no other
EKG changes or troponin. She also presented with mild DKA and
diabetic foot ulcer. She had a stress test with reversible
ischemia in the LAD territory (___) and went to cardiac
catheterization ___ which showed stable disease and no new
obstructive lesions. Overall her chest pain was felt to have
been either musculoskeletal or demand in the setting of DKA and
diabetic foot ulcer. She was discharged on ASA 81, atorvastatin
80, Metoprolol XL 100mg daily.
#DKA/IDDM: Patient presented with anion gap metabolic acidosis
and felt to be in mild DKA. She had insulin gtt in the ED but
was rapidly switched to subcutaneous insulin. Her A1c returned
at 12%, which is the highest it has been recorded for her in our
records. She had followed with ___ previously and was
on canagliflozin and glipizide as well as SC insulin prior to
admission. However, she reported intermittent adherence to her
medications and this was the likely reason for her DKA. While
she was in house the ___ followed along and she met
with a diabetes educator. Her canagliflozin was stopped at
discharge due to increased risk of amputation.
#Diabetic foot ulcer: Present for at least 3 weeks prior to
admission. She underwent bedside debridement by Podiatry in ED.
XR suggested presence of osteomyelitis . She was maintained on
vanc/cefepime/flagyl in house, and was switched to cipro/clinda
at discharge per podiatry recs with plans for close follow up.
Her wound swab at time of discharge was polymicrobial but was
growing Group B strep (sensitivities pending) and klebsiella
(pan sensitive).
#Med noncompliance: She reported intermittent medication
compliance related to difficulty remembering to take her
medications as well as periods of depression and stress where
taking her medication was not a priority. She has recently
obtained a pillbox and her granddaughter is helping her with
remembering to take her medications.
#HFpEF: Metoprolol as above, continued torsemide 20mg and she
appeared euvolemic throughout admission.
#HL: Continued atorvastatin
#HTN: Metoprolol lowered to XL 100mg daily, losartan kept at
25mg daily. Imdur stopped.
#COPD: Duonebs q6h in house, continued home inhalers on
discharge.
#Restless legs: continued ropinerole
Transitional issues:
- Please follow up her diabetic foot ulcer in ___ clinic.
Plan at time of discharge was to take to OR for further surgical
debridement, patient was discharged with cipro/clinda until
Podiatry follow up
- Please review her blood sugars at home and continue to
reinforce compliance with diabetes medications. Her
Canagliflozin was stopped due to increased risk of amputation.
Consider reintroducing metformin as this was stopped ___ years ago
for diarrhea but may be a better option for her.
- Follow up blood pressures and heart rate on the current
regimen. Suspect that due to noncompliance her medications were
uptitrated to higher doses than she actually needs. We cut back
her Metoprolol and stoped her imdur
- Can restart imdur if requiring for chest pain on outpatient
basis
- Please continue to work with patient on med compliance and
possible barriers. She denied depression with our social worker
but does endorse that stress makes it hard to take her
medications.
- f/u final wound swab cultures
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 25 mg PO DAILY
2. MetronidAZOLE Topical 1 % Gel 1 Appl TP BID:PRN Rosacea
3. Gabapentin 300 mg PO QHS:PRN Headache
4. Metoprolol Succinate XL 250 mg PO DAILY
5. linaGLIPtin 5 mg oral DAILY
6. Atorvastatin 80 mg PO QPM
7. Furosemide 20 mg PO DAILY
8. Isosorbide Mononitrate 120 mg PO DAILY
9. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN angina
10. rOPINIRole 0.5 mg PO QHS restless leg syndrome
11. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain -
Severe
12. Fluticasone Propionate 110mcg 2 PUFF IH BID
13. Pantoprazole 40 mg PO BID
14. Aspirin 325 mg PO DAILY
15. TraZODone 50 mg PO QHS:PRN insomnia
16. canagliflozin 100 mg oral DAILY
17. albuterol sulfate 90 mcg/actuation inhalation Q8H:PRN
18. Lidocaine 5% Patch 1 PTCH TD QPM
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*14 Tablet Refills:*0
2. Clindamycin 300 mg PO Q6H
RX *clindamycin HCl 300 mg 1 capsule(s) by mouth four times per
day Disp #*28 Capsule Refills:*0
3. Glargine 50 Units Bedtime
Humalog 18 Units Breakfast
Humalog 18 Units Lunch
Humalog 18 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
4. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate 100 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
5. albuterol sulfate 90 mcg/actuation inhalation Q8H:PRN
6. Aspirin 325 mg PO DAILY
7. Atorvastatin 80 mg PO QPM
8. Fluticasone Propionate 110mcg 2 PUFF IH BID
9. Furosemide 20 mg PO DAILY
10. Gabapentin 300 mg PO QHS:PRN Headache
11. linaGLIPtin 5 mg oral DAILY
12. Losartan Potassium 25 mg PO DAILY
13. MetronidAZOLE Topical 1 % Gel 1 Appl TP BID:PRN Rosacea
14. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN angina
15. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain
- Severe
RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth
three times daily Disp #*15 Tablet Refills:*0
16. Pantoprazole 40 mg PO BID
17. rOPINIRole 0.5 mg PO QHS restless leg syndrome
18. TraZODone 50 mg PO QHS:PRN insomnia
19. HELD- canagliflozin 100 mg oral DAILY This medication was
held. Do not restart canagliflozin until you speak with your
endocrinologist
20. HELD- Lidocaine 5% Patch 1 PTCH TD QPM This medication was
held. Do not restart Lidocaine 5% Patch until you speak with
your PCP
___:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY
=======
Diabetic foot ulcer
Diabetic ketoacidosis
Chest pain
SECONDARY
=========
DIABETES MELLITUS (INSULIN DEPENDENT)
COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted because you had chest pain.
- You also had a process called DKA from not taking enough
insulin
- You also had a bad infection in your foot.
WHAT HAPPENED IN THE HOSPITAL?
==============================
- We did several tests to figure our if your chest pain was
caused by a heart attack. The first was a stress test, which had
a positive results. We then did a procedure called a cardiac
cath, which showed that you did NOT have a heart attack.
- Our podiatrists did a debridement of your foot.
- We gave you antibiotics for your foot.
- We adjusted your insulin levels.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Take all of your medications:
- Ciproflocaxin and Clindamycin are antibiotics you need to
take until the podiatrists tell you to stop. You are scheduled
to see them ___
- Your insulin regimen will be slightly different from your
old regimen.
- You need to take aspirin and Atorvastatin every day to
prevent blockages in your heart from forming.
- You will have many appointments in the next week. It is very
important that you go to all of these, to help get your health
on track!
- Your weight at discharge is 79.1 kg (174.38 lb) . Please
weigh yourself today at home and use this as your new baseline
-Please weigh yourself every day in the morning. Call your
doctor if your weight goes up by more than 3 lbs.
- Seek medical attention if you have new or concerning symptoms
or you develop swelling in your legs, abdominal distention, or
shortness of breath. If you have worsening pain or redness in
your foot, urinating frequently or very thirsty, or if your
blood sugar is consistently above 300 or below 70 please cal
your doctor.
It was a pleasure participating in your care. We wish you the
___!
-Your ___ Care Team
Followup Instructions:
___
|
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"E1110",
"E1122",
"E11319",
"M869",
"I5032",
"I130",
"T82855A",
"E11621",
"E1142",
"E1165",
"E1169",
"L97529",
"N183",
"J449",
"B961",
"B951",
"F329",
"K219",
"G4733",
"Z87891",
"Z951",
"Z794",
"Z9114",
"G2581",
"Z955",
"Y840",
"Y929"
] |
Allergies: lisinopril Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Cardiac cath ([MASKED]) Past Medical History: -COPD -CAD s/p BMS proximal-LAD [MASKED], DES to mid LAD [MASKED], DES to edge ISR of mid LAD DES and stenosis distal to stent [MASKED], DES to OM1 [MASKED], s/p 3 v CABG LIMA-LAD, SVG-OM1, [MASKED] -HFpEF -Depression -DM -GERD -Hypertension -Migraines -Chronic shoulder pain on narcotics -OSA -Peripheral neuropathy -Restless leg Social History: [MASKED] Family History: Patient was ward of the state, doesn't know full details of family history. Mother with possible alcohol abuse. Father deceased at [MASKED] from Hodgkin's Disease per old records. Physical Exam: ADMISSION EXAM ============== GENERAL:NAD AOx3 Pleasant woman. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no pallor or cyanosis of the oral mucosa NECK: Supple with no JVD CARDIAC: RRR normal S1/S2. No thrills, lifts. LUNGS: CTAB. No crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No [MASKED] edema PULSES: [MASKED] and DP palpable on the right side. Did not take bandage down for exam as podiatry had just dressed. DISCHARGE EXAM ============== VITALS: [MASKED] 0412 Temp: 97.8 PO BP: 105/67 R Lying HR: 71 RR: 18 O2 sat: 97% O2 delivery: Ra GENERAL:NAD AOx3 Pleasant woman. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no pallor or cyanosis of the oral mucosa NECK: Supple with no JVD CARDIAC: RRR normal S1/S2. No thrills, lifts. LUNGS: CTAB. No crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. EXTREMITIES: No [MASKED] edema PULSES: [MASKED] and DP palpable on the right side. Did not take bandage down for exam as podiatry had just dressed. Per podiatry exam ([MASKED]) [See attached picture on OMR] [MASKED] pulses palpable b/l. CFT <3 sec to digits bilaterally. There is a L hallux wound present at the medial aspect of the toe at the level of the IPJ. Wound has eschar over top of the base w/ surrounding hyperkeratotic skin and surrounding erythema. There is no malodor or proximal streaking present. Once the wound was debrided and the eschar was deroofed, there is fibrotic skin at the base of the wound. It does not probe deep to bone. 2cc of purulent drainage was expressed from wound. Wound is extremely TTP. Gross sensation is intact to b/l lower extremities. MMT [MASKED] to all [MASKED] muscle groups crossing the ankle jt. No gross deformities noted. Pertinent Results: ADMISSION LABS ============== [MASKED] 12:50AM BLOOD WBC-12.7* RBC-4.34 Hgb-14.4 Hct-41.7 MCV-96 MCH-33.2* MCHC-34.5 RDW-11.8 RDWSD-41.3 Plt [MASKED] [MASKED] 12:50AM BLOOD Glucose-318* UreaN-21* Creat-1.1 Na-134* K-4.2 Cl-92* HCO3-19* AnGap-23* [MASKED] 12:50AM BLOOD cTropnT-<0.01 [MASKED] 06:00AM BLOOD cTropnT-<0.01 [MASKED] 11:40AM BLOOD cTropnT-<0.01 [MASKED] 05:20PM BLOOD CK-MB-1 cTropnT-<0.01 [MASKED] 05:20PM BLOOD Albumin-3.5 Calcium-8.6 Phos-3.6 Mg-1.8 [MASKED] 05:20PM BLOOD %HbA1c-12.0* eAG-298* [MASKED] 12:50AM BLOOD CRP-36.4* [MASKED] 12:50AM BLOOD ASA-NEG Acetmnp-NEG Tricycl-NEG STUDIES ======= [MASKED] Coronary Angiogram Coronary Anatomy Dominance: Right * Left Main Coronary Artery The LMCA is. * Left Anterior Descending The LAD has diffuse 60% in-stent restenosis with patent LIMA to distal vessel. The [MASKED] Diagonal is small and diffusely diseased. * Circumflex The Circumflex is occluded after a small OM1. There is a patent SVG to OM2. * Right Coronary Artery The RCA has focal mid 50% stenosis. SVG to OM patent. LIMA to LAD patent. Intra-procedural Complications: None Impressions: 1. three vessel CAD. 2. Patent SVG to OM and LIMA to LAD. Recommendations 1. Medical therapy. Pharmacological MIBI [MASKED] IMPRESSION: 1. Reversible, medium sized, moderate severity perfusion defect involving the LAD territory. 2. Normal left ventricular cavity size and systolic function. Compared to the prior study of [MASKED], the perfusion defect is new. ECHO [MASKED] LEFT ATRIUM: Normal LA volume index. LEFT VENTRICLE: Normal LV wall thickness, cavity size, and regional/global systolic function (biplane LVEF>55%). Doppler parameters are most consistent with normal LV diastolic function. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. Paradoxic septal motion consistent with prior cardiac surgery. AORTA: Normal diameter of aorta at the sinus, ascending and arch levels. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. [MASKED] mitral valve supporting structures. No MS. [MASKED] VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS. Physiologic PR. PERICARDIUM: No pericardial effusion. Conclusions The left atrial volume index is normal. Normal left ventricular wall thickness, cavity size, and regional/global systolic function (biplane LVEF = 63 %). Doppler parameters are most consistent with normal left ventricular diastolic function. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: 1) Normal biventricular regional/global systolic function. Compared with the prior study (images reviewed) of [MASKED], no clinically significant change noted DISCHARGE LABS ============== [MASKED] 06:10AM BLOOD WBC-7.7 RBC-3.53* Hgb-11.6 Hct-33.8* MCV-96 MCH-32.9* MCHC-34.3 RDW-11.7 RDWSD-40.6 Plt [MASKED] [MASKED] 06:10AM BLOOD Glucose-245* UreaN-12 Creat-1.0 Na-140 K-4.3 Cl-101 HCO3-25 AnGap-14 [MASKED] 02:45AM BLOOD ALT-14 AST-17 AlkPhos-50 TotBili-0.4 [MASKED] 06:10AM BLOOD Calcium-8.0* Phos-2.6* Mg-1.[MASKED] year old female with CAD(s/p BMS proximal-LAD [MASKED], DES to mid LAD [MASKED], DES to edge ISR of mid LAD DES and stenosis distal to stent [MASKED], DES to [MASKED], s/p 3 v CABG LIMA-LAD, SVG-OM1, SVG-D1(occluded) [MASKED], HFpEF, IDDM, HTN who presented with several days atypical chest pain both with exertion and at rest, with mild T wave deepening but no other EKG changes or troponin. She also presented with mild DKA and diabetic foot ulcer. She had a stress test with reversible ischemia in the LAD territory ([MASKED]) and went to cardiac catheterization [MASKED] which showed stable disease and no new obstructive lesions. Overall her chest pain was felt to have been either musculoskeletal or demand in the setting of DKA and diabetic foot ulcer. She was discharged on ASA 81, atorvastatin 80, Metoprolol XL 100mg daily. #DKA/IDDM: Patient presented with anion gap metabolic acidosis and felt to be in mild DKA. She had insulin gtt in the ED but was rapidly switched to subcutaneous insulin. Her A1c returned at 12%, which is the highest it has been recorded for her in our records. She had followed with [MASKED] previously and was on canagliflozin and glipizide as well as SC insulin prior to admission. However, she reported intermittent adherence to her medications and this was the likely reason for her DKA. While she was in house the [MASKED] followed along and she met with a diabetes educator. Her canagliflozin was stopped at discharge due to increased risk of amputation. #Diabetic foot ulcer: Present for at least 3 weeks prior to admission. She underwent bedside debridement by Podiatry in ED. XR suggested presence of osteomyelitis . She was maintained on vanc/cefepime/flagyl in house, and was switched to cipro/clinda at discharge per podiatry recs with plans for close follow up. Her wound swab at time of discharge was polymicrobial but was growing Group B strep (sensitivities pending) and klebsiella (pan sensitive). #Med noncompliance: She reported intermittent medication compliance related to difficulty remembering to take her medications as well as periods of depression and stress where taking her medication was not a priority. She has recently obtained a pillbox and her granddaughter is helping her with remembering to take her medications. #HFpEF: Metoprolol as above, continued torsemide 20mg and she appeared euvolemic throughout admission. #HL: Continued atorvastatin #HTN: Metoprolol lowered to XL 100mg daily, losartan kept at 25mg daily. Imdur stopped. #COPD: Duonebs q6h in house, continued home inhalers on discharge. #Restless legs: continued ropinerole Transitional issues: - Please follow up her diabetic foot ulcer in [MASKED] clinic. Plan at time of discharge was to take to OR for further surgical debridement, patient was discharged with cipro/clinda until Podiatry follow up - Please review her blood sugars at home and continue to reinforce compliance with diabetes medications. Her Canagliflozin was stopped due to increased risk of amputation. Consider reintroducing metformin as this was stopped [MASKED] years ago for diarrhea but may be a better option for her. - Follow up blood pressures and heart rate on the current regimen. Suspect that due to noncompliance her medications were uptitrated to higher doses than she actually needs. We cut back her Metoprolol and stoped her imdur - Can restart imdur if requiring for chest pain on outpatient basis - Please continue to work with patient on med compliance and possible barriers. She denied depression with our social worker but does endorse that stress makes it hard to take her medications. - f/u final wound swab cultures Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Losartan Potassium 25 mg PO DAILY 2. MetronidAZOLE Topical 1 % Gel 1 Appl TP BID:PRN Rosacea 3. Gabapentin 300 mg PO QHS:PRN Headache 4. Metoprolol Succinate XL 250 mg PO DAILY 5. linaGLIPtin 5 mg oral DAILY 6. Atorvastatin 80 mg PO QPM 7. Furosemide 20 mg PO DAILY 8. Isosorbide Mononitrate 120 mg PO DAILY 9. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN angina 10. rOPINIRole 0.5 mg PO QHS restless leg syndrome 11. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain - Severe 12. Fluticasone Propionate 110mcg 2 PUFF IH BID 13. Pantoprazole 40 mg PO BID 14. Aspirin 325 mg PO DAILY 15. TraZODone 50 mg PO QHS:PRN insomnia 16. canagliflozin 100 mg oral DAILY 17. albuterol sulfate 90 mcg/actuation inhalation Q8H:PRN 18. Lidocaine 5% Patch 1 PTCH TD QPM Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0 2. Clindamycin 300 mg PO Q6H RX *clindamycin HCl 300 mg 1 capsule(s) by mouth four times per day Disp #*28 Capsule Refills:*0 3. Glargine 50 Units Bedtime Humalog 18 Units Breakfast Humalog 18 Units Lunch Humalog 18 Units Dinner Insulin SC Sliding Scale using HUM Insulin 4. Metoprolol Succinate XL 100 mg PO DAILY RX *metoprolol succinate 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 5. albuterol sulfate 90 mcg/actuation inhalation Q8H:PRN 6. Aspirin 325 mg PO DAILY 7. Atorvastatin 80 mg PO QPM 8. Fluticasone Propionate 110mcg 2 PUFF IH BID 9. Furosemide 20 mg PO DAILY 10. Gabapentin 300 mg PO QHS:PRN Headache 11. linaGLIPtin 5 mg oral DAILY 12. Losartan Potassium 25 mg PO DAILY 13. MetronidAZOLE Topical 1 % Gel 1 Appl TP BID:PRN Rosacea 14. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN angina 15. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain - Severe RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth three times daily Disp #*15 Tablet Refills:*0 16. Pantoprazole 40 mg PO BID 17. rOPINIRole 0.5 mg PO QHS restless leg syndrome 18. TraZODone 50 mg PO QHS:PRN insomnia 19. HELD- canagliflozin 100 mg oral DAILY This medication was held. Do not restart canagliflozin until you speak with your endocrinologist 20. HELD- Lidocaine 5% Patch 1 PTCH TD QPM This medication was held. Do not restart Lidocaine 5% Patch until you speak with your PCP [MASKED]: Home With Service Facility: [MASKED] Discharge Diagnosis: PRIMARY ======= Diabetic foot ulcer Diabetic ketoacidosis Chest pain SECONDARY ========= DIABETES MELLITUS (INSULIN DEPENDENT) COPD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], It was a pleasure taking care of you at the [MASKED] [MASKED]! WHY WAS I IN THE HOSPITAL? ========================== - You were admitted because you had chest pain. - You also had a process called DKA from not taking enough insulin - You also had a bad infection in your foot. WHAT HAPPENED IN THE HOSPITAL? ============================== - We did several tests to figure our if your chest pain was caused by a heart attack. The first was a stress test, which had a positive results. We then did a procedure called a cardiac cath, which showed that you did NOT have a heart attack. - Our podiatrists did a debridement of your foot. - We gave you antibiotics for your foot. - We adjusted your insulin levels. WHAT SHOULD I DO WHEN I GO HOME? ================================ - Take all of your medications: - Ciproflocaxin and Clindamycin are antibiotics you need to take until the podiatrists tell you to stop. You are scheduled to see them [MASKED] - Your insulin regimen will be slightly different from your old regimen. - You need to take aspirin and Atorvastatin every day to prevent blockages in your heart from forming. - You will have many appointments in the next week. It is very important that you go to all of these, to help get your health on track! - Your weight at discharge is 79.1 kg (174.38 lb) . Please weigh yourself today at home and use this as your new baseline -Please weigh yourself every day in the morning. Call your doctor if your weight goes up by more than 3 lbs. - Seek medical attention if you have new or concerning symptoms or you develop swelling in your legs, abdominal distention, or shortness of breath. If you have worsening pain or redness in your foot, urinating frequently or very thirsty, or if your blood sugar is consistently above 300 or below 70 please cal your doctor. It was a pleasure participating in your care. We wish you the [MASKED]! -Your [MASKED] Care Team Followup Instructions: [MASKED]
|
[] |
[
"E1122",
"I5032",
"I130",
"E1165",
"J449",
"F329",
"K219",
"G4733",
"Z87891",
"Z951",
"Z794",
"Z955",
"Y929"
] |
[
"I25110: Atherosclerotic heart disease of native coronary artery with unstable angina pectoris",
"E1110: Type 2 diabetes mellitus with ketoacidosis without coma",
"E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease",
"E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema",
"M869: Osteomyelitis, unspecified",
"I5032: Chronic diastolic (congestive) heart failure",
"I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease",
"T82855A: Stenosis of coronary artery stent, initial encounter",
"E11621: Type 2 diabetes mellitus with foot ulcer",
"E1142: Type 2 diabetes mellitus with diabetic polyneuropathy",
"E1165: Type 2 diabetes mellitus with hyperglycemia",
"E1169: Type 2 diabetes mellitus with other specified complication",
"L97529: Non-pressure chronic ulcer of other part of left foot with unspecified severity",
"N183: Chronic kidney disease, stage 3 (moderate)",
"J449: Chronic obstructive pulmonary disease, unspecified",
"B961: Klebsiella pneumoniae [K. pneumoniae] as the cause of diseases classified elsewhere",
"B951: Streptococcus, group B, as the cause of diseases classified elsewhere",
"F329: Major depressive disorder, single episode, unspecified",
"K219: Gastro-esophageal reflux disease without esophagitis",
"G4733: Obstructive sleep apnea (adult) (pediatric)",
"Z87891: Personal history of nicotine dependence",
"Z951: Presence of aortocoronary bypass graft",
"Z794: Long term (current) use of insulin",
"Z9114: Patient's other noncompliance with medication regimen",
"G2581: Restless legs syndrome",
"Z955: Presence of coronary angioplasty implant and graft",
"Y840: Cardiac catheterization as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure",
"Y929: Unspecified place or not applicable"
] |
10,002,013 | 25,442,395 |
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:
___
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Allergies: lisinopril Chief Complaint: Left diabetic foot ulcer Major Surgical or Invasive Procedure: Left partial hallux amputation History of Present Illness: [MASKED] with poorly controlled diabetes (complicated by retinopathy, neuropathy, PAD, foot ulcer L hallux), CAD with [MASKED] 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 [MASKED], 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 [MASKED] urgent care in [MASKED], found to be febrile to [MASKED], 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 ([MASKED]). [MASKED] 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 [MASKED], DES to mid LAD [MASKED], DES to edge ISR of mid LAD DES and stenosis distal to stent [MASKED], DES to OM1 [MASKED], s/p 3 v CABG LIMA-LAD, SVG-OM1, [MASKED] -HFpEF -Depression -DM -GERD -Hypertension -Migraines -Chronic shoulder pain on narcotics -OSA -Peripheral neuropathy -Restless leg Social History: [MASKED] Family History: Patient was ward of the [MASKED], doesn't know full details of family history. Mother with possible alcohol abuse. Father deceased at [MASKED] 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 ============== [MASKED] 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 [MASKED] [MASKED] 05:50PM BLOOD Neuts-81.4* Lymphs-10.5* Monos-7.1 Eos-0.0* Baso-0.3 Im [MASKED] AbsNeut-19.09* AbsLymp-2.47 AbsMono-1.66* AbsEos-0.00* AbsBaso-0.06 [MASKED] 05:50PM BLOOD Glucose-266* UreaN-26* Creat-1.6* Na-136 K-4.2 Cl-98 HCO3-18* AnGap-20* [MASKED] 05:50PM BLOOD CRP-180.1* [MASKED] 07:45PM BLOOD [MASKED] pO2-22* pCO2-44 pH-7.32* calTCO2-24 Base XS--4 [MASKED] 05:50PM BLOOD Lactate-2.4* [MASKED] 07:40PM URINE Color-Straw Appear-Clear Sp [MASKED] [MASKED] 07:40PM URINE Blood-NEG Nitrite-NEG Protein-TR* Glucose-1000* Ketone-TR* Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM* [MASKED] 07:40PM URINE RBC-4* WBC-7* Bacteri-FEW* Yeast-NONE Epi-1 TransE-<1 [MASKED] 07:40PM URINE Mucous-RARE* PERTINENT INTERVAL LABS ======================= [MASKED] 09:48AM BLOOD ALT-25 AST-29 LD(LDH)-210 AlkPhos-130* TotBili-0.8 DISCHARGE LABS ============== [MASKED] 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 [MASKED] [MASKED] 07:29AM BLOOD Glucose-109* UreaN-18 Creat-1.2* Na-140 K-4.0 Cl-100 HCO3-25 AnGap-15 [MASKED] 07:29AM BLOOD Calcium-8.8 Phos-4.3 Mg-1.8 [MASKED] 07:29AM BLOOD CRP-44.6* IMAGING ======= LEFT FOOT XRAY ([MASKED]) 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 ([MASKED]) --------------- 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 ([MASKED]) -------------- IMPRESSION: Comparison to [MASKED]. 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 ([MASKED]) 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 ([MASKED]) 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 ([MASKED]) - Bone with reparative changes, consistent with chronic osteomyelitis. - There is no evidence of acute osteomyelitis. SURGICAL TISSUE ([MASKED]) 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 ============ [MASKED] 10:00 am TISSUE PROXIMAL PHALYNX. GRAM STAIN (Final [MASKED]: 2+ [MASKED] per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ [MASKED] per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS. Reported to and read back by [MASKED] ([MASKED]) ON [MASKED] AT 1:20PM. TISSUE (Final [MASKED]: STAPH AUREUS COAG +. SPARSE GROWTH. Susceptibility testing performed on culture # [MASKED] [MASKED]. ANAEROBIC CULTURE (Final [MASKED]: NO ANAEROBES ISOLATED. ACID FAST SMEAR (Final [MASKED]: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): [MASKED] [MASKED] 7:00 pm BLOOD CULTURE **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] [MASKED] 5:38 pm BLOOD CULTURE **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] [MASKED] 12:34 am BLOOD CULTURE **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] [MASKED] 11:00 pm BLOOD CULTURE **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] [MASKED] 12:18 am BLOOD CULTURE **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] [MASKED] 10:53 pm BLOOD CULTURE **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. Brief Hospital Course: ============= SUMMARY ============= [MASKED] 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 [MASKED]. However the infection persisted, and she underwent left hallux amputation on [MASKED]. She was started on IV nafcillin for MSSA infection with plan to continue home infusions of nafcillin until at least [MASKED] ACTIVE ISSUES ============= #Osteomyelitis of left hallux: Due to diabetic ulcer of left hallux. Patient underwent partial left hallux amputation on [MASKED] 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 [MASKED] for total left hallux amputation given lack of clinical improvement. Her [MASKED] 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 [MASKED]. A PICC line was placed in the right arm [MASKED] with tentative plan to complete a two-week course of IV nafcillin on [MASKED]. 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 [MASKED] 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 [MASKED] 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 [MASKED] 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 [MASKED] diabetes consult team we adjusted her insulin doses as needed. [MASKED] 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: [MASKED] (grandson's girlfriend) [MASKED] 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 [MASKED]. Please re-assess pain management. [ ] Osteomyelitis, infected diabetic foot ulcer: Surgical margin from total left hallux amputation on [MASKED] 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 [MASKED] provider on [MASKED], [MASKED] at 1 [MASKED]. 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. [ ] [MASKED]: Discharge creatinine 1.2 on [MASKED]. Suspect patient will have a slight bump in creatinine after restarting losartan on [MASKED]. 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: [MASKED] (grandson's girlfriend) [MASKED] >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. [MASKED] 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 [MASKED] and [MASKED] LAB TEST: CBC with differential, BUN, Cr, AST, ALT, Total Bili, ALK PHOS, ESR, CRP PLEASE FAX RESULTS TO: ATTN: [MASKED] CLINIC - FAX: [MASKED] 28.Rolling Walker EQUIPMENT: Rolling Walker DIAGNOSIS: Left hallux amputation ICD-10: [MASKED] PX: Good [MASKED]: 13 months Discharge Disposition: Home With Service Facility: [MASKED] 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. [MASKED], 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 [MASKED] appointment on [MASKED] at 1:00 pm so that they can adjust your medication regimen appropriately. Please follow-up with Dr. [MASKED] team on [MASKED] at 11:00 am. Please follow up with Dr. [MASKED] your antibiotic regimen on [MASKED] at 10:30 am. Please follow-up with Dr. [MASKED] in [MASKED] [MASKED] on [MASKED] at 1:00 pm. Be well, Your [MASKED] Care Team Followup Instructions: [MASKED]
|
[] |
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"I252",
"G4733",
"K219",
"N189",
"E1122",
"Z794",
"Z951",
"Z955",
"Z87891"
] |
[
"A419: Sepsis, unspecified organism",
"M86672: Other chronic osteomyelitis, left ankle and foot",
"M86172: Other acute osteomyelitis, left ankle and foot",
"N179: Acute kidney failure, unspecified",
"L03116: Cellulitis of left lower limb",
"J9811: Atelectasis",
"I5032: Chronic diastolic (congestive) heart failure",
"I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease",
"E1152: Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene",
"I96: Gangrene, not elsewhere classified",
"E1169: Type 2 diabetes mellitus with other specified complication",
"L97524: Non-pressure chronic ulcer of other part of left foot with necrosis of bone",
"E11621: Type 2 diabetes mellitus with foot ulcer",
"B9561: Methicillin susceptible Staphylococcus aureus infection as the cause of diseases classified elsewhere",
"J449: Chronic obstructive pulmonary disease, unspecified",
"E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema",
"E1142: Type 2 diabetes mellitus with diabetic polyneuropathy",
"E1165: Type 2 diabetes mellitus with hyperglycemia",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"I252: Old myocardial infarction",
"G4733: Obstructive sleep apnea (adult) (pediatric)",
"K219: Gastro-esophageal reflux disease without esophagitis",
"G2581: Restless legs syndrome",
"N189: Chronic kidney disease, unspecified",
"E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease",
"Z794: Long term (current) use of insulin",
"Z951: Presence of aortocoronary bypass graft",
"Z955: Presence of coronary angioplasty implant and graft",
"Z87891: Personal history of nicotine dependence"
] |
10,002,013 | 27,574,273 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old woman with extensive cardiac history
including multivessel vessel CAD S/P stenting of the LAD with
in-stent restenosis and stenting of the CX, S/P CABG in ___ with known occluded SVG-D1 with patent LIMA-LAD and SVG-OM
in ___, poorly controlled type 2 diabetes mellitus,
hypertension, COPD, GERD, now presenting with new chest pain.
At 5 pm on the day of presentation, she was resting at home
when she had onset of severe stabbing pain left of the sternum.
This pain radiated across her chest but not to the arm or jaw.
She took 1 nitroglycerin, which improved her pain slightly. She
reports that the pain came in waves lasting 5 minutes. She also
endorsed left chest wall tenderness. She did not remember when
she last had chest pain prior to this. The pain was not clearly
exertional. The sharp pains occurred when she was lying down.
She says the area is very tender. Lying on the left side causes
pain. She did have nausea the past 3 mornings which resolved.
She denied vomiting, diaphoresis, fevers or chills. She had an
episode of diarrhea yesterday, but no abdominal pain. She
already took a full dose aspirin on the day of presentation.
In the ED, initial vitals were: T 98.0, HR 88, BP 127/65, RR
16, SaO2 100% on RA. FSBG 302->94. Labs notable for Troponin-T <
0.01, CK-MB < 1, D-Dimer 268, Cr 1.2, Mg 1.4. Normal LFTs; CBC,
Chem 7, coags WNL. CXR showed no acute cardiopulmonary
abnormality. Bedside echocardiogram showed no substantial
pericardial effusion or tamponade. Patient was given fluticasone
propionate inhaled, OxyCODONE--Acetaminophen (5mg-325mg),
Magnesium Sulfate 2 gm IV.
On arrival to the cardiology ward, the patient reported that her
pain was still there but it felt "slow" ___ but at its worse
was ___. The area was tender. She had no breathing complaints.
She felt a little congested this evening when the pain started.
Past Medical History:
-COPD
-CAD s/p CABG and stenting, as above
-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:
On admission
General: Obese middle aged ___ woman, alert, oriented, in no
acute distress
Vital Signs: T 98.7, BP 98/65, HR 79, RR 18, SaO2 95% on RA
Weight: 89 kg
HEENT: Sclera anicteric, mucous membranes moist, oropharynx
clear
NECK: difficult to appreciate JVP
CV: Regular rate and rhythm, normal S1 + S2; no murmurs, rubs,
gallops
Chest: Tenderness to palpation of the left anterior chest wall
Lungs: Clear to auscultation bilaterally--no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, obese
GU: No Foley
Ext: Warm, well perfused; no clubbing, cyanosis or edema
Exam unchanged at discharge, left chest wall tender with
palpation with pain after change in position
Pertinent Results:
___ 10:31PM BLOOD WBC-9.4 RBC-3.51* Hgb-12.0 Hct-34.3
MCV-98 MCH-34.2* MCHC-35.0 RDW-11.8 RDWSD-42.3 Plt ___
___ 10:31PM BLOOD Glucose-105* UreaN-21* Creat-1.2* Na-137
K-3.4 Cl-97 HCO3-24 AnGap-19
___ 10:31PM BLOOD ALT-15 AST-16 CK(CPK)-39 AlkPhos-53
TotBili-0.3
___ 10:31PM BLOOD Albumin-3.9 Calcium-9.1 Phos-4.4 Mg-1.4*
___ 10:57PM BLOOD D-Dimer-268
___ 10:31PM BLOOD CK-MB-1 cTropnT-<0.01
___ 06:00AM BLOOD CK-MB-<1 cTropnT-<0.01
___ 06:00AM BLOOD WBC-9.3 RBC-3.44* Hgb-11.8 Hct-33.1*
MCV-96 MCH-34.3* MCHC-35.6 RDW-11.9 RDWSD-41.3 Plt ___
___ 06:00AM BLOOD Glucose-147* UreaN-21* Creat-1.2* Na-139
K-3.0* Cl-99 HCO3-24 AnGap-19
___ 06:00AM BLOOD Calcium-8.7 Phos-4.4 Mg-2.0
ECG ___ 8:33:29 ___
Baseline artifact. Sinus rhythm. Borderline P-R interval
prolongation. Prominent voltage in leads I and aVL but does not
meet criteria for left ventricular hypertrophy. There are marked
ST segment depressions and T wave inversions in leads I, II, aVL
and apical lateral leads. Compared to the previous tracing of
___ the rate then was faster. ST-T wave abnormalities were
similar. Consider left ventricular hypertrophy as before.
Clinical correlation is suggested.
CXR ___
Patient is status post median sternotomy and CABG. Heart size is
normal. Mediastinal and hilar contours are unchanged. Pulmonary
vasculature is normal. No focal consolidation, pleural effusion
or pneumothorax is seen. No acute osseous abnormality is
detected.
IMPRESSION: No acute cardiopulmonary abnormality.
Dipyridamole-MIBI Stress test ___
___ yp woman with HL, HTN, DM, PVD and diastolic CHF; s/p MI and
multiple PCIs f/b CABG x 3 in ___ with known SVG-OM occlusion
was referred to evaluate an atypical chest discomfort. The
patient was administered 0.142 mg/kg/min of Persantine over 4
minutes. Prior to the procedure the patient reported an isolated
left-sided chest discomfort that had been present since
admission and was tender to mild palpation; ___. This
discomfort did not change in intensity during the procedure. In
the presence of diffuse ST-T wave changes, no additional ECG
changes were noted during the procedure. The hemodynamic
response to the Persantine infusion was appropriate.
Post-infusion, the patient was administered 125 mg Aminophylline
IV.
IMPRESSION: Non-anginal type symptoms with no additional ST
segment changes from baseline.
Imaging:
Left ventricular cavity size is normal.
Rest and stress perfusion images reveal uniform tracer uptake
throughout the left ventricular myocardium. The previously
noted perfusion defect involving the inferolateral wall has
resolved.
Gated images reveal normal wall motion. The calculated left
ventricular ejection fraction is 64%.
IMPRESSION: Normal myocardial perfusion study. Interval
normalization of prior LCx territory perfusion defect.
Brief Hospital Course:
This is a ___ with type 2 diabetes mellitus on insulin, CAD s/p
MI, S/P multiple PCIs and CABG ___ (LIMA-LAD, SVG-OM1; also
SVG-D1 known occluded ___ with chronic stable angina
admitted with atypical, stabbing, focal chest pain.
# Chest pain: Initially the patient was started on a heparin
drip and other ACS protocol medications. Her home losartan and
furosemide were held due to low blood pressures. Suspicion for
cardiac etiology of chest pain was ultimately not high. She had
an isolated ongoing ___ left-sided chest discomfort exacerbated
by changes in position and with chest wall tenderness to light
palpation. Despite prolonged chest pain, troponin-T and CK-MB
negative x2 and EKGs mostly unchanged from prior. Given known
H/O CAD, a vasodilator nuclear stress test was performed and was
reassuring. Her discomfort did not change in intensity during
the stress test drug infusion. In the presence of diffuse ST-T
wave changes, no additional ECG changes were noted during the
procedure. The hemodynamic response to the Persantine infusion
was appropriate. Her perfusion study was normal with interval
normalization of prior LCx territory perfusion defect. Given the
stabbing quality and tenderness to palpation of the area of
discomfort, her symptoms were most likely related to
costochondritis or other musculoskeletal causes. She was started
on aspirin 650 mg q6h with plans to trial for 2 days and
continue through the week if symptoms improve.
Chronic medical problems:
# Diabetes mellitus: Continued levemir and was switched to a
sliding scale of Humalog.
# Hypertension: Losartan was held as above due to hypotension
and once daily isosorbide mononitrate was switched temporarily
to isosorbide dinitrate TID.
# For her hyperlipidemia, COPD and GERD, her home regimens were
continued.
TRANSITIONAL ISSUES:
- Patient had low blood pressures initially (88-92 systolic).
Would benefit from close monitoring and titration of blood
pressure medications as an outpatient
- She was hypokalemic (K 3.0) during admission (with ___ and
furosemide already held). Please recheck CHEM-10 at ___ ___
visit on ___ to determine whether she might benefit from K
supplementation
- Cr elevated to 1.2 on discharge (up from most recent 1.1.1).
Please recheck at ___ office on ___
- Full code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
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 250 mg PO DAILY
4. Levemir Flexpen (insulin detemir) 90 units subcutaneous in
the evening
5. albuterol sulfate 90 mcg/actuation inhalation q4hrs wheezing
6. Vitamin D 1000 UNIT PO DAILY
7. TraZODone 100 mg PO HS
8. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
9. Aspirin 325 mg PO DAILY
10. Atorvastatin 80 mg PO HS
11. Fluticasone Propionate 110mcg 2 PUFF IH BID
12. Pantoprazole 40 mg PO Q12H
13. Ropinirole 0.5 mg PO QPM
14. HumaLOG KwikPen (insulin lispro) 0 SUBCUTANEOUS AS
DIRECTED
15. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze
16. Methocarbamol 500 mg PO TID:PRN muscle pain
17. Losartan Potassium 25 mg PO DAILY
18. Furosemide 20 mg PO DAILY
19. diclofenac sodium 1 % topical TID:PRN pain
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze
2. Atorvastatin 80 mg PO HS
3. Fluticasone Propionate 110mcg 2 PUFF IH BID
4. Methocarbamol 500 mg PO TID:PRN muscle pain
5. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN pain
6. Pantoprazole 40 mg PO Q12H
7. Ropinirole 0.5 mg PO QPM
8. TraZODone 100 mg PO HS
9. Vitamin D 1000 UNIT PO DAILY
10. albuterol sulfate 90 mcg/actuation INHALATION Q4HRS wheezing
11. diclofenac sodium 1 % topical TID:PRN pain
12. Furosemide 20 mg PO DAILY
13. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
14. Metoprolol Succinate XL 250 mg PO DAILY
15. HumaLOG KwikPen (insulin lispro) 0 SUBCUTANEOUS AS
DIRECTED
16. Levemir Flexpen (insulin detemir) 90 units subcutaneous in
the evening
17. Losartan Potassium 25 mg PO DAILY
18. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN pain
19. Aspirin 650 mg PO Q6H
RX *aspirin 650 mg 1 tablet(s) by mouth every six (6) hours Disp
#*28 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
- Chest wall pain atypical for angina
- Musculoskeletal pain
- Known native coronary artery and bypass graft disease
- Type 2 Diabetes mellitus, with
- Chronic kidney disease, stage 3
- Acute kidney injury
- Chronic obstructive pulmonary disease
- Hypertension
- Hypotension
- Hypokalemia
- Chronic shoulder pain on narcotics
- Obstructive sleep apnea
- Gastroseophageal reflux disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was our pleasure participating in your care here at ___.
You were admitted with severe chest pain. You underwent a stress
test that showed the pain is unlikely from a big blockage in the
arteries that feed your heart. Your lab work also did not
suggest injury to the heart.
The pain you are experiencing is most likely musculoskeletal and
should hopefully improve with supportive measures such as
Tylenol (maximum 3 grams per day) and time. You will also be
prescribed high dose aspirin (650mg). Please try this for two
days and if there is improvement in your symptoms continue it
for the week.
If your symptoms worsen, you develop shortness of breath or any
other concerning symptom, please let your doctor know right
away.
Again, it was our pleasure participating in your care.
We wish you the very ___,
Your ___ Cardiology Team
Followup Instructions:
___
|
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Allergies: lisinopril Chief Complaint: Chest pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] year old woman with extensive cardiac history including multivessel vessel CAD S/P stenting of the LAD with in-stent restenosis and stenting of the CX, S/P CABG in [MASKED] with known occluded SVG-D1 with patent LIMA-LAD and SVG-OM in [MASKED], poorly controlled type 2 diabetes mellitus, hypertension, COPD, GERD, now presenting with new chest pain. At 5 pm on the day of presentation, she was resting at home when she had onset of severe stabbing pain left of the sternum. This pain radiated across her chest but not to the arm or jaw. She took 1 nitroglycerin, which improved her pain slightly. She reports that the pain came in waves lasting 5 minutes. She also endorsed left chest wall tenderness. She did not remember when she last had chest pain prior to this. The pain was not clearly exertional. The sharp pains occurred when she was lying down. She says the area is very tender. Lying on the left side causes pain. She did have nausea the past 3 mornings which resolved. She denied vomiting, diaphoresis, fevers or chills. She had an episode of diarrhea yesterday, but no abdominal pain. She already took a full dose aspirin on the day of presentation. In the ED, initial vitals were: T 98.0, HR 88, BP 127/65, RR 16, SaO2 100% on RA. FSBG 302->94. Labs notable for Troponin-T < 0.01, CK-MB < 1, D-Dimer 268, Cr 1.2, Mg 1.4. Normal LFTs; CBC, Chem 7, coags WNL. CXR showed no acute cardiopulmonary abnormality. Bedside echocardiogram showed no substantial pericardial effusion or tamponade. Patient was given fluticasone propionate inhaled, OxyCODONE--Acetaminophen (5mg-325mg), Magnesium Sulfate 2 gm IV. On arrival to the cardiology ward, the patient reported that her pain was still there but it felt "slow" [MASKED] but at its worse was [MASKED]. The area was tender. She had no breathing complaints. She felt a little congested this evening when the pain started. Past Medical History: -COPD -CAD s/p CABG and stenting, as above -Depression -DM -GERD -Hypertension -Migraines -Chronic shoulder pain on narcotics -OSA -Peripheral neuropathy -Restless leg Social History: [MASKED] Family History: Patient was ward of the [MASKED], doesn't know full details of family history. Mother with possible alcohol abuse. Father deceased at [MASKED] from Hodgkin's Disease per old records. Physical Exam: On admission General: Obese middle aged [MASKED] woman, alert, oriented, in no acute distress Vital Signs: T 98.7, BP 98/65, HR 79, RR 18, SaO2 95% on RA Weight: 89 kg HEENT: Sclera anicteric, mucous membranes moist, oropharynx clear NECK: difficult to appreciate JVP CV: Regular rate and rhythm, normal S1 + S2; no murmurs, rubs, gallops Chest: Tenderness to palpation of the left anterior chest wall Lungs: Clear to auscultation bilaterally--no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, obese GU: No Foley Ext: Warm, well perfused; no clubbing, cyanosis or edema Exam unchanged at discharge, left chest wall tender with palpation with pain after change in position Pertinent Results: [MASKED] 10:31PM BLOOD WBC-9.4 RBC-3.51* Hgb-12.0 Hct-34.3 MCV-98 MCH-34.2* MCHC-35.0 RDW-11.8 RDWSD-42.3 Plt [MASKED] [MASKED] 10:31PM BLOOD Glucose-105* UreaN-21* Creat-1.2* Na-137 K-3.4 Cl-97 HCO3-24 AnGap-19 [MASKED] 10:31PM BLOOD ALT-15 AST-16 CK(CPK)-39 AlkPhos-53 TotBili-0.3 [MASKED] 10:31PM BLOOD Albumin-3.9 Calcium-9.1 Phos-4.4 Mg-1.4* [MASKED] 10:57PM BLOOD D-Dimer-268 [MASKED] 10:31PM BLOOD CK-MB-1 cTropnT-<0.01 [MASKED] 06:00AM BLOOD CK-MB-<1 cTropnT-<0.01 [MASKED] 06:00AM BLOOD WBC-9.3 RBC-3.44* Hgb-11.8 Hct-33.1* MCV-96 MCH-34.3* MCHC-35.6 RDW-11.9 RDWSD-41.3 Plt [MASKED] [MASKED] 06:00AM BLOOD Glucose-147* UreaN-21* Creat-1.2* Na-139 K-3.0* Cl-99 HCO3-24 AnGap-19 [MASKED] 06:00AM BLOOD Calcium-8.7 Phos-4.4 Mg-2.0 ECG [MASKED] 8:33:29 [MASKED] Baseline artifact. Sinus rhythm. Borderline P-R interval prolongation. Prominent voltage in leads I and aVL but does not meet criteria for left ventricular hypertrophy. There are marked ST segment depressions and T wave inversions in leads I, II, aVL and apical lateral leads. Compared to the previous tracing of [MASKED] the rate then was faster. ST-T wave abnormalities were similar. Consider left ventricular hypertrophy as before. Clinical correlation is suggested. CXR [MASKED] Patient is status post median sternotomy and CABG. Heart size is normal. Mediastinal and hilar contours are unchanged. Pulmonary vasculature is normal. No focal consolidation, pleural effusion or pneumothorax is seen. No acute osseous abnormality is detected. IMPRESSION: No acute cardiopulmonary abnormality. Dipyridamole-MIBI Stress test [MASKED] [MASKED] yp woman with HL, HTN, DM, PVD and diastolic CHF; s/p MI and multiple PCIs f/b CABG x 3 in [MASKED] with known SVG-OM occlusion was referred to evaluate an atypical chest discomfort. The patient was administered 0.142 mg/kg/min of Persantine over 4 minutes. Prior to the procedure the patient reported an isolated left-sided chest discomfort that had been present since admission and was tender to mild palpation; [MASKED]. This discomfort did not change in intensity during the procedure. In the presence of diffuse ST-T wave changes, no additional ECG changes were noted during the procedure. The hemodynamic response to the Persantine infusion was appropriate. Post-infusion, the patient was administered 125 mg Aminophylline IV. IMPRESSION: Non-anginal type symptoms with no additional ST segment changes from baseline. Imaging: Left ventricular cavity size is normal. Rest and stress perfusion images reveal uniform tracer uptake throughout the left ventricular myocardium. The previously noted perfusion defect involving the inferolateral wall has resolved. Gated images reveal normal wall motion. The calculated left ventricular ejection fraction is 64%. IMPRESSION: Normal myocardial perfusion study. Interval normalization of prior LCx territory perfusion defect. Brief Hospital Course: This is a [MASKED] with type 2 diabetes mellitus on insulin, CAD s/p MI, S/P multiple PCIs and CABG [MASKED] (LIMA-LAD, SVG-OM1; also SVG-D1 known occluded [MASKED] with chronic stable angina admitted with atypical, stabbing, focal chest pain. # Chest pain: Initially the patient was started on a heparin drip and other ACS protocol medications. Her home losartan and furosemide were held due to low blood pressures. Suspicion for cardiac etiology of chest pain was ultimately not high. She had an isolated ongoing [MASKED] left-sided chest discomfort exacerbated by changes in position and with chest wall tenderness to light palpation. Despite prolonged chest pain, troponin-T and CK-MB negative x2 and EKGs mostly unchanged from prior. Given known H/O CAD, a vasodilator nuclear stress test was performed and was reassuring. Her discomfort did not change in intensity during the stress test drug infusion. In the presence of diffuse ST-T wave changes, no additional ECG changes were noted during the procedure. The hemodynamic response to the Persantine infusion was appropriate. Her perfusion study was normal with interval normalization of prior LCx territory perfusion defect. Given the stabbing quality and tenderness to palpation of the area of discomfort, her symptoms were most likely related to costochondritis or other musculoskeletal causes. She was started on aspirin 650 mg q6h with plans to trial for 2 days and continue through the week if symptoms improve. Chronic medical problems: # Diabetes mellitus: Continued levemir and was switched to a sliding scale of Humalog. # Hypertension: Losartan was held as above due to hypotension and once daily isosorbide mononitrate was switched temporarily to isosorbide dinitrate TID. # For her hyperlipidemia, COPD and GERD, her home regimens were continued. TRANSITIONAL ISSUES: - Patient had low blood pressures initially (88-92 systolic). Would benefit from close monitoring and titration of blood pressure medications as an outpatient - She was hypokalemic (K 3.0) during admission (with [MASKED] and furosemide already held). Please recheck CHEM-10 at [MASKED] [MASKED] visit on [MASKED] to determine whether she might benefit from K supplementation - Cr elevated to 1.2 on discharge (up from most recent 1.1.1). Please recheck at [MASKED] office on [MASKED] - Full code Medications on Admission: The Preadmission Medication list is accurate and complete. 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 250 mg PO DAILY 4. Levemir Flexpen (insulin detemir) 90 units subcutaneous in the evening 5. albuterol sulfate 90 mcg/actuation inhalation q4hrs wheezing 6. Vitamin D 1000 UNIT PO DAILY 7. TraZODone 100 mg PO HS 8. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY 9. Aspirin 325 mg PO DAILY 10. Atorvastatin 80 mg PO HS 11. Fluticasone Propionate 110mcg 2 PUFF IH BID 12. Pantoprazole 40 mg PO Q12H 13. Ropinirole 0.5 mg PO QPM 14. HumaLOG KwikPen (insulin lispro) 0 SUBCUTANEOUS AS DIRECTED 15. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze 16. Methocarbamol 500 mg PO TID:PRN muscle pain 17. Losartan Potassium 25 mg PO DAILY 18. Furosemide 20 mg PO DAILY 19. diclofenac sodium 1 % topical TID:PRN pain Discharge Medications: 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze 2. Atorvastatin 80 mg PO HS 3. Fluticasone Propionate 110mcg 2 PUFF IH BID 4. Methocarbamol 500 mg PO TID:PRN muscle pain 5. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN pain 6. Pantoprazole 40 mg PO Q12H 7. Ropinirole 0.5 mg PO QPM 8. TraZODone 100 mg PO HS 9. Vitamin D 1000 UNIT PO DAILY 10. albuterol sulfate 90 mcg/actuation INHALATION Q4HRS wheezing 11. diclofenac sodium 1 % topical TID:PRN pain 12. Furosemide 20 mg PO DAILY 13. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY 14. Metoprolol Succinate XL 250 mg PO DAILY 15. HumaLOG KwikPen (insulin lispro) 0 SUBCUTANEOUS AS DIRECTED 16. Levemir Flexpen (insulin detemir) 90 units subcutaneous in the evening 17. Losartan Potassium 25 mg PO DAILY 18. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN pain 19. Aspirin 650 mg PO Q6H RX *aspirin 650 mg 1 tablet(s) by mouth every six (6) hours Disp #*28 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: - Chest wall pain atypical for angina - Musculoskeletal pain - Known native coronary artery and bypass graft disease - Type 2 Diabetes mellitus, with - Chronic kidney disease, stage 3 - Acute kidney injury - Chronic obstructive pulmonary disease - Hypertension - Hypotension - Hypokalemia - Chronic shoulder pain on narcotics - Obstructive sleep apnea - Gastroseophageal reflux disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], It was our pleasure participating in your care here at [MASKED]. You were admitted with severe chest pain. You underwent a stress test that showed the pain is unlikely from a big blockage in the arteries that feed your heart. Your lab work also did not suggest injury to the heart. The pain you are experiencing is most likely musculoskeletal and should hopefully improve with supportive measures such as Tylenol (maximum 3 grams per day) and time. You will also be prescribed high dose aspirin (650mg). Please try this for two days and if there is improvement in your symptoms continue it for the week. If your symptoms worsen, you develop shortness of breath or any other concerning symptom, please let your doctor know right away. Again, it was our pleasure participating in your care. We wish you the very [MASKED], Your [MASKED] Cardiology Team Followup Instructions: [MASKED]
|
[] |
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"Z951",
"Z955",
"E1122",
"E1165",
"I129",
"E785",
"J449",
"K219",
"F329",
"E669",
"G8929",
"G4733",
"Z794",
"I252",
"Z87891"
] |
[
"R0789: Other chest pain",
"E876: Hypokalemia",
"I25119: Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris",
"I25709: Atherosclerosis of coronary artery bypass graft(s), unspecified, with unspecified angina pectoris",
"Z951: Presence of aortocoronary bypass graft",
"Z955: Presence of coronary angioplasty implant and graft",
"E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease",
"E1165: Type 2 diabetes mellitus with hyperglycemia",
"I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease",
"N183: Chronic kidney disease, stage 3 (moderate)",
"E785: Hyperlipidemia, unspecified",
"J449: Chronic obstructive pulmonary disease, unspecified",
"K219: Gastro-esophageal reflux disease without esophagitis",
"E1140: Type 2 diabetes mellitus with diabetic neuropathy, unspecified",
"F329: Major depressive disorder, single episode, unspecified",
"E669: Obesity, unspecified",
"Z6837: Body mass index [BMI] 37.0-37.9, adult",
"G8929: Other chronic pain",
"M25519: Pain in unspecified shoulder",
"G4733: Obstructive sleep apnea (adult) (pediatric)",
"Z794: Long term (current) use of insulin",
"I252: Old myocardial infarction",
"Z87891: Personal history of nicotine dependence"
] |
10,002,131 | 24,065,018 |
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:
___
|
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Allergies: Penicillins / Dilantin Kapseal / Zofran (as hydrochloride) Chief Complaint: Right hip pain Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] is a [MASKED] 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 [MASKED] 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 [MASKED] in [MASKED] given worsening of her dementia. She was in her USOH, bowling weekly and very social, until [MASKED] when she developed acute SOB with ambulation prompting admission to [MASKED] 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 [MASKED] clinic by Dr. [MASKED] new diagnosis of CHF. She underwent an TTE at [MASKED] yesterday [MASKED] 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. [MASKED] 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: [MASKED] 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 [MASKED]: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, soft [MASKED] 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 [MASKED] 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 [MASKED]: Sclera anicteric, MMM CV: Irregularly irregular, normal S1 + S2, soft [MASKED] 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 ============== [MASKED] 11:35AM URINE RBC-2 WBC-22* BACTERIA-NONE YEAST-NONE EPI-<1 TRANS EPI-<1 [MASKED] 11:35AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-MOD [MASKED] 12:00PM PLT COUNT-168 [MASKED] 12:00PM NEUTS-81.1* LYMPHS-10.8* MONOS-6.7 EOS-0.1* BASOS-0.2 IM [MASKED] AbsNeut-11.29* AbsLymp-1.51 AbsMono-0.94* AbsEos-0.02* AbsBaso-0.03 [MASKED] 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* [MASKED] 12:00PM CALCIUM-7.8* PHOSPHATE-3.7 MAGNESIUM-1.6 [MASKED] 12:00PM cTropnT-0.03* proBNP-8428* [MASKED] 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 =============================== [MASKED] 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 [MASKED] [MASKED] 06:55AM BLOOD Glucose-109* UreaN-32* Creat-0.9 Na-144 K-3.7 Cl-96 HCO3-37* AnGap-15 [MASKED] 06:55AM BLOOD Albumin-2.5* Calcium-8.0* Phos-3.2 Mg-1.5* Brief Hospital Course: [MASKED] is a [MASKED] 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 [MASKED] 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 [MASKED] [MASKED] 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 =================== - [MASKED] 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 [MASKED] (daughter) [MASKED] Primary, secondary [MASKED] (son) [MASKED] 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 [MASKED] 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: [MASKED] 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 [MASKED], 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 [MASKED] for hospice care. We wish you and your family the [MASKED], Your [MASKED] Treatment Team Followup Instructions: [MASKED]
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"I82412: Acute embolism and thrombosis of left femoral vein",
"I5033: Acute on chronic diastolic (congestive) heart failure",
"E873: Alkalosis",
"E46: Unspecified protein-calorie malnutrition",
"I482: Chronic atrial fibrillation",
"G309: Alzheimer's disease, unspecified",
"I82432: Acute embolism and thrombosis of left popliteal vein",
"F0280: Dementia in other diseases classified elsewhere without behavioral disturbance",
"I10: Essential (primary) hypertension",
"E876: Hypokalemia",
"M810: Age-related osteoporosis without current pathological fracture",
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"Z515: Encounter for palliative care",
"Z993: Dependence on wheelchair",
"H9192: Unspecified hearing loss, left ear",
"H409: Unspecified glaucoma",
"M25551: Pain in right hip",
"K5900: Constipation, unspecified",
"Z6827: Body mass index [BMI] 27.0-27.9, adult",
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10,002,221 | 20,195,471 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Codeine / Augmentin / Topamax
Attending: ___.
Chief Complaint:
left knee osteoarthritis/pain
Major Surgical or Invasive Procedure:
___: left total knee arthroplasty
History of Present Illness:
___ year old female w/left knee osteoarthritis/pain who failed
conservative measures, now admitted for left total knee
arthroplasty.
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:
No family hx of DVT or PE, two sisters have atrial fibrillation.
Physical Exam:
Well appearing in no acute distress
Afebrile with stable vital signs
Pain well-controlled
Respiratory: CTAB
Cardiovascular: RRR
Gastrointestinal: NT/ND
Genitourinary: Voiding independently
Neurologic: Intact with no focal deficits
Psychiatric: Pleasant, A&O x3
Musculoskeletal Lower Extremity:
* Aquacel dressing with scant serosanguinous drainage
* Thigh full but soft
* No calf tenderness
* ___ strength
* SILT, NVI distally
* Toes warm
Pertinent Results:
___ 06:30AM BLOOD WBC-6.8 RBC-2.69* Hgb-8.3* Hct-25.3*
MCV-94 MCH-30.9 MCHC-32.8 RDW-13.0 RDWSD-44.0 Plt ___
___ 06:10AM BLOOD WBC-6.4 RBC-2.77* Hgb-8.6* Hct-26.0*
MCV-94 MCH-31.0 MCHC-33.1 RDW-13.1 RDWSD-44.7 Plt ___
___ 06:22AM BLOOD WBC-7.6 RBC-3.31* Hgb-10.2*# Hct-30.5*#
MCV-92 MCH-30.8 MCHC-33.4 RDW-12.8 RDWSD-42.6 Plt ___
___ 06:30AM BLOOD Plt ___
___ 06:30AM BLOOD ___
___ 06:10AM BLOOD Plt ___
___ 06:10AM BLOOD ___
___ 06:22AM BLOOD Plt ___
___ 06:22AM BLOOD ___
___ 10:55AM BLOOD ___
___ 06:22AM BLOOD Glucose-136* UreaN-8 Creat-0.7 Na-138
K-3.7 Cl-96 HCO3-27 AnGap-15
___ 06:22AM BLOOD Calcium-8.4 Phos-3.1 Mg-1.7
Brief Hospital Course:
The patient was admitted to the Orthopaedic surgery service and
was taken to the operating room for above described procedure.
Please see separately dictated operative report for details. The
surgery was uncomplicated and the patient tolerated the
procedure well. Patient received perioperative IV antibiotics.
Postoperative course was remarkable for the following:
POD #1, patient was administered 500ml bolus of IV fluids for
hypotension ___, which she responded to appropriately. She
reported nausea on oxycodone and was switched to dilaudid with
no reported adverse effects.
POD #2, patient had INR of 1.8 and lovenox was discontinued.
Patient will continue Coumadin 5mg daily. Next INR check day
after discharge. Please direct results and all questions to PCP
for INR monitoring/Coumadin dosing.
POD #3, INR 2.0 and patient will be due for 5mg Coumadin upon
arrival to rehab facility.
Otherwise, pain was controlled with a combination of IV and oral
pain medications. The patient received Coumadin starting on
POD#0 with a Lovenox bridge starting on POD#1. Lovenox to be
continued until INR > 1.5 and discontinued on POD #2 with INR
1.8. Coumadin was dosed daily based on her INR levels. The
surgical dressing will remain on until POD#7 after surgery. The
patient was seen daily by physical therapy. Labs were checked
throughout the hospital course and repleted accordingly. At the
time of discharge the patient was tolerating a regular diet and
feeling well. The patient was afebrile with stable vital signs.
The patient's hematocrit was acceptable and pain was adequately
controlled on an oral regimen. The operative extremity was
neurovascularly intact and the dressing was intact.
The patient's weight-bearing status is weight bearing as
tolerated on the operative extremity. Please use walker or 2
crutches, wean as able.
Ms. ___ is discharged to rehab in stable condition.
**Patient will be in rehab facility for less than 30 days**
Medications on Admission:
1. Albuterol 0.083% Neb Soln 2 NEB IH Q4H:PRN wheezing, cough
2. Atorvastatin 40 mg PO QPM
3. econazole 1 % topical BID
4. Enoxaparin Sodium 110 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
5. Furosemide ___ mg PO DAILY:PRN leg swelling
6. MetFORMIN (Glucophage) 500 mg PO QPM
7. Omeprazole 20 mg PO BID
8. Sertraline 100 mg PO DAILY
9. TraZODone 50 mg PO QHS:PRN insomnia
10. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID:PRN
rash/itching
11. Warfarin ___ mg PO DAILY16
12. Aspirin 81 mg PO DAILY
13. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Gabapentin 100 mg PO TID
3. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
do NOT drink alcohol or drive while taking med
4. Senna 8.6 mg PO BID
5. Acetaminophen 1000 mg PO Q8H
6. Warfarin 5 mg PO TO BE DOSED DAILY PER PCP
DOSED DAILY PER PCP, GOAL INR 1.8-2.2
7. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath
8. Aspirin 81 mg PO DAILY
9. Atorvastatin 40 mg PO QPM
10. econazole 1 % topical BID
11. Furosemide ___ mg PO DAILY:PRN leg swelling
12. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
13. Omeprazole 20 mg PO BID
14. Sertraline 100 mg PO DAILY
15. TraZODone 50 mg PO QHS:PRN insomnia
16. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID:PRN
rash/itching
17. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
left knee osteoarthritis/pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool softener (such as Colace) as needed to prevent
this side effect. Call your surgeons office 3 days before you
are out of medication so that it can be refilled. These
medications cannot be called into your pharmacy and must be
picked up in the clinic or mailed to your house. Please allow
an extra 2 days if you would like your medication mailed to your
home.
5. You may not drive a car until cleared to do so by your
surgeon.
6. Please call your surgeon's office to schedule or confirm your
follow-up appointment.
7. SWELLING: Ice the operative joint 20 minutes at a time,
especially after activity or physical therapy. Do not place ice
directly on the skin. You may wrap the knee with an ace bandage
for added compression. Please DO NOT take any non-steroidal
anti-inflammatory medications (NSAIDs such as Celebrex,
ibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by
your physician.
8. ANTICOAGULATION: Lovenox discontinued on ___ due to INR
1.8. INR goal is 1.8-2.2. Please continue Coumadin 5mg daily.
INR to be checked day after discharge. Please direct all INR
results to patient's PCP. You may continue your dose of Aspirin
81mg daily.
9. WOUND CARE: Please remove Aquacel dressing on POD#7 after
surgery. It is okay to shower after surgery after 5 days but no
tub baths, swimming, or submerging your incision until after
your four (4) week checkup. Please place a dry sterile dressing
on the wound after aqaucel is removed each day if there is
drainage, otherwise leave it open to air. Check wound regularly
for signs of infection such as redness or thick yellow drainage.
10. ___ (once at home): Home ___, dressing changes as
instructed, and wound checks.
11. ACTIVITY: Weight bearing as tolerated on the operative
extremity. Two crutches or walker. Wean assistive device as
able. Mobilize. ROM as tolerated. No strenuous exercise or
heavy lifting until follow up appointment.
Physical Therapy:
WBAT LLE
No range of motion restrictions
Wean assistive devices as able
Mobilize frequently
Treatments Frequency:
remove aquacel POD#7 after surgery
apply dry sterile dressing daily if needed after aquacel
dressing is removed
wound checks daily after aquacel removed
Followup Instructions:
___
|
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Allergies: Codeine / Augmentin / Topamax Chief Complaint: left knee osteoarthritis/pain Major Surgical or Invasive Procedure: [MASKED]: left total knee arthroplasty History of Present Illness: [MASKED] year old female w/left knee osteoarthritis/pain who failed conservative measures, now admitted for left total knee arthroplasty. Past Medical History: Dyslipidemia, varicose veins (R>L) s/p ligation, COPD, OSA (+CPap), recent URI (received course of Zithromax), bilateral PEs ([MASKED]), antiphospholipid antibody syndrome (on lifelong anticoagulation), T2DM (last A1C 6.2 on [MASKED], cerebral aneurysm (followed by Dr. [MASKED], unchanged), GERD, diverticulosis, h/o colon polyps, depression, s/p right CMC joint arthroplasty, b/l rotator cuff repair, excision right [MASKED] digit mass, CCY w/stone & pancreatic duct exploration ([MASKED]), hysterectomy, tonsillectomy Social History: [MASKED] Family History: No family hx of DVT or PE, two sisters have atrial fibrillation. Physical Exam: Well appearing in no acute distress Afebrile with stable vital signs Pain well-controlled Respiratory: CTAB Cardiovascular: RRR Gastrointestinal: NT/ND Genitourinary: Voiding independently Neurologic: Intact with no focal deficits Psychiatric: Pleasant, A&O x3 Musculoskeletal Lower Extremity: * Aquacel dressing with scant serosanguinous drainage * Thigh full but soft * No calf tenderness * [MASKED] strength * SILT, NVI distally * Toes warm Pertinent Results: [MASKED] 06:30AM BLOOD WBC-6.8 RBC-2.69* Hgb-8.3* Hct-25.3* MCV-94 MCH-30.9 MCHC-32.8 RDW-13.0 RDWSD-44.0 Plt [MASKED] [MASKED] 06:10AM BLOOD WBC-6.4 RBC-2.77* Hgb-8.6* Hct-26.0* MCV-94 MCH-31.0 MCHC-33.1 RDW-13.1 RDWSD-44.7 Plt [MASKED] [MASKED] 06:22AM BLOOD WBC-7.6 RBC-3.31* Hgb-10.2*# Hct-30.5*# MCV-92 MCH-30.8 MCHC-33.4 RDW-12.8 RDWSD-42.6 Plt [MASKED] [MASKED] 06:30AM BLOOD Plt [MASKED] [MASKED] 06:30AM BLOOD [MASKED] [MASKED] 06:10AM BLOOD Plt [MASKED] [MASKED] 06:10AM BLOOD [MASKED] [MASKED] 06:22AM BLOOD Plt [MASKED] [MASKED] 06:22AM BLOOD [MASKED] [MASKED] 10:55AM BLOOD [MASKED] [MASKED] 06:22AM BLOOD Glucose-136* UreaN-8 Creat-0.7 Na-138 K-3.7 Cl-96 HCO3-27 AnGap-15 [MASKED] 06:22AM BLOOD Calcium-8.4 Phos-3.1 Mg-1.7 Brief Hospital Course: The patient was admitted to the Orthopaedic surgery service and was taken to the operating room for above described procedure. Please see separately dictated operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Patient received perioperative IV antibiotics. Postoperative course was remarkable for the following: POD #1, patient was administered 500ml bolus of IV fluids for hypotension [MASKED], which she responded to appropriately. She reported nausea on oxycodone and was switched to dilaudid with no reported adverse effects. POD #2, patient had INR of 1.8 and lovenox was discontinued. Patient will continue Coumadin 5mg daily. Next INR check day after discharge. Please direct results and all questions to PCP for INR monitoring/Coumadin dosing. POD #3, INR 2.0 and patient will be due for 5mg Coumadin upon arrival to rehab facility. Otherwise, pain was controlled with a combination of IV and oral pain medications. The patient received Coumadin starting on POD#0 with a Lovenox bridge starting on POD#1. Lovenox to be continued until INR > 1.5 and discontinued on POD #2 with INR 1.8. Coumadin was dosed daily based on her INR levels. The surgical dressing will remain on until POD#7 after surgery. The patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was acceptable and pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact and the dressing was intact. The patient's weight-bearing status is weight bearing as tolerated on the operative extremity. Please use walker or 2 crutches, wean as able. Ms. [MASKED] is discharged to rehab in stable condition. **Patient will be in rehab facility for less than 30 days** Medications on Admission: 1. Albuterol 0.083% Neb Soln 2 NEB IH Q4H:PRN wheezing, cough 2. Atorvastatin 40 mg PO QPM 3. econazole 1 % topical BID 4. Enoxaparin Sodium 110 mg SC Q12H Start: Today - [MASKED], First Dose: Next Routine Administration Time 5. Furosemide [MASKED] mg PO DAILY:PRN leg swelling 6. MetFORMIN (Glucophage) 500 mg PO QPM 7. Omeprazole 20 mg PO BID 8. Sertraline 100 mg PO DAILY 9. TraZODone 50 mg PO QHS:PRN insomnia 10. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID:PRN rash/itching 11. Warfarin [MASKED] mg PO DAILY16 12. Aspirin 81 mg PO DAILY 13. Vitamin D [MASKED] UNIT PO DAILY Discharge Medications: 1. Docusate Sodium 100 mg PO BID 2. Gabapentin 100 mg PO TID 3. HYDROmorphone (Dilaudid) [MASKED] mg PO Q4H:PRN Pain - Moderate do NOT drink alcohol or drive while taking med 4. Senna 8.6 mg PO BID 5. Acetaminophen 1000 mg PO Q8H 6. Warfarin 5 mg PO TO BE DOSED DAILY PER PCP DOSED DAILY PER PCP, GOAL INR 1.8-2.2 7. Albuterol Inhaler [MASKED] PUFF IH Q6H:PRN shortness of breath 8. Aspirin 81 mg PO DAILY 9. Atorvastatin 40 mg PO QPM 10. econazole 1 % topical BID 11. Furosemide [MASKED] mg PO DAILY:PRN leg swelling 12. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY 13. Omeprazole 20 mg PO BID 14. Sertraline 100 mg PO DAILY 15. TraZODone 50 mg PO QHS:PRN insomnia 16. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID:PRN rash/itching 17. Vitamin D [MASKED] UNIT PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: left knee osteoarthritis/pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as Colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon. 6. Please call your surgeon's office to schedule or confirm your follow-up appointment. 7. SWELLING: Ice the operative joint 20 minutes at a time, especially after activity or physical therapy. Do not place ice directly on the skin. You may wrap the knee with an ace bandage for added compression. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as Celebrex, ibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by your physician. 8. ANTICOAGULATION: Lovenox discontinued on [MASKED] due to INR 1.8. INR goal is 1.8-2.2. Please continue Coumadin 5mg daily. INR to be checked day after discharge. Please direct all INR results to patient's PCP. You may continue your dose of Aspirin 81mg daily. 9. WOUND CARE: Please remove Aquacel dressing on POD#7 after surgery. It is okay to shower after surgery after 5 days but no tub baths, swimming, or submerging your incision until after your four (4) week checkup. Please place a dry sterile dressing on the wound after aqaucel is removed each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. 10. [MASKED] (once at home): Home [MASKED], dressing changes as instructed, and wound checks. 11. ACTIVITY: Weight bearing as tolerated on the operative extremity. Two crutches or walker. Wean assistive device as able. Mobilize. ROM as tolerated. No strenuous exercise or heavy lifting until follow up appointment. Physical Therapy: WBAT LLE No range of motion restrictions Wean assistive devices as able Mobilize frequently Treatments Frequency: remove aquacel POD#7 after surgery apply dry sterile dressing daily if needed after aquacel dressing is removed wound checks daily after aquacel removed Followup Instructions: [MASKED]
|
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"G4733: Obstructive sleep apnea (adult) (pediatric)",
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] |
10,002,221 | 20,237,862 |
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:
___
|
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Allergies: Codeine / Augmentin / Topamax 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 [MASKED] woman with a history of breast cancer with BRCA1 gene mutation, COPD, cerebral aneurysm, sleep apnea, depression, hyperlipidemia, antiphospholipid syndrome with hx DVT/PE [MASKED] 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 [MASKED], complicated by hematoma status post evacuation on [MASKED]. Prior to these procedures, she had severe right lower extremity pain similar to today and underwent a DVT ultrasound on [MASKED] 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 [MASKED]. 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: [MASKED] 14.8, PTT 28.2, INR 1.4 Lactate 1.1 UA: Mod Leuk, few bacteria - Imaging notable for: RLE Ultrasound [MASKED] Right calf veins not visualized. Otherwise, no evidence of deep venous thrombosis in the right lower extremity veins. CT Lower Extremity Right [MASKED] 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 [MASKED]. She reports again that this pain is similar to the pain she had on [MASKED] 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 [MASKED]. 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 ([MASKED]), antiphospholipid antibody syndrome (on lifelong anticoagulation), T2DM (last A1C 6.2 on [MASKED], cerebral aneurysm (followed by Dr. [MASKED], unchanged), GERD, diverticulosis, h/o colon polyps, depression, s/p right CMC joint arthroplasty, b/l rotator cuff repair, excision right [MASKED] digit mass, CCY w/stone & pancreatic duct exploration ([MASKED]), hysterectomy, tonsillectomy Social History: [MASKED] Family History: Mother [MASKED] [MASKED] OVARIAN CANCER dx age [MASKED] Father [MASKED] [MASKED] BRAIN CANCER PGM OVARIAN CANCER Aunt OVARIAN CANCER paternal aunt in [MASKED] MGM ENDOMETRIAL CANCER MGF PROSTATE CANCER Brother [MASKED] [MASKED] KIDNEY CANCER RENAL FAILURE CONGESTIVE HEART FAILURE DIABETES MELLITUS TOBACCO ABUSE ALCOHOL ABUSE Sister [MASKED] [MASKED] OVARIAN CANCER dx age [MASKED] Brother [MASKED] THROAT CANCER dx age [MASKED], died in [MASKED] Sister BRCA1 MUTATION, BREAST CANCER Daughter Living [MASKED] ABNORMAL PAP SMEAR [MASKED] SUBSTANCE ABUSE Son Died [MASKED] SUBSTANCE ABUSE [MASKED] - heroin overdose on [MASKED]. 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+ [MASKED] 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+ [MASKED] 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: ================ [MASKED] 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 [MASKED] [MASKED] 12:00PM BLOOD Neuts-73.6* [MASKED] Monos-4.9* Eos-0.9* Baso-0.7 Im [MASKED] AbsNeut-4.09 AbsLymp-1.08* AbsMono-0.27 AbsEos-0.05 AbsBaso-0.04 [MASKED] 12:00PM BLOOD [MASKED] PTT-28.2 [MASKED] [MASKED] 12:00PM BLOOD Glucose-107* UreaN-7 Creat-0.8 Na-139 K-4.0 Cl-100 HCO3-26 AnGap-13 [MASKED] 05:40AM BLOOD Calcium-8.6 Phos-4.8* Mg-2.2 Iron-36 [MASKED] 05:40AM BLOOD calTIBC-291 VitB12-331 Ferritn-50 TRF-224 [MASKED] 07:15AM BLOOD 25VitD-45 [MASKED] 12:25PM BLOOD Lactate-1.1 DISCHARGE LABS: ================ [MASKED] 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 [MASKED] [MASKED] 04:41AM BLOOD [MASKED] [MASKED] 04:41AM BLOOD Glucose-132* UreaN-15 Creat-0.7 Na-140 K-5.0 Cl-103 HCO3-26 AnGap-11 [MASKED] 04:41AM BLOOD Calcium-9.2 Phos-4.0 Mg-2.4 IMAGING: =================== Unilat lower extremity vein- R [MASKED] Right calf veins not visualized. Otherwise, no evidence of deep venous thrombosis in the right lower extremity veins. CT RLE [MASKED] 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 [MASKED]: 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. [MASKED] is a [MASKED] 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; [MASKED] 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 [MASKED] 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 [MASKED]. 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 ([MASKED]) for which she is on a BID PPI; prior colonoscopy [MASKED] 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 [MASKED]. TTG was repeated and pending at discharge. CHRONIC ISSUES: =================== # History of DVT/PE on warfarin: # Antiphospholipid antibody syndrome: # Subtherapeutic INR: Lupus anticoagulant positive in [MASKED]. She has been taking her home dose of warfarin (5 mg [MASKED] and 7.5 mg other days). Her warfarin was held last [MASKED] 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 [MASKED]. 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 [MASKED]. # 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: [MASKED], granddaughter - [MASKED]. - 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 [MASKED] clinic on [MASKED]. 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 [MASKED] 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 ([MASKED]) 17. Warfarin 5 mg PO 5X/WEEK ([MASKED]) 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 [MASKED] 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 [MASKED] UNIT PO DAILY 17. Warfarin 5 mg PO 2X/WEEK ([MASKED]) 18. Warfarin 7.5 mg PO 5X/WEEK ([MASKED]) Discharge Disposition: Home With Service Facility: [MASKED] 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 [MASKED], 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 [MASKED]. 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 [MASKED] Followup Instructions: [MASKED]
|
[] |
[
"D509",
"Z87891",
"Z7901",
"G4733",
"E785",
"E119",
"K219",
"F329",
"J449"
] |
[
"M7061: Trochanteric bursitis, right hip",
"D6861: Antiphospholipid syndrome",
"D509: Iron deficiency anemia, unspecified",
"E559: Vitamin D deficiency, unspecified",
"Z87891: Personal history of nicotine dependence",
"Z86711: Personal history of pulmonary embolism",
"Z7901: Long term (current) use of anticoagulants",
"C50912: Malignant neoplasm of unspecified site of left female breast",
"G4733: Obstructive sleep apnea (adult) (pediatric)",
"E785: Hyperlipidemia, unspecified",
"E119: Type 2 diabetes mellitus without complications",
"K219: Gastro-esophageal reflux disease without esophagitis",
"K5790: Diverticulosis of intestine, part unspecified, without perforation or abscess without bleeding",
"F329: Major depressive disorder, single episode, unspecified",
"J449: Chronic obstructive pulmonary disease, unspecified",
"I83811: Varicose veins of right lower extremity with pain"
] |
10,002,221 | 21,729,093 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Codeine / Augmentin / Topamax
Attending: ___
___ Complaint:
left breast swelling and pain
Major Surgical or Invasive Procedure:
Evacuation of hematoma
History of Present Illness:
___ woman on anticoagulation with L breast IDC Grade 3
now s/p L breast lumpectomy and SLNB with left breast swelling
and pain concerning for a hematoma.
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:
No family hx of DVT or PE, two sisters have atrial fibrillation.
Physical Exam:
Physical Exam:
VS: ___ 0313 Temp: 98.2 PO BP: 98/62 HR: 79 RR: 18 O2 sat:
95% O2 delivery: RA
GEN: NAD, pleasant, conversant
HEENT: NCAT, EOMI, sclera anicteric
CV: RRR
PULM: no increased work of breathing, comfortable on RA
BREAST: L breast with dependent ecchymosis, mildly ttp inferior
breast, incision C/D/I. JP drain with serosanguineous output.
ABD: soft, non-tender, non-distended, no masses or hernia
EXT: Warm, well-perfused, no edema, no tenderness
NEURO: A&Ox3, no focal neurologic deficits
PSYCH: normal judgment/insight, normal memory, normal
mood/affect
Pertinent Results:
___ 07:33AM BLOOD WBC-4.8 RBC-2.86* Hgb-8.6* Hct-27.2*
MCV-95 MCH-30.1 MCHC-31.6* RDW-14.7 RDWSD-48.7* Plt ___
___ 07:33AM BLOOD ___ PTT-26.2 ___
___ 07:33AM BLOOD Glucose-130* UreaN-7 Creat-0.8 Na-141
K-4.2 Cl-101 HCO3-31 AnGap-9*
___ 07:33AM BLOOD Calcium-8.2* Phos-3.8 Mg-2.0
EXAMINATION: CTA CHEST WITH CONTRAST
COMPARISON: Chest CT dated ___.
FINDINGS:
HEART AND VASCULATURE: There is no central pulmonary embolism.
The thoracic
aorta is normal in caliber without evidence of dissection or
intramural
hematoma. The heart, pericardium, and great vessels are within
normal limits.
No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: There is a 8.8 x 5.8 x 9.8 cm
collection in the
left breast, with density measuring 39 Hounsfield units,
consistent with
hematoma. There are few foci of air within the collection,
likely from prior
aspiration, as well as few punctate hyperdensities at the
periphery. No
axillary, mediastinal, or hilar lymphadenopathy is present. The
right axilla
is not included on the study. No mediastinal mass.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Partially visualized lungs are clear without
masses or areas of
parenchymal opacification. The airways are patent to the level
of the
segmental bronchi bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show
no abnormality.
BONES: No suspicious osseous abnormality is seen.? There is no
acute fracture.
IMPRESSION:
8.8 x 5.8 x 9.8 cm left breast hematoma, with no evidence of
active bleed.
Please note, timing was suboptimal as the patient needed to be
re-scanned due
to incomplete field-of-view on initial images, however, the
density of the
collection was unchanged on all series.
Brief Hospital Course:
Ms. ___ is a ___ woman who was admitted to the
breast service following a left breast lumpectomy for invasive
carcinoma performed on ___. She presented with a recurrent
left breast hematoma after it was evacuated by needle aspiration
in clinic on ___. She was admitted for observation and
surgical evacuation of her hematoma.
On ___ she was brought to the operating room for evacuation
of the left ___ hematoma and placement of a surgical drain.
Hospital course as detailed below:
Neuro: pain was controlled with oral pain medication including
acetaminophen and tramadol.
___: Vital signs were monitored per protocol. She was continued
on her home medications.
Resp: she was continued on her home albuterol medications
FEN/GI: she was continued on a regular diet throughout her
admission. She was briefly made NPO for the operating room and
hydrated with IV fluids in the perioperative period.
GU: She voided without issue throughout her hospital course
Heme: H/H was closely monitored with daily labs and found to be
stable. Her home anticoagulation was held during her hospital
course. She was resumed on her home dose of warfarin on
discharge without a lovenox bridge. She remained on compression
boots during her hospital course to prevent DVTs.
ID: She was given ancef 2gm IV Q8hrs for prophylaxis, she
remained afebrile and did not develop a leukocytosis during her
hospital course.
Endo: Due to a history of metabolic syndrome and pre-diabetes
she was kept on a constant carbohydrate diet.
On the day of discharge she was tolerating a regular diet w/o
nausea or emesis. She was ambulating independently. Her pain was
controlled with oral pain medications. She was afebrile and did
not have a leukocytosis, all antibiotics were discontinued. She
was discharged home with ___ for drain management and close
follow up with Dr. ___ in clinic for drain removal. She
will also follow up with Dr. ___ in clinic in early ___
for routine follow up.
Medications on Admission:
Active Medication list as of ___:
Medications - Prescription
ALBUTEROL SULFATE - albuterol sulfate 2.5 mg/3 mL (0.083 %)
solution for nebulization. 3 ml inhalation four times a day as
needed for cough, wheeze
ALBUTEROL SULFATE [PROAIR HFA] - ProAir HFA 90 mcg/actuation
aerosol inhaler. 2 puffs inhalation q4-6 hours as needed for
cough/wheeze
ATORVASTATIN - atorvastatin 40 mg tablet. 1 (One) tablet(s) by
mouth at bedtime - (Prescribed by Other Provider; Dose
adjustment - no new Rx)
ENOXAPARIN - enoxaparin 100 mg/mL subcutaneous syringe. 100 mg
SC
twice daily approximately 12 hours apart (will start ___,
last dose ___ AM). - (Prescribed by Other Provider; Dose
adjustment - no new Rx)
ERYTHROMYCIN - erythromycin 5 mg/gram (0.5 %) eye ointment.
Apply
___ inch affected eye four times a day
FUROSEMIDE - furosemide 20 mg tablet. ___ tablet(s) by mouth
once a day as needed for leg swelling
HYDROMORPHONE - hydromorphone 2 mg tablet. ___ tablet(s) by
mouth every four (4) hours as needed for severe pain do not
drink
alcohol or drive while taking this medication
NEBULIZER AND COMPRESSOR [PORTABLE NEBULIZER SYSTEM] - Portable
Nebulizer System. Use with albuterol nebulizer soln four times a
day as needed for cough/wheeze
OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. TAKE 1
CAPSULE TWICE DAILY FOR GASTROESOPHAGEAL REFLUXDISEASE
SERTRALINE - sertraline 100 mg tablet. 1.5 tablet(s) by mouth
once a day
TRAMADOL - tramadol 50 mg tablet. one tablet(s) by mouth three
times a day
TRAZODONE - trazodone 50 mg tablet. 1 tablet(s) by mouth at
bedtime as needed for insomia
WARFARIN - warfarin 5 mg tablet. 1 (One) tablet(s) by mouth 2
times a ___, ___ tabs po 5 times a week (last dose per
___ clinic ___ - (Prescribed by Other Provider; Dose
adjustment - no new Rx)
Medications - OTC
ACETAMINOPHEN - acetaminophen 500 mg tablet. 2 tablet(s) by
mouth
3 times daily as needed for pain - ___ DC med rec)
CHOLECALCIFEROL (VITAMIN D3) - cholecalciferol (vitamin D3)
2,000
unit tablet. 1 tablet(s) by mouth once a day - (OTC)
POLYETHYLENE GLYCOL 3350 [MIRALAX] - Miralax 17 gram/dose oral
powder. 1 powder(s) by mouth once a day as needed for
constipation - (Prescribed by Other Provider; Dose adjustment -
no new Rx)
SENNOSIDES [SENNA] - senna 8.6 mg tablet. 1 tablet(s) by mouth
once a day as needed for constipation - (OTC)
Discharge Medications:
1. TraMADol 50 mg PO Q4H:PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *tramadol 50 mg 1 tablet(s) by mouth Q4hr prn Disp #*7 Tablet
Refills:*0
2. Atorvastatin 40 mg PO QPM
3. Docusate Sodium 100 mg PO BID
4. Omeprazole 20 mg PO BID
5. Senna 17.2 mg PO HS
6. Sertraline 150 mg PO DAILY
7. TraZODone 50 mg PO QHS:PRN sleep
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
breast hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Personal Care:
1. You may keep your incisions open to air or covered with a
clean, sterile gauze that you change daily.
2. Clean around the drain site(s), where the tubing exits the
skin, with soap and water.
3. Strip drain tubing, empty bulb(s), and record output(s) ___
times per day.
4. A written record of the daily output from each drain should
be brought to every follow-up appointment. Your drains will be
removed as soon as possible when the daily output tapers off to
an acceptable amount.
5. You may wear a surgical bra or soft, loose camisole for
comfort.
6. Do not shower while your drain is in place.
7. The Dermabond skin glue will begin to flake off in about ___
days.
Activity:
1. You may resume your regular diet.
2. Walk several times a day.
3. DO NOT lift anything heavier than 5 pounds or engage in
strenuous activity for 6 weeks following surgery.
Medications:
1. Resume your regular medications unless instructed otherwise
and take any new meds as ordered .
2. You may take your prescribed pain medication for moderate to
severe pain. You may switch to Tylenol or Extra Strength Tylenol
for mild pain as directed on the packaging. Please note that
Percocet and Vicodin have Tylenol as an active ingredient so do
not take these meds with additional Tylenol.
3. Take prescription pain medications for pain not relieved by
Tylenol.
4. Take Colace, 100 mg by mouth 2 times per day, while taking
the prescription pain medication. You may use a different
over-the-counter stool softener if you wish.
5. Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
Call the office IMMEDIATELY if you have any of the following:
1. Signs of infection: fever with chills, increased redness,
swelling, warmth or tenderness at the surgical site, or unusual
drainage from the incision(s).
2. A large amount of bleeding from the incision(s) or drain(s).
3. Fever greater than 101.5 oF
4. Severe pain NOT relieved by your medication.
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you.
ANTICOAGULATION:
You should begin taking your home warfarin dose this evening
(___) and resume taking warfarin at your regular scheduled
doses. You will not need a bridge therapy to begin warfarin.
DRAIN DISCHARGE INSTRUCTIONS
You are being discharged with drains in place. Drain care is a
clean procedure. Wash your hands thoroughly with soap and warm
water before performing drain care. Perform drainage care twice
a day. Try to empty the drain at the same time each day. Pull
the stopper out of the drainage bottle and empty the drainage
fluid into the measuring cup. Record the amount of drainage
fluid on the record sheet. Reestablish drain suction.
Please assist patient with drain care. A daily log of individual
drain outputs should be maintained and brought with patient to
follow up appointment with your surgeon.
Followup Instructions:
___
|
[
"L7632",
"C50912",
"D6861",
"K760",
"K219",
"G4733",
"E785",
"I671",
"J449",
"E119",
"Y838",
"F329",
"Z7901",
"Z86711",
"Z87891",
"Z803",
"Z8041",
"Z9012"
] |
Allergies: Codeine / Augmentin / Topamax [MASKED] Complaint: left breast swelling and pain Major Surgical or Invasive Procedure: Evacuation of hematoma History of Present Illness: [MASKED] woman on anticoagulation with L breast IDC Grade 3 now s/p L breast lumpectomy and SLNB with left breast swelling and pain concerning for a hematoma. Past Medical History: Dyslipidemia, varicose veins (R>L) s/p ligation, COPD, OSA (+CPap), recent URI (received course of Zithromax), bilateral PEs ([MASKED]), antiphospholipid antibody syndrome (on lifelong anticoagulation), T2DM (last A1C 6.2 on [MASKED], cerebral aneurysm (followed by Dr. [MASKED], unchanged), GERD, diverticulosis, h/o colon polyps, depression, s/p right CMC joint arthroplasty, b/l rotator cuff repair, excision right [MASKED] digit mass, CCY w/stone & pancreatic duct exploration ([MASKED]), hysterectomy, tonsillectomy Social History: [MASKED] Family History: No family hx of DVT or PE, two sisters have atrial fibrillation. Physical Exam: Physical Exam: VS: [MASKED] 0313 Temp: 98.2 PO BP: 98/62 HR: 79 RR: 18 O2 sat: 95% O2 delivery: RA GEN: NAD, pleasant, conversant HEENT: NCAT, EOMI, sclera anicteric CV: RRR PULM: no increased work of breathing, comfortable on RA BREAST: L breast with dependent ecchymosis, mildly ttp inferior breast, incision C/D/I. JP drain with serosanguineous output. ABD: soft, non-tender, non-distended, no masses or hernia EXT: Warm, well-perfused, no edema, no tenderness NEURO: A&Ox3, no focal neurologic deficits PSYCH: normal judgment/insight, normal memory, normal mood/affect Pertinent Results: [MASKED] 07:33AM BLOOD WBC-4.8 RBC-2.86* Hgb-8.6* Hct-27.2* MCV-95 MCH-30.1 MCHC-31.6* RDW-14.7 RDWSD-48.7* Plt [MASKED] [MASKED] 07:33AM BLOOD [MASKED] PTT-26.2 [MASKED] [MASKED] 07:33AM BLOOD Glucose-130* UreaN-7 Creat-0.8 Na-141 K-4.2 Cl-101 HCO3-31 AnGap-9* [MASKED] 07:33AM BLOOD Calcium-8.2* Phos-3.8 Mg-2.0 EXAMINATION: CTA CHEST WITH CONTRAST COMPARISON: Chest CT dated [MASKED]. FINDINGS: HEART AND VASCULATURE: There is no central pulmonary embolism. The thoracic aorta is normal in caliber without evidence of dissection or intramural hematoma. The heart, pericardium, and great vessels are within normal limits. No pericardial effusion is seen. AXILLA, HILA, AND MEDIASTINUM: There is a 8.8 x 5.8 x 9.8 cm collection in the left breast, with density measuring 39 Hounsfield units, consistent with hematoma. There are few foci of air within the collection, likely from prior aspiration, as well as few punctate hyperdensities at the periphery. No axillary, mediastinal, or hilar lymphadenopathy is present. The right axilla is not included on the study. No mediastinal mass. PLEURAL SPACES: No pleural effusion or pneumothorax. LUNGS/AIRWAYS: Partially visualized lungs are clear without masses or areas of parenchymal opacification. The airways are patent to the level of the segmental bronchi bilaterally. BASE OF NECK: Visualized portions of the base of the neck show no abnormality. BONES: No suspicious osseous abnormality is seen.? There is no acute fracture. IMPRESSION: 8.8 x 5.8 x 9.8 cm left breast hematoma, with no evidence of active bleed. Please note, timing was suboptimal as the patient needed to be re-scanned due to incomplete field-of-view on initial images, however, the density of the collection was unchanged on all series. Brief Hospital Course: Ms. [MASKED] is a [MASKED] woman who was admitted to the breast service following a left breast lumpectomy for invasive carcinoma performed on [MASKED]. She presented with a recurrent left breast hematoma after it was evacuated by needle aspiration in clinic on [MASKED]. She was admitted for observation and surgical evacuation of her hematoma. On [MASKED] she was brought to the operating room for evacuation of the left [MASKED] hematoma and placement of a surgical drain. Hospital course as detailed below: Neuro: pain was controlled with oral pain medication including acetaminophen and tramadol. [MASKED]: Vital signs were monitored per protocol. She was continued on her home medications. Resp: she was continued on her home albuterol medications FEN/GI: she was continued on a regular diet throughout her admission. She was briefly made NPO for the operating room and hydrated with IV fluids in the perioperative period. GU: She voided without issue throughout her hospital course Heme: H/H was closely monitored with daily labs and found to be stable. Her home anticoagulation was held during her hospital course. She was resumed on her home dose of warfarin on discharge without a lovenox bridge. She remained on compression boots during her hospital course to prevent DVTs. ID: She was given ancef 2gm IV Q8hrs for prophylaxis, she remained afebrile and did not develop a leukocytosis during her hospital course. Endo: Due to a history of metabolic syndrome and pre-diabetes she was kept on a constant carbohydrate diet. On the day of discharge she was tolerating a regular diet w/o nausea or emesis. She was ambulating independently. Her pain was controlled with oral pain medications. She was afebrile and did not have a leukocytosis, all antibiotics were discontinued. She was discharged home with [MASKED] for drain management and close follow up with Dr. [MASKED] in clinic for drain removal. She will also follow up with Dr. [MASKED] in clinic in early [MASKED] for routine follow up. Medications on Admission: Active Medication list as of [MASKED]: Medications - Prescription ALBUTEROL SULFATE - albuterol sulfate 2.5 mg/3 mL (0.083 %) solution for nebulization. 3 ml inhalation four times a day as needed for cough, wheeze ALBUTEROL SULFATE [PROAIR HFA] - ProAir HFA 90 mcg/actuation aerosol inhaler. 2 puffs inhalation q4-6 hours as needed for cough/wheeze ATORVASTATIN - atorvastatin 40 mg tablet. 1 (One) tablet(s) by mouth at bedtime - (Prescribed by Other Provider; Dose adjustment - no new Rx) ENOXAPARIN - enoxaparin 100 mg/mL subcutaneous syringe. 100 mg SC twice daily approximately 12 hours apart (will start [MASKED], last dose [MASKED] AM). - (Prescribed by Other Provider; Dose adjustment - no new Rx) ERYTHROMYCIN - erythromycin 5 mg/gram (0.5 %) eye ointment. Apply [MASKED] inch affected eye four times a day FUROSEMIDE - furosemide 20 mg tablet. [MASKED] tablet(s) by mouth once a day as needed for leg swelling HYDROMORPHONE - hydromorphone 2 mg tablet. [MASKED] tablet(s) by mouth every four (4) hours as needed for severe pain do not drink alcohol or drive while taking this medication NEBULIZER AND COMPRESSOR [PORTABLE NEBULIZER SYSTEM] - Portable Nebulizer System. Use with albuterol nebulizer soln four times a day as needed for cough/wheeze OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. TAKE 1 CAPSULE TWICE DAILY FOR GASTROESOPHAGEAL REFLUXDISEASE SERTRALINE - sertraline 100 mg tablet. 1.5 tablet(s) by mouth once a day TRAMADOL - tramadol 50 mg tablet. one tablet(s) by mouth three times a day TRAZODONE - trazodone 50 mg tablet. 1 tablet(s) by mouth at bedtime as needed for insomia WARFARIN - warfarin 5 mg tablet. 1 (One) tablet(s) by mouth 2 times a [MASKED], [MASKED] tabs po 5 times a week (last dose per [MASKED] clinic [MASKED] - (Prescribed by Other Provider; Dose adjustment - no new Rx) Medications - OTC ACETAMINOPHEN - acetaminophen 500 mg tablet. 2 tablet(s) by mouth 3 times daily as needed for pain - [MASKED] DC med rec) CHOLECALCIFEROL (VITAMIN D3) - cholecalciferol (vitamin D3) 2,000 unit tablet. 1 tablet(s) by mouth once a day - (OTC) POLYETHYLENE GLYCOL 3350 [MIRALAX] - Miralax 17 gram/dose oral powder. 1 powder(s) by mouth once a day as needed for constipation - (Prescribed by Other Provider; Dose adjustment - no new Rx) SENNOSIDES [SENNA] - senna 8.6 mg tablet. 1 tablet(s) by mouth once a day as needed for constipation - (OTC) Discharge Medications: 1. TraMADol 50 mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity RX *tramadol 50 mg 1 tablet(s) by mouth Q4hr prn Disp #*7 Tablet Refills:*0 2. Atorvastatin 40 mg PO QPM 3. Docusate Sodium 100 mg PO BID 4. Omeprazole 20 mg PO BID 5. Senna 17.2 mg PO HS 6. Sertraline 150 mg PO DAILY 7. TraZODone 50 mg PO QHS:PRN sleep Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: breast hematoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Personal Care: 1. You may keep your incisions open to air or covered with a clean, sterile gauze that you change daily. 2. Clean around the drain site(s), where the tubing exits the skin, with soap and water. 3. Strip drain tubing, empty bulb(s), and record output(s) [MASKED] times per day. 4. A written record of the daily output from each drain should be brought to every follow-up appointment. Your drains will be removed as soon as possible when the daily output tapers off to an acceptable amount. 5. You may wear a surgical bra or soft, loose camisole for comfort. 6. Do not shower while your drain is in place. 7. The Dermabond skin glue will begin to flake off in about [MASKED] days. Activity: 1. You may resume your regular diet. 2. Walk several times a day. 3. DO NOT lift anything heavier than 5 pounds or engage in strenuous activity for 6 weeks following surgery. Medications: 1. Resume your regular medications unless instructed otherwise and take any new meds as ordered . 2. You may take your prescribed pain medication for moderate to severe pain. You may switch to Tylenol or Extra Strength Tylenol for mild pain as directed on the packaging. Please note that Percocet and Vicodin have Tylenol as an active ingredient so do not take these meds with additional Tylenol. 3. Take prescription pain medications for pain not relieved by Tylenol. 4. Take Colace, 100 mg by mouth 2 times per day, while taking the prescription pain medication. You may use a different over-the-counter stool softener if you wish. 5. Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. Call the office IMMEDIATELY if you have any of the following: 1. Signs of infection: fever with chills, increased redness, swelling, warmth or tenderness at the surgical site, or unusual drainage from the incision(s). 2. A large amount of bleeding from the incision(s) or drain(s). 3. Fever greater than 101.5 oF 4. Severe pain NOT relieved by your medication. Return to the ER if: * If you are vomiting and cannot keep in fluids or your medications. * If you have shaking chills, fever greater than 101.5 (F) degrees or 38 (C) degrees, increased redness, swelling or discharge from incision, chest pain, shortness of breath, or anything else that is troubling you. * Any serious change in your symptoms, or any new symptoms that concern you. ANTICOAGULATION: You should begin taking your home warfarin dose this evening ([MASKED]) and resume taking warfarin at your regular scheduled doses. You will not need a bridge therapy to begin warfarin. DRAIN DISCHARGE INSTRUCTIONS You are being discharged with drains in place. Drain care is a clean procedure. Wash your hands thoroughly with soap and warm water before performing drain care. Perform drainage care twice a day. Try to empty the drain at the same time each day. Pull the stopper out of the drainage bottle and empty the drainage fluid into the measuring cup. Record the amount of drainage fluid on the record sheet. Reestablish drain suction. Please assist patient with drain care. A daily log of individual drain outputs should be maintained and brought with patient to follow up appointment with your surgeon. Followup Instructions: [MASKED]
|
[] |
[
"K219",
"G4733",
"E785",
"J449",
"E119",
"F329",
"Z7901",
"Z87891"
] |
[
"L7632: Postprocedural hematoma of skin and subcutaneous tissue following other procedure",
"C50912: Malignant neoplasm of unspecified site of left female breast",
"D6861: Antiphospholipid syndrome",
"K760: Fatty (change of) liver, not elsewhere classified",
"K219: Gastro-esophageal reflux disease without esophagitis",
"G4733: Obstructive sleep apnea (adult) (pediatric)",
"E785: Hyperlipidemia, unspecified",
"I671: Cerebral aneurysm, nonruptured",
"J449: Chronic obstructive pulmonary disease, unspecified",
"E119: Type 2 diabetes mellitus without complications",
"Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure",
"F329: Major depressive disorder, single episode, unspecified",
"Z7901: Long term (current) use of anticoagulants",
"Z86711: Personal history of pulmonary embolism",
"Z87891: Personal history of nicotine dependence",
"Z803: Family history of malignant neoplasm of breast",
"Z8041: Family history of malignant neoplasm of ovary",
"Z9012: Acquired absence of left breast and nipple"
] |
10,002,221 | 29,399,017 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Codeine / Augmentin / Topamax
Attending: ___.
Chief Complaint:
Low back pain with radiation down the right leg
Major Surgical or Invasive Procedure:
DECOMPRESSION L2-S1, FUSION L4-L5, DURAPLASTY on ___
History of Present Illness:
Ms. ___ is a ___ female with a past medical
history significant for cerebral aneurysm, abdominal aortic
aneurysm, antiphospholipid syndrome w/ multiple DVTs and one
event of bilateral large PEs on warfarin, BRCA1 mutation w/
L-sided breast cancer s/p lumpectomy, who presents with over one
month of right lower back pain with radicular pain down the
right leg pain. She had recent admission ___ for acute
worsening of RLE pain and swelling in background of about 4
months right leg pain. RLE US did not show evidence of DVT. Exam
was most consistent with right trochanteric bursitis and pt
received a steroid injection. Her right tibia pain was felt to
be ___ to her varicose veins. On this admission Imaging notable
for: Normal CT A/P with no e/o nephrolithiasis, MR ___ spine with
disc bulge at L2-L3 and L3-4 cause severe narrowing of the
spinal canal with crowding of the traversing cauda equina.
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 40 ABNORMAL PAP SMEAR ___
SUBSTANCE ABUSE
Son Died ___ SUBSTANCE ABUSE ___ - heroin overdose on ___.
Physical Exam:
Physical Exam On Admission:
VITALS: ___ 1104 Temp: 97.9 PO BP: 129/79 R Lying HR: 82
RR: 16 O2 sat: 96% O2 delivery: Ra
General: Tearful, expressing right back and leg pain with spasms
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: Grossly oriented
MSK exam: Right SI Joint tenderness. Radicular pain worsened
with
back flexion and relieved with extension. ___ strength
bilaterally w/ hip flexion and extension, knee flexion and
extension, foot plantar and dorsiflexion, sensation in tact
bilaterally
___ Ortho Spine Exam
PE:
VS
___ ___ Temp: 98.7 PO BP: 135/66 R Lying HR: 99 RR: 18 O2
sat: 94% O2 delivery: Ra
___ ___ Temp: 98.7 PO BP: 135/66 R Lying HR: 99 RR: 18 O2
sat: 94% O2 delivery: Ra
NAD, A&Ox4
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
Pertinent Results:
IMAGING:
MR THORACIC SPINE W/O CONTRAST; MR ___ SPINE W/O CONTRAST ___
IMPRESSION:
1. Severe central canal narrowing at L4-5 level from
degenerative changes.
2. Large right paramedian, superior disc extrusion L4-5 level,
extends into
right L4 lateral recess, mass effect on exiting right L4,
traversing L5
nerves, severe right L4-5 foraminal narrowing..
3. Advanced degenerative changes lumbar spine.
4. Moderate central canal narrowing L2-L3, moderate to severe at
L3-L4 levels.
5. Multilevel significant foraminal narrowing lumbar spine, as
above.
6. Degenerative changes thoracic spine, mild-to-moderate central
canal
narrowing, foraminal narrowing.
CT ABD & PELVIS WITH CONTRAST ___
IMPRESSION:
1. No acute CT findings in the abdomen or pelvis to correlate
with patient's
reported symptoms. Specifically, no evidence of obstructive
renal stone or
pyelonephritis.
2. Sigmoid diverticulosis without evidence of acute
diverticulitis.
Admission Labs:
___ 12:49PM BLOOD WBC-6.3 RBC-3.97 Hgb-11.9 Hct-37.2 MCV-94
MCH-30.0 MCHC-32.0 RDW-14.3 RDWSD-49.1* Plt ___
___ 12:49PM BLOOD ___ PTT-34.3 ___
___ 12:49PM BLOOD Glucose-117* UreaN-11 Creat-0.8 Na-143
K-4.3 Cl-106 HCO3-26 AnGap-11
___ 10:06AM BLOOD WBC-5.8 RBC-2.81* Hgb-8.5* Hct-26.1*
MCV-93 MCH-30.2 MCHC-32.6 RDW-14.0 RDWSD-47.6* Plt ___
___ 05:53AM BLOOD WBC-6.6 RBC-2.88* Hgb-8.9* Hct-27.6*
MCV-96 MCH-30.9 MCHC-32.2 RDW-14.4 RDWSD-50.4* Plt ___
___ 04:30AM BLOOD WBC-6.9 RBC-3.40* Hgb-10.2* Hct-32.6*
MCV-96 MCH-30.0 MCHC-31.3* RDW-14.4 RDWSD-50.3* Plt ___
___ 10:06AM BLOOD Plt ___
___ 04:30AM BLOOD Glucose-107* UreaN-10 Creat-0.7 Na-142
K-4.8 Cl-105 HCO3-25 AnGap-12
___ 04:30AM BLOOD Glucose-147* UreaN-12 Creat-0.9 Na-142
K-4.8 Cl-99 HCO3-28 AnGap-15
___ 08:49AM BLOOD Glucose-128* UreaN-10 Creat-0.9 Na-141
K-4.3 Cl-102 HCO3-28 AnGap-11
___ 04:30AM BLOOD Calcium-8.2* Phos-2.9 Mg-2.0
___ 08:49AM BLOOD Calcium-9.5 Phos-4.3 Mg-2.1
___ 04:30AM BLOOD Calcium-8.8 Phos-4.6* Mg-2.1
Brief Hospital Course:
Initial Admission:
ACTIVE ISSUES:
==================
# R Low Back pain and Leg Pain
# Radiculopathy
Patient presents with severe right lower back pain with
prominent
lancinating component. CT A/P with no evidence of visceral
pathology or nephrolithiasis. MRI L spine with significant disc
bulge at L2-L3 and L3-4 cause severe narrowing of the spinal
canal and extrusion at L4-5 with significant L4 nerve root
compression, likely the cause of patient's pain. She was
recently
admitted with right leg pain, with exam notable for trochanteric
bursitis, now s/p injection of corticosteroid. Currently
neruovascularly intact, with no evidence of cord compression by
history or on exam. Per ortho spine, would benefit from
decompression. She had a DECOMPRESSION L2-S1, FUSION L4-L5,
DURAPLASTY on ___ w/ ortho-spine once her INR was 1.2. She
was started on a heparin bridge on ___ when her INR dropped
below 2.0 and transitioned to lovenox bridge to coumadin on
___
# Dysuria (resolved)
# UTI
States she has been having burning pain with urination recently.
She also feels that she needs to push on her abdomen to urinate.
Most concerning for UTI. UA demonstrating large leukocytes and 8
WBC. However, urine culture showing mixed bacterial flora
consistent with contamination. Will treat given symptoms.
Abdominal pain could also be from constipation in the setting of
opioid use. Reports resolution of symptoms on ___. Was treated
with bactrim DS BID for 3 days starting ___ and ending ___.
CHRONIC ISSUES:
===================
# History of DVT/PE
# Antiphospholipid antibody syndrome:
Lupus anticoagulant positive in ___. Had bilateral PE in ___.
She has been taking her home dose of warfarin (7.5 mg ___ and
5
mg other days). Warfarin held on admission for procedure with
heparin drip until procedure.
# AAA
Has a reported history of AAA in chart, but does not follow up
with anyone for surveillance and CT abd/pelvis did not show an
abdominal aortic aneurysm.
# Vitamin D deficiency:
- Continued Vitamin D ___ daily
# OSA
- Remained on CPAP
#Other Home Meds:
- Continued omeprazole 20mg BID for GERD
- Continued sertraline 150mg PO daily for depression
- Continued Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN cough,
wheeze
- Held ProAir
- Held trazadone while getting opioids
- Held furosemide 20mg PO daily PRN: takes rarely
- d/c gabapentin: not helping and not taking
- d/c erythromycin- no longer taking
Admission to Ortho spine:
Ms. ___ is a ___ female with a past medical
history significant for OSA, cerebral aneurysm, abdominal aortic
aneurysm, antiphospholipid syndrome w/ multiple DVTs and one
event of bilateral large PEs on warfarin, BRCA1 mutation w/
L-sided breast cancer s/p lumpectomy, who presents with over one
month of right lower back pain with radicular pain down the
right leg pain found to have significant disc herniations at
L2-L5. She is now s/p L2-5 lami, L4-5 discectomy, and
non-instrumented fusion c/b durotomy s/p ___, ___
Post op course:
Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for the above procedure.Refer to the
dictated operative note for further details.The surgery was
without complication and the patient was transferred to the PACU
in a stable condition.
Postoperative DVT ___ drip post
op with trasition back to lovenox bridge to coumadin on ___.
Activity remained flat/bedrest for dural tear precautions for 48
hours.
Activity was advanced after 48 hours. Intravenous antibiotics
were continued for 24hrs postop per standard protocol.
Initial postop pain was controlled with oral and IV pain
medication.Diet was advanced as tolerated.Foley was removed on
POD#3. Physical therapy and Occupational therapy were consulted
for mobilization OOB to ambulate and ADL's.
Post op course was notable for acute blood loss anemia,
constipation, pain and hypokalemia. Acute blood loss anemia is
stable and did not require intervention. She was treated with
Immediate release morphine, Valium and Tylenol for pain control.
Oral Potassium was given for hypokalemia of 3.3 on ___. Vitals
and labs are otherwise stable.
Hospital course was otherwise unremarkable.On the day of
discharge the patient was afebrile with stable vital signs,
comfortable on oral pain control and tolerating a regular diet.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN cough, wheeze
3. Atorvastatin 40 mg PO QPM
4. Docusate Sodium 100 mg PO BID
5. Omeprazole 20 mg PO BID
6. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
7. Senna 8.6 mg PO HS
8. Sertraline 150 mg PO DAILY
9. TraZODone 50 mg PO QHS:PRN sleep
10. Vitamin D ___ UNIT PO DAILY
11. Warfarin 7.5 mg PO 2X/WEEK (___)
12. Lidocaine 5% Patch 1 PTCH TD QAM right hip
13. Furosemide 20 mg PO DAILY:PRN Leg swelling
14. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN
15. Warfarin 5 mg PO 5X/WEEK (___)
16. Gabapentin 600 mg PO TID
17. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
Discharge Medications:
1. Diazepam 5 mg PO Q8H:PRN pain/spasm
may cause drowsiness
RX *diazepam 5 mg 1 tablet by mouth every eight (8) hours Disp
#*25 Tablet Refills:*0
2. Enoxaparin Sodium 110 mg SC Q12H Antiphospholipid Syndrome
Treatment Bridge Dosing
3. Morphine Sulfate ___ 15 mg PO Q6H:PRN Pain - Severe
please do not operate heavy machinery, drink alcohol or drive
RX *morphine 15 mg 1 tablet(s) by mouth every six (6) hours Disp
#*30 Tablet Refills:*0
4. Furosemide 10 mg PO DAILY:PRN Leg swelling
5. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
6. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN cough, wheeze
7. Atorvastatin 40 mg PO QPM
8. Docusate Sodium 100 mg PO BID
9. Lidocaine 5% Patch 1 PTCH TD QAM right hip
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 5X/WEEK (___)
18. Warfarin 7.5 mg PO 2X/WEEK (___)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
-Lumbar spinal stenosis.
-Spondylolisthesis, L4-L5.
-UTI
-Constipation
Secondary Diagnoses:
- History of DVT/PE
- Antiphospholipid antibody syndrome
- AAA
- OSA on CPAP
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure to care for you at the ___
___.
Why did you come to the hospital?
- You came to the hospital because you were having worsening
back pain with pain radiating down your right leg. This pain
started about a month ago and progressively got worse, making it
difficult to walk. You also had burning pain with urination.
What did you receive in the hospital?
- You had an MRI that showed significant disc herniation in your
lower back, which was the cause of your pain. The spine surgeons
felt that you would benefit from surgery given that your pain
was constant and worsening over the past month. We gave you pain
medications and stopped your warfarin until it was safe for you
to have surgery. You had a spinal decompression on ___. We
also gave you antibiotics for your burning pain with urination,
which we believe was caused by a urinary tract infection.
What should you do once you leave the hospital?
Lumbar Decompression With Fusion:
You have undergone the following operation: Lumbar Decompression
With 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 ___ times a
day you should go for a walk for ___ minutes as part of your
recovery.You can walk as much as you can tolerate.Limit any kind
of lifting.
Diet: Eat a normal healthy diet.You may have
some constipation after surgery.You have been given medication
to help with this issue.
Brace:You may have been given a brace.If you
have been given a brace,this brace is to be worn when you are
walking.You may take it off when sitting in a chair or while
lying in bed.
Wound Care:Please keep the incision covered
with a dry dressing on until your follow up appointment. 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.
You should resume taking your normal home
medications.
You have also been given Additional Medications
to control your pain.Please allow 72 hours for refill of
narcotic prescriptions,so please plan ahead.You can either have
them mailed to your home or pick them up at the clinic located
on ___.We are not allowed to call in or fax narcotic
prescriptions(oxycontin,oxycodone,percocet) to your pharmacy.In
addition,we are only allowed to write for pain medications for
90 days from the date of surgery.
Follow up:
Please Call the office and make an appointment
for 2 weeks after the day of your operation if this has not been
done already.
At the 2-week visit we will check your
incision,take baseline X-rays and answer any questions.We may at
that time start physical therapy
We will then see you at 6 weeks from the day of
the operation and at that time release you to full activity.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
1)Weight bearing as tolerated.2)Gait,balance training.3)No
lifting >10 lbs.4)No significant bending/twisting.
Treatments Frequency:
Please keep the incision covered with a dry dressing on until
your follow up appointment. 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.
Followup Instructions:
___
|
[
"M5116",
"D6861",
"N390",
"D62",
"I83811",
"D509",
"Z87891",
"Z86711",
"Z7901",
"E559",
"C50912",
"E785",
"G4733",
"E119",
"K219",
"K5790",
"F329",
"J449",
"I671",
"M48061",
"K5900",
"E876"
] |
Allergies: Codeine / Augmentin / Topamax Chief Complaint: Low back pain with radiation down the right leg Major Surgical or Invasive Procedure: DECOMPRESSION L2-S1, FUSION L4-L5, DURAPLASTY on [MASKED] History of Present Illness: Ms. [MASKED] is a [MASKED] female with a past medical history significant for cerebral aneurysm, abdominal aortic aneurysm, antiphospholipid syndrome w/ multiple DVTs and one event of bilateral large PEs on warfarin, BRCA1 mutation w/ L-sided breast cancer s/p lumpectomy, who presents with over one month of right lower back pain with radicular pain down the right leg pain. She had recent admission [MASKED] for acute worsening of RLE pain and swelling in background of about 4 months right leg pain. RLE US did not show evidence of DVT. Exam was most consistent with right trochanteric bursitis and pt received a steroid injection. Her right tibia pain was felt to be [MASKED] to her varicose veins. On this admission Imaging notable for: Normal CT A/P with no e/o nephrolithiasis, MR [MASKED] spine with disc bulge at L2-L3 and L3-4 cause severe narrowing of the spinal canal with crowding of the traversing cauda equina. Past Medical History: Dyslipidemia, Varicose veins (R>L) s/p ligation, COPD, OSA (+CPap), recent URI (received course of Zithromax), bilateral PEs ([MASKED]), antiphospholipid antibody syndrome (on lifelong anticoagulation), T2DM (last A1C 6.2 on [MASKED], cerebral aneurysm (followed by Dr. [MASKED], unchanged), GERD, diverticulosis, h/o colon polyps, depression, s/p right CMC joint arthroplasty, b/l rotator cuff repair, excision right [MASKED] digit mass, CCY w/stone & pancreatic duct exploration ([MASKED]), hysterectomy, tonsillectomy Social History: [MASKED] Family History: Mother [MASKED] [MASKED] OVARIAN CANCER dx age [MASKED] Father [MASKED] [MASKED] BRAIN CANCER PGM OVARIAN CANCER Aunt OVARIAN CANCER paternal aunt in [MASKED] MGM ENDOMETRIAL CANCER MGF PROSTATE CANCER Brother [MASKED] [MASKED] KIDNEY CANCER RENAL FAILURE CONGESTIVE HEART FAILURE DIABETES MELLITUS TOBACCO ABUSE ALCOHOL ABUSE Sister [MASKED] [MASKED] OVARIAN CANCER dx age [MASKED] Brother [MASKED] THROAT CANCER dx age [MASKED], died in [MASKED] Sister BRCA1 MUTATION, BREAST CANCER Daughter Living 40 ABNORMAL PAP SMEAR [MASKED] SUBSTANCE ABUSE Son Died [MASKED] SUBSTANCE ABUSE [MASKED] - heroin overdose on [MASKED]. Physical Exam: Physical Exam On Admission: VITALS: [MASKED] 1104 Temp: 97.9 PO BP: 129/79 R Lying HR: 82 RR: 16 O2 sat: 96% O2 delivery: Ra General: Tearful, expressing right back and leg pain with spasms 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+ [MASKED] pulses bilaterally. Skin: Warm, dry, varicose veins noted in lower extremities. Neuro: Grossly oriented MSK exam: Right SI Joint tenderness. Radicular pain worsened with back flexion and relieved with extension. [MASKED] strength bilaterally w/ hip flexion and extension, knee flexion and extension, foot plantar and dorsiflexion, sensation in tact bilaterally [MASKED] Ortho Spine Exam PE: VS [MASKED] [MASKED] Temp: 98.7 PO BP: 135/66 R Lying HR: 99 RR: 18 O2 sat: 94% O2 delivery: Ra [MASKED] [MASKED] Temp: 98.7 PO BP: 135/66 R Lying HR: 99 RR: 18 O2 sat: 94% O2 delivery: Ra NAD, A&Ox4 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 [MASKED] L2 L3 L4 L5 S1 S2 (Groin) (Knee) (Med Calf) (Grt Toe) (Sm Toe) (Post Thigh) R SILT SILT SILT SILT SILT SILT L SILT SILT SILT SILT SILT SILT Motor: 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 [MASKED] Flex(L1) Add(L2) Quad(L3) TA(L4) [MASKED] [MASKED] R 5 5 5 5 5 5 5 L 5 5 5 5 5 5 5 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 [MASKED]: Negative Babinski: Downgoing Clonus: No beats Pertinent Results: IMAGING: MR THORACIC SPINE W/O CONTRAST; MR [MASKED] SPINE W/O CONTRAST [MASKED] IMPRESSION: 1. Severe central canal narrowing at L4-5 level from degenerative changes. 2. Large right paramedian, superior disc extrusion L4-5 level, extends into right L4 lateral recess, mass effect on exiting right L4, traversing L5 nerves, severe right L4-5 foraminal narrowing.. 3. Advanced degenerative changes lumbar spine. 4. Moderate central canal narrowing L2-L3, moderate to severe at L3-L4 levels. 5. Multilevel significant foraminal narrowing lumbar spine, as above. 6. Degenerative changes thoracic spine, mild-to-moderate central canal narrowing, foraminal narrowing. CT ABD & PELVIS WITH CONTRAST [MASKED] IMPRESSION: 1. No acute CT findings in the abdomen or pelvis to correlate with patient's reported symptoms. Specifically, no evidence of obstructive renal stone or pyelonephritis. 2. Sigmoid diverticulosis without evidence of acute diverticulitis. Admission Labs: [MASKED] 12:49PM BLOOD WBC-6.3 RBC-3.97 Hgb-11.9 Hct-37.2 MCV-94 MCH-30.0 MCHC-32.0 RDW-14.3 RDWSD-49.1* Plt [MASKED] [MASKED] 12:49PM BLOOD [MASKED] PTT-34.3 [MASKED] [MASKED] 12:49PM BLOOD Glucose-117* UreaN-11 Creat-0.8 Na-143 K-4.3 Cl-106 HCO3-26 AnGap-11 [MASKED] 10:06AM BLOOD WBC-5.8 RBC-2.81* Hgb-8.5* Hct-26.1* MCV-93 MCH-30.2 MCHC-32.6 RDW-14.0 RDWSD-47.6* Plt [MASKED] [MASKED] 05:53AM BLOOD WBC-6.6 RBC-2.88* Hgb-8.9* Hct-27.6* MCV-96 MCH-30.9 MCHC-32.2 RDW-14.4 RDWSD-50.4* Plt [MASKED] [MASKED] 04:30AM BLOOD WBC-6.9 RBC-3.40* Hgb-10.2* Hct-32.6* MCV-96 MCH-30.0 MCHC-31.3* RDW-14.4 RDWSD-50.3* Plt [MASKED] [MASKED] 10:06AM BLOOD Plt [MASKED] [MASKED] 04:30AM BLOOD Glucose-107* UreaN-10 Creat-0.7 Na-142 K-4.8 Cl-105 HCO3-25 AnGap-12 [MASKED] 04:30AM BLOOD Glucose-147* UreaN-12 Creat-0.9 Na-142 K-4.8 Cl-99 HCO3-28 AnGap-15 [MASKED] 08:49AM BLOOD Glucose-128* UreaN-10 Creat-0.9 Na-141 K-4.3 Cl-102 HCO3-28 AnGap-11 [MASKED] 04:30AM BLOOD Calcium-8.2* Phos-2.9 Mg-2.0 [MASKED] 08:49AM BLOOD Calcium-9.5 Phos-4.3 Mg-2.1 [MASKED] 04:30AM BLOOD Calcium-8.8 Phos-4.6* Mg-2.1 Brief Hospital Course: Initial Admission: ACTIVE ISSUES: ================== # R Low Back pain and Leg Pain # Radiculopathy Patient presents with severe right lower back pain with prominent lancinating component. CT A/P with no evidence of visceral pathology or nephrolithiasis. MRI L spine with significant disc bulge at L2-L3 and L3-4 cause severe narrowing of the spinal canal and extrusion at L4-5 with significant L4 nerve root compression, likely the cause of patient's pain. She was recently admitted with right leg pain, with exam notable for trochanteric bursitis, now s/p injection of corticosteroid. Currently neruovascularly intact, with no evidence of cord compression by history or on exam. Per ortho spine, would benefit from decompression. She had a DECOMPRESSION L2-S1, FUSION L4-L5, DURAPLASTY on [MASKED] w/ ortho-spine once her INR was 1.2. She was started on a heparin bridge on [MASKED] when her INR dropped below 2.0 and transitioned to lovenox bridge to coumadin on [MASKED] # Dysuria (resolved) # UTI States she has been having burning pain with urination recently. She also feels that she needs to push on her abdomen to urinate. Most concerning for UTI. UA demonstrating large leukocytes and 8 WBC. However, urine culture showing mixed bacterial flora consistent with contamination. Will treat given symptoms. Abdominal pain could also be from constipation in the setting of opioid use. Reports resolution of symptoms on [MASKED]. Was treated with bactrim DS BID for 3 days starting [MASKED] and ending [MASKED]. CHRONIC ISSUES: =================== # History of DVT/PE # Antiphospholipid antibody syndrome: Lupus anticoagulant positive in [MASKED]. Had bilateral PE in [MASKED]. She has been taking her home dose of warfarin (7.5 mg [MASKED] and 5 mg other days). Warfarin held on admission for procedure with heparin drip until procedure. # AAA Has a reported history of AAA in chart, but does not follow up with anyone for surveillance and CT abd/pelvis did not show an abdominal aortic aneurysm. # Vitamin D deficiency: - Continued Vitamin D [MASKED] daily # OSA - Remained on CPAP #Other Home Meds: - Continued omeprazole 20mg BID for GERD - Continued sertraline 150mg PO daily for depression - Continued Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN cough, wheeze - Held ProAir - Held trazadone while getting opioids - Held furosemide 20mg PO daily PRN: takes rarely - d/c gabapentin: not helping and not taking - d/c erythromycin- no longer taking Admission to Ortho spine: Ms. [MASKED] is a [MASKED] female with a past medical history significant for OSA, cerebral aneurysm, abdominal aortic aneurysm, antiphospholipid syndrome w/ multiple DVTs and one event of bilateral large PEs on warfarin, BRCA1 mutation w/ L-sided breast cancer s/p lumpectomy, who presents with over one month of right lower back pain with radicular pain down the right leg pain found to have significant disc herniations at L2-L5. She is now s/p L2-5 lami, L4-5 discectomy, and non-instrumented fusion c/b durotomy s/p [MASKED], [MASKED] Post op course: Patient was admitted to the [MASKED] Spine Surgery Service and taken to the Operating Room for the above procedure.Refer to the dictated operative note for further details.The surgery was without complication and the patient was transferred to the PACU in a stable condition. Postoperative DVT [MASKED] drip post op with trasition back to lovenox bridge to coumadin on [MASKED]. Activity remained flat/bedrest for dural tear precautions for 48 hours. Activity was advanced after 48 hours. Intravenous antibiotics were continued for 24hrs postop per standard protocol. Initial postop pain was controlled with oral and IV pain medication.Diet was advanced as tolerated.Foley was removed on POD#3. Physical therapy and Occupational therapy were consulted for mobilization OOB to ambulate and ADL's. Post op course was notable for acute blood loss anemia, constipation, pain and hypokalemia. Acute blood loss anemia is stable and did not require intervention. She was treated with Immediate release morphine, Valium and Tylenol for pain control. Oral Potassium was given for hypokalemia of 3.3 on [MASKED]. Vitals and labs are otherwise stable. Hospital course was otherwise unremarkable.On the day of discharge the patient was afebrile with stable vital signs, comfortable on oral pain control and tolerating a regular diet. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever 2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN cough, wheeze 3. Atorvastatin 40 mg PO QPM 4. Docusate Sodium 100 mg PO BID 5. Omeprazole 20 mg PO BID 6. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First Line 7. Senna 8.6 mg PO HS 8. Sertraline 150 mg PO DAILY 9. TraZODone 50 mg PO QHS:PRN sleep 10. Vitamin D [MASKED] UNIT PO DAILY 11. Warfarin 7.5 mg PO 2X/WEEK ([MASKED]) 12. Lidocaine 5% Patch 1 PTCH TD QAM right hip 13. Furosemide 20 mg PO DAILY:PRN Leg swelling 14. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q4H:PRN 15. Warfarin 5 mg PO 5X/WEEK ([MASKED]) 16. Gabapentin 600 mg PO TID 17. TraMADol 50 mg PO Q6H:PRN Pain - Moderate Discharge Medications: 1. Diazepam 5 mg PO Q8H:PRN pain/spasm may cause drowsiness RX *diazepam 5 mg 1 tablet by mouth every eight (8) hours Disp #*25 Tablet Refills:*0 2. Enoxaparin Sodium 110 mg SC Q12H Antiphospholipid Syndrome Treatment Bridge Dosing 3. Morphine Sulfate [MASKED] 15 mg PO Q6H:PRN Pain - Severe please do not operate heavy machinery, drink alcohol or drive RX *morphine 15 mg 1 tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills:*0 4. Furosemide 10 mg PO DAILY:PRN Leg swelling 5. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever 6. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN cough, wheeze 7. Atorvastatin 40 mg PO QPM 8. Docusate Sodium 100 mg PO BID 9. Lidocaine 5% Patch 1 PTCH TD QAM right hip 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 [MASKED] UNIT PO DAILY 17. Warfarin 5 mg PO 5X/WEEK ([MASKED]) 18. Warfarin 7.5 mg PO 2X/WEEK ([MASKED]) Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: -Lumbar spinal stenosis. -Spondylolisthesis, L4-L5. -UTI -Constipation Secondary Diagnoses: - History of DVT/PE - Antiphospholipid antibody syndrome - AAA - OSA on CPAP Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: It was a pleasure to care for you at the [MASKED] [MASKED]. Why did you come to the hospital? - You came to the hospital because you were having worsening back pain with pain radiating down your right leg. This pain started about a month ago and progressively got worse, making it difficult to walk. You also had burning pain with urination. What did you receive in the hospital? - You had an MRI that showed significant disc herniation in your lower back, which was the cause of your pain. The spine surgeons felt that you would benefit from surgery given that your pain was constant and worsening over the past month. We gave you pain medications and stopped your warfarin until it was safe for you to have surgery. You had a spinal decompression on [MASKED]. We also gave you antibiotics for your burning pain with urination, which we believe was caused by a urinary tract infection. What should you do once you leave the hospital? Lumbar Decompression With Fusion: You have undergone the following operation: Lumbar Decompression With 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 [MASKED] times a day you should go for a walk for [MASKED] minutes as part of your recovery.You can walk as much as you can tolerate.Limit any kind of lifting. Diet: Eat a normal healthy diet.You may have some constipation after surgery.You have been given medication to help with this issue. Brace:You may have been given a brace.If you have been given a brace,this brace is to be worn when you are walking.You may take it off when sitting in a chair or while lying in bed. Wound Care:Please keep the incision covered with a dry dressing on until your follow up appointment. 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. You should resume taking your normal home medications. You have also been given Additional Medications to control your pain.Please allow 72 hours for refill of narcotic prescriptions,so please plan ahead.You can either have them mailed to your home or pick them up at the clinic located on [MASKED].We are not allowed to call in or fax narcotic prescriptions(oxycontin,oxycodone,percocet) to your pharmacy.In addition,we are only allowed to write for pain medications for 90 days from the date of surgery. Follow up: Please Call the office and make an appointment for 2 weeks after the day of your operation if this has not been done already. At the 2-week visit we will check your incision,take baseline X-rays and answer any questions.We may at that time start physical therapy We will then see you at 6 weeks from the day of the operation and at that time release you to full activity. Please call the office if you have a fever>101.5 degrees Fahrenheit and/or drainage from your wound. Physical Therapy: 1)Weight bearing as tolerated.2)Gait,balance training.3)No lifting >10 lbs.4)No significant bending/twisting. Treatments Frequency: Please keep the incision covered with a dry dressing on until your follow up appointment. 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. Followup Instructions: [MASKED]
|
[] |
[
"N390",
"D62",
"D509",
"Z87891",
"Z7901",
"E785",
"G4733",
"E119",
"K219",
"F329",
"J449",
"K5900"
] |
[
"M5116: Intervertebral disc disorders with radiculopathy, lumbar region",
"D6861: Antiphospholipid syndrome",
"N390: Urinary tract infection, site not specified",
"D62: Acute posthemorrhagic anemia",
"I83811: Varicose veins of right lower extremity with pain",
"D509: Iron deficiency anemia, unspecified",
"Z87891: Personal history of nicotine dependence",
"Z86711: Personal history of pulmonary embolism",
"Z7901: Long term (current) use of anticoagulants",
"E559: Vitamin D deficiency, unspecified",
"C50912: Malignant neoplasm of unspecified site of left female breast",
"E785: Hyperlipidemia, unspecified",
"G4733: Obstructive sleep apnea (adult) (pediatric)",
"E119: Type 2 diabetes mellitus without complications",
"K219: Gastro-esophageal reflux disease without esophagitis",
"K5790: Diverticulosis of intestine, part unspecified, without perforation or abscess without bleeding",
"F329: Major depressive disorder, single episode, unspecified",
"J449: Chronic obstructive pulmonary disease, unspecified",
"I671: Cerebral aneurysm, nonruptured",
"M48061: Spinal stenosis, lumbar region without neurogenic claudication",
"K5900: Constipation, unspecified",
"E876: Hypokalemia"
] |
10,002,348 | 22,725,460 |
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:
___
|
[
"C7931",
"G935",
"G936",
"G911",
"C3490",
"F05",
"I10",
"F17210",
"G510",
"M21372",
"E039",
"M810",
"Z781",
"R001",
"R739",
"T380X5A",
"Y92239",
"D72829",
"R3915"
] |
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Headaches Major Surgical or Invasive Procedure: [MASKED] - Suboccipital craniotomy for resection of cerebellar lesion History of Present Illness: [MASKED] is a [MASKED] female with hx cerebral aneurysm clipping in [MASKED] 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 [MASKED]. 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 [MASKED]. Of note, patient reports her aneurysm clip is not MRI compatible. Past Medical History: - [MASKED] - Hypertension - S/p aneurysm clipping [MASKED] at [MASKED] by Dr. [MASKED] Social History: [MASKED] 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 [MASKED], R [MASKED] 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 [MASKED] 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 [MASKED] 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 [MASKED] at [MASKED]. Patient was admitted to the [MASKED] 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 [MASKED], 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 [MASKED] 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 [MASKED] 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 [MASKED]. #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 [MASKED] inpatient team on [MASKED], 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 [MASKED]. #Bradycardia She was due to transfer out to the [MASKED] on POD1, however was kept in the ICU for asymptomatic bradycardia to the [MASKED]. She remained asymptomatic, and her heartrate improved with fluids, and administration of her levothyroxine. She intermittently dipped to the [MASKED], 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 [MASKED] and OT who cleared her for home with services. She was discharged on [MASKED] in stable condition. She will follow up in [MASKED] on [MASKED]. Medications on Admission: - ASA 81mg - Alendronate 70mg weekly - Vitamin D3 [MASKED] 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 [MASKED]: 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 [MASKED] UNIT PO DAILY 13. HELD- Alendronate Sodium 70 mg PO 1X/WEEK ([MASKED]) This medication was held. Do not restart Alendronate Sodium until POD [MASKED] - [MASKED] 14. HELD- Aspirin 81 mg PO DAILY This medication was held. Do not restart Aspirin until POD 14 - [MASKED] [MASKED] glucometer [MASKED] Freestyle glucometer. Check blood sugars [MASKED] hours after a starchy meal. Record numbers and show to your Oncologist. [MASKED] test strips #50. Check blood sugars QD. 3 refills. [MASKED] Lancets #50. Check blood sugars QD. 3 refills. Discharge Disposition: Home With Service Facility: [MASKED] 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. [MASKED] 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 ([MASKED]). - We held your home Alendronate during this admission. You are cleared to resume this medication on POD 14 ([MASKED]). - 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 [MASKED] regarding the results. Your goal blood sugar is less than 200. What You [MASKED] 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 [MASKED] 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 [MASKED] and go to the nearest Emergency Room if you experience any of the following: - Sudden numbness or weakness in the face, arm, or leg - Sudden confusion or trouble speaking or understanding - Sudden trouble walking, dizziness, or loss of balance or coordination - Sudden severe headaches with no known reason Followup Instructions: [MASKED]
|
[] |
[
"I10",
"F17210",
"E039"
] |
[
"C7931: Secondary malignant neoplasm of brain",
"G935: Compression of brain",
"G936: Cerebral edema",
"G911: Obstructive hydrocephalus",
"C3490: Malignant neoplasm of unspecified part of unspecified bronchus or lung",
"F05: Delirium due to known physiological condition",
"I10: Essential (primary) hypertension",
"F17210: Nicotine dependence, cigarettes, uncomplicated",
"G510: Bell's palsy",
"M21372: Foot drop, left foot",
"E039: Hypothyroidism, unspecified",
"M810: Age-related osteoporosis without current pathological fracture",
"Z781: Physical restraint status",
"R001: Bradycardia, unspecified",
"R739: Hyperglycemia, unspecified",
"T380X5A: Adverse effect of glucocorticoids and synthetic analogues, initial encounter",
"Y92239: Unspecified place in hospital as the place of occurrence of the external cause",
"D72829: Elevated white blood cell count, unspecified",
"R3915: Urgency of urination"
] |
10,002,428 | 28,295,257 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
meropenem / Penicillins
Attending: ___.
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
aborted flexible sigmoidoscopy attempt (due to stool in vault)
___
Flexible sigmoidoscopy ___
History of Present Illness:
This is an ___ year old female with past medical history of
sjogrens, hypothyroidism, recent diagnosis of L1 compression
fracture, prior cdiff infection, presenting with bright red
blood
per rectum. Patient reports that on morning of presentation,
she
awoke in her normal state of health. Her home health aid helped
her to the commode and she suddenly had a large volume over
blood
per rectum. Over the next ___ minutes she then had 2 subsequent
episodes. Home health aid consulted with family and then called
___.
In the ED VS were 97.2 98 158/89 14 98%RA ___ 99. Labs were
notable for WBC 10.1, Hgb 9.8, Plt 245; K 4.4, Cr 0.6; lactate
1.0; UA neg leuk, nitr. Exam reported as tachycardia, grossly
blood rectum without large hemorrhoids. PEG lavage reported as
negative for blood.
GI note on the ED dashboard stated ___ with C.diff on flagyl,
presenting with maroon colored GIB. HDS. HCT 30.7 with normal
Coag. Please continue with supportive care with fluids and
transfusion as needed. If on-going bleeding or hemodynamic
changes, please get CTA. If concern of upper GI bleeding, can
lavage via PEG. Please give PPI if positive."
Patient was given 1L normal saline and was admitted to medicine.
On arrival to the floor patient reported above. Reported recent
diagnosis of L1 compression fracture and intermittent difficulty
with flushing her PEG tube at home. Full 10 point review of
systems positive where noted, otherwise negative.
Past Medical History:
Sjogrens
Hypothyroidism
h/o severe Cdiff
Protein calorie malnutrition s/p PEG
Osteoporosis s/p L1 compression fracture
Depression
Hemorrhoids
Normocytic anemia
Bronchiectasis
h/o Shingles
Dementia (___ ___
Mitral regurgitation
Social History:
___
Family History:
Has 2 children. Father had hemorrhoids. No history of cancer,
GI bleeding.
Physical Exam:
ADMISSION
VS: 187-106 (128/78 on recheck) 112 16 96%RA
Gen - supine in bed, comfortable, pale
Eyes - EOMI
ENT - OP clear, MMM
Heart - regularly tachycardic; II/VI systolic murmur loudest at
axilla;
Lungs - CTA bilaterally
Abd - soft nontender, normoactive bowel sounds; PEG in place
Rectum - dark maroon blood in vault, no large hemorrhoids
palpated
Ext - trace edema to mid-shin
Skin - +pale; no rashes
Vasc - 2+ DP/radial pulses
Neuro - AOx2-3 (full name, ___", ___,
moving all extremities
Psych - appropriate
DISCHARGE
VS: 98.1 135/64 103 20 95%RA
Gen - supine in bed, comfortable appearing
Eyes - EOMI
ENT - OP clear, MMM
Heart - RRR, II/VI systolic murmur loudest at axilla;
Lungs - CTA bilaterally, unchanged from day prior
Abd - soft nontender, normoactive bowel sounds; PEG in place;
unchanged from yesterday
Ext - no edema
Skin - no rashes
Vasc - 2+ DP/radial pulses
Neuro - AOx3 (full name, ___, ___,
moving all extremities
Psych - appropriate
Pertinent Results:
ADMISSION
___ 10:37AM BLOOD WBC-10.1* RBC-3.15* Hgb-9.8* Hct-30.7*
MCV-98 MCH-31.1 MCHC-31.9* RDW-13.6 RDWSD-48.4* Plt ___
___ 10:37AM BLOOD Glucose-96 UreaN-27* Creat-0.6 Na-136
K-4.4 Cl-97 HCO3-30 AnGap-13
___ 06:00AM BLOOD ALT-12 AST-19 AlkPhos-81 TotBili-0.3
DISCHARGE
___ 06:20AM BLOOD WBC-8.9 RBC-3.35* Hgb-10.5* Hct-32.7*
MCV-98 MCH-31.3 MCHC-32.1 RDW-13.4 RDWSD-47.7* Plt ___
___ 06:20AM BLOOD Glucose-106* UreaN-18 Creat-0.7 Na-137
K-3.8 Cl-100 HCO3-28 AnGap-13
Flexible Sigmoidoscopy - ___
Mucosa: Normal mucosa was noted in the rectum and sigmoid colon.
Other No bleeding sources or blood identified, though extent of
sigmoid colon evaluated was limited by poor prep.
Impression: Normal mucosa in the rectum and sigmoid colon
No bleeding sources or blood identified, though extent of
sigmoid colon evaluated was limited by poor prep.
Otherwise normal sigmoidoscopy to sigmoid colon at 25 cm
Recommendations: If bleeding recurs, would recommend full
colonoscopy with prep.
Brief Hospital Course:
This is an ___ year old female with past medical history of
sjogrens, hemorrhoids, prior cdiff infection, admitted ___
with bright red blood per rectum thought to be acute lower GI
bleed, subsequently stabilizing without intervention, status
post flexible sigmoidoscopy without identifiable source,
remaining stable x greater than 4 days, able to be discharged to
rehab facility.
# Acute GI Bleed NOS - Patient presented with acute episode of
BRBPR concerning for lower GI source. Patient subsequently
monitored without new or worsening anemia. After discussion
with family and patient regarding whether or not to further
workup, they opted for flexible sigmoidoscopy (felt colonoscopy
might be too invasive). Patient underwent aborted flexible
sigmoidoscopy on ___ due to pressence of copious stool in
rectal vault, and then underwent successful flexible
sigmoidoscopy on ___ without identifiable source for her
bleeding. From admission Hgb 9.8, discharge hemoglobin was
10.5. Per GI, could consider outpatient colonoscopy if
consistent with patient's wishes.
# Osteoporosis / chronic L1 compression fracture /
deconditioning - patient with recent L1 compression fracture as
outpatient prior to admission; patient noted to be significantly
deconditioned this admission, requiring assistance with ADLs;
patient seen by ___ and recommended for rehab. Continued home
Calcium 500 + vitamin D, calcitonin. Placed on Tylenol and
tramadol for pain control with good effect
# Chronic Severe Protein Calorie Malnutrition - per discussion
with family and review of chart, patient has lost weight despite
PEG placement and bolus tube feeds (has had difficulty
maintaining PO intake due to her Sjogrens). At home patient has
not be using full recommended 2 cans of Nutren 2.0, 500
Cal/250ml BID. Here patient seen by nutrition, continued on
above 2 cans, and was given oral supplementation with her PO
meals as well.
# Depression - continued home BuPROPion and mirtazapine
# Hypothryoidism - continued levothyroxine
Transitional Issues
- Code status - DNR/DNI
- Discharged to rehab
- No source for bleeding identified this admission; can consider
future colonoscopy to look for source of bleeding, but would
first discuss if consistent with patient's goals of care
- Would consider encouragement of PO intake and PEG-tube
supplementation given her malnutrition
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BuPROPion XL (Once Daily) 150 mg PO DAILY
2. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral DAILY
3. Levothyroxine Sodium 75 mcg PO DAILY
4. Mirtazapine 30 mg PO QHS
5. TraMADol 50 mg PO BID:PRN back pain
6. Acetaminophen 500 mg PO Q6H:PRN back pain
7. Alendronate Sodium 70 mg PO QSUN
8. Calcitonin Salmon 200 UNIT NAS DAILY
9. Multivitamins 1 TAB PO DAILY
10. TraMADol 100 mg PO QHS:PRN back pain
11. Artificial Tears ___ DROP BOTH EYES QID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. BuPROPion XL (Once Daily) 150 mg PO DAILY
3. Calcitonin Salmon 200 UNIT NAS DAILY
4. Levothyroxine Sodium 75 mcg PO DAILY
5. Mirtazapine 30 mg PO QHS
6. Multivitamins 1 TAB PO DAILY
7. TraMADol 50 mg PO BID:PRN back pain
8. Alendronate Sodium 70 mg PO QSUN
9. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral DAILY
10. TraMADol 100 mg PO QHS:PRN back pain
11. Artificial Tears ___ DROP BOTH EYES QID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
# Acute GI Bleed NOS
# Depression
# Osteoporosis / chronic L1 compression fracture
# Hypothryoidism
# Chronic Severe Protein Calorie Malnutrition
# Dementia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms. ___:
It was a pleasure caring for you at ___. You were admitted
with gastrointestinal bleeding. You were seen by GI specialists
and underwent a flexible sigmoidiscopy without signs of a source
of your bleeding. You were monitored and your blood levels were
stable. You are now ready for discharge home.
In the future you may wish to consider a colonoscopy to look for
the source of your bleeding, especially if it occurs again. You
should discuss with your family and primary care doctor
regarding if this is within your goals of care.
Followup Instructions:
___
|
[
"K922",
"E43",
"M8008XA",
"F0390",
"Z681",
"R000",
"I10",
"F329",
"E039",
"Z66",
"Z931",
"M3500",
"Z5309",
"I340"
] |
Allergies: meropenem / Penicillins Chief Complaint: BRBPR Major Surgical or Invasive Procedure: aborted flexible sigmoidoscopy attempt (due to stool in vault) [MASKED] Flexible sigmoidoscopy [MASKED] History of Present Illness: This is an [MASKED] year old female with past medical history of sjogrens, hypothyroidism, recent diagnosis of L1 compression fracture, prior cdiff infection, presenting with bright red blood per rectum. Patient reports that on morning of presentation, she awoke in her normal state of health. Her home health aid helped her to the commode and she suddenly had a large volume over blood per rectum. Over the next [MASKED] minutes she then had 2 subsequent episodes. Home health aid consulted with family and then called [MASKED]. In the ED VS were 97.2 98 158/89 14 98%RA [MASKED] 99. Labs were notable for WBC 10.1, Hgb 9.8, Plt 245; K 4.4, Cr 0.6; lactate 1.0; UA neg leuk, nitr. Exam reported as tachycardia, grossly blood rectum without large hemorrhoids. PEG lavage reported as negative for blood. GI note on the ED dashboard stated [MASKED] with C.diff on flagyl, presenting with maroon colored GIB. HDS. HCT 30.7 with normal Coag. Please continue with supportive care with fluids and transfusion as needed. If on-going bleeding or hemodynamic changes, please get CTA. If concern of upper GI bleeding, can lavage via PEG. Please give PPI if positive." Patient was given 1L normal saline and was admitted to medicine. On arrival to the floor patient reported above. Reported recent diagnosis of L1 compression fracture and intermittent difficulty with flushing her PEG tube at home. Full 10 point review of systems positive where noted, otherwise negative. Past Medical History: Sjogrens Hypothyroidism h/o severe Cdiff Protein calorie malnutrition s/p PEG Osteoporosis s/p L1 compression fracture Depression Hemorrhoids Normocytic anemia Bronchiectasis h/o Shingles Dementia ([MASKED] [MASKED] Mitral regurgitation Social History: [MASKED] Family History: Has 2 children. Father had hemorrhoids. No history of cancer, GI bleeding. Physical Exam: ADMISSION VS: 187-106 (128/78 on recheck) 112 16 96%RA Gen - supine in bed, comfortable, pale Eyes - EOMI ENT - OP clear, MMM Heart - regularly tachycardic; II/VI systolic murmur loudest at axilla; Lungs - CTA bilaterally Abd - soft nontender, normoactive bowel sounds; PEG in place Rectum - dark maroon blood in vault, no large hemorrhoids palpated Ext - trace edema to mid-shin Skin - +pale; no rashes Vasc - 2+ DP/radial pulses Neuro - AOx2-3 (full name, [MASKED]", [MASKED], moving all extremities Psych - appropriate DISCHARGE VS: 98.1 135/64 103 20 95%RA Gen - supine in bed, comfortable appearing Eyes - EOMI ENT - OP clear, MMM Heart - RRR, II/VI systolic murmur loudest at axilla; Lungs - CTA bilaterally, unchanged from day prior Abd - soft nontender, normoactive bowel sounds; PEG in place; unchanged from yesterday Ext - no edema Skin - no rashes Vasc - 2+ DP/radial pulses Neuro - AOx3 (full name, [MASKED], [MASKED], moving all extremities Psych - appropriate Pertinent Results: ADMISSION [MASKED] 10:37AM BLOOD WBC-10.1* RBC-3.15* Hgb-9.8* Hct-30.7* MCV-98 MCH-31.1 MCHC-31.9* RDW-13.6 RDWSD-48.4* Plt [MASKED] [MASKED] 10:37AM BLOOD Glucose-96 UreaN-27* Creat-0.6 Na-136 K-4.4 Cl-97 HCO3-30 AnGap-13 [MASKED] 06:00AM BLOOD ALT-12 AST-19 AlkPhos-81 TotBili-0.3 DISCHARGE [MASKED] 06:20AM BLOOD WBC-8.9 RBC-3.35* Hgb-10.5* Hct-32.7* MCV-98 MCH-31.3 MCHC-32.1 RDW-13.4 RDWSD-47.7* Plt [MASKED] [MASKED] 06:20AM BLOOD Glucose-106* UreaN-18 Creat-0.7 Na-137 K-3.8 Cl-100 HCO3-28 AnGap-13 Flexible Sigmoidoscopy - [MASKED] Mucosa: Normal mucosa was noted in the rectum and sigmoid colon. Other No bleeding sources or blood identified, though extent of sigmoid colon evaluated was limited by poor prep. Impression: Normal mucosa in the rectum and sigmoid colon No bleeding sources or blood identified, though extent of sigmoid colon evaluated was limited by poor prep. Otherwise normal sigmoidoscopy to sigmoid colon at 25 cm Recommendations: If bleeding recurs, would recommend full colonoscopy with prep. Brief Hospital Course: This is an [MASKED] year old female with past medical history of sjogrens, hemorrhoids, prior cdiff infection, admitted [MASKED] with bright red blood per rectum thought to be acute lower GI bleed, subsequently stabilizing without intervention, status post flexible sigmoidoscopy without identifiable source, remaining stable x greater than 4 days, able to be discharged to rehab facility. # Acute GI Bleed NOS - Patient presented with acute episode of BRBPR concerning for lower GI source. Patient subsequently monitored without new or worsening anemia. After discussion with family and patient regarding whether or not to further workup, they opted for flexible sigmoidoscopy (felt colonoscopy might be too invasive). Patient underwent aborted flexible sigmoidoscopy on [MASKED] due to pressence of copious stool in rectal vault, and then underwent successful flexible sigmoidoscopy on [MASKED] without identifiable source for her bleeding. From admission Hgb 9.8, discharge hemoglobin was 10.5. Per GI, could consider outpatient colonoscopy if consistent with patient's wishes. # Osteoporosis / chronic L1 compression fracture / deconditioning - patient with recent L1 compression fracture as outpatient prior to admission; patient noted to be significantly deconditioned this admission, requiring assistance with ADLs; patient seen by [MASKED] and recommended for rehab. Continued home Calcium 500 + vitamin D, calcitonin. Placed on Tylenol and tramadol for pain control with good effect # Chronic Severe Protein Calorie Malnutrition - per discussion with family and review of chart, patient has lost weight despite PEG placement and bolus tube feeds (has had difficulty maintaining PO intake due to her Sjogrens). At home patient has not be using full recommended 2 cans of Nutren 2.0, 500 Cal/250ml BID. Here patient seen by nutrition, continued on above 2 cans, and was given oral supplementation with her PO meals as well. # Depression - continued home BuPROPion and mirtazapine # Hypothryoidism - continued levothyroxine Transitional Issues - Code status - DNR/DNI - Discharged to rehab - No source for bleeding identified this admission; can consider future colonoscopy to look for source of bleeding, but would first discuss if consistent with patient's goals of care - Would consider encouragement of PO intake and PEG-tube supplementation given her malnutrition Medications on Admission: The Preadmission Medication list is accurate and complete. 1. BuPROPion XL (Once Daily) 150 mg PO DAILY 2. Calcium 500 + D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -400 unit oral DAILY 3. Levothyroxine Sodium 75 mcg PO DAILY 4. Mirtazapine 30 mg PO QHS 5. TraMADol 50 mg PO BID:PRN back pain 6. Acetaminophen 500 mg PO Q6H:PRN back pain 7. Alendronate Sodium 70 mg PO QSUN 8. Calcitonin Salmon 200 UNIT NAS DAILY 9. Multivitamins 1 TAB PO DAILY 10. TraMADol 100 mg PO QHS:PRN back pain 11. Artificial Tears [MASKED] DROP BOTH EYES QID Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN pain 2. BuPROPion XL (Once Daily) 150 mg PO DAILY 3. Calcitonin Salmon 200 UNIT NAS DAILY 4. Levothyroxine Sodium 75 mcg PO DAILY 5. Mirtazapine 30 mg PO QHS 6. Multivitamins 1 TAB PO DAILY 7. TraMADol 50 mg PO BID:PRN back pain 8. Alendronate Sodium 70 mg PO QSUN 9. Calcium 500 + D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -400 unit oral DAILY 10. TraMADol 100 mg PO QHS:PRN back pain 11. Artificial Tears [MASKED] DROP BOTH EYES QID Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: # Acute GI Bleed NOS # Depression # Osteoporosis / chronic L1 compression fracture # Hypothryoidism # Chronic Severe Protein Calorie Malnutrition # Dementia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Ms. [MASKED]: It was a pleasure caring for you at [MASKED]. You were admitted with gastrointestinal bleeding. You were seen by GI specialists and underwent a flexible sigmoidiscopy without signs of a source of your bleeding. You were monitored and your blood levels were stable. You are now ready for discharge home. In the future you may wish to consider a colonoscopy to look for the source of your bleeding, especially if it occurs again. You should discuss with your family and primary care doctor regarding if this is within your goals of care. Followup Instructions: [MASKED]
|
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"K922: Gastrointestinal hemorrhage, unspecified",
"E43: Unspecified severe protein-calorie malnutrition",
"M8008XA: Age-related osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture",
"F0390: Unspecified dementia without behavioral disturbance",
"Z681: Body mass index [BMI] 19.9 or less, adult",
"R000: Tachycardia, unspecified",
"I10: Essential (primary) hypertension",
"F329: Major depressive disorder, single episode, unspecified",
"E039: Hypothyroidism, unspecified",
"Z66: Do not resuscitate",
"Z931: Gastrostomy status",
"M3500: Sicca syndrome, unspecified",
"Z5309: Procedure and treatment not carried out because of other contraindication",
"I340: Nonrheumatic mitral (valve) insufficiency"
] |
10,002,430 | 24,513,842 |
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:
___
|
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Allergies: Corgard / Vasotec Chief Complaint: leg edema Major Surgical or Invasive Procedure: None History of Present Illness: HISTORY OF PRESENTING ILLNESS: Mr. [MASKED] is an [MASKED] year old gentleman with history of CAD (s/p 3V CABG [MASKED], LM PCI [MASKED], pulmonary HTN, AFib on anticoagulation, [MASKED] (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. [MASKED] today for evaluation. There he had a TTE that showed new RV dilation and was referred to the [MASKED] 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 [MASKED] RIGHT LOWER LOBE LOBECTOMY [MASKED] CORONARY BYPASS SURGERY [MASKED] Social History: [MASKED] 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, [MASKED] 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: [MASKED] 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 [MASKED] 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 [MASKED] [MASKED] 04:02PM BLOOD [MASKED] PTT-35.8 [MASKED] [MASKED] 04:02PM BLOOD Glucose-93 UreaN-17 Creat-1.1 Na-131* K-3.8 Cl-93* HCO3-27 AnGap-15 [MASKED] 04:02PM BLOOD ALT-81* AST-64* AlkPhos-89 TotBili-0.7 [MASKED] 04:02PM BLOOD CK-MB-3 cTropnT-<0.01 proBNP-1284* [MASKED] 04:02PM BLOOD Albumin-4.2 Calcium-9.7 Mg-2.2 [MASKED] 04:34PM BLOOD D-Dimer-<150 [MASKED] 04:02PM BLOOD TSH-3.0 DISCHARGE [MASKED] 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 [MASKED] [MASKED] 04:04AM BLOOD [MASKED] PTT-34.1 [MASKED] [MASKED] 04:04AM BLOOD Glucose-113* UreaN-32* Creat-1.4* Na-133 K-3.9 Cl-94* HCO3-26 AnGap-17 [MASKED] 04:04AM BLOOD ALT-79* AST-57* AlkPhos-83 TotBili-0.6 [MASKED] 04:04AM BLOOD Calcium-10.0 Phos-4.4 Mg-2.0 ECHO [MASKED] 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. [MASKED] is an [MASKED] 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. [MASKED] 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. [MASKED] 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. [MASKED] [] 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. [MASKED], 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. [MASKED] 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 [MASKED] outpatient to see if this may be contributing. It was a pleasure taking care of you! Your [MASKED] team Followup Instructions: [MASKED]
|
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"I281: Aneurysm of pulmonary artery",
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"E871: Hypo-osmolality and hyponatremia",
"J449: Chronic obstructive pulmonary disease, unspecified",
"I2781: Cor pulmonale (chronic)",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
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"I10: Essential (primary) hypertension",
"N400: Benign prostatic hyperplasia without lower urinary tract symptoms",
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"Z902: Acquired absence of lung [part of]",
"Z7982: Long term (current) use of aspirin",
"Z9861: Coronary angioplasty status",
"Z87891: Personal history of nicotine dependence"
] |
10,002,430 | 24,648,311 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Corgard / Vasotec
Attending: ___.
