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Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Penicillins / rifampin / Lamictal / lorazepam / risperidone / mushrooms Attending: ___. Chief Complaint: T1 compression fracture, T6 burst fracture Major Surgical or Invasive Procedure: ___ - T4-T8 fusion History of Present Illness: ___. is a ___ year old male status post liver transplant who presented to the Emergency Department on ___ as a transfer from an outside facility status post mechanical fall. Imaging at the outside facility showed a T1 compression fracture and T6 burst fracture. Patient was transferred to ___ ___ for further evaluation and management. The Neurosurgery Service was consulted for evaluation and management recommendations related to the T1 compression fracture and T6 burst fracture. Past Medical History: - attention deficit hyperactivity disorder - bipolar disorder - hemorrhoids - history of alcohol abuse - history of deep vein thrombosis in ___ - history of hemorrhagic pericarditis complicated by cardiac tamponade status post pericardial window in ___, recurrent pericarditis in ___ - history of neutropenia complicated by neutropenic fever - history of positive tuberculin skin test status post INH - hyperlipidemia - osteoporosis - primary biliary cirrhosis status post orthotopic liver transplant Social History: ___ Family History: Noncontributory Physical Exam: On Admission: ------------- Vital Signs: T 97.8F, HR 90, BP 127/91, RR 20, O2Sat 96% room air General: Well dressed, well nourished, comfortable, no acute distress. Extremities: Warm and well perfused. Neurologic: Mental status: Awake and alert, cooperative with exam, normal affect. Motor: Deltoid Biceps Triceps Wrist Flexion Wrist Extension Right 5 5 5 5 5 Left 5 5 5 5 5 IP Quadriceps Hamstring AT ___ Gastrocnemius Right 5 5 5 5 5 5 Left 5 5 5 5 5 5 Sensation: Intact to light touch. Reflexes: Biceps Triceps Brachial Right 2+ 2+ 2+ Left 2+ 2+ 2+ Propioception intact. Rectal tone within normal limits per Acute Care Surgery resident, patient refused rectal tone when attempted by us. No ___, no clonus. On Discharge: ------------- VS: 98.4, 102, 121/88, 18, 95% RA Alert and Orient x 3, conversant, pain managed HEENT: Anicteric, no JVD Card: Sl tachy, regular Lungs: No respiratory distress Abd: Sl obese, well healed incision, non-distended, non-tender Extr: No edema, . Weight at discharge: 71.2 kg Pertinent Results: Please see OMR for relevant laboratory and imaging results. CTA ABDOMEN AND PELVIS ___ IMPRESSION: 1. Mild distension of the small bowel up to a maximum caliber of 3.8 cm with air-fluid levels coming to a single transition point at the distal ileum compatible with small-bowel obstruction. 2. Unremarkable appearance of the orthotopic liver transplant. 3. Splenomegaly to a maximum dimension of 17 cm. 4. Small bilateral pleural effusions with adjacent compressive atelectasis. . Labs on Admission: ___ WBC-4.7 RBC-4.37* Hgb-12.8* Hct-38.7* MCV-89 MCH-29.3 MCHC-33.1 RDW-17.7* RDWSD-52.9* Plt ___ PTT-27.7 ___ Glucose-85 UreaN-11 Creat-1.2 Na-141 K-4.7 Cl-107 HCO3-23 AnGap-11 ALT-14 AST-19 AlkPhos-244* TotBili-0.7 Lipase-23 Calcium-8.2* Phos-3.2 Mg-1.7 Albumin-3.4* tacroFK-2.4* . Labs at Discharge ___ WBC-2.8* RBC-3.36* Hgb-9.7* Hct-30.2* MCV-90 MCH-28.9 MCHC-32.1 RDW-20.0* RDWSD-60.2* Plt ___ PTT-30.5 ___ Glucose-79 UreaN-3* Creat-0.9 Na-147 K-3.9 Cl-108 HCO3-20* AnGap-19* ALT-9 AST-15 AlkPhos-179* TotBili-0.8 Calcium-8.2* Phos-3.0 Mg-1.8 tacroFK-5.___ year old male who was admitted on ___ status post fall with findings of a T1 compression fracture and T6 burst fracture on MRI. . #T1 Compression Fracture and T6 Burst Fracture The Neurosurgery Spine Service was consulted on ___ for evaluation and management recommendations related to the patient's T1 compression fracture and T6 burst fracture. Initially, we recommended that the patient be placed in a ___ brace at all times when out of bed or when head of bed greater than 30 degrees. Physical Therapy and Occupational Therapy were consulted and recommended discharge to rehabilitation. While pending bed availability at rehabilitation, patient complained of persistent back pain despite narcotic administration. The Neurosurgery Spine Service was reconsulted on ___ given the patient's persistent back pain. It was decided that the patient would undergo operative intervention. Patient went to the operating room on ___ for a T4-T8 fusion. The procedure was uncomplicated. Please see separately dictated operative report by Dr. ___ further details. The patient was extubated in the operating room and recovered in the PACU. He was transferred to the floor postoperatively for close neurologic monitoring. Patient was neurologically stable after surgery. . #Primary Biliary Cirrhosis Patient with primary biliary cirrhosis status post liver transplant. Patient was followed by Transplant Hepatology while inpatient. They recommended continuing the patient's home regimen of prednisone and tacrolimus. Creatinine and tacrolimus levels were checked daily. Per Transplant Hepatology, the patient's liver appears to be functioning well and Tacro and prednisone should be continued. . #Chest Pressure, Tachycardia, and Oxygen Desaturations Medicine was consulted as the patient complained of chest pressure and was tachycardic with low oxygen saturations. An ECG was done, which showed some nonspecific ST depressions. Cardiac biomarkers were negative. Repeat cardiac biomarkers were also negative. CTA of the chest was obtained and was negative for pulmonary embolism, but revealed bibasilar atelectasis and baseline emphysema. Per Medicine, these signs and symptoms are most likely related to pain, atelectasis, and baseline emphysema. They recommended a Chronic Pain consult, which was ordered. They also stated that there is no need to for additional repeat ECGs and cardiac biomarkers. They also recommended standing DuoNebs every six hours and instruction to keep the head of bed greater than 30 degrees when eating to avoid aspiration. Patient was encouraged to do aggressive incentive spirometry and mobilization. ___ patient had no further complaint of chest pain and tachycardia was improving. Patient was triggered for sustained tachycardia, worsening oxygen requirement and fever on ___. Repeat infectious workup was started and patient was started on empiric antibiotics. . #Abdominal distention Patient began to complain of abdominal distension on ___ and nausea/1 episode of emesis . KUB showed multiple dilated small bowel loops as well as nondistended, air-filled colon are most suggestive of ileus. Bowel regimen was increased. Patient was able to move his bowels later that day on ___. Repeat KUB on ___ showed improvement and patient denied any further nausea or vomiting. Patient was having bowel movements and tolerating a regular diet for several days prior to his discharge. He has a history of ? IBS that has been evaluated and continues to be followed by GI. . #Thrombocytopenia, Elevated ___ and INR, and Hematuria After starting prophylactic subcutaneous heparin on ___, the patient's platelet count decreased and ___ and INR slightly increased. Per the nurse, the patient also had some hematuria. The prophylactic subcutaneous heparin was held on ___ given these findings. It was discussed with ___ whether or not these findings were related to the patient's liver. Transplant Hepatology stated that the patient's liver is functioning well and that these findings are likely not related to his liver. Platelet count and ___ and INR were trended daily. SQH was restarted given normal PTT on ___ and platelet count is 120 on discharge. . #Acute on Chronic Pain Patient was continued on his home gabapentin and tramadol. Patient complained of significant postoperative pain not relieved by the typical postoperative pain regimen of acetaminophen and narcotics. Patient was initially started on a PCA however this did not provide good pain control. He was started on standing oxycodone, flexeril, and acetaminophen with better results. . **MEDICINE FLOOR COURSE: ___ - ___ On ___, Mr. ___ was transferred to medicine due to persistent tachycardia, worse in the setting of a fever on the morning of ___ prior to transfer. On transfer, he was known to have ileus that seemed to be improving, with several small-volume loose stools on the day prior to transfer. Patient had bilateral LENIs on ___ that were negative for DVT, which were ordered due to persistent concern for PE despite negative CTA on ___. He was also started on Ceftazidime/Vancomycin on the morning of transfer given fever to 101.8F (course dates ___. These antibiotics were continued during his time on the Medicine service due to concern for hospital-acquired PNA despite the lack of a clear consolidation on CXR. He had no further hypoxia on the medicine service but persistent rhonchi, likely ___ COPD and for which he was continued on duonebs/albuterol PRN. On ___ into ___ in the AM, the patient tolerated sips/liquids but abdominal exam was quiet. On ___ in the afternoon, he then developed ___ pain without any change in his Cr or lactate. He had a KUB followed by a CT scan that were consistent with SBO. NGT was placed. Given increased tenderness on exam and concern for SBO, he was transferred to the Transplant Surgery service for further management. The patient was having return of bowel function with passing flatus, having bowel movement and improvement in abdominal exam. He was started on clears and then transitioned to a regular diet with good tolerance. Other notations are recent treatment for odonophagia with 3 weeks of acyclovir which was completed on ___, and he will need follow up with the ___ clinic which will be scheduled. . Patient will be transferred to Care ___ where he is planned for a Less than 30 day stay. Medications on Admission: - acetaminophen 650mg PO Q6H - acyclovir 800mg PO Q8H - atorvastatin 10mg PO QPM - bupropion extended length 150mg PO daily - colchicine 0.6mg PO BID - dicyclomine 20mg PO QID - gabapentin 600mg PO BID - ondansetron 4mg PO Q8H PRN nausea - pantoprazole 40mg PO BID - prednisone 5mg PO daily - ranitidine 150mg PO BID - sucralfate 1g PO QID - tacrolimus 1mg PO Q12H - tramadol 25mg PO BID PRN moderate pain - ursodiol 300mg PO TID Discharge Medications: 1. Acetaminophen 500 mg PO Q6H Maximum 2 grams Tylenol for Liver transplant recipients 2. Cyclobenzaprine 5 mg PO Q8H:PRN muscle spasm ___ discontinue use if not using 3. Docusate Sodium 100 mg NG BID 4. HYDROmorphone (Dilaudid) ___ mg PO Q6H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity Taper as tolerated 5. Lidocaine 5% Patch 1 PTCH TD QPM Has been using near incision 6. Polyethylene Glycol 17 g PO DAILY:PRN constipation 7. Senna 8.6 mg PO BID:PRN Constipation - First Line 8. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing 9. Aspirin 325 mg PO DAILY 10. Atorvastatin 10 mg PO QPM 11. BuPROPion XL (Once Daily) 150 mg PO DAILY 12. Colchicine 0.6 mg PO BID 13. DICYCLOMine 10 mg PO QID 14. Gabapentin 600 mg PO BID 15. Ondansetron 4 mg PO Q8H:PRN nausea 16. Pantoprazole 40 mg PO Q12H 17. PredniSONE 5 mg PO DAILY 18. Ranitidine 150 mg PO DAILY 19. Tacrolimus 1 mg PO Q12H 20. TraMADol 50 mg PO BID Transition to tramadol off narcotics as indicated 21. Ursodiol 300 mg PO TID 22. Vitamin D ___ UNIT PO 1X/WEEK (FR) Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: - Manubrium fracture - Right L1 transverse process fracture - T1 compression fracture - T6 burst fracture - Tachycardia - Ileus - History of liver transplant ___ - History of ? IBS - Recent Odophaghia treated with 3 weeks Acyclovir. Completed ___ Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory, must wear ___ brace at all times when out of bed or when head of bed is greater than 30 degrees. Please see ___ notes Discharge Instructions: Discharge Facility: ___ Address: ___ Telephone: ___ . Plan is Less than 30 days stay . Patient must wear your ___ brace at all times when out of bed. Patient may apply your brace sitting at the edge of the bed. Patient does not need to sleep with brace on. . Surgery: - Your incision is closed with staples. You will need 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 fever, redness, 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. - You may shower briefly without your brace if you are sitting in a shower chair. If not, you must wear your brace while showering. - We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. - You make take leisurely walks and slowly increase your activity at your own pace. ___ try to do too much all at once. - No driving while taking any narcotic or sedating medication. - No contact sports until cleared by your neurosurgeon. - Do NOT smoke. Smoking can affect your healing and fusion. Medications: - ***Please do NOT take any blood thinning medication (aspirin, Coumadin, ibuprofen, Plavix) until cleared by the neurosurgeon. - Do not take any anti-inflammatory medications, such as Advil, aspirin, ibuprofen, or Motrin, until cleared by the neurosurgeon. - You may use acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. Do not take more than 2000mg in 24 hours. - 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 ___: - Severe pain, redness, swelling, or drainage from the incision site - Fever greater than 101.5 degrees Fahrenheit - New weakness or changes in sensation in your arms or legs. . Please assure patient receives all transplant related medications are given to patient as prescribed. . For liver transplant recipients, Please call the transplant clinic at ___ for fever of 101 or greater, chills, nausea, vomiting, diarrhea, constipation, inability to tolerate food, fluids or medications, yellowing of skin or eyes, increased abdominal pain, incisional redness, drainage or bleeding, dizziness or weakness, decreased urine output or dark, cloudy urine, swelling of abdomen or ankles, weight gain of 3 pounds in a day or any other concerning symptoms. . You will have labwork drawn as arranged by the transplant clinic, with results to the transplant clinic (Fax ___ . CBC, Chem 10, AST, ALT, Alk Phos, T Bili, Trough Tacro level, . *** On the days you have your labs drawn, do not take your Tacrolimus until your labs are drawn. Bring your Tacrolimus with you so you may take your medication as soon as your labwork has been drawn. Followup Instructions: ___
[ "S22052A", "J9601", "S2221XA", "S32018A", "Z944", "J9811", "J441", "K9131", "D6832", "S22018A", "W001XXA", "Y9289", "E785", "F319", "Z87891", "Z86718", "R000", "E8342", "R5082", "R197", "D649", "D696", "M810", "F909", "F1021", "R319", "T45515A", "Y92230", "G8929", "G8918" ]
Allergies: Penicillins / rifampin / Lamictal / lorazepam / risperidone / mushrooms Chief Complaint: T1 compression fracture, T6 burst fracture Major Surgical or Invasive Procedure: [MASKED] - T4-T8 fusion History of Present Illness: [MASKED]. is a [MASKED] year old male status post liver transplant who presented to the Emergency Department on [MASKED] as a transfer from an outside facility status post mechanical fall. Imaging at the outside facility showed a T1 compression fracture and T6 burst fracture. Patient was transferred to [MASKED] [MASKED] for further evaluation and management. The Neurosurgery Service was consulted for evaluation and management recommendations related to the T1 compression fracture and T6 burst fracture. Past Medical History: - attention deficit hyperactivity disorder - bipolar disorder - hemorrhoids - history of alcohol abuse - history of deep vein thrombosis in [MASKED] - history of hemorrhagic pericarditis complicated by cardiac tamponade status post pericardial window in [MASKED], recurrent pericarditis in [MASKED] - history of neutropenia complicated by neutropenic fever - history of positive tuberculin skin test status post INH - hyperlipidemia - osteoporosis - primary biliary cirrhosis status post orthotopic liver transplant Social History: [MASKED] Family History: Noncontributory Physical Exam: On Admission: ------------- Vital Signs: T 97.8F, HR 90, BP 127/91, RR 20, O2Sat 96% room air General: Well dressed, well nourished, comfortable, no acute distress. Extremities: Warm and well perfused. Neurologic: Mental status: Awake and alert, cooperative with exam, normal affect. Motor: Deltoid Biceps Triceps Wrist Flexion Wrist Extension Right 5 5 5 5 5 Left 5 5 5 5 5 IP Quadriceps Hamstring AT [MASKED] Gastrocnemius Right 5 5 5 5 5 5 Left 5 5 5 5 5 5 Sensation: Intact to light touch. Reflexes: Biceps Triceps Brachial Right 2+ 2+ 2+ Left 2+ 2+ 2+ Propioception intact. Rectal tone within normal limits per Acute Care Surgery resident, patient refused rectal tone when attempted by us. No [MASKED], no clonus. On Discharge: ------------- VS: 98.4, 102, 121/88, 18, 95% RA Alert and Orient x 3, conversant, pain managed HEENT: Anicteric, no JVD Card: Sl tachy, regular Lungs: No respiratory distress Abd: Sl obese, well healed incision, non-distended, non-tender Extr: No edema, . Weight at discharge: 71.2 kg Pertinent Results: Please see OMR for relevant laboratory and imaging results. CTA ABDOMEN AND PELVIS [MASKED] IMPRESSION: 1. Mild distension of the small bowel up to a maximum caliber of 3.8 cm with air-fluid levels coming to a single transition point at the distal ileum compatible with small-bowel obstruction. 2. Unremarkable appearance of the orthotopic liver transplant. 3. Splenomegaly to a maximum dimension of 17 cm. 4. Small bilateral pleural effusions with adjacent compressive atelectasis. . Labs on Admission: [MASKED] WBC-4.7 RBC-4.37* Hgb-12.8* Hct-38.7* MCV-89 MCH-29.3 MCHC-33.1 RDW-17.7* RDWSD-52.9* Plt [MASKED] PTT-27.7 [MASKED] Glucose-85 UreaN-11 Creat-1.2 Na-141 K-4.7 Cl-107 HCO3-23 AnGap-11 ALT-14 AST-19 AlkPhos-244* TotBili-0.7 Lipase-23 Calcium-8.2* Phos-3.2 Mg-1.7 Albumin-3.4* tacroFK-2.4* . Labs at Discharge [MASKED] WBC-2.8* RBC-3.36* Hgb-9.7* Hct-30.2* MCV-90 MCH-28.9 MCHC-32.1 RDW-20.0* RDWSD-60.2* Plt [MASKED] PTT-30.5 [MASKED] Glucose-79 UreaN-3* Creat-0.9 Na-147 K-3.9 Cl-108 HCO3-20* AnGap-19* ALT-9 AST-15 AlkPhos-179* TotBili-0.8 Calcium-8.2* Phos-3.0 Mg-1.8 tacroFK-5.[MASKED] year old male who was admitted on [MASKED] status post fall with findings of a T1 compression fracture and T6 burst fracture on MRI. . #T1 Compression Fracture and T6 Burst Fracture The Neurosurgery Spine Service was consulted on [MASKED] for evaluation and management recommendations related to the patient's T1 compression fracture and T6 burst fracture. Initially, we recommended that the patient be placed in a [MASKED] brace at all times when out of bed or when head of bed greater than 30 degrees. Physical Therapy and Occupational Therapy were consulted and recommended discharge to rehabilitation. While pending bed availability at rehabilitation, patient complained of persistent back pain despite narcotic administration. The Neurosurgery Spine Service was reconsulted on [MASKED] given the patient's persistent back pain. It was decided that the patient would undergo operative intervention. Patient went to the operating room on [MASKED] for a T4-T8 fusion. The procedure was uncomplicated. Please see separately dictated operative report by Dr. [MASKED] further details. The patient was extubated in the operating room and recovered in the PACU. He was transferred to the floor postoperatively for close neurologic monitoring. Patient was neurologically stable after surgery. . #Primary Biliary Cirrhosis Patient with primary biliary cirrhosis status post liver transplant. Patient was followed by Transplant Hepatology while inpatient. They recommended continuing the patient's home regimen of prednisone and tacrolimus. Creatinine and tacrolimus levels were checked daily. Per Transplant Hepatology, the patient's liver appears to be functioning well and Tacro and prednisone should be continued. . #Chest Pressure, Tachycardia, and Oxygen Desaturations Medicine was consulted as the patient complained of chest pressure and was tachycardic with low oxygen saturations. An ECG was done, which showed some nonspecific ST depressions. Cardiac biomarkers were negative. Repeat cardiac biomarkers were also negative. CTA of the chest was obtained and was negative for pulmonary embolism, but revealed bibasilar atelectasis and baseline emphysema. Per Medicine, these signs and symptoms are most likely related to pain, atelectasis, and baseline emphysema. They recommended a Chronic Pain consult, which was ordered. They also stated that there is no need to for additional repeat ECGs and cardiac biomarkers. They also recommended standing DuoNebs every six hours and instruction to keep the head of bed greater than 30 degrees when eating to avoid aspiration. Patient was encouraged to do aggressive incentive spirometry and mobilization. [MASKED] patient had no further complaint of chest pain and tachycardia was improving. Patient was triggered for sustained tachycardia, worsening oxygen requirement and fever on [MASKED]. Repeat infectious workup was started and patient was started on empiric antibiotics. . #Abdominal distention Patient began to complain of abdominal distension on [MASKED] and nausea/1 episode of emesis . KUB showed multiple dilated small bowel loops as well as nondistended, air-filled colon are most suggestive of ileus. Bowel regimen was increased. Patient was able to move his bowels later that day on [MASKED]. Repeat KUB on [MASKED] showed improvement and patient denied any further nausea or vomiting. Patient was having bowel movements and tolerating a regular diet for several days prior to his discharge. He has a history of ? IBS that has been evaluated and continues to be followed by GI. . #Thrombocytopenia, Elevated [MASKED] and INR, and Hematuria After starting prophylactic subcutaneous heparin on [MASKED], the patient's platelet count decreased and [MASKED] and INR slightly increased. Per the nurse, the patient also had some hematuria. The prophylactic subcutaneous heparin was held on [MASKED] given these findings. It was discussed with [MASKED] whether or not these findings were related to the patient's liver. Transplant Hepatology stated that the patient's liver is functioning well and that these findings are likely not related to his liver. Platelet count and [MASKED] and INR were trended daily. SQH was restarted given normal PTT on [MASKED] and platelet count is 120 on discharge. . #Acute on Chronic Pain Patient was continued on his home gabapentin and tramadol. Patient complained of significant postoperative pain not relieved by the typical postoperative pain regimen of acetaminophen and narcotics. Patient was initially started on a PCA however this did not provide good pain control. He was started on standing oxycodone, flexeril, and acetaminophen with better results. . **MEDICINE FLOOR COURSE: [MASKED] - [MASKED] On [MASKED], Mr. [MASKED] was transferred to medicine due to persistent tachycardia, worse in the setting of a fever on the morning of [MASKED] prior to transfer. On transfer, he was known to have ileus that seemed to be improving, with several small-volume loose stools on the day prior to transfer. Patient had bilateral LENIs on [MASKED] that were negative for DVT, which were ordered due to persistent concern for PE despite negative CTA on [MASKED]. He was also started on Ceftazidime/Vancomycin on the morning of transfer given fever to 101.8F (course dates [MASKED]. These antibiotics were continued during his time on the Medicine service due to concern for hospital-acquired PNA despite the lack of a clear consolidation on CXR. He had no further hypoxia on the medicine service but persistent rhonchi, likely [MASKED] COPD and for which he was continued on duonebs/albuterol PRN. On [MASKED] into [MASKED] in the AM, the patient tolerated sips/liquids but abdominal exam was quiet. On [MASKED] in the afternoon, he then developed [MASKED] pain without any change in his Cr or lactate. He had a KUB followed by a CT scan that were consistent with SBO. NGT was placed. Given increased tenderness on exam and concern for SBO, he was transferred to the Transplant Surgery service for further management. The patient was having return of bowel function with passing flatus, having bowel movement and improvement in abdominal exam. He was started on clears and then transitioned to a regular diet with good tolerance. Other notations are recent treatment for odonophagia with 3 weeks of acyclovir which was completed on [MASKED], and he will need follow up with the [MASKED] clinic which will be scheduled. . Patient will be transferred to Care [MASKED] where he is planned for a Less than 30 day stay. Medications on Admission: - acetaminophen 650mg PO Q6H - acyclovir 800mg PO Q8H - atorvastatin 10mg PO QPM - bupropion extended length 150mg PO daily - colchicine 0.6mg PO BID - dicyclomine 20mg PO QID - gabapentin 600mg PO BID - ondansetron 4mg PO Q8H PRN nausea - pantoprazole 40mg PO BID - prednisone 5mg PO daily - ranitidine 150mg PO BID - sucralfate 1g PO QID - tacrolimus 1mg PO Q12H - tramadol 25mg PO BID PRN moderate pain - ursodiol 300mg PO TID Discharge Medications: 1. Acetaminophen 500 mg PO Q6H Maximum 2 grams Tylenol for Liver transplant recipients 2. Cyclobenzaprine 5 mg PO Q8H:PRN muscle spasm [MASKED] discontinue use if not using 3. Docusate Sodium 100 mg NG BID 4. HYDROmorphone (Dilaudid) [MASKED] mg PO Q6H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity Taper as tolerated 5. Lidocaine 5% Patch 1 PTCH TD QPM Has been using near incision 6. Polyethylene Glycol 17 g PO DAILY:PRN constipation 7. Senna 8.6 mg PO BID:PRN Constipation - First Line 8. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing 9. Aspirin 325 mg PO DAILY 10. Atorvastatin 10 mg PO QPM 11. BuPROPion XL (Once Daily) 150 mg PO DAILY 12. Colchicine 0.6 mg PO BID 13. DICYCLOMine 10 mg PO QID 14. Gabapentin 600 mg PO BID 15. Ondansetron 4 mg PO Q8H:PRN nausea 16. Pantoprazole 40 mg PO Q12H 17. PredniSONE 5 mg PO DAILY 18. Ranitidine 150 mg PO DAILY 19. Tacrolimus 1 mg PO Q12H 20. TraMADol 50 mg PO BID Transition to tramadol off narcotics as indicated 21. Ursodiol 300 mg PO TID 22. Vitamin D [MASKED] UNIT PO 1X/WEEK (FR) Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: - Manubrium fracture - Right L1 transverse process fracture - T1 compression fracture - T6 burst fracture - Tachycardia - Ileus - History of liver transplant [MASKED] - History of ? IBS - Recent Odophaghia treated with 3 weeks Acyclovir. Completed [MASKED] Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory, must wear [MASKED] brace at all times when out of bed or when head of bed is greater than 30 degrees. Please see [MASKED] notes Discharge Instructions: Discharge Facility: [MASKED] Address: [MASKED] Telephone: [MASKED] . Plan is Less than 30 days stay . Patient must wear your [MASKED] brace at all times when out of bed. Patient may apply your brace sitting at the edge of the bed. Patient does not need to sleep with brace on. . Surgery: - Your incision is closed with staples. You will need 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 fever, redness, or drainage. Activity: - You must wear your [MASKED] brace at all times when out of bed. You may apply your brace sitting at the edge of the bed. You do not need to sleep with it on. - You may shower briefly without your brace if you are sitting in a shower chair. If not, you must wear your brace while showering. - We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. - You make take leisurely walks and slowly increase your activity at your own pace. [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, Coumadin, ibuprofen, Plavix) until cleared by the neurosurgeon. - Do not take any anti-inflammatory medications, such as Advil, aspirin, ibuprofen, or Motrin, until cleared by the neurosurgeon. - You may use acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. Do not take more than 2000mg in 24 hours. - 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]: - Severe pain, redness, swelling, or drainage from the incision site - Fever greater than 101.5 degrees Fahrenheit - New weakness or changes in sensation in your arms or legs. . Please assure patient receives all transplant related medications are given to patient as prescribed. . For liver transplant recipients, Please call the transplant clinic at [MASKED] for fever of 101 or greater, chills, nausea, vomiting, diarrhea, constipation, inability to tolerate food, fluids or medications, yellowing of skin or eyes, increased abdominal pain, incisional redness, drainage or bleeding, dizziness or weakness, decreased urine output or dark, cloudy urine, swelling of abdomen or ankles, weight gain of 3 pounds in a day or any other concerning symptoms. . You will have labwork drawn as arranged by the transplant clinic, with results to the transplant clinic (Fax [MASKED] . CBC, Chem 10, AST, ALT, Alk Phos, T Bili, Trough Tacro level, . *** On the days you have your labs drawn, do not take your Tacrolimus until your labs are drawn. Bring your Tacrolimus with you so you may take your medication as soon as your labwork has been drawn. Followup Instructions: [MASKED]
[]
[ "J9601", "E785", "Z87891", "Z86718", "D649", "D696", "Y92230", "G8929" ]
[ "S22052A: Unstable burst fracture of T5-T6 vertebra, initial encounter for closed fracture", "J9601: Acute respiratory failure with hypoxia", "S2221XA: Fracture of manubrium, initial encounter for closed fracture", "S32018A: Other fracture of first lumbar vertebra, initial encounter for closed fracture", "Z944: Liver transplant status", "J9811: Atelectasis", "J441: Chronic obstructive pulmonary disease with (acute) exacerbation", "K9131: Postprocedural partial intestinal obstruction", "D6832: Hemorrhagic disorder due to extrinsic circulating anticoagulants", "S22018A: Other fracture of first thoracic vertebra, initial encounter for closed fracture", "W001XXA: Fall from stairs and steps due to ice and snow, initial encounter", "Y9289: Other specified places as the place of occurrence of the external cause", "E785: Hyperlipidemia, unspecified", "F319: Bipolar disorder, unspecified", "Z87891: Personal history of nicotine dependence", "Z86718: Personal history of other venous thrombosis and embolism", "R000: Tachycardia, unspecified", "E8342: Hypomagnesemia", "R5082: Postprocedural fever", "R197: Diarrhea, unspecified", "D649: Anemia, unspecified", "D696: Thrombocytopenia, unspecified", "M810: Age-related osteoporosis without current pathological fracture", "F909: Attention-deficit hyperactivity disorder, unspecified type", "F1021: Alcohol dependence, in remission", "R319: Hematuria, unspecified", "T45515A: Adverse effect of anticoagulants, initial encounter", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "G8929: Other chronic pain", "G8918: Other acute postprocedural pain" ]
19,992,875
24,374,834
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / rifampin / Lamictal / lorazepam / risperidone / mushrooms Attending: ___. Chief Complaint: Abdominal pain, diarrhea Major Surgical or Invasive Procedure: Sigmoidoscopy (___) History of Present Illness: Mr ___ is a ___ w/hx of Mr. ___ is a ___ with a history of PBC s/p OLT in ___, Pericarditis, Bipolar, COPD who p/w abd pain, diarrhea. Pt states he has been having 4d of worsening abd pain, nausea, and diarrhea. Denies GIB though states stools are khaki colored. Feels similar to when previously had CMV infection. No recent Abx. Endorsing chills but no fever/NS. No emesis, dysuria, cough, confusion, ___ swelling. Endorsing SOB, orthopnea though these are baseline Sx for him. Hasn't been taking his COPD inhalers. Of note, pt states he developed severe chest pain x2d, squeezing/non-radiating, upper chest, worse with exertion. States this is similar to his pericarditis pain and not to his prior CAD pain. Hasn't had pain like this in last 6 mo. No LH/dizziness, palp, vision changes. -In the ED, initial vitals: T99.0 85 113/99 18 99% RA -On exam, sig for Abd with diffuse TTP worse over epigastrum and LLQ; nondistended -Labs sig for: neg UA, INR 1.2, WBC 4.0, Plt 97, AlkP 140, AST/ALT wnl, Cr 1.4, Trop neg, Lac 0.9 -Studies sig for: EKG with Diffuse ST segment depression V2-V5/V6, I, II, ?ST elevation in aVR, with TWI in V2-V5/V6 as compared to ___. Pericarditis vs demand ischemia? CT A/P w/possible early colitis vs underdistention CXR wnl -Pt was given: 2L NS, 2mg IV Morphine x2, 4mg IV Zofran x2, 0.6mg colchicine, 600mg gabapentin, 40mg omeprazole, 150mg ranitdine, 1mg tacro -Transplant hepatology was consulted, recommended admit to ET for infectious w/u, trend trops -Vitals before transfer: 64 121/87 18 97% RA On the floor, pt's abdominal pain was improved s/p Morphine. ROS: per HPI, denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: PAST MEDICAL HISTORY: PBC s/p deceased liver donor tx ___ Neutropenia DVT ___ Prior alcohol abuse now abstinent Hemorrhagic pericarditis c/b tamponade with pericardial window ___ Positive PPD s/p INH HLD Osteoporosis Bipolar disorder Hemorrhoids ADHD PTSD Social History: ___ Family History: Father (living): coronary artery disease, diabetes, hypercholesterolemia, and depression. Prostate and head and neck cancer Mother (deceased): brain aneurysm and hyperthyroidism Physical Exam: ADMISSION EXAM: Vital Signs: 97.6 127/84 48 16 100 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. No pulsus on exam. Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, +diffuse abdominal tenderness, 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, gait deferred. DISCHARGE EXAM: VS Tc 98.0 BP 110/81 HR 89 RR 16 O2 100% RA I/Os: 3260/925 B+2335 General: Alert, oriented, mild distress due to pain HEENT: MMM, oropharynx clear, EOMI, CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops. Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, +diffuse mild abdominal tenderness, 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, no focal deficits. Pertinent Results: ADMISSION LABS: ___ 06:01PM LACTATE-0.9 ___ 05:54PM GLUCOSE-91 UREA N-17 CREAT-1.4* SODIUM-136 POTASSIUM-3.7 CHLORIDE-101 TOTAL CO2-22 ANION GAP-17 ___ 05:54PM ALT(SGPT)-28 AST(SGOT)-31 ALK PHOS-140* TOT BILI-0.8 ___ 05:54PM LIPASE-20 ___ 05:54PM cTropnT-<0.01 ___ 05:54PM ALBUMIN-4.6 ___ 05:54PM WBC-4.0 RBC-5.80 HGB-17.3 HCT-48.7 MCV-84 MCH-29.8 MCHC-35.5 RDW-16.0* RDWSD-47.3* ___ 05:54PM NEUTS-45.2 ___ MONOS-11.6 EOS-0.8* BASOS-1.5* IM ___ AbsNeut-1.79 AbsLymp-1.60 AbsMono-0.46 AbsEos-0.03* AbsBaso-0.06 ___ 05:54PM ___ PTT-29.5 ___ ___ 04:41PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG ___ 04:41PM URINE RBC-3* WBC-1 BACTERIA-FEW YEAST-NONE EPI-<1 INTERIM LABS: ___ 05:54PM BLOOD cTropnT-<0.01 ___ 05:21AM BLOOD cTropnT-<0.01 ___ 05:21AM BLOOD tacroFK-11.2 ___ 05:43AM BLOOD tacroFK-7.8 ___ 04:58AM BLOOD tacroFK-7.7 DISCHARGE LABS: ___ 04:58AM BLOOD tacroFK-7.7 ___ 04:58AM BLOOD WBC-2.6* RBC-4.70 Hgb-14.0 Hct-41.0 MCV-87 MCH-29.8 MCHC-34.1 RDW-16.2* RDWSD-51.4* Plt Ct-68* ___ 04:58AM BLOOD Glucose-127* UreaN-7 Creat-1.4* Na-138 K-4.5 Cl-102 HCO3-27 AnGap-1 MICROBIOLOGY: URINE CULTURE (Final ___: < 10,000 CFU/mL. Blood Culture, Routine (Final ___: NO GROWTH. CMV Viral Load (Final ___: CMV DNA not detected. Performed by Cobas Ampliprep / Cobas Taqman CMV Test. Linear range of quantification: 137 IU/mL - 9,100,000 IU/mL. Limit of detection 91 IU/mL. This test has been verified for use in the ___ patient population. C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. VIRAL CULTURE (Final ___: NO VIRUS ISOLATED. IMAGING/STUDIES: EKG ___: Sinus rhythm. Prominent early R wave progression. Anterior ST-T wave abnormalities. Cannot rule out underlying myocardial ischemia. Compared to the previous tracing of ___ wave abnormalities are new. Clinical correlation is suggested. EKG ___: Sinus bradycardia. Compared to tracing #2 there is no significant diagnostic change. CXR ___ FINDINGS: The cardiomediastinal silhouette and pulmonary vasculature are unchanged. The lungs are clear. There is no pleural effusion or pneumothorax. No acute osseous injury. IMPRESSION: No acute intrathoracic abnormality. CT Abd/Pelvis w/ CONTRAST ___: IMPRESSION: 1. Equivocal mucosal hyper enhancement of the sigmoid and proximal transverse colon are likely related to underdistention, correlate for possibility of an early colitis. 2. Status post liver transplant with expected postsurgical changes. Patent main portal vein. 3. Stable mild splenomegaly. 4. 0.9 cm right lower pole renal hypodensity is better characterized on prior MRCP as benign. ECHO ___: The left atrium is normal in size. 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%). There is no ventricular septal defect. 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. Trace aortic regurgitation is seen.There is also a small turbulent diastolic color doppler signal seen at the margin between the left and non-coronary aortic valve cusps ( clips #9, 14, 30, 37) in the aortic root that likely reflects brisk coronary artery flow. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Colonoscopy ___ Biopsies pending at discharge: Prelim results positive for colitis in multiple locations. Brief Hospital Course: Mr. ___ is a ___ male with a PMH of PBC s/p OLT in ___, pericarditis, bipolar disorder, COPD who p/w abd pain, diarrhea, and chest pain. Patient was ruled out for acute coronary syndrome with EKG, CXR, and troponins negative. CT for the abdomen found new colitis. It was felt this was most likely due to an infectious etiology. Highest concern was for CMV, given previous infections and patient's immunosuppressed state. CMV serology was negative for active infection. Colonoscopy showed colitis but otherwise no other abnormalities. Patient symptoms were improved with addition of dicyclomine. No other infectious source for his colitis was found. Since symptoms were improving, it was felt his symptoms represented resolving viral gastroenteritis with on-going post-infectiuos IBS. #Abdominal pain and diarrhea: Patient presented with four days of worsening abdominal pain and diarrhea. He had CT imaging concerning for colitis. An infectious workup was initiated, but CMV and C diff were negative. Fecal cultures and other stool studies (camoylobacter, viral/fecal cultures) have thus far been negative. Final viral stool culture was pending at discharge. Patient had a sigmoidoscopy on ___ to evaluate CT imaging findings of colitis that was unrevealing. Pain was controlled with oxycodone 5 mg q6h prn pain and dicyclomine 20mg QID. Discharged on dicyclomine only. Since no infectious etiology was determined, it was felt the patient had a viral gastroenteritis that lead to post-infectious IBS causing on-going abdominal pain, diarrhea. It was recommended to try ___ as an over the counter medication for further symptom control and follow up with outpatient providers. #Chest pain: Pt presented with severe upper chest pain x2d that was squeezing and non-radiating, and worse with exertion. His EKG showed new T wave inversions in lateral leads but his troponins were negative. ECHO was without wall motion abnormalities or pericardial effusion. Chest pain seemed to be related to his abdominal pain which was greatest in his epigastric region. Patient was continued on his home anti-inflammatory meds (ASA 650 BID, colchicine, oxycodone) during this hospitalization for chronic pericarditis. Chest pain was improved by time of discharge. Follow up appointment with cardiology was made prior to discharge. #COPD: Patient reports dyspnea and orthopnea greater than baseline on admission. He was not taking his home meds (albuterol, salmeterol), but these were restarted during this hospitalization. CXR was negative for acute intrathoracic abnormalities. SOB resolved and no further work up was performed. ============== CHRONIC ISSUES ============== #PBC S/P OLT WITH CMV+ DONOR C/B CELLULAR REJECTION, HEMORRHAGIC PERICARDITIS, RECURRENT PERICARDITIS: LFTs remained normal throughout the admission. Patient reported compliance with his tacrolimus, prednisone. Tacrolimus levels were monitored daily. His dosing was decreased to tacrolimus 1mg Q12hrs from 1.5mg Q12hrs. He was discharged to follow up with his hepatologist and re-check tacrolimus levels as an outpatient. #THROMBOCYTOPENIA: Chronic thrombocytopenia likely due to liver disease or immunosuppression. Stable in comparison to prior labs. CBC was trended daily. #BIPOLAR DISORDER: Patient was recently off of Abilify, Symptoms were monitored as inpatient and patient mental status remained stable. #GERD: Known GERD possibly contributing to epigastric abdominal pain. Continued on home omeprazole 40mg BID and home ranitidine 150mg qHS. #CHRONIC NEUROPATHIC PAIN: Patient noted that he has been having increased neuropathy in hands bilaterally. Continued on home gabapentin 600mg BID without exacerbation or changes in neuropathic sx. ======================= TRANSITIONAL ISSUES: ======================= -Tacrolimus changed to 1 mg BID; check levels at next appointment -Follow-up final viral stool studies. -Follow-up biopsies from colonoscopy -Follow-up cardiology appointment as scheduled above Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Colchicine 0.6 mg PO BID 2. Gabapentin 600 mg PO BID 3. Omeprazole 40 mg PO BID 4. Ondansetron 4 mg PO Q8H:PRN nausea 5. PredniSONE 5 mg PO DAILY 6. Ranitidine 150 mg PO QHS 7. Tacrolimus 1.5 mg PO QAM 8. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain 9. Aspirin 650 mg PO BID 10. Tacrolimus 1 mg PO QPM Discharge Medications: 1. DICYCLOMine 20 mg PO TID abdominal pain RX *dicyclomine 20 mg 1 tablet(s) by mouth TID PRN Disp #*30 Tablet Refills:*0 2. IBgard (peppermint oil) 90 mg oral TID:PRN abdominal pain RX *peppermint oil [___] 90 mg 1 capsule(s) by mouth TID PRN Disp #*48 Capsule Refills:*0 3. Aspirin 650 mg PO BID 4. Colchicine 0.6 mg PO BID 5. Gabapentin 600 mg PO BID 6. Omeprazole 40 mg PO BID 7. Ondansetron 4 mg PO Q8H:PRN nausea 8. PredniSONE 5 mg PO DAILY 9. Ranitidine 150 mg PO QHS 10. Tacrolimus 1 mg PO QPM RX *tacrolimus 1 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 11. Tacrolimus 1 mg PO QAM 12. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain Discharge Disposition: Home Discharge Diagnosis: Abdominal pain concerning for colitis Diarrhea Chest pain COPD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted because you had abdominal pain. We got images of your abdomen that showed you had some mild inflammation in your colon. This was likely due to a viral infection. We controlled your pain with medications. It is important for your to follow-up with your PCP and Dr. ___. There are biopsy results pending from the colonoscopy that you will discuss with Dr. ___. We have given you a prescription for dicyclomine to help your abdominal pain. There is also a form of peppermint oil called "IBgard" that you can buy over the counter to help with your pain. Your pain should improve with time. Avoid dairy products and eat a bland diet. Lastly, we decreased the dose of your tacrolimus to 1 mg twice daily. It was a pleasure taking care of you. Sincerely, Your ___ Team Followup Instructions: ___
[ "K529", "N179", "Z944", "D696", "J449", "F319", "I2510", "Z86718", "Z87891", "Z8249", "K219", "R079" ]
Allergies: Penicillins / rifampin / Lamictal / lorazepam / risperidone / mushrooms Chief Complaint: Abdominal pain, diarrhea Major Surgical or Invasive Procedure: Sigmoidoscopy ([MASKED]) History of Present Illness: Mr [MASKED] is a [MASKED] w/hx of Mr. [MASKED] is a [MASKED] with a history of PBC s/p OLT in [MASKED], Pericarditis, Bipolar, COPD who p/w abd pain, diarrhea. Pt states he has been having 4d of worsening abd pain, nausea, and diarrhea. Denies GIB though states stools are khaki colored. Feels similar to when previously had CMV infection. No recent Abx. Endorsing chills but no fever/NS. No emesis, dysuria, cough, confusion, [MASKED] swelling. Endorsing SOB, orthopnea though these are baseline Sx for him. Hasn't been taking his COPD inhalers. Of note, pt states he developed severe chest pain x2d, squeezing/non-radiating, upper chest, worse with exertion. States this is similar to his pericarditis pain and not to his prior CAD pain. Hasn't had pain like this in last 6 mo. No LH/dizziness, palp, vision changes. -In the ED, initial vitals: T99.0 85 113/99 18 99% RA -On exam, sig for Abd with diffuse TTP worse over epigastrum and LLQ; nondistended -Labs sig for: neg UA, INR 1.2, WBC 4.0, Plt 97, AlkP 140, AST/ALT wnl, Cr 1.4, Trop neg, Lac 0.9 -Studies sig for: EKG with Diffuse ST segment depression V2-V5/V6, I, II, ?ST elevation in aVR, with TWI in V2-V5/V6 as compared to [MASKED]. Pericarditis vs demand ischemia? CT A/P w/possible early colitis vs underdistention CXR wnl -Pt was given: 2L NS, 2mg IV Morphine x2, 4mg IV Zofran x2, 0.6mg colchicine, 600mg gabapentin, 40mg omeprazole, 150mg ranitdine, 1mg tacro -Transplant hepatology was consulted, recommended admit to ET for infectious w/u, trend trops -Vitals before transfer: 64 121/87 18 97% RA On the floor, pt's abdominal pain was improved s/p Morphine. ROS: per HPI, denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: PAST MEDICAL HISTORY: PBC s/p deceased liver donor tx [MASKED] Neutropenia DVT [MASKED] Prior alcohol abuse now abstinent Hemorrhagic pericarditis c/b tamponade with pericardial window [MASKED] Positive PPD s/p INH HLD Osteoporosis Bipolar disorder Hemorrhoids ADHD PTSD Social History: [MASKED] Family History: Father (living): coronary artery disease, diabetes, hypercholesterolemia, and depression. Prostate and head and neck cancer Mother (deceased): brain aneurysm and hyperthyroidism Physical Exam: ADMISSION EXAM: Vital Signs: 97.6 127/84 48 16 100 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. No pulsus on exam. Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, +diffuse abdominal tenderness, 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, gait deferred. DISCHARGE EXAM: VS Tc 98.0 BP 110/81 HR 89 RR 16 O2 100% RA I/Os: 3260/925 B+2335 General: Alert, oriented, mild distress due to pain HEENT: MMM, oropharynx clear, EOMI, CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops. Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, +diffuse mild abdominal tenderness, 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, no focal deficits. Pertinent Results: ADMISSION LABS: [MASKED] 06:01PM LACTATE-0.9 [MASKED] 05:54PM GLUCOSE-91 UREA N-17 CREAT-1.4* SODIUM-136 POTASSIUM-3.7 CHLORIDE-101 TOTAL CO2-22 ANION GAP-17 [MASKED] 05:54PM ALT(SGPT)-28 AST(SGOT)-31 ALK PHOS-140* TOT BILI-0.8 [MASKED] 05:54PM LIPASE-20 [MASKED] 05:54PM cTropnT-<0.01 [MASKED] 05:54PM ALBUMIN-4.6 [MASKED] 05:54PM WBC-4.0 RBC-5.80 HGB-17.3 HCT-48.7 MCV-84 MCH-29.8 MCHC-35.5 RDW-16.0* RDWSD-47.3* [MASKED] 05:54PM NEUTS-45.2 [MASKED] MONOS-11.6 EOS-0.8* BASOS-1.5* IM [MASKED] AbsNeut-1.79 AbsLymp-1.60 AbsMono-0.46 AbsEos-0.03* AbsBaso-0.06 [MASKED] 05:54PM [MASKED] PTT-29.5 [MASKED] [MASKED] 04:41PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [MASKED] 04:41PM URINE RBC-3* WBC-1 BACTERIA-FEW YEAST-NONE EPI-<1 INTERIM LABS: [MASKED] 05:54PM BLOOD cTropnT-<0.01 [MASKED] 05:21AM BLOOD cTropnT-<0.01 [MASKED] 05:21AM BLOOD tacroFK-11.2 [MASKED] 05:43AM BLOOD tacroFK-7.8 [MASKED] 04:58AM BLOOD tacroFK-7.7 DISCHARGE LABS: [MASKED] 04:58AM BLOOD tacroFK-7.7 [MASKED] 04:58AM BLOOD WBC-2.6* RBC-4.70 Hgb-14.0 Hct-41.0 MCV-87 MCH-29.8 MCHC-34.1 RDW-16.2* RDWSD-51.4* Plt Ct-68* [MASKED] 04:58AM BLOOD Glucose-127* UreaN-7 Creat-1.4* Na-138 K-4.5 Cl-102 HCO3-27 AnGap-1 MICROBIOLOGY: URINE CULTURE (Final [MASKED]: < 10,000 CFU/mL. Blood Culture, Routine (Final [MASKED]: NO GROWTH. CMV Viral Load (Final [MASKED]: CMV DNA not detected. Performed by Cobas Ampliprep / Cobas Taqman CMV Test. Linear range of quantification: 137 IU/mL - 9,100,000 IU/mL. Limit of detection 91 IU/mL. This test has been verified for use in the [MASKED] patient population. C. difficile DNA amplification assay (Final [MASKED]: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). FECAL CULTURE (Final [MASKED]: NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [MASKED]: NO CAMPYLOBACTER FOUND. VIRAL CULTURE (Final [MASKED]: NO VIRUS ISOLATED. IMAGING/STUDIES: EKG [MASKED]: Sinus rhythm. Prominent early R wave progression. Anterior ST-T wave abnormalities. Cannot rule out underlying myocardial ischemia. Compared to the previous tracing of [MASKED] wave abnormalities are new. Clinical correlation is suggested. EKG [MASKED]: Sinus bradycardia. Compared to tracing #2 there is no significant diagnostic change. CXR [MASKED] FINDINGS: The cardiomediastinal silhouette and pulmonary vasculature are unchanged. The lungs are clear. There is no pleural effusion or pneumothorax. No acute osseous injury. IMPRESSION: No acute intrathoracic abnormality. CT Abd/Pelvis w/ CONTRAST [MASKED]: IMPRESSION: 1. Equivocal mucosal hyper enhancement of the sigmoid and proximal transverse colon are likely related to underdistention, correlate for possibility of an early colitis. 2. Status post liver transplant with expected postsurgical changes. Patent main portal vein. 3. Stable mild splenomegaly. 4. 0.9 cm right lower pole renal hypodensity is better characterized on prior MRCP as benign. ECHO [MASKED]: The left atrium is normal in size. 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%). There is no ventricular septal defect. 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. Trace aortic regurgitation is seen.There is also a small turbulent diastolic color doppler signal seen at the margin between the left and non-coronary aortic valve cusps ( clips #9, 14, 30, 37) in the aortic root that likely reflects brisk coronary artery flow. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Colonoscopy [MASKED] Biopsies pending at discharge: Prelim results positive for colitis in multiple locations. Brief Hospital Course: Mr. [MASKED] is a [MASKED] male with a PMH of PBC s/p OLT in [MASKED], pericarditis, bipolar disorder, COPD who p/w abd pain, diarrhea, and chest pain. Patient was ruled out for acute coronary syndrome with EKG, CXR, and troponins negative. CT for the abdomen found new colitis. It was felt this was most likely due to an infectious etiology. Highest concern was for CMV, given previous infections and patient's immunosuppressed state. CMV serology was negative for active infection. Colonoscopy showed colitis but otherwise no other abnormalities. Patient symptoms were improved with addition of dicyclomine. No other infectious source for his colitis was found. Since symptoms were improving, it was felt his symptoms represented resolving viral gastroenteritis with on-going post-infectiuos IBS. #Abdominal pain and diarrhea: Patient presented with four days of worsening abdominal pain and diarrhea. He had CT imaging concerning for colitis. An infectious workup was initiated, but CMV and C diff were negative. Fecal cultures and other stool studies (camoylobacter, viral/fecal cultures) have thus far been negative. Final viral stool culture was pending at discharge. Patient had a sigmoidoscopy on [MASKED] to evaluate CT imaging findings of colitis that was unrevealing. Pain was controlled with oxycodone 5 mg q6h prn pain and dicyclomine 20mg QID. Discharged on dicyclomine only. Since no infectious etiology was determined, it was felt the patient had a viral gastroenteritis that lead to post-infectious IBS causing on-going abdominal pain, diarrhea. It was recommended to try [MASKED] as an over the counter medication for further symptom control and follow up with outpatient providers. #Chest pain: Pt presented with severe upper chest pain x2d that was squeezing and non-radiating, and worse with exertion. His EKG showed new T wave inversions in lateral leads but his troponins were negative. ECHO was without wall motion abnormalities or pericardial effusion. Chest pain seemed to be related to his abdominal pain which was greatest in his epigastric region. Patient was continued on his home anti-inflammatory meds (ASA 650 BID, colchicine, oxycodone) during this hospitalization for chronic pericarditis. Chest pain was improved by time of discharge. Follow up appointment with cardiology was made prior to discharge. #COPD: Patient reports dyspnea and orthopnea greater than baseline on admission. He was not taking his home meds (albuterol, salmeterol), but these were restarted during this hospitalization. CXR was negative for acute intrathoracic abnormalities. SOB resolved and no further work up was performed. ============== CHRONIC ISSUES ============== #PBC S/P OLT WITH CMV+ DONOR C/B CELLULAR REJECTION, HEMORRHAGIC PERICARDITIS, RECURRENT PERICARDITIS: LFTs remained normal throughout the admission. Patient reported compliance with his tacrolimus, prednisone. Tacrolimus levels were monitored daily. His dosing was decreased to tacrolimus 1mg Q12hrs from 1.5mg Q12hrs. He was discharged to follow up with his hepatologist and re-check tacrolimus levels as an outpatient. #THROMBOCYTOPENIA: Chronic thrombocytopenia likely due to liver disease or immunosuppression. Stable in comparison to prior labs. CBC was trended daily. #BIPOLAR DISORDER: Patient was recently off of Abilify, Symptoms were monitored as inpatient and patient mental status remained stable. #GERD: Known GERD possibly contributing to epigastric abdominal pain. Continued on home omeprazole 40mg BID and home ranitidine 150mg qHS. #CHRONIC NEUROPATHIC PAIN: Patient noted that he has been having increased neuropathy in hands bilaterally. Continued on home gabapentin 600mg BID without exacerbation or changes in neuropathic sx. ======================= TRANSITIONAL ISSUES: ======================= -Tacrolimus changed to 1 mg BID; check levels at next appointment -Follow-up final viral stool studies. -Follow-up biopsies from colonoscopy -Follow-up cardiology appointment as scheduled above Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Colchicine 0.6 mg PO BID 2. Gabapentin 600 mg PO BID 3. Omeprazole 40 mg PO BID 4. Ondansetron 4 mg PO Q8H:PRN nausea 5. PredniSONE 5 mg PO DAILY 6. Ranitidine 150 mg PO QHS 7. Tacrolimus 1.5 mg PO QAM 8. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain 9. Aspirin 650 mg PO BID 10. Tacrolimus 1 mg PO QPM Discharge Medications: 1. DICYCLOMine 20 mg PO TID abdominal pain RX *dicyclomine 20 mg 1 tablet(s) by mouth TID PRN Disp #*30 Tablet Refills:*0 2. IBgard (peppermint oil) 90 mg oral TID:PRN abdominal pain RX *peppermint oil [[MASKED]] 90 mg 1 capsule(s) by mouth TID PRN Disp #*48 Capsule Refills:*0 3. Aspirin 650 mg PO BID 4. Colchicine 0.6 mg PO BID 5. Gabapentin 600 mg PO BID 6. Omeprazole 40 mg PO BID 7. Ondansetron 4 mg PO Q8H:PRN nausea 8. PredniSONE 5 mg PO DAILY 9. Ranitidine 150 mg PO QHS 10. Tacrolimus 1 mg PO QPM RX *tacrolimus 1 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 11. Tacrolimus 1 mg PO QAM 12. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain Discharge Disposition: Home Discharge Diagnosis: Abdominal pain concerning for colitis Diarrhea Chest pain COPD 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 because you had abdominal pain. We got images of your abdomen that showed you had some mild inflammation in your colon. This was likely due to a viral infection. We controlled your pain with medications. It is important for your to follow-up with your PCP and Dr. [MASKED]. There are biopsy results pending from the colonoscopy that you will discuss with Dr. [MASKED]. We have given you a prescription for dicyclomine to help your abdominal pain. There is also a form of peppermint oil called "IBgard" that you can buy over the counter to help with your pain. Your pain should improve with time. Avoid dairy products and eat a bland diet. Lastly, we decreased the dose of your tacrolimus to 1 mg twice daily. It was a pleasure taking care of you. Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "N179", "D696", "J449", "I2510", "Z86718", "Z87891", "K219" ]
[ "K529: Noninfective gastroenteritis and colitis, unspecified", "N179: Acute kidney failure, unspecified", "Z944: Liver transplant status", "D696: Thrombocytopenia, unspecified", "J449: Chronic obstructive pulmonary disease, unspecified", "F319: Bipolar disorder, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z86718: Personal history of other venous thrombosis and embolism", "Z87891: Personal history of nicotine dependence", "Z8249: Family history of ischemic heart disease and other diseases of the circulatory system", "K219: Gastro-esophageal reflux disease without esophagitis", "R079: Chest pain, unspecified" ]
19,992,875
24,912,961
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / rifampin / Lamictal / lorazepam / risperidone / mushrooms / propofol Attending: ___. Chief Complaint: Weakness Major Surgical or Invasive Procedure: Endoscopy ___ colonoscopy ___ History of Present Illness: Patient is a ___ male with a past medical history significant for liver transplant in ___ for PBC, hemorrhagic pericarditis in ___ status post pericardial window, MI x2 in ___, IBS versus Crohn's, osteoporosis with multiple pathological fractures presenting to the emergency department with generalized weakness and found to have an ___. Patient had a colonoscopy performed approximately 2 weeks ago. At this time the patient did receive propofol. Per review of records, it seems that the patient became hypoxic and the colonoscopy was not performed. Upon awakening, the patient noted some chest pain and shortness of breath. For this the patient was taken to ___. He was observed for 1 day from the fifth to the sixth of this month. At that time, the patient's creatinine was noted to be 1.6. The patient was discharged in stable condition. Patient states that today he developed generalized weakness. He does not note any focal weakness. The patient describes dizziness upon standing up quickly. This dizziness is not related to rapid movements of the head. The patient does not have dizziness here in the emergency department. The patient notes that he has not been eating or drinking well for the past 2 weeks and that he has had some diarrhea over the past two weeks. The patient does not note any new cough or any urinary changes. He does have some nausea but no vomiting. The patient has some chills but no fever. Patient does not have any chest pain. He does describe some shortness of breath. Patient presented to an outside hospital where he was noted to have an increase in his creatinine to 2.0. Patient was transferred here for further workup given this was where he had his liver transplant. Patient presents to us in no acute distress. He states that he has been compliant with all of his medications. He is on immunosuppression at this time consisting of tacrolimus and prednisone. Past Medical History: - attention deficit hyperactivity disorder - bipolar disorder - hemorrhoids - history of alcohol abuse - history of deep vein thrombosis in ___ - history of hemorrhagic pericarditis complicated by cardiac tamponade status post pericardial window in ___, recurrent pericarditis in ___ - history of neutropenia complicated by neutropenic fever - history of positive tuberculin skin test status post INH - hyperlipidemia - osteoporosis - primary biliary cirrhosis status post orthotopic liver transplant - PULMONARY NODULE - CHRONIC OBSTRUCTIVE PULMONARY DISEASE - ALTERNATING CONSTIPATION/DIARRHEA, ?IBS vs chrons - HISTORY OF CAD W/ MI x2 in ___ - T1 COMPRESSION FRACTURE, T6 BURST FRACTURE Social History: ___ Family History: Noncontributory to the patients current admission, Father passed away from head and neck cancer Physical Exam: Admission Exam: ================== VITALS: Reviewed in OMR ___: Weight: 172.2 GEN: Alert, cooperative, no distress, appears stated age HENT: NC/AT, MMM. Nares patent, no drainage or sinus tenderness. no teeth, and normal gums normal. EYES: PERRL, EOM intact, conjunctivae clear, no scleral icterus. NECK: No cervical lymphadenopathy. No JVD, Neck supple, symmetrical, trachea midline. LUNG: CTA ___, good air movement, no accessory muscle use HEART: RRR, Normal S1/S2, No M/R/G BACK: Symmetric, no curvature. ROM normal. No CVA tenderness. ABD: Soft, non-tender, non-distended; nl bowel sounds; midline well healed scar, no rebound or guarding, no organomegaly GU: Not examined EXTRM: Extremities warm, no edema, tender to palpation over the left shin, no cyanosis, positive ___ pulses bilaterally SKIN: Skin color and temperature, appropriate. No rashes or lesions NEUR: CN II-XII intact grossly. Moving all extremities, strength, sensation equal and intact throughout. PSYC: Mood and affect appropriate Discharge Exam: ================ Gen: NAD HENT: NC/AT, sclerae anicteric, normal conjunctivae, oropharynx clear, MMM LUNG: CTAB, no increased work of breathing HEART: RRR, normal S1/S2, no m/r/g ABD: Soft, non-tender, non-distended EXTRM: Warm, DP pulses 2+ bilaterally, no edema SKIN: Well-healed scar along upper spine, well-healed scar over RUQ of abdomen NEUR: AOx3 Pertinent Results: Admission labs: ================== ___ 11:15PM BLOOD WBC-2.8* RBC-4.67 Hgb-10.8* Hct-36.8* MCV-79* MCH-23.1* MCHC-29.3* RDW-17.4* RDWSD-49.3* Plt ___ ___ 11:15PM BLOOD Neuts-36.2 ___ Monos-15.2* Eos-5.1 Baso-2.2* Im ___ AbsNeut-1.00* AbsLymp-1.11* AbsMono-0.42 AbsEos-0.14 AbsBaso-0.06 ___ 11:15PM BLOOD Plt ___ ___ 11:15PM BLOOD Glucose-87 UreaN-15 Creat-1.7* Na-142 K-4.3 Cl-109* HCO3-24 AnGap-9* ___ 11:15PM BLOOD ALT-20 AST-24 CK(CPK)-33* AlkPhos-131* TotBili-0.3 ___ 11:15PM BLOOD Lipase-19 ___ 11:15PM BLOOD cTropnT-<0.01 ___ 06:15PM BLOOD cTropnT-<0.01 ___ 11:15PM BLOOD Albumin-3.8 Calcium-8.6 Phos-3.5 Mg-1.8 ___ 04:27AM BLOOD calTIBC-283 VitB12-440 Folate-8 Hapto-47 Ferritn-23* TRF-218 ___ 11:15PM BLOOD Osmolal-283 ___ 06:13AM BLOOD TSH-2.6 ___ 06:13AM BLOOD Cortsol-<0.3* ___ 05:20PM BLOOD Cortsol-0.5* ___ 07:45PM BLOOD Cortsol-0.8* ___ 09:38AM BLOOD tacroFK-2.9* Key labs: =================== ___ 04:27AM BLOOD Ret Aut-2.2* Abs Ret-0.09 ___ 05:20PM BLOOD Cortsol-0.5* ___ 07:45PM BLOOD Cortsol-0.8* ___ 04:36AM BLOOD tacroFK-3.3* ___ 11:23AM BLOOD CMV VL-DETECTED, ___ 05:31AM BLOOD CMV VL-DETECTED, ___ 07:45PM BLOOD ALDOSTERONE-Test ___ 05:20PM BLOOD ALDOSTERONE-Test ___ 05:20PM BLOOD ACTH - FROZEN-Test Discharge labs: ====================== ___ 04:36AM BLOOD WBC-3.6* RBC-4.32* Hgb-9.8* Hct-33.0* MCV-76* MCH-22.7* MCHC-29.7* RDW-17.8* RDWSD-48.1* Plt Ct-95* ___ 05:31AM BLOOD Neuts-44.3 ___ Monos-12.9 Eos-1.2 Baso-1.6* Im ___ AbsNeut-1.13* AbsLymp-1.00* AbsMono-0.33 AbsEos-0.03* AbsBaso-0.04 ___ 04:36AM BLOOD Plt Ct-95* ___ 04:36AM BLOOD Glucose-106* UreaN-13 Creat-1.4* Na-138 K-4.4 Cl-107 HCO3-21* AnGap-10 ___ 05:09AM BLOOD ALT-18 AST-21 AlkPhos-109 TotBili-0.4 ___ 04:36AM BLOOD Calcium-9.2 Phos-3.2 Mg-1.9 Imaging: ==================== ___ Dupplex abdominal Doppler 1. Patent hepatic vasculature with appropriate waveforms. Please note that the left hepatic artery was not able to be visualized secondary to poor acoustic windows and patient breathing. 2. Splenomegaly. ___ TTE Prominent epicardial fat without clear pericardial effusion. Mild global right ventricular hypokinesis. Low normal global left ventricular systolic function. ___ EGD Ring in the distal esophagus Normal mucosa in the whole stomach normal mucosa in the duodenum ___ Colonoscopy High residue material and unable to visualize adequately Normal as far as visualized. Not adequate for screening purposes. Terminal ileum was not intubated due to patient discomfort Path: ===================== ___ GI mucosal biopsy 1. Terminal ileum: Terminal ileal mucosa, within normal limits. 2. Colon: Colonic mucosa with patchy moderately active colitis (multiple neutrophilic crypt abscesses), focal basal crypt regeneration, and scattered prominent basal apoptotic debris; no definitive evidence of chronic colitis, granulomas, or viral inclusions/cytopathic effect are identified. Immunostain for cytomegalovirus is in progress and the results will be reported in a revised report. Note: The colonic mucosal biopsy findings are favored to represent an acute infectious colitis versus a drug-induced change. Correlation with clinical and laboratory findings is needed. ___ GI biopsy 1. Esophagus, biopsy: - Squamous mucosa with active erosive esophagitis. - Numerous Herpes simplex virus viral cytopathic changes (confirmed by HSV I/II immunostain) . 2. Stomach, biopsy: - Antral and corpus mucosa within normal limits. ___ GI Biopsy 1. Duodenum, biopsy: -Duodenal mucosa with crypt regeneration (non-specific), otherwise within normal limits. -CMV immunostain highlights rare positive cells in the lamina propria (see note). Note: The clinical significance of this finding is uncertain, since no significant duodenitis is identified. 2. Random colon, biopsy: -Colonic mucosa within normal limits. -Immunohistochemical stain for CMV is negative with adequate controls. Brief Hospital Course: PATIENT SUMMARY ================= Patient is a ___ male with a past medical history significant for liver transplant in ___ for PBC, hemorrhagic pericarditis in ___ status post pericardial window, MI x2 in ___, IBS versus Crohn's, osteoporosis with multiple pathological fractures who presented to the emergency department with generalized weakness and was found to have an ___. Diagnosed with secondary adrenal insufficiency and CMV. Treated for both. Colonoscopy and EGD unrevealing. Transitional Issues =================== [] Prednisone course: 7.5mg for three days (___) then 5mg daily [] Will need f/u CMV viral titers until negative [] discharge tacro dosing of 1 mg BID discharge tacro level of 3.3 [] Patient ASA reduced to 325mg daily from BID dosing and continue colchicine 0.6 bid due to his history of pericarditis. Will need follow up arranged with Dr. ___ likely discontinuation or downtitration of medications. Unable to reach via E-mail ============== Active Issues ============== #Weakness #Anemia #Orthostasis #Exertional dyspnea Patient presented with recent weakness, exertional dyspnea, with initial differential including worsening anemia, dehydration, infectious process, cardiac etiology, and adrenal insufficiency. Patient has baseline pancytopenia (see below) but with an acute drop in Hgb shortly after admission from 11 to 9.5, and from recent baseline ~13 in ___. Remained hemodynamically stable. No overt bleeding, melena, or hematochezia. EGD and colonoscopy on ___, revealing no inflammation or source of bleeding. Alternating diarrhea and constipation chronic ("since forever") per patient, with no acute change.. CXR and abdominal US unremarkable (aside from splenomegaly on US). AM cortisol <0.3, with further testing consistent with adrenal insufficiency that may be have contributed to overall weakness. #CMV Viremia #CMV Duodenal infection Patient presents with the symptoms, discussed below, raising concern for CMV infection. CMV titer returned as detectable, but below 1.7 on two separate titers which does not meet criteria for induction therapy. Endoscopic biopsy of the duodenum revealed positive staining for CMV without evidence of inflammation, which is of unclear significance. Given the overall clinical picture discussed below, in addition to the CMV viral load and biopsy findings, valganciclovir treatment was initiated with 450mg bid (dose reduced for renal function) for 28 days as is recommended for treatment. #Secondary Adrenal insufficiency Low morning cortisol, low ACTH and cosyntropin stimulation test results obtained when he received corticosteroids on the day of the stim test, and values were also obtained 2 hours after adminisration of cosyntropin, making these less reliable. However it seems very likely that he is adrenally insufficient. We ultimately increased his prednisone dosing to 10mg daily while treating for CMV with slower taper to 7.5mg x3 days and back to 5mg daily given worsening nausea with quick taper. ___ Patient admitted with ___, pre-renal in setting of poor PO intake and diarrhea. Peaked at 2.0, subsequently downtrended to 1.4. Baseline appeared to range 0.6 to 0.9. No major electrolyte abnormalities. Per Dr. ___ for discharge with current Cr elevation with follow up outpatient. #PBC s/p DDLT #immunosuppression #Leukopenia/pancytopenia Patient reported he has had pancytopenia since his liver transplant ___ years ago. This is likely immunosuppressive effect from his Tacrolimus resulting in chronic iatrogenic myelosuppression. He had a workup for this including BM-biopsy in ___ iso CMV viremia, which was non-revealing. CMV viral load this admission was Detected, discussed above. Acute on chronic anemia was further evaluated as above. #Hx pericarditis with loculated pericardial effusion Patient has a history of hemorrhagic pericarditis c/b tamponade s/p pericardial window ___ and recurrent pericarditis ___ and moderate pericardial effusion seen on TTE on ___. The patient has no new chest pain or pressure symptoms and does not endorse any tachycardia or palpitations. Repeat TTE showed no effusion. Patient was continued on colchicine and ASA though dose of ASA reduced to 325mg daily for GI protection as unclear why such high dose has been maintained and unable to reach outpatient providers. ============== Chronic Issues ============== #Osteoporosis Per OMR review, has had since before his liver transplant so likely not related to prednisone. #Bipolar Continued home bupropion. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 325 mg PO BID 2. Atorvastatin 10 mg PO QPM 3. BuPROPion (Sustained Release) 300 mg PO QAM 4. Colchicine 0.6 mg PO BID 5. DICYCLOMine 20 mg PO TID:PRN diarrhea 6. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line 7. Gabapentin 800 mg PO BID 8. Pantoprazole 40 mg PO Q12H 9. PredniSONE 5 mg PO DAILY 10. Ranitidine 150 mg PO DAILY 11. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever 12. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate 13. Tacrolimus 0.5 mg PO QPM 14. Tacrolimus 1 mg PO QAM 15. Naloxone Nasal Spray 4 mg IH ONCE MR1 Discharge Medications: 1. Senna 8.6 mg PO BID RX *sennosides [senna] 8.6 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 2. ValGANCIclovir 450 mg PO Q12H Duration: 28 Days RX *valganciclovir 450 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 3. Aspirin 325 mg PO DAILY 4. Pantoprazole 40 mg PO Q24H 5. PredniSONE 7.5 mg PO DAILY RX *prednisone 5 mg 1.5 tablet(s) by mouth once a day for 3 days then one tablet daily thereafter Disp #*30 Tablet Refills:*0 6. Tacrolimus 1 mg PO QAM RX *tacrolimus 1 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 7. Tacrolimus 1 mg PO QPM 8. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever 9. Atorvastatin 10 mg PO QPM 10. BuPROPion (Sustained Release) 300 mg PO QAM 11. Colchicine 0.6 mg PO BID 12. DICYCLOMine 20 mg PO TID:PRN diarrhea 13. Naloxone Nasal Spray 4 mg IH ONCE MR1 14. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate 15. Ranitidine 150 mg PO DAILY 16. HELD- Gabapentin 800 mg PO BID This medication was held. Do not restart Gabapentin until seen by PCP ___: Home Discharge Diagnosis: #Adrenal Insufficiency #Anemia #CMV viremia #CMV duodenitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking part in your care here at ___! Why was I admitted to the hospital? - You were admitted for weakness What was done for me while I was in the hospital? We found that your adrenal glands were not working very well and we gave you steroid medication We performed an endoscopy and colonoscopy to look for evidence of inflammation in you GI tract We found that you are infected by a virus that can cause GI symptoms and started you on the appropriate treatment What should I do when I leave the hospital? -Please take all of your medications and keep all of your appointments - Dr. ___ will contact you with an appointment - The Endocrinology department is working on scheduling an earlier appointment for you as well. *****Prednisone course**** 7.5mg for three days (___) then 5mg daily Sincerely, Your ___ Care Team Followup Instructions: ___
[ "N179", "D61811", "B258", "Z944", "E273", "K625", "M810", "I252", "I2510", "E785", "F319", "E860", "R197", "J449", "T451X5A", "T380X5A", "Z87891", "Z981", "Z86718", "Z79899" ]
Allergies: Penicillins / rifampin / Lamictal / lorazepam / risperidone / mushrooms / propofol Chief Complaint: Weakness Major Surgical or Invasive Procedure: Endoscopy [MASKED] colonoscopy [MASKED] History of Present Illness: Patient is a [MASKED] male with a past medical history significant for liver transplant in [MASKED] for PBC, hemorrhagic pericarditis in [MASKED] status post pericardial window, MI x2 in [MASKED], IBS versus Crohn's, osteoporosis with multiple pathological fractures presenting to the emergency department with generalized weakness and found to have an [MASKED]. Patient had a colonoscopy performed approximately 2 weeks ago. At this time the patient did receive propofol. Per review of records, it seems that the patient became hypoxic and the colonoscopy was not performed. Upon awakening, the patient noted some chest pain and shortness of breath. For this the patient was taken to [MASKED]. He was observed for 1 day from the fifth to the sixth of this month. At that time, the patient's creatinine was noted to be 1.6. The patient was discharged in stable condition. Patient states that today he developed generalized weakness. He does not note any focal weakness. The patient describes dizziness upon standing up quickly. This dizziness is not related to rapid movements of the head. The patient does not have dizziness here in the emergency department. The patient notes that he has not been eating or drinking well for the past 2 weeks and that he has had some diarrhea over the past two weeks. The patient does not note any new cough or any urinary changes. He does have some nausea but no vomiting. The patient has some chills but no fever. Patient does not have any chest pain. He does describe some shortness of breath. Patient presented to an outside hospital where he was noted to have an increase in his creatinine to 2.0. Patient was transferred here for further workup given this was where he had his liver transplant. Patient presents to us in no acute distress. He states that he has been compliant with all of his medications. He is on immunosuppression at this time consisting of tacrolimus and prednisone. Past Medical History: - attention deficit hyperactivity disorder - bipolar disorder - hemorrhoids - history of alcohol abuse - history of deep vein thrombosis in [MASKED] - history of hemorrhagic pericarditis complicated by cardiac tamponade status post pericardial window in [MASKED], recurrent pericarditis in [MASKED] - history of neutropenia complicated by neutropenic fever - history of positive tuberculin skin test status post INH - hyperlipidemia - osteoporosis - primary biliary cirrhosis status post orthotopic liver transplant - PULMONARY NODULE - CHRONIC OBSTRUCTIVE PULMONARY DISEASE - ALTERNATING CONSTIPATION/DIARRHEA, ?IBS vs chrons - HISTORY OF CAD W/ MI x2 in [MASKED] - T1 COMPRESSION FRACTURE, T6 BURST FRACTURE Social History: [MASKED] Family History: Noncontributory to the patients current admission, Father passed away from head and neck cancer Physical Exam: Admission Exam: ================== VITALS: Reviewed in OMR [MASKED]: Weight: 172.2 GEN: Alert, cooperative, no distress, appears stated age HENT: NC/AT, MMM. Nares patent, no drainage or sinus tenderness. no teeth, and normal gums normal. EYES: PERRL, EOM intact, conjunctivae clear, no scleral icterus. NECK: No cervical lymphadenopathy. No JVD, Neck supple, symmetrical, trachea midline. LUNG: CTA [MASKED], good air movement, no accessory muscle use HEART: RRR, Normal S1/S2, No M/R/G BACK: Symmetric, no curvature. ROM normal. No CVA tenderness. ABD: Soft, non-tender, non-distended; nl bowel sounds; midline well healed scar, no rebound or guarding, no organomegaly GU: Not examined EXTRM: Extremities warm, no edema, tender to palpation over the left shin, no cyanosis, positive [MASKED] pulses bilaterally SKIN: Skin color and temperature, appropriate. No rashes or lesions NEUR: CN II-XII intact grossly. Moving all extremities, strength, sensation equal and intact throughout. PSYC: Mood and affect appropriate Discharge Exam: ================ Gen: NAD HENT: NC/AT, sclerae anicteric, normal conjunctivae, oropharynx clear, MMM LUNG: CTAB, no increased work of breathing HEART: RRR, normal S1/S2, no m/r/g ABD: Soft, non-tender, non-distended EXTRM: Warm, DP pulses 2+ bilaterally, no edema SKIN: Well-healed scar along upper spine, well-healed scar over RUQ of abdomen NEUR: AOx3 Pertinent Results: Admission labs: ================== [MASKED] 11:15PM BLOOD WBC-2.8* RBC-4.67 Hgb-10.8* Hct-36.8* MCV-79* MCH-23.1* MCHC-29.3* RDW-17.4* RDWSD-49.3* Plt [MASKED] [MASKED] 11:15PM BLOOD Neuts-36.2 [MASKED] Monos-15.2* Eos-5.1 Baso-2.2* Im [MASKED] AbsNeut-1.00* AbsLymp-1.11* AbsMono-0.42 AbsEos-0.14 AbsBaso-0.06 [MASKED] 11:15PM BLOOD Plt [MASKED] [MASKED] 11:15PM BLOOD Glucose-87 UreaN-15 Creat-1.7* Na-142 K-4.3 Cl-109* HCO3-24 AnGap-9* [MASKED] 11:15PM BLOOD ALT-20 AST-24 CK(CPK)-33* AlkPhos-131* TotBili-0.3 [MASKED] 11:15PM BLOOD Lipase-19 [MASKED] 11:15PM BLOOD cTropnT-<0.01 [MASKED] 06:15PM BLOOD cTropnT-<0.01 [MASKED] 11:15PM BLOOD Albumin-3.8 Calcium-8.6 Phos-3.5 Mg-1.8 [MASKED] 04:27AM BLOOD calTIBC-283 VitB12-440 Folate-8 Hapto-47 Ferritn-23* TRF-218 [MASKED] 11:15PM BLOOD Osmolal-283 [MASKED] 06:13AM BLOOD TSH-2.6 [MASKED] 06:13AM BLOOD Cortsol-<0.3* [MASKED] 05:20PM BLOOD Cortsol-0.5* [MASKED] 07:45PM BLOOD Cortsol-0.8* [MASKED] 09:38AM BLOOD tacroFK-2.9* Key labs: =================== [MASKED] 04:27AM BLOOD Ret Aut-2.2* Abs Ret-0.09 [MASKED] 05:20PM BLOOD Cortsol-0.5* [MASKED] 07:45PM BLOOD Cortsol-0.8* [MASKED] 04:36AM BLOOD tacroFK-3.3* [MASKED] 11:23AM BLOOD CMV VL-DETECTED, [MASKED] 05:31AM BLOOD CMV VL-DETECTED, [MASKED] 07:45PM BLOOD ALDOSTERONE-Test [MASKED] 05:20PM BLOOD ALDOSTERONE-Test [MASKED] 05:20PM BLOOD ACTH - FROZEN-Test Discharge labs: ====================== [MASKED] 04:36AM BLOOD WBC-3.6* RBC-4.32* Hgb-9.8* Hct-33.0* MCV-76* MCH-22.7* MCHC-29.7* RDW-17.8* RDWSD-48.1* Plt Ct-95* [MASKED] 05:31AM BLOOD Neuts-44.3 [MASKED] Monos-12.9 Eos-1.2 Baso-1.6* Im [MASKED] AbsNeut-1.13* AbsLymp-1.00* AbsMono-0.33 AbsEos-0.03* AbsBaso-0.04 [MASKED] 04:36AM BLOOD Plt Ct-95* [MASKED] 04:36AM BLOOD Glucose-106* UreaN-13 Creat-1.4* Na-138 K-4.4 Cl-107 HCO3-21* AnGap-10 [MASKED] 05:09AM BLOOD ALT-18 AST-21 AlkPhos-109 TotBili-0.4 [MASKED] 04:36AM BLOOD Calcium-9.2 Phos-3.2 Mg-1.9 Imaging: ==================== [MASKED] Dupplex abdominal Doppler 1. Patent hepatic vasculature with appropriate waveforms. Please note that the left hepatic artery was not able to be visualized secondary to poor acoustic windows and patient breathing. 2. Splenomegaly. [MASKED] TTE Prominent epicardial fat without clear pericardial effusion. Mild global right ventricular hypokinesis. Low normal global left ventricular systolic function. [MASKED] EGD Ring in the distal esophagus Normal mucosa in the whole stomach normal mucosa in the duodenum [MASKED] Colonoscopy High residue material and unable to visualize adequately Normal as far as visualized. Not adequate for screening purposes. Terminal ileum was not intubated due to patient discomfort Path: ===================== [MASKED] GI mucosal biopsy 1. Terminal ileum: Terminal ileal mucosa, within normal limits. 2. Colon: Colonic mucosa with patchy moderately active colitis (multiple neutrophilic crypt abscesses), focal basal crypt regeneration, and scattered prominent basal apoptotic debris; no definitive evidence of chronic colitis, granulomas, or viral inclusions/cytopathic effect are identified. Immunostain for cytomegalovirus is in progress and the results will be reported in a revised report. Note: The colonic mucosal biopsy findings are favored to represent an acute infectious colitis versus a drug-induced change. Correlation with clinical and laboratory findings is needed. [MASKED] GI biopsy 1. Esophagus, biopsy: - Squamous mucosa with active erosive esophagitis. - Numerous Herpes simplex virus viral cytopathic changes (confirmed by HSV I/II immunostain) . 2. Stomach, biopsy: - Antral and corpus mucosa within normal limits. [MASKED] GI Biopsy 1. Duodenum, biopsy: -Duodenal mucosa with crypt regeneration (non-specific), otherwise within normal limits. -CMV immunostain highlights rare positive cells in the lamina propria (see note). Note: The clinical significance of this finding is uncertain, since no significant duodenitis is identified. 2. Random colon, biopsy: -Colonic mucosa within normal limits. -Immunohistochemical stain for CMV is negative with adequate controls. Brief Hospital Course: PATIENT SUMMARY ================= Patient is a [MASKED] male with a past medical history significant for liver transplant in [MASKED] for PBC, hemorrhagic pericarditis in [MASKED] status post pericardial window, MI x2 in [MASKED], IBS versus Crohn's, osteoporosis with multiple pathological fractures who presented to the emergency department with generalized weakness and was found to have an [MASKED]. Diagnosed with secondary adrenal insufficiency and CMV. Treated for both. Colonoscopy and EGD unrevealing. Transitional Issues =================== [] Prednisone course: 7.5mg for three days ([MASKED]) then 5mg daily [] Will need f/u CMV viral titers until negative [] discharge tacro dosing of 1 mg BID discharge tacro level of 3.3 [] Patient ASA reduced to 325mg daily from BID dosing and continue colchicine 0.6 bid due to his history of pericarditis. Will need follow up arranged with Dr. [MASKED] likely discontinuation or downtitration of medications. Unable to reach via E-mail ============== Active Issues ============== #Weakness #Anemia #Orthostasis #Exertional dyspnea Patient presented with recent weakness, exertional dyspnea, with initial differential including worsening anemia, dehydration, infectious process, cardiac etiology, and adrenal insufficiency. Patient has baseline pancytopenia (see below) but with an acute drop in Hgb shortly after admission from 11 to 9.5, and from recent baseline ~13 in [MASKED]. Remained hemodynamically stable. No overt bleeding, melena, or hematochezia. EGD and colonoscopy on [MASKED], revealing no inflammation or source of bleeding. Alternating diarrhea and constipation chronic ("since forever") per patient, with no acute change.. CXR and abdominal US unremarkable (aside from splenomegaly on US). AM cortisol <0.3, with further testing consistent with adrenal insufficiency that may be have contributed to overall weakness. #CMV Viremia #CMV Duodenal infection Patient presents with the symptoms, discussed below, raising concern for CMV infection. CMV titer returned as detectable, but below 1.7 on two separate titers which does not meet criteria for induction therapy. Endoscopic biopsy of the duodenum revealed positive staining for CMV without evidence of inflammation, which is of unclear significance. Given the overall clinical picture discussed below, in addition to the CMV viral load and biopsy findings, valganciclovir treatment was initiated with 450mg bid (dose reduced for renal function) for 28 days as is recommended for treatment. #Secondary Adrenal insufficiency Low morning cortisol, low ACTH and cosyntropin stimulation test results obtained when he received corticosteroids on the day of the stim test, and values were also obtained 2 hours after adminisration of cosyntropin, making these less reliable. However it seems very likely that he is adrenally insufficient. We ultimately increased his prednisone dosing to 10mg daily while treating for CMV with slower taper to 7.5mg x3 days and back to 5mg daily given worsening nausea with quick taper. [MASKED] Patient admitted with [MASKED], pre-renal in setting of poor PO intake and diarrhea. Peaked at 2.0, subsequently downtrended to 1.4. Baseline appeared to range 0.6 to 0.9. No major electrolyte abnormalities. Per Dr. [MASKED] for discharge with current Cr elevation with follow up outpatient. #PBC s/p DDLT #immunosuppression #Leukopenia/pancytopenia Patient reported he has had pancytopenia since his liver transplant [MASKED] years ago. This is likely immunosuppressive effect from his Tacrolimus resulting in chronic iatrogenic myelosuppression. He had a workup for this including BM-biopsy in [MASKED] iso CMV viremia, which was non-revealing. CMV viral load this admission was Detected, discussed above. Acute on chronic anemia was further evaluated as above. #Hx pericarditis with loculated pericardial effusion Patient has a history of hemorrhagic pericarditis c/b tamponade s/p pericardial window [MASKED] and recurrent pericarditis [MASKED] and moderate pericardial effusion seen on TTE on [MASKED]. The patient has no new chest pain or pressure symptoms and does not endorse any tachycardia or palpitations. Repeat TTE showed no effusion. Patient was continued on colchicine and ASA though dose of ASA reduced to 325mg daily for GI protection as unclear why such high dose has been maintained and unable to reach outpatient providers. ============== Chronic Issues ============== #Osteoporosis Per OMR review, has had since before his liver transplant so likely not related to prednisone. #Bipolar Continued home bupropion. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 325 mg PO BID 2. Atorvastatin 10 mg PO QPM 3. BuPROPion (Sustained Release) 300 mg PO QAM 4. Colchicine 0.6 mg PO BID 5. DICYCLOMine 20 mg PO TID:PRN diarrhea 6. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line 7. Gabapentin 800 mg PO BID 8. Pantoprazole 40 mg PO Q12H 9. PredniSONE 5 mg PO DAILY 10. Ranitidine 150 mg PO DAILY 11. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever 12. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate 13. Tacrolimus 0.5 mg PO QPM 14. Tacrolimus 1 mg PO QAM 15. Naloxone Nasal Spray 4 mg IH ONCE MR1 Discharge Medications: 1. Senna 8.6 mg PO BID RX *sennosides [senna] 8.6 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 2. ValGANCIclovir 450 mg PO Q12H Duration: 28 Days RX *valganciclovir 450 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 3. Aspirin 325 mg PO DAILY 4. Pantoprazole 40 mg PO Q24H 5. PredniSONE 7.5 mg PO DAILY RX *prednisone 5 mg 1.5 tablet(s) by mouth once a day for 3 days then one tablet daily thereafter Disp #*30 Tablet Refills:*0 6. Tacrolimus 1 mg PO QAM RX *tacrolimus 1 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 7. Tacrolimus 1 mg PO QPM 8. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever 9. Atorvastatin 10 mg PO QPM 10. BuPROPion (Sustained Release) 300 mg PO QAM 11. Colchicine 0.6 mg PO BID 12. DICYCLOMine 20 mg PO TID:PRN diarrhea 13. Naloxone Nasal Spray 4 mg IH ONCE MR1 14. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate 15. Ranitidine 150 mg PO DAILY 16. HELD- Gabapentin 800 mg PO BID This medication was held. Do not restart Gabapentin until seen by PCP [MASKED]: Home Discharge Diagnosis: #Adrenal Insufficiency #Anemia #CMV viremia #CMV duodenitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], It was a pleasure taking part in your care here at [MASKED]! Why was I admitted to the hospital? - You were admitted for weakness What was done for me while I was in the hospital? We found that your adrenal glands were not working very well and we gave you steroid medication We performed an endoscopy and colonoscopy to look for evidence of inflammation in you GI tract We found that you are infected by a virus that can cause GI symptoms and started you on the appropriate treatment What should I do when I leave the hospital? -Please take all of your medications and keep all of your appointments - Dr. [MASKED] will contact you with an appointment - The Endocrinology department is working on scheduling an earlier appointment for you as well. *****Prednisone course**** 7.5mg for three days ([MASKED]) then 5mg daily Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "N179", "I252", "I2510", "E785", "J449", "Z87891", "Z86718" ]
[ "N179: Acute kidney failure, unspecified", "D61811: Other drug-induced pancytopenia", "B258: Other cytomegaloviral diseases", "Z944: Liver transplant status", "E273: Drug-induced adrenocortical insufficiency", "K625: Hemorrhage of anus and rectum", "M810: Age-related osteoporosis without current pathological fracture", "I252: Old myocardial infarction", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E785: Hyperlipidemia, unspecified", "F319: Bipolar disorder, unspecified", "E860: Dehydration", "R197: Diarrhea, unspecified", "J449: Chronic obstructive pulmonary disease, unspecified", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "T380X5A: Adverse effect of glucocorticoids and synthetic analogues, initial encounter", "Z87891: Personal history of nicotine dependence", "Z981: Arthrodesis status", "Z86718: Personal history of other venous thrombosis and embolism", "Z79899: Other long term (current) drug therapy" ]
19,992,875
25,704,626
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / rifampin / Lamictal / lorazepam / risperidone / mushrooms Attending: ___ Chief Complaint: Rib pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ h/o idiopathic hemorrhagic pericarditis (___) requiring pericardial window, osteoporosis c/b multiple pathologic fractures, PBC s/p liver transplant (___) on tacro/pred c/b HSV esophagitis (___), presenting now with ongoing positional/inspiratory CP in the setting of sustaining rib fractures 2 weeks ago during a workout. He is a military veteran and 2 weeks ago was doing some physical exercises with a bunch of infantry friends, when during a maneuver where he was pulling himself up by his arms, he felt a pop in his sternum and thereafter experienced severe pain in his chest with movement or deep breaths, but little/none at rest. He went to ___ ED, where he was assured that this was rib fractures and not his heart, and sent home. ___ he re-presented to ___ because his chest pain and associated SOB (again, clarifies that this was exertional but largely because it hurt him to breathe) if anything had gotten a bit worse in the few preceding days. At ___ he was reported to have an ANC of 600 and therefore transferred here to ___ for further workup. Patient denies any fevers or chills, rash, headache, abdominal pain, changes in bowel movement or changes in urination. Normal p.o. intake with no weight loss or night sweats. Past Medical History: - attention deficit hyperactivity disorder - bipolar disorder - hemorrhoids - history of alcohol abuse - history of deep vein thrombosis in ___ - history of hemorrhagic pericarditis complicated by cardiac tamponade status post pericardial window in ___, recurrent pericarditis in ___ - history of neutropenia complicated by neutropenic fever - history of positive tuberculin skin test status post INH - hyperlipidemia - osteoporosis - primary biliary cirrhosis status post orthotopic liver transplant Social History: ___ Family History: Noncontributory Physical Exam: ADMISSION PHYSICAL EXAM: ======================== T 97.4 BP 164 / 114 HR 67 RR 18 SpO2 99% RA Young man resting comfortably in bed, alert/conversing appropriately. Heart regular without murmurs, lungs CTAB, Abdomen soft/ND, legs without edema. MSK: moderate/severe TTP in sternum, L lateral ribcage, one of the cervical vertebra. His sensation and strength is normal and symmetric in upper extremities. DISCHARGE PHYSICAL EXAM: ======================= VS: ___ 0722 Temp: 97.5 PO BP: 150/84 HR: 80 RR: 18 O2 sat: 96% O2 delivery: Ra GENERAL: Pleasant, conversant. HEENT: Normocephalic, atraumatic. PEERL. MMM. Extraocular movements grossly intact. Tender over c4-c7 posteriorly. Tender diffusely to palpation over sternum. CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops. LUNG: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi. ABD: Normal bowel sounds, soft, no hepatomegaly, no splenomegaly. Slightly distended. TTP in epigastrum primarily, and LUQ/RUQ. EXT: Warm, well perfused, no lower extremity edema. PULSES: 1+ ___ & DP pulses NEURO: Alert, oriented, motor and sensory function grossly intact. SKIN: No significant rashes. Pertinent Results: Admission labs: =============== ___ 09:20PM GLUCOSE-86 UREA N-13 CREAT-1.3* SODIUM-140 POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-21* ANION GAP-14 ___ 09:20PM estGFR-Using this ___ 09:20PM ALT(SGPT)-18 AST(SGOT)-27 ALK PHOS-133* TOT BILI-0.5 ___ 09:20PM LIPASE-12 ___ 09:20PM cTropnT-<0.01 ___ 09:20PM ALBUMIN-3.9 IRON-41* ___ 09:20PM calTIBC-333 VIT B12-440 FOLATE-14 FERRITIN-27* TRF-256 ___ 09:20PM WBC-2.1* RBC-4.81 HGB-12.6* HCT-39.1* MCV-81* MCH-26.2 MCHC-32.2 RDW-16.3* RDWSD-47.5* ___ 09:20PM NEUTS-48.6 ___ MONOS-7.9 EOS-1.4 BASOS-1.9* IM ___ AbsNeut-1.04* AbsLymp-0.85* AbsMono-0.17* AbsEos-0.03* AbsBaso-0.04 ___ 09:20PM HOS-AVAILABLE ___ 09:20PM HYPOCHROM-2+* ANISOCYT-1+* POIKILOCY-1+* MACROCYT-NORMAL MICROCYT-1+* POLYCHROM-1+* SPHEROCYT-OCCASIONAL OVALOCYT-1+* SCHISTOCY-OCCASIONAL BURR-1+* TEARDROP-OCCASIONAL ___ 09:20PM PLT COUNT-68* ___ 09:20PM ___ PTT-27.0 ___ ___ 09:20PM RET AUT-2.1* ABS RET-0.10 Discharge Labs: =============== ___:23AM BLOOD WBC-3.1* RBC-5.10 Hgb-13.6* Hct-40.9 MCV-80* MCH-26.7 MCHC-33.3 RDW-16.5* RDWSD-47.5* Plt Ct-84* ___ 07:23AM BLOOD Plt Ct-84* ___ 07:23AM BLOOD Glucose-87 UreaN-11 Creat-1.1 Na-141 K-4.2 Cl-104 HCO3-23 AnGap-14 ___ 07:23AM BLOOD Calcium-9.0 Phos-3.3 Mg-1.9 ___ 07:23AM BLOOD tacroFK-4.2* Imaging: ___ Final Report EXAMINATION: RIB BILAT, W/AP CHEST INDICATION: ___ year old man with chest pain w previous fracture and mechanical cause of pain// eval rib frx TECHNIQUE: Frontal and oblique views of the chest COMPARISON: Chest radiographs between ___ and ___ FINDINGS: The lungs are well expanded. Linear atelectasis in the lower left lung is improved. No focal consolidation. No pleural effusion or pneumothorax. Heart size is normal. The mediastinal silhouette is unremarkable. There are minimally displaced anterolateral right probably fifth through seventh rib fractures. Thoracic spine fusion hardware is noted. IMPRESSION: Minimally displaced anterolateral right probably fifth through seventh rib fractures. CT C-Spine without contrast Final Report EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE INDICATION: ___ year old man with history of previously status post liver transplant ___ years ago, leukopenia, with osteoporosis complicated by several fractures, now presenting with ongoing chest pain in the setting of recent rib fractures from exercising, found to have C-spine tenderness on exam. Please evaluate for cervical spine fractures. TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue and bone algorithm images were generated. Coronal and sagittal reformations were then constructed. DOSE: Acquisition sequence: 1) Spiral Acquisition 5.8 s, 22.7 cm; CTDIvol = 25.1 mGy (Body) DLP = 568.8 mGy-cm. Total DLP (Body) = 569 mGy-cm. COMPARISON: C-spine CT from ___. FINDINGS: Alignment is normal. There is diffuse osseous demineralization. Compression deformities with loss of vertebral body height are noted at C4, C5, C6, and T1, largely unchanged compared to previous study. No acute fractures are identified. There is no evidence of spinal canal or neural foraminal stenosis. There is no prevertebral soft tissue swelling. There is no evidence of infection or neoplasm. Emphysematous changes are noted at the lung apices bilaterally. IMPRESSION: 1. Diffuse bone demineralization with compression deformities at C4, C5, C6 and T1, similar to the previous study. 2. No evidence of acute fractures or traumatic malalignment. ___ Final Report EXAMINATION: CT CHEST W/O CONTRAST INDICATION: ___ year old man with PBC s/p liver transplant ___ yrs ago osteoporosis c/b multiple fractures now p/w chest cervical vertebral pain s/p injury 2 weeks ago probable ___ rib fxs on CXR. Evaluate rib fractures. TECHNIQUE: Multi-detector helical scanning of the chest was performed without intravenous iodinated contrast agent and reconstructed as 5 and 1.25 mm thick axial, 2.5 mm thick coronal and sagittal, and 8 mm MIP axial images. DOSE: Acquisition sequence: 1) Spiral Acquisition 2.6 s, 41.7 cm; CTDIvol = 13.2 mGy (Body) DLP = 550.9 mGy-cm. Total DLP (Body) = 551 mGy-cm. COMPARISON: Rib x-rays ___. Chest CTA ___. CT abdomen and pelvis ___. FINDINGS: NECK, THORACIC INLET, AXILLAE, CHEST WALL: The imaged thyroid is unremarkable. There is no supraclavicular or axillary lymphadenopathy. The esophagus is patulous. UPPER ABDOMEN: The transplant liver demonstrates homogeneous attenuation. Nonobstructing right renal stones measure up to 3 mm, near a focal area of cortical thinning. Moderate pancreatic atrophy. MEDIASTINUM: There is no mediastinal mass or lymphadenopathy. HILA: There is no hilar mass or lymphadenopathy. HEART and PERICARDIUM: Heart size is normal. The thoracic aorta is normal in caliber. There is no pericardial effusion. PLEURA: No pleural effusion or pneumothorax. LUNG: 1. PARENCHYMA: Probable bilateral lower lobe scarring and atelectasis, less likely interstitial disease. Mild, apical predominant paraseptal emphysema. A sub 3 mm right lower lobe pulmonary nodule is not definitively identified on the prior study (302:139), possibly due to differences in technique. No other pulmonary nodules identified. 2. AIRWAYS: The airways are patent to the level of the segmental bronchi bilaterally. 3. VESSELS: Main pulmonary artery diameter is within normal limits. CHEST CAGE: Thoracic spinal fusion hardware is in place. The bones are diffusely osteopenic. A chronic appearing deformity of the right scapula (302:125) appears new since ___. Chronic deformities of the right anterior second through seventh ribs, similar to multiple priors dating back to ___. A compression deformity of the T6 vertebral body is redemonstrated. Redemonstrated manubrial fracture. There is no acute fracture. IMPRESSION: 1. Multiple, chronic right-sided rib fractures, similar in appearance to at least ___. No acute rib fractures identified. 2. Chronic appearing right scapular deformity, new since ___. 3. Stable T6 compression fracture and manubrial fracture. 4. Sub 3 mm right lower lobe pulmonary nodule, not definitively identified on the prior study from ___, possibly due to differences in study technique. No other pulmonary nodules identified. 5. Nonobstructing right renal stones, measuring up to 3 mm. ___ CONCLUSION: The left atrial volume index is normal. There is mild symmetric left ventricular hypertrophy with a normal cavity size. There is normal regional left ventricular systolic function. Overall left ventricular systolic function is normal. Quantitative biplane left ventricular ejection fraction is 53 %. Normal right ventricular cavity size with normal free wall motion. The aortic sinus diameter is normal for gender. The aortic valve leaflets (3) appear structurally normal. There is no aortic valve stenosis. There is no aortic regur gitation. The mitral valve leaflets appear structurally normal with no mitral valve prolapse. There is trivial mitral regur gitation. The tricuspid valve leaflets appear structurally normal. There is trivial tricuspid regurgitation. There is a moderate pericardial effusion. There is increased respiratory variation in transmitral/transtricuspid inflow but no right atrial/right ventricular diastolic collapse. IMPRESSION: 1) Moderate pericardial effusion largely anterior to the right atrium. It appears to be serous and loculated. There appears to be an epicardial fat pat in addition to the pericardial effusion. The pericardial effusion is difficult to be reached by either percutaneous approaches. 2) There is respiratory variation in mitral inflow reaching threshold of hemodynamically significant pericardial pressure elevation. However, there is no RA/RV collapse. RA pressure could not be estimated on this study. There is a septal bounce on this echocardiogram however no clear signs of pericaridal constriction are note Brief Hospital Course: ASSESSMENT & PLAN: ___ h/o idiopathic hemorrhagic pericarditis (___) requiring pericardial window, osteoporosis c/b multiple pathologic fractures, PBC s/p liver transplant (___) on tacro/pred c/b HSV esophagitis (___), admitted for neutropenia, acute kidney injury, and pain management of right rib fractures. ACUTE ISSUES: ============== #Acute kidney injury Admitted with a creatinine of 1.4. Likely a combination of pre-renal in the setting of decreased PO intake due to rib fractures as well as a possible component of tacrolimus toxicity. He initially responded to maintence fluids but then his creatinine returned to 1.4. We then decreased his tacrolimus to 0.5 mg at night and 1 mg in the morning, his creatinine was 1.1 on discharge. #Pancytopenia #Neutropenia Patient reports he has had pancytopenia since his liver transplant ___ years ago. This is likely immunosuppressive effect from his Tacrolimus resulting in chronic iatrogenic myelosuppression. He had a workup for this including BM-biopsy in ___ iso CMV viremia, which was non-revealing. This is most likely a chronic issue however given his history we need to rule out acute infectious causes of myelosuppression such as CMV, his viral load was negative. His EBV viral load was pending on discharge. Another contributor is possibly his colchicine as well. Per chart review, he appears to be at his baseline. #R-sided rib Fractures #Dyspnea #Pericardial effusion Pt reports continued sternal/chest pain from over-exertion during workout 2 weeks ago. CXR w/ bilat rib imaging ___ demonstrated minimally displaced anterolateral R-sided ___ ribs. Pain and hx most c/w rib fractures. He also has RF for fracture with known osteoporosis. Acute coronary syndrome is less likely given normal EKG & troponin. He also has a history of pericarditis requiring pericardial window. We were concerned We checked an echocardiogram which showed a loculated pericardial effusion, he had no evidence of tamponade physiology and had a pulsus of 6mmhg. He was never hypotensive. We consulted cardiology who saw the patient and advised follow up with his primary provider, Dr. ___, in ___ weeks. At the time of discharge, the note was not signed by the supervising provider. I reached out the cardiology fellow who was on call on ___ and they were unable to assist in the finalization of the recommendations. However, I was able to speak with cardiology fellow on the day of consult (___) who said that the recommendations would likely be follow up in ___ weeks. I also discussed the cause ___ with the consulting resident who had reportedly staffed the case with the attending per the note at that time. #C-spine tenderness Patient had C4, 5, or 6 tenderness on physical exam, which he said was new. Given his h/o pathologic fractures and recent mechanical trauma, we checked a CT of the C spine which showed no evidence of acute fracture. At this time we feel that the c spine tenderness is likely caused by muscle spasm. #Iron Deficiency Anemia On admission, low ferritin, serum iron, transferrin saturation, microcytic anemia and hypochromic cells on smear c/w iron deficiency anemia. Pt reports this is baseline since his liver transplant ___ years ago, currently on Tacrolimus. Also a chronic issue iso pancytopenia which underwent work-up in ___ (Above). PPI regimen and/or nutrition iso rib fractures may also be contributing factors. He is currently at his baseline so no acute concerns. Hgb 13.7 today. #HTN SBP in the 160s on admission, likely I/s/o pain from rib fractures. Not on antihypertensives at home. Improved throughout the admission. CHRONIC ISSUES: =============== #PBC s/p liver transplant -Continued home tacrolimus at 1 mg PO BID and prednisone 5 mg PO daily for immunosuppression. Tacro level was 6.1 #Osteoporosis Per OMR review, has had since before his liver transplant so likely not caused by prednisone but if definitely exacerbated by it. Has not seen his ___ endocrinologist since ___ several no-shows since that time. Does not appear that he has been on any bisphosphonate treatmentsalthough at one point was taking high-dose vitamin D. #Pericarditis: -We Continued home colchicine and ASA 325 mg Transitional Issues: ==================== []CT scan in 6 months to evaluate right lower lobe pulmonary nodule []Hypertension to 160s in setting of acute pain, will need a BP recheck at ___ ___ []Evaluate for treatment of osteoporosis []F/u with Endocrinology []F/u with cardiology in ___ weeks []F/u with hepatology in 2 months []Recheck CBC in one week []Check chem 7 in one week to ensure normalization of kidney function []Decreased tacro dosing to 1 mg qam and 0.5 qpm 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. Atorvastatin 10 mg PO QPM 2. BuPROPion (Sustained Release) 300 mg PO QAM 3. Colchicine 0.6 mg PO BID 4. Cyclobenzaprine 5 mg PO TID:PRN muscle spasm 5. DICYCLOMine 20 mg PO TID:PRN diarrhea 6. Gabapentin 600 mg PO BID 7. Pantoprazole 40 mg PO Q12H 8. PredniSONE 5 mg PO DAILY 9. Ranitidine 150 mg PO DAILY 10. Tacrolimus 1 mg PO Q12H 11. Aspirin 325 mg PO BID 12. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line 13. LidoPatch (lidocaine-menthol) ___ % topical DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H RX *acetaminophen 500 mg 2 tablet(s) by mouth q8hrs Disp #*60 Tablet Refills:*0 2. Naloxone Nasal Spray 4 mg IH ONCE MR1 Duration: 1 Dose Use if very tired after oxycodone RX *naloxone [Narcan] 4 mg/actuation 1 spray IN once, MR1 Disp #*1 Spray Refills:*2 3. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate RX *oxycodone 5 mg 1 tablet(s) by mouth q6hrs PRN Disp #*10 Tablet Refills:*0 4. Tacrolimus 0.5 mg PO QPM RX *tacrolimus 0.5 mg 1 capsule(s) by mouth qPM Disp #*30 Capsule Refills:*1 5. Tacrolimus 1 mg PO QAM RX *tacrolimus 1 mg 1 capsule(s) by mouth qAM Disp #*30 Capsule Refills:*1 6. Aspirin 325 mg PO BID 7. Atorvastatin 10 mg PO QPM 8. BuPROPion (Sustained Release) 300 mg PO QAM 9. Colchicine 0.6 mg PO BID 10. DICYCLOMine 20 mg PO TID:PRN diarrhea 11. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line 12. Gabapentin 600 mg PO BID 13. LidoPatch (lidocaine-menthol) ___ % topical DAILY 14. Pantoprazole 40 mg PO Q12H 15. PredniSONE 5 mg PO DAILY 16. Ranitidine 150 mg PO DAILY 17. HELD- Cyclobenzaprine 5 mg PO TID:PRN muscle spasm This medication was held. Do not restart Cyclobenzaprine until you see your PCP ___: Home Discharge Diagnosis: Primary Diagnosis ================= 1) Right ___ rib fractures 2) Liver transplant 3) Osteoporosis 4) Acute kidney injury Secondary Diagnosis =================== 1)Pericarditis 2)Iron decifiency anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking part in your care here at ___! Why was I admitted to the hospital? -You were admitted for low white blood cell counts and rib pain What was done for me while I was in the hospital? -We controlled your pain with medication -We decreased your tacrolimus dose -We did an echocardiogram which was mostly normal What should I do when I leave the hospital? -Please take all of your medications as prescribed, especially your tacrolimus and prednisone -Please follow up with your endocrinologist -Please follow up with your cardiologist -Please follow up with your hepatologist in 2 months -Please follow up with you PCP ___, Your ___ Care Team Followup Instructions: ___
[ "M8000XA", "N179", "I319", "Z944", "I313", "D509", "I10", "Z87891", "D702" ]
Allergies: Penicillins / rifampin / Lamictal / lorazepam / risperidone / mushrooms Chief Complaint: Rib pain Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] h/o idiopathic hemorrhagic pericarditis ([MASKED]) requiring pericardial window, osteoporosis c/b multiple pathologic fractures, PBC s/p liver transplant ([MASKED]) on tacro/pred c/b HSV esophagitis ([MASKED]), presenting now with ongoing positional/inspiratory CP in the setting of sustaining rib fractures 2 weeks ago during a workout. He is a military veteran and 2 weeks ago was doing some physical exercises with a bunch of infantry friends, when during a maneuver where he was pulling himself up by his arms, he felt a pop in his sternum and thereafter experienced severe pain in his chest with movement or deep breaths, but little/none at rest. He went to [MASKED] ED, where he was assured that this was rib fractures and not his heart, and sent home. [MASKED] he re-presented to [MASKED] because his chest pain and associated SOB (again, clarifies that this was exertional but largely because it hurt him to breathe) if anything had gotten a bit worse in the few preceding days. At [MASKED] he was reported to have an ANC of 600 and therefore transferred here to [MASKED] for further workup. Patient denies any fevers or chills, rash, headache, abdominal pain, changes in bowel movement or changes in urination. Normal p.o. intake with no weight loss or night sweats. Past Medical History: - attention deficit hyperactivity disorder - bipolar disorder - hemorrhoids - history of alcohol abuse - history of deep vein thrombosis in [MASKED] - history of hemorrhagic pericarditis complicated by cardiac tamponade status post pericardial window in [MASKED], recurrent pericarditis in [MASKED] - history of neutropenia complicated by neutropenic fever - history of positive tuberculin skin test status post INH - hyperlipidemia - osteoporosis - primary biliary cirrhosis status post orthotopic liver transplant Social History: [MASKED] Family History: Noncontributory Physical Exam: ADMISSION PHYSICAL EXAM: ======================== T 97.4 BP 164 / 114 HR 67 RR 18 SpO2 99% RA Young man resting comfortably in bed, alert/conversing appropriately. Heart regular without murmurs, lungs CTAB, Abdomen soft/ND, legs without edema. MSK: moderate/severe TTP in sternum, L lateral ribcage, one of the cervical vertebra. His sensation and strength is normal and symmetric in upper extremities. DISCHARGE PHYSICAL EXAM: ======================= VS: [MASKED] 0722 Temp: 97.5 PO BP: 150/84 HR: 80 RR: 18 O2 sat: 96% O2 delivery: Ra GENERAL: Pleasant, conversant. HEENT: Normocephalic, atraumatic. PEERL. MMM. Extraocular movements grossly intact. Tender over c4-c7 posteriorly. Tender diffusely to palpation over sternum. CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops. LUNG: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi. ABD: Normal bowel sounds, soft, no hepatomegaly, no splenomegaly. Slightly distended. TTP in epigastrum primarily, and LUQ/RUQ. EXT: Warm, well perfused, no lower extremity edema. PULSES: 1+ [MASKED] & DP pulses NEURO: Alert, oriented, motor and sensory function grossly intact. SKIN: No significant rashes. Pertinent Results: Admission labs: =============== [MASKED] 09:20PM GLUCOSE-86 UREA N-13 CREAT-1.3* SODIUM-140 POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-21* ANION GAP-14 [MASKED] 09:20PM estGFR-Using this [MASKED] 09:20PM ALT(SGPT)-18 AST(SGOT)-27 ALK PHOS-133* TOT BILI-0.5 [MASKED] 09:20PM LIPASE-12 [MASKED] 09:20PM cTropnT-<0.01 [MASKED] 09:20PM ALBUMIN-3.9 IRON-41* [MASKED] 09:20PM calTIBC-333 VIT B12-440 FOLATE-14 FERRITIN-27* TRF-256 [MASKED] 09:20PM WBC-2.1* RBC-4.81 HGB-12.6* HCT-39.1* MCV-81* MCH-26.2 MCHC-32.2 RDW-16.3* RDWSD-47.5* [MASKED] 09:20PM NEUTS-48.6 [MASKED] MONOS-7.9 EOS-1.4 BASOS-1.9* IM [MASKED] AbsNeut-1.04* AbsLymp-0.85* AbsMono-0.17* AbsEos-0.03* AbsBaso-0.04 [MASKED] 09:20PM HOS-AVAILABLE [MASKED] 09:20PM HYPOCHROM-2+* ANISOCYT-1+* POIKILOCY-1+* MACROCYT-NORMAL MICROCYT-1+* POLYCHROM-1+* SPHEROCYT-OCCASIONAL OVALOCYT-1+* SCHISTOCY-OCCASIONAL BURR-1+* TEARDROP-OCCASIONAL [MASKED] 09:20PM PLT COUNT-68* [MASKED] 09:20PM [MASKED] PTT-27.0 [MASKED] [MASKED] 09:20PM RET AUT-2.1* ABS RET-0.10 Discharge Labs: =============== [MASKED]:23AM BLOOD WBC-3.1* RBC-5.10 Hgb-13.6* Hct-40.9 MCV-80* MCH-26.7 MCHC-33.3 RDW-16.5* RDWSD-47.5* Plt Ct-84* [MASKED] 07:23AM BLOOD Plt Ct-84* [MASKED] 07:23AM BLOOD Glucose-87 UreaN-11 Creat-1.1 Na-141 K-4.2 Cl-104 HCO3-23 AnGap-14 [MASKED] 07:23AM BLOOD Calcium-9.0 Phos-3.3 Mg-1.9 [MASKED] 07:23AM BLOOD tacroFK-4.2* Imaging: [MASKED] Final Report EXAMINATION: RIB BILAT, W/AP CHEST INDICATION: [MASKED] year old man with chest pain w previous fracture and mechanical cause of pain// eval rib frx TECHNIQUE: Frontal and oblique views of the chest COMPARISON: Chest radiographs between [MASKED] and [MASKED] FINDINGS: The lungs are well expanded. Linear atelectasis in the lower left lung is improved. No focal consolidation. No pleural effusion or pneumothorax. Heart size is normal. The mediastinal silhouette is unremarkable. There are minimally displaced anterolateral right probably fifth through seventh rib fractures. Thoracic spine fusion hardware is noted. IMPRESSION: Minimally displaced anterolateral right probably fifth through seventh rib fractures. CT C-Spine without contrast Final Report EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE INDICATION: [MASKED] year old man with history of previously status post liver transplant [MASKED] years ago, leukopenia, with osteoporosis complicated by several fractures, now presenting with ongoing chest pain in the setting of recent rib fractures from exercising, found to have C-spine tenderness on exam. Please evaluate for cervical spine fractures. TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue and bone algorithm images were generated. Coronal and sagittal reformations were then constructed. DOSE: Acquisition sequence: 1) Spiral Acquisition 5.8 s, 22.7 cm; CTDIvol = 25.1 mGy (Body) DLP = 568.8 mGy-cm. Total DLP (Body) = 569 mGy-cm. COMPARISON: C-spine CT from [MASKED]. FINDINGS: Alignment is normal. There is diffuse osseous demineralization. Compression deformities with loss of vertebral body height are noted at C4, C5, C6, and T1, largely unchanged compared to previous study. No acute fractures are identified. There is no evidence of spinal canal or neural foraminal stenosis. There is no prevertebral soft tissue swelling. There is no evidence of infection or neoplasm. Emphysematous changes are noted at the lung apices bilaterally. IMPRESSION: 1. Diffuse bone demineralization with compression deformities at C4, C5, C6 and T1, similar to the previous study. 2. No evidence of acute fractures or traumatic malalignment. [MASKED] Final Report EXAMINATION: CT CHEST W/O CONTRAST INDICATION: [MASKED] year old man with PBC s/p liver transplant [MASKED] yrs ago osteoporosis c/b multiple fractures now p/w chest cervical vertebral pain s/p injury 2 weeks ago probable [MASKED] rib fxs on CXR. Evaluate rib fractures. TECHNIQUE: Multi-detector helical scanning of the chest was performed without intravenous iodinated contrast agent and reconstructed as 5 and 1.25 mm thick axial, 2.5 mm thick coronal and sagittal, and 8 mm MIP axial images. DOSE: Acquisition sequence: 1) Spiral Acquisition 2.6 s, 41.7 cm; CTDIvol = 13.2 mGy (Body) DLP = 550.9 mGy-cm. Total DLP (Body) = 551 mGy-cm. COMPARISON: Rib x-rays [MASKED]. Chest CTA [MASKED]. CT abdomen and pelvis [MASKED]. FINDINGS: NECK, THORACIC INLET, AXILLAE, CHEST WALL: The imaged thyroid is unremarkable. There is no supraclavicular or axillary lymphadenopathy. The esophagus is patulous. UPPER ABDOMEN: The transplant liver demonstrates homogeneous attenuation. Nonobstructing right renal stones measure up to 3 mm, near a focal area of cortical thinning. Moderate pancreatic atrophy. MEDIASTINUM: There is no mediastinal mass or lymphadenopathy. HILA: There is no hilar mass or lymphadenopathy. HEART and PERICARDIUM: Heart size is normal. The thoracic aorta is normal in caliber. There is no pericardial effusion. PLEURA: No pleural effusion or pneumothorax. LUNG: 1. PARENCHYMA: Probable bilateral lower lobe scarring and atelectasis, less likely interstitial disease. Mild, apical predominant paraseptal emphysema. A sub 3 mm right lower lobe pulmonary nodule is not definitively identified on the prior study (302:139), possibly due to differences in technique. No other pulmonary nodules identified. 2. AIRWAYS: The airways are patent to the level of the segmental bronchi bilaterally. 3. VESSELS: Main pulmonary artery diameter is within normal limits. CHEST CAGE: Thoracic spinal fusion hardware is in place. The bones are diffusely osteopenic. A chronic appearing deformity of the right scapula (302:125) appears new since [MASKED]. Chronic deformities of the right anterior second through seventh ribs, similar to multiple priors dating back to [MASKED]. A compression deformity of the T6 vertebral body is redemonstrated. Redemonstrated manubrial fracture. There is no acute fracture. IMPRESSION: 1. Multiple, chronic right-sided rib fractures, similar in appearance to at least [MASKED]. No acute rib fractures identified. 2. Chronic appearing right scapular deformity, new since [MASKED]. 3. Stable T6 compression fracture and manubrial fracture. 4. Sub 3 mm right lower lobe pulmonary nodule, not definitively identified on the prior study from [MASKED], possibly due to differences in study technique. No other pulmonary nodules identified. 5. Nonobstructing right renal stones, measuring up to 3 mm. [MASKED] CONCLUSION: The left atrial volume index is normal. There is mild symmetric left ventricular hypertrophy with a normal cavity size. There is normal regional left ventricular systolic function. Overall left ventricular systolic function is normal. Quantitative biplane left ventricular ejection fraction is 53 %. Normal right ventricular cavity size with normal free wall motion. The aortic sinus diameter is normal for gender. The aortic valve leaflets (3) appear structurally normal. There is no aortic valve stenosis. There is no aortic regur gitation. The mitral valve leaflets appear structurally normal with no mitral valve prolapse. There is trivial mitral regur gitation. The tricuspid valve leaflets appear structurally normal. There is trivial tricuspid regurgitation. There is a moderate pericardial effusion. There is increased respiratory variation in transmitral/transtricuspid inflow but no right atrial/right ventricular diastolic collapse. IMPRESSION: 1) Moderate pericardial effusion largely anterior to the right atrium. It appears to be serous and loculated. There appears to be an epicardial fat pat in addition to the pericardial effusion. The pericardial effusion is difficult to be reached by either percutaneous approaches. 2) There is respiratory variation in mitral inflow reaching threshold of hemodynamically significant pericardial pressure elevation. However, there is no RA/RV collapse. RA pressure could not be estimated on this study. There is a septal bounce on this echocardiogram however no clear signs of pericaridal constriction are note Brief Hospital Course: ASSESSMENT & PLAN: [MASKED] h/o idiopathic hemorrhagic pericarditis ([MASKED]) requiring pericardial window, osteoporosis c/b multiple pathologic fractures, PBC s/p liver transplant ([MASKED]) on tacro/pred c/b HSV esophagitis ([MASKED]), admitted for neutropenia, acute kidney injury, and pain management of right rib fractures. ACUTE ISSUES: ============== #Acute kidney injury Admitted with a creatinine of 1.4. Likely a combination of pre-renal in the setting of decreased PO intake due to rib fractures as well as a possible component of tacrolimus toxicity. He initially responded to maintence fluids but then his creatinine returned to 1.4. We then decreased his tacrolimus to 0.5 mg at night and 1 mg in the morning, his creatinine was 1.1 on discharge. #Pancytopenia #Neutropenia Patient reports he has had pancytopenia since his liver transplant [MASKED] years ago. This is likely immunosuppressive effect from his Tacrolimus resulting in chronic iatrogenic myelosuppression. He had a workup for this including BM-biopsy in [MASKED] iso CMV viremia, which was non-revealing. This is most likely a chronic issue however given his history we need to rule out acute infectious causes of myelosuppression such as CMV, his viral load was negative. His EBV viral load was pending on discharge. Another contributor is possibly his colchicine as well. Per chart review, he appears to be at his baseline. #R-sided rib Fractures #Dyspnea #Pericardial effusion Pt reports continued sternal/chest pain from over-exertion during workout 2 weeks ago. CXR w/ bilat rib imaging [MASKED] demonstrated minimally displaced anterolateral R-sided [MASKED] ribs. Pain and hx most c/w rib fractures. He also has RF for fracture with known osteoporosis. Acute coronary syndrome is less likely given normal EKG & troponin. He also has a history of pericarditis requiring pericardial window. We were concerned We checked an echocardiogram which showed a loculated pericardial effusion, he had no evidence of tamponade physiology and had a pulsus of 6mmhg. He was never hypotensive. We consulted cardiology who saw the patient and advised follow up with his primary provider, Dr. [MASKED], in [MASKED] weeks. At the time of discharge, the note was not signed by the supervising provider. I reached out the cardiology fellow who was on call on [MASKED] and they were unable to assist in the finalization of the recommendations. However, I was able to speak with cardiology fellow on the day of consult ([MASKED]) who said that the recommendations would likely be follow up in [MASKED] weeks. I also discussed the cause [MASKED] with the consulting resident who had reportedly staffed the case with the attending per the note at that time. #C-spine tenderness Patient had C4, 5, or 6 tenderness on physical exam, which he said was new. Given his h/o pathologic fractures and recent mechanical trauma, we checked a CT of the C spine which showed no evidence of acute fracture. At this time we feel that the c spine tenderness is likely caused by muscle spasm. #Iron Deficiency Anemia On admission, low ferritin, serum iron, transferrin saturation, microcytic anemia and hypochromic cells on smear c/w iron deficiency anemia. Pt reports this is baseline since his liver transplant [MASKED] years ago, currently on Tacrolimus. Also a chronic issue iso pancytopenia which underwent work-up in [MASKED] (Above). PPI regimen and/or nutrition iso rib fractures may also be contributing factors. He is currently at his baseline so no acute concerns. Hgb 13.7 today. #HTN SBP in the 160s on admission, likely I/s/o pain from rib fractures. Not on antihypertensives at home. Improved throughout the admission. CHRONIC ISSUES: =============== #PBC s/p liver transplant -Continued home tacrolimus at 1 mg PO BID and prednisone 5 mg PO daily for immunosuppression. Tacro level was 6.1 #Osteoporosis Per OMR review, has had since before his liver transplant so likely not caused by prednisone but if definitely exacerbated by it. Has not seen his [MASKED] endocrinologist since [MASKED] several no-shows since that time. Does not appear that he has been on any bisphosphonate treatmentsalthough at one point was taking high-dose vitamin D. #Pericarditis: -We Continued home colchicine and ASA 325 mg Transitional Issues: ==================== []CT scan in 6 months to evaluate right lower lobe pulmonary nodule []Hypertension to 160s in setting of acute pain, will need a BP recheck at [MASKED] [MASKED] []Evaluate for treatment of osteoporosis []F/u with Endocrinology []F/u with cardiology in [MASKED] weeks []F/u with hepatology in 2 months []Recheck CBC in one week []Check chem 7 in one week to ensure normalization of kidney function []Decreased tacro dosing to 1 mg qam and 0.5 qpm 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. Atorvastatin 10 mg PO QPM 2. BuPROPion (Sustained Release) 300 mg PO QAM 3. Colchicine 0.6 mg PO BID 4. Cyclobenzaprine 5 mg PO TID:PRN muscle spasm 5. DICYCLOMine 20 mg PO TID:PRN diarrhea 6. Gabapentin 600 mg PO BID 7. Pantoprazole 40 mg PO Q12H 8. PredniSONE 5 mg PO DAILY 9. Ranitidine 150 mg PO DAILY 10. Tacrolimus 1 mg PO Q12H 11. Aspirin 325 mg PO BID 12. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line 13. LidoPatch (lidocaine-menthol) [MASKED] % topical DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H RX *acetaminophen 500 mg 2 tablet(s) by mouth q8hrs Disp #*60 Tablet Refills:*0 2. Naloxone Nasal Spray 4 mg IH ONCE MR1 Duration: 1 Dose Use if very tired after oxycodone RX *naloxone [Narcan] 4 mg/actuation 1 spray IN once, MR1 Disp #*1 Spray Refills:*2 3. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate RX *oxycodone 5 mg 1 tablet(s) by mouth q6hrs PRN Disp #*10 Tablet Refills:*0 4. Tacrolimus 0.5 mg PO QPM RX *tacrolimus 0.5 mg 1 capsule(s) by mouth qPM Disp #*30 Capsule Refills:*1 5. Tacrolimus 1 mg PO QAM RX *tacrolimus 1 mg 1 capsule(s) by mouth qAM Disp #*30 Capsule Refills:*1 6. Aspirin 325 mg PO BID 7. Atorvastatin 10 mg PO QPM 8. BuPROPion (Sustained Release) 300 mg PO QAM 9. Colchicine 0.6 mg PO BID 10. DICYCLOMine 20 mg PO TID:PRN diarrhea 11. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line 12. Gabapentin 600 mg PO BID 13. LidoPatch (lidocaine-menthol) [MASKED] % topical DAILY 14. Pantoprazole 40 mg PO Q12H 15. PredniSONE 5 mg PO DAILY 16. Ranitidine 150 mg PO DAILY 17. HELD- Cyclobenzaprine 5 mg PO TID:PRN muscle spasm This medication was held. Do not restart Cyclobenzaprine until you see your PCP [MASKED]: Home Discharge Diagnosis: Primary Diagnosis ================= 1) Right [MASKED] rib fractures 2) Liver transplant 3) Osteoporosis 4) Acute kidney injury Secondary Diagnosis =================== 1)Pericarditis 2)Iron decifiency anemia 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 here at [MASKED]! Why was I admitted to the hospital? -You were admitted for low white blood cell counts and rib pain What was done for me while I was in the hospital? -We controlled your pain with medication -We decreased your tacrolimus dose -We did an echocardiogram which was mostly normal What should I do when I leave the hospital? -Please take all of your medications as prescribed, especially your tacrolimus and prednisone -Please follow up with your endocrinologist -Please follow up with your cardiologist -Please follow up with your hepatologist in 2 months -Please follow up with you PCP [MASKED], Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "N179", "D509", "I10", "Z87891" ]
[ "M8000XA: Age-related osteoporosis with current pathological fracture, unspecified site, initial encounter for fracture", "N179: Acute kidney failure, unspecified", "I319: Disease of pericardium, unspecified", "Z944: Liver transplant status", "I313: Pericardial effusion (noninflammatory)", "D509: Iron deficiency anemia, unspecified", "I10: Essential (primary) hypertension", "Z87891: Personal history of nicotine dependence", "D702: Other drug-induced agranulocytosis" ]
19,992,875
26,305,032
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / rifampin / Lamictal / lorazepam / risperidone / mushrooms Attending: ___. Chief Complaint: colonoscopy Major Surgical or Invasive Procedure: Colonoscopy ___ History of Present Illness: Patient is a ___ year old man with PBC s/p liver transplantation in ___ (on tacrolimus/ prednisone), pericarditis complicated by tamponade with pericardial window, bipolar disorder, & recurrent C Difficile, who presents for colonoscopy prep. Pt reports that for the past 6 months he has had intermittent diarrhea, watery, ___ episodes daily, ongoing for periods of ___ days before being constipated with no BMs for a ___ days. Also reports chronic abdominal pain, nausea, dyspepsia, chills. No blood in stools, no hematemesis, fever. He has been hospitalized multiple times, most recently in ___, for diarrhea, stool studies and C diff PCR was negative. A flexible sigmoidoscopy showed inflammation in the rectum, biopsy results showed active colitis that was consistent with ischemic type. Special stains for cytomegalovirus at that time were negative. He also has had a tissue transglutaminase IgA antibody, which has been low only for pretty much excluding celiac disease. Per pathology, changes seen on his biopsies seemed most consistent with medication-induced injury, infectious injury and less likely ischemia. They have not favored idiopathic inflammatory bowel disease and there has been no evidence of the same. Per GI "need to consider diarrhea of a multifactorial origin, possibly medication, irritable bowel syndrome of the alternating type versus other etiologies. Recommended reassessment with colonoscopy and multiple biopsies of the ileum and of the colon. I see no need to repeat stool samples." On arrival to floor (direct admit from home), he denies any current sxs, VSS. Past Medical History: PAST MEDICAL HISTORY: PBC s/p deceased liver donor tx ___ Neutropenia DVT ___ Prior alcohol abuse now abstinent Hemorrhagic pericarditis c/b tamponade with pericardial window ___ Positive PPD s/p INH HLD Osteoporosis Bipolar disorder Hemorrhoids ADHD PTSD Social History: ___ Family History: Father (living): coronary artery disease, diabetes, hypercholesterolemia, and depression. Prostate and head and neck cancer Mother (deceased): brain aneurysm and hyperthyroidism Physical Exam: Admission Exam: ================== 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, temder to palpation of epigastrium, well healed incisional scars from prior surgeries, non distended, BS+ 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: ================= 97.3 PO 114 / 78 67 16 98 Ra 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, mild ttp in epigastrium, well healed incisional scars from prior liver transplant, non distended, BS+ MSK: No edema Skin: No visible rash. No jaundice. Neuro: AAOx3. Moving all extremities Psych: Full range of affect Pertinent Results: ___ 10:16PM BLOOD WBC-4.2 RBC-5.97 Hgb-17.0 Hct-50.4 MCV-84 MCH-28.5 MCHC-33.7 RDW-15.4 RDWSD-47.6* Plt Ct-95* ___ 10:16PM BLOOD ___ PTT-32.5 ___ ___ 09:57AM BLOOD Glucose-78 UreaN-9 Creat-1.4* Na-141 K-3.8 Cl-107 HCO3-22 AnGap-16 ___ 10:16PM BLOOD Glucose-78 UreaN-7 Creat-1.4* Na-142 K-5.0 Cl-105 HCO3-26 AnGap-16 ___ 09:57AM BLOOD Calcium-8.9 Phos-2.7 Mg-2.4 Imaging: ========= Colonoscopy ___: Those portions of the mucosa that were well visualized appeared to be normal. The mucosa of the terminal ileum also appeared normal. Many areas were not well prepped. Cold forceps biopsies were performed for histology at the terminal ileum. Other procedures: Cold forceps biopsies were performed for histology at the whole colon at random. Impression: Those portions of the mucosa that were well visualized appeared to be normal. The mucosa of the terminal ileum also appeared normal. Many areas were not well prepped. (biopsy) (biopsy) Otherwise normal colonoscopy to cecum and terminal ileum Recommendations: ___ biopsy results ___ with Dr. ___ as needed ___ with endoscopist within 6 weeks Brief Hospital Course: A/P: Patient is a ___ year old man with PBC s/p liver transplantation in ___ (on tacrolimus/ prednisone), pericarditis complicated by tamponade with pericardial window, bipolar disorder, & recurrent C Difficile, who presents for colonoscopy prep. # Chronic diarrhea # Colonoscopy prep Mr. ___ presented with 6 months of alternating constipation and severe diarrhea. He has had C diff infections in the past but none recently, and no evidence of an infectious process given chronicity. Per GI note, changes seen on his colonic biopsies seem most consistent with medication-induced injury, infectious injury and less likely ischemia. They have not favored idiopathic inflammatory bowel disease and there has been no evidence of the same. Etiology is thought to be multifactorial, possibly medication, irritable bowel syndrome of the alternating type versus other etiologies. He was admitted for inpatient colonoscopy prep in the setting of severe dehydration from GI losses with prior preps. He was prepped with moviprep overnight and given IV fluids with stable electrolytes on morning of colonoscopy. He underwent colonoscopy on ___ successfully with biopsies taken. He recovered on the floor and was discharged that evening. # PBC s/p OLT: Chronic abdominal pain, nausea likely ___ PBC. Most recent LFTs and abdominal imaging have been normal. He was continued on his prednisone, tacrolimus, Zofran and gabapentin. # Hx of pericardial effusion/pericarditis complicated by tampondade: No further recurrence, followed by Dr ___. Continued on prednisone, aspirin and colchicine. Transitional Issues: ======================== []f/u with Colonic biopsies from ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 650 mg PO BID 2. Colchicine 0.6 mg PO BID 3. Gabapentin 600 mg PO BID 4. Ondansetron 4 mg PO Q8H:PRN nausea 5. PredniSONE 5 mg PO DAILY 6. Ranitidine 150 mg PO QHS 7. Tacrolimus 1 mg PO QPM 8. Tacrolimus 1 mg PO QAM 9. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain 10. Sulfameth/Trimethoprim DS 1 TAB PO BID 11. Docusate Sodium 100 mg PO BID 12. Senna 8.6 mg PO BID Discharge Medications: 1. Docusate Sodium 100 mg PO BID:PRN constipation 2. Senna 8.6 mg PO BID:PRN constipation 3. Aspirin 650 mg PO BID 4. Colchicine 0.6 mg PO BID 5. Gabapentin 600 mg PO BID 6. Ondansetron 4 mg PO Q8H:PRN nausea 7. PredniSONE 5 mg PO DAILY 8. Ranitidine 150 mg PO QHS 9. Tacrolimus 1 mg PO QPM 10. Tacrolimus 1 mg PO QAM 11. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain Discharge Disposition: Home Discharge Diagnosis: Diarrhea Colonoscopy preparation 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 inpatient colonoscopy preparation. You tolerated the procedure well and your colonoscopy was unremarkable. Biopsies were taken and you will be called with the results of these biopsies. You are ready for discharge. Please continue to take all of your medications as prescribed. It was a pleasure taking care of you, Your ___ Care Team Followup Instructions: ___
[ "K529", "K830", "R109", "G8929", "J449", "R634", "Z6823", "R110", "Z87891", "F319", "F909", "F4310", "Z944", "Z86718" ]
Allergies: Penicillins / rifampin / Lamictal / lorazepam / risperidone / mushrooms Chief Complaint: colonoscopy Major Surgical or Invasive Procedure: Colonoscopy [MASKED] History of Present Illness: Patient is a [MASKED] year old man with PBC s/p liver transplantation in [MASKED] (on tacrolimus/ prednisone), pericarditis complicated by tamponade with pericardial window, bipolar disorder, & recurrent C Difficile, who presents for colonoscopy prep. Pt reports that for the past 6 months he has had intermittent diarrhea, watery, [MASKED] episodes daily, ongoing for periods of [MASKED] days before being constipated with no BMs for a [MASKED] days. Also reports chronic abdominal pain, nausea, dyspepsia, chills. No blood in stools, no hematemesis, fever. He has been hospitalized multiple times, most recently in [MASKED], for diarrhea, stool studies and C diff PCR was negative. A flexible sigmoidoscopy showed inflammation in the rectum, biopsy results showed active colitis that was consistent with ischemic type. Special stains for cytomegalovirus at that time were negative. He also has had a tissue transglutaminase IgA antibody, which has been low only for pretty much excluding celiac disease. Per pathology, changes seen on his biopsies seemed most consistent with medication-induced injury, infectious injury and less likely ischemia. They have not favored idiopathic inflammatory bowel disease and there has been no evidence of the same. Per GI "need to consider diarrhea of a multifactorial origin, possibly medication, irritable bowel syndrome of the alternating type versus other etiologies. Recommended reassessment with colonoscopy and multiple biopsies of the ileum and of the colon. I see no need to repeat stool samples." On arrival to floor (direct admit from home), he denies any current sxs, VSS. Past Medical History: PAST MEDICAL HISTORY: PBC s/p deceased liver donor tx [MASKED] Neutropenia DVT [MASKED] Prior alcohol abuse now abstinent Hemorrhagic pericarditis c/b tamponade with pericardial window [MASKED] Positive PPD s/p INH HLD Osteoporosis Bipolar disorder Hemorrhoids ADHD PTSD Social History: [MASKED] Family History: Father (living): coronary artery disease, diabetes, hypercholesterolemia, and depression. Prostate and head and neck cancer Mother (deceased): brain aneurysm and hyperthyroidism Physical Exam: Admission Exam: ================== 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, temder to palpation of epigastrium, well healed incisional scars from prior surgeries, non distended, BS+ 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: ================= 97.3 PO 114 / 78 67 16 98 Ra 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, mild ttp in epigastrium, well healed incisional scars from prior liver transplant, non distended, BS+ MSK: No edema Skin: No visible rash. No jaundice. Neuro: AAOx3. Moving all extremities Psych: Full range of affect Pertinent Results: [MASKED] 10:16PM BLOOD WBC-4.2 RBC-5.97 Hgb-17.0 Hct-50.4 MCV-84 MCH-28.5 MCHC-33.7 RDW-15.4 RDWSD-47.6* Plt Ct-95* [MASKED] 10:16PM BLOOD [MASKED] PTT-32.5 [MASKED] [MASKED] 09:57AM BLOOD Glucose-78 UreaN-9 Creat-1.4* Na-141 K-3.8 Cl-107 HCO3-22 AnGap-16 [MASKED] 10:16PM BLOOD Glucose-78 UreaN-7 Creat-1.4* Na-142 K-5.0 Cl-105 HCO3-26 AnGap-16 [MASKED] 09:57AM BLOOD Calcium-8.9 Phos-2.7 Mg-2.4 Imaging: ========= Colonoscopy [MASKED]: Those portions of the mucosa that were well visualized appeared to be normal. The mucosa of the terminal ileum also appeared normal. Many areas were not well prepped. Cold forceps biopsies were performed for histology at the terminal ileum. Other procedures: Cold forceps biopsies were performed for histology at the whole colon at random. Impression: Those portions of the mucosa that were well visualized appeared to be normal. The mucosa of the terminal ileum also appeared normal. Many areas were not well prepped. (biopsy) (biopsy) Otherwise normal colonoscopy to cecum and terminal ileum Recommendations: [MASKED] biopsy results [MASKED] with Dr. [MASKED] as needed [MASKED] with endoscopist within 6 weeks Brief Hospital Course: A/P: Patient is a [MASKED] year old man with PBC s/p liver transplantation in [MASKED] (on tacrolimus/ prednisone), pericarditis complicated by tamponade with pericardial window, bipolar disorder, & recurrent C Difficile, who presents for colonoscopy prep. # Chronic diarrhea # Colonoscopy prep Mr. [MASKED] presented with 6 months of alternating constipation and severe diarrhea. He has had C diff infections in the past but none recently, and no evidence of an infectious process given chronicity. Per GI note, changes seen on his colonic biopsies seem most consistent with medication-induced injury, infectious injury and less likely ischemia. They have not favored idiopathic inflammatory bowel disease and there has been no evidence of the same. Etiology is thought to be multifactorial, possibly medication, irritable bowel syndrome of the alternating type versus other etiologies. He was admitted for inpatient colonoscopy prep in the setting of severe dehydration from GI losses with prior preps. He was prepped with moviprep overnight and given IV fluids with stable electrolytes on morning of colonoscopy. He underwent colonoscopy on [MASKED] successfully with biopsies taken. He recovered on the floor and was discharged that evening. # PBC s/p OLT: Chronic abdominal pain, nausea likely [MASKED] PBC. Most recent LFTs and abdominal imaging have been normal. He was continued on his prednisone, tacrolimus, Zofran and gabapentin. # Hx of pericardial effusion/pericarditis complicated by tampondade: No further recurrence, followed by Dr [MASKED]. Continued on prednisone, aspirin and colchicine. Transitional Issues: ======================== []f/u with Colonic biopsies from [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 650 mg PO BID 2. Colchicine 0.6 mg PO BID 3. Gabapentin 600 mg PO BID 4. Ondansetron 4 mg PO Q8H:PRN nausea 5. PredniSONE 5 mg PO DAILY 6. Ranitidine 150 mg PO QHS 7. Tacrolimus 1 mg PO QPM 8. Tacrolimus 1 mg PO QAM 9. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain 10. Sulfameth/Trimethoprim DS 1 TAB PO BID 11. Docusate Sodium 100 mg PO BID 12. Senna 8.6 mg PO BID Discharge Medications: 1. Docusate Sodium 100 mg PO BID:PRN constipation 2. Senna 8.6 mg PO BID:PRN constipation 3. Aspirin 650 mg PO BID 4. Colchicine 0.6 mg PO BID 5. Gabapentin 600 mg PO BID 6. Ondansetron 4 mg PO Q8H:PRN nausea 7. PredniSONE 5 mg PO DAILY 8. Ranitidine 150 mg PO QHS 9. Tacrolimus 1 mg PO QPM 10. Tacrolimus 1 mg PO QAM 11. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain Discharge Disposition: Home Discharge Diagnosis: Diarrhea Colonoscopy preparation 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 inpatient colonoscopy preparation. You tolerated the procedure well and your colonoscopy was unremarkable. Biopsies were taken and you will be called with the results of these biopsies. You are ready for discharge. Please continue to take all of your medications as prescribed. It was a pleasure taking care of you, Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "G8929", "J449", "Z87891", "Z86718" ]
[ "K529: Noninfective gastroenteritis and colitis, unspecified", "K830: Cholangitis", "R109: Unspecified abdominal pain", "G8929: Other chronic pain", "J449: Chronic obstructive pulmonary disease, unspecified", "R634: Abnormal weight loss", "Z6823: Body mass index [BMI] 23.0-23.9, adult", "R110: Nausea", "Z87891: Personal history of nicotine dependence", "F319: Bipolar disorder, unspecified", "F909: Attention-deficit hyperactivity disorder, unspecified type", "F4310: Post-traumatic stress disorder, unspecified", "Z944: Liver transplant status", "Z86718: Personal history of other venous thrombosis and embolism" ]
19,992,875
26,793,370
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / rifampin / Lamictal / lorazepam / risperidone / mushrooms Attending: ___. Chief Complaint: Diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ yo man with PBC s/p liver transplantation in ___ (on tacrolimus/ prednisone), pericarditis complicated by tamponade with pericardial window, bipolar disorder, & recurrent C Difficile with recent hospitalization, who presents with diarrhea, nausea, vomiting, and abdominal pain. He reports that his diarrhea had improved by the time of his last discharge from the hospital. However, it started to increase in frequency once he got home. He reports that he did not change his diet at all. No sick contacts. Has not consumed any raw or undercooked shellfish or other food. His bowel diarrhea is watery and non-bloody. He reports he has anywhere from ___ bowel movements per day. He reports his vomit is non-bloody and non-bilious. Denies fever, chills, chest pain, shortness of breath. Past Medical History: PAST MEDICAL HISTORY: PBC s/p deceased liver donor tx ___ Neutropenia DVT ___ Prior alcohol abuse now abstinent Hemorrhagic pericarditis c/b tamponade with pericardial window ___ Positive PPD s/p INH HLD Osteoporosis Bipolar disorder Hemorrhoids ADHD PTSD Social History: ___ Family History: Father (living): coronary artery disease, diabetes, hypercholesterolemia, and depression. Prostate and head and neck cancer Mother (deceased): brain aneurysm and hyperthyroidism Physical Exam: ADMISSION PHYSICAL EXAM ===================== VITAL SIGNS - 97.7 PO 104 / 69 L Lying 60 18 98 RA GENERAL - Appears stated age in NAD HEENT - neck supple, PERRLA, EOMI, no appreciable cervical or supravlavicular LAD. mucous membranes dry. CARDIAC - S1/S2, bradycardic, regular rhythm PULMONARY - CTAB ABDOMEN - one large surgical scar on L side of abdomen. Well healed. Tender to palpation in the epigastric area and the LUQ EXTREMITIES - No edema, well-perfused SKIN - no bruising or notable rashes. NEUROLOGIC - A&O x 3, normal gait, ___ strength in upper and lower extremities DISCHARGE PHYSICAL EXAM ====================== VITAL SIGNS - 97.5 PO 121 / 85 56 18 97 ra GENERAL - lying in bed, sleeping HEENT - neck supple, PERRLA, EOMI, no appreciable cervical or supravlavicular LAD. Area of mild erythema periortibally on lateral left eye has resolved. Mild tenderness to palpation over erythema and also posterior auricular lymph nodes have resolved. CARDIAC - S1/S2, bradycardic, regular rhythm PULMONARY - CTAB ABDOMEN - one large surgical scar on L side of abdomen. Well healed. Tender to palpation in the epigastric area and the LUQ EXTREMITIES - No edema, well-perfused SKIN - no bruising or notable rashes. NEUROLOGIC - A&O x 3, normal gait, ___ strength in upper and lower extremities Pertinent Results: ADMISSION LAB RESULTS =================== ___ 09:00AM BLOOD WBC-3.1* RBC-4.93 Hgb-15.0 Hct-43.7 MCV-89 MCH-30.4 MCHC-34.3 RDW-15.2 RDWSD-48.1* Plt ___ ___ 09:00AM BLOOD Neuts-49.3 ___ Monos-10.3 Eos-1.6 Baso-2.3* Im ___ AbsNeut-1.53* AbsLymp-1.10* AbsMono-0.32 AbsEos-0.05 AbsBaso-0.07 ___ 09:00AM BLOOD ___ PTT-25.7 ___ ___ 09:00AM BLOOD Glucose-77 UreaN-11 Creat-1.2 Na-136 K-4.4 Cl-103 HCO3-16* AnGap-21* ___ 09:00AM BLOOD ALT-25 AST-34 AlkPhos-98 TotBili-0.8 ___ 09:00AM BLOOD Albumin-4.0 Calcium-8.9 Mg-1.9 ___ 09:12AM BLOOD Lactate-1.0 DISCHARGE LAB RESULTS ==================== ___ 04:52AM BLOOD WBC-3.3* RBC-4.65 Hgb-13.9 Hct-40.1 MCV-86 MCH-29.9 MCHC-34.7 RDW-14.5 RDWSD-45.1 Plt Ct-96* ___ 04:52AM BLOOD ___ PTT-32.1 ___ ___ 04:52AM BLOOD Glucose-77 UreaN-10 Creat-1.3* Na-137 K-4.6 Cl-101 HCO3-25 AnGap-16 ___ 04:52AM BLOOD ALT-18 AST-18 AlkPhos-98 TotBili-0.6 ___ 04:52AM BLOOD Calcium-9.0 Phos-3.5 Mg-2.1 MICROBIOLOGY ============ ___ Stool Culture FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final ___: NO OVA AND PARASITES SEEN. ___ C diff: Negative ___ Urine culture: Negative ___ Blood culture: Pending IMAGING ======= ___ Chest X-Ray: Faint linear densities in the lower lungs likely reflect platelike atelectasis. The lungs are otherwise clear. There is stable prominence of the mediastinal silhouette, which has been previously assessed by CT chest from ___. The heart size is normal. Bony structures are intact. No free air below the right hemidiaphragm. ___ Abdominal X-Ray: Supine and upright views of the abdomen pelvis were provided. Bowel gas pattern is unremarkable without signs of ileus or obstruction. No free air is seen below the right hemidiaphragm. No worrisome calcifications. The imaged osseous structures appear intact. There is a mild dextroscoliosis of the thoracolumbar spine, apex at L1. A clip again noted in the right upper quadrant. ___ RUQ Ultrasound with Doppler: The main hepatic arterial waveform is within normal limits, with prompt systolic upstrokes and continuous antegrade diastolic flow. Peak systolic velocity in the main hepatic artery is 24. Appropriate arterial waveforms are seen in the right hepatic artery and the left hepatic artery with resistive indices of 0.74, and 0.79, respectively. The main portal vein and the right and left portal veins are patent with hepatopetal flow and normal waveform. Appropriate flow is seen in the hepatic veins and the IVC. Brief Hospital Course: Mr. ___ is a ___ man with PBC s/p liver transplantation in ___ (on tacrolimus/prednisone), pericarditis complicated by tamponade with pericardial window, bipolar disorder, & recurrent C Difficile with recent hospitalization, who presents with worsening diarrhea, n/v, and abdominal pain. # Diarrhea, Nausea, Vomiting: The patient initially presented with abdominal pain, vomiting x3 the night prior to admission, and reports of increase in diarrhea. There was initial concern for toxic megacolon or SBO. However, ___ ruled out those etiologies. It was thought that this may either be viral gastroenteritis or relapsed C. Diff infection. Flex sigmoidoscopy on previous hospitalization showed active colitis with focal superficial features suggestive of a component of ischemic type injury. Stool studies were sent including norovirus NAAT, and C. Diff which were negative. The patient's last bowel movement was in the emergency department. He did not have one for three days after that. The patient had still not had a bowel movement on the day of discharge, so he was given senna, colace, and miralax. #Cellulitis: The patient had some erythema and swelling without warmth over the lateral left ___ area. He remained afebrile. ID was consulted for questionable cellulitis since the patient was at a higher risk for infection given immunosuppression. A diagnosis of pre-septal cellulitis was made, and the patient was started on Bactrim. He was sent home on Bactrim 1 DS tab BID x 7 days to finish the course for facial cellulitis. # PBC s/p orthotopic liver transplant with CMV+ donor complicated by cellular rejection: The patient was continued on his home tacrolimus/prednisone and tacrolimus troughs were checked daily; they ranged from ___. # Normocytic Anemia: The patient's hemoglobin dropped from 15 to 12.8 the day after admission. This was likely dilutional given that the patient received IV fluids in the ED. Hemolysis labs were negative. Iron deficiency labs ___ ferritin, but otherwise normal. # Thrombocytopenia: Patient has known chronic thrombocytopenia likely due to liver disease, immunosuppression and hypersplenism. # Bipolar Disorder: The patient was recently taken off Abilify. He was monitored during his hospitalization, and there were no acute issues. # GERD: Stable. Possibly contributing to abdominal pain as described above. He was continued on his home ranitidine 150mg qHS, maalox PRN. # Chronic neuropathic pain: He was continued on his home Gabapentin 600mg BID. # COPD: There was no SOB throughout the admission. He was continued on home albuterol PRN TRANSITIONAL ISSUES ==================== -Patient will follow up with Dr. ___ as outpatient to monitor alternating diarrhea and constipation. -Consider follow up colonoscopy in several months to monitor for resolution of active colitis. -Patient will be discharged on Bactrim 1 DS tab BID for total course of 7 days (end date ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 650 mg PO BID 2. Colchicine 0.6 mg PO BID 3. Gabapentin 600 mg PO BID 4. PredniSONE 5 mg PO DAILY 5. Ranitidine 150 mg PO QHS 6. Tacrolimus 1 mg PO QPM 7. Tacrolimus 1 mg PO QAM 8. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain 9. Ondansetron 4 mg PO Q8H:PRN nausea Discharge Medications: 1. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*45 Capsule Refills:*0 2. Senna 8.6 mg PO BID RX *sennosides 8.6 mg 1 tablet by mouth twice a day Disp #*45 Tablet Refills:*0 3. Sulfameth/Trimethoprim DS 1 TAB PO BID RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by mouth twice a day Disp #*11 Tablet Refills:*0 4. Aspirin 650 mg PO BID 5. Colchicine 0.6 mg PO BID 6. Gabapentin 600 mg PO BID 7. Ondansetron 4 mg PO Q8H:PRN nausea 8. PredniSONE 5 mg PO DAILY 9. Ranitidine 150 mg PO QHS 10. Tacrolimus 1 mg PO QPM 11. Tacrolimus 1 mg PO QAM 12. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS ================= Diarrhea SECONDARY DIAGNOSIS ==================== Chronic pain Primary Biliary Cirrohsis S/P Liver Transplant Cellular Rejection Anemia Bipolar Disorder Gastroesophageal Reflux Disease Cellulitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. ___, You were admitted to ___. Why were you admitted? ====================== You had abdominal pain, diarrhea, nausea and vomiting What did we do for you? ======================= -We gave you fluids because of dehydration from diarrhea and vomiting. -We sent off tests of your stool to ensure you do not have another infection. The tests that did come back were negative. Some of the other cultures were still pending at time of discharge. What should you do when you get home? ===================================== -Continue to take your anti-nausea medication before meals when you are feeling nauseous. -We suggest that you follow the "BRAT" diet until you feel better. This consists of bananas, rice, applesauce and toast. You can advance your diet when you feel you are able -Expect to have loose stools, up to 1 or 2 per day, for the next few months. Your colon is still recovering from your Clostridium difficile infection in ___. - Call the doctor if you have 6 or more loose stools per day. - Attend a follow-up appointment with your primary care doctor. - Attend a follow-up appointment with your liver transplant doctor. - Consider seeing a pain specialist to help treat your multiple causes of pain. It was a pleasure taking part in your care. Your ___ Team Followup Instructions: ___
[ "K529", "T8641", "D6959", "G629", "E860", "L03213", "F319", "Z590", "R0789", "K219", "D731", "J449", "D649", "K5900", "F909", "F4310", "G8929", "Z86718", "Z87891", "Y830", "Y929" ]
Allergies: Penicillins / rifampin / Lamictal / lorazepam / risperidone / mushrooms Chief Complaint: Diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is a [MASKED] yo man with PBC s/p liver transplantation in [MASKED] (on tacrolimus/ prednisone), pericarditis complicated by tamponade with pericardial window, bipolar disorder, & recurrent C Difficile with recent hospitalization, who presents with diarrhea, nausea, vomiting, and abdominal pain. He reports that his diarrhea had improved by the time of his last discharge from the hospital. However, it started to increase in frequency once he got home. He reports that he did not change his diet at all. No sick contacts. Has not consumed any raw or undercooked shellfish or other food. His bowel diarrhea is watery and non-bloody. He reports he has anywhere from [MASKED] bowel movements per day. He reports his vomit is non-bloody and non-bilious. Denies fever, chills, chest pain, shortness of breath. Past Medical History: PAST MEDICAL HISTORY: PBC s/p deceased liver donor tx [MASKED] Neutropenia DVT [MASKED] Prior alcohol abuse now abstinent Hemorrhagic pericarditis c/b tamponade with pericardial window [MASKED] Positive PPD s/p INH HLD Osteoporosis Bipolar disorder Hemorrhoids ADHD PTSD Social History: [MASKED] Family History: Father (living): coronary artery disease, diabetes, hypercholesterolemia, and depression. Prostate and head and neck cancer Mother (deceased): brain aneurysm and hyperthyroidism Physical Exam: ADMISSION PHYSICAL EXAM ===================== VITAL SIGNS - 97.7 PO 104 / 69 L Lying 60 18 98 RA GENERAL - Appears stated age in NAD HEENT - neck supple, PERRLA, EOMI, no appreciable cervical or supravlavicular LAD. mucous membranes dry. CARDIAC - S1/S2, bradycardic, regular rhythm PULMONARY - CTAB ABDOMEN - one large surgical scar on L side of abdomen. Well healed. Tender to palpation in the epigastric area and the LUQ EXTREMITIES - No edema, well-perfused SKIN - no bruising or notable rashes. NEUROLOGIC - A&O x 3, normal gait, [MASKED] strength in upper and lower extremities DISCHARGE PHYSICAL EXAM ====================== VITAL SIGNS - 97.5 PO 121 / 85 56 18 97 ra GENERAL - lying in bed, sleeping HEENT - neck supple, PERRLA, EOMI, no appreciable cervical or supravlavicular LAD. Area of mild erythema periortibally on lateral left eye has resolved. Mild tenderness to palpation over erythema and also posterior auricular lymph nodes have resolved. CARDIAC - S1/S2, bradycardic, regular rhythm PULMONARY - CTAB ABDOMEN - one large surgical scar on L side of abdomen. Well healed. Tender to palpation in the epigastric area and the LUQ EXTREMITIES - No edema, well-perfused SKIN - no bruising or notable rashes. NEUROLOGIC - A&O x 3, normal gait, [MASKED] strength in upper and lower extremities Pertinent Results: ADMISSION LAB RESULTS =================== [MASKED] 09:00AM BLOOD WBC-3.1* RBC-4.93 Hgb-15.0 Hct-43.7 MCV-89 MCH-30.4 MCHC-34.3 RDW-15.2 RDWSD-48.1* Plt [MASKED] [MASKED] 09:00AM BLOOD Neuts-49.3 [MASKED] Monos-10.3 Eos-1.6 Baso-2.3* Im [MASKED] AbsNeut-1.53* AbsLymp-1.10* AbsMono-0.32 AbsEos-0.05 AbsBaso-0.07 [MASKED] 09:00AM BLOOD [MASKED] PTT-25.7 [MASKED] [MASKED] 09:00AM BLOOD Glucose-77 UreaN-11 Creat-1.2 Na-136 K-4.4 Cl-103 HCO3-16* AnGap-21* [MASKED] 09:00AM BLOOD ALT-25 AST-34 AlkPhos-98 TotBili-0.8 [MASKED] 09:00AM BLOOD Albumin-4.0 Calcium-8.9 Mg-1.9 [MASKED] 09:12AM BLOOD Lactate-1.0 DISCHARGE LAB RESULTS ==================== [MASKED] 04:52AM BLOOD WBC-3.3* RBC-4.65 Hgb-13.9 Hct-40.1 MCV-86 MCH-29.9 MCHC-34.7 RDW-14.5 RDWSD-45.1 Plt Ct-96* [MASKED] 04:52AM BLOOD [MASKED] PTT-32.1 [MASKED] [MASKED] 04:52AM BLOOD Glucose-77 UreaN-10 Creat-1.3* Na-137 K-4.6 Cl-101 HCO3-25 AnGap-16 [MASKED] 04:52AM BLOOD ALT-18 AST-18 AlkPhos-98 TotBili-0.6 [MASKED] 04:52AM BLOOD Calcium-9.0 Phos-3.5 Mg-2.1 MICROBIOLOGY ============ [MASKED] Stool Culture FECAL CULTURE (Final [MASKED]: NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [MASKED]: NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final [MASKED]: NO OVA AND PARASITES SEEN. [MASKED] C diff: Negative [MASKED] Urine culture: Negative [MASKED] Blood culture: Pending IMAGING ======= [MASKED] Chest X-Ray: Faint linear densities in the lower lungs likely reflect platelike atelectasis. The lungs are otherwise clear. There is stable prominence of the mediastinal silhouette, which has been previously assessed by CT chest from [MASKED]. The heart size is normal. Bony structures are intact. No free air below the right hemidiaphragm. [MASKED] Abdominal X-Ray: Supine and upright views of the abdomen pelvis were provided. Bowel gas pattern is unremarkable without signs of ileus or obstruction. No free air is seen below the right hemidiaphragm. No worrisome calcifications. The imaged osseous structures appear intact. There is a mild dextroscoliosis of the thoracolumbar spine, apex at L1. A clip again noted in the right upper quadrant. [MASKED] RUQ Ultrasound with Doppler: The main hepatic arterial waveform is within normal limits, with prompt systolic upstrokes and continuous antegrade diastolic flow. Peak systolic velocity in the main hepatic artery is 24. Appropriate arterial waveforms are seen in the right hepatic artery and the left hepatic artery with resistive indices of 0.74, and 0.79, respectively. The main portal vein and the right and left portal veins are patent with hepatopetal flow and normal waveform. Appropriate flow is seen in the hepatic veins and the IVC. Brief Hospital Course: Mr. [MASKED] is a [MASKED] man with PBC s/p liver transplantation in [MASKED] (on tacrolimus/prednisone), pericarditis complicated by tamponade with pericardial window, bipolar disorder, & recurrent C Difficile with recent hospitalization, who presents with worsening diarrhea, n/v, and abdominal pain. # Diarrhea, Nausea, Vomiting: The patient initially presented with abdominal pain, vomiting x3 the night prior to admission, and reports of increase in diarrhea. There was initial concern for toxic megacolon or SBO. However, [MASKED] ruled out those etiologies. It was thought that this may either be viral gastroenteritis or relapsed C. Diff infection. Flex sigmoidoscopy on previous hospitalization showed active colitis with focal superficial features suggestive of a component of ischemic type injury. Stool studies were sent including norovirus NAAT, and C. Diff which were negative. The patient's last bowel movement was in the emergency department. He did not have one for three days after that. The patient had still not had a bowel movement on the day of discharge, so he was given senna, colace, and miralax. #Cellulitis: The patient had some erythema and swelling without warmth over the lateral left [MASKED] area. He remained afebrile. ID was consulted for questionable cellulitis since the patient was at a higher risk for infection given immunosuppression. A diagnosis of pre-septal cellulitis was made, and the patient was started on Bactrim. He was sent home on Bactrim 1 DS tab BID x 7 days to finish the course for facial cellulitis. # PBC s/p orthotopic liver transplant with CMV+ donor complicated by cellular rejection: The patient was continued on his home tacrolimus/prednisone and tacrolimus troughs were checked daily; they ranged from [MASKED]. # Normocytic Anemia: The patient's hemoglobin dropped from 15 to 12.8 the day after admission. This was likely dilutional given that the patient received IV fluids in the ED. Hemolysis labs were negative. Iron deficiency labs [MASKED] ferritin, but otherwise normal. # Thrombocytopenia: Patient has known chronic thrombocytopenia likely due to liver disease, immunosuppression and hypersplenism. # Bipolar Disorder: The patient was recently taken off Abilify. He was monitored during his hospitalization, and there were no acute issues. # GERD: Stable. Possibly contributing to abdominal pain as described above. He was continued on his home ranitidine 150mg qHS, maalox PRN. # Chronic neuropathic pain: He was continued on his home Gabapentin 600mg BID. # COPD: There was no SOB throughout the admission. He was continued on home albuterol PRN TRANSITIONAL ISSUES ==================== -Patient will follow up with Dr. [MASKED] as outpatient to monitor alternating diarrhea and constipation. -Consider follow up colonoscopy in several months to monitor for resolution of active colitis. -Patient will be discharged on Bactrim 1 DS tab BID for total course of 7 days (end date [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 650 mg PO BID 2. Colchicine 0.6 mg PO BID 3. Gabapentin 600 mg PO BID 4. PredniSONE 5 mg PO DAILY 5. Ranitidine 150 mg PO QHS 6. Tacrolimus 1 mg PO QPM 7. Tacrolimus 1 mg PO QAM 8. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain 9. Ondansetron 4 mg PO Q8H:PRN nausea Discharge Medications: 1. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*45 Capsule Refills:*0 2. Senna 8.6 mg PO BID RX *sennosides 8.6 mg 1 tablet by mouth twice a day Disp #*45 Tablet Refills:*0 3. Sulfameth/Trimethoprim DS 1 TAB PO BID RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by mouth twice a day Disp #*11 Tablet Refills:*0 4. Aspirin 650 mg PO BID 5. Colchicine 0.6 mg PO BID 6. Gabapentin 600 mg PO BID 7. Ondansetron 4 mg PO Q8H:PRN nausea 8. PredniSONE 5 mg PO DAILY 9. Ranitidine 150 mg PO QHS 10. Tacrolimus 1 mg PO QPM 11. Tacrolimus 1 mg PO QAM 12. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS ================= Diarrhea SECONDARY DIAGNOSIS ==================== Chronic pain Primary Biliary Cirrohsis S/P Liver Transplant Cellular Rejection Anemia Bipolar Disorder Gastroesophageal Reflux Disease Cellulitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [MASKED], You were admitted to [MASKED]. Why were you admitted? ====================== You had abdominal pain, diarrhea, nausea and vomiting What did we do for you? ======================= -We gave you fluids because of dehydration from diarrhea and vomiting. -We sent off tests of your stool to ensure you do not have another infection. The tests that did come back were negative. Some of the other cultures were still pending at time of discharge. What should you do when you get home? ===================================== -Continue to take your anti-nausea medication before meals when you are feeling nauseous. -We suggest that you follow the "BRAT" diet until you feel better. This consists of bananas, rice, applesauce and toast. You can advance your diet when you feel you are able -Expect to have loose stools, up to 1 or 2 per day, for the next few months. Your colon is still recovering from your Clostridium difficile infection in [MASKED]. - Call the doctor if you have 6 or more loose stools per day. - Attend a follow-up appointment with your primary care doctor. - Attend a follow-up appointment with your liver transplant doctor. - Consider seeing a pain specialist to help treat your multiple causes of pain. It was a pleasure taking part in your care. Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "K219", "J449", "D649", "K5900", "G8929", "Z86718", "Z87891", "Y929" ]