Chief Complaint:
Dyspnea on Exertion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
=======================================================
___ FAILURE ADMISSION NOTE
=======================================================
OUTPATIENT CARDIOLOGIST: ___., MD ___
cardiology), ___ ___., MD(CHF)
PCP: ___., MD
CHIEF COMPLAINT: Dyspnea on Exertion
HISTORY OF PRESENTING ILLNESS:
Mr. ___ is a ___ gentleman with a past medical
history pertinent for HFrEF (35% ___ CAD s/p CABG and
subsequent PCI, moderate tricuspid regurgitation, right
ventricular dysfunction, moderate pulmonary hypertension, and
paroxysmal atrial fibrillation on apixaban, stage III chronic
kidney disease (Baseline Cr 2.0-2.1), cerebrovascular disease,
and metastatic melanoma of unknown primary on checkpoint
inhibitor pembrolizumab who was found volume overloaded with
increased DOE, admitted to ___ for IV diuresis.
Per most recent outpatient CHF notes:
He was seen by his primary car primary Cardiologist, Dr. ___ increased fatigue and exertional dyspnea. Dr. ___
a
___ and felt his LVEF was ~30% and reduced from prior. He was
started on low-dose Entresto, but couldn't tolerate it from a BP
prospective. He was previously on losartan which was stopped
due to this lightheadedness, dizziness and worsening renal
function. Dr. ___ concern about the possibility of
myocarditis secondary to the checkpoint inhibitor. When he
followed up with the Oncology team on ___, his symptoms were
somewhat improved. Cardiac biomarkers were notable for a rising
NTproBNP to >10K but normal CK-MB and minimally elevated
troponin
T of 0.03, which is not unexpected in the setting
of decompensated ___ failure and chronic kidney disease. He
was
planned to receive immunotherapy on ___, but treatment was
held due to elevated Cr. Recheck showed improvement. The patient
restarted pembrolizumab on ___. Pembrolizumab was again
held
in ___ for diarrhea and elevated LFTs
In addition, he also received intravenous hydration.
Subsequently, he was noted to be more volume overloaded, at
which
time Torsemide from 20 mg daily to 30 mg daily then 40 mg daily.
Troponin testing showed Trop-T of 0.04, attributed to renal
insufficiency. The patient was also noted to have mild
hyperkalemia (K 5.7) for which potassium supplementation was
stopped and torsemide dose increased. He was also seen in the
Emergency room in the ___ ___ due to a
fall with resultant scalp laceration. CT head and neck was
unremarkable.
He presented this morning ___ for his scheduled visit at
___ clinic where he noted that his weight had been 126 lbs most
recently on his home scale. He also reported decreased appetite
that he attributes to eating a different diet. He currently has
a
___ care taker that makes ___ food for him, adhering
to a low sodium diet, that he does not like as much as his
regular diet. He drinks ___ glasses of water or juice daily. He
was taking torsemide 40 mg daily, that he decreased to 30 mg
daily several days ago as he felt he was urinating too
frequently. He also ran out of tamsulosin several days ago so
stopped taking this around the same time. He noted becoming
short
of breath after taking 20 steps or less. Due to his volume
overloaded noted on exam he was recommended for admission to ___
for IV diuresis
On the floor, he endorses the above history. He noted that his
SOB has progressive gotten worse. Mostly occurs with activity.
None at rest. He noted that his weight has been slowly
decreasing
due lack of appetite and him being to lazy. He has a home health
aid everyday from 11am-7pm, who helps him with ADL. He endorses
abdominal bloading.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope,
or presyncope.
ROS otherwise negative, unless otherwise noted above
Past Medical History:
Past Medical History:
BILATERAL MODERATE CAROTID DISEASE
CONGESTIVE ___ 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 PHYSICAL EXAMINATION:
===============================
24 HR Data (last updated ___ @ 1335)
Temp: 97.4 (Tm 97.4), BP: 115/66, HR: 61, RR: 18, O2 sat:
99%, O2 delivery: ra, Wt: 130.73 lb/59.3 kg
GENERAL: Well developed, well nourished male in NAD. Oriented
x3.
Mood, affect appropriate.
HEENT: Scalp laceration noted. Sclera slightly icteric. PERRL.
EOMI. Conjunctiva were pink. No pallor or cyanosis of the oral
mucosa. No xanthelasma.
NECK: Supple. JVP ~ 20 cm with positive hepatojugular reflex.
CARDIAC: Regular rate and rhythm. Normal S1, S2. ___
holosystolic
murmur at the LLSB and the apex, no rubs, or gallops. No thrills
or lifts.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. Bibasilar crackles
ABDOMEN: mildly distended; normoactive bowel sounds; soft and
non-tender to palpation; there is no appreciable organomegaly or
mass
EXTREMITIES: Cool, 1+ pitting edema to knee caps. bilateral
status dermatitis.
SKIN: Eccymosis noted on left hand, Multiple open biopsy
excision
sites on left shin and right calf
PULSES: Distal pulses palpable and symmetric.
Discharge Physical exam
=======================
24 HR Data (last updated ___ @ 751)
Temp: 98.2 (Tm 98.6), BP: 110/61 (100-121/54-63), HR: 72
(60-99), RR: 16 (___), O2 sat: 91% (91-95), O2 delivery: Ra
General: elderly gentleman in NAD
HEENT: dressing in place on scalp from recent fall/scalp
laceration/c/d/i. Sclera mildly icteric, pupils equally round,
MMM
NECK: JVP~10cm, with positive hepatojugular reflex
CV: irregularly irregular ; the precordium is quiet without RV
heave; normal S1 with fixed split S2; there is a soft ___
holosystolic
murmur at the LLSB and the apex;
LUNGS: Normal effort. Fine Bibasilar crackles
Abd: soft, mildy distended, no guarding / rebound.
EXT: 1+ pitting edema to the mid-calf L leg > R leg
SKIN: Multiple excision biopsy wounds on legs, covered with
dressing c/d/i
NEURO: Speech fluent, strength grossly intact
Pertinent Results:
___ 01:00PM ___ PTT-34.4 ___
___ 01:00PM PLT COUNT-169
___ 01:00PM NEUTS-81.6* LYMPHS-6.6* MONOS-10.4 EOS-0.1*
BASOS-0.1 IM ___ AbsNeut-6.00 AbsLymp-0.49* AbsMono-0.77
AbsEos-0.01* AbsBaso-0.01
___ 01:00PM WBC-7.4 RBC-3.02* HGB-9.1* HCT-30.2* MCV-100*
MCH-30.1 MCHC-30.1* RDW-16.4* RDWSD-59.2*
___ 01:00PM calTIBC-352 FERRITIN-111 TRF-271
___ 01:00PM CALCIUM-9.2 PHOSPHATE-3.7 MAGNESIUM-2.8*
IRON-88
___ 01:00PM CK-MB-4 cTropnT-0.01 ___
___ 01:00PM ALT(SGPT)-56* AST(SGOT)-52* LD(LDH)-277* ALK
PHOS-135* TOT BILI-0.7
___ 01:00PM estGFR-Using this
___ 01:00PM GLUCOSE-100 UREA N-52* CREAT-2.1* SODIUM-135
POTASSIUM-5.4 CHLORIDE-100 TOTAL CO2-24 ANION GAP-11
___ 04:54PM URINE HYALINE-1*
___ 04:54PM URINE RBC-0 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 04:54PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 04:54PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 07:53AM BLOOD WBC-6.5 RBC-2.70* Hgb-8.2* Hct-26.5*
MCV-98 MCH-30.4 MCHC-30.9* RDW-16.0* RDWSD-56.3* Plt ___
___ 07:53AM BLOOD Plt ___
___ 07:53AM BLOOD Glucose-105* UreaN-43* Creat-2.2* Na-140
K-4.2 Cl-102 HCO3-27 AnGap-11
___:04AM BLOOD ALT-45* AST-42* AlkPhos-113 TotBili-0.6
___ 07:53AM BLOOD Calcium-8.6 Phos-3.5 Mg-2.4
___ 01:00PM BLOOD calTIBC-352 Ferritn-111 TRF-271
Brief Hospital Course:
TRANSITIONAL ISSUES
====================
DISCHARGE WEIGHT: 55.6 kg (122.57 lb)
DISCHARGE Cr/BUN: Cr 2.2, BUN 43
DISCHARGE DIURETIC: 40 Torsemide daily
MEDICATION CHANGES: Decreased daily potassium to 40 mEq daily
(from 30 mEq twice dailye)
[] Please obtain repeat Chem10 within 2 weeks and after 4 weeks.
Adjust electrolyte repletion accordingly.
[] Please follow up weight and volume status and adjust
torsemide accordingly.
#CODE STATUS: Presumed full
Health care proxy chosen: Yes
Name of health care proxy: ___
___: son
Phone number: ___
====================
PATIENT SUMMARY:
====================
Mr. ___ is a ___ gentleman with PMHx of CAD s/p
CABG
and subsequent PCI, HFrEF (35% ___, moderate tricuspid
regurgitation, right ventricular dysfunction, moderate pulmonary
hypertension, and paroxysmal atrial fibrillation on apixaban,
stage III chronic kidney disease (Baseline Cr 2.0-2.1),
cerebrovascular disease, and metastatic melanoma of unknown
primary on checkpoint inhibitor pembrolizumab who was found
volume overloaded with increased DOE, admitted to acute ___
failure for IV diuresis, now transitioned to oral duiretics.
# CORONARIES: Left Main and two vessel coronary disease (___).
# PUMP: 35% ___
# RHYTHM: Ectopic rhythm, PR prolongation, left axis deviation,
RBBB
ACTIVE ISSUES:
==============
# ___ Failure with reduced ejection fraction
# Right ventricular dysfunction, TR, pulm HTN
# Volume overload
His ___ failure exacerbation is likely secondary to his recent
administration of IV fluids in addition to his self down
titration of his torsemide over the last week. In addition, he
does not follow a restricted fluid intake and drinks ___ glasses
of water or juice daily. Furthermore, he has not tolerated
guideline directed medical therapy due to recurrent issues with
acute kidney injury and elevated transaminitis while on
pembrolizumab therapy. He was clinically volume overloaded with
elevated BNP 16020. We initiated IV lasix 160 bolus and put him
on a lasix gtt with good response, however he his Cr increased
from 2.1-->2.7. His Cr. improved with transition to PO Torsemide
40 mg daily. We monitored and aggressively repleted his
potassium. No afterload reduction or neural hormonal blockade
was added.
# Chronic Kidney Disease: Baseline 2.1-2.3 .
Cr 2.1 on admission(Stable )- Cr on discharge:2.2
Cr initially uptrended above baseline from 2.1---> 2.7. Felt
likely due to increased diuretic usage as it improved with
stopping diuretics. Less likely cardiorenal syndrome. In
addition,patient was recently seen in follow-up by nephrology.
They felt his CKD was less likely to be related to pembrolizumab
and more likely related to age-related decline in renal
function. Creatinine 2.2 on discharge (stable).
# Metastatic Melanoma
He is followed by Dr. ___. He was previously on
Pembrolizumab which was held due diarrhea, elevated LFTs and
worsening kidney function. Negative troponin and CK MB, no
concern
for drug-induced myocarditis at this point. Followup in
___ clinic in 2weeks after discharge
# Elevated transaminiatis
Stable. Statin and ___ had previously been held. No changes made
during admission.
# Urinary frequency
Likely due to diuretic use. Afebrile and asx otherwise
-Continued home tamsulosin
# Coronary artery disease, s/p CABG and LAD PCI.
-Continued aspirin 81 mg daily
-Statin stopped prior to admission due to elevated LFTs.
Continued holding.
CHRONIC ISSUES:
==============
# Paroxysmal Atrial fibrillation
Rythym: Continue amiodarone 200mg for rhythm control strategy
(monitoring safety labs)
-Continued anticoagulation with apixaban 2.5mg twice daily
# Hypertension: Stable.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
further investigation.
1. Amiodarone 200 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Senna 17.2 mg PO HS
5. Vitamin D 1000 UNIT PO DAILY
6. Align (bifidobacterium infantis) 4 mg oral DAILY
7. coenzyme Q10 100 mg oral DAILY
8. Tamsulosin 0.4 mg PO QHS
9. Torsemide 40 mg PO DAILY
10. Ferrous Sulfate 325 mg PO DAILY
11. Sertraline 50 mg PO DAILY
12. Potassium Chloride 30 mEq PO BID
13. Apixaban 2.5 mg PO BID
14. Cephalexin 500 mg PO Q6H
Discharge Medications:
1. Potassium Chloride 40 mEq PO DAILY
RX *potassium chloride 20 mEq 2 packet(s) by mouth once a day
Disp #*60 Tablet Refills:*0
2. Align (bifidobacterium infantis) 4 mg oral DAILY
3. Amiodarone 200 mg PO DAILY
4. Apixaban 2.5 mg PO BID
5. Aspirin 81 mg PO DAILY
6. coenzyme Q10 100 mg oral DAILY
7. Docusate Sodium 100 mg PO BID
8. Ferrous Sulfate 325 mg PO DAILY
9. Senna 17.2 mg PO HS
10. Sertraline 50 mg PO DAILY
11. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth nightly Disp #*30
Capsule Refills:*0
12. Torsemide 40 mg PO DAILY
13. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
=================
HFrEF excerterbation
Secondary diagnosis
===================
Transaminitis
Metastatic melanoma
CKD
Coronary artery disease, s/p CABG and LAD PCI
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
==========================
Dear Mr. ___ ,
It was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
You were feeling short of breath because you had fluid in your
lungs. This was caused by a condition called ___ failure,
where your ___ does not pump hard enough and fluid backs up
into your lungs.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
You were given medications to help get the fluid out. Your
breathing got better and were ready to leave the hospital.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Follow up with your doctors as listed below
- Weigh yourself every morning. Your weight on discharge is
122.57 lbs. Call your doctor if your weight goes up more than 3
pounds.
- Call you doctor if you notice any of the "danger signs" below.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
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Allergies: Corgard / Vasotec Chief Complaint: Dyspnea on Exertion Major Surgical or Invasive Procedure: None History of Present Illness: ======================================================= [MASKED] FAILURE ADMISSION NOTE ======================================================= OUTPATIENT CARDIOLOGIST: [MASKED]., MD [MASKED] cardiology), [MASKED] [MASKED]., MD(CHF) PCP: [MASKED]., MD CHIEF COMPLAINT: Dyspnea on Exertion HISTORY OF PRESENTING ILLNESS: Mr. [MASKED] is a [MASKED] gentleman with a past medical history pertinent for HFrEF (35% [MASKED] CAD s/p CABG and subsequent PCI, moderate tricuspid regurgitation, right ventricular dysfunction, moderate pulmonary hypertension, and paroxysmal atrial fibrillation on apixaban, stage III chronic kidney disease (Baseline Cr 2.0-2.1), cerebrovascular disease, and metastatic melanoma of unknown primary on checkpoint inhibitor pembrolizumab who was found volume overloaded with increased DOE, admitted to [MASKED] for IV diuresis. Per most recent outpatient CHF notes: He was seen by his primary car primary Cardiologist, Dr. [MASKED] increased fatigue and exertional dyspnea. Dr. [MASKED] a [MASKED] and felt his LVEF was ~30% and reduced from prior. He was started on low-dose Entresto, but couldn't tolerate it from a BP prospective. He was previously on losartan which was stopped due to this lightheadedness, dizziness and worsening renal function. Dr. [MASKED] concern about the possibility of myocarditis secondary to the checkpoint inhibitor. When he followed up with the Oncology team on [MASKED], his symptoms were somewhat improved. Cardiac biomarkers were notable for a rising NTproBNP to >10K but normal CK-MB and minimally elevated troponin T of 0.03, which is not unexpected in the setting of decompensated [MASKED] failure and chronic kidney disease. He was planned to receive immunotherapy on [MASKED], but treatment was held due to elevated Cr. Recheck showed improvement. The patient restarted pembrolizumab on [MASKED]. Pembrolizumab was again held in [MASKED] for diarrhea and elevated LFTs In addition, he also received intravenous hydration. Subsequently, he was noted to be more volume overloaded, at which time Torsemide from 20 mg daily to 30 mg daily then 40 mg daily. Troponin testing showed Trop-T of 0.04, attributed to renal insufficiency. The patient was also noted to have mild hyperkalemia (K 5.7) for which potassium supplementation was stopped and torsemide dose increased. He was also seen in the Emergency room in the [MASKED] [MASKED] due to a fall with resultant scalp laceration. CT head and neck was unremarkable. He presented this morning [MASKED] for his scheduled visit at [MASKED] clinic where he noted that his weight had been 126 lbs most recently on his home scale. He also reported decreased appetite that he attributes to eating a different diet. He currently has a [MASKED] care taker that makes [MASKED] food for him, adhering to a low sodium diet, that he does not like as much as his regular diet. He drinks [MASKED] glasses of water or juice daily. He was taking torsemide 40 mg daily, that he decreased to 30 mg daily several days ago as he felt he was urinating too frequently. He also ran out of tamsulosin several days ago so stopped taking this around the same time. He noted becoming short of breath after taking 20 steps or less. Due to his volume overloaded noted on exam he was recommended for admission to [MASKED] for IV diuresis On the floor, he endorses the above history. He noted that his SOB has progressive gotten worse. Mostly occurs with activity. None at rest. He noted that his weight has been slowly decreasing due lack of appetite and him being to lazy. He has a home health aid everyday from 11am-7pm, who helps him with ADL. He endorses abdominal bloading. Cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope, or presyncope. ROS otherwise negative, unless otherwise noted above Past Medical History: Past Medical History: BILATERAL MODERATE CAROTID DISEASE CONGESTIVE [MASKED] 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 [MASKED] RIGHT LOWER LOBE LOBECTOMY [MASKED] CORONARY BYPASS SURGERY [MASKED] Social History: [MASKED] Family History: Non-contributory Physical Exam: ADMISSION PHYSICAL EXAMINATION: =============================== 24 HR Data (last updated [MASKED] @ 1335) Temp: 97.4 (Tm 97.4), BP: 115/66, HR: 61, RR: 18, O2 sat: 99%, O2 delivery: ra, Wt: 130.73 lb/59.3 kg GENERAL: Well developed, well nourished male in NAD. Oriented x3. Mood, affect appropriate. HEENT: Scalp laceration noted. Sclera slightly icteric. PERRL. EOMI. Conjunctiva were pink. No pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple. JVP ~ 20 cm with positive hepatojugular reflex. CARDIAC: Regular rate and rhythm. Normal S1, S2. [MASKED] holosystolic murmur at the LLSB and the apex, no rubs, or gallops. No thrills or lifts. LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. Bibasilar crackles ABDOMEN: mildly distended; normoactive bowel sounds; soft and non-tender to palpation; there is no appreciable organomegaly or mass EXTREMITIES: Cool, 1+ pitting edema to knee caps. bilateral status dermatitis. SKIN: Eccymosis noted on left hand, Multiple open biopsy excision sites on left shin and right calf PULSES: Distal pulses palpable and symmetric. Discharge Physical exam ======================= 24 HR Data (last updated [MASKED] @ 751) Temp: 98.2 (Tm 98.6), BP: 110/61 (100-121/54-63), HR: 72 (60-99), RR: 16 ([MASKED]), O2 sat: 91% (91-95), O2 delivery: Ra General: elderly gentleman in NAD HEENT: dressing in place on scalp from recent fall/scalp laceration/c/d/i. Sclera mildly icteric, pupils equally round, MMM NECK: JVP~10cm, with positive hepatojugular reflex CV: irregularly irregular ; the precordium is quiet without RV heave; normal S1 with fixed split S2; there is a soft [MASKED] holosystolic murmur at the LLSB and the apex; LUNGS: Normal effort. Fine Bibasilar crackles Abd: soft, mildy distended, no guarding / rebound. EXT: 1+ pitting edema to the mid-calf L leg > R leg SKIN: Multiple excision biopsy wounds on legs, covered with dressing c/d/i NEURO: Speech fluent, strength grossly intact Pertinent Results: [MASKED] 01:00PM [MASKED] PTT-34.4 [MASKED] [MASKED] 01:00PM PLT COUNT-169 [MASKED] 01:00PM NEUTS-81.6* LYMPHS-6.6* MONOS-10.4 EOS-0.1* BASOS-0.1 IM [MASKED] AbsNeut-6.00 AbsLymp-0.49* AbsMono-0.77 AbsEos-0.01* AbsBaso-0.01 [MASKED] 01:00PM WBC-7.4 RBC-3.02* HGB-9.1* HCT-30.2* MCV-100* MCH-30.1 MCHC-30.1* RDW-16.4* RDWSD-59.2* [MASKED] 01:00PM calTIBC-352 FERRITIN-111 TRF-271 [MASKED] 01:00PM CALCIUM-9.2 PHOSPHATE-3.7 MAGNESIUM-2.8* IRON-88 [MASKED] 01:00PM CK-MB-4 cTropnT-0.01 [MASKED] [MASKED] 01:00PM ALT(SGPT)-56* AST(SGOT)-52* LD(LDH)-277* ALK PHOS-135* TOT BILI-0.7 [MASKED] 01:00PM estGFR-Using this [MASKED] 01:00PM GLUCOSE-100 UREA N-52* CREAT-2.1* SODIUM-135 POTASSIUM-5.4 CHLORIDE-100 TOTAL CO2-24 ANION GAP-11 [MASKED] 04:54PM URINE HYALINE-1* [MASKED] 04:54PM URINE RBC-0 WBC-<1 BACTERIA-NONE YEAST-NONE EPI-<1 [MASKED] 04:54PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR* GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [MASKED] 04:54PM URINE COLOR-Straw APPEAR-Clear SP [MASKED] [MASKED] 07:53AM BLOOD WBC-6.5 RBC-2.70* Hgb-8.2* Hct-26.5* MCV-98 MCH-30.4 MCHC-30.9* RDW-16.0* RDWSD-56.3* Plt [MASKED] [MASKED] 07:53AM BLOOD Plt [MASKED] [MASKED] 07:53AM BLOOD Glucose-105* UreaN-43* Creat-2.2* Na-140 K-4.2 Cl-102 HCO3-27 AnGap-11 [MASKED]:04AM BLOOD ALT-45* AST-42* AlkPhos-113 TotBili-0.6 [MASKED] 07:53AM BLOOD Calcium-8.6 Phos-3.5 Mg-2.4 [MASKED] 01:00PM BLOOD calTIBC-352 Ferritn-111 TRF-271 Brief Hospital Course: TRANSITIONAL ISSUES ==================== DISCHARGE WEIGHT: 55.6 kg (122.57 lb) DISCHARGE Cr/BUN: Cr 2.2, BUN 43 DISCHARGE DIURETIC: 40 Torsemide daily MEDICATION CHANGES: Decreased daily potassium to 40 mEq daily (from 30 mEq twice dailye) [] Please obtain repeat Chem10 within 2 weeks and after 4 weeks. Adjust electrolyte repletion accordingly. [] Please follow up weight and volume status and adjust torsemide accordingly. #CODE STATUS: Presumed full Health care proxy chosen: Yes Name of health care proxy: [MASKED] [MASKED]: son Phone number: [MASKED] ==================== PATIENT SUMMARY: ==================== Mr. [MASKED] is a [MASKED] gentleman with PMHx of CAD s/p CABG and subsequent PCI, HFrEF (35% [MASKED], moderate tricuspid regurgitation, right ventricular dysfunction, moderate pulmonary hypertension, and paroxysmal atrial fibrillation on apixaban, stage III chronic kidney disease (Baseline Cr 2.0-2.1), cerebrovascular disease, and metastatic melanoma of unknown primary on checkpoint inhibitor pembrolizumab who was found volume overloaded with increased DOE, admitted to acute [MASKED] failure for IV diuresis, now transitioned to oral duiretics. # CORONARIES: Left Main and two vessel coronary disease ([MASKED]). # PUMP: 35% [MASKED] # RHYTHM: Ectopic rhythm, PR prolongation, left axis deviation, RBBB ACTIVE ISSUES: ============== # [MASKED] Failure with reduced ejection fraction # Right ventricular dysfunction, TR, pulm HTN # Volume overload His [MASKED] failure exacerbation is likely secondary to his recent administration of IV fluids in addition to his self down titration of his torsemide over the last week. In addition, he does not follow a restricted fluid intake and drinks [MASKED] glasses of water or juice daily. Furthermore, he has not tolerated guideline directed medical therapy due to recurrent issues with acute kidney injury and elevated transaminitis while on pembrolizumab therapy. He was clinically volume overloaded with elevated BNP 16020. We initiated IV lasix 160 bolus and put him on a lasix gtt with good response, however he his Cr increased from 2.1-->2.7. His Cr. improved with transition to PO Torsemide 40 mg daily. We monitored and aggressively repleted his potassium. No afterload reduction or neural hormonal blockade was added. # Chronic Kidney Disease: Baseline 2.1-2.3 . Cr 2.1 on admission(Stable )- Cr on discharge:2.2 Cr initially uptrended above baseline from 2.1---> 2.7. Felt likely due to increased diuretic usage as it improved with stopping diuretics. Less likely cardiorenal syndrome. In addition,patient was recently seen in follow-up by nephrology. They felt his CKD was less likely to be related to pembrolizumab and more likely related to age-related decline in renal function. Creatinine 2.2 on discharge (stable). # Metastatic Melanoma He is followed by Dr. [MASKED]. He was previously on Pembrolizumab which was held due diarrhea, elevated LFTs and worsening kidney function. Negative troponin and CK MB, no concern for drug-induced myocarditis at this point. Followup in [MASKED] clinic in 2weeks after discharge # Elevated transaminiatis Stable. Statin and [MASKED] had previously been held. No changes made during admission. # Urinary frequency Likely due to diuretic use. Afebrile and asx otherwise -Continued home tamsulosin # Coronary artery disease, s/p CABG and LAD PCI. -Continued aspirin 81 mg daily -Statin stopped prior to admission due to elevated LFTs. Continued holding. CHRONIC ISSUES: ============== # Paroxysmal Atrial fibrillation Rythym: Continue amiodarone 200mg for rhythm control strategy (monitoring safety labs) -Continued anticoagulation with apixaban 2.5mg twice daily # Hypertension: Stable. Medications on Admission: The Preadmission Medication list may be inaccurate and requires further investigation. 1. Amiodarone 200 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Senna 17.2 mg PO HS 5. Vitamin D 1000 UNIT PO DAILY 6. Align (bifidobacterium infantis) 4 mg oral DAILY 7. coenzyme Q10 100 mg oral DAILY 8. Tamsulosin 0.4 mg PO QHS 9. Torsemide 40 mg PO DAILY 10. Ferrous Sulfate 325 mg PO DAILY 11. Sertraline 50 mg PO DAILY 12. Potassium Chloride 30 mEq PO BID 13. Apixaban 2.5 mg PO BID 14. Cephalexin 500 mg PO Q6H Discharge Medications: 1. Potassium Chloride 40 mEq PO DAILY RX *potassium chloride 20 mEq 2 packet(s) by mouth once a day Disp #*60 Tablet Refills:*0 2. Align (bifidobacterium infantis) 4 mg oral DAILY 3. Amiodarone 200 mg PO DAILY 4. Apixaban 2.5 mg PO BID 5. Aspirin 81 mg PO DAILY 6. coenzyme Q10 100 mg oral DAILY 7. Docusate Sodium 100 mg PO BID 8. Ferrous Sulfate 325 mg PO DAILY 9. Senna 17.2 mg PO HS 10. Sertraline 50 mg PO DAILY 11. Tamsulosin 0.4 mg PO QHS RX *tamsulosin 0.4 mg 1 capsule(s) by mouth nightly Disp #*30 Capsule Refills:*0 12. Torsemide 40 mg PO DAILY 13. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Primary Diagnosis ================= HFrEF excerterbation Secondary diagnosis =================== Transaminitis Metastatic melanoma CKD Coronary artery disease, s/p CABG and LAD PCI 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 ========================== Dear Mr. [MASKED] , It was a pleasure taking care of you at [MASKED] [MASKED]. WHY WAS I ADMITTED TO THE HOSPITAL? You were feeling short of breath because you had fluid in your lungs. This was caused by a condition called [MASKED] failure, where your [MASKED] does not pump hard enough and fluid backs up into your lungs. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? You were given medications to help get the fluid out. Your breathing got better and were ready to leave the hospital. WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? - Take all of your medications as prescribed (listed below) - Follow up with your doctors as listed below - Weigh yourself every morning. Your weight on discharge is 122.57 lbs. Call your doctor if your weight goes up more than 3 pounds. - Call you doctor if you notice any of the "danger signs" below. We wish you the best! Your [MASKED] Care Team Followup Instructions: [MASKED]
|
[] |
[
"I130",
"N179",
"Z87891",
"Z951",
"Z955",
"I480",
"Z7902",
"Z8673",
"K219",
"N400"
] |
[
"I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease",
"I5023: Acute on chronic systolic (congestive) heart failure",
"N179: Acute kidney failure, unspecified",
"C799: Secondary malignant neoplasm of unspecified site",
"N183: Chronic kidney disease, stage 3 (moderate)",
"Z87891: Personal history of nicotine dependence",
"J439: Emphysema, unspecified",
"Z951: Presence of aortocoronary bypass graft",
"Z955: Presence of coronary angioplasty implant and graft",
"I071: Rheumatic tricuspid insufficiency",
"I2720: Pulmonary hypertension, unspecified",
"I480: Paroxysmal atrial fibrillation",
"Z7902: Long term (current) use of antithrombotics/antiplatelets",
"Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits",
"C439: Malignant melanoma of skin, unspecified",
"I6523: Occlusion and stenosis of bilateral carotid arteries",
"K219: Gastro-esophageal reflux disease without esophagitis",
"I4510: Unspecified right bundle-branch block",
"N400: Benign prostatic hyperplasia without lower urinary tract symptoms",
"E7849: Other hyperlipidemia",
"Z902: Acquired absence of lung [part of]",
"R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]",
"I255: Ischemic cardiomyopathy"
] |
10,002,430 | 26,295,318 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Corgard / ___
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
ADMISSION LABS:
===============
___ 12:48AM BLOOD WBC-10.3* RBC-3.71* Hgb-10.6* Hct-36.6*
MCV-99* MCH-28.6 MCHC-29.0* RDW-18.6* RDWSD-55.8* Plt ___
___ 12:48AM BLOOD ___ PTT-82.4* ___
___ 12:48AM BLOOD Glucose-128* UreaN-47* Creat-2.2* Na-144
K-3.8 Cl-105 HCO3-22 AnGap-17
___ 12:48AM BLOOD ALT-75* AST-55* AlkPhos-150* TotBili-1.1
___ 12:48AM BLOOD ___
___ 12:48AM BLOOD Calcium-9.2 Phos-4.0 Mg-2.3
___ 01:19AM BLOOD ___ pO2-59* pCO2-42 pH-7.34*
calTCO2-24 Base XS--2
RELEVANT LABS:
==============
___ 12:48AM BLOOD ___
IMAGING:
========
CXR: ___
No comparison. The lung volumes are low. Moderate cardiomegaly
is present. Normal alignment of the sternal wires after CABG.
Mild bilateral pleural effusions. Signs of moderate pulmonary
edema. Retrocardiac atelectasis, no evidence of pneumonia.
CXR: ___
There are stable postsurgical changes following wedge resection
the right
lower lobe. Small bilateral effusions right greater than left
are unchanged. Cardiomediastinal silhouette is stable. There is
moderate cardiomegaly. No pneumothorax. Mild pulmonary edema
is unchanged.
DISCARHGE LABS:
===================
___ 08:00AM BLOOD WBC-5.4 RBC-3.54* Hgb-10.3* Hct-34.1*
MCV-96 MCH-29.1 MCHC-30.2* RDW-19.0* RDWSD-65.7* Plt ___
___ 08:00AM BLOOD Glucose-94 UreaN-44* Creat-2.0* Na-140
K-3.6 Cl-99 HCO3-27 AnGap-14
___ 08:00AM BLOOD ALT-38 AST-46* LD(LDH)-198 AlkPhos-108
TotBili-0.5
___ 08:00AM BLOOD Calcium-9.0 Phos-3.5 Mg-2.3
Brief Hospital Course:
TRANSITIONAL ISSUES:
====================
[] Consider discontinuing amiodarone given persistence of AF
despite this medication
[] Consider starting beta blocker, if BP is able to tolerate.
Patient previously did not tolerate this medication while on
pembrolizumab (dizziness and ___, but patient has been off of
pembrolizumab since ___
[] Consider starting spironolactone and ___ pending blood
pressures; trialed losartan and spironolactone during this
admission, but ultimately held due to hypotension.
[] His LFTs should be rechecked ~2 weeks after discharge
(___). He has a history of transaminitis attributed in part
to statin use in the past; he was restarted on rosuvastatin this
admission (given history of CAD s/p CABG), and LFTs on day of
admission were ALT 38, AST 46, Alk phos 108, Tbili 0.5.
[] Follow up with Oncology regarding melanoma.
[] Monitor for resolution of supplemental O2 requirement after
discharge. He was requiring ___ of O2 by NC at time of
discharge, in the setting of recovering from pneumonia.
DISCHARGE WT: 116.18 lbs
DISCHARTE Cr: 2.0
DISCHARGE DIURETIC: torsemide 60 mg PO BID
SUMMARY:
===============
Mr. ___ is a ___ man with PMH of HFrEF (35%
___,
CAD s/p 3v CABG (___) and subsequent PCI to the LAD (___),
moderate tricuspid regurgitation, right ventricular dysfunction,
moderate pulmonary hypertension, and paroxysmal atrial
fibrillation on apixaban, stage III chronic kidney disease
(Baseline Cr 2.0-2.1), cerebrovascular disease, and metastatic
melanoma of unknown primary on Pembrolizumab (on hold since
___ iso worsening transaminitis and concern for
cardiotoxicity). He was admitted with volume overload from heart
failure exacerbation and pneumonia with high oxygen
requirements. He initially required CCU admission for high flow
oxygen, weaned to nasal cannula after aggressive IV diuresis and
treatment of pneumonia with 5 day course of Zosyn after
receiving vancomycin at OSH. He was transferred to cardiology
floor where he continued to diurese well and his oxygen
requirement was weaned to ___. He was transitioned to 60 mg
torsemide PO BID which adequately maintained euvolemia.
ACUTE ISSUES:
=============
# Acute on chronic systolic heart failure exacerbation
Patient with history of heart failure with etiology likely
ischemic cardiomyopathy given history of CAD s/p CABG and PCI.
Admitted with fluid overload and pleural effusion. Trigger for
current exacerbation could be infectious given evidence of
pneumonia in left lower lobe on admission. Patient with high
oxygen requirements prior to admission but responded
appropriately to diuresis with Lasix. After IV diuresis, patient
was transitioned PO torsemide and maintained at euvolemia. With
effective diuresis, the patient's oxygen requirement gradually
lowered from 4L NC to ___ NC. He was discharged on torsemide 60
mg PO BID. He was unable to tolerate afterload reducing agents
or neurohormonal blockade agents due to hypotension.
# Lower left lobe pneumonia
Patient with evidence of pneumonia in the left lower lobe,
received vanc/zosyn at outside hospital and continued on Zosyn
here for a total of 5 day course with resolution of symptoms. We
suspect that his lingering O2 requirement is at least in part
due to slowly resorbing consolidation left over from his
infection. He was requiring ___ of supplemental O2 by NC at
time of discharge.
# Pleural effusion, bilateral
Patient with evidence of right pleural effusion. Etiology likely
fluid overload given heart failure with reduced ejection
fraction. Pleural effusion resolved improved with diuresis and
his oxygen requirement trended down to ___ NC. Given this,
thoracentesis was deferred.
# Atrial fibrillation
Patient with chronic history of atrial fibrillation. In afib
throughout this admission. Continued amiodarone and apixaban.
Rates appropriately controlled.
CHRONIC ISSUES
================
# Coronary artery disease s/p CABG
Patient with history of 3 vessel CABG on ___ (___) and
subsequent PCI to LAD (___). Continued home aspirin. Patient
was started on low dose rosuvastatin 5 mg daily. On review, it
appears he had been on this medication at this dose in the past
but it was discontinued due to transamnitis; however, at the
time it was unclear whether this was an effect of the statin or
pembrolizumab. Given that the patient has not had his checkpoint
inhibitor therapy since ___, the decision was to restart
rosuvastatin.
# Chronic kidney disease
Baseline Cr appears to be 2.1-2.2 over past year. Cr remained
between 1.8-2.4 throughout admission.
# Anemia
Chronic, although worsening since ___. On admission
hemoglobin
10.6 and remained stable.
# Thrombocytopenia
Uncertain etiology, appears subacute/chronic. On admission
platelets 130 down-trended to 100s. No concern for bleeding
throughout admission.
# Melanoma
Patient with history of metastatic melanoma with unknown
primary.
On treatment with pembrolizumab, but held since ___ iso
toxicity.
CODE: DNR/DNI
CONTACT: ___ (___)
Relationship: Son
Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 200 mg PO DAILY
2. Apixaban 2.5 mg PO BID
3. Aspirin 81 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Ferrous Sulfate 325 mg PO DAILY
6. Senna 17.2 mg PO HS
7. Sertraline 50 mg PO DAILY
8. Tamsulosin 0.4 mg PO QHS
9. Torsemide 40 mg PO DAILY
10. coenzyme Q10 100 mg oral DAILY
11. Align (bifidobacterium infantis) 4 mg oral DAILY
12. Potassium Chloride 40 mEq PO DAILY
Discharge Medications:
1. Rosuvastatin Calcium 5 mg PO QPM
2. Vitamin D 1000 UNIT PO DAILY
3. Torsemide 60 mg PO BID
4. Align (bifidobacterium infantis) 4 mg oral DAILY
5. Amiodarone 200 mg PO DAILY
6. Apixaban 2.5 mg PO BID
7. Aspirin 81 mg PO DAILY
8. coenzyme Q10 100 mg oral DAILY
9. Docusate Sodium 100 mg PO BID
10. Ferrous Sulfate 325 mg PO DAILY
11. Potassium Chloride 40 mEq PO DAILY
12. Senna 17.2 mg PO HS
13. Sertraline 50 mg PO DAILY
14. Tamsulosin 0.4 mg PO QHS
___ and mineralocorticoid receptor antagonist held in the
setting of hypotension and CKD. Patient is intolerant of beta
blockers due to dizziness/hypotension previously.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
=====================
Acute on chronic systolic heart failure exacerbation
Lower left lobe pneumonia
Bilateral pleural effusion
Atrial fibrillation
Secondary diagnosis:
=====================
Coronary artery disease status post CABG
Chronic kidney disease
Anemia
Thrombocytopenia
Metastatic melanoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___.
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted because of you were short of breath
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You were found to have fluid on your lungs. This was because
you have a medical condition called heart failure, where your
heart does not pump hard enough and fluid backs up into your
lungs.
- You were given a diuretic medication to help get the fluid
out. You improved considerably and are ready to leave the
hospital.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Be sure to take all your medications and attend all of your
appointments listed below.
- Your weight at discharge is 116.18 lbs. Please weigh yourself
today at home and use this as your new baseline
- Please weigh yourself every day in the morning. Call your
doctor or the HeartLine at ___ if your weight goes up
by more than 3 lbs or you experience significant chest pain and
shortness of breath.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
[
"I5023",
"J189",
"J9691",
"C7951",
"J90",
"N179",
"I255",
"I480",
"Z7902",
"I2720",
"I079",
"I2510",
"Z951",
"N183",
"D638",
"D696",
"C439",
"Z87891"
] |
Allergies: Corgard / [MASKED] Major Surgical or Invasive Procedure: None attach Pertinent Results: ADMISSION LABS: =============== [MASKED] 12:48AM BLOOD WBC-10.3* RBC-3.71* Hgb-10.6* Hct-36.6* MCV-99* MCH-28.6 MCHC-29.0* RDW-18.6* RDWSD-55.8* Plt [MASKED] [MASKED] 12:48AM BLOOD [MASKED] PTT-82.4* [MASKED] [MASKED] 12:48AM BLOOD Glucose-128* UreaN-47* Creat-2.2* Na-144 K-3.8 Cl-105 HCO3-22 AnGap-17 [MASKED] 12:48AM BLOOD ALT-75* AST-55* AlkPhos-150* TotBili-1.1 [MASKED] 12:48AM BLOOD [MASKED] [MASKED] 12:48AM BLOOD Calcium-9.2 Phos-4.0 Mg-2.3 [MASKED] 01:19AM BLOOD [MASKED] pO2-59* pCO2-42 pH-7.34* calTCO2-24 Base XS--2 RELEVANT LABS: ============== [MASKED] 12:48AM BLOOD [MASKED] IMAGING: ======== CXR: [MASKED] No comparison. The lung volumes are low. Moderate cardiomegaly is present. Normal alignment of the sternal wires after CABG. Mild bilateral pleural effusions. Signs of moderate pulmonary edema. Retrocardiac atelectasis, no evidence of pneumonia. CXR: [MASKED] There are stable postsurgical changes following wedge resection the right lower lobe. Small bilateral effusions right greater than left are unchanged. Cardiomediastinal silhouette is stable. There is moderate cardiomegaly. No pneumothorax. Mild pulmonary edema is unchanged. DISCARHGE LABS: =================== [MASKED] 08:00AM BLOOD WBC-5.4 RBC-3.54* Hgb-10.3* Hct-34.1* MCV-96 MCH-29.1 MCHC-30.2* RDW-19.0* RDWSD-65.7* Plt [MASKED] [MASKED] 08:00AM BLOOD Glucose-94 UreaN-44* Creat-2.0* Na-140 K-3.6 Cl-99 HCO3-27 AnGap-14 [MASKED] 08:00AM BLOOD ALT-38 AST-46* LD(LDH)-198 AlkPhos-108 TotBili-0.5 [MASKED] 08:00AM BLOOD Calcium-9.0 Phos-3.5 Mg-2.3 Brief Hospital Course: TRANSITIONAL ISSUES: ==================== [] Consider discontinuing amiodarone given persistence of AF despite this medication [] Consider starting beta blocker, if BP is able to tolerate. Patient previously did not tolerate this medication while on pembrolizumab (dizziness and [MASKED], but patient has been off of pembrolizumab since [MASKED] [] Consider starting spironolactone and [MASKED] pending blood pressures; trialed losartan and spironolactone during this admission, but ultimately held due to hypotension. [] His LFTs should be rechecked ~2 weeks after discharge ([MASKED]). He has a history of transaminitis attributed in part to statin use in the past; he was restarted on rosuvastatin this admission (given history of CAD s/p CABG), and LFTs on day of admission were ALT 38, AST 46, Alk phos 108, Tbili 0.5. [] Follow up with Oncology regarding melanoma. [] Monitor for resolution of supplemental O2 requirement after discharge. He was requiring [MASKED] of O2 by NC at time of discharge, in the setting of recovering from pneumonia. DISCHARGE WT: 116.18 lbs DISCHARTE Cr: 2.0 DISCHARGE DIURETIC: torsemide 60 mg PO BID SUMMARY: =============== Mr. [MASKED] is a [MASKED] man with PMH of HFrEF (35% [MASKED], CAD s/p 3v CABG ([MASKED]) and subsequent PCI to the LAD ([MASKED]), moderate tricuspid regurgitation, right ventricular dysfunction, moderate pulmonary hypertension, and paroxysmal atrial fibrillation on apixaban, stage III chronic kidney disease (Baseline Cr 2.0-2.1), cerebrovascular disease, and metastatic melanoma of unknown primary on Pembrolizumab (on hold since [MASKED] iso worsening transaminitis and concern for cardiotoxicity). He was admitted with volume overload from heart failure exacerbation and pneumonia with high oxygen requirements. He initially required CCU admission for high flow oxygen, weaned to nasal cannula after aggressive IV diuresis and treatment of pneumonia with 5 day course of Zosyn after receiving vancomycin at OSH. He was transferred to cardiology floor where he continued to diurese well and his oxygen requirement was weaned to [MASKED]. He was transitioned to 60 mg torsemide PO BID which adequately maintained euvolemia. ACUTE ISSUES: ============= # Acute on chronic systolic heart failure exacerbation Patient with history of heart failure with etiology likely ischemic cardiomyopathy given history of CAD s/p CABG and PCI. Admitted with fluid overload and pleural effusion. Trigger for current exacerbation could be infectious given evidence of pneumonia in left lower lobe on admission. Patient with high oxygen requirements prior to admission but responded appropriately to diuresis with Lasix. After IV diuresis, patient was transitioned PO torsemide and maintained at euvolemia. With effective diuresis, the patient's oxygen requirement gradually lowered from 4L NC to [MASKED] NC. He was discharged on torsemide 60 mg PO BID. He was unable to tolerate afterload reducing agents or neurohormonal blockade agents due to hypotension. # Lower left lobe pneumonia Patient with evidence of pneumonia in the left lower lobe, received vanc/zosyn at outside hospital and continued on Zosyn here for a total of 5 day course with resolution of symptoms. We suspect that his lingering O2 requirement is at least in part due to slowly resorbing consolidation left over from his infection. He was requiring [MASKED] of supplemental O2 by NC at time of discharge. # Pleural effusion, bilateral Patient with evidence of right pleural effusion. Etiology likely fluid overload given heart failure with reduced ejection fraction. Pleural effusion resolved improved with diuresis and his oxygen requirement trended down to [MASKED] NC. Given this, thoracentesis was deferred. # Atrial fibrillation Patient with chronic history of atrial fibrillation. In afib throughout this admission. Continued amiodarone and apixaban. Rates appropriately controlled. CHRONIC ISSUES ================ # Coronary artery disease s/p CABG Patient with history of 3 vessel CABG on [MASKED] ([MASKED]) and subsequent PCI to LAD ([MASKED]). Continued home aspirin. Patient was started on low dose rosuvastatin 5 mg daily. On review, it appears he had been on this medication at this dose in the past but it was discontinued due to transamnitis; however, at the time it was unclear whether this was an effect of the statin or pembrolizumab. Given that the patient has not had his checkpoint inhibitor therapy since [MASKED], the decision was to restart rosuvastatin. # Chronic kidney disease Baseline Cr appears to be 2.1-2.2 over past year. Cr remained between 1.8-2.4 throughout admission. # Anemia Chronic, although worsening since [MASKED]. On admission hemoglobin 10.6 and remained stable. # Thrombocytopenia Uncertain etiology, appears subacute/chronic. On admission platelets 130 down-trended to 100s. No concern for bleeding throughout admission. # Melanoma Patient with history of metastatic melanoma with unknown primary. On treatment with pembrolizumab, but held since [MASKED] iso toxicity. CODE: DNR/DNI CONTACT: [MASKED] ([MASKED]) Relationship: Son Phone number: [MASKED] [MASKED] on Admission: The Preadmission Medication list is accurate and complete. 1. Amiodarone 200 mg PO DAILY 2. Apixaban 2.5 mg PO BID 3. Aspirin 81 mg PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Ferrous Sulfate 325 mg PO DAILY 6. Senna 17.2 mg PO HS 7. Sertraline 50 mg PO DAILY 8. Tamsulosin 0.4 mg PO QHS 9. Torsemide 40 mg PO DAILY 10. coenzyme Q10 100 mg oral DAILY 11. Align (bifidobacterium infantis) 4 mg oral DAILY 12. Potassium Chloride 40 mEq PO DAILY Discharge Medications: 1. Rosuvastatin Calcium 5 mg PO QPM 2. Vitamin D 1000 UNIT PO DAILY 3. Torsemide 60 mg PO BID 4. Align (bifidobacterium infantis) 4 mg oral DAILY 5. Amiodarone 200 mg PO DAILY 6. Apixaban 2.5 mg PO BID 7. Aspirin 81 mg PO DAILY 8. coenzyme Q10 100 mg oral DAILY 9. Docusate Sodium 100 mg PO BID 10. Ferrous Sulfate 325 mg PO DAILY 11. Potassium Chloride 40 mEq PO DAILY 12. Senna 17.2 mg PO HS 13. Sertraline 50 mg PO DAILY 14. Tamsulosin 0.4 mg PO QHS [MASKED] and mineralocorticoid receptor antagonist held in the setting of hypotension and CKD. Patient is intolerant of beta blockers due to dizziness/hypotension previously. Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Primary diagnosis: ===================== Acute on chronic systolic heart failure exacerbation Lower left lobe pneumonia Bilateral pleural effusion Atrial fibrillation Secondary diagnosis: ===================== Coronary artery disease status post CABG Chronic kidney disease Anemia Thrombocytopenia Metastatic melanoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [MASKED], It was a pleasure taking care of you at the [MASKED] [MASKED]. WHY WAS I IN THE HOSPITAL? ========================== - You were admitted because of you were short of breath WHAT HAPPENED IN THE HOSPITAL? ============================== - You were found to have fluid on your lungs. This was because you have a medical condition called heart failure, where your heart does not pump hard enough and fluid backs up into your lungs. - You were given a diuretic medication to help get the fluid out. You improved considerably and are ready to leave the hospital. WHAT SHOULD I DO WHEN I GO HOME? ================================ - Be sure to take all your medications and attend all of your appointments listed below. - Your weight at discharge is 116.18 lbs. Please weigh yourself today at home and use this as your new baseline - Please weigh yourself every day in the morning. Call your doctor or the HeartLine at [MASKED] if your weight goes up by more than 3 lbs or you experience significant chest pain and shortness of breath. Thank you for allowing us to be involved in your care, we wish you all the best! Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]
|
[] |
[
"N179",
"I480",
"Z7902",
"I2510",
"Z951",
"D696",
"Z87891"
] |
[
"I5023: Acute on chronic systolic (congestive) heart failure",
"J189: Pneumonia, unspecified organism",
"J9691: Respiratory failure, unspecified with hypoxia",
"C7951: Secondary malignant neoplasm of bone",
"J90: Pleural effusion, not elsewhere classified",
"N179: Acute kidney failure, unspecified",
"I255: Ischemic cardiomyopathy",
"I480: Paroxysmal atrial fibrillation",
"Z7902: Long term (current) use of antithrombotics/antiplatelets",
"I2720: Pulmonary hypertension, unspecified",
"I079: Rheumatic tricuspid valve disease, unspecified",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"Z951: Presence of aortocoronary bypass graft",
"N183: Chronic kidney disease, stage 3 (moderate)",
"D638: Anemia in other chronic diseases classified elsewhere",
"D696: Thrombocytopenia, unspecified",
"C439: Malignant melanoma of skin, unspecified",
"Z87891: Personal history of nicotine dependence"
] |
10,002,430 | 27,218,502 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Corgard / Vasotec
Attending: ___.
Chief Complaint:
incarcerated inguinal hernia
Major Surgical or Invasive Procedure:
Left inguinal hernia repair
History of Present Illness:
___ with afib on apixiban, CAD s/p CABG, b/l carotid disease,
COPD/emphysema with recent pneumonia presents for elective left
inguinal hernia repair (large, with incarcerated sigmoid colon)
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:
Gen: Awake and alert
CV: Irregularly irregular rhythm, normal rate
Resp: CTAB
GI: Soft, appropriately tender near incision, non-distended
Incision clean, dry, and intact with no erythema
Ext: Warm and well perfused
Pertinent Results:
Brief Hospital Course:
Mr. ___ was admitted to ___
___ on ___ after undergoing repair of a left
incarcerated inguinal hernia. For details of the procedure,
please refer to the operative report. His postoperative course
was uncomplicated. After a brief stay in the PACU, he was
transferred to the regular nursing floor. His pain was
controlled with IV medication. On POD #1, he was started on a
regular diet, and his pain was controlled with PO pain
medication. He voided without issue. He was ambulating
independently in the halls. He was given a bowel regimen, and
passed flatus. On POD #2, he continued to tolerate his diet, his
pain was well-controlled on oral medication, and he continued to
ambulate independently. He was discharged home in stable
condition on POD #2 with plans to follow-up with Dr. ___.
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. Omeprazole 10 mg PO DAILY
7. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
8. Acetaminophen 1000 mg PO Q6H:PRN pain or fever
Do not exceed 4 grams per day.
RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours
Disp #*60 Tablet Refills:*0
9. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp
#*40 Tablet Refills:*0
10. Senna 17.2 mg PO HS
Take this while you are taking oxycodone.
RX *sennosides [Evac-U-Gen (sennosides)] 8.6 mg 1 capsule by
mouth daily Disp #*30 Tablet Refills:*0
11. Align (bifidobacterium infantis) 4 mg oral DAILY
12. coenzyme Q10 100 mg oral DAILY
13. Rosuvastatin Calcium 40 mg PO QPM
14. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Inguinal hernia
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 here at ___
___. You were admitted to our hospital
after undergoing repair of your inguinal hernia. You have
recovered from surgery and are now ready to be discharged home.
Please follow the recommendations below to ensure a speedy and
uneventful recovery.
ACTIVITY:
- Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
- You may climb stairs.
- You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
- Don't lift more than 10 lbs for 6 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
- You may start some light exercise when you feel comfortable.
- You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
- Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
- You may resume sexual activity unless your doctor has told you
otherwise.
HOW YOU MAY FEEL:
- You may feel weak or "washed out" for 6 weeks. You might want
to nap often. Simple tasks may exhaust you.
- You may have a sore throat because of a tube that was in your
throat during surgery.
- You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
- You could have a poor appetite for a while. Food may seem
unappealing.
- All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
- Your incision may be slightly red around the edges. This is
normal.
- If you have steri strips, do not remove them for 2 weeks.
(These are the thin paper strips that are on your incision.) But
if they fall off before that that's okay).
- You may gently wash away dried material around your incision.
- It is normal to feel a firm ridge along the incision. This
will go away.
- Avoid direct sun exposure to the incision area.
- Do not use any ointments on the incision unless you were told
otherwise.
- You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
- You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
- Over the next ___ months, your incision will fade and become
less prominent.
YOUR BOWELS:
- Constipation is a common side effect of medicine such as
Percocet or codeine. If needed, you may take a stool softener
(such as Colace, one capsule) or gentle laxative (such as milk
of magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
- If you go 48 hours without a bowel movement, or have pain
moving your bowels, call your surgeon.
- After some operations, diarrhea can occur. If you get
diarrhea, don't take anti-diarrhea medicines. Drink plenty of
fluids and see if it goes away. If it does not go away, or is
severe and you feel ill, please call your surgeon.
PAIN MANAGEMENT:
- It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
- Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
-You will receive a prescription from your surgeon for pain
medicine to take by mouth. It is important to take this medicine
as directed.
- Do not take it more frequently than prescribed. Do not take
more medicine at one time than prescribed.
- Your pain medicine will work better if you take it before your
pain gets too severe.
- If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
If you experience any of the folloiwng, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
- Take all the medicines you were on before the operation just
as you did before, unless you have been told differently.
- If you have any questions about what medicine to take or not
to take, please call your surgeon.
Followup Instructions:
___
|
[
"K4030",
"I480",
"I272",
"I509",
"I2510",
"I10",
"K219",
"N400",
"E785",
"J439",
"I4510",
"Z7982",
"Z951",
"Z87891"
] |
Allergies: Corgard / Vasotec Chief Complaint: incarcerated inguinal hernia Major Surgical or Invasive Procedure: Left inguinal hernia repair History of Present Illness: [MASKED] with afib on apixiban, CAD s/p CABG, b/l carotid disease, COPD/emphysema with recent pneumonia presents for elective left inguinal hernia repair (large, with incarcerated sigmoid colon) 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 [MASKED] RIGHT LOWER LOBE LOBECTOMY [MASKED] CORONARY BYPASS SURGERY [MASKED] Social History: [MASKED] Family History: Non-contributory Physical Exam: Gen: Awake and alert CV: Irregularly irregular rhythm, normal rate Resp: CTAB GI: Soft, appropriately tender near incision, non-distended Incision clean, dry, and intact with no erythema Ext: Warm and well perfused Pertinent Results: Brief Hospital Course: Mr. [MASKED] was admitted to [MASKED] [MASKED] on [MASKED] after undergoing repair of a left incarcerated inguinal hernia. For details of the procedure, please refer to the operative report. His postoperative course was uncomplicated. After a brief stay in the PACU, he was transferred to the regular nursing floor. His pain was controlled with IV medication. On POD #1, he was started on a regular diet, and his pain was controlled with PO pain medication. He voided without issue. He was ambulating independently in the halls. He was given a bowel regimen, and passed flatus. On POD #2, he continued to tolerate his diet, his pain was well-controlled on oral medication, and he continued to ambulate independently. He was discharged home in stable condition on POD #2 with plans to follow-up with Dr. [MASKED]. 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. Omeprazole 10 mg PO DAILY 7. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY 8. Acetaminophen 1000 mg PO Q6H:PRN pain or fever Do not exceed 4 grams per day. RX *acetaminophen 500 mg [MASKED] tablet(s) by mouth every 6 hours Disp #*60 Tablet Refills:*0 9. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain RX *oxycodone 5 mg [MASKED] tablet(s) by mouth every 4 hours Disp #*40 Tablet Refills:*0 10. Senna 17.2 mg PO HS Take this while you are taking oxycodone. RX *sennosides [Evac-U-Gen (sennosides)] 8.6 mg 1 capsule by mouth daily Disp #*30 Tablet Refills:*0 11. Align (bifidobacterium infantis) 4 mg oral DAILY 12. coenzyme Q10 100 mg oral DAILY 13. Rosuvastatin Calcium 40 mg PO QPM 14. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Inguinal hernia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], It was a pleasure taking care of you here at [MASKED] [MASKED]. You were admitted to our hospital after undergoing repair of your inguinal hernia. You have recovered from surgery and are now ready to be discharged home. Please follow the recommendations below to ensure a speedy and uneventful recovery. ACTIVITY: - Do not drive until you have stopped taking pain medicine and feel you could respond in an emergency. - You may climb stairs. - You may go outside, but avoid traveling long distances until you see your surgeon at your next visit. - Don't lift more than 10 lbs for 6 weeks. (This is about the weight of a briefcase or a bag of groceries.) This applies to lifting children, but they may sit on your lap. - You may start some light exercise when you feel comfortable. - You will need to stay out of bathtubs or swimming pools for a time while your incision is healing. Ask your doctor when you can resume tub baths or swimming. - Heavy exercise may be started after 6 weeks, but use common sense and go slowly at first. - You may resume sexual activity unless your doctor has told you otherwise. HOW YOU MAY FEEL: - You may feel weak or "washed out" for 6 weeks. You might want to nap often. Simple tasks may exhaust you. - You may have a sore throat because of a tube that was in your throat during surgery. - You might have trouble concentrating or difficulty sleeping. You might feel somewhat depressed. - You could have a poor appetite for a while. Food may seem unappealing. - All of these feelings and reactions are normal and should go away in a short time. If they do not, tell your surgeon. YOUR INCISION: - Your incision may be slightly red around the edges. This is normal. - If you have steri strips, do not remove them for 2 weeks. (These are the thin paper strips that are on your incision.) But if they fall off before that that's okay). - You may gently wash away dried material around your incision. - It is normal to feel a firm ridge along the incision. This will go away. - Avoid direct sun exposure to the incision area. - Do not use any ointments on the incision unless you were told otherwise. - You may see a small amount of clear or light red fluid staining your dressing or clothes. If the staining is severe, please call your surgeon. - You may shower. As noted above, ask your doctor when you may resume tub baths or swimming. - Over the next [MASKED] months, your incision will fade and become less prominent. YOUR BOWELS: - Constipation is a common side effect of medicine such as Percocet or codeine. If needed, you may take a stool softener (such as Colace, one capsule) or gentle laxative (such as milk of magnesia, 1 tbs) twice a day. You can get both of these medicines without a prescription. - If you go 48 hours without a bowel movement, or have pain moving your bowels, call your surgeon. - After some operations, diarrhea can occur. If you get diarrhea, don't take anti-diarrhea medicines. Drink plenty of fluids and see if it goes away. If it does not go away, or is severe and you feel ill, please call your surgeon. PAIN MANAGEMENT: - It is normal to feel some discomfort/pain following abdominal surgery. This pain is often described as "soreness". - Your pain should get better day by day. If you find the pain is getting worse instead of better, please contact your surgeon. -You will receive a prescription from your surgeon for pain medicine to take by mouth. It is important to take this medicine as directed. - Do not take it more frequently than prescribed. Do not take more medicine at one time than prescribed. - Your pain medicine will work better if you take it before your pain gets too severe. - If you are experiencing no pain, it is okay to skip a dose of pain medicine. If you experience any of the folloiwng, please contact your surgeon: - sharp pain or any severe pain that lasts several hours - pain that is getting worse over time - pain accompanied by fever of more than 101 - a drastic change in nature or quality of your pain MEDICATIONS: - Take all the medicines you were on before the operation just as you did before, unless you have been told differently. - If you have any questions about what medicine to take or not to take, please call your surgeon. Followup Instructions: [MASKED]
|
[] |
[
"I480",
"I2510",
"I10",
"K219",
"N400",
"E785",
"Z951",
"Z87891"
] |
[
"K4030: Unilateral inguinal hernia, with obstruction, without gangrene, not specified as recurrent",
"I480: Paroxysmal atrial fibrillation",
"I272: Other secondary pulmonary hypertension",
"I509: Heart failure, unspecified",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"I10: Essential (primary) hypertension",
"K219: Gastro-esophageal reflux disease without esophagitis",
"N400: Benign prostatic hyperplasia without lower urinary tract symptoms",
"E785: Hyperlipidemia, unspecified",
"J439: Emphysema, unspecified",
"I4510: Unspecified right bundle-branch block",
"Z7982: Long term (current) use of aspirin",
"Z951: Presence of aortocoronary bypass graft",
"Z87891: Personal history of nicotine dependence"
] |
10,002,443 | 21,329,021 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
___ - bedside pericardiocentesis at ___
History of Present Illness:
HISTORY OF PRESENTING ILLNESS: Mr. ___ is a ___
male with rheumatoid arthritis, DMARD holiday, and recent, brief
hospitalization for presumptive pericarditis, returned to
outside
hospital with probable cardiac tamponade now post-bedside
pericardiocentesis with drain placement prior to transfer.
Importantly, patient was hospitalized at ___ on ___ with acute pleuritic chest pain of two-day duration in the
context of constellation of fatigue, malaise, upper respiratory
symptoms, and non-productive cough. While CTA exonerated
pulmonary embolism, thickened pericardium and small effusion
were
noted, suggesting pericarditis. ECG revealed subtle diffuse ST
elevations in keeping with pericarditis. Echocardiogram
confirmed
said effusion, though no features of tamponade were appreciated.
He was discharged the same day with ibuprofen 600 mg TID and
colchicine 0.6 mg BID. He had persistence of minor residual
chest
pain, which began to worsen two days later, but was tolerable
until yesterday evening when it evolved to severe, unrelenting
pain across his precordium likened to "wearing shoulder pads
bearing down on him." He notes a new concurrent substernal chest
pain that "goes straight to his back." He then became dyspneic,
prompting him to seek care. He arrived at ___ hypotensive
with SBP in the 80-range. He was borderline tachycardic and in
mild respiratory distress, but oxygenation was acceptable. He
rapidly received three liters of fluid for presumptive tamponade
within the confines of poor windows on bedside echocardiogram.
Pericardiocentesis yielded 400 cc or more of serous fluid and a
pericardial drain was placed. Hemodynamics rapidly improved. On
arrival to ___ ED, patient was indeed hemodynamically stable
but was then in moderate respiratory distress, requiring
non-rebreather. He was given Lasix 20 mg IV. Bedside
echocardiogram was limited, but preliminarily suggestive of
small
residual effusion. In the CCU, patient notes resurgence of said
chest pain. His dyspnea is improving. An additional 250 cc was
drained.
Past Medical History:
PAST MEDICAL HISTORY:
Cardiac History:
-Pericarditis, as above.
-Hypertension.
-Dyslipidemia.
Other PMH:
-Rheumatoid arthritis.
-Remote traumatic DVT.
-Cholecystectomy.
-Appendectomy.
-Tonsillectomy.
-Left wrist reconstruction.
-Right rotator cuff reconstruction.
Social History:
___
Family History:
paternal history of ureothelial carcinoma.
Maternal history of diabetes.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
=================================
VS: T 96.7, HR 81, BP 136/81, O2 94% 6L
GENERAL: obese male in mild to moderate respiratory distress.
HEENT: anicteric sclerae. Oropharynx clear.
NECK: JVP at mandibular angle.
CARDIAC: tachycardic, regular with rare ectopy, S1/S2 within
the
confines of body habitus. Subtle pericardial rub. Pericardial
drain with serosanguinous fluid. Sternal tenderness.
LUNGS: Conversational dyspnea but tachypnea is slowing. Diffuse
wheezing and crackles in bilateral lung fields.
ABDOMEN: obese, soft, non-tender.
EXTREMITIES: Warm, well perfused, 2+ pitting edema to knees.
SKIN: Chronic bilateral venous stasis dermatitis.
PULSES: Distal pulses palpable and symmetric.
NEURO: non-focal.
DISCHARGE PHYSICAL EXAMINATION:
=================================
GENERAL: obese male in mild to moderate respiratory distress.
HEENT: anicteric sclerae. Oropharynx clear.
NECK: JVP not appreciated.
CARDIAC: normal rate and rhythm, S1/S2 within the confines of
body habitus. No pericardial rub appreciated.
LUNGS: Decreased respiratory effort compared to yesterday.
Expiratory wheezing and bibasilar crackles.
ABDOMEN: obese, soft, non-tender, non-distended.
EXTREMITIES: Warm, well perfused, 1 to 2+ pitting edema to
knees.
SKIN: Chronic venous stasis dermatitis.
PULSES: Distal pulses palpable and symmetric.
NEURO: non-focal.
Pertinent Results:
ADMISSION LABS:
===============
___ 10:57PM WBC-16.9* RBC-4.63 HGB-14.2 HCT-43.1 MCV-93
MCH-30.7 MCHC-32.9 RDW-13.1 RDWSD-44.1
___ 10:57PM NEUTS-85.5* LYMPHS-4.3* MONOS-9.4 EOS-0.1*
BASOS-0.2 IM ___ AbsNeut-14.43* AbsLymp-0.72* AbsMono-1.58*
AbsEos-0.01* AbsBaso-0.04
___ 10:57PM ___ PTT-27.2 ___
___ 10:57PM GLUCOSE-269* UREA N-20 CREAT-0.9 SODIUM-135
POTASSIUM-5.3 CHLORIDE-106 TOTAL CO2-18* ANION GAP-11
___ 10:57PM CALCIUM-7.4* PHOSPHATE-3.1 MAGNESIUM-1.6
___ 10:57PM cTropnT-<0.01
___ 11:03PM LACTATE-2.0
___ 01:05AM PLEURAL FLUID STUDIES ___
Polys-94* Lymphs-2* Monos-4*
IMAGING:
========
___ TTE
The left atrium is normal in size. The inferior vena cava is
dilated (>2.5 cm). There is normal left ventricular
wall thickness with a normal cavity size. There is suboptimal
image quality to assess regional left ventricular
function. Overall left ventricular systolic function is normal.
Quantitative biplane left ventricular ejection
fraction is 66 %. Left ventricular cardiac index is normal (>2.5
L/min/m2). No ventricular septal defect is
seen. Normal right ventricular cavity size with normal free wall
motion. There is abnormal interventricular
septal motion. The aortic sinus diameter is normal for gender
with normal ascending aorta diameter for
gender. The aortic arch diameter is normal. There is no evidence
for an aortic arch coarctation. The aortic
valve leaflets (?#) appear structurally normal. There is no
aortic valve stenosis. There is no aortic
regurgitation. The mitral valve is not well visualized. The
tricuspid valve is not well seen. The pulmonary
artery systolic pressure could not be estimated. There is no
pericardial effusion.
MICRO:
======
___ 1:05 am FLUID,OTHER PERICARDIAL FLUID.
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Preliminary):
Reported to and read back by ___ ___
1:53PM.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. 1 COLONY ON 1
PLATE.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Preliminary):
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
DISCHARGE LABS:
===============
___ 04:01AM BLOOD WBC-13.0* RBC-4.05* Hgb-12.3* Hct-37.3*
MCV-92 MCH-30.4 MCHC-33.0 RDW-13.0 RDWSD-43.8 Plt ___
___ 03:30PM BLOOD Glucose-115* UreaN-22* Creat-0.6 Na-138
K-4.1 Cl-100 HCO3-24 AnGap-14
___ 04:01AM BLOOD ALT-43* AST-27 AlkPhos-99 TotBili-0.5
___ 03:30PM BLOOD Calcium-8.2* Phos-2.9 Mg-1.9
___ 10:57PM BLOOD proBNP-110
___ 03:29AM BLOOD TSH-0.93
___ 11:04AM BLOOD ___ pO2-82* pCO2-42 pH-7.34*
calTCO2-24 Base XS--2
Brief Hospital Course:
SUMMARY:
=====================
___ male with rheumatoid arthritis, DMARD holiday, and
recent, brief hospitalization for presumptive pericarditis,
returned to outside hospital with pericardial effusion with
possible tamponade physiology now post-bedside
pericardiocentesis prior to transfer, with persistent
pericardial effusion now s/p drain placement with course
complicated by acute hypercapneic respiratory distress.
#CORONARIES: unknown.
#PUMP: normal biventricular structure and function.
#RHYTHM: NSR. pAF ___
TRANSITIONAL ISSUES:
====================
[] He was discharged on ibuprofen 600mg TID and colchicine 0.6mg
BID for his inflammatory pericarditis. He should continue
colchicine for 3 months. He should have his ibuprofen tapered
weekly following resolution of his symptoms over 3 weeks to
reduce the risk of recurrence.
[] He was discharged on a PPI and should continue this while on
ibuprofen.
[] Strongly recommend that patient receive outpatient PFTs given
high suspicion for baseline obstructive/restrictive pulmonary
disease
[] Patient developed paroxysmal afib with RVR during this
admission which is a new diagnosis. CHADSVASC 2 for hypertension
and diabetes. Anticoagulation was not started during this
admission given that he was felt to have relatively low risk for
CVA, however please make a note of this new diagnosis and
reassess need for anticoagulation as medically appropriate.
[] He was newly diagnosed with DM (HbA1c 7.9 at ___
and will be discharged on metformin 500 BID. Will require
outpatient follow-up for this and can consider uptitration in
the outpatient setting.
[] Please reassess need for diuretic in the outpatient setting.
He had no echocardiographic evidence of heart failure during
this admission so was not discharged on diuretics.
New medications:
Metformin 500mg BID
Metoprolol XL 50mg QD
Omeprazole 20mg QD
Continued medications:
Atorvastatin 10mg QPM
Colchicine 0.6mg BID
Ibuprofen 600mg TID
Folic acid 1mg PO QD
Sertraline 100mg PO QD
Stopped medications:
Methotrexate 20mg PO
Famotidine 20mg QD
ACUTE ISSUES:
=============
#) Acute pericarditis
#) Cardiac tamponade, now s/p pericardiocentesis and drain
placement
He presented with inflammatory pericarditis of probable viral
nature in the context of viral-like prodrome versus rheumatic
pericarditis, given serologic positive active disease in the
absence of DMARD. Pericardial fluid cultures from ___
negative, cultures here with 1 colony on 1 plate of coag
negative staph felt to be contaminant, negative acid fast smear.
No biochemical evidence of myocardial injury on admission,
unlikely to have concurrent myocarditis or cardiac event
sequelae. At ___ was initially noted to have SBPs in
the ___ and received fluid resuscitation and pericardiocentesis
given concern for tamponade physiology. Hemodynamics
subsequently stabilized and remained so throughout the duration
of his admission here. TTE on ___ showed no pericardial
effusion. Pericardial drain was initially left to gravity due to
continued output, and was removed ___. He was treated with
colchicine 0.6mg BID which he will continue for 3 months after
discharge. He also received ibuprofen 600mg PO TID and will be
discharged on a slow taper; he received PPI while receiving
NSAIDs.
#) Acute hypercapnic respiratory failure - resolving
Probable flash pulmonary edema from rapid large-volume fluid
administration on tamponade, as evidenced by radiographic
pulmonary edema. Earlier echocardiogram otherwise not suggestive
of ventricular dysfunction and BNP is within normal limits. TTE
on ___ was without evidence of cardiac etiology for his
pulmonary edema/respiratory failure.
Patient likely has unappreciated restrictive pulmonary
physiology. Additionally, no emphysematous changes noted on CT
one week ago, but
background obstructive defect is conceivable, given compelling
smoking history. He had a negative CTA one week prior to
admission. Patient had leukocytosis on admission without clear
radiographic consolidation suggestive of pneumonia - one dose of
empiric azithromycin was given overnight and discontinued on
___. He received IV diuresis with significant improvement in
his respiratory status. O2 weaned ___ morning. He was breathing
comfortably on RA at the time of discharge with ambulatory
saturations >90%.
#) Paroxysmal AFib, new diagnosis
Patient went into Afib with RVR on ___, and subsequently
received metoprolol. He subsequently flipped back into NSR. His
CHADsVASC = 2 (DM, HTN). Anticoagulation was discussed but
ultimately deferred at the time of discharge given the patient's
lower overall risk for CVA and concerns regarding medication
adherence/cost. He was discharged on metoprolol. He should have
his need for anticoagulation reassessed as an outpatient as
medically appropriate.
#) Type II diabetes:
He was newly diagnosed with DM with a A1C of 7.9% during this
admission. He was maintained on an insulin sliding scale during
this admission and will be discharged on metformin 500mg BID.
CHRONIC/STABLE ISSUES:
====================
#) Rheumatoid arthritis:
RF and anti-CCP positive per outpatient rheumatology. Not
currently endorsing sx suggestive of RA flare. Per discussion
with OP rheumatologist, deferred restarting MTX and/or other
DMARD until outpatient.
#) HTN
His home BP meds were held initially due to soft BPs and were
stopped at the time of discharge as he remained normotensive.
CORE MEASURES:
==============
#CODE: DNR/DNI.
#CONTACT/HCP: ___, ex-wife (___)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 10 mg PO QPM
2. Colchicine 0.6 mg PO BID
3. Ibuprofen 600 mg PO TID
4. Famotidine 20 mg PO DAILY
5. lisinopril-hydrochlorothiazide ___ mg oral DAILY
6. Methotrexate 20 mg PO 1X/WEEK (___)
7. Sertraline 100 mg PO DAILY
8. FoLIC Acid 1 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing, shortness of
breath
RX *albuterol sulfate [ProAir HFA] 90 mcg 2 puffs ih every 6
hours as needed Disp #*1 Inhaler Refills:*0
2. MetFORMIN (Glucophage) 500 mg PO BID
RX *metformin 500 mg 1 tablet(s) by mouth Twice a day Disp #*60
Tablet Refills:*2
3. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth Daily Disp
#*30 Tablet Refills:*2
4. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth Daily Disp #*30
Capsule Refills:*2
5. Atorvastatin 10 mg PO QPM
6. Colchicine 0.6 mg PO BID
RX *colchicine 0.6 mg 1 capsule(s) by mouth Twice a day Disp
#*60 Capsule Refills:*2
7. FoLIC Acid 1 mg PO DAILY
8. Ibuprofen 600 mg PO TID
9. Sertraline 100 mg PO DAILY
10. HELD- lisinopril-hydrochlorothiazide ___ mg oral DAILY
This medication was held. Do not restart
lisinopril-hydrochlorothiazide until instructed by your primary
care doctor or cardiologist
11. HELD- Methotrexate 20 mg PO 1X/WEEK (___) This medication
was held. Do not restart Methotrexate until a doctor tells you
to
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: inflammatory pericarditis
Secondary Diagnosis: rheumatoid arthritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital with chest pain.
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL?
- You were found to have inflammation and a build up of fluid
in the lining of the heart.
- You had a procedure to remove the fluid from the lining of the
heart and a temporary drain placed. This was removed before you
left the hospital.
- You received medication to help you pee off the excess fluid
in your body.
- You developed an abnormal heart rhythm (afib) while in the
hospital. You were started on a new medication for this
(metoprolol).
- You were diagnosed with diabetes during this admission. You
were started on a new medication for this (metformin).
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Follow up with your doctors as listed below
- Weigh yourself every morning, seek medical attention if your
weight goes up more than 3 lbs.
- Seek medical attention if you have new or concerning symptoms
or you develop swelling in your legs, abdominal distention, or
shortness of breath at night.
Please see below for more information on your hospitalization.
It was a pleasure taking part in your care here at ___!
We wish you all the best!
- Your ___ Care Team
Followup Instructions:
___
|
[
"I309",
"J9602",
"I314",
"I480",
"E119",
"Z66",
"I10",
"M069",
"E785",
"Z86718",
"Z87891"
] |
Allergies: No Allergies/ADRs on File Chief Complaint: chest pain Major Surgical or Invasive Procedure: [MASKED] - bedside pericardiocentesis at [MASKED] History of Present Illness: HISTORY OF PRESENTING ILLNESS: Mr. [MASKED] is a [MASKED] male with rheumatoid arthritis, DMARD holiday, and recent, brief hospitalization for presumptive pericarditis, returned to outside hospital with probable cardiac tamponade now post-bedside pericardiocentesis with drain placement prior to transfer. Importantly, patient was hospitalized at [MASKED] on [MASKED] with acute pleuritic chest pain of two-day duration in the context of constellation of fatigue, malaise, upper respiratory symptoms, and non-productive cough. While CTA exonerated pulmonary embolism, thickened pericardium and small effusion were noted, suggesting pericarditis. ECG revealed subtle diffuse ST elevations in keeping with pericarditis. Echocardiogram confirmed said effusion, though no features of tamponade were appreciated. He was discharged the same day with ibuprofen 600 mg TID and colchicine 0.6 mg BID. He had persistence of minor residual chest pain, which began to worsen two days later, but was tolerable until yesterday evening when it evolved to severe, unrelenting pain across his precordium likened to "wearing shoulder pads bearing down on him." He notes a new concurrent substernal chest pain that "goes straight to his back." He then became dyspneic, prompting him to seek care. He arrived at [MASKED] hypotensive with SBP in the 80-range. He was borderline tachycardic and in mild respiratory distress, but oxygenation was acceptable. He rapidly received three liters of fluid for presumptive tamponade within the confines of poor windows on bedside echocardiogram. Pericardiocentesis yielded 400 cc or more of serous fluid and a pericardial drain was placed. Hemodynamics rapidly improved. On arrival to [MASKED] ED, patient was indeed hemodynamically stable but was then in moderate respiratory distress, requiring non-rebreather. He was given Lasix 20 mg IV. Bedside echocardiogram was limited, but preliminarily suggestive of small residual effusion. In the CCU, patient notes resurgence of said chest pain. His dyspnea is improving. An additional 250 cc was drained. Past Medical History: PAST MEDICAL HISTORY: Cardiac History: -Pericarditis, as above. -Hypertension. -Dyslipidemia. Other PMH: -Rheumatoid arthritis. -Remote traumatic DVT. -Cholecystectomy. -Appendectomy. -Tonsillectomy. -Left wrist reconstruction. -Right rotator cuff reconstruction. Social History: [MASKED] Family History: paternal history of ureothelial carcinoma. Maternal history of diabetes. Physical Exam: ADMISSION PHYSICAL EXAMINATION: ================================= VS: T 96.7, HR 81, BP 136/81, O2 94% 6L GENERAL: obese male in mild to moderate respiratory distress. HEENT: anicteric sclerae. Oropharynx clear. NECK: JVP at mandibular angle. CARDIAC: tachycardic, regular with rare ectopy, S1/S2 within the confines of body habitus. Subtle pericardial rub. Pericardial drain with serosanguinous fluid. Sternal tenderness. LUNGS: Conversational dyspnea but tachypnea is slowing. Diffuse wheezing and crackles in bilateral lung fields. ABDOMEN: obese, soft, non-tender. EXTREMITIES: Warm, well perfused, 2+ pitting edema to knees. SKIN: Chronic bilateral venous stasis dermatitis. PULSES: Distal pulses palpable and symmetric. NEURO: non-focal. DISCHARGE PHYSICAL EXAMINATION: ================================= GENERAL: obese male in mild to moderate respiratory distress. HEENT: anicteric sclerae. Oropharynx clear. NECK: JVP not appreciated. CARDIAC: normal rate and rhythm, S1/S2 within the confines of body habitus. No pericardial rub appreciated. LUNGS: Decreased respiratory effort compared to yesterday. Expiratory wheezing and bibasilar crackles. ABDOMEN: obese, soft, non-tender, non-distended. EXTREMITIES: Warm, well perfused, 1 to 2+ pitting edema to knees. SKIN: Chronic venous stasis dermatitis. PULSES: Distal pulses palpable and symmetric. NEURO: non-focal. Pertinent Results: ADMISSION LABS: =============== [MASKED] 10:57PM WBC-16.9* RBC-4.63 HGB-14.2 HCT-43.1 MCV-93 MCH-30.7 MCHC-32.9 RDW-13.1 RDWSD-44.1 [MASKED] 10:57PM NEUTS-85.5* LYMPHS-4.3* MONOS-9.4 EOS-0.1* BASOS-0.2 IM [MASKED] AbsNeut-14.43* AbsLymp-0.72* AbsMono-1.58* AbsEos-0.01* AbsBaso-0.04 [MASKED] 10:57PM [MASKED] PTT-27.2 [MASKED] [MASKED] 10:57PM GLUCOSE-269* UREA N-20 CREAT-0.9 SODIUM-135 POTASSIUM-5.3 CHLORIDE-106 TOTAL CO2-18* ANION GAP-11 [MASKED] 10:57PM CALCIUM-7.4* PHOSPHATE-3.1 MAGNESIUM-1.6 [MASKED] 10:57PM cTropnT-<0.01 [MASKED] 11:03PM LACTATE-2.0 [MASKED] 01:05AM PLEURAL FLUID STUDIES [MASKED] Polys-94* Lymphs-2* Monos-4* IMAGING: ======== [MASKED] TTE The left atrium is normal in size. The inferior vena cava is dilated (>2.5 cm). There is normal left ventricular wall thickness with a normal cavity size. There is suboptimal image quality to assess regional left ventricular function. Overall left ventricular systolic function is normal. Quantitative biplane left ventricular ejection fraction is 66 %. Left ventricular cardiac index is normal (>2.5 L/min/m2). No ventricular septal defect is seen. Normal right ventricular cavity size with normal free wall motion. There is abnormal interventricular septal motion. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. The aortic arch diameter is normal. There is no evidence for an aortic arch coarctation. The aortic valve leaflets (?#) appear structurally normal. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral valve is not well visualized. The tricuspid valve is not well seen. The pulmonary artery systolic pressure could not be estimated. There is no pericardial effusion. MICRO: ====== [MASKED] 1:05 am FLUID,OTHER PERICARDIAL FLUID. GRAM STAIN (Final [MASKED]: 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Preliminary): Reported to and read back by [MASKED] [MASKED] 1:53PM. STAPHYLOCOCCUS, COAGULASE NEGATIVE. 1 COLONY ON 1 PLATE. ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED. FUNGAL CULTURE (Preliminary): ACID FAST SMEAR (Final [MASKED]: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): DISCHARGE LABS: =============== [MASKED] 04:01AM BLOOD WBC-13.0* RBC-4.05* Hgb-12.3* Hct-37.3* MCV-92 MCH-30.4 MCHC-33.0 RDW-13.0 RDWSD-43.8 Plt [MASKED] [MASKED] 03:30PM BLOOD Glucose-115* UreaN-22* Creat-0.6 Na-138 K-4.1 Cl-100 HCO3-24 AnGap-14 [MASKED] 04:01AM BLOOD ALT-43* AST-27 AlkPhos-99 TotBili-0.5 [MASKED] 03:30PM BLOOD Calcium-8.2* Phos-2.9 Mg-1.9 [MASKED] 10:57PM BLOOD proBNP-110 [MASKED] 03:29AM BLOOD TSH-0.93 [MASKED] 11:04AM BLOOD [MASKED] pO2-82* pCO2-42 pH-7.34* calTCO2-24 Base XS--2 Brief Hospital Course: SUMMARY: ===================== [MASKED] male with rheumatoid arthritis, DMARD holiday, and recent, brief hospitalization for presumptive pericarditis, returned to outside hospital with pericardial effusion with possible tamponade physiology now post-bedside pericardiocentesis prior to transfer, with persistent pericardial effusion now s/p drain placement with course complicated by acute hypercapneic respiratory distress. #CORONARIES: unknown. #PUMP: normal biventricular structure and function. #RHYTHM: NSR. pAF [MASKED] TRANSITIONAL ISSUES: ==================== [] He was discharged on ibuprofen 600mg TID and colchicine 0.6mg BID for his inflammatory pericarditis. He should continue colchicine for 3 months. He should have his ibuprofen tapered weekly following resolution of his symptoms over 3 weeks to reduce the risk of recurrence. [] He was discharged on a PPI and should continue this while on ibuprofen. [] Strongly recommend that patient receive outpatient PFTs given high suspicion for baseline obstructive/restrictive pulmonary disease [] Patient developed paroxysmal afib with RVR during this admission which is a new diagnosis. CHADSVASC 2 for hypertension and diabetes. Anticoagulation was not started during this admission given that he was felt to have relatively low risk for CVA, however please make a note of this new diagnosis and reassess need for anticoagulation as medically appropriate. [] He was newly diagnosed with DM (HbA1c 7.9 at [MASKED] and will be discharged on metformin 500 BID. Will require outpatient follow-up for this and can consider uptitration in the outpatient setting. [] Please reassess need for diuretic in the outpatient setting. He had no echocardiographic evidence of heart failure during this admission so was not discharged on diuretics. New medications: Metformin 500mg BID Metoprolol XL 50mg QD Omeprazole 20mg QD Continued medications: Atorvastatin 10mg QPM Colchicine 0.6mg BID Ibuprofen 600mg TID Folic acid 1mg PO QD Sertraline 100mg PO QD Stopped medications: Methotrexate 20mg PO Famotidine 20mg QD ACUTE ISSUES: ============= #) Acute pericarditis #) Cardiac tamponade, now s/p pericardiocentesis and drain placement He presented with inflammatory pericarditis of probable viral nature in the context of viral-like prodrome versus rheumatic pericarditis, given serologic positive active disease in the absence of DMARD. Pericardial fluid cultures from [MASKED] negative, cultures here with 1 colony on 1 plate of coag negative staph felt to be contaminant, negative acid fast smear. No biochemical evidence of myocardial injury on admission, unlikely to have concurrent myocarditis or cardiac event sequelae. At [MASKED] was initially noted to have SBPs in the [MASKED] and received fluid resuscitation and pericardiocentesis given concern for tamponade physiology. Hemodynamics subsequently stabilized and remained so throughout the duration of his admission here. TTE on [MASKED] showed no pericardial effusion. Pericardial drain was initially left to gravity due to continued output, and was removed [MASKED]. He was treated with colchicine 0.6mg BID which he will continue for 3 months after discharge. He also received ibuprofen 600mg PO TID and will be discharged on a slow taper; he received PPI while receiving NSAIDs. #) Acute hypercapnic respiratory failure - resolving Probable flash pulmonary edema from rapid large-volume fluid administration on tamponade, as evidenced by radiographic pulmonary edema. Earlier echocardiogram otherwise not suggestive of ventricular dysfunction and BNP is within normal limits. TTE on [MASKED] was without evidence of cardiac etiology for his pulmonary edema/respiratory failure. Patient likely has unappreciated restrictive pulmonary physiology. Additionally, no emphysematous changes noted on CT one week ago, but background obstructive defect is conceivable, given compelling smoking history. He had a negative CTA one week prior to admission. Patient had leukocytosis on admission without clear radiographic consolidation suggestive of pneumonia - one dose of empiric azithromycin was given overnight and discontinued on [MASKED]. He received IV diuresis with significant improvement in his respiratory status. O2 weaned [MASKED] morning. He was breathing comfortably on RA at the time of discharge with ambulatory saturations >90%. #) Paroxysmal AFib, new diagnosis Patient went into Afib with RVR on [MASKED], and subsequently received metoprolol. He subsequently flipped back into NSR. His CHADsVASC = 2 (DM, HTN). Anticoagulation was discussed but ultimately deferred at the time of discharge given the patient's lower overall risk for CVA and concerns regarding medication adherence/cost. He was discharged on metoprolol. He should have his need for anticoagulation reassessed as an outpatient as medically appropriate. #) Type II diabetes: He was newly diagnosed with DM with a A1C of 7.9% during this admission. He was maintained on an insulin sliding scale during this admission and will be discharged on metformin 500mg BID. CHRONIC/STABLE ISSUES: ==================== #) Rheumatoid arthritis: RF and anti-CCP positive per outpatient rheumatology. Not currently endorsing sx suggestive of RA flare. Per discussion with OP rheumatologist, deferred restarting MTX and/or other DMARD until outpatient. #) HTN His home BP meds were held initially due to soft BPs and were stopped at the time of discharge as he remained normotensive. CORE MEASURES: ============== #CODE: DNR/DNI. #CONTACT/HCP: [MASKED], ex-wife ([MASKED]) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 10 mg PO QPM 2. Colchicine 0.6 mg PO BID 3. Ibuprofen 600 mg PO TID 4. Famotidine 20 mg PO DAILY 5. lisinopril-hydrochlorothiazide [MASKED] mg oral DAILY 6. Methotrexate 20 mg PO 1X/WEEK ([MASKED]) 7. Sertraline 100 mg PO DAILY 8. FoLIC Acid 1 mg PO DAILY Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing, shortness of breath RX *albuterol sulfate [ProAir HFA] 90 mcg 2 puffs ih every 6 hours as needed Disp #*1 Inhaler Refills:*0 2. MetFORMIN (Glucophage) 500 mg PO BID RX *metformin 500 mg 1 tablet(s) by mouth Twice a day Disp #*60 Tablet Refills:*2 3. Metoprolol Succinate XL 50 mg PO DAILY RX *metoprolol succinate 50 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*2 4. Omeprazole 20 mg PO DAILY RX *omeprazole 20 mg 1 capsule(s) by mouth Daily Disp #*30 Capsule Refills:*2 5. Atorvastatin 10 mg PO QPM 6. Colchicine 0.6 mg PO BID RX *colchicine 0.6 mg 1 capsule(s) by mouth Twice a day Disp #*60 Capsule Refills:*2 7. FoLIC Acid 1 mg PO DAILY 8. Ibuprofen 600 mg PO TID 9. Sertraline 100 mg PO DAILY 10. HELD- lisinopril-hydrochlorothiazide [MASKED] mg oral DAILY This medication was held. Do not restart lisinopril-hydrochlorothiazide until instructed by your primary care doctor or cardiologist 11. HELD- Methotrexate 20 mg PO 1X/WEEK ([MASKED]) This medication was held. Do not restart Methotrexate until a doctor tells you to Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: inflammatory pericarditis Secondary Diagnosis: rheumatoid arthritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], WHY WERE YOU ADMITTED TO THE HOSPITAL? - You were admitted to the hospital with chest pain. WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL? - You were found to have inflammation and a build up of fluid in the lining of the heart. - You had a procedure to remove the fluid from the lining of the heart and a temporary drain placed. This was removed before you left the hospital. - You received medication to help you pee off the excess fluid in your body. - You developed an abnormal heart rhythm (afib) while in the hospital. You were started on a new medication for this (metoprolol). - You were diagnosed with diabetes during this admission. You were started on a new medication for this (metformin). WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? - Take all of your medications as prescribed (listed below) - Follow up with your doctors as listed below - Weigh yourself every morning, seek medical attention if your weight goes up more than 3 lbs. - Seek medical attention if you have new or concerning symptoms or you develop swelling in your legs, abdominal distention, or shortness of breath at night. Please see below for more information on your hospitalization. It was a pleasure taking part in your care here at [MASKED]! We wish you all the best! - Your [MASKED] Care Team Followup Instructions: [MASKED]
|
[] |
[
"I480",
"E119",
"Z66",
"I10",
"E785",
"Z86718",
"Z87891"
] |
[
"I309: Acute pericarditis, unspecified",
"J9602: Acute respiratory failure with hypercapnia",
"I314: Cardiac tamponade",
"I480: Paroxysmal atrial fibrillation",
"E119: Type 2 diabetes mellitus without complications",
"Z66: Do not resuscitate",
"I10: Essential (primary) hypertension",
"M069: Rheumatoid arthritis, unspecified",
"E785: Hyperlipidemia, unspecified",
"Z86718: Personal history of other venous thrombosis and embolism",
"Z87891: Personal history of nicotine dependence"
] |
10,002,495 | 24,982,426 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
cardiogenic ___, NSTEMI
Major Surgical or Invasive Procedure:
- cardiac catheterization with DES to mid-LAD occlusion via R
radial access
- IABP placement and removal
History of Present Illness:
Mr. ___ is a ___ M with HTN, HLD, DMII, and prior MI with
medical management w/o cath presented to ___ with ___
transferred to ___ for catheterization for concern for STEMI.
Patient has long standing angina pain w/ exertion. On ___ night
had acute onset b/l non-radiating ___ CP not resolved with SL
NTG that persisted on ___ morning. In addition had 3 episodes
of diarrhea and weakness/malaise so he went to ___. No
orthopnea, PND, ___ edema, palpitations, or SOB.
In the ED, initial vitals were:
Exam: Chest pain ___ nonradiating
Labs: Trop I 1.14, WBC 29.6, Hct 38.7, Plt 148, INR 1.25, Na
127, K+ 4.6, BUN 30/Cr1.86
Imaging: EKG showed ST elevations in AVR (2mm), borderline
elevation in V1, and otherwise diffuse ST depressions. Bedside
ECHO w/ septal wall motion abnormalities. CXR w/o any acute
abnormalities.
Patient was given: Heparin gtt, Nitro gtt, ASA 324mg, Ticagrelor
180mg @ 1500, Vanco 125mg PO, ___
Transferred to ___ for cardiac cath. Vitals on transfer were:
106/64, 86, 100% on 2L, afebrile
Cath lab where he still had ___ pain on heparin and nitro gtt.
Catheterization showed mid-LAD septal occlusion, diffuse disease
throughout RCA, complete occlusion of circumflex w/ collaterals,
and 20% stenosis of L main. DES to mid-LAD occlusion via R
radial access. Hypotensive throughout so given 750cc IVF.
Coughing post-procedure with LVEDP 25 so given Lasix 20mg IV.
Was then hypertensive to 150 so given further Lasix 40mg IV.
Admitted to CCU for hypotension throughout procedure, WBC 30,
and lack of ___ beds. In the CCU, patient reports no chest pain
but continues to have productive cough and diarrhea.
Of note, two weeks ago had endoscopy and diagnosed with H
Pylori. Currently on clarithromycin and amoxicillin. On ___
night developed diarrhea. Also had 15lb weight loss in past 4
months.
Past Medical History:
1) HTN
2) HLD
3) DMII
4) CAD s/p MI - medically managed
5) H. Pylori
6) Spinal stenosis
Social History:
___
Family History:
Father: possible dilated cardiomyopathy
No family history of early MI, arrhythmia, or sudden cardiac
death; otherwise non-contributory.
Physical Exam:
On admission:
---------------
VS: afebrile, 160/80, 114, 94% on 15L Non-rebreather
Weight: 69kg
Tele: NSR
Gen: Slightly tachypneic older man audibly wheezing but
comfortably finishing sentences
HEENT: EOMI, PERRLA,
NECK: No JVD
CV: Tachycardic, difficult to appreciate heart sounds due to
significant rhonchi
LUNGS: b/l rhonchi throughout w/ mild end expiratory wheezing
and R base crackles
ABD: Soft, Non-tender, non-distended
EXT: 2+ L radial pulses, R arm w/ band in place and normal
motor/sensory function intact distally, RLE non-palpable DP but
dopplerable, 1+ LLE DP. b/l ___ slightly cold but normal
sensation w/ full motor strength and ROM
SKIN: No rashes or chronic edematous changes
NEURO: Alert and attentive, AOX3, Moving all extremities
At discharge:
--------------
Weight: 63.7kg (63.4)
I/O: 980/800
T 98.4 BP 123/68 (102-133/62-87) P 86 (71-100) RR 20 O2 99% RA
Gen: awake, alert, oriented to self, date, hospital
HEENT: EOMI, PERRLA,
NECK: No JVD
CV: Tachycardic, difficult to appreciate heart sounds
LUNGS: Bibasilar crackles
ABD: Soft, Non-tender, non-distended
EXT: 2+ b/l radial pulses, R arm normal motor/sensory function
intact distally, RLE non-palpable DP but dopplerable, trace
edema b/l. b/l ___ slightly cold but normal sensation w/ full
motor strength and ROM
SKIN: No rashes or chronic edematous changes
NEURO: Alert and attentive, AOX3, Moving all extremities
Pertinent Results:
Labs on Admission:
-------------------
___ 09:23PM WBC-36.8* RBC-4.40* HGB-14.0 HCT-40.6 MCV-92
MCH-31.8 MCHC-34.5 RDW-12.5 RDWSD-41.8
___ 09:23PM PLT SMR-NORMAL PLT COUNT-176
___ 09:23PM NEUTS-81* BANDS-10* LYMPHS-3* MONOS-6 EOS-0
BASOS-0 ___ MYELOS-0 AbsNeut-33.49* AbsLymp-1.10*
AbsMono-2.21* AbsEos-0.00* AbsBaso-0.00*
___ 09:23PM ___ PTT-49.6* ___
___ 09:23PM GLUCOSE-264* UREA N-30* CREAT-1.4*
SODIUM-129* POTASSIUM-4.1 CHLORIDE-96 TOTAL CO2-14* ANION
GAP-23*
___ 09:23PM CALCIUM-8.2* PHOSPHATE-3.0 MAGNESIUM-1.7
CHOLEST-157
___ 09:23PM %HbA1c-5.9 eAG-123
___ 09:23PM CK-MB-44* cTropnT-0.69*
___ 09:23PM TRIGLYCER-90 HDL CHOL-42 CHOL/HDL-3.7
LDL(CALC)-97
___ 09:23PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL BURR-1+
Labs at Discharge:
-------------------
___ 05:50AM BLOOD WBC-11.2* RBC-3.59* Hgb-11.2* Hct-34.7*
MCV-97 MCH-31.2 MCHC-32.3 RDW-13.2 RDWSD-46.7* Plt ___
___ 05:50AM BLOOD Neuts-76* Bands-0 Lymphs-16* Monos-5
Eos-2 Baso-0 ___ Metas-1* Myelos-0 AbsNeut-8.51*
AbsLymp-1.79 AbsMono-0.56 AbsEos-0.22 AbsBaso-0.00*
___ 05:50AM BLOOD ___ PTT-27.3 ___
___ 05:50AM BLOOD Glucose-165* UreaN-43* Creat-1.1 Na-136
K-4.3 Cl-103 HCO3-22 AnGap-15
___ 05:50AM BLOOD ALT-38 AST-32 LD(LDH)-481* AlkPhos-99
TotBili-0.4
___ 05:50AM BLOOD Albumin-3.3* Calcium-8.4 Phos-3.6 Mg-2.4
Relevant Imaging:
-----------------
TTE ___:
The left atrium is mildly dilated. The estimated right atrial
pressure is ___ mmHg. Left ventricular wall thicknesses and
cavity size are normal. Overall left ventricular systolic
function is moderately depressed (LVEF= ? 35-40% - assessment
limited by suboptimal image quality and significant beat to beat
variability). There is hypokinesis of the mid-distal LV segments
and apex. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. The number of aortic valve
leaflets cannot be determined. There is mild aortic valve
stenosis (valve area 1.2-1.9cm2). No aortic regurgitation is
seen. The mitral valve appears structurally normal with trivial
mitral regurgitation. The pulmonary artery systolic pressure
could not be determined. There is a trivial/physiologic
pericardial effusion.
Compared with the prior focused study (images reviewed) of
___, left ventricular systolic function is probably
similar, although suboptimal image quality of both studies
precludes definite comparison.
___ CXR
IMPRESSION:
Generalized improvement in both lungs is probably due to
decrease in pulmonary
edema, now mild, and decrease in previous moderate right pleural
effusion.
There is still substantial consolidation in the right upper lobe
probably
pneumonia but the bilateral lower lobe components have improved.
Heart size
top-normal. No pneumothorax.
MICRO
========
FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C. difficile by the Illumigene
DNA
amplification. (Reference Range-Negative).
___ 12:53 pm SPUTUM Source: Expectorated.
GRAM STAIN (Final ___:
<10 PMNs and <10 epithelial cells/100X field.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ ___ per 1000X FIELD): BUDDING YEAST.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Preliminary):
Further incubation required to determine the presence or
absence of
commensal respiratory flora.
KLEBSIELLA PNEUMONIAE. SPARSE GROWTH.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
GRAM NEGATIVE ROD #2. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
Mr. ___ is a ___ M w/ HTN, HLD, DMII, and old MI transferred
from ___ w/ NSTEMI w/ diffuse 3 vessel disease s/p DES to
mid-LAD occlusion found to have severe Cdiff.
ACTIVE ISSUES
==============
# NSTEMI
NSTEMI based on STE aVR and V1 but o/w ST depressions w/
significant multi vessel disease but significant stenosis in LAD
s/p DES that occluded diagnonal. Repeat cath unchanged. He was
started on plavix, atorvastatin, ACE-I, and metoprolol. Echo
showed LVEF 35-40% with hypokinesis of mid-distal LV segments
and apex. He was started on warfarin for his hypokinetic LV as
well as his atrial fibrillation as discussed below.
# ___
Possibly mixed cardiogenic/distributive given mixed venous O2
65%, CI 2.1, PCWP 25. He initially required pressors and balloon
pump and was then successfully weaned off both. He remained
hemodynamically stable during rest of hospital course.
# Atrial Fibrillation
Patient with a reported history of paroxysmal afib per his PCP
for which he was maintained on digoxin as well as aspirin 325mg
PO daily prior to admission. He was found to be in atrial
fibrillation during admission and the decision was made to
anticoagulate with Coumadin. He was continued on home dose
digoxin. His home dose aspirin was decreased as discussed above
with initiation of Coumadin.
# Hematuria:
Likely traumatic in setting of systemic anticoagulation, as
patient pulled at ___. Cytology was negative. He will followup
outpatient with urology.
# Dyspnea:
Patient had acute episodes of dyspnea. This was mainly
attributed to pulmonary edema and improved with diruesis.
Additionally, CXR showed possible consolidation of RUL,
concerning for aspiration pneumonia. However, treatment was
deferred as he had no other focal signs of infectious pna. He
did have sputum cultures which grew Klebsiella pneumonia but on
discussion with ID, felt this did not warrant any treatment as
he was asymptomatic. He was discharged on po lasix 20 mg daily
with next electrolytes to be checked ___.
# C diff, severe:
Had loose stool in setting of antibiotic tx for Hpylori
(initiated outpatient). Given WBC >15, ___, age >___ treated as
severe. Patient was started on vancomycin 125mg PO qid for 14
day course (day ___, last day ___.
# GASTROESOPHAGEAL REFLUX DISEASE (GERD):
Endoscopy confirmed H Pylori treated with PPI +
clarithromycin/amoxicillin since ___ for 14 days. Omeprazole
was continued. Antibiotics held in setting of c.diff infection.
# Delirium:
Patient with frequent sundowning during hospitalization
requiring Seroquel po.
CHRONIC ISSUES
===============
# Spinal Stenosis: Continued gabapentin, d/ced naproxen. Did
not complain of pain throughout hospital course. Explained he
should not take any more NSAIDS in setting of recent ACS and now
on Coumadin, Plavix and asa.
# DM: maintained on ISS during admission and discharged on home
glipizide and metformin
# HTN: Home dose metoprolol uptitrated. Home dose lisinopril
decreased. Home dose imdur discontinued.
# HLD: Transitioned home dose simvastatin to atorvastatin
TRANSITIONAL ISSUES
=====================
- Discharge weight: 63.7kg
- patient will require urology followup given hematuria during
admission. Urine cytology negative.
- patient will need to be treated for hpylori once he completes
a course of PO Vancomycin for Severe CDiff
- Please check electrolytes on ___ on lasix
- Coumadin initiated given atrial fibrillation, ASA decreased
from 325 mg to 81 mg daily
- Started on Plavix given recent stent placement, atorvastatin
80 mg (stopped simvastatin), and Lasix 20 mg po daily
- Home metoprolol was increased from 25 mg XL to 50 mg XL daily,
lisinopril decreased to 2.5 mg po daily and home imdur was
discontinued
- patient will need to continue a 14 day course of PO Vanc (day
___- ___ last day ___ for cdiff infection
- Patient instructed to not take any NSAIDS
- SLP treatment at rehab for pharyngeal strengthening exercises
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 600 mg PO TID
2. Naproxen 500 mg PO DAILY
3. MetFORMIN (Glucophage) 500 mg PO BID
4. Metoprolol Succinate XL 25 mg PO DAILY
5. GlipiZIDE 2.5 mg PO BID
6. Simvastatin 40 mg PO QPM
7. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
8. Lisinopril 10 mg PO DAILY
9. Digoxin 0.125 mg PO DAILY
10. Aspirin 325 mg PO DAILY
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. Digoxin 0.125 mg PO DAILY
3. Metoprolol Succinate XL 50 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Warfarin 4 mg PO DAILY16
6. GlipiZIDE 2.5 mg PO BID
7. Clopidogrel 75 mg PO DAILY
8. Omeprazole 20 mg PO BID
9. Vancomycin Oral Liquid ___ mg PO Q6H
10. MetFORMIN (Glucophage) 500 mg PO BID
11. Gabapentin 600 mg PO TID
12. Lisinopril 2.5 mg PO DAILY
13. Furosemide 20 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
NSTEMI s/p ___, likely mixed cardiogenic/distributive
Hematuria
Dyspnea
C. dif, severe
GERD
Delirium
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ because you were experiencing chest
pain due to a heart attack. In the cath lab you were found to
have blockage of your arteries, and a stent was placed. We also
managed your low blood pressure, infectious diarrhea, and trauma
from foley placement. You responded well.
Please continue taking your medications as prescribed. You are
being started on coumadin. Please do not take any non-steroidal
antiinflammatory drugs (NSAIDS) such as ibuprofen, advil,
motrin, aleve, naproxen. Please also follow-up with your
cardiology and PCP appointments as scheduled
It was a pleasure taking care of you,
Your ___ Care Team
Followup Instructions:
___
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Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: cardiogenic [MASKED], NSTEMI Major Surgical or Invasive Procedure: - cardiac catheterization with DES to mid-LAD occlusion via R radial access - IABP placement and removal History of Present Illness: Mr. [MASKED] is a [MASKED] M with HTN, HLD, DMII, and prior MI with medical management w/o cath presented to [MASKED] with [MASKED] transferred to [MASKED] for catheterization for concern for STEMI. Patient has long standing angina pain w/ exertion. On [MASKED] night had acute onset b/l non-radiating [MASKED] CP not resolved with SL NTG that persisted on [MASKED] morning. In addition had 3 episodes of diarrhea and weakness/malaise so he went to [MASKED]. No orthopnea, PND, [MASKED] edema, palpitations, or SOB. In the ED, initial vitals were: Exam: Chest pain [MASKED] nonradiating Labs: Trop I 1.14, WBC 29.6, Hct 38.7, Plt 148, INR 1.25, Na 127, K+ 4.6, BUN 30/Cr1.86 Imaging: EKG showed ST elevations in AVR (2mm), borderline elevation in V1, and otherwise diffuse ST depressions. Bedside ECHO w/ septal wall motion abnormalities. CXR w/o any acute abnormalities. Patient was given: Heparin gtt, Nitro gtt, ASA 324mg, Ticagrelor 180mg @ 1500, Vanco 125mg PO, [MASKED] Transferred to [MASKED] for cardiac cath. Vitals on transfer were: 106/64, 86, 100% on 2L, afebrile Cath lab where he still had [MASKED] pain on heparin and nitro gtt. Catheterization showed mid-LAD septal occlusion, diffuse disease throughout RCA, complete occlusion of circumflex w/ collaterals, and 20% stenosis of L main. DES to mid-LAD occlusion via R radial access. Hypotensive throughout so given 750cc IVF. Coughing post-procedure with LVEDP 25 so given Lasix 20mg IV. Was then hypertensive to 150 so given further Lasix 40mg IV. Admitted to CCU for hypotension throughout procedure, WBC 30, and lack of [MASKED] beds. In the CCU, patient reports no chest pain but continues to have productive cough and diarrhea. Of note, two weeks ago had endoscopy and diagnosed with H Pylori. Currently on clarithromycin and amoxicillin. On [MASKED] night developed diarrhea. Also had 15lb weight loss in past 4 months. Past Medical History: 1) HTN 2) HLD 3) DMII 4) CAD s/p MI - medically managed 5) H. Pylori 6) Spinal stenosis Social History: [MASKED] Family History: Father: possible dilated cardiomyopathy No family history of early MI, arrhythmia, or sudden cardiac death; otherwise non-contributory. Physical Exam: On admission: --------------- VS: afebrile, 160/80, 114, 94% on 15L Non-rebreather Weight: 69kg Tele: NSR Gen: Slightly tachypneic older man audibly wheezing but comfortably finishing sentences HEENT: EOMI, PERRLA, NECK: No JVD CV: Tachycardic, difficult to appreciate heart sounds due to significant rhonchi LUNGS: b/l rhonchi throughout w/ mild end expiratory wheezing and R base crackles ABD: Soft, Non-tender, non-distended EXT: 2+ L radial pulses, R arm w/ band in place and normal motor/sensory function intact distally, RLE non-palpable DP but dopplerable, 1+ LLE DP. b/l [MASKED] slightly cold but normal sensation w/ full motor strength and ROM SKIN: No rashes or chronic edematous changes NEURO: Alert and attentive, AOX3, Moving all extremities At discharge: -------------- Weight: 63.7kg (63.4) I/O: 980/800 T 98.4 BP 123/68 (102-133/62-87) P 86 (71-100) RR 20 O2 99% RA Gen: awake, alert, oriented to self, date, hospital HEENT: EOMI, PERRLA, NECK: No JVD CV: Tachycardic, difficult to appreciate heart sounds LUNGS: Bibasilar crackles ABD: Soft, Non-tender, non-distended EXT: 2+ b/l radial pulses, R arm normal motor/sensory function intact distally, RLE non-palpable DP but dopplerable, trace edema b/l. b/l [MASKED] slightly cold but normal sensation w/ full motor strength and ROM SKIN: No rashes or chronic edematous changes NEURO: Alert and attentive, AOX3, Moving all extremities Pertinent Results: Labs on Admission: ------------------- [MASKED] 09:23PM WBC-36.8* RBC-4.40* HGB-14.0 HCT-40.6 MCV-92 MCH-31.8 MCHC-34.5 RDW-12.5 RDWSD-41.8 [MASKED] 09:23PM PLT SMR-NORMAL PLT COUNT-176 [MASKED] 09:23PM NEUTS-81* BANDS-10* LYMPHS-3* MONOS-6 EOS-0 BASOS-0 [MASKED] MYELOS-0 AbsNeut-33.49* AbsLymp-1.10* AbsMono-2.21* AbsEos-0.00* AbsBaso-0.00* [MASKED] 09:23PM [MASKED] PTT-49.6* [MASKED] [MASKED] 09:23PM GLUCOSE-264* UREA N-30* CREAT-1.4* SODIUM-129* POTASSIUM-4.1 CHLORIDE-96 TOTAL CO2-14* ANION GAP-23* [MASKED] 09:23PM CALCIUM-8.2* PHOSPHATE-3.0 MAGNESIUM-1.7 CHOLEST-157 [MASKED] 09:23PM %HbA1c-5.9 eAG-123 [MASKED] 09:23PM CK-MB-44* cTropnT-0.69* [MASKED] 09:23PM TRIGLYCER-90 HDL CHOL-42 CHOL/HDL-3.7 LDL(CALC)-97 [MASKED] 09:23PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL BURR-1+ Labs at Discharge: ------------------- [MASKED] 05:50AM BLOOD WBC-11.2* RBC-3.59* Hgb-11.2* Hct-34.7* MCV-97 MCH-31.2 MCHC-32.3 RDW-13.2 RDWSD-46.7* Plt [MASKED] [MASKED] 05:50AM BLOOD Neuts-76* Bands-0 Lymphs-16* Monos-5 Eos-2 Baso-0 [MASKED] Metas-1* Myelos-0 AbsNeut-8.51* AbsLymp-1.79 AbsMono-0.56 AbsEos-0.22 AbsBaso-0.00* [MASKED] 05:50AM BLOOD [MASKED] PTT-27.3 [MASKED] [MASKED] 05:50AM BLOOD Glucose-165* UreaN-43* Creat-1.1 Na-136 K-4.3 Cl-103 HCO3-22 AnGap-15 [MASKED] 05:50AM BLOOD ALT-38 AST-32 LD(LDH)-481* AlkPhos-99 TotBili-0.4 [MASKED] 05:50AM BLOOD Albumin-3.3* Calcium-8.4 Phos-3.6 Mg-2.4 Relevant Imaging: ----------------- TTE [MASKED]: The left atrium is mildly dilated. The estimated right atrial pressure is [MASKED] mmHg. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is moderately depressed (LVEF= ? 35-40% - assessment limited by suboptimal image quality and significant beat to beat variability). There is hypokinesis of the mid-distal LV segments and apex. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The number of aortic valve leaflets cannot be determined. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is a trivial/physiologic pericardial effusion. Compared with the prior focused study (images reviewed) of [MASKED], left ventricular systolic function is probably similar, although suboptimal image quality of both studies precludes definite comparison. [MASKED] CXR IMPRESSION: Generalized improvement in both lungs is probably due to decrease in pulmonary edema, now mild, and decrease in previous moderate right pleural effusion. There is still substantial consolidation in the right upper lobe probably pneumonia but the bilateral lower lobe components have improved. Heart size top-normal. No pneumothorax. MICRO ======== FINAL REPORT [MASKED] C. difficile DNA amplification assay (Final [MASKED]: CLOSTRIDIUM DIFFICILE. Positive for toxigenic C. difficile by the Illumigene DNA amplification. (Reference Range-Negative). [MASKED] 12:53 pm SPUTUM Source: Expectorated. GRAM STAIN (Final [MASKED]: <10 PMNs and <10 epithelial cells/100X field. 2+ [MASKED] per 1000X FIELD): GRAM NEGATIVE ROD(S). 2+ [MASKED] per 1000X FIELD): BUDDING YEAST. QUALITY OF SPECIMEN CANNOT BE ASSESSED. RESPIRATORY CULTURE (Preliminary): Further incubation required to determine the presence or absence of commensal respiratory flora. KLEBSIELLA PNEUMONIAE. SPARSE GROWTH. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. GRAM NEGATIVE ROD #2. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Brief Hospital Course: Mr. [MASKED] is a [MASKED] M w/ HTN, HLD, DMII, and old MI transferred from [MASKED] w/ NSTEMI w/ diffuse 3 vessel disease s/p DES to mid-LAD occlusion found to have severe Cdiff. ACTIVE ISSUES ============== # NSTEMI NSTEMI based on STE aVR and V1 but o/w ST depressions w/ significant multi vessel disease but significant stenosis in LAD s/p DES that occluded diagnonal. Repeat cath unchanged. He was started on plavix, atorvastatin, ACE-I, and metoprolol. Echo showed LVEF 35-40% with hypokinesis of mid-distal LV segments and apex. He was started on warfarin for his hypokinetic LV as well as his atrial fibrillation as discussed below. # [MASKED] Possibly mixed cardiogenic/distributive given mixed venous O2 65%, CI 2.1, PCWP 25. He initially required pressors and balloon pump and was then successfully weaned off both. He remained hemodynamically stable during rest of hospital course. # Atrial Fibrillation Patient with a reported history of paroxysmal afib per his PCP for which he was maintained on digoxin as well as aspirin 325mg PO daily prior to admission. He was found to be in atrial fibrillation during admission and the decision was made to anticoagulate with Coumadin. He was continued on home dose digoxin. His home dose aspirin was decreased as discussed above with initiation of Coumadin. # Hematuria: Likely traumatic in setting of systemic anticoagulation, as patient pulled at [MASKED]. Cytology was negative. He will followup outpatient with urology. # Dyspnea: Patient had acute episodes of dyspnea. This was mainly attributed to pulmonary edema and improved with diruesis. Additionally, CXR showed possible consolidation of RUL, concerning for aspiration pneumonia. However, treatment was deferred as he had no other focal signs of infectious pna. He did have sputum cultures which grew Klebsiella pneumonia but on discussion with ID, felt this did not warrant any treatment as he was asymptomatic. He was discharged on po lasix 20 mg daily with next electrolytes to be checked [MASKED]. # C diff, severe: Had loose stool in setting of antibiotic tx for Hpylori (initiated outpatient). Given WBC >15, [MASKED], age >[MASKED] treated as severe. Patient was started on vancomycin 125mg PO qid for 14 day course (day [MASKED], last day [MASKED]. # GASTROESOPHAGEAL REFLUX DISEASE (GERD): Endoscopy confirmed H Pylori treated with PPI + clarithromycin/amoxicillin since [MASKED] for 14 days. Omeprazole was continued. Antibiotics held in setting of c.diff infection. # Delirium: Patient with frequent sundowning during hospitalization requiring Seroquel po. CHRONIC ISSUES =============== # Spinal Stenosis: Continued gabapentin, d/ced naproxen. Did not complain of pain throughout hospital course. Explained he should not take any more NSAIDS in setting of recent ACS and now on Coumadin, Plavix and asa. # DM: maintained on ISS during admission and discharged on home glipizide and metformin # HTN: Home dose metoprolol uptitrated. Home dose lisinopril decreased. Home dose imdur discontinued. # HLD: Transitioned home dose simvastatin to atorvastatin TRANSITIONAL ISSUES ===================== - Discharge weight: 63.7kg - patient will require urology followup given hematuria during admission. Urine cytology negative. - patient will need to be treated for hpylori once he completes a course of PO Vancomycin for Severe CDiff - Please check electrolytes on [MASKED] on lasix - Coumadin initiated given atrial fibrillation, ASA decreased from 325 mg to 81 mg daily - Started on Plavix given recent stent placement, atorvastatin 80 mg (stopped simvastatin), and Lasix 20 mg po daily - Home metoprolol was increased from 25 mg XL to 50 mg XL daily, lisinopril decreased to 2.5 mg po daily and home imdur was discontinued - patient will need to continue a 14 day course of PO Vanc (day [MASKED]- [MASKED] last day [MASKED] for cdiff infection - Patient instructed to not take any NSAIDS - SLP treatment at rehab for pharyngeal strengthening exercises Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Gabapentin 600 mg PO TID 2. Naproxen 500 mg PO DAILY 3. MetFORMIN (Glucophage) 500 mg PO BID 4. Metoprolol Succinate XL 25 mg PO DAILY 5. GlipiZIDE 2.5 mg PO BID 6. Simvastatin 40 mg PO QPM 7. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 8. Lisinopril 10 mg PO DAILY 9. Digoxin 0.125 mg PO DAILY 10. Aspirin 325 mg PO DAILY Discharge Medications: 1. Aspirin EC 81 mg PO DAILY 2. Digoxin 0.125 mg PO DAILY 3. Metoprolol Succinate XL 50 mg PO DAILY 4. Atorvastatin 80 mg PO QPM 5. Warfarin 4 mg PO DAILY16 6. GlipiZIDE 2.5 mg PO BID 7. Clopidogrel 75 mg PO DAILY 8. Omeprazole 20 mg PO BID 9. Vancomycin Oral Liquid [MASKED] mg PO Q6H 10. MetFORMIN (Glucophage) 500 mg PO BID 11. Gabapentin 600 mg PO TID 12. Lisinopril 2.5 mg PO DAILY 13. Furosemide 20 mg PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: NSTEMI s/p [MASKED], likely mixed cardiogenic/distributive Hematuria Dyspnea C. dif, severe GERD Delirium Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Discharge Instructions: Dear Mr. [MASKED], You were admitted to [MASKED] because you were experiencing chest pain due to a heart attack. In the cath lab you were found to have blockage of your arteries, and a stent was placed. We also managed your low blood pressure, infectious diarrhea, and trauma from foley placement. You responded well. Please continue taking your medications as prescribed. You are being started on coumadin. Please do not take any non-steroidal antiinflammatory drugs (NSAIDS) such as ibuprofen, advil, motrin, aleve, naproxen. Please also follow-up with your cardiology and PCP appointments as scheduled It was a pleasure taking care of you, Your [MASKED] Care Team Followup Instructions: [MASKED]
|
[] |
[
"N179",
"I2510",
"I10",
"E785",
"Z86718",
"Z7901",
"Z7902",
"I480",
"Z87891",
"I252",
"K219"
] |
[
"I214: Non-ST elevation (NSTEMI) myocardial infarction",
"R570: Cardiogenic shock",
"I509: Heart failure, unspecified",
"R578: Other shock",
"A047: Enterocolitis due to Clostridium difficile",
"N179: Acute kidney failure, unspecified",
"S3730XA: Unspecified injury of urethra, initial encounter",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"E118: Type 2 diabetes mellitus with unspecified complications",
"X58XXXA: Exposure to other specified factors, initial encounter",
"Y92239: Unspecified place in hospital as the place of occurrence of the external cause",
"I10: Essential (primary) hypertension",
"E785: Hyperlipidemia, unspecified",
"T45515A: Adverse effect of anticoagulants, initial encounter",
"Z86718: Personal history of other venous thrombosis and embolism",
"Z7901: Long term (current) use of anticoagulants",
"R310: Gross hematuria",
"Z7902: Long term (current) use of antithrombotics/antiplatelets",
"I480: Paroxysmal atrial fibrillation",
"Z23: Encounter for immunization",
"K2960: Other gastritis without bleeding",
"B9681: Helicobacter pylori [H. pylori] as the cause of diseases classified elsewhere",
"Z87891: Personal history of nicotine dependence",
"I252: Old myocardial infarction",
"R410: Disorientation, unspecified",
"K219: Gastro-esophageal reflux disease without esophagitis"
] |
10,002,528 | 23,193,578 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
amoxicillin
Attending: ___.
Chief Complaint:
Weakness and lethargy
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ year old female with history of chronic
abdominal pain and anemia w/ recent Fe sucrose infusion (___)
complicated by infusion reaction (mottling and discoloration of
feet) s/p IV steroids who presents with increasing lethargy and
headache.
History per ___ records and per her Aunt as patient cannot
provide much history. Per her aunt, ___ has been doing well
recently without any illness, behavioral change. She had a cold
she was getting over but otherwise doing well. She had an Fe
transfusion on ___ around 3:30P at ___ and the aunt
accompanied her to the visit. Towards the end of the infusion,
___ developed mottle purple lower extremities and was having
nausea, heart racing. She was sent to ___ where she had SBP
up to 144. Her exam per ___ records notable for "shivering...
doesn't open her eyes...mottled hands and feet". There was no
concern for respiratory distress. She was given 50 mg IV
Benadryl, 100 mg IV hydrocortisone and observed for 5 hours and
then discharged. At that time ___ was reportedly "lethargic"
meaning sleeping frequently but able to sit up and walk without
issue. They arrived home and ___ went to bed. Around 6:00 AM
on ___, ___ aunt check on her and she was still sleeping.
She was reporting a headache (which the transfusion place said
would happen) but did not mention other characteristic.
___
aunt gave her acetaminophen and water and ___ went back to
sleep. Over the next few hours, she heard ___ awake several
times and use the bathroom. Then as it got later and later into
the day and ___ was not up and about yet, her aunt became
worried. She told ___ to call the ___ which she
was able to do. She reportedly said she continued to have a
headache and felt sleepy. She was instructed to go to the ED.
She went to the ED at ___ for evaluation. At ___ she
had T 99.5, P 58, RR 15 and sat 100%. BP 110/67. She was
reportedly drowsy and arousing to voice, "alert oriented x3",
consistent eye fluttering, pupils reactive to light and
extraocular eye movements full, with reportedly "non focal
exam".
Lab work notable for WBC 7.2, Hgb 13.2, Na 142, bicarb 26, Cr
0.9, Ca 9.4, normal LFTs, Fe 360, Ferritin 438. VBG pH was 7.43,
PCO2 was 45.She had a normal ___ and LP with WBC 2, 100%
monocytes glucose 57, protein 24, no xanthochromia. She
ultimately had MRA and MRV which showed no thrombus or venoous
thrombosis. She was transferred to ___ for further management.
On my interview she cannot provide much history other than to
say
she is here because "I'm tired". She keeps her eyes closed
during
questioning. She reports headache but cannot describe where it
is
or features other than +photophobia. She is unable to
participate
in other questioning, often getting tearful and saying "the
questions are hard".
Per her father and aunt, she has no history of seizures, or CNS
infection. She did have a concussion at ___ years old.
Past Medical History:
Anemia
Social History:
___
Family History:
Mother with a celiac disease and autoimmune hypothyroidism. Dad
is healthy. She has a cousin with seizures.
Physical Exam:
Admission exam:
98.1 76 130/78 14 96% RA
General: appears to be sleeping, occasional eye lid fluttering,
lip movements, occasional slow movements of head from side to
side
HEENT: no trauma, no jaundice, no lesions of oropharynx
CV: RRR, wwp
Pulm: breathing comfortably on RA
Ext: clammy, warm and no rash
Neurologic:
-Mental Status: She frequently gets upset during exam and is
tearful at times, then abulic at other times. Eyes open only
briefly to voice. She is oriented to ___ but not full
date. Knows she is in a "hospital" but not the name. She says
she
is in the hospital because, "I'm tired". She is unable to
provide
history. Speech is not dysarthric, says ___ words when asked
questions, no spontaneous speech output. Follows simple commands
like open eyes, lift legs. She is able to name "key" and
"feather" on stroke card but then stops naming and closes her
eyes. She reads the first sentence on stroke card but then no
more and closes her eyes. When asked to describe stroke card
picture she says, "dishes". She does not participate in further
exam.
-Cranial Nerves:
II, III, IV, VI: Pupils 8 mm->6 mm. EOMI without nystagmus.
VFF
to confrontation. Fundoscopic exam revealed no papilledema,
exudates, or hemorrhages.
VII: No facial droop, facial musculature symmetric with
grimace.
VIII: Hearing intact to exam
IX, X: Palate elevates symmetrically.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. She says she cannot move
her arms. When arms placed over her head, her arms slowly miss
her face and slowly drops to the bed in a controlled fashion.
She
does lift her arms to hold the side rails of the bed
spontaneously. She lifts her legs antigravity and holds them
without drift.
-Sensory: slightly withdrawals in upper extremities and says
"ouch", briskly withdrawals in lower extremities to noxious
stimuli and says "ouch"
-DTRs:
___ Tri ___ Pat Ach
L 2 2 0 3 2
R 2 2 0 3 2
Plantar response was flexor bilaterally.
-Coordination: patient could not participate
-Gait: could not assess as patient would not get out of bed
Discharge Exam:
General: sitting up in her chair with eyes closed
HEENT: no trauma, no jaundice, no lesions of oropharynx
CV: sinus bradycardia, no m/r/g
Pulm: Breathing comfortably on RA
Ext: Warm and well perfused, no rash or mottling
Neurologic:
-Mental Status: Answering questions with slow short sentence.
More humor and complex sentences observed today.
Eyes intermittently close while she is talking. Speech
is not dysarthric, no spontaneous speech output. Follows
simple commands.
-Cranial Nerves:
II, III, IV, VI: Pupils 8 mm->4 mm. EOMI without nystagmus.
V: facial sensation intact throughout
VII: No facial droop, facial musculature symmetric with grimace
but limited facial movements.
IX, X, XII: palate elevates symmetrically, tongue midline
-Motor: Normal bulk, tone throughout. Lifting arms and legs
against gravity but not against resistance (___)
-Sensory: Sensation intact to touch and temperature throughout
-DTRs: 1+ patellar, biceps, brachioradialis throughout
-Coordination: No dysmetria or tremor.
-Gait: Ambulated well with a ___.
Pertinent Results:
Admission labs:
===============
___ 12:59PM GLUCOSE-77 UREA N-8 CREAT-0.7 SODIUM-142
POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-24 ANION GAP-14
___ 12:59PM ALT(SGPT)-9 AST(SGOT)-13 ALK PHOS-39 TOT
BILI-0.3
___ 12:59PM CALCIUM-8.7 PHOSPHATE-4.0 MAGNESIUM-1.7
___ 12:59PM tTG-IgA-7
___ 12:59PM WBC-5.0 RBC-3.89* HGB-11.5 HCT-34.4 MCV-88
MCH-29.6 MCHC-33.4 RDW-12.4 RDWSD-39.8
___ 12:59PM PLT COUNT-235
___ 05:11AM URINE HOURS-RANDOM
___ 05:11AM URINE UCG-NEGATIVE
___ 05:11AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 05:11AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 05:11AM URINE BLOOD-LG* NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR* BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 05:11AM URINE RBC-5* WBC-1 BACTERIA-FEW* YEAST-NONE
EPI-0
___ 05:11AM URINE MUCOUS-RARE*
___ 04:34AM ___ PTT-27.2 ___
___ 04:28AM WBC-6.4 RBC-4.17 HGB-12.6 HCT-37.4 MCV-90
MCH-30.2 MCHC-33.7 RDW-12.4 RDWSD-40.8
___ 04:28AM NEUTS-58.2 ___ MONOS-7.1 EOS-0.2*
BASOS-0.6 IM ___ AbsNeut-3.70 AbsLymp-2.14 AbsMono-0.45
AbsEos-0.01* AbsBaso-0.04
___ 04:28AM PLT COUNT-246
___ 04:11AM ___ PO2-50* PCO2-34* PH-7.44 TOTAL
CO2-24 BASE XS-0 COMMENTS-GREEN TOP
___ 04:10AM GLUCOSE-84 UREA N-7 CREAT-0.8 SODIUM-143
POTASSIUM-3.6 CHLORIDE-106 TOTAL CO2-23 ANION GAP-14
___ 04:10AM estGFR-Using this
___ 04:10AM ALT(SGPT)-9 AST(SGOT)-14 CK(CPK)-67 ALK
PHOS-41 TOT BILI-0.3
___ 04:10AM CK-MB-<1
___ 04:10AM ALBUMIN-3.9 CALCIUM-8.8 PHOSPHATE-2.9
MAGNESIUM-1.8
___ 04:10AM VIT B12-227*
___ 04:10AM TSH-2.7
___ 04:10AM TSH-2.6
___ 04:10AM ___ TITER-1:1280* CRP-3.4
dsDNA-NEGATIVE
___ 04:10AM C3-121 C4-27
___ 04:10AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
tricyclic-NEG
EEG ___:
==============
IMPRESSION: This telemetry captured no pushbutton activations.
The background showed normal waking and sleep patterns. There
were no focal abnormalities, epileptiform features, or
electrographic seizures. A bradycardia was noted.
IMAGING:
========
MRI BRAIN WITH/WITHOUT CONTRAST ___
FINDINGS:
A 5 mm FLAIR hypointense and T1 isointense lesion at midline
between the
anterior and posterior pituitary is noted. There is no evidence
of
hemorrhage, edema, mass effect, midline shift or infarction. The
ventricles and sulci are normal in caliber and configuration.
There is no abnormal enhancement after contrast administration.
IMPRESSION:
A 5 mm FLAIR hypointense and T1 isointense lesion at midline
between the
anterior and posterior pituitary likely represents a Rathke's
cleft cyst.
Further evaluation is needed, dedicated pituitary MR may be
obtained.
Brief Hospital Course:
See worksheet
Medications on Admission:
famotidine 40 mg daily
birth control per her aunt
___:
1. ___ 250 mcg PO DAILY
2. Famotidine 40 mg PO DAILY
3. Metoprolol Tartrate 12.5 mg PO DAILY
4. Multivitamins W/minerals 1 TAB PO DAILY
5. Nortriptyline 10 mg PO QHS
6. ___ 1 item miscellaneous ONCE
Prognosis: Good
___: 13 months
RX ___ Once Disp #*1 Each Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Functional neurological syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___
___.
You were in the hospital because of headache, lethargy, and
weakness after an iron infusion.
You had a number of tests performed in the hospital, all of
which were reassuring. An MRI of your brain showed no evidence
of stroke or inflammation. An EEG to monitor your brain waves
showed no evidence of seizure. Your weakness gradually improved
over the course of your hospitalization and will continue to
improve after you leave the hospital.
After leaving the hospital, you should continue to work on
improving your strength. It will improve as long as you work
hard!
We wish you the best,
Your ___ Care Team
Followup Instructions:
___
|
[
"F4489",
"R29818",
"I7300",
"I951",
"R000",
"F410",
"E869",
"K219",
"D509",
"D519",
"F329"
] |
Allergies: amoxicillin Chief Complaint: Weakness and lethargy Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a [MASKED] year old female with history of chronic abdominal pain and anemia w/ recent Fe sucrose infusion ([MASKED]) complicated by infusion reaction (mottling and discoloration of feet) s/p IV steroids who presents with increasing lethargy and headache. History per [MASKED] records and per her Aunt as patient cannot provide much history. Per her aunt, [MASKED] has been doing well recently without any illness, behavioral change. She had a cold she was getting over but otherwise doing well. She had an Fe transfusion on [MASKED] around 3:30P at [MASKED] and the aunt accompanied her to the visit. Towards the end of the infusion, [MASKED] developed mottle purple lower extremities and was having nausea, heart racing. She was sent to [MASKED] where she had SBP up to 144. Her exam per [MASKED] records notable for "shivering... doesn't open her eyes...mottled hands and feet". There was no concern for respiratory distress. She was given 50 mg IV Benadryl, 100 mg IV hydrocortisone and observed for 5 hours and then discharged. At that time [MASKED] was reportedly "lethargic" meaning sleeping frequently but able to sit up and walk without issue. They arrived home and [MASKED] went to bed. Around 6:00 AM on [MASKED], [MASKED] aunt check on her and she was still sleeping. She was reporting a headache (which the transfusion place said would happen) but did not mention other characteristic. [MASKED] aunt gave her acetaminophen and water and [MASKED] went back to sleep. Over the next few hours, she heard [MASKED] awake several times and use the bathroom. Then as it got later and later into the day and [MASKED] was not up and about yet, her aunt became worried. She told [MASKED] to call the [MASKED] which she was able to do. She reportedly said she continued to have a headache and felt sleepy. She was instructed to go to the ED. She went to the ED at [MASKED] for evaluation. At [MASKED] she had T 99.5, P 58, RR 15 and sat 100%. BP 110/67. She was reportedly drowsy and arousing to voice, "alert oriented x3", consistent eye fluttering, pupils reactive to light and extraocular eye movements full, with reportedly "non focal exam". Lab work notable for WBC 7.2, Hgb 13.2, Na 142, bicarb 26, Cr 0.9, Ca 9.4, normal LFTs, Fe 360, Ferritin 438. VBG pH was 7.43, PCO2 was 45.She had a normal [MASKED] and LP with WBC 2, 100% monocytes glucose 57, protein 24, no xanthochromia. She ultimately had MRA and MRV which showed no thrombus or venoous thrombosis. She was transferred to [MASKED] for further management. On my interview she cannot provide much history other than to say she is here because "I'm tired". She keeps her eyes closed during questioning. She reports headache but cannot describe where it is or features other than +photophobia. She is unable to participate in other questioning, often getting tearful and saying "the questions are hard". Per her father and aunt, she has no history of seizures, or CNS infection. She did have a concussion at [MASKED] years old. Past Medical History: Anemia Social History: [MASKED] Family History: Mother with a celiac disease and autoimmune hypothyroidism. Dad is healthy. She has a cousin with seizures. Physical Exam: Admission exam: 98.1 76 130/78 14 96% RA General: appears to be sleeping, occasional eye lid fluttering, lip movements, occasional slow movements of head from side to side HEENT: no trauma, no jaundice, no lesions of oropharynx CV: RRR, wwp Pulm: breathing comfortably on RA Ext: clammy, warm and no rash Neurologic: -Mental Status: She frequently gets upset during exam and is tearful at times, then abulic at other times. Eyes open only briefly to voice. She is oriented to [MASKED] but not full date. Knows she is in a "hospital" but not the name. She says she is in the hospital because, "I'm tired". She is unable to provide history. Speech is not dysarthric, says [MASKED] words when asked questions, no spontaneous speech output. Follows simple commands like open eyes, lift legs. She is able to name "key" and "feather" on stroke card but then stops naming and closes her eyes. She reads the first sentence on stroke card but then no more and closes her eyes. When asked to describe stroke card picture she says, "dishes". She does not participate in further exam. -Cranial Nerves: II, III, IV, VI: Pupils 8 mm->6 mm. EOMI without nystagmus. VFF to confrontation. Fundoscopic exam revealed no papilledema, exudates, or hemorrhages. VII: No facial droop, facial musculature symmetric with grimace. VIII: Hearing intact to exam IX, X: Palate elevates symmetrically. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. She says she cannot move her arms. When arms placed over her head, her arms slowly miss her face and slowly drops to the bed in a controlled fashion. She does lift her arms to hold the side rails of the bed spontaneously. She lifts her legs antigravity and holds them without drift. -Sensory: slightly withdrawals in upper extremities and says "ouch", briskly withdrawals in lower extremities to noxious stimuli and says "ouch" -DTRs: [MASKED] Tri [MASKED] Pat Ach L 2 2 0 3 2 R 2 2 0 3 2 Plantar response was flexor bilaterally. -Coordination: patient could not participate -Gait: could not assess as patient would not get out of bed Discharge Exam: General: sitting up in her chair with eyes closed HEENT: no trauma, no jaundice, no lesions of oropharynx CV: sinus bradycardia, no m/r/g Pulm: Breathing comfortably on RA Ext: Warm and well perfused, no rash or mottling Neurologic: -Mental Status: Answering questions with slow short sentence. More humor and complex sentences observed today. Eyes intermittently close while she is talking. Speech is not dysarthric, no spontaneous speech output. Follows simple commands. -Cranial Nerves: II, III, IV, VI: Pupils 8 mm->4 mm. EOMI without nystagmus. V: facial sensation intact throughout VII: No facial droop, facial musculature symmetric with grimace but limited facial movements. IX, X, XII: palate elevates symmetrically, tongue midline -Motor: Normal bulk, tone throughout. Lifting arms and legs against gravity but not against resistance ([MASKED]) -Sensory: Sensation intact to touch and temperature throughout -DTRs: 1+ patellar, biceps, brachioradialis throughout -Coordination: No dysmetria or tremor. -Gait: Ambulated well with a [MASKED]. Pertinent Results: Admission labs: =============== [MASKED] 12:59PM GLUCOSE-77 UREA N-8 CREAT-0.7 SODIUM-142 POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-24 ANION GAP-14 [MASKED] 12:59PM ALT(SGPT)-9 AST(SGOT)-13 ALK PHOS-39 TOT BILI-0.3 [MASKED] 12:59PM CALCIUM-8.7 PHOSPHATE-4.0 MAGNESIUM-1.7 [MASKED] 12:59PM tTG-IgA-7 [MASKED] 12:59PM WBC-5.0 RBC-3.89* HGB-11.5 HCT-34.4 MCV-88 MCH-29.6 MCHC-33.4 RDW-12.4 RDWSD-39.8 [MASKED] 12:59PM PLT COUNT-235 [MASKED] 05:11AM URINE HOURS-RANDOM [MASKED] 05:11AM URINE UCG-NEGATIVE [MASKED] 05:11AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG [MASKED] 05:11AM URINE COLOR-Straw APPEAR-Clear SP [MASKED] [MASKED] 05:11AM URINE BLOOD-LG* NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR* BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [MASKED] 05:11AM URINE RBC-5* WBC-1 BACTERIA-FEW* YEAST-NONE EPI-0 [MASKED] 05:11AM URINE MUCOUS-RARE* [MASKED] 04:34AM [MASKED] PTT-27.2 [MASKED] [MASKED] 04:28AM WBC-6.4 RBC-4.17 HGB-12.6 HCT-37.4 MCV-90 MCH-30.2 MCHC-33.7 RDW-12.4 RDWSD-40.8 [MASKED] 04:28AM NEUTS-58.2 [MASKED] MONOS-7.1 EOS-0.2* BASOS-0.6 IM [MASKED] AbsNeut-3.70 AbsLymp-2.14 AbsMono-0.45 AbsEos-0.01* AbsBaso-0.04 [MASKED] 04:28AM PLT COUNT-246 [MASKED] 04:11AM [MASKED] PO2-50* PCO2-34* PH-7.44 TOTAL CO2-24 BASE XS-0 COMMENTS-GREEN TOP [MASKED] 04:10AM GLUCOSE-84 UREA N-7 CREAT-0.8 SODIUM-143 POTASSIUM-3.6 CHLORIDE-106 TOTAL CO2-23 ANION GAP-14 [MASKED] 04:10AM estGFR-Using this [MASKED] 04:10AM ALT(SGPT)-9 AST(SGOT)-14 CK(CPK)-67 ALK PHOS-41 TOT BILI-0.3 [MASKED] 04:10AM CK-MB-<1 [MASKED] 04:10AM ALBUMIN-3.9 CALCIUM-8.8 PHOSPHATE-2.9 MAGNESIUM-1.8 [MASKED] 04:10AM VIT B12-227* [MASKED] 04:10AM TSH-2.7 [MASKED] 04:10AM TSH-2.6 [MASKED] 04:10AM [MASKED] TITER-1:1280* CRP-3.4 dsDNA-NEGATIVE [MASKED] 04:10AM C3-121 C4-27 [MASKED] 04:10AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG tricyclic-NEG EEG [MASKED]: ============== IMPRESSION: This telemetry captured no pushbutton activations. The background showed normal waking and sleep patterns. There were no focal abnormalities, epileptiform features, or electrographic seizures. A bradycardia was noted. IMAGING: ======== MRI BRAIN WITH/WITHOUT CONTRAST [MASKED] FINDINGS: A 5 mm FLAIR hypointense and T1 isointense lesion at midline between the anterior and posterior pituitary is noted. There is no evidence of hemorrhage, edema, mass effect, midline shift or infarction. The ventricles and sulci are normal in caliber and configuration. There is no abnormal enhancement after contrast administration. IMPRESSION: A 5 mm FLAIR hypointense and T1 isointense lesion at midline between the anterior and posterior pituitary likely represents a Rathke's cleft cyst. Further evaluation is needed, dedicated pituitary MR may be obtained. Brief Hospital Course: See worksheet Medications on Admission: famotidine 40 mg daily birth control per her aunt [MASKED]: 1. [MASKED] 250 mcg PO DAILY 2. Famotidine 40 mg PO DAILY 3. Metoprolol Tartrate 12.5 mg PO DAILY 4. Multivitamins W/minerals 1 TAB PO DAILY 5. Nortriptyline 10 mg PO QHS 6. [MASKED] 1 item miscellaneous ONCE Prognosis: Good [MASKED]: 13 months RX [MASKED] Once Disp #*1 Each Refills:*0 Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Functional neurological syndrome Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], It was a pleasure taking care of you at [MASKED] [MASKED]. You were in the hospital because of headache, lethargy, and weakness after an iron infusion. You had a number of tests performed in the hospital, all of which were reassuring. An MRI of your brain showed no evidence of stroke or inflammation. An EEG to monitor your brain waves showed no evidence of seizure. Your weakness gradually improved over the course of your hospitalization and will continue to improve after you leave the hospital. After leaving the hospital, you should continue to work on improving your strength. It will improve as long as you work hard! We wish you the best, Your [MASKED] Care Team Followup Instructions: [MASKED]
|
[] |
[
"K219",
"D509",
"F329"
] |
[
"F4489: Other dissociative and conversion disorders",
"R29818: Other symptoms and signs involving the nervous system",
"I7300: Raynaud's syndrome without gangrene",
"I951: Orthostatic hypotension",
"R000: Tachycardia, unspecified",
"F410: Panic disorder [episodic paroxysmal anxiety]",
"E869: Volume depletion, unspecified",
"K219: Gastro-esophageal reflux disease without esophagitis",
"D509: Iron deficiency anemia, unspecified",
"D519: Vitamin B12 deficiency anemia, unspecified",
"F329: Major depressive disorder, single episode, unspecified"
] |
10,002,528 | 28,605,730 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
amoxicillin / iron
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
ADMISSION LABS:
===============
___ 10:45PM PLT COUNT-244
___ 10:45PM NEUTS-55.7 ___ MONOS-10.8 EOS-0.7*
BASOS-0.9 IM ___ AbsNeut-2.99 AbsLymp-1.70 AbsMono-0.58
AbsEos-0.04 AbsBaso-0.05
___ 10:45PM WBC-5.4 RBC-4.19 HGB-13.4 HCT-41.2 MCV-98
MCH-32.0 MCHC-32.5 RDW-12.4 RDWSD-44.2
___ 10:45PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
tricyclic-NEG
___ 10:45PM ALBUMIN-4.8 CALCIUM-9.6 PHOSPHATE-3.0
MAGNESIUM-2.1
___ 10:45PM LIPASE-31
___ 10:45PM ALT(SGPT)-20 AST(SGOT)-26 ALK PHOS-48 TOT
BILI-0.4
___ 10:45PM GLUCOSE-128* UREA N-15 CREAT-1.1 SODIUM-137
POTASSIUM-3.7 CHLORIDE-100 TOTAL CO2-23 ANION GAP-14
___ 03:17AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-10* BILIRUBIN-NEG UROBILNGN-NORMAL PH-6.5
LEUK-NEG
___ 03:17AM URINE COLOR-Straw APPEAR-CLEAR SP ___
___ 03:17AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 03:17AM URINE UCG-NEGATIVE
___ 03:17AM URINE HOURS-RANDOM
PERTINENT LABS:
===============
___ 05:45AM BLOOD VitB12-956*
___ 05:45AM BLOOD TSH-0.99
___ 05:45AM BLOOD Free T4-1.3
___ 05:45AM BLOOD VITAMIN B1-WHOLE BLOOD-PND
MICRO:
======
___ 3:17 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING:
========
none
DISCHARGE LABS:
===============
no labs on day of discharge
DISCHARGE PHYSICAL EXAM:
========================
VITALS: ___ 1136 Temp: 98.1 PO BP: 107/68 R lying HR: 68
RR: 18 O2
sat: 100% O2 delivery: RA
GENERAL: NAD, sitting up in chair, smiling, moving head around
EYES: Sclera anicteric and without injection.
CARDIAC: RRR. Audible S1 and S2. No murmurs/rubs/gallops.
RESP: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender.
EXTREMITIES: Pulses DP/Radial 2+ bilaterally.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: Speech slow but markedly improved today and speaks
in simple
sentences. Sitting in a chair and able to move all extremities,
follow commands such as moving fingers/toes on command and
sticking thumb up.
PSYCH: Alert and awake, pleasant, smiling
Brief Hospital Course:
BRIEF HOSPITAL SUMMARY:
=======================
___ female with history of disordered eating, PTSD, GAD
with panic disorder, depression and functional neurological
disorder presenting from a therapy session with weakness,
abnormal movement, and aphasia concerning for an acute
functional neurological episode. She was evaluated by neurology
and psychology who felt this was consistent with functional
neurological disorder, similar to her prior presentation. She
began working with ___ and OT and had made great improvement at
time of discharge to acute rehab.
TRANSITIONAL ISSUES:
====================
For rehab:
[] Please continue aggressive ___ and OT for further improvement
in functional status.
[] On discharge, please ensure patient has follow up with her
PCP and her therapist.
[] Patient was having some intermittent nausea as appetite
improved. Please continue Zofran TID prn. QTc was 441 on EKG on
___. If continuing Zofran use for >1 week, please recheck QTc
on ___ and d/c medication if prolonged.
[] Patient has a history of disordered and restrictive eating.
She does well eating with encouragement and did not show any
evidence of eating disorder while inpatient. Please continue
ensure supplements TID with meals.
For PCP/therapist:
[] Please refer patient to psychiatrist for further titration of
psychiatric medications, given report of previous sensitivity to
medications and concern for possible bipolar disorder diagnosis.
[] Please follow up pending thiamine level.
ACUTE ISSUES:
=============
# GAD/Panic disorder
# Depression
# PTSD
# Functional neurological disorder
Patient presented from a therapy session where she had acute
onset of weakness, abnormal movement and aphasia in the setting
of potential trigger of seeing shadows outside the door. Per her
therapist, over the past several weeks she has been increasingly
more hypervigilant and stressed about going home for the
holidays to see her mom, which is a major trigger for her PTSD.
Her therapist also reports a history of sexual/physical/verbal
abuse but patient is very guarded about it and will not discuss
it. On presentation to the ___ had significant and acute
functional neurological symptoms, including weakness, abnormal
movement, and aphasia, resulting in impaired functioning. There
was concern for catatonia and she improved after 1 mg IV ativan
in the ER. She endorsed significant anxiety, but denied SI and,
per Psychiatry, she did not meet ___ criteria. She had a
similar episode in ___ after IV iron infusion and was
admitted to the neurology service, where she was diagnosed with
functional neurological disorder and she improved with ___ and
rehab. She was also started on nortriptyline 10 mg QHS at that
time. Per her therapist, she is sensitive to medications and
when she was on SSRIs she became manic, although she has not
formally been diagnosed with bipolar disorder. Once admitted,
she was re-evaluated by neuro and psychiatry who determined this
was not consistent with catatonia and instead was likely
functional neurological disorder. She was recommended for acute
rehab to continue aggressive ___. She was continued on home
nortriptyline 10mg qhs.
#Disordered eating
#Restrictive eating
#Over-exercising
She has a history of restrictive eating and over-exercising and
in the past she has had bradycardia and electrolyte
abnormalities. Per her therapist, her disordered eating has
become much worse over the past few months in the setting of
traveling a lot for work. She started an intensive outpatient
program at ___ Eating ___ on ___. Per her
therapist, she restricts her calories to about 1,000 or less a
day and over-exercises and is good at hiding it from people.
From review of OMR, her BMI seems to be normal (between ___
and she currently does not have any electrolyte abnormalities
but she has been intermittently bradycardic with HR in the ___.
Her appetite improved as her neurological symptoms began
resolving. Per nutrition evaluation, no need for eating disorder
protocol while inpatient. She received Ensure supplements. Heart
rates were stable, bradycardic in ___. Electrolytes were
monitored. TSH, T4 and B12 levels were all normal. She received
thiamine supplementation. She received Zofran PRN for nausea
(QTc 441).