[ "K529: Noninfective gastroenteritis and colitis, unspecified", "T8641: Liver transplant rejection", "D6959: Other secondary thrombocytopenia", "G629: Polyneuropathy, unspecified", "E860: Dehydration", "L03213: Periorbital cellulitis", "F319: Bipolar disorder, unspecified", "Z590: Homelessness", "R0789: Other chest pain", "K219: Gastro-esophageal reflux disease without esophagitis", "D731: Hypersplenism", "J449: Chronic obstructive pulmonary disease, unspecified", "D649: Anemia, unspecified", "K5900: Constipation, unspecified", "F909: Attention-deficit hyperactivity disorder, unspecified type", "F4310: Post-traumatic stress disorder, unspecified", "G8929: Other chronic pain", "Z86718: Personal history of other venous thrombosis and embolism", "Z87891: Personal history of nicotine dependence", "Y830: Surgical operation with transplant of whole organ 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" ]
19,992,875
28,407,679
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / rifampin / Lamictal / lorazepam / risperidone Attending: ___ Chief Complaint: BRBPR Major Surgical or Invasive Procedure: Sigmoidoscopy ___ History of Present Illness: ___ with hx of COPD, PBC s/p DDLTx (SCD ___ c/b CMV viremia and acute rejection, and pericarditis (on ASA 975mg TID) and hx of hemmorhoids who presents with BRBPR. Patient noted blood in the toilet bowel water and on the toilet paper and on his stool. Stool brown in appearance and formed. Had 2x episodes of blood with BM starting at noon today. No further BMs or blood. Patient also endorses periumbilical abdominal pain since first ___ where he noted blood. Pain is located in LLQ and comes and goes in waves. Occasional nausea but no vomiting. Patient has been tolerating PO without issues or associated pain/nausea. No recent illness, sick contacts, diarrhea. Patient initially presented to ___ who directed him to ___ given his transplant status. Most recent labs from ___ demonstrate an H/H of 13.9/40.9, INR of 0.9, and plt ct of 67K. Mr ___ denies any symptoms of orthostasis including dizziness, lightheadedness, or weakness. In the ED, initial VS were pain ___. T 96.6, HR 80, BP 137/92, RR 18 satting 100% on RA. Initial labs notable for Cr of 1.3, Alt 49, AST 33, TBili 0.5, WBC 3.8, Hgb 14, Plt 69. INR 1. Patient given 500cc NS and 5mg Morphine x3. Blood Cx, Urine Cx obtained. CT abdomen/Pelvis without evidence of acute pathology. On arrival to the floor, patient states that he continues to have mild LLQ pain, but this has improved with IV morphine. He has not other complaints. REVIEW OF SYSTEMS: Denies fever, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, melena, dysuria, hematuria. All other 10-system review negative in detail. Past Medical History: PBC s/p deceased liver donor tx ___ Neutropenia DVT ___ Alcohol abuse now abstinent Hemorrhagic pericarditis c/b tamponade with pericardial window ___ Positive PPD HLD Osteoporosis Bipolar disorder Hemorrhoids ADHD PTSD Social History: ___ Family History: Father (living): coronary artery disease, diabetes, hypercholesterolemia, and depression. Prostate and head and neck cancer Mother (deceased): brain aneurysm and hyperthyroidism Physical Exam: ADMISSION PHYSICAL EXAM ======================== VS - 96.8; 131/87; 77; 18; 77; 18; 99RA; Pain ___ GENERAL: NAD HEENT: AT/NC, EOMI, PER, anicteric sclera, pink conjunctiva, MMM, good dentition NECK: nontender supple neck CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, mild TTP in LLQ, no rebound/guarding, no hepatosplenomegaly appreciated. No CVA Tenderness Rectal: large anal skin tag, no visible external hemmorhoids EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 extremities with purpose PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3. No gross deficits SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAM ======================= Vitals: T:98.3 BP:113/77 P:69 R:22 O2:99 RA GENERAL: Appears chronically ill, mild jaundice HEENT: AT/NC, EOMI, PER, anicteric sclera, pink conjunctiva, MMM, good dentition CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: well healed abdominal scar, +BS, mild TTP in RUQ and RLQ, no rebound/guarding, no hepatosplenomegaly appreciated. No CVA Tenderness Rectal: Per admission exam: large anal skin tag, no visible external hemmorhoids EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 extremities with purpose PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3. No gross deficits SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ============== ADMISSION LABS ============== ___ 04:00PM BLOOD WBC-3.8* RBC-4.58* Hgb-14.0 Hct-40.1 MCV-88 MCH-30.6 MCHC-34.9 RDW-14.5 RDWSD-46.1 Plt Ct-69* ___ 04:00PM BLOOD Neuts-75.4* Lymphs-15.2* Monos-6.6 Eos-0.5* Baso-0.5 Im ___ AbsNeut-2.87# AbsLymp-0.58* AbsMono-0.25 AbsEos-0.02* AbsBaso-0.02 ___ 04:00PM BLOOD Plt Ct-69* ___ 04:00PM BLOOD Glucose-95 UreaN-17 Creat-1.3* Na-140 K-4.1 Cl-105 HCO3-26 AnGap-13 ___ 04:00PM BLOOD ALT-49* AST-33 AlkPhos-76 TotBili-0.5 ============== PERTINENT LABS ============== ___ 07:10AM BLOOD CRP-0.7 ___ 07:10AM BLOOD tacroFK-4.8* ___ 10:00AM BLOOD tacroFK-8.0 ___ 09:35AM BLOOD tacroFK-6.6 ============= MICROBIOLOGY ============= ___ 7:15 am STOOL CONSISTENCY: LOOSE Source: Stool. **FINAL REPORT ___ OVA + PARASITES (Final ___: NO OVA AND PARASITES SEEN. This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. __________________________________________________________ ___ 10:00 am Immunology (CMV) **FINAL REPORT ___ CMV Viral Load (Final ___: CMV DNA not detected. Performed by Cobas Ampliprep / Cobas Taqman CMV Test. Linear range of quantification: 137 IU/mL - 9,100,000 IU/mL. Limit of detection 91 IU/mL. This test has been verified for use in the ___ patient population. __________________________________________________________ ___ 8:26 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final ___: NO OVA AND PARASITES SEEN. This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO FOUND. FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA FOUND. FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___: NO E.COLI 0157:H7 FOUND. __________________________________________________________ ___ 5:05 pm BLOOD CULTURE Blood Culture, Routine (Pending): __________________________________________________________ ___ 4:55 pm BLOOD CULTURE Blood Culture, Routine (Pending): __________________________________________________________ ___ 4:55 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: <10,000 organisms/ml. ======= IMAGING ======= CT Abdomen and Pelvis w/ Contrast 1. No evidence of diverticulosis or diverticulitis. 2. Status post liver transplant with normal appearance of the transplanted liver. 3. Stable splenomegaly. Flexible Sigmoidoscopy Biopsy: Results Pending ============== DISCHARGE LABS ============== ___ 07:33AM BLOOD WBC-2.4* RBC-4.48* Hgb-13.5* Hct-40.6 MCV-91 MCH-30.1 MCHC-33.3 RDW-14.8 RDWSD-49.0* Plt Ct-58* ___ 07:33AM BLOOD Plt Ct-58* ___ 07:33AM BLOOD Glucose-79 UreaN-6 Creat-1.2 Na-142 K-4.1 Cl-107 HCO3-28 AnGap-11 ___ 07:33AM BLOOD ALT-45* AST-32 AlkPhos-76 TotBili-0.7 ___ 07:33AM BLOOD Calcium-8.4 Phos-2.6* Mg-2.4 ___ 09:35AM BLOOD tacroFK-6.___ with hx of COPD, PBC s/p DDLTx (SCD ___ and pericarditis (on ASA 975mg TID) and hx of hemmorhoids who presents with BRBPR and abdominal pain. ============= ACTIVE ISSUES ============= #BRBPR/Abdominal Pain. He presented with BRBPR at home but did not exhibit further episodes of bleeding upon hospitalization. CT Abdomen and pelvis did not show any diverticulosis or diverticulitis. Hemoglobin/Hematocrit was trended and stable. C. diff was negative and stool studies were negative. CMV viral load was not detected. He underwent flexible sigmoidoscopy which showed rectal erythema and perianal skin tag/condyloma. Biopsies were taken and were pending at the time of discharge. Home Aspirin (for treatment of pericarditis) was held and outpatient cardiologist was notified who was in agreement with this plan. The patient will have follow up with colorectal surgery as an outpatient for evaluation of perianal skin tissues. On the day of discharge the patient was having normal bowel movements without blood and denies nausea and vomiting. His baseline adnominal pain was mild and stable. #H/o idiopathic hemorrhagic pericarditis/Recurrent chest pain: He did not exhibit chest pain during admission. Home Aspirin was held and outpatient cardiologist was notified who was in agreement with this plan. Colchicine and tramadol were continued. He will contact his outpatient cardiologist for recurrence of chest pain and advice on when/how to restart aspirin. #S/P PBC s/p liver tx ___ from CMV+ donor; cellular rejection in ___ ___s a hemorrhagic pericarditis with recurrent pericarditis. He was continued on home Prednisone and Tacrolimus with daily tacrolmius levels. LFTs were trended and demonstrated a mild ALT elevation ongoing and stable since ___. His last liver biopsy from ___ did not show any e/o rejection. ============== CHRONIC ISSUES ============== #Bipolar disorder: Continued home ARIPiprazole #COPD - Continued home albuterol, salmeterol. #GERD - Continued home omeprazole 40mg BID, ranitidine 150mg qHS #Chronic Neuropathic Pain - Continued Gabapentin 600mg BID #Nutritional Deficiency- Continued home Vit D 800U qD, calcium carbonate 500mg qD #Lymphopenia: This was trended and thought secondary to his immunosuppression. C diff was negative. #Thrombocytopenia: This was trended and thought secondary to his immunosuppression/liver disease. =================== Transitional Issues =================== Liver Transplant - Tacrolimus level on discharge: 6.6, dose 1mg BID Cardiology - Aspirin held in the setting of presenting GIB. Recommend discussion with Dr. ___ as an outpatient on appropriate timing of restarting ASA if chest pain reoccurs Mild Leukopenia: Patient found to have mild leukopenia in the setting of immunosuppression from transplant, please f/u and trend as outpatient. Gastroenterology - Please follow up biopsies from sigmoidoscopy. - Patient to follow up with colorectal surgery (to be scheduled) for evaluation of perianal skin # CODE: Full (confirmed) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea 2. Calcium Carbonate 500 mg PO DAILY 3. Colchicine 0.6 mg PO BID 4. Docusate Sodium 100 mg PO BID:PRN constipation 5. Gabapentin 600 mg PO BID 6. Omeprazole 40 mg PO BID 7. Ondansetron 4 mg PO Q8H:PRN nausea 8. PredniSONE 5 mg PO DAILY 9. Ranitidine 150 mg PO QHS 10. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H 11. Tacrolimus 1 mg PO Q12H 12. TraMADOL (Ultram) 50 mg PO TID:PRN pain 13. Vitamin D 800 UNIT PO DAILY 14. Aspirin EC 975 mg PO TID 15. ARIPiprazole 20 mg PO QHS 16. HydrOXYzine 25 mg PO QHS:PRN insomnia Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea 2. ARIPiprazole 20 mg PO QHS 3. Calcium Carbonate 500 mg PO DAILY 4. Colchicine 0.6 mg PO BID 5. Docusate Sodium 100 mg PO BID:PRN constipation 6. Gabapentin 600 mg PO BID 7. HydrOXYzine 25 mg PO QHS:PRN insomnia 8. Omeprazole 40 mg PO BID 9. Ondansetron 4 mg PO Q8H:PRN nausea 10. Ranitidine 150 mg PO QHS 11. TraMADOL (Ultram) 50 mg PO TID:PRN pain 12. Vitamin D 800 UNIT PO DAILY 13. PredniSONE 5 mg PO DAILY 14. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H 15. Tacrolimus 1 mg PO Q12H Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS ------------------- HEMATOCHEZIA SECONDARY DIAGNOSIS ------------------- H/o Pericarditis H/o Liver Transplant Bipolar COPD GERD Chronic neuropathic pain Lymphopenia Thrombocytopenia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were evaluated in the hospital for having bloody stools. You underwent a flexible sigmoidoscopy which did not show any evidence of bleeding. Several biopsies were taken which will be reviewed in the outpatient setting. Your home aspirin was held in the setting of bleeding. You will be following up with Dr. ___ on ___ to further determine your pericarditis treatment. Please follow up with you liver doctor for further evaluation on ___. You will also be set up to see a colorectal surgeon to evaluate a possible skin tag. We wish you the best, Your ___ Treatment Team Followup Instructions: ___
[ "K625", "Z944", "D6959", "R161", "G629", "J449", "Z86718", "E785", "F319", "M818", "Z87891", "A630", "I2510", "F909", "Z7982", "Z7952", "Z8249", "K219", "G8929", "D72810", "D72819", "K644", "L538" ]
Allergies: Penicillins / rifampin / Lamictal / lorazepam / risperidone Chief Complaint: BRBPR Major Surgical or Invasive Procedure: Sigmoidoscopy [MASKED] History of Present Illness: [MASKED] with hx of COPD, PBC s/p DDLTx (SCD [MASKED] c/b CMV viremia and acute rejection, and pericarditis (on ASA 975mg TID) and hx of hemmorhoids who presents with BRBPR. Patient noted blood in the toilet bowel water and on the toilet paper and on his stool. Stool brown in appearance and formed. Had 2x episodes of blood with BM starting at noon today. No further BMs or blood. Patient also endorses periumbilical abdominal pain since first [MASKED] where he noted blood. Pain is located in LLQ and comes and goes in waves. Occasional nausea but no vomiting. Patient has been tolerating PO without issues or associated pain/nausea. No recent illness, sick contacts, diarrhea. Patient initially presented to [MASKED] who directed him to [MASKED] given his transplant status. Most recent labs from [MASKED] demonstrate an H/H of 13.9/40.9, INR of 0.9, and plt ct of 67K. Mr [MASKED] denies any symptoms of orthostasis including dizziness, lightheadedness, or weakness. In the ED, initial VS were pain [MASKED]. T 96.6, HR 80, BP 137/92, RR 18 satting 100% on RA. Initial labs notable for Cr of 1.3, Alt 49, AST 33, TBili 0.5, WBC 3.8, Hgb 14, Plt 69. INR 1. Patient given 500cc NS and 5mg Morphine x3. Blood Cx, Urine Cx obtained. CT abdomen/Pelvis without evidence of acute pathology. On arrival to the floor, patient states that he continues to have mild LLQ pain, but this has improved with IV morphine. He has not other complaints. REVIEW OF SYSTEMS: Denies fever, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, melena, dysuria, hematuria. All other 10-system review negative in detail. Past Medical History: PBC s/p deceased liver donor tx [MASKED] Neutropenia DVT [MASKED] Alcohol abuse now abstinent Hemorrhagic pericarditis c/b tamponade with pericardial window [MASKED] Positive PPD HLD Osteoporosis Bipolar disorder Hemorrhoids ADHD PTSD Social History: [MASKED] Family History: Father (living): coronary artery disease, diabetes, hypercholesterolemia, and depression. Prostate and head and neck cancer Mother (deceased): brain aneurysm and hyperthyroidism Physical Exam: ADMISSION PHYSICAL EXAM ======================== VS - 96.8; 131/87; 77; 18; 77; 18; 99RA; Pain [MASKED] GENERAL: NAD HEENT: AT/NC, EOMI, PER, anicteric sclera, pink conjunctiva, MMM, good dentition NECK: nontender supple neck CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, mild TTP in LLQ, no rebound/guarding, no hepatosplenomegaly appreciated. No CVA Tenderness Rectal: large anal skin tag, no visible external hemmorhoids EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 extremities with purpose PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3. No gross deficits SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAM ======================= Vitals: T:98.3 BP:113/77 P:69 R:22 O2:99 RA GENERAL: Appears chronically ill, mild jaundice HEENT: AT/NC, EOMI, PER, anicteric sclera, pink conjunctiva, MMM, good dentition CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: well healed abdominal scar, +BS, mild TTP in RUQ and RLQ, no rebound/guarding, no hepatosplenomegaly appreciated. No CVA Tenderness Rectal: Per admission exam: large anal skin tag, no visible external hemmorhoids EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 extremities with purpose PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3. No gross deficits SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ============== ADMISSION LABS ============== [MASKED] 04:00PM BLOOD WBC-3.8* RBC-4.58* Hgb-14.0 Hct-40.1 MCV-88 MCH-30.6 MCHC-34.9 RDW-14.5 RDWSD-46.1 Plt Ct-69* [MASKED] 04:00PM BLOOD Neuts-75.4* Lymphs-15.2* Monos-6.6 Eos-0.5* Baso-0.5 Im [MASKED] AbsNeut-2.87# AbsLymp-0.58* AbsMono-0.25 AbsEos-0.02* AbsBaso-0.02 [MASKED] 04:00PM BLOOD Plt Ct-69* [MASKED] 04:00PM BLOOD Glucose-95 UreaN-17 Creat-1.3* Na-140 K-4.1 Cl-105 HCO3-26 AnGap-13 [MASKED] 04:00PM BLOOD ALT-49* AST-33 AlkPhos-76 TotBili-0.5 ============== PERTINENT LABS ============== [MASKED] 07:10AM BLOOD CRP-0.7 [MASKED] 07:10AM BLOOD tacroFK-4.8* [MASKED] 10:00AM BLOOD tacroFK-8.0 [MASKED] 09:35AM BLOOD tacroFK-6.6 ============= MICROBIOLOGY ============= [MASKED] 7:15 am STOOL CONSISTENCY: LOOSE Source: Stool. **FINAL REPORT [MASKED] OVA + PARASITES (Final [MASKED]: NO OVA AND PARASITES SEEN. This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. [MASKED] [MASKED] 10:00 am Immunology (CMV) **FINAL REPORT [MASKED] CMV Viral Load (Final [MASKED]: CMV DNA not detected. Performed by Cobas Ampliprep / Cobas Taqman CMV Test. Linear range of quantification: 137 IU/mL - 9,100,000 IU/mL. Limit of detection 91 IU/mL. This test has been verified for use in the [MASKED] patient population. [MASKED] [MASKED] 8:26 pm 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). FECAL CULTURE (Final [MASKED]: NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [MASKED]: NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final [MASKED]: NO OVA AND PARASITES SEEN. This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. FECAL CULTURE - R/O 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 0157:H7 FOUND. [MASKED] [MASKED] 5:05 pm BLOOD CULTURE Blood Culture, Routine (Pending): [MASKED] [MASKED] 4:55 pm BLOOD CULTURE Blood Culture, Routine (Pending): [MASKED] [MASKED] 4:55 pm URINE **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: <10,000 organisms/ml. ======= IMAGING ======= CT Abdomen and Pelvis w/ Contrast 1. No evidence of diverticulosis or diverticulitis. 2. Status post liver transplant with normal appearance of the transplanted liver. 3. Stable splenomegaly. Flexible Sigmoidoscopy Biopsy: Results Pending ============== DISCHARGE LABS ============== [MASKED] 07:33AM BLOOD WBC-2.4* RBC-4.48* Hgb-13.5* Hct-40.6 MCV-91 MCH-30.1 MCHC-33.3 RDW-14.8 RDWSD-49.0* Plt Ct-58* [MASKED] 07:33AM BLOOD Plt Ct-58* [MASKED] 07:33AM BLOOD Glucose-79 UreaN-6 Creat-1.2 Na-142 K-4.1 Cl-107 HCO3-28 AnGap-11 [MASKED] 07:33AM BLOOD ALT-45* AST-32 AlkPhos-76 TotBili-0.7 [MASKED] 07:33AM BLOOD Calcium-8.4 Phos-2.6* Mg-2.4 [MASKED] 09:35AM BLOOD tacroFK-6.[MASKED] with hx of COPD, PBC s/p DDLTx (SCD [MASKED] and pericarditis (on ASA 975mg TID) and hx of hemmorhoids who presents with BRBPR and abdominal pain. ============= ACTIVE ISSUES ============= #BRBPR/Abdominal Pain. He presented with BRBPR at home but did not exhibit further episodes of bleeding upon hospitalization. CT Abdomen and pelvis did not show any diverticulosis or diverticulitis. Hemoglobin/Hematocrit was trended and stable. C. diff was negative and stool studies were negative. CMV viral load was not detected. He underwent flexible sigmoidoscopy which showed rectal erythema and perianal skin tag/condyloma. Biopsies were taken and were pending at the time of discharge. Home Aspirin (for treatment of pericarditis) was held and outpatient cardiologist was notified who was in agreement with this plan. The patient will have follow up with colorectal surgery as an outpatient for evaluation of perianal skin tissues. On the day of discharge the patient was having normal bowel movements without blood and denies nausea and vomiting. His baseline adnominal pain was mild and stable. #H/o idiopathic hemorrhagic pericarditis/Recurrent chest pain: He did not exhibit chest pain during admission. Home Aspirin was held and outpatient cardiologist was notified who was in agreement with this plan. Colchicine and tramadol were continued. He will contact his outpatient cardiologist for recurrence of chest pain and advice on when/how to restart aspirin. #S/P PBC s/p liver tx [MASKED] from CMV+ donor; cellular rejection in [MASKED] s a hemorrhagic pericarditis with recurrent pericarditis. He was continued on home Prednisone and Tacrolimus with daily tacrolmius levels. LFTs were trended and demonstrated a mild ALT elevation ongoing and stable since [MASKED]. His last liver biopsy from [MASKED] did not show any e/o rejection. ============== CHRONIC ISSUES ============== #Bipolar disorder: Continued home ARIPiprazole #COPD - Continued home albuterol, salmeterol. #GERD - Continued home omeprazole 40mg BID, ranitidine 150mg qHS #Chronic Neuropathic Pain - Continued Gabapentin 600mg BID #Nutritional Deficiency- Continued home Vit D 800U qD, calcium carbonate 500mg qD #Lymphopenia: This was trended and thought secondary to his immunosuppression. C diff was negative. #Thrombocytopenia: This was trended and thought secondary to his immunosuppression/liver disease. =================== Transitional Issues =================== Liver Transplant - Tacrolimus level on discharge: 6.6, dose 1mg BID Cardiology - Aspirin held in the setting of presenting GIB. Recommend discussion with Dr. [MASKED] as an outpatient on appropriate timing of restarting ASA if chest pain reoccurs Mild Leukopenia: Patient found to have mild leukopenia in the setting of immunosuppression from transplant, please f/u and trend as outpatient. Gastroenterology - Please follow up biopsies from sigmoidoscopy. - Patient to follow up with colorectal surgery (to be scheduled) for evaluation of perianal skin # CODE: Full (confirmed) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea 2. Calcium Carbonate 500 mg PO DAILY 3. Colchicine 0.6 mg PO BID 4. Docusate Sodium 100 mg PO BID:PRN constipation 5. Gabapentin 600 mg PO BID 6. Omeprazole 40 mg PO BID 7. Ondansetron 4 mg PO Q8H:PRN nausea 8. PredniSONE 5 mg PO DAILY 9. Ranitidine 150 mg PO QHS 10. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H 11. Tacrolimus 1 mg PO Q12H 12. TraMADOL (Ultram) 50 mg PO TID:PRN pain 13. Vitamin D 800 UNIT PO DAILY 14. Aspirin EC 975 mg PO TID 15. ARIPiprazole 20 mg PO QHS 16. HydrOXYzine 25 mg PO QHS:PRN insomnia Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea 2. ARIPiprazole 20 mg PO QHS 3. Calcium Carbonate 500 mg PO DAILY 4. Colchicine 0.6 mg PO BID 5. Docusate Sodium 100 mg PO BID:PRN constipation 6. Gabapentin 600 mg PO BID 7. HydrOXYzine 25 mg PO QHS:PRN insomnia 8. Omeprazole 40 mg PO BID 9. Ondansetron 4 mg PO Q8H:PRN nausea 10. Ranitidine 150 mg PO QHS 11. TraMADOL (Ultram) 50 mg PO TID:PRN pain 12. Vitamin D 800 UNIT PO DAILY 13. PredniSONE 5 mg PO DAILY 14. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H 15. Tacrolimus 1 mg PO Q12H Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS ------------------- HEMATOCHEZIA SECONDARY DIAGNOSIS ------------------- H/o Pericarditis H/o Liver Transplant Bipolar COPD GERD Chronic neuropathic pain Lymphopenia Thrombocytopenia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], You were evaluated in the hospital for having bloody stools. You underwent a flexible sigmoidoscopy which did not show any evidence of bleeding. Several biopsies were taken which will be reviewed in the outpatient setting. Your home aspirin was held in the setting of bleeding. You will be following up with Dr. [MASKED] on [MASKED] to further determine your pericarditis treatment. Please follow up with you liver doctor for further evaluation on [MASKED]. You will also be set up to see a colorectal surgeon to evaluate a possible skin tag. We wish you the best, Your [MASKED] Treatment Team Followup Instructions: [MASKED]
[]
[ "J449", "Z86718", "E785", "Z87891", "I2510", "K219", "G8929" ]
[ "K625: Hemorrhage of anus and rectum", "Z944: Liver transplant status", "D6959: Other secondary thrombocytopenia", "R161: Splenomegaly, not elsewhere classified", "G629: Polyneuropathy, unspecified", "J449: Chronic obstructive pulmonary disease, unspecified", "Z86718: Personal history of other venous thrombosis and embolism", "E785: Hyperlipidemia, unspecified", "F319: Bipolar disorder, unspecified", "M818: Other osteoporosis without current pathological fracture", "Z87891: Personal history of nicotine dependence", "A630: Anogenital (venereal) warts", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "F909: Attention-deficit hyperactivity disorder, unspecified type", "Z7982: Long term (current) use of aspirin", "Z7952: Long term (current) use of systemic steroids", "Z8249: Family history of ischemic heart disease and other diseases of the circulatory system", "K219: Gastro-esophageal reflux disease without esophagitis", "G8929: Other chronic pain", "D72810: Lymphocytopenia", "D72819: Decreased white blood cell count, unspecified", "K644: Residual hemorrhoidal skin tags", "L538: Other specified erythematous conditions" ]
19,992,875
28,476,580
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / rifampin / Lamictal / lorazepam / risperidone / mushrooms Attending: ___ Chief Complaint: Diarrhea Major Surgical or Invasive Procedure: Flexible sigmoidoscopy (___) History of Present Illness: Mr. ___ is a ___ man with PBC s/p liver transplantation in ___ (on tacrolimus/prednisone), pericarditis c/b tamponade with pericardial window, bipolar disorder, & recurrent C Difficile with recent hospitalization, who presents with diarrhea & abdominal pain. Patient was discharged on ___ with a course of oral Vancomycin for C diff colitis, which he completed on ___. He had minor improvement in his watery stools, experiencing ___ days of formed stool at the end of his antibiotic treatment course. After completing his Vancomycin course, he continued to have intermittent diarrhea. Three days ago, he developed acutely worsening diarrhea with ___ episodes of loose, water, brown stool. Diarrhea has been getting worse. It is associated with abdominal pain, subjective fevers, nausea, & limited PO intake. No vomiting. Abdominal pain is diffuse, and a ___ at worse. He has been on a stable dose of Prednisone/Tacrolimus for years, with no recent changes in dose. In the ED, initial vitals were: 98.3 114 127/99 18 100% RA Exam notable for diffuse ttp, no r/g Labs notable for WBC 2.6, plts 88 (baseline) Imaging notable for KUB without evidence of obstruction or perforation GI was consulted and recommended: PO Vancomycin Patient was given: 1L NS, 4mg IV Morphine, & 4mg IV Zofran. Decision was made to admit for likely C diff colitis. Vitals prior to transfer: 110 154/84 18 100% RA On the floor, he feels okay. He has diffuse, ___ abdominal pain, slightly better than when he first came to the ED. He hasn't had diarrhea since coming to the ED. No pain anywhere else. He says this feels similar to when he has been admitted for C dif in the past, but this time his abdominal pain is worse. Past Medical History: PAST MEDICAL HISTORY: PBC s/p deceased liver donor tx ___ Neutropenia DVT ___ Prior alcohol abuse now abstinent Hemorrhagic pericarditis c/b tamponade with pericardial window ___ Positive PPD s/p INH HLD Osteoporosis Bipolar disorder Hemorrhoids ADHD PTSD Social History: ___ Family History: Father (living): coronary artery disease, diabetes, hypercholesterolemia, and depression. Prostate and head and neck cancer Mother (deceased): brain aneurysm and hyperthyroidism Physical Exam: ADMISSION PHYSICAL EXAM: ======================== Vital Signs: 97.9 PO 133 / 97 63 18 98 RA Gen: well appearing man, NAD, nontoxic HEENT: no scleral icterus, dry mm CV: Tachycardic, no m/r/g PULM: lungs clear bilaterally ABD: soft, mildly tender to palpation diffusely no r/g, normal bowel sounds GU: no foley EXT: warm, no edema NEURO: CN II-XII intact, moving all 4 extremities, mentating well DISCHARGE PHYSICAL EXAM: ======================== VS: 97.4 ___ 16 97 ra General: Alert, oriented, no acute distress HEENT: Round face with puffy cheeks and jaw, sclera anicteric, MMM, oropharynx clear Neck: supple, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Soft, non-distended with scar in RUQ. Diffusely tender to deep palpation. No rebound. No psoas or heel tap sign. Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. Tender to palpation throughout. Skin: Skin is thin, no rashes noted. Multiple tattoos. Neuro: CNII-XII intact. Sensation intact to light touch in all four extremities. Pertinent Results: ADMISSION LAB VALUES: ===================== ___ 05:50PM BLOOD WBC-2.6* RBC-5.27 Hgb-15.8 Hct-45.1 MCV-86 MCH-30.0 MCHC-35.0 RDW-14.8 RDWSD-46.4* Plt Ct-88* ___ 05:50PM BLOOD Neuts-62.0 ___ Monos-7.8 Eos-0.4* Baso-1.2* Im ___ AbsNeut-1.58*# AbsLymp-0.71* AbsMono-0.20 AbsEos-0.01* AbsBaso-0.03 ___ 05:50PM BLOOD ___ PTT-28.9 ___ ___ 05:50PM BLOOD Glucose-94 UreaN-10 Creat-1.0 Na-139 K-4.2 Cl-105 HCO3-22 AnGap-16 ___ 05:50PM BLOOD ALT-23 AST-26 AlkPhos-102 TotBili-0.8 ___ 05:50PM BLOOD Lipase-23 ___ 05:50PM BLOOD Albumin-4.7 Calcium-9.1 Phos-3.1 Mg-1.9 ___ 06:20PM BLOOD Lactate-1.2 ___ 05:50PM URINE Color-Straw Appear-Clear Sp ___ ___ 05:50PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG OTHER PERTINENT LABS: ===================== ___ 06:31AM BLOOD WBC-2.8* RBC-4.68 Hgb-14.3 Hct-41.2 MCV-88 MCH-30.6 MCHC-34.7 RDW-15.2 RDWSD-49.1* Plt Ct-67* ___ 07:48AM BLOOD WBC-3.9* RBC-5.13 Hgb-15.7 Hct-44.3 MCV-86 MCH-30.6 MCHC-35.4 RDW-15.1 RDWSD-48.3* Plt Ct-99* ___ 06:31AM BLOOD Glucose-77 UreaN-9 Creat-1.1 Na-139 K-3.7 Cl-105 HCO3-26 AnGap-12 ___ 07:48AM BLOOD Glucose-87 UreaN-12 Creat-1.3* Na-139 K-4.3 Cl-102 HCO3-23 AnGap-18 ___ 06:31AM BLOOD Calcium-8.3* Phos-3.1 Mg-1.9 ___ 10:30AM BLOOD tacroFK-5.9 ___ 07:48AM BLOOD tacroFK-6.4 MICROBIOLOGY: ============= ___ 5:50 URINE CULTURE (Final ___: NO GROWTH. ___ 5:50 pm BLOOD CULTURE:Routine (Pending) ___ 6:08 pm BLOOD CULTURE:Routine (Pending) ___ 7:44 pm CMV Viral Load (Pending): IMAGING/OTHER STUDIES: ====================== ___ 7:28 ___ ABDOMEN (SUPINE & ERECT): IMPRESSION: No evidence for small bowel obstruction, ileus or toxic megacolon. Air-fluid levels in the right abdomen likely reflect fluid within the colon, compatible with the history of diarrhea. DISCHARGE LABS: =============== ___ 06:45AM BLOOD WBC-2.7* RBC-4.42* Hgb-13.2* Hct-39.1* MCV-89 MCH-29.9 MCHC-33.8 RDW-14.8 RDWSD-47.9* Plt Ct-73* ___ 06:45AM BLOOD Plt Ct-73* ___ 06:45AM BLOOD Glucose-84 UreaN-12 Creat-1.2 Na-139 K-4.0 Cl-104 HCO3-24 AnGap-15 ___ 06:45AM BLOOD Calcium-8.5 Phos-3.2 Mg-1.8 ___ 06:45AM BLOOD tacroFK-4.9* Brief Hospital Course: Mr. ___ is a ___ man with PBC s/p liver transplantation in ___ (on tacrolimus/ prednisone), pericarditis c/b tamponade with pericardial window, bipolar disorder, & recurrent C Difficile with recent hospitalization, who presents with diarrhea & abdominal pain, concerning for relapsed C diff diarrhea. ACUTE ISSUES: ============= # DIARRHEA & # ABDOMINAL PAIN: Initial presentation with diffusely tender abdomen concerning for toxic megacolon or SBO, however, ___ ruled out those etiologies. Patient continued to pass gas, but had no bowel movements for his first 72 hours in the hospital. This was felt to be a C diff relapse based on his history and reports of frequent loose stools at home. The team added IV metronidazole to his usual oral vancomycin regimen. ID was consulted. Stool studies were obtained. On hospital day 4 a flexible sigmoidoscopy was completed. It showed erythema consistent with prior tap water enema. On discharge the patient was informed of the usual course of recovery from C diff infections, including to expect intermittent loose stools for the next few months. He was hemodynamically stable, tolerating PO, and not having diarrhea. # ORTHOSTATIC HYPOTENSION: Patient had reported subjective lightheadedness that did not resolve with initial PO intake on hospital days 1 and 2. On hospital day 3, he was confirmed to have orthostatic vital signs. He was treated with a 1L bolus of NS. On subsequent days he improved. CHRONIC ISSUES: =============== # PBC S/P OLT WITH CMV+ DONOR C/B CELLULAR REJECTION, HEMORRHAGIC PERICARDITIS, RECURRENT PERICARDITIS: Had one episode of chest pain on ___ in the AM. EKG and trops were obtained, ruled out ACS. Pulsus was 5mmHg. This was most likely costochondritis, for which he received ASA 650mg x1 and hydromorphone 1mg PO x1. Patient continued on home tacrolimus/prednisone doses and daily tacro levels were appropriate. Daily LFTs were also WNL. # THROMBOCYTOPENIA. Stable throughout admission. Patient has known chronic thrombocytopenia likely due to liver disease, immunosuppression and hypersplenism. # BIPOLAR DISORDER. No acute issues. Recently off of Abilify. Monitored without need to restart therapy. # GERD: Stable. Possibly contributing to abdominal pain as described above with C diff infection. Continued home ranitidine 150mg qHS, maalox PRN. # CHRONIC NEUROPATHIC PAIN: Stable. Continued on home Gabapentin 600mg BID # COPD: No SOB throughout admission. Continued home albuterol prn TRANSITIONAL ISSUES: -------------------- # LOOSE STOOLS: Patient informed that C diff recovery includes loose stools for months and he should expect this. # PAIN: Consider referral to pain specialist. Would benefit from weaning opiates and possibly starting duloxetine or nortriptyline. Patient discharged with 15 tramadol 50mg, as he has a follow-up appointment in 6 days. # BLOOD COUNTS: Chronic leukopenia and thrombocytopenia, stable this hospitalization. # PENDING STUDIES: Some stool and STI studies are pending at the time of discharge. The patient will be contacted if results are positive. ------------------ Important numbers WBC: 2.7 (___) PLT: 73 (___) Tacro: 5.4 (___) ------------------ # CODE: Full (presumed) # CONTACT: father/HCP ___ ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 650 mg PO BID 2. Colchicine 0.6 mg PO BID 3. Gabapentin 600 mg PO BID 4. Ondansetron 4 mg PO Q8H:PRN nausea 5. PredniSONE 5 mg PO DAILY 6. Ranitidine 150 mg PO QHS 7. Tacrolimus 1 mg PO QPM 8. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain 9. Tacrolimus 1 mg PO QAM Discharge Medications: 1. Aspirin 650 mg PO BID 2. Colchicine 0.6 mg PO BID 3. Gabapentin 600 mg PO BID 4. Ondansetron 4 mg PO Q8H:PRN nausea 5. PredniSONE 5 mg PO DAILY 6. Ranitidine 150 mg PO QHS 7. Tacrolimus 1 mg PO QPM 8. Tacrolimus 1 mg PO QAM 9. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES: ================== Diarrhea, unspecified Generalized abdominal pain Orthostatic Hypotension SECONDARY DIAGNOSES: ==================== Primary biliary cirrhosis status-post orthotopic liver transplant with cytomegalovirus-positive donor, complicated by cellular rejection, hemorrhagic pericarditis and recurrent pericarditis Thrombocytopenia Chronic immunosuppression Gastroesophageal reflux disease Chronic neuropathic pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You came to ___ because you had abdominal pain and diarrhea. What was done for me while I was in the hospital? - You received fluids because you had become dehydrated - We did studies of your blood and stool to look for a cause of your infection. There was no infection. - The gastroenterologists did a flexible sigmoidoscopy to examine your sigmoid colon for evidence of infection. They did not see any evidence of infection. - You were visited by our Infectious Diseases doctors for ___ and treatment of your diarrhea. They recommended some additional studies. They agreed with the decision to stop your antibiotics. - You received a new antibiotic for your diarrhea in case it was recurrent Clostridium difficile diarrhea. Fortunately, you did not have recurrent diarrhea, so we stopped your antibiotics. What should I do now that I am leaving the hospital? - Continue to take your medications as prescribed. You do not need to take any more antibiotics. - Expect to have loose stools, up to 1 or 2 per day, for the next few months. Your colon is recovering from your Clostridium difficile infection in ___. - Call the doctor if you have 6 or more loose stools per day. - Attend a follow-up appointment with your primary care doctor. - Attend a follow-up appointment with your liver transplant doctor. - Consider seeing a pain specialist to help treat your multiple causes of pain. It was a pleasure taking care of you. Wishing you all the best! - Your ___ Team Followup Instructions: ___
[ "R197", "D6959", "Z944", "G629", "R1084", "I951", "K219", "F319", "D72818", "Z87891", "F901", "F4310", "M940", "J449", "K6289", "K5289", "Z86718" ]
Allergies: Penicillins / rifampin / Lamictal / lorazepam / risperidone / mushrooms Chief Complaint: Diarrhea Major Surgical or Invasive Procedure: Flexible sigmoidoscopy ([MASKED]) History of Present Illness: Mr. [MASKED] is a [MASKED] man with PBC s/p liver transplantation in [MASKED] (on tacrolimus/prednisone), pericarditis c/b tamponade with pericardial window, bipolar disorder, & recurrent C Difficile with recent hospitalization, who presents with diarrhea & abdominal pain. Patient was discharged on [MASKED] with a course of oral Vancomycin for C diff colitis, which he completed on [MASKED]. He had minor improvement in his watery stools, experiencing [MASKED] days of formed stool at the end of his antibiotic treatment course. After completing his Vancomycin course, he continued to have intermittent diarrhea. Three days ago, he developed acutely worsening diarrhea with [MASKED] episodes of loose, water, brown stool. Diarrhea has been getting worse. It is associated with abdominal pain, subjective fevers, nausea, & limited PO intake. No vomiting. Abdominal pain is diffuse, and a [MASKED] at worse. He has been on a stable dose of Prednisone/Tacrolimus for years, with no recent changes in dose. In the ED, initial vitals were: 98.3 114 127/99 18 100% RA Exam notable for diffuse ttp, no r/g Labs notable for WBC 2.6, plts 88 (baseline) Imaging notable for KUB without evidence of obstruction or perforation GI was consulted and recommended: PO Vancomycin Patient was given: 1L NS, 4mg IV Morphine, & 4mg IV Zofran. Decision was made to admit for likely C diff colitis. Vitals prior to transfer: 110 154/84 18 100% RA On the floor, he feels okay. He has diffuse, [MASKED] abdominal pain, slightly better than when he first came to the ED. He hasn't had diarrhea since coming to the ED. No pain anywhere else. He says this feels similar to when he has been admitted for C dif in the past, but this time his abdominal pain is worse. Past Medical History: PAST MEDICAL HISTORY: PBC s/p deceased liver donor tx [MASKED] Neutropenia DVT [MASKED] Prior alcohol abuse now abstinent Hemorrhagic pericarditis c/b tamponade with pericardial window [MASKED] Positive PPD s/p INH HLD Osteoporosis Bipolar disorder Hemorrhoids ADHD PTSD Social History: [MASKED] Family History: Father (living): coronary artery disease, diabetes, hypercholesterolemia, and depression. Prostate and head and neck cancer Mother (deceased): brain aneurysm and hyperthyroidism Physical Exam: ADMISSION PHYSICAL EXAM: ======================== Vital Signs: 97.9 PO 133 / 97 63 18 98 RA Gen: well appearing man, NAD, nontoxic HEENT: no scleral icterus, dry mm CV: Tachycardic, no m/r/g PULM: lungs clear bilaterally ABD: soft, mildly tender to palpation diffusely no r/g, normal bowel sounds GU: no foley EXT: warm, no edema NEURO: CN II-XII intact, moving all 4 extremities, mentating well DISCHARGE PHYSICAL EXAM: ======================== VS: 97.4 [MASKED] 16 97 ra General: Alert, oriented, no acute distress HEENT: Round face with puffy cheeks and jaw, sclera anicteric, MMM, oropharynx clear Neck: supple, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Soft, non-distended with scar in RUQ. Diffusely tender to deep palpation. No rebound. No psoas or heel tap sign. Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. Tender to palpation throughout. Skin: Skin is thin, no rashes noted. Multiple tattoos. Neuro: CNII-XII intact. Sensation intact to light touch in all four extremities. Pertinent Results: ADMISSION LAB VALUES: ===================== [MASKED] 05:50PM BLOOD WBC-2.6* RBC-5.27 Hgb-15.8 Hct-45.1 MCV-86 MCH-30.0 MCHC-35.0 RDW-14.8 RDWSD-46.4* Plt Ct-88* [MASKED] 05:50PM BLOOD Neuts-62.0 [MASKED] Monos-7.8 Eos-0.4* Baso-1.2* Im [MASKED] AbsNeut-1.58*# AbsLymp-0.71* AbsMono-0.20 AbsEos-0.01* AbsBaso-0.03 [MASKED] 05:50PM BLOOD [MASKED] PTT-28.9 [MASKED] [MASKED] 05:50PM BLOOD Glucose-94 UreaN-10 Creat-1.0 Na-139 K-4.2 Cl-105 HCO3-22 AnGap-16 [MASKED] 05:50PM BLOOD ALT-23 AST-26 AlkPhos-102 TotBili-0.8 [MASKED] 05:50PM BLOOD Lipase-23 [MASKED] 05:50PM BLOOD Albumin-4.7 Calcium-9.1 Phos-3.1 Mg-1.9 [MASKED] 06:20PM BLOOD Lactate-1.2 [MASKED] 05:50PM URINE Color-Straw Appear-Clear Sp [MASKED] [MASKED] 05:50PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG OTHER PERTINENT LABS: ===================== [MASKED] 06:31AM BLOOD WBC-2.8* RBC-4.68 Hgb-14.3 Hct-41.2 MCV-88 MCH-30.6 MCHC-34.7 RDW-15.2 RDWSD-49.1* Plt Ct-67* [MASKED] 07:48AM BLOOD WBC-3.9* RBC-5.13 Hgb-15.7 Hct-44.3 MCV-86 MCH-30.6 MCHC-35.4 RDW-15.1 RDWSD-48.3* Plt Ct-99* [MASKED] 06:31AM BLOOD Glucose-77 UreaN-9 Creat-1.1 Na-139 K-3.7 Cl-105 HCO3-26 AnGap-12 [MASKED] 07:48AM BLOOD Glucose-87 UreaN-12 Creat-1.3* Na-139 K-4.3 Cl-102 HCO3-23 AnGap-18 [MASKED] 06:31AM BLOOD Calcium-8.3* Phos-3.1 Mg-1.9 [MASKED] 10:30AM BLOOD tacroFK-5.9 [MASKED] 07:48AM BLOOD tacroFK-6.4 MICROBIOLOGY: ============= [MASKED] 5:50 URINE CULTURE (Final [MASKED]: NO GROWTH. [MASKED] 5:50 pm BLOOD CULTURE:Routine (Pending) [MASKED] 6:08 pm BLOOD CULTURE:Routine (Pending) [MASKED] 7:44 pm CMV Viral Load (Pending): IMAGING/OTHER STUDIES: ====================== [MASKED] 7:28 [MASKED] ABDOMEN (SUPINE & ERECT): IMPRESSION: No evidence for small bowel obstruction, ileus or toxic megacolon. Air-fluid levels in the right abdomen likely reflect fluid within the colon, compatible with the history of diarrhea. DISCHARGE LABS: =============== [MASKED] 06:45AM BLOOD WBC-2.7* RBC-4.42* Hgb-13.2* Hct-39.1* MCV-89 MCH-29.9 MCHC-33.8 RDW-14.8 RDWSD-47.9* Plt Ct-73* [MASKED] 06:45AM BLOOD Plt Ct-73* [MASKED] 06:45AM BLOOD Glucose-84 UreaN-12 Creat-1.2 Na-139 K-4.0 Cl-104 HCO3-24 AnGap-15 [MASKED] 06:45AM BLOOD Calcium-8.5 Phos-3.2 Mg-1.8 [MASKED] 06:45AM BLOOD tacroFK-4.9* Brief Hospital Course: Mr. [MASKED] is a [MASKED] man with PBC s/p liver transplantation in [MASKED] (on tacrolimus/ prednisone), pericarditis c/b tamponade with pericardial window, bipolar disorder, & recurrent C Difficile with recent hospitalization, who presents with diarrhea & abdominal pain, concerning for relapsed C diff diarrhea. ACUTE ISSUES: ============= # DIARRHEA & # ABDOMINAL PAIN: Initial presentation with diffusely tender abdomen concerning for toxic megacolon or SBO, however, [MASKED] ruled out those etiologies. Patient continued to pass gas, but had no bowel movements for his first 72 hours in the hospital. This was felt to be a C diff relapse based on his history and reports of frequent loose stools at home. The team added IV metronidazole to his usual oral vancomycin regimen. ID was consulted. Stool studies were obtained. On hospital day 4 a flexible sigmoidoscopy was completed. It showed erythema consistent with prior tap water enema. On discharge the patient was informed of the usual course of recovery from C diff infections, including to expect intermittent loose stools for the next few months. He was hemodynamically stable, tolerating PO, and not having diarrhea. # ORTHOSTATIC HYPOTENSION: Patient had reported subjective lightheadedness that did not resolve with initial PO intake on hospital days 1 and 2. On hospital day 3, he was confirmed to have orthostatic vital signs. He was treated with a 1L bolus of NS. On subsequent days he improved. CHRONIC ISSUES: =============== # PBC S/P OLT WITH CMV+ DONOR C/B CELLULAR REJECTION, HEMORRHAGIC PERICARDITIS, RECURRENT PERICARDITIS: Had one episode of chest pain on [MASKED] in the AM. EKG and trops were obtained, ruled out ACS. Pulsus was 5mmHg. This was most likely costochondritis, for which he received ASA 650mg x1 and hydromorphone 1mg PO x1. Patient continued on home tacrolimus/prednisone doses and daily tacro levels were appropriate. Daily LFTs were also WNL. # THROMBOCYTOPENIA. Stable throughout admission. Patient has known chronic thrombocytopenia likely due to liver disease, immunosuppression and hypersplenism. # BIPOLAR DISORDER. No acute issues. Recently off of Abilify. Monitored without need to restart therapy. # GERD: Stable. Possibly contributing to abdominal pain as described above with C diff infection. Continued home ranitidine 150mg qHS, maalox PRN. # CHRONIC NEUROPATHIC PAIN: Stable. Continued on home Gabapentin 600mg BID # COPD: No SOB throughout admission. Continued home albuterol prn TRANSITIONAL ISSUES: -------------------- # LOOSE STOOLS: Patient informed that C diff recovery includes loose stools for months and he should expect this. # PAIN: Consider referral to pain specialist. Would benefit from weaning opiates and possibly starting duloxetine or nortriptyline. Patient discharged with 15 tramadol 50mg, as he has a follow-up appointment in 6 days. # BLOOD COUNTS: Chronic leukopenia and thrombocytopenia, stable this hospitalization. # PENDING STUDIES: Some stool and STI studies are pending at the time of discharge. The patient will be contacted if results are positive. ------------------ Important numbers WBC: 2.7 ([MASKED]) PLT: 73 ([MASKED]) Tacro: 5.4 ([MASKED]) ------------------ # CODE: Full (presumed) # CONTACT: father/HCP [MASKED] [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 650 mg PO BID 2. Colchicine 0.6 mg PO BID 3. Gabapentin 600 mg PO BID 4. Ondansetron 4 mg PO Q8H:PRN nausea 5. PredniSONE 5 mg PO DAILY 6. Ranitidine 150 mg PO QHS 7. Tacrolimus 1 mg PO QPM 8. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain 9. Tacrolimus 1 mg PO QAM Discharge Medications: 1. Aspirin 650 mg PO BID 2. Colchicine 0.6 mg PO BID 3. Gabapentin 600 mg PO BID 4. Ondansetron 4 mg PO Q8H:PRN nausea 5. PredniSONE 5 mg PO DAILY 6. Ranitidine 150 mg PO QHS 7. Tacrolimus 1 mg PO QPM 8. Tacrolimus 1 mg PO QAM 9. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES: ================== Diarrhea, unspecified Generalized abdominal pain Orthostatic Hypotension SECONDARY DIAGNOSES: ==================== Primary biliary cirrhosis status-post orthotopic liver transplant with cytomegalovirus-positive donor, complicated by cellular rejection, hemorrhagic pericarditis and recurrent pericarditis Thrombocytopenia Chronic immunosuppression Gastroesophageal reflux disease Chronic neuropathic pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], You came to [MASKED] because you had abdominal pain and diarrhea. What was done for me while I was in the hospital? - You received fluids because you had become dehydrated - We did studies of your blood and stool to look for a cause of your infection. There was no infection. - The gastroenterologists did a flexible sigmoidoscopy to examine your sigmoid colon for evidence of infection. They did not see any evidence of infection. - You were visited by our Infectious Diseases doctors for [MASKED] and treatment of your diarrhea. They recommended some additional studies. They agreed with the decision to stop your antibiotics. - You received a new antibiotic for your diarrhea in case it was recurrent Clostridium difficile diarrhea. Fortunately, you did not have recurrent diarrhea, so we stopped your antibiotics. What should I do now that I am leaving the hospital? - Continue to take your medications as prescribed. You do not need to take any more antibiotics. - Expect to have loose stools, up to 1 or 2 per day, for the next few months. Your colon is recovering from your Clostridium difficile infection in [MASKED]. - Call the doctor if you have 6 or more loose stools per day. - Attend a follow-up appointment with your primary care doctor. - Attend a follow-up appointment with your liver transplant doctor. - Consider seeing a pain specialist to help treat your multiple causes of pain. It was a pleasure taking care of you. Wishing you all the best! - Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "K219", "Z87891", "J449", "Z86718" ]
[ "R197: Diarrhea, unspecified", "D6959: Other secondary thrombocytopenia", "Z944: Liver transplant status", "G629: Polyneuropathy, unspecified", "R1084: Generalized abdominal pain", "I951: Orthostatic hypotension", "K219: Gastro-esophageal reflux disease without esophagitis", "F319: Bipolar disorder, unspecified", "D72818: Other decreased white blood cell count", "Z87891: Personal history of nicotine dependence", "F901: Attention-deficit hyperactivity disorder, predominantly hyperactive type", "F4310: Post-traumatic stress disorder, unspecified", "M940: Chondrocostal junction syndrome [Tietze]", "J449: Chronic obstructive pulmonary disease, unspecified", "K6289: Other specified diseases of anus and rectum", "K5289: Other specified noninfective gastroenteritis and colitis", "Z86718: Personal history of other venous thrombosis and embolism" ]
19,992,875
29,765,419
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / rifampin / Lamictal / lorazepam / risperidone / mushrooms Attending: ___ Chief Complaint: Abdominal pain, diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo M w/ PMH PBC s/p liver transplant ___, pericarditis, bipolar disorder, COPD, with recent admission at ___ for diarrhea who re-presents with ongoing diarrhea and muscle aches. He reports that he is having watery diarrhea ___ per day. He has aches all over his body and feels weak. He also endorses tinnitus. He says this feels similar to when he had CMV infection in the past. He did not hear the results of his colonoscopy yet. Of note, his colonoscopy biopsies showed active colitis throughout the colon. CMV testing was pending. In the ED, initial vitals were: T97.0 HR67 BP115/96 RR18 O2Sat100% RA. Labs notable for WBC 2.9, ANC 1260, Plt 93, Cr 1.1, HCO3 21. Patient was given 4 mg IV morphine and 4 mg Zofran. Decision was made to admit for continued diarrhea. Vitals prior to transfer: T98.4 HR50 BP112/82 RR16 O2Sat100% RA. On the floor, he reported that he had ongoing abdominal pain, nausea, and body aches. He reports that he has not started any new medications except for 1 dose of Adderall last week. ROS: per HPI, denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: PAST MEDICAL HISTORY: PBC s/p deceased liver donor tx ___ Neutropenia DVT ___ Prior alcohol abuse now abstinent Hemorrhagic pericarditis c/b tamponade with pericardial window ___ Positive PPD s/p INH HLD Osteoporosis Bipolar disorder Hemorrhoids ADHD PTSD Social History: ___ Family History: Father (living): coronary artery disease, diabetes, hypercholesterolemia, and depression. Prostate and head and neck cancer Mother (deceased): brain aneurysm and hyperthyroidism Physical Exam: ================ ADMISSION EXAM: ================ Vital Signs: 97.6 115/77 53 18 100% on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, most tender over epigastric area and LLQ with voluntary guarding, but diffusely mildly tender to palpation, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. ================ DISCHARGE EXAM: ================ VS - T 97.9 HR 67 BP 110/78 RR 18 02 99% sat on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL, Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: +BS Soft, mild diffuse tenderness to palpation most in epigastric region, minimal distension, no organomegaly, no rebound or guarding . Large RUQ scar. GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, No focal deficits. Pertinent Results: ================ ADMISSION LABS: ================ ___ 08:05PM WBC-2.9* RBC-5.05 HGB-15.0 HCT-42.9 MCV-85 MCH-29.7 MCHC-35.0 RDW-15.7* RDWSD-47.9* ___ 08:05PM NEUTS-43.1 ___ MONOS-10.3 EOS-1.7 BASOS-1.4* IM ___ AbsNeut-1.26*# AbsLymp-1.25 AbsMono-0.30 AbsEos-0.05 AbsBaso-0.04 ___ 08:05PM ___ PTT-28.2 ___ ___ 08:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 08:05PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 08:05PM ALT(SGPT)-37 AST(SGOT)-27 ALK PHOS-120 TOT BILI-0.4 ___ 08:05PM LIPASE-24 ___ 08:05PM ALBUMIN-4.3 ___ 08:05PM GLUCOSE-88 UREA N-15 CREAT-1.1 SODIUM-137 POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-21* ANION GAP-15 ================ DISCHARGE LABS: ================ ___ 04:40AM BLOOD WBC-3.2* RBC-4.71 Hgb-13.9 Hct-40.7 MCV-86 MCH-29.5 MCHC-34.2 RDW-15.4 RDWSD-48.0* Plt Ct-78* ___ 04:40AM BLOOD Glucose-96 UreaN-14 Creat-1.0 Na-139 K-3.9 Cl-102 HCO3-25 AnGap-16 ___ 04:17AM BLOOD ALT-34 AST-32 LD(LDH)-192 AlkPhos-110 Amylase-23 TotBili-0.4 ___ 04:40AM BLOOD Calcium-8.9 Phos-3.5 Mg-1.9 ___ 04:40AM BLOOD tacroFK-6.3 ============== MICROBIOLOGY: ============== ___ 5:05 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT ___ MICROSPORIDIA STAIN (Final ___: NO MICROSPORIDIUM SEEN. CYCLOSPORA STAIN (Final ___: NO CYCLOSPORA SEEN. C. difficile DNA amplification assay (Final ___: Reported to and read back by ___ ___ ___ 10AM. CLOSTRIDIUM DIFFICILE. Positive for toxigenic C. difficile by the Illumigene DNA amplification. (Reference Range-Negative). FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final ___: NO OVA AND PARASITES SEEN. This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. ___ CRYSTALS PRESENT. FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO FOUND. FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA FOUND. FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___: NO E.COLI 0157:H7 FOUND. Cryptosporidium/Giardia (DFA) (Final ___: NO CRYPTOSPORIDIUM OR GIARDIA SEEN. O&P MACROSCOPIC EXAM - WORM (Final ___: NO WORM SEEN. ___ 8:25 pm BLOOD CULTURES x2 **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ================= IMAGING/STUDIES: ================= EKG ___: Sinus rhythm with non-specific T wave flattening in leads aVL and V2. There is early R wave progression in the precordium. Compared to the previous tracing of ___ the previously seen T wave inversions are no longer present. KUB ___ FINDINGS: There is gas distending the colon. The colon does not exceed 4.5-5 cm in caliber. There is gas in scattered nondilated small bowel loops. Supine assessment limits detection for free air; there is no gross pneumoperitoneum. A surgical clip is seen in the right upper quadrant. There are degenerative changes in the femoroacetabular joints. There are no unexplained soft tissue calcifications or radiopaque foreign bodies. IMPRESSION: No radiographic evidence of toxic megacolon. Brief Hospital Course: ___ y/o M with ___ PBC s/p liver transplant in ___, bipolar disorder, pericarditis p/w worsening abdominal pain, chest pain, diarrhea. Patient was recently admitted and discharged from ___ for the same complaint on ___. Colonoscopy was performed on ___ and showed colitis. Stool studies were positive of C diff on this admission (previously negative on prior admission). Therefore, patient was started on vancomycin PO on ___ for treatment of C diff colitis with plans to complete a 14-day total course. Abdominal pain and diarrhea gradually improved during the admission. Patient maintained good PO intake throughout admission. # Diarrhea ___ to C diff Colitis: Patient presented again to the ED on ___ for worsening abdominal pain, nausea, diarrhea (7 watery BMs daily). He was recently discharged on ___ for the same complaint. Repeat stool studies were obtained that returned positive for C diff on ___. CMV stains of colonoscopy specimens were negative. Antibiotic therapy was started with PO vancomycin since patient had no elevated WBC count or ___. Nausea was managed with PRN Zofran with good effect. During admission, patient had gradual improvement in abdominal pain/diarrhea. KUB was ordered to r/o toxic megacolon and showed only distended bowel loops with gas. Gradually pain improved with PRN acetaminophen, simethicone, dicyclomine, tramadol. On discharge, patient was tolerating regular diet with good PO intake and diarrhea/abdominal pain were improving. He was discharged with a script to complete a full 14-day course of PO vancomycin at home. ================ Chronic Issues ================ #PBC S/P OLT WITH CMV+ DONOR C/B CELLULAR REJECTION, HEMORRHAGIC PERICARDITIS, RECURRENT PERICARDITIS: No active issues while inpatient. Patient continued on home tacrolimus/prednisone doses and daily tacro levels were appropriate. Daily LFTs were also WNL. #THROMBOCYTOPENIA. Stable throughout admission. Patient has known chronic thrombocytopenia likely due to liver disease vs immunosuppression. #BIPOLAR DISORDER. No acute issues. Recently off of Abilify. Monitored without need to restart therapy. #GERD: Stable. Possibly contributing to abdominal pain as described above with C diff infection. Continued on home omeprazole 40mg BID, ranitidine 150mg qHS. #CHRONIC NEUROPATHIC PAIN: Stable. Continued on home Gabapentin 600mg BID #COPD: No SOB throughout admission. Continued home albuterol prn TRANSITIONAL ISSUES: [ ] Complete Vancomycin 125 mg PO Q6H x 14 days (___) [ ] Follow up with PCP, ___. [ ] Full Code (confirmed) Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Aspirin 650 mg PO BID 2. Colchicine 0.6 mg PO BID 3. Gabapentin 600 mg PO BID 4. Omeprazole 40 mg PO BID 5. Ondansetron 4 mg PO Q8H:PRN nausea 6. PredniSONE 5 mg PO DAILY 7. Ranitidine 150 mg PO QHS 8. Tacrolimus 1 mg PO QPM 9. Tacrolimus 1 mg PO QAM 10. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain 11. DICYCLOMine 20 mg PO TID abdominal pain 12. IBgard (peppermint oil) 90 mg oral TID:PRN abdominal pain Discharge Medications: 1. Simethicone 80 mg PO QID pain RX *simethicone 80 mg 1 tablet by mouth QID PRN Disp #*60 Tablet Refills:*0 2. Vancomycin Oral Liquid ___ mg PO Q6H RX *vancomycin 125 mg 1 capsule(s) by mouth every six (6) hours Disp #*40 Capsule Refills:*0 3. DICYCLOMine 20 mg PO TID abdominal pain You may continue to take this medication as needed for abdominal pain. RX *dicyclomine [Bentyl] 20 mg 1 tablet(s) by mouth TID PRN Disp #*30 Tablet Refills:*0 4. Aspirin 650 mg PO BID 5. Colchicine 0.6 mg PO BID 6. Gabapentin 600 mg PO BID 7. Omeprazole 40 mg PO BID 8. Ondansetron 4 mg PO Q8H:PRN nausea RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours Disp #*30 Tablet Refills:*0 9. PredniSONE 5 mg PO DAILY 10. Ranitidine 150 mg PO QHS 11. Tacrolimus 1 mg PO QAM 12. Tacrolimus 1 mg PO QPM 13. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp #*15 Tablet Refills:*0 14. HELD- IBgard (peppermint oil) 90 mg oral TID:PRN abdominal pain This medication was held. Do not restart IBgard until you discuss this with your transplant doctor. Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES: C. diff Colitis SECONDARY DIAGNOSES: PBC s/p liver transplant ___, Neutropenia, DVT ___, HLD, HLD, Osteoporosis, Bipolar disorder, Hemorrhoids, ADHD, PTSD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to ___. Why you were in the hospital: - You were having abdominal pain and diarrhea and your colonoscopy results showed inflammation in your colon. This was due to an infection in your colon with C. Diff. What was done while you were in the hospital: - You were started on an antibiotic called vancomycin and were given medications for your nausea and pain. What you need to do when you go home: - You will continue taking antibiotics for your C. diff infection through ___ (10 more days). - Please follow up with your primary ___ doctor's office on ___. - Please also follow up with your liver transplant doctor, ___. ___ on ___. It was a pleasure taking ___ of you at ___ Deaconess. ___, Your ___ ___ Team Followup Instructions: ___
[ "A047", "I319", "D696", "Z944", "I509", "G629", "R110", "M810", "I252", "F319", "J449", "F4310", "K219", "G8929" ]
Allergies: Penicillins / rifampin / Lamictal / lorazepam / risperidone / mushrooms Chief Complaint: Abdominal pain, diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] yo M w/ PMH PBC s/p liver transplant [MASKED], pericarditis, bipolar disorder, COPD, with recent admission at [MASKED] for diarrhea who re-presents with ongoing diarrhea and muscle aches. He reports that he is having watery diarrhea [MASKED] per day. He has aches all over his body and feels weak. He also endorses tinnitus. He says this feels similar to when he had CMV infection in the past. He did not hear the results of his colonoscopy yet. Of note, his colonoscopy biopsies showed active colitis throughout the colon. CMV testing was pending. In the ED, initial vitals were: T97.0 HR67 BP115/96 RR18 O2Sat100% RA. Labs notable for WBC 2.9, ANC 1260, Plt 93, Cr 1.1, HCO3 21. Patient was given 4 mg IV morphine and 4 mg Zofran. Decision was made to admit for continued diarrhea. Vitals prior to transfer: T98.4 HR50 BP112/82 RR16 O2Sat100% RA. On the floor, he reported that he had ongoing abdominal pain, nausea, and body aches. He reports that he has not started any new medications except for 1 dose of Adderall last week. ROS: per HPI, denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: PAST MEDICAL HISTORY: PBC s/p deceased liver donor tx [MASKED] Neutropenia DVT [MASKED] Prior alcohol abuse now abstinent Hemorrhagic pericarditis c/b tamponade with pericardial window [MASKED] Positive PPD s/p INH HLD Osteoporosis Bipolar disorder Hemorrhoids ADHD PTSD Social History: [MASKED] Family History: Father (living): coronary artery disease, diabetes, hypercholesterolemia, and depression. Prostate and head and neck cancer Mother (deceased): brain aneurysm and hyperthyroidism Physical Exam: ================ ADMISSION EXAM: ================ Vital Signs: 97.6 115/77 53 18 100% on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, most tender over epigastric area and LLQ with voluntary guarding, but diffusely mildly tender to palpation, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, [MASKED] strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. ================ DISCHARGE EXAM: ================ VS - T 97.9 HR 67 BP 110/78 RR 18 02 99% sat on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL, Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: +BS Soft, mild diffuse tenderness to palpation most in epigastric region, minimal distension, no organomegaly, no rebound or guarding . Large RUQ scar. GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, No focal deficits. Pertinent Results: ================ ADMISSION LABS: ================ [MASKED] 08:05PM WBC-2.9* RBC-5.05 HGB-15.0 HCT-42.9 MCV-85 MCH-29.7 MCHC-35.0 RDW-15.7* RDWSD-47.9* [MASKED] 08:05PM NEUTS-43.1 [MASKED] MONOS-10.3 EOS-1.7 BASOS-1.4* IM [MASKED] AbsNeut-1.26*# AbsLymp-1.25 AbsMono-0.30 AbsEos-0.05 AbsBaso-0.04 [MASKED] 08:05PM [MASKED] PTT-28.2 [MASKED] [MASKED] 08:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [MASKED] 08:05PM URINE COLOR-Straw APPEAR-Clear SP [MASKED] [MASKED] 08:05PM ALT(SGPT)-37 AST(SGOT)-27 ALK PHOS-120 TOT BILI-0.4 [MASKED] 08:05PM LIPASE-24 [MASKED] 08:05PM ALBUMIN-4.3 [MASKED] 08:05PM GLUCOSE-88 UREA N-15 CREAT-1.1 SODIUM-137 POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-21* ANION GAP-15 ================ DISCHARGE LABS: ================ [MASKED] 04:40AM BLOOD WBC-3.2* RBC-4.71 Hgb-13.9 Hct-40.7 MCV-86 MCH-29.5 MCHC-34.2 RDW-15.4 RDWSD-48.0* Plt Ct-78* [MASKED] 04:40AM BLOOD Glucose-96 UreaN-14 Creat-1.0 Na-139 K-3.9 Cl-102 HCO3-25 AnGap-16 [MASKED] 04:17AM BLOOD ALT-34 AST-32 LD(LDH)-192 AlkPhos-110 Amylase-23 TotBili-0.4 [MASKED] 04:40AM BLOOD Calcium-8.9 Phos-3.5 Mg-1.9 [MASKED] 04:40AM BLOOD tacroFK-6.3 ============== MICROBIOLOGY: ============== [MASKED] 5:05 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT [MASKED] MICROSPORIDIA STAIN (Final [MASKED]: NO MICROSPORIDIUM SEEN. CYCLOSPORA STAIN (Final [MASKED]: NO CYCLOSPORA SEEN. C. difficile DNA amplification assay (Final [MASKED]: Reported to and read back by [MASKED] [MASKED] [MASKED] 10AM. CLOSTRIDIUM DIFFICILE. Positive for toxigenic C. difficile by the Illumigene DNA amplification. (Reference Range-Negative). FECAL CULTURE (Final [MASKED]: NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [MASKED]: NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final [MASKED]: NO OVA AND PARASITES SEEN. This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. [MASKED] CRYSTALS PRESENT. 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 0157:H7 FOUND. Cryptosporidium/Giardia (DFA) (Final [MASKED]: NO CRYPTOSPORIDIUM OR GIARDIA SEEN. O&P MACROSCOPIC EXAM - WORM (Final [MASKED]: NO WORM SEEN. [MASKED] 8:25 pm BLOOD CULTURES x2 **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. ================= IMAGING/STUDIES: ================= EKG [MASKED]: Sinus rhythm with non-specific T wave flattening in leads aVL and V2. There is early R wave progression in the precordium. Compared to the previous tracing of [MASKED] the previously seen T wave inversions are no longer present. KUB [MASKED] FINDINGS: There is gas distending the colon. The colon does not exceed 4.5-5 cm in caliber. There is gas in scattered nondilated small bowel loops. Supine assessment limits detection for free air; there is no gross pneumoperitoneum. A surgical clip is seen in the right upper quadrant. There are degenerative changes in the femoroacetabular joints. There are no unexplained soft tissue calcifications or radiopaque foreign bodies. IMPRESSION: No radiographic evidence of toxic megacolon. Brief Hospital Course: [MASKED] y/o M with [MASKED] PBC s/p liver transplant in [MASKED], bipolar disorder, pericarditis p/w worsening abdominal pain, chest pain, diarrhea. Patient was recently admitted and discharged from [MASKED] for the same complaint on [MASKED]. Colonoscopy was performed on [MASKED] and showed colitis. Stool studies were positive of C diff on this admission (previously negative on prior admission). Therefore, patient was started on vancomycin PO on [MASKED] for treatment of C diff colitis with plans to complete a 14-day total course. Abdominal pain and diarrhea gradually improved during the admission. Patient maintained good PO intake throughout admission. # Diarrhea [MASKED] to C diff Colitis: Patient presented again to the ED on [MASKED] for worsening abdominal pain, nausea, diarrhea (7 watery BMs daily). He was recently discharged on [MASKED] for the same complaint. Repeat stool studies were obtained that returned positive for C diff on [MASKED]. CMV stains of colonoscopy specimens were negative. Antibiotic therapy was started with PO vancomycin since patient had no elevated WBC count or [MASKED]. Nausea was managed with PRN Zofran with good effect. During admission, patient had gradual improvement in abdominal pain/diarrhea. KUB was ordered to r/o toxic megacolon and showed only distended bowel loops with gas. Gradually pain improved with PRN acetaminophen, simethicone, dicyclomine, tramadol. On discharge, patient was tolerating regular diet with good PO intake and diarrhea/abdominal pain were improving. He was discharged with a script to complete a full 14-day course of PO vancomycin at home. ================ Chronic Issues ================ #PBC S/P OLT WITH CMV+ DONOR C/B CELLULAR REJECTION, HEMORRHAGIC PERICARDITIS, RECURRENT PERICARDITIS: No active issues while inpatient. Patient continued on home tacrolimus/prednisone doses and daily tacro levels were appropriate. Daily LFTs were also WNL. #THROMBOCYTOPENIA. Stable throughout admission. Patient has known chronic thrombocytopenia likely due to liver disease vs immunosuppression. #BIPOLAR DISORDER. No acute issues. Recently off of Abilify. Monitored without need to restart therapy. #GERD: Stable. Possibly contributing to abdominal pain as described above with C diff infection. Continued on home omeprazole 40mg BID, ranitidine 150mg qHS. #CHRONIC NEUROPATHIC PAIN: Stable. Continued on home Gabapentin 600mg BID #COPD: No SOB throughout admission. Continued home albuterol prn TRANSITIONAL ISSUES: [ ] Complete Vancomycin 125 mg PO Q6H x 14 days ([MASKED]) [ ] Follow up with PCP, [MASKED]. [ ] Full Code (confirmed) Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Aspirin 650 mg PO BID 2. Colchicine 0.6 mg PO BID 3. Gabapentin 600 mg PO BID 4. Omeprazole 40 mg PO BID 5. Ondansetron 4 mg PO Q8H:PRN nausea 6. PredniSONE 5 mg PO DAILY 7. Ranitidine 150 mg PO QHS 8. Tacrolimus 1 mg PO QPM 9. Tacrolimus 1 mg PO QAM 10. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain 11. DICYCLOMine 20 mg PO TID abdominal pain 12. IBgard (peppermint oil) 90 mg oral TID:PRN abdominal pain Discharge Medications: 1. Simethicone 80 mg PO QID pain RX *simethicone 80 mg 1 tablet by mouth QID PRN Disp #*60 Tablet Refills:*0 2. Vancomycin Oral Liquid [MASKED] mg PO Q6H RX *vancomycin 125 mg 1 capsule(s) by mouth every six (6) hours Disp #*40 Capsule Refills:*0 3. DICYCLOMine 20 mg PO TID abdominal pain You may continue to take this medication as needed for abdominal pain. RX *dicyclomine [Bentyl] 20 mg 1 tablet(s) by mouth TID PRN Disp #*30 Tablet Refills:*0 4. Aspirin 650 mg PO BID 5. Colchicine 0.6 mg PO BID 6. Gabapentin 600 mg PO BID 7. Omeprazole 40 mg PO BID 8. Ondansetron 4 mg PO Q8H:PRN nausea RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours Disp #*30 Tablet Refills:*0 9. PredniSONE 5 mg PO DAILY 10. Ranitidine 150 mg PO QHS 11. Tacrolimus 1 mg PO QAM 12. Tacrolimus 1 mg PO QPM 13. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp #*15 Tablet Refills:*0 14. HELD- IBgard (peppermint oil) 90 mg oral TID:PRN abdominal pain This medication was held. Do not restart IBgard until you discuss this with your transplant doctor. Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES: C. diff Colitis SECONDARY DIAGNOSES: PBC s/p liver transplant [MASKED], Neutropenia, DVT [MASKED], HLD, HLD, Osteoporosis, Bipolar disorder, Hemorrhoids, ADHD, PTSD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], You were admitted to [MASKED]. Why you were in the hospital: - You were having abdominal pain and diarrhea and your colonoscopy results showed inflammation in your colon. This was due to an infection in your colon with C. Diff. What was done while you were in the hospital: - You were started on an antibiotic called vancomycin and were given medications for your nausea and pain. What you need to do when you go home: - You will continue taking antibiotics for your C. diff infection through [MASKED] (10 more days). - Please follow up with your primary [MASKED] doctor's office on [MASKED]. - Please also follow up with your liver transplant doctor, [MASKED]. [MASKED] on [MASKED]. It was a pleasure taking [MASKED] of you at [MASKED] Deaconess. [MASKED], Your [MASKED] [MASKED] Team Followup Instructions: [MASKED]
[]
[ "D696", "I252", "J449", "K219", "G8929" ]
[ "A047: Enterocolitis due to Clostridium difficile", "I319: Disease of pericardium, unspecified", "D696: Thrombocytopenia, unspecified", "Z944: Liver transplant status", "I509: Heart failure, unspecified", "G629: Polyneuropathy, unspecified", "R110: Nausea", "M810: Age-related osteoporosis without current pathological fracture", "I252: Old myocardial infarction", "F319: Bipolar disorder, unspecified", "J449: Chronic obstructive pulmonary disease, unspecified", "F4310: Post-traumatic stress disorder, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "G8929: Other chronic pain" ]
19,992,875
29,951,097
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / rifampin / Lamictal / lorazepam / risperidone Attending: ___. Chief Complaint: Bright red blood per rectum with abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ gentleman with a history of PBC s/p OLT in ___ and recent admission for BRBPR/abdominal pain found to have an anal skin tag/condyloma on sigmoidoscopy now s/p excision on ___ who presents with one episode of BRBPR. He has not had any recent bleeding. This episode occurred this afternoon and was approximately one cup of bright red blood per rectum not mixed with stool. He then developed lower abdominal cramping. No further BMs or bleeding subsequently. Mild nausea but no vomiting, no fevers. He was seen at ___ and was referred here for further work up as patient is liver transplant recipient. He is followed by Dr. ___ saw him today in clinic for follow up of chest pain. This is thought to be due to chondrochondritis. He is on tramadol, high dose aspirin, and colchicine for this. In the ED, initial vitals were: T 96.6, HR 72, BP 133/88, RR 18, SaO2 100% RA. - Labs were notable for: WBC 3.1 (stable), H/H 13.9/40.8, plts 84 (stable), Cr 1.3 (stable); RUQ with Dopplers showed normal transplanted liver, splenomegaly. - Rectal exam notable for intact suture, no masses or hemorrhoids, dark stool guaiac positive - Patient was given: tacrolimus 1 mg, morphine 4 mg, and Zofran. - Consults: Transplant surgery, who recommended inpatient colorectal surgery consult; GI, who recommended hepatology consult On the floor, patient continued to report mild lower abdominal pain and chest pain. No nausea currently. He does have an appetite but has not eaten today. Review of systems: (+) Per HPI. Chronic chills, chronic shortness of breath. (-) Denies fever, night sweats, recent weight loss or gain. Denies headache, cough, vomiting, diarrhea, constipation. No recent change in bowel or bladder habits. No dysuria. Past Medical History: PAST MEDICAL HISTORY: PBC s/p deceased liver donor tx ___ Neutropenia DVT ___ Prior alcohol abuse now abstinent Hemorrhagic pericarditis c/b tamponade with pericardial window ___ Positive PPD s/p INH HLD Osteoporosis Bipolar disorder Hemorrhoids ADHD PTSD Social History: ___ Family History: Father (living): coronary artery disease, diabetes, hypercholesterolemia, and depression. Prostate and head and neck cancer Mother (deceased): brain aneurysm and hyperthyroidism Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T 97.3, HR 57, BP 114/81, RR 18, SaO2 99% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: Supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops, severe pain to palpation of right costochondral junctions Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Scar present, soft, bowel sounds present, nondistended, tender to palpation diffusely though no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Rectal: skin tag removal site intact without bleeding or signs of infection, external hemorrhoids appreciated, old blood in rectal vault without masses. DISCHARGE PHYSICAL EXAM: Vitals: T 97.5/97.4, 105-117/59-70, HR 62-80, RR 18, O2 Sat >97% RA General: Well-appearing, NAD. HEENT: MMM, PERRL, EOMI w/o nystagmus. Lungs: CTAB CV: RRR, normal S1 and S2 appreciated. No murmurs, rubs, gallops. Abdomen: Soft, non-distended, mild tenderness to deep palpation of the bilateral LLQ and suprapubic region. Normal bowel sounds. Ext: Warm, well-perfused. No edema. Bilateral pulses +2 Pertinent Results: ADMISSION LABS: ___ 08:25PM BLOOD WBC-3.1* RBC-4.66 Hgb-13.9 Hct-40.8 MCV-88 MCH-29.8 MCHC-34.1 RDW-14.7 RDWSD-46.9* Plt Ct-84* ___ 08:25PM BLOOD Neuts-48.9 ___ Monos-9.7 Eos-3.9 Baso-1.9* Im ___ AbsNeut-1.51* AbsLymp-1.09* AbsMono-0.30 AbsEos-0.12 AbsBaso-0.06 ___ 08:00AM BLOOD ___ PTT-28.9 ___ ___ 08:25PM BLOOD Glucose-91 UreaN-19 Creat-1.3* Na-141 K-4.1 Cl-108 HCO3-22 AnGap-15 ___ 08:00AM BLOOD ALT-37 AST-33 LD(LDH)-189 AlkPhos-77 TotBili-0.5 ___ 08:00AM BLOOD Albumin-4.1 Calcium-9.0 Phos-2.8 Mg-1.8 ___ 08:00AM BLOOD tacroFK-6.0 IMAGING / STUDIES: RUQ US ___ IMPRESSION: 1. Unremarkable liver transplant with patent hepatic vasculature and normal waveforms. 2. Splenomegaly. GU Ultrasound ___ FINDINGS: The right kidney measures 9.3 cm and contains a simple appearing 1.1 cm lower pole cyst. The left kidney measures 9.7 cm. There is no hydronephrosis, stones, or masses bilaterally. Normal cortical echogenicity and corticomedullary differentiation are seen bilaterally. The bladder is normal in appearance. Postvoid images of the bladder were not obtained secondary to the patient's inability to void. Calculated prostate volume is 22 cc. IMPRESSION: Normal appearance of the bilateral kidneys. DISCHARGE LABS: ___ 08:00AM BLOOD WBC-1.9* RBC-4.43* Hgb-13.3* Hct-40.0 MCV-90 MCH-30.0 MCHC-33.3 RDW-14.6 RDWSD-48.4* Plt Ct-64* ___ 08:00AM BLOOD ___ PTT-27.9 ___ ___ 08:00AM BLOOD Glucose-102* UreaN-20 Creat-1.0 Na-142 K-3.6 Cl-109* HCO3-24 AnGap-13 ___ 08:00AM BLOOD ALT-37 AST-29 AlkPhos-82 TotBili-0.4 ___ 08:00AM BLOOD Calcium-8.9 Phos-3.4 Mg-1.7 ___ 08:00AM BLOOD tacroFK-6.0 Brief Hospital Course: Mr. ___ is a ___ gentleman with a history of PBC s/p OLT in ___ and recent admission for BRBPR/abdominal pain found to have an anal skin tag/condyloma on sigmoidoscopy now s/p excision on ___ who presents with one episode of BRBPR. # BRBPR: Patient with single episode of BRBPR, possibly related to recent excision of anal skin tag/condyloma. Examination of the area showed intact excision site without active bleed. He also had associated lower abdominal pain of unclear etiology. No recent fevers or diarrhea to suggest infectious or inflammatory etiology. After his anal tag excision he reports regular soft stools without straining. H&H on admission at baseline. Potentially diverticular bleed vs. vascular malformation. Rectal exam with old blood in rectal vault without active bleeding or mass. He did not have any further bleeding during admission and his lower abdominal pain was controlled with home tramadol Q6H. Recommend outpatient colonoscopy and continued Metamucil use. His high dose ASA was stopped in the setting of recurrent GI bleeds. # Abdominal pain: Continued despite resolution of BRBPR. Patient with similar presentation in ___ with work-up (CT A/P, stool studies) unrevealing aside from sigmoidoscopy showing rectal erythema and perianal skin tag/condyloma. RUQ ultrasound with Dopplers in the ED was normal. Patient complained of urinary hesitancy on ROS but was voiding without difficulty. GU ultrasound showed normal kidneys bilaterally and bladder with normal prostate mass of 22cc. Post-void bladder was not visualized as patient did not void. Low suspicion for bladder obstruction as cause of supra-pubic pain. He was instructed to seek urology referral should his urinary symptoms persist or worsen. # Acute kidney injury: Patient noted to have mild ___ on admission labs. Likely from hypovolemia in the setting of high dose NSAIDs. Serum Cr normalized to 1.1 on discharge; no evidence of renal pathology on GU U/S (___). He was discharged off aspirin as above. # PBC s/p liver transplant in ___ from CMV+ donor, cellular rejection in ___ ___s a hemorrhagic pericardial effusion with recurrent pericarditis: RUQ ultrasound with Dopplers in the ED was normal. LFTs normal. Continued home tacrolimus 1 mg PO Q12H. Tacro level 6.0 on admission. Continued prednisone 5 mg daily. # Costochondritis: Followed by Dr. ___ in cardiology. On high dose ASA, prednisone, and tramadol, recently increased from TID to QID. Pain is at baseline on admission. His high dose ASA was held and tramadol continued. He was discharged off of aspirin as above. # Pericarditis: Followed by Dr. ___ in cardiology. On high dose ASA and colchicine. Pain at baseline on admission and his colchicine was continued but ASA stopped as above. # Thrombocytopenia: Patient presented with chronic low platelet count around baseline. Chronic thrombocytopenia likely due to liver disease and immunosuppression. His platelets were monitored without acute event. Of note high dose ASA in setting of thrombocytopenia likely contributing to recurrent GIB. # Bipolar disorder: Continued home ARIPiprazole # COPD: Continued home albuterol, salmeterol. # GERD: Continued home omeprazole 40mg BID, ranitidine 150mg qHS # Chronic Neuropathic Pain: Continued Gabapentin 600mg BID TRANSITIONAL ISSUES: - Patient discharged off of aspirin given GIB. Please address restating or alternative therapy at next cardiology appointment. - Recommend outpatient colonoscopy for evaluation of likely distal GIB. Follow up scheduled with GI. - Patient continued on tramadol QID for pain control. - Recommend urology follow up for lower urinary tract symptoms if persistent. - H&H stable throughout admission. Please re-check at GI follow up appointment if continued GI bleeding. - Patient continued on tacrolimus during admission with random level of 6.0. LFTs normal. CODE: Full (confirmed) CONTACT: ___ (father) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea 2. ARIPiprazole 20 mg PO QHS 3. Calcium Carbonate 500 mg PO DAILY 4. Colchicine 0.6 mg PO BID 5. Docusate Sodium 100 mg PO BID:PRN constipation 6. Gabapentin 600 mg PO BID 7. HydrOXYzine 25 mg PO QHS:PRN insomnia 8. Omeprazole 40 mg PO BID 9. Ondansetron 4 mg PO Q8H:PRN nausea 10. Ranitidine 150 mg PO QHS 11. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain 12. Vitamin D 800 UNIT PO DAILY 13. PredniSONE 5 mg PO DAILY 14. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H 15. Tacrolimus 1 mg PO Q12H 16. Aspirin 975 mg PO TID 17. Benefiber Clear SF (dextrin) (wheat dextrin) 3 gram/3.5 gram oral DAILY Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea 2. ARIPiprazole 20 mg PO QHS 3. Colchicine 0.6 mg PO BID 4. Docusate Sodium 100 mg PO BID:PRN constipation 5. Gabapentin 600 mg PO BID 6. HydrOXYzine 25 mg PO QHS:PRN insomnia 7. Omeprazole 40 mg PO BID 8. Ondansetron 4 mg PO Q8H:PRN nausea 9. PredniSONE 5 mg PO DAILY 10. Ranitidine 150 mg PO QHS 11. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H 12. Tacrolimus 1 mg PO Q12H 13. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain 14. Vitamin D 800 UNIT PO DAILY 15. Benefiber Clear SF (dextrin) (wheat dextrin) 3 gram/3.5 gram oral DAILY 16. Calcium Carbonate 500 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY: Gastrointestinal Bleed Abdominal Pain SECONDARY: H/O Primary biliary cirrhosis s/p liver transplant Urinary hesitancy Chronic pericarditis Costochondritis Bipolar disorder COPD GERD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure participating in your care here at ___ ___. You were admitted with rectal bleeding and abdominal pain. We checked you blood counts and everything was stable. Your recent skin tag removal site looked good and was not actively bleeding. You did not have another episode of bleeding and recovered without incident. An ultrasound of your liver was normal and you were kept on your home tramadol for pain. You also were noted to have some difficulty initiating urination. You had an ultrasound done of your kidneys and bladder which was also normal. You prostate on ultrasound was a normal size. If you continue to have urinary symptoms please see your PCP about referral to urology. ___ clinic number: ___. You were discharged with the follow up appointments scheduled below,. Please make sure to attend these appointments because you will likely need a colonoscopy aks an outpatient. If you have another single episode of bleeding please call your gastroenterologist. Please continue taking your medications as prescribed but stop taking your aspirin until you see your cardiologist. You can continue taking your tramadol every 6 hours as needed. Thank you for choosing ___ for your healthcare needs. Sincerely, Your ___ Team Followup Instructions: ___
[ "K922", "Z944", "N179", "I319", "D6959", "G629", "J449", "K219", "R3911", "Z7982", "Z7952", "Z86718", "E785", "Z87891", "F909", "F319", "M940", "G8929" ]
Allergies: Penicillins / rifampin / Lamictal / lorazepam / risperidone Chief Complaint: Bright red blood per rectum with abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is a [MASKED] gentleman with a history of PBC s/p OLT in [MASKED] and recent admission for BRBPR/abdominal pain found to have an anal skin tag/condyloma on sigmoidoscopy now s/p excision on [MASKED] who presents with one episode of BRBPR. He has not had any recent bleeding. This episode occurred this afternoon and was approximately one cup of bright red blood per rectum not mixed with stool. He then developed lower abdominal cramping. No further BMs or bleeding subsequently. Mild nausea but no vomiting, no fevers. He was seen at [MASKED] and was referred here for further work up as patient is liver transplant recipient. He is followed by Dr. [MASKED] saw him today in clinic for follow up of chest pain. This is thought to be due to chondrochondritis. He is on tramadol, high dose aspirin, and colchicine for this. In the ED, initial vitals were: T 96.6, HR 72, BP 133/88, RR 18, SaO2 100% RA. - Labs were notable for: WBC 3.1 (stable), H/H 13.9/40.8, plts 84 (stable), Cr 1.3 (stable); RUQ with Dopplers showed normal transplanted liver, splenomegaly. - Rectal exam notable for intact suture, no masses or hemorrhoids, dark stool guaiac positive - Patient was given: tacrolimus 1 mg, morphine 4 mg, and Zofran. - Consults: Transplant surgery, who recommended inpatient colorectal surgery consult; GI, who recommended hepatology consult On the floor, patient continued to report mild lower abdominal pain and chest pain. No nausea currently. He does have an appetite but has not eaten today. Review of systems: (+) Per HPI. Chronic chills, chronic shortness of breath. (-) Denies fever, night sweats, recent weight loss or gain. Denies headache, cough, vomiting, diarrhea, constipation. No recent change in bowel or bladder habits. No dysuria. Past Medical History: PAST MEDICAL HISTORY: PBC s/p deceased liver donor tx [MASKED] Neutropenia DVT [MASKED] Prior alcohol abuse now abstinent Hemorrhagic pericarditis c/b tamponade with pericardial window [MASKED] Positive PPD s/p INH HLD Osteoporosis Bipolar disorder Hemorrhoids ADHD PTSD Social History: [MASKED] Family History: Father (living): coronary artery disease, diabetes, hypercholesterolemia, and depression. Prostate and head and neck cancer Mother (deceased): brain aneurysm and hyperthyroidism Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T 97.3, HR 57, BP 114/81, RR 18, SaO2 99% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: Supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops, severe pain to palpation of right costochondral junctions Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Scar present, soft, bowel sounds present, nondistended, tender to palpation diffusely though no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Rectal: skin tag removal site intact without bleeding or signs of infection, external hemorrhoids appreciated, old blood in rectal vault without masses. DISCHARGE PHYSICAL EXAM: Vitals: T 97.5/97.4, 105-117/59-70, HR 62-80, RR 18, O2 Sat >97% RA General: Well-appearing, NAD. HEENT: MMM, PERRL, EOMI w/o nystagmus. Lungs: CTAB CV: RRR, normal S1 and S2 appreciated. No murmurs, rubs, gallops. Abdomen: Soft, non-distended, mild tenderness to deep palpation of the bilateral LLQ and suprapubic region. Normal bowel sounds. Ext: Warm, well-perfused. No edema. Bilateral pulses +2 Pertinent Results: ADMISSION LABS: [MASKED] 08:25PM BLOOD WBC-3.1* RBC-4.66 Hgb-13.9 Hct-40.8 MCV-88 MCH-29.8 MCHC-34.1 RDW-14.7 RDWSD-46.9* Plt Ct-84* [MASKED] 08:25PM BLOOD Neuts-48.9 [MASKED] Monos-9.7 Eos-3.9 Baso-1.9* Im [MASKED] AbsNeut-1.51* AbsLymp-1.09* AbsMono-0.30 AbsEos-0.12 AbsBaso-0.06 [MASKED] 08:00AM BLOOD [MASKED] PTT-28.9 [MASKED] [MASKED] 08:25PM BLOOD Glucose-91 UreaN-19 Creat-1.3* Na-141 K-4.1 Cl-108 HCO3-22 AnGap-15 [MASKED] 08:00AM BLOOD ALT-37 AST-33 LD(LDH)-189 AlkPhos-77 TotBili-0.5 [MASKED] 08:00AM BLOOD Albumin-4.1 Calcium-9.0 Phos-2.8 Mg-1.8 [MASKED] 08:00AM BLOOD tacroFK-6.0 IMAGING / STUDIES: RUQ US [MASKED] IMPRESSION: 1. Unremarkable liver transplant with patent hepatic vasculature and normal waveforms. 2. Splenomegaly. GU Ultrasound [MASKED] FINDINGS: The right kidney measures 9.3 cm and contains a simple appearing 1.1 cm lower pole cyst. The left kidney measures 9.7 cm. There is no hydronephrosis, stones, or masses bilaterally. Normal cortical echogenicity and corticomedullary differentiation are seen bilaterally. The bladder is normal in appearance. Postvoid images of the bladder were not obtained secondary to the patient's inability to void. Calculated prostate volume is 22 cc. IMPRESSION: Normal appearance of the bilateral kidneys. DISCHARGE LABS: [MASKED] 08:00AM BLOOD WBC-1.9* RBC-4.43* Hgb-13.3* Hct-40.0 MCV-90 MCH-30.0 MCHC-33.3 RDW-14.6 RDWSD-48.4* Plt Ct-64* [MASKED] 08:00AM BLOOD [MASKED] PTT-27.9 [MASKED] [MASKED] 08:00AM BLOOD Glucose-102* UreaN-20 Creat-1.0 Na-142 K-3.6 Cl-109* HCO3-24 AnGap-13 [MASKED] 08:00AM BLOOD ALT-37 AST-29 AlkPhos-82 TotBili-0.4 [MASKED] 08:00AM BLOOD Calcium-8.9 Phos-3.4 Mg-1.7 [MASKED] 08:00AM BLOOD tacroFK-6.0 Brief Hospital Course: Mr. [MASKED] is a [MASKED] gentleman with a history of PBC s/p OLT in [MASKED] and recent admission for BRBPR/abdominal pain found to have an anal skin tag/condyloma on sigmoidoscopy now s/p excision on [MASKED] who presents with one episode of BRBPR. # BRBPR: Patient with single episode of BRBPR, possibly related to recent excision of anal skin tag/condyloma. Examination of the area showed intact excision site without active bleed. He also had associated lower abdominal pain of unclear etiology. No recent fevers or diarrhea to suggest infectious or inflammatory etiology. After his anal tag excision he reports regular soft stools without straining. H&H on admission at baseline. Potentially diverticular bleed vs. vascular malformation. Rectal exam with old blood in rectal vault without active bleeding or mass. He did not have any further bleeding during admission and his lower abdominal pain was controlled with home tramadol Q6H. Recommend outpatient colonoscopy and continued Metamucil use. His high dose ASA was stopped in the setting of recurrent GI bleeds. # Abdominal pain: Continued despite resolution of BRBPR. Patient with similar presentation in [MASKED] with work-up (CT A/P, stool studies) unrevealing aside from sigmoidoscopy showing rectal erythema and perianal skin tag/condyloma. RUQ ultrasound with Dopplers in the ED was normal. Patient complained of urinary hesitancy on ROS but was voiding without difficulty. GU ultrasound showed normal kidneys bilaterally and bladder with normal prostate mass of 22cc. Post-void bladder was not visualized as patient did not void. Low suspicion for bladder obstruction as cause of supra-pubic pain. He was instructed to seek urology referral should his urinary symptoms persist or worsen. # Acute kidney injury: Patient noted to have mild [MASKED] on admission labs. Likely from hypovolemia in the setting of high dose NSAIDs. Serum Cr normalized to 1.1 on discharge; no evidence of renal pathology on GU U/S ([MASKED]). He was discharged off aspirin as above. # PBC s/p liver transplant in [MASKED] from CMV+ donor, cellular rejection in [MASKED] s a hemorrhagic pericardial effusion with recurrent pericarditis: RUQ ultrasound with Dopplers in the ED was normal. LFTs normal. Continued home tacrolimus 1 mg PO Q12H. Tacro level 6.0 on admission. Continued prednisone 5 mg daily. # Costochondritis: Followed by Dr. [MASKED] in cardiology. On high dose ASA, prednisone, and tramadol, recently increased from TID to QID. Pain is at baseline on admission. His high dose ASA was held and tramadol continued. He was discharged off of aspirin as above. # Pericarditis: Followed by Dr. [MASKED] in cardiology. On high dose ASA and colchicine. Pain at baseline on admission and his colchicine was continued but ASA stopped as above. # Thrombocytopenia: Patient presented with chronic low platelet count around baseline. Chronic thrombocytopenia likely due to liver disease and immunosuppression. His platelets were monitored without acute event. Of note high dose ASA in setting of thrombocytopenia likely contributing to recurrent GIB. # Bipolar disorder: Continued home ARIPiprazole # COPD: Continued home albuterol, salmeterol. # GERD: Continued home omeprazole 40mg BID, ranitidine 150mg qHS # Chronic Neuropathic Pain: Continued Gabapentin 600mg BID TRANSITIONAL ISSUES: - Patient discharged off of aspirin given GIB. Please address restating or alternative therapy at next cardiology appointment. - Recommend outpatient colonoscopy for evaluation of likely distal GIB. Follow up scheduled with GI. - Patient continued on tramadol QID for pain control. - Recommend urology follow up for lower urinary tract symptoms if persistent. - H&H stable throughout admission. Please re-check at GI follow up appointment if continued GI bleeding. - Patient continued on tacrolimus during admission with random level of 6.0. LFTs normal. CODE: Full (confirmed) CONTACT: [MASKED] (father) [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea 2. ARIPiprazole 20 mg PO QHS 3. Calcium Carbonate 500 mg PO DAILY 4. Colchicine 0.6 mg PO BID 5. Docusate Sodium 100 mg PO BID:PRN constipation 6. Gabapentin 600 mg PO BID 7. HydrOXYzine 25 mg PO QHS:PRN insomnia 8. Omeprazole 40 mg PO BID 9. Ondansetron 4 mg PO Q8H:PRN nausea 10. Ranitidine 150 mg PO QHS 11. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain 12. Vitamin D 800 UNIT PO DAILY 13. PredniSONE 5 mg PO DAILY 14. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H 15. Tacrolimus 1 mg PO Q12H 16. Aspirin 975 mg PO TID 17. Benefiber Clear SF (dextrin) (wheat dextrin) 3 gram/3.5 gram oral DAILY Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea 2. ARIPiprazole 20 mg PO QHS 3. Colchicine 0.6 mg PO BID 4. Docusate Sodium 100 mg PO BID:PRN constipation 5. Gabapentin 600 mg PO BID 6. HydrOXYzine 25 mg PO QHS:PRN insomnia 7. Omeprazole 40 mg PO BID 8. Ondansetron 4 mg PO Q8H:PRN nausea 9. PredniSONE 5 mg PO DAILY 10. Ranitidine 150 mg PO QHS 11. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H 12. Tacrolimus 1 mg PO Q12H 13. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain 14. Vitamin D 800 UNIT PO DAILY 15. Benefiber Clear SF (dextrin) (wheat dextrin) 3 gram/3.5 gram oral DAILY 16. Calcium Carbonate 500 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY: Gastrointestinal Bleed Abdominal Pain SECONDARY: H/O Primary biliary cirrhosis s/p liver transplant Urinary hesitancy Chronic pericarditis Costochondritis Bipolar disorder COPD GERD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], It was a pleasure participating in your care here at [MASKED] [MASKED]. You were admitted with rectal bleeding and abdominal pain. We checked you blood counts and everything was stable. Your recent skin tag removal site looked good and was not actively bleeding. You did not have another episode of bleeding and recovered without incident. An ultrasound of your liver was normal and you were kept on your home tramadol for pain. You also were noted to have some difficulty initiating urination. You had an ultrasound done of your kidneys and bladder which was also normal. You prostate on ultrasound was a normal size. If you continue to have urinary symptoms please see your PCP about referral to urology. [MASKED] clinic number: [MASKED]. You were discharged with the follow up appointments scheduled below,. Please make sure to attend these appointments because you will likely need a colonoscopy aks an outpatient. If you have another single episode of bleeding please call your gastroenterologist. Please continue taking your medications as prescribed but stop taking your aspirin until you see your cardiologist. You can continue taking your tramadol every 6 hours as needed. Thank you for choosing [MASKED] for your healthcare needs. Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "N179", "J449", "K219", "Z86718", "E785", "Z87891", "G8929" ]
[ "K922: Gastrointestinal hemorrhage, unspecified", "Z944: Liver transplant status", "N179: Acute kidney failure, unspecified", "I319: Disease of pericardium, unspecified", "D6959: Other secondary thrombocytopenia", "G629: Polyneuropathy, unspecified", "J449: Chronic obstructive pulmonary disease, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "R3911: Hesitancy of micturition", "Z7982: Long term (current) use of aspirin", "Z7952: Long term (current) use of systemic steroids", "Z86718: Personal history of other venous thrombosis and embolism", "E785: Hyperlipidemia, unspecified", "Z87891: Personal history of nicotine dependence", "F909: Attention-deficit hyperactivity disorder, unspecified type", "F319: Bipolar disorder, unspecified", "M940: Chondrocostal junction syndrome [Tietze]", "G8929: Other chronic pain" ]
19,992,938
22,834,610
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: right hip pain Major Surgical or Invasive Procedure: ___: Intramedullary nail (short trochanteric fixation nail), right hip History of Present Illness: Mrs. ___ is a ___ year old female with dementia who was brought to ___ after being found down on he floor in her bedroom. According to notes, the patient did not pick up the phone when family called in the evening. The family found her seated on he floor in her bedroom with her back to the wall. She was complaining of right hip pain. She does not remember how she fell, and when questioned says she did not fall. She reports no head or neck pain, no chest pain, abdominal pain or back pain. Review of systems is otherwise limited due to patient's dementia. Past Medical History: - Hypothyroidism - Hypertension - dementia - bladder cancer PSH: - cholecystectomy Social History: ___ Family History: n/c Physical Exam: Admission Physical Exam: ==================== VS: T 97.3, HR 72, BP 111/68, RR 18, SaO2 97% RA GEN: Resting comfortably, alert, oriented to person and place HEENT: C-collar in place, nontender CV: regular rate and rhythm PULM: Clear to auscultation ABD: Soft, nontender, nondistended, no guarding or rebound tenderness MSK: Right hip tender to palpation. No ecchymosis, no midline back tenderness. NEURO: CII-XII intact PSYCH: Pleasant Discharge Physical Exam: ==================== T 99.5 BP 139/69 75 18 96%RA General: Comfortable, AAOX3 HEENT: sclera anicteric CV: systolic ejection murmur heard best at RUSB, regular rate and rhythm Neck: JVP at clavicle PULM: CTAB ABD: Soft, Soft, nontender, nondistended, no guarding or rebound tenderness MSK: R hip mild TTP. Dressing in place with blood overlying. No frank echymosses. R thigh > L thigh but soft, no TTP. Moving RLE toes. +DP pulse. NEURO: CN2-12 grossly intact. ___ upper extremity strength grossly intact. ___ strength LLE, unable to test RLE strength secondary to discomfort. Pertinent Results: Admission Labs: ============= ___ 02:00AM BLOOD WBC-16.9* RBC-3.16* Hgb-10.1* Hct-31.0* MCV-98 MCH-32.0 MCHC-32.6 RDW-14.4 RDWSD-51.5* Plt ___ ___ 02:00AM BLOOD Neuts-82* Bands-0 Lymphs-8* Monos-9 Eos-0 Baso-1 ___ Myelos-0 AbsNeut-13.86* AbsLymp-1.35 AbsMono-1.52* AbsEos-0.00* AbsBaso-0.17* ___ 02:00AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-2+ Microcy-NORMAL Polychr-NORMAL ___ 02:00AM BLOOD ___ PTT-31.0 ___ ___ 02:00AM BLOOD Plt Smr-NORMAL Plt ___ ___ 02:00AM BLOOD Glucose-131* UreaN-19 Creat-0.8 Na-140 K-3.7 Cl-101 HCO3-28 AnGap-15 ___ 02:00AM BLOOD CK(CPK)-1517* ___ 08:45AM BLOOD CK(CPK)-1231* ___ 02:00AM BLOOD cTropnT-0.04* ___ 08:45AM BLOOD cTropnT-0.03* ___ 04:30AM BLOOD Iron-26* ___ 04:30AM BLOOD calTIBC-260 VitB12-621 Ferritn-249* TRF-200 ___ 04:30AM BLOOD TSH-1.3 ___ 02:18AM BLOOD Lactate-2.2* Microbiology: ========== ___ 2:00 am BLOOD CULTURE Blood Culture, Routine (Pending): ___ 4:51 am URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: <10,000 organisms/ml. Urine: ===== ___ 04:50AM URINE Color-Yellow Appear-Clear Sp ___ ___ 04:50AM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-7.0 Leuks-NEG ___ 04:50AM URINE RBC-11* WBC-2 Bacteri-FEW Yeast-NONE Epi-<1 ___ 04:51AM URINE CastHy-3* EKG: ==== ECGStudy Date of ___ 1:52:25 AM Clinical indication for EKG: W19.XXXA - Unspecified fall, initial encounter Atrial fibrillation with mean ventricular rate of 73. Possible left ventricular hypertrophy with secondary repolarization abnormalities. No previous tracing available for comparison. Rate 73 PR 124 QRS 80 QT399 QTC421/440 Imaging: ======= FEMUR (AP & LAT) RIGHTStudy Date of ___ 2:09 AM IMPRESSION: No distal femoral fracture is seen. There is comminuted right intertrochanteric proximal femoral fracture. HIP NAILING IN OR W/FILMS & FLUORO RIGHT IN O.R.Study Date of ___ 4:18 ___ IMPRESSION: Fluoroscopic images show placement of a fixation device about fracture of the proximal femur. Further information can be gathered from the operative report. CHEST (PA & LAT)Study Date of ___ 7:12 ___ IMPRESSION: Cardiomegaly is substantial. Large hiatal hernia is projecting over the cardiac silhouette. Lungs assessment demonstrate vascular congestion but no focal consolidations to suggest pneumonia. Bilateral pleural effusion is moderate, increased as compared to ___. Portable TTE (Complete) Done ___ at 3:15:49 ___ FINAL ___ ___ MRN: ___ Portable TTE (Complete) Done ___ at 3:15:49 ___ FINAL GENERAL COMMENTS: The patient appears to be in sinus rhythm. Echocardiographic results were reviewed by telephone with the houseofficer caring for the patient. Conclusions The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is ___ mmHg. Mild symmetric left ventricular hypertrophy with normal cavity size, and regional/global systolic function (biplane LVEF = 61 %). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. There is severe aortic valve stenosis (valve area <1.0cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is a small circumferential pericardial effusion without evidence for hemodynamic compromise. IMPRESSION: Severe aortic valve stenosis. Mild symmetric left ventricular hypertrophy with preserved regional and global biventricular systolic function. Moderate mitral regurgitation. Moderate pulmonary artery systolic hypertension. Small circumferential pericardial effusion. CLINICAL IMPLICATIONS: The patient has severe aortic valve stenosis. Based on ___ ACC/AHA Valvular Heart Disease Guidelines, if the patient is asymptomatic, it is reasonable to consider an exercise stress test to confirm symptom status. In addition, a follow-up study is suggested in ___ months. If they are symptomatic (angina, syncope, CHF) and a surgical or TAVI candidate, a mechanical intervention is recommended. CAROTID SERIES COMPLETEStudy Date of ___ 10:50 AM IMPRESSION: No evidence of atherosclerotic disease in the bilateral carotid vasculature. Tortuous bilateral ICAs are incidentally noted. Discharge Labs: ============ ___ 04:15AM BLOOD WBC-13.0* RBC-3.06* Hgb-9.6* Hct-29.5* MCV-96 MCH-31.4 MCHC-32.5 RDW-15.3 RDWSD-52.3* Plt ___ ___ 04:15AM BLOOD Plt ___ ___ 04:15AM BLOOD Glucose-85 UreaN-14 Creat-0.6 Na-141 K-4.1 Cl-104 HCO3-25 AnGap-16 ___ 04:15AM BLOOD Calcium-8.1* Phos-2.3* Mg-1.9 Brief Hospital Course: Summary: ======== ___ yo F with PMH of HTN, hypothyroidism, and dementia who was transferred from OSH after unwitnessed fall with imaging concerning for C6-C7 anterior osteophyte fracture and right subtrochanteric fractures, now s/p ORIF ___ and transferred to medicine for syncope workup found to have new paroxysmal atrial fibrillation and aortic stenosis. # Presumed syncope w/ fall: Circumstances surrounding fall unclear given patient's dementia. Found down by son . ___ for fall included mechanical fall, however was also found to have new paroxysmal atrial fibrillation and new aortic stenosis noted on TTE, thus raising concern for potential cardiac etiology. Orthostatics negative. Blood pressures tolerated restarting home losartan. Pulmonary embolus was lower on differential given absence of tachycardia, chest pain, or new O2 requirement. EKG was without acute ischemic changes and no q waves noted. No prior seizure history. Patient was initially monitored on telemetry which captured intermittent atrial fibrillation. # Anemia: Downtrend during hospital stay with concern for acute on chronic etiology. Patient noted to be iron deficient and with normal B12. Exam notable for enlargement of right thigh compared to left, concerning for accumulating hematoma in prior operative site. No evidence of compartment syndrome on exam. Received 2 units pRBC transfusion with appropriate h/h bump. Orthopedic surgery aware and recommended continuing enoxaparin 30mg QHS. # Aortic stenosis: Moderate to severe aortic stenosis noted on echo ___ with preserved EF. Moderate pulmonary effusions noted on CXR but patient was satting well on room air and thus no active diuresis was performed. Home losartan was restarted. Seen by CT surgery. Carotid US normal. Pat not deemed candidate for open AV replacement. Should be referred for Trans-aortic valve replacement to TABR team who saw her while in hospital Since patient was not particularly otherwise symptomatic and had low AV gradients, plan was for a 3 month follow-up with Dr ___. The rehab or PCP can call the Call center to set that up ___. (This information was relayed to the rehab center by resident Dr. ___ discharge). # Paroxysmal atrial fibrillation: CHADs2 score 2 (age, HTN); CHADSs2Vasc 3 (age, HTN, sex) New onset per conversation with PCP and review of last office EKG by PCP ___ ___. Spontaneously rhythm controlled and on post operative enoxaparin per orthopedic surgery. Given CHADs score, decision regarding anticoagulation deferred to outpatient setting. TSH normal. No evidence of infection on UA, UCx. Blood cultures NGTD but final read pending at time of discharge. # Intertrochanteric fracture: s/p ORIF ___. Concern for hematoma per above with no evidence of compartment syndrome on exam. Pain control with acetaminophen and oxycodone. Anticoagulation with enoxaparin 30mg QHS x 4 weeks per ortho (Day ___= ___. Follow up 2 weeks post op with ortho. Per ortho, WBAT. Patient worked with physical therapy who recommended d/c to rehab. # Concern for C6-C7 anterior osteophyte fracture: Concern given imaging findings at OSH. Examined by neurosurgery in ___ who noted no deficits on neuro exam, no neck pain and determined no neurosurgical intervention required. Per neurosurgery, no c-collar, follow up imaging, or neurosurgery follow up required. # Leukocytosis: Stress response from fall, surgery, hematoma noted above. Afebrile and VSS with stable to downtrending leukocytosis. No infectious source identified at this time with negative UA, final neg UCx, and BCx NGTD. CXR without PNA. # Thrombocytopenia: Resolved at time of discharge. Attributed to post surgical stress response. On enoxaparin but 4T score was 2 (40% drop; plt fall <4d without prior exposure, other probable cause, no thrombosislow probability). # Rhabdomyolysis: 1517 on admission, likely secondary to being found down. Downtrending with no evidence of renal compromise. # Hypothyroidism: TSH wnl. Continued on Levothyroxine Sodium 125 mcg PO/NG DAILY # Osteoporosis: Given age and hip fracture, osteoporosis is likely. Started on Calcium Carbonate 1000 mg PO/NG DAILY and Vitamin D 800 UNIT PO/NG DAILY. Consider outpatient bisphosphonate therapy. # DVT prophylaxis: High risk of VTE ___. Started lovenox QHS per ortho for 4 weeks. Transitional Issues: ==================== - started calcium and vitamin D for likely osteoporosis given hip fracture. Consider bisphosphonate therapy. - 4 weeks lovenox 30mg QHS from operation date (___) - s/p ORIF ___ of R hip c/b hematoma. Please monitor hematoma. - orthopedic surgery follow up 2 weeks post op. - aortic stenosis newly noted on echo. TAVR workup started. Please follow up for further consideration of TAVR surgery. Seen by CT surgery. Carotid US normal. Pat not deemed candidate for open AV replacement. Should be referred for Trans-aortic valve replacement to TABR team who saw her while in hospital Since patient was not particularly otherwise symptomatic and had low AV gradients, plan was for a 3 month follow-up with Dr ___. The rehab or PCP can call the Call center to set that up ___. (This information was relayed to the rehab center by resident Dr. ___ discharge). - new paroxysmal atrial fibrillation noted. No rate control required. Started on ASA 81 mg daily. Consideration of further anticoagulation deferred to outpatient setting. - per conversation with PCP and son, concern for ability to care for self at home. Please consider discharge from rehab with home services. #Full Code Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Losartan Potassium 100 mg PO DAILY 2. Levothyroxine Sodium 125 mcg PO DAILY 3. Multivitamins 1 TAB PO DAILY 4. Vitamin D Dose is Unknown PO DAILY Discharge Medications: 1. Levothyroxine Sodium 125 mcg PO DAILY 2. Losartan Potassium 100 mg PO DAILY 3. Multivitamins 1 TAB PO DAILY 4. Vitamin D 800 UNIT PO DAILY 5. Acetaminophen 650 mg PO TID 6. Calcium Carbonate 1000 mg PO DAILY please take 4 hours after your levothyroxine 7. Enoxaparin Sodium 30 mg SC Q12H Start: Tomorrow - ___, First Dose: First Routine Administration Time 8. Aspirin 81 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: -Right intertrochanteric hip fracture -Aortic stenosis -Paroxysmal atrial fibrillation -Acute blood loss anemia Secondary: -Hypothyroidism -Hypertension Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, It was our pleasure caring for you during your admission to ___. You were transferred to our hospital after you experienced a fall. You were initially felt to have a fracture of your neck, but after evaluation by our neurosurgeons, this was felt to be unlikely. This fall did however result in a fracture of your hip that required orthopedic surgery. After your surgery, you experienced some bleeding into your thigh and required a blood transfusion. This can occasionally occur after hip surgery. Please see below for specific instructions from our orthopedic surgeons. While you were in the hospital, we noted that your heart was occasionally going into an abnormal rhythm called "atrial fibrillation." We also performed a image of your heart called an "echocardiogram" that showed that one of your heart valves had narrowed ("aortic stenosis"). One or both of these cardiac issues may have contributed to the fall that you experienced. You should follow up with your primary care physician to decide if you need to start any new medications for the atrial fibrillation. You should also follow up with our cardiac surgery team to find out if you might benefit from surgery for your aortic stenosis. Our physical therapists felt that you would benefit from going to rehab after this hospital stay. Please follow up with your primary care physician, ___, and our cardiac surgery team. We wish you the best! Your ___ Care Team INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - You are encouraged to bear weight as tolerated on your right lower extremity. MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take Lovenox 40 MG 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. Followup Instructions: ___
[ "S72141A", "T796XXA", "D696", "F0390", "I080", "I272", "M96830", "D62", "W1830XA", "Y92013", "D509", "E039", "I10", "M810", "I4891", "M25512", "Z8551", "Z87891" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: right hip pain Major Surgical or Invasive Procedure: [MASKED]: Intramedullary nail (short trochanteric fixation nail), right hip History of Present Illness: Mrs. [MASKED] is a [MASKED] year old female with dementia who was brought to [MASKED] after being found down on he floor in her bedroom. According to notes, the patient did not pick up the phone when family called in the evening. The family found her seated on he floor in her bedroom with her back to the wall. She was complaining of right hip pain. She does not remember how she fell, and when questioned says she did not fall. She reports no head or neck pain, no chest pain, abdominal pain or back pain. Review of systems is otherwise limited due to patient's dementia. Past Medical History: - Hypothyroidism - Hypertension - dementia - bladder cancer PSH: - cholecystectomy Social History: [MASKED] Family History: n/c Physical Exam: Admission Physical Exam: ==================== VS: T 97.3, HR 72, BP 111/68, RR 18, SaO2 97% RA GEN: Resting comfortably, alert, oriented to person and place HEENT: C-collar in place, nontender CV: regular rate and rhythm PULM: Clear to auscultation ABD: Soft, nontender, nondistended, no guarding or rebound tenderness MSK: Right hip tender to palpation. No ecchymosis, no midline back tenderness. NEURO: CII-XII intact PSYCH: Pleasant Discharge Physical Exam: ==================== T 99.5 BP 139/69 75 18 96%RA General: Comfortable, AAOX3 HEENT: sclera anicteric CV: systolic ejection murmur heard best at RUSB, regular rate and rhythm Neck: JVP at clavicle PULM: CTAB ABD: Soft, Soft, nontender, nondistended, no guarding or rebound tenderness MSK: R hip mild TTP. Dressing in place with blood overlying. No frank echymosses. R thigh > L thigh but soft, no TTP. Moving RLE toes. +DP pulse. NEURO: CN2-12 grossly intact. [MASKED] upper extremity strength grossly intact. [MASKED] strength LLE, unable to test RLE strength secondary to discomfort. Pertinent Results: Admission Labs: ============= [MASKED] 02:00AM BLOOD WBC-16.9* RBC-3.16* Hgb-10.1* Hct-31.0* MCV-98 MCH-32.0 MCHC-32.6 RDW-14.4 RDWSD-51.5* Plt [MASKED] [MASKED] 02:00AM BLOOD Neuts-82* Bands-0 Lymphs-8* Monos-9 Eos-0 Baso-1 [MASKED] Myelos-0 AbsNeut-13.86* AbsLymp-1.35 AbsMono-1.52* AbsEos-0.00* AbsBaso-0.17* [MASKED] 02:00AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-2+ Microcy-NORMAL Polychr-NORMAL [MASKED] 02:00AM BLOOD [MASKED] PTT-31.0 [MASKED] [MASKED] 02:00AM BLOOD Plt Smr-NORMAL Plt [MASKED] [MASKED] 02:00AM BLOOD Glucose-131* UreaN-19 Creat-0.8 Na-140 K-3.7 Cl-101 HCO3-28 AnGap-15 [MASKED] 02:00AM BLOOD CK(CPK)-1517* [MASKED] 08:45AM BLOOD CK(CPK)-1231* [MASKED] 02:00AM BLOOD cTropnT-0.04* [MASKED] 08:45AM BLOOD cTropnT-0.03* [MASKED] 04:30AM BLOOD Iron-26* [MASKED] 04:30AM BLOOD calTIBC-260 VitB12-621 Ferritn-249* TRF-200 [MASKED] 04:30AM BLOOD TSH-1.3 [MASKED] 02:18AM BLOOD Lactate-2.2* Microbiology: ========== [MASKED] 2:00 am BLOOD CULTURE Blood Culture, Routine (Pending): [MASKED] 4:51 am URINE Source: [MASKED]. **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: <10,000 organisms/ml. Urine: ===== [MASKED] 04:50AM URINE Color-Yellow Appear-Clear Sp [MASKED] [MASKED] 04:50AM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-7.0 Leuks-NEG [MASKED] 04:50AM URINE RBC-11* WBC-2 Bacteri-FEW Yeast-NONE Epi-<1 [MASKED] 04:51AM URINE CastHy-3* EKG: ==== ECGStudy Date of [MASKED] 1:52:25 AM Clinical indication for EKG: W19.XXXA - Unspecified fall, initial encounter Atrial fibrillation with mean ventricular rate of 73. Possible left ventricular hypertrophy with secondary repolarization abnormalities. No previous tracing available for comparison. Rate 73 PR 124 QRS 80 QT399 QTC421/440 Imaging: ======= FEMUR (AP & LAT) RIGHTStudy Date of [MASKED] 2:09 AM IMPRESSION: No distal femoral fracture is seen. There is comminuted right intertrochanteric proximal femoral fracture. HIP NAILING IN OR W/FILMS & FLUORO RIGHT IN O.R.Study Date of [MASKED] 4:18 [MASKED] IMPRESSION: Fluoroscopic images show placement of a fixation device about fracture of the proximal femur. Further information can be gathered from the operative report. CHEST (PA & LAT)Study Date of [MASKED] 7:12 [MASKED] IMPRESSION: Cardiomegaly is substantial. Large hiatal hernia is projecting over the cardiac silhouette. Lungs assessment demonstrate vascular congestion but no focal consolidations to suggest pneumonia. Bilateral pleural effusion is moderate, increased as compared to [MASKED]. Portable TTE (Complete) Done [MASKED] at 3:15:49 [MASKED] FINAL [MASKED] [MASKED] MRN: [MASKED] Portable TTE (Complete) Done [MASKED] at 3:15:49 [MASKED] FINAL GENERAL COMMENTS: The patient appears to be in sinus rhythm. Echocardiographic results were reviewed by telephone with the houseofficer caring for the patient. Conclusions The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is [MASKED] mmHg. Mild symmetric left ventricular hypertrophy with normal cavity size, and regional/global systolic function (biplane LVEF = 61 %). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. There is severe aortic valve stenosis (valve area <1.0cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is a small circumferential pericardial effusion without evidence for hemodynamic compromise. IMPRESSION: Severe aortic valve stenosis. Mild symmetric left ventricular hypertrophy with preserved regional and global biventricular systolic function. Moderate mitral regurgitation. Moderate pulmonary artery systolic hypertension. Small circumferential pericardial effusion. CLINICAL IMPLICATIONS: The patient has severe aortic valve stenosis. Based on [MASKED] ACC/AHA Valvular Heart Disease Guidelines, if the patient is asymptomatic, it is reasonable to consider an exercise stress test to confirm symptom status. In addition, a follow-up study is suggested in [MASKED] months. If they are symptomatic (angina, syncope, CHF) and a surgical or TAVI candidate, a mechanical intervention is recommended. CAROTID SERIES COMPLETEStudy Date of [MASKED] 10:50 AM IMPRESSION: No evidence of atherosclerotic disease in the bilateral carotid vasculature. Tortuous bilateral ICAs are incidentally noted. Discharge Labs: ============ [MASKED] 04:15AM BLOOD WBC-13.0* RBC-3.06* Hgb-9.6* Hct-29.5* MCV-96 MCH-31.4 MCHC-32.5 RDW-15.3 RDWSD-52.3* Plt [MASKED] [MASKED] 04:15AM BLOOD Plt [MASKED] [MASKED] 04:15AM BLOOD Glucose-85 UreaN-14 Creat-0.6 Na-141 K-4.1 Cl-104 HCO3-25 AnGap-16 [MASKED] 04:15AM BLOOD Calcium-8.1* Phos-2.3* Mg-1.9 Brief Hospital Course: Summary: ======== [MASKED] yo F with PMH of HTN, hypothyroidism, and dementia who was transferred from OSH after unwitnessed fall with imaging concerning for C6-C7 anterior osteophyte fracture and right subtrochanteric fractures, now s/p ORIF [MASKED] and transferred to medicine for syncope workup found to have new paroxysmal atrial fibrillation and aortic stenosis. # Presumed syncope w/ fall: Circumstances surrounding fall unclear given patient's dementia. Found down by son . [MASKED] for fall included mechanical fall, however was also found to have new paroxysmal atrial fibrillation and new aortic stenosis noted on TTE, thus raising concern for potential cardiac etiology. Orthostatics negative. Blood pressures tolerated restarting home losartan. Pulmonary embolus was lower on differential given absence of tachycardia, chest pain, or new O2 requirement. EKG was without acute ischemic changes and no q waves noted. No prior seizure history. Patient was initially monitored on telemetry which captured intermittent atrial fibrillation. # Anemia: Downtrend during hospital stay with concern for acute on chronic etiology. Patient noted to be iron deficient and with normal B12. Exam notable for enlargement of right thigh compared to left, concerning for accumulating hematoma in prior operative site. No evidence of compartment syndrome on exam. Received 2 units pRBC transfusion with appropriate h/h bump. Orthopedic surgery aware and recommended continuing enoxaparin 30mg QHS. # Aortic stenosis: Moderate to severe aortic stenosis noted on echo [MASKED] with preserved EF. Moderate pulmonary effusions noted on CXR but patient was satting well on room air and thus no active diuresis was performed. Home losartan was restarted. Seen by CT surgery. Carotid US normal. Pat not deemed candidate for open AV replacement. Should be referred for Trans-aortic valve replacement to TABR team who saw her while in hospital Since patient was not particularly otherwise symptomatic and had low AV gradients, plan was for a 3 month follow-up with Dr [MASKED]. The rehab or PCP can call the Call center to set that up [MASKED]. (This information was relayed to the rehab center by resident Dr. [MASKED] discharge). # Paroxysmal atrial fibrillation: CHADs2 score 2 (age, HTN); CHADSs2Vasc 3 (age, HTN, sex) New onset per conversation with PCP and review of last office EKG by PCP [MASKED] [MASKED]. Spontaneously rhythm controlled and on post operative enoxaparin per orthopedic surgery. Given CHADs score, decision regarding anticoagulation deferred to outpatient setting. TSH normal. No evidence of infection on UA, UCx. Blood cultures NGTD but final read pending at time of discharge. # Intertrochanteric fracture: s/p ORIF [MASKED]. Concern for hematoma per above with no evidence of compartment syndrome on exam. Pain control with acetaminophen and oxycodone. Anticoagulation with enoxaparin 30mg QHS x 4 weeks per ortho (Day [MASKED]= [MASKED]. Follow up 2 weeks post op with ortho. Per ortho, WBAT. Patient worked with physical therapy who recommended d/c to rehab. # Concern for C6-C7 anterior osteophyte fracture: Concern given imaging findings at OSH. Examined by neurosurgery in [MASKED] who noted no deficits on neuro exam, no neck pain and determined no neurosurgical intervention required. Per neurosurgery, no c-collar, follow up imaging, or neurosurgery follow up required. # Leukocytosis: Stress response from fall, surgery, hematoma noted above. Afebrile and VSS with stable to downtrending leukocytosis. No infectious source identified at this time with negative UA, final neg UCx, and BCx NGTD. CXR without PNA. # Thrombocytopenia: Resolved at time of discharge. Attributed to post surgical stress response. On enoxaparin but 4T score was 2 (40% drop; plt fall <4d without prior exposure, other probable cause, no thrombosislow probability). # Rhabdomyolysis: 1517 on admission, likely secondary to being found down. Downtrending with no evidence of renal compromise. # Hypothyroidism: TSH wnl. Continued on Levothyroxine Sodium 125 mcg PO/NG DAILY # Osteoporosis: Given age and hip fracture, osteoporosis is likely. Started on Calcium Carbonate 1000 mg PO/NG DAILY and Vitamin D 800 UNIT PO/NG DAILY. Consider outpatient bisphosphonate therapy. # DVT prophylaxis: High risk of VTE [MASKED]. Started lovenox QHS per ortho for 4 weeks. Transitional Issues: ==================== - started calcium and vitamin D for likely osteoporosis given hip fracture. Consider bisphosphonate therapy. - 4 weeks lovenox 30mg QHS from operation date ([MASKED]) - s/p ORIF [MASKED] of R hip c/b hematoma. Please monitor hematoma. - orthopedic surgery follow up 2 weeks post op. - aortic stenosis newly noted on echo. TAVR workup started. Please follow up for further consideration of TAVR surgery. Seen by CT surgery. Carotid US normal. Pat not deemed candidate for open AV replacement. Should be referred for Trans-aortic valve replacement to TABR team who saw her while in hospital Since patient was not particularly otherwise symptomatic and had low AV gradients, plan was for a 3 month follow-up with Dr [MASKED]. The rehab or PCP can call the Call center to set that up [MASKED]. (This information was relayed to the rehab center by resident Dr. [MASKED] discharge). - new paroxysmal atrial fibrillation noted. No rate control required. Started on ASA 81 mg daily. Consideration of further anticoagulation deferred to outpatient setting. - per conversation with PCP and son, concern for ability to care for self at home. Please consider discharge from rehab with home services. #Full Code Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Losartan Potassium 100 mg PO DAILY 2. Levothyroxine Sodium 125 mcg PO DAILY 3. Multivitamins 1 TAB PO DAILY 4. Vitamin D Dose is Unknown PO DAILY Discharge Medications: 1. Levothyroxine Sodium 125 mcg PO DAILY 2. Losartan Potassium 100 mg PO DAILY 3. Multivitamins 1 TAB PO DAILY 4. Vitamin D 800 UNIT PO DAILY 5. Acetaminophen 650 mg PO TID 6. Calcium Carbonate 1000 mg PO DAILY please take 4 hours after your levothyroxine 7. Enoxaparin Sodium 30 mg SC Q12H Start: Tomorrow - [MASKED], First Dose: First Routine Administration Time 8. Aspirin 81 mg PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Primary: -Right intertrochanteric hip fracture -Aortic stenosis -Paroxysmal atrial fibrillation -Acute blood loss anemia Secondary: -Hypothyroidism -Hypertension 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], It was our pleasure caring for you during your admission to [MASKED]. You were transferred to our hospital after you experienced a fall. You were initially felt to have a fracture of your neck, but after evaluation by our neurosurgeons, this was felt to be unlikely. This fall did however result in a fracture of your hip that required orthopedic surgery. After your surgery, you experienced some bleeding into your thigh and required a blood transfusion. This can occasionally occur after hip surgery. Please see below for specific instructions from our orthopedic surgeons. While you were in the hospital, we noted that your heart was occasionally going into an abnormal rhythm called "atrial fibrillation." We also performed a image of your heart called an "echocardiogram" that showed that one of your heart valves had narrowed ("aortic stenosis"). One or both of these cardiac issues may have contributed to the fall that you experienced. You should follow up with your primary care physician to decide if you need to start any new medications for the atrial fibrillation. You should also follow up with our cardiac surgery team to find out if you might benefit from surgery for your aortic stenosis. Our physical therapists felt that you would benefit from going to rehab after this hospital stay. Please follow up with your primary care physician, [MASKED], and our cardiac surgery team. We wish you the best! Your [MASKED] Care Team INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - You are encouraged to bear weight as tolerated on your right lower extremity. MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take Lovenox 40 MG 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. Followup Instructions: [MASKED]
[]
[ "D696", "D62", "D509", "E039", "I10", "I4891", "Z87891" ]
[ "S72141A: Displaced intertrochanteric fracture of right femur, initial encounter for closed fracture", "T796XXA: Traumatic ischemia of muscle, initial encounter", "D696: Thrombocytopenia, unspecified", "F0390: Unspecified dementia without behavioral disturbance", "I080: Rheumatic disorders of both mitral and aortic valves", "I272: Other secondary pulmonary hypertension", "M96830: Postprocedural hemorrhage of a musculoskeletal structure following a musculoskeletal system procedure", "D62: Acute posthemorrhagic anemia", "W1830XA: Fall on same level, unspecified, initial encounter", "Y92013: Bedroom of single-family (private) house as the place of occurrence of the external cause", "D509: Iron deficiency anemia, unspecified", "E039: Hypothyroidism, unspecified", "I10: Essential (primary) hypertension", "M810: Age-related osteoporosis without current pathological fracture", "I4891: Unspecified atrial fibrillation", "M25512: Pain in left shoulder", "Z8551: Personal history of malignant neoplasm of bladder", "Z87891: Personal history of nicotine dependence" ]
19,993,089
20,556,903
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Left arm and jaw pain with GI upset Major Surgical or Invasive Procedure: Cardiac catheterization Left Ventriculography: The ejection fraction was visually estimated to be 30%. The left ventricle was of normal size. Anterobasal: Normal Anterolateral: Dyskinesis Apical: Dyskinesis Diaphragmatic: Dyskinesis Posterobasal: Normal Coronary Anatomy LM: Normal LAD: Mild lumenal irregularities LCx: Mild lumenal irregularities RCA: Mild lumenal irregularites. Impressions: There is no significant CAD. There is an area of apical dyskinesis and "ballooning" with moderately reduced LV systolic function. Overall this picture is consistent with Takotsubo cardiomyopathy. History of Present Illness: ___ without significant PMHx presented to ___ with 1 day of left arm pain, now transferred to ___ for further evaluation. Patient was in her USOH until last evening when she had left arm pain at rest. Lasted fromo ___-0400 with some residual pain left in the morning. Also noted to have belching and some chest discomfort. ROS negative for nausea/vomiting, sob, dizziness. She presented to her PCP with EKG showing new TWI in lateral leads and inferior TW changes concerning for ischemia. She was referred into the ED at ___. At ___ initial vitals were stable. Labs were notable for: Labs at ___: - CBC 8.54/13.9/40.6/248 - INR 0.9 - CMP: ___, AST 26, ALT 23 - Trp T 0.232, CK-MB 9, CPK 169 She was given ASA and started on a heparin gtt prior to transfer. In the ED initial vitals were: 95, 109/71, 18, 95% RA Pt arrives awake and alert. Denies CP at this time. Heparin infusing on arrival EKG: Sinus rhythm, rate 79, QTc 470/502, TWI V3-V6, qwaves in II, no clear STE or STD Labs/studies notable for: Trp 0.17->0.12 Patient was given: IV Heparin Vitals on transfer: 98.5, 75, 113/68, 16, 98% RA On the floor patient was resting comfortably without chest pain. Denies any other symptoms. Inquisitive about possible interventions tomorrow. Past Medical History: None Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Physical Exam: PHYSICAL EXAMINATION ON ADMISSION: Tele: HR ___, TWI throughout VS: T 98.2 BP ___ HR ___ RR 15 O2 sat 94% on RA Weight: 90.2 GENERAL: Resting comfortably. Oriented x3. Mood, affect appropriate. HEENT: Sclera anicteric. EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple with JVP 1 cm above clavicle at 30 degrees. CARDIAC: Slightly distant heart sounds, RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: Diffuse crackles right lower ___, clear on left. Resp were unlabored, no accessory muscle use. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: Warm, 2+ radial and ___ pulses SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PHYSICAL EXAMINATION ON DISCHARGE: Vitals: T= 97.9 HR=60-70s BP=100-110s/40-50s RR=18 O2= 95% on RA Telemetry: HR ___, persisting TWI, no alarms General: Resting comfortably HEENT: JVP not visible at 45 degrees. Lungs: CTAB, no wheezes CV: RRR, normal S1, S2, no murmurs Abdomen: NT, ND, no masses Ext: warm, 2+ radial and ___ pulses Neuro: right pupil 7-8 mm, left pupil 3-4 mm, both respond to light. Visual fields full to confrontation. EOMI, smile and tongue symmetric, SCM strength symmetric, hearing grossly intact bilaterally. Pertinent Results: LABS ON ADMISSION: ___ 11:10PM BLOOD WBC-8.0 RBC-4.48 Hgb-14.0 Hct-41.7 MCV-93 MCH-31.3 MCHC-33.6 RDW-13.2 RDWSD-44.6 Plt ___ ___ 11:10PM BLOOD ___ PTT-61.2* ___ ___ 11:10PM BLOOD Glucose-111* UreaN-12 Creat-0.8 Na-138 K-5.4* Cl-104 HCO3-21* AnGap-18 ___ 08:30PM BLOOD cTropnT-0.17* ___ 11:10PM BLOOD cTropnT-0.12* ___ 06:15AM BLOOD CK-MB-7 cTropnT-0.08* LABS ON DISCHARGE: ___ 07:05AM BLOOD WBC-6.6 RBC-4.52 Hgb-14.5 Hct-42.4 MCV-94 MCH-32.1* MCHC-34.2 RDW-13.3 RDWSD-45.4 Plt ___ ___ 07:05AM BLOOD ___ PTT-32.2 ___ ___ 07:05AM BLOOD Glucose-97 UreaN-13 Creat-0.9 Na-141 K-4.1 Cl-104 HCO3-25 AnGap-16 ___ 07:05AM BLOOD cTropnT-0.03* OTHER FINDINGS: EKGs ___: TWI V2-V6, QRS 100 mm, left axis Cardiac catheterization ___ PRELIMINARY REPORT: There is no significant CAD. There is an area of apical dyskinesis and "ballooning" with moderately reduced LV systolic function. Overall this picture is consistent with Takotsubo cardiomyopathy. TEE ___ FINAL: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is ___ mmHg. Left ventricular wall thicknesses are normal. There is moderate regional left ventricular systolic dysfunction with akinesis of the mid-anterior and anteroseptal segments and the distal ___ of the left ventricle. The remaining segments contract normally (LVEF = 30%). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. No aortic regurgitation is seen. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: Moderate regional left ventricular systolic dysfunction. Mild mitral regurgitation. Findings are most c/w takotsubo cardiomyopathy. LAD-territory infarction cannot be reliably excluded, however. Brief Hospital Course: Mrs. ___, ___ without significant past medical history, presented with 1 day of left arm and jaw pain and belching and was found to have new T wave inversions on EKG and troponin elevated to 0.232. We were concerned for NSTEMI and initiated treatment with ASA, heparin gtt, atorvastatin 80 mg, and metroprolol. Subsequently, TTE revealed apical akinesis with LVEF 30% and apical ballooning, and cardiac catheterization revealed non-obstructive disease and confirmed with left ventriculogram apical ballooning and akinesis, overall consistent with Takotsubo's cardiomyopathy. The patient did endorse losing two close friends in the last 6 months. In light of echo markedly reduced EF (30%), we initiated treatment for heart failure intended to be short-term. We transitioned from heparin to apixiban for anticoagulation (given apical akinesis and risk for LV thrombus), initiated treatment with ACE inhibitor and continued metoprolol. We continued a low dose of atorvastatin at 20 mg daily as well as aspirin 81 daily. We recommend revisiting the need for these medications at the patient's next cardiology appointment. #Transitional issues: - NEW MEDICATIONS: apixiban, metoprolol, atorvastatin, ASA, and lisinopril until EF improves - recommend consideration for outpatient cardiac rehab - recommend discussing need for continued ASA and atorvastatin given limited utility in heart failure, but mild CAD (mild luminal irregularities on catheterization) - can consider uptitrating lisinopril from 2.5 to 5 mg daily as blood pressure tolerates Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. Apixaban 5 mg PO/NG BID RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*1 2. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*1 3. Atorvastatin 20 mg PO QPM RX *atorvastatin 20 mg 1 tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*1 4. Lisinopril 2.5 mg PO DAILY RX *lisinopril 2.5 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*1 5. Metoprolol Succinate XL 50 mg PO DAILY RX *metoprolol succinate 50 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*1 Discharge Disposition: Home Discharge Diagnosis: Stress cardiomyopathy (aka Takotsubo cardiomyopathy) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, You were hospitalized due to arm and jaw pain with stomach upset, and found to have stress cardiomyopathy, also called Takotsubo cardiomyopathy. This condition is a temporary reduction in heart function that is sometimes, but not always, associated with a recent physical or emotion stress. Fortunately, this is not a permanent condition and we expect your heart to return to normal in the next ___ months. Because your heart function is currently decreased, it is important that you take several new medications listed below until your cardiologist tells you to stop taking these medications. Your follow-up appointments are listed below. It was a pleasure taking care of you. Sincerely, Your ___ Cardiology Team Followup Instructions: ___
[ "I5181", "R9431", "Z7902", "Z23" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Left arm and jaw pain with GI upset Major Surgical or Invasive Procedure: Cardiac catheterization Left Ventriculography: The ejection fraction was visually estimated to be 30%. The left ventricle was of normal size. Anterobasal: Normal Anterolateral: Dyskinesis Apical: Dyskinesis Diaphragmatic: Dyskinesis Posterobasal: Normal Coronary Anatomy LM: Normal LAD: Mild lumenal irregularities LCx: Mild lumenal irregularities RCA: Mild lumenal irregularites. Impressions: There is no significant CAD. There is an area of apical dyskinesis and "ballooning" with moderately reduced LV systolic function. Overall this picture is consistent with Takotsubo cardiomyopathy. History of Present Illness: [MASKED] without significant PMHx presented to [MASKED] with 1 day of left arm pain, now transferred to [MASKED] for further evaluation. Patient was in her USOH until last evening when she had left arm pain at rest. Lasted fromo [MASKED]-0400 with some residual pain left in the morning. Also noted to have belching and some chest discomfort. ROS negative for nausea/vomiting, sob, dizziness. She presented to her PCP with EKG showing new TWI in lateral leads and inferior TW changes concerning for ischemia. She was referred into the ED at [MASKED]. At [MASKED] initial vitals were stable. Labs were notable for: Labs at [MASKED]: - CBC 8.54/13.9/40.6/248 - INR 0.9 - CMP: [MASKED], AST 26, ALT 23 - Trp T 0.232, CK-MB 9, CPK 169 She was given ASA and started on a heparin gtt prior to transfer. In the ED initial vitals were: 95, 109/71, 18, 95% RA Pt arrives awake and alert. Denies CP at this time. Heparin infusing on arrival EKG: Sinus rhythm, rate 79, QTc 470/502, TWI V3-V6, qwaves in II, no clear STE or STD Labs/studies notable for: Trp 0.17->0.12 Patient was given: IV Heparin Vitals on transfer: 98.5, 75, 113/68, 16, 98% RA On the floor patient was resting comfortably without chest pain. Denies any other symptoms. Inquisitive about possible interventions tomorrow. Past Medical History: None Social History: [MASKED] Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Physical Exam: PHYSICAL EXAMINATION ON ADMISSION: Tele: HR [MASKED], TWI throughout VS: T 98.2 BP [MASKED] HR [MASKED] RR 15 O2 sat 94% on RA Weight: 90.2 GENERAL: Resting comfortably. Oriented x3. Mood, affect appropriate. HEENT: Sclera anicteric. EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple with JVP 1 cm above clavicle at 30 degrees. CARDIAC: Slightly distant heart sounds, RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: Diffuse crackles right lower [MASKED], clear on left. Resp were unlabored, no accessory muscle use. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: Warm, 2+ radial and [MASKED] pulses SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PHYSICAL EXAMINATION ON DISCHARGE: Vitals: T= 97.9 HR=60-70s BP=100-110s/40-50s RR=18 O2= 95% on RA Telemetry: HR [MASKED], persisting TWI, no alarms General: Resting comfortably HEENT: JVP not visible at 45 degrees. Lungs: CTAB, no wheezes CV: RRR, normal S1, S2, no murmurs Abdomen: NT, ND, no masses Ext: warm, 2+ radial and [MASKED] pulses Neuro: right pupil 7-8 mm, left pupil 3-4 mm, both respond to light. Visual fields full to confrontation. EOMI, smile and tongue symmetric, SCM strength symmetric, hearing grossly intact bilaterally. Pertinent Results: LABS ON ADMISSION: [MASKED] 11:10PM BLOOD WBC-8.0 RBC-4.48 Hgb-14.0 Hct-41.7 MCV-93 MCH-31.3 MCHC-33.6 RDW-13.2 RDWSD-44.6 Plt [MASKED] [MASKED] 11:10PM BLOOD [MASKED] PTT-61.2* [MASKED] [MASKED] 11:10PM BLOOD Glucose-111* UreaN-12 Creat-0.8 Na-138 K-5.4* Cl-104 HCO3-21* AnGap-18 [MASKED] 08:30PM BLOOD cTropnT-0.17* [MASKED] 11:10PM BLOOD cTropnT-0.12* [MASKED] 06:15AM BLOOD CK-MB-7 cTropnT-0.08* LABS ON DISCHARGE: [MASKED] 07:05AM BLOOD WBC-6.6 RBC-4.52 Hgb-14.5 Hct-42.4 MCV-94 MCH-32.1* MCHC-34.2 RDW-13.3 RDWSD-45.4 Plt [MASKED] [MASKED] 07:05AM BLOOD [MASKED] PTT-32.2 [MASKED] [MASKED] 07:05AM BLOOD Glucose-97 UreaN-13 Creat-0.9 Na-141 K-4.1 Cl-104 HCO3-25 AnGap-16 [MASKED] 07:05AM BLOOD cTropnT-0.03* OTHER FINDINGS: EKGs [MASKED]: TWI V2-V6, QRS 100 mm, left axis Cardiac catheterization [MASKED] PRELIMINARY REPORT: There is no significant CAD. There is an area of apical dyskinesis and "ballooning" with moderately reduced LV systolic function. Overall this picture is consistent with Takotsubo cardiomyopathy. TEE [MASKED] FINAL: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is [MASKED] mmHg. Left ventricular wall thicknesses are normal. There is moderate regional left ventricular systolic dysfunction with akinesis of the mid-anterior and anteroseptal segments and the distal [MASKED] of the left ventricle. The remaining segments contract normally (LVEF = 30%). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. No aortic regurgitation is seen. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: Moderate regional left ventricular systolic dysfunction. Mild mitral regurgitation. Findings are most c/w takotsubo cardiomyopathy. LAD-territory infarction cannot be reliably excluded, however. Brief Hospital Course: Mrs. [MASKED], [MASKED] without significant past medical history, presented with 1 day of left arm and jaw pain and belching and was found to have new T wave inversions on EKG and troponin elevated to 0.232. We were concerned for NSTEMI and initiated treatment with ASA, heparin gtt, atorvastatin 80 mg, and metroprolol. Subsequently, TTE revealed apical akinesis with LVEF 30% and apical ballooning, and cardiac catheterization revealed non-obstructive disease and confirmed with left ventriculogram apical ballooning and akinesis, overall consistent with Takotsubo's cardiomyopathy. The patient did endorse losing two close friends in the last 6 months. In light of echo markedly reduced EF (30%), we initiated treatment for heart failure intended to be short-term. We transitioned from heparin to apixiban for anticoagulation (given apical akinesis and risk for LV thrombus), initiated treatment with ACE inhibitor and continued metoprolol. We continued a low dose of atorvastatin at 20 mg daily as well as aspirin 81 daily. We recommend revisiting the need for these medications at the patient's next cardiology appointment. #Transitional issues: - NEW MEDICATIONS: apixiban, metoprolol, atorvastatin, ASA, and lisinopril until EF improves - recommend consideration for outpatient cardiac rehab - recommend discussing need for continued ASA and atorvastatin given limited utility in heart failure, but mild CAD (mild luminal irregularities on catheterization) - can consider uptitrating lisinopril from 2.5 to 5 mg daily as blood pressure tolerates Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. Apixaban 5 mg PO/NG BID RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*1 2. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*1 3. Atorvastatin 20 mg PO QPM RX *atorvastatin 20 mg 1 tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*1 4. Lisinopril 2.5 mg PO DAILY RX *lisinopril 2.5 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*1 5. Metoprolol Succinate XL 50 mg PO DAILY RX *metoprolol succinate 50 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*1 Discharge Disposition: Home Discharge Diagnosis: Stress cardiomyopathy (aka Takotsubo cardiomyopathy) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear [MASKED], You were hospitalized due to arm and jaw pain with stomach upset, and found to have stress cardiomyopathy, also called Takotsubo cardiomyopathy. This condition is a temporary reduction in heart function that is sometimes, but not always, associated with a recent physical or emotion stress. Fortunately, this is not a permanent condition and we expect your heart to return to normal in the next [MASKED] months. Because your heart function is currently decreased, it is important that you take several new medications listed below until your cardiologist tells you to stop taking these medications. Your follow-up appointments are listed below. It was a pleasure taking care of you. Sincerely, Your [MASKED] Cardiology Team Followup Instructions: [MASKED]
[]
[ "Z7902" ]
[ "I5181: Takotsubo syndrome", "R9431: Abnormal electrocardiogram [ECG] [EKG]", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "Z23: Encounter for immunization" ]
19,993,336
20,406,110
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: amiodarone / ceftriaxone / Bactrim / Cipro Attending: ___ Chief Complaint: nausea, vomiting Major Surgical or Invasive Procedure: none History of Present Illness: Ms. ___ is a ___ year old female patient with recent mechanical TAVR, Afib, VT arrest, PPM who presented early ___ with an incarcerated left femoral hernia. She was taken promptly to the operating room on ___. She underwent femoral hernia repair and postoperatively was in the cardiac ICU for close monitoring, later on transferred to the surgical floor, she tolerated a regular diet and was discharged home with ___. She now returns complaining of nausea, 1 episode of emesis and constipation. She reports that since her discharge she has only had 3 bowel movements, last one being over 5 days ago, she has been eating small amounts of food daily and her appetite has not returned fully yet. She reports that this morning due to discomfort because of constipation she drank milk of magnesia which made her nauseus and had 1 episode of half a cup of bilious emesis. She reports also using a small fleet enema this morning with a very small bowel movement after this. She denies any other complaint. Reports passing flatus multiple times a day, last one being minutes before arriving to ___. Of note patient reports that she has started treatment for a UTI 2 days ago with Bactrim. Due to these symptoms patient presented to ___ and was transferred here for further management. Past Medical History: PMH: - HFrEF ___ - HTN - HLD - Known severe AS - Esophageal rupture s/p endoscopic clipping - OA - Endometrial polyps - Cholecystectomy PSH: - CCY Social History: ___ Family History: FAMILY HISTORY: - no family history of cancer, heart disease - Father: died of alcohol use - Mother: died in ___ - Grandmother: died at 99 of unknown cause Physical Exam: Admission Physical Exam: Temp 97.7 HR 89 BP 121/61 RR 17 02Sat: 98% RA ___: resting comfortably in NAD, generalized scaly rash HEENT: EOMI, PERRL, anicteric Neck: supple, no LAD Chest: CTAB, no respiratory distress Heart: RRR, normal S1&S2 Abdomen: soft, non tender, non distended, no rebound or guarding. L 9cm induration around left groin incision. Suprapubic bruising. Discharge Physical Exam: VS: 98.1, 96/52, 84, 18, 97 Ra Gen: A&O x3. Sitting up in chair, talkative, appears comfortable Pulm: LS ctab Abd: soft, NT/ND. Left groin with hernia repair incision, moderate sized firm hematoma present. Ext: chronic discoloration of vascular disease, trace edema Pertinent Results: ___ 06:16AM BLOOD WBC-5.9 RBC-2.42* Hgb-7.8* Hct-25.0* MCV-103* MCH-32.2* MCHC-31.2* RDW-14.2 RDWSD-53.9* Plt ___ ___ 11:02AM BLOOD WBC-10.3* RBC-3.09* Hgb-10.1* Hct-31.7* MCV-103* MCH-32.7* MCHC-31.9* RDW-14.4 RDWSD-54.0* Plt ___ ___ 09:40AM BLOOD WBC-7.9 RBC-2.90* Hgb-9.5* Hct-29.7* MCV-102* MCH-32.8* MCHC-32.0 RDW-14.3 RDWSD-53.8* Plt ___ ___ 06:39AM BLOOD WBC-4.8 RBC-2.22* Hgb-7.2* Hct-22.6* MCV-102* MCH-32.4* MCHC-31.9* RDW-14.1 RDWSD-52.9* Plt ___ ___ 06:16AM BLOOD Glucose-85 UreaN-9 Creat-1.0 Na-138 K-4.4 Cl-103 HCO3-21* AnGap-14 ___ 06:39AM BLOOD Glucose-87 UreaN-12 Creat-0.9 Na-137 K-4.5 Cl-105 HCO3-22 AnGap-10 ___ 06:00AM BLOOD Glucose-79 UreaN-15 Creat-1.0 Na-139 K-4.4 Cl-107 HCO3-22 AnGap-10 Imaging: CT scan of abdomen and pelvis from OSH showed a 9cm hematoma around prior hernia site with no distended loops of bowel and no evidence of small bowel obstruction. ___ KUB: Mildly dilated loops of small bowel in the abdomen with air-fluid levels on the upright view, concerning for small bowel obstruction. Brief Hospital Course: The patient was admitted to the ___ Surgical Service on ___ for evaluation and treatment of abdominal pain. Admission abdominal/pelvic CT revealed a 9cm hematoma at the site of her left femoral hernia repair. The patient was hemodynamically stable. She was admitted for bowel rest, IV fluids, bowel regimen, and monitoring of H&H. Once nausea subsided, diet was progressively advanced as tolerated to a regular diet with good tolerability. The patient voided without problem. During this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirometry, and actively participated in the plan of care. The patient received home eliquis and venodyne boots were used during this stay. Hematocrit remained stable. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged home with ___ services. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: Medications - Prescription APIXABAN [ELIQUIS] - Eliquis 5 mg tablet. 1 tablet(s) by mouth twice a day LISINOPRIL - lisinopril 2.5 mg tablet. 1 tablet(s) by mouth once a day METOPROLOL SUCCINATE - metoprolol succinate ER 25 mg tablet,extended release 24 hr. 0.5 (One half) tablet(s) by mouth once a day SPIRONOLACTONE - spironolactone 25 mg tablet. 0.5 (One half) tablet(s) by mouth once a day TRIAMCINOLONE ACETONIDE - triamcinolone acetonide 0.1 % topical cream. Apply to instructed area as needed three times a day as needed for prn Medications - OTC ASPIRIN - aspirin 81 mg tablet,delayed release. 1 tablet(s) by mouth once a day Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever 2. Apixaban 5 mg PO BID 3. Lansoprazole Oral Disintegrating Tab 30 mg PO BID 4. Polyethylene Glycol 17 g PO DAILY 5. Senna 8.6 mg PO BID 6. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 9 Doses 7. aspirin 81 mg tablet one tablet PO daily Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Left femoral hernia repair site post-op hematoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to ___ with nausea and vomiting after your left femoral hernia repair. CT scan was done which showed a hematoma beneath your hernia repair incision but it was not causing any obstruction. Your diet was slowly advanced and you are now tolerating food without any issues. Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. Followup Instructions: ___
[ "L7632", "K567", "D6832", "N390", "I5020", "Y839", "Y92009", "I4891", "Z952", "Z950", "Z7902", "I10", "E785", "I110" ]
Allergies: amiodarone / ceftriaxone / Bactrim / Cipro Chief Complaint: nausea, vomiting Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [MASKED] is a [MASKED] year old female patient with recent mechanical TAVR, Afib, VT arrest, PPM who presented early [MASKED] with an incarcerated left femoral hernia. She was taken promptly to the operating room on [MASKED]. She underwent femoral hernia repair and postoperatively was in the cardiac ICU for close monitoring, later on transferred to the surgical floor, she tolerated a regular diet and was discharged home with [MASKED]. She now returns complaining of nausea, 1 episode of emesis and constipation. She reports that since her discharge she has only had 3 bowel movements, last one being over 5 days ago, she has been eating small amounts of food daily and her appetite has not returned fully yet. She reports that this morning due to discomfort because of constipation she drank milk of magnesia which made her nauseus and had 1 episode of half a cup of bilious emesis. She reports also using a small fleet enema this morning with a very small bowel movement after this. She denies any other complaint. Reports passing flatus multiple times a day, last one being minutes before arriving to [MASKED]. Of note patient reports that she has started treatment for a UTI 2 days ago with Bactrim. Due to these symptoms patient presented to [MASKED] and was transferred here for further management. Past Medical History: PMH: - HFrEF [MASKED] - HTN - HLD - Known severe AS - Esophageal rupture s/p endoscopic clipping - OA - Endometrial polyps - Cholecystectomy PSH: - CCY Social History: [MASKED] Family History: FAMILY HISTORY: - no family history of cancer, heart disease - Father: died of alcohol use - Mother: died in [MASKED] - Grandmother: died at 99 of unknown cause Physical Exam: Admission Physical Exam: Temp 97.7 HR 89 BP 121/61 RR 17 02Sat: 98% RA [MASKED]: resting comfortably in NAD, generalized scaly rash HEENT: EOMI, PERRL, anicteric Neck: supple, no LAD Chest: CTAB, no respiratory distress Heart: RRR, normal S1&S2 Abdomen: soft, non tender, non distended, no rebound or guarding. L 9cm induration around left groin incision. Suprapubic bruising. Discharge Physical Exam: VS: 98.1, 96/52, 84, 18, 97 Ra Gen: A&O x3. Sitting up in chair, talkative, appears comfortable Pulm: LS ctab Abd: soft, NT/ND. Left groin with hernia repair incision, moderate sized firm hematoma present. Ext: chronic discoloration of vascular disease, trace edema Pertinent Results: [MASKED] 06:16AM BLOOD WBC-5.9 RBC-2.42* Hgb-7.8* Hct-25.0* MCV-103* MCH-32.2* MCHC-31.2* RDW-14.2 RDWSD-53.9* Plt [MASKED] [MASKED] 11:02AM BLOOD WBC-10.3* RBC-3.09* Hgb-10.1* Hct-31.7* MCV-103* MCH-32.7* MCHC-31.9* RDW-14.4 RDWSD-54.0* Plt [MASKED] [MASKED] 09:40AM BLOOD WBC-7.9 RBC-2.90* Hgb-9.5* Hct-29.7* MCV-102* MCH-32.8* MCHC-32.0 RDW-14.3 RDWSD-53.8* Plt [MASKED] [MASKED] 06:39AM BLOOD WBC-4.8 RBC-2.22* Hgb-7.2* Hct-22.6* MCV-102* MCH-32.4* MCHC-31.9* RDW-14.1 RDWSD-52.9* Plt [MASKED] [MASKED] 06:16AM BLOOD Glucose-85 UreaN-9 Creat-1.0 Na-138 K-4.4 Cl-103 HCO3-21* AnGap-14 [MASKED] 06:39AM BLOOD Glucose-87 UreaN-12 Creat-0.9 Na-137 K-4.5 Cl-105 HCO3-22 AnGap-10 [MASKED] 06:00AM BLOOD Glucose-79 UreaN-15 Creat-1.0 Na-139 K-4.4 Cl-107 HCO3-22 AnGap-10 Imaging: CT scan of abdomen and pelvis from OSH showed a 9cm hematoma around prior hernia site with no distended loops of bowel and no evidence of small bowel obstruction. [MASKED] KUB: Mildly dilated loops of small bowel in the abdomen with air-fluid levels on the upright view, concerning for small bowel obstruction. Brief Hospital Course: The patient was admitted to the [MASKED] Surgical Service on [MASKED] for evaluation and treatment of abdominal pain. Admission abdominal/pelvic CT revealed a 9cm hematoma at the site of her left femoral hernia repair. The patient was hemodynamically stable. She was admitted for bowel rest, IV fluids, bowel regimen, and monitoring of H&H. Once nausea subsided, diet was progressively advanced as tolerated to a regular diet with good tolerability. The patient voided without problem. During this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirometry, and actively participated in the plan of care. The patient received home eliquis and venodyne boots were used during this stay. Hematocrit remained stable. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged home with [MASKED] services. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: Medications - Prescription APIXABAN [ELIQUIS] - Eliquis 5 mg tablet. 1 tablet(s) by mouth twice a day LISINOPRIL - lisinopril 2.5 mg tablet. 1 tablet(s) by mouth once a day METOPROLOL SUCCINATE - metoprolol succinate ER 25 mg tablet,extended release 24 hr. 0.5 (One half) tablet(s) by mouth once a day SPIRONOLACTONE - spironolactone 25 mg tablet. 0.5 (One half) tablet(s) by mouth once a day TRIAMCINOLONE ACETONIDE - triamcinolone acetonide 0.1 % topical cream. Apply to instructed area as needed three times a day as needed for prn Medications - OTC ASPIRIN - aspirin 81 mg tablet,delayed release. 1 tablet(s) by mouth once a day Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever 2. Apixaban 5 mg PO BID 3. Lansoprazole Oral Disintegrating Tab 30 mg PO BID 4. Polyethylene Glycol 17 g PO DAILY 5. Senna 8.6 mg PO BID 6. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 9 Doses 7. aspirin 81 mg tablet one tablet PO daily Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Left femoral hernia repair site post-op hematoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to [MASKED] with nausea and vomiting after your left femoral hernia repair. CT scan was done which showed a hematoma beneath your hernia repair incision but it was not causing any obstruction. Your diet was slowly advanced and you are now tolerating food without any issues. Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within [MASKED] hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [MASKED] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. Followup Instructions: [MASKED]
[]
[ "N390", "I4891", "Z7902", "I10", "E785", "I110" ]
[ "L7632: Postprocedural hematoma of skin and subcutaneous tissue following other procedure", "K567: Ileus, unspecified", "D6832: Hemorrhagic disorder due to extrinsic circulating anticoagulants", "N390: Urinary tract infection, site not specified", "I5020: Unspecified systolic (congestive) heart failure", "Y839: Surgical procedure, unspecified as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause", "I4891: Unspecified atrial fibrillation", "Z952: Presence of prosthetic heart valve", "Z950: Presence of cardiac pacemaker", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "I110: Hypertensive heart disease with heart failure" ]
19,993,336
22,782,498
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: amiodarone / ceftriaxone / Bactrim / Cipro Attending: ___. Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: ___: Mesh repair of incarcerated left femoral hernia. History of Present Illness: Ms. ___ is an ___ year old woman with recent TAVR c/b CHB, VT arrest requiring PPM placement who presents as a transfer from OSH with incarcerated left femoral hernia. She was admitted in ___ with afib with RVR and a type two NSTEMI and found to have critical aortic stenosis. She subsequently underwent TAVR as above with PPM. In the setting of this, her apixaban was held and she has not resumed it. She began to have lower abdominal pain yesterday afternoon which has progressively worsened and been associated with emesis. She gave herself an enema and had a small loose bowel movement, but her symptoms persisted. She presented to OSH where CT scan demonstrated a left femoral hernia and she was transferred to ___ for further care. Prior to her arrival here she was given cefoxitin and unasyn as well as 2L crystalloid. At this time she reports ongoing moderate to severe abdominal pain. Of note, she has not taken her medications including aspirin and Plavix since ___ as she was told she had borderline low blood pressure and should hold all her medications. Past Medical History: PMH: - HFrEF ___ - HTN - HLD - Known severe AS - Esophageal rupture s/p endoscopic clipping - OA - Endometrial polyps - Cholecystectomy PSH: - CCY Social History: ___ Family History: FAMILY HISTORY: - no family history of cancer, heart disease - Father: died of alcohol use - Mother: died in ___ - Grandmother: died at ___ of unknown cause Physical Exam: Physical Exam on Admission: Vitals: 97.8 85 101/51 18 96RA GEN: A&O, NAD CV: RRR, No M/G/R PULM: Clear to auscultation ABD: moderate distension. Soft. TTP suprapubic and LLQ. There is a left femoral hernia which is not reducible Ext: No ___ edema, ___ warm and well perfused PHYSICAL EXAM ON DISCHARGE: VS: 97.6, 108/69, 84, 18, 97 RA Gen: A&O x3. Sitting up in bed in NAD. CV: Normal rate, regular rhythm. No murmurs, rubs, or gallops. LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. No adventitious breath sounds. Abd: soft, NT/ND Skin: Left groin hernia repair site with some swelling / hematoma. Scant serosanguinous drainage oozing from incision. Bruising tracking down into suprapubic area. Ext: WWP. BLE discoloration of chronic PVD. skin dry/flaky. Pertinent Results: Transthoracic Echocardiogram Report: ___ Well-seated, normally functioning Lotus Edge aortic bioprosthesis with mild paravalvular leak. Severe regional left ventricular systolic dysfunction c/w multivessel CAD. Mildly hypokinetic right ventricle. Mild mitral and tricuspid regurgitation. Normal pulmonary pressure. PORTABLE ABDOMEN Study Date of ___ Borderline dilatation of air-filled small bowel loops throughout the mid-abdomen, which may represent a postoperative ileus in this setting or, small bowel obstruction not excluded in the appropriate clinical setting. LAB DATA: ___ 08:08AM BLOOD WBC-8.0 RBC-2.94* Hgb-9.8* Hct-30.5* MCV-104* MCH-33.3* MCHC-32.1 RDW-13.0 RDWSD-48.7* Plt ___ ___ 04:20AM BLOOD WBC-7.9 RBC-3.10* Hgb-10.2* Hct-31.6* MCV-102* MCH-32.9* MCHC-32.3 RDW-13.2 RDWSD-49.1* Plt ___ ___ 05:05PM BLOOD Glucose-99 UreaN-15 Creat-0.9 Na-143 K-4.0 Cl-105 HCO3-20* AnGap-18 ___ 08:08AM BLOOD Glucose-118* UreaN-17 Creat-0.9 Na-140 K-5.0 Cl-101 HCO3-23 AnGap-16 ___ 05:05PM BLOOD Calcium-8.9 Phos-2.5* Mg-1.8 ___ 08:08AM BLOOD Calcium-9.1 Phos-2.7 Mg-2.___ with PMHx of non-ischemic HFrEF (EF 26%), severe AS s/p TAVR, pAF (CHADS2VASc 5) , HTN, HLD, and esophageal dissection s/p clipping. On previous admission patient had TAVR complicated by CHB for which she received temporary pacing c/b RV puncture from pacing wire and polymorphic VT arrest s/p ROSC. The patient had a dual-chamber PPM placed ___. On this occasion presented with abdominal pain and was found to have incarcerated left femoral hernia. The patient was taken to the operating room for repair. See operative note for details.In the ___ procedural interval patient was hypotensive and required pressor support. She was transferred to the CCU postoperatively. On bedside echo no evidence of pericardial effusion concerning for cardiac tamponade but signs of hypovolemia. Phenylephrine weaned, given IVF. Patient also noted to have evidence of erythematous pruritic rash in bilateral upper extremities. She states it is similar to the one she got with the amiodarone during her last admission. Bactrim (started outpatient for UTI) was stopped. Once the patient had weaned from pressures and was hemodynamically stable, she was transferred back to the ___ service for furether post-op care on POD2. An NGT was placed on POD1 for ileus, nausea and vomiting. The patient was maintained on bowel rest with supportive care and gentle IV fluids. On POD4, the NGT output had diminished and the patient was passing gas. the NGT was removed and she was given sips. POD5, diet was advanced as tolerated to regular. The Foley catheter was removed at midnight and the patient voided. ___ worked with the patient and she was cleared for discharge home with home ___ and ___ services. On the day of discharge, apixaban was restarted per Cardiology recs, and home meds were slowly re-introduced. During this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirometry, and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged home with ___ services. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. She was going to call to schedule Cardiology follow-up within a week of discharge and also would schedule ___ clinic follow-up. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Lisinopril 2.5 mg PO DAILY 3. Spironolactone 12.5 mg PO DAILY 4. Clopidogrel 75 mg PO/NG DAILY 5. Metoprolol Succinate XL 12.5 mg PO DAILY 6. Apixaban 5 mg PO BID Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever 2. Polyethylene Glycol 17 g PO DAILY 3. Apixaban 5 mg PO BID 4. Aspirin 81 mg PO DAILY 5. Lisinopril 2.5 mg PO DAILY 6. Metoprolol Succinate XL 12.5 mg PO DAILY 7. Spironolactone 12.5 mg PO DAILY 8. HELD- Clopidogrel 75 mg PO/NG DAILY This medication was held. Do not restart Clopidogrel until seen by cardiology Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Incarcerated left femoral hernia. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to ___ for abdominal pain and were found to have an acute obstruction from an incarcerated left femoral hernia. You were taken urgently to the operating room and underwent mesh repair of incarcerated left femoral hernia. After surgery, you had low blood pressure and were managed by the Cardiology service. Once you were stable from a cardiology standpoint, you were transferred back to the Surgery service. You are recovering well and are now ready for discharge. Please follow the instructions below to continue your recovery: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon. Weigh yourself every morning, call MD if weight goes up more than 3 lbs. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips ___ days after surgery. Followup Instructions: ___
[ "K4130", "I5022", "I442", "I429", "K567", "I130", "D696", "I480", "E785", "I252", "E861", "N189", "Z23", "I959", "L270", "T368X5A", "T361X5A", "M1990", "R339", "Y92230", "Z7901", "Z950", "Z952", "Z8674" ]
Allergies: amiodarone / ceftriaxone / Bactrim / Cipro Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: [MASKED]: Mesh repair of incarcerated left femoral hernia. History of Present Illness: Ms. [MASKED] is an [MASKED] year old woman with recent TAVR c/b CHB, VT arrest requiring PPM placement who presents as a transfer from OSH with incarcerated left femoral hernia. She was admitted in [MASKED] with afib with RVR and a type two NSTEMI and found to have critical aortic stenosis. She subsequently underwent TAVR as above with PPM. In the setting of this, her apixaban was held and she has not resumed it. She began to have lower abdominal pain yesterday afternoon which has progressively worsened and been associated with emesis. She gave herself an enema and had a small loose bowel movement, but her symptoms persisted. She presented to OSH where CT scan demonstrated a left femoral hernia and she was transferred to [MASKED] for further care. Prior to her arrival here she was given cefoxitin and unasyn as well as 2L crystalloid. At this time she reports ongoing moderate to severe abdominal pain. Of note, she has not taken her medications including aspirin and Plavix since [MASKED] as she was told she had borderline low blood pressure and should hold all her medications. Past Medical History: PMH: - HFrEF [MASKED] - HTN - HLD - Known severe AS - Esophageal rupture s/p endoscopic clipping - OA - Endometrial polyps - Cholecystectomy PSH: - CCY Social History: [MASKED] Family History: FAMILY HISTORY: - no family history of cancer, heart disease - Father: died of alcohol use - Mother: died in [MASKED] - Grandmother: died at [MASKED] of unknown cause Physical Exam: Physical Exam on Admission: Vitals: 97.8 85 101/51 18 96RA GEN: A&O, NAD CV: RRR, No M/G/R PULM: Clear to auscultation ABD: moderate distension. Soft. TTP suprapubic and LLQ. There is a left femoral hernia which is not reducible Ext: No [MASKED] edema, [MASKED] warm and well perfused PHYSICAL EXAM ON DISCHARGE: VS: 97.6, 108/69, 84, 18, 97 RA Gen: A&O x3. Sitting up in bed in NAD. CV: Normal rate, regular rhythm. No murmurs, rubs, or gallops. LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. No adventitious breath sounds. Abd: soft, NT/ND Skin: Left groin hernia repair site with some swelling / hematoma. Scant serosanguinous drainage oozing from incision. Bruising tracking down into suprapubic area. Ext: WWP. BLE discoloration of chronic PVD. skin dry/flaky. Pertinent Results: Transthoracic Echocardiogram Report: [MASKED] Well-seated, normally functioning Lotus Edge aortic bioprosthesis with mild paravalvular leak. Severe regional left ventricular systolic dysfunction c/w multivessel CAD. Mildly hypokinetic right ventricle. Mild mitral and tricuspid regurgitation. Normal pulmonary pressure. PORTABLE ABDOMEN Study Date of [MASKED] Borderline dilatation of air-filled small bowel loops throughout the mid-abdomen, which may represent a postoperative ileus in this setting or, small bowel obstruction not excluded in the appropriate clinical setting. LAB DATA: [MASKED] 08:08AM BLOOD WBC-8.0 RBC-2.94* Hgb-9.8* Hct-30.5* MCV-104* MCH-33.3* MCHC-32.1 RDW-13.0 RDWSD-48.7* Plt [MASKED] [MASKED] 04:20AM BLOOD WBC-7.9 RBC-3.10* Hgb-10.2* Hct-31.6* MCV-102* MCH-32.9* MCHC-32.3 RDW-13.2 RDWSD-49.1* Plt [MASKED] [MASKED] 05:05PM BLOOD Glucose-99 UreaN-15 Creat-0.9 Na-143 K-4.0 Cl-105 HCO3-20* AnGap-18 [MASKED] 08:08AM BLOOD Glucose-118* UreaN-17 Creat-0.9 Na-140 K-5.0 Cl-101 HCO3-23 AnGap-16 [MASKED] 05:05PM BLOOD Calcium-8.9 Phos-2.5* Mg-1.8 [MASKED] 08:08AM BLOOD Calcium-9.1 Phos-2.7 Mg-2.[MASKED] with PMHx of non-ischemic HFrEF (EF 26%), severe AS s/p TAVR, pAF (CHADS2VASc 5) , HTN, HLD, and esophageal dissection s/p clipping. On previous admission patient had TAVR complicated by CHB for which she received temporary pacing c/b RV puncture from pacing wire and polymorphic VT arrest s/p ROSC. The patient had a dual-chamber PPM placed [MASKED]. On this occasion presented with abdominal pain and was found to have incarcerated left femoral hernia. The patient was taken to the operating room for repair. See operative note for details.In the [MASKED] procedural interval patient was hypotensive and required pressor support. She was transferred to the CCU postoperatively. On bedside echo no evidence of pericardial effusion concerning for cardiac tamponade but signs of hypovolemia. Phenylephrine weaned, given IVF. Patient also noted to have evidence of erythematous pruritic rash in bilateral upper extremities. She states it is similar to the one she got with the amiodarone during her last admission. Bactrim (started outpatient for UTI) was stopped. Once the patient had weaned from pressures and was hemodynamically stable, she was transferred back to the [MASKED] service for furether post-op care on POD2. An NGT was placed on POD1 for ileus, nausea and vomiting. The patient was maintained on bowel rest with supportive care and gentle IV fluids. On POD4, the NGT output had diminished and the patient was passing gas. the NGT was removed and she was given sips. POD5, diet was advanced as tolerated to regular. The Foley catheter was removed at midnight and the patient voided. [MASKED] worked with the patient and she was cleared for discharge home with home [MASKED] and [MASKED] services. On the day of discharge, apixaban was restarted per Cardiology recs, and home meds were slowly re-introduced. During this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirometry, and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged home with [MASKED] services. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. She was going to call to schedule Cardiology follow-up within a week of discharge and also would schedule [MASKED] clinic follow-up. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Lisinopril 2.5 mg PO DAILY 3. Spironolactone 12.5 mg PO DAILY 4. Clopidogrel 75 mg PO/NG DAILY 5. Metoprolol Succinate XL 12.5 mg PO DAILY 6. Apixaban 5 mg PO BID Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever 2. Polyethylene Glycol 17 g PO DAILY 3. Apixaban 5 mg PO BID 4. Aspirin 81 mg PO DAILY 5. Lisinopril 2.5 mg PO DAILY 6. Metoprolol Succinate XL 12.5 mg PO DAILY 7. Spironolactone 12.5 mg PO DAILY 8. HELD- Clopidogrel 75 mg PO/NG DAILY This medication was held. Do not restart Clopidogrel until seen by cardiology Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Incarcerated left femoral hernia. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to [MASKED] for abdominal pain and were found to have an acute obstruction from an incarcerated left femoral hernia. You were taken urgently to the operating room and underwent mesh repair of incarcerated left femoral hernia. After surgery, you had low blood pressure and were managed by the Cardiology service. Once you were stable from a cardiology standpoint, you were transferred back to the Surgery service. You are recovering well and are now ready for discharge. Please follow the instructions below to continue your recovery: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within [MASKED] hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [MASKED] lbs until you follow-up with your surgeon. Weigh yourself every morning, call MD if weight goes up more than 3 lbs. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips [MASKED] days after surgery. Followup Instructions: [MASKED]
[]
[ "I130", "D696", "I480", "E785", "I252", "N189", "Y92230", "Z7901" ]
[ "K4130: Unilateral femoral hernia, with obstruction, without gangrene, not specified as recurrent", "I5022: Chronic systolic (congestive) heart failure", "I442: Atrioventricular block, complete", "I429: Cardiomyopathy, unspecified", "K567: Ileus, unspecified", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "D696: Thrombocytopenia, unspecified", "I480: Paroxysmal atrial fibrillation", "E785: Hyperlipidemia, unspecified", "I252: Old myocardial infarction", "E861: Hypovolemia", "N189: Chronic kidney disease, unspecified", "Z23: Encounter for immunization", "I959: Hypotension, unspecified", "L270: Generalized skin eruption due to drugs and medicaments taken internally", "T368X5A: Adverse effect of other systemic antibiotics, initial encounter", "T361X5A: Adverse effect of cephalosporins and other beta-lactam antibiotics, initial encounter", "M1990: Unspecified osteoarthritis, unspecified site", "R339: Retention of urine, unspecified", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "Z7901: Long term (current) use of anticoagulants", "Z950: Presence of cardiac pacemaker", "Z952: Presence of prosthetic heart valve", "Z8674: Personal history of sudden cardiac arrest" ]
19,993,336
23,077,223
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: amiodarone / ceftriaxone / Bactrim / Cipro Attending: ___ Chief Complaint: Shortness of breath, lethargy Major Surgical or Invasive Procedure: ___: TAVR ___: Temporary pacing wire placement ___: Permanent pacemaker placement History of Present Illness: ___ with H/O severe aortic stenosis, hypertension, hyperlipidemia, esophageal dissection s/p clipping, and recent admission to ___ ___ for atrial fibrillation with a rapid ventricular rate, new diagnosis of HFrEF (LVEF<20%) and Type II NSTEMI, who initially presented to ___ on the day of admission with shortness of breath and lethargy. She was found to be in an acute heart failure exacerbation, now transferred to ___ for further management. She initially presented to ___ on the day of admission with shortness of breath and increased lethargy/generalized weakness for 1 week, which was worse on the day of presentation. Labs there were notable for BNP>35,000, troponin I 0.56. She was felt to be in HFrEF exacerbation and received diuresis with furosemide 40 mg IV x2. She additionally reports that since discharge, she developed a worsening pruritic rash which was present during her recent hospitalization but has since spread to her torso, arms, and legs. She called the Heartline and it was felt that this was possibly a reaction to amiodarone. She was subsequently instructed to discontinue amiodarone by her outpatient cardiologist, and the rash resolved. Additionally she was recently started on furosemide 20 mg a couple of days prior to presentation. Upon arrival to the cardiology ward, she endorsed the above history. She denies any shortness of breath or pain anywhere including chest pain currently, though she reported that if she were to move around, she would develop palpitations and weakness. She denied fevers, chills, lightheadedness, dizziness, nausea, vomiting, cough, abdominal pain, black or bloody stool, pain with urinating. REVIEW OF SYSTEMS: Pertinent positives per HPI. All of the other review of systems were negative. Past Medical History: - Hypertension - Hyperlipidemia - Severe aortic stenosis - Atrial fibrillation with rapid ventricular rate - Esophageal rupture s/p endoscopic clipping - OA - Endometrial polyps - Cholecystectomy Social History: ___ Family History: - no family history of cancer, heart disease - Father: died of alcohol use - Mother: died in ___ - Grandmother: died at ___ of unknown cause Physical Exam: On admission ___: Well-developed, well-nourished elderly white woman in NAD. Mood, affect appropriate. VITALS: 24 HR Data (last updated ___ @ 2358) Temp: 97.8 (Tm 97.8), BP: 96/66 (96-104/66-69), HR: 85 (85-91), RR: 17, O2 sat: 93% (93-95), O2 delivery: Ra, Wt: 180.11 lb/81.7 kg HEENT: NCAT. Sclera anicteric. EOMI. NECK: Supple with JVP elevated to midneck at 45 degrees CARDIAC: RRR, normal S1, S2. ___ systolic ejection murmur at RUSB LUNGS: Resp were unlabored, no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, non-tender, not distended. No HSM or tenderness. EXTREMITIES: Warm and well perfused, trace edema bilaterally SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Distal pulses palpable and symmetric At discharge ___: Well developed, well nourished, in NAD. Oriented x3. Mood, affect appropriate. ___ 1117 Temp: 98.2 PO BP: 92/50 L Sitting HR: 85 RR: 17 O2 sat: 94% O2 delivery: RA HEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI. NECK: Supple. JVP non-elevated at 45 degrees CARDIAC: Normal rate, regular rhythm. Faint systolic murmur at RUSB. Distant heart sounds. LUNGS: CTAB--no rales/crackles. ABDOMEN: Soft, non-tender, not distended. No palpable hepatomegaly or splenomegaly. EXTREMITIES: Warm, well perfused. No clubbing, cyanosis. Left arm slightly edematous vs. Right. No pedal edema. SKIN: erythema of trunk and extremities, no edema PULSES: Distal pulses palpable and symmetric. Pertinent Results: ___ 09:50PM BLOOD WBC-8.6 RBC-3.29* Hgb-11.4 Hct-35.1 MCV-107* MCH-34.7* MCHC-32.5 RDW-12.8 RDWSD-50.0* Plt ___ ___ 09:50PM BLOOD ___ PTT-46.7* ___ ___ 09:50PM BLOOD Glucose-115* UreaN-13 Creat-1.2* Na-140 K-3.3* Cl-100 HCO3-23 AnGap-17 ___ 09:50PM BLOOD Calcium-9.0 Phos-3.5 Mg-1.6 ___ 09:50PM BLOOD ALT-16 AST-34 CK(CPK)-53 AlkPhos-56 TotBili-0.9 ___ 09:50PM BLOOD CK-MB-3 cTropnT-0.03* ___ ECG ___ 21:22:02 Sinus rhythm with 1st degree AV delay. Left axis deviation. Left bundle branch block. Abnormal EC. GWhen compared with ECG of ___ 08:40,PR interval has increased. Left bundle branch block is now present. ECG ___ 09:14:03 Probable A sensing V pacing. When compared with ECG of ___ 17:35, (Unconfirmed), Sinus rhythm has replaced Electronic atrial pacemaker. T wave amplitude has decreased in Lateral leads CXR ___ In comparison with the prior study a right lower lobe parahilar consolidation has developed in the interval. Left hemidiaphragm obscuration with retrocardiac opacification is stable in appearance, a superimposed consolidation cannot be ruled out. Hilar congestion with engorged pulmonary vasculature although resolved in the ___ study has developed again, however, this could also be merely due to reduced lungs volume in the present study. Stable cardiomediastinal silhouette. The left-sided central line has been removed in the interval. IMPRESSION: Right lower lobe parahilar developing consolidation could potentially represent an infectious process, however, given the limitations of the chest radiograph, pulmonary embolism cannot be ruled out and if clinically suspected, assessment with a separate CT angiography is recommended. Left lower lung volume loss with associated pleural effusion is stable in appearance, superimposed consolidation cannot be ruled out. Hilar congestion and engorged pulmonary vasculature could reflect underlying pulmonary edema, however, this could be merely representation of the reduced lung volumes. TAVR ___ Lotus Edge 27mm TAVR using Sentinel cerebral protection, complicated by complete heart block with junctional escape rhythm in the ___ but with AV dissociation, treated with temporary transvenous pacing. Echocardiogram ___ 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 depressed. Quantitative biplane left ventricular ejection fraction is 33 % (normal 54-73%).The right ventricle has depressed free wall motion. There is abnormal septal motion c/w conduction abnormality/paced rhythm. There is a small to moderate, echodense, circumferential pericardial effusion generally measuring no more than 0.6 cm in greatest dimension. In one subcostal clip up to 1.6 cm of fluid is seen anterior to the free wall of the proximal right ventricle. No RA/RV invagination or collapse to suggest tamponade physiology. There is no right atrial systolic or right ventricular diastolic collapse, suggesting absence of tamponade physiology. IMPRESSION: Small-moderate echodense, circumferential pericardial effusion (although generally very small to small) without echocardiographic evidence of tamponade. Depressed biventricular systolic function. Compared with the prior TTE, there is no obvious change seen, but the suboptimal image quality/limited views of the studies precludes definitive comparison TEE ___ Pre-TAVR: Overall left ventricular systolic function is moderate to severely depressed. The right ventricle has depressed free wall motion. Aortic valve stenosis is present (not quantified). There is mild [1+] aortic regurgitation. There is mitral regurgitation (cannot be qualified). There is mild [1+] tricuspid regurgitation. Due to acoustic shadowing, the severity of tricuspid regurgitation may be UNDERestimated. There is a very small pericardial effusion. Bilateral pleural effusions are present. POST-PROCEDURE: The Lotus Edge TAVR with leaflets not well seen but normal gradient. There is a paravalvular jet of trace aortic regurgitation is seen. The effusion may be slightly larger although many more images with alternative angles used post implant so cannot be directly compared. Compared with the prior TTE(images reviewed) of ___, the pericardial effusion is slightly larger. TAVR now present Echocardiogram ___ Overall left ventricular systolic function is depressed. The right ventricle has depressed free wall motion. A Lotus Edge aortic valve bioprosthesis is present. Due to acoustic shadowing, the severity of tricuspid regurgitation may be UNDERestimated. There is a small circumferential pericardial effusion. There are no 2Dor Doppler echocardiographic evidence of tamponade. Bilateral pleural effusions are present. Ascites is seen. IMPRESSION: Small circumferential pericardial effusion without tamponade. Pacing wire placed in the RV free wall and is seated deeply in the myocardium ? through it. Compared with the prior TTE(images reviewed) of ___, looking back across echos from the Pre-TAVR to now, it is hard to say that there has been a significant change in the size of the effusion. The pre-TAVR echo had limited images. The post TAVR echo suggests there could be slightly more fluid, but many more images taken highlighting the effusion. The current study is similar to the post TAVR study and looking back the temporary pacing wire placement was seen int he RV free wall on the post TAVR echo (not noted in the report). CXR ___ The size of the cardiac silhouette is enlarged but unchanged. A new a temporary pacing wire is seen overlying the medial left lower hemithorax, possibly in the region of the tricuspid valve or upper right ventricle. There is no pneumothorax identified. Pulmonary edema is increased since prior as well as retrocardiac opacification and bilateral pleural effusions, left greater than right. A TAVR is present. Echocardiogram ___ The estimated right atrial pressure is ___ mmHg. Quantitative biplane left ventricular ejection fraction is 27 % (normal 54-73%).Due to acoustic shadowing, the severity of tricuspid regurgitation may be UNDERestimated. There is a small-moderate, echodense circumferential pericardial effusion, measuring up to 1.4 cm anterior to the proximal free wall of the right ventricle in the subcostal view, but generally up to only 0.6 cm of pericardial fluid is seen at end diastole. There is no right atrial systolic or right ventricular diastolic collapse, suggesting absence of tamponade physiology. IMPRESSION: Small-moderate (although generally very small to small), circumferential, echodense pericardial effusion without echocardiographic evidence of tamponade physiology. Compared with the prior ___, there is no obvious change, but the suboptimal image quality of the studies precludes definitive comparison Echocardiogram ___ There is suboptimal image quality to assess regional left ventricular function. Overall left ventricular systolic function is moderate to severely depressed. The visually estimated left ventricular ejection fraction is 30%.Due to acoustic shadowing, the severity of tricuspid regurgitation may be UNDERestimated. There is a small to moderate circumferential pericardial effusion. There is no right atrial systolic or right ventricular diastolic collapse, suggesting absence of tamponade physiology. IMPRESSION: Small to moderate pericardial effusion (predominantly very small to small (0.6cm) with up to 1.3 cm anterolateral to the left ventricle in the apical 4-chamber view) without echocardiographic signs of tamponade physiology. Depressed left ventricular systolic function. Compared with the prior ___, a catheter/pacing wire is no longer appreciated in the right ventricle. The pericardial effusion size/distribution is similar. CXR ___ Comparison to ___. The patient has received the new left pectoral pacemaker. The position of the generator is unremarkable. 1 lead projects over the right atrium and 1 over the right ventricle. The temporary previously-seen pacemaker has been removed. Pre-existing pulmonary edema is completely resolved. Moderate cardiomegaly persists. Also persistent is a relatively extensive left lower lobe atelectasis. No pneumonia. Echocardiogram ___ 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 >15mmHg. There is mild symmetric left ventricular hypertrophy with a borderline increased/dilated cavity. There are moderate to extensive areas of severe regional left ventricular systolic dysfunction with hypokinesis to akinesis of the mid to distal ventricle (see schematic) and preserved/normal contractility of the remaining segments. No thrombus or mass is seen in the left ventricle. Overall left ventricular systolic function is moderate to severely depressed. Quantitative 3D volumetric left ventricular ejection fraction is 33 % (normal 54-73%). Left ventricular cardiac index is normal (>2.5 L/min/m2). Global longitudinal strain is depressed (-7%; normal less than -20%) There is no resting left ventricular outflow tract gradient. Normal right ventricular cavity size with mild global free wall hypokinesis. Tricuspid annular plane systolic excursion(TAPSE) is depressed. The aortic sinus diameter is normal for gender with mildly dilated ascending aorta. The aortic arch is mildly dilated with a normal descending aorta diameter. A Lotus Edge aortic valve bioprosthesis is present. The prosthesis is well seated with normal leaflet motion and gradient. There is a paravalvular jet of mild [1+] aortic regurgitation. The mitral valve leaflets are mildly thickened with no mitral valve prolapse. There is mild [1+] mitral regurgitation. The pulmonic valve leaflets are normal. The tricuspid valve leaflets appear structurally normal. There is mild [1+] tricuspid regurgitation. Due to acoustic shadowing, the severity of tricuspid regurgitation may be UNDERestimated. The estimated pulmonary artery systolic pressure is normal. There is a small circumferential pericardial effusion. The effusion is echo dense, c/w blood, inflammation or other cellular elements. There are no 2D or Doppler echocardiographic evidence of tamponade. Bilateral pleural effusions are present. IMPRESSION: Well seated, normal functioning TAVR with normal gradient and mild paravalvular aortic regurgitation. Mild symmetric left ventricular hypertrophy with mildly dilated LV cavity and regional systolic dysfunction most consistent with multivessel coronary artery disease, with moderately reduced ejection fraction and depressed global longitudinal strain. Mildly dilated thoracic aorta. Mild mitral and tricuspid regurgitation. Small pericardial effusion and bilateral pleural effusions. Compared with the prior TTE(images reviewed) of ___, the findings are similar. Echocardiogram ___ The left atrium is elongated. The right atrium is mildly enlarged. The estimated right atrial pressure is10-15 mmHg. There is moderate symmetric left ventricular hypertrophy with a normal cavity size. There is moderate global left ventricular hypokinesis. The apex is aneurysmal. Quantitative biplane left ventricular ejection fraction is 26 % (normal 54-73%).Normal right ventricular cavity size with focal hypokinesis of the apical free wall. There is a normal descending aorta diameter. A Lotus Edge aortic valve bioprosthesis is present. The prosthesis is well seated with normal gradient. The effective orifice area index is normal (>=0.85 cm2/m2). There is a paravalvular jet of mild [1+] aortic regurgitation. The mitral valve leaflets are mildly thickened. There is moderate mitral annular calcification. 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 mild [1+] tricuspid regurgitation. Due to acoustic shadowing, the severity of tricuspid regurgitation may be UNDERestimated. The estimated pulmonary artery systolic pressure is normal. There is a small to moderate pericardial effusion most prominent anterior to the RA/RV junction. There are no 2D or Doppler echocardiographic evidence of tamponade. A left pleural effusion is present. IMPRESSION: Suboptimal image quality. Symmetric left ventricular hypertrophy with normal cavity size and apical aneurysm/dysfunction with moderate hypokinesis of other segments. The basal anterior and anterolateral walls contract best. Small-moderate circumferential pericardial effusion without echocardiographic evidence for tamponade physiology. Well seated, normal functioning Lotus Edge TAVR with normal gradient and mild paravalvular aortic regurgitation. Compared with the prior TTE (images reviewed) of ___, the left ventricular systolic function is now more reduced. The pericardial effusion and other findings are similar. DISCHARGE LABS ___ 06:19AM BLOOD WBC-4.9 RBC-2.81* Hgb-9.6* Hct-29.8* MCV-106* MCH-34.2* MCHC-32.2 RDW-12.8 RDWSD-50.1* Plt ___ ___ 06:19AM BLOOD Glucose-87 UreaN-8 Creat-0.9 Na-141 K-4.2 Cl-104 HCO3-24 AnGap-13 ___ 06:19AM BLOOD Calcium-9.3 Phos-3.2 Mg-1.___ with H/O non-ischemic cardiomyopathy HFrEF (LVEF 31%; no CAD on coronary angiogram ___, severe aortic stenosis, paroxysmal atrial fibrillation on apixiban (CHADS2VASc 5), hypertension, hyperlipidemia, and esophageal dissection s/p clipping who presented with acute decompensated heart failure. Following diuresis, she underwent Lotus TAVR placement complicated by complete heart block. She had a transvenous pacing electrode placed complicated by RV puncture and polymorphic VT arrest with ROSC. The patient had a dual-chamber PPM placed ___. ACUTE ISSUES: # Severe AS (peak velocity 4.8, peak gradient 92, mean gradient 53, valve area 0.9): Patient with severe aortic stenosis and possible resultant systolic dysfunction. She had a Lotus Edge 27mm LIS TAVR placed ___ with improved gradients and no concern for paravalvular leak with mild aortic regurgitation (peak velocity 4.3->1.5, peak gradient 74->9, mean gradient 49->6). Procedure was complicated by complete heart block treated with venous pacing (see below). She was continued on ASA + clopidogrel and will discontinue clopidogrel after two weeks and start apixaban with continued aspirin thereafter (assuming stable pericardial effusion). # CHB s/p dual-chamber PPM placement in setting of prior LBBB and AV delay: Patient developed CHB after Lotus TAVR deployment after TAVR (in setting of underlying conduction disease with LBBB and PR prolongation). She had a temporary transvenous pacing electrode placed, complicated by right ventricular puncture. She then had polymorphic VT arrest with ROSC. Dual-chamber permanent pacemaker placed ___. Post procedure echocardiogram revealed small-moderate pericardial effusion (0.6 cm) on ___. Echo on ___ showed effusion was unchanged and repeat echocardiogram on ___ showed small-moderate effusion without evidence of tamponade physiology. She remained stable without evidence of tamponade. Apixiban resumption was deferred for at least 2 weeks as above. # Polymorphic VT arrest iso long QT: Patient with long-QT in setting of relative bradycardia with pacer rate set at 60, and significant ectopy with PVCs/bigeminy. SHe had R on T phenomenon and resultant polymorphic VT. She required one round of CPR, one shock at 200 J, and one dose of epinepherine before achieving ROSC. After pacer rate increased to 100, had 100% ventricular pacing again. Dual-chamber PPM placed ___. # Non-ischemic HFrEF (LVEF 33%): Patient initially volume overloaded on admission, now s/p successful IV diuresis. Post-TAVR echocardiogram on ___ showed LVEF of 33% (vs 31% before), moderate to extensive areas of severe regional LV systolic dysfunction with hypokinesis to akinesis of mid to distal left ventricle. She was transitioned to PO furosemide, however, furosemide was discontinued ___ due to seeming euvolemic status and started on spirolactone 12.5 mg for cardioprotective effects. This was continued upon discharge. # New Erythematous Rash: After pacemaker placement on ___, patient developed truncal rash, which expanded to all four distal extremities with edema, not associated with pain, itching, or fever that was present during the amiodarone reaction during previous admission. Suspected reaction to ___ antibiotics (Vancomycin and cefazolin). These improved with sarna and diphenhydramine. CHRONIC ISSUES: # CKD: Baseline Cr around 1.1-1.3, stable. # Paroxsymal atrial fibrillation (CHADS2VASc 5): During last admission, patient developed atrial fibrillation with rapid ventricular rates to 130-140, subsequently converted to sinus after adenosine, amiodarone, diltiazem, and digoxin. She was discharged on amiodarone, however this was subsequently discontinued as an outpatient due to rash. She presented in NSR. Apixaban was held for two weeks in setting of pericardial effusion. TRANSITIONAL ISSUES Discharge Wt: 177.25 lb Discharge Cr: 0.9 Discharge diuretic: Spironolactone 12.5 mg PO DAILY [] TTE in two weeks to monitor pericardial effusion. At that time, can start apixaban if no worsening of pericardial effusion and discontinue clopidogrel (per structural cardiology team) [] lab check (BMP w Cr, K+) on ___ [] Patient should be referred to outpatient cardiac rehabilitation [] Continue incentive spirometry [] Please monitor volume status and adjust diuretic accordingly [] Please check CBC within 1 week to follow up hemoglobin [] Please weigh patient and perform vital signs check at nursing visits [] Patient developed full body rash while taking amiodarone. This drug should be avoided in the future. # CODE: Full code # CONTACT/HCP: ___ ___ (cell) ___ ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Apixaban 5 mg PO BID 2. Furosemide 20 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Clopidogrel 75 mg PO/NG DAILY 3. Lisinopril 2.5 mg PO DAILY 4. Metoprolol Succinate XL 12.5 mg PO DAILY 5. Spironolactone 12.5 mg PO DAILY 6. HELD- Apixaban 5 mg PO BID This medication was held. Do not restart Apixaban until 2 weeks (due to fluid around heart) 7.Outpatient Lab Work I35.0 Please obtain creatinine, potassium and fax results to Dr. ___ at ___ Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: -Aortic stenosis, severe -Transcatheter aortic valve replacement complicated by -Complete heart block, complicated by -Polymorphic ventricular tachycardia cardiac arrest -Prolonged QT interval -Pericardial effusion -Permanent dual chamber pacemaker implantation -Paroxysmal atrial fibrillation -Acute on chronic left ventricular systolic and diastolic heart failure with reduced ejection fraction -Rash attributed to vancomycin and/or cefazolin -Prior rash attributed to amiodarone -Chronic Kidney Disease stage 3 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 of shortness of breath WHAT HAPPENED IN THE HOSPITAL? ============================== - You were admitted to the hospital because you had been feeling short of breath and you were found to have fluid in your lungs. This was felt to be due to a 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 through the IV to help get the fluid out. You were also found to have a valve in your heart that was narrow (Aortic valve). You underwent a procedure to repair the valve - You were also found to have an abnormal rhythm and fluid around your heart. A pacemaker was placed to help your heart beat normally and the fluid around your heart was monitored with serial ultrasounds. - Your medication furosemide (or lasix) was discontinued and you were started on a different diuretic (spironolactone) 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 177.25 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 or down by more than 3 pounds in a day or 5 pounds in a week. -Do not stop taking your aspirin or clopidogrel (also known as Plavix) unless told to do so by your cardiologist Followup Instructions: ___
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Allergies: amiodarone / ceftriaxone / Bactrim / Cipro Chief Complaint: Shortness of breath, lethargy Major Surgical or Invasive Procedure: [MASKED]: TAVR [MASKED]: Temporary pacing wire placement [MASKED]: Permanent pacemaker placement History of Present Illness: [MASKED] with H/O severe aortic stenosis, hypertension, hyperlipidemia, esophageal dissection s/p clipping, and recent admission to [MASKED] [MASKED] for atrial fibrillation with a rapid ventricular rate, new diagnosis of HFrEF (LVEF<20%) and Type II NSTEMI, who initially presented to [MASKED] on the day of admission with shortness of breath and lethargy. She was found to be in an acute heart failure exacerbation, now transferred to [MASKED] for further management. She initially presented to [MASKED] on the day of admission with shortness of breath and increased lethargy/generalized weakness for 1 week, which was worse on the day of presentation. Labs there were notable for BNP>35,000, troponin I 0.56. She was felt to be in HFrEF exacerbation and received diuresis with furosemide 40 mg IV x2. She additionally reports that since discharge, she developed a worsening pruritic rash which was present during her recent hospitalization but has since spread to her torso, arms, and legs. She called the Heartline and it was felt that this was possibly a reaction to amiodarone. She was subsequently instructed to discontinue amiodarone by her outpatient cardiologist, and the rash resolved. Additionally she was recently started on furosemide 20 mg a couple of days prior to presentation. Upon arrival to the cardiology ward, she endorsed the above history. She denies any shortness of breath or pain anywhere including chest pain currently, though she reported that if she were to move around, she would develop palpitations and weakness. She denied fevers, chills, lightheadedness, dizziness, nausea, vomiting, cough, abdominal pain, black or bloody stool, pain with urinating. REVIEW OF SYSTEMS: Pertinent positives per HPI. All of the other review of systems were negative. Past Medical History: - Hypertension - Hyperlipidemia - Severe aortic stenosis - Atrial fibrillation with rapid ventricular rate - Esophageal rupture s/p endoscopic clipping - OA - Endometrial polyps - Cholecystectomy Social History: [MASKED] Family History: - no family history of cancer, heart disease - Father: died of alcohol use - Mother: died in [MASKED] - Grandmother: died at [MASKED] of unknown cause Physical Exam: On admission [MASKED]: Well-developed, well-nourished elderly white woman in NAD. Mood, affect appropriate. VITALS: 24 HR Data (last updated [MASKED] @ 2358) Temp: 97.8 (Tm 97.8), BP: 96/66 (96-104/66-69), HR: 85 (85-91), RR: 17, O2 sat: 93% (93-95), O2 delivery: Ra, Wt: 180.11 lb/81.7 kg HEENT: NCAT. Sclera anicteric. EOMI. NECK: Supple with JVP elevated to midneck at 45 degrees CARDIAC: RRR, normal S1, S2. [MASKED] systolic ejection murmur at RUSB LUNGS: Resp were unlabored, no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, non-tender, not distended. No HSM or tenderness. EXTREMITIES: Warm and well perfused, trace edema bilaterally SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Distal pulses palpable and symmetric At discharge [MASKED]: Well developed, well nourished, in NAD. Oriented x3. Mood, affect appropriate. [MASKED] 1117 Temp: 98.2 PO BP: 92/50 L Sitting HR: 85 RR: 17 O2 sat: 94% O2 delivery: RA HEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI. NECK: Supple. JVP non-elevated at 45 degrees CARDIAC: Normal rate, regular rhythm. Faint systolic murmur at RUSB. Distant heart sounds. LUNGS: CTAB--no rales/crackles. ABDOMEN: Soft, non-tender, not distended. No palpable hepatomegaly or splenomegaly. EXTREMITIES: Warm, well perfused. No clubbing, cyanosis. Left arm slightly edematous vs. Right. No pedal edema. SKIN: erythema of trunk and extremities, no edema PULSES: Distal pulses palpable and symmetric. Pertinent Results: [MASKED] 09:50PM BLOOD WBC-8.6 RBC-3.29* Hgb-11.4 Hct-35.1 MCV-107* MCH-34.7* MCHC-32.5 RDW-12.8 RDWSD-50.0* Plt [MASKED] [MASKED] 09:50PM BLOOD [MASKED] PTT-46.7* [MASKED] [MASKED] 09:50PM BLOOD Glucose-115* UreaN-13 Creat-1.2* Na-140 K-3.3* Cl-100 HCO3-23 AnGap-17 [MASKED] 09:50PM BLOOD Calcium-9.0 Phos-3.5 Mg-1.6 [MASKED] 09:50PM BLOOD ALT-16 AST-34 CK(CPK)-53 AlkPhos-56 TotBili-0.9 [MASKED] 09:50PM BLOOD CK-MB-3 cTropnT-0.03* [MASKED] ECG [MASKED] 21:22:02 Sinus rhythm with 1st degree AV delay. Left axis deviation. Left bundle branch block. Abnormal EC. GWhen compared with ECG of [MASKED] 08:40,PR interval has increased. Left bundle branch block is now present. ECG [MASKED] 09:14:03 Probable A sensing V pacing. When compared with ECG of [MASKED] 17:35, (Unconfirmed), Sinus rhythm has replaced Electronic atrial pacemaker. T wave amplitude has decreased in Lateral leads CXR [MASKED] In comparison with the prior study a right lower lobe parahilar consolidation has developed in the interval. Left hemidiaphragm obscuration with retrocardiac opacification is stable in appearance, a superimposed consolidation cannot be ruled out. Hilar congestion with engorged pulmonary vasculature although resolved in the [MASKED] study has developed again, however, this could also be merely due to reduced lungs volume in the present study. Stable cardiomediastinal silhouette. The left-sided central line has been removed in the interval. IMPRESSION: Right lower lobe parahilar developing consolidation could potentially represent an infectious process, however, given the limitations of the chest radiograph, pulmonary embolism cannot be ruled out and if clinically suspected, assessment with a separate CT angiography is recommended. Left lower lung volume loss with associated pleural effusion is stable in appearance, superimposed consolidation cannot be ruled out. Hilar congestion and engorged pulmonary vasculature could reflect underlying pulmonary edema, however, this could be merely representation of the reduced lung volumes. TAVR [MASKED] Lotus Edge 27mm TAVR using Sentinel cerebral protection, complicated by complete heart block with junctional escape rhythm in the [MASKED] but with AV dissociation, treated with temporary transvenous pacing. Echocardiogram [MASKED] 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 depressed. Quantitative biplane left ventricular ejection fraction is 33 % (normal 54-73%).The right ventricle has depressed free wall motion. There is abnormal septal motion c/w conduction abnormality/paced rhythm. There is a small to moderate, echodense, circumferential pericardial effusion generally measuring no more than 0.6 cm in greatest dimension. In one subcostal clip up to 1.6 cm of fluid is seen anterior to the free wall of the proximal right ventricle. No RA/RV invagination or collapse to suggest tamponade physiology. There is no right atrial systolic or right ventricular diastolic collapse, suggesting absence of tamponade physiology. IMPRESSION: Small-moderate echodense, circumferential pericardial effusion (although generally very small to small) without echocardiographic evidence of tamponade. Depressed biventricular systolic function. Compared with the prior TTE, there is no obvious change seen, but the suboptimal image quality/limited views of the studies precludes definitive comparison TEE [MASKED] Pre-TAVR: Overall left ventricular systolic function is moderate to severely depressed. The right ventricle has depressed free wall motion. Aortic valve stenosis is present (not quantified). There is mild [1+] aortic regurgitation. There is mitral regurgitation (cannot be qualified). There is mild [1+] tricuspid regurgitation. Due to acoustic shadowing, the severity of tricuspid regurgitation may be UNDERestimated. There is a very small pericardial effusion. Bilateral pleural effusions are present. POST-PROCEDURE: The Lotus Edge TAVR with leaflets not well seen but normal gradient. There is a paravalvular jet of trace aortic regurgitation is seen. The effusion may be slightly larger although many more images with alternative angles used post implant so cannot be directly compared. Compared with the prior TTE(images reviewed) of [MASKED], the pericardial effusion is slightly larger. TAVR now present Echocardiogram [MASKED] Overall left ventricular systolic function is depressed. The right ventricle has depressed free wall motion. A Lotus Edge aortic valve bioprosthesis is present. Due to acoustic shadowing, the severity of tricuspid regurgitation may be UNDERestimated. There is a small circumferential pericardial effusion. There are no 2Dor Doppler echocardiographic evidence of tamponade. Bilateral pleural effusions are present. Ascites is seen. IMPRESSION: Small circumferential pericardial effusion without tamponade. Pacing wire placed in the RV free wall and is seated deeply in the myocardium ? through it. Compared with the prior TTE(images reviewed) of [MASKED], looking back across echos from the Pre-TAVR to now, it is hard to say that there has been a significant change in the size of the effusion. The pre-TAVR echo had limited images. The post TAVR echo suggests there could be slightly more fluid, but many more images taken highlighting the effusion. The current study is similar to the post TAVR study and looking back the temporary pacing wire placement was seen int he RV free wall on the post TAVR echo (not noted in the report). CXR [MASKED] The size of the cardiac silhouette is enlarged but unchanged. A new a temporary pacing wire is seen overlying the medial left lower hemithorax, possibly in the region of the tricuspid valve or upper right ventricle. There is no pneumothorax identified. Pulmonary edema is increased since prior as well as retrocardiac opacification and bilateral pleural effusions, left greater than right. A TAVR is present. Echocardiogram [MASKED] The estimated right atrial pressure is [MASKED] mmHg. Quantitative biplane left ventricular ejection fraction is 27 % (normal 54-73%).Due to acoustic shadowing, the severity of tricuspid regurgitation may be UNDERestimated. There is a small-moderate, echodense circumferential pericardial effusion, measuring up to 1.4 cm anterior to the proximal free wall of the right ventricle in the subcostal view, but generally up to only 0.6 cm of pericardial fluid is seen at end diastole. There is no right atrial systolic or right ventricular diastolic collapse, suggesting absence of tamponade physiology. IMPRESSION: Small-moderate (although generally very small to small), circumferential, echodense pericardial effusion without echocardiographic evidence of tamponade physiology. Compared with the prior [MASKED], there is no obvious change, but the suboptimal image quality of the studies precludes definitive comparison Echocardiogram [MASKED] There is suboptimal image quality to assess regional left ventricular function. Overall left ventricular systolic function is moderate to severely depressed. The visually estimated left ventricular ejection fraction is 30%.Due to acoustic shadowing, the severity of tricuspid regurgitation may be UNDERestimated. There is a small to moderate circumferential pericardial effusion. There is no right atrial systolic or right ventricular diastolic collapse, suggesting absence of tamponade physiology. IMPRESSION: Small to moderate pericardial effusion (predominantly very small to small (0.6cm) with up to 1.3 cm anterolateral to the left ventricle in the apical 4-chamber view) without echocardiographic signs of tamponade physiology. Depressed left ventricular systolic function. Compared with the prior [MASKED], a catheter/pacing wire is no longer appreciated in the right ventricle. The pericardial effusion size/distribution is similar. CXR [MASKED] Comparison to [MASKED]. The patient has received the new left pectoral pacemaker. The position of the generator is unremarkable. 1 lead projects over the right atrium and 1 over the right ventricle. The temporary previously-seen pacemaker has been removed. Pre-existing pulmonary edema is completely resolved. Moderate cardiomegaly persists. Also persistent is a relatively extensive left lower lobe atelectasis. No pneumonia. Echocardiogram [MASKED] 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 >15mmHg. There is mild symmetric left ventricular hypertrophy with a borderline increased/dilated cavity. There are moderate to extensive areas of severe regional left ventricular systolic dysfunction with hypokinesis to akinesis of the mid to distal ventricle (see schematic) and preserved/normal contractility of the remaining segments. No thrombus or mass is seen in the left ventricle. Overall left ventricular systolic function is moderate to severely depressed. Quantitative 3D volumetric left ventricular ejection fraction is 33 % (normal 54-73%). Left ventricular cardiac index is normal (>2.5 L/min/m2). Global longitudinal strain is depressed (-7%; normal less than -20%) There is no resting left ventricular outflow tract gradient. Normal right ventricular cavity size with mild global free wall hypokinesis. Tricuspid annular plane systolic excursion(TAPSE) is depressed. The aortic sinus diameter is normal for gender with mildly dilated ascending aorta. The aortic arch is mildly dilated with a normal descending aorta diameter. A Lotus Edge aortic valve bioprosthesis is present. The prosthesis is well seated with normal leaflet motion and gradient. There is a paravalvular jet of mild [1+] aortic regurgitation. The mitral valve leaflets are mildly thickened with no mitral valve prolapse. There is mild [1+] mitral regurgitation. The pulmonic valve leaflets are normal. The tricuspid valve leaflets appear structurally normal. There is mild [1+] tricuspid regurgitation. Due to acoustic shadowing, the severity of tricuspid regurgitation may be UNDERestimated. The estimated pulmonary artery systolic pressure is normal. There is a small circumferential pericardial effusion. The effusion is echo dense, c/w blood, inflammation or other cellular elements. There are no 2D or Doppler echocardiographic evidence of tamponade. Bilateral pleural effusions are present. IMPRESSION: Well seated, normal functioning TAVR with normal gradient and mild paravalvular aortic regurgitation. Mild symmetric left ventricular hypertrophy with mildly dilated LV cavity and regional systolic dysfunction most consistent with multivessel coronary artery disease, with moderately reduced ejection fraction and depressed global longitudinal strain. Mildly dilated thoracic aorta. Mild mitral and tricuspid regurgitation. Small pericardial effusion and bilateral pleural effusions. Compared with the prior TTE(images reviewed) of [MASKED], the findings are similar. Echocardiogram [MASKED] The left atrium is elongated. The right atrium is mildly enlarged. The estimated right atrial pressure is10-15 mmHg. There is moderate symmetric left ventricular hypertrophy with a normal cavity size. There is moderate global left ventricular hypokinesis. The apex is aneurysmal. Quantitative biplane left ventricular ejection fraction is 26 % (normal 54-73%).Normal right ventricular cavity size with focal hypokinesis of the apical free wall. There is a normal descending aorta diameter. A Lotus Edge aortic valve bioprosthesis is present. The prosthesis is well seated with normal gradient. The effective orifice area index is normal (>=0.85 cm2/m2). There is a paravalvular jet of mild [1+] aortic regurgitation. The mitral valve leaflets are mildly thickened. There is moderate mitral annular calcification. 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 mild [1+] tricuspid regurgitation. Due to acoustic shadowing, the severity of tricuspid regurgitation may be UNDERestimated. The estimated pulmonary artery systolic pressure is normal. There is a small to moderate pericardial effusion most prominent anterior to the RA/RV junction. There are no 2D or Doppler echocardiographic evidence of tamponade. A left pleural effusion is present. IMPRESSION: Suboptimal image quality. Symmetric left ventricular hypertrophy with normal cavity size and apical aneurysm/dysfunction with moderate hypokinesis of other segments. The basal anterior and anterolateral walls contract best. Small-moderate circumferential pericardial effusion without echocardiographic evidence for tamponade physiology. Well seated, normal functioning Lotus Edge TAVR with normal gradient and mild paravalvular aortic regurgitation. Compared with the prior TTE (images reviewed) of [MASKED], the left ventricular systolic function is now more reduced. The pericardial effusion and other findings are similar. DISCHARGE LABS [MASKED] 06:19AM BLOOD WBC-4.9 RBC-2.81* Hgb-9.6* Hct-29.8* MCV-106* MCH-34.2* MCHC-32.2 RDW-12.8 RDWSD-50.1* Plt [MASKED] [MASKED] 06:19AM BLOOD Glucose-87 UreaN-8 Creat-0.9 Na-141 K-4.2 Cl-104 HCO3-24 AnGap-13 [MASKED] 06:19AM BLOOD Calcium-9.3 Phos-3.2 Mg-1.[MASKED] with H/O non-ischemic cardiomyopathy HFrEF (LVEF 31%; no CAD on coronary angiogram [MASKED], severe aortic stenosis, paroxysmal atrial fibrillation on apixiban (CHADS2VASc 5), hypertension, hyperlipidemia, and esophageal dissection s/p clipping who presented with acute decompensated heart failure. Following diuresis, she underwent Lotus TAVR placement complicated by complete heart block. She had a transvenous pacing electrode placed complicated by RV puncture and polymorphic VT arrest with ROSC. The patient had a dual-chamber PPM placed [MASKED]. ACUTE ISSUES: # Severe AS (peak velocity 4.8, peak gradient 92, mean gradient 53, valve area 0.9): Patient with severe aortic stenosis and possible resultant systolic dysfunction. She had a Lotus Edge 27mm LIS TAVR placed [MASKED] with improved gradients and no concern for paravalvular leak with mild aortic regurgitation (peak velocity 4.3->1.5, peak gradient 74->9, mean gradient 49->6). Procedure was complicated by complete heart block treated with venous pacing (see below). She was continued on ASA + clopidogrel and will discontinue clopidogrel after two weeks and start apixaban with continued aspirin thereafter (assuming stable pericardial effusion). # CHB s/p dual-chamber PPM placement in setting of prior LBBB and AV delay: Patient developed CHB after Lotus TAVR deployment after TAVR (in setting of underlying conduction disease with LBBB and PR prolongation). She had a temporary transvenous pacing electrode placed, complicated by right ventricular puncture. She then had polymorphic VT arrest with ROSC. Dual-chamber permanent pacemaker placed [MASKED]. Post procedure echocardiogram revealed small-moderate pericardial effusion (0.6 cm) on [MASKED]. Echo on [MASKED] showed effusion was unchanged and repeat echocardiogram on [MASKED] showed small-moderate effusion without evidence of tamponade physiology. She remained stable without evidence of tamponade. Apixiban resumption was deferred for at least 2 weeks as above. # Polymorphic VT arrest iso long QT: Patient with long-QT in setting of relative bradycardia with pacer rate set at 60, and significant ectopy with PVCs/bigeminy. SHe had R on T phenomenon and resultant polymorphic VT. She required one round of CPR, one shock at 200 J, and one dose of epinepherine before achieving ROSC. After pacer rate increased to 100, had 100% ventricular pacing again. Dual-chamber PPM placed [MASKED]. # Non-ischemic HFrEF (LVEF 33%): Patient initially volume overloaded on admission, now s/p successful IV diuresis. Post-TAVR echocardiogram on [MASKED] showed LVEF of 33% (vs 31% before), moderate to extensive areas of severe regional LV systolic dysfunction with hypokinesis to akinesis of mid to distal left ventricle. She was transitioned to PO furosemide, however, furosemide was discontinued [MASKED] due to seeming euvolemic status and started on spirolactone 12.5 mg for cardioprotective effects. This was continued upon discharge. # New Erythematous Rash: After pacemaker placement on [MASKED], patient developed truncal rash, which expanded to all four distal extremities with edema, not associated with pain, itching, or fever that was present during the amiodarone reaction during previous admission. Suspected reaction to [MASKED] antibiotics (Vancomycin and cefazolin). These improved with sarna and diphenhydramine. CHRONIC ISSUES: # CKD: Baseline Cr around 1.1-1.3, stable. # Paroxsymal atrial fibrillation (CHADS2VASc 5): During last admission, patient developed atrial fibrillation with rapid ventricular rates to 130-140, subsequently converted to sinus after adenosine, amiodarone, diltiazem, and digoxin. She was discharged on amiodarone, however this was subsequently discontinued as an outpatient due to rash. She presented in NSR. Apixaban was held for two weeks in setting of pericardial effusion. TRANSITIONAL ISSUES Discharge Wt: 177.25 lb Discharge Cr: 0.9 Discharge diuretic: Spironolactone 12.5 mg PO DAILY [] TTE in two weeks to monitor pericardial effusion. At that time, can start apixaban if no worsening of pericardial effusion and discontinue clopidogrel (per structural cardiology team) [] lab check (BMP w Cr, K+) on [MASKED] [] Patient should be referred to outpatient cardiac rehabilitation [] Continue incentive spirometry [] Please monitor volume status and adjust diuretic accordingly [] Please check CBC within 1 week to follow up hemoglobin [] Please weigh patient and perform vital signs check at nursing visits [] Patient developed full body rash while taking amiodarone. This drug should be avoided in the future. # CODE: Full code # CONTACT/HCP: [MASKED] [MASKED] (cell) [MASKED] [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Apixaban 5 mg PO BID 2. Furosemide 20 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Clopidogrel 75 mg PO/NG DAILY 3. Lisinopril 2.5 mg PO DAILY 4. Metoprolol Succinate XL 12.5 mg PO DAILY 5. Spironolactone 12.5 mg PO DAILY 6. HELD- Apixaban 5 mg PO BID This medication was held. Do not restart Apixaban until 2 weeks (due to fluid around heart) 7.Outpatient Lab Work I35.0 Please obtain creatinine, potassium and fax results to Dr. [MASKED] at [MASKED] Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: -Aortic stenosis, severe -Transcatheter aortic valve replacement complicated by -Complete heart block, complicated by -Polymorphic ventricular tachycardia cardiac arrest -Prolonged QT interval -Pericardial effusion -Permanent dual chamber pacemaker implantation -Paroxysmal atrial fibrillation -Acute on chronic left ventricular systolic and diastolic heart failure with reduced ejection fraction -Rash attributed to vancomycin and/or cefazolin -Prior rash attributed to amiodarone -Chronic Kidney Disease stage 3 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 of shortness of breath WHAT HAPPENED IN THE HOSPITAL? ============================== - You were admitted to the hospital because you had been feeling short of breath and you were found to have fluid in your lungs. This was felt to be due to a 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 through the IV to help get the fluid out. You were also found to have a valve in your heart that was narrow (Aortic valve). You underwent a procedure to repair the valve - You were also found to have an abnormal rhythm and fluid around your heart. A pacemaker was placed to help your heart beat normally and the fluid around your heart was monitored with serial ultrasounds. - Your medication furosemide (or lasix) was discontinued and you were started on a different diuretic (spironolactone) 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 177.25 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 or down by more than 3 pounds in a day or 5 pounds in a week. -Do not stop taking your aspirin or clopidogrel (also known as Plavix) unless told to do so by your cardiologist Followup Instructions: [MASKED]
[]
[ "I130", "Z7901", "I480" ]
[ "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I468: Cardiac arrest due to other underlying condition", "I5043: Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure", "I21A1: Myocardial infarction type 2", "I442: Atrioventricular block, complete", "I313: Pericardial effusion (noninflammatory)", "I9751: Accidental puncture and laceration of a circulatory system organ or structure during a circulatory system procedure", "T85628A: Displacement of other specified internal prosthetic devices, implants and grafts, initial encounter", "I97790: Other intraoperative cardiac functional disturbances during cardiac surgery", "I083: Combined rheumatic disorders of mitral, aortic and tricuspid valves", "I447: Left bundle-branch block, 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", "Y92234: Operating room of hospital as the place of occurrence of the external cause", "L270: Generalized skin eruption due to drugs and medicaments taken internally", "T361X5A: Adverse effect of cephalosporins and other beta-lactam antibiotics, initial encounter", "T368X5A: Adverse effect of other systemic antibiotics, initial encounter", "I4581: Long QT syndrome", "Z7901: Long term (current) use of anticoagulants", "Z006: Encounter for examination for normal comparison and control in clinical research program", "I480: Paroxysmal atrial fibrillation", "Y738: Miscellaneous gastroenterology and urology devices associated with adverse incidents, not elsewhere classified", "N183: Chronic kidney disease, stage 3 (moderate)", "Y711: Therapeutic (nonsurgical) and rehabilitative cardiovascular devices associated with adverse incidents" ]
19,993,336
24,615,303
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Chest pain & SOB Major Surgical or Invasive Procedure: None History of Present Illness: ___ Hx HTN, HLD, esophageal dissection s/p clipping, aortic stenosis(followed by outside cardiology, ___ with planned cardiac cath in ___ and referral for TAVR, who presented to OSH ED with 1 week hx of increasing substernal chest pain and SOB, found to be in Afib with RVR, transferred here for management of acute systolic HF and ACS. In the OSH, she reported intermittent chest pain that worsens on exertion and lying down and was associated with weakness, fatigue, & diaphoresis. She denies palpitations, SOB, n/v, ___ edema. She was found to be in Afib with RVR 140s-150s, SBP 80-100s. EKG showed + ischemic changes, and she received given ASA 325mg, Adenosisine 6mg and 12mg, Digoxin 500mcg, Diltiazem gtt 10mg/hr, and calcium gluconate 1mg. She was then transferred to the ICU and given Verapamil 5mg, another dose of Digoxin 250, IV amiodarone bolus 150mg followed by 1mg/min gtt. She then converted to sinus rhythm with LVH and ST depressions laterally on EKG. She was given morphine 2mg x2 for pain and was started on IV heparin gtt. A bedside TTE showed LVEF <20%, akinetic anterior wall and global hypokinesis. Troponins were 5.07->6.240. She continues to have persistent chest pain. On transfer, - Initial vitals were: T 98.0 HR 88 BP 94/65 RR 34 99% ___ NC - Exam notable for: tachycardic, irregularly irregular rate, normal S1, S2; access: left subclavian TLC - Labs notable for: - BMP: BUN 17 Cr 1.09 - CBC: WBC 9.2 Hgb 13.3 Plt 176 - coags: PTT 43.8 (pre heparin), INR 1.18 - LFTs: AST 90 ALT 36 tbili 1.9 - troponins: 5.07->6.240 - Studies notable for: - CXR: bilateral lung opacities. interstitial and patchy opacities consistent with CHF and pulmonary edema - EKG: NSR with LVH, STD in lateral leads, prelim critical AS - TTE: LVEF <20%, mild concentric LVH, akinetic anterior wall and global hypokinesis, severe AS, mild MR with mod ___, dilated IVC, mild pulm HTN, trace TR, normal RV - AS grading: LVOT peak velocity 75.5cm/s, mean velocity 52.8cm/s, peak gradient 2mmHg, mean gradient 1mmHg - Patient was given: 2 mg morphine IV x 2, IV heparin at 15 units/kg/hr (awaiting first PTT), ASA 325mg x 1, Amiodarone gtt (bolus150mg x 1 now 1mg/hr up at 1500), Dilt 10mg/hr IV stopped 1600, 250mcg IV digoxin x1 at 1400, 5mg IV Verapamil x 1 at 1400, 0.5mg IV Ativan plus and 1mg IV Ativanat 1530, IN ED 1gram calcium gluconate, 500mcg IV digoxin, Adenosine x 2 (6mg and 12mg) On arrival to the CCU, she confirms the above history. She reports she is still in ___ chest pain but denies SOB, palpitations, cough, ___ edema. She is also complaining of her chronic low back pain. Additionally, she denies recent falls, syncope, or lightheadedness. She sustained a fall ___ ago when she "got up too quickly" and syncopized. Past Medical History: - HTN - HLD - Known severe AS - Esophageal rupture s/p endoscopic clipping - OA - Endometrial polyps - Cholecystectomy Social History: ___ Family History: - no family history of cancer, heart disease - Father: died of alcohol use - Mother: died in ___ - Grandmother: died at ___ of unknown cause Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: T98.3 HR 75 BP 100/66 RR 21 SpO2 99% GENERAL: Well developed, well nourished in NAD. Oriented x3. Mood, affect appropriate. HEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI. NECK: Supple. JVP elevated to mid neck at 45 degrees. CARDIAC: Normal rate, regular rhythm. LUSB ___ systolic ejection murmur. No gallop or rub. LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. Crackles present bilaterally to mid lung fields. No wheezes or ronchi. ABDOMEN: Soft, non-tender, non-distended. No palpable hepatomegaly or splenomegaly. EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. SKIN: No significant lesions or rashes. PULSES: Distal pulses palpable and symmetric. Radial pulses 2+. NEURO: AOx3 DISCHARGE PHYSICAL EXAM: ======================== VS: Reviewed in OMR GENERAL: Well developed, well nourished in NAD. Oriented x3. Mood, affect appropriate. HEENT: Normocephalic, atraumatic. Sclera anicteric. EOMI. NECK: Supple. JVP at level of clavicle. CARDIAC: Normal rate, regular rhythm. LUSB ___ systolic ejection murmur. No gallop or rub. LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. Crackles present at bases bilaterally to mid lung fields. No wheezes or ronchi. ABDOMEN: Soft, non-tender, non-distended. No palpable hepatomegaly or splenomegaly. EXTREMITIES: Warm, well perfused. 1+ peripheral edema. SKIN: No significant lesions or rashes. PULSES: Distal pulses palpable and symmetric. Radial pulses 2+. NEURO: AOx3 Pertinent Results: ADMISSION LABS: ___ 09:08PM LACTATE-0.8 ___ 09:01PM GLUCOSE-146* UREA N-17 CREAT-0.9 SODIUM-136 POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-19* ANION GAP-13 ___ 09:01PM estGFR-Using this ___ 09:01PM ALT(SGPT)-24 AST(SGOT)-71* LD(LDH)-362* CK(CPK)-237* ALK PHOS-50 TOT BILI-1.2 ___ 09:01PM CK-MB-19* MB INDX-8.0* cTropnT-0.85* ___ 09:01PM ALBUMIN-4.0 CALCIUM-9.2 PHOSPHATE-3.1 MAGNESIUM-1.8 ___ 09:01PM WBC-9.0 RBC-3.22* HGB-11.7 HCT-34.9 MCV-108* MCH-36.3* MCHC-33.5 RDW-12.4 RDWSD-49.3* ___ 09:01PM NEUTS-76.5* LYMPHS-11.7* MONOS-11.2 EOS-0.0* BASOS-0.3 IM ___ AbsNeut-6.90* AbsLymp-1.06* AbsMono-1.01* AbsEos-0.00* AbsBaso-0.03 ___ 09:01PM PLT COUNT-132* ___ 09:01PM ___ PTT-150* ___ KEY INTERVAL LABS: ___ 03:41AM BLOOD ALT-22 AST-65* AlkPhos-47 TotBili-1.5 ___ 05:42AM BLOOD ALT-17 AST-36 AlkPhos-54 TotBili-1.1 ___ 09:01PM BLOOD CK-MB-19* MB Indx-8.0* cTropnT-0.85* ___ 03:41AM BLOOD CK-MB-17* cTropnT-1.12* ___ 10:43AM BLOOD CK-MB-13* cTropnT-1.00* ___ 03:41AM BLOOD ___ PTT-105.2* ___ ___ 06:30PM BLOOD TSH-5.8* ___ 06:30PM BLOOD Free T4-1.4 KEY REPORTS: ___: CXR Portable AP Left subclavian central venous catheter terminates in the superior vena cava. Lung volumes are low. Heart appears mildly enlarged. Azygos vein is perhaps distended. Each hilum shows perihilar opacification in the context of a more generalized mild interstitial abnormality. This is consistent with congestive heart failure. Left basilar opacification is a typical site for atelectasis and may also involve a small pleural effusion. Small pleural effusion is not excluded on the right. No visible pneumothorax. ___: Coronary angiogram The coronary circulation is right dominant. LM: The Left Main, arising from the left cusp, is a large caliber vessel. This vessel bifurcates into the Left Anterior Descending and Left Circumflex systems. LAD: The Left Anterior Descending artery, which arises from the LM, is a large caliber vessel. The Diagonal, arising from the proximal segment, is a medium caliber vessel. Cx: The Circumflex artery, which arises from the LM, is a large caliber vessel. The ___ Obtuse Marginal, arising from the proximal segment, is a medium caliber vessel. The ___ Obtuse Marginal, arising from the mid segment, is a medium caliber vessel. RCA: The Right Coronary Artery, arising from the right cusp, is a large caliber vessel. The Right Posterior Descending Artery, arising from the distal segment, is a medium caliber vessel. ___: CXR Portable AP Comparison to ___. Pre-existing signs of centralized pulmonary edema have resolved. There is now a small left pleural effusion with subsequent left retrocardiac atelectasis. Moderate cardiomegaly persists. Correct position of the left central venous access line. No pneumonia, no pneumothorax. ___: Transthoracic Echo The left atrial volume index is moderately increased. There is no evidence for an atrial septal defect by 2D/color Doppler. The estimated right atrial pressure is ___ mmHg. There is focal non-obstructive hypertrophy of the basal septum with a SEVERELY increased/dilated cavity. There are moderate to extensive areas of severe regional left ventricular systolic dysfunction with akinesis of the distal ___ of the ventricle (see schematic) and preserved/normal contractility of the remaining segments. No thrombus or mass is seen in the left ventricle. Quantitative biplane left ventricular ejection fraction is 31 % (normal 54-73%). There is no resting left ventricular outflow tract gradient. No ventricular septal defect is seen. Tissue Doppler suggests an increased left ventricular filling pressure (PCWP greater than 18 mmHg). Normal right ventricular cavity size with normal free wall motion. The aortic sinus is mildly dilated with mildly dilated ascending aorta. There is a normal descending aorta diameter. The abdominal aorta diameter is normal. There is no evidence for an aortic arch coarctation. The aortic valve leaflets are severely thickened. There is SEVERE aortic valve stenosis (valve area 1.0 cm2 or less). There is trace aortic regurgitation. The mitral valve leaflets appear structurally normal with no mitral valve prolapse. There is mild to moderate [___] mitral regurgitation. The pulmonic valve leaflets are normal. The tricuspid valve leaflets appear structurally normal. There is mild to moderate [___] tricuspid regurgitation. There is moderate pulmonary artery systolic hypertension. There is a trivial pericardial effusion. A left pleural effusion is present. IMPRESSION: Mild basal septal hypertrophy with severe cavity dilation and severe regional systolic dysfunction most c/w ___'s cardiomyopathy though an LAD lesion cannot be fully excluded. Increased PCWP. Normal right ventricular cavity size and systolic function. Severe trileaflet calcific aortic stenosis. Mild to moderatoe mitral regurgitation. Mild to moderate tricuspid regurgitation. Moderate pulmonary artery systolic hypertension. MICROBIOLOGY: None DISCHARGE LABS: ___ 03:15AM BLOOD WBC-5.2 RBC-2.79* Hgb-10.0* Hct-29.6* MCV-106* MCH-35.8* MCHC-33.8 RDW-12.3 RDWSD-48.3* Plt ___ ___ 04:47AM BLOOD PTT-84.5* ___ 04:47AM BLOOD Glucose-107* UreaN-11 Creat-1.0 Na-139 K-4.3 Cl-99 HCO3-23 AnGap-17 ___ 04:47AM BLOOD Calcium-9.4 Phos-3.8 Mg-2.___RIEF HOSPITAL COURSE: ___ Hx HTN, HLD, esophageal dissection s/p clipping, aortic stenosis(followed by cardiology, ___ with planned cardiac cath in ___ and referral for TAVR, who presented to OSH ED with 1 week hx of increasing intermittent substernal chest pain and SOB, found to be in Afib with RVR with new HFrEF<20%, transferred here for management of NSTEMI c/b acute HFrEF & afib w/ RVR in the context of severe AS. She was started on rhythm control therapy and anticoagulation for her afib and diuresed until euvolemic. She also received a CT scan for her upcoming TAVR. ACUTE ISSUES: ============= #NSTEMI c/b acute HFrEF (<20%) #Hypotension TropI at OSH 6.240, tropT 0.85 here. ECG with diffuse ST depressions. No ST elevations. S/p ASA 325mg at OSH, transferred on hep gtt. Unknown prior baseline EF, OSH TTE EF<20% w/ akinetic anterior wall and global hypokinesis. Hypervolemic on exam w/ pulm edema on CXR. Plavix not given. Diuresed with Lasix with good response and became euvolemic over the next 2 days. Did not tolerate metoprolol d/t asymptomatic hypotension. Given HFrEF with clean coronaries, ASA/Atorvastatin not indicated. Tx: - F/u with outpatient cardiologist about starting HF meds (BB, ACE-I, etc) -Initially given statin and Aspirin, though no longer indicated. # Afib with RVR On presentation HR 130-140, now converted to sinus s/p adenosine, amio, dilt, and digoxin. Maintained in sinus rhythm with HR ___ on amio gtt, now transitioned to PO. Tx: - Amiodarone 200mg TID, amiodarone 200 QD starting ___ - Transition to apixaban 5mg BID # Severe AS Previously identified. Was planning on TAVR eval in ___ with outpatient cardiologist Dr. ___. Not a SAVR candidate due to high risk per c-surg. Structural team to arrange TAVR. Spoke to structural cardiology, OK to d/c on DOAC with plan for outpatient TAVR. TAVR CT performed on day of discharge prior to surgery, result pending on DC. Tx: - f/u as outpatient structural heart team for TVAR - workup: dental clearance #Rash Noted to have rash on back, possibly ___ contact dermatitis. Previous rashes in past responded to Triamcinolone, which was started prior to DC to continue going forward. CHRONIC/STABLE ISSUES: ===================== # HTN - D/c home losartan 100mg/HCTZ 12.5mg d/t hypotension TRANSITIONAL ISSUES: ==================== [ ] Follow up with structural cardiology for scheduling of TAVR [ ] Needs dental clearance prior to TAVR [ ] To continue Amiodarone 200mg TID through ___. Transition to Amiodarone 200mg daily on ___ [ ] Noted to have rash on back/trunk. Treated with Triamcinolone. Ensure resolution as outpatient [ ] f/u TAVR CT [ ] Stopped HCTZ-Losartan given relative hypotension. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. losartan-hydrochlorothiazide 100-12.5 mg oral DAILY Discharge Medications: 1. Amiodarone 200 mg PO TID 2. Apixaban 5 mg PO BID STOP: 3. losartan-hydrochlorothiazide 100-12.5 mg oral DAILY Discharge Disposition: Home With Service Facility: ___ ___ Diagnosis: Atrial Fibrillation Heart failure with reduced ejection fraction (HFrEF) Aortic Stenosis Discharge Condition: Alert and oriented x3 Ambulatory, d/c to home with ___ Discharge Instructions: DISCHARGE INSTRUCTIONS ====================== Dear ___, WHY WERE YOU ADMITTED TO THE HOSPITAL? - Abnormal, fast heart rhythm (atrial fibrillation) - Heart failure exacerbation - Aortic stenosis WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL? You were admitted to the hospital for a fast, irregular heart rhythm called atrial fibrillation as well as heart failure. We found that your heart wasn't beating as well as it should be, which caused you to accumulate some fluid in your legs and lungs. We helped you get rid of this extra fluid with pills that help you pee it out. We also started you on a medication to help your heart rate stay normal and regular. On your last day, we performed a CAT scan of your torso for your workup for TAVR. After monitoring you for several days in the hospital and treating your problems, we felt it was safe to discharge you home with continued follow up with your primary care doctor and the structural cardiology team for your upcoming TAVR. WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? - Take all of your medications as prescribed (listed below): - Amiodarone 200mg three times daily - Apixaban 5mg twice daily - 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: ___
[ "I110", "I5021", "I214", "E785", "I350", "I482", "Z7901", "I952", "T447X5A", "L259", "M1990", "K219" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Chest pain & SOB Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] Hx HTN, HLD, esophageal dissection s/p clipping, aortic stenosis(followed by outside cardiology, [MASKED] with planned cardiac cath in [MASKED] and referral for TAVR, who presented to OSH ED with 1 week hx of increasing substernal chest pain and SOB, found to be in Afib with RVR, transferred here for management of acute systolic HF and ACS. In the OSH, she reported intermittent chest pain that worsens on exertion and lying down and was associated with weakness, fatigue, & diaphoresis. She denies palpitations, SOB, n/v, [MASKED] edema. She was found to be in Afib with RVR 140s-150s, SBP 80-100s. EKG showed + ischemic changes, and she received given ASA 325mg, Adenosisine 6mg and 12mg, Digoxin 500mcg, Diltiazem gtt 10mg/hr, and calcium gluconate 1mg. She was then transferred to the ICU and given Verapamil 5mg, another dose of Digoxin 250, IV amiodarone bolus 150mg followed by 1mg/min gtt. She then converted to sinus rhythm with LVH and ST depressions laterally on EKG. She was given morphine 2mg x2 for pain and was started on IV heparin gtt. A bedside TTE showed LVEF <20%, akinetic anterior wall and global hypokinesis. Troponins were 5.07->6.240. She continues to have persistent chest pain. On transfer, - Initial vitals were: T 98.0 HR 88 BP 94/65 RR 34 99% [MASKED] NC - Exam notable for: tachycardic, irregularly irregular rate, normal S1, S2; access: left subclavian TLC - Labs notable for: - BMP: BUN 17 Cr 1.09 - CBC: WBC 9.2 Hgb 13.3 Plt 176 - coags: PTT 43.8 (pre heparin), INR 1.18 - LFTs: AST 90 ALT 36 tbili 1.9 - troponins: 5.07->6.240 - Studies notable for: - CXR: bilateral lung opacities. interstitial and patchy opacities consistent with CHF and pulmonary edema - EKG: NSR with LVH, STD in lateral leads, prelim critical AS - TTE: LVEF <20%, mild concentric LVH, akinetic anterior wall and global hypokinesis, severe AS, mild MR with mod [MASKED], dilated IVC, mild pulm HTN, trace TR, normal RV - AS grading: LVOT peak velocity 75.5cm/s, mean velocity 52.8cm/s, peak gradient 2mmHg, mean gradient 1mmHg - Patient was given: 2 mg morphine IV x 2, IV heparin at 15 units/kg/hr (awaiting first PTT), ASA 325mg x 1, Amiodarone gtt (bolus150mg x 1 now 1mg/hr up at 1500), Dilt 10mg/hr IV stopped 1600, 250mcg IV digoxin x1 at 1400, 5mg IV Verapamil x 1 at 1400, 0.5mg IV Ativan plus and 1mg IV Ativanat 1530, IN ED 1gram calcium gluconate, 500mcg IV digoxin, Adenosine x 2 (6mg and 12mg) On arrival to the CCU, she confirms the above history. She reports she is still in [MASKED] chest pain but denies SOB, palpitations, cough, [MASKED] edema. She is also complaining of her chronic low back pain. Additionally, she denies recent falls, syncope, or lightheadedness. She sustained a fall [MASKED] ago when she "got up too quickly" and syncopized. Past Medical History: - HTN - HLD - Known severe AS - Esophageal rupture s/p endoscopic clipping - OA - Endometrial polyps - Cholecystectomy Social History: [MASKED] Family History: - no family history of cancer, heart disease - Father: died of alcohol use - Mother: died in [MASKED] - Grandmother: died at [MASKED] of unknown cause Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: T98.3 HR 75 BP 100/66 RR 21 SpO2 99% GENERAL: Well developed, well nourished in NAD. Oriented x3. Mood, affect appropriate. HEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI. NECK: Supple. JVP elevated to mid neck at 45 degrees. CARDIAC: Normal rate, regular rhythm. LUSB [MASKED] systolic ejection murmur. No gallop or rub. LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. Crackles present bilaterally to mid lung fields. No wheezes or ronchi. ABDOMEN: Soft, non-tender, non-distended. No palpable hepatomegaly or splenomegaly. EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. SKIN: No significant lesions or rashes. PULSES: Distal pulses palpable and symmetric. Radial pulses 2+. NEURO: AOx3 DISCHARGE PHYSICAL EXAM: ======================== VS: Reviewed in OMR GENERAL: Well developed, well nourished in NAD. Oriented x3. Mood, affect appropriate. HEENT: Normocephalic, atraumatic. Sclera anicteric. EOMI. NECK: Supple. JVP at level of clavicle. CARDIAC: Normal rate, regular rhythm. LUSB [MASKED] systolic ejection murmur. No gallop or rub. LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. Crackles present at bases bilaterally to mid lung fields. No wheezes or ronchi. ABDOMEN: Soft, non-tender, non-distended. No palpable hepatomegaly or splenomegaly. EXTREMITIES: Warm, well perfused. 1+ peripheral edema. SKIN: No significant lesions or rashes. PULSES: Distal pulses palpable and symmetric. Radial pulses 2+. NEURO: AOx3 Pertinent Results: ADMISSION LABS: [MASKED] 09:08PM LACTATE-0.8 [MASKED] 09:01PM GLUCOSE-146* UREA N-17 CREAT-0.9 SODIUM-136 POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-19* ANION GAP-13 [MASKED] 09:01PM estGFR-Using this [MASKED] 09:01PM ALT(SGPT)-24 AST(SGOT)-71* LD(LDH)-362* CK(CPK)-237* ALK PHOS-50 TOT BILI-1.2 [MASKED] 09:01PM CK-MB-19* MB INDX-8.0* cTropnT-0.85* [MASKED] 09:01PM ALBUMIN-4.0 CALCIUM-9.2 PHOSPHATE-3.1 MAGNESIUM-1.8 [MASKED] 09:01PM WBC-9.0 RBC-3.22* HGB-11.7 HCT-34.9 MCV-108* MCH-36.3* MCHC-33.5 RDW-12.4 RDWSD-49.3* [MASKED] 09:01PM NEUTS-76.5* LYMPHS-11.7* MONOS-11.2 EOS-0.0* BASOS-0.3 IM [MASKED] AbsNeut-6.90* AbsLymp-1.06* AbsMono-1.01* AbsEos-0.00* AbsBaso-0.03 [MASKED] 09:01PM PLT COUNT-132* [MASKED] 09:01PM [MASKED] PTT-150* [MASKED] KEY INTERVAL LABS: [MASKED] 03:41AM BLOOD ALT-22 AST-65* AlkPhos-47 TotBili-1.5 [MASKED] 05:42AM BLOOD ALT-17 AST-36 AlkPhos-54 TotBili-1.1 [MASKED] 09:01PM BLOOD CK-MB-19* MB Indx-8.0* cTropnT-0.85* [MASKED] 03:41AM BLOOD CK-MB-17* cTropnT-1.12* [MASKED] 10:43AM BLOOD CK-MB-13* cTropnT-1.00* [MASKED] 03:41AM BLOOD [MASKED] PTT-105.2* [MASKED] [MASKED] 06:30PM BLOOD TSH-5.8* [MASKED] 06:30PM BLOOD Free T4-1.4 KEY REPORTS: [MASKED]: CXR Portable AP Left subclavian central venous catheter terminates in the superior vena cava. Lung volumes are low. Heart appears mildly enlarged. Azygos vein is perhaps distended. Each hilum shows perihilar opacification in the context of a more generalized mild interstitial abnormality. This is consistent with congestive heart failure. Left basilar opacification is a typical site for atelectasis and may also involve a small pleural effusion. Small pleural effusion is not excluded on the right. No visible pneumothorax. [MASKED]: Coronary angiogram The coronary circulation is right dominant. LM: The Left Main, arising from the left cusp, is a large caliber vessel. This vessel bifurcates into the Left Anterior Descending and Left Circumflex systems. LAD: The Left Anterior Descending artery, which arises from the LM, is a large caliber vessel. The Diagonal, arising from the proximal segment, is a medium caliber vessel. Cx: The Circumflex artery, which arises from the LM, is a large caliber vessel. The [MASKED] Obtuse Marginal, arising from the proximal segment, is a medium caliber vessel. The [MASKED] Obtuse Marginal, arising from the mid segment, is a medium caliber vessel. RCA: The Right Coronary Artery, arising from the right cusp, is a large caliber vessel. The Right Posterior Descending Artery, arising from the distal segment, is a medium caliber vessel. [MASKED]: CXR Portable AP Comparison to [MASKED]. Pre-existing signs of centralized pulmonary edema have resolved. There is now a small left pleural effusion with subsequent left retrocardiac atelectasis. Moderate cardiomegaly persists. Correct position of the left central venous access line. No pneumonia, no pneumothorax. [MASKED]: Transthoracic Echo The left atrial volume index is moderately increased. There is no evidence for an atrial septal defect by 2D/color Doppler. The estimated right atrial pressure is [MASKED] mmHg. There is focal non-obstructive hypertrophy of the basal septum with a SEVERELY increased/dilated cavity. There are moderate to extensive areas of severe regional left ventricular systolic dysfunction with akinesis of the distal [MASKED] of the ventricle (see schematic) and preserved/normal contractility of the remaining segments. No thrombus or mass is seen in the left ventricle. Quantitative biplane left ventricular ejection fraction is 31 % (normal 54-73%). There is no resting left ventricular outflow tract gradient. No ventricular septal defect is seen. Tissue Doppler suggests an increased left ventricular filling pressure (PCWP greater than 18 mmHg). Normal right ventricular cavity size with normal free wall motion. The aortic sinus is mildly dilated with mildly dilated ascending aorta. There is a normal descending aorta diameter. The abdominal aorta diameter is normal. There is no evidence for an aortic arch coarctation. The aortic valve leaflets are severely thickened. There is SEVERE aortic valve stenosis (valve area 1.0 cm2 or less). There is trace aortic regurgitation. The mitral valve leaflets appear structurally normal with no mitral valve prolapse. There is mild to moderate [[MASKED]] mitral regurgitation. The pulmonic valve leaflets are normal. The tricuspid valve leaflets appear structurally normal. There is mild to moderate [[MASKED]] tricuspid regurgitation. There is moderate pulmonary artery systolic hypertension. There is a trivial pericardial effusion. A left pleural effusion is present. IMPRESSION: Mild basal septal hypertrophy with severe cavity dilation and severe regional systolic dysfunction most c/w [MASKED]'s cardiomyopathy though an LAD lesion cannot be fully excluded. Increased PCWP. Normal right ventricular cavity size and systolic function. Severe trileaflet calcific aortic stenosis. Mild to moderatoe mitral regurgitation. Mild to moderate tricuspid regurgitation. Moderate pulmonary artery systolic hypertension. MICROBIOLOGY: None DISCHARGE LABS: [MASKED] 03:15AM BLOOD WBC-5.2 RBC-2.79* Hgb-10.0* Hct-29.6* MCV-106* MCH-35.8* MCHC-33.8 RDW-12.3 RDWSD-48.3* Plt [MASKED] [MASKED] 04:47AM BLOOD PTT-84.5* [MASKED] 04:47AM BLOOD Glucose-107* UreaN-11 Creat-1.0 Na-139 K-4.3 Cl-99 HCO3-23 AnGap-17 [MASKED] 04:47AM BLOOD Calcium-9.4 Phos-3.8 Mg-2. RIEF HOSPITAL COURSE: [MASKED] Hx HTN, HLD, esophageal dissection s/p clipping, aortic stenosis(followed by cardiology, [MASKED] with planned cardiac cath in [MASKED] and referral for TAVR, who presented to OSH ED with 1 week hx of increasing intermittent substernal chest pain and SOB, found to be in Afib with RVR with new HFrEF<20%, transferred here for management of NSTEMI c/b acute HFrEF & afib w/ RVR in the context of severe AS. She was started on rhythm control therapy and anticoagulation for her afib and diuresed until euvolemic. She also received a CT scan for her upcoming TAVR. ACUTE ISSUES: ============= #NSTEMI c/b acute HFrEF (<20%) #Hypotension TropI at OSH 6.240, tropT 0.85 here. ECG with diffuse ST depressions. No ST elevations. S/p ASA 325mg at OSH, transferred on hep gtt. Unknown prior baseline EF, OSH TTE EF<20% w/ akinetic anterior wall and global hypokinesis. Hypervolemic on exam w/ pulm edema on CXR. Plavix not given. Diuresed with Lasix with good response and became euvolemic over the next 2 days. Did not tolerate metoprolol d/t asymptomatic hypotension. Given HFrEF with clean coronaries, ASA/Atorvastatin not indicated. Tx: - F/u with outpatient cardiologist about starting HF meds (BB, ACE-I, etc) -Initially given statin and Aspirin, though no longer indicated. # Afib with RVR On presentation HR 130-140, now converted to sinus s/p adenosine, amio, dilt, and digoxin. Maintained in sinus rhythm with HR [MASKED] on amio gtt, now transitioned to PO. Tx: - Amiodarone 200mg TID, amiodarone 200 QD starting [MASKED] - Transition to apixaban 5mg BID # Severe AS Previously identified. Was planning on TAVR eval in [MASKED] with outpatient cardiologist Dr. [MASKED]. Not a SAVR candidate due to high risk per c-surg. Structural team to arrange TAVR. Spoke to structural cardiology, OK to d/c on DOAC with plan for outpatient TAVR. TAVR CT performed on day of discharge prior to surgery, result pending on DC. Tx: - f/u as outpatient structural heart team for TVAR - workup: dental clearance #Rash Noted to have rash on back, possibly [MASKED] contact dermatitis. Previous rashes in past responded to Triamcinolone, which was started prior to DC to continue going forward. CHRONIC/STABLE ISSUES: ===================== # HTN - D/c home losartan 100mg/HCTZ 12.5mg d/t hypotension TRANSITIONAL ISSUES: ==================== [ ] Follow up with structural cardiology for scheduling of TAVR [ ] Needs dental clearance prior to TAVR [ ] To continue Amiodarone 200mg TID through [MASKED]. Transition to Amiodarone 200mg daily on [MASKED] [ ] Noted to have rash on back/trunk. Treated with Triamcinolone. Ensure resolution as outpatient [ ] f/u TAVR CT [ ] Stopped HCTZ-Losartan given relative hypotension. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. losartan-hydrochlorothiazide 100-12.5 mg oral DAILY Discharge Medications: 1. Amiodarone 200 mg PO TID 2. Apixaban 5 mg PO BID STOP: 3. losartan-hydrochlorothiazide 100-12.5 mg oral DAILY Discharge Disposition: Home With Service Facility: [MASKED] [MASKED] Diagnosis: Atrial Fibrillation Heart failure with reduced ejection fraction (HFrEF) Aortic Stenosis Discharge Condition: Alert and oriented x3 Ambulatory, d/c to home with [MASKED] Discharge Instructions: DISCHARGE INSTRUCTIONS ====================== Dear [MASKED], WHY WERE YOU ADMITTED TO THE HOSPITAL? - Abnormal, fast heart rhythm (atrial fibrillation) - Heart failure exacerbation - Aortic stenosis WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL? You were admitted to the hospital for a fast, irregular heart rhythm called atrial fibrillation as well as heart failure. We found that your heart wasn't beating as well as it should be, which caused you to accumulate some fluid in your legs and lungs. We helped you get rid of this extra fluid with pills that help you pee it out. We also started you on a medication to help your heart rate stay normal and regular. On your last day, we performed a CAT scan of your torso for your workup for TAVR. After monitoring you for several days in the hospital and treating your problems, we felt it was safe to discharge you home with continued follow up with your primary care doctor and the structural cardiology team for your upcoming TAVR. WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? - Take all of your medications as prescribed (listed below): - Amiodarone 200mg three times daily - Apixaban 5mg twice daily - 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]
[]
[ "I110", "E785", "Z7901", "K219" ]
[ "I110: Hypertensive heart disease with heart failure", "I5021: Acute systolic (congestive) heart failure", "I214: Non-ST elevation (NSTEMI) myocardial infarction", "E785: Hyperlipidemia, unspecified", "I350: Nonrheumatic aortic (valve) stenosis", "I482: Chronic atrial fibrillation", "Z7901: Long term (current) use of anticoagulants", "I952: Hypotension due to drugs", "T447X5A: Adverse effect of beta-adrenoreceptor antagonists, initial encounter", "L259: Unspecified contact dermatitis, unspecified cause", "M1990: Unspecified osteoarthritis, unspecified site", "K219: Gastro-esophageal reflux disease without esophagitis" ]
19,993,501
23,659,176
Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: ___ Attending: ___. Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: None History of Present Illness: ___ with hx Hep C, polysubstance abuse and ? withdrawal seizures vs. PNES presenting after overdose and seizure. EMS was called after a bystander found him in a car. He was unresponsive at that time reportedly. Patient is unable to provide any history at all history is taken from EMS and outside hospital records. Reportedly patient received 4 mg of intranasal Narcan on scene at which time he became alert and responsive. Not long after he became unresponsive again and another 2 mg of IV Narcan failed to change his mental status. At ___ he was found to have a GCS of 7 and there was concern for bilateral upper extremity shaking movements with concern for seizure activity. He reportedly arrived with a small bag of pills as well as a white powder with Klonopin and Suboxone tablets in a bag. Blood glucose on arrival was 74. Utox + opiates, fentanyl, cocaine. He was loaded with a gram of Keppra and intubated for airway protection with etomidate and succinylcholine. He also received 2 doses of rocuronium in the outside hospital ER. Reported neg NCHCT, cervical spine CT. Of note, was hospitalized from ___ with concern for seizure activity after getting admitted to OSH for w/u of abdominal pain. Was treated with a benzo taper for detox, and was transferred to ___ on ___ after had activity concerning for seizure. Per prior neurology notes, has a history of these episodes in the past with many EEGs that have been unrevealing. EEG was unrevealing. Felt seizure episodes were nonepileptiform in nature. Had planned to discharge to a detox bed, but eloped. Returned to the ED later that day with opiate overdose requiring narcan. Was discharged w/ detox placement at ___ ___. In ED initial VS: 97.5 61 148/94 18 100% RA Exam: Moves all 4 ext vigorously Patient was given: nothing Imaging notable for: CXR neg, OSH Head CT neg Consults: neurology VS prior to transfer: 97.5 61 148/94 18 100% RA On arrival to the MICU, patient was intubated and sedated and unable to give any history. Attempted to reach patient's mother but listed number is a fax number. Past Medical History: -bipolar disorder h/o suicide attempt -hepatitis C (s/p successful treatment with Harvoni) -Self-reported history of seizure disorder (previously on valproate 500mg BID prescribed by neurologist in CA; has not taken for "years) -Polysubstance abuse - He used to be a heroin addict but he stopped "awhile ago". In the past has been on methadone and suboxone, unclear if taking currently. Also abuse of cocaine, benzos and etoh in the past. Social History: ___ Family History: unknown Physical Exam: ADMISSION PHYSICAL EXAM: VITALS:97.9 72 131/91 22 on CMV, FiO2 50%, Vt 600, PEEP 5 GENERAL: sedated, intubated HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops 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: no rashes noted NEURO: sedated, not following commands, however noted to be moving all 4 extremities following commands with nursing on arrival DISCHARGE PHYSICAL EXAM: VITALS: 97.8 140/85 95 18 98% Ra GENERAL: sitting upright in bed, in NAD, NECK: supple LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops. no chest tenderness to palpation ABD: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, no clubbing, cyanosis or edema. + bilateral fine tremor on outstretched hands bilaterally SKIN: no rashes noted NEURO: moving all extremities, CN II-XII grossly intact bilaterally Pertinent Results: ADMISSION LABS ___ 03:48AM BLOOD WBC-7.7 RBC-4.60 Hgb-13.5* Hct-40.5 MCV-88 MCH-29.3 MCHC-33.3 RDW-14.4 RDWSD-46.0 Plt ___ ___ 11:10PM BLOOD Neuts-66.6 ___ Monos-7.4 Eos-1.6 Baso-0.5 Im ___ AbsNeut-6.35* AbsLymp-2.25 AbsMono-0.71 AbsEos-0.15 AbsBaso-0.05 ___ 03:48AM BLOOD Glucose-78 UreaN-13 Creat-1.0 Na-144 K-3.7 Cl-110* HCO3-25 AnGap-13 ___ 11:10PM BLOOD ALT-11 AST-16 AlkPhos-56 TotBili-0.5 ___ 03:48AM BLOOD Calcium-8.4 Phos-3.3 Mg-2.1 ___ 11:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 11:37PM BLOOD ___ Rates-18/ PEEP-5 FiO2-50 pO2-117* pCO2-42 pH-7.38 calTCO2-26 Base XS-0 Intubat-INTUBATED Vent-CONTROLLED ___ 11:37PM BLOOD Lactate-1.0 ___ 11:37PM BLOOD O2 Sat-95 PERTINENT/DISCHARGE LABS ___ 05:55AM BLOOD WBC-9.2 RBC-4.69 Hgb-13.6* Hct-40.8 MCV-87 MCH-29.0 MCHC-33.3 RDW-14.5 RDWSD-46.2 Plt ___ ___ 05:55AM BLOOD Glucose-94 UreaN-14 Creat-0.9 Na-141 K-3.8 Cl-105 HCO3-23 AnGap-17 ___ 11:10PM BLOOD ALT-11 AST-16 AlkPhos-56 TotBili-0.5 ___ 05:55AM BLOOD Calcium-8.8 Phos-3.9 Mg-1.9 ___ 09:20AM BLOOD Valproa-38* ___ 11:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 11:10PM URINE bnzodzp-POS* barbitr-NEG opiates-POS* cocaine-POS* amphetm-NEG oxycodn-NEG mthdone-NEG MICROBIOLOGY Urine culture: No growth Brief Hospital Course: This is a ___ with HCV and polysubstance abuse who presented with altered mental status and possible seizure activiy requiring intubation in the setting of polysubstance abuse, overall most concerning for opiate overdose. ============== ACTIVE ISSUES ============== #Altered mental status: #Polysubstance abuse Utox positive for opiates, benzos, cocaine at OSH. Patient reports use of heroin/cocaine "one last time" before he presented to ___ facility which likely explains his respiratory failure. Initiated on ___ protocol while inpatient, and had moderate opiate withdrawal symptoms, but did not require benzodiazepines for alcohol withdrawal. Social work and substance abuse RN were consulted during his inpatient stay. Ultimately, decision was made to discharge patient to ___ ___ facility in ___. #Respiratory failure: Patient admits to using heroin/fentanyl prior to being hospitalized. Intubated at OSH for airway protection. Extubated without issue within 12 hours of admission to ICU at ___. Respiratory rate remained stable while he was on the floor. #Question of seizure: per report had episode of bilateral upper extremity shaking movements at OSH after intubation with concern for seizure. Was given Keppra load at OSH. Patient states that his seizures have been in the setting of withdrawal. However, prior history of seizure like episodes thought to be likely psychogenic in nature given multiple negative EEGs. Neurology service here recommended restarting home Depakote which patient had been prescribed in past but not taking for the last month. (Dual indication with bipolar disorder history.) #Hepatitis C: per review of chart h/o treatment w. ___ in the past, LFTs normal now #Bipolar disorder: He reported history of bipolar disorder; on buproprion as an outpatient. Continued BuPROPion (Sustained Release) 150 mg PO BID at this admission. TRANSITIONAL ISSUES: -Pt will be discharged home and will present immediately to ___ ___ Detox program in ___. -Pt provided with Rx for Clonazepam 1mg TID. He reported taking higher doses as an outpatient but we were unable to verify this. Consider titration of Clonazepam as indicated. -Pt provided with Rx for Narcan nasal spray. Billing: >30 minutes spent coordinating discharge to home Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Gabapentin 1200 mg PO TID 2. ClonazePAM 2 mg PO BID 3. ClonazePAM 1 mg PO QHS 4. Divalproex (EXTended Release) 500 mg PO BID 5. BuPROPion (Sustained Release) 150 mg PO BID Discharge Medications: 1. FoLIC Acid 1 mg PO DAILY RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 2. Multivitamins 1 TAB PO DAILY RX *multivitamin 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 3. Narcan (naloxone) 4 mg/actuation nasal ONCE:PRN For overdose RX *naloxone [Narcan] 4 mg/actuation 1 spray NU ONCE Disp #*1 Canister Refills:*0 4. Thiamine 100 mg PO DAILY RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 5. ClonazePAM 1 mg PO TID RX *clonazepam 1 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0 6. BuPROPion (Sustained Release) 150 mg PO BID RX *bupropion HCl [Wellbutrin XL] 150 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 7. Divalproex (EXTended Release) 500 mg PO BID RX *divalproex ___ mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 8. Gabapentin 1200 mg PO TID Discharge Disposition: Home Discharge Diagnosis: PRIMARY ======= Acute hypoxic respiratory failure Polysubstance abuse Overdose Seizure Bipolar disorder Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr ___, It was a pleasure taking care of you at ___ ___. You were in the hospital after overdosing. You briefly had a tube inserted in your throat to breath for you. Once this was removed, we monitored you for withdrawal, but you did not require medicine for withdrawal. When you leave the hospital, we encourage you to maintain sobriety. You may benefit from a Suboxone or Methadone program, but this decision is up to you. You should continue to take your same medications as prescribed. We will give you a prescription for Narcan nasal spray. This can be used in case of overdose. Best wishes, Your ___ team Followup Instructions: ___
[ "T401X1A", "J9601", "T424X1A", "T405X1A", "T404X1A", "R4182", "Y92810", "F1123", "F17210", "F319", "S0990XS", "G629", "F54", "R569", "B1920", "T426X6A", "Y92038", "Z915" ]
Allergies: [MASKED] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] with hx Hep C, polysubstance abuse and ? withdrawal seizures vs. PNES presenting after overdose and seizure. EMS was called after a bystander found him in a car. He was unresponsive at that time reportedly. Patient is unable to provide any history at all history is taken from EMS and outside hospital records. Reportedly patient received 4 mg of intranasal Narcan on scene at which time he became alert and responsive. Not long after he became unresponsive again and another 2 mg of IV Narcan failed to change his mental status. At [MASKED] he was found to have a GCS of 7 and there was concern for bilateral upper extremity shaking movements with concern for seizure activity. He reportedly arrived with a small bag of pills as well as a white powder with Klonopin and Suboxone tablets in a bag. Blood glucose on arrival was 74. Utox + opiates, fentanyl, cocaine. He was loaded with a gram of Keppra and intubated for airway protection with etomidate and succinylcholine. He also received 2 doses of rocuronium in the outside hospital ER. Reported neg NCHCT, cervical spine CT. Of note, was hospitalized from [MASKED] with concern for seizure activity after getting admitted to OSH for w/u of abdominal pain. Was treated with a benzo taper for detox, and was transferred to [MASKED] on [MASKED] after had activity concerning for seizure. Per prior neurology notes, has a history of these episodes in the past with many EEGs that have been unrevealing. EEG was unrevealing. Felt seizure episodes were nonepileptiform in nature. Had planned to discharge to a detox bed, but eloped. Returned to the ED later that day with opiate overdose requiring narcan. Was discharged w/ detox placement at [MASKED] [MASKED]. In ED initial VS: 97.5 61 148/94 18 100% RA Exam: Moves all 4 ext vigorously Patient was given: nothing Imaging notable for: CXR neg, OSH Head CT neg Consults: neurology VS prior to transfer: 97.5 61 148/94 18 100% RA On arrival to the MICU, patient was intubated and sedated and unable to give any history. Attempted to reach patient's mother but listed number is a fax number. Past Medical History: -bipolar disorder h/o suicide attempt -hepatitis C (s/p successful treatment with Harvoni) -Self-reported history of seizure disorder (previously on valproate 500mg BID prescribed by neurologist in CA; has not taken for "years) -Polysubstance abuse - He used to be a heroin addict but he stopped "awhile ago". In the past has been on methadone and suboxone, unclear if taking currently. Also abuse of cocaine, benzos and etoh in the past. Social History: [MASKED] Family History: unknown Physical Exam: ADMISSION PHYSICAL EXAM: VITALS:97.9 72 131/91 22 on CMV, FiO2 50%, Vt 600, PEEP 5 GENERAL: sedated, intubated HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops 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: no rashes noted NEURO: sedated, not following commands, however noted to be moving all 4 extremities following commands with nursing on arrival DISCHARGE PHYSICAL EXAM: VITALS: 97.8 140/85 95 18 98% Ra GENERAL: sitting upright in bed, in NAD, NECK: supple LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops. no chest tenderness to palpation ABD: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, no clubbing, cyanosis or edema. + bilateral fine tremor on outstretched hands bilaterally SKIN: no rashes noted NEURO: moving all extremities, CN II-XII grossly intact bilaterally Pertinent Results: ADMISSION LABS [MASKED] 03:48AM BLOOD WBC-7.7 RBC-4.60 Hgb-13.5* Hct-40.5 MCV-88 MCH-29.3 MCHC-33.3 RDW-14.4 RDWSD-46.0 Plt [MASKED] [MASKED] 11:10PM BLOOD Neuts-66.6 [MASKED] Monos-7.4 Eos-1.6 Baso-0.5 Im [MASKED] AbsNeut-6.35* AbsLymp-2.25 AbsMono-0.71 AbsEos-0.15 AbsBaso-0.05 [MASKED] 03:48AM BLOOD Glucose-78 UreaN-13 Creat-1.0 Na-144 K-3.7 Cl-110* HCO3-25 AnGap-13 [MASKED] 11:10PM BLOOD ALT-11 AST-16 AlkPhos-56 TotBili-0.5 [MASKED] 03:48AM BLOOD Calcium-8.4 Phos-3.3 Mg-2.1 [MASKED] 11:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [MASKED] 11:37PM BLOOD [MASKED] Rates-18/ PEEP-5 FiO2-50 pO2-117* pCO2-42 pH-7.38 calTCO2-26 Base XS-0 Intubat-INTUBATED Vent-CONTROLLED [MASKED] 11:37PM BLOOD Lactate-1.0 [MASKED] 11:37PM BLOOD O2 Sat-95 PERTINENT/DISCHARGE LABS [MASKED] 05:55AM BLOOD WBC-9.2 RBC-4.69 Hgb-13.6* Hct-40.8 MCV-87 MCH-29.0 MCHC-33.3 RDW-14.5 RDWSD-46.2 Plt [MASKED] [MASKED] 05:55AM BLOOD Glucose-94 UreaN-14 Creat-0.9 Na-141 K-3.8 Cl-105 HCO3-23 AnGap-17 [MASKED] 11:10PM BLOOD ALT-11 AST-16 AlkPhos-56 TotBili-0.5 [MASKED] 05:55AM BLOOD Calcium-8.8 Phos-3.9 Mg-1.9 [MASKED] 09:20AM BLOOD Valproa-38* [MASKED] 11:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [MASKED] 11:10PM URINE bnzodzp-POS* barbitr-NEG opiates-POS* cocaine-POS* amphetm-NEG oxycodn-NEG mthdone-NEG MICROBIOLOGY Urine culture: No growth Brief Hospital Course: This is a [MASKED] with HCV and polysubstance abuse who presented with altered mental status and possible seizure activiy requiring intubation in the setting of polysubstance abuse, overall most concerning for opiate overdose. ============== ACTIVE ISSUES ============== #Altered mental status: #Polysubstance abuse Utox positive for opiates, benzos, cocaine at OSH. Patient reports use of heroin/cocaine "one last time" before he presented to [MASKED] facility which likely explains his respiratory failure. Initiated on [MASKED] protocol while inpatient, and had moderate opiate withdrawal symptoms, but did not require benzodiazepines for alcohol withdrawal. Social work and substance abuse RN were consulted during his inpatient stay. Ultimately, decision was made to discharge patient to [MASKED] [MASKED] facility in [MASKED]. #Respiratory failure: Patient admits to using heroin/fentanyl prior to being hospitalized. Intubated at OSH for airway protection. Extubated without issue within 12 hours of admission to ICU at [MASKED]. Respiratory rate remained stable while he was on the floor. #Question of seizure: per report had episode of bilateral upper extremity shaking movements at OSH after intubation with concern for seizure. Was given Keppra load at OSH. Patient states that his seizures have been in the setting of withdrawal. However, prior history of seizure like episodes thought to be likely psychogenic in nature given multiple negative EEGs. Neurology service here recommended restarting home Depakote which patient had been prescribed in past but not taking for the last month. (Dual indication with bipolar disorder history.) #Hepatitis C: per review of chart h/o treatment w. [MASKED] in the past, LFTs normal now #Bipolar disorder: He reported history of bipolar disorder; on buproprion as an outpatient. Continued BuPROPion (Sustained Release) 150 mg PO BID at this admission. TRANSITIONAL ISSUES: -Pt will be discharged home and will present immediately to [MASKED] [MASKED] Detox program in [MASKED]. -Pt provided with Rx for Clonazepam 1mg TID. He reported taking higher doses as an outpatient but we were unable to verify this. Consider titration of Clonazepam as indicated. -Pt provided with Rx for Narcan nasal spray. Billing: >30 minutes spent coordinating discharge to home Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Gabapentin 1200 mg PO TID 2. ClonazePAM 2 mg PO BID 3. ClonazePAM 1 mg PO QHS 4. Divalproex (EXTended Release) 500 mg PO BID 5. BuPROPion (Sustained Release) 150 mg PO BID Discharge Medications: 1. FoLIC Acid 1 mg PO DAILY RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 2. Multivitamins 1 TAB PO DAILY RX *multivitamin 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 3. Narcan (naloxone) 4 mg/actuation nasal ONCE:PRN For overdose RX *naloxone [Narcan] 4 mg/actuation 1 spray NU ONCE Disp #*1 Canister Refills:*0 4. Thiamine 100 mg PO DAILY RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 5. ClonazePAM 1 mg PO TID RX *clonazepam 1 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*0 6. BuPROPion (Sustained Release) 150 mg PO BID RX *bupropion HCl [Wellbutrin XL] 150 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 7. Divalproex (EXTended Release) 500 mg PO BID RX *divalproex [MASKED] mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 8. Gabapentin 1200 mg PO TID Discharge Disposition: Home Discharge Diagnosis: PRIMARY ======= Acute hypoxic respiratory failure Polysubstance abuse Overdose Seizure Bipolar disorder Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr [MASKED], It was a pleasure taking care of you at [MASKED] [MASKED]. You were in the hospital after overdosing. You briefly had a tube inserted in your throat to breath for you. Once this was removed, we monitored you for withdrawal, but you did not require medicine for withdrawal. When you leave the hospital, we encourage you to maintain sobriety. You may benefit from a Suboxone or Methadone program, but this decision is up to you. You should continue to take your same medications as prescribed. We will give you a prescription for Narcan nasal spray. This can be used in case of overdose. Best wishes, Your [MASKED] team Followup Instructions: [MASKED]
[]
[ "J9601", "F17210" ]
[ "T401X1A: Poisoning by heroin, accidental (unintentional), initial encounter", "J9601: Acute respiratory failure with hypoxia", "T424X1A: Poisoning by benzodiazepines, accidental (unintentional), initial encounter", "T405X1A: Poisoning by cocaine, accidental (unintentional), initial encounter", "T404X1A: Poisoning by, adverse effect of and underdosing of other synthetic narcotics", "R4182: Altered mental status, unspecified", "Y92810: Car as the place of occurrence of the external cause", "F1123: Opioid dependence with withdrawal", "F17210: Nicotine dependence, cigarettes, uncomplicated", "F319: Bipolar disorder, unspecified", "S0990XS: Unspecified injury of head, sequela", "G629: Polyneuropathy, unspecified", "F54: Psychological and behavioral factors associated with disorders or diseases classified elsewhere", "R569: Unspecified convulsions", "B1920: Unspecified viral hepatitis C without hepatic coma", "T426X6A: Underdosing of other antiepileptic and sedative-hypnotic drugs, initial encounter", "Y92038: Other place in apartment as the place of occurrence of the external cause", "Z915: Personal history of self-harm" ]
19,993,501
29,469,659
Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: ___ Attending: ___. Chief Complaint: seizure like activity Major Surgical or Invasive Procedure: n/a History of Present Illness: The patient is a ___ yo man with history of polysubstance abuse and ? withdrawal seizures vs. ___ transferred from an OSH for management of bilateral dysynchronous movements of alternating limbs which were aborted with sternal rub. Neurology consulted to assess for seizure vs. PNES. He initially presented to the OSH ED on ___ for evaluation of abdominal pain, was found to have biliary sludge and discharged home. He later represented on the same day after falling forward and hitting his head at his ___ facility (___), with subsequent shaking episodes concerning for seizure. At the time he was treated with a total of 5 mg of Ativan, as well as a Keppra dose of 1000 mg. CT C-spine was unremarkable. Basic labs were unremarkable. Tox screen was ordered, which was positive for benzos and barbiturates. Shaking activity was decreased, however later on patient developed agitation and behavior that was threatening towards staff he was placed in 4. restraints and transferred immediately to ___. On arrival to the ED he had at least 2 witnessed episodes of alternating asynchronous bilateral upper and lower extremity shaking. These episodes were aborted with sternal rub. He was given Ativan total of 2 mg. As he became progressively agitated he was also given Zyprexa 10 mg. Last drink 3 days ago. Also states he is prescribed benzos and states he ran out of this 3 days ago. Per PMP prescribed 1mg alprazolam ___ last for 7 day course. States he also buys benzos off the street. Unable to obtain general or neurologic review of systems due to drowsiness and perseveration. Past Medical History: Polysubstance abuse - He used to be a heroin addict but he stopped "awhile ago". He goes to a ___ clinic. He currently uses cocaine and buys benzos on the street. He denies other medical problems. Social History: ___ Family History: NC Physical Exam: PHYSICAL EXAMINATION Vitals: 74 116/82 20 96% RA General: NAD HEENT: NCAT, dried blood in his mouth ___: RRR, no M/R/G Pulmonary: CTAB, no crackles or wheezes Abdomen: Soft, NT, ND, +BS, no guarding Extremities: Warm, no edema Neurologic Examination: MS: Drowsy but arousable to voice oriented to person and hospital but thinks he is at ___ and unsure of date. Able to state basic history with repeated questioning. Able to relate history without difficulty. Inattentive, perseverating on restraint removal, which is not possible at this time. Following commands with repetitive stimulation. Cranial Nerves: PERRL 2.5->2mm brisk. BTT bilaterally in all fields. V1-V3 with grimace to pinprick symmetrically. No facial movement asymmetry. Palate elevation symmetric. Tongue midline. Motor: Examination limited by the need of restraints but can move all extremites antigravity on command and briskly withdraws to noxious. Sensory: Withdraws to noxious symmetrically. -DTRs: Bi Tri ___ Pat Ach L 2 2 2 2 2 R 2 2 2 2 2 Plantar response flexor bilaterally. LAB DATA: As per OMR DISCHARGE PHYSICAL EXAMINATION: Temp 97.4, BP 104-165/65-82, HR 60, RR 18, 96% RA General: NAD HEENT: NCAT, dried blood in his mouth ___: RRR, no M/R/G Pulmonary: CTAB, no crackles or wheezes Abdomen: Soft, NT, ND, +BS, no guarding Extremities: Warm, no edema Neurologic Examination: MS: Patient alert, oriented x3. Able to follow all commands. Language intact, no paraphasic errors, repetition intact. naming high and low frequency items intact. Cranial Nerves: PERRL 2.5->2mm brisk. BTT bilaterally in all fields. V1-V3 with grimace to pinprick symmetrically. No facial movement asymmetry. Palate elevation symmetric. Tongue midline. Motor: Moves all extremities antigravity. ___ in all muscle groups to confrontation testing. Sensory: Withdraws to noxious symmetrically. -DTRs: Bi Tri ___ Pat Ach L 2 2 2 2 2 R 2 2 2 2 2 Plantar response flexor bilaterally. Pertinent Results: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW RDWSD Plt Ct ___ 07:55AM 6.6 5.08 14.7 43.8 86 28.9 33.6 15.0 47.1* 181 Import Result ___ 08:33AM 5.7 5.09 14.1 43.3 85 27.7 32.6 14.8 45.8 150 Import Result DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas Im ___ AbsLymp AbsMono AbsEos AbsBaso ___ 08:33AM 52.3 33.7 10.5 2.8 0.5 0.2 2.99 1.93 0.60 0.16 0.03 Import Result BASIC COAGULATION ___, PTT, PLT, INR) Plt Smr Plt Ct ___ 07:55AM 181 Import Result ___ 08:33AM LOW 150 Import Result Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap ___ 07:55AM 106* 14 0.9 142 4.3 ___ Import Result ___ 08:33AM ___ 145 4.3 108 21* 20 Import Result ESTIMATED GFR (MDRD CALCULATION) estGFR ___ 08:33AM Using this Import Result ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili ___ 08:33AM 23 29 68 0.3 Import Result CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron ___ 07:55AM 9.0 4.2 2.3 Import Result ___ 08:33AM 3.8 9.0 2.7 2.4 Import Result TOXICOLOGY, SERUM AND OTHER DRUGS ASA Ethanol Carbamz Acetmnp Bnzodzp Barbitr Tricycl ___ 09:52PM NEG NEG NEG POS* NEG NEG Import Result ___ 07:55AM 1.1* Import Result ___ 08:33AM NEG NEG NEG POS* NEG NEG Import Result IMAGES: CXR ___: There is no focal consolidation, pleural effusion or pneumothorax identified. The size the cardiomediastinal silhouette is within normal limits. Brief Hospital Course: ___ is a ___ yo man with history of polysubstance abuse transferred from detox to an OSH and ultimately to ___ for management of bilateral asynchronous movements of alternating limbs. Patient endorses a history of having these episodes in the past with many EEGs and work up. Hospital course was complicated by patient's conflicting history about his home medications, current substance use, outpatient providers, and social history. He had multiple non epileptic episodes during hospitalization after which patient immediately returned to his baseline mental status. His vital signs remained stable during all of these events. He endorsed abusing benzos heavily prior to checking himself into detox (which he entered for detoxification from alcohol), and he continued to take his own personal stash of benzodiazepenes's (primarily klonopin and Xanax) secretly while in detox. The patient presented to an OSH with abdominal pain initially from detox and had a non epileptic event which prompted transfer to ___ in ___. At this point, the patient had finished his complete alcohol detox taper and was staying at the detox program for after-care. When the patient was admitted to ___, he was placed on Ativan 1mg BID which was later changed to klonopin 1mg BID. The plan was to arrange for a safe discharge back to detox with the intent for him to undergo a detox program for benzodiazepenes. On the day that the patient left, he was found to have opiates positive in his urine. He endorsed sniffing heroin during detox prior to coming to the hospital. Neurologically, the patient remained intact and his seizure episodes were non epileptiform in nature, which the patient endorsed are triggered by anxiety. Prior to the team organizing a safe discharge plan, the patient left AMA/eloped prior to us confirming that the patient had a detox bed. He left prior to us providing prescriptions for his home medications. 1. Transitions of care issues: Patient stated he will call detox to find a bed for benzo withdrawal Medications on Admission: MEDICATIONS: (Unconfirmed as he has multiple prescribers and multiple pharmacies) alprazolam 2 mg tid wellbutrin 150 mg tid gabapentin 1200 mg tid suboxone 16 daily Discharge Medications: None as patient left AMA Discharge Disposition: Home Discharge Diagnosis: Probable Non-Epileptic Event Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were hospitalized at ___ following events concerning for seizure. On discussion with you, you have had similar events in the past and are triggered by stress and anxiety. You were monitored on video EEG that measures when you have seizures to correlate it with brain activity. We were unable to capture any seizures on EEG. You left prior to us able to discharge you safely with prescriptions or a bed in detox. Followup Instructions: ___
[ "R569", "F329", "B1920", "F1910", "F1010", "Z590", "Z87820", "F17210" ]
Allergies: [MASKED] Chief Complaint: seizure like activity Major Surgical or Invasive Procedure: n/a History of Present Illness: The patient is a [MASKED] yo man with history of polysubstance abuse and ? withdrawal seizures vs. [MASKED] transferred from an OSH for management of bilateral dysynchronous movements of alternating limbs which were aborted with sternal rub. Neurology consulted to assess for seizure vs. PNES. He initially presented to the OSH ED on [MASKED] for evaluation of abdominal pain, was found to have biliary sludge and discharged home. He later represented on the same day after falling forward and hitting his head at his [MASKED] facility ([MASKED]), with subsequent shaking episodes concerning for seizure. At the time he was treated with a total of 5 mg of Ativan, as well as a Keppra dose of 1000 mg. CT C-spine was unremarkable. Basic labs were unremarkable. Tox screen was ordered, which was positive for benzos and barbiturates. Shaking activity was decreased, however later on patient developed agitation and behavior that was threatening towards staff he was placed in 4. restraints and transferred immediately to [MASKED]. On arrival to the ED he had at least 2 witnessed episodes of alternating asynchronous bilateral upper and lower extremity shaking. These episodes were aborted with sternal rub. He was given Ativan total of 2 mg. As he became progressively agitated he was also given Zyprexa 10 mg. Last drink 3 days ago. Also states he is prescribed benzos and states he ran out of this 3 days ago. Per PMP prescribed 1mg alprazolam [MASKED] last for 7 day course. States he also buys benzos off the street. Unable to obtain general or neurologic review of systems due to drowsiness and perseveration. Past Medical History: Polysubstance abuse - He used to be a heroin addict but he stopped "awhile ago". He goes to a [MASKED] clinic. He currently uses cocaine and buys benzos on the street. He denies other medical problems. Social History: [MASKED] Family History: NC Physical Exam: PHYSICAL EXAMINATION Vitals: 74 116/82 20 96% RA General: NAD HEENT: NCAT, dried blood in his mouth [MASKED]: RRR, no M/R/G Pulmonary: CTAB, no crackles or wheezes Abdomen: Soft, NT, ND, +BS, no guarding Extremities: Warm, no edema Neurologic Examination: MS: Drowsy but arousable to voice oriented to person and hospital but thinks he is at [MASKED] and unsure of date. Able to state basic history with repeated questioning. Able to relate history without difficulty. Inattentive, perseverating on restraint removal, which is not possible at this time. Following commands with repetitive stimulation. Cranial Nerves: PERRL 2.5->2mm brisk. BTT bilaterally in all fields. V1-V3 with grimace to pinprick symmetrically. No facial movement asymmetry. Palate elevation symmetric. Tongue midline. Motor: Examination limited by the need of restraints but can move all extremites antigravity on command and briskly withdraws to noxious. Sensory: Withdraws to noxious symmetrically. -DTRs: Bi Tri [MASKED] Pat Ach L 2 2 2 2 2 R 2 2 2 2 2 Plantar response flexor bilaterally. LAB DATA: As per OMR DISCHARGE PHYSICAL EXAMINATION: Temp 97.4, BP 104-165/65-82, HR 60, RR 18, 96% RA General: NAD HEENT: NCAT, dried blood in his mouth [MASKED]: RRR, no M/R/G Pulmonary: CTAB, no crackles or wheezes Abdomen: Soft, NT, ND, +BS, no guarding Extremities: Warm, no edema Neurologic Examination: MS: Patient alert, oriented x3. Able to follow all commands. Language intact, no paraphasic errors, repetition intact. naming high and low frequency items intact. Cranial Nerves: PERRL 2.5->2mm brisk. BTT bilaterally in all fields. V1-V3 with grimace to pinprick symmetrically. No facial movement asymmetry. Palate elevation symmetric. Tongue midline. Motor: Moves all extremities antigravity. [MASKED] in all muscle groups to confrontation testing. Sensory: Withdraws to noxious symmetrically. -DTRs: Bi Tri [MASKED] Pat Ach L 2 2 2 2 2 R 2 2 2 2 2 Plantar response flexor bilaterally. Pertinent Results: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW RDWSD Plt Ct [MASKED] 07:55AM 6.6 5.08 14.7 43.8 86 28.9 33.6 15.0 47.1* 181 Import Result [MASKED] 08:33AM 5.7 5.09 14.1 43.3 85 27.7 32.6 14.8 45.8 150 Import Result DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas Im [MASKED] AbsLymp AbsMono AbsEos AbsBaso [MASKED] 08:33AM 52.3 33.7 10.5 2.8 0.5 0.2 2.99 1.93 0.60 0.16 0.03 Import Result BASIC COAGULATION [MASKED], PTT, PLT, INR) Plt Smr Plt Ct [MASKED] 07:55AM 181 Import Result [MASKED] 08:33AM LOW 150 Import Result Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [MASKED] 07:55AM 106* 14 0.9 142 4.3 [MASKED] Import Result [MASKED] 08:33AM [MASKED] 145 4.3 108 21* 20 Import Result ESTIMATED GFR (MDRD CALCULATION) estGFR [MASKED] 08:33AM Using this Import Result ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili [MASKED] 08:33AM 23 29 68 0.3 Import Result CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [MASKED] 07:55AM 9.0 4.2 2.3 Import Result [MASKED] 08:33AM 3.8 9.0 2.7 2.4 Import Result TOXICOLOGY, SERUM AND OTHER DRUGS ASA Ethanol Carbamz Acetmnp Bnzodzp Barbitr Tricycl [MASKED] 09:52PM NEG NEG NEG POS* NEG NEG Import Result [MASKED] 07:55AM 1.1* Import Result [MASKED] 08:33AM NEG NEG NEG POS* NEG NEG Import Result IMAGES: CXR [MASKED]: There is no focal consolidation, pleural effusion or pneumothorax identified. The size the cardiomediastinal silhouette is within normal limits. Brief Hospital Course: [MASKED] is a [MASKED] yo man with history of polysubstance abuse transferred from detox to an OSH and ultimately to [MASKED] for management of bilateral asynchronous movements of alternating limbs. Patient endorses a history of having these episodes in the past with many EEGs and work up. Hospital course was complicated by patient's conflicting history about his home medications, current substance use, outpatient providers, and social history. He had multiple non epileptic episodes during hospitalization after which patient immediately returned to his baseline mental status. His vital signs remained stable during all of these events. He endorsed abusing benzos heavily prior to checking himself into detox (which he entered for detoxification from alcohol), and he continued to take his own personal stash of benzodiazepenes's (primarily klonopin and Xanax) secretly while in detox. The patient presented to an OSH with abdominal pain initially from detox and had a non epileptic event which prompted transfer to [MASKED] in [MASKED]. At this point, the patient had finished his complete alcohol detox taper and was staying at the detox program for after-care. When the patient was admitted to [MASKED], he was placed on Ativan 1mg BID which was later changed to klonopin 1mg BID. The plan was to arrange for a safe discharge back to detox with the intent for him to undergo a detox program for benzodiazepenes. On the day that the patient left, he was found to have opiates positive in his urine. He endorsed sniffing heroin during detox prior to coming to the hospital. Neurologically, the patient remained intact and his seizure episodes were non epileptiform in nature, which the patient endorsed are triggered by anxiety. Prior to the team organizing a safe discharge plan, the patient left AMA/eloped prior to us confirming that the patient had a detox bed. He left prior to us providing prescriptions for his home medications. 1. Transitions of care issues: Patient stated he will call detox to find a bed for benzo withdrawal Medications on Admission: MEDICATIONS: (Unconfirmed as he has multiple prescribers and multiple pharmacies) alprazolam 2 mg tid wellbutrin 150 mg tid gabapentin 1200 mg tid suboxone 16 daily Discharge Medications: None as patient left AMA Discharge Disposition: Home Discharge Diagnosis: Probable Non-Epileptic Event Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], You were hospitalized at [MASKED] following events concerning for seizure. On discussion with you, you have had similar events in the past and are triggered by stress and anxiety. You were monitored on video EEG that measures when you have seizures to correlate it with brain activity. We were unable to capture any seizures on EEG. You left prior to us able to discharge you safely with prescriptions or a bed in detox. Followup Instructions: [MASKED]
[]
[ "F329", "F17210" ]
[ "R569: Unspecified convulsions", "F329: Major depressive disorder, single episode, unspecified", "B1920: Unspecified viral hepatitis C without hepatic coma", "F1910: Other psychoactive substance abuse, uncomplicated", "F1010: Alcohol abuse, uncomplicated", "Z590: Homelessness", "Z87820: Personal history of traumatic brain injury", "F17210: Nicotine dependence, cigarettes, uncomplicated" ]
19,993,764
23,707,485
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: ___: ERCP with sphincterotomy and stent with removal of stones and pus. ___: Laparoscopic cholecystectomy History of Present Illness: Patient is a ___ y/o male with Diabetes who was in his usual state of health until morning of ___ he went to ___ ___ and a few hours later had abrupt "attack" of severe lower abdominal pain. Accompanied by some mild shortness of breath. Went to ___ where labs showed lipase greater than 12K and imaging showed choledocholithiasis; he was transferred to ___ for ERCP and surgical evaluation. Patient reports good relief of pain at ___ with IV dilaudid. At present, no n/v/ha/cp/sob. Is briefly lightheaded when he stands up. Past Medical History: 1. Diabetes Mellitus 2. Gout 3. Hyperlipidemia 4. Prostate cancer Social History: ___ Family History: noncontributory Physical Exam: Admission Physical Exam: Vitals: 103 60 121/69 18 95 RA GEN: A&Ox3, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR PULM: Clear to auscultation b/l ABD: Soft, nondistended, tender over epigastrum, no rebound or guarding, large nonreducible left inguinal hernia, nontender, no skin changes Ext: No ___ edema, ___ warm and well perfused Discharge Physical Exam: VS: 98.5, 78, 130/70, 18, 99%ra GEN: AA&O x 3, NAD, calm, cooperative. HEENT: (-)LAD, mucous membranes moist, trachea midline, EOMI, PERRL. CHEST: Clear to auscultation bilaterally, (-) cyanosis. ABDOMEN: (+) BS x 4 quadrants, soft, mildly tender to palpation incisionally, non-distended. Incisions: clean, dry and intact, dressed and closed with steristrips. EXTREMITIES: Warm, well perfused, pulses palpable, (-) edema Pertinent Results: ___ 10:48PM BLOOD WBC-13.3* RBC-4.07* Hgb-12.3* Hct-36.8* MCV-90 MCH-30.2 MCHC-33.4 RDW-14.3 RDWSD-46.8* Plt ___ ___ 10:48PM BLOOD Glucose-212* UreaN-19 Creat-0.9 Na-133 K-4.8 Cl-98 HCO3-26 AnGap-14 ___ 10:48PM BLOOD ALT-191* AST-196* AlkPhos-70 TotBili-3.1* ___ 10:48PM BLOOD Lipase-722* ___ 10:48PM BLOOD Albumin-3.8 ___ 10:45PM BLOOD Lactate-2.4* ___: ___ ___ CT scan ___: Several biliary stones in CBD, largest measuring 7.5 mm Left inguinal hernia containing a significant portion of the sigmoid colon Brachytherapy seeds throughout prostate glands Prominent bibasilar atelectasis u/s: CBD measures 9.5 mm Brief Hospital Course: ___ y/o male with DM, gout, history of prostate cancer admitted with one day of abdominal pain, found to have lipase greater than 12K and choledocholitiasis, consistent with gallstone pancreatitis. The patient was made NPO with IV fluids. By morning of HD2 the lipase had fallen to 700s. The patient underwent ERCP on HD2 with sphincterotomy and removal of pus, sludge, and stones. The patient tolerated the procedure well and remained hemodynamically stable. On HD3 the patient was transferred to the Acute Care Surgery service. He was consented and taken to the operating room for a laparoscopic cholecystectomy, which went well without complications (reader referred to the Operative Note for details). After a brief, uneventful stay in the PACU, the patient arrived on the floor tolerating sips, on IV fluids, and IV analgesia for pain control. The patient was hemodynamically stable. . When tolerating a diet, the patient was converted to oral pain medication with continued good effect. Diet was progressively advanced as tolerated to a regular diet with good tolerability. The patient voided without problem. During this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirometry, and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged home without services. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Pravastatin 40 mg PO QPM 4. glimepiride 2 mg oral DAILY 5. MetFORMIN (Glucophage) 500 mg PO DAILY Discharge Medications: 1. Allopurinol ___ mg PO DAILY 2. glimepiride 2 mg oral DAILY 3. MetFORMIN (Glucophage) 500 mg PO DAILY 4. Pravastatin 40 mg PO QPM 5. Acetaminophen 650 mg PO Q6H pain RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills:*0 6. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*20 Capsule Refills:*0 7. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*25 Tablet Refills:*0 8. Senna 8.6 mg PO BID:PRN constipation Discharge Disposition: Home Discharge Diagnosis: Gallstone pancreatitis, choledocholithiasis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital with gallstone pancreatitis and choledocholithiasis. You underwent an ERCP in the GI suite. Later, you were taken to the operating room and had your gallbladder removed laparoscopically. You tolerated the procedure well and are now being discharged home to continue your recovery with the following instructions: Please follow up in the Acute Care Surgery clinic at the appointment listed below. Please hold your Aspirin for 5 days from the ERCP, until ___. ACTIVITY: o Do not drive until you have stopped taking pain medicine and feel you could respond in an emergency. o You may climb stairs. o You may go outside, but avoid traveling long distances until you see your surgeon at your next visit. o Don't lift more than ___ lbs for 4 weeks. (This is about the weight of a briefcase or a bag of groceries.) This applies to lifting children, but they may sit on your lap. o You may start some light exercise when you feel comfortable. o You will need to stay out of bathtubs or swimming pools for a time while your incision is healing. Ask your doctor when you can resume tub baths or swimming. HOW YOU MAY FEEL: o You may feel weak or "washed out" for a couple of weeks. You might want to nap often. Simple tasks may exhaust you. o You may have a sore throat because of a tube that was in your throat during surgery. o You might have trouble concentrating or difficulty sleeping. You might feel somewhat depressed. o You could have a poor appetite for a while. Food may seem unappealing. o All of these feelings and reactions are normal and should go away in a short time. If they do not, tell your surgeon. YOUR INCISION: o Tomorrow you may shower and remove the gauzes over your incisions. Under these dressing you have small plastic bandages called steri-strips. Do not remove steri-strips for 2 weeks. (These are the thin paper strips that might be on your incision.) But if they fall off before that that's okay). o Your incisions may be slightly red around the stitches. This is normal. o You may gently wash away dried material around your incision. o Avoid direct sun exposure to the incision area. o Do not use any ointments on the incision unless you were told otherwise. o You may see a small amount of clear or light red fluid staining your dressing or clothes. If the staining is severe, please call your surgeon. o You may shower. As noted above, ask your doctor when you may resume tub baths or swimming. YOUR BOWELS: o Constipation is a common side effect of narcotic pain medications. If needed, you may take a stool softener (such as Colace, one capsule) or gentle laxative (such as milk of magnesia, 1 tbs) twice a day. You can get both of these medicines without a prescription. o If you go 48 hours without a bowel movement, or have pain moving the bowels, call your surgeon. PAIN MANAGEMENT: o It is normal to feel some discomfort/pain following abdominal surgery. This pain is often described as "soreness". o Your pain should get better day by day. If you find the pain is getting worse instead of better, please contact your surgeon. o You will receive a prescription for pain medicine to take by mouth. It is important to take this medicine as directed. o Do not take it more frequently than prescribed. Do not take more medicine at one time than prescribed. o Your pain medicine will work better if you take it before your pain gets too severe. o Talk with your surgeon about how long you will need to take prescription pain medicine. Please don't take any other pain medicine, including non-prescription pain medicine, unless your surgeon has said its okay. o If you are experiencing no pain, it is okay to skip a dose of pain medicine. o Remember to use your "cough pillow" for splinting when you cough or when you are doing your deep breathing exercises. If you experience any of the following, please contact your surgeon: - sharp pain or any severe pain that lasts several hours - pain that is getting worse over time - pain accompanied by fever of more than 101 - a drastic change in nature or quality of your pain MEDICATIONS: Take all the medicines you were on before the operation just as you did before, unless you have been told differently. If you have any questions about what medicine to take or not to take, please call your surgeon. Followup Instructions: ___
[ "K851", "K8033", "K8063", "E119", "K269", "K4030", "M109", "Z794", "E785", "I10", "Z8546", "E806" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: [MASKED]: ERCP with sphincterotomy and stent with removal of stones and pus. [MASKED]: Laparoscopic cholecystectomy History of Present Illness: Patient is a [MASKED] y/o male with Diabetes who was in his usual state of health until morning of [MASKED] he went to [MASKED] [MASKED] and a few hours later had abrupt "attack" of severe lower abdominal pain. Accompanied by some mild shortness of breath. Went to [MASKED] where labs showed lipase greater than 12K and imaging showed choledocholithiasis; he was transferred to [MASKED] for ERCP and surgical evaluation. Patient reports good relief of pain at [MASKED] with IV dilaudid. At present, no n/v/ha/cp/sob. Is briefly lightheaded when he stands up. Past Medical History: 1. Diabetes Mellitus 2. Gout 3. Hyperlipidemia 4. Prostate cancer Social History: [MASKED] Family History: noncontributory Physical Exam: Admission Physical Exam: Vitals: 103 60 121/69 18 95 RA GEN: A&Ox3, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR PULM: Clear to auscultation b/l ABD: Soft, nondistended, tender over epigastrum, no rebound or guarding, large nonreducible left inguinal hernia, nontender, no skin changes Ext: No [MASKED] edema, [MASKED] warm and well perfused Discharge Physical Exam: VS: 98.5, 78, 130/70, 18, 99%ra GEN: AA&O x 3, NAD, calm, cooperative. HEENT: (-)LAD, mucous membranes moist, trachea midline, EOMI, PERRL. CHEST: Clear to auscultation bilaterally, (-) cyanosis. ABDOMEN: (+) BS x 4 quadrants, soft, mildly tender to palpation incisionally, non-distended. Incisions: clean, dry and intact, dressed and closed with steristrips. EXTREMITIES: Warm, well perfused, pulses palpable, (-) edema Pertinent Results: [MASKED] 10:48PM BLOOD WBC-13.3* RBC-4.07* Hgb-12.3* Hct-36.8* MCV-90 MCH-30.2 MCHC-33.4 RDW-14.3 RDWSD-46.8* Plt [MASKED] [MASKED] 10:48PM BLOOD Glucose-212* UreaN-19 Creat-0.9 Na-133 K-4.8 Cl-98 HCO3-26 AnGap-14 [MASKED] 10:48PM BLOOD ALT-191* AST-196* AlkPhos-70 TotBili-3.1* [MASKED] 10:48PM BLOOD Lipase-722* [MASKED] 10:48PM BLOOD Albumin-3.8 [MASKED] 10:45PM BLOOD Lactate-2.4* [MASKED]: [MASKED] [MASKED] CT scan [MASKED]: Several biliary stones in CBD, largest measuring 7.5 mm Left inguinal hernia containing a significant portion of the sigmoid colon Brachytherapy seeds throughout prostate glands Prominent bibasilar atelectasis u/s: CBD measures 9.5 mm Brief Hospital Course: [MASKED] y/o male with DM, gout, history of prostate cancer admitted with one day of abdominal pain, found to have lipase greater than 12K and choledocholitiasis, consistent with gallstone pancreatitis. The patient was made NPO with IV fluids. By morning of HD2 the lipase had fallen to 700s. The patient underwent ERCP on HD2 with sphincterotomy and removal of pus, sludge, and stones. The patient tolerated the procedure well and remained hemodynamically stable. On HD3 the patient was transferred to the Acute Care Surgery service. He was consented and taken to the operating room for a laparoscopic cholecystectomy, which went well without complications (reader referred to the Operative Note for details). After a brief, uneventful stay in the PACU, the patient arrived on the floor tolerating sips, on IV fluids, and IV analgesia for pain control. The patient was hemodynamically stable. . When tolerating a diet, the patient was converted to oral pain medication with continued good effect. Diet was progressively advanced as tolerated to a regular diet with good tolerability. The patient voided without problem. During this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirometry, and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged home without services. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol [MASKED] mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Pravastatin 40 mg PO QPM 4. glimepiride 2 mg oral DAILY 5. MetFORMIN (Glucophage) 500 mg PO DAILY Discharge Medications: 1. Allopurinol [MASKED] mg PO DAILY 2. glimepiride 2 mg oral DAILY 3. MetFORMIN (Glucophage) 500 mg PO DAILY 4. Pravastatin 40 mg PO QPM 5. Acetaminophen 650 mg PO Q6H pain RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills:*0 6. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*20 Capsule Refills:*0 7. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN pain RX *oxycodone 5 mg [MASKED] tablet(s) by mouth every four (4) hours Disp #*25 Tablet Refills:*0 8. Senna 8.6 mg PO BID:PRN constipation Discharge Disposition: Home Discharge Diagnosis: Gallstone pancreatitis, choledocholithiasis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital with gallstone pancreatitis and choledocholithiasis. You underwent an ERCP in the GI suite. Later, you were taken to the operating room and had your gallbladder removed laparoscopically. You tolerated the procedure well and are now being discharged home to continue your recovery with the following instructions: Please follow up in the Acute Care Surgery clinic at the appointment listed below. Please hold your Aspirin for 5 days from the ERCP, until [MASKED]. ACTIVITY: o Do not drive until you have stopped taking pain medicine and feel you could respond in an emergency. o You may climb stairs. o You may go outside, but avoid traveling long distances until you see your surgeon at your next visit. o Don't lift more than [MASKED] lbs for 4 weeks. (This is about the weight of a briefcase or a bag of groceries.) This applies to lifting children, but they may sit on your lap. o You may start some light exercise when you feel comfortable. o You will need to stay out of bathtubs or swimming pools for a time while your incision is healing. Ask your doctor when you can resume tub baths or swimming. HOW YOU MAY FEEL: o You may feel weak or "washed out" for a couple of weeks. You might want to nap often. Simple tasks may exhaust you. o You may have a sore throat because of a tube that was in your throat during surgery. o You might have trouble concentrating or difficulty sleeping. You might feel somewhat depressed. o You could have a poor appetite for a while. Food may seem unappealing. o All of these feelings and reactions are normal and should go away in a short time. If they do not, tell your surgeon. YOUR INCISION: o Tomorrow you may shower and remove the gauzes over your incisions. Under these dressing you have small plastic bandages called steri-strips. Do not remove steri-strips for 2 weeks. (These are the thin paper strips that might be on your incision.) But if they fall off before that that's okay). o Your incisions may be slightly red around the stitches. This is normal. o You may gently wash away dried material around your incision. o Avoid direct sun exposure to the incision area. o Do not use any ointments on the incision unless you were told otherwise. o You may see a small amount of clear or light red fluid staining your dressing or clothes. If the staining is severe, please call your surgeon. o You may shower. As noted above, ask your doctor when you may resume tub baths or swimming. YOUR BOWELS: o Constipation is a common side effect of narcotic pain medications. If needed, you may take a stool softener (such as Colace, one capsule) or gentle laxative (such as milk of magnesia, 1 tbs) twice a day. You can get both of these medicines without a prescription. o If you go 48 hours without a bowel movement, or have pain moving the bowels, call your surgeon. PAIN MANAGEMENT: o It is normal to feel some discomfort/pain following abdominal surgery. This pain is often described as "soreness". o Your pain should get better day by day. If you find the pain is getting worse instead of better, please contact your surgeon. o You will receive a prescription for pain medicine to take by mouth. It is important to take this medicine as directed. o Do not take it more frequently than prescribed. Do not take more medicine at one time than prescribed. o Your pain medicine will work better if you take it before your pain gets too severe. o Talk with your surgeon about how long you will need to take prescription pain medicine. Please don't take any other pain medicine, including non-prescription pain medicine, unless your surgeon has said its okay. o If you are experiencing no pain, it is okay to skip a dose of pain medicine. o Remember to use your "cough pillow" for splinting when you cough or when you are doing your deep breathing exercises. If you experience any of the following, please contact your surgeon: - sharp pain or any severe pain that lasts several hours - pain that is getting worse over time - pain accompanied by fever of more than 101 - a drastic change in nature or quality of your pain MEDICATIONS: Take all the medicines you were on before the operation just as you did before, unless you have been told differently. If you have any questions about what medicine to take or not to take, please call your surgeon. Followup Instructions: [MASKED]
[]
[ "E119", "M109", "Z794", "E785", "I10" ]
[ "K851: Biliary acute pancreatitis", "K8033: Calculus of bile duct with acute cholangitis with obstruction", "K8063: Calculus of gallbladder and bile duct with acute cholecystitis with obstruction", "E119: Type 2 diabetes mellitus without complications", "K269: Duodenal ulcer, unspecified as acute or chronic, without hemorrhage or perforation", "K4030: Unilateral inguinal hernia, with obstruction, without gangrene, not specified as recurrent", "M109: Gout, unspecified", "Z794: Long term (current) use of insulin", "E785: Hyperlipidemia, unspecified", "I10: Essential (primary) hypertension", "Z8546: Personal history of malignant neoplasm of prostate", "E806: Other disorders of bilirubin metabolism" ]
19,993,951
23,271,921
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Lipitor / Atenolol Attending: ___. Chief Complaint: Fatigue Major Surgical or Invasive Procedure: ___ EPS with Biventricular pacemaker implant History of Present Illness: CC: fatigue ___ yo gentleman with Amyloid cardiomyopathy (EF 30%) identified by endomyocardial biopsy in ___ at which time he presented with acute systolic ___ failure. He went to ___ urgent care with symptoms of 2 days increased fatigue. He reports stable 5-pillow orthopnea and LEs edema. He denies any PND, CP, palpitations, dizziness, lightheadedness, fevers, or chills. Of note, since ___ admission he has been seen in diuresis with torsemide dosing titrated as needed. Upon arrival to the ED, he was noted to be bradycardic in the ___. With concern for 2:1 AV block, EP was consulted for the management of bradycardia. He was admitted for planned EPS and pacemaker placement. Past Medical History: Coronary artery disease s/p DES x1 to LAD (___) Chronic systolic ___ failure EF 30% TTR amyloid Hypertension Hyperlipidemia Atrial fibrillation Lumbar spinal stenosis Diabetes mellitus 2 Chronic kidney disease stage III Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: PHYSICAL EXAM: Vital Signs: 96.2 ___ 18 96%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, II/VI systolic murmur 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: trace edema, 2+ pulses, no clubbing/cyanosis Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. PHYSICAL EXAM ON DAY OF DISCHARGE ___: Afebrile, tele SR with biv pacing with rates 60's to 80's Tele: A-V paced and BiV paced 60-80's ___: 111, 108, 138, 128 Wt: 78.2 kg (75.2 kg) - determined yesterday's wt. close to accurate 24 HR I&O 2380 (2400) **Pertinent exam findings: VS: T 98 HR 60-80's RR 16 BP 90/50 to 86/50's 95% RA Gen: No acute distress, denies pain Neck/JVD: no elevation appreciated CV:RRR, II/VI holosystolic best heard LUSB Chest:Lungs clear bilaterally ABD:Abdomen soft, bowel sounds present, last BM 1 week ago Extr: trace to 1+ lower extremity edema L>R Access sites: PIV Skin: Feet cool, skin dry and intact. Left chest wall pacer sites, soft, diffuse ecchymosis noted, improved over ___, mildly tender to palpation, hematoma appears to be resolving, no active drainage, shadowing of old drainage noted on dressing approx. 2 cm Neuro:A+Ox3, no focal deficts Pertinent Results: ___ 07:35AM BLOOD Glucose-63* UreaN-49* Creat-1.9* Na-137 K-3.7 Cl-97 HCO3-20* AnGap-24* ___ 07:10AM BLOOD UreaN-43* Creat-1.6* K-3.3 ___ 07:20AM BLOOD Glucose-98 UreaN-32* Creat-1.4* Na-137 K-3.4 Cl-99 HCO3-27 AnGap-14 ___ 07:00AM BLOOD UreaN-33* Creat-1.3* K-4.0 ___ 09:30AM BLOOD UreaN-38* Creat-1.5* Na-130* K-4.2 ___ 02:47PM BLOOD ALT-13 AST-24 AlkPhos-114 TotBili-2.4* ___ 09:30AM BLOOD Albumin-4.1 ___ 07:35AM BLOOD Calcium-9.2 Phos-3.9 Mg-1.8 ___ 02:47PM BLOOD VitB12-317 Folate-12.2 ___ 02:47PM BLOOD TSH-2.8 ___ 02:47PM GLUCOSE-98 UREA N-49* CREAT-2.0* SODIUM-131* POTASSIUM-4.3 CHLORIDE-95* TOTAL CO2-21* ANION GAP-19 ___ 02:47PM ALT(SGPT)-13 AST(SGOT)-24 ALK PHOS-114 TOT BILI-2.4* ___ 02:47PM proBNP-6774* ___ 02:47PM VIT B12-317 FOLATE-12.2 ___ 02:47PM TSH-2.8 ___ 02:47PM WBC-5.3 RBC-3.48* HGB-11.6*# HCT-35.0* MCV-101*# MCH-33.3*# MCHC-33.1 RDW-18.4* RDWSD-67.4* ___ 02:47PM NEUTS-62.1 ___ MONOS-9.7 EOS-5.1 BASOS-1.0 IM ___ AbsNeut-3.27 AbsLymp-1.14* AbsMono-0.51 AbsEos-0.27 AbsBaso-0.05 ___ 02:47PM PLT COUNT-127* ___ 07:35AM BLOOD WBC-4.6 RBC-3.50* Hgb-11.5* Hct-36.4* MCV-104* MCH-32.9* MCHC-31.6* RDW-18.5* RDWSD-70.0* Plt ___ ___ 07:10AM BLOOD WBC-6.3 RBC-2.71* Hgb-9.0* Hct-28.2* MCV-104* MCH-33.2* MCHC-31.9* RDW-18.2* RDWSD-68.9* Plt ___ ___ 12:50PM BLOOD Hct-27.8* ___ 07:20AM BLOOD WBC-4.9 RBC-2.30* Hgb-7.7* Hct-23.7* MCV-103* MCH-33.5* MCHC-32.5 RDW-18.1* RDWSD-67.4* Plt ___ ___ 10:45AM BLOOD Hct-24.8* ___ 07:00AM BLOOD Hct-25.1* ___ 03:20PM BLOOD WBC-5.5 RBC-2.51* Hgb-8.3* Hct-26.3* MCV-105* MCH-33.1* MCHC-31.6* RDW-17.9* RDWSD-68.9* Plt ___ Brief Hospital Course: The patient had a course postoperatively that was marked by some atrial tachycardia requiring pacer modifications which resolved without issue, with a burden of afib of approximately 20 to no more than 30%. He had low blood pressures and on clinical exam was noted to be hydrating inadequately with concentrated urine and well below his 2 liter daily restriction. He was given two fluid boluses and received one liter of normal saline to good effect. His blood pressure returned to baseline mid 80's to 90's with a peak of 100's. He continued on his adjusted Torsemide dose once this resolved. He has underlying anemia of chronic disease which requires further management by his Rheumatologist and his PCP given his underlying amyloid diagnosis. He reported not having a bowel movement for a week and was given a suppository with no results. He should increase his laxative use on discharge to home, we recommend Miralax x 3 doses 20 minutes apart, or his laxative of choice, including Mag Citrate, all available over the counter. # AV ___ BLOCK with bradycardia: s/p BiV pacer implant on ___ - EP interrogated device and feels AT requiring pacer setting modifications, no addition of beta blocker necessary, continue to monitor on telemetry - Vanco in house postop, followed by Keflex in house for total 3 days - Follow up in device clinic in a week - EP f/u with Dr. ___: requested through Care Connections # ATRIAL FIBRILLATION - A-V and BiV pacing and having runs of atrial tachycardia vs atrial flutter - Atrial arrhythmia reviewed with EP, pacemaker settings adjusted ___, improved - Continue Apixaban # CHRONIC SYSTOLIC ___ FALURE: - Euvolemic on exam, still with sporadic hypotension. Review of ___ reveals he rec'd 40 mg Torsemide last evening and has since had low pressures now to the 70's systolic, rec'd 60 mg ___ ___ and had lows yesterday as well. Improved fluid status with IV boluses and PO intake. No further fluids needed, patient remains asymptomatic with MAP > 60. - Hct improving gradually, baseline ___ but admitted here w/Hct 35. Last admit ___ shows baseline 32, currently 26.2 and dilute from fluids. Follow with both PCP and ___ for ongoing care - Torsemide 60 mg AM and 40 mg ___ continues - no dose adjustment since he had increased his intake to his fluid restriction, urine clearing - Daily weights - inaccurate weights vs. I&O's - see above - No ___ in setting of CKD stage III - Cardiology f/u Dr ___ ___ clinic (pt goes to the ___ clinic every ___ # ___: - Now resolving. CKD stage 3. Cr stable at 1.3 - Torsemide resumed and re-evaluated on day of discharge. Given appropriate hydration and improved clinical status, discharge on the 60 mg and 40 mg divided day dosing as determined during recent ___ clinic visit - Continue Keflex for 2 days - Avoid nephrotoxins # Macrocytic anemia: - patient with baseline anemia, MCV 101. Overall, Hct 27 which is baseline ___. Denies heavy EtOH use - Hct stable at 26.2, no active bleeding seen, hematoma at pacer site improved, seen by Fellow. No active drainage noted and currently appears stable - suspect low Hct in setting of overdiuresis, procedure loss and resolving hematoma with no active drainage - Pt denies knowledge of anemia and has not been transfused - Further follow up ___ MD who is following for Amyloid # HLD: - Continue rosuvastatin 10mg daily # T2DM: FBS 156, sugars 86-161 - Humalog sliding scale while in-house - Resume Metformin at discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Apixaban 5 mg PO BID 2. Aspirin 81 mg PO DAILY 3. Ferrous Sulfate 325 mg PO BID 4. MetFORMIN (Glucophage) 500 mg PO BID 5. Rosuvastatin Calcium 10 mg PO ___ 6. Torsemide 80 mg PO DAILY (per instructions by diuresis clininc was due to decrease to 60 mg QQM and ___ ___ on ___ 7. Potassium Chloride 60 mEq PO BID Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Rosuvastatin Calcium 10 mg PO ___ 3. Ferrous Sulfate 325 mg PO BID 4. Apixaban 5 mg PO BID restart on ___ 5. MetFORMIN (Glucophage) 500 mg PO BID restart on ___ morning 6. Cephalexin 500 mg PO Q6H x 2 days 7. Potassium Chloride 60 mEq PO BID 8. Torsemide 60 mg PO QAM 9. Torsemide 40 mg PO ___ Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: CAD remote MI Cardiac Amyloidosis ___ ___ block Atrial fibrillation Chronic systolic ___ failure Hyperlipidemia DM2 CKD stage III Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted after evaluation for symptoms of fatigue showed a slow heartbeat. A pacemaker was placed by Dr. ___. This pacemaker is set to help prevent your ___ from beating to slowing and also to coordinate the beating of the 2 bottom ___ chambers so that symptoms of ___ failure may be improved. Activity restrictions and care of the incision as per written nursing discharge instructions. Please continue all your usual medicines. Your Apixaban was resumed ___. In addition you will need to take an antibiotic for 2 days to prevent infection at the pacemaker site and were started on this while in the hospital. You should resume your Metformin on arrival to home. While hospitalized, your blood glucose remained stable and you were maintained on a sliding scale insulin regimen. Your hemoglobin did drop post procedure but has been trending up steadily since then. You did not receive any blood transfusions and your last hemoglobin/hematocrit was 8.3 and 26.3 respectively. Please continue to weigh yourself daily and report any weight gain to your ___ failure Nurse Practitioner. ___ your weight goes up ___ lbs in ___ hours, contact your ___ NP. You should continue a 2 gram ___ healthy low sodium diet and limit free fluids, including those that melt at room temperature to 2 liters daily. Post procedure you were noted to be dehydrated and drinking inadequate amounts of fluid, even with a 2 liter fluid restriction. Your blood pressure dropped to a low of 70/50's and has improved to baseline 80-90's systolic. Continue measuring and tracking your fluids and your sodium intake. Keep all of your follow up appointments as noted below. Followup Instructions: ___
[ "I441", "E854", "N179", "I43", "I5022", "E1122", "I447", "I2510", "Z955", "I129", "N183", "Z794", "E785", "I4891", "D638", "I9581", "I252", "Z7982", "Z7902" ]