CORE MEASURES
=============
#CODE: full code
#CONTACT: Per patient's request, do not contact her mother
(___)
-Emergency Contacts: ___ (___) ___ and ___ (Uncle) ___
-Therapist: ___, ___ ___ and coordinates
all of her care and available for questions/calls at anytime
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Nortriptyline 10 mg PO QHS
Discharge Medications:
1. Multivitamins W/minerals 1 TAB PO DAILY
2. Ondansetron ODT 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
3. Thiamine 100 mg PO DAILY
4. Nortriptyline 10 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
#Functional neurological disorder
#GAD/depression
#PTSD
#H/o disordered eating
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 privilege taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
===================================
-You came to the hospital because you acutely had trouble moving
and speaking.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
==========================================
-You were seen by the neurologists who diagnosed you with
functional neurological disorder.
-You worked with physical and occupational therapists.
-Your symptoms began to improve.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
============================================
- Please continue to take all your medications and follow up
with your doctors at your ___ appointments.
- Please continue to work with your physical and occupational
therapists.
We wish you all the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
[
"R29818",
"F411",
"F329",
"F4310",
"F5082",
"Z6822",
"D649"
] |
Allergies: amoxicillin / iron Major Surgical or Invasive Procedure: None attach Pertinent Results: ADMISSION LABS: =============== [MASKED] 10:45PM PLT COUNT-244 [MASKED] 10:45PM NEUTS-55.7 [MASKED] MONOS-10.8 EOS-0.7* BASOS-0.9 IM [MASKED] AbsNeut-2.99 AbsLymp-1.70 AbsMono-0.58 AbsEos-0.04 AbsBaso-0.05 [MASKED] 10:45PM WBC-5.4 RBC-4.19 HGB-13.4 HCT-41.2 MCV-98 MCH-32.0 MCHC-32.5 RDW-12.4 RDWSD-44.2 [MASKED] 10:45PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG tricyclic-NEG [MASKED] 10:45PM ALBUMIN-4.8 CALCIUM-9.6 PHOSPHATE-3.0 MAGNESIUM-2.1 [MASKED] 10:45PM LIPASE-31 [MASKED] 10:45PM ALT(SGPT)-20 AST(SGOT)-26 ALK PHOS-48 TOT BILI-0.4 [MASKED] 10:45PM GLUCOSE-128* UREA N-15 CREAT-1.1 SODIUM-137 POTASSIUM-3.7 CHLORIDE-100 TOTAL CO2-23 ANION GAP-14 [MASKED] 03:17AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-10* BILIRUBIN-NEG UROBILNGN-NORMAL PH-6.5 LEUK-NEG [MASKED] 03:17AM URINE COLOR-Straw APPEAR-CLEAR SP [MASKED] [MASKED] 03:17AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG [MASKED] 03:17AM URINE UCG-NEGATIVE [MASKED] 03:17AM URINE HOURS-RANDOM PERTINENT LABS: =============== [MASKED] 05:45AM BLOOD VitB12-956* [MASKED] 05:45AM BLOOD TSH-0.99 [MASKED] 05:45AM BLOOD Free T4-1.3 [MASKED] 05:45AM BLOOD VITAMIN B1-WHOLE BLOOD-PND MICRO: ====== [MASKED] 3:17 am URINE **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. IMAGING: ======== none DISCHARGE LABS: =============== no labs on day of discharge DISCHARGE PHYSICAL EXAM: ======================== VITALS: [MASKED] 1136 Temp: 98.1 PO BP: 107/68 R lying HR: 68 RR: 18 O2 sat: 100% O2 delivery: RA GENERAL: NAD, sitting up in chair, smiling, moving head around EYES: Sclera anicteric and without injection. CARDIAC: RRR. Audible S1 and S2. No murmurs/rubs/gallops. RESP: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. ABDOMEN: Normal bowels sounds, non distended, non-tender. EXTREMITIES: Pulses DP/Radial 2+ bilaterally. SKIN: Warm. Cap refill <2s. No rash. NEUROLOGIC: Speech slow but markedly improved today and speaks in simple sentences. Sitting in a chair and able to move all extremities, follow commands such as moving fingers/toes on command and sticking thumb up. PSYCH: Alert and awake, pleasant, smiling Brief Hospital Course: BRIEF HOSPITAL SUMMARY: ======================= [MASKED] female with history of disordered eating, PTSD, GAD with panic disorder, depression and functional neurological disorder presenting from a therapy session with weakness, abnormal movement, and aphasia concerning for an acute functional neurological episode. She was evaluated by neurology and psychology who felt this was consistent with functional neurological disorder, similar to her prior presentation. She began working with [MASKED] and OT and had made great improvement at time of discharge to acute rehab. TRANSITIONAL ISSUES: ==================== For rehab: [] Please continue aggressive [MASKED] and OT for further improvement in functional status. [] On discharge, please ensure patient has follow up with her PCP and her therapist. [] Patient was having some intermittent nausea as appetite improved. Please continue Zofran TID prn. QTc was 441 on EKG on [MASKED]. If continuing Zofran use for >1 week, please recheck QTc on [MASKED] and d/c medication if prolonged. [] Patient has a history of disordered and restrictive eating. She does well eating with encouragement and did not show any evidence of eating disorder while inpatient. Please continue ensure supplements TID with meals. For PCP/therapist: [] Please refer patient to psychiatrist for further titration of psychiatric medications, given report of previous sensitivity to medications and concern for possible bipolar disorder diagnosis. [] Please follow up pending thiamine level. ACUTE ISSUES: ============= # GAD/Panic disorder # Depression # PTSD # Functional neurological disorder Patient presented from a therapy session where she had acute onset of weakness, abnormal movement and aphasia in the setting of potential trigger of seeing shadows outside the door. Per her therapist, over the past several weeks she has been increasingly more hypervigilant and stressed about going home for the holidays to see her mom, which is a major trigger for her PTSD. Her therapist also reports a history of sexual/physical/verbal abuse but patient is very guarded about it and will not discuss it. On presentation to the [MASKED] had significant and acute functional neurological symptoms, including weakness, abnormal movement, and aphasia, resulting in impaired functioning. There was concern for catatonia and she improved after 1 mg IV ativan in the ER. She endorsed significant anxiety, but denied SI and, per Psychiatry, she did not meet [MASKED] criteria. She had a similar episode in [MASKED] after IV iron infusion and was admitted to the neurology service, where she was diagnosed with functional neurological disorder and she improved with [MASKED] and rehab. She was also started on nortriptyline 10 mg QHS at that time. Per her therapist, she is sensitive to medications and when she was on SSRIs she became manic, although she has not formally been diagnosed with bipolar disorder. Once admitted, she was re-evaluated by neuro and psychiatry who determined this was not consistent with catatonia and instead was likely functional neurological disorder. She was recommended for acute rehab to continue aggressive [MASKED]. She was continued on home nortriptyline 10mg qhs. #Disordered eating #Restrictive eating #Over-exercising She has a history of restrictive eating and over-exercising and in the past she has had bradycardia and electrolyte abnormalities. Per her therapist, her disordered eating has become much worse over the past few months in the setting of traveling a lot for work. She started an intensive outpatient program at [MASKED] Eating [MASKED] on [MASKED]. Per her therapist, she restricts her calories to about 1,000 or less a day and over-exercises and is good at hiding it from people. From review of OMR, her BMI seems to be normal (between [MASKED] and she currently does not have any electrolyte abnormalities but she has been intermittently bradycardic with HR in the [MASKED]. Her appetite improved as her neurological symptoms began resolving. Per nutrition evaluation, no need for eating disorder protocol while inpatient. She received Ensure supplements. Heart rates were stable, bradycardic in [MASKED]. Electrolytes were monitored. TSH, T4 and B12 levels were all normal. She received thiamine supplementation. She received Zofran PRN for nausea (QTc 441). CORE MEASURES ============= #CODE: full code #CONTACT: Per patient's request, do not contact her mother ([MASKED]) -Emergency Contacts: [MASKED] ([MASKED]) [MASKED] and [MASKED] (Uncle) [MASKED] -Therapist: [MASKED], [MASKED] [MASKED] and coordinates all of her care and available for questions/calls at anytime Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Nortriptyline 10 mg PO QHS Discharge Medications: 1. Multivitamins W/minerals 1 TAB PO DAILY 2. Ondansetron ODT 4 mg PO Q8H:PRN Nausea/Vomiting - First Line 3. Thiamine 100 mg PO DAILY 4. Nortriptyline 10 mg PO QHS Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: #Functional neurological disorder #GAD/depression #PTSD #H/o disordered eating Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. [MASKED], It was a privilege taking care of you at [MASKED] [MASKED]. WHY WAS I ADMITTED TO THE HOSPITAL? =================================== -You came to the hospital because you acutely had trouble moving and speaking. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? ========================================== -You were seen by the neurologists who diagnosed you with functional neurological disorder. -You worked with physical and occupational therapists. -Your symptoms began to improve. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? ============================================ - Please continue to take all your medications and follow up with your doctors at your [MASKED] appointments. - Please continue to work with your physical and occupational therapists. We wish you all the best! Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED]
|
[] |
[
"F329",
"D649"
] |
[
"R29818: Other symptoms and signs involving the nervous system",
"F411: Generalized anxiety disorder",
"F329: Major depressive disorder, single episode, unspecified",
"F4310: Post-traumatic stress disorder, unspecified",
"F5082: Avoidant/restrictive food intake disorder",
"Z6822: Body mass index [BMI] 22.0-22.9, adult",
"D649: Anemia, unspecified"
] |
10,002,800 | 20,798,638 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Percocet / cucumber / Tegaderm
Attending: ___.
Chief Complaint:
cracked tooth, s/p fall
Major Surgical or Invasive Procedure:
tooth extraction
History of Present Illness:
Patient is a ___ year old G1P0 at ___ by U/S w/ h/o breast CA
on DDAC chemotherapy in pregnancy and thyroid CA who presents
after transfer from ED for tooth pain and for evaluation after a
fall two days ago when she tripped on the ice and hit her
shoulder.
She reports progressive dental pain in the right lower molar.
She has been unable to get dental treatment of her fractured
molar in the outpatient setting due to concerns about pregnancy
and medical complexity. She was therefore referred to the ED.
OMFS was consulted while she was in the ED w/ plan for removal
in the OR tomorrow. Findings included cracked tooth #29 w/
carriers extending to pulp. The patient was sent to OB triage
given the mechanical fall.
The patient denies any abdominal trauma or bruising. She has
been having very irregular cramping, no contractions. She also
reports intermittent sharp shooting pain from the groin to her
belly button. Not exacerbated by anything. Pain cannot be
reproduced. She denies and VB or LOF.
Past Medical History:
PNC:
- ___ ___ by US
- Labs: Rh+/ab neg/RPRNR/RI/HBsAg neg/HIV neg/ GBS unknown
- Genetics: LR ERA
- FFS: wnl
- GLT: wnl
- US: ___, 67%, breech, ___, nl fluid, anterior placenta
- Issues:
*) breast cancer in pregnancy: unilateral mastectomy w/ sentinel
LN biopsy, s/p chemotherapy completed ___, plan for PP
tamoxifen
*) mild asthma
*) History of papillary thyroid cancer x 2, on levothyroxine
175mcg daily; labs ___ - TSH 4.3 (elevated) but normal FT4
(1.1)
ROS: per hpi
GYNHx: h/o breast cancer
OBHx: G1, current
PMH: h/o breast cancer, mild asthma, h/o papillary
PSH: s/p unilateral mastectomy w/ sentinel LN biopsy
Social History:
___
Family History:
Family history: Aunt and mother with ALS. Mother, aunt,
grandmother: ___. Father--prostate cancer (age ___
Physical Exam:
On admission:
___ 19:03Temp.: 98.0°F
___ 19:03BP: 121/65 (76)
___ ___: 69
___ ___: 67
GEN: NAD
Respiratory: no increased WOB
Abdomen: no bruising, non-tender, gravid
SVE: LCP
TAUS: vtx, anterior placenta, no sonographic evidence of
abruption, MVP 5.4
FHT: 130/moderate/+accels/ no decels
On discharge:
VS: 98.0, 114/71, 73, 16, O2 96%
Gen: [x] NAD
Resp: [x] No evidence of respiratory distress
Abd: [x] soft [x] non-tender
Ext: [x] no edema [x] non-tender
Date: ___ Time: ___
FHT: 120s, mod var, +accels, no decels reactive
Toco: occ ctx
Pertinent Results:
n/a
Brief Hospital Course:
Patient is a ___ year old G1 with hx of breast CA on DDAC
chemotherapy in pregnancy and thyroid CA admitted at 34w2d after
a fall. On admission, she had no evidence of abruption or
preterm labor. She reported mild cramping and her cervix was
LCP. Fetal testing was reassuring. She also had a painful,
cracked tooth and had been evaluated by OMFS in the emergency
room. A plan was made for extraction in the OR. On HD#2, she
underwent an uncomplicated tooth extraction under local
anesthesia. Her pain resolved. She continued to have some
intermittent cramping and pink discharge, however, she had no
evidence of preterm labor. She was discharged to home in stable
condition on HD#3 and will have close outpatient follow up.
Medications on Admission:
albuterol, levothyroxine
Discharge Medications:
Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours
Disp #*50 Tablet Refills:*0
Levothyroxine Sodium 200 mcg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Cracked tooth
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 ___ service for monitoring after
a fall and prior to your procedure with the oral surgeons for a
tooth extraction. You procedure went well and your baby was
monitored before and after the procedure. You are now stable to
be discharged home. Please see instructions below.
You should continue biting down on a piece of gauze for 30
minute interval. You may stop after ___ gauze changes.
You should NOT have any hot/solid foods for the time being. You
may continue drinking cool liquids.
You may transition to soft foods (eggs, pasta, pancake) tonight.
For pain control, you may take Tylenol as needed (do not take
more than 4000mg in 24 hours).
Please call your primary dentist with any questions or concerns.
Please call the office for:
- Worsening, painful or regular contractions
- Vaginal bleeding
- Leakage of water or concern that your water broke
- Abdominal pain
- Nausea/vomiting
- Fever, chills
- Decreased fetal movement
- Other concerns
Followup Instructions:
___
|
[
"O99613",
"K029",
"Z3A34",
"O99513",
"J45998",
"O9989",
"O99013",
"O99283",
"E890",
"Y836",
"M170",
"M479",
"Z853",
"Z85850",
"Z87891",
"K219"
] |
Allergies: Percocet / cucumber / Tegaderm Chief Complaint: cracked tooth, s/p fall Major Surgical or Invasive Procedure: tooth extraction History of Present Illness: Patient is a [MASKED] year old G1P0 at [MASKED] by U/S w/ h/o breast CA on DDAC chemotherapy in pregnancy and thyroid CA who presents after transfer from ED for tooth pain and for evaluation after a fall two days ago when she tripped on the ice and hit her shoulder. She reports progressive dental pain in the right lower molar. She has been unable to get dental treatment of her fractured molar in the outpatient setting due to concerns about pregnancy and medical complexity. She was therefore referred to the ED. OMFS was consulted while she was in the ED w/ plan for removal in the OR tomorrow. Findings included cracked tooth #29 w/ carriers extending to pulp. The patient was sent to OB triage given the mechanical fall. The patient denies any abdominal trauma or bruising. She has been having very irregular cramping, no contractions. She also reports intermittent sharp shooting pain from the groin to her belly button. Not exacerbated by anything. Pain cannot be reproduced. She denies and VB or LOF. Past Medical History: PNC: - [MASKED] [MASKED] by US - Labs: Rh+/ab neg/RPRNR/RI/HBsAg neg/HIV neg/ GBS unknown - Genetics: LR ERA - FFS: wnl - GLT: wnl - US: [MASKED], 67%, breech, [MASKED], nl fluid, anterior placenta - Issues: *) breast cancer in pregnancy: unilateral mastectomy w/ sentinel LN biopsy, s/p chemotherapy completed [MASKED], plan for PP tamoxifen *) mild asthma *) History of papillary thyroid cancer x 2, on levothyroxine 175mcg daily; labs [MASKED] - TSH 4.3 (elevated) but normal FT4 (1.1) ROS: per hpi GYNHx: h/o breast cancer OBHx: G1, current PMH: h/o breast cancer, mild asthma, h/o papillary PSH: s/p unilateral mastectomy w/ sentinel LN biopsy Social History: [MASKED] Family History: Family history: Aunt and mother with ALS. Mother, aunt, grandmother: [MASKED]. Father--prostate cancer (age [MASKED] Physical Exam: On admission: [MASKED] 19:03Temp.: 98.0°F [MASKED] 19:03BP: 121/65 (76) [MASKED] [MASKED]: 69 [MASKED] [MASKED]: 67 GEN: NAD Respiratory: no increased WOB Abdomen: no bruising, non-tender, gravid SVE: LCP TAUS: vtx, anterior placenta, no sonographic evidence of abruption, MVP 5.4 FHT: 130/moderate/+accels/ no decels On discharge: VS: 98.0, 114/71, 73, 16, O2 96% Gen: [x] NAD Resp: [x] No evidence of respiratory distress Abd: [x] soft [x] non-tender Ext: [x] no edema [x] non-tender Date: [MASKED] Time: [MASKED] FHT: 120s, mod var, +accels, no decels reactive Toco: occ ctx Pertinent Results: n/a Brief Hospital Course: Patient is a [MASKED] year old G1 with hx of breast CA on DDAC chemotherapy in pregnancy and thyroid CA admitted at 34w2d after a fall. On admission, she had no evidence of abruption or preterm labor. She reported mild cramping and her cervix was LCP. Fetal testing was reassuring. She also had a painful, cracked tooth and had been evaluated by OMFS in the emergency room. A plan was made for extraction in the OR. On HD#2, she underwent an uncomplicated tooth extraction under local anesthesia. Her pain resolved. She continued to have some intermittent cramping and pink discharge, however, she had no evidence of preterm labor. She was discharged to home in stable condition on HD#3 and will have close outpatient follow up. Medications on Admission: albuterol, levothyroxine Discharge Medications: Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild RX *acetaminophen 500 mg [MASKED] tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills:*0 Levothyroxine Sodium 200 mcg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Cracked tooth Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You were admitted to the [MASKED] service for monitoring after a fall and prior to your procedure with the oral surgeons for a tooth extraction. You procedure went well and your baby was monitored before and after the procedure. You are now stable to be discharged home. Please see instructions below. You should continue biting down on a piece of gauze for 30 minute interval. You may stop after [MASKED] gauze changes. You should NOT have any hot/solid foods for the time being. You may continue drinking cool liquids. You may transition to soft foods (eggs, pasta, pancake) tonight. For pain control, you may take Tylenol as needed (do not take more than 4000mg in 24 hours). Please call your primary dentist with any questions or concerns. Please call the office for: - Worsening, painful or regular contractions - Vaginal bleeding - Leakage of water or concern that your water broke - Abdominal pain - Nausea/vomiting - Fever, chills - Decreased fetal movement - Other concerns Followup Instructions: [MASKED]
|
[] |
[
"Z87891",
"K219"
] |
[
"O99613: Diseases of the digestive system complicating pregnancy, third trimester",
"K029: Dental caries, unspecified",
"Z3A34: 34 weeks gestation of pregnancy",
"O99513: Diseases of the respiratory system complicating pregnancy, third trimester",
"J45998: Other asthma",
"O9989: Other specified diseases and conditions complicating pregnancy, childbirth and the puerperium",
"O99013: Anemia complicating pregnancy, third trimester",
"O99283: Endocrine, nutritional and metabolic diseases complicating pregnancy, third trimester",
"E890: Postprocedural hypothyroidism",
"Y836: Removal of other organ (partial) (total) as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure",
"M170: Bilateral primary osteoarthritis of knee",
"M479: Spondylosis, unspecified",
"Z853: Personal history of malignant neoplasm of breast",
"Z85850: Personal history of malignant neoplasm of thyroid",
"Z87891: Personal history of nicotine dependence",
"K219: Gastro-esophageal reflux disease without esophagitis"
] |
10,002,800 | 22,634,923 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Percocet / cucumber
Attending: ___
Chief Complaint:
Left breast invasive ductal carcinoma
Major Surgical or Invasive Procedure:
LEFT BREAST TOTAL MASTECTOMY W/ SENTINEL LYMPH NODE BIOPSY
___
History of Present Illness:
Ms ___ is a ___ year old pregnant female with breast
cancer. She had a palpable left breast lump, underwent
ultrasound, MRI, and core biopsy that showed a grade 2 invasive
ductal carcinoma, ER positive, PR positive, HER2 negative. She
later was found to be pregnant. She
is currently feeling fine apart from tiredness. She reports that
her levothyroxine dose was increased earlier this week. She also
notes some left nipple crusting, that there initially (after the
biopsy) was some bloody output that has since declined and
become
mild and crusty. Otherwise no changes.
Past Medical History:
PAST MEDICAL HISTORY: thyroid CA, postsurgical hypothyroidism,
IBS, ovarian cysts, PID, spine arthritis, asthma,
mononucleosisreported history of Lyme disease status post 3
weeks
of antibiotic therapy. Hashimotos negative prior to surgery per
her report
Social History:
___
Family History:
Family history: Aunt and mother with ALS. Mother, aunt,
grandmother: ___. Father--prostate cancer (age ___.
Physical Exam:
VS: Refer to flowsheet
GEN: WD, WN in NAD
CV: RRR
PULM: no respiratory distress
BREAST: L breast - No evidence of hematoma, seroma. Small amount
of ecchymoses. Mildly tender to palpation. Incision healing
well.
ABD: soft, NT, ND
EXT: WWP
NEURO: A&Ox3
Brief Hospital Course:
The patient was admitted on ___ with left breast invasive
ductal carcinoma for left total mastectomy and left axillary
sentinel lymph node biopsy with Dr. ___. Please see
operative note. The patient tolerated the procedure well. There
were no immediate complications. She was awoken from general
anesthesia in the operating room and transferred to the
recovery room in stable condition. On post-operative check, she
reported pain at the site of the incision and nausea, and had an
episode of emesis. The OB/GYN team recommended pain control with
Dilaudid. She was placed on subQ heparin and compression devices
for prophylaxis. She tolerated a regular diet. On ___, the
pain continued to have pain, which was discussed with OB/GYN,
and her dosage of Dilaudid was increased. She was given stool
softener given the usage of narcotics. She reported some mild
pink spotting, which was discussed with OB, and they performed
an ultrasound which showed a strong fetal heart rate of 158. Per
their report, she has been spotting since earlier in the
pregnancy as well. The dressing on the incision site continued
to be clean dry and intact. There was no ecchymoses or hematoma
on the chest wall. Drain output was serosanguineous. At the
time of discharge on ___, vitals were stable, pain
well-controlled, and patient felt ready for discharge to home
with ___, with follow up appointments in place.
Medications on Admission:
Meds/Allergies: reviewed in OMR and medications listed here
ALBUTEROL SULFATE [PROAIR HFA] - Dosage uncertain - (Prescribed
by Other Provider)
LEVOTHYROXINE - levothyroxine 175 mcg tablet. 1 tablet(s) by
mouth daily in the morning on empty stomach, 90 minutes prior to
any food or other meds
PNV ___ FUMARATE-FA [PRENATAL] - Dosage uncertain -
(Prescribed by Other Provider)
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
2. Docusate Sodium 100 mg PO BID
3. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN Pain - Severe
4. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing, dyspnea
5. Levothyroxine Sodium 175 mcg PO DAILY
6. Prenatal Vitamins 1 TAB PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
left breast invasive ductal carcinoma
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 LEFT BREAST TOTAL MASTECTOMY W/
SENTINEL LYMPH NODE BIOPSY. You are now stable for discharge.
Personal Care:
1. You may keep your incisions open to air or covered with a
clean, sterile gauze that you change daily.
2. Clean around the drain site(s), where the tubing exits the
skin, with soap and water.
3. Strip drain tubing, empty bulb(s), and record output(s) ___
times per day.
4. A written record of the daily output from each drain should
be brought to every follow-up appointment. Your drains will be
removed as soon as possible when the daily output tapers off to
an acceptable amount.
5. You may wear a surgical bra or soft, loose camisole for
comfort.
6. You may shower daily with assistance as needed. Be sure to
secure your drains so they don't hang down loosely and pull out.
7. The Dermabond skin glue will begin to flake off in about ___
days.
Activity:
1. You may resume your regular diet.
2. Walk several times a day.
3. DO NOT lift anything heavier than 5 pounds or engage in
strenuous activity for 6 weeks following surgery.
Medications:
1. Resume your regular medications unless instructed otherwise
and take any new meds as ordered .
2. You may take your prescribed pain medication for moderate to
severe pain. You may switch to Tylenol or Extra Strength Tylenol
for mild pain as directed on the packaging. Please note that
Percocet and Vicodin have Tylenol as an active ingredient so do
not take these meds with additional Tylenol.
3. Take prescription pain medications for pain not relieved by
Tylenol.
4. Take Colace, 100 mg by mouth 2 times per day, while taking
the prescription pain medication. You may use a different
over-the-counter stool softener if you wish.
5. Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
Call the office IMMEDIATELY if you have any of the following:
1. Signs of infection: fever with chills, increased redness,
swelling, warmth or tenderness at the surgical site, or unusual
drainage from the incision(s).
2. A large amount of bleeding from the incision(s) or drain(s).
3. Fever greater than 101.5 oF
4. Severe pain NOT relieved by your medication.
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you.
DRAIN DISCHARGE INSTRUCTIONS
You are being discharged with drains in place. Drain care is a
clean procedure. Wash your hands thoroughly with soap and warm
water before performing drain care. Perform drainage care twice
a day. Try to empty the drain at the same time each day. Pull
the stopper out of the drainage bottle and empty the drainage
fluid into the measuring cup. Record the amount of drainage
fluid on the record sheet. Reestablish drain suction.
Please assist patient with drain care. A daily log of individual
drain outputs should be maintained and brought with patient to
follow up appointment with your surgeon.
Followup Instructions:
___
|
[
"O9A112",
"C50412",
"O99512",
"Y836",
"E890",
"O99282",
"O26852",
"Z3A14",
"Z170",
"J45909",
"Z85850",
"Z87891"
] |
Allergies: Percocet / cucumber Chief Complaint: Left breast invasive ductal carcinoma Major Surgical or Invasive Procedure: LEFT BREAST TOTAL MASTECTOMY W/ SENTINEL LYMPH NODE BIOPSY [MASKED] History of Present Illness: Ms [MASKED] is a [MASKED] year old pregnant female with breast cancer. She had a palpable left breast lump, underwent ultrasound, MRI, and core biopsy that showed a grade 2 invasive ductal carcinoma, ER positive, PR positive, HER2 negative. She later was found to be pregnant. She is currently feeling fine apart from tiredness. She reports that her levothyroxine dose was increased earlier this week. She also notes some left nipple crusting, that there initially (after the biopsy) was some bloody output that has since declined and become mild and crusty. Otherwise no changes. Past Medical History: PAST MEDICAL HISTORY: thyroid CA, postsurgical hypothyroidism, IBS, ovarian cysts, PID, spine arthritis, asthma, mononucleosisreported history of Lyme disease status post 3 weeks of antibiotic therapy. Hashimotos negative prior to surgery per her report Social History: [MASKED] Family History: Family history: Aunt and mother with ALS. Mother, aunt, grandmother: [MASKED]. Father--prostate cancer (age [MASKED]. Physical Exam: VS: Refer to flowsheet GEN: WD, WN in NAD CV: RRR PULM: no respiratory distress BREAST: L breast - No evidence of hematoma, seroma. Small amount of ecchymoses. Mildly tender to palpation. Incision healing well. ABD: soft, NT, ND EXT: WWP NEURO: A&Ox3 Brief Hospital Course: The patient was admitted on [MASKED] with left breast invasive ductal carcinoma for left total mastectomy and left axillary sentinel lymph node biopsy with Dr. [MASKED]. Please see operative note. The patient tolerated the procedure well. There were no immediate complications. She was awoken from general anesthesia in the operating room and transferred to the recovery room in stable condition. On post-operative check, she reported pain at the site of the incision and nausea, and had an episode of emesis. The OB/GYN team recommended pain control with Dilaudid. She was placed on subQ heparin and compression devices for prophylaxis. She tolerated a regular diet. On [MASKED], the pain continued to have pain, which was discussed with OB/GYN, and her dosage of Dilaudid was increased. She was given stool softener given the usage of narcotics. She reported some mild pink spotting, which was discussed with OB, and they performed an ultrasound which showed a strong fetal heart rate of 158. Per their report, she has been spotting since earlier in the pregnancy as well. The dressing on the incision site continued to be clean dry and intact. There was no ecchymoses or hematoma on the chest wall. Drain output was serosanguineous. At the time of discharge on [MASKED], vitals were stable, pain well-controlled, and patient felt ready for discharge to home with [MASKED], with follow up appointments in place. Medications on Admission: Meds/Allergies: reviewed in OMR and medications listed here ALBUTEROL SULFATE [PROAIR HFA] - Dosage uncertain - (Prescribed by Other Provider) LEVOTHYROXINE - levothyroxine 175 mcg tablet. 1 tablet(s) by mouth daily in the morning on empty stomach, 90 minutes prior to any food or other meds PNV [MASKED] FUMARATE-FA [PRENATAL] - Dosage uncertain - (Prescribed by Other Provider) Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H 2. Docusate Sodium 100 mg PO BID 3. HYDROmorphone (Dilaudid) [MASKED] mg PO Q3H:PRN Pain - Severe 4. Albuterol Inhaler [MASKED] PUFF IH Q6H:PRN wheezing, dyspnea 5. Levothyroxine Sodium 175 mcg PO DAILY 6. Prenatal Vitamins 1 TAB PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: left breast invasive ductal carcinoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You were admitted to [MASKED] for LEFT BREAST TOTAL MASTECTOMY W/ SENTINEL LYMPH NODE BIOPSY. You are now stable for discharge. Personal Care: 1. You may keep your incisions open to air or covered with a clean, sterile gauze that you change daily. 2. Clean around the drain site(s), where the tubing exits the skin, with soap and water. 3. Strip drain tubing, empty bulb(s), and record output(s) [MASKED] times per day. 4. A written record of the daily output from each drain should be brought to every follow-up appointment. Your drains will be removed as soon as possible when the daily output tapers off to an acceptable amount. 5. You may wear a surgical bra or soft, loose camisole for comfort. 6. You may shower daily with assistance as needed. Be sure to secure your drains so they don't hang down loosely and pull out. 7. The Dermabond skin glue will begin to flake off in about [MASKED] days. Activity: 1. You may resume your regular diet. 2. Walk several times a day. 3. DO NOT lift anything heavier than 5 pounds or engage in strenuous activity for 6 weeks following surgery. Medications: 1. Resume your regular medications unless instructed otherwise and take any new meds as ordered . 2. You may take your prescribed pain medication for moderate to severe pain. You may switch to Tylenol or Extra Strength Tylenol for mild pain as directed on the packaging. Please note that Percocet and Vicodin have Tylenol as an active ingredient so do not take these meds with additional Tylenol. 3. Take prescription pain medications for pain not relieved by Tylenol. 4. Take Colace, 100 mg by mouth 2 times per day, while taking the prescription pain medication. You may use a different over-the-counter stool softener if you wish. 5. Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. Call the office IMMEDIATELY if you have any of the following: 1. Signs of infection: fever with chills, increased redness, swelling, warmth or tenderness at the surgical site, or unusual drainage from the incision(s). 2. A large amount of bleeding from the incision(s) or drain(s). 3. Fever greater than 101.5 oF 4. Severe pain NOT relieved by your medication. Return to the ER if: * If you are vomiting and cannot keep in fluids or your medications. * If you have shaking chills, fever greater than 101.5 (F) degrees or 38 (C) degrees, increased redness, swelling or discharge from incision, chest pain, shortness of breath, or anything else that is troubling you. * Any serious change in your symptoms, or any new symptoms that concern you. DRAIN DISCHARGE INSTRUCTIONS You are being discharged with drains in place. Drain care is a clean procedure. Wash your hands thoroughly with soap and warm water before performing drain care. Perform drainage care twice a day. Try to empty the drain at the same time each day. Pull the stopper out of the drainage bottle and empty the drainage fluid into the measuring cup. Record the amount of drainage fluid on the record sheet. Reestablish drain suction. Please assist patient with drain care. A daily log of individual drain outputs should be maintained and brought with patient to follow up appointment with your surgeon. Followup Instructions: [MASKED]
|
[] |
[
"J45909",
"Z87891"
] |
[
"O9A112: Malignant neoplasm complicating pregnancy, second trimester",
"C50412: Malignant neoplasm of upper-outer quadrant of left female breast",
"O99512: Diseases of the respiratory system complicating pregnancy, second trimester",
"Y836: Removal of other organ (partial) (total) as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure",
"E890: Postprocedural hypothyroidism",
"O99282: Endocrine, nutritional and metabolic diseases complicating pregnancy, second trimester",
"O26852: Spotting complicating pregnancy, second trimester",
"Z3A14: 14 weeks gestation of pregnancy",
"Z170: Estrogen receptor positive status [ER+]",
"J45909: Unspecified asthma, uncomplicated",
"Z85850: Personal history of malignant neoplasm of thyroid",
"Z87891: Personal history of nicotine dependence"
] |
10,002,800 | 26,199,514 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: PLASTIC
Allergies:
cucumber / Tegaderm
Attending: ___
Chief Complaint:
Surgical absence of L breast
Major Surgical or Invasive Procedure:
1) ___ - Right prophylactic mastectomy, bilateral ___
reconstruction
2) ___ - take back to OR for exploration of left flap
vessels
History of Present Illness:
___ is a ___ year old female with history of L breast
cancer (Stage I IDC and Paget's) and previous left sided
mastectomy & SLNB. She was admitted to the hospital after her
prophylactic R mastectomy with ___ reconstruction on
___. She was taken back to the OR on ___ for flap
exploration due to declining Vioptix recordings.
Past Medical History:
PNC:
- ___ ___ by US
- Labs: Rh+/ab neg/RPRNR/RI/HBsAg neg/HIV neg/ GBS unknown
- Genetics: LR ERA
- FFS: wnl
- GLT: wnl
- US: ___, 67%, breech, ___, nl fluid, anterior placenta
- Issues:
*) breast cancer in pregnancy: unilateral mastectomy w/ sentinel
LN biopsy, s/p chemotherapy completed ___, plan for PP
tamoxifen
*) mild asthma
*) History of papillary thyroid cancer x 2, on levothyroxine
175mcg daily; labs ___ - TSH 4.3 (elevated) but normal FT4
(1.1)
ROS: per hpi
GYNHx: h/o breast cancer
OBHx: G1, current
PMH: h/o breast cancer, mild asthma, h/o papillary
PSH: s/p unilateral mastectomy w/ sentinel LN biopsy
Social History:
___
Family History:
Family history: Aunt and mother with ALS. Mother, aunt,
grandmother: ___. Father--prostate cancer (age ___
Physical Exam:
Gen: Well-appearing F in no acute distress.
HEENT: Normocephalic. Sclerae anicteric.
CV: RRR
R: Breathing comfortably on room air. No wheezing.
Breasts: Bilateral reconstructed breasts soft and without
palpable fluid collection, right mastectomy flap with lateral
ecchymosis, ___ skin paddles warm bilaterally with good
capillary refill, JP drains x 2 to bulb suction draining
serosanguinous fluid
Abdomen: Soft, non-distended; umbilicus viable; lower abdominal
incision without erythema or drainage; JP drains x2 to bulb
suction draining serosanguinous fluid
Ext: No cyanosis or edema
Pertinent Results:
___ 04:38AM BLOOD WBC-12.0* RBC-2.88* Hgb-8.8* Hct-26.3*
MCV-91 MCH-30.6 MCHC-33.5 RDW-13.2 RDWSD-44.3 Plt ___
___ 03:44AM BLOOD WBC-11.3* RBC-3.32* Hgb-10.2* Hct-29.5*
MCV-89 MCH-30.7 MCHC-34.6 RDW-13.0 RDWSD-42.0 Plt ___ - OR - Right prophylactic mastectomy, bilateral ___
reconstruction. Per protocol, patient stayed in PACU overnight.
___ - OR - Patient was recovering well in PACU, with morning
plan of clear liquid diet, out of bed to chair, and transfer to
floor. However, Vioptix signal of Left breast with declining
values, so patient taken back to OR for exploration of L breast
flap. Again stayed in PACU overnight per protocol
___ - Recovering well. Febrile overnight to "103" but nurse
removed BAIR hugger and re-measured temperature at 99. clear
liquid diet, out of bed to chair, transfer to floor
She was admitted to the plastic surgery service, where she was
began the ___ postoperative pathway. She was given ASA 121.5
daily (to be continued at discharge), Ancef (transitioned to
Duricef at discharge), and SCH during her stay. She will
discharge home 4 with drains in place, to be removed at office
visit. She will daily bacitracin BID application to right
mastectomy flap necrosis site.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 175 mcg PO DAILY
2. BuPROPion XL (Once Daily) 300 mg PO DAILY
3. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN
Discharge Medications:
Resume taking your previous home prescriptions, including
1. Levothyroxine Sodium 175 mcg PO DAILY
2. BuPROPion XL (Once Daily) 300 mg PO DAILY
3. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN
4. LIDOCAINE-PRILOCAINE - lidocaine-prilocaine 2.5 %-2.5 %
topical
cream. Apply thick layer to port-a-cath site at least 30 minutes
prior to port access. C___ - (Not Taking as Prescribed)
5. OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. 1
capsule
by mouth daily for heartburn symptoms - (Not Taking as
Prescribed)
6. TAMOXIFEN - tamoxifen 20 mg tablet. 1 tablet(s) by mouth
daily
In addition, patient discharged with these new medications:
1. Aspirin 121.5 mg QD for 1 month
2. Duricef 500mg PO BID x7 days w/ 1 refill
2. Oxycodone ___ tablets, q4-6 hours #50
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Surgical absence of left breast; breast cancer
Discharge Condition:
Awake, alert, oriented. Stable
Discharge Instructions:
Personal Care:
1. You may keep your incisions open to air or covered with a
clean, ___
ile gauze that you change daily. If
any areas develop blistering, you will need to apply Bactroban
cream
twice a day.
2. Clean around the drain site(s), where the tubing exits the
skin, w
ith soap and water.
3. Strip drain tubing, empty bulb(s), and record output(s) ___
times
per day.
4. A written record of the daily output from each drain should
be broug
ht to every follow-up
appointment. your drains will be removed as soon as possible
when
the daily output tapers off to an
acceptable amount.
5. DO NOT wear a normal bra for 3 weeks. You may wear a soft,
loose
camisole for comfort.
6. You may shower daily with assistance as needed. Be sure to
secure
your upper drains to a lanyard that
hangs down from your neck so they don't hang down and pull out.
Y
___ may secure your lower drains to
a fabric belt tied around your waist.
7. The Dermabond skin glue will begin to flake off in about ___
days.
8. No pressure on your chest or abdomen
9. Okay to shower, but no baths until after directed by your
doctor.
.
Activity:
1. You may resume your regular diet.
2. Keep hips flexed at all times, and then gradually stand
upright
as tolerated.
3. DO NOT lift anything heavier than 5 pounds or engage in
strenuous
activity for 6 weeks following
surgery.
.
Medications:
1. Resume your regular medications unless instructed otherwise
and
take any new meds as ordered .
2. You may take your prescribed pain medication for moderate to
severe ___
n. You may switch to Tylenol
or Extra Strength Tylenol for mild pain as directed on the
packaging
3. Take prescription pain medications for pain not relieved by
tyleno
l.
4. Take Colace, 100 mg by mouth 2 times per day, while taking
the prescript
ion pain medication. You
may use a different over-the-counter stool softener if you wish.
5. Do not drive or operate heavy machinery while taking any
narcotic pain m
edication. You may have
constipation when taking narcotic pain medications (oxycodone,
percocet, vicodin, hydrocodone, dilaudid,
etc.); you should continue drinking fluids, you may take stool
soften
ers, and should eat foods that are
high in fiber.
.
Call the office IMMEDIATELY if you have any of the following:
1. Signs of infection: fever with chills, increased redness, sw
___, warmth or tenderness at the surgical
site, or unusual drainage from the incision(s).
2. A large amount of bleeding from the incision(s) or drain(s).
3. Fever greater than 101.5 oF
4. Severe pain NOT relieved by your medication.
.
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) ___
es, increased redness,
swelling or discharge from incision, chest pain, shortness of
breath, or anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern
you.
.
DRAIN DISCHARGE INSTRUCTIONS
You are being discharged with drains in place. Drain care is a c
lean procedure. Wash your hands
thoroughly with soap and warm water before performing drain
care. Perfo
rm drainage care twice a day.
Try to empty the drain at the same time each day. Pull the
stopper out of
the drainage bottle and empty
the drainage fluid into the measuring cup. Record the amount of
d
rainage fluid on the record sheet.
Reestablish drain suction.
Followup Instructions:
___
|
[
"Z421",
"Z4001",
"T85898A",
"Y834",
"Y92238",
"J4520",
"E890",
"F329",
"R509",
"Z9012",
"Z853",
"Z85850"
] |
Allergies: cucumber / Tegaderm Chief Complaint: Surgical absence of L breast Major Surgical or Invasive Procedure: 1) [MASKED] - Right prophylactic mastectomy, bilateral [MASKED] reconstruction 2) [MASKED] - take back to OR for exploration of left flap vessels History of Present Illness: [MASKED] is a [MASKED] year old female with history of L breast cancer (Stage I IDC and Paget's) and previous left sided mastectomy & SLNB. She was admitted to the hospital after her prophylactic R mastectomy with [MASKED] reconstruction on [MASKED]. She was taken back to the OR on [MASKED] for flap exploration due to declining Vioptix recordings. Past Medical History: PNC: - [MASKED] [MASKED] by US - Labs: Rh+/ab neg/RPRNR/RI/HBsAg neg/HIV neg/ GBS unknown - Genetics: LR ERA - FFS: wnl - GLT: wnl - US: [MASKED], 67%, breech, [MASKED], nl fluid, anterior placenta - Issues: *) breast cancer in pregnancy: unilateral mastectomy w/ sentinel LN biopsy, s/p chemotherapy completed [MASKED], plan for PP tamoxifen *) mild asthma *) History of papillary thyroid cancer x 2, on levothyroxine 175mcg daily; labs [MASKED] - TSH 4.3 (elevated) but normal FT4 (1.1) ROS: per hpi GYNHx: h/o breast cancer OBHx: G1, current PMH: h/o breast cancer, mild asthma, h/o papillary PSH: s/p unilateral mastectomy w/ sentinel LN biopsy Social History: [MASKED] Family History: Family history: Aunt and mother with ALS. Mother, aunt, grandmother: [MASKED]. Father--prostate cancer (age [MASKED] Physical Exam: Gen: Well-appearing F in no acute distress. HEENT: Normocephalic. Sclerae anicteric. CV: RRR R: Breathing comfortably on room air. No wheezing. Breasts: Bilateral reconstructed breasts soft and without palpable fluid collection, right mastectomy flap with lateral ecchymosis, [MASKED] skin paddles warm bilaterally with good capillary refill, JP drains x 2 to bulb suction draining serosanguinous fluid Abdomen: Soft, non-distended; umbilicus viable; lower abdominal incision without erythema or drainage; JP drains x2 to bulb suction draining serosanguinous fluid Ext: No cyanosis or edema Pertinent Results: [MASKED] 04:38AM BLOOD WBC-12.0* RBC-2.88* Hgb-8.8* Hct-26.3* MCV-91 MCH-30.6 MCHC-33.5 RDW-13.2 RDWSD-44.3 Plt [MASKED] [MASKED] 03:44AM BLOOD WBC-11.3* RBC-3.32* Hgb-10.2* Hct-29.5* MCV-89 MCH-30.7 MCHC-34.6 RDW-13.0 RDWSD-42.0 Plt [MASKED] - OR - Right prophylactic mastectomy, bilateral [MASKED] reconstruction. Per protocol, patient stayed in PACU overnight. [MASKED] - OR - Patient was recovering well in PACU, with morning plan of clear liquid diet, out of bed to chair, and transfer to floor. However, Vioptix signal of Left breast with declining values, so patient taken back to OR for exploration of L breast flap. Again stayed in PACU overnight per protocol [MASKED] - Recovering well. Febrile overnight to "103" but nurse removed BAIR hugger and re-measured temperature at 99. clear liquid diet, out of bed to chair, transfer to floor She was admitted to the plastic surgery service, where she was began the [MASKED] postoperative pathway. She was given ASA 121.5 daily (to be continued at discharge), Ancef (transitioned to Duricef at discharge), and SCH during her stay. She will discharge home 4 with drains in place, to be removed at office visit. She will daily bacitracin BID application to right mastectomy flap necrosis site. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 175 mcg PO DAILY 2. BuPROPion XL (Once Daily) 300 mg PO DAILY 3. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN Discharge Medications: Resume taking your previous home prescriptions, including 1. Levothyroxine Sodium 175 mcg PO DAILY 2. BuPROPion XL (Once Daily) 300 mg PO DAILY 3. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN 4. LIDOCAINE-PRILOCAINE - lidocaine-prilocaine 2.5 %-2.5 % topical cream. Apply thick layer to port-a-cath site at least 30 minutes prior to port access. C - (Not Taking as Prescribed) 5. OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. 1 capsule by mouth daily for heartburn symptoms - (Not Taking as Prescribed) 6. TAMOXIFEN - tamoxifen 20 mg tablet. 1 tablet(s) by mouth daily In addition, patient discharged with these new medications: 1. Aspirin 121.5 mg QD for 1 month 2. Duricef 500mg PO BID x7 days w/ 1 refill 2. Oxycodone [MASKED] tablets, q4-6 hours #50 Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Surgical absence of left breast; breast cancer Discharge Condition: Awake, alert, oriented. Stable Discharge Instructions: Personal Care: 1. You may keep your incisions open to air or covered with a clean, [MASKED] ile gauze that you change daily. If any areas develop blistering, you will need to apply Bactroban cream twice a day. 2. Clean around the drain site(s), where the tubing exits the skin, w ith soap and water. 3. Strip drain tubing, empty bulb(s), and record output(s) [MASKED] times per day. 4. A written record of the daily output from each drain should be broug ht to every follow-up appointment. your drains will be removed as soon as possible when the daily output tapers off to an acceptable amount. 5. DO NOT wear a normal bra for 3 weeks. You may wear a soft, loose camisole for comfort. 6. You may shower daily with assistance as needed. Be sure to secure your upper drains to a lanyard that hangs down from your neck so they don't hang down and pull out. Y [MASKED] may secure your lower drains to a fabric belt tied around your waist. 7. The Dermabond skin glue will begin to flake off in about [MASKED] days. 8. No pressure on your chest or abdomen 9. Okay to shower, but no baths until after directed by your doctor. . Activity: 1. You may resume your regular diet. 2. Keep hips flexed at all times, and then gradually stand upright as tolerated. 3. DO NOT lift anything heavier than 5 pounds or engage in strenuous activity for 6 weeks following surgery. . Medications: 1. Resume your regular medications unless instructed otherwise and take any new meds as ordered . 2. You may take your prescribed pain medication for moderate to severe [MASKED] n. You may switch to Tylenol or Extra Strength Tylenol for mild pain as directed on the packaging 3. Take prescription pain medications for pain not relieved by tyleno l. 4. Take Colace, 100 mg by mouth 2 times per day, while taking the prescript ion pain medication. You may use a different over-the-counter stool softener if you wish. 5. Do not drive or operate heavy machinery while taking any narcotic pain m edication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool soften ers, and should eat foods that are high in fiber. . Call the office IMMEDIATELY if you have any of the following: 1. Signs of infection: fever with chills, increased redness, sw [MASKED], warmth or tenderness at the surgical site, or unusual drainage from the incision(s). 2. A large amount of bleeding from the incision(s) or drain(s). 3. Fever greater than 101.5 oF 4. Severe pain NOT relieved by your medication. . Return to the ER if: * If you are vomiting and cannot keep in fluids or your medications. * If you have shaking chills, fever greater than 101.5 (F) degrees or 38 (C) [MASKED] es, increased redness, swelling or discharge from incision, chest pain, shortness of breath, or anything else that is troubling you. * Any serious change in your symptoms, or any new symptoms that concern you. . DRAIN DISCHARGE INSTRUCTIONS You are being discharged with drains in place. Drain care is a c lean procedure. Wash your hands thoroughly with soap and warm water before performing drain care. Perfo rm drainage care twice a day. Try to empty the drain at the same time each day. Pull the stopper out of the drainage bottle and empty the drainage fluid into the measuring cup. Record the amount of d rainage fluid on the record sheet. Reestablish drain suction. Followup Instructions: [MASKED]
|
[] |
[
"F329"
] |
[
"Z421: Encounter for breast reconstruction following mastectomy",
"Z4001: Encounter for prophylactic removal of breast",
"T85898A: Other specified complication of other internal prosthetic devices, implants and grafts, initial encounter",
"Y834: Other reconstructive surgery as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure",
"Y92238: Other place in hospital as the place of occurrence of the external cause",
"J4520: Mild intermittent asthma, uncomplicated",
"E890: Postprocedural hypothyroidism",
"F329: Major depressive disorder, single episode, unspecified",
"R509: Fever, unspecified",
"Z9012: Acquired absence of left breast and nipple",
"Z853: Personal history of malignant neoplasm of breast",
"Z85850: Personal history of malignant neoplasm of thyroid"
] |
10,002,930 | 22,733,922 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: PSYCHIATRY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
"I'm still hearing the voices"
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Please see psychiatry consult notes by Drs ___, and
___ dated ___ for details of HPI, past psychiatric,
medical, family, and social histories. Additionally, please
refer to medicine discharge summary dated ___ for details of
medicine ICU and floor course.
Briefly, this is a ___ y/o homeless ___ F with PMH of
TBI, HIV (not on HAART), HCV (not treated), and past psychiatric
hx of polysubstance abuse (EtOH, crack cocaine, and heroin),
unspecified mood disorder (MDD with psychotic features vs.
___ mood disorder), and chronic AH who presented
to
the ED from ___ station with tangential thoughts and complaint of
repeat head strikes after multiple falls. She was found to be
exhibiting signs of severe EtOH withdrawal and was admitted to
the ICU where she was initiated on the phenobarb protocol. She
was transferred to the medical
On arrival to Deac 4: Pt stated that she was continuing to hear
voices and have suicidal thoughts. She declined to give details
regarding her SI, stating, "why would I tell you about it? I
would just do it." She also notes, "and obviously you guys are
not gonna give me a razor to shave with or anything."
She reported that the voices she hears are both male and female.
They are not voices that she recognizes, and she cannot make out
what they are saying. They are frequently worse as she tries to
fall asleep. She has a difficult time discerning whether they
have been bothering her more frequently during the past several
weeks, because she has been drinking and "maybe doing crack."
She
becomes fixated on a story about smoking a crack pipe and
throwing it onto the ground "where any kid could pick it up and
light it and smoke it," and she retells this multiple times.
Past Medical History:
PAST PSYCHIATRIC HISTORY: Per Dr. ___ note (___),
confirmed with ___ and updated as relevant:
- Diagnosis on discharge from ___ 4 on ___: MDD with
psychotic features vs. ___ mood disorder
- Hospitalizations: ___ reports many prior hospitalizations
(>10, including Arbour; >20 detox admissions per OMR). Most
recent hospitalization at ___ with discharge one day prior to
ED presentation (___).
- Suicide ___ stated she ODed on
Amitriptyline ___ years ago, per prior records stated she took
___ pills, went to sleep on a park bench, and then woke up and
went to her shelter, did not go to the hospital. In the past she
has also reported ingestion of alcohol as a possible suicide
attempt and a suicide attempt in ___ by overdose on unknown
pills to ED staff. ___ 4 discharge summary dated ___: "Per
pt, OD on Ultram "probably to hurt [her]self" ___ yrs ago)"
- Violence: ___
- Medication Trials: Reports h/o successful treatment with
Zoloft
(denies knowledge of when). Also reports being txed with Haldol
"once" and states she "took too much, and my jaw was locked for
___ hours." Past documentation from ___ 4 discharge summary
dated ___ stated h/o treatment with Elavil. BEST indicated
previous reported treatment with Risperdal. OMR reveals past tx
with Risperdal and Zoloft (last filled ___. Stabilized on
Deac 4 during most recent hospitalization with Amitriptyline and
Seroquel.
- Treaters: Denies past or present outpatient psychiatric
treaters. Per records, last had pending appointment at ___
for
psychiatry (Dr. ___, ___ at 9 AM). Currently states she
doesn't remember last time she saw psych.
-Access to weapons: Denies
PAST MEDICAL HISTORY:
PCP: ___, MD
- HIV (not currently taking antiretrovirals) - today denies that
she has HIV at all.
- Hepatitis C
- H/o head injury (Per ___ 4 ___ 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")
HOME MEDICATIONS:
Not currently taking any medications.
Per Deac 4 Discharge Summary dated ___:
1. Amitriptyline 50 mg PO QHS
2. QUEtiapine Fumarate 50 mg PO QHS
Social History:
SUBSTANCE ABUSE HISTORY: Per Dr. ___ note (___),
confirmed with ___ and updated as relevant:
- Alcohol: ___ reports starting drinking age ___ due to
conflict with parents. Reports numerous detox admissions (>20
per
OMR). States that she was sober from ___ and only involved
with AA for 1 week of that time, which she stopped because she
"did not like it". Most recent drink was 13 nips of vodka today.
Currently states she drinks about 1x/week. Denies history of
complicated alcohol withdrawal but has required benzodiazepines
during detox admissions.
- Benzodiazepines: Denies lifetime illicit use. Reports only use
in detox when prescribed.
- Marijuana: Reports remote use in high school, denies recent
use.
- Crack cocaine: Denies current use, though say she has used in
the past.
- Heroin: Reports h/o IVDU w/ heroin ___ years, previously
reported ending ___ yrs ago. Denies current use.
- Tobacco: past smoker, but denies currently.
FORENSIC HISTORY:
Says "not lately" and can't remember last time.
Per Dr. ___ note (___): Inconsistent history: said
she spent ___ yrs" in jail for "shoplifting, drug related
issues."
Then states she was last in jail "probably in early ___
Family History:
States she doesn't know.
Physical Exam:
VS: T:98.4 P:106 BP:137/90 RR:16 SpO2: 100%(RA)
* General: ___, in no apparent
distress. Appears stated age.
* HEENT: Normocephalic. PERRL, EOMI. Oropharynx clear.
* Neck: Supple, trachea midline. No adenopathy or thyromegaly.
* Back: No significant deformity, no focal tenderness.
* Lungs: Clear to auscultation; no crackles or wheezes.
* CV: Regular rate and rhythm; no murmurs/rubs/gallops; 2+
pedal
pulses.
* Abdomen: Soft, nontender, nondistended; no masses or
organomegaly.
* Extremities: No clubbing, cyanosis, or edema.
* Skin: Warm and dry, no rashes, scars, or lesions.
Neurological:
*Cranial Nerves-
I: Not tested.
II: Pupils equally round and reactive to light
bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally;
significant horizontal nystagmus (>7 beats) bilaterally.
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, no tremor. Strength full power ___ throughout. No
gross focal motor or sensory deficits, normal gait.
*Coordination- Normal on ___.
*Deep tendon reflexes- 2+ and symmetrical, toes downgoing.
*Sensation- intact to light touch, position sense intact.
*Gait- steady, no truncal ataxia, normal stance and posture.
*Romberg- negative.
Pertinent Results:
___ 06:05AM ___
___
___ 06:05AM ___
___ IM ___
___
___ 06:05AM PLT ___
___ 06:05AM ___ ___ ABS ___ ABS
___ ABS ___ ABS ___
Brief Hospital Course:
SAFETY: ___ was placed on 15 minute checks on admission and
remained here on that level of observation throughout. She was
unit restricted. There were no acute safety issues during this
hospitalization.
LEGAL: ___
PSYCHIATRIC:
___ is a ___ year old ___ female with a
history of TBI, HIV (not on HAART therapy), HCV (not treated),
polysubstance use (EtOH, crack cocaine, and heroin), unspecified
mood disorder, and chronic auditory hallucinations who presented
to the emergency department on ___ with alcohol
intoxication, tangential thoughts, and complaints of repeated
head strikes, now s/p ICU/medicine course for alcohol withdrawal
with phenobarbital taper. On the unit, ___ was started on
quetiapine (uptitrated to 300 mg BID) and on sertraline 25 mg
daily to good effect. ___ did well on the unit and attended
groups regularly. She recognized effect illicit drugs and
alcohol have had on her mental health, social situation, and
interpersonal relationships. Although she has a history of
multiple relapses, failing to ___, and medication
nonadherence, she kept repeating that this admission was
different and that she wants to maintain her sobriety. She
showered daily and had no issues with sleep or appetite. On the
day of discharge, ___ endorsed/exhibited "good" mood and
euthymic affect. Denied SI/HI and AVH. She expressed continued
motivation to maintain her sobriety, do 90 AA meetings in 90
days, and desire to ___ at ___. A ___ application was
submitted. Her PCP was updated on the plan and ___
appointments were coordinated.
MEDICAL:
#HIV: ___ not currently taking HAART. Most recent CD4 count
42
on ___.
- Continued Bactrim DS 1 tab daily for PCP ppx
- ___ has appointment with Dr. ___ on ___
on ___
to discuss reinitiation of HAART
#Hepatitis C: HCV Ab positive on ___. Not treated.
- ___ has appointment with Dr. ___ on ___
on ___
to discuss treatment
PSYCHOSOCIAL:
#) GROUPS/MILIEU: ___ was encouraged to participate in
units groups, milieu, and therapy opportunities. Usage of
coping skills, mindfulness, and relaxation methods were
encouraged. Therapy addressed family, social, work, and housing
issues. The ___ enjoyed groups and participated. She also
participated in AA meetings on the unit.
#) COLLATERAL CONTACTS:
-Treaters- PCP (Dr. ___
-Records- Per OMR
-Family- ___ refused family meetings
#) FAMILY INVOLVEMENT:
Despite encouragement from the team throughout her admission,
___ refused family meetings.
#) INTERVENTIONS:
-D___ Referral: The team submitted a DMH application for the
___ to receive services and ___ support.
-Pharmacological treatment: Quetiapine and sertraline as above.
-Individual/group/milieu therapy
-Coordinated aftercare with SW
INFORMED CONSENT:
-Quetiapine, sertraline
The Team discussed the indications for, intended benefits of,
and possible side effects and risks of this medication, and
risks and benefits of possible alternatives, including not
taking the medication, with this ___. We discussed the
___ right to decide whether to take this medication as
well as the importance of the ___ actively participating
in the treatment and discussing any questions about medications
with the treatment team, and I answered the ___ questions.
The ___ appeared able to understand and consented to begin
the medication.
RISK ASSESSMENT:
Low imminent risk of harm/violence to self/others.
#) Chronic/Static Risk Factors:
Chronic mental illness, chronic medical illness, single, ongoing
homelessness.
#) Modifiable Risk Factors:
-Acute major mood episode with suicidal ideation - Modified by
medication adjustments and psychotherapeutic interventions as
above.
-Active polysubstance misuse - Modified by phenobarbital taper
while on medical floor for alcohol withdrawal and detox;
attendance to AA meetings on the unit; list of free substance
use recovery resources in the community.
-Limited outpatient/social support - Modified by aftercare
planning with SW; outpatient appointments; list of community
resources.
-___ - Modified by counseling on the unit. ___
was adherent with medications on the unit.
#) Protective Factors:
Protective factors include current outpatient
providers/treatment, knowledge of community resources,
motivation to maintain sobriety, ___, and
___ behaviors.
PROGNOSIS:
Good: ___ was engaged on the unit, adherent with
medications, and attended groups regularly. She has outpatient
appointments and community resources. Current risk is low for
intentional ___ given that ___ denies suicidal
ideation, intent and plan, is accepting of treatment, is
currently sober and is ___ with plans.
Medications on Admission:
___ was not taking medications prior to admission.
Per Deac 4 Discharge Summary dated ___:
1. Amitriptyline 50 mg PO QHS
2. QUEtiapine Fumarate 50 mg PO QHS
Discharge Medications:
1. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
RX ___ [Bactrim DS] 800 ___ mg 1
tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0
2. QUEtiapine Fumarate 300 mg PO BID
RX *quetiapine [Seroquel] 100 mg 3 tablet(s) by mouth twice a
day Disp #*180 Tablet Refills:*0
3. Sertraline 25 mg PO DAILY
RX *sertraline [Zoloft] 25 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Unspecified psychotic disorder ___ vs.
schizophrenia spectrum)
EtOH use disorder
Cocaine use disorder
Heroin use disorder (in full sustained remission)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Mental Status Examination:
*Appearance: Woman who appears older than stated age, wearing
jeans and a sweater, tattoo on neck, hair in a bun, appropriate
hygiene, no acute distress.
Behavior: Good eye contact, cooperative, engaged. No
psychomotor agitation/retardation.
*Mood and Affect: 'Good' / Mostly euthymic, some smiling.
*Speech: Normal rate, volume, rhythm, prosody, articulation.
Fluent in ___.
*Thought process: Linear and ___. No loosening of
associations.
*Thought Content: Denies SI/HI and AVH. Focused on maintaining
her sobriety.
*Judgment and Insight: Fair/Fair. ___ recognizes effect
drug use has had on her mental health, social situation, and
interpersonal relationships. She has a history of multiple
relapses, failing to ___, and medication nonadherence but
keeps repeating that this admission is different and that she
wants to maintain her sobriety.
Cognition: Awake, alert, attentive throughout interview.
Memory
intact to recent and remote history.
Discharge Instructions:
You were hospitalized at ___ for alcohol detox, depressed
mood, and suicidal ideation. We adjusted your medications, and
you are now ready for discharge and continued treatment on an
outpatient basis.
-Please follow up with all outpatient appointments as listed -
take this discharge paperwork to your appointments.
-Please continue all medications as directed.
-Please avoid abusing alcohol and any drugs--whether
prescription drugs or illegal drugs--as this can further worsen
your medical and psychiatric illnesses.
-Please contact your outpatient psychiatrist or other providers
if you have any concerns.
-Please call ___ or go to your nearest emergency room if you
feel unsafe in any way and are unable to immediately reach your
health care providers.
It was a pleasure to have worked with you, and we wish you the
best of health.
Followup Instructions:
___
|
[
"F1994",
"B20",
"F1490",
"F1099",
"F209",
"Z87820",
"B1920",
"Z87891"
] |
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: "I'm still hearing the voices" Major Surgical or Invasive Procedure: None History of Present Illness: Please see psychiatry consult notes by Drs [MASKED], and [MASKED] dated [MASKED] for details of HPI, past psychiatric, medical, family, and social histories. Additionally, please refer to medicine discharge summary dated [MASKED] for details of medicine ICU and floor course. Briefly, this is a [MASKED] y/o homeless [MASKED] F with PMH of TBI, HIV (not on HAART), HCV (not treated), and past psychiatric hx of polysubstance abuse (EtOH, crack cocaine, and heroin), unspecified mood disorder (MDD with psychotic features vs. [MASKED] mood disorder), and chronic AH who presented to the ED from [MASKED] station with tangential thoughts and complaint of repeat head strikes after multiple falls. She was found to be exhibiting signs of severe EtOH withdrawal and was admitted to the ICU where she was initiated on the phenobarb protocol. She was transferred to the medical On arrival to Deac 4: Pt stated that she was continuing to hear voices and have suicidal thoughts. She declined to give details regarding her SI, stating, "why would I tell you about it? I would just do it." She also notes, "and obviously you guys are not gonna give me a razor to shave with or anything." She reported that the voices she hears are both male and female. They are not voices that she recognizes, and she cannot make out what they are saying. They are frequently worse as she tries to fall asleep. She has a difficult time discerning whether they have been bothering her more frequently during the past several weeks, because she has been drinking and "maybe doing crack." She becomes fixated on a story about smoking a crack pipe and throwing it onto the ground "where any kid could pick it up and light it and smoke it," and she retells this multiple times. Past Medical History: PAST PSYCHIATRIC HISTORY: Per Dr. [MASKED] note ([MASKED]), confirmed with [MASKED] and updated as relevant: - Diagnosis on discharge from [MASKED] 4 on [MASKED]: MDD with psychotic features vs. [MASKED] mood disorder - Hospitalizations: [MASKED] reports many prior hospitalizations (>10, including Arbour; >20 detox admissions per OMR). Most recent hospitalization at [MASKED] with discharge one day prior to ED presentation ([MASKED]). - Suicide [MASKED] stated she ODed on Amitriptyline [MASKED] years ago, per prior records stated she took [MASKED] pills, went to sleep on a park bench, and then woke up and went to her shelter, did not go to the hospital. In the past she has also reported ingestion of alcohol as a possible suicide attempt and a suicide attempt in [MASKED] by overdose on unknown pills to ED staff. [MASKED] 4 discharge summary dated [MASKED]: "Per pt, OD on Ultram "probably to hurt [her]self" [MASKED] yrs ago)" - Violence: [MASKED] - Medication Trials: Reports h/o successful treatment with Zoloft (denies knowledge of when). Also reports being txed with Haldol "once" and states she "took too much, and my jaw was locked for [MASKED] hours." Past documentation from [MASKED] 4 discharge summary dated [MASKED] stated h/o treatment with Elavil. BEST indicated previous reported treatment with Risperdal. OMR reveals past tx with Risperdal and Zoloft (last filled [MASKED]. Stabilized on Deac 4 during most recent hospitalization with Amitriptyline and Seroquel. - Treaters: Denies past or present outpatient psychiatric treaters. Per records, last had pending appointment at [MASKED] for psychiatry (Dr. [MASKED], [MASKED] at 9 AM). Currently states she doesn't remember last time she saw psych. -Access to weapons: Denies PAST MEDICAL HISTORY: PCP: [MASKED], MD - HIV (not currently taking antiretrovirals) - today denies that she has HIV at all. - Hepatitis C - H/o head injury (Per [MASKED] 4 [MASKED] summary [MASKED]: "pt reports she was "assaulted" and subsequently received 300 stitches, was hospitalized x 2wks, and underwent rehab at [MASKED] she denies LOC or persistent deficits but receives SSDI for this injury") HOME MEDICATIONS: Not currently taking any medications. Per Deac 4 Discharge Summary dated [MASKED]: 1. Amitriptyline 50 mg PO QHS 2. QUEtiapine Fumarate 50 mg PO QHS Social History: SUBSTANCE ABUSE HISTORY: Per Dr. [MASKED] note ([MASKED]), confirmed with [MASKED] and updated as relevant: - Alcohol: [MASKED] reports starting drinking age [MASKED] due to conflict with parents. Reports numerous detox admissions (>20 per OMR). States that she was sober from [MASKED] and only involved with AA for 1 week of that time, which she stopped because she "did not like it". Most recent drink was 13 nips of vodka today. Currently states she drinks about 1x/week. Denies history of complicated alcohol withdrawal but has required benzodiazepines during detox admissions. - Benzodiazepines: Denies lifetime illicit use. Reports only use in detox when prescribed. - Marijuana: Reports remote use in high school, denies recent use. - Crack cocaine: Denies current use, though say she has used in the past. - Heroin: Reports h/o IVDU w/ heroin [MASKED] years, previously reported ending [MASKED] yrs ago. Denies current use. - Tobacco: past smoker, but denies currently. FORENSIC HISTORY: Says "not lately" and can't remember last time. Per Dr. [MASKED] note ([MASKED]): Inconsistent history: said she spent [MASKED] yrs" in jail for "shoplifting, drug related issues." Then states she was last in jail "probably in early [MASKED] Family History: States she doesn't know. Physical Exam: VS: T:98.4 P:106 BP:137/90 RR:16 SpO2: 100%(RA) * General: [MASKED], in no apparent distress. Appears stated age. * HEENT: Normocephalic. PERRL, EOMI. Oropharynx clear. * Neck: Supple, trachea midline. No adenopathy or thyromegaly. * Back: No significant deformity, no focal tenderness. * Lungs: Clear to auscultation; no crackles or wheezes. * CV: Regular rate and rhythm; no murmurs/rubs/gallops; 2+ pedal pulses. * Abdomen: Soft, nontender, nondistended; no masses or organomegaly. * Extremities: No clubbing, cyanosis, or edema. * Skin: Warm and dry, no rashes, scars, or lesions. Neurological: *Cranial Nerves- I: Not tested. II: Pupils equally round and reactive to light bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally; significant horizontal nystagmus (>7 beats) bilaterally. 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, no tremor. Strength full power [MASKED] throughout. No gross focal motor or sensory deficits, normal gait. *Coordination- Normal on [MASKED]. *Deep tendon reflexes- 2+ and symmetrical, toes downgoing. *Sensation- intact to light touch, position sense intact. *Gait- steady, no truncal ataxia, normal stance and posture. *Romberg- negative. Pertinent Results: [MASKED] 06:05AM [MASKED] [MASKED] [MASKED] 06:05AM [MASKED] [MASKED] IM [MASKED] [MASKED] [MASKED] 06:05AM PLT [MASKED] [MASKED] 06:05AM [MASKED] [MASKED] ABS [MASKED] ABS [MASKED] ABS [MASKED] ABS [MASKED] Brief Hospital Course: SAFETY: [MASKED] was placed on 15 minute checks on admission and remained here on that level of observation throughout. She was unit restricted. There were no acute safety issues during this hospitalization. LEGAL: [MASKED] PSYCHIATRIC: [MASKED] is a [MASKED] year old [MASKED] female with a history of TBI, HIV (not on HAART therapy), HCV (not treated), polysubstance use (EtOH, crack cocaine, and heroin), unspecified mood disorder, and chronic auditory hallucinations who presented to the emergency department on [MASKED] with alcohol intoxication, tangential thoughts, and complaints of repeated head strikes, now s/p ICU/medicine course for alcohol withdrawal with phenobarbital taper. On the unit, [MASKED] was started on quetiapine (uptitrated to 300 mg BID) and on sertraline 25 mg daily to good effect. [MASKED] did well on the unit and attended groups regularly. She recognized effect illicit drugs and alcohol have had on her mental health, social situation, and interpersonal relationships. Although she has a history of multiple relapses, failing to [MASKED], and medication nonadherence, she kept repeating that this admission was different and that she wants to maintain her sobriety. She showered daily and had no issues with sleep or appetite. On the day of discharge, [MASKED] endorsed/exhibited "good" mood and euthymic affect. Denied SI/HI and AVH. She expressed continued motivation to maintain her sobriety, do 90 AA meetings in 90 days, and desire to [MASKED] at [MASKED]. A [MASKED] application was submitted. Her PCP was updated on the plan and [MASKED] appointments were coordinated. MEDICAL: #HIV: [MASKED] not currently taking HAART. Most recent CD4 count 42 on [MASKED]. - Continued Bactrim DS 1 tab daily for PCP ppx - [MASKED] has appointment with Dr. [MASKED] on [MASKED] on [MASKED] to discuss reinitiation of HAART #Hepatitis C: HCV Ab positive on [MASKED]. Not treated. - [MASKED] has appointment with Dr. [MASKED] on [MASKED] on [MASKED] to discuss treatment PSYCHOSOCIAL: #) GROUPS/MILIEU: [MASKED] was encouraged to participate in units groups, milieu, and therapy opportunities. Usage of coping skills, mindfulness, and relaxation methods were encouraged. Therapy addressed family, social, work, and housing issues. The [MASKED] enjoyed groups and participated. She also participated in AA meetings on the unit. #) COLLATERAL CONTACTS: -Treaters- PCP (Dr. [MASKED] -Records- Per OMR -Family- [MASKED] refused family meetings #) FAMILY INVOLVEMENT: Despite encouragement from the team throughout her admission, [MASKED] refused family meetings. #) INTERVENTIONS: -D Referral: The team submitted a DMH application for the [MASKED] to receive services and [MASKED] support. -Pharmacological treatment: Quetiapine and sertraline as above. -Individual/group/milieu therapy -Coordinated aftercare with SW INFORMED CONSENT: -Quetiapine, sertraline The Team discussed the indications for, intended benefits of, and possible side effects and risks of this medication, and risks and benefits of possible alternatives, including not taking the medication, with this [MASKED]. We discussed the [MASKED] right to decide whether to take this medication as well as the importance of the [MASKED] actively participating in the treatment and discussing any questions about medications with the treatment team, and I answered the [MASKED] questions. The [MASKED] appeared able to understand and consented to begin the medication. RISK ASSESSMENT: Low imminent risk of harm/violence to self/others. #) Chronic/Static Risk Factors: Chronic mental illness, chronic medical illness, single, ongoing homelessness. #) Modifiable Risk Factors: -Acute major mood episode with suicidal ideation - Modified by medication adjustments and psychotherapeutic interventions as above. -Active polysubstance misuse - Modified by phenobarbital taper while on medical floor for alcohol withdrawal and detox; attendance to AA meetings on the unit; list of free substance use recovery resources in the community. -Limited outpatient/social support - Modified by aftercare planning with SW; outpatient appointments; list of community resources. -[MASKED] - Modified by counseling on the unit. [MASKED] was adherent with medications on the unit. #) Protective Factors: Protective factors include current outpatient providers/treatment, knowledge of community resources, motivation to maintain sobriety, [MASKED], and [MASKED] behaviors. PROGNOSIS: Good: [MASKED] was engaged on the unit, adherent with medications, and attended groups regularly. She has outpatient appointments and community resources. Current risk is low for intentional [MASKED] given that [MASKED] denies suicidal ideation, intent and plan, is accepting of treatment, is currently sober and is [MASKED] with plans. Medications on Admission: [MASKED] was not taking medications prior to admission. Per Deac 4 Discharge Summary dated [MASKED]: 1. Amitriptyline 50 mg PO QHS 2. QUEtiapine Fumarate 50 mg PO QHS Discharge Medications: 1. Sulfameth/Trimethoprim DS 1 TAB PO DAILY RX [MASKED] [Bactrim DS] 800 [MASKED] mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 2. QUEtiapine Fumarate 300 mg PO BID RX *quetiapine [Seroquel] 100 mg 3 tablet(s) by mouth twice a day Disp #*180 Tablet Refills:*0 3. Sertraline 25 mg PO DAILY RX *sertraline [Zoloft] 25 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Unspecified psychotic disorder [MASKED] vs. schizophrenia spectrum) EtOH use disorder Cocaine use disorder Heroin use disorder (in full sustained remission) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Mental Status Examination: *Appearance: Woman who appears older than stated age, wearing jeans and a sweater, tattoo on neck, hair in a bun, appropriate hygiene, no acute distress. Behavior: Good eye contact, cooperative, engaged. No psychomotor agitation/retardation. *Mood and Affect: 'Good' / Mostly euthymic, some smiling. *Speech: Normal rate, volume, rhythm, prosody, articulation. Fluent in [MASKED]. *Thought process: Linear and [MASKED]. No loosening of associations. *Thought Content: Denies SI/HI and AVH. Focused on maintaining her sobriety. *Judgment and Insight: Fair/Fair. [MASKED] recognizes effect drug use has had on her mental health, social situation, and interpersonal relationships. She has a history of multiple relapses, failing to [MASKED], and medication nonadherence but keeps repeating that this admission is different and that she wants to maintain her sobriety. Cognition: Awake, alert, attentive throughout interview. Memory intact to recent and remote history. Discharge Instructions: You were hospitalized at [MASKED] for alcohol detox, depressed mood, and suicidal ideation. We adjusted your medications, and you are now ready for discharge and continued treatment on an outpatient basis. -Please follow up with all outpatient appointments as listed - take this discharge paperwork to your appointments. -Please continue all medications as directed. -Please avoid abusing alcohol and any drugs--whether prescription drugs or illegal drugs--as this can further worsen your medical and psychiatric illnesses. -Please contact your outpatient psychiatrist or other providers if you have any concerns. -Please call [MASKED] or go to your nearest emergency room if you feel unsafe in any way and are unable to immediately reach your health care providers. It was a pleasure to have worked with you, and we wish you the best of health. Followup Instructions: [MASKED]
|
[] |
[
"Z87891"
] |
[
"F1994: Other psychoactive substance use, unspecified with psychoactive substance-induced mood disorder",
"B20: Human immunodeficiency virus [HIV] disease",
"F1490: Cocaine use, unspecified, uncomplicated",
"F1099: Alcohol use, unspecified with unspecified alcohol-induced disorder",
"F209: Schizophrenia, unspecified",
"Z87820: Personal history of traumatic brain injury",
"B1920: Unspecified viral hepatitis C without hepatic coma",
"Z87891: Personal history of nicotine dependence"
] |
10,002,930 | 25,922,998 |
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:
___
|
[
"F10239",
"F1110",
"R45851",
"Z87820",
"B1920",
"Z23",
"Z590",
"F1410",
"R509",
"F29",
"Z21",
"Z9114",
"D72819"
] |
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: alcohol intoxication Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] y/o [MASKED] 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 [MASKED] 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 [MASKED] falling asleep. Of note, she reports active EtOH use and states her last drink was at 1200 on [MASKED]. 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, [MASKED], Tricyc Negative Lactate 1.0 U/A with ketones, 6 WBCs, few bacteria, negative leuks, negative nitrites - Imaging showed: NCHCT ([MASKED]): 1. No acute intracranial abnormality. 2. Stable left parietal encephalomalacia. CXR ([MASKED]): 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 [MASKED] 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. [MASKED] ([MASKED]), confirmed with patient and updated as relevant: - HIV - Hepatitis C - H/o head injury (Per Deac 4 DC summary [MASKED]: "pt reports she was "assaulted" and subsequently received 300 stitches, was hospitalized x 2wks, and underwent rehab at [MASKED] she denies LOC or persistent deficits but receives SSDI for this injury" Social History: Per Dr. [MASKED] ([MASKED]), confirmed with patient and updated as relevant: "The patient reports that she was born and raised in [MASKED] and that her parents were separated while she was growing up. She states that she lives with her grandmother her whole life until [MASKED] years ago when her mother died and that she has been living in the [MASKED] since. She states that she has 2 daughters (age [MASKED] and [MASKED], named [MASKED] and [MASKED] who are both enrolled at [MASKED] 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 [MASKED]. 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: =========================== [MASKED] 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 [MASKED] [MASKED] 03:27PM BLOOD Neuts-74.0* [MASKED] Monos-4.5* Eos-0.7* Baso-0.3 AbsNeut-2.16 AbsLymp-0.60* AbsMono-0.13* AbsEos-0.02* AbsBaso-0.01 [MASKED] 03:27PM BLOOD Glucose-111* UreaN-15 Creat-0.6 Na-140 K-3.5 Cl-103 HCO3-24 AnGap-17 [MASKED] 03:27PM BLOOD ALT-77* AST-196* AlkPhos-98 TotBili-0.6 [MASKED] 03:27PM BLOOD Albumin-3.9 [MASKED] 03:27PM BLOOD Osmolal-295 [MASKED] 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 ([MASKED]): 1. No acute intracranial abnormality. 2. Stable left parietal encephalomalacia. -CXR ([MASKED]): No acute cardiopulmonary abnormality or fracture. DISCHARGE LABS: =========================== Brief Hospital Course: [MASKED] y/o [MASKED] 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 [MASKED] 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 [MASKED]. 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 [MASKED] 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 [MASKED] 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: [MASKED] Discharge Diagnosis: Polysubstance abuse Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You were admitted to [MASKED] 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: [MASKED]
|
[] |
[] |
[
"F10239: Alcohol dependence with withdrawal, unspecified",
"F1110: Opioid abuse, uncomplicated",
"R45851: Suicidal ideations",
"Z87820: Personal history of traumatic brain injury",
"B1920: Unspecified viral hepatitis C without hepatic coma",
"Z23: Encounter for immunization",
"Z590: Homelessness",
"F1410: Cocaine abuse, uncomplicated",
"R509: Fever, unspecified",
"F29: Unspecified psychosis not due to a substance or known physiological condition",
"Z21: Asymptomatic human immunodeficiency virus [HIV] infection status",
"Z9114: Patient's other noncompliance with medication regimen",
"D72819: Decreased white blood cell count, unspecified"
] |
10,003,019 | 28,836,362 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Ragweed
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
s/p TRANSCATHETER MITRAL VALVE REPAIR on ___
History of Present Illness:
___ year old male with a past medical history of
hyperlipidemia, congestive heart failure (EF 61%), mitral
regurgitation, lymphoma, sarcoidosis, and obstructive sleep
apnea
who has been experiencing progressive dyspnea on exertion over
the last several months. His most recent echo showed moderate to
severe mitral regurgitation. He presented for planned mitraclip.
Past Medical History:
CHF
Mitral regurgitation
CKD
Hyperlipidemia
OSA
Asthma
Duodenal ulcer
Lymphoma
GERD
Sarcoidosis with pulmonary and intestinal involvement
BPH
Inflammatory bowel disease
Hard of hearing with cochlear implants
PSH:
cochlear implants
cataract surgery
knee surgery
splenectomy
hernia repair
tonsillectomy
appendectomy
rotator cuff repair
?brain biopsy
vasectomy
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 PE:
VS: 103/51, HR 63 SR, O2 sat 99% RA
Gen: alert, not oriented but answers to name and asking
appropriate questions. NAD.
Neuro: PERLA, CN ___ intact. MAE, strengths ___. speech
clear.
Neck: no JVD lying flat.
CV: RRR, ___ diastolic course murmur at ___.
Chest: clear ant
ABD: soft, NT
Extr: no edema, feet warm, pulses palp
Skin: intact, warm and dry
Access sites: right fem: DSD with no hematoma or ecchymosis.
GU: condom cath with clear urine
Weight:
EKG: ___: SR, LAD, nl intervals
Tele: SR
.
DC:
Gen: alert, talkative, mildly confused
Neuro: PERLA, CN ___ intact. MAE, strengths ___. speech
clear.
Neck: supple
CV: RRR, ___ diastolic course murmur at LUSB.
Chest: clear ant
ABD: soft, NT
Extr: no edema, feet warm, pulses palp
Skin: intact, warm and dry
Access sites: right fem: DSD with no hematoma or ecchymosis.
Pertinent Results:
Admission labs:
___ 12:53PM BLOOD WBC-10.1* RBC-3.44* Hgb-10.6* Hct-32.0*
MCV-93 MCH-30.8 MCHC-33.1 RDW-14.4 RDWSD-48.7* Plt ___
___ 12:53PM BLOOD ___ PTT-150* ___
___ 12:53PM BLOOD Glucose-94 UreaN-21* Creat-1.2 Na-142
K-4.3 Cl-106 HCO3-24 AnGap-12
___ 09:15AM BLOOD GGT-41
___ 12:53PM BLOOD Calcium-8.6 Phos-3.4 Mg-1.6
___ 09:15AM BLOOD Albumin-3.5
TRANSCATHETER MITRAL VALVE REPAIR ___
Transfemoral Extreme Risk MITRAL REGURGITATION
Procedures: TransSEPTAL transcatheter MITRAL valve repair
Catheter Placement, Mitraclip sheath
right femoral vein Percutaneous mitral Valve
case complexity required a multidisciplinary approach with
Cardiac Surgery and Interventional Cardiology. Vascular access
was obtained in the right femoral veinusing vascular ultrasound
techniques.
RHC and LHC performed by transeptal approach and showed
significant V waves
Transeptal Puncture was done Using Lamp 45 and needle under
fluoro and TEE guidance to ensure 4 cm
clearance from annulus Unfractionated heparin was given to
achieve an ACT> 250 seconds.
A 0.035" confida wire was advanced through sheath and used to
advance the Pascal Guide system The
Pascal was advanced through the guide and positioned across A2
and P2 under fluoro and TEE guidance. First Grab resulted in
only modest reduction in MR therefore, the leaflets were
released and
independently grabbed again with reduction in MR to ___, and
great hemodynamics (no V waves). An additional device was placed
with resultant 1+ MR and gradient of 2 mmHg The clip were
released and sheath pulled to RA. No significant shunting seen,
therefore, sheath removed
after proglide in preclose fashion and applying skin suture
There was no evidence of complications following the procedure.
The patient was transported to PACU the in stable condition
Transesophageal echocardiogram on ___:
Ejection Fraction:55-100%(nl M:52-72;F:54-74)
FINDINGS:
ADDITIONAL FINDINGS: No TEE related complications.
PRE-OPERATIVE STATE: Pre-bypass assessment.
Left Atrium ___ Veins: Dilated ___. No spontaneous
echo contrast is seen in the ___. No ___ mass/thrombus
Right Atrium (RA)/Interatrial Septum/Inferior Vena Cava (IVC):
DIlated RA. No spontaneous echo
contrast is seen in the RA/RA appendage. Lipomatous interatrial
septum. No atrial septal defect by 2D/color
flow Doppler.
Left Ventricle (LV): Normal cavity size. Normal regional &
global systolic function Normal ejection fraction.
No resting LV outflow tract gradient. No mass/thrombus.
Right Ventricle (RV): Normal cavity size. Normal free wall
motion.
Aorta: Normal sinus diameter. Normal ascending diameter. Normal
descending aorta diameter. No dissection.
Simple sinus atheroma. Siimple atheroma of ascending aorta.
Simple arch atheroma.
Aortic Valve: Mildly thickened (3) leaflets. Minimal leaflet
calcification. No stenosis. Trace regurgitation.
Central jet.
Mitral Valve: Mildly thickened/myxomatous leaflets. No stenosis.
Mild annular calcification. SEVERE [4+]
regurgitation. Eccentric jet.
Tricuspid Valve: Mildly thickened leaflets. Trace regurgitation.
Pericardium: No effusion.
POST-OP STATE: The post-bypass TEE was performed at 13:18:00.
Sinus rhythm.
Post-op Comments ___ guidance provided for
trans-septal puncture and positioning
and deployment of the two PASCAL devices
Support: Vasopressor(s): none.
Interatrial Septum: Small residual secundum atrial septal defect
on color Doppler.
Left Ventricle: Similar to preoperative findings. SImilar
regional function. Global ejection fraction
is normal.
Right Ventricle: No change in systolic function.
Aorta: Intact. No dissection.
Aortic Valve: No change in aortic valve morphology from
preoperative state. Unchanged gradient.
No change in aortic regurgitation.
Mitral Valve: MitraClip(s). MitraClip(s) attached to both
leaflets. Post-bypass, mean mitral valve
gradient = 1.75mmHg. Similar gradient to preoperative state.
Mild [1+] valvular regurgitation.
Tricuspid Valve: No change in tricuspid valve morphology vs.
preoperative state. No change in
regurgitation vs preoperative state.
Pericardium: No effusion.
.
DC:
___ 08:13AM BLOOD WBC-10.1* RBC-3.48* Hgb-10.8* Hct-32.8*
MCV-94 MCH-31.0 MCHC-32.9 RDW-14.6 RDWSD-49.9* Plt ___
___ 08:13AM BLOOD Glucose-86 UreaN-19 Creat-1.2 Na-141
K-4.7 Cl-106 HCO3-24 AnGap-11
___ 12:53PM BLOOD Calcium-8.6 Phos-3.4 Mg-1.___ yo M with PMH of severe MR, HFpEF, OSA,
sarcoid, BPH s/p Mitraclip using Pascal system.
# Severe mitral regurgitation: s/p Mitraclip with no
complications. Full report above. MR now dec to ___. right
groin site without sig ecchymosis or hematoma.
Metoprolol restarted before discharge but lisinopril will be
held because of soft blood pressures on day of discharge. Please
consider restarting low-dose lisinopril at follow-up
appointments. Anticoagulation is aspirin and Plavix for the
mitral clip. He will return in 1 month for an echocardiogram to
assess positioning of the mitral clips and will see Dr ___ in
approximately 2 months
# Chronic diastolic heart failure: looks euvolemic on exam. Pt's
main symptom was SOB. holding BB and ACEI for lowish BP after
anesthesia. As noted above restarted metoprolol before discharge
but lisinopril was held. Started on Lasix 20 mg and low-dose
potassium which is standard post mitral clip. His weight at
discharge is 154 pounds.
# sarcoidosis: w/pulmonary and intestinal involvement. Good O2
sats on RA. Unknown if he has cardiac involvement.
- cont prednisone 1mg
# hyperlipidemia: LDL 130, TC 212, HDL 57. on simva 20. Patient
could benefit from an increased dose of simvastatin if he has
been tolerating at home.
# asthma: no wheezes on exam and nl O2 sats. Continued Advair
# GERD: change omeprazole to pantoprazole because of new Plavix.
# BPH: currently on no meds, no trouble with urinary retention
after the procedure.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fludrocortisone Acetate 0.1 mg PO 3X/WEEK (___)
2. PredniSONE 1 mg PO DAILY
3. Lisinopril 2.5 mg PO DAILY
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Simvastatin 20 mg PO QPM
6. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
7. Omeprazole 20 mg PO DAILY
8. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN SOB
9. FLUoxetine 40 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Furosemide 20 mg PO DAILY
4. Pantoprazole 40 mg PO Q24H
5. Potassium Chloride 20 mEq PO DAILY
6. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN SOB
7. Fludrocortisone Acetate 0.1 mg PO 3X/WEEK (___)
8. FLUoxetine 40 mg PO DAILY
9. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
10. Metoprolol Succinate XL 25 mg PO DAILY
11. PredniSONE 1 mg PO DAILY
12. Simvastatin 20 mg PO QPM
13. HELD- Lisinopril 2.5 mg PO DAILY This medication was held.
Do not restart Lisinopril until after you see Dr ___
___ Disposition:
Home
Discharge Diagnosis:
Severe mitral regurgitation s/p Mitraclip
Hypertension
Hyperlipidemia
chronic diastolic heart failure
Sleep apnea
Sarcoid
GERD
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for your mitral valve clip procedure. By
repairing the valve your heart can pump blood more easily and
your shortness of breath should improve.
It is very important to take all of your heart healthy
medications. In particular, you are now taking Aspirin and
Clopidogrel (Plavix). These medications help to prevent blood
clots from forming in/around the heart valve. If you stop these
medications or miss ___ dose, you risk causing a blood clot
forming on your heart valve. This could cause it to malfunction
and it may be life threatening. Please do not stop taking
Aspirin or Plavix without taking to your heart doctor, even if
another doctor tells you to stop the medications.
You will need prophylactic antibiotics prior to any dental
procedure. Please obtain a prescription for a one-time dose of
antibiotics prior to procedures, and inform your dentist about
your recent cardiac procedure.
Please weigh yourself every day in the morning after you go to
the bathroom and before you get dressed. If your weight goes up
by more than 3 lbs in 1 day or more than 5 lbs in 3 days, please
call your heart doctor or your primary care doctor and alert
them to this change. Your weight at discharge is 154 pounds.
We have made changes to your medication list, so please make
sure to take your medications as directed. You will also need to
have close follow up with your heart doctor and your primary
care doctor.
If you were given any prescriptions on discharge, any future
refills will need to be authorized by your outpatient providers,
primary care or cardiologist.
If you have any urgent questions that are related to your
recovery from your procedure or are experiencing any symptoms
that are concerning to you and you think you may need to return
to the hospital, please call the ___ Heart Line at
___ to speak to a cardiologist or cardiac nurse
practitioner.
It has been a pleasure to have participated in your care and we
wish you the best with your health.
Followup Instructions:
___
|
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"I340",
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"K219",
"N400",
"Z8042",
"G4733",
"Z8572",
"Z87891",
"Z9621",
"H9190"
] |
Allergies: Ragweed Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: s/p TRANSCATHETER MITRAL VALVE REPAIR on [MASKED] History of Present Illness: [MASKED] year old male with a past medical history of hyperlipidemia, congestive heart failure (EF 61%), mitral regurgitation, lymphoma, sarcoidosis, and obstructive sleep apnea who has been experiencing progressive dyspnea on exertion over the last several months. His most recent echo showed moderate to severe mitral regurgitation. He presented for planned mitraclip. Past Medical History: CHF Mitral regurgitation CKD Hyperlipidemia OSA Asthma Duodenal ulcer Lymphoma GERD Sarcoidosis with pulmonary and intestinal involvement BPH Inflammatory bowel disease Hard of hearing with cochlear implants PSH: cochlear implants cataract surgery knee surgery splenectomy hernia repair tonsillectomy appendectomy rotator cuff repair ?brain biopsy vasectomy Social History: [MASKED] Family History: Mother: [MASKED], cardiac disease. Father: diverticulosis, peptic ulcer disease, died at age [MASKED]. Maternal grandfather: [MASKED] cancer. Two siblings, living and healthy. Physical Exam: Admission PE: VS: 103/51, HR 63 SR, O2 sat 99% RA Gen: alert, not oriented but answers to name and asking appropriate questions. NAD. Neuro: PERLA, CN [MASKED] intact. MAE, strengths [MASKED]. speech clear. Neck: no JVD lying flat. CV: RRR, [MASKED] diastolic course murmur at [MASKED]. Chest: clear ant ABD: soft, NT Extr: no edema, feet warm, pulses palp Skin: intact, warm and dry Access sites: right fem: DSD with no hematoma or ecchymosis. GU: condom cath with clear urine Weight: EKG: [MASKED]: SR, LAD, nl intervals Tele: SR . DC: Gen: alert, talkative, mildly confused Neuro: PERLA, CN [MASKED] intact. MAE, strengths [MASKED]. speech clear. Neck: supple CV: RRR, [MASKED] diastolic course murmur at LUSB. Chest: clear ant ABD: soft, NT Extr: no edema, feet warm, pulses palp Skin: intact, warm and dry Access sites: right fem: DSD with no hematoma or ecchymosis. Pertinent Results: Admission labs: [MASKED] 12:53PM BLOOD WBC-10.1* RBC-3.44* Hgb-10.6* Hct-32.0* MCV-93 MCH-30.8 MCHC-33.1 RDW-14.4 RDWSD-48.7* Plt [MASKED] [MASKED] 12:53PM BLOOD [MASKED] PTT-150* [MASKED] [MASKED] 12:53PM BLOOD Glucose-94 UreaN-21* Creat-1.2 Na-142 K-4.3 Cl-106 HCO3-24 AnGap-12 [MASKED] 09:15AM BLOOD GGT-41 [MASKED] 12:53PM BLOOD Calcium-8.6 Phos-3.4 Mg-1.6 [MASKED] 09:15AM BLOOD Albumin-3.5 TRANSCATHETER MITRAL VALVE REPAIR [MASKED] Transfemoral Extreme Risk MITRAL REGURGITATION Procedures: TransSEPTAL transcatheter MITRAL valve repair Catheter Placement, Mitraclip sheath right femoral vein Percutaneous mitral Valve case complexity required a multidisciplinary approach with Cardiac Surgery and Interventional Cardiology. Vascular access was obtained in the right femoral veinusing vascular ultrasound techniques. RHC and LHC performed by transeptal approach and showed significant V waves Transeptal Puncture was done Using Lamp 45 and needle under fluoro and TEE guidance to ensure 4 cm clearance from annulus Unfractionated heparin was given to achieve an ACT> 250 seconds. A 0.035" confida wire was advanced through sheath and used to advance the Pascal Guide system The Pascal was advanced through the guide and positioned across A2 and P2 under fluoro and TEE guidance. First Grab resulted in only modest reduction in MR therefore, the leaflets were released and independently grabbed again with reduction in MR to [MASKED], and great hemodynamics (no V waves). An additional device was placed with resultant 1+ MR and gradient of 2 mmHg The clip were released and sheath pulled to RA. No significant shunting seen, therefore, sheath removed after proglide in preclose fashion and applying skin suture There was no evidence of complications following the procedure. The patient was transported to PACU the in stable condition Transesophageal echocardiogram on [MASKED]: Ejection Fraction:55-100%(nl M:52-72;F:54-74) FINDINGS: ADDITIONAL FINDINGS: No TEE related complications. PRE-OPERATIVE STATE: Pre-bypass assessment. Left Atrium [MASKED] Veins: Dilated [MASKED]. No spontaneous echo contrast is seen in the [MASKED]. No [MASKED] mass/thrombus Right Atrium (RA)/Interatrial Septum/Inferior Vena Cava (IVC): DIlated RA. No spontaneous echo contrast is seen in the RA/RA appendage. Lipomatous interatrial septum. No atrial septal defect by 2D/color flow Doppler. Left Ventricle (LV): Normal cavity size. Normal regional & global systolic function Normal ejection fraction. No resting LV outflow tract gradient. No mass/thrombus. Right Ventricle (RV): Normal cavity size. Normal free wall motion. Aorta: Normal sinus diameter. Normal ascending diameter. Normal descending aorta diameter. No dissection. Simple sinus atheroma. Siimple atheroma of ascending aorta. Simple arch atheroma. Aortic Valve: Mildly thickened (3) leaflets. Minimal leaflet calcification. No stenosis. Trace regurgitation. Central jet. Mitral Valve: Mildly thickened/myxomatous leaflets. No stenosis. Mild annular calcification. SEVERE [4+] regurgitation. Eccentric jet. Tricuspid Valve: Mildly thickened leaflets. Trace regurgitation. Pericardium: No effusion. POST-OP STATE: The post-bypass TEE was performed at 13:18:00. Sinus rhythm. Post-op Comments [MASKED] guidance provided for trans-septal puncture and positioning and deployment of the two PASCAL devices Support: Vasopressor(s): none. Interatrial Septum: Small residual secundum atrial septal defect on color Doppler. Left Ventricle: Similar to preoperative findings. SImilar regional function. Global ejection fraction is normal. Right Ventricle: No change in systolic function. Aorta: Intact. No dissection. Aortic Valve: No change in aortic valve morphology from preoperative state. Unchanged gradient. No change in aortic regurgitation. Mitral Valve: MitraClip(s). MitraClip(s) attached to both leaflets. Post-bypass, mean mitral valve gradient = 1.75mmHg. Similar gradient to preoperative state. Mild [1+] valvular regurgitation. Tricuspid Valve: No change in tricuspid valve morphology vs. preoperative state. No change in regurgitation vs preoperative state. Pericardium: No effusion. . DC: [MASKED] 08:13AM BLOOD WBC-10.1* RBC-3.48* Hgb-10.8* Hct-32.8* MCV-94 MCH-31.0 MCHC-32.9 RDW-14.6 RDWSD-49.9* Plt [MASKED] [MASKED] 08:13AM BLOOD Glucose-86 UreaN-19 Creat-1.2 Na-141 K-4.7 Cl-106 HCO3-24 AnGap-11 [MASKED] 12:53PM BLOOD Calcium-8.6 Phos-3.4 Mg-1.[MASKED] yo M with PMH of severe MR, HFpEF, OSA, sarcoid, BPH s/p Mitraclip using Pascal system. # Severe mitral regurgitation: s/p Mitraclip with no complications. Full report above. MR now dec to [MASKED]. right groin site without sig ecchymosis or hematoma. Metoprolol restarted before discharge but lisinopril will be held because of soft blood pressures on day of discharge. Please consider restarting low-dose lisinopril at follow-up appointments. Anticoagulation is aspirin and Plavix for the mitral clip. He will return in 1 month for an echocardiogram to assess positioning of the mitral clips and will see Dr [MASKED] in approximately 2 months # Chronic diastolic heart failure: looks euvolemic on exam. Pt's main symptom was SOB. holding BB and ACEI for lowish BP after anesthesia. As noted above restarted metoprolol before discharge but lisinopril was held. Started on Lasix 20 mg and low-dose potassium which is standard post mitral clip. His weight at discharge is 154 pounds. # sarcoidosis: w/pulmonary and intestinal involvement. Good O2 sats on RA. Unknown if he has cardiac involvement. - cont prednisone 1mg # hyperlipidemia: LDL 130, TC 212, HDL 57. on simva 20. Patient could benefit from an increased dose of simvastatin if he has been tolerating at home. # asthma: no wheezes on exam and nl O2 sats. Continued Advair # GERD: change omeprazole to pantoprazole because of new Plavix. # BPH: currently on no meds, no trouble with urinary retention after the procedure. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Fludrocortisone Acetate 0.1 mg PO 3X/WEEK ([MASKED]) 2. PredniSONE 1 mg PO DAILY 3. Lisinopril 2.5 mg PO DAILY 4. Metoprolol Succinate XL 25 mg PO DAILY 5. Simvastatin 20 mg PO QPM 6. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 7. Omeprazole 20 mg PO DAILY 8. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN SOB 9. FLUoxetine 40 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Clopidogrel 75 mg PO DAILY 3. Furosemide 20 mg PO DAILY 4. Pantoprazole 40 mg PO Q24H 5. Potassium Chloride 20 mEq PO DAILY 6. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN SOB 7. Fludrocortisone Acetate 0.1 mg PO 3X/WEEK ([MASKED]) 8. FLUoxetine 40 mg PO DAILY 9. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 10. Metoprolol Succinate XL 25 mg PO DAILY 11. PredniSONE 1 mg PO DAILY 12. Simvastatin 20 mg PO QPM 13. HELD- Lisinopril 2.5 mg PO DAILY This medication was held. Do not restart Lisinopril until after you see Dr [MASKED] [MASKED] Disposition: Home Discharge Diagnosis: Severe mitral regurgitation s/p Mitraclip Hypertension Hyperlipidemia chronic diastolic heart failure Sleep apnea Sarcoid GERD Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for your mitral valve clip procedure. By repairing the valve your heart can pump blood more easily and your shortness of breath should improve. It is very important to take all of your heart healthy medications. In particular, you are now taking Aspirin and Clopidogrel (Plavix). These medications help to prevent blood clots from forming in/around the heart valve. If you stop these medications or miss [MASKED] dose, you risk causing a blood clot forming on your heart valve. This could cause it to malfunction and it may be life threatening. Please do not stop taking Aspirin or Plavix without taking to your heart doctor, even if another doctor tells you to stop the medications. You will need prophylactic antibiotics prior to any dental procedure. Please obtain a prescription for a one-time dose of antibiotics prior to procedures, and inform your dentist about your recent cardiac procedure. Please weigh yourself every day in the morning after you go to the bathroom and before you get dressed. If your weight goes up by more than 3 lbs in 1 day or more than 5 lbs in 3 days, please call your heart doctor or your primary care doctor and alert them to this change. Your weight at discharge is 154 pounds. We have made changes to your medication list, so please make sure to take your medications as directed. You will also need to have close follow up with your heart doctor and your primary care doctor. If you were given any prescriptions on discharge, any future refills will need to be authorized by your outpatient providers, primary care or cardiologist. If you have any urgent questions that are related to your recovery from your procedure or are experiencing any symptoms that are concerning to you and you think you may need to return to the hospital, please call the [MASKED] Heart Line at [MASKED] to speak to a cardiologist or cardiac nurse practitioner. It has been a pleasure to have participated in your care and we wish you the best with your health. Followup Instructions: [MASKED]
|
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[
"I5032",
"E785",
"J45909",
"K219",
"N400",
"G4733",
"Z87891"
] |
[
"I340: Nonrheumatic mitral (valve) insufficiency",
"I5032: Chronic diastolic (congestive) heart failure",
"Z006: Encounter for examination for normal comparison and control in clinical research program",
"D8689: Sarcoidosis of other sites",
"E785: Hyperlipidemia, unspecified",
"J45909: Unspecified asthma, uncomplicated",
"K219: Gastro-esophageal reflux disease without esophagitis",
"N400: Benign prostatic hyperplasia without lower urinary tract symptoms",
"Z8042: Family history of malignant neoplasm of prostate",
"G4733: Obstructive sleep apnea (adult) (pediatric)",
"Z8572: Personal history of non-Hodgkin lymphomas",
"Z87891: Personal history of nicotine dependence",
"Z9621: Cochlear implant status",
"H9190: Unspecified hearing loss, unspecified ear"
] |
10,003,299 | 20,940,957 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Iodine-Iodine Containing
Attending: ___.
Chief Complaint:
difficulty with swallowing
painful swallowing
diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female with history of stage
IIIA squamous cell carcinoma of lung undergoing chemoradiation
completed at end of ___, multiple strokes, hypertension,
hyperlipidemia, DMII, and prior colon cancer s/p hemicolectomy
who presents with throat pain and difficulty swallowing.
She was recently seen in the ED on ___ after a fall with head
strike. Imaging was negative and she was discharged home. K was
noted to be 3.2 so she was called back to the ED. Her K was
repleted and she was discharged home. Since then she has had
significant odynophagia with difficulty swallowing leading to
poor appetite, weakness, poor PO intake, and continued weight
loss. She has also been having diarrhea that is occasionally
bloody. She also notes persistent dry cough. She called her
Oncologist who recommended she present to the ED for further
evaluation.
On arrival to the ED, initial vitals were 96.8 84 ___ 18 100%
RA. Exam was notable for fatigued-appearing woman. Labs were
notable for WBC 2.9, H/H 10.5/31.9, Plt 178, Na 145, K 3.0,
BUN/Cr ___, and lactate 1.1. Blood cultures were done. No
imaging obtained. Patient was given 40mEq IV potassium. Prior to
transfer vitals were 98.1 72 134/69 20 100% RA.
On arrival to the floor, patient endorses the above history. She
has no acute issues or concerns. She denies fevers/chills, night
sweats, headache, vision changes, dizziness/lightheadedness,
weakness/numbnesss, shortness of breath, hemoptysis, chest pain,
palpitations, abdominal pain, nausea/vomiting, hematemesis,
dysuria, hematuria, and new rashes.
REVIEW OF SYSTEMS: A complete 10-point review of systems was
performed and was negative unless otherwise noted in the HPI.
PAST ONCOLOGIC HISTORY:
Briefly, patient initially presented to care in ___ with
hemoptysis. She was subsequently admitted for workup of same and
had a CT of the chest which showed a right infrahilar mass with
complete occlusion of the right middle lobe bronchus and
atelectasis of the right middle lobe with high suspicion for
lung
cancer; there was evidence of bilateral intrathoracic
adenopathy.
During her hospital admission, she was seen by the
interventional
pulmonary team and scheduled for outpatient bronchoscopy.
She underwent bronchoscopy with EBUS under Dr. ___ care on
___. FNA of the right middle lobe mass showed findings
consistent with squamous cell carcinoma; there was biopsy-proven
involvement of the level 4L lymph node; sampling of the 11 L
lymph node showed no malignant cells.
Patient underwent staging PET scan on ___. This showed an
FDG
avid 3.2 cm mass in the right infrahilar region with evidence of
occlusion of the right middle lobe bronchus and atelectasis of
the right middle lobe. FDG avid subcarinal adenopathy measuring
up to 1.3 cm was noted; additionally enlarged mediastinal and
and
hilar lymph nodes are also noted. A 2.2 cm left lower lobe
subpleural FDG avid lesion was also noted. No other distant
metastatic sites of disease were noted.
___: Weekly ___ and radiation started.
Past Medical History:
- prior paramedian pontine infarct (___)
- right-sided lenticulostriate territory infarct ___
- Hypertension as per prior medical records(patient denies)
- Dyslipidemia
- Colon cancer 2/p right colectomy in ___ with prolonged
stuttering course of adjuvant chemotherapy (diagnosed in setting
of GI bleeding)
- Cholecystectomy for chronic cholecystitis and gallstones in
___
- Diverticulosis
- Hemorrhoids
Social History:
___
Family History:
Mother had stroke in her ___ or ___. Her paternal
grandfather,
father, and brother all had colon cancer. Sister had ovarian
cancer and has prostate cancer in her family.
Physical Exam:
ADMISSION PHYSICAL EXAM:
===========================
VS: Temp 98.3, BP 110/62, HR 66, 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: Soft, non-tender, non-distended, normal bowel sounds.
EXT: Warm, well perfused, no lower extremity edema, erythema or
tenderness.
NEURO: A&Ox3, good attention and linear thought, CN II-XII
intact. Strength full throughout. Sensation to light touch
intact.
SKIN: No significant rashes.
ACCESS: Right chest wall port without erythema.
DISCHARGE PHYSICAL EXAM:
===========================
VS: 24 HR Data (last updated ___ @ 2327)
Temp: 98.3 (Tm 98.4), BP: 127/66 (115-131/53-69), HR: 66
(58-73), RR: 18 (___), O2 sat: 97% (97-99%), O2 delivery: Ra
GENERAL: Pleasant woman, in no distress, lying in bed
comfortably.
HEENT: Anicteric, PERLLA, OP clear.
CARDIAC: RRR, normal s1/s2, no m/r/g.
LUNG: CTAB, no increased work of breathing
ABD: Soft, non-tender, non-distended, normoactive BS
EXT: Warm, well perfused, no lower extremity edema, erythema or
tenderness.
NEURO: A&Ox3, alert and interactive thought, CN II-XII intact.
Strength full throughout. Sensation to light touch intact.
SKIN: No significant rashes.
Pertinent Results:
ADMISSION LABS:
==================
___ 05:30PM BLOOD WBC-2.9* RBC-4.03 Hgb-10.5* Hct-31.9*
MCV-79* MCH-26.1 MCHC-32.9 RDW-25.4* RDWSD-70.9* Plt ___
___ 05:30PM BLOOD Neuts-54.0 ___ Monos-21.1*
Eos-0.0* Baso-0.3 NRBC-1.0* Im ___ AbsNeut-1.56*
AbsLymp-0.69* AbsMono-0.61 AbsEos-0.00* AbsBaso-0.01
___ 05:30PM BLOOD Glucose-99 UreaN-7 Creat-0.6 Na-145
K-3.0* Cl-107 HCO3-27 AnGap-11
___ 05:30PM BLOOD Calcium-9.7 Phos-2.8 Mg-1.8
DISCHARGE LABS:
==================
___ 05:33AM BLOOD WBC-6.0 RBC-3.75* Hgb-9.6* Hct-29.6*
MCV-79* MCH-25.6* MCHC-32.4 RDW-25.7* RDWSD-71.3* Plt ___
___ 05:33AM BLOOD Glucose-81 UreaN-4* Creat-0.7 Na-141
K-4.0 Cl-105 HCO3-26 AnGap-10
___ 05:33AM BLOOD Calcium-9.3 Phos-2.2* Mg-1.9
MICROBIO:
==============
___ urine culture: MIXED BACTERIAL FLORA ( >= 3 COLONY
TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION.
___ blood culture: final, no growth
C. difficile PCR (Final ___:
NEGATIVE.
(Reference Range-Negative).
___ 12:20 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Pending):
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 O157:H7 found.
Cryptosporidium/Giardia (DFA) (Final ___:
NO CRYPTOSPORIDIUM OR GIARDIA SEEN.
IMAGING AND STUDIES:
===================
None
Brief Hospital Course:
SUMMARY:
=============
Ms. ___ is a ___ woman with stage IIIA squamous cell
carcinoma of lung undergoing chemoradiation completed on
___, history of multiple strokes and prior colon cancer s/p
hemicolectomy who presents with odynophagia x several weeks,
attributed to radiation esophagitis.
ACUTE ISSUES:
====================
# Odynophagia/Dysphagia
#Radiation Esophagitis
Managed with oral liquid lidocaine formulation, which improved
patient's ability to tolerate PO. Speech and language pathology
consutled, recommended soft ground diet and thin liquids, which
was advanced to regular solids. Nutrition consulted as well. If
symptoms fail to improve with liquid lidocaine and with a time
course consistent with radiation esophagitis, will need further
workup as outpatient, such as barium swallow or EGD. Patient was
started on lansoprazole for any contribution of GERD, should
continue to assess need for PPI as an outpatient.
# Hypernatremia
Patient with rising Na this admission, up to 149. Likely poor
oral intake iso radiation esophagitis. Patient received 1L D5W
with improvement of Na to 141 on day of discharge. She was
encouraged to maintain liquids throughout the day.
# Severe Malnutrition
Patient with poor PO intake and weight loss. Nutrition was
consulted, and per their recommendations she received Carnation
supplements with soy milk with meals, as well as Ensure Clear
with meals and multivitamins. PO intake was encouraged. SW was
consulted due to concern about her having adequate resources at
home (but she denies having issues with resources). ___ assessed
her and recommended home, where she already has a walker. OOB
with assistance was encouraged during the admission.
# Vitamin B12 deficiency
B12 was noted to be low this admission, so the patient received
cyanocobalamin 1000 mcg IM on ___ and was started on PO
cyanocobalamin daily. MMA was obtained, which was pending at
time of discharge. CBC was obtained daily.
# Stage IIIA Squamous Cell Lung Carcinoma
Undergoing concurrent chemoradiation. Will follow up with Dr.
___ as outpatient.
CHRONIC ISSUES:
=================
# Hypokalemia, chronic
Hypokalemia has been chronic. Etiology unclear as patient is not
on diuretics. Other etiologies include kidney dysfunction such
as rental tubular acidosis. Reportedly does not take potassium
as often as necessary at home d/t difficulty swallowing pill.
Urine
electrolytes notable for >20 K which seems inappropriate in
setting of hypokalemia. Potassium powder was trialed during the
admission.
# Diarrhea, stable
Patient reports loose stool since radiation. On admission did
report blood in stool that is streaky and superficial; patient
denied tarry stools or frank blood. The most concerning etiology
would be recurrence of colorectal carcinoma (s/p hemicolectomy),
although more likely causes include diverticulosis flare or
hemorrhoidal bleeding. Cdiff negative. Hb stable throughout this
admission.
# Tobacco Abuse: Managed inpatient with nicotine patch.
TRANSITIONAL ISSUES:
===========================
[] Ensure that patient is eating and drinking without difficulty
[] Continue to assess for presence of blood in stools
[] Should repeat CBC and BMP at next PCP visit to ensure stable
Hb and Na/K
[] Previously on potassium tablets, but discharged on potassium
powder given odynophagia, will need to follow up with ability to
tolerate this.
[] Patient was started on lansoprazole for any contribution of
GERD, should continue to assess need for PPI as an outpatient.
[] Found to have B12 deficiency anemia during this admission,
received cyanocobalamin 1000 mcg IM on ___ and was started on
PO cyanocobalamin daily, which she should continue.
[] Follow up on lab tests that were pending at time of
discharge: campylobacter stool culture, stool ova + parasites,
fecal culture r/o Yersinia, methylmalonic acid.
[] Patient was scheduled for outpatient CT chest ___, unable to
complete as an inpatient, will need to be rescheduled by her
oncology team
==========================
CODE: Full Code (confirmed)
EMERGENCY CONTACT HCP: ___ (daughter)
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lidocaine Viscous 2% 15 mL PO TID:PRN throat pain
2. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
3. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
4. Potassium Chloride 20 mEq PO DAILY
5. Nicotine Patch 7 mg/day TD DAILY
Discharge Medications:
1. Cyanocobalamin ___ mcg PO DAILY
RX *cyanocobalamin (vitamin B-12) 2,500 mcg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*3
2. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
RX *lansoprazole 30 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*3
3. Maalox/Diphenhydramine/Lidocaine ___ mL PO QID:PRN throat
pain
4. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*3
5. Potassium Chloride (Powder) 20 mEq PO DAILY
RX *potassium chloride 20 mEq 1 packet(s) by mouth daily Disp
#*30 Packet Refills:*3
6. Lidocaine Viscous 2% 15 mL PO TID:PRN throat pain
7. Nicotine Patch 7 mg/day TD DAILY
8. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
9. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
Radiation Esophagitis
stage IIIA squamous cell carcinoma of lung
Severe Malnutrition
Secondary diagnoses:
B12 deficiency
Chronic hypokalemia
Diarrhea
Tobacco abuse
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 caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were having pain with swallowing and difficulty eating
enough food.
- You were having diarrhea.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You received medication that decreased throat discomfort.
- You were seen by speech and swallow specialists who made
recommendations for your diet. You received a soft liquid diet
initially, which was advanced to regular solid foods as
tolerated.
- Studies were done on your stool to make sure that your
diarrhea wasn't caused by an infection.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
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"Z85038",
"E119",
"Z8673",
"E785",
"Z6822",
"R32",
"R1310"
] |
Allergies: Iodine-Iodine Containing Chief Complaint: difficulty with swallowing painful swallowing diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] female with history of stage IIIA squamous cell carcinoma of lung undergoing chemoradiation completed at end of [MASKED], multiple strokes, hypertension, hyperlipidemia, DMII, and prior colon cancer s/p hemicolectomy who presents with throat pain and difficulty swallowing. She was recently seen in the ED on [MASKED] after a fall with head strike. Imaging was negative and she was discharged home. K was noted to be 3.2 so she was called back to the ED. Her K was repleted and she was discharged home. Since then she has had significant odynophagia with difficulty swallowing leading to poor appetite, weakness, poor PO intake, and continued weight loss. She has also been having diarrhea that is occasionally bloody. She also notes persistent dry cough. She called her Oncologist who recommended she present to the ED for further evaluation. On arrival to the ED, initial vitals were 96.8 84 [MASKED] 18 100% RA. Exam was notable for fatigued-appearing woman. Labs were notable for WBC 2.9, H/H 10.5/31.9, Plt 178, Na 145, K 3.0, BUN/Cr [MASKED], and lactate 1.1. Blood cultures were done. No imaging obtained. Patient was given 40mEq IV potassium. Prior to transfer vitals were 98.1 72 134/69 20 100% RA. On arrival to the floor, patient endorses the above history. She has no acute issues or concerns. She denies fevers/chills, night sweats, headache, vision changes, dizziness/lightheadedness, weakness/numbnesss, shortness of breath, hemoptysis, chest pain, palpitations, abdominal pain, nausea/vomiting, hematemesis, dysuria, hematuria, and new rashes. REVIEW OF SYSTEMS: A complete 10-point review of systems was performed and was negative unless otherwise noted in the HPI. PAST ONCOLOGIC HISTORY: Briefly, patient initially presented to care in [MASKED] with hemoptysis. She was subsequently admitted for workup of same and had a CT of the chest which showed a right infrahilar mass with complete occlusion of the right middle lobe bronchus and atelectasis of the right middle lobe with high suspicion for lung cancer; there was evidence of bilateral intrathoracic adenopathy. During her hospital admission, she was seen by the interventional pulmonary team and scheduled for outpatient bronchoscopy. She underwent bronchoscopy with EBUS under Dr. [MASKED] care on [MASKED]. FNA of the right middle lobe mass showed findings consistent with squamous cell carcinoma; there was biopsy-proven involvement of the level 4L lymph node; sampling of the 11 L lymph node showed no malignant cells. Patient underwent staging PET scan on [MASKED]. This showed an FDG avid 3.2 cm mass in the right infrahilar region with evidence of occlusion of the right middle lobe bronchus and atelectasis of the right middle lobe. FDG avid subcarinal adenopathy measuring up to 1.3 cm was noted; additionally enlarged mediastinal and and hilar lymph nodes are also noted. A 2.2 cm left lower lobe subpleural FDG avid lesion was also noted. No other distant metastatic sites of disease were noted. [MASKED]: Weekly [MASKED] and radiation started. Past Medical History: - prior paramedian pontine infarct ([MASKED]) - right-sided lenticulostriate territory infarct [MASKED] - Hypertension as per prior medical records(patient denies) - Dyslipidemia - Colon cancer 2/p right colectomy in [MASKED] with prolonged stuttering course of adjuvant chemotherapy (diagnosed in setting of GI bleeding) - Cholecystectomy for chronic cholecystitis and gallstones in [MASKED] - Diverticulosis - Hemorrhoids Social History: [MASKED] Family History: Mother had stroke in her [MASKED] or [MASKED]. Her paternal grandfather, father, and brother all had colon cancer. Sister had ovarian cancer and has prostate cancer in her family. Physical Exam: ADMISSION PHYSICAL EXAM: =========================== VS: Temp 98.3, BP 110/62, HR 66, 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: Soft, non-tender, non-distended, normal bowel sounds. EXT: Warm, well perfused, no lower extremity edema, erythema or tenderness. NEURO: A&Ox3, good attention and linear thought, CN II-XII intact. Strength full throughout. Sensation to light touch intact. SKIN: No significant rashes. ACCESS: Right chest wall port without erythema. DISCHARGE PHYSICAL EXAM: =========================== VS: 24 HR Data (last updated [MASKED] @ 2327) Temp: 98.3 (Tm 98.4), BP: 127/66 (115-131/53-69), HR: 66 (58-73), RR: 18 ([MASKED]), O2 sat: 97% (97-99%), O2 delivery: Ra GENERAL: Pleasant woman, in no distress, lying in bed comfortably. HEENT: Anicteric, PERLLA, OP clear. CARDIAC: RRR, normal s1/s2, no m/r/g. LUNG: CTAB, no increased work of breathing ABD: Soft, non-tender, non-distended, normoactive BS EXT: Warm, well perfused, no lower extremity edema, erythema or tenderness. NEURO: A&Ox3, alert and interactive thought, CN II-XII intact. Strength full throughout. Sensation to light touch intact. SKIN: No significant rashes. Pertinent Results: ADMISSION LABS: ================== [MASKED] 05:30PM BLOOD WBC-2.9* RBC-4.03 Hgb-10.5* Hct-31.9* MCV-79* MCH-26.1 MCHC-32.9 RDW-25.4* RDWSD-70.9* Plt [MASKED] [MASKED] 05:30PM BLOOD Neuts-54.0 [MASKED] Monos-21.1* Eos-0.0* Baso-0.3 NRBC-1.0* Im [MASKED] AbsNeut-1.56* AbsLymp-0.69* AbsMono-0.61 AbsEos-0.00* AbsBaso-0.01 [MASKED] 05:30PM BLOOD Glucose-99 UreaN-7 Creat-0.6 Na-145 K-3.0* Cl-107 HCO3-27 AnGap-11 [MASKED] 05:30PM BLOOD Calcium-9.7 Phos-2.8 Mg-1.8 DISCHARGE LABS: ================== [MASKED] 05:33AM BLOOD WBC-6.0 RBC-3.75* Hgb-9.6* Hct-29.6* MCV-79* MCH-25.6* MCHC-32.4 RDW-25.7* RDWSD-71.3* Plt [MASKED] [MASKED] 05:33AM BLOOD Glucose-81 UreaN-4* Creat-0.7 Na-141 K-4.0 Cl-105 HCO3-26 AnGap-10 [MASKED] 05:33AM BLOOD Calcium-9.3 Phos-2.2* Mg-1.9 MICROBIO: ============== [MASKED] urine culture: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. [MASKED] blood culture: final, no growth C. difficile PCR (Final [MASKED]: NEGATIVE. (Reference Range-Negative). [MASKED] 12:20 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. FECAL CULTURE (Final [MASKED]: NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [MASKED]: NO CAMPYLOBACTER FOUND. OVA + PARASITES (Pending): FECAL CULTURE - R/O VIBRIO (Final [MASKED]: NO VIBRIO FOUND. FECAL CULTURE - R/O YERSINIA (Final [MASKED]: NO YERSINIA FOUND. FECAL CULTURE - R/O E.COLI 0157:H7 (Final [MASKED]: No E. coli O157:H7 found. Cryptosporidium/Giardia (DFA) (Final [MASKED]: NO CRYPTOSPORIDIUM OR GIARDIA SEEN. IMAGING AND STUDIES: =================== None Brief Hospital Course: SUMMARY: ============= Ms. [MASKED] is a [MASKED] woman with stage IIIA squamous cell carcinoma of lung undergoing chemoradiation completed on [MASKED], history of multiple strokes and prior colon cancer s/p hemicolectomy who presents with odynophagia x several weeks, attributed to radiation esophagitis. ACUTE ISSUES: ==================== # Odynophagia/Dysphagia #Radiation Esophagitis Managed with oral liquid lidocaine formulation, which improved patient's ability to tolerate PO. Speech and language pathology consutled, recommended soft ground diet and thin liquids, which was advanced to regular solids. Nutrition consulted as well. If symptoms fail to improve with liquid lidocaine and with a time course consistent with radiation esophagitis, will need further workup as outpatient, such as barium swallow or EGD. Patient was started on lansoprazole for any contribution of GERD, should continue to assess need for PPI as an outpatient. # Hypernatremia Patient with rising Na this admission, up to 149. Likely poor oral intake iso radiation esophagitis. Patient received 1L D5W with improvement of Na to 141 on day of discharge. She was encouraged to maintain liquids throughout the day. # Severe Malnutrition Patient with poor PO intake and weight loss. Nutrition was consulted, and per their recommendations she received Carnation supplements with soy milk with meals, as well as Ensure Clear with meals and multivitamins. PO intake was encouraged. SW was consulted due to concern about her having adequate resources at home (but she denies having issues with resources). [MASKED] assessed her and recommended home, where she already has a walker. OOB with assistance was encouraged during the admission. # Vitamin B12 deficiency B12 was noted to be low this admission, so the patient received cyanocobalamin 1000 mcg IM on [MASKED] and was started on PO cyanocobalamin daily. MMA was obtained, which was pending at time of discharge. CBC was obtained daily. # Stage IIIA Squamous Cell Lung Carcinoma Undergoing concurrent chemoradiation. Will follow up with Dr. [MASKED] as outpatient. CHRONIC ISSUES: ================= # Hypokalemia, chronic Hypokalemia has been chronic. Etiology unclear as patient is not on diuretics. Other etiologies include kidney dysfunction such as rental tubular acidosis. Reportedly does not take potassium as often as necessary at home d/t difficulty swallowing pill. Urine electrolytes notable for >20 K which seems inappropriate in setting of hypokalemia. Potassium powder was trialed during the admission. # Diarrhea, stable Patient reports loose stool since radiation. On admission did report blood in stool that is streaky and superficial; patient denied tarry stools or frank blood. The most concerning etiology would be recurrence of colorectal carcinoma (s/p hemicolectomy), although more likely causes include diverticulosis flare or hemorrhoidal bleeding. Cdiff negative. Hb stable throughout this admission. # Tobacco Abuse: Managed inpatient with nicotine patch. TRANSITIONAL ISSUES: =========================== [] Ensure that patient is eating and drinking without difficulty [] Continue to assess for presence of blood in stools [] Should repeat CBC and BMP at next PCP visit to ensure stable Hb and Na/K [] Previously on potassium tablets, but discharged on potassium powder given odynophagia, will need to follow up with ability to tolerate this. [] Patient was started on lansoprazole for any contribution of GERD, should continue to assess need for PPI as an outpatient. [] Found to have B12 deficiency anemia during this admission, received cyanocobalamin 1000 mcg IM on [MASKED] and was started on PO cyanocobalamin daily, which she should continue. [] Follow up on lab tests that were pending at time of discharge: campylobacter stool culture, stool ova + parasites, fecal culture r/o Yersinia, methylmalonic acid. [] Patient was scheduled for outpatient CT chest [MASKED], unable to complete as an inpatient, will need to be rescheduled by her oncology team ========================== CODE: Full Code (confirmed) EMERGENCY CONTACT HCP: [MASKED] (daughter) [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lidocaine Viscous 2% 15 mL PO TID:PRN throat pain 2. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 3. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting 4. Potassium Chloride 20 mEq PO DAILY 5. Nicotine Patch 7 mg/day TD DAILY Discharge Medications: 1. Cyanocobalamin [MASKED] mcg PO DAILY RX *cyanocobalamin (vitamin B-12) 2,500 mcg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*3 2. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY RX *lansoprazole 30 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*3 3. Maalox/Diphenhydramine/Lidocaine [MASKED] mL PO QID:PRN throat pain 4. Multivitamins W/minerals 1 TAB PO DAILY RX *multivitamin,tx-minerals 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*3 5. Potassium Chloride (Powder) 20 mEq PO DAILY RX *potassium chloride 20 mEq 1 packet(s) by mouth daily Disp #*30 Packet Refills:*3 6. Lidocaine Viscous 2% 15 mL PO TID:PRN throat pain 7. Nicotine Patch 7 mg/day TD DAILY 8. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 9. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Primary diagnoses: Radiation Esophagitis stage IIIA squamous cell carcinoma of lung Severe Malnutrition Secondary diagnoses: B12 deficiency Chronic hypokalemia Diarrhea Tobacco abuse Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [MASKED], It was a pleasure caring for you at [MASKED] [MASKED]. WHY WAS I IN THE HOSPITAL? - You were having pain with swallowing and difficulty eating enough food. - You were having diarrhea. WHAT HAPPENED TO ME IN THE HOSPITAL? - You received medication that decreased throat discomfort. - You were seen by speech and swallow specialists who made recommendations for your diet. You received a soft liquid diet initially, which was advanced to regular solid foods as tolerated. - Studies were done on your stool to make sure that your diarrhea wasn't caused by an infection. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Continue to take all your medicines and keep your appointments. We wish you the best! Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]
|
[] |
[
"F17210",
"E119",
"Z8673",
"E785"
] |
[
"K208: Other esophagitis",
"E870: Hyperosmolality and hypernatremia",
"C342: Malignant neoplasm of middle lobe, bronchus or lung",
"E46: Unspecified protein-calorie malnutrition",
"Y842: Radiological procedure and radiotherapy as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure",
"Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause",
"D519: Vitamin B12 deficiency anemia, unspecified",
"E876: Hypokalemia",
"R197: Diarrhea, unspecified",
"F17210: Nicotine dependence, cigarettes, uncomplicated",
"Z85038: Personal history of other malignant neoplasm of large intestine",
"E119: Type 2 diabetes mellitus without complications",
"Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits",
"E785: Hyperlipidemia, unspecified",
"Z6822: Body mass index [BMI] 22.0-22.9, adult",
"R32: Unspecified urinary incontinence",
"R1310: Dysphagia, unspecified"
] |
10,003,299 | 21,476,780 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Iodine-Iodine Containing
Attending: ___.
Chief Complaint:
hematemesis
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Ms. ___ is a ___ female with medical history notable for DM2,
HTN, HLD, multiple strokes on Plavix and aspirin, inferior MI,
tobacco use, primary hyperparathyroidism, and colon cancer s/p
colectomy and chemotherapy who presented with hemoptysis.
Patient was initially seen for hemoptysis at ___ on ___ HPI
reported "She first noticed coughing and hemoptysis
approximately ___ weeks ago, and noticed very small blood clots
at that time. She saw her PCP in clinic on ___ for this, and
CT
with contrast was ordered, but has not yet been scheduled (note,
she has allergy to contrast). Over the past 3 days, she has
noticed worsening of her cough, sputum production, and
hemoptysis, with large clots on the order of teaspoons. No
fevers
or chills, shortness of breath, chest pain, or lightheadedness.
Has some weight loss. No night sweats, homelessness, or prison
exposure. No recent travel, surgery, immobility, ___
swelling/pain. Notes some LUQ abdominal pain that began last
night, that is worsened by cough.
It is not associated with food, and she has no
n/v/d/constipation, and has regular BMs with no hematochezia or
melena."
A CT chest was obtained which was notable for infrahilar mass
with complete occlusion of the right middle lobe. She was not
able to connect with her PCP to discuss the results.
In the ED, initial VS:
Pain 0 Temp 97.7 HR 78 BP 170/88 RR 16 POx 97% RA
Exam:
O: lung mild wheeze in the RLL.
Work-up:
Leukocytosis to 16,
Elevated Ca ___
She received:
PO Oxybutynin 5 mg
PO Azithromycin 500 mg
IV CefTRIAXone (1 g ordered)
Consults:
IP: Decision was made to admit for expedited oncology work-up.
On arrival to the floor, the patient the endorsed the history
per above. In addition, she clarified that she has lost 3 pounds
in the past month. She denies any decrease PO intake or
abdominal
pain. She denies SOB. She says she feels a lot better after
receiving medications in the ED.
Past Medical History:
- prior paramedian pontine infarct (___)
- right-sided lenticulostriate territory infarct ___
- Hypertension as per prior medical records(patient denies)
- Dyslipidemia
- Colon cancer 2/p right colectomy in ___ with prolonged
stuttering course of adjuvant chemotherapy (diagnosed in setting
of GI bleeding)
- Cholecystectomy for chronic cholecystitis and gallstones in
___
- Diverticulosis
- Hemorrhoids
Social History:
___
Family History:
Mother had stroke in her ___ or ___. Her paternal
grandfather,
father, and brother all had colon cancer. Sister had ovarian
cancer and has prostate cancer in her family.
Physical Exam:
Admission:
General: Older woman who appears stated ago, NAD, lying flat on
bed
HEENT: EOMI, PERRLA, MMM
Neck: No JVD, no JVP elevation, neck supple, no cervical
lymphadenopathy
Lungs: Decreased breath sounds on R side, L side CTAB @ bases,
b/l ronchi in b/l upper lobes
CV: RRR, distant heart sounds, bradycardic, no murmurs/rubs/or
gallops
Lymph: 0.5 cm x 2 R enlarged supraclaviular node, 0.5 cm x1 L
enlarged supraclavicular node
GI: Soft, nondistended, nonrigid, nontender to palpation
Ext: No lower extremity swelling, distal pulses b/l intact in
UE and ___
___: CNII-XII intact, L eyebrow lower than R eyebrow, no
lower facial droop, ___ strength R grip strength, RUE flexion
and
extension @ elbow, RLE ___ strength on plantar flexion and
dorsiflexion, RUE +antigravity, L grip strength ___, LUE ___
flexion and extension @ elbow joint, LLE +antigravity, LLE
plantar and dorsiflexion ___, A&O grossly
Discharge:
No significant changes
Pertinent Results:
Admission:
___ 06:57AM PTH-106*
___ 06:57AM WBC-13.3* RBC-4.63 HGB-12.1 HCT-36.7 MCV-79*
MCH-26.1 MCHC-33.0 RDW-14.5 RDWSD-41.5
___ 06:57AM PLT COUNT-275
___ 12:05AM ___ PTT-30.5 ___
___ 10:18PM GLUCOSE-110* UREA N-12 CREAT-1.1 SODIUM-146
POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-28 ANION GAP-14
___ 10:18PM estGFR-Using this
___ 10:18PM ALT(SGPT)-7 AST(SGOT)-15 LD(LDH)-362* ALK
PHOS-107* TOT BILI-<0.2
___ 10:18PM ALBUMIN-3.4* CALCIUM-10.5* PHOSPHATE-3.0
MAGNESIUM-2.3 URIC ACID-6.7*
___ 10:18PM WBC-16.9* RBC-4.99 HGB-13.3 HCT-39.5 MCV-79*
MCH-26.7 MCHC-33.7 RDW-14.7 RDWSD-41.8
___ 10:18PM NEUTS-75.3* LYMPHS-18.1* MONOS-5.8 EOS-0.2*
BASOS-0.2 IM ___ AbsNeut-12.72* AbsLymp-3.05 AbsMono-0.98*
AbsEos-0.04 AbsBaso-0.03
___ 10:18PM PLT COUNT-348
Imaging:
CT Chest ___:
IMPRESSION:
Right infrahilar mass with complete occlusion of the right
middle
lobe bronchus with complete atelectasis of the right middle lob,
concerning for bronchogenic carcinoma mediastinal bilateral
hilar
adenopathy. Diffuse enlargement the thyroid with multiple
hypodense areas within it which most likely represent goiter.
Brief Hospital Course:
Mrs. ___ is a ___ female with a medical history notable for
DM2,
HTN, HLD, multiple strokes, inferior MI, tobacco use, and colon
cancer, who presented with 3 weeks of increasing hemoptysis
i/s/o a R hilar lung mass found on CT.
#Hemoptysis, R hilar mass
Her hemoptysis and R hilar mass is concerning for bronchogenic
carcinoma given her history of smoking, colon cancer, and weight
loss. She was stable without hypoxia or respiratory distress.
Her home Plavix and aspirin were held, and her hemoptysis
improved. IP consulted and planned for biopsy
electrocautery/cryo +/- stent placement on ___, ___. She
had a brain MRI on the evening of discharge that showed nothing
acute, though follow-up on final read will be needed. She will
also need a PET-CT for complete staging. She has been told to
hold home Plavix until further notice (last dose ___ but
continue her home aspirin.
#Hypercalcemia
She has a history of primary hyperparathyroidism, but an
elevated calcium level can also be seen as paraneoplastic
syndrome. Her Ca was 10.5 on admission, in the same range as has
been historically. She received her home Vitamin D, but no
specific treatment was started.
# CVA
We held her home Plavix and aspirin per above.
# T2DM
She was on SSI, but did not require any.
# HLD
We continued her home statin.
# Tobacco use
She was given a Nicotine patch.
TRANSITIONAL ISSUES:
====================
[] MRI wet read negative for acute pathology, will need to be
followed up for final read
[] PET/CT scan to complete staging
[] ___, ___ flex and rigid bronchoscopy + EBUS TBNA and
possible stenting
[] Discuss restarting Plavix post-procedurally
[] Smoking cessation discussion
-------------
CODE: Full (confirmed)
CONTACT: ___ (Daughter) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Clopidogrel 75 mg PO DAILY
4. Oxybutynin 5 mg PO DAILY
5. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Oxybutynin 5 mg PO DAILY
4. Vitamin D ___ UNIT PO DAILY
5. HELD- Clopidogrel 75 mg PO DAILY This medication was held.
Do not restart Clopidogrel until you have spoken with your
doctors and it is safe to resume. Certainly, not before ___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Hemoptysis
Secondary: Hypercalcemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___ was a pleasure taking part in your ___ here at ___!
Why was I admitted to the hospital?
You were admitted because you were on blood thinners and were
coughing up blood.
What was done for me while I was in the hospital?
- We were concerned about the blood that you were coughing up,
so we did a number of tests. We also stopped your Plavix, a
medicine that can make you bleed easier - and that helped to
reduce the amount of blood that you were coughing up.
- The lung doctors spoke with ___ about the results of your
recent lung CT, and explained that they will need to get a
sample of tissue in order to find out what is in your lungs.
- You also got a head MRI to look for any changes in your brain.
Since you were stable and did not need to be in the hospital for
any other tests, it was decided that you could go home safely.
What should I do when I leave the hospital?
-You have a bronchoscopy schedule for ___. Please
DO NOT eat after 11:59PM on ___ and do not eat breakfast
or lunch. You can take your morning medicines with water.
-Your appointments are as below
-Please DO NOT TAKE Plavix (clopidogrel) UNTIL after your
procedure with the pulmonary doctors
-___ call Health ___ Associates to make a follow-up
appointment with your primary ___ doctor about this
hospitalization (number below)
Sincerely,
Your ___ ___ Team
Followup Instructions:
___
|
[
"R042",
"E210",
"R918",
"Z8673",
"E119",
"E785",
"F17210",
"I252",
"Z85038",
"J9819"
] |
Allergies: Iodine-Iodine Containing Chief Complaint: hematemesis Major Surgical or Invasive Procedure: None. History of Present Illness: Ms. [MASKED] is a [MASKED] female with medical history notable for DM2, HTN, HLD, multiple strokes on Plavix and aspirin, inferior MI, tobacco use, primary hyperparathyroidism, and colon cancer s/p colectomy and chemotherapy who presented with hemoptysis. Patient was initially seen for hemoptysis at [MASKED] on [MASKED] HPI reported "She first noticed coughing and hemoptysis approximately [MASKED] weeks ago, and noticed very small blood clots at that time. She saw her PCP in clinic on [MASKED] for this, and CT with contrast was ordered, but has not yet been scheduled (note, she has allergy to contrast). Over the past 3 days, she has noticed worsening of her cough, sputum production, and hemoptysis, with large clots on the order of teaspoons. No fevers or chills, shortness of breath, chest pain, or lightheadedness. Has some weight loss. No night sweats, homelessness, or prison exposure. No recent travel, surgery, immobility, [MASKED] swelling/pain. Notes some LUQ abdominal pain that began last night, that is worsened by cough. It is not associated with food, and she has no n/v/d/constipation, and has regular BMs with no hematochezia or melena." A CT chest was obtained which was notable for infrahilar mass with complete occlusion of the right middle lobe. She was not able to connect with her PCP to discuss the results. In the ED, initial VS: Pain 0 Temp 97.7 HR 78 BP 170/88 RR 16 POx 97% RA Exam: O: lung mild wheeze in the RLL. Work-up: Leukocytosis to 16, Elevated Ca [MASKED] She received: PO Oxybutynin 5 mg PO Azithromycin 500 mg IV CefTRIAXone (1 g ordered) Consults: IP: Decision was made to admit for expedited oncology work-up. On arrival to the floor, the patient the endorsed the history per above. In addition, she clarified that she has lost 3 pounds in the past month. She denies any decrease PO intake or abdominal pain. She denies SOB. She says she feels a lot better after receiving medications in the ED. Past Medical History: - prior paramedian pontine infarct ([MASKED]) - right-sided lenticulostriate territory infarct [MASKED] - Hypertension as per prior medical records(patient denies) - Dyslipidemia - Colon cancer 2/p right colectomy in [MASKED] with prolonged stuttering course of adjuvant chemotherapy (diagnosed in setting of GI bleeding) - Cholecystectomy for chronic cholecystitis and gallstones in [MASKED] - Diverticulosis - Hemorrhoids Social History: [MASKED] Family History: Mother had stroke in her [MASKED] or [MASKED]. Her paternal grandfather, father, and brother all had colon cancer. Sister had ovarian cancer and has prostate cancer in her family. Physical Exam: Admission: General: Older woman who appears stated ago, NAD, lying flat on bed HEENT: EOMI, PERRLA, MMM Neck: No JVD, no JVP elevation, neck supple, no cervical lymphadenopathy Lungs: Decreased breath sounds on R side, L side CTAB @ bases, b/l ronchi in b/l upper lobes CV: RRR, distant heart sounds, bradycardic, no murmurs/rubs/or gallops Lymph: 0.5 cm x 2 R enlarged supraclaviular node, 0.5 cm x1 L enlarged supraclavicular node GI: Soft, nondistended, nonrigid, nontender to palpation Ext: No lower extremity swelling, distal pulses b/l intact in UE and [MASKED] [MASKED]: CNII-XII intact, L eyebrow lower than R eyebrow, no lower facial droop, [MASKED] strength R grip strength, RUE flexion and extension @ elbow, RLE [MASKED] strength on plantar flexion and dorsiflexion, RUE +antigravity, L grip strength [MASKED], LUE [MASKED] flexion and extension @ elbow joint, LLE +antigravity, LLE plantar and dorsiflexion [MASKED], A&O grossly Discharge: No significant changes Pertinent Results: Admission: [MASKED] 06:57AM PTH-106* [MASKED] 06:57AM WBC-13.3* RBC-4.63 HGB-12.1 HCT-36.7 MCV-79* MCH-26.1 MCHC-33.0 RDW-14.5 RDWSD-41.5 [MASKED] 06:57AM PLT COUNT-275 [MASKED] 12:05AM [MASKED] PTT-30.5 [MASKED] [MASKED] 10:18PM GLUCOSE-110* UREA N-12 CREAT-1.1 SODIUM-146 POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-28 ANION GAP-14 [MASKED] 10:18PM estGFR-Using this [MASKED] 10:18PM ALT(SGPT)-7 AST(SGOT)-15 LD(LDH)-362* ALK PHOS-107* TOT BILI-<0.2 [MASKED] 10:18PM ALBUMIN-3.4* CALCIUM-10.5* PHOSPHATE-3.0 MAGNESIUM-2.3 URIC ACID-6.7* [MASKED] 10:18PM WBC-16.9* RBC-4.99 HGB-13.3 HCT-39.5 MCV-79* MCH-26.7 MCHC-33.7 RDW-14.7 RDWSD-41.8 [MASKED] 10:18PM NEUTS-75.3* LYMPHS-18.1* MONOS-5.8 EOS-0.2* BASOS-0.2 IM [MASKED] AbsNeut-12.72* AbsLymp-3.05 AbsMono-0.98* AbsEos-0.04 AbsBaso-0.03 [MASKED] 10:18PM PLT COUNT-348 Imaging: CT Chest [MASKED]: IMPRESSION: Right infrahilar mass with complete occlusion of the right middle lobe bronchus with complete atelectasis of the right middle lob, concerning for bronchogenic carcinoma mediastinal bilateral hilar adenopathy. Diffuse enlargement the thyroid with multiple hypodense areas within it which most likely represent goiter. Brief Hospital Course: Mrs. [MASKED] is a [MASKED] female with a medical history notable for DM2, HTN, HLD, multiple strokes, inferior MI, tobacco use, and colon cancer, who presented with 3 weeks of increasing hemoptysis i/s/o a R hilar lung mass found on CT. #Hemoptysis, R hilar mass Her hemoptysis and R hilar mass is concerning for bronchogenic carcinoma given her history of smoking, colon cancer, and weight loss. She was stable without hypoxia or respiratory distress. Her home Plavix and aspirin were held, and her hemoptysis improved. IP consulted and planned for biopsy electrocautery/cryo +/- stent placement on [MASKED], [MASKED]. She had a brain MRI on the evening of discharge that showed nothing acute, though follow-up on final read will be needed. She will also need a PET-CT for complete staging. She has been told to hold home Plavix until further notice (last dose [MASKED] but continue her home aspirin. #Hypercalcemia She has a history of primary hyperparathyroidism, but an elevated calcium level can also be seen as paraneoplastic syndrome. Her Ca was 10.5 on admission, in the same range as has been historically. She received her home Vitamin D, but no specific treatment was started. # CVA We held her home Plavix and aspirin per above. # T2DM She was on SSI, but did not require any. # HLD We continued her home statin. # Tobacco use She was given a Nicotine patch. TRANSITIONAL ISSUES: ==================== [] MRI wet read negative for acute pathology, will need to be followed up for final read [] PET/CT scan to complete staging [] [MASKED], [MASKED] flex and rigid bronchoscopy + EBUS TBNA and possible stenting [] Discuss restarting Plavix post-procedurally [] Smoking cessation discussion ------------- CODE: Full (confirmed) CONTACT: [MASKED] (Daughter) [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 325 mg PO DAILY 2. Atorvastatin 80 mg PO QPM 3. Clopidogrel 75 mg PO DAILY 4. Oxybutynin 5 mg PO DAILY 5. Vitamin D [MASKED] UNIT PO DAILY Discharge Medications: 1. Aspirin 325 mg PO DAILY 2. Atorvastatin 80 mg PO QPM 3. Oxybutynin 5 mg PO DAILY 4. Vitamin D [MASKED] UNIT PO DAILY 5. HELD- Clopidogrel 75 mg PO DAILY This medication was held. Do not restart Clopidogrel until you have spoken with your doctors and it is safe to resume. Certainly, not before [MASKED] Discharge Disposition: Home Discharge Diagnosis: Primary: Hemoptysis Secondary: Hypercalcemia 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 [MASKED] was a pleasure taking part in your [MASKED] here at [MASKED]! Why was I admitted to the hospital? You were admitted because you were on blood thinners and were coughing up blood. What was done for me while I was in the hospital? - We were concerned about the blood that you were coughing up, so we did a number of tests. We also stopped your Plavix, a medicine that can make you bleed easier - and that helped to reduce the amount of blood that you were coughing up. - The lung doctors spoke with [MASKED] about the results of your recent lung CT, and explained that they will need to get a sample of tissue in order to find out what is in your lungs. - You also got a head MRI to look for any changes in your brain. Since you were stable and did not need to be in the hospital for any other tests, it was decided that you could go home safely. What should I do when I leave the hospital? -You have a bronchoscopy schedule for [MASKED]. Please DO NOT eat after 11:59PM on [MASKED] and do not eat breakfast or lunch. You can take your morning medicines with water. -Your appointments are as below -Please DO NOT TAKE Plavix (clopidogrel) UNTIL after your procedure with the pulmonary doctors -[MASKED] call Health [MASKED] Associates to make a follow-up appointment with your primary [MASKED] doctor about this hospitalization (number below) Sincerely, Your [MASKED] [MASKED] Team Followup Instructions: [MASKED]
|
[] |
[
"Z8673",
"E119",
"E785",
"F17210",
"I252"
] |
[
"R042: Hemoptysis",
"E210: Primary hyperparathyroidism",
"R918: Other nonspecific abnormal finding of lung field",
"Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits",
"E119: Type 2 diabetes mellitus without complications",
"E785: Hyperlipidemia, unspecified",
"F17210: Nicotine dependence, cigarettes, uncomplicated",
"I252: Old myocardial infarction",
"Z85038: Personal history of other malignant neoplasm of large intestine",
"J9819: Other pulmonary collapse"
] |
10,003,299 | 27,373,340 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Iodine-Iodine Containing
Attending: ___.
Chief Complaint:
Throat Pain, confusion, worsening L hemiparesis
Major Surgical or Invasive Procedure:
___ and biopsy
History of Present Illness:
Ms. ___ is a ___ w/ stage IIIA squamous cell carcinoma
of lung, s/p completion of concurrent ___ ___,
also w/ a h/o multiple strokes w/ residual left hemiparesis,
HTN,
DL, and prior colon cancer s/p hemicolectomy who is transferred
from ___ for continuity of care.
Dr ___, the oncology service resident, called me for
signout. She presented there on ___ with subacute worsening
of
her chronic L-sided hemiparesis and confusion. She was seen by
neurology and her head CT and brain MRI did not reveal any
new/acute stroke or other acute process. The neurologic symptoms
were therefore felt to be recrudescence of prior stroke symptoms
in the setting of dehydration, deconditioning, malnutrition. She
had a CXR that was concerning for pneumonia. She had a Chest CT
which revealed no pneumonia but did reveal b/l scapular mets.
Her
confusion resolved with some maintenance fluids and her lue
weakness improved. Nutrition and ___ saw her as well.
Her symptoms of poor po intake and esophagitis are known to her
oncology team and they have been working closely together,
respecting her wishes to remain independent at home. She was
even
recently admitted ___ and her sx improved w/ oral liquid
lidocaine formulation. She states this helps and is not taking
it
because she doesn't have it at home.
I spoke w/ her daughter, who is her HCP and she noted that her
mom has been having increased confusion for weeks now at least.
She thinks she may have dementia. She notes that she does have a
new bottle of lidocaine at home. She notes worsening PO intake.
REVIEW OF SYSTEMS: A complete 10-point review of systems was
performed and was negative unless otherwise noted in the HPI.
Past Medical History:
PAST ONCOLOGIC HISTORY:
Briefly, patient initially presented to care in ___ with
hemoptysis. She was subsequently admitted for workup of same and
had a CT of the chest which showed a right infrahilar mass with
complete occlusion of the right middle lobe bronchus and
atelectasis of the right middle lobe with high suspicion for
lung
cancer; there was evidence of bilateral intrathoracic
adenopathy.
During her hospital admission, she was seen by the
interventional
pulmonary team and scheduled for outpatient bronchoscopy.
She underwent bronchoscopy with EBUS under Dr. ___ care on
___. FNA of the right middle lobe mass showed findings
consistent with squamous cell carcinoma; there was biopsy-proven
involvement of the level 4L lymph node; sampling of the 11 L
lymph node showed no malignant cells.
Patient underwent staging PET scan on ___. This showed an
FDG
avid 3.2 cm mass in the right infrahilar region with evidence of
occlusion of the right middle lobe bronchus and atelectasis of
the right middle lobe. FDG avid subcarinal adenopathy measuring
up to 1.3 cm was noted; additionally enlarged mediastinal and
and
hilar lymph nodes are also noted. A 2.2 cm left lower lobe
subpleural FDG avid lesion was also noted. No other distant
metastatic sites of disease were noted.
-___: weekly ___ and radiation started
-___ completed weekly ___ + RT
-___ ED visit for fall, head scrape
-___ ED visit for hypokalemia
-___ Admission for esophagitis
PAST MEDICAL HISTORY:
- H/o paramedian pontine infarct in ___
- H/o right-sided lenticulostriate territory infarct in ___
- Hypertension
- Dyslipidemia
- Colon cancer, s/p right hemicolectomy in ___
- Cholecystectomy for chronic cholecystitis and gallstones in
___
- Diverticulosis
- Hemorrhoids
- Tobacco Abuse
Social History:
___
Family History:
Mother had stroke in her ___ or ___. Her
paternal grandfather, father, and brother all had colon cancer.
Two brothers had gastric cancer. Sister had ovarian cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: Temp 98.3, 74, 140/64, 100% on RA
GENERAL: Pleasant woman, in no distress, lying in bed
omfortably.
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: Soft, non-tender, non-distended, normal bowel sounds.
EXT: Warm, well perfused, no lower extremity edema, erythema or
tenderness.
NEURO: A&Ox3, L temporal field deficit, CN XI weak, ___ LUE,
good
attention and linear thought, CN III-XII otherwise intact but
she
has a mild R facial drop but symmetric smile. Strength ___ RUE
and RLE, but 3+/5 proximal LLE with ___ on plantar flexion and
dorsiflexion. No nystagmus. gait not assessed
SKIN: xerosis on upper extremities
ACCESS: Right chest wall port without erythema, accessed,
dressing c/d/i
DISCHARGE PHYSICAL EXAM:
VS: ___ 0740 Temp: 99.0 PO BP: 133/79 HR: 96 RR: 18 O2 sat:
100% O2 delivery: RA
GENERAL: Pleasant, in no distress, lying in bed comfortably
HEENT: Anicteric sclera, EOMI
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: Soft, non-tender, non-distended, normal bowel sounds.
EXT: Warm, well perfused, no lower extremity edema, erythema or
tenderness.
NEURO: A&Ox3, strength ___ RLE&RUE, ___ LLE&LUE
SKIN: xerosis on upper extremities
ACCESS: Right chest wall port without erythema, accessed,
dressing c/d/i
Pertinent Results:
ADMISSION LABS:
==============
___ 05:39AM BLOOD WBC-21.5* RBC-3.78* Hgb-9.6* Hct-29.9*
MCV-79* MCH-25.4* MCHC-32.1 RDW-23.9* RDWSD-69.0* Plt ___
___ 05:39AM BLOOD Neuts-89.5* Lymphs-5.0* Monos-3.9*
Eos-0.2* Baso-0.3 Im ___ AbsNeut-18.96* AbsLymp-1.07*
AbsMono-0.83* AbsEos-0.04 AbsBaso-0.06
___ 05:39AM BLOOD ___ PTT-30.1 ___
___ 05:39AM BLOOD Glucose-174* UreaN-5* Creat-0.6 Na-145
K-3.6 Cl-107 HCO3-23 AnGap-15
___ 05:39AM BLOOD ALT-21 AST-15 LD(LDH)-343* AlkPhos-240*
TotBili-0.4
___ 05:39AM BLOOD Albumin-2.5* Calcium-9.2 Phos-3.2 Mg-2.0
MICRO:
======
___ c diff stool test - negative
IMAGING/STUDIES:
===============
___ second opinion CT Torso:
1. Within the confines of a motion limited, unenhanced study,
the known,
approximately 1.8 cm right hilar mass appears stable.
2. Stable postobstructive collapse of the right middle lobe in
the setting of
right hilar mass.
3. Stable 3 mm left upper lobe pulmonary nodule. No definite
new or growing
pulmonary nodules.
4. Moderate paraseptal emphysema.
___ right upper extremity US:
1. Nonocclusive thrombus is seen in the right internal jugular
vein.
2. The remaining visualized veins of the right upper extremity
are patent.
___ EGD:
- erythema in middle third of esophagus, consistent with
non-erosive esophagitis
- esophageal hiatal hernia
- erythema and erosion in gastric antrum and stomach body
consistent with non-erosive gastritis
- duodenitis
- ring in the distal esophagus
___ x-rays of pelvis and femurs:
No evidence of lytic or sclerotic lesions within either femur or
pelvis.