Allergies: Lipitor / Atenolol Chief Complaint: Fatigue Major Surgical or Invasive Procedure: [MASKED] EPS with Biventricular pacemaker implant History of Present Illness: CC: fatigue [MASKED] yo gentleman with Amyloid cardiomyopathy (EF 30%) identified by endomyocardial biopsy in [MASKED] at which time he presented with acute systolic [MASKED] failure. He went to [MASKED] urgent care with symptoms of 2 days increased fatigue. He reports stable 5-pillow orthopnea and LEs edema. He denies any PND, CP, palpitations, dizziness, lightheadedness, fevers, or chills. Of note, since [MASKED] admission he has been seen in diuresis with torsemide dosing titrated as needed. Upon arrival to the ED, he was noted to be bradycardic in the [MASKED]. With concern for 2:1 AV block, EP was consulted for the management of bradycardia. He was admitted for planned EPS and pacemaker placement. Past Medical History: Coronary artery disease s/p DES x1 to LAD ([MASKED]) Chronic systolic [MASKED] failure EF 30% TTR amyloid Hypertension Hyperlipidemia Atrial fibrillation Lumbar spinal stenosis Diabetes mellitus 2 Chronic kidney disease stage III Social History: [MASKED] Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: PHYSICAL EXAM: Vital Signs: 96.2 [MASKED] 18 96%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, II/VI systolic murmur 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: trace edema, 2+ pulses, no clubbing/cyanosis Neuro: CNII-XII intact, [MASKED] strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. PHYSICAL EXAM ON DAY OF DISCHARGE [MASKED]: Afebrile, tele SR with biv pacing with rates 60's to 80's Tele: A-V paced and BiV paced 60-80's [MASKED]: 111, 108, 138, 128 Wt: 78.2 kg (75.2 kg) - determined yesterday's wt. close to accurate 24 HR I&O 2380 (2400) **Pertinent exam findings: VS: T 98 HR 60-80's RR 16 BP 90/50 to 86/50's 95% RA Gen: No acute distress, denies pain Neck/JVD: no elevation appreciated CV:RRR, II/VI holosystolic best heard LUSB Chest:Lungs clear bilaterally ABD:Abdomen soft, bowel sounds present, last BM 1 week ago Extr: trace to 1+ lower extremity edema L>R Access sites: PIV Skin: Feet cool, skin dry and intact. Left chest wall pacer sites, soft, diffuse ecchymosis noted, improved over [MASKED], mildly tender to palpation, hematoma appears to be resolving, no active drainage, shadowing of old drainage noted on dressing approx. 2 cm Neuro:A+Ox3, no focal deficts Pertinent Results: [MASKED] 07:35AM BLOOD Glucose-63* UreaN-49* Creat-1.9* Na-137 K-3.7 Cl-97 HCO3-20* AnGap-24* [MASKED] 07:10AM BLOOD UreaN-43* Creat-1.6* K-3.3 [MASKED] 07:20AM BLOOD Glucose-98 UreaN-32* Creat-1.4* Na-137 K-3.4 Cl-99 HCO3-27 AnGap-14 [MASKED] 07:00AM BLOOD UreaN-33* Creat-1.3* K-4.0 [MASKED] 09:30AM BLOOD UreaN-38* Creat-1.5* Na-130* K-4.2 [MASKED] 02:47PM BLOOD ALT-13 AST-24 AlkPhos-114 TotBili-2.4* [MASKED] 09:30AM BLOOD Albumin-4.1 [MASKED] 07:35AM BLOOD Calcium-9.2 Phos-3.9 Mg-1.8 [MASKED] 02:47PM BLOOD VitB12-317 Folate-12.2 [MASKED] 02:47PM BLOOD TSH-2.8 [MASKED] 02:47PM GLUCOSE-98 UREA N-49* CREAT-2.0* SODIUM-131* POTASSIUM-4.3 CHLORIDE-95* TOTAL CO2-21* ANION GAP-19 [MASKED] 02:47PM ALT(SGPT)-13 AST(SGOT)-24 ALK PHOS-114 TOT BILI-2.4* [MASKED] 02:47PM proBNP-6774* [MASKED] 02:47PM VIT B12-317 FOLATE-12.2 [MASKED] 02:47PM TSH-2.8 [MASKED] 02:47PM WBC-5.3 RBC-3.48* HGB-11.6*# HCT-35.0* MCV-101*# MCH-33.3*# MCHC-33.1 RDW-18.4* RDWSD-67.4* [MASKED] 02:47PM NEUTS-62.1 [MASKED] MONOS-9.7 EOS-5.1 BASOS-1.0 IM [MASKED] AbsNeut-3.27 AbsLymp-1.14* AbsMono-0.51 AbsEos-0.27 AbsBaso-0.05 [MASKED] 02:47PM PLT COUNT-127* [MASKED] 07:35AM BLOOD WBC-4.6 RBC-3.50* Hgb-11.5* Hct-36.4* MCV-104* MCH-32.9* MCHC-31.6* RDW-18.5* RDWSD-70.0* Plt [MASKED] [MASKED] 07:10AM BLOOD WBC-6.3 RBC-2.71* Hgb-9.0* Hct-28.2* MCV-104* MCH-33.2* MCHC-31.9* RDW-18.2* RDWSD-68.9* Plt [MASKED] [MASKED] 12:50PM BLOOD Hct-27.8* [MASKED] 07:20AM BLOOD WBC-4.9 RBC-2.30* Hgb-7.7* Hct-23.7* MCV-103* MCH-33.5* MCHC-32.5 RDW-18.1* RDWSD-67.4* Plt [MASKED] [MASKED] 10:45AM BLOOD Hct-24.8* [MASKED] 07:00AM BLOOD Hct-25.1* [MASKED] 03:20PM BLOOD WBC-5.5 RBC-2.51* Hgb-8.3* Hct-26.3* MCV-105* MCH-33.1* MCHC-31.6* RDW-17.9* RDWSD-68.9* Plt [MASKED] Brief Hospital Course: The patient had a course postoperatively that was marked by some atrial tachycardia requiring pacer modifications which resolved without issue, with a burden of afib of approximately 20 to no more than 30%. He had low blood pressures and on clinical exam was noted to be hydrating inadequately with concentrated urine and well below his 2 liter daily restriction. He was given two fluid boluses and received one liter of normal saline to good effect. His blood pressure returned to baseline mid 80's to 90's with a peak of 100's. He continued on his adjusted Torsemide dose once this resolved. He has underlying anemia of chronic disease which requires further management by his Rheumatologist and his PCP given his underlying amyloid diagnosis. He reported not having a bowel movement for a week and was given a suppository with no results. He should increase his laxative use on discharge to home, we recommend Miralax x 3 doses 20 minutes apart, or his laxative of choice, including Mag Citrate, all available over the counter. # AV [MASKED] BLOCK with bradycardia: s/p BiV pacer implant on [MASKED] - EP interrogated device and feels AT requiring pacer setting modifications, no addition of beta blocker necessary, continue to monitor on telemetry - Vanco in house postop, followed by Keflex in house for total 3 days - Follow up in device clinic in a week - EP f/u with Dr. [MASKED]: requested through Care Connections # ATRIAL FIBRILLATION - A-V and BiV pacing and having runs of atrial tachycardia vs atrial flutter - Atrial arrhythmia reviewed with EP, pacemaker settings adjusted [MASKED], improved - Continue Apixaban # CHRONIC SYSTOLIC [MASKED] FALURE: - Euvolemic on exam, still with sporadic hypotension. Review of [MASKED] reveals he rec'd 40 mg Torsemide last evening and has since had low pressures now to the 70's systolic, rec'd 60 mg [MASKED] [MASKED] and had lows yesterday as well. Improved fluid status with IV boluses and PO intake. No further fluids needed, patient remains asymptomatic with MAP > 60. - Hct improving gradually, baseline [MASKED] but admitted here w/Hct 35. Last admit [MASKED] shows baseline 32, currently 26.2 and dilute from fluids. Follow with both PCP and [MASKED] for ongoing care - Torsemide 60 mg AM and 40 mg [MASKED] continues - no dose adjustment since he had increased his intake to his fluid restriction, urine clearing - Daily weights - inaccurate weights vs. I&O's - see above - No [MASKED] in setting of CKD stage III - Cardiology f/u Dr [MASKED] [MASKED] clinic (pt goes to the [MASKED] clinic every [MASKED] # [MASKED]: - Now resolving. CKD stage 3. Cr stable at 1.3 - Torsemide resumed and re-evaluated on day of discharge. Given appropriate hydration and improved clinical status, discharge on the 60 mg and 40 mg divided day dosing as determined during recent [MASKED] clinic visit - Continue Keflex for 2 days - Avoid nephrotoxins # Macrocytic anemia: - patient with baseline anemia, MCV 101. Overall, Hct 27 which is baseline [MASKED]. Denies heavy EtOH use - Hct stable at 26.2, no active bleeding seen, hematoma at pacer site improved, seen by Fellow. No active drainage noted and currently appears stable - suspect low Hct in setting of overdiuresis, procedure loss and resolving hematoma with no active drainage - Pt denies knowledge of anemia and has not been transfused - Further follow up [MASKED] MD who is following for Amyloid # HLD: - Continue rosuvastatin 10mg daily # T2DM: FBS 156, sugars 86-161 - Humalog sliding scale while in-house - Resume Metformin at discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Apixaban 5 mg PO BID 2. Aspirin 81 mg PO DAILY 3. Ferrous Sulfate 325 mg PO BID 4. MetFORMIN (Glucophage) 500 mg PO BID 5. Rosuvastatin Calcium 10 mg PO [MASKED] 6. Torsemide 80 mg PO DAILY (per instructions by diuresis clininc was due to decrease to 60 mg QQM and [MASKED] [MASKED] on [MASKED] 7. Potassium Chloride 60 mEq PO BID Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Rosuvastatin Calcium 10 mg PO [MASKED] 3. Ferrous Sulfate 325 mg PO BID 4. Apixaban 5 mg PO BID restart on [MASKED] 5. MetFORMIN (Glucophage) 500 mg PO BID restart on [MASKED] morning 6. Cephalexin 500 mg PO Q6H x 2 days 7. Potassium Chloride 60 mEq PO BID 8. Torsemide 60 mg PO QAM 9. Torsemide 40 mg PO [MASKED] Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: CAD remote MI Cardiac Amyloidosis [MASKED] [MASKED] block Atrial fibrillation Chronic systolic [MASKED] failure Hyperlipidemia DM2 CKD stage III Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted after evaluation for symptoms of fatigue showed a slow heartbeat. A pacemaker was placed by Dr. [MASKED]. This pacemaker is set to help prevent your [MASKED] from beating to slowing and also to coordinate the beating of the 2 bottom [MASKED] chambers so that symptoms of [MASKED] failure may be improved. Activity restrictions and care of the incision as per written nursing discharge instructions. Please continue all your usual medicines. Your Apixaban was resumed [MASKED]. In addition you will need to take an antibiotic for 2 days to prevent infection at the pacemaker site and were started on this while in the hospital. You should resume your Metformin on arrival to home. While hospitalized, your blood glucose remained stable and you were maintained on a sliding scale insulin regimen. Your hemoglobin did drop post procedure but has been trending up steadily since then. You did not receive any blood transfusions and your last hemoglobin/hematocrit was 8.3 and 26.3 respectively. Please continue to weigh yourself daily and report any weight gain to your [MASKED] failure Nurse Practitioner. [MASKED] your weight goes up [MASKED] lbs in [MASKED] hours, contact your [MASKED] NP. You should continue a 2 gram [MASKED] healthy low sodium diet and limit free fluids, including those that melt at room temperature to 2 liters daily. Post procedure you were noted to be dehydrated and drinking inadequate amounts of fluid, even with a 2 liter fluid restriction. Your blood pressure dropped to a low of 70/50's and has improved to baseline 80-90's systolic. Continue measuring and tracking your fluids and your sodium intake. Keep all of your follow up appointments as noted below. Followup Instructions: [MASKED]
[]
[ "N179", "E1122", "I2510", "Z955", "I129", "Z794", "E785", "I4891", "I252", "Z7902" ]
[ "I441: Atrioventricular block, second degree", "E854: Organ-limited amyloidosis", "N179: Acute kidney failure, unspecified", "I43: Cardiomyopathy in diseases classified elsewhere", "I5022: Chronic systolic (congestive) heart failure", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "I447: Left bundle-branch block, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "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", "N183: Chronic kidney disease, stage 3 (moderate)", "Z794: Long term (current) use of insulin", "E785: Hyperlipidemia, unspecified", "I4891: Unspecified atrial fibrillation", "D638: Anemia in other chronic diseases classified elsewhere", "I9581: Postprocedural hypotension", "I252: Old myocardial infarction", "Z7982: Long term (current) use of aspirin", "Z7902: Long term (current) use of antithrombotics/antiplatelets" ]
19,993,951
24,151,632
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Lipitor / Atenolol Attending: ___. Chief Complaint: dyspnea on exertion Major Surgical or Invasive Procedure: PICC Line placement. History of Present Illness: ___ yo male with PMH significant for mixed ischemic/senile amyloid cardiomyopathy, HFrEF (EF 22%), coronary artery disease s/p PCI to LAD, atrial fibrillation, and history of high degree AV block s/p biventricular pacemaker, recent hospitalization with decompensated ___ presenting with increased dyspnea and fatigue. Patient was admitted with fatigue and dyspnea, decompensated possibly in the setting of increased Afib burden vs excessive fluid intake vs progression of advanced CHF. It was also thought that some of his symptoms were actually related to his pacer since after his BiV pacer setting was increased to 95, he had significant symptom resolution. Discharge weight was 72.6kg. Per report, since discharge, pt has had dyspnea and overall fatigue that has been worsening. He has not noted any weight gain or edema. He has some orthopnea but is primarily dyspnea on exertion. He denies any chest pain. Denies any fever chills or cough. He does endorse some heaviness in his legs. He was seen in clinic on ___ and was found to be volume overloaded, and recommended admission, but he declined. Was discharged from clinic on increased dose of 60mg QAM and 40mg QPM. However, he presented to ED today due to worsening symptoms. In the ED initial vitals were: 84/62 95 afebrile 96RA. EKG: Afib, V-paced Labs/studies notable for: CKMB 13/trop .12, repeat trop .1. Na 131. Cr 2.2(2 on ___, on discharge on ___ BNP ___ 13000s), lactate 2.6. Patient was given: asp 325 Vitals on transfer: ___ On the floor, pt appears comfortable. Denies any SOB/CP/abdominal pain while sitting. Past Medical History: Coronary artery disease s/p DES x1 to LAD (___) systolic heart failure EF 30% TTR amyloid Hypertension Hyperlipidemia Atrial fibrillation Lumbar spinal stenosis Diabetes mellitus 2 Chronic kidney disease stage III Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Physical Exam: ADMISSION PHYSICAL EXAM: ==================== VS: afebrile 97/62 96 18 96RA Wt 73kg, dry weight 72.6kg GENERAL: Appears comfortable and can have a full conversation. Oriented x3. Mood, affect appropriate. HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. Conjunctiva were pink. No pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple. JVP 15cm, above angle of jaw. CARDIAC: Irregularly irregular. Normal S1, S2. No murmurs, rubs, or gallops. LUNGS: clear to auscultation bilaterally ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No splenomegaly. EXTREMITIES: cool to touch upper and lower extremities SKIN: No significant skin lesions or rashes. PULSES: Distal pulses palpable and symmetric. DISCHARGE PHYSICAL EXAM: ======================== Vitals: 98, 90-100/61-66, 95, ___, 100% on RA. I/O= ___ on ___. 1624/2200 on ___. 2284/3050 on ___. 1864/6150 on ___, 1560/4630 on ___, 2150/4150 ___, ___ ___ from 12a-8a Weight: 69.4 < 70.3 < 71.1 < 70.7 < 75.8 < 75.4 < 73.3 < 74.0 < 73.2 < 71.8 kg on ___ (73.0 kg on admission) GENERAL: Alert and oriented x 3, pleasant, comfortable HEENT: Normocephalic atraumatic. Sclera anicteric. NECK: Supple. JVP 11 cm, +HJR CARDIAC: regular rate and rhythm, Normal S1, S2. No murmurs, rubs, or gallops. LUNGS: CTAB ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No splenomegaly. EXTREMITIES: warm, wp, no ___ edema SKIN: No significant skin lesions or rashes. PULSES: Distal pulses palpable and symmetric. Pertinent Results: ADMISSION LABS: ================ ___ 01:22PM BLOOD WBC-4.1 RBC-3.89* Hgb-13.4* Hct-41.6 MCV-107* MCH-34.4* MCHC-32.2 RDW-15.7* RDWSD-61.7* Plt ___ ___ 01:22PM BLOOD Neuts-58.1 ___ Monos-10.9 Eos-2.4 Baso-1.5* Im ___ AbsNeut-2.40 AbsLymp-1.11* AbsMono-0.45 AbsEos-0.10 AbsBaso-0.06 ___ 01:22PM BLOOD Glucose-73 UreaN-58* Creat-2.2* Na-131* K-4.6 Cl-92* HCO3-22 AnGap-22* ___ 01:22PM BLOOD CK(CPK)-260 ___ 01:22PM BLOOD CK-MB-13* MB Indx-5.0 ___ ___ 03:42PM BLOOD ALT-23 AST-35 LD(LDH)-360* AlkPhos-138* TotBili-2.4* ___ 01:45PM BLOOD ___ Comment-GREEN TOP ___ 01:45PM BLOOD Lactate-2.6* ___ 02:06PM BLOOD Lactate-2.1* OTHER RELEVANT LABS: ================== ___ 04:50AM BLOOD WBC-3.4* RBC-3.44* Hgb-11.6* Hct-36.8* MCV-107* MCH-33.7* MCHC-31.5* RDW-15.4 RDWSD-60.5* Plt ___ ___ 05:42AM BLOOD WBC-4.5 RBC-3.28* Hgb-11.2* Hct-35.4* MCV-108* MCH-34.1* MCHC-31.6* RDW-15.2 RDWSD-60.9* Plt ___ ___ 01:00PM BLOOD Glucose-101* UreaN-51* Creat-1.7* Na-137 K-3.9 Cl-97 HCO3-26 AnGap-18 ___ 03:00PM BLOOD Glucose-165* UreaN-44* Creat-1.5* Na-137 K-3.7 Cl-98 HCO3-27 AnGap-16 ___ 04:50AM BLOOD ALT-21 AST-30 LD(LDH)-325* AlkPhos-137* TotBili-2.1* ___ 05:42AM BLOOD ALT-19 AST-28 LD(LDH)-277* AlkPhos-133* TotBili-1.9* ___ 01:22PM BLOOD cTropnT-0.12* ___ 03:42PM BLOOD cTropnT-0.10* ___ 02:06PM BLOOD Lactate-2.1* ___ 06:26AM BLOOD Lactate-1.0 ___ 05:00AM BLOOD Glucose-78 UreaN-40* Creat-1.7* Na-140 K-3.7 Cl-100 HCO3-25 AnGap-19 ___ 04:47AM BLOOD Glucose-130* UreaN-50* Creat-1.5* Na-137 K-3.4 Cl-99 HCO3-26 AnGap-15 ___ 09:46PM BLOOD Glucose-143* UreaN-69* Creat-1.6* Na-135 K-3.9 Cl-93* HCO3-30 AnGap-16 ___ 09:30AM BLOOD Lactate-1.2 ___ 06:38AM BLOOD O2 Sat-67 ___ 09:30AM BLOOD O2 Sat-50 DISCHARGE LABS: ================= ___ 05:24AM BLOOD Glucose-94 UreaN-68* Creat-1.5* Na-137 K-3.3 Cl-93* HCO3-29 AnGap-18 ___ 05:24AM BLOOD Calcium-8.9 Phos-4.3 Mg-2.0 ___ 05:24AM BLOOD WBC-5.5 RBC-3.18* Hgb-10.8* Hct-33.8* MCV-106* MCH-34.0* MCHC-32.0 RDW-14.9 RDWSD-58.0* Plt ___ CXR (___): IMPRESSION: Moderate cardiomegaly without congestive heart failure. Brief Hospital Course: ___ yo male with PMH significant for mixed ischemic/senile amyloid cardiomyopathy, HFrEF (EF 22%), coronary artery disease s/p PCI to LAD, atrial fibrillation, and history of high degree AV block s/p biventricular pacemaker, recent hospitalization with decompensated ___ who presented with with increased dyspnea. # I50.42 Chronic combined systolic and diastolic heart failure # Acute on Chronic Heart Failure with Reduced Ejection Fraction # Mixed Ischemic and Amyloid Cardiomyopathy Pt re-presented with dyspnea/fatigue, elevated BNP (higher than previous admissions), thought to be in a low output state. He was given inotrope support with dobutamine 2.5 mcg/kg/min (dosed at a weight of 73 kg) to augment output to result in lower JVP and his symptoms improved. His was initially given 40 Lasix IV, then transitioned to PO toresemide 100 daily BID at discharge. Also required additional doses of metolazone for diuresis. Responded very briskly to 2.5 mg so was decided that he should take 1.25 mg of metolazone every second or third day. Prescribed daily KCl repletion with 40 mEq BID on days in which he only received torsemide 100 mg BID and 40 TID on days in which he receives torsemide + metolazone days. Also started on spironolactone 12.5 daily. #Home Support The patient was accepted by ___ service. He will be assigned ___ home ___ and ___ worker. The patient will be confined to his home for the next ___ weeks and will have Meals on Wheels Delivered. # Acute on chronic renal failure: thought to be a result of low cardiac output. Cr remained stable around 1.4-1.6 with dobutamine and diuresis CHRONIC ISSUES: =============== # Coronary artery disease: s/p DES x1 to LAD (___)- aspirin was continued, and the pt was started on rosuvastatin 10 QPM. # Hyperlipidemia: Rosuvastatin was restarted during this hospitalization, as above. # Atrial fibrillation: Home apixiban 5 mg BID was continued. # Diabetes Mellitus type II: Patient was started on ISS and metformin was on hold. Can resume metformin at discharge. TRANSITIONAL ISSUES: ================== -Medications added: 1. dobutamine 2.5 mcg/kg/min infusion, based on weight of 73 kg 2. rosuvastatin 10 mg nightly 3. metolazone 1.25 mg every second or third day depending on patient's weight, to be coordinated by ___ service and Cardiologist. 4. spironolactone 12.5 mg daily -Medications stopped: none -Medications changed: 1. torsemide 60 mg QAM, 40 mg QPM -> torsemide 100 BID 2. Potassium Chloride 60 mEq PO DAILY -> Potassium Chloride 40 mEq PO BID on torsemide days, and 40 mEq PO TID on torsemide+metolazone days. -Discharge weight: 69.4 kg- 153 pounds (PLEASE NOTE THAT THE DOSE OF THE DOBUTAMINE SHOULD BE DOSED FOR A WEIGHT OF 73 KILOGRAMS AS DESCRIBED ABOVE). -Creatinine at the time of discharge 1.5. [ ] follow up LFT's, CBC, chemistry as outpatient [ ] if patient remains anemic as outpatient, please perform anemia workup. [ ] coordinate set up with Care ___ service for dobutamine drip education and monitoring [ ] f/u with ___ (Heart failure) on ___ [ ] f/u with Dr. ___ within 2 weeks for heart failure [ ] Patient cannot drive while on dobutamine due to arrhythmia risk with inotropes [ ] discuss a schedule for metolazone. If taking metolazone, discuss a potassium supplementation regimen patient should be on. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Apixaban 5 mg PO BID 2. Aspirin 81 mg PO DAILY 3. Ferrous Sulfate 325 mg PO BID 4. Torsemide 60 mg PO QAM 5. MetFORMIN (Glucophage) 500 mg PO BID 6. Torsemide 40 mg PO QPM 7. Potassium Chloride 60 mEq PO BID Discharge Medications: 1. DOBUTamine 2.5 mcg/kg/min IV DRIP INFUSION RX *dobutamine 250 mg/20 mL (12.5 mg/mL) 2.5 mcg/kg/min intravenous continuous infusion Disp #*30 Vial Refills:*50 2. Metolazone 1.25 mg PO AS DIRECTED BY YOUR CARDIOLOGIST RX *metolazone 2.5 mg 0.5 (One half) tablet(s) by mouth as directed by your cardiologist Disp #*5 Tablet Refills:*0 3. Potassium Chloride 40 mEq PO TID WHEN YOU TAKE A DOSE OF METOLAZONE Hold for K > 4.5 RX *potassium chloride 20 mEq 2 tablet(s) by mouth three times a day Disp #*56 Tablet Refills:*0 4. Rosuvastatin Calcium 10 mg PO QPM RX *rosuvastatin 10 mg 1 tablet(s) by mouth every night Disp #*28 Tablet Refills:*0 5. Spironolactone 12.5 mg PO DAILY RX *spironolactone 25 mg 0.5 (One half) tablet(s) by mouth daily Disp #*14 Tablet Refills:*0 6. Potassium Chloride 40 mEq PO BID RX *potassium chloride 20 mEq 2 tablet(s) by mouth twice a day. Disp #*112 Tablet Refills:*0 7. Torsemide 100 mg PO BID RX *torsemide 100 mg 1 tablet(s) by mouth twice a day Disp #*56 Tablet Refills:*0 8. Apixaban 5 mg PO BID RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day Disp #*56 Tablet Refills:*0 9. Aspirin 81 mg PO DAILY 10. Ferrous Sulfate 325 mg PO BID 11. MetFORMIN (Glucophage) 500 mg PO BID Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY ======= Acute on Chronic Systolic and Diastolic Heart Failure Mixed Ischemic and Amyloid Cardiomyopathy SECONDARY ========= Coronary Artery Disease Atrial Fibrillation Chronic Kidney Disease Hypertension Hyperlipidemia Diabetes Mellitus type II 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 ___ because you had a heart failure exacerbation. You were treated with water pills to get rid of the extra fluid in your lungs, and you were put on a continuous ("drip") medication called dobutamine that helps your heart pump blood to your organs more effectively. It is very important to take all of your heart healthy medications, including aspirin, rosuvastatin, torsemide and dobutamine. Please do not stop any of these medications without talking to your Cardiologist first. You will also need to have close follow up with your heart doctor and your primary care doctor. For your water pill medication, you will require torsemide EVERY DAY. Please take torsemide 100 milligrams EVERY 12 HOURS. You will require potassium supplementation with potassium chloride 40 milliequivalents TWICE on those days. On certain days you will require a medication called metolazone (this will be given in addition to the standing torsemide dose you take). You may require the metolazone once every three days, however this will need to be discussed at your next Cardiology appointment. Please do not take the metolazone until you have your follow up appointment in the heart failure clinic. The dose of the metolazone and the schedule of the metolazone will be discussed at your next visit. If they recommend that you take the metolazone in addition to the torsemide (as described above) on certain days, the amount of potassium supplementation will be 40 milliequivalents of potassium chloride THREE TIMES on the days you take the metolazone. Since you are on dobutamine, you CANNOT DRIVE, as there are risks associated with developing arrhythmias which can lead to motor vehicle accidents. 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 the time of discharge was 153 pounds. It was a pleasure to take care of you. We wish you the best with your health! Your ___ Cardiac Care Team Followup Instructions: ___
[ "I130", "I5043", "N179", "E854", "I255", "I43", "I081", "I2510", "E785", "E119", "I4891", "I129", "Z950", "Z955", "N183", "Z7902", "Z66" ]
Allergies: Lipitor / Atenolol Chief Complaint: dyspnea on exertion Major Surgical or Invasive Procedure: PICC Line placement. History of Present Illness: [MASKED] yo male with PMH significant for mixed ischemic/senile amyloid cardiomyopathy, HFrEF (EF 22%), coronary artery disease s/p PCI to LAD, atrial fibrillation, and history of high degree AV block s/p biventricular pacemaker, recent hospitalization with decompensated [MASKED] presenting with increased dyspnea and fatigue. Patient was admitted with fatigue and dyspnea, decompensated possibly in the setting of increased Afib burden vs excessive fluid intake vs progression of advanced CHF. It was also thought that some of his symptoms were actually related to his pacer since after his BiV pacer setting was increased to 95, he had significant symptom resolution. Discharge weight was 72.6kg. Per report, since discharge, pt has had dyspnea and overall fatigue that has been worsening. He has not noted any weight gain or edema. He has some orthopnea but is primarily dyspnea on exertion. He denies any chest pain. Denies any fever chills or cough. He does endorse some heaviness in his legs. He was seen in clinic on [MASKED] and was found to be volume overloaded, and recommended admission, but he declined. Was discharged from clinic on increased dose of 60mg QAM and 40mg QPM. However, he presented to ED today due to worsening symptoms. In the ED initial vitals were: 84/62 95 afebrile 96RA. EKG: Afib, V-paced Labs/studies notable for: CKMB 13/trop .12, repeat trop .1. Na 131. Cr 2.2(2 on [MASKED], on discharge on [MASKED] BNP [MASKED] 13000s), lactate 2.6. Patient was given: asp 325 Vitals on transfer: [MASKED] On the floor, pt appears comfortable. Denies any SOB/CP/abdominal pain while sitting. Past Medical History: Coronary artery disease s/p DES x1 to LAD ([MASKED]) systolic heart failure EF 30% TTR amyloid Hypertension Hyperlipidemia Atrial fibrillation Lumbar spinal stenosis Diabetes mellitus 2 Chronic kidney disease stage III Social History: [MASKED] Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Physical Exam: ADMISSION PHYSICAL EXAM: ==================== VS: afebrile 97/62 96 18 96RA Wt 73kg, dry weight 72.6kg GENERAL: Appears comfortable and can have a full conversation. Oriented x3. Mood, affect appropriate. HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. Conjunctiva were pink. No pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple. JVP 15cm, above angle of jaw. CARDIAC: Irregularly irregular. Normal S1, S2. No murmurs, rubs, or gallops. LUNGS: clear to auscultation bilaterally ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No splenomegaly. EXTREMITIES: cool to touch upper and lower extremities SKIN: No significant skin lesions or rashes. PULSES: Distal pulses palpable and symmetric. DISCHARGE PHYSICAL EXAM: ======================== Vitals: 98, 90-100/61-66, 95, [MASKED], 100% on RA. I/O= [MASKED] on [MASKED]. 1624/2200 on [MASKED]. 2284/3050 on [MASKED]. 1864/6150 on [MASKED], 1560/4630 on [MASKED], 2150/4150 [MASKED], [MASKED] [MASKED] from 12a-8a Weight: 69.4 < 70.3 < 71.1 < 70.7 < 75.8 < 75.4 < 73.3 < 74.0 < 73.2 < 71.8 kg on [MASKED] (73.0 kg on admission) GENERAL: Alert and oriented x 3, pleasant, comfortable HEENT: Normocephalic atraumatic. Sclera anicteric. NECK: Supple. JVP 11 cm, +HJR CARDIAC: regular rate and rhythm, Normal S1, S2. No murmurs, rubs, or gallops. LUNGS: CTAB ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No splenomegaly. EXTREMITIES: warm, wp, no [MASKED] edema SKIN: No significant skin lesions or rashes. PULSES: Distal pulses palpable and symmetric. Pertinent Results: ADMISSION LABS: ================ [MASKED] 01:22PM BLOOD WBC-4.1 RBC-3.89* Hgb-13.4* Hct-41.6 MCV-107* MCH-34.4* MCHC-32.2 RDW-15.7* RDWSD-61.7* Plt [MASKED] [MASKED] 01:22PM BLOOD Neuts-58.1 [MASKED] Monos-10.9 Eos-2.4 Baso-1.5* Im [MASKED] AbsNeut-2.40 AbsLymp-1.11* AbsMono-0.45 AbsEos-0.10 AbsBaso-0.06 [MASKED] 01:22PM BLOOD Glucose-73 UreaN-58* Creat-2.2* Na-131* K-4.6 Cl-92* HCO3-22 AnGap-22* [MASKED] 01:22PM BLOOD CK(CPK)-260 [MASKED] 01:22PM BLOOD CK-MB-13* MB Indx-5.0 [MASKED] [MASKED] 03:42PM BLOOD ALT-23 AST-35 LD(LDH)-360* AlkPhos-138* TotBili-2.4* [MASKED] 01:45PM BLOOD [MASKED] Comment-GREEN TOP [MASKED] 01:45PM BLOOD Lactate-2.6* [MASKED] 02:06PM BLOOD Lactate-2.1* OTHER RELEVANT LABS: ================== [MASKED] 04:50AM BLOOD WBC-3.4* RBC-3.44* Hgb-11.6* Hct-36.8* MCV-107* MCH-33.7* MCHC-31.5* RDW-15.4 RDWSD-60.5* Plt [MASKED] [MASKED] 05:42AM BLOOD WBC-4.5 RBC-3.28* Hgb-11.2* Hct-35.4* MCV-108* MCH-34.1* MCHC-31.6* RDW-15.2 RDWSD-60.9* Plt [MASKED] [MASKED] 01:00PM BLOOD Glucose-101* UreaN-51* Creat-1.7* Na-137 K-3.9 Cl-97 HCO3-26 AnGap-18 [MASKED] 03:00PM BLOOD Glucose-165* UreaN-44* Creat-1.5* Na-137 K-3.7 Cl-98 HCO3-27 AnGap-16 [MASKED] 04:50AM BLOOD ALT-21 AST-30 LD(LDH)-325* AlkPhos-137* TotBili-2.1* [MASKED] 05:42AM BLOOD ALT-19 AST-28 LD(LDH)-277* AlkPhos-133* TotBili-1.9* [MASKED] 01:22PM BLOOD cTropnT-0.12* [MASKED] 03:42PM BLOOD cTropnT-0.10* [MASKED] 02:06PM BLOOD Lactate-2.1* [MASKED] 06:26AM BLOOD Lactate-1.0 [MASKED] 05:00AM BLOOD Glucose-78 UreaN-40* Creat-1.7* Na-140 K-3.7 Cl-100 HCO3-25 AnGap-19 [MASKED] 04:47AM BLOOD Glucose-130* UreaN-50* Creat-1.5* Na-137 K-3.4 Cl-99 HCO3-26 AnGap-15 [MASKED] 09:46PM BLOOD Glucose-143* UreaN-69* Creat-1.6* Na-135 K-3.9 Cl-93* HCO3-30 AnGap-16 [MASKED] 09:30AM BLOOD Lactate-1.2 [MASKED] 06:38AM BLOOD O2 Sat-67 [MASKED] 09:30AM BLOOD O2 Sat-50 DISCHARGE LABS: ================= [MASKED] 05:24AM BLOOD Glucose-94 UreaN-68* Creat-1.5* Na-137 K-3.3 Cl-93* HCO3-29 AnGap-18 [MASKED] 05:24AM BLOOD Calcium-8.9 Phos-4.3 Mg-2.0 [MASKED] 05:24AM BLOOD WBC-5.5 RBC-3.18* Hgb-10.8* Hct-33.8* MCV-106* MCH-34.0* MCHC-32.0 RDW-14.9 RDWSD-58.0* Plt [MASKED] CXR ([MASKED]): IMPRESSION: Moderate cardiomegaly without congestive heart failure. Brief Hospital Course: [MASKED] yo male with PMH significant for mixed ischemic/senile amyloid cardiomyopathy, HFrEF (EF 22%), coronary artery disease s/p PCI to LAD, atrial fibrillation, and history of high degree AV block s/p biventricular pacemaker, recent hospitalization with decompensated [MASKED] who presented with with increased dyspnea. # I50.42 Chronic combined systolic and diastolic heart failure # Acute on Chronic Heart Failure with Reduced Ejection Fraction # Mixed Ischemic and Amyloid Cardiomyopathy Pt re-presented with dyspnea/fatigue, elevated BNP (higher than previous admissions), thought to be in a low output state. He was given inotrope support with dobutamine 2.5 mcg/kg/min (dosed at a weight of 73 kg) to augment output to result in lower JVP and his symptoms improved. His was initially given 40 Lasix IV, then transitioned to PO toresemide 100 daily BID at discharge. Also required additional doses of metolazone for diuresis. Responded very briskly to 2.5 mg so was decided that he should take 1.25 mg of metolazone every second or third day. Prescribed daily KCl repletion with 40 mEq BID on days in which he only received torsemide 100 mg BID and 40 TID on days in which he receives torsemide + metolazone days. Also started on spironolactone 12.5 daily. #Home Support The patient was accepted by [MASKED] service. He will be assigned [MASKED] home [MASKED] and [MASKED] worker. The patient will be confined to his home for the next [MASKED] weeks and will have Meals on Wheels Delivered. # Acute on chronic renal failure: thought to be a result of low cardiac output. Cr remained stable around 1.4-1.6 with dobutamine and diuresis CHRONIC ISSUES: =============== # Coronary artery disease: s/p DES x1 to LAD ([MASKED])- aspirin was continued, and the pt was started on rosuvastatin 10 QPM. # Hyperlipidemia: Rosuvastatin was restarted during this hospitalization, as above. # Atrial fibrillation: Home apixiban 5 mg BID was continued. # Diabetes Mellitus type II: Patient was started on ISS and metformin was on hold. Can resume metformin at discharge. TRANSITIONAL ISSUES: ================== -Medications added: 1. dobutamine 2.5 mcg/kg/min infusion, based on weight of 73 kg 2. rosuvastatin 10 mg nightly 3. metolazone 1.25 mg every second or third day depending on patient's weight, to be coordinated by [MASKED] service and Cardiologist. 4. spironolactone 12.5 mg daily -Medications stopped: none -Medications changed: 1. torsemide 60 mg QAM, 40 mg QPM -> torsemide 100 BID 2. Potassium Chloride 60 mEq PO DAILY -> Potassium Chloride 40 mEq PO BID on torsemide days, and 40 mEq PO TID on torsemide+metolazone days. -Discharge weight: 69.4 kg- 153 pounds (PLEASE NOTE THAT THE DOSE OF THE DOBUTAMINE SHOULD BE DOSED FOR A WEIGHT OF 73 KILOGRAMS AS DESCRIBED ABOVE). -Creatinine at the time of discharge 1.5. [ ] follow up LFT's, CBC, chemistry as outpatient [ ] if patient remains anemic as outpatient, please perform anemia workup. [ ] coordinate set up with Care [MASKED] service for dobutamine drip education and monitoring [ ] f/u with [MASKED] (Heart failure) on [MASKED] [ ] f/u with Dr. [MASKED] within 2 weeks for heart failure [ ] Patient cannot drive while on dobutamine due to arrhythmia risk with inotropes [ ] discuss a schedule for metolazone. If taking metolazone, discuss a potassium supplementation regimen patient should be on. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Apixaban 5 mg PO BID 2. Aspirin 81 mg PO DAILY 3. Ferrous Sulfate 325 mg PO BID 4. Torsemide 60 mg PO QAM 5. MetFORMIN (Glucophage) 500 mg PO BID 6. Torsemide 40 mg PO QPM 7. Potassium Chloride 60 mEq PO BID Discharge Medications: 1. DOBUTamine 2.5 mcg/kg/min IV DRIP INFUSION RX *dobutamine 250 mg/20 mL (12.5 mg/mL) 2.5 mcg/kg/min intravenous continuous infusion Disp #*30 Vial Refills:*50 2. Metolazone 1.25 mg PO AS DIRECTED BY YOUR CARDIOLOGIST RX *metolazone 2.5 mg 0.5 (One half) tablet(s) by mouth as directed by your cardiologist Disp #*5 Tablet Refills:*0 3. Potassium Chloride 40 mEq PO TID WHEN YOU TAKE A DOSE OF METOLAZONE Hold for K > 4.5 RX *potassium chloride 20 mEq 2 tablet(s) by mouth three times a day Disp #*56 Tablet Refills:*0 4. Rosuvastatin Calcium 10 mg PO QPM RX *rosuvastatin 10 mg 1 tablet(s) by mouth every night Disp #*28 Tablet Refills:*0 5. Spironolactone 12.5 mg PO DAILY RX *spironolactone 25 mg 0.5 (One half) tablet(s) by mouth daily Disp #*14 Tablet Refills:*0 6. Potassium Chloride 40 mEq PO BID RX *potassium chloride 20 mEq 2 tablet(s) by mouth twice a day. Disp #*112 Tablet Refills:*0 7. Torsemide 100 mg PO BID RX *torsemide 100 mg 1 tablet(s) by mouth twice a day Disp #*56 Tablet Refills:*0 8. Apixaban 5 mg PO BID RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day Disp #*56 Tablet Refills:*0 9. Aspirin 81 mg PO DAILY 10. Ferrous Sulfate 325 mg PO BID 11. MetFORMIN (Glucophage) 500 mg PO BID Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: PRIMARY ======= Acute on Chronic Systolic and Diastolic Heart Failure Mixed Ischemic and Amyloid Cardiomyopathy SECONDARY ========= Coronary Artery Disease Atrial Fibrillation Chronic Kidney Disease Hypertension Hyperlipidemia Diabetes Mellitus type II Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], You were admitted to [MASKED] because you had a heart failure exacerbation. You were treated with water pills to get rid of the extra fluid in your lungs, and you were put on a continuous ("drip") medication called dobutamine that helps your heart pump blood to your organs more effectively. It is very important to take all of your heart healthy medications, including aspirin, rosuvastatin, torsemide and dobutamine. Please do not stop any of these medications without talking to your Cardiologist first. You will also need to have close follow up with your heart doctor and your primary care doctor. For your water pill medication, you will require torsemide EVERY DAY. Please take torsemide 100 milligrams EVERY 12 HOURS. You will require potassium supplementation with potassium chloride 40 milliequivalents TWICE on those days. On certain days you will require a medication called metolazone (this will be given in addition to the standing torsemide dose you take). You may require the metolazone once every three days, however this will need to be discussed at your next Cardiology appointment. Please do not take the metolazone until you have your follow up appointment in the heart failure clinic. The dose of the metolazone and the schedule of the metolazone will be discussed at your next visit. If they recommend that you take the metolazone in addition to the torsemide (as described above) on certain days, the amount of potassium supplementation will be 40 milliequivalents of potassium chloride THREE TIMES on the days you take the metolazone. Since you are on dobutamine, you CANNOT DRIVE, as there are risks associated with developing arrhythmias which can lead to motor vehicle accidents. 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 the time of discharge was 153 pounds. It was a pleasure to take care of you. We wish you the best with your health! Your [MASKED] Cardiac Care Team Followup Instructions: [MASKED]
[]
[ "I130", "N179", "I2510", "E785", "E119", "I4891", "I129", "Z955", "Z7902", "Z66" ]
[ "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I5043: Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure", "N179: Acute kidney failure, unspecified", "E854: Organ-limited amyloidosis", "I255: Ischemic cardiomyopathy", "I43: Cardiomyopathy in diseases classified elsewhere", "I081: Rheumatic disorders of both mitral and tricuspid valves", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E785: Hyperlipidemia, unspecified", "E119: Type 2 diabetes mellitus without complications", "I4891: Unspecified atrial fibrillation", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "Z950: Presence of cardiac pacemaker", "Z955: Presence of coronary angioplasty implant and graft", "N183: Chronic kidney disease, stage 3 (moderate)", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "Z66: Do not resuscitate" ]
19,993,951
25,021,512
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Lipitor / Atenolol Attending: ___. Chief Complaint: Edema, Dyspnea on Exertion Major Surgical or Invasive Procedure: - cardiac catheterization with endomyocardial biopsy (___) History of Present Illness: Mr. ___ is a ___ y/o man with a PMH of atrial fibrillation (on dabigatran), CHF/cardiomyopathy (LVEF 24%), HTN, CAD, who presented with 1 week of progressive dyspnea on exertion, fatigue, and cough. He reports worsening fatigue and dyspnea associated with climbing stairs, hills or walking. He now notes that he has to use a walker, which he says he has not used in a long time. Reports increased dry cough during this period and 4 pillow orthopnea (he says that he has been having this for ___ months), without PND. He denies any history of dietary indiscretion, any medication changes, chest pain, or signs and symptoms of infection. He was seen in clinic today, where he was found to have a BP 90/70 mmHg, HR in the ___, with edema, cool extremities. EKG showed known atrial fibrillation with low voltage, and he was referred to the ED for concern for acute decompensated heart failure and low output state. ED COURSE In the ED intial vitals were: T 97.9F BP 147/97 P 60 RR 26 O2 98% RA Labs/studies notable for: Na 131, K 4.3, Cl 101, HCO3 15, BUN 31, Cr 1.4, Gluc 73. CK 286, MB 21, MBI 7.3. Ca 8.6, Mg 2.0, P 3.5, ALT 18, AST 30, Alk phos 106, Tbili 1.8, Alb 3.9. proBNP of 54___. UA was negative. Lactate 2.3. Trop-T 0.07. Exam notable for JVD, irregularly irregular cardiac exam without murmurs, mildly distended abdomen with no tenderness to palpation, 3+ lower extremity edema, and cool extremities. Patient was given: ___ 14:10 IV Furosemide 20 mg ___ 17:00 IV Furosemide 40 mg Vitals on transfer: P 81 BP 116/73 mmHg RR 18 O2 97% RA POC ultrasound demonstrated: Bilateral pleural effusions, intraperitoneal fluid. No pericardial effusion. CXR notable for cardiomegaly. Past Medical History: Hypertension Hyperlipidemia Atrial fibrillation Lumbar spinal stenosis Diabetes mellitus Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: =============== ADMISSION EXAM: =============== Weight: 212 lbs (ED) VS: BP 122/86 mmHg P 40 RR 18 O2 100% RA General: Well appearing man, in NAD. Mood, affected appropriate. HEENT: Sclerae anicteric. EOMs intact. OP clear. Neck: Supple. JVP elevated above clavicle while seated upright. EJ prominent. CV: Bradycardic, regular, normal S1/S2. No MRGs. Pulm: CTA b/l; no wheezes, rhonchi, or rales. Abd: Soft, non-tender, non-distended. NABS. Ext: 2+ pitting edema up to mid thigh. Cool to touch. 2+ pulses. Neuro: A&Ox3. CNs II-XII grossly intact. Full strength in upper and lower extremities b/l. . =============== DISCHARGE EXAM: =============== Weight: 78.1 <-- 77.3 kg VS: 97.8 60 100/64 16 100% RA General: Well appearing man, in NAD. Mood, affect appropriate. HEENT: Sclerae anicteric. EOMs intact. OP clear. Neck: Supple. JVP elevated to jaw at 45 degrees but disappears upright. CV: Irregular, normal S1/S2. No MRGs. Pulm: CTA b/l; no wheezes, rhonchi, or rales. Abd: Soft, non-tender, non-distended. NABS. Ext: 1+ edema in feet b/l. Extremities warm. Distal pulses difficult to assess given edema. Neuro: A&Ox3. CNs II-XII grossly intact. Full strength in upper and lower extremities b/l. Pertinent Results: =============== ADMISSION LABS: =============== ___ 12:00PM ___ PTT-55.0* ___ ___ 12:00PM PLT COUNT-203 ___ 12:00PM NEUTS-59.9 ___ MONOS-12.2 EOS-1.3 BASOS-1.3* NUC RBCS-0.4* IM ___ AbsNeut-2.68 AbsLymp-1.12* AbsMono-0.55 AbsEos-0.06 AbsBaso-0.06 ___ 12:00PM WBC-4.5 RBC-3.38* HGB-9.8* HCT-32.1* MCV-95# MCH-29.0# MCHC-30.5* RDW-16.7* RDWSD-57.6* ___ 12:00PM ALBUMIN-3.9 CALCIUM-8.6 PHOSPHATE-3.5 MAGNESIUM-2.0 ___ 12:00PM CK-MB-21* MB INDX-7.3* proBNP-5469* ___ 12:00PM cTropnT-0.07* ___ 12:00PM ALT(SGPT)-18 AST(SGOT)-30 CK(CPK)-286 ALK PHOS-106 TOT BILI-1.8* ___ 12:00PM estGFR-Using this ___ 12:00PM GLUCOSE-73 UREA N-31* CREAT-1.4* SODIUM-131* POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-15* ANION GAP-19 ___ 12:59PM LACTATE-2.3* ___ 01:40PM URINE MUCOUS-RARE ___ 01:40PM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE EPI-0 ___ 01:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.0 LEUK-NEG ___ 01:40PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 01:40PM URINE GR HOLD-HOLD ___ 01:40PM URINE UHOLD-HOLD ___ 01:40PM URINE HOURS-RANDOM ___ 01:40PM URINE HOURS-RANDOM ___ 03:42PM cTropnT-0.08* ___ 09:10PM PLT COUNT-214 ___ 09:10PM WBC-3.9* RBC-3.67* HGB-10.7* HCT-35.0* MCV-95 MCH-29.2 MCHC-30.6* RDW-16.7* RDWSD-57.9* ___ 09:10PM TSH-2.3 ___ 09:10PM calTIBC-451 FERRITIN-32 TRF-347 ___ 09:10PM TOT PROT-6.9 CALCIUM-9.1 MAGNESIUM-2.1 IRON-26* ___ 09:10PM GLUCOSE-114* UREA N-32* CREAT-1.5* SODIUM-134 POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-17* ANION GAP-21* ___ 09:20PM LACTATE-2.1* ___ 10:46PM URINE HOURS-RANDOM TOT PROT-<6 . ============= INTERIM LABS: ============= ___ 05:25AM BLOOD WBC-4.4 RBC-3.36* Hgb-9.4* Hct-31.0* MCV-92 MCH-28.0 MCHC-30.3* RDW-16.5* RDWSD-55.7* Plt ___ ___ 05:25AM BLOOD WBC-5.2 RBC-3.21* Hgb-9.0* Hct-29.6* MCV-92 MCH-28.0 MCHC-30.4* RDW-16.7* RDWSD-55.0* Plt ___ ___ 07:50PM BLOOD PTT-30.0 ___ 10:06PM BLOOD PTT-69.3* ___ 05:25AM BLOOD ___ PTT-48.9* ___ ___ 03:25PM BLOOD Glucose-114* UreaN-34* Creat-1.5* Na-136 K-4.0 Cl-102 HCO3-19* AnGap-19 ___ 03:20PM BLOOD Glucose-88 UreaN-42* Creat-1.4* Na-138 K-3.8 Cl-100 HCO3-24 AnGap-18 ___ 05:25AM BLOOD Glucose-100 UreaN-55* Creat-1.7* Na-134 K-4.5 Cl-95* HCO3-30 AnGap-14 ___ 08:45AM BLOOD LD(___)-307* DirBili-1.0* ___ 05:25AM BLOOD ALT-15 AST-27 LD(LDH)-288* AlkPhos-105 TotBili-1.3 ___ 12:00PM BLOOD cTropnT-0.07* ___ 03:42PM BLOOD cTropnT-0.08* ___ 05:25AM BLOOD Calcium-8.9 Phos-3.7 Mg-1.9 ___ 05:25PM BLOOD Calcium-9.3 Phos-5.2* Mg-2.2 ___ 09:10PM BLOOD %HbA1c-5.5 eAG-111 ___ 08:45AM BLOOD FreeKap-39.3* FreeLam-27.8* Fr K/L-1.42 ___ 09:20AM BLOOD Lactate-1.9 ___ 06:07AM BLOOD Lactate-1.8 ___ 05:52AM BLOOD Lactate-1.3 . =============== DISCHARGE LABS: =============== ___ 05:35AM BLOOD WBC-5.3 RBC-3.09* Hgb-8.8* Hct-28.7* MCV-93 MCH-28.5 MCHC-30.7* RDW-17.0* RDWSD-55.8* Plt ___ ___ 05:35AM BLOOD Plt ___ ___ 05:35AM BLOOD Glucose-101* UreaN-40* Creat-1.5* Na-133 K-4.7 Cl-95* HCO3-27 AnGap-16 ___ 05:35AM BLOOD Calcium-8.7 Phos-3.1 Mg-2.3 . =============== IMAGING/STUDIES =============== CHEST (PA & LAT) (___): FINDINGS: PA and lateral views of the chest provided. Mild cardiomegaly is grossly unchanged from comparison study. There is no pneumothorax, effusion, or focal consolidation. There is no pulmonary interstitial edema or congestion. Imaged osseous structures are unremarkable. No free air below the right hemidiaphragm is seen. IMPRESSION: Cardiomegaly without pulmonary edema or other acute intrathoracic abnormality. ECHO (___): Findings This study was compared to the prior study of ___. LEFT ATRIUM: Moderate ___. RIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA. Normal interatrial septum. IVC dilated (>2.1cm) with <50% decrease with sniff (estimated RA pressure (>=15 mmHg). LEFT VENTRICLE: Severe symmetric LVH. Normal LV cavity size. [Intrinsic LV systolic function likely depressed given the severity of valvular regurgitation.] Estimated cardiac index is depressed (<2.0L/min/m2). No LV mass/thrombus. TDI E/e' >13, suggesting PCWP>18mmHg. No resting LVOT gradient. RIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free wall hypokinesis. [Intrinsic RV systolic function likely more depressed given the severity of TR]. Abnormal septal motion/position consistent with RV pressure/volume overload. Prominent moderator band/trabeculations are noted in the RV apex. AORTA: Mildy dilated aortic root. Mildly dilated ascending aorta. Mildly dilated aortic arch. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. AR vena contracta is <0.3cm. Mild (1+) AR. MITRAL VALVE: Normal mitral valve leaflets. No MVP. Moderate (2+) MR. ___ VALVE: Normal tricuspid valve leaflets. Moderate to severe [3+] TR. Given severity of TR, PASP may be underestimated due to elevated RA pressure. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. No PS. Mild PR. PERICARDIUM: Very small pericardial effusion. GENERAL COMMENTS: Ascites. Conclusions The left atrium is moderately dilated. The right atrium is markedly dilated. The estimated right atrial pressure is at least 15 mmHg. There is severe symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] LVEF = 50 %. The estimated cardiac index is depressed (<2.0L/min/m2). No masses or thrombi are seen in the left ventricle. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. Moderate to severe [3+] tricuspid regurgitation is seen. [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] There is a very small pericardial effusion. IMPRESSION: Marked symmetric left ventricular hypertrophy with normal cavity size and global hypokinesis. Mild right ventricular dilation and systolic dysfunction. Moderate to severe tricuspid regurgitation. Moderate mitral regurgitation. Increased PCWP and reduced cardiac index. Findings are suggestive of an infiltrative cardiomyopathy, such as amyloidosis. Compared with the prior study (images reviewed) of ___, the severity of mitral and tricuspid regurgitation has increased. Ascites is now present. CARDIAC CATHETERIZATION (___): Coronary Anatomy Dominance: Right * Left Main Coronary Artery The LMCA is normal * Left Anterior Descending The LAD has a widely patent proximal stent. There is otherwise minimal disease. The ___ Diagonal is a small vessel with 50% proximal disease * Circumflex The Circumflex is normal. * Right Coronary Artery The RCA has 90% stenosis just after the origin of a large normal acute marginal brsanch. Bejons this there is a long segment of severe disease with total occlusion in the proximal PDA branch. The PDA fills via left coronary collaterals Impressions: Upper normal PCW and PA pressures Occluded RCA ___ distal vessel filling via left coronary arteries. Patent LAD stent Successful RV endomyocardial biopsy - specimens to be reporeted by Pathology Recommendations Continued medical therapy PATHOLOGY: MYOCARDIUM, BIOPSY (___): Right ventricular endomyocardial biopsy: - AMYLOID HEART DISEASE. - ___ Red and Trichrome stains highlight the interstitial amyloid deposits. - Mild interstitial fibrosis (also highlighted by a Trichrome stain). - Specimen adequacy: Two fragments of myocardium and one fragment of fibrous tissue/blood clot. Brief Hospital Course: ___ y/o man with a PMH of T2DM, CAD s/p DESx1 to LAD in ___, persistent atrial fibrillation (on dabigatran), hypertension, and hyperlipidemia, who presented with acute decompensated heart failure (massive peripheral edema, 4 pillow orthopnea, cool extremities marked JVD, proBNP ___, lactate 2.3). . # Acute decompensated heart failure. Initially diuresed with IV furosemide 5 mg gtt to dry weight of 75.6 kg. EKG demonstrated coarse atrial fibrillation, rate of 62, Q waves in II, III, aVF, poor R wave progression, TTE demonstrated LVEF 50%, marked symmetric left ventricular hypertrophy with normal cavity size and global hypokinesis, with moderate to severe TR and moderate MR suggestive of infiltrative cardiomyopathy. Underwent cardiac catheterization which demonstrated occluded RCA with distal vessel filling via left coronary arteries and patient LAD stent. Right heart catheterization demonstrated pressures of RA: 6 mmHg, PA ___ mmHg, PCWP 13 mmHg, cardiac index 1.9. Underwent endomyocardial biopsy, which showed amyloid heart disease by ___ Red and Trichome stains. Etiology of his acute heart failure was therefore thought to be a mixed picture of ischemic and infiltrative. He was not treated with a beta blocker given heart rates in ___. He was subsequently transitioned to maintenance diuresis with 20 mg torsemide daily. No ACE inhibitors were started given that the etiology of his heart failure was likely amyloidosis. . # Atrial fibrillation. CHA2DS2-Vasc score of 6. He was switched from dabigatran to apixaban for anticoagulation. . # HLD. Switched from simvastatin to rosuvastatin 10 mg daily. . # T2DM. Home metformin was held, and he was placed on an insulin sliding scale. =================== TRANSITIONAL ISSUES =================== # Discharge weight: 78.1 kg # Discharge creatinine: 1.5 # Patient to have labs drawn on ___ with results forwarded to Dr. ___ at ___ service Ms. ___ and Dr. ___ ___, intern and attending on ___ service # Patient has follow up with PCP on following week; please have weight rechecked on this visit. If significant weight ___ consider titrating torsemide dose and contacting Dr. ___ ___ CHF attending on week of ___ and Dr. ___ # Medication changes: Aspirin reduced from full-dose to 81 mg daily. Started apixaban 5 mg daily. Started iron supplementation. Home lisinopril and spironolactone were stopped. Maintenance diuresis was started with 20 mg torsemide daily. -The patient's simvastatin was switched to rosuvastatin 10 mg daily # CODE: FULL # CONTACT: ___ (friend), ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Dabigatran Etexilate 150 mg PO BID 2. Furosemide 20 mg PO DAILY 3. Lisinopril 5 mg PO DAILY 4. MetFORMIN (Glucophage) 500 mg PO BID 5. Simvastatin 40 mg PO QPM 6. Spironolactone 12.5 mg PO DAILY 7. Aspirin 325 mg PO DAILY Discharge Medications: 1. Apixaban 5 mg PO BID RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 2. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 (one) tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. Ferrous Sulfate 325 mg PO BID RX *ferrous sulfate 325 mg (65 mg iron) 1 (one) tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. MetFORMIN (Glucophage) 500 mg PO BID 5. Rosuvastatin Calcium 10 mg PO QPM RX *rosuvastatin [Crestor] 10 mg 1 (one) tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 6. Torsemide 20 mg PO DAILY RX *torsemide 20 mg 1 (one) tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: ================= PRIMARY DIAGNOSES ================= - acute decompensated systolic heart failure - amyloidosis - atrial fibrillation =================== SECONDARY DIAGNOSES =================== - type 2 diabetes mellitus - hypertension - hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure caring for you at ___ ___. You were admitted with worsening heart failure. While you were here, we gave you diuretics, which are medications to help you urinate. First, we did this through your IV and then we switched you to an oral regimen. At discharge, you weighed 172 pounds. It is very important that you weigh yourself every morning before getting dressed and after going to the bathroom. Call your doctors if your ___ goes up by more than 3 lbs in 1 day or more than 5 lbs in 3 days. We wish you all the best! Warmly, Your ___ Cardiology team Followup Instructions: ___
[ "I5021", "E873", "E854", "I43", "I481", "I081", "Z7901", "I10", "I2510", "E785", "E119", "Z955" ]
Allergies: Lipitor / Atenolol Chief Complaint: Edema, Dyspnea on Exertion Major Surgical or Invasive Procedure: - cardiac catheterization with endomyocardial biopsy ([MASKED]) History of Present Illness: Mr. [MASKED] is a [MASKED] y/o man with a PMH of atrial fibrillation (on dabigatran), CHF/cardiomyopathy (LVEF 24%), HTN, CAD, who presented with 1 week of progressive dyspnea on exertion, fatigue, and cough. He reports worsening fatigue and dyspnea associated with climbing stairs, hills or walking. He now notes that he has to use a walker, which he says he has not used in a long time. Reports increased dry cough during this period and 4 pillow orthopnea (he says that he has been having this for [MASKED] months), without PND. He denies any history of dietary indiscretion, any medication changes, chest pain, or signs and symptoms of infection. He was seen in clinic today, where he was found to have a BP 90/70 mmHg, HR in the [MASKED], with edema, cool extremities. EKG showed known atrial fibrillation with low voltage, and he was referred to the ED for concern for acute decompensated heart failure and low output state. ED COURSE In the ED intial vitals were: T 97.9F BP 147/97 P 60 RR 26 O2 98% RA Labs/studies notable for: Na 131, K 4.3, Cl 101, HCO3 15, BUN 31, Cr 1.4, Gluc 73. CK 286, MB 21, MBI 7.3. Ca 8.6, Mg 2.0, P 3.5, ALT 18, AST 30, Alk phos 106, Tbili 1.8, Alb 3.9. proBNP of 54 . UA was negative. Lactate 2.3. Trop-T 0.07. Exam notable for JVD, irregularly irregular cardiac exam without murmurs, mildly distended abdomen with no tenderness to palpation, 3+ lower extremity edema, and cool extremities. Patient was given: [MASKED] 14:10 IV Furosemide 20 mg [MASKED] 17:00 IV Furosemide 40 mg Vitals on transfer: P 81 BP 116/73 mmHg RR 18 O2 97% RA POC ultrasound demonstrated: Bilateral pleural effusions, intraperitoneal fluid. No pericardial effusion. CXR notable for cardiomegaly. Past Medical History: Hypertension Hyperlipidemia Atrial fibrillation Lumbar spinal stenosis Diabetes mellitus Social History: [MASKED] Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: =============== ADMISSION EXAM: =============== Weight: 212 lbs (ED) VS: BP 122/86 mmHg P 40 RR 18 O2 100% RA General: Well appearing man, in NAD. Mood, affected appropriate. HEENT: Sclerae anicteric. EOMs intact. OP clear. Neck: Supple. JVP elevated above clavicle while seated upright. EJ prominent. CV: Bradycardic, regular, normal S1/S2. No MRGs. Pulm: CTA b/l; no wheezes, rhonchi, or rales. Abd: Soft, non-tender, non-distended. NABS. Ext: 2+ pitting edema up to mid thigh. Cool to touch. 2+ pulses. Neuro: A&Ox3. CNs II-XII grossly intact. Full strength in upper and lower extremities b/l. . =============== DISCHARGE EXAM: =============== Weight: 78.1 <-- 77.3 kg VS: 97.8 60 100/64 16 100% RA General: Well appearing man, in NAD. Mood, affect appropriate. HEENT: Sclerae anicteric. EOMs intact. OP clear. Neck: Supple. JVP elevated to jaw at 45 degrees but disappears upright. CV: Irregular, normal S1/S2. No MRGs. Pulm: CTA b/l; no wheezes, rhonchi, or rales. Abd: Soft, non-tender, non-distended. NABS. Ext: 1+ edema in feet b/l. Extremities warm. Distal pulses difficult to assess given edema. Neuro: A&Ox3. CNs II-XII grossly intact. Full strength in upper and lower extremities b/l. Pertinent Results: =============== ADMISSION LABS: =============== [MASKED] 12:00PM [MASKED] PTT-55.0* [MASKED] [MASKED] 12:00PM PLT COUNT-203 [MASKED] 12:00PM NEUTS-59.9 [MASKED] MONOS-12.2 EOS-1.3 BASOS-1.3* NUC RBCS-0.4* IM [MASKED] AbsNeut-2.68 AbsLymp-1.12* AbsMono-0.55 AbsEos-0.06 AbsBaso-0.06 [MASKED] 12:00PM WBC-4.5 RBC-3.38* HGB-9.8* HCT-32.1* MCV-95# MCH-29.0# MCHC-30.5* RDW-16.7* RDWSD-57.6* [MASKED] 12:00PM ALBUMIN-3.9 CALCIUM-8.6 PHOSPHATE-3.5 MAGNESIUM-2.0 [MASKED] 12:00PM CK-MB-21* MB INDX-7.3* proBNP-5469* [MASKED] 12:00PM cTropnT-0.07* [MASKED] 12:00PM ALT(SGPT)-18 AST(SGOT)-30 CK(CPK)-286 ALK PHOS-106 TOT BILI-1.8* [MASKED] 12:00PM estGFR-Using this [MASKED] 12:00PM GLUCOSE-73 UREA N-31* CREAT-1.4* SODIUM-131* POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-15* ANION GAP-19 [MASKED] 12:59PM LACTATE-2.3* [MASKED] 01:40PM URINE MUCOUS-RARE [MASKED] 01:40PM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE EPI-0 [MASKED] 01:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.0 LEUK-NEG [MASKED] 01:40PM URINE COLOR-Yellow APPEAR-Clear SP [MASKED] [MASKED] 01:40PM URINE GR HOLD-HOLD [MASKED] 01:40PM URINE UHOLD-HOLD [MASKED] 01:40PM URINE HOURS-RANDOM [MASKED] 01:40PM URINE HOURS-RANDOM [MASKED] 03:42PM cTropnT-0.08* [MASKED] 09:10PM PLT COUNT-214 [MASKED] 09:10PM WBC-3.9* RBC-3.67* HGB-10.7* HCT-35.0* MCV-95 MCH-29.2 MCHC-30.6* RDW-16.7* RDWSD-57.9* [MASKED] 09:10PM TSH-2.3 [MASKED] 09:10PM calTIBC-451 FERRITIN-32 TRF-347 [MASKED] 09:10PM TOT PROT-6.9 CALCIUM-9.1 MAGNESIUM-2.1 IRON-26* [MASKED] 09:10PM GLUCOSE-114* UREA N-32* CREAT-1.5* SODIUM-134 POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-17* ANION GAP-21* [MASKED] 09:20PM LACTATE-2.1* [MASKED] 10:46PM URINE HOURS-RANDOM TOT PROT-<6 . ============= INTERIM LABS: ============= [MASKED] 05:25AM BLOOD WBC-4.4 RBC-3.36* Hgb-9.4* Hct-31.0* MCV-92 MCH-28.0 MCHC-30.3* RDW-16.5* RDWSD-55.7* Plt [MASKED] [MASKED] 05:25AM BLOOD WBC-5.2 RBC-3.21* Hgb-9.0* Hct-29.6* MCV-92 MCH-28.0 MCHC-30.4* RDW-16.7* RDWSD-55.0* Plt [MASKED] [MASKED] 07:50PM BLOOD PTT-30.0 [MASKED] 10:06PM BLOOD PTT-69.3* [MASKED] 05:25AM BLOOD [MASKED] PTT-48.9* [MASKED] [MASKED] 03:25PM BLOOD Glucose-114* UreaN-34* Creat-1.5* Na-136 K-4.0 Cl-102 HCO3-19* AnGap-19 [MASKED] 03:20PM BLOOD Glucose-88 UreaN-42* Creat-1.4* Na-138 K-3.8 Cl-100 HCO3-24 AnGap-18 [MASKED] 05:25AM BLOOD Glucose-100 UreaN-55* Creat-1.7* Na-134 K-4.5 Cl-95* HCO3-30 AnGap-14 [MASKED] 08:45AM BLOOD LD([MASKED])-307* DirBili-1.0* [MASKED] 05:25AM BLOOD ALT-15 AST-27 LD(LDH)-288* AlkPhos-105 TotBili-1.3 [MASKED] 12:00PM BLOOD cTropnT-0.07* [MASKED] 03:42PM BLOOD cTropnT-0.08* [MASKED] 05:25AM BLOOD Calcium-8.9 Phos-3.7 Mg-1.9 [MASKED] 05:25PM BLOOD Calcium-9.3 Phos-5.2* Mg-2.2 [MASKED] 09:10PM BLOOD %HbA1c-5.5 eAG-111 [MASKED] 08:45AM BLOOD FreeKap-39.3* FreeLam-27.8* Fr K/L-1.42 [MASKED] 09:20AM BLOOD Lactate-1.9 [MASKED] 06:07AM BLOOD Lactate-1.8 [MASKED] 05:52AM BLOOD Lactate-1.3 . =============== DISCHARGE LABS: =============== [MASKED] 05:35AM BLOOD WBC-5.3 RBC-3.09* Hgb-8.8* Hct-28.7* MCV-93 MCH-28.5 MCHC-30.7* RDW-17.0* RDWSD-55.8* Plt [MASKED] [MASKED] 05:35AM BLOOD Plt [MASKED] [MASKED] 05:35AM BLOOD Glucose-101* UreaN-40* Creat-1.5* Na-133 K-4.7 Cl-95* HCO3-27 AnGap-16 [MASKED] 05:35AM BLOOD Calcium-8.7 Phos-3.1 Mg-2.3 . =============== IMAGING/STUDIES =============== CHEST (PA & LAT) ([MASKED]): FINDINGS: PA and lateral views of the chest provided. Mild cardiomegaly is grossly unchanged from comparison study. There is no pneumothorax, effusion, or focal consolidation. There is no pulmonary interstitial edema or congestion. Imaged osseous structures are unremarkable. No free air below the right hemidiaphragm is seen. IMPRESSION: Cardiomegaly without pulmonary edema or other acute intrathoracic abnormality. ECHO ([MASKED]): Findings This study was compared to the prior study of [MASKED]. LEFT ATRIUM: Moderate [MASKED]. RIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA. Normal interatrial septum. IVC dilated (>2.1cm) with <50% decrease with sniff (estimated RA pressure (>=15 mmHg). LEFT VENTRICLE: Severe symmetric LVH. Normal LV cavity size. [Intrinsic LV systolic function likely depressed given the severity of valvular regurgitation.] Estimated cardiac index is depressed (<2.0L/min/m2). No LV mass/thrombus. TDI E/e' >13, suggesting PCWP>18mmHg. No resting LVOT gradient. RIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free wall hypokinesis. [Intrinsic RV systolic function likely more depressed given the severity of TR]. Abnormal septal motion/position consistent with RV pressure/volume overload. Prominent moderator band/trabeculations are noted in the RV apex. AORTA: Mildy dilated aortic root. Mildly dilated ascending aorta. Mildly dilated aortic arch. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. AR vena contracta is <0.3cm. Mild (1+) AR. MITRAL VALVE: Normal mitral valve leaflets. No MVP. Moderate (2+) MR. [MASKED] VALVE: Normal tricuspid valve leaflets. Moderate to severe [3+] TR. Given severity of TR, PASP may be underestimated due to elevated RA pressure. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. No PS. Mild PR. PERICARDIUM: Very small pericardial effusion. GENERAL COMMENTS: Ascites. Conclusions The left atrium is moderately dilated. The right atrium is markedly dilated. The estimated right atrial pressure is at least 15 mmHg. There is severe symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] LVEF = 50 %. The estimated cardiac index is depressed (<2.0L/min/m2). No masses or thrombi are seen in the left ventricle. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. Moderate to severe [3+] tricuspid regurgitation is seen. [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] There is a very small pericardial effusion. IMPRESSION: Marked symmetric left ventricular hypertrophy with normal cavity size and global hypokinesis. Mild right ventricular dilation and systolic dysfunction. Moderate to severe tricuspid regurgitation. Moderate mitral regurgitation. Increased PCWP and reduced cardiac index. Findings are suggestive of an infiltrative cardiomyopathy, such as amyloidosis. Compared with the prior study (images reviewed) of [MASKED], the severity of mitral and tricuspid regurgitation has increased. Ascites is now present. CARDIAC CATHETERIZATION ([MASKED]): Coronary Anatomy Dominance: Right * Left Main Coronary Artery The LMCA is normal * Left Anterior Descending The LAD has a widely patent proximal stent. There is otherwise minimal disease. The [MASKED] Diagonal is a small vessel with 50% proximal disease * Circumflex The Circumflex is normal. * Right Coronary Artery The RCA has 90% stenosis just after the origin of a large normal acute marginal brsanch. Bejons this there is a long segment of severe disease with total occlusion in the proximal PDA branch. The PDA fills via left coronary collaterals Impressions: Upper normal PCW and PA pressures Occluded RCA [MASKED] distal vessel filling via left coronary arteries. Patent LAD stent Successful RV endomyocardial biopsy - specimens to be reporeted by Pathology Recommendations Continued medical therapy PATHOLOGY: MYOCARDIUM, BIOPSY ([MASKED]): Right ventricular endomyocardial biopsy: - AMYLOID HEART DISEASE. - [MASKED] Red and Trichrome stains highlight the interstitial amyloid deposits. - Mild interstitial fibrosis (also highlighted by a Trichrome stain). - Specimen adequacy: Two fragments of myocardium and one fragment of fibrous tissue/blood clot. Brief Hospital Course: [MASKED] y/o man with a PMH of T2DM, CAD s/p DESx1 to LAD in [MASKED], persistent atrial fibrillation (on dabigatran), hypertension, and hyperlipidemia, who presented with acute decompensated heart failure (massive peripheral edema, 4 pillow orthopnea, cool extremities marked JVD, proBNP [MASKED], lactate 2.3). . # Acute decompensated heart failure. Initially diuresed with IV furosemide 5 mg gtt to dry weight of 75.6 kg. EKG demonstrated coarse atrial fibrillation, rate of 62, Q waves in II, III, aVF, poor R wave progression, TTE demonstrated LVEF 50%, marked symmetric left ventricular hypertrophy with normal cavity size and global hypokinesis, with moderate to severe TR and moderate MR suggestive of infiltrative cardiomyopathy. Underwent cardiac catheterization which demonstrated occluded RCA with distal vessel filling via left coronary arteries and patient LAD stent. Right heart catheterization demonstrated pressures of RA: 6 mmHg, PA [MASKED] mmHg, PCWP 13 mmHg, cardiac index 1.9. Underwent endomyocardial biopsy, which showed amyloid heart disease by [MASKED] Red and Trichome stains. Etiology of his acute heart failure was therefore thought to be a mixed picture of ischemic and infiltrative. He was not treated with a beta blocker given heart rates in [MASKED]. He was subsequently transitioned to maintenance diuresis with 20 mg torsemide daily. No ACE inhibitors were started given that the etiology of his heart failure was likely amyloidosis. . # Atrial fibrillation. CHA2DS2-Vasc score of 6. He was switched from dabigatran to apixaban for anticoagulation. . # HLD. Switched from simvastatin to rosuvastatin 10 mg daily. . # T2DM. Home metformin was held, and he was placed on an insulin sliding scale. =================== TRANSITIONAL ISSUES =================== # Discharge weight: 78.1 kg # Discharge creatinine: 1.5 # Patient to have labs drawn on [MASKED] with results forwarded to Dr. [MASKED] at [MASKED] service Ms. [MASKED] and Dr. [MASKED] [MASKED], intern and attending on [MASKED] service # Patient has follow up with PCP on following week; please have weight rechecked on this visit. If significant weight [MASKED] consider titrating torsemide dose and contacting Dr. [MASKED] [MASKED] CHF attending on week of [MASKED] and Dr. [MASKED] # Medication changes: Aspirin reduced from full-dose to 81 mg daily. Started apixaban 5 mg daily. Started iron supplementation. Home lisinopril and spironolactone were stopped. Maintenance diuresis was started with 20 mg torsemide daily. -The patient's simvastatin was switched to rosuvastatin 10 mg daily # CODE: FULL # CONTACT: [MASKED] (friend), [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Dabigatran Etexilate 150 mg PO BID 2. Furosemide 20 mg PO DAILY 3. Lisinopril 5 mg PO DAILY 4. MetFORMIN (Glucophage) 500 mg PO BID 5. Simvastatin 40 mg PO QPM 6. Spironolactone 12.5 mg PO DAILY 7. Aspirin 325 mg PO DAILY Discharge Medications: 1. Apixaban 5 mg PO BID RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 2. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 (one) tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. Ferrous Sulfate 325 mg PO BID RX *ferrous sulfate 325 mg (65 mg iron) 1 (one) tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. MetFORMIN (Glucophage) 500 mg PO BID 5. Rosuvastatin Calcium 10 mg PO QPM RX *rosuvastatin [Crestor] 10 mg 1 (one) tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 6. Torsemide 20 mg PO DAILY RX *torsemide 20 mg 1 (one) tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: ================= PRIMARY DIAGNOSES ================= - acute decompensated systolic heart failure - amyloidosis - atrial fibrillation =================== SECONDARY DIAGNOSES =================== - type 2 diabetes mellitus - hypertension - hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], It was a pleasure caring for you at [MASKED] [MASKED]. You were admitted with worsening heart failure. While you were here, we gave you diuretics, which are medications to help you urinate. First, we did this through your IV and then we switched you to an oral regimen. At discharge, you weighed 172 pounds. It is very important that you weigh yourself every morning before getting dressed and after going to the bathroom. Call your doctors if your [MASKED] goes up by more than 3 lbs in 1 day or more than 5 lbs in 3 days. We wish you all the best! Warmly, Your [MASKED] Cardiology team Followup Instructions: [MASKED]
[]
[ "Z7901", "I10", "I2510", "E785", "E119", "Z955" ]
[ "I5021: Acute systolic (congestive) heart failure", "E873: Alkalosis", "E854: Organ-limited amyloidosis", "I43: Cardiomyopathy in diseases classified elsewhere", "I481: Persistent atrial fibrillation", "I081: Rheumatic disorders of both mitral and tricuspid valves", "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", "E119: Type 2 diabetes mellitus without complications", "Z955: Presence of coronary angioplasty implant and graft" ]
19,993,951
28,863,685
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Lipitor / Atenolol Attending: ___. Chief Complaint: Fall with trauma and ___ Major Surgical or Invasive Procedure: None. History of Present Illness: Mr. ___ is a ___ w/ systolic heart failure on dobutamine gtt, ischemic/amyloid cardiomyopathy, Afib on apixaban, and s/p BiV PPM for multilevel disease, coronary artery disease s/p DES x1 to LAD (___), DM2, CKD3, HTN, presenting after a fall. Patient states Was getting out of his car when he fell today. It is unclear if fall was mechanical or syncopal, he believes he was reaching for his cane but does not recall the events exactly. He fell forward and hit his face on the curb but denies LOC. No associated CP, SOB, palpitations. He has had oral bleeding since the injury. In the ED, initial vitals: T 97.5F, 94, 91/60, 18, 100%RA - Exam notable for: 3cm laceration to bridge of nose with hematoma, scattered abrasions to face, small stellate interior upper lip laceration not containing tooth. He is missing tooth 10. Tooth 8 and 9 are chipped. No C-spine tenderness or pain with ROM neck No chest wall tenderness. Ranging hips w/o discomfort. - Labs notable for: WBC 4.8, Hgb 11.4, Plt 126, Na 127, BUN/Cr 73/2.8 - Imaging notable for: CT Head w/o acute process, CXR w/ , CT Sinus/Mandible/Maxillofacial w/ ___ tooth 10 is not visualized. Suspected fractures seen through the tips of the roots ___ tooth numbers 24 and 25. No facial fracture. Soft tissue swelling overlying the nasal bridge and overlying the chin on the left without underlying fracture. - Patient given: KCl 40meQ, Torsemide 100mg qd, Metformin 500mg, Rosuvastatin 10mg, TDaP - His lip was sutured. - Vitals prior to transfer: 97.7F, 95, 96/68, 16, 100% RA He was admitted to cardiology for ___ (Cr 2.8 from 1.6) and for monitoring of oropharyngeal bleeding on eliquis which has been stable/resolved. Past Medical History: Coronary artery disease s/p DES x1 to LAD (___) Combined systolic and diastolic HF (EF 22%) on dobutamine gtt Mixed ischemic/senile amyloid cardiomyopathy TTR amyloid Hypertension Hyperlipidemia Atrial fibrillation on apixaban Infranodal AV disease with multilevel conduction disease s/p Bi-V pacemaker ___ Valitude ___ Lumbar spinal stenosis Diabetes mellitus 2 Chronic kidney disease stage III (Baseline Cr 1.4-1.6) - suspect due to low CO Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 97.7F, 95, 96/68, 16, 100% RA General: Alert, oriented, no acute distress HEENT: abrasion of forehead and lips with dried blood around mouth Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, no cyanosis or edema Skin: Without rashes or lesions Neuro: A&Ox3. Grossly intact. DISCHARGE PHYSICAL EXAM: Vitals: 98.0 ___ 80s-90s/___-70s 100%RA I/O= 2701/2925 Weight: 69.4 <-- 68.5 <-- 70.1 <-- 71.0<--72.2<--71.2<--70.5 <--71.9 <-- 70.2 Weight on admission: 69.0 Telemetry: V-paced General: Alert, oriented, no acute distress HEENT: abrasion of forehead and lips with dried blood around mouth Neck: JVP to mid-neck at 90 degrees Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm lower extremities from shin down, no clubbing or edema. Skin: Without rashes or lesions Neuro: A&Ox3. Grossly intact. Pertinent Results: ====================================== ADMISSION/IMPORTANT LABS ====================================== ___ 10:15PM BLOOD WBC-4.8 RBC-3.38* Hgb-11.4* Hct-35.0* MCV-104* MCH-33.7* MCHC-32.6 RDW-16.0* RDWSD-61.0* Plt ___ ___ 10:15PM BLOOD Neuts-69.5 Lymphs-18.2* Monos-9.0 Eos-1.7 Baso-1.0 NRBC-0.6* Im ___ AbsNeut-3.33 AbsLymp-0.87* AbsMono-0.43 AbsEos-0.08 AbsBaso-0.05 ___ 10:15PM BLOOD ___ PTT-34.7 ___ ___ 10:15PM BLOOD Glucose-103* UreaN-73* Creat-2.8* Na-127* K-4.2 Cl-86* HCO3-22 AnGap-23* ___ 06:40AM BLOOD ALT-17 AST-33 LD(LDH)-358* AlkPhos-117 TotBili-2.6* ___ 06:40AM BLOOD CK-MB-20* cTropnT-0.15* ___ ___ 11:54AM BLOOD CK-MB-17* MB Indx-3.9 ___ 06:40AM BLOOD Calcium-9.6 Phos-4.0 Mg-1.8 ___ 06:47PM BLOOD Type-MIX pH-7.43 ___ 06:40AM BLOOD Lactate-3.0* ___ 08:26AM BLOOD Lactate-3.0* ___ 07:50AM BLOOD Lactate-1.6 ___ 06:47PM BLOOD Lactate-2.3* ___ 10:39AM BLOOD Lactate-1.9 ___ 09:12AM BLOOD Lactate-1.3 ___ 09:30AM BLOOD Lactate-2.2* ___ 03:34PM BLOOD Lactate-2.1* ___ 05:08PM BLOOD O2 Sat-47 ___ 05:46AM BLOOD O2 Sat-55 ___ 05:06AM BLOOD O2 Sat-88 ___ 06:47PM BLOOD O2 Sat-60 ___ 10:39AM BLOOD O2 Sat-49 ___ 05:06AM BLOOD O2 Sat-79 ___ 09:12AM BLOOD O2 Sat-56 ======================================= MICROBIOLOGY ======================================= URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ======================================= IMAGING/STUDIES ======================================= CXR ___: Cardiomegaly without superimposed acute cardiopulmonary process. CT SINUS MANDIBLE/MAXILLARY: ___ tooth 10 is not visualized. Suspected fractures seen through the tips of the roots ___ tooth numbers 24 and 25. No facial fracture. Soft tissue swelling overlying the nasal bridge and overlying the chin on the left without underlying fracture. CT HEAD ___: No acute intracranial process. CHEST XR ___: In comparison to ___ radiograph, a right PICC is present, terminating in the expected location of the cavoatrial junction. Persistent marked cardiomegaly without evidence of pulmonary edema. ======================================= DISCHARGE LABS ======================================= ___ 05:58AM BLOOD WBC-4.7 RBC-3.04* Hgb-10.4* Hct-32.5* MCV-107* MCH-34.2* MCHC-32.0 RDW-17.2* RDWSD-67.0* Plt ___ ___ 05:58AM BLOOD Glucose-93 UreaN-79* Creat-1.9* Na-131* K-3.4 Cl-87* HCO3-27 AnGap-20 ___ 04:41AM BLOOD ALT-19 AST-32 LD(LDH)-330* AlkPhos-149* TotBili-2.5* ___ 03:42AM BLOOD ALT-19 AST-33 LD(LDH)-353* AlkPhos-143* TotBili-2.6* DirBili-1.4* IndBili-1.2 ___ 05:58AM BLOOD Calcium-9.3 Phos-5.1* Mg-2.7* ___ 03:34PM BLOOD Lactate-2.1* Brief Hospital Course: Mr. ___ is a ___ year old gentleman with advanced heart failure on dobutamine gtt, ischemic/amyloid cardiomyopathy, Afib on apixaban, and s/p BiV PPM for multilevel disease, coronary artery disease s/p DES x1 to LAD (___), DM2, CKD3, HTN, presenting after a fall with s/s HF exacerbation (elev JVP, hyponatremia, ___ on CKD). # Acute on chronic systolic heart failure exacerbation: Pt has ischemic/amyloid cardiomyopathy on dobutamine gtt at home with EF 22%. On admission, Cr 2.8 from 1.6, elevated JVP, and hyponatremia to 127, suggestive of AoC CHF exacerbation. Precipitating factor unclear given he is adherent to medications, though there may be a component of dietary indiscretion. No chest pain. Story of fall was not suggestive of syncope given that there was no loss of consciousness. Lactate 3.0, but there was no evidence of shock on exam, and this downtrended. Pro-BNP elevated at ___ with prior ___ in clinic with mild exacerbation in ___. CK-MB index was flat. Pacer function normal with acceptable lead measurements and battery status. SvO2 was low at 47 on ___ and improved to 55 on ___. Lactate improved to 1.3. He was diuresed with lasix gtt at 25, IV lasix boluses of 160mg and metolazone 1.25mg as needed. ___ and hyponatremia improved with diuresis. Diuresis course was prolonged by the fact that the patient was drinking water from the sink. Evenutally approached euvolemia and was transitioned to PO torsemide 100mg BID (home dose). Dobutamine drip was increased to 5 from 2.5 because of low lactate, poor diuresis, and mildly cool extremities on exam. He felt symptomatic improvement with increase in dobutamine. Spironolactone was initially held for ___, but re-started as ___ resolved (with diuresis). Of note, the patient admitted to driving, and was counseled on the dangers of driving given his advanced heart failure requiring dobutamine gtt. [ ] Medication change: dobutamine gtt increased to 5 from 2.5. [ ] Continue to counsel patient on the dangers of driving given his condition. #Facial trauma: Had open wound on front of forehead, as well as several tooth injuries and bleeding from the mouth. OMFS was consulted and recommended no surgery at this time. Sutures were placed in the ED for the forehead lesion, and removed after 5 days. Panorex scan revealed fractured central incisors, upper left lateral incisor appears to have been lost. Dental was consulted and recommended full dental evaluation and restoration as an outpatient. Patient experienced occaisional oozing, which resolved with pressure and biting down on gauze. Bleeding, swelling and erythma were markedly improved at discharge. [ ] Full dental evaluation and restoration as outpatient #Atrial fibrillation: Apixiban was initially held given his mouth wounds and bleeding. It was re-started at lower dose of 2.5mg for the ___ and ___ increased to 5mg once ___ improved. #CHRONIC -HLD: continued rosuvstatin -CAD: continued ASA and rosuvastatin -DMII: held metformin, started ISS ============================= TRANSITIONAL ISSUES ============================= [ ] Medication change: dobutamine gtt increased to 5 from 2.5. [ ] Continue to counsel patient on the dangers of driving given his condition. [ ] Full dental evaluation and restoration as outpatient. [ ] Home ___. Discharge weight: 69.4 kg Discharge Cr: 1.9 Discharge Hgb: 10.4 # CODE STATUS: DNR/DNI # CONTACT/HCP: ___ (landlady): ___. Preferred HCP is brother Dr. ___, but patient does not have number. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Apixaban 5 mg PO BID 2. DOBUTamine 2.5 mcg/kg/min IV DRIP INFUSION 3. MetFORMIN (Glucophage) 500 mg PO BID 4. Metolazone 1.25 mg PO ONLY AS DIRECTED BY CARDIOLOGY 5. Potassium Chloride 40 mEq PO BID 6. Rosuvastatin Calcium 10 mg PO QPM 7. Spironolactone 12.5 mg PO DAILY 8. Torsemide 100 mg PO BID 9. Aspirin 81 mg PO DAILY 10. Ferrous Sulfate 325 mg PO BID Discharge Medications: 1. DOBUTamine 5 mcg/kg/min IV DRIP INFUSION RX *dobutamine 250 mg/20 mL (12.5 mg/mL) 5 mcg/kg/min IV continuous infusion Disp #*52 Vial Refills:*0 2. Apixaban 5 mg PO BID 3. Aspirin 81 mg PO DAILY 4. Ferrous Sulfate 325 mg PO BID 5. MetFORMIN (Glucophage) 500 mg PO BID 6. Metolazone 1.25 mg PO ONLY AS DIRECTED BY CARDIOLOGY 7. Potassium Chloride 40 mEq PO BID Hold for K > 8. Rosuvastatin Calcium 10 mg PO QPM 9. Spironolactone 12.5 mg PO DAILY 10. Torsemide 100 mg PO BID Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: - Acute on chronic systolic heart failure exacerbation. - Facial trauma. - Dental fractures. Secondary: - Atrial fibrillation. - Diabetes. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. ___, You were admitted to ___ because you had a fall and were found to have a heart failure exacerbation. While you were here, the oral surgeons saw you and you did not need any surgery. The dentists saw you and recommended you see a dentist after the hospitalization to repair your teeth. You were having a heart failure exacerbation, with too much fluid backing up from your heart. We gave you lasix and metolazone to help remove some of the fluid. Eventually, you were able to go back onto your home torsemide. We increased your dobutamine drip to 5 from 2.5, and you felt better. When you go home, it is very important that you DO NOT DRIVE. Driving can be very dangerous because your heart could go into an abnormal heart rhythm and you could pass out behind the wheel. Please weigh yourself every morning and call your doctor if weight goes up more than 3 lbs. Your medications and appointments are below. It was a pleasure taking care of you! Sincerely, Your ___ Cardiology Team Followup Instructions: ___
[ "I130", "I5023", "N179", "E854", "E1122", "I43", "E871", "I4891", "N183", "I2510", "Z66", "Z955", "E785", "Z7902", "S025XXA", "W101XXA", "S0181XA", "Y929", "I255", "E669", "Z6823", "S01511A", "S0121XA", "Z45018", "V484XXA" ]
Allergies: Lipitor / Atenolol Chief Complaint: Fall with trauma and [MASKED] Major Surgical or Invasive Procedure: None. History of Present Illness: Mr. [MASKED] is a [MASKED] w/ systolic heart failure on dobutamine gtt, ischemic/amyloid cardiomyopathy, Afib on apixaban, and s/p BiV PPM for multilevel disease, coronary artery disease s/p DES x1 to LAD ([MASKED]), DM2, CKD3, HTN, presenting after a fall. Patient states Was getting out of his car when he fell today. It is unclear if fall was mechanical or syncopal, he believes he was reaching for his cane but does not recall the events exactly. He fell forward and hit his face on the curb but denies LOC. No associated CP, SOB, palpitations. He has had oral bleeding since the injury. In the ED, initial vitals: T 97.5F, 94, 91/60, 18, 100%RA - Exam notable for: 3cm laceration to bridge of nose with hematoma, scattered abrasions to face, small stellate interior upper lip laceration not containing tooth. He is missing tooth 10. Tooth 8 and 9 are chipped. No C-spine tenderness or pain with ROM neck No chest wall tenderness. Ranging hips w/o discomfort. - Labs notable for: WBC 4.8, Hgb 11.4, Plt 126, Na 127, BUN/Cr 73/2.8 - Imaging notable for: CT Head w/o acute process, CXR w/ , CT Sinus/Mandible/Maxillofacial w/ [MASKED] tooth 10 is not visualized. Suspected fractures seen through the tips of the roots [MASKED] tooth numbers 24 and 25. No facial fracture. Soft tissue swelling overlying the nasal bridge and overlying the chin on the left without underlying fracture. - Patient given: KCl 40meQ, Torsemide 100mg qd, Metformin 500mg, Rosuvastatin 10mg, TDaP - His lip was sutured. - Vitals prior to transfer: 97.7F, 95, 96/68, 16, 100% RA He was admitted to cardiology for [MASKED] (Cr 2.8 from 1.6) and for monitoring of oropharyngeal bleeding on eliquis which has been stable/resolved. Past Medical History: Coronary artery disease s/p DES x1 to LAD ([MASKED]) Combined systolic and diastolic HF (EF 22%) on dobutamine gtt Mixed ischemic/senile amyloid cardiomyopathy TTR amyloid Hypertension Hyperlipidemia Atrial fibrillation on apixaban Infranodal AV disease with multilevel conduction disease s/p Bi-V pacemaker [MASKED] Valitude [MASKED] Lumbar spinal stenosis Diabetes mellitus 2 Chronic kidney disease stage III (Baseline Cr 1.4-1.6) - suspect due to low CO Social History: [MASKED] Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 97.7F, 95, 96/68, 16, 100% RA General: Alert, oriented, no acute distress HEENT: abrasion of forehead and lips with dried blood around mouth Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, no cyanosis or edema Skin: Without rashes or lesions Neuro: A&Ox3. Grossly intact. DISCHARGE PHYSICAL EXAM: Vitals: 98.0 [MASKED] 80s-90s/[MASKED]-70s 100%RA I/O= 2701/2925 Weight: 69.4 <-- 68.5 <-- 70.1 <-- 71.0<--72.2<--71.2<--70.5 <--71.9 <-- 70.2 Weight on admission: 69.0 Telemetry: V-paced General: Alert, oriented, no acute distress HEENT: abrasion of forehead and lips with dried blood around mouth Neck: JVP to mid-neck at 90 degrees Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm lower extremities from shin down, no clubbing or edema. Skin: Without rashes or lesions Neuro: A&Ox3. Grossly intact. Pertinent Results: ====================================== ADMISSION/IMPORTANT LABS ====================================== [MASKED] 10:15PM BLOOD WBC-4.8 RBC-3.38* Hgb-11.4* Hct-35.0* MCV-104* MCH-33.7* MCHC-32.6 RDW-16.0* RDWSD-61.0* Plt [MASKED] [MASKED] 10:15PM BLOOD Neuts-69.5 Lymphs-18.2* Monos-9.0 Eos-1.7 Baso-1.0 NRBC-0.6* Im [MASKED] AbsNeut-3.33 AbsLymp-0.87* AbsMono-0.43 AbsEos-0.08 AbsBaso-0.05 [MASKED] 10:15PM BLOOD [MASKED] PTT-34.7 [MASKED] [MASKED] 10:15PM BLOOD Glucose-103* UreaN-73* Creat-2.8* Na-127* K-4.2 Cl-86* HCO3-22 AnGap-23* [MASKED] 06:40AM BLOOD ALT-17 AST-33 LD(LDH)-358* AlkPhos-117 TotBili-2.6* [MASKED] 06:40AM BLOOD CK-MB-20* cTropnT-0.15* [MASKED] [MASKED] 11:54AM BLOOD CK-MB-17* MB Indx-3.9 [MASKED] 06:40AM BLOOD Calcium-9.6 Phos-4.0 Mg-1.8 [MASKED] 06:47PM BLOOD Type-MIX pH-7.43 [MASKED] 06:40AM BLOOD Lactate-3.0* [MASKED] 08:26AM BLOOD Lactate-3.0* [MASKED] 07:50AM BLOOD Lactate-1.6 [MASKED] 06:47PM BLOOD Lactate-2.3* [MASKED] 10:39AM BLOOD Lactate-1.9 [MASKED] 09:12AM BLOOD Lactate-1.3 [MASKED] 09:30AM BLOOD Lactate-2.2* [MASKED] 03:34PM BLOOD Lactate-2.1* [MASKED] 05:08PM BLOOD O2 Sat-47 [MASKED] 05:46AM BLOOD O2 Sat-55 [MASKED] 05:06AM BLOOD O2 Sat-88 [MASKED] 06:47PM BLOOD O2 Sat-60 [MASKED] 10:39AM BLOOD O2 Sat-49 [MASKED] 05:06AM BLOOD O2 Sat-79 [MASKED] 09:12AM BLOOD O2 Sat-56 ======================================= MICROBIOLOGY ======================================= URINE CULTURE (Final [MASKED]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ======================================= IMAGING/STUDIES ======================================= CXR [MASKED]: Cardiomegaly without superimposed acute cardiopulmonary process. CT SINUS MANDIBLE/MAXILLARY: [MASKED] tooth 10 is not visualized. Suspected fractures seen through the tips of the roots [MASKED] tooth numbers 24 and 25. No facial fracture. Soft tissue swelling overlying the nasal bridge and overlying the chin on the left without underlying fracture. CT HEAD [MASKED]: No acute intracranial process. CHEST XR [MASKED]: In comparison to [MASKED] radiograph, a right PICC is present, terminating in the expected location of the cavoatrial junction. Persistent marked cardiomegaly without evidence of pulmonary edema. ======================================= DISCHARGE LABS ======================================= [MASKED] 05:58AM BLOOD WBC-4.7 RBC-3.04* Hgb-10.4* Hct-32.5* MCV-107* MCH-34.2* MCHC-32.0 RDW-17.2* RDWSD-67.0* Plt [MASKED] [MASKED] 05:58AM BLOOD Glucose-93 UreaN-79* Creat-1.9* Na-131* K-3.4 Cl-87* HCO3-27 AnGap-20 [MASKED] 04:41AM BLOOD ALT-19 AST-32 LD(LDH)-330* AlkPhos-149* TotBili-2.5* [MASKED] 03:42AM BLOOD ALT-19 AST-33 LD(LDH)-353* AlkPhos-143* TotBili-2.6* DirBili-1.4* IndBili-1.2 [MASKED] 05:58AM BLOOD Calcium-9.3 Phos-5.1* Mg-2.7* [MASKED] 03:34PM BLOOD Lactate-2.1* Brief Hospital Course: Mr. [MASKED] is a [MASKED] year old gentleman with advanced heart failure on dobutamine gtt, ischemic/amyloid cardiomyopathy, Afib on apixaban, and s/p BiV PPM for multilevel disease, coronary artery disease s/p DES x1 to LAD ([MASKED]), DM2, CKD3, HTN, presenting after a fall with s/s HF exacerbation (elev JVP, hyponatremia, [MASKED] on CKD). # Acute on chronic systolic heart failure exacerbation: Pt has ischemic/amyloid cardiomyopathy on dobutamine gtt at home with EF 22%. On admission, Cr 2.8 from 1.6, elevated JVP, and hyponatremia to 127, suggestive of AoC CHF exacerbation. Precipitating factor unclear given he is adherent to medications, though there may be a component of dietary indiscretion. No chest pain. Story of fall was not suggestive of syncope given that there was no loss of consciousness. Lactate 3.0, but there was no evidence of shock on exam, and this downtrended. Pro-BNP elevated at [MASKED] with prior [MASKED] in clinic with mild exacerbation in [MASKED]. CK-MB index was flat. Pacer function normal with acceptable lead measurements and battery status. SvO2 was low at 47 on [MASKED] and improved to 55 on [MASKED]. Lactate improved to 1.3. He was diuresed with lasix gtt at 25, IV lasix boluses of 160mg and metolazone 1.25mg as needed. [MASKED] and hyponatremia improved with diuresis. Diuresis course was prolonged by the fact that the patient was drinking water from the sink. Evenutally approached euvolemia and was transitioned to PO torsemide 100mg BID (home dose). Dobutamine drip was increased to 5 from 2.5 because of low lactate, poor diuresis, and mildly cool extremities on exam. He felt symptomatic improvement with increase in dobutamine. Spironolactone was initially held for [MASKED], but re-started as [MASKED] resolved (with diuresis). Of note, the patient admitted to driving, and was counseled on the dangers of driving given his advanced heart failure requiring dobutamine gtt. [ ] Medication change: dobutamine gtt increased to 5 from 2.5. [ ] Continue to counsel patient on the dangers of driving given his condition. #Facial trauma: Had open wound on front of forehead, as well as several tooth injuries and bleeding from the mouth. OMFS was consulted and recommended no surgery at this time. Sutures were placed in the ED for the forehead lesion, and removed after 5 days. Panorex scan revealed fractured central incisors, upper left lateral incisor appears to have been lost. Dental was consulted and recommended full dental evaluation and restoration as an outpatient. Patient experienced occaisional oozing, which resolved with pressure and biting down on gauze. Bleeding, swelling and erythma were markedly improved at discharge. [ ] Full dental evaluation and restoration as outpatient #Atrial fibrillation: Apixiban was initially held given his mouth wounds and bleeding. It was re-started at lower dose of 2.5mg for the [MASKED] and [MASKED] increased to 5mg once [MASKED] improved. #CHRONIC -HLD: continued rosuvstatin -CAD: continued ASA and rosuvastatin -DMII: held metformin, started ISS ============================= TRANSITIONAL ISSUES ============================= [ ] Medication change: dobutamine gtt increased to 5 from 2.5. [ ] Continue to counsel patient on the dangers of driving given his condition. [ ] Full dental evaluation and restoration as outpatient. [ ] Home [MASKED]. Discharge weight: 69.4 kg Discharge Cr: 1.9 Discharge Hgb: 10.4 # CODE STATUS: DNR/DNI # CONTACT/HCP: [MASKED] (landlady): [MASKED]. Preferred HCP is brother Dr. [MASKED], but patient does not have number. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Apixaban 5 mg PO BID 2. DOBUTamine 2.5 mcg/kg/min IV DRIP INFUSION 3. MetFORMIN (Glucophage) 500 mg PO BID 4. Metolazone 1.25 mg PO ONLY AS DIRECTED BY CARDIOLOGY 5. Potassium Chloride 40 mEq PO BID 6. Rosuvastatin Calcium 10 mg PO QPM 7. Spironolactone 12.5 mg PO DAILY 8. Torsemide 100 mg PO BID 9. Aspirin 81 mg PO DAILY 10. Ferrous Sulfate 325 mg PO BID Discharge Medications: 1. DOBUTamine 5 mcg/kg/min IV DRIP INFUSION RX *dobutamine 250 mg/20 mL (12.5 mg/mL) 5 mcg/kg/min IV continuous infusion Disp #*52 Vial Refills:*0 2. Apixaban 5 mg PO BID 3. Aspirin 81 mg PO DAILY 4. Ferrous Sulfate 325 mg PO BID 5. MetFORMIN (Glucophage) 500 mg PO BID 6. Metolazone 1.25 mg PO ONLY AS DIRECTED BY CARDIOLOGY 7. Potassium Chloride 40 mEq PO BID Hold for K > 8. Rosuvastatin Calcium 10 mg PO QPM 9. Spironolactone 12.5 mg PO DAILY 10. Torsemide 100 mg PO BID Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Primary: - Acute on chronic systolic heart failure exacerbation. - Facial trauma. - Dental fractures. Secondary: - Atrial fibrillation. - Diabetes. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [MASKED], You were admitted to [MASKED] because you had a fall and were found to have a heart failure exacerbation. While you were here, the oral surgeons saw you and you did not need any surgery. The dentists saw you and recommended you see a dentist after the hospitalization to repair your teeth. You were having a heart failure exacerbation, with too much fluid backing up from your heart. We gave you lasix and metolazone to help remove some of the fluid. Eventually, you were able to go back onto your home torsemide. We increased your dobutamine drip to 5 from 2.5, and you felt better. When you go home, it is very important that you DO NOT DRIVE. Driving can be very dangerous because your heart could go into an abnormal heart rhythm and you could pass out behind the wheel. Please weigh yourself every morning and call your doctor if weight goes up more than 3 lbs. Your medications and appointments are below. It was a pleasure taking care of you! Sincerely, Your [MASKED] Cardiology Team Followup Instructions: [MASKED]
[]
[ "I130", "N179", "E1122", "E871", "I4891", "I2510", "Z66", "Z955", "E785", "Z7902", "Y929", "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", "I5023: Acute on chronic systolic (congestive) heart failure", "N179: Acute kidney failure, unspecified", "E854: Organ-limited amyloidosis", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "I43: Cardiomyopathy in diseases classified elsewhere", "E871: Hypo-osmolality and hyponatremia", "I4891: Unspecified atrial fibrillation", "N183: Chronic kidney disease, stage 3 (moderate)", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z66: Do not resuscitate", "Z955: Presence of coronary angioplasty implant and graft", "E785: Hyperlipidemia, unspecified", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "S025XXA: Fracture of tooth (traumatic), initial encounter for closed fracture", "W101XXA: Fall (on)(from) sidewalk curb, initial encounter", "S0181XA: Laceration without foreign body of other part of head, initial encounter", "Y929: Unspecified place or not applicable", "I255: Ischemic cardiomyopathy", "E669: Obesity, unspecified", "Z6823: Body mass index [BMI] 23.0-23.9, adult", "S01511A: Laceration without foreign body of lip, initial encounter", "S0121XA: Laceration without foreign body of nose, initial encounter", "Z45018: Encounter for adjustment and management of other part of cardiac pacemaker", "V484XXA: Person boarding or alighting a car injured in noncollision transport accident, initial encounter" ]
19,993,951
29,858,732
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Lipitor / Atenolol Attending: ___. Chief Complaint: Dyspnea, Fatigue Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ yo male with PMH significant for mixed ischemic/senile amyloid cardiomyopathy, chronic systolic heart failure (EF 50%), severe tricuspid regurgitation, moderate mitral regurgitation, mild pulmonary hypertension, coronary artery disease s/p PCI to LAD, atrial fibrillation, and history of high degree AV block s/p biventricular pacemaker presenting with increased dyspnea and fatigue. The patient was last seen in ___ clinic on ___ during which time he stated that his breathing became more labored and he felt more fatigued. He stated that by noontime his legs feel tired and it is difficult to catch his breath. The patient states that he can walk about 50 feet before feeling short of breath. He denies CP, palpitations, nausea, dizziness, lightheadedness, presyncope, or syncope. Of note, the patient states that he has noticed greater orthopnea and has had a poor appetite. The was last hospitalized at ___ from ___ for newly diagnosed AV block necessitating biventricular pacemaker implantation ___ Valitude ___. He has subsequently followed up in the heart failure clinic several times, most recently with the nurse practitioner on ___. At his last visit, Mr. ___ complained of mildly increased dyspnea and fatigue. His weight at the time was 154 lbs and he appeared euvolemic on exam. His device was interrogated and he was noted to be Bi-V paced only 92% of the time. Therefore, several programming changes were made as well as his rate increased to 80 bpm (for potential symptomatic benefit). No medication changes were made. On the floor, the patient's vital signs were T 97.7F, BP 91/63, HR 80, RR 18, PO2 99% RA. He denied shortness of breath, CP, lightheadedness, dizziness, nausea, or vomiting. Past Medical History: Coronary artery disease s/p DES x1 to LAD (___) Chronic systolic heart failure EF 30% TTR amyloid Hypertension Hyperlipidemia Atrial fibrillation Lumbar spinal stenosis Diabetes mellitus 2 Chronic kidney disease stage III Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ON ADMISSION: T 97.7F, BP: 91/63, HR: 80, RR 18, PO2 99% RA Weight: 73.2 kg General: ___ male, no acute distress HEENT: NC/AT, PERRL, EOMI, MMM, neck supple; +elevated JVP to base of jaw at 90 degrees (~15 cm H2O) with dilated EJ Lungs: CTA bilaterally, no crackles/rhonchi/wheezes CV: Irregularly irregular, no audible murmurs; no edema Abd: Soft, NT/ND, +BS Ext: Slightly cool thighs with 2+ ___ pulses bilaterally; no clubbing, cyanosis, or edema Neuro: A&O x 4, no focal neurologic deficits ON DISCHARGE: VS: T 97.6, BP: 88/53, HR: 95, RR: 18, PO2: 100 RA I/O: 24h ___ (-725cc), 8h ___ (-900cc) Weight: 73.2 kg > 70.9 > 71.5 > 70.4 > 71.8 > 71.1 > 72.6 General: ___ male, no acute distress HEENT: NC/AT, PERRL, EOMI, MMM, neck supple; JVP ~8 cm H2O Lungs: CTA bilaterally, no crackles/rhonchi/wheezes CV: Irregularly irregular, no m/r/g Abd: Soft, NT/ND, +BS Ext: WWP with 2+ DP pulses bilaterally; no clubbing, cyanosis, or edema Neuro: AAOx3, no focal neurologic deficits Pertinent Results: ADMISSION LABS: ___ 04:56PM BLOOD ___ PTT-36.5 ___ ___ 04:56PM BLOOD Glucose-70 UreaN-43* Creat-1.9* Na-132* K-4.0 Cl-95* HCO3-20* AnGap-21* ___ 04:56PM BLOOD ALT-18 AST-32 LD(LDH)-373* AlkPhos-118 TotBili-2.3* ___ 04:56PM BLOOD Albumin-4.1 Calcium-9.3 Phos-4.0 Mg-1.6 INTERVAL LABS: ___ 06:20AM BLOOD WBC-3.3* RBC-3.51* Hgb-11.8* Hct-37.3* MCV-106* MCH-33.6* MCHC-31.6* RDW-15.2 RDWSD-59.7* Plt ___ ___ 06:40AM BLOOD WBC-4.1 RBC-3.67* Hgb-12.4* Hct-39.6* MCV-108* MCH-33.8* MCHC-31.3* RDW-15.2 RDWSD-59.8* Plt ___ ___ 06:40AM BLOOD WBC-4.6 RBC-3.46* Hgb-11.7* Hct-37.5* MCV-108* MCH-33.8* MCHC-31.2* RDW-15.6* RDWSD-62.0* Plt ___ ___ 06:20AM BLOOD Neuts-49.8 ___ Monos-13.0 Eos-3.9 Baso-1.5* Im ___ AbsNeut-1.64 AbsLymp-1.04* AbsMono-0.43 AbsEos-0.13 AbsBaso-0.05 ___ 04:56PM BLOOD Plt ___ ___ 06:20AM BLOOD ___ PTT-36.5 ___ ___ 05:29AM BLOOD ___ PTT-34.9 ___ ___ 05:29AM BLOOD Plt ___ ___ 06:20AM BLOOD Glucose-57* UreaN-42* Creat-1.8* Na-137 K-3.4 Cl-98 HCO3-24 AnGap-18 ___ 05:29AM BLOOD Glucose-95 UreaN-44* Creat-1.8* Na-138 K-4.3 Cl-99 HCO3-26 AnGap-17 ___ 08:45PM BLOOD Glucose-124* UreaN-49* Creat-1.6* Na-137 K-3.6 Cl-98 HCO3-27 AnGap-16 ___ 04:16PM BLOOD Glucose-113* UreaN-46* Creat-1.5* Na-140 K-3.8 Cl-98 HCO3-29 AnGap-17 ___ 11:54PM BLOOD Glucose-96 UreaN-52* Creat-1.5* Na-135 K-3.3 Cl-97 HCO3-27 AnGap-14 ___ 12:32AM BLOOD Glucose-113* UreaN-61* Creat-1.5* Na-137 K-3.9 Cl-98 HCO3-24 AnGap-19 ___ 06:20AM BLOOD ALT-17 AST-29 LD(LDH)-351* AlkPhos-117 TotBili-2.2* ___ 06:40AM BLOOD ALT-16 AST-25 LD(LDH)-306* AlkPhos-127 TotBili-2.1* ___ 02:55PM BLOOD Calcium-9.5 Phos-3.7 Mg-2.3 ___ 06:17AM BLOOD Calcium-9.1 Phos-3.8 Mg-2.2 ___:32AM BLOOD Calcium-9.0 Phos-4.6* Mg-2.3 DISCHARGE LABS: ___ 06:14AM BLOOD WBC-4.2 RBC-3.47* Hgb-11.8* Hct-37.2* MCV-107* MCH-34.0* MCHC-31.7* RDW-15.3 RDWSD-60.0* Plt ___ ___ 06:14AM BLOOD Plt ___ ___ 06:14AM BLOOD Glucose-91 UreaN-59* Creat-1.4* Na-140 K-3.6 Cl-99 HCO3-24 AnGap-21* ___ 06:14AM BLOOD Calcium-9.0 Phos-4.4 Mg-2.3 IMAGING: CHEST (PORTABLE AP) ___: IMPRESSION: Comparison to ___. No relevant change. Moderate cardiomegaly with elongation of the descending aorta. No pulmonary edema. No pleural effusions. No pneumonia. Left pectoral pacemaker in situ. ECG (___): Probable underlying atrial fibrillation with biventricular pacing. Low QRS voltage throughout, most consistent with a dilated cardiomyopathy. TRACING #2 ECHO (___): The left atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is ___ mmHg. There is moderate symmetric left ventricular hypertrophy with normal cavity size. There is severe global left ventricular hypokinesis. Systolic function of apical segments is relatively preserved. Quantitative (biplane) LVEF = 22 %. The right ventricular cavity is mildly dilated with moderate global free wall hypokinesis. The aortic arch and descending thoracic aorta are mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosisn. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. IMPRESSION: Symmetric left ventricular hypertrophy with severe global biventricular hypokinesis in a pattern most suggestive of an infiltrative process (e.g., amyloid). Mild mitral regurgitation. Mild aortic regurgitation. PA hypertension. Compared with the prior study (images reviewed) of ___, global left ventricular systolic function is slightly worse. CLINICAL IMPLICATIONS: The left ventricular ejection fraction is <40%, a threshold for which the patient may benefit from a beta blocker and an ACE inhibitor or ___. MICROBIOLOGY: None Brief Hospital Course: #Acute on Chronic Systolic heart failure: Mixed ischemic and non-ischemic cardiomyopathy (cardiac amyloid). Patient was admitted with fatigue and dyspnea, decompensated possibly in the setting of increased Afib burden vs excessive fluid intake vs progression of advanced CHF. Patient diuresed with Lasix 120 mg IV on admission on ___, 80 mg IV on ___. Patient's volume exam was not very convincing for hypervolemia apart from markedly elevated JVD. Transitioned from IV diuretics to torsemide PO. Patient markedly improved since admission despite his current weight being roughly his weight on admission. It seems likely that setting his BiV pacer to 95 helped to resolve his dyspnea on exertion in combination with diuresis as this change occurred just prior to him beginning to feel subjectively better. He will be discharged with close cardiology follow up. #Atrial fibrillation: Patient with BiV pacer implant on ___. Previous EKGs showed e/o atrial tachycardia vs. atrial flutter. - Continued apixiban 5 mg PO BID #CKD: Patient with stage 3 CKD, baseline Cr around 1.5, elevated at 1.9 on admission. Improved to 1.4 at time of discharge. -continue to monitor -renally dose medications - Avoid nephrotoxins # HLD: Patient noted to have muscle aches on atorvastatin. Statin held at time of discharge but can be can possibly be restarted as an outpatient. # T2DM: ISS while in hospital. TRANSITIONAL ISSUES: Discharge weight: 72.6kg Discharge diuretics: Torsemide 80 mg PO/NG DAILY Discharge afterload: None - Follow up with PCP and cardiologist for potential changes to heart failure regimen - Consider re-starting rosuvastatin. Stopped during hospitalization due to reported muscle cramps. - Changed potassium 60 mEq BID to 60 mEq daily. Please follow up with electrolyte check at next PCP ___. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Potassium Chloride 60 mEq PO BID 2. Aspirin 81 mg PO DAILY 3. Ferrous Sulfate 325 mg PO BID 4. Apixaban 5 mg PO BID 5. Torsemide 80 mg PO DAILY Discharge Medications: 1. Potassium Chloride 60 mEq PO DAILY RX *potassium chloride 20 mEq 3 tablet(s) by mouth daily Disp #*90 Tablet Refills:*0 2. Apixaban 5 mg PO BID 3. Aspirin 81 mg PO DAILY 4. Ferrous Sulfate 325 mg PO BID 5. MetFORMIN (Glucophage) 500 mg PO BID 6. Torsemide 80 mg PO DAILY RX *torsemide 20 mg 4 tablet(s) by mouth daily Disp #*120 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: - Acute on chronic systolic heart failure - Atrial fibrillation - Chronic kidney disease stage 3 Secondary diagnoses: - Hyperlipidemia - Type 2 diabetes mellitus - Severe malnutrition Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. ___, It was a pleasure taking care of you. You were admitted to the hospital because you were having shortness of breath when exerting yourself. We believe this was because your heart was having a difficult time managing the fluid in your body. You were given diuretics to help take fluid off. When you leave the hospital, it is very important that you take your medications as directed. Weigh yourself every morning, call MD if weight goes up more than 3 lbs. You will follow up with your PCP, ___ your cardiologist, Dr. ___. All our best, Your ___ Care Team Followup Instructions: ___
[ "I5023", "E43", "N179", "E854", "I4891", "I428", "I361", "I340", "I43", "I130", "Z6825", "E785", "I2510", "N183", "M4806", "I4430", "Z955", "Z950", "Z7901" ]
Allergies: Lipitor / Atenolol Chief Complaint: Dyspnea, Fatigue Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is a [MASKED] yo male with PMH significant for mixed ischemic/senile amyloid cardiomyopathy, chronic systolic heart failure (EF 50%), severe tricuspid regurgitation, moderate mitral regurgitation, mild pulmonary hypertension, coronary artery disease s/p PCI to LAD, atrial fibrillation, and history of high degree AV block s/p biventricular pacemaker presenting with increased dyspnea and fatigue. The patient was last seen in [MASKED] clinic on [MASKED] during which time he stated that his breathing became more labored and he felt more fatigued. He stated that by noontime his legs feel tired and it is difficult to catch his breath. The patient states that he can walk about 50 feet before feeling short of breath. He denies CP, palpitations, nausea, dizziness, lightheadedness, presyncope, or syncope. Of note, the patient states that he has noticed greater orthopnea and has had a poor appetite. The was last hospitalized at [MASKED] from [MASKED] for newly diagnosed AV block necessitating biventricular pacemaker implantation [MASKED] Valitude [MASKED]. He has subsequently followed up in the heart failure clinic several times, most recently with the nurse practitioner on [MASKED]. At his last visit, Mr. [MASKED] complained of mildly increased dyspnea and fatigue. His weight at the time was 154 lbs and he appeared euvolemic on exam. His device was interrogated and he was noted to be Bi-V paced only 92% of the time. Therefore, several programming changes were made as well as his rate increased to 80 bpm (for potential symptomatic benefit). No medication changes were made. On the floor, the patient's vital signs were T 97.7F, BP 91/63, HR 80, RR 18, PO2 99% RA. He denied shortness of breath, CP, lightheadedness, dizziness, nausea, or vomiting. Past Medical History: Coronary artery disease s/p DES x1 to LAD ([MASKED]) Chronic systolic heart failure EF 30% TTR amyloid Hypertension Hyperlipidemia Atrial fibrillation Lumbar spinal stenosis Diabetes mellitus 2 Chronic kidney disease stage III Social History: [MASKED] Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ON ADMISSION: T 97.7F, BP: 91/63, HR: 80, RR 18, PO2 99% RA Weight: 73.2 kg General: [MASKED] male, no acute distress HEENT: NC/AT, PERRL, EOMI, MMM, neck supple; +elevated JVP to base of jaw at 90 degrees (~15 cm H2O) with dilated EJ Lungs: CTA bilaterally, no crackles/rhonchi/wheezes CV: Irregularly irregular, no audible murmurs; no edema Abd: Soft, NT/ND, +BS Ext: Slightly cool thighs with 2+ [MASKED] pulses bilaterally; no clubbing, cyanosis, or edema Neuro: A&O x 4, no focal neurologic deficits ON DISCHARGE: VS: T 97.6, BP: 88/53, HR: 95, RR: 18, PO2: 100 RA I/O: 24h [MASKED] (-725cc), 8h [MASKED] (-900cc) Weight: 73.2 kg > 70.9 > 71.5 > 70.4 > 71.8 > 71.1 > 72.6 General: [MASKED] male, no acute distress HEENT: NC/AT, PERRL, EOMI, MMM, neck supple; JVP ~8 cm H2O Lungs: CTA bilaterally, no crackles/rhonchi/wheezes CV: Irregularly irregular, no m/r/g Abd: Soft, NT/ND, +BS Ext: WWP with 2+ DP pulses bilaterally; no clubbing, cyanosis, or edema Neuro: AAOx3, no focal neurologic deficits Pertinent Results: ADMISSION LABS: [MASKED] 04:56PM BLOOD [MASKED] PTT-36.5 [MASKED] [MASKED] 04:56PM BLOOD Glucose-70 UreaN-43* Creat-1.9* Na-132* K-4.0 Cl-95* HCO3-20* AnGap-21* [MASKED] 04:56PM BLOOD ALT-18 AST-32 LD(LDH)-373* AlkPhos-118 TotBili-2.3* [MASKED] 04:56PM BLOOD Albumin-4.1 Calcium-9.3 Phos-4.0 Mg-1.6 INTERVAL LABS: [MASKED] 06:20AM BLOOD WBC-3.3* RBC-3.51* Hgb-11.8* Hct-37.3* MCV-106* MCH-33.6* MCHC-31.6* RDW-15.2 RDWSD-59.7* Plt [MASKED] [MASKED] 06:40AM BLOOD WBC-4.1 RBC-3.67* Hgb-12.4* Hct-39.6* MCV-108* MCH-33.8* MCHC-31.3* RDW-15.2 RDWSD-59.8* Plt [MASKED] [MASKED] 06:40AM BLOOD WBC-4.6 RBC-3.46* Hgb-11.7* Hct-37.5* MCV-108* MCH-33.8* MCHC-31.2* RDW-15.6* RDWSD-62.0* Plt [MASKED] [MASKED] 06:20AM BLOOD Neuts-49.8 [MASKED] Monos-13.0 Eos-3.9 Baso-1.5* Im [MASKED] AbsNeut-1.64 AbsLymp-1.04* AbsMono-0.43 AbsEos-0.13 AbsBaso-0.05 [MASKED] 04:56PM BLOOD Plt [MASKED] [MASKED] 06:20AM BLOOD [MASKED] PTT-36.5 [MASKED] [MASKED] 05:29AM BLOOD [MASKED] PTT-34.9 [MASKED] [MASKED] 05:29AM BLOOD Plt [MASKED] [MASKED] 06:20AM BLOOD Glucose-57* UreaN-42* Creat-1.8* Na-137 K-3.4 Cl-98 HCO3-24 AnGap-18 [MASKED] 05:29AM BLOOD Glucose-95 UreaN-44* Creat-1.8* Na-138 K-4.3 Cl-99 HCO3-26 AnGap-17 [MASKED] 08:45PM BLOOD Glucose-124* UreaN-49* Creat-1.6* Na-137 K-3.6 Cl-98 HCO3-27 AnGap-16 [MASKED] 04:16PM BLOOD Glucose-113* UreaN-46* Creat-1.5* Na-140 K-3.8 Cl-98 HCO3-29 AnGap-17 [MASKED] 11:54PM BLOOD Glucose-96 UreaN-52* Creat-1.5* Na-135 K-3.3 Cl-97 HCO3-27 AnGap-14 [MASKED] 12:32AM BLOOD Glucose-113* UreaN-61* Creat-1.5* Na-137 K-3.9 Cl-98 HCO3-24 AnGap-19 [MASKED] 06:20AM BLOOD ALT-17 AST-29 LD(LDH)-351* AlkPhos-117 TotBili-2.2* [MASKED] 06:40AM BLOOD ALT-16 AST-25 LD(LDH)-306* AlkPhos-127 TotBili-2.1* [MASKED] 02:55PM BLOOD Calcium-9.5 Phos-3.7 Mg-2.3 [MASKED] 06:17AM BLOOD Calcium-9.1 Phos-3.8 Mg-2.2 [MASKED]:32AM BLOOD Calcium-9.0 Phos-4.6* Mg-2.3 DISCHARGE LABS: [MASKED] 06:14AM BLOOD WBC-4.2 RBC-3.47* Hgb-11.8* Hct-37.2* MCV-107* MCH-34.0* MCHC-31.7* RDW-15.3 RDWSD-60.0* Plt [MASKED] [MASKED] 06:14AM BLOOD Plt [MASKED] [MASKED] 06:14AM BLOOD Glucose-91 UreaN-59* Creat-1.4* Na-140 K-3.6 Cl-99 HCO3-24 AnGap-21* [MASKED] 06:14AM BLOOD Calcium-9.0 Phos-4.4 Mg-2.3 IMAGING: CHEST (PORTABLE AP) [MASKED]: IMPRESSION: Comparison to [MASKED]. No relevant change. Moderate cardiomegaly with elongation of the descending aorta. No pulmonary edema. No pleural effusions. No pneumonia. Left pectoral pacemaker in situ. ECG ([MASKED]): Probable underlying atrial fibrillation with biventricular pacing. Low QRS voltage throughout, most consistent with a dilated cardiomyopathy. TRACING #2 ECHO ([MASKED]): The left atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is [MASKED] mmHg. There is moderate symmetric left ventricular hypertrophy with normal cavity size. There is severe global left ventricular hypokinesis. Systolic function of apical segments is relatively preserved. Quantitative (biplane) LVEF = 22 %. The right ventricular cavity is mildly dilated with moderate global free wall hypokinesis. The aortic arch and descending thoracic aorta are mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosisn. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. IMPRESSION: Symmetric left ventricular hypertrophy with severe global biventricular hypokinesis in a pattern most suggestive of an infiltrative process (e.g., amyloid). Mild mitral regurgitation. Mild aortic regurgitation. PA hypertension. Compared with the prior study (images reviewed) of [MASKED], global left ventricular systolic function is slightly worse. CLINICAL IMPLICATIONS: The left ventricular ejection fraction is <40%, a threshold for which the patient may benefit from a beta blocker and an ACE inhibitor or [MASKED]. MICROBIOLOGY: None Brief Hospital Course: #Acute on Chronic Systolic heart failure: Mixed ischemic and non-ischemic cardiomyopathy (cardiac amyloid). Patient was admitted with fatigue and dyspnea, decompensated possibly in the setting of increased Afib burden vs excessive fluid intake vs progression of advanced CHF. Patient diuresed with Lasix 120 mg IV on admission on [MASKED], 80 mg IV on [MASKED]. Patient's volume exam was not very convincing for hypervolemia apart from markedly elevated JVD. Transitioned from IV diuretics to torsemide PO. Patient markedly improved since admission despite his current weight being roughly his weight on admission. It seems likely that setting his BiV pacer to 95 helped to resolve his dyspnea on exertion in combination with diuresis as this change occurred just prior to him beginning to feel subjectively better. He will be discharged with close cardiology follow up. #Atrial fibrillation: Patient with BiV pacer implant on [MASKED]. Previous EKGs showed e/o atrial tachycardia vs. atrial flutter. - Continued apixiban 5 mg PO BID #CKD: Patient with stage 3 CKD, baseline Cr around 1.5, elevated at 1.9 on admission. Improved to 1.4 at time of discharge. -continue to monitor -renally dose medications - Avoid nephrotoxins # HLD: Patient noted to have muscle aches on atorvastatin. Statin held at time of discharge but can be can possibly be restarted as an outpatient. # T2DM: ISS while in hospital. TRANSITIONAL ISSUES: Discharge weight: 72.6kg Discharge diuretics: Torsemide 80 mg PO/NG DAILY Discharge afterload: None - Follow up with PCP and cardiologist for potential changes to heart failure regimen - Consider re-starting rosuvastatin. Stopped during hospitalization due to reported muscle cramps. - Changed potassium 60 mEq BID to 60 mEq daily. Please follow up with electrolyte check at next PCP [MASKED]. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Potassium Chloride 60 mEq PO BID 2. Aspirin 81 mg PO DAILY 3. Ferrous Sulfate 325 mg PO BID 4. Apixaban 5 mg PO BID 5. Torsemide 80 mg PO DAILY Discharge Medications: 1. Potassium Chloride 60 mEq PO DAILY RX *potassium chloride 20 mEq 3 tablet(s) by mouth daily Disp #*90 Tablet Refills:*0 2. Apixaban 5 mg PO BID 3. Aspirin 81 mg PO DAILY 4. Ferrous Sulfate 325 mg PO BID 5. MetFORMIN (Glucophage) 500 mg PO BID 6. Torsemide 80 mg PO DAILY RX *torsemide 20 mg 4 tablet(s) by mouth daily Disp #*120 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: - Acute on chronic systolic heart failure - Atrial fibrillation - Chronic kidney disease stage 3 Secondary diagnoses: - Hyperlipidemia - Type 2 diabetes mellitus - Severe malnutrition Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [MASKED], It was a pleasure taking care of you. You were admitted to the hospital because you were having shortness of breath when exerting yourself. We believe this was because your heart was having a difficult time managing the fluid in your body. You were given diuretics to help take fluid off. When you leave the hospital, it is very important that you take your medications as directed. Weigh yourself every morning, call MD if weight goes up more than 3 lbs. You will follow up with your PCP, [MASKED] your cardiologist, Dr. [MASKED]. All our best, Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "N179", "I4891", "I130", "E785", "I2510", "Z955", "Z7901" ]
[ "I5023: Acute on chronic systolic (congestive) heart failure", "E43: Unspecified severe protein-calorie malnutrition", "N179: Acute kidney failure, unspecified", "E854: Organ-limited amyloidosis", "I4891: Unspecified atrial fibrillation", "I428: Other cardiomyopathies", "I361: Nonrheumatic tricuspid (valve) insufficiency", "I340: Nonrheumatic mitral (valve) insufficiency", "I43: Cardiomyopathy in diseases classified elsewhere", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "Z6825: Body mass index [BMI] 25.0-25.9, adult", "E785: Hyperlipidemia, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "N183: Chronic kidney disease, stage 3 (moderate)", "M4806: Spinal stenosis, lumbar region", "I4430: Unspecified atrioventricular block", "Z955: Presence of coronary angioplasty implant and graft", "Z950: Presence of cardiac pacemaker", "Z7901: Long term (current) use of anticoagulants" ]
19,994,379
23,099,193
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / oxycodone Attending: ___. Chief Complaint: Syncope Major Surgical or Invasive Procedure: Pacemaker and ICD placement History of Present Illness: ___ yo M with atrial fibrillation on rivaroxaban, CAD s/p stent placement (unknown vessel), HFrEF (EF ___, mitral valve prolapse, HTN, HLD, depression, multiple spine surgeries, cholecystectomy who presents from heart failure clinic for acute HF management. On arrival, patient was alert and oriented with no distress with O2 at 3L 89% sats. At 3pm, he had a sip of water, and then started coughing and vomiting during phlebotomy. Per PCT, he passed out briefly with his eyes rolling back in his head and he was unconscious for a few minutes. He responded to calling his name and shaking. He then started coughing and was disoriented. He vomited brown bilous mucous/clear. His systolic blood pressure was in the low ___ and he was then put on 4L of O2 and his coughing and vomiting stopped. He remembers drinking water but not precipitating events. There were no reported shaking episodes or stool/urine incontinence. Of note, patient recently discharged from ___ on ___. He was found to have acute heart failure exacerbation likely due to missed diuretic doses at rehab. He was treating with Lasix drip in the MICU as well as anitbiotics (vancomycin, ceftazidime, and azithromycin) for HCAP. While here, he developed ___ on CKD with a discharge creatinine of 1.7 (baseline of 1.1-1.2) thought to be in setting of possible diuresis and initiation of spironolactone and ace-I and also elevated vancomycin level (66) several days prior to d/c. Past Medical History: PAST MEDICAL HISTORY: ======================= 1. CARDIAC RISK FACTORS - Hypertension - Dyslipidemia 2. CARDIAC HISTORY - CAD s/p stent placement - CHF with EF ___ - Afib on warfarin - mitral valve prolapse 3. OTHER PAST MEDICAL HISTORY depression chronic neck pain secondary to cervical disc disease multiple spine surgeries including fusion of L-S1 laminectomy cholecystectomy Total knee replacement B/l shoulder surgery c diff infection ___ Social History: ___ Family History: Mother: alive, age ___. Macular degeneration Father: deceased in mid ___. ?brain tumor and heart issues Physical Exam: Admission Physical Exam: ======================== GENERAL: Well developed, pleasant, lying in bed in NAD. Oriented x3. Mood, affect appropriate. HEENT: Normocephalic atraumatic. Sclera anicteric. Conjunctiva pink. No pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple. JVP to earlobe at 30 degrees. CARDIAC: Irregularly irregular. Normal S1, S2. No murmurs, rubs, or gallops. No thrills or lifts. LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. Clear to auscultation bilaterally. No wheezes, rales, or rhonchi. ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No splenomegaly. EXTREMITIES: Patient with warm distal extremities and warm proximal extremities. 1+-2+ peripheral edema to the mid-shin. SKIN: No significant skin lesions or rashes. PULSES: Distal pulses palpable and symmetric. Discharge Physical Exam: ======================== 24 HR Data (last updated ___ @ 917) Temp: 97.4 (Tm 99.1), BP: 92/56 (88-116/44-73), HR: 80 (75-96), RR: 20 (___), O2 sat: 92% (92-95), O2 delivery: RA, Wt: 183.2 lb/83.1 kg I: 660 O: ___ B: -___ Wt: 83.1 kg <- 84 kg <- 84.2 kg <- 83.7 kg <- 82.6 kg <- 82.9 kg <- 83.2<-83.0 kg <- 82.6 kg <- 84.7 kg <- 87.1 kg <- 87 kg <- 87.09 <- 86.96 <- 90.22 Tele: AFib with no paced beats GENERAL: Well developed, pleasant, lying in bed in NAD. Oriented x3. Mood, affect appropriate. HEENT: Normocephalic atraumatic. Sclera anicteric. Conjunctiva pink. NECK: Supple. JVP 10 cm CARDIAC: Irregularly irregular. Normal S1, S2. No murmurs, rubs, or gallops. No thrills or lifts. LUNGS: No chest wall deformities or tenderness. Respiration is comfortable, particularly when laying flat. trace bibasilar crackles R side > L. very diminished on R ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No splenomegaly. EXTREMITIES: Patient with warm distal extremities and warm proximal extremities. no peripheral edema . PULSES: Distal pulses palpable and symmetric. Pertinent Results: Admission Labs: =============== ___ 12:34PM BLOOD WBC-6.1 RBC-2.40* Hgb-7.6* Hct-25.1* MCV-105* MCH-31.7 MCHC-30.3* RDW-16.1* RDWSD-62.5* Plt ___ ___ 09:30PM BLOOD Glucose-120* UreaN-57* Creat-1.8* Na-135 K-4.7 Cl-92* HCO3-26 AnGap-17 ___ 12:34PM BLOOD ALT-22 AST-38 LD(LDH)-259* AlkPhos-264* TotBili-1.1 ___ 04:52AM BLOOD ALT-292* AST-467* AlkPhos-357* TotBili-1.4 ___ 12:34PM BLOOD CK-MB-2 cTropnT-0.02* ___ ___ 12:34PM BLOOD TSH-4.6* ___ 03:18PM BLOOD Lactate-3.3* Imaging: ======== CXR ___: No appreciable change since the prior chest radiograph including right lower lobe collapse and loculated right pleural fluid. CT Chest w/out contrast ___ Renal U/S ___: No hydronephrosis. Trace perihepatic ascites CT CHEST W/O CONTRAST IMPRESSION: 1. Unchanged volume of a moderate right pleural effusion with decreased locule of gas likely from prior chest tube with persistent diffuse pleural thickening and areas of dependent pleural nodularity. Correlation with pleural fluid analysis is advised. 2. Previously seen extensive ground-glass opacities throughout the left lung have nearly completely resolved as has the left-sided pleural effusion. 3. Stable 2 mm left lower lobe pulmonary nodules. 4. Dilated main pulmonary artery to 4 cm suggesting pulmonary arterial hypertension. 5. Posterior gastric diverticulum. Discharge Labs: =============== ___ 06:20AM BLOOD WBC-5.9 RBC-2.65* Hgb-8.6* Hct-27.0* MCV-102* MCH-32.5* MCHC-31.9* RDW-16.4* RDWSD-61.2* Plt ___ ___ 07:25AM BLOOD Glucose-97 UreaN-39* Creat-1.3* Na-140 K-3.8 Cl-96 HCO3-31 AnGap-13 ___ 06:20AM BLOOD ALT-9 AST-14 AlkPhos-154* TotBili-0.7 Brief Hospital Course: Mr. ___ is a ___ year-old man with a history of atrial fibrillation on rivaroxaban, CAD s/p stent placement (unknown vessel), HFrEF (EF ___, mitral valve prolapse, HTN, HLD, depression, multiple spine surgeries, and cholecystectomy, who initially presented from heart failure clinic for acute HF management. Subsequently, was noted to have sinus arrest and syncope requiring placement of single-chamber ICD implant. His heart failure regimen was optimized but somewhat limited by hypotension. ACUTE ISSUES: ============= # SYNCOPE # SINUS PAUSES # SINUS ARREST The patient experienced a 9-second pause with associated unresponsiveness. Subsequently was noted to have ventricular escape beats. The patient spontaneously recovered. He had an uncomplicated single-chamber ICD implant via L cephalic on ___ without any further pauses or syncope. # ACUTE ON CHRONIC SYSTOLIC HEART FAILURE # HYPOXEMIA The patient has an EF of 34% ___, and presented with weight gain, elevated JVP, hypoxemia, evidence of pulmonary edema on CXR, all suggestive of acute decompensation, likely secondary to decreased regimen at rehab due to a rise in creatinine. He initially responded well to IV diuresis and was transitioned to PO diuretics, but again developed an oxygen requirement. He was placed back on IV diuretics including a furosemide drip and once euvolemic was transitioned to PO torsemide 100 mg BID. He required intermittent metolozone. He required signifincant repletion of low potassium levels prior to starting spironolactone. His metoprolol was increased and he did not tolerate afterload reduction given low blood pressures. His weight on discharge was 83.1 kg (183.2 lb). # RIGHT PLEURAL EFFUSION / TRAPPED LUNG # HYPOXEMIA The patient has known right lower lobe collapse and loculated right pleural fluid, which appears similar to prior CXR. Given history of having been weaned off O2, and then having an increase requirement with holding of diuresis, acute CHF exacerbation is most likely explanation for hypoxemia. He was diuresed with improvement his oxygenation. Pulmonology was consulted given hypoxia on exertion and believes that the patient may have some underlying COPD in addition to his CHF contributing to hypoxia. He will benefit from having outpatient pulmonary function testing and follow up with ___ clinic (IP + thoracic surgery). # ATRIAL FIBRILLATION He was transitioned to apixaban given high INRs on rivaroxaban and concern for GI bleed. Metoprolol was continued at a slightly reduced dose based on patient's tolerance. # MACROCYTIC ANEMIA The patient has a hemoglobin baseline of ___, presenting with Hgb 7.6. Methylmalonic acid was WNL during recent admission and ferritin 500 suggesting anemia of chronic inflammation. Patient does have history of GI bleed requiring 2 pRBCs during last admission. Denies melena, hematochezia. He received 1 U of blood this admission and his hemoglobin was stable on discharge at 8.6. # ___ on CKD Baseline ~1.2, however up to 1.7 on last discharge and on this admission. Improved to near baseline with diuresis. Discharged with Cr of 1.3. CHRONIC ISSUES: =============== # CHRONIC PAIN The patient has history of multiple prior spinal surgeries with ardware in place. Etiology of pain is unclear but likely multifactorial from degenerative disc disease and frequent surgeries. He continued on prn lidocaine patches, gabapentin, and tramadol. # GOUT He continued allopurinol. # DEPRESSION He continued sertraline. Transitional Issues: ==================== [ ] DISCHARGE WEIGHT: 83.1 kg (183.2 lb) [ ] DISCHARGE DIURETIC: 100 torsemide BID [ ] DISCHARGE Cr/BUN: 1.___ [ ] GOAL BLOOD PRESSURE: MAP ___ [ ] MEDICATIONS STOPPED: - Ferrous Sulfate 325 mg PO DAILY - Rivaroxaban 20 mg PO QHS [ ] MEDICATIONS CHANGED: - Torsemide 40 mg PO DAILY increased to Torsemide 100 mg PO/NG BID - Metoprolol Succinate XL 50 mg PO BID decreased to Metoprolol Succinate XL 37.5 mg PO BID [ ] MEDICATIONS STARTED: - Apixaban 5 mg PO/NG BID - Spironolactone 12.5 mg PO/NG DAILY [ ] The patient has a known trapped lung and imaging suggestive of COPD. He will benefit from outpatient PFTs and an appointment with interventional ___ clinic. [ ] Weigh the patient daily. If his weight increases by 3 lbs in one day or 5 lbs in two days, please call his cardiologist at ___ for further directions and possible dosing of metolazone. [ ] If planning to adjust torsemide dose based on Cr increase or other parameter, please discuss with heart failure team @ ___. His CHF doctor will be Dr. ___ [ ] The patient required significant repletion of potassium while diuresing as an inpatient. He was started on spironolactone prior to discharge. Please continue to check BMP on ___ and then every other day until creatinine and potassium have stabilized. He was discharged on 40mEq of potassium daily. Please adjust potassium supplementation as indicated. [ ] The patient will benefit from a right and left heart catheterization once his ICD has been in place for ___ months ___ or ___. He would benefit from vasodilator study and full evaluation for pulmonary hypertension. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Acetaminophen 1000 mg PO TID 2. Allopurinol ___ mg PO DAILY 3. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO QID:PRN upset stomach 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 40 mg PO QPM 6. Calcium Carbonate 500 mg PO QID:PRN heartburn 7. Docusate Sodium 100 mg PO TID:PRN constipation 8. Gabapentin 300 mg PO BID 9. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN SOB, wheezing 10. Lidocaine 5% Patch 1 PTCH TD QPM 11. Metoprolol Succinate XL 50 mg PO BID 12. Pantoprazole 40 mg PO Q24H 13. Rivaroxaban 20 mg PO QHS 14. Senna 17.2 mg PO QHS:PRN constipation 15. Sertraline 50 mg PO DAILY 16. TraMADol 75 mg PO BID:PRN Pain - Moderate 17. Torsemide 40 mg PO DAILY 18. Bisacodyl ___AILY:PRN constipation 19. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q2H:PRN sore throat 20. Cholestyramine 2 mg gm PO BID 21. Ferrous Sulfate 325 mg PO DAILY 22. Hydrocerin 1 Appl TP DAILY dry skin 23. Magnesium Oxide 400 mg PO DAILY 24. melatonin 3 mg oral QHS:PRN 25. Milk of Magnesia 30 mL PO QHS:PRN constipation 26. Ondansetron ODT 8 mg PO Q8H:PRN nausea, vomiting Discharge Medications: 1. Apixaban 5 mg PO BID 2. Potassium Chloride 40 mEq PO DAILY Hold for K > 3. Spironolactone 12.5 mg PO DAILY 4. Metoprolol Succinate XL 37.5 mg PO BID 5. Torsemide 100 mg PO BID 6. TraMADol 50 mg PO Q6H:PRN Pain - Severe 7. Acetaminophen 1000 mg PO TID 8. Allopurinol ___ mg PO DAILY 9. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO QID:PRN upset stomach 10. Aspirin 81 mg PO DAILY 11. Atorvastatin 40 mg PO QPM 12. Bisacodyl ___AILY:PRN constipation 13. Calcium Carbonate 500 mg PO QID:PRN heartburn 14. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q2H:PRN sore throat 15. Cholestyramine 2 mg gm PO BID 16. Docusate Sodium 100 mg PO TID:PRN constipation 17. Gabapentin 300 mg PO BID 18. Hydrocerin 1 Appl TP DAILY dry skin 19. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN SOB, wheezing 20. Lidocaine 5% Patch 1 PTCH TD QPM 21. Magnesium Oxide 400 mg PO DAILY 22. melatonin 3 mg oral QHS:PRN 23. Milk of Magnesia 30 mL PO QHS:PRN constipation 24. Ondansetron ODT 8 mg PO Q8H:PRN nausea, vomiting 25. Pantoprazole 40 mg PO Q24H 26. Senna 17.2 mg PO QHS:PRN constipation 27. Sertraline 50 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary Diagnosis: #Syncope #Sinus arrest #Heart failure with reduced ejection fraction, acute on chronic #Right pleural effusion/Trapped lung #Hypoxemia Secondary Diagnosis: # Atrial fibrillation # Macrocytic Anemia # ___ on CKD # Chronic back pain # Gout # Depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. ___, It was a pleasure taking part in your care here at ___! Why was I admitted to the hospital? - You had too much fluid backed up and were short of breath, a condition known as heart failure. - You passed out while you were having your blood drawn. - You were found to have a dangerous heart rhythm. - This rhythm was causing your heart to have pauses which were causing you to pass out. What was done for me in the hospital? - You were transferred to the ICU and received a device near your heart to prevent you from passing out. - You received medications through your IV to help you urinate off the extra fluid. - Your breathing improved with this medication, and you were switched to an oral version. - When you no longer had extra fluid, you were discharged to rehab. What should I do when I leave the hospital? - Please take all of your medicines and attend all of your follow-up appointments. - Weigh yourself every morning, call your doctor if your weight goes up by more than three pounds in one day or five pounds in two days. You weighed 183 lbs at discharge. If your weight increases, please call our heart failure specialists for directions on what to do. - Call your doctors ___ develop worsening shortness of breath, chest pressure, or any other symptoms that concern you - You will need to make appointment with the lung doctors ___ ___ to follow up on the best course of action for your trapped lung. We wish you the best of luck in your health! Your ___ Team Followup Instructions: ___
[ "I130", "N179", "D689", "D62", "I959", "E872", "I482", "I495", "I5023", "L7632", "J9811", "D539", "R55", "E785", "I255", "I455", "F329", "I2510", "G8929", "I341", "I340", "N189", "J449", "M109", "M5080", "R740", "R0902", "Z4502", "Z87891", "Z7902", "Z96659", "Z955", "Y838", "Y92230" ]
Allergies: Penicillins / oxycodone Chief Complaint: Syncope Major Surgical or Invasive Procedure: Pacemaker and ICD placement History of Present Illness: [MASKED] yo M with atrial fibrillation on rivaroxaban, CAD s/p stent placement (unknown vessel), HFrEF (EF [MASKED], mitral valve prolapse, HTN, HLD, depression, multiple spine surgeries, cholecystectomy who presents from heart failure clinic for acute HF management. On arrival, patient was alert and oriented with no distress with O2 at 3L 89% sats. At 3pm, he had a sip of water, and then started coughing and vomiting during phlebotomy. Per PCT, he passed out briefly with his eyes rolling back in his head and he was unconscious for a few minutes. He responded to calling his name and shaking. He then started coughing and was disoriented. He vomited brown bilous mucous/clear. His systolic blood pressure was in the low [MASKED] and he was then put on 4L of O2 and his coughing and vomiting stopped. He remembers drinking water but not precipitating events. There were no reported shaking episodes or stool/urine incontinence. Of note, patient recently discharged from [MASKED] on [MASKED]. He was found to have acute heart failure exacerbation likely due to missed diuretic doses at rehab. He was treating with Lasix drip in the MICU as well as anitbiotics (vancomycin, ceftazidime, and azithromycin) for HCAP. While here, he developed [MASKED] on CKD with a discharge creatinine of 1.7 (baseline of 1.1-1.2) thought to be in setting of possible diuresis and initiation of spironolactone and ace-I and also elevated vancomycin level (66) several days prior to d/c. Past Medical History: PAST MEDICAL HISTORY: ======================= 1. CARDIAC RISK FACTORS - Hypertension - Dyslipidemia 2. CARDIAC HISTORY - CAD s/p stent placement - CHF with EF [MASKED] - Afib on warfarin - mitral valve prolapse 3. OTHER PAST MEDICAL HISTORY depression chronic neck pain secondary to cervical disc disease multiple spine surgeries including fusion of L-S1 laminectomy cholecystectomy Total knee replacement B/l shoulder surgery c diff infection [MASKED] Social History: [MASKED] Family History: Mother: alive, age [MASKED]. Macular degeneration Father: deceased in mid [MASKED]. ?brain tumor and heart issues Physical Exam: Admission Physical Exam: ======================== GENERAL: Well developed, pleasant, lying in bed in NAD. Oriented x3. Mood, affect appropriate. HEENT: Normocephalic atraumatic. Sclera anicteric. Conjunctiva pink. No pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple. JVP to earlobe at 30 degrees. CARDIAC: Irregularly irregular. Normal S1, S2. No murmurs, rubs, or gallops. No thrills or lifts. LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. Clear to auscultation bilaterally. No wheezes, rales, or rhonchi. ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No splenomegaly. EXTREMITIES: Patient with warm distal extremities and warm proximal extremities. 1+-2+ peripheral edema to the mid-shin. SKIN: No significant skin lesions or rashes. PULSES: Distal pulses palpable and symmetric. Discharge Physical Exam: ======================== 24 HR Data (last updated [MASKED] @ 917) Temp: 97.4 (Tm 99.1), BP: 92/56 (88-116/44-73), HR: 80 (75-96), RR: 20 ([MASKED]), O2 sat: 92% (92-95), O2 delivery: RA, Wt: 183.2 lb/83.1 kg I: 660 O: [MASKED] B: -[MASKED] Wt: 83.1 kg <- 84 kg <- 84.2 kg <- 83.7 kg <- 82.6 kg <- 82.9 kg <- 83.2<-83.0 kg <- 82.6 kg <- 84.7 kg <- 87.1 kg <- 87 kg <- 87.09 <- 86.96 <- 90.22 Tele: AFib with no paced beats GENERAL: Well developed, pleasant, lying in bed in NAD. Oriented x3. Mood, affect appropriate. HEENT: Normocephalic atraumatic. Sclera anicteric. Conjunctiva pink. NECK: Supple. JVP 10 cm CARDIAC: Irregularly irregular. Normal S1, S2. No murmurs, rubs, or gallops. No thrills or lifts. LUNGS: No chest wall deformities or tenderness. Respiration is comfortable, particularly when laying flat. trace bibasilar crackles R side > L. very diminished on R ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No splenomegaly. EXTREMITIES: Patient with warm distal extremities and warm proximal extremities. no peripheral edema . PULSES: Distal pulses palpable and symmetric. Pertinent Results: Admission Labs: =============== [MASKED] 12:34PM BLOOD WBC-6.1 RBC-2.40* Hgb-7.6* Hct-25.1* MCV-105* MCH-31.7 MCHC-30.3* RDW-16.1* RDWSD-62.5* Plt [MASKED] [MASKED] 09:30PM BLOOD Glucose-120* UreaN-57* Creat-1.8* Na-135 K-4.7 Cl-92* HCO3-26 AnGap-17 [MASKED] 12:34PM BLOOD ALT-22 AST-38 LD(LDH)-259* AlkPhos-264* TotBili-1.1 [MASKED] 04:52AM BLOOD ALT-292* AST-467* AlkPhos-357* TotBili-1.4 [MASKED] 12:34PM BLOOD CK-MB-2 cTropnT-0.02* [MASKED] [MASKED] 12:34PM BLOOD TSH-4.6* [MASKED] 03:18PM BLOOD Lactate-3.3* Imaging: ======== CXR [MASKED]: No appreciable change since the prior chest radiograph including right lower lobe collapse and loculated right pleural fluid. CT Chest w/out contrast [MASKED] Renal U/S [MASKED]: No hydronephrosis. Trace perihepatic ascites CT CHEST W/O CONTRAST IMPRESSION: 1. Unchanged volume of a moderate right pleural effusion with decreased locule of gas likely from prior chest tube with persistent diffuse pleural thickening and areas of dependent pleural nodularity. Correlation with pleural fluid analysis is advised. 2. Previously seen extensive ground-glass opacities throughout the left lung have nearly completely resolved as has the left-sided pleural effusion. 3. Stable 2 mm left lower lobe pulmonary nodules. 4. Dilated main pulmonary artery to 4 cm suggesting pulmonary arterial hypertension. 5. Posterior gastric diverticulum. Discharge Labs: =============== [MASKED] 06:20AM BLOOD WBC-5.9 RBC-2.65* Hgb-8.6* Hct-27.0* MCV-102* MCH-32.5* MCHC-31.9* RDW-16.4* RDWSD-61.2* Plt [MASKED] [MASKED] 07:25AM BLOOD Glucose-97 UreaN-39* Creat-1.3* Na-140 K-3.8 Cl-96 HCO3-31 AnGap-13 [MASKED] 06:20AM BLOOD ALT-9 AST-14 AlkPhos-154* TotBili-0.7 Brief Hospital Course: Mr. [MASKED] is a [MASKED] year-old man with a history of atrial fibrillation on rivaroxaban, CAD s/p stent placement (unknown vessel), HFrEF (EF [MASKED], mitral valve prolapse, HTN, HLD, depression, multiple spine surgeries, and cholecystectomy, who initially presented from heart failure clinic for acute HF management. Subsequently, was noted to have sinus arrest and syncope requiring placement of single-chamber ICD implant. His heart failure regimen was optimized but somewhat limited by hypotension. ACUTE ISSUES: ============= # SYNCOPE # SINUS PAUSES # SINUS ARREST The patient experienced a 9-second pause with associated unresponsiveness. Subsequently was noted to have ventricular escape beats. The patient spontaneously recovered. He had an uncomplicated single-chamber ICD implant via L cephalic on [MASKED] without any further pauses or syncope. # ACUTE ON CHRONIC SYSTOLIC HEART FAILURE # HYPOXEMIA The patient has an EF of 34% [MASKED], and presented with weight gain, elevated JVP, hypoxemia, evidence of pulmonary edema on CXR, all suggestive of acute decompensation, likely secondary to decreased regimen at rehab due to a rise in creatinine. He initially responded well to IV diuresis and was transitioned to PO diuretics, but again developed an oxygen requirement. He was placed back on IV diuretics including a furosemide drip and once euvolemic was transitioned to PO torsemide 100 mg BID. He required intermittent metolozone. He required signifincant repletion of low potassium levels prior to starting spironolactone. His metoprolol was increased and he did not tolerate afterload reduction given low blood pressures. His weight on discharge was 83.1 kg (183.2 lb). # RIGHT PLEURAL EFFUSION / TRAPPED LUNG # HYPOXEMIA The patient has known right lower lobe collapse and loculated right pleural fluid, which appears similar to prior CXR. Given history of having been weaned off O2, and then having an increase requirement with holding of diuresis, acute CHF exacerbation is most likely explanation for hypoxemia. He was diuresed with improvement his oxygenation. Pulmonology was consulted given hypoxia on exertion and believes that the patient may have some underlying COPD in addition to his CHF contributing to hypoxia. He will benefit from having outpatient pulmonary function testing and follow up with [MASKED] clinic (IP + thoracic surgery). # ATRIAL FIBRILLATION He was transitioned to apixaban given high INRs on rivaroxaban and concern for GI bleed. Metoprolol was continued at a slightly reduced dose based on patient's tolerance. # MACROCYTIC ANEMIA The patient has a hemoglobin baseline of [MASKED], presenting with Hgb 7.6. Methylmalonic acid was WNL during recent admission and ferritin 500 suggesting anemia of chronic inflammation. Patient does have history of GI bleed requiring 2 pRBCs during last admission. Denies melena, hematochezia. He received 1 U of blood this admission and his hemoglobin was stable on discharge at 8.6. # [MASKED] on CKD Baseline ~1.2, however up to 1.7 on last discharge and on this admission. Improved to near baseline with diuresis. Discharged with Cr of 1.3. CHRONIC ISSUES: =============== # CHRONIC PAIN The patient has history of multiple prior spinal surgeries with ardware in place. Etiology of pain is unclear but likely multifactorial from degenerative disc disease and frequent surgeries. He continued on prn lidocaine patches, gabapentin, and tramadol. # GOUT He continued allopurinol. # DEPRESSION He continued sertraline. Transitional Issues: ==================== [ ] DISCHARGE WEIGHT: 83.1 kg (183.2 lb) [ ] DISCHARGE DIURETIC: 100 torsemide BID [ ] DISCHARGE Cr/BUN: 1.[MASKED] [ ] GOAL BLOOD PRESSURE: MAP [MASKED] [ ] MEDICATIONS STOPPED: - Ferrous Sulfate 325 mg PO DAILY - Rivaroxaban 20 mg PO QHS [ ] MEDICATIONS CHANGED: - Torsemide 40 mg PO DAILY increased to Torsemide 100 mg PO/NG BID - Metoprolol Succinate XL 50 mg PO BID decreased to Metoprolol Succinate XL 37.5 mg PO BID [ ] MEDICATIONS STARTED: - Apixaban 5 mg PO/NG BID - Spironolactone 12.5 mg PO/NG DAILY [ ] The patient has a known trapped lung and imaging suggestive of COPD. He will benefit from outpatient PFTs and an appointment with interventional [MASKED] clinic. [ ] Weigh the patient daily. If his weight increases by 3 lbs in one day or 5 lbs in two days, please call his cardiologist at [MASKED] for further directions and possible dosing of metolazone. [ ] If planning to adjust torsemide dose based on Cr increase or other parameter, please discuss with heart failure team @ [MASKED]. His CHF doctor will be Dr. [MASKED] [ ] The patient required significant repletion of potassium while diuresing as an inpatient. He was started on spironolactone prior to discharge. Please continue to check BMP on [MASKED] and then every other day until creatinine and potassium have stabilized. He was discharged on 40mEq of potassium daily. Please adjust potassium supplementation as indicated. [ ] The patient will benefit from a right and left heart catheterization once his ICD has been in place for [MASKED] months [MASKED] or [MASKED]. He would benefit from vasodilator study and full evaluation for pulmonary hypertension. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Acetaminophen 1000 mg PO TID 2. Allopurinol [MASKED] mg PO DAILY 3. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO QID:PRN upset stomach 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 40 mg PO QPM 6. Calcium Carbonate 500 mg PO QID:PRN heartburn 7. Docusate Sodium 100 mg PO TID:PRN constipation 8. Gabapentin 300 mg PO BID 9. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN SOB, wheezing 10. Lidocaine 5% Patch 1 PTCH TD QPM 11. Metoprolol Succinate XL 50 mg PO BID 12. Pantoprazole 40 mg PO Q24H 13. Rivaroxaban 20 mg PO QHS 14. Senna 17.2 mg PO QHS:PRN constipation 15. Sertraline 50 mg PO DAILY 16. TraMADol 75 mg PO BID:PRN Pain - Moderate 17. Torsemide 40 mg PO DAILY 18. Bisacodyl AILY:PRN constipation 19. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q2H:PRN sore throat 20. Cholestyramine 2 mg gm PO BID 21. Ferrous Sulfate 325 mg PO DAILY 22. Hydrocerin 1 Appl TP DAILY dry skin 23. Magnesium Oxide 400 mg PO DAILY 24. melatonin 3 mg oral QHS:PRN 25. Milk of Magnesia 30 mL PO QHS:PRN constipation 26. Ondansetron ODT 8 mg PO Q8H:PRN nausea, vomiting Discharge Medications: 1. Apixaban 5 mg PO BID 2. Potassium Chloride 40 mEq PO DAILY Hold for K > 3. Spironolactone 12.5 mg PO DAILY 4. Metoprolol Succinate XL 37.5 mg PO BID 5. Torsemide 100 mg PO BID 6. TraMADol 50 mg PO Q6H:PRN Pain - Severe 7. Acetaminophen 1000 mg PO TID 8. Allopurinol [MASKED] mg PO DAILY 9. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO QID:PRN upset stomach 10. Aspirin 81 mg PO DAILY 11. Atorvastatin 40 mg PO QPM 12. Bisacodyl AILY:PRN constipation 13. Calcium Carbonate 500 mg PO QID:PRN heartburn 14. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q2H:PRN sore throat 15. Cholestyramine 2 mg gm PO BID 16. Docusate Sodium 100 mg PO TID:PRN constipation 17. Gabapentin 300 mg PO BID 18. Hydrocerin 1 Appl TP DAILY dry skin 19. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN SOB, wheezing 20. Lidocaine 5% Patch 1 PTCH TD QPM 21. Magnesium Oxide 400 mg PO DAILY 22. melatonin 3 mg oral QHS:PRN 23. Milk of Magnesia 30 mL PO QHS:PRN constipation 24. Ondansetron ODT 8 mg PO Q8H:PRN nausea, vomiting 25. Pantoprazole 40 mg PO Q24H 26. Senna 17.2 mg PO QHS:PRN constipation 27. Sertraline 50 mg PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Primary Diagnosis: #Syncope #Sinus arrest #Heart failure with reduced ejection fraction, acute on chronic #Right pleural effusion/Trapped lung #Hypoxemia Secondary Diagnosis: # Atrial fibrillation # Macrocytic Anemia # [MASKED] on CKD # Chronic back pain # Gout # Depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [MASKED], It was a pleasure taking part in your care here at [MASKED]! Why was I admitted to the hospital? - You had too much fluid backed up and were short of breath, a condition known as heart failure. - You passed out while you were having your blood drawn. - You were found to have a dangerous heart rhythm. - This rhythm was causing your heart to have pauses which were causing you to pass out. What was done for me in the hospital? - You were transferred to the ICU and received a device near your heart to prevent you from passing out. - You received medications through your IV to help you urinate off the extra fluid. - Your breathing improved with this medication, and you were switched to an oral version. - When you no longer had extra fluid, you were discharged to rehab. What should I do when I leave the hospital? - Please take all of your medicines and attend all of your follow-up appointments. - Weigh yourself every morning, call your doctor if your weight goes up by more than three pounds in one day or five pounds in two days. You weighed 183 lbs at discharge. If your weight increases, please call our heart failure specialists for directions on what to do. - Call your doctors [MASKED] develop worsening shortness of breath, chest pressure, or any other symptoms that concern you - You will need to make appointment with the lung doctors [MASKED] [MASKED] to follow up on the best course of action for your trapped lung. We wish you the best of luck in your health! Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "I130", "N179", "D62", "E872", "E785", "F329", "I2510", "G8929", "N189", "J449", "M109", "Z87891", "Z7902", "Z955", "Y92230" ]
[ "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N179: Acute kidney failure, unspecified", "D689: Coagulation defect, unspecified", "D62: Acute posthemorrhagic anemia", "I959: Hypotension, unspecified", "E872: Acidosis", "I482: Chronic atrial fibrillation", "I495: Sick sinus syndrome", "I5023: Acute on chronic systolic (congestive) heart failure", "L7632: Postprocedural hematoma of skin and subcutaneous tissue following other procedure", "J9811: Atelectasis", "D539: Nutritional anemia, unspecified", "R55: Syncope and collapse", "E785: Hyperlipidemia, unspecified", "I255: Ischemic cardiomyopathy", "I455: Other specified heart block", "F329: Major depressive disorder, single episode, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "G8929: Other chronic pain", "I341: Nonrheumatic mitral (valve) prolapse", "I340: Nonrheumatic mitral (valve) insufficiency", "N189: Chronic kidney disease, unspecified", "J449: Chronic obstructive pulmonary disease, unspecified", "M109: Gout, unspecified", "M5080: Other cervical disc disorders, unspecified cervical region", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "R0902: Hypoxemia", "Z4502: Encounter for adjustment and management of automatic implantable cardiac defibrillator", "Z87891: Personal history of nicotine dependence", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "Z96659: Presence of unspecified artificial knee joint", "Z955: Presence of coronary angioplasty implant and graft", "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", "Y92230: Patient room in hospital as the place of occurrence of the external cause" ]
19,994,379
27,052,619
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / oxycodone Attending: ___. Chief Complaint: Back pain Major Surgical or Invasive Procedure: ___: Thoracentesis w chest tube insertion ___: Thoracentesis w chest tube insertion History of Present Illness: ___ male history of afib, ___, previous lumbar and cervical spine surgeries by Dr. ___ osteomyelitis ___, and HFrEF who presents now with one half weeks of worsening back pain. He was seen prior to arrival at ___ ___ emergency room where he was found to have had a CT of lumbar spine concerning for discitis at L1-L2 with epidural abscess and probable to level as well as the pathologic fractures involving the L1-L2 vertebral bodies. Patient transferred to ___ for further management. Workup prior to arrival notable for white blood cell count 7.96, hemoglobin 11.6, hematocrit 34.6, MCV 107, platelet count 178, neutrophils 81%, ESR 17, normal range ___, GFR 38, BUN 49, glucose 110, creatinine 1.76, calcium 8.9, sodium 142, potassium 4.1, chloride 105, bicarb 25, bilirubin 0.6, alk phos 168, AST 11, ALT 15, CRP 36.6. He was transferred from OSH after CT L-spine showed L1-2 discitis, osteomyelitis and pathologic fracture. He presents today with low back and hip pain for the past several months which has worsened over the past 4 days. He reports intermittent weakness of the left lower extremity when changing from seated to standing which resolves with ambulation. Denies paresthesias or other weakness, intermittent bowel incontinence at baseline and no other bowel/bladder symptoms. Denies fevers/chills. He has recent falls due to losing his balance while walking and carrying large items but is unable to elaborate on this. Patient states he has a long history of chronic hip/back pain. His typical pain is bilateral hip, front think and buttock "shock like pain" without radiation that is daily, intensifies with movement (worst in AM when getting out of bed and out of a chair) and when laying flat. He typically takes ___ advil in the morning before he gets out of bed but this doesn't help very much. He reports he has never tried typical neuropathic pain agents. He describes worsening of the pain for the last ___ months without a clear provoking etiology. For the last ___ days, he has noted working shock like pain especially in hips and a mild ache in his mid back. He does report he fell up the stairs 3 weeks ago while carrying packages (the weight carried him forward) and he landed on his chest but did not note worsening in his chronic pain at that time. He specifically denies chest pain, dyspnea, jaw/arm pain, diaphoresis, nausea recently or today. He denies recent fevers, chills, night sweats, weight loss. He reports he has had two episodes of spinal infection and was unsure of his symptoms at that point. Patient denied any saddle anesthesia, urinary retention, bowel or bladder incontinence, or fevers. Patient did describe intermittent weakness of left lower extremity and numbness of the whole leg that occurs with position but none now. Past Medical History: Afib on warfarin CAD s/p stent placement CHF with EF ___ mitral valve prolapse HTN HLD depression chronic neck pain secondary to cervical disc disease multiple spine surgeries including fusion of L-S1 laminectomy cholecystectomy Total knee replacement B/l shoulder surgery Social History: ___ Family History: Mother: alive, age ___. Macular degeneration Father: deceased in ___. ?brain tumor and heart issues Physical Exam: ADMISSON PHYSICAL EXAM ===================== VITALS: 98.1 110 / 61 87 20 97 2LNc GENERAL: Alert and interactive. In no acute distress. HEENT: Normocephalic, atraumatic. Pupils equal, round bilaterally, extraocular muscles intact. Sclera anicteric and without injection. Moist mucous membranes, good dentition. Oropharynx is clear. NECK: No JVD. CARDIAC: Irreg irreg rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally w/appropriate breath sounds appreciated in all fields. No wheezes, rhonchi or rales. No increased work of breathing. BACK: No spinous process tenderness. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. Cap refill <2s. No rash. NEUROLOGIC: CN2-12 intact. ___ strength throughout, patient grimacing when checking hip flexion. Normal sensation. AOx3. DISCHARGE PHYSICAL EXAM: ========================= VITALS: 97.7 PO 99/61 L Lying 80 18 92 2L GENERAL: Laying in bed, NAD HEENT: EOMI grossly, anicteric sclera, MMM HEART: Irregular rhythm, normal S1/S2, no murmurs, gallops, or rubs. LUNGS: Diffusely decreased breath sounds ABDOMEN: Normoactive bowel sounds. Soft, distended, tympanic, nontender in all quadrants, no rebound/guarding. EXTREMITIES: no cyanosis, clubbing, or edema, moving all 4 extremities with purpose, warm w good cap refill NEURO: A/O X3 (person, place, time) Pertinent Results: ___ ===================== ___ 11:30PM BLOOD WBC-7.3 RBC-3.18* Hgb-11.5* Hct-34.1* MCV-107*# MCH-36.2*# MCHC-33.7 RDW-16.2* RDWSD-62.9* Plt ___ ___ 11:30PM BLOOD Neuts-77.1* Lymphs-10.3* Monos-10.0 Eos-1.4 Baso-0.8 Im ___ AbsNeut-5.63 AbsLymp-0.75* AbsMono-0.73 AbsEos-0.10 AbsBaso-0.06 ___ 11:30PM BLOOD ___ PTT-28.8 ___ ___ 11:30PM BLOOD Glucose-102* UreaN-44* Creat-1.5* Na-144 K-3.5 Cl-103 HCO3-24 AnGap-17 ___ 01:35PM BLOOD Calcium-8.5 Phos-4.2 Mg-1.2* ___ 01:35PM BLOOD VitB12-321 ___ 07:12AM BLOOD TSH-1.6 ___ 11:30PM BLOOD CRP-50.0* ___ 05:30PM BLOOD Cortsol-19.6 ___ 07:56PM BLOOD CK-MB-3 cTropnT-0.46* ___ ___ 06:27AM BLOOD ALT-30 AST-27 AlkPhos-191* TotBili-0.5 ___ 03:00PM BLOOD calTIBC-251* Ferritn-829* TRF-193* ___ 01:35PM BLOOD SED RATE- 46 MICROBIOLOGY ===================== ___ 2:00 am BLOOD CULTURE Blood Culture, Routine (Pending): ___ 2:33 am URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ___ STOOL C. difficile DNA amplification assay- POSITIVE ___ 2:35 pm PLEURAL FLUID PLEURAL FLUID. **FINAL REPORT ___ GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Final ___: NO GROWTH. ___ MRSA SCREEN- NEGATIVE ___ Blood Culture x2: NO GROWTH ___ 10:35 am PLEURAL FLUID PLEURAL FLUID. **FINAL REPORT ___ GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Final ___: NO GROWTH. ___ Blood Culture x2: NO GROWTH, Routine-FINAL INPATIENT ___ URINE CULTURE- NO GROWTH ___ Blood Culture x2 NO GROWTH PLEURAL FLUID ANALYSIS: ======================= ___ 10:35AM PLEURAL TotProt-2.4 Glucose-90 Creat-3.5 LD(___)-104 Albumin-1.2 ___ Misc-BODY FLUID ___ 10:35AM PLEURAL TNC-62* RBC-___* Polys-4* Lymphs-75* Monos-8* Atyps-8* Macro-5* Other-0 ___ 02:35PM PLEURAL TotProt-1.7 Glucose-89 Creat-1.6 LD(___)-103 Albumin-1.1 Cholest-20 ___ 02:35PM PLEURAL TNC-49* ___ Polys-23* Lymphs-74* Monos-2* Macro-1* ___ CTYOLOGY: NEGATIVE FOR MALIGNANT CELLS. ___ CTYOLOGY: NEGATIVE FOR MALIGNANT CELLS. DISCHARGE LABS: ================ ___ 04:35AM BLOOD WBC-7.1 RBC-2.53* Hgb-8.8* Hct-27.3* MCV-108* MCH-34.8* MCHC-32.2 RDW-16.7* RDWSD-66.0* Plt ___ ___ 04:35AM BLOOD Glucose-88 UreaN-20 Creat-1.2 Na-140 K-4.1 Cl-100 HCO3-26 AnGap-14 ___ 04:35AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.1 IMAGING ====================== MRI spine ___ IMPRESSION: 1. Study is degraded by motion and by lumbar spinal fusion hardware artifact. 2. Cervical degenerative disc disease as detailed above, without high-grade spinal canal narrowing or cord signal abnormality. There is severe neural foraminal narrowing at multiple levels. 3. Mild thoracic degenerative disc disease, without high-grade spinal canal or neural foraminal narrowing. 4. Loculated right pleural effusion basilar right lower lobe could reflect atelectasis, however pneumonia cannot be excluded. Chest CT is suggested. 5. Instrumented lumbar fusion at L4-S1, interbody fusion graft at L3-4 with partial osseous fusion, and solid osseous fusion of the L2-3 level as detailed above. 6. L1-2 disc extrusion with superior migration results in severe spinal canal narrowing. There is probable impingement of the traversing L2 and possibly other nerve roots. Allowing for difference technique, finding may be slightly progressed compared to ___ prior exam. 7. Within limits of study, no definite evidence of discitis-osteomyelitis, or epidural abscess. 8. Probable subacute to chronic oblique fracture of the superior endplate of L2 with lateral extension through the lateral vertebral body. 9. Right L1-2 and bilateral L2-3 Severe neural foraminal narrowing. CXR ___ IMPRESSION: There is a mild to moderate layering right pleural effusion. There is dilation of colon at the splenic fracture. CT A/P ___ IMPRESSION: 1. Volume loss in the right lower lobe may represent atelectasis or infection. Please correlate with clinical status. 2. No retroperitoneal hematoma or free intra-abdominal fluid. 3. Intermediate density fluid in the bladder may represent delayed excretion of iodinated contrast from prior CT study or hemorrhage products. Please correlate with visual inspection of the urine or urinalysis. 4. Moderate right pleural effusion. TTE ___ IMPRESSION: Normal left ventricular cavity size with regional systolic dysfunction most c/w CAD (mid-LAD distribution vs. Takotsubo CM). Moderate mitral regurgitation. Mild pulmonary artery systolic hypertension. Mild-mderate tricuspid regurgitation. Abdominal x-ray ___ IMPRESSION: Gaseous distension of the colon, appearing unchanged compared to the recent CT scan DX PELVIS & FEMUR ___: No fracture of the bilateral femurs. CT CHEST ___: 1. Mild to moderate right pleural collection containing loculated fluid and air with a chest tube in situ. Mild-to-moderate free-flowing left pleural effusion. 2. Bilateral patchy peripheral ground-glass opacities are concerning for an atypical infection. Presence of interlobular septal thickening may be secondary to pulmonary edema. Clinical correlation is recommended. 3. Mild mediastinal and hilar lymphadenopathy is nonspecific and could be related to infections. PORTABLE ABDOMEN ___ Interval improvement of dilation of large bowel, however large bowel dilation has not resolved. There is no evidence of intraperitoneal free air. Brief Hospital Course: PATIENT SUMMARY: ================ Mr. ___ is a ___ year old man with w/ HFrEF, CAD s/p stent, atrial fibrillation on Xarelto, ___ syndrome, CKD, chronic neck pain ___ cervical disc disease and multiple spine surgeries including fusion of L-S1 laminectomy who presented to OSH with ___ weeks of worsening back pain and left hip pain, transferred for spine eval, with MRI negative for infection, admitted for pain management. Hospital course was complicated by oliguric renal failure in setting of contrast load on ___ and NSAID use, and hypotension in setting of receiving entresto and diuresis, requiring transfer to the MICU for worsening hypoxia and persistent hypotension. He was found to have R side pleural effusion with improvement after chest tube placement x2 ___, removed, replaced ___. Further hospital course complicated by C difficile. ACUTE ISSUES: ============= #Hypoxemia #Right pleural effusion #Concern for RLL PNA #Trapped lung On arrive to ED at ___, pt noted to be developing progressive hypoxemia requiring nasal cannula in setting of developing oliguric renal failure. Suspected multifactorial due to PNA, pleural effusion, & pulmonary edema from volume overload. Effusion likely chronic per review of imaging, and potentially has formed fibrosis causing trapped lung. s/p R side chest tube ___, which was removed same day after minimal draining, replaced ___ for reaccumulation and quickly removed again. CT chest ___ also indicated possible atypical PNA, completed 7 day course of cefepime for HAP (___), transitioned briefly to ceftriaxone/azithro (___). He was also found to have e/o volume overload in setting of diuretic held and receiving IVF for hypotension. Hypoxia improved somewhat with gentle diuresis, and home Lasix was restarted three days prior to discharge with stable volume status and oxygen requirement. At time of discharge, he is still requiring oxygen although has decreased from 4L to 1.5-2L. Likely will remain dependent on oxygen until decortication after rehab. Eventual plan is to likely decortication per IP, who will follow outpt with patient in 4 weeks, when he will also receive a chest CT. #Hypotension #History of Hypertension Initially suspected PNA & Entresto use I/s/o sepsis. Entresto and diuretics were held. Per nephrology, sacubitril's inhibition of neprilysin leads to increase in several vasoactive substances including BNP and bradykinin which are vasodilators, and likely culprits for what appears to be his prior distributive hypotension. Metoprolol succinate home dose is 225 mg; he was switched to metoprolol succinate 50mg daily with good blood pressure and HR control. BP remained stable 99-103/62-70 since ___. Discussed ___ meds with outpatient cardiologist Dr. ___ requested that patient remain on BB and at least a low-dose ACEi if tolerated. Started lisinopril 2.5mg daily on ___, patient tolerating well on discharge. Holding home entresto on discharge. #C difficile infection Pt w frequent loose stools that developed during hospitalization, found to be cdiff+ on ___ and started on PO vanc ___. Switched to PO flagyl (___) as infection not considered to be complicated, for 10d course ending ___. ___ #?CKD Likely multifactorial from CIN (given contrast on ___ at OSH), NSAID-use, valsartan in Entrosto +/- ATN. Cr 1.5 on admission ___ and peaked to 3.4. Creatinine stable around 1.2-1.4 for the week prior to discharge, baseline unknown but likely has some underlying mild CKD. #Acute on chronic back pain #Hip/leg pain Patient with hx of multiple prior spinal surgeries with hardware in place and spinal osteomyelitis/discitis/epidural abscess in ___. He presented with 4 days of worsening back pain. CRP 50, concerning for infectious process, however MRI showed no e/o infection. Spine surgery consulted and no acute intervention needed. XR b/l femur showed generalized degenerative changes throughout b/l SI joints, hip joints, and pubic symphysis. No fracture. Etiology of pain unclear but likely multifactorial from DJD and frequent surgeries. Managed with lidocaine patches, acetaminophen standing, and tramadol PRN. CHRONIC ISSUES: =============== #HFrEF, CAD #Troponinemia Pt with hx of CAD and HFrEF 35%, likely iCMP. Troponins mildly elevated in setting ___ to 0.46 without CK-MB elevation or ischemic changes on EKG. Continued home ASA 81mg and atorvastatin 10mg PO QD. For preload, held home metolazone given hypotension, diuresis as above. Home metop dosing was changed as above. Held home entresto given ___ and hypotension as above, started 2.5mg lisinopril for afterload mgmt per outpatient cardiologist. Will have outpatient followup. #Afib (CHADS2VASC = 3) Anticoagulation was briefly held for chest tube placement, after which home Xarelto was held. Home metoprolol changed as above, discharged on 50 mg succinate daily with good rate control. ___ syndrome Pt dx during an admission in ___. Was monitored during hospitalization, especially in setting of receiving narcotics, with some abdominal distension noted. KUB obtained ___ showed interval improvement in colonic distention from prior imaging. #Gout: Continued home allopurinol ___ mg QD #Depression: Continued home sertraline 50 mg PO QD #GERD: Continued home omeprazole 20 mg PO QD #Acute on chronic macrocytic anemia MCV elevated from last admission: Continued Ferrous Sulfate 65 mg PO DAILY TRANSITIONAL ISSUES: ====================== NEW MEDICATIONS -Acetaminophen 1g TID (for pain) -Calcium carbonate 500mg QID PRN (heartburn) -Ipratropium-Albuterol Neb Q4H PRN (SOB, wheezing) -Lidocaine 5% patch QPM (for pain) -Lisinopril 2.5mg PO daily (for CHF, HTN) -Flagyl 500mg PO Q8H (cdiff, abx course ___ -Ondansetron ODT 8mg PO Q8H PRN (nausea, vomiting) -Tramadol 50mg PO Q4H PRN (moderate pain) -Tramadol 50mg PO BID PRN (severe pain) -Oxygen support (usually on ___ NC) CHANGED MEDICATIONS -Metoprolol succinate XL 50mg PO daily (changed from 125 QAM and 100 QPM given hypotension) STOPPED/HELD MEDICATIONS -Metolazone 2.5mg PO every other day (held for hypotension, ___ -Sacubitril-Valsartan 24mg-26mg BID (held for hypotension, ___ OTHER: [ ]Will follow-up with interventional pulm and Thoracics in 4 weeks for chest CT and to discuss need for decortication of fibrotic trapped lung [ ]S/P R side chest tube ___ [ ]Please discuss mgmt. of patient's HTN and CHF, his BPs remained soft (100s/50s) throughout hospitalization despite ___ agents had been held for a week. [ ___ appt w PCP/cardiology Dr. ___ on ___ [ ___ appt with IP to be scheduled, likely ___ as pt has chest CT scheduled that day [ ]Pt being discharged to rehab on oxygen ___ NC). If unable to wean at rehab, will need home O2 as well. [ ___ need further titration of pain medication with increased activity at rehab. #code status: full #contact: ___ ___ (daughter) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 10 mg PO QPM 4. Sertraline 50 mg PO DAILY 5. Omeprazole 20 mg PO DAILY 6. Metolazone 2.5 mg PO EVERY OTHER DAY 7. Sacubitril-Valsartan (24mg-26mg) 1 TAB PO BID 8. Metoprolol Succinate XL 125 mg PO DAILY 9. Metoprolol Succinate XL 100 mg PO QHS 10. Ferrous Sulfate 65 mg PO DAILY 11. magnesium chloride 1250 oral DAILY 12. Rivaroxaban 20 mg PO DAILY 13. Furosemide 80 mg PO QAM 14. Furosemide 40 mg PO QPM Discharge Medications: 1. Acetaminophen 1000 mg PO TID 2. Calcium Carbonate 500 mg PO QID:PRN heartburn 3. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN SOB, wheezing 4. Lidocaine 5% Patch 1 PTCH TD QPM 5. Lisinopril 2.5 mg PO DAILY 6. MetroNIDAZOLE 500 mg PO Q8H ___ - ___ 7. Ondansetron ODT 8 mg PO Q8H:PRN nausea, vomiting 8. TraMADol 50 mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity hold for somnolence or RR<12 RX *tramadol 50 mg 1 tablet(s) by mouth every 4 hours as needed Disp #*18 Tablet Refills:*0 9. Metoprolol Succinate XL 50 mg PO DAILY 10. Allopurinol ___ mg PO DAILY 11. Aspirin 81 mg PO DAILY 12. Atorvastatin 10 mg PO QPM 13. Ferrous Sulfate 65 mg PO DAILY 14. Furosemide 80 mg PO QAM 15. Furosemide 40 mg PO QPM 16. magnesium chloride 1250 oral DAILY 17. Omeprazole 20 mg PO DAILY 18. Rivaroxaban 20 mg PO DAILY 19. Sertraline 50 mg PO DAILY 20. HELD- Metolazone 2.5 mg PO EVERY OTHER DAY This medication was held. Do not restart Metolazone until until you talk to your cardiologist 21. HELD- Sacubitril-Valsartan (24mg-26mg) 1 TAB PO BID This medication was held. Do not restart Sacubitril-Valsartan (24mg-26mg) until you talk to you cardiologist Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary -Acute hypoxemic respiratory failure -Chronic pleural effusions -Trapped lung, R side -Hypotension -Acute kidney injury -Cdiff infection -Acute on chronic back, hip pain SECONDARY -Heart failure with reduced ejection fraction -Coronary artery disease -Atrial fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. ___, You came to the hospital because you were having terrible back pain and the doctors at the ___ hospital were concerned you might have an infection in your back. While you were here, we did not see any evidence of infection in your back, but we did notice you had fluid behind your lungs (pleural effusions). We drained these, treated you for pneumonia, and gave you oxygen to support your breathing. We also noticed that your blood pressure was very low. We stopped your blood pressure medications for a little while, and restarted some of them at lower doses. Your cardiologist should talk to you about these at your follow-up appointment next week. When you leave, you will go to rehab to work on your strength and mobility. You will continue to use your oxygen until you feel more comfortable off of it. It was a pleasure to care for you. We wish you the best in your recovery. ___ Medicine Care Team Followup Instructions: ___