DISCHARGE LABS:
==============
___ 05:21AM BLOOD WBC-22.4* RBC-3.44* Hgb-8.8* Hct-27.3*
MCV-79* MCH-25.6* MCHC-32.2 RDW-23.0* RDWSD-65.7* Plt ___
___ 05:21AM BLOOD Plt ___
___ 05:21AM BLOOD Glucose-178* UreaN-8 Creat-0.6 Na-147
K-3.6 Cl-109* HCO3-25 AnGap-13
___ 04:40AM BLOOD ALT-17 AST-13 AlkPhos-242* TotBili-0.4
___ 05:21AM BLOOD Calcium-9.2 Phos-2.7 Mg-2.5
Brief Hospital Course:
SUMMARY:
=========
___ w/ stage IIIA squamous cell carcinoma of lung, s/p
completion of concurrent ___ ___, also w/ a h/o
multiple strokes w/ residual left hemiparesis, HTN, DL, and
prior colon cancer s/p hemicolectomy who is transferred from
___ for continuity of care after presenting
there w/ confusion and worsening LUE weakness.
ACTIVE ISSUES:
============
#Odynophagia/Dysphagia: Most likely radiation esophagitis,
reflux esophagitis. ___ EGD with esophagitis, gastritis,
duodenitis. Gastric biopsy showed H. pylori. She was given
viscous lidocaine with meals, BID PPI, fluids as needed, and a
regular diet. We had long discussions about her goals of care
with both her outpatient oncology team as well as her palliative
care team (detailed below) and it was ultimately decided to not
pursue full antibiotic therapy for H. pylori as her primary
symptom of odynophagia is most likely primarily related to
strictures and radiation esophagitis.
#Failure to thrive
Seems like most likely etiology is poor po intake. Felt to be
due to progressive esophagitis (presumably radiation induced).
She has odynophagia. TSH wnl. No e/o pulmonary infection. UA neg
at OSH. C diff negative this admission. Geriatrics was involved
in the patient's care during this admission. Her throat and body
pain was controlled with IV morphine, and she received viscous
lidocaine to help her eat/drink more comfortably. She was
supported with IVF as needed. ___ and OT evaluated her and
recommended rehab placement however after long discussions of
her GOC and it was decided that she would not want tube feeding
and would like to go home on hospice.
#Nonocclusive thrombus in right IJ
In the setting of being hypercoagulable from malignancy.
HAS-BLED score is 3 (HTN, stroke Hx, age she is at high risk for
major bleeding, but is hypercogulable iso malignancy. The
definitive treatment for her hypercoagulable state is treatment
of her malignancy, if within GOC. Her home ASA/Plavix were
continued, and she was started on enoxaparin 80 mg SC daily,
with the plan to treat for 1 month.
#Stage IIIA Squamous Cell Lung Carcinoma
#Bilateral lytic scapular lesions
Most recent imaging, CT chest on ___, revealed substantial
decrease in size of the pre-existing right hilar mass, which now
measures 20 x 20 mm in diameter. However CT abd revealed "new
1.3 cm hepatic segment VII lesion ... suspicious for
metastasis." ___ elevated this admission, consistent with liver
involvement. Now CT from ___ revealed new bilateral lytic
scapular lesions.
Outpatient team arranging PET scan in ___, with future
cancer treatment directed therapies to be determined. Her
outpatient oncology team (Drs ___ was contacted
with updates. Hip/femur x-rays were obtained to eval for
osseous/lytic lesions (because of delays with scheduling a bone
scan).
#Encephalopathy
She's been having episodes of confusion for some time now per
daughter. She locked herself in the bathroom last week.
"Thetiles have me locked in the bathroom and I can't get out."
But the bathroom was not locked. A few weeks ago, she had left
the stove on during a hot day, and she stated she was heating
food for her son (who was murdered ___. Daughter is
concerned
about dementia. MRI brain did not reveal mets or new stroke.
although pt is oriented x 3, she seems to have poor insight into
reason for admission and her hospitalization. Confusion possibly
also due to impaired sleep (sleeps during day, as lives with her
son who works nights), dehydration, pain from malignancy.
Geriatrics was consulted and assisted with her care. Her
nutrition and hydration status were optimized and her pain was
controlled with IV morphine. She received high dose thiamine for
possible Wernicke's encephalopathy. She received folic acid
repletion for severe protein calorie malnutrition.
CHRONIC/RESOLVED ISSUES:
========================
#Worsening LUE and LLE weakness - stable
#History of CVA w/ residual hemiparesis
Likely recrudescence from prior CVA and improved w/ hydration
and nutrition. Her home aspirin, Plavix, and atorvastatin were
continued. Her neurologic status was checked daily. She was
started on Lovenox ___aily.
#Severe protein calorie malnutrition:
- Nutrition was consulted. She received a regular diet, high
dose thiamine, folic acid and MVI. Her electrolytes were
monitored daily and repleted as needed.
#Tobacco Abuse: Continued nicotine patch.
TRANSITIONAL ISSUES:
====================
[] Due to esophageal spasms seen during EGD, outpatient
esophageal mannometry should be considered to further work up
her dysphagia/odynophagia.
[] Consider starting a bisphosphonate, if osseous metastases are
confirmed through bone scan/bone biopsy.
Code status: DNR/DNI
EMERGENCY CONTACT HCP: ___ (daughter)
___
This patient was prescribed, or continued on, an opioid pain
medication at the time of discharge (please see the attached
medication list for details). As part of our safe opioid
prescribing process, all patients are provided with an opioid
risks and treatment resource education sheet and encouraged to
discuss this therapy with their outpatient providers to
determine if opioid pain medication is still indicated.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Nicotine Patch 21 mg/day TD DAILY
2. Cyanocobalamin ___ mcg PO DAILY
3. Multivitamins W/minerals 1 TAB PO DAILY
4. Lidocaine Viscous 2% 15 mL PO QID:PRN throat pain
5. Potassium Chloride (Powder) 20 mEq PO DAILY
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 40 mg PO QPM
8. Oxybutynin 5 mg PO DAILY
9. Clopidogrel 75 mg PO DAILY
Discharge Medications:
1. Enoxaparin Sodium 80 mg SC DAILY
RX *enoxaparin 80 mg/0.8 mL 80 mg SC daily Disp #*30 Syringe
Refills:*3
2. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL 10 mg
PO Q4H:PRN Pain - Severe
RX *morphine concentrate 100 mg/5 mL (20 mg/mL) 10 mg by mouth
q4hrs PRN Refills:*0
3. Naloxone Nasal Spray 4 mg IH ONCE MR1 Duration: 1 Dose
RX *naloxone [Narcan] 4 mg/actuation 1 spray nasal once AS
NEEDED Disp #*1 Spray Refills:*0
4. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*3
5. Lidocaine Viscous 2% 15 mL PO QID:PRN throat pain
6. Nicotine Patch 21 mg/day TD DAILY
7. Oxybutynin 5 mg PO DAILY
8. Potassium Chloride (Powder) 20 mEq PO DAILY
Hold for K > 4.0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
==================
1) Odynophagia/Dysphagia
2) Failure to Thrive
3) H pylori gastritis
4) Stage IIA squamous cell carcinoma of the lung
5) Non-occlusive thrombus of the right IJ
6) Severe protein calorie malnutrition
Secondary Diagnosis
===================
1) History of CVA
2) Tobacco Abuse
Discharge Condition:
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were having pain in your throat and body. You were not
getting enough to eat and drink. Because of this, you were
weaker than usual, which made your old stroke symptoms seem
worse. Your children were concerned that you were more confused
than usual.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You received scans to make sure that you did not have a new
stroke.
- You were watched closely for signs of infection.
- You were supported with fluids and nutritious food.
- You underwent an endoscopy procedure, which showed a lot of
inflammation that is probably causing your swallowing pain. You
were given liquid lidocaine for throat pain, as well as an acid
blocker medicine.
- Your body pain was treated with morphine.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
[
"K208",
"E43",
"I82C11",
"C342",
"D6869",
"E512",
"I69354",
"R627",
"K2950",
"B9681",
"E860",
"K222",
"I10",
"K224",
"K449",
"K2980",
"F17210",
"Z66",
"Z6822",
"Y842",
"Y92009",
"Z9221",
"Z7901",
"Z85038",
"Z9049"
] |
Allergies: Iodine-Iodine Containing Chief Complaint: Throat Pain, confusion, worsening L hemiparesis Major Surgical or Invasive Procedure: [MASKED] and biopsy History of Present Illness: Ms. [MASKED] is a [MASKED] w/ stage IIIA squamous cell carcinoma of lung, s/p completion of concurrent [MASKED] [MASKED], also w/ a h/o multiple strokes w/ residual left hemiparesis, HTN, DL, and prior colon cancer s/p hemicolectomy who is transferred from [MASKED] for continuity of care. Dr [MASKED], the oncology service resident, called me for signout. She presented there on [MASKED] with subacute worsening of her chronic L-sided hemiparesis and confusion. She was seen by neurology and her head CT and brain MRI did not reveal any new/acute stroke or other acute process. The neurologic symptoms were therefore felt to be recrudescence of prior stroke symptoms in the setting of dehydration, deconditioning, malnutrition. She had a CXR that was concerning for pneumonia. She had a Chest CT which revealed no pneumonia but did reveal b/l scapular mets. Her confusion resolved with some maintenance fluids and her lue weakness improved. Nutrition and [MASKED] saw her as well. Her symptoms of poor po intake and esophagitis are known to her oncology team and they have been working closely together, respecting her wishes to remain independent at home. She was even recently admitted [MASKED] and her sx improved w/ oral liquid lidocaine formulation. She states this helps and is not taking it because she doesn't have it at home. I spoke w/ her daughter, who is her HCP and she noted that her mom has been having increased confusion for weeks now at least. She thinks she may have dementia. She notes that she does have a new bottle of lidocaine at home. She notes worsening PO intake. REVIEW OF SYSTEMS: A complete 10-point review of systems was performed and was negative unless otherwise noted in the HPI. Past Medical History: PAST ONCOLOGIC HISTORY: Briefly, patient initially presented to care in [MASKED] with hemoptysis. She was subsequently admitted for workup of same and had a CT of the chest which showed a right infrahilar mass with complete occlusion of the right middle lobe bronchus and atelectasis of the right middle lobe with high suspicion for lung cancer; there was evidence of bilateral intrathoracic adenopathy. During her hospital admission, she was seen by the interventional pulmonary team and scheduled for outpatient bronchoscopy. She underwent bronchoscopy with EBUS under Dr. [MASKED] care on [MASKED]. FNA of the right middle lobe mass showed findings consistent with squamous cell carcinoma; there was biopsy-proven involvement of the level 4L lymph node; sampling of the 11 L lymph node showed no malignant cells. Patient underwent staging PET scan on [MASKED]. This showed an FDG avid 3.2 cm mass in the right infrahilar region with evidence of occlusion of the right middle lobe bronchus and atelectasis of the right middle lobe. FDG avid subcarinal adenopathy measuring up to 1.3 cm was noted; additionally enlarged mediastinal and and hilar lymph nodes are also noted. A 2.2 cm left lower lobe subpleural FDG avid lesion was also noted. No other distant metastatic sites of disease were noted. -[MASKED]: weekly [MASKED] and radiation started -[MASKED] completed weekly [MASKED] + RT -[MASKED] ED visit for fall, head scrape -[MASKED] ED visit for hypokalemia -[MASKED] Admission for esophagitis PAST MEDICAL HISTORY: - H/o paramedian pontine infarct in [MASKED] - H/o right-sided lenticulostriate territory infarct in [MASKED] - Hypertension - Dyslipidemia - Colon cancer, s/p right hemicolectomy in [MASKED] - Cholecystectomy for chronic cholecystitis and gallstones in [MASKED] - Diverticulosis - Hemorrhoids - Tobacco Abuse Social History: [MASKED] Family History: Mother had stroke in her [MASKED] or [MASKED]. Her paternal grandfather, father, and brother all had colon cancer. Two brothers had gastric cancer. Sister had ovarian cancer. Physical Exam: ADMISSION PHYSICAL EXAM: VS: Temp 98.3, 74, 140/64, 100% on RA GENERAL: Pleasant woman, in no distress, lying in bed omfortably. 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: Soft, non-tender, non-distended, normal bowel sounds. EXT: Warm, well perfused, no lower extremity edema, erythema or tenderness. NEURO: A&Ox3, L temporal field deficit, CN XI weak, [MASKED] LUE, good attention and linear thought, CN III-XII otherwise intact but she has a mild R facial drop but symmetric smile. Strength [MASKED] RUE and RLE, but 3+/5 proximal LLE with [MASKED] on plantar flexion and dorsiflexion. No nystagmus. gait not assessed SKIN: xerosis on upper extremities ACCESS: Right chest wall port without erythema, accessed, dressing c/d/i DISCHARGE PHYSICAL EXAM: VS: [MASKED] 0740 Temp: 99.0 PO BP: 133/79 HR: 96 RR: 18 O2 sat: 100% O2 delivery: RA GENERAL: Pleasant, in no distress, lying in bed comfortably HEENT: Anicteric sclera, EOMI 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: Soft, non-tender, non-distended, normal bowel sounds. EXT: Warm, well perfused, no lower extremity edema, erythema or tenderness. NEURO: A&Ox3, strength [MASKED] RLE&RUE, [MASKED] LLE&LUE SKIN: xerosis on upper extremities ACCESS: Right chest wall port without erythema, accessed, dressing c/d/i Pertinent Results: ADMISSION LABS: ============== [MASKED] 05:39AM BLOOD WBC-21.5* RBC-3.78* Hgb-9.6* Hct-29.9* MCV-79* MCH-25.4* MCHC-32.1 RDW-23.9* RDWSD-69.0* Plt [MASKED] [MASKED] 05:39AM BLOOD Neuts-89.5* Lymphs-5.0* Monos-3.9* Eos-0.2* Baso-0.3 Im [MASKED] AbsNeut-18.96* AbsLymp-1.07* AbsMono-0.83* AbsEos-0.04 AbsBaso-0.06 [MASKED] 05:39AM BLOOD [MASKED] PTT-30.1 [MASKED] [MASKED] 05:39AM BLOOD Glucose-174* UreaN-5* Creat-0.6 Na-145 K-3.6 Cl-107 HCO3-23 AnGap-15 [MASKED] 05:39AM BLOOD ALT-21 AST-15 LD(LDH)-343* AlkPhos-240* TotBili-0.4 [MASKED] 05:39AM BLOOD Albumin-2.5* Calcium-9.2 Phos-3.2 Mg-2.0 MICRO: ====== [MASKED] c diff stool test - negative IMAGING/STUDIES: =============== [MASKED] second opinion CT Torso: 1. Within the confines of a motion limited, unenhanced study, the known, approximately 1.8 cm right hilar mass appears stable. 2. Stable postobstructive collapse of the right middle lobe in the setting of right hilar mass. 3. Stable 3 mm left upper lobe pulmonary nodule. No definite new or growing pulmonary nodules. 4. Moderate paraseptal emphysema. [MASKED] right upper extremity US: 1. Nonocclusive thrombus is seen in the right internal jugular vein. 2. The remaining visualized veins of the right upper extremity are patent. [MASKED] EGD: - erythema in middle third of esophagus, consistent with non-erosive esophagitis - esophageal hiatal hernia - erythema and erosion in gastric antrum and stomach body consistent with non-erosive gastritis - duodenitis - ring in the distal esophagus [MASKED] x-rays of pelvis and femurs: No evidence of lytic or sclerotic lesions within either femur or pelvis. DISCHARGE LABS: ============== [MASKED] 05:21AM BLOOD WBC-22.4* RBC-3.44* Hgb-8.8* Hct-27.3* MCV-79* MCH-25.6* MCHC-32.2 RDW-23.0* RDWSD-65.7* Plt [MASKED] [MASKED] 05:21AM BLOOD Plt [MASKED] [MASKED] 05:21AM BLOOD Glucose-178* UreaN-8 Creat-0.6 Na-147 K-3.6 Cl-109* HCO3-25 AnGap-13 [MASKED] 04:40AM BLOOD ALT-17 AST-13 AlkPhos-242* TotBili-0.4 [MASKED] 05:21AM BLOOD Calcium-9.2 Phos-2.7 Mg-2.5 Brief Hospital Course: SUMMARY: ========= [MASKED] w/ stage IIIA squamous cell carcinoma of lung, s/p completion of concurrent [MASKED] [MASKED], also w/ a h/o multiple strokes w/ residual left hemiparesis, HTN, DL, and prior colon cancer s/p hemicolectomy who is transferred from [MASKED] for continuity of care after presenting there w/ confusion and worsening LUE weakness. ACTIVE ISSUES: ============ #Odynophagia/Dysphagia: Most likely radiation esophagitis, reflux esophagitis. [MASKED] EGD with esophagitis, gastritis, duodenitis. Gastric biopsy showed H. pylori. She was given viscous lidocaine with meals, BID PPI, fluids as needed, and a regular diet. We had long discussions about her goals of care with both her outpatient oncology team as well as her palliative care team (detailed below) and it was ultimately decided to not pursue full antibiotic therapy for H. pylori as her primary symptom of odynophagia is most likely primarily related to strictures and radiation esophagitis. #Failure to thrive Seems like most likely etiology is poor po intake. Felt to be due to progressive esophagitis (presumably radiation induced). She has odynophagia. TSH wnl. No e/o pulmonary infection. UA neg at OSH. C diff negative this admission. Geriatrics was involved in the patient's care during this admission. Her throat and body pain was controlled with IV morphine, and she received viscous lidocaine to help her eat/drink more comfortably. She was supported with IVF as needed. [MASKED] and OT evaluated her and recommended rehab placement however after long discussions of her GOC and it was decided that she would not want tube feeding and would like to go home on hospice. #Nonocclusive thrombus in right IJ In the setting of being hypercoagulable from malignancy. HAS-BLED score is 3 (HTN, stroke Hx, age she is at high risk for major bleeding, but is hypercogulable iso malignancy. The definitive treatment for her hypercoagulable state is treatment of her malignancy, if within GOC. Her home ASA/Plavix were continued, and she was started on enoxaparin 80 mg SC daily, with the plan to treat for 1 month. #Stage IIIA Squamous Cell Lung Carcinoma #Bilateral lytic scapular lesions Most recent imaging, CT chest on [MASKED], revealed substantial decrease in size of the pre-existing right hilar mass, which now measures 20 x 20 mm in diameter. However CT abd revealed "new 1.3 cm hepatic segment VII lesion ... suspicious for metastasis." [MASKED] elevated this admission, consistent with liver involvement. Now CT from [MASKED] revealed new bilateral lytic scapular lesions. Outpatient team arranging PET scan in [MASKED], with future cancer treatment directed therapies to be determined. Her outpatient oncology team (Drs [MASKED] was contacted with updates. Hip/femur x-rays were obtained to eval for osseous/lytic lesions (because of delays with scheduling a bone scan). #Encephalopathy She's been having episodes of confusion for some time now per daughter. She locked herself in the bathroom last week. "Thetiles have me locked in the bathroom and I can't get out." But the bathroom was not locked. A few weeks ago, she had left the stove on during a hot day, and she stated she was heating food for her son (who was murdered [MASKED]. Daughter is concerned about dementia. MRI brain did not reveal mets or new stroke. although pt is oriented x 3, she seems to have poor insight into reason for admission and her hospitalization. Confusion possibly also due to impaired sleep (sleeps during day, as lives with her son who works nights), dehydration, pain from malignancy. Geriatrics was consulted and assisted with her care. Her nutrition and hydration status were optimized and her pain was controlled with IV morphine. She received high dose thiamine for possible Wernicke's encephalopathy. She received folic acid repletion for severe protein calorie malnutrition. CHRONIC/RESOLVED ISSUES: ======================== #Worsening LUE and LLE weakness - stable #History of CVA w/ residual hemiparesis Likely recrudescence from prior CVA and improved w/ hydration and nutrition. Her home aspirin, Plavix, and atorvastatin were continued. Her neurologic status was checked daily. She was started on Lovenox aily. #Severe protein calorie malnutrition: - Nutrition was consulted. She received a regular diet, high dose thiamine, folic acid and MVI. Her electrolytes were monitored daily and repleted as needed. #Tobacco Abuse: Continued nicotine patch. TRANSITIONAL ISSUES: ==================== [] Due to esophageal spasms seen during EGD, outpatient esophageal mannometry should be considered to further work up her dysphagia/odynophagia. [] Consider starting a bisphosphonate, if osseous metastases are confirmed through bone scan/bone biopsy. Code status: DNR/DNI EMERGENCY CONTACT HCP: [MASKED] (daughter) [MASKED] This patient was prescribed, or continued on, an opioid pain medication at the time of discharge (please see the attached medication list for details). As part of our safe opioid prescribing process, all patients are provided with an opioid risks and treatment resource education sheet and encouraged to discuss this therapy with their outpatient providers to determine if opioid pain medication is still indicated. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Nicotine Patch 21 mg/day TD DAILY 2. Cyanocobalamin [MASKED] mcg PO DAILY 3. Multivitamins W/minerals 1 TAB PO DAILY 4. Lidocaine Viscous 2% 15 mL PO QID:PRN throat pain 5. Potassium Chloride (Powder) 20 mEq PO DAILY 6. Aspirin 81 mg PO DAILY 7. Atorvastatin 40 mg PO QPM 8. Oxybutynin 5 mg PO DAILY 9. Clopidogrel 75 mg PO DAILY Discharge Medications: 1. Enoxaparin Sodium 80 mg SC DAILY RX *enoxaparin 80 mg/0.8 mL 80 mg SC daily Disp #*30 Syringe Refills:*3 2. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL 10 mg PO Q4H:PRN Pain - Severe RX *morphine concentrate 100 mg/5 mL (20 mg/mL) 10 mg by mouth q4hrs PRN Refills:*0 3. Naloxone Nasal Spray 4 mg IH ONCE MR1 Duration: 1 Dose RX *naloxone [Narcan] 4 mg/actuation 1 spray nasal once AS NEEDED Disp #*1 Spray Refills:*0 4. Omeprazole 40 mg PO DAILY RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*3 5. Lidocaine Viscous 2% 15 mL PO QID:PRN throat pain 6. Nicotine Patch 21 mg/day TD DAILY 7. Oxybutynin 5 mg PO DAILY 8. Potassium Chloride (Powder) 20 mEq PO DAILY Hold for K > 4.0 Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Primary Diagnosis ================== 1) Odynophagia/Dysphagia 2) Failure to Thrive 3) H pylori gastritis 4) Stage IIA squamous cell carcinoma of the lung 5) Non-occlusive thrombus of the right IJ 6) Severe protein calorie malnutrition Secondary Diagnosis =================== 1) History of CVA 2) Tobacco Abuse Discharge Condition: Level of Consciousness: Alert and interactive. Mental Status: Clear and coherent. Activity Status: Bedbound. Discharge Instructions: Dear Ms. [MASKED], It was a pleasure caring for you at [MASKED] [MASKED]. WHY WAS I IN THE HOSPITAL? - You were having pain in your throat and body. You were not getting enough to eat and drink. Because of this, you were weaker than usual, which made your old stroke symptoms seem worse. Your children were concerned that you were more confused than usual. WHAT HAPPENED TO ME IN THE HOSPITAL? - You received scans to make sure that you did not have a new stroke. - You were watched closely for signs of infection. - You were supported with fluids and nutritious food. - You underwent an endoscopy procedure, which showed a lot of inflammation that is probably causing your swallowing pain. You were given liquid lidocaine for throat pain, as well as an acid blocker medicine. - Your body pain was treated with morphine. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Continue to take all your medicines and keep your appointments. We wish you the best! Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]
|
[] |
[
"I10",
"F17210",
"Z66",
"Z7901"
] |
[
"K208: Other esophagitis",
"E43: Unspecified severe protein-calorie malnutrition",
"I82C11: Acute embolism and thrombosis of right internal jugular vein",
"C342: Malignant neoplasm of middle lobe, bronchus or lung",
"D6869: Other thrombophilia",
"E512: Wernicke's encephalopathy",
"I69354: Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side",
"R627: Adult failure to thrive",
"K2950: Unspecified chronic gastritis without bleeding",
"B9681: Helicobacter pylori [H. pylori] as the cause of diseases classified elsewhere",
"E860: Dehydration",
"K222: Esophageal obstruction",
"I10: Essential (primary) hypertension",
"K224: Dyskinesia of esophagus",
"K449: Diaphragmatic hernia without obstruction or gangrene",
"K2980: Duodenitis without bleeding",
"F17210: Nicotine dependence, cigarettes, uncomplicated",
"Z66: Do not resuscitate",
"Z6822: Body mass index [BMI] 22.0-22.9, adult",
"Y842: Radiological procedure and radiotherapy as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure",
"Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause",
"Z9221: Personal history of antineoplastic chemotherapy",
"Z7901: Long term (current) use of anticoagulants",
"Z85038: Personal history of other malignant neoplasm of large intestine",
"Z9049: Acquired absence of other specified parts of digestive tract"
] |
10,003,299 | 29,323,205 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Iodine-Iodine Containing
Attending: ___.
Chief Complaint:
left leg weakness, falls
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ RH female with a PMHx of
paramedian pontine infarct (___), right-sided lenticulostriate
territory infarct (___), multiple strokes in the right
posterior
MCA/PCA watershed region (thought to be cardioembolic but no
source identified, ___, followed by Dr. ___, on
Plavix and ASA), hypertension, hyperlipidemia, prior MI, colon
cancer s/p resection and chemotherapy in ___, extensive tobacco
use, recent DM diagnosis, and recent diagnosis of B12 deficiency
who presents with ___ weeks of frequent falls and 4 weeks of
left
leg weakness.
The left leg weakness was gradual in onset and began about 4
weeks ago; it has remained relatively stable. She now needs help
getting off a toilet or up off of chairs. The falls occur when
she is pivoting while using her cane, and she has had 5 falls in
the last week including once into her bathtub. Her legs feel
like
"they get tangled up." She has only landed on her bottom; no
headstrikes or LOC. No prodrome prior to falls. She also has
baseline LUE weakness that remains unchanged since her strokes
in
___ she has trouble twisting caps and opening jars, but
she
does not have trouble reaching up. Denies missing Plavix doses.
Missed ___ doses of atorvastatin since starting it.
She has also had urinary and fecal incontinence (3 months per
prior notes; since last stroke in ___ per patient); per
prior notes, she loses control just after getting the urge to
urinate or move her bowels; today, she says she sometimes does
not get the urge to go. She sometimes does not have time to make
it to the bathroom, but this is not the chief reason for
incontinence. Reports 2 days of lower back pain (midline).
Denies
saddle anesthesia.
She was seen by her PCP ___ she was noted to be dragging her
left foot on the ground and she was noted to have left ankle
dorsiflexion>plantarflexion, knee flexion/extension, and hip
flexion/extension weakness with more brisk reflexes on that
side.
Per ED, she was noted to have ___ left hip flexion, 4+ hip
extension, 4+ knee extension, upgoing toes on left, left arm."
Of note, she last saw Dr. ___ in ___ in clinic.
At
that time, she was noted to have SCM weakness, mild L pronation
with upward drift, and ___ left deltoid strength. She had brisk
reflexes at left biceps and patella, and her plantar response
was
mute bilaterally. She also had a broad-based gait with small
steps that was safe. She was continued on Plavix 75mg daily, and
a stronger statin was recommended, but the patient preferred to
stay on rosuvastatin (Crestor).
+:Left facial droop noticed during sleep by daughter one week
which subsequently resolved (date of resolution unknown), per
patient
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus, and hearing difficulty. Denies difficulties
producing or comprehending speech. Denies focal numbness and
parasthesiae.
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 dysuria. Denies arthralgias or myalgias.
Denies rash.
Past Medical History:
- prior paramedian pontine infarct (___)
- right-sided lenticulostriate territory infarct ___
- Hypertension as per prior medical records(patient denies)
- Dyslipidemia
- Colon cancer 2/p right colectomy in ___ with prolonged
stuttering course of adjuvant chemotherapy (diagnosed in setting
of GI bleeding)
- Cholecystectomy for chronic cholecystitis and gallstones in
___
- Diverticulosis
- Hemorrhoids
Social History:
___
Family History:
Mother had stroke in her ___ or ___. Her paternal
grandfather,
father, and brother all had colon cancer. Sister had ovarian
cancer and has prostate cancer in her family.
Physical Exam:
Admission Exam:
Vitals: T: 97.4 P: 65 R: 16 BP: 153/70 SaO2: 97%RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
NIHSS as above.
-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. Pt was able to
register 3 objects and recall ___ at 5 minutes ___ with
prompting). There was no evidence of apraxia or neglect. No
cortical sensory loss.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation. Visual acuity
___ bilaterally. Fundoscopic exam revealed no papilledema,
exudates, or hemorrhages.
V: Facial sensation intact to light touch.
VII: Mild L NLFF.
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 and tone. Subtle LUE pronation without
drift.
RUE orbiting around left. No adventitious movements, such as
tremor, noted. No asterixis noted.
[___]
[C5] [C5] [C7] [C6] [C7] [T1][L2] [L3] [L5] [L4] [S1][L5]
L 5- 5 5 5 5 5 4+ 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, cold sensation,
vibratory sense. ___ errors to proprioception in LLE. No
extinction to DSS. No spinal sensory level.
-DTRs: brisk diffusely L>R. Left toe upgoing, right downgoing.
-Coordination: Missed target mildly with RUE on FNF. RAM slow
bilaterally. FNF ok. HKS ok.
-Gait: Dragging left leg when ambulating with some
circumduction.
******************
Discharge exam:
Vitals: T: 97.4 P: 65 R: 16 BP: 164/70 SaO2: 97%RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
NIHSS as above.
-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. Normal saccades. VFF to confrontation. Visual acuity
___ bilaterally.
V: Facial sensation intact to light touch.
VII: 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 and tone. Subtle LUE pronation without
drift.
RUE orbiting around left. No adventitious movements, such as
tremor, noted. No asterixis noted.
[___]
[C5] [C5] [C7] [C6] [C7] [T1][L2] [L3] [L5] [L4] [S1][L5]
L 5- 5 5 5 4 5 5 5 5 ___
R 5 5 5 5 5 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense. Intact proprioception b/l. No
extinction to DSS. No spinal sensory level.
-DTRs: brisk diffusely L>R. Left toe upgoing, right downgoing.
-Coordination: Missed target mildly with RUE on FNF. RAM slow
bilaterally. FNF ok. HKS ok.
-Gait: Dragging left leg but stable with cane
Pertinent Results:
___ 01:10PM GLUCOSE-125* UREA N-9 CREAT-0.9 SODIUM-144
POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-26 ANION GAP-17
___ 01:10PM estGFR-Using this
___ 01:10PM ALT(SGPT)-18 AST(SGOT)-30 ALK PHOS-97 TOT
BILI-0.5
___ 01:10PM ALBUMIN-3.7 CALCIUM-11.2* PHOSPHATE-3.4
MAGNESIUM-2.3
___ 01:10PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
___ 01:10PM WBC-9.4 RBC-4.87 HGB-13.4 HCT-41.0 MCV-84
MCH-27.5 MCHC-32.7 RDW-14.4 RDWSD-44.0
___ 01:10PM NEUTS-64.6 ___ MONOS-5.8 EOS-0.5*
BASOS-0.2 IM ___ AbsNeut-6.06 AbsLymp-2.68 AbsMono-0.54
AbsEos-0.05 AbsBaso-0.02
___ 01:10PM PLT COUNT-276
CT head
IMPRESSION:
1. Small right caudate hypodensity/lacunar infarct is new from
___, but
otherwise appears chronic to possibly subacute, lacunar infarct.
Correlate
with clinical symptoms. MRI is more sensitive in detecting
acute ischemia.
2. Sequelae of prior right frontal lobe infarct and left pontine
infarct.
3. Nonspecific bilateral white matter changes are similar the
prior exam and
consistent with sequelae of chronic small vessel ischemic
disease.
4. No acute intracranial hemorrhage.
5. Cortical atrophy.
CXR
IMPRESSION:
No focal consolidation to suggest pneumonia. Possible minimal
pulmonary
vascular congestion. Stable mild cardiomegaly.
MRI/MRA brain and neck
IMPRESSION:
1. Substantially motion limited exam.
2. Punctate, likely subacute infarcts of the right frontal
periventricular
white matter, posterior limb of the right internal capsule or
right thalamus ,
and right periatrial white matter.
3. Chronic right frontal cortical infarct is again seen.
Extensive
supratentorial white matter signal abnormalities, similar to
prior,
nonspecific but likely sequela of chronic small vessel ischemic
disease in
this age group.
4. Nondominant left vertebral artery is diminutive and not
adequately assessed
on this motion limited exam. 0
5. Atherosclerosis of the proximal right internal carotid artery
is again seen
but could be exaggerated by artifact. Apparent irregularity of
the left
proximal internal carotid artery, of the V2 and V3 segments of
the right
vertebral artery, of the left greater than right carotid
siphons, and of the
distal M1 and M2 segments of the left middle cerebral artery
probably
represents a combination of atherosclerosis and artifacts.
Brief Hospital Course:
___ RH female with a PMHx of paramedian pontine infarct (___),
right-sided lenticulostriate territory infarct (___), multiple
strokes in the right posterior MCA/PCA watershed region (thought
to be cardioembolic but no source identified, ___
Plavix and ASA, HTN, HLD, prior MI, colon cancer s/p resection
and chemotherapy in ___, extensive tobacco use, recent DM
diagnosis, and recent diagnosis of B12 deficiency presents with
4 week hx of progressively worsening left leg weakness and
falls. On exam she had no signs of neuropathy, intact sensation
to light touch, temperature and Pin Prick as well as intact
proprioception. CT Head with right caudate hypodensity of
indeterminate age, but appears subacute/chronic. MRI/MRA brain
and neck with punctate, likely subacute infarcts of the right
frontal periventricular white matter, posterior limb of the
right internal capsule or right thalamus and right periatrial
white matter.
Etiology most likely secondary to known intracranial athero seen
on imaging vs. small vessel disease. Patient already on
appropriate secondary stroke prophylaxis and thus no changes to
her medications were made. She was evaluated by physical therapy
who recommended home ___.
Stroke risk factors: LDL 48, A1C6.6
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 =48 ) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) (x) Yes - () No [if
LDL >100, reason not given: ]
6. Smoking cessation counseling given? (x) Yes - () No [reason
() non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Oxybutynin 5 mg PO DAILY
3. MetFORMIN (Glucophage) 500 mg PO DAILY
4. Vitamin D 1000 UNIT PO DAILY
5. Clopidogrel 75 mg PO DAILY
6. Atorvastatin 80 mg PO QPM
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Clopidogrel 75 mg PO DAILY
4. MetFORMIN (Glucophage) 500 mg PO DAILY
5. Oxybutynin 5 mg PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Ischemic stroke
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 ___ were hospitalized due to symptoms of left leg weakness and
falls resulting from 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.
Stroke can have many different causes, so we assessed ___ for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
HTN
atherosclerotic disease
No changes to your medications were made since ___ are already
on the appropriate secondary stroke prevention.
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If ___ experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
___
- 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:
___
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Allergies: Iodine-Iodine Containing Chief Complaint: left leg weakness, falls Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] is a [MASKED] RH female with a PMHx of paramedian pontine infarct ([MASKED]), right-sided lenticulostriate territory infarct ([MASKED]), multiple strokes in the right posterior MCA/PCA watershed region (thought to be cardioembolic but no source identified, [MASKED], followed by Dr. [MASKED], on Plavix and ASA), hypertension, hyperlipidemia, prior MI, colon cancer s/p resection and chemotherapy in [MASKED], extensive tobacco use, recent DM diagnosis, and recent diagnosis of B12 deficiency who presents with [MASKED] weeks of frequent falls and 4 weeks of left leg weakness. The left leg weakness was gradual in onset and began about 4 weeks ago; it has remained relatively stable. She now needs help getting off a toilet or up off of chairs. The falls occur when she is pivoting while using her cane, and she has had 5 falls in the last week including once into her bathtub. Her legs feel like "they get tangled up." She has only landed on her bottom; no headstrikes or LOC. No prodrome prior to falls. She also has baseline LUE weakness that remains unchanged since her strokes in [MASKED] she has trouble twisting caps and opening jars, but she does not have trouble reaching up. Denies missing Plavix doses. Missed [MASKED] doses of atorvastatin since starting it. She has also had urinary and fecal incontinence (3 months per prior notes; since last stroke in [MASKED] per patient); per prior notes, she loses control just after getting the urge to urinate or move her bowels; today, she says she sometimes does not get the urge to go. She sometimes does not have time to make it to the bathroom, but this is not the chief reason for incontinence. Reports 2 days of lower back pain (midline). Denies saddle anesthesia. She was seen by her PCP [MASKED] she was noted to be dragging her left foot on the ground and she was noted to have left ankle dorsiflexion>plantarflexion, knee flexion/extension, and hip flexion/extension weakness with more brisk reflexes on that side. Per ED, she was noted to have [MASKED] left hip flexion, 4+ hip extension, 4+ knee extension, upgoing toes on left, left arm." Of note, she last saw Dr. [MASKED] in [MASKED] in clinic. At that time, she was noted to have SCM weakness, mild L pronation with upward drift, and [MASKED] left deltoid strength. She had brisk reflexes at left biceps and patella, and her plantar response was mute bilaterally. She also had a broad-based gait with small steps that was safe. She was continued on Plavix 75mg daily, and a stronger statin was recommended, but the patient preferred to stay on rosuvastatin (Crestor). +:Left facial droop noticed during sleep by daughter one week which subsequently resolved (date of resolution unknown), per patient On neuro ROS, the pt denies headache, loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus, and hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal numbness and parasthesiae. 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 dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: - prior paramedian pontine infarct ([MASKED]) - right-sided lenticulostriate territory infarct [MASKED] - Hypertension as per prior medical records(patient denies) - Dyslipidemia - Colon cancer 2/p right colectomy in [MASKED] with prolonged stuttering course of adjuvant chemotherapy (diagnosed in setting of GI bleeding) - Cholecystectomy for chronic cholecystitis and gallstones in [MASKED] - Diverticulosis - Hemorrhoids Social History: [MASKED] Family History: Mother had stroke in her [MASKED] or [MASKED]. Her paternal grandfather, father, and brother all had colon cancer. Sister had ovarian cancer and has prostate cancer in her family. Physical Exam: Admission Exam: Vitals: T: 97.4 P: 65 R: 16 BP: 153/70 SaO2: 97%RA General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: NIHSS as above. -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name [MASKED] backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt was able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. Pt was able to register 3 objects and recall [MASKED] at 5 minutes [MASKED] with prompting). There was no evidence of apraxia or neglect. No cortical sensory loss. -Cranial Nerves: II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without nystagmus. Normal saccades. VFF to confrontation. Visual acuity [MASKED] bilaterally. Fundoscopic exam revealed no papilledema, exudates, or hemorrhages. V: Facial sensation intact to light touch. VII: Mild L NLFF. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: [MASKED] strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk and tone. Subtle LUE pronation without drift. RUE orbiting around left. No adventitious movements, such as tremor, noted. No asterixis noted. [[MASKED]] [C5] [C5] [C7] [C6] [C7] [T1][L2] [L3] [L5] [L4] [S1][L5] L 5- 5 5 5 5 5 4+ 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, cold sensation, vibratory sense. [MASKED] errors to proprioception in LLE. No extinction to DSS. No spinal sensory level. -DTRs: brisk diffusely L>R. Left toe upgoing, right downgoing. -Coordination: Missed target mildly with RUE on FNF. RAM slow bilaterally. FNF ok. HKS ok. -Gait: Dragging left leg when ambulating with some circumduction. ****************** Discharge exam: Vitals: T: 97.4 P: 65 R: 16 BP: 164/70 SaO2: 97%RA General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: NIHSS as above. -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name [MASKED] backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt was able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial Nerves: II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without nystagmus. Normal saccades. VFF to confrontation. Visual acuity [MASKED] bilaterally. V: Facial sensation intact to light touch. VII: symmetric VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: [MASKED] strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk and tone. Subtle LUE pronation without drift. RUE orbiting around left. No adventitious movements, such as tremor, noted. No asterixis noted. [[MASKED]] [C5] [C5] [C7] [C6] [C7] [T1][L2] [L3] [L5] [L4] [S1][L5] L 5- 5 5 5 4 5 5 5 5 [MASKED] R 5 5 5 5 5 5 5 5 5 5 5 5 -Sensory: No deficits to light touch, pinprick, cold sensation, vibratory sense. Intact proprioception b/l. No extinction to DSS. No spinal sensory level. -DTRs: brisk diffusely L>R. Left toe upgoing, right downgoing. -Coordination: Missed target mildly with RUE on FNF. RAM slow bilaterally. FNF ok. HKS ok. -Gait: Dragging left leg but stable with cane Pertinent Results: [MASKED] 01:10PM GLUCOSE-125* UREA N-9 CREAT-0.9 SODIUM-144 POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-26 ANION GAP-17 [MASKED] 01:10PM estGFR-Using this [MASKED] 01:10PM ALT(SGPT)-18 AST(SGOT)-30 ALK PHOS-97 TOT BILI-0.5 [MASKED] 01:10PM ALBUMIN-3.7 CALCIUM-11.2* PHOSPHATE-3.4 MAGNESIUM-2.3 [MASKED] 01:10PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [MASKED] 01:10PM WBC-9.4 RBC-4.87 HGB-13.4 HCT-41.0 MCV-84 MCH-27.5 MCHC-32.7 RDW-14.4 RDWSD-44.0 [MASKED] 01:10PM NEUTS-64.6 [MASKED] MONOS-5.8 EOS-0.5* BASOS-0.2 IM [MASKED] AbsNeut-6.06 AbsLymp-2.68 AbsMono-0.54 AbsEos-0.05 AbsBaso-0.02 [MASKED] 01:10PM PLT COUNT-276 CT head IMPRESSION: 1. Small right caudate hypodensity/lacunar infarct is new from [MASKED], but otherwise appears chronic to possibly subacute, lacunar infarct. Correlate with clinical symptoms. MRI is more sensitive in detecting acute ischemia. 2. Sequelae of prior right frontal lobe infarct and left pontine infarct. 3. Nonspecific bilateral white matter changes are similar the prior exam and consistent with sequelae of chronic small vessel ischemic disease. 4. No acute intracranial hemorrhage. 5. Cortical atrophy. CXR IMPRESSION: No focal consolidation to suggest pneumonia. Possible minimal pulmonary vascular congestion. Stable mild cardiomegaly. MRI/MRA brain and neck IMPRESSION: 1. Substantially motion limited exam. 2. Punctate, likely subacute infarcts of the right frontal periventricular white matter, posterior limb of the right internal capsule or right thalamus , and right periatrial white matter. 3. Chronic right frontal cortical infarct is again seen. Extensive supratentorial white matter signal abnormalities, similar to prior, nonspecific but likely sequela of chronic small vessel ischemic disease in this age group. 4. Nondominant left vertebral artery is diminutive and not adequately assessed on this motion limited exam. 0 5. Atherosclerosis of the proximal right internal carotid artery is again seen but could be exaggerated by artifact. Apparent irregularity of the left proximal internal carotid artery, of the V2 and V3 segments of the right vertebral artery, of the left greater than right carotid siphons, and of the distal M1 and M2 segments of the left middle cerebral artery probably represents a combination of atherosclerosis and artifacts. Brief Hospital Course: [MASKED] RH female with a PMHx of paramedian pontine infarct ([MASKED]), right-sided lenticulostriate territory infarct ([MASKED]), multiple strokes in the right posterior MCA/PCA watershed region (thought to be cardioembolic but no source identified, [MASKED] Plavix and ASA, HTN, HLD, prior MI, colon cancer s/p resection and chemotherapy in [MASKED], extensive tobacco use, recent DM diagnosis, and recent diagnosis of B12 deficiency presents with 4 week hx of progressively worsening left leg weakness and falls. On exam she had no signs of neuropathy, intact sensation to light touch, temperature and Pin Prick as well as intact proprioception. CT Head with right caudate hypodensity of indeterminate age, but appears subacute/chronic. MRI/MRA brain and neck with punctate, likely subacute infarcts of the right frontal periventricular white matter, posterior limb of the right internal capsule or right thalamus and right periatrial white matter. Etiology most likely secondary to known intracranial athero seen on imaging vs. small vessel disease. Patient already on appropriate secondary stroke prophylaxis and thus no changes to her medications were made. She was evaluated by physical therapy who recommended home [MASKED]. Stroke risk factors: LDL 48, A1C6.6 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 =48 ) - () No 5. Intensive statin therapy administered? (simvastatin 80mg, simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin 20mg or 40mg, for LDL > 100) (x) Yes - () No [if LDL >100, reason not given: ] 6. Smoking cessation counseling given? (x) Yes - () No [reason () non-smoker - () unable to participate] 7. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given (verbally or written)? (x) Yes - () No 8. Assessment for rehabilitation or rehab services considered? (x) Yes - () No 9. Discharged on statin therapy? (x) Yes - () No [if LDL >100, reason not given: ] 10. Discharged on antithrombotic therapy? (x) Yes [Type: (x) Antiplatelet - () Anticoagulation] - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? () Yes - () No - (x) N/A Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Oxybutynin 5 mg PO DAILY 3. MetFORMIN (Glucophage) 500 mg PO DAILY 4. Vitamin D 1000 UNIT PO DAILY 5. Clopidogrel 75 mg PO DAILY 6. Atorvastatin 80 mg PO QPM Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO QPM 3. Clopidogrel 75 mg PO DAILY 4. MetFORMIN (Glucophage) 500 mg PO DAILY 5. Oxybutynin 5 mg PO DAILY 6. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Ischemic stroke 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 [MASKED] were hospitalized due to symptoms of left leg weakness and falls resulting from 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. Stroke can have many different causes, so we assessed [MASKED] for medical conditions that might raise your risk of having stroke. In order to prevent future strokes, we plan to modify those risk factors. Your risk factors are: HTN atherosclerotic disease No changes to your medications were made since [MASKED] are already on the appropriate secondary stroke prevention. Please take your other medications as prescribed. Please follow up with Neurology and your primary care physician as listed below. If [MASKED] experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - Sudden partial or complete loss of vision - Sudden loss of the ability to speak words from your mouth - Sudden loss of the ability to understand others speaking to [MASKED] - Sudden weakness of one side of the body - Sudden drooping of one side of the face - Sudden loss of sensation of one side of the body Sincerely, Your [MASKED] Neurology Team Followup Instructions: [MASKED]
|
[] |
[
"E119",
"Z8673",
"I10",
"E785",
"I252",
"F17210",
"I2510",
"Z7902"
] |
[
"I639: Cerebral infarction, unspecified",
"G8194: Hemiplegia, unspecified affecting left nondominant side",
"E119: Type 2 diabetes mellitus without complications",
"I672: Cerebral atherosclerosis",
"Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits",
"I10: Essential (primary) hypertension",
"E785: Hyperlipidemia, unspecified",
"I252: Old myocardial infarction",
"Z85038: Personal history of other malignant neoplasm of large intestine",
"E538: Deficiency of other specified B group vitamins",
"Z9181: History of falling",
"F17210: Nicotine dependence, cigarettes, uncomplicated",
"I6529: Occlusion and stenosis of unspecified carotid artery",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"R32: Unspecified urinary incontinence",
"R159: Full incontinence of feces",
"M8580: Other specified disorders of bone density and structure, unspecified site",
"Z7902: Long term (current) use of antithrombotics/antiplatelets"
] |
10,003,372 | 22,448,043 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: UROLOGY
Allergies:
Celexa
Attending: ___.
Chief Complaint:
Adrenal Mass
Major Surgical or Invasive Procedure:
1. Laparoscopic right adrenalectomy with removal of large
adrenal mass (12cm).
2. Percutaneous liver biopsy.
History of Present Illness:
___ yo F with right 10 cm nonfunctional adrenal mass.
Past Medical History:
Past medical history of hypertension, denies history of MI or
stroke. 3 vaginal deliveries, appendectomy
Social History:
___
Family History:
Family history is negative for adrenal issues
Physical Exam:
WdWn, NAD, AVSS
Interactive, cooperative
Abdomen soft, appropriately tender along incisions
Incisions otherwise c/d/i
Extremities w/out edema or pitting and there is no reported calf
pain to deep palpation
Pertinent Results:
___ 12:50PM BLOOD WBC-6.4 RBC-2.72*# Hgb-7.6*# Hct-23.8*#
MCV-88 MCH-27.9 MCHC-31.9* RDW-15.8* RDWSD-50.2* Plt ___
___ 12:50PM BLOOD Glucose-91 UreaN-7 Creat-0.6 Na-137 K-4.1
Cl-103 HCO3-23 AnGap-11
___ 12:50PM BLOOD Calcium-7.7* Mg-1.7
Brief Hospital Course:
Ms. ___ was admitted to Urology with right adrenal mass and
underwent laparoscopic right adrenalectomy with percutaneous
liver biopsy. No concerning intraoperative events occurred;
please see dictated operative note for details. The patient
received perioperative antibiotic prophylaxis. The patient was
transferred to the floor from the PACU in stable condition. On
POD0, pain was well controlled on PCA, hydrated for urine output
>30cc/hour, provided with pneumoboots and incentive spirometry
for prophylaxis, and ambulated once. On POD1, the patient was
restarted on home medications, basic metabolic panel and
complete blood count were checked, pain control was transitioned
from PCA to oral analgesics, diet was advanced to a clears/toast
and crackers diet. Urethral Foley catheter was removed without
difficulty and on POD2, diet was advanced as tolerated. The
remainder of the hospital course was relatively unremarkable.
The patient was discharged in stable condition, eating well,
ambulating independently, voiding without difficulty, and with
pain control on oral analgesics. On exam, incision was clean,
dry, and intact, with no evidence of hematoma collection or
infection. The patient was given explicit instructions to
follow-up in clinic in four weeks.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. lisinopril-hydrochlorothiazide ___ mg oral DAILY
2. Omeprazole 20 mg PO DAILY
3. raloxifene 60 mg oral DAILY
4. Simvastatin 20 mg PO QPM
5. Citracal + D3 (calcium phos) (calcium phosphate-vitamin D3)
250 mg calcium- 500 unit oral DAILY
6. Vitamin D 1000 UNIT PO DAILY
7. Centrum Silver Women (multivit-min-iron-FA-lutein) 8 mg
iron-400 mcg-300 mcg oral DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild
RX *ibuprofen 600 mg ONE tablet(s) by mouth Q8hrs Disp #*25
Tablet Refills:*0
3. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg HALF to ONE FULL tablet by mouth Q4hrs Disp
#*30 Tablet Refills:*0
4. Senna 8.6 mg PO BID Duration: 4 Doses
RX *sennosides [Senokot] 8.6 mg ONE tab by mouth ___ x daily
Disp #*30 Tablet Refills:*0
5. Centrum Silver Women (multivit-min-iron-FA-lutein) 8 mg
iron-400 mcg-300 mcg oral DAILY
6. Citracal + D3 (calcium phos) (calcium phosphate-vitamin D3)
250 mg calcium- 500 unit oral DAILY
7. lisinopril-hydrochlorothiazide ___ mg oral DAILY
8. Omeprazole 20 mg PO DAILY
9. raloxifene 60 mg oral DAILY
10. Simvastatin 20 mg PO QPM
11. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PREOPERATIVE DIAGNOSIS: Right adrenal mass.
POSTOPERATIVE DIAGNOSIS: Right adrenal mass with possible
liver fibrosis.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
-Please also refer to the provided handout that details
instructions and expectations for your post-operative phase as
made available by your urologist.
-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.
-___ reduce the strain/pressure on your abdomen and incision
sites; remember to log roll onto your side and then use your
hands to push yourself upright while taking advantage of the
momentum of putting your legs/feet to the ground.
--There may be bandage strips called steristrips which have
been applied to reinforce wound closure. Allow these bandage
strips to fall off on their own over time but PLEASE REMOVE ANY
REMAINING GAUZE DRESSINGS WITHIN 2 DAYS OF DISCHARGE. You may
get the steristrips wet.
-UNLESS OTHERWISE NOTED; AVOID aspirin or aspirin containing
products and supplements that may have blood-thinning effects
(like Fish Oil, Vitamin E, etc.). This will be noted in your
medication reconciliation.
IF PRESCRIBED (see the MEDICATION RECONCILIATION):
-IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken
even though you may also be taking Tylenol/Acetaminophen. You
may alternate these medications for pain control.
For pain control, try TYLENOL (acetaminophen) FIRST, then
ibuprofen, and then take the narcotic pain medication as
prescribed if additional pain relief is needed.
-Ibuprofen should always be taken with food. Please discontinue
taking and notify your doctor should you develop blood in your
stool (dark, tarry stools)
-Call your Urologist's office to schedule/confirm your follow-up
appointment in 4 weeks AND if you have any questions.
-Do not eat constipating foods for ___ weeks, drink plenty of
fluids to keep hydrated
-No vigorous physical activity or sports for 4 weeks or until
otherwise advised. Light household chores/activity and leisurely
walking/activity is OK and should be continued. Do NOT be a
couch potato
-Tylenol should be your first-line pain medication. A narcotic
pain medication has been prescribed for breakthrough pain ___.
-Max daily Tylenol (acetaminophen) dose is THREE to FOUR grams
from ALL sources
AVOID lifting/pushing/pulling items heavier than 10 pounds (or
3 kilos; about a gallon of milk) or participate in high
intensity physical activity (which includes intercourse) until
you are cleared by your Urologist in follow-up.
-No DRIVING for THREE WEEKS or until you are cleared by your
Urologist
-You may shower normally but do NOT immerse your incisions or
bathe
-Do not drive or drink alcohol while taking narcotics and do not
operate dangerous machinery
-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.
-If you have fevers > 101.5 F, vomiting, or increased redness,
swelling, or discharge from your incision, call your doctor or
go to the nearest emergency room.
Followup Instructions:
___
|
[
"D497",
"K740",
"I10",
"K219",
"K660",
"Z87891"
] |
Allergies: Celexa Chief Complaint: Adrenal Mass Major Surgical or Invasive Procedure: 1. Laparoscopic right adrenalectomy with removal of large adrenal mass (12cm). 2. Percutaneous liver biopsy. History of Present Illness: [MASKED] yo F with right 10 cm nonfunctional adrenal mass. Past Medical History: Past medical history of hypertension, denies history of MI or stroke. 3 vaginal deliveries, appendectomy Social History: [MASKED] Family History: Family history is negative for adrenal issues Physical Exam: WdWn, NAD, AVSS Interactive, cooperative Abdomen soft, appropriately tender along incisions Incisions otherwise c/d/i Extremities w/out edema or pitting and there is no reported calf pain to deep palpation Pertinent Results: [MASKED] 12:50PM BLOOD WBC-6.4 RBC-2.72*# Hgb-7.6*# Hct-23.8*# MCV-88 MCH-27.9 MCHC-31.9* RDW-15.8* RDWSD-50.2* Plt [MASKED] [MASKED] 12:50PM BLOOD Glucose-91 UreaN-7 Creat-0.6 Na-137 K-4.1 Cl-103 HCO3-23 AnGap-11 [MASKED] 12:50PM BLOOD Calcium-7.7* Mg-1.7 Brief Hospital Course: Ms. [MASKED] was admitted to Urology with right adrenal mass and underwent laparoscopic right adrenalectomy with percutaneous liver biopsy. No concerning intraoperative events occurred; please see dictated operative note for details. The patient received perioperative antibiotic prophylaxis. The patient was transferred to the floor from the PACU in stable condition. On POD0, pain was well controlled on PCA, hydrated for urine output >30cc/hour, provided with pneumoboots and incentive spirometry for prophylaxis, and ambulated once. On POD1, the patient was restarted on home medications, basic metabolic panel and complete blood count were checked, pain control was transitioned from PCA to oral analgesics, diet was advanced to a clears/toast and crackers diet. Urethral Foley catheter was removed without difficulty and on POD2, diet was advanced as tolerated. The remainder of the hospital course was relatively unremarkable. The patient was discharged in stable condition, eating well, ambulating independently, voiding without difficulty, and with pain control on oral analgesics. On exam, incision was clean, dry, and intact, with no evidence of hematoma collection or infection. The patient was given explicit instructions to follow-up in clinic in four weeks. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. lisinopril-hydrochlorothiazide [MASKED] mg oral DAILY 2. Omeprazole 20 mg PO DAILY 3. raloxifene 60 mg oral DAILY 4. Simvastatin 20 mg PO QPM 5. Citracal + D3 (calcium phos) (calcium phosphate-vitamin D3) 250 mg calcium- 500 unit oral DAILY 6. Vitamin D 1000 UNIT PO DAILY 7. Centrum Silver Women (multivit-min-iron-FA-lutein) 8 mg iron-400 mcg-300 mcg oral DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild RX *ibuprofen 600 mg ONE tablet(s) by mouth Q8hrs Disp #*25 Tablet Refills:*0 3. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg HALF to ONE FULL tablet by mouth Q4hrs Disp #*30 Tablet Refills:*0 4. Senna 8.6 mg PO BID Duration: 4 Doses RX *sennosides [Senokot] 8.6 mg ONE tab by mouth [MASKED] x daily Disp #*30 Tablet Refills:*0 5. Centrum Silver Women (multivit-min-iron-FA-lutein) 8 mg iron-400 mcg-300 mcg oral DAILY 6. Citracal + D3 (calcium phos) (calcium phosphate-vitamin D3) 250 mg calcium- 500 unit oral DAILY 7. lisinopril-hydrochlorothiazide [MASKED] mg oral DAILY 8. Omeprazole 20 mg PO DAILY 9. raloxifene 60 mg oral DAILY 10. Simvastatin 20 mg PO QPM 11. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: PREOPERATIVE DIAGNOSIS: Right adrenal mass. POSTOPERATIVE DIAGNOSIS: Right adrenal mass with possible liver fibrosis. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: -Please also refer to the provided handout that details instructions and expectations for your post-operative phase as made available by your urologist. -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. -[MASKED] reduce the strain/pressure on your abdomen and incision sites; remember to log roll onto your side and then use your hands to push yourself upright while taking advantage of the momentum of putting your legs/feet to the ground. --There may be bandage strips called steristrips which have been applied to reinforce wound closure. Allow these bandage strips to fall off on their own over time but PLEASE REMOVE ANY REMAINING GAUZE DRESSINGS WITHIN 2 DAYS OF DISCHARGE. You may get the steristrips wet. -UNLESS OTHERWISE NOTED; AVOID aspirin or aspirin containing products and supplements that may have blood-thinning effects (like Fish Oil, Vitamin E, etc.). This will be noted in your medication reconciliation. IF PRESCRIBED (see the MEDICATION RECONCILIATION): -IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken even though you may also be taking Tylenol/Acetaminophen. You may alternate these medications for pain control. For pain control, try TYLENOL (acetaminophen) FIRST, then ibuprofen, and then take the narcotic pain medication as prescribed if additional pain relief is needed. -Ibuprofen should always be taken with food. Please discontinue taking and notify your doctor should you develop blood in your stool (dark, tarry stools) -Call your Urologist's office to schedule/confirm your follow-up appointment in 4 weeks AND if you have any questions. -Do not eat constipating foods for [MASKED] weeks, drink plenty of fluids to keep hydrated -No vigorous physical activity or sports for 4 weeks or until otherwise advised. Light household chores/activity and leisurely walking/activity is OK and should be continued. Do NOT be a couch potato -Tylenol should be your first-line pain medication. A narcotic pain medication has been prescribed for breakthrough pain [MASKED]. -Max daily Tylenol (acetaminophen) dose is THREE to FOUR grams from ALL sources AVOID lifting/pushing/pulling items heavier than 10 pounds (or 3 kilos; about a gallon of milk) or participate in high intensity physical activity (which includes intercourse) until you are cleared by your Urologist in follow-up. -No DRIVING for THREE WEEKS or until you are cleared by your Urologist -You may shower normally but do NOT immerse your incisions or bathe -Do not drive or drink alcohol while taking narcotics and do not operate dangerous machinery -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. -If you have fevers > 101.5 F, vomiting, or increased redness, swelling, or discharge from your incision, call your doctor or go to the nearest emergency room. Followup Instructions: [MASKED]
|
[] |
[
"I10",
"K219",
"Z87891"
] |
[
"D497: Neoplasm of unspecified behavior of endocrine glands and other parts of nervous system",
"K740: Hepatic fibrosis",
"I10: Essential (primary) hypertension",
"K219: Gastro-esophageal reflux disease without esophagitis",
"K660: Peritoneal adhesions (postprocedural) (postinfection)",
"Z87891: Personal history of nicotine dependence"
] |
10,003,385 | 23,040,642 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___ / ___
Attending: ___
Chief Complaint:
perianal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ man with history of hypertension who
presents with perianal pain and purulent discharge.
Patient states that he has had longstanding problems with
"hemorrhoids". He reports that for the past ___ years, he has
had intermittent sensation of "swelling" and "rectal pain" with
defecation. This lasted for a few weeks followed by drainage of
pus from the rectal areas, followed by some asymptomatic months.
However for the past month, he has felt significant pain and
irritation, worse with sitting. He also see bloody drainage
occasionally from the anal area. In the past, he was seen at
___ ED in ___ for possibly possibly thrombosed painful
internal hemmorhoid. He reports he has tried Anusol HC
suppository without relief. He works using computers and
therefore is quite sedentary at work. He was recently seen by
his PCP ___ ___ due to worsening pain and purulent discharge. His
doctor prescribed him augmentin and mupriocin, as well as derm
referral. HIV and RPR negative at that time. The patient states
that the symptoms have not improved. He denies any history of
receptive anal intercourse, Crohn's disease, ulcerative colitis,
fevers, chills, abdominal pain, dysuria, hematuria, diarrhea.
Patient denies any similar pustules in his inguinal region or
armpits. No family history of Crohn's disease. Patient reports
exquisite pain with defecation.
In the ED, initial VS were: 99.9 96 148/102 16 100% RA
ED physical exam was recorded as multiple pustules along the
left buttock crease
ED labs were notable for WBC 13.7
CT pelvis showed soft tissue thickening in the perianal region
and extending along the left buttock, without fluid collection.
Patient was given 1g Tylenol and vancomycin 1gm
Transfer VS were 98.0 67 141/91 18 100% RA
REVIEW OF SYSTEMS:
A ten point ROS was conducted and was negative except as above
in the HPI.
Past Medical History:
HYPERTENSION
SICKLE CELL TRAIT
ASTHMA
HEMORRHOIDS
OBESITY
KELOID
H/O TOBACCO ABUSE
H/O ACL TEAR
H/O BACK PAIN
Social History:
___
Family History:
-Mother: ___
-Grandmother: Lung Cancer (still alive)
Physical Exam:
ADMISSION & DISCHARGE EXAM:
Gen: NAD, lying in bed
Eyes: EOMI, sclerae anicteric
ENT: MMM, OP clear
Cardiovasc: RRR, no MRG, full pulses, no edema
Resp: normal effort, no accessory muscle use, lungs CTA ___.
GI: soft, NT, ND, BS+
MSK: No significant kyphosis. No palpable synovitis.
Skin: Multiple nodular/pustular lesions on the left ___
region extending to the gluteal folds. Some of these are
erythematous and draining pus. On the right perianal region at 6
o clock, there is also an area of condylomatous lesions, with no
pus. No anal fissures observed. No external hemorrhoid
observed. There are keloid lesions in the pubic area
Neuro: AAOx3. No facial droop.
Pertinent Results:
___ 12:10AM URINE HOURS-RANDOM
___ 12:10AM URINE UHOLD-HOLD
___ 12:10AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 12:10AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 12:10AM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
___ 12:10AM URINE MUCOUS-RARE
___ 11:24PM estGFR-Using this
CT
Soft tissue thickening in the perianal region and extending
along the left buttock, without fluid collection.
Brief Hospital Course:
Mr. ___ is a ___ man with history of hypertension
who presents with perianal pain and purulent discharge. He has
had a history of multiple ___ lesions for ___ years
(pustules with some drainage and warts) and discussed this with
his PCP for the first time last week. He was prescribed a
course of augmentin, which he nearly completed, and referred to
Dermatology urgently for consideration of biopsy and further
evaluation. Given the weather, his outpatient appointment was
canceled so presented to the ED and was admitted. He had no
worsening symptoms from the ___ years of his chronic lesions, with
the exception of pain relieved with ibuprofen. He denied any
fevers, chills, or sweats. His exam did not reveal s/s
cellulitis and CT was negative for an abscess. His dermatology
appt was rescheduled for the following morning, so he was
discharged a few hours after admission in stable condition with
instructions to keep his Dermatology appointment. No changes
were made to his medications.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 40 mg PO DAILY
Discharge Medications:
1. Lisinopril 40 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
___ lesions, chronic
HTN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were admitted for ongoing pain due to the lesions in the
___ area. You have an appointment with Dermatology
tomorrow AM - it is very important you keep this appointment so
these lesions can be evaluated.
Please complete the antibiotics Dr. ___ for you last
week.
No other changes were made to your medications.
We wish you the best,
___ Team
Followup Instructions:
___
|
[
"K629",
"L910",
"I10",
"D573",
"E669",
"Z6831",
"Z87891"
] |
Allergies: [MASKED] / [MASKED] Chief Complaint: perianal pain Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a [MASKED] man with history of hypertension who presents with perianal pain and purulent discharge. Patient states that he has had longstanding problems with "hemorrhoids". He reports that for the past [MASKED] years, he has had intermittent sensation of "swelling" and "rectal pain" with defecation. This lasted for a few weeks followed by drainage of pus from the rectal areas, followed by some asymptomatic months. However for the past month, he has felt significant pain and irritation, worse with sitting. He also see bloody drainage occasionally from the anal area. In the past, he was seen at [MASKED] ED in [MASKED] for possibly possibly thrombosed painful internal hemmorhoid. He reports he has tried Anusol HC suppository without relief. He works using computers and therefore is quite sedentary at work. He was recently seen by his PCP [MASKED] [MASKED] due to worsening pain and purulent discharge. His doctor prescribed him augmentin and mupriocin, as well as derm referral. HIV and RPR negative at that time. The patient states that the symptoms have not improved. He denies any history of receptive anal intercourse, Crohn's disease, ulcerative colitis, fevers, chills, abdominal pain, dysuria, hematuria, diarrhea. Patient denies any similar pustules in his inguinal region or armpits. No family history of Crohn's disease. Patient reports exquisite pain with defecation. In the ED, initial VS were: 99.9 96 148/102 16 100% RA ED physical exam was recorded as multiple pustules along the left buttock crease ED labs were notable for WBC 13.7 CT pelvis showed soft tissue thickening in the perianal region and extending along the left buttock, without fluid collection. Patient was given 1g Tylenol and vancomycin 1gm Transfer VS were 98.0 67 141/91 18 100% RA REVIEW OF SYSTEMS: A ten point ROS was conducted and was negative except as above in the HPI. Past Medical History: HYPERTENSION SICKLE CELL TRAIT ASTHMA HEMORRHOIDS OBESITY KELOID H/O TOBACCO ABUSE H/O ACL TEAR H/O BACK PAIN Social History: [MASKED] Family History: -Mother: [MASKED] -Grandmother: Lung Cancer (still alive) Physical Exam: ADMISSION & DISCHARGE EXAM: Gen: NAD, lying in bed Eyes: EOMI, sclerae anicteric ENT: MMM, OP clear Cardiovasc: RRR, no MRG, full pulses, no edema Resp: normal effort, no accessory muscle use, lungs CTA [MASKED]. GI: soft, NT, ND, BS+ MSK: No significant kyphosis. No palpable synovitis. Skin: Multiple nodular/pustular lesions on the left [MASKED] region extending to the gluteal folds. Some of these are erythematous and draining pus. On the right perianal region at 6 o clock, there is also an area of condylomatous lesions, with no pus. No anal fissures observed. No external hemorrhoid observed. There are keloid lesions in the pubic area Neuro: AAOx3. No facial droop. Pertinent Results: [MASKED] 12:10AM URINE HOURS-RANDOM [MASKED] 12:10AM URINE UHOLD-HOLD [MASKED] 12:10AM URINE COLOR-Straw APPEAR-Clear SP [MASKED] [MASKED] 12:10AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [MASKED] 12:10AM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE EPI-0 [MASKED] 12:10AM URINE MUCOUS-RARE [MASKED] 11:24PM estGFR-Using this CT Soft tissue thickening in the perianal region and extending along the left buttock, without fluid collection. Brief Hospital Course: Mr. [MASKED] is a [MASKED] man with history of hypertension who presents with perianal pain and purulent discharge. He has had a history of multiple [MASKED] lesions for [MASKED] years (pustules with some drainage and warts) and discussed this with his PCP for the first time last week. He was prescribed a course of augmentin, which he nearly completed, and referred to Dermatology urgently for consideration of biopsy and further evaluation. Given the weather, his outpatient appointment was canceled so presented to the ED and was admitted. He had no worsening symptoms from the [MASKED] years of his chronic lesions, with the exception of pain relieved with ibuprofen. He denied any fevers, chills, or sweats. His exam did not reveal s/s cellulitis and CT was negative for an abscess. His dermatology appt was rescheduled for the following morning, so he was discharged a few hours after admission in stable condition with instructions to keep his Dermatology appointment. No changes were made to his medications. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 40 mg PO DAILY Discharge Medications: 1. Lisinopril 40 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: [MASKED] lesions, chronic HTN Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [MASKED], You were admitted for ongoing pain due to the lesions in the [MASKED] area. You have an appointment with Dermatology tomorrow AM - it is very important you keep this appointment so these lesions can be evaluated. Please complete the antibiotics Dr. [MASKED] for you last week. No other changes were made to your medications. We wish you the best, [MASKED] Team Followup Instructions: [MASKED]
|
[] |
[
"I10",
"E669",
"Z87891"
] |
[
"K629: Disease of anus and rectum, unspecified",
"L910: Hypertrophic scar",
"I10: Essential (primary) hypertension",
"D573: Sickle-cell trait",
"E669: Obesity, unspecified",
"Z6831: Body mass index [BMI] 31.0-31.9, adult",
"Z87891: Personal history of nicotine dependence"
] |
10,003,400 | 23,559,586 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Sacral ulcer
Major Surgical or Invasive Procedure:
Uretropelvic junction stent replacement
Intubation
PICC line placement
Right Chest tube placement
History of Present Illness:
Ms. ___ is a ___ year-old woman a PMH significant for AFib on
coumadin, UPJ obstruction s/p stent placement in ___ c/b
chronic Klebsiella bacturia, IgG myeloma on lenolidamide, and
adenocarcinoma of the anal canal (followed by Dr. ___
admitted to ___ for evaluation of anemia (Hgb 8.6)
with course complicated by atrial fibrillation with RVR
requiring ICU admission for dilt gtt, Acute of chronic kidney
injury osteomyelitis from sacral decubitus ucler who was
transferred to ___ for debridement of sacral ulcer.
In the ED she developed afib with RVR with hypotension where
she briefly required a dilt gtt. She was then transferred to the
floor.
Hospital course thus far has included an MRI without
osteomyelitis, abdominal distension w/ NGT placement draining
bilious contents, CBI and urology procedure for evaluation of
hematuria. She underwent cystoscopy ___ to exchange ureteral
stent and found purulence behind stent. There was no etiology of
hematuria seen. She was started on vanc and zosyn and kept on
fluconazole started pre-procedure. Culture significant for
___ albicans and MDR pseudomonas SN to Gentamicin which was
held ___ ___.
Following cystoscopy, were unable to extubate and couldn't get
off pressors. Per report, black colored liquid was coming out of
NGT.
Required FICU transfer
FICU Course Significant for: Extubation and starting on tube
feeding.
Was restabilized and discharged from the FICU where CT Torso
revealed
New retroperitoneal soft tissue mass encasing the aorta and
common iliac vessels in comparison to the ___
examination. The mass abuts the second and third portion of the
duodenum and pancreatic head. Suspected involvement of the
pancreatic head and distal CBD with new intra and extrahepatic
bile duct dilation.
Encasement of both ureters, with new left and worsened right
moderate hydronephrosis in comparison to the ___
Transferred to ___ where course was complicated by hypotension
and worsening of anemia in the setting of gross hematuria. Her
VS were 85/Doppler and HR of high ___. She received one unit
prbc at the time of initial assessment and 2nd unit being hung.
Prior to transfer: hung 2nd unit prbc (first at about 3).
-Obtained ABG.
-Guiac positive
On arrival to the CCU, pt in respiratory distress with shallow
breathing. Intermittently responsive, able to follow some
commands. Felt "ok" but increasingly somnolent.
Past Medical History:
PAST ONCOLOGIC HISTORY:
#ANAL ADENOCA: Per Dr. ___: Admitted to ___ ___ for
BRBPR. Found to have anal adenocarcinoma, T2N0 based on MRI and
CT. Seen by Dr ___ in the hospital from surgery but has
been noncompliant with f/u with her despite multiple outreaches
from her office.
#MM: ___ woman who presented with anemia in ___. Further testing demonstrated an M-spike of
approximately 3.3 g/dL, IgG was 5800 mg/dL. Eventually, the
patient was referred to Hematology, IgG increased to 7100mg/dL
at
the start of treatment. Initial Hematology consult was ___. Bone marrow biopsy revealed 60% of her bone marrow
occupied by plasma cells, cytogenetics demonstrated
translocation
of chromosomes 11 and 14, also monosomy 13. Skeletal survey was
negative. Initial beta 2 microglobulin was 4.08, she started
cycle 1 of Revlimid and dexamethasone on ___,
Revlimid
at 25 mg. She was admitted to ___ on ___,
with pneumonia, she was also coagulopathic and quite leukopenic.
She was discharged on ___. On
___, she presented with severe back pain, and she has
sustained a compression fracture of L3 vertebra. Her white
blood
cell count was still low, the Revlimid was held, and restarted
on
___ at a lower dose of 15 mg, in combination with
weekly dexamethasone at 20 mg. She was started on Zometa. The
patient did well on this lower dose of Revlimid with a nice
improvement in her IgG and M-spike, M-spike going down to 1.0
g/dL by ___, and her IgG going into the normal range
at
the same time, she continued on Revlimid 15 mg every days ___,
with weekly dexamethasone at 20 mg, repeated every month, with
Zometa every 3 months, for quite some time, although by ___, the patient was becoming more leukopenic. At the start of
cycle 19 of Revlimid and dexamethasone, in ___, the
M-spike was down to 0.6 g/dL, and the Revlimid was reduced to 10
mg per day because of severe neutropenia. Unfortunately by
___ timeframe, the M-spike started to creep up, to 0.8
g/dL fairly consistently through the ___, and by
___, at her ___ cycle of Revlimid and dexamethasone, the
M-spike increased to 0.9 g/dL. She was increased to Rev 15 mg
and
her counts are holding. She reports she missed a month of Rev
due
to her hospitalization in ___ Cycle #27 Rev 15mg -Dex
___ Clinic appt start Biaxin
___ Cycle #28 Rev-Dex
___ Clinic appt reviewed labs M-spike 0.8g/dL
___ Cycle #29 Rev-Dex
___ Admitted for hematuria, elevated INR
attributed to Ultram-warfarin interaction
___ Clinic appt Zometa, on cycle #29
___ Cycle #30 Rev-Dex
___ Cycle #31-- decided to continue without a clinic
appt,
she was having a great time visiting family in ___
___ Cycle #31 day #19
___ Cycle #32
___ Cycle #33 and Zometa
___ Cycle #34 start on ___ end ___.
___ Cycle #35 start ___ end ___. M-spike 0.9g/dL
___ Cycle #36, start ___ or ___, Zometa, end ___.
M-spike 0.8g/dL
___ Cycle ___ M-spike 0.9g/dL. Now ___ years on
Rev-dex
(first cycle was ___ Cycle ___ M-spike 0.9g/dL IgG stable. Start Rev ___
___ finish ___ See me in clinic before cycle #39
start ___ finish ___ See me in clinic, Zometa, cycle #40
will start ___ ( I am out of office ___
___ Admitted ___ obstructive uropathy and
enterococcal UTI discharged ___ to rehab
___ ___
discharged
___ Touched base by phone, hold Revlimid until next
follow
up
___ Cycle #41 start ___ end ___ Stent change scheduled
___ Cycle #42 planned start
___ Zometa, Previously followed in hem/onc by Dr
___ today to establish care with me.
___ Cycle 44
___ Cycle 45, zometa
___ Cycle 46
___ Cycle 47, zometa
___ Cycle 48 Rev
___ Cycle 49 rev, zometa
___ Cycle 50 rev
___ Cycle 51 rev
___ Anal cancer - adeno diagnosed
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
PSH:
___ - EUA, biopsy of ___ lesion
___ - cystoscopy and R ureteral stent exchange
___ - lap CCY
Hysterectomy
___ - unknown ___ procedure
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: 97.8 120/77 118 20 100RA
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. Ostomy in place
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:
deceased
Pertinent Results:
Admission Labs:
---------------
___ 04:38AM BLOOD WBC-4.3 RBC-2.88* Hgb-8.6* Hct-25.9*
MCV-90 MCH-29.9 MCHC-33.2 RDW-15.9* RDWSD-52.1* Plt ___
___ 04:38AM BLOOD Neuts-53 Bands-0 Lymphs-14* Monos-25*
Eos-3 Baso-0 ___ Metas-2* Myelos-3* AbsNeut-2.28
AbsLymp-0.60* AbsMono-1.08* AbsEos-0.13 AbsBaso-0.00*
___ 04:38AM BLOOD Hypochr-2+ Anisocy-NORMAL Poiklo-NORMAL
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 04:38AM BLOOD ___ PTT-27.0 ___
___ 04:38AM BLOOD Glucose-101* UreaN-35* Creat-2.0*# Na-134
K-4.9 Cl-98 HCO3-27 AnGap-14
___ 04:38AM BLOOD ALT-6 AST-18 LD(LDH)-182 AlkPhos-75
TotBili-0.4
___ 04:38AM BLOOD Albumin-2.4* Calcium-8.1* Phos-3.6 Mg-2.1
___ 04:38AM BLOOD Vanco-14.6
IMAGES:
-------
___ CXR
Port-A-Cath catheter tip is at the level of the right
ventricular outflow tract. The double tube has been removed.
There is substantial distension of the stomach that might
potentially benefit from the NG tube insertion. What appears to
be a E ureteral stent is partially imaged. Bilateral pleural
effusions, right more than left are present. Vascular congestion
is noted, borderline with mild interstitial pulmonary edema.
___ KUB
1. A right double J stent projects over the expected location of
the right renal pelvis and bladder. The stent is unchanged in
position since ___.
2. The stomach is distended with air.
___ TTE
The left atrium is moderately dilated. Left ventricular wall
thicknesses and cavity size are normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is low normal (LVEF 50-55%). The estimated
cardiac index is normal (>=2.5L/min/m2). Tissue Doppler imaging
suggests a normal left ventricular filling pressure
(PCWP<12mmHg). The right ventricular cavity is mildly dilated
with normal free wall contractility. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present.
Trace aortic regurgitation is seen. The mitral valve leaflets
are structurally normal. There is no mitral valve prolapse. Mild
to moderate (___) mitral regurgitation is seen. There is mild
to moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of ___, the
findings are similar.
___ Renal US
1. Moderate hydronephrosis and cortical thinning on the right.
Mild
hydronephrosis on the left. These findings are unchanged from
CT ___.
2. A large pleural effusion is unchanged from ___.
___ CXR
As compared to the previous radiograph, the right sided J-stent
is unchanged. The previously severe gastric over distension has
further increased in severity and is now massive.
___ CXR
As compared to ___, the patient has received a new
nasogastric tube. The tube is located in the middle parts of
the stomach. The previous overinflation of the stomach is no
longer present. The lung volumes remain low. Moderate
cardiomegaly. Moderate bilateral areas of atelectasis and mild
to moderate right pleural effusion.
___ MRI Sacrum
PND - preliminary read is no osteomylelitis
Discharge Labs: N/A
---------------
Brief Hospital Course:
Ms. ___ is a ___ year-old woman a PMH significant for AFib on
coumadin, UPJ obstruction s/p stent placement in ___ c/b
chronic Klebsiella bacturia, IgG myeloma on lenolidamide, and
adenocarcinoma of the anal canal (followed by Dr. ___
admitted to ___ for evaluation of anemia (Hgb 8.6) with
course complicated by atrial fibrillation with RVR requiring ICU
admission for dilt gtt, Acute of chronic kidney injury,
?osteomyelitis from sacral decubitus ulcer now transferred to
___ for debridement of sacral ulcer. Became hypotensive and
quite anemic on the floor with H/H of ___ and was transferred
to the MICU ___.
She peacefully passed away with her family and family pastor
present in the room at ___ on ___.
#Hypercarbic respiratory failure: The pt consistently required
nasal cannula up to 6 L while on the floor. This was thought to
be due to volume overload and increased work of breathing. While
in the CCU pt became more lethargic and an ABG showed
hypercarbic respiratory failure. She was intubated by
anesthesia. CXR showed large bilateral pleural effusions and
she was grossly anasarcic. IP placed a right chest tube to
drain the effusion which showed that it was malignant with
cytology showing adenocarcinoma. She was extubated successfully
on ___ and was weaned down to room air thereafter. She was
able to be comfortable on room air for the rest of her
admission.
# Encephalopathy: although the pt's mental status had noticed to
be declining on the floor, she was still able to answer
appropriately. After extubation, the pt was noted to be very
lethargic and minimally responsive. EEG was done which showed
triphasic waves consistent with an encephalopathy. The pt was
trialed on Ativan and Keppra. Her mental status remained very
poor in spite of continued Keppra. Neuro signed off after head
imaging was unrevealing. Mental status continued to wax and
wane through the rest of her time.
# Stage IV surgical dehiscence: Patient had correction of
abdominoperineal resection defect with a right vertical rectus
abdominis muscular cutaneous flap in ___ following
resection of anal cancer. She presented to the hospital with
stage IV, MRSA + sacral ulcer with concern for osteomyelitis, as
wound probes to bone. CT scan with no mention of sacral
osteomyelitis. GI deferred to plastics as they did flap surgery.
Plastics does not recommend surgical intervention at this time.
MRI shows no signs of osteomyelitis. This wound remained stable
during her hospital course.
# ___: Baseline Creatinine 0.8. Creatinine on admission was 2.1
in setting of diuresis but also possible hypotension from afib
with RVR. Pt is grossly volume overloaded with hypoalbumenemia.
Concern for prerenal vs. intrinsic with possible multiple
myeloma involvement vs obstructive. Creatinine remains above 2.0
today. Renal consulted and believed that her ___ was
predominantly secondary to obstruction. After stent exchange by
urology ___, renal function improved with a Cr to 1.5 with IV
fluids and remained stable.
# Gastric Distension: Patient developed nausea and 1 episode of
vomiting ___ with increasing distention. And xray ___
showed significant gastric distension. NG tube was placed and
>1L was drawn off. Patient's reported symptomatic improvement.
Patient continued to have ostomy output throughout episode. No
mass appreciated on exam though obese abdomen. Patient not on
narcotic medication. On ___, NG tube was clamped without
recurrence of distention, patient denies nausea or distension.
Unable to get CT abd due to poor kidney function, but got OSH CT
read by our radiologists. It was notable for new retroperitoneal
mass encasing aorta throughout abdomen. It is touching and
possibly invading ___ and ___ portion of duodenum, potentially
explaining gastric obstruction symptoms. Invades pancreatic
head, explaining ductal dilatation. Also surrounding common
iliac vessels, and both ureters (hydronephrosis worse since
___. Speech and swallow was consulted who said the pt
should be strict NPO. Tube feeds were started.
# Tube feeds: On ___ Ms. ___ was no longer tolerating
her tube feeds due to very high residuals. Tube feeds were
stopped and she was given nutrition with D5NS at 75/hr. ___
attempted to place the Dobhoff tube post-pyloric but they were
unable to pass the tube through the pylorus and noted contrast
barely trickles through ___ obstruction. In family meetings the
family was informed that the feeding tube could not be advanced,
and that other options such as TPN would likely harm the pt more
than help her because of her risk for bloodstream infection and
metabolic derangements.
# Metastatic anal adenocarcinoma: large retroperitoneal mass
compressing the abdomen and constricting the aorta at the level
of the iliacs noted on CT from OSH, thought to be metastasis
from her known anal adenocarcinoma. Per onc, not a candidate for
chemotherapy, so likely not worth biopsying even though
definitive diagnosis would not otherwise be reached. Recommend
getting palliative care involved and having goals of care
discussion with family. First family meeting was ___ and
son, ___, wanted us to do everything we could to help Ms.
___. This continued to be a theme during her hospital stay,
and several meetings were held with the family to discuss goals
of care. On ___ it was decided to switch to focusing on her
comfort only.
# Volume overload: Likely from diastolic heart failure but will
need to rule out hypoalbuminemic state, and cirrhosis. Patient
with gross volume overload with 2+ ___ edema, bilateral effusions
and CT with anasarca on abdominal imaging. TTE unchanged from
previous with EF 55% and no gross valvular dysfunction. TSH
elevated, T4 WNLs. Patient given albumin ___ with good
response. However, patient still significantly overloaded. On
___ she was anuric and hypotensive despite having
significant lower extremity and abdominal edema. She was
transferred to the MICU on this day. While in the MICU she was
stabilized and pressors were downtitrated. Poor response to
Lasix alone but given Lasix and Chlorothiazide with good UOP.
# Hematuria: Unclear cause but patient was on anticoagulation.
Concern would be primarily for tumor infiltration. Hematuria
intermittent, but seems to recur during transport. Potential
mechanical irritation. Patient continues to pass dime sized
clots. Stent exchange done ___ by urology, with improvement in
her hematuria. Hematuria with clots returned on ___.
Urology recommended CBI which was started ___. She had
CBI intermittently throughout her stay to relieve foley
obstructions.
# Normocytic Anemia: Hgb at ___ 8.6. No evidence of
bleeding. She does have stage III CKD. MCV within normal range
and iron studies not particularly suggestive of iron deficiency
anemia with ferritin of 781. Folate level of 7.4 and B12 of 411.
Concern could possibly be for chronic low grade bleed from gut
or hematuria. (transfused evening of ___. Hgb remained
stable in the 7's until ___ when H/H dropped to ___.
This same day she triggered for hypotension of 86/Doppler. As
she was anuric at this time there was concern of intraabdominal
bleeding and was one of the indications for MICU transfer. Pt
had episode of gross hematuria requiring CBI and pRBC
transfusion for BP control. Pt required Vasopressin and
Phenylephrine while in the MICU but was able to be weaned off.
She required intermittent pRBC transfusions during her time in
the MICU.
# AFib on coumadin: CHADS 2 of 3. Hemodynamically unstable with
RVR upon arrival, but controlled with diltiazem and metoprolol.
She remained in AFib during her hospital stay. Due to her
hematuria and dropping H/H, blood pressure medications and
ultimately SQH were discontinued on ___. Pt put on an
esmolol gtt as she had afib with RVR into the 130s on her first
day in the ICU. She was taken off the esmolol drip and
thereafter controlled with IV metoprolol and achieved good
control on PO metoprolol with heart rates in the ___.
# Hypertension: Currently normotensive. See above for issues
with hypotension and reason for MICU transfer ___.
# IgG Myeloma: Patient with longstanding IgG MM, followed by
___ Oncology. Currently not on revlimid or dexamethasone.
Kappa:lamba increase, but can be seen in kidney disease. Atrius
oncology followed patient throughout hospital stay.
====================
TRANSITIONAL ISSUES:
====================
- Family Bereavement Counseling
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen (Liquid) 1000 mg PO TID
2. Diltiazem 30 mg PO QID
3. Heparin Flush (10 units/ml) 5 mL IV DAILY and PRN, line flush
4. Artificial Tears ___ DROP BOTH EYES PRN Dry eyes
5. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port
6. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
7. Dexamethasone 4 mg PO 1X/WEEK (TH)
8. Calcium Carbonate 500 mg PO BID:PRN heart burn
9. Collagenase Ointment 1 Appl TP DAILY
10. Escitalopram Oxalate 5 mg PO DAILY
11. Metoprolol Succinate XL 200 mg PO DAILY
12. Mirtazapine 7.5 mg PO QHS
13. Pantoprazole 40 mg PO Q24H
14. Furosemide 80 mg PO DAILY
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient Expired
Discharge Condition:
Patient Expired
Discharge Instructions:
Patient Expired
Followup Instructions:
___
|
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Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Sacral ulcer Major Surgical or Invasive Procedure: Uretropelvic junction stent replacement Intubation PICC line placement Right Chest tube placement History of Present Illness: Ms. [MASKED] is a [MASKED] year-old woman a PMH significant for AFib on coumadin, UPJ obstruction s/p stent placement in [MASKED] c/b chronic Klebsiella bacturia, IgG myeloma on lenolidamide, and adenocarcinoma of the anal canal (followed by Dr. [MASKED] admitted to [MASKED] for evaluation of anemia (Hgb 8.6) with course complicated by atrial fibrillation with RVR requiring ICU admission for dilt gtt, Acute of chronic kidney injury osteomyelitis from sacral decubitus ucler who was transferred to [MASKED] for debridement of sacral ulcer. In the ED she developed afib with RVR with hypotension where she briefly required a dilt gtt. She was then transferred to the floor. Hospital course thus far has included an MRI without osteomyelitis, abdominal distension w/ NGT placement draining bilious contents, CBI and urology procedure for evaluation of hematuria. She underwent cystoscopy [MASKED] to exchange ureteral stent and found purulence behind stent. There was no etiology of hematuria seen. She was started on vanc and zosyn and kept on fluconazole started pre-procedure. Culture significant for [MASKED] albicans and MDR pseudomonas SN to Gentamicin which was held [MASKED] [MASKED]. Following cystoscopy, were unable to extubate and couldn't get off pressors. Per report, black colored liquid was coming out of NGT. Required FICU transfer FICU Course Significant for: Extubation and starting on tube feeding. Was restabilized and discharged from the FICU where CT Torso revealed New retroperitoneal soft tissue mass encasing the aorta and common iliac vessels in comparison to the [MASKED] examination. The mass abuts the second and third portion of the duodenum and pancreatic head. Suspected involvement of the pancreatic head and distal CBD with new intra and extrahepatic bile duct dilation. Encasement of both ureters, with new left and worsened right moderate hydronephrosis in comparison to the [MASKED] Transferred to [MASKED] where course was complicated by hypotension and worsening of anemia in the setting of gross hematuria. Her VS were 85/Doppler and HR of high [MASKED]. She received one unit prbc at the time of initial assessment and 2nd unit being hung. Prior to transfer: hung 2nd unit prbc (first at about 3). -Obtained ABG. -Guiac positive On arrival to the CCU, pt in respiratory distress with shallow breathing. Intermittently responsive, able to follow some commands. Felt "ok" but increasingly somnolent. Past Medical History: PAST ONCOLOGIC HISTORY: #ANAL ADENOCA: Per Dr. [MASKED]: Admitted to [MASKED] [MASKED] for BRBPR. Found to have anal adenocarcinoma, T2N0 based on MRI and CT. Seen by Dr [MASKED] in the hospital from surgery but has been noncompliant with f/u with her despite multiple outreaches from her office. #MM: [MASKED] woman who presented with anemia in [MASKED]. Further testing demonstrated an M-spike of approximately 3.3 g/dL, IgG was 5800 mg/dL. Eventually, the patient was referred to Hematology, IgG increased to 7100mg/dL at the start of treatment. Initial Hematology consult was [MASKED]. Bone marrow biopsy revealed 60% of her bone marrow occupied by plasma cells, cytogenetics demonstrated translocation of chromosomes 11 and 14, also monosomy 13. Skeletal survey was negative. Initial beta 2 microglobulin was 4.08, she started cycle 1 of Revlimid and dexamethasone on [MASKED], Revlimid at 25 mg. She was admitted to [MASKED] on [MASKED], with pneumonia, she was also coagulopathic and quite leukopenic. She was discharged on [MASKED]. On [MASKED], she presented with severe back pain, and she has sustained a compression fracture of L3 vertebra. Her white blood cell count was still low, the Revlimid was held, and restarted on [MASKED] at a lower dose of 15 mg, in combination with weekly dexamethasone at 20 mg. She was started on Zometa. The patient did well on this lower dose of Revlimid with a nice improvement in her IgG and M-spike, M-spike going down to 1.0 g/dL by [MASKED], and her IgG going into the normal range at the same time, she continued on Revlimid 15 mg every days [MASKED], with weekly dexamethasone at 20 mg, repeated every month, with Zometa every 3 months, for quite some time, although by [MASKED], the patient was becoming more leukopenic. At the start of cycle 19 of Revlimid and dexamethasone, in [MASKED], the M-spike was down to 0.6 g/dL, and the Revlimid was reduced to 10 mg per day because of severe neutropenia. Unfortunately by [MASKED] timeframe, the M-spike started to creep up, to 0.8 g/dL fairly consistently through the [MASKED], and by [MASKED], at her [MASKED] cycle of Revlimid and dexamethasone, the M-spike increased to 0.9 g/dL. She was increased to Rev 15 mg and her counts are holding. She reports she missed a month of Rev due to her hospitalization in [MASKED] Cycle #27 Rev 15mg -Dex [MASKED] Clinic appt start Biaxin [MASKED] Cycle #28 Rev-Dex [MASKED] Clinic appt reviewed labs M-spike 0.8g/dL [MASKED] Cycle #29 Rev-Dex [MASKED] Admitted for hematuria, elevated INR attributed to Ultram-warfarin interaction [MASKED] Clinic appt Zometa, on cycle #29 [MASKED] Cycle #30 Rev-Dex [MASKED] Cycle #31-- decided to continue without a clinic appt, she was having a great time visiting family in [MASKED] [MASKED] Cycle #31 day #19 [MASKED] Cycle #32 [MASKED] Cycle #33 and Zometa [MASKED] Cycle #34 start on [MASKED] end [MASKED]. [MASKED] Cycle #35 start [MASKED] end [MASKED]. M-spike 0.9g/dL [MASKED] Cycle #36, start [MASKED] or [MASKED], Zometa, end [MASKED]. M-spike 0.8g/dL [MASKED] Cycle [MASKED] M-spike 0.9g/dL. Now [MASKED] years on Rev-dex (first cycle was [MASKED] Cycle [MASKED] M-spike 0.9g/dL IgG stable. Start Rev [MASKED] [MASKED] finish [MASKED] See me in clinic before cycle #39 start [MASKED] finish [MASKED] See me in clinic, Zometa, cycle #40 will start [MASKED] ( I am out of office [MASKED] [MASKED] Admitted [MASKED] obstructive uropathy and enterococcal UTI discharged [MASKED] to rehab [MASKED] [MASKED] discharged [MASKED] Touched base by phone, hold Revlimid until next follow up [MASKED] Cycle #41 start [MASKED] end [MASKED] Stent change scheduled [MASKED] Cycle #42 planned start [MASKED] Zometa, Previously followed in hem/onc by Dr [MASKED] today to establish care with me. [MASKED] Cycle 44 [MASKED] Cycle 45, zometa [MASKED] Cycle 46 [MASKED] Cycle 47, zometa [MASKED] Cycle 48 Rev [MASKED] Cycle 49 rev, zometa [MASKED] Cycle 50 rev [MASKED] Cycle 51 rev [MASKED] Anal cancer - adeno diagnosed PAST MEDICAL HISTORY: Hypertension Atrial fibrillation on coumadin Obesity Myeloma Osteoarthritis of right knee UPJ obstruction s/p stent placement [MASKED] c/b persistent Klebsiella bacteruria Anal adenocarcinoma (dx [MASKED] ? Perirectal cyst drainage in 1980s PSH: [MASKED] - EUA, biopsy of [MASKED] lesion [MASKED] - cystoscopy and R ureteral stent exchange [MASKED] - lap CCY Hysterectomy [MASKED] - unknown [MASKED] procedure Social History: [MASKED] Family History: Her parents died in their [MASKED] or [MASKED] 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: 97.8 120/77 118 20 100RA 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. Ostomy in place 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: deceased Pertinent Results: Admission Labs: --------------- [MASKED] 04:38AM BLOOD WBC-4.3 RBC-2.88* Hgb-8.6* Hct-25.9* MCV-90 MCH-29.9 MCHC-33.2 RDW-15.9* RDWSD-52.1* Plt [MASKED] [MASKED] 04:38AM BLOOD Neuts-53 Bands-0 Lymphs-14* Monos-25* Eos-3 Baso-0 [MASKED] Metas-2* Myelos-3* AbsNeut-2.28 AbsLymp-0.60* AbsMono-1.08* AbsEos-0.13 AbsBaso-0.00* [MASKED] 04:38AM BLOOD Hypochr-2+ Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL [MASKED] 04:38AM BLOOD [MASKED] PTT-27.0 [MASKED] [MASKED] 04:38AM BLOOD Glucose-101* UreaN-35* Creat-2.0*# Na-134 K-4.9 Cl-98 HCO3-27 AnGap-14 [MASKED] 04:38AM BLOOD ALT-6 AST-18 LD(LDH)-182 AlkPhos-75 TotBili-0.4 [MASKED] 04:38AM BLOOD Albumin-2.4* Calcium-8.1* Phos-3.6 Mg-2.1 [MASKED] 04:38AM BLOOD Vanco-14.6 IMAGES: ------- [MASKED] CXR Port-A-Cath catheter tip is at the level of the right ventricular outflow tract. The double tube has been removed. There is substantial distension of the stomach that might potentially benefit from the NG tube insertion. What appears to be a E ureteral stent is partially imaged. Bilateral pleural effusions, right more than left are present. Vascular congestion is noted, borderline with mild interstitial pulmonary edema. [MASKED] KUB 1. A right double J stent projects over the expected location of the right renal pelvis and bladder. The stent is unchanged in position since [MASKED]. 2. The stomach is distended with air. [MASKED] TTE The left atrium is moderately dilated. Left ventricular wall thicknesses and cavity size are normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). The estimated cardiac index is normal (>=2.5L/min/m2). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). The right ventricular cavity is mildly dilated with normal free wall contractility. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild to moderate ([MASKED]) mitral regurgitation is seen. There is mild to moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [MASKED], the findings are similar. [MASKED] Renal US 1. Moderate hydronephrosis and cortical thinning on the right. Mild hydronephrosis on the left. These findings are unchanged from CT [MASKED]. 2. A large pleural effusion is unchanged from [MASKED]. [MASKED] CXR As compared to the previous radiograph, the right sided J-stent is unchanged. The previously severe gastric over distension has further increased in severity and is now massive. [MASKED] CXR As compared to [MASKED], the patient has received a new nasogastric tube. The tube is located in the middle parts of the stomach. The previous overinflation of the stomach is no longer present. The lung volumes remain low. Moderate cardiomegaly. Moderate bilateral areas of atelectasis and mild to moderate right pleural effusion. [MASKED] MRI Sacrum PND - preliminary read is no osteomylelitis Discharge Labs: N/A --------------- Brief Hospital Course: Ms. [MASKED] is a [MASKED] year-old woman a PMH significant for AFib on coumadin, UPJ obstruction s/p stent placement in [MASKED] c/b chronic Klebsiella bacturia, IgG myeloma on lenolidamide, and adenocarcinoma of the anal canal (followed by Dr. [MASKED] admitted to [MASKED] for evaluation of anemia (Hgb 8.6) with course complicated by atrial fibrillation with RVR requiring ICU admission for dilt gtt, Acute of chronic kidney injury, ?osteomyelitis from sacral decubitus ulcer now transferred to [MASKED] for debridement of sacral ulcer. Became hypotensive and quite anemic on the floor with H/H of [MASKED] and was transferred to the MICU [MASKED]. She peacefully passed away with her family and family pastor present in the room at [MASKED] on [MASKED]. #Hypercarbic respiratory failure: The pt consistently required nasal cannula up to 6 L while on the floor. This was thought to be due to volume overload and increased work of breathing. While in the CCU pt became more lethargic and an ABG showed hypercarbic respiratory failure. She was intubated by anesthesia. CXR showed large bilateral pleural effusions and she was grossly anasarcic. IP placed a right chest tube to drain the effusion which showed that it was malignant with cytology showing adenocarcinoma. She was extubated successfully on [MASKED] and was weaned down to room air thereafter. She was able to be comfortable on room air for the rest of her admission. # Encephalopathy: although the pt's mental status had noticed to be declining on the floor, she was still able to answer appropriately. After extubation, the pt was noted to be very lethargic and minimally responsive. EEG was done which showed triphasic waves consistent with an encephalopathy. The pt was trialed on Ativan and Keppra. Her mental status remained very poor in spite of continued Keppra. Neuro signed off after head imaging was unrevealing. Mental status continued to wax and wane through the rest of her time. # Stage IV surgical dehiscence: Patient had correction of abdominoperineal resection defect with a right vertical rectus abdominis muscular cutaneous flap in [MASKED] following resection of anal cancer. She presented to the hospital with stage IV, MRSA + sacral ulcer with concern for osteomyelitis, as wound probes to bone. CT scan with no mention of sacral osteomyelitis. GI deferred to plastics as they did flap surgery. Plastics does not recommend surgical intervention at this time. MRI shows no signs of osteomyelitis. This wound remained stable during her hospital course. # [MASKED]: Baseline Creatinine 0.8. Creatinine on admission was 2.1 in setting of diuresis but also possible hypotension from afib with RVR. Pt is grossly volume overloaded with hypoalbumenemia. Concern for prerenal vs. intrinsic with possible multiple myeloma involvement vs obstructive. Creatinine remains above 2.0 today. Renal consulted and believed that her [MASKED] was predominantly secondary to obstruction. After stent exchange by urology [MASKED], renal function improved with a Cr to 1.5 with IV fluids and remained stable. # Gastric Distension: Patient developed nausea and 1 episode of vomiting [MASKED] with increasing distention. And xray [MASKED] showed significant gastric distension. NG tube was placed and >1L was drawn off. Patient's reported symptomatic improvement. Patient continued to have ostomy output throughout episode. No mass appreciated on exam though obese abdomen. Patient not on narcotic medication. On [MASKED], NG tube was clamped without recurrence of distention, patient denies nausea or distension. Unable to get CT abd due to poor kidney function, but got OSH CT read by our radiologists. It was notable for new retroperitoneal mass encasing aorta throughout abdomen. It is touching and possibly invading [MASKED] and [MASKED] portion of duodenum, potentially explaining gastric obstruction symptoms. Invades pancreatic head, explaining ductal dilatation. Also surrounding common iliac vessels, and both ureters (hydronephrosis worse since [MASKED]. Speech and swallow was consulted who said the pt should be strict NPO. Tube feeds were started. # Tube feeds: On [MASKED] Ms. [MASKED] was no longer tolerating her tube feeds due to very high residuals. Tube feeds were stopped and she was given nutrition with D5NS at 75/hr. [MASKED] attempted to place the Dobhoff tube post-pyloric but they were unable to pass the tube through the pylorus and noted contrast barely trickles through [MASKED] obstruction. In family meetings the family was informed that the feeding tube could not be advanced, and that other options such as TPN would likely harm the pt more than help her because of her risk for bloodstream infection and metabolic derangements. # Metastatic anal adenocarcinoma: large retroperitoneal mass compressing the abdomen and constricting the aorta at the level of the iliacs noted on CT from OSH, thought to be metastasis from her known anal adenocarcinoma. Per onc, not a candidate for chemotherapy, so likely not worth biopsying even though definitive diagnosis would not otherwise be reached. Recommend getting palliative care involved and having goals of care discussion with family. First family meeting was [MASKED] and son, [MASKED], wanted us to do everything we could to help Ms. [MASKED]. This continued to be a theme during her hospital stay, and several meetings were held with the family to discuss goals of care. On [MASKED] it was decided to switch to focusing on her comfort only. # Volume overload: Likely from diastolic heart failure but will need to rule out hypoalbuminemic state, and cirrhosis. Patient with gross volume overload with 2+ [MASKED] edema, bilateral effusions and CT with anasarca on abdominal imaging. TTE unchanged from previous with EF 55% and no gross valvular dysfunction. TSH elevated, T4 WNLs. Patient given albumin [MASKED] with good response. However, patient still significantly overloaded. On [MASKED] she was anuric and hypotensive despite having significant lower extremity and abdominal edema. She was transferred to the MICU on this day. While in the MICU she was stabilized and pressors were downtitrated. Poor response to Lasix alone but given Lasix and Chlorothiazide with good UOP. # Hematuria: Unclear cause but patient was on anticoagulation. Concern would be primarily for tumor infiltration. Hematuria intermittent, but seems to recur during transport. Potential mechanical irritation. Patient continues to pass dime sized clots. Stent exchange done [MASKED] by urology, with improvement in her hematuria. Hematuria with clots returned on [MASKED]. Urology recommended CBI which was started [MASKED]. She had CBI intermittently throughout her stay to relieve foley obstructions. # Normocytic Anemia: Hgb at [MASKED] 8.6. No evidence of bleeding. She does have stage III CKD. MCV within normal range and iron studies not particularly suggestive of iron deficiency anemia with ferritin of 781. Folate level of 7.4 and B12 of 411. Concern could possibly be for chronic low grade bleed from gut or hematuria. (transfused evening of [MASKED]. Hgb remained stable in the 7's until [MASKED] when H/H dropped to [MASKED]. This same day she triggered for hypotension of 86/Doppler. As she was anuric at this time there was concern of intraabdominal bleeding and was one of the indications for MICU transfer. Pt had episode of gross hematuria requiring CBI and pRBC transfusion for BP control. Pt required Vasopressin and Phenylephrine while in the MICU but was able to be weaned off. She required intermittent pRBC transfusions during her time in the MICU. # AFib on coumadin: CHADS 2 of 3. Hemodynamically unstable with RVR upon arrival, but controlled with diltiazem and metoprolol. She remained in AFib during her hospital stay. Due to her hematuria and dropping H/H, blood pressure medications and ultimately SQH were discontinued on [MASKED]. Pt put on an esmolol gtt as she had afib with RVR into the 130s on her first day in the ICU. She was taken off the esmolol drip and thereafter controlled with IV metoprolol and achieved good control on PO metoprolol with heart rates in the [MASKED]. # Hypertension: Currently normotensive. See above for issues with hypotension and reason for MICU transfer [MASKED]. # IgG Myeloma: Patient with longstanding IgG MM, followed by [MASKED] Oncology. Currently not on revlimid or dexamethasone. Kappa:lamba increase, but can be seen in kidney disease. Atrius oncology followed patient throughout hospital stay. ==================== TRANSITIONAL ISSUES: ==================== - Family Bereavement Counseling Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen (Liquid) 1000 mg PO TID 2. Diltiazem 30 mg PO QID 3. Heparin Flush (10 units/ml) 5 mL IV DAILY and PRN, line flush 4. Artificial Tears [MASKED] DROP BOTH EYES PRN Dry eyes 5. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port 6. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain 7. Dexamethasone 4 mg PO 1X/WEEK (TH) 8. Calcium Carbonate 500 mg PO BID:PRN heart burn 9. Collagenase Ointment 1 Appl TP DAILY 10. Escitalopram Oxalate 5 mg PO DAILY 11. Metoprolol Succinate XL 200 mg PO DAILY 12. Mirtazapine 7.5 mg PO QHS 13. Pantoprazole 40 mg PO Q24H 14. Furosemide 80 mg PO DAILY Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Patient Expired Discharge Condition: Patient Expired Discharge Instructions: Patient Expired Followup Instructions: [MASKED]
|
[] |
[
"J9601",
"N179",
"I5032",
"D62",
"Z66",
"Z515",
"Z7901",
"I129",
"E669",
"D696"
] |
[
"T8131XA: Disruption of external operation (surgical) wound, not elsewhere classified, initial encounter",
"R6521: Severe sepsis with septic shock",
"J9601: Acute respiratory failure with hypoxia",
"N179: Acute kidney failure, unspecified",
"A419: Sepsis, unspecified organism",
"G9340: Encephalopathy, unspecified",
"C9000: Multiple myeloma not having achieved remission",
"J910: Malignant pleural effusion",
"K5660: Unspecified intestinal obstruction",
"C786: Secondary malignant neoplasm of retroperitoneum and peritoneum",
"C7889: Secondary malignant neoplasm of other digestive organs",
"C211: Malignant neoplasm of anal canal",
"E46: Unspecified protein-calorie malnutrition",
"Q620: Congenital hydronephrosis",
"T814XXA: Infection following a procedure",
"T8359XA: Infection and inflammatory reaction due to prosthetic device, implant and graft in urinary system",
"N12: Tubulo-interstitial nephritis, not specified as acute or chronic",
"B3749: Other urogenital candidiasis",
"K311: Adult hypertrophic pyloric stenosis",
"I5032: Chronic diastolic (congestive) heart failure",
"D62: Acute posthemorrhagic anemia",
"Z66: Do not resuscitate",
"Z515: Encounter for palliative care",
"E8809: Other disorders of plasma-protein metabolism, not elsewhere classified",
"I482: Chronic atrial fibrillation",
"Z7901: Long term (current) use of anticoagulants",
"M179: Osteoarthritis of knee, unspecified",
"I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease",
"B9562: Methicillin resistant Staphylococcus aureus infection as the cause of diseases classified elsewhere",
"N183: Chronic kidney disease, stage 3 (moderate)",
"Z433: Encounter for attention to colostomy",
"R310: Gross hematuria",
"E669: Obesity, unspecified",
"Z6838: Body mass index [BMI] 38.0-38.9, adult",
"Y848: Other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure",
"Y92239: Unspecified place in hospital as the place of occurrence of the external cause",
"B965: Pseudomonas (aeruginosa) (mallei) (pseudomallei) as the cause of diseases classified elsewhere",
"D696: Thrombocytopenia, unspecified"
] |
10,003,412 | 28,884,815 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
Chloroquine
Attending: ___
Chief Complaint:
L2 fracture, back pain
Major Surgical or Invasive Procedure:
___: L2 corpectomy (retroperitoneal approach) and
revision of posterior L1-L3 fusion
History of Present Illness:
Mr. ___ is a ___ Ph.D. researcher at ___ who was
in ___ for
research projects in ___. He had to jump out of a
second-floor window secondary to a terrorist attack and broke
his leg and fractured his L2 vertebrae. He initially received
care for this in ___. The patient continued to have back
pain and after exhausting medical treatment, remained
symptomatic. The decision was made to proceed with L2 corpectomy
with a revision
of posterior instrumentation and fusion.
Past Medical History:
Mitral valve prolapse
headaches
GERD
Past Surgical:
___: L ankle ORIF
___ L1-L3 fusion
Social History:
___
Family History:
NC
Physical Exam:
UPON DISCHARGE:
Afebrile
Vital sigs stable
No apparent distress
Heart rate regular
Respirations non-labored
Abdomen, soft, non-tender, non-distended
Back incision clean, dry and intact with staples place
___ strength throughout
Sensation intact throughout
Pertinent Results:
___: Portable abdomen xray
IMPRESSION:
Diffuse dilatation of the large bowel in a pattern most
consistent with ileus. No pneumoperitoneum or pneumatosis.
___: Ultrasound Bilateral ___ veins
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
___: CTA Chest
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Bilateral small nonhemorrhagic pleural effusions and adjacent
bibasilar
atelectasis.
___: Xray abdomen
IMPRESSION:
1. Interval improvement of colonic ileus.
2. Left loculated pleural effusion, better assessed on CT chest
from the same day.
___ Lumbosacral spine xray
IMPRESSION:
Postsurgical changes. No acute fracture.
___ KUB **
Brief Hospital Course:
On ___, the patient was admitted for elective L2 corpectomy
(retroperitoneal approach) and revision of posterior L1-L3
fusion. He underwent this procedure with Dr. ___ was
subsequently transferred out of the OR to the PACU for
post-anesthesia care and monitoring.
On ___ Patient was neurologically stable. He continued to
complain of uncontrolled back pain so pain regimen was adjusted.
On ___, the patient continued with back pain which he states
was mildly improved. He complained of abdominal pain and
distention and KUB showed large bowel ileus. His bowel regimen
was increased and he received enema with no immediate BM,but
large amount of flatus. The patient underwent workup for
tachycardia, EKG showed sinus tach and Trops were negative.
LENIs were negative for any DVTs and tachycardia improved to 110
after pain improved.
On ___, overnight the patient's oxygen saturation dipped down
to 80% while sleeping, and he was therefore placed on 1L NC. In
the morning, his neurological and motor exam was stable. When
working with ___ he had tachyacardia with a heart rate of 100
that increased to 140 when he rose from sitting to standin. He
also had a correlating O2 drop to the ___. A CTA was ordered and
was negative for PE, though it revealed some atelectasis. A
follow-up KUB was ordered for investigation of resolution of
ileus, as he had a BM overnight. It showed interval improvement
of colonic ileus.
On ___, the patient remained neurologically stable. While
trying to reposition himself in bed he reports he "snapped" his
low back and has new posterior right sided lumbar pain. He
denies numbness, tingling in his lower extremities. He is full
strength bilaterally. A repeat AP/LAT xray are stable. Per CPS
his diazepam was d/c'd and he was started on Tizanidine. Diet
changed to full liquids.
On ___ the patient remained neurologically stable, and was
awaiting a rehab bed. He continued to endorse right lower back
pain, although continued on pain medication as needed.
On ___ the patient remained neurologically and hemodynamically
stable. The patient was awaiting a rehab bed.
On ___, the patient remained neurologically and hemodynamically
stable. Patient complaining of diarrhea with intermittent
abdominal pain. Ordered repeat KUB to evaluate previous ileus
which showed resolving ileus. Diet was advanced as patient
tolerates.
At the time of discharge on ___ 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 will follow up with Dr. ___
routine. The patient expressed readiness for discharge.
Medications on Admission:
Gabapentin 300mg PO TID
lansoprazole 15mg PO daily
oxycodone prn
tramadol prn
Cialis 20mg q72 hours
Discharge Medications:
1. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Every four (4) hours
as needed Disp #*60 Tablet Refills:*0
2. Gabapentin 600 mg PO TID
RX *gabapentin 600 mg 1 tablet(s) by mouth three times a day
Disp #*42 Tablet Refills:*0
3. Calcium Carbonate 1000 mg PO QID:PRN indisgestion
4. Acetaminophen 650 mg PO Q6H
5. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth Twice daily Disp
#*28 Tablet Refills:*0
6. Tizanidine 2 mg PO TID:PRN muscle spasm
RX *tizanidine 2 mg 1 tablet(s) by mouth Three times daily as
needed Disp #*42 Tablet Refills:*0
7. Cyanocobalamin 1000 mcg PO DAILY
8. FoLIC Acid ___ mcg PO DAILY
9. lansoprazole 15 mg oral DAILY
10. Multivitamins 1 TAB PO DAILY
11. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
L2 fracture, back pain
Discharge Condition:
Stable
Discharge Instructions:
Surgery
Your dressing was removed on the second day after surgery. The
wound may remain uncovered.
Your incision is closed with staples. You will need to have
staple removal.
Do not apply any lotions or creams to the site.
Please keep your incision dry until removal of your staples.
Please avoid swimming for two weeks after staple removal.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
You must wear your brace at all times when out of bed. You may
apply your brace sitting at the edge of the bed. You do not need
to sleep with it on.
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace. ___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
No contact sports until cleared by your neurosurgeon.
Do NOT smoke. Smoking can affect your healing and fusion.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc
until cleared by your
neurosurgeon.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
It is important to increase fluid intake while taking pain
medications. We also recommend a stool softener like Colace.
Pain medications can cause constipation.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
New weakness or changes in sensation in your arms or legs.
Followup Instructions:
___
|
[
"M4856XA",
"K913",
"T8489XA",
"M5136",
"Y831",
"Y92239",
"Y838",
"Y92009"
] |
Allergies: Chloroquine Chief Complaint: L2 fracture, back pain Major Surgical or Invasive Procedure: [MASKED]: L2 corpectomy (retroperitoneal approach) and revision of posterior L1-L3 fusion History of Present Illness: Mr. [MASKED] is a [MASKED] Ph.D. researcher at [MASKED] who was in [MASKED] for research projects in [MASKED]. He had to jump out of a second-floor window secondary to a terrorist attack and broke his leg and fractured his L2 vertebrae. He initially received care for this in [MASKED]. The patient continued to have back pain and after exhausting medical treatment, remained symptomatic. The decision was made to proceed with L2 corpectomy with a revision of posterior instrumentation and fusion. Past Medical History: Mitral valve prolapse headaches GERD Past Surgical: [MASKED]: L ankle ORIF [MASKED] L1-L3 fusion Social History: [MASKED] Family History: NC Physical Exam: UPON DISCHARGE: Afebrile Vital sigs stable No apparent distress Heart rate regular Respirations non-labored Abdomen, soft, non-tender, non-distended Back incision clean, dry and intact with staples place [MASKED] strength throughout Sensation intact throughout Pertinent Results: [MASKED]: Portable abdomen xray IMPRESSION: Diffuse dilatation of the large bowel in a pattern most consistent with ileus. No pneumoperitoneum or pneumatosis. [MASKED]: Ultrasound Bilateral [MASKED] veins IMPRESSION: No evidence of deep venous thrombosis in the right or left lower extremity veins. [MASKED]: CTA Chest IMPRESSION: 1. No evidence of pulmonary embolism or aortic abnormality. 2. Bilateral small nonhemorrhagic pleural effusions and adjacent bibasilar atelectasis. [MASKED]: Xray abdomen IMPRESSION: 1. Interval improvement of colonic ileus. 2. Left loculated pleural effusion, better assessed on CT chest from the same day. [MASKED] Lumbosacral spine xray IMPRESSION: Postsurgical changes. No acute fracture. [MASKED] KUB ** Brief Hospital Course: On [MASKED], the patient was admitted for elective L2 corpectomy (retroperitoneal approach) and revision of posterior L1-L3 fusion. He underwent this procedure with Dr. [MASKED] was subsequently transferred out of the OR to the PACU for post-anesthesia care and monitoring. On [MASKED] Patient was neurologically stable. He continued to complain of uncontrolled back pain so pain regimen was adjusted. On [MASKED], the patient continued with back pain which he states was mildly improved. He complained of abdominal pain and distention and KUB showed large bowel ileus. His bowel regimen was increased and he received enema with no immediate BM,but large amount of flatus. The patient underwent workup for tachycardia, EKG showed sinus tach and Trops were negative. LENIs were negative for any DVTs and tachycardia improved to 110 after pain improved. On [MASKED], overnight the patient's oxygen saturation dipped down to 80% while sleeping, and he was therefore placed on 1L NC. In the morning, his neurological and motor exam was stable. When working with [MASKED] he had tachyacardia with a heart rate of 100 that increased to 140 when he rose from sitting to standin. He also had a correlating O2 drop to the [MASKED]. A CTA was ordered and was negative for PE, though it revealed some atelectasis. A follow-up KUB was ordered for investigation of resolution of ileus, as he had a BM overnight. It showed interval improvement of colonic ileus. On [MASKED], the patient remained neurologically stable. While trying to reposition himself in bed he reports he "snapped" his low back and has new posterior right sided lumbar pain. He denies numbness, tingling in his lower extremities. He is full strength bilaterally. A repeat AP/LAT xray are stable. Per CPS his diazepam was d/c'd and he was started on Tizanidine. Diet changed to full liquids. On [MASKED] the patient remained neurologically stable, and was awaiting a rehab bed. He continued to endorse right lower back pain, although continued on pain medication as needed. On [MASKED] the patient remained neurologically and hemodynamically stable. The patient was awaiting a rehab bed. On [MASKED], the patient remained neurologically and hemodynamically stable. Patient complaining of diarrhea with intermittent abdominal pain. Ordered repeat KUB to evaluate previous ileus which showed resolving ileus. Diet was advanced as patient tolerates. At the time of discharge on [MASKED] 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 will follow up with Dr. [MASKED] routine. The patient expressed readiness for discharge. Medications on Admission: Gabapentin 300mg PO TID lansoprazole 15mg PO daily oxycodone prn tramadol prn Cialis 20mg q72 hours Discharge Medications: 1. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN pain RX *oxycodone 5 mg [MASKED] tablet(s) by mouth Every four (4) hours as needed Disp #*60 Tablet Refills:*0 2. Gabapentin 600 mg PO TID RX *gabapentin 600 mg 1 tablet(s) by mouth three times a day Disp #*42 Tablet Refills:*0 3. Calcium Carbonate 1000 mg PO QID:PRN indisgestion 4. Acetaminophen 650 mg PO Q6H 5. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth Twice daily Disp #*28 Tablet Refills:*0 6. Tizanidine 2 mg PO TID:PRN muscle spasm RX *tizanidine 2 mg 1 tablet(s) by mouth Three times daily as needed Disp #*42 Tablet Refills:*0 7. Cyanocobalamin 1000 mcg PO DAILY 8. FoLIC Acid [MASKED] mcg PO DAILY 9. lansoprazole 15 mg oral DAILY 10. Multivitamins 1 TAB PO DAILY 11. Vitamin D [MASKED] UNIT PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: L2 fracture, back pain Discharge Condition: Stable Discharge Instructions: Surgery Your dressing was removed on the second day after surgery. The wound may remain uncovered. Your incision is closed with staples. You will need to have staple removal. Do not apply any lotions or creams to the site. Please keep your incision dry until removal of your staples. Please avoid swimming for two weeks after staple removal. Call your surgeon if there are any signs of infection like redness, fever, or drainage. Activity You must wear your brace at all times when out of bed. You may apply your brace sitting at the edge of the bed. You do not need to sleep with it on. 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. [MASKED] try to do too much all at once. No driving while taking any narcotic or sedating medication. No contact sports until cleared by your neurosurgeon. Do NOT smoke. Smoking can affect your healing and fusion. Medications Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. Do not take any anti-inflammatory medications such as Motrin, Advil, Aspirin, and Ibuprofen etc until cleared by your neurosurgeon. You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. It is important to increase fluid intake while taking pain medications. We also recommend a stool softener like Colace. Pain medications can cause constipation. When to Call Your Doctor at [MASKED] for: Severe pain, swelling, redness or drainage from the incision site. Fever greater than 101.5 degrees Fahrenheit New weakness or changes in sensation in your arms or legs. Followup Instructions: [MASKED]
|
[] |
[] |
[
"M4856XA: Collapsed vertebra, not elsewhere classified, lumbar region, initial encounter for fracture",
"K913: Postprocedural intestinal obstruction",
"T8489XA: Other specified complication of internal orthopedic prosthetic devices, implants and grafts, initial encounter",
"M5136: Other intervertebral disc degeneration, lumbar region",
"Y831: Surgical operation with implant of artificial internal device as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure",
"Y92239: Unspecified place in hospital as the place of occurrence of the external cause",
"Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure",
"Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause"
] |
10,003,502 | 29,011,269 |
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:
___
|
[
"R001",
"I5033",
"F0391",
"I2582",
"E871",
"Z9181",
"I2510",
"I252",
"I10",
"I350",
"I4891",
"Z7902",
"E785",
"Z66"
] |
Allergies: nifedipine / Amitriptyline / Prilosec OTC / Terazosin / Amlodipine / Atenolol / Oxybutynin / Hydrochlorothiazide / spironolactone / furosemide Chief Complaint: Fall, bradycardia. Major Surgical or Invasive Procedure: None. History of Present Illness: [MASKED] 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 [MASKED], 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 [MASKED]. 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 [MASKED] and atrial activity. She was then transferred to [MASKED] for possible PPM. Here at [MASKED], noted to be intermittently lethargic and poorly responsive. CT head and neck negative. EP was consulted for possible PPM and initially recommended admission to [MASKED], deferred PPM for the time being. She continued to be intermittently bradycardic to the [MASKED] 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 [MASKED]: 14.8 PTT: 42.4 INR: 1.4 AGap=12 BNP 2900 Lactate 1.5. ABG: [MASKED] On arrival to the CCU: Awake but not answering questions. Pt does not speak [MASKED], per report. On NRB. Past Medical History: 1. CARDIAC RISK FACTORS - Hypertension - Dyslipidemia 2. CARDIAC HISTORY - CAD (100% LAD occlusion). MI [MASKED] year ago. Unclear history of PCI. - Afib/flutter on dabigatran - Mild aortic stenosis 3. OTHER PAST MEDICAL HISTORY - Chronic hyponatremia - Dementia Social History: [MASKED] Family History: Mother deceased at [MASKED] yo from breast cancer. Father deceased at [MASKED] yo. Son deceased at [MASKED] 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 [MASKED] 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 [MASKED] 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: [MASKED] 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 [MASKED] [MASKED] 12:45PM BLOOD Neuts-87.3* Lymphs-5.0* Monos-7.0 Eos-0.0* Baso-0.2 Im [MASKED] AbsNeut-8.76* AbsLymp-0.50* AbsMono-0.70 AbsEos-0.00* AbsBaso-0.02 [MASKED] 12:45PM BLOOD [MASKED] PTT-42.4* [MASKED] [MASKED] 12:45PM BLOOD Glucose-125* UreaN-58* Creat-1.2* Na-140 K-4.6 Cl-98 HCO3-35* AnGap-12 [MASKED] 12:45PM BLOOD proBNP-2915* [MASKED] 12:45PM BLOOD cTropnT-0.05* [MASKED] 05:51AM BLOOD CK-MB-9 cTropnT-0.13* [MASKED] 05:51AM BLOOD Calcium-10.1 Phos-4.6* Mg-2.5 [MASKED] 08:10PM BLOOD [MASKED] pO2-23* pCO2-79* pH-7.29* calTCO2-40* Base XS-6 [MASKED] 12:52PM BLOOD Lactate-1.5 PERTINENT RESULTS: [MASKED] 12:45PM BLOOD cTropnT-0.05* [MASKED] 05:51AM BLOOD CK-MB-9 cTropnT-0.13* [MASKED] 12:52PM BLOOD Lactate-1.5 [MASKED] 11:47PM BLOOD Lactate-1.0 [MASKED] 06:04AM BLOOD Lactate-2.9* DISCHARGE LABS: [MASKED] 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 [MASKED] [MASKED] 05:51AM BLOOD [MASKED] PTT-36.7* [MASKED] [MASKED] 05:51AM BLOOD Glucose-89 UreaN-56* Creat-1.2* Na-141 K-4.1 Cl-97 HCO3-31 AnGap-17 [MASKED] 05:51AM BLOOD CK-MB-9 cTropnT-0.13* IMAGING: CHEST XRAY [MASKED]: 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. [MASKED] is [MASKED] year old female with a past medical history significant for CAD, mild AS, afib/flutter on dabigatran, HTN, HLD, chronic hyponatremia, who presented to [MASKED] on transfer from OSH after a fall and headstrike when subsequently found to be bradycardic to the [MASKED]. 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 [MASKED] beats per minute but stabilized to the [MASKED] 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, [MASKED], patient was made DNH in addition to her DNR/DNI. She will need a new MOLST signed by her sister and the doctors at [MASKED] [MASKED] - 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 [MASKED] DROP BOTH EYES BID 2. Aspirin 81 mg PO DAILY 3. Dabigatran Etexilate 75 mg PO BID 4. Vitamin D [MASKED] 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 [MASKED] 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 [MASKED] 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 [MASKED] SPRY NU BID:PRN congestion 11. Torsemide 60 mg PO DAILY 12. Vitamin D [MASKED] UNIT PO EVERY 3 WEEKS Discharge Disposition: Extended Care Facility: [MASKED] 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. [MASKED], It was a pleasure taking care of you at [MASKED]. 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 [MASKED] 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 [MASKED] team Followup Instructions: [MASKED]
|
[] |
[
"E871",
"I2510",
"I252",
"I10",
"I4891",
"Z7902",
"E785",
"Z66"
] |
[
"R001: Bradycardia, unspecified",
"I5033: Acute on chronic diastolic (congestive) heart failure",
"F0391: Unspecified dementia with behavioral disturbance",
"I2582: Chronic total occlusion of coronary artery",
"E871: Hypo-osmolality and hyponatremia",
"Z9181: History of falling",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"I252: Old myocardial infarction",
"I10: Essential (primary) hypertension",
"I350: Nonrheumatic aortic (valve) stenosis",
"I4891: Unspecified atrial fibrillation",
"Z7902: Long term (current) use of antithrombotics/antiplatelets",
"E785: Hyperlipidemia, unspecified",
"Z66: Do not resuscitate"
] |
10,003,637 | 22,082,422 |
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:
___
|
[
"N179",
"I5022",
"I959",
"E8339",
"I2510",
"Z951",
"Z950",
"Z8673",
"D649",
"F17210",
"I10",
"E785",
"I255"
] |
Allergies: lisinopril Chief Complaint: Hypotension Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] hx of ischemic cardiomyopathy sent from [MASKED] clinic when his BP was noted to be systolic [MASKED]. 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 [MASKED]. He denies fevers or recent illness. Had perirectal abscess drained in [MASKED], 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 [MASKED] CXR: No acute cardiopulmonary abnormality. Patient was given: 500 cc IVF Decision was made to admit for hypotension and [MASKED] 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 ([MASKED]), Anal fistula, s/p EUA, [MASKED] placement Social History: [MASKED] 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, [MASKED] 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: [MASKED] 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 [MASKED] 02:05PM NEUTS-72.3* LYMPHS-13.0* MONOS-12.7 EOS-1.2 BASOS-0.4 IM [MASKED] AbsNeut-9.68* AbsLymp-1.74 AbsMono-1.70* AbsEos-0.16 AbsBaso-0.05 [MASKED] 02:05PM PLT COUNT-223 [MASKED] 02:21PM [MASKED] PTT-34.1 [MASKED] [MASKED] 02:05PM GLUCOSE-143* UREA N-78* CREAT-2.8*# SODIUM-133 POTASSIUM-3.7 CHLORIDE-89* TOTAL CO2-23 ANION GAP-25* [MASKED] 02:05PM CALCIUM-10.4* PHOSPHATE-4.6* MAGNESIUM-2.4 [MASKED] 02:05PM CK(CPK)-59 [MASKED] 02:05PM cTropnT-0.04* [MASKED] 02:05PM CK-MB-2 proBNP-5890* [MASKED] 07:30PM URINE HOURS-RANDOM [MASKED] 07:30PM URINE COLOR-Straw APPEAR-Clear SP [MASKED] [MASKED] 07:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [MASKED] 07:30PM URINE RBC-<1 WBC-2 BACTERIA-FEW YEAST-NONE EPI-0 [MASKED]:30PM URINE MUCOUS-RARE [MASKED] 07:30PM URINE HYALINE-13* DISCHARGE LABS: [MASKED] 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 [MASKED] [MASKED] 07:35AM BLOOD Plt [MASKED] [MASKED] 07:35AM BLOOD [MASKED] PTT-34.7 [MASKED] [MASKED] 07:35AM BLOOD Glucose-105* UreaN-91* Creat-2.6* Na-134 K-3.5 Cl-91* HCO3-25 AnGap-22* [MASKED] 03:14PM BLOOD Glucose-96 UreaN-84* Creat-1.8* Na-134 K-3.4 Cl-95* HCO3-22 AnGap-20 [MASKED] 07:35AM BLOOD CK-MB-4 cTropnT-0.03* [MASKED] 07:35AM BLOOD Calcium-9.6 Phos-5.1* Mg-2.6 [MASKED] 03:14PM BLOOD Digoxin-0.2* DIAGNOSTICS: ECHO (CHA [MASKED] 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 [MASKED], there is no significant change. CXR [MASKED] 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: [MASKED] 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 [MASKED] in the setting fluid restriction while taking multiple diuretics and anti-hypertensives. #Hypotension: Pt presented with a baseline SBP in [MASKED] 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. [MASKED]: 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 [MASKED]. Overall findings were pre-renal [MASKED], likely [MASKED] 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 [MASKED]. Likely [MASKED] renal insufficiency. He was given a low phosphate diet for one day. #Normocytic Anemia: H/H down to 11.3/33.8 on [MASKED] 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 [MASKED] AM, likely [MASKED] 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 [MASKED]. Losartan, Spironolactone, Torsemide, Carvedilol in were held in the setting of hypotension and [MASKED], 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 [MASKED] 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. [MASKED], 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 [MASKED] 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! -[MASKED] Team Followup Instructions: [MASKED]
|
[] |
[
"N179",
"I2510",
"Z951",
"Z8673",
"D649",
"F17210",
"I10",
"E785"
] |
[
"N179: Acute kidney failure, unspecified",
"I5022: Chronic systolic (congestive) heart failure",
"I959: Hypotension, unspecified",
"E8339: Other disorders of phosphorus metabolism",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"Z951: Presence of aortocoronary bypass graft",
"Z950: Presence of cardiac pacemaker",
"Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits",
"D649: Anemia, unspecified",
"F17210: Nicotine dependence, cigarettes, uncomplicated",
"I10: Essential (primary) hypertension",
"E785: Hyperlipidemia, unspecified",
"I255: Ischemic cardiomyopathy"
] |
10,003,637 | 23,487,925 |
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:
___
|
[
"K611",
"I2582",
"I509",
"I2510",
"I252",
"Z950",
"Z951",
"Z8673",
"E785",
"I255",
"F17210"
] |
Allergies: lisinopril 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: [MASKED] with PMH significant for fistula in ano with rectal abscess s/p 3 OR drainages, CAD, CHF, hx of stroke and [MASKED] 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 [MASKED] 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 [MASKED] he was admitted to [MASKED] with cough c/w pulmonary edema and was treated with lasix. He was discharged on [MASKED] with continuing worsening rectal pain. On presentation, he describes his pain as [MASKED], 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 ([MASKED]), Hx perirectal abscess s/p I&D ([MASKED]) [MASKED]: I&D perirectal abscess ([MASKED]), EUA, [MASKED] placement ([MASKED]) Medications: ASA 81', metoprolol succinate ER 25' Allergies: NKDA Social History: [MASKED] 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: [MASKED] 11:43PM [MASKED] PTT-32.4 [MASKED] [MASKED] 05:30PM URINE HOURS-RANDOM [MASKED] 05:30PM URINE GR HOLD-HOLD [MASKED] 05:30PM URINE COLOR-Straw APPEAR-Clear SP [MASKED] [MASKED] 05:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [MASKED] 05:30PM URINE RBC-0 WBC-1 BACTERIA-NONE YEAST-NONE EPI-0 [MASKED] 05:30PM URINE HYALINE-1* [MASKED] 05:30PM URINE MUCOUS-RARE [MASKED] 01:02PM LACTATE-2.1* [MASKED] 11:30AM GLUCOSE-103* UREA N-37* CREAT-1.6* SODIUM-135 POTASSIUM-4.1 CHLORIDE-96 TOTAL CO2-22 ANION GAP-21* [MASKED] 11:30AM estGFR-Using this [MASKED] 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* [MASKED] 11:30AM NEUTS-78.2* LYMPHS-9.6* MONOS-11.3 EOS-0.3* BASOS-0.2 IM [MASKED] AbsNeut-12.33* AbsLymp-1.51 AbsMono-1.79* AbsEos-0.05 AbsBaso-0.03 [MASKED] 11:30AM PLT COUNT-183 Brief Hospital Course: Patient was taken to the OR on [MASKED] 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 [MASKED], 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 [MASKED] 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 ([MASKED]) Discharge Disposition: Home With Service Facility: [MASKED] 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. [MASKED], You were admitted to the [MASKED] on [MASKED] 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. [MASKED] in his clinic. You will receive [MASKED] to help you flush the drain twice daily. Followup Instructions: [MASKED]
|
[] |
[
"I2510",
"I252",
"Z951",
"Z8673",
"E785",
"F17210"
] |
[
"K611: Rectal abscess",
"I2582: Chronic total occlusion of coronary artery",
"I509: Heart failure, unspecified",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"I252: Old myocardial infarction",
"Z950: Presence of cardiac pacemaker",
"Z951: Presence of aortocoronary bypass graft",
"Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits",
"E785: Hyperlipidemia, unspecified",
"I255: Ischemic cardiomyopathy",
"F17210: Nicotine dependence, cigarettes, uncomplicated"
] |
10,003,637 | 28,484,061 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril
Attending: ___
Major Surgical or Invasive Procedure:
___: Right heart catheterization
___: Anal exam under anesthesia with anal fistuolotomy
___: Bronchoscopy with EBUS and lymph node biopsies
attach
Pertinent Results:
ADMISSION LABS:
===============
___ 05:49PM BLOOD WBC-9.0 RBC-3.71* Hgb-11.3* Hct-34.3*
MCV-93 MCH-30.5 MCHC-32.9 RDW-16.9* RDWSD-56.8* Plt ___
___ 05:49PM BLOOD Glucose-112* UreaN-69* Creat-1.9* Na-140
K-4.5 Cl-102 HCO3-24 AnGap-14
___ 05:49PM BLOOD Calcium-10.1 Phos-3.3 Mg-2.3 Iron-65
PERTINENT INTERVAL LABS:
========================
___ 05:49PM BLOOD calTIBC-300 Ferritn-246 TRF-231
MICRO:
======
___ 11:12 am BRONCHOALVEOLAR LAVAGE RIGHT LOWER LOBE.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ CLUSTERS.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count, if
applicable.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final ___:
10,000-100,000 CFU/mL Commensal Respiratory Flora.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
Test cancelled by laboratory.
PATIENT CREDITED.
This is a low yield procedure based on our ___
studies.
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (___).
ACID FAST CULTURE (Pending):
___ 11:44 am TISSUE MEDIASTINAL LYMPH NODE.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Preliminary): RESULTS PENDING.
ANAEROBIC CULTURE (Preliminary):
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Preliminary):
STUDIES:
========
___: CT chest w/o contrast
Mediastinal and hilar lymphadenopathy could be reactive ___
nature or sequela of the evident prior granulomatous infection,
however, a lymphoproliferative disorder such as lymphoma cannot
be excluded. A PET-CT scan is recommended for further
assessment.
Moderate cardiomegaly with associated extensive coronary artery
atherosclerotic disease and CABG postsurgical changes.
Moderate pulmonary edema.
___: Right heart cath
Normal right heart filling pressure. Mildly elevated left
heart filling pressure.
Mild pulmonary hypertension (mPA 24mmHg) with hemodynamic
features consistent with
predominant post-capillary PH (TPG 8, DPG 3, PVR 1.35 ___.
Normal systemic blood pressure and SVR.
Normal cardiac output/index as estimated by both the indirect
Fick method and by thermodilution.
DISCHARGE LABS:
===============
___ 07:33AM BLOOD WBC-8.8 RBC-2.92* Hgb-9.0* Hct-28.1*
MCV-96 MCH-30.8 MCHC-32.0 RDW-17.9* RDWSD-62.1* Plt ___
___ 07:33AM BLOOD Glucose-102* UreaN-53* Creat-2.1* Na-139
K-4.4 Cl-101 HCO3-22 AnGap-16
___ 07:33AM BLOOD Calcium-9.2 Phos-3.4 Mg-2.0
Brief Hospital Course:
PATIENT SUMMARY:
================
Mr. ___ is a ___ with CAD/MI s/p PCIs and CABG ___, HFrEF
(EF 28%) s/p ___ ICD ___ and cardiomems ___,
pAF on apixaban, HTN, DLD, prior L MCA CVA, CKD, and recurrent
perirectal abscesses who presented as direct admit from home for
heparin gtt bridge for planned procedures including RHC and anal
fistulotomy. Chest CT was also performed which demonstrated
enlarged lymph nodes, now s/p bronchoscopy with biopsies. He was
actively diuresed for slight volume overload until euvolemic and
then discharged on his home diuretic regimen.
# CORONARIES: Unknown; needs repeat stress
___ RHC: RA 5, PA ___ (24), PCWP 16 CO 5.89 CI 2.92 SVR 1005
# PUMP: TTE ___ showed ___. IVS 1.0, PW 1.0. LVEDD 6.1, LVEF
___. RV normal size/function. No AS/AR. 1+ MR. ___+ TR. Mild
pHTN.
# RHYTHM: NSR w/ non-specific intraventricular delay
TRANSITIONAL ISSUES:
====================
Discharge Weight: 195.8 lbs
Discharge Creatinine: 2.1
Discharge diuretic: Home torsemide 60mg BID
[ ] Tooth extraction: According to OMFS, it is appropriate to
continue apixaban prior to outpatient extraction. If his primary
dentist has concerns, he can be referred to our oral surgeons by
calling ___. Recommend not holding apixaban for given
his prior stroke.
[ ] Stress testing: Recommend another CPET (cardiopulmonary
stress test) now that he is euvolemic and optimized.
[ ] Interventional pulmonology: Pt will follow up with IP ___ 2
weeks, where he will review the results from his
bronchoscopy/biopsy.
[ ] Cardiology: Outpatient notes had said his spironolactone was
increased from 25mg to 50mg PO daily but patient only reports
taking 25mg per day. He was continued on 25mg daily of
spironolactone while inpatient.
ACTIVE ISSUES:
==============
# Chronic HFrEF s/p ICD and cardiomems (EF ___
History of dilated ischemic cardiomyopathy, ___ Class II, EDW
previously documented as 185-187lbs, but likely closer to
190-195lbs given relatively dry RHC at this weight. On
presentation he was well compensated. RHC was performed while
inpatient which had largely normal pressures and it was
discovered that his cardiomems was not calibrated correctly and
still is reporting falsely elevated numbers. He had a few days
off diuretics due to NPO status for procedures and mild
hypotension, then restarted on his home dosing at discharge. He
previously had a CPET that demonstrated poor function. This
should be repeated now that he is optimized to reassess his need
for LVAD/transplant.
- PRELOAD: Torsemide 60mg PO BID
- AFTERLOAD: Entresto 97-103mg PO BID, Carvedilol 12.5/18.75mg
PO BID
- NHBK: Spironolactone 25mg PO daily, Carvedilol as above
- Ionotrope: Digoxin 0.125mcg PO daily
- ICD: s/p ___ ICD placement ___ ___
- Transplant/VAD: undergoing workup
# Transplant workup
Evaluation for advanced therapies for VAD/transplant started
___.
- Dental/OMFS were consulted for teeth removal. He was found to
have no acute dental infections requiring intervention.
Therefore, extractions were not performed during this admission.
Dental/OMFS recommended pursuing extraction of mobile tooth #9
as an outpatient with an outpatient dentist with no need to hold
apixaban. If there are concerns from his primary dentist, he can
be referred to our outpatient ___ clinic for extraction.
- Underwent right heart catheterization on ___ which
demonstrated only mildly elevated filling pressures including a
mildly elevated PASP, which is significantly improved from
prior. Vasodilator study was not performed given low pulmonary
pressures.
- CT chest was performed as part of workup, found asymmetric
pulmonary edema (R>L) and enlarged mediastinal/hilar lymph
nodes. Given these findings, IP was consulted and he underwent
bronchoscopy w/ EBUS and lymph node biopsies on ___. Per
pulmonology, unclear etiology of the lymph nodes. Initially
thought to be just pulmonary edema but RHC showed he was fairly
euvolemic. Other possibilities include prior granulomatous
disease or, less likely, lymphoma.
# Perianal fistula
Initially presented ___ s/p multiple exams under anesthesia,
I&D, most recently ___ abscess was drained and malecot
catheter placed. Evaluated by ___ ___ ___ clinic after
referral from cardiology for pre-transplant evaluation. They
noted no evidence of abscess but recommended exam under
anesthesia with management of fistula ___ ano. He underwent anal
fistulotomy with colorectal surgery on ___. The procedure was
without complications and he had a cutting ___ placed that
will remain until outpatient follow up.
- Outpatient CRS follow up on ___. At that visit they will
schedule further follow up with Dr. ___.
CHRONIC ISSUES:
==============
# CAD c/b MI s/p PCI and subsequent CABG
- Continued ASA 81mg
- Continued atorvastatin 80mg
# Paroxysmal atrial fibrillation
# Hx CVA
- Continued ASA 81, atorvastatin 80
- Continued carvedilol, digoxin per above
- Resumed home apixaban 5mg BID
# History of GI bleed
- Continued omeprazole
# ___ on CKD stage ___
B/l 1.3-1.6. Cr 1.9 on admission, had been up to 2.2 as
outpatient. Fluctuated throughout admission, 2.1 on discharge,
which may be new baseline.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sacubitril-Valsartan (97mg-103mg) 1 TAB PO BID
2. Allopurinol ___ mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. CARVedilol 12.5 mg PO BID
5. CARVedilol 6.25 mg PO QPM
6. Digoxin 0.125 mg PO DAILY
7. Omeprazole 40 mg PO BID
8. Spironolactone 25 mg PO DAILY
9. Torsemide 60 mg PO BID
10. Apixaban 5 mg PO BID
11. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Apixaban 5 mg PO BID
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. CARVedilol 12.5 mg PO BID
6. CARVedilol 6.25 mg PO QPM
7. Digoxin 0.125 mg PO DAILY
8. Omeprazole 40 mg PO BID
9. Sacubitril-Valsartan (97mg-103mg) 1 TAB PO BID
10. Spironolactone 25 mg PO DAILY
11. Torsemide 60 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Chronic heart failure with reduced ejection fraction
Paroxysmal atrial fibrillation
Perianal fistula
Mediastinal/hilar lymphadenopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital for heparin (a blood thinner
similar to the apixaban you take at home) while getting multiple
procedures done. Please see below for more information on your
hospitalization. It was a pleasure participating ___ your care!
What happened while you were ___ the hospital?
- We held your apixaban and started you on a heparin drip for
continued anticoagulation for your atrial fibrillation
- You underwent multiple procedures while you were
hospitalized; this includes a right heart catheterization, an
anal fistulotomy, and a bronchoscopy with lymph node biopsies
- We gave you a little extra diuretics while you were ___ the
hospital to help keep fluid off you.
What should you do after leaving the hospital?
- Please take your medications as listed below and follow up at
the listed appointments. We have made NO changes to your
medications.
- You have an appointment with the lung doctors ___ ___. They
will go over the results of your biopsy then.
- Your weight at discharge is 195.8 lbs. Please weigh yourself
today at home and use this as your new baseline.
- Please weigh yourself every day ___ the morning. Call your
doctor if your weight goes up or down by more than 3 lbs ___ one
day or 5 lb ___ one week
We wish you the best!
- Your ___ Healthcare Team
Followup Instructions:
___
|
[
"K603",
"I130",
"I5022",
"N179",
"N183",
"E785",
"I2510",
"I480",
"Z7682",
"I255",
"R590",
"I2722",
"I252",
"Z7901",
"Z8673",
"Z95810",
"Z951",
"Z955",
"Z87891"
] |
Allergies: lisinopril Major Surgical or Invasive Procedure: [MASKED]: Right heart catheterization [MASKED]: Anal exam under anesthesia with anal fistuolotomy [MASKED]: Bronchoscopy with EBUS and lymph node biopsies attach Pertinent Results: ADMISSION LABS: =============== [MASKED] 05:49PM BLOOD WBC-9.0 RBC-3.71* Hgb-11.3* Hct-34.3* MCV-93 MCH-30.5 MCHC-32.9 RDW-16.9* RDWSD-56.8* Plt [MASKED] [MASKED] 05:49PM BLOOD Glucose-112* UreaN-69* Creat-1.9* Na-140 K-4.5 Cl-102 HCO3-24 AnGap-14 [MASKED] 05:49PM BLOOD Calcium-10.1 Phos-3.3 Mg-2.3 Iron-65 PERTINENT INTERVAL LABS: ======================== [MASKED] 05:49PM BLOOD calTIBC-300 Ferritn-246 TRF-231 MICRO: ====== [MASKED] 11:12 am BRONCHOALVEOLAR LAVAGE RIGHT LOWER LOBE. GRAM STAIN (Final [MASKED]: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 3+ [MASKED] per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. [MASKED] CLUSTERS. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count, if applicable. SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final [MASKED]: 10,000-100,000 CFU/mL Commensal Respiratory Flora. ACID FAST SMEAR (Final [MASKED]: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final [MASKED]: Test cancelled by laboratory. PATIENT CREDITED. This is a low yield procedure based on our [MASKED] studies. if pulmonary Histoplasmosis, Coccidioidomycosis, Blastomycosis, Aspergillosis or Mucormycosis is strongly suspected, contact the Microbiology Laboratory ([MASKED]). ACID FAST CULTURE (Pending): [MASKED] 11:44 am TISSUE MEDIASTINAL LYMPH NODE. GRAM STAIN (Final [MASKED]: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Preliminary): RESULTS PENDING. ANAEROBIC CULTURE (Preliminary): ACID FAST SMEAR (Final [MASKED]: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Preliminary): STUDIES: ======== [MASKED]: CT chest w/o contrast Mediastinal and hilar lymphadenopathy could be reactive [MASKED] nature or sequela of the evident prior granulomatous infection, however, a lymphoproliferative disorder such as lymphoma cannot be excluded. A PET-CT scan is recommended for further assessment. Moderate cardiomegaly with associated extensive coronary artery atherosclerotic disease and CABG postsurgical changes. Moderate pulmonary edema. [MASKED]: Right heart cath Normal right heart filling pressure. Mildly elevated left heart filling pressure. Mild pulmonary hypertension (mPA 24mmHg) with hemodynamic features consistent with predominant post-capillary PH (TPG 8, DPG 3, PVR 1.35 [MASKED]. Normal systemic blood pressure and SVR. Normal cardiac output/index as estimated by both the indirect Fick method and by thermodilution. DISCHARGE LABS: =============== [MASKED] 07:33AM BLOOD WBC-8.8 RBC-2.92* Hgb-9.0* Hct-28.1* MCV-96 MCH-30.8 MCHC-32.0 RDW-17.9* RDWSD-62.1* Plt [MASKED] [MASKED] 07:33AM BLOOD Glucose-102* UreaN-53* Creat-2.1* Na-139 K-4.4 Cl-101 HCO3-22 AnGap-16 [MASKED] 07:33AM BLOOD Calcium-9.2 Phos-3.4 Mg-2.0 Brief Hospital Course: PATIENT SUMMARY: ================ Mr. [MASKED] is a [MASKED] with CAD/MI s/p PCIs and CABG [MASKED], HFrEF (EF 28%) s/p [MASKED] ICD [MASKED] and cardiomems [MASKED], pAF on apixaban, HTN, DLD, prior L MCA CVA, CKD, and recurrent perirectal abscesses who presented as direct admit from home for heparin gtt bridge for planned procedures including RHC and anal fistulotomy. Chest CT was also performed which demonstrated enlarged lymph nodes, now s/p bronchoscopy with biopsies. He was actively diuresed for slight volume overload until euvolemic and then discharged on his home diuretic regimen. # CORONARIES: Unknown; needs repeat stress [MASKED] RHC: RA 5, PA [MASKED] (24), PCWP 16 CO 5.89 CI 2.92 SVR 1005 # PUMP: TTE [MASKED] showed [MASKED]. IVS 1.0, PW 1.0. LVEDD 6.1, LVEF [MASKED]. RV normal size/function. No AS/AR. 1+ MR. [MASKED]+ TR. Mild pHTN. # RHYTHM: NSR w/ non-specific intraventricular delay TRANSITIONAL ISSUES: ==================== Discharge Weight: 195.8 lbs Discharge Creatinine: 2.1 Discharge diuretic: Home torsemide 60mg BID [ ] Tooth extraction: According to OMFS, it is appropriate to continue apixaban prior to outpatient extraction. If his primary dentist has concerns, he can be referred to our oral surgeons by calling [MASKED]. Recommend not holding apixaban for given his prior stroke. [ ] Stress testing: Recommend another CPET (cardiopulmonary stress test) now that he is euvolemic and optimized. [ ] Interventional pulmonology: Pt will follow up with IP [MASKED] 2 weeks, where he will review the results from his bronchoscopy/biopsy. [ ] Cardiology: Outpatient notes had said his spironolactone was increased from 25mg to 50mg PO daily but patient only reports taking 25mg per day. He was continued on 25mg daily of spironolactone while inpatient. ACTIVE ISSUES: ============== # Chronic HFrEF s/p ICD and cardiomems (EF [MASKED] History of dilated ischemic cardiomyopathy, [MASKED] Class II, EDW previously documented as 185-187lbs, but likely closer to 190-195lbs given relatively dry RHC at this weight. On presentation he was well compensated. RHC was performed while inpatient which had largely normal pressures and it was discovered that his cardiomems was not calibrated correctly and still is reporting falsely elevated numbers. He had a few days off diuretics due to NPO status for procedures and mild hypotension, then restarted on his home dosing at discharge. He previously had a CPET that demonstrated poor function. This should be repeated now that he is optimized to reassess his need for LVAD/transplant. - PRELOAD: Torsemide 60mg PO BID - AFTERLOAD: Entresto 97-103mg PO BID, Carvedilol 12.5/18.75mg PO BID - NHBK: Spironolactone 25mg PO daily, Carvedilol as above - Ionotrope: Digoxin 0.125mcg PO daily - ICD: s/p [MASKED] ICD placement [MASKED] [MASKED] - Transplant/VAD: undergoing workup # Transplant workup Evaluation for advanced therapies for VAD/transplant started [MASKED]. - Dental/OMFS were consulted for teeth removal. He was found to have no acute dental infections requiring intervention. Therefore, extractions were not performed during this admission. Dental/OMFS recommended pursuing extraction of mobile tooth #9 as an outpatient with an outpatient dentist with no need to hold apixaban. If there are concerns from his primary dentist, he can be referred to our outpatient [MASKED] clinic for extraction. - Underwent right heart catheterization on [MASKED] which demonstrated only mildly elevated filling pressures including a mildly elevated PASP, which is significantly improved from prior. Vasodilator study was not performed given low pulmonary pressures. - CT chest was performed as part of workup, found asymmetric pulmonary edema (R>L) and enlarged mediastinal/hilar lymph nodes. Given these findings, IP was consulted and he underwent bronchoscopy w/ EBUS and lymph node biopsies on [MASKED]. Per pulmonology, unclear etiology of the lymph nodes. Initially thought to be just pulmonary edema but RHC showed he was fairly euvolemic. Other possibilities include prior granulomatous disease or, less likely, lymphoma. # Perianal fistula Initially presented [MASKED] s/p multiple exams under anesthesia, I&D, most recently [MASKED] abscess was drained and malecot catheter placed. Evaluated by [MASKED] [MASKED] [MASKED] clinic after referral from cardiology for pre-transplant evaluation. They noted no evidence of abscess but recommended exam under anesthesia with management of fistula [MASKED] ano. He underwent anal fistulotomy with colorectal surgery on [MASKED]. The procedure was without complications and he had a cutting [MASKED] placed that will remain until outpatient follow up. - Outpatient CRS follow up on [MASKED]. At that visit they will schedule further follow up with Dr. [MASKED]. CHRONIC ISSUES: ============== # CAD c/b MI s/p PCI and subsequent CABG - Continued ASA 81mg - Continued atorvastatin 80mg # Paroxysmal atrial fibrillation # Hx CVA - Continued ASA 81, atorvastatin 80 - Continued carvedilol, digoxin per above - Resumed home apixaban 5mg BID # History of GI bleed - Continued omeprazole # [MASKED] on CKD stage [MASKED] B/l 1.3-1.6. Cr 1.9 on admission, had been up to 2.2 as outpatient. Fluctuated throughout admission, 2.1 on discharge, which may be new baseline. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Sacubitril-Valsartan (97mg-103mg) 1 TAB PO BID 2. Allopurinol [MASKED] mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. CARVedilol 12.5 mg PO BID 5. CARVedilol 6.25 mg PO QPM 6. Digoxin 0.125 mg PO DAILY 7. Omeprazole 40 mg PO BID 8. Spironolactone 25 mg PO DAILY 9. Torsemide 60 mg PO BID 10. Apixaban 5 mg PO BID 11. Aspirin 81 mg PO DAILY Discharge Medications: 1. Allopurinol [MASKED] mg PO DAILY 2. Apixaban 5 mg PO BID 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 80 mg PO QPM 5. CARVedilol 12.5 mg PO BID 6. CARVedilol 6.25 mg PO QPM 7. Digoxin 0.125 mg PO DAILY 8. Omeprazole 40 mg PO BID 9. Sacubitril-Valsartan (97mg-103mg) 1 TAB PO BID 10. Spironolactone 25 mg PO DAILY 11. Torsemide 60 mg PO BID Discharge Disposition: Home Discharge Diagnosis: Chronic heart failure with reduced ejection fraction Paroxysmal atrial fibrillation Perianal fistula Mediastinal/hilar lymphadenopathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], You were admitted to the hospital for heparin (a blood thinner similar to the apixaban you take at home) while getting multiple procedures done. Please see below for more information on your hospitalization. It was a pleasure participating [MASKED] your care! What happened while you were [MASKED] the hospital? - We held your apixaban and started you on a heparin drip for continued anticoagulation for your atrial fibrillation - You underwent multiple procedures while you were hospitalized; this includes a right heart catheterization, an anal fistulotomy, and a bronchoscopy with lymph node biopsies - We gave you a little extra diuretics while you were [MASKED] the hospital to help keep fluid off you. What should you do after leaving the hospital? - Please take your medications as listed below and follow up at the listed appointments. We have made NO changes to your medications. - You have an appointment with the lung doctors [MASKED] [MASKED]. They will go over the results of your biopsy then. - Your weight at discharge is 195.8 lbs. Please weigh yourself today at home and use this as your new baseline. - Please weigh yourself every day [MASKED] the morning. Call your doctor if your weight goes up or down by more than 3 lbs [MASKED] one day or 5 lb [MASKED] one week We wish you the best! - Your [MASKED] Healthcare Team Followup Instructions: [MASKED]
|
[] |
[
"I130",
"N179",
"E785",
"I2510",
"I480",
"I252",
"Z7901",
"Z8673",
"Z951",
"Z955",
"Z87891"
] |
[
"K603: Anal fistula",
"I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease",
"I5022: Chronic systolic (congestive) heart failure",
"N179: Acute kidney failure, unspecified",
"N183: Chronic kidney disease, stage 3 (moderate)",
"E785: Hyperlipidemia, unspecified",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"I480: Paroxysmal atrial fibrillation",
"Z7682: Awaiting organ transplant status",
"I255: Ischemic cardiomyopathy",
"R590: Localized enlarged lymph nodes",
"I2722: Pulmonary hypertension due to left heart disease",
"I252: Old myocardial infarction",
"Z7901: Long term (current) use of anticoagulants",
"Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits",
"Z95810: Presence of automatic (implantable) cardiac defibrillator",
"Z951: Presence of aortocoronary bypass graft",
"Z955: Presence of coronary angioplasty implant and graft",
"Z87891: Personal history of nicotine dependence"
] |
10,003,757 | 26,829,618 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / nitrofurantoin
Attending: ___.
Chief Complaint:
Fall from wheelchair
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ female with a history of peripheral vascular
disease, hypertension, coronary artery disease, emphysema,
pelvic fracture s/p hip replacement presents to the ED after a
fall and a head CT from OSH showing ___ for neurosurgery
evaluation.
Patient was in her usual state of health until today when she
fell from her wheelchair at home. Patient has a laceration to
her forehead. Per report from outside hospital, patient was
getting up from her wheelchair when she tripped and fell forward
hitting her head. Patient denies any chest pain and there is no
nausea or vomiting
Past Medical History:
Past medical history:
- Peripheral vascular disease
- Hypertension
- Coronary artery disease
- Emphysema
- Pelvic fracture
Past surgical history:
- Right hip replacement
Social History:
___
Family History:
NC
Physical Exam:
ADMISSION:
Vital signs: reviewed
General: alert and oriented x3, cooperative, speaks in full
sentences
HEENT: EOMI PERLA, left periorbital ecchymosis, left forehead
laceration sutured by ED team. Neck supple.
Pulmonary: clear to auscultation bilaterally
Cardiovascular: regular rate and rhythm, no murmurs
Abdomen: soft, nontedner, nondistended.
Extremities: warm and well perfussed. Normal ___ 2+
DISCHARGE
Vitals: 97.5 122/58R Lying 87 18 95 Ra
Gen: Calm, alert, NAD
HEENT: Ecchymosis surrounding the left eye, improving, no
conjunctival hemorrhage
CV: RRR, ___ harsh systolic murmur with radiation to the
carotids
Resp: Lungs clear to auscultation bilaterally, no w/r/r
Abd: Soft, NTND
Ext: warm, no edema, L calf > R calf
MSK: ecchymosis of L shoulder, mild ttp and with movement, large
hematoma on lateral L hip/buttock
Neuro: alert, oriented to self and place, not date
Pertinent Results:
ADMISSION:
___ 10:30PM BLOOD WBC-23.6* RBC-2.90* Hgb-9.4* Hct-29.5*
MCV-102* MCH-32.4* MCHC-31.9* RDW-15.0 RDWSD-55.3* Plt ___
___ 10:30PM BLOOD Neuts-79.6* Lymphs-8.2* Monos-10.3
Eos-0.6* Baso-0.5 Im ___ AbsNeut-18.76* AbsLymp-1.92
AbsMono-2.42* AbsEos-0.15 AbsBaso-0.12*
___ 10:30PM BLOOD ___ PTT-25.3 ___
___ 10:30PM BLOOD Glucose-134* UreaN-16 Creat-0.5 Na-136
K-4.7 Cl-98 HCO3-26 AnGap-12
___ 10:44AM BLOOD Calcium-8.0* Phos-3.4 Mg-1.6
DISCHARGE:
___ 05:57AM BLOOD WBC-9.9 RBC-2.42* Hgb-7.7* Hct-24.8*
MCV-103* MCH-31.8 MCHC-31.0* RDW-17.2* RDWSD-61.1* Plt ___
MICRO:
___ BLOOD CULTURE Blood Culture,
Routine-PENDING EMERGENCY WARD
___ BLOOD CULTURE Blood Culture,
Routine-PENDING
___ 1:52 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 8 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
IMAGING
___ CT C/A/P:
1. Severe T12 compression fracture with slight retropulsion of
the superior T2 endplate, indeterminate age.
2. Multiple fractures of posterior and lateral ___ ribs,
some of which demonstrate developing callus, suggesting subacute
chronicity.
3. Acute appearing right L1 transverse process fracture, and
probable T10 and T11 spinous process fractures.
4. Status post aortic bifemoral bypass with complete occlusion
of right bypass graft.
5. 3.5 cm fluid collection encasing the left bypass graft in the
left lower quadrant, likely representing a seroma.
6. Apparent filling defect in the left common femoral vein,
likely mixing
artifact. However, ultrasound is recommended to evaluate for
possible DVT.
7. UIP pattern of pulmonary fibrosis in the bilateral lung
bases.
8. Diverticulosis without evidence of acute diverticulitis.
9. 4.2 cm abdominal aortic aneurysm at the level of the aortic
hiatus.
___ L ___:
IMPRESSION:
No evidence of deep venous thrombosis in the left lower
extremity veins.
___ CT head:
1. Mild left frontal subarachnoid hemorrhage. No prior studies
available for comparison.
2. Presumed arachnoid cyst in the left middle cranial fossa.
___ TTE:
The left atrial volume index is normal. There is no evidence for
an atrial septal defect by 2D/color Doppler.
The estimated right atrial pressure is ___ mmHg. There is mild
(non-obstructive) hypertrophy of the basal
septum with a normal cavity size. There is normal regional left
ventricular systolic function. Global left
ventricular systolic function is normal. The visually estimated
left ventricular ejection fraction is 60%. Left
ventricular cardiac index is normal (>2.5L/min/m2) No
ventricular septal defect is seen. There is no resting
left ventricular outflow tract gradient. Normal right
ventricular cavity size with normal free wall motion. The
aortic sinus diameter is normal with normal ascending aorta
diameter. The aortic arch diameter is normal.
There are simple atheroma in the abdominal aorta. The aortic
valve leaflets (3) are mildly thickened. There is
moderate aortic valve stenosis (valve area 1.0-1.5 cm2). There
is no aortic regurgitation. The mitral leaflets
are mildly thickened with no mitral valve prolapse. There is
moderate mitral annular calcification. There is no
mitral valve stenosis. There is mild [1+] mitral regurgitation.
Due to acoustic shadowing, the severity of mitral
regurgitation could be UNDERestimated. The tricuspid valve
leaflets appear structurally normal. There is trivial
tricuspid regurgitation. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial
effusion.
IMPRESSION: Adequate image quality. Moderate low gradient aortic
stenosis. Normal biventricular systolic
function.
___ XR shoulder/humerus:
1. No fracture or dislocation.
2. Multiple focal lucencies in the left humeral shaft could
reflect osteopenia but raise concern for multiple myeloma or
diffuse metastatic disease, which could be further evaluated
with MRI, SPEP, and UPEP.
3. Moderate to severe degenerative changes of the
acromioclavicular
glenohumeral joints.
Brief Hospital Course:
___ is an ___ with history of dementia, PAD, HTN,
CAD, COPD, prior pelvic fracture s/p hip replacement who
presented to an OSH with an unwitnessed fall and was transferred
to ___ due to CT head showing SAH. Transferred to the medicine
service for encephalopathy.
# Encephalopathy, toxic/metabolic: Patient was acutely altered
on admission with waxing and waning mental status consistent
with delirium on baseline of mild dementia. Found to have
symptomatic UTI which was a like contributor as well as
pain/trauma from her fall. She was started on antibiotics and
improved back to baseline.
# Small left frontal traumatic SAH: Sustained in her fall. She
had repeat head CT that showed stability. She was evaluated by
neurosurgery who felt no surgical intervention was needed. Her
home aspirin and prophylactic subcutaneous heparin were started
on ___. Her goal blood pressure was under 160 and was maintained
throughout her hospitalization. Per neurosurgery she did not
need seizure prophylaxis and did not need neurosurgery follow up
as an outpatient. Sutures were placed for her head laceration
and can be removed on ___.
# T12 compression fracture
# L1 transverse fracture: Per orthospine, likely chronic and
unrelated to recent fall. She worked with ___ who recommended
rehab. She is weight bearing as tolerated and ROM as tolerated.
She should follow up with spine clinic 2 weeks after discharge.
Pain control was with lidocaine patch and Tylenol. Her home
tramadol was restarted on discharge at reduced dose.
# Fall: She suffered an unwitnessed fall and had poor memory of
the event. She is on a number of medications that could
pre-dispose to falls including multiple antihypertensives (and
had positive orthostatics in-house) and sedating/pain
mediations. Symptomatic UTI likely contributer as well. A TTE
revealed moderate AS. Telemetry revealed rare short runs of
self-terminating SVT. Low suspicion overall for cardiac cause of
her fall. Her antihypertensives were held with acceptable blood
pressures throughout (SBPs < 160). Her tramadol and gabapentin
(which had been newly started/uptitrated) were also held.
Tramadol was restarted at a lower dose on the day of discharge
and well tolerated.
# Urinary tract infection: patient with urinary frequency and
pansensitive E coli in her urine culture. She was treated with
ceftriaxone starting ___ and discharged with one day of
cefpodoxime to complete a ___nemia: She was found to be anemic on admission around 7s with
a small drop to 6.4 for which she received 1U pRBC with
appropriate increase. Her H/H remained stable thereafter. Per
her family she has chronic anemia. She may have element of MDS
as she has borderline thrombocytopenia as well. She has a
hip/buttock hematoma that remained stable. Iron studies showed
an elevated ferritin and normal Fe, consistent with ACD.
TRANSITIONAL ISSUES:
[] Patient discharged on cefpodoxime for 400 mg q12h for one day
to complete a 5 day course of antibiotics for UTI
[] Patient with sutures in place; can be removed ___
[] Patient found to be anemic with unknown baseline; if not
previously evaluated could consider further work up
[] Xray of the L humerus revealed: "Multiple focal lucencies in
the left humeral shaft could reflect osteopenia but raise
concern for multiple myeloma or diffuse metastatic disease,
which could be further evaluated with MRI, SPEP, and UPEP."
[] Patients antihypertensives (atenolol and lisinopril) were
stopped on admission due to fall and orthostatic hypotension. If
she develops hypertension, can consider restarting.
[] Patient started on metoprolol succinate 25 mg daily for
cardiac protection as atenolol was stopped
[] Patient's tramadol was decreased to 50 mg TID PRN
[] Patient's gabapentin was held on discharge
**The patient was seen and examined today and is stable for
discharge. Greater than 30 minutes were spent on discharge
coordination and counseling.**
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral DAILY
5. Docusate Sodium 100 mg PO BID
6. Donepezil 5 mg PO QHS
7. Bisacodyl ___AILY:PRN constipation
8. DULoxetine 60 mg PO DAILY
9. Florastor (Saccharomyces boulardii) 250 mg oral BID
10. Gabapentin 100 mg PO QHS
11. Lisinopril 10 mg PO DAILY
12. Loratadine 10 mg PO DAILY
13. Milk of Magnesia 30 mL PO PRN constipation
14. Multivitamins 1 TAB PO DAILY
15. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
16. Omeprazole 20 mg PO BID
17. Senna 17.2 mg PO BID
18. TraMADol 100 mg PO TID
19. Acetaminophen 1000 mg PO Q8H
20. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
21. Ondansetron 4 mg PO Q8H:PRN nausea
Discharge Medications:
1. Cefpodoxime Proxetil 400 mg PO Q12H Duration: 2 Doses
Give on ___. Metoprolol Succinate XL 25 mg PO DAILY
3. TraMADol 50 mg PO TID:PRN Pain - Moderate
4. Acetaminophen 1000 mg PO Q8H
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 40 mg PO QPM
7. Bisacodyl ___AILY:PRN constipation
8. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral DAILY
9. Docusate Sodium 100 mg PO BID
10. Donepezil 5 mg PO QHS
11. DULoxetine 60 mg PO DAILY
12. Florastor (Saccharomyces boulardii) 250 mg oral BID
13. Loratadine 10 mg PO DAILY
14. Milk of Magnesia 30 mL PO PRN constipation
15. Multivitamins 1 TAB PO DAILY
16. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
17. Omeprazole 20 mg PO BID
18. Ondansetron 4 mg PO Q8H:PRN nausea
19. Senna 17.2 mg PO BID
20. HELD- Gabapentin 100 mg PO QHS This medication was held. Do
not restart Gabapentin until talking with your PCP
21. HELD- Lisinopril 10 mg PO DAILY This medication was held.
Do not restart Lisinopril until talking with your PCP
___:
Extended Care
Facility:
___
Discharge Diagnosis:
Small left frontal SAH
T12 compression fracture
Urinary tract infection
Acute right L1 transverse process fracture and T10/T11 spinous
process fractures.
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital after you fell and hit your
head. You had a bleed in your brain but did not need surgery.
You were found to have a small fracture in one of the small
bones in your back but this was thought to have been present
before you fell. You will follow up with spine doctors after ___
leave the hospital for this. You also hit your arm and hip but
did not have any broken bones.
You were found to have a urinary tract infection and treated
with antibiotics. This may have contributed to your fall. You
also were found to have low blood pressure when you stand up, so
your blood pressure medications stopped. You can discuss
restarting them with your primary care doctor.
You were found to be anemic (to have low blood counts) and got a
blood transfusion. Your blood counts were stable after this. You
may need further evaluation of your anemia by your primary care
doctor unless this has already been done.
It was a pleasure participating in your care. We wish you all
the best in the future!
Sincerely,
Your ___ team
Followup Instructions:
___
|
[
"S066X0A",
"G92",
"N390",
"W050XXA",
"Y92009",
"I2510",
"I10",
"I739",
"J439",
"Z96641",
"B9620",
"F0390",
"I350",
"D649",
"D469",
"S0181XA",
"M4854XD",
"J8410",
"Z66",
"M8448XD",
"S7002XA",
"R402142",
"R402362",
"R402252"
] |
Allergies: Sulfa (Sulfonamide Antibiotics) / nitrofurantoin Chief Complaint: Fall from wheelchair Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] female with a history of peripheral vascular disease, hypertension, coronary artery disease, emphysema, pelvic fracture s/p hip replacement presents to the ED after a fall and a head CT from OSH showing [MASKED] for neurosurgery evaluation. Patient was in her usual state of health until today when she fell from her wheelchair at home. Patient has a laceration to her forehead. Per report from outside hospital, patient was getting up from her wheelchair when she tripped and fell forward hitting her head. Patient denies any chest pain and there is no nausea or vomiting Past Medical History: Past medical history: - Peripheral vascular disease - Hypertension - Coronary artery disease - Emphysema - Pelvic fracture Past surgical history: - Right hip replacement Social History: [MASKED] Family History: NC Physical Exam: ADMISSION: Vital signs: reviewed General: alert and oriented x3, cooperative, speaks in full sentences HEENT: EOMI PERLA, left periorbital ecchymosis, left forehead laceration sutured by ED team. Neck supple. Pulmonary: clear to auscultation bilaterally Cardiovascular: regular rate and rhythm, no murmurs Abdomen: soft, nontedner, nondistended. Extremities: warm and well perfussed. Normal [MASKED] 2+ DISCHARGE Vitals: 97.5 122/58R Lying 87 18 95 Ra Gen: Calm, alert, NAD HEENT: Ecchymosis surrounding the left eye, improving, no conjunctival hemorrhage CV: RRR, [MASKED] harsh systolic murmur with radiation to the carotids Resp: Lungs clear to auscultation bilaterally, no w/r/r Abd: Soft, NTND Ext: warm, no edema, L calf > R calf MSK: ecchymosis of L shoulder, mild ttp and with movement, large hematoma on lateral L hip/buttock Neuro: alert, oriented to self and place, not date Pertinent Results: ADMISSION: [MASKED] 10:30PM BLOOD WBC-23.6* RBC-2.90* Hgb-9.4* Hct-29.5* MCV-102* MCH-32.4* MCHC-31.9* RDW-15.0 RDWSD-55.3* Plt [MASKED] [MASKED] 10:30PM BLOOD Neuts-79.6* Lymphs-8.2* Monos-10.3 Eos-0.6* Baso-0.5 Im [MASKED] AbsNeut-18.76* AbsLymp-1.92 AbsMono-2.42* AbsEos-0.15 AbsBaso-0.12* [MASKED] 10:30PM BLOOD [MASKED] PTT-25.3 [MASKED] [MASKED] 10:30PM BLOOD Glucose-134* UreaN-16 Creat-0.5 Na-136 K-4.7 Cl-98 HCO3-26 AnGap-12 [MASKED] 10:44AM BLOOD Calcium-8.0* Phos-3.4 Mg-1.6 DISCHARGE: [MASKED] 05:57AM BLOOD WBC-9.9 RBC-2.42* Hgb-7.7* Hct-24.8* MCV-103* MCH-31.8 MCHC-31.0* RDW-17.2* RDWSD-61.1* Plt [MASKED] MICRO: [MASKED] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY WARD [MASKED] BLOOD CULTURE Blood Culture, Routine-PENDING [MASKED] 1:52 am URINE **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: ESCHERICHIA COLI. >100,000 CFU/mL. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] ESCHERICHIA COLI | AMPICILLIN------------ 8 S AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S IMAGING [MASKED] CT C/A/P: 1. Severe T12 compression fracture with slight retropulsion of the superior T2 endplate, indeterminate age. 2. Multiple fractures of posterior and lateral [MASKED] ribs, some of which demonstrate developing callus, suggesting subacute chronicity. 3. Acute appearing right L1 transverse process fracture, and probable T10 and T11 spinous process fractures. 4. Status post aortic bifemoral bypass with complete occlusion of right bypass graft. 5. 3.5 cm fluid collection encasing the left bypass graft in the left lower quadrant, likely representing a seroma. 6. Apparent filling defect in the left common femoral vein, likely mixing artifact. However, ultrasound is recommended to evaluate for possible DVT. 7. UIP pattern of pulmonary fibrosis in the bilateral lung bases. 8. Diverticulosis without evidence of acute diverticulitis. 9. 4.2 cm abdominal aortic aneurysm at the level of the aortic hiatus. [MASKED] L [MASKED]: IMPRESSION: No evidence of deep venous thrombosis in the left lower extremity veins. [MASKED] CT head: 1. Mild left frontal subarachnoid hemorrhage. No prior studies available for comparison. 2. Presumed arachnoid cyst in the left middle cranial fossa. [MASKED] TTE: The left atrial volume index is normal. There is no evidence for an atrial septal defect by 2D/color Doppler. The estimated right atrial pressure is [MASKED] mmHg. There is mild (non-obstructive) hypertrophy of the basal septum with a normal cavity size. There is normal regional left ventricular systolic function. Global left ventricular systolic function is normal. The visually estimated left ventricular ejection fraction is 60%. Left ventricular cardiac index is normal (>2.5L/min/m2) No ventricular septal defect is seen. There is no resting left ventricular outflow tract gradient. Normal right ventricular cavity size with normal free wall motion. The aortic sinus diameter is normal with normal ascending aorta diameter. The aortic arch diameter is normal. There are simple atheroma in the abdominal aorta. The aortic valve leaflets (3) are mildly thickened. There is moderate aortic valve stenosis (valve area 1.0-1.5 cm2). There is no aortic regurgitation. The mitral leaflets are mildly thickened with no mitral valve prolapse. There is moderate mitral annular calcification. There is no mitral valve stenosis. There is mild [1+] mitral regurgitation. Due to acoustic shadowing, the severity of mitral regurgitation could be UNDERestimated. The tricuspid valve leaflets appear structurally normal. There is trivial tricuspid regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Adequate image quality. Moderate low gradient aortic stenosis. Normal biventricular systolic function. [MASKED] XR shoulder/humerus: 1. No fracture or dislocation. 2. Multiple focal lucencies in the left humeral shaft could reflect osteopenia but raise concern for multiple myeloma or diffuse metastatic disease, which could be further evaluated with MRI, SPEP, and UPEP. 3. Moderate to severe degenerative changes of the acromioclavicular glenohumeral joints. Brief Hospital Course: [MASKED] is an [MASKED] with history of dementia, PAD, HTN, CAD, COPD, prior pelvic fracture s/p hip replacement who presented to an OSH with an unwitnessed fall and was transferred to [MASKED] due to CT head showing SAH. Transferred to the medicine service for encephalopathy. # Encephalopathy, toxic/metabolic: Patient was acutely altered on admission with waxing and waning mental status consistent with delirium on baseline of mild dementia. Found to have symptomatic UTI which was a like contributor as well as pain/trauma from her fall. She was started on antibiotics and improved back to baseline. # Small left frontal traumatic SAH: Sustained in her fall. She had repeat head CT that showed stability. She was evaluated by neurosurgery who felt no surgical intervention was needed. Her home aspirin and prophylactic subcutaneous heparin were started on [MASKED]. Her goal blood pressure was under 160 and was maintained throughout her hospitalization. Per neurosurgery she did not need seizure prophylaxis and did not need neurosurgery follow up as an outpatient. Sutures were placed for her head laceration and can be removed on [MASKED]. # T12 compression fracture # L1 transverse fracture: Per orthospine, likely chronic and unrelated to recent fall. She worked with [MASKED] who recommended rehab. She is weight bearing as tolerated and ROM as tolerated. She should follow up with spine clinic 2 weeks after discharge. Pain control was with lidocaine patch and Tylenol. Her home tramadol was restarted on discharge at reduced dose. # Fall: She suffered an unwitnessed fall and had poor memory of the event. She is on a number of medications that could pre-dispose to falls including multiple antihypertensives (and had positive orthostatics in-house) and sedating/pain mediations. Symptomatic UTI likely contributer as well. A TTE revealed moderate AS. Telemetry revealed rare short runs of self-terminating SVT. Low suspicion overall for cardiac cause of her fall. Her antihypertensives were held with acceptable blood pressures throughout (SBPs < 160). Her tramadol and gabapentin (which had been newly started/uptitrated) were also held. Tramadol was restarted at a lower dose on the day of discharge and well tolerated. # Urinary tract infection: patient with urinary frequency and pansensitive E coli in her urine culture. She was treated with ceftriaxone starting [MASKED] and discharged with one day of cefpodoxime to complete a nemia: She was found to be anemic on admission around 7s with a small drop to 6.4 for which she received 1U pRBC with appropriate increase. Her H/H remained stable thereafter. Per her family she has chronic anemia. She may have element of MDS as she has borderline thrombocytopenia as well. She has a hip/buttock hematoma that remained stable. Iron studies showed an elevated ferritin and normal Fe, consistent with ACD. TRANSITIONAL ISSUES: [] Patient discharged on cefpodoxime for 400 mg q12h for one day to complete a 5 day course of antibiotics for UTI [] Patient with sutures in place; can be removed [MASKED] [] Patient found to be anemic with unknown baseline; if not previously evaluated could consider further work up [] Xray of the L humerus revealed: "Multiple focal lucencies in the left humeral shaft could reflect osteopenia but raise concern for multiple myeloma or diffuse metastatic disease, which could be further evaluated with MRI, SPEP, and UPEP." [] Patients antihypertensives (atenolol and lisinopril) were stopped on admission due to fall and orthostatic hypotension. If she develops hypertension, can consider restarting. [] Patient started on metoprolol succinate 25 mg daily for cardiac protection as atenolol was stopped [] Patient's tramadol was decreased to 50 mg TID PRN [] Patient's gabapentin was held on discharge **The patient was seen and examined today and is stable for discharge. Greater than 30 minutes were spent on discharge coordination and counseling.** Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Atenolol 25 mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. Calcium 500 + D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -200 unit oral DAILY 5. Docusate Sodium 100 mg PO BID 6. Donepezil 5 mg PO QHS 7. Bisacodyl AILY:PRN constipation 8. DULoxetine 60 mg PO DAILY 9. Florastor (Saccharomyces boulardii) 250 mg oral BID 10. Gabapentin 100 mg PO QHS 11. Lisinopril 10 mg PO DAILY 12. Loratadine 10 mg PO DAILY 13. Milk of Magnesia 30 mL PO PRN constipation 14. Multivitamins 1 TAB PO DAILY 15. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 16. Omeprazole 20 mg PO BID 17. Senna 17.2 mg PO BID 18. TraMADol 100 mg PO TID 19. Acetaminophen 1000 mg PO Q8H 20. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 21. Ondansetron 4 mg PO Q8H:PRN nausea Discharge Medications: 1. Cefpodoxime Proxetil 400 mg PO Q12H Duration: 2 Doses Give on [MASKED]. Metoprolol Succinate XL 25 mg PO DAILY 3. TraMADol 50 mg PO TID:PRN Pain - Moderate 4. Acetaminophen 1000 mg PO Q8H 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 40 mg PO QPM 7. Bisacodyl AILY:PRN constipation 8. Calcium 500 + D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -200 unit oral DAILY 9. Docusate Sodium 100 mg PO BID 10. Donepezil 5 mg PO QHS 11. DULoxetine 60 mg PO DAILY 12. Florastor (Saccharomyces boulardii) 250 mg oral BID 13. Loratadine 10 mg PO DAILY 14. Milk of Magnesia 30 mL PO PRN constipation 15. Multivitamins 1 TAB PO DAILY 16. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 17. Omeprazole 20 mg PO BID 18. Ondansetron 4 mg PO Q8H:PRN nausea 19. Senna 17.2 mg PO BID 20. HELD- Gabapentin 100 mg PO QHS This medication was held. Do not restart Gabapentin until talking with your PCP 21. HELD- Lisinopril 10 mg PO DAILY This medication was held. Do not restart Lisinopril until talking with your PCP [MASKED]: Extended Care Facility: [MASKED] Discharge Diagnosis: Small left frontal SAH T12 compression fracture Urinary tract infection Acute right L1 transverse process fracture and T10/T11 spinous process fractures. Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [MASKED], You were admitted to the hospital after you fell and hit your head. You had a bleed in your brain but did not need surgery. You were found to have a small fracture in one of the small bones in your back but this was thought to have been present before you fell. You will follow up with spine doctors after [MASKED] leave the hospital for this. You also hit your arm and hip but did not have any broken bones. You were found to have a urinary tract infection and treated with antibiotics. This may have contributed to your fall. You also were found to have low blood pressure when you stand up, so your blood pressure medications stopped. You can discuss restarting them with your primary care doctor. You were found to be anemic (to have low blood counts) and got a blood transfusion. Your blood counts were stable after this. You may need further evaluation of your anemia by your primary care doctor unless this has already been done. It was a pleasure participating in your care. We wish you all the best in the future! Sincerely, Your [MASKED] team Followup Instructions: [MASKED]
|
[] |
[
"N390",
"I2510",
"I10",
"D649",
"Z66"
] |
[
"S066X0A: Traumatic subarachnoid hemorrhage without loss of consciousness, initial encounter",
"G92: Toxic encephalopathy",
"N390: Urinary tract infection, site not specified",
"W050XXA: Fall from non-moving wheelchair, initial encounter",
"Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"I10: Essential (primary) hypertension",
"I739: Peripheral vascular disease, unspecified",
"J439: Emphysema, unspecified",
"Z96641: Presence of right artificial hip joint",
"B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere",
"F0390: Unspecified dementia without behavioral disturbance",
"I350: Nonrheumatic aortic (valve) stenosis",
"D649: Anemia, unspecified",
"D469: Myelodysplastic syndrome, unspecified",
"S0181XA: Laceration without foreign body of other part of head, initial encounter",
"M4854XD: Collapsed vertebra, not elsewhere classified, thoracic region, subsequent encounter for fracture with routine healing",
"J8410: Pulmonary fibrosis, unspecified",
"Z66: Do not resuscitate",
"M8448XD: Pathological fracture, other site, subsequent encounter for fracture with routine healing",
"S7002XA: Contusion of left hip, initial encounter",
"R402142: Coma scale, eyes open, spontaneous, at arrival to emergency department",
"R402362: Coma scale, best motor response, obeys commands, at arrival to emergency department",
"R402252: Coma scale, best verbal response, oriented, at arrival to emergency department"
] |
10,004,113 | 29,879,900 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Seizures, Headaches, left frontal cavernous Malformation
Major Surgical or Invasive Procedure:
___ craniotomy for RSX of Cavernous malformation
History of Present Illness:
Mr. ___ is a very pleasant ___ Caucasian male who was
diagnosed with a left inferolateral frontal lobe cavernous
malformation approximately ___ years ago in around ___. He
has had an episode where he had twitching of the right side of
his tongue, some dysarthria and that resulted into more
extensive simple partial seizures. Now, this past ___, he
again had a similar episode where he had twitching of the right
side of his tongue and he had difficulty speaking. He is
currently taking Keppra 1000 mg once a day at night.
A recent CT shows some hyperdensity within the lesion that is
indicative of recent hemorrhage. Given the fact that he has
continuous seizures despite management of antiepileptic drugs
and the vicinity of the small cavernoma to the brain surface, we
think it is reasonable to remove it surgically. We will set him
up for surgical resection to a preresection Wand Brain Lab MRI
prior. He reviewed the risks and benefits of this operation and
he is okay with preceding.
Past Medical History:
Left frontal cavernous malformation w/seizures & headaches
Social History:
___
Family History:
NC
Physical Exam:
On Discharge:
alert, oriented x3. PERRL. Face symmetric. Tongue midline. EOM
intact.
Strength ___ throughout. Sensation intact to light touch.
No pronator drift.
Incision c/d/I with staples - no erythema. Mild L facial
swelling
Pertinent Results:
MR HEAD W/ CONTRAST Study Date of ___ 5:16 AM
IMPRESSION:
1. Unchanged appearance of a left temporal operculum 1.0 cm
lesion compatible with a cavernoma with associated large
developmental venous anomaly.
2. Unchanged appearance of a right posterior parasagittal 0.8 cm
meningioma.
Brief Hospital Course:
___ Caucasian male who was diagnosed with a left
inferolateral frontal lobe cavernous malformation approximately
___ years ago, with recent recurrent seizure activity, who
presents for elective left craniotomy for Cav Mal resection.
#Inferolateral frontal lobe cavernous malformation: The patient
was taken to the OR on ___ for a left craniotomy for
frontal lobe cavernous malformation resection with Dr. ___.
The procedure was uncomplicated, the patient was extubated and
recovered in the PACU. He was closely monitored and then was
transferred to the step down unit when stable. He remained
neurologically intact. No postop imaging was indicated. Keppra
was increased to 500 mg qAM and 1000 mg q ___. Foley was removed
and he was urinating without retention. His diet was advanced
and well tolerated, he was ambulating, and pain was well
controlled with PO medications. He was discharged home on POD#2.
Medications on Admission:
Keppra 1gm Daily, lorazepam (PRN seizures), isotretinoin
Discharge Medications:
1. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN Headache
no not take >4g acetaminophen in 24 hours from any source
RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg ___
capsule(s) by mouth every 6 hours as needed Disp #*30 Capsule
Refills:*0
2. Docusate Sodium 100 mg PO BID
3. LevETIRAcetam 500 mg PO QAM
RX *levetiracetam [Keppra] 500 mg 1 tablet(s) by mouth every
morning Disp #*30 Tablet Refills:*0
4. LevETIRAcetam 1000 mg PO QHS
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours as needed
Disp #*30 Tablet Refills:*0
6. Senna 8.6 mg PO BID:PRN Constipation
Discharge Disposition:
Home
Discharge Diagnosis:
cavernous malformation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Discharge Instructions
Brain Tumor
Surgery
You underwent surgery to remove a Cavernous Malformation from
your brain.
Please keep your incision dry until your staples are removed.
You may shower at this time but keep your incision dry.
It is best to keep your incision open to air but it is ok to
cover it when outside.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may experience headaches and incisional pain.
You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
Feeling more tired or restlessness is also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason
Followup Instructions:
___
|
[
"D1802",
"I619",
"G40909"
] |
Allergies: Penicillins Chief Complaint: Seizures, Headaches, left frontal cavernous Malformation Major Surgical or Invasive Procedure: [MASKED] craniotomy for RSX of Cavernous malformation History of Present Illness: Mr. [MASKED] is a very pleasant [MASKED] Caucasian male who was diagnosed with a left inferolateral frontal lobe cavernous malformation approximately [MASKED] years ago in around [MASKED]. He has had an episode where he had twitching of the right side of his tongue, some dysarthria and that resulted into more extensive simple partial seizures. Now, this past [MASKED], he again had a similar episode where he had twitching of the right side of his tongue and he had difficulty speaking. He is currently taking Keppra 1000 mg once a day at night. A recent CT shows some hyperdensity within the lesion that is indicative of recent hemorrhage. Given the fact that he has continuous seizures despite management of antiepileptic drugs and the vicinity of the small cavernoma to the brain surface, we think it is reasonable to remove it surgically. We will set him up for surgical resection to a preresection Wand Brain Lab MRI prior. He reviewed the risks and benefits of this operation and he is okay with preceding. Past Medical History: Left frontal cavernous malformation w/seizures & headaches Social History: [MASKED] Family History: NC Physical Exam: On Discharge: alert, oriented x3. PERRL. Face symmetric. Tongue midline. EOM intact. Strength [MASKED] throughout. Sensation intact to light touch. No pronator drift. Incision c/d/I with staples - no erythema. Mild L facial swelling Pertinent Results: MR HEAD W/ CONTRAST Study Date of [MASKED] 5:16 AM IMPRESSION: 1. Unchanged appearance of a left temporal operculum 1.0 cm lesion compatible with a cavernoma with associated large developmental venous anomaly. 2. Unchanged appearance of a right posterior parasagittal 0.8 cm meningioma. Brief Hospital Course: [MASKED] Caucasian male who was diagnosed with a left inferolateral frontal lobe cavernous malformation approximately [MASKED] years ago, with recent recurrent seizure activity, who presents for elective left craniotomy for Cav Mal resection. #Inferolateral frontal lobe cavernous malformation: The patient was taken to the OR on [MASKED] for a left craniotomy for frontal lobe cavernous malformation resection with Dr. [MASKED]. The procedure was uncomplicated, the patient was extubated and recovered in the PACU. He was closely monitored and then was transferred to the step down unit when stable. He remained neurologically intact. No postop imaging was indicated. Keppra was increased to 500 mg qAM and 1000 mg q [MASKED]. Foley was removed and he was urinating without retention. His diet was advanced and well tolerated, he was ambulating, and pain was well controlled with PO medications. He was discharged home on POD#2. Medications on Admission: Keppra 1gm Daily, lorazepam (PRN seizures), isotretinoin Discharge Medications: 1. Acetaminophen-Caff-Butalbital [MASKED] TAB PO Q6H:PRN Headache no not take >4g acetaminophen in 24 hours from any source RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg [MASKED] capsule(s) by mouth every 6 hours as needed Disp #*30 Capsule Refills:*0 2. Docusate Sodium 100 mg PO BID 3. LevETIRAcetam 500 mg PO QAM RX *levetiracetam [Keppra] 500 mg 1 tablet(s) by mouth every morning Disp #*30 Tablet Refills:*0 4. LevETIRAcetam 1000 mg PO QHS 5. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours as needed Disp #*30 Tablet Refills:*0 6. Senna 8.6 mg PO BID:PRN Constipation Discharge Disposition: Home Discharge Diagnosis: cavernous malformation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Discharge Instructions Brain Tumor Surgery You underwent surgery to remove a Cavernous Malformation from your brain. Please keep your incision dry until your staples are removed. You may shower at this time but keep your incision dry. It is best to keep your incision open to air but it is 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. [MASKED] try to do too much all at once. No driving while taking any narcotic or sedating medication. If you experienced a seizure while admitted, you are NOT allowed to drive by law. No contact sports until cleared by your neurosurgeon. You should avoid contact sports for 6 months. Medications Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. You have been discharged on Keppra (Levetiracetam). This medication helps to prevent seizures. Please continue this medication as indicated on your discharge instruction. It is important that you take this medication consistently and on time. You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. What You [MASKED] 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 [MASKED] 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 [MASKED] and go to the nearest Emergency Room if you experience any of the following: Sudden numbness or weakness in the face, arm, or leg Sudden confusion or trouble speaking or understanding Sudden trouble walking, dizziness, or loss of balance or coordination Sudden severe headaches with no known reason Followup Instructions: [MASKED]
|
[] |
[] |
[
"D1802: Hemangioma of intracranial structures",
"I619: Nontraumatic intracerebral hemorrhage, unspecified",
"G40909: Epilepsy, unspecified, not intractable, without status epilepticus"
] |
10,004,296 | 21,736,479 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Sulfamethoxazole / Penicillins
Attending: ___.
Chief Complaint:
arrest of descent, gHTN, incisional cellulitis with wound
abscess
Major Surgical or Invasive Procedure:
primary low transverse cesarean section
History of Present Illness:
Patient is a ___ year-old G3P0 with EDC = ___ (EGA = 37w1d on
___ with elevated blood pressures in the office as
high as 140/70 over the past week. Repeat BP in OB triage =
142/70, 141/72, 139/85. PIH labs on ___ showed:
CBC 15.6 > 10.6 / 30.3 < 312
ALT 21
Cr 0.5
Uric Acid 5.0
UP:C 0.1
She currently denies headache, visual changes,
epigastric or RUQ pain. Denies ctx, VB, LOF. +FM
Past Medical History:
MEDICAL HISTORY
Allergies (Last Verified ___ by ___:
Penicillins
Sulfamethoxazole
--------------- --------------- --------------- ---------------
Active Medication list as of ___:
Medications - Prescription
ALBUTEROL SULFATE [PROAIR HFA] - ProAir HFA 90 mcg/actuation
aerosol inhaler. 2 puffs every four (4) hours PRN
BUDESONIDE-FORMOTEROL [SYMBICORT] - Symbicort 160 mcg-4.5
mcg/actuation HFA aerosol inhaler. 2 puffs inh twice a day
PNV WITH CALCIUM ___ [PRENATAL VITAMINS LOW IRON] -
Dosage uncertain - (Prescribed by Other Provider)
Medications - OTC
DOCUSATE SODIUM - docusate sodium 100 mg capsule. 1 capsule(s)
by
mouth once per day, as needed, for constipation
--------------- --------------- --------------- ---------------
Problems (Last Verified ___ by ___, MD):
ASTHMA, EXTRINSIC W/ ACUTE EXACERBATION
493.02
ECZEMATOUS DERMATITIS
H/O TOBACCO USE
305.1
Surgical History (Last Verified ___ by ___,
MD):
Surgical History updated, no known surgical history.
Family History (Last Verified ___ by ___, MD):
Relative Status Age Problem Comments
Other ASTHMA V17.5
F/H GI MALIGNANCY V16.0
Social History:
___
Family History:
NC
Physical Exam:
VSS
Gen: NAD
Lungs: CTA
CV: RRR
Abd: 2cm opening on right side of incision with packing,
erythema improved from prior, no pus
Ext: 1+ pitting edema bilaterally with no calf tenderness
Brief Hospital Course:
The patient is a ___ G3, P0 at 37 weeks
4 days admitted for induction of labor due to gestational
hypertension. After a prolonged induction, the patient
progressed to fully dilated and +2 station. However, after 5
hours fully dilated and ___ hours pushing, there was no
descent of the fetal head and significant caput was noted. The
patient was recommended to undergo delivery via cesarean
section.
She experienced a PPH with EBL 1200cc from cervical extension,
but remained stable postpartum. In terms of her gestational
hypertension, she had normal labs. She was started on labetalol
200mg BID on ___, which was increased to 300mg BID on
___ for elevated pressures. During her postpartum course she
developed an incisional cellulitis with wound abscess. She was
noted to have erythema and induration on right side of incision
and extending to mons. She was started on IV gent/clinda -> PO
clindamycin started ___ ___, 10d course. She incision was
opened at bedside ___ and she underwent BID wet to dry
dressing changes. She had a wound culture with mixed flora, a
negative urine culture, and blood cultures with no growth.
Patient also experienced bilateral lower extremity edema during
her stay that she found very bothersome. She received Lasix 20mg
PO x1, with improvement of symptoms. She was also maintained on
Lovenox 40mg daily.
She was discharged on ___ in stable condition with plan for
outpatient ___ for BID dressing changes and blood pressure
monitoring.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Prenatal Vitamins 1 TAB PO DAILY
2. Docusate Sodium 100 mg PO DAILY:PRN constipation
3. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation 2 puffs bid
4. ProAir HFA (albuterol sulfate) 90 mcg/actuation 2 puffs
Q4H:PRN wheezing
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN asthma
2. Docusate Sodium 100 mg PO BID:PRN Constipation
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*40 Capsule Refills:*1
3. Ibuprofen 600 mg PO Q6H:PRN Pain
RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp
#*30 Tablet Refills:*0
4. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
5. Clindamycin 450 mg PO Q6H Duration: 10 Days
RX *clindamycin HCl 150 mg 3 capsule(s) by mouth every 6 hrs
Disp #*108 Capsule Refills:*0
6. Ferrous Sulfate 325 mg PO BID
RX *ferrous sulfate 140 mg (45 mg iron) 1 tablet(s) by mouth
twice a day Disp #*60 Tablet Refills:*1
7. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth q4hrs
Disp #*30 Tablet Refills:*0
8. Labetalol 300 mg PO BID
RX *labetalol 300 mg 1 tablet(s) by mouth twice a day Disp #*40
Tablet Refills:*0
9. Prenatal Vitamins 1 TAB PO DAILY
10. ProAir HFA (albuterol sulfate) 90 mcg/actuation 2 PUFFS
Q4H:PRN wheezing
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
primary low transverse cesarean section
gestational hypertension
asthma
arrest of descent
endometritis, cellulitis, wound infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
pelvic rest x 6 weeks until postpartum visit
no heavy lifting or driving x 2 weeks
keep incision clean and dry
Followup Instructions:
___
|
[
"O133",
"O722",
"O8612",
"O639",
"L03311",
"L02211",
"O324XX0",
"O99334",
"O9952",
"R609",
"J45909",
"O860",
"Z3A37",
"Z370"
] |
Allergies: Sulfamethoxazole / Penicillins Chief Complaint: arrest of descent, gHTN, incisional cellulitis with wound abscess Major Surgical or Invasive Procedure: primary low transverse cesarean section History of Present Illness: Patient is a [MASKED] year-old G3P0 with EDC = [MASKED] (EGA = 37w1d on [MASKED] with elevated blood pressures in the office as high as 140/70 over the past week. Repeat BP in OB triage = 142/70, 141/72, 139/85. PIH labs on [MASKED] showed: CBC 15.6 > 10.6 / 30.3 < 312 ALT 21 Cr 0.5 Uric Acid 5.0 UP:C 0.1 She currently denies headache, visual changes, epigastric or RUQ pain. Denies ctx, VB, LOF. +FM Past Medical History: MEDICAL HISTORY Allergies (Last Verified [MASKED] by [MASKED]: Penicillins Sulfamethoxazole --------------- --------------- --------------- --------------- Active Medication list as of [MASKED]: Medications - Prescription ALBUTEROL SULFATE [PROAIR HFA] - ProAir HFA 90 mcg/actuation aerosol inhaler. 2 puffs every four (4) hours PRN BUDESONIDE-FORMOTEROL [SYMBICORT] - Symbicort 160 mcg-4.5 mcg/actuation HFA aerosol inhaler. 2 puffs inh twice a day PNV WITH CALCIUM [MASKED] [PRENATAL VITAMINS LOW IRON] - Dosage uncertain - (Prescribed by Other Provider) Medications - OTC DOCUSATE SODIUM - docusate sodium 100 mg capsule. 1 capsule(s) by mouth once per day, as needed, for constipation --------------- --------------- --------------- --------------- Problems (Last Verified [MASKED] by [MASKED], MD): ASTHMA, EXTRINSIC W/ ACUTE EXACERBATION 493.02 ECZEMATOUS DERMATITIS H/O TOBACCO USE 305.1 Surgical History (Last Verified [MASKED] by [MASKED], MD): Surgical History updated, no known surgical history. Family History (Last Verified [MASKED] by [MASKED], MD): Relative Status Age Problem Comments Other ASTHMA V17.5 F/H GI MALIGNANCY V16.0 Social History: [MASKED] Family History: NC Physical Exam: VSS Gen: NAD Lungs: CTA CV: RRR Abd: 2cm opening on right side of incision with packing, erythema improved from prior, no pus Ext: 1+ pitting edema bilaterally with no calf tenderness Brief Hospital Course: The patient is a [MASKED] G3, P0 at 37 weeks 4 days admitted for induction of labor due to gestational hypertension. After a prolonged induction, the patient progressed to fully dilated and +2 station. However, after 5 hours fully dilated and [MASKED] hours pushing, there was no descent of the fetal head and significant caput was noted. The patient was recommended to undergo delivery via cesarean section. She experienced a PPH with EBL 1200cc from cervical extension, but remained stable postpartum. In terms of her gestational hypertension, she had normal labs. She was started on labetalol 200mg BID on [MASKED], which was increased to 300mg BID on [MASKED] for elevated pressures. During her postpartum course she developed an incisional cellulitis with wound abscess. She was noted to have erythema and induration on right side of incision and extending to mons. She was started on IV gent/clinda -> PO clindamycin started [MASKED] [MASKED], 10d course. She incision was opened at bedside [MASKED] and she underwent BID wet to dry dressing changes. She had a wound culture with mixed flora, a negative urine culture, and blood cultures with no growth. Patient also experienced bilateral lower extremity edema during her stay that she found very bothersome. She received Lasix 20mg PO x1, with improvement of symptoms. She was also maintained on Lovenox 40mg daily. She was discharged on [MASKED] in stable condition with plan for outpatient [MASKED] for BID dressing changes and blood pressure monitoring. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Prenatal Vitamins 1 TAB PO DAILY 2. Docusate Sodium 100 mg PO DAILY:PRN constipation 3. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation 2 puffs bid 4. ProAir HFA (albuterol sulfate) 90 mcg/actuation 2 puffs Q4H:PRN wheezing Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q4H:PRN asthma 2. Docusate Sodium 100 mg PO BID:PRN Constipation RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*40 Capsule Refills:*1 3. Ibuprofen 600 mg PO Q6H:PRN Pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*30 Tablet Refills:*0 4. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation BID 5. Clindamycin 450 mg PO Q6H Duration: 10 Days RX *clindamycin HCl 150 mg 3 capsule(s) by mouth every 6 hrs Disp #*108 Capsule Refills:*0 6. Ferrous Sulfate 325 mg PO BID RX *ferrous sulfate 140 mg (45 mg iron) 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*1 7. HYDROmorphone (Dilaudid) [MASKED] mg PO Q4H:PRN pain RX *hydromorphone [Dilaudid] 2 mg [MASKED] tablet(s) by mouth q4hrs Disp #*30 Tablet Refills:*0 8. Labetalol 300 mg PO BID RX *labetalol 300 mg 1 tablet(s) by mouth twice a day Disp #*40 Tablet Refills:*0 9. Prenatal Vitamins 1 TAB PO DAILY 10. ProAir HFA (albuterol sulfate) 90 mcg/actuation 2 PUFFS Q4H:PRN wheezing Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: primary low transverse cesarean section gestational hypertension asthma arrest of descent endometritis, cellulitis, wound infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: pelvic rest x 6 weeks until postpartum visit no heavy lifting or driving x 2 weeks keep incision clean and dry Followup Instructions: [MASKED]
|
[] |
[
"J45909"
] |
[
"O133: Gestational [pregnancy-induced] hypertension without significant proteinuria, third trimester",
"O722: Delayed and secondary postpartum hemorrhage",
"O8612: Endometritis following delivery",
"O639: Long labor, unspecified",
"L03311: Cellulitis of abdominal wall",
"L02211: Cutaneous abscess of abdominal wall",
"O324XX0: Maternal care for high head at term, not applicable or unspecified",
"O99334: Smoking (tobacco) complicating childbirth",
"O9952: Diseases of the respiratory system complicating childbirth",
"R609: Edema, unspecified",
"J45909: Unspecified asthma, uncomplicated",
"O860: Infection of obstetric surgical wound",
"Z3A37: 37 weeks gestation of pregnancy",
"Z370: Single live birth"
] |
10,004,322 | 20,356,134 |
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:
___
|
[
"T83511A",
"G92",
"I10",
"B9620",
"J449",
"E119",
"F200",
"N390",
"Y846",
"Y929",
"Z87891",
"K210",
"I2510",
"E785",
"D649"
] |
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] is a [MASKED] year old male with history of schizophrenia with most recent ED visit [MASKED], COPD, DM, mechanical falls most recently in [MASKED] and s/p negative syncope workup in [MASKED], history of urinary retention s/p indwelling foley in [MASKED], admission in [MASKED] for sepsis from pneumonia, presenting with complaints of fever and altered mental status. [MASKED] 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 [MASKED] on [MASKED] by Dr. [MASKED] for evaluation of need for chronic foley which was placed in late [MASKED] after [MASKED] presented to the ED after a fall and was found to be in [MASKED] (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 [MASKED] 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: [MASKED], 99.2F, HR111(106-113), BP135/67 (91-135/55-67), RR25 ([MASKED]), 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 ([MASKED]) 3. T2DM (last HbA1c 7.1 in [MASKED] 4. COPD (last FEV1 unknown) 5. GERD/Reflux Esophagitis 6. CAD 7. HTN 8. Hyperlipidemia Social History: [MASKED] 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 [MASKED] 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 [MASKED] 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: =============== [MASKED] 12:54PM PLT SMR-NORMAL PLT COUNT-376 [MASKED] 12:54PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL [MASKED] 12:54PM NEUTS-85.6* LYMPHS-4.5* MONOS-8.7 EOS-0.0* BASOS-0.2 IM [MASKED] AbsNeut-23.37*# AbsLymp-1.23 AbsMono-2.36* AbsEos-0.00* AbsBaso-0.05 [MASKED] 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 [MASKED] 12:54PM ALBUMIN-3.8 [MASKED] 12:54PM ALT(SGPT)-5 AST(SGOT)-14 ALK PHOS-167* TOT BILI-0.5 [MASKED] 12:54PM estGFR-Using this [MASKED] 12:54PM GLUCOSE-159* UREA N-28* CREAT-1.5* SODIUM-134 POTASSIUM-4.2 CHLORIDE-94* TOTAL CO2-20* ANION GAP-24* [MASKED] 01:19PM LACTATE-1.6 [MASKED] 01:53PM OTHER BODY FLUID FluAPCR-NEGATIVE FluBPCR-NEGATIVE [MASKED] 03:00PM URINE MUCOUS-RARE [MASKED] 03:00PM URINE HYALINE-4* [MASKED] 03:00PM URINE RBC-10* WBC->182* BACTERIA-FEW YEAST-NONE EPI-<1 [MASKED] 03:00PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-LG [MASKED] 03:00PM URINE COLOR-Yellow APPEAR-Hazy SP [MASKED] [MASKED] 03:00PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG oxycodn-NEG [MASKED] 03:00PM URINE UHOLD-HOLD [MASKED] 03:00PM URINE HOURS-RANDOM [MASKED] 09:32PM PLT COUNT-334 [MASKED] 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* [MASKED] 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: ========================= [MASKED] 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 [MASKED] [MASKED] 07:05AM BLOOD Glucose-118* UreaN-6 Creat-0.6 Na-140 K-3.5 Cl-101 HCO3-24 AnGap-19 [MASKED] 07:00AM BLOOD [MASKED] PTT-35.2 [MASKED] [MASKED] 07:00AM BLOOD ALT-6 AST-14 LD(LDH)-176 AlkPhos-127 TotBili-0.4 [MASKED] 07:05AM BLOOD Calcium-8.5 Phos-2.5* Mg-1.7 MICROBIOLOGY: ============== [MASKED] 3:00 pm URINE **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: ESCHERICHIA COLI. 10,000-100,000 CFU/mL. Fosfomycin Susceptibility testing requested by [MASKED]. [MASKED] [MASKED] ([MASKED]) ON [MASKED]. FOSFOMYCIN = 24MM = SUSCEPTIBLE. FOSFOMYCIN sensitivity testing performed by [MASKED] [MASKED]. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] 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: ======== [MASKED] Imaging ABDOMEN (SUPINE & ERECT) Nonobstructive bowel gas pattern in the stomach, small bowel and colon. No evidence of pneumoperitoneum. [MASKED] Imaging CHEST (SINGLE VIEW) No acute cardiopulmonary process. No focal consolidation to suggest pneumonia. [MASKED]-SPINE W/O CONTRAST No acute fracture or malalignment of the cervical spine. [MASKED] Imaging CT HEAD W/O CONTRAST No acute intracranial process. Brief Hospital Course: Mr. [MASKED] is a [MASKED] man with history of paranoid schizophrenia, COPD, Type 2 DM, urinary retention s/p indwelling foley catheter placement in [MASKED], 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 ([MASKED]). # 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 [MASKED] to [MASKED]. 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 [MASKED]. # CODE: Full # CONTACT: [MASKED] ([MASKED]) 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: [MASKED] 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. [MASKED], It was a pleasure taking care of you. You were admitted to the [MASKED] 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 [MASKED] weeks of discharge. Wishing you a speedy recovery, [MASKED] Care Team Followup Instructions: [MASKED]
|
[] |
[
"I10",
"J449",
"E119",
"N390",
"Y929",
"Z87891",
"I2510",
"E785",
"D649"
] |
[
"T83511A: Infection and inflammatory reaction due to indwelling urethral catheter, initial encounter",
"G92: Toxic encephalopathy",
"I10: Essential (primary) hypertension",
"B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere",
"J449: Chronic obstructive pulmonary disease, unspecified",
"E119: Type 2 diabetes mellitus without complications",
"F200: Paranoid schizophrenia",
"N390: Urinary tract infection, site not specified",
"Y846: Urinary catheterization as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure",
"Y929: Unspecified place or not applicable",
"Z87891: Personal history of nicotine dependence",
"K210: Gastro-esophageal reflux disease with esophagitis",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"E785: Hyperlipidemia, unspecified",
"D649: Anemia, unspecified"
] |
10,004,322 | 22,602,599 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
WEAKNESS
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
___ is a ___ year-old M (poor historian) with a PMH of
psychosis, mechanical falls with negative syncope w/u in ___,
T2DM (last HbA1c unknown, on metformin and insulin), and COPD
(last FEV1 unknown), who presents with a 2-week history of
weakness and cough with sputum production.
He was in his usual state of health until 2 weeks ago, when he
began to feel weak and short of breath. Of note, he has had
similar episodes in the past that last for several days and said
directly that "this feels like pneumonia to me." This was
associated with a frequent cough productive of yellow-green
sputum and anorexia with poor PO intake. He denies hemoptysis,
fevers, chills, and night sweats. He denies orthopnea and PND.
He
denies nausea, vomiting, diarrhea, constipation, hematochezia,
melena, dysuria, and hematuria. Yesterday, he experienced
worsening lightheadedness and he had frequent episodes of
tripping. He denies falls, LOC, or head strike with these
episodes.
This morning, he had an episode of chest pain that was
midsternal, sharp, and pleuritic without radiation into the arm
or neck or worsened SOB. Concurrently, he was too weak to rise
from his chair. Last FSG 138. Given his weakness and worsening
respiratory status, he presented to the ED.
___ ED
--------
+ Initial Vitals:
97.5 91 126/81 17 100% RA
+ Exam was notable for:
Dry MM, R tonsillar fullness. No focality to pulmonary exam.
+ Labs were significant for:
BUN 33, Cr 1.5, AGAP 21
WBC 13, Hgb 12.4, Plt 341
Trop <0.01
+ Imaging:
- CT head showed no acute process.
- CXR showed streaky posteroinferior left lobe opacity may
reflect atelectasis, though infection cannot be entirely
excluded.
- EKG showed NSR, rate 90.
+ Interventions: 1L IVF, azithromycin 500mg IV x1, CTX 1g x1.
+ Vitals Prior to Transfer:
97.9 84 132/78 17 99% RA
Currently, he continues to have a cough with intermittent sputum
production. His appetite has returned and he was eating dinner
at
the time of the exam. He denies any other complaints.
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)
Social History:
___
Family History:
Unknown to patient.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: T 97.7 BP 137/80 HR 98 RR 20 SaO2 100% RA Wt 78.88kg
GEN: Man appearing older than stated age, alert, lying in bed
watching TV, no acute distress.
HEENT: Dry MM, anicteric sclerae, no conjunctival pallor. +R
tonsillar fullness.
NECK: Supple without LAD.
PULM: Globally decreased breath sounds with intermittent
expiratory wheeze, no rhonchi or rales, symmetric air movement,
no increased work of breathing.
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, non-tender, non-distended, +bowel sounds.
EXTREM: Warm, well-perfused, no edema. +2 ___ pulses.
NEURO: A&Ox3. CN II-XII grossly intact, motor function grossly
normal. Diminished sensation in bilateral distal ___ (although
difficult to pinpoint given intermittent compliance with the
exam).
DISCHARGE PHYSICAL EXAM
VS: 97.2 141/86 83 18 97 RA
Orthostatics ___:
154/77 82 (lying)
143/78 90 (sitting)
120/86 97 (standing)
GEN: Elderly gentleman lying in bed, arousable but falls asleep
quickly, NAD.
HEENT: Chapped lips, anicteric sclerae. Multiple missing teeth
of front lower jaw.
NECK: Supple without LAD.
PULM: Breath sounds clearer than ___ bilaterally but general
poor air movement decreased, intermittent expiratory wheeze, no
increased work of breathing. No egophony.
COR: RRR (+)S1/S2 no m/r/g, heart sounds distant.
ABD: Soft, non-tender, non-distended, +bowel sounds.
EXTREM: Warm, well-perfused, no edema. +2 ___ pulses.
No e/o diabetic foot ulcers.
NEURO: Refused to answer orientation Qs this AM. Gait deferred.
Pertinent Results:
ADMISSION LABS
------------------
___ 12:30PM BLOOD WBC-13.0* RBC-4.26* Hgb-12.4* Hct-36.5*
MCV-86 MCH-29.1 MCHC-34.0 RDW-13.8 RDWSD-42.5 Plt ___
___ 12:30PM BLOOD Neuts-77.3* Lymphs-16.1* Monos-5.3
Eos-0.5* Baso-0.2 Im ___ AbsNeut-10.01* AbsLymp-2.08
AbsMono-0.69 AbsEos-0.06 AbsBaso-0.03
___ 12:30PM BLOOD Glucose-139* UreaN-33* Creat-1.5* Na-136
K-4.2 Cl-97 HCO3-22 AnGap-21*
OTHER LABS
------------------
___ 06:55AM BLOOD Cortsol-13.0
___ 06:33AM BLOOD Triglyc-379* HDL-25 CHOL/HD-8.8
LDLcalc-120
___ 07:25AM BLOOD WBC-7.2 RBC-3.77* Hgb-10.9* Hct-32.7*
MCV-87 MCH-28.9 MCHC-33.3 RDW-13.9 RDWSD-43.2 Plt ___
___ 06:33AM BLOOD %HbA1c-7.1* eAG-157*
___ 06:33AM BLOOD Triglyc-379* HDL-25 CHOL/HD-8.8
LDLcalc-120
___ 06:33AM BLOOD HBsAg-Negative HBsAb-Negative IgM
HBc-Negative
___ 06:33AM BLOOD HIV Ab-Negative
___ 06:33AM BLOOD HCV Ab-Negative
___ 10:07AM BLOOD ___ pO2-195* pCO2-33* pH-7.43
calTCO2-23 Base XS-0
___ 12:30PM BLOOD cTropnT-<0.01
DISCHARGE LABS
___ 06:13AM BLOOD WBC-9.3 RBC-4.19* Hgb-11.9* Hct-36.5*
MCV-87 MCH-28.4 MCHC-32.6 RDW-13.7 RDWSD-43.2 Plt ___
___ 06:13AM BLOOD Glucose-114* UreaN-16 Creat-1.1 Na-137
K-4.3 Cl-99 HCO3-21* AnGap-21*
IMAGING
---------
+ CXR (___)
Streaky left lobe opacity may reflect atelectasis, though
infection cannot be entirely excluded.
+ CT Head (___)
No acute intracranial abnormalities. Specifically, no evidence
of intra-axial or extra-axial hemorrhage.
+ EKG (___)
NSR, rate 90
Brief Hospital Course:
___ is a ___ year-old M (poor historian) with a PMH of
psychosis, mechanical falls with negative syncope w/u in ___,
T2DM (last HbA1c 7.1 in ___, on metformin and insulin), and
COPD (last FEV1 unknown), who presents with a 2-week history of
weakness and cough with sputum production concerning for CAP as
well as orthostatic hypotension.
# Cough: Likely CAP given leukocytosis (13k), malaise, sputum
production, and LLL infiltrate on CXR. Never met SIRS criteria
during hospitalization. He always saturated well on RA with no
evidence of increased work of breathing. SputumCx indeterminate,
urine legionella negative. He received a 5-day course of
antibiotics with ceftriaxone/azithromycin (___). On
discharge, he was feeling significantly better with no
complaints of cough.
# Dizziness/Weakness: The patient presented with orthostatic
hypotension thought secondary hypovolemia in the setting of poor
PO intake, given positive orthostatics and BUN/Cr > 20:1
suggestive of dehydration. Patient relies on cane at home. ECG
NSR, trops neg. CT Head with no acute process. Electrolytes WNL.
Despite brisk fluid resuscitation and now likely euvolemic
status, orthostatics remain positive and he has a persistent
unsteady gait. Underlying etiology unclear, possibly autonomic
dysfunction ___ DM versus medication (on clozapine). Per
outpatient psychiatrist Dr. ___ has been on the same dose
of clozapine for ___ years. Adrenal insufficiency unlikely as
___ AM cortisol level 13.0. ___ evaluated him on ___ and
recommended rehab. On discharge, his orthostatic vital signs
remained positive and he continued to require assistance with
walking. He was initiated on fludrocortisone 0.1mg QD on ___
with some symptom relief.
# ___: Likely due to hypovolemia in the setting of poor PO
intake given BUN/Cr > 20:1. Last baseline 0.95 in ___. We
gave him IVF as above with resolution of his ___ to Cr 0.9. On
discharge, his BUN/Cr were ___.
# Prior IVDU: Patient reports prior history of heroin use and
"other drugs." He gave consent for HIV testing. HIV, HepB, HepC
were all negative.
CHRONIC ISSUES:
===============
# Psychosis: Continued clozapine.
# Diabetes: RISS, held home metformin. Repeat HbA1c 7.2. FSGs
120s-180s here. No evidence of diabetic foot ulcers.
# COPD: Continued home fluticasone and tiotropium inhaler.
# GERD: Continued home ranitidine.
# CAD: Continued home ASA.
# HTN: Held home lisinopril given orthostatic hypotension.
# HL: Continued home gemfibrozil. Total Chol 221 Triglycerides
379* elevated. HDL low at 25. Chol/HD 8.8, LDL calc 120.
TRANSITIONAL ISSUES
===================
# Fludrocortisone: The patient was initiated on Fluricil on ___
at 0.1mg daily. This can be uptitrated at a rate of 0.1mg per
week to a maximum of 0.3mg daily.
# Transthoracic echo: The patient was scheduled for an
outpatient echo. ECHO office will call patient to make
appointment. He should follow up with a cardiologist to review
the results.
# Nutrition: The patient arrived with evidence of dehydration.
Please ensure that he is reminded to drink water and other
fluids throughout the day, especially if he is feeling ill.
# Former IVDU: HIV, HepC, HepB found to be negative on this
admission. No evidence of active IVDU.
# ? Diabetic neuropathy: The patient intermittently reported
reduced sensation and proprioception in bilateral distal
extremities. His HbA1c was 7.2 on admission, which is mildly
elevated. His orthostatic hypotension may also be an effect of
autonomic neuropathy. His primary care physician should
reevaluate this at their next appointment.
# Orthostatic hypotension: He will be scheduled for an
outpatient follow-up appointment with neurology to evaluate for
potential causes of autonomic neuropathy. If negative, his
psychiatrist should consider redosing of his clozapine to
minimize potential side effects. His primary care physician
should continue to work closely with him to ensure his diabetes
mellitus is being treated adequately.
# Blood cultures: Negative since ___, final result pending at
discharge. If any growth observed, the patient will be notified.
# Lipid panel: Total Chol 221 Triglycerides 379* elevated. HDL
low at 25. Chol/HD 8.8, LDL calc 120. He should have a repeat
lipid panel performed with his primary care physician and
consider alternative agents/dosing to better manage his low HDL
and high triglycerides.
===========================
# CODE STATUS: Full (unconfirmed)
# CONTACT: ___ ___ or ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Clozapine 200 mg PO BID
4. Clozapine 75 mg PO HS
5. Docusate Sodium 100 mg PO BID
6. Fluticasone Propionate 110mcg 2 PUFF IH BID
7. Gemfibrozil 600 mg PO BID
8. Lisinopril 5 mg PO DAILY
9. Ranitidine 150 mg PO BID
10. Tiotropium Bromide 1 CAP IH DAILY
11. MetFORMIN (Glucophage) 1000 mg PO BID
12. Detemir 32 Units Breakfast
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Clozapine 200 mg PO BID
4. Clozapine 75 mg PO HS
5. Docusate Sodium 100 mg PO BID
6. Fluticasone Propionate 110mcg 2 PUFF IH BID
7. Gemfibrozil 600 mg PO BID
8. Lisinopril 5 mg PO DAILY
9. Ranitidine 150 mg PO BID
10. Tiotropium Bromide 1 CAP IH DAILY
11. MetFORMIN (Glucophage) 1000 mg PO BID
12. Detemir 32 Units Breakfast
Discharge Medications:
1. Fludrocortisone Acetate 0.1 mg PO DAILY hypotension
2. Acetaminophen 650 mg PO Q6H:PRN pain
3. Aspirin 81 mg PO DAILY
4. Clozapine 200 mg PO BID
5. Clozapine 75 mg PO HS
6. Docusate Sodium 100 mg PO BID
7. Fluticasone Propionate 110mcg 2 PUFF IH BID
8. Gemfibrozil 600 mg PO BID
9. Detemir 32 Units Breakfast
10. MetFORMIN (Glucophage) 1000 mg PO BID
11. Ranitidine 150 mg PO BID
12. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
COMMUNITY-ACQUIRED PNEUMONIA
DEHYDRATION
ACUTE KIDNEY INJURY
ORTHOSTATIC HYPOTENSION
SECONDARY DIAGNOSES:
TYPE II DIABETES MELLITUS
HYPERTENSION
HYPERLIPIDEMIA
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
PARANOID SCHIZOPHRENIA
CORONARY ARTERY DISEASE
GASTROESOPHAGEAL REFLUX DISORDER
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital for weakness and cough. We
found that you had a pneumonia (infection of the lungs) and gave
you antibiotics. We also found that you were very dehydrated and
gave you IV fluids. Our physical therapists also evaluated you
and decided you were strong enough to go home.
You will need to continue your antibiotics until _____. It is
very important not to stop your antibiotics early as this can
lead to repeated or worse infections.
Please make sure to drink enough water (at least 8 cups a day)
and eat three meals a day.
It was a pleasure taking care of you, and we hope you continue
to feel better.
Sincerely,
Your Team at ___
Followup Instructions:
___
|
[
"J189",
"F200",
"N179",
"E1143",
"J449",
"Z794",
"Z87891",
"I951",
"K219",
"I2510",
"I10",
"E785",
"Z9181"
] |
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: WEAKNESS Major Surgical or Invasive Procedure: N/A History of Present Illness: [MASKED] is a [MASKED] year-old M (poor historian) with a PMH of psychosis, mechanical falls with negative syncope w/u in [MASKED], T2DM (last HbA1c unknown, on metformin and insulin), and COPD (last FEV1 unknown), who presents with a 2-week history of weakness and cough with sputum production. He was in his usual state of health until 2 weeks ago, when he began to feel weak and short of breath. Of note, he has had similar episodes in the past that last for several days and said directly that "this feels like pneumonia to me." This was associated with a frequent cough productive of yellow-green sputum and anorexia with poor PO intake. He denies hemoptysis, fevers, chills, and night sweats. He denies orthopnea and PND. He denies nausea, vomiting, diarrhea, constipation, hematochezia, melena, dysuria, and hematuria. Yesterday, he experienced worsening lightheadedness and he had frequent episodes of tripping. He denies falls, LOC, or head strike with these episodes. This morning, he had an episode of chest pain that was midsternal, sharp, and pleuritic without radiation into the arm or neck or worsened SOB. Concurrently, he was too weak to rise from his chair. Last FSG 138. Given his weakness and worsening respiratory status, he presented to the ED. [MASKED] ED -------- + Initial Vitals: 97.5 91 126/81 17 100% RA + Exam was notable for: Dry MM, R tonsillar fullness. No focality to pulmonary exam. + Labs were significant for: BUN 33, Cr 1.5, AGAP 21 WBC 13, Hgb 12.4, Plt 341 Trop <0.01 + Imaging: - CT head showed no acute process. - CXR showed streaky posteroinferior left lobe opacity may reflect atelectasis, though infection cannot be entirely excluded. - EKG showed NSR, rate 90. + Interventions: 1L IVF, azithromycin 500mg IV x1, CTX 1g x1. + Vitals Prior to Transfer: 97.9 84 132/78 17 99% RA Currently, he continues to have a cough with intermittent sputum production. His appetite has returned and he was eating dinner at the time of the exam. He denies any other complaints. 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 ([MASKED]) 3. T2DM (last HbA1c 7.1 in [MASKED] 4. COPD (last FEV1 unknown) Social History: [MASKED] Family History: Unknown to patient. Physical Exam: ADMISSION PHYSICAL EXAM VS: T 97.7 BP 137/80 HR 98 RR 20 SaO2 100% RA Wt 78.88kg GEN: Man appearing older than stated age, alert, lying in bed watching TV, no acute distress. HEENT: Dry MM, anicteric sclerae, no conjunctival pallor. +R tonsillar fullness. NECK: Supple without LAD. PULM: Globally decreased breath sounds with intermittent expiratory wheeze, no rhonchi or rales, symmetric air movement, no increased work of breathing. COR: RRR (+)S1/S2 no m/r/g ABD: Soft, non-tender, non-distended, +bowel sounds. EXTREM: Warm, well-perfused, no edema. +2 [MASKED] pulses. NEURO: A&Ox3. CN II-XII grossly intact, motor function grossly normal. Diminished sensation in bilateral distal [MASKED] (although difficult to pinpoint given intermittent compliance with the exam). DISCHARGE PHYSICAL EXAM VS: 97.2 141/86 83 18 97 RA Orthostatics [MASKED]: 154/77 82 (lying) 143/78 90 (sitting) 120/86 97 (standing) GEN: Elderly gentleman lying in bed, arousable but falls asleep quickly, NAD. HEENT: Chapped lips, anicteric sclerae. Multiple missing teeth of front lower jaw. NECK: Supple without LAD. PULM: Breath sounds clearer than [MASKED] bilaterally but general poor air movement decreased, intermittent expiratory wheeze, no increased work of breathing. No egophony. COR: RRR (+)S1/S2 no m/r/g, heart sounds distant. ABD: Soft, non-tender, non-distended, +bowel sounds. EXTREM: Warm, well-perfused, no edema. +2 [MASKED] pulses. No e/o diabetic foot ulcers. NEURO: Refused to answer orientation Qs this AM. Gait deferred. Pertinent Results: ADMISSION LABS ------------------ [MASKED] 12:30PM BLOOD WBC-13.0* RBC-4.26* Hgb-12.4* Hct-36.5* MCV-86 MCH-29.1 MCHC-34.0 RDW-13.8 RDWSD-42.5 Plt [MASKED] [MASKED] 12:30PM BLOOD Neuts-77.3* Lymphs-16.1* Monos-5.3 Eos-0.5* Baso-0.2 Im [MASKED] AbsNeut-10.01* AbsLymp-2.08 AbsMono-0.69 AbsEos-0.06 AbsBaso-0.03 [MASKED] 12:30PM BLOOD Glucose-139* UreaN-33* Creat-1.5* Na-136 K-4.2 Cl-97 HCO3-22 AnGap-21* OTHER LABS ------------------ [MASKED] 06:55AM BLOOD Cortsol-13.0 [MASKED] 06:33AM BLOOD Triglyc-379* HDL-25 CHOL/HD-8.8 LDLcalc-120 [MASKED] 07:25AM BLOOD WBC-7.2 RBC-3.77* Hgb-10.9* Hct-32.7* MCV-87 MCH-28.9 MCHC-33.3 RDW-13.9 RDWSD-43.2 Plt [MASKED] [MASKED] 06:33AM BLOOD %HbA1c-7.1* eAG-157* [MASKED] 06:33AM BLOOD Triglyc-379* HDL-25 CHOL/HD-8.8 LDLcalc-120 [MASKED] 06:33AM BLOOD HBsAg-Negative HBsAb-Negative IgM HBc-Negative [MASKED] 06:33AM BLOOD HIV Ab-Negative [MASKED] 06:33AM BLOOD HCV Ab-Negative [MASKED] 10:07AM BLOOD [MASKED] pO2-195* pCO2-33* pH-7.43 calTCO2-23 Base XS-0 [MASKED] 12:30PM BLOOD cTropnT-<0.01 DISCHARGE LABS [MASKED] 06:13AM BLOOD WBC-9.3 RBC-4.19* Hgb-11.9* Hct-36.5* MCV-87 MCH-28.4 MCHC-32.6 RDW-13.7 RDWSD-43.2 Plt [MASKED] [MASKED] 06:13AM BLOOD Glucose-114* UreaN-16 Creat-1.1 Na-137 K-4.3 Cl-99 HCO3-21* AnGap-21* IMAGING --------- + CXR ([MASKED]) Streaky left lobe opacity may reflect atelectasis, though infection cannot be entirely excluded. + CT Head ([MASKED]) No acute intracranial abnormalities. Specifically, no evidence of intra-axial or extra-axial hemorrhage. + EKG ([MASKED]) NSR, rate 90 Brief Hospital Course: [MASKED] is a [MASKED] year-old M (poor historian) with a PMH of psychosis, mechanical falls with negative syncope w/u in [MASKED], T2DM (last HbA1c 7.1 in [MASKED], on metformin and insulin), and COPD (last FEV1 unknown), who presents with a 2-week history of weakness and cough with sputum production concerning for CAP as well as orthostatic hypotension. # Cough: Likely CAP given leukocytosis (13k), malaise, sputum production, and LLL infiltrate on CXR. Never met SIRS criteria during hospitalization. He always saturated well on RA with no evidence of increased work of breathing. SputumCx indeterminate, urine legionella negative. He received a 5-day course of antibiotics with ceftriaxone/azithromycin ([MASKED]). On discharge, he was feeling significantly better with no complaints of cough. # Dizziness/Weakness: The patient presented with orthostatic hypotension thought secondary hypovolemia in the setting of poor PO intake, given positive orthostatics and BUN/Cr > 20:1 suggestive of dehydration. Patient relies on cane at home. ECG NSR, trops neg. CT Head with no acute process. Electrolytes WNL. Despite brisk fluid resuscitation and now likely euvolemic status, orthostatics remain positive and he has a persistent unsteady gait. Underlying etiology unclear, possibly autonomic dysfunction [MASKED] DM versus medication (on clozapine). Per outpatient psychiatrist Dr. [MASKED] has been on the same dose of clozapine for [MASKED] years. Adrenal insufficiency unlikely as [MASKED] AM cortisol level 13.0. [MASKED] evaluated him on [MASKED] and recommended rehab. On discharge, his orthostatic vital signs remained positive and he continued to require assistance with walking. He was initiated on fludrocortisone 0.1mg QD on [MASKED] with some symptom relief. # [MASKED]: Likely due to hypovolemia in the setting of poor PO intake given BUN/Cr > 20:1. Last baseline 0.95 in [MASKED]. We gave him IVF as above with resolution of his [MASKED] to Cr 0.9. On discharge, his BUN/Cr were [MASKED]. # Prior IVDU: Patient reports prior history of heroin use and "other drugs." He gave consent for HIV testing. HIV, HepB, HepC were all negative. CHRONIC ISSUES: =============== # Psychosis: Continued clozapine. # Diabetes: RISS, held home metformin. Repeat HbA1c 7.2. FSGs 120s-180s here. No evidence of diabetic foot ulcers. # COPD: Continued home fluticasone and tiotropium inhaler. # GERD: Continued home ranitidine. # CAD: Continued home ASA. # HTN: Held home lisinopril given orthostatic hypotension. # HL: Continued home gemfibrozil. Total Chol 221 Triglycerides 379* elevated. HDL low at 25. Chol/HD 8.8, LDL calc 120. TRANSITIONAL ISSUES =================== # Fludrocortisone: The patient was initiated on Fluricil on [MASKED] at 0.1mg daily. This can be uptitrated at a rate of 0.1mg per week to a maximum of 0.3mg daily. # Transthoracic echo: The patient was scheduled for an outpatient echo. ECHO office will call patient to make appointment. He should follow up with a cardiologist to review the results. # Nutrition: The patient arrived with evidence of dehydration. Please ensure that he is reminded to drink water and other fluids throughout the day, especially if he is feeling ill. # Former IVDU: HIV, HepC, HepB found to be negative on this admission. No evidence of active IVDU. # ? Diabetic neuropathy: The patient intermittently reported reduced sensation and proprioception in bilateral distal extremities. His HbA1c was 7.2 on admission, which is mildly elevated. His orthostatic hypotension may also be an effect of autonomic neuropathy. His primary care physician should reevaluate this at their next appointment. # Orthostatic hypotension: He will be scheduled for an outpatient follow-up appointment with neurology to evaluate for potential causes of autonomic neuropathy. If negative, his psychiatrist should consider redosing of his clozapine to minimize potential side effects. His primary care physician should continue to work closely with him to ensure his diabetes mellitus is being treated adequately. # Blood cultures: Negative since [MASKED], final result pending at discharge. If any growth observed, the patient will be notified. # Lipid panel: Total Chol 221 Triglycerides 379* elevated. HDL low at 25. Chol/HD 8.8, LDL calc 120. He should have a repeat lipid panel performed with his primary care physician and consider alternative agents/dosing to better manage his low HDL and high triglycerides. =========================== # CODE STATUS: Full (unconfirmed) # CONTACT: [MASKED] [MASKED] or [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Aspirin 81 mg PO DAILY 3. Clozapine 200 mg PO BID 4. Clozapine 75 mg PO HS 5. Docusate Sodium 100 mg PO BID 6. Fluticasone Propionate 110mcg 2 PUFF IH BID 7. Gemfibrozil 600 mg PO BID 8. Lisinopril 5 mg PO DAILY 9. Ranitidine 150 mg PO BID 10. Tiotropium Bromide 1 CAP IH DAILY 11. MetFORMIN (Glucophage) 1000 mg PO BID 12. Detemir 32 Units Breakfast The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Aspirin 81 mg PO DAILY 3. Clozapine 200 mg PO BID 4. Clozapine 75 mg PO HS 5. Docusate Sodium 100 mg PO BID 6. Fluticasone Propionate 110mcg 2 PUFF IH BID 7. Gemfibrozil 600 mg PO BID 8. Lisinopril 5 mg PO DAILY 9. Ranitidine 150 mg PO BID 10. Tiotropium Bromide 1 CAP IH DAILY 11. MetFORMIN (Glucophage) 1000 mg PO BID 12. Detemir 32 Units Breakfast Discharge Medications: 1. Fludrocortisone Acetate 0.1 mg PO DAILY hypotension 2. Acetaminophen 650 mg PO Q6H:PRN pain 3. Aspirin 81 mg PO DAILY 4. Clozapine 200 mg PO BID 5. Clozapine 75 mg PO HS 6. Docusate Sodium 100 mg PO BID 7. Fluticasone Propionate 110mcg 2 PUFF IH BID 8. Gemfibrozil 600 mg PO BID 9. Detemir 32 Units Breakfast 10. MetFORMIN (Glucophage) 1000 mg PO BID 11. Ranitidine 150 mg PO BID 12. Tiotropium Bromide 1 CAP IH DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSES: COMMUNITY-ACQUIRED PNEUMONIA DEHYDRATION ACUTE KIDNEY INJURY ORTHOSTATIC HYPOTENSION SECONDARY DIAGNOSES: TYPE II DIABETES MELLITUS HYPERTENSION HYPERLIPIDEMIA CHRONIC OBSTRUCTIVE PULMONARY DISEASE PARANOID SCHIZOPHRENIA CORONARY ARTERY DISEASE GASTROESOPHAGEAL REFLUX DISORDER Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [MASKED], You were admitted to the hospital for weakness and cough. We found that you had a pneumonia (infection of the lungs) and gave you antibiotics. We also found that you were very dehydrated and gave you IV fluids. Our physical therapists also evaluated you and decided you were strong enough to go home. You will need to continue your antibiotics until [MASKED]. It is very important not to stop your antibiotics early as this can lead to repeated or worse infections. Please make sure to drink enough water (at least 8 cups a day) and eat three meals a day. It was a pleasure taking care of you, and we hope you continue to feel better. Sincerely, Your Team at [MASKED] Followup Instructions: [MASKED]
|
[] |
[
"N179",
"J449",
"Z794",
"Z87891",
"K219",
"I2510",
"I10",
"E785"
] |
[
"J189: Pneumonia, unspecified organism",
"F200: Paranoid schizophrenia",
"N179: Acute kidney failure, unspecified",
"E1143: Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy",
"J449: Chronic obstructive pulmonary disease, unspecified",
"Z794: Long term (current) use of insulin",
"Z87891: Personal history of nicotine dependence",
"I951: Orthostatic hypotension",
"K219: Gastro-esophageal reflux disease without esophagitis",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"I10: Essential (primary) hypertension",
"E785: Hyperlipidemia, unspecified",
"Z9181: History of falling"
] |
10,004,457 | 28,108,313 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Penicillins / Tetracycline Analogues / Amoxicillin / IV Dye,
Iodine Containing Contrast Media / Lactose / Statins-Hmg-Coa
Reductase Inhibitors / metoprolol
Attending: ___.
Chief Complaint:
Asymptomatic carotid stenosis
Major Surgical or Invasive Procedure:
___ RIGHT CAROTID ENDARTERECTOMY
History of Present Illness:
The patient is a ___ male with progressive carotid
stenosis, now greater than 80%. In addition, he is intolerant
of statin, so we discussed elective preventative repair. He
understood the risks including stroke, cranial nerve injury,
restenosis, and bleeding.
Past Medical History:
CAD (s/p DES to LAD in ___
Prostate cancer s/p prostatectomy ___
Hodgkin's Lymphoma ___ s/p splenectomy, chemotherapy and
radiation,
Gout
Tonsillectomy
Spontaneous subarachnoid hemorrhage ___, treated conservatively
Hemorrhoids
Herpes zoster and simplex
Hyperlipidemia
asthma
peptic ulcer disease
Social History:
___
Family History:
Father had an MI at age ___, died at age ___.
Physical Exam:
Physical Exam as of **** ___
132 / 76, 107, 18 93 RA
Gen: NAD, AOx3
HEENT: PEERLA, no neck masses, right neck incision clean, dry
and intact / flat - his trachea is mobile
PULM: unlabored breathing, normal chest excursion
CV: RRR, no m/r/g
Abd: soft, non-distended, non-tender, no masses
Ext: no edema
Pertinent Results:
___ 05:01AM BLOOD WBC-8.0 RBC-3.78* Hgb-12.2* Hct-37.8*
MCV-100* MCH-32.3* MCHC-32.3 RDW-15.6* RDWSD-57.1* Plt ___
___ 06:00AM BLOOD ___ PTT-25.3 ___
___ 05:01AM BLOOD Plt ___
___ 05:01AM BLOOD Glucose-98 UreaN-13 Creat-0.9 Na-141
K-4.3 Cl-105 HCO3-26 AnGap-10
___ 05:01AM BLOOD Calcium-7.8* Phos-3.4 Mg-1.8
Brief Hospital Course:
Neuro: Pain was well controlled on Tylenol and oxycodone
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.
He was seen and evaluated by Physical Therapy - The pt has a
history of Tremor/postural tremor and felt unsteady on his feet.
___ deemed him an appropriate rehab candidate.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Testosterone Cypionate 300 mg sc Q3 WEEKS
2. Fish Oil (Omega 3) 1000 mg PO BID
3. Niacin 100 mg PO BID
4. Diltiazem Extended-Release 120 mg PO DAILY
5. Budesonide Nasal Inhaler (*NF*) 90 mcg Other DAILY
6. lysine ___ mg oral TID
7. Vitamin E 400 UNIT PO DAILY
8. Vitamin D ___ UNIT PO TID
9. Aspirin 325 mg PO DAILY
10. Clindamycin 600 mg PO ONE HOUR BEFORE DENTAL CLEANING
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze
3. Docusate Sodium 100 mg PO BID
4. Levalbuterol Neb 0.63 mg NEB Q4H:PRN sob
5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *oxycodone 5 mg 1 tablet(s) by mouth Q 4 HOURS Disp #*10
Tablet Refills:*0
6. Pulmicort Flexhaler (budesonide) 180 mcg/actuation
inhalation PRN
7. Senna 17.2 mg PO QHS
8. Aspirin 325 mg PO DAILY
9. Budesonide Nasal Inhaler (*NF*) 90 mcg Other DAILY
10. Clindamycin 600 mg PO ONE HOUR BEFORE DENTAL CLEANING
11. Diltiazem Extended-Release 120 mg PO DAILY
12. Fish Oil (Omega 3) 1000 mg PO BID
13. lysine ___ mg oral TID
14. Niacin 100 mg PO BID
15. Testosterone Cypionate 300 mg sc Q3 WEEKS
16. Vitamin D ___ UNIT PO TID
17. Vitamin E 400 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
ASYMPTOMATIC CAROTID STENOSIS
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Carotid Endarterectomy Surgery Discharge Instructions
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 surgeons office
4. It is normal to feel tired, this will last for ___ weeks
You should get up out of bed every day and gradually increase
your activity each day
You may walk and you may go up and down stairs
Increase your activities as you can tolerate- do not do too
much right away!
5. It is normal to have a decreased appetite, your appetite will
return with time
You will probably lose your taste for food and lose some
weight
Eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
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:
___
|
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"Z951",
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Allergies: Penicillins / Tetracycline Analogues / Amoxicillin / IV Dye, Iodine Containing Contrast Media / Lactose / Statins-Hmg-Coa Reductase Inhibitors / metoprolol Chief Complaint: Asymptomatic carotid stenosis Major Surgical or Invasive Procedure: [MASKED] RIGHT CAROTID ENDARTERECTOMY History of Present Illness: The patient is a [MASKED] male with progressive carotid stenosis, now greater than 80%. In addition, he is intolerant of statin, so we discussed elective preventative repair. He understood the risks including stroke, cranial nerve injury, restenosis, and bleeding. Past Medical History: CAD (s/p DES to LAD in [MASKED] Prostate cancer s/p prostatectomy [MASKED] Hodgkin's Lymphoma [MASKED] s/p splenectomy, chemotherapy and radiation, Gout Tonsillectomy Spontaneous subarachnoid hemorrhage [MASKED], treated conservatively Hemorrhoids Herpes zoster and simplex Hyperlipidemia asthma peptic ulcer disease Social History: [MASKED] Family History: Father had an MI at age [MASKED], died at age [MASKED]. Physical Exam: Physical Exam as of **** [MASKED] 132 / 76, 107, 18 93 RA Gen: NAD, AOx3 HEENT: PEERLA, no neck masses, right neck incision clean, dry and intact / flat - his trachea is mobile PULM: unlabored breathing, normal chest excursion CV: RRR, no m/r/g Abd: soft, non-distended, non-tender, no masses Ext: no edema Pertinent Results: [MASKED] 05:01AM BLOOD WBC-8.0 RBC-3.78* Hgb-12.2* Hct-37.8* MCV-100* MCH-32.3* MCHC-32.3 RDW-15.6* RDWSD-57.1* Plt [MASKED] [MASKED] 06:00AM BLOOD [MASKED] PTT-25.3 [MASKED] [MASKED] 05:01AM BLOOD Plt [MASKED] [MASKED] 05:01AM BLOOD Glucose-98 UreaN-13 Creat-0.9 Na-141 K-4.3 Cl-105 HCO3-26 AnGap-10 [MASKED] 05:01AM BLOOD Calcium-7.8* Phos-3.4 Mg-1.8 Brief Hospital Course: Neuro: Pain was well controlled on Tylenol and oxycodone 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. He was seen and evaluated by Physical Therapy - The pt has a history of Tremor/postural tremor and felt unsteady on his feet. [MASKED] deemed him an appropriate rehab candidate. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Testosterone Cypionate 300 mg sc Q3 WEEKS 2. Fish Oil (Omega 3) 1000 mg PO BID 3. Niacin 100 mg PO BID 4. Diltiazem Extended-Release 120 mg PO DAILY 5. Budesonide Nasal Inhaler (*NF*) 90 mcg Other DAILY 6. lysine [MASKED] mg oral TID 7. Vitamin E 400 UNIT PO DAILY 8. Vitamin D [MASKED] UNIT PO TID 9. Aspirin 325 mg PO DAILY 10. Clindamycin 600 mg PO ONE HOUR BEFORE DENTAL CLEANING Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever 2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze 3. Docusate Sodium 100 mg PO BID 4. Levalbuterol Neb 0.63 mg NEB Q4H:PRN sob 5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity RX *oxycodone 5 mg 1 tablet(s) by mouth Q 4 HOURS Disp #*10 Tablet Refills:*0 6. Pulmicort Flexhaler (budesonide) 180 mcg/actuation inhalation PRN 7. Senna 17.2 mg PO QHS 8. Aspirin 325 mg PO DAILY 9. Budesonide Nasal Inhaler (*NF*) 90 mcg Other DAILY 10. Clindamycin 600 mg PO ONE HOUR BEFORE DENTAL CLEANING 11. Diltiazem Extended-Release 120 mg PO DAILY 12. Fish Oil (Omega 3) 1000 mg PO BID 13. lysine [MASKED] mg oral TID 14. Niacin 100 mg PO BID 15. Testosterone Cypionate 300 mg sc Q3 WEEKS 16. Vitamin D [MASKED] UNIT PO TID 17. Vitamin E 400 UNIT PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] [MASKED] Diagnosis: ASYMPTOMATIC CAROTID STENOSIS Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Carotid Endarterectomy Surgery Discharge Instructions 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 surgeons office 4. It is normal to feel tired, this will last for [MASKED] 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: [MASKED] 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: [MASKED]
|
[] |
[
"I2510",
"Z955",
"E785",
"Z951",
"G4733"
] |
[
"I6521: Occlusion and stenosis of right carotid artery",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"Z955: Presence of coronary angioplasty implant and graft",
"Z8546: Personal history of malignant neoplasm of prostate",
"Z8571: Personal history of Hodgkin lymphoma",
"E785: Hyperlipidemia, unspecified",
"Z951: Presence of aortocoronary bypass graft",
"I081: Rheumatic disorders of both mitral and tricuspid valves",
"Z952: Presence of prosthetic heart valve",
"G4733: Obstructive sleep apnea (adult) (pediatric)"
] |
10,004,606 | 23,517,634 |
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:
___
|
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Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Weakness Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] 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 [MASKED] 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 [MASKED] and required the upper GI which found a likely AVM. She reports the records from that hospitalization or at [MASKED] in [MASKED]. 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 [MASKED] 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: [MASKED] Family History: [MASKED] 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 -------------- [MASKED] 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 [MASKED] [MASKED] 03:46PM BLOOD Neuts-71.9* Lymphs-17.5* Monos-6.9 Eos-2.6 Baso-0.7 Im [MASKED] AbsNeut-7.65* AbsLymp-1.86 AbsMono-0.73 AbsEos-0.28 AbsBaso-0.07 [MASKED] 02:22PM BLOOD Glucose-108* UreaN-12 Creat-1.0 Na-145 K-4.8 Cl-104 HCO3-24 AnGap-17 [MASKED] 02:22PM BLOOD ALT-18 AST-17 AlkPhos-121* TotBili-0.5 MICROBIOLOGY ------------ [MASKED] 4:55 pm URINE **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: 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 [MASKED] 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 -------------- [MASKED] 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 [MASKED] [MASKED] 08:10AM BLOOD Glucose-101* UreaN-11 Creat-1.0 Na-142 K-4.6 Cl-101 HCO3-30 AnGap-11 [MASKED] 07:10AM BLOOD ALT-16 AST-17 AlkPhos-91 TotBili-0.4 [MASKED] 07:45AM BLOOD Calcium-9.7 Phos-3.8 Mg-1.7 [MASKED] 03:46PM BLOOD calTIBC-411 Ferritn-[MASKED]-[MASKED] [MASKED] 02:35PM BLOOD Lactate-1.8 KUB: IMPRESSION: Normal bowel gas pattern. Brief Hospital Course: [MASKED] 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 [MASKED] 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 [MASKED] in [MASKED]. 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. [MASKED] consulted. She progressed and was able to be discharged home. #Constipation Patient noted to constipated likely [MASKED] 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. [MASKED], It was a pleasure caring for you during your recent admission at [MASKED]. 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 [MASKED]. Please arrange to have you labs checked. Good luck! Followup Instructions: [MASKED]
|
[] |
[
"N390",
"N179",
"I10",
"K219",
"Y92230",
"Z86718"
] |
[
"N390: Urinary tract infection, site not specified",
"K2971: Gastritis, unspecified, with bleeding",
"N179: Acute kidney failure, unspecified",
"F05: Delirium due to known physiological condition",
"I701: Atherosclerosis of renal artery",
"G40409: Other generalized epilepsy and epileptic syndromes, not intractable, without status epilepticus",
"I10: Essential (primary) hypertension",
"D500: Iron deficiency anemia secondary to blood loss (chronic)",
"I739: Peripheral vascular disease, unspecified",
"Z720: Tobacco use",
"K219: Gastro-esophageal reflux disease without esophagitis",
"B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere",
"K5903: Drug induced constipation",
"T402X5A: Adverse effect of other opioids, initial encounter",
"Y92230: Patient room in hospital as the place of occurrence of the external cause",
"Z86718: Personal history of other venous thrombosis and embolism"
] |
10,004,606 | 28,691,361 |
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:
___
|
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"K31811",
"B1910",
"S0990XA",
"G629",
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"F1120",
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"I951",
"F319",
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"I10",
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"Y92008",
"I701",
"M5416",
"E039",
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"J449",
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"Z86718",
"Z87891",
"K2270",
"R110",
"T402X5A",
"Y929",
"I739",
"I69398",
"R531",
"R42",
"N3090",
"R079",
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] |
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Presyncope, Fall Major Surgical or Invasive Procedure: EGD [MASKED] Capsule endoscopy [MASKED] Colonoscopy [MASKED] History of Present Illness: [MASKED] with history of CVA, seizures, upper GI AVM's with chronic anemia, HTN, presents after presyncopal fall. On [MASKED] 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 [MASKED]. CT head and CT C-spine negative for acute bleed or fracture. Today she went to her GI appointment and was referred to [MASKED]. Last [MASKED] 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 [MASKED], 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: [MASKED] 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 ================== [MASKED] [MASKED] 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+ [MASKED] pulses bilaterally, no edema NEURO: A&Ox3, no facial asymmetry, moving all 4 extremities with purpose Pertinent Results: ADMISSION LABS ============== [MASKED] 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 [MASKED] [MASKED] 05:50PM BLOOD Neuts-47.5 [MASKED] Monos-8.9 Eos-7.5* Baso-0.5 Im [MASKED] AbsNeut-2.60 AbsLymp-1.94 AbsMono-0.49 AbsEos-0.41 AbsBaso-0.03 [MASKED] 05:50PM BLOOD [MASKED] PTT-34.2 [MASKED] [MASKED] 05:50PM BLOOD Glucose-101* UreaN-12 Creat-1.1 Na-138 K-4.2 Cl-99 HCO3-24 AnGap-15 [MASKED] 05:50PM BLOOD ALT-14 AST-13 AlkPhos-43 TotBili-0.3 [MASKED] 05:50PM BLOOD Lipase-22 [MASKED] 05:50PM BLOOD proBNP-78 [MASKED] 05:50PM BLOOD cTropnT-<0.01 [MASKED] 05:50PM BLOOD Albumin-4.8 Calcium-9.6 Phos-3.7 Mg-1.8 PERTINENT INTERVAL LABS ======================= [MASKED] 09:10AM BLOOD Calcium-9.4 Phos-4.1 Mg-1.8 Iron-16* [MASKED] 09:10AM BLOOD calTIBC-382 VitB12-318 Folate-14 Ferritn-14 TRF-294 [MASKED] 06:48AM BLOOD TSH-3.6 [MASKED] 06:48AM BLOOD Free T4-0.9* DISCHARGE LABS ============== [MASKED] 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 [MASKED] [MASKED] 05:35AM BLOOD Glucose-91 UreaN-20 Creat-1.1 Na-144 K-4.5 Cl-104 HCO3-24 AnGap-16 [MASKED] 05:35AM BLOOD Calcium-9.6 Phos-5.0* Mg-2.0 MICROBIOLOGY ============ Urine Culture [MASKED]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION IMAGING AND STUDIES =================== [MASKED] 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. [MASKED] 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. [MASKED] ECHO (TTE) The left atrial volume index is normal. The estimated right atrial pressure is [MASKED] 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. [MASKED] 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. [MASKED] EGD Mucosa suggestive of [MASKED] Esophagus Erosion in pylorus Angioectasias in stomach and second part of duodenum (Thermal Therapy applied) Capsule released in duodenum [MASKED] COLONOSCOPY Aborted due to high residue material [MASKED] 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. [MASKED] KUB Endoscopy capsule in the proximal descending colon. [MASKED] KUB Endoscopy pill capsule has migrated since [MASKED], now possibly in the sigmoid colon. Brief Hospital Course: [MASKED] 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 [MASKED]. Required 2u pRBCs during her hospitalization. EGD showed several duodenal/gastric AVMs that were cauterized, as well as likely [MASKED] 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 [MASKED], 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 [MASKED] 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 [MASKED]. 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 [MASKED]. Review of MassPMP indicates pt also prescribed vicodin in OSH [MASKED] 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 [MASKED] 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 [MASKED]. 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 [MASKED] esophagus: Noted on EGD. Will have follow up endoscopy with plan for biopsy in [MASKED] []Labs: Repeat CBC at clinic visit to ensure stability, discharge Hgb 9.9 []Vascular Followup: Has appointment with Dr. [MASKED] [MASKED] for CEA evaluation []Neurology Followup: Has appointment for further management of anti-seizure medications # Contact/HCP: [MASKED] (daughter) [MASKED] # 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 [MASKED] 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 [MASKED] 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 [MASKED] 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 [MASKED]: 13 Months Discharge Disposition: Home With Service Facility: [MASKED] 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 [MASKED], [MASKED] 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 [MASKED] Care Team Followup Instructions: [MASKED]
|
[] |
[
"D62",
"I10",
"E039",
"E785",
"J449",
"K219",
"Z86718",
"Z87891",
"Y929",
"K5900"
] |
[
"K31811: Angiodysplasia of stomach and duodenum with bleeding",
"B1910: Unspecified viral hepatitis B without hepatic coma",
"S0990XA: Unspecified injury of head, initial encounter",
"G629: Polyneuropathy, unspecified",
"D62: Acute posthemorrhagic anemia",
"F1120: Opioid dependence, uncomplicated",
"I452: Bifascicular block",
"I6523: Occlusion and stenosis of bilateral carotid arteries",
"G40909: Epilepsy, unspecified, not intractable, without status epilepticus",
"I951: Orthostatic hypotension",
"F319: Bipolar disorder, unspecified",
"Q2733: Arteriovenous malformation of digestive system vessel",
"I10: Essential (primary) hypertension",
"W01198A: Fall on same level from slipping, tripping and stumbling with subsequent striking against other object, initial encounter",
"Y92008: Other place in unspecified non-institutional (private) residence as the place of occurrence of the external cause",
"I701: Atherosclerosis of renal artery",
"M5416: Radiculopathy, lumbar region",
"E039: Hypothyroidism, unspecified",
"E785: Hyperlipidemia, unspecified",
"J449: Chronic obstructive pulmonary disease, unspecified",
"K219: Gastro-esophageal reflux disease without esophagitis",
"Z86718: Personal history of other venous thrombosis and embolism",
"Z87891: Personal history of nicotine dependence",
"K2270: Barrett's esophagus without dysplasia",
"R110: Nausea",
"T402X5A: Adverse effect of other opioids, initial encounter",
"Y929: Unspecified place or not applicable",
"I739: Peripheral vascular disease, unspecified",
"I69398: Other sequelae of cerebral infarction",
"R531: Weakness",
"R42: Dizziness and giddiness",
"N3090: Cystitis, unspecified without hematuria",
"R079: Chest pain, unspecified",
"I459: Conduction disorder, unspecified",
"K5900: Constipation, unspecified"
] |
10,004,606 | 28,731,738 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
Endoscopy ___
Capsule Endoscopy ___
History of Present Illness:
___ with history of GI bleed with unidentified etiology,
gallstone pancreatitis requiring lap CCY (course c/b seizures
thought triggered by pancreatitis and possible prior stroke) who
presents from home with dark stools, abd pain, dysuria,
polyuria.
In the ED, initial VS were: 98.5 76 179/62 18 100% RA
Exam notable for:
TTP RLQ, LLQ, suprapubic region
Labs showed:
Hgb 7.9
UA with few bacteria, lg leuk, 2 WBC
Lactate 1.5
Imaging showed:
CTA ABD/PELVIS
1. No evidence of active contrast extravasation into the bowel.
2. Colonic diverticulosis without diverticulitis.
3. Interval increased extrahepatic and central intrahepatic
biliary dilation is likely due to post cholecystectomy status.
Correlation with LFTs is Recommended and if there is continued
concern for biliary obstruction, consider MRCP for further
assessment.
Patient received:
___ 15:00 IV Morphine Sulfate 4 mg
___ 16:39 IV Esomeprazole sodium 40 mg
___ 17:59 IV Morphine Sulfate 4 mg
___ 20:19 IV Morphine Sulfate 4 mg
___ 21:54 IV CefTRIAXone
___ 22:23 PO/NG Atorvastatin 40 mg
___ 22:23 PO/NG Labetalol 200 mg
___ 22:23 PO LevETIRAcetam 1500 mg
___ 23:30 IV Ondansetron 4 mg ___
***1 unit PRBCs ___ @ 1752***
GI was consulted:
H/H down from discharge at 7.9/24.5. Discharged on ___ at
8.9/27.2.
Recommend:
- 2 large bore IVs
- Trend CBC q12h
- IV PPI BID
- NPO at midnight
- Transfuse for hgb >7
- Plan for EGD in AM
Transfer VS were: 98.3 67 164/70 16 100% RA
On arrival to the floor, patient reports that she simply does
not feel well. She has been unable to sleep, feeling weak upon
standing, melena x 2 days, diffuse abdominal pain, and dysuria.
She typically knows when she has a UTI, and these symptoms are
consistent. She denies fevers, weight change, chest pain,
shortness of breath.
Recently hospitalized ___ for weakness, thought ___ UTI
and possible slow GI bleed. UTI grew pan-sensitive E coli
treated with CTX -> ciprofloxacin. H/H trended, H pylori
serology came back negative, patient did not undergo endoscopy.
Discharge Hgb 8.9.
REVIEW OF SYSTEMS:
10 point ROS reviewed and negative except as per HPI
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 PHYSICAL EXAM:
VS: 98.2 162/75 63 18 96% RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: slightly TTP diffusely
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE EXAM:
VS: 98.4 ___
GENERAL: NAD , pale
HEENT: AT/NC, anicteric sclera, pink conjunctiva, MMM
NECK: supple
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB
ABDOMEN: Soft nondistended, tender over umbilicus, no
rebound/guarding.
EXTREMITIES: no cyanosis, clubbing, or edema. Warm
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
PSYCH: Appropriate affect
Pertinent Results:
ADMISSION LABS:
___ 01:49PM BLOOD WBC-7.6 RBC-2.70* Hgb-7.9* Hct-24.5*
MCV-91 MCH-29.3 MCHC-32.2 RDW-13.2 RDWSD-43.4 Plt ___
___ 01:49PM BLOOD Neuts-58.9 ___ Monos-6.2 Eos-5.4
Baso-0.4 Im ___ AbsNeut-4.48 AbsLymp-2.19 AbsMono-0.47
AbsEos-0.41 AbsBaso-0.03
___ 01:49PM BLOOD ___ PTT-30.9 ___
___ 01:49PM BLOOD Glucose-106* UreaN-15 Creat-1.0 Na-143
K-4.3 Cl-103 HCO3-22 AnGap-18
___ 01:49PM BLOOD ALT-15 AST-15 LD(LDH)-136 AlkPhos-62
TotBili-0.2
___ 05:05AM BLOOD Calcium-9.4 Phos-4.1 Mg-1.9
___ 02:09PM BLOOD Lactate-1.5
IMAGING:
KUB ___:
1. Enteric capsule in the small bowel of the left lower abdomen
in similar position to the study 2 days ago.
2. Nonobstructive bowel gas pattern.
KUB ___:
Enteric capsule in the left lower abdomen.
GI Endoscopy ___:
Angioectasias in the body (thermal therapy)
Otherwise normal EGD to third part of the duodenum
CTA ABD/PELVIS ___:
1. No evidence of active contrast extravasation into the bowel.
2. Colonic diverticulosis without diverticulitis.
3. Interval increased extrahepatic and central intrahepatic
biliary dilation is likely due to post cholecystectomy status.
Correlation with LFTs is Recommended and if there is continued
concern for biliary obstruction, consider MRCP for further
assessment.
DISCHARGE LABS:
___ 05:15AM BLOOD WBC-4.8 RBC-2.66* Hgb-7.8* Hct-24.7*
MCV-93 MCH-29.3 MCHC-31.6* RDW-13.2 RDWSD-44.8 Plt ___
___ 05:00AM BLOOD Glucose-93 UreaN-9 Creat-1.0 Na-144 K-4.7
Cl-105 HCO3-26 AnGap-13
___ 05:15AM BLOOD ___ PTT-31.1 ___
___ 05:00AM BLOOD ALT-10 AST-9 AlkPhos-55 TotBili-0.3
___ 05:00AM BLOOD Calcium-9.1 Phos-4.2 Mg-2.___ with history of recurrent GIB of unidentified source who
presents with melena, drop in H/H, and abdominal pain also with
UTI and GPC bactermia.
#Acute blood loss anemia
#Melena,Upper GI bleeding: suspect recurrence of prior GIB. Has
had reported extensive workup in past at hospital in ___
including capsule study. Required 3 transfusions in ___. No
endoscopy in our system. Prior thought to be AVM in small bowel.
EGD showed angiectasias in the body of the stomach. No further
bleeding while inpatient. Capsule endoscopy ___ was
complicated by poor transit time through the stomach and poor
bowel prep. Capsule remained in colon by day of discharge, will
need visualization in stool or KUB ___ to ensure passage. Will
need to be repeated as an outpatient.
#Staph bacteremia, contaminant:
Coag negative staph and staph hemolyticus growing out of initial
cultures. Unclear if contaminant however as affecting 2 out of 2
bottles. Patient without white count or systemic symptoms of
infection and no further positive cultures. Treated with
vancomycin until preantibiotic repeat cultures resulted
negative. Overall thought to be contaminant.
#UTI/Dysuria/suprapubic pain: in setting of recent E coli in
urine, dysuria, and suprapubic tenderness, concern for UTI
despite equivocal urine. Initial urine culture was contaminated.
Postvoid residual was 0. Pain was managed with Tylenol and
oxycodone. S/p ceftriaxone x 3 days for presumed UTI.
#Abdominal pain: Patient had some gassy abdominal pain following
MoviPrep. Treated with simethicone. She subsequently had
abdominal pain following jerking with subcu heparin injection;
abdominal exam benign.
#History of seizure: per neuro notes, thought triggered by
pancreatitis vs prior stroke. Continued Keppra
#HA: Likely related to SBPs in 190s. Pain management with
Tylenol/oxycodone. Avoided NSAIDs given GIB. Trialed fioricet.
#Dizziness, bradycardia: Patient endorsed significant dizziness
during hospitalization. Was bradycardic to the ___ on home
labetalol. Labetalol was discontinued and patient was treated
with IV fluids.
#HTN: HTN to 190s inpatient. Restarted home amlodipine,
lisinopril.
#HLD: atorvastatin. Restarted Asa on discharge.
#Chronic pain in bilateral legs: no longer takes oxycodone at
home. Not a complaint here.
#CTA findings of intrahepatic biliary dilation: likely ___
post-CCY state. LFTs negative. No RUQ pain.
TRANSITIONAL ISSUES:
====================
[] Outpatient follow up with Dr. ___ on ___ as already
scheduled to determine whether EGD for capsule placement is
needed
[] Titrate antihypertensives
[] Labetalol was held for bradycardia
[] Needs KUB ___ to ensure passage of capsule
#CODE: Full (confirmed)
#CONTACT: ___ (daughter) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY hypertension
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. LevETIRAcetam 1500 mg PO Q12H
5. Labetalol 400 mg PO BID Hypertension
6. Famotidine 20 mg PO BID
7. Ondansetron 4 mg PO Q8H:PRN nausea
8. Pantoprazole 40 mg PO Q12H
9. Lisinopril 40 mg PO DAILY
Discharge Medications:
1. Simethicone 40-80 mg PO QID:PRN abd pain
RX *simethicone 80 mg 1 tab by mouth four times a day Disp #*80
Tablet Refills:*0
2. amLODIPine 10 mg PO DAILY hypertension
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Famotidine 20 mg PO BID
6. LevETIRAcetam 1500 mg PO Q12H
7. Lisinopril 40 mg PO DAILY
8. Ondansetron 4 mg PO Q8H:PRN nausea
9. Pantoprazole 40 mg PO Q12H
Discharge Disposition:
Home
Discharge Diagnosis:
Upper GI bleed
UTI
Bacteremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were seen at ___ for gastrointestinal bleed. You
underwent an endoscopic procedure that showed a small blood
vessel abnormality in your stomach. We suspected that a similar
abnormality in your small bowel could be the cause of your
bleed. We tried to verify this with the capsule endoscopy,
however the images were of poor quality. You may need to have
this capsule study repeated as an outpatient. You may require
further transfusions in the future.
You also had some burning pain in her lower abdomen that was
likely due to a urinary tract infection. You were treated with
antibiotics for this.
Your initial blood cultures showed growth of some bacteria.
Given that you did not have symptoms of a bloodstream infection,
it is likely that these were a contaminant. You were treated
with antibiotics while we waited for these bacterial colonies to
grow enough to be identified as contaminants from your skin.
Please take all your medications as prescribed and follow-up at
your outpatient appointments.
It was a pleasure taking care of you,
Your ___ team
Followup Instructions:
___
|
[
"K31811",
"E440",
"R569",
"D62",
"I150",
"Z681",
"N390",
"E785",
"I739",
"I69398",
"R531",
"R2681",
"R51",
"R001",
"T448X5A",
"Y92230",
"R109",
"F1011",
"Z86718",
"Z87891"
] |
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: GI bleed Major Surgical or Invasive Procedure: Endoscopy [MASKED] Capsule Endoscopy [MASKED] History of Present Illness: [MASKED] with history of GI bleed with unidentified etiology, gallstone pancreatitis requiring lap CCY (course c/b seizures thought triggered by pancreatitis and possible prior stroke) who presents from home with dark stools, abd pain, dysuria, polyuria. In the ED, initial VS were: 98.5 76 179/62 18 100% RA Exam notable for: TTP RLQ, LLQ, suprapubic region Labs showed: Hgb 7.9 UA with few bacteria, lg leuk, 2 WBC Lactate 1.5 Imaging showed: CTA ABD/PELVIS 1. No evidence of active contrast extravasation into the bowel. 2. Colonic diverticulosis without diverticulitis. 3. Interval increased extrahepatic and central intrahepatic biliary dilation is likely due to post cholecystectomy status. Correlation with LFTs is Recommended and if there is continued concern for biliary obstruction, consider MRCP for further assessment. Patient received: [MASKED] 15:00 IV Morphine Sulfate 4 mg [MASKED] 16:39 IV Esomeprazole sodium 40 mg [MASKED] 17:59 IV Morphine Sulfate 4 mg [MASKED] 20:19 IV Morphine Sulfate 4 mg [MASKED] 21:54 IV CefTRIAXone [MASKED] 22:23 PO/NG Atorvastatin 40 mg [MASKED] 22:23 PO/NG Labetalol 200 mg [MASKED] 22:23 PO LevETIRAcetam 1500 mg [MASKED] 23:30 IV Ondansetron 4 mg [MASKED] ***1 unit PRBCs [MASKED] @ 1752*** GI was consulted: H/H down from discharge at 7.9/24.5. Discharged on [MASKED] at 8.9/27.2. Recommend: - 2 large bore IVs - Trend CBC q12h - IV PPI BID - NPO at midnight - Transfuse for hgb >7 - Plan for EGD in AM Transfer VS were: 98.3 67 164/70 16 100% RA On arrival to the floor, patient reports that she simply does not feel well. She has been unable to sleep, feeling weak upon standing, melena x 2 days, diffuse abdominal pain, and dysuria. She typically knows when she has a UTI, and these symptoms are consistent. She denies fevers, weight change, chest pain, shortness of breath. Recently hospitalized [MASKED] for weakness, thought [MASKED] UTI and possible slow GI bleed. UTI grew pan-sensitive E coli treated with CTX -> ciprofloxacin. H/H trended, H pylori serology came back negative, patient did not undergo endoscopy. Discharge Hgb 8.9. REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as per HPI Past Medical History: Gallstone pancreatitis status post cholecystectomy [MASKED] 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: [MASKED] Family History: [MASKED] 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 PHYSICAL EXAM: VS: 98.2 162/75 63 18 96% RA GENERAL: NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM NECK: supple, no LAD, no JVD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: slightly TTP diffusely EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, moving all 4 extremities with purpose SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE EXAM: VS: 98.4 [MASKED] GENERAL: NAD , pale HEENT: AT/NC, anicteric sclera, pink conjunctiva, MMM NECK: supple HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB ABDOMEN: Soft nondistended, tender over umbilicus, no rebound/guarding. EXTREMITIES: no cyanosis, clubbing, or edema. Warm NEURO: A&Ox3, moving all 4 extremities with purpose SKIN: warm and well perfused, no excoriations or lesions, no rashes PSYCH: Appropriate affect Pertinent Results: ADMISSION LABS: [MASKED] 01:49PM BLOOD WBC-7.6 RBC-2.70* Hgb-7.9* Hct-24.5* MCV-91 MCH-29.3 MCHC-32.2 RDW-13.2 RDWSD-43.4 Plt [MASKED] [MASKED] 01:49PM BLOOD Neuts-58.9 [MASKED] Monos-6.2 Eos-5.4 Baso-0.4 Im [MASKED] AbsNeut-4.48 AbsLymp-2.19 AbsMono-0.47 AbsEos-0.41 AbsBaso-0.03 [MASKED] 01:49PM BLOOD [MASKED] PTT-30.9 [MASKED] [MASKED] 01:49PM BLOOD Glucose-106* UreaN-15 Creat-1.0 Na-143 K-4.3 Cl-103 HCO3-22 AnGap-18 [MASKED] 01:49PM BLOOD ALT-15 AST-15 LD(LDH)-136 AlkPhos-62 TotBili-0.2 [MASKED] 05:05AM BLOOD Calcium-9.4 Phos-4.1 Mg-1.9 [MASKED] 02:09PM BLOOD Lactate-1.5 IMAGING: KUB [MASKED]: 1. Enteric capsule in the small bowel of the left lower abdomen in similar position to the study 2 days ago. 2. Nonobstructive bowel gas pattern. KUB [MASKED]: Enteric capsule in the left lower abdomen. GI Endoscopy [MASKED]: Angioectasias in the body (thermal therapy) Otherwise normal EGD to third part of the duodenum CTA ABD/PELVIS [MASKED]: 1. No evidence of active contrast extravasation into the bowel. 2. Colonic diverticulosis without diverticulitis. 3. Interval increased extrahepatic and central intrahepatic biliary dilation is likely due to post cholecystectomy status. Correlation with LFTs is Recommended and if there is continued concern for biliary obstruction, consider MRCP for further assessment. DISCHARGE LABS: [MASKED] 05:15AM BLOOD WBC-4.8 RBC-2.66* Hgb-7.8* Hct-24.7* MCV-93 MCH-29.3 MCHC-31.6* RDW-13.2 RDWSD-44.8 Plt [MASKED] [MASKED] 05:00AM BLOOD Glucose-93 UreaN-9 Creat-1.0 Na-144 K-4.7 Cl-105 HCO3-26 AnGap-13 [MASKED] 05:15AM BLOOD [MASKED] PTT-31.1 [MASKED] [MASKED] 05:00AM BLOOD ALT-10 AST-9 AlkPhos-55 TotBili-0.3 [MASKED] 05:00AM BLOOD Calcium-9.1 Phos-4.2 Mg-2.[MASKED] with history of recurrent GIB of unidentified source who presents with melena, drop in H/H, and abdominal pain also with UTI and GPC bactermia. #Acute blood loss anemia #Melena,Upper GI bleeding: suspect recurrence of prior GIB. Has had reported extensive workup in past at hospital in [MASKED] including capsule study. Required 3 transfusions in [MASKED]. No endoscopy in our system. Prior thought to be AVM in small bowel. EGD showed angiectasias in the body of the stomach. No further bleeding while inpatient. Capsule endoscopy [MASKED] was complicated by poor transit time through the stomach and poor bowel prep. Capsule remained in colon by day of discharge, will need visualization in stool or KUB [MASKED] to ensure passage. Will need to be repeated as an outpatient. #Staph bacteremia, contaminant: Coag negative staph and staph hemolyticus growing out of initial cultures. Unclear if contaminant however as affecting 2 out of 2 bottles. Patient without white count or systemic symptoms of infection and no further positive cultures. Treated with vancomycin until preantibiotic repeat cultures resulted negative. Overall thought to be contaminant. #UTI/Dysuria/suprapubic pain: in setting of recent E coli in urine, dysuria, and suprapubic tenderness, concern for UTI despite equivocal urine. Initial urine culture was contaminated. Postvoid residual was 0. Pain was managed with Tylenol and oxycodone. S/p ceftriaxone x 3 days for presumed UTI. #Abdominal pain: Patient had some gassy abdominal pain following MoviPrep. Treated with simethicone. She subsequently had abdominal pain following jerking with subcu heparin injection; abdominal exam benign. #History of seizure: per neuro notes, thought triggered by pancreatitis vs prior stroke. Continued Keppra #HA: Likely related to SBPs in 190s. Pain management with Tylenol/oxycodone. Avoided NSAIDs given GIB. Trialed fioricet. #Dizziness, bradycardia: Patient endorsed significant dizziness during hospitalization. Was bradycardic to the [MASKED] on home labetalol. Labetalol was discontinued and patient was treated with IV fluids. #HTN: HTN to 190s inpatient. Restarted home amlodipine, lisinopril. #HLD: atorvastatin. Restarted Asa on discharge. #Chronic pain in bilateral legs: no longer takes oxycodone at home. Not a complaint here. #CTA findings of intrahepatic biliary dilation: likely [MASKED] post-CCY state. LFTs negative. No RUQ pain. TRANSITIONAL ISSUES: ==================== [] Outpatient follow up with Dr. [MASKED] on [MASKED] as already scheduled to determine whether EGD for capsule placement is needed [] Titrate antihypertensives [] Labetalol was held for bradycardia [] Needs KUB [MASKED] to ensure passage of capsule #CODE: Full (confirmed) #CONTACT: [MASKED] (daughter) [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY hypertension 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. LevETIRAcetam 1500 mg PO Q12H 5. Labetalol 400 mg PO BID Hypertension 6. Famotidine 20 mg PO BID 7. Ondansetron 4 mg PO Q8H:PRN nausea 8. Pantoprazole 40 mg PO Q12H 9. Lisinopril 40 mg PO DAILY Discharge Medications: 1. Simethicone 40-80 mg PO QID:PRN abd pain RX *simethicone 80 mg 1 tab by mouth four times a day Disp #*80 Tablet Refills:*0 2. amLODIPine 10 mg PO DAILY hypertension 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 40 mg PO QPM 5. Famotidine 20 mg PO BID 6. LevETIRAcetam 1500 mg PO Q12H 7. Lisinopril 40 mg PO DAILY 8. Ondansetron 4 mg PO Q8H:PRN nausea 9. Pantoprazole 40 mg PO Q12H Discharge Disposition: Home Discharge Diagnosis: Upper GI bleed UTI Bacteremia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You were seen at [MASKED] for gastrointestinal bleed. You underwent an endoscopic procedure that showed a small blood vessel abnormality in your stomach. We suspected that a similar abnormality in your small bowel could be the cause of your bleed. We tried to verify this with the capsule endoscopy, however the images were of poor quality. You may need to have this capsule study repeated as an outpatient. You may require further transfusions in the future. You also had some burning pain in her lower abdomen that was likely due to a urinary tract infection. You were treated with antibiotics for this. Your initial blood cultures showed growth of some bacteria. Given that you did not have symptoms of a bloodstream infection, it is likely that these were a contaminant. You were treated with antibiotics while we waited for these bacterial colonies to grow enough to be identified as contaminants from your skin. Please take all your medications as prescribed and follow-up at your outpatient appointments. It was a pleasure taking care of you, Your [MASKED] team Followup Instructions: [MASKED]
|
[] |
[
"D62",
"N390",
"E785",
"Y92230",
"Z86718",
"Z87891"
] |
[
"K31811: Angiodysplasia of stomach and duodenum with bleeding",
"E440: Moderate protein-calorie malnutrition",
"R569: Unspecified convulsions",
"D62: Acute posthemorrhagic anemia",
"I150: Renovascular hypertension",
"Z681: Body mass index [BMI] 19.9 or less, adult",
"N390: Urinary tract infection, site not specified",
"E785: Hyperlipidemia, unspecified",
"I739: Peripheral vascular disease, unspecified",
"I69398: Other sequelae of cerebral infarction",
"R531: Weakness",
"R2681: Unsteadiness on feet",
"R51: Headache",
"R001: Bradycardia, unspecified",
"T448X5A: Adverse effect of centrally-acting and adrenergic-neuron-blocking agents, initial encounter",
"Y92230: Patient room in hospital as the place of occurrence of the external cause",
"R109: Unspecified abdominal pain",
"F1011: Alcohol abuse, in remission",
"Z86718: Personal history of other venous thrombosis and embolism",
"Z87891: Personal history of nicotine dependence"
] |
10,004,606 | 29,242,151 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
seizures, abdominal pain
Major Surgical or Invasive Procedure:
mechanical intubation
History of Present Illness:
Ms. ___ is a ___ woman with HTN who presents with
seizure. Around ___ on ___, daughter received a text from her
cousin that the patient was vomiting. The patien't daughter then
got back from work in the morning of ___ when she found her
mother sleeping on her R side facing opposite direction. She
then did a full turn out of bed and fell on the floor face
first. Per the daughter, the patient had positive head strike on
the night stand on her way down to the floor. Daughter turned
her over and saw pt's bottom jaw retracted and top part of mouth
sticking out, eyes open, arms straight out stiffly. Tongue was
starting to come out, and pt was "banging up against the bed."
After ___ min, convulsions stopped, and pt developed heavy
breathing/snoring. Her eyes kind of cracked open but she was not
responsive to daughter. EMS came and brought her outside, but
head was flopping around as they were transporting her. When
they got close to ___, pt started to "come to" and kept
taking off the O2 mask. Seemed to go "in and out" of
consciousness per daughter. She would get intermittently
agitated, pupils were dilated, and she would have episodes of
intermittent staring where she did not seem to be registering
things. No further shaking. Reportedly got 2mg IV Ativan at
___ and transferred to ___. Once she arrived at ___, the
patient was complaining of abdominal pain. CT abd/pelvis showed
acute pancreatitis. Patient was then intubated given her
agitation and need for diagnostic procedures. LP was completed.
Nicardipine gtt was initated at OSH for SBP >220. She is now
admitted to the neuro ICU, remains intubated on nicardipine gtt
for further workup and management.
Of note, about 1mo ago, pt was sitting with daughter's cousin.
There was a yell, so daughter went to go find her mother. At
that time, pt was sitting up with a "deer caught in headlights
look." Cousin who witnessed the episode said that she sat
upright, then started falling backwards and became stiff. Was
shaking. Lasted a few seconds, then came out of it. After the
episode, she said she was thirsty and did not remember the
episode happening at all.
Per son at bedside, she did have a seizure ___ years ago without
any clear cause. She was living in ___ alone at that time.
She was taking a lot of Klonopin, vicodin, and Percocet along
with antidepressants, so unclear if this was a trigger. He does
not know any further information about the seizure. Also unclear
if she ever had strokes before. She had fallen ___ months ago in
___, but son does not think she had any brain hemorrhages
from that. She came back to ___ about 5 months ago to live
with her daughter. Since that time, she has only been taking
lisinopril. No other pain medications. Patient's daughter
denies any further drug use over the past 5 months.
Past Medical History:
HTN, DVTs
-internal bleed from small intestine
- tubes tied
- plantar wart removed
- procedure in groin
- colonoscopies
Social History:
___
Family History:
no history of seizures or strokes
Physical Exam:
===ADMISSION EXAM===
General: agitated, refusing to participate in exam
HEENT: contusions on forehead with a few scrapes
___: tachycardic
Pulmonary: breathing comfortably on RA
Abdomen: Soft, NT, ND
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: awake, agitated, oriented to ___ and ___. Able to name "thumb" and "watch" and "green." Speech is
clear and not dysarthric. No gibberish.
- Cranial Nerves: PERRL 6->5mm brisk. BTT bilaterally. Face
appears symmetric. Looks around the room fully. Unable to
perform
more dedicated CN exam ___ pt's agitation
- Motor: moves all extremities spontaneously and equally
- Reflexes: unable to obtain, pt moving too much and is not
relaxing
- Sensory: withdraws to light touch in all extremities
- Coordination: no ataxia when reaching for bed rails or trying
to pull out foley catheter
- Gait: unable to assess
DISCHARGE EXAM
VS: 98.8 PO 100 / 56 53 18 97 RA
GENERAL: Pleasant elderly woman, sitting up in bed, appears
comfortable in no acute distress. Persistent paranoid delusions.
HEENT: Sclerae anicteric, EOMI, moist mucous membranes
LUNGS: Clear to auscultation bilaterally, no wheezes, rales, or
rhonchi. Good inspiratory effort.
HEART: Regular rate and rhythm, normal S1 and S2, no murmurs,
rubs, gallops, or thrills
ABDOMEN: Normal bowel sounds. Soft, non-distended. Mild
improving tenderness and hyperesthesia around lap port incision
sites. No organomegaly. No rebound tenderness or guarding.
EXTREMITIES: Warm and well perfused. No clubbing, cyanosis, or
lower extremity edema.
NEURO: A&Ox3, moving all 4 extremities with purpose
Pertinent Results:
ADMISSION LABS
___ 12:00PM BLOOD WBC-15.7* RBC-5.35* Hgb-16.2* Hct-48.4*
MCV-91 MCH-30.3 MCHC-33.5 RDW-13.6 RDWSD-45.3 Plt ___
___ 12:00PM BLOOD Neuts-91.3* Lymphs-3.8* Monos-4.1*
Eos-0.1* Baso-0.2 Im ___ AbsNeut-14.36* AbsLymp-0.59*
AbsMono-0.65 AbsEos-0.01* AbsBaso-0.03
___ 12:00PM BLOOD ___ PTT-29.7 ___
___ 12:00PM BLOOD Glucose-228* UreaN-13 Creat-1.3* Na-132*
K-8.4* Cl-93* HCO3-21* AnGap-18*
___ 06:30PM BLOOD ALT-523* AST-333* AlkPhos-252*
TotBili-1.7*
___ 06:30PM BLOOD Lipase-1222*
___ 06:30PM BLOOD Calcium-9.6 Phos-2.7 Mg-1.7
___ 12:00PM BLOOD Osmolal-287
___ 12:00PM BLOOD TSH-3.5
___ 12:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 12:11PM BLOOD Lactate-3.4* K-4.5
PERTINENT LABS
___ 01:55PM BLOOD Lactate-1.1
___ 01:45PM BLOOD WBC-10.5* RBC-3.25* Hgb-9.8* Hct-30.3*
MCV-93 MCH-30.2 MCHC-32.3 RDW-14.4 RDWSD-49.2* Plt ___
___ 05:25AM BLOOD WBC-7.0 RBC-3.04* Hgb-9.1* Hct-28.1*
MCV-92 MCH-29.9 MCHC-32.4 RDW-14.3 RDWSD-48.3* Plt ___
___ 04:45PM BLOOD Glucose-93 UreaN-5* Creat-0.7 Na-139
K-3.6 Cl-100 HCO3-24 AnGap-15
___ 09:45AM BLOOD Glucose-144* UreaN-8 Creat-0.9 Na-138
K-3.7 Cl-100 HCO3-22 AnGap-16
___ 01:36AM BLOOD ALT-177* AST-50* AlkPhos-110*
Amylase-149* TotBili-0.6
___ 02:32AM BLOOD ALT-139* AST-38 AlkPhos-131* Amylase-302*
TotBili-0.9
___ 03:58AM BLOOD Lipase-442*
___ 01:36AM BLOOD Lipase-67*
___ 02:32AM BLOOD Lipase-40
DISCHARGE LABS
___ 05:41AM BLOOD WBC-7.0 RBC-2.81* Hgb-8.7* Hct-26.8*
MCV-95 MCH-31.0 MCHC-32.5 RDW-14.0 RDWSD-48.2* Plt ___
___ 05:41AM BLOOD Glucose-98 UreaN-7 Creat-0.9 Na-140 K-4.4
Cl-101 HCO3-28 AnGap-11
IMAGING/STUDIES
CT A/P: ___- 1. Mild to moderate intra and extrahepatic
biliary ductal dilatation with
probable calculus in the distal common bile duct indicative of
choledocholithiasis. If needed, MRCP can provide further
confirmation and assessment.
2. Edematous pancreas with peripancreatic fat stranding and
fluid most suggestive of acute interstitial edematous
pancreatitis. In the setting of probable choledocholithiasis,
constellation of findings likely indicate gallstone
pancreatitis. Correlation with serum amylase and lipase levels
are
recommended.
3. Cholelithiasis. Pericholecystic fluid and stranding may be
secondary to pancreatitis.
4. Extensive atherosclerotic disease with severe stenosis of the
SMA and right renal artery with resultant atrophy of the right
kidney.
5. Bilateral nodular adrenal glands which are incompletely
characterized.
6. 0.5 cm pulmonary nodule in the right upper lobe. Please see
recommendations section.
MRI Brain w/ and w/o: ___: 1. Motion limited exam.
2. No evidence for acute infarction.
3. Nonmasslike FLAIR signal abnormality within the right
posteriorperiventricular white matter, with discontiguous foci
of cystic encephalomalacia and no evidence for blood products.
These may represent sequela of prior infarction, demyelination,
infection, or other insult.
4. Small chronic infarcts in the left cerebellar hemisphere.
Punctate cortical FLAIR hyperintensity in the right frontal lobe
may also represent a chronic infarct.
5. Small area of FLAIR hyperintensity and contrast enhancement
in the right occipital cortex, with associated chronic blood
products, and with questionable involvement of the adjacent
sulci. This may represent a chronic infarct with hemorrhagic
transformation or sequela of amyloid angiopathy.
6. Small chronic microhemorrhage in the right posterior internal
capsule, most likely hypertensive.
7. 6 mm round structure in the region of the left petroclival
confluence, with diagnostic considerations including a
cholesterol granuloma, another type of lesion, or an aberrant
blood vessel. Partial left mastoid air cell opacification.
Brief Hospital Course:
================
PATIENT SUMMARY:
================
___ year old woman who presented with generalized tonic-clonic
seizure in the setting of gallstone pancreatitis who was found
to have right side renal artery stenosis. Seizures were
controlled with keppra and patient underwent cholecystectomy and
patients blood pressure was well controlled with medical
management.
=============
ACUTE ISSUES:
=============
#Generalized tonic clonic seizures:
Patient presented after a witnessed generalized tonic-clonic
seizures. She presented to the emergency room and seizures were
initially controlled with ativan in the emergency room.
Neurology followed the patient during this hospitalization for
workup of seizures. Patient was found to have gallstone induced
pancreatitis which is believed to have caused seizures in a
patient with underlying susceptibility given history of CVA. She
underwent cholecystectomy. Infectious workup was negative. LP
was preformed which was bland. MRI demonstrated existing
infarcts, but no evidence of acute infarction or intracranial
process. The patient was maintained on Keppra 1500 BID and had
no further seizures during hospitalization. Neurology recommends
that the patient continue keppra 1500 BID indefinitely until
potential modification by outpatient neurology in 6 months. If
there is concern for mild encephalopathy and gait unsteadiness,
Keppra could be decreased to 1250 mg twice daily prior to
follow-up. She was started on atorvastatin and aspirin for
primary prevention of CVA.
#Renal artery stenosis:
Patient was found to have right sided renal artery stenosis on
CT during hospitalization. Systolic blood pressure were
initially 170 systolic. Her blood pressure was controlled with
nicardipine drip. Vascular surgery evaluated the patient and
recommended no surgical intervention. She was medically managed
with oral antihypertensive regime and blood pressure was
successfully controlled to the 100-160s systolic. she should
continue lisinopril, amlodapine and labetalol as an outpatient.
#Gallstone pancreatitis
Patient was found to have choledocolithiasis induced
pancreatitis. She underwent cholecystectomy and had an
uneventful postoperative course. Pain was well controlled with
oral oxycodone in the postoperative period. The patient will
follow with acute care surgery two weeks after discharge.
===============
CHRONIC ISSUES:
===============
#GERD: Home famotidine was continued
====================
TRANSITIONAL ISSUES:
====================
[ ] Please recheck patient blood pressure and adjust blood
pressure medications accordingly as an outpatient
[ ] Neurology recommends that the patient continue keppra 1500
BID indefinitely until potential modification by outpatient
neurology in 6 months. If there is concern for mild
encephalopathy and gait unsteadiness, Keppra could be decreased
to 1250 mg twice daily prior to follow-up. She was started on
atorvastatin and aspirin for primary prevention of CVA.
[ ] Follow up with surgery for post-operative check after
cholecystectomy
[ ] Follow up with new PCP to establish care and also for
cardiology referral for her known peripheral vascular disease
for which she was on aspirin and Plavix, but were stopped for GI
bleeding in ___.
[ ] given recent seizure, patient should not drive until cleared
by her Neurologist
FULL CODE
HCP daughter ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO BID
2. Famotidine 20 mg PO BID
3. Acetaminophen 500 mg PO Q12H:PRN Pain - Mild
Discharge Medications:
1. amLODIPine 10 mg PO DAILY hypertension
RX *amlodipine [Norvasc] 10 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
4. Labetalol 400 mg PO BID Hypertension
RX *labetalol 200 mg 2 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
5. LevETIRAcetam 1500 mg PO Q12H
RX *levetiracetam 1,000 mg 1.5 tablet(s) by mouth every twelve
(12) hours Disp #*90 Tablet Refills:*0
6. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Severe
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*8 Tablet Refills:*0
7. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
8. Lisinopril 40 mg PO DAILY
RX *lisinopril 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
9. Famotidine 20 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
=================
Primary diagnosis
=================
Generalized tonic-Clonic Seizures
cholecystitis
===================
Secondary diagnosis
===================
Right Renal Artery Stenosis
Hypertension
Gallstone Pancreatitis
Encephalopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
DISCHARGE WORKSHEET INSTRUCTIONS:
Dear Ms. ___,
It was a pleasure caring for you at ___
___!
WHY WERE YOU ADMITTED?
You were admitted to the hospital because you had seizures.
WHAT HAPPENED IN THE HOSPITAL?
Your seizures were controlled with medication. You were found to
have abdominal pain caused by inflammation in your gallbladder
and pancreas. Your gallbladder was removed and this helped the
inflammation. We think that your seizures were caused by the
inflammation in your gallbladder and pancreas. You were also
found to have hypertension caused by a partial blockage to the
artery for your right kidney. You were started on new
medications to treat your blood pressure and your blood pressure
improved.
WHAT SHOULD YOU DO AT HOME?
You should continue the new medications for your seizures and
blood pressure and follow up with the surgeons and neurologist
at your next scheduled appointment. You also have a primary care
physician appointment scheduled for you to follow up and
establish care. You will have to discuss with the new PCP about
cardiologist referral for your peripheral vascular disease that
was treated with aspirin, Plavix, and procedures in your lower
extremity arteries in ___ last year. As you know, your
Plavix was stopped due to GI bleeding that occurred in ___
last year. You need a new cardiologist to continue to manage
your antiplatelet agents.
Because you had a seizure, please do not drive a car until you
are cleared by your Neurologist.
Please work on switching your insurance to ___ so that
you can continue to get care here.
Thank you for allowing us be involved in your care, we wish you
all the best!
Your ___ Team
Followup Instructions:
___
|
[
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"K8510",
"G9340",
"K8064",
"E871",
"I701",
"I10",
"I160",
"K219",
"I739",
"E785",
"F17210",
"Z95820",
"Z86718",
"Z8673"
] |
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: seizures, abdominal pain Major Surgical or Invasive Procedure: mechanical intubation History of Present Illness: Ms. [MASKED] is a [MASKED] woman with HTN who presents with seizure. Around [MASKED] on [MASKED], daughter received a text from her cousin that the patient was vomiting. The patien't daughter then got back from work in the morning of [MASKED] when she found her mother sleeping on her R side facing opposite direction. She then did a full turn out of bed and fell on the floor face first. Per the daughter, the patient had positive head strike on the night stand on her way down to the floor. Daughter turned her over and saw pt's bottom jaw retracted and top part of mouth sticking out, eyes open, arms straight out stiffly. Tongue was starting to come out, and pt was "banging up against the bed." After [MASKED] min, convulsions stopped, and pt developed heavy breathing/snoring. Her eyes kind of cracked open but she was not responsive to daughter. EMS came and brought her outside, but head was flopping around as they were transporting her. When they got close to [MASKED], pt started to "come to" and kept taking off the O2 mask. Seemed to go "in and out" of consciousness per daughter. She would get intermittently agitated, pupils were dilated, and she would have episodes of intermittent staring where she did not seem to be registering things. No further shaking. Reportedly got 2mg IV Ativan at [MASKED] and transferred to [MASKED]. Once she arrived at [MASKED], the patient was complaining of abdominal pain. CT abd/pelvis showed acute pancreatitis. Patient was then intubated given her agitation and need for diagnostic procedures. LP was completed. Nicardipine gtt was initated at OSH for SBP >220. She is now admitted to the neuro ICU, remains intubated on nicardipine gtt for further workup and management. Of note, about 1mo ago, pt was sitting with daughter's cousin. There was a yell, so daughter went to go find her mother. At that time, pt was sitting up with a "deer caught in headlights look." Cousin who witnessed the episode said that she sat upright, then started falling backwards and became stiff. Was shaking. Lasted a few seconds, then came out of it. After the episode, she said she was thirsty and did not remember the episode happening at all. Per son at bedside, she did have a seizure [MASKED] years ago without any clear cause. She was living in [MASKED] alone at that time. She was taking a lot of Klonopin, vicodin, and Percocet along with antidepressants, so unclear if this was a trigger. He does not know any further information about the seizure. Also unclear if she ever had strokes before. She had fallen [MASKED] months ago in [MASKED], but son does not think she had any brain hemorrhages from that. She came back to [MASKED] about 5 months ago to live with her daughter. Since that time, she has only been taking lisinopril. No other pain medications. Patient's daughter denies any further drug use over the past 5 months. Past Medical History: HTN, DVTs -internal bleed from small intestine - tubes tied - plantar wart removed - procedure in groin - colonoscopies Social History: [MASKED] Family History: no history of seizures or strokes Physical Exam: ===ADMISSION EXAM=== General: agitated, refusing to participate in exam HEENT: contusions on forehead with a few scrapes [MASKED]: tachycardic Pulmonary: breathing comfortably on RA Abdomen: Soft, NT, ND Extremities: Warm, no edema Neurologic Examination: - Mental status: awake, agitated, oriented to [MASKED] and [MASKED]. Able to name "thumb" and "watch" and "green." Speech is clear and not dysarthric. No gibberish. - Cranial Nerves: PERRL 6->5mm brisk. BTT bilaterally. Face appears symmetric. Looks around the room fully. Unable to perform more dedicated CN exam [MASKED] pt's agitation - Motor: moves all extremities spontaneously and equally - Reflexes: unable to obtain, pt moving too much and is not relaxing - Sensory: withdraws to light touch in all extremities - Coordination: no ataxia when reaching for bed rails or trying to pull out foley catheter - Gait: unable to assess DISCHARGE EXAM VS: 98.8 PO 100 / 56 53 18 97 RA GENERAL: Pleasant elderly woman, sitting up in bed, appears comfortable in no acute distress. Persistent paranoid delusions. HEENT: Sclerae anicteric, EOMI, moist mucous membranes LUNGS: Clear to auscultation bilaterally, no wheezes, rales, or rhonchi. Good inspiratory effort. HEART: Regular rate and rhythm, normal S1 and S2, no murmurs, rubs, gallops, or thrills ABDOMEN: Normal bowel sounds. Soft, non-distended. Mild improving tenderness and hyperesthesia around lap port incision sites. No organomegaly. No rebound tenderness or guarding. EXTREMITIES: Warm and well perfused. No clubbing, cyanosis, or lower extremity edema. NEURO: A&Ox3, moving all 4 extremities with purpose Pertinent Results: ADMISSION LABS [MASKED] 12:00PM BLOOD WBC-15.7* RBC-5.35* Hgb-16.2* Hct-48.4* MCV-91 MCH-30.3 MCHC-33.5 RDW-13.6 RDWSD-45.3 Plt [MASKED] [MASKED] 12:00PM BLOOD Neuts-91.3* Lymphs-3.8* Monos-4.1* Eos-0.1* Baso-0.2 Im [MASKED] AbsNeut-14.36* AbsLymp-0.59* AbsMono-0.65 AbsEos-0.01* AbsBaso-0.03 [MASKED] 12:00PM BLOOD [MASKED] PTT-29.7 [MASKED] [MASKED] 12:00PM BLOOD Glucose-228* UreaN-13 Creat-1.3* Na-132* K-8.4* Cl-93* HCO3-21* AnGap-18* [MASKED] 06:30PM BLOOD ALT-523* AST-333* AlkPhos-252* TotBili-1.7* [MASKED] 06:30PM BLOOD Lipase-1222* [MASKED] 06:30PM BLOOD Calcium-9.6 Phos-2.7 Mg-1.7 [MASKED] 12:00PM BLOOD Osmolal-287 [MASKED] 12:00PM BLOOD TSH-3.5 [MASKED] 12:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [MASKED] 12:11PM BLOOD Lactate-3.4* K-4.5 PERTINENT LABS [MASKED] 01:55PM BLOOD Lactate-1.1 [MASKED] 01:45PM BLOOD WBC-10.5* RBC-3.25* Hgb-9.8* Hct-30.3* MCV-93 MCH-30.2 MCHC-32.3 RDW-14.4 RDWSD-49.2* Plt [MASKED] [MASKED] 05:25AM BLOOD WBC-7.0 RBC-3.04* Hgb-9.1* Hct-28.1* MCV-92 MCH-29.9 MCHC-32.4 RDW-14.3 RDWSD-48.3* Plt [MASKED] [MASKED] 04:45PM BLOOD Glucose-93 UreaN-5* Creat-0.7 Na-139 K-3.6 Cl-100 HCO3-24 AnGap-15 [MASKED] 09:45AM BLOOD Glucose-144* UreaN-8 Creat-0.9 Na-138 K-3.7 Cl-100 HCO3-22 AnGap-16 [MASKED] 01:36AM BLOOD ALT-177* AST-50* AlkPhos-110* Amylase-149* TotBili-0.6 [MASKED] 02:32AM BLOOD ALT-139* AST-38 AlkPhos-131* Amylase-302* TotBili-0.9 [MASKED] 03:58AM BLOOD Lipase-442* [MASKED] 01:36AM BLOOD Lipase-67* [MASKED] 02:32AM BLOOD Lipase-40 DISCHARGE LABS [MASKED] 05:41AM BLOOD WBC-7.0 RBC-2.81* Hgb-8.7* Hct-26.8* MCV-95 MCH-31.0 MCHC-32.5 RDW-14.0 RDWSD-48.2* Plt [MASKED] [MASKED] 05:41AM BLOOD Glucose-98 UreaN-7 Creat-0.9 Na-140 K-4.4 Cl-101 HCO3-28 AnGap-11 IMAGING/STUDIES CT A/P: [MASKED]- 1. Mild to moderate intra and extrahepatic biliary ductal dilatation with probable calculus in the distal common bile duct indicative of choledocholithiasis. If needed, MRCP can provide further confirmation and assessment. 2. Edematous pancreas with peripancreatic fat stranding and fluid most suggestive of acute interstitial edematous pancreatitis. In the setting of probable choledocholithiasis, constellation of findings likely indicate gallstone pancreatitis. Correlation with serum amylase and lipase levels are recommended. 3. Cholelithiasis. Pericholecystic fluid and stranding may be secondary to pancreatitis. 4. Extensive atherosclerotic disease with severe stenosis of the SMA and right renal artery with resultant atrophy of the right kidney. 5. Bilateral nodular adrenal glands which are incompletely characterized. 6. 0.5 cm pulmonary nodule in the right upper lobe. Please see recommendations section. MRI Brain w/ and w/o: [MASKED]: 1. Motion limited exam. 2. No evidence for acute infarction. 3. Nonmasslike FLAIR signal abnormality within the right posteriorperiventricular white matter, with discontiguous foci of cystic encephalomalacia and no evidence for blood products. These may represent sequela of prior infarction, demyelination, infection, or other insult. 4. Small chronic infarcts in the left cerebellar hemisphere. Punctate cortical FLAIR hyperintensity in the right frontal lobe may also represent a chronic infarct. 5. Small area of FLAIR hyperintensity and contrast enhancement in the right occipital cortex, with associated chronic blood products, and with questionable involvement of the adjacent sulci. This may represent a chronic infarct with hemorrhagic transformation or sequela of amyloid angiopathy. 6. Small chronic microhemorrhage in the right posterior internal capsule, most likely hypertensive. 7. 6 mm round structure in the region of the left petroclival confluence, with diagnostic considerations including a cholesterol granuloma, another type of lesion, or an aberrant blood vessel. Partial left mastoid air cell opacification. Brief Hospital Course: ================ PATIENT SUMMARY: ================ [MASKED] year old woman who presented with generalized tonic-clonic seizure in the setting of gallstone pancreatitis who was found to have right side renal artery stenosis. Seizures were controlled with keppra and patient underwent cholecystectomy and patients blood pressure was well controlled with medical management. ============= ACUTE ISSUES: ============= #Generalized tonic clonic seizures: Patient presented after a witnessed generalized tonic-clonic seizures. She presented to the emergency room and seizures were initially controlled with ativan in the emergency room. Neurology followed the patient during this hospitalization for workup of seizures. Patient was found to have gallstone induced pancreatitis which is believed to have caused seizures in a patient with underlying susceptibility given history of CVA. She underwent cholecystectomy. Infectious workup was negative. LP was preformed which was bland. MRI demonstrated existing infarcts, but no evidence of acute infarction or intracranial process. The patient was maintained on Keppra 1500 BID and had no further seizures during hospitalization. Neurology recommends that the patient continue keppra 1500 BID indefinitely until potential modification by outpatient neurology in 6 months. If there is concern for mild encephalopathy and gait unsteadiness, Keppra could be decreased to 1250 mg twice daily prior to follow-up. She was started on atorvastatin and aspirin for primary prevention of CVA. #Renal artery stenosis: Patient was found to have right sided renal artery stenosis on CT during hospitalization. Systolic blood pressure were initially 170 systolic. Her blood pressure was controlled with nicardipine drip. Vascular surgery evaluated the patient and recommended no surgical intervention. She was medically managed with oral antihypertensive regime and blood pressure was successfully controlled to the 100-160s systolic. she should continue lisinopril, amlodapine and labetalol as an outpatient. #Gallstone pancreatitis Patient was found to have choledocolithiasis induced pancreatitis. She underwent cholecystectomy and had an uneventful postoperative course. Pain was well controlled with oral oxycodone in the postoperative period. The patient will follow with acute care surgery two weeks after discharge. =============== CHRONIC ISSUES: =============== #GERD: Home famotidine was continued ==================== TRANSITIONAL ISSUES: ==================== [ ] Please recheck patient blood pressure and adjust blood pressure medications accordingly as an outpatient [ ] Neurology recommends that the patient continue keppra 1500 BID indefinitely until potential modification by outpatient neurology in 6 months. If there is concern for mild encephalopathy and gait unsteadiness, Keppra could be decreased to 1250 mg twice daily prior to follow-up. She was started on atorvastatin and aspirin for primary prevention of CVA. [ ] Follow up with surgery for post-operative check after cholecystectomy [ ] Follow up with new PCP to establish care and also for cardiology referral for her known peripheral vascular disease for which she was on aspirin and Plavix, but were stopped for GI bleeding in [MASKED]. [ ] given recent seizure, patient should not drive until cleared by her Neurologist FULL CODE HCP daughter [MASKED] [MASKED] [MASKED] on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 20 mg PO BID 2. Famotidine 20 mg PO BID 3. Acetaminophen 500 mg PO Q12H:PRN Pain - Mild Discharge Medications: 1. amLODIPine 10 mg PO DAILY hypertension RX *amlodipine [Norvasc] 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 2. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. Atorvastatin 40 mg PO QPM RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. Labetalol 400 mg PO BID Hypertension RX *labetalol 200 mg 2 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 5. LevETIRAcetam 1500 mg PO Q12H RX *levetiracetam 1,000 mg 1.5 tablet(s) by mouth every twelve (12) hours Disp #*90 Tablet Refills:*0 6. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Severe RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp #*8 Tablet Refills:*0 7. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 8. Lisinopril 40 mg PO DAILY RX *lisinopril 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 9. Famotidine 20 mg PO BID Discharge Disposition: Home Discharge Diagnosis: ================= Primary diagnosis ================= Generalized tonic-Clonic Seizures cholecystitis =================== Secondary diagnosis =================== Right Renal Artery Stenosis Hypertension Gallstone Pancreatitis Encephalopathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: DISCHARGE WORKSHEET INSTRUCTIONS: Dear Ms. [MASKED], It was a pleasure caring for you at [MASKED] [MASKED]! WHY WERE YOU ADMITTED? You were admitted to the hospital because you had seizures. WHAT HAPPENED IN THE HOSPITAL? Your seizures were controlled with medication. You were found to have abdominal pain caused by inflammation in your gallbladder and pancreas. Your gallbladder was removed and this helped the inflammation. We think that your seizures were caused by the inflammation in your gallbladder and pancreas. You were also found to have hypertension caused by a partial blockage to the artery for your right kidney. You were started on new medications to treat your blood pressure and your blood pressure improved. WHAT SHOULD YOU DO AT HOME? You should continue the new medications for your seizures and blood pressure and follow up with the surgeons and neurologist at your next scheduled appointment. You also have a primary care physician appointment scheduled for you to follow up and establish care. You will have to discuss with the new PCP about cardiologist referral for your peripheral vascular disease that was treated with aspirin, Plavix, and procedures in your lower extremity arteries in [MASKED] last year. As you know, your Plavix was stopped due to GI bleeding that occurred in [MASKED] last year. You need a new cardiologist to continue to manage your antiplatelet agents. Because you had a seizure, please do not drive a car until you are cleared by your Neurologist. Please work on switching your insurance to [MASKED] so that you can continue to get care here. Thank you for allowing us be involved in your care, we wish you all the best! Your [MASKED] Team Followup Instructions: [MASKED]
|
[] |
[
"E871",
"I10",
"K219",
"E785",
"F17210",
"Z86718",
"Z8673"
] |
[
"G40409: Other generalized epilepsy and epileptic syndromes, not intractable, without status epilepticus",
"K8510: Biliary acute pancreatitis without necrosis or infection",
"G9340: Encephalopathy, unspecified",
"K8064: Calculus of gallbladder and bile duct with chronic cholecystitis without obstruction",
"E871: Hypo-osmolality and hyponatremia",
"I701: Atherosclerosis of renal artery",
"I10: Essential (primary) hypertension",
"I160: Hypertensive urgency",
"K219: Gastro-esophageal reflux disease without esophagitis",
"I739: Peripheral vascular disease, unspecified",
"E785: Hyperlipidemia, unspecified",
"F17210: Nicotine dependence, cigarettes, uncomplicated",
"Z95820: Peripheral vascular angioplasty status with implants and grafts",
"Z86718: Personal history of other venous thrombosis and embolism",
"Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits"
] |
10,004,719 | 21,197,153 |
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:
___
|
[
"T82868A",
"I82441",
"Y832",
"Y92009",
"I70411",
"Z86718",
"J45909"
] |
Allergies: Percocet Chief Complaint: Right leg/foot pain Major Surgical or Invasive Procedure: [MASKED] Right lower extremity angiogram, angioJet mechanical thrombectomy of occluded bypass graft, balloon angioplasty of outflow stenosis. [MASKED] Right lower extremity angiogram, angioJet mechanical thrombectomy of occluded bypass graft, balloon angioplasty of outflow stenosis. History of Present Illness: [MASKED] w Rt AK pop to [MASKED] bypass with NRGSV for a thrombosed popliteal aneurysm in [MASKED] present with worsening new onset right foot claudication. Past Medical History: PMH: DVT R pop v ([MASKED]), asthma, Rt pop artery thrombus with negative hypercoagulable workup PSH: Rt AK pop to [MASKED] bypass with NRGSV [MASKED] 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: [MASKED] 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 [MASKED] [MASKED] 05:45AM BLOOD Plt [MASKED] [MASKED] 05:45AM BLOOD Glucose-108* UreaN-10 Creat-0.8 Na-141 K-3.7 Cl-107 HCO3-26 AnGap-12 [MASKED] 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: [MASKED] sp Rt AK pop to [MASKED] bypass with NRGSV [MASKED] 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 [[MASKED]] 15 mg 1 tablet(s) by mouth twice daily Disp #*42 Tablet Refills:*0 2. Clopidogrel 75 mg PO DAILY For the next [MASKED] 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 [MASKED] after loading dose of 15 mg twice daily. RX *rivaroxaban [[MASKED]] 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. [MASKED], It was a pleasure taking care of you at [MASKED] [MASKED]. 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: [MASKED]
|
[] |
[
"Z86718",
"J45909"
] |
[
"T82868A: Thrombosis due to vascular prosthetic devices, implants and grafts, initial encounter",
"I82441: Acute embolism and thrombosis of right tibial vein",
"Y832: Surgical operation with anastomosis, bypass or graft as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure",
"Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause",
"I70411: Atherosclerosis of autologous vein bypass graft(s) of the extremities with intermittent claudication, right leg",
"Z86718: Personal history of other venous thrombosis and embolism",
"J45909: Unspecified asthma, uncomplicated"
] |
10,004,720 | 22,081,550 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Haldol
Attending: ___
___ Complaint:
s/p cardiac arrest
Major Surgical or Invasive Procedure:
chest thoracostomy tube placement
intubation
central venous catheter placement
History of Present Illness:
___ with PMHx significant for schizophrenia, hypertension and
anemia who p/w from nursing home with cardiac arrest.