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Allergies: Penicillins / oxycodone Chief Complaint: Back pain Major Surgical or Invasive Procedure: [MASKED]: Thoracentesis w chest tube insertion [MASKED]: Thoracentesis w chest tube insertion History of Present Illness: [MASKED] male history of afib, [MASKED], previous lumbar and cervical spine surgeries by Dr. [MASKED] osteomyelitis [MASKED], and HFrEF who presents now with one half weeks of worsening back pain. He was seen prior to arrival at [MASKED] [MASKED] emergency room where he was found to have had a CT of lumbar spine concerning for discitis at L1-L2 with epidural abscess and probable to level as well as the pathologic fractures involving the L1-L2 vertebral bodies. Patient transferred to [MASKED] for further management. Workup prior to arrival notable for white blood cell count 7.96, hemoglobin 11.6, hematocrit 34.6, MCV 107, platelet count 178, neutrophils 81%, ESR 17, normal range [MASKED], GFR 38, BUN 49, glucose 110, creatinine 1.76, calcium 8.9, sodium 142, potassium 4.1, chloride 105, bicarb 25, bilirubin 0.6, alk phos 168, AST 11, ALT 15, CRP 36.6. He was transferred from OSH after CT L-spine showed L1-2 discitis, osteomyelitis and pathologic fracture. He presents today with low back and hip pain for the past several months which has worsened over the past 4 days. He reports intermittent weakness of the left lower extremity when changing from seated to standing which resolves with ambulation. Denies paresthesias or other weakness, intermittent bowel incontinence at baseline and no other bowel/bladder symptoms. Denies fevers/chills. He has recent falls due to losing his balance while walking and carrying large items but is unable to elaborate on this. Patient states he has a long history of chronic hip/back pain. His typical pain is bilateral hip, front think and buttock "shock like pain" without radiation that is daily, intensifies with movement (worst in AM when getting out of bed and out of a chair) and when laying flat. He typically takes [MASKED] advil in the morning before he gets out of bed but this doesn't help very much. He reports he has never tried typical neuropathic pain agents. He describes worsening of the pain for the last [MASKED] months without a clear provoking etiology. For the last [MASKED] days, he has noted working shock like pain especially in hips and a mild ache in his mid back. He does report he fell up the stairs 3 weeks ago while carrying packages (the weight carried him forward) and he landed on his chest but did not note worsening in his chronic pain at that time. He specifically denies chest pain, dyspnea, jaw/arm pain, diaphoresis, nausea recently or today. He denies recent fevers, chills, night sweats, weight loss. He reports he has had two episodes of spinal infection and was unsure of his symptoms at that point. Patient denied any saddle anesthesia, urinary retention, bowel or bladder incontinence, or fevers. Patient did describe intermittent weakness of left lower extremity and numbness of the whole leg that occurs with position but none now. Past Medical History: Afib on warfarin CAD s/p stent placement CHF with EF [MASKED] mitral valve prolapse HTN HLD depression chronic neck pain secondary to cervical disc disease multiple spine surgeries including fusion of L-S1 laminectomy cholecystectomy Total knee replacement B/l shoulder surgery Social History: [MASKED] Family History: Mother: alive, age [MASKED]. Macular degeneration Father: deceased in [MASKED]. ?brain tumor and heart issues Physical Exam: ADMISSON PHYSICAL EXAM ===================== VITALS: 98.1 110 / 61 87 20 97 2LNc GENERAL: Alert and interactive. In no acute distress. HEENT: Normocephalic, atraumatic. Pupils equal, round bilaterally, extraocular muscles intact. Sclera anicteric and without injection. Moist mucous membranes, good dentition. Oropharynx is clear. NECK: No JVD. CARDIAC: Irreg irreg rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally w/appropriate breath sounds appreciated in all fields. No wheezes, rhonchi or rales. No increased work of breathing. BACK: No spinous process tenderness. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. Cap refill <2s. No rash. NEUROLOGIC: CN2-12 intact. [MASKED] strength throughout, patient grimacing when checking hip flexion. Normal sensation. AOx3. DISCHARGE PHYSICAL EXAM: ========================= VITALS: 97.7 PO 99/61 L Lying 80 18 92 2L GENERAL: Laying in bed, NAD HEENT: EOMI grossly, anicteric sclera, MMM HEART: Irregular rhythm, normal S1/S2, no murmurs, gallops, or rubs. LUNGS: Diffusely decreased breath sounds ABDOMEN: Normoactive bowel sounds. Soft, distended, tympanic, nontender in all quadrants, no rebound/guarding. EXTREMITIES: no cyanosis, clubbing, or edema, moving all 4 extremities with purpose, warm w good cap refill NEURO: A/O X3 (person, place, time) Pertinent Results: [MASKED] ===================== [MASKED] 11:30PM BLOOD WBC-7.3 RBC-3.18* Hgb-11.5* Hct-34.1* MCV-107*# MCH-36.2*# MCHC-33.7 RDW-16.2* RDWSD-62.9* Plt [MASKED] [MASKED] 11:30PM BLOOD Neuts-77.1* Lymphs-10.3* Monos-10.0 Eos-1.4 Baso-0.8 Im [MASKED] AbsNeut-5.63 AbsLymp-0.75* AbsMono-0.73 AbsEos-0.10 AbsBaso-0.06 [MASKED] 11:30PM BLOOD [MASKED] PTT-28.8 [MASKED] [MASKED] 11:30PM BLOOD Glucose-102* UreaN-44* Creat-1.5* Na-144 K-3.5 Cl-103 HCO3-24 AnGap-17 [MASKED] 01:35PM BLOOD Calcium-8.5 Phos-4.2 Mg-1.2* [MASKED] 01:35PM BLOOD VitB12-321 [MASKED] 07:12AM BLOOD TSH-1.6 [MASKED] 11:30PM BLOOD CRP-50.0* [MASKED] 05:30PM BLOOD Cortsol-19.6 [MASKED] 07:56PM BLOOD CK-MB-3 cTropnT-0.46* [MASKED] [MASKED] 06:27AM BLOOD ALT-30 AST-27 AlkPhos-191* TotBili-0.5 [MASKED] 03:00PM BLOOD calTIBC-251* Ferritn-829* TRF-193* [MASKED] 01:35PM BLOOD SED RATE- 46 MICROBIOLOGY ===================== [MASKED] 2:00 am BLOOD CULTURE Blood Culture, Routine (Pending): [MASKED] 2:33 am URINE Source: [MASKED]. **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: NO GROWTH. [MASKED] STOOL C. difficile DNA amplification assay- POSITIVE [MASKED] 2:35 pm PLEURAL FLUID PLEURAL FLUID. **FINAL REPORT [MASKED] GRAM STAIN (Final [MASKED]: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [MASKED]: NO GROWTH. ANAEROBIC CULTURE (Final [MASKED]: NO GROWTH. [MASKED] MRSA SCREEN- NEGATIVE [MASKED] Blood Culture x2: NO GROWTH [MASKED] 10:35 am PLEURAL FLUID PLEURAL 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.. FLUID CULTURE (Final [MASKED]: NO GROWTH. ANAEROBIC CULTURE (Final [MASKED]: NO GROWTH. [MASKED] Blood Culture x2: NO GROWTH, Routine-FINAL INPATIENT [MASKED] URINE CULTURE- NO GROWTH [MASKED] Blood Culture x2 NO GROWTH PLEURAL FLUID ANALYSIS: ======================= [MASKED] 10:35AM PLEURAL TotProt-2.4 Glucose-90 Creat-3.5 LD([MASKED])-104 Albumin-1.2 [MASKED] Misc-BODY FLUID [MASKED] 10:35AM PLEURAL TNC-62* RBC-[MASKED]* Polys-4* Lymphs-75* Monos-8* Atyps-8* Macro-5* Other-0 [MASKED] 02:35PM PLEURAL TotProt-1.7 Glucose-89 Creat-1.6 LD([MASKED])-103 Albumin-1.1 Cholest-20 [MASKED] 02:35PM PLEURAL TNC-49* [MASKED] Polys-23* Lymphs-74* Monos-2* Macro-1* [MASKED] CTYOLOGY: NEGATIVE FOR MALIGNANT CELLS. [MASKED] CTYOLOGY: NEGATIVE FOR MALIGNANT CELLS. DISCHARGE LABS: ================ [MASKED] 04:35AM BLOOD WBC-7.1 RBC-2.53* Hgb-8.8* Hct-27.3* MCV-108* MCH-34.8* MCHC-32.2 RDW-16.7* RDWSD-66.0* Plt [MASKED] [MASKED] 04:35AM BLOOD Glucose-88 UreaN-20 Creat-1.2 Na-140 K-4.1 Cl-100 HCO3-26 AnGap-14 [MASKED] 04:35AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.1 IMAGING ====================== MRI spine [MASKED] IMPRESSION: 1. Study is degraded by motion and by lumbar spinal fusion hardware artifact. 2. Cervical degenerative disc disease as detailed above, without high-grade spinal canal narrowing or cord signal abnormality. There is severe neural foraminal narrowing at multiple levels. 3. Mild thoracic degenerative disc disease, without high-grade spinal canal or neural foraminal narrowing. 4. Loculated right pleural effusion basilar right lower lobe could reflect atelectasis, however pneumonia cannot be excluded. Chest CT is suggested. 5. Instrumented lumbar fusion at L4-S1, interbody fusion graft at L3-4 with partial osseous fusion, and solid osseous fusion of the L2-3 level as detailed above. 6. L1-2 disc extrusion with superior migration results in severe spinal canal narrowing. There is probable impingement of the traversing L2 and possibly other nerve roots. Allowing for difference technique, finding may be slightly progressed compared to [MASKED] prior exam. 7. Within limits of study, no definite evidence of discitis-osteomyelitis, or epidural abscess. 8. Probable subacute to chronic oblique fracture of the superior endplate of L2 with lateral extension through the lateral vertebral body. 9. Right L1-2 and bilateral L2-3 Severe neural foraminal narrowing. CXR [MASKED] IMPRESSION: There is a mild to moderate layering right pleural effusion. There is dilation of colon at the splenic fracture. CT A/P [MASKED] IMPRESSION: 1. Volume loss in the right lower lobe may represent atelectasis or infection. Please correlate with clinical status. 2. No retroperitoneal hematoma or free intra-abdominal fluid. 3. Intermediate density fluid in the bladder may represent delayed excretion of iodinated contrast from prior CT study or hemorrhage products. Please correlate with visual inspection of the urine or urinalysis. 4. Moderate right pleural effusion. TTE [MASKED] IMPRESSION: Normal left ventricular cavity size with regional systolic dysfunction most c/w CAD (mid-LAD distribution vs. Takotsubo CM). Moderate mitral regurgitation. Mild pulmonary artery systolic hypertension. Mild-mderate tricuspid regurgitation. Abdominal x-ray [MASKED] IMPRESSION: Gaseous distension of the colon, appearing unchanged compared to the recent CT scan DX PELVIS & FEMUR [MASKED]: No fracture of the bilateral femurs. CT CHEST [MASKED]: 1. Mild to moderate right pleural collection containing loculated fluid and air with a chest tube in situ. Mild-to-moderate free-flowing left pleural effusion. 2. Bilateral patchy peripheral ground-glass opacities are concerning for an atypical infection. Presence of interlobular septal thickening may be secondary to pulmonary edema. Clinical correlation is recommended. 3. Mild mediastinal and hilar lymphadenopathy is nonspecific and could be related to infections. PORTABLE ABDOMEN [MASKED] Interval improvement of dilation of large bowel, however large bowel dilation has not resolved. There is no evidence of intraperitoneal free air. Brief Hospital Course: PATIENT SUMMARY: ================ Mr. [MASKED] is a [MASKED] year old man with w/ HFrEF, CAD s/p stent, atrial fibrillation on Xarelto, [MASKED] syndrome, CKD, chronic neck pain [MASKED] cervical disc disease and multiple spine surgeries including fusion of L-S1 laminectomy who presented to OSH with [MASKED] weeks of worsening back pain and left hip pain, transferred for spine eval, with MRI negative for infection, admitted for pain management. Hospital course was complicated by oliguric renal failure in setting of contrast load on [MASKED] and NSAID use, and hypotension in setting of receiving entresto and diuresis, requiring transfer to the MICU for worsening hypoxia and persistent hypotension. He was found to have R side pleural effusion with improvement after chest tube placement x2 [MASKED], removed, replaced [MASKED]. Further hospital course complicated by C difficile. ACUTE ISSUES: ============= #Hypoxemia #Right pleural effusion #Concern for RLL PNA #Trapped lung On arrive to ED at [MASKED], pt noted to be developing progressive hypoxemia requiring nasal cannula in setting of developing oliguric renal failure. Suspected multifactorial due to PNA, pleural effusion, & pulmonary edema from volume overload. Effusion likely chronic per review of imaging, and potentially has formed fibrosis causing trapped lung. s/p R side chest tube [MASKED], which was removed same day after minimal draining, replaced [MASKED] for reaccumulation and quickly removed again. CT chest [MASKED] also indicated possible atypical PNA, completed 7 day course of cefepime for HAP ([MASKED]), transitioned briefly to ceftriaxone/azithro ([MASKED]). He was also found to have e/o volume overload in setting of diuretic held and receiving IVF for hypotension. Hypoxia improved somewhat with gentle diuresis, and home Lasix was restarted three days prior to discharge with stable volume status and oxygen requirement. At time of discharge, he is still requiring oxygen although has decreased from 4L to 1.5-2L. Likely will remain dependent on oxygen until decortication after rehab. Eventual plan is to likely decortication per IP, who will follow outpt with patient in 4 weeks, when he will also receive a chest CT. #Hypotension #History of Hypertension Initially suspected PNA & Entresto use I/s/o sepsis. Entresto and diuretics were held. Per nephrology, sacubitril's inhibition of neprilysin leads to increase in several vasoactive substances including BNP and bradykinin which are vasodilators, and likely culprits for what appears to be his prior distributive hypotension. Metoprolol succinate home dose is 225 mg; he was switched to metoprolol succinate 50mg daily with good blood pressure and HR control. BP remained stable 99-103/62-70 since [MASKED]. Discussed [MASKED] meds with outpatient cardiologist Dr. [MASKED] requested that patient remain on BB and at least a low-dose ACEi if tolerated. Started lisinopril 2.5mg daily on [MASKED], patient tolerating well on discharge. Holding home entresto on discharge. #C difficile infection Pt w frequent loose stools that developed during hospitalization, found to be cdiff+ on [MASKED] and started on PO vanc [MASKED]. Switched to PO flagyl ([MASKED]) as infection not considered to be complicated, for 10d course ending [MASKED]. [MASKED] #?CKD Likely multifactorial from CIN (given contrast on [MASKED] at OSH), NSAID-use, valsartan in Entrosto +/- ATN. Cr 1.5 on admission [MASKED] and peaked to 3.4. Creatinine stable around 1.2-1.4 for the week prior to discharge, baseline unknown but likely has some underlying mild CKD. #Acute on chronic back pain #Hip/leg pain Patient with hx of multiple prior spinal surgeries with hardware in place and spinal osteomyelitis/discitis/epidural abscess in [MASKED]. He presented with 4 days of worsening back pain. CRP 50, concerning for infectious process, however MRI showed no e/o infection. Spine surgery consulted and no acute intervention needed. XR b/l femur showed generalized degenerative changes throughout b/l SI joints, hip joints, and pubic symphysis. No fracture. Etiology of pain unclear but likely multifactorial from DJD and frequent surgeries. Managed with lidocaine patches, acetaminophen standing, and tramadol PRN. CHRONIC ISSUES: =============== #HFrEF, CAD #Troponinemia Pt with hx of CAD and HFrEF 35%, likely iCMP. Troponins mildly elevated in setting [MASKED] to 0.46 without CK-MB elevation or ischemic changes on EKG. Continued home ASA 81mg and atorvastatin 10mg PO QD. For preload, held home metolazone given hypotension, diuresis as above. Home metop dosing was changed as above. Held home entresto given [MASKED] and hypotension as above, started 2.5mg lisinopril for afterload mgmt per outpatient cardiologist. Will have outpatient followup. #Afib (CHADS2VASC = 3) Anticoagulation was briefly held for chest tube placement, after which home Xarelto was held. Home metoprolol changed as above, discharged on 50 mg succinate daily with good rate control. [MASKED] syndrome Pt dx during an admission in [MASKED]. Was monitored during hospitalization, especially in setting of receiving narcotics, with some abdominal distension noted. KUB obtained [MASKED] showed interval improvement in colonic distention from prior imaging. #Gout: Continued home allopurinol [MASKED] mg QD #Depression: Continued home sertraline 50 mg PO QD #GERD: Continued home omeprazole 20 mg PO QD #Acute on chronic macrocytic anemia MCV elevated from last admission: Continued Ferrous Sulfate 65 mg PO DAILY TRANSITIONAL ISSUES: ====================== NEW MEDICATIONS -Acetaminophen 1g TID (for pain) -Calcium carbonate 500mg QID PRN (heartburn) -Ipratropium-Albuterol Neb Q4H PRN (SOB, wheezing) -Lidocaine 5% patch QPM (for pain) -Lisinopril 2.5mg PO daily (for CHF, HTN) -Flagyl 500mg PO Q8H (cdiff, abx course [MASKED] -Ondansetron ODT 8mg PO Q8H PRN (nausea, vomiting) -Tramadol 50mg PO Q4H PRN (moderate pain) -Tramadol 50mg PO BID PRN (severe pain) -Oxygen support (usually on [MASKED] NC) CHANGED MEDICATIONS -Metoprolol succinate XL 50mg PO daily (changed from 125 QAM and 100 QPM given hypotension) STOPPED/HELD MEDICATIONS -Metolazone 2.5mg PO every other day (held for hypotension, [MASKED] -Sacubitril-Valsartan 24mg-26mg BID (held for hypotension, [MASKED] OTHER: [ ]Will follow-up with interventional pulm and Thoracics in 4 weeks for chest CT and to discuss need for decortication of fibrotic trapped lung [ ]S/P R side chest tube [MASKED] [ ]Please discuss mgmt. of patient's HTN and CHF, his BPs remained soft (100s/50s) throughout hospitalization despite [MASKED] agents had been held for a week. [ [MASKED] appt w PCP/cardiology Dr. [MASKED] on [MASKED] [ [MASKED] appt with IP to be scheduled, likely [MASKED] as pt has chest CT scheduled that day [ ]Pt being discharged to rehab on oxygen [MASKED] NC). If unable to wean at rehab, will need home O2 as well. [ [MASKED] need further titration of pain medication with increased activity at rehab. #code status: full #contact: [MASKED] [MASKED] (daughter) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol [MASKED] mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 10 mg PO QPM 4. Sertraline 50 mg PO DAILY 5. Omeprazole 20 mg PO DAILY 6. Metolazone 2.5 mg PO EVERY OTHER DAY 7. Sacubitril-Valsartan (24mg-26mg) 1 TAB PO BID 8. Metoprolol Succinate XL 125 mg PO DAILY 9. Metoprolol Succinate XL 100 mg PO QHS 10. Ferrous Sulfate 65 mg PO DAILY 11. magnesium chloride 1250 oral DAILY 12. Rivaroxaban 20 mg PO DAILY 13. Furosemide 80 mg PO QAM 14. Furosemide 40 mg PO QPM Discharge Medications: 1. Acetaminophen 1000 mg PO TID 2. Calcium Carbonate 500 mg PO QID:PRN heartburn 3. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN SOB, wheezing 4. Lidocaine 5% Patch 1 PTCH TD QPM 5. Lisinopril 2.5 mg PO DAILY 6. MetroNIDAZOLE 500 mg PO Q8H [MASKED] - [MASKED] 7. Ondansetron ODT 8 mg PO Q8H:PRN nausea, vomiting 8. TraMADol 50 mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity hold for somnolence or RR<12 RX *tramadol 50 mg 1 tablet(s) by mouth every 4 hours as needed Disp #*18 Tablet Refills:*0 9. Metoprolol Succinate XL 50 mg PO DAILY 10. Allopurinol [MASKED] mg PO DAILY 11. Aspirin 81 mg PO DAILY 12. Atorvastatin 10 mg PO QPM 13. Ferrous Sulfate 65 mg PO DAILY 14. Furosemide 80 mg PO QAM 15. Furosemide 40 mg PO QPM 16. magnesium chloride 1250 oral DAILY 17. Omeprazole 20 mg PO DAILY 18. Rivaroxaban 20 mg PO DAILY 19. Sertraline 50 mg PO DAILY 20. HELD- Metolazone 2.5 mg PO EVERY OTHER DAY This medication was held. Do not restart Metolazone until until you talk to your cardiologist 21. HELD- Sacubitril-Valsartan (24mg-26mg) 1 TAB PO BID This medication was held. Do not restart Sacubitril-Valsartan (24mg-26mg) until you talk to you cardiologist Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Primary -Acute hypoxemic respiratory failure -Chronic pleural effusions -Trapped lung, R side -Hypotension -Acute kidney injury -Cdiff infection -Acute on chronic back, hip pain SECONDARY -Heart failure with reduced ejection fraction -Coronary artery disease -Atrial fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [MASKED], You came to the hospital because you were having terrible back pain and the doctors at the [MASKED] hospital were concerned you might have an infection in your back. While you were here, we did not see any evidence of infection in your back, but we did notice you had fluid behind your lungs (pleural effusions). We drained these, treated you for pneumonia, and gave you oxygen to support your breathing. We also noticed that your blood pressure was very low. We stopped your blood pressure medications for a little while, and restarted some of them at lower doses. Your cardiologist should talk to you about these at your follow-up appointment next week. When you leave, you will go to rehab to work on your strength and mobility. You will continue to use your oxygen until you feel more comfortable off of it. It was a pleasure to care for you. We wish you the best in your recovery. [MASKED] Medicine Care Team Followup Instructions: [MASKED]
[]
[ "I130", "J9601", "I4891", "I2510", "N189", "Z7902", "Z955", "E785", "F329", "Z87891", "M109", "K219" ]
[ "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "J9601: Acute respiratory failure with hypoxia", "N170: Acute kidney failure with tubular necrosis", "R578: Other shock", "J189: Pneumonia, unspecified organism", "A0472: Enterocolitis due to Clostridium difficile, not specified as recurrent", "I4891: Unspecified atrial fibrillation", "J918: Pleural effusion in other conditions classified elsewhere", "I5022: Chronic systolic (congestive) heart failure", "J9811: Atelectasis", "E8342: Hypomagnesemia", "J984: Other disorders of lung", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "N189: Chronic kidney disease, unspecified", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "K598: Other specified functional intestinal disorders", "Z955: Presence of coronary angioplasty implant and graft", "I341: Nonrheumatic mitral (valve) prolapse", "E785: Hyperlipidemia, unspecified", "F329: Major depressive disorder, single episode, unspecified", "Z96659: Presence of unspecified artificial knee joint", "Z87891: Personal history of nicotine dependence", "T39395A: Adverse effect of other nonsteroidal anti-inflammatory drugs [NSAID], initial encounter", "T508X5A: Adverse effect of diagnostic agents, initial encounter", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "T502X5A: Adverse effect of carbonic-anhydrase inhibitors, benzothiadiazides and other diuretics, initial encounter", "T465X5A: Adverse effect of other antihypertensive drugs, initial encounter", "Z9981: Dependence on supplemental oxygen", "M159: Polyosteoarthritis, unspecified", "T8189XA: Other complications of procedures, not elsewhere classified, initial encounter", "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", "I255: Ischemic cardiomyopathy", "M109: Gout, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "D539: Nutritional anemia, unspecified", "M5126: Other intervertebral disc displacement, lumbar region", "M48061: Spinal stenosis, lumbar region without neurogenic claudication", "N141: Nephropathy induced by other drugs, medicaments and biological substances", "R112: Nausea with vomiting, unspecified" ]
19,994,379
27,334,101
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / oxycodone Attending: ___. Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: ___ YO M with afib on rovarozaban, CAD s/p stent placement, HFrEF (EF ___, mitral valve prolapse, HTN, HLD, depression, multiple spine surgeries, cholecystectomy who presents from rehab with dyspnea, felt to be in acute heart failure exacerbation ___ holding of diuretic regimen at rehab in setting of hypotension. He brought in from rehab with concern of shortness of breath and increased pleural effusion on CXR at rehab. Per ED notes: He's had recent hospitalization for hypoxemia, pneumonia and right sided pleural effusion. He had a chest tube placed x2 by IP with fluid consistent with HF and concern for trapped lung as well. Patient treated with abx for presumed pneumonia and discharged to rehab on 1.5-2L NC. While in rehab weaned off O2 by ___ but started to have new O2 requrimenet yesterday that increased to 2L NC again today. SOB worse with movement. No chest pain, fever/chills/ night sweates or new cough. Notes increase in abdominal distension though diarrhea has improved now while he remains on antibiotics for c.diff. Notes weight gain of ~15 lbs with dry weight of 205 and 220 this am at rehab In the ED initial vitals were: 97.9 86 107/57 22 99% 2L NC ED exam notable for: Gen:NAD, breathing comfortably on 2L O2, AOx3 CV: irregularly irregular, no murmurs, JVD to jawline Pulm: Decreased right sided lower breath sounds, no crakcles Abd: soft, significantly distended, no peritoneal signs, non-tender, ___: 3+ edema bilaterally up to the low thigh Labs/studies notable for: 6.7 > 8.___.7 < ___ ------------<116 AGap=14 5.4 23 1.1 Trop-T: <0.01 proBNP: ___ Lactate:2.6 CXR notable for: FINDINGS: AP portable upright view of the chest. No significant change from recent prior exam with loculated right pleural effusion tracking circumferentially with a similar overall pattern. Opacities within the right lung again noted. Left lung is grossly clear. The heart appears mildly enlarged. Mediastinal contour stable. Imaged bony structures are intact. Multiple surgical anchors are noted at bilateral humeral heads. IMPRESSION: No significant interval change. Patient was given: ___ 16:28 IV Furosemide 80 mg Patient was seen by cardiology: Per Cards ED evaluation: "Patient presenting with likely primarily CHF exacerbation. Patient unclear if he has been taking diuretics appropriately, which could be precipitant. Given this is the primary reason for admission, his reduced EF, and some concern that diuresis was being held at rehab due to hypotension." Recommended admission to Cardiology. Per ED assessment: "Likely HFrEF exacerbation with weight gain and increase in shortness of breath and ___ edema. AM Lasix held for a few days while in rehab given soft BP that may have caused volume overload. Will touch base wit IP re worsening shortness of breath and history of concern for trapped lung and placement of chest tube. CXR without evidence of new consolidation or significantly worsening pulm edema though has right sided pleural effusion tracking circumferentially. Clinically without fever, new cough, or sputum production concerning for pneumonia. No evidence of pericardial effusion on bedside echo. No ascites on bedside echo either. Abdominal distenstion without n/v and with regular bowel movement unlikely caused by obstruction though has history of ___ syndrome." Of note, patient is s/p discharge on ___ after presenting to OSH with ___ weeks of worsening back pain and left hip pain, transferred for spine eval, with MRI negative for infection, admitted for pain management. Hospital course was complicated by oliguric renal failure in setting of contrast load on ___ and NSAID use, and hypotension in setting of receiving entresto and diuresis, requiring transfer to the MICU for worsening hypoxia and persistent hypotension. He was found to have R side pleural effusion with improvement after chest tube placement x2 ___, removed, replaced ___. Further hospital course complicated by C difficile. Vitals on transfer: 97.6 109 100/76 22 94% 3L NC On the floor... He reports he was at rehab and things were going fairly well. He reported they took him off O2 on ___ through the weekend until ___ (back on O2). He reports that he didn't have much activity over the weekend, but this Am he reported that he felt more SOB and was sent back. He reports he feels "bloated" but denies weight gain; he reports his weight at rehab was 223-224; he doesn't remember what his weight was when he got to rehab (?220). He reports his dry weight is about 205 lbs. He reports his SOB has been going on "for a long time"; he first noticed it a few months. He reports some improvement after his chest tubes; he reported once he was active at rehab his respiratory symptoms had improved. Denies CP, but does report occasional "palpitations" but he denies attributing this to his afib (and reports it has seemed to have gotten better.) Rpeorts some lightheadedness this AM. Denies LOC. Reports significant leg swelling. Denies recent infections, cough or cold symptoms. Denies abd pain, n/v but reports some nausea with c diff medication but none in the past two days. Reports + diarrhea at admission today x2. He reports this seems like his C. diff symptoms. Denies dysuria. Denies blood in stool or urine. Past Medical History: PAST MEDICAL HISTORY: ======================= 1. CARDIAC RISK FACTORS - Hypertension - Dyslipidemia 2. CARDIAC HISTORY - CAD s/p stent placement - CHF with EF ___ - Afib on warfarin - mitral valve prolapse 3. OTHER PAST MEDICAL HISTORY depression chronic neck pain secondary to cervical disc disease multiple spine surgeries including fusion of L-S1 laminectomy cholecystectomy Total knee replacement B/l shoulder surgery c diff infection ___ Social History: ___ Family History: Mother: alive, age ___. Macular degeneration Father: deceased in mid ___. ?brain tumor and heart issues Physical Exam: ADMISSION PHYSICAL EXAMINATION: ================================= VS: Temp: 98.4 (Tm 98.4), BP: 103/74 (90-134/49-87), HR: 111 (111-148), RR: 26 (___), O2 sat: 93% (86-97), O2 delivery: 2LNC (2LNC-3L), Wt: 218 lb/98.88 kg GENERAL: Well developed, well nourished M, sitting at bedside in NAD. Oriented x3. Mood, affect appropriate. HEENT: Normocephalic atraumatic. Sclera anicteric. EOMI grossly. Conjunctiva were pink. No pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple. JVP to angle of mandible at 90 degrees CARDIAC: PMI located in ___ intercostal space, midclavicular line. irregularly irregular rate, Tachycardic. LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. diminished lung sounds R lung extending up to mid lung fields. no crackles appreciated bilaterally; no wheezes. ABDOMEN: Soft, non-tender, mildly distended EXTREMITIES: extremities slightly cool perfused. 3+ pitting edema to knees bilaterally DISCHARGE PHYSICAL EXAMINATION: ================================= PHYSICAL EXAM: VS: 98.3 90/52 89 18 94% Ra GENERAL: Alert, oriented, no acute distress HEENT: Sclera anicteric NECK: supple, JVP to 10 cm LUNGS: Decreased BS in RLL, no wheezing CV: Irrregular, tachycardic, ___ pansystolic murmur at apex and LLSB ABD: mild distention, non-tender, and soft, normoactive BS EXT: Warm, non-edematous bilaterally, non-tender NEURO: No gross motor or coordination abnormalities Pertinent Results: ADMISSION LABS ======================== ___ 12:50PM BLOOD WBC-6.7 RBC-2.63* Hgb-8.9* Hct-27.7* MCV-105* MCH-33.8* MCHC-32.1 RDW-16.2* RDWSD-62.4* Plt ___ ___ 12:50PM BLOOD Neuts-76.2* Lymphs-7.2* Monos-13.8* Eos-1.4 Baso-0.9 Im ___ AbsNeut-5.08 AbsLymp-0.48* AbsMono-0.92* AbsEos-0.09 AbsBaso-0.06 ___ 12:50PM BLOOD Glucose-116* UreaN-18 Creat-1.1 Na-135 K-5.4* Cl-98 HCO3-23 AnGap-14 ___ 12:50PM BLOOD CK(CPK)-42* ___ 06:20AM BLOOD ALT-<5 AST-9 LD(LDH)-180 AlkPhos-94 TotBili-0.7 ___ 12:50PM BLOOD CK-MB-2 proBNP-6666* ___ 12:50PM BLOOD cTropnT-<0.01 ___ 09:35PM BLOOD Calcium-8.9 Phos-2.6* Mg-1.2* ___ 01:11PM BLOOD Lactate-2.6* K-5.1 ___ 01:34PM BLOOD Lactate-1.8 PERTIENT LABS ======================== ___ 06:20AM BLOOD calTIBC-212* VitB12-498 Folate-3 Ferritn-500* TRF-163* ___ 06:50AM BLOOD Vanco-66.0* DISCHARGE LABS ======================== ___ 08:10AM BLOOD WBC-7.2 RBC-2.55* Hgb-8.2* Hct-26.0* MCV-102* MCH-32.2* MCHC-31.5* RDW-17.0* RDWSD-63.9* Plt ___ ___ 08:10AM BLOOD Plt ___ ___ 08:10AM BLOOD ___ PTT-35.1 ___ ___ 08:10AM BLOOD Glucose-93 UreaN-31* Creat-1.7* Na-136 K-3.9 Cl-93* HCO3-30 AnGap-13 ___ 02:11AM BLOOD ALT-<5 AST-11 LD(LDH)-217 AlkPhos-79 TotBili-1.0 DirBili-0.4* IndBili-0.6 ___ 08:10AM BLOOD Calcium-8.9 Phos-4.1 Mg-1.7 IMAGING ======================== CXR ___ AP portable upright view of the chest. No significant change from recent prior exam with loculated right pleural effusion tracking circumferentially with a similar overall pattern. Opacities within the right lung again noted. Left lung is grossly clear. The heart appears mildly enlarged. Mediastinal contour stable. Imaged bony structures are intact. Multiple surgical anchors are noted at bilateral humeral heads. CT CHEST ___ Persistent large and probably loculated right hydropneumothorax, probably reflecting chronic restrictive right pleural thickening, in combination with severe lower lobe atelectasis. No contributory bronchial obstruction. Severe coronary atherosclerosis. Mild cardiomegaly. Substantially improved bilateral airspace pulmonary abnormality, nature indeterminate, could be post infectious or slow to resolve hemorrhage. KUB ___ Colonic obstruction, worse than on prior examination. There is an abrupt cutoff of the colonic dilatation in the proximal descending colon, as on prior CT. The possibility of a stricture at this level is suggested. No free air on supine. CT A/P ___. Colonic distension is minimally increased since the prior study measures approximately 8.1 cm, previously measured 7 cm with smooth tapering in the proximal descending colon is suggestive ___ syndrome. No gross stricture identified. 2. Small bowel is normal caliber. No evidence of bowel obstruction. 3. Air-fluid levels within the colon suggests a diarrheal state. 4. Partially visualized known right hydropneumothorax. 5. Ground-glass opacifications in the visualized central left lower and anterior left upper lobe are nonspecific and may reflect an infectious or inflammatory process. CT CHEST ___. Extensive progression of more confluent areas of ground-glass opacification in a peribronchovascular distribution involving the entire left lung since the prior study of ___, raises concern for infection. Asymmetric pulmonary edema could also be considered.. 2. Overall stable appearance moderate right hydropneumothorax and associated collapse of the left lower lobe. 3. Slightly increased size of small left pleural effusion. CXR ___ FINDINGS: The heart size is enlarged, stable in appearance as compared to ___. Re-demonstrated are bilateral parenchymal opacities, unchanged with associated air bronchograms, more prominent on the right. There is a loculated right pleural effusion, no left pleural effusion. There is near complete atelectasis with the right lower lobe. There is unchanged over distention of the stomach. There is no pneumothorax. IMPRESSION: In comparison to the prior radiograph dated ___, there is stable appearance of near complete right lower lobe atelectasis with a now larger loculated right pleural effusion. Persistent bibasilar opacities. MICROBIOLOGY ======================== Blood Cx ___: No growth Blood Cx ___: No growth Blood Cx ___: No growth Urine Cx ___: No growth MRSA Screen ___: Negative C. Difficile ___: Negative Brief Hospital Course: BRIEF HOSPITAL COURSE =================================== ___ yo M with atrial fibrillation on rivaroxaban, CAD s/p stent placement, HFrEF (EF ___, mitral valve prolapse, HTN, HLD, depression, multiple spine surgeries, cholecystectomy who presents from rehab with dyspnea and weight gain consistent with acute heart failure exacerbation likely secondary to missed diuretic doses at rehab (held for SBP < 100), treated with a Lasix drip to euvolemia. Once euvolemic, he still required 2L O2 and thoracic surgery was consulted for possible intervention for trapped lung. While awaiting intervention, patient had a vagal episode followed by hypotension and bradycardia requiring ICU admission. There was suspicion of GI bleed and he was transfused 2u pRBCs. He was briefly on pressors but was able to be quickly weaned. On transfer back to the floor, he continued diuresis but repeat chest CT showed increased ground glass opacities of the left lung concerning for infection versus pulmonary edema, so he was treated for HAP with vancomycin, ceftazidime and azithromycin. With antibiotics and diuresis, his dyspnea, hypoxia improved. ___ Course: Mr. ___ is a ___ man with A fib on rivaroxaban, CAD s/p PCI/stent, chronic systolic congestive heart failure (LV EF ___, mitral valve prolapse, hypertension, hyperlipidemia, and other issues admitted with acute pulmonary edema attributed to acute on chronic systolic congestive failure, with his hospital course complicated by GI bleeding and vasovagal event resulting in bradycardia to ___ when using the commode on ___. He recovered spontaneously without atropine. He subsequently became progressively hypotensive to ___, lactate 6.9, hgb drop 6.1 from 7.4. Dark brown, guaiac + stool. GI and ACS were consulted who did not recommend immediate intervention. KUB w/o free air. On arrival to the MICU, patient was awake and mentating well. Complaining mostly of back pain. Cdiff was ordered given for significant abdominal distention. Norepinephrine max 0.15 mcg/kg/hr, nurse was able to quickly wean to .04 prior to receiving blood. He was transfused with 2uPRBC and 1U FFP, chased with 100 mg Lasix. He was weaned off Levophed prior to transfer.) =============== ACTIVE ISSUES: =============== #Heart failure with reduced ejection fraction, acute decompensation: Patient with history of heart failure with reduced ejection fraction secondary to ischemic cardiomyopathy. Patient presented with >20lbs weight gain from dry weight and increased SOB, consistent with heart failure exacerbation likely secondary to missed diuretic doses at rehab (held for SBP < 100). He was treated with a lasix drip 20 mg/hr and lasix boluses of 160 mg IV to euvolemia. He was unable to tolerate a Persantine MIBI due to back pain, despite pre-medication. He was changed to Torsemide 60mg daily and remained euvolemic, however this dose was changed to 40mg daily given creatinine up to 1.7 (from baseline 1.2). He was discharged on diuretic regimen torsemide 40 mg daily. His metoprolol was uptitrated and he was discharged on metoprolol succinate XL 50 mg BID. Lisinopril 2.5 mg daily was HELD due to ___ on CKD (see below). Spironolactone could not be added on to regimen due to low blood pressure and increase in creatinine after two doses. #Hypoxemia: #Right pleural effusion/Trapped lung: #Pneumonia: Patient developed trapped lung as complication of anterior approach to L2-L3 fusion. Patient was hypoxic during last admission due in part to trapped lung and right sided pleural effusion, and he had chest tube placed x 2. Thoracic surgery was consulted, and deferred intervention urgently given poor clinical status. ___ benefit from VATS vs possible open thoracotomy decortication of entrapped right lung. Toward end of hospital course, patient developed more SOB and hypoxia requiring up to 4L NC. Repeat CT chest suggested increased ground glass opacities of left lung concerning for infection vs pulmonary edema, stable hydropneumothorax. Completed a course of vancomycin/ceftazidime/azithromycin (___). MRSA screen was negative. After management with antibiotics and diuresis, patient's oxygen requirement decreased to 96% RA. However, patient did occasionally require ___ with exertion (desat to 87%). Thoracic surgery and IP will follow up as outpatient. #Atrial fibrillation: Patient's rates were well controlled after up-titrating metoprolol to succinate XL 50 mg BID (HR ___, peaked in 130s with significant exertion). Patient was on metoprolol XL 225mg daily prior to last admission, which was decreased to 50mg daily at discharge ___. This had been further reduced to 12.5mg at rehab prior to this admission. He was continued on Rivaroxaban 20 mg PO QHS and Metop XL 50mg BID. #C diff infection: Patient was diagnosed with C. difficile during last admission, and planned to complete PO flagyl 10 day course on ___. Per rehab records, it was unclear whether he completed this course. Given he reported ongoing diarrhea on admission, he was treated with a second 10 day course of PO vancomycin to ensure complete treatment, with course from ___. C. diff negative on ___. #Abdominal distention with Ogilvies: Pt with known history of ___ syndrome. He was noted to have prominent abdominal distention without pain, constipation, or other concerning signs. Had CT abdomen consistent with Ogilvies. A bowel regimen was continued. Abdominal distention improved. ___ on CKD: Baseline 1.2, initially uptrended in the setting of diuresis despite appearing overloaded on exam, possibly related to ATN in setting of transient hypotension from valsalva, bradycardic episode. Cr improved later with continued diuresis but increased again on ___ possibly in the setting of starting spironolactone, which was discontinued. On ___, a vancomycin level was checked which was elevated at 66. Creatinine started to increase 48 hours after this, and additionally patient was given Spirinolactone x 2 days. Likely both of these insults explain the worsening ___. His lisinopril was stopped and Torsemide was decreased to 40mg daily. On discharge, Cr 1.7 (baseline 1.2). Patient euvolemic and I/Os and weight stable, however Torsemide was decreased due Cr 1.7. It is expected that patient's creatinine will start to improve ___ weeks after Vancomycin, Spirinolactone, Lisinopril were stopped, and Torsemide decreased. A post void residual was 21. Patient should avoid all NSAIDs going forward. #Macrocytic Anemia: Noted to have macrocytic anemia with hemoglobin ___ during admission. Prior to transfer to ICU, he was noted to have guaiac positive stool with hemoglobin drop and was transfused 2u pRBCs. Iron studies showed an Fe/TIBC 22%, consistent with mild iron deficiency. B12 and folate were normal. Methylmalonic acid was WNL. His Ferrous Sulfate 325 mg PO DAILY was continued at discharge. Please re-check iron studies to ensure no iron toxicity on supplemental iron and discontinue supplemental iron when iron replete. If within goals, pt may be further evaluated for MDS. # Shock, hypotension, lactic acidosis (resolved): Patient developed hypotension and bradycardia in setting of valsalva c/w vagal event. However, had persistent hypotension after event with elevated lactate to 6.9 and hgb drop to from 7.4 to 6.1, guaiac positive stools, cool extermities, and volume overload with elevated JVP. Initially, concern for hemorrhagic shock (Hgb drop and guaiac positive stools) vs abdominal ischemia (distended abdomen, lactate) vs cardiogenic shock (cool, elevated JVP, increased BNP). Levophed was maxed, but rapidly weaned off prior to any other treatments. Lactate also resolved prior to any other treatments. ACS and GI were consulted for concern for abdominal compartment syndrome vs ischemia, but felt that exam was not concerning. He received 2U pRBC and 1U FFP chased with 100mg IV lasix with good Hgb response. No further signs of bleeding. Weaned off of pressors and was warm on exam. ================ CHRONIC ISSUES: ================ #Chronic back pain: #Hip/leg pain: Per last discharge summary, patient has history of multiple prior spinal surgeries with hardware in place. No evidence of infection during last admission. Etiology of pain is unclear but likely multifactorial from degenerative disc disease and frequent surgeries. He was continued on lidocaine patches, acetaminophen standing, gabapentin, and tramadol prn. His neurologic exam was intact. Consider chronic pain clinic outpatient for possible injection/nerve block. #Gout: Continued allopurinol ___ mg daily #Depression: Continued Sertraline 50 mg PO DAILY TRANSITIONAL ISSUES: ============================= [ ] DISCHARGE WEIGHT: 89.3 kg (196.87 lb) [ ] DISCHARGE DIURETIC: Torsemide 40 mg daily [ ] DISCHARGE ANTICOAGULATION: Rivaroxaban 20 mg PO QHS [ ] DISCHARGE BUN/CR: ___ [ ] FOLLOW UP LABORATORY TESTING: Recheck Chem 10, monitor lytes and creatinine ON ___. [ ] If Cr continues to uptrend, >2, would refer to Nephrology. [ ] Please continue to monitor weights and volume overload. Call Cardiology office with > 3 lb weight change. [ ] Please ensure follow-up with thoracic surgery and interventional pulmonology (appointments scheduled) for trapped lung. [ ] Please continue to monitor heart rates and atrial fibrillation. Metoprolol was uptitrated with improvement in rates (final dose Metop XL 50mg BID). [ ] Torsemide reduced to 40 mg daily due to uptrending Cr [ ] Rivaroxaban dosing continued given GFR > 50, but may need to reduce dose if Cr continues to uptrend >1.7. [ ] Holding lisinopril due to ___ on CKD. Please restart lisinopril 2.5mg daily if Cr normalizes. [ ] Please re-check iron studies to ensure no iron toxicity on supplemental iron and discontinue supplemental iron when iron replete. [ ] Follow up on macrocytic anemia with further work up (?MDS). [ ] Please continue to counsel patients to avoid NSAIDs given his heart failure diagnosis and history of NSAID implicated acute tubular necrosis during last admission. [ ] Consider adding spironolactone as tolerated by creatinine to optimize HF regimen. [ ] Please note that Tramadol and Gabapentin were decreased given delirium earlier in hospitalization; pain was appropriately controlled at these smaller doses. [ ] Atorvastatin was increased to 40mg QPM this hospitalization. # CODE STATUS: FULL CODE # CONTACT: Name of health care proxy: ___ Relationship: daughter Phone number: ___ Cell phone: ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 10 mg PO QPM 4. Furosemide 80 mg PO QAM 5. Furosemide 40 mg PO QPM 6. Metoprolol Succinate XL 12.5 mg PO DAILY 7. Rivaroxaban 20 mg PO QHS 8. Sertraline 50 mg PO DAILY 9. Acetaminophen 1000 mg PO TID 10. Calcium Carbonate 500 mg PO QID:PRN heartburn 11. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN SOB, wheezing 12. Lidocaine 5% Patch 1 PTCH TD QPM 13. Lisinopril 2.5 mg PO DAILY 14. MetroNIDAZOLE 500 mg PO Q8H 15. Ondansetron ODT 8 mg PO Q8H:PRN nausea, vomiting 16. TraMADol 100 mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity 17. Ferrous Sulfate 325 mg PO DAILY 18. Pantoprazole 40 mg PO Q24H 19. Hydrocerin 1 Appl TP DAILY dry skin 20. Cholestyramine 2 mg gm PO BID 21. Gabapentin 300 mg PO TID 22. Milk of Magnesia 30 mL PO QHS:PRN constipation 23. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO QID:PRN upset stomach 24. Bisacodyl ___AILY:PRN constipation 25. Docusate Sodium 100 mg PO TID:PRN constipation 26. Senna 17.2 mg PO QHS:PRN constipation 27. melatonin 3 mg oral QHS:PRN 28. Vancomycin Oral Liquid ___ mg PO Q6H 29. Magnesium Oxide 400 mg PO DAILY 30. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q2H:PRN sore throat Discharge Medications: 1. Torsemide 40 mg PO DAILY 2. Allopurinol ___ mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. Gabapentin 300 mg PO BID 5. Metoprolol Succinate XL 50 mg PO BID 6. TraMADol 75 mg PO BID:PRN Pain - Moderate 7. Acetaminophen 1000 mg PO TID 8. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO QID:PRN upset stomach 9. Aspirin 81 mg PO DAILY 10. Bisacodyl ___AILY:PRN constipation 11. Calcium Carbonate 500 mg PO QID:PRN heartburn 12. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q2H:PRN sore throat 13. Cholestyramine 2 mg gm PO BID 14. Docusate Sodium 100 mg PO TID:PRN constipation 15. Ferrous Sulfate 325 mg PO DAILY 16. Hydrocerin 1 Appl TP DAILY dry skin 17. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN SOB, wheezing 18. Lidocaine 5% Patch 1 PTCH TD QPM 19. Magnesium Oxide 400 mg PO DAILY 20. melatonin 3 mg oral QHS:PRN 21. Milk of Magnesia 30 mL PO QHS:PRN constipation 22. Ondansetron ODT 8 mg PO Q8H:PRN nausea, vomiting 23. Pantoprazole 40 mg PO Q24H 24. Rivaroxaban 20 mg PO QHS 25. Senna 17.2 mg PO QHS:PRN constipation 26. Sertraline 50 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: ============= - Heart failure with reduced ejection fraction, acute on chronic - Atrial fibrillation - Trapped lung, right pleural effusion - Pneumonia - Anemia - ___ syndrome - Acute on chronic kidney disease Secondary: ================== - C. difficile colitis - Chronic back pain - Gout - Depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. ___, You were admitted to the hospital because you were short of breath. What happened while I was in the hospital? - You were found to have a lot of extra fluid in your body, so you were started on Lasix (a water pill). The fluid built up in your body because of your heart failure. - The thoracic surgery team evaluated your lung, and you should follow-up with them to discuss possible surgery for your lung. - You were treated with an antibiotic for a c. diff infection in your bowel. - You were briefly treated in the intensive care unit for low blood pressure and low heart rates. - You developed a pneumonia in the hospital, which was treated with antibiotics. What should I do when I go home? - Please take all your medicines as described in this discharge paperwork. - Please keep all your appointments with your doctors, as listed below. - You should not take any Advil, ibuprofen, Aleve or other pain relievers in the medication family called NSAIDS (non-steroidal anti-inflammatory drugs). - Please weigh yourself every morning, and call MD if weight goes up more than 3 lbs in 1 day or is steadily increasing. Your weight at discharge was 89.3 kg (196.9 lb). It was a pleasure to participate in your care, and we wish you all the best. Sincerely, Your ___ team Followup Instructions: ___
[ "I130", "J189", "N170", "R578", "E872", "A0472", "F05", "J948", "I5023", "K921", "I482", "I255", "D539", "I2510", "M5030", "J984", "I081", "K9289", "R001", "I341", "N189", "R0902", "M109", "Z96659", "G8929", "F329", "Z955", "Z7901", "Z87891" ]
Allergies: Penicillins / oxycodone Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] YO M with afib on rovarozaban, CAD s/p stent placement, HFrEF (EF [MASKED], mitral valve prolapse, HTN, HLD, depression, multiple spine surgeries, cholecystectomy who presents from rehab with dyspnea, felt to be in acute heart failure exacerbation [MASKED] holding of diuretic regimen at rehab in setting of hypotension. He brought in from rehab with concern of shortness of breath and increased pleural effusion on CXR at rehab. Per ED notes: He's had recent hospitalization for hypoxemia, pneumonia and right sided pleural effusion. He had a chest tube placed x2 by IP with fluid consistent with HF and concern for trapped lung as well. Patient treated with abx for presumed pneumonia and discharged to rehab on 1.5-2L NC. While in rehab weaned off O2 by [MASKED] but started to have new O2 requrimenet yesterday that increased to 2L NC again today. SOB worse with movement. No chest pain, fever/chills/ night sweates or new cough. Notes increase in abdominal distension though diarrhea has improved now while he remains on antibiotics for c.diff. Notes weight gain of ~15 lbs with dry weight of 205 and 220 this am at rehab In the ED initial vitals were: 97.9 86 107/57 22 99% 2L NC ED exam notable for: Gen:NAD, breathing comfortably on 2L O2, AOx3 CV: irregularly irregular, no murmurs, JVD to jawline Pulm: Decreased right sided lower breath sounds, no crakcles Abd: soft, significantly distended, no peritoneal signs, non-tender, [MASKED]: 3+ edema bilaterally up to the low thigh Labs/studies notable for: 6.7 > 8.[MASKED].7 < [MASKED] ------------<116 AGap=14 5.4 23 1.1 Trop-T: <0.01 proBNP: [MASKED] Lactate:2.6 CXR notable for: FINDINGS: AP portable upright view of the chest. No significant change from recent prior exam with loculated right pleural effusion tracking circumferentially with a similar overall pattern. Opacities within the right lung again noted. Left lung is grossly clear. The heart appears mildly enlarged. Mediastinal contour stable. Imaged bony structures are intact. Multiple surgical anchors are noted at bilateral humeral heads. IMPRESSION: No significant interval change. Patient was given: [MASKED] 16:28 IV Furosemide 80 mg Patient was seen by cardiology: Per Cards ED evaluation: "Patient presenting with likely primarily CHF exacerbation. Patient unclear if he has been taking diuretics appropriately, which could be precipitant. Given this is the primary reason for admission, his reduced EF, and some concern that diuresis was being held at rehab due to hypotension." Recommended admission to Cardiology. Per ED assessment: "Likely HFrEF exacerbation with weight gain and increase in shortness of breath and [MASKED] edema. AM Lasix held for a few days while in rehab given soft BP that may have caused volume overload. Will touch base wit IP re worsening shortness of breath and history of concern for trapped lung and placement of chest tube. CXR without evidence of new consolidation or significantly worsening pulm edema though has right sided pleural effusion tracking circumferentially. Clinically without fever, new cough, or sputum production concerning for pneumonia. No evidence of pericardial effusion on bedside echo. No ascites on bedside echo either. Abdominal distenstion without n/v and with regular bowel movement unlikely caused by obstruction though has history of [MASKED] syndrome." Of note, patient is s/p discharge on [MASKED] after presenting to OSH with [MASKED] weeks of worsening back pain and left hip pain, transferred for spine eval, with MRI negative for infection, admitted for pain management. Hospital course was complicated by oliguric renal failure in setting of contrast load on [MASKED] and NSAID use, and hypotension in setting of receiving entresto and diuresis, requiring transfer to the MICU for worsening hypoxia and persistent hypotension. He was found to have R side pleural effusion with improvement after chest tube placement x2 [MASKED], removed, replaced [MASKED]. Further hospital course complicated by C difficile. Vitals on transfer: 97.6 109 100/76 22 94% 3L NC On the floor... He reports he was at rehab and things were going fairly well. He reported they took him off O2 on [MASKED] through the weekend until [MASKED] (back on O2). He reports that he didn't have much activity over the weekend, but this Am he reported that he felt more SOB and was sent back. He reports he feels "bloated" but denies weight gain; he reports his weight at rehab was 223-224; he doesn't remember what his weight was when he got to rehab (?220). He reports his dry weight is about 205 lbs. He reports his SOB has been going on "for a long time"; he first noticed it a few months. He reports some improvement after his chest tubes; he reported once he was active at rehab his respiratory symptoms had improved. Denies CP, but does report occasional "palpitations" but he denies attributing this to his afib (and reports it has seemed to have gotten better.) Rpeorts some lightheadedness this AM. Denies LOC. Reports significant leg swelling. Denies recent infections, cough or cold symptoms. Denies abd pain, n/v but reports some nausea with c diff medication but none in the past two days. Reports + diarrhea at admission today x2. He reports this seems like his C. diff symptoms. Denies dysuria. Denies blood in stool or urine. Past Medical History: PAST MEDICAL HISTORY: ======================= 1. CARDIAC RISK FACTORS - Hypertension - Dyslipidemia 2. CARDIAC HISTORY - CAD s/p stent placement - CHF with EF [MASKED] - Afib on warfarin - mitral valve prolapse 3. OTHER PAST MEDICAL HISTORY depression chronic neck pain secondary to cervical disc disease multiple spine surgeries including fusion of L-S1 laminectomy cholecystectomy Total knee replacement B/l shoulder surgery c diff infection [MASKED] Social History: [MASKED] Family History: Mother: alive, age [MASKED]. Macular degeneration Father: deceased in mid [MASKED]. ?brain tumor and heart issues Physical Exam: ADMISSION PHYSICAL EXAMINATION: ================================= VS: Temp: 98.4 (Tm 98.4), BP: 103/74 (90-134/49-87), HR: 111 (111-148), RR: 26 ([MASKED]), O2 sat: 93% (86-97), O2 delivery: 2LNC (2LNC-3L), Wt: 218 lb/98.88 kg GENERAL: Well developed, well nourished M, sitting at bedside in NAD. Oriented x3. Mood, affect appropriate. HEENT: Normocephalic atraumatic. Sclera anicteric. EOMI grossly. Conjunctiva were pink. No pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple. JVP to angle of mandible at 90 degrees CARDIAC: PMI located in [MASKED] intercostal space, midclavicular line. irregularly irregular rate, Tachycardic. LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. diminished lung sounds R lung extending up to mid lung fields. no crackles appreciated bilaterally; no wheezes. ABDOMEN: Soft, non-tender, mildly distended EXTREMITIES: extremities slightly cool perfused. 3+ pitting edema to knees bilaterally DISCHARGE PHYSICAL EXAMINATION: ================================= PHYSICAL EXAM: VS: 98.3 90/52 89 18 94% Ra GENERAL: Alert, oriented, no acute distress HEENT: Sclera anicteric NECK: supple, JVP to 10 cm LUNGS: Decreased BS in RLL, no wheezing CV: Irrregular, tachycardic, [MASKED] pansystolic murmur at apex and LLSB ABD: mild distention, non-tender, and soft, normoactive BS EXT: Warm, non-edematous bilaterally, non-tender NEURO: No gross motor or coordination abnormalities Pertinent Results: ADMISSION LABS ======================== [MASKED] 12:50PM BLOOD WBC-6.7 RBC-2.63* Hgb-8.9* Hct-27.7* MCV-105* MCH-33.8* MCHC-32.1 RDW-16.2* RDWSD-62.4* Plt [MASKED] [MASKED] 12:50PM BLOOD Neuts-76.2* Lymphs-7.2* Monos-13.8* Eos-1.4 Baso-0.9 Im [MASKED] AbsNeut-5.08 AbsLymp-0.48* AbsMono-0.92* AbsEos-0.09 AbsBaso-0.06 [MASKED] 12:50PM BLOOD Glucose-116* UreaN-18 Creat-1.1 Na-135 K-5.4* Cl-98 HCO3-23 AnGap-14 [MASKED] 12:50PM BLOOD CK(CPK)-42* [MASKED] 06:20AM BLOOD ALT-<5 AST-9 LD(LDH)-180 AlkPhos-94 TotBili-0.7 [MASKED] 12:50PM BLOOD CK-MB-2 proBNP-6666* [MASKED] 12:50PM BLOOD cTropnT-<0.01 [MASKED] 09:35PM BLOOD Calcium-8.9 Phos-2.6* Mg-1.2* [MASKED] 01:11PM BLOOD Lactate-2.6* K-5.1 [MASKED] 01:34PM BLOOD Lactate-1.8 PERTIENT LABS ======================== [MASKED] 06:20AM BLOOD calTIBC-212* VitB12-498 Folate-3 Ferritn-500* TRF-163* [MASKED] 06:50AM BLOOD Vanco-66.0* DISCHARGE LABS ======================== [MASKED] 08:10AM BLOOD WBC-7.2 RBC-2.55* Hgb-8.2* Hct-26.0* MCV-102* MCH-32.2* MCHC-31.5* RDW-17.0* RDWSD-63.9* Plt [MASKED] [MASKED] 08:10AM BLOOD Plt [MASKED] [MASKED] 08:10AM BLOOD [MASKED] PTT-35.1 [MASKED] [MASKED] 08:10AM BLOOD Glucose-93 UreaN-31* Creat-1.7* Na-136 K-3.9 Cl-93* HCO3-30 AnGap-13 [MASKED] 02:11AM BLOOD ALT-<5 AST-11 LD(LDH)-217 AlkPhos-79 TotBili-1.0 DirBili-0.4* IndBili-0.6 [MASKED] 08:10AM BLOOD Calcium-8.9 Phos-4.1 Mg-1.7 IMAGING ======================== CXR [MASKED] AP portable upright view of the chest. No significant change from recent prior exam with loculated right pleural effusion tracking circumferentially with a similar overall pattern. Opacities within the right lung again noted. Left lung is grossly clear. The heart appears mildly enlarged. Mediastinal contour stable. Imaged bony structures are intact. Multiple surgical anchors are noted at bilateral humeral heads. CT CHEST [MASKED] Persistent large and probably loculated right hydropneumothorax, probably reflecting chronic restrictive right pleural thickening, in combination with severe lower lobe atelectasis. No contributory bronchial obstruction. Severe coronary atherosclerosis. Mild cardiomegaly. Substantially improved bilateral airspace pulmonary abnormality, nature indeterminate, could be post infectious or slow to resolve hemorrhage. KUB [MASKED] Colonic obstruction, worse than on prior examination. There is an abrupt cutoff of the colonic dilatation in the proximal descending colon, as on prior CT. The possibility of a stricture at this level is suggested. No free air on supine. CT A/P [MASKED]. Colonic distension is minimally increased since the prior study measures approximately 8.1 cm, previously measured 7 cm with smooth tapering in the proximal descending colon is suggestive [MASKED] syndrome. No gross stricture identified. 2. Small bowel is normal caliber. No evidence of bowel obstruction. 3. Air-fluid levels within the colon suggests a diarrheal state. 4. Partially visualized known right hydropneumothorax. 5. Ground-glass opacifications in the visualized central left lower and anterior left upper lobe are nonspecific and may reflect an infectious or inflammatory process. CT CHEST [MASKED]. Extensive progression of more confluent areas of ground-glass opacification in a peribronchovascular distribution involving the entire left lung since the prior study of [MASKED], raises concern for infection. Asymmetric pulmonary edema could also be considered.. 2. Overall stable appearance moderate right hydropneumothorax and associated collapse of the left lower lobe. 3. Slightly increased size of small left pleural effusion. CXR [MASKED] FINDINGS: The heart size is enlarged, stable in appearance as compared to [MASKED]. Re-demonstrated are bilateral parenchymal opacities, unchanged with associated air bronchograms, more prominent on the right. There is a loculated right pleural effusion, no left pleural effusion. There is near complete atelectasis with the right lower lobe. There is unchanged over distention of the stomach. There is no pneumothorax. IMPRESSION: In comparison to the prior radiograph dated [MASKED], there is stable appearance of near complete right lower lobe atelectasis with a now larger loculated right pleural effusion. Persistent bibasilar opacities. MICROBIOLOGY ======================== Blood Cx [MASKED]: No growth Blood Cx [MASKED]: No growth Blood Cx [MASKED]: No growth Urine Cx [MASKED]: No growth MRSA Screen [MASKED]: Negative C. Difficile [MASKED]: Negative Brief Hospital Course: BRIEF HOSPITAL COURSE =================================== [MASKED] yo M with atrial fibrillation on rivaroxaban, CAD s/p stent placement, HFrEF (EF [MASKED], mitral valve prolapse, HTN, HLD, depression, multiple spine surgeries, cholecystectomy who presents from rehab with dyspnea and weight gain consistent with acute heart failure exacerbation likely secondary to missed diuretic doses at rehab (held for SBP < 100), treated with a Lasix drip to euvolemia. Once euvolemic, he still required 2L O2 and thoracic surgery was consulted for possible intervention for trapped lung. While awaiting intervention, patient had a vagal episode followed by hypotension and bradycardia requiring ICU admission. There was suspicion of GI bleed and he was transfused 2u pRBCs. He was briefly on pressors but was able to be quickly weaned. On transfer back to the floor, he continued diuresis but repeat chest CT showed increased ground glass opacities of the left lung concerning for infection versus pulmonary edema, so he was treated for HAP with vancomycin, ceftazidime and azithromycin. With antibiotics and diuresis, his dyspnea, hypoxia improved. [MASKED] Course: Mr. [MASKED] is a [MASKED] man with A fib on rivaroxaban, CAD s/p PCI/stent, chronic systolic congestive heart failure (LV EF [MASKED], mitral valve prolapse, hypertension, hyperlipidemia, and other issues admitted with acute pulmonary edema attributed to acute on chronic systolic congestive failure, with his hospital course complicated by GI bleeding and vasovagal event resulting in bradycardia to [MASKED] when using the commode on [MASKED]. He recovered spontaneously without atropine. He subsequently became progressively hypotensive to [MASKED], lactate 6.9, hgb drop 6.1 from 7.4. Dark brown, guaiac + stool. GI and ACS were consulted who did not recommend immediate intervention. KUB w/o free air. On arrival to the MICU, patient was awake and mentating well. Complaining mostly of back pain. Cdiff was ordered given for significant abdominal distention. Norepinephrine max 0.15 mcg/kg/hr, nurse was able to quickly wean to .04 prior to receiving blood. He was transfused with 2uPRBC and 1U FFP, chased with 100 mg Lasix. He was weaned off Levophed prior to transfer.) =============== ACTIVE ISSUES: =============== #Heart failure with reduced ejection fraction, acute decompensation: Patient with history of heart failure with reduced ejection fraction secondary to ischemic cardiomyopathy. Patient presented with >20lbs weight gain from dry weight and increased SOB, consistent with heart failure exacerbation likely secondary to missed diuretic doses at rehab (held for SBP < 100). He was treated with a lasix drip 20 mg/hr and lasix boluses of 160 mg IV to euvolemia. He was unable to tolerate a Persantine MIBI due to back pain, despite pre-medication. He was changed to Torsemide 60mg daily and remained euvolemic, however this dose was changed to 40mg daily given creatinine up to 1.7 (from baseline 1.2). He was discharged on diuretic regimen torsemide 40 mg daily. His metoprolol was uptitrated and he was discharged on metoprolol succinate XL 50 mg BID. Lisinopril 2.5 mg daily was HELD due to [MASKED] on CKD (see below). Spironolactone could not be added on to regimen due to low blood pressure and increase in creatinine after two doses. #Hypoxemia: #Right pleural effusion/Trapped lung: #Pneumonia: Patient developed trapped lung as complication of anterior approach to L2-L3 fusion. Patient was hypoxic during last admission due in part to trapped lung and right sided pleural effusion, and he had chest tube placed x 2. Thoracic surgery was consulted, and deferred intervention urgently given poor clinical status. [MASKED] benefit from VATS vs possible open thoracotomy decortication of entrapped right lung. Toward end of hospital course, patient developed more SOB and hypoxia requiring up to 4L NC. Repeat CT chest suggested increased ground glass opacities of left lung concerning for infection vs pulmonary edema, stable hydropneumothorax. Completed a course of vancomycin/ceftazidime/azithromycin ([MASKED]). MRSA screen was negative. After management with antibiotics and diuresis, patient's oxygen requirement decreased to 96% RA. However, patient did occasionally require [MASKED] with exertion (desat to 87%). Thoracic surgery and IP will follow up as outpatient. #Atrial fibrillation: Patient's rates were well controlled after up-titrating metoprolol to succinate XL 50 mg BID (HR [MASKED], peaked in 130s with significant exertion). Patient was on metoprolol XL 225mg daily prior to last admission, which was decreased to 50mg daily at discharge [MASKED]. This had been further reduced to 12.5mg at rehab prior to this admission. He was continued on Rivaroxaban 20 mg PO QHS and Metop XL 50mg BID. #C diff infection: Patient was diagnosed with C. difficile during last admission, and planned to complete PO flagyl 10 day course on [MASKED]. Per rehab records, it was unclear whether he completed this course. Given he reported ongoing diarrhea on admission, he was treated with a second 10 day course of PO vancomycin to ensure complete treatment, with course from [MASKED]. C. diff negative on [MASKED]. #Abdominal distention with Ogilvies: Pt with known history of [MASKED] syndrome. He was noted to have prominent abdominal distention without pain, constipation, or other concerning signs. Had CT abdomen consistent with Ogilvies. A bowel regimen was continued. Abdominal distention improved. [MASKED] on CKD: Baseline 1.2, initially uptrended in the setting of diuresis despite appearing overloaded on exam, possibly related to ATN in setting of transient hypotension from valsalva, bradycardic episode. Cr improved later with continued diuresis but increased again on [MASKED] possibly in the setting of starting spironolactone, which was discontinued. On [MASKED], a vancomycin level was checked which was elevated at 66. Creatinine started to increase 48 hours after this, and additionally patient was given Spirinolactone x 2 days. Likely both of these insults explain the worsening [MASKED]. His lisinopril was stopped and Torsemide was decreased to 40mg daily. On discharge, Cr 1.7 (baseline 1.2). Patient euvolemic and I/Os and weight stable, however Torsemide was decreased due Cr 1.7. It is expected that patient's creatinine will start to improve [MASKED] weeks after Vancomycin, Spirinolactone, Lisinopril were stopped, and Torsemide decreased. A post void residual was 21. Patient should avoid all NSAIDs going forward. #Macrocytic Anemia: Noted to have macrocytic anemia with hemoglobin [MASKED] during admission. Prior to transfer to ICU, he was noted to have guaiac positive stool with hemoglobin drop and was transfused 2u pRBCs. Iron studies showed an Fe/TIBC 22%, consistent with mild iron deficiency. B12 and folate were normal. Methylmalonic acid was WNL. His Ferrous Sulfate 325 mg PO DAILY was continued at discharge. Please re-check iron studies to ensure no iron toxicity on supplemental iron and discontinue supplemental iron when iron replete. If within goals, pt may be further evaluated for MDS. # Shock, hypotension, lactic acidosis (resolved): Patient developed hypotension and bradycardia in setting of valsalva c/w vagal event. However, had persistent hypotension after event with elevated lactate to 6.9 and hgb drop to from 7.4 to 6.1, guaiac positive stools, cool extermities, and volume overload with elevated JVP. Initially, concern for hemorrhagic shock (Hgb drop and guaiac positive stools) vs abdominal ischemia (distended abdomen, lactate) vs cardiogenic shock (cool, elevated JVP, increased BNP). Levophed was maxed, but rapidly weaned off prior to any other treatments. Lactate also resolved prior to any other treatments. ACS and GI were consulted for concern for abdominal compartment syndrome vs ischemia, but felt that exam was not concerning. He received 2U pRBC and 1U FFP chased with 100mg IV lasix with good Hgb response. No further signs of bleeding. Weaned off of pressors and was warm on exam. ================ CHRONIC ISSUES: ================ #Chronic back pain: #Hip/leg pain: Per last discharge summary, patient has history of multiple prior spinal surgeries with hardware in place. No evidence of infection during last admission. Etiology of pain is unclear but likely multifactorial from degenerative disc disease and frequent surgeries. He was continued on lidocaine patches, acetaminophen standing, gabapentin, and tramadol prn. His neurologic exam was intact. Consider chronic pain clinic outpatient for possible injection/nerve block. #Gout: Continued allopurinol [MASKED] mg daily #Depression: Continued Sertraline 50 mg PO DAILY TRANSITIONAL ISSUES: ============================= [ ] DISCHARGE WEIGHT: 89.3 kg (196.87 lb) [ ] DISCHARGE DIURETIC: Torsemide 40 mg daily [ ] DISCHARGE ANTICOAGULATION: Rivaroxaban 20 mg PO QHS [ ] DISCHARGE BUN/CR: [MASKED] [ ] FOLLOW UP LABORATORY TESTING: Recheck Chem 10, monitor lytes and creatinine ON [MASKED]. [ ] If Cr continues to uptrend, >2, would refer to Nephrology. [ ] Please continue to monitor weights and volume overload. Call Cardiology office with > 3 lb weight change. [ ] Please ensure follow-up with thoracic surgery and interventional pulmonology (appointments scheduled) for trapped lung. [ ] Please continue to monitor heart rates and atrial fibrillation. Metoprolol was uptitrated with improvement in rates (final dose Metop XL 50mg BID). [ ] Torsemide reduced to 40 mg daily due to uptrending Cr [ ] Rivaroxaban dosing continued given GFR > 50, but may need to reduce dose if Cr continues to uptrend >1.7. [ ] Holding lisinopril due to [MASKED] on CKD. Please restart lisinopril 2.5mg daily if Cr normalizes. [ ] Please re-check iron studies to ensure no iron toxicity on supplemental iron and discontinue supplemental iron when iron replete. [ ] Follow up on macrocytic anemia with further work up (?MDS). [ ] Please continue to counsel patients to avoid NSAIDs given his heart failure diagnosis and history of NSAID implicated acute tubular necrosis during last admission. [ ] Consider adding spironolactone as tolerated by creatinine to optimize HF regimen. [ ] Please note that Tramadol and Gabapentin were decreased given delirium earlier in hospitalization; pain was appropriately controlled at these smaller doses. [ ] Atorvastatin was increased to 40mg QPM this hospitalization. # CODE STATUS: FULL CODE # CONTACT: Name of health care proxy: [MASKED] Relationship: daughter Phone number: [MASKED] Cell phone: [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol [MASKED] mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 10 mg PO QPM 4. Furosemide 80 mg PO QAM 5. Furosemide 40 mg PO QPM 6. Metoprolol Succinate XL 12.5 mg PO DAILY 7. Rivaroxaban 20 mg PO QHS 8. Sertraline 50 mg PO DAILY 9. Acetaminophen 1000 mg PO TID 10. Calcium Carbonate 500 mg PO QID:PRN heartburn 11. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN SOB, wheezing 12. Lidocaine 5% Patch 1 PTCH TD QPM 13. Lisinopril 2.5 mg PO DAILY 14. MetroNIDAZOLE 500 mg PO Q8H 15. Ondansetron ODT 8 mg PO Q8H:PRN nausea, vomiting 16. TraMADol 100 mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity 17. Ferrous Sulfate 325 mg PO DAILY 18. Pantoprazole 40 mg PO Q24H 19. Hydrocerin 1 Appl TP DAILY dry skin 20. Cholestyramine 2 mg gm PO BID 21. Gabapentin 300 mg PO TID 22. Milk of Magnesia 30 mL PO QHS:PRN constipation 23. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO QID:PRN upset stomach 24. Bisacodyl AILY:PRN constipation 25. Docusate Sodium 100 mg PO TID:PRN constipation 26. Senna 17.2 mg PO QHS:PRN constipation 27. melatonin 3 mg oral QHS:PRN 28. Vancomycin Oral Liquid [MASKED] mg PO Q6H 29. Magnesium Oxide 400 mg PO DAILY 30. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q2H:PRN sore throat Discharge Medications: 1. Torsemide 40 mg PO DAILY 2. Allopurinol [MASKED] mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. Gabapentin 300 mg PO BID 5. Metoprolol Succinate XL 50 mg PO BID 6. TraMADol 75 mg PO BID:PRN Pain - Moderate 7. Acetaminophen 1000 mg PO TID 8. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO QID:PRN upset stomach 9. Aspirin 81 mg PO DAILY 10. Bisacodyl AILY:PRN constipation 11. Calcium Carbonate 500 mg PO QID:PRN heartburn 12. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q2H:PRN sore throat 13. Cholestyramine 2 mg gm PO BID 14. Docusate Sodium 100 mg PO TID:PRN constipation 15. Ferrous Sulfate 325 mg PO DAILY 16. Hydrocerin 1 Appl TP DAILY dry skin 17. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN SOB, wheezing 18. Lidocaine 5% Patch 1 PTCH TD QPM 19. Magnesium Oxide 400 mg PO DAILY 20. melatonin 3 mg oral QHS:PRN 21. Milk of Magnesia 30 mL PO QHS:PRN constipation 22. Ondansetron ODT 8 mg PO Q8H:PRN nausea, vomiting 23. Pantoprazole 40 mg PO Q24H 24. Rivaroxaban 20 mg PO QHS 25. Senna 17.2 mg PO QHS:PRN constipation 26. Sertraline 50 mg PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Primary: ============= - Heart failure with reduced ejection fraction, acute on chronic - Atrial fibrillation - Trapped lung, right pleural effusion - Pneumonia - Anemia - [MASKED] syndrome - Acute on chronic kidney disease Secondary: ================== - C. difficile colitis - Chronic back pain - Gout - Depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [MASKED], You were admitted to the hospital because you were short of breath. What happened while I was in the hospital? - You were found to have a lot of extra fluid in your body, so you were started on Lasix (a water pill). The fluid built up in your body because of your heart failure. - The thoracic surgery team evaluated your lung, and you should follow-up with them to discuss possible surgery for your lung. - You were treated with an antibiotic for a c. diff infection in your bowel. - You were briefly treated in the intensive care unit for low blood pressure and low heart rates. - You developed a pneumonia in the hospital, which was treated with antibiotics. What should I do when I go home? - Please take all your medicines as described in this discharge paperwork. - Please keep all your appointments with your doctors, as listed below. - You should not take any Advil, ibuprofen, Aleve or other pain relievers in the medication family called NSAIDS (non-steroidal anti-inflammatory drugs). - Please weigh yourself every morning, and call MD if weight goes up more than 3 lbs in 1 day or is steadily increasing. Your weight at discharge was 89.3 kg (196.9 lb). It was a pleasure to participate in your care, and we wish you all the best. Sincerely, Your [MASKED] team Followup Instructions: [MASKED]
[]
[ "I130", "E872", "I2510", "N189", "M109", "G8929", "F329", "Z955", "Z7901", "Z87891" ]
[ "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "J189: Pneumonia, unspecified organism", "N170: Acute kidney failure with tubular necrosis", "R578: Other shock", "E872: Acidosis", "A0472: Enterocolitis due to Clostridium difficile, not specified as recurrent", "F05: Delirium due to known physiological condition", "J948: Other specified pleural conditions", "I5023: Acute on chronic systolic (congestive) heart failure", "K921: Melena", "I482: Chronic atrial fibrillation", "I255: Ischemic cardiomyopathy", "D539: Nutritional anemia, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "M5030: Other cervical disc degeneration, unspecified cervical region", "J984: Other disorders of lung", "I081: Rheumatic disorders of both mitral and tricuspid valves", "K9289: Other specified diseases of the digestive system", "R001: Bradycardia, unspecified", "I341: Nonrheumatic mitral (valve) prolapse", "N189: Chronic kidney disease, unspecified", "R0902: Hypoxemia", "M109: Gout, unspecified", "Z96659: Presence of unspecified artificial knee joint", "G8929: Other chronic pain", "F329: Major depressive disorder, single episode, unspecified", "Z955: Presence of coronary angioplasty implant and graft", "Z7901: Long term (current) use of anticoagulants", "Z87891: Personal history of nicotine dependence" ]
19,994,592
22,001,973
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: altered mental status Major Surgical or Invasive Procedure: none History of Present Illness: Ms. ___ is a ___ woman with a past medical history of bipolar disorder, OSA, GERD, and anemia; presenting with confusion for 3 days. History is difficult to obtain due to patient confusion, language barrier with family (despite translator), and records scattered across multiple providers ___, new PCP and new psychiatrist). She was brought to the ED by her family for 3 days of confusion. Her husband says that she has been walking around the house "like a zombie", "not making any sense" when she speaks, not eating, bathing, or sleeping. Family also notes intermittent outbursts of arm raising and shaking that is nonsynchronized, nonrhythmic, and resembles a protracted startle response (which they demonstrated). Her husband believes her symptoms are the result of recent medication changes by a new psychiatrist she is seeing. At a recent PCP ___ visit on ___ she was noted to be alert and oriented with an essentially normal exam. She complained of 15 days of headache at that time. She was referred to a new psychiatrist, who the husband says she saw on ___ and who reportedly changed her medications. The husband believes her altered mental status is result of the medication changes but he does not know specifically what these are. He believes she may be taking too many of some of her medications. The OMR note on ___ noted she was taking lithium 600mg BID, but apparently this has been stopped at present (-- her husband did not bring the medication and her serum level is low.) In the ED a CT head revealed a left posterior fossa mass consistent with a meningioma, exerting mass-effect on the left cerebellum causing edema and minor distortion of the fourth ventricle. Neurosurgery was consulted and they did not think that this mass was related to her alterations in mental status, so neurology was consulted. Past Medical History: -Bipolar disorder -OSA -GERD -Anemia -Hyperlipidemia -Hepatic steatosis Social History: ___ Family History: Mother with hypertension. Maternal grandfather with CAD. Aunt with colon cancer. Physical Exam: Admission Physical Exam: Vitals: T:98.8 P:99 BP:143/72 r:20 SaO2:100% General: Awake, frequently moving in bed. Inattentive and not cooperative with exam. HEENT: NC/AT, no scleral icterus noted. Neck: Supple. Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR Abdomen: Obese, soft, NT/ND. Neurologic: -Mental Status: Alert, not oriented no self, place, situation; said "I don't know" in ___ these questions but replied yes to whether her name was ___. Profoundly inattentive, continuously moving in bed and unable to cooperate with exam. -Cranial Nerves: PERRL, EOM appear intact. BTT bilaterally. -Motor: Moved all extremities equally. -Sensory: Reacted to light touch in all extremities. -Coordination: Appeared able to grab bed rails with both hands without apparent ataxia. -Gait: Able to stand unassisted. Stable gait, short steps. Discharge Physical Exam: Vitals: Tm 37.2, HR 65-87, BP 75-175/46-155, RR ___, >97% RA General: Awake, lying in bed quietly, NAD HEENT: NC/AT, no scleral icterus noted. Neck: Supple. Pulmonary: Lungs CTA bilaterally Cardiac: RRR Abdomen: Obese, soft, NT/ND. Neurologic: -Mental Status: Awake, alert, refuses to participate with exam; looks away to avoid eye contact -Cranial Nerves: PERRL, EOM appear intact. BTT bilaterally. -Motor: Moved all extremities equally antigravity -Sensory: Withdraws to light touch in all extremities. -Coordination: No truncal ataxia, no dysmetria reaching for objects Pertinent Results: ___ 05:15AM BLOOD WBC-8.8 RBC-4.44 Hgb-11.3 Hct-36.6 MCV-82 MCH-25.5* MCHC-30.9* RDW-18.8* RDWSD-56.3* Plt ___ ___ 05:48PM BLOOD Neuts-63.2 ___ Monos-9.9 Eos-0.8* Baso-0.5 Im ___ AbsNeut-8.24* AbsLymp-3.28 AbsMono-1.29* AbsEos-0.11 AbsBaso-0.07 ___ 08:23PM BLOOD ___ PTT-29.6 ___ ___ 05:15AM BLOOD Glucose-107* UreaN-10 Creat-0.7 Na-142 K-3.3 Cl-107 HCO3-23 AnGap-15 ___ 06:35AM BLOOD ALT-19 AST-21 CK(CPK)-404* AlkPhos-67 TotBili-0.4 ___ 05:15AM BLOOD Calcium-9.4 Phos-3.0 Mg-2.1 ___ 06:35AM BLOOD TSH-1.2 ___ 08:00PM BLOOD Lithium-0.2* ___ 08:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 12:08AM BLOOD Lactate-1.1 CXR: FINDINGS: There are low lung volumes.No definite focal consolidation is seen. There is no large pleural effusion or pneumothorax. The cardiac silhouette is mildly enlarged, likely accentuated by low lung volumes and AP technique. Mediastinal contours unremarkable. No pulmonary edema is seen. IMPRESSION: Low lung volumes without focal consolidation or pleural effusion seen. CT Head ___: FINDINGS: Abutting the superolateral left cerebellar hemisphere and the tentorium, there is a 3.2 x 2.6 x 2.8 cm dense lesion with adjacent vasogenic edema with resultant mass effect on the quadrigeminal plate cistern and fourth ventricle. No evidence of herniation currently. There is no evidence of acute fracture. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: A dense mass abutting the tentorium and left cerebellar hemisphere with adjacent vasogenic edema and mass effect effacing the fourth ventricle and quadrigeminal plate cistern, most likely represents meningioma. No current herniation. Recommend MRI with intravenous contrast for further evaluation, if no contraindication. MRI Brain ___: FINDINGS: In the left posterior fossa, there is a round 3.2 x 2.9 x 3.0 cm dural-based mass inseparable from the left tentorium, abutting the superolateral aspect of the left cerebellar hemisphere, presumably meningioma. It is isointense to gray matter on T1 and T2 weighted imaging with homogeneous avid enhancement. There is regional T2 prolongation within the left cerebellar hemisphere consistent with vasogenic edema with and mild effacement of the fourth ventricle. No hydrocephalus. No evidence of hemorrhage or infarction. The left transverse sinus is hypoplastic. The left distal transverse sinus and sigmoid sinus do not enhance and may be compressed or occluded by the presumed meningioma. The left internal jugular vein traits postcontrast enhancement. The remainder of the dural venous sinuses are patent. IMPRESSION: Dural-based mass in the left posterior fossa, consistent with a meningioma. There is regional vasogenic edema with mild effacement of the fourth ventricle but no obstructing hydrocephalus. No definite enhancement of the distal left transverse sinus and sigmoid sinus which may be severely compressed with occlusion a possibility. There is reconstitution of contrast enhancement of the left internal jugular vein. Brief Hospital Course: Ms. ___ is a ___ woman with a history of bipolar disorder who presented with headache and increasing psychosis in the setting of medication non-compliance. Her exam was notable for limited speech output, paranoia and paratonia without clear focal neurologic deficits. CT demonstrated a left posterior fossa mass adjacent to the cerebellum with MRI confirming the diagnosis of meningioma (3.1 x2.6cm enhancing extra-axial mass abutting tentorium and left cerebellum), which per Neurosurgery required no acute surgical intervention and will be followed over time as an outpatient. She remained in a state of decompensated psychosis and Psychiatry recommended restarting her home Invega (paliperidone) 9mg daily, as she was likely non-compliant with this medication. She had notably last had this medication filled on ___ in quantity of 30 and there were still 20 pills left in bottle she brought with her to the hospital. EKG with QTc 473msec. She remained afebrile with stable vital signs throughout her admission and she is medically cleared for discharge. She will be discharged to ___ accepting MD ___. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. paliperidone 9 mg oral DAILY 2. Omeprazole 20 mg PO DAILY 3. Ferrous Sulfate 325 mg PO DAILY Discharge Medications: 1. Ferrous Sulfate 325 mg PO DAILY 2. Omeprazole 20 mg PO DAILY 3. paliperidone 9 mg oral DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: meningioma, psychosis Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted due to concern for a mass in the brain (cerebellum) that was found to be a meningioma. No surgical intervention was required and you will be followed as an outpatient by Neurosurgery. You were seen by Psychiatry who recommended restarting your home paliparidone (Invega) and your medications will continued to be titrated at ___ ___. Best, Your ___ Neurology Team Followup Instructions: ___
[ "F29", "G936", "D320", "F319", "G4733", "K219", "D649", "E669", "T43596A", "Y929", "R278" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: altered mental status Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [MASKED] is a [MASKED] woman with a past medical history of bipolar disorder, OSA, GERD, and anemia; presenting with confusion for 3 days. History is difficult to obtain due to patient confusion, language barrier with family (despite translator), and records scattered across multiple providers [MASKED], new PCP and new psychiatrist). She was brought to the ED by her family for 3 days of confusion. Her husband says that she has been walking around the house "like a zombie", "not making any sense" when she speaks, not eating, bathing, or sleeping. Family also notes intermittent outbursts of arm raising and shaking that is nonsynchronized, nonrhythmic, and resembles a protracted startle response (which they demonstrated). Her husband believes her symptoms are the result of recent medication changes by a new psychiatrist she is seeing. At a recent PCP [MASKED] visit on [MASKED] she was noted to be alert and oriented with an essentially normal exam. She complained of 15 days of headache at that time. She was referred to a new psychiatrist, who the husband says she saw on [MASKED] and who reportedly changed her medications. The husband believes her altered mental status is result of the medication changes but he does not know specifically what these are. He believes she may be taking too many of some of her medications. The OMR note on [MASKED] noted she was taking lithium 600mg BID, but apparently this has been stopped at present (-- her husband did not bring the medication and her serum level is low.) In the ED a CT head revealed a left posterior fossa mass consistent with a meningioma, exerting mass-effect on the left cerebellum causing edema and minor distortion of the fourth ventricle. Neurosurgery was consulted and they did not think that this mass was related to her alterations in mental status, so neurology was consulted. Past Medical History: -Bipolar disorder -OSA -GERD -Anemia -Hyperlipidemia -Hepatic steatosis Social History: [MASKED] Family History: Mother with hypertension. Maternal grandfather with CAD. Aunt with colon cancer. Physical Exam: Admission Physical Exam: Vitals: T:98.8 P:99 BP:143/72 r:20 SaO2:100% General: Awake, frequently moving in bed. Inattentive and not cooperative with exam. HEENT: NC/AT, no scleral icterus noted. Neck: Supple. Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR Abdomen: Obese, soft, NT/ND. Neurologic: -Mental Status: Alert, not oriented no self, place, situation; said "I don't know" in [MASKED] these questions but replied yes to whether her name was [MASKED]. Profoundly inattentive, continuously moving in bed and unable to cooperate with exam. -Cranial Nerves: PERRL, EOM appear intact. BTT bilaterally. -Motor: Moved all extremities equally. -Sensory: Reacted to light touch in all extremities. -Coordination: Appeared able to grab bed rails with both hands without apparent ataxia. -Gait: Able to stand unassisted. Stable gait, short steps. Discharge Physical Exam: Vitals: Tm 37.2, HR 65-87, BP 75-175/46-155, RR [MASKED], >97% RA General: Awake, lying in bed quietly, NAD HEENT: NC/AT, no scleral icterus noted. Neck: Supple. Pulmonary: Lungs CTA bilaterally Cardiac: RRR Abdomen: Obese, soft, NT/ND. Neurologic: -Mental Status: Awake, alert, refuses to participate with exam; looks away to avoid eye contact -Cranial Nerves: PERRL, EOM appear intact. BTT bilaterally. -Motor: Moved all extremities equally antigravity -Sensory: Withdraws to light touch in all extremities. -Coordination: No truncal ataxia, no dysmetria reaching for objects Pertinent Results: [MASKED] 05:15AM BLOOD WBC-8.8 RBC-4.44 Hgb-11.3 Hct-36.6 MCV-82 MCH-25.5* MCHC-30.9* RDW-18.8* RDWSD-56.3* Plt [MASKED] [MASKED] 05:48PM BLOOD Neuts-63.2 [MASKED] Monos-9.9 Eos-0.8* Baso-0.5 Im [MASKED] AbsNeut-8.24* AbsLymp-3.28 AbsMono-1.29* AbsEos-0.11 AbsBaso-0.07 [MASKED] 08:23PM BLOOD [MASKED] PTT-29.6 [MASKED] [MASKED] 05:15AM BLOOD Glucose-107* UreaN-10 Creat-0.7 Na-142 K-3.3 Cl-107 HCO3-23 AnGap-15 [MASKED] 06:35AM BLOOD ALT-19 AST-21 CK(CPK)-404* AlkPhos-67 TotBili-0.4 [MASKED] 05:15AM BLOOD Calcium-9.4 Phos-3.0 Mg-2.1 [MASKED] 06:35AM BLOOD TSH-1.2 [MASKED] 08:00PM BLOOD Lithium-0.2* [MASKED] 08:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [MASKED] 12:08AM BLOOD Lactate-1.1 CXR: FINDINGS: There are low lung volumes.No definite focal consolidation is seen. There is no large pleural effusion or pneumothorax. The cardiac silhouette is mildly enlarged, likely accentuated by low lung volumes and AP technique. Mediastinal contours unremarkable. No pulmonary edema is seen. IMPRESSION: Low lung volumes without focal consolidation or pleural effusion seen. CT Head [MASKED]: FINDINGS: Abutting the superolateral left cerebellar hemisphere and the tentorium, there is a 3.2 x 2.6 x 2.8 cm dense lesion with adjacent vasogenic edema with resultant mass effect on the quadrigeminal plate cistern and fourth ventricle. No evidence of herniation currently. There is no evidence of acute fracture. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: A dense mass abutting the tentorium and left cerebellar hemisphere with adjacent vasogenic edema and mass effect effacing the fourth ventricle and quadrigeminal plate cistern, most likely represents meningioma. No current herniation. Recommend MRI with intravenous contrast for further evaluation, if no contraindication. MRI Brain [MASKED]: FINDINGS: In the left posterior fossa, there is a round 3.2 x 2.9 x 3.0 cm dural-based mass inseparable from the left tentorium, abutting the superolateral aspect of the left cerebellar hemisphere, presumably meningioma. It is isointense to gray matter on T1 and T2 weighted imaging with homogeneous avid enhancement. There is regional T2 prolongation within the left cerebellar hemisphere consistent with vasogenic edema with and mild effacement of the fourth ventricle. No hydrocephalus. No evidence of hemorrhage or infarction. The left transverse sinus is hypoplastic. The left distal transverse sinus and sigmoid sinus do not enhance and may be compressed or occluded by the presumed meningioma. The left internal jugular vein traits postcontrast enhancement. The remainder of the dural venous sinuses are patent. IMPRESSION: Dural-based mass in the left posterior fossa, consistent with a meningioma. There is regional vasogenic edema with mild effacement of the fourth ventricle but no obstructing hydrocephalus. No definite enhancement of the distal left transverse sinus and sigmoid sinus which may be severely compressed with occlusion a possibility. There is reconstitution of contrast enhancement of the left internal jugular vein. Brief Hospital Course: Ms. [MASKED] is a [MASKED] woman with a history of bipolar disorder who presented with headache and increasing psychosis in the setting of medication non-compliance. Her exam was notable for limited speech output, paranoia and paratonia without clear focal neurologic deficits. CT demonstrated a left posterior fossa mass adjacent to the cerebellum with MRI confirming the diagnosis of meningioma (3.1 x2.6cm enhancing extra-axial mass abutting tentorium and left cerebellum), which per Neurosurgery required no acute surgical intervention and will be followed over time as an outpatient. She remained in a state of decompensated psychosis and Psychiatry recommended restarting her home Invega (paliperidone) 9mg daily, as she was likely non-compliant with this medication. She had notably last had this medication filled on [MASKED] in quantity of 30 and there were still 20 pills left in bottle she brought with her to the hospital. EKG with QTc 473msec. She remained afebrile with stable vital signs throughout her admission and she is medically cleared for discharge. She will be discharged to [MASKED] accepting MD [MASKED]. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. paliperidone 9 mg oral DAILY 2. Omeprazole 20 mg PO DAILY 3. Ferrous Sulfate 325 mg PO DAILY Discharge Medications: 1. Ferrous Sulfate 325 mg PO DAILY 2. Omeprazole 20 mg PO DAILY 3. paliperidone 9 mg oral DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: meningioma, psychosis Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You were admitted due to concern for a mass in the brain (cerebellum) that was found to be a meningioma. No surgical intervention was required and you will be followed as an outpatient by Neurosurgery. You were seen by Psychiatry who recommended restarting your home paliparidone (Invega) and your medications will continued to be titrated at [MASKED] [MASKED]. Best, Your [MASKED] Neurology Team Followup Instructions: [MASKED]
[]
[ "G4733", "K219", "D649", "E669", "Y929" ]
[ "F29: Unspecified psychosis not due to a substance or known physiological condition", "G936: Cerebral edema", "D320: Benign neoplasm of cerebral meninges", "F319: Bipolar disorder, unspecified", "G4733: Obstructive sleep apnea (adult) (pediatric)", "K219: Gastro-esophageal reflux disease without esophagitis", "D649: Anemia, unspecified", "E669: Obesity, unspecified", "T43596A: Underdosing of other antipsychotics and neuroleptics, initial encounter", "Y929: Unspecified place or not applicable", "R278: Other lack of coordination" ]
19,994,592
23,241,344
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 am feeling sick" Major Surgical or Invasive Procedure: None History of Present Illness: Per Dr. ___ initial psychiatry note: "___ ___, homeless, unemployed, ___ client, w/PPHx of schizoaffective disorder (bipolar type), multiple psychiatric hospitalizations, prior suicide attempts, but no substance use, w/PMHx of meningioma s/p resection now on anti-epileptics, was BIBA after she was found on the street agitated and walking into the traffic. Per RN notes, in triage, patient was agitated and yelling in ___, providing little information and getting even more agitated when a ___ interpreter tried helping. After she was brought inside the ___, patient calmed down and answered some questions with the help of a ___ security guard. She said she had a long Hx of depression with thoughts of SI and reported that she has not taken her medications "in a very long time." Psychiatry attempted interviewing patient twice, first in ___, then with the help of a ___ interpreter. Overall, patient was minimally cooperative with both interviews, turning her back to the interviewers early in the interview, answering most questions with "I don't know, I don't know, I don't know" ("no se, no se, no se"), others with "I don't want to talk about it" (specifically regarding her breakup with her former partner), and ended up the interview with stating, "You cannot force me to talk about anything". Patient did say that she was not feeling well and didn't want to live. She refused to elaborate on what exactly she meant by not feeling well (whether physically or psychologically). She denied any intent or plan to commit suicide herself, stating that she wanted to be killed by someone else. She was able to give her name and knew she was at ___" but couldn't state a year even after being given several choices ("no se, no se, no se"). She couldn't state why she was at the hospital and how she ended up here, but seemed to remember walking in the traffic after she was reminded about it; she refused to answer whether it was a suicide attempt. When asked about her current living situation, she said she was living on the street since she and her partner in whose apartment she used to live broke up, and she emphatically refused to talk about it any further. Patient denied any drug use. She refused to talk about her medications or psychiatric providers. Patient refused to answer questions on psychiatric or general medical ROS. COLLATERAL from BEST: - per BEST records, patient had 18 psychiatric hospitalizations since ___ - her psychiatric hospitalizations between now and ___ when she was last seen at ___ ___ are: --- ___: BIB police to ___ ___ for erratic behavior on the street, was very agitated and had to be physically and chemically restrained, was then hospitalized at ___ for psychosis; --- ___: was BIB police to ___ ___ for agitation and psychosis on the street (patient was found lying on the street w/o shoes and yelling insults at passerby's), evaluators struggled to interview her, was hospitalized at ___; --- ___: patient self-presented to ___ reporting being depressed and a recent suicide attempt (details unavailable), reported being on lithium and Risperdal, denied substance use, hospitalized at ___" Reviewed and selected pertinent information from Dr. ___ ___ Collateral information from patient's significant other (___): -psychiatrically admitted from ___ to ___ at ___. -Stayed in a shelter for one night then returned to live with ___, then left home ___ and was on streets. -Saw her on streets on ___, offered her food and asked her to return home which she declined. -Saying only "God help me." -"patient seemed like a zombie" -___ unable to provide medication list -Trauma history, family difficulties, Reviewed and selected pertinent information from Dr. ___ physician ___ evaluation on ___ -Review of discharge summary from Deaconess 4 ___ - ___, patient also exhibited signs of catatonia and had responded to lorazepam 2 mg Q8H with significant improvement. ___ Catatonia Rating Scale (___) score = 27 Excitement 1 Immobility/stupor 1 Mutism 0 Staring 2 Posturing/catalepsy 0 Grimacing 0 Echopraxia/echolalia 1 Stereotypy 0 Mannerisms 0 Verbigeration 1 Rigidity 1 Negativism 1 Waxy Flexibility 3 Withdrawal 2 Impulsivity 0 Automatic obedience ___ Mitgehen 3 Gegenhalten 3 Ambitendency 3 Grasp reflex 0 Perseveration 3 Combativeness 0 Autonomic abnormality 1 In the ___, Ms. ___ had a leukocytosis of 14 without evidence of fever or tachycardia and thus medically cleared by ___ physician, ___, MD ___ borderline at times). On review by this examiner, TSH normal, no hypo/hyperkalemia, hypo/hypernatremia. Serum tox negative. ___ ECG HR 100 QRS 90 QTc 496 ms. ___ arrival to the inpatient psychiatry unit, interview was conducted and legal paperwork reviewed with a trained ___ staff ___ interpreter. Ms. ___ reports she came to the hospital because "she was feeling sick." On attempted clarification of "sick" patient replied via direct translation, "sick, not very sick, like a bit sick." Spontaneous speech is not present. The following obtained from direct questioning only. The police brought her in while she was on the streets. They stopped her when she was trying to go into a store and wanted to ask her questions. They then asked her to get into the car and was brought to the ___. She feels confused, has some trouble remembering things, but not "as bad as before." She reports feeling happy and denies suicidal thoughts. She denies difficulty with sleep, auditory or visual hallucinations. She reports she is religious, does not have a favorite passage of scripture at this time. She reports diarrhea two days ago, has mild right anterior knee pain but denies recent or current shortness of breath, palpitations, rapid heart beat, chest pain, dysuria, frequency. Interview is terminated early due to patient report of distress associated with repeated questioning. REVIEW OF SYSTEMS: -Psychiatric: currently denies thoughts of death/SI, sleep disturbance including insomnia or hypersomnia, worry, rumination, flight of ideas, increased activity, decreased need for sleep, or talkativeness/pressured speech, auditory or visual hallucinations, or delusions of reference, paranoia, thought insertion/broadcasting. -General: Denies fatigue, fever, chills, polyuria, cough, SOB, CP, palpitations, abdominal pain, nausea, vomiting, constipation, dysuria, increased urinary frequency or odor. +edema on lower extremities, left knee pain, +diarrhea two days previously. Past Medical History: Per ___ ___ neuro-oncology note: 1. Left-sided posterior fossa meningioma 2. Dyslipidemia 3. Bipolar disorder, psychosis 4. Cardiomegaly 5. Kidney stones 6. Prediabetes 7. Sleep apnea, not on CPAP 8. Steatosis 9. Left sided thoracic pain 10. Catatonia after medication non-compliance 11. Chronic R knee pain (per Dr. ___ ___ Social History: ___ Family History: Mother with hypertension. Maternal grandfather with CAD. Aunt with colon cancer. Patient denies any family psychiatric history, though prior OMR notes have suggested a mother with possible ___. Physical Exam: Physical Exam on admission: General: -HEENT: Normocephalic, atraumatic. Moist mucous membranes, oropharynx clear. No scleral icterus, -Cardiovascular: +tachycardia, hyperdynamic, no rubs or murmurs -Pulmonary: No increased work of breathing. Lungs clear to auscultation bilaterally. No rhonchi/rales. +exp. wheezes -Abdominal: Non-distended, bowel sounds normoactive. No tenderness to palpation in all quadrants. No guarding, no rebound tenderness. -Extremities: Warm and well-perfused. chronic ___ non-pitting edema -Skin: No rashes or lesions noted. Neurological: -Cranial Nerves: ---I: Olfaction not tested. ---II: pupils 2mm, equal, round ---III, IV, VI: EOMI without nystagmus ---V: Masseter ___ bilaterally ---VII: nasolabial folds symmetric bilaterally ---VIII: deferred ---IX, X: Palate elevates symmetrically ---XI: trapezii ___ symmetric bilaterally ---XII: Tongue protrudes midline -Motor: Normal bulk and tone bilaterally. Strength ___ in deltoids, biceps, triceps, quadriceps, hamstrings, -Sensory: deferred -DTRs: 2+ patellar, biceps, Coordination: Normal on finger to nose test, no intention tremor noted -Gait: deferred Absence of resting tremor, absence of action tremor +rigidity Cognition: EXAM limited by limited participation with the following: -Wakefulness/alertness: Awake and alert -Orientation: ___, ___ -Executive function: absence of ideomotor apraxia: able to brush teeth, comb hair -Visuospatial: Left thumb to right ear -Memory: unable to recall ___, blue"..."apple, flower, I don't remember" -Fund of knowledge: unable to assess -Calculations: unable to assess -Abstraction: unable to assess -Attention: unable to assess -Language: non-fluent with ___ interpreter, ___ speaking Mental Status: -Appearance/Behavior: overweight female, sitting in chair, deep sighs at times, fair eye contact, mild psychomotor retardation -Attitude: engaged -Mood: "Happy" -Affect: mood incongruent, dysphoric, blunted, non reactive, mostly appropriate -Speech: decreased spontaneity of speech, no latency, normal rate, decreased prosody -Thought process: linear, vague, mildly disorganized -Thought Content: ---Safety: Denies SI/HI ---Delusions: No evidence of paranoia, etc. ---Obsessions/Compulsions: No evidence based on current encounter ---Hallucinations: Denies AVH, not appearing to be attending to internal stimuli -Insight: limited -Judgment: poor ___ 1+ Mutism 1+ posturing 2+ rigidity 2+ negativism 3+ Waxy Flexibility 3+Ambitendency 3+Gegenhalten Discharge MSE: Appearance: Obese, age-appearing woman, slightly frizzy hair, dressed casually, fair hygiene Behavior: Cooperative with interview, albeit a bit irritable Speech: Slightly rapid rate, otherwise normal rhythm/tone/prosody Mood: 'Good' Affect: Slightly irritable, constricted-range Thought process: Slightly tangential, but goal-directed Thought content: Denies SI/HI/AVH, perseverative on leaving with her husband instead of her ___ case worker Insight/judgment: Improved/improved Pertinent Results: ___ 04:00PM BLOOD WBC-9.9 RBC-4.33 Hgb-10.9* Hct-37.0 MCV-86 MCH-25.2* MCHC-29.5* RDW-20.0* RDWSD-61.5* Plt ___ ___ 12:25PM BLOOD Glucose-135* UreaN-10 Creat-0.7 Na-141 K-3.7 Cl-105 HCO3-23 AnGap-13 ___ 04:00PM BLOOD Phos-3.2 ___ 12:25PM BLOOD calTIBC-329 Ferritn-24 TRF-253 ___ 06:30AM BLOOD %HbA1c-5.9 eAG-123 ___ 06:30AM BLOOD Triglyc-202* HDL-29* CHOL/HD-6.1 LDLcalc-108 ___ 12:25PM BLOOD TSH-3.8 ___ 06:30AM BLOOD 25VitD-28* ___ 12:25PM BLOOD Trep Ab-NEG **FINAL REPORT ___ URINE CULTURE (Final ___: Culture workup discontinued. Further incubation showed contamination with mixed skin/genital flora. Clinical significance of isolate(s) uncertain. Interpret with caution. PROTEUS MIRABILIS. >100,000 CFU/mL. PRESUMPTIVE IDENTIFICATION. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PROTEUS MIRABILIS | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 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---- =>16 R SMEAR FOR BACTERIAL VAGINOSIS (Final ___: GRAM STAIN NEGATIVE FOR BACTERIAL VAGINOSIS. Brief Hospital Course: 1. LEGAL & SAFETY: On admission, the patient signed a conditional voluntary agreement (Section 10 & 11) and remained on that level throughout her admission. She was also placed on 15 minute checks status on admission and remained on that level of observation throughout while being unit restricted. Ms. ___ also signed a 3-day notice on ___ as she felt she was ready for discharge at the time. This 3-day notice expired on ___, on the day of discharge. 2. PSYCHIATRIC: #) Schizoaffective disorder/Catatonia During initial presentation to the ___, patient demonstrated signs and symptoms suggestive of catatonia. After receiving several doses of ativan in ___, patient did not demonstrate any overt signs of catatonia on the inpatient unit, though appeared thought disordered, disorganized, and paranoid. She was continued on ativan 1 mg TID throughout hospital course. She was irritable, with blunted affect. She was started on olanzapine for psychotic symptoms which was titrated to 5 mg QHS. She tolerated this medication well and responded well to this, becoming more organized, linear, and brighter in affect. Diagnostically, presentation is consistent with decompensated schizoaffective disorder in the setting of medication non-adherence. Her outpatient psychiatrist suggested that she be restarted on injectable antipsychotics due to her history of medication non-compliance; however, the patient declined to do so multiple times. Given repetitive inpatient psychiatric medications due to medication non-compliance, this ___ be something that can be implemented in the future. On day of discharge, ___ denied having any thoughts of wanting to hurt herself, others, and did not appear to be responding to internal stimuli. She voiced a preference to leave the hospital; though she was irritable, she did appear overtly psychotic. She was told the importance of medication-adherence, the importance of going to her outpatient providers, and that she should report back to the ___ or reach out to her ___ team should she begin to feel more paranoid. 3. SUBSTANCE USE DISORDERS: #) Patient does not have a history of substance use disorder. 4. MEDICAL #Seizure prophylaxis: Ongoing, chronic -The patient was continued on her home regimen of Oxcarbazepine 300mg BID. No seizures were observed during hospitalization. #QTc prolongation: Ongoing, chronic Patient was noted have a slightly prolonged qtc at 448 ms; her home haldol was held and she was started on olanzapine. ECG obtained prior to discharge was: #UTI: Resolved The patient was found to have an uncomplicated UTI and was appropriately treated with nitrofurantoin. #?Bacterial vaginosis: Resolved Staff noted she and her room had a persistent, malodorous fishy smell concerning for BV. OB-GYN was consulted and obtained smear which was negative for bacterial vaginosis and gonorrhea/chlamydia. 5. PSYCHOSOCIAL #) GROUPS/MILIEU: The patient was encouraged to participate in the various groups and milieu therapy opportunities offered by the unit. Despite gentle encouragment, the patient declined to participate in groups. In the milieu, ___ was a bit isolative, seen spending most time by herself watching television or walking around in the unit. #) COLLATERAL INFORMATION AND FAMILY INVOLVEMENT Family meeting was held with her spouse, ___, ___ workers, and inpatient clinicians present. Clinical team spoke with the patient's outpatient psychiatrist to provide clinical updates, schedule aftercare appointments, and gather additional collateral. ___ therapist also visited her while she was on the inpatient unit. #) INTERVENTIONS - Medications: Olanzapine - Psychotherapeutic Interventions: Individual, group, and milieu therapy. - Coordination of aftercare: Clinical team was in correspondence with her ___ outpatient treatment team as mentioned above. - Behavioral Interventions: Increased coping skills and distress tolerance INFORMED CONSENT: Clinical team attempted to discuss the indications for, intended benefits of, and possible side effects and risks of Zyprexa, and risks and benefits of possible alternatives, including not taking the medication, with this patient. We discussed the patient's right to decide whether to take this medication as well as the importance of the patient's actively participating in the treatment and discussing any questions about medications with the treatment team. The patient appeared able to understand and consented to continue and to adjust the medication to clinical response. Overall, her participation was decreased. RISK ASSESSMENT & PROGNOSIS On initial presentation, the patient was evaluated and felt to be at increased risk of harm to self due to her chronic mental illness, history of inpatient psychiatric hospitalizations, history of suicide attempts; she was at acutely elevated risk of harm to self due to medication non-compliance, ongoing psychosis, and lack of community supports. Protective factors include her long-term relationship with her husband, her good relationship with her outpatient providers, and lack of suicidal ideation. Inpatient psychiatric hospitalization was able to address her modifiable risk factors of psychosis and medication non-compliance with the initiation of antipsychotic medications. Overall, the patient is no longer at acutely elevated risk of self-harm. Overall prognosis is guarded, as patient's longstanding history of psychosis with periods of medication non-compliance. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lithium Carbonate 300 mg PO BID 2. OXcarbazepine 300 mg PO BID 3. Pantoprazole 20 mg PO Q24H 4. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line Discharge Medications: 1. LORazepam 1 mg PO TID RX *lorazepam 1 mg 1 tablet(s) by mouth three times a day Disp #*42 Tablet Refills:*0 2. OLANZapine 7.5 mg PO QHS mood dos RX *olanzapine 7.5 mg 1 tablet(s) by mouth at bedtime Disp #*14 Tablet Refills:*0 3. Lithium Carbonate 600 mg PO QHS RX *lithium carbonate 600 mg 1 capsule(s) by mouth at bedtime Disp #*14 Capsule Refills:*0 4. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line RX *docusate sodium 100 mg 1 capsule(s) by mouth at bedtime Disp #*28 Capsule Refills:*0 5. OXcarbazepine 300 mg PO BID RX *oxcarbazepine 300 mg 1 tablet(s) by mouth twice a day Disp #*28 Tablet Refills:*0 6. Pantoprazole 20 mg PO Q24H RX *pantoprazole 20 mg 1 tablet(s) by mouth once a day Disp #*14 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Schizoaffective disorder Discharge Condition: On day of discharge, ___ denied having any thoughts of wanting to hurt herself, others, and did not appear to be responding to internal stimuli. She voiced a preference to leave the hospital; though she was irritable, she did appear overtly psychotic. She was told the importance of medication-adherence, the importance of going to her outpatient providers, and that she should report back to the ___ or reach out to her ___ team should she begin to feel more paranoid. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Mental Status: Appearance: Obese, age-appearing woman, slightly frizzy hair, dressed casually, fair hygiene Behavior: Cooperative with interview, albeit a bit irritable Speech: Slightly rapid rate, otherwise normal rhythm/tone/prosody Mood: 'Good' Affect: Slightly irritable, constricted-range Thought process: Slightly tangential, but goal-directed Thought content: Denies SI/HI/AVH, perseverative on leaving with her husband instead of her ___ case worker Insight/judgment: Improved/improved Discharge Instructions: -Please follow up with all outpatient appointments as listed - take this discharge paperwork to your appointments. -Unless a limited duration is specified in the prescription, please continue all medications as directed until your prescriber tells you to stop or change. -Please avoid abusing alcohol and any drugs--whether prescription drugs or illegal drugs--as this can further worsen your medical and psychiatric illnesses. -Please contact your outpatient psychiatrist or other providers if you have any concerns. -Please call ___ 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: ___
[ "F250", "N390", "R45851", "B964", "I4581", "M25561", "Z590", "Z560", "Z9114", "E663", "Z6835" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: "I am feeling sick" Major Surgical or Invasive Procedure: None History of Present Illness: Per Dr. [MASKED] initial psychiatry note: "[MASKED] [MASKED], homeless, unemployed, [MASKED] client, w/PPHx of schizoaffective disorder (bipolar type), multiple psychiatric hospitalizations, prior suicide attempts, but no substance use, w/PMHx of meningioma s/p resection now on anti-epileptics, was BIBA after she was found on the street agitated and walking into the traffic. Per RN notes, in triage, patient was agitated and yelling in [MASKED], providing little information and getting even more agitated when a [MASKED] interpreter tried helping. After she was brought inside the [MASKED], patient calmed down and answered some questions with the help of a [MASKED] security guard. She said she had a long Hx of depression with thoughts of SI and reported that she has not taken her medications "in a very long time." Psychiatry attempted interviewing patient twice, first in [MASKED], then with the help of a [MASKED] interpreter. Overall, patient was minimally cooperative with both interviews, turning her back to the interviewers early in the interview, answering most questions with "I don't know, I don't know, I don't know" ("no se, no se, no se"), others with "I don't want to talk about it" (specifically regarding her breakup with her former partner), and ended up the interview with stating, "You cannot force me to talk about anything". Patient did say that she was not feeling well and didn't want to live. She refused to elaborate on what exactly she meant by not feeling well (whether physically or psychologically). She denied any intent or plan to commit suicide herself, stating that she wanted to be killed by someone else. She was able to give her name and knew she was at [MASKED]" but couldn't state a year even after being given several choices ("no se, no se, no se"). She couldn't state why she was at the hospital and how she ended up here, but seemed to remember walking in the traffic after she was reminded about it; she refused to answer whether it was a suicide attempt. When asked about her current living situation, she said she was living on the street since she and her partner in whose apartment she used to live broke up, and she emphatically refused to talk about it any further. Patient denied any drug use. She refused to talk about her medications or psychiatric providers. Patient refused to answer questions on psychiatric or general medical ROS. COLLATERAL from BEST: - per BEST records, patient had 18 psychiatric hospitalizations since [MASKED] - her psychiatric hospitalizations between now and [MASKED] when she was last seen at [MASKED] [MASKED] are: --- [MASKED]: BIB police to [MASKED] [MASKED] for erratic behavior on the street, was very agitated and had to be physically and chemically restrained, was then hospitalized at [MASKED] for psychosis; --- [MASKED]: was BIB police to [MASKED] [MASKED] for agitation and psychosis on the street (patient was found lying on the street w/o shoes and yelling insults at passerby's), evaluators struggled to interview her, was hospitalized at [MASKED]; --- [MASKED]: patient self-presented to [MASKED] reporting being depressed and a recent suicide attempt (details unavailable), reported being on lithium and Risperdal, denied substance use, hospitalized at [MASKED]" Reviewed and selected pertinent information from Dr. [MASKED] [MASKED] Collateral information from patient's significant other ([MASKED]): -psychiatrically admitted from [MASKED] to [MASKED] at [MASKED]. -Stayed in a shelter for one night then returned to live with [MASKED], then left home [MASKED] and was on streets. -Saw her on streets on [MASKED], offered her food and asked her to return home which she declined. -Saying only "God help me." -"patient seemed like a zombie" -[MASKED] unable to provide medication list -Trauma history, family difficulties, Reviewed and selected pertinent information from Dr. [MASKED] physician [MASKED] evaluation on [MASKED] -Review of discharge summary from Deaconess 4 [MASKED] - [MASKED], patient also exhibited signs of catatonia and had responded to lorazepam 2 mg Q8H with significant improvement. [MASKED] Catatonia Rating Scale ([MASKED]) score = 27 Excitement 1 Immobility/stupor 1 Mutism 0 Staring 2 Posturing/catalepsy 0 Grimacing 0 Echopraxia/echolalia 1 Stereotypy 0 Mannerisms 0 Verbigeration 1 Rigidity 1 Negativism 1 Waxy Flexibility 3 Withdrawal 2 Impulsivity 0 Automatic obedience [MASKED] Mitgehen 3 Gegenhalten 3 Ambitendency 3 Grasp reflex 0 Perseveration 3 Combativeness 0 Autonomic abnormality 1 In the [MASKED], Ms. [MASKED] had a leukocytosis of 14 without evidence of fever or tachycardia and thus medically cleared by [MASKED] physician, [MASKED], MD [MASKED] borderline at times). On review by this examiner, TSH normal, no hypo/hyperkalemia, hypo/hypernatremia. Serum tox negative. [MASKED] ECG HR 100 QRS 90 QTc 496 ms. [MASKED] arrival to the inpatient psychiatry unit, interview was conducted and legal paperwork reviewed with a trained [MASKED] staff [MASKED] interpreter. Ms. [MASKED] reports she came to the hospital because "she was feeling sick." On attempted clarification of "sick" patient replied via direct translation, "sick, not very sick, like a bit sick." Spontaneous speech is not present. The following obtained from direct questioning only. The police brought her in while she was on the streets. They stopped her when she was trying to go into a store and wanted to ask her questions. They then asked her to get into the car and was brought to the [MASKED]. She feels confused, has some trouble remembering things, but not "as bad as before." She reports feeling happy and denies suicidal thoughts. She denies difficulty with sleep, auditory or visual hallucinations. She reports she is religious, does not have a favorite passage of scripture at this time. She reports diarrhea two days ago, has mild right anterior knee pain but denies recent or current shortness of breath, palpitations, rapid heart beat, chest pain, dysuria, frequency. Interview is terminated early due to patient report of distress associated with repeated questioning. REVIEW OF SYSTEMS: -Psychiatric: currently denies thoughts of death/SI, sleep disturbance including insomnia or hypersomnia, worry, rumination, flight of ideas, increased activity, decreased need for sleep, or talkativeness/pressured speech, auditory or visual hallucinations, or delusions of reference, paranoia, thought insertion/broadcasting. -General: Denies fatigue, fever, chills, polyuria, cough, SOB, CP, palpitations, abdominal pain, nausea, vomiting, constipation, dysuria, increased urinary frequency or odor. +edema on lower extremities, left knee pain, +diarrhea two days previously. Past Medical History: Per [MASKED] [MASKED] neuro-oncology note: 1. Left-sided posterior fossa meningioma 2. Dyslipidemia 3. Bipolar disorder, psychosis 4. Cardiomegaly 5. Kidney stones 6. Prediabetes 7. Sleep apnea, not on CPAP 8. Steatosis 9. Left sided thoracic pain 10. Catatonia after medication non-compliance 11. Chronic R knee pain (per Dr. [MASKED] [MASKED] Social History: [MASKED] Family History: Mother with hypertension. Maternal grandfather with CAD. Aunt with colon cancer. Patient denies any family psychiatric history, though prior OMR notes have suggested a mother with possible [MASKED]. Physical Exam: Physical Exam on admission: General: -HEENT: Normocephalic, atraumatic. Moist mucous membranes, oropharynx clear. No scleral icterus, -Cardiovascular: +tachycardia, hyperdynamic, no rubs or murmurs -Pulmonary: No increased work of breathing. Lungs clear to auscultation bilaterally. No rhonchi/rales. +exp. wheezes -Abdominal: Non-distended, bowel sounds normoactive. No tenderness to palpation in all quadrants. No guarding, no rebound tenderness. -Extremities: Warm and well-perfused. chronic [MASKED] non-pitting edema -Skin: No rashes or lesions noted. Neurological: -Cranial Nerves: ---I: Olfaction not tested. ---II: pupils 2mm, equal, round ---III, IV, VI: EOMI without nystagmus ---V: Masseter [MASKED] bilaterally ---VII: nasolabial folds symmetric bilaterally ---VIII: deferred ---IX, X: Palate elevates symmetrically ---XI: trapezii [MASKED] symmetric bilaterally ---XII: Tongue protrudes midline -Motor: Normal bulk and tone bilaterally. Strength [MASKED] in deltoids, biceps, triceps, quadriceps, hamstrings, -Sensory: deferred -DTRs: 2+ patellar, biceps, Coordination: Normal on finger to nose test, no intention tremor noted -Gait: deferred Absence of resting tremor, absence of action tremor +rigidity Cognition: EXAM limited by limited participation with the following: -Wakefulness/alertness: Awake and alert -Orientation: [MASKED], [MASKED] -Executive function: absence of ideomotor apraxia: able to brush teeth, comb hair -Visuospatial: Left thumb to right ear -Memory: unable to recall [MASKED], blue"..."apple, flower, I don't remember" -Fund of knowledge: unable to assess -Calculations: unable to assess -Abstraction: unable to assess -Attention: unable to assess -Language: non-fluent with [MASKED] interpreter, [MASKED] speaking Mental Status: -Appearance/Behavior: overweight female, sitting in chair, deep sighs at times, fair eye contact, mild psychomotor retardation -Attitude: engaged -Mood: "Happy" -Affect: mood incongruent, dysphoric, blunted, non reactive, mostly appropriate -Speech: decreased spontaneity of speech, no latency, normal rate, decreased prosody -Thought process: linear, vague, mildly disorganized -Thought Content: ---Safety: Denies SI/HI ---Delusions: No evidence of paranoia, etc. ---Obsessions/Compulsions: No evidence based on current encounter ---Hallucinations: Denies AVH, not appearing to be attending to internal stimuli -Insight: limited -Judgment: poor [MASKED] 1+ Mutism 1+ posturing 2+ rigidity 2+ negativism 3+ Waxy Flexibility 3+Ambitendency 3+Gegenhalten Discharge MSE: Appearance: Obese, age-appearing woman, slightly frizzy hair, dressed casually, fair hygiene Behavior: Cooperative with interview, albeit a bit irritable Speech: Slightly rapid rate, otherwise normal rhythm/tone/prosody Mood: 'Good' Affect: Slightly irritable, constricted-range Thought process: Slightly tangential, but goal-directed Thought content: Denies SI/HI/AVH, perseverative on leaving with her husband instead of her [MASKED] case worker Insight/judgment: Improved/improved Pertinent Results: [MASKED] 04:00PM BLOOD WBC-9.9 RBC-4.33 Hgb-10.9* Hct-37.0 MCV-86 MCH-25.2* MCHC-29.5* RDW-20.0* RDWSD-61.5* Plt [MASKED] [MASKED] 12:25PM BLOOD Glucose-135* UreaN-10 Creat-0.7 Na-141 K-3.7 Cl-105 HCO3-23 AnGap-13 [MASKED] 04:00PM BLOOD Phos-3.2 [MASKED] 12:25PM BLOOD calTIBC-329 Ferritn-24 TRF-253 [MASKED] 06:30AM BLOOD %HbA1c-5.9 eAG-123 [MASKED] 06:30AM BLOOD Triglyc-202* HDL-29* CHOL/HD-6.1 LDLcalc-108 [MASKED] 12:25PM BLOOD TSH-3.8 [MASKED] 06:30AM BLOOD 25VitD-28* [MASKED] 12:25PM BLOOD Trep Ab-NEG **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: Culture workup discontinued. Further incubation showed contamination with mixed skin/genital flora. Clinical significance of isolate(s) uncertain. Interpret with caution. PROTEUS MIRABILIS. >100,000 CFU/mL. PRESUMPTIVE IDENTIFICATION. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] PROTEUS MIRABILIS | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 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---- =>16 R SMEAR FOR BACTERIAL VAGINOSIS (Final [MASKED]: GRAM STAIN NEGATIVE FOR BACTERIAL VAGINOSIS. Brief Hospital Course: 1. LEGAL & SAFETY: On admission, the patient signed a conditional voluntary agreement (Section 10 & 11) and remained on that level throughout her admission. She was also placed on 15 minute checks status on admission and remained on that level of observation throughout while being unit restricted. Ms. [MASKED] also signed a 3-day notice on [MASKED] as she felt she was ready for discharge at the time. This 3-day notice expired on [MASKED], on the day of discharge. 2. PSYCHIATRIC: #) Schizoaffective disorder/Catatonia During initial presentation to the [MASKED], patient demonstrated signs and symptoms suggestive of catatonia. After receiving several doses of ativan in [MASKED], patient did not demonstrate any overt signs of catatonia on the inpatient unit, though appeared thought disordered, disorganized, and paranoid. She was continued on ativan 1 mg TID throughout hospital course. She was irritable, with blunted affect. She was started on olanzapine for psychotic symptoms which was titrated to 5 mg QHS. She tolerated this medication well and responded well to this, becoming more organized, linear, and brighter in affect. Diagnostically, presentation is consistent with decompensated schizoaffective disorder in the setting of medication non-adherence. Her outpatient psychiatrist suggested that she be restarted on injectable antipsychotics due to her history of medication non-compliance; however, the patient declined to do so multiple times. Given repetitive inpatient psychiatric medications due to medication non-compliance, this [MASKED] be something that can be implemented in the future. On day of discharge, [MASKED] denied having any thoughts of wanting to hurt herself, others, and did not appear to be responding to internal stimuli. She voiced a preference to leave the hospital; though she was irritable, she did appear overtly psychotic. She was told the importance of medication-adherence, the importance of going to her outpatient providers, and that she should report back to the [MASKED] or reach out to her [MASKED] team should she begin to feel more paranoid. 3. SUBSTANCE USE DISORDERS: #) Patient does not have a history of substance use disorder. 4. MEDICAL #Seizure prophylaxis: Ongoing, chronic -The patient was continued on her home regimen of Oxcarbazepine 300mg BID. No seizures were observed during hospitalization. #QTc prolongation: Ongoing, chronic Patient was noted have a slightly prolonged qtc at 448 ms; her home haldol was held and she was started on olanzapine. ECG obtained prior to discharge was: #UTI: Resolved The patient was found to have an uncomplicated UTI and was appropriately treated with nitrofurantoin. #?Bacterial vaginosis: Resolved Staff noted she and her room had a persistent, malodorous fishy smell concerning for BV. OB-GYN was consulted and obtained smear which was negative for bacterial vaginosis and gonorrhea/chlamydia. 5. PSYCHOSOCIAL #) GROUPS/MILIEU: The patient was encouraged to participate in the various groups and milieu therapy opportunities offered by the unit. Despite gentle encouragment, the patient declined to participate in groups. In the milieu, [MASKED] was a bit isolative, seen spending most time by herself watching television or walking around in the unit. #) COLLATERAL INFORMATION AND FAMILY INVOLVEMENT Family meeting was held with her spouse, [MASKED], [MASKED] workers, and inpatient clinicians present. Clinical team spoke with the patient's outpatient psychiatrist to provide clinical updates, schedule aftercare appointments, and gather additional collateral. [MASKED] therapist also visited her while she was on the inpatient unit. #) INTERVENTIONS - Medications: Olanzapine - Psychotherapeutic Interventions: Individual, group, and milieu therapy. - Coordination of aftercare: Clinical team was in correspondence with her [MASKED] outpatient treatment team as mentioned above. - Behavioral Interventions: Increased coping skills and distress tolerance INFORMED CONSENT: Clinical team attempted to discuss the indications for, intended benefits of, and possible side effects and risks of Zyprexa, and risks and benefits of possible alternatives, including not taking the medication, with this patient. We discussed the patient's right to decide whether to take this medication as well as the importance of the patient's actively participating in the treatment and discussing any questions about medications with the treatment team. The patient appeared able to understand and consented to continue and to adjust the medication to clinical response. Overall, her participation was decreased. RISK ASSESSMENT & PROGNOSIS On initial presentation, the patient was evaluated and felt to be at increased risk of harm to self due to her chronic mental illness, history of inpatient psychiatric hospitalizations, history of suicide attempts; she was at acutely elevated risk of harm to self due to medication non-compliance, ongoing psychosis, and lack of community supports. Protective factors include her long-term relationship with her husband, her good relationship with her outpatient providers, and lack of suicidal ideation. Inpatient psychiatric hospitalization was able to address her modifiable risk factors of psychosis and medication non-compliance with the initiation of antipsychotic medications. Overall, the patient is no longer at acutely elevated risk of self-harm. Overall prognosis is guarded, as patient's longstanding history of psychosis with periods of medication non-compliance. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lithium Carbonate 300 mg PO BID 2. OXcarbazepine 300 mg PO BID 3. Pantoprazole 20 mg PO Q24H 4. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line Discharge Medications: 1. LORazepam 1 mg PO TID RX *lorazepam 1 mg 1 tablet(s) by mouth three times a day Disp #*42 Tablet Refills:*0 2. OLANZapine 7.5 mg PO QHS mood dos RX *olanzapine 7.5 mg 1 tablet(s) by mouth at bedtime Disp #*14 Tablet Refills:*0 3. Lithium Carbonate 600 mg PO QHS RX *lithium carbonate 600 mg 1 capsule(s) by mouth at bedtime Disp #*14 Capsule Refills:*0 4. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line RX *docusate sodium 100 mg 1 capsule(s) by mouth at bedtime Disp #*28 Capsule Refills:*0 5. OXcarbazepine 300 mg PO BID RX *oxcarbazepine 300 mg 1 tablet(s) by mouth twice a day Disp #*28 Tablet Refills:*0 6. Pantoprazole 20 mg PO Q24H RX *pantoprazole 20 mg 1 tablet(s) by mouth once a day Disp #*14 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Schizoaffective disorder Discharge Condition: On day of discharge, [MASKED] denied having any thoughts of wanting to hurt herself, others, and did not appear to be responding to internal stimuli. She voiced a preference to leave the hospital; though she was irritable, she did appear overtly psychotic. She was told the importance of medication-adherence, the importance of going to her outpatient providers, and that she should report back to the [MASKED] or reach out to her [MASKED] team should she begin to feel more paranoid. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Mental Status: Appearance: Obese, age-appearing woman, slightly frizzy hair, dressed casually, fair hygiene Behavior: Cooperative with interview, albeit a bit irritable Speech: Slightly rapid rate, otherwise normal rhythm/tone/prosody Mood: 'Good' Affect: Slightly irritable, constricted-range Thought process: Slightly tangential, but goal-directed Thought content: Denies SI/HI/AVH, perseverative on leaving with her husband instead of her [MASKED] case worker Insight/judgment: Improved/improved Discharge Instructions: -Please follow up with all outpatient appointments as listed - take this discharge paperwork to your appointments. -Unless a limited duration is specified in the prescription, please continue all medications as directed until your prescriber tells you to stop or change. -Please avoid abusing alcohol and any drugs--whether prescription drugs or illegal drugs--as this can further worsen your medical and psychiatric illnesses. -Please contact your outpatient psychiatrist or other providers if you have any concerns. -Please call [MASKED] or go to your nearest emergency room if you feel unsafe in any way and are unable to immediately reach your health care providers. It was a pleasure to have worked with you, and we wish you the best of health. Followup Instructions: [MASKED]
[]
[ "N390" ]
[ "F250: Schizoaffective disorder, bipolar type", "N390: Urinary tract infection, site not specified", "R45851: Suicidal ideations", "B964: Proteus (mirabilis) (morganii) as the cause of diseases classified elsewhere", "I4581: Long QT syndrome", "M25561: Pain in right knee", "Z590: Homelessness", "Z560: Unemployment, unspecified", "Z9114: Patient's other noncompliance with medication regimen", "E663: Overweight", "Z6835: Body mass index [BMI] 35.0-35.9, adult" ]
19,994,592
24,090,308
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: PSYCHIATRY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: "..." Major Surgical or Invasive Procedure: Ninguno ============================================================ None History of Present Illness: HISTORY OF PRESENT ILLNESS: Mrs ___ is a ___ year old ___ female with a history of bipolar disorder, psychosis, and meningioma who presents with altered mental status, sent here overnight from ___ where she had walked in for unknown reason. Minimal communication on initial attempts to interview, even with ___ interpreter, saying nothing or- per report- repeatedly mumbling either ___ or "muerto" (dead). Nursing staff report patient has been minimally interactive but has followed instructions to robe/disrobe, and patient has also asked for the bathroom. Poor PO intake. On repeat interview with interpreter patient was somewhat more interactive. When asked why she is here does not respond. States her name and location ("deaconess" "emergency"). Asked if she takes lithium says she takes it, asked who helps her says "I take it." Successfully identifies a pen and its colors "black and white." When asked to write her name and date of birth writes "blac and whit." Per collateral from BEST, patient last seen ___ with confusion and psychosis and was admitted to ___. Patient's psych meds are prescribed by ___ at ___. Dr ___ is currently away. Left message with covering physician Dr ___ (___). On chart review, patient had somewhat similar episode ___ in the setting of non-adherence to lithium: "She was brought to the ED by her family for 3 days of confusion. Her husband says that she has been walking around the house "like a zombie", "not making any sense" when she speaks, not eating, bathing, or sleeping. Family also notes intermittent outbursts of arm raising and shaking that is nonsynchronized, nonrhythmic, and resembles a protracted startle response (which they demonstrated)." ___ Rating scale: 16 Excitement: 0 Immobility/stupor: ___ Mutism: 1 Staring: 2 Posturing/catalepsy: 0 Grimacing: 1 Echopraxia/echolalia: 1 Stereotypy: 1 Mannerisms: 0 Verbigeration: 1 Rigidity: 1 Negativism: 2 Waxy flexibility: 0 Withdrawal: 2 Impulsivity: 0 Automatic obedience: ___ Mitgehen: 0 Gegenhalten: 0 Ambitendency: 0 Grasp reflex: - Perseveration: 3 Combativeness: 0 Autonomic abnormality: 0 On re-examination the following day: Patient much more interactive this morning and able to give some history. Says she got out of Arbour 3 days ago. Went home. Continued taking her meds. On day of presentation was only able to say that she ate and then came here. Does not know why. Asked about the large amount of money she was found to be carrying, says she went to the bank to move her money to her house. Denies any triggers, denies fighting with her husband. This morning patient says she is "good" and her mood is "good." However she also endorses feeling tired and "heavy" and says she "felt more alive yesterday". Denies SI/HI and AH/VH. ___ Scale: 5 Scoring only for... Immobility/stupor: 1 Staring: 1 Rigidity: 1 Negativism: 1 Withdrawal: 1 On arrival to the inpatient unit: Briefly, ___ is a ___ year old female with a history of bipolar disorder type 1, meningioma, HLD and OSA who was sent to the ___ ED from ___ where she had gone for no apparent reason. In the ED, the patient appeared catatonic and received Ativan which resulted in some improvement. Per chart review, patient was seen at ___ in ___ for AMS and was found to have a meningioma on head CT. However, per neurological evaluation at that time was not felt to be the cause of her AMS and agitation. Psychiatry was consulted and patient was found to be psychotic and likely not taking her lithium. A lithium level from ___ was <0.1 which is concerning for medication non-compliance for this admission as well. Neurology examined the patient in the ED during this admission for concerns of seizures and did an EEG but her AMS was felt to be more likely due to psychosis rather than infection or seizure. On admission to deaconess 4, the patient was not cooperative with interview and lay down face first on the floor and wouldn't answer questions. Patient was brought to her room and she lay down on the bed. Attempted to interview her with ___ interpreter but she asked interviewer to leave and stated she wanted to sleep. She denied SI. She then stopped answering questions. Past Medical History: Past Psychiatric History: Dx: Bipolar disorder Hospitalizations: Treaters: - Psychiatrist: Dr. ___ (___) - Therapist: ___, ___ (___) - PCP: Dr. ___ (___) Medication and ECT Trials: Invega, Lithium, Zyprexa, (has never tried Depakote) Self-Injury/Self harm: ___ past suicide attempts Past Medical History -OSA (per patient, does not use CPAP at home) -GERD -Anemia -Hyperlipidemia -Hepatic steatosis -left posterior fossa benign meningioma Social History: ___ Family History: Mother with hypertension. Maternal grandfather with CAD. Aunt with colon cancer. Physical Exam: PHYSICAL EXAM ON ADMISSION: VS: 98.5, 94 / 61, 73, 16, 95% GEN:NAD, obese, Hispanic female lying in bed with her eyes closed and covers pulled up. Refusing to answer further questions. Moving limbs spontaneously, speaking fluent ___. HEENT: Normocephalic, atraumatic. Moist mucous membranes. Cardio: Regular Rate and Rhythm, no murmurs/rubs/gallops Pulm: Normal work of breathing, clear to auscultation bilaterally. Abd: Non-distended, non-tender to palpation, positive bowel sounds Ext: Warm and well perfused, capillary refill < 2 seconds Neuro: CN: PERRLA, EOM full, facial sensation to touch equal in all 3 divisions bilaterally, face symmetric on eye closure and smile, hearing normal bilaterally to rubbing fingers, phonation normal, head turning and shoulder shrug intact, tongue midline. Strength: ___ throughout. Sensation: within normal limits to light touch. Gait and station: Normal gait, no ataxia noted. Abnormal movements: No tremor or abnormal movements appreciated. MSE on discharge: Appearance: well groomed facial expression: friendly build: overweight Behavior: Engaging, cooperative psychomotor: no abnormal involuntary movements, no agitation Speech: slightly pressured today, normal tone and volume mood/affect: stable, no angry outbursts thought process/content: reality oriented, goal directed, denied SI/HI, denied AH/VH/ paranoid delusions Intellectual Functioning: Decreased concentration Oriented: ×4 memory: Grossly intact insight: fair Judgment: fair Pertinent Results: CBC: ___ 07:35AM WBC-7.5 RBC-4.32 HGB-12.0 HCT-37.9 MCV-88 MCH-27.8 MCHC-31.7* RDW-20.5* RDWSD-65.9* ___ 07:35AM NEUTS-54.9 ___ MONOS-8.8 EOS-2.1 BASOS-0.3 IM ___ AbsNeut-4.12 AbsLymp-2.52 AbsMono-0.66 AbsEos-0.16 AbsBaso-0.02 ___ 07:35AM PLT COUNT-265 BMP: ___ 04:35AM GLUCOSE-95 UREA N-8 CREAT-0.6 SODIUM-138 POTASSIUM-4.1 CHLORID ___ TOTAL CO2-24 ANION GAP-15 ___ 07:35AM GLUCOSE-111* UREA N-12 CREAT-0.6 SODIUM-138 POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-22 ANION GAP-16 UA: ___ 02:00PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 02:00PM URINE BLOOD-TR* NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-10* BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG ___ 02:00PM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE EPI-1 ___ 02:00PM URINE MUCOUS-RARE* UTox: ___ 02:00PM URINE BLOOD-TR* NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-10* BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG Serum Tox: ___ 07:35AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG Lithium: ___: LITHIUM <0.1 ___: LITHIUM 0.7 ___: LITHIUM 0.7 TSH: ___: 52.5 ___: 7.6,, free T4 0.9 ___: 5.4 ___: 4.5 B-HCG: ___: <___. LEGAL & SAFETY: On admission, Ms. ___ was unwilling to cooperate with interview and thus, was admitted on a ___ which expired on ___. She signed a conditional voluntary agreement (Section 10 & 11) on ___ which was accepted. Ms. ___ was also placed on q15 minute checks status on admission and remained on that level of observation throughout while being unit restricted. Evaluation for fresh air access: Ms. ___ was deemed to not be eligible for access to the outdoors based on danger to self and inability to ensure safety in an open environment even with supervision as evidenced by depression, catatonia, poor cooperativeness with initial interview, psychotic 2. PSYCHIATRIC: #) Catatonia Ms. ___ presented to the ED with symptoms concerning for non-malignant, retarded catatonia on presentation to the ED with ___ of 16. Neurology was consulted to rule out seizures and other neurologic processes as a potential contributor. EEG did not show any epileptiform activity and CT Head was stable. Ms. ___ level was sub therapeutic (<0.1) suggesting medication non-compliance as a likely etiology (and per her outpatient psychiatrist's collateral, Ms. ___ has a history of recurring hospitalization in the setting of medication non-compliance. She was started on standing ativan (2mg q8h) with dramatic improvement in her symptoms, scoring ___ of 5 on re-evaluation. She was re-started on her Lithium at a lower dose (300mg BID) and Olanzapine 5mg PO BID for management of psychosis. Per ___'s recent discharge summary, she had been recently discharged on Lithium ER 600mg PO BID and Zyprexa 15mg PO bedtime. Ms. ___ tolerated an ___ taper with continued improvement of her symptoms. Her lithium was gradually up-titrated to 600mg BID (dose on discharge). Her olanzapine was tapered given her daytime sleepiness, however, Ms. ___ began exhibiting some symptoms concerning for mania including irritability, rapid and pressured speech, and disorganization (with reoccurring concern that insurance won't cover her outpatient ___ providers despite reassurance). She was re-started on Paliperidone (Invega) which she had previously taken as an outpatient and had been stable-on as an injectable which was up-titrated to 9mg. The team discussed switching from PO to IM administration on discharge with the patient, however, Ms. ___ refused stating the the injectable form had previously affected her ability to walk. She continued to improve, however, on routine labs, Ms. ___ had an increase in her TSH to 7.6 with a free T4 of 0.7 concerning for Lithium induced hypothyroidism given that her TSH had been within normal limits on admission (and per collateral had been previously unremarkable). Her lithium was decreased to 300mg BID with subsequent decrease in TSH to 5.4, however, patient began demonstrating some worsening of her symptoms (more irritability, disorganization, constricted affect) and her Lithium was increased to 300mg qAM and 600mg qhs, with reduction of TSH on discharge to 4.5 and a Lithium level of 0.7. Ms. ___ was eager to return home and continue care with her outpatient providers on discharge no longer demonstrating symptoms of catatonia or mania. She denied suicidal and homicidal ideation throughout her hospitalization and denied any auditory or visual hallucinations. 3. SUBSTANCE USE DISORDERS: Ms. ___ does not have any substance use disorders, and therefore did not require any counseling or treatment in this regard. 4. MEDICAL Ms. ___ was evaluated by the Neurology Consult service on initial presentation to the ED to evaluate for seizures as a possible etiology of her presenting symptoms. Per their assessment: "There are no clear toxic, metabolic or infectious triggers to explain her presentation. Her presentation is likely ___ noncompliance given subtherapeutic lithium level on arrival (though patient endorses compliance with lithium). As improved participation in exam and no focal deficits, no further workup needed at this time. I would defer LP at this time, as patient is afebrile, without leukocytosis and given location of meningioma. Important Diagnostic Tests: - EEG: negative - CT brain --- 1. No acute hemorrhage or territorial infarction. --- 2. Stable appearance of left extra-axial mass abutting the tentorium and left cerebellar hemisphere, most consistent with a meningioma. Stable associated vasogenic edema and mass effect on the fourth ventricle and quadrigeminal cistern. She was ultimately medically cleared in the ED and no acute medical issues prevented admission to Deac #) Benign Meningioma: - Ms. ___ was supposed to follow-up with Dr. ___ ___ (neurosurgeon) but missed her follow-up appointment. Dr. ___ was contacted by inpatient psychiatry team, they will contact patient following discharge to arrange follow-up. Neurosurgeon: Dr ___: ___ Office will call Ms. ___ following discharge to arrange for follow-up appointment. Will also provide Ms. ___ with number to assist in arranging appointment. #) GERD - Ms. ___ was continued on her home omeprazole #)Anemia - Ms. ___ was continued on her home iron supplementation 5. PSYCHOSOCIAL #) GROUPS/MILIEU: Ms. ___ was encouraged to participate in the various groups and milieu therapy opportunities offered by the unit. The occupational therapy and social work groups that focus on teaching patients various coping skills. Ms. ___ infrequently attended these groups, occasionally attending projects group, though notably participation may have been limited by language barrier. Patient was often visible on the unit, occasionally smiling at staff though had limited interaction with staff and peers. #) COLLATERAL CONTACTS & FAMILY INVOLVEMENT: Ms. ___ gave verbal permission for the team to contact her outpatient psychiatrist, Dr. ___, and outpatient therapist, ___. Both were contacted upon Ms. ___ presentation to the ___ ED/Deac 4 and an update of her progress since admission on Deac 4, and they provided collateral information and treatment recommendations. 6. INFORMED CONSENT: Ms. ___ was not started on any new medications during this hospitalization and was in agreement to re-starting Lithium and Invega as she had been previously taking. 7. RISK ASSESSMENT On presentation, Ms. ___ evaluated and felt to be at an increased risk of harm to herself given her symptoms of catatonia. Ms. ___ static risk factors noted at that time include Static risk factors include history of suicide attempts (per collateral ___ previous attempts), chronic mental illness with lack of insight, recent discharge from an inpatient psychiatric unit, unemployment, chronic medical illness. Modifiable risk factors include psychosis, disorganized and unpredictable behavior, medication noncompliance, poorly controlled mental illness, intermittent engagement with outpatient treatment, and poor reality testing which were mitigated on the inpatient setting with re-starting outpatient medications, treating her catatonia which has since resolved, contacting outpatient providers to arrange follow-up and coordinating ___ services post discharge. These modifiable risk factors were also addressed with acute stabilization in a safe environment on a locked inpatient unit, psychopharmacologic adjustments, psychotherapeutic interventions (OT groups, SW groups, individual therapy meetings with psychiatrists), and presence on a social milieu environment. Ms. ___ is being discharged with many protective factors, including female gender, age, children (though not in the home), sense of responsibility to family, long-term relationship, some strong social supports, lack of suicidal ideation, positive therapeutic relationship with outpatient providers, no chronic substance use. Overall, based on the totality of our assessment at this time, Ms. ___ is not at an acutely elevated risk of harm to self nor danger to others. Our prognosis of this patient is limited to fair as patient has long-term outpatient treaters and has done well when medication compliant. However, patient has a history of decompensation with medication non-compliance and is not amenable to injectable formulations at this time. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Omeprazole 20 mg PO DAILY 2. OLANZapine 15 mg PO QHS 3. Lithium Carbonate 600 mg PO BID 4. Ferrous Sulfate 325 mg PO DAILY 5. PALIperidone ER 12 mg PO DAILY Discharge Medications: 1. Lithium Carbonate 300 mg PO QAM RX *lithium carbonate 300 mg 1 tablet(s) by mouth every morning Disp #*30 Tablet Refills:*0 2. Lithium Carbonate 600 mg PO QHS RX *lithium carbonate 300 mg 2 tablet(s) by mouth nightly Disp #*30 Tablet Refills:*0 3. PALIperidone ER 9 mg PO QHS RX *paliperidone [Invega] 9 mg 1 tablet(s) by mouth nightly Disp #*30 Tablet Refills:*0 4. 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 5. Omeprazole 20 mg PO DAILY RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Catatonia Bipolar disorder with psychotic features Discharge Condition: alert and oriented, ambulating well. Linear thought process, euthymic and bright affect. Discharge Instructions: -Por favor, siga con todas las citas para pacientes ambulatorios indicados -- tomar este papeleo de descarga a sus citas. -Una duración limitada ___ se ___, por favor continúe todos ___ según las instrucciones hasta ___ dice para detener o cambiar. -Evitar abusar ___ alcohol y ___ droga, ___ sea medicamentos o drogas ilegales, como ___ más empeoran sus enfermedades médicas y psiquiátricas. -Póngase en contacto con el ___ ambulatorio u otros proveedores si tiene ___. -Por favor, llame al 911 o ___ de emergencias más cercana si se siente inseguro de ___ y no inmediatamente llegar a sus proveedores de atención médica. Fue un placer ___ con ___ de ___. =========================================================== -Please follow up with all outpatient appointments as listed -- take this discharge paperwork to your appointments. -Unless a limited duration is specified in the prescription, please continue all medications as directed until your prescriber tells you to stop or change. -Please avoid abusing alcohol and any drugs -- whether prescription drugs or illegal drugs -- as this can further worsen your medical and psychiatric illnesses. -Please contact your outpatient psychiatrist or other providers if you have any concerns. -Please call ___ 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: ___