Per EMS, he choked while sitting in his chair eating, found
slumped over in chair without e/o trauma, turned blue. Found
cyanotic without pulses. Heimelich productive of large food
bolus. ROSC ___ s/p CPR and epi x2 and intubated w/ IO placed.
In ___, became bradycardic transitioning to Asystole
1330. Given Epi, further CPR, obtained ROSC. His SBP of ___,
started on levo.
In ED initial VS: T 34.9 HR 83 BP 111/63 RR 14 100% ra
Exam: Tube in place, some secretions suctioned, No e/o trauma or
prolonged down time, Psoriatic plaques, 2mm minimally responsive
pupils, Unresponsive, No spontaneous limb movements
Labs were notable for: wbc 16.1, hgb 12.4, plt 635, Na 134, K
4.2, cr 0.3, TnT 0.47, AP 164, normal ALT/AST, INR 1.4, ABG
___, lactate 2.6->1.3
Imaging notable for: NCCTH w/o hemorrhage, CXR w/ possible LLL
PNA.
EKG 88 NS NA No STTW changes concerning for ischemia
Patient was given: RIJ placed, given rocuronium 80 mg,
norepinephrine gtt, midazolam gtt, fentanyl gtt
Consults: Post-arrest response team recommended TTM at 35
degrees for 24 hours w/ EEG in ICU. TTM was initiated. He
developed a CTX after the RIJ was placed that required chest
tube placement.
VS prior to transfer: T 34.9 HR 87 BP 137/76 RR 20 99% RA
On arrival to the MICU: Patient is intubated and sedated, chest
tube in place.
Past Medical History:
Basal cell carcinoma
Schizophrenia
Anemia
Cataracts
Constipation
Hyponatremia
Tobacco abuse
Osteoporosis
Psoriasis
Actinic keratosis
Dupuytrens
Squamous cell carcinoma
Hypertension
Allergic rhinitis
Social History:
___
Family History:
Mother: deceased, old age
Father: prostate cancer
Physical Exam:
ADMISSION PHYSICAL EXAM
============================
VITALS: Reviewed in metavision.
GENERAL: Intubated and sedated
HEENT: Sclera anicteric, PERRLA, ETT in place
NECK: supple, right CVL
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Cool, well perfused, 2+ pulses, no edema
SKIN: Artic sun in place
Pertinent Results:
LABS ON ADMISSION
==========================
___ 06:38PM TYPE-CENTRAL VE PO2-40* PCO2-31* PH-7.45
TOTAL CO2-22 BASE XS-0
___ 06:38PM LACTATE-1.5
___ 06:38PM O2 SAT-72
___ 06:10PM GLUCOSE-182* UREA N-13 CREAT-0.3* SODIUM-134
POTASSIUM-4.2 CHLORIDE-97 TOTAL CO2-20* ANION GAP-17*
___ 06:10PM ALT(SGPT)-14 AST(SGOT)-31 CK(CPK)-279 ALK
PHOS-164* TOT BILI-0.6
___ 06:10PM ALBUMIN-3.0* CALCIUM-8.5 PHOSPHATE-2.8
___ 06:10PM NEUTS-86.9* LYMPHS-5.1* MONOS-6.7 EOS-0.1*
BASOS-0.2 IM ___ AbsNeut-14.01* AbsLymp-0.83*
AbsMono-1.08* AbsEos-0.01* AbsBaso-0.04
___ 06:10PM ___ PTT-29.3 ___
PERTIENT LABS
===============
Trops
___ 06:10PM BLOOD cTropnT-0.47*
___ 12:30AM BLOOD CK-MB-41* MB Indx-13.4* cTropnT-0.41*
___ 07:32AM BLOOD CK-MB-29* MB Indx-12.0* cTropnT-0.30*
___ 02:29PM BLOOD CK-MB-27* MB Indx-13.6* cTropnT-0.22*
MICRO
===========
BCx ___ pending
GRAM STAIN (Final ___:
>25 PMNs and >10 epithelial cells/100X field.
___ MRSA SCREEN (Final ___: No MRSA isolated.
IMAGING
==================
___ MRI Head
Diffusion abnormalities along the cortex of both cerebral
hemispheres predominantly in the parieto-occipital lobes are
suggestive of early ischemic brain injury.
___ LENIs
1. Limited examination, but no evidence of deep vein thrombosis
in the right upper extremity.
2. Probable hematoma in the upper inner arm as described.
Correlate with
physical examination for chronicity, and advise clinical
follow-up to ensure resolution over time.
___ TTE
The left atrial volume index is normal. Normal left ventricular
wall thickness, cavity size, and regional/global systolic
function (biplane LVEF = 64 %). Tissue Doppler imaging suggests
a normal left ventricular filling pressure (PCWP<12mmHg). 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 (?#) appear structurally
normal with good leaflet excursion. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
The estimated pulmonary artery systolic pressure is high normal.
There is no pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
regional and global biventricular systolic function. No valvular
pathology or pathologic flow identified. No pericardial
effusion.
___ EEG
This is an abnormal ICU continuous video EEG monitoring study
due to the presence of a burst suppression pattern, indicative
of a severe ecphalopathy. By the late afternoon, overall
amplitudes began to diminish, and more prolonged background
attenuation was seen, with plentiful artifact. By the end of the
recording, definitive activity of cerebral origin was not
clearly seen. These findings are indicative of worsening of the
severe encephalopathy, which could be related to medication
effects, toxic/metabolic disturbances or progression of
neurologic injury. There were no clear epileptiform discharges
or electrographic seizures in this recording.
___ Shoulder ___ views
Displaced humeral head fracture corresponding to given history,
with exact relation of fracture fragments difficult to identify
given limited included two views.
___ CXR
AP portable supine view of the chest. The endotracheal tube is
positioned with its tip 3.8 cm above the carina. There is a
vague opacity in the right lower lung which could reflect a
focus of pneumonia though attention on followup advised. There
is mild retrocardiac opacity likely atelectasis. No large
effusion or pneumothorax is seen. The cardiomediastinal
silhouette appears grossly unremarkable. There is a
dextroscoliotic curvature of the thoracic spine. No acute bony
abnormalities.
Brief Hospital Course:
Mr ___ was admitted to the MICU at ___ for post-cardiac
arrest management. He received 5 rounds of CPR prior to ROSC.
Unfortunately, despite obtaining ROSC, he suffered a devastating
brain injury likely ___ anoxia. This was confirmed on MRI as
well as with consult from the neurology team. After speaking
with his HCP, we agreed to progress to CMO. He was extubated and
expired on ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
2. Calcium Carbonate 500 mg PO BID
3. Citalopram 10 mg PO DAILY
4. Apixaban 5 mg PO BID
5. OLANZapine 20 mg PO DAILY
6. Divalproex (DELayed Release) 500 mg PO TID
7. Ketoconazole Shampoo 1 Appl TP ASDIR
8. Docusate Sodium 100 mg PO DAILY
9. Hydrocortisone Cream 2.5% 1 Appl TP BID
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
___
|
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"J690",
"G931",
"I82621",
"Z8674",
"J95811",
"I959",
"J9600",
"I10",
"D638",
"Y848",
"Y92238",
"Z66",
"Z515",
"Z781",
"F209",
"S42291D",
"W1830XD",
"Z9181",
"Z85828",
"H269",
"Z720",
"L409",
"M810",
"L570",
"M720",
"J309",
"F1021",
"Z7902",
"H6120"
] |
Allergies: Penicillins / Haldol [MASKED] Complaint: s/p cardiac arrest Major Surgical or Invasive Procedure: chest thoracostomy tube placement intubation central venous catheter placement History of Present Illness: [MASKED] with PMHx significant for schizophrenia, hypertension and anemia who p/w from nursing home with cardiac arrest. Per EMS, he choked while sitting in his chair eating, found slumped over in chair without e/o trauma, turned blue. Found cyanotic without pulses. Heimelich productive of large food bolus. ROSC [MASKED] s/p CPR and epi x2 and intubated w/ IO placed. In [MASKED], became bradycardic transitioning to Asystole 1330. Given Epi, further CPR, obtained ROSC. His SBP of [MASKED], started on levo. In ED initial VS: T 34.9 HR 83 BP 111/63 RR 14 100% ra Exam: Tube in place, some secretions suctioned, No e/o trauma or prolonged down time, Psoriatic plaques, 2mm minimally responsive pupils, Unresponsive, No spontaneous limb movements Labs were notable for: wbc 16.1, hgb 12.4, plt 635, Na 134, K 4.2, cr 0.3, TnT 0.47, AP 164, normal ALT/AST, INR 1.4, ABG [MASKED], lactate 2.6->1.3 Imaging notable for: NCCTH w/o hemorrhage, CXR w/ possible LLL PNA. EKG 88 NS NA No STTW changes concerning for ischemia Patient was given: RIJ placed, given rocuronium 80 mg, norepinephrine gtt, midazolam gtt, fentanyl gtt Consults: Post-arrest response team recommended TTM at 35 degrees for 24 hours w/ EEG in ICU. TTM was initiated. He developed a CTX after the RIJ was placed that required chest tube placement. VS prior to transfer: T 34.9 HR 87 BP 137/76 RR 20 99% RA On arrival to the MICU: Patient is intubated and sedated, chest tube in place. Past Medical History: Basal cell carcinoma Schizophrenia Anemia Cataracts Constipation Hyponatremia Tobacco abuse Osteoporosis Psoriasis Actinic keratosis Dupuytrens Squamous cell carcinoma Hypertension Allergic rhinitis Social History: [MASKED] Family History: Mother: deceased, old age Father: prostate cancer Physical Exam: ADMISSION PHYSICAL EXAM ============================ VITALS: Reviewed in metavision. GENERAL: Intubated and sedated HEENT: Sclera anicteric, PERRLA, ETT in place NECK: supple, right CVL LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Cool, well perfused, 2+ pulses, no edema SKIN: Artic sun in place Pertinent Results: LABS ON ADMISSION ========================== [MASKED] 06:38PM TYPE-CENTRAL VE PO2-40* PCO2-31* PH-7.45 TOTAL CO2-22 BASE XS-0 [MASKED] 06:38PM LACTATE-1.5 [MASKED] 06:38PM O2 SAT-72 [MASKED] 06:10PM GLUCOSE-182* UREA N-13 CREAT-0.3* SODIUM-134 POTASSIUM-4.2 CHLORIDE-97 TOTAL CO2-20* ANION GAP-17* [MASKED] 06:10PM ALT(SGPT)-14 AST(SGOT)-31 CK(CPK)-279 ALK PHOS-164* TOT BILI-0.6 [MASKED] 06:10PM ALBUMIN-3.0* CALCIUM-8.5 PHOSPHATE-2.8 [MASKED] 06:10PM NEUTS-86.9* LYMPHS-5.1* MONOS-6.7 EOS-0.1* BASOS-0.2 IM [MASKED] AbsNeut-14.01* AbsLymp-0.83* AbsMono-1.08* AbsEos-0.01* AbsBaso-0.04 [MASKED] 06:10PM [MASKED] PTT-29.3 [MASKED] PERTIENT LABS =============== Trops [MASKED] 06:10PM BLOOD cTropnT-0.47* [MASKED] 12:30AM BLOOD CK-MB-41* MB Indx-13.4* cTropnT-0.41* [MASKED] 07:32AM BLOOD CK-MB-29* MB Indx-12.0* cTropnT-0.30* [MASKED] 02:29PM BLOOD CK-MB-27* MB Indx-13.6* cTropnT-0.22* MICRO =========== BCx [MASKED] pending GRAM STAIN (Final [MASKED]: >25 PMNs and >10 epithelial cells/100X field. [MASKED] MRSA SCREEN (Final [MASKED]: No MRSA isolated. IMAGING ================== [MASKED] MRI Head Diffusion abnormalities along the cortex of both cerebral hemispheres predominantly in the parieto-occipital lobes are suggestive of early ischemic brain injury. [MASKED] LENIs 1. Limited examination, but no evidence of deep vein thrombosis in the right upper extremity. 2. Probable hematoma in the upper inner arm as described. Correlate with physical examination for chronicity, and advise clinical follow-up to ensure resolution over time. [MASKED] TTE The left atrial volume index is normal. Normal left ventricular wall thickness, cavity size, and regional/global systolic function (biplane LVEF = 64 %). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). 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 (?#) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is high normal. There is no pericardial effusion. IMPRESSION: Normal biventricular cavity sizes with preserved regional and global biventricular systolic function. No valvular pathology or pathologic flow identified. No pericardial effusion. [MASKED] EEG This is an abnormal ICU continuous video EEG monitoring study due to the presence of a burst suppression pattern, indicative of a severe ecphalopathy. By the late afternoon, overall amplitudes began to diminish, and more prolonged background attenuation was seen, with plentiful artifact. By the end of the recording, definitive activity of cerebral origin was not clearly seen. These findings are indicative of worsening of the severe encephalopathy, which could be related to medication effects, toxic/metabolic disturbances or progression of neurologic injury. There were no clear epileptiform discharges or electrographic seizures in this recording. [MASKED] Shoulder [MASKED] views Displaced humeral head fracture corresponding to given history, with exact relation of fracture fragments difficult to identify given limited included two views. [MASKED] CXR AP portable supine view of the chest. The endotracheal tube is positioned with its tip 3.8 cm above the carina. There is a vague opacity in the right lower lung which could reflect a focus of pneumonia though attention on followup advised. There is mild retrocardiac opacity likely atelectasis. No large effusion or pneumothorax is seen. The cardiomediastinal silhouette appears grossly unremarkable. There is a dextroscoliotic curvature of the thoracic spine. No acute bony abnormalities. Brief Hospital Course: Mr [MASKED] was admitted to the MICU at [MASKED] for post-cardiac arrest management. He received 5 rounds of CPR prior to ROSC. Unfortunately, despite obtaining ROSC, he suffered a devastating brain injury likely [MASKED] anoxia. This was confirmed on MRI as well as with consult from the neurology team. After speaking with his HCP, we agreed to progress to CMO. He was extubated and expired on [MASKED]. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 5 mg PO DAILY 2. Calcium Carbonate 500 mg PO BID 3. Citalopram 10 mg PO DAILY 4. Apixaban 5 mg PO BID 5. OLANZapine 20 mg PO DAILY 6. Divalproex (DELayed Release) 500 mg PO TID 7. Ketoconazole Shampoo 1 Appl TP ASDIR 8. Docusate Sodium 100 mg PO DAILY 9. Hydrocortisone Cream 2.5% 1 Appl TP BID Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: [MASKED]
|
[] |
[
"I10",
"Z66",
"Z515",
"Z7902"
] |
[
"J690: Pneumonitis due to inhalation of food and vomit",
"G931: Anoxic brain damage, not elsewhere classified",
"I82621: Acute embolism and thrombosis of deep veins of right upper extremity",
"Z8674: Personal history of sudden cardiac arrest",
"J95811: Postprocedural pneumothorax",
"I959: Hypotension, unspecified",
"J9600: Acute respiratory failure, unspecified whether with hypoxia or hypercapnia",
"I10: Essential (primary) hypertension",
"D638: Anemia in other chronic diseases classified elsewhere",
"Y848: Other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure",
"Y92238: Other place in hospital as the place of occurrence of the external cause",
"Z66: Do not resuscitate",
"Z515: Encounter for palliative care",
"Z781: Physical restraint status",
"F209: Schizophrenia, unspecified",
"S42291D: Other displaced fracture of upper end of right humerus, subsequent encounter for fracture with routine healing",
"W1830XD: Fall on same level, unspecified, subsequent encounter",
"Z9181: History of falling",
"Z85828: Personal history of other malignant neoplasm of skin",
"H269: Unspecified cataract",
"Z720: Tobacco use",
"L409: Psoriasis, unspecified",
"M810: Age-related osteoporosis without current pathological fracture",
"L570: Actinic keratosis",
"M720: Palmar fascial fibromatosis [Dupuytren]",
"J309: Allergic rhinitis, unspecified",
"F1021: Alcohol dependence, in remission",
"Z7902: Long term (current) use of antithrombotics/antiplatelets",
"H6120: Impacted cerumen, unspecified ear"
] |
10,004,764 | 24,817,563 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
___
Urgent coronary artery bypass graft x3, left internal
mammary artery to left anterior descending artery,
saphenous vein graft to diagonal and distal right
coronary arteries.
2. Endoscopic harvesting of long saphenous vein.
History of Present Illness:
___ old male hx of CAD, underwent PCI ___ ago BMS to left circ
and balloon angioplasty to diagonal branch. At that time was
note
to have RCA and LAD disease. He reports that over the past few
months he has been having worsening chest discomfort, described
as burning sensation mid chest that radiates down both arms. He
has pain with exertion, relieved with rest. Yesterday he
developed chest pain and took SL nitro,pain reslved. He was seen
by his PCP today who referred him to ___. His EKG was
unremarkable, troponin 0.22. He underwent cardiac cath today
which revealed significant multivessel disease. He was
transferred to ___ for CABG evaluation.
Past Medical History:
Past Medical History:
CAD,
HTN,
Hypercholesterolemia
Past Surgical History:
PCI ___
s/p T+A
Social History:
___
Family History:
unremarkable
Physical Exam:
___:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+[x]
Extremities: Warm [x] well-perfused [x] Edema [] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 1+ Left: 1+
___ Right: 1+ Left: 1+
Radial Right: cath site Left: 2+
Carotid Bruit: Right: no Left: no
Pertinent Results:
Cardiac Catheterization: Date: ___ Place: ___
LM 90% stenosis
LAD ___ 90% stenosis
Circ: 100% stenosis, existing stent unknown, instent stenosis,
no
thrombosis
RCA: mid ___ 60% stenosis, mid 70%
Left heart cath revealed: EF 65% grade 2 MR, aortic valve Ok
Cardiac Echocardiogram:
___ ECHOCARDIOGRAPHY REPORT
___ ___ MRN: ___ TEE
(Complete) Done ___ at 9:24:37 AM FINAL
Referring Physician ___
___ of Cardiothoracic Surg
___ ___
___ Status: Inpatient DOB: ___
Age (years): ___ M Hgt (in): 70
BP (mm Hg): 127/60 Wgt (lb): 143
HR (bpm): 68 BSA (m2): 1.81 m2
Indication: Intraoperative TEE for CABG
Diagnosis: I25.9, I34.0
___ Information
Date/Time: ___ at 09:24 ___ MD: ___,
MD
___ Type: TEE (Complete) Sonographer: ___, MD
Doppler: Full Doppler and color Doppler ___ Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Machine:
Echocardiographic Measurements
Results
Measurements
Normal Range
Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1
cm
Left Ventricle - Ejection Fraction: 60% to 65% >= 55%
Findings
LEFT ATRIUM: Dilated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Dilated RA.
LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
global systolic function (LVEF>55%). Normal regional LV systolic
function.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Normal aortic arch
diameter. Focal calcifications in aortic arch. Normal descending
aorta diameter. Simple atheroma in descending aorta. Focal
calcifications in descending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS.
___ (1+) MR.
___ VALVE: Normal tricuspid valve leaflets with trivial
TR. No TS.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized.
No PS. Physiologic PR.
PERICARDIUM: Very small pericardial effusion.
___ COMMENTS: Written informed consent was obtained from the
___. The ___ was under ___ anesthesia throughout the
procedure. No TEE related complications. The ___ appears to
be in sinus rhythm. Results were personally reviewed with the MD
caring for the ___. See Conclusions for post-bypass data
Conclusions
PRE-BYPASS:
The left atrium is dilated. The right atrium is dilated. Left
ventricular wall thickness, cavity size, and global systolic
function are normal (LVEF>55%). Regional left ventricular wall
motion is normal. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve leaflets are
mildly thickened. There is billowing of the anterior mitral
leaflet. Mild (1+) mitral regurgitation is seen. Trace tricuspid
regurgitation is seen. There is a very small pericardial
effusion.
POST-BYPASS:
The ___ is in sinus rhythm and receiving a phenylephrine
infusion.
Biventricular function remains preserved. There are no regional
wall motion abnormalities.
Valvular function is unchanged.
The thoracic aorta is intact following decannulation.
Brief Hospital Course:
Mr. ___ was transferred to ___ on ___. On ___ he
underwent a coronary artery bypass grafting times three. Please
see operative note for full details. He tolerated the procedure
well and was transferred to the CVICU in stable condition for
recovery and invasive monitoring. He was weaned from sedation,
awoke neurologically intact, and was extubated on post-operative
day one. He weaned from inotropic and vasopressor support. Beta
blocker was initiated and he was diuresed toward his
preoperative weight. Mr. ___ remained hemodynamically
stable and was transferred to the telemetry floor for further
recovery. Chest tubes and epicardial wires were removed per
protocol. He was evaluated by the physical therapy service for
assistance with strength and mobility. On the evening of
post-operative day two he had about two hours of atrial
fibrillation and therefore was placed on oral amiodarone. His
beta blockade was up-titrated as tolerated. By the time of
discharge on post-operative day four he was ambulating freely,
his wounds were healing well, and his pain was controlled with
oral analgesics. He was discharged to home in good condition
with appropriate follow up instructions.
Medications on Admission:
ASA 81mg daily
atenolol 25mg daily
atorvastatin 80mg daily
Discharge Medications:
1. Acetaminophen 1000 mg PO/PR QID:PRN pain or temperature
>38.0
2. Amiodarone 200 mg PO BID
take 200mg twice daily for one week, then decrease to 200mg
daily ongoing
RX *amiodarone 200 mg one tablet(s) by mouth twice daily Disp
#*120 Tablet Refills:*2
3. Metoprolol Succinate XL 150 mg PO DAILY
RX *metoprolol succinate 50 mg three tablet(s) by mouth daily
Disp #*90 Tablet Refills:*2
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain:
moderate/severe
RX *oxycodone 5 mg ___ tablet(s) by mouth every four hours Disp
#*40 Tablet Refills:*0
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 80 mg PO QPM
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Coronary Artery Disease
Hypertension
HTN,
Hypercholesterolemia
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema trace
Discharge Instructions:
Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Followup Instructions:
___
|
[
"I2510",
"I959",
"I4891",
"D649",
"I10",
"E7800",
"Z955",
"Z87891",
"R0902"
] |
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [MASKED] Urgent coronary artery bypass graft x3, left internal mammary artery to left anterior descending artery, saphenous vein graft to diagonal and distal right coronary arteries. 2. Endoscopic harvesting of long saphenous vein. History of Present Illness: [MASKED] old male hx of CAD, underwent PCI [MASKED] ago BMS to left circ and balloon angioplasty to diagonal branch. At that time was note to have RCA and LAD disease. He reports that over the past few months he has been having worsening chest discomfort, described as burning sensation mid chest that radiates down both arms. He has pain with exertion, relieved with rest. Yesterday he developed chest pain and took SL nitro,pain reslved. He was seen by his PCP today who referred him to [MASKED]. His EKG was unremarkable, troponin 0.22. He underwent cardiac cath today which revealed significant multivessel disease. He was transferred to [MASKED] for CABG evaluation. Past Medical History: Past Medical History: CAD, HTN, Hypercholesterolemia Past Surgical History: PCI [MASKED] s/p T+A Social History: [MASKED] Family History: unremarkable Physical Exam: [MASKED]: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade [MASKED] Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds +[x] Extremities: Warm [x] well-perfused [x] Edema [] [MASKED] Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: 2+ Left: 2+ DP Right: 1+ Left: 1+ [MASKED] Right: 1+ Left: 1+ Radial Right: cath site Left: 2+ Carotid Bruit: Right: no Left: no Pertinent Results: Cardiac Catheterization: Date: [MASKED] Place: [MASKED] LM 90% stenosis LAD [MASKED] 90% stenosis Circ: 100% stenosis, existing stent unknown, instent stenosis, no thrombosis RCA: mid [MASKED] 60% stenosis, mid 70% Left heart cath revealed: EF 65% grade 2 MR, aortic valve Ok Cardiac Echocardiogram: [MASKED] ECHOCARDIOGRAPHY REPORT [MASKED] [MASKED] MRN: [MASKED] TEE (Complete) Done [MASKED] at 9:24:37 AM FINAL Referring Physician [MASKED] [MASKED] of Cardiothoracic Surg [MASKED] [MASKED] [MASKED] Status: Inpatient DOB: [MASKED] Age (years): [MASKED] M Hgt (in): 70 BP (mm Hg): 127/60 Wgt (lb): 143 HR (bpm): 68 BSA (m2): 1.81 m2 Indication: Intraoperative TEE for CABG Diagnosis: I25.9, I34.0 [MASKED] Information Date/Time: [MASKED] at 09:24 [MASKED] MD: [MASKED], MD [MASKED] Type: TEE (Complete) Sonographer: [MASKED], MD Doppler: Full Doppler and color Doppler [MASKED] Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Machine: Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Ejection Fraction: 60% to 65% >= 55% Findings LEFT ATRIUM: Dilated LA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Dilated RA. LEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic function (LVEF>55%). Normal regional LV systolic function. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal ascending aorta diameter. Normal aortic arch diameter. Focal calcifications in aortic arch. Normal descending aorta diameter. Simple atheroma in descending aorta. Focal calcifications in descending aorta. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS. [MASKED] (1+) MR. [MASKED] VALVE: Normal tricuspid valve leaflets with trivial TR. No TS. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS. Physiologic PR. PERICARDIUM: Very small pericardial effusion. [MASKED] COMMENTS: Written informed consent was obtained from the [MASKED]. The [MASKED] was under [MASKED] anesthesia throughout the procedure. No TEE related complications. The [MASKED] appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the [MASKED]. See Conclusions for post-bypass data Conclusions PRE-BYPASS: The left atrium is dilated. The right atrium is dilated. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are mildly thickened. There is billowing of the anterior mitral leaflet. Mild (1+) mitral regurgitation is seen. Trace tricuspid regurgitation is seen. There is a very small pericardial effusion. POST-BYPASS: The [MASKED] is in sinus rhythm and receiving a phenylephrine infusion. Biventricular function remains preserved. There are no regional wall motion abnormalities. Valvular function is unchanged. The thoracic aorta is intact following decannulation. Brief Hospital Course: Mr. [MASKED] was transferred to [MASKED] on [MASKED]. On [MASKED] he underwent a coronary artery bypass grafting times three. Please see operative note for full details. He tolerated the procedure well and was transferred to the CVICU in stable condition for recovery and invasive monitoring. He was weaned from sedation, awoke neurologically intact, and was extubated on post-operative day one. He weaned from inotropic and vasopressor support. Beta blocker was initiated and he was diuresed toward his preoperative weight. Mr. [MASKED] remained hemodynamically stable and was transferred to the telemetry floor for further recovery. Chest tubes and epicardial wires were removed per protocol. He was evaluated by the physical therapy service for assistance with strength and mobility. On the evening of post-operative day two he had about two hours of atrial fibrillation and therefore was placed on oral amiodarone. His beta blockade was up-titrated as tolerated. By the time of discharge on post-operative day four he was ambulating freely, his wounds were healing well, and his pain was controlled with oral analgesics. He was discharged to home in good condition with appropriate follow up instructions. Medications on Admission: ASA 81mg daily atenolol 25mg daily atorvastatin 80mg daily Discharge Medications: 1. Acetaminophen 1000 mg PO/PR QID:PRN pain or temperature >38.0 2. Amiodarone 200 mg PO BID take 200mg twice daily for one week, then decrease to 200mg daily ongoing RX *amiodarone 200 mg one tablet(s) by mouth twice daily Disp #*120 Tablet Refills:*2 3. Metoprolol Succinate XL 150 mg PO DAILY RX *metoprolol succinate 50 mg three tablet(s) by mouth daily Disp #*90 Tablet Refills:*2 4. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain: moderate/severe RX *oxycodone 5 mg [MASKED] tablet(s) by mouth every four hours Disp #*40 Tablet Refills:*0 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 80 mg PO QPM Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Coronary Artery Disease Hypertension HTN, Hypercholesterolemia Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema trace Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [MASKED]. Answering service will contact on call person during off hours** Followup Instructions: [MASKED]
|
[] |
[
"I2510",
"I4891",
"D649",
"I10",
"Z955",
"Z87891"
] |
[
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"I959: Hypotension, unspecified",
"I4891: Unspecified atrial fibrillation",
"D649: Anemia, unspecified",
"I10: Essential (primary) hypertension",
"E7800: Pure hypercholesterolemia, unspecified",
"Z955: Presence of coronary angioplasty implant and graft",
"Z87891: Personal history of nicotine dependence",
"R0902: Hypoxemia"
] |
10,005,001 | 23,954,664 |
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:
Malignant transformation of endometriosis - final pathology
report pending.
Major Surgical or Invasive Procedure:
exploratory laparotomy, total abdominal hysterectomy, left
salingo-oophrectomy, omentectomy, para-aortic lymph node biopsy,
liver resection, cystoscopy
History of Present Illness:
Ms. ___ is a ___ G0 with a history of fibroids and
endometriosis who presents today for consultation regarding a
large left adnexal mass identified on imaging. In ___
she
underwent an abdominal myomectomy with left ovarian cystectomy
for 27 fibroids and a 15-cm endometrioma. She reports recovering
well until around ___, when she started to experience
epigastric discomfort and occasional shortness of breath. She
underwent CTA of the chest to evaluate for PE, which was
negative
and there was no lymphadenopathy or suspicious nodule seen. In
___, she got the heaviest period she has had since her
Mirena IUD was placed. She underwent endometrial biopsy on
___, which showed chronic endometritis. She was already
taking doxycycline for a positive Lyme titer while awaiting
confirmatory testing, but continued to have vaginal bleeding.
Her
followup Lyme testing was negative.
She continued to feel quite fatigued and noted abdominal pain
epigastrically as well as in the LLQ, back pain, and decreased
appetite and constipation which got progressively more
bothersome
during ___. She ultimately went to the ED on ___ where
she underwent CT scan of the abdomen and pelvis, which showed a
large 10-cm left complex adnexal cystic mass with septations and
irregular solid components. Additionally, there were multiple
subcapsular hepatic lesions and peritoneal implants, as well as
retroperitoneal lymphadenopathy. Findings
were concerning for a metastatic primary ovarian neoplasm, such
as cystadenocarcinoma, versus atypical distribution of
endometriotic implants.
On ___ patient underwent an MRI of the abdomen and pelvis
lower thorax showed clear lung bases no focal consolidations no
pleural or pericardial effusion. Liver showed multiple
nonenhancing cystic subcapsular implants likely representing
hemorrhage. The largest right arises from the right lobe of the
liver and measured 4.1 x 2.8 cm. There was no associated
enhancement likely represent adherent clot. There were no
suspicious enhancing lesions intrinsic to the hepatic
parenchyma.
Again, in regard to the pelvis, there was a large cystic
multiloculated left adnexal structure measuring up to 10.8 x
10.1
cm. The septations were thin without significant enhancement or
nodular components. The loculations demonstrated fluid-filled
areas correction fluid-filled levels also likely representing
hemorrhage. Within one of the loculations, there was a dark spot
sign a finding that could be consistent with endometriosis. A
smaller right adnexal cystic structure was seen measuring 3.5 x
3.0 cm. Uterus was enlarged with multiple small fibroids and
IUD
was seen within the endometrial cavity at. There was a trace
free fluid within the pelvis multiple cystic anterior peritoneal
implants were visualized with fluid-filled levels likely
representing hemorrhage. There was peripheral enhancement,
which
may be reactive in nature. One of these peritoneal implants
appeared to have significant surrounding fat stranding. A left
periaortic retroperitoneal lesion had a similar appearance.
Multiple subcentimeter periaortic lymph nodes were nonspecific.
There was no inguinal or pelvic lymphadenopathy.
She saw Dr. ___ in the office on ___ and received a
1-month dose of Lupron. She was referred to ___ Oncology for
further evaluation given atypical imaging findings.
Of note, she had a CA125 checked on ___, which was 108,
decreased from 209 in ___. CEA was 0.9 on ___.
Today she reports abdominal bloating, constipation, decreased
appetite and increased abdominal girth. She noted decreased
vaginal spotting since her Lupron shot, but it has been
persistent. She also reports continued fatigue and occasional
nausea. She denies chest pain, shortness of breath, diarrhea or
dysuria.
Past Medical History:
GYN HX:
G0
- LMP ___, only minor spotting while IUD in place except
when bleeding began in ___
- Currently sexually active with female partner
- ___ history of abnormal Pap smears; last Pap ___
- Denies history of pelvic infections or sexually transmitted
infections
- Known history of fibroids and ovarian cysts
- Known endometriosis
PMH:
- allergic rhinitis
- depression
- pseudocholinesterase deficiency
- Denies hypertension, diabetes, asthma, thromboembolic disease
PSH:
- ___ knee surgery
- ___ abdominal myomectomy
- ___ RSO, L ov cystectomy -> Path: endometriotic cyst with
focal metaplastic/reactive changes
- ___ abdominal myomectomy, LOA, L ovarian cystectomy -> Path:
leiomyomata with degenerative changes, endometriotic cyst
Social History:
___
Family History:
FHx:
- Father living, hx of bladder, prostate, skin, and throat
cancer
(non-smoker)
- Mother died age ___ of colon cancer, also had DM and glaucoma
- Brother is healthy
- Niece with cystic fibrosis
- No known family history of breast, uterine, ovarian, or
cervical
Physical Exam:
On day of discharge:
Afebrile, vitals stable
No acute distress
CV: regular rate and rhythm
Pulm: clear to auscultation bilaterally
Abd: soft, appropriately tender, nondistended, incision
clean/dry/intact, no rebound/guarding
___: nontender, nonedematous
Brief Hospital Course:
Ms. ___ was admitted to the gynecologic oncology service
after undergoing exploratory laparaotomy, total abdominal
hysterectomy, left salpingo-oophorectomy, omentectomy,
para-aortic lymph node biopsy, liver resection and cystoscopy
for malignant transformation of endometriosis. Please see the
operative report for full details.
Her post-operative course is detailed as follows. Immediately
postoperatively, her pain was controlled with an epidural and
Dilaudid PCA with toradol. Her diet was gradually advanced
without difficulty and she was transitioned to oral oxycodone,
Tylenol and ibuprofen. On post-operative day #2, her urine
output was adequate so her Foley catheter was removed and she
voided spontaneously.
By post-operative day 5, she was tolerating a regular diet,
voiding spontaneously, ambulating independently, and pain was
controlled with oral medications. She was then discharged home
in stable condition with outpatient follow-up scheduled.
Medications on Admission:
duloxetine 60mg daily
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
do not exceed 4000mg in 24 hours
RX *acetaminophen 500 mg 2 tablet(s) by mouth every 6 hours Disp
#*60 Tablet Refills:*2
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily
Disp #*60 Capsule Refills:*2
3. Enoxaparin Sodium 30 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
Take this medication for a total of 28 days after your surgery,
ending ___.
RX *enoxaparin 30 mg/0.3 mL 30 mg SC twice a day Disp #*50
Syringe Refills:*0
4. Ferrous GLUCONATE 324 mg PO DAILY
RX *ferrous gluconate 324 mg (36 mg iron) 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*2
5. Ibuprofen 600 mg PO Q6H:PRN Pain - Moderate
take with food
RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp
#*60 Tablet Refills:*1
6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Severe
do not drive or drink alcohol, causes sedation
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp
#*50 Tablet Refills:*0
7. DULoxetine 60 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
malignant transformation of endometriosis
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 gynecologic oncology service after
undergoing the procedures listed below. You have recovered well
after your operation, and the team feels that you are safe to be
discharged home. Please follow these instructions:
.
Abdominal instructions:
* Take your medications as prescribed. We recommend you take
non-narcotics (i.e. Tylenol, ibuprofen) regularly for the first
few days post-operatively, and use the narcotic as needed. As
you start to feel better and need less medication, you should
decrease/stop the narcotic first.
* Do not drive while taking narcotics.
* Do not combine narcotic and sedative medications or alcohol.
* Do not take more than 4000mg acetaminophen (tylenol) in 24
hrs.
* No strenuous activity until your post-op appointment.
* Nothing in the vagina (no tampons, no douching, no sex) for 12
weeks.
* No heavy lifting of objects >10 lbs for 6 weeks.
* You may eat a regular diet.
* It is safe to walk up stairs.
.
Incision care:
* You may shower and allow soapy water to run over incision; no
scrubbing of incision. No bath tubs for 6 weeks.
* If you have staples, they will be removed at your follow-up
visit.
.
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
.
Call your doctor at ___ for:
* fever > 100.4
* severe abdominal pain
* difficulty urinating
* vaginal bleeding requiring >1 pad/hr
* abnormal vaginal discharge
* redness or drainage from incision
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
* chest pain or difficulty breathing
* onset of any concerning symptoms
Followup Instructions:
___
|
[
"C562",
"C786",
"C772",
"C787",
"E669",
"F419",
"F329",
"Z6836"
] |
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Malignant transformation of endometriosis - final pathology report pending. Major Surgical or Invasive Procedure: exploratory laparotomy, total abdominal hysterectomy, left salingo-oophrectomy, omentectomy, para-aortic lymph node biopsy, liver resection, cystoscopy History of Present Illness: Ms. [MASKED] is a [MASKED] G0 with a history of fibroids and endometriosis who presents today for consultation regarding a large left adnexal mass identified on imaging. In [MASKED] she underwent an abdominal myomectomy with left ovarian cystectomy for 27 fibroids and a 15-cm endometrioma. She reports recovering well until around [MASKED], when she started to experience epigastric discomfort and occasional shortness of breath. She underwent CTA of the chest to evaluate for PE, which was negative and there was no lymphadenopathy or suspicious nodule seen. In [MASKED], she got the heaviest period she has had since her Mirena IUD was placed. She underwent endometrial biopsy on [MASKED], which showed chronic endometritis. She was already taking doxycycline for a positive Lyme titer while awaiting confirmatory testing, but continued to have vaginal bleeding. Her followup Lyme testing was negative. She continued to feel quite fatigued and noted abdominal pain epigastrically as well as in the LLQ, back pain, and decreased appetite and constipation which got progressively more bothersome during [MASKED]. She ultimately went to the ED on [MASKED] where she underwent CT scan of the abdomen and pelvis, which showed a large 10-cm left complex adnexal cystic mass with septations and irregular solid components. Additionally, there were multiple subcapsular hepatic lesions and peritoneal implants, as well as retroperitoneal lymphadenopathy. Findings were concerning for a metastatic primary ovarian neoplasm, such as cystadenocarcinoma, versus atypical distribution of endometriotic implants. On [MASKED] patient underwent an MRI of the abdomen and pelvis lower thorax showed clear lung bases no focal consolidations no pleural or pericardial effusion. Liver showed multiple nonenhancing cystic subcapsular implants likely representing hemorrhage. The largest right arises from the right lobe of the liver and measured 4.1 x 2.8 cm. There was no associated enhancement likely represent adherent clot. There were no suspicious enhancing lesions intrinsic to the hepatic parenchyma. Again, in regard to the pelvis, there was a large cystic multiloculated left adnexal structure measuring up to 10.8 x 10.1 cm. The septations were thin without significant enhancement or nodular components. The loculations demonstrated fluid-filled areas correction fluid-filled levels also likely representing hemorrhage. Within one of the loculations, there was a dark spot sign a finding that could be consistent with endometriosis. A smaller right adnexal cystic structure was seen measuring 3.5 x 3.0 cm. Uterus was enlarged with multiple small fibroids and IUD was seen within the endometrial cavity at. There was a trace free fluid within the pelvis multiple cystic anterior peritoneal implants were visualized with fluid-filled levels likely representing hemorrhage. There was peripheral enhancement, which may be reactive in nature. One of these peritoneal implants appeared to have significant surrounding fat stranding. A left periaortic retroperitoneal lesion had a similar appearance. Multiple subcentimeter periaortic lymph nodes were nonspecific. There was no inguinal or pelvic lymphadenopathy. She saw Dr. [MASKED] in the office on [MASKED] and received a 1-month dose of Lupron. She was referred to [MASKED] Oncology for further evaluation given atypical imaging findings. Of note, she had a CA125 checked on [MASKED], which was 108, decreased from 209 in [MASKED]. CEA was 0.9 on [MASKED]. Today she reports abdominal bloating, constipation, decreased appetite and increased abdominal girth. She noted decreased vaginal spotting since her Lupron shot, but it has been persistent. She also reports continued fatigue and occasional nausea. She denies chest pain, shortness of breath, diarrhea or dysuria. Past Medical History: GYN HX: G0 - LMP [MASKED], only minor spotting while IUD in place except when bleeding began in [MASKED] - Currently sexually active with female partner - [MASKED] history of abnormal Pap smears; last Pap [MASKED] - Denies history of pelvic infections or sexually transmitted infections - Known history of fibroids and ovarian cysts - Known endometriosis PMH: - allergic rhinitis - depression - pseudocholinesterase deficiency - Denies hypertension, diabetes, asthma, thromboembolic disease PSH: - [MASKED] knee surgery - [MASKED] abdominal myomectomy - [MASKED] RSO, L ov cystectomy -> Path: endometriotic cyst with focal metaplastic/reactive changes - [MASKED] abdominal myomectomy, LOA, L ovarian cystectomy -> Path: leiomyomata with degenerative changes, endometriotic cyst Social History: [MASKED] Family History: FHx: - Father living, hx of bladder, prostate, skin, and throat cancer (non-smoker) - Mother died age [MASKED] of colon cancer, also had DM and glaucoma - Brother is healthy - Niece with cystic fibrosis - No known family history of breast, uterine, ovarian, or cervical Physical Exam: On day of discharge: Afebrile, vitals stable No acute distress CV: regular rate and rhythm Pulm: clear to auscultation bilaterally Abd: soft, appropriately tender, nondistended, incision clean/dry/intact, no rebound/guarding [MASKED]: nontender, nonedematous Brief Hospital Course: Ms. [MASKED] was admitted to the gynecologic oncology service after undergoing exploratory laparaotomy, total abdominal hysterectomy, left salpingo-oophorectomy, omentectomy, para-aortic lymph node biopsy, liver resection and cystoscopy for malignant transformation of endometriosis. Please see the operative report for full details. Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with an epidural and Dilaudid PCA with toradol. Her diet was gradually advanced without difficulty and she was transitioned to oral oxycodone, Tylenol and ibuprofen. On post-operative day #2, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. By post-operative day 5, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled. Medications on Admission: duloxetine 60mg daily Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild do not exceed 4000mg in 24 hours RX *acetaminophen 500 mg 2 tablet(s) by mouth every 6 hours Disp #*60 Tablet Refills:*2 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily Disp #*60 Capsule Refills:*2 3. Enoxaparin Sodium 30 mg SC Q12H Start: [MASKED], First Dose: Next Routine Administration Time Take this medication for a total of 28 days after your surgery, ending [MASKED]. RX *enoxaparin 30 mg/0.3 mL 30 mg SC twice a day Disp #*50 Syringe Refills:*0 4. Ferrous GLUCONATE 324 mg PO DAILY RX *ferrous gluconate 324 mg (36 mg iron) 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*2 5. Ibuprofen 600 mg PO Q6H:PRN Pain - Moderate take with food RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*60 Tablet Refills:*1 6. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain - Severe do not drive or drink alcohol, causes sedation RX *oxycodone 5 mg [MASKED] tablet(s) by mouth every 4 hours Disp #*50 Tablet Refills:*0 7. DULoxetine 60 mg PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: malignant transformation of endometriosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], . You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: . Abdominal instructions: * Take your medications as prescribed. We recommend you take non-narcotics (i.e. Tylenol, ibuprofen) regularly for the first few days post-operatively, and use the narcotic as needed. As you start to feel better and need less medication, you should decrease/stop the narcotic first. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 12 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * It is safe to walk up stairs. . Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have staples, they will be removed at your follow-up visit. . To reach medical records to get the records from this hospitalization sent to your doctor at home, call [MASKED]. . Call your doctor at [MASKED] for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication * chest pain or difficulty breathing * onset of any concerning symptoms Followup Instructions: [MASKED]
|
[] |
[
"E669",
"F419",
"F329"
] |
[
"C562: Malignant neoplasm of left ovary",
"C786: Secondary malignant neoplasm of retroperitoneum and peritoneum",
"C772: Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes",
"C787: Secondary malignant neoplasm of liver and intrahepatic bile duct",
"E669: Obesity, unspecified",
"F419: Anxiety disorder, unspecified",
"F329: Major depressive disorder, single episode, unspecified",
"Z6836: Body mass index [BMI] 36.0-36.9, adult"
] |
10,005,001 | 25,115,899 |
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:
symptomatic fibroid uterus, left ovarian cyst
Major Surgical or Invasive Procedure:
exploratory laparotomy, lysis of adhesions, multiple myomectomy,
left ovarian cystectomy
History of Present Illness:
Ms. ___ is a ___ gravida 0 with a long history of
recurrent ovarian cyst and endometriosis who on ___, underwent a right salpingo-oophorectomy, left ovarian
cystectomy for endometriomas. In ___, she had a multiple
myomectomies for symptomatic fibroid uterus. The patient
presents today for followup of unknown left adnexal cyst.
The patient notes that she has no abdominal pain. She is simply
experiencing increased bloatedness and pelvic pressure. New
symptoms, she has developed stress urinary incontinence with
sneezing. We discussed that this certainly can be related to
this large adnexal cyst in addition to her overweightedness.
On ___, she had an ultrasound, which showed an
anteverted uterus that measured 14.3 x 6.7 x 9.2 cm, slightly
smaller than previous measurement on ___, where it
measured 15.2 x 7.4 x 10.4 cm. Multiple masses were consistent
with uterine fibroids. The dominant fibroid was seen at the
fundus and measured 3.3 x 3.3 x 3.5 cm. The endometrium was
distorted due to fibroids and not well evaluated. An IUD was
demonstrated within the endometrial cavity. The patient is
status post right oophorectomy, previously seen 10.7 cm left
adnexal cyst again visualized and now measuring slightly larger
at 10.8 x 10 cm. It predominantly was thin walled; however,
there was one area with the appearance of an incomplete
septation. This either represented a hydrosalpinx or peritoneal
inclusion cyst, less likely a cystadenoma. There was no free
pelvic fluid. These findings were discussed with the patient.
Past Medical History:
Past OB/GYN: The patient has regular menses. She has never had a
pregnancy. She does have a history of genital warts. The patient
has a long history of uterine fibroids, endometriosis,
endometriomas. She is in a monogamous relationship with a female
partner.
PMH:
___ rhinitis
Depression
Uterine fibroids
Endometriosis
Endometriomas
Pseudocholinesterase deficiency
PSH:
Medial collateral ligament release ___
Abdominal MMY
Social History:
___
Family History:
Her mother had hypertension and died of colon cancer. Her father
has hypertension and prostate cancer.
Physical Exam:
Discharge Physical Exam:
AVSS
Gen NAD
CV RRR
P CTAB
Abd soft, nondistended, appropriately tender to palpation,
incision c/d/I
Ext WWP
Pertinent Results:
___ 07:25AM WBC-5.9 RBC-4.30 HGB-13.4 HCT-40.5 MCV-94
MCH-31.2 MCHC-33.1 RDW-11.9 RDWSD-41.6
___ 07:25AM PLT COUNT-268
Brief Hospital Course:
On ___, Ms. ___ was admitted to the gynecology service
after undergoing an exploratory laparotomy, lysis of adhesions,
left ovarian cystectomy, abdominal myomectomy for symptomatic
fibroid uterus and left ovarian cyst. Please see the operative
report for full details.
Her post-operative course was uncomplicated. Immediately
post-op, her pain was controlled with IV dilaudid and toradol.
On post-operative day 1, her urine output was adequate so her
foley was removed and she voided spontaneously. Her diet was
advanced without difficulty and she was transitioned to PO
oxycodone, Tylenol and ibuprofen (pain meds).
By post-operative day 2, she was tolerating a regular diet,
voiding spontaneously, ambulating independently, and pain was
controlled with oral medications. She was then discharged home
in stable condition with outpatient follow-up scheduled.
Medications on Admission:
Duloxetine 60mg QD
Discharge Medications:
1. DULoxetine 60 mg PO DAILY
2. Ibuprofen 600 mg PO Q6H:PRN pain
RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours
Disp #*50 Tablet Refills:*0
3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN severe pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*3
Discharge Disposition:
Home
Discharge Diagnosis:
fibroid uterus, 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 gynecology service after your
procedure. You have recovered well and the team believes you are
ready to be discharged home. Please call Dr. ___
office with any questions or concerns. Please follow the
instructions below.
General instructions:
* Take your medications as prescribed.
* Do not drive while taking narcotics.
* Take a stool softener such as colace while taking narcotics to
prevent constipation.
* Do not combine narcotic and sedative medications or alcohol.
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs.
* No strenuous activity until your post-op appointment.
* No heavy lifting of objects >10 lbs for 6 weeks.
* You may eat a regular diet.
* You may walk up and down stairs.
Incision care:
* You may shower and allow soapy water to run over incision; no
scrubbing of incision. No tub baths for 6 weeks.
* If you have steri-strips, leave them on. They will fall off on
their own or be removed during your followup visit.
* If you have staples, they will be removed at your follow-up
visit.
Call your doctor for:
* fever > 100.4F
* severe abdominal pain
* difficulty urinating
* vaginal bleeding requiring >1 pad/hr
* abnormal vaginal discharge
* redness or drainage from incision
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
Followup Instructions:
___
|
[
"D259",
"E8809",
"N3289",
"N8320",
"N736",
"Z90721",
"Z9079",
"N393",
"Z975",
"J309",
"F329",
"Z800",
"Z8042"
] |
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: symptomatic fibroid uterus, left ovarian cyst Major Surgical or Invasive Procedure: exploratory laparotomy, lysis of adhesions, multiple myomectomy, left ovarian cystectomy History of Present Illness: Ms. [MASKED] is a [MASKED] gravida 0 with a long history of recurrent ovarian cyst and endometriosis who on [MASKED], underwent a right salpingo-oophorectomy, left ovarian cystectomy for endometriomas. In [MASKED], she had a multiple myomectomies for symptomatic fibroid uterus. The patient presents today for followup of unknown left adnexal cyst. The patient notes that she has no abdominal pain. She is simply experiencing increased bloatedness and pelvic pressure. New symptoms, she has developed stress urinary incontinence with sneezing. We discussed that this certainly can be related to this large adnexal cyst in addition to her overweightedness. On [MASKED], she had an ultrasound, which showed an anteverted uterus that measured 14.3 x 6.7 x 9.2 cm, slightly smaller than previous measurement on [MASKED], where it measured 15.2 x 7.4 x 10.4 cm. Multiple masses were consistent with uterine fibroids. The dominant fibroid was seen at the fundus and measured 3.3 x 3.3 x 3.5 cm. The endometrium was distorted due to fibroids and not well evaluated. An IUD was demonstrated within the endometrial cavity. The patient is status post right oophorectomy, previously seen 10.7 cm left adnexal cyst again visualized and now measuring slightly larger at 10.8 x 10 cm. It predominantly was thin walled; however, there was one area with the appearance of an incomplete septation. This either represented a hydrosalpinx or peritoneal inclusion cyst, less likely a cystadenoma. There was no free pelvic fluid. These findings were discussed with the patient. Past Medical History: Past OB/GYN: The patient has regular menses. She has never had a pregnancy. She does have a history of genital warts. The patient has a long history of uterine fibroids, endometriosis, endometriomas. She is in a monogamous relationship with a female partner. PMH: [MASKED] rhinitis Depression Uterine fibroids Endometriosis Endometriomas Pseudocholinesterase deficiency PSH: Medial collateral ligament release [MASKED] Abdominal MMY Social History: [MASKED] Family History: Her mother had hypertension and died of colon cancer. Her father has hypertension and prostate cancer. Physical Exam: Discharge Physical Exam: AVSS Gen NAD CV RRR P CTAB Abd soft, nondistended, appropriately tender to palpation, incision c/d/I Ext WWP Pertinent Results: [MASKED] 07:25AM WBC-5.9 RBC-4.30 HGB-13.4 HCT-40.5 MCV-94 MCH-31.2 MCHC-33.1 RDW-11.9 RDWSD-41.6 [MASKED] 07:25AM PLT COUNT-268 Brief Hospital Course: On [MASKED], Ms. [MASKED] was admitted to the gynecology service after undergoing an exploratory laparotomy, lysis of adhesions, left ovarian cystectomy, abdominal myomectomy for symptomatic fibroid uterus and left ovarian cyst. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV dilaudid and toradol. On post-operative day 1, her urine output was adequate so her foley was removed and she voided spontaneously. Her diet was advanced without difficulty and she was transitioned to PO oxycodone, Tylenol and ibuprofen (pain meds). By post-operative day 2, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled. Medications on Admission: Duloxetine 60mg QD Discharge Medications: 1. DULoxetine 60 mg PO DAILY 2. Ibuprofen 600 mg PO Q6H:PRN pain RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills:*0 3. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN severe pain RX *oxycodone 5 mg [MASKED] tablet(s) by mouth every four (4) hours Disp #*40 Tablet Refills:*0 4. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*3 Discharge Disposition: Home Discharge Diagnosis: fibroid uterus, ovarian cyst Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. [MASKED] office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. * If you have staples, they will be removed at your follow-up visit. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call [MASKED]. Followup Instructions: [MASKED]
|
[] |
[
"F329"
] |
[
"D259: Leiomyoma of uterus, unspecified",
"E8809: Other disorders of plasma-protein metabolism, not elsewhere classified",
"N3289: Other specified disorders of bladder",
"N8320: Unspecified ovarian cysts",
"N736: Female pelvic peritoneal adhesions (postinfective)",
"Z90721: Acquired absence of ovaries, unilateral",
"Z9079: Acquired absence of other genital organ(s)",
"N393: Stress incontinence (female) (male)",
"Z975: Presence of (intrauterine) contraceptive device",
"J309: Allergic rhinitis, unspecified",
"F329: Major depressive disorder, single episode, unspecified",
"Z800: Family history of malignant neoplasm of digestive organs",
"Z8042: Family history of malignant neoplasm of prostate"
] |
10,005,123 | 20,470,681 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Surgical or Invasive Procedure:
___: Redo TIPS
___: Redo TIPS
attach
Pertinent Results:
ADMISSION LABS:
___ 07:30AM BLOOD WBC-4.2 RBC-4.29* Hgb-12.1* Hct-37.9*
MCV-88 MCH-28.2 MCHC-31.9* RDW-14.7 RDWSD-47.1* Plt Ct-63*
___ 07:30AM BLOOD ___
___ 07:30AM BLOOD Plt Ct-63*
___ 06:11PM BLOOD ___
___ 07:30AM BLOOD UreaN-21* Creat-1.0 Na-142 K-4.6 Cl-109*
HCO3-22 AnGap-11
___ 07:30AM BLOOD ALT-75* AST-88* AlkPhos-487* TotBili-1.0
___ 06:11PM BLOOD Albumin-4.0 Calcium-8.7 Phos-2.7 Mg-1.9
DISCHARGE LABS:
___ 04:54AM BLOOD WBC-5.1 RBC-3.97* Hgb-11.2* Hct-35.4*
MCV-89 MCH-28.2 MCHC-31.6* RDW-14.7 RDWSD-48.1* Plt Ct-71*
___ 12:07PM BLOOD PTT-83.3*
___ 04:54AM BLOOD Plt Ct-71*
___ 03:22PM BLOOD ___ 04:54AM BLOOD Glucose-95 UreaN-24* Creat-1.0 Na-140
K-4.4 Cl-109* HCO3-19* AnGap-12
___ 04:54AM BLOOD ALT-501* AST-660* LD(LDH)-696*
AlkPhos-428* TotBili-2.7*
___ 04:54AM BLOOD Albumin-3.6 Calcium-8.3* Phos-3.0 Mg-1.9
MICRO:
n/a
IMAGING:
___ REDO TIPS
Successful right internal jugular access with direct
transjugular intrahepatic portosystemic shunt revision with
extension of the TIPS cranially.
New direct TIPS aspiration thrombectomy.
Thrombolysis catheter placement through the right IJ sheath for
overnight
thrombolysis
___BD & PELVIS W & W/O
1. Interval redo TIPS procedure, with persistent thrombus in the
TIPS shunt.
The new TIPS shunt lies parallel to the superior most aspect of
the
pre-existing stent, with its upper portion approximately 1 cm
below the
cavoatrial junction. The tPA infusion catheter localizes in the
lower right atrium, with the lowest radiopaque marker overlying
the lower cavoatrial junction.
2. There is increased burden of nonocclusive thrombus in the
main portal vein.
3. Interval development of trace ascites.
4. Stable cirrhosis with secondary changes representing the
sequela of portal hypertension including perisplenic,
perigastric and periesophageal varices, and splenomegaly.
___ REDO TIPS
Successful revision of occluded TIPS and thrombosed portal vein
with a
postprocedural portosystemic gradient of 11 mm Hg.
Technically successful coronary variceal embolization and
sclerotherapy.
Brief Hospital Course:
___ male with congenital hepatic fibrosis complicated by
portal hypertension and variceal bleeding s/p TIPS ___ who
presented to the MICU s/p TIPS revision with thrombolysis
complicated by hypoxia.
ACUTE ISSUES
=======================
#Hypoxic respiratory failure:
Patient developed new oxygen requirement after ___ TIPS revision.
Unclear if VTE or atelectasis
or just some orthodeoxia but responded to oxygen and remained on
room air for the majority of his ICU course.
# Congenital Hepatic Fibrosis c/b portal hypertension and
variceal bleeding:
# S/p TIPS ___ and revision ___
Pt with congenital hepatic fibrosis c/b portal HTN and variceal
bleeding. TIPS revision complicated by hypoxia. He had a right
IJ sheath with lysis catheter placed. He underwent CTV with
persistent thrombus in TIPS shunt. Now s/p revision of occuled
TIPS and thrombosed portal vein with a postprocedural
portosystemic gradient of 11 mm Hg. He also had successful
coronary variceal embolization and sclerotherapy. He was placed
on a heparin drip post TIPS and transitioned to lovenox on
discharge.
- GIB/VARICES: EGD ___ which showed scarring at GE junction,
proximal grade 2 EVs s/p esophageal band ligation x4 and large
gastric varices. Pt also presented to an outside ED in ___
with acute UGIB/variceal bleed. Not able to be banded/embolized;
considered for future procedure. On nadolol at home which was
continued while inpatient.
- ASCITES: no history of ascites, not on diuretics, he was not
overloaded on exam.
#Transminitis
Likely due to liver disease and TIPS procedure
# Thrombocytopenia
Likely ___ to liver disease and sequestration
CHRONIC ISSUES
=======================
# Hyperlipidemia:
- Continued Pravastatin 40 mg QHS
TRANSITIONAL ISSUES:
=======================
[ ] please recheck LFTs in 1 week to ensure downtrending
[ ] check CBC within 1 week as on anticoagulation and patient
has bleeding history
[ ] f/u US of TIPS shunt in 1 week
[ ] continue lovenox for one month
[ ] follow up with ___ in 1 month
#CODE STATUS: Presumed FULL
#CONTACT: ___ - wife - ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Nadolol 40 mg PO DAILY
2. Pravastatin 40 mg PO QPM
3. Pantoprazole 40 mg PO Q24H
Discharge Medications:
1. Enoxaparin Sodium 90 mg SC Q12H
2. Nadolol 40 mg PO DAILY
3. Pantoprazole 40 mg PO Q24H
4. Pravastatin 40 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIANGOSIS:
Hypoxic respiratory failure
Congenital Hepatic Fibrosis c/b portal hypertension and variceal
bleeding
TIPS occlusion
Portal vein thrombosis occlusion
SECONDARY DIAGNOSIS:
Transaminitis
Thrombocytopenia
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
WHY WAS I ADMITTED TO THE HOSPITAL?
You were admitted because you had a blood clot in your TIPS and
your oxygen was low.
WHAT WAS DONE WHILE I WAS HERE?
We opened up the vessels/TIPS. We started you on a blood
thinner. We watched your breathing closely.
WHAT SHOULD I DO NOW?
You should take your medications as instructed.
You should go to your doctor's appointments as below.
We wish you the best!
-Your ___ Care Team
Followup Instructions:
___
|
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"K740",
"I864",
"D6959",
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"Y92238"
] |
Allergies: No Known Allergies / Adverse Drug Reactions [MASKED] Surgical or Invasive Procedure: [MASKED]: Redo TIPS [MASKED]: Redo TIPS attach Pertinent Results: ADMISSION LABS: [MASKED] 07:30AM BLOOD WBC-4.2 RBC-4.29* Hgb-12.1* Hct-37.9* MCV-88 MCH-28.2 MCHC-31.9* RDW-14.7 RDWSD-47.1* Plt Ct-63* [MASKED] 07:30AM BLOOD [MASKED] [MASKED] 07:30AM BLOOD Plt Ct-63* [MASKED] 06:11PM BLOOD [MASKED] [MASKED] 07:30AM BLOOD UreaN-21* Creat-1.0 Na-142 K-4.6 Cl-109* HCO3-22 AnGap-11 [MASKED] 07:30AM BLOOD ALT-75* AST-88* AlkPhos-487* TotBili-1.0 [MASKED] 06:11PM BLOOD Albumin-4.0 Calcium-8.7 Phos-2.7 Mg-1.9 DISCHARGE LABS: [MASKED] 04:54AM BLOOD WBC-5.1 RBC-3.97* Hgb-11.2* Hct-35.4* MCV-89 MCH-28.2 MCHC-31.6* RDW-14.7 RDWSD-48.1* Plt Ct-71* [MASKED] 12:07PM BLOOD PTT-83.3* [MASKED] 04:54AM BLOOD Plt Ct-71* [MASKED] 03:22PM BLOOD [MASKED] 04:54AM BLOOD Glucose-95 UreaN-24* Creat-1.0 Na-140 K-4.4 Cl-109* HCO3-19* AnGap-12 [MASKED] 04:54AM BLOOD ALT-501* AST-660* LD(LDH)-696* AlkPhos-428* TotBili-2.7* [MASKED] 04:54AM BLOOD Albumin-3.6 Calcium-8.3* Phos-3.0 Mg-1.9 MICRO: n/a IMAGING: [MASKED] REDO TIPS Successful right internal jugular access with direct transjugular intrahepatic portosystemic shunt revision with extension of the TIPS cranially. New direct TIPS aspiration thrombectomy. Thrombolysis catheter placement through the right IJ sheath for overnight thrombolysis BD & PELVIS W & W/O 1. Interval redo TIPS procedure, with persistent thrombus in the TIPS shunt. The new TIPS shunt lies parallel to the superior most aspect of the pre-existing stent, with its upper portion approximately 1 cm below the cavoatrial junction. The tPA infusion catheter localizes in the lower right atrium, with the lowest radiopaque marker overlying the lower cavoatrial junction. 2. There is increased burden of nonocclusive thrombus in the main portal vein. 3. Interval development of trace ascites. 4. Stable cirrhosis with secondary changes representing the sequela of portal hypertension including perisplenic, perigastric and periesophageal varices, and splenomegaly. [MASKED] REDO TIPS Successful revision of occluded TIPS and thrombosed portal vein with a postprocedural portosystemic gradient of 11 mm Hg. Technically successful coronary variceal embolization and sclerotherapy. Brief Hospital Course: [MASKED] male with congenital hepatic fibrosis complicated by portal hypertension and variceal bleeding s/p TIPS [MASKED] who presented to the MICU s/p TIPS revision with thrombolysis complicated by hypoxia. ACUTE ISSUES ======================= #Hypoxic respiratory failure: Patient developed new oxygen requirement after [MASKED] TIPS revision. Unclear if VTE or atelectasis or just some orthodeoxia but responded to oxygen and remained on room air for the majority of his ICU course. # Congenital Hepatic Fibrosis c/b portal hypertension and variceal bleeding: # S/p TIPS [MASKED] and revision [MASKED] Pt with congenital hepatic fibrosis c/b portal HTN and variceal bleeding. TIPS revision complicated by hypoxia. He had a right IJ sheath with lysis catheter placed. He underwent CTV with persistent thrombus in TIPS shunt. Now s/p revision of occuled TIPS and thrombosed portal vein with a postprocedural portosystemic gradient of 11 mm Hg. He also had successful coronary variceal embolization and sclerotherapy. He was placed on a heparin drip post TIPS and transitioned to lovenox on discharge. - GIB/VARICES: EGD [MASKED] which showed scarring at GE junction, proximal grade 2 EVs s/p esophageal band ligation x4 and large gastric varices. Pt also presented to an outside ED in [MASKED] with acute UGIB/variceal bleed. Not able to be banded/embolized; considered for future procedure. On nadolol at home which was continued while inpatient. - ASCITES: no history of ascites, not on diuretics, he was not overloaded on exam. #Transminitis Likely due to liver disease and TIPS procedure # Thrombocytopenia Likely [MASKED] to liver disease and sequestration CHRONIC ISSUES ======================= # Hyperlipidemia: - Continued Pravastatin 40 mg QHS TRANSITIONAL ISSUES: ======================= [ ] please recheck LFTs in 1 week to ensure downtrending [ ] check CBC within 1 week as on anticoagulation and patient has bleeding history [ ] f/u US of TIPS shunt in 1 week [ ] continue lovenox for one month [ ] follow up with [MASKED] in 1 month #CODE STATUS: Presumed FULL #CONTACT: [MASKED] - wife - [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Nadolol 40 mg PO DAILY 2. Pravastatin 40 mg PO QPM 3. Pantoprazole 40 mg PO Q24H Discharge Medications: 1. Enoxaparin Sodium 90 mg SC Q12H 2. Nadolol 40 mg PO DAILY 3. Pantoprazole 40 mg PO Q24H 4. Pravastatin 40 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIANGOSIS: Hypoxic respiratory failure Congenital Hepatic Fibrosis c/b portal hypertension and variceal bleeding TIPS occlusion Portal vein thrombosis occlusion SECONDARY DIAGNOSIS: Transaminitis Thrombocytopenia Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], WHY WAS I ADMITTED TO THE HOSPITAL? You were admitted because you had a blood clot in your TIPS and your oxygen was low. WHAT WAS DONE WHILE I WAS HERE? We opened up the vessels/TIPS. We started you on a blood thinner. We watched your breathing closely. WHAT SHOULD I DO NOW? You should take your medications as instructed. You should go to your doctor's appointments as below. We wish you the best! -Your [MASKED] Care Team Followup Instructions: [MASKED]
|
[] |
[
"E785"
] |
[
"J95821: Acute postprocedural respiratory failure",
"I81: Portal vein thrombosis",
"T82868A: Thrombosis due to vascular prosthetic devices, implants and grafts, initial encounter",
"K766: Portal hypertension",
"I8510: Secondary esophageal varices without bleeding",
"K740: Hepatic fibrosis",
"I864: Gastric varices",
"D6959: Other secondary thrombocytopenia",
"E785: Hyperlipidemia, unspecified",
"Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure",
"K7460: Unspecified cirrhosis of liver",
"Y92238: Other place in hospital as the place of occurrence of the external cause"
] |
10,005,123 | 24,274,954 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
post TIPS monitoring
Major Surgical or Invasive Procedure:
TIPS ___
History of Present Illness:
Mr. ___ is a ___ male with congenital hepatic
fibrosis complicated by portal hypertension and variceal
bleeding
who presents to the medicine floor s/p TIPS procedure for TIPS
monitoring.
The patient recently presented to the ED on ___ with severe
variceal bleeding requiring blood/plasma transfusion as well as
endoscopic banding of his esophageal/gastric varices. He
ultimately elected to undergo a TIPS placement by ___ on ___.
Per sign out, the TIPS procedure was quite complicated, lasting
a
total of 6 hours. The HVPG was reduced to 10. His
esophageal/gastric were not embolized though he did receive tPA
for his portal vein thrombosis.
Past Medical History:
- Congenital hepatic fibrosis
-- Portal hypertension
-- Gastric and esophageal varices s/p band ligation
- Hyperlipidemia
Social History:
___
Family History:
non contributory to this admission
Physical Exam:
VS: 24 HR Data (last updated ___ @ 1213)
Temp: 97.9 (Tm 98.5), BP: 133/78 (129-146/75-78), HR: 71
(71-82), RR: 16 (___), O2 sat: 98% (95-98), O2 delivery: RA,
Wt: 203.7 lb/92.4 kg
GENERAL: well appearing man in no acute distress
HEENT: anicteric sclera, right neck access site bandaged &
clean. no active bleeding
HEART: RRR, no murmurs, rubs, gallops
LUNGS: clear bilaterally
ABDOMEN: soft, mildly distended, non-tender to palpation but
subjective discomfort, RUQ dressing c/d/I without surrounding
erythema, drainage, bleeding
EXTREMITIES: wwp, no edema
NEURO: A&Ox3, moving all 4 extremities with purpose, no
asterixis. Able to say months of the year backwards.
Pertinent Results:
___ 06:47AM BLOOD WBC-4.2 RBC-3.93* Hgb-11.0* Hct-33.8*
MCV-86 MCH-28.0 MCHC-32.5 RDW-15.2 RDWSD-47.3* Plt Ct-29*
___ 06:47AM BLOOD Glucose-109* UreaN-15 Creat-1.0 Na-141
K-3.8 Cl-104 HCO3-23 AnGap-14
___ 06:47AM BLOOD ALT-824* AST-556* LD(LDH)-289*
AlkPhos-360* TotBili-1.8*
Brief Hospital Course:
Mr. ___ is a ___ male with congenital hepatic
fibrosis complicated by portal hypertension and variceal
bleeding who presents to the medicine floor for post TIPS
monitoring. Mild ___ post-op s/p 25gm albumin; otherwise
uncomplicated course. Surgical wounds stable; dressing clean and
dry. Patient able to tolerate PO without issue. No evidence of
hepatic encephalopathy prior to discharge. No further planned
intervention by ___ this hospitalization; they will see him in
follow-up in ___ weeks.
TRANSITIONAL ISSUES:
====================
[ ] please obtain repeat LFTs on ___ with results faxed to
___ (f: ___
[ ] consider repeat hepatitis A and B serologies to ensure
immunization (non immune as of ___ in ___ records)
[ ] consider repeat AFP as last AFP in BID system is from ___
[ ] please consider stopping lactulose that was continued on
discharge depending on post-op course regarding HE
ACTIVE ISSUES
=============
# Congenital Hepatic Fibrosis c/b portal hypertension:
# S/p TIPS ___:
As above, patient presented in ___ with variceal bleeding
requiring transfusions and banding of his esophageal/gastric
varices, now s/p elective TIPS placement on ___ with ___ (10 x 6
and 10 x 8 R TIPS placed). He has no history of HE or ascites.
Per ___ team, the TIPS procedure was complicated, lasting 6
hours. His post-TIPS HVPG is between ___ mmHg (pre-tips HVPG
not documented). His varices were not embolized though he did
receive tPA for his portal vein thrombosis. Tentatively may need
another procedure in the near future. He was discharged on
lactulose with instructions to titrate to two BMs daily.
Consider stopping this at his follow-up appointment.
Post-op, his vitals have remained stable. His neck and abdominal
access sites appear to be healing appropriately. His LFTs are up
but expected post-op changes, downtrending by discharge.
Telemetry and foley were dc'd. Patient has been able to urinate
and has had multiple bowel movements with lactulose. His MELD-NA
post-op on ___ was 16. Pain control with acetaminophen +
hot/cold packs. He post-op course was uncomplicated except for a
mild ___ discussed below which resolved with albumin.
Discharge MELD-NA: 11
Discharge HgB: 11
___
SCR 1.1 --> 1.4 ---> 1.0
Most likely related to NPO prior to procedure and prolonged
operation. HRS very unlikely has patient has no ascites or
hepatic hydrothorax (on exam or history of). Urine lytes were
unremarkable with UNa <20 which is an appropriate response to
pre-renal dehydration. UA and sediment unremarkable. Discharge
Creatinine: 1.0
# Thrombocytopenia:
Plts in the ___, at baseline. Secondary to cirrhosis,
splenomegaly. SQH was held ___ thrombocytopenia. Patient had no
e/o bleeding or petichiae during his hospital course.
Discharge platelets: 29
CHRONIC ISSUES
==============
# Hyperlipidemia:
Continued Pravastatin 40 mg QHS
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Nadolol 40 mg PO DAILY
2. Pravastatin 40 mg PO QPM
Discharge Medications:
1. Lactulose 30 mL PO DAILY
RX *lactulose 10 gram/15 mL (15 mL) 30 ml by mouth once a day
Disp #*1 Bottle Refills:*2
2. Nadolol 40 mg PO DAILY
3. Pravastatin 40 mg PO QPM
4.Outpatient Lab Work
DX: Elevated Liver Enzymes
ICD-10: R94.5
Tests: AST, ALT, ALP, Total Bili, Direct Bili
Please fax results to ___ at ___.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Congenital hepatic fibrosis
Portal hypertension
Cirrhosis
SECONDARY:
History of esophageal and gastric varices
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted because you had a TIPS procedure and needed
routine monitoring afterwards
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You had a TIPS procedure performed
- Post-procedure, your mental status, liver/kidney tests, and
blood counts were monitored
- You received a medicine to help you have regular bowel
movements
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Be sure to take all your medications and attend all of your
appointments listed below.
- Take your lactulose enough times daily to have two bowel
movements every day.
- If you notice black or bloody stool or if you are vomiting
blood, please go to the ER right away
- Interventional Radiology will call you with an appointment in
___ weeks.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team
Followup Instructions:
___
|
[
"K7460",
"I81",
"N179",
"K766",
"I8510",
"K740",
"D6959",
"E785",
"I864"
] |
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: post TIPS monitoring Major Surgical or Invasive Procedure: TIPS [MASKED] History of Present Illness: Mr. [MASKED] is a [MASKED] male with congenital hepatic fibrosis complicated by portal hypertension and variceal bleeding who presents to the medicine floor s/p TIPS procedure for TIPS monitoring. The patient recently presented to the ED on [MASKED] with severe variceal bleeding requiring blood/plasma transfusion as well as endoscopic banding of his esophageal/gastric varices. He ultimately elected to undergo a TIPS placement by [MASKED] on [MASKED]. Per sign out, the TIPS procedure was quite complicated, lasting a total of 6 hours. The HVPG was reduced to 10. His esophageal/gastric were not embolized though he did receive tPA for his portal vein thrombosis. Past Medical History: - Congenital hepatic fibrosis -- Portal hypertension -- Gastric and esophageal varices s/p band ligation - Hyperlipidemia Social History: [MASKED] Family History: non contributory to this admission Physical Exam: VS: 24 HR Data (last updated [MASKED] @ 1213) Temp: 97.9 (Tm 98.5), BP: 133/78 (129-146/75-78), HR: 71 (71-82), RR: 16 ([MASKED]), O2 sat: 98% (95-98), O2 delivery: RA, Wt: 203.7 lb/92.4 kg GENERAL: well appearing man in no acute distress HEENT: anicteric sclera, right neck access site bandaged & clean. no active bleeding HEART: RRR, no murmurs, rubs, gallops LUNGS: clear bilaterally ABDOMEN: soft, mildly distended, non-tender to palpation but subjective discomfort, RUQ dressing c/d/I without surrounding erythema, drainage, bleeding EXTREMITIES: wwp, no edema NEURO: A&Ox3, moving all 4 extremities with purpose, no asterixis. Able to say months of the year backwards. Pertinent Results: [MASKED] 06:47AM BLOOD WBC-4.2 RBC-3.93* Hgb-11.0* Hct-33.8* MCV-86 MCH-28.0 MCHC-32.5 RDW-15.2 RDWSD-47.3* Plt Ct-29* [MASKED] 06:47AM BLOOD Glucose-109* UreaN-15 Creat-1.0 Na-141 K-3.8 Cl-104 HCO3-23 AnGap-14 [MASKED] 06:47AM BLOOD ALT-824* AST-556* LD(LDH)-289* AlkPhos-360* TotBili-1.8* Brief Hospital Course: Mr. [MASKED] is a [MASKED] male with congenital hepatic fibrosis complicated by portal hypertension and variceal bleeding who presents to the medicine floor for post TIPS monitoring. Mild [MASKED] post-op s/p 25gm albumin; otherwise uncomplicated course. Surgical wounds stable; dressing clean and dry. Patient able to tolerate PO without issue. No evidence of hepatic encephalopathy prior to discharge. No further planned intervention by [MASKED] this hospitalization; they will see him in follow-up in [MASKED] weeks. TRANSITIONAL ISSUES: ==================== [ ] please obtain repeat LFTs on [MASKED] with results faxed to [MASKED] (f: [MASKED] [ ] consider repeat hepatitis A and B serologies to ensure immunization (non immune as of [MASKED] in [MASKED] records) [ ] consider repeat AFP as last AFP in BID system is from [MASKED] [ ] please consider stopping lactulose that was continued on discharge depending on post-op course regarding HE ACTIVE ISSUES ============= # Congenital Hepatic Fibrosis c/b portal hypertension: # S/p TIPS [MASKED]: As above, patient presented in [MASKED] with variceal bleeding requiring transfusions and banding of his esophageal/gastric varices, now s/p elective TIPS placement on [MASKED] with [MASKED] (10 x 6 and 10 x 8 R TIPS placed). He has no history of HE or ascites. Per [MASKED] team, the TIPS procedure was complicated, lasting 6 hours. His post-TIPS HVPG is between [MASKED] mmHg (pre-tips HVPG not documented). His varices were not embolized though he did receive tPA for his portal vein thrombosis. Tentatively may need another procedure in the near future. He was discharged on lactulose with instructions to titrate to two BMs daily. Consider stopping this at his follow-up appointment. Post-op, his vitals have remained stable. His neck and abdominal access sites appear to be healing appropriately. His LFTs are up but expected post-op changes, downtrending by discharge. Telemetry and foley were dc'd. Patient has been able to urinate and has had multiple bowel movements with lactulose. His MELD-NA post-op on [MASKED] was 16. Pain control with acetaminophen + hot/cold packs. He post-op course was uncomplicated except for a mild [MASKED] discussed below which resolved with albumin. Discharge MELD-NA: 11 Discharge HgB: 11 [MASKED] SCR 1.1 --> 1.4 ---> 1.0 Most likely related to NPO prior to procedure and prolonged operation. HRS very unlikely has patient has no ascites or hepatic hydrothorax (on exam or history of). Urine lytes were unremarkable with UNa <20 which is an appropriate response to pre-renal dehydration. UA and sediment unremarkable. Discharge Creatinine: 1.0 # Thrombocytopenia: Plts in the [MASKED], at baseline. Secondary to cirrhosis, splenomegaly. SQH was held [MASKED] thrombocytopenia. Patient had no e/o bleeding or petichiae during his hospital course. Discharge platelets: 29 CHRONIC ISSUES ============== # Hyperlipidemia: Continued Pravastatin 40 mg QHS Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Nadolol 40 mg PO DAILY 2. Pravastatin 40 mg PO QPM Discharge Medications: 1. Lactulose 30 mL PO DAILY RX *lactulose 10 gram/15 mL (15 mL) 30 ml by mouth once a day Disp #*1 Bottle Refills:*2 2. Nadolol 40 mg PO DAILY 3. Pravastatin 40 mg PO QPM 4.Outpatient Lab Work DX: Elevated Liver Enzymes ICD-10: R94.5 Tests: AST, ALT, ALP, Total Bili, Direct Bili Please fax results to [MASKED] at [MASKED]. Discharge Disposition: Home Discharge Diagnosis: PRIMARY: Congenital hepatic fibrosis Portal hypertension Cirrhosis SECONDARY: History of esophageal and gastric varices Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], It was a pleasure taking care of you at the [MASKED] [MASKED]! WHY WAS I IN THE HOSPITAL? ========================== - You were admitted because you had a TIPS procedure and needed routine monitoring afterwards WHAT HAPPENED IN THE HOSPITAL? ============================== - You had a TIPS procedure performed - Post-procedure, your mental status, liver/kidney tests, and blood counts were monitored - You received a medicine to help you have regular bowel movements WHAT SHOULD I DO WHEN I GO HOME? ================================ - Be sure to take all your medications and attend all of your appointments listed below. - Take your lactulose enough times daily to have two bowel movements every day. - If you notice black or bloody stool or if you are vomiting blood, please go to the ER right away - Interventional Radiology will call you with an appointment in [MASKED] weeks. Thank you for allowing us to be involved in your care, we wish you all the best! Your [MASKED] Healthcare Team Followup Instructions: [MASKED]
|
[] |
[
"N179",
"E785"
] |
[
"K7460: Unspecified cirrhosis of liver",
"I81: Portal vein thrombosis",
"N179: Acute kidney failure, unspecified",
"K766: Portal hypertension",
"I8510: Secondary esophageal varices without bleeding",
"K740: Hepatic fibrosis",
"D6959: Other secondary thrombocytopenia",
"E785: Hyperlipidemia, unspecified",
"I864: Gastric varices"
] |
10,005,236 | 23,384,508 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
morphine / Demerol
Attending: ___.
Chief Complaint:
Right femoral neck fracture
Major Surgical or Invasive Procedure:
Closed reduction, internal fixation with cannulated screws of
Right femoral neck fracture
History of Present Illness:
___ M presents with right femoral neck fracture s/p mechanical
fall. He fell on his right side earlier this morning, with
immediate right hip pain and inability to ambulate. He denies
pain elsewhere. He ambulates without assistance at baseline,
but reports he does not walk as much as he used to due to
antecedent bilateral hip pain. He is fairly active and enjoys
fishing regularly.
Past Medical History:
PMH/PSH:
DM
HTN
COPD
Claudication
Carotid stenosis
S/p L carotid endarterectomy ___
Social History:
___
Family History:
Father CAD/PVD; Diabetes - Type II
Mother chf [OTHER]
Sister ___
Physical ___:
Right lower extremity:
- Skin intact
- Fires ___
- SILT S/S/SP/DP/T distributions
- 1+ ___ pulses, 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 right femoral neck fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for closed reduction and cannulated
screw fixation, which the patient tolerated well. For full
details of the procedure please see the separately dictated
operative report. The patient was taken from the OR to the PACU
in stable condition and after satisfactory recovery from
anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given ___ antibiotics and anticoagulation
per routine. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to rehab was appropriate. The
___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
NVI distally in the right extremity, and will be discharged on
lovenox for DVT prophylaxis. The patient will follow up with Dr.
___ routine. A thorough discussion was had with the
patient regarding the diagnosis and expected post-discharge
course including reasons to call the office or return to the
hospital, and all questions were answered. The patient was also
given written instructions concerning precautionary instructions
and the appropriate follow-up care. The patient expressed
readiness for discharge.
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Calcium Carbonate 500 mg PO QID:PRN indigestion
3. Docusate Sodium 100 mg PO BID
4. Enoxaparin Sodium 40 mg SC QPM Duration: 4 Weeks
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 40 mg SC QPM Disp #*28 Syringe
Refills:*0
5. Lisinopril 2.5 mg PO DAILY
6. Metoprolol Succinate XL 25 mg PO DAILY
7. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Q4H: PRN Disp #*60
Tablet Refills:*0
8. Senna 8.6 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Right femoral neck fracture
Discharge Condition:
AOX3, OOB with assistance of ___, overall stable
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Touchdown weight bearing RLE
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Lovenox 40mg 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.
- No dressing is needed if wound continues to be non-draining.
Physical Therapy:
Activity: Activity: Out of bed w/ assist
Right lower extremity: Touchdown weight bearing
Left lower extremity: Full weight bearing
Encourage turning, deep breathing and coughing qhour when awake.
Treatments Frequency:
DSD as needed. Sutures/staples removed at clinic. Elevation as
tolerated.
Followup Instructions:
___
|
[
"S72001A",
"E119",
"J449",
"I10",
"W1839XA",
"Y92009",
"Z87891",
"I70209",
"Z23"
] |
Allergies: morphine / Demerol Chief Complaint: Right femoral neck fracture Major Surgical or Invasive Procedure: Closed reduction, internal fixation with cannulated screws of Right femoral neck fracture History of Present Illness: [MASKED] M presents with right femoral neck fracture s/p mechanical fall. He fell on his right side earlier this morning, with immediate right hip pain and inability to ambulate. He denies pain elsewhere. He ambulates without assistance at baseline, but reports he does not walk as much as he used to due to antecedent bilateral hip pain. He is fairly active and enjoys fishing regularly. Past Medical History: PMH/PSH: DM HTN COPD Claudication Carotid stenosis S/p L carotid endarterectomy [MASKED] Social History: [MASKED] Family History: Father CAD/PVD; Diabetes - Type II Mother chf [OTHER] Sister [MASKED] Physical [MASKED]: Right lower extremity: - Skin intact - Fires [MASKED] - SILT S/S/SP/DP/T distributions - 1+ [MASKED] pulses, 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 right femoral neck fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on [MASKED] for closed reduction and cannulated screw fixation, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given [MASKED] antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with [MASKED] who determined that discharge to rehab was appropriate. The [MASKED] 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 NVI distally in the right extremity, and will be discharged on lovenox for DVT prophylaxis. The patient will follow up with Dr. [MASKED] routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. Calcium Carbonate 500 mg PO QID:PRN indigestion 3. Docusate Sodium 100 mg PO BID 4. Enoxaparin Sodium 40 mg SC QPM Duration: 4 Weeks Start: Today - [MASKED], First Dose: Next Routine Administration Time RX *enoxaparin 40 mg/0.4 mL 40 mg SC QPM Disp #*28 Syringe Refills:*0 5. Lisinopril 2.5 mg PO DAILY 6. Metoprolol Succinate XL 25 mg PO DAILY 7. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain RX *oxycodone 5 mg [MASKED] tablet(s) by mouth Q4H: PRN Disp #*60 Tablet Refills:*0 8. Senna 8.6 mg PO BID Discharge Disposition: Extended Care Facility: [MASKED] [MASKED] Diagnosis: Right femoral neck fracture Discharge Condition: AOX3, OOB with assistance of [MASKED], overall stable Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - Touchdown weight bearing RLE MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take Lovenox 40mg 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. - No dressing is needed if wound continues to be non-draining. Physical Therapy: Activity: Activity: Out of bed w/ assist Right lower extremity: Touchdown weight bearing Left lower extremity: Full weight bearing Encourage turning, deep breathing and coughing qhour when awake. Treatments Frequency: DSD as needed. Sutures/staples removed at clinic. Elevation as tolerated. Followup Instructions: [MASKED]
|
[] |
[
"E119",
"J449",
"I10",
"Z87891"
] |
[
"S72001A: Fracture of unspecified part of neck of right femur, initial encounter for closed fracture",
"E119: Type 2 diabetes mellitus without complications",
"J449: Chronic obstructive pulmonary disease, unspecified",
"I10: Essential (primary) hypertension",
"W1839XA: Other fall on same level, initial encounter",
"Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause",
"Z87891: Personal history of nicotine dependence",
"I70209: Unspecified atherosclerosis of native arteries of extremities, unspecified extremity",
"Z23: Encounter for immunization"
] |
10,005,308 | 20,445,854 |
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:
___
|
[
"S82851A",
"W108XXA",
"Y92009"
] |
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: right ankle fracture dislocation Major Surgical or Invasive Procedure: right ankle surgical fixation History of Present Illness: [MASKED] 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 [MASKED] currently. She is here with her husband and son. Past Medical History: none Social History: [MASKED] 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 [MASKED] 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 [MASKED] antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with [MASKED] who determined that discharge to home was appropriate. The [MASKED] 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. [MASKED] routine. Alternatively, since she is from [MASKED] she may choose to follow-up with an orthopedic provider [MASKED]. 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) [MASKED] mg PO Q4H:PRN Pain don't drink or drive while taking RX *oxycodone 5 mg [MASKED] 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 [MASKED] every 6 hours around the clock. This is an over the counter medication. 2) Add oxycodone as needed for increased pain. Aim to wean off this medication in 1 week or sooner. This is an example on how to wean down: Take 1 tablet every 3 hours as needed x 1 day, then 1 tablet every 4 hours as needed x 1 day, then 1 tablet every 6 hours as needed x 1 day, then 1 tablet every 8 hours as needed x 2 days, then 1 tablet every 12 hours as needed x 1 day, then 1 tablet every before bedtime as needed x 1 day. Then continue with Tylenol for pain. 3) Do not stop the Tylenol until you are off of the narcotic medication. 4) Per state regulations, we are limited in the amount of narcotics we can prescribe. If you require more, you must contact the office to set up an appointment because we cannot refill this type of pain medication over the phone. 5) Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and continue following the bowel regimen as stated on your medication prescription list. These meds (senna, colace, miralax) are over the counter and may be obtained at any pharmacy. 6) Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. 7) Please take all medications as prescribed by your physicians at discharge. 8) Continue all home medications unless specifically instructed to stop by your surgeon. ANTICOAGULATION: - 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 [MASKED] 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 [MASKED] DAYS OF REHAB Followup Instructions: [MASKED]
|
[] |
[] |
[
"S82851A: Displaced trimalleolar fracture of right lower leg, initial encounter for closed fracture",
"W108XXA: Fall (on) (from) other stairs and steps, initial encounter",
"Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause"
] |
10,005,606 | 22,751,751 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Nausea, Vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ male, history of cervical fusion in ___, ETOH
abuse, and HTN presenting with nausea, hematemesis/coffee-ground
emesis and ? melena.
He was in his usual state of health, consuming ___ shot
glasses per night of ETOH (last night however ___ shots), and
also using NSAIDS 1600 mg/day and Tylenol ___ mg/day for his
neck pain after the surgery. On ___, he began having
intermittent abdominal discomfort with food intake. He also had
nausea and vomiting, with hematemesis on day prior to
presentation and 2 episodes of coffee-ground emesis on day of
presentation. He reports lightheadedness with standing. In the
ED, noted to have a dark tarry BM with subsequent dizziness.
He reports no chest pain, shortness of breath, abdominal pain,
diarrhea.
In ED, vital signs were notable for tachycardia 110s-120s, BP
130s/70s-80s, satting well on RA. Labs are notable for Hgb 12.9,
which is above his baseline of ___. He had elevated
transaminases to 169/257, elevated from prior with normal AP,
Tbili, and lipase. He has ___ with Cr of 1.2 from baseline of
0.5 and BUN of 29. Chemistry notable for K 5.0, Cl 82, and anion
gap of 26. INR was 1.2. GI was consulted and recommended IV PPI,
NPO, transfusion goal of ___, anti-emetic, and potential EGD. He
was given NS, pantoprazole, ondansetron, and morphine.
On arrival to the floor, patient reports severe pain in his
neck at the site of his recent surgery. Otherwise feels well
without complaints.
REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as
per HPI
Past Medical History:
ETOH abuse
HTN
S/p posterior cervical decompression and fusion ___
C. diff
Social History:
___
Family History:
No family history of liver disease
Physical Exam:
ADMISSION PHYSICAL
==================
VS: 97.7 PO 177 / 92L Lying ___ Ra
GENERAL: NAD
HEENT: anicteric sclera, pink conjunctiva, MMM
NECK: supple, no LAD, no JVD
HEART: tachycardia, 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 on exam
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL
==================
___ 0720 Temp: 98.3 PO BP: 107/56 R Lying HR: 67 RR: 16
O2 sat: 97% O2 delivery: Ra
GENERAL: NAD
HEENT: anicteric sclera, pink conjunctiva, MMM
HEART: normal 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 on exam
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS
==============
___ 04:00PM BLOOD WBC-8.4 RBC-4.51* Hgb-12.9* Hct-38.4*
MCV-85 MCH-28.6 MCHC-33.6 RDW-16.7* RDWSD-48.5* Plt ___
___ 04:00PM BLOOD Neuts-85.4* Lymphs-7.9* Monos-5.4
Eos-0.5* Baso-0.4 Im ___ AbsNeut-7.15* AbsLymp-0.66*
AbsMono-0.45 AbsEos-0.04 AbsBaso-0.03
___ 04:11PM BLOOD ___ PTT-27.5 ___
___ 04:00PM BLOOD Glucose-109* UreaN-29* Creat-1.2 Na-138
K-5.0 Cl-82* HCO3-30 AnGap-26*
___ 04:00PM BLOOD ALT-169* AST-257* AlkPhos-112 TotBili-0.6
___ 04:00PM BLOOD Lipase-30
___ 04:00PM BLOOD Albumin-4.8 Calcium-11.2* Phos-4.1 Mg-1.6
___ 09:48PM URINE Hours-RANDOM Creat-200 Na-81
PERTINENT LABS
==============
___ 08:57AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 08:57AM BLOOD HCV Ab-NEG
___ 01:52PM STOOL HELICOBACTER ANTIGEN DETECTION, STOOL-PND
MICRO
=====
None
STUDIES
=======
US Liver ___. Echogenic liver consistent with steatosis. Mildly nodular
suggests
cirrhosis.
2. No cholelithiasis, evidence of cholecystitis, or biliary
dilation.
3. Patent portal vein.
DISCHARGE LABS
==============
___ 04:47AM BLOOD WBC-3.7* RBC-2.81* Hgb-8.2* Hct-25.3*
MCV-90 MCH-29.2 MCHC-32.4 RDW-15.6* RDWSD-51.0* Plt Ct-96*
___ 04:47AM BLOOD Glucose-82 UreaN-10 Creat-0.8 Na-141
K-3.7 Cl-99 HCO3-29 AnGap-13
___ 04:47AM BLOOD Calcium-8.5 Phos-2.5* Mg-2.___ male, history of cervical fusion in ___, ETOH
abuse, and HTN presenting with hematemesis and coffee-ground
emesis as well melena concerning for UGIB likely ___ alcoholic
gastritis vs. esophagitis vs ___ tear.
# UGIB
Patient presented after having two episodes of
hematemesis/coffee-ground emesis, and then proceeded to have
large melena in ED. Hgb at presentation was 12.9 but
subsequently dropped to 9.5 and then 8.9 in the setting of
getting 2L IVF. Possible etiologies include ___ Tear,
esophagitis, alcoholic gastritis, and NSAID use. Patient was
planned to undergo EGD on ___ but unfortunately, given
spinal fusion, anesthesia felt that it would be safest to
perform procedure in the OR. Patient was hemodynamically stable
for 48 hours since admission and had no major changes in his
hemoglobin. Multiple conversations were had with the patient and
the inpatient GI team about our preference of having him stay
and undergo EGD in the OR given possible evidence of cirrhotic
changes on liver US. Patient preferred to leave due to multiple
life stressors outside of the hospital (including significant
work issues with his boss) and the patient's presentation was
thought to be less concerning for acute variceal bleed. This
plan was discussed with GI consultants. Patient was educated
about danger signs that should prompt an immediate return to the
ED, and otherwise was encouraged to attend his scheduled follow
up liver clinic where the EGD could be setup as an outpatient.
# ___
Cr was elevated to 1.2 at presentation from baseline 0.5. Likely
pre-renal in setting of ongoing nausea limiting PO intake and
vomiting. Patient received 2L IVF and Cr downtrended.
# Cirrhosis
# Transaminitis
Patient's liver enzymes were elevated on admission, AST/ALT
100s-200s. Baseline abnormal likely due to ongoing alcohol use
vs. fatty liver disease. He was also found to be leukopenic and
thrombocytopenic. No stigmata of chronic liver disease on exam.
RUQ U/S demonstrated stigmata of cirrhosis. Hepatitis serologies
(HBV, HCV) were obtained and were all negative. Patient was
started on hepatitis B vaccination series and received the first
immunization on ___.
# Alcohol abuse
Patient formerly frank ten shots a night every night and drank
continuously on weekends. He has since cut down and now drinks
___ shots ___ nights a week. No history of withdrawal seizures
though did require phenobarb during prior admission. At his
reduced level of drinking, he did not have withdrawal on this
admission.
___ w/ EtOH abuse admitted w/ hematemesis and melena. Imaging
and labs c/w a new diagnosis of cirrhosis.
The patient was advised that even though he has cut down his
drinking, his liver is now much more fragile than before and
even small amounts of alcohol can cause further damage. He was
educated on the life-threatening complications of cirrhosis and
how he may not have any symptoms until it has become too late to
undo the damage. He verbalized understanding of this, but does
not feel quite ready to quit drinking. He was educated about
naltrexone and other resources and agrees to readdress sobriety
at his follow up visit.
# H/o cervical fusion in ___
Pain was controlled with Tylenol, tizanadine, gabapentin, and
oxycodone PRN.
TRANSITIONAL ISSUES
===================
[]EGD: Prompt outpatient EGD is recommended to clarify the cause
of bleeding. Even if he has no further bleeding, the patient
still needs to complete an EGD to screen for esophageal varices.
[]Pending Labs: f/u h pylori stool antigen
[]Hepatology: Close followup in liver clinic given new diagnosis
of cirrhosis
[]___ Screening: Patient will require q6 month ___ screening
with abdominal ultrasound
[]Hepatitis B, non-immune: Patient was found to be hepatitis B
non-immune, received first vaccine on ___, followup with
course per recommended schedule
[]PPI: Discharged on PPI BID which should be continued until
patient has GI follow up at ___
[] NO NSAIDS.
[] Continue discussion regarding alcohol cessation. He is
potentially interested in naltrexone.
#CODE: Full (presumed)
#CONTACT: ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q6H
2. Gabapentin 300 mg PO Q8H
3. Tizanidine 4 mg PO TID:PRN neck pain
4. Ibuprofen 400 mg PO Q6H
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Gabapentin 300 mg PO Q8H
3. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals [Vitamins and Minerals] 1
tablet(s) by mouth daily Disp #*30 Tablet Refills:*0
4. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
5. Thiamine 200 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
6. Tizanidine 4 mg PO TID:PRN neck pain
7. HELD- Acetaminophen 1000 mg PO Q6H This medication was held.
Do not restart Acetaminophen until you really need it, and this
should be no more than 2 grams per day
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses
=================
Upper GI bleed
Alcoholic cirrhosis
___
Secondary Diagnoses
===================
Alcohol abuse
Nicotine dependence
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 in the hospital.
WHY WERE YOU ADMITTED:
- You were having bloody vomit and dark stools which concerned
us that you were having a bleed from somewhere in your
esophagus, stomach, or intestines.
WHAT HAPPENED IN THE HOSPITAL:
- We gave you fluids
- We took lab tests to see if you were bleeding quickly
- We had the GI doctors ___ by and ___ you, and they
recommended that you get a procedure in which we look with a
camera into your stomach. However, because of your neck
surgeries, this would have to be done in the operating room. You
decided that you did not want to wait and have this done so you
were discharged with strict instructions to return if you start
feeling ANY symptoms or experienced ANY bleeding
- You had imaging that suggested that you had cirrhosis in your
liver. This needs follow up and further work up and it will be
extremely important for you to follow up with a liver
specialist.
- Importantly, you should NOT take any further ibuprofen, advil,
naproxen, aleve. You should STOP drinking and consider a
detoxification center.
WHAT SHOULD I DO AFTER LEAVING:
- Please take all of your medications as prescribed including a
new medication:
1.) Pantoprazole 40mg twice daily
- Please follow-up with your primary care doctor within the next
___ weeks to have a repeat blood draw.
- Please return to the hospital if you develop the following
signs:
1.) More bloody or dark vomiting
2.) More black, tarry stools
3.) New lightheadedness or shortness of breath
Thank you for allowing us to participate in your care.
Your ___ Team
Followup Instructions:
___
|
[
"K920",
"N179",
"F1010",
"I10",
"F17200",
"E8352",
"E876",
"E8342",
"K7030",
"D6959"
] |
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Nausea, Vomiting Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] male, history of cervical fusion in [MASKED], ETOH abuse, and HTN presenting with nausea, hematemesis/coffee-ground emesis and ? melena. He was in his usual state of health, consuming [MASKED] shot glasses per night of ETOH (last night however [MASKED] shots), and also using NSAIDS 1600 mg/day and Tylenol [MASKED] mg/day for his neck pain after the surgery. On [MASKED], he began having intermittent abdominal discomfort with food intake. He also had nausea and vomiting, with hematemesis on day prior to presentation and 2 episodes of coffee-ground emesis on day of presentation. He reports lightheadedness with standing. In the ED, noted to have a dark tarry BM with subsequent dizziness. He reports no chest pain, shortness of breath, abdominal pain, diarrhea. In ED, vital signs were notable for tachycardia 110s-120s, BP 130s/70s-80s, satting well on RA. Labs are notable for Hgb 12.9, which is above his baseline of [MASKED]. He had elevated transaminases to 169/257, elevated from prior with normal AP, Tbili, and lipase. He has [MASKED] with Cr of 1.2 from baseline of 0.5 and BUN of 29. Chemistry notable for K 5.0, Cl 82, and anion gap of 26. INR was 1.2. GI was consulted and recommended IV PPI, NPO, transfusion goal of [MASKED], anti-emetic, and potential EGD. He was given NS, pantoprazole, ondansetron, and morphine. On arrival to the floor, patient reports severe pain in his neck at the site of his recent surgery. Otherwise feels well without complaints. REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as per HPI Past Medical History: ETOH abuse HTN S/p posterior cervical decompression and fusion [MASKED] C. diff Social History: [MASKED] Family History: No family history of liver disease Physical Exam: ADMISSION PHYSICAL ================== VS: 97.7 PO 177 / 92L Lying [MASKED] Ra GENERAL: NAD HEENT: anicteric sclera, pink conjunctiva, MMM NECK: supple, no LAD, no JVD HEART: tachycardia, 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 on exam EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, moving all 4 extremities with purpose SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL ================== [MASKED] 0720 Temp: 98.3 PO BP: 107/56 R Lying HR: 67 RR: 16 O2 sat: 97% O2 delivery: Ra GENERAL: NAD HEENT: anicteric sclera, pink conjunctiva, MMM HEART: normal 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 on exam EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, moving all 4 extremities with purpose SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ADMISSION LABS ============== [MASKED] 04:00PM BLOOD WBC-8.4 RBC-4.51* Hgb-12.9* Hct-38.4* MCV-85 MCH-28.6 MCHC-33.6 RDW-16.7* RDWSD-48.5* Plt [MASKED] [MASKED] 04:00PM BLOOD Neuts-85.4* Lymphs-7.9* Monos-5.4 Eos-0.5* Baso-0.4 Im [MASKED] AbsNeut-7.15* AbsLymp-0.66* AbsMono-0.45 AbsEos-0.04 AbsBaso-0.03 [MASKED] 04:11PM BLOOD [MASKED] PTT-27.5 [MASKED] [MASKED] 04:00PM BLOOD Glucose-109* UreaN-29* Creat-1.2 Na-138 K-5.0 Cl-82* HCO3-30 AnGap-26* [MASKED] 04:00PM BLOOD ALT-169* AST-257* AlkPhos-112 TotBili-0.6 [MASKED] 04:00PM BLOOD Lipase-30 [MASKED] 04:00PM BLOOD Albumin-4.8 Calcium-11.2* Phos-4.1 Mg-1.6 [MASKED] 09:48PM URINE Hours-RANDOM Creat-200 Na-81 PERTINENT LABS ============== [MASKED] 08:57AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG [MASKED] 08:57AM BLOOD HCV Ab-NEG [MASKED] 01:52PM STOOL HELICOBACTER ANTIGEN DETECTION, STOOL-PND MICRO ===== None STUDIES ======= US Liver [MASKED]. Echogenic liver consistent with steatosis. Mildly nodular suggests cirrhosis. 2. No cholelithiasis, evidence of cholecystitis, or biliary dilation. 3. Patent portal vein. DISCHARGE LABS ============== [MASKED] 04:47AM BLOOD WBC-3.7* RBC-2.81* Hgb-8.2* Hct-25.3* MCV-90 MCH-29.2 MCHC-32.4 RDW-15.6* RDWSD-51.0* Plt Ct-96* [MASKED] 04:47AM BLOOD Glucose-82 UreaN-10 Creat-0.8 Na-141 K-3.7 Cl-99 HCO3-29 AnGap-13 [MASKED] 04:47AM BLOOD Calcium-8.5 Phos-2.5* Mg-2.[MASKED] male, history of cervical fusion in [MASKED], ETOH abuse, and HTN presenting with hematemesis and coffee-ground emesis as well melena concerning for UGIB likely [MASKED] alcoholic gastritis vs. esophagitis vs [MASKED] tear. # UGIB Patient presented after having two episodes of hematemesis/coffee-ground emesis, and then proceeded to have large melena in ED. Hgb at presentation was 12.9 but subsequently dropped to 9.5 and then 8.9 in the setting of getting 2L IVF. Possible etiologies include [MASKED] Tear, esophagitis, alcoholic gastritis, and NSAID use. Patient was planned to undergo EGD on [MASKED] but unfortunately, given spinal fusion, anesthesia felt that it would be safest to perform procedure in the OR. Patient was hemodynamically stable for 48 hours since admission and had no major changes in his hemoglobin. Multiple conversations were had with the patient and the inpatient GI team about our preference of having him stay and undergo EGD in the OR given possible evidence of cirrhotic changes on liver US. Patient preferred to leave due to multiple life stressors outside of the hospital (including significant work issues with his boss) and the patient's presentation was thought to be less concerning for acute variceal bleed. This plan was discussed with GI consultants. Patient was educated about danger signs that should prompt an immediate return to the ED, and otherwise was encouraged to attend his scheduled follow up liver clinic where the EGD could be setup as an outpatient. # [MASKED] Cr was elevated to 1.2 at presentation from baseline 0.5. Likely pre-renal in setting of ongoing nausea limiting PO intake and vomiting. Patient received 2L IVF and Cr downtrended. # Cirrhosis # Transaminitis Patient's liver enzymes were elevated on admission, AST/ALT 100s-200s. Baseline abnormal likely due to ongoing alcohol use vs. fatty liver disease. He was also found to be leukopenic and thrombocytopenic. No stigmata of chronic liver disease on exam. RUQ U/S demonstrated stigmata of cirrhosis. Hepatitis serologies (HBV, HCV) were obtained and were all negative. Patient was started on hepatitis B vaccination series and received the first immunization on [MASKED]. # Alcohol abuse Patient formerly frank ten shots a night every night and drank continuously on weekends. He has since cut down and now drinks [MASKED] shots [MASKED] nights a week. No history of withdrawal seizures though did require phenobarb during prior admission. At his reduced level of drinking, he did not have withdrawal on this admission. [MASKED] w/ EtOH abuse admitted w/ hematemesis and melena. Imaging and labs c/w a new diagnosis of cirrhosis. The patient was advised that even though he has cut down his drinking, his liver is now much more fragile than before and even small amounts of alcohol can cause further damage. He was educated on the life-threatening complications of cirrhosis and how he may not have any symptoms until it has become too late to undo the damage. He verbalized understanding of this, but does not feel quite ready to quit drinking. He was educated about naltrexone and other resources and agrees to readdress sobriety at his follow up visit. # H/o cervical fusion in [MASKED] Pain was controlled with Tylenol, tizanadine, gabapentin, and oxycodone PRN. TRANSITIONAL ISSUES =================== []EGD: Prompt outpatient EGD is recommended to clarify the cause of bleeding. Even if he has no further bleeding, the patient still needs to complete an EGD to screen for esophageal varices. []Pending Labs: f/u h pylori stool antigen []Hepatology: Close followup in liver clinic given new diagnosis of cirrhosis [][MASKED] Screening: Patient will require q6 month [MASKED] screening with abdominal ultrasound []Hepatitis B, non-immune: Patient was found to be hepatitis B non-immune, received first vaccine on [MASKED], followup with course per recommended schedule []PPI: Discharged on PPI BID which should be continued until patient has GI follow up at [MASKED] [] NO NSAIDS. [] Continue discussion regarding alcohol cessation. He is potentially interested in naltrexone. #CODE: Full (presumed) #CONTACT: [MASKED] [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 1000 mg PO Q6H 2. Gabapentin 300 mg PO Q8H 3. Tizanidine 4 mg PO TID:PRN neck pain 4. Ibuprofen 400 mg PO Q6H Discharge Medications: 1. FoLIC Acid 1 mg PO DAILY RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 2. Gabapentin 300 mg PO Q8H 3. Multivitamins W/minerals 1 TAB PO DAILY RX *multivitamin,tx-minerals [Vitamins and Minerals] 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. Omeprazole 40 mg PO BID RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 5. Thiamine 200 mg PO DAILY RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 6. Tizanidine 4 mg PO TID:PRN neck pain 7. HELD- Acetaminophen 1000 mg PO Q6H This medication was held. Do not restart Acetaminophen until you really need it, and this should be no more than 2 grams per day Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses ================= Upper GI bleed Alcoholic cirrhosis [MASKED] Secondary Diagnoses =================== Alcohol abuse Nicotine dependence Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], It was a pleasure taking care of you in the hospital. WHY WERE YOU ADMITTED: - You were having bloody vomit and dark stools which concerned us that you were having a bleed from somewhere in your esophagus, stomach, or intestines. WHAT HAPPENED IN THE HOSPITAL: - We gave you fluids - We took lab tests to see if you were bleeding quickly - We had the GI doctors [MASKED] by and [MASKED] you, and they recommended that you get a procedure in which we look with a camera into your stomach. However, because of your neck surgeries, this would have to be done in the operating room. You decided that you did not want to wait and have this done so you were discharged with strict instructions to return if you start feeling ANY symptoms or experienced ANY bleeding - You had imaging that suggested that you had cirrhosis in your liver. This needs follow up and further work up and it will be extremely important for you to follow up with a liver specialist. - Importantly, you should NOT take any further ibuprofen, advil, naproxen, aleve. You should STOP drinking and consider a detoxification center. WHAT SHOULD I DO AFTER LEAVING: - Please take all of your medications as prescribed including a new medication: 1.) Pantoprazole 40mg twice daily - Please follow-up with your primary care doctor within the next [MASKED] weeks to have a repeat blood draw. - Please return to the hospital if you develop the following signs: 1.) More bloody or dark vomiting 2.) More black, tarry stools 3.) New lightheadedness or shortness of breath Thank you for allowing us to participate in your care. Your [MASKED] Team Followup Instructions: [MASKED]
|
[] |
[
"N179",
"I10"
] |
[
"K920: Hematemesis",
"N179: Acute kidney failure, unspecified",
"F1010: Alcohol abuse, uncomplicated",
"I10: Essential (primary) hypertension",
"F17200: Nicotine dependence, unspecified, uncomplicated",
"E8352: Hypercalcemia",
"E876: Hypokalemia",
"E8342: Hypomagnesemia",
"K7030: Alcoholic cirrhosis of liver without ascites",
"D6959: Other secondary thrombocytopenia"
] |
10,005,606 | 29,646,384 |
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
surgeons 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:
___
|
[
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"S2220XA",
"F10121",
"A0472",
"G960",
"S22020A",
"S12490A",
"S12590A",
"S12690A",
"S93409A",
"W109XXA",
"Y9289",
"S0101XA",
"F17210",
"F1290",
"D649",
"M5382"
] |
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: neck fracture Major Surgical or Invasive Procedure: [MASKED] C5/6 corpectomy, C4-C7 ACDF [MASKED] C2-T2 posterior cervical fusion, C4-6 cervical laminectomy History of Present Illness: [MASKED] year-old male who presents s/p intoxicated fall from [MASKED] 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: [MASKED] 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 [MASKED] L2 L3 L4 L5 S1 S2 (Groin) (Knee) (Med Calf) (Grt Toe) (Sm Toe) (Post Thigh) R SILT SILT SILT SILT SILT SILT L SILT SILT SILT SILT SILT SILT Motor: 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 [MASKED] Flex(L1) Add(L2) Quad(L3) TA(L4) [MASKED] [MASKED] R 5 5 5 5 5 5 5 L 5 5 5 5 5 5 5 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 [MASKED]: Negative Babinski: Downgoing Clonus: No beats Postop: gen: awake, pleasant, Dressings with staining skin: warm and dry, incision are intact [MASKED]: 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 [MASKED] 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 [MASKED] IMPRESSION: 1. No acute cardiopulmonary process. No obvious rib fractures. 2. No fracture or dislocation involving the [MASKED], hips, and partially imaged femurs. [MASKED] 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 [MASKED] 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 [MASKED] 1. Large scalp hematoma over the vertex with skin laceration. No underlying calvarial fracture. No evidence of acute intracranial hemorrhage. CT Head angiogram [MASKED] 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 [MASKED] . 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 [MASKED] In comparison with the study of [MASKED], 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 [MASKED] in the trauma ICU for further management. He underwent the above stated procedure on [MASKED] and [MASKED]. 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: [MASKED]- paresthesias in bilateral thumbs, consented to remain intubated x2d for procedures if needed > to OR for ACDF EBL 2.2L [MASKED], 2u pRBC, 4u FFP remained intubated (easy with [MASKED], lactate downtrending. plan for OR likely [MASKED]. started phenobarb load postop. BPs with MAPS in [MASKED], UOP trending down > gave albumin bolus, expect Hct to continue slow downtrend for now but holding off on blood. [MASKED]- Neuro exam improved, only mild numbness in left [MASKED] 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. [MASKED]: 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. [MASKED]: Og tube replaced. stays flat for 24h, until [MASKED] on [MASKED]. 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 [MASKED]. will monitor. does not think it is csf leak. [MASKED]: 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 [MASKED]: recommending rehab [MASKED]: pt continues on dex intermittently, was interactive and appropriate with friend today. will continue to monitor for agitation [MASKED]: 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 [MASKED]. During the patient's course [MASKED] 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 [MASKED] and CDIFF was sent. On [MASKED], patient + for CDIFF and was started on flagyl po for 10 days. His diarrhea improved as of [MASKED]. 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 [MASKED] 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 [MASKED] weeks after surgery. 1.You can reach the office at [MASKED] 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 surgeons office if you notice any of the following: [MASKED] redness along the length of the incision [MASKED] swelling of the area around your incision [MASKED] from the incision [MASKED] of your extremities greater than before surgery [MASKED] of bowel or bladder control [MASKED] of severe headache [MASKED] swelling or calf tenderness [MASKED] above 101.5 At your wound check visit, the Nurse Practitioner or [MASKED] [MASKED], 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 [MASKED]. You are allowed to gradually reduce the number of pills you take when the pain begins to subside. If you are taking more than the recommended dose, please contact the office to discuss this with a practitioner [MASKED] medication may need to be increased or changed). Constipation: Pain medications (narcotics) may cause constipation (difficulty having a bowel movement). It is important to be aware of your bowel habits so you [MASKED] 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 [MASKED] 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 [MASKED] 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 [MASKED] 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 [MASKED] immediately. Questions Any questions may be directed to your surgeon or nurse practitioner/ physician [MASKED]. 1.During normal business hours (8:30am- 5:00pm), you can call our office directly at [MASKED]. 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: [MASKED] collar is labeled front and back with arrows indicating top and bottom. [MASKED] the back section on your neck first. Apply the front section placing your chin in the chin rest. [MASKED] 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. [MASKED] 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: [MASKED] alert to pressures under your chin. Some pressure is necessary but do not allow a blister or pressure sore to develop. [MASKED] 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. [MASKED] 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 [MASKED] times a day you should go for a walk for [MASKED] minutes as part of your recovery.You can walk as much as you can tolerate.Limit any kind of lifting. 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 [MASKED] 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 [MASKED] 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: [MASKED] Please Call the office and make an appointment for 2 weeks after the day of your operation if this has not been done already. [MASKED] 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: [MASKED]
|
[] |
[
"F17210",
"D649"
] |
[
"S12390A: Other displaced fracture of fourth cervical vertebra, initial encounter for closed fracture",
"J9690: Respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia",
"S27321A: Contusion of lung, unilateral, initial encounter",
"S14109A: Unspecified injury at unspecified level of cervical spinal cord, initial encounter",
"S2220XA: Unspecified fracture of sternum, initial encounter for closed fracture",
"F10121: Alcohol abuse with intoxication delirium",
"A0472: Enterocolitis due to Clostridium difficile, not specified as recurrent",
"G960: Cerebrospinal fluid leak",
"S22020A: Wedge compression fracture of second thoracic vertebra, initial encounter for closed fracture",
"S12490A: Other displaced fracture of fifth cervical vertebra, initial encounter for closed fracture",
"S12590A: Other displaced fracture of sixth cervical vertebra, initial encounter for closed fracture",
"S12690A: Other displaced fracture of seventh cervical vertebra, initial encounter for closed fracture",
"S93409A: Sprain of unspecified ligament of unspecified ankle, initial encounter",
"W109XXA: Fall (on) (from) unspecified stairs and steps, initial encounter",
"Y9289: Other specified places as the place of occurrence of the external cause",
"S0101XA: Laceration without foreign body of scalp, initial encounter",
"F17210: Nicotine dependence, cigarettes, uncomplicated",
"F1290: Cannabis use, unspecified, uncomplicated",
"D649: Anemia, unspecified",
"M5382: Other specified dorsopathies, cervical region"
] |
10,005,749 | 24,015,009 |
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:
___
|
[
"E1165",
"N179",
"E1122",
"I130",
"N189",
"I5022",
"N390",
"E871",
"E876",
"I482",
"F419",
"Z940",
"Z794",
"Z7901",
"E785"
] |
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: High blood sugars, labs showing acute on chronic kidney injury Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] with a h/o renal transplant, CHF, AFib on Coumadin, DM who presented to the ED on [MASKED] with hyperglycemia (600s) and worsening kidney function on routine tests at PCP. On [MASKED], 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 [MASKED] (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 [MASKED] SHINGLES - FOREHEAD DIABETES MELLITUS MITRAL REGURGITATION URINARY TRACT INFECTION RENAL TRANSPLANT [MASKED] BILATERAL NEPHRECTOMIES [MASKED] SPHINCTEROTOMY BREAST AUGMENTATION Social History: [MASKED] 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 [MASKED] 05:42PM BLOOD UreaN-46* Creat-2.1* Na-127* K-4.0 Cl-86* HCO3-22 AnGap-23* [MASKED] 05:42PM BLOOD Glucose-665* [MASKED] 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 [MASKED] [MASKED] 05:42PM BLOOD %HbA1c-12.7* eAG-318* [MASKED] 12:15PM BLOOD Glucose-548* UreaN-47* Creat-1.9* Na-122* K-3.8 Cl-85* HCO3-21* AnGap-20 [MASKED] 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 [MASKED] [MASKED] 12:15PM BLOOD Neuts-90.2* Lymphs-6.1* Monos-2.1* Eos-0.2* Baso-0.2 Im [MASKED] AbsNeut-10.14* AbsLymp-0.68* AbsMono-0.24 AbsEos-0.02* AbsBaso-0.02 LABS UPON DISCHARGE: [MASKED] 11:19AM BLOOD Glucose-221* UreaN-42* Creat-1.8* Na-130* K-3.1* Cl-91* HCO3-22 AnGap-20 [MASKED] 05:56PM BLOOD Glucose-356* UreaN-43* Creat-1.9* Na-126* K-4.0 Cl-89* HCO3-23 AnGap-18 [MASKED] 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 [MASKED] [MASKED] 11:19AM BLOOD [MASKED] PTT-35.5 [MASKED] IMAGING: RENAL US [MASKED] IMPRESSION: 1. Patent renal transplant vasculature. 2. Borderline to minimally elevated intrarenal resistive indices measuring up to 0.79 in the interpolar region. CXR [MASKED] IMPRESSION: Persistent small left and trace right pleural effusions and cardiomegaly. No pulmonary edema. Brief Hospital Course: [MASKED] with a history of renal transplant, CHF, AFib on Coumadin, DM who was admitted on [MASKED] after she was found to have hyperglycemia (600s) and worsening renal function on routine lab tests at PCP (Cr 2.1 on [MASKED], up from most recent 1.4 on [MASKED]. # Hyperglycemia / T2DM: Pt presented with significant hyperglycemia with [MASKED] 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. [MASKED] 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 [MASKED]. 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 [MASKED]. 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 [MASKED] per [MASKED] clinic because INR was high. Continued diltiazem, metoprolol and digoxin. # CHF ECHO [MASKED] 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 [MASKED]. Furosemide held in setting of [MASKED]. # 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 [MASKED] STOPPED MEDICATIONS: Glipizide Furosemide (Lasix) Losartan -Pt needs close f/u with PCP, [MASKED], and [MASKED]. PCP is [MASKED]. Discussed with patient and family -Pt should have repeat labs on [MASKED], 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, [MASKED] fax to: [MASKED], MD [MASKED], MD [MASKED] 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. [MASKED], 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 [MASKED]. 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 [MASKED] STOPPED MEDICATIONS: Glipizide Furosemide (Lasix) Losartan MAKE AN APPOINTMENT WITH YOUR NEPHROLOGIST FOR WITHIN ONE WEEK - Dr. [MASKED] AN APPOINTMENT WITH YOUR PRIMARY CARE DOCTOR - Call [MASKED] PLEASE ATTEND YOUR [MASKED] APPOINTMENT Please get your labs checked next [MASKED]. It was a pleasure taking care of you. Your [MASKED] Team Followup Instructions: [MASKED]
|
[] |
[
"E1165",
"N179",
"E1122",
"I130",
"N189",
"N390",
"E871",
"F419",
"Z794",
"Z7901",
"E785"
] |
[
"E1165: Type 2 diabetes mellitus with hyperglycemia",
"N179: Acute kidney failure, unspecified",
"E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease",
"I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease",
"N189: Chronic kidney disease, unspecified",
"I5022: Chronic systolic (congestive) heart failure",
"N390: Urinary tract infection, site not specified",
"E871: Hypo-osmolality and hyponatremia",
"E876: Hypokalemia",
"I482: Chronic atrial fibrillation",
"F419: Anxiety disorder, unspecified",
"Z940: Kidney transplant status",
"Z794: Long term (current) use of insulin",
"Z7901: Long term (current) use of anticoagulants",
"E785: Hyperlipidemia, unspecified"
] |
10,005,817 | 28,661,809 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
weakness, hypoxia secondary to superior vena cava syndrome
Major Surgical or Invasive Procedure:
intubation ___
Left femoral line placement ___
R femoral line placement
Left chest tube placement
Radiation Therapy
Left PICC placement
History of Present Illness:
___ h/o COPD, CAD s/p CABG, pAfib on xarelto, CKD, HTN, HLD, L
supraclaviular mass dx as neuroendocrine tumor, who presented to
___ on ___ for dehydration and failure to thrive. He did
report scapular pain and dyspnea on exertion x 4 weeks starting
about 2 months prior to presentation. Outpatient CT showed
mediastinal lymphadenopathy and a supraclavicular mass. Biopsy
on ___ showed poorly differentiated neuroendocrine tumor.
Initial plan was to start chemotherapy of etoposide and
carbaplantiunum x 3 days, as well as additioning to PET scan to
___, however patient was unable to tolerate lying flat and PET
scan was not performed. The patient was sent by his outpatient
oncologist to ___ on ___ for failure to thrive and
hypotension with SBPs in the ___. CT scan on ___ showed
mediastinal adenopathy and SVC compromise and rec'd radiation
but this was not done due to clinical decompensation. However,
once the disease is staged, if the patient has no sign of
metastatic disease, than chemotherapy would be curative.
During his time at ___, his hospital course was notable for
increased upper extremity swelling, facial swelling, and
increased hypoxia. RUE ultrasound was negative for DVT. He had
an increasing oxygen requirement from 2L to 7L. Given concern
for airway compromise, the patient was transferred to the
___ ICU on ___. Due to lack of surgical backup at
___, the patient was not intubated at ___ and
subsequently transferred here for further airway evaluation.
Of note, the patient had a recent admission at ___ on
___ for pneumonia, at which time he was treated with
levaquin.
Vital signs at the time of transfer were 97.6 80 160/76 19 96%
on high flow NC 8L.
Physical exam notable for facial flushing, able to speak in full
sentences, RUE swelling.
Labs prior to transfer notable for a WBC of 12.6, H/H ___,
platelets WNL. VBG 7.40/___. Cr 1.7. Lactate 3.8 -> 2.2.
Procalcitonin <0.05 (undetectable).
On arrival to the MICU, the patient was hemodynamically stable
with pulse of 76 are blood pressure of 127/64. He had an
increased work of breathing using his abdominal muscles. He was
sitting upright, unable to tolerate laying flat.
Past Medical History:
- Coronary artery disease w/LAD stent; now s/p CABG x3:
Left internal mammary artery to left anterior descending artery,
saphenous vein graft to diagonal and obtuse marginal arteries
- Chronic obstructive pulmonary disease
- hypertension
- Congestive heart failure EF 40-45%.
- Diabetes mellitus
- Rectal Cancer ___ - treated w Chemo/ Rad followed by a
surgical
procedure to remove residual tumor via the rectum
- Post traumatic stress disorder (pt is ___ veteran)
- atrial fibrillation
- CKD
Social History:
___
Family History:
FAMILY HISTORY: No premature coronary artery disease, or
neuroendocrine carcinomas
Physical Exam:
MICU ADMISSION
============================
Vitals: T 97.7 HR 76 BP 127/64 R 20 93% 6L NC
GENERAL: fatigued, no acute distress
HEENT: Sclera anicteric, noted ___ swelling with
rightsided facial fullness. Difficult to visualize posterior
oropharynx
___: Regular without murmurs
RESP: Increased work of breathing with abnormal muscles. No
stridor. RLL crackles
ABD: Non-tender, non-distended
EXT: Warm, no edema ___, Mild edema RUE
NEURO: CN II-XII intact. Strength ___ UE and ___ b/l
DEATH EXAM ___ - ___)
============================
Pupils non-reactive to light
No cardiac sounds auscultated
No respiratory effort seen
Telemetry without cardiac electrical activity
Pertinent Results:
ADMISSION LABS:
==============================
___ 10:30PM WBC-12.1*# RBC-3.67*# HGB-10.9*# HCT-33.4*
MCV-91 MCH-29.7 MCHC-32.6 RDW-14.0 RDWSD-46.3
___ 10:30PM PLT COUNT-359#
___ 10:30PM GLUCOSE-190* UREA N-48* CREAT-1.6* SODIUM-138
POTASSIUM-4.5 CHLORIDE-101 TOTAL CO2-23 ANION GAP-19
___ 10:51PM freeCa-1.11*
___ 10:30PM CALCIUM-9.0 PHOSPHATE-3.1 MAGNESIUM-2.4 URIC
ACID-8.3*
___ 10:51PM LACTATE-2.3*
DISCHARGE LABS:
==============================
___ 01:02PM BLOOD WBC-9.8 RBC-3.06* Hgb-8.9* Hct-26.2*
MCV-86 MCH-29.1 MCHC-34.0 RDW-14.6 RDWSD-44.7 Plt ___
___ 05:00AM BLOOD ___ PTT-67.6* ___
___ 11:14AM BLOOD Glucose-161* UreaN-102* Creat-2.7*
Na-131* K-3.9 Cl-89* HCO3-28 AnGap-18
___ 05:00AM BLOOD ALT-27 AST-55* LD(LDH)-925* AlkPhos-93
TotBili-0.4
___ 11:14AM BLOOD Calcium-7.0* Phos-6.0* Mg-1.8
MICROBIOLOGY:
==============================
___ FLUID RECEIVED IN BLOOD CULTURE BOTTLES
Fluid Culture in Bottles-PRELIMINARY INPATIENT
___ PLEURAL FLUID GRAM STAIN-FINAL; FLUID
CULTURE-FINAL; ANAEROBIC CULTURE-PRELIMINARY INPATIENT
___ URINE URINE CULTURE-FINAL INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL {YEAST} INPATIENT
___ URINE URINE CULTURE-FINAL INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
___ STOOL C. difficile DNA amplification
assay-FINAL INPATIENT
___ BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL;
RESPIRATORY CULTURE-FINAL {YEAST}; POTASSIUM HYDROXIDE
PREPARATION-FINAL; FUNGAL CULTURE-PRELIMINARY {YEAST} INPATIENT
___ MRSA SCREEN MRSA SCREEN-FINAL {STAPH AUREUS
COAG +} INPATIENT
___ PLEURAL FLUID GRAM STAIN-FINAL; FLUID
CULTURE-FINAL; ANAEROBIC CULTURE-FINAL
PATHOLOGY:
===============================
PLEURAL FLUID, LATERALITY NOT SPECIFIED:
POSITIVE FOR MALIGNANT CELLS.
Consistent with metastatic poorly-differentiated non-small cell
neuroendocrine carcinoma.
A few small groups of and scattered single atypical epithelioid
cells are seen on the cell block
preparation. Immunohistochemical stains show the atypical cells
to be focally, weakly positive for
synaptophysin, and CK5/6. No immunoreactive cells for
chromogranin are seen. The patient's prior
slides of lymph node biopsy (___) were not available for
comparison. Drs. ___ and ___ were informed of the diagnosis via e-mail by Dr. ___
on ___
STUDIES:
===============================
+ TTE ___: The left atrium is mildly dilated. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function is normal
(LVEF = 65%). 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 is not
well seen. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. The left
ventricular inflow pattern suggests impaired relaxation. There
is mild pulmonary artery systolic hypertension. There is a small
pericardial effusion. There are no echocardiographic signs of
tamponade.
Brief Hospital Course:
Mr. ___ is a ___ year-old man with recently-diagnosed
metastatic poorly-differentiated high-grade neuroendocrine
carcinoma (likely of pulmonary origin), with bulky
retroperitoneal/common iliac/mediastinal lymphadenopathy
concerning for metastatic disease, who was admitted to ___ on
___ with progressive dyspnea and hypoxemia thought to be at
least partially related to ___ syndrome from an enlarging
chest/neck mass, which was treated with external radiotherapy.
Hospital course was been complicated by hypoxemic respiratory
failure requiring prolonged mechanical intubation, sepsis ___
obstructive pneumonia, acute kidney injury ___ acute tubular
necrosis, malignant pleural effusions requiring bilateral chest
tube placement and hemodynamically unstable atrial fibrillation.
Mr. ___ was followed closely by numerous consulting services
(Heme-Onc, Pulmonary, Radiation Oncology, Nephrology, Infectious
Disease). He developed progressive multi-system organ failure
despite aggressive supportive care. Given his progressive
decline and based on family wishes, his care was transitioned to
a comfort focus and he was extubated with family at the bedside
in accordance with his goals of care. He expired soon thereafter
with official time of death being ___ @ 18:36. Autopsy was
deferred.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO QPM
2. Carvedilol 12.5 mg PO BID
3. Diltiazem Extended-Release 240 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Fenofibrate 160 mg PO DAILY
6. Levothyroxine Sodium 50 mcg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Rivaroxaban 15 mg PO DAILY
9. SAXagliptin 2.5 mg oral DAILY
10. GlipiZIDE XL 10 mg PO QAM
11. GlipiZIDE XL 5 mg PO QPM
12. LamoTRIgine 100 mg PO DAILY
13. Omeprazole 20 mg PO DAILY
14. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain
- Moderate
15. QUEtiapine Fumarate 25 mg PO QHS
16. Fentanyl Patch 75 mcg/h TD Q72H
17. Midodrine 5 mg PO TID
Discharge Medications:
patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
- Superior Vena Cava Syndrome
- Poorly differentiated neuroendocrine tumor
- Acute Hypoxemic Respiratory failure
- Healthcare associated pneumonia
- Malignant Pleural Effusions
- Acute tubular necrosis
- Tumor lysis syndrome
- New onset atrial fibrillation/flutter with rapid ventricular
response.
Discharge Condition:
Patient expired
Discharge Instructions:
Patient expired
Followup Instructions:
___
|
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"C7B8",
"I5022",
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"C7A8",
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"I2510",
"F17210",
"Z951",
"Z955",
"E119",
"Z85048",
"F4310",
"I4891",
"Z515",
"I129",
"N189",
"R410",
"Z9981",
"Z7902"
] |
Allergies: Penicillins Chief Complaint: weakness, hypoxia secondary to superior vena cava syndrome Major Surgical or Invasive Procedure: intubation [MASKED] Left femoral line placement [MASKED] R femoral line placement Left chest tube placement Radiation Therapy Left PICC placement History of Present Illness: [MASKED] h/o COPD, CAD s/p CABG, pAfib on xarelto, CKD, HTN, HLD, L supraclaviular mass dx as neuroendocrine tumor, who presented to [MASKED] on [MASKED] for dehydration and failure to thrive. He did report scapular pain and dyspnea on exertion x 4 weeks starting about 2 months prior to presentation. Outpatient CT showed mediastinal lymphadenopathy and a supraclavicular mass. Biopsy on [MASKED] showed poorly differentiated neuroendocrine tumor. Initial plan was to start chemotherapy of etoposide and carbaplantiunum x 3 days, as well as additioning to PET scan to [MASKED], however patient was unable to tolerate lying flat and PET scan was not performed. The patient was sent by his outpatient oncologist to [MASKED] on [MASKED] for failure to thrive and hypotension with SBPs in the [MASKED]. CT scan on [MASKED] showed mediastinal adenopathy and SVC compromise and rec'd radiation but this was not done due to clinical decompensation. However, once the disease is staged, if the patient has no sign of metastatic disease, than chemotherapy would be curative. During his time at [MASKED], his hospital course was notable for increased upper extremity swelling, facial swelling, and increased hypoxia. RUE ultrasound was negative for DVT. He had an increasing oxygen requirement from 2L to 7L. Given concern for airway compromise, the patient was transferred to the [MASKED] ICU on [MASKED]. Due to lack of surgical backup at [MASKED], the patient was not intubated at [MASKED] and subsequently transferred here for further airway evaluation. Of note, the patient had a recent admission at [MASKED] on [MASKED] for pneumonia, at which time he was treated with levaquin. Vital signs at the time of transfer were 97.6 80 160/76 19 96% on high flow NC 8L. Physical exam notable for facial flushing, able to speak in full sentences, RUE swelling. Labs prior to transfer notable for a WBC of 12.6, H/H [MASKED], platelets WNL. VBG 7.40/[MASKED]. Cr 1.7. Lactate 3.8 -> 2.2. Procalcitonin <0.05 (undetectable). On arrival to the MICU, the patient was hemodynamically stable with pulse of 76 are blood pressure of 127/64. He had an increased work of breathing using his abdominal muscles. He was sitting upright, unable to tolerate laying flat. Past Medical History: - Coronary artery disease w/LAD stent; now s/p CABG x3: Left internal mammary artery to left anterior descending artery, saphenous vein graft to diagonal and obtuse marginal arteries - Chronic obstructive pulmonary disease - hypertension - Congestive heart failure EF 40-45%. - Diabetes mellitus - Rectal Cancer [MASKED] - treated w Chemo/ Rad followed by a surgical procedure to remove residual tumor via the rectum - Post traumatic stress disorder (pt is [MASKED] veteran) - atrial fibrillation - CKD Social History: [MASKED] Family History: FAMILY HISTORY: No premature coronary artery disease, or neuroendocrine carcinomas Physical Exam: MICU ADMISSION ============================ Vitals: T 97.7 HR 76 BP 127/64 R 20 93% 6L NC GENERAL: fatigued, no acute distress HEENT: Sclera anicteric, noted [MASKED] swelling with rightsided facial fullness. Difficult to visualize posterior oropharynx [MASKED]: Regular without murmurs RESP: Increased work of breathing with abnormal muscles. No stridor. RLL crackles ABD: Non-tender, non-distended EXT: Warm, no edema [MASKED], Mild edema RUE NEURO: CN II-XII intact. Strength [MASKED] UE and [MASKED] b/l DEATH EXAM [MASKED] - [MASKED]) ============================ Pupils non-reactive to light No cardiac sounds auscultated No respiratory effort seen Telemetry without cardiac electrical activity Pertinent Results: ADMISSION LABS: ============================== [MASKED] 10:30PM WBC-12.1*# RBC-3.67*# HGB-10.9*# HCT-33.4* MCV-91 MCH-29.7 MCHC-32.6 RDW-14.0 RDWSD-46.3 [MASKED] 10:30PM PLT COUNT-359# [MASKED] 10:30PM GLUCOSE-190* UREA N-48* CREAT-1.6* SODIUM-138 POTASSIUM-4.5 CHLORIDE-101 TOTAL CO2-23 ANION GAP-19 [MASKED] 10:51PM freeCa-1.11* [MASKED] 10:30PM CALCIUM-9.0 PHOSPHATE-3.1 MAGNESIUM-2.4 URIC ACID-8.3* [MASKED] 10:51PM LACTATE-2.3* DISCHARGE LABS: ============================== [MASKED] 01:02PM BLOOD WBC-9.8 RBC-3.06* Hgb-8.9* Hct-26.2* MCV-86 MCH-29.1 MCHC-34.0 RDW-14.6 RDWSD-44.7 Plt [MASKED] [MASKED] 05:00AM BLOOD [MASKED] PTT-67.6* [MASKED] [MASKED] 11:14AM BLOOD Glucose-161* UreaN-102* Creat-2.7* Na-131* K-3.9 Cl-89* HCO3-28 AnGap-18 [MASKED] 05:00AM BLOOD ALT-27 AST-55* LD(LDH)-925* AlkPhos-93 TotBili-0.4 [MASKED] 11:14AM BLOOD Calcium-7.0* Phos-6.0* Mg-1.8 MICROBIOLOGY: ============================== [MASKED] FLUID RECEIVED IN BLOOD CULTURE BOTTLES Fluid Culture in Bottles-PRELIMINARY INPATIENT [MASKED] PLEURAL FLUID GRAM STAIN-FINAL; FLUID CULTURE-FINAL; ANAEROBIC CULTURE-PRELIMINARY INPATIENT [MASKED] URINE URINE CULTURE-FINAL INPATIENT [MASKED] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [MASKED] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL {YEAST} INPATIENT [MASKED] URINE URINE CULTURE-FINAL INPATIENT [MASKED] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [MASKED] STOOL C. difficile DNA amplification assay-FINAL INPATIENT [MASKED] BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL {YEAST}; POTASSIUM HYDROXIDE PREPARATION-FINAL; FUNGAL CULTURE-PRELIMINARY {YEAST} INPATIENT [MASKED] MRSA SCREEN MRSA SCREEN-FINAL {STAPH AUREUS COAG +} INPATIENT [MASKED] PLEURAL FLUID GRAM STAIN-FINAL; FLUID CULTURE-FINAL; ANAEROBIC CULTURE-FINAL PATHOLOGY: =============================== PLEURAL FLUID, LATERALITY NOT SPECIFIED: POSITIVE FOR MALIGNANT CELLS. Consistent with metastatic poorly-differentiated non-small cell neuroendocrine carcinoma. A few small groups of and scattered single atypical epithelioid cells are seen on the cell block preparation. Immunohistochemical stains show the atypical cells to be focally, weakly positive for synaptophysin, and CK5/6. No immunoreactive cells for chromogranin are seen. The patient's prior slides of lymph node biopsy ([MASKED]) were not available for comparison. Drs. [MASKED] and [MASKED] were informed of the diagnosis via e-mail by Dr. [MASKED] on [MASKED] STUDIES: =============================== + TTE [MASKED]: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF = 65%). 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 is not well seen. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. There is mild pulmonary artery systolic hypertension. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. Brief Hospital Course: Mr. [MASKED] is a [MASKED] year-old man with recently-diagnosed metastatic poorly-differentiated high-grade neuroendocrine carcinoma (likely of pulmonary origin), with bulky retroperitoneal/common iliac/mediastinal lymphadenopathy concerning for metastatic disease, who was admitted to [MASKED] on [MASKED] with progressive dyspnea and hypoxemia thought to be at least partially related to [MASKED] syndrome from an enlarging chest/neck mass, which was treated with external radiotherapy. Hospital course was been complicated by hypoxemic respiratory failure requiring prolonged mechanical intubation, sepsis [MASKED] obstructive pneumonia, acute kidney injury [MASKED] acute tubular necrosis, malignant pleural effusions requiring bilateral chest tube placement and hemodynamically unstable atrial fibrillation. Mr. [MASKED] was followed closely by numerous consulting services (Heme-Onc, Pulmonary, Radiation Oncology, Nephrology, Infectious Disease). He developed progressive multi-system organ failure despite aggressive supportive care. Given his progressive decline and based on family wishes, his care was transitioned to a comfort focus and he was extubated with family at the bedside in accordance with his goals of care. He expired soon thereafter with official time of death being [MASKED] @ 18:36. Autopsy was deferred. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 80 mg PO QPM 2. Carvedilol 12.5 mg PO BID 3. Diltiazem Extended-Release 240 mg PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Fenofibrate 160 mg PO DAILY 6. Levothyroxine Sodium 50 mcg PO DAILY 7. Multivitamins 1 TAB PO DAILY 8. Rivaroxaban 15 mg PO DAILY 9. SAXagliptin 2.5 mg oral DAILY 10. GlipiZIDE XL 10 mg PO QAM 11. GlipiZIDE XL 5 mg PO QPM 12. LamoTRIgine 100 mg PO DAILY 13. Omeprazole 20 mg PO DAILY 14. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain - Moderate 15. QUEtiapine Fumarate 25 mg PO QHS 16. Fentanyl Patch 75 mcg/h TD Q72H 17. Midodrine 5 mg PO TID Discharge Medications: patient expired Discharge Disposition: Expired Discharge Diagnosis: - Superior Vena Cava Syndrome - Poorly differentiated neuroendocrine tumor - Acute Hypoxemic Respiratory failure - Healthcare associated pneumonia - Malignant Pleural Effusions - Acute tubular necrosis - Tumor lysis syndrome - New onset atrial fibrillation/flutter with rapid ventricular response. Discharge Condition: Patient expired Discharge Instructions: Patient expired Followup Instructions: [MASKED]
|
[] |
[
"J449",
"I2510",
"F17210",
"Z951",
"Z955",
"E119",
"I4891",
"Z515",
"I129",
"N189",
"Z7902"
] |
[
"J9621: Acute and chronic respiratory failure with hypoxia",
"J910: Malignant pleural effusion",
"J189: Pneumonia, unspecified organism",
"N170: Acute kidney failure with tubular necrosis",
"E883: Tumor lysis syndrome",
"I82412: Acute embolism and thrombosis of left femoral vein",
"C7B8: Other secondary neuroendocrine tumors",
"I5022: Chronic systolic (congestive) heart failure",
"I871: Compression of vein",
"C7A8: Other malignant neuroendocrine tumors",
"J449: Chronic obstructive pulmonary disease, unspecified",
"I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris",
"F17210: Nicotine dependence, cigarettes, uncomplicated",
"Z951: Presence of aortocoronary bypass graft",
"Z955: Presence of coronary angioplasty implant and graft",
"E119: Type 2 diabetes mellitus without complications",
"Z85048: Personal history of other malignant neoplasm of rectum, rectosigmoid junction, and anus",
"F4310: Post-traumatic stress disorder, unspecified",
"I4891: Unspecified atrial fibrillation",
"Z515: Encounter for palliative care",
"I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease",
"N189: Chronic kidney disease, unspecified",
"R410: Disorientation, unspecified",
"Z9981: Dependence on supplemental oxygen",
"Z7902: Long term (current) use of antithrombotics/antiplatelets"
] |
10,005,858 | 24,193,796 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: PLASTIC
Allergies:
Aspirin / Adhesive Tape / Percocet / Erythromycin Base / Bee
Sting Kit / adhesive bandage / Caffeine
Attending: ___.
Chief Complaint:
Symptomatic macromastia
Major Surgical or Invasive Procedure:
MAMMOPLASTY REDUCTION BILATERAL
History of Present Illness:
___ yo morbidly obese woman with multinodular goiter, sarcoid,
HTN, SPinal stenosis, B TKAs, lami and fusion with symptomatic
macromastia. She is here today for bilateral breast reduction.
Past Medical History:
ARTHRITIS
BRAIN ANEURYSM
HYPOTHYROIDISM
MULTINODULAR GOITER
LOW BACK PAIN
HYPERSENSITIVITY
RASH
FRONTAL LOBE SYNDROME
HEADACHE
OBESITY
ROTATOR CUFF INJURY
LYMPHADENOPATHY
PULMONARY NODULE
SARCOID
RIGHT WRIST PAIN
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:
Physical exam per PRS post op check ___ 1516 Temp: 97.7 PO BP: 112/72 L Lying HR: 66 RR: 16 O2
sat: 94% O2 delivery: RA
___ 1520 Dyspnea: 0 RASS: -1 Pain Score: ___ Pedal Pulses:
Left DPP: + Right DPP: +
___ 1521 IV Solution: OR/PACU IVF IV Amt Infused: 1613ml
___ 1521 Urine Amt: No Foley DTV@1600
General: Sleepy, NAD
Mental/psych: A+Ox3
chest: bilateral breasts soft, no evidence of hematoma.
Bilateral
IMF incisions intact with small amount of bleeding around
xeroform strip. Nipples intact with xeroform dressings.
Surgibra
in place.
Heart: RRR
Lungs: CTAB
Abd: Large, round and soft, NT.
BLE: No ankle edema. Pneumoboots in place.
Brief Hospital Course:
The patient was admitted to the plastic surgery service on
___ and had a bilateral breast reduction. The patient
tolerated the procedure well.
.
Neuro: Post-operatively, the patient was heavily sedated and
difficult to arouse. She was given narcan with good effect in
the PACU and then transferred to floor. Upon further assessment
on the floor, the patient, again, became difficult to arouse and
was given a repeat dose of narcan with good result. She became
much more alert and responsive. Patient was monitored with
continuous oxygen monitoring overnight for safety.
.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
.
GI/GU: Post-operatively, the patient was given IV fluids until
tolerating oral intake. Her diet was advanced when appropriate,
which was tolerated well. Intake and output were closely
monitored.
.
Prophylaxis: The patient was encouraged to get up and ambulate
as early as possible.
.
At the time of discharge on POD#1, the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating with cane and assistance, voiding without assistance,
and pain was well controlled. Bilateral breasts soft without
evidence of hematoma, bilateral nipples warm, pink and viable.
+ ___ ecchymosis about IMF incisions bilaterally.
Incisions intact. Surgibra in place. Patient discharged to
rehab facility due to inability to safely go up and down stairs.
She lives alone and needs to be able to go up and down stairs.
She will continue work with ___ at rehab.
Medications on Admission:
1. Acetaminophen 650 mg PO Q6H pain
2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
3. Calcium Carbonate 1000 mg PO BID
4. Levothyroxine Sodium 50 mcg PO DAILY
5. Minocycline 100 mg PO Q12H
6. Multivitamins 1 TAB PO DAILY
7. Pramipexole 0.25 mg PO TID
8. Topiramate (Topamax) 50 mg PO BID
9. trospium 60 mg oral DAILY
10. Venlafaxine 200 mg PO QHS
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H pain
2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
3. Calcium Carbonate 1000 mg PO BID
4. Levothyroxine Sodium 50 mcg PO DAILY
5. Minocycline 100 mg PO Q12H
6. Multivitamins 1 TAB PO DAILY
7. Pramipexole 0.25 mg PO TID
8. Topiramate (Topamax) 50 mg PO BID
9. trospium 60 mg oral DAILY
10. Venlafaxine 200 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
symptomatic macromastia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted on ___ for a bilateral breast reduction.
Please follow these discharge instructions.
.
Personal Care:
1. You may remove any dressings from your incision sites 48
hours after surgery.
2. You may shower 48 hours after surgery.
3. You should keep your surgibra in place. You may remove for
laundering and showering.
4. You may expect some drainage from your incisions for up to 1
month.
TIP: You may pad your bras with clean ___ to absorb any
drainage. This provides a clean and absorbent dressing!
.
Activity:
1. You may resume your regular diet.
2. DO NOT lift anything heavier than 5 pounds or engage in
strenuous activity until instructed by Dr. ___.
.
Medications:
1. Resume your regular medications unless instructed otherwise
and take any new meds as ordered.
2. You may take your prescribed pain medication for moderate to
severe pain. You may switch to Tylenol or Extra Strength Tylenol
for mild pain as directed on the packaging.
3. Take Colace, 100 mg by mouth 2 times per day, while taking
the prescription pain medication. You may use a different
over-the-counter stool softener if you wish.
4. Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
5. Do not take any medicines such as Motrin, Aspirin, Advil or
Ibuprofen, unless instructed to do so by Dr. ___.
.
Call the office IMMEDIATELY if you have any of the following:
1. Signs of infection: fever with chills, increased redness,
swelling, warmth or tenderness at the surgical site, or unusual
drainage from the incision(s).
2. A large amount of bleeding from the incision(s) or drain(s).
3. Fever greater than 101.5 oF
4. Severe pain NOT relieved by your medication.
.