[ "F315", "G936", "D320", "Z9114", "D649", "K219", "G4733", "E7800", "E785", "F4310" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: "..." Major Surgical or Invasive Procedure: Ninguno ============================================================ None History of Present Illness: HISTORY OF PRESENT ILLNESS: Mrs [MASKED] is a [MASKED] year old [MASKED] female with a history of bipolar disorder, psychosis, and meningioma who presents with altered mental status, sent here overnight from [MASKED] where she had walked in for unknown reason. Minimal communication on initial attempts to interview, even with [MASKED] interpreter, saying nothing or- per report- repeatedly mumbling either [MASKED] or "muerto" (dead). Nursing staff report patient has been minimally interactive but has followed instructions to robe/disrobe, and patient has also asked for the bathroom. Poor PO intake. On repeat interview with interpreter patient was somewhat more interactive. When asked why she is here does not respond. States her name and location ("deaconess" "emergency"). Asked if she takes lithium says she takes it, asked who helps her says "I take it." Successfully identifies a pen and its colors "black and white." When asked to write her name and date of birth writes "blac and whit." Per collateral from BEST, patient last seen [MASKED] with confusion and psychosis and was admitted to [MASKED]. Patient's psych meds are prescribed by [MASKED] at [MASKED]. Dr [MASKED] is currently away. Left message with covering physician Dr [MASKED] ([MASKED]). On chart review, patient had somewhat similar episode [MASKED] in the setting of non-adherence to lithium: "She was brought to the ED by her family for 3 days of confusion. Her husband says that she has been walking around the house "like a zombie", "not making any sense" when she speaks, not eating, bathing, or sleeping. Family also notes intermittent outbursts of arm raising and shaking that is nonsynchronized, nonrhythmic, and resembles a protracted startle response (which they demonstrated)." [MASKED] Rating scale: 16 Excitement: 0 Immobility/stupor: [MASKED] Mutism: 1 Staring: 2 Posturing/catalepsy: 0 Grimacing: 1 Echopraxia/echolalia: 1 Stereotypy: 1 Mannerisms: 0 Verbigeration: 1 Rigidity: 1 Negativism: 2 Waxy flexibility: 0 Withdrawal: 2 Impulsivity: 0 Automatic obedience: [MASKED] Mitgehen: 0 Gegenhalten: 0 Ambitendency: 0 Grasp reflex: - Perseveration: 3 Combativeness: 0 Autonomic abnormality: 0 On re-examination the following day: Patient much more interactive this morning and able to give some history. Says she got out of Arbour 3 days ago. Went home. Continued taking her meds. On day of presentation was only able to say that she ate and then came here. Does not know why. Asked about the large amount of money she was found to be carrying, says she went to the bank to move her money to her house. Denies any triggers, denies fighting with her husband. This morning patient says she is "good" and her mood is "good." However she also endorses feeling tired and "heavy" and says she "felt more alive yesterday". Denies SI/HI and AH/VH. [MASKED] Scale: 5 Scoring only for... Immobility/stupor: 1 Staring: 1 Rigidity: 1 Negativism: 1 Withdrawal: 1 On arrival to the inpatient unit: Briefly, [MASKED] is a [MASKED] year old female with a history of bipolar disorder type 1, meningioma, HLD and OSA who was sent to the [MASKED] ED from [MASKED] where she had gone for no apparent reason. In the ED, the patient appeared catatonic and received Ativan which resulted in some improvement. Per chart review, patient was seen at [MASKED] in [MASKED] for AMS and was found to have a meningioma on head CT. However, per neurological evaluation at that time was not felt to be the cause of her AMS and agitation. Psychiatry was consulted and patient was found to be psychotic and likely not taking her lithium. A lithium level from [MASKED] was <0.1 which is concerning for medication non-compliance for this admission as well. Neurology examined the patient in the ED during this admission for concerns of seizures and did an EEG but her AMS was felt to be more likely due to psychosis rather than infection or seizure. On admission to deaconess 4, the patient was not cooperative with interview and lay down face first on the floor and wouldn't answer questions. Patient was brought to her room and she lay down on the bed. Attempted to interview her with [MASKED] interpreter but she asked interviewer to leave and stated she wanted to sleep. She denied SI. She then stopped answering questions. Past Medical History: Past Psychiatric History: Dx: Bipolar disorder Hospitalizations: Treaters: - Psychiatrist: Dr. [MASKED] ([MASKED]) - Therapist: [MASKED], [MASKED] ([MASKED]) - PCP: Dr. [MASKED] ([MASKED]) Medication and ECT Trials: Invega, Lithium, Zyprexa, (has never tried Depakote) Self-Injury/Self harm: [MASKED] past suicide attempts Past Medical History -OSA (per patient, does not use CPAP at home) -GERD -Anemia -Hyperlipidemia -Hepatic steatosis -left posterior fossa benign meningioma Social History: [MASKED] Family History: Mother with hypertension. Maternal grandfather with CAD. Aunt with colon cancer. Physical Exam: PHYSICAL EXAM ON ADMISSION: VS: 98.5, 94 / 61, 73, 16, 95% GEN:NAD, obese, Hispanic female lying in bed with her eyes closed and covers pulled up. Refusing to answer further questions. Moving limbs spontaneously, speaking fluent [MASKED]. HEENT: Normocephalic, atraumatic. Moist mucous membranes. Cardio: Regular Rate and Rhythm, no murmurs/rubs/gallops Pulm: Normal work of breathing, clear to auscultation bilaterally. Abd: Non-distended, non-tender to palpation, positive bowel sounds Ext: Warm and well perfused, capillary refill < 2 seconds Neuro: CN: PERRLA, EOM full, facial sensation to touch equal in all 3 divisions bilaterally, face symmetric on eye closure and smile, hearing normal bilaterally to rubbing fingers, phonation normal, head turning and shoulder shrug intact, tongue midline. Strength: [MASKED] throughout. Sensation: within normal limits to light touch. Gait and station: Normal gait, no ataxia noted. Abnormal movements: No tremor or abnormal movements appreciated. MSE on discharge: Appearance: well groomed facial expression: friendly build: overweight Behavior: Engaging, cooperative psychomotor: no abnormal involuntary movements, no agitation Speech: slightly pressured today, normal tone and volume mood/affect: stable, no angry outbursts thought process/content: reality oriented, goal directed, denied SI/HI, denied AH/VH/ paranoid delusions Intellectual Functioning: Decreased concentration Oriented: ×4 memory: Grossly intact insight: fair Judgment: fair Pertinent Results: CBC: [MASKED] 07:35AM WBC-7.5 RBC-4.32 HGB-12.0 HCT-37.9 MCV-88 MCH-27.8 MCHC-31.7* RDW-20.5* RDWSD-65.9* [MASKED] 07:35AM NEUTS-54.9 [MASKED] MONOS-8.8 EOS-2.1 BASOS-0.3 IM [MASKED] AbsNeut-4.12 AbsLymp-2.52 AbsMono-0.66 AbsEos-0.16 AbsBaso-0.02 [MASKED] 07:35AM PLT COUNT-265 BMP: [MASKED] 04:35AM GLUCOSE-95 UREA N-8 CREAT-0.6 SODIUM-138 POTASSIUM-4.1 CHLORID [MASKED] TOTAL CO2-24 ANION GAP-15 [MASKED] 07:35AM GLUCOSE-111* UREA N-12 CREAT-0.6 SODIUM-138 POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-22 ANION GAP-16 UA: [MASKED] 02:00PM URINE COLOR-Straw APPEAR-Clear SP [MASKED] [MASKED] 02:00PM URINE BLOOD-TR* NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-10* BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [MASKED] 02:00PM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE EPI-1 [MASKED] 02:00PM URINE MUCOUS-RARE* UTox: [MASKED] 02:00PM URINE BLOOD-TR* NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-10* BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG Serum Tox: [MASKED] 07:35AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG Lithium: [MASKED]: LITHIUM <0.1 [MASKED]: LITHIUM 0.7 [MASKED]: LITHIUM 0.7 TSH: [MASKED]: 52.5 [MASKED]: 7.6,, free T4 0.9 [MASKED]: 5.4 [MASKED]: 4.5 B-HCG: [MASKED]: <[MASKED]. LEGAL & SAFETY: On admission, Ms. [MASKED] was unwilling to cooperate with interview and thus, was admitted on a [MASKED] which expired on [MASKED]. She signed a conditional voluntary agreement (Section 10 & 11) on [MASKED] which was accepted. Ms. [MASKED] was also placed on q15 minute checks status on admission and remained on that level of observation throughout while being unit restricted. Evaluation for fresh air access: Ms. [MASKED] was deemed to not be eligible for access to the outdoors based on danger to self and inability to ensure safety in an open environment even with supervision as evidenced by depression, catatonia, poor cooperativeness with initial interview, psychotic 2. PSYCHIATRIC: #) Catatonia Ms. [MASKED] presented to the ED with symptoms concerning for non-malignant, retarded catatonia on presentation to the ED with [MASKED] of 16. Neurology was consulted to rule out seizures and other neurologic processes as a potential contributor. EEG did not show any epileptiform activity and CT Head was stable. Ms. [MASKED] level was sub therapeutic (<0.1) suggesting medication non-compliance as a likely etiology (and per her outpatient psychiatrist's collateral, Ms. [MASKED] has a history of recurring hospitalization in the setting of medication non-compliance. She was started on standing ativan (2mg q8h) with dramatic improvement in her symptoms, scoring [MASKED] of 5 on re-evaluation. She was re-started on her Lithium at a lower dose (300mg BID) and Olanzapine 5mg PO BID for management of psychosis. Per [MASKED]'s recent discharge summary, she had been recently discharged on Lithium ER 600mg PO BID and Zyprexa 15mg PO bedtime. Ms. [MASKED] tolerated an [MASKED] taper with continued improvement of her symptoms. Her lithium was gradually up-titrated to 600mg BID (dose on discharge). Her olanzapine was tapered given her daytime sleepiness, however, Ms. [MASKED] began exhibiting some symptoms concerning for mania including irritability, rapid and pressured speech, and disorganization (with reoccurring concern that insurance won't cover her outpatient [MASKED] providers despite reassurance). She was re-started on Paliperidone (Invega) which she had previously taken as an outpatient and had been stable-on as an injectable which was up-titrated to 9mg. The team discussed switching from PO to IM administration on discharge with the patient, however, Ms. [MASKED] refused stating the the injectable form had previously affected her ability to walk. She continued to improve, however, on routine labs, Ms. [MASKED] had an increase in her TSH to 7.6 with a free T4 of 0.7 concerning for Lithium induced hypothyroidism given that her TSH had been within normal limits on admission (and per collateral had been previously unremarkable). Her lithium was decreased to 300mg BID with subsequent decrease in TSH to 5.4, however, patient began demonstrating some worsening of her symptoms (more irritability, disorganization, constricted affect) and her Lithium was increased to 300mg qAM and 600mg qhs, with reduction of TSH on discharge to 4.5 and a Lithium level of 0.7. Ms. [MASKED] was eager to return home and continue care with her outpatient providers on discharge no longer demonstrating symptoms of catatonia or mania. She denied suicidal and homicidal ideation throughout her hospitalization and denied any auditory or visual hallucinations. 3. SUBSTANCE USE DISORDERS: Ms. [MASKED] does not have any substance use disorders, and therefore did not require any counseling or treatment in this regard. 4. MEDICAL Ms. [MASKED] was evaluated by the Neurology Consult service on initial presentation to the ED to evaluate for seizures as a possible etiology of her presenting symptoms. Per their assessment: "There are no clear toxic, metabolic or infectious triggers to explain her presentation. Her presentation is likely [MASKED] noncompliance given subtherapeutic lithium level on arrival (though patient endorses compliance with lithium). As improved participation in exam and no focal deficits, no further workup needed at this time. I would defer LP at this time, as patient is afebrile, without leukocytosis and given location of meningioma. Important Diagnostic Tests: - EEG: negative - CT brain --- 1. No acute hemorrhage or territorial infarction. --- 2. Stable appearance of left extra-axial mass abutting the tentorium and left cerebellar hemisphere, most consistent with a meningioma. Stable associated vasogenic edema and mass effect on the fourth ventricle and quadrigeminal cistern. She was ultimately medically cleared in the ED and no acute medical issues prevented admission to Deac #) Benign Meningioma: - Ms. [MASKED] was supposed to follow-up with Dr. [MASKED] [MASKED] (neurosurgeon) but missed her follow-up appointment. Dr. [MASKED] was contacted by inpatient psychiatry team, they will contact patient following discharge to arrange follow-up. Neurosurgeon: Dr [MASKED]: [MASKED] Office will call Ms. [MASKED] following discharge to arrange for follow-up appointment. Will also provide Ms. [MASKED] with number to assist in arranging appointment. #) GERD - Ms. [MASKED] was continued on her home omeprazole #)Anemia - Ms. [MASKED] was continued on her home iron supplementation 5. PSYCHOSOCIAL #) GROUPS/MILIEU: Ms. [MASKED] was encouraged to participate in the various groups and milieu therapy opportunities offered by the unit. The occupational therapy and social work groups that focus on teaching patients various coping skills. Ms. [MASKED] infrequently attended these groups, occasionally attending projects group, though notably participation may have been limited by language barrier. Patient was often visible on the unit, occasionally smiling at staff though had limited interaction with staff and peers. #) COLLATERAL CONTACTS & FAMILY INVOLVEMENT: Ms. [MASKED] gave verbal permission for the team to contact her outpatient psychiatrist, Dr. [MASKED], and outpatient therapist, [MASKED]. Both were contacted upon Ms. [MASKED] presentation to the [MASKED] ED/Deac 4 and an update of her progress since admission on Deac 4, and they provided collateral information and treatment recommendations. 6. INFORMED CONSENT: Ms. [MASKED] was not started on any new medications during this hospitalization and was in agreement to re-starting Lithium and Invega as she had been previously taking. 7. RISK ASSESSMENT On presentation, Ms. [MASKED] evaluated and felt to be at an increased risk of harm to herself given her symptoms of catatonia. Ms. [MASKED] static risk factors noted at that time include Static risk factors include history of suicide attempts (per collateral [MASKED] previous attempts), chronic mental illness with lack of insight, recent discharge from an inpatient psychiatric unit, unemployment, chronic medical illness. Modifiable risk factors include psychosis, disorganized and unpredictable behavior, medication noncompliance, poorly controlled mental illness, intermittent engagement with outpatient treatment, and poor reality testing which were mitigated on the inpatient setting with re-starting outpatient medications, treating her catatonia which has since resolved, contacting outpatient providers to arrange follow-up and coordinating [MASKED] services post discharge. These modifiable risk factors were also addressed with acute stabilization in a safe environment on a locked inpatient unit, psychopharmacologic adjustments, psychotherapeutic interventions (OT groups, SW groups, individual therapy meetings with psychiatrists), and presence on a social milieu environment. Ms. [MASKED] is being discharged with many protective factors, including female gender, age, children (though not in the home), sense of responsibility to family, long-term relationship, some strong social supports, lack of suicidal ideation, positive therapeutic relationship with outpatient providers, no chronic substance use. Overall, based on the totality of our assessment at this time, Ms. [MASKED] is not at an acutely elevated risk of harm to self nor danger to others. Our prognosis of this patient is limited to fair as patient has long-term outpatient treaters and has done well when medication compliant. However, patient has a history of decompensation with medication non-compliance and is not amenable to injectable formulations at this time. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Omeprazole 20 mg PO DAILY 2. OLANZapine 15 mg PO QHS 3. Lithium Carbonate 600 mg PO BID 4. Ferrous Sulfate 325 mg PO DAILY 5. PALIperidone ER 12 mg PO DAILY Discharge Medications: 1. Lithium Carbonate 300 mg PO QAM RX *lithium carbonate 300 mg 1 tablet(s) by mouth every morning Disp #*30 Tablet Refills:*0 2. Lithium Carbonate 600 mg PO QHS RX *lithium carbonate 300 mg 2 tablet(s) by mouth nightly Disp #*30 Tablet Refills:*0 3. PALIperidone ER 9 mg PO QHS RX *paliperidone [Invega] 9 mg 1 tablet(s) by mouth nightly Disp #*30 Tablet Refills:*0 4. 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 5. Omeprazole 20 mg PO DAILY RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*0 Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Catatonia Bipolar disorder with psychotic features Discharge Condition: alert and oriented, ambulating well. Linear thought process, euthymic and bright affect. Discharge Instructions: -Por favor, siga con todas las citas para pacientes ambulatorios indicados -- tomar este papeleo de descarga a sus citas. -Una duración limitada [MASKED] se [MASKED], por favor continúe todos [MASKED] según las instrucciones hasta [MASKED] dice para detener o cambiar. -Evitar abusar [MASKED] alcohol y [MASKED] droga, [MASKED] sea medicamentos o drogas ilegales, como [MASKED] más empeoran sus enfermedades médicas y psiquiátricas. -Póngase en contacto con el [MASKED] ambulatorio u otros proveedores si tiene [MASKED]. -Por favor, llame al 911 o [MASKED] de emergencias más cercana si se siente inseguro de [MASKED] y no inmediatamente llegar a sus proveedores de atención médica. Fue un placer [MASKED] con [MASKED] de [MASKED]. =========================================================== -Please follow up with all outpatient appointments as listed -- take this discharge paperwork to your appointments. -Unless a limited duration is specified in the prescription, please continue all medications as directed until your prescriber tells you to stop or change. -Please avoid abusing alcohol and any drugs -- whether prescription drugs or illegal drugs -- as this can further worsen your medical and psychiatric illnesses. -Please contact your outpatient psychiatrist or other providers if you have any concerns. -Please call [MASKED] or go to your nearest emergency room if you feel unsafe in any way and are unable to immediately reach your health care providers. It was a pleasure to have worked with you, and we wish you the best of health. Followup Instructions: [MASKED]
[]
[ "D649", "K219", "G4733", "E785" ]
[ "F315: Bipolar disorder, current episode depressed, severe, with psychotic features", "G936: Cerebral edema", "D320: Benign neoplasm of cerebral meninges", "Z9114: Patient's other noncompliance with medication regimen", "D649: Anemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "G4733: Obstructive sleep apnea (adult) (pediatric)", "E7800: Pure hypercholesterolemia, unspecified", "E785: Hyperlipidemia, unspecified", "F4310: Post-traumatic stress disorder, unspecified" ]
19,994,592
24,603,431
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Nausea and vomiting Major Surgical or Invasive Procedure: Sub-occipital craniectomy for cerebellar meningioma resection, ___ History of Present Illness: ___ y/o female with known left cerebellar lesion, believed to be a meningioma returns to the ED with complaints of a headache which started last week and three days of nausea and vomiting several days ago. The patient has been taking Aleve and Acetaminophen without improvement to her symptoms. She presents to the ED with these concerning symptoms. She describes the headache as located globally and denies nausea and vomiting today. She experienced nausea and vomiting for three days earlier this week on ___, and ___ but has not suffered from these symptoms since that time. She denies diplopia, blurred vision, chest pain, shortness of breath, confusion, difficulties with speech and language, and extremity pain, numbness or weakness. Past Medical History: Past Psychiatric History: Dx: Bipolar disorder Hospitalizations: Treaters: - Psychiatrist: Dr. ___ (___) - Therapist: ___ (___) - PCP: Dr. ___ (___) Medication and ECT Trials: Invega, Lithium, Zyprexa, (has never tried Depakote) Self-Injury/Self harm: ___ past suicide attempts Past Medical History -OSA (per patient, does not use CPAP at home) -GERD -Anemia -Hyperlipidemia -Hepatic steatosis -left posterior fossa benign meningioma Social History: ___ Family History: Mother with hypertension. Maternal grandfather with CAD. Aunt with colon cancer. Physical Exam: Upon Admission: =============== Gen: WD/WN, comfortable, NAD. HEENT: Pupils: 4-3mm bilaterally. EOMs intact throughout. Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested. II: Pupils equally round and reactive to light, 4mm to 3mm bilaterally. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power ___ throughout. No pronator drift. Sensation: Intact to light touch bilaterally. Upon Discharge: =============== VS: Temp:98.5PO BP: 113/80 HR:84 RR:18 Sat:96% RA Bowel Regimen: [x]Yes [ ]No Exam: Primarily ___ speaking Opens Eyes: [x]Spontaneous [ ]To voice [ ]To noxious Orientation: [x]Person [x]Place [x]Time Follows Commands: [ ]Simple [x]Complex [ ]None Pupils: PERRLA EOM: [x]Full [ ]Restricted Face Symmetric: [x]Yes [ ]No Tongue Midline: [x]Yes [ ]No Pronator Drift: [ ]Yes [x]No Speech Fluent: [x]Yes [ ]No Comprehension Intact: [x]Yes [ ]No Motor: Trap Deltoid Bicep Tricep Grip Right5 5 5 5 5 Left5 5 5 5 5 IP Quad Ham AT ___ ___ ___ 5 55 Left5 5 5 5 5 5 [x]Sensation intact to light touch Wound: [x]Clean, dry, intact [x]Sutures [x]Staples Pertinent Results: Please see OMR for relevant findings. Brief Hospital Course: ___ is a ___ year old female with known left cerebellar lesion who presents with three days of nausea and vomiting that has resolved. #Cerebellar lesion Ms. ___ underwent MRI brain, which showed slight increase in lesion with increased surrounding edema and mass effect. She was started on Dexamethasone. She underwent CTA/V for pre-operative planning. She was intermittently uncooperative with care. After Ativan challenge on ___ (see below), she was neurologically intact. Surgery was scheduled for ___. However given the psychiatric issue described below, there was concern that patient did not understand her current and planned treatments and need for invoking health care proxy with the legal team was discussed, and surgery was delayed until consent from a health care proxy could be obtained. Consent was obtained on ___ and patient was rescheduled to go to the OR on ___ ___. While in the OR, A-line access was unattainable, and the surgery was aborted. Once the patient had both A-line and PICC placed, she underwent suboccipital craniotomy for tumor resection. On ___, subgaleal drain was removed without difficulty. She was transferred to the floor. Physical therapy and occupational therapy were consulted for disposition planning and recommended that she be discharge. #Catatonia During her stay she has had an odd affect, with occasional increases in agitation, uncooperativeness with exam, and refusal of all PO intake including meds. She is prescribed 300/600mg lithium qam/qpm. On admission, a lithium level was ordered, which was sub-therapeutic. On ___, psychiatry was consulted, and she was diagnosed with catatonia. Recommended Ativan challenge, which showed a large improvement in cooperativeness with exam. Psychiatry recommended continued Ativan 2mg TID, which was tapered over time and discontinued prior to discharge. The patient's lithium level was therapeutic and stable x2 prior to discharge. #UTI Initial pre-operative urinalysis was suspicious for a UTI and the patient was started on a three day course of Ciprofloxacin. Culture grew out mixed flora and Cipro was discontinued. #Leukocytosis The patient's WBC uptrended, and on ___ a chest x-ray was performed and negative for pneumonia. A repeat urinalysis was sent, and negative for UTI. She underwent LENIs, which were negative for DVT. WBC downtrended from 22 to 16. Leukocytosis likely ___ dexamethasone given negative infectious work-up but should be followed up with PCP ___ patient had a mild insulin requirement (FSBGs consistently in the mid- to high-100s, requiring 2u insulin qmeal). Her hyperglycemia is likely secondary to dexamethasone but should be followed as an outpatient. Medications on Admission: Ferrous sulfate 325mg PO daily; Levothyroxine 25mcg PO daily; Lithium carbonate ER 300mg 1 tab PO QAM & 2 tabs PO QPM; Omeprazole 20mg PO daily; Paliperidone ER 9mg PO daily Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Cerebellar meningioma Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Surgery •You underwent surgery to remove a brain lesion from your brain. •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 •You may use Acetaminophen (Tylenol) for minor discomfort •Continue medications as indicated on your discharge paperwork 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: ___
[ "D320", "G936", "F202", "E785", "F319", "G4733", "K219", "D649", "K760", "D72829", "R739" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Nausea and vomiting Major Surgical or Invasive Procedure: Sub-occipital craniectomy for cerebellar meningioma resection, [MASKED] History of Present Illness: [MASKED] y/o female with known left cerebellar lesion, believed to be a meningioma returns to the ED with complaints of a headache which started last week and three days of nausea and vomiting several days ago. The patient has been taking Aleve and Acetaminophen without improvement to her symptoms. She presents to the ED with these concerning symptoms. She describes the headache as located globally and denies nausea and vomiting today. She experienced nausea and vomiting for three days earlier this week on [MASKED], and [MASKED] but has not suffered from these symptoms since that time. She denies diplopia, blurred vision, chest pain, shortness of breath, confusion, difficulties with speech and language, and extremity pain, numbness or weakness. Past Medical History: Past Psychiatric History: Dx: Bipolar disorder Hospitalizations: Treaters: - Psychiatrist: Dr. [MASKED] ([MASKED]) - Therapist: [MASKED] ([MASKED]) - PCP: Dr. [MASKED] ([MASKED]) Medication and ECT Trials: Invega, Lithium, Zyprexa, (has never tried Depakote) Self-Injury/Self harm: [MASKED] past suicide attempts Past Medical History -OSA (per patient, does not use CPAP at home) -GERD -Anemia -Hyperlipidemia -Hepatic steatosis -left posterior fossa benign meningioma Social History: [MASKED] Family History: Mother with hypertension. Maternal grandfather with CAD. Aunt with colon cancer. Physical Exam: Upon Admission: =============== Gen: WD/WN, comfortable, NAD. HEENT: Pupils: 4-3mm bilaterally. EOMs intact throughout. Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested. II: Pupils equally round and reactive to light, 4mm to 3mm bilaterally. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [MASKED] throughout. No pronator drift. Sensation: Intact to light touch bilaterally. Upon Discharge: =============== VS: Temp:98.5PO BP: 113/80 HR:84 RR:18 Sat:96% RA Bowel Regimen: [x]Yes [ ]No Exam: Primarily [MASKED] speaking Opens Eyes: [x]Spontaneous [ ]To voice [ ]To noxious Orientation: [x]Person [x]Place [x]Time Follows Commands: [ ]Simple [x]Complex [ ]None Pupils: PERRLA EOM: [x]Full [ ]Restricted Face Symmetric: [x]Yes [ ]No Tongue Midline: [x]Yes [ ]No Pronator Drift: [ ]Yes [x]No Speech Fluent: [x]Yes [ ]No Comprehension Intact: [x]Yes [ ]No Motor: Trap Deltoid Bicep Tricep Grip Right5 5 5 5 5 Left5 5 5 5 5 IP Quad Ham AT [MASKED] [MASKED] [MASKED] 5 55 Left5 5 5 5 5 5 [x]Sensation intact to light touch Wound: [x]Clean, dry, intact [x]Sutures [x]Staples Pertinent Results: Please see OMR for relevant findings. Brief Hospital Course: [MASKED] is a [MASKED] year old female with known left cerebellar lesion who presents with three days of nausea and vomiting that has resolved. #Cerebellar lesion Ms. [MASKED] underwent MRI brain, which showed slight increase in lesion with increased surrounding edema and mass effect. She was started on Dexamethasone. She underwent CTA/V for pre-operative planning. She was intermittently uncooperative with care. After Ativan challenge on [MASKED] (see below), she was neurologically intact. Surgery was scheduled for [MASKED]. However given the psychiatric issue described below, there was concern that patient did not understand her current and planned treatments and need for invoking health care proxy with the legal team was discussed, and surgery was delayed until consent from a health care proxy could be obtained. Consent was obtained on [MASKED] and patient was rescheduled to go to the OR on [MASKED] [MASKED]. While in the OR, A-line access was unattainable, and the surgery was aborted. Once the patient had both A-line and PICC placed, she underwent suboccipital craniotomy for tumor resection. On [MASKED], subgaleal drain was removed without difficulty. She was transferred to the floor. Physical therapy and occupational therapy were consulted for disposition planning and recommended that she be discharge. #Catatonia During her stay she has had an odd affect, with occasional increases in agitation, uncooperativeness with exam, and refusal of all PO intake including meds. She is prescribed 300/600mg lithium qam/qpm. On admission, a lithium level was ordered, which was sub-therapeutic. On [MASKED], psychiatry was consulted, and she was diagnosed with catatonia. Recommended Ativan challenge, which showed a large improvement in cooperativeness with exam. Psychiatry recommended continued Ativan 2mg TID, which was tapered over time and discontinued prior to discharge. The patient's lithium level was therapeutic and stable x2 prior to discharge. #UTI Initial pre-operative urinalysis was suspicious for a UTI and the patient was started on a three day course of Ciprofloxacin. Culture grew out mixed flora and Cipro was discontinued. #Leukocytosis The patient's WBC uptrended, and on [MASKED] a chest x-ray was performed and negative for pneumonia. A repeat urinalysis was sent, and negative for UTI. She underwent LENIs, which were negative for DVT. WBC downtrended from 22 to 16. Leukocytosis likely [MASKED] dexamethasone given negative infectious work-up but should be followed up with PCP [MASKED] patient had a mild insulin requirement (FSBGs consistently in the mid- to high-100s, requiring 2u insulin qmeal). Her hyperglycemia is likely secondary to dexamethasone but should be followed as an outpatient. Medications on Admission: Ferrous sulfate 325mg PO daily; Levothyroxine 25mcg PO daily; Lithium carbonate ER 300mg 1 tab PO QAM & 2 tabs PO QPM; Omeprazole 20mg PO daily; Paliperidone ER 9mg PO daily Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Cerebellar meningioma Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Surgery •You underwent surgery to remove a brain lesion from your brain. •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 •You may use Acetaminophen (Tylenol) for minor discomfort •Continue medications as indicated on your discharge paperwork 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]
[]
[ "E785", "G4733", "K219", "D649" ]
[ "D320: Benign neoplasm of cerebral meninges", "G936: Cerebral edema", "F202: Catatonic schizophrenia", "E785: Hyperlipidemia, unspecified", "F319: Bipolar disorder, unspecified", "G4733: Obstructive sleep apnea (adult) (pediatric)", "K219: Gastro-esophageal reflux disease without esophagitis", "D649: Anemia, unspecified", "K760: Fatty (change of) liver, not elsewhere classified", "D72829: Elevated white blood cell count, unspecified", "R739: Hyperglycemia, unspecified" ]
19,994,873
29,045,765
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: primidone Attending: ___ Chief Complaint: Fall Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ year old man s/p fall from standing. His wife was in the same room and heard him fall, but does not know if there was a associated syncope or seizure activity. OSH CT showed a small SAH and R clavulcular frx. He was transferred to ___ for further care. Past Medical History: PMH: hypercholesterolemia, HTN, afib, arthritis, adenocarcinoma lung, squamous cell face, left knee surgery, DM ___, CVA, Sick sinus syndrome, essential tremor, recurrent falls. PSH: Cholecystectomy, lung tumor removal Social History: ___ Family History: Non-contributory Physical Exam: Admission Physical Exam: Temp: 98.1 HR: 94 BP: 142/89 Resp: 16 O(2)Sat: 95 Normal Constitutional: Comfortable HEENT: small skin abrasion lateral to right eyebrow, no active bleeding, Extraocular muscles intact No C-spine tenderness Chest: Clear to auscultation, no chest wall tenderness Cardiovascular: Regular Rate and Rhythm Abdominal: Nontender, Soft GU/Flank: No costovertebral angle tenderness Extr/Back: Right clavicle swelling and tenderness, pain with ROM. Skin: Warm and dry Neuro: Speech fluent, moves all extremities except for right arm, answering questions and following commands appropriately, no focal neurological deficits Psych: Normal mentation, Normal mood ___: No petechiae Discharge Physical Exam: VS: 97.4 PO 138 / 82 102 18 96 Ra GENERAL: Elderly gentleman in NAD, daughter and wife at bedside HEENT: dried scabs on R side of forehead, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM, poor dentition NECK: nontender supple neck, no LAD, no JVD HEART: irregularly irregular, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 extremities with purpose; lower legs both cool to touch PULSES: 2+ DP pulses bilaterally NEURO: CN ___ intact, strength ___ x ___xam limited by clavicle fracture SKIN: forehead lesions as above, cool ___ as above Pertinent Results: ADMISSION LABS: =============== ___ 05:28AM BLOOD WBC-5.2 RBC-3.95* Hgb-13.6* Hct-38.7* MCV-98 MCH-34.4* MCHC-35.1 RDW-12.2 RDWSD-44.3 Plt ___ ___ 04:29AM BLOOD WBC-7.0 RBC-4.06* Hgb-13.9 Hct-39.4* MCV-97 MCH-34.2* MCHC-35.3 RDW-12.3 RDWSD-43.9 Plt ___ ___ 04:29AM BLOOD ___ PTT-28.4 ___ ___ 05:28AM BLOOD Glucose-152* UreaN-20 Creat-0.8 Na-136 K-4.0 Cl-98 HCO3-30 AnGap-12 ___ 04:29AM BLOOD Glucose-111* UreaN-21* Creat-0.9 Na-139 K-3.5 Cl-100 HCO3-29 AnGap-14 ___ 04:29AM BLOOD cTropnT-<0.01 ___ 04:29AM BLOOD Calcium-8.7 Phos-3.4 DISCHARGE LABS: ============== ___ 05:04AM BLOOD WBC-6.2 RBC-3.88* Hgb-13.3* Hct-37.1* MCV-96 MCH-34.3* MCHC-35.8 RDW-12.1 RDWSD-42.1 Plt ___ ___ 05:04AM BLOOD Glucose-171* UreaN-13 Creat-0.8 Na-135 K-4.0 Cl-97 HCO3-28 AnGap-14 ___ 05:04AM BLOOD Calcium-8.1* Phos-3.2 Mg-1.9 ___ 05:28AM BLOOD VitB12-552 MICRO: ===== Urine Culture: No Growth IMAGING/STUDIES: ================ ___ CXR: IMPRESSION: Increased heart size, mild pulmonary vascular congestion. Suggestion of pleural effusion. Basilar opacity, likely atelectasis, repeat lateral radiograph suggested. Acute or subacute fracture distal right clavicle. NCHCT ___: Acute subarachnoid hemorrhage involving the right hemisphere, the magnitude of which is mild. No midlines shift. Age-related atrophy and chronic white matter ischemic changes, no evidence of additional acute intracranial abnormality. CT C-spine ___: Marked degenerative disease, no definite fracture, soft tissues unremarkable. XR R shoulder ___: Distal right clavicular fracture. No dislocation or shoulder or humerus fracture. Brief Hospital Course: ___ HTN, DM, Afib (not on AC), hx ___ presenting s/p fall c/b SAH and clavicular fracture, initially admitted to ___ and subsequently transferred to medicine for fall/?syncope workup. ACUTE ISSUES ============ # SAH/R clavicular fracture: Pt initially presented to ___ where CT imaging showed small right new acute subdural hemorrhage. Xray imaging showed new acute right clavicle fracture. He was transferred to ___ for neurosurgical evaluation. Neurosurgery was consulted and recommended no intervention, frequent neurologic monitoring, and maintain systolic blood pressure less than 160. Initially admitted to surgery service. No neurosurgical intervention needed as SAH small and stable. R clavicular fracture nonoperative. Sling provided as needed for comfort. No need for keppra prophylaxis per neurosurgery. Pt was on q4h neuro checks. He exhibited no neurologic deficits, and did not require additional medication for blood pressure control. ___ was consulted and recommended discharge to rehab. # Fall/syncope workup: Patient transferred to medicine service for further workup of recent falls. Orthostatics positive. Pt maintained on telemetry without arrhythmias noted (besides his baseline Afib). TTE was ordered, but patient and family wished to be discharged to rehab prior to the completion of this study. This can be completed as an outpatient. No further falls/syncope. B12 normal and infectious workup negative (negative blood/urine cultures, CXR). Continued home florinef (which was started for orthostatic hypotension). # Afib: Pt not anticoagulated in setting of recent falls (was previously on Eliquis, stopped in ___ due to falls). Maintained good rate control on home meds and did not require any further intervention. # Urinary retention: Patient retained urine during hospitalization, requiring foley catheter. Tamsulosin started. UA with neg nit/leuks, 3 RBCs, 1 WBC. Foley catheter able to be removed and patient voided without issue before discharge. CHRONIC ISSUES ============== # Hx ___: Continued home AED. According to outpatient neurologist and family, pt's possible seizures are typically characterized by aphasia and confusion. No concerning neuro changes while in-house. #Afib: Pt was previously on eliquis, but this was stopped I/s/o frequent falls. Continued home propranolol (this is prescribed for essential tremor but may be contributing to rate control). HR was well controlled. #HTN, HLD: continue home propranolol and simvastatin #DM: ISS while in house # Goals of care: Palliative care consulted per patient's family request for more information about hospice. We confirmed pt's DNR/DNI status, and filled out a MOLST with him before discharge. TRANSITIONAL ISSUES: [] Consider obtaining TTE as an outpatient for further workup of falls. [] Pt noted to have incidental thrombocytopenia while admitted. Platelets 121 on discharge. HCV negative. He had no evidence of active bleeding other than provoked SAH as above. Consider ongoing monitoring of platelets as an outpatient. [] Clavicle fracture: pt should avoid lifting with R arm, but ROM exercises as tolerated are fine #Code Status: DNR/DNI (confirmed with patient and family) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Simvastatin 20 mg PO QPM 2. Propranolol 10 mg PO DAILY 3. Valproic Acid ___ mg PO Q8H 4. Fludrocortisone Acetate 0.1 mg PO DAILY 5. Nexium 40 mg Other DAILY 6. 70/30 20 Units Breakfast 70/30 10 Units Bedtime Discharge Medications: 1. Acetaminophen 650 mg PO TID 2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes 3. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 4. Docusate Sodium 100 mg PO BID 5. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol 6. Glucose Gel 15 g PO PRN hypoglycemia protocol 7. Heparin 5000 UNIT SC BID 8. Lidocaine 5% Patch 1 PTCH TD QAM 9. Senna 8.6 mg PO BID:PRN constipation 10. Tamsulosin 0.4 mg PO QHS 11. TraMADol 25 mg PO Q6H:PRN pain RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth q6 hours Disp #*16 Tablet Refills:*0 12. 70/30 20 Units Breakfast 70/30 10 Units Bedtime 13. Fludrocortisone Acetate 0.1 mg PO DAILY 14. Nexium 40 mg Other DAILY 15. Propranolol 10 mg PO DAILY 16. Simvastatin 20 mg PO QPM 17. Valproic Acid ___ mg PO Q12H Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary diagnoses: Subarachnoid hemorrhage R Clavicular fracture Fall Secondary diagnoses: Hypertension Diabetes Atrial fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dr. ___, You were admitted to the Acute Care Trauma Surgery Service at ___ after a fall that caused a small bleed in your head and a right clavicle fracture. You were seen and evaluated by the neurosurgery team for your head bleed and no intervention was needed. Your clavicle fracture is stable and will continue to heal without surgical intervention. Please continue to avoid using your right arm for activity but range of motion exercises as tolerated are okay. Wear your sling for comfort as needed. The medical team was contacted to further evaluate for underlying causes of your falls. You chose not to stay for an echocardiogram of your heart. This can be done as an outpatient. Thank you for allowing us to participate in your care. Sincerely, Your ___ Team Followup Instructions: ___
[ "S066X0A", "D696", "E119", "I4891", "G40909", "I10", "E785", "I6521", "W010XXA", "Z9181", "S42031A", "Z66", "R339", "Z794", "Z8673", "Z85118", "Y92009" ]
Allergies: primidone Chief Complaint: Fall Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is a [MASKED] year old man s/p fall from standing. His wife was in the same room and heard him fall, but does not know if there was a associated syncope or seizure activity. OSH CT showed a small SAH and R clavulcular frx. He was transferred to [MASKED] for further care. Past Medical History: PMH: hypercholesterolemia, HTN, afib, arthritis, adenocarcinoma lung, squamous cell face, left knee surgery, DM [MASKED], CVA, Sick sinus syndrome, essential tremor, recurrent falls. PSH: Cholecystectomy, lung tumor removal Social History: [MASKED] Family History: Non-contributory Physical Exam: Admission Physical Exam: Temp: 98.1 HR: 94 BP: 142/89 Resp: 16 O(2)Sat: 95 Normal Constitutional: Comfortable HEENT: small skin abrasion lateral to right eyebrow, no active bleeding, Extraocular muscles intact No C-spine tenderness Chest: Clear to auscultation, no chest wall tenderness Cardiovascular: Regular Rate and Rhythm Abdominal: Nontender, Soft GU/Flank: No costovertebral angle tenderness Extr/Back: Right clavicle swelling and tenderness, pain with ROM. Skin: Warm and dry Neuro: Speech fluent, moves all extremities except for right arm, answering questions and following commands appropriately, no focal neurological deficits Psych: Normal mentation, Normal mood [MASKED]: No petechiae Discharge Physical Exam: VS: 97.4 PO 138 / 82 102 18 96 Ra GENERAL: Elderly gentleman in NAD, daughter and wife at bedside HEENT: dried scabs on R side of forehead, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM, poor dentition NECK: nontender supple neck, no LAD, no JVD HEART: irregularly irregular, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 extremities with purpose; lower legs both cool to touch PULSES: 2+ DP pulses bilaterally NEURO: CN [MASKED] intact, strength [MASKED] x xam limited by clavicle fracture SKIN: forehead lesions as above, cool [MASKED] as above Pertinent Results: ADMISSION LABS: =============== [MASKED] 05:28AM BLOOD WBC-5.2 RBC-3.95* Hgb-13.6* Hct-38.7* MCV-98 MCH-34.4* MCHC-35.1 RDW-12.2 RDWSD-44.3 Plt [MASKED] [MASKED] 04:29AM BLOOD WBC-7.0 RBC-4.06* Hgb-13.9 Hct-39.4* MCV-97 MCH-34.2* MCHC-35.3 RDW-12.3 RDWSD-43.9 Plt [MASKED] [MASKED] 04:29AM BLOOD [MASKED] PTT-28.4 [MASKED] [MASKED] 05:28AM BLOOD Glucose-152* UreaN-20 Creat-0.8 Na-136 K-4.0 Cl-98 HCO3-30 AnGap-12 [MASKED] 04:29AM BLOOD Glucose-111* UreaN-21* Creat-0.9 Na-139 K-3.5 Cl-100 HCO3-29 AnGap-14 [MASKED] 04:29AM BLOOD cTropnT-<0.01 [MASKED] 04:29AM BLOOD Calcium-8.7 Phos-3.4 DISCHARGE LABS: ============== [MASKED] 05:04AM BLOOD WBC-6.2 RBC-3.88* Hgb-13.3* Hct-37.1* MCV-96 MCH-34.3* MCHC-35.8 RDW-12.1 RDWSD-42.1 Plt [MASKED] [MASKED] 05:04AM BLOOD Glucose-171* UreaN-13 Creat-0.8 Na-135 K-4.0 Cl-97 HCO3-28 AnGap-14 [MASKED] 05:04AM BLOOD Calcium-8.1* Phos-3.2 Mg-1.9 [MASKED] 05:28AM BLOOD VitB12-552 MICRO: ===== Urine Culture: No Growth IMAGING/STUDIES: ================ [MASKED] CXR: IMPRESSION: Increased heart size, mild pulmonary vascular congestion. Suggestion of pleural effusion. Basilar opacity, likely atelectasis, repeat lateral radiograph suggested. Acute or subacute fracture distal right clavicle. NCHCT [MASKED]: Acute subarachnoid hemorrhage involving the right hemisphere, the magnitude of which is mild. No midlines shift. Age-related atrophy and chronic white matter ischemic changes, no evidence of additional acute intracranial abnormality. CT C-spine [MASKED]: Marked degenerative disease, no definite fracture, soft tissues unremarkable. XR R shoulder [MASKED]: Distal right clavicular fracture. No dislocation or shoulder or humerus fracture. Brief Hospital Course: [MASKED] HTN, DM, Afib (not on AC), hx [MASKED] presenting s/p fall c/b SAH and clavicular fracture, initially admitted to [MASKED] and subsequently transferred to medicine for fall/?syncope workup. ACUTE ISSUES ============ # SAH/R clavicular fracture: Pt initially presented to [MASKED] where CT imaging showed small right new acute subdural hemorrhage. Xray imaging showed new acute right clavicle fracture. He was transferred to [MASKED] for neurosurgical evaluation. Neurosurgery was consulted and recommended no intervention, frequent neurologic monitoring, and maintain systolic blood pressure less than 160. Initially admitted to surgery service. No neurosurgical intervention needed as SAH small and stable. R clavicular fracture nonoperative. Sling provided as needed for comfort. No need for keppra prophylaxis per neurosurgery. Pt was on q4h neuro checks. He exhibited no neurologic deficits, and did not require additional medication for blood pressure control. [MASKED] was consulted and recommended discharge to rehab. # Fall/syncope workup: Patient transferred to medicine service for further workup of recent falls. Orthostatics positive. Pt maintained on telemetry without arrhythmias noted (besides his baseline Afib). TTE was ordered, but patient and family wished to be discharged to rehab prior to the completion of this study. This can be completed as an outpatient. No further falls/syncope. B12 normal and infectious workup negative (negative blood/urine cultures, CXR). Continued home florinef (which was started for orthostatic hypotension). # Afib: Pt not anticoagulated in setting of recent falls (was previously on Eliquis, stopped in [MASKED] due to falls). Maintained good rate control on home meds and did not require any further intervention. # Urinary retention: Patient retained urine during hospitalization, requiring foley catheter. Tamsulosin started. UA with neg nit/leuks, 3 RBCs, 1 WBC. Foley catheter able to be removed and patient voided without issue before discharge. CHRONIC ISSUES ============== # Hx [MASKED]: Continued home AED. According to outpatient neurologist and family, pt's possible seizures are typically characterized by aphasia and confusion. No concerning neuro changes while in-house. #Afib: Pt was previously on eliquis, but this was stopped I/s/o frequent falls. Continued home propranolol (this is prescribed for essential tremor but may be contributing to rate control). HR was well controlled. #HTN, HLD: continue home propranolol and simvastatin #DM: ISS while in house # Goals of care: Palliative care consulted per patient's family request for more information about hospice. We confirmed pt's DNR/DNI status, and filled out a MOLST with him before discharge. TRANSITIONAL ISSUES: [] Consider obtaining TTE as an outpatient for further workup of falls. [] Pt noted to have incidental thrombocytopenia while admitted. Platelets 121 on discharge. HCV negative. He had no evidence of active bleeding other than provoked SAH as above. Consider ongoing monitoring of platelets as an outpatient. [] Clavicle fracture: pt should avoid lifting with R arm, but ROM exercises as tolerated are fine #Code Status: DNR/DNI (confirmed with patient and family) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Simvastatin 20 mg PO QPM 2. Propranolol 10 mg PO DAILY 3. Valproic Acid [MASKED] mg PO Q8H 4. Fludrocortisone Acetate 0.1 mg PO DAILY 5. Nexium 40 mg Other DAILY 6. 70/30 20 Units Breakfast 70/30 10 Units Bedtime Discharge Medications: 1. Acetaminophen 650 mg PO TID 2. Artificial Tears [MASKED] DROP BOTH EYES PRN dry eyes 3. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 4. Docusate Sodium 100 mg PO BID 5. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol 6. Glucose Gel 15 g PO PRN hypoglycemia protocol 7. Heparin 5000 UNIT SC BID 8. Lidocaine 5% Patch 1 PTCH TD QAM 9. Senna 8.6 mg PO BID:PRN constipation 10. Tamsulosin 0.4 mg PO QHS 11. TraMADol 25 mg PO Q6H:PRN pain RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth q6 hours Disp #*16 Tablet Refills:*0 12. 70/30 20 Units Breakfast 70/30 10 Units Bedtime 13. Fludrocortisone Acetate 0.1 mg PO DAILY 14. Nexium 40 mg Other DAILY 15. Propranolol 10 mg PO DAILY 16. Simvastatin 20 mg PO QPM 17. Valproic Acid [MASKED] mg PO Q12H Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Primary diagnoses: Subarachnoid hemorrhage R Clavicular fracture Fall Secondary diagnoses: Hypertension Diabetes Atrial fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dr. [MASKED], You were admitted to the Acute Care Trauma Surgery Service at [MASKED] after a fall that caused a small bleed in your head and a right clavicle fracture. You were seen and evaluated by the neurosurgery team for your head bleed and no intervention was needed. Your clavicle fracture is stable and will continue to heal without surgical intervention. Please continue to avoid using your right arm for activity but range of motion exercises as tolerated are okay. Wear your sling for comfort as needed. The medical team was contacted to further evaluate for underlying causes of your falls. You chose not to stay for an echocardiogram of your heart. This can be done as an outpatient. Thank you for allowing us to participate in your care. Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "D696", "E119", "I4891", "I10", "E785", "Z66", "Z794", "Z8673" ]
[ "S066X0A: Traumatic subarachnoid hemorrhage without loss of consciousness, initial encounter", "D696: Thrombocytopenia, unspecified", "E119: Type 2 diabetes mellitus without complications", "I4891: Unspecified atrial fibrillation", "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "I6521: Occlusion and stenosis of right carotid artery", "W010XXA: Fall on same level from slipping, tripping and stumbling without subsequent striking against object, initial encounter", "Z9181: History of falling", "S42031A: Displaced fracture of lateral end of right clavicle, initial encounter for closed fracture", "Z66: Do not resuscitate", "R339: Retention of urine, unspecified", "Z794: Long term (current) use of insulin", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "Z85118: Personal history of other malignant neoplasm of bronchus and lung", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause" ]
19,995,012
23,737,876
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Ace Inhibitors / Penicillins / Percocet / metformin Attending: ___ Chief Complaint: SOB Major Surgical or Invasive Procedure: Diagnostic coronary angiogram Coronary Anatomy Dominance: Right * Left Main Coronary Artery The LMCA is.free of significant disease. * Left Anterior Descending The LAD has mid 40% stenosis. * Circumflex The Circumflex has origin 40% stenosis. The ___ Marginal has origin 50% stenosis. * Right Coronary Artery The RCA is very difficult to engage. Non-selective angiography shows mid ___ stenosis. The Right PDA is a small vessel and the distal RCA is possibly occluded before a small RPL branch. Impressions: 1. Moderate 3 vessel CAD with possible branch occlusion of distal RCA. There are no good targets for PCI or surgery. Recommendations 1. Medical therapy, History of Present Illness: This patient is a ___ year old female who complains of headache following a fall at a casino three days ago, injuring the left side of her face. She has poor recall of the circumstances and since has had left sided headaches and facial pain. She reports three weeks of dyspnea and non-productive cough for which she saw her PCP one week ago. Past Medical History: diabetes hypothyroidism hypertension obesity arthritis, chronic pain -s/p: bilateral TKRs hernia repair x5 cholecystectomy Social History: ___ Family History: Family history of arthritis Physical Exam: On Admission: PHYSICAL EXAMINATION Temp: 98.9 HR: 72 BP: 153/69 Resp: 16 O(2)Sat: 99 Normal Constitutional: Comfortable HEENT: abrasion over her left zygoma, Pupils equal, round and reactive to light, Extraocular muscles intact diffuse C-spine tenderness Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm Abdominal: Soft, Nontender Extr/Back: No cyanosis, clubbing or edema Skin: Warm and dry Neuro: Speech fluent Psych: Normal mentation ___: No petechiae ECG Heart Rate: 70 Rhythm: Sinus Ischemia: None ECG Axis: Normal Intervals: Normal Comparison to prior results: Same At Discharge: VS: T 98 HR 70 RR 18 BP 138/78 97% RA tele: SR 70-90's General: no c/o discomfort currently, asking why her BP was so high post procedure and her severe headache cause HEENT: no JVP appreciated. supple, thick neck, no masses CHEST: CTAB CV: RRR no m/r/g ABD: Soft, obese, NT, +BS Skin: Warm and dry, R radial access site with gauze and Tegaderm c/d/I, no erythema or excess warmth Neuro: Grossly N/V/I, moving all 4 extremities, thoughts linear, crosses hemispheres, answering questions appropriately Pertinent Results: LABS ON ADMISSION: ___ 09:30AM BLOOD WBC-6.3 RBC-3.96 Hgb-11.9 Hct-36.9 MCV-93 MCH-30.1 MCHC-32.2 RDW-13.2 RDWSD-45.1 Plt ___ ___ 09:30AM BLOOD Neuts-59.3 ___ Monos-8.1 Eos-2.2 Baso-1.0 Im ___ AbsNeut-3.71 AbsLymp-1.79 AbsMono-0.51 AbsEos-0.14 AbsBaso-0.06 ___ 09:30AM BLOOD ___ PTT-34.3 ___ ___ 09:30AM BLOOD Glucose-169* UreaN-10 Creat-0.7 Na-139 K-3.6 Cl-100 HCO3-23 AnGap-20 ___ 09:30AM BLOOD cTropnT-<0.01 ___ 04:30PM BLOOD cTropnT-<0.01 ___ 09:30AM BLOOD proBNP-111 ___ 09:30AM BLOOD Calcium-8.8 Phos-3.1 Mg-1.6 LABS AT DISCHARGE: ___ 06:00AM BLOOD WBC-10.6* RBC-3.78* Hgb-11.9 Hct-35.1 MCV-93 MCH-31.5 MCHC-33.9 RDW-13.5 RDWSD-46.5* Plt ___ ___ 06:00AM BLOOD ___ PTT-33.3 ___ ___ 06:00AM BLOOD Glucose-209* UreaN-12 Creat-0.8 Na-136 K-4.4 Cl-98 HCO3-19* AnGap-23* ___ 06:00AM BLOOD Calcium-9.1 Phos-3.8 Mg-1.7 CATHETERIZATIN REPORT ___: Coronary Anatomy Dominance: Right * Left Main Coronary Artery The LMCA is.free of significant disease. * Left Anterior Descending The LAD has mid 40% stenosis. * Circumflex The Circumflex has orign 40% stenosis. The ___ Marginal has oirigin 50% stenosis. * Right Coronary Artery The RCA is very difficult to engage. Non-selective angiography shows mid ___ stenosis. The Right PDA is a small vessel and the distal RCA is possibly occluded before a small RPL branch. Impressions: 1. Moderate 3 vessel CAD with possible branch occlusion of distal RCA. There are no good targets for PCI or surgery. Recommendations 1. Medical therapy, CARDIAC PERFUSION STUDY ___: SUMMARY FROM THE EXERCISE LAB: For pharmacologic stress dipyridamole was infused intravenously for approximately 4 minutes at a dose of 0.142 milligram/kilogram/min. 1 to 2 minutes after the cessation of infusion, the stress dose of the radiotracer was injected. She had no anginal symptoms or ischemic ECG changes. TECHNIQUE: ISOTOPE DATA: (___) 31.9 mCi Tc-99m Sestamibi Stress; DRUG DATA: (Non-NM admin) Dipyridamole; Following intravenous infusion of the pharmacologic agent, Tc-99m sestamibi was administered intravenously. Stress images were obtained approximately 30 minutes following tracer injection. Resting perfusion images were obtained on a subsequent day with Tc-99m sestamibi. Tracer was injected approximately 45 minutes prior to obtaining the resting images. Imaging protocol: Gated SPECT. This study was interpreted using the 17-segment myocardial perfusion model. FINDINGS: The image quality is adequate but limited due to soft tissue and breast attenuation. Left ventricular cavity size is normal. Rest and stress perfusion images reveal a reversible, mild reduction in photon counts involving the entire inferior wall. Gated images reveal normal wall motion. The calculated left ventricular ejection fraction is 57% with an EDV of 77 ml. IMPRESSION: 1. Reversible, medium sized, mild perfusion defect involving the RCA territory. 2. Normal left ventricular cavity size and systolic function. CT HEAD w/o CONTRAST ___: COMPARISON: CT head without contrast ___ FINDINGS: There is no evidence of infarction, hemorrhage, edema, or mass. There is prominence of the ventricles and sulci suggestive of involutional changes. There is no evidence of fracture. Small mucous retention cyst is noted in the right anterior ethmoid sinus. The visualized portion of the orbits are unremarkable. IMPRESSION: 1. No acute intracranial process. CT C-SPINE w/o CONTRAST ___: FINDINGS: Alignment is normal. No fractures are identified. There is no prevertebral soft tissue swelling. Degenerative changes notable for disc bulges and thickening of the ligamentum flavum. Disc protrusion at C2-3 and C3-4 effaces the ventral CSF and may contact the ventral aspect of the cord. Thyroid is small but grossly unremarkable. Lung apices are notable for a 3 mm right apical nodule (3:70), unchanged from prior. IMPRESSION: No acute fracture or malalignment of the cervical spine. A 3 mm right apical pulmonary nodule unchanged since prior ___. RECOMMENDATION(S): If patient has risk factors such as smoking or malignancy, ___ year followup suggested for followup of a 3 mm right apical pulmonary nodule. Otherwise no additional imaging necessary. CT SINUS ___: FINDINGS: There is no facial bone fracture. Pterygoid plates are intact. There is no mandibular fracture and the temporomandibular joints are anatomically aligned. The orbits are intact. The globes and extra-ocular muscles are unremarkable. There is no orbital hematoma. Included paranasal sinuses are clear besides a mucous retention cyst in the right maxillary sinus. Included extracranial soft tissues are unremarkable. IMPRESSION: No fracture. CXR PA & LATERAL ___: FINDINGS: Slightly lower lung volumes on the current exam. Lungs remain clear without consolidation, effusion, or edema. Cardiomediastinal silhouette is stable. Atherosclerotic calcifications seen at the aortic arch. No acute osseous abnormalities, hypertrophic changes again noted in the spine. IMPRESSION: No acute cardiopulmonary process. Brief Hospital Course: The patient presented to the ED complaining of a headache, SOB and facial pain following a fall at a casino several days earlier. She reports no significant headaches in the past and when quizzed regarding her blood pressure control states she checks her pressure at home and it typically runs in the 120's systolic. She was subsequently transferred to the ___ for further observation until she underwent numerous studies include a pharmacological stress test indicating a mild perfusion defect. It was suspected given her history that she could have coronary artery disease. She underwent catheterization on ___ and had three vessel moderate disease not obstructive or amenable to PCI or surgery and to continue/enhance medical management, particularly in light of her other co-morbidities including obesity and diabetes. She was expected to discharge home following the catheterization but reported a severe headache and had a high blood pressure running to 230/97. She was subsequently triggered and had vomiting. She was given Zofran, Hydralazine and persistently hypertensive. A nitro drip was started and she was given Ativan to help with her anxiety and her nausea, which subsequently resolved. She was started on Atorvastatin and Metoprolol. Her blood pressure normalized by the early morning hours on ___ and her nitro drip was discontinued. At the time of discharge, her blood pressure was ranging in the 130's systolic. She had no further headache, was tolerating her diet and voiding without difficulty. She was counseled regarding lifestyle changes, management of blood pressure and close follow up with her physicians. Her headache was felt to be multi-factorial, including her NPO status until her late day catheterization, and her high blood pressures, which likely exist at home. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Losartan Potassium 100 mg PO DAILY 2. Sucralfate 1 gm PO QID 3. Levothyroxine Sodium 125 mcg PO DAILY 4. Cyanocobalamin 1000 mcg PO DAILY 5. GlipiZIDE 5 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO QPM 3. Metoprolol Tartrate 25 mg PO BID 4. Cyanocobalamin 1000 mcg PO DAILY 5. GlipiZIDE 5 mg PO DAILY 6. Levothyroxine Sodium 125 mcg PO DAILY 7. Losartan Potassium 100 mg PO DAILY 8. Sucralfate 1 gm PO QID Discharge Disposition: Home Discharge Diagnosis: NEW: Abnormal stress test: Cardiac Cath: multivessel moderate disease, no obstructive CAD w/o good targets for PCI or surgery - manage medically PRIOR: DM Type 2 Hypertension Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). VS: T 98 HR 70 RR 18 BP 134/65 97% RA tele: SR 70-90's LABS: Na2+ 136; K+ 4.4; Cl- 98; HCO3 19; BUN 12; Cr 0.8; Ca2+ 9.1; P 3.8; Mg2+ 1.7 PHYSICAL EXAM: Gen: ___ yr old woman in NAD. Seen post-procedure. She is alert and oriented and resting comfortably with no CP, SOB, palpitations or dizziness Neck: No JVD appreciated Lungs: CTAB, no wheezing or rhonchi Heart: S1S2 regular, no MRG Abd: soft, obese, non-tender, BS + PV: right radial site is soft with no bleeding or hematoma. gauze and Tegaderm c/d/I. Good CSM to wrist. Pedal pulses palpable. No clubbing, cyanosis or edema Neuro: Alert and oriented x 3. No focal deficits or asymmetries noted. A/P: ___ from ED after + pharm stress showing a 'reversible, medium sized, mild perfusion defect involving the RCA territory'. Initially presented with left sided headache s/p fall at a casino on ___ with ongoing sharp left-sided headaches and facial pain. Her head CT was negative. At that time, she complained of dyspnea with exertion, prompting cardiac workup. EKG: NSR @ 70, NA/NI, no ischemia or ectopy, Trop- negative x2. She underwent a coronary angiogram, which showed moderate 3 vessel CAD #. CAD -start ASA 81 -start Atorvastatin (escripted to her pharmacy) -start Metoprolol 25 mg bid (escripted to her pharmacy) -follow up with Dr. ___ in ___ wks #. DM A1C 7.3% -cont Glipizide -heart healthy carb consistent diet #. Hypertension -cont Losartan -Added Metoprolol #. Disp -DC home Discharge Instructions: You were admitted overnight to our cardiac direct access unit for monitoring due to your symptoms of shortness of breath and abnormal stress test. You had an elevated blood pressures that required some additional medication. We also imaged your head which was negative for any bleeding or stroke. You had a cardiac catheterization which showed that you had some blockages in 3 of your heart arteries. Because of these blockages, you were started on a low dose Aspirin, Atorvastatin and Metoprolol. You will follow up with Dr. ___ in ___ weeks. Activity restrictions and care of our wrist site will be included in your discharge instructions. Please follow up with your PCP within the next ___ weeks for continued outpatient management. Followup Instructions: ___
[ "I25110", "E119", "E785", "E669", "Z6841", "E7800", "G4733", "I169", "R112", "E876", "G44309", "Z9181" ]
Allergies: Ace Inhibitors / Penicillins / Percocet / metformin Chief Complaint: SOB Major Surgical or Invasive Procedure: Diagnostic coronary angiogram Coronary Anatomy Dominance: Right * Left Main Coronary Artery The LMCA is.free of significant disease. * Left Anterior Descending The LAD has mid 40% stenosis. * Circumflex The Circumflex has origin 40% stenosis. The [MASKED] Marginal has origin 50% stenosis. * Right Coronary Artery The RCA is very difficult to engage. Non-selective angiography shows mid [MASKED] stenosis. The Right PDA is a small vessel and the distal RCA is possibly occluded before a small RPL branch. Impressions: 1. Moderate 3 vessel CAD with possible branch occlusion of distal RCA. There are no good targets for PCI or surgery. Recommendations 1. Medical therapy, History of Present Illness: This patient is a [MASKED] year old female who complains of headache following a fall at a casino three days ago, injuring the left side of her face. She has poor recall of the circumstances and since has had left sided headaches and facial pain. She reports three weeks of dyspnea and non-productive cough for which she saw her PCP one week ago. Past Medical History: diabetes hypothyroidism hypertension obesity arthritis, chronic pain -s/p: bilateral TKRs hernia repair x5 cholecystectomy Social History: [MASKED] Family History: Family history of arthritis Physical Exam: On Admission: PHYSICAL EXAMINATION Temp: 98.9 HR: 72 BP: 153/69 Resp: 16 O(2)Sat: 99 Normal Constitutional: Comfortable HEENT: abrasion over her left zygoma, Pupils equal, round and reactive to light, Extraocular muscles intact diffuse C-spine tenderness Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm Abdominal: Soft, Nontender Extr/Back: No cyanosis, clubbing or edema Skin: Warm and dry Neuro: Speech fluent Psych: Normal mentation [MASKED]: No petechiae ECG Heart Rate: 70 Rhythm: Sinus Ischemia: None ECG Axis: Normal Intervals: Normal Comparison to prior results: Same At Discharge: VS: T 98 HR 70 RR 18 BP 138/78 97% RA tele: SR 70-90's General: no c/o discomfort currently, asking why her BP was so high post procedure and her severe headache cause HEENT: no JVP appreciated. supple, thick neck, no masses CHEST: CTAB CV: RRR no m/r/g ABD: Soft, obese, NT, +BS Skin: Warm and dry, R radial access site with gauze and Tegaderm c/d/I, no erythema or excess warmth Neuro: Grossly N/V/I, moving all 4 extremities, thoughts linear, crosses hemispheres, answering questions appropriately Pertinent Results: LABS ON ADMISSION: [MASKED] 09:30AM BLOOD WBC-6.3 RBC-3.96 Hgb-11.9 Hct-36.9 MCV-93 MCH-30.1 MCHC-32.2 RDW-13.2 RDWSD-45.1 Plt [MASKED] [MASKED] 09:30AM BLOOD Neuts-59.3 [MASKED] Monos-8.1 Eos-2.2 Baso-1.0 Im [MASKED] AbsNeut-3.71 AbsLymp-1.79 AbsMono-0.51 AbsEos-0.14 AbsBaso-0.06 [MASKED] 09:30AM BLOOD [MASKED] PTT-34.3 [MASKED] [MASKED] 09:30AM BLOOD Glucose-169* UreaN-10 Creat-0.7 Na-139 K-3.6 Cl-100 HCO3-23 AnGap-20 [MASKED] 09:30AM BLOOD cTropnT-<0.01 [MASKED] 04:30PM BLOOD cTropnT-<0.01 [MASKED] 09:30AM BLOOD proBNP-111 [MASKED] 09:30AM BLOOD Calcium-8.8 Phos-3.1 Mg-1.6 LABS AT DISCHARGE: [MASKED] 06:00AM BLOOD WBC-10.6* RBC-3.78* Hgb-11.9 Hct-35.1 MCV-93 MCH-31.5 MCHC-33.9 RDW-13.5 RDWSD-46.5* Plt [MASKED] [MASKED] 06:00AM BLOOD [MASKED] PTT-33.3 [MASKED] [MASKED] 06:00AM BLOOD Glucose-209* UreaN-12 Creat-0.8 Na-136 K-4.4 Cl-98 HCO3-19* AnGap-23* [MASKED] 06:00AM BLOOD Calcium-9.1 Phos-3.8 Mg-1.7 CATHETERIZATIN REPORT [MASKED]: Coronary Anatomy Dominance: Right * Left Main Coronary Artery The LMCA is.free of significant disease. * Left Anterior Descending The LAD has mid 40% stenosis. * Circumflex The Circumflex has orign 40% stenosis. The [MASKED] Marginal has oirigin 50% stenosis. * Right Coronary Artery The RCA is very difficult to engage. Non-selective angiography shows mid [MASKED] stenosis. The Right PDA is a small vessel and the distal RCA is possibly occluded before a small RPL branch. Impressions: 1. Moderate 3 vessel CAD with possible branch occlusion of distal RCA. There are no good targets for PCI or surgery. Recommendations 1. Medical therapy, CARDIAC PERFUSION STUDY [MASKED]: SUMMARY FROM THE EXERCISE LAB: For pharmacologic stress dipyridamole was infused intravenously for approximately 4 minutes at a dose of 0.142 milligram/kilogram/min. 1 to 2 minutes after the cessation of infusion, the stress dose of the radiotracer was injected. She had no anginal symptoms or ischemic ECG changes. TECHNIQUE: ISOTOPE DATA: ([MASKED]) 31.9 mCi Tc-99m Sestamibi Stress; DRUG DATA: (Non-NM admin) Dipyridamole; Following intravenous infusion of the pharmacologic agent, Tc-99m sestamibi was administered intravenously. Stress images were obtained approximately 30 minutes following tracer injection. Resting perfusion images were obtained on a subsequent day with Tc-99m sestamibi. Tracer was injected approximately 45 minutes prior to obtaining the resting images. Imaging protocol: Gated SPECT. This study was interpreted using the 17-segment myocardial perfusion model. FINDINGS: The image quality is adequate but limited due to soft tissue and breast attenuation. Left ventricular cavity size is normal. Rest and stress perfusion images reveal a reversible, mild reduction in photon counts involving the entire inferior wall. Gated images reveal normal wall motion. The calculated left ventricular ejection fraction is 57% with an EDV of 77 ml. IMPRESSION: 1. Reversible, medium sized, mild perfusion defect involving the RCA territory. 2. Normal left ventricular cavity size and systolic function. CT HEAD w/o CONTRAST [MASKED]: COMPARISON: CT head without contrast [MASKED] FINDINGS: There is no evidence of infarction, hemorrhage, edema, or mass. There is prominence of the ventricles and sulci suggestive of involutional changes. There is no evidence of fracture. Small mucous retention cyst is noted in the right anterior ethmoid sinus. The visualized portion of the orbits are unremarkable. IMPRESSION: 1. No acute intracranial process. CT C-SPINE w/o CONTRAST [MASKED]: FINDINGS: Alignment is normal. No fractures are identified. There is no prevertebral soft tissue swelling. Degenerative changes notable for disc bulges and thickening of the ligamentum flavum. Disc protrusion at C2-3 and C3-4 effaces the ventral CSF and may contact the ventral aspect of the cord. Thyroid is small but grossly unremarkable. Lung apices are notable for a 3 mm right apical nodule (3:70), unchanged from prior. IMPRESSION: No acute fracture or malalignment of the cervical spine. A 3 mm right apical pulmonary nodule unchanged since prior [MASKED]. RECOMMENDATION(S): If patient has risk factors such as smoking or malignancy, [MASKED] year followup suggested for followup of a 3 mm right apical pulmonary nodule. Otherwise no additional imaging necessary. CT SINUS [MASKED]: FINDINGS: There is no facial bone fracture. Pterygoid plates are intact. There is no mandibular fracture and the temporomandibular joints are anatomically aligned. The orbits are intact. The globes and extra-ocular muscles are unremarkable. There is no orbital hematoma. Included paranasal sinuses are clear besides a mucous retention cyst in the right maxillary sinus. Included extracranial soft tissues are unremarkable. IMPRESSION: No fracture. CXR PA & LATERAL [MASKED]: FINDINGS: Slightly lower lung volumes on the current exam. Lungs remain clear without consolidation, effusion, or edema. Cardiomediastinal silhouette is stable. Atherosclerotic calcifications seen at the aortic arch. No acute osseous abnormalities, hypertrophic changes again noted in the spine. IMPRESSION: No acute cardiopulmonary process. Brief Hospital Course: The patient presented to the ED complaining of a headache, SOB and facial pain following a fall at a casino several days earlier. She reports no significant headaches in the past and when quizzed regarding her blood pressure control states she checks her pressure at home and it typically runs in the 120's systolic. She was subsequently transferred to the [MASKED] for further observation until she underwent numerous studies include a pharmacological stress test indicating a mild perfusion defect. It was suspected given her history that she could have coronary artery disease. She underwent catheterization on [MASKED] and had three vessel moderate disease not obstructive or amenable to PCI or surgery and to continue/enhance medical management, particularly in light of her other co-morbidities including obesity and diabetes. She was expected to discharge home following the catheterization but reported a severe headache and had a high blood pressure running to 230/97. She was subsequently triggered and had vomiting. She was given Zofran, Hydralazine and persistently hypertensive. A nitro drip was started and she was given Ativan to help with her anxiety and her nausea, which subsequently resolved. She was started on Atorvastatin and Metoprolol. Her blood pressure normalized by the early morning hours on [MASKED] and her nitro drip was discontinued. At the time of discharge, her blood pressure was ranging in the 130's systolic. She had no further headache, was tolerating her diet and voiding without difficulty. She was counseled regarding lifestyle changes, management of blood pressure and close follow up with her physicians. Her headache was felt to be multi-factorial, including her NPO status until her late day catheterization, and her high blood pressures, which likely exist at home. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Losartan Potassium 100 mg PO DAILY 2. Sucralfate 1 gm PO QID 3. Levothyroxine Sodium 125 mcg PO DAILY 4. Cyanocobalamin 1000 mcg PO DAILY 5. GlipiZIDE 5 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO QPM 3. Metoprolol Tartrate 25 mg PO BID 4. Cyanocobalamin 1000 mcg PO DAILY 5. GlipiZIDE 5 mg PO DAILY 6. Levothyroxine Sodium 125 mcg PO DAILY 7. Losartan Potassium 100 mg PO DAILY 8. Sucralfate 1 gm PO QID Discharge Disposition: Home Discharge Diagnosis: NEW: Abnormal stress test: Cardiac Cath: multivessel moderate disease, no obstructive CAD w/o good targets for PCI or surgery - manage medically PRIOR: DM Type 2 Hypertension Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). VS: T 98 HR 70 RR 18 BP 134/65 97% RA tele: SR 70-90's LABS: Na2+ 136; K+ 4.4; Cl- 98; HCO3 19; BUN 12; Cr 0.8; Ca2+ 9.1; P 3.8; Mg2+ 1.7 PHYSICAL EXAM: Gen: [MASKED] yr old woman in NAD. Seen post-procedure. She is alert and oriented and resting comfortably with no CP, SOB, palpitations or dizziness Neck: No JVD appreciated Lungs: CTAB, no wheezing or rhonchi Heart: S1S2 regular, no MRG Abd: soft, obese, non-tender, BS + PV: right radial site is soft with no bleeding or hematoma. gauze and Tegaderm c/d/I. Good CSM to wrist. Pedal pulses palpable. No clubbing, cyanosis or edema Neuro: Alert and oriented x 3. No focal deficits or asymmetries noted. A/P: [MASKED] from ED after + pharm stress showing a 'reversible, medium sized, mild perfusion defect involving the RCA territory'. Initially presented with left sided headache s/p fall at a casino on [MASKED] with ongoing sharp left-sided headaches and facial pain. Her head CT was negative. At that time, she complained of dyspnea with exertion, prompting cardiac workup. EKG: NSR @ 70, NA/NI, no ischemia or ectopy, Trop- negative x2. She underwent a coronary angiogram, which showed moderate 3 vessel CAD #. CAD -start ASA 81 -start Atorvastatin (escripted to her pharmacy) -start Metoprolol 25 mg bid (escripted to her pharmacy) -follow up with Dr. [MASKED] in [MASKED] wks #. DM A1C 7.3% -cont Glipizide -heart healthy carb consistent diet #. Hypertension -cont Losartan -Added Metoprolol #. Disp -DC home Discharge Instructions: You were admitted overnight to our cardiac direct access unit for monitoring due to your symptoms of shortness of breath and abnormal stress test. You had an elevated blood pressures that required some additional medication. We also imaged your head which was negative for any bleeding or stroke. You had a cardiac catheterization which showed that you had some blockages in 3 of your heart arteries. Because of these blockages, you were started on a low dose Aspirin, Atorvastatin and Metoprolol. You will follow up with Dr. [MASKED] in [MASKED] weeks. Activity restrictions and care of our wrist site will be included in your discharge instructions. Please follow up with your PCP within the next [MASKED] weeks for continued outpatient management. Followup Instructions: [MASKED]
[]
[ "E119", "E785", "E669", "G4733" ]
[ "I25110: Atherosclerotic heart disease of native coronary artery with unstable angina pectoris", "E119: Type 2 diabetes mellitus without complications", "E785: Hyperlipidemia, unspecified", "E669: Obesity, unspecified", "Z6841: Body mass index [BMI]40.0-44.9, adult", "E7800: Pure hypercholesterolemia, unspecified", "G4733: Obstructive sleep apnea (adult) (pediatric)", "I169: Hypertensive crisis, unspecified", "R112: Nausea with vomiting, unspecified", "E876: Hypokalemia", "G44309: Post-traumatic headache, unspecified, not intractable", "Z9181: History of falling" ]
19,995,012
27,305,089
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Ace Inhibitors / Penicillins / Percocet / metformin Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: ___ incisional hernia repair with underlay mesh, lipoma excision History of Present Illness: Ms. ___ is a ___ year old female with history of NIDDM, CAD (cath ___ and PDA occlusion not amenable to revascularization), hyperlipidemia presents with abdominal pain and acute onset diarrhea starting at 7pm last evening. She denies nausea or vomiting. She has never experienced similar episodes; however, she continues to pass flatus and have bowel movements. She continues to have pain but has been alleviated with medication. The pain is constant in her abdomen and has not remitted. Past Medical History: diabetes hypothyroidism hypertension obesity arthritis, chronic pain -s/p: bilateral TKRs hernia repair x5 cholecystectomy Social History: ___ Family History: Family history of arthritis Physical Exam: Admission Physical Exam: Vitals: 97.8 63 179/78 18 100%RA GEN: AOx3, NAD, obese HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, tender over paramedian incision +guarding, no rebound, unable to reduce as the exam is limited by pain, 2 separate hernias appreciated on exam. Ext: No ___ edema, ___ warm and well perfused Discharge Physical Exam: VS: 97.6, 147/73, 60, 20, 95% RA Gen: A&O x3 CV: HRR Pulm: CTAB Abd: soft, NT/ND. Midline incision w/ staples, OTA Ext: No edema Pertinent Results: ___ 12:25AM BLOOD WBC-11.1* RBC-3.88* Hgb-11.3 Hct-35.4 MCV-91 MCH-29.1 MCHC-31.9* RDW-13.1 RDWSD-43.2 Plt ___ ___ 10:46AM BLOOD WBC-9.6 RBC-3.64* Hgb-10.7* Hct-33.6* MCV-92 MCH-29.4 MCHC-31.8* RDW-13.1 RDWSD-44.3 Plt ___ ___ 10:00PM BLOOD WBC-12.8* RBC-3.71* Hgb-11.1* Hct-34.2 MCV-92 MCH-29.9 MCHC-32.5 RDW-13.2 RDWSD-44.6 Plt ___ ___ 05:16AM BLOOD WBC-13.3* RBC-3.60* Hgb-10.8* Hct-33.5* MCV-93 MCH-30.0 MCHC-32.2 RDW-13.4 RDWSD-45.4 Plt ___ ___ 05:40AM BLOOD WBC-9.6 RBC-3.21* Hgb-9.5* Hct-30.0* MCV-94 MCH-29.6 MCHC-31.7* RDW-13.2 RDWSD-45.5 Plt ___ ___ 06:15AM BLOOD WBC-8.7 RBC-2.97* Hgb-8.9* Hct-27.9* MCV-94 MCH-30.0 MCHC-31.9* RDW-13.2 RDWSD-45.9 Plt ___ ___ 05:30AM BLOOD WBC-7.6 RBC-2.99* Hgb-8.9* Hct-27.9* MCV-93 MCH-29.8 MCHC-31.9* RDW-13.1 RDWSD-44.5 Plt ___ ___ 05:30AM BLOOD Glucose-147* UreaN-7 Creat-0.7 Na-139 K-3.7 Cl-102 HCO3-27 AnGap-14 ___ 06:15AM BLOOD Glucose-140* UreaN-6 Creat-0.7 Na-140 K-3.4 Cl-102 HCO3-24 AnGap-17 ___ 05:40AM BLOOD Glucose-143* UreaN-7 Creat-0.8 Na-138 K-3.3 Cl-100 HCO3-25 AnGap-16 ___ 05:16AM BLOOD Glucose-155* UreaN-12 Creat-1.0 Na-144 K-4.0 Cl-106 HCO3-24 AnGap-18 ___ 10:00PM BLOOD Glucose-214* UreaN-15 Creat-1.0 Na-139 K-3.2* Cl-103 HCO3-21* AnGap-18 ___ 05:30AM BLOOD Calcium-8.3* Phos-2.5* Mg-1.7 ___ 06:15AM BLOOD Calcium-7.7* Phos-2.5* Mg-1.8 ___ 05:40AM BLOOD Calcium-7.5* Phos-2.6* Mg-1.4* CT A/P: 1. Re-demonstrated are 2 midline, ventral abdominal wall hernias-the hernia located more cranially contains a small segment of the nonobstructed transverse colon, while the hernia located caudally contains a small portion of a small bowel loop. There is trace fluid within the hernial sac containing the small bowel however no transition point or other evidence to suggest bowel obstruction noted. There has been prior mesh repair of the ventral abdominal wall and the mesh is located inferior to the latter hernial sac. 2. Mild hepatic steatosis, extensive sigmoid diverticulosis, severe atherosclerotic calcification of the abdominal aorta and its branches with focal narrowing (up to 50%) at the origin of the celiac artery are additional incidental findings. Brief Hospital Course: Ms. ___ is a ___ year old female who presented to the Emergency Department on ___ with abdominal pain. The patient was evaluated by the Acute Care Surgery Service and a CT scan of abdomen and pelvis was obtained. These images revealed an incarcerated hernia. Given these findings, the patient was taken to the operating room for repair. There were no adverse events in the operating room; please see the operative note for details. She was extubated, taken to the PACU until stable, then transferred to the surgical floor for observation. The patient was alert and oriented throughout hospitalization; pain was initially managed with IV Tylenol and Dilaudid and then transitioned to oral Tylenol and Tramadol once tolerating a diet. The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. She remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toileting, early ambulation and incentive spirometry were encouraged throughout hospitalization. The patient was initially kept NPO. On POD1 diet was advanced to clears with good tolerability. On POD2 the patient tolerated a regular diet. Patient's intake and output were closely monitored She has a midline incision to her abdomen with staples that are clean, dry and intact (will be removed at follow up appointment with Dr. ___. Her bowel function returned and began to pass gas and have bowel movements. The patient's fever curves were closely watched for signs of infection, of which there were none. The patient's blood counts were closely watched for signs of bleeding, of which there were none. The patient received subcutaneous heparin and ___ dyne boots were used during this stay and was encouraged to get up and ambulate as early as possible. The patient was seen and evaluated by physical therapy who recommended discharge to home with continued home physical therapy. At the time of discharge, the patient was doing well, afebrile and hemodynamically stable. The patient was tolerating a diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: AMMONIUM LACTATE - ammonium lactate 12 % topical cream. apply to dry skin on feet but not between toes twice a day ATORVASTATIN - atorvastatin 80 mg tablet. 1 tablet(s) by mouth once a day ERGOCALCIFEROL (VITAMIN D2) - ergocalciferol (vitamin D2) 50,000 unit capsule. 1 capsule(s) by mouth 1 week for 40 weeks get repeat level when this is completed - (Not Taking as Prescribed) FLUTICASONE - fluticasone 50 mcg/actuation nasal spray,suspension. 2 sprays(s) each nostril daily as needed for congestion or post nasal drip for 2 weeks GLIPIZIDE - glipizide 5 mg tablet. One tablet(s) by mouth daily HYDROCORTISONE - hydrocortisone 2.5 % topical ointment. apply pea size to affected area every day after bathing for 14 days, then as needed for itching ISOSORBIDE MONONITRATE - isosorbide mononitrate ER 30 mg tablet,extended release 24 hr. 1 tablet(s) by mouth daily LEVOTHYROXINE - levothyroxine 150 mcg tablet. 1 tablet(s) by mouth daily This is an INCREASED dose LOSARTAN - losartan 100 mg tablet. 1 tablet(s) by mouth once a day METOPROLOL TARTRATE - metoprolol tartrate 25 mg tablet. 1 tablet(s) by mouth twice a day PENCICLOVIR [DENAVIR] - Denavir 1 % topical cream. apply to lips every 2 hours until cold sores resolve - (Not Taking as Prescribed: discontinued) SUCRALFATE - sucralfate 1 gram tablet. 1 tablet(s) by mouth tid before meals and hs tell her to take about 30min before meals. STOP THE PANTAPROZOLE Medications - OTC ASPIRIN - aspirin 81 mg tablet,delayed release. 1 Tablet(s) by mouth once a day - (Not Taking as Prescribed) BLOOD SUGAR DIAGNOSTIC [ONETOUCH ULTRA TEST] - OneTouch Ultra Test strips. Use as directed for blood sugar monitoring twice a day and as needed. Dx Code: 250.00 - (Not Taking as Prescribed: discontinued) BLOOD-GLUCOSE METER [ONETOUCH ULTRA2] - OneTouch Ultra2 kit. Use as directed for blood sugar monitoring twice a day and as needed Dx Code: 250.00 - (Not Taking as Prescribed: discontinued) CAMPHOR-MENTHOL [ANTI-ITCH (MENTHOL/CAMPHOR)] - Anti-Itch (menthol/camphor) 0.5 %-0.5 % lotion. apply to affected areas as needed as needed for itch disp qs for 30 days - (Pt denies taking) (Not Taking as Prescribed: discontinued) CYANOCOBALAMIN (VITAMIN B-12) - cyanocobalamin (vit B-12) 1,000 mcg tablet. 1 tablet(s) by mouth daily LANCETS [ONETOUCH ULTRASOFT LANCETS] - OneTouch UltraSoft Lancets. Use as directed for blood sugar monitoring twice a day and as needed Dx Code: 250.00 - (Not Taking as Prescribed: discontinued) Discharge Medications: 1. Acetaminophen 650 mg PO Q6H RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6) hours Disp #*20 Tablet Refills:*0 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*20 Capsule Refills:*0 3. Polyethylene Glycol 17 g PO DAILY 4. TraMADol ___ mg PO Q6H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity RX *tramadol 50 mg ___ tablet(s) by mouth every six (6) hours Disp #*15 Tablet Refills:*0 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 80 mg PO QPM 7. Fluticasone Propionate NASAL 2 SPRY NU BID 8. GlipiZIDE 5 mg PO DAILY 9. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 10. Levothyroxine Sodium 150 mcg PO DAILY 11. Losartan Potassium 100 mg PO DAILY 12. Metoprolol Tartrate 25 mg PO BID Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Ventral hernia, lipoma of the abdominal wall Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to the ___ on ___ with abdominal pain. You were evaluated by the Acute Care Surgery Service and after a CT scan was done, we found a piece of your bowel was entrapped in your stomach lining. We took you to the operating room and repaired this. You tolerated the procedure well and are now being discharged home to continue your recovery. Please note the following discharge instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. It was a pleasure being part of your care! Followup Instructions: ___
[ "K430", "Z6841", "E1121", "D1779", "E1140", "E11319", "I2510", "E785", "E039", "E669", "M1990", "G8929", "Z96653", "E876" ]
Allergies: Ace Inhibitors / Penicillins / Percocet / metformin Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: [MASKED] incisional hernia repair with underlay mesh, lipoma excision History of Present Illness: Ms. [MASKED] is a [MASKED] year old female with history of NIDDM, CAD (cath [MASKED] and PDA occlusion not amenable to revascularization), hyperlipidemia presents with abdominal pain and acute onset diarrhea starting at 7pm last evening. She denies nausea or vomiting. She has never experienced similar episodes; however, she continues to pass flatus and have bowel movements. She continues to have pain but has been alleviated with medication. The pain is constant in her abdomen and has not remitted. Past Medical History: diabetes hypothyroidism hypertension obesity arthritis, chronic pain -s/p: bilateral TKRs hernia repair x5 cholecystectomy Social History: [MASKED] Family History: Family history of arthritis Physical Exam: Admission Physical Exam: Vitals: 97.8 63 179/78 18 100%RA GEN: AOx3, NAD, obese HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, tender over paramedian incision +guarding, no rebound, unable to reduce as the exam is limited by pain, 2 separate hernias appreciated on exam. Ext: No [MASKED] edema, [MASKED] warm and well perfused Discharge Physical Exam: VS: 97.6, 147/73, 60, 20, 95% RA Gen: A&O x3 CV: HRR Pulm: CTAB Abd: soft, NT/ND. Midline incision w/ staples, OTA Ext: No edema Pertinent Results: [MASKED] 12:25AM BLOOD WBC-11.1* RBC-3.88* Hgb-11.3 Hct-35.4 MCV-91 MCH-29.1 MCHC-31.9* RDW-13.1 RDWSD-43.2 Plt [MASKED] [MASKED] 10:46AM BLOOD WBC-9.6 RBC-3.64* Hgb-10.7* Hct-33.6* MCV-92 MCH-29.4 MCHC-31.8* RDW-13.1 RDWSD-44.3 Plt [MASKED] [MASKED] 10:00PM BLOOD WBC-12.8* RBC-3.71* Hgb-11.1* Hct-34.2 MCV-92 MCH-29.9 MCHC-32.5 RDW-13.2 RDWSD-44.6 Plt [MASKED] [MASKED] 05:16AM BLOOD WBC-13.3* RBC-3.60* Hgb-10.8* Hct-33.5* MCV-93 MCH-30.0 MCHC-32.2 RDW-13.4 RDWSD-45.4 Plt [MASKED] [MASKED] 05:40AM BLOOD WBC-9.6 RBC-3.21* Hgb-9.5* Hct-30.0* MCV-94 MCH-29.6 MCHC-31.7* RDW-13.2 RDWSD-45.5 Plt [MASKED] [MASKED] 06:15AM BLOOD WBC-8.7 RBC-2.97* Hgb-8.9* Hct-27.9* MCV-94 MCH-30.0 MCHC-31.9* RDW-13.2 RDWSD-45.9 Plt [MASKED] [MASKED] 05:30AM BLOOD WBC-7.6 RBC-2.99* Hgb-8.9* Hct-27.9* MCV-93 MCH-29.8 MCHC-31.9* RDW-13.1 RDWSD-44.5 Plt [MASKED] [MASKED] 05:30AM BLOOD Glucose-147* UreaN-7 Creat-0.7 Na-139 K-3.7 Cl-102 HCO3-27 AnGap-14 [MASKED] 06:15AM BLOOD Glucose-140* UreaN-6 Creat-0.7 Na-140 K-3.4 Cl-102 HCO3-24 AnGap-17 [MASKED] 05:40AM BLOOD Glucose-143* UreaN-7 Creat-0.8 Na-138 K-3.3 Cl-100 HCO3-25 AnGap-16 [MASKED] 05:16AM BLOOD Glucose-155* UreaN-12 Creat-1.0 Na-144 K-4.0 Cl-106 HCO3-24 AnGap-18 [MASKED] 10:00PM BLOOD Glucose-214* UreaN-15 Creat-1.0 Na-139 K-3.2* Cl-103 HCO3-21* AnGap-18 [MASKED] 05:30AM BLOOD Calcium-8.3* Phos-2.5* Mg-1.7 [MASKED] 06:15AM BLOOD Calcium-7.7* Phos-2.5* Mg-1.8 [MASKED] 05:40AM BLOOD Calcium-7.5* Phos-2.6* Mg-1.4* CT A/P: 1. Re-demonstrated are 2 midline, ventral abdominal wall hernias-the hernia located more cranially contains a small segment of the nonobstructed transverse colon, while the hernia located caudally contains a small portion of a small bowel loop. There is trace fluid within the hernial sac containing the small bowel however no transition point or other evidence to suggest bowel obstruction noted. There has been prior mesh repair of the ventral abdominal wall and the mesh is located inferior to the latter hernial sac. 2. Mild hepatic steatosis, extensive sigmoid diverticulosis, severe atherosclerotic calcification of the abdominal aorta and its branches with focal narrowing (up to 50%) at the origin of the celiac artery are additional incidental findings. Brief Hospital Course: Ms. [MASKED] is a [MASKED] year old female who presented to the Emergency Department on [MASKED] with abdominal pain. The patient was evaluated by the Acute Care Surgery Service and a CT scan of abdomen and pelvis was obtained. These images revealed an incarcerated hernia. Given these findings, the patient was taken to the operating room for repair. There were no adverse events in the operating room; please see the operative note for details. She was extubated, taken to the PACU until stable, then transferred to the surgical floor for observation. The patient was alert and oriented throughout hospitalization; pain was initially managed with IV Tylenol and Dilaudid and then transitioned to oral Tylenol and Tramadol once tolerating a diet. The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. She remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toileting, early ambulation and incentive spirometry were encouraged throughout hospitalization. The patient was initially kept NPO. On POD1 diet was advanced to clears with good tolerability. On POD2 the patient tolerated a regular diet. Patient's intake and output were closely monitored She has a midline incision to her abdomen with staples that are clean, dry and intact (will be removed at follow up appointment with Dr. [MASKED]. Her bowel function returned and began to pass gas and have bowel movements. The patient's fever curves were closely watched for signs of infection, of which there were none. The patient's blood counts were closely watched for signs of bleeding, of which there were none. The patient received subcutaneous heparin and [MASKED] dyne boots were used during this stay and was encouraged to get up and ambulate as early as possible. The patient was seen and evaluated by physical therapy who recommended discharge to home with continued home physical therapy. At the time of discharge, the patient was doing well, afebrile and hemodynamically stable. The patient was tolerating a diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: AMMONIUM LACTATE - ammonium lactate 12 % topical cream. apply to dry skin on feet but not between toes twice a day ATORVASTATIN - atorvastatin 80 mg tablet. 1 tablet(s) by mouth once a day ERGOCALCIFEROL (VITAMIN D2) - ergocalciferol (vitamin D2) 50,000 unit capsule. 1 capsule(s) by mouth 1 week for 40 weeks get repeat level when this is completed - (Not Taking as Prescribed) FLUTICASONE - fluticasone 50 mcg/actuation nasal spray,suspension. 2 sprays(s) each nostril daily as needed for congestion or post nasal drip for 2 weeks GLIPIZIDE - glipizide 5 mg tablet. One tablet(s) by mouth daily HYDROCORTISONE - hydrocortisone 2.5 % topical ointment. apply pea size to affected area every day after bathing for 14 days, then as needed for itching ISOSORBIDE MONONITRATE - isosorbide mononitrate ER 30 mg tablet,extended release 24 hr. 1 tablet(s) by mouth daily LEVOTHYROXINE - levothyroxine 150 mcg tablet. 1 tablet(s) by mouth daily This is an INCREASED dose LOSARTAN - losartan 100 mg tablet. 1 tablet(s) by mouth once a day METOPROLOL TARTRATE - metoprolol tartrate 25 mg tablet. 1 tablet(s) by mouth twice a day PENCICLOVIR [DENAVIR] - Denavir 1 % topical cream. apply to lips every 2 hours until cold sores resolve - (Not Taking as Prescribed: discontinued) SUCRALFATE - sucralfate 1 gram tablet. 1 tablet(s) by mouth tid before meals and hs tell her to take about 30min before meals. STOP THE PANTAPROZOLE Medications - OTC ASPIRIN - aspirin 81 mg tablet,delayed release. 1 Tablet(s) by mouth once a day - (Not Taking as Prescribed) BLOOD SUGAR DIAGNOSTIC [ONETOUCH ULTRA TEST] - OneTouch Ultra Test strips. Use as directed for blood sugar monitoring twice a day and as needed. Dx Code: 250.00 - (Not Taking as Prescribed: discontinued) BLOOD-GLUCOSE METER [ONETOUCH ULTRA2] - OneTouch Ultra2 kit. Use as directed for blood sugar monitoring twice a day and as needed Dx Code: 250.00 - (Not Taking as Prescribed: discontinued) CAMPHOR-MENTHOL [ANTI-ITCH (MENTHOL/CAMPHOR)] - Anti-Itch (menthol/camphor) 0.5 %-0.5 % lotion. apply to affected areas as needed as needed for itch disp qs for 30 days - (Pt denies taking) (Not Taking as Prescribed: discontinued) CYANOCOBALAMIN (VITAMIN B-12) - cyanocobalamin (vit B-12) 1,000 mcg tablet. 1 tablet(s) by mouth daily LANCETS [ONETOUCH ULTRASOFT LANCETS] - OneTouch UltraSoft Lancets. Use as directed for blood sugar monitoring twice a day and as needed Dx Code: 250.00 - (Not Taking as Prescribed: discontinued) Discharge Medications: 1. Acetaminophen 650 mg PO Q6H RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6) hours Disp #*20 Tablet Refills:*0 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*20 Capsule Refills:*0 3. Polyethylene Glycol 17 g PO DAILY 4. TraMADol [MASKED] mg PO Q6H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity RX *tramadol 50 mg [MASKED] tablet(s) by mouth every six (6) hours Disp #*15 Tablet Refills:*0 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 80 mg PO QPM 7. Fluticasone Propionate NASAL 2 SPRY NU BID 8. GlipiZIDE 5 mg PO DAILY 9. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 10. Levothyroxine Sodium 150 mcg PO DAILY 11. Losartan Potassium 100 mg PO DAILY 12. Metoprolol Tartrate 25 mg PO BID Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Ventral hernia, lipoma of the abdominal wall Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You were admitted to the [MASKED] on [MASKED] with abdominal pain. You were evaluated by the Acute Care Surgery Service and after a CT scan was done, we found a piece of your bowel was entrapped in your stomach lining. We took you to the operating room and repaired this. You tolerated the procedure well and are now being discharged home to continue your recovery. Please note the following discharge instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within [MASKED] hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [MASKED] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. It was a pleasure being part of your care! Followup Instructions: [MASKED]
[]
[ "I2510", "E785", "E039", "E669", "G8929" ]
[ "K430: Incisional hernia with obstruction, without gangrene", "Z6841: Body mass index [BMI]40.0-44.9, adult", "E1121: Type 2 diabetes mellitus with diabetic nephropathy", "D1779: Benign lipomatous neoplasm of other sites", "E1140: Type 2 diabetes mellitus with diabetic neuropathy, unspecified", "E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E785: Hyperlipidemia, unspecified", "E039: Hypothyroidism, unspecified", "E669: Obesity, unspecified", "M1990: Unspecified osteoarthritis, unspecified site", "G8929: Other chronic pain", "Z96653: Presence of artificial knee joint, bilateral", "E876: Hypokalemia" ]
19,995,012
29,354,459
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Ace Inhibitors / Penicillins / Percocet / metformin Attending: ___. Chief Complaint: muscle cramps, lightheadedness Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a ___ year old woman with DM, CAD, recent incarcerated hernia s/p ventral hernia repair (___) who presents at the recommendation of her PCP for hypomagnesemia. She recently underwent ventral hernia repair (___) which was uncomplicated. DUring that admission, she was noted to be hypomagenesemic on ___ and ___ requiring repletion. On ___, she went to see her surgeon for staple removal from her surgery and had blood work checked. Mg was 0.9. PCP was notified of the result, and called the patient to come in for Mg repletion. She reports for the past few days she has been having left sided muscle cramping/spasms, lightheadedness/dizziness and fatigue. Denies nausea, vomiting, diarrhea but has had ~2 loose BMs/day. Pt is not on diuretics. No new meds recently. Reports mediocre PO intake. In the ED, initial VS were: 98.1 76 180/78 17 97% RA ED physical exam was recorded as abdomen non-distended, soft, large midline surgical incision with steristrips over wound, no drainage or surrounding erythema/induration. TTP around incision, otherwise non-tender. ED labs were notable for: H/H 10.8/32.7 Ca 6.8, Mg 0.8 K 3.8 EKG showed NSR with QTC 520 Patient was given: ___ 11:56 PO/NG Azithromycin 500 mg ___ 11:56 IV CefePIME 2 g ___ 13:31 PO/NG Aspirin 324 mg Later, Mg 2.1 freeCa 0.94 pH on VBG 7.42 Transfer VS were: 98.1 64 154/73 16 99% RA When seen on the floor a ten point ROS was conducted and was negative except as above in the HPI. Past Medical History: -CAD: Cath on ___ with moderate 3VD and PDA occlusion not amenable to revascularization. diabetes hypothyroidism hypertension obesity arthritis, chronic pain -s/p: bilateral TKRs hernia repair x5 cholecystectomy Social History: ___ Family History: Family history of arthritis Physical Exam: Admission PE 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: No visible rash. No jaundice. Neuro: AAOx3. No facial droop. Psych: Full range of affect Discharge PE 97.9 151 / 84 63 20 98 RA 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: No visible rash. No jaundice. Neuro: AAOx3. No facial droop. Psych: Full range of affect Pertinent Results: ___ 10:31PM CALCIUM-7.7* MAGNESIUM-1.6 ___ 07:20PM URINE HOURS-RANDOM ___ 07:20PM URINE UHOLD-HOLD ___ 07:20PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 07:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-MOD ___ 07:20PM URINE RBC-2 WBC-1 BACTERIA-FEW YEAST-NONE EPI-2 ___ 07:20PM URINE MUCOUS-RARE ___ 04:38PM PH-7.42 ___ 04:38PM freeCa-0.94* ___ 04:31PM CALCIUM-7.5* MAGNESIUM-2.1 ___ 12:17PM GLUCOSE-130* UREA N-14 CREAT-0.9 SODIUM-140 POTASSIUM-3.8 CHLORIDE-97 TOTAL CO2-25 ANION GAP-22* ___ 12:17PM ALBUMIN-4.1 CALCIUM-6.8* PHOSPHATE-3.6 MAGNESIUM-0.8* ___ 12:17PM PTH-67* ___ 12:17PM WBC-7.4 RBC-3.56* HGB-10.8* HCT-32.7* MCV-92 MCH-30.3 MCHC-33.0 RDW-13.4 RDWSD-45.1 ___ 12:17PM NEUTS-62.8 ___ MONOS-10.5 EOS-2.4 BASOS-0.9 IM ___ AbsNeut-4.64 AbsLymp-1.70 AbsMono-0.78 AbsEos-0.18 AbsBaso-0.07 ___ 12:17PM PLT COUNT-328 ___ 02:00PM GLUCOSE-157* ___ 02:00PM UREA N-16 CREAT-0.9 SODIUM-143 POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-26 ANION GAP-21* ___ 02:00PM estGFR-Using this ___ 02:00PM CALCIUM-7.1* PHOSPHATE-4.4 MAGNESIUM-0.9* ___ 02:00PM TSH-3.7 Discharge labs: ___ 08:10AM BLOOD WBC-6.7 RBC-3.54* Hgb-10.5* Hct-32.0* MCV-90 MCH-29.7 MCHC-32.8 RDW-13.4 RDWSD-44.3 Plt ___ ___ 08:10AM BLOOD Glucose-194* UreaN-12 Creat-0.7 Na-140 K-3.3 Cl-101 HCO3-24 AnGap-18 ___ 08:10AM BLOOD Calcium-8.0* Phos-3.9 Mg-2.___/P: Patient is a ___ year old woman with DM, CAD, recent incarcerated hernia s/p ventral hernia repair (___) who presents at the recommendation of her PCP for hypomagnesemia. # hypomagnesemia and hypocalcemia She appears to have periodic hypomagnesemia as ___ as ___, per chart review without clear etiology. Most recently she presented with sxs of muscle cramps most likely due to above electrolyte abnormalities. Unclear etiology, she reports chronic loose stools and intermittent diarrhea which may cause her hypomagnesemia. Mild hypocalcemia, PTH appropriately elevated at 67, possibly due to vitamin D deficiency. She was repleted with IV magnesium and calcium. - Started on PO magnesium and calcium carbonate-vitamin D on discharge - Follow-up 25-hydoxy vitamin D level (pending on discharge) - Recommend repeat chem 10 as outpatient # Fatigue: # Lightheadedness: Chronic, multifactorial including poor sleep, deconditioning and known OSA with noncompliance with CPAP. She also has had prior neurological workup suggestive of small fiber neuropathy or generalized dysfunction of sudomotor function which may have caused autonomic dysfunction. - Encourage follow up with sleep clinic for CPAP after discharge # CAD: Cath on ___ with moderate 3VD and PDA occlusion not amenable to revascularization. Exertional sxs have improved since adding imdur, although per cards, she does not have clearly anginal sxs. - continue ASA - continue atorvastatin 80mg - continue isosorbide mononitrate 30mg - continue Metoprolol Tartrate 25 mg PO BID # Hypothyroidism: TSH 3.7. - continue home Levothyroxine Sodium 150 mcg PO DAILY # HTN - continue Losartan Potassium 100 mg PO DAILY # DM2: A1C 7% in ___ - continue GlipiZIDE 5 mg PO DAILY - diabetic diet Full code SQH PIV Regular diet Dispo home with resumed home services Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H 2. Atorvastatin 80 mg PO QPM 3. Fluticasone Propionate NASAL 2 SPRY NU BID 4. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 5. Levothyroxine Sodium 150 mcg PO DAILY 6. Losartan Potassium 100 mg PO DAILY 7. TraMADol ___ mg PO Q6H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity 8. Metoprolol Tartrate 25 mg PO BID 9. GlipiZIDE 5 mg PO DAILY 10. Docusate Sodium 100 mg PO BID 11. Polyethylene Glycol 17 g PO DAILY 12. Aspirin 81 mg PO DAILY Discharge Medications: 1. calcium carbonate-vitamin D3 600 mg (1,500 mg)-800 unit oral DAILY RX *calcium carbonate-vitamin D3 600 mg calcium (1,500 mg)-800 unit 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 2. Docusate Sodium 100 mg PO BID 3. Magnesium Oxide 400 mg PO BID RX *magnesium oxide 400 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 4. Polyethylene Glycol 17 g PO DAILY 5. TraMADol ___ mg PO Q6H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity 6. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 7. Aspirin 81 mg PO DAILY 8. Atorvastatin 80 mg PO QPM 9. Fluticasone Propionate NASAL 2 SPRY NU BID 10. GlipiZIDE 5 mg PO DAILY 11. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 12. Levothyroxine Sodium 150 mcg PO DAILY 13. Losartan Potassium 100 mg PO DAILY 14. Metoprolol Tartrate 25 mg PO BID Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Hypomagnesemia Hypocalcemia 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 with lightheadedness, low magnesium and low calcium levels. You were given IV magnesium and calcium and your lightheadedness improved. Please follow-up with your primary care physician ___ 1 week. Followup Instructions: ___
[ "E8342", "E119", "Z6841", "E8351", "R42", "R5383", "I2510", "E039", "I10", "E669", "M1990", "G8929", "Z96653", "G4733", "Z9119" ]
Allergies: Ace Inhibitors / Penicillins / Percocet / metformin Chief Complaint: muscle cramps, lightheadedness Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a [MASKED] year old woman with DM, CAD, recent incarcerated hernia s/p ventral hernia repair ([MASKED]) who presents at the recommendation of her PCP for hypomagnesemia. She recently underwent ventral hernia repair ([MASKED]) which was uncomplicated. DUring that admission, she was noted to be hypomagenesemic on [MASKED] and [MASKED] requiring repletion. On [MASKED], she went to see her surgeon for staple removal from her surgery and had blood work checked. Mg was 0.9. PCP was notified of the result, and called the patient to come in for Mg repletion. She reports for the past few days she has been having left sided muscle cramping/spasms, lightheadedness/dizziness and fatigue. Denies nausea, vomiting, diarrhea but has had ~2 loose BMs/day. Pt is not on diuretics. No new meds recently. Reports mediocre PO intake. In the ED, initial VS were: 98.1 76 180/78 17 97% RA ED physical exam was recorded as abdomen non-distended, soft, large midline surgical incision with steristrips over wound, no drainage or surrounding erythema/induration. TTP around incision, otherwise non-tender. ED labs were notable for: H/H 10.8/32.7 Ca 6.8, Mg 0.8 K 3.8 EKG showed NSR with QTC 520 Patient was given: [MASKED] 11:56 PO/NG Azithromycin 500 mg [MASKED] 11:56 IV CefePIME 2 g [MASKED] 13:31 PO/NG Aspirin 324 mg Later, Mg 2.1 freeCa 0.94 pH on VBG 7.42 Transfer VS were: 98.1 64 154/73 16 99% RA When seen on the floor a ten point ROS was conducted and was negative except as above in the HPI. Past Medical History: -CAD: Cath on [MASKED] with moderate 3VD and PDA occlusion not amenable to revascularization. diabetes hypothyroidism hypertension obesity arthritis, chronic pain -s/p: bilateral TKRs hernia repair x5 cholecystectomy Social History: [MASKED] Family History: Family history of arthritis Physical Exam: Admission PE 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: No visible rash. No jaundice. Neuro: AAOx3. No facial droop. Psych: Full range of affect Discharge PE 97.9 151 / 84 63 20 98 RA 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: No visible rash. No jaundice. Neuro: AAOx3. No facial droop. Psych: Full range of affect Pertinent Results: [MASKED] 10:31PM CALCIUM-7.7* MAGNESIUM-1.6 [MASKED] 07:20PM URINE HOURS-RANDOM [MASKED] 07:20PM URINE UHOLD-HOLD [MASKED] 07:20PM URINE COLOR-Yellow APPEAR-Clear SP [MASKED] [MASKED] 07:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-MOD [MASKED] 07:20PM URINE RBC-2 WBC-1 BACTERIA-FEW YEAST-NONE EPI-2 [MASKED] 07:20PM URINE MUCOUS-RARE [MASKED] 04:38PM PH-7.42 [MASKED] 04:38PM freeCa-0.94* [MASKED] 04:31PM CALCIUM-7.5* MAGNESIUM-2.1 [MASKED] 12:17PM GLUCOSE-130* UREA N-14 CREAT-0.9 SODIUM-140 POTASSIUM-3.8 CHLORIDE-97 TOTAL CO2-25 ANION GAP-22* [MASKED] 12:17PM ALBUMIN-4.1 CALCIUM-6.8* PHOSPHATE-3.6 MAGNESIUM-0.8* [MASKED] 12:17PM PTH-67* [MASKED] 12:17PM WBC-7.4 RBC-3.56* HGB-10.8* HCT-32.7* MCV-92 MCH-30.3 MCHC-33.0 RDW-13.4 RDWSD-45.1 [MASKED] 12:17PM NEUTS-62.8 [MASKED] MONOS-10.5 EOS-2.4 BASOS-0.9 IM [MASKED] AbsNeut-4.64 AbsLymp-1.70 AbsMono-0.78 AbsEos-0.18 AbsBaso-0.07 [MASKED] 12:17PM PLT COUNT-328 [MASKED] 02:00PM GLUCOSE-157* [MASKED] 02:00PM UREA N-16 CREAT-0.9 SODIUM-143 POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-26 ANION GAP-21* [MASKED] 02:00PM estGFR-Using this [MASKED] 02:00PM CALCIUM-7.1* PHOSPHATE-4.4 MAGNESIUM-0.9* [MASKED] 02:00PM TSH-3.7 Discharge labs: [MASKED] 08:10AM BLOOD WBC-6.7 RBC-3.54* Hgb-10.5* Hct-32.0* MCV-90 MCH-29.7 MCHC-32.8 RDW-13.4 RDWSD-44.3 Plt [MASKED] [MASKED] 08:10AM BLOOD Glucose-194* UreaN-12 Creat-0.7 Na-140 K-3.3 Cl-101 HCO3-24 AnGap-18 [MASKED] 08:10AM BLOOD Calcium-8.0* Phos-3.9 Mg-2.[MASKED]/P: Patient is a [MASKED] year old woman with DM, CAD, recent incarcerated hernia s/p ventral hernia repair ([MASKED]) who presents at the recommendation of her PCP for hypomagnesemia. # hypomagnesemia and hypocalcemia She appears to have periodic hypomagnesemia as [MASKED] as [MASKED], per chart review without clear etiology. Most recently she presented with sxs of muscle cramps most likely due to above electrolyte abnormalities. Unclear etiology, she reports chronic loose stools and intermittent diarrhea which may cause her hypomagnesemia. Mild hypocalcemia, PTH appropriately elevated at 67, possibly due to vitamin D deficiency. She was repleted with IV magnesium and calcium. - Started on PO magnesium and calcium carbonate-vitamin D on discharge - Follow-up 25-hydoxy vitamin D level (pending on discharge) - Recommend repeat chem 10 as outpatient # Fatigue: # Lightheadedness: Chronic, multifactorial including poor sleep, deconditioning and known OSA with noncompliance with CPAP. She also has had prior neurological workup suggestive of small fiber neuropathy or generalized dysfunction of sudomotor function which may have caused autonomic dysfunction. - Encourage follow up with sleep clinic for CPAP after discharge # CAD: Cath on [MASKED] with moderate 3VD and PDA occlusion not amenable to revascularization. Exertional sxs have improved since adding imdur, although per cards, she does not have clearly anginal sxs. - continue ASA - continue atorvastatin 80mg - continue isosorbide mononitrate 30mg - continue Metoprolol Tartrate 25 mg PO BID # Hypothyroidism: TSH 3.7. - continue home Levothyroxine Sodium 150 mcg PO DAILY # HTN - continue Losartan Potassium 100 mg PO DAILY # DM2: A1C 7% in [MASKED] - continue GlipiZIDE 5 mg PO DAILY - diabetic diet Full code SQH PIV Regular diet Dispo home with resumed home services Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H 2. Atorvastatin 80 mg PO QPM 3. Fluticasone Propionate NASAL 2 SPRY NU BID 4. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 5. Levothyroxine Sodium 150 mcg PO DAILY 6. Losartan Potassium 100 mg PO DAILY 7. TraMADol [MASKED] mg PO Q6H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity 8. Metoprolol Tartrate 25 mg PO BID 9. GlipiZIDE 5 mg PO DAILY 10. Docusate Sodium 100 mg PO BID 11. Polyethylene Glycol 17 g PO DAILY 12. Aspirin 81 mg PO DAILY Discharge Medications: 1. calcium carbonate-vitamin D3 600 mg (1,500 mg)-800 unit oral DAILY RX *calcium carbonate-vitamin D3 600 mg calcium (1,500 mg)-800 unit 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 2. Docusate Sodium 100 mg PO BID 3. Magnesium Oxide 400 mg PO BID RX *magnesium oxide 400 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 4. Polyethylene Glycol 17 g PO DAILY 5. TraMADol [MASKED] mg PO Q6H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity 6. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 7. Aspirin 81 mg PO DAILY 8. Atorvastatin 80 mg PO QPM 9. Fluticasone Propionate NASAL 2 SPRY NU BID 10. GlipiZIDE 5 mg PO DAILY 11. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 12. Levothyroxine Sodium 150 mcg PO DAILY 13. Losartan Potassium 100 mg PO DAILY 14. Metoprolol Tartrate 25 mg PO BID Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Hypomagnesemia Hypocalcemia 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 with lightheadedness, low magnesium and low calcium levels. You were given IV magnesium and calcium and your lightheadedness improved. Please follow-up with your primary care physician [MASKED] 1 week. Followup Instructions: [MASKED]
[]
[ "E119", "I2510", "E039", "I10", "E669", "G8929", "G4733" ]
[ "E8342: Hypomagnesemia", "E119: Type 2 diabetes mellitus without complications", "Z6841: Body mass index [BMI]40.0-44.9, adult", "E8351: Hypocalcemia", "R42: Dizziness and giddiness", "R5383: Other fatigue", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E039: Hypothyroidism, unspecified", "I10: Essential (primary) hypertension", "E669: Obesity, unspecified", "M1990: Unspecified osteoarthritis, unspecified site", "G8929: Other chronic pain", "Z96653: Presence of artificial knee joint, bilateral", "G4733: Obstructive sleep apnea (adult) (pediatric)", "Z9119: Patient's noncompliance with other medical treatment and regimen" ]
19,995,258
26,871,572
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: anastrozole / Augmentin / barocat / Latex, Natural Rubber Attending: ___. Chief Complaint: complicated diverticulitis Major Surgical or Invasive Procedure: ___: exploratory laparotomy, complicated sigmoid colectomy, ileocecectomy, and total abdominal hysterectomy and bilateral salpingo-oopherectomy with diverting loop ileostomy History of Present Illness: ___ hx of sigmoid diverticulitis in ___, breast ca presents with over 1wk of LLQ abdominal pain, N/V and imaging consistent with large bowel obstruction and a focal thickening of sigmoid colon concerning for a diverticular stricture vs malignant obstruction. Colorectal surgery is consulted for a surgical evaluation. Patient reports she has had an uncomplicated sigmoid diverticulitis ___ where she was admitted to ___ medicine service for about 2 days and resolved with antibiotics. She subsequently underwent a colonoscopy at the time that showed diverticulosis and no other abnormalities. She has been feeling well until about 4 weeks ago, had a similar LLQ abdominal pain and was seen by her PCP and underwent ___ CT ___ scan which showed a focal thickening in the sigmoid colon and a proximal obstruction. She was sent home with 5 days of Cipro/Flagyl and feeling better however started having recurrent crampy LLQ abdominal pain, nausea, vomiting and ostipation. She presented to ___ ED where she underwent a CT A/P w/IV contrast which showed a worsened large bowel obstruction at a focal thickening of the sigmoid colon. She was transferred to ___ ED for further management. Upon transfer, patient had normal vitals, labs only notable for elevated lipase at 587. She currently endorses stable LLQ pain, no nausea, last passed flatus yesterday, last BM 2 days ago. She denies any fevers, chills, night sweats, weight loss or bloody stools Past Medical History: sigmoid diverticulitis ___ HTN, HL Mitral valve prolapse. Autoimmune disorder of unclear etiology, manifesting as neutrophilic dermatosis, diagnosed in ___ for which she is under the care of Dr. ___ and ___ recently Dr. ___. Social History: ___ Family History: The patient's mother developed breast cancer at age ___. Her father had lymphoma at age ___. She underwent BRCA1-2 testing drawn on ___ at ___, which was negative. She is of ___ ethnic background. Physical Exam: afebrile, vital signs stable General: well appearing, NAD HEENT: normocephalic, atraumatic, no scleral icterus Resp: breathing comfortably on room air CV: regular rate and rhythm on monitor Abdomen: soft, NT, ND, incision clean, dry, intact Brief Hospital Course: Mrs. ___ presented to the emergency department with abdominal pain and imaging consistent with complicated diverticulitis with a malignant vs inflammatory stricture on ___. She underwent a sigmoidosocopy on ___ which showed a 3 cm stricture that decompressed with rectal tube in the proximal sigmoid colon. NGT was placed and the patient was kept NPO. The decision was made to take her to the operating room on ___ for Sigmoid colectomy, ileocecectomy, TAH/BSO, and diverting loop ileostomy. The procedure was complicated by intraoperative blood loss of 1.2L. She remained hemodynamically unstable with pressor requirement in the immediate post operative period, thus she was transferred to the surgical ICU for further management. Neuro: Pain was initially controlled with dilaudid PCA until the patient had return of bowel function. At this point the patient was transitioned to PO pain meds. CV: The patient was hemodynamically unstable after the OR with persistent tachycardia and hypotension requiring pressors, likely secondary to post operative systemic inflammatory response. She was resuscitated with chrystalloid and colloid, and her lactate normalized by the end of post op day 1. She no longer required pressors to maintain her pressure by the end of post operative day one, and her tachycardia resolved by post operative day 2. Pulm: She was extubated in the PACU after her operation. She had a persistent oxygen requirement until post operative day 3 when she was able to be weaned off of oxygen. She was transferred to the floor on post operative day 3. GI: Diet was advanced in a stepwise fashion until the patient was tolerating a regular diet without difficulty. GU: foley was removed on POD 2, patient voided appropriately without issue. ID: Due to presumed intra-abdominal contamination from the visualized abscesses, she was started on a 7 day course of antibiotics. When she was tolerating a regular diet, she was transitioned to PO antibiotics. Previna vac was used over her wound until post operative day 5. It was removed on the day of discharge. Heme: No major issues. On POD 5, the patient was discharged to home. At discharge, the patient was tolerating a regular diet, passing flatus, stooling, voiding, and ambulating independently. The patient will follow-up in the clinic in ___ weeks. This information was communicated to the patient directly prior to discharge. [ ] Post-Operative Ileus resolving w/o NGT [ ] Post-Operative Ileus requiring management with NGT [ ] UTI [ ] Wound Infection [ ] Anastomotic Leak [ ] Staple Line Bleed [ ] Congestive Heart failure [ ] ARF [ ] Acute Urinary retention, failure to void after Foley D/C'd [ ] Acute Urinary Retention requiring discharge with Foley Catheter [ ] DVT [ ] Pneumonia [x] Abscess [ ] None Social Issues Causing a Delay in Discharge: [ ] Delay in organization of ___ services [ ] Difficulty finding appropriate rehabilitation hospital disposition. [ ] Lack of insurance coverage for ___ services [ ] Lack of insurance coverage for prescribed medications. [ ] Family not agreeable to discharge plan. [ ] Patient knowledge deficit related to ileostomy delaying discharge. [x] No social factors contributing in delay of discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Influenza Vaccine Quadrivalent 0.5 mL IM NOW X1 Start: ___, First Dose: Next Routine Administration Time 2. Lisinopril 10 mg PO DAILY 3. Fluticasone Propionate NASAL 2 SPRY NU DAILY Discharge Medications: 1. Lisinopril 10 mg PO DAILY 2. Acetaminophen 1000 mg PO Q6H RX *acetaminophen 80 mg ___ tablet(s) by mouth every six (6) hours Disp #*100 Tablet Refills:*0 3. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #*4 Tablet Refills:*0 4. Enoxaparin Sodium 40 mg SC DAILY Start: Today - ___, First Dose: Next Routine Administration Time RX *enoxaparin 40 mg/0.4 mL ___aily Disp #*25 Syringe Refills:*0 5. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #*6 Tablet Refills:*0 6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth Q4H PRN Disp #*45 Tablet Refills:*0 7. Psyllium Wafer ___ WAF PO BID RX *psyllium [Metamucil] 1.7 g ___ wafer(s) by mouth twice a day Disp #*100 Wafer Refills:*0 8. Fluticasone Propionate NASAL 2 SPRY NU DAILY 9. Medical Assist Device: Commode please provide patient with commode upon discharge Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: recurrent diverticulitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ___ were admitted to the hospital after an exploratory laparotomy, complicated sigmoid colectomy, ileocecectomy, and total abdominal hysterectomy and bilateral salpingo-oopherectomy with diverting loop ileostomy. ___ have recovered from this procedure well and ___ are now ready to return home. Samples from your colon were taken and this tissue has been sent to the pathology department for analysis. ___ will receive these pathology results at your follow-up appointment. If there is an urgent need for the surgeon to contact ___ regarding these results they will contact ___ before this time. ___ have tolerated a regular diet, passing gas and your pain is controlled with pain medications by mouth. ___ may return home to finish your recovery. Please monitor your bowel function closely. ___ may or may not have had a bowel movement prior to your discharge which is acceptable, however it is important that ___ have a bowel movement in the next ___ days. After anesthesia it is not uncommon for patient’s to have some decrease in bowel function but ___ should not have prolonged constipation. Some loose stool and passing of small amounts of dark, old appearing blood are expected. However, if ___ notice that ___ are passing bright red blood with bowel movements or having loose stool without improvement please call the office or go to the emergency room if the symptoms are severe. If ___ are taking narcotic pain medications there is a risk that ___ will have some constipation. Please take an over the counter stool softener such as Colace, and if the symptoms do not improve call the office. If ___ have any of the following symptoms please call the office for advice or go to the emergency room if severe: increasing abdominal distension, increasing abdominal pain, nausea, vomiting, inability to tolerate food or liquids, prolonged loose stool, or extended constipation. ___ have an ileostomy. The most common complication from a new ileostomy placement is dehydration. The output from the stoma is stool from the small intestine and the water content is very high. The stool is no longer passing through the large intestine which is where the water from the stool is reabsorbed into the body and the stool becomes formed. ___ must measure your ileostomy output for the next few weeks. The output from the stoma should not be more than 1200cc or less than 500cc. If ___ find that your output has become too much or too little, please call the office for advice. The office nurse or nurse practitioner can recommend medications to increase or slow the ileostomy output. Keep yourself well hydrated, if ___ notice your ileostomy output increasing, take in more electrolyte drink such as Gatorade. Please monitor yourself for signs and symptoms of dehydration including: dizziness (especially upon standing), weakness, dry mouth, headache, or fatigue. If ___ notice these symptoms please call the office or return to the emergency room for evaluation if these symptoms are severe. ___ may eat a regular diet with your new ileostomy. However it is a good idea to avoid fatty or spicy foods and follow diet suggestions made to ___ by the ostomy nurses. Please monitor the appearance of the ostomy and stoma and care for it as instructed by the wound/ostomy nurses. ___ stoma (intestine that protrudes outside of your abdomen) should be beefy red or pink, it may ooze small amounts of blood at times when touched and this should subside with time. The skin around the ostomy site should be kept clean and intact. Monitor the skin around the stoma for bulging or signs of infection listed above. Please care for the ostomy as ___ have been instructed by the wound/ostomy nurses. ___ will be able to make an appointment with the ostomy nurse in the clinic 7 days after surgery. ___ will have a visiting nurse at home for the next few weeks helping to monitor your ostomy until ___ are comfortable caring for it on your own. ___ have a long vertical incision on your abdomen that is closed with staples. This incision can be left open to air or covered with a dry sterile gauze dressing if the staples become irritated from clothing. The staples will stay in place until your first post-operative visit at which time they can be removed in the clinic, most likely by the office nurse. Please monitor the incision for signs and symptoms of infection including: increasing redness at the incision, opening of the incision, increased pain at the incision line, draining of white/green/yellow/foul smelling drainage, or if ___ develop a fever. Please call the office if ___ develop these symptoms or go to the emergency room if the symptoms are severe. ___ may shower, let the warm water run over the incision line and pat the area dry with a towel, do not rub. No heavy lifting for at least 6 weeks after surgery unless instructed otherwise by your surgical team. ___ may gradually increase your activity as tolerated but clear heavy exercise with your surgical team. ___ will be prescribed a small amount of the pain medication oxycodone. Please take this medication exactly as prescribed. ___ may take Tylenol as recommended for pain. Please do not take more than 4000mg of Tylenol daily. Do not drink alcohol while taking narcotic pain medication or Tylenol. Please do not drive a car while taking narcotic pain medication. Thank ___ for allowing us to participate in your care! Our hope is that ___ will have a quick return to your life and usual activities. Good luck! Followup Instructions: ___
[ "K5732", "K651", "K5669", "R6510", "M9689", "K9161", "K9181", "T814XXA", "Z853", "Z923", "N736", "I10", "E785", "I341", "R000", "I9581", "Y92239", "Y836", "M359" ]
Allergies: anastrozole / Augmentin / barocat / Latex, Natural Rubber Chief Complaint: complicated diverticulitis Major Surgical or Invasive Procedure: [MASKED]: exploratory laparotomy, complicated sigmoid colectomy, ileocecectomy, and total abdominal hysterectomy and bilateral salpingo-oopherectomy with diverting loop ileostomy History of Present Illness: [MASKED] hx of sigmoid diverticulitis in [MASKED], breast ca presents with over 1wk of LLQ abdominal pain, N/V and imaging consistent with large bowel obstruction and a focal thickening of sigmoid colon concerning for a diverticular stricture vs malignant obstruction. Colorectal surgery is consulted for a surgical evaluation. Patient reports she has had an uncomplicated sigmoid diverticulitis [MASKED] where she was admitted to [MASKED] medicine service for about 2 days and resolved with antibiotics. She subsequently underwent a colonoscopy at the time that showed diverticulosis and no other abnormalities. She has been feeling well until about 4 weeks ago, had a similar LLQ abdominal pain and was seen by her PCP and underwent [MASKED] CT [MASKED] scan which showed a focal thickening in the sigmoid colon and a proximal obstruction. She was sent home with 5 days of Cipro/Flagyl and feeling better however started having recurrent crampy LLQ abdominal pain, nausea, vomiting and ostipation. She presented to [MASKED] ED where she underwent a CT A/P w/IV contrast which showed a worsened large bowel obstruction at a focal thickening of the sigmoid colon. She was transferred to [MASKED] ED for further management. Upon transfer, patient had normal vitals, labs only notable for elevated lipase at 587. She currently endorses stable LLQ pain, no nausea, last passed flatus yesterday, last BM 2 days ago. She denies any fevers, chills, night sweats, weight loss or bloody stools Past Medical History: sigmoid diverticulitis [MASKED] HTN, HL Mitral valve prolapse. Autoimmune disorder of unclear etiology, manifesting as neutrophilic dermatosis, diagnosed in [MASKED] for which she is under the care of Dr. [MASKED] and [MASKED] recently Dr. [MASKED]. Social History: [MASKED] Family History: The patient's mother developed breast cancer at age [MASKED]. Her father had lymphoma at age [MASKED]. She underwent BRCA1-2 testing drawn on [MASKED] at [MASKED], which was negative. She is of [MASKED] ethnic background. Physical Exam: afebrile, vital signs stable General: well appearing, NAD HEENT: normocephalic, atraumatic, no scleral icterus Resp: breathing comfortably on room air CV: regular rate and rhythm on monitor Abdomen: soft, NT, ND, incision clean, dry, intact Brief Hospital Course: Mrs. [MASKED] presented to the emergency department with abdominal pain and imaging consistent with complicated diverticulitis with a malignant vs inflammatory stricture on [MASKED]. She underwent a sigmoidosocopy on [MASKED] which showed a 3 cm stricture that decompressed with rectal tube in the proximal sigmoid colon. NGT was placed and the patient was kept NPO. The decision was made to take her to the operating room on [MASKED] for Sigmoid colectomy, ileocecectomy, TAH/BSO, and diverting loop ileostomy. The procedure was complicated by intraoperative blood loss of 1.2L. She remained hemodynamically unstable with pressor requirement in the immediate post operative period, thus she was transferred to the surgical ICU for further management. Neuro: Pain was initially controlled with dilaudid PCA until the patient had return of bowel function. At this point the patient was transitioned to PO pain meds. CV: The patient was hemodynamically unstable after the OR with persistent tachycardia and hypotension requiring pressors, likely secondary to post operative systemic inflammatory response. She was resuscitated with chrystalloid and colloid, and her lactate normalized by the end of post op day 1. She no longer required pressors to maintain her pressure by the end of post operative day one, and her tachycardia resolved by post operative day 2. Pulm: She was extubated in the PACU after her operation. She had a persistent oxygen requirement until post operative day 3 when she was able to be weaned off of oxygen. She was transferred to the floor on post operative day 3. GI: Diet was advanced in a stepwise fashion until the patient was tolerating a regular diet without difficulty. GU: foley was removed on POD 2, patient voided appropriately without issue. ID: Due to presumed intra-abdominal contamination from the visualized abscesses, she was started on a 7 day course of antibiotics. When she was tolerating a regular diet, she was transitioned to PO antibiotics. Previna vac was used over her wound until post operative day 5. It was removed on the day of discharge. Heme: No major issues. On POD 5, the patient was discharged to home. At discharge, the patient was tolerating a regular diet, passing flatus, stooling, voiding, and ambulating independently. The patient will follow-up in the clinic in [MASKED] weeks. This information was communicated to the patient directly prior to discharge. [ ] Post-Operative Ileus resolving w/o NGT [ ] Post-Operative Ileus requiring management with NGT [ ] UTI [ ] Wound Infection [ ] Anastomotic Leak [ ] Staple Line Bleed [ ] Congestive Heart failure [ ] ARF [ ] Acute Urinary retention, failure to void after Foley D/C'd [ ] Acute Urinary Retention requiring discharge with Foley Catheter [ ] DVT [ ] Pneumonia [x] Abscess [ ] None Social Issues Causing a Delay in Discharge: [ ] Delay in organization of [MASKED] services [ ] Difficulty finding appropriate rehabilitation hospital disposition. [ ] Lack of insurance coverage for [MASKED] services [ ] Lack of insurance coverage for prescribed medications. [ ] Family not agreeable to discharge plan. [ ] Patient knowledge deficit related to ileostomy delaying discharge. [x] No social factors contributing in delay of discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Influenza Vaccine Quadrivalent 0.5 mL IM NOW X1 Start: [MASKED], First Dose: Next Routine Administration Time 2. Lisinopril 10 mg PO DAILY 3. Fluticasone Propionate NASAL 2 SPRY NU DAILY Discharge Medications: 1. Lisinopril 10 mg PO DAILY 2. Acetaminophen 1000 mg PO Q6H RX *acetaminophen 80 mg [MASKED] tablet(s) by mouth every six (6) hours Disp #*100 Tablet Refills:*0 3. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #*4 Tablet Refills:*0 4. Enoxaparin Sodium 40 mg SC DAILY Start: Today - [MASKED], First Dose: Next Routine Administration Time RX *enoxaparin 40 mg/0.4 mL aily Disp #*25 Syringe Refills:*0 5. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #*6 Tablet Refills:*0 6. OxycoDONE (Immediate Release) [MASKED] mg PO Q4H:PRN pain RX *oxycodone 5 mg [MASKED] tablet(s) by mouth Q4H PRN Disp #*45 Tablet Refills:*0 7. Psyllium Wafer [MASKED] WAF PO BID RX *psyllium [Metamucil] 1.7 g [MASKED] wafer(s) by mouth twice a day Disp #*100 Wafer Refills:*0 8. Fluticasone Propionate NASAL 2 SPRY NU DAILY 9. Medical Assist Device: Commode please provide patient with commode upon discharge Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: recurrent diverticulitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: [MASKED] were admitted to the hospital after an exploratory laparotomy, complicated sigmoid colectomy, ileocecectomy, and total abdominal hysterectomy and bilateral salpingo-oopherectomy with diverting loop ileostomy. [MASKED] have recovered from this procedure well and [MASKED] are now ready to return home. Samples from your colon were taken and this tissue has been sent to the pathology department for analysis. [MASKED] will receive these pathology results at your follow-up appointment. If there is an urgent need for the surgeon to contact [MASKED] regarding these results they will contact [MASKED] before this time. [MASKED] have tolerated a regular diet, passing gas and your pain is controlled with pain medications by mouth. [MASKED] may return home to finish your recovery. Please monitor your bowel function closely. [MASKED] may or may not have had a bowel movement prior to your discharge which is acceptable, however it is important that [MASKED] have a bowel movement in the next [MASKED] days. After anesthesia it is not uncommon for patient’s to have some decrease in bowel function but [MASKED] should not have prolonged constipation. Some loose stool and passing of small amounts of dark, old appearing blood are expected. However, if [MASKED] notice that [MASKED] are passing bright red blood with bowel movements or having loose stool without improvement please call the office or go to the emergency room if the symptoms are severe. If [MASKED] are taking narcotic pain medications there is a risk that [MASKED] will have some constipation. Please take an over the counter stool softener such as Colace, and if the symptoms do not improve call the office. If [MASKED] have any of the following symptoms please call the office for advice or go to the emergency room if severe: increasing abdominal distension, increasing abdominal pain, nausea, vomiting, inability to tolerate food or liquids, prolonged loose stool, or extended constipation. [MASKED] have an ileostomy. The most common complication from a new ileostomy placement is dehydration. The output from the stoma is stool from the small intestine and the water content is very high. The stool is no longer passing through the large intestine which is where the water from the stool is reabsorbed into the body and the stool becomes formed. [MASKED] must measure your ileostomy output for the next few weeks. The output from the stoma should not be more than 1200cc or less than 500cc. If [MASKED] find that your output has become too much or too little, please call the office for advice. The office nurse or nurse practitioner can recommend medications to increase or slow the ileostomy output. Keep yourself well hydrated, if [MASKED] notice your ileostomy output increasing, take in more electrolyte drink such as Gatorade. Please monitor yourself for signs and symptoms of dehydration including: dizziness (especially upon standing), weakness, dry mouth, headache, or fatigue. If [MASKED] notice these symptoms please call the office or return to the emergency room for evaluation if these symptoms are severe. [MASKED] may eat a regular diet with your new ileostomy. However it is a good idea to avoid fatty or spicy foods and follow diet suggestions made to [MASKED] by the ostomy nurses. Please monitor the appearance of the ostomy and stoma and care for it as instructed by the wound/ostomy nurses. [MASKED] stoma (intestine that protrudes outside of your abdomen) should be beefy red or pink, it may ooze small amounts of blood at times when touched and this should subside with time. The skin around the ostomy site should be kept clean and intact. Monitor the skin around the stoma for bulging or signs of infection listed above. Please care for the ostomy as [MASKED] have been instructed by the wound/ostomy nurses. [MASKED] will be able to make an appointment with the ostomy nurse in the clinic 7 days after surgery. [MASKED] will have a visiting nurse at home for the next few weeks helping to monitor your ostomy until [MASKED] are comfortable caring for it on your own. [MASKED] have a long vertical incision on your abdomen that is closed with staples. This incision can be left open to air or covered with a dry sterile gauze dressing if the staples become irritated from clothing. The staples will stay in place until your first post-operative visit at which time they can be removed in the clinic, most likely by the office nurse. Please monitor the incision for signs and symptoms of infection including: increasing redness at the incision, opening of the incision, increased pain at the incision line, draining of white/green/yellow/foul smelling drainage, or if [MASKED] develop a fever. Please call the office if [MASKED] develop these symptoms or go to the emergency room if the symptoms are severe. [MASKED] may shower, let the warm water run over the incision line and pat the area dry with a towel, do not rub. No heavy lifting for at least 6 weeks after surgery unless instructed otherwise by your surgical team. [MASKED] may gradually increase your activity as tolerated but clear heavy exercise with your surgical team. [MASKED] will be prescribed a small amount of the pain medication oxycodone. Please take this medication exactly as prescribed. [MASKED] may take Tylenol as recommended for pain. Please do not take more than 4000mg of Tylenol daily. Do not drink alcohol while taking narcotic pain medication or Tylenol. Please do not drive a car while taking narcotic pain medication. Thank [MASKED] for allowing us to participate in your care! Our hope is that [MASKED] will have a quick return to your life and usual activities. Good luck! Followup Instructions: [MASKED]
[]
[ "I10", "E785" ]
[ "K5732: Diverticulitis of large intestine without perforation or abscess without bleeding", "K651: Peritoneal abscess", "K5669: Other intestinal obstruction", "R6510: Systemic inflammatory response syndrome (SIRS) of non-infectious origin without acute organ dysfunction", "M9689: Other intraoperative and postprocedural complications and disorders of the musculoskeletal system", "K9161: Intraoperative hemorrhage and hematoma of a digestive system organ or structure complicating a digestive system procedure", "K9181: Other intraoperative complications of digestive system", "T814XXA: Infection following a procedure", "Z853: Personal history of malignant neoplasm of breast", "Z923: Personal history of irradiation", "N736: Female pelvic peritoneal adhesions (postinfective)", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "I341: Nonrheumatic mitral (valve) prolapse", "R000: Tachycardia, unspecified", "I9581: Postprocedural hypotension", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "Y836: Removal of other organ (partial) (total) as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "M359: Systemic involvement of connective tissue, unspecified" ]
19,995,258
28,255,343
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: anastrozole / Augmentin / barocat / Latex, Natural Rubber Attending: ___. Chief Complaint: S/p ileostomy takedown Major Surgical or Invasive Procedure: Ileostomy Takedown History of Present Illness: ___ s/p sigmoid colectomy, loop ileostomy, TAH and BSO for severe diverticulitis, now s/p ileostomy takedown Past Medical History: sigmoid diverticulitis ___ HTN, HL Mitral valve prolapse. Autoimmune disorder of unclear etiology, manifesting as neutrophilic dermatosis, diagnosed in ___ for which she is under the care of Dr. ___ and ___ recently Dr. ___. Social History: ___ Family History: The patient's mother developed breast cancer at age ___. Her father had lymphoma at age ___. She underwent BRCA1-2 testing drawn on ___ at ___, which was negative. She is of ___ ethnic background. Physical Exam: General: Awake and alert in no apparent distress Cardiac: Regular rate and rhythm Pulm: Breathing comfortably on room air GI: Soft, non-distended, minimal incisional tenderness. Incisions c/d/i Pertinent Results: ___ 06:30AM BLOOD WBC-10.7* RBC-3.41* Hgb-10.2* Hct-31.0* MCV-91 MCH-29.9 MCHC-32.9 RDW-16.1* RDWSD-52.8* Plt ___ ___ 06:30AM BLOOD Glucose-95 UreaN-12 Creat-0.7 Na-138 K-3.9 Cl-106 HCO3-19* AnGap-17 ___ 06:30AM BLOOD Calcium-9.1 Phos-4.2 Mg-2.0 Brief Hospital Course: Mrs ___ was admitted to the inpatient Colorectal Surgery Service after ileostomy takedown. She recovered without issue in the PACU. She was transferred to the inpatient unit without issue. On ___ the patient tolerated a clear liquid diet. The Foley catheter was removed and the patient did void however, on ___ the patient did not void and was straight cathed for 525 on blader scan and the catheter was left in place. When the patient passed gas, her diet was advanced. The ileostomy takedown site was cared for appropriately and was intact. The patient was discharged home when tolerating a regular diet. Her pain was controlled. Medications on Admission: iron 325 mg daily CaCO3/VitD daily MVI daily Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN pain do not take more than 3000mg of Tylenol in 24hr or drink alcohol while taking RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8) hours Disp #*50 Tablet Refills:*0 2. Docusate Sodium 100 mg PO BID 3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain so not drink alcohol or drive a car while taking this medication RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*40 Tablet Refills:*0 4. Ferrous Sulfate 325 mg PO DAILY 5. Multivitamins 1 TAB PO DAILY 6. home vitamin ok to take home calcium and vitamin D Discharge Disposition: Home Discharge Diagnosis: Unneeded Ileostomy 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 an ileostomy takedown. You have recovered from this procedure well and you are now ready to return home. You have tolerated a regular diet, passing gas and your pain is controlled with pain medications by mouth. You may return home to finish your recovery. Please monitor your bowel function closely. You may or may not have had a bowel movement prior to your discharge which is acceptable, however it is important that you have a bowel movement in the next ___ days. After anesthesia it is not uncommon for patient’s to have some decrease in bowel function but your should not have prolonged constipation. Some loose stool and passing of small amounts of dark, old appearing blood are expected however, if you notice that you are passing bright red blood with bowel your please seek medical attention. If you are passing loose stool without improvement please call the office or go to the emergency room if the symptoms are severe. If you are taking narcotic pain medications there is a risk that you will have some constipation. Please take an over the counter stool softener such as Colace, and if the symptoms does not improve call the office. It is also not uncommon after an ileostomy takedown to have frequent loose stools until you are taking more regular food however this should improve. The muscles of the sphincters have not been used in quite some time and you may experience urgency or small amounts of incontinence however this should improve. If you do not show improvement in these symptoms within ___ days please call the office for advice. Occasionally, patients will need to take a medication to slow their bowel movements as their bodies adjust to the new normal without an ileostomy, you should consult with our office for advice. If you have any of the following symptoms please call the office for advice or go to the emergency room if severe: increasing abdominal distension, increasing abdominal pain, nausea, vomiting, inability to tolerate food or liquids, prolonged loose stool, or constipation. You have an incision where the old ileostomy once was. This should be covered with a dry sterile gauze dressing. The wound no longer requires packing with gauze packing strip. Please monitor the incision for signs and symptoms of infection including: increasing redness at the incision, opening of the incision, increased pain at the incision line, draining of white/green/yellow/foul smelling drainage, or if you develop a fever. Please call the office if you develop these symptoms or go to the emergency room if the symptoms are severe. You may shower, let the warm water run over the wound line and pat the area dry with a towel, do not rub. Please apply a new gauze dressing after showering. No heavy lifting for at least 6 weeks after surgery unless instructed otherwise by your surgical team. You may gradually increase your activity as tolerated but clear heavy exercise with your surgical team. You will be prescribed a small amount of the pain medication Oxycodone. Please take this medication exactly as prescribed. You may take Tylenol as recommended for pain. Please do not take more than 3000mg of Tylenol daily. Do not drink alcohol while taking narcotic pain medication or Tylenol. Please do not drive a car while taking narcotic pain medication. Thank you for allowing us to participate in your care! Our hope is that you will have a quick return to your life and usual activities. Good luck! Followup Instructions: ___
[ "Z432", "I10", "E785", "L989", "M359", "K660", "K5790", "Z85828" ]
Allergies: anastrozole / Augmentin / barocat / Latex, Natural Rubber Chief Complaint: S/p ileostomy takedown Major Surgical or Invasive Procedure: Ileostomy Takedown History of Present Illness: [MASKED] s/p sigmoid colectomy, loop ileostomy, TAH and BSO for severe diverticulitis, now s/p ileostomy takedown Past Medical History: sigmoid diverticulitis [MASKED] HTN, HL Mitral valve prolapse. Autoimmune disorder of unclear etiology, manifesting as neutrophilic dermatosis, diagnosed in [MASKED] for which she is under the care of Dr. [MASKED] and [MASKED] recently Dr. [MASKED]. Social History: [MASKED] Family History: The patient's mother developed breast cancer at age [MASKED]. Her father had lymphoma at age [MASKED]. She underwent BRCA1-2 testing drawn on [MASKED] at [MASKED], which was negative. She is of [MASKED] ethnic background. Physical Exam: General: Awake and alert in no apparent distress Cardiac: Regular rate and rhythm Pulm: Breathing comfortably on room air GI: Soft, non-distended, minimal incisional tenderness. Incisions c/d/i Pertinent Results: [MASKED] 06:30AM BLOOD WBC-10.7* RBC-3.41* Hgb-10.2* Hct-31.0* MCV-91 MCH-29.9 MCHC-32.9 RDW-16.1* RDWSD-52.8* Plt [MASKED] [MASKED] 06:30AM BLOOD Glucose-95 UreaN-12 Creat-0.7 Na-138 K-3.9 Cl-106 HCO3-19* AnGap-17 [MASKED] 06:30AM BLOOD Calcium-9.1 Phos-4.2 Mg-2.0 Brief Hospital Course: Mrs [MASKED] was admitted to the inpatient Colorectal Surgery Service after ileostomy takedown. She recovered without issue in the PACU. She was transferred to the inpatient unit without issue. On [MASKED] the patient tolerated a clear liquid diet. The Foley catheter was removed and the patient did void however, on [MASKED] the patient did not void and was straight cathed for 525 on blader scan and the catheter was left in place. When the patient passed gas, her diet was advanced. The ileostomy takedown site was cared for appropriately and was intact. The patient was discharged home when tolerating a regular diet. Her pain was controlled. Medications on Admission: iron 325 mg daily CaCO3/VitD daily MVI daily Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN pain do not take more than 3000mg of Tylenol in 24hr or drink alcohol while taking RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8) hours Disp #*50 Tablet Refills:*0 2. Docusate Sodium 100 mg PO BID 3. OxycoDONE (Immediate Release) [MASKED] mg PO Q4H:PRN pain so not drink alcohol or drive a car while taking this medication RX *oxycodone 5 mg [MASKED] tablet(s) by mouth every four (4) hours Disp #*40 Tablet Refills:*0 4. Ferrous Sulfate 325 mg PO DAILY 5. Multivitamins 1 TAB PO DAILY 6. home vitamin ok to take home calcium and vitamin D Discharge Disposition: Home Discharge Diagnosis: Unneeded Ileostomy 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 an ileostomy takedown. You have recovered from this procedure well and you are now ready to return home. You have tolerated a regular diet, passing gas and your pain is controlled with pain medications by mouth. You may return home to finish your recovery. Please monitor your bowel function closely. You may or may not have had a bowel movement prior to your discharge which is acceptable, however it is important that you have a bowel movement in the next [MASKED] days. After anesthesia it is not uncommon for patient’s to have some decrease in bowel function but your should not have prolonged constipation. Some loose stool and passing of small amounts of dark, old appearing blood are expected however, if you notice that you are passing bright red blood with bowel your please seek medical attention. If you are passing loose stool without improvement please call the office or go to the emergency room if the symptoms are severe. If you are taking narcotic pain medications there is a risk that you will have some constipation. Please take an over the counter stool softener such as Colace, and if the symptoms does not improve call the office. It is also not uncommon after an ileostomy takedown to have frequent loose stools until you are taking more regular food however this should improve. The muscles of the sphincters have not been used in quite some time and you may experience urgency or small amounts of incontinence however this should improve. If you do not show improvement in these symptoms within [MASKED] days please call the office for advice. Occasionally, patients will need to take a medication to slow their bowel movements as their bodies adjust to the new normal without an ileostomy, you should consult with our office for advice. If you have any of the following symptoms please call the office for advice or go to the emergency room if severe: increasing abdominal distension, increasing abdominal pain, nausea, vomiting, inability to tolerate food or liquids, prolonged loose stool, or constipation. You have an incision where the old ileostomy once was. This should be covered with a dry sterile gauze dressing. The wound no longer requires packing with gauze packing strip. Please monitor the incision for signs and symptoms of infection including: increasing redness at the incision, opening of the incision, increased pain at the incision line, draining of white/green/yellow/foul smelling drainage, or if you develop a fever. Please call the office if you develop these symptoms or go to the emergency room if the symptoms are severe. You may shower, let the warm water run over the wound line and pat the area dry with a towel, do not rub. Please apply a new gauze dressing after showering. No heavy lifting for at least 6 weeks after surgery unless instructed otherwise by your surgical team. You may gradually increase your activity as tolerated but clear heavy exercise with your surgical team. You will be prescribed a small amount of the pain medication Oxycodone. Please take this medication exactly as prescribed. You may take Tylenol as recommended for pain. Please do not take more than 3000mg of Tylenol daily. Do not drink alcohol while taking narcotic pain medication or Tylenol. Please do not drive a car while taking narcotic pain medication. Thank you for allowing us to participate in your care! Our hope is that you will have a quick return to your life and usual activities. Good luck! Followup Instructions: [MASKED]
[]
[ "I10", "E785" ]
[ "Z432: Encounter for attention to ileostomy", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "L989: Disorder of the skin and subcutaneous tissue, unspecified", "M359: Systemic involvement of connective tissue, unspecified", "K660: Peritoneal adhesions (postprocedural) (postinfection)", "K5790: Diverticulosis of intestine, part unspecified, without perforation or abscess without bleeding", "Z85828: Personal history of other malignant neoplasm of skin" ]
19,995,478
24,108,472
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Pneumococcal Vaccine Attending: ___. Chief Complaint: s/p MVC with intrusion into driver's side Major Surgical or Invasive Procedure: None History of Present Illness: ___ s/p MVC restr driver with intrusion, L comminuted clavicle Fx, small R abdominal hematoma extending to L iliacus with ? bone fragment vs small extrav by R iliac crest, L5 R TP Fx Past Medical History: PMH: chron MRSA, A fib, ?CKD, pulmonary infection PSH: hx RLL resection Social History: ___ Family History: Noncontributory Physical Exam: Exam at discharge: Vitals: 98.0F, HR 60, RR 18, SpO2 97% RA, BP 148/74 Gen app: sitting upright in bedside chair, appears comfortable, NAD HEENT: EOMI, PERRL. There is erythema of the left eye but no drainage or pain. Vision grossly intact. Oral mucosa pink and moist. Neck: trachea midline CV: RRR, no m/r/g Lungs: CTA Abd: bowel sounds present. Soft, NT. Extrem: warm, well-perfused Neuro: CN II-XII intact. Sensation intact and symmetric throughout. Strength ___ in all muscle groups, except for LUE, which was unable to be tested ___ presence of sling. Gait intact. Skin: large ecchymosis at left upper chest and over the left shoulder. Pertinent Results: On admission: ___ 10:44AM BLOOD WBC-9.0 RBC-4.32* Hgb-13.8 Hct-42.9 MCV-99* MCH-31.9 MCHC-32.2 RDW-12.6 RDWSD-46.0 Plt ___ ___ 10:44AM BLOOD ___ PTT-37.3* ___ ___ 10:44AM BLOOD UreaN-19 ___ 05:00AM BLOOD Calcium-9.1 Phos-3.8 Mg-2.1 On day of discharge: ___ 03:20PM BLOOD Hct-37.6* ___ 05:00AM BLOOD WBC-8.9 RBC-3.69* Hgb-11.9* Hct-36.8* MCV-100* MCH-32.2* MCHC-32.3 RDW-12.7 RDWSD-46.6* Plt ___ Brief Hospital Course: Pt brought to ___ via EMS after ___ where pt was the driver of a car that was T-boned with intrusion into the driver's side. Found to have L comminuted and displaced clavicular fx, L5 right transverse process fx, and R abdominal wall hematoma. On CT abdomen/pelvis, there was a small hyperdense area in the R low abdomen that was felt to represent either a bone fragment or possible extravasation of IV contrast. Given that pt was on Eliquis, the pt was admitted for observation. His hematocrits were trended and initially dropped from 42.9 on arrival to 36.8. Subsequent labs demonstrated stable hemocrit with last value prior to discharge 37.6. He was seen and evaluated by the orthopedic service for his clavicle fracture. They recommended sling for the L arm and follow up in their clinic in 2 weeks. His pain was well controlled with Tylenol alone. He was doing well and was discharged to home. He was instructed to stop his Eliquis until he sees his cardiologist. Medications on Admission: Eliquis Bactrim Discharge Medications: Bactrim Discharge Disposition: Home Discharge Diagnosis: 1. s/p motor vehicle collision 2. Displaced comminuted left clavicle fx 3. Right abdominal wall hematoma 4. L5 right transverse process fx Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You came to the hospital after a car accident. You were found to have a broken left collarbone, a broken piece of bone in your low back, and a blood collection in your right abdomen. You were monitored overnight to ensure there was no evidence of continued bleeding. Your blood counts decreased initially but were stable on repeat lab work. You were discharged to home in stable condition. You should not restart your Eliquis unless told to do so by your cardiologist. You should keep your left arm in the sling until told otherwise by the orthopedic surgeons at your follow up appointment. You may take Tylenol for the pain. You should take no more than 3,000mg of Tylenol per day. Followup Instructions: ___
[ "S42022A", "S301XXA", "S32058A", "V4352XA", "Y9289", "M549", "R001", "Z85828", "Z85038", "E785", "I10", "N289", "M109", "Z87891", "I4891", "Z7902", "Z8614" ]
Allergies: Pneumococcal Vaccine Chief Complaint: s/p MVC with intrusion into driver's side Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] s/p MVC restr driver with intrusion, L comminuted clavicle Fx, small R abdominal hematoma extending to L iliacus with ? bone fragment vs small extrav by R iliac crest, L5 R TP Fx Past Medical History: PMH: chron MRSA, A fib, ?CKD, pulmonary infection PSH: hx RLL resection Social History: [MASKED] Family History: Noncontributory Physical Exam: Exam at discharge: Vitals: 98.0F, HR 60, RR 18, SpO2 97% RA, BP 148/74 Gen app: sitting upright in bedside chair, appears comfortable, NAD HEENT: EOMI, PERRL. There is erythema of the left eye but no drainage or pain. Vision grossly intact. Oral mucosa pink and moist. Neck: trachea midline CV: RRR, no m/r/g Lungs: CTA Abd: bowel sounds present. Soft, NT. Extrem: warm, well-perfused Neuro: CN II-XII intact. Sensation intact and symmetric throughout. Strength [MASKED] in all muscle groups, except for LUE, which was unable to be tested [MASKED] presence of sling. Gait intact. Skin: large ecchymosis at left upper chest and over the left shoulder. Pertinent Results: On admission: [MASKED] 10:44AM BLOOD WBC-9.0 RBC-4.32* Hgb-13.8 Hct-42.9 MCV-99* MCH-31.9 MCHC-32.2 RDW-12.6 RDWSD-46.0 Plt [MASKED] [MASKED] 10:44AM BLOOD [MASKED] PTT-37.3* [MASKED] [MASKED] 10:44AM BLOOD UreaN-19 [MASKED] 05:00AM BLOOD Calcium-9.1 Phos-3.8 Mg-2.1 On day of discharge: [MASKED] 03:20PM BLOOD Hct-37.6* [MASKED] 05:00AM BLOOD WBC-8.9 RBC-3.69* Hgb-11.9* Hct-36.8* MCV-100* MCH-32.2* MCHC-32.3 RDW-12.7 RDWSD-46.6* Plt [MASKED] Brief Hospital Course: Pt brought to [MASKED] via EMS after [MASKED] where pt was the driver of a car that was T-boned with intrusion into the driver's side. Found to have L comminuted and displaced clavicular fx, L5 right transverse process fx, and R abdominal wall hematoma. On CT abdomen/pelvis, there was a small hyperdense area in the R low abdomen that was felt to represent either a bone fragment or possible extravasation of IV contrast. Given that pt was on Eliquis, the pt was admitted for observation. His hematocrits were trended and initially dropped from 42.9 on arrival to 36.8. Subsequent labs demonstrated stable hemocrit with last value prior to discharge 37.6. He was seen and evaluated by the orthopedic service for his clavicle fracture. They recommended sling for the L arm and follow up in their clinic in 2 weeks. His pain was well controlled with Tylenol alone. He was doing well and was discharged to home. He was instructed to stop his Eliquis until he sees his cardiologist. Medications on Admission: Eliquis Bactrim Discharge Medications: Bactrim Discharge Disposition: Home Discharge Diagnosis: 1. s/p motor vehicle collision 2. Displaced comminuted left clavicle fx 3. Right abdominal wall hematoma 4. L5 right transverse process fx Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You came to the hospital after a car accident. You were found to have a broken left collarbone, a broken piece of bone in your low back, and a blood collection in your right abdomen. You were monitored overnight to ensure there was no evidence of continued bleeding. Your blood counts decreased initially but were stable on repeat lab work. You were discharged to home in stable condition. You should not restart your Eliquis unless told to do so by your cardiologist. You should keep your left arm in the sling until told otherwise by the orthopedic surgeons at your follow up appointment. You may take Tylenol for the pain. You should take no more than 3,000mg of Tylenol per day. Followup Instructions: [MASKED]
[]
[ "E785", "I10", "M109", "Z87891", "I4891", "Z7902" ]
[ "S42022A: Displaced fracture of shaft of left clavicle, initial encounter for closed fracture", "S301XXA: Contusion of abdominal wall, initial encounter", "S32058A: Other fracture of fifth lumbar vertebra, initial encounter for closed fracture", "V4352XA: Car driver injured in collision with other type car in traffic accident, initial encounter", "Y9289: Other specified places as the place of occurrence of the external cause", "M549: Dorsalgia, unspecified", "R001: Bradycardia, unspecified", "Z85828: Personal history of other malignant neoplasm of skin", "Z85038: Personal history of other malignant neoplasm of large intestine", "E785: Hyperlipidemia, unspecified", "I10: Essential (primary) hypertension", "N289: Disorder of kidney and ureter, unspecified", "M109: Gout, unspecified", "Z87891: Personal history of nicotine dependence", "I4891: Unspecified atrial fibrillation", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "Z8614: Personal history of Methicillin resistant Staphylococcus aureus infection" ]
19,995,595
21,784,060