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incisions, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Followup Instructions:
___
|
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"K589",
"M170",
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Allergies: Aspirin / Adhesive Tape / Percocet / Erythromycin Base / Bee Sting Kit / adhesive bandage / Caffeine Chief Complaint: Symptomatic macromastia Major Surgical or Invasive Procedure: MAMMOPLASTY REDUCTION BILATERAL History of Present Illness: [MASKED] yo morbidly obese woman with multinodular goiter, sarcoid, HTN, SPinal stenosis, B TKAs, lami and fusion with symptomatic macromastia. She is here today for bilateral breast reduction. Past Medical History: ARTHRITIS BRAIN ANEURYSM HYPOTHYROIDISM MULTINODULAR GOITER LOW BACK PAIN HYPERSENSITIVITY RASH FRONTAL LOBE SYNDROME HEADACHE OBESITY ROTATOR CUFF INJURY LYMPHADENOPATHY PULMONARY NODULE SARCOID RIGHT WRIST PAIN Social History: [MASKED] Family History: Positive for breast cancer in the patient's mother. Brother and father both status post CABG. Brother with type [MASKED] diabetes. Physical Exam: Physical exam per PRS post op check [MASKED] 1516 Temp: 97.7 PO BP: 112/72 L Lying HR: 66 RR: 16 O2 sat: 94% O2 delivery: RA [MASKED] 1520 Dyspnea: 0 RASS: -1 Pain Score: [MASKED] Pedal Pulses: Left DPP: + Right DPP: + [MASKED] 1521 IV Solution: OR/PACU IVF IV Amt Infused: 1613ml [MASKED] 1521 Urine Amt: No Foley DTV@1600 General: Sleepy, NAD Mental/psych: A+Ox3 chest: bilateral breasts soft, no evidence of hematoma. Bilateral IMF incisions intact with small amount of bleeding around xeroform strip. Nipples intact with xeroform dressings. Surgibra in place. Heart: RRR Lungs: CTAB Abd: Large, round and soft, NT. BLE: No ankle edema. Pneumoboots in place. Brief Hospital Course: The patient was admitted to the plastic surgery service on [MASKED] and had a bilateral breast reduction. The patient tolerated the procedure well. . Neuro: Post-operatively, the patient was heavily sedated and difficult to arouse. She was given narcan with good effect in the PACU and then transferred to floor. Upon further assessment on the floor, the patient, again, became difficult to arouse and was given a repeat dose of narcan with good result. She became much more alert and responsive. Patient was monitored with continuous oxygen monitoring overnight for safety. . CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. . Pulmonary: The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. . GI/GU: Post-operatively, the patient was given IV fluids until tolerating oral intake. Her diet was advanced when appropriate, which was tolerated well. Intake and output were closely monitored. . Prophylaxis: The patient was encouraged to get up and ambulate as early as possible. . At the time of discharge on POD#1, the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating with cane and assistance, voiding without assistance, and pain was well controlled. Bilateral breasts soft without evidence of hematoma, bilateral nipples warm, pink and viable. + [MASKED] ecchymosis about IMF incisions bilaterally. Incisions intact. Surgibra in place. Patient discharged to rehab facility due to inability to safely go up and down stairs. She lives alone and needs to be able to go up and down stairs. She will continue work with [MASKED] at rehab. Medications on Admission: 1. Acetaminophen 650 mg PO Q6H pain 2. Artificial Tears [MASKED] DROP BOTH EYES PRN dry eyes 3. Calcium Carbonate 1000 mg PO BID 4. Levothyroxine Sodium 50 mcg PO DAILY 5. Minocycline 100 mg PO Q12H 6. Multivitamins 1 TAB PO DAILY 7. Pramipexole 0.25 mg PO TID 8. Topiramate (Topamax) 50 mg PO BID 9. trospium 60 mg oral DAILY 10. Venlafaxine 200 mg PO QHS Discharge Medications: 1. Acetaminophen 650 mg PO Q6H pain 2. Artificial Tears [MASKED] DROP BOTH EYES PRN dry eyes 3. Calcium Carbonate 1000 mg PO BID 4. Levothyroxine Sodium 50 mcg PO DAILY 5. Minocycline 100 mg PO Q12H 6. Multivitamins 1 TAB PO DAILY 7. Pramipexole 0.25 mg PO TID 8. Topiramate (Topamax) 50 mg PO BID 9. trospium 60 mg oral DAILY 10. Venlafaxine 200 mg PO QHS Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: symptomatic macromastia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted on [MASKED] for a bilateral breast reduction. Please follow these discharge instructions. . Personal Care: 1. You may remove any dressings from your incision sites 48 hours after surgery. 2. You may shower 48 hours after surgery. 3. You should keep your surgibra in place. You may remove for laundering and showering. 4. You may expect some drainage from your incisions for up to 1 month. TIP: You may pad your bras with clean [MASKED] to absorb any drainage. This provides a clean and absorbent dressing! . Activity: 1. You may resume your regular diet. 2. DO NOT lift anything heavier than 5 pounds or engage in strenuous activity until instructed by Dr. [MASKED]. . Medications: 1. Resume your regular medications unless instructed otherwise and take any new meds as ordered. 2. You may take your prescribed pain medication for moderate to severe pain. You may switch to Tylenol or Extra Strength Tylenol for mild pain as directed on the packaging. 3. Take Colace, 100 mg by mouth 2 times per day, while taking the prescription pain medication. You may use a different over-the-counter stool softener if you wish. 4. Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. 5. Do not take any medicines such as Motrin, Aspirin, Advil or Ibuprofen, unless instructed to do so by Dr. [MASKED]. . Call the office IMMEDIATELY if you have any of the following: 1. Signs of infection: fever with chills, increased redness, swelling, warmth or tenderness at the surgical site, or unusual drainage from the incision(s). 2. A large amount of bleeding from the incision(s) or drain(s). 3. Fever greater than 101.5 oF 4. Severe pain NOT relieved by your medication. . Return to the ER if: * If you are vomiting and cannot keep in fluids or your medications. * If you have shaking chills, fever greater than 101.5 (F) degrees or 38 (C) degrees, increased redness, swelling or discharge from incisions, chest pain, shortness of breath, or anything else that is troubling you. * Any serious change in your symptoms, or any new symptoms that concern you. Followup Instructions: [MASKED]
|
[] |
[
"E039",
"G8929",
"I10",
"G4733",
"F329"
] |
[
"N62: Hypertrophy of breast",
"N6082: Other benign mammary dysplasias of left breast",
"N6081: Other benign mammary dysplasias of right breast",
"E6601: Morbid (severe) obesity due to excess calories",
"Z6842: Body mass index [BMI] 45.0-49.9, adult",
"E039: Hypothyroidism, unspecified",
"E042: Nontoxic multinodular goiter",
"G8929: Other chronic pain",
"D869: Sarcoidosis, unspecified",
"I10: Essential (primary) hypertension",
"G4733: Obstructive sleep apnea (adult) (pediatric)",
"M4802: Spinal stenosis, cervical region",
"K589: Irritable bowel syndrome without diarrhea",
"M170: Bilateral primary osteoarthritis of knee",
"M545: Low back pain",
"F329: Major depressive disorder, single episode, unspecified",
"M25531: Pain in right wrist",
"R7303: Prediabetes",
"Z96653: Presence of artificial knee joint, bilateral",
"Z8679: Personal history of other diseases of the circulatory system",
"Z833: Family history of diabetes mellitus",
"Z8249: Family history of ischemic heart disease and other diseases of the circulatory system",
"Z803: Family history of malignant neoplasm of breast"
] |
10,005,858 | 29,569,314 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Aspirin / Adhesive Tape / Percocet / Erythromycin Base / Bee
Sting Kit / adhesive bandage / Caffeine
Attending: ___.
Chief Complaint:
20 lb weight gain, DOE
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old F w/ history of hypertension,
obesity, osteoarthritis, hypothyroidism, and sarcoidosis
presenting for evaluation of a 20 lb weight gain in 1 week, DOE,
and lower extremity edema. She was seen by Cognitive Neurology
today who sent her in for evaluation. She reports that she woke
up approximately 3 days before admission with new lower
extremity
swelling, DOE, bendopnea, and orthopnea. She also endorses chest
pain while walking that stops with slowing down. On ___, she
was
265 pounds and today her weight is 293. She denies any chest
pain. She also has had three weeks of rhinorrhea, sore throat,
and a productive cough.
In the ED, initial vital signs were T 99 HR 87 BP 135/106 RR 22
SPO2 96% RA. Her exam was notable for volume overload with
bilateral crackles and lower extremity edema. proBNP was only
221. TSH was normal. Hgb was newly decreased to 10.7. Urine
alb/Cr ratio was high at 109 and she had a low total protein of
5.8. ECG was unchanged from prior with sinus rhythm and
borderline LVH. Bedside cardiac ultrasound reportedly performed,
but not documented anywhere. CXR in the ED showed pulmonary
vascular congestion, so she was given 40 mg IV Lasix.
Upon arrival to the floor, the patient reports the above story.
She is currently chest pain free, although notes dyspnea with
walking to the bathroom. Her legs feel lighter than before since
she received IV Lasix. This reminds her exactly of when she had
strep-induced nephritis at ___ years old.
REVIEW OF SYSTEMS:
==================
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, palpitations, syncope, or presyncope. On
further review of systems, denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, hemoptysis, black stools or red
stools. Denies exertional buttock or calf pain. Denies recent
fevers, chills or rigors. All of the other review of systems
were
negative.
Past Medical History:
1. CARDIAC RISK FACTORS
- Hypertension
- Obesity
2. CARDIAC HISTORY
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
- Mitral valve prolapse
3. OTHER PAST MEDICAL HISTORY
- Hypothyroidism, s/p partial thyroidectomy for multinodular
goiter
- Sarcoidosis
- Acute nephritis diagnosed at age ___
- Urinary incontinence
- Spinal stenosis, lumbar region with neurogenic claudication,
s/p 3. Laminectomy lumbar L2-5, fusion I3-I5, instrumentation,
bone
graft, ___ S.viridans PJI of right knee (___)
- Chronic bilateral knee pain s/p bilateral total knee
replacement, ___
- Cerebral aneurysm s/p clips
- Pulmonary nodule
- Irritable bowel syndrome
- Hx of CCY, APPY, TAH/RSO
- S/p remote CTS release
Social History:
___
Family History:
Mother - breast cancer
Brother - type ___ DM, CAD s/p CABG
Father - CAD s/p CABG, iCM
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: 98.7 PO 154 / 84 74 20 92 ra
GENERAL: Obese elderly woman sitting up in bed in no acute
distress
HEENT: PERRL, EOMI, anicteric sclera, MMM, no oropharyngeal
erythema or exudates, no rhinorrhea
NECK: supple, no LAD, JVP @ 12 cm
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen obese, soft, multiple surgical scar, nontender in
all
quadrants, no rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis or clubbing. 1+ pitting ___ to knees.
Bruising on knees
PULSES: 1+ radial pulses bilaterally
BACK: Buffalo hump present
NEURO: Alert although sometimes forgetful when asked questions,
CN intact, strength ___ x4 extremities, sensation to LT intact
DERM: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
========================
VS: 24 HR Data (last updated ___ @ 722)
Temp: 97.7 (Tm 98.3), BP: 124/63 (117-142/63-75), HR: 64
(64-75), RR: 16 (___), O2 sat: 96% (92-98), O2 delivery: RA,
Wt: 264.33 lb/119.9 kg
GENERAL: Obese elderly woman, NAD
HEENT: anicteric sclera
NECK: supple, JVP not appreciated
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no increased work of breathing
GI: abdomen obese, soft, nontender
EXTREMITIES: No ___ edema
PULSES: palpable distal pulses
BACK: Buffalo hump present
NEURO: alert, moves all four extremities with purpose
DERM: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
===============
___ 03:00PM BLOOD WBC-9.6 RBC-4.07 Hgb-10.7* Hct-35.6
MCV-88 MCH-26.3 MCHC-30.1* RDW-16.4* RDWSD-52.0* Plt ___
___ 03:00PM BLOOD Neuts-77.9* Lymphs-12.4* Monos-7.1
Eos-1.6 Baso-0.4 Im ___ AbsNeut-7.47* AbsLymp-1.19*
AbsMono-0.68 AbsEos-0.15 AbsBaso-0.04
___ 03:00PM BLOOD ___ PTT-28.2 ___
___ 03:00PM BLOOD Glucose-97 UreaN-18 Creat-0.9 Na-147
K-4.6 Cl-110* HCO3-29 AnGap-8*
___ 03:00PM BLOOD ALT-13 AST-20 AlkPhos-97 TotBili-0.2
___ 03:00PM BLOOD cTropnT-<0.01 proBNP-221
___ 03:00PM BLOOD Albumin-3.5 Calcium-9.1 Phos-3.4 Mg-2.0
Cholest-188
___ 03:00PM BLOOD VitB12-713
___ 03:00PM BLOOD Triglyc-114 HDL-71 CHOL/HD-2.6 LDLcalc-94
___ 03:00PM BLOOD TSH-0.84
MICROBIOLOGY:
=============
___ 3:00 pm SEROLOGY/BLOOD
**FINAL REPORT ___
RAPID PLASMA REAGIN TEST (Final ___:
NONREACTIVE.
Reference Range: Non-Reactive.
INTERVAL LABS:
==============
___ C1 ESTERASE INHIBITOR PROTEIN, Result 34, Ref ___
mg/dL
___ COMPLEMENT, TOTAL (CH50), Result >60 H, Ref ___ U/mL
___ 06:18AM BLOOD cTropnT-<0.01
___ 01:18AM BLOOD %HbA1c-5.3 eAG-105
___ 03:10PM BLOOD C3-134 C4-28
IMAGING AND REPORTS:
====================
CHEST (PA & LAT) ___
Pulmonary vascular congestion without overt edema or focal
consolidation.
Transthoracic Echo Report ___
The left atrial volume index is mildly increased. The right
atrium is moderately enlarged. There is no evidence for an
atrial septal defect by 2D/color Doppler
. The estimated right atrial pressure is ___ mmHg. There is mild
symmetric left ventricular hypertrophy with a normal cavity
size. There is normal regional and global left ventricular
systolic function. Quantitative biplane left ventricular
ejection fraction is 56 %.
There is no resting left ventricular outflow tract gradient. No
ventricular septal defect is seen. Diastolic parameters are
indeterminate. Normal right ventricular cavity size with mild
global free wall hypokinesis. The aortic sinus diameter is
normal for gender with normal ascending aorta diameter for
gender
. The aortic arch diameter is normal. There is no evidence for
an aortic arch coarctation. The aortic valve leaflets (3) are
mildly thickened. There is no aortic valve stenosis. There is
no aortic regurgitation. The mitral valve leaflets are mildly
thickened with no mitral valve prolapse.
There is trivial mitral regurgitation. The tricuspid valve
leaflets appear structurally normal. There is physiologic
tricuspid regurgitation. The estimated pulmonary artery systolic
pressure is borderline elevated. There is a trivial pericardial
effusion.
IMPRESSION: Biatrial enlargement. Mild symmetric left
ventricular hypertrophy
. Preserved biventricular systolic function. Borderline
pulmonary hypertension.
Compared with the prior TTE ___, the findings are similar
.
DISCHARGE LABS:
===============
___ 08:14AM BLOOD WBC-7.6 RBC-4.39 Hgb-11.6 Hct-38.5 MCV-88
MCH-26.4 MCHC-30.1* RDW-16.5* RDWSD-52.8* Plt ___
___ 08:14AM BLOOD Glucose-98 UreaN-34* Creat-1.0 Na-143
K-4.3 Cl-100 HCO3-32 AnGap-11
___ 08:14AM BLOOD Calcium-9.7 Phos-4.1 Mg-2.2
Brief Hospital Course:
Ms. ___ is a ___ year old F w/ history of hypertension,
obesity, osteoarthritis, hypothyroidism, and sarcoidosis
who presented for evaluation of a 20 lb weight gain in 1 week,
DOE,
and lower extremity edema which improved after diuresis.
ACUTE PROBLEMS:
===============
# HFpEF
# Volume overload
Patient with 20 lb weight gain in one week, new ___ edema, DOE,
orthopnea, and bendopnea. TTE w/ LVEF 56% and biatrial
enlargement. Diastolic parameters were indeterminate, but
clinical suspicion is for diastolic failure likely ___ obesity.
Diastolic CHF likely given her symptoms. Renal disease or DI
unlikely with unremarkable studies. Unlikely hypothyroidism
given normal TSH, or liver disease given normal LFTs and no
stigmata on exam. Euvolemic and back to baseline weight s/p
Lasix diuresis. Transitioned to Lasix 20 mg PO.
Admission Weight: 133.6 kg, 294.53 lb.
Discharge Weight: 119.9 kg, 264.33 lb
# Chest pain
Patient endorsed exertional chest pain. Unclear if this is
similar to pain she has had in the past when she had stress
tests. ECG unchanged and trops negative x1. ___ be stable angina
vs. severe DOE vs. pulmonary HTN vs. MSK. No evidence of
myocarditis or active ischemia. CP resolved. Should consider
pMIBI.
# Acute normocytic anemia
___ be secondary to dilution from acute volume overload. No
history of bleeding. Hgb increased with diuresis.
CHRONIC PROBLEMS:
=================
# Hypothyroidism
Continued levothyroxine.
# Hx of spinal hardware infection
Continued home suppressive minocycline.
# Memory loss
Seeing Cognitive Neurology for poor short term memory. B12 and
TSH normal. RPR negative. Continued topiramate.
# GERD
Continued omeprazole.
# Restless legs
Continued Pramipexole.
# Insomnia
Continued trazodone, venlafaxine.
# Dry Eyes
Held home restasis; substituted for artificial tears.
# Urinary urgency
Held home mirabegron and trospium given non-formulary
TRANSITIONAL ISSUES:
====================
[] Consider pMIBI to further evaluate etiology of her chest
pain.
[] Started on Lasix 20 mg PO on discharge. Titrate as needed and
please ensure the patient monitors her weight.
[] Consider initiation of a statin.
[] Please weigh yourself every day in the morning. Call your
doctor at if your weight goes up by more than 3 lbs. PCP: Dr.
___ ___.
[] Discharge Weight: 119.9 kg, 264.33 lb
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcium Carbonate 1000 mg PO BID
2. L-Lysine (lysine) 500 mg oral BID
3. Multivitamins 1 TAB PO DAILY
4. Restasis 0.05 % ophthalmic (eye) BID
5. Minocycline 100 mg PO Q12H
6. Omeprazole 20 mg PO BID
7. Pramipexole 0.25 mg PO TID
8. Topiramate (Topamax) 50 mg PO BID
9. TraZODone 100 mg PO QHS
10. trospium 60 mg oral DAILY
11. Venlafaxine 200 mg PO QHS
12. mirabegron 25 mg oral DAILY
13. Levothyroxine Sodium 50 mcg PO DAILY
Discharge Medications:
1. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*90
Tablet Refills:*2
2. Calcium Carbonate 1000 mg PO BID
3. L-Lysine (lysine) 500 mg oral BID
4. Levothyroxine Sodium 50 mcg PO DAILY
5. Minocycline 100 mg PO Q12H
6. mirabegron 25 mg oral DAILY
7. Multivitamins 1 TAB PO DAILY
8. Omeprazole 20 mg PO BID
9. Pramipexole 0.25 mg PO TID
10. Restasis 0.05 % ophthalmic (eye) BID
11. Topiramate (Topamax) 50 mg PO BID
12. TraZODone 100 mg PO QHS
13. trospium 60 mg oral DAILY
14. Venlafaxine 200 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Heart failure with preserved ejection fraction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital for rapid weight gain and
leg swelling.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- You were given medication to remove fluid from your body. You
should continue to take this medication after you leave the
hospital.
- You got imaging of your heart. The study showed normal pumping
function but part of the results were indeterminate. You should
follow-up with your PCP and cardiologist to review these
results.
WHAT SHOULD I DO WHEN I GO HOME?
- You should continue to take your medications as prescribed.
- You should attend the appointments listed below.
- Please weigh yourself every day in the morning. Call your
doctor at ___ if your weight goes up by more than 3
lbs.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
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"I5031",
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"E039",
"R413",
"K219",
"G2581",
"G4700",
"H04129",
"R3915"
] |
Allergies: Aspirin / Adhesive Tape / Percocet / Erythromycin Base / Bee Sting Kit / adhesive bandage / Caffeine Chief Complaint: 20 lb weight gain, DOE Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] year old F w/ history of hypertension, obesity, osteoarthritis, hypothyroidism, and sarcoidosis presenting for evaluation of a 20 lb weight gain in 1 week, DOE, and lower extremity edema. She was seen by Cognitive Neurology today who sent her in for evaluation. She reports that she woke up approximately 3 days before admission with new lower extremity swelling, DOE, bendopnea, and orthopnea. She also endorses chest pain while walking that stops with slowing down. On [MASKED], she was 265 pounds and today her weight is 293. She denies any chest pain. She also has had three weeks of rhinorrhea, sore throat, and a productive cough. In the ED, initial vital signs were T 99 HR 87 BP 135/106 RR 22 SPO2 96% RA. Her exam was notable for volume overload with bilateral crackles and lower extremity edema. proBNP was only 221. TSH was normal. Hgb was newly decreased to 10.7. Urine alb/Cr ratio was high at 109 and she had a low total protein of 5.8. ECG was unchanged from prior with sinus rhythm and borderline LVH. Bedside cardiac ultrasound reportedly performed, but not documented anywhere. CXR in the ED showed pulmonary vascular congestion, so she was given 40 mg IV Lasix. Upon arrival to the floor, the patient reports the above story. She is currently chest pain free, although notes dyspnea with walking to the bathroom. Her legs feel lighter than before since she received IV Lasix. This reminds her exactly of when she had strep-induced nephritis at [MASKED] years old. REVIEW OF SYSTEMS: ================== Cardiac review of systems is notable for absence of paroxysmal nocturnal dyspnea, palpitations, syncope, or presyncope. On further review of systems, denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, hemoptysis, black stools or red stools. Denies exertional buttock or calf pain. Denies recent fevers, chills or rigors. All of the other review of systems were negative. Past Medical History: 1. CARDIAC RISK FACTORS - Hypertension - Obesity 2. CARDIAC HISTORY - CABG: None - PERCUTANEOUS CORONARY INTERVENTIONS: None - PACING/ICD: None - Mitral valve prolapse 3. OTHER PAST MEDICAL HISTORY - Hypothyroidism, s/p partial thyroidectomy for multinodular goiter - Sarcoidosis - Acute nephritis diagnosed at age [MASKED] - Urinary incontinence - Spinal stenosis, lumbar region with neurogenic claudication, s/p 3. Laminectomy lumbar L2-5, fusion I3-I5, instrumentation, bone graft, [MASKED] S.viridans PJI of right knee ([MASKED]) - Chronic bilateral knee pain s/p bilateral total knee replacement, [MASKED] - Cerebral aneurysm s/p clips - Pulmonary nodule - Irritable bowel syndrome - Hx of CCY, APPY, TAH/RSO - S/p remote CTS release Social History: [MASKED] Family History: Mother - breast cancer Brother - type [MASKED] DM, CAD s/p CABG Father - CAD s/p CABG, iCM Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: 98.7 PO 154 / 84 74 20 92 ra GENERAL: Obese elderly woman sitting up in bed in no acute distress HEENT: PERRL, EOMI, anicteric sclera, MMM, no oropharyngeal erythema or exudates, no rhinorrhea NECK: supple, no LAD, JVP @ 12 cm CV: RRR, S1/S2, no murmurs, gallops, or rubs PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles GI: abdomen obese, soft, multiple surgical scar, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis or clubbing. 1+ pitting [MASKED] to knees. Bruising on knees PULSES: 1+ radial pulses bilaterally BACK: Buffalo hump present NEURO: Alert although sometimes forgetful when asked questions, CN intact, strength [MASKED] x4 extremities, sensation to LT intact DERM: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAM: ======================== VS: 24 HR Data (last updated [MASKED] @ 722) Temp: 97.7 (Tm 98.3), BP: 124/63 (117-142/63-75), HR: 64 (64-75), RR: 16 ([MASKED]), O2 sat: 96% (92-98), O2 delivery: RA, Wt: 264.33 lb/119.9 kg GENERAL: Obese elderly woman, NAD HEENT: anicteric sclera NECK: supple, JVP not appreciated CV: RRR, S1/S2, no murmurs, gallops, or rubs PULM: CTAB, no increased work of breathing GI: abdomen obese, soft, nontender EXTREMITIES: No [MASKED] edema PULSES: palpable distal pulses BACK: Buffalo hump present NEURO: alert, moves all four extremities with purpose DERM: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ADMISSION LABS: =============== [MASKED] 03:00PM BLOOD WBC-9.6 RBC-4.07 Hgb-10.7* Hct-35.6 MCV-88 MCH-26.3 MCHC-30.1* RDW-16.4* RDWSD-52.0* Plt [MASKED] [MASKED] 03:00PM BLOOD Neuts-77.9* Lymphs-12.4* Monos-7.1 Eos-1.6 Baso-0.4 Im [MASKED] AbsNeut-7.47* AbsLymp-1.19* AbsMono-0.68 AbsEos-0.15 AbsBaso-0.04 [MASKED] 03:00PM BLOOD [MASKED] PTT-28.2 [MASKED] [MASKED] 03:00PM BLOOD Glucose-97 UreaN-18 Creat-0.9 Na-147 K-4.6 Cl-110* HCO3-29 AnGap-8* [MASKED] 03:00PM BLOOD ALT-13 AST-20 AlkPhos-97 TotBili-0.2 [MASKED] 03:00PM BLOOD cTropnT-<0.01 proBNP-221 [MASKED] 03:00PM BLOOD Albumin-3.5 Calcium-9.1 Phos-3.4 Mg-2.0 Cholest-188 [MASKED] 03:00PM BLOOD VitB12-713 [MASKED] 03:00PM BLOOD Triglyc-114 HDL-71 CHOL/HD-2.6 LDLcalc-94 [MASKED] 03:00PM BLOOD TSH-0.84 MICROBIOLOGY: ============= [MASKED] 3:00 pm SEROLOGY/BLOOD **FINAL REPORT [MASKED] RAPID PLASMA REAGIN TEST (Final [MASKED]: NONREACTIVE. Reference Range: Non-Reactive. INTERVAL LABS: ============== [MASKED] C1 ESTERASE INHIBITOR PROTEIN, Result 34, Ref [MASKED] mg/dL [MASKED] COMPLEMENT, TOTAL (CH50), Result >60 H, Ref [MASKED] U/mL [MASKED] 06:18AM BLOOD cTropnT-<0.01 [MASKED] 01:18AM BLOOD %HbA1c-5.3 eAG-105 [MASKED] 03:10PM BLOOD C3-134 C4-28 IMAGING AND REPORTS: ==================== CHEST (PA & LAT) [MASKED] Pulmonary vascular congestion without overt edema or focal consolidation. Transthoracic Echo Report [MASKED] The left atrial volume index is mildly increased. The right atrium is moderately enlarged. There is no evidence for an atrial septal defect by 2D/color Doppler . The estimated right atrial pressure is [MASKED] mmHg. There is mild symmetric left ventricular hypertrophy with a normal cavity size. There is normal regional and global left ventricular systolic function. Quantitative biplane left ventricular ejection fraction is 56 %. There is no resting left ventricular outflow tract gradient. No ventricular septal defect is seen. Diastolic parameters are indeterminate. Normal right ventricular cavity size with mild global free wall hypokinesis. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender . The aortic arch diameter is normal. There is no evidence for an aortic arch coarctation. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral valve leaflets are mildly thickened with no mitral valve prolapse. There is trivial mitral regurgitation. The tricuspid valve leaflets appear structurally normal. There is physiologic tricuspid regurgitation. The estimated pulmonary artery systolic pressure is borderline elevated. There is a trivial pericardial effusion. IMPRESSION: Biatrial enlargement. Mild symmetric left ventricular hypertrophy . Preserved biventricular systolic function. Borderline pulmonary hypertension. Compared with the prior TTE [MASKED], the findings are similar . DISCHARGE LABS: =============== [MASKED] 08:14AM BLOOD WBC-7.6 RBC-4.39 Hgb-11.6 Hct-38.5 MCV-88 MCH-26.4 MCHC-30.1* RDW-16.5* RDWSD-52.8* Plt [MASKED] [MASKED] 08:14AM BLOOD Glucose-98 UreaN-34* Creat-1.0 Na-143 K-4.3 Cl-100 HCO3-32 AnGap-11 [MASKED] 08:14AM BLOOD Calcium-9.7 Phos-4.1 Mg-2.2 Brief Hospital Course: Ms. [MASKED] is a [MASKED] year old F w/ history of hypertension, obesity, osteoarthritis, hypothyroidism, and sarcoidosis who presented for evaluation of a 20 lb weight gain in 1 week, DOE, and lower extremity edema which improved after diuresis. ACUTE PROBLEMS: =============== # HFpEF # Volume overload Patient with 20 lb weight gain in one week, new [MASKED] edema, DOE, orthopnea, and bendopnea. TTE w/ LVEF 56% and biatrial enlargement. Diastolic parameters were indeterminate, but clinical suspicion is for diastolic failure likely [MASKED] obesity. Diastolic CHF likely given her symptoms. Renal disease or DI unlikely with unremarkable studies. Unlikely hypothyroidism given normal TSH, or liver disease given normal LFTs and no stigmata on exam. Euvolemic and back to baseline weight s/p Lasix diuresis. Transitioned to Lasix 20 mg PO. Admission Weight: 133.6 kg, 294.53 lb. Discharge Weight: 119.9 kg, 264.33 lb # Chest pain Patient endorsed exertional chest pain. Unclear if this is similar to pain she has had in the past when she had stress tests. ECG unchanged and trops negative x1. [MASKED] be stable angina vs. severe DOE vs. pulmonary HTN vs. MSK. No evidence of myocarditis or active ischemia. CP resolved. Should consider pMIBI. # Acute normocytic anemia [MASKED] be secondary to dilution from acute volume overload. No history of bleeding. Hgb increased with diuresis. CHRONIC PROBLEMS: ================= # Hypothyroidism Continued levothyroxine. # Hx of spinal hardware infection Continued home suppressive minocycline. # Memory loss Seeing Cognitive Neurology for poor short term memory. B12 and TSH normal. RPR negative. Continued topiramate. # GERD Continued omeprazole. # Restless legs Continued Pramipexole. # Insomnia Continued trazodone, venlafaxine. # Dry Eyes Held home restasis; substituted for artificial tears. # Urinary urgency Held home mirabegron and trospium given non-formulary TRANSITIONAL ISSUES: ==================== [] Consider pMIBI to further evaluate etiology of her chest pain. [] Started on Lasix 20 mg PO on discharge. Titrate as needed and please ensure the patient monitors her weight. [] Consider initiation of a statin. [] Please weigh yourself every day in the morning. Call your doctor at if your weight goes up by more than 3 lbs. PCP: Dr. [MASKED] [MASKED]. [] Discharge Weight: 119.9 kg, 264.33 lb Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Calcium Carbonate 1000 mg PO BID 2. L-Lysine (lysine) 500 mg oral BID 3. Multivitamins 1 TAB PO DAILY 4. Restasis 0.05 % ophthalmic (eye) BID 5. Minocycline 100 mg PO Q12H 6. Omeprazole 20 mg PO BID 7. Pramipexole 0.25 mg PO TID 8. Topiramate (Topamax) 50 mg PO BID 9. TraZODone 100 mg PO QHS 10. trospium 60 mg oral DAILY 11. Venlafaxine 200 mg PO QHS 12. mirabegron 25 mg oral DAILY 13. Levothyroxine Sodium 50 mcg PO DAILY Discharge Medications: 1. Furosemide 20 mg PO DAILY RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*90 Tablet Refills:*2 2. Calcium Carbonate 1000 mg PO BID 3. L-Lysine (lysine) 500 mg oral BID 4. Levothyroxine Sodium 50 mcg PO DAILY 5. Minocycline 100 mg PO Q12H 6. mirabegron 25 mg oral DAILY 7. Multivitamins 1 TAB PO DAILY 8. Omeprazole 20 mg PO BID 9. Pramipexole 0.25 mg PO TID 10. Restasis 0.05 % ophthalmic (eye) BID 11. Topiramate (Topamax) 50 mg PO BID 12. TraZODone 100 mg PO QHS 13. trospium 60 mg oral DAILY 14. Venlafaxine 200 mg PO QHS Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Heart failure with preserved ejection fraction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [MASKED], It was a pleasure taking care of you at [MASKED] [MASKED]. WHY WAS I ADMITTED TO THE HOSPITAL? - You were admitted to the hospital for rapid weight gain and leg swelling. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? - You were given medication to remove fluid from your body. You should continue to take this medication after you leave the hospital. - You got imaging of your heart. The study showed normal pumping function but part of the results were indeterminate. You should follow-up with your PCP and cardiologist to review these results. WHAT SHOULD I DO WHEN I GO HOME? - You should continue to take your medications as prescribed. - You should attend the appointments listed below. - Please weigh yourself every day in the morning. Call your doctor at [MASKED] if your weight goes up by more than 3 lbs. We wish you the best! Your [MASKED] Care Team Followup Instructions: [MASKED]
|
[] |
[
"D649",
"E669",
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"K219",
"G4700"
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[
"I5031: Acute diastolic (congestive) heart failure",
"Z6843: Body mass index [BMI] 50.0-59.9, adult",
"R079: Chest pain, unspecified",
"D649: Anemia, unspecified",
"E669: Obesity, unspecified",
"E039: Hypothyroidism, unspecified",
"R413: Other amnesia",
"K219: Gastro-esophageal reflux disease without esophagitis",
"G2581: Restless legs syndrome",
"G4700: Insomnia, unspecified",
"H04129: Dry eye syndrome of unspecified lacrimal gland",
"R3915: Urgency of urination"
] |
10,005,866 | 20,364,112 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Neurontin
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___ Exploratory laparotomy
___ EGD
___ EGD nasojejeunal placed and bridled (removed ___ CT-guided placement of an ___ pigtail catheter into
the lesser sac collection. (removed ___
PICC placement.
History of Present Illness:
___ man with multiple recent admissions for waxing
and waning abdominal pain, history of EtOH/hep C cirrhosis, now
presents with 24 hours of acutely worsening epigastric pain
associated with multiple episodes of emesis and dark stools.
Patient states that his abdominal pain was at its baseline
yesterday at which point he noticed an acute worsening of his
pain that he describes as sharp and in his upper abdomen. He
also had several episodes of emesis, reporting his vomit as
being
dark brown in character. Decided to re-present to ED for
reevaluation of abdominal pain given acute worsening status.
Most recently presented to the ED over the weekend where he got
a
CT abdomen pelvis that did not show any acute interval changes
compared to prior scans. Was discharged home with expectant
management, transplant surgery was not consulted at that time.
Now, underwent repeat CT scan showing free air and fluid in the
lesser sac concerning for gastric perforation. Transplant
surgery is consulted for surgical management of this disease.
ROS:
(+) per 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:
=========================
Vitals: T 97.8 HR 96 BP 145/79 RR 20 100 RA
GEN: A&O, uncomfortable appearing
HEENT: No scleral icterus, mucus membranes moist
CV: RRR
PULM: No respiratory distress
ABD: Firm, tender to percussion in the epigastric region,
guarding present, moderately distended, no fluid wave
DRE: Deferred
Neuro: CSM grossly intact x 4
Ext: No ___ edema, UE and ___ warm and well perfused bilat
Discharge Physical Exam:
=========================
VS:97.5 95/56 65 18 99 Ra
GENERAL: cachectic appearing older male, sitting up in bed, more
conversant and interactive today.
HEENT: anicteric sclera, temporal muscle wasting
Neck: supple
HEART: irregular rhythm, no m/r/g
LUNGS: CTAB on anterior exam
ABDOMEN: protuberant but soft, +BS, tenderness to palpation
in right upper quadrant, midline surgical incision with staples
removed, well healed, dressing over RLQ with drain place
draining
dark brown serosanguineous fluid
EXTREMITIES: no lower extremity edema, no clubbing or cyanosis
SKIN: no jaundice, warm and dry
NEURO: alert, oriented, no asterixis, moving all extremities
Pertinent Results:
Admission Labs: ___ 02:35AM
================
WBC-15.9*# RBC-3.39* Hgb-11.7* Hct-35.5* MCV-105* MCH-34.5*
MCHC-33.0 RDW-14.7 RDWSD-56.3* Plt ___ PTT-29.5 ___
Glucose-122* UreaN-15 Creat-0.5 Na-134* K-4.3 Cl-97 HCO3-22
AnGap-15
ALT-24 AST-63* AlkPhos-92 TotBili-2.5*
Lipase-24
Calcium-6.8* Phos-3.7 Mg-1.7
Triglyc-36
Microbiology
============
Blood Culture, Routine (Final ___: NO GROWTH.
HELICOBACTER PYLORI ANTIBODY TEST (Final ___: NEGATIVE BY
EIA.(Reference Range-Negative).
___ 7:44 pm PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
Imaging:
=========
CT Abdomen Pelvis ___
IMPRESSION:
1. Free air and increased fluid within the lesser sac concerning
for
perforated viscus, which could be from the stomach based on
location.
2. Mildly dilated small bowel bowel a transition point. This
could represent ileus versus partial small bowel obstruction.
No initial in of the bowel or pneumatosis.
3. Cirrhotic liver with findings of portal hypertension
including varices and ascites.
Upper GI Contrast Study: ___
IMPRESSION: Leak of contrast from the posterior antrum of the
stomach.
CXR: ___
COMPARISON: ___
IMPRESSION: Pulmonary edema has slightly worsened.
Cardiomediastinal silhouette is stable. Left-sided PICC line is
unchanged the NG tube projects below the left hemidiaphragm.
Small bilateral effusions left greater than right are
unchanged. No pneumothorax is seen
CT Abdomen Pelvis ___
IMPRESSION:
1. A 8.5 x 5.9 cm loculated fluid collection with rim
enhancement in the
lesser sac is identified. Compared to ___, the fluid
collection
demonstrates thicker and more discrete wall.
2. Small ascites and peritonitis is similar to before.
3. Liver cirrhosis with mild splenomegaly and portosystemic
shunt.
4. Small bilateral pleural effusions.
CT Abdomen for Interventional Procedure: ___
IMPRESSION: Successful CT-guided placement of an ___
pigtail catheter into the lesser sac collection. Samples were
sent for microbiology evaluation.
Abdominal Ultrasound ___:
IMPRESSION: No fluid pocket amenable to percutaneous sampling.
A diagnostic paracentesis was not performed.
Transfer Labs: ___ 06:32AM
===============
WBC-5.0 RBC-2.99* Hgb-9.7* Hct-31.0* MCV-104* MCH-32.4*
MCHC-31.3* RDW-17.1* RDWSD-64.6* Plt ___ PTT-28.8 ___
Glucose-108* UreaN-15 Creat-0.5 Na-137 K-4.5 Cl-106 HCO3-24
AnGap-7*
ALT-18 AST-58* AlkPhos-194* TotBili-1.2
Albumin-2.2* Calcium-7.3* Phos-2.6* Mg-1.8
Discharge Labs: ___ 05:55AM
===============
WBC-4.2 RBC-2.72* Hgb-9.0* Hct-28.7* MCV-106* MCH-33.1*
MCHC-31.4* RDW-16.6* RDWSD-65.1* Plt ___
Glucose-97 UreaN-14 Creat-0.5 Na-136 K-4.8 Cl-105 HCO3-21*
AnGap-10
ALT-19 AST-59* AlkPhos-198* TotBili-1.2
Albumin-2.1* Calcium-7.3* Phos-2.6* Mg-1.8
Brief Hospital Course:
Summary:
---------
Mr ___ is a ___ man with alcoholic and hepatitis C
cirrhosis who presented with abdominal pain, and was found to
have a perforated inoperable duodenal and stomach ulcer.
Active Issues:
--------------
# DUODENAL AND GASTRIC ULCERS with
# ___ GUIDED DRAINAGE OF LESSER SAC COLLECTION:
The patient presented to the ___ Emergency Department with
abdominal pain. There was evidence of perforated ulcer on both
CT abdomen and upper GI series (posterior antral leak to lesser
sac). Initially he was kept NPO with IV hydration and placed on
broad-spectrum antibiotics with pip-tazo and fluconazole from
___.
He underwent EGD on ___ with the following finding: large
ulcer measuring approximately 5-6cm was seen in the first part
of the duodenum. There was likely perforation around the edge
of the ulcer measuring 2-3cm -This appeared contained. The
perforation was too large for endoscopic intervention. There was
also moderate to severe esophagitis in the distal esophagus with
portal hypertensive gastropathy seen. H. pylori was negative. He
was put on the maximum dose of PPI. A NG was in place.
He underwent exploratory laparotomy by Dr. ___, but
was found to have a frozen abdomen thus unable to see perforated
stomach. Postop, he was transferred to the SICU for management
as he was hypotensive and hematocrit had decreased. He was given
albumin and 4 units of PRBC. Hct stabilized, but on ___, he
had brief episode of SVT with rate of 160 without blood pressure
drop; afib with intermittent RVR that was treated with
metoprolol IV x 2 with decrease in BP. The patient required
pressors and amiodarone was started (please see #Afib below).
He transferred out of the SICU and was started on TPN. Afib was
managed with metoprolol. Metoprolol dose was increased and he
was given intermittent doses of Lasix for volume control and
pulmonary edema seen on CXR.
His diet was initially advanced to clears then full liquids.
However, he did not tolerate advancement to a regular diet. He
experienced a lot of abdominal pain. Diet was changed to just
sips of clears and pain was managed with a Dilaudid PCA. His
diet was eventually changed to tube feeds and then regular diet
as per an initial goals of care discussion. An abdominal CT
___ an 8cm loculated fluid collection in lesser
sac. He then underwent ___ placement of a drain in the
fluid collection. Microbiology evaluation of the fluid
collection did not grow any organisms, so antibiotics were
discontinued on ___. ___ continued to follow the drain until
output was < 5cc for 2 consecutive days, at which point the
drain was pulled. Diet was advanced slowly for comfort, with
supplemental nutrition from nasogastric tube feeds. After a
goals of care meeting on ___, Pt endorsed a desire to
transition towards measures that would improve his comfort. In
light of this, his NGT was pulled ___ and he was permitted a
regular PO diet, which he tolerated well. Patient was continued
on sucralfate for continued gastric coating and comfort. PPI
and other unnecessary medicines were held.
# GOALS OF CARE DISCUSSION:
Pt with poor prognosis due to his perforated viscus, surgically
frozen abdomen, and non-transplant candidacy. A goals of care
meeting was held on ___ with the patient and his friend, as
well as newly-chosen HCP, ___. At this meeting, Pt
acknowledged the severity of his illness and endorsed a
willingness to transition his course more towards
comfort-focused care. Medicines that would not contribute to
his comfort were discontinued. Unnecessary tubes and lines,
including his NGT and PICC line, were removed prior to
discharge. Patient was discharged to a ___ facility for
housing and further titration of his care.
# ETOH/HCV CIRRHOSIS with
# ASCITES and
# NEED FOR SBP PPX:
Previously complicated by hepatic encephalopathy, ascites, grade
I esophageal varices. Pt without significant hepatic
encephalopathy or large ascites during his hospital stay; he was
initially put on oral diuretics to minimize the ascites and risk
of wound dehiscence, but these were held in the setting of
significant weight loss while on tube feeds and overall hypo- to
euvolemic appearance on exam. Patient was continued on Bactrim
for SBP prophylaxis. He was continued on lactulose to keep his
mental status clear. Given goals of care discussion as above,
vitamins such as thiamine and multivitamin were discontinued.
# ATRIAL FIBRILLATION:
Had one episode of Afib on ___, for which he was amiodarone
loaded and started on amio gtt. He was stable on PO metoprolol
in-house, though sometimes limited due to soft blood pressures.
He had a CHADS-VASC of 0. Given his goals of care discussion at
discharge, PO metoprolol was discontinued. Anticoagulation was
deferred given recent surgery as well as goals of care
discussion as above.
# NUTRITION:
Initially requiring TPN, then tube feeds by ___. He
continued to lose muscle mass despite optimal nutrition on TF's.
After goals of care discussion ___, patient was provided with
a regular diet - which he tolerated well.
TRANSITIONAL ISSUES:
--------------------
# CODE STATUS: DNR/DNI, CMO, Do not Hospitalize
# CONTACT: Friend/HCP, ___ (___)
[ ] GOALS OF CARE:
- Pt transitioned to DNR/DNI and comfort measures only, given
his poor prognosis and lack of surgical alternatives for his
medical conditions.
[ ] PAIN MANAGEMENT:
- If patient is requiring more than 3 daily doses of oxycodone
for breakthrough pain, consider uptitrating his TID oxyconTIN
for further long-lasting pain relief.
[ ] MEDICATION CHANGES:
- Added: Oxycodone 10mg PO q2h:PRN breakthrough pain,
acetaminophen 500mg Q6H, Bactrim DS 1 tab daily, lidocaine
patch, oxyconTIN 20mg PO TID, sucralfate 1gm PO QID,
polyethylene glycol 17g daily
- Changed: Lactulose (QID -> TID), Bactrim (1 SS tab -> 1 DS
tab for SBP Ppx)
- Stopped: Metoprolol, Vitamins, furosemide, lansoprazole
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Famotidine 20 mg PO BID
2. Furosemide 20 mg PO DAILY
3. Lactulose 30 mL PO QID
4. Spironolactone 50 mg PO DAILY
5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY SBP prophylaxis
6. Polyethylene Glycol 17 g PO DAILY
7. Bisacodyl ___AILY:PRN constipation
8. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral DAILY
9. Multivitamins 1 TAB PO DAILY
10. Potassium Chloride 20 mEq PO DAILY
11. Simethicone 40-80 mg PO TID:PRN gas pain
12. Thiamine 100 mg PO DAILY
13. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain -
Moderate
Discharge Medications:
1. Acetaminophen 500 mg NG Q6H
2. Lidocaine 5% Patch 1 PTCH TD QAM
apply to abdomen
remove in pm
3. OxyCODONE SR (OxyconTIN) 20 mg PO TID abdominal pain
RX *oxycodone 5 mg/5 mL 20 mL by mouth three times a day
Refills:*0
4. Simethicone 40-80 mg PO TID:PRN gas pain
5. Sucralfate 1 gm PO QID
6. Sulfameth/Trimethoprim DS 1 TAB PO/NG DAILY
7. OxyCODONE (Immediate Release) 10 mg PO Q2H:PRN BREAKTHROUGH
PAIN
RX *oxycodone 5 mg/5 mL 10 mL by mouth every 2 hours Refills:*0
8. Bisacodyl ___AILY:PRN constipation
9. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral DAILY
10. Lactulose 30 mL PO TID
11. Multivitamins 1 TAB PO DAILY
12. Polyethylene Glycol 17 g PO DAILY
13. Thiamine 100 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Gastric perforation, frozen abdomen.
Duodenal ulcer
Esophagitis
SECONDARY DIAGNOSES:
portal hypertensive gastropathy
anemia
malnutrition
Cirrhosis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were having pain in your abdomen.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- You were found to have a hole in your intestine (perforated
ulcer), that could not be repaired due to scarred down tissue in
your abdomen (frozen abdomen)
- You were given antibiotics to prevent infection
- You had a temporary drain placed in your abdomen to drain an
infection, and this was removed.
- You initially were given a feeding tube to bypass the hole,
but as it healed from the inside, you were able to eat regular
food.
- Because you were so sick and there was no cure for your
advance liver disease and holes in your stomach and intestines,
you chose hospice care.
WHAT SHOULD I DO WHEN I GO HOME
-Take medications to help your pain
-Eat for comfort
Thank you for letting us be a part of your care!
Your ___ Team
Followup Instructions:
___
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Allergies: Neurontin Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: [MASKED] Exploratory laparotomy [MASKED] EGD [MASKED] EGD nasojejeunal placed and bridled (removed [MASKED] CT-guided placement of an [MASKED] pigtail catheter into the lesser sac collection. (removed [MASKED] PICC placement. History of Present Illness: [MASKED] man with multiple recent admissions for waxing and waning abdominal pain, history of EtOH/hep C cirrhosis, now presents with 24 hours of acutely worsening epigastric pain associated with multiple episodes of emesis and dark stools. Patient states that his abdominal pain was at its baseline yesterday at which point he noticed an acute worsening of his pain that he describes as sharp and in his upper abdomen. He also had several episodes of emesis, reporting his vomit as being dark brown in character. Decided to re-present to ED for reevaluation of abdominal pain given acute worsening status. Most recently presented to the ED over the weekend where he got a CT abdomen pelvis that did not show any acute interval changes compared to prior scans. Was discharged home with expectant management, transplant surgery was not consulted at that time. Now, underwent repeat CT scan showing free air and fluid in the lesser sac concerning for gastric perforation. Transplant surgery is consulted for surgical management of this disease. ROS: (+) per 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 ([MASKED]) -SBO requiring Ex lap & repair of ruptured umbilical hernia with lysis of adhesions ([MASKED]) - Abdominal Hematoma evacuation ([MASKED]) - Abdominal incision opened, wound vac placed ([MASKED]) Social History: [MASKED] Family History: Sister and brother both with "collapsed lungs." No family history of liver disease. Physical Exam: Admission Physical Exam: ========================= Vitals: T 97.8 HR 96 BP 145/79 RR 20 100 RA GEN: A&O, uncomfortable appearing HEENT: No scleral icterus, mucus membranes moist CV: RRR PULM: No respiratory distress ABD: Firm, tender to percussion in the epigastric region, guarding present, moderately distended, no fluid wave DRE: Deferred Neuro: CSM grossly intact x 4 Ext: No [MASKED] edema, UE and [MASKED] warm and well perfused bilat Discharge Physical Exam: ========================= VS:97.5 95/56 65 18 99 Ra GENERAL: cachectic appearing older male, sitting up in bed, more conversant and interactive today. HEENT: anicteric sclera, temporal muscle wasting Neck: supple HEART: irregular rhythm, no m/r/g LUNGS: CTAB on anterior exam ABDOMEN: protuberant but soft, +BS, tenderness to palpation in right upper quadrant, midline surgical incision with staples removed, well healed, dressing over RLQ with drain place draining dark brown serosanguineous fluid EXTREMITIES: no lower extremity edema, no clubbing or cyanosis SKIN: no jaundice, warm and dry NEURO: alert, oriented, no asterixis, moving all extremities Pertinent Results: Admission Labs: [MASKED] 02:35AM ================ WBC-15.9*# RBC-3.39* Hgb-11.7* Hct-35.5* MCV-105* MCH-34.5* MCHC-33.0 RDW-14.7 RDWSD-56.3* Plt [MASKED] PTT-29.5 [MASKED] Glucose-122* UreaN-15 Creat-0.5 Na-134* K-4.3 Cl-97 HCO3-22 AnGap-15 ALT-24 AST-63* AlkPhos-92 TotBili-2.5* Lipase-24 Calcium-6.8* Phos-3.7 Mg-1.7 Triglyc-36 Microbiology ============ Blood Culture, Routine (Final [MASKED]: NO GROWTH. HELICOBACTER PYLORI ANTIBODY TEST (Final [MASKED]: NEGATIVE BY EIA.(Reference Range-Negative). [MASKED] 7:44 pm PERITONEAL FLUID PERITONEAL FLUID. GRAM STAIN (Final [MASKED]: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [MASKED]: NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. Imaging: ========= CT Abdomen Pelvis [MASKED] IMPRESSION: 1. Free air and increased fluid within the lesser sac concerning for perforated viscus, which could be from the stomach based on location. 2. Mildly dilated small bowel bowel a transition point. This could represent ileus versus partial small bowel obstruction. No initial in of the bowel or pneumatosis. 3. Cirrhotic liver with findings of portal hypertension including varices and ascites. Upper GI Contrast Study: [MASKED] IMPRESSION: Leak of contrast from the posterior antrum of the stomach. CXR: [MASKED] COMPARISON: [MASKED] IMPRESSION: Pulmonary edema has slightly worsened. Cardiomediastinal silhouette is stable. Left-sided PICC line is unchanged the NG tube projects below the left hemidiaphragm. Small bilateral effusions left greater than right are unchanged. No pneumothorax is seen CT Abdomen Pelvis [MASKED] IMPRESSION: 1. A 8.5 x 5.9 cm loculated fluid collection with rim enhancement in the lesser sac is identified. Compared to [MASKED], the fluid collection demonstrates thicker and more discrete wall. 2. Small ascites and peritonitis is similar to before. 3. Liver cirrhosis with mild splenomegaly and portosystemic shunt. 4. Small bilateral pleural effusions. CT Abdomen for Interventional Procedure: [MASKED] IMPRESSION: Successful CT-guided placement of an [MASKED] pigtail catheter into the lesser sac collection. Samples were sent for microbiology evaluation. Abdominal Ultrasound [MASKED]: IMPRESSION: No fluid pocket amenable to percutaneous sampling. A diagnostic paracentesis was not performed. Transfer Labs: [MASKED] 06:32AM =============== WBC-5.0 RBC-2.99* Hgb-9.7* Hct-31.0* MCV-104* MCH-32.4* MCHC-31.3* RDW-17.1* RDWSD-64.6* Plt [MASKED] PTT-28.8 [MASKED] Glucose-108* UreaN-15 Creat-0.5 Na-137 K-4.5 Cl-106 HCO3-24 AnGap-7* ALT-18 AST-58* AlkPhos-194* TotBili-1.2 Albumin-2.2* Calcium-7.3* Phos-2.6* Mg-1.8 Discharge Labs: [MASKED] 05:55AM =============== WBC-4.2 RBC-2.72* Hgb-9.0* Hct-28.7* MCV-106* MCH-33.1* MCHC-31.4* RDW-16.6* RDWSD-65.1* Plt [MASKED] Glucose-97 UreaN-14 Creat-0.5 Na-136 K-4.8 Cl-105 HCO3-21* AnGap-10 ALT-19 AST-59* AlkPhos-198* TotBili-1.2 Albumin-2.1* Calcium-7.3* Phos-2.6* Mg-1.8 Brief Hospital Course: Summary: --------- Mr [MASKED] is a [MASKED] man with alcoholic and hepatitis C cirrhosis who presented with abdominal pain, and was found to have a perforated inoperable duodenal and stomach ulcer. Active Issues: -------------- # DUODENAL AND GASTRIC ULCERS with # [MASKED] GUIDED DRAINAGE OF LESSER SAC COLLECTION: The patient presented to the [MASKED] Emergency Department with abdominal pain. There was evidence of perforated ulcer on both CT abdomen and upper GI series (posterior antral leak to lesser sac). Initially he was kept NPO with IV hydration and placed on broad-spectrum antibiotics with pip-tazo and fluconazole from [MASKED]. He underwent EGD on [MASKED] with the following finding: large ulcer measuring approximately 5-6cm was seen in the first part of the duodenum. There was likely perforation around the edge of the ulcer measuring 2-3cm -This appeared contained. The perforation was too large for endoscopic intervention. There was also moderate to severe esophagitis in the distal esophagus with portal hypertensive gastropathy seen. H. pylori was negative. He was put on the maximum dose of PPI. A NG was in place. He underwent exploratory laparotomy by Dr. [MASKED], but was found to have a frozen abdomen thus unable to see perforated stomach. Postop, he was transferred to the SICU for management as he was hypotensive and hematocrit had decreased. He was given albumin and 4 units of PRBC. Hct stabilized, but on [MASKED], he had brief episode of SVT with rate of 160 without blood pressure drop; afib with intermittent RVR that was treated with metoprolol IV x 2 with decrease in BP. The patient required pressors and amiodarone was started (please see #Afib below). He transferred out of the SICU and was started on TPN. Afib was managed with metoprolol. Metoprolol dose was increased and he was given intermittent doses of Lasix for volume control and pulmonary edema seen on CXR. His diet was initially advanced to clears then full liquids. However, he did not tolerate advancement to a regular diet. He experienced a lot of abdominal pain. Diet was changed to just sips of clears and pain was managed with a Dilaudid PCA. His diet was eventually changed to tube feeds and then regular diet as per an initial goals of care discussion. An abdominal CT [MASKED] an 8cm loculated fluid collection in lesser sac. He then underwent [MASKED] placement of a drain in the fluid collection. Microbiology evaluation of the fluid collection did not grow any organisms, so antibiotics were discontinued on [MASKED]. [MASKED] continued to follow the drain until output was < 5cc for 2 consecutive days, at which point the drain was pulled. Diet was advanced slowly for comfort, with supplemental nutrition from nasogastric tube feeds. After a goals of care meeting on [MASKED], Pt endorsed a desire to transition towards measures that would improve his comfort. In light of this, his NGT was pulled [MASKED] and he was permitted a regular PO diet, which he tolerated well. Patient was continued on sucralfate for continued gastric coating and comfort. PPI and other unnecessary medicines were held. # GOALS OF CARE DISCUSSION: Pt with poor prognosis due to his perforated viscus, surgically frozen abdomen, and non-transplant candidacy. A goals of care meeting was held on [MASKED] with the patient and his friend, as well as newly-chosen HCP, [MASKED]. At this meeting, Pt acknowledged the severity of his illness and endorsed a willingness to transition his course more towards comfort-focused care. Medicines that would not contribute to his comfort were discontinued. Unnecessary tubes and lines, including his NGT and PICC line, were removed prior to discharge. Patient was discharged to a [MASKED] facility for housing and further titration of his care. # ETOH/HCV CIRRHOSIS with # ASCITES and # NEED FOR SBP PPX: Previously complicated by hepatic encephalopathy, ascites, grade I esophageal varices. Pt without significant hepatic encephalopathy or large ascites during his hospital stay; he was initially put on oral diuretics to minimize the ascites and risk of wound dehiscence, but these were held in the setting of significant weight loss while on tube feeds and overall hypo- to euvolemic appearance on exam. Patient was continued on Bactrim for SBP prophylaxis. He was continued on lactulose to keep his mental status clear. Given goals of care discussion as above, vitamins such as thiamine and multivitamin were discontinued. # ATRIAL FIBRILLATION: Had one episode of Afib on [MASKED], for which he was amiodarone loaded and started on amio gtt. He was stable on PO metoprolol in-house, though sometimes limited due to soft blood pressures. He had a CHADS-VASC of 0. Given his goals of care discussion at discharge, PO metoprolol was discontinued. Anticoagulation was deferred given recent surgery as well as goals of care discussion as above. # NUTRITION: Initially requiring TPN, then tube feeds by [MASKED]. He continued to lose muscle mass despite optimal nutrition on TF's. After goals of care discussion [MASKED], patient was provided with a regular diet - which he tolerated well. TRANSITIONAL ISSUES: -------------------- # CODE STATUS: DNR/DNI, CMO, Do not Hospitalize # CONTACT: Friend/HCP, [MASKED] ([MASKED]) [ ] GOALS OF CARE: - Pt transitioned to DNR/DNI and comfort measures only, given his poor prognosis and lack of surgical alternatives for his medical conditions. [ ] PAIN MANAGEMENT: - If patient is requiring more than 3 daily doses of oxycodone for breakthrough pain, consider uptitrating his TID oxyconTIN for further long-lasting pain relief. [ ] MEDICATION CHANGES: - Added: Oxycodone 10mg PO q2h:PRN breakthrough pain, acetaminophen 500mg Q6H, Bactrim DS 1 tab daily, lidocaine patch, oxyconTIN 20mg PO TID, sucralfate 1gm PO QID, polyethylene glycol 17g daily - Changed: Lactulose (QID -> TID), Bactrim (1 SS tab -> 1 DS tab for SBP Ppx) - Stopped: Metoprolol, Vitamins, furosemide, lansoprazole Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Famotidine 20 mg PO BID 2. Furosemide 20 mg PO DAILY 3. Lactulose 30 mL PO QID 4. Spironolactone 50 mg PO DAILY 5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY SBP prophylaxis 6. Polyethylene Glycol 17 g PO DAILY 7. Bisacodyl AILY:PRN constipation 8. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral DAILY 9. Multivitamins 1 TAB PO DAILY 10. Potassium Chloride 20 mEq PO DAILY 11. Simethicone 40-80 mg PO TID:PRN gas pain 12. Thiamine 100 mg PO DAILY 13. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Moderate Discharge Medications: 1. Acetaminophen 500 mg NG Q6H 2. Lidocaine 5% Patch 1 PTCH TD QAM apply to abdomen remove in pm 3. OxyCODONE SR (OxyconTIN) 20 mg PO TID abdominal pain RX *oxycodone 5 mg/5 mL 20 mL by mouth three times a day Refills:*0 4. Simethicone 40-80 mg PO TID:PRN gas pain 5. Sucralfate 1 gm PO QID 6. Sulfameth/Trimethoprim DS 1 TAB PO/NG DAILY 7. OxyCODONE (Immediate Release) 10 mg PO Q2H:PRN BREAKTHROUGH PAIN RX *oxycodone 5 mg/5 mL 10 mL by mouth every 2 hours Refills:*0 8. Bisacodyl AILY:PRN constipation 9. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral DAILY 10. Lactulose 30 mL PO TID 11. Multivitamins 1 TAB PO DAILY 12. Polyethylene Glycol 17 g PO DAILY 13. Thiamine 100 mg PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSES: Gastric perforation, frozen abdomen. Duodenal ulcer Esophagitis SECONDARY DIAGNOSES: portal hypertensive gastropathy anemia malnutrition Cirrhosis Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [MASKED], WHY WAS I ADMITTED TO THE HOSPITAL? - You were having pain in your abdomen. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? - You were found to have a hole in your intestine (perforated ulcer), that could not be repaired due to scarred down tissue in your abdomen (frozen abdomen) - You were given antibiotics to prevent infection - You had a temporary drain placed in your abdomen to drain an infection, and this was removed. - You initially were given a feeding tube to bypass the hole, but as it healed from the inside, you were able to eat regular food. - Because you were so sick and there was no cure for your advance liver disease and holes in your stomach and intestines, you chose hospice care. WHAT SHOULD I DO WHEN I GO HOME -Take medications to help your pain -Eat for comfort Thank you for letting us be a part of your care! Your [MASKED] Team Followup Instructions: [MASKED]
|
[] |
[
"D62",
"I4891",
"G8929",
"Z66",
"Z515"
] |
[
"K265: Chronic or unspecified duodenal ulcer with perforation",
"E43: Unspecified severe protein-calorie malnutrition",
"J811: Chronic pulmonary edema",
"D688: Other specified coagulation defects",
"K766: Portal hypertension",
"D6959: Other secondary thrombocytopenia",
"D62: Acute posthemorrhagic anemia",
"I471: Supraventricular tachycardia",
"I959: Hypotension, unspecified",
"K255: Chronic or unspecified gastric ulcer with perforation",
"I4891: Unspecified atrial fibrillation",
"K209: Esophagitis, unspecified",
"B182: Chronic viral hepatitis C",
"K7031: Alcoholic cirrhosis of liver with ascites",
"F1011: Alcohol abuse, in remission",
"K660: Peritoneal adhesions (postprocedural) (postinfection)",
"K3189: Other diseases of stomach and duodenum",
"Z5309: Procedure and treatment not carried out because of other contraindication",
"G8929: Other chronic pain",
"I8510: Secondary esophageal varices without bleeding",
"Z66: Do not resuscitate",
"Z515: Encounter for palliative care",
"R0902: Hypoxemia",
"D638: Anemia in other chronic diseases classified elsewhere",
"Z590: Homelessness",
"Z6824: Body mass index [BMI] 24.0-24.9, adult",
"K449: Diaphragmatic hernia without obstruction or gangrene",
"Z720: Tobacco use"
] |
10,005,866 | 21,636,229 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Tylenol / Neurontin
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ man presents for evaluation of abdominal pain.
Patient recently hospitalized for acute exacerbation of his
chronic abdominal pain, likely partial bowel obstruction.
Discharged yesterday after undergoing conservative management of
likely partial bowel obstruction; of note at the time of
discharge he was pain-free and tolerating a regular diet, as
well
as having bowel function. Also had repeat ultrasound of liver
which showed resolution of prior portal vein partially occlusive
thrombus. Patient reports arriving to his daughter's home,
having
a cup of tea and dinner without issue. However overnight his
abdominal pain recurred and he decided to come back in for
evaluation. He denies any nausea or vomiting, has not had a
bowel movement since leaving the hospital yesterday. Denies any
fevers, chills, dysuria, chest pain, shortness of breath,
numbness, tingling. Transplant surgery is consulted to evaluate
for surgical causes of recurrent abdominal pain.
ROS:
(+) per 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 Exam:
==================
VITAL SIGNS: 97.9 65 165/75 16 99% RA
GENERAL: AAOx3 NAD
HEENT: NCAT, EOMI, PERRLA, No scleral icterus, mucosa moist, no
LAD
CARDIOVASCULAR: R/R/R
PULMONARY: CTA ___, No crackles or rhonchi
GASTROINTESTINAL: protuberant, soft, more distended than usual,
tender to palpation in right hemi-abdomen, left hemi-abdomen
mildly tender, No guarding, rebound, or peritoneal signs.
EXT/MS/SKIN: No C/C/E; Feet warm. Good perfusion.
NEUROLOGICAL: Reflexes, strength, and sensation grossly intact
.
Discharge Exam:
===================
VS: 97.8 123/72 70 18 98% RA
GENERAL: NAD, patient appears chronically ill, sunken temples,
A&Ox3
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
adentulous
NECK: supple, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: protuberant abdomen, not tense, decreased bowel sounds.
Tender to moderate palpation, mostly on R side. Multiple
surgical
scars appearing c/d/i.
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
Labs on admission:
========================
___ 07:00AM BLOOD WBC-5.7 RBC-3.43* Hgb-11.5* Hct-35.6*
MCV-104* MCH-33.5* MCHC-32.3 RDW-14.9 RDWSD-57.2* Plt ___
___ 07:45AM BLOOD WBC-5.9 RBC-3.49* Hgb-11.7* Hct-36.4*
MCV-104* MCH-33.5* MCHC-32.1 RDW-14.7 RDWSD-57.0* Plt ___
___ 07:00AM BLOOD ___ PTT-35.6 ___
___ 07:45AM BLOOD ___
___ 04:42AM BLOOD Glucose-90 UreaN-4* Creat-0.7 Na-136
K-4.6 Cl-102 HCO3-26 AnGap-8*
___ 04:42AM BLOOD ALT-17 AST-50* AlkPhos-110 TotBili-2.4*
.
Microbiology:
========================
___ 7:31 am PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
.
___ 07:31AM ASCITES TNC-37* RBC-92* Polys-1* Lymphs-30*
Monos-8* Basos-1* Macroph-60*
___ 07:31AM ASCITES TotPro-0.4 Glucose-101
.
.
Reports/imaging:
========================
RUQ ultrasound:
IMPRESSION:
1. Cirrhotic liver, without evidence of focal lesion.
2. Mild to moderate ascites and a right pleural effusion.
3. Patent main and right portal vein with appropriate direction
of flow.
.
Abdominal XR:
IMPRESSION:
Borderline diameter of a single loop of small bowel with a few
small
nonspecific small bowel air-fluid levels and air seen in the
colon. Findings are nonspecific, but a very early/very mild
partial small bowel obstruction is not entirely excluded in the
appropriate clinical setting.
.
CT abd and pelvis with contrast
IMPRESSION:
1. Redemonstration cirrhotic liver with sequela of portal
hypertension. New branching hypoattenuation in segments VIII
and ___ may be due to periportal edema or inflammation along
intrahepatic biliary ducts, the latter possibly related to
cholangitis. The main portal vasculature is patent.
2. Moderate amount of ascites, as on prior. Mild peritoneal
enhancement
without free air or drainable fluid collections, could represent
peritonitis or secondary to recent paracentesis.
.
Labs on discharge:
========================
___ 06:32AM BLOOD WBC-6.6 RBC-2.84* Hgb-9.8* Hct-29.5*
MCV-104* MCH-34.5* MCHC-33.2 RDW-14.2 RDWSD-54.1* Plt ___
___ 06:32AM BLOOD Glucose-109* UreaN-7 Creat-0.7 Na-133*
K-4.3 Cl-100 HCO3-24 AnGap-9*
___ 06:32AM BLOOD ALT-17 AST-50* AlkPhos-104 Amylase-110*
TotBili-1.7*
___ 07:00AM BLOOD Lipase-42
___ 06:32AM BLOOD Lipase-32
___ 06:32AM BLOOD Calcium-7.6* Phos-2.8 Mg-1.___ with Cirrhosis, Child's Class C due EtOH and HCV d/b hepatic
encephalopathy, portal hypertension with ascites and esophageal
varices, portal hypertensive gastropathy; hx numerous abdominal
surgeries with suspected frozen abdomen, chronic abdominal pain
with subacute worsening. Patient had recent admission with small
bowel obstruction that was treated conservatively with NG tube
and bowel rest and resolved, who went home with decreased pain
med regimen, and who is now returning with worsening abdominal
pain.
.
#Abdominal pain
CT abd pain pelvis showed no obstruction or extravasation of
contrast. Patient was first placed on home pain regiment (oxy
10mg q6hr) with improvement of pain, but given increased pain at
4hours after oxy dose, chronic pain service recommended a
regimen of 7.5mg oxy every 4 hours, which better controlled
pain. Lidocaine patch attempted for back pain but without
noticeable change. Patient was eating regular diet and with
ongoing ___ pain but appearing comfortable, walking,
eating and passing soft stool.
.
#Cirrhosis
With regards to cirrhosis, Child's Class C due EtOH and HCV,
with past hepatic
encephalopathy, portal hypertension with ascites and esophageal
varices, portal hypertensive gastropathy. No evidence of
decompensation during this hospitalization. Para was done that
did not show SBP.
.
TRANSITIONAL ISSUES:
[] CHANGED oxycodone 10mg q6hr to 7.5mg q4hr with improvement in
pain control
[] STARTED miralax, thiamine
[] Please consider outpatient pain consult if worsening pain
[] CONTACT: ___ (HCP, sister) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Famotidine 20 mg PO BID
2. Furosemide 20 mg PO DAILY
3. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN pain
4. Spironolactone 50 mg PO DAILY
5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY SBP prophylaxis
6. Simethicone 40-80 mg PO TID:PRN gas pain
7. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral DAILY
8. Lactulose 30 mL PO QID
9. Multivitamins 1 TAB PO DAILY
10. Potassium Chloride 20 mEq PO DAILY
11. Bisacodyl ___AILY:PRN constipation
Discharge Medications:
1. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [ClearLax] 17 gram/dose 1 scoop
powder(s) by mouth daily Disp #*1 Package Refills:*0
2. Simethicone 40-80 mg PO TID:PRN gas pain
3. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
4. OxyCODONE (Immediate Release) 7.5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone [Oxaydo] 7.5 mg 1 tablet(s) by mouth every 4 hours
Disp #*42 Tablet Refills:*0
5. Bisacodyl ___AILY:PRN constipation
6. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral DAILY
7. Famotidine 20 mg PO BID
8. Furosemide 20 mg PO DAILY
9. Lactulose 30 mL PO QID
Titrate to ___ bowel movements daily
10. Multivitamins 1 TAB PO DAILY
11. Potassium Chloride 20 mEq PO DAILY
12. Spironolactone 50 mg PO DAILY
13. Sulfameth/Trimethoprim SS 1 TAB PO DAILY SBP prophylaxis
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
=============
Cirrhosis
Intermittent abdominal pain of unknown origin
Intraabdominal bowel adhesions
.
Secondary:
=============
History of multiple abdominal surgeries
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear. Mr. ___,
.
It was a pleasure taking part in your care at ___
___. You were seen for increasing abdominal
pain. A number of tests, including laboratory and a CT scan were
reassuring. You were initially on the surgical service, but the
surgical team did not feel there was any problem requiring
surgery. You were seen by the chronic pain service that made an
adjustment to the dose and timing of your pain medication.
Please take this new dose as prescribed. Please take the new
medications as prescribed.
.
Please call the surgery doctor, ___ office at
___ if you are having increasing abdominal pain,
inability to tolerate diet, not passing gas or having bowel
movements, nausea, vomiting or any other concerning GI
complaints.
.
You are likely to be having intermittent abdominal pain. Please
work with your primary care physician regarding your pain
management strategies.
.
No driving if taking narcotic pain medication.
.
Try to eat small frequent meals, using no additional salt, stay
hydrated.
.
We wish you the best,
Your ___ care team
Followup Instructions:
___
|
[
"K660",
"E43",
"K766",
"Z720",
"K7031",
"Z6820",
"R1084"
] |
Allergies: Tylenol / Neurontin Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] man presents for evaluation of abdominal pain. Patient recently hospitalized for acute exacerbation of his chronic abdominal pain, likely partial bowel obstruction. Discharged yesterday after undergoing conservative management of likely partial bowel obstruction; of note at the time of discharge he was pain-free and tolerating a regular diet, as well as having bowel function. Also had repeat ultrasound of liver which showed resolution of prior portal vein partially occlusive thrombus. Patient reports arriving to his daughter's home, having a cup of tea and dinner without issue. However overnight his abdominal pain recurred and he decided to come back in for evaluation. He denies any nausea or vomiting, has not had a bowel movement since leaving the hospital yesterday. Denies any fevers, chills, dysuria, chest pain, shortness of breath, numbness, tingling. Transplant surgery is consulted to evaluate for surgical causes of recurrent abdominal pain. ROS: (+) per 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 ([MASKED]) -SBO requiring Ex lap & repair of ruptured umbilical hernia with lysis of adhesions ([MASKED]) - Abdominal Hematoma evacuation ([MASKED]) - Abdominal incision opened, wound vac placed ([MASKED]) Social History: [MASKED] Family History: Sister and brother both with "collapsed lungs." No family history of liver disease. Physical Exam: Admission Exam: ================== VITAL SIGNS: 97.9 65 165/75 16 99% RA GENERAL: AAOx3 NAD HEENT: NCAT, EOMI, PERRLA, No scleral icterus, mucosa moist, no LAD CARDIOVASCULAR: R/R/R PULMONARY: CTA [MASKED], No crackles or rhonchi GASTROINTESTINAL: protuberant, soft, more distended than usual, tender to palpation in right hemi-abdomen, left hemi-abdomen mildly tender, No guarding, rebound, or peritoneal signs. EXT/MS/SKIN: No C/C/E; Feet warm. Good perfusion. NEUROLOGICAL: Reflexes, strength, and sensation grossly intact . Discharge Exam: =================== VS: 97.8 123/72 70 18 98% RA GENERAL: NAD, patient appears chronically ill, sunken temples, A&Ox3 HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, adentulous NECK: supple, no JVD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: protuberant abdomen, not tense, decreased bowel sounds. Tender to moderate palpation, mostly on R side. Multiple surgical scars appearing c/d/i. EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 extremities with purpose PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: Labs on admission: ======================== [MASKED] 07:00AM BLOOD WBC-5.7 RBC-3.43* Hgb-11.5* Hct-35.6* MCV-104* MCH-33.5* MCHC-32.3 RDW-14.9 RDWSD-57.2* Plt [MASKED] [MASKED] 07:45AM BLOOD WBC-5.9 RBC-3.49* Hgb-11.7* Hct-36.4* MCV-104* MCH-33.5* MCHC-32.1 RDW-14.7 RDWSD-57.0* Plt [MASKED] [MASKED] 07:00AM BLOOD [MASKED] PTT-35.6 [MASKED] [MASKED] 07:45AM BLOOD [MASKED] [MASKED] 04:42AM BLOOD Glucose-90 UreaN-4* Creat-0.7 Na-136 K-4.6 Cl-102 HCO3-26 AnGap-8* [MASKED] 04:42AM BLOOD ALT-17 AST-50* AlkPhos-110 TotBili-2.4* . Microbiology: ======================== [MASKED] 7:31 am PERITONEAL FLUID PERITONEAL FLUID. GRAM STAIN (Final [MASKED]: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final [MASKED]: NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. . [MASKED] 07:31AM ASCITES TNC-37* RBC-92* Polys-1* Lymphs-30* Monos-8* Basos-1* Macroph-60* [MASKED] 07:31AM ASCITES TotPro-0.4 Glucose-101 . . Reports/imaging: ======================== RUQ ultrasound: IMPRESSION: 1. Cirrhotic liver, without evidence of focal lesion. 2. Mild to moderate ascites and a right pleural effusion. 3. Patent main and right portal vein with appropriate direction of flow. . Abdominal XR: IMPRESSION: Borderline diameter of a single loop of small bowel with a few small nonspecific small bowel air-fluid levels and air seen in the colon. Findings are nonspecific, but a very early/very mild partial small bowel obstruction is not entirely excluded in the appropriate clinical setting. . CT abd and pelvis with contrast IMPRESSION: 1. Redemonstration cirrhotic liver with sequela of portal hypertension. New branching hypoattenuation in segments VIII and [MASKED] may be due to periportal edema or inflammation along intrahepatic biliary ducts, the latter possibly related to cholangitis. The main portal vasculature is patent. 2. Moderate amount of ascites, as on prior. Mild peritoneal enhancement without free air or drainable fluid collections, could represent peritonitis or secondary to recent paracentesis. . Labs on discharge: ======================== [MASKED] 06:32AM BLOOD WBC-6.6 RBC-2.84* Hgb-9.8* Hct-29.5* MCV-104* MCH-34.5* MCHC-33.2 RDW-14.2 RDWSD-54.1* Plt [MASKED] [MASKED] 06:32AM BLOOD Glucose-109* UreaN-7 Creat-0.7 Na-133* K-4.3 Cl-100 HCO3-24 AnGap-9* [MASKED] 06:32AM BLOOD ALT-17 AST-50* AlkPhos-104 Amylase-110* TotBili-1.7* [MASKED] 07:00AM BLOOD Lipase-42 [MASKED] 06:32AM BLOOD Lipase-32 [MASKED] 06:32AM BLOOD Calcium-7.6* Phos-2.8 Mg-1.[MASKED] with Cirrhosis, Child's Class C due EtOH and HCV d/b hepatic encephalopathy, portal hypertension with ascites and esophageal varices, portal hypertensive gastropathy; hx numerous abdominal surgeries with suspected frozen abdomen, chronic abdominal pain with subacute worsening. Patient had recent admission with small bowel obstruction that was treated conservatively with NG tube and bowel rest and resolved, who went home with decreased pain med regimen, and who is now returning with worsening abdominal pain. . #Abdominal pain CT abd pain pelvis showed no obstruction or extravasation of contrast. Patient was first placed on home pain regiment (oxy 10mg q6hr) with improvement of pain, but given increased pain at 4hours after oxy dose, chronic pain service recommended a regimen of 7.5mg oxy every 4 hours, which better controlled pain. Lidocaine patch attempted for back pain but without noticeable change. Patient was eating regular diet and with ongoing [MASKED] pain but appearing comfortable, walking, eating and passing soft stool. . #Cirrhosis With regards to cirrhosis, Child's Class C due EtOH and HCV, with past hepatic encephalopathy, portal hypertension with ascites and esophageal varices, portal hypertensive gastropathy. No evidence of decompensation during this hospitalization. Para was done that did not show SBP. . TRANSITIONAL ISSUES: [] CHANGED oxycodone 10mg q6hr to 7.5mg q4hr with improvement in pain control [] STARTED miralax, thiamine [] Please consider outpatient pain consult if worsening pain [] CONTACT: [MASKED] (HCP, sister) [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Famotidine 20 mg PO BID 2. Furosemide 20 mg PO DAILY 3. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN pain 4. Spironolactone 50 mg PO DAILY 5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY SBP prophylaxis 6. Simethicone 40-80 mg PO TID:PRN gas pain 7. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral DAILY 8. Lactulose 30 mL PO QID 9. Multivitamins 1 TAB PO DAILY 10. Potassium Chloride 20 mEq PO DAILY 11. Bisacodyl AILY:PRN constipation Discharge Medications: 1. Polyethylene Glycol 17 g PO DAILY RX *polyethylene glycol 3350 [ClearLax] 17 gram/dose 1 scoop powder(s) by mouth daily Disp #*1 Package Refills:*0 2. Simethicone 40-80 mg PO TID:PRN gas pain 3. Thiamine 100 mg PO DAILY RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. OxyCODONE (Immediate Release) 7.5 mg PO Q4H:PRN Pain - Moderate RX *oxycodone [Oxaydo] 7.5 mg 1 tablet(s) by mouth every 4 hours Disp #*42 Tablet Refills:*0 5. Bisacodyl AILY:PRN constipation 6. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral DAILY 7. Famotidine 20 mg PO BID 8. Furosemide 20 mg PO DAILY 9. Lactulose 30 mL PO QID Titrate to [MASKED] bowel movements daily 10. Multivitamins 1 TAB PO DAILY 11. Potassium Chloride 20 mEq PO DAILY 12. Spironolactone 50 mg PO DAILY 13. Sulfameth/Trimethoprim SS 1 TAB PO DAILY SBP prophylaxis Discharge Disposition: Home Discharge Diagnosis: Primary: ============= Cirrhosis Intermittent abdominal pain of unknown origin Intraabdominal bowel adhesions . Secondary: ============= History of multiple abdominal surgeries Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear. Mr. [MASKED], . It was a pleasure taking part in your care at [MASKED] [MASKED]. You were seen for increasing abdominal pain. A number of tests, including laboratory and a CT scan were reassuring. You were initially on the surgical service, but the surgical team did not feel there was any problem requiring surgery. You were seen by the chronic pain service that made an adjustment to the dose and timing of your pain medication. Please take this new dose as prescribed. Please take the new medications as prescribed. . Please call the surgery doctor, [MASKED] office at [MASKED] if you are having increasing abdominal pain, inability to tolerate diet, not passing gas or having bowel movements, nausea, vomiting or any other concerning GI complaints. . You are likely to be having intermittent abdominal pain. Please work with your primary care physician regarding your pain management strategies. . No driving if taking narcotic pain medication. . Try to eat small frequent meals, using no additional salt, stay hydrated. . We wish you the best, Your [MASKED] care team Followup Instructions: [MASKED]
|
[] |
[] |
[
"K660: Peritoneal adhesions (postprocedural) (postinfection)",
"E43: Unspecified severe protein-calorie malnutrition",
"K766: Portal hypertension",
"Z720: Tobacco use",
"K7031: Alcoholic cirrhosis of liver with ascites",
"Z6820: Body mass index [BMI] 20.0-20.9, adult",
"R1084: Generalized abdominal pain"
] |
10,005,866 | 22,589,518 |
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:
___
|
[
"A084",
"I81",
"R188",
"E872",
"K766",
"E871",
"K7469",
"K7290",
"Z720"
] |
Allergies: Tylenol / Neurontin Chief Complaint: RUQ abdominal pain, vomiting, diarrhea Major Surgical or Invasive Procedure: -diagnostic para [MASKED] History of Present Illness: Mr [MASKED] is a [MASKED] 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 [MASKED] following his last [MASKED] hospitalization in [MASKED], 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. [MASKED] checked [MASKED]. Last filled oxycodone 10mg 30 day supply (120 pills) [MASKED]. 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 [MASKED] 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 [MASKED]: 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 [MASKED]: 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 [MASKED]. 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 ([MASKED]) -SBO requiring Ex lap & repair of ruptured umbilical hernia with lysis of adhesions ([MASKED]) - Abdominal Hematoma evacuation ([MASKED]) - Abdominal incision opened, wound vac placed ([MASKED]) Social History: [MASKED] 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: ========================== [MASKED] 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 [MASKED] [MASKED] 09:36AM BLOOD Neuts-65.3 [MASKED] Monos-10.4 Eos-1.9 Baso-1.7* Im [MASKED] AbsNeut-3.51 AbsLymp-1.08* AbsMono-0.56 AbsEos-0.10 AbsBaso-0.09* [MASKED] 11:21AM BLOOD [MASKED] PTT-38.7* [MASKED] [MASKED] 09:36AM BLOOD Glucose-144* UreaN-9 Creat-0.8 Na-130* K-4.8 Cl-101 HCO3-15* AnGap-19 [MASKED] 09:36AM BLOOD ALT-32 AST-127* AlkPhos-145* TotBili-4.7* [MASKED] 09:36AM BLOOD Albumin-2.8* [MASKED] 05:00AM BLOOD Calcium-7.7* Phos-2.9 Mg-1.4* [MASKED] 09:44AM BLOOD Lactate-2.6* DISCHARGE LABS: ========================== [MASKED] 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 [MASKED] [MASKED] 04:46AM BLOOD [MASKED] PTT-36.8* [MASKED] [MASKED] 04:46AM BLOOD Glucose-93 UreaN-9 Creat-0.9 Na-133 K-4.2 Cl-99 HCO3-26 AnGap-12 [MASKED] 04:46AM BLOOD ALT-21 AST-63* AlkPhos-159* TotBili-2.3* [MASKED] 04:46AM BLOOD Albumin-2.4* Calcium-8.0* Phos-3.6 Mg-1.6 PERTINENT RESULTS: ========================== [MASKED] 01:55PM ASCITES TNC-64* RBC-650* Polys-1* Lymphs-48* Monos-6* Mesothe-2* Macroph-43* Other-0 [MASKED] 01:55PM ASCITES TotPro-1.7 Glucose-103 LD(LDH)-104 Albumin-0.7 Cholest-19 [MASKED] 08:58PM STOOL NoroGI-NEGATIVE NoroGII-NEGATIVE MICROBIOLOGY: ========================== [MASKED] 1:55 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES PERITONEAL FLUID. Fluid Culture in Bottles (Preliminary): NO GROWTH. [MASKED] 1:48 pm PERITONEAL FLUID PERITONEAL FLUID. **FINAL REPORT [MASKED] GRAM STAIN (Final [MASKED]: 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: ========================== [MASKED] 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 [MASKED]. 4. New 1.6 cm focus within the right hepatic lobe is incompletely characterized. Follow-up MR for further evaluation is recommended. [MASKED] IMPRESSION: Tiny right pleural effusion, otherwise unremarkable exam. [MASKED] 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: [MASKED] 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 [MASKED] 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. [MASKED] 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 [MASKED] 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 [MASKED] ultrasound. Lactate slightly elevated on initial presentation normalized with IVF less c/f ischemia. Outpatient hepatologist (Dr. [MASKED] 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 [MASKED] 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 [MASKED] [MASKED] 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 [MASKED], 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 [MASKED] Care Team Followup Instructions: [MASKED]
|
[] |
[
"E872",
"E871"
] |
[
"A084: Viral intestinal infection, unspecified",
"I81: Portal vein thrombosis",
"R188: Other ascites",
"E872: Acidosis",
"K766: Portal hypertension",
"E871: Hypo-osmolality and hyponatremia",
"K7469: Other cirrhosis of liver",
"K7290: Hepatic failure, unspecified without coma",
"Z720: Tobacco use"
] |
10,005,866 | 23,514,107 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Tylenol / Neurontin
Attending: ___.
Chief Complaint:
Acute Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This patient is a ___ year old male, with ETOH and Hep C
cirrhosis, child's class B (MELD 16) presenting to the ED with
acute abdominal pain concerning for recurrent bowel obstruction.
Patient is now being seen by Transplant surgery in consultation.
As above, the patient has a history of cirrhosis secondary to
both ethanol and Hep C. Currently compensated. Last paracentesis
performed ___ years ago. His surgical history is pertinent for a
prior umbilical repair, and an exploratory laparotomy for a
closed loop obstruction requiring lysis of an internal hernia.
The patient was in his usual state of health until last night
when he developed an acute abdominal pain. He describes the pain
as stabbing in nature and constant. The pain is located in his
right flank. He has had around 10 episodes of bilious emesis.
Denies hematemesis. Last episode of vomiting was this morning at
10:00. He has not felt better after the emesis triggering this
ED
visit. He describes this pain similar in nature as prior one
last
year when he required exploration. The patient endorses chills
but denies any fever, chest pain, SOB, dysuria, or urinary
urgency or frequency. He last passed gas this morning and has
not had a bowel movement in the last two days.
In the ED, VSS. Patient with persistent nausea. No NG in place.
Abdomen soft but tender to right flank. No peritoneal. Labs w/o
leukocytosis or acidosis. Imaging studies c/w distal ileum bowel
obstruction. No signs of bowel ischemia. Moderate ascites.
ROS:
(+) per HPI
(-) Denies pain, fevers chills, night sweats, unexplained weight
loss, fatigue/malaise/lethargy, changes in appetite, trouble
with
sleep, pruritis, jaundice, rashes, bleeding, easy bruising,
headache, dizziness, vertigo, syncope, weakness, paresthesias,
nausea, vomiting, hematemesis, bloating, cramping, melena,
BRBPR,
dysphagia, chest pain, shortness of breath, cough, edema,
urinary
frequency, urgency
Past Medical History:
- 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:
Vitals: 98.1, 121/70, 57, 18, 98% RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, tender to deep palpation to right flank. No rebound.
Ascites. Dull to percussion.
Ext: No ___ edema, ___ warm and well perfused
.
Weight at discharge: 64.5 kg
Pertinent Results:
Labs on Admission: ___
WBC-6.1 RBC-4.29* Hgb-14.8 Hct-44.0 MCV-103* MCH-34.5* MCHC-33.6
RDW-15.7* RDWSD-56.9* Plt ___ PTT-38.3* ___
Glucose-121* UreaN-9 Creat-0.7 Na-138 K-4.4 Cl-100 HCO3-24
AnGap-14
ALT-27 AST-102* AlkPhos-135* TotBili-4.1*
Albumin-3.1* Calcium-8.5 Phos-4.2 Mg-1.6
.
Labs at Discharge: ___
WBC-5.8 RBC-3.88* Hgb-13.3* Hct-39.9* MCV-103* MCH-34.3*
MCHC-33.3 RDW-15.7* RDWSD-58.6* Plt ___
Glucose-145* UreaN-6 Creat-0.8 Na-136 K-5.3* Cl-105 HCO3-23
AnGap-8
ALT-18 AST-54* AlkPhos-94 TotBili-3.8*
Calcium-7.6* Phos-3.7 Mg-1.___ y/o male with HCV, ETOH cirrhosis with prior ex-lap who now
presents with acute abdominal pain.
On admission the patient had a CT done with findings suspicious
for partial small bowel obstruction with adhesive disease in the
right lower quadrant involving loops of ileum with alternating
areas of luminal narrowing and dilatation. Overall, the
appearance of the small bowel is similar to the previous CT from
___.
Of note there is liver cirrhosis with small to moderate ascites,
mild splenomegaly, and portosystemic varices. There is also a
nonocclusive small thrombus in the main portal vein which is
slightly smaller compared to ___.
An NG tube was placed, and he was having bilious output from the
NG tube. He reported passing some flatus, and the abdominal pain
was present but stable on exam.
On hospital day two, he was reporting an increase in abdominal
pain. A KUB was done showing that there was no evidence of free
air. The abdominal exam still showed him to be soft, and serial
exams over the next ___ hours showed him to be less tender.
A suppository was given resulting in a loose bowel movement and
he was reporting passing some flatus still. The NG tube output
was lightening in colr and less volume. Prior to the NG tube
being discontinued, another KUB was obtained, with no evidence
of obstruction.
The NG tube was removed and he was kept NPO for the next ___
hours. He had no nausea with tube removed, and so he was started
on a clear diet which he tolerated without nausea or vomiting.
The abdominal exam was significantly improved so he was deemed
safe for discharge with plan for clears for three days.
Liver function tests were slightly improved at discharge.
Additionally the patient has a follow up appointment with his
hepatologist this week which the patient was advised to keep.
Home medications including diuretics were resumed at discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Famotidine 20 mg PO BID
2. Fentanyl Patch 50 mcg/h TD Q72H
3. Furosemide 20 mg PO DAILY
4. Lactulose 30 mL PO QID
5. Lidocaine 5% Patch 1 PTCH TD QAM
6. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain -
Moderate
7. Potassium Chloride 20 mEq PO DAILY
8. Spironolactone 50 mg PO DAILY
9. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
10. Bisacodyl 10 mg PR QHS:PRN constipation
11. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral DAILY
12. Polyethylene Glycol 17 g PO DAILY
Discharge Medications:
1. Bisacodyl 10 mg PR QHS:PRN constipation
2. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral DAILY
3. Famotidine 20 mg PO BID
4. Fentanyl Patch 50 mcg/h TD Q72H
5. Furosemide 20 mg PO DAILY
6. Lactulose 30 mL PO QID
7. Lidocaine 5% Patch 1 PTCH TD QAM
8. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain -
Moderate
9. Polyethylene Glycol 17 g PO DAILY
10. Potassium Chloride 20 mEq PO DAILY
11. Spironolactone 50 mg PO DAILY
12. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction: Resolved
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call Dr. ___ office at ___ if you have fever
greater than 101, chills, nausea, vomiting, constipation, you
are not passing gas, you have a lot of hiccupping or burping,
your abdomen is becoming more distended, you have pain in your
abdomen or any other concerning symptoms.
Continue all your home medications as they have been prescribed
to you. Follow up with your primary providers if you have
questions about those medications.
To help your bowel heal and not become obstructed again, you
should continue a clear diet through ___. This means
liquids you can see through, clear sodas, water, clear juices,
jello and broth.
Followup Instructions:
___
|
[
"K565",
"K7031",
"I8510",
"K766",
"F17210",
"Z6823",
"B1920",
"I81",
"E43"
] |
Allergies: Tylenol / Neurontin Chief Complaint: Acute Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: This patient is a [MASKED] year old male, with ETOH and Hep C cirrhosis, child's class B (MELD 16) presenting to the ED with acute abdominal pain concerning for recurrent bowel obstruction. Patient is now being seen by Transplant surgery in consultation. As above, the patient has a history of cirrhosis secondary to both ethanol and Hep C. Currently compensated. Last paracentesis performed [MASKED] years ago. His surgical history is pertinent for a prior umbilical repair, and an exploratory laparotomy for a closed loop obstruction requiring lysis of an internal hernia. The patient was in his usual state of health until last night when he developed an acute abdominal pain. He describes the pain as stabbing in nature and constant. The pain is located in his right flank. He has had around 10 episodes of bilious emesis. Denies hematemesis. Last episode of vomiting was this morning at 10:00. He has not felt better after the emesis triggering this ED visit. He describes this pain similar in nature as prior one last year when he required exploration. The patient endorses chills but denies any fever, chest pain, SOB, dysuria, or urinary urgency or frequency. He last passed gas this morning and has not had a bowel movement in the last two days. In the ED, VSS. Patient with persistent nausea. No NG in place. Abdomen soft but tender to right flank. No peritoneal. Labs w/o leukocytosis or acidosis. Imaging studies c/w distal ileum bowel obstruction. No signs of bowel ischemia. Moderate ascites. ROS: (+) per HPI (-) Denies pain, fevers chills, night sweats, unexplained weight loss, fatigue/malaise/lethargy, changes in appetite, trouble with sleep, pruritis, jaundice, rashes, bleeding, easy bruising, headache, dizziness, vertigo, syncope, weakness, paresthesias, nausea, vomiting, hematemesis, bloating, cramping, melena, BRBPR, dysphagia, chest pain, shortness of breath, cough, edema, urinary frequency, urgency Past Medical History: - 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 ([MASKED]) -SBO requiring Ex lap & repair of ruptured umbilical hernia with lysis of adhesions ([MASKED]) - Abdominal Hematoma evacuation ([MASKED]) - Abdominal incision opened, wound vac placed ([MASKED]) Social History: [MASKED] Family History: Sister and brother both with "collapsed lungs." No family history of liver disease. Physical Exam: Vitals: 98.1, 121/70, 57, 18, 98% RA GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, tender to deep palpation to right flank. No rebound. Ascites. Dull to percussion. Ext: No [MASKED] edema, [MASKED] warm and well perfused . Weight at discharge: 64.5 kg Pertinent Results: Labs on Admission: [MASKED] WBC-6.1 RBC-4.29* Hgb-14.8 Hct-44.0 MCV-103* MCH-34.5* MCHC-33.6 RDW-15.7* RDWSD-56.9* Plt [MASKED] PTT-38.3* [MASKED] Glucose-121* UreaN-9 Creat-0.7 Na-138 K-4.4 Cl-100 HCO3-24 AnGap-14 ALT-27 AST-102* AlkPhos-135* TotBili-4.1* Albumin-3.1* Calcium-8.5 Phos-4.2 Mg-1.6 . Labs at Discharge: [MASKED] WBC-5.8 RBC-3.88* Hgb-13.3* Hct-39.9* MCV-103* MCH-34.3* MCHC-33.3 RDW-15.7* RDWSD-58.6* Plt [MASKED] Glucose-145* UreaN-6 Creat-0.8 Na-136 K-5.3* Cl-105 HCO3-23 AnGap-8 ALT-18 AST-54* AlkPhos-94 TotBili-3.8* Calcium-7.6* Phos-3.7 Mg-1.[MASKED] y/o male with HCV, ETOH cirrhosis with prior ex-lap who now presents with acute abdominal pain. On admission the patient had a CT done with findings suspicious for partial small bowel obstruction with adhesive disease in the right lower quadrant involving loops of ileum with alternating areas of luminal narrowing and dilatation. Overall, the appearance of the small bowel is similar to the previous CT from [MASKED]. Of note there is liver cirrhosis with small to moderate ascites, mild splenomegaly, and portosystemic varices. There is also a nonocclusive small thrombus in the main portal vein which is slightly smaller compared to [MASKED]. An NG tube was placed, and he was having bilious output from the NG tube. He reported passing some flatus, and the abdominal pain was present but stable on exam. On hospital day two, he was reporting an increase in abdominal pain. A KUB was done showing that there was no evidence of free air. The abdominal exam still showed him to be soft, and serial exams over the next [MASKED] hours showed him to be less tender. A suppository was given resulting in a loose bowel movement and he was reporting passing some flatus still. The NG tube output was lightening in colr and less volume. Prior to the NG tube being discontinued, another KUB was obtained, with no evidence of obstruction. The NG tube was removed and he was kept NPO for the next [MASKED] hours. He had no nausea with tube removed, and so he was started on a clear diet which he tolerated without nausea or vomiting. The abdominal exam was significantly improved so he was deemed safe for discharge with plan for clears for three days. Liver function tests were slightly improved at discharge. Additionally the patient has a follow up appointment with his hepatologist this week which the patient was advised to keep. Home medications including diuretics were resumed at discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Famotidine 20 mg PO BID 2. Fentanyl Patch 50 mcg/h TD Q72H 3. Furosemide 20 mg PO DAILY 4. Lactulose 30 mL PO QID 5. Lidocaine 5% Patch 1 PTCH TD QAM 6. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain - Moderate 7. Potassium Chloride 20 mEq PO DAILY 8. Spironolactone 50 mg PO DAILY 9. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 10. Bisacodyl 10 mg PR QHS:PRN constipation 11. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral DAILY 12. Polyethylene Glycol 17 g PO DAILY Discharge Medications: 1. Bisacodyl 10 mg PR QHS:PRN constipation 2. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral DAILY 3. Famotidine 20 mg PO BID 4. Fentanyl Patch 50 mcg/h TD Q72H 5. Furosemide 20 mg PO DAILY 6. Lactulose 30 mL PO QID 7. Lidocaine 5% Patch 1 PTCH TD QAM 8. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain - Moderate 9. Polyethylene Glycol 17 g PO DAILY 10. Potassium Chloride 20 mEq PO DAILY 11. Spironolactone 50 mg PO DAILY 12. Sulfameth/Trimethoprim SS 1 TAB PO DAILY Discharge Disposition: Home Discharge Diagnosis: Small bowel obstruction: Resolved Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call Dr. [MASKED] office at [MASKED] if you have fever greater than 101, chills, nausea, vomiting, constipation, you are not passing gas, you have a lot of hiccupping or burping, your abdomen is becoming more distended, you have pain in your abdomen or any other concerning symptoms. Continue all your home medications as they have been prescribed to you. Follow up with your primary providers if you have questions about those medications. To help your bowel heal and not become obstructed again, you should continue a clear diet through [MASKED]. This means liquids you can see through, clear sodas, water, clear juices, jello and broth. Followup Instructions: [MASKED]
|
[] |
[
"F17210"
] |
[
"K565: Intestinal adhesions [bands] with obstruction (postinfection)",
"K7031: Alcoholic cirrhosis of liver with ascites",
"I8510: Secondary esophageal varices without bleeding",
"K766: Portal hypertension",
"F17210: Nicotine dependence, cigarettes, uncomplicated",
"Z6823: Body mass index [BMI] 23.0-23.9, adult",
"B1920: Unspecified viral hepatitis C without hepatic coma",
"I81: Portal vein thrombosis",
"E43: Unspecified severe protein-calorie malnutrition"
] |
10,005,866 | 26,134,779 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Tylenol / Neurontin
Attending: ___.
Chief Complaint:
Abdominal pain, nausea, vomiting
Major Surgical or Invasive Procedure:
Paracentesis, ___
History of Present Illness:
___ year old male, with ETOH and Hep C cirrhosis,
child's class B (MELD 16) presenting to the ED with acute
abdominal pain concerning for recurrent bowel obstruction. His
surgical history is pertinent for a prior umbilical repair, and
an exploratory laparotomy for a closed loop obstruction
requiring
lysis of an internal hernia.
The patient was in his usual state of health until 5 days ago
when he started having mild diffuse abdominal pain associated
with nausea and multiple episodes of emesis. Denies bilious or
bloody emesis. Last episode of emesis was 2 days ago but still
complains of nausea and abdominal pain. He also mentions that
his
last bowel movement was 2 days ago, same time when he last
passed
flatus. He also mentions some subjective fevers, but denies
taking his temperature. Off note, on ___ this year he
presented
to the ED with similar symptoms which required hospitalization
for SBO that was managed conservatively. Other than that he
denies shortness of breath, palpitations, night sweats,
unexplained weight loss, fatigue/malaise/lethargy, changes in
appetite, trouble with sleep, dysuria.
In the ED, VSS. Patient with persistent nausea and abdominal
pain. No NG tube in place. Abdomen soft but tender to palpation
in right hemi-abdomen. No peritoneal. Labs w/o leukocytosis or
acidosis. Imaging studies suggestive of SBO with transition in
right hemi-abdomen. No signs of bowel ischemia. Moderate
ascites.
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:
VITAL SIGNS: T97.7, BP 156/76, HR 58, RR 18, SpO2 97%RA
GENERAL: AAOx3 NAD
HEENT: NCAT, no scleral icterus
CARDIOVASCULAR: rrr, S1S2
PULMONARY: CTABL, non-labored respirations
GASTROINTESTINAL: soft, minimally distended per baseline, mildly
TTP over R abdomen - much improved from admission and consistent
with baseline. No guarding, rebound, or peritoneal signs.
EXT/MS/SKIN: No cyanosis, clubbing, or edema
NEUROLOGICAL: Strength and sensation grossly intact
Pertinent Results:
Admission labs:
___ 06:10PM BLOOD WBC-7.8 RBC-3.46* Hgb-12.0* Hct-35.9*
MCV-104* MCH-34.7* MCHC-33.4 RDW-15.6* RDWSD-58.6* Plt ___
___ 06:10PM BLOOD Glucose-99 UreaN-5* Creat-0.6 Na-134*
K-3.6 Cl-98 HCO3-25 AnGap-11
___ 06:10PM BLOOD ALT-16 AST-44* AlkPhos-122 TotBili-2.7*
___ 06:10PM BLOOD Albumin-2.7* Calcium-8.1* Phos-2.9
Mg-1.4*
___ 06:10PM BLOOD Lipase-___ year old male with ETOH and Hep C cirrhosis, child's class
B, presented to the ED with acute abdominal pain, nausea and
vomiting concerning for recurrent bowel obstruction. His initial
CT abdomen showed slightly dilated loops of jejunum with
relative transition point right hemiabdomen followed by
decompressed bowel, distal small bowel loops were normal in
caliber with air and stool present. No pneumatosis, bowel wall
thickening, or pneumoperitoneum were seen. He was admitted to
Transplant surgery and kept NPO with IV fluid. Serial abdominal
exams were done noting increased distension and tenderness. No
free air was seen on KUB. A nasogastric tube was placed to
decompress the stomach and a Foley catheter was placed to
closely monitor urine output. He was given a dulcolax
suppository with passage of a BM.
Lactate increased the next day to 2.1 then 3.1. A CT was done
that showed colonic thickening but no obstruction. He continued
to require IV fluid bolus for low u/o.Lactate decrease to 1.9.
By hospital day 4, exam was improved and lactate had decreased.
The foley was removed. On ___, he tolerated NG clamp trials
and the NG was removed.
On ___, a clear diet was tolerated and this advanced to
regular diet that he also tolerated. However, over night, he c/o
sudden right hemi-abdominal pain and gas pain. Simethicone was
administered with relief. He was moving his bowels without
difficulty.
Hepatology was consulted and recommended a paracentesis. This
done on ___ with 0.4 liter removed. Cell count was notable for
WBC-TNC and zero polys. Culture of ascites was negative.
On ___, he felt ready for discharge to home. His home Nadolol
was held as his heart rates were in the ___. SBP ranged
between 104-160s.
On ___, t.bili increased from 2.0 to 2.4. A liver duplex was
done to evaluate his portal vein given h/o portal vein thrombus.
U/S demonstrated patent main and right portal vein, small
ascites and small right pleural effusion.
He was discharged to home in stable condition.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Famotidine 20 mg PO BID
2. Furosemide 20 mg PO DAILY
3. Lactulose 30 mL PO QID
4. Lidocaine 5% Patch 1 PTCH TD QAM
5. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN pain
6. Potassium Chloride 20 mEq PO DAILY
7. Spironolactone 50 mg PO DAILY
8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY SBP prophylaxis
9. Bisacodyl ___AILY:PRN constipation
10. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral DAILY
11. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Simethicone 40-80 mg PO TID:PRN gas pain
2. Bisacodyl ___AILY:PRN constipation
3. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral DAILY
4. Famotidine 20 mg PO BID
5. Furosemide 20 mg PO DAILY
6. Lactulose 30 mL PO QID
7. Multivitamins 1 TAB PO DAILY
8. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN pain
continue to follow up with your outpatient provider for
management
9. Potassium Chloride 20 mEq PO DAILY
Hold for K > 5.0
10. Spironolactone 50 mg PO DAILY
11. Sulfameth/Trimethoprim SS 1 TAB PO DAILY SBP prophylaxis
Discharge Disposition:
Home
Discharge Diagnosis:
Cirrhosis
Abdominal pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call Dr. ___ office at ___ for fever > 101,
chills, nausea, vomiting, diarrhea, constipation, increased
abdominal pain, pain not controlled by your pain medication,
swelling of the abdomen or ankles, yellowing of the skin or
eyes, inability to tolerate food, fluids or medications, or any
other concerning symptoms.
You may return to your usual healthy diet. If your abdomen
becomes distended, you stop passing gas, or you begin burping,
go back to having only sips of clear liquids. If your symptoms
worsen or do not resolve, call the clinic number above or come
to the ED.
No driving if taking narcotic pain medications.
You did not have surgery on this admission and do not need a
surgical follow-up visit. However, please keep the appointment
we have made for you with your usual hepatologist Dr. ___ to
monitor your liver function.
Followup Instructions:
___
|
[
"K56600",
"K766",
"I8510",
"K7031",
"F17210",
"M47818"
] |
Allergies: Tylenol / Neurontin Chief Complaint: Abdominal pain, nausea, vomiting Major Surgical or Invasive Procedure: Paracentesis, [MASKED] History of Present Illness: [MASKED] year old male, with ETOH and Hep C cirrhosis, child's class B (MELD 16) presenting to the ED with acute abdominal pain concerning for recurrent bowel obstruction. His surgical history is pertinent for a prior umbilical repair, and an exploratory laparotomy for a closed loop obstruction requiring lysis of an internal hernia. The patient was in his usual state of health until 5 days ago when he started having mild diffuse abdominal pain associated with nausea and multiple episodes of emesis. Denies bilious or bloody emesis. Last episode of emesis was 2 days ago but still complains of nausea and abdominal pain. He also mentions that his last bowel movement was 2 days ago, same time when he last passed flatus. He also mentions some subjective fevers, but denies taking his temperature. Off note, on [MASKED] this year he presented to the ED with similar symptoms which required hospitalization for SBO that was managed conservatively. Other than that he denies shortness of breath, palpitations, night sweats, unexplained weight loss, fatigue/malaise/lethargy, changes in appetite, trouble with sleep, dysuria. In the ED, VSS. Patient with persistent nausea and abdominal pain. No NG tube in place. Abdomen soft but tender to palpation in right hemi-abdomen. No peritoneal. Labs w/o leukocytosis or acidosis. Imaging studies suggestive of SBO with transition in right hemi-abdomen. No signs of bowel ischemia. Moderate ascites. 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 ([MASKED]) -SBO requiring Ex lap & repair of ruptured umbilical hernia with lysis of adhesions ([MASKED]) - Abdominal Hematoma evacuation ([MASKED]) - Abdominal incision opened, wound vac placed ([MASKED]) Social History: [MASKED] Family History: Sister and brother both with "collapsed lungs." No family history of liver disease. Physical Exam: VITAL SIGNS: T97.7, BP 156/76, HR 58, RR 18, SpO2 97%RA GENERAL: AAOx3 NAD HEENT: NCAT, no scleral icterus CARDIOVASCULAR: rrr, S1S2 PULMONARY: CTABL, non-labored respirations GASTROINTESTINAL: soft, minimally distended per baseline, mildly TTP over R abdomen - much improved from admission and consistent with baseline. No guarding, rebound, or peritoneal signs. EXT/MS/SKIN: No cyanosis, clubbing, or edema NEUROLOGICAL: Strength and sensation grossly intact Pertinent Results: Admission labs: [MASKED] 06:10PM BLOOD WBC-7.8 RBC-3.46* Hgb-12.0* Hct-35.9* MCV-104* MCH-34.7* MCHC-33.4 RDW-15.6* RDWSD-58.6* Plt [MASKED] [MASKED] 06:10PM BLOOD Glucose-99 UreaN-5* Creat-0.6 Na-134* K-3.6 Cl-98 HCO3-25 AnGap-11 [MASKED] 06:10PM BLOOD ALT-16 AST-44* AlkPhos-122 TotBili-2.7* [MASKED] 06:10PM BLOOD Albumin-2.7* Calcium-8.1* Phos-2.9 Mg-1.4* [MASKED] 06:10PM BLOOD Lipase-[MASKED] year old male with ETOH and Hep C cirrhosis, child's class B, presented to the ED with acute abdominal pain, nausea and vomiting concerning for recurrent bowel obstruction. His initial CT abdomen showed slightly dilated loops of jejunum with relative transition point right hemiabdomen followed by decompressed bowel, distal small bowel loops were normal in caliber with air and stool present. No pneumatosis, bowel wall thickening, or pneumoperitoneum were seen. He was admitted to Transplant surgery and kept NPO with IV fluid. Serial abdominal exams were done noting increased distension and tenderness. No free air was seen on KUB. A nasogastric tube was placed to decompress the stomach and a Foley catheter was placed to closely monitor urine output. He was given a dulcolax suppository with passage of a BM. Lactate increased the next day to 2.1 then 3.1. A CT was done that showed colonic thickening but no obstruction. He continued to require IV fluid bolus for low u/o.Lactate decrease to 1.9. By hospital day 4, exam was improved and lactate had decreased. The foley was removed. On [MASKED], he tolerated NG clamp trials and the NG was removed. On [MASKED], a clear diet was tolerated and this advanced to regular diet that he also tolerated. However, over night, he c/o sudden right hemi-abdominal pain and gas pain. Simethicone was administered with relief. He was moving his bowels without difficulty. Hepatology was consulted and recommended a paracentesis. This done on [MASKED] with 0.4 liter removed. Cell count was notable for WBC-TNC and zero polys. Culture of ascites was negative. On [MASKED], he felt ready for discharge to home. His home Nadolol was held as his heart rates were in the [MASKED]. SBP ranged between 104-160s. On [MASKED], t.bili increased from 2.0 to 2.4. A liver duplex was done to evaluate his portal vein given h/o portal vein thrombus. U/S demonstrated patent main and right portal vein, small ascites and small right pleural effusion. He was discharged to home in stable condition. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Famotidine 20 mg PO BID 2. Furosemide 20 mg PO DAILY 3. Lactulose 30 mL PO QID 4. Lidocaine 5% Patch 1 PTCH TD QAM 5. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN pain 6. Potassium Chloride 20 mEq PO DAILY 7. Spironolactone 50 mg PO DAILY 8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY SBP prophylaxis 9. Bisacodyl AILY:PRN constipation 10. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral DAILY 11. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Simethicone 40-80 mg PO TID:PRN gas pain 2. Bisacodyl AILY:PRN constipation 3. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit oral DAILY 4. Famotidine 20 mg PO BID 5. Furosemide 20 mg PO DAILY 6. Lactulose 30 mL PO QID 7. Multivitamins 1 TAB PO DAILY 8. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN pain continue to follow up with your outpatient provider for management 9. Potassium Chloride 20 mEq PO DAILY Hold for K > 5.0 10. Spironolactone 50 mg PO DAILY 11. Sulfameth/Trimethoprim SS 1 TAB PO DAILY SBP prophylaxis Discharge Disposition: Home Discharge Diagnosis: Cirrhosis Abdominal pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call Dr. [MASKED] office at [MASKED] for fever > 101, chills, nausea, vomiting, diarrhea, constipation, increased abdominal pain, pain not controlled by your pain medication, swelling of the abdomen or ankles, yellowing of the skin or eyes, inability to tolerate food, fluids or medications, or any other concerning symptoms. You may return to your usual healthy diet. If your abdomen becomes distended, you stop passing gas, or you begin burping, go back to having only sips of clear liquids. If your symptoms worsen or do not resolve, call the clinic number above or come to the ED. No driving if taking narcotic pain medications. You did not have surgery on this admission and do not need a surgical follow-up visit. However, please keep the appointment we have made for you with your usual hepatologist Dr. [MASKED] to monitor your liver function. Followup Instructions: [MASKED]
|
[] |
[
"F17210"
] |
[
"K56600: Partial intestinal obstruction, unspecified as to cause",
"K766: Portal hypertension",
"I8510: Secondary esophageal varices without bleeding",
"K7031: Alcoholic cirrhosis of liver with ascites",
"F17210: Nicotine dependence, cigarettes, uncomplicated",
"M47818: Spondylosis without myelopathy or radiculopathy, sacral and sacrococcygeal region"
] |
10,005,866 | 27,167,814 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abd pain
Major Surgical or Invasive Procedure:
___: ex-lap and LOA
___: hematoma evacuation
___: Incision opened and VAC placed
History of Present Illness:
___ with HCV, ETOH cirrhosis (MELD 13, MELD-Na 18)p/w 5 days of
nausea, vomiting, abdominal pain and melena. His symptoms
started 5 days ago and he has not been able to maintain adequate
PO intake since. His pain was initially diffuse but is now
localized to the RLQ. Denies fevers or chills. No prior similar
episodes in the past. The patient is followed by Dr. ___ at
___. Per patient report his liver disease has
been stable in the past ___ years and his ascites has been well
controlled with medical
therapy (last paracenthesis over one year ago per pt report).
Last EGD on file done in ___, significant for 2 bleeding
gastric ulcers and one duodenal ulcer.
Past Medical History:
HCV, cirrhosis,lumbar and sacral osteoarthritis, FTT, gastric
and
duodenal ulcers
Social History:
___
Family History:
Non-Contributory
Physical Exam:
Temp: 98.5; P: 89; BP: 109/69; RR: 18; O2: 100% RA
General: alert, OrientedX3; in no acute distress
HEENT: atraumatic, normocephalic; oral mucosa moist
Resp: clear breath sounds bilaterally
CV: RRR; no murmurs, rubs, or gallops
Abd: soft, protuberant, mid-line vac intact
Vac measurement: 5cm long x2cm wide x1cm deep; low suction,
-75mm Hg
Extr: atraumatic, skin intact
Pertinent Results:
___ 05:00AM BLOOD WBC-7.2 RBC-2.11* Hgb-7.2* Hct-22.2*
MCV-105* MCH-34.1* MCHC-32.4 RDW-19.5* RDWSD-73.1* Plt ___
___ 07:30AM BLOOD WBC-7.3 RBC-3.44* Hgb-11.9* Hct-35.3*
MCV-103* MCH-34.6* MCHC-33.7 RDW-14.8 RDWSD-55.3* Plt ___
___ 05:20AM BLOOD ___ PTT-41.5* ___
___ 05:00AM BLOOD Glucose-86 UreaN-10 Creat-0.5 Na-131*
K-3.8 Cl-103 HCO3-22 AnGap-10
___ 04:40AM BLOOD ALT-14 AST-38 AlkPhos-83 TotBili-3.4*
___ 07:30AM BLOOD Lipase-126*
___ 05:00AM BLOOD Albumin-2.2* Calcium-7.2* Phos-2.4*
Mg-1.7
___
CT ABD & PELVIS WITH CO
IMPRESSION:
1. Large right rectus sheath hematoma measuring 9 x 5.9 x 8.5 cm
with evidence of active extravasation. Given patient's history
of cirrhosis and portal hypertension and venous collaterals, it
is unclear whether the source of this hematoma is arterial or
venous.
2. Moderate right-sided pleural effusion.
3. Cirrhotic appearing liver, extensive esophageal, perigastric,
and
perisplenic varices, and large volume ascites.
___
PARACENTESIS DIAG/THERA
IMPRESSION:
Technically successful ultrasound-guided diagnostic and
therapeutic
paracentesis removing 0.8 L of serosanguineous ascitic fluid.
Brief Hospital Course:
Mr. ___ is a ___ year old male with a history of HCV cirrhosis
who presented to ___ on ___ with the chief complaint of
abdominal pain; evaluation in the ED by surgery revealed
localized abdominal pain, with clinical and radiological signs
of an acute abdomen with concern for an internal hernia. The
patient was taken to the OR for a lysis of adhesions and relief
of obstruction due to multiple adhesions into the pelvis causing
an internal loop obstruction. The patient tolerated the
procedure well, please refer to the operative report for further
details. Post-procedure the patient was extubated in PACU due to
prolonged sedation, which went unremarkably. He did receive 24
hours of cefazolin after surgery, in addition to 5% albumin for
a total of 500cc for volume support.
On POD1: The patient was kept NPO, with a NG tube in place. He
electrolytes were closely monitored and repleted as necessary.
His pain was further managed with IV and PO pain medications.
POD2: a NGT clamp trial was performed, and the patient was
started on glutamine supplementation. His electrolytes were
continued to be closely monitored and repleted. There was a
concern for a RUE DVT due to difficult CVL placement in the OR;
however, a repeat RUE/neck US showed no evidence of a DVT.
POD3: the patient underwent a KUB, which did not show signs of
obstruction or ileus. NGT was dc'd, and the patient was kept
NPO. He electrolytes were repleted as per protocol. His foley
catheter was removed at mid-night, and the patient voided
spontaneously.
POD4: the patient complained of a cough with intermittent sputum
production, he was given a PRN nebulizer therapy and a PA/LAT
cxr was consistent with clearing of a prior mucous plug. The
patient was started on a clear liquid diet, and his IVF were
stopped once he was taking in a good amount PO. His home Lasix
dose was continued as well. The patient's expected
post-operative pain and transient electrolyte abnormalities were
followed and corrected.
POD5: overnight the patient complained of ___
erythema, along with fluctuance and increased pain/tenderness.
An Abd/Pelv CT scan without contrast revealed a large right
rectus sheath hematoma measuring 9 x 5.9 x 8.5 cm with evidence
of active extravasation; given those findings, several wound
staples were removed at bed-side with the plan to take to OR as
soon as possible. The patient received a ___ in the
interim due to continuous oozing from his abdominal wound. A
foley was placed due to urinary retention. The patient was taken
to the OR and a rectus sheath hematoma was evacuated, and any
active bleeders were treated with argon beam laser. A wound vac
was placed in the OR for wound management. Post-op the patient's
medications were resumed, and he was started on a clear liquid
diet.
POD6: the patient tolerated his clear diet well and was advanced
to a regular diet, while his IVF were dc'd. His diuretics were
restarted and he was given 1U of FFP due to a high INR and
anticipation of a paracentesis. The patient's levaquin for
presumed pneumonia was changed to vanc, cefepime for broader
coverage; in addition, he underwent a nasal MRSA screen which
was negative, along with sputum cx which grew commensal flora.
The patient under paracentesis due to abdominal distention,
where 0.8L were removed, and cell count was not consistent with
SBP. The patient received 12.5 grams of albumin for repletion.
POD7: the patient was restarted on his lactulose, his foley
dc'd, and a vac placed.
POD8: the patient was managed for his routine pain control,
electrolyte repletion, along with ambulation.
POD9: a physical therapy consult was placed, and the patient
resumed his PO levaquin to complete a 7-day course.
POD10-11: an occupation therapy consult was placed, and the
patient was discharged to rehab.
The patient's vac was changed on ___ its measurements are
5cmX2cmX1cm deep, and the vac is set on min suction at -75 mmHg
At the time of discharge, the patient was comfortable with the
discharge plan and recommendations.
Medications on Admission:
Spironolactone 50 mg daily
Furosemide 20 mg daily
Lactulose 20 GM/30 ML solution 30 mLs by mouth 3 (three) times
daily.
Lidocaine 5 % patch
MVI
Potassium chloride ___ MEQ tablet1 tablet by mouth daily.
Discharge Medications:
1. Furosemide 20 mg PO DAILY
2. Lactulose 30 mL PO TID
Titrate to ___ bowel movements daily
3. Spironolactone 50 mg PO DAILY
4. Famotidine 20 mg PO Q12H
5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
6. Lidocaine 5% Patch 1 PTCH TD QAM
7. Multivitamins 1 TAB PO DAILY
8. Potassium Chloride 10 mEq PO DAILY
Hold for K > 5
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
ETOH Cirrhosis
Small bowel obstruction
Rectus sheath hematoma
Pneumonia
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 contact Dr. ___ office at ___ if the patient
develops fever > 101, chills, bleeding from the wound, nausea,
vomiting, diarrhea, constipation, inability to tolerate food,
fluids or medications, increased abdominal pain, jaundice ;
yellowing of the skin or eyes, VAC fails to hold suction or any
other concerns
No lifting more than 10 pounds
VAC dressing change to abdominal wound q 3 days using black foam
and 75 mmHG continuous suction. If VAC fails, wound may be
temporarily dressed with a NS damp to dry dressing.
Followup Instructions:
___
|
[
"K565",
"E43",
"J189",
"J952",
"K766",
"M96831",
"D62",
"T814XXA",
"L03311",
"K7031",
"M47817",
"Z6823",
"F17210",
"D696",
"Y838",
"Y92239",
"T17990A",
"R339"
] |
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Abd pain Major Surgical or Invasive Procedure: [MASKED]: ex-lap and LOA [MASKED]: hematoma evacuation [MASKED]: Incision opened and VAC placed History of Present Illness: [MASKED] with HCV, ETOH cirrhosis (MELD 13, MELD-Na 18)p/w 5 days of nausea, vomiting, abdominal pain and melena. His symptoms started 5 days ago and he has not been able to maintain adequate PO intake since. His pain was initially diffuse but is now localized to the RLQ. Denies fevers or chills. No prior similar episodes in the past. The patient is followed by Dr. [MASKED] at [MASKED]. Per patient report his liver disease has been stable in the past [MASKED] years and his ascites has been well controlled with medical therapy (last paracenthesis over one year ago per pt report). Last EGD on file done in [MASKED], significant for 2 bleeding gastric ulcers and one duodenal ulcer. Past Medical History: HCV, cirrhosis,lumbar and sacral osteoarthritis, FTT, gastric and duodenal ulcers Social History: [MASKED] Family History: Non-Contributory Physical Exam: Temp: 98.5; P: 89; BP: 109/69; RR: 18; O2: 100% RA General: alert, OrientedX3; in no acute distress HEENT: atraumatic, normocephalic; oral mucosa moist Resp: clear breath sounds bilaterally CV: RRR; no murmurs, rubs, or gallops Abd: soft, protuberant, mid-line vac intact Vac measurement: 5cm long x2cm wide x1cm deep; low suction, -75mm Hg Extr: atraumatic, skin intact Pertinent Results: [MASKED] 05:00AM BLOOD WBC-7.2 RBC-2.11* Hgb-7.2* Hct-22.2* MCV-105* MCH-34.1* MCHC-32.4 RDW-19.5* RDWSD-73.1* Plt [MASKED] [MASKED] 07:30AM BLOOD WBC-7.3 RBC-3.44* Hgb-11.9* Hct-35.3* MCV-103* MCH-34.6* MCHC-33.7 RDW-14.8 RDWSD-55.3* Plt [MASKED] [MASKED] 05:20AM BLOOD [MASKED] PTT-41.5* [MASKED] [MASKED] 05:00AM BLOOD Glucose-86 UreaN-10 Creat-0.5 Na-131* K-3.8 Cl-103 HCO3-22 AnGap-10 [MASKED] 04:40AM BLOOD ALT-14 AST-38 AlkPhos-83 TotBili-3.4* [MASKED] 07:30AM BLOOD Lipase-126* [MASKED] 05:00AM BLOOD Albumin-2.2* Calcium-7.2* Phos-2.4* Mg-1.7 [MASKED] CT ABD & PELVIS WITH CO IMPRESSION: 1. Large right rectus sheath hematoma measuring 9 x 5.9 x 8.5 cm with evidence of active extravasation. Given patient's history of cirrhosis and portal hypertension and venous collaterals, it is unclear whether the source of this hematoma is arterial or venous. 2. Moderate right-sided pleural effusion. 3. Cirrhotic appearing liver, extensive esophageal, perigastric, and perisplenic varices, and large volume ascites. [MASKED] PARACENTESIS DIAG/THERA IMPRESSION: Technically successful ultrasound-guided diagnostic and therapeutic paracentesis removing 0.8 L of serosanguineous ascitic fluid. Brief Hospital Course: Mr. [MASKED] is a [MASKED] year old male with a history of HCV cirrhosis who presented to [MASKED] on [MASKED] with the chief complaint of abdominal pain; evaluation in the ED by surgery revealed localized abdominal pain, with clinical and radiological signs of an acute abdomen with concern for an internal hernia. The patient was taken to the OR for a lysis of adhesions and relief of obstruction due to multiple adhesions into the pelvis causing an internal loop obstruction. The patient tolerated the procedure well, please refer to the operative report for further details. Post-procedure the patient was extubated in PACU due to prolonged sedation, which went unremarkably. He did receive 24 hours of cefazolin after surgery, in addition to 5% albumin for a total of 500cc for volume support. On POD1: The patient was kept NPO, with a NG tube in place. He electrolytes were closely monitored and repleted as necessary. His pain was further managed with IV and PO pain medications. POD2: a NGT clamp trial was performed, and the patient was started on glutamine supplementation. His electrolytes were continued to be closely monitored and repleted. There was a concern for a RUE DVT due to difficult CVL placement in the OR; however, a repeat RUE/neck US showed no evidence of a DVT. POD3: the patient underwent a KUB, which did not show signs of obstruction or ileus. NGT was dc'd, and the patient was kept NPO. He electrolytes were repleted as per protocol. His foley catheter was removed at mid-night, and the patient voided spontaneously. POD4: the patient complained of a cough with intermittent sputum production, he was given a PRN nebulizer therapy and a PA/LAT cxr was consistent with clearing of a prior mucous plug. The patient was started on a clear liquid diet, and his IVF were stopped once he was taking in a good amount PO. His home Lasix dose was continued as well. The patient's expected post-operative pain and transient electrolyte abnormalities were followed and corrected. POD5: overnight the patient complained of [MASKED] erythema, along with fluctuance and increased pain/tenderness. An Abd/Pelv CT scan without contrast revealed a large right rectus sheath hematoma measuring 9 x 5.9 x 8.5 cm with evidence of active extravasation; given those findings, several wound staples were removed at bed-side with the plan to take to OR as soon as possible. The patient received a [MASKED] in the interim due to continuous oozing from his abdominal wound. A foley was placed due to urinary retention. The patient was taken to the OR and a rectus sheath hematoma was evacuated, and any active bleeders were treated with argon beam laser. A wound vac was placed in the OR for wound management. Post-op the patient's medications were resumed, and he was started on a clear liquid diet. POD6: the patient tolerated his clear diet well and was advanced to a regular diet, while his IVF were dc'd. His diuretics were restarted and he was given 1U of FFP due to a high INR and anticipation of a paracentesis. The patient's levaquin for presumed pneumonia was changed to vanc, cefepime for broader coverage; in addition, he underwent a nasal MRSA screen which was negative, along with sputum cx which grew commensal flora. The patient under paracentesis due to abdominal distention, where 0.8L were removed, and cell count was not consistent with SBP. The patient received 12.5 grams of albumin for repletion. POD7: the patient was restarted on his lactulose, his foley dc'd, and a vac placed. POD8: the patient was managed for his routine pain control, electrolyte repletion, along with ambulation. POD9: a physical therapy consult was placed, and the patient resumed his PO levaquin to complete a 7-day course. POD10-11: an occupation therapy consult was placed, and the patient was discharged to rehab. The patient's vac was changed on [MASKED] its measurements are 5cmX2cmX1cm deep, and the vac is set on min suction at -75 mmHg At the time of discharge, the patient was comfortable with the discharge plan and recommendations. Medications on Admission: Spironolactone 50 mg daily Furosemide 20 mg daily Lactulose 20 GM/30 ML solution 30 mLs by mouth 3 (three) times daily. Lidocaine 5 % patch MVI Potassium chloride [MASKED] MEQ tablet1 tablet by mouth daily. Discharge Medications: 1. Furosemide 20 mg PO DAILY 2. Lactulose 30 mL PO TID Titrate to [MASKED] bowel movements daily 3. Spironolactone 50 mg PO DAILY 4. Famotidine 20 mg PO Q12H 5. OxycoDONE (Immediate Release) [MASKED] mg PO Q4H:PRN pain 6. Lidocaine 5% Patch 1 PTCH TD QAM 7. Multivitamins 1 TAB PO DAILY 8. Potassium Chloride 10 mEq PO DAILY Hold for K > 5 Discharge Disposition: Extended Care Facility: [MASKED] [MASKED] Diagnosis: ETOH Cirrhosis Small bowel obstruction Rectus sheath hematoma Pneumonia 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 contact Dr. [MASKED] office at [MASKED] if the patient develops fever > 101, chills, bleeding from the wound, nausea, vomiting, diarrhea, constipation, inability to tolerate food, fluids or medications, increased abdominal pain, jaundice ; yellowing of the skin or eyes, VAC fails to hold suction or any other concerns No lifting more than 10 pounds VAC dressing change to abdominal wound q 3 days using black foam and 75 mmHG continuous suction. If VAC fails, wound may be temporarily dressed with a NS damp to dry dressing. Followup Instructions: [MASKED]
|
[] |
[
"D62",
"F17210",
"D696"
] |
[
"K565: Intestinal adhesions [bands] with obstruction (postinfection)",
"E43: Unspecified severe protein-calorie malnutrition",
"J189: Pneumonia, unspecified organism",
"J952: Acute pulmonary insufficiency following nonthoracic surgery",
"K766: Portal hypertension",
"M96831: Postprocedural hemorrhage of a musculoskeletal structure following other procedure",
"D62: Acute posthemorrhagic anemia",
"T814XXA: Infection following a procedure",
"L03311: Cellulitis of abdominal wall",
"K7031: Alcoholic cirrhosis of liver with ascites",
"M47817: Spondylosis without myelopathy or radiculopathy, lumbosacral region",
"Z6823: Body mass index [BMI] 23.0-23.9, adult",
"F17210: Nicotine dependence, cigarettes, uncomplicated",
"D696: Thrombocytopenia, unspecified",
"Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure",
"Y92239: Unspecified place in hospital as the place of occurrence of the external cause",
"T17990A: Other foreign object in respiratory tract, part unspecified in causing asphyxiation, initial encounter",
"R339: Retention of urine, unspecified"
] |
10,005,909 | 20,199,380 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
amoxicillin
Attending: ___.
Chief Complaint:
___ Syndrome
Major Surgical or Invasive Procedure:
___ Thrombolysis, mechanical thrombectomy
___ IVC filter placement
Repeat mechanical thrombectomy, angiojet
Common iliac wall stent x2
History of Present Illness:
Ms. ___ is a ___ with hx of hypothyroidism presenting with
left
leg swelling and pain. She was in her usual state of health
until
last night when she noted progressive left leg swelling and
pain.
Over the night she developed worsening pain in her left groin
pain radiating down her leg which prompted her to present to
___ for further evaluation in the morning. On
venous duplex, she was found to extensive left leg DVT. She was
started on a heparin gtt with a loading bolus and transferred to
___ for further management. She denies recent long periods of
immobility, travel history, or history of DVT. No recent surgery
or leg trauma. Denies shortness or breath or leg weakness,
parasthesias or loss of sensation. No known hypercoaguability
disorder. Her mother notes a possible GSV aneurysm which was
resected after a pregnancy many years ago. Her father had a DVT
after a prolonged ICU course. Vascular surgery was consulted for
further management.
Past Medical History:
Hypothyroidism, depression
Social History:
___
Family History:
No family history of hypercoagulability disorders. Father had
history of DVT while hospitalized in the ICU.
Physical Exam:
Physical Exam on Discharge:
Vitals: 99 100 122/74 24 100%RA
GEN: AOx3, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses
Ext: LLE mildly swollen, wrapped with ace wrap, no RLE swelling,
no evidence of phlegmasia, strength and sensation equal
Pulses: R: p/p/p/p L: p/p/p/p
Pertinent Results:
___ 07:14AM BLOOD WBC-13.1* RBC-2.88* Hgb-8.5* Hct-26.6*
MCV-92 MCH-29.5 MCHC-32.0 RDW-13.5 RDWSD-45.2 Plt ___
___ 07:14AM BLOOD Plt ___
___ 07:14AM BLOOD ___ PTT-84.5* ___
___ 07:14AM BLOOD Glucose-92 UreaN-6 Creat-0.6 Na-140 K-3.3
Cl-104 HCO3-25 AnGap-14
___ 07:14AM BLOOD Calcium-8.2* Phos-2.6* Mg-1.9
___ 07:14AM BLOOD
Brief Hospital Course:
The patient was admitted on ___ for left lower extremity
swelling. CTA demonstrated right iliac artery compression of the
left iliac vein, and the patient was started on heparin. The
patient was brought to the operating room on ___ and underwent
IVC filter placement and catheter-directed thrombolysis, which
was the patient had no evidence of hematoma and was transferred
to the PACU for recovery, where she remained hemodynamically
stable. Hematocrit q6hrs remained stable, and the patient
complained of mild back pain, which improved with pain
management.
The patient was closely monitored in the ICU and remained
stable. She was brought back to the OR on ___ for mechanical
thrombectomy and placement of left CIV wall stent. The procedure
was without complications. The patient did well intraoperatively
and was transferred back to the ICU, where she continued to
recover. On ___, her diet was advanced and foley was
d/c'ed. She was discharged to home on POD#2 in stable condition
with rivaroxaban 15mg BID for first 3 weeks, followed by 20mg
daily. Follow-up has been arranged with Dr. ___ in clinic
with surveillance with LLE duplex in 3 wks.
At the time of discharge the patient's pain was well controlled
with oral medications, thrombectomy incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient will follow up with a LLE duplex and
Dr. ___ in three weeks. She will be discharged on xarelto. A
thorough discussion was had with the patient regarding the
diagnosis and expected post-discharge course including reasons
to call the office or return to the hospital,
and all questions were answered. The patient was also given
written instructions concerning precautionary instructions and
the appropriate follow-up care. The patient expressed readiness
for discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. DULoxetine 120 mg PO DAILY
2. Levothyroxine Sodium 75 mcg PO DAILY
3. ClonazePAM 0.5 mg PO BID
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every four hours Disp
#*30 Tablet Refills:*0
3. Rivaroxaban 15 mg PO BID
for first three weeks only
RX *rivaroxaban [___] 15 mg 1 tablet(s) by mouth twice a day
Disp #*42 Tablet Refills:*0
4. Rivaroxaban 20 mg PO DAILY
after first 3 weeks
RX *rivaroxaban [___] 20 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*2
5. ClonazePAM 0.5 mg PO BID
6. DULoxetine 120 mg PO DAILY
7. Levothyroxine Sodium 75 mcg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
___ syndrome - DVT in LLE
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Lower Extremity Angioplasty/Stent Discharge Instructions
MEDICATION:
Take Aspirin 325mg (enteric coated) once daily
If instructed, take Plavix (Clopidogrel) 75mg once daily
Continue all other medications you were taking before surgery,
unless otherwise directed
You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
WHAT TO EXPECT:
It is normal to have slight swelling of the legs:
Elevate your leg above the level of your heart with pillows
every ___ hours throughout the day and night
Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
Drink plenty of fluids and 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
ACTIVITIES:
When you go home, you may walk and use stairs
You may shower (let the soapy water run over groin incision,
rinse and pat dry)
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area
No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
After 1 week, you may resume sexual activity
After 1 week, gradually increase your activities and distance
walked as you can tolerate
No driving until you are no longer taking pain medications
CALL THE OFFICE FOR: ___
Numbness, coldness or pain in lower extremities
Temperature greater than 101.5F for 24 hours
New or increased drainage from incision or white, yellow or
green drainage from incisions
Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site)
Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office ___. If bleeding does not stop, call
___ for transfer to closest Emergency Room.
Followup Instructions:
___
|
[
"I82422",
"I871",
"I9751",
"Y838",
"Y92234"
] |
Allergies: amoxicillin Chief Complaint: [MASKED] Syndrome Major Surgical or Invasive Procedure: [MASKED] Thrombolysis, mechanical thrombectomy [MASKED] IVC filter placement Repeat mechanical thrombectomy, angiojet Common iliac wall stent x2 History of Present Illness: Ms. [MASKED] is a [MASKED] with hx of hypothyroidism presenting with left leg swelling and pain. She was in her usual state of health until last night when she noted progressive left leg swelling and pain. Over the night she developed worsening pain in her left groin pain radiating down her leg which prompted her to present to [MASKED] for further evaluation in the morning. On venous duplex, she was found to extensive left leg DVT. She was started on a heparin gtt with a loading bolus and transferred to [MASKED] for further management. She denies recent long periods of immobility, travel history, or history of DVT. No recent surgery or leg trauma. Denies shortness or breath or leg weakness, parasthesias or loss of sensation. No known hypercoaguability disorder. Her mother notes a possible GSV aneurysm which was resected after a pregnancy many years ago. Her father had a DVT after a prolonged ICU course. Vascular surgery was consulted for further management. Past Medical History: Hypothyroidism, depression Social History: [MASKED] Family History: No family history of hypercoagulability disorders. Father had history of DVT while hospitalized in the ICU. Physical Exam: Physical Exam on Discharge: Vitals: 99 100 122/74 24 100%RA GEN: AOx3, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, nontender, no rebound or guarding, normoactive bowel sounds, no palpable masses Ext: LLE mildly swollen, wrapped with ace wrap, no RLE swelling, no evidence of phlegmasia, strength and sensation equal Pulses: R: p/p/p/p L: p/p/p/p Pertinent Results: [MASKED] 07:14AM BLOOD WBC-13.1* RBC-2.88* Hgb-8.5* Hct-26.6* MCV-92 MCH-29.5 MCHC-32.0 RDW-13.5 RDWSD-45.2 Plt [MASKED] [MASKED] 07:14AM BLOOD Plt [MASKED] [MASKED] 07:14AM BLOOD [MASKED] PTT-84.5* [MASKED] [MASKED] 07:14AM BLOOD Glucose-92 UreaN-6 Creat-0.6 Na-140 K-3.3 Cl-104 HCO3-25 AnGap-14 [MASKED] 07:14AM BLOOD Calcium-8.2* Phos-2.6* Mg-1.9 [MASKED] 07:14AM BLOOD Brief Hospital Course: The patient was admitted on [MASKED] for left lower extremity swelling. CTA demonstrated right iliac artery compression of the left iliac vein, and the patient was started on heparin. The patient was brought to the operating room on [MASKED] and underwent IVC filter placement and catheter-directed thrombolysis, which was the patient had no evidence of hematoma and was transferred to the PACU for recovery, where she remained hemodynamically stable. Hematocrit q6hrs remained stable, and the patient complained of mild back pain, which improved with pain management. The patient was closely monitored in the ICU and remained stable. She was brought back to the OR on [MASKED] for mechanical thrombectomy and placement of left CIV wall stent. The procedure was without complications. The patient did well intraoperatively and was transferred back to the ICU, where she continued to recover. On [MASKED], her diet was advanced and foley was d/c'ed. She was discharged to home on POD#2 in stable condition with rivaroxaban 15mg BID for first 3 weeks, followed by 20mg daily. Follow-up has been arranged with Dr. [MASKED] in clinic with surveillance with LLE duplex in 3 wks. At the time of discharge the patient's pain was well controlled with oral medications, thrombectomy incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient will follow up with a LLE duplex and Dr. [MASKED] in three weeks. She will be discharged on xarelto. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. DULoxetine 120 mg PO DAILY 2. Levothyroxine Sodium 75 mcg PO DAILY 3. ClonazePAM 0.5 mg PO BID Discharge Medications: 1. Docusate Sodium 100 mg PO BID 2. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg 1 tablet(s) by mouth every four hours Disp #*30 Tablet Refills:*0 3. Rivaroxaban 15 mg PO BID for first three weeks only RX *rivaroxaban [[MASKED]] 15 mg 1 tablet(s) by mouth twice a day Disp #*42 Tablet Refills:*0 4. Rivaroxaban 20 mg PO DAILY after first 3 weeks RX *rivaroxaban [[MASKED]] 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*2 5. ClonazePAM 0.5 mg PO BID 6. DULoxetine 120 mg PO DAILY 7. Levothyroxine Sodium 75 mcg PO DAILY Discharge Disposition: Home Discharge Diagnosis: [MASKED] syndrome - DVT in LLE Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Lower Extremity Angioplasty/Stent Discharge Instructions MEDICATION: Take Aspirin 325mg (enteric coated) once daily If instructed, take Plavix (Clopidogrel) 75mg once daily Continue all other medications you were taking before surgery, unless otherwise directed You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort WHAT TO EXPECT: It is normal to have slight swelling of the legs: Elevate your leg above the level of your heart with pillows every [MASKED] hours throughout the day and night Avoid prolonged periods of standing or sitting without your legs elevated It is normal to feel tired and have a decreased appetite, your appetite will return with time Drink plenty of fluids and 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 ACTIVITIES: When you go home, you may walk and use stairs You may shower (let the soapy water run over groin incision, rinse and pat dry) Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal) After 1 week, you may resume sexual activity After 1 week, gradually increase your activities and distance walked as you can tolerate No driving until you are no longer taking pain medications CALL THE OFFICE FOR: [MASKED] Numbness, coldness or pain in lower extremities Temperature greater than 101.5F for 24 hours New or increased drainage from incision or white, yellow or green drainage from incisions Bleeding from groin puncture site SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site) Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call vascular office [MASKED]. If bleeding does not stop, call [MASKED] for transfer to closest Emergency Room. Followup Instructions: [MASKED]
|
[] |
[] |
[
"I82422: Acute embolism and thrombosis of left iliac vein",
"I871: Compression of vein",
"I9751: Accidental puncture and laceration of a circulatory system organ or structure during a circulatory system procedure",
"Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure",
"Y92234: Operating room of hospital as the place of occurrence of the external cause"
] |
10,006,029 | 20,850,584 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___
Chief Complaint:
Hypotension, ___ on CKD
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ male with history metastatic
RCC, locally advanced cholangiocarcinoma s/p six months of
gemcitabine and cisplatin, and recent diagnosis of pancreatic
acinar cell carcinoma receiving liposomal irinotecan and
___ who presents with hypotension and acute on
chronic renal failure.
He reports that he checks his blood pressure using a machine at
home every morning. His BP this morning was 79/44 about 15
minutes after taking amlodipine, atenolol, and lisinopril. This
was associated with dizziness. Later in the morning repeat check
was 110/70. He notes decreased appetite. He had one loose small
bowel movement yesterday but otherwise no diarrhea.
He presented to clinic for follow-up His vitals were Temp 97.3,
BP 125/58, HR 72, RR 16, and O2 sat 100% RA. Labs were notable
for Cr 2.7 from baseline Cr 1.7-1.8. He was given 2L NS and
referred for direct admission to 11 ___.
On arrival to the floor, patient reports shortness of breath
with
exertion, mild nausea without vomiting, and tingling in his
hands. He denies fevers/chills, night sweats, headache, vision
changes, weakness, cough, hemoptysis, chest pain, palpitations,
abdominal pain, nausea/vomiting, hematemesis,
hematochezia/melena, dysuria, hematuria, and new rashes.
REVIEW OF SYSTEMS: A complete 10-point review of systems was
performed and was negative unless otherwise noted in the HPI.
PAST ONCOLOGIC HISTORY:
- ___: 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
- ___: C25D1 held, admitted for biliary stricture
- ___: Resumed cycle 25 day 1
- ___: Admitted for biliary stricture and
cholangitis, diagnosed with pancreatobiliary adenocarcinoma and
taken off study. ERCP x2 with placement of plastic, then metal
biliary stent. EUS/biopsy of CBD mass showed new
pancreatobiliary
adenocardinoma.
- ___: C1D1 Gemcitabine 1000mg/m2 Cisplatin 25 mg/m2 D1,___: C2D1 Gemcitabine 1000mg/m2 Cisplatin 25 mg/m2 D1,___: C3D1 Gemcitabine 1000mg/m2 Cisplatin 25 mg/m2 D1,___: CT torso showed stable disease
- ___: C4D1 Gemcitabine 1000mg/m2 Cisplatin 25 mg/m2 D1,___: C5D1 Gemcitabine 1000mg/m2 Cisplatin 25 mg/m2 D1,___: MR liver showed ongoing inoperable disease but
stable
- ___: C6D1 Gemcitabine 1000mg/m2 Cisplatin 25 mg/m2
D1,15
dose modified for low counts
- ___: CT torso showed stable disease
- ___: C7D1 Gemcitabine 1000mg/m2 Cisplatin 25 mg/m2
D1,15
- ___: C8D1 Gemcitabine 1000mg/m2 Cisplatin 18.75 mg/m2
D1,15 reduced for CKD
- ___: CT torso showed possible liver lesion and
pancreatic lesion. Biopsy of liver lesion suggests poorly
differentiated carcinoma. Biopsy of pancreas lesion suggests
acinar cell carcinoma.
- ___: C1D1 nanoliposomal irinotecan / ___ / leucovorin
___ I)
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 PHYSICAL EXAM:
VS: Temp 97.9, BP 150/74, HR 71, RR 20, O2 sat 100% RA.
GENERAL: Pleasant man, 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: Soft, non-tender, non-distended, normal bowel sounds.
EXT: Warm, well perfused, no lower extremity edema.
NEURO: A&Ox3, good attention and linear thought, CN II-XII
intact. Gross strength and sensation intact.
SKIN: No significant rashes.
ACCESS: Right chest wall port without erythema.
DISCHARGE PHYSICAL EXAM:
VS: ___ 1623 Temp: 98.1 PO BP: 148/78 HR: 76 RR: 18 O2 sat:
97% O2 delivery: RA
GENERAL: Pleasant man, 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: Soft, non-tender, non-distended, normal bowel sounds.
EXT: Warm, well perfused, no lower extremity edema.
NEURO: A&Ox3, good attention and linear thought, CN II-XII
intact. Gross strength and sensation intact.
SKIN: No significant rashes.
ACCESS: Right chest wall port without erythema.
Pertinent Results:
ADMISSION LABS:
___ 12:45PM BLOOD WBC-5.6 RBC-3.04* Hgb-9.1* Hct-28.6*
MCV-94 MCH-29.9 MCHC-31.8* RDW-14.6 RDWSD-49.4* Plt ___
___ 12:45PM BLOOD Neuts-72.3* Lymphs-17.0* Monos-8.0
Eos-2.0 Baso-0.2 Im ___ AbsNeut-4.05 AbsLymp-0.95*
AbsMono-0.45 AbsEos-0.11 AbsBaso-0.01
___ 12:45PM BLOOD Plt ___
___ 12:45PM BLOOD UreaN-48* Creat-2.7* Na-135 K-4.7 Cl-102
HCO3-18* AnGap-15
___ 12:45PM BLOOD ALT-24 AST-31 LD(LDH)-667* AlkPhos-173*
TotBili-0.4
___ 12:45PM BLOOD Albumin-3.9 Calcium-9.4 Phos-3.1 Mg-2.1
___ 05:54AM BLOOD Hapto-271*
___ 10:41PM URINE Color-Straw Appear-Clear Sp ___
___ 10:41PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 10:41PM URINE Hours-RANDOM Creat-78 Na-34
DISCHARGE LABS:
___ 05:47AM BLOOD WBC-5.2 RBC-2.74* Hgb-8.3* Hct-26.1*
MCV-95 MCH-30.3 MCHC-31.8* RDW-14.6 RDWSD-49.2* Plt ___
___ 05:47AM BLOOD Plt ___
___ 05:47AM BLOOD Glucose-120* UreaN-26* Creat-1.7* Na-141
K-4.9 Cl-106 HCO3-23 AnGap-12
___ 05:47AM BLOOD Calcium-9.0 Phos-3.9 Mg-2.0
PERTINENT STUDIES:
Radiology Report RENAL U.S. Study Date of ___ 8:18 AM
COMPARISON: CT abdomen and pelvis ___
FINDINGS:
The left kidney is surgically absent. A cortical defect is
re-demonstrated in
the interpolar region of the right kidney. There is a 1.3 cm
exophytic simple
cyst arising from the lower pole of the right kidney, stable
from the prior
CT. There is no hydronephrosis or stones bilaterally. Normal
cortical
echogenicity and corticomedullary differentiation are seen
bilaterally.
Right kidney: 11.5 cm
The bladder is moderately well distended and normal in
appearance.
IMPRESSION:
No hydronephrosis. Normal cortical echogenicity and
corticomedullary
differentiation within the remaining right kidney.
Radiology Report CHEST (PORTABLE AP) Study Date of ___
7:22 ___
COMPARISON: CT is available from ___.
FINDINGS:
Port terminates in the mid superior vena cava. Cardiac,
mediastinal and hilar
contours appear stable. There is no pleural effusion or
pneumothorax. Lungs
appear clear.
IMPRESSION:
No evidence of acute cardiopulmonary process.
MICROBIOLOGY:
___ 10:41 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
Brief Hospital Course:
Brief hospital summary:
=======================
Mr. ___ is a ___ male with history metastatic
RCC, locally advanced cholangiocarcinoma s/p six months of
gemcitabine and cisplatin, and recent diagnosis of pancreatic
acinar cell carcinoma receiving liposomal irinotecan and
___ who presents with hypotension and acute on
chronic renal failure. Hypotension and ___ resolved with IVFs
and holding BP medications. He was discharged in stable
condition.
Transitional issues:
==============
[] Hgb on discharge 8.3.
[] Held home lisinopril, atenolol, and amlodipine given concern
for dehydration and hypotension. BPs improved during course of
hospital stay.
[] Please titrate BP medications on outpatient basis as
clinically indicated
[] Cr on discharge 1.7 (baseline appears to be 1.4-1.7). Please
recheck BMP within one week of discharge to trend Cr.
[] Glipizide held on discharge due to increase risk of
hypoglycemia. Would consider d/c vs restart based on renal
function
Acute issues:
==========
# Hypotension: Likely combination of poor PO intake and
dehydration in setting of poor appetite and nausea from new
chemotherapy regimen while continuing multiple home BP
medications. Given IVF and held BP medications with resolution
of hypotension. Orthostatics prior to discharge unremarkable.
# ___ on CKD: Likely prerenal in setting of poor PO intake. FeNa
<1% consistent with diagnosis. Held lisinopril which we will
continue to hold upon discharge. Renal ultrasound without
evidence of hydronephrosis.
# Anemia: Likely secondary to chemotherapy and malignancy.
Hemolysis labs reassuring. No clinical evidence of bleeding. Hgb
on discharge 8.3.
Chronic issues:
===============
# Fatigue: Likely from anemia and chemotherapy side effect.
Stable during course of hospitalization
# Pancreatic Acinar Cell Carcinoma:
# Cholangiocarcinoma:
# Secondary Neoplasm of Liver: Currently on palliative liposomal
___. Follow-up with Dr. ___
# Metastatic Renal Cell Carcinoma:
# Secondary Neoplasm of Lung: He is on a treatment hold due to
the management of his cholangiocarcinoma and now pancreatic
cancer.
# Portal Vein Thrombus: continued home rivaroxaban
# BPH: continued home Flomax
# Hypothyroidism: continued home levothyroxine
# Diabetes: continued home lantus, started humalog ISS, and held
home glipizide while in house and on discharge.
# Anxiety: continued home citalopram
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Ascorbic Acid ___ mg PO DAILY
3. Atenolol 50 mg PO DAILY
4. Levothyroxine Sodium 100 mcg PO DAILY
5. LORazepam 0.5 mg PO DAILY:PRN anxiety/insomnia
6. Multivitamins 1 TAB PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
9. Prochlorperazine 5 mg PO Q8H:PRN nausea/vomiting
10. Tamsulosin 0.4 mg PO QHS
11. Vitamin D 5000 UNIT PO DAILY
12. GlipiZIDE 2.5 mg PO BID
13. Lisinopril 10 mg PO DAILY
14. Fenofibrate 48 mg PO DAILY
15. Amoxicillin ___ mg PO PREOP
16. Citalopram 20 mg PO DAILY
17. Glargine 16 Units Bedtime
18. Rivaroxaban 10 mg PO DAILY
19. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild/Fever
20. Cyanocobalamin 1000 mcg PO DAILY
Discharge Medications:
1. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild/Fever
2. Ascorbic Acid ___ mg PO DAILY
3. Citalopram 20 mg PO DAILY
4. Cyanocobalamin 1000 mcg PO DAILY
5. Fenofibrate 48 mg PO DAILY
6. Glargine 16 Units Bedtime
7. Levothyroxine Sodium 100 mcg PO DAILY
8. LORazepam 0.5 mg PO DAILY:PRN anxiety/insomnia
9. Multivitamins 1 TAB PO DAILY
10. Omeprazole 20 mg PO DAILY
11. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
12. Prochlorperazine 5 mg PO Q8H:PRN nausea/vomiting
13. Rivaroxaban 10 mg PO DAILY
14. Tamsulosin 0.4 mg PO QHS
15. Vitamin D 5000 UNIT PO DAILY
16. HELD- amLODIPine 10 mg PO DAILY This medication was held.
Do not restart amLODIPine until you discuss with your primary
care doctor.
17. HELD- Atenolol 50 mg PO DAILY This medication was held. Do
not restart Atenolol until you discuss with your primary care
doctor.
18. HELD- GlipiZIDE 2.5 mg PO BID This medication was held. Do
not restart GlipiZIDE until you follow up with your PCP.
19. HELD- Lisinopril 10 mg PO DAILY This medication was held.
Do not restart Lisinopril until you discuss with your primary
care doctor.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute Issues:
==========
Hypotension
Acute on chronic CKD
Secondary Issues:
=============
Hypertension
CKD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
======================
DISCHARGE INSTRUCTIONS
======================
Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were admitted for low blood pressures
WHAT HAPPENED TO ME IN THE HOSPITAL?
- We gave you fluids through an IV, and we held your blood
pressure medications. Your blood pressures eventually improved
to normal range.