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: heparin Attending: ___. Chief Complaint: Abdominal aortic aneurysm rupture with hemodynamic instability Major Surgical or Invasive Procedure: ___ INFRARENAL PROXIMAL AORTIC CUFF X 4, OPEN ABDOMEN FOR WASHOUT OF HEMATOMA ___ ABDOMINAL WASHOUT, LOA, ABTHERA PLACEMENT ___ ABDOMINAL WASHOUT, CLOSURE OF ABDOMEN History of Present Illness: HPI: Mr. ___ is a ___, former smoker, with PVD s/p aortobifemoral bypass (___ ___ vs ___ per wife), who presented to the OSH with sudden onset abdominal pain this morning. He underwent a CTA which showed a disrupted proximal anastomosis of the aorto-femoral graft with rupture. Additionally he has a right groin pseudoaneurysm between the right limb of the aort-bifemoral graft with the native artery which appears contained. He was therefore transferred to ___ for further management. On Medflight, he became hypotensive with worsening abdominal distention and was given a total of 4u pRBC and ___ FFP. He was taken directly to the OR for definitive treatment. Past Medical History: PMH: afib, stroke (no neuro deficits ___, PVD, HTN PSH: - aortobifemoral bypass ___ vs ___ - >___nd endovascular procedures including left iliac artery stent, fem-fem bypass, ultimately resulting in R BKA Social History: ___ Family History: FH: unknown Physical Exam: Physical Exam: ON ARRIVAL Vitals: HR 112 BP 135/110 GEN: in acute distress, conversant CV: tachycardic PULM: no respiratory distreess ABD: tense, distended abdomen, tender to palpation Ext: No ___ edema, ___ warm and well perfused Pulses: R: p/d/BKA L: p/d/d/d ON DISCHARGE *************** Pertinent Results: ___ 05:37AM BLOOD WBC-8.7 RBC-3.49* Hgb-9.7* Hct-33.4* MCV-96 MCH-27.8 MCHC-29.0* RDW-21.0* RDWSD-74.2* Plt ___ ___ 05:37AM BLOOD ___ PTT-33.4 ___ ___ 05:37AM BLOOD Glucose-96 UreaN-41* Creat-0.8 Na-138 K-5.0 Cl-97 HCO3-27 AnGap-14 ___ 05:37AM BLOOD Calcium-8.8 Phos-5.6* Mg-2.2 ___ 06:41AM BLOOD calTIBC-332 Ferritn-277 TRF-255 Brief Hospital Course: Mr. ___ is a ___ PVD s/p aortobifemoral bypass (___) who presented to the OSH with sudden onset of abdominal pain with CTA confirming p/w ruptured ___ anastomosis. He was transfused 4u rPBC 2uFFP in medflight with worsening hypotension. He was taken immediately to the OR where he underwent infrarenal ___ aortic cuff x4 w open abdomen (see op note for further details). He was transferred to the ICU in critical condition. He was started on fondaparinux prophylaxis due to his history of HIT. His respiratory status was tenuous and he frequently desatted and required increasing FiO2 while he remained intubated. Pulmonology was consulted and he was started on Lasix. During this initial post-op period his antibiotic coverage was adjusted as appropriate and he was started on tube feeds. He had a TTE that showed a PFO, but cardiology did not feel that any intervention was necessary at this time. He returned to the OR on POD4 for an abdominal washout, lysis of adhesions, and abthera placement. Following his second trip to the OR he had continued PRN Lasix requirements in the ICU. Two days following this he became febrile and his R IJ line had evidence of pus when it was removed, so a L IJ was placed. His fevers continued and he was taken back to the OR again for another washout and at this time his abdomen was closed. After this third trip to the OR he was persistently hypertensive and required nicardipine for BP control. In the following days the ICU team attempted to wean him from the vent but it was not well tolerated. He also went into Afib and was started on metoprolol. He continued to be febrile so a CTA of his torso was obtained, but it showed no obvious source of infection that would explain his fevers. On POD12 from his original operation he was extubated, but developed respiratory distress and needed to be reintubated. The following day he continued to be febrile so ID was consulted. The following day he went into Afib with RVR again and was started on a dilt drip. He had an echo for unexplained hypotension which didn't show a cardiac cause, but revealed a thrombus in his IJ. At this time he was also transitioned to bivalirudin for a short period before being restarted on fondaparinux. On POD16 from his original operation he was successfully extubated and his oxygen requirements were subsequently weaned down. His mental status then became one of his chief issues, as he would only occasionally follow commands and would not communicate in any meaningful manner. His fevers subsided and on POD18 he was transferred to the VICU. While on the floor in the VICU his blood pressure and mental status were his main issues. Vascular medicine provided assistance with his anti-hypertensive regimen, which needed to be adjusted multiple times for adequate control. Neurology was consulted for his altered mental status, which they attributed to delirium secondary to an extended ICU stay. Additionally, ACS was consulted for placement of a PEG tube as he would likely need long term feeding access due to his mental status. Ultimately, his family opted not to go through with the PEG so that they could avoid reintubation, so his feedings were continued with the Dobhoff. Neurology attributed his mental status to delirium related to his prolonged ICU stay, so delirium precautions were put in place. His mental status began to improve and he became more conversant and oriented as time progressed. Vascular medicine continued to be involved in his care and he was diuresed as necessary. On hospital day ___ he had a brief run of afib that was seen on telemetry, but had no further issues with afib afterwards. On hospital day ___ he was hemodynamically stable and his mental status continued to improve so he was determined to be fit for discharge. His discharge was ultimately delayed due to difficulties with finding rehab placement, but by hospital day 27 case management had found a rehab facility and he was transferred there with plans to follow up with vascular surgery clinic for re-imaging of his abdomen. Medications on Admission: Lisinopril Lovastatin Gabapentin Prilosec Warfarin Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever 2. amLODIPine 10 mg PO DAILY RX *amlodipine 10 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 3. Artificial Tears Preserv. Free ___ DROP BOTH EYES Q4H:PRN dry eyes 4. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 5. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line 6. Captopril 37.5 mg PO TID RX *captopril 25 mg 1.5 tablet(s) by mouth three times a day Disp #*135 Tablet Refills:*0 7. CARVedilol 12.5 mg PO BID RX *carvedilol 12.5 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 8. Chlorthalidone 25 mg PO DAILY RX *chlorthalidone 25 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 9. Docusate Sodium (Liquid) 100 mg PO BID 10. Fondaparinux 7.5 mg SC DAILY RX *fondaparinux 7.5 mg/0.6 mL 1 once a day Disp #*30 Syringe Refills:*0 11. Ipratropium-Albuterol Neb 1 NEB NEB Q4H 12. Metoclopramide 10 mg PO Q6H 13. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line 14. QUEtiapine Fumarate 12.5 mg PO QHS agitation 15. Senna 8.6 mg PO BID 16. Divalproex (DELayed Release) 500 mg PO BID 17. Gabapentin 800 mg PO TID 18. Lovastatin 40 mg oral DAILY 19. Memantine 10 mg PO DAILY ___ 20. Memantine 5 mg PO DAILY AM 21. Omeprazole 20 mg PO DAILY 22. Warfarin 2 mg PO 5X/WEEK (___) 23. Warfarin 4 mg PO 2X/WEEK (___) Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Abdominal Aortic Aneurysm Rupture Peripheral Vascular Disease Anemia secondary to rupture requiring transfusion Oliguria Pleural effusions with pulmonary edema requiring diuresis Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Mr. ___- It was a pleasure taking care of you at ___ ___. You were admitted to the hospital after transfer from an outside institution for ruptured abdominal aortic aneurysm. You underwent emergent repair which required placement of a graft in you aorta. You also required an incision made into your abdomen to release the blood that collected after the rupture. Please follow the recommendations below to ensure a speedy and uneventful recovery. Division of Vascular and Endovascular Surgery Endovascular Abdominal Aortic Aneurysm Repair Discharge Instructions PLEASE NOTE: After endovascular aortic repair (EVAR), it is very important to have regular appointments (every ___ months) for the rest of your life. These appointments will include a CT (“CAT”) scan and/or ultrasound of your graft. If you miss an appointment, please call to reschedule. WHAT TO EXPECT: •Bruising, tenderness, and a sensation of fullness at the groin puncture sites (or incisions) is normal and will go away in one-two weeks CARE OF THE GROIN PUNCTURE SITES: •It is normal to have mild swelling, a small bruise, or small amounts of drainage at the groin puncture sites. In two weeks, you may feel a small, painless, pea sized knot at the puncture sites. This too is normal. Male patients may notice some swelling in the scrotum. The swelling will get better over one-two weeks. •Look at the area daily to see if there are any changes. Be sure to report signs of infection. These include: increasing redness; worsening pain; new or increasing drainage, or drainage that is white, yellow, or green; or fever of 101.5 or more. (If you have taken aspirin, Tylenol, or other fever reducing medicine, wait at least ___ hours after taking it before you check your temperature in order to get an accurate reading.) FOR SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or incision) •If you have sudden, severe bleeding or swelling at either of the groin puncture sites: -Lie down, keep leg straight and apply (or have someone apply) firm pressure to area for ___ minutes with a gauze pad or clean cloth. -Once bleeding has stopped, call your surgeon to report what happened. -If bleeding does not stop, call ___ for transfer to closest Emergency Room. •You may shower 48 hours after surgery. Let the soapy water run over the puncture sites, then rinse and pat dry. Do not rub these sites and do not apply cream, lotion, ointment or powder. •Wear loose-fitting pants and clothing as this will be less irritating to the groin puncture sites. MEDICATIONS •Take aspirin daily. Aspirin helps prevent blood clots that could form in your repaired artery. •It is very important that you never stop taking aspirin or other blood thinning medicines-even for a short while- unless the surgeon who repaired your aneurysm tells you it is okay to stop. Do not stop taking them, even if another doctor or nurse tells you to, without getting an okay from the surgeon who first prescribed them. •You will be given prescriptions for any new medication started during your hospital stay. •Before you go home, your nurse ___ give you information about new medication and will review all the medications you should take at home. Be sure to ask any questions you may have. If something you normally take or may take is not on the list you receive from the nurse, please ask if it is okay to take it. PAIN MANAGEMENT •Most patients do not have much pain following placement of the stent alone. You had an abdominal incision in addition to this, so recovery may take longer. Your puncture sites may be a little sore. This will improve daily. If it is getting worse, please let us know. •You will be given instructions about taking pain medicine if you need it. ACTIVITY •You must limit activity to protect the puncture sites in your groin. For ONE WEEK: -Do not drive -Do not swim, take a tub bath or go in a Jacuzzi or hot tub -Do not lift, push, pull or carry anything heavier than five pounds -Do not do any exercise or activity that causes you to hold your breath or bear down with your abdominal muscles. -Do not resume sexual activity •Discuss with your surgeon when you may return to other regular activities, including work. If needed, we will give you a letter for your workplace. •It is normal to feel weak and tired. This can last six-eight weeks, but should get better day by day. You may want to have help around the house during this time. ___ push yourself too hard during your recovery. Rest when you feel tired. Gradually return to normal activities over the next month. •We encourage you to walk regularly. Walking, especially outdoors in good weather is the best exercise for circulation. Walk short distances at first, even in the house, then do a little more each day. •It is okay to climb stairs. You may need to climb them slowly and pause after every few steps. BOWEL AND BLADDER FUNCTION •You should be able to pass urine without difficulty. Call you doctor if you have any problems urinating, such as burning, pain, bleeding, going too often, or having trouble urinating or starting the flow of urine. Call if you have a decrease in the amount of urine. •You may experience some constipation after surgery because of pain medicine and changes in activity. Increasing fluids and fiber in your diet and staying active can help. To relief constipation, you may talk a mild laxative. Please take to your pharmacist for advice about what to take. SMOKING •If you smoke, it is very important that you STOP. Research shows smoking makes vascular disease worse. This could increase the chance of a blockage in your new graft. Talk to your primary care physician about ways to quit smoking. Followup Instructions: ___
[ "T82898A", "I713", "T80211A", "J9601", "R578", "D62", "J90", "Q211", "F05", "J811", "T17890A", "J9811", "D6861", "J95851", "N179", "E873", "E870", "Y832", "Y92009", "I724", "I10", "Z8673", "Z87891", "I739", "I4891", "R680", "Z89511", "G40909", "X58XXXA", "Y929", "K660", "B9689", "Y848", "Y92230", "R34", "E806", "T82868A" ]
Allergies: heparin Chief Complaint: Abdominal aortic aneurysm rupture with hemodynamic instability Major Surgical or Invasive Procedure: [MASKED] INFRARENAL PROXIMAL AORTIC CUFF X 4, OPEN ABDOMEN FOR WASHOUT OF HEMATOMA [MASKED] ABDOMINAL WASHOUT, LOA, ABTHERA PLACEMENT [MASKED] ABDOMINAL WASHOUT, CLOSURE OF ABDOMEN History of Present Illness: HPI: Mr. [MASKED] is a [MASKED], former smoker, with PVD s/p aortobifemoral bypass ([MASKED] [MASKED] vs [MASKED] per wife), who presented to the OSH with sudden onset abdominal pain this morning. He underwent a CTA which showed a disrupted proximal anastomosis of the aorto-femoral graft with rupture. Additionally he has a right groin pseudoaneurysm between the right limb of the aort-bifemoral graft with the native artery which appears contained. He was therefore transferred to [MASKED] for further management. On Medflight, he became hypotensive with worsening abdominal distention and was given a total of 4u pRBC and [MASKED] FFP. He was taken directly to the OR for definitive treatment. Past Medical History: PMH: afib, stroke (no neuro deficits [MASKED], PVD, HTN PSH: - aortobifemoral bypass [MASKED] vs [MASKED] - > nd endovascular procedures including left iliac artery stent, fem-fem bypass, ultimately resulting in R BKA Social History: [MASKED] Family History: FH: unknown Physical Exam: Physical Exam: ON ARRIVAL Vitals: HR 112 BP 135/110 GEN: in acute distress, conversant CV: tachycardic PULM: no respiratory distreess ABD: tense, distended abdomen, tender to palpation Ext: No [MASKED] edema, [MASKED] warm and well perfused Pulses: R: p/d/BKA L: p/d/d/d ON DISCHARGE *************** Pertinent Results: [MASKED] 05:37AM BLOOD WBC-8.7 RBC-3.49* Hgb-9.7* Hct-33.4* MCV-96 MCH-27.8 MCHC-29.0* RDW-21.0* RDWSD-74.2* Plt [MASKED] [MASKED] 05:37AM BLOOD [MASKED] PTT-33.4 [MASKED] [MASKED] 05:37AM BLOOD Glucose-96 UreaN-41* Creat-0.8 Na-138 K-5.0 Cl-97 HCO3-27 AnGap-14 [MASKED] 05:37AM BLOOD Calcium-8.8 Phos-5.6* Mg-2.2 [MASKED] 06:41AM BLOOD calTIBC-332 Ferritn-277 TRF-255 Brief Hospital Course: Mr. [MASKED] is a [MASKED] PVD s/p aortobifemoral bypass ([MASKED]) who presented to the OSH with sudden onset of abdominal pain with CTA confirming p/w ruptured [MASKED] anastomosis. He was transfused 4u rPBC 2uFFP in medflight with worsening hypotension. He was taken immediately to the OR where he underwent infrarenal [MASKED] aortic cuff x4 w open abdomen (see op note for further details). He was transferred to the ICU in critical condition. He was started on fondaparinux prophylaxis due to his history of HIT. His respiratory status was tenuous and he frequently desatted and required increasing FiO2 while he remained intubated. Pulmonology was consulted and he was started on Lasix. During this initial post-op period his antibiotic coverage was adjusted as appropriate and he was started on tube feeds. He had a TTE that showed a PFO, but cardiology did not feel that any intervention was necessary at this time. He returned to the OR on POD4 for an abdominal washout, lysis of adhesions, and abthera placement. Following his second trip to the OR he had continued PRN Lasix requirements in the ICU. Two days following this he became febrile and his R IJ line had evidence of pus when it was removed, so a L IJ was placed. His fevers continued and he was taken back to the OR again for another washout and at this time his abdomen was closed. After this third trip to the OR he was persistently hypertensive and required nicardipine for BP control. In the following days the ICU team attempted to wean him from the vent but it was not well tolerated. He also went into Afib and was started on metoprolol. He continued to be febrile so a CTA of his torso was obtained, but it showed no obvious source of infection that would explain his fevers. On POD12 from his original operation he was extubated, but developed respiratory distress and needed to be reintubated. The following day he continued to be febrile so ID was consulted. The following day he went into Afib with RVR again and was started on a dilt drip. He had an echo for unexplained hypotension which didn't show a cardiac cause, but revealed a thrombus in his IJ. At this time he was also transitioned to bivalirudin for a short period before being restarted on fondaparinux. On POD16 from his original operation he was successfully extubated and his oxygen requirements were subsequently weaned down. His mental status then became one of his chief issues, as he would only occasionally follow commands and would not communicate in any meaningful manner. His fevers subsided and on POD18 he was transferred to the VICU. While on the floor in the VICU his blood pressure and mental status were his main issues. Vascular medicine provided assistance with his anti-hypertensive regimen, which needed to be adjusted multiple times for adequate control. Neurology was consulted for his altered mental status, which they attributed to delirium secondary to an extended ICU stay. Additionally, ACS was consulted for placement of a PEG tube as he would likely need long term feeding access due to his mental status. Ultimately, his family opted not to go through with the PEG so that they could avoid reintubation, so his feedings were continued with the Dobhoff. Neurology attributed his mental status to delirium related to his prolonged ICU stay, so delirium precautions were put in place. His mental status began to improve and he became more conversant and oriented as time progressed. Vascular medicine continued to be involved in his care and he was diuresed as necessary. On hospital day [MASKED] he had a brief run of afib that was seen on telemetry, but had no further issues with afib afterwards. On hospital day [MASKED] he was hemodynamically stable and his mental status continued to improve so he was determined to be fit for discharge. His discharge was ultimately delayed due to difficulties with finding rehab placement, but by hospital day 27 case management had found a rehab facility and he was transferred there with plans to follow up with vascular surgery clinic for re-imaging of his abdomen. Medications on Admission: Lisinopril Lovastatin Gabapentin Prilosec Warfarin Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever 2. amLODIPine 10 mg PO DAILY RX *amlodipine 10 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 3. Artificial Tears Preserv. Free [MASKED] DROP BOTH EYES Q4H:PRN dry eyes 4. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 5. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line 6. Captopril 37.5 mg PO TID RX *captopril 25 mg 1.5 tablet(s) by mouth three times a day Disp #*135 Tablet Refills:*0 7. CARVedilol 12.5 mg PO BID RX *carvedilol 12.5 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 8. Chlorthalidone 25 mg PO DAILY RX *chlorthalidone 25 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 9. Docusate Sodium (Liquid) 100 mg PO BID 10. Fondaparinux 7.5 mg SC DAILY RX *fondaparinux 7.5 mg/0.6 mL 1 once a day Disp #*30 Syringe Refills:*0 11. Ipratropium-Albuterol Neb 1 NEB NEB Q4H 12. Metoclopramide 10 mg PO Q6H 13. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line 14. QUEtiapine Fumarate 12.5 mg PO QHS agitation 15. Senna 8.6 mg PO BID 16. Divalproex (DELayed Release) 500 mg PO BID 17. Gabapentin 800 mg PO TID 18. Lovastatin 40 mg oral DAILY 19. Memantine 10 mg PO DAILY [MASKED] 20. Memantine 5 mg PO DAILY AM 21. Omeprazole 20 mg PO DAILY 22. Warfarin 2 mg PO 5X/WEEK ([MASKED]) 23. Warfarin 4 mg PO 2X/WEEK ([MASKED]) Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Abdominal Aortic Aneurysm Rupture Peripheral Vascular Disease Anemia secondary to rupture requiring transfusion Oliguria Pleural effusions with pulmonary edema requiring diuresis Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Mr. [MASKED]- It was a pleasure taking care of you at [MASKED] [MASKED]. You were admitted to the hospital after transfer from an outside institution for ruptured abdominal aortic aneurysm. You underwent emergent repair which required placement of a graft in you aorta. You also required an incision made into your abdomen to release the blood that collected after the rupture. Please follow the recommendations below to ensure a speedy and uneventful recovery. Division of Vascular and Endovascular Surgery Endovascular Abdominal Aortic Aneurysm Repair Discharge Instructions PLEASE NOTE: After endovascular aortic repair (EVAR), it is very important to have regular appointments (every [MASKED] months) for the rest of your life. These appointments will include a CT (“CAT”) scan and/or ultrasound of your graft. If you miss an appointment, please call to reschedule. WHAT TO EXPECT: •Bruising, tenderness, and a sensation of fullness at the groin puncture sites (or incisions) is normal and will go away in one-two weeks CARE OF THE GROIN PUNCTURE SITES: •It is normal to have mild swelling, a small bruise, or small amounts of drainage at the groin puncture sites. In two weeks, you may feel a small, painless, pea sized knot at the puncture sites. This too is normal. Male patients may notice some swelling in the scrotum. The swelling will get better over one-two weeks. •Look at the area daily to see if there are any changes. Be sure to report signs of infection. These include: increasing redness; worsening pain; new or increasing drainage, or drainage that is white, yellow, or green; or fever of 101.5 or more. (If you have taken aspirin, Tylenol, or other fever reducing medicine, wait at least [MASKED] hours after taking it before you check your temperature in order to get an accurate reading.) FOR SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or incision) •If you have sudden, severe bleeding or swelling at either of the groin puncture sites: -Lie down, keep leg straight and apply (or have someone apply) firm pressure to area for [MASKED] minutes with a gauze pad or clean cloth. -Once bleeding has stopped, call your surgeon to report what happened. -If bleeding does not stop, call [MASKED] for transfer to closest Emergency Room. •You may shower 48 hours after surgery. Let the soapy water run over the puncture sites, then rinse and pat dry. Do not rub these sites and do not apply cream, lotion, ointment or powder. •Wear loose-fitting pants and clothing as this will be less irritating to the groin puncture sites. MEDICATIONS •Take aspirin daily. Aspirin helps prevent blood clots that could form in your repaired artery. •It is very important that you never stop taking aspirin or other blood thinning medicines-even for a short while- unless the surgeon who repaired your aneurysm tells you it is okay to stop. Do not stop taking them, even if another doctor or nurse tells you to, without getting an okay from the surgeon who first prescribed them. •You will be given prescriptions for any new medication started during your hospital stay. •Before you go home, your nurse [MASKED] give you information about new medication and will review all the medications you should take at home. Be sure to ask any questions you may have. If something you normally take or may take is not on the list you receive from the nurse, please ask if it is okay to take it. PAIN MANAGEMENT •Most patients do not have much pain following placement of the stent alone. You had an abdominal incision in addition to this, so recovery may take longer. Your puncture sites may be a little sore. This will improve daily. If it is getting worse, please let us know. •You will be given instructions about taking pain medicine if you need it. ACTIVITY •You must limit activity to protect the puncture sites in your groin. For ONE WEEK: -Do not drive -Do not swim, take a tub bath or go in a Jacuzzi or hot tub -Do not lift, push, pull or carry anything heavier than five pounds -Do not do any exercise or activity that causes you to hold your breath or bear down with your abdominal muscles. -Do not resume sexual activity •Discuss with your surgeon when you may return to other regular activities, including work. If needed, we will give you a letter for your workplace. •It is normal to feel weak and tired. This can last six-eight weeks, but should get better day by day. You may want to have help around the house during this time. [MASKED] push yourself too hard during your recovery. Rest when you feel tired. Gradually return to normal activities over the next month. •We encourage you to walk regularly. Walking, especially outdoors in good weather is the best exercise for circulation. Walk short distances at first, even in the house, then do a little more each day. •It is okay to climb stairs. You may need to climb them slowly and pause after every few steps. BOWEL AND BLADDER FUNCTION •You should be able to pass urine without difficulty. Call you doctor if you have any problems urinating, such as burning, pain, bleeding, going too often, or having trouble urinating or starting the flow of urine. Call if you have a decrease in the amount of urine. •You may experience some constipation after surgery because of pain medicine and changes in activity. Increasing fluids and fiber in your diet and staying active can help. To relief constipation, you may talk a mild laxative. Please take to your pharmacist for advice about what to take. SMOKING •If you smoke, it is very important that you STOP. Research shows smoking makes vascular disease worse. This could increase the chance of a blockage in your new graft. Talk to your primary care physician about ways to quit smoking. Followup Instructions: [MASKED]
[]
[ "J9601", "D62", "N179", "I10", "Z8673", "Z87891", "I4891", "Y929", "Y92230" ]
[ "T82898A: Other specified complication of vascular prosthetic devices, implants and grafts, initial encounter", "I713: Abdominal aortic aneurysm, ruptured", "T80211A: Bloodstream infection due to central venous catheter, initial encounter", "J9601: Acute respiratory failure with hypoxia", "R578: Other shock", "D62: Acute posthemorrhagic anemia", "J90: Pleural effusion, not elsewhere classified", "Q211: Atrial septal defect", "F05: Delirium due to known physiological condition", "J811: Chronic pulmonary edema", "T17890A: Other foreign object in other parts of respiratory tract causing asphyxiation, initial encounter", "J9811: Atelectasis", "D6861: Antiphospholipid syndrome", "J95851: Ventilator associated pneumonia", "N179: Acute kidney failure, unspecified", "E873: Alkalosis", "E870: Hyperosmolality and hypernatremia", "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", "I724: Aneurysm of artery of lower extremity", "I10: Essential (primary) hypertension", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "Z87891: Personal history of nicotine dependence", "I739: Peripheral vascular disease, unspecified", "I4891: Unspecified atrial fibrillation", "R680: Hypothermia, not associated with low environmental temperature", "Z89511: Acquired absence of right leg below knee", "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "X58XXXA: Exposure to other specified factors, initial encounter", "Y929: Unspecified place or not applicable", "K660: Peritoneal adhesions (postprocedural) (postinfection)", "B9689: Other specified bacterial agents as the cause of 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", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "R34: Anuria and oliguria", "E806: Other disorders of bilirubin metabolism", "T82868A: Thrombosis due to vascular prosthetic devices, implants and grafts, initial encounter" ]
19,995,832
23,014,132
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Allergies/ADRs on File Attending: ___ Chief Complaint: sustained VT Major Surgical or Invasive Procedure: cardiac cath: ___ - No angiographically apparent coronary artery disease History of Present Illness: ___ y/o M with history of bladder cancer, lymphoma, BPH who presented initially to ___ for palpitations, found to have sustained VT, transferred for further care. He endorses 1 week of palpitations for which he was advised by his PCP to stop drinking EtOH and caffeine and was planned for an outpatient TTE. Palpitations last usually about a couple of seconds. On the night of admission, he was at home watching TV when he started having palpitations again. This episode was longer lasting, caused some lightheadedness and shortness of breath, and lead to them calling the ED. While at ___, his lab work was unremarkable, including negative troponin. While there, he had multiple episodes of ventricular tachycardia for which he was given amiodarone bolus and started on gtt and intubated for mental status. In total, he received heparin bolus, 150 IV amiodarone x 3 and started on gtt, 2 gm Mg, 3 mg lorazepam, 10 mg metoprolol. He was then transferred to the ___. En route to ___, he had 10 episodes of sustained ventricular tachycardia requiring cardioversion and 2 episodes of ventricular fibrillation requiring defibrillation. These were mostly Monomorphic VT per report. In review there is one strip available which shows possible polymorphic VT as well. On arrival to the ED, he was intubated and sedated with fentanyl and propofol, which was transitioned to midazolam. He was continued on amiodarone gtt, lidocaine 100 mg x 1, 1 L NS at 200 ml/hr. In the ED, initial vials with HR 51, BP 91/65, O2 99% intubated. WBC 5.8, Hgb 10.1, Hct 30.6, Plt 128, pro BNP 229. Trop negative x 1. When examined off sedation, he was able to follow commands, pupils equal and reactive with non-purposeful movements. Bedside TTE without pericardial effusion. On arrival to the CCU, the patient was intubated and sedated, though was responsive. Past Medical History: - "Blood cancer" s/p chemotherapy, none for past ___ years as was told counts looked better Cardiac History: - "bad valve" scheduled for TTE - Recent palpitations, started on Metoprolol succinate 25mg PO daily Social History: ___ Family History: - Father died of old age (no cardiac history) - Mother died from lung cancer (smoker) - No sudden cardiac death in family, no unexplained deaths (MVCs, drownings) Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS: HR 74, O2 99, 140/85 GENERAL: Intubated, sedated. Comfortable and responding to questions this morning. Following commands. HEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI. NECK: Supple. JVP at 8-9 cm CARDIAC: Normal rate, regular rhythm. ___ holosystolic murmur heard best at the apex. LUNGS: No chest wall deformities or tenderness. No adventitious breath sounds. ABDOMEN: Soft, non-tender, non-distended. No palpable hepatomegaly or splenomegaly. EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. SKIN: No significant lesions or rashes. PULSES: Distal pulses palpable and symmetric. DISCHARGE PHYSICAL EXAMINATION: VS: tmax 98.9, BP ___, HR 90's Tele: SR 90, had some ST overnight for 5 minutes, no VT Weight: 206.5 lbs (214.9 lbs on admit) Gen: Pleasant, calm HEENT: NC/AT. NECK: Supple. No JVD CV: RRR. normal S1,S2. No murmurs heard. LUNGS: CTAB. No wheezes, rales, or rhonchi. ABD: Soft, NT, ND. +BS Lower EXT: No edema, no erythema. Pertinent Results: ADMISSION LABS ___ 10:07PM BLOOD WBC-5.8 RBC-3.38* Hgb-10.1* Hct-30.6* MCV-91 MCH-29.9 MCHC-33.0 RDW-14.2 RDWSD-46.8* Plt ___ ___ 10:07PM BLOOD Neuts-60.3 ___ Monos-3.9* Eos-0.0* Baso-0.2 Im ___ AbsNeut-3.52 AbsLymp-2.05 AbsMono-0.23 AbsEos-0.00* AbsBaso-0.01 ___ 10:07PM BLOOD ___ PTT-45.9* ___ ___ 10:07PM BLOOD Glucose-183* UreaN-21* Creat-1.1 Na-138 K-4.2 Cl-109* HCO3-23 AnGap-6* ___ 10:07PM BLOOD Calcium-8.1* Phos-3.5 Mg-2.4 ___ 10:07PM BLOOD proBNP-229* ___ 10:07PM BLOOD cTropnT-<0.01 ___ 05:17AM BLOOD Triglyc-65 HDL-26* CHOL/HD-3.8 LDLcalc-59 ___ 05:17AM BLOOD %HbA1c-5.4 eAG-108 INTERVAL LABS: ___ 06:00AM BLOOD WBC-4.9 RBC-3.59* Hgb-10.7* Hct-32.2* MCV-90 MCH-29.8 MCHC-33.2 RDW-14.1 RDWSD-45.7 Plt ___ ___ 05:53AM BLOOD WBC-4.9 RBC-3.68* Hgb-11.0* Hct-33.2* MCV-90 MCH-29.9 MCHC-33.1 RDW-13.8 RDWSD-45.7 Plt ___ ___ 05:32AM BLOOD WBC-4.5 RBC-3.57* Hgb-10.7* Hct-33.0* MCV-92 MCH-30.0 MCHC-32.4 RDW-14.2 RDWSD-48.0* Plt ___ ___ 05:17AM BLOOD WBC-5.2 RBC-3.21* Hgb-9.6* Hct-29.0* MCV-90 MCH-29.9 MCHC-33.1 RDW-14.3 RDWSD-47.1* Plt ___ ___ 05:17AM BLOOD Neuts-59.3 ___ Monos-3.9* Eos-0.0* Baso-0.2 Im ___ AbsNeut-3.06 AbsLymp-1.88 AbsMono-0.20 AbsEos-0.00* AbsBaso-0.01 ___ 06:00AM BLOOD ___ PTT-27.6 ___ ___ 05:53AM BLOOD ___ PTT-27.9 ___ ___ 05:32AM BLOOD ___ PTT-27.0 ___ ___ 05:17AM BLOOD ___ PTT-27.6 ___ ___ 06:48AM BLOOD Glucose-133* UreaN-17 Creat-1.1 Na-138 K-4.1 Cl-102 HCO3-24 AnGap-12 ___ 06:00AM BLOOD Glucose-118* UreaN-18 Creat-1.0 Na-137 K-4.0 Cl-104 HCO3-25 AnGap-8* ___ 05:53AM BLOOD Glucose-116* UreaN-12 Creat-0.9 Na-136 K-4.1 Cl-104 HCO3-23 AnGap-9* ___ 11:00PM BLOOD Glucose-230* UreaN-13 Creat-1.0 Na-135 K-3.6 Cl-100 HCO3-26 AnGap-9* ___ 05:32AM BLOOD Glucose-110* UreaN-13 Creat-1.0 Na-138 K-4.2 Cl-105 HCO3-24 AnGap-9* ___ 05:17AM BLOOD Glucose-131* UreaN-20 Creat-0.9 Na-140 K-4.0 Cl-108 HCO3-24 AnGap-8* ___ 06:48AM BLOOD Mg-1.8 ___ 06:00AM BLOOD Calcium-8.5 Phos-4.0 Mg-2.0 ___ 05:53AM BLOOD Calcium-8.0* Phos-3.5 Mg-2.3 ___ 11:00PM BLOOD Mg-1.6 ___ 05:32AM BLOOD Calcium-8.3* Phos-3.2 Mg-1.8 ___ 05:17AM BLOOD Calcium-8.2* Phos-3.7 Mg-2.2 Cholest-98 ___ 05:17AM BLOOD %HbA1c-5.4 eAG-108 ___ 05:17AM BLOOD Triglyc-65 HDL-26* CHOL/HD-3.8 LDLcalc-59 DISCHARGE LABS: ___ 06:48AM BLOOD Hct-33.0* Plt ___ ___ 06:18AM BLOOD Na-137 K-4.2 ___ 06:18AM BLOOD Mg-1.9 MICRODATA: none ============== REPORTS ============== ___ CARDIAC CATH: Right dominant system; The left main, left anterior descending, circumflex and right coronary artery have no angiographically significant coronary abnormalities. ___ Cardiac MR FINDINGS Left Atrium (LA)/Pumonary Veins (PV): Normal LA volume index. Right Atrium (RA)/Coronary Sinus: Normal RA length. Normal coronary sinus diameter. Left Ventricle (LV): Normal wall thickness. Mildly increased mass index. Normal ___. Mod increased EDV. Mildly increased EDVI. Normal regional/global systolic function. Normal EF. Midwall LGE. Right Ventricle (RV): No free wall fat. Normal cavity size. Mild increase end-diastolic volume (EDV) index. Normal regional/global free wall motion Low normal ejection fraction (EF). Aorta: Normal origin of the L main; RCA origin not seen. Normal sinus diameter. Normal ascending aorta diameter. Mildly dilated aortic arch. Normal BSA indexed aortic arch. Mild dilation descending aorta. Normal descending aorta indexed diameter. MIld dilation abdominal aorta. Normal BSA indexed abdominal aorta. No coactation. Pulmonary Artery: Normal diameter. Aortic Valve (AV): 3 leaflets. Mildly thickened leaflets. No stenosis. Trace regurgitation. Mitral Valve (MV): Bileaflet prolapse. MIld-moderate regurgitation. Pulmonic Valve (PV)/Tricuspid Valve (TV): Trivial pulmonic regurgitation. Mild tricuspid regurgitation. Pericardium/Pleura: Small effusion. Normal thickness. No pleural effusions. Non-cardiac Findings There is a 2.2 cm nodule at the right lung base, which appears hypointense on fat suppressed sequences suggesting a possible pulmonary hamartoma (___). Multiple smaller areas of subpleural nodularity are seen in the region of the right middle and upper lobe (___). These findings should be further assessed with a dedicated chest CT. Spleen is mildly enlarged, measuring up to 16.9 cm. There is a 2.4 cm T2 hyperintense lesion in the interpolar region of the right kidney, which may represent a cyst (___). CONCLUSION/IMPRESSION: Normal left atrial volume index. Right atrial size is normal. There is normal left ventricular wall thickness with mildly increased mass index. The left ventricular end-diastolic dimension was normal with moderately increased left ventricular end-diastolic volume and mildly increased end-diastolic volume index. There is normal regional and global left ventricular systolic function with normal ejection fraction. There is left ventricular mid-wall late gadolinium enhancement in the basal lateral wall (see schematic) consistent with non-ischemic cardiomyopathy. There is no fatty infiltration of the right ventricular free wall. Mildly dilated right ventricle with low normal ejection fraction. Normal origin of the left main coronary artery; right coronary IMPRESSION: 1. Mildly dilated left ventricle with normal global and regional LV systolic function. 2. Small amount of mid-myocardial fibrosis in the basal lateral LV wall. 3. Mildly dilated right ventricle with low-normal RV systolic function. 4. Bileaflet mitral valve prolapse with mild to moderate mitral regurgitation. 5. Mild tricuspid regurgitation. 6. Small pericardial effusion. 7. Multiple non-cardiac findings, as described above, which should be further assessed with a dedicated chest CT scan. ___ EP report Findings Spontaneous PVCs at baseline. Trabeculated RV. Earlierst septum/apical RV in trabeculations. 30 ms pre QRS with QS unipolar. Ablation caused VT and supressed. Multiple lesions in the area. After ablation no more spontaneous/catheter stimulated clinical VT, but other likely catheter related VTs with manipulation of trabeculations. Run of VT induced Vflutter - DCCV. Very irritable with cathter manipulation. Plan for ICD ___ Stress Test INTERPRETATION: This ___ year old man was referred to the lab from the EP service for evaluation of VT, s/p recent ablation and ICD placement now on flecainide therapy for the past 24 hours. The patient exercised for 6.0 minutes of a Gervino protocol and was stopped for achieving the target sub-max HR. The patient perceived the work as hard to very hard. No arm, neck, back or chest discomfort was reported by the patient throughout the study. The baseline EKG showed RBBB with secondary inverted T waves. There were no significant ST segment changes throughout. The rhythm was sinus with rare isolated vpbs vs abps with aberrant conduction. The QRS duration at rest, peak exercise and 10 minutes of recovery was 160, 156 and 154 msec, respectively. Appropriate heart rate and blood pressure response to exercise and recovery. IMPRESSION: No significant ectopy, ST segment changes or symptoms to achieved workload. Normal hemodynamnic response to exercise. Brief Hospital Course: ___ y/o M with history of bladder cancer, lymphoma, BPH who presented initially to ___ for palpitations x1 week, found to have sustained VT, and subsequently transferred to ___ for further management of VT. ACUTE ISSUES: ============= #Monomorphic wide complex ventricular tachycardia Reported a history of 1 week of palpitations prior to presentation. On the day of presentation to ___, reported persistent palpitations, dyspnea, and lightheadedness. At ___, patient had multiple episodes of Vtach for which he was given amiodarone 150mg boluses x3 + gtt, 2gm Mg, 3mg Ativan, 10mg metoprolol and intubated for altered mental status. On his way to ___, patient had ~10 episodes of sustained monomorphic and polymorphic VT requiring cardioversion, along with 2 episodes of ventricular fibrillation requiring defibrillation. He received lidocaine 100 mg x 1 upon arrival to ___ ED, another dose of 100 mg IV lidocaine in the CCU followed by drip at 1 mg/hr. Amiodarone gtt was discontinued on ___ in favor of lidocaine. ___ TTE showed LVEF >/=55%, biatrial enlargement, mild symmetric LVH with normal systolic function; no valvular pathology identified. Per EP, he underwent cardiac MRI on ___ which showed CMR mildly dilated left ventricle with normal global and regional LV systolic function, small amount of mid-myocardial fibrosis in the basal lateral LV wall, mildly dilated right ventricle with low-normal RV systolic function, bileaflet mitral valve prolapse with mild to moderate mitral regurgitation, mild tricuspid regurgitation, small pericardial effusion and multiple non-cardiac findings, as described above, which should be further assessed with a dedicated chest CT scan. He underwent cardiac catheterization on ___ which showed no angiographically apparent coronary artery disease. He underwent EP study on ___ with ablation (inducible VT); found to have flutter circuit and irritable myocardium. After the study, he continued to have multiple runs of monomorphic VT lasting ___ sec for which he was started on lidocaine gtt. Started verapamil 120mg on ___, increased to 120mg bid on ___. Dual chamber ___ ICD was implanted on ___ and the site and interrogation are all within normal limits. Verapamil was stopped on ___ and flecinaine 100mg BID started. No VT noted since initially of flecainide, had brief episode of NSVT 6 beats between ___. He underwent a stress test (no imaging) and QRS complex remained stable as well his vital signs. He will be discharged on flecainide 100mg and will follow up on ___ in the device clinic and Dr. ___ will see him during that appointment. He will decide at that time whether another stress test is needed. #Encephalopathy - resolved #Mechanical ventilation He was intubated at ___ for altered mental status i/s/o V-tach. Encephalopathy resolved and he was subsequently extubated on ___ in the CCU. #Anemia #Thrombocytopenia: Unknown baseline, though wife reports a history of a "blood cancer." Outpatient oncologist is at ___. Discharge hemocrit 33.0, Discharge plt: 150 - ___ with PCP #BPH: - Continued home Doxazosin #HTN: - continue Metoprolol and lisinopril TRANSITIONAL ISSUES =================== [ ] MR ___ showed findings c/f pulmonary nodules that may be c/w hamartoma. Needs chest CT. - discharge summary to be sent to PCP, cardiologist and oncologist Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 25 mg PO QAM 2. Lisinopril 30 mg PO QPM 3. Doxazosin 6 mg PO HS 4. Viagra (sildenafil) 50 mg oral DAILY:PRN Discharge Medications: 1. Flecainide Acetate 100 mg PO Q12H 2. Doxazosin 6 mg PO HS 3. Lisinopril 30 mg PO QPM 4. Metoprolol Succinate XL 25 mg PO QAM 5. HELD- Viagra (sildenafil) 50 mg oral DAILY:PRN This medication was held. Do not restart Viagra until you talk to Dr. ___ ___ Disposition: Home Discharge Diagnosis: ventricular tachycardia 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 transferred from ___ to ___ ___ for "ventricular tachycardia." This is an abnormal fast heart rate. WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL? - We started you on IV medications to help control your heart rate. - The doctors at ___ placed a breathing to in your lungs to help you breathe, because you were confused due to this rapid heart rate. - Our electrophysiology doctors saw ___ and several different medications were trailed and decision was to keep you on flecainide 100mg twice a day since it was most effective in keeping you out of the arrhythmia. You had a stress test to further assess this new medication. You tolerated the procedure well and we feel comfortable sending you on this new medication. Written drug information has been provided to you. WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? - Resume your lisinopril tomorrow night - take a one time dose of short acting Metoprolol (which we gave you) and take that tonight around 8pm. Resume your long acting Metoprolol tomorrow morning - Do not drive until you see and speak with Dr. ___ week and from that appointment Dr. ___ will decide when you can resume. - Follow up with your primary care doctor about the need for chest CT to further assess the pulmonary nodules found on the Cardiac MR that was done while you were here. - Take all of your medications as prescribed (listed below) - Follow up with your doctors as listed below . - 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: ___
[ "I472", "G9340", "I081", "R0689", "D696", "I10", "D649", "N400", "R918", "Z8579", "Z8551", "Z4502" ]
Allergies: No Allergies/ADRs on File Chief Complaint: sustained VT Major Surgical or Invasive Procedure: cardiac cath: [MASKED] - No angiographically apparent coronary artery disease History of Present Illness: [MASKED] y/o M with history of bladder cancer, lymphoma, BPH who presented initially to [MASKED] for palpitations, found to have sustained VT, transferred for further care. He endorses 1 week of palpitations for which he was advised by his PCP to stop drinking EtOH and caffeine and was planned for an outpatient TTE. Palpitations last usually about a couple of seconds. On the night of admission, he was at home watching TV when he started having palpitations again. This episode was longer lasting, caused some lightheadedness and shortness of breath, and lead to them calling the ED. While at [MASKED], his lab work was unremarkable, including negative troponin. While there, he had multiple episodes of ventricular tachycardia for which he was given amiodarone bolus and started on gtt and intubated for mental status. In total, he received heparin bolus, 150 IV amiodarone x 3 and started on gtt, 2 gm Mg, 3 mg lorazepam, 10 mg metoprolol. He was then transferred to the [MASKED]. En route to [MASKED], he had 10 episodes of sustained ventricular tachycardia requiring cardioversion and 2 episodes of ventricular fibrillation requiring defibrillation. These were mostly Monomorphic VT per report. In review there is one strip available which shows possible polymorphic VT as well. On arrival to the ED, he was intubated and sedated with fentanyl and propofol, which was transitioned to midazolam. He was continued on amiodarone gtt, lidocaine 100 mg x 1, 1 L NS at 200 ml/hr. In the ED, initial vials with HR 51, BP 91/65, O2 99% intubated. WBC 5.8, Hgb 10.1, Hct 30.6, Plt 128, pro BNP 229. Trop negative x 1. When examined off sedation, he was able to follow commands, pupils equal and reactive with non-purposeful movements. Bedside TTE without pericardial effusion. On arrival to the CCU, the patient was intubated and sedated, though was responsive. Past Medical History: - "Blood cancer" s/p chemotherapy, none for past [MASKED] years as was told counts looked better Cardiac History: - "bad valve" scheduled for TTE - Recent palpitations, started on Metoprolol succinate 25mg PO daily Social History: [MASKED] Family History: - Father died of old age (no cardiac history) - Mother died from lung cancer (smoker) - No sudden cardiac death in family, no unexplained deaths (MVCs, drownings) Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS: HR 74, O2 99, 140/85 GENERAL: Intubated, sedated. Comfortable and responding to questions this morning. Following commands. HEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI. NECK: Supple. JVP at 8-9 cm CARDIAC: Normal rate, regular rhythm. [MASKED] holosystolic murmur heard best at the apex. LUNGS: No chest wall deformities or tenderness. No adventitious breath sounds. ABDOMEN: Soft, non-tender, non-distended. No palpable hepatomegaly or splenomegaly. EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. SKIN: No significant lesions or rashes. PULSES: Distal pulses palpable and symmetric. DISCHARGE PHYSICAL EXAMINATION: VS: tmax 98.9, BP [MASKED], HR 90's Tele: SR 90, had some ST overnight for 5 minutes, no VT Weight: 206.5 lbs (214.9 lbs on admit) Gen: Pleasant, calm HEENT: NC/AT. NECK: Supple. No JVD CV: RRR. normal S1,S2. No murmurs heard. LUNGS: CTAB. No wheezes, rales, or rhonchi. ABD: Soft, NT, ND. +BS Lower EXT: No edema, no erythema. Pertinent Results: ADMISSION LABS [MASKED] 10:07PM BLOOD WBC-5.8 RBC-3.38* Hgb-10.1* Hct-30.6* MCV-91 MCH-29.9 MCHC-33.0 RDW-14.2 RDWSD-46.8* Plt [MASKED] [MASKED] 10:07PM BLOOD Neuts-60.3 [MASKED] Monos-3.9* Eos-0.0* Baso-0.2 Im [MASKED] AbsNeut-3.52 AbsLymp-2.05 AbsMono-0.23 AbsEos-0.00* AbsBaso-0.01 [MASKED] 10:07PM BLOOD [MASKED] PTT-45.9* [MASKED] [MASKED] 10:07PM BLOOD Glucose-183* UreaN-21* Creat-1.1 Na-138 K-4.2 Cl-109* HCO3-23 AnGap-6* [MASKED] 10:07PM BLOOD Calcium-8.1* Phos-3.5 Mg-2.4 [MASKED] 10:07PM BLOOD proBNP-229* [MASKED] 10:07PM BLOOD cTropnT-<0.01 [MASKED] 05:17AM BLOOD Triglyc-65 HDL-26* CHOL/HD-3.8 LDLcalc-59 [MASKED] 05:17AM BLOOD %HbA1c-5.4 eAG-108 INTERVAL LABS: [MASKED] 06:00AM BLOOD WBC-4.9 RBC-3.59* Hgb-10.7* Hct-32.2* MCV-90 MCH-29.8 MCHC-33.2 RDW-14.1 RDWSD-45.7 Plt [MASKED] [MASKED] 05:53AM BLOOD WBC-4.9 RBC-3.68* Hgb-11.0* Hct-33.2* MCV-90 MCH-29.9 MCHC-33.1 RDW-13.8 RDWSD-45.7 Plt [MASKED] [MASKED] 05:32AM BLOOD WBC-4.5 RBC-3.57* Hgb-10.7* Hct-33.0* MCV-92 MCH-30.0 MCHC-32.4 RDW-14.2 RDWSD-48.0* Plt [MASKED] [MASKED] 05:17AM BLOOD WBC-5.2 RBC-3.21* Hgb-9.6* Hct-29.0* MCV-90 MCH-29.9 MCHC-33.1 RDW-14.3 RDWSD-47.1* Plt [MASKED] [MASKED] 05:17AM BLOOD Neuts-59.3 [MASKED] Monos-3.9* Eos-0.0* Baso-0.2 Im [MASKED] AbsNeut-3.06 AbsLymp-1.88 AbsMono-0.20 AbsEos-0.00* AbsBaso-0.01 [MASKED] 06:00AM BLOOD [MASKED] PTT-27.6 [MASKED] [MASKED] 05:53AM BLOOD [MASKED] PTT-27.9 [MASKED] [MASKED] 05:32AM BLOOD [MASKED] PTT-27.0 [MASKED] [MASKED] 05:17AM BLOOD [MASKED] PTT-27.6 [MASKED] [MASKED] 06:48AM BLOOD Glucose-133* UreaN-17 Creat-1.1 Na-138 K-4.1 Cl-102 HCO3-24 AnGap-12 [MASKED] 06:00AM BLOOD Glucose-118* UreaN-18 Creat-1.0 Na-137 K-4.0 Cl-104 HCO3-25 AnGap-8* [MASKED] 05:53AM BLOOD Glucose-116* UreaN-12 Creat-0.9 Na-136 K-4.1 Cl-104 HCO3-23 AnGap-9* [MASKED] 11:00PM BLOOD Glucose-230* UreaN-13 Creat-1.0 Na-135 K-3.6 Cl-100 HCO3-26 AnGap-9* [MASKED] 05:32AM BLOOD Glucose-110* UreaN-13 Creat-1.0 Na-138 K-4.2 Cl-105 HCO3-24 AnGap-9* [MASKED] 05:17AM BLOOD Glucose-131* UreaN-20 Creat-0.9 Na-140 K-4.0 Cl-108 HCO3-24 AnGap-8* [MASKED] 06:48AM BLOOD Mg-1.8 [MASKED] 06:00AM BLOOD Calcium-8.5 Phos-4.0 Mg-2.0 [MASKED] 05:53AM BLOOD Calcium-8.0* Phos-3.5 Mg-2.3 [MASKED] 11:00PM BLOOD Mg-1.6 [MASKED] 05:32AM BLOOD Calcium-8.3* Phos-3.2 Mg-1.8 [MASKED] 05:17AM BLOOD Calcium-8.2* Phos-3.7 Mg-2.2 Cholest-98 [MASKED] 05:17AM BLOOD %HbA1c-5.4 eAG-108 [MASKED] 05:17AM BLOOD Triglyc-65 HDL-26* CHOL/HD-3.8 LDLcalc-59 DISCHARGE LABS: [MASKED] 06:48AM BLOOD Hct-33.0* Plt [MASKED] [MASKED] 06:18AM BLOOD Na-137 K-4.2 [MASKED] 06:18AM BLOOD Mg-1.9 MICRODATA: none ============== REPORTS ============== [MASKED] CARDIAC CATH: Right dominant system; The left main, left anterior descending, circumflex and right coronary artery have no angiographically significant coronary abnormalities. [MASKED] Cardiac MR FINDINGS Left Atrium (LA)/Pumonary Veins (PV): Normal LA volume index. Right Atrium (RA)/Coronary Sinus: Normal RA length. Normal coronary sinus diameter. Left Ventricle (LV): Normal wall thickness. Mildly increased mass index. Normal [MASKED]. Mod increased EDV. Mildly increased EDVI. Normal regional/global systolic function. Normal EF. Midwall LGE. Right Ventricle (RV): No free wall fat. Normal cavity size. Mild increase end-diastolic volume (EDV) index. Normal regional/global free wall motion Low normal ejection fraction (EF). Aorta: Normal origin of the L main; RCA origin not seen. Normal sinus diameter. Normal ascending aorta diameter. Mildly dilated aortic arch. Normal BSA indexed aortic arch. Mild dilation descending aorta. Normal descending aorta indexed diameter. MIld dilation abdominal aorta. Normal BSA indexed abdominal aorta. No coactation. Pulmonary Artery: Normal diameter. Aortic Valve (AV): 3 leaflets. Mildly thickened leaflets. No stenosis. Trace regurgitation. Mitral Valve (MV): Bileaflet prolapse. MIld-moderate regurgitation. Pulmonic Valve (PV)/Tricuspid Valve (TV): Trivial pulmonic regurgitation. Mild tricuspid regurgitation. Pericardium/Pleura: Small effusion. Normal thickness. No pleural effusions. Non-cardiac Findings There is a 2.2 cm nodule at the right lung base, which appears hypointense on fat suppressed sequences suggesting a possible pulmonary hamartoma ([MASKED]). Multiple smaller areas of subpleural nodularity are seen in the region of the right middle and upper lobe ([MASKED]). These findings should be further assessed with a dedicated chest CT. Spleen is mildly enlarged, measuring up to 16.9 cm. There is a 2.4 cm T2 hyperintense lesion in the interpolar region of the right kidney, which may represent a cyst ([MASKED]). CONCLUSION/IMPRESSION: Normal left atrial volume index. Right atrial size is normal. There is normal left ventricular wall thickness with mildly increased mass index. The left ventricular end-diastolic dimension was normal with moderately increased left ventricular end-diastolic volume and mildly increased end-diastolic volume index. There is normal regional and global left ventricular systolic function with normal ejection fraction. There is left ventricular mid-wall late gadolinium enhancement in the basal lateral wall (see schematic) consistent with non-ischemic cardiomyopathy. There is no fatty infiltration of the right ventricular free wall. Mildly dilated right ventricle with low normal ejection fraction. Normal origin of the left main coronary artery; right coronary IMPRESSION: 1. Mildly dilated left ventricle with normal global and regional LV systolic function. 2. Small amount of mid-myocardial fibrosis in the basal lateral LV wall. 3. Mildly dilated right ventricle with low-normal RV systolic function. 4. Bileaflet mitral valve prolapse with mild to moderate mitral regurgitation. 5. Mild tricuspid regurgitation. 6. Small pericardial effusion. 7. Multiple non-cardiac findings, as described above, which should be further assessed with a dedicated chest CT scan. [MASKED] EP report Findings Spontaneous PVCs at baseline. Trabeculated RV. Earlierst septum/apical RV in trabeculations. 30 ms pre QRS with QS unipolar. Ablation caused VT and supressed. Multiple lesions in the area. After ablation no more spontaneous/catheter stimulated clinical VT, but other likely catheter related VTs with manipulation of trabeculations. Run of VT induced Vflutter - DCCV. Very irritable with cathter manipulation. Plan for ICD [MASKED] Stress Test INTERPRETATION: This [MASKED] year old man was referred to the lab from the EP service for evaluation of VT, s/p recent ablation and ICD placement now on flecainide therapy for the past 24 hours. The patient exercised for 6.0 minutes of a Gervino protocol and was stopped for achieving the target sub-max HR. The patient perceived the work as hard to very hard. No arm, neck, back or chest discomfort was reported by the patient throughout the study. The baseline EKG showed RBBB with secondary inverted T waves. There were no significant ST segment changes throughout. The rhythm was sinus with rare isolated vpbs vs abps with aberrant conduction. The QRS duration at rest, peak exercise and 10 minutes of recovery was 160, 156 and 154 msec, respectively. Appropriate heart rate and blood pressure response to exercise and recovery. IMPRESSION: No significant ectopy, ST segment changes or symptoms to achieved workload. Normal hemodynamnic response to exercise. Brief Hospital Course: [MASKED] y/o M with history of bladder cancer, lymphoma, BPH who presented initially to [MASKED] for palpitations x1 week, found to have sustained VT, and subsequently transferred to [MASKED] for further management of VT. ACUTE ISSUES: ============= #Monomorphic wide complex ventricular tachycardia Reported a history of 1 week of palpitations prior to presentation. On the day of presentation to [MASKED], reported persistent palpitations, dyspnea, and lightheadedness. At [MASKED], patient had multiple episodes of Vtach for which he was given amiodarone 150mg boluses x3 + gtt, 2gm Mg, 3mg Ativan, 10mg metoprolol and intubated for altered mental status. On his way to [MASKED], patient had ~10 episodes of sustained monomorphic and polymorphic VT requiring cardioversion, along with 2 episodes of ventricular fibrillation requiring defibrillation. He received lidocaine 100 mg x 1 upon arrival to [MASKED] ED, another dose of 100 mg IV lidocaine in the CCU followed by drip at 1 mg/hr. Amiodarone gtt was discontinued on [MASKED] in favor of lidocaine. [MASKED] TTE showed LVEF >/=55%, biatrial enlargement, mild symmetric LVH with normal systolic function; no valvular pathology identified. Per EP, he underwent cardiac MRI on [MASKED] which showed CMR mildly dilated left ventricle with normal global and regional LV systolic function, small amount of mid-myocardial fibrosis in the basal lateral LV wall, mildly dilated right ventricle with low-normal RV systolic function, bileaflet mitral valve prolapse with mild to moderate mitral regurgitation, mild tricuspid regurgitation, small pericardial effusion and multiple non-cardiac findings, as described above, which should be further assessed with a dedicated chest CT scan. He underwent cardiac catheterization on [MASKED] which showed no angiographically apparent coronary artery disease. He underwent EP study on [MASKED] with ablation (inducible VT); found to have flutter circuit and irritable myocardium. After the study, he continued to have multiple runs of monomorphic VT lasting [MASKED] sec for which he was started on lidocaine gtt. Started verapamil 120mg on [MASKED], increased to 120mg bid on [MASKED]. Dual chamber [MASKED] ICD was implanted on [MASKED] and the site and interrogation are all within normal limits. Verapamil was stopped on [MASKED] and flecinaine 100mg BID started. No VT noted since initially of flecainide, had brief episode of NSVT 6 beats between [MASKED]. He underwent a stress test (no imaging) and QRS complex remained stable as well his vital signs. He will be discharged on flecainide 100mg and will follow up on [MASKED] in the device clinic and Dr. [MASKED] will see him during that appointment. He will decide at that time whether another stress test is needed. #Encephalopathy - resolved #Mechanical ventilation He was intubated at [MASKED] for altered mental status i/s/o V-tach. Encephalopathy resolved and he was subsequently extubated on [MASKED] in the CCU. #Anemia #Thrombocytopenia: Unknown baseline, though wife reports a history of a "blood cancer." Outpatient oncologist is at [MASKED]. Discharge hemocrit 33.0, Discharge plt: 150 - [MASKED] with PCP #BPH: - Continued home Doxazosin #HTN: - continue Metoprolol and lisinopril TRANSITIONAL ISSUES =================== [ ] MR [MASKED] showed findings c/f pulmonary nodules that may be c/w hamartoma. Needs chest CT. - discharge summary to be sent to PCP, cardiologist and oncologist Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 25 mg PO QAM 2. Lisinopril 30 mg PO QPM 3. Doxazosin 6 mg PO HS 4. Viagra (sildenafil) 50 mg oral DAILY:PRN Discharge Medications: 1. Flecainide Acetate 100 mg PO Q12H 2. Doxazosin 6 mg PO HS 3. Lisinopril 30 mg PO QPM 4. Metoprolol Succinate XL 25 mg PO QAM 5. HELD- Viagra (sildenafil) 50 mg oral DAILY:PRN This medication was held. Do not restart Viagra until you talk to Dr. [MASKED] [MASKED] Disposition: Home Discharge Diagnosis: ventricular tachycardia 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 transferred from [MASKED] to [MASKED] [MASKED] for "ventricular tachycardia." This is an abnormal fast heart rate. WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL? - We started you on IV medications to help control your heart rate. - The doctors at [MASKED] placed a breathing to in your lungs to help you breathe, because you were confused due to this rapid heart rate. - Our electrophysiology doctors saw [MASKED] and several different medications were trailed and decision was to keep you on flecainide 100mg twice a day since it was most effective in keeping you out of the arrhythmia. You had a stress test to further assess this new medication. You tolerated the procedure well and we feel comfortable sending you on this new medication. Written drug information has been provided to you. WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? - Resume your lisinopril tomorrow night - take a one time dose of short acting Metoprolol (which we gave you) and take that tonight around 8pm. Resume your long acting Metoprolol tomorrow morning - Do not drive until you see and speak with Dr. [MASKED] week and from that appointment Dr. [MASKED] will decide when you can resume. - Follow up with your primary care doctor about the need for chest CT to further assess the pulmonary nodules found on the Cardiac MR that was done while you were here. - Take all of your medications as prescribed (listed below) - Follow up with your doctors as listed below . - 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]
[]
[ "D696", "I10", "D649", "N400" ]
[ "I472: Ventricular tachycardia", "G9340: Encephalopathy, unspecified", "I081: Rheumatic disorders of both mitral and tricuspid valves", "R0689: Other abnormalities of breathing", "D696: Thrombocytopenia, unspecified", "I10: Essential (primary) hypertension", "D649: Anemia, unspecified", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "R918: Other nonspecific abnormal finding of lung field", "Z8579: Personal history of other malignant neoplasms of lymphoid, hematopoietic and related tissues", "Z8551: Personal history of malignant neoplasm of bladder", "Z4502: Encounter for adjustment and management of automatic implantable cardiac defibrillator" ]
19,996,406
29,048,379
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: Iodinated Contrast Media / methylprednisolone / Nubain / Biaxin / Caltrate / Avelox / shellfish derived Attending: ___. Chief Complaint: ACA aneurysm Major Surgical or Invasive Procedure: ___ Pipeline embolization of A2 aneurysm History of Present Illness: ___ is a ___ female with PMH of subclavian steal syndrome and COPD who was found to have a 6mm ACA aneurysm on workup of dizziness. Diagnostic angiogram ___ confirmed left A2 bifurcation aneurysm and left PCOM aneurysm. Plan was made for elective pipeline embolization of A2 aneurysm. Past Medical History: subclavian steal syndrome COPD Social History: ___ Family History: She had a mother who died of an abdominal aortic aneurysm, but no brain aneurysm history in the family. Physical Exam: ON DISCHARGE: Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious Orientation: [x]Person [x]Place [x]Time Follows commands: [ ]Simple [x]Complex [ ]None Pupils: PERRL EOM: [x]Full [ ]Restricted Face Symmetric: [x]Yes [ ]NoTongue Midline: [x]Yes [ ]No Pronator Drift [ ]Yes [x]No Speech Fluent: [x]Yes [ ]No Comprehension intact [x]Yes [ ]No Motor: TrapDeltoidBicepTricepGrip 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 Angio Groin Site: [x]Palpable pulses [x]soft, no hematoma, extensive ecchymosis over lower right abdomen and thigh with extension across midline Pertinent Results: Please refer to ___ for pertinent lab and imaging results. Brief Hospital Course: #pipeline embolization A2 aneurysm Patient presented to ___ on ___ for elective cerebral angiogram for pipeline embolization of A2 aneurysm. Please see dedicate report for further detail. Case was uncomplicated and the patient recovered from anesthesia in the PACU. Patient's groin site was noted to have small palpable hematoma at the access site therefore HOB was kept flat for a total of 3 hours postop and then activity was advanced to as tolerated. Patient was started on aspirin 325mg and Brillinta 90mg BID postoperatively. Patient's blood pressure goal was 120-190 postoperatively; she received IVF initially and then was requiring vasopressors in the PACU to maintain SBP goal. POD1 she was liberalized to SBP > 100.but still did not maintain goal and so midodrine was started at 5mg PO TID. She was liberalized to SBP > 90 but still did not maintain goal and so midodrine was uptitrated to 10mg TID. Hematocrit was stable. She transferred to the ___. Foley and Aline were removed. On POD 2, the patient was maintaining her SBP and remained neurologically intact. She was transferred home with the plan for Daily blood pressure monitoring while on midodrine. Prior to discharge her prescriptions were faxed to her pharmacy in ___ for her family to obtain prior to the pharmacy closing. She was sent with 3 tabs of Midodrine from ___ pharmacy because ___ would not have it in stock until tomorrow. At the time of discharge she was tolerating a regular diet, ambulating without difficulty, afebrile with stable vital signs. Medications on Admission: albuterol; HFA 90 mcg 2 puffs q 4, alendronate 70 mg qweek, Xanax 0.5 mg, atorvastatin 10 mg qday,azelastine ? dose, Prednisone 50 mg pre contrat, zanta 150 mg BID, Stiolto Respimat 2.5mcg-2.5mcg 2 ___ 81 qd, Brilinta 90 bId, Vit D3 2000u qd, Claritin 10 mg QD, Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN fever or pain 2. Aspirin 325 mg PO DAILY RX *aspirin 325 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*3 3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 4. Docusate Sodium 100 mg PO BID 5. Midodrine 10 mg PO TID RX *midodrine 10 mg 1 tablet(s) by mouth every eight (8) hours Disp #*90 Tablet Refills:*1 6. Senna 17.2 mg PO QHS 7. TiCAGRELOR 90 mg PO BID RX *ticagrelor [Brilinta] 90 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*3 8. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze 9. Atorvastatin 10 mg PO QPM 10. Loratadine 10 mg PO DAILY 11. Stiolto Respimat (tiotropium-olodaterol) 2.5-2.5 mcg/actuation inhalation DAILY 12. Vitamin D ___ UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: cerebral ACA aneurysm Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Discharge Instructions Dr. ___ & Dr. ___ Activity - You will need to check your Blood pressure every day while you are on Midodrine. If your systolic blood pressure is above ___ you should call the Neurosurgery Office at ___. •You may gradually return to your normal activities, but we recommend you take it easy for the next ___ hours to avoid bleeding from your groin. •Heavy lifting, running, climbing, or other strenuous exercise should be avoided for ten (10) days. This is to prevent bleeding from your groin. •You make take leisurely walks and slowly increase your activity at your own pace. ___ try to do too much all at once. •Do not go swimming or submerge yourself in water for five (5) days after your procedure. •You make take a shower. Medications •Resume your normal medications and begin new medications as directed. •You have been instructed by your doctor to take Aspirin 325mg daily and Brilinta 90mg twice daily. Do not take any other products that have aspirin in them. If you are unsure of what products contain Aspirin, as your pharmacist or call our office. •You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. •If you take Metformin (Glucophage) you may start it again three (3) days after your procedure. Care of the Puncture Site •You will have a small bandage over the site. •Remove the bandage in 24 hours by soaking it with water and gently peeling it off. •Keep the site clean with soap and water and dry it carefully. •You may use a band-aid if you wish. What You ___ Experience: •Mild tenderness and bruising at the puncture site (groin). •Soreness in your arms from the intravenous lines. •Mild to moderate headaches that last several days to a few weeks. •Fatigue is very normal •Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. If you are taking narcotics (prescription pain medications), try an over-the-counter stool softener. When to Call Your Doctor at ___ for: •Severe pain, swelling, redness or drainage from the puncture site. •Fever greater than 101.5 degrees Fahrenheit •Constipation •Blood in your stool or urine •Nausea and/or vomiting •Extreme sleepiness and not being able to stay awake •Severe headaches not relieved by pain relievers •Seizures •Any new problems with your vision or ability to speak •Weakness or changes in sensation in your face, arms, or leg Followup Instructions: ___
[ "I671", "J449", "Z87891", "E785", "F419" ]
Allergies: Iodinated Contrast Media / methylprednisolone / Nubain / Biaxin / Caltrate / Avelox / shellfish derived Chief Complaint: ACA aneurysm Major Surgical or Invasive Procedure: [MASKED] Pipeline embolization of A2 aneurysm History of Present Illness: [MASKED] is a [MASKED] female with PMH of subclavian steal syndrome and COPD who was found to have a 6mm ACA aneurysm on workup of dizziness. Diagnostic angiogram [MASKED] confirmed left A2 bifurcation aneurysm and left PCOM aneurysm. Plan was made for elective pipeline embolization of A2 aneurysm. Past Medical History: subclavian steal syndrome COPD Social History: [MASKED] Family History: She had a mother who died of an abdominal aortic aneurysm, but no brain aneurysm history in the family. Physical Exam: ON DISCHARGE: Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious Orientation: [x]Person [x]Place [x]Time Follows commands: [ ]Simple [x]Complex [ ]None Pupils: PERRL EOM: [x]Full [ ]Restricted Face Symmetric: [x]Yes [ ]NoTongue Midline: [x]Yes [ ]No Pronator Drift [ ]Yes [x]No Speech Fluent: [x]Yes [ ]No Comprehension intact [x]Yes [ ]No Motor: TrapDeltoidBicepTricepGrip 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 Angio Groin Site: [x]Palpable pulses [x]soft, no hematoma, extensive ecchymosis over lower right abdomen and thigh with extension across midline Pertinent Results: Please refer to [MASKED] for pertinent lab and imaging results. Brief Hospital Course: #pipeline embolization A2 aneurysm Patient presented to [MASKED] on [MASKED] for elective cerebral angiogram for pipeline embolization of A2 aneurysm. Please see dedicate report for further detail. Case was uncomplicated and the patient recovered from anesthesia in the PACU. Patient's groin site was noted to have small palpable hematoma at the access site therefore HOB was kept flat for a total of 3 hours postop and then activity was advanced to as tolerated. Patient was started on aspirin 325mg and Brillinta 90mg BID postoperatively. Patient's blood pressure goal was 120-190 postoperatively; she received IVF initially and then was requiring vasopressors in the PACU to maintain SBP goal. POD1 she was liberalized to SBP > 100.but still did not maintain goal and so midodrine was started at 5mg PO TID. She was liberalized to SBP > 90 but still did not maintain goal and so midodrine was uptitrated to 10mg TID. Hematocrit was stable. She transferred to the [MASKED]. Foley and Aline were removed. On POD 2, the patient was maintaining her SBP and remained neurologically intact. She was transferred home with the plan for Daily blood pressure monitoring while on midodrine. Prior to discharge her prescriptions were faxed to her pharmacy in [MASKED] for her family to obtain prior to the pharmacy closing. She was sent with 3 tabs of Midodrine from [MASKED] pharmacy because [MASKED] would not have it in stock until tomorrow. At the time of discharge she was tolerating a regular diet, ambulating without difficulty, afebrile with stable vital signs. Medications on Admission: albuterol; HFA 90 mcg 2 puffs q 4, alendronate 70 mg qweek, Xanax 0.5 mg, atorvastatin 10 mg qday,azelastine ? dose, Prednisone 50 mg pre contrat, zanta 150 mg BID, Stiolto Respimat 2.5mcg-2.5mcg 2 [MASKED] 81 qd, Brilinta 90 bId, Vit D3 2000u qd, Claritin 10 mg QD, Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN fever or pain 2. Aspirin 325 mg PO DAILY RX *aspirin 325 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*3 3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 4. Docusate Sodium 100 mg PO BID 5. Midodrine 10 mg PO TID RX *midodrine 10 mg 1 tablet(s) by mouth every eight (8) hours Disp #*90 Tablet Refills:*1 6. Senna 17.2 mg PO QHS 7. TiCAGRELOR 90 mg PO BID RX *ticagrelor [Brilinta] 90 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*3 8. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze 9. Atorvastatin 10 mg PO QPM 10. Loratadine 10 mg PO DAILY 11. Stiolto Respimat (tiotropium-olodaterol) 2.5-2.5 mcg/actuation inhalation DAILY 12. Vitamin D [MASKED] UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: cerebral ACA aneurysm Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Discharge Instructions Dr. [MASKED] & Dr. [MASKED] Activity - You will need to check your Blood pressure every day while you are on Midodrine. If your systolic blood pressure is above [MASKED] you should call the Neurosurgery Office at [MASKED]. •You may gradually return to your normal activities, but we recommend you take it easy for the next [MASKED] hours to avoid bleeding from your groin. •Heavy lifting, running, climbing, or other strenuous exercise should be avoided for ten (10) days. This is to prevent bleeding from your groin. •You make take leisurely walks and slowly increase your activity at your own pace. [MASKED] try to do too much all at once. •Do not go swimming or submerge yourself in water for five (5) days after your procedure. •You make take a shower. Medications •Resume your normal medications and begin new medications as directed. •You have been instructed by your doctor to take Aspirin 325mg daily and Brilinta 90mg twice daily. Do not take any other products that have aspirin in them. If you are unsure of what products contain Aspirin, as your pharmacist or call our office. •You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. •If you take Metformin (Glucophage) you may start it again three (3) days after your procedure. Care of the Puncture Site •You will have a small bandage over the site. •Remove the bandage in 24 hours by soaking it with water and gently peeling it off. •Keep the site clean with soap and water and dry it carefully. •You may use a band-aid if you wish. What You [MASKED] Experience: •Mild tenderness and bruising at the puncture site (groin). •Soreness in your arms from the intravenous lines. •Mild to moderate headaches that last several days to a few weeks. •Fatigue is very normal •Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. If you are taking narcotics (prescription pain medications), try an over-the-counter stool softener. When to Call Your Doctor at [MASKED] for: •Severe pain, swelling, redness or drainage from the puncture site. •Fever greater than 101.5 degrees Fahrenheit •Constipation •Blood in your stool or urine •Nausea and/or vomiting •Extreme sleepiness and not being able to stay awake •Severe headaches not relieved by pain relievers •Seizures •Any new problems with your vision or ability to speak •Weakness or changes in sensation in your face, arms, or leg Followup Instructions: [MASKED]
[]
[ "J449", "Z87891", "E785", "F419" ]
[ "I671: Cerebral aneurysm, nonruptured", "J449: Chronic obstructive pulmonary disease, unspecified", "Z87891: Personal history of nicotine dependence", "E785: Hyperlipidemia, unspecified", "F419: Anxiety disorder, unspecified" ]
19,996,654
26,946,592
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: lisinopril Attending: ___. Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ male with the past medical history of morbid obesity, T2DM, HTN, HLD, CKD3, anemia, neuropathy, venous ulcer, and and venous insufficiency who initially presented to ___ from his PCP for new hypoxemia (SpO2 88% on RA), fatigue, and dyspnea on exertion. He was transferred to ___ for CTA to rule out PE (___ does not have equipment that can fit the patient). Per the ER MD, "In the ED, he has been on ___ with SpO2 > 94%, breathing comfortably. He tells me that his dyspnea has been at his recent baseline and typically is related to exertion. I spoke with his PCP regarding his symptoms, and he strongly feels that the patient should be admitted for further evaluation. Even though the patient reports little change from his baseline, his PCP who has known him for years, reports that his mobility and functional status has declined relatively acutely and that he has not had a low SpO2 in clinic prior to the day of presentation. He has been referred to sleep medicine in the past out of suspicion for OSA but has not had a formal sleep study or PFTs. Of note, the patient has had similar presentations in the past. Specifically, a hospitalization at ___ ___ for dyspnea. At that time his SpO2 was 89% RA. He had negative trops, negative d-dimer, negative infxs workup, neg cardiac w/u." He states that the dyspnea is acute on chronic, worse with exertion where he can only walk ___ feet, moderate to severe, not associated with chest pain, improved with rest. He denies any wheezing. He does report orthopnea and states that he sleeps on 4 pillows. He has not had PND. He used to walk his dog using a wheelchair as his walker, but now he has to sit in the wheelchair to walk these distances. Vitals in the ER: 98.8 97 142/78 16 94% 4L NC There, the patient received: ___ 08:15 PO/NG Gabapentin 600 mg ___ ___ 15:08 PO/NG Gabapentin 600 mg ___ ___ 15:08 PO/NG MetFORMIN (Glucophage) 1000 mg ___ 21:05 NEB Ipratropium-Albuterol Neb 1 NEB ___ 21:32 PO/NG Gabapentin 600 mg ___ ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: PAST MEDICAL/SURGICAL HISTORY: morbid obesity, T2DM, HTN, HLD, CKD3, anemia, neuropathy, venous ulcer, and and venous insufficiency. S/p puncutured lung and other injuries from motorcycle accident ___ years ago Social History: ___ Family History: Father had MI, no known lung disease Physical Exam: EXAM: VITALS: (see eFlowsheet) GENERAL: Alert and in no apparent distress, malodorous 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 rate; normal perfusion, no appreciable JVD but difficult to assess with neck habitus RESP: Symmetric breathing pattern with no stridor. Breathing is non-labored GI: Abdomen soft, non-distended, no hepatosplenomegaly appreciated. GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, normal muscle bulk and tone SKIN: RLE anterior leg ulcer noted and is dressed, edema is present NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, impaired mobility PSYCH: normal thought content, logical thought process, appropriate affect Pertinent Results: ___:00AM BLOOD WBC-9.9 RBC-5.64 Hgb-13.2* Hct-45.0 MCV-80* MCH-23.4* MCHC-29.3* RDW-18.6* RDWSD-49.1* Plt ___ ___ 01:00AM BLOOD Glucose-129* UreaN-14 Creat-0.9 Na-142 K-4.8 Cl-99 HCO3-32 AnGap-11 ___ 03:00PM BLOOD cTropnT-<0.01 ___ 05:24PM BLOOD Type-ART pO2-58* pCO2-65* pH-7.38 calTCO2-40* Base XS-9 CTPA ___. Limited study due to poor penetration and suboptimal bolus timing. Within this limitation, no evidence of pulmonary embolism or aortic abnormality. 2. Enlarged main pulmonary artery suggests pulmonary arterial hypertension. TTE: EF 55%, poor windows, limited views, patient refused ECHO contrast Brief Hospital Course: Mr. ___ is a ___ male with the past medical history of morbid obesity, T2DM, HTN, HLD, CKD3, anemia, neuropathy, venous ulcer, and and venous insufficiency who initially presented to ___ from his PCP for hyperemic respiratory failure # Hypoxemic respiratory failure Acute on Chronic, patient evaluated by pulmonary service who suspects large component of obesity hypoventilation syndrome. CTPE (poor quality) did not show PE: unable to get VQ scan due to habitus. ECHO was also poor quality due to habitus, reveals normal EF. Pulmonary service also recommended daily lasix to optimize right heart function, and inpatient trial of BiPAP. With bipap his ABGs significantly improved and was discharged home with bipap for obesity hypoventilation syndrome. We will have close pulmonology follow up. Also discussed the role for weight loss and gave him the number to the weight clinic associated with his PCP. #DM2 causing CKD and neuropathy - Home medications continued on discharge #Right leg venous ulcer - cont dressing daily, evaluated by wound RN, did not find any evidence of superinfection. Will have ___ for dressing changes # Depression: Patient without SI/HI, engaged with ease with our social worker, noted closeness to his dog and finance, attempts to expand social connections and desire for volunteer opportunities. Dysthymia appears secondary to loss of mobility, independence from his morbid obesity. # Obesity: PCP can consider referral to outpatient ___ clinic, but patient would have to demonstrate significant lifestyle changes to be a candidate for bariatric surgery. He endorses poor dietary habits #Obesity - outpatient exercise program #HTN - losartan >30 minutes spent on complex discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. MetFORMIN (Glucophage) 1000 mg PO BID 2. glimepiride 4 mg oral DAILY 3. Pioglitazone 30 mg PO DAILY 4. Losartan Potassium 50 mg PO DAILY 5. Gabapentin 600 mg PO TID 6. Vitamin D ___ UNIT PO DAILY 7. Ferrous Sulfate 325 mg PO DAILY Discharge Medications: 1. Docusate Sodium 100 mg PO BID:PRN Constipation - Second Line RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 2. Furosemide 40 mg PO DAILY RX *furosemide 40 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 3. Miconazole Powder 2% 1 Appl TP TID RX *miconazole nitrate [Micro-Guard] 2 % apply to groin three times a day Refills:*0 4. Polyethylene Glycol 17 g PO BID RX *polyethylene glycol 3350 [Gavilax] 17 gram/dose 1 powder(s) by mouth once a day Refills:*0 5. Ferrous Sulfate 325 mg PO DAILY 6. Gabapentin 600 mg PO TID 7. glimepiride 4 mg oral DAILY 8. Losartan Potassium 50 mg PO DAILY 9. MetFORMIN (Glucophage) 1000 mg PO BID 10. Pioglitazone 30 mg PO DAILY 11. Vitamin D ___ UNIT PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: 1. Shortness of breath and hypoxia due to obesity hypoventilation and presumed pulmonary hypertension 2. Diabetes Mellitus 3. Venous stasis ulcer 4. Tinea corporis 5. OSA Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital for evaluation of your shortness of breath and wheezing. You were evaluated by the pulmonary team, social worker and wound care nurse. The pulmonary team recommends that you take lasix 40 mg a day to help reduce the fluid in your lungs. You were found to have low oxygen levels likely from the stress on your lungs from extra weight. This is called obesity hypoventilation syndrome. For this you were started on continuous oxygen. You were also found to have severe sleep apnea. You were started on bipap. With Bipap you improved. You will have a bipap delivered to your home tonight. It is important you wear this every night. As we discussed losing weight is extremely important. This would help alleviate many of your illnesses including diabetes, sleep apnea, and your need for oxygen. After discharge please call the medical weight management center at ___. Our nutritionist met with you and as we discussed it is important to eat ___ calories or less a day. It is also important to avoid concentrated sweets like soda. It is also important that you find a therapist to help you with your weight loss journey. It was a pleasure caring for you, Your ___ Team Followup Instructions: ___
[ "E662", "J9601", "Z6844", "L97811", "E872", "I2723", "G4733", "E1122", "E1140", "I129", "N183", "B354", "E785", "D649", "I872", "Z993" ]
Allergies: lisinopril Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is a [MASKED] male with the past medical history of morbid obesity, T2DM, HTN, HLD, CKD3, anemia, neuropathy, venous ulcer, and and venous insufficiency who initially presented to [MASKED] from his PCP for new hypoxemia (SpO2 88% on RA), fatigue, and dyspnea on exertion. He was transferred to [MASKED] for CTA to rule out PE ([MASKED] does not have equipment that can fit the patient). Per the ER MD, "In the ED, he has been on [MASKED] with SpO2 > 94%, breathing comfortably. He tells me that his dyspnea has been at his recent baseline and typically is related to exertion. I spoke with his PCP regarding his symptoms, and he strongly feels that the patient should be admitted for further evaluation. Even though the patient reports little change from his baseline, his PCP who has known him for years, reports that his mobility and functional status has declined relatively acutely and that he has not had a low SpO2 in clinic prior to the day of presentation. He has been referred to sleep medicine in the past out of suspicion for OSA but has not had a formal sleep study or PFTs. Of note, the patient has had similar presentations in the past. Specifically, a hospitalization at [MASKED] [MASKED] for dyspnea. At that time his SpO2 was 89% RA. He had negative trops, negative d-dimer, negative infxs workup, neg cardiac w/u." He states that the dyspnea is acute on chronic, worse with exertion where he can only walk [MASKED] feet, moderate to severe, not associated with chest pain, improved with rest. He denies any wheezing. He does report orthopnea and states that he sleeps on 4 pillows. He has not had PND. He used to walk his dog using a wheelchair as his walker, but now he has to sit in the wheelchair to walk these distances. Vitals in the ER: 98.8 97 142/78 16 94% 4L NC There, the patient received: [MASKED] 08:15 PO/NG Gabapentin 600 mg [MASKED] [MASKED] 15:08 PO/NG Gabapentin 600 mg [MASKED] [MASKED] 15:08 PO/NG MetFORMIN (Glucophage) 1000 mg [MASKED] 21:05 NEB Ipratropium-Albuterol Neb 1 NEB [MASKED] 21:32 PO/NG Gabapentin 600 mg [MASKED] ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: PAST MEDICAL/SURGICAL HISTORY: morbid obesity, T2DM, HTN, HLD, CKD3, anemia, neuropathy, venous ulcer, and and venous insufficiency. S/p puncutured lung and other injuries from motorcycle accident [MASKED] years ago Social History: [MASKED] Family History: Father had MI, no known lung disease Physical Exam: EXAM: VITALS: (see eFlowsheet) GENERAL: Alert and in no apparent distress, malodorous 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 rate; normal perfusion, no appreciable JVD but difficult to assess with neck habitus RESP: Symmetric breathing pattern with no stridor. Breathing is non-labored GI: Abdomen soft, non-distended, no hepatosplenomegaly appreciated. GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, normal muscle bulk and tone SKIN: RLE anterior leg ulcer noted and is dressed, edema is present NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, impaired mobility PSYCH: normal thought content, logical thought process, appropriate affect Pertinent Results: [MASKED]:00AM BLOOD WBC-9.9 RBC-5.64 Hgb-13.2* Hct-45.0 MCV-80* MCH-23.4* MCHC-29.3* RDW-18.6* RDWSD-49.1* Plt [MASKED] [MASKED] 01:00AM BLOOD Glucose-129* UreaN-14 Creat-0.9 Na-142 K-4.8 Cl-99 HCO3-32 AnGap-11 [MASKED] 03:00PM BLOOD cTropnT-<0.01 [MASKED] 05:24PM BLOOD Type-ART pO2-58* pCO2-65* pH-7.38 calTCO2-40* Base XS-9 CTPA [MASKED]. Limited study due to poor penetration and suboptimal bolus timing. Within this limitation, no evidence of pulmonary embolism or aortic abnormality. 2. Enlarged main pulmonary artery suggests pulmonary arterial hypertension. TTE: EF 55%, poor windows, limited views, patient refused ECHO contrast Brief Hospital Course: Mr. [MASKED] is a [MASKED] male with the past medical history of morbid obesity, T2DM, HTN, HLD, CKD3, anemia, neuropathy, venous ulcer, and and venous insufficiency who initially presented to [MASKED] from his PCP for hyperemic respiratory failure # Hypoxemic respiratory failure Acute on Chronic, patient evaluated by pulmonary service who suspects large component of obesity hypoventilation syndrome. CTPE (poor quality) did not show PE: unable to get VQ scan due to habitus. ECHO was also poor quality due to habitus, reveals normal EF. Pulmonary service also recommended daily lasix to optimize right heart function, and inpatient trial of BiPAP. With bipap his ABGs significantly improved and was discharged home with bipap for obesity hypoventilation syndrome. We will have close pulmonology follow up. Also discussed the role for weight loss and gave him the number to the weight clinic associated with his PCP. #DM2 causing CKD and neuropathy - Home medications continued on discharge #Right leg venous ulcer - cont dressing daily, evaluated by wound RN, did not find any evidence of superinfection. Will have [MASKED] for dressing changes # Depression: Patient without SI/HI, engaged with ease with our social worker, noted closeness to his dog and finance, attempts to expand social connections and desire for volunteer opportunities. Dysthymia appears secondary to loss of mobility, independence from his morbid obesity. # Obesity: PCP can consider referral to outpatient [MASKED] clinic, but patient would have to demonstrate significant lifestyle changes to be a candidate for bariatric surgery. He endorses poor dietary habits #Obesity - outpatient exercise program #HTN - losartan >30 minutes spent on complex discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. MetFORMIN (Glucophage) 1000 mg PO BID 2. glimepiride 4 mg oral DAILY 3. Pioglitazone 30 mg PO DAILY 4. Losartan Potassium 50 mg PO DAILY 5. Gabapentin 600 mg PO TID 6. Vitamin D [MASKED] UNIT PO DAILY 7. Ferrous Sulfate 325 mg PO DAILY Discharge Medications: 1. Docusate Sodium 100 mg PO BID:PRN Constipation - Second Line RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 2. Furosemide 40 mg PO DAILY RX *furosemide 40 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 3. Miconazole Powder 2% 1 Appl TP TID RX *miconazole nitrate [Micro-Guard] 2 % apply to groin three times a day Refills:*0 4. Polyethylene Glycol 17 g PO BID RX *polyethylene glycol 3350 [Gavilax] 17 gram/dose 1 powder(s) by mouth once a day Refills:*0 5. Ferrous Sulfate 325 mg PO DAILY 6. Gabapentin 600 mg PO TID 7. glimepiride 4 mg oral DAILY 8. Losartan Potassium 50 mg PO DAILY 9. MetFORMIN (Glucophage) 1000 mg PO BID 10. Pioglitazone 30 mg PO DAILY 11. Vitamin D [MASKED] UNIT PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: 1. Shortness of breath and hypoxia due to obesity hypoventilation and presumed pulmonary hypertension 2. Diabetes Mellitus 3. Venous stasis ulcer 4. Tinea corporis 5. OSA Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital for evaluation of your shortness of breath and wheezing. You were evaluated by the pulmonary team, social worker and wound care nurse. The pulmonary team recommends that you take lasix 40 mg a day to help reduce the fluid in your lungs. You were found to have low oxygen levels likely from the stress on your lungs from extra weight. This is called obesity hypoventilation syndrome. For this you were started on continuous oxygen. You were also found to have severe sleep apnea. You were started on bipap. With Bipap you improved. You will have a bipap delivered to your home tonight. It is important you wear this every night. As we discussed losing weight is extremely important. This would help alleviate many of your illnesses including diabetes, sleep apnea, and your need for oxygen. After discharge please call the medical weight management center at [MASKED]. Our nutritionist met with you and as we discussed it is important to eat [MASKED] calories or less a day. It is also important to avoid concentrated sweets like soda. It is also important that you find a therapist to help you with your weight loss journey. It was a pleasure caring for you, Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "J9601", "E872", "G4733", "E1122", "I129", "E785", "D649" ]
[ "E662: Morbid (severe) obesity with alveolar hypoventilation", "J9601: Acute respiratory failure with hypoxia", "Z6844: Body mass index [BMI] 60.0-69.9, adult", "L97811: Non-pressure chronic ulcer of other part of right lower leg limited to breakdown of skin", "E872: Acidosis", "I2723: Pulmonary hypertension due to lung diseases and hypoxia", "G4733: Obstructive sleep apnea (adult) (pediatric)", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "E1140: Type 2 diabetes mellitus with diabetic neuropathy, unspecified", "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)", "B354: Tinea corporis", "E785: Hyperlipidemia, unspecified", "D649: Anemia, unspecified", "I872: Venous insufficiency (chronic) (peripheral)", "Z993: Dependence on wheelchair" ]
19,996,783
21,880,161
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Chest Pain, SOB Major Surgical or Invasive Procedure: EGD with duodenal stenting ___ History of Present Illness: Mr. ___ is an ___ year-old gentleman with hypertension, hyperlipidemia, T2DM and recently diagnosed pancreatic ductal adenonocarcinoma with biliary/duodenal involvement who presents with nausea, vomiting, chest pain and shortness of breath. Per ED report he presented to ED complaining of shortness of breath and chest discomfort since the morning of ___ via son as interpreter. He also had intermittent diarrhea and nausea. ED initial vitals were 97.1 106 114/63 18 99% RA Prior to transfer vitals were 97.7 103 113/56 16 100% RA Exam in the ED showed : "Gen: Comfortable, appears chronically ill but in no acute distress. HEENT: NC/AT. EOMI. Neck: No swelling. Cor: RRR. No m/r/g. Pulm: CTAB, Nonlabored respirations. Abd: Soft, NT, ND. Ext: No edema, cyanosis, or clubbing. Skin: No rash, skin pale Neuro: AAOx3. Gross sensorimotor intact. Psych: Normal mentation. " ED work-up significant for: -CBC: WBC: 5.2. HGB: 8.3*. Plt Count: 206. Neuts%: 90*. -Chemistry: Na: 125*. K: 4.0 . Cl: 86*. CO2: 13* . BUN: 21*. Creat: 1.0. Ca: 8.0*. Mg: 1.2*. PO4: 3.3. -Lactate:4.4-> 1.9 -Coags: INR: 2.1*. PTT: 31.6. -UA: WBC 4, Gluc 300, Ket 40, UA -EKG read as "sinus, ischemia:non-specific" -TnT: 0.02 -CT Torso: "1. Small, subsegmental right lower lobe pulmonary embolus. No evidence of right heart strain or definite pulmonary infarction. 2. ___ and ground-glass opacities most conspicuous at left lung base and lingula, appear similar to ___ and are likely infectious or inflammatory. 3. No significant interval change in the large hypoenhancing mass arising from the head of the pancreas. Peripancreatic adenopathy is overall minimally increased. The mass invades the second and third portion of the duodenum resulting in upstream obstruction which appears progressed in comparison to the prior examination. There has been interval CBD stent placement with decompression of the intrahepatic biliary tree and expected pneumobilia, however there is extensive soft tissue at the inferior ostium of the stent and partial or pending obstruction can't be excluded. The mass again obliterates the main portal vein, but the aorta and encases the SMA. 4. 8 mm right middle lobe pulmonary nodule, unchanged from ___. 5. Multiple bilateral old rib fractures are noted." -CT head: No acute intracranial hemorrhage -___: negative ED management significant for: -Medications: MgSO4 2g iv, CTX 1g, Levofloxacin 750mg iv, enoxaparin 60mg sc x1 Patient had bed assignment 15:56, accepted by HMED. First documented vital signs at 1823. Patient transferred from HMED to this writer at 20:00, signout out as stable. When asked about his symptoms patient reports having had an episode of nausea, diarrhea and malaise on ___ that subsided. On the morning of ___ he woke up with nausea, chest pain and shortness of breath. He tried to eat but could not as he vomited. He also reports having 2 episodes of loose stool. He felt unwell and had prominent malaise and was brought in to ED by son. Here he continues to feel unwell, no longer has shortness of breath or chest discomfort. He feels much better than in the morning. Patient denies fevers/chills, night sweats, headache, vision changes, dizziness/lightheadedness, weakness/numbnesss, cough, hemoptysis, chest pain, abdominal pain, nausea/vomiting, diarrhea, hematemesis, hematochezia/melena, dysuria, hematuria, and new rashes. REVIEW OF SYSTEMS: A complete 10-point review of systems was performed and was negative unless otherwise noted in the HPI. Past Medical History: 1. Cardiac Risk Factors -Hypertension -Hyperlipidemia -DM2 2. Cardiac History -None 3. Other PMH -Stage III/IV pancreatic adenocarcinoma -Pituitary macroadenoma complicated by ___ Social History: ___ Family History: No known family history of malignancy. His mother lived to ___ years. His father died at a young age of unknown causes. He had 4 brothers and 3 sisters most of whom lived to their ___. He has 2 sons without health concerns. Physical Exam: ADMISSION PHYSICAL ================= VS: T:97.9, BP: 109/58, HR: 97, RR: 17, O2: 100% RA GENERAL: Chronically ill appearing, NAD HEENT: NC/AT, Sclera anicteric, PERRL, EOMI, dry MM NECK: Supple. No appreciable JVD. CARDIAC: RRR, +S1/2, no murmurs, rubs, gallops LUNGS: CTAB ABDOMEN: Soft, NTND, +BS EXTREMITIES: Warm, 1+ symmetric pitting edema upto knees SKIN: no rashes PULSES: symmetric distal pulses DISCHARGE PHYSICAL ================= VS: ___ 0511 Temp: 97.8 PO BP: 90/54 R Lying HR: 114 RR: 16 GENERAL: Chronically ill appearing, cachectic, NAD HEENT: NC/AT, Sclera anicteric, PERRL, EOMI, dry MM NECK: Supple. No appreciable JVD CARDIAC: sinus tachycardia, +S1/2, no murmurs, rubs, gallops LUNGS: CTAB ABDOMEN: Distended. Epigastric TTP throughout. No rebound or guarding EXTREMITIES: Warm, 1+ symmetric pitting edema upto knees SKIN: no rashes PULSES: symmetric distal pulses Pertinent Results: ADMISSION LABS ============= ___ 05:25AM BLOOD WBC-5.2 RBC-3.26* Hgb-8.3* Hct-25.3* MCV-78* MCH-25.5* MCHC-32.8 RDW-15.3 RDWSD-42.7 Plt ___ ___ 05:25AM BLOOD Neuts-90* Bands-3 Lymphs-7* Monos-0 Eos-0 Baso-0 ___ Myelos-0 AbsNeut-4.84 AbsLymp-0.36* AbsMono-0.00* AbsEos-0.00* AbsBaso-0.00* ___ 05:25AM BLOOD Hypochr-1+* Anisocy-NORMAL Poiklo-1+* Macrocy-NORMAL Microcy-3+* Polychr-NORMAL Burr-1+* ___ 05:25AM BLOOD ___ PTT-31.6 ___ ___ 05:25AM BLOOD Glucose-297* UreaN-21* Creat-1.0 Na-125* K-4.0 Cl-86* HCO3-13* AnGap-26* ___ 05:25AM BLOOD CK(CPK)-58 ___ 05:25AM BLOOD CK-MB-5 ___ 05:25AM BLOOD cTropnT-0.02* ___ 09:56PM BLOOD CK-MB-40* MB Indx-13.6* cTropnT-1.37* ___ 05:25AM BLOOD Calcium-8.0* Phos-3.3 Mg-1.2* ___ 05:31AM BLOOD Lactate-4.4* Na-122* K-3.8 ___ 08:09AM URINE Color-Yellow Appear-Clear Sp ___ ___ 08:09AM URINE Blood-NEG Nitrite-NEG Protein-TR* Glucose-300* Ketone-40* Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 08:09AM URINE RBC-1 WBC-4 Bacteri-NONE Yeast-NONE Epi-<1 ___ 08:09AM URINE CastHy-35* ___ 08:09AM URINE Mucous-RARE* ___ 08:09AM URINE Hours-RANDOM Na-80 ___ 08:09AM URINE Osmolal-405 PERTINENT RESULTS ================ ___ 05:28AM BLOOD ___ ___ 04:46AM BLOOD ___ 05:28AM BLOOD Ret Aut-0.4 Abs Ret-0.01* ___ 03:56AM BLOOD CK-MB-24* MB Indx-11.8* cTropnT-1.92* ___ 05:28AM BLOOD calTIBC-101* VitB12-324 Hapto-347* Ferritn-695* TRF-78* ___ 11:30AM BLOOD ___ pO2-165* pCO2-20* pH-7.34* calTCO2-11* Base XS--12 Comment-GREEN TOP ___ 08:52AM BLOOD Lactate-1.9 ___ 11:30AM BLOOD Lactate-7.6* ___ 07:30PM BLOOD Lactate-1.8 ___ 12:18PM BLOOD Lactate-2.3* ___ 09:12PM BLOOD Lactate-1.4 ___ 12:04PM BLOOD Lactate-2.2* MICRO ===== ___ 11:18 am BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 11:13 am BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 8:45 am BLOOD CULTURE #2. **FINAL REPORT ___ Blood Culture, Routine (Final ___: STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. Anaerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN CLUSTERS. Reported to and read back by ___ (___) @12:26 (___). __________________________________________________________ ___ 5:25 am BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. STUDIES ======= CXR PA and LAT ___ An infrahilar opacity best seen on lateral view is unchanged from ___. In the appropriate clinical setting this may represent pneumonia, although this could represent atelectasis given low volumes. CTA Chest, CT Abdomen ___. Small, subsegmental right lower lobe pulmonary embolus. No evidence of right heart strain or definite pulmonary infarction. 2. ___ and ground-glass opacities most conspicuous at left lung base and lingula, appear similar to ___ and are likely infectious or inflammatory. 3. No significant interval change in the large hypoenhancing mass arising from the head of the pancreas. Peripancreatic adenopathy is overall minimally increased. The mass invades the second and third portion of the duodenum resulting in upstream obstruction which appears progressed in comparison to the prior examination. There has been interval CBD stent placement with decompression of the intrahepatic biliary tree and expected pneumobilia, however there is extensive soft tissue at the inferior ostium of the stent and partial or impending obstruction can't be excluded. The mass again obliterates the main portal vein, abuts the aorta and encases the SMA. 4. 8 mm right middle lobe pulmonary nodule, unchanged from ___. 5. Multiple bilateral old rib fractures are noted. CT Head w/o Contrast ___. No acute intracranial process. 2. Paranasal sinus retention cysts, similar to previous study. ___ ___ No evidence of deep venous thrombosis in the lower extremities. TTE ___ The left atrial volume index is normal. There is normal left ventricular wall thickness with a normal cavity size. There is mild regional left ventricular systolic dysfunction with near-akinesis of the distal ___ of the left ventricle (distal LAD territory; see schematic) and preserved/normal contractility of the remaining segments. The visually estimated left ventricular ejection fraction is 40%. No thrombus or mass is seen in the left ventricle. Normal right ventricular cavity size with normal free wall motion. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. The aortic arch diameter is normal. There is no evidence for an aortic arch coarctation. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral leaflets are mildly thickened with no mitral valve prolapse. There is mild [1+] mitral regurgitation. The tricuspid valve leaflets appear structurally normal. There is trivial tricuspid regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Adequate image quality. Mild regional left ventricular systolic dysfunction most consistent with coronary artery disease (LAD distribution). Mild mitral regurgitation. CXR ___ Patchy retrocardiac opacity, potentially atelectasis with infection or aspiration not excluded in the correct clinical setting. Marked distension of the stomach. Abdomen Xray ___ Massive distention of the stomach for which nasogastric tube decompression is recommended. No evidence for small or large bowel obstruction. Abdomen Xray ___ NG tube in the stomach loops back into the still esophagus. Improvement of the gastric distension. Abdomen Xray ___ Massive distention of the stomach similar in appearance to study of ___ with duodenal air-fluid levels compatible with gastric outlet obstruction. CXR ___ Extensive dilatation of the stomach is re-demonstrated with the stomach bubble approaching 27 x 19 cm. NG tube tip is projecting over the stomach bubble left basal consolidation is most likely representing atelectasis. Right PICC line tip is at the cavoatrial junction no appreciable pleural effusion demonstrated. CXR ___ (NG Placement) Extensive dilatation of the stomach is re-demonstrated with the stomach bubble approaching 27 x 19 cm. NG tube tip is projecting over the stomach bubble left basal consolidation is most likely representing atelectasis. Right PICC line tip is at the cavoatrial junction no appreciable pleural effusion demonstrated. EGD ___ Large gastric ulcer. Malignant duodenal sweep ulcer. Duodenal stricture s/p placement of uncovered duodenal stent. DISCHARGE LABS ============= ___ 06:26AM BLOOD WBC-6.7 RBC-3.66* Hgb-10.7* Hct-32.5* MCV-89 MCH-29.2 MCHC-32.9 RDW-21.2* RDWSD-59.5* Plt ___ ___ 06:26AM BLOOD Glucose-186* UreaN-32* Creat-1.6* Na-137 K-5.1 Cl-107 HCO3-17* AnGap-13 ___ 06:26AM BLOOD Calcium-7.8* Phos-4.4 Mg-2.0 Brief Hospital Course: Mr. ___ is a ___ year old male with PMHx of stage III/IV pancreatic adenocarcinoma, DM2, Hyponatremia, SIADH who presented with a 1-day history of chest pain and shortness of breath found to have anterior missed STEMI s/p medical management (high risk for PCI, missed window, no symptoms), hospital course complicated by GI bleed in the setting of anticoagulation with heparin and known active malignancy with gastric and duodenal ulcerations, now s/p 5U PRBC with improved hemodynamics, evidence of gastric obstruction likely ___ malignancy s/p palliative duodenal stent discharged to hospice care. ACUTE ISSUES: ============ #GOC Mr. ___ presented with known advanced pancreatic cancer on palliative chemotherapy, complicated by symptomatic gastric outlet obstruction. Patient was also noted to have a GI bleed in the setting of anticoagulation for STEMI and small subsegmental PE. Several goals of care discussions were held with the patient's son and the patient was made DNR/DNI based on these conversations. Goals of care discussions included patient's primary oncologist as well as the inpatient palliative care team. He was screened for hospice eligibility and is now being discharged to hospice care. #Melena #Acute Blood Loss Anemia Hospital course complicated by GI bleed requiring 5U PRBC total. The patient had a GI bleed was secondary to known necrotic gastric and duodenal malignant ulcerations. Patient's anticoagulation as well as antiplatelet therapy (started for medical management of STEMI) were held in the setting of an active GI bleed. Gastroenterology was consulted and placed a palliative uncovered duodenal stent via EGD for symptomatic relief of gastric outlet obstruction. #Bilious emesis #Gastric outlet obstruction The ___ hospital course was complicated by gastric obstruction in setting of known pancreatic malignancy invading duodenum and KUB revealed severely distended stomach without evidence of small or large bowel obstruction. Patient underwent EGD with palliative duodenal stenting with marked improvement in symptoms. An NG tube was also placed prior to stenting and was removed once stent was placed. ___ Patient was noted to have ___ on presentation. This was thought to be likely in the setting of hypotension and decreased PO intake secondary to gastric obstruction. He was managed supportively. His creatinine initially improved with fluids however had a repeat ___ likely in the setting of hypotension with Cr 1.6 at discharge. #STEMI The patient presented with 1 day history of chest pain and was initially admitted to oncology service but was transferred to CCU after EKG showing STE in V2-V3 and troponin elevation at 1.02. Onset of symptoms occurred ___ hours prior to presentation and given complex comorbidities and complete resolution of symptoms, cardiac cath was deferred and medical management was pursued. A TTE showing mild regional LV systolic dysfunction in LAD distribution with EF 40%. The patient was initially started on heparin drip and on dual anti platelet therapy but these were deferred in the setting of GI bleed. Metoprolol and lisinopril were not started due to hypotension and significant GI bleed per above. # Small Subsegmental Pulmonary Embolus On admission, there was evidence of small sub-subsegmental PE on CTA chest. He was started on anticoagulation for STEMI that would also cover small segmental PE, however given active GI bleed, continuation of anticoagulation was deferred. # Hyponatremia # ___ Patient presented with known history of hyponatremia thought to be SIADH in the setting of a macroadenoma in the pituitary. Sodium was trended daily and improved with IVF and PO intake # Possible LLL Pneumonia, CAP Patient was initially started on a 5 day course of ceftriaxone and briefly broadened to vancomycin and cefepime. However given lack of fevers, leukocytosis, clinical signs of pneumonia, the patient's antibiotics were stopped and he was closely monitored. # H. pylori Infection The patient was continued on metronidazole QID, tetracycline QID, omeprazole, bismuth x 2 weeks (___) # Pancreatic Adenocarcinoma, Stage III-IV # Functional Gastric Outlet Obstruction Recently diagnosed with stage III-IV pancreatic adenocarcinoma (7.5cm) obliterating SMV and encasing SMA on cycle 1 of palliative gemcitabine (first/last dose ___. CT torso ___ again with large hypodense mass in pancreatic head invading second and third portions of the duodenum. Possible or impending obstruction of CBD stent also noted. Patient underwent palliative duodenal stenting. CHRONIC ISSUES: =============== # Type 2 Diabetes Mellitus Patient had known history of type 2 diabetes. He was on a regimen of metformin and glimepiride at home. These oral hypoglycemics were held in the inpatient setting and the patient was started on insulin sliding scale. # Pituitary Macroadenoma 14mm non-enhancing lesion in anterior right pituitary noted on MRI ___. Thought to possibly be cystic. Further management not within goals of care. TRANSITIONAL ISSUES =================== []Pain control: Recommend titration of pain control to make patient comfortable []Nausea/Vomiting: Recommend use of anti-emetics/benzodiazepines to aggressively control symptoms # CODE: DNR/DNI, MOLST in chart # CONTACT/HCP: ___ (son, lives with him) ___ ___ (son) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ondansetron 4 mg PO Q8H:PRN nausea 2. Bismuth Subsalicylate 15 mL PO QID 3. Simethicone 120 mg PO QID:PRN gas 4. MetroNIDAZOLE 250 mg PO QID 5. Omeprazole 20 mg PO DAILY 6. glimepiride 4 mg oral DAILY 7. Tetracycline 500 mg PO QID 8. Nephrocaps 1 CAP PO DAILY Discharge Medications: 1. GlipiZIDE XL 2.5 mg PO DAILY 2. HYDROmorphone (Dilaudid) 0.5-1 mg IV Q3H:PRN Pain - Moderate 3. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Mild 4. Sucralfate 1 gm PO QID 5. Bismuth Subsalicylate 15 mL PO QID 6. Ondansetron 4 mg PO Q8H:PRN nausea 7. Simethicone 120 mg PO QID:PRN gas Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary Diagnoses ================= Acute blood loss anemia Upper GI bleed Gastric outlet obstruction Thrombocytopenia Leukocytosis Acute Kidney Injury STEMI Pulmonary embolus, small sub-submental Hyponatremia SIADH Left lower lobe pneumonia, community-acquired Secondary Diagnoses =================== Pancreatic adenocarcinoma, stage III–IV H pylori infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you in the hospital! Why was I admitted? You were admitted to the hospital because had a heart attack What happened while I was admitted? -You had a heart attack and were given blood thinning medications -You had a stent placed in your stomach to help with nausea and vomiting -You were given blood back because you were bleeding What should I do after I leave the hospital? -Spend time with your family and loved ones We wish you the very best! Your ___ Care Team Followup Instructions: ___
[ "I2109", "J189", "E43", "K254", "K264", "I2699", "E222", "N179", "K311", "E872", "K56609", "C170", "C259", "I2510", "E785", "I10", "E861", "I959", "Z66", "D696", "D649", "Z7401", "E8809", "B9681" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Chest Pain, SOB Major Surgical or Invasive Procedure: EGD with duodenal stenting [MASKED] History of Present Illness: Mr. [MASKED] is an [MASKED] year-old gentleman with hypertension, hyperlipidemia, T2DM and recently diagnosed pancreatic ductal adenonocarcinoma with biliary/duodenal involvement who presents with nausea, vomiting, chest pain and shortness of breath. Per ED report he presented to ED complaining of shortness of breath and chest discomfort since the morning of [MASKED] via son as interpreter. He also had intermittent diarrhea and nausea. ED initial vitals were 97.1 106 114/63 18 99% RA Prior to transfer vitals were 97.7 103 113/56 16 100% RA Exam in the ED showed : "Gen: Comfortable, appears chronically ill but in no acute distress. HEENT: NC/AT. EOMI. Neck: No swelling. Cor: RRR. No m/r/g. Pulm: CTAB, Nonlabored respirations. Abd: Soft, NT, ND. Ext: No edema, cyanosis, or clubbing. Skin: No rash, skin pale Neuro: AAOx3. Gross sensorimotor intact. Psych: Normal mentation. " ED work-up significant for: -CBC: WBC: 5.2. HGB: 8.3*. Plt Count: 206. Neuts%: 90*. -Chemistry: Na: 125*. K: 4.0 . Cl: 86*. CO2: 13* . BUN: 21*. Creat: 1.0. Ca: 8.0*. Mg: 1.2*. PO4: 3.3. -Lactate:4.4-> 1.9 -Coags: INR: 2.1*. PTT: 31.6. -UA: WBC 4, Gluc 300, Ket 40, UA -EKG read as "sinus, ischemia:non-specific" -TnT: 0.02 -CT Torso: "1. Small, subsegmental right lower lobe pulmonary embolus. No evidence of right heart strain or definite pulmonary infarction. 2. [MASKED] and ground-glass opacities most conspicuous at left lung base and lingula, appear similar to [MASKED] and are likely infectious or inflammatory. 3. No significant interval change in the large hypoenhancing mass arising from the head of the pancreas. Peripancreatic adenopathy is overall minimally increased. The mass invades the second and third portion of the duodenum resulting in upstream obstruction which appears progressed in comparison to the prior examination. There has been interval CBD stent placement with decompression of the intrahepatic biliary tree and expected pneumobilia, however there is extensive soft tissue at the inferior ostium of the stent and partial or pending obstruction can't be excluded. The mass again obliterates the main portal vein, but the aorta and encases the SMA. 4. 8 mm right middle lobe pulmonary nodule, unchanged from [MASKED]. 5. Multiple bilateral old rib fractures are noted." -CT head: No acute intracranial hemorrhage -[MASKED]: negative ED management significant for: -Medications: MgSO4 2g iv, CTX 1g, Levofloxacin 750mg iv, enoxaparin 60mg sc x1 Patient had bed assignment 15:56, accepted by HMED. First documented vital signs at 1823. Patient transferred from HMED to this writer at 20:00, signout out as stable. When asked about his symptoms patient reports having had an episode of nausea, diarrhea and malaise on [MASKED] that subsided. On the morning of [MASKED] he woke up with nausea, chest pain and shortness of breath. He tried to eat but could not as he vomited. He also reports having 2 episodes of loose stool. He felt unwell and had prominent malaise and was brought in to ED by son. Here he continues to feel unwell, no longer has shortness of breath or chest discomfort. He feels much better than in the morning. Patient denies fevers/chills, night sweats, headache, vision changes, dizziness/lightheadedness, weakness/numbnesss, cough, hemoptysis, chest pain, abdominal pain, nausea/vomiting, diarrhea, hematemesis, hematochezia/melena, dysuria, hematuria, and new rashes. REVIEW OF SYSTEMS: A complete 10-point review of systems was performed and was negative unless otherwise noted in the HPI. Past Medical History: 1. Cardiac Risk Factors -Hypertension -Hyperlipidemia -DM2 2. Cardiac History -None 3. Other PMH -Stage III/IV pancreatic adenocarcinoma -Pituitary macroadenoma complicated by [MASKED] Social History: [MASKED] Family History: No known family history of malignancy. His mother lived to [MASKED] years. His father died at a young age of unknown causes. He had 4 brothers and 3 sisters most of whom lived to their [MASKED]. He has 2 sons without health concerns. Physical Exam: ADMISSION PHYSICAL ================= VS: T:97.9, BP: 109/58, HR: 97, RR: 17, O2: 100% RA GENERAL: Chronically ill appearing, NAD HEENT: NC/AT, Sclera anicteric, PERRL, EOMI, dry MM NECK: Supple. No appreciable JVD. CARDIAC: RRR, +S1/2, no murmurs, rubs, gallops LUNGS: CTAB ABDOMEN: Soft, NTND, +BS EXTREMITIES: Warm, 1+ symmetric pitting edema upto knees SKIN: no rashes PULSES: symmetric distal pulses DISCHARGE PHYSICAL ================= VS: [MASKED] 0511 Temp: 97.8 PO BP: 90/54 R Lying HR: 114 RR: 16 GENERAL: Chronically ill appearing, cachectic, NAD HEENT: NC/AT, Sclera anicteric, PERRL, EOMI, dry MM NECK: Supple. No appreciable JVD CARDIAC: sinus tachycardia, +S1/2, no murmurs, rubs, gallops LUNGS: CTAB ABDOMEN: Distended. Epigastric TTP throughout. No rebound or guarding EXTREMITIES: Warm, 1+ symmetric pitting edema upto knees SKIN: no rashes PULSES: symmetric distal pulses Pertinent Results: ADMISSION LABS ============= [MASKED] 05:25AM BLOOD WBC-5.2 RBC-3.26* Hgb-8.3* Hct-25.3* MCV-78* MCH-25.5* MCHC-32.8 RDW-15.3 RDWSD-42.7 Plt [MASKED] [MASKED] 05:25AM BLOOD Neuts-90* Bands-3 Lymphs-7* Monos-0 Eos-0 Baso-0 [MASKED] Myelos-0 AbsNeut-4.84 AbsLymp-0.36* AbsMono-0.00* AbsEos-0.00* AbsBaso-0.00* [MASKED] 05:25AM BLOOD Hypochr-1+* Anisocy-NORMAL Poiklo-1+* Macrocy-NORMAL Microcy-3+* Polychr-NORMAL Burr-1+* [MASKED] 05:25AM BLOOD [MASKED] PTT-31.6 [MASKED] [MASKED] 05:25AM BLOOD Glucose-297* UreaN-21* Creat-1.0 Na-125* K-4.0 Cl-86* HCO3-13* AnGap-26* [MASKED] 05:25AM BLOOD CK(CPK)-58 [MASKED] 05:25AM BLOOD CK-MB-5 [MASKED] 05:25AM BLOOD cTropnT-0.02* [MASKED] 09:56PM BLOOD CK-MB-40* MB Indx-13.6* cTropnT-1.37* [MASKED] 05:25AM BLOOD Calcium-8.0* Phos-3.3 Mg-1.2* [MASKED] 05:31AM BLOOD Lactate-4.4* Na-122* K-3.8 [MASKED] 08:09AM URINE Color-Yellow Appear-Clear Sp [MASKED] [MASKED] 08:09AM URINE Blood-NEG Nitrite-NEG Protein-TR* Glucose-300* Ketone-40* Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG [MASKED] 08:09AM URINE RBC-1 WBC-4 Bacteri-NONE Yeast-NONE Epi-<1 [MASKED] 08:09AM URINE CastHy-35* [MASKED] 08:09AM URINE Mucous-RARE* [MASKED] 08:09AM URINE Hours-RANDOM Na-80 [MASKED] 08:09AM URINE Osmolal-405 PERTINENT RESULTS ================ [MASKED] 05:28AM BLOOD [MASKED] [MASKED] 04:46AM BLOOD [MASKED] 05:28AM BLOOD Ret Aut-0.4 Abs Ret-0.01* [MASKED] 03:56AM BLOOD CK-MB-24* MB Indx-11.8* cTropnT-1.92* [MASKED] 05:28AM BLOOD calTIBC-101* VitB12-324 Hapto-347* Ferritn-695* TRF-78* [MASKED] 11:30AM BLOOD [MASKED] pO2-165* pCO2-20* pH-7.34* calTCO2-11* Base XS--12 Comment-GREEN TOP [MASKED] 08:52AM BLOOD Lactate-1.9 [MASKED] 11:30AM BLOOD Lactate-7.6* [MASKED] 07:30PM BLOOD Lactate-1.8 [MASKED] 12:18PM BLOOD Lactate-2.3* [MASKED] 09:12PM BLOOD Lactate-1.4 [MASKED] 12:04PM BLOOD Lactate-2.2* MICRO ===== [MASKED] 11:18 am BLOOD CULTURE **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] [MASKED] 11:13 am BLOOD CULTURE **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] [MASKED] 8:45 am BLOOD CULTURE #2. **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. Anaerobic Bottle Gram Stain (Final [MASKED]: GRAM POSITIVE COCCI IN CLUSTERS. Reported to and read back by [MASKED] ([MASKED]) @12:26 ([MASKED]). [MASKED] [MASKED] 5:25 am BLOOD CULTURE **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. STUDIES ======= CXR PA and LAT [MASKED] An infrahilar opacity best seen on lateral view is unchanged from [MASKED]. In the appropriate clinical setting this may represent pneumonia, although this could represent atelectasis given low volumes. CTA Chest, CT Abdomen [MASKED]. Small, subsegmental right lower lobe pulmonary embolus. No evidence of right heart strain or definite pulmonary infarction. 2. [MASKED] and ground-glass opacities most conspicuous at left lung base and lingula, appear similar to [MASKED] and are likely infectious or inflammatory. 3. No significant interval change in the large hypoenhancing mass arising from the head of the pancreas. Peripancreatic adenopathy is overall minimally increased. The mass invades the second and third portion of the duodenum resulting in upstream obstruction which appears progressed in comparison to the prior examination. There has been interval CBD stent placement with decompression of the intrahepatic biliary tree and expected pneumobilia, however there is extensive soft tissue at the inferior ostium of the stent and partial or impending obstruction can't be excluded. The mass again obliterates the main portal vein, abuts the aorta and encases the SMA. 4. 8 mm right middle lobe pulmonary nodule, unchanged from [MASKED]. 5. Multiple bilateral old rib fractures are noted. CT Head w/o Contrast [MASKED]. No acute intracranial process. 2. Paranasal sinus retention cysts, similar to previous study. [MASKED] [MASKED] No evidence of deep venous thrombosis in the lower extremities. TTE [MASKED] The left atrial volume index is normal. There is normal left ventricular wall thickness with a normal cavity size. There is mild regional left ventricular systolic dysfunction with near-akinesis of the distal [MASKED] of the left ventricle (distal LAD territory; see schematic) and preserved/normal contractility of the remaining segments. The visually estimated left ventricular ejection fraction is 40%. No thrombus or mass is seen in the left ventricle. Normal right ventricular cavity size with normal free wall motion. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. The aortic arch diameter is normal. There is no evidence for an aortic arch coarctation. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral leaflets are mildly thickened with no mitral valve prolapse. There is mild [1+] mitral regurgitation. The tricuspid valve leaflets appear structurally normal. There is trivial tricuspid regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Adequate image quality. Mild regional left ventricular systolic dysfunction most consistent with coronary artery disease (LAD distribution). Mild mitral regurgitation. CXR [MASKED] Patchy retrocardiac opacity, potentially atelectasis with infection or aspiration not excluded in the correct clinical setting. Marked distension of the stomach. Abdomen Xray [MASKED] Massive distention of the stomach for which nasogastric tube decompression is recommended. No evidence for small or large bowel obstruction. Abdomen Xray [MASKED] NG tube in the stomach loops back into the still esophagus. Improvement of the gastric distension. Abdomen Xray [MASKED] Massive distention of the stomach similar in appearance to study of [MASKED] with duodenal air-fluid levels compatible with gastric outlet obstruction. CXR [MASKED] Extensive dilatation of the stomach is re-demonstrated with the stomach bubble approaching 27 x 19 cm. NG tube tip is projecting over the stomach bubble left basal consolidation is most likely representing atelectasis. Right PICC line tip is at the cavoatrial junction no appreciable pleural effusion demonstrated. CXR [MASKED] (NG Placement) Extensive dilatation of the stomach is re-demonstrated with the stomach bubble approaching 27 x 19 cm. NG tube tip is projecting over the stomach bubble left basal consolidation is most likely representing atelectasis. Right PICC line tip is at the cavoatrial junction no appreciable pleural effusion demonstrated. EGD [MASKED] Large gastric ulcer. Malignant duodenal sweep ulcer. Duodenal stricture s/p placement of uncovered duodenal stent. DISCHARGE LABS ============= [MASKED] 06:26AM BLOOD WBC-6.7 RBC-3.66* Hgb-10.7* Hct-32.5* MCV-89 MCH-29.2 MCHC-32.9 RDW-21.2* RDWSD-59.5* Plt [MASKED] [MASKED] 06:26AM BLOOD Glucose-186* UreaN-32* Creat-1.6* Na-137 K-5.1 Cl-107 HCO3-17* AnGap-13 [MASKED] 06:26AM BLOOD Calcium-7.8* Phos-4.4 Mg-2.0 Brief Hospital Course: Mr. [MASKED] is a [MASKED] year old male with PMHx of stage III/IV pancreatic adenocarcinoma, DM2, Hyponatremia, SIADH who presented with a 1-day history of chest pain and shortness of breath found to have anterior missed STEMI s/p medical management (high risk for PCI, missed window, no symptoms), hospital course complicated by GI bleed in the setting of anticoagulation with heparin and known active malignancy with gastric and duodenal ulcerations, now s/p 5U PRBC with improved hemodynamics, evidence of gastric obstruction likely [MASKED] malignancy s/p palliative duodenal stent discharged to hospice care. ACUTE ISSUES: ============ #GOC Mr. [MASKED] presented with known advanced pancreatic cancer on palliative chemotherapy, complicated by symptomatic gastric outlet obstruction. Patient was also noted to have a GI bleed in the setting of anticoagulation for STEMI and small subsegmental PE. Several goals of care discussions were held with the patient's son and the patient was made DNR/DNI based on these conversations. Goals of care discussions included patient's primary oncologist as well as the inpatient palliative care team. He was screened for hospice eligibility and is now being discharged to hospice care. #Melena #Acute Blood Loss Anemia Hospital course complicated by GI bleed requiring 5U PRBC total. The patient had a GI bleed was secondary to known necrotic gastric and duodenal malignant ulcerations. Patient's anticoagulation as well as antiplatelet therapy (started for medical management of STEMI) were held in the setting of an active GI bleed. Gastroenterology was consulted and placed a palliative uncovered duodenal stent via EGD for symptomatic relief of gastric outlet obstruction. #Bilious emesis #Gastric outlet obstruction The [MASKED] hospital course was complicated by gastric obstruction in setting of known pancreatic malignancy invading duodenum and KUB revealed severely distended stomach without evidence of small or large bowel obstruction. Patient underwent EGD with palliative duodenal stenting with marked improvement in symptoms. An NG tube was also placed prior to stenting and was removed once stent was placed. [MASKED] Patient was noted to have [MASKED] on presentation. This was thought to be likely in the setting of hypotension and decreased PO intake secondary to gastric obstruction. He was managed supportively. His creatinine initially improved with fluids however had a repeat [MASKED] likely in the setting of hypotension with Cr 1.6 at discharge. #STEMI The patient presented with 1 day history of chest pain and was initially admitted to oncology service but was transferred to CCU after EKG showing STE in V2-V3 and troponin elevation at 1.02. Onset of symptoms occurred [MASKED] hours prior to presentation and given complex comorbidities and complete resolution of symptoms, cardiac cath was deferred and medical management was pursued. A TTE showing mild regional LV systolic dysfunction in LAD distribution with EF 40%. The patient was initially started on heparin drip and on dual anti platelet therapy but these were deferred in the setting of GI bleed. Metoprolol and lisinopril were not started due to hypotension and significant GI bleed per above. # Small Subsegmental Pulmonary Embolus On admission, there was evidence of small sub-subsegmental PE on CTA chest. He was started on anticoagulation for STEMI that would also cover small segmental PE, however given active GI bleed, continuation of anticoagulation was deferred. # Hyponatremia # [MASKED] Patient presented with known history of hyponatremia thought to be SIADH in the setting of a macroadenoma in the pituitary. Sodium was trended daily and improved with IVF and PO intake # Possible LLL Pneumonia, CAP Patient was initially started on a 5 day course of ceftriaxone and briefly broadened to vancomycin and cefepime. However given lack of fevers, leukocytosis, clinical signs of pneumonia, the patient's antibiotics were stopped and he was closely monitored. # H. pylori Infection The patient was continued on metronidazole QID, tetracycline QID, omeprazole, bismuth x 2 weeks ([MASKED]) # Pancreatic Adenocarcinoma, Stage III-IV # Functional Gastric Outlet Obstruction Recently diagnosed with stage III-IV pancreatic adenocarcinoma (7.5cm) obliterating SMV and encasing SMA on cycle 1 of palliative gemcitabine (first/last dose [MASKED]. CT torso [MASKED] again with large hypodense mass in pancreatic head invading second and third portions of the duodenum. Possible or impending obstruction of CBD stent also noted. Patient underwent palliative duodenal stenting. CHRONIC ISSUES: =============== # Type 2 Diabetes Mellitus Patient had known history of type 2 diabetes. He was on a regimen of metformin and glimepiride at home. These oral hypoglycemics were held in the inpatient setting and the patient was started on insulin sliding scale. # Pituitary Macroadenoma 14mm non-enhancing lesion in anterior right pituitary noted on MRI [MASKED]. Thought to possibly be cystic. Further management not within goals of care. TRANSITIONAL ISSUES =================== []Pain control: Recommend titration of pain control to make patient comfortable []Nausea/Vomiting: Recommend use of anti-emetics/benzodiazepines to aggressively control symptoms # CODE: DNR/DNI, MOLST in chart # CONTACT/HCP: [MASKED] (son, lives with him) [MASKED] [MASKED] (son) [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ondansetron 4 mg PO Q8H:PRN nausea 2. Bismuth Subsalicylate 15 mL PO QID 3. Simethicone 120 mg PO QID:PRN gas 4. MetroNIDAZOLE 250 mg PO QID 5. Omeprazole 20 mg PO DAILY 6. glimepiride 4 mg oral DAILY 7. Tetracycline 500 mg PO QID 8. Nephrocaps 1 CAP PO DAILY Discharge Medications: 1. GlipiZIDE XL 2.5 mg PO DAILY 2. HYDROmorphone (Dilaudid) 0.5-1 mg IV Q3H:PRN Pain - Moderate 3. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Mild 4. Sucralfate 1 gm PO QID 5. Bismuth Subsalicylate 15 mL PO QID 6. Ondansetron 4 mg PO Q8H:PRN nausea 7. Simethicone 120 mg PO QID:PRN gas Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Primary Diagnoses ================= Acute blood loss anemia Upper GI bleed Gastric outlet obstruction Thrombocytopenia Leukocytosis Acute Kidney Injury STEMI Pulmonary embolus, small sub-submental Hyponatremia SIADH Left lower lobe pneumonia, community-acquired Secondary Diagnoses =================== Pancreatic adenocarcinoma, stage III–IV H pylori infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: Dear Mr. [MASKED], It was a pleasure taking care of you in the hospital! Why was I admitted? You were admitted to the hospital because had a heart attack What happened while I was admitted? -You had a heart attack and were given blood thinning medications -You had a stent placed in your stomach to help with nausea and vomiting -You were given blood back because you were bleeding What should I do after I leave the hospital? -Spend time with your family and loved ones We wish you the very best! Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "N179", "E872", "I2510", "E785", "I10", "Z66", "D696", "D649" ]
[ "I2109: ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior wall", "J189: Pneumonia, unspecified organism", "E43: Unspecified severe protein-calorie malnutrition", "K254: Chronic or unspecified gastric ulcer with hemorrhage", "K264: Chronic or unspecified duodenal ulcer with hemorrhage", "I2699: Other pulmonary embolism without acute cor pulmonale", "E222: Syndrome of inappropriate secretion of antidiuretic hormone", "N179: Acute kidney failure, unspecified", "K311: Adult hypertrophic pyloric stenosis", "E872: Acidosis", "K56609: Unspecified intestinal obstruction, unspecified as to partial versus complete obstruction", "C170: Malignant neoplasm of duodenum", "C259: Malignant neoplasm of pancreas, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E785: Hyperlipidemia, unspecified", "I10: Essential (primary) hypertension", "E861: Hypovolemia", "I959: Hypotension, unspecified", "Z66: Do not resuscitate", "D696: Thrombocytopenia, unspecified", "D649: Anemia, unspecified", "Z7401: Bed confinement status", "E8809: Other disorders of plasma-protein metabolism, not elsewhere classified", "B9681: Helicobacter pylori [H. pylori] as the cause of diseases classified elsewhere" ]
19,996,783
22,140,408
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: nausea, abdominal discomfort Major Surgical or Invasive Procedure: none History of Present Illness: ___ y/o M with PMhx of HTN, NIDDM, pituitary macroadenoma and recently diagnosed pancreatic mass causing biliary obstruction s/p recent ERCP with stent who returns after discharge with nausea, abd discomfort and inability to tolerate much po. Pt reports feeling much better after ERCP with stent and felt return of appetite. He went home and ate well initially. However, he soon developed abd discomfort and intractable nausea. He tried simethicone without any relief and was unable to sleep because of symptoms. He returned to the ED and was found to have mild dehydration, acute on chronic hyponatremia and persistent LFT abnormalities. He was able to have a BM in the ED which provided some relief. He has not eaten much all day and feels some improvement in symptoms. Denies any nausea currently and abd discomfort has improved. He is concerned about how to manage symptoms at home and feels his stomach may be blocked up. Denies any CP, SOB, cough, LH, HA, congestion, dysuria, hematuria, rash or abd pain currently. He has not noticed and worsening in ___ edema and is wearing TEDs currently. Past Medical History: NIDDM HTN Recently Dx with large pancreatic mass causing biliary obstruction now s/p ERCP with stent, final path pending though prelim + adenocarcinoma Social History: ___ Family History: none relevant to current presentation Physical Exam: PE: ___ Temp: 98.3 PO BP: 133/75 L Lying HR: 91 RR: 18 O2 sat: 100% O2 delivery: Ra GEN: pleasant elderly Asian male in NAD HEENT: MMM CV: RRR RESP: CTAB no w/r ABD: distended, mild TTP over RUQ but no rebound, BS present GU: no foley EXTR: thin, trace ankle edema bilaterally, TEDS in place NEURO: alert, appropriate, oriented x 3 Pertinent Results: ___ 07:20AM BLOOD WBC-9.1 RBC-3.19* Hgb-8.3* Hct-26.0* MCV-82 MCH-26.0 MCHC-31.9* RDW-16.1* RDWSD-47.8* Plt ___ ___ 07:15AM BLOOD WBC-9.6 RBC-3.04* Hgb-8.0* Hct-23.8* MCV-78* MCH-26.3 MCHC-33.6 RDW-15.7* RDWSD-43.9 Plt ___ ___ 08:55AM BLOOD WBC-9.6 RBC-3.59* Hgb-9.5* Hct-28.0* MCV-78* MCH-26.5 MCHC-33.9 RDW-15.7* RDWSD-43.5 Plt ___ ___ 06:47AM BLOOD WBC-9.8 RBC-3.13* Hgb-8.2* Hct-24.5* MCV-78* MCH-26.2 MCHC-33.5 RDW-15.5 RDWSD-42.9 Plt ___ ___ 08:55AM BLOOD Neuts-84.4* Lymphs-7.4* Monos-6.4 Eos-0.8* Baso-0.2 Im ___ AbsNeut-8.11* AbsLymp-0.71* AbsMono-0.62 AbsEos-0.08 AbsBaso-0.02 ___ 07:20AM BLOOD Glucose-129* UreaN-13 Creat-0.7 Na-130* K-3.8 Cl-91* HCO3-24 AnGap-15 ___ 07:15AM BLOOD Glucose-158* UreaN-13 Creat-0.6 Na-131* K-3.7 Cl-95* HCO3-24 AnGap-12 ___ 10:25PM BLOOD Glucose-260* UreaN-15 Creat-0.8 Na-129* K-3.8 Cl-92* HCO3-24 AnGap-13 ___ 10:20AM BLOOD Glucose-208* UreaN-17 Creat-0.9 Na-126* K-5.0 Cl-92* HCO3-20* AnGap-14 ___ 06:47AM BLOOD Glucose-104* UreaN-9 Creat-0.6 Na-131* K-3.9 Cl-93* HCO3-21* AnGap-17 ___ 07:20AM BLOOD ALT-43* AST-29 AlkPhos-217* TotBili-2.0* ___ 07:15AM BLOOD ALT-47* AST-31 AlkPhos-235* TotBili-2.1* ___ 10:20AM BLOOD ALT-59* AST-57* AlkPhos-286* TotBili-2.5* ___ 06:47AM BLOOD ALT-59* AST-44* LD(LDH)-218 AlkPhos-291* TotBili-3.0* ___ 10:20AM BLOOD Lipase-61* KUB: IMPRESSION: Nonspecific bowel gas pattern. Stomach is mildly dilated. No evidence of small-bowel obstruction. Gas and stool filling the large bowel loops Brief Hospital Course: ___ y/o M with NIDDM, HTN and recently diagnosed pancreatic cancer causing biliary obstruction s/p ERCP with stent who returns with nausea and decreased ability to tolerate po. #possible functional duodenal/gastric outlet obstruction #Pancreatic adenocarcinoma #Nausea/abd discomfort: mass invasion of duodenum may be causing functional gastric outlet obstruction. Pt's symptoms improved with decreased PO intake, after ERCP, and after BM, gas may be contributing. Pt tolerated better PO during admission. D/w Pt importance of nutrition and taking what he is able to tolerate and to supplement with ensure or boost if needed. Nutrition consulted. Discussed attempting a liquid diet if he is unable to tolerate solid food. Discussed symptom control with ___, simethicone, bowel regimen. Discussed case with oncology and ERCP teams. Plan for outpt onc f/u (as already arranged ___ and per ERCP team, no significant intestinal stricture noted on ERCP to intervene upon at this time. #Hyponatremia/SIADH: clinically euvolemic now and Na improved on repeat labs likely because pt was taking decreased PO. Na stable during admission without IVF or fluid restriction. #anemia-no clear evidence of bleeding. Trend/monitor. Outpt f/u. #NIDDM: Restarted home oral agents on DC. If PO intake over the long run becomes an issue, he may need to DC some of these agents. #Pituitary Macroadenoma: outpt f/u Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Bisacodyl 10 mg PO DAILY:PRN Constipation - First Line 2. Polyethylene Glycol 17 g PO BID 3. Senna 17.2 mg PO BID 4. Simethicone 40-80 mg PO QID:PRN stomach upset 5. Simvastatin 10 mg PO QPM 6. glimepiride 4 mg oral DAILY 7. MetFORMIN (Glucophage) 1000 mg PO BID 8. Nepro Carb Steady (nut.tx.imp.renal fxn,lac-reduc) 0.08 gram-1.8 kcal/mL oral TID W/MEALS Discharge Medications: 1. Docusate Sodium 100 mg PO BID you may purchase over the counter RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 2. Ondansetron 4 mg PO Q8H:PRN nausea RX *ondansetron HCl 4 mg 1 tablet(s) by mouth daily Disp #*20 Tablet Refills:*0 3. Bisacodyl 10 mg PO DAILY:PRN Constipation - First Line RX *bisacodyl [Dulcolax (bisacodyl)] 5 mg ___ tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. glimepiride 4 mg oral DAILY 5. MetFORMIN (Glucophage) 1000 mg PO BID 6. Nepro Carb Steady (nut.tx.imp.renal fxn,lac-reduc) 0.08 gram-1.8 kcal/mL oral TID W/MEALS 7. Polyethylene Glycol 17 g PO BID RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 17gm powder(s) by mouth daily Refills:*0 8. Senna 17.2 mg PO BID RX *sennosides [Senna-Gen] 8.6 mg 1 tab by mouth twice a day Disp #*60 Tablet Refills:*0 9. Simethicone 40-80 mg PO QID:PRN stomach upset 10. Simvastatin 10 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: pancreatic cancer nausea constipation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted for evaluation and treatment of abdominal pain/bloating and nausea and decreased ability to eat and drink likely secondary to your pancreatic cancer and also some constipation. For this, you were evaluated by the nutritionist and we discussed using supplements such as boost or ensure if you are unable to eat and drink well. Please try to eat and drink as you are able. You may need to have a liquid or a softer diet if you feel unable to eat and drink well. You will meet with the cancer doctors this week to discuss the next steps in your treatment. Followup Instructions: ___
[ "C259", "E222", "K315", "K311", "R110", "K5900", "E119", "I10", "D649", "E860" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: nausea, abdominal discomfort Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] y/o M with PMhx of HTN, NIDDM, pituitary macroadenoma and recently diagnosed pancreatic mass causing biliary obstruction s/p recent ERCP with stent who returns after discharge with nausea, abd discomfort and inability to tolerate much po. Pt reports feeling much better after ERCP with stent and felt return of appetite. He went home and ate well initially. However, he soon developed abd discomfort and intractable nausea. He tried simethicone without any relief and was unable to sleep because of symptoms. He returned to the ED and was found to have mild dehydration, acute on chronic hyponatremia and persistent LFT abnormalities. He was able to have a BM in the ED which provided some relief. He has not eaten much all day and feels some improvement in symptoms. Denies any nausea currently and abd discomfort has improved. He is concerned about how to manage symptoms at home and feels his stomach may be blocked up. Denies any CP, SOB, cough, LH, HA, congestion, dysuria, hematuria, rash or abd pain currently. He has not noticed and worsening in [MASKED] edema and is wearing TEDs currently. Past Medical History: NIDDM HTN Recently Dx with large pancreatic mass causing biliary obstruction now s/p ERCP with stent, final path pending though prelim + adenocarcinoma Social History: [MASKED] Family History: none relevant to current presentation Physical Exam: PE: [MASKED] Temp: 98.3 PO BP: 133/75 L Lying HR: 91 RR: 18 O2 sat: 100% O2 delivery: Ra GEN: pleasant elderly Asian male in NAD HEENT: MMM CV: RRR RESP: CTAB no w/r ABD: distended, mild TTP over RUQ but no rebound, BS present GU: no foley EXTR: thin, trace ankle edema bilaterally, TEDS in place NEURO: alert, appropriate, oriented x 3 Pertinent Results: [MASKED] 07:20AM BLOOD WBC-9.1 RBC-3.19* Hgb-8.3* Hct-26.0* MCV-82 MCH-26.0 MCHC-31.9* RDW-16.1* RDWSD-47.8* Plt [MASKED] [MASKED] 07:15AM BLOOD WBC-9.6 RBC-3.04* Hgb-8.0* Hct-23.8* MCV-78* MCH-26.3 MCHC-33.6 RDW-15.7* RDWSD-43.9 Plt [MASKED] [MASKED] 08:55AM BLOOD WBC-9.6 RBC-3.59* Hgb-9.5* Hct-28.0* MCV-78* MCH-26.5 MCHC-33.9 RDW-15.7* RDWSD-43.5 Plt [MASKED] [MASKED] 06:47AM BLOOD WBC-9.8 RBC-3.13* Hgb-8.2* Hct-24.5* MCV-78* MCH-26.2 MCHC-33.5 RDW-15.5 RDWSD-42.9 Plt [MASKED] [MASKED] 08:55AM BLOOD Neuts-84.4* Lymphs-7.4* Monos-6.4 Eos-0.8* Baso-0.2 Im [MASKED] AbsNeut-8.11* AbsLymp-0.71* AbsMono-0.62 AbsEos-0.08 AbsBaso-0.02 [MASKED] 07:20AM BLOOD Glucose-129* UreaN-13 Creat-0.7 Na-130* K-3.8 Cl-91* HCO3-24 AnGap-15 [MASKED] 07:15AM BLOOD Glucose-158* UreaN-13 Creat-0.6 Na-131* K-3.7 Cl-95* HCO3-24 AnGap-12 [MASKED] 10:25PM BLOOD Glucose-260* UreaN-15 Creat-0.8 Na-129* K-3.8 Cl-92* HCO3-24 AnGap-13 [MASKED] 10:20AM BLOOD Glucose-208* UreaN-17 Creat-0.9 Na-126* K-5.0 Cl-92* HCO3-20* AnGap-14 [MASKED] 06:47AM BLOOD Glucose-104* UreaN-9 Creat-0.6 Na-131* K-3.9 Cl-93* HCO3-21* AnGap-17 [MASKED] 07:20AM BLOOD ALT-43* AST-29 AlkPhos-217* TotBili-2.0* [MASKED] 07:15AM BLOOD ALT-47* AST-31 AlkPhos-235* TotBili-2.1* [MASKED] 10:20AM BLOOD ALT-59* AST-57* AlkPhos-286* TotBili-2.5* [MASKED] 06:47AM BLOOD ALT-59* AST-44* LD(LDH)-218 AlkPhos-291* TotBili-3.0* [MASKED] 10:20AM BLOOD Lipase-61* KUB: IMPRESSION: Nonspecific bowel gas pattern. Stomach is mildly dilated. No evidence of small-bowel obstruction. Gas and stool filling the large bowel loops Brief Hospital Course: [MASKED] y/o M with NIDDM, HTN and recently diagnosed pancreatic cancer causing biliary obstruction s/p ERCP with stent who returns with nausea and decreased ability to tolerate po. #possible functional duodenal/gastric outlet obstruction #Pancreatic adenocarcinoma #Nausea/abd discomfort: mass invasion of duodenum may be causing functional gastric outlet obstruction. Pt's symptoms improved with decreased PO intake, after ERCP, and after BM, gas may be contributing. Pt tolerated better PO during admission. D/w Pt importance of nutrition and taking what he is able to tolerate and to supplement with ensure or boost if needed. Nutrition consulted. Discussed attempting a liquid diet if he is unable to tolerate solid food. Discussed symptom control with [MASKED], simethicone, bowel regimen. Discussed case with oncology and ERCP teams. Plan for outpt onc f/u (as already arranged [MASKED] and per ERCP team, no significant intestinal stricture noted on ERCP to intervene upon at this time. #Hyponatremia/SIADH: clinically euvolemic now and Na improved on repeat labs likely because pt was taking decreased PO. Na stable during admission without IVF or fluid restriction. #anemia-no clear evidence of bleeding. Trend/monitor. Outpt f/u. #NIDDM: Restarted home oral agents on DC. If PO intake over the long run becomes an issue, he may need to DC some of these agents. #Pituitary Macroadenoma: outpt f/u Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Bisacodyl 10 mg PO DAILY:PRN Constipation - First Line 2. Polyethylene Glycol 17 g PO BID 3. Senna 17.2 mg PO BID 4. Simethicone 40-80 mg PO QID:PRN stomach upset 5. Simvastatin 10 mg PO QPM 6. glimepiride 4 mg oral DAILY 7. MetFORMIN (Glucophage) 1000 mg PO BID 8. Nepro Carb Steady (nut.tx.imp.renal fxn,lac-reduc) 0.08 gram-1.8 kcal/mL oral TID W/MEALS Discharge Medications: 1. Docusate Sodium 100 mg PO BID you may purchase over the counter RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 2. Ondansetron 4 mg PO Q8H:PRN nausea RX *ondansetron HCl 4 mg 1 tablet(s) by mouth daily Disp #*20 Tablet Refills:*0 3. Bisacodyl 10 mg PO DAILY:PRN Constipation - First Line RX *bisacodyl [Dulcolax (bisacodyl)] 5 mg [MASKED] tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. glimepiride 4 mg oral DAILY 5. MetFORMIN (Glucophage) 1000 mg PO BID 6. Nepro Carb Steady (nut.tx.imp.renal fxn,lac-reduc) 0.08 gram-1.8 kcal/mL oral TID W/MEALS 7. Polyethylene Glycol 17 g PO BID RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 17gm powder(s) by mouth daily Refills:*0 8. Senna 17.2 mg PO BID RX *sennosides [Senna-Gen] 8.6 mg 1 tab by mouth twice a day Disp #*60 Tablet Refills:*0 9. Simethicone 40-80 mg PO QID:PRN stomach upset 10. Simvastatin 10 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: pancreatic cancer nausea constipation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted for evaluation and treatment of abdominal pain/bloating and nausea and decreased ability to eat and drink likely secondary to your pancreatic cancer and also some constipation. For this, you were evaluated by the nutritionist and we discussed using supplements such as boost or ensure if you are unable to eat and drink well. Please try to eat and drink as you are able. You may need to have a liquid or a softer diet if you feel unable to eat and drink well. You will meet with the cancer doctors this week to discuss the next steps in your treatment. Followup Instructions: [MASKED]
[]
[ "K5900", "E119", "I10", "D649" ]
[ "C259: Malignant neoplasm of pancreas, unspecified", "E222: Syndrome of inappropriate secretion of antidiuretic hormone", "K315: Obstruction of duodenum", "K311: Adult hypertrophic pyloric stenosis", "R110: Nausea", "K5900: Constipation, unspecified", "E119: Type 2 diabetes mellitus without complications", "I10: Essential (primary) hypertension", "D649: Anemia, unspecified", "E860: Dehydration" ]
19,996,783
25,894,657
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: lower extremity weakness Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is an ___ year old ___ and ___ speaking man with PMH of HTN, non-insulin dependent DM2, HLD, referred by his PCP at ___ (Dr. ___, who presented to the ED with BLE weakness of 2 weeks' duration. He also had a fall on ___. He is a very good historian. Patient reports he was using a walker, felt weak, and fell to the floor gently on his knees (able to support himself on walker). No LOC, no head strike, no presyncopal symptoms, no dizziness, lightheadedness, or palpitations. He did not have the strength to get back up after he fell, so he was on the floor for 2 hours until his son came and helped him. Patient states he also has increasing difficulty with urinary retention and incontinence. Denies change in urinary frequency. Also reports constipation and increased urgency but no diarrhea or uncontrolled bowel movements. He checks his blood glucose daily in the morning. They are normally high 100's-200. No recent fever, chills, sweats, headache, problems with speaking, gait problems, chest pain, cough, shortness of breath, abdominal pain, trauma to back. No ___ services. Usually just cared for by family. In the ED, initial VS were 97.6, HR 100, BP 146/64, RR 16, 100% RA. Labs showed Na 110, K 5.6, glucose 223, WBC 10.5, Hgb 10.6, lactate 1.4, VBG 7.35/33. UA showed SGr 1.012, 14 RBCs, few bacteria, 400 glucose, 10 ketones. Urine Na 67, osm 460. He has no recent labs prior to presentation, per ED report. He was given 1L NS, and another L was running prior to transfer to MICU. UOP>50cc/h, increased with fluids. Guaiac negative. He had normal rectal tone, no saddle anesthesia. EKG showed sinus tachycardia. CXR showed bibasilar patchy opacities, may reflect atelectasis with pneumonia or aspiration not excluded. Vitals on transfer 98.1, HR 101, BP 147/60; RR 18, 100% RA. On arrival to the MICU, patient reports history as above. Since the ___ year 2 weeks ago, has had worsening ___ weakness, now requiring a walker to walk. Onlychange at that time was that he may have eaten more sugar than normal. Reports low appetite over this time as well, eating only oatmeal and rice. He usually has low sodium diet, now just eating less of it. Denies increased thirst/excessive water intake. Currently has some abdominal discomfort but no pain, nausuea, vomiting. Urinating ok today, but as above has been having incontinence/retention issue. Constipated over last few days, passing flatus. No chest pain, SOB, cough, dizziness. Past Medical History: Type II Diabetes HTN HLD Social History: ___ Family History: Non-contributory Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: Reviewed in metavision HEENT: PERRL, EOMI. NC/AT. Oropharynx: moist mucous membranes CV: Regular rate and rhythm, normal S1/S2 Resp: Normal work of breathing, bibasilar crackles. Chest with some discomfort on deep palpation diffusely Abd: Soft, nontender, distended at baseline. Tympanic. Rectal: good tone, hemoccult negative MSK: Able to move all extremities, no saddle anesthesia Extremities: Intact to sensation bilaterally in upper and lower extremities, ___ strength in upper and lower extremities proximally and distally. No lower extremity edema. Neuro: Alert, oriented, normal speech, able to respond to commands and follow directions. ___ strength diffusely, CN II-XII intact. DISCHARGE PHYSICAL EXAM: ======================== Oropharynx: moist mucous membranes CV: Regular rate and rhythm, normal S1/S2 Resp: Normal work of breathing, clear bilaterally. Abd: Soft, nontender, distended at baseline. MSK: Able to move all extremities Extremities: Intact to sensation bilaterally in upper and lower extremities, ___ strength in upper and lower extremities proximally and distally. No lower extremity edema. Neuro: Alert, oriented, normal speech, able to respond to commands and follow directions. ___ strength diffusely, CN II-XII intact. Pertinent Results: =============== ADMISSION LABS =============== ___ 05:04PM BLOOD WBC-10.5* RBC-3.97* Hgb-10.6* Hct-30.7* MCV-77* MCH-26.7 MCHC-34.5 RDW-11.8 RDWSD-32.8* Plt ___ ___ 05:04PM BLOOD Neuts-82.1* Lymphs-9.2* Monos-7.0 Eos-0.7* Baso-0.4 Im ___ AbsNeut-8.62* AbsLymp-0.97* AbsMono-0.73 AbsEos-0.07 AbsBaso-0.04 ___ 05:04PM BLOOD Glucose-223* UreaN-23* Creat-0.9 Na-110* K-5.6* Cl-78* HCO3-16* AnGap-16 ___ 06:08PM BLOOD ALT-10 AST-17 LD(LDH)-200 AlkPhos-68 TotBili-0.4 ___ 05:04PM BLOOD Calcium-8.7 Phos-3.1 Mg-1.5* ___ 10:00PM BLOOD calTIBC-218* Ferritn-288 TRF-168* ___ 06:08PM BLOOD TSH-1.4 ___ 06:19PM BLOOD pO2-38* pCO2-32* pH-7.34* calTCO2-18* Base XS--7 =============== DISCHARGE LABS =============== ___ 05:06AM BLOOD WBC-7.9 RBC-2.85* Hgb-7.7* Hct-23.1* MCV-81* MCH-27.0 MCHC-33.3 RDW-12.6 RDWSD-36.6 Plt ___ ___ 05:04PM BLOOD Neuts-82.1* Lymphs-9.2* Monos-7.0 Eos-0.7* Baso-0.4 Im ___ AbsNeut-8.62* AbsLymp-0.97* AbsMono-0.73 AbsEos-0.07 AbsBaso-0.04 ___ 05:06AM BLOOD Plt ___ ___ 05:06AM BLOOD Glucose-200* UreaN-17 Creat-0.9 Na-133* K-4.5 Cl-97 HCO3-22 AnGap-14 ___ 05:06AM BLOOD Calcium-8.6 Phos-4.0 Mg-1.8 ___ 05:17AM BLOOD calTIBC-215* Ferritn-289 TRF-165* ================== STUDIES/PATHOLOGY ================== MRI pituitary (___): FINDINGS:  1 4   x   1 0   x   9   m m   ( A P   b y   T V   b y   S I )   n o n e n h a n c i n g   s l i g h t l y   T 1   h y p e r i n t e n s e   l e s i n i s   i d e n t i f i e d   i n   t h e   r i g h t   p i t u i t a r y .     I n f u n d i b u l u m   i s   m i l d l y   d e v i a t e d   t o   t h e l e f t .   T h e   s u p r a s e l l a r   c i s t e r n   a n d   c a v e r n o u s   s i n u s e s a p p e a r   u n r e m a r k a b l e .     T h e l i m i t e d   p o r t i o n   o f   t h e   b r a i n   i n c l u d e d   o n   i s   n o t a b l e   f o r   p e r i v e n t r i c u l a r   a n d s u b c o r t i c a l   w h i t e   m a t t e r   T 2   h y p e r i n t e n s i t i e s   c o n s i s t e n t   w i t h   c h r o n i c   s m a l l v e s s e l   d i s e a s e .     Small mucous retention cyst is noted in the right sphenoidsinus. CT head w/o contrast (___):   IMPRESSION: 1 .   N o intracranial hemorrhage.  No acute intracranial abnormality on noncontrast head CT. 2. Probable sequelae of chronic small vessel ischemic disease. 3. Cortical atrophy. 4. Paranasal sinus disease. CXR (___): IMPRESSION:  Compared to chest radiographs ___. U p p e r   l o b e s are clear and pulmonary vasculature is not engorged.  Previous v o l ume loss in the left lower lobe has improved, but there is still s u b s t a n t i a l peribronchial opacification.  This could be atelectasis due to r e t a i n ed secretions.  Pleural effusion is small on the right, if any.  Moderate cardiomegaly stable. CXR (___): IMPRESSION:  B i b a silar patchy opacities may reflect atelectasis with pneumonia or aspiration not excluded in the correct clinical setting. ============ MICROBIOLOGY ============ Urine culture (___): negative Brief Hospital Course: ==================== PATIENT SUMMARY: ==================== Mr. ___ is an ___ year old ___ speaking man with PMH of HTN, non-insulin dependent DM2, HLD, referred by his PCP at ___ (Dr. ___, who presented to the ED with BLE weakness of 2 weeks' duration, found to be profoundly hyponatremic to 110, likely secondary to hypovolemia and SIADH perhaps due to an underlying pituitary mass. ==================== ACUTE ISSUES: ==================== #Hyponatremia: The patient was profoundly hyponatremic on admission with Na of 110. There was almost certainly some component of hypovolemic hyponatremia initially given the robust initial response to IVF. However, given sustained elevated urine Osms and lack of continued response to volume resuscitation alone, the continued hyponatremia was likely driven by SIADH. The etiology for SIADH is also unclear, though possibly related to pituitary mass (discussed below). There was also likely some component of Type IV RTA secondary to Lisinopril use, and Lisinopril was held which we continued to hold on discharge. The patient continued treatment for SIADH with 1L free water restriction and TID ensure shakes with a high salt diet as well as 20mg PO Lasix. The patient was refusing ensure shakes while in the hospital, however we discharged him with TID shakes and recommended that he continue to take these with every meal. His TSH and AM cortisol (x2) were normal. He was discharged with primary care follow up and should have his sodium checked at his first follow up. #Pituitary lesion: MRI showed 14mm lesion in the anterior pituitary with ddx including cystic macroadenoma with possible subacute hemorrhage vs Rathke's cleft cyst (less likely based on location of lesion). Macroadenoma may be non-functioning or functioning (with excess secretion of LH/FSH vs ___ vs prolactin; TSH or ACTH-secreting microadenoma is less likely given normal TSH and AM free cortisol on this admission). Unclear if this lesion is responsible for hyponatremia leading to excess ADH secretion but so far there is no other possible explanation for SIADH. Visual field testing normal by ICU team and ophtho. Neurosurgery consulted and given no optic chiasm compression no need for intervention at this time. Will need f/u MRI as outpatient in 6 months and neurosurgery follow up. ___ Weakness/fall, resolved Neuro exam intact. Good rectal tone. No spinal tenderness. Most likely Hyponatremia related as improved with treatment. Of note, he was found to have some orthostatic hypotension though was asymptomatic and was ambulating well with physical therapy. #Metabolic Acidosis, resolved #Ketonuria, resolved Patient with bicarb 16, gap 16, pH 7.34, 10 ketones urine, normal lactate. Given poor diet most likely some element of starvation ketosis. His blood sugar was 400 on initial check, but has been low 200s on repeat checks, and type II diabetic not on SGL-2 inhibitor, less concern for DKA/HONK. #Abdominal distension #Constipation Abdominal exam benign. Likely due to constipation. TSH normal. Given bowel regimen. #Urinary retention/incontinence Normal rectal exam, less concern for neurological process. Sugars have been more elevated lately, so could be symptomatic from glucosuria/osmotic diuresis. Improved. ==================== CHRONIC ISSUES: ==================== #HTN: Held Lisinopril i/s/o hyperkalemia on admission. Blood pressure was normal during admission. If needs better BP control as outpatient, would recommend starting on a non-Ace inhibitor regimen. #DM: Held home oral medications and gave sliding scale insulin during hospitalization. Restarted home meds on discharge. #Microcytic anemia: Unknown baseline. Iron studies consistent with anemia of chronic disease. Consider colonoscopy as outpatient ==================== TRANSITIONAL ISSUES: ==================== [ ] 14 mm pituitary mass: Will need f/u MRI as outpatient in 6 months and neurosurgery follow up. [ ] Lisinopril held with stable blood pressure due to hyperkalemia on admission as well as possible contribution to Type IV RTA, can consider starting different antihypertensive if needs better BP control as outpatient [ ] Found to have mild asymptomatic orthostatic hypotension. Can consider midodrine if develops issues with pre-syncope/syncope [ ] Found to have stable microcytic anemia. Ensure he is up to date on colonoscopies. - New Meds: lasix - Stopped/Held Meds: lisinopril - Changed Meds: none - Follow-up appointments: PCP, ___, neurosurgery - Post-Discharge Follow-up Labs Needed: chem 10 - Incidental Findings: pituitary mass - Discharge weight: 194 lb. - Discharge creatinine: 0.9 # Communication: ___ (son, lives with him) ___ ___ (son) ___ # Code: Full confirmed Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 5 mg PO DAILY 2. Simvastatin 10 mg PO QPM 3. MetFORMIN (Glucophage) 500 mg PO BID 4. glimepiride 4 mg oral DAILY Discharge Medications: 1. Bisacodyl 10 mg PO DAILY:PRN Constipation - First Line RX *bisacodyl 5 mg 2 tablet(s) by mouth Daily Disp #*60 Tablet Refills:*0 2. Nepro Carb Steady (nut.tx.imp.renal fxn,lac-reduc) 0.08 gram-1.8 kcal/mL oral TID W/MEALS RX *nut.tx.imp.renal fxn,lac-reduc [Nepro Carb Steady] 0.08 gram-1.8 kcal/mL 8 ounces by mouth TID with meals Refills:*0 3. Polyethylene Glycol 17 g PO BID RX *polyethylene glycol 3350 17 gram/dose 1 powder(s) by mouth Twice daily Refills:*0 4. Senna 17.2 mg PO BID RX *sennosides [senna] 8.8 mg/5 mL 10 mL by mouth Twice daily Refills:*0 5. Simethicone 40-80 mg PO QID:PRN stomach upset RX *simethicone 125 mg 1 tablet by mouth Four times per day Disp #*60 Capsule Refills:*0 6. MetFORMIN (Glucophage) 1000 mg PO BID RX *metformin 1,000 mg 1 tablet(s) by mouth Twice daily Disp #*60 Tablet Refills:*0 7. glimepiride 4 mg oral DAILY 8. Simvastatin 10 mg PO QPM 9. HELD- Lisinopril 5 mg PO DAILY This medication was held. Do not restart Lisinopril until you are told to do so by your primary care doctor 10.Outpatient Lab Work Please draw a basic metabolic panel: ICD-9 code 253.6 Please fax results to ___. at ___ Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS ==================== SIADH Pituitary mass SECONDARY DIAGNOSIS ==================== T2DM HTN Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You came to ___ because you had a fall. You were found to have very low sodium. Please see more details listed below about what happened while you were in the hospital and your instructions for what to do after leaving the hospital. It was a pleasure participating in your care. We wish you the best! Sincerely, Your ___ Care Team WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL: - You underwent work up which revealed a mass in your brain which is thought to be benign, but you should follow up with the Neurosurgery team as below - You were treated with a low fluid and high salt diet to improve the low sodium - You were started on a water pill called lasix - You improved considerably and were ready to leave the hospital WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL: - Please continue the low fluid diet and restrict fluids to 1 liter per day - Please drink one glucerna shake with EACH meal (three times per day) - Please follow up with your primary care doctor and other health care providers (see below) - Please take all of your medications as prescribed (see below). - Seek medical attention if you have light-headedness, falls, weakness or other symptoms of concern. Followup Instructions: ___