- We monitored your kidney function which improved with fluids
and holding your blood pressure medications.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Do not take any of your blood pressure medications until you
discuss with your primary care doctor.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
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Allergies: [MASKED] Chief Complaint: Hypotension, [MASKED] on CKD Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [MASKED] is a [MASKED] male with history metastatic RCC, locally advanced cholangiocarcinoma s/p six months of gemcitabine and cisplatin, and recent diagnosis of pancreatic acinar cell carcinoma receiving liposomal irinotecan and [MASKED] who presents with hypotension and acute on chronic renal failure. He reports that he checks his blood pressure using a machine at home every morning. His BP this morning was 79/44 about 15 minutes after taking amlodipine, atenolol, and lisinopril. This was associated with dizziness. Later in the morning repeat check was 110/70. He notes decreased appetite. He had one loose small bowel movement yesterday but otherwise no diarrhea. He presented to clinic for follow-up His vitals were Temp 97.3, BP 125/58, HR 72, RR 16, and O2 sat 100% RA. Labs were notable for Cr 2.7 from baseline Cr 1.7-1.8. He was given 2L NS and referred for direct admission to 11 [MASKED]. On arrival to the floor, patient reports shortness of breath with exertion, mild nausea without vomiting, and tingling in his hands. He denies fevers/chills, night sweats, headache, vision changes, weakness, cough, hemoptysis, chest pain, palpitations, abdominal pain, nausea/vomiting, hematemesis, hematochezia/melena, dysuria, hematuria, and new rashes. REVIEW OF SYSTEMS: A complete 10-point review of systems was performed and was negative unless otherwise noted in the HPI. PAST ONCOLOGIC HISTORY: - [MASKED]: 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 [MASKED], 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. - [MASKED]: Underwent a laparoscopic hand assisted radical right nephrectomy by Dr. [MASKED] pathology showed a renal cell carcinoma, clear cell type, [MASKED] 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 [MASKED], 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 [MASKED] which was a CT torso showed no evidence of recurrent or metastatic disease. - [MASKED]: CT chest showed interval increase in prominence of mediastinal lymph nodes and minimal interval increase in multiple b/l pulmonary nodules, concerning for progression - [MASKED]: Fine needle aspirate of 11R and 11L lymph nodes, which was consistent with metastatic RCC - [MASKED]: CT Torso - mediastinal and hilar nodes and pulmonary lesions increased in size. No definite intra-abdominal sites of disease - [MASKED]: C1D1 [MASKED], randomized to sunitinib - [MASKED]: Multiple grade [MASKED] 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. - [MASKED]: CT Torso: Response of mediastinal lymphadenopathy, bilateral hilar lymphadenopathy, and numerous parenchymal metastases. Stable disease by RECIST (decrease 19.1% from baseline). - [MASKED]: Sunitinib reduced to 37.5 mg daily due to erythematous rash and blistering on palms and sole of right foot. - [MASKED]: CT Torso: Decrease in pulmonary and mediastinal lesions. Stable disease by RECIST 1.1 (decrease 22.5% from baseline). - [MASKED]: CT Torso: Partial response by RECIST 1.1 (decrease 39.8% from baseline). - [MASKED]: CT Torso: Partial response by RECIST 1.1 (decrease 46.3% from baseline). - [MASKED]: CT Torso: Partial response by RECIST 1.1 (decrease 40.3% from baseline). - [MASKED]: CT Torso: Partial response by RECIST 1.1 (decrease 42.6% from baseline). - [MASKED]: CT Torso: Partial response by RECIST 1.1 (decrease 47.7% from baseline). - [MASKED]: CT torso: Ongoing partial response comments: No significant change compared to prior scan. No new lesions. - [MASKED]: CT Torso: PR by RECIST 1.1 - [MASKED]: CT Torso: PR by RECIST 1.1: -54.22% change from baseline and -10.29% change from last scan. -[MASKED]: CT Torso: Partial response: -57.79% from baseline, -7.79% from nadir - [MASKED]: CT Torso shows continued partial response, no significant change compared to prior - [MASKED]: C25D1 held, admitted for biliary stricture - [MASKED]: Resumed cycle 25 day 1 - [MASKED]: Admitted for biliary stricture and cholangitis, diagnosed with pancreatobiliary adenocarcinoma and taken off study. ERCP x2 with placement of plastic, then metal biliary stent. EUS/biopsy of CBD mass showed new pancreatobiliary adenocardinoma. - [MASKED]: C1D1 Gemcitabine 1000mg/m2 Cisplatin 25 mg/m2 D1,[MASKED]: C2D1 Gemcitabine 1000mg/m2 Cisplatin 25 mg/m2 D1,[MASKED]: C3D1 Gemcitabine 1000mg/m2 Cisplatin 25 mg/m2 D1,[MASKED]: CT torso showed stable disease - [MASKED]: C4D1 Gemcitabine 1000mg/m2 Cisplatin 25 mg/m2 D1,[MASKED]: C5D1 Gemcitabine 1000mg/m2 Cisplatin 25 mg/m2 D1,[MASKED]: MR liver showed ongoing inoperable disease but stable - [MASKED]: C6D1 Gemcitabine 1000mg/m2 Cisplatin 25 mg/m2 D1,15 dose modified for low counts - [MASKED]: CT torso showed stable disease - [MASKED]: C7D1 Gemcitabine 1000mg/m2 Cisplatin 25 mg/m2 D1,15 - [MASKED]: C8D1 Gemcitabine 1000mg/m2 Cisplatin 18.75 mg/m2 D1,15 reduced for CKD - [MASKED]: CT torso showed possible liver lesion and pancreatic lesion. Biopsy of liver lesion suggests poorly differentiated carcinoma. Biopsy of pancreas lesion suggests acinar cell carcinoma. - [MASKED]: C1D1 nanoliposomal irinotecan / [MASKED] / leucovorin [MASKED] I) Past Medical History: PAST ONCOLOGIC HISTORY (per OMR): -[MASKED]: 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 [MASKED], 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. -[MASKED]: underwent a laparoscopic hand assisted radical right nephrectomy by Dr. [MASKED] pathology showed a renal cell carcinoma, clear cell type, [MASKED] 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 [MASKED], 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 [MASKED] which was a CT torso showed no evidence of recurrent or metastatic disease. -[MASKED]: CT chest showed interval increase in prominence of mediastinal lymph nodes and minimal interval increase in multiple b/l pulmonary nodules, concerning for progression -[MASKED]: Fine needle aspirate of 11R and 11L lymph nodes, which was consistent with metastatic RCC -[MASKED]: CT Torso - mediastinal and hilar nodes and pulmonary lesions increased in size. No definite intra-abdominal sites of disease -[MASKED]: C1D1 [MASKED], randomized to sunitinib -[MASKED]: Multiple grade [MASKED] 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. -[MASKED]: CT Torso: Response of mediastinal lymphadenopathy, bilateral hilar lymphadenopathy, and numerous parenchymal metastases. Stable disease by RECIST (decrease 19.1% from baseline). -[MASKED]: Sunitinib reduced to 37.5 mg daily due to erythematous rash and blistering on palms and sole of right foot. -[MASKED]: CT Torso: Decrease in pulmonary and mediastinal lesions. Stable disease by RECIST 1.1 (decrease 22.5% from baseline). -[MASKED]: CT Torso: Partial response by RECIST 1.1 (decrease 39.8% from baseline). -[MASKED]: CT Torso: Partial response by RECIST 1.1 (decrease 46.3% from baseline). -[MASKED]: CT Torso: Partial response by RECIST 1.1 (decrease 40.3% from baseline). -[MASKED]: CT Torso: Partial response by RECIST 1.1 (decrease 42.6% from baseline). -[MASKED]: CT Torso: Partial response by RECIST 1.1 (decrease 47.7% from baseline). -[MASKED]: CT torso: Ongoing partial response comments: No significant change compared to prior scan. No new lesions. -[MASKED]: CT Torso: PR by RECIST 1.1 -[MASKED]: CT Torso: PR by RECIST 1.1: -54.22% change from baseline and -10.29% change from last scan. -[MASKED]: CT Torso: partial response: -57.79% from baseline, -7.79% from nadir -[MASKED]: 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: [MASKED] Family History: Colorectal cancer - mother [MASKED] cancer - sister (dx at age [MASKED] Liver cancer - brother [MASKED] cell leukemia - brother [MASKED] - father Physical [MASKED]: ADMISSION PHYSICAL EXAM: VS: Temp 97.9, BP 150/74, HR 71, RR 20, O2 sat 100% RA. GENERAL: Pleasant man, 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: Soft, non-tender, non-distended, normal bowel sounds. EXT: Warm, well perfused, no lower extremity edema. NEURO: A&Ox3, good attention and linear thought, CN II-XII intact. Gross strength and sensation intact. SKIN: No significant rashes. ACCESS: Right chest wall port without erythema. DISCHARGE PHYSICAL EXAM: VS: [MASKED] 1623 Temp: 98.1 PO BP: 148/78 HR: 76 RR: 18 O2 sat: 97% O2 delivery: RA GENERAL: Pleasant man, 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: Soft, non-tender, non-distended, normal bowel sounds. EXT: Warm, well perfused, no lower extremity edema. NEURO: A&Ox3, good attention and linear thought, CN II-XII intact. Gross strength and sensation intact. SKIN: No significant rashes. ACCESS: Right chest wall port without erythema. Pertinent Results: ADMISSION LABS: [MASKED] 12:45PM BLOOD WBC-5.6 RBC-3.04* Hgb-9.1* Hct-28.6* MCV-94 MCH-29.9 MCHC-31.8* RDW-14.6 RDWSD-49.4* Plt [MASKED] [MASKED] 12:45PM BLOOD Neuts-72.3* Lymphs-17.0* Monos-8.0 Eos-2.0 Baso-0.2 Im [MASKED] AbsNeut-4.05 AbsLymp-0.95* AbsMono-0.45 AbsEos-0.11 AbsBaso-0.01 [MASKED] 12:45PM BLOOD Plt [MASKED] [MASKED] 12:45PM BLOOD UreaN-48* Creat-2.7* Na-135 K-4.7 Cl-102 HCO3-18* AnGap-15 [MASKED] 12:45PM BLOOD ALT-24 AST-31 LD(LDH)-667* AlkPhos-173* TotBili-0.4 [MASKED] 12:45PM BLOOD Albumin-3.9 Calcium-9.4 Phos-3.1 Mg-2.1 [MASKED] 05:54AM BLOOD Hapto-271* [MASKED] 10:41PM URINE Color-Straw Appear-Clear Sp [MASKED] [MASKED] 10:41PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG [MASKED] 10:41PM URINE Hours-RANDOM Creat-78 Na-34 DISCHARGE LABS: [MASKED] 05:47AM BLOOD WBC-5.2 RBC-2.74* Hgb-8.3* Hct-26.1* MCV-95 MCH-30.3 MCHC-31.8* RDW-14.6 RDWSD-49.2* Plt [MASKED] [MASKED] 05:47AM BLOOD Plt [MASKED] [MASKED] 05:47AM BLOOD Glucose-120* UreaN-26* Creat-1.7* Na-141 K-4.9 Cl-106 HCO3-23 AnGap-12 [MASKED] 05:47AM BLOOD Calcium-9.0 Phos-3.9 Mg-2.0 PERTINENT STUDIES: Radiology Report RENAL U.S. Study Date of [MASKED] 8:18 AM COMPARISON: CT abdomen and pelvis [MASKED] FINDINGS: The left kidney is surgically absent. A cortical defect is re-demonstrated in the interpolar region of the right kidney. There is a 1.3 cm exophytic simple cyst arising from the lower pole of the right kidney, stable from the prior CT. There is no hydronephrosis or stones bilaterally. Normal cortical echogenicity and corticomedullary differentiation are seen bilaterally. Right kidney: 11.5 cm The bladder is moderately well distended and normal in appearance. IMPRESSION: No hydronephrosis. Normal cortical echogenicity and corticomedullary differentiation within the remaining right kidney. Radiology Report CHEST (PORTABLE AP) Study Date of [MASKED] 7:22 [MASKED] COMPARISON: CT is available from [MASKED]. FINDINGS: Port terminates in the mid superior vena cava. Cardiac, mediastinal and hilar contours appear stable. There is no pleural effusion or pneumothorax. Lungs appear clear. IMPRESSION: No evidence of acute cardiopulmonary process. MICROBIOLOGY: [MASKED] 10:41 pm URINE Source: [MASKED]. **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: NO GROWTH. Brief Hospital Course: Brief hospital summary: ======================= Mr. [MASKED] is a [MASKED] male with history metastatic RCC, locally advanced cholangiocarcinoma s/p six months of gemcitabine and cisplatin, and recent diagnosis of pancreatic acinar cell carcinoma receiving liposomal irinotecan and [MASKED] who presents with hypotension and acute on chronic renal failure. Hypotension and [MASKED] resolved with IVFs and holding BP medications. He was discharged in stable condition. Transitional issues: ============== [] Hgb on discharge 8.3. [] Held home lisinopril, atenolol, and amlodipine given concern for dehydration and hypotension. BPs improved during course of hospital stay. [] Please titrate BP medications on outpatient basis as clinically indicated [] Cr on discharge 1.7 (baseline appears to be 1.4-1.7). Please recheck BMP within one week of discharge to trend Cr. [] Glipizide held on discharge due to increase risk of hypoglycemia. Would consider d/c vs restart based on renal function Acute issues: ========== # Hypotension: Likely combination of poor PO intake and dehydration in setting of poor appetite and nausea from new chemotherapy regimen while continuing multiple home BP medications. Given IVF and held BP medications with resolution of hypotension. Orthostatics prior to discharge unremarkable. # [MASKED] on CKD: Likely prerenal in setting of poor PO intake. FeNa <1% consistent with diagnosis. Held lisinopril which we will continue to hold upon discharge. Renal ultrasound without evidence of hydronephrosis. # Anemia: Likely secondary to chemotherapy and malignancy. Hemolysis labs reassuring. No clinical evidence of bleeding. Hgb on discharge 8.3. Chronic issues: =============== # Fatigue: Likely from anemia and chemotherapy side effect. Stable during course of hospitalization # Pancreatic Acinar Cell Carcinoma: # Cholangiocarcinoma: # Secondary Neoplasm of Liver: Currently on palliative liposomal [MASKED]. Follow-up with Dr. [MASKED] # Metastatic Renal Cell Carcinoma: # Secondary Neoplasm of Lung: He is on a treatment hold due to the management of his cholangiocarcinoma and now pancreatic cancer. # Portal Vein Thrombus: continued home rivaroxaban # BPH: continued home Flomax # Hypothyroidism: continued home levothyroxine # Diabetes: continued home lantus, started humalog ISS, and held home glipizide while in house and on discharge. # Anxiety: continued home citalopram Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Ascorbic Acid [MASKED] mg PO DAILY 3. Atenolol 50 mg PO DAILY 4. Levothyroxine Sodium 100 mcg PO DAILY 5. LORazepam 0.5 mg PO DAILY:PRN anxiety/insomnia 6. Multivitamins 1 TAB PO DAILY 7. Omeprazole 20 mg PO DAILY 8. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 9. Prochlorperazine 5 mg PO Q8H:PRN nausea/vomiting 10. Tamsulosin 0.4 mg PO QHS 11. Vitamin D 5000 UNIT PO DAILY 12. GlipiZIDE 2.5 mg PO BID 13. Lisinopril 10 mg PO DAILY 14. Fenofibrate 48 mg PO DAILY 15. Amoxicillin [MASKED] mg PO PREOP 16. Citalopram 20 mg PO DAILY 17. Glargine 16 Units Bedtime 18. Rivaroxaban 10 mg PO DAILY 19. Acetaminophen [MASKED] mg PO Q8H:PRN Pain - Mild/Fever 20. Cyanocobalamin 1000 mcg PO DAILY Discharge Medications: 1. Acetaminophen [MASKED] mg PO Q8H:PRN Pain - Mild/Fever 2. Ascorbic Acid [MASKED] mg PO DAILY 3. Citalopram 20 mg PO DAILY 4. Cyanocobalamin 1000 mcg PO DAILY 5. Fenofibrate 48 mg PO DAILY 6. Glargine 16 Units Bedtime 7. Levothyroxine Sodium 100 mcg PO DAILY 8. LORazepam 0.5 mg PO DAILY:PRN anxiety/insomnia 9. Multivitamins 1 TAB PO DAILY 10. Omeprazole 20 mg PO DAILY 11. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 12. Prochlorperazine 5 mg PO Q8H:PRN nausea/vomiting 13. Rivaroxaban 10 mg PO DAILY 14. Tamsulosin 0.4 mg PO QHS 15. Vitamin D 5000 UNIT PO DAILY 16. HELD- amLODIPine 10 mg PO DAILY This medication was held. Do not restart amLODIPine until you discuss with your primary care doctor. 17. HELD- Atenolol 50 mg PO DAILY This medication was held. Do not restart Atenolol until you discuss with your primary care doctor. 18. HELD- GlipiZIDE 2.5 mg PO BID This medication was held. Do not restart GlipiZIDE until you follow up with your PCP. 19. HELD- Lisinopril 10 mg PO DAILY This medication was held. Do not restart Lisinopril until you discuss with your primary care doctor. Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Acute Issues: ========== Hypotension Acute on chronic CKD Secondary Issues: ============= Hypertension CKD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ====================== DISCHARGE INSTRUCTIONS ====================== Dear Mr. [MASKED], It was a pleasure caring for you at [MASKED] [MASKED]. WHY WAS I IN THE HOSPITAL? - You were admitted for low blood pressures WHAT HAPPENED TO ME IN THE HOSPITAL? - We gave you fluids through an IV, and we held your blood pressure medications. Your blood pressures eventually improved to normal range. - We monitored your kidney function which improved with fluids and holding your blood pressure medications. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Continue to take all your medicines and keep your appointments. - Do not take any of your blood pressure medications until you discuss with your primary care doctor. We wish you the best! Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]
|
[] |
[
"N179",
"I10",
"E785",
"F419",
"N400",
"I129",
"E1122",
"N189",
"Z87891",
"Y929",
"E039",
"Z794",
"Z7901"
] |
[
"N179: Acute kidney failure, unspecified",
"C221: Intrahepatic bile duct carcinoma",
"C259: Malignant neoplasm of pancreas, unspecified",
"C7802: Secondary malignant neoplasm of left lung",
"C7801: Secondary malignant neoplasm of right lung",
"I10: Essential (primary) hypertension",
"E785: Hyperlipidemia, unspecified",
"F419: Anxiety disorder, unspecified",
"N400: Benign prostatic hyperplasia without lower urinary tract symptoms",
"I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease",
"E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease",
"N189: Chronic kidney disease, unspecified",
"Z7984: Long term (current) use of oral hypoglycemic drugs",
"Z87891: Personal history of nicotine dependence",
"T464X5A: Adverse effect of angiotensin-converting-enzyme inhibitors, initial encounter",
"Y929: Unspecified place or not applicable",
"D6481: Anemia due to antineoplastic chemotherapy",
"T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter",
"E039: Hypothyroidism, unspecified",
"Z794: Long term (current) use of insulin",
"Z905: Acquired absence of kidney",
"I959: Hypotension, unspecified",
"E860: Dehydration",
"Z7901: Long term (current) use of anticoagulants"
] |
10,006,029 | 25,426,298 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
mirtazapine
Attending: ___.
Chief Complaint:
Nausea and vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a pleasant ___ w/ ID-T2DM, HTN, DL, BPH, and
three concurrent cancers (1) metastatic clear cell RCC, s/p
radical L nephrectomy in ___, found to have pulmonary,
mediastinal, and hilar mets ___ (now off sunitinib w/o
disease progression), (2) metastatic cholangiocarcinoma s/p 6
months gem/cisplatin, who subsequently had new (3) acinar cell
carcinoma of the pancreas, now on ___ I regimen of liposomal
irinotecan and ___, last dose ___, p/w nausea/vomiting that
started last evening.
Patient was interviewed with his daughter at bedside and she
helped provide collateral.
They note that he has had n/v the past few weeks, especially
with chemo. He had poor appetite as well since chemo. The
vomiting seemed to be intermittent, sometimes able to tolerate
PO. Last night he developed abdominal pain and vomiting. He had
regular bowel movements last night. This morning he had
diarrhea but no further episodes of vomiting and his abdominal
pain improved and nausea improved. He had special K cereal with
skim milk today and tolerated it well.
He called into his ___ clinic where he was seen this am. There
he had 2L NS and obtained a KUB which suggested SBO. He is only
a little tender in the epigastrium on exam. He was then admitted
to 12R to the oncology service.
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:
VITAL SIGNS: 98.4 PO 112 / 71 89 18 97 Ra
General: NAD, Resting in bed comfortably with daughter at
bedside
___: + xerostomia, + healing dried cold sore the L lower lip
CV: RR, NL S1S2 no S3S4 No MRG
PULM: CTAB, No C/W/R, No respiratory distress
ABD: scant bowel sounds, mostly tympanic, soft, minimally tender
in epigastrium, no peritoneal signs, no significant distention
LIMBS: WWP, no ___, no tremors
SKIN: No notable rashes on trunk nor extremities
NEURO: Face symmetric, speech clear and fluent, strength b/l
___ intact
PSYCH: Thought process logical, linear, future oriented
ACCESS: R Chest port site intact w/o overlying erythema,
accessed and dressing C/D/I
DISCHARGE EXAM:
___ 0910 Temp: 97.4 PO BP: 136/89 HR: 102 RR: 18 O2 sat:
95%
O2 delivery: RA FSBG: 269
___ 0918 Pain Score: ___
GENERAL: appears uncomfortable, weaker and pale.
EYES: Anicteric
ENT: MMM, no lesions noted
CV: RRR, no murmur. Right chest port.
RESP: anterior exam, quiet lungs, normal respiratory effort.
GI: Abdomen soft, mild distention, G-tube in place.
MSK: no edema or swelling
NEURO: sleepy, but awakens with gentle touch, face symmetric,
speech fluent, moves all limbs, answers all questions, fully
oriented.
PSYCH: Pleasant, appropriate affect
Pertinent Results:
ADMISSION LABS:
___ 01:15PM BLOOD WBC-3.5* RBC-2.83* Hgb-8.4* Hct-26.9*
MCV-95 MCH-29.7 MCHC-31.2* RDW-17.2* RDWSD-58.1* Plt ___
___ 01:15PM BLOOD Neuts-74* Lymphs-12* Monos-13 Eos-0*
___ Metas-1* AbsNeut-2.59 AbsLymp-0.42* AbsMono-0.46
AbsEos-0.00* AbsBaso-0.00*
___ 05:41AM BLOOD ___ PTT-25.9 ___
___ 01:15PM BLOOD UreaN-26* Creat-1.8* Na-132* K-4.4 Cl-95*
HCO3-22 AnGap-15
___ 01:15PM BLOOD ALT-20 AST-28 LD(___)-861* AlkPhos-150*
TotBili-0.4
___ 01:15PM BLOOD Albumin-3.3* Calcium-9.1 Phos-3.9 Mg-2.2
=======================
DISCHARGE LABS:
___ 06:25AM BLOOD WBC-19.0* RBC-3.27* Hgb-9.4* Hct-31.4*
MCV-96 MCH-28.7 MCHC-29.9* RDW-17.6* RDWSD-59.2* Plt ___
___ 06:25AM BLOOD Glucose-176* UreaN-35* Creat-1.5* Na-141
K-4.8 Cl-100 HCO3-22 AnGap-19*
___ 06:25AM BLOOD ALT-24 AST-79* LD(LDH)-1713* AlkPhos-184*
TotBili-0.8
___ 06:25AM BLOOD Calcium-9.0 Phos-4.0 Mg-2.1
=======================
MICROBIOLOGY:
___ 3:07 am STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT ___
C. difficile PCR (Final ___:
NEGATIVE.
___ 3:07 am STOOL CONSISTENCY: LOOSE Source:
Stool.
FECAL CULTURE - R/O E.COLI 0157:H7 (Pending):
=======================
ABDOMINAL X-RAY ___:
FINDINGS:
There are multiple centrally located distended loops of small
bowel, concerning for small bowel obstruction. There is no free
intraperitoneal air. Osseous structures are unremarkable.
Re-demonstrated is a common bile duct extent in grossly
unchanged position compared to the prior study given differences
in techniques. Two small linear
hyperdensities noted over the midline adjacent to the biliary
stent, likely surgical clips.
IMPRESSION: Imaging findings concerning for small-bowel
obstruction. Further evaluation with CT abdomen and pelvis,
with iv contrast, is recommended.
CT ABDOMEN/PELVIS WITH ORAL CONTRAST ___:
1. Interval increase in size of pancreatic head mass, now
measuring up to 8.0 cm, previously 6.0 cm.
2. Numerous metastatic lesions throughout the liver, increased
in size and number.
3. Interval worsening of retroperitoneal lymphadenopathy.
4. Wall thickening of an approximately 20 cm segment of distal
and terminal ileum with adjacent fat stranding, compatible with
infectious or inflammatory ileitis. No small bowel obstruction.
Oral contrast is seen to the rectum.
5. New 3 mm pulmonary nodule in the left lower lobe.
Brief Hospital Course:
Mr. ___ is a ___ year old male with type 2 diabetes,
hypertension, hyperlipidemia, BPH, and three concurrent cancers:
(1) metastatic clear cell renal cell carcinoma, s/p radical L
nephrectomy in ___, found to have pulmonary,
mediastinal, and hilar metastases ___ (now off sunitinib
without disease progression), (2) metastatic cholangiocarcinoma
s/p 6 months gem/cisplatin, who subsequently had new (3) acinar
cell carcinoma of the pancreas, now on ___ I regimen of
liposomal irinotecan and ___, last dose ___, who went to
___ clinic with nausea, vomiting, abdominal pain and was
found to have possible SBO on KUB. This led to direct admission
for workup. CT abdomen/pelvis with oral contrast showed no
evidence of bowel obstruction, but showed findings of ileitis,
as well as increasing pancreatic mass size and new hepatic
lesions all concerning for progression of his cancer. While
hospitalized, he developed recurrent symptoms of nausea,
vomiting after an initial improvement, and then developed signs
and symptoms of frank obstruction likely related to his
pancreatic mass or peritoneal carcinomatosis. No further
imaging was pursued. An NG tube was placed for decompression
and he had significant improved symptoms. He subsequently
underwent palliative venting G-tube is a transition to hospice.
ACUTE/ACTIVE PROBLEMS:
# Abdominal pain
# Nausea and vomiting, with malignant obstruction, in setting of
progressive acinar cell cancer, and large pancreatic mass
# Acinar cell pancreatic cancer
He has been off sutinib as his other cancers are being managed
and his pulm/hepatic mets have been stable. He is not yet due
for restaging imaging. He is due for
___, LV, liposomal irinotecan. His oncologists are Dr ___
___ Dr ___ seen on ___. CT abdomen/pelvis showed
increased size of pancreatic head mass (from 6.0 to 8.0 cm),
numerous metastatic liver lesions (increased in size and
number), interval worsening of retroperitoneal lymphadenopathy,
and new 3 mm pulmonary nodule in the left lower lobe. He had
been having nausea and vomiting likely related to chemo for
several weeks, but then developed diarrhea, vomiting, and
abdominal pain the night prior to presentation. His symptoms
have resolved. He had 2 watery bowel movements after admission.
KUB had showed multiple centrally located distended loops of
small bowel, concerning for small bowel obstruction. He has not
had prior bowel obstruction. Since he has only 1 kidney with a
Cr of 1.6, initial CT was done without IV contrast. CT
abdomen/pelvis with oral contrast showed no evidence of bowel
obstruction, but showed wall thickening of distal and terminal
ileum with adjacent fat stranding, compatible with infectious or
inflammatory ileitis. Since he was afebrile with improved
symptoms, empiric antibiotics were not started. C. difficile
was negative as was ecoli. He was initially treated with bowel
rest and IV fluids, then diet was advanced. The CT scan also
showed increasing size of pancreatic mass, enlarging and new
hepatic lesions, new left lung nodule, worsening retroperitoneal
lymphadenopathy, all concerning for progression of disease.
Given this new complication of his pancreatic cancer, family
meeting was held on ___, with a decision to pursue hospice
care at home given no other therapeutic options. His prognosis
was given as weeks. He was transitioned to liquid concentrated
morphine for pain, as well as lorazepam for anxiety, and
dexamethasone for nausea. Oral medications were given after his
PEG was placed, with clear instructions on how to take them.
This included dexamethasone, concentrated morphine, and
olanzapine. Other home medications were continued at this time,
with decisions to stop these medications going forward to occur
with hospice services and Dr. ___, patient's
oncologist. MOLST form was completed.
# Acute on chronic anemia: Baseline hemoglobin is ___.
Hemoglobin was low at 6.7 on ___, so he was transfused 1 unit
PRBCs with improvement to 8.3. He had no obvious signs of acute
blood loss anemia and stool has not appeared grossly bloody or
signs of melena evident. His blood count remained stable. Labs
were not checked after goals of care were changed.
CHRONIC/STABLE PROBLEMS:
# Chronic kidney disease: Creatinine is 1.4-1.6 at baseline. He
had recent ___ with Cr of 2.2 on ___ and 1.8 on admission,
likely due to dehydration. Renal function returned to baseline
after getting IV fluids then rose after he likely developed
recurrent dehydration. As stated above labs were not rechecked
after goals of care change.
# History of Portal Vein Thrombus: He was continued on home
Rivaroxaban 10mg daily, except for initially being held while
NPO. This was continued for now, but should be stopped if
decided not consistent with comfort going forward.
# Severe protein-calorie malnutrition: He has low albumin and
reported low oral intake due to nausea, vomiting, and abdominal
pain, which has been ongoing off/on for weeks, likely due to
chemo and his known cancers. Consulted nutrition who
recommended low fiber diet with Ensure Clear early in
hospitalization, but given transition to hospice, he was
recommended to have diet as tolerated.
# Type 2 diabetes: His glargine was initially decreased while
NPO on IV D5LR, then stopped and treated with sliding scale
insulin only and Glipizide was held. On discharge, glipizide
was continued.
TRANSITIONS OF CARE
-------------------
# Follow-up: patient is being discharged to hospice. Dr. ___
___ be the physician responsible for decisions going
forward.
# Code status: DNR/DNI, comfort-focused care
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild/Fever
2. Citalopram 20 mg PO DAILY
3. Levothyroxine Sodium 100 mcg PO DAILY
4. LORazepam 0.5 mg PO DAILY:PRN anxiety/insomnia
5. Multivitamins 1 TAB PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Prochlorperazine 5 mg PO Q8H:PRN nausea/vomiting
8. Rivaroxaban 10 mg PO DAILY
9. Tamsulosin 0.4 mg PO QHS
10. Vitamin D 5000 UNIT PO DAILY
11. Ascorbic Acid ___ mg PO DAILY
12. Cyanocobalamin 1000 mcg PO DAILY
13. Fenofibrate 48 mg PO DAILY
14. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
15. GlipiZIDE 2.5 mg PO BID
16. Abreva (docosanol) 10 % topical ___ times daily prn cold
sore
Discharge Medications:
1. Dexamethasone 4 mg PO DAILY
RX *dexamethasone 4 mg 1 tablet(s) by mouth once a day Disp #*5
Tablet Refills:*0
2. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL ___
mg PO Q2H:PRN Breakthrough pain
RX *morphine concentrate 100 mg/5 mL (20 mg/mL) 0.25-0.75 ml by
mouth q2h Refills:*0
3. OLANZapine (Disintegrating Tablet) 5 mg PO BID:PRN nausea
not addressed by ondansetron
RX *olanzapine 5 mg 1 tablet(s) by mouth twice a day Disp #*10
Tablet Refills:*0
4. Abreva (docosanol) 10 % topical ___ times daily prn cold
sore
5. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild/Fever
6. Ascorbic Acid ___ mg PO DAILY
7. Citalopram 20 mg PO DAILY
8. Cyanocobalamin 1000 mcg PO DAILY
9. Fenofibrate 48 mg PO DAILY
10. Levothyroxine Sodium 100 mcg PO DAILY
11. LORazepam 0.5 mg PO DAILY:PRN anxiety/insomnia
12. Multivitamins 1 TAB PO DAILY
13. Omeprazole 20 mg PO DAILY
14. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
15. Prochlorperazine 5 mg PO Q8H:PRN nausea/vomiting
16. Rivaroxaban 10 mg PO DAILY
17. Tamsulosin 0.4 mg PO QHS
18. HELD- GlipiZIDE 2.5 mg PO BID This medication was held. Do
not restart GlipiZIDE until someone tells you to
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Abdominal pain
Nausea with vomiting
Diarrhea
Ileitis
Metastatic cholangiocarcinoma
Acinar cell pancreatic cancer
Metastatic renal cell carcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized with abdominal pain. Despite the fact
that you initially improved, you subsequently worsened and the
symptoms were all related to progressive cancer. We talked
about the meaning of this with you and your family and you are
opting to go home with hospice care. We put a gastric tube in
to help alleviate any symptoms of obstruction. You should keep
the gastric tube hooked up to low suction overnight and when you
are not doing anything during the day. When you are active, and
for ___ minutes after taking oral medications, you should
clamp the tube.
You were continued on most of your oral medications that you
take at home. Over time, you may decide to discontinue these
medications if they are not necessary for your comfort (for
instance, your vitamin supplements), and can discuss this with
your hospice team.
The hospice team will help you manage your symptoms at home.
We wish you the best of luck going forward.
Thanks,
Your ___ Team
Followup Instructions:
___
|
[
"C786",
"E43",
"C250",
"C787",
"C781",
"C771",
"N179",
"E871",
"G893",
"K8681",
"Z85528",
"Z8589",
"Z905",
"Z66",
"Z515",
"E1122",
"I129",
"N189",
"Z794",
"E7849",
"N400",
"K529",
"Z87891",
"K117",
"D630",
"E860",
"Z6826",
"Z7902",
"B001",
"F419",
"G4700",
"R739",
"T380X5A",
"Y92230",
"K5900"
] |
Allergies: mirtazapine Chief Complaint: Nausea and vomiting Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is a pleasant [MASKED] w/ ID-T2DM, HTN, DL, BPH, and three concurrent cancers (1) metastatic clear cell RCC, s/p radical L nephrectomy in [MASKED], found to have pulmonary, mediastinal, and hilar mets [MASKED] (now off sunitinib w/o disease progression), (2) metastatic cholangiocarcinoma s/p 6 months gem/cisplatin, who subsequently had new (3) acinar cell carcinoma of the pancreas, now on [MASKED] I regimen of liposomal irinotecan and [MASKED], last dose [MASKED], p/w nausea/vomiting that started last evening. Patient was interviewed with his daughter at bedside and she helped provide collateral. They note that he has had n/v the past few weeks, especially with chemo. He had poor appetite as well since chemo. The vomiting seemed to be intermittent, sometimes able to tolerate PO. Last night he developed abdominal pain and vomiting. He had regular bowel movements last night. This morning he had diarrhea but no further episodes of vomiting and his abdominal pain improved and nausea improved. He had special K cereal with skim milk today and tolerated it well. He called into his [MASKED] clinic where he was seen this am. There he had 2L NS and obtained a KUB which suggested SBO. He is only a little tender in the epigastrium on exam. He was then admitted to 12R to the oncology service. Past Medical History: PAST ONCOLOGIC HISTORY (per OMR): -[MASKED]: 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 [MASKED], 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. -[MASKED]: underwent a laparoscopic hand assisted radical right nephrectomy by Dr. [MASKED] pathology showed a renal cell carcinoma, clear cell type, [MASKED] 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 [MASKED], 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 [MASKED] which was a CT torso showed no evidence of recurrent or metastatic disease. -[MASKED]: CT chest showed interval increase in prominence of mediastinal lymph nodes and minimal interval increase in multiple b/l pulmonary nodules, concerning for progression -[MASKED]: Fine needle aspirate of 11R and 11L lymph nodes, which was consistent with metastatic RCC -[MASKED]: CT Torso - mediastinal and hilar nodes and pulmonary lesions increased in size. No definite intra-abdominal sites of disease -[MASKED]: C1D1 [MASKED], randomized to sunitinib -[MASKED]: Multiple grade [MASKED] 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. -[MASKED]: CT Torso: Response of mediastinal lymphadenopathy, bilateral hilar lymphadenopathy, and numerous parenchymal metastases. Stable disease by RECIST (decrease 19.1% from baseline). -[MASKED]: Sunitinib reduced to 37.5 mg daily due to erythematous rash and blistering on palms and sole of right foot. -[MASKED]: CT Torso: Decrease in pulmonary and mediastinal lesions. Stable disease by RECIST 1.1 (decrease 22.5% from baseline). -[MASKED]: CT Torso: Partial response by RECIST 1.1 (decrease 39.8% from baseline). -[MASKED]: CT Torso: Partial response by RECIST 1.1 (decrease 46.3% from baseline). -[MASKED]: CT Torso: Partial response by RECIST 1.1 (decrease 40.3% from baseline). -[MASKED]: CT Torso: Partial response by RECIST 1.1 (decrease 42.6% from baseline). -[MASKED]: CT Torso: Partial response by RECIST 1.1 (decrease 47.7% from baseline). -[MASKED]: CT torso: Ongoing partial response comments: No significant change compared to prior scan. No new lesions. -[MASKED]: CT Torso: PR by RECIST 1.1 -[MASKED]: CT Torso: PR by RECIST 1.1: -54.22% change from baseline and -10.29% change from last scan. -[MASKED]: CT Torso: partial response: -57.79% from baseline, -7.79% from nadir -[MASKED]: 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: [MASKED] Family History: Colorectal cancer - mother [MASKED] cancer - sister (dx at age [MASKED] Liver cancer - brother [MASKED] cell leukemia - brother [MASKED] - father Physical [MASKED]: ADMISSION EXAM: VITAL SIGNS: 98.4 PO 112 / 71 89 18 97 Ra General: NAD, Resting in bed comfortably with daughter at bedside [MASKED]: + xerostomia, + healing dried cold sore the L lower lip CV: RR, NL S1S2 no S3S4 No MRG PULM: CTAB, No C/W/R, No respiratory distress ABD: scant bowel sounds, mostly tympanic, soft, minimally tender in epigastrium, no peritoneal signs, no significant distention LIMBS: WWP, no [MASKED], no tremors SKIN: No notable rashes on trunk nor extremities NEURO: Face symmetric, speech clear and fluent, strength b/l [MASKED] intact PSYCH: Thought process logical, linear, future oriented ACCESS: R Chest port site intact w/o overlying erythema, accessed and dressing C/D/I DISCHARGE EXAM: [MASKED] 0910 Temp: 97.4 PO BP: 136/89 HR: 102 RR: 18 O2 sat: 95% O2 delivery: RA FSBG: 269 [MASKED] 0918 Pain Score: [MASKED] GENERAL: appears uncomfortable, weaker and pale. EYES: Anicteric ENT: MMM, no lesions noted CV: RRR, no murmur. Right chest port. RESP: anterior exam, quiet lungs, normal respiratory effort. GI: Abdomen soft, mild distention, G-tube in place. MSK: no edema or swelling NEURO: sleepy, but awakens with gentle touch, face symmetric, speech fluent, moves all limbs, answers all questions, fully oriented. PSYCH: Pleasant, appropriate affect Pertinent Results: ADMISSION LABS: [MASKED] 01:15PM BLOOD WBC-3.5* RBC-2.83* Hgb-8.4* Hct-26.9* MCV-95 MCH-29.7 MCHC-31.2* RDW-17.2* RDWSD-58.1* Plt [MASKED] [MASKED] 01:15PM BLOOD Neuts-74* Lymphs-12* Monos-13 Eos-0* [MASKED] Metas-1* AbsNeut-2.59 AbsLymp-0.42* AbsMono-0.46 AbsEos-0.00* AbsBaso-0.00* [MASKED] 05:41AM BLOOD [MASKED] PTT-25.9 [MASKED] [MASKED] 01:15PM BLOOD UreaN-26* Creat-1.8* Na-132* K-4.4 Cl-95* HCO3-22 AnGap-15 [MASKED] 01:15PM BLOOD ALT-20 AST-28 LD([MASKED])-861* AlkPhos-150* TotBili-0.4 [MASKED] 01:15PM BLOOD Albumin-3.3* Calcium-9.1 Phos-3.9 Mg-2.2 ======================= DISCHARGE LABS: [MASKED] 06:25AM BLOOD WBC-19.0* RBC-3.27* Hgb-9.4* Hct-31.4* MCV-96 MCH-28.7 MCHC-29.9* RDW-17.6* RDWSD-59.2* Plt [MASKED] [MASKED] 06:25AM BLOOD Glucose-176* UreaN-35* Creat-1.5* Na-141 K-4.8 Cl-100 HCO3-22 AnGap-19* [MASKED] 06:25AM BLOOD ALT-24 AST-79* LD(LDH)-1713* AlkPhos-184* TotBili-0.8 [MASKED] 06:25AM BLOOD Calcium-9.0 Phos-4.0 Mg-2.1 ======================= MICROBIOLOGY: [MASKED] 3:07 am STOOL CONSISTENCY: LOOSE Source: Stool. **FINAL REPORT [MASKED] C. difficile PCR (Final [MASKED]: NEGATIVE. [MASKED] 3:07 am STOOL CONSISTENCY: LOOSE Source: Stool. FECAL CULTURE - R/O E.COLI 0157:H7 (Pending): ======================= ABDOMINAL X-RAY [MASKED]: FINDINGS: There are multiple centrally located distended loops of small bowel, concerning for small bowel obstruction. There is no free intraperitoneal air. Osseous structures are unremarkable. Re-demonstrated is a common bile duct extent in grossly unchanged position compared to the prior study given differences in techniques. Two small linear hyperdensities noted over the midline adjacent to the biliary stent, likely surgical clips. IMPRESSION: Imaging findings concerning for small-bowel obstruction. Further evaluation with CT abdomen and pelvis, with iv contrast, is recommended. CT ABDOMEN/PELVIS WITH ORAL CONTRAST [MASKED]: 1. Interval increase in size of pancreatic head mass, now measuring up to 8.0 cm, previously 6.0 cm. 2. Numerous metastatic lesions throughout the liver, increased in size and number. 3. Interval worsening of retroperitoneal lymphadenopathy. 4. Wall thickening of an approximately 20 cm segment of distal and terminal ileum with adjacent fat stranding, compatible with infectious or inflammatory ileitis. No small bowel obstruction. Oral contrast is seen to the rectum. 5. New 3 mm pulmonary nodule in the left lower lobe. Brief Hospital Course: Mr. [MASKED] is a [MASKED] year old male with type 2 diabetes, hypertension, hyperlipidemia, BPH, and three concurrent cancers: (1) metastatic clear cell renal cell carcinoma, s/p radical L nephrectomy in [MASKED], found to have pulmonary, mediastinal, and hilar metastases [MASKED] (now off sunitinib without disease progression), (2) metastatic cholangiocarcinoma s/p 6 months gem/cisplatin, who subsequently had new (3) acinar cell carcinoma of the pancreas, now on [MASKED] I regimen of liposomal irinotecan and [MASKED], last dose [MASKED], who went to [MASKED] clinic with nausea, vomiting, abdominal pain and was found to have possible SBO on KUB. This led to direct admission for workup. CT abdomen/pelvis with oral contrast showed no evidence of bowel obstruction, but showed findings of ileitis, as well as increasing pancreatic mass size and new hepatic lesions all concerning for progression of his cancer. While hospitalized, he developed recurrent symptoms of nausea, vomiting after an initial improvement, and then developed signs and symptoms of frank obstruction likely related to his pancreatic mass or peritoneal carcinomatosis. No further imaging was pursued. An NG tube was placed for decompression and he had significant improved symptoms. He subsequently underwent palliative venting G-tube is a transition to hospice. ACUTE/ACTIVE PROBLEMS: # Abdominal pain # Nausea and vomiting, with malignant obstruction, in setting of progressive acinar cell cancer, and large pancreatic mass # Acinar cell pancreatic cancer He has been off sutinib as his other cancers are being managed and his pulm/hepatic mets have been stable. He is not yet due for restaging imaging. He is due for [MASKED], LV, liposomal irinotecan. His oncologists are Dr [MASKED] [MASKED] Dr [MASKED] seen on [MASKED]. CT abdomen/pelvis showed increased size of pancreatic head mass (from 6.0 to 8.0 cm), numerous metastatic liver lesions (increased in size and number), interval worsening of retroperitoneal lymphadenopathy, and new 3 mm pulmonary nodule in the left lower lobe. He had been having nausea and vomiting likely related to chemo for several weeks, but then developed diarrhea, vomiting, and abdominal pain the night prior to presentation. His symptoms have resolved. He had 2 watery bowel movements after admission. KUB had showed multiple centrally located distended loops of small bowel, concerning for small bowel obstruction. He has not had prior bowel obstruction. Since he has only 1 kidney with a Cr of 1.6, initial CT was done without IV contrast. CT abdomen/pelvis with oral contrast showed no evidence of bowel obstruction, but showed wall thickening of distal and terminal ileum with adjacent fat stranding, compatible with infectious or inflammatory ileitis. Since he was afebrile with improved symptoms, empiric antibiotics were not started. C. difficile was negative as was ecoli. He was initially treated with bowel rest and IV fluids, then diet was advanced. The CT scan also showed increasing size of pancreatic mass, enlarging and new hepatic lesions, new left lung nodule, worsening retroperitoneal lymphadenopathy, all concerning for progression of disease. Given this new complication of his pancreatic cancer, family meeting was held on [MASKED], with a decision to pursue hospice care at home given no other therapeutic options. His prognosis was given as weeks. He was transitioned to liquid concentrated morphine for pain, as well as lorazepam for anxiety, and dexamethasone for nausea. Oral medications were given after his PEG was placed, with clear instructions on how to take them. This included dexamethasone, concentrated morphine, and olanzapine. Other home medications were continued at this time, with decisions to stop these medications going forward to occur with hospice services and Dr. [MASKED], patient's oncologist. MOLST form was completed. # Acute on chronic anemia: Baseline hemoglobin is [MASKED]. Hemoglobin was low at 6.7 on [MASKED], so he was transfused 1 unit PRBCs with improvement to 8.3. He had no obvious signs of acute blood loss anemia and stool has not appeared grossly bloody or signs of melena evident. His blood count remained stable. Labs were not checked after goals of care were changed. CHRONIC/STABLE PROBLEMS: # Chronic kidney disease: Creatinine is 1.4-1.6 at baseline. He had recent [MASKED] with Cr of 2.2 on [MASKED] and 1.8 on admission, likely due to dehydration. Renal function returned to baseline after getting IV fluids then rose after he likely developed recurrent dehydration. As stated above labs were not rechecked after goals of care change. # History of Portal Vein Thrombus: He was continued on home Rivaroxaban 10mg daily, except for initially being held while NPO. This was continued for now, but should be stopped if decided not consistent with comfort going forward. # Severe protein-calorie malnutrition: He has low albumin and reported low oral intake due to nausea, vomiting, and abdominal pain, which has been ongoing off/on for weeks, likely due to chemo and his known cancers. Consulted nutrition who recommended low fiber diet with Ensure Clear early in hospitalization, but given transition to hospice, he was recommended to have diet as tolerated. # Type 2 diabetes: His glargine was initially decreased while NPO on IV D5LR, then stopped and treated with sliding scale insulin only and Glipizide was held. On discharge, glipizide was continued. TRANSITIONS OF CARE ------------------- # Follow-up: patient is being discharged to hospice. Dr. [MASKED] [MASKED] be the physician responsible for decisions going forward. # Code status: DNR/DNI, comfort-focused care Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen [MASKED] mg PO Q8H:PRN Pain - Mild/Fever 2. Citalopram 20 mg PO DAILY 3. Levothyroxine Sodium 100 mcg PO DAILY 4. LORazepam 0.5 mg PO DAILY:PRN anxiety/insomnia 5. Multivitamins 1 TAB PO DAILY 6. Omeprazole 20 mg PO DAILY 7. Prochlorperazine 5 mg PO Q8H:PRN nausea/vomiting 8. Rivaroxaban 10 mg PO DAILY 9. Tamsulosin 0.4 mg PO QHS 10. Vitamin D 5000 UNIT PO DAILY 11. Ascorbic Acid [MASKED] mg PO DAILY 12. Cyanocobalamin 1000 mcg PO DAILY 13. Fenofibrate 48 mg PO DAILY 14. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 15. GlipiZIDE 2.5 mg PO BID 16. Abreva (docosanol) 10 % topical [MASKED] times daily prn cold sore Discharge Medications: 1. Dexamethasone 4 mg PO DAILY RX *dexamethasone 4 mg 1 tablet(s) by mouth once a day Disp #*5 Tablet Refills:*0 2. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL [MASKED] mg PO Q2H:PRN Breakthrough pain RX *morphine concentrate 100 mg/5 mL (20 mg/mL) 0.25-0.75 ml by mouth q2h Refills:*0 3. OLANZapine (Disintegrating Tablet) 5 mg PO BID:PRN nausea not addressed by ondansetron RX *olanzapine 5 mg 1 tablet(s) by mouth twice a day Disp #*10 Tablet Refills:*0 4. Abreva (docosanol) 10 % topical [MASKED] times daily prn cold sore 5. Acetaminophen [MASKED] mg PO Q8H:PRN Pain - Mild/Fever 6. Ascorbic Acid [MASKED] mg PO DAILY 7. Citalopram 20 mg PO DAILY 8. Cyanocobalamin 1000 mcg PO DAILY 9. Fenofibrate 48 mg PO DAILY 10. Levothyroxine Sodium 100 mcg PO DAILY 11. LORazepam 0.5 mg PO DAILY:PRN anxiety/insomnia 12. Multivitamins 1 TAB PO DAILY 13. Omeprazole 20 mg PO DAILY 14. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 15. Prochlorperazine 5 mg PO Q8H:PRN nausea/vomiting 16. Rivaroxaban 10 mg PO DAILY 17. Tamsulosin 0.4 mg PO QHS 18. HELD- GlipiZIDE 2.5 mg PO BID This medication was held. Do not restart GlipiZIDE until someone tells you to Discharge Disposition: Home With Service Facility: [MASKED] [MASKED] Diagnosis: Abdominal pain Nausea with vomiting Diarrhea Ileitis Metastatic cholangiocarcinoma Acinar cell pancreatic cancer Metastatic renal cell carcinoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], You were hospitalized with abdominal pain. Despite the fact that you initially improved, you subsequently worsened and the symptoms were all related to progressive cancer. We talked about the meaning of this with you and your family and you are opting to go home with hospice care. We put a gastric tube in to help alleviate any symptoms of obstruction. You should keep the gastric tube hooked up to low suction overnight and when you are not doing anything during the day. When you are active, and for [MASKED] minutes after taking oral medications, you should clamp the tube. You were continued on most of your oral medications that you take at home. Over time, you may decide to discontinue these medications if they are not necessary for your comfort (for instance, your vitamin supplements), and can discuss this with your hospice team. The hospice team will help you manage your symptoms at home. We wish you the best of luck going forward. Thanks, Your [MASKED] Team Followup Instructions: [MASKED]
|
[] |
[
"N179",
"E871",
"Z66",
"Z515",
"E1122",
"I129",
"N189",
"Z794",
"N400",
"Z87891",
"Z7902",
"F419",
"G4700",
"Y92230",
"K5900"
] |
[
"C786: Secondary malignant neoplasm of retroperitoneum and peritoneum",
"E43: Unspecified severe protein-calorie malnutrition",
"C250: Malignant neoplasm of head of pancreas",
"C787: Secondary malignant neoplasm of liver and intrahepatic bile duct",
"C781: Secondary malignant neoplasm of mediastinum",
"C771: Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes",
"N179: Acute kidney failure, unspecified",
"E871: Hypo-osmolality and hyponatremia",
"G893: Neoplasm related pain (acute) (chronic)",
"K8681: Exocrine pancreatic insufficiency",
"Z85528: Personal history of other malignant neoplasm of kidney",
"Z8589: Personal history of malignant neoplasm of other organs and systems",
"Z905: Acquired absence of kidney",
"Z66: Do not resuscitate",
"Z515: Encounter for palliative care",
"E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease",
"I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease",
"N189: Chronic kidney disease, unspecified",
"Z794: Long term (current) use of insulin",
"E7849: Other hyperlipidemia",
"N400: Benign prostatic hyperplasia without lower urinary tract symptoms",
"K529: Noninfective gastroenteritis and colitis, unspecified",
"Z87891: Personal history of nicotine dependence",
"K117: Disturbances of salivary secretion",
"D630: Anemia in neoplastic disease",
"E860: Dehydration",
"Z6826: Body mass index [BMI] 26.0-26.9, adult",
"Z7902: Long term (current) use of antithrombotics/antiplatelets",
"B001: Herpesviral vesicular dermatitis",
"F419: Anxiety disorder, unspecified",
"G4700: Insomnia, unspecified",
"R739: Hyperglycemia, unspecified",
"T380X5A: Adverse effect of glucocorticoids and synthetic analogues, initial encounter",
"Y92230: Patient room in hospital as the place of occurrence of the external cause",
"K5900: Constipation, unspecified"
] |
10,006,029 | 27,104,518 |
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:
___
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Allergies: [MASKED] Chief Complaint: Fatigue Major Surgical or Invasive Procedure: [MASKED]: ERCP and EUS History of Present Illness: Mr. [MASKED] is a [MASKED] male with IDDM, HTN, BPH, and clear cell RCC s/p radical L nephrectomy ([MASKED]) metastatic to the lungs, mediastinum, and hilum currently on chemotherapy (experimental trial; on sunitinib), with recent admission ([MASKED]) 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 [MASKED] weeks (planned for the week of [MASKED] off sunatinib). He last followed up in [MASKED] clinic with Dr. [MASKED] on [MASKED]. 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 [MASKED]. He was transferred from there to the [MASKED] 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 [MASKED] 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 [MASKED], 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): -[MASKED]: 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 [MASKED], 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. -[MASKED]: underwent a laparoscopic hand assisted radical right nephrectomy by Dr. [MASKED] pathology showed a renal cell carcinoma, clear cell type, [MASKED] 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 [MASKED], 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 [MASKED] which was a CT torso showed no evidence of recurrent or metastatic disease. -[MASKED]: CT chest showed interval increase in prominence of mediastinal lymph nodes and minimal interval increase in multiple b/l pulmonary nodules, concerning for progression -[MASKED]: Fine needle aspirate of 11R and 11L lymph nodes, which was consistent with metastatic RCC -[MASKED]: CT Torso - mediastinal and hilar nodes and pulmonary lesions increased in size. No definite intra-abdominal sites of disease -[MASKED]: C1D1 [MASKED], randomized to sunitinib -[MASKED]: Multiple grade [MASKED] 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. -[MASKED]: CT Torso: Response of mediastinal lymphadenopathy, bilateral hilar lymphadenopathy, and numerous parenchymal metastases. Stable disease by RECIST (decrease 19.1% from baseline). -[MASKED]: Sunitinib reduced to 37.5 mg daily due to erythematous rash and blistering on palms and sole of right foot. -[MASKED]: CT Torso: Decrease in pulmonary and mediastinal lesions. Stable disease by RECIST 1.1 (decrease 22.5% from baseline). -[MASKED]: CT Torso: Partial response by RECIST 1.1 (decrease 39.8% from baseline). -[MASKED]: CT Torso: Partial response by RECIST 1.1 (decrease 46.3% from baseline). -[MASKED]: CT Torso: Partial response by RECIST 1.1 (decrease 40.3% from baseline). -[MASKED]: CT Torso: Partial response by RECIST 1.1 (decrease 42.6% from baseline). -[MASKED]: CT Torso: Partial response by RECIST 1.1 (decrease 47.7% from baseline). -[MASKED]: CT torso: Ongoing partial response comments: No significant change compared to prior scan. No new lesions. -[MASKED]: CT Torso: PR by RECIST 1.1 -[MASKED]: CT Torso: PR by RECIST 1.1: -54.22% change from baseline and -10.29% change from last scan. -[MASKED]: CT Torso: partial response: -57.79% from baseline, -7.79% from nadir -[MASKED]: 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: [MASKED] Family History: Colorectal cancer - mother [MASKED] cancer - sister (dx at age [MASKED] Liver cancer - brother [MASKED] cell leukemia - brother [MASKED] - father Physical [MASKED]: ADMISSION EXAM: VITALS: T 97.6, HR 68, BP 115/76, RR 16, SpO2 98% on RA [MASKED]: 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 [MASKED]: 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: [MASKED] 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 [MASKED] [MASKED] 05:43AM BLOOD Glucose-95 UreaN-24* Creat-1.5* Na-138 K-4.4 Cl-106 HCO3-18* AnGap-14 [MASKED] 05:55AM BLOOD Albumin-2.5* Calcium-8.1* Phos-3.5 Mg-1.9 Iron-18* [MASKED] 05:43AM BLOOD Albumin-2.8* [MASKED] 05:55AM BLOOD calTIBC-160* Hapto-230* Ferritn-990* TRF-123* [MASKED] 05:43AM BLOOD ALT-97* AST-71* AlkPhos-214* TotBili-7.6* DirBili-5.6* IndBili-2.0 MICRO: BCx [MASKED]: NGTD Blood culture ([MASKED]): STREPTOCOCCUS ANGINOSUS ([MASKED]) 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 ([MASKED]): Minute fragment of highly atypical cells with sclerotic stroma consistent with adenocarcinoma Common bile duct stricture brushings ([MASKED]): POSITIVE FOR MALIGNANT CELLS. - Adenocarcinoma. IMAGING: RUQ US ([MASKED]): 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 [MASKED]: 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 [MASKED]: 1.8 x 1.1 cm ill-defined hypoechoic area around the distal CBD. FNB was performed x3 CT torso [MASKED]: 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 [MASKED]: Biliary plastic stent removed with a snare. A metal stent was placed over 2cm long malignant appearing stricture in the distal CBD. TTE [MASKED]: 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. [MASKED] is a [MASKED] male with IDDM, HTN, BPH, and metastatic clear cell RCC s/p radical L nephrectomy ([MASKED]) on chemotherapy (sunitinib), with recent admission ([MASKED]) 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 [MASKED] 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 [MASKED] 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 [MASKED] 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 [MASKED] 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 [MASKED] - [MASKED]. A PICC was placed prior to discharge. TTE did not show evidence of endocarditis. # [MASKED] 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 [MASKED], 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 [MASKED] 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 [MASKED] by Dr. [MASKED]. He was diagnosed in [MASKED] in workup of gross hematuria and flank pain. He underwent a laparoscopic radical right nephrectomy in [MASKED]. He was found to have metastases to the lungs, mediastinal lymph nodes, and hilar lymph nodes in [MASKED]. In [MASKED] 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 [MASKED] 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. [MASKED] 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: [MASKED], First Dose: Next Routine Administration Time 2. amLODIPine 10 mg PO DAILY 3. Ascorbic Acid [MASKED] 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 [MASKED] mg PO DAILY 6. Atenolol 100 mg PO DAILY 7. cariprazine 1.5 mg oral DAILY 8. Enoxaparin Sodium 120 mg SC DAILY Start: [MASKED], 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: [MASKED] [MASKED] 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. [MASKED], 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 [MASKED] Team Followup Instructions: [MASKED]
|
[] |
[
"N179",
"F419",
"N400",
"E785",
"Z87891",
"F329",
"E039",
"E1122",
"I129",
"N189",
"Z794"
] |
[
"A408: Other streptococcal sepsis",
"K831: Obstruction of bile duct",
"I81: Portal vein thrombosis",
"J189: Pneumonia, unspecified organism",
"K830: Cholangitis",
"C7802: Secondary malignant neoplasm of left lung",
"C7801: Secondary malignant neoplasm of right lung",
"C771: Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes",
"N179: Acute kidney failure, unspecified",
"C249: Malignant neoplasm of biliary tract, unspecified",
"R6520: Severe sepsis without septic shock",
"F419: Anxiety disorder, unspecified",
"N400: Benign prostatic hyperplasia without lower urinary tract symptoms",
"Z85528: Personal history of other malignant neoplasm of kidney",
"E785: Hyperlipidemia, unspecified",
"Z87891: Personal history of nicotine dependence",
"D539: Nutritional anemia, unspecified",
"F329: Major depressive disorder, single episode, unspecified",
"E039: Hypothyroidism, unspecified",
"E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease",
"I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease",
"N189: Chronic kidney disease, unspecified",
"Z794: Long term (current) use of insulin"
] |
10,006,029 | 29,107,716 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___
Chief Complaint:
anbormal lfts
Major Surgical or Invasive Procedure:
ERCP ___
History of Present Illness:
PRIMARY ONCOLOGIST: Dr ___
___: Metastatic clear cell renal cell carcinoma
TREATMENT: ___, randomized to sunitinib 50 mg PO daily x 4
weeks followed by 2 weeks off. Dose reduced sunitinib to 37.5 mg
daily. Cycle 25, Week 1.
CHIEF COMPLAINT: Abnormal LFTs
HISTORY OF PRESENT ILLNESS:
Mr. ___ is a pleasant ___ w/ ID-T2DM, HTN, DL, BPH, and
metastatic clear cell RCC, s/p radical L nephrectomy in ___,
found to have pulmonary, mediastinal, and hilar mets ___, now
on ___, randomized to sunitinib, dose-reduced, currently 2
weeks off sunitinib per protocol, who is directly admitted from
clinic for abnormal LFTs found on routine lab screening.
He feels tired but has no localizing symptoms. He did not have
any F/C, no abd pain, no N/V. Appeared mildly lethargic today
after he took his Ativan today for anxiety related coming into
___. His family reported ___ episodes of confusion since his
last clinic visit. He states he's had greasy foods lately
without
any n/v, no abd pain. He drinks a couple beers a week during his
weeks off sunitinib. No new meds. No apap/nsaids. No recent
travel. No camping.
REVIEW OF SYSTEMS:
10 point ROS reviewed in detail and negative except for what is
mentioned above in HPI
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:
Mother: Died of rectal/colon cancer.
Father: No cancers, history of diabetes.
Other: He has a sister with ovarian cancer diagnosed at age ___
and a brother with liver cancer at age ___ and another brother
with hairy cell leukemia, which is in remission.
Physical Exam:
VITAL SIGNS: 97.5 PO 160 / 89 R Sitting 71 18 99 ra
General: NAD, Resting in bed comfortably with daughter at
bedside
___: MMM, no OP lesions, no cervical/supraclavicular
adenopathy, no icterus
CV: RR, NL S1S2 no S3S4 No MRG
PULM: CTAB, No C/W/R, No respiratory distress
ABD: BS+, soft, NTND, no palpable masses or HSM
LIMBS: WWP, trace b/l pitting edema at the distal ___, no tremors
SKIN: No rashes on the extremities
NEURO: Grossly normal, speech clear, AOx3
ACCESS: No port
Pertinent Results:
___ 06:55AM BLOOD WBC-3.9* RBC-3.12* Hgb-10.5* Hct-33.5*
MCV-107* MCH-33.7* MCHC-31.3* RDW-16.8* RDWSD-65.9* Plt ___
___ 07:25AM BLOOD WBC-3.0* RBC-3.03* Hgb-10.2* Hct-32.2*
MCV-106* MCH-33.7* MCHC-31.7* RDW-16.9* RDWSD-66.0* Plt ___
___ 11:30AM BLOOD WBC-3.6* RBC-3.21* Hgb-10.8* Hct-34.9*
MCV-109* MCH-33.6* MCHC-30.9* RDW-17.0* RDWSD-68.3* Plt ___
___ 06:55AM BLOOD Glucose-121* UreaN-14 Creat-1.2 Na-147
K-4.5 Cl-106 HCO3-27 AnGap-14
___ 07:25AM BLOOD Glucose-204* UreaN-18 Creat-1.3* Na-140
K-4.3 Cl-103 HCO3-25 AnGap-12
___ 11:30AM BLOOD UreaN-19 Creat-1.4* Na-139 K-5.3 Cl-101
___ 06:55AM BLOOD ALT-101* AST-47* LD(___)-239 AlkPhos-188*
TotBili-1.5 DirBili-0.7* IndBili-0.8
___ 09:45PM BLOOD ALT-123* AST-57* LD(LDH)-274* CK(CPK)-106
AlkPhos-241* TotBili-2.3*
___ 11:30AM BLOOD ALT-133* AST-71* LD(___)-289*
AlkPhos-259* Amylase-210* TotBili-3.0* DirBili-1.8* IndBili-1.2
___ 09:45PM BLOOD cTropnT-<0.01
___ 11:30AM BLOOD Lipase-252*
___ 06:55AM BLOOD Lipase-63*
___ 06:55AM BLOOD Albumin-3.7 Calcium-9.3 Phos-3.7 Mg-2.0
___ 09:45PM BLOOD calTIBC-306 VitB12-356 Folate->20
___ Ferritn-597* TRF-235
___ 09:45PM BLOOD Triglyc-207* HDL-30* CHOL/HD-4.7
LDLcalc-70
___ 11:30AM BLOOD Free T4-1.2
___ 09:45PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 09:45PM BLOOD Smooth-NEGATIVE
___ 09:45PM BLOOD ___
___ 09:45PM BLOOD IgG-666* IgA-165 IgM-120
___ 09:45PM BLOOD HCV Ab-NEG
___ 09:46PM BLOOD Lactate-0.7
___ 11:30AM BLOOD FREE T3-Test
___ 11:30AM BLOOD Free T4-1.2
Brief Hospital Course:
IMAGING:
RUQ US ___:
1. Biliary sludge without evidence of gallbladder-wall
thickening
or intrahepatic biliary dilatation.
2. No evidence of focal liver lesions
MRCP ___:
1. Moderate intra and extrahepatic biliary ductal dilatation
with
duct penetrating sign suggestive of inflammatory rather than
neoplastic stricture. Correlation with ERCP may be considered.
No
evidence of choledocholithiasis or definite obstructing mass. 2.
Short-segment (11 mm) eccentric filling defect within the main
portal vein, suspicious for nonocclusive thrombus. 3. Sludge
within the gallbladder lumen. 4. Status post left nephrectomy
with stable soft tissue within the left nephrectomy bed. 5.
Multiple pancreatic cystic lesions, likely small side branch
IPMNs, measuring up to 10 mm.
ASSESSMENT AND PLAN:
___ w/ ID-T2DM, HTN, DL, BPH, and metastatic clear cell RCC, s/p
radical L nephrectomy in ___, found to have pulmonary,
mediastinal, and hilar mets ___, now on ___, randomized
to
sunitinib, dose-reduced, currently 2 weeks off sunitinib per
protocol, who is directly admitted from clinic for abnormal LFTs
found on routine lab screening.
# Elevated LFTs
Non-specific elevations. US did not reveal any focal lesions nor
any biliary dilatation nor stones. Lipase elevated at 252 but in
absence of any abd pain, unlikely pancreatitis. Unlikely
sunitinib effect per oncology. Pt did appear to be lethargic per
oncologist but is AOx3 and no asterixis, but cannot rule out
some
element of encephalopathy. Found on MRCP to have moderate
intra/extrahepatic biliary ductal dilatation suggestive of
stricture. Hepto wnl and anemia stable, so unlikely hemolysis.
SPEP largely wnl.
ERCP on ___ revealed stricture in bile duct and had plastic
biliary
stent placed. He tolerated procedure well. Had no infectious
symptoms
nor any signs of post-ercp pancreatitis. He was advanced to full
diet
and instructed to f/u with oncology for the results of the
brushings
done during ERCP. Their team will coordinate a repeat ERCP in 4
wks.
# Portal Vein THrombus
MRCP revealed a small non-occlusive filling defect within the
main portal vein suspicious for thrombus. Due to risk of
progression,
patient was started on once daily dosing lovenox at 1.5 mg/kg.
Due to sphincterotomy during the ERCP, patient was instructed to
wait 5 days after ercp to start the lovenox. He was provided
teaching
on how to inject and warning signs while he was here.
# Pancreatic cysts
Found on MRCP, per radiology, felt to be to be small side branch
Intraductal papillary mucinous neoplasm.
- f/u in ___ year
# ___
CT scans from ___ revealed partial response to sunitinib.
- sunitinib is currently on hold
- will f/u w/ Dr ___
# Macrocytic Anemia
Chronic and at baseline. TSH WNL as well as VIt B12, Folate,
spep, and ferritin/TIBC.
# Depressed mood/anxiety
- hold cariprazine ___ lfts
- cont fluoxetine
# T2DM: cont home insulin, glipizide
# HTN: cont amlodipine, atenolol, lisinopril
# DL: hold statin/fibrate
# CKD: cr baseline
# Hypothyroidism: cont levothyroxine (TSH WNL)
# BPH: cont flomax
FEN: Regular low fat diabetic diet
DVT PROPHYLAXIS: HSQ
ACCESS: PIV
CODE STATUS: Full code, presumed
PCP: ___, MD
DISPO: Home w/o services
BILLING: 45 min spent coordinating care for discharge
________________
___, D.O.
Heme/Onc Hospitalist
p: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Atenolol 100 mg PO DAILY
3. cariprazine 1.5 mg oral DAILY
4. Fenofibrate 48 mg PO DAILY
5. FLUoxetine 20 mg PO DAILY
6. Gabapentin 100 mg PO DAILY
7. GlipiZIDE 2.5 mg PO BID
8. Lantus Solostar U-100 Insulin (insulin glargine) ___ units
subcutaneous QPM
9. Levothyroxine Sodium 100 mcg PO DAILY
10. LORazepam 0.5 mg PO DAILY:PRN anxiety
11. Ondansetron 4 mg PO Q8H:PRN nausea
12. Prochlorperazine 5 mg PO Q8H:PRN nausea
13. Simvastatin 40 mg PO QPM
14. Tamsulosin 0.4 mg PO QHS
15. Ascorbic Acid ___ mg PO DAILY
16. Vitamin D 5000 UNIT PO DAILY
17. Omeprazole 20 mg PO DAILY
18. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry
eyes
19. Lisinopril 40 mg PO DAILY
Discharge Medications:
1. Enoxaparin Sodium 120 mg SC DAILY
Start: Future Date - ___, First Dose: First Routine
Administration Time
RX *enoxaparin 120 mg/0.8 mL 120 mg sc daily Disp #*30 Syringe
Refills:*0
2. amLODIPine 10 mg PO DAILY
3. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry
eyes
4. Ascorbic Acid ___ mg PO DAILY
5. Atenolol 100 mg PO DAILY
6. cariprazine 1.5 mg oral DAILY
7. FLUoxetine 20 mg PO DAILY
8. Gabapentin 100 mg PO DAILY
9. GlipiZIDE 2.5 mg PO BID
10. Lantus Solostar U-100 Insulin (insulin glargine) ___
units subcutaneous QPM
11. Levothyroxine Sodium 100 mcg PO DAILY
12. Lisinopril 40 mg PO DAILY
13. LORazepam 0.5 mg PO DAILY:PRN anxiety
14. Omeprazole 20 mg PO DAILY
15. Ondansetron 4 mg PO Q8H:PRN nausea
16. Prochlorperazine 5 mg PO Q8H:PRN nausea
17. Tamsulosin 0.4 mg PO QHS
18. Vitamin D 5000 UNIT PO DAILY
19. HELD- Fenofibrate 48 mg PO DAILY This medication was held.
Do not restart Fenofibrate until discussed with your oncologist
20. HELD- Simvastatin 40 mg PO QPM This medication was held. Do
not restart Simvastatin until discussed with your oncologist
Discharge Disposition:
Home
Discharge Diagnosis:
Biliary Stricture
Portal Vein Thrombus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___
___ were admitted to the hospital because ___ had abnormal liver
enzymes. MRI of your liver (MRCP) revealed a narrowing in your
bile duct, also known as a stricture. ___ had an ERCP (endoscopy
and a camera into your bile duct) which confirmed a stricture.
These improved after ___ had an ERCP. ___ had a plastic stent
placed in your bile duct and ___ tolerated this well. Your liver
enzymes are already improving. ERCP team will call ___ to
schedule another ERCP in 4 weeks or so to possibly remove the
stent. ___ will follow up on the biopsy results with your
oncology team. ___ were also found to have a clot in one of your
veins (portal vein) which will need to be treated with a blood
thinner. ___ will start this ___. Call your oncology team if
there are any issues or questions.
Regards,
Your ___ team
Followup Instructions:
___
|
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"D539",
"F329",
"E039",
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"Z905",
"Z87891",
"Z800",
"Z807",
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] |
Allergies: [MASKED] Chief Complaint: anbormal lfts Major Surgical or Invasive Procedure: ERCP [MASKED] History of Present Illness: PRIMARY ONCOLOGIST: Dr [MASKED] [MASKED]: Metastatic clear cell renal cell carcinoma TREATMENT: [MASKED], randomized to sunitinib 50 mg PO daily x 4 weeks followed by 2 weeks off. Dose reduced sunitinib to 37.5 mg daily. Cycle 25, Week 1. CHIEF COMPLAINT: Abnormal LFTs HISTORY OF PRESENT ILLNESS: Mr. [MASKED] is a pleasant [MASKED] w/ ID-T2DM, HTN, DL, BPH, and metastatic clear cell RCC, s/p radical L nephrectomy in [MASKED], found to have pulmonary, mediastinal, and hilar mets [MASKED], now on [MASKED], randomized to sunitinib, dose-reduced, currently 2 weeks off sunitinib per protocol, who is directly admitted from clinic for abnormal LFTs found on routine lab screening. He feels tired but has no localizing symptoms. He did not have any F/C, no abd pain, no N/V. Appeared mildly lethargic today after he took his Ativan today for anxiety related coming into [MASKED]. His family reported [MASKED] episodes of confusion since his last clinic visit. He states he's had greasy foods lately without any n/v, no abd pain. He drinks a couple beers a week during his weeks off sunitinib. No new meds. No apap/nsaids. No recent travel. No camping. REVIEW OF SYSTEMS: 10 point ROS reviewed in detail and negative except for what is mentioned above in HPI Past Medical History: PAST ONCOLOGIC HISTORY (per OMR): -[MASKED]: 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 [MASKED], 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. -[MASKED]: underwent a laparoscopic hand assisted radical right nephrectomy by Dr. [MASKED] pathology showed a renal cell carcinoma, clear cell type, [MASKED] 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 [MASKED], 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 [MASKED] which was a CT torso showed no evidence of recurrent or metastatic disease. -[MASKED]: CT chest showed interval increase in prominence of mediastinal lymph nodes and minimal interval increase in multiple b/l pulmonary nodules, concerning for progression -[MASKED]: Fine needle aspirate of 11R and 11L lymph nodes, which was consistent with metastatic RCC -[MASKED]: CT Torso - mediastinal and hilar nodes and pulmonary lesions increased in size. No definite intra-abdominal sites of disease -[MASKED]: C1D1 [MASKED], randomized to sunitinib -[MASKED]: Multiple grade [MASKED] 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. -[MASKED]: CT Torso: Response of mediastinal lymphadenopathy, bilateral hilar lymphadenopathy, and numerous parenchymal metastases. Stable disease by RECIST (decrease 19.1% from baseline). -[MASKED]: Sunitinib reduced to 37.5 mg daily due to erythematous rash and blistering on palms and sole of right foot. -[MASKED]: CT Torso: Decrease in pulmonary and mediastinal lesions. Stable disease by RECIST 1.1 (decrease 22.5% from baseline). -[MASKED]: CT Torso: Partial response by RECIST 1.1 (decrease 39.8% from baseline). -[MASKED]: CT Torso: Partial response by RECIST 1.1 (decrease 46.3% from baseline). -[MASKED]: CT Torso: Partial response by RECIST 1.1 (decrease 40.3% from baseline). -[MASKED]: CT Torso: Partial response by RECIST 1.1 (decrease 42.6% from baseline). -[MASKED]: CT Torso: Partial response by RECIST 1.1 (decrease 47.7% from baseline). -[MASKED]: CT torso: Ongoing partial response comments: No significant change compared to prior scan. No new lesions. -[MASKED]: CT Torso: PR by RECIST 1.1 -[MASKED]: CT Torso: PR by RECIST 1.1: -54.22% change from baseline and -10.29% change from last scan. -[MASKED]: CT Torso: partial response: -57.79% from baseline, -7.79% from nadir -[MASKED]: 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: [MASKED] Family History: Mother: Died of rectal/colon cancer. Father: No cancers, history of diabetes. Other: He has a sister with ovarian cancer diagnosed at age [MASKED] and a brother with liver cancer at age [MASKED] and another brother with hairy cell leukemia, which is in remission. Physical Exam: VITAL SIGNS: 97.5 PO 160 / 89 R Sitting 71 18 99 ra General: NAD, Resting in bed comfortably with daughter at bedside [MASKED]: MMM, no OP lesions, no cervical/supraclavicular adenopathy, no icterus CV: RR, NL S1S2 no S3S4 No MRG PULM: CTAB, No C/W/R, No respiratory distress ABD: BS+, soft, NTND, no palpable masses or HSM LIMBS: WWP, trace b/l pitting edema at the distal [MASKED], no tremors SKIN: No rashes on the extremities NEURO: Grossly normal, speech clear, AOx3 ACCESS: No port Pertinent Results: [MASKED] 06:55AM BLOOD WBC-3.9* RBC-3.12* Hgb-10.5* Hct-33.5* MCV-107* MCH-33.7* MCHC-31.3* RDW-16.8* RDWSD-65.9* Plt [MASKED] [MASKED] 07:25AM BLOOD WBC-3.0* RBC-3.03* Hgb-10.2* Hct-32.2* MCV-106* MCH-33.7* MCHC-31.7* RDW-16.9* RDWSD-66.0* Plt [MASKED] [MASKED] 11:30AM BLOOD WBC-3.6* RBC-3.21* Hgb-10.8* Hct-34.9* MCV-109* MCH-33.6* MCHC-30.9* RDW-17.0* RDWSD-68.3* Plt [MASKED] [MASKED] 06:55AM BLOOD Glucose-121* UreaN-14 Creat-1.2 Na-147 K-4.5 Cl-106 HCO3-27 AnGap-14 [MASKED] 07:25AM BLOOD Glucose-204* UreaN-18 Creat-1.3* Na-140 K-4.3 Cl-103 HCO3-25 AnGap-12 [MASKED] 11:30AM BLOOD UreaN-19 Creat-1.4* Na-139 K-5.3 Cl-101 [MASKED] 06:55AM BLOOD ALT-101* AST-47* LD([MASKED])-239 AlkPhos-188* TotBili-1.5 DirBili-0.7* IndBili-0.8 [MASKED] 09:45PM BLOOD ALT-123* AST-57* LD(LDH)-274* CK(CPK)-106 AlkPhos-241* TotBili-2.3* [MASKED] 11:30AM BLOOD ALT-133* AST-71* LD([MASKED])-289* AlkPhos-259* Amylase-210* TotBili-3.0* DirBili-1.8* IndBili-1.2 [MASKED] 09:45PM BLOOD cTropnT-<0.01 [MASKED] 11:30AM BLOOD Lipase-252* [MASKED] 06:55AM BLOOD Lipase-63* [MASKED] 06:55AM BLOOD Albumin-3.7 Calcium-9.3 Phos-3.7 Mg-2.0 [MASKED] 09:45PM BLOOD calTIBC-306 VitB12-356 Folate->20 [MASKED] Ferritn-597* TRF-235 [MASKED] 09:45PM BLOOD Triglyc-207* HDL-30* CHOL/HD-4.7 LDLcalc-70 [MASKED] 11:30AM BLOOD Free T4-1.2 [MASKED] 09:45PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG [MASKED] 09:45PM BLOOD Smooth-NEGATIVE [MASKED] 09:45PM BLOOD [MASKED] [MASKED] 09:45PM BLOOD IgG-666* IgA-165 IgM-120 [MASKED] 09:45PM BLOOD HCV Ab-NEG [MASKED] 09:46PM BLOOD Lactate-0.7 [MASKED] 11:30AM BLOOD FREE T3-Test [MASKED] 11:30AM BLOOD Free T4-1.2 Brief Hospital Course: IMAGING: RUQ US [MASKED]: 1. Biliary sludge without evidence of gallbladder-wall thickening or intrahepatic biliary dilatation. 2. No evidence of focal liver lesions MRCP [MASKED]: 1. Moderate intra and extrahepatic biliary ductal dilatation with duct penetrating sign suggestive of inflammatory rather than neoplastic stricture. Correlation with ERCP may be considered. No evidence of choledocholithiasis or definite obstructing mass. 2. Short-segment (11 mm) eccentric filling defect within the main portal vein, suspicious for nonocclusive thrombus. 3. Sludge within the gallbladder lumen. 4. Status post left nephrectomy with stable soft tissue within the left nephrectomy bed. 5. Multiple pancreatic cystic lesions, likely small side branch IPMNs, measuring up to 10 mm. ASSESSMENT AND PLAN: [MASKED] w/ ID-T2DM, HTN, DL, BPH, and metastatic clear cell RCC, s/p radical L nephrectomy in [MASKED], found to have pulmonary, mediastinal, and hilar mets [MASKED], now on [MASKED], randomized to sunitinib, dose-reduced, currently 2 weeks off sunitinib per protocol, who is directly admitted from clinic for abnormal LFTs found on routine lab screening. # Elevated LFTs Non-specific elevations. US did not reveal any focal lesions nor any biliary dilatation nor stones. Lipase elevated at 252 but in absence of any abd pain, unlikely pancreatitis. Unlikely sunitinib effect per oncology. Pt did appear to be lethargic per oncologist but is AOx3 and no asterixis, but cannot rule out some element of encephalopathy. Found on MRCP to have moderate intra/extrahepatic biliary ductal dilatation suggestive of stricture. Hepto wnl and anemia stable, so unlikely hemolysis. SPEP largely wnl. ERCP on [MASKED] revealed stricture in bile duct and had plastic biliary stent placed. He tolerated procedure well. Had no infectious symptoms nor any signs of post-ercp pancreatitis. He was advanced to full diet and instructed to f/u with oncology for the results of the brushings done during ERCP. Their team will coordinate a repeat ERCP in 4 wks. # Portal Vein THrombus MRCP revealed a small non-occlusive filling defect within the main portal vein suspicious for thrombus. Due to risk of progression, patient was started on once daily dosing lovenox at 1.5 mg/kg. Due to sphincterotomy during the ERCP, patient was instructed to wait 5 days after ercp to start the lovenox. He was provided teaching on how to inject and warning signs while he was here. # Pancreatic cysts Found on MRCP, per radiology, felt to be to be small side branch Intraductal papillary mucinous neoplasm. - f/u in [MASKED] year # [MASKED] CT scans from [MASKED] revealed partial response to sunitinib. - sunitinib is currently on hold - will f/u w/ Dr [MASKED] # Macrocytic Anemia Chronic and at baseline. TSH WNL as well as VIt B12, Folate, spep, and ferritin/TIBC. # Depressed mood/anxiety - hold cariprazine [MASKED] lfts - cont fluoxetine # T2DM: cont home insulin, glipizide # HTN: cont amlodipine, atenolol, lisinopril # DL: hold statin/fibrate # CKD: cr baseline # Hypothyroidism: cont levothyroxine (TSH WNL) # BPH: cont flomax FEN: Regular low fat diabetic diet DVT PROPHYLAXIS: HSQ ACCESS: PIV CODE STATUS: Full code, presumed PCP: [MASKED], MD DISPO: Home w/o services BILLING: 45 min spent coordinating care for discharge [MASKED] [MASKED], D.O. Heme/Onc Hospitalist p: [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Atenolol 100 mg PO DAILY 3. cariprazine 1.5 mg oral DAILY 4. Fenofibrate 48 mg PO DAILY 5. FLUoxetine 20 mg PO DAILY 6. Gabapentin 100 mg PO DAILY 7. GlipiZIDE 2.5 mg PO BID 8. Lantus Solostar U-100 Insulin (insulin glargine) [MASKED] units subcutaneous QPM 9. Levothyroxine Sodium 100 mcg PO DAILY 10. LORazepam 0.5 mg PO DAILY:PRN anxiety 11. Ondansetron 4 mg PO Q8H:PRN nausea 12. Prochlorperazine 5 mg PO Q8H:PRN nausea 13. Simvastatin 40 mg PO QPM 14. Tamsulosin 0.4 mg PO QHS 15. Ascorbic Acid [MASKED] mg PO DAILY 16. Vitamin D 5000 UNIT PO DAILY 17. Omeprazole 20 mg PO DAILY 18. Artificial Tears Preserv. Free [MASKED] DROP BOTH EYES PRN dry eyes 19. Lisinopril 40 mg PO DAILY Discharge Medications: 1. Enoxaparin Sodium 120 mg SC DAILY Start: Future Date - [MASKED], First Dose: First Routine Administration Time RX *enoxaparin 120 mg/0.8 mL 120 mg sc daily Disp #*30 Syringe Refills:*0 2. amLODIPine 10 mg PO DAILY 3. Artificial Tears Preserv. Free [MASKED] DROP BOTH EYES PRN dry eyes 4. Ascorbic Acid [MASKED] mg PO DAILY 5. Atenolol 100 mg PO DAILY 6. cariprazine 1.5 mg oral DAILY 7. FLUoxetine 20 mg PO DAILY 8. Gabapentin 100 mg PO DAILY 9. GlipiZIDE 2.5 mg PO BID 10. Lantus Solostar U-100 Insulin (insulin glargine) [MASKED] units subcutaneous QPM 11. Levothyroxine Sodium 100 mcg PO DAILY 12. Lisinopril 40 mg PO DAILY 13. LORazepam 0.5 mg PO DAILY:PRN anxiety 14. Omeprazole 20 mg PO DAILY 15. Ondansetron 4 mg PO Q8H:PRN nausea 16. Prochlorperazine 5 mg PO Q8H:PRN nausea 17. Tamsulosin 0.4 mg PO QHS 18. Vitamin D 5000 UNIT PO DAILY 19. HELD- Fenofibrate 48 mg PO DAILY This medication was held. Do not restart Fenofibrate until discussed with your oncologist 20. HELD- Simvastatin 40 mg PO QPM This medication was held. Do not restart Simvastatin until discussed with your oncologist Discharge Disposition: Home Discharge Diagnosis: Biliary Stricture Portal Vein Thrombus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear [MASKED] [MASKED] were admitted to the hospital because [MASKED] had abnormal liver enzymes. MRI of your liver (MRCP) revealed a narrowing in your bile duct, also known as a stricture. [MASKED] had an ERCP (endoscopy and a camera into your bile duct) which confirmed a stricture. These improved after [MASKED] had an ERCP. [MASKED] had a plastic stent placed in your bile duct and [MASKED] tolerated this well. Your liver enzymes are already improving. ERCP team will call [MASKED] to schedule another ERCP in 4 weeks or so to possibly remove the stent. [MASKED] will follow up on the biopsy results with your oncology team. [MASKED] were also found to have a clot in one of your veins (portal vein) which will need to be treated with a blood thinner. [MASKED] will start this [MASKED]. Call your oncology team if there are any issues or questions. Regards, Your [MASKED] team Followup Instructions: [MASKED]
|
[] |
[
"E785",
"I129",
"E1122",
"N189",
"F419",
"N400",
"F329",
"E039",
"Z87891"
] |
[
"K831: Obstruction of bile duct",
"I81: Portal vein thrombosis",
"C7800: Secondary malignant neoplasm of unspecified lung",
"K862: Cyst of pancreas",
"C771: Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes",
"E785: Hyperlipidemia, unspecified",
"I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease",
"E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease",
"N189: Chronic kidney disease, unspecified",
"F419: Anxiety disorder, unspecified",
"N400: Benign prostatic hyperplasia without lower urinary tract symptoms",
"D539: Nutritional anemia, unspecified",
"F329: Major depressive disorder, single episode, unspecified",
"E039: Hypothyroidism, unspecified",
"Z85528: Personal history of other malignant neoplasm of kidney",
"Z905: Acquired absence of kidney",
"Z87891: Personal history of nicotine dependence",
"Z800: Family history of malignant neoplasm of digestive organs",
"Z807: Family history of other malignant neoplasms of lymphoid, hematopoietic and related tissues",
"Z8041: Family history of malignant neoplasm of ovary"
] |
10,006,269 | 27,357,430 |
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:
___
|
[
"B003",
"C20",
"K626",
"K2960",
"K2980",
"I10",
"F329",
"D508"
] |
Allergies: No Known Allergies / Adverse Drug Reactions Major Surgical or Invasive Procedure: EGD Colonoscopy Biopsy during colonoscopy Lumbar puncture attach Pertinent Results: ADMISSION LABS: [MASKED] 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 [MASKED] 11:00AM NEUTS-85.1* LYMPHS-6.6* MONOS-7.7 EOS-0.0* BASOS-0.2 IM [MASKED] AbsNeut-8.47* AbsLymp-0.66* AbsMono-0.77 AbsEos-0.00* AbsBaso-0.02 [MASKED] 11:00AM PLT COUNT-225 [MASKED] 11:00AM GLUCOSE-111* UREA N-15 CREAT-1.0 SODIUM-128* POTASSIUM-4.6 CHLORIDE-95* TOTAL CO2-18* ANION GAP-15 [MASKED] 11:00AM ALT(SGPT)-13 AST(SGOT)-20 ALK PHOS-80 TOT BILI-1.0 [MASKED] 11:00AM ALBUMIN-4.9 [MASKED] 07:20AM BLOOD Hypochr-1+* Anisocy-1+* Macrocy-1+* Microcy-1+* Polychr-1+* Tear Dr-1+* RBC Mor-SLIDE REVI [MASKED] 11:42AM BLOOD Ret Aut-3.1* Abs Ret-0.13* [MASKED] 07:20AM BLOOD calTIBC-371 VitB12-293 Folate-8 Ferritn-5.6* TRF-285 [MASKED] 11:42AM BLOOD Hapto-208* [MASKED] 07:20AM BLOOD TSH-1.1 [MASKED] 07:20AM BLOOD 25VitD-17* [MASKED] 03:30AM BLOOD IgA-162 [MASKED] 03:40PM CEREBROSPINAL FLUID (CSF) TNC-146* RBC-7* POLYS-1 [MASKED] MONOS-12 BASOS-1 OTHER-0 [MASKED] 03:40PM CEREBROSPINAL FLUID (CSF) TNC-141* RBC-2 POLYS-1 [MASKED] MONOS-3 OTHER-0 [MASKED] 03:40PM CEREBROSPINAL FLUID (CSF) PROTEIN-100* GLUCOSE-57 [MASKED] 11:00AM Lyme Ab-NEG [MASKED] 04:45PM BLOOD Trep Ab-NEG [MASKED] 07:20AM BLOOD HIV Ab-NEG [MASKED] 03:05PM BLOOD Parst S-NEGATIVE MICRO: [MASKED] 3:40 pm CSF;SPINAL FLUID Site: LUMBAR PUNCTURE TUBE #3. GRAM STAIN (Final [MASKED]: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [MASKED]: NO GROWTH. HSV CSF HSV2 + low positive IMAGING: CT head w/o acute intracranial process Discharge Labs: [MASKED] 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 [MASKED] [MASKED] 06:00AM BLOOD Glucose-80 UreaN-12 Creat-0.8 Na-143 K-3.9 Cl-111* HCO3-21* AnGap-11 [MASKED] 06:00AM BLOOD Calcium-8.2* Phos-4.5 Mg-1.7 [MASKED] 05:45AM BLOOD Hapto-126 [MASKED] 07:20AM BLOOD TSH-1.1 [MASKED] 05:50AM BLOOD CEA-1.9 [MASKED] 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. [MASKED] is a [MASKED] 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 [MASKED] 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 [MASKED], 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 [MASKED]: "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 [MASKED]. He denies any known bleeding. GI was consulted and recommended EGD + colonoscopy, performed [MASKED]. 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 [MASKED] HSV Iron deficiency anemia Rectal cancer Discharge Condition: Stable for outpatient follow up Discharge Instructions: Dear [MASKED], 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 [MASKED] 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 [MASKED] 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: [MASKED]. We wish you the best in your recovery. -- Your medical team Followup Instructions: [MASKED]
|
[] |
[
"I10",
"F329"
] |
[
"B003: Herpesviral meningitis",
"C20: Malignant neoplasm of rectum",
"K626: Ulcer of anus and rectum",
"K2960: Other gastritis without bleeding",
"K2980: Duodenitis without bleeding",
"I10: Essential (primary) hypertension",
"F329: Major depressive disorder, single episode, unspecified",
"D508: Other iron deficiency anemias"
] |
10,006,431 | 24,638,489 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
latex
Attending: ___
Chief Complaint:
abd pain
Major Surgical or Invasive Procedure:
___: EUS was performed using a linear echoendoscope at ___ MHz
frequency. Celiac Plexus Neurolysis was performed. The take-off
of the celiac artery was identified. A 22-gauge EUS needle was
primed with saline and advanced adjacent to the Aorta, just
superior to the celiac artery take-off. The celiac plexus was
visualized. This was aspirated to assess for vascular injection.
No blood was noted. Bupivacaine 0.25% x 10 cc was injected
bilaterally. Dehydrated 98% alcohol x 10 cc was injected. The
needle was then withdrawn.
History of Present Illness:
=============================================================
ONCOLOGY HOSPITALIST ADMISSION NOTE ___
=============================================================
PRIMARY ONCOLOGIST: ___
PRIMARY DIAGNOSIS: Metastatic pancreatic cancer
TREATMENT REGIMEN: C7D1 Gemcitabine ___
CC: ___ pain
HISTORY OF PRESENTING ILLNESS:
___ is a ___ year old woman with metastatic pancreatic
cancer on palliative gemcitabine who is admitted with one week
of
progressive epigastric abdominal pain. Patient is deaf and uses
ASL; interview conducted with the aid of her son translating.
Patient developed insidious onset of progressive epigastric
abdominal pain after chemotherapy on ___. Her pain progressed,
and was associated with nausea, dry heaves, and poor po intake.
Olanzapine was prescribed for her worsening nausea on ___,
which
made her very sleepy. By ___ she was not tolerating po intake
with emesis x2 and her pain was up to ___. She discusse with
her oncologist, and presented to the ___ ED.
There, her lipase was 2800. CT a/p reportedly showed 'large
infiltrative pancreatic head tumor along with tumor infiltrate
and/or pancreatitis in the lesser sac and about the celiac
axis'.
She was transferred to ___ ED.
In the ED, initial VS were pain 10, T 99.6, HR 94, BP 115/75, RR
16, O2 97%RA. Initial labs notable for Na 137, K 4.4, HCO3 24,
Cr
0.5, Ca 9.6, Mg 2.0, P 2.9, ALT 14, AST 14, ALP 138, TBili 0.6,
Alb 3.3, Lipase 508, INR 1.2, lactate 1.2. Patient was given IV
lR along with IV Zofran and IV morphine. VS prior to transfer
were T 98.4, HR 80, BP 121/57, RR 16, O2 98%RA.
On arrival to the floor, patient reports progressive epigastric
pain, up to ___ with occaisional radiation into RUQ and LUQ.
It
is worse with any po intake. Minimal relief with home oxycodone
and tramadol. She has mild intermittent abdominal pain but
nothing like this. She has associated poor appetite and nausea.
No fevers or chills. No dysphagia or odynophagia. No UTRI
symptoms. No SOB, cough, or chest pian. No dysuria, although has
had low UOP. No BM in last two days and no diarrhea. No new
joint
pains, rashes, or leg swelling.
REVIEW OF SYSTEMS:
A complete 10-point review of systems was performed and was
negative unless otherwise noted in the HPI.
Past Medical History:
PAST ONCOLOGIC HISTORY:
___ has a history of hypertension,
congenital deafness, and GERD, and presented in ___ 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 ___, which 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 was dose reduced for N/V/D. She was hospitalized
___ with diarrhea, nausea, anorexia, and
neutropenia. Her C2D15 treatment was held. With cycle 3 she
transitioned to mFOLFOX. She completed five infusion and was
taken to the OR ___. Liver metastases were identified
intraoperatively, and plans for resection were aborted. She
initiated palliative chemotherapy with gemcitabine ___.
The dose was reduced to 750mg/m2 on C1D8 due to neutropenia.
With cycle 2 she transitioned to day 1 and 15 schedule.
Following six cycles there was further progression, and she was
referred for combination gemcitabine/nab-paclitaxel.
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:
VITAL SIGNS: 97.9 PO 108 / 66 Lying 70 18 95 RA
___: NAD
HEENT: MMM
CV: RR, NL S1S2 no S3S4, no MRG
PULM: CTAB, respirations unlabored
ABD: BS+, S, less TTP epigastric area
LIMBS: No ___
SKIN: No rashes on extremities
NEURO: Grossly WNL
Pertinent Results:
___ 05:19AM BLOOD WBC-12.0* RBC-3.41* Hgb-9.6* Hct-30.0*
MCV-88 MCH-28.2 MCHC-32.0 RDW-14.7 RDWSD-46.3 Plt ___
___ 05:19AM BLOOD Glucose-69* UreaN-4* Creat-0.4 Na-135
K-3.6 Cl-98 HCO3-25 AnGap-12
___ 05:19AM BLOOD ALT-9 AST-14 LD(LDH)-127 AlkPhos-109*
TotBili-0.5
___ 04:46AM BLOOD Lipase-293*
___ 05:19AM BLOOD Albumin-2.7* Calcium-8.5 Phos-2.1* Mg-1.7
___ 04:46AM BLOOD Triglyc-73
Brief Hospital Course:
IMAGING:
___BDOMEN (___)
- Image loaded into PACS. Read in chart:
" Large infiltrative pancreatic head tumor. There is tumor
infiltrate and/or pancreatitis in the lesser sac and about the
celiac axis/SMA. Attenuation of the portal vein and splenic vein
due to tumor. Multiple liver metastases. Large amount stool in
the right colon "
ASSESSMENT AND PLAN:
___ w/ metastatic pancreatic cancer on palliative gemcitabine
who
is admitted with one week of progressive epigastric abdominal
pain
# Pancreatitis
# Abdominal pain:
Patient with one week of progressive worsening of epigastric
abdominal pain/nausea. Found to have elevated lipase and OSH
imaging suggestive of acute inflammation c/w pancreatitis flare
(although difficult to interpret given her pancreatic cancer).
No
elevation in LFT's to suggest acute obstruction. Pain has been
largely insidious since diagnosis of pancreatic ca so possibly
acute pancreatitis but largely pain is due to the tumor hence
celiac plexus block ___. Symptoms cont to improve slowly.
- low fat diet
- appreciate Pal care c/l for sx control
- started on oxycontin 10 mg bid w/ modicum of improvement of
her sx
- cont oxycodone prn (uses rarely)
# Metastatic pancreatic cancer: Initially thought locally
advanced and went to OR for Whipple after neoadjuvant
chemotherapy, unfortunately found to have metastatic liver
disease intraoperatively. Recently progressive after 6C
palliative gemcitabine. Plan has been to initiate nab-paclitaxel
for C7D15 however she noted several times she is not interested
in receiving any more chemo until she regains her strength.
- chemo on hold for this week
- f/u Onc arranged
- f/u w/ palliative care being arranged
# Hypertension: now hypotensive, hence dc'd home acei w/ SBP
___
# GERD: cont PPI
CODE: DNR/DNI
COMMUNICATION: Patient
EMERGENCY CONTACT HCP:
Health care proxy chosen: Yes
Name of health care proxy: ___
Cell phone: ___ phone)
DISPO: Home w/ ___
BILLING: >30 min spent coordinating care for discharge
______________
___, D.O.
Heme/Onc Hospitalist
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. OLANZapine 5 mg PO BID:PRN nausea
3. Omeprazole 20 mg PO DAILY
4. Ondansetron 8 mg PO Q8H:PRN nausea
5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate
6. Prochlorperazine 10 mg PO Q6H:PRN nausea
7. TraMADol 50-100 mg PO Q6H:PRN Pain - Moderate
8. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
Discharge Medications:
1. Lidocaine 5% Patch ___ PTCH TD QAM to LUQ area
RX *lidocaine 5 % ___ patches daily to LUQ daily, 12 hrs on, 12
hrs off Disp #*30 Patch Refills:*0
2. Magnesium Citrate 300 mL PO ONCE Duration: 1 Dose
RX *magnesium citrate 300 ml by mouth q3 days Refills:*0
3. Milk of Magnesia 30 mL PO Q6H:PRN constipation
RX *magnesium hydroxide [Milk of Magnesia] 400 mg/5 mL 30 ml by
mouth q6h prn Refills:*0
4. Multivitamins W/minerals 1 TAB PO DAILY
5. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H
RX *oxycodone 10 mg 1 tablet(s) by mouth q12 Disp #*60 Tablet
Refills:*0
6. Polyethylene Glycol 17 g PO DAILY constipation
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth daily
Disp #*30 Packet Refills:*0
7. Senna 17.2 mg PO BID constipation
RX *sennosides [senna] 8.6 mg 17.2 mg by mouth twice a day Disp
#*120 Tablet Refills:*0
8. Ondansetron ODT ___ mg PO Q8H:PRN nausea
RX *ondansetron 4 mg ___ tablet(s) by mouth every eight (8)
hours Disp #*60 Tablet Refills:*0
9. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
10. OLANZapine 5 mg PO BID:PRN nausea
11. Omeprazole 20 mg PO DAILY
12. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Acute Pancreatitis
Pancreatic Cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was a pleasure caring for ___ in the hospital. ___ were
admitted because of worsening abdominal pain. ___ had a celiac
plexus block and were started on oxycontin with improvement of
your pain. ___ will need to continue a low fat diet. ___ were
seen by the nutritionist who recommended eating small frequent
meals. Please eat high protein, nutrient-dense diets that
include fruits, vegetables, whole grains, low fat dairy, and
other lean protein sources. Abstinence from alcohol and greasy
or fried foods is important in helping to prevent malnutrition
and pain.
Best,
Your ___ Team
Followup Instructions:
___
|
[
"G893",
"Z66",
"K8580",
"E43",
"C250",
"C787",
"C7900",
"I959",
"K219",
"Z681",
"I10",
"E049",
"E7800",
"K5900"
] |
Allergies: latex Chief Complaint: abd pain Major Surgical or Invasive Procedure: [MASKED]: EUS was performed using a linear echoendoscope at [MASKED] MHz frequency. Celiac Plexus Neurolysis was performed. The take-off of the celiac artery was identified. A 22-gauge EUS needle was primed with saline and advanced adjacent to the Aorta, just superior to the celiac artery take-off. The celiac plexus was visualized. This was aspirated to assess for vascular injection. No blood was noted. Bupivacaine 0.25% x 10 cc was injected bilaterally. Dehydrated 98% alcohol x 10 cc was injected. The needle was then withdrawn. History of Present Illness: ============================================================= ONCOLOGY HOSPITALIST ADMISSION NOTE [MASKED] ============================================================= PRIMARY ONCOLOGIST: [MASKED] PRIMARY DIAGNOSIS: Metastatic pancreatic cancer TREATMENT REGIMEN: C7D1 Gemcitabine [MASKED] CC: [MASKED] pain HISTORY OF PRESENTING ILLNESS: [MASKED] is a [MASKED] year old woman with metastatic pancreatic cancer on palliative gemcitabine who is admitted with one week of progressive epigastric abdominal pain. Patient is deaf and uses ASL; interview conducted with the aid of her son translating. Patient developed insidious onset of progressive epigastric abdominal pain after chemotherapy on [MASKED]. Her pain progressed, and was associated with nausea, dry heaves, and poor po intake. Olanzapine was prescribed for her worsening nausea on [MASKED], which made her very sleepy. By [MASKED] she was not tolerating po intake with emesis x2 and her pain was up to [MASKED]. She discusse with her oncologist, and presented to the [MASKED] ED. There, her lipase was 2800. CT a/p reportedly showed 'large infiltrative pancreatic head tumor along with tumor infiltrate and/or pancreatitis in the lesser sac and about the celiac axis'. She was transferred to [MASKED] ED. In the ED, initial VS were pain 10, T 99.6, HR 94, BP 115/75, RR 16, O2 97%RA. Initial labs notable for Na 137, K 4.4, HCO3 24, Cr 0.5, Ca 9.6, Mg 2.0, P 2.9, ALT 14, AST 14, ALP 138, TBili 0.6, Alb 3.3, Lipase 508, INR 1.2, lactate 1.2. Patient was given IV lR along with IV Zofran and IV morphine. VS prior to transfer were T 98.4, HR 80, BP 121/57, RR 16, O2 98%RA. On arrival to the floor, patient reports progressive epigastric pain, up to [MASKED] with occaisional radiation into RUQ and LUQ. It is worse with any po intake. Minimal relief with home oxycodone and tramadol. She has mild intermittent abdominal pain but nothing like this. She has associated poor appetite and nausea. No fevers or chills. No dysphagia or odynophagia. No UTRI symptoms. No SOB, cough, or chest pian. No dysuria, although has had low UOP. No BM in last two days and no diarrhea. No new joint pains, rashes, or leg swelling. REVIEW OF SYSTEMS: A complete 10-point review of systems was performed and was negative unless otherwise noted in the HPI. Past Medical History: PAST ONCOLOGIC HISTORY: [MASKED] has a history of hypertension, congenital deafness, and GERD, and presented in [MASKED] to [MASKED] 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 [MASKED] where she underwent ERCP. This study identified a stricture in the common bile duct due to external compression. Brushings were atypical. Her CA [MASKED] was elevated at 180 U/mL. She underwent endoscopic ultrasound [MASKED], which identified a 1.8 x 1.6 cm pancreatic head mass without vascular involvement. Biopsy by [MASKED] 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. [MASKED] was diagnosed with borderline resectable PDA and initiated chemotherapy with neoadjuvant FOLFIRINOX [MASKED]. C1D15 was dose reduced for N/V/D. She was hospitalized [MASKED] with diarrhea, nausea, anorexia, and neutropenia. Her C2D15 treatment was held. With cycle 3 she transitioned to mFOLFOX. She completed five infusion and was taken to the OR [MASKED]. Liver metastases were identified intraoperatively, and plans for resection were aborted. She initiated palliative chemotherapy with gemcitabine [MASKED]. The dose was reduced to 750mg/m2 on C1D8 due to neutropenia. With cycle 2 she transitioned to day 1 and 15 schedule. Following six cycles there was further progression, and she was referred for combination gemcitabine/nab-paclitaxel. 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: [MASKED] Family History: The patient's father died of an MI at [MASKED] years. Her mother died with type 2 diabetes mellitus. A sister died with colon cancer at [MASKED] years. Another sister died of [MASKED] disease. She has two sons without health concerns. Physical Exam: VITAL SIGNS: 97.9 PO 108 / 66 Lying 70 18 95 RA [MASKED]: NAD HEENT: MMM CV: RR, NL S1S2 no S3S4, no MRG PULM: CTAB, respirations unlabored ABD: BS+, S, less TTP epigastric area LIMBS: No [MASKED] SKIN: No rashes on extremities NEURO: Grossly WNL Pertinent Results: [MASKED] 05:19AM BLOOD WBC-12.0* RBC-3.41* Hgb-9.6* Hct-30.0* MCV-88 MCH-28.2 MCHC-32.0 RDW-14.7 RDWSD-46.3 Plt [MASKED] [MASKED] 05:19AM BLOOD Glucose-69* UreaN-4* Creat-0.4 Na-135 K-3.6 Cl-98 HCO3-25 AnGap-12 [MASKED] 05:19AM BLOOD ALT-9 AST-14 LD(LDH)-127 AlkPhos-109* TotBili-0.5 [MASKED] 04:46AM BLOOD Lipase-293* [MASKED] 05:19AM BLOOD Albumin-2.7* Calcium-8.5 Phos-2.1* Mg-1.7 [MASKED] 04:46AM BLOOD Triglyc-73 Brief Hospital Course: IMAGING: BDOMEN ([MASKED]) - Image loaded into PACS. Read in chart: " Large infiltrative pancreatic head tumor. There is tumor infiltrate and/or pancreatitis in the lesser sac and about the celiac axis/SMA. Attenuation of the portal vein and splenic vein due to tumor. Multiple liver metastases. Large amount stool in the right colon " ASSESSMENT AND PLAN: [MASKED] w/ metastatic pancreatic cancer on palliative gemcitabine who is admitted with one week of progressive epigastric abdominal pain # Pancreatitis # Abdominal pain: Patient with one week of progressive worsening of epigastric abdominal pain/nausea. Found to have elevated lipase and OSH imaging suggestive of acute inflammation c/w pancreatitis flare (although difficult to interpret given her pancreatic cancer). No elevation in LFT's to suggest acute obstruction. Pain has been largely insidious since diagnosis of pancreatic ca so possibly acute pancreatitis but largely pain is due to the tumor hence celiac plexus block [MASKED]. Symptoms cont to improve slowly. - low fat diet - appreciate Pal care c/l for sx control - started on oxycontin 10 mg bid w/ modicum of improvement of her sx - cont oxycodone prn (uses rarely) # Metastatic pancreatic cancer: Initially thought locally advanced and went to OR for Whipple after neoadjuvant chemotherapy, unfortunately found to have metastatic liver disease intraoperatively. Recently progressive after 6C palliative gemcitabine. Plan has been to initiate nab-paclitaxel for C7D15 however she noted several times she is not interested in receiving any more chemo until she regains her strength. - chemo on hold for this week - f/u Onc arranged - f/u w/ palliative care being arranged # Hypertension: now hypotensive, hence dc'd home acei w/ SBP [MASKED] # GERD: cont PPI CODE: DNR/DNI COMMUNICATION: Patient EMERGENCY CONTACT HCP: Health care proxy chosen: Yes Name of health care proxy: [MASKED] Cell phone: [MASKED] phone) DISPO: Home w/ [MASKED] BILLING: >30 min spent coordinating care for discharge [MASKED] [MASKED], D.O. Heme/Onc Hospitalist [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 20 mg PO DAILY 2. OLANZapine 5 mg PO BID:PRN nausea 3. Omeprazole 20 mg PO DAILY 4. Ondansetron 8 mg PO Q8H:PRN nausea 5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate 6. Prochlorperazine 10 mg PO Q6H:PRN nausea 7. TraMADol 50-100 mg PO Q6H:PRN Pain - Moderate 8. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild Discharge Medications: 1. Lidocaine 5% Patch [MASKED] PTCH TD QAM to LUQ area RX *lidocaine 5 % [MASKED] patches daily to LUQ daily, 12 hrs on, 12 hrs off Disp #*30 Patch Refills:*0 2. Magnesium Citrate 300 mL PO ONCE Duration: 1 Dose RX *magnesium citrate 300 ml by mouth q3 days Refills:*0 3. Milk of Magnesia 30 mL PO Q6H:PRN constipation RX *magnesium hydroxide [Milk of Magnesia] 400 mg/5 mL 30 ml by mouth q6h prn Refills:*0 4. Multivitamins W/minerals 1 TAB PO DAILY 5. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H RX *oxycodone 10 mg 1 tablet(s) by mouth q12 Disp #*60 Tablet Refills:*0 6. Polyethylene Glycol 17 g PO DAILY constipation RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth daily Disp #*30 Packet Refills:*0 7. Senna 17.2 mg PO BID constipation RX *sennosides [senna] 8.6 mg 17.2 mg by mouth twice a day Disp #*120 Tablet Refills:*0 8. Ondansetron ODT [MASKED] mg PO Q8H:PRN nausea RX *ondansetron 4 mg [MASKED] tablet(s) by mouth every eight (8) hours Disp #*60 Tablet Refills:*0 9. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild 10. OLANZapine 5 mg PO BID:PRN nausea 11. Omeprazole 20 mg PO DAILY 12. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate Discharge Disposition: Home With Service Facility: [MASKED] [MASKED] Diagnosis: Acute Pancreatitis Pancreatic Cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear [MASKED], [MASKED] was a pleasure caring for [MASKED] in the hospital. [MASKED] were admitted because of worsening abdominal pain. [MASKED] had a celiac plexus block and were started on oxycontin with improvement of your pain. [MASKED] will need to continue a low fat diet. [MASKED] were seen by the nutritionist who recommended eating small frequent meals. Please eat high protein, nutrient-dense diets that include fruits, vegetables, whole grains, low fat dairy, and other lean protein sources. Abstinence from alcohol and greasy or fried foods is important in helping to prevent malnutrition and pain. Best, Your [MASKED] Team Followup Instructions: [MASKED]
|
[] |
[
"Z66",
"K219",
"I10",
"K5900"
] |
[
"G893: Neoplasm related pain (acute) (chronic)",
"Z66: Do not resuscitate",
"K8580: Other acute pancreatitis without necrosis or infection",
"E43: Unspecified severe protein-calorie malnutrition",
"C250: Malignant neoplasm of head of pancreas",
"C787: Secondary malignant neoplasm of liver and intrahepatic bile duct",
"C7900: Secondary malignant neoplasm of unspecified kidney and renal pelvis",
"I959: Hypotension, unspecified",
"K219: Gastro-esophageal reflux disease without esophagitis",
"Z681: Body mass index [BMI] 19.9 or less, adult",
"I10: Essential (primary) hypertension",
"E049: Nontoxic goiter, unspecified",
"E7800: Pure hypercholesterolemia, unspecified",
"K5900: Constipation, unspecified"
] |
10,006,431 | 25,086,012 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
latex
Attending: ___.
Chief Complaint:
Nausea, anorexia, abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ PMH of Deafness (uses ASL), GERD, HTN, Metastatic Pancreatic
Cancer (mets to liver, recently on palliative gemcitabine), CBD
obstruction (s/p sphincerotomy and metal stent placement) who
recently was admitted for pain control and possible pancreatitis
(s/p celiac plexus block and increased pain regimen), now
returns
with nausea, vomiting, abdominal pain and decreased PO intake
Pt was last discharged on ___ after being admitted for possible
pancreatitis vs pain ___ progression of malignancy. She had
celiac nerve plexus block and had oxycontin initiated. As a
result pain was improved and patient was discharged with
outpatient oncology followup
OF note, patient is deaf and uses ASL to communicate for complex
decision making, but was able to communicate by writing and with
lip reading for purposes of this interview. Pt noted that since
discharge she has had intermittent abdominal pain which is
epigastric and radiating to the back, which comes on in spasms,
with sharp stabbing sensation. She noted that her pain may be
slightly improved compared to prior though. However, she is more
concerned with nausea/vomiting at home with yellow colored
vomitus and lack of po intake ___ decreased appetite. Denied
fever, chills, sore throat, dysuria, rash, significant diarrhea.
In the ED, initial vitals: 98.1 107 122/87 18 99% RA. Labs
revealed WBC of 23 (recent baseline was 12), Hgb 11.9 (baseline
9.5), plt 585 (baseline 268). Chem wnl, LFTs unchanged since
last
admission. Lipase 123 down from 500 on last admit. Lactate
normal. She was given IVF, Zofran, and dilaudid. She noted that
she felt unsafe going home as did not feel remarkably improved
so
was admitted to oncology for further care.
REVIEW OF SYSTEMS:
A complete 10-point review of systems was performed and was
negative unless otherwise noted in the HPI.
Past Medical History:
PAST ONCOLOGIC HISTORY:
As per OMR
"presented in ___ 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 ___, which 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 ___ and ___. There was no evidence of distant
metastases.
Ms. ___ was diagnosed with borderline resectable PDA and
initiated chemotherapy with neoadjuvant FOLFIRINOX ___.
C1D15 was dose reduced for N/V/D. She was hospitalized
___ with diarrhea, nausea, anorexia, and
neutropenia. Her C2D15 treatment was held. With cycle 3 she
transitioned to mFOLFOX. She completed five infusion and was
taken to the OR ___. Liver metastases were identified
intraoperatively, and plans for resection were aborted. She
initiated palliative chemotherapy with gemcitabine ___.
The dose was reduced to 750mg/m2 on C1D8 due to neutropenia.
With cycle 2 she transitioned to day 1 and 15 schedule.
Following six cycles there was further progression, and she was
referred for combination gemcitabine/nab-paclitaxel"
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.
8. CBD obstruction s/p sphincerotomy and metal stent placement
via ERCP
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:
Vitals: 98.3 134/84 104 18 98RA
___: Sitting in bed, appears comfortable, no acute distress
EYES: PERRLA
HEENT: Moist mucous membranes, oropharynx clear
NECK: Supple
LUNGS: Clear to auscultation bilaterally no wheezes rales or
rhonchi, normal respiratory rate
CV: Regular rate and rhythm without any murmurs rubs or gallops
ABD: Slight epigastric tenderness to moderate palpation,
nondistended, normoactive bowel sounds, no ascites
EXT: Normal bulk/tone, no deformity
SKIN: Warm/dry, no rash
NEURO: Alert and oriented ×3, fluent speech but has difficulty
with correct pronunciation as is deaf, but reads lips and writes
to communicate
ACCESS: chest port with dressing c/d/i
Pertinent Results:
___ 02:10PM WBC-23.0*# RBC-4.30# HGB-11.9 HCT-37.1 MCV-86
MCH-27.7 MCHC-32.1 RDW-16.1* RDWSD-48.4*
___ 02:10PM PLT COUNT-585*#
___ 02:10PM cTropnT-0.05*
___ 02:10PM ALT(SGPT)-10 AST(SGOT)-18 ALK PHOS-153* TOT
BILI-0.5
___ 02:10PM LIPASE-123*
___ 02:10PM GLUCOSE-132* UREA N-10 CREAT-0.4 SODIUM-138
POTASSIUM-4.3 CHLORIDE-97 TOTAL CO2-23 ANION GAP-18*
___ 02:53PM LACTATE-1.7
Brief Hospital Course:
Ms ___ is a pleasant ___ year-old female with deafness
admitted with recurrent abdominal pain, nausea, and poor
appetite attributed to her pancreatic cancer. Her anti-nausea
and pain medications were adjusted to achieve better symptom
control, including increase of her oxycontin dose from bid to
tid, and adding baclofen to address some element of back spasm.
Her appetite remained minimal, but she was able to tolerate
fluids throughout her stay. She met with Dr ___ our
___ Care service and discussed options for home hospice,
though at the time of discharge she remains uncertain whether
she may pursue palliative chemotherapy instead. Her ___ agency
has the ability to deliver hospice care and will continue to
offer information on this option after she arrives home.
Throughout her admission she was seen at least daily with the
assistance of our ASL interpreter.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
2. Ondansetron ODT ___ mg PO Q8H:PRN nausea
3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate
4. Omeprazole 20 mg PO DAILY
5. Lidocaine 5% Patch ___ PTCH TD QAM to LUQ area
6. Milk of Magnesia 30 mL PO Q6H:PRN constipation
7. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H
8. Polyethylene Glycol 17 g PO DAILY constipation
9. Senna 17.2 mg PO BID constipation
10. OLANZapine 5 mg PO BID:PRN nausea
11. Magnesium Citrate 300 mL PO ONCE
12. Multivitamins W/minerals 1 TAB PO DAILY
Discharge Medications:
1. Baclofen 5 mg PO Q8H:PRN Back Pain
RX *baclofen 10 mg 0.5 (One half) tablet(s) by mouth every eight
(8) hours Disp #*90 Tablet Refills:*2
2. lidocaine 5 % topical QAM
RX *lidocaine [Lidoderm] 5 % apply to left upper abdomen qam
Disp #*30 Patch Refills:*3
RX *lidocaine 5 % apply to left upper abdomen qam Disp #*30
Patch Refills:*2
3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
4. OxyCODONE SR (OxyconTIN) 10 mg PO Q8H abdominal pain
5. Lidocaine 5% Patch ___ PTCH TD QAM to LUQ area
6. Magnesium Citrate 300 mL PO ONCE
7. Milk of Magnesia 30 mL PO Q6H:PRN constipation
8. Multivitamins W/minerals 1 TAB PO DAILY
9. OLANZapine 5 mg PO BID:PRN nausea
10. Omeprazole 20 mg PO DAILY
11. Ondansetron ODT ___ mg PO Q8H:PRN nausea
12. Polyethylene Glycol 17 g PO DAILY constipation
13. Senna 17.2 mg PO BID constipation
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Metastatic pancreatic cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Please take your medications as prescribed.
Followup Instructions:
___
|
[
"C250",
"C787",
"E860",
"H903",
"K219",
"I10",
"D473",
"D72829",
"E861",
"R112",
"Z66",
"G893",
"Z800",
"R634",
"Z6821"
] |
Allergies: latex Chief Complaint: Nausea, anorexia, abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] PMH of Deafness (uses ASL), GERD, HTN, Metastatic Pancreatic Cancer (mets to liver, recently on palliative gemcitabine), CBD obstruction (s/p sphincerotomy and metal stent placement) who recently was admitted for pain control and possible pancreatitis (s/p celiac plexus block and increased pain regimen), now returns with nausea, vomiting, abdominal pain and decreased PO intake Pt was last discharged on [MASKED] after being admitted for possible pancreatitis vs pain [MASKED] progression of malignancy. She had celiac nerve plexus block and had oxycontin initiated. As a result pain was improved and patient was discharged with outpatient oncology followup OF note, patient is deaf and uses ASL to communicate for complex decision making, but was able to communicate by writing and with lip reading for purposes of this interview. Pt noted that since discharge she has had intermittent abdominal pain which is epigastric and radiating to the back, which comes on in spasms, with sharp stabbing sensation. She noted that her pain may be slightly improved compared to prior though. However, she is more concerned with nausea/vomiting at home with yellow colored vomitus and lack of po intake [MASKED] decreased appetite. Denied fever, chills, sore throat, dysuria, rash, significant diarrhea. In the ED, initial vitals: 98.1 107 122/87 18 99% RA. Labs revealed WBC of 23 (recent baseline was 12), Hgb 11.9 (baseline 9.5), plt 585 (baseline 268). Chem wnl, LFTs unchanged since last admission. Lipase 123 down from 500 on last admit. Lactate normal. She was given IVF, Zofran, and dilaudid. She noted that she felt unsafe going home as did not feel remarkably improved so was admitted to oncology for further care. REVIEW OF SYSTEMS: A complete 10-point review of systems was performed and was negative unless otherwise noted in the HPI. Past Medical History: PAST ONCOLOGIC HISTORY: As per OMR "presented in [MASKED] to [MASKED] 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 [MASKED] where she underwent ERCP. This study identified a stricture in the common bile duct due to external compression. Brushings were atypical. Her CA [MASKED] was elevated at 180 U/mL. She underwent endoscopic ultrasound [MASKED], which identified a 1.8 x 1.6 cm pancreatic head mass without vascular involvement. Biopsy by [MASKED] 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 [MASKED] and [MASKED]. There was no evidence of distant metastases. Ms. [MASKED] was diagnosed with borderline resectable PDA and initiated chemotherapy with neoadjuvant FOLFIRINOX [MASKED]. C1D15 was dose reduced for N/V/D. She was hospitalized [MASKED] with diarrhea, nausea, anorexia, and neutropenia. Her C2D15 treatment was held. With cycle 3 she transitioned to mFOLFOX. She completed five infusion and was taken to the OR [MASKED]. Liver metastases were identified intraoperatively, and plans for resection were aborted. She initiated palliative chemotherapy with gemcitabine [MASKED]. The dose was reduced to 750mg/m2 on C1D8 due to neutropenia. With cycle 2 she transitioned to day 1 and 15 schedule. Following six cycles there was further progression, and she was referred for combination gemcitabine/nab-paclitaxel" 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. 8. CBD obstruction s/p sphincerotomy and metal stent placement via ERCP Social History: [MASKED] Family History: The patient's father died of an MI at [MASKED] years. Her mother died with type 2 diabetes mellitus. A sister died with colon cancer at [MASKED] years. Another sister died of [MASKED] disease. She has two sons without health concerns. Physical Exam: Vitals: 98.3 134/84 104 18 98RA [MASKED]: Sitting in bed, appears comfortable, no acute distress EYES: PERRLA HEENT: Moist mucous membranes, oropharynx clear NECK: Supple LUNGS: Clear to auscultation bilaterally no wheezes rales or rhonchi, normal respiratory rate CV: Regular rate and rhythm without any murmurs rubs or gallops ABD: Slight epigastric tenderness to moderate palpation, nondistended, normoactive bowel sounds, no ascites EXT: Normal bulk/tone, no deformity SKIN: Warm/dry, no rash NEURO: Alert and oriented ×3, fluent speech but has difficulty with correct pronunciation as is deaf, but reads lips and writes to communicate ACCESS: chest port with dressing c/d/i Pertinent Results: [MASKED] 02:10PM WBC-23.0*# RBC-4.30# HGB-11.9 HCT-37.1 MCV-86 MCH-27.7 MCHC-32.1 RDW-16.1* RDWSD-48.4* [MASKED] 02:10PM PLT COUNT-585*# [MASKED] 02:10PM cTropnT-0.05* [MASKED] 02:10PM ALT(SGPT)-10 AST(SGOT)-18 ALK PHOS-153* TOT BILI-0.5 [MASKED] 02:10PM LIPASE-123* [MASKED] 02:10PM GLUCOSE-132* UREA N-10 CREAT-0.4 SODIUM-138 POTASSIUM-4.3 CHLORIDE-97 TOTAL CO2-23 ANION GAP-18* [MASKED] 02:53PM LACTATE-1.7 Brief Hospital Course: Ms [MASKED] is a pleasant [MASKED] year-old female with deafness admitted with recurrent abdominal pain, nausea, and poor appetite attributed to her pancreatic cancer. Her anti-nausea and pain medications were adjusted to achieve better symptom control, including increase of her oxycontin dose from bid to tid, and adding baclofen to address some element of back spasm. Her appetite remained minimal, but she was able to tolerate fluids throughout her stay. She met with Dr [MASKED] our [MASKED] Care service and discussed options for home hospice, though at the time of discharge she remains uncertain whether she may pursue palliative chemotherapy instead. Her [MASKED] agency has the ability to deliver hospice care and will continue to offer information on this option after she arrives home. Throughout her admission she was seen at least daily with the assistance of our ASL interpreter. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild 2. Ondansetron ODT [MASKED] mg PO Q8H:PRN nausea 3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate 4. Omeprazole 20 mg PO DAILY 5. Lidocaine 5% Patch [MASKED] PTCH TD QAM to LUQ area 6. Milk of Magnesia 30 mL PO Q6H:PRN constipation 7. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H 8. Polyethylene Glycol 17 g PO DAILY constipation 9. Senna 17.2 mg PO BID constipation 10. OLANZapine 5 mg PO BID:PRN nausea 11. Magnesium Citrate 300 mL PO ONCE 12. Multivitamins W/minerals 1 TAB PO DAILY Discharge Medications: 1. Baclofen 5 mg PO Q8H:PRN Back Pain RX *baclofen 10 mg 0.5 (One half) tablet(s) by mouth every eight (8) hours Disp #*90 Tablet Refills:*2 2. lidocaine 5 % topical QAM RX *lidocaine [Lidoderm] 5 % apply to left upper abdomen qam Disp #*30 Patch Refills:*3 RX *lidocaine 5 % apply to left upper abdomen qam Disp #*30 Patch Refills:*2 3. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg [MASKED] tablet(s) by mouth every four (4) hours Disp #*60 Tablet Refills:*0 4. OxyCODONE SR (OxyconTIN) 10 mg PO Q8H abdominal pain 5. Lidocaine 5% Patch [MASKED] PTCH TD QAM to LUQ area 6. Magnesium Citrate 300 mL PO ONCE 7. Milk of Magnesia 30 mL PO Q6H:PRN constipation 8. Multivitamins W/minerals 1 TAB PO DAILY 9. OLANZapine 5 mg PO BID:PRN nausea 10. Omeprazole 20 mg PO DAILY 11. Ondansetron ODT [MASKED] mg PO Q8H:PRN nausea 12. Polyethylene Glycol 17 g PO DAILY constipation 13. Senna 17.2 mg PO BID constipation Discharge Disposition: Home With Service Facility: [MASKED] [MASKED] Diagnosis: Metastatic pancreatic cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Please take your medications as prescribed. Followup Instructions: [MASKED]
|
[] |
[
"K219",
"I10",
"Z66"
] |
[
"C250: Malignant neoplasm of head of pancreas",
"C787: Secondary malignant neoplasm of liver and intrahepatic bile duct",
"E860: Dehydration",
"H903: Sensorineural hearing loss, bilateral",
"K219: Gastro-esophageal reflux disease without esophagitis",
"I10: Essential (primary) hypertension",
"D473: Essential (hemorrhagic) thrombocythemia",
"D72829: Elevated white blood cell count, unspecified",
"E861: Hypovolemia",
"R112: Nausea with vomiting, unspecified",
"Z66: Do not resuscitate",
"G893: Neoplasm related pain (acute) (chronic)",
"Z800: Family history of malignant neoplasm of digestive organs",
"R634: Abnormal weight loss",
"Z6821: Body mass index [BMI] 21.0-21.9, adult"
] |
10,006,431 | 25,589,898 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
latex
Attending: ___
Chief Complaint:
Painless jaundice, nausea
Major Surgical or Invasive Procedure:
EUS
History of Present Illness:
Ms. ___ is a ___ PMHx HTN and congenital deafness who was
initially admitted to ___ on ___ for
painless
jaundice/biliary obstruction associated with n/v, post-prandial
abdominal pain and unintentional weight loss over the past
month.
History is obtained with assistance of her son who is fluent in
___ sign language. She had an MRCP as an outpatient which
showed concern for possible lesion at uncinated process. She
was then sent to ___ on ___ for ERCP evaluation; ERCP
showed stricture with post-obstructive dilation with severely
dilated proximal CBD. These findings were compatible with
extrinsic compression of malignant pancreatic lesion at the
head/uncinate process of the pancreas. She underwent
sphincterotomy with stent placement; brushings showed atypical
cells on cytology. She was transferred back to ___
___. Post-ERCP, the patient has had ongoing obstructive
symptoms of n/v, abdominal pain and very limited PO tolerance
(barely tolerating a liquid diet). EUS was performed on ___
which was
wnl, but her CA ___ level was elevated to 180. She has been
afebrile, and labs have shown improvement of her LFTs with
AST46, ALT 86, alkphos 376 at admission to 303 today. Tbili 18
at admission to 10.1 today. WBC nml. Transfer is requested for
repeat ERCP evaluation and further work-up for malignancy.
Upon arrival to the floor, the patient feels overall well and
endorses just some mild epigastric and RUQ abdominal soreness.
She has been only on liquids for the past 2 weeks without any
significant PO intake.
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. No recent
change in bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias.
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:
Vital Signs: 98.3, 158/92, 71, 18, 99% on RA
___: Well-appearing elderly jaundiced female, oriented, no
acute distress
HEENT: Sclera icteric, 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, obese, nondistended, mild TTP of epigastrium and
RUQ, normal bowel sounds
GU: No foley
Ext: Warm, well perfused, 2+ pulses, trace pitting edema of BLE
Neuro: AOX3, moving all extremities spontaneously, nml gait.
Can read lips, responding to all commands
On discharge:
GEN: Lying in bed, in NAD, jaundiced
HEENT: EOMI, sclerae anicteric, MMM, OP clear
NECK: No LAD, no JVD
CARDIAC: RRR, no M/R/G
PULM: normal effort, no accessory muscle use, LCAB
GI: soft, NT, ND, NABS
MSK: No visible joint effusions or deformities.
DERM: No visible rash. No jaundice.
NEURO: AAOx3. No facial droop, moving all extremities.
PSYCH: Full range of affect
EXTREMITIES: WWP, trace edema
Pertinent Results:
___ OSH labs
WBC 7.6
Hgb 11.1 (down from 14.8 at admission on ___
Plt 260
MCV 77
Na 142
K 4.1
Cl 107
CO2 28
Cr 0.672
Tbili 10.1
AST 46
ALT 86
AP 303
CEA 112
CA ___ 180.6
On Admission:
___ 06:50AM BLOOD WBC-8.2 RBC-3.78* Hgb-10.2* Hct-29.4*
MCV-78* MCH-27.0 MCHC-34.7 RDW-18.1* RDWSD-48.0* Plt ___
___ 06:50AM BLOOD ___ PTT-26.9 ___
___ 06:50AM BLOOD Glucose-110* UreaN-6 Creat-0.7 Na-142
K-4.1 Cl-106 HCO3-31 AnGap-9
___ 06:50AM BLOOD ALT-69* AST-56* AlkPhos-277* TotBili-8.8*
___ 06:50AM BLOOD calTIBC-177* Ferritn-755* TRF-136*
On Discharge:
___ 06:44AM BLOOD WBC-9.1 RBC-3.81* Hgb-10.1* Hct-30.4*
MCV-80* MCH-26.5 MCHC-33.2 RDW-18.6* RDWSD-50.7* Plt ___
___ 06:44AM BLOOD Glucose-144* UreaN-6 Creat-0.5 Na-141
K-3.3 Cl-104 HCO3-29 AnGap-11
___ 06:44AM BLOOD ALT-61* AST-51* AlkPhos-257* TotBili-6.1*
___ 06:44AM BLOOD Calcium-9.1 Phos-2.6* Mg-1.9
___ 06:15AM BLOOD IGG SUBCLASSES 1,2,3,4-Test
IMAGING & STUDIES
=================
___ ERCP
Findings:
Esophagus: Limited exam of the esophagus was normal
Stomach: Limited exam of the stomach was normal
Duodenum: Limited exam of the duodenum was normal
Major Papilla: Normal major papilla was noted.
Cannulation: Cannulation of the biliary duct was successful and
deep with a sphincterotome using a free-hand technique. Contrast
medium was injected resulting in complete opacification. The
procedure was not difficult.
Biliary Tree/Fluoroscopy Interpretation: The scout film was
normal. A single 1.5 cm stricture was seen at the lower third of
the common bile duct. There was post-obstructive dilation with
severely dilated proximal CBD. with both CBD. These findings are
compatible with extrinsic compression of malignant pancreatic
lesion at the head/uncinate process of pancreas. A
sphincterotomy was performed in the 12 o'clock position using a
sphincterotome over an existing guidewire. No evidence of post
sphincterotomy bleeding was noted. Cytology samples were
obtained for histology using a brush in the lower third of the
common bile duct for final diagnosis. Due to obstructive pattern
a ___ biliary plastic stent was placed into the distal
common bile duct. Post stent deployment a good contrast and bile
drainage was noted both endoscopically and fluoroscopically. I
supervised the acquisition and interpretation of the fluoroscopy
images. The quality of the images was good.
Impression: The scout film was normal.
Normal major papilla was noted.
Cannulation of the biliary duct was successful and deep with a
sphincterotome using a free-hand technique.
Contrast medium was injected resulting in complete
opacification.
A single 1.5 cm stricture was seen at the lower third of the
common bile duct.
There was post-obstructive dilation with severely dilated
proximal CBD.
These findings are compatible with extrinsic compression of
malignant pancreatic lesion at the head/uncinate process of
pancreas.
A sphincterotomy was performed in the 12 o'clock position using
a sphincterotome over an existing guidewire.
No evidence of post sphincterotomy bleeding was noted.
Cytology samples were obtained for histology using a brush in
the lower third of the common bile duct for final diagnosis.
Due to obstructive pattern a ___ biliary plastic stent was
placed into the distal common bile duct.
Post stent deployment a good contrast and bile drainage was
noted both endoscopically and fluoroscopically.
Otherwise normal ercp to third part of the duodenum
___: Tissue biopsy pancreas: Adenocarcinoma
___ CT Chest
IMPRESSION:
No evidence of metastasis.
Large goiter, substantially narrows the trachea at the thoracic
inlet and
could contribute to malacia, though not assessed by this study.
Ultrasound recommended to exclude concurrent thyroid nodules.
Small bilateral pleural effusions. Severe bibasilar relaxation
atelectasis.
___ CT A/P Pancreas Protocol
1. Patient is now status post biliary stenting, with the stent
extending from the common hepatic duct to the duodenum. There
is associated pneumobilia, the but interval reduction in the
intra and extrahepatic biliary dilatation.
2. A approximately 1.6 cm x 1.4 cm x 1.4 cm poorly-defined
hypoenhancing
lesion is seen at the head of the pancreas.
3. Peripancreatic fluid and fat stranding, particularly
surrounding the head of the pancreas, SMA and SMV. This may
represent pancreatitis in the
appropriate clinical setting.
4. Subcentimeter hypodensity in segment 4B of the liver likely
represents a biliary hamartoma versus simple cyst.
5. Multiple bilateral subcentimeter renal hypodensities are too
small to
characterize but likely represent simple renal cysts.
6. 1.7 cm homogeneously enhancing lesion in the uterus, likely a
fibroid.
7. Please see separate report of CT chest performed on the same
date.
___ Thyroid US
Multinodular goiter. Dominant solid nodules arising from the
isthmus and
right lower pole measuring 3.2 cm and at least 4.9 cm,
respectively, are
recommended for biopsy.
RECOMMENDATION(S): Thyroid biopsy of the dominant isthmic and
right lower
pole nodules, as above.
Brief Hospital Course:
Ms. ___ is a ___ PMHx HTN and congenital deafness who was
initially admitted to ___ on ___ for
painless jaundice/biliary obstruction associated with n/v,
post-prandial abdominal pain and unintentional weight loss s/p
ERCP with sphincterotomy and stent placement for CBD dilation,
transferred for repeat ERCP evaluation for likely ongoing
obstruction.
# Pancreatic adenocarcinoma: Resulting in painless jaundice and
nausea. She underwent ERCP with sphincterotomy on ___ with
plastic stent placement to relieve the obstruction. Her LFTs
subsequently downtrended and her nausea improved. CT pancreas
notable for 1.6 cm x 1.4 cm x 1.4 cm poorly-defined
hypoenhancing lesion is seen at the head of the pancreas.
Staging CT of the chest was negative for metastases. She was
seen by the surgery team and is scheduled for follow up in the
surgery clinic on ___ to discuss the next steps in surgical
management.
# Goiter: Patient has known goiter and reportedly has an
outpatient endocrinologist. Staging CT of the chest noted this
large goiter and advised for further evaluation with ultrasound.
Ultrasound revealed multinodular goiter. Dominant solid nodules
arising from the isthmus and right lower pole measuring 3.2 cm
and at least 4.9 cm, respectively, are recommended for biopsy.
On discussion of these findings with the patient she revealed
that she has in fact recently undergone biopsy of her thyroid
and has follow up with her endocrinologist in the near future.
# Pruritis: Likely secondary to elevated bilirubin. She found
most symptomatic relief with sarna lotion (rather than
cholestyramine) and was discharged with a prescription.
# HTN: Continued home lisinopril
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. Omeprazole 40 mg PO DAILY
3. Aspirin 81 mg 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 #*30 Capsule Refills:*0
2. Polyethylene Glycol 17 g PO DAILY
Do not take if you are having loose stools
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by
mouth daily Disp #*15 Packet Refills:*0
3. Sarna Lotion 1 Appl TP QID:PRN pruritus
RX *camphor-menthol [Sarna Anti-Itch] 0.5 %-0.5 % Apply to
affected area Four times daily Refills:*0
4. Senna 8.6 mg PO BID
Please do not take this if you are having loose stools
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice daily Disp
#*30 Tablet Refills:*0
5. Aspirin 81 mg PO DAILY
6. Cholestyramine 4 gm PO DAILY
7. Lisinopril 20 mg PO DAILY
8. Omeprazole 40 mg PO DAILY
9. Ondansetron 4 mg PO Q4H:PRN nausea
10. zaleplon 5 mg oral QHS:PRN
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
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 the hospital because of an inability to
tolerate food. This is likely from compression of part of your
GI tract by a mass. Fortunately, your symptoms improved during
your hospitalization. You underwent imaging to help further
characterize what may be going on in your GI tract to cause
these symptoms. You are scheduled for follow up with the surgery
team to discuss the next steps in your diagnosis and treatment
plan.
Of note, your CT scan revealed a large goiter. The
recommendation was to obtain an ultrasound to determine the
presence of nodules. The ultrasound did reveal some nodules that
were recommended for biopsy. However, it appears that you have
recently undergone a thyroid nodule biopsy. Please continue to
follow up with your thyroid specialist as previously scheduled.
Please follow up with your primary care doctor as previously
scheduled.
It was a pleasure to be a part of your care!
Your ___ treatment team
Followup Instructions:
___
|
[
"C250",
"H905",
"I10",
"E042",
"K838",
"L298",
"K219",
"D509",
"G4700",
"Z800"
] |
Allergies: latex Chief Complaint: Painless jaundice, nausea Major Surgical or Invasive Procedure: EUS History of Present Illness: Ms. [MASKED] is a [MASKED] PMHx HTN and congenital deafness who was initially admitted to [MASKED] on [MASKED] for painless jaundice/biliary obstruction associated with n/v, post-prandial abdominal pain and unintentional weight loss over the past month. History is obtained with assistance of her son who is fluent in [MASKED] sign language. She had an MRCP as an outpatient which showed concern for possible lesion at uncinated process. She was then sent to [MASKED] on [MASKED] for ERCP evaluation; ERCP showed stricture with post-obstructive dilation with severely dilated proximal CBD. These findings were compatible with extrinsic compression of malignant pancreatic lesion at the head/uncinate process of the pancreas. She underwent sphincterotomy with stent placement; brushings showed atypical cells on cytology. She was transferred back to [MASKED] [MASKED]. Post-ERCP, the patient has had ongoing obstructive symptoms of n/v, abdominal pain and very limited PO tolerance (barely tolerating a liquid diet). EUS was performed on [MASKED] which was wnl, but her CA [MASKED] level was elevated to 180. She has been afebrile, and labs have shown improvement of her LFTs with AST46, ALT 86, alkphos 376 at admission to 303 today. Tbili 18 at admission to 10.1 today. WBC nml. Transfer is requested for repeat ERCP evaluation and further work-up for malignancy. Upon arrival to the floor, the patient feels overall well and endorses just some mild epigastric and RUQ abdominal soreness. She has been only on liquids for the past 2 weeks without any significant PO intake. 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. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Past Medical History: HTN congenital deafness GERD Goiter Social History: [MASKED] Family History: Father passed away from complications of gangrenous colitis. Mother with T2DM. Sister with colon CA. Sister deceased, [MASKED]. Physical Exam: Vital Signs: 98.3, 158/92, 71, 18, 99% on RA [MASKED]: Well-appearing elderly jaundiced female, oriented, no acute distress HEENT: Sclera icteric, 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, obese, nondistended, mild TTP of epigastrium and RUQ, normal bowel sounds GU: No foley Ext: Warm, well perfused, 2+ pulses, trace pitting edema of BLE Neuro: AOX3, moving all extremities spontaneously, nml gait. Can read lips, responding to all commands On discharge: GEN: Lying in bed, in NAD, jaundiced HEENT: EOMI, sclerae anicteric, MMM, OP clear NECK: No LAD, no JVD CARDIAC: RRR, no M/R/G PULM: normal effort, no accessory muscle use, LCAB GI: soft, NT, ND, NABS MSK: No visible joint effusions or deformities. DERM: No visible rash. No jaundice. NEURO: AAOx3. No facial droop, moving all extremities. PSYCH: Full range of affect EXTREMITIES: WWP, trace edema Pertinent Results: [MASKED] OSH labs WBC 7.6 Hgb 11.1 (down from 14.8 at admission on [MASKED] Plt 260 MCV 77 Na 142 K 4.1 Cl 107 CO2 28 Cr 0.672 Tbili 10.1 AST 46 ALT 86 AP 303 CEA 112 CA [MASKED] 180.6 On Admission: [MASKED] 06:50AM BLOOD WBC-8.2 RBC-3.78* Hgb-10.2* Hct-29.4* MCV-78* MCH-27.0 MCHC-34.7 RDW-18.1* RDWSD-48.0* Plt [MASKED] [MASKED] 06:50AM BLOOD [MASKED] PTT-26.9 [MASKED] [MASKED] 06:50AM BLOOD Glucose-110* UreaN-6 Creat-0.7 Na-142 K-4.1 Cl-106 HCO3-31 AnGap-9 [MASKED] 06:50AM BLOOD ALT-69* AST-56* AlkPhos-277* TotBili-8.8* [MASKED] 06:50AM BLOOD calTIBC-177* Ferritn-755* TRF-136* On Discharge: [MASKED] 06:44AM BLOOD WBC-9.1 RBC-3.81* Hgb-10.1* Hct-30.4* MCV-80* MCH-26.5 MCHC-33.2 RDW-18.6* RDWSD-50.7* Plt [MASKED] [MASKED] 06:44AM BLOOD Glucose-144* UreaN-6 Creat-0.5 Na-141 K-3.3 Cl-104 HCO3-29 AnGap-11 [MASKED] 06:44AM BLOOD ALT-61* AST-51* AlkPhos-257* TotBili-6.1* [MASKED] 06:44AM BLOOD Calcium-9.1 Phos-2.6* Mg-1.9 [MASKED] 06:15AM BLOOD IGG SUBCLASSES 1,2,3,4-Test IMAGING & STUDIES ================= [MASKED] ERCP Findings: Esophagus: Limited exam of the esophagus was normal Stomach: Limited exam of the stomach was normal Duodenum: Limited exam of the duodenum was normal Major Papilla: Normal major papilla was noted. Cannulation: Cannulation of the biliary duct was successful and deep with a sphincterotome using a free-hand technique. Contrast medium was injected resulting in complete opacification. The procedure was not difficult. Biliary Tree/Fluoroscopy Interpretation: The scout film was normal. A single 1.5 cm stricture was seen at the lower third of the common bile duct. There was post-obstructive dilation with severely dilated proximal CBD. with both CBD. These findings are compatible with extrinsic compression of malignant pancreatic lesion at the head/uncinate process of pancreas. A sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. No evidence of post sphincterotomy bleeding was noted. Cytology samples were obtained for histology using a brush in the lower third of the common bile duct for final diagnosis. Due to obstructive pattern a [MASKED] biliary plastic stent was placed into the distal common bile duct. Post stent deployment a good contrast and bile drainage was noted both endoscopically and fluoroscopically. I supervised the acquisition and interpretation of the fluoroscopy images. The quality of the images was good. Impression: The scout film was normal. Normal major papilla was noted. Cannulation of the biliary duct was successful and deep with a sphincterotome using a free-hand technique. Contrast medium was injected resulting in complete opacification. A single 1.5 cm stricture was seen at the lower third of the common bile duct. There was post-obstructive dilation with severely dilated proximal CBD. These findings are compatible with extrinsic compression of malignant pancreatic lesion at the head/uncinate process of pancreas. A sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. No evidence of post sphincterotomy bleeding was noted. Cytology samples were obtained for histology using a brush in the lower third of the common bile duct for final diagnosis. Due to obstructive pattern a [MASKED] biliary plastic stent was placed into the distal common bile duct. Post stent deployment a good contrast and bile drainage was noted both endoscopically and fluoroscopically. Otherwise normal ercp to third part of the duodenum [MASKED]: Tissue biopsy pancreas: Adenocarcinoma [MASKED] CT Chest IMPRESSION: No evidence of metastasis. Large goiter, substantially narrows the trachea at the thoracic inlet and could contribute to malacia, though not assessed by this study. Ultrasound recommended to exclude concurrent thyroid nodules. Small bilateral pleural effusions. Severe bibasilar relaxation atelectasis. [MASKED] CT A/P Pancreas Protocol 1. Patient is now status post biliary stenting, with the stent extending from the common hepatic duct to the duodenum. There is associated pneumobilia, the but interval reduction in the intra and extrahepatic biliary dilatation. 2. A approximately 1.6 cm x 1.4 cm x 1.4 cm poorly-defined hypoenhancing lesion is seen at the head of the pancreas. 3. Peripancreatic fluid and fat stranding, particularly surrounding the head of the pancreas, SMA and SMV. This may represent pancreatitis in the appropriate clinical setting. 4. Subcentimeter hypodensity in segment 4B of the liver likely represents a biliary hamartoma versus simple cyst. 5. Multiple bilateral subcentimeter renal hypodensities are too small to characterize but likely represent simple renal cysts. 6. 1.7 cm homogeneously enhancing lesion in the uterus, likely a fibroid. 7. Please see separate report of CT chest performed on the same date. [MASKED] Thyroid US Multinodular goiter. Dominant solid nodules arising from the isthmus and right lower pole measuring 3.2 cm and at least 4.9 cm, respectively, are recommended for biopsy. RECOMMENDATION(S): Thyroid biopsy of the dominant isthmic and right lower pole nodules, as above. Brief Hospital Course: Ms. [MASKED] is a [MASKED] PMHx HTN and congenital deafness who was initially admitted to [MASKED] on [MASKED] for painless jaundice/biliary obstruction associated with n/v, post-prandial abdominal pain and unintentional weight loss s/p ERCP with sphincterotomy and stent placement for CBD dilation, transferred for repeat ERCP evaluation for likely ongoing obstruction. # Pancreatic adenocarcinoma: Resulting in painless jaundice and nausea. She underwent ERCP with sphincterotomy on [MASKED] with plastic stent placement to relieve the obstruction. Her LFTs subsequently downtrended and her nausea improved. CT pancreas notable for 1.6 cm x 1.4 cm x 1.4 cm poorly-defined hypoenhancing lesion is seen at the head of the pancreas. Staging CT of the chest was negative for metastases. She was seen by the surgery team and is scheduled for follow up in the surgery clinic on [MASKED] to discuss the next steps in surgical management. # Goiter: Patient has known goiter and reportedly has an outpatient endocrinologist. Staging CT of the chest noted this large goiter and advised for further evaluation with ultrasound. Ultrasound revealed multinodular goiter. Dominant solid nodules arising from the isthmus and right lower pole measuring 3.2 cm and at least 4.9 cm, respectively, are recommended for biopsy. On discussion of these findings with the patient she revealed that she has in fact recently undergone biopsy of her thyroid and has follow up with her endocrinologist in the near future. # Pruritis: Likely secondary to elevated bilirubin. She found most symptomatic relief with sarna lotion (rather than cholestyramine) and was discharged with a prescription. # HTN: Continued home lisinopril Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 20 mg PO DAILY 2. Omeprazole 40 mg PO DAILY 3. Aspirin 81 mg 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 #*30 Capsule Refills:*0 2. Polyethylene Glycol 17 g PO DAILY Do not take if you are having loose stools RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by mouth daily Disp #*15 Packet Refills:*0 3. Sarna Lotion 1 Appl TP QID:PRN pruritus RX *camphor-menthol [Sarna Anti-Itch] 0.5 %-0.5 % Apply to affected area Four times daily Refills:*0 4. Senna 8.6 mg PO BID Please do not take this if you are having loose stools RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice daily Disp #*30 Tablet Refills:*0 5. Aspirin 81 mg PO DAILY 6. Cholestyramine 4 gm PO DAILY 7. Lisinopril 20 mg PO DAILY 8. Omeprazole 40 mg PO DAILY 9. Ondansetron 4 mg PO Q4H:PRN nausea 10. zaleplon 5 mg oral QHS:PRN Discharge Disposition: Home Discharge Diagnosis: Primary: Pancreatic adenocarcinoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You were admitted to the hospital because of an inability to tolerate food. This is likely from compression of part of your GI tract by a mass. Fortunately, your symptoms improved during your hospitalization. You underwent imaging to help further characterize what may be going on in your GI tract to cause these symptoms. You are scheduled for follow up with the surgery team to discuss the next steps in your diagnosis and treatment plan. Of note, your CT scan revealed a large goiter. The recommendation was to obtain an ultrasound to determine the presence of nodules. The ultrasound did reveal some nodules that were recommended for biopsy. However, it appears that you have recently undergone a thyroid nodule biopsy. Please continue to follow up with your thyroid specialist as previously scheduled. Please follow up with your primary care doctor as previously scheduled. It was a pleasure to be a part of your care! Your [MASKED] treatment team Followup Instructions: [MASKED]
|
[] |
[
"I10",
"K219",
"D509",
"G4700"
] |
[
"C250: Malignant neoplasm of head of pancreas",
"H905: Unspecified sensorineural hearing loss",
"I10: Essential (primary) hypertension",
"E042: Nontoxic multinodular goiter",
"K838: Other specified diseases of biliary tract",
"L298: Other pruritus",
"K219: Gastro-esophageal reflux disease without esophagitis",
"D509: Iron deficiency anemia, unspecified",
"G4700: Insomnia, unspecified",
"Z800: Family history of malignant neoplasm of digestive organs"
] |
10,006,431 | 27,715,811 |
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:
___
|
[
"K521",
"K831",
"C250",
"D6959",
"E860",
"I10",
"K219",
"R110",
"T451X5A",
"Y929"
] |
Allergies: latex Chief Complaint: diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a pleasant [MASKED] 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: [MASKED] Family History: Father passed away from complications of gangrenous colitis. Mother with T2DM. Sister with colon CA. Sister deceased, [MASKED]. 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: [MASKED] is a pleasant [MASKED] 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 [MASKED] 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 [MASKED], 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 [MASKED] on [MASKED]. Sincerely, [MASKED] MD Followup Instructions: [MASKED]
|
[] |
[
"I10",
"K219",
"Y929"
] |
[
"K521: Toxic gastroenteritis and colitis",
"K831: Obstruction of bile duct",
"C250: Malignant neoplasm of head of pancreas",
"D6959: Other secondary thrombocytopenia",
"E860: Dehydration",
"I10: Essential (primary) hypertension",
"K219: Gastro-esophageal reflux disease without esophagitis",
"R110: Nausea",
"T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter",
"Y929: Unspecified place or not applicable"
] |
10,006,431 | 28,771,670 |
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:
___
|
[
"E860",
"C250",
"K521",
"D701",
"H905",
"I10",
"K219",
"R112",
"T451X5A",
"Z6823",
"R630",
"E7800",
"F419",
"Y929"
] |
Allergies: latex Chief Complaint: Nausea/vomting, diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] 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 [MASKED] 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 [MASKED] to [MASKED] 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 [MASKED], 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: [MASKED] has a history of hypertension, congenital deafness, and GERD, and presented in early [MASKED] to [MASKED] 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 [MASKED] where she underwent ERCP. This study identified a stricture in the common bile duct due to external compression. Brushings were atypical. Her CA [MASKED] was elevated at 180 U/mL. She underwent endoscopic ultrasound [MASKED]. This study identified a 1.8 x 1.6 cm pancreatic head mass without vascular involvement. Biopsy by [MASKED] 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. [MASKED] was diagnosed with borderline resectable PDA and initiated chemotherapy with neoadjuvant FOLFIRINOX [MASKED]. C1D15 dose reduced for N/V/D. She underwent biliary stent change and was then hospitalized [MASKED] 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: [MASKED] Family History: The patient's father died of an MI at [MASKED] years. Her mother died with type 2 diabetes mellitus. A sister died with colon cancer at [MASKED] years. Another sister died of [MASKED] 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. [MASKED]: 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 [MASKED]: 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: [MASKED] 10:35AM URINE COLOR-Straw APPEAR-Clear SP [MASKED] [MASKED] 10:35AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [MASKED] 10:35AM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE EPI-1 [MASKED] 04:29AM GLUCOSE-103* UREA N-10 CREAT-0.5 SODIUM-134 POTASSIUM-3.5 CHLORIDE-99 TOTAL CO2-20* ANION GAP-19 [MASKED] 04:29AM ALT(SGPT)-29 AST(SGOT)-22 ALK PHOS-60 TOT BILI-0.4 [MASKED] 04:29AM LIPASE-33 [MASKED] 04:29AM ALBUMIN-3.0* CALCIUM-8.1* PHOSPHATE-2.3* MAGNESIUM-1.6 [MASKED] 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 [MASKED] 04:29AM NEUTS-41 BANDS-3 [MASKED] MONOS-21* EOS-2 BASOS-0 ATYPS-1* [MASKED] MYELOS-0 AbsNeut-1.32* AbsLymp-0.99* AbsMono-0.63 AbsEos-0.06 AbsBaso-0.00* [MASKED] 04:29AM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-3+ MACROCYT-NORMAL MICROCYT-2+ POLYCHROM-NORMAL OVALOCYT-1+ SCHISTOCY-OCCASIONAL BURR-3+ TEARDROP-OCCASIONAL [MASKED] 04:29AM [MASKED] PTT-22.7* [MASKED] DISCHARGE LABS: [MASKED] 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 [MASKED] [MASKED] 06:17AM BLOOD Glucose-94 UreaN-8 Creat-0.4 Na-137 K-4.0 Cl-99 HCO3-29 AnGap-13 [MASKED] 06:17AM BLOOD Calcium-8.9 Phos-3.4 Mg-1.7 MICRO: URINE CULTURE (Final [MASKED]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. [MASKED] C diff, stool studies negative IMAGING: [MASKED] CXR IMPRESSION: In comparison with the study of [MASKED], 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. [MASKED] 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: [MASKED] 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 [MASKED]. GI sx likely [MASKED] further plans for administration of this drug. Neutropenic with ANC [MASKED], likely [MASKED] recent chemotx, no fevers to date, WBC now improved with ANC >2800. Will follow with Dr. [MASKED]. - 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. [MASKED] [MASKED] 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. [MASKED] [MASKED] 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: [MASKED] [MASKED] 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. [MASKED], You were admitted to [MASKED] 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 [MASKED] Healthcare Team Followup Instructions: [MASKED]
|
[] |
[
"I10",
"K219",
"F419",
"Y929"
] |
[
"E860: Dehydration",
"C250: Malignant neoplasm of head of pancreas",
"K521: Toxic gastroenteritis and colitis",
"D701: Agranulocytosis secondary to cancer chemotherapy",
"H905: Unspecified sensorineural hearing loss",
"I10: Essential (primary) hypertension",
"K219: Gastro-esophageal reflux disease without esophagitis",
"R112: Nausea with vomiting, unspecified",
"T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter",
"Z6823: Body mass index [BMI] 23.0-23.9, adult",
"R630: Anorexia",
"E7800: Pure hypercholesterolemia, unspecified",
"F419: Anxiety disorder, unspecified",
"Y929: Unspecified place or not applicable"
] |
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