[ "E222", "E872", "E1165", "E875", "E861", "E236", "I10", "Z7984", "E785", "Z9181", "R338", "R32", "K5900", "T464X5A", "Y92018", "I951", "R824", "D638", "H547", "H353131", "R531" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: lower extremity weakness Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is an [MASKED] year old [MASKED] and [MASKED] speaking man with PMH of HTN, non-insulin dependent DM2, HLD, referred by his PCP at [MASKED] (Dr. [MASKED], who presented to the ED with BLE weakness of 2 weeks' duration. He also had a fall on [MASKED]. He is a very good historian. Patient reports he was using a walker, felt weak, and fell to the floor gently on his knees (able to support himself on walker). No LOC, no head strike, no presyncopal symptoms, no dizziness, lightheadedness, or palpitations. He did not have the strength to get back up after he fell, so he was on the floor for 2 hours until his son came and helped him. Patient states he also has increasing difficulty with urinary retention and incontinence. Denies change in urinary frequency. Also reports constipation and increased urgency but no diarrhea or uncontrolled bowel movements. He checks his blood glucose daily in the morning. They are normally high 100's-200. No recent fever, chills, sweats, headache, problems with speaking, gait problems, chest pain, cough, shortness of breath, abdominal pain, trauma to back. No [MASKED] services. Usually just cared for by family. In the ED, initial VS were 97.6, HR 100, BP 146/64, RR 16, 100% RA. Labs showed Na 110, K 5.6, glucose 223, WBC 10.5, Hgb 10.6, lactate 1.4, VBG 7.35/33. UA showed SGr 1.012, 14 RBCs, few bacteria, 400 glucose, 10 ketones. Urine Na 67, osm 460. He has no recent labs prior to presentation, per ED report. He was given 1L NS, and another L was running prior to transfer to MICU. UOP>50cc/h, increased with fluids. Guaiac negative. He had normal rectal tone, no saddle anesthesia. EKG showed sinus tachycardia. CXR showed bibasilar patchy opacities, may reflect atelectasis with pneumonia or aspiration not excluded. Vitals on transfer 98.1, HR 101, BP 147/60; RR 18, 100% RA. On arrival to the MICU, patient reports history as above. Since the [MASKED] year 2 weeks ago, has had worsening [MASKED] weakness, now requiring a walker to walk. Onlychange at that time was that he may have eaten more sugar than normal. Reports low appetite over this time as well, eating only oatmeal and rice. He usually has low sodium diet, now just eating less of it. Denies increased thirst/excessive water intake. Currently has some abdominal discomfort but no pain, nausuea, vomiting. Urinating ok today, but as above has been having incontinence/retention issue. Constipated over last few days, passing flatus. No chest pain, SOB, cough, dizziness. Past Medical History: Type II Diabetes HTN HLD Social History: [MASKED] Family History: Non-contributory Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: Reviewed in metavision HEENT: PERRL, EOMI. NC/AT. Oropharynx: moist mucous membranes CV: Regular rate and rhythm, normal S1/S2 Resp: Normal work of breathing, bibasilar crackles. Chest with some discomfort on deep palpation diffusely Abd: Soft, nontender, distended at baseline. Tympanic. Rectal: good tone, hemoccult negative MSK: Able to move all extremities, no saddle anesthesia Extremities: Intact to sensation bilaterally in upper and lower extremities, [MASKED] strength in upper and lower extremities proximally and distally. No lower extremity edema. Neuro: Alert, oriented, normal speech, able to respond to commands and follow directions. [MASKED] strength diffusely, CN II-XII intact. DISCHARGE PHYSICAL EXAM: ======================== Oropharynx: moist mucous membranes CV: Regular rate and rhythm, normal S1/S2 Resp: Normal work of breathing, clear bilaterally. Abd: Soft, nontender, distended at baseline. MSK: Able to move all extremities Extremities: Intact to sensation bilaterally in upper and lower extremities, [MASKED] strength in upper and lower extremities proximally and distally. No lower extremity edema. Neuro: Alert, oriented, normal speech, able to respond to commands and follow directions. [MASKED] strength diffusely, CN II-XII intact. Pertinent Results: =============== ADMISSION LABS =============== [MASKED] 05:04PM BLOOD WBC-10.5* RBC-3.97* Hgb-10.6* Hct-30.7* MCV-77* MCH-26.7 MCHC-34.5 RDW-11.8 RDWSD-32.8* Plt [MASKED] [MASKED] 05:04PM BLOOD Neuts-82.1* Lymphs-9.2* Monos-7.0 Eos-0.7* Baso-0.4 Im [MASKED] AbsNeut-8.62* AbsLymp-0.97* AbsMono-0.73 AbsEos-0.07 AbsBaso-0.04 [MASKED] 05:04PM BLOOD Glucose-223* UreaN-23* Creat-0.9 Na-110* K-5.6* Cl-78* HCO3-16* AnGap-16 [MASKED] 06:08PM BLOOD ALT-10 AST-17 LD(LDH)-200 AlkPhos-68 TotBili-0.4 [MASKED] 05:04PM BLOOD Calcium-8.7 Phos-3.1 Mg-1.5* [MASKED] 10:00PM BLOOD calTIBC-218* Ferritn-288 TRF-168* [MASKED] 06:08PM BLOOD TSH-1.4 [MASKED] 06:19PM BLOOD pO2-38* pCO2-32* pH-7.34* calTCO2-18* Base XS--7 =============== DISCHARGE LABS =============== [MASKED] 05:06AM BLOOD WBC-7.9 RBC-2.85* Hgb-7.7* Hct-23.1* MCV-81* MCH-27.0 MCHC-33.3 RDW-12.6 RDWSD-36.6 Plt [MASKED] [MASKED] 05:04PM BLOOD Neuts-82.1* Lymphs-9.2* Monos-7.0 Eos-0.7* Baso-0.4 Im [MASKED] AbsNeut-8.62* AbsLymp-0.97* AbsMono-0.73 AbsEos-0.07 AbsBaso-0.04 [MASKED] 05:06AM BLOOD Plt [MASKED] [MASKED] 05:06AM BLOOD Glucose-200* UreaN-17 Creat-0.9 Na-133* K-4.5 Cl-97 HCO3-22 AnGap-14 [MASKED] 05:06AM BLOOD Calcium-8.6 Phos-4.0 Mg-1.8 [MASKED] 05:17AM BLOOD calTIBC-215* Ferritn-289 TRF-165* ================== STUDIES/PATHOLOGY ================== MRI pituitary ([MASKED]): FINDINGS: 1 4 x 1 0 x 9 m m ( A P b y T V b y S I ) n o n e n h a n c i n g s l i g h t l y T 1 h y p e r i n t e n s e l e s i n i s i d e n t i f i e d i n t h e r i g h t p i t u i t a r y . I n f u n d i b u l u m i s m i l d l y d e v i a t e d t o t h e l e f t . T h e s u p r a s e l l a r c i s t e r n a n d c a v e r n o u s s i n u s e s a p p e a r u n r e m a r k a b l e . T h e l i m i t e d p o r t i o n o f t h e b r a i n i n c l u d e d o n i s n o t a b l e f o r p e r i v e n t r i c u l a r a n d s u b c o r t i c a l w h i t e m a t t e r T 2 h y p e r i n t e n s i t i e s c o n s i s t e n t w i t h c h r o n i c s m a l l v e s s e l d i s e a s e . Small mucous retention cyst is noted in the right sphenoidsinus. CT head w/o contrast ([MASKED]): IMPRESSION: 1 . N o intracranial hemorrhage. No acute intracranial abnormality on noncontrast head CT. 2. Probable sequelae of chronic small vessel ischemic disease. 3. Cortical atrophy. 4. Paranasal sinus disease. CXR ([MASKED]): IMPRESSION: Compared to chest radiographs [MASKED]. U p p e r l o b e s are clear and pulmonary vasculature is not engorged. Previous v o l ume loss in the left lower lobe has improved, but there is still s u b s t a n t i a l peribronchial opacification. This could be atelectasis due to r e t a i n ed secretions. Pleural effusion is small on the right, if any. Moderate cardiomegaly stable. CXR ([MASKED]): IMPRESSION: B i b a silar patchy opacities may reflect atelectasis with pneumonia or aspiration not excluded in the correct clinical setting. ============ MICROBIOLOGY ============ Urine culture ([MASKED]): negative Brief Hospital Course: ==================== PATIENT SUMMARY: ==================== Mr. [MASKED] is an [MASKED] year old [MASKED] speaking man with PMH of HTN, non-insulin dependent DM2, HLD, referred by his PCP at [MASKED] (Dr. [MASKED], who presented to the ED with BLE weakness of 2 weeks' duration, found to be profoundly hyponatremic to 110, likely secondary to hypovolemia and SIADH perhaps due to an underlying pituitary mass. ==================== ACUTE ISSUES: ==================== #Hyponatremia: The patient was profoundly hyponatremic on admission with Na of 110. There was almost certainly some component of hypovolemic hyponatremia initially given the robust initial response to IVF. However, given sustained elevated urine Osms and lack of continued response to volume resuscitation alone, the continued hyponatremia was likely driven by SIADH. The etiology for SIADH is also unclear, though possibly related to pituitary mass (discussed below). There was also likely some component of Type IV RTA secondary to Lisinopril use, and Lisinopril was held which we continued to hold on discharge. The patient continued treatment for SIADH with 1L free water restriction and TID ensure shakes with a high salt diet as well as 20mg PO Lasix. The patient was refusing ensure shakes while in the hospital, however we discharged him with TID shakes and recommended that he continue to take these with every meal. His TSH and AM cortisol (x2) were normal. He was discharged with primary care follow up and should have his sodium checked at his first follow up. #Pituitary lesion: MRI showed 14mm lesion in the anterior pituitary with ddx including cystic macroadenoma with possible subacute hemorrhage vs Rathke's cleft cyst (less likely based on location of lesion). Macroadenoma may be non-functioning or functioning (with excess secretion of LH/FSH vs [MASKED] vs prolactin; TSH or ACTH-secreting microadenoma is less likely given normal TSH and AM free cortisol on this admission). Unclear if this lesion is responsible for hyponatremia leading to excess ADH secretion but so far there is no other possible explanation for SIADH. Visual field testing normal by ICU team and ophtho. Neurosurgery consulted and given no optic chiasm compression no need for intervention at this time. Will need f/u MRI as outpatient in 6 months and neurosurgery follow up. [MASKED] Weakness/fall, resolved Neuro exam intact. Good rectal tone. No spinal tenderness. Most likely Hyponatremia related as improved with treatment. Of note, he was found to have some orthostatic hypotension though was asymptomatic and was ambulating well with physical therapy. #Metabolic Acidosis, resolved #Ketonuria, resolved Patient with bicarb 16, gap 16, pH 7.34, 10 ketones urine, normal lactate. Given poor diet most likely some element of starvation ketosis. His blood sugar was 400 on initial check, but has been low 200s on repeat checks, and type II diabetic not on SGL-2 inhibitor, less concern for DKA/HONK. #Abdominal distension #Constipation Abdominal exam benign. Likely due to constipation. TSH normal. Given bowel regimen. #Urinary retention/incontinence Normal rectal exam, less concern for neurological process. Sugars have been more elevated lately, so could be symptomatic from glucosuria/osmotic diuresis. Improved. ==================== CHRONIC ISSUES: ==================== #HTN: Held Lisinopril i/s/o hyperkalemia on admission. Blood pressure was normal during admission. If needs better BP control as outpatient, would recommend starting on a non-Ace inhibitor regimen. #DM: Held home oral medications and gave sliding scale insulin during hospitalization. Restarted home meds on discharge. #Microcytic anemia: Unknown baseline. Iron studies consistent with anemia of chronic disease. Consider colonoscopy as outpatient ==================== TRANSITIONAL ISSUES: ==================== [ ] 14 mm pituitary mass: Will need f/u MRI as outpatient in 6 months and neurosurgery follow up. [ ] Lisinopril held with stable blood pressure due to hyperkalemia on admission as well as possible contribution to Type IV RTA, can consider starting different antihypertensive if needs better BP control as outpatient [ ] Found to have mild asymptomatic orthostatic hypotension. Can consider midodrine if develops issues with pre-syncope/syncope [ ] Found to have stable microcytic anemia. Ensure he is up to date on colonoscopies. - New Meds: lasix - Stopped/Held Meds: lisinopril - Changed Meds: none - Follow-up appointments: PCP, [MASKED], neurosurgery - Post-Discharge Follow-up Labs Needed: chem 10 - Incidental Findings: pituitary mass - Discharge weight: 194 lb. - Discharge creatinine: 0.9 # Communication: [MASKED] (son, lives with him) [MASKED] [MASKED] (son) [MASKED] # Code: Full confirmed Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 5 mg PO DAILY 2. Simvastatin 10 mg PO QPM 3. MetFORMIN (Glucophage) 500 mg PO BID 4. glimepiride 4 mg oral DAILY Discharge Medications: 1. Bisacodyl 10 mg PO DAILY:PRN Constipation - First Line RX *bisacodyl 5 mg 2 tablet(s) by mouth Daily Disp #*60 Tablet Refills:*0 2. Nepro Carb Steady (nut.tx.imp.renal fxn,lac-reduc) 0.08 gram-1.8 kcal/mL oral TID W/MEALS RX *nut.tx.imp.renal fxn,lac-reduc [Nepro Carb Steady] 0.08 gram-1.8 kcal/mL 8 ounces by mouth TID with meals Refills:*0 3. Polyethylene Glycol 17 g PO BID RX *polyethylene glycol 3350 17 gram/dose 1 powder(s) by mouth Twice daily Refills:*0 4. Senna 17.2 mg PO BID RX *sennosides [senna] 8.8 mg/5 mL 10 mL by mouth Twice daily Refills:*0 5. Simethicone 40-80 mg PO QID:PRN stomach upset RX *simethicone 125 mg 1 tablet by mouth Four times per day Disp #*60 Capsule Refills:*0 6. MetFORMIN (Glucophage) 1000 mg PO BID RX *metformin 1,000 mg 1 tablet(s) by mouth Twice daily Disp #*60 Tablet Refills:*0 7. glimepiride 4 mg oral DAILY 8. Simvastatin 10 mg PO QPM 9. HELD- Lisinopril 5 mg PO DAILY This medication was held. Do not restart Lisinopril until you are told to do so by your primary care doctor 10.Outpatient Lab Work Please draw a basic metabolic panel: ICD-9 code 253.6 Please fax results to [MASKED]. at [MASKED] Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSIS ==================== SIADH Pituitary mass SECONDARY DIAGNOSIS ==================== T2DM HTN Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], You came to [MASKED] because you had a fall. You were found to have very low sodium. Please see more details listed below about what happened while you were in the hospital and your instructions for what to do after leaving the hospital. It was a pleasure participating in your care. We wish you the best! Sincerely, Your [MASKED] Care Team WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL: - You underwent work up which revealed a mass in your brain which is thought to be benign, but you should follow up with the Neurosurgery team as below - You were treated with a low fluid and high salt diet to improve the low sodium - You were started on a water pill called lasix - You improved considerably and were ready to leave the hospital WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL: - Please continue the low fluid diet and restrict fluids to 1 liter per day - Please drink one glucerna shake with EACH meal (three times per day) - Please follow up with your primary care doctor and other health care providers (see below) - Please take all of your medications as prescribed (see below). - Seek medical attention if you have light-headedness, falls, weakness or other symptoms of concern. Followup Instructions: [MASKED]
[]
[ "E872", "E1165", "I10", "E785", "K5900" ]
[ "E222: Syndrome of inappropriate secretion of antidiuretic hormone", "E872: Acidosis", "E1165: Type 2 diabetes mellitus with hyperglycemia", "E875: Hyperkalemia", "E861: Hypovolemia", "E236: Other disorders of pituitary gland", "I10: Essential (primary) hypertension", "Z7984: Long term (current) use of oral hypoglycemic drugs", "E785: Hyperlipidemia, unspecified", "Z9181: History of falling", "R338: Other retention of urine", "R32: Unspecified urinary incontinence", "K5900: Constipation, unspecified", "T464X5A: Adverse effect of angiotensin-converting-enzyme inhibitors, initial encounter", "Y92018: Other place in single-family (private) house as the place of occurrence of the external cause", "I951: Orthostatic hypotension", "R824: Acetonuria", "D638: Anemia in other chronic diseases classified elsewhere", "H547: Unspecified visual loss", "H353131: Nonexudative age-related macular degeneration, bilateral, early dry stage", "R531: Weakness" ]
19,996,783
28,526,413
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: abdominal bloating Major Surgical or Invasive Procedure: ERCP with biopsy History of Present Illness: ___ old gentleman with HTN, NIDDM. He was admitted last month for ___ weakness and noted to have severe hyponatremia of 110. It partially corrected with IVF and was thought to be combination of hypovolemia and SIADH. Pituitary mass was found on imaging and it was unclear if this macroadenoma was functional. Outpatient follow up was advised after inpatient consultation by endocrine/neurosurgery and ophthalmology. He reports being in usual ___ till about 2 weeks ago. He started having abdominal discomfort, more in upper abdomen, along with nausea and poor intake. Pain is worse on eating. also abdomen in bloated. no constipation with his new laxative regimen. c/o generalized weakness but no other complaints. He has been adherent to 1L fluid restriction. Unable to take protein shakes because they are 'too sweet'. Review of Systems: ================== Complete ROS obtained and is otherwise negative. no dyspnea/chest pain. no urinary complaints. no fever/chills. no vomiting Past Medical History: pituitary macroadenoma SIADH Type II Diabetes HTN HLD Social History: ___ Family History: Non-contributory Physical Exam: VITALS: 97.4PO 153 / 76R Lying 85 18 100 Ra Orthostatic vital: SBP 149-->115 on standing HEENT: has icterus. dry mucosa CV: Regular rate and rhythm, normal S1/S2 Resp: Normal work of breathing, clear bilaterally. Abd: Soft, distended, tympanic, mild generalized tenderness, BS present MSK: Able to move all extremities Extremities: trace ___ edema Neuro: Alert, oriented, normal speech, able to respond to commands and follow directions Pertinent Results: ___ 06:47AM BLOOD WBC-9.8 RBC-3.13* Hgb-8.2* Hct-24.5* MCV-78* MCH-26.2 MCHC-33.5 RDW-15.5 RDWSD-42.9 Plt ___ ___ 07:45AM BLOOD WBC-10.7* RBC-3.32* Hgb-8.8* Hct-25.8* MCV-78* MCH-26.5 MCHC-34.1 RDW-15.1 RDWSD-41.9 Plt ___ ___ 09:45PM BLOOD WBC-10.8* RBC-3.78* Hgb-10.1* Hct-29.5* MCV-78* MCH-26.7 MCHC-34.2 RDW-15.2 RDWSD-42.6 Plt ___ ___ 09:45PM BLOOD Neuts-84.6* Lymphs-7.7* Monos-5.4 Eos-1.4 Baso-0.3 Im ___ AbsNeut-9.17* AbsLymp-0.84* AbsMono-0.59 AbsEos-0.15 AbsBaso-0.03 ___ 06:47AM BLOOD ___ PTT-29.7 ___ ___ 06:47AM BLOOD Glucose-104* UreaN-9 Creat-0.6 Na-131* K-3.9 Cl-93* HCO3-21* AnGap-17 ___ 05:23PM BLOOD Na-127* ___ 07:45AM BLOOD Glucose-145* UreaN-12 Creat-0.7 Na-129* K-4.1 Cl-92* HCO3-22 AnGap-15 ___ 10:10PM BLOOD Glucose-185* UreaN-17 Creat-1.1 Na-123* K-6.6* Cl-91* HCO3-17* AnGap-15 ___ 06:47AM BLOOD ALT-59* AST-44* LD(LDH)-218 AlkPhos-291* TotBili-3.0* ___ 07:45AM BLOOD ALT-77* AST-59* AlkPhos-378* TotBili-5.8* ___ 10:10PM BLOOD ALT-87* AST-102* AlkPhos-386* TotBili-5.9* ___ 10:10PM BLOOD Lipase-108* ___ 06:47AM BLOOD Calcium-7.6* Phos-2.9 Mg-1.8 ___ 07:45AM BLOOD Albumin-2.8* Calcium-8.2* Phos-2.8 ___ 10:10PM BLOOD Albumin-2.7* Calcium-8.0* Phos-3.1 Mg-1.4* Liver u/s: IMPRESSION: 1. Diffuse severe intra- and extrahepatic biliary ductal dilation, with the CBD measuring up to 19 mm. No obstructing stone or mass is seen, however the distal CBD is not well seen by ultrasound due to bowel gas. This could be further evaluated with CT or MRCP. 2. Gallbladder is distended but there is no pericholecystic fluid, wall edema, or gallstones to suggest acute cholecystitis. RECOMMENDATION(S): Consider CT or MRCP for further evaluation of diffuse severe intra and extrahepatic biliary ductal dilation CT:IMPRESSION: 1. Large at least 7.5 cm heterogeneously hypoenhancing mass centered in the head of the pancreas with mild upstream pancreatic ductal dilation, concerning for pancreatic neoplasm, specifically pancreatic ductal adenocarcinoma. 2. The mass obliterates the SMV, encases the SMA, and abuts the portal splenic confluence and the anterior aspect of the infrarenal abdominal aorta, also with wide abutment of the duodenum, as detailed above. 3. Enlarged and heterogeneously hypoenhancing metastatic mesenteric lymph nodes. No definite omental or peritoneal disease identified. No ascites. 4. Marked, severe upstream intra- and extrahepatic biliary ductal dilation upstream from the mass, including a distended gallbladder and cystic duct. Gallbladder does not appear inflamed by CT. 5. Chronic rib fractures of right posterior ribs ___. Other incidental findings, as above CXR: IMPRESSION: Difficult to say whether left basilar peribronchial opacification is due to atelectasis or early pneumonia. Suggest repeat chest radiographs at full inspiration. RECOMMENDATION(S): Repeat chest radiographs at full inspiration. ___: IMPRESSION: No evidence of left deep venous thrombosis in the left lower extremity veins. ERCP ___: biliary stricture, metal stent placed. Biospy taken. Pathology: though path pending in computer per email by ERCP team, +adenocarcinoma Brief Hospital Course: Pt is a ___ y.o male with h.o HTN, DM, hyponatremia, ?recent pituitary macroadenoma who presented with jaundice and bloating and was found to have a pancreatic mass with biliary obstruction, now s/p ERCP. #pancreatic mass- adenocarcinoma #biliary obstruction with jaundice Imaging concerning for pancreatic adenocarcinoma with concern for metastasis. S/p ERCP with metal stent placement, biopsy taken, pathology per email pertinent for adenocarcinoma. Pt aware. Will need to ___ with oncology after discharge to discuss next steps in treatment and options. Diet successfully advanced prior to DC. Outpt ___ for repeat labs. #hyponatremia-has been felt to be combination of hypovolemic and SIADH. Improved after IVF. Na 131 on DC. Outpt ___ for repeat labs. ___ edema-neg for DVT #?pituitary ___ with repeat MRI in 6 months and outpt neurosurg per prior dc summary. #DM-HISS, Fs qid, resume home regimen on DC, metformin to be resumed ___. #HTN-not on any home meds #anemia-no clear signs of bleeding. Outpt ___. Trend HCT. Transitional care 1. outpt oncology referral (referral made, office supposed to call pt with ___. 2.outpt PCP ___ for repeat labs-Na and LFTs Medications on Admission: The Preadmission Medication list is accurate and complete. 1. MetFORMIN (Glucophage) 1000 mg PO BID 2. Simvastatin 10 mg PO QPM 3. Bisacodyl 10 mg PO DAILY:PRN Constipation - First Line 4. Polyethylene Glycol 17 g PO BID 5. Senna 17.2 mg PO BID 6. Simethicone 40-80 mg PO QID:PRN stomach upset 7. glimepiride 4 mg oral DAILY 8. Nepro Carb Steady (nut.tx.imp.renal fxn,lac-reduc) 0.08 gram-1.8 kcal/mL oral TID W/MEALS Discharge Medications: 1. Bisacodyl 10 mg PO DAILY:PRN Constipation - First Line 2. glimepiride 4 mg oral DAILY 3. Nepro Carb Steady (nut.tx.imp.renal fxn,lac-reduc) 0.08 gram-1.8 kcal/mL oral TID W/MEALS 4. Polyethylene Glycol 17 g PO BID 5. Senna 17.2 mg PO BID 6. Simethicone 40-80 mg PO QID:PRN stomach upset 7. Simvastatin 10 mg PO QPM 8. HELD- MetFORMIN (Glucophage) 1000 mg PO BID This medication was held. Do not restart MetFORMIN (Glucophage) until ___ Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: bile duct obstruction and jaundice due to 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: You were admitted for jaundice. You had a CT scan that showed a pancreatic mass. You then had an ERCP where a stent was placed and a biopsy was taken. The biopsy results show pancreatic cancer and you will need to follow up with an oncologist for ongoing care and to discuss your options. Your diet was advanced during admission and you tolerated this well. Followup Instructions: ___
[ "C250", "K831", "E222", "K311", "K315", "D352", "E119", "I10", "E785", "K259", "K269", "R600", "D649", "I951", "R110", "K5900", "E860" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: abdominal bloating Major Surgical or Invasive Procedure: ERCP with biopsy History of Present Illness: [MASKED] old gentleman with HTN, NIDDM. He was admitted last month for [MASKED] weakness and noted to have severe hyponatremia of 110. It partially corrected with IVF and was thought to be combination of hypovolemia and SIADH. Pituitary mass was found on imaging and it was unclear if this macroadenoma was functional. Outpatient follow up was advised after inpatient consultation by endocrine/neurosurgery and ophthalmology. He reports being in usual [MASKED] till about 2 weeks ago. He started having abdominal discomfort, more in upper abdomen, along with nausea and poor intake. Pain is worse on eating. also abdomen in bloated. no constipation with his new laxative regimen. c/o generalized weakness but no other complaints. He has been adherent to 1L fluid restriction. Unable to take protein shakes because they are 'too sweet'. Review of Systems: ================== Complete ROS obtained and is otherwise negative. no dyspnea/chest pain. no urinary complaints. no fever/chills. no vomiting Past Medical History: pituitary macroadenoma SIADH Type II Diabetes HTN HLD Social History: [MASKED] Family History: Non-contributory Physical Exam: VITALS: 97.4PO 153 / 76R Lying 85 18 100 Ra Orthostatic vital: SBP 149-->115 on standing HEENT: has icterus. dry mucosa CV: Regular rate and rhythm, normal S1/S2 Resp: Normal work of breathing, clear bilaterally. Abd: Soft, distended, tympanic, mild generalized tenderness, BS present MSK: Able to move all extremities Extremities: trace [MASKED] edema Neuro: Alert, oriented, normal speech, able to respond to commands and follow directions Pertinent Results: [MASKED] 06:47AM BLOOD WBC-9.8 RBC-3.13* Hgb-8.2* Hct-24.5* MCV-78* MCH-26.2 MCHC-33.5 RDW-15.5 RDWSD-42.9 Plt [MASKED] [MASKED] 07:45AM BLOOD WBC-10.7* RBC-3.32* Hgb-8.8* Hct-25.8* MCV-78* MCH-26.5 MCHC-34.1 RDW-15.1 RDWSD-41.9 Plt [MASKED] [MASKED] 09:45PM BLOOD WBC-10.8* RBC-3.78* Hgb-10.1* Hct-29.5* MCV-78* MCH-26.7 MCHC-34.2 RDW-15.2 RDWSD-42.6 Plt [MASKED] [MASKED] 09:45PM BLOOD Neuts-84.6* Lymphs-7.7* Monos-5.4 Eos-1.4 Baso-0.3 Im [MASKED] AbsNeut-9.17* AbsLymp-0.84* AbsMono-0.59 AbsEos-0.15 AbsBaso-0.03 [MASKED] 06:47AM BLOOD [MASKED] PTT-29.7 [MASKED] [MASKED] 06:47AM BLOOD Glucose-104* UreaN-9 Creat-0.6 Na-131* K-3.9 Cl-93* HCO3-21* AnGap-17 [MASKED] 05:23PM BLOOD Na-127* [MASKED] 07:45AM BLOOD Glucose-145* UreaN-12 Creat-0.7 Na-129* K-4.1 Cl-92* HCO3-22 AnGap-15 [MASKED] 10:10PM BLOOD Glucose-185* UreaN-17 Creat-1.1 Na-123* K-6.6* Cl-91* HCO3-17* AnGap-15 [MASKED] 06:47AM BLOOD ALT-59* AST-44* LD(LDH)-218 AlkPhos-291* TotBili-3.0* [MASKED] 07:45AM BLOOD ALT-77* AST-59* AlkPhos-378* TotBili-5.8* [MASKED] 10:10PM BLOOD ALT-87* AST-102* AlkPhos-386* TotBili-5.9* [MASKED] 10:10PM BLOOD Lipase-108* [MASKED] 06:47AM BLOOD Calcium-7.6* Phos-2.9 Mg-1.8 [MASKED] 07:45AM BLOOD Albumin-2.8* Calcium-8.2* Phos-2.8 [MASKED] 10:10PM BLOOD Albumin-2.7* Calcium-8.0* Phos-3.1 Mg-1.4* Liver u/s: IMPRESSION: 1. Diffuse severe intra- and extrahepatic biliary ductal dilation, with the CBD measuring up to 19 mm. No obstructing stone or mass is seen, however the distal CBD is not well seen by ultrasound due to bowel gas. This could be further evaluated with CT or MRCP. 2. Gallbladder is distended but there is no pericholecystic fluid, wall edema, or gallstones to suggest acute cholecystitis. RECOMMENDATION(S): Consider CT or MRCP for further evaluation of diffuse severe intra and extrahepatic biliary ductal dilation CT:IMPRESSION: 1. Large at least 7.5 cm heterogeneously hypoenhancing mass centered in the head of the pancreas with mild upstream pancreatic ductal dilation, concerning for pancreatic neoplasm, specifically pancreatic ductal adenocarcinoma. 2. The mass obliterates the SMV, encases the SMA, and abuts the portal splenic confluence and the anterior aspect of the infrarenal abdominal aorta, also with wide abutment of the duodenum, as detailed above. 3. Enlarged and heterogeneously hypoenhancing metastatic mesenteric lymph nodes. No definite omental or peritoneal disease identified. No ascites. 4. Marked, severe upstream intra- and extrahepatic biliary ductal dilation upstream from the mass, including a distended gallbladder and cystic duct. Gallbladder does not appear inflamed by CT. 5. Chronic rib fractures of right posterior ribs [MASKED]. Other incidental findings, as above CXR: IMPRESSION: Difficult to say whether left basilar peribronchial opacification is due to atelectasis or early pneumonia. Suggest repeat chest radiographs at full inspiration. RECOMMENDATION(S): Repeat chest radiographs at full inspiration. [MASKED]: IMPRESSION: No evidence of left deep venous thrombosis in the left lower extremity veins. ERCP [MASKED]: biliary stricture, metal stent placed. Biospy taken. Pathology: though path pending in computer per email by ERCP team, +adenocarcinoma Brief Hospital Course: Pt is a [MASKED] y.o male with h.o HTN, DM, hyponatremia, ?recent pituitary macroadenoma who presented with jaundice and bloating and was found to have a pancreatic mass with biliary obstruction, now s/p ERCP. #pancreatic mass- adenocarcinoma #biliary obstruction with jaundice Imaging concerning for pancreatic adenocarcinoma with concern for metastasis. S/p ERCP with metal stent placement, biopsy taken, pathology per email pertinent for adenocarcinoma. Pt aware. Will need to [MASKED] with oncology after discharge to discuss next steps in treatment and options. Diet successfully advanced prior to DC. Outpt [MASKED] for repeat labs. #hyponatremia-has been felt to be combination of hypovolemic and SIADH. Improved after IVF. Na 131 on DC. Outpt [MASKED] for repeat labs. [MASKED] edema-neg for DVT #?pituitary [MASKED] with repeat MRI in 6 months and outpt neurosurg per prior dc summary. #DM-HISS, Fs qid, resume home regimen on DC, metformin to be resumed [MASKED]. #HTN-not on any home meds #anemia-no clear signs of bleeding. Outpt [MASKED]. Trend HCT. Transitional care 1. outpt oncology referral (referral made, office supposed to call pt with [MASKED]. 2.outpt PCP [MASKED] for repeat labs-Na and LFTs Medications on Admission: The Preadmission Medication list is accurate and complete. 1. MetFORMIN (Glucophage) 1000 mg PO BID 2. Simvastatin 10 mg PO QPM 3. Bisacodyl 10 mg PO DAILY:PRN Constipation - First Line 4. Polyethylene Glycol 17 g PO BID 5. Senna 17.2 mg PO BID 6. Simethicone 40-80 mg PO QID:PRN stomach upset 7. glimepiride 4 mg oral DAILY 8. Nepro Carb Steady (nut.tx.imp.renal fxn,lac-reduc) 0.08 gram-1.8 kcal/mL oral TID W/MEALS Discharge Medications: 1. Bisacodyl 10 mg PO DAILY:PRN Constipation - First Line 2. glimepiride 4 mg oral DAILY 3. Nepro Carb Steady (nut.tx.imp.renal fxn,lac-reduc) 0.08 gram-1.8 kcal/mL oral TID W/MEALS 4. Polyethylene Glycol 17 g PO BID 5. Senna 17.2 mg PO BID 6. Simethicone 40-80 mg PO QID:PRN stomach upset 7. Simvastatin 10 mg PO QPM 8. HELD- MetFORMIN (Glucophage) 1000 mg PO BID This medication was held. Do not restart MetFORMIN (Glucophage) until [MASKED] Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: bile duct obstruction and jaundice due to 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: You were admitted for jaundice. You had a CT scan that showed a pancreatic mass. You then had an ERCP where a stent was placed and a biopsy was taken. The biopsy results show pancreatic cancer and you will need to follow up with an oncologist for ongoing care and to discuss your options. Your diet was advanced during admission and you tolerated this well. Followup Instructions: [MASKED]
[]
[ "E119", "I10", "E785", "D649", "K5900" ]
[ "C250: Malignant neoplasm of head of pancreas", "K831: Obstruction of bile duct", "E222: Syndrome of inappropriate secretion of antidiuretic hormone", "K311: Adult hypertrophic pyloric stenosis", "K315: Obstruction of duodenum", "D352: Benign neoplasm of pituitary gland", "E119: Type 2 diabetes mellitus without complications", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "K259: Gastric ulcer, unspecified as acute or chronic, without hemorrhage or perforation", "K269: Duodenal ulcer, unspecified as acute or chronic, without hemorrhage or perforation", "R600: Localized edema", "D649: Anemia, unspecified", "I951: Orthostatic hypotension", "R110: Nausea", "K5900: Constipation, unspecified", "E860: Dehydration" ]
19,997,062
20,096,107
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Remicade Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: ___ ERCP with sphincterotomy and sludge and stone removal History of Present Illness: ___ year old male with history of ulcerative colitis complicated by primary sclerosing cholangitis (followed by Dr. ___, presenting as a transfer from ___, with concern for cholangitis. Last week, the patient had a four hour episode of nausea, PO intolerance and RUQ/epigastric pain which completely resolved. He now has had 2 days of recurrence of symptoms with RUQ/epigastric pain, nausea and vomiting. He reports no fever/chills, diarrhea/constipation. At the OSH, CAST 140, ALT 136, AP 771, TBili 5.8 WBC 9.6, H&H 15.3/44.8, plt 327K. CT A/P at the OSH showed asymmetric L>R central intrahepatic biliary dilatation, with CBD also mildly dilated with suggestion of multisegmental mild narrowing. No discrete mass was identified. Areas of mural thickening involving portions of the descending colon and mild to distal sigmoid and rectum were suggestive of colitis or sequlae of colitis, may be inflammatory or infectious. He received piperacillin/tazobactam at the OSH. In the ED, initial vitals were 98.0 77 123/80 19 98% RA. Labs showed ALT 136, AST 155, AP 741, Tbili 7.1, WBC 10.2K, lacate 1.2. Blood cultures x 2 were sent, as well as urine culture. UA was unremarkable. Patient received 1 liter NS as well as 1 mg IV hydromorphone. Currently, the patient notes ___ pain, located periumbilically at this time. There is no current nausea, fevers or chills. Review of systems: 10 pt ROS negative other than noted Past Medical History: Ulcerative colitis Primary sclerosing cholangitis Retinal detachment Social History: ___ Family History: No history of UC or Crohns. No colon, liver, pancreas, or GB cancer. Physical Exam: ADMISSION EXAM: Vitals: 98.3PO 142/75 86 18 98% on RA GEN: Alert, oriented to name, place and situation. Fatigued appearing but comfortable, no acute signs of distress. Thin. HEENT: NCAT, Pupils equal and reactive, sclerae anicteric, OP clear, MMM. Neck: Supple, no JVD Lymph nodes: No cervical, supraclavicular LAD. CV: S1S2, reg rate and rhythm, no murmurs, rubs or gallops. RESP: Good air movement bilaterally, no rhonchi or wheezing. ABD: Soft, mildly tender in the periumbilical area, non-distended, + bowel sounds. EXTR: No lower leg edema, no clubbing or cyanosis DERM: No active rash. Neuro: non-focal. PSYCH: Appropriate and calm. Discharge Exam Pertinent Results: ADMISSION LABS -------------- ___ 05:30PM BLOOD WBC-10.2*# RBC-4.66 Hgb-14.1 Hct-42.3 MCV-91 MCH-30.3 MCHC-33.3 RDW-14.1 RDWSD-47.5* Plt ___ ___ 05:30PM BLOOD Neuts-76.1* Lymphs-13.3* Monos-8.8 Eos-1.0 Baso-0.4 Im ___ AbsNeut-7.73* AbsLymp-1.35 AbsMono-0.89* AbsEos-0.10 AbsBaso-0.04 ___ 05:30PM BLOOD ___ PTT-32.4 ___ ___ 05:30PM BLOOD Glucose-94 UreaN-7 Creat-0.7 Na-137 K-3.8 Cl-97 HCO3-26 AnGap-18 ___ 05:30PM BLOOD ALT-136* AST-155* AlkPhos-741* TotBili-7.1* ___ 05:30PM BLOOD Albumin-4.2 Calcium-9.8 Phos-2.8 Mg-1.9 ___ 05:50PM BLOOD Lactate-1.2 IMAGING ------- CT A/P (OSH): Asymmetric L>R central intrahepatic biliary dilatation. CBD is also mildly dilated with suggestion of multisegmental mild narrowing. Findings may be related to patient's known PSC. No discrete mass is identified. Areas of mural thickening involving portions of the descending colon and mild to distal sigmoid and rectum suggestive of colitis or sequlae of colitis, may be inflammatory or infectious. Patient has a hx of UC which typically does not demonstrate skip areas. CXR (OSH): Increased lung volumes consistent with COPD. Cardiomediastinal silhouette and hilar shadows without significant change from prior study. There are no pleural effusions. There is no acute consolidating lung infiltrate. ___ 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: Evidence of a previous sphincterotomy was noted in the major papilla. 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. Biliary Tree: The scout film was normal. The bile duct was deeply cannulated with the sphincterotome. Contrast was injected and there was brisk flow through the ducts. Contrast extended to the entire biliary tree. Multiple intrahepatic bile duct strictures and beading was found in keeping with patints knonw diagnosis of primary sclerosing cholangiditis. No dominant stricture was identified. The left intrahepatic duct was more dilated than the right intrahepatic duct. The biliary tree was swept with a 9-12mm balloon starting in the left intrahepatic duct. Multiple stone fragments, debris and sludge was. The left intrahepatic, CBD and CHD were swept repeatedly until no further stones were seen. Excellent bile and contrast drainage was seen endoscopically and fluoroscopically.I supervised the acquisition and interpretation of the fluoroscopic images. The quality of the fluoroscopic images was good. Impression: (cannulation) Otherwise normal ercp to third part of the duodenum Recommendations: Continue antibiotics to complete atleast 7 days Return to ward ongoing care. Follow for response and complications. If any abdominal pain, fever, jaundice, gastrointestinal bleeding please call ERCP fellow on call ___ MICRO ----------- ___ Blood Culture, Routine-PENDING EMERGENCY WARD ___ Blood Culture, Routine-PENDING EMERGENCY WARD ___ URINE CULTURE-PENDING EMERGENCY WARD Discharge Day labs ------------------ Brief Hospital Course: ___ man w/PMHx UC c/b PSC now txf from ___ with concern for cholangitis based on sx, labs and imaging UC c/b PSC txf from OSH for cholangitis, s/p ERCP on ___ - RUQ pain, N/V w/obstructive LFTs at OSH w/CT A/P showing L>R intrahepatic biliary dilation w/CBD dil w/a suggestion of multisegmental narrowing, no mass, also with descd colon and mid-distal sigmoid + rectum with mural thickening c/w colitis - f/u BCx - was initially placed on pip/tazo, and was then transitioned to cipro with a plan for 7d total, D1 ___ day of "source control") - takes mesalamine at home -- continued this -- has allergy to infliximab (convulsions) - follow up arranged with Dr. ___ - he did have some pain with advancing diet and was given a short prescription for oxycodone with instructions not to drive while taking this medication. Significant EtOH use - ___ wines daily for several months now - knows he should cut down Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ___ (mesalamine) 4.8 grams oral DAILY Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth q12 Disp #*14 Tablet Refills:*0 2. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg 1 tablet(s) by mouth q4h prn Disp #*6 Tablet Refills:*0 3. ___ (mesalamine) 4.8 grams oral DAILY Discharge Disposition: Home Discharge Diagnosis: Cholangitis Primary sclerosing cholangitis (PSC) Ulcerative colitis (UC) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with cholangitis (infection of the bile ducts in the liver) which was likely caused by your primary sclerosing cholangitis (PSC), which is associated with your ulcerative colitis. You underwent ERCP on ___ at which time sludge and stones were removed. You were treated with antibiotics and improved. You are being given a short supply of pain medications for your abdominal pain. Do not drive while taking this medication (oxycodone). Followup Instructions: ___
[ "K8036", "K5150", "K743", "H3320", "F1020", "K838", "R1011", "K5289" ]
Allergies: Remicade Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: [MASKED] ERCP with sphincterotomy and sludge and stone removal History of Present Illness: [MASKED] year old male with history of ulcerative colitis complicated by primary sclerosing cholangitis (followed by Dr. [MASKED], presenting as a transfer from [MASKED], with concern for cholangitis. Last week, the patient had a four hour episode of nausea, PO intolerance and RUQ/epigastric pain which completely resolved. He now has had 2 days of recurrence of symptoms with RUQ/epigastric pain, nausea and vomiting. He reports no fever/chills, diarrhea/constipation. At the OSH, CAST 140, ALT 136, AP 771, TBili 5.8 WBC 9.6, H&H 15.3/44.8, plt 327K. CT A/P at the OSH showed asymmetric L>R central intrahepatic biliary dilatation, with CBD also mildly dilated with suggestion of multisegmental mild narrowing. No discrete mass was identified. Areas of mural thickening involving portions of the descending colon and mild to distal sigmoid and rectum were suggestive of colitis or sequlae of colitis, may be inflammatory or infectious. He received piperacillin/tazobactam at the OSH. In the ED, initial vitals were 98.0 77 123/80 19 98% RA. Labs showed ALT 136, AST 155, AP 741, Tbili 7.1, WBC 10.2K, lacate 1.2. Blood cultures x 2 were sent, as well as urine culture. UA was unremarkable. Patient received 1 liter NS as well as 1 mg IV hydromorphone. Currently, the patient notes [MASKED] pain, located periumbilically at this time. There is no current nausea, fevers or chills. Review of systems: 10 pt ROS negative other than noted Past Medical History: Ulcerative colitis Primary sclerosing cholangitis Retinal detachment Social History: [MASKED] Family History: No history of UC or Crohns. No colon, liver, pancreas, or GB cancer. Physical Exam: ADMISSION EXAM: Vitals: 98.3PO 142/75 86 18 98% on RA GEN: Alert, oriented to name, place and situation. Fatigued appearing but comfortable, no acute signs of distress. Thin. HEENT: NCAT, Pupils equal and reactive, sclerae anicteric, OP clear, MMM. Neck: Supple, no JVD Lymph nodes: No cervical, supraclavicular LAD. CV: S1S2, reg rate and rhythm, no murmurs, rubs or gallops. RESP: Good air movement bilaterally, no rhonchi or wheezing. ABD: Soft, mildly tender in the periumbilical area, non-distended, + bowel sounds. EXTR: No lower leg edema, no clubbing or cyanosis DERM: No active rash. Neuro: non-focal. PSYCH: Appropriate and calm. Discharge Exam Pertinent Results: ADMISSION LABS -------------- [MASKED] 05:30PM BLOOD WBC-10.2*# RBC-4.66 Hgb-14.1 Hct-42.3 MCV-91 MCH-30.3 MCHC-33.3 RDW-14.1 RDWSD-47.5* Plt [MASKED] [MASKED] 05:30PM BLOOD Neuts-76.1* Lymphs-13.3* Monos-8.8 Eos-1.0 Baso-0.4 Im [MASKED] AbsNeut-7.73* AbsLymp-1.35 AbsMono-0.89* AbsEos-0.10 AbsBaso-0.04 [MASKED] 05:30PM BLOOD [MASKED] PTT-32.4 [MASKED] [MASKED] 05:30PM BLOOD Glucose-94 UreaN-7 Creat-0.7 Na-137 K-3.8 Cl-97 HCO3-26 AnGap-18 [MASKED] 05:30PM BLOOD ALT-136* AST-155* AlkPhos-741* TotBili-7.1* [MASKED] 05:30PM BLOOD Albumin-4.2 Calcium-9.8 Phos-2.8 Mg-1.9 [MASKED] 05:50PM BLOOD Lactate-1.2 IMAGING ------- CT A/P (OSH): Asymmetric L>R central intrahepatic biliary dilatation. CBD is also mildly dilated with suggestion of multisegmental mild narrowing. Findings may be related to patient's known PSC. No discrete mass is identified. Areas of mural thickening involving portions of the descending colon and mild to distal sigmoid and rectum suggestive of colitis or sequlae of colitis, may be inflammatory or infectious. Patient has a hx of UC which typically does not demonstrate skip areas. CXR (OSH): Increased lung volumes consistent with COPD. Cardiomediastinal silhouette and hilar shadows without significant change from prior study. There are no pleural effusions. There is no acute consolidating lung infiltrate. [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: Evidence of a previous sphincterotomy was noted in the major papilla. 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. Biliary Tree: The scout film was normal. The bile duct was deeply cannulated with the sphincterotome. Contrast was injected and there was brisk flow through the ducts. Contrast extended to the entire biliary tree. Multiple intrahepatic bile duct strictures and beading was found in keeping with patints knonw diagnosis of primary sclerosing cholangiditis. No dominant stricture was identified. The left intrahepatic duct was more dilated than the right intrahepatic duct. The biliary tree was swept with a 9-12mm balloon starting in the left intrahepatic duct. Multiple stone fragments, debris and sludge was. The left intrahepatic, CBD and CHD were swept repeatedly until no further stones were seen. Excellent bile and contrast drainage was seen endoscopically and fluoroscopically.I supervised the acquisition and interpretation of the fluoroscopic images. The quality of the fluoroscopic images was good. Impression: (cannulation) Otherwise normal ercp to third part of the duodenum Recommendations: Continue antibiotics to complete atleast 7 days Return to ward ongoing care. Follow for response and complications. If any abdominal pain, fever, jaundice, gastrointestinal bleeding please call ERCP fellow on call [MASKED] MICRO ----------- [MASKED] Blood Culture, Routine-PENDING EMERGENCY WARD [MASKED] Blood Culture, Routine-PENDING EMERGENCY WARD [MASKED] URINE CULTURE-PENDING EMERGENCY WARD Discharge Day labs ------------------ Brief Hospital Course: [MASKED] man w/PMHx UC c/b PSC now txf from [MASKED] with concern for cholangitis based on sx, labs and imaging UC c/b PSC txf from OSH for cholangitis, s/p ERCP on [MASKED] - RUQ pain, N/V w/obstructive LFTs at OSH w/CT A/P showing L>R intrahepatic biliary dilation w/CBD dil w/a suggestion of multisegmental narrowing, no mass, also with descd colon and mid-distal sigmoid + rectum with mural thickening c/w colitis - f/u BCx - was initially placed on pip/tazo, and was then transitioned to cipro with a plan for 7d total, D1 [MASKED] day of "source control") - takes mesalamine at home -- continued this -- has allergy to infliximab (convulsions) - follow up arranged with Dr. [MASKED] - he did have some pain with advancing diet and was given a short prescription for oxycodone with instructions not to drive while taking this medication. Significant EtOH use - [MASKED] wines daily for several months now - knows he should cut down Medications on Admission: The Preadmission Medication list is accurate and complete. 1. [MASKED] (mesalamine) 4.8 grams oral DAILY Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth q12 Disp #*14 Tablet Refills:*0 2. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg 1 tablet(s) by mouth q4h prn Disp #*6 Tablet Refills:*0 3. [MASKED] (mesalamine) 4.8 grams oral DAILY Discharge Disposition: Home Discharge Diagnosis: Cholangitis Primary sclerosing cholangitis (PSC) Ulcerative colitis (UC) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with cholangitis (infection of the bile ducts in the liver) which was likely caused by your primary sclerosing cholangitis (PSC), which is associated with your ulcerative colitis. You underwent ERCP on [MASKED] at which time sludge and stones were removed. You were treated with antibiotics and improved. You are being given a short supply of pain medications for your abdominal pain. Do not drive while taking this medication (oxycodone). Followup Instructions: [MASKED]
[]
[]
[ "K8036: Calculus of bile duct with acute and chronic cholangitis without obstruction", "K5150: Left sided colitis without complications", "K743: Primary biliary cirrhosis", "H3320: Serous retinal detachment, unspecified eye", "F1020: Alcohol dependence, uncomplicated", "K838: Other specified diseases of biliary tract", "R1011: Right upper quadrant pain", "K5289: Other specified noninfective gastroenteritis and colitis" ]
19,997,062
22,001,840
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Remicade / erythromycin base Attending: ___. Chief Complaint: Ulcerative colitis with multifocal high-grade dysplasia Major Surgical or Invasive Procedure: Laparoscopic proctocolectomy with end ileostomy and parastomal mesh History of Present Illness: Pt is a ___ male with a history of ulcerative colitis and primary sclerosing cholangitis. He was diagnosed with UC ___ years ago when he was in his ___. In the early days, he was taking Azocol. He was taking that for many years on and off. In___, he started taking Azocol again for few years. He has been on and off ___ for a while. He is currently taking ___ for the last ___ years and ursodiol for PSC (taking this on and off for ___ years). Currently, he has no significant active symptoms. He has some mild pain in the lower abdomen. He has BM about 5 times per week. He has not had a flare "in a while" but unable to say when his last major flare was. He had a colonoscopy in ___, which showed low grade dysplasia on random biopsies in the right colon. He underwent another colonoscopy in ___, which showed high grade dysplasia. He denies any fevers, chills, no weight loss. He denies any symptoms from his PSC, but occasionally does have RUQ pain. He has no other complaints at this time. Past Medical History: Ulcerative colitis Primary sclerosing cholangitis Retinal detachment OSTEOPOROSIS CCY ___ years ago Social History: ___ Family History: Family History: no history of colon cancer/IBD in the family. Denies family history of stomach, colon, or pancreatic cancer. Physical Exam: Objective ___ ___ Temp: 97.7 PO BP: 114/70 HR: 90 RR: 18 O2 sat: 98% O2 delivery: Ra GENERAL: NAD, A/O x 3 CV: RRR PULM: no respiratory distress ABD: soft, minimally distended, minimally tender, no rebound/guarding, ostomy mucosa pink, with bilious liquid output and gas WOUND: Incisions and dressings c/d/i Pertinent Results: ___ 07:02AM BLOOD WBC-12.4* RBC-3.83* Hgb-11.9* Hct-36.6* MCV-96 MCH-31.1 MCHC-32.5 RDW-13.8 RDWSD-48.2* Plt ___ ___ 06:46AM BLOOD Glucose-90 UreaN-10 Creat-0.7 Na-137 K-4.1 Cl-101 HCO3-28 AnGap-8* ___ 06:46AM BLOOD ALT-55* AST-59* AlkPhos-412* TotBili-3.1* DirBili-2.2* IndBili-0.9 ___ 06:46AM BLOOD Calcium-8.9 Phos-2.6* Mg-1.6 ___ 07:02AM BLOOD CRP-73.7* Brief Hospital Course: Mr. ___ presented to ___ holding at ___ on ___ for laparoscopic proctocolectomy with end ileostomy and parastomal mesh. He tolerated the procedure well without complications (Please see operative note for further details). After a brief and uneventful stay in the PACU, the patient was transferred to the floor for further post-operative management. Neuro: Pain was well controlled on Tylenol and tramadol for breakthrough pain. CV: Vital signs were routinely monitored. He was noted to be orthostatic on postop day 1 and received IV fluid boluses with good response. On the day prior to discharge, ___, he was mildly dizzy while working with physical therapy. He improved with another fluid bolus. He was encouraged to increase his p.o. fluid intake. On the day of discharge, he was ambulating independently with without lightheadedness. He was cleared by physical therapy for discharge home without additional ___. Pulm: The patient remained stable from a pulmonary standpoint; oxygen saturation was routinely monitored. He had good pulmonary toileting, as early ambulation and incentive spirometry were encouraged throughout hospitalization. GI: The patient was briefly kept NPO after the procedure. The patient was advanced to and tolerated a regular diet starting on postoperative day 2. Patient's intake and output were closely monitored. He was kept on peritoneal precautions after his operation. He received teaching from the ostomy nurse and demonstrated good understanding of the function and use of the ostomy. He will continue to have ostomy teaching through ___ at home. The patient was advised to follow-up as soon as possible with his primary care provider and hepatologist once discharged. GU: The patient had a Foley catheter that was removed prior to discharge. At time of discharge, the patient was voiding without difficulty. Urine output was monitored as indicated. ID: The patient was closely monitored for signs and symptoms of infection and fever, of which there was none. Heme: The patient received subcutaneous heparin and ___ dyne boots during this stay. He was encouraged to get up and ambulate as early as possible. The patient is being discharged on prophylactic Lovenox. On ___, the patient was discharged to home. At discharge, he was tolerating a regular diet, passing flatus, voiding, and ambulating independently. He will follow-up in the clinic in ___ weeks. This information was communicated to the patient directly prior to discharge. Post-Surgical Complications During Inpatient Admission: [ ] Post-Operative Ileus resolving w/o NGT [ ] Post-Operative Ileus requiring management with NGT [ ] UTI [ ] Wound Infection [ ] Anastomotic Leak [ ] Staple Line Bleed [ ] Congestive Heart failure [ ] ARF [ ] Acute Urinary retention, failure to void after Foley D/C'd [ ] Acute Urinary Retention requiring discharge with Foley Catheter [ ] DVT [ ] Pneumonia [ ] Abscess [x] None Social Issues Causing a Delay in Discharge: [ ] Delay in organization of ___ services [ ] Difficulty finding appropriate rehab hospital disposition. [ ] Lack of insurance coverage for ___ services [ ] Lack of insurance coverage for prescribed medications. [ ] Family not agreeable to discharge plan. [ ] Patient knowledge deficit related to ileostomy delaying dispo [x] No social factors contributing in delay of discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ursodiol 300 mg PO TID Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Bacitracin Ointment 1 Appl TP BID perineum 3. Enoxaparin Sodium 40 mg SC DAILY Start: Today - ___, First Dose: Next Routine Administration Time RX *enoxaparin 40 mg/0.4 mL 40 SC once a day Disp #*24 Syringe Refills:*0 4. TraMADol 50-100 mg PO Q4H:PRN Pain - Moderate RX *tramadol 50 mg ___ tablet(s) by mouth every six (6) hours Disp #*16 Tablet Refills:*0 5. Ursodiol 300 mg PO TID Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: ___ with history of ulcerative colitis for ___ years & current multifocal dysplasia s/p laparoscopic proctocolectomy with end ileostomy and parastomal mesh. 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 a laparoscopic proctocolectomy w/end ileostomy and parastomal mesh placement for surgical management of your ulcerative colitis with multifocal high-grade dysplasia. You have recovered from this procedure and you are now ready to return home. You have a new ileostomy and stool no longer passes through the colon (part of the body where water and electrolytes are reabsorbed back into the body), so your output will be liquid. The most common complication from an ileostomy is dehydration. You must measure your ileostomy output for the next few weeks- please bring your I&O sheet to your post-op appointment. The output should be no less than 500cc or greater than 1200cc per day. If you find that your output has become too much or too little, please call the office. Please monitor for signs and symptoms of dehydration. If you notice these symptoms, please call the office or go to the emergency room. You will need to keep yourself well hydrated, if you notice your ileostomy output increasing, drink liquids with electrolytes such as Gatorade. Please monitor the appearance of your stoma and care for it as instructed by the ostomy nurses. ___ you notice that the stoma is turning darker blue or purple please call the office or go to the emergency room. The stoma may ooze small amounts of blood at times when touched which will improve over time. Monitor the skin around the stoma for any bulging or signs of infection. You will follow up with the ostomy nurses in the clinic ___ weeks after surgery. You will also have a visiting nurse at home for the next few weeks to help to monitor your ostomy (until you are comfortable caring for it on your own). You have ___ laparoscopic surgical incisions on your abdomen which are closed with internal sutures. It is important that you monitor these areas for signs and symptoms of infection including: increasing redness of the incision lines, white/green/yellow/foul smelling drainage, increased pain at the incision, increased warmth of the skin at the incision, or swelling of the area. You may shower; pat the incisions dry with a towel, do not rub. If you have steri-strips (the small white strips), they will fall off over time, please do not remove them. Please do not take a bath or swim until cleared by the surgical team. Pain is expected after surgery. This will gradually improve over the first week or so you are home. You should continue to take 2 Extra Strength Tylenol (___) for pain every 8 hours around the clock. Please do not take more than 3000mg of Tylenol in 24 hours or any other medications that contain Tylenol such as cold medication. Do not drink alcohol while taking Tylenol. You may also take Advil (Ibuprofen) 600mg every 8 hours for 7 days. Please take Advil with food. If these medications are not controlling your pain to a point where you can ambulate and perform minor tasks, you should take a dose of the narcotic pain medication tramadol. Please do not take sedating medications, drink alcohol, or drive while taking the narcotic pain medication. You will be going home with your JP (surgical) drain, which will be removed at your post-op visit. Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). Maintain suction of the bulb. Note color, consistency, and amount of fluid in the drain. Call the doctor, nurse practitioner, or ___ nurse if the amount increases significantly or changes in character. Be sure to empty the drain as needed and record output. You may shower; wash the area gently with warm, soapy water. Keep the insertion site clean and dry otherwise. Avoid swimming, baths, hot tubs; do not submerge yourself in water. Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. You may feel weak or "washed out" for up to 6 weeks after surgery. Do not lift greater than a gallon of milk for 3 weeks. At your post op appointment, your surgical team will clear you for heavier exercise. In the meantime, you may climb stairs and go outside and walk. Please avoid traveling long distances until you speak with your surgical team at your post-op visit. Thank you for allowing us to participate in your care, we wish you all the best! Sincerely, Your ___ Care Team Followup Instructions: ___
[ "K5100", "K8301", "I951", "D122" ]
Allergies: Remicade / erythromycin base Chief Complaint: Ulcerative colitis with multifocal high-grade dysplasia Major Surgical or Invasive Procedure: Laparoscopic proctocolectomy with end ileostomy and parastomal mesh History of Present Illness: Pt is a [MASKED] male with a history of ulcerative colitis and primary sclerosing cholangitis. He was diagnosed with UC [MASKED] years ago when he was in his [MASKED]. In the early days, he was taking Azocol. He was taking that for many years on and off. In , he started taking Azocol again for few years. He has been on and off [MASKED] for a while. He is currently taking [MASKED] for the last [MASKED] years and ursodiol for PSC (taking this on and off for [MASKED] years). Currently, he has no significant active symptoms. He has some mild pain in the lower abdomen. He has BM about 5 times per week. He has not had a flare "in a while" but unable to say when his last major flare was. He had a colonoscopy in [MASKED], which showed low grade dysplasia on random biopsies in the right colon. He underwent another colonoscopy in [MASKED], which showed high grade dysplasia. He denies any fevers, chills, no weight loss. He denies any symptoms from his PSC, but occasionally does have RUQ pain. He has no other complaints at this time. Past Medical History: Ulcerative colitis Primary sclerosing cholangitis Retinal detachment OSTEOPOROSIS CCY [MASKED] years ago Social History: [MASKED] Family History: Family History: no history of colon cancer/IBD in the family. Denies family history of stomach, colon, or pancreatic cancer. Physical Exam: Objective [MASKED] [MASKED] Temp: 97.7 PO BP: 114/70 HR: 90 RR: 18 O2 sat: 98% O2 delivery: Ra GENERAL: NAD, A/O x 3 CV: RRR PULM: no respiratory distress ABD: soft, minimally distended, minimally tender, no rebound/guarding, ostomy mucosa pink, with bilious liquid output and gas WOUND: Incisions and dressings c/d/i Pertinent Results: [MASKED] 07:02AM BLOOD WBC-12.4* RBC-3.83* Hgb-11.9* Hct-36.6* MCV-96 MCH-31.1 MCHC-32.5 RDW-13.8 RDWSD-48.2* Plt [MASKED] [MASKED] 06:46AM BLOOD Glucose-90 UreaN-10 Creat-0.7 Na-137 K-4.1 Cl-101 HCO3-28 AnGap-8* [MASKED] 06:46AM BLOOD ALT-55* AST-59* AlkPhos-412* TotBili-3.1* DirBili-2.2* IndBili-0.9 [MASKED] 06:46AM BLOOD Calcium-8.9 Phos-2.6* Mg-1.6 [MASKED] 07:02AM BLOOD CRP-73.7* Brief Hospital Course: Mr. [MASKED] presented to [MASKED] holding at [MASKED] on [MASKED] for laparoscopic proctocolectomy with end ileostomy and parastomal mesh. He tolerated the procedure well without complications (Please see operative note for further details). After a brief and uneventful stay in the PACU, the patient was transferred to the floor for further post-operative management. Neuro: Pain was well controlled on Tylenol and tramadol for breakthrough pain. CV: Vital signs were routinely monitored. He was noted to be orthostatic on postop day 1 and received IV fluid boluses with good response. On the day prior to discharge, [MASKED], he was mildly dizzy while working with physical therapy. He improved with another fluid bolus. He was encouraged to increase his p.o. fluid intake. On the day of discharge, he was ambulating independently with without lightheadedness. He was cleared by physical therapy for discharge home without additional [MASKED]. Pulm: The patient remained stable from a pulmonary standpoint; oxygen saturation was routinely monitored. He had good pulmonary toileting, as early ambulation and incentive spirometry were encouraged throughout hospitalization. GI: The patient was briefly kept NPO after the procedure. The patient was advanced to and tolerated a regular diet starting on postoperative day 2. Patient's intake and output were closely monitored. He was kept on peritoneal precautions after his operation. He received teaching from the ostomy nurse and demonstrated good understanding of the function and use of the ostomy. He will continue to have ostomy teaching through [MASKED] at home. The patient was advised to follow-up as soon as possible with his primary care provider and hepatologist once discharged. GU: The patient had a Foley catheter that was removed prior to discharge. At time of discharge, the patient was voiding without difficulty. Urine output was monitored as indicated. ID: The patient was closely monitored for signs and symptoms of infection and fever, of which there was none. Heme: The patient received subcutaneous heparin and [MASKED] dyne boots during this stay. He was encouraged to get up and ambulate as early as possible. The patient is being discharged on prophylactic Lovenox. On [MASKED], the patient was discharged to home. At discharge, he was tolerating a regular diet, passing flatus, voiding, and ambulating independently. He will follow-up in the clinic in [MASKED] weeks. This information was communicated to the patient directly prior to discharge. Post-Surgical Complications During Inpatient Admission: [ ] Post-Operative Ileus resolving w/o NGT [ ] Post-Operative Ileus requiring management with NGT [ ] UTI [ ] Wound Infection [ ] Anastomotic Leak [ ] Staple Line Bleed [ ] Congestive Heart failure [ ] ARF [ ] Acute Urinary retention, failure to void after Foley D/C'd [ ] Acute Urinary Retention requiring discharge with Foley Catheter [ ] DVT [ ] Pneumonia [ ] Abscess [x] None Social Issues Causing a Delay in Discharge: [ ] Delay in organization of [MASKED] services [ ] Difficulty finding appropriate rehab hospital disposition. [ ] Lack of insurance coverage for [MASKED] services [ ] Lack of insurance coverage for prescribed medications. [ ] Family not agreeable to discharge plan. [ ] Patient knowledge deficit related to ileostomy delaying dispo [x] No social factors contributing in delay of discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ursodiol 300 mg PO TID Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Bacitracin Ointment 1 Appl TP BID perineum 3. Enoxaparin Sodium 40 mg SC DAILY Start: Today - [MASKED], First Dose: Next Routine Administration Time RX *enoxaparin 40 mg/0.4 mL 40 SC once a day Disp #*24 Syringe Refills:*0 4. TraMADol 50-100 mg PO Q4H:PRN Pain - Moderate RX *tramadol 50 mg [MASKED] tablet(s) by mouth every six (6) hours Disp #*16 Tablet Refills:*0 5. Ursodiol 300 mg PO TID Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: [MASKED] with history of ulcerative colitis for [MASKED] years & current multifocal dysplasia s/p laparoscopic proctocolectomy with end ileostomy and parastomal mesh. 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 a laparoscopic proctocolectomy w/end ileostomy and parastomal mesh placement for surgical management of your ulcerative colitis with multifocal high-grade dysplasia. You have recovered from this procedure and you are now ready to return home. You have a new ileostomy and stool no longer passes through the colon (part of the body where water and electrolytes are reabsorbed back into the body), so your output will be liquid. The most common complication from an ileostomy is dehydration. You must measure your ileostomy output for the next few weeks- please bring your I&O sheet to your post-op appointment. The output should be no less than 500cc or greater than 1200cc per day. If you find that your output has become too much or too little, please call the office. Please monitor for signs and symptoms of dehydration. If you notice these symptoms, please call the office or go to the emergency room. You will need to keep yourself well hydrated, if you notice your ileostomy output increasing, drink liquids with electrolytes such as Gatorade. Please monitor the appearance of your stoma and care for it as instructed by the ostomy nurses. [MASKED] you notice that the stoma is turning darker blue or purple please call the office or go to the emergency room. The stoma may ooze small amounts of blood at times when touched which will improve over time. Monitor the skin around the stoma for any bulging or signs of infection. You will follow up with the ostomy nurses in the clinic [MASKED] weeks after surgery. You will also have a visiting nurse at home for the next few weeks to help to monitor your ostomy (until you are comfortable caring for it on your own). You have [MASKED] laparoscopic surgical incisions on your abdomen which are closed with internal sutures. It is important that you monitor these areas for signs and symptoms of infection including: increasing redness of the incision lines, white/green/yellow/foul smelling drainage, increased pain at the incision, increased warmth of the skin at the incision, or swelling of the area. You may shower; pat the incisions dry with a towel, do not rub. If you have steri-strips (the small white strips), they will fall off over time, please do not remove them. Please do not take a bath or swim until cleared by the surgical team. Pain is expected after surgery. This will gradually improve over the first week or so you are home. You should continue to take 2 Extra Strength Tylenol ([MASKED]) for pain every 8 hours around the clock. Please do not take more than 3000mg of Tylenol in 24 hours or any other medications that contain Tylenol such as cold medication. Do not drink alcohol while taking Tylenol. You may also take Advil (Ibuprofen) 600mg every 8 hours for 7 days. Please take Advil with food. If these medications are not controlling your pain to a point where you can ambulate and perform minor tasks, you should take a dose of the narcotic pain medication tramadol. Please do not take sedating medications, drink alcohol, or drive while taking the narcotic pain medication. You will be going home with your JP (surgical) drain, which will be removed at your post-op visit. Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). Maintain suction of the bulb. Note color, consistency, and amount of fluid in the drain. Call the doctor, nurse practitioner, or [MASKED] nurse if the amount increases significantly or changes in character. Be sure to empty the drain as needed and record output. You may shower; wash the area gently with warm, soapy water. Keep the insertion site clean and dry otherwise. Avoid swimming, baths, hot tubs; do not submerge yourself in water. Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. You may feel weak or "washed out" for up to 6 weeks after surgery. Do not lift greater than a gallon of milk for 3 weeks. At your post op appointment, your surgical team will clear you for heavier exercise. In the meantime, you may climb stairs and go outside and walk. Please avoid traveling long distances until you speak with your surgical team at your post-op visit. Thank you for allowing us to participate in your care, we wish you all the best! Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[]
[ "K5100: Ulcerative (chronic) pancolitis without complications", "K8301: Primary sclerosing cholangitis", "I951: Orthostatic hypotension", "D122: Benign neoplasm of ascending colon" ]
19,997,448
23,069,082
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Ampicillin / Wellbutrin / Penicillins Attending: ___ Chief Complaint: colonscopy prep Major Surgical or Invasive Procedure: colonoscopy History of Present Illness: ___ hospitalized for elective colonoscopy for colon cancer screening. She is hospitalized in the setting of aortic stenosis with aortic valve area below 1.0 cm2. She has not had any worsening cardio-pulmonary symptoms or syncope. The patient has had chronic SOB with walking up stairs. She also has chronic dizziness when she stands up or bends down quickly. She saw GI earlier this month who arranged colonoscopy. The patient has not had palpitations. She and I commented on fast pulse approx. 110. She does feel anxious currently. ROS negative for leg swelling, PND, cough, fevers, chills, diarrhea Past Medical History: anxiety excezma aortic stenosis glucose intolerance photosensitivity Social History: ___ Family History: not pertinent to management of current hospital diagnosis Physical Exam: 98.4 136/72 109 99RA slightly anxious female, attentive and cooperative asymmetry of her eyes due to "lazy eye" chronic moist oral mucosa clear breath sounds regular s1 and s2 with loud mid systolic murmur, loudest near R clavicle soft abdomen obese no peripheral edema DISCHARGE EXAM afebrile, HR 95, BP and respiratory status wnl anxious, NAD L sided ptosis (baseline per pt) MMM CTAB mildly tachycardic, III/VI SEM heard throughout precordium and into back but best at RUSB sntnd wwp, neg edema Pertinent Results: Colonoscopy: Impression: Normal mucosa in the colon from the rectum to the cecum Recommendations: Repeat colonoscopy in ___ years. Brief Hospital Course: ___ with anxiety, aortic stenosis w ___ <1.0cm2 hospitalized to complete colonoscopy prep for screening colonoscopy. She tolerated colonoscopy well. She had tachycardia on admission with negative orthostatics, but after the procedure when she was less anxious HR returned to high ___, which is baseline HR based on review of records. EKG also noted new RBBB and RVH; suggest TTE which had previously been scheduled for several months from now be performed sooner to assess R sided structures, but defer to cardiology and primary care. Continued home clonazepam, doxepin, venlafaxine for anxiety. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Clindamycin 1% Solution 1 Appl TP BID 2. ClonazePAM 0.5 mg PO DAILY 3. Venlafaxine XR 225 mg PO DAILY 4. Doxepin HCl 10 mg PO HS Discharge Medications: 1. Clindamycin 1% Solution 1 Appl TP BID 2. ClonazePAM 0.5 mg PO DAILY 3. Doxepin HCl 10 mg PO HS 4. Venlafaxine XR 225 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: colonoscopy prep aortic stenosis Discharge Condition: Alert, ambulatory Discharge Instructions: Ms. ___, You were admitted for colonoscopy preparation. You tolerated the prep and the procedure well. Your colonoscopy was normal. You had a few minor changes on your EKG. Please follow up with your primary care doctor and your cardiologist. Followup Instructions: ___
[ "Z1211", "Q231", "R000", "F419" ]
Allergies: Ampicillin / Wellbutrin / Penicillins Chief Complaint: colonscopy prep Major Surgical or Invasive Procedure: colonoscopy History of Present Illness: [MASKED] hospitalized for elective colonoscopy for colon cancer screening. She is hospitalized in the setting of aortic stenosis with aortic valve area below 1.0 cm2. She has not had any worsening cardio-pulmonary symptoms or syncope. The patient has had chronic SOB with walking up stairs. She also has chronic dizziness when she stands up or bends down quickly. She saw GI earlier this month who arranged colonoscopy. The patient has not had palpitations. She and I commented on fast pulse approx. 110. She does feel anxious currently. ROS negative for leg swelling, PND, cough, fevers, chills, diarrhea Past Medical History: anxiety excezma aortic stenosis glucose intolerance photosensitivity Social History: [MASKED] Family History: not pertinent to management of current hospital diagnosis Physical Exam: 98.4 136/72 109 99RA slightly anxious female, attentive and cooperative asymmetry of her eyes due to "lazy eye" chronic moist oral mucosa clear breath sounds regular s1 and s2 with loud mid systolic murmur, loudest near R clavicle soft abdomen obese no peripheral edema DISCHARGE EXAM afebrile, HR 95, BP and respiratory status wnl anxious, NAD L sided ptosis (baseline per pt) MMM CTAB mildly tachycardic, III/VI SEM heard throughout precordium and into back but best at RUSB sntnd wwp, neg edema Pertinent Results: Colonoscopy: Impression: Normal mucosa in the colon from the rectum to the cecum Recommendations: Repeat colonoscopy in [MASKED] years. Brief Hospital Course: [MASKED] with anxiety, aortic stenosis w [MASKED] <1.0cm2 hospitalized to complete colonoscopy prep for screening colonoscopy. She tolerated colonoscopy well. She had tachycardia on admission with negative orthostatics, but after the procedure when she was less anxious HR returned to high [MASKED], which is baseline HR based on review of records. EKG also noted new RBBB and RVH; suggest TTE which had previously been scheduled for several months from now be performed sooner to assess R sided structures, but defer to cardiology and primary care. Continued home clonazepam, doxepin, venlafaxine for anxiety. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Clindamycin 1% Solution 1 Appl TP BID 2. ClonazePAM 0.5 mg PO DAILY 3. Venlafaxine XR 225 mg PO DAILY 4. Doxepin HCl 10 mg PO HS Discharge Medications: 1. Clindamycin 1% Solution 1 Appl TP BID 2. ClonazePAM 0.5 mg PO DAILY 3. Doxepin HCl 10 mg PO HS 4. Venlafaxine XR 225 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: colonoscopy prep aortic stenosis Discharge Condition: Alert, ambulatory Discharge Instructions: Ms. [MASKED], You were admitted for colonoscopy preparation. You tolerated the prep and the procedure well. Your colonoscopy was normal. You had a few minor changes on your EKG. Please follow up with your primary care doctor and your cardiologist. Followup Instructions: [MASKED]
[]
[ "F419" ]
[ "Z1211: Encounter for screening for malignant neoplasm of colon", "Q231: Congenital insufficiency of aortic valve", "R000: Tachycardia, unspecified", "F419: Anxiety disorder, unspecified" ]
19,997,448
23,560,173
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: CARDIOTHORACIC Allergies: Ampicillin / Wellbutrin / Penicillins Attending: ___. Chief Complaint: chest pain Major Surgical or Invasive Procedure: 1. Aortic root enlargement with bovine pericardial patch. 2. Aortic valve replacement with a 21 ___ Ease pericardial tissue valve, model ___. Serial number is ___. History of Present Illness: ___ year old male presented in ___ with palpitations and shortness of breath found to be in atrial fibrillation and ruled in for NSTEMI. He underwent TEE that revealed left atrial thrombus, cardioversion was deferred and he was anticoagulated with Eliquis. In ___ he noticed chest pain and dyspnea with minimal exertion that resolved with 1 nitroglycerin and rest. He had palpitations that he was taking additional Lopressor for approximately 4 times during ___ month. He underwent cardiac catheterization which revealed coronary artery disease and cardiac surgery was consulted. He underwent TEE that revealed no clot and was cardioverted. ___ discussed with Dr ___ the surgery for a least 30 days from cardioversion unless his symptoms worsened and he required surgery sooner. He presents today for preop work up for CABG in AM with ___. Past Medical History: - Bicuspid aortic valve stenosis. - Moderate mitral annular calcification, mild mitral valve prolapse with no significant MR. - Anxiety - Cognitive Delay - Eczema - Glucose intolerance - Recent colonoscopy was normal Social History: ___ Family History: Denies premature coronary artery disease Physical Exam: Vitals: 98.5, 18 RR, 94% RA, 91bpm, 95/68 General: No acute distress Skin: Dry [X] intact [X] Eczema present HEENT: PERRLA [X] EOMI [X] Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: RRR [X] Irregular [] Murmur [X] grade ___ systolic Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [] Extremities: Warm [X], well-perfused [X] Edema [] _trace pedal edema____ Varicosities: None [X] Neuro: Grossly intact [X] Pulses: Femoral Right: 1+ Left: 1+ DP Right: 1+ Left: 1+ ___ Right: 1+ Left: 1+ Radial Right: 1+ Left: 1+ Carotid Bruit Right: - Left: - Pertinent Results: ___ Intra-op TEE Conclusions Pre Bypass: No thrombus is seen in the left atrial appendage. Color-flow imaging of the interatrial septum raises the suspicion of an atrial septal defect, but this could not be confirmed on the basis of this study. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve is bicuspid. There is severe aortic valve stenosis (valve area <1.0cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. Post Bypass: Patient is AV paced on phenylepherine infusion. There is a tissue prosthesis in the aortic position without AI or perivalvular leaks. Peak gradient 30, mean 15 mm Hg. Aortic contours intact. Preserved biventricular function. Mitral regurgitation unchanged. Remaining exam is unchanged. All findings discussed with surgeons at the time of the exam. CXR: ___ IMPRESSION: Comparison to ___. Stable moderate to severe cardiomegaly with extensive pleural effusions and signs of moderate pulmonary edema. Stable alignment of the sternal wires. Stable position of the right central venous access line. . ___ 04:08AM BLOOD WBC-7.3 RBC-3.24* Hgb-9.5* Hct-30.0* MCV-93 MCH-29.3 MCHC-31.7* RDW-14.5 RDWSD-48.2* Plt ___ ___ 03:43AM BLOOD WBC-12.2* RBC-3.63*# Hgb-10.6*# Hct-32.9*# MCV-91 MCH-29.2 MCHC-32.2 RDW-13.9 RDWSD-45.4 Plt ___ ___ 02:12AM BLOOD ___ PTT-24.4* ___ ___ 04:08AM BLOOD Glucose-124* UreaN-22* Creat-0.5 Na-140 K-3.9 Cl-97 HCO3-31 AnGap-16 ___ 02:12AM BLOOD Glucose-125* UreaN-25* Creat-0.5 Na-143 K-3.3 Cl-100 HCO3-30 AnGap-16 ___ 04:08AM BLOOD Mg-2.3 Brief Hospital Course: The patient was brought to the Operating Room on ___ where the patient underwent Aortic root enlargement with bovine pericardial patch and Aortic valve replacement with a 21 mm ___ Ease pericardial tissue valve. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable. Beta blocker was initiated. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was transfused with 2 units of RBCs for acute blood loss anemia. There was no concern for hemorrhage and the patient's hematocrit responded appropriately. She was started on iron supplementation. On POD 4 the patient developed acute respiratory distress and was transferred to the ICU. She was placed on BiPAP with improvement of her dyspnea. A CXR showed volume overload and she was placed on IV Lasix. She developed atrial fibrillation and was started on amiodarone. With diuresis her SOB resolved and she was transferred back to the floor. Her discharge CXR shows small bilateral pleural effusions and she will be discharged on a 14 day course of Lasix. The patient was evaluated by the speech pathology team due to concern for aspiration. She was deemed to be deconditioned and she will be discharged tolerating a nectar thick liquid and regular solid diet. The patient was evaluated by the physical therapy service for assistance with strength and mobility and was deemed appropriate for rehab. By the time of discharge on POD 7 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to ___ Rehab in ___, ___ in good condition with appropriate follow up instructions. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ClonazePAM 0.5-1 mg PO DAILY 2. Doxepin HCl 10 mg PO HS 3. Venlafaxine 225 mg PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO/PR Q6H:PRN pain or temperature >38.0 2. Amiodarone 200 mg PO BID ___ bid x 7 days, then 200mg daily 3. Ascorbic Acid ___ mg PO BID 4. Aspirin EC 81 mg PO DAILY 5. Docusate Sodium 100 mg PO BID hold for loose stool 6. Ferrous Sulfate 325 mg PO DAILY 7. FoLIC Acid 1 mg PO DAILY 8. Furosemide 40 mg PO BID Duration: 14 Days 9. Metoprolol Tartrate 50 mg PO TID 10. Multivitamins 1 TAB PO DAILY 11. Potassium Chloride 20 mEq PO BID Duration: 14 Days 12. Ranitidine 150 mg PO BID 13. ClonazePAM 0.25 mg PO BID RX *clonazepam 0.5 mg 0.5 (One half) tablet(s) by mouth twice a day Disp #*30 Tablet Refills:*0 14. Doxepin HCl 10 mg PO HS 15. Venlafaxine XR 225 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: - Bicuspid aortic valve stenosis. - Moderate mitral annular calcification, mild mitral valve prolapse with no significant MR. - Anxiety - Cognitive Delay - Eczema - Glucose intolerance - Recent colonoscopy was normal Discharge Condition: Alert and oriented x3 non-focal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Edema- 1+ Discharge Instructions: Please shower daily -wash incisions gently with mild soap, no baths or swimming, look at your incisions daily Please - NO lotion, cream, powder or ointment to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics Clearance to drive will be discussed at follow up appointment with surgeon No lifting more than 10 pounds for 10 weeks **Please call cardiac surgery office with any questions or concerns ___. Answering service will contact on call person during off hours** Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: ___
[ "Q231", "J9601", "I5030", "I959", "D62", "F410", "I4891", "I252", "I2510", "I341", "E785" ]
Allergies: Ampicillin / Wellbutrin / Penicillins Chief Complaint: chest pain Major Surgical or Invasive Procedure: 1. Aortic root enlargement with bovine pericardial patch. 2. Aortic valve replacement with a 21 [MASKED] Ease pericardial tissue valve, model [MASKED]. Serial number is [MASKED]. History of Present Illness: [MASKED] year old male presented in [MASKED] with palpitations and shortness of breath found to be in atrial fibrillation and ruled in for NSTEMI. He underwent TEE that revealed left atrial thrombus, cardioversion was deferred and he was anticoagulated with Eliquis. In [MASKED] he noticed chest pain and dyspnea with minimal exertion that resolved with 1 nitroglycerin and rest. He had palpitations that he was taking additional Lopressor for approximately 4 times during [MASKED] month. He underwent cardiac catheterization which revealed coronary artery disease and cardiac surgery was consulted. He underwent TEE that revealed no clot and was cardioverted. [MASKED] discussed with Dr [MASKED] the surgery for a least 30 days from cardioversion unless his symptoms worsened and he required surgery sooner. He presents today for preop work up for CABG in AM with [MASKED]. Past Medical History: - Bicuspid aortic valve stenosis. - Moderate mitral annular calcification, mild mitral valve prolapse with no significant MR. - Anxiety - Cognitive Delay - Eczema - Glucose intolerance - Recent colonoscopy was normal Social History: [MASKED] Family History: Denies premature coronary artery disease Physical Exam: Vitals: 98.5, 18 RR, 94% RA, 91bpm, 95/68 General: No acute distress Skin: Dry [X] intact [X] Eczema present HEENT: PERRLA [X] EOMI [X] Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: RRR [X] Irregular [] Murmur [X] grade [MASKED] systolic Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [] Extremities: Warm [X], well-perfused [X] Edema [] trace pedal edema Varicosities: None [X] Neuro: Grossly intact [X] Pulses: Femoral Right: 1+ Left: 1+ DP Right: 1+ Left: 1+ [MASKED] Right: 1+ Left: 1+ Radial Right: 1+ Left: 1+ Carotid Bruit Right: - Left: - Pertinent Results: [MASKED] Intra-op TEE Conclusions Pre Bypass: No thrombus is seen in the left atrial appendage. Color-flow imaging of the interatrial septum raises the suspicion of an atrial septal defect, but this could not be confirmed on the basis of this study. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve is bicuspid. There is severe aortic valve stenosis (valve area <1.0cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. Post Bypass: Patient is AV paced on phenylepherine infusion. There is a tissue prosthesis in the aortic position without AI or perivalvular leaks. Peak gradient 30, mean 15 mm Hg. Aortic contours intact. Preserved biventricular function. Mitral regurgitation unchanged. Remaining exam is unchanged. All findings discussed with surgeons at the time of the exam. CXR: [MASKED] IMPRESSION: Comparison to [MASKED]. Stable moderate to severe cardiomegaly with extensive pleural effusions and signs of moderate pulmonary edema. Stable alignment of the sternal wires. Stable position of the right central venous access line. . [MASKED] 04:08AM BLOOD WBC-7.3 RBC-3.24* Hgb-9.5* Hct-30.0* MCV-93 MCH-29.3 MCHC-31.7* RDW-14.5 RDWSD-48.2* Plt [MASKED] [MASKED] 03:43AM BLOOD WBC-12.2* RBC-3.63*# Hgb-10.6*# Hct-32.9*# MCV-91 MCH-29.2 MCHC-32.2 RDW-13.9 RDWSD-45.4 Plt [MASKED] [MASKED] 02:12AM BLOOD [MASKED] PTT-24.4* [MASKED] [MASKED] 04:08AM BLOOD Glucose-124* UreaN-22* Creat-0.5 Na-140 K-3.9 Cl-97 HCO3-31 AnGap-16 [MASKED] 02:12AM BLOOD Glucose-125* UreaN-25* Creat-0.5 Na-143 K-3.3 Cl-100 HCO3-30 AnGap-16 [MASKED] 04:08AM BLOOD Mg-2.3 Brief Hospital Course: The patient was brought to the Operating Room on [MASKED] where the patient underwent Aortic root enlargement with bovine pericardial patch and Aortic valve replacement with a 21 mm [MASKED] Ease pericardial tissue valve. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable. Beta blocker was initiated. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was transfused with 2 units of RBCs for acute blood loss anemia. There was no concern for hemorrhage and the patient's hematocrit responded appropriately. She was started on iron supplementation. On POD 4 the patient developed acute respiratory distress and was transferred to the ICU. She was placed on BiPAP with improvement of her dyspnea. A CXR showed volume overload and she was placed on IV Lasix. She developed atrial fibrillation and was started on amiodarone. With diuresis her SOB resolved and she was transferred back to the floor. Her discharge CXR shows small bilateral pleural effusions and she will be discharged on a 14 day course of Lasix. The patient was evaluated by the speech pathology team due to concern for aspiration. She was deemed to be deconditioned and she will be discharged tolerating a nectar thick liquid and regular solid diet. The patient was evaluated by the physical therapy service for assistance with strength and mobility and was deemed appropriate for rehab. By the time of discharge on POD 7 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to [MASKED] Rehab in [MASKED], [MASKED] in good condition with appropriate follow up instructions. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ClonazePAM 0.5-1 mg PO DAILY 2. Doxepin HCl 10 mg PO HS 3. Venlafaxine 225 mg PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO/PR Q6H:PRN pain or temperature >38.0 2. Amiodarone 200 mg PO BID [MASKED] bid x 7 days, then 200mg daily 3. Ascorbic Acid [MASKED] mg PO BID 4. Aspirin EC 81 mg PO DAILY 5. Docusate Sodium 100 mg PO BID hold for loose stool 6. Ferrous Sulfate 325 mg PO DAILY 7. FoLIC Acid 1 mg PO DAILY 8. Furosemide 40 mg PO BID Duration: 14 Days 9. Metoprolol Tartrate 50 mg PO TID 10. Multivitamins 1 TAB PO DAILY 11. Potassium Chloride 20 mEq PO BID Duration: 14 Days 12. Ranitidine 150 mg PO BID 13. ClonazePAM 0.25 mg PO BID RX *clonazepam 0.5 mg 0.5 (One half) tablet(s) by mouth twice a day Disp #*30 Tablet Refills:*0 14. Doxepin HCl 10 mg PO HS 15. Venlafaxine XR 225 mg PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: - Bicuspid aortic valve stenosis. - Moderate mitral annular calcification, mild mitral valve prolapse with no significant MR. - Anxiety - Cognitive Delay - Eczema - Glucose intolerance - Recent colonoscopy was normal Discharge Condition: Alert and oriented x3 non-focal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Edema- 1+ Discharge Instructions: Please shower daily -wash incisions gently with mild soap, no baths or swimming, look at your incisions daily Please - NO lotion, cream, powder or ointment to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics Clearance to drive will be discussed at follow up appointment with surgeon No lifting more than 10 pounds for 10 weeks **Please call cardiac surgery office with any questions or concerns [MASKED]. Answering service will contact on call person during off hours** Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: [MASKED]
[]
[ "J9601", "D62", "I4891", "I252", "I2510", "E785" ]
[ "Q231: Congenital insufficiency of aortic valve", "J9601: Acute respiratory failure with hypoxia", "I5030: Unspecified diastolic (congestive) heart failure", "I959: Hypotension, unspecified", "D62: Acute posthemorrhagic anemia", "F410: Panic disorder [episodic paroxysmal anxiety]", "I4891: Unspecified atrial fibrillation", "I252: Old myocardial infarction", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I341: Nonrheumatic mitral (valve) prolapse", "E785: Hyperlipidemia, unspecified" ]
19,997,473
27,787,494
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: dyspnea Major Surgical or Invasive Procedure: Cardiac Catheterization ___ ===================================== R femoral artery approach L dominance LMCA - calcified and 99% stenosed at its ostium LAD - long calcified 95% stenosis LCx - serial 70% stenosis in its midcourse ___ marginal is subtotally occluded RCA - small, diffusely diseased and non dominant with a 90% mid stenosis Impression: critical L main and 3v disease in an elderly woman with an EF of 18% Cardiac Catheterization, Impella placement, Percutaneous Coronary Intervention ___ ====================================== R femoral artery approach Co-dominant LMCA - 80% stenosis in LMCA. TIMI flow 2 and has moderate calcification noted. This lesion is further described as focal. An intervention was performed on the LMCA with a final stenosis of 0%. No lesion complications. LAD - 90% stenosis of proximal LAD. TIMI flow 2 and severe calcification noted. Diffusely diseased. An intervention was performed on the proximal LAD with final stenosis of 0%. There were no lesion complications. There is diffuse mid and distal disease without focal stenosis. LCx - diffuse distal 60% stenosis. ___ marginal is occluded in mid portion. RCA - not injected Impressions: 1. Severe left main and 3v CAD 2. Cardiogenic shock (CI 1.6, cardiorenal syndrome) 3. Successful ___ main and LAD 4. Successful impella placement History of Present Illness: This is a ___ year old female with no known PMH though patient has not seen PCP ___ ___ years presents with a chief complaint of dyspnea on exertion for the past 5 days. DOE acutely worse over the past 2 days. Patient reports she felt unwell with nonspecific malaise and nausea 5 days ago while the family was on ___; she normally enjoys walks with her family but stayed inside due to her symptoms. She has had progressively worsening shortness of breath with minimal exertion since then. Denies active chest pain, current nausea or vomiting. No SOB at rest. Patient typically uses 2 pillows to sleep at night and this has not changed. No recent fever/chills, nausea, vomiting. or diarrhea though with mild decreased appetite. Patient also without worsening lower extremity edema. Daughter brought patient into the ___ where EKG showed possible ST changes in anterior leads - V1, V2, V3 with no old EKG for comparison. She was referred into ED for further evaluation. CXR was concerning for pulmonary edema. U/A with evidence of UTI and Creatinine elevated at 1.6. Vitals on transfer to ED were ___, P94, R20, 125/82, 97%RA In the ED initial vitals were: 22:23 ___ 98.1 90 126/78 16 96% RA EKG: STE V1-V3 and Q wave in III Labs/studies notable for: h/h 9.4/29.7 (no baseline), creat 1.6, u/a with neg nitrite, >50wbc, many bacteria, sm leuk. CXR with cardiomegaly with small bilateral pleural effusions and pulmonary vascular congestion. Patient was given: 325mg aspirin, 20mg IV Lasix, 500mg ciprofloxacin. Vitals on transfer: Today 01:10 0 98.1 96 149/93 21 99% RA On the floor, patient states that she does not want to be here. She denies any chest pain or shortness of breath. She did have some decreased appetite over the last week. She is typically able to ambulate around the ___ without difficulty and believes she would still be able to do at this time. ROS: On review of systems, 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. Denies recent fevers, chills or rigors. 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, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: s/p appendectomy unknown year Social History: ___ Family History: Father died when she was very young due to a bowel issue. Mother died at ___ due to an unknown cause. No early CAD or sudden cardiac death. Physical Exam: ADMISSION PHYSICAL EXAM VS: T97.5 BP143/83 HR102 RR18 95%RA 64.5kg GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple with JVP to level of jaw. CARDIAC: ___ systolic murmur LUNGS: Crackles in b/l bases ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Distal pulses palpable and symmetric DISCHARGE PHYSICAL EXAM: VS: 98.5 91-117/46-69 ___ 20 94%RA DISCHARGE WEIGHT: 58.4 kg GENERAL: no respiratory distress HEENT: conjunctiva pale, NCAT, sclera anicteric, PERRL, OP clear NECK: no JVD CARDIAC: RRR, nl S1 S2, ___ systolic murmur RUSB/LUSB LUNGS: poor air movement at bases, no wheezes or crackles appreciated ABDOMEN: soft, NT, ND, NABS EXTREMITIES: WWP, no ___ edema Pertinent Results: ADMISSION LABS: ========================== ___ 08:20PM BLOOD WBC-8.9 RBC-3.64* Hgb-9.4* Hct-29.7* MCV-82 MCH-25.8* MCHC-31.6* RDW-14.8 RDWSD-43.9 Plt ___ ___ 08:20PM BLOOD Neuts-64.2 ___ Monos-11.0 Eos-1.4 Baso-0.7 Im ___ AbsNeut-5.69 AbsLymp-1.98 AbsMono-0.97* AbsEos-0.12 AbsBaso-0.06 ___ 08:20PM BLOOD Plt ___ ___ 08:20PM BLOOD Glucose-189* UreaN-46* Creat-1.6* Na-134 K-4.0 Cl-98 HCO3-21* AnGap-19 ___ 08:20PM BLOOD ALT-52* AST-58* CK(CPK)-151 AlkPhos-179* TotBili-0.6 ___ 08:20PM BLOOD CK-MB-6 cTropnT-2.35* ___ ___ 08:20PM BLOOD Calcium-8.8 Phos-3.5 Mg-2.0 Iron-11* Cholest-210* ___ 08:20PM BLOOD calTIBC-360 Ferritn-25 TRF-277 ___ 02:19AM BLOOD %HbA1c-6.5* eAG-140* ___ 08:20PM BLOOD Triglyc-139 HDL-45 CHOL/HD-4.7 LDLcalc-137* LDLmeas-140* PERTINENT INTERVAL LABS: ========================== ___ 09:30AM BLOOD ALT-67* AST-90* AlkPhos-258* TotBili-0.6 ___ 06:40PM BLOOD CK-MB-39* cTropnT-3.24* ___ 05:26PM BLOOD ___ pO2-59* pCO2-39 pH-7.34* calTCO2-22 Base XS--4 Comment-GREEN-TOP ___ 03:24PM BLOOD Lactate-3.1* ___ 05:26PM BLOOD Lactate-3.3* ___ 10:57PM BLOOD Lactate-1.8 ___ 02:07PM BLOOD Glucose-163* UreaN-96* Creat-4.2* Na-131* K-4.6 Cl-97 HCO3-19* AnGap-20 ___ 03:57AM BLOOD Glucose-124* UreaN-101* Creat-4.1* Na-132* K-4.0 Cl-98 HCO3-21* AnGap-17 ___ 06:00AM BLOOD Glucose-107* UreaN-93* Creat-3.4* Na-130* K-3.9 Cl-95* HCO3-22 AnGap-17 ___ 04:45AM BLOOD Glucose-105* UreaN-84* Creat-2.5* Na-133 K-3.7 Cl-95* HCO3-27 AnGap-15 ___ 05:08AM BLOOD ALT-124* AST-171* LD(LDH)-671* AlkPhos-766* TotBili-1.4 ___ 03:35PM BLOOD ALT-109* AST-162* LD(LDH)-602* AlkPhos-651* TotBili-1.4 ___ 06:00AM BLOOD ALT-79* AST-134* LD(LDH)-462* AlkPhos-267* TotBili-0.8 ___ 08:20PM BLOOD CK-MB-6 cTropnT-2.35* ___ ___ 07:50AM BLOOD CK-MB-7 cTropnT-2.28* ___ 03:15AM BLOOD CK-MB-9 ___ 07:02AM BLOOD CK-MB-20* cTropnT-2.11* ___ 07:10AM BLOOD CK-MB-52* cTropnT-3.04* ___ 06:40PM BLOOD CK-MB-39* cTropnT-3.24* ___ 10:50PM BLOOD CK-MB-30* MB Indx-7.2* cTropnT-3.12* ___ 04:56AM BLOOD CK-MB-24* MB Indx-6.5* cTropnT-3.08* ___ 08:06PM BLOOD cTropnT-4.87* ___ 06:16AM BLOOD cTropnT-5.33* ___ 08:20PM BLOOD TSH-2.4 TEST RESULT REFERENCE RANGE UNITS ____________________ ______ _______________ _____ PF4 Heparin Antibody 0.47 0.00 -0.39 OD ___ 08:40PM URINE Type-RANDOM Color-Yellow Appear-Cloudy Sp ___ ___ 08:40PM URINE Blood-MOD Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-1 pH-5.5 Leuks-SM ___ 08:40PM URINE ___ WBC->50 Bacteri-MANY Yeast-NONE ___ 08:40PM URINE Mucous-FEW ___ 11:00AM URINE Color-Yellow Appear-Hazy Sp ___ ___ 11:00AM URINE Blood-TR Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG ___ 11:00AM URINE RBC-2 WBC-9* Bacteri-FEW Yeast-NONE Epi-0 ___ 11:00AM URINE Mucous-RARE ___ 03:14AM URINE Hours-RANDOM Creat-46 Na-91 K-27 Cl-107 ___ 08:05PM URINE Hours-RANDOM UreaN-791 Creat-52 Na-23 K-21 Cl-13 ___ 08:05PM URINE Osmolal-479 ___ 10:59AM URINE Hours-RANDOM UreaN-303 Creat-34 Na-60 K-30 Cl-76 MICROBIOLOGY: ========================== MRSA SCREEN (Final ___: No MRSA isolated. Staph aureus Screen (Final ___: NO STAPHYLOCOCCUS AUREUS ISOLATED. Blood Culture, Routine (Final ___: NO GROWTH. Blood Culture, Routine (Final ___: NO GROWTH. URINE CULTURE (Final ___: NO GROWTH. IMAGING/STUDIES: ========================== ECG Study Date of ___ 8:44:30 ___ Sinus rhythm. Delayed R wave progression across the precordium. Possible old anterior myocardial infarction. No previous tracing available for comparison. CHEST (PA & LAT) Study Date of ___ Cardiomegaly with small bilateral pleural effusions and pulmonary vascular congestion. RENAL U.S. Study Date of ___ No hydronephrosis. Numerous cysts are seen bilaterally in the kidneys. Mild caliectasis is noted in the right kidney and the left renal pelvis is ectatic. TTE ___ The left atrium is mildly dilated. The estimated right atrial pressure is at least 15 mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size. Overall left ventricular systolic function is severely depressed (Quantitative (biplane) LVEF = 18%) secondary to akinesis of the mid-distal LV. The basal LV segments are normo to hypokinetic. Doppler parameters are indeterminate for left ventricular diastolic function. Right ventricular chamber size is normal with focal hypokinesis of the apical free wall. The aortic valve leaflets are moderately thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. The mitral valve leaflets do not fully coapt. Moderate (2+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] There is no pericardial effusion. IMPRESSION: Severe regional and global systolic dysfunction suggestive of CAD. Moderate functional mitral regurgitation. Focal right ventricular systolic dysfunction with moderate tricuspid regurgitation and moderate pulmonary artery systolic hypertension. TTE ___ Overall left ventricular systolic function is severely depressed (LVEF<= 20 %). An Impella catheter is seen in the left ventricualr apex. The inlet area appears to be advanced slightly too far into the LV (~5.4cm), but the color doppler signal is consistent with appropriate outflow location when interrogated from the apical 5-chamber view (standard would be form the parasternal view). Right ventricular chamber size is normal with focal hypokinesis of the apical free wall. Mild (1+) aortic regurgitation is seen. [Due to acoustic shadowing, the severity of aortic regurgitation may be significantly UNDERestimated.] The mitral valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. TTE ___ Overall left ventricular systolic function is severely depressed. No masses or thrombi are seen in the left ventricle. The IMPELLA appears imrpoerply positioned with inflow about 3.0 cm below the aortic valve from an apical view. The outflow appears above the aortic valve but not well seen. RV with depressed free wall contractility. There is no pericardial effusion. Mild AR and MR are suggested. Compared with the prior study (images reviewed) of ___, the inflow may have migrated closer to the aortic valve. MR and AR are similar. Basal lateral LV systolic function appears more vigorous. DISCHARGE LABS: ============================= ___ 06:30AM BLOOD WBC-8.3 RBC-3.77* Hgb-10.0* Hct-32.6* MCV-87 MCH-26.5 MCHC-30.7* RDW-16.6* RDWSD-52.3* Plt ___ ___ 06:30AM BLOOD Plt ___ ___ 06:30AM BLOOD Glucose-99 UreaN-47* Creat-1.5* Na-139 K-4.0 Cl-96 HCO3-33* AnGap-14 ___ 06:30AM BLOOD Calcium-8.3* Phos-4.2 Mg-1.___ year old female with no known PMH though patient has not seen PCP ___ ___ years presents with a chief complaint of dyspnea on exertion found to have acute systolic heart failure. # ACUTE DECOMPENSATED SYSTOLIC HEART FAILURE: The patient presented with progressive dyspnea, found to have elevated BNP and CXR with pulmonary edema. TTE showed severe systolic dysfunction with EF of 18%. CHF was thought to be precipitated by ischemia as the patient presented with elevated troponin. The patient was started on metoprolol and aspirin (see below). ACEi was not started given ___ and soft pressures and unknown baseline (see below). She was treated with repeated doses of 20mg IV furosemide, but ultimately was transferred to the CCU for further management due to concern for cardiogenic shock. In the CCU she underwent RHC and LHC notable for cardiogenic shock and an impella was placed and removed as further described below. She also had a swan placed for monitoring in the CCU which was removed prior to transfer to the floor. She diuresed well with IV Lasix, and was euvolemic upon transfer to the floor. She continued to autodiurese on the floor thought secondary to post ATN diuresis. She had an episode of shortness of breath prior to discharge that was thought to be due to volume overload, and was restarted on IV lasix with good effect. This was transitioned to 80 mg torsemide on discharge. As an outpatient will need consideration of ICD/lifevest. # CAD s/p NSTEMI: The patient presented with vague symptoms of chest pain and dyspnea. ECG as outside facility showed old anterior infarct. Upon CCU transfer, patient had uptrending MB and Troponins, concerning for ongoing NSTEMI. ECG showed stable anterior Q waves with poor R wave progression. Trops peaked at 5.33 on ___. Pt had cath on ___, which showed severe 3 vessel disease: LMCA 99% at ostium, LAD 95%, LCX mid 70%, RCA mid 90%. CABG recommended, but CT surgery evaluated her on ___, and determined she was not a surgical candidate. Underwent PCI and Impella placement ___ c/b displacement of Impella on ___ and ___ with bedside repositioning as well as ongoing bleeding from femoral access sites requiring 3 U pRBCs. The impella was removed on ___. She was started on Aspirin 81mg daily, metoprolol, Atorvastatin 80mg daily, and Plavix 75mg daily which were continued on discharge. # ___ on CKD: On admission, patient had ___ on CKD with uptrending BUN/Cr > 20 consistent with pre-renal picture and concerning for cardiogenic shock. Also had received contrast, so the ___ was thought to be possibly multifactorial with contribution from post-contrast nephropathy as well. She had multiple loads of contrast with a second catheterization/PCI ___. The patient was evaluated with renal US which showed no obstruction but some evidence of ectatic cortex of left kidney. The patient's creatinine ultimately peaked at 4.2 on ___. The creatinine subsequently downtrended and on discharge the patient's creatinine was 1.5. # UTI: The patient was found to have positive UA. Though she did not report symptoms of dysuria, she was treated with ciprofloxacin x3 days given additional comorbidities. # THROMBOCYTOPENIA: Patient had decreasing platelets since admission. She had never had heparin before, with score of 5 for HIT. Discontinued heparin on ___. Differential also included shearing from impella device. HIT antibody was 0.47. The patient's heparin products were discontinued and platelets uptrended to within normal limits. The Serotonin Release Assay was sent and was pending at discharge. Platelets at discharge were 351. # ANEMIA: Unknown baseline. Patient found to have iron studies consistent with iron deficiency anemia. Patient has never had hx colonoscopy. Patient without hx of melena/hematochezia or hemoptysis. There was also thought to be a contribution from bleeding during her CCU course as described above. The patient was started on iron supplementation and should f/u as outpatient for colonoscopy. Hgb 10 on discharge. # TRANSAMINITIS: The patient was found to have a transaminitis during the admission that was thought to be due to congestion vs. poor perfusion in the setting of cardiogenic shock. This improved with treatment of the cardiogenic shock. # FATIGUE: The patient was noted to profoundly fatigued during the end of her admission. course including acute systolic heart failure/cardiogenic shock requiring PCI and impella assist as above, renal failure, and iron deficiency anemia. Patient's mood appeared down overall, and SW was consulted. # DIABETES: Patient was found to have HbA1c of 6.5% on admission. She will need follow up as an outpatient for management. Transitional Issues ===================== # Anemia: Please follow up her CBC at next follow up, Hgb 10 likely from chronic disease. # Acute on Chronic Systolic Heart Failure: Please continue to trend Cr and trend weights. Patient was tolerating torsemide prior to discharge. # Diabetes Mellitus Type II: HgbA1c 6.5% - not started on any medications for diabetes while inpatient. Please monitor sugars. # Acute Decompensated Heart Failure: Please re-evaluate and when blood pressure can tolerate, start low dose lisinopril. Consider addition of spironolactone and consider placement of ICD pending possible improvement in cardiac function and resolution ___ # Anemia: Consider EGD/colonoscopy as outpatient for further work-up of iron deficiency anemia DISCHARGE WEIGHT: 58.4 kg DISCHARGE Cr: 1.5 # CODE: Full # CONTACT: ___, daughter ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO QPM 3. Clopidogrel 75 mg PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Ferrous Sulfate 325 mg PO DAILY 6. Multivitamins W/minerals 1 TAB PO DAILY 7. Senna 17.2 mg PO QHS:PRN CONSTIPATION 8. TraZODone ___ mg PO QHS:PRN insomnia 9. Metoprolol Succinate XL 37.5 mg PO DAILY 10. Torsemide 80 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary Diagnoses ==================== acute systolic heart failure coronary artery disease s/p percutaneous coronary intervention with drug eluting stent to LAD and LCMA type 2 diabetes iron deficiency anemia thrombocytopenia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, Thank you for allowing us to participate in your care at ___. You were admitted to the hospital with shortness of breath. You were found to have heart failure. This was likely caused by coronary artery disease. You were evaluated with an ultrasound of your heart which showed poor heart function. You had to be treated briefly with a device called an Impella to help pump blood in your body. You were evaluated with a cardiac catheterization which showed coronary artery disease. You were evaluated by the cardiac surgeons who did not believe you were a candidate for cardiac surgery, so you were treated with stents to help keep the arteries in your heart open. You were started on several medications to help protect your heart and help your heart function. Your medications are and appointments are listed below. After discharge, please weight yourself daily and call your doctor if your weight goes up more than 3 pounds. We wish you the best! Sincerely, Your ___ Care Team Followup Instructions: ___
[ "I214", "R570", "I5023", "N179", "N390", "D62", "I97610", "T82528A", "D696", "I083", "I2584", "I2510", "I252", "E119", "D509", "R740", "Z87891", "T508X5A", "Y840", "R5383", "N189", "D72829", "M549", "N141", "Y848", "Y92230" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: dyspnea Major Surgical or Invasive Procedure: Cardiac Catheterization [MASKED] ===================================== R femoral artery approach L dominance LMCA - calcified and 99% stenosed at its ostium LAD - long calcified 95% stenosis LCx - serial 70% stenosis in its midcourse [MASKED] marginal is subtotally occluded RCA - small, diffusely diseased and non dominant with a 90% mid stenosis Impression: critical L main and 3v disease in an elderly woman with an EF of 18% Cardiac Catheterization, Impella placement, Percutaneous Coronary Intervention [MASKED] ====================================== R femoral artery approach Co-dominant LMCA - 80% stenosis in LMCA. TIMI flow 2 and has moderate calcification noted. This lesion is further described as focal. An intervention was performed on the LMCA with a final stenosis of 0%. No lesion complications. LAD - 90% stenosis of proximal LAD. TIMI flow 2 and severe calcification noted. Diffusely diseased. An intervention was performed on the proximal LAD with final stenosis of 0%. There were no lesion complications. There is diffuse mid and distal disease without focal stenosis. LCx - diffuse distal 60% stenosis. [MASKED] marginal is occluded in mid portion. RCA - not injected Impressions: 1. Severe left main and 3v CAD 2. Cardiogenic shock (CI 1.6, cardiorenal syndrome) 3. Successful [MASKED] main and LAD 4. Successful impella placement History of Present Illness: This is a [MASKED] year old female with no known PMH though patient has not seen PCP [MASKED] [MASKED] years presents with a chief complaint of dyspnea on exertion for the past 5 days. DOE acutely worse over the past 2 days. Patient reports she felt unwell with nonspecific malaise and nausea 5 days ago while the family was on [MASKED]; she normally enjoys walks with her family but stayed inside due to her symptoms. She has had progressively worsening shortness of breath with minimal exertion since then. Denies active chest pain, current nausea or vomiting. No SOB at rest. Patient typically uses 2 pillows to sleep at night and this has not changed. No recent fever/chills, nausea, vomiting. or diarrhea though with mild decreased appetite. Patient also without worsening lower extremity edema. Daughter brought patient into the [MASKED] where EKG showed possible ST changes in anterior leads - V1, V2, V3 with no old EKG for comparison. She was referred into ED for further evaluation. CXR was concerning for pulmonary edema. U/A with evidence of UTI and Creatinine elevated at 1.6. Vitals on transfer to ED were [MASKED], P94, R20, 125/82, 97%RA In the ED initial vitals were: 22:23 [MASKED] 98.1 90 126/78 16 96% RA EKG: STE V1-V3 and Q wave in III Labs/studies notable for: h/h 9.4/29.7 (no baseline), creat 1.6, u/a with neg nitrite, >50wbc, many bacteria, sm leuk. CXR with cardiomegaly with small bilateral pleural effusions and pulmonary vascular congestion. Patient was given: 325mg aspirin, 20mg IV Lasix, 500mg ciprofloxacin. Vitals on transfer: Today 01:10 0 98.1 96 149/93 21 99% RA On the floor, patient states that she does not want to be here. She denies any chest pain or shortness of breath. She did have some decreased appetite over the last week. She is typically able to ambulate around the [MASKED] without difficulty and believes she would still be able to do at this time. ROS: On review of systems, 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. Denies recent fevers, chills or rigors. 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, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: s/p appendectomy unknown year Social History: [MASKED] Family History: Father died when she was very young due to a bowel issue. Mother died at [MASKED] due to an unknown cause. No early CAD or sudden cardiac death. Physical Exam: ADMISSION PHYSICAL EXAM VS: T97.5 BP143/83 HR102 RR18 95%RA 64.5kg GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple with JVP to level of jaw. CARDIAC: [MASKED] systolic murmur LUNGS: Crackles in b/l bases ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Distal pulses palpable and symmetric DISCHARGE PHYSICAL EXAM: VS: 98.5 91-117/46-69 [MASKED] 20 94%RA DISCHARGE WEIGHT: 58.4 kg GENERAL: no respiratory distress HEENT: conjunctiva pale, NCAT, sclera anicteric, PERRL, OP clear NECK: no JVD CARDIAC: RRR, nl S1 S2, [MASKED] systolic murmur RUSB/LUSB LUNGS: poor air movement at bases, no wheezes or crackles appreciated ABDOMEN: soft, NT, ND, NABS EXTREMITIES: WWP, no [MASKED] edema Pertinent Results: ADMISSION LABS: ========================== [MASKED] 08:20PM BLOOD WBC-8.9 RBC-3.64* Hgb-9.4* Hct-29.7* MCV-82 MCH-25.8* MCHC-31.6* RDW-14.8 RDWSD-43.9 Plt [MASKED] [MASKED] 08:20PM BLOOD Neuts-64.2 [MASKED] Monos-11.0 Eos-1.4 Baso-0.7 Im [MASKED] AbsNeut-5.69 AbsLymp-1.98 AbsMono-0.97* AbsEos-0.12 AbsBaso-0.06 [MASKED] 08:20PM BLOOD Plt [MASKED] [MASKED] 08:20PM BLOOD Glucose-189* UreaN-46* Creat-1.6* Na-134 K-4.0 Cl-98 HCO3-21* AnGap-19 [MASKED] 08:20PM BLOOD ALT-52* AST-58* CK(CPK)-151 AlkPhos-179* TotBili-0.6 [MASKED] 08:20PM BLOOD CK-MB-6 cTropnT-2.35* [MASKED] [MASKED] 08:20PM BLOOD Calcium-8.8 Phos-3.5 Mg-2.0 Iron-11* Cholest-210* [MASKED] 08:20PM BLOOD calTIBC-360 Ferritn-25 TRF-277 [MASKED] 02:19AM BLOOD %HbA1c-6.5* eAG-140* [MASKED] 08:20PM BLOOD Triglyc-139 HDL-45 CHOL/HD-4.7 LDLcalc-137* LDLmeas-140* PERTINENT INTERVAL LABS: ========================== [MASKED] 09:30AM BLOOD ALT-67* AST-90* AlkPhos-258* TotBili-0.6 [MASKED] 06:40PM BLOOD CK-MB-39* cTropnT-3.24* [MASKED] 05:26PM BLOOD [MASKED] pO2-59* pCO2-39 pH-7.34* calTCO2-22 Base XS--4 Comment-GREEN-TOP [MASKED] 03:24PM BLOOD Lactate-3.1* [MASKED] 05:26PM BLOOD Lactate-3.3* [MASKED] 10:57PM BLOOD Lactate-1.8 [MASKED] 02:07PM BLOOD Glucose-163* UreaN-96* Creat-4.2* Na-131* K-4.6 Cl-97 HCO3-19* AnGap-20 [MASKED] 03:57AM BLOOD Glucose-124* UreaN-101* Creat-4.1* Na-132* K-4.0 Cl-98 HCO3-21* AnGap-17 [MASKED] 06:00AM BLOOD Glucose-107* UreaN-93* Creat-3.4* Na-130* K-3.9 Cl-95* HCO3-22 AnGap-17 [MASKED] 04:45AM BLOOD Glucose-105* UreaN-84* Creat-2.5* Na-133 K-3.7 Cl-95* HCO3-27 AnGap-15 [MASKED] 05:08AM BLOOD ALT-124* AST-171* LD(LDH)-671* AlkPhos-766* TotBili-1.4 [MASKED] 03:35PM BLOOD ALT-109* AST-162* LD(LDH)-602* AlkPhos-651* TotBili-1.4 [MASKED] 06:00AM BLOOD ALT-79* AST-134* LD(LDH)-462* AlkPhos-267* TotBili-0.8 [MASKED] 08:20PM BLOOD CK-MB-6 cTropnT-2.35* [MASKED] [MASKED] 07:50AM BLOOD CK-MB-7 cTropnT-2.28* [MASKED] 03:15AM BLOOD CK-MB-9 [MASKED] 07:02AM BLOOD CK-MB-20* cTropnT-2.11* [MASKED] 07:10AM BLOOD CK-MB-52* cTropnT-3.04* [MASKED] 06:40PM BLOOD CK-MB-39* cTropnT-3.24* [MASKED] 10:50PM BLOOD CK-MB-30* MB Indx-7.2* cTropnT-3.12* [MASKED] 04:56AM BLOOD CK-MB-24* MB Indx-6.5* cTropnT-3.08* [MASKED] 08:06PM BLOOD cTropnT-4.87* [MASKED] 06:16AM BLOOD cTropnT-5.33* [MASKED] 08:20PM BLOOD TSH-2.4 TEST RESULT REFERENCE RANGE UNITS [MASKED] [MASKED] [MASKED] [MASKED] PF4 Heparin Antibody 0.47 0.00 -0.39 OD [MASKED] 08:40PM URINE Type-RANDOM Color-Yellow Appear-Cloudy Sp [MASKED] [MASKED] 08:40PM URINE Blood-MOD Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-1 pH-5.5 Leuks-SM [MASKED] 08:40PM URINE [MASKED] WBC->50 Bacteri-MANY Yeast-NONE [MASKED] 08:40PM URINE Mucous-FEW [MASKED] 11:00AM URINE Color-Yellow Appear-Hazy Sp [MASKED] [MASKED] 11:00AM URINE Blood-TR Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [MASKED] 11:00AM URINE RBC-2 WBC-9* Bacteri-FEW Yeast-NONE Epi-0 [MASKED] 11:00AM URINE Mucous-RARE [MASKED] 03:14AM URINE Hours-RANDOM Creat-46 Na-91 K-27 Cl-107 [MASKED] 08:05PM URINE Hours-RANDOM UreaN-791 Creat-52 Na-23 K-21 Cl-13 [MASKED] 08:05PM URINE Osmolal-479 [MASKED] 10:59AM URINE Hours-RANDOM UreaN-303 Creat-34 Na-60 K-30 Cl-76 MICROBIOLOGY: ========================== MRSA SCREEN (Final [MASKED]: No MRSA isolated. Staph aureus Screen (Final [MASKED]: NO STAPHYLOCOCCUS AUREUS ISOLATED. Blood Culture, Routine (Final [MASKED]: NO GROWTH. Blood Culture, Routine (Final [MASKED]: NO GROWTH. URINE CULTURE (Final [MASKED]: NO GROWTH. IMAGING/STUDIES: ========================== ECG Study Date of [MASKED] 8:44:30 [MASKED] Sinus rhythm. Delayed R wave progression across the precordium. Possible old anterior myocardial infarction. No previous tracing available for comparison. CHEST (PA & LAT) Study Date of [MASKED] Cardiomegaly with small bilateral pleural effusions and pulmonary vascular congestion. RENAL U.S. Study Date of [MASKED] No hydronephrosis. Numerous cysts are seen bilaterally in the kidneys. Mild caliectasis is noted in the right kidney and the left renal pelvis is ectatic. TTE [MASKED] The left atrium is mildly dilated. The estimated right atrial pressure is at least 15 mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size. Overall left ventricular systolic function is severely depressed (Quantitative (biplane) LVEF = 18%) secondary to akinesis of the mid-distal LV. The basal LV segments are normo to hypokinetic. Doppler parameters are indeterminate for left ventricular diastolic function. Right ventricular chamber size is normal with focal hypokinesis of the apical free wall. The aortic valve leaflets are moderately thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. The mitral valve leaflets do not fully coapt. Moderate (2+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] There is no pericardial effusion. IMPRESSION: Severe regional and global systolic dysfunction suggestive of CAD. Moderate functional mitral regurgitation. Focal right ventricular systolic dysfunction with moderate tricuspid regurgitation and moderate pulmonary artery systolic hypertension. TTE [MASKED] Overall left ventricular systolic function is severely depressed (LVEF<= 20 %). An Impella catheter is seen in the left ventricualr apex. The inlet area appears to be advanced slightly too far into the LV (~5.4cm), but the color doppler signal is consistent with appropriate outflow location when interrogated from the apical 5-chamber view (standard would be form the parasternal view). Right ventricular chamber size is normal with focal hypokinesis of the apical free wall. Mild (1+) aortic regurgitation is seen. [Due to acoustic shadowing, the severity of aortic regurgitation may be significantly UNDERestimated.] The mitral valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. TTE [MASKED] Overall left ventricular systolic function is severely depressed. No masses or thrombi are seen in the left ventricle. The IMPELLA appears imrpoerply positioned with inflow about 3.0 cm below the aortic valve from an apical view. The outflow appears above the aortic valve but not well seen. RV with depressed free wall contractility. There is no pericardial effusion. Mild AR and MR are suggested. Compared with the prior study (images reviewed) of [MASKED], the inflow may have migrated closer to the aortic valve. MR and AR are similar. Basal lateral LV systolic function appears more vigorous. DISCHARGE LABS: ============================= [MASKED] 06:30AM BLOOD WBC-8.3 RBC-3.77* Hgb-10.0* Hct-32.6* MCV-87 MCH-26.5 MCHC-30.7* RDW-16.6* RDWSD-52.3* Plt [MASKED] [MASKED] 06:30AM BLOOD Plt [MASKED] [MASKED] 06:30AM BLOOD Glucose-99 UreaN-47* Creat-1.5* Na-139 K-4.0 Cl-96 HCO3-33* AnGap-14 [MASKED] 06:30AM BLOOD Calcium-8.3* Phos-4.2 Mg-1.[MASKED] year old female with no known PMH though patient has not seen PCP [MASKED] [MASKED] years presents with a chief complaint of dyspnea on exertion found to have acute systolic heart failure. # ACUTE DECOMPENSATED SYSTOLIC HEART FAILURE: The patient presented with progressive dyspnea, found to have elevated BNP and CXR with pulmonary edema. TTE showed severe systolic dysfunction with EF of 18%. CHF was thought to be precipitated by ischemia as the patient presented with elevated troponin. The patient was started on metoprolol and aspirin (see below). ACEi was not started given [MASKED] and soft pressures and unknown baseline (see below). She was treated with repeated doses of 20mg IV furosemide, but ultimately was transferred to the CCU for further management due to concern for cardiogenic shock. In the CCU she underwent RHC and LHC notable for cardiogenic shock and an impella was placed and removed as further described below. She also had a swan placed for monitoring in the CCU which was removed prior to transfer to the floor. She diuresed well with IV Lasix, and was euvolemic upon transfer to the floor. She continued to autodiurese on the floor thought secondary to post ATN diuresis. She had an episode of shortness of breath prior to discharge that was thought to be due to volume overload, and was restarted on IV lasix with good effect. This was transitioned to 80 mg torsemide on discharge. As an outpatient will need consideration of ICD/lifevest. # CAD s/p NSTEMI: The patient presented with vague symptoms of chest pain and dyspnea. ECG as outside facility showed old anterior infarct. Upon CCU transfer, patient had uptrending MB and Troponins, concerning for ongoing NSTEMI. ECG showed stable anterior Q waves with poor R wave progression. Trops peaked at 5.33 on [MASKED]. Pt had cath on [MASKED], which showed severe 3 vessel disease: LMCA 99% at ostium, LAD 95%, LCX mid 70%, RCA mid 90%. CABG recommended, but CT surgery evaluated her on [MASKED], and determined she was not a surgical candidate. Underwent PCI and Impella placement [MASKED] c/b displacement of Impella on [MASKED] and [MASKED] with bedside repositioning as well as ongoing bleeding from femoral access sites requiring 3 U pRBCs. The impella was removed on [MASKED]. She was started on Aspirin 81mg daily, metoprolol, Atorvastatin 80mg daily, and Plavix 75mg daily which were continued on discharge. # [MASKED] on CKD: On admission, patient had [MASKED] on CKD with uptrending BUN/Cr > 20 consistent with pre-renal picture and concerning for cardiogenic shock. Also had received contrast, so the [MASKED] was thought to be possibly multifactorial with contribution from post-contrast nephropathy as well. She had multiple loads of contrast with a second catheterization/PCI [MASKED]. The patient was evaluated with renal US which showed no obstruction but some evidence of ectatic cortex of left kidney. The patient's creatinine ultimately peaked at 4.2 on [MASKED]. The creatinine subsequently downtrended and on discharge the patient's creatinine was 1.5. # UTI: The patient was found to have positive UA. Though she did not report symptoms of dysuria, she was treated with ciprofloxacin x3 days given additional comorbidities. # THROMBOCYTOPENIA: Patient had decreasing platelets since admission. She had never had heparin before, with score of 5 for HIT. Discontinued heparin on [MASKED]. Differential also included shearing from impella device. HIT antibody was 0.47. The patient's heparin products were discontinued and platelets uptrended to within normal limits. The Serotonin Release Assay was sent and was pending at discharge. Platelets at discharge were 351. # ANEMIA: Unknown baseline. Patient found to have iron studies consistent with iron deficiency anemia. Patient has never had hx colonoscopy. Patient without hx of melena/hematochezia or hemoptysis. There was also thought to be a contribution from bleeding during her CCU course as described above. The patient was started on iron supplementation and should f/u as outpatient for colonoscopy. Hgb 10 on discharge. # TRANSAMINITIS: The patient was found to have a transaminitis during the admission that was thought to be due to congestion vs. poor perfusion in the setting of cardiogenic shock. This improved with treatment of the cardiogenic shock. # FATIGUE: The patient was noted to profoundly fatigued during the end of her admission. course including acute systolic heart failure/cardiogenic shock requiring PCI and impella assist as above, renal failure, and iron deficiency anemia. Patient's mood appeared down overall, and SW was consulted. # DIABETES: Patient was found to have HbA1c of 6.5% on admission. She will need follow up as an outpatient for management. Transitional Issues ===================== # Anemia: Please follow up her CBC at next follow up, Hgb 10 likely from chronic disease. # Acute on Chronic Systolic Heart Failure: Please continue to trend Cr and trend weights. Patient was tolerating torsemide prior to discharge. # Diabetes Mellitus Type II: HgbA1c 6.5% - not started on any medications for diabetes while inpatient. Please monitor sugars. # Acute Decompensated Heart Failure: Please re-evaluate and when blood pressure can tolerate, start low dose lisinopril. Consider addition of spironolactone and consider placement of ICD pending possible improvement in cardiac function and resolution [MASKED] # Anemia: Consider EGD/colonoscopy as outpatient for further work-up of iron deficiency anemia DISCHARGE WEIGHT: 58.4 kg DISCHARGE Cr: 1.5 # CODE: Full # CONTACT: [MASKED], daughter [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO QPM 3. Clopidogrel 75 mg PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Ferrous Sulfate 325 mg PO DAILY 6. Multivitamins W/minerals 1 TAB PO DAILY 7. Senna 17.2 mg PO QHS:PRN CONSTIPATION 8. TraZODone [MASKED] mg PO QHS:PRN insomnia 9. Metoprolol Succinate XL 37.5 mg PO DAILY 10. Torsemide 80 mg PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Primary Diagnoses ==================== acute systolic heart failure coronary artery disease s/p percutaneous coronary intervention with drug eluting stent to LAD and LCMA type 2 diabetes iron deficiency anemia thrombocytopenia 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], Thank you for allowing us to participate in your care at [MASKED]. You were admitted to the hospital with shortness of breath. You were found to have heart failure. This was likely caused by coronary artery disease. You were evaluated with an ultrasound of your heart which showed poor heart function. You had to be treated briefly with a device called an Impella to help pump blood in your body. You were evaluated with a cardiac catheterization which showed coronary artery disease. You were evaluated by the cardiac surgeons who did not believe you were a candidate for cardiac surgery, so you were treated with stents to help keep the arteries in your heart open. You were started on several medications to help protect your heart and help your heart function. Your medications are and appointments are listed below. After discharge, please weight yourself daily and call your doctor if your weight goes up more than 3 pounds. We wish you the best! Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "N179", "N390", "D62", "D696", "I2510", "I252", "E119", "D509", "Z87891", "N189", "Y92230" ]
[ "I214: Non-ST elevation (NSTEMI) myocardial infarction", "R570: Cardiogenic shock", "I5023: Acute on chronic systolic (congestive) heart failure", "N179: Acute kidney failure, unspecified", "N390: Urinary tract infection, site not specified", "D62: Acute posthemorrhagic anemia", "I97610: Postprocedural hemorrhage of a circulatory system organ or structure following a cardiac catheterization", "T82528A: Displacement of other cardiac and vascular devices and implants, initial encounter", "D696: Thrombocytopenia, unspecified", "I083: Combined rheumatic disorders of mitral, aortic and tricuspid valves", "I2584: Coronary atherosclerosis due to calcified coronary lesion", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I252: Old myocardial infarction", "E119: Type 2 diabetes mellitus without complications", "D509: Iron deficiency anemia, unspecified", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "Z87891: Personal history of nicotine dependence", "T508X5A: Adverse effect of diagnostic agents, initial encounter", "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", "R5383: Other fatigue", "N189: Chronic kidney disease, unspecified", "D72829: Elevated white blood cell count, unspecified", "M549: Dorsalgia, unspecified", "N141: Nephropathy induced by other drugs, medicaments and biological substances", "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", "Y92230: Patient room in hospital as the place of occurrence of the external cause" ]
19,997,538
22,701,415
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: rectal cancer Major Surgical or Invasive Procedure: Laparoscopic Low Anterior Resection Ileostomy takedown History of Present Illness: The patient is a ___ man with previously identified malignant polyp that was removed. He had multiple discussions. He chose to proceed with observation, which was done. However, on the recent colonoscopy, a polyp was noted to be regrowing, although the biopsies were negative. We had additional number of discussions whether to proceed with transanal excision versus LAR, and he chose to proceed with radical excision. Risks and benefits including but not limited to infection, bleeding, leak, injury to surrounding organs, conversion to open, need for more procedures were discussed, urinary, sexual dysfunction. The patient understood and agreed. Past Medical History: Hypertension, essential Hypertriglyceridemia Fatty liver Pulmonary nodule/lesion, solitary Alcohol abuse Obesity Proliferative diabetic retinopathy(362.02) Amblyopia Uncontrolled type 2 diabetes mellitus with proteinuric diabetic nephropathy Hyperlipidemia associated with type 2 diabetes mellitus Spondylosis of cervical joint Proteinuria B12 deficiency Cancer of rectum PROGRAM - Clinical Pharmacy Medication Management (not Dx, for prob list only) Chronic right-sided low back pain without sciatica Coronary artery calcification seen on CT scan Liver nodule Social History: ___ Family History: non-contributory Physical Exam: GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, incisions well approximated Ext: WWP. NEURO: A&Ox3, no focal neurologic deficits PSYCH: normal judgment/insight, normal memory, normal mood/affect Pertinent Results: ___ 10:25PM POTASSIUM-4.7 ___ 10:25PM MAGNESIUM-1.4* ___ 10:25PM HCT-32.5* Brief Hospital Course: Mr. ___ presented to ___ holding at ___ on ___ for a laparoscopic low anterior resection. During the procedure, his ureter was severed and required a ureteral stent to be placed intraoperatively. He tolerated the procedure well despite the complication (Please see operative note for further details). After a brief and uneventful stay in the PACU, the patient was transferred to the floor for further post-operative management. When he arrived on the floor, he failed his foley void trial and a foley catheter was replaced in his bladder. Over the next several days, his post-operative course was further complicated by high ileostomy output. He was trialed on a variety of medications to decrease his ostomy output but he continued to lose large amounts of fluid through his stoma. He became hyponatremic and was treated with a high sodium diet, free water restriction, and IV normal saline boluses. His electrolyte abnormalities slowly resolved but he continued to have high ostomy output and he was taken back to the operating room on ___ for an ileostomy reversal. He was initially kept NPO after the procedure but was slowly advanced to a regular diet, which he tolerated well. He underwent a third foley-catheter void trial, but again failed and a foley catheter was placed in his bladder. During his hospitalization, he remained stable from a cardiovascular standpoint and his vital signs were routinely monitored. He also had good pulmonary toileting, as early ambulation and incentive spirometry were encouraged throughout hospitalization. He was found to have a urinary tract infection and was started on a prescription for ciprofloxacin. Additionally, he developed a minor soft-tissue infection on his abdomen which resolved after a short course of Keflex. During his hospitalization, his blood levels were checked daily to monitor for signs of bleeding. The patient received subcutaneous heparin and ___ dyne boots were used during this stay. He was encouraged to get up and ambulate as early as possible. The patient is being discharged on a prophylactic dose of Lovenox. On ___, the patient was discharged to home. At discharge, he was tolerating a regular diet and ambulating independently. He had a foley catheter in place and an appointment was scheduled at the outpatient ___ clinic for a void trial. He will follow-up in the colorectal surgery clinic in ___ weeks. This information was communicated to the patient directly prior to discharge. Post-Surgical Complications During Inpatient Admission: [ ] Post-Operative Ileus resolving w/o NGT [x] Post-Operative Ileus requiring management with NGT [x] UTI [ ] Wound Infection [ ] Anastomotic Leak [ ] Staple Line Bleed [ ] Congestive Heart failure [ ] ARF [ ] Acute Urinary retention, failure to void after Foley D/C'd [ ] Acute Urinary Retention requiring discharge with Foley Catheter [ ] DVT [ ] Pneumonia [ ] Abscess [x] Intraoperative ureteral injury resulting in post-operative foley catheter placememt and JP drain placement. Social Issues Causing a Delay in Discharge: [ ] Delay in organization of ___ services [ ] Difficulty finding appropriate rehab hospital disposition. [ ] Lack of insurance coverage for ___ services [ ] Lack of insurance coverage for prescribed medications. [ ] Family not agreeable to discharge plan. [ ] Patient knowledge deficit related to ileostomy delaying dispo [x] No social factors contributing in delay of discharge. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Hydrochlorothiazide 25 mg PO DAILY 2. MetFORMIN (Glucophage) 1000 mg PO BID 3. amLODIPine 5 mg PO DAILY 4. GlipiZIDE 10 mg PO BID 5. Lisinopril 40 mg PO DAILY 6. Atorvastatin 80 mg PO QPM 7. Glargine 22 Units Bedtime Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #*13 Tablet Refills:*0 3. Enoxaparin Sodium 40 mg SC DAILY RX *enoxaparin 40 mg/0.4 mL 1 syringe subcutaneous once a day Disp #*8 Syringe Refills:*0 4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Severe RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*20 Tablet Refills:*0 5. Tamsulosin 0.4 mg PO QHS 6. Glargine 20 Units Bedtime 7. amLODIPine 5 mg PO DAILY 8. Atorvastatin 80 mg PO QPM 9. GlipiZIDE 10 mg PO BID 10. Hydrochlorothiazide 25 mg PO DAILY 11. Lisinopril 40 mg PO DAILY 12. MetFORMIN (Glucophage) 1000 mg PO BID Discharge Disposition: Home Discharge Diagnosis: Rectal Cancer 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 a laparoscopic low anterior resection to treat your rectal cancer. Samples of tissue were taken and the pathology results were reviewed with you during your hospitilization. Due to the high volume output of your new ileostomy, you were trialed on new medications. After several weeks, you were taken back to the OR to have an ileostomy reversal. You have recovered from this procedure well and you are now ready to return home. You are tolerating a regular diet, passing gas and your pain is controlled with pain medications by mouth. Please monitor your bowel function closely. You may or may not have had a bowel movement prior to discharge which is acceptable; however it is important that you have a bowel movement in the next ___ days. After anesthesia it is not uncommon for patients to have some decrease in bowel function but you should not have prolonged constipation. Some loose stool and passing of small amounts of dark, old appearing blood are expected. However, if you notice that you are passing bright red blood with bowel movements or having large amounts of loose stool without improvement please call the office or go to the emergency room. While taking narcotic pain medications you are at risk for constipation. Please take an over the counter stool softener such as Colace, and if the symptoms do not improve call the office. If you are passing loose stool without improvement please call the office or go to the emergency room if you are having symptoms of dehydration: headache, lightheadedness, dizziness, dark urine, or dry mouth. While taking narcotic pain medications there is a risk that you will have some constipation. Please take an over the counter stool softener such as Colace, and if the symptoms does not improve call the office. It is also not uncommon after an ileostomy takedown to have frequent loose stools until you are taking more regular food however this should improve. The muscles of the sphincters have not been used in quite some time and you may experience urgency or small amounts of incontinence, however, this should improve. If you do not see improvement in these symptoms within ___ days please call the office. If you experience any of the following symptoms please call the office or go to the emergency room: increasing abdominal distension, increasing abdominal pain, nausea, vomiting, inability to tolerate food or liquids, prolonged loose stool, or constipation. You have a small wound where the old ileostomy once was. This should be covered with a dry sterile gauze dressing. Please monitor the incision for signs and symptoms of infection including: increasing redness and pain at the incision site, draining of white/green/yellow/foul smelling drainage, or if you develop a fever. If you develop these symptoms please call the office or go to the emergency room. You may shower, let the warm water run over the wound line and pat the area dry with a towel, do not rub. Please apply a new gauze dressing after showering. Pain It is expected that you will have pain after surgery, this will gradually improve over the first week or so you are home. You should continue to take 2 Extra Strength Tylenol (___) for pain every 8 hours around the clock. Please do not take more than 3000mg of Tylenol in 24 hours or any other medications that contain Tylenol such as cold medication. Do not drink alcohol while taking Tylenol. You may also take Advil (Ibuprofen) 600mg every 8 hours for 7 days, please take Advil with food. If these medications are not controlling your pain to a point where you can ambulate and perform minor tasks, you should take a dose of the narcotic pain medication oxycodone. Please do not take sedating medications or drink alcohol while taking the narcotic pain medication. Do not drive while taking narcotic medications. Activity You may feel weak or "washed out" for up to 6 weeks after surgery. Do not lift greater than a gallon of milk for 3 weeks. At your post op appointment, your surgical team will clear you for heavier exercise. In the meantime, you may climb stairs, and go outside and walk. Please avoid traveling long distances until you speak with your surgical team at your post-op visit. Again, please do not drive while taking narcotic pain medications. You will be discharged home on Lovenox injections to prevent blood clots after surgery. You will take this for 30 days after your surgery date, please finish the entire prescription. This will be given once daily. Please follow all nursing teaching instruction given by the nursing staff. Please monitor for any signs of bleeding: fast heart rate, bloody bowel movements, abdominal pain, bruising, feeling faint or weak. If you have any of these symptoms please call our office or seek medical attention. Avoid any contact activity while taking Lovenox. Please take extra caution to avoid falling. Foley catheter instructions: Return to the emergency department if: •Your catheter comes out. •You suddenly have material that looks like sand in the tubing or drainage bag. •No urine is draining into the bag and you have checked the system. •You have pain in your hip, back, pelvis, or lower abdomen. •You are confused or cannot think clearly. Contact your healthcare provider ___: •You have a fever. •You have bladder spasms for more than 1 day after the catheter is placed. •You see blood in the tubing or drainage bag. •You have a rash or itching where the catheter tube is secured to your skin. •Urine leaks from or around the catheter, tubing, or drainage bag. •The closed drainage system has accidently come open or apart. •You see a layer of crystals inside the tubing. •You have questions or concerns about your condition or care. Care for your Foley catheter: •Clean your genital area 2 times every day. Clean your catheter and the area around where it was inserted. Use soap and water. Clean your anal opening and catheter area after every bowel movement. •Secure the catheter tube so you do not pull or move the catheter. This helps prevent pain and bladder spasms. Healthcare providers ___ show you how to use medical tape or a strap to secure the catheter tube to your body. •Keep a closed drainage system. Your Foley catheter should always be attached to the drainage bag to form a closed system. Do not disconnect any part of the closed system unless you need to change the bag. Care for your drainage bag: •Ask if a leg bag is right for you. A leg bag can be worn under your clothes. Ask your healthcare provider for more information about a leg bag. •Keep the drainage bag below the level of your waist. This helps stop urine from moving back up the tubing and into your bladder. Do not loop or kink the tubing. This can cause urine to back up and collect in your bladder. Do not let the drainage bag touch or lie on the floor. •Empty the drainage bag when needed. The weight of a full drainage bag can be painful. Empty the drainage bag every 3 to 6 hours or when it is 75% full. •Clean and change the drainage bag as directed. Ask your healthcare provider how often you should change the drainage bag and what cleaning solution to use. Wear disposable gloves when you change the bag. Do not allow the end of the catheter or tubing to touch anything. Clean the ends with an alcohol pad before you reconnect them. What to do if problems develop: •No urine is draining into the bag: ___ for kinks in the tubing and straighten them out. Check the tape or strap used to secure the catheter tube to your skin. Make sure it is not blocking the tube. Make sure you are not sitting or lying on the tubing.Make sure the urine bag is hanging below the level of your waist. •Urine leaks from or around the catheter, tubing, or drainage bag: Check if the closed drainage system has accidently come open or apart. Clean the catheter and tubing ends with a new alcohol pad and reconnect them. Prevent an infection: •Wash your hands often. Wash before and after you touch your catheter, tubing, or drainage bag. Use soap and water. Wear clean disposable gloves when you care for your catheter or disconnect the drainage bag. Wash your hands before you prepare or eat food. •Drink liquids as directed. Ask your healthcare provider how much liquid to drink each day and which liquids are best for you. Liquids will help flush your kidneys and bladder to help prevent infection. Thank you for allowing us to participate in your care, we wish you all the best! Followup Instructions: ___
[ "C20", "C7989", "T83511A", "N390", "N9972", "T814XXA", "E871", "K567", "B965", "R339", "E113599", "E11649", "E1142", "E1121", "K760", "E784", "M47892", "I10", "Y846", "Y832", "Y92234", "Z794", "Z87891", "Y92230", "B9689" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: rectal cancer Major Surgical or Invasive Procedure: Laparoscopic Low Anterior Resection Ileostomy takedown History of Present Illness: The patient is a [MASKED] man with previously identified malignant polyp that was removed. He had multiple discussions. He chose to proceed with observation, which was done. However, on the recent colonoscopy, a polyp was noted to be regrowing, although the biopsies were negative. We had additional number of discussions whether to proceed with transanal excision versus LAR, and he chose to proceed with radical excision. Risks and benefits including but not limited to infection, bleeding, leak, injury to surrounding organs, conversion to open, need for more procedures were discussed, urinary, sexual dysfunction. The patient understood and agreed. Past Medical History: Hypertension, essential Hypertriglyceridemia Fatty liver Pulmonary nodule/lesion, solitary Alcohol abuse Obesity Proliferative diabetic retinopathy(362.02) Amblyopia Uncontrolled type 2 diabetes mellitus with proteinuric diabetic nephropathy Hyperlipidemia associated with type 2 diabetes mellitus Spondylosis of cervical joint Proteinuria B12 deficiency Cancer of rectum PROGRAM - Clinical Pharmacy Medication Management (not Dx, for prob list only) Chronic right-sided low back pain without sciatica Coronary artery calcification seen on CT scan Liver nodule Social History: [MASKED] Family History: non-contributory Physical Exam: GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, incisions well approximated Ext: WWP. NEURO: A&Ox3, no focal neurologic deficits PSYCH: normal judgment/insight, normal memory, normal mood/affect Pertinent Results: [MASKED] 10:25PM POTASSIUM-4.7 [MASKED] 10:25PM MAGNESIUM-1.4* [MASKED] 10:25PM HCT-32.5* Brief Hospital Course: Mr. [MASKED] presented to [MASKED] holding at [MASKED] on [MASKED] for a laparoscopic low anterior resection. During the procedure, his ureter was severed and required a ureteral stent to be placed intraoperatively. He tolerated the procedure well despite the complication (Please see operative note for further details). After a brief and uneventful stay in the PACU, the patient was transferred to the floor for further post-operative management. When he arrived on the floor, he failed his foley void trial and a foley catheter was replaced in his bladder. Over the next several days, his post-operative course was further complicated by high ileostomy output. He was trialed on a variety of medications to decrease his ostomy output but he continued to lose large amounts of fluid through his stoma. He became hyponatremic and was treated with a high sodium diet, free water restriction, and IV normal saline boluses. His electrolyte abnormalities slowly resolved but he continued to have high ostomy output and he was taken back to the operating room on [MASKED] for an ileostomy reversal. He was initially kept NPO after the procedure but was slowly advanced to a regular diet, which he tolerated well. He underwent a third foley-catheter void trial, but again failed and a foley catheter was placed in his bladder. During his hospitalization, he remained stable from a cardiovascular standpoint and his vital signs were routinely monitored. He also had good pulmonary toileting, as early ambulation and incentive spirometry were encouraged throughout hospitalization. He was found to have a urinary tract infection and was started on a prescription for ciprofloxacin. Additionally, he developed a minor soft-tissue infection on his abdomen which resolved after a short course of Keflex. During his hospitalization, his blood levels were checked daily to monitor for signs of bleeding. The patient received subcutaneous heparin and [MASKED] dyne boots were used during this stay. He was encouraged to get up and ambulate as early as possible. The patient is being discharged on a prophylactic dose of Lovenox. On [MASKED], the patient was discharged to home. At discharge, he was tolerating a regular diet and ambulating independently. He had a foley catheter in place and an appointment was scheduled at the outpatient [MASKED] clinic for a void trial. He will follow-up in the colorectal surgery clinic in [MASKED] weeks. This information was communicated to the patient directly prior to discharge. Post-Surgical Complications During Inpatient Admission: [ ] Post-Operative Ileus resolving w/o NGT [x] Post-Operative Ileus requiring management with NGT [x] UTI [ ] Wound Infection [ ] Anastomotic Leak [ ] Staple Line Bleed [ ] Congestive Heart failure [ ] ARF [ ] Acute Urinary retention, failure to void after Foley D/C'd [ ] Acute Urinary Retention requiring discharge with Foley Catheter [ ] DVT [ ] Pneumonia [ ] Abscess [x] Intraoperative ureteral injury resulting in post-operative foley catheter placememt and JP drain placement. Social Issues Causing a Delay in Discharge: [ ] Delay in organization of [MASKED] services [ ] Difficulty finding appropriate rehab hospital disposition. [ ] Lack of insurance coverage for [MASKED] services [ ] Lack of insurance coverage for prescribed medications. [ ] Family not agreeable to discharge plan. [ ] Patient knowledge deficit related to ileostomy delaying dispo [x] No social factors contributing in delay of discharge. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Hydrochlorothiazide 25 mg PO DAILY 2. MetFORMIN (Glucophage) 1000 mg PO BID 3. amLODIPine 5 mg PO DAILY 4. GlipiZIDE 10 mg PO BID 5. Lisinopril 40 mg PO DAILY 6. Atorvastatin 80 mg PO QPM 7. Glargine 22 Units Bedtime Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #*13 Tablet Refills:*0 3. Enoxaparin Sodium 40 mg SC DAILY RX *enoxaparin 40 mg/0.4 mL 1 syringe subcutaneous once a day Disp #*8 Syringe Refills:*0 4. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain - Severe RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*20 Tablet Refills:*0 5. Tamsulosin 0.4 mg PO QHS 6. Glargine 20 Units Bedtime 7. amLODIPine 5 mg PO DAILY 8. Atorvastatin 80 mg PO QPM 9. GlipiZIDE 10 mg PO BID 10. Hydrochlorothiazide 25 mg PO DAILY 11. Lisinopril 40 mg PO DAILY 12. MetFORMIN (Glucophage) 1000 mg PO BID Discharge Disposition: Home Discharge Diagnosis: Rectal Cancer 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 a laparoscopic low anterior resection to treat your rectal cancer. Samples of tissue were taken and the pathology results were reviewed with you during your hospitilization. Due to the high volume output of your new ileostomy, you were trialed on new medications. After several weeks, you were taken back to the OR to have an ileostomy reversal. You have recovered from this procedure well and you are now ready to return home. You are tolerating a regular diet, passing gas and your pain is controlled with pain medications by mouth. Please monitor your bowel function closely. You may or may not have had a bowel movement prior to discharge which is acceptable; however it is important that you have a bowel movement in the next [MASKED] days. After anesthesia it is not uncommon for patients to have some decrease in bowel function but you should not have prolonged constipation. Some loose stool and passing of small amounts of dark, old appearing blood are expected. However, if you notice that you are passing bright red blood with bowel movements or having large amounts of loose stool without improvement please call the office or go to the emergency room. While taking narcotic pain medications you are at risk for constipation. Please take an over the counter stool softener such as Colace, and if the symptoms do not improve call the office. If you are passing loose stool without improvement please call the office or go to the emergency room if you are having symptoms of dehydration: headache, lightheadedness, dizziness, dark urine, or dry mouth. While taking narcotic pain medications there is a risk that you will have some constipation. Please take an over the counter stool softener such as Colace, and if the symptoms does not improve call the office. It is also not uncommon after an ileostomy takedown to have frequent loose stools until you are taking more regular food however this should improve. The muscles of the sphincters have not been used in quite some time and you may experience urgency or small amounts of incontinence, however, this should improve. If you do not see improvement in these symptoms within [MASKED] days please call the office. If you experience any of the following symptoms please call the office or go to the emergency room: increasing abdominal distension, increasing abdominal pain, nausea, vomiting, inability to tolerate food or liquids, prolonged loose stool, or constipation. You have a small wound where the old ileostomy once was. This should be covered with a dry sterile gauze dressing. Please monitor the incision for signs and symptoms of infection including: increasing redness and pain at the incision site, draining of white/green/yellow/foul smelling drainage, or if you develop a fever. If you develop these symptoms please call the office or go to the emergency room. You may shower, let the warm water run over the wound line and pat the area dry with a towel, do not rub. Please apply a new gauze dressing after showering. Pain It is expected that you will have pain after surgery, this will gradually improve over the first week or so you are home. You should continue to take 2 Extra Strength Tylenol ([MASKED]) for pain every 8 hours around the clock. Please do not take more than 3000mg of Tylenol in 24 hours or any other medications that contain Tylenol such as cold medication. Do not drink alcohol while taking Tylenol. You may also take Advil (Ibuprofen) 600mg every 8 hours for 7 days, please take Advil with food. If these medications are not controlling your pain to a point where you can ambulate and perform minor tasks, you should take a dose of the narcotic pain medication oxycodone. Please do not take sedating medications or drink alcohol while taking the narcotic pain medication. Do not drive while taking narcotic medications. Activity You may feel weak or "washed out" for up to 6 weeks after surgery. Do not lift greater than a gallon of milk for 3 weeks. At your post op appointment, your surgical team will clear you for heavier exercise. In the meantime, you may climb stairs, and go outside and walk. Please avoid traveling long distances until you speak with your surgical team at your post-op visit. Again, please do not drive while taking narcotic pain medications. You will be discharged home on Lovenox injections to prevent blood clots after surgery. You will take this for 30 days after your surgery date, please finish the entire prescription. This will be given once daily. Please follow all nursing teaching instruction given by the nursing staff. Please monitor for any signs of bleeding: fast heart rate, bloody bowel movements, abdominal pain, bruising, feeling faint or weak. If you have any of these symptoms please call our office or seek medical attention. Avoid any contact activity while taking Lovenox. Please take extra caution to avoid falling. Foley catheter instructions: Return to the emergency department if: •Your catheter comes out. •You suddenly have material that looks like sand in the tubing or drainage bag. •No urine is draining into the bag and you have checked the system. •You have pain in your hip, back, pelvis, or lower abdomen. •You are confused or cannot think clearly. Contact your healthcare provider [MASKED]: •You have a fever. •You have bladder spasms for more than 1 day after the catheter is placed. •You see blood in the tubing or drainage bag. •You have a rash or itching where the catheter tube is secured to your skin. •Urine leaks from or around the catheter, tubing, or drainage bag. •The closed drainage system has accidently come open or apart. •You see a layer of crystals inside the tubing. •You have questions or concerns about your condition or care. Care for your Foley catheter: •Clean your genital area 2 times every day. Clean your catheter and the area around where it was inserted. Use soap and water. Clean your anal opening and catheter area after every bowel movement. •Secure the catheter tube so you do not pull or move the catheter. This helps prevent pain and bladder spasms. Healthcare providers [MASKED] show you how to use medical tape or a strap to secure the catheter tube to your body. •Keep a closed drainage system. Your Foley catheter should always be attached to the drainage bag to form a closed system. Do not disconnect any part of the closed system unless you need to change the bag. Care for your drainage bag: •Ask if a leg bag is right for you. A leg bag can be worn under your clothes. Ask your healthcare provider for more information about a leg bag. •Keep the drainage bag below the level of your waist. This helps stop urine from moving back up the tubing and into your bladder. Do not loop or kink the tubing. This can cause urine to back up and collect in your bladder. Do not let the drainage bag touch or lie on the floor. •Empty the drainage bag when needed. The weight of a full drainage bag can be painful. Empty the drainage bag every 3 to 6 hours or when it is 75% full. •Clean and change the drainage bag as directed. Ask your healthcare provider how often you should change the drainage bag and what cleaning solution to use. Wear disposable gloves when you change the bag. Do not allow the end of the catheter or tubing to touch anything. Clean the ends with an alcohol pad before you reconnect them. What to do if problems develop: •No urine is draining into the bag: [MASKED] for kinks in the tubing and straighten them out. Check the tape or strap used to secure the catheter tube to your skin. Make sure it is not blocking the tube. Make sure you are not sitting or lying on the tubing.Make sure the urine bag is hanging below the level of your waist. •Urine leaks from or around the catheter, tubing, or drainage bag: Check if the closed drainage system has accidently come open or apart. Clean the catheter and tubing ends with a new alcohol pad and reconnect them. Prevent an infection: •Wash your hands often. Wash before and after you touch your catheter, tubing, or drainage bag. Use soap and water. Wear clean disposable gloves when you care for your catheter or disconnect the drainage bag. Wash your hands before you prepare or eat food. •Drink liquids as directed. Ask your healthcare provider how much liquid to drink each day and which liquids are best for you. Liquids will help flush your kidneys and bladder to help prevent infection. Thank you for allowing us to participate in your care, we wish you all the best! Followup Instructions: [MASKED]
[]
[ "N390", "E871", "I10", "Z794", "Z87891", "Y92230" ]
[ "C20: Malignant neoplasm of rectum", "C7989: Secondary malignant neoplasm of other specified sites", "T83511A: Infection and inflammatory reaction due to indwelling urethral catheter, initial encounter", "N390: Urinary tract infection, site not specified", "N9972: Accidental puncture and laceration of a genitourinary system organ or structure during other procedure", "T814XXA: Infection following a procedure", "E871: Hypo-osmolality and hyponatremia", "K567: Ileus, unspecified", "B965: Pseudomonas (aeruginosa) (mallei) (pseudomallei) as the cause of diseases classified elsewhere", "R339: Retention of urine, unspecified", "E113599: Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, unspecified eye", "E11649: Type 2 diabetes mellitus with hypoglycemia without coma", "E1142: Type 2 diabetes mellitus with diabetic polyneuropathy", "E1121: Type 2 diabetes mellitus with diabetic nephropathy", "K760: Fatty (change of) liver, not elsewhere classified", "E784: Other hyperlipidemia", "M47892: Other spondylosis, cervical region", "I10: Essential (primary) hypertension", "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", "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", "Y92234: Operating room of hospital as the place of occurrence of the external cause", "Z794: Long term (current) use of insulin", "Z87891: Personal history of nicotine dependence", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "B9689: Other specified bacterial agents as the cause of diseases classified elsewhere" ]
19,997,538
26,704,044
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Abdominal pain, nausea, vomiting Major Surgical or Invasive Procedure: None History of Present Illness: Per admission note: ___ Hx rectal CA s/p robotic LAR, diverting loop ileostomy (reversed), repair L ureteral injury in ___ now presenting with abdominal pain and N/V. Sudden onset crampy, intermittent LLQ abdominal pain at 11 AM today that worsened during the day. Emesis x 3, bilious. +chills, no fevers. Denies nausea now. +flatus, multiple BMs last night He completed FOLFOX about 3 weeks ago. Denies history of prior bowel obstructions. In the ED, NGT was placed with 300 cc of light-colored output. Patient received 8 mg of IV morphine and 2 mg IV dilaudid. Past Medical History: PMH: rectal CA, HTN, DM PSH: ___: Reversal of ileostomy and placement of left internal jugular Port-A-Cath ___: Robotic low anterior resection, diverting loop ileostomy, repair of left ureteral injury. Social History: ___ Family History: non-contributory Physical Exam: Admission Physical Exam: VS: 98.5, 104, 134/71, 18, 95% RA Gen - NAD Heart - borderline tachycardic, regular rhythm Lungs - CTAB Abdomen - soft, mildly distended, tender to deep palpation on the left, no rebound or guarding, well-healed abdominal incisions Extrem - warm, no edema ======================== Discharge Physical Exam: 98.1, 132/86, 104, 18, 100%/RA GEN: NAD, A&Ox3 HEENT: NCAT, EOMI CV: RRR, No JVD PULM: normal excursion, no respiratory distress ABD: soft, mild distension, non tender, no rebound, no guarding EXT: WWP, no CCE, 2+ B/L radial NEURO: A&Ox3, no focal neurologic deficits PSYCH: normal judgment/insight, normal memory, normal mood/affect Pertinent Results: ___ 06:59AM BLOOD WBC-6.3 RBC-3.14* Hgb-9.4* Hct-29.1* MCV-93 MCH-29.9 MCHC-32.3 RDW-13.4 RDWSD-45.4 Plt ___ ___ 06:40AM BLOOD WBC-6.6 RBC-3.25* Hgb-9.8* Hct-30.5* MCV-94 MCH-30.2 MCHC-32.1 RDW-13.3 RDWSD-45.9 Plt ___ ___ 07:00AM BLOOD WBC-7.1 RBC-3.29* Hgb-10.1* Hct-30.9* MCV-94 MCH-30.7 MCHC-32.7 RDW-13.7 RDWSD-46.5* Plt ___ ___ 05:22AM BLOOD WBC-8.9 RBC-3.32* Hgb-10.1* Hct-30.9* MCV-93 MCH-30.4 MCHC-32.7 RDW-14.1 RDWSD-47.7* Plt ___ ___ 02:45PM BLOOD WBC-12.8* RBC-3.69* Hgb-11.1* Hct-33.8* MCV-92 MCH-30.1 MCHC-32.8 RDW-13.7 RDWSD-45.9 Plt ___ ___ 02:45PM BLOOD Neuts-87.1* Lymphs-6.7* Monos-4.1* Eos-1.1 Baso-0.5 Im ___ AbsNeut-11.16* AbsLymp-0.86* AbsMono-0.53 AbsEos-0.14 AbsBaso-0.06 ___ 06:59AM BLOOD Glucose-165* UreaN-10 Creat-0.9 Na-143 K-4.3 Cl-102 HCO3-29 AnGap-12 ___ 06:40AM BLOOD Glucose-178* UreaN-15 Creat-1.0 Na-147 K-4.3 Cl-105 HCO3-30 AnGap-14 ___ 07:00AM BLOOD Glucose-121* UreaN-21* Creat-0.9 Na-147 K-4.3 Cl-105 HCO3-33* AnGap-9* ___ 05:22AM BLOOD Glucose-146* UreaN-32* Creat-1.2 Na-142 K-4.7 Cl-105 HCO3-24 AnGap-13 ___ 02:45PM BLOOD Glucose-195* UreaN-24* Creat-1.0 Na-140 K-5.4 Cl-109* HCO3-16* AnGap-15 ___ 02:45PM BLOOD ALT-21 AST-24 AlkPhos-138* TotBili-0.7 ___ 02:45PM BLOOD Lipase-155* ___ 06:59AM BLOOD Calcium-8.8 Phos-4.1 Mg-1.7 ___ 06:40AM BLOOD Calcium-9.0 Phos-3.7 Mg-1.6 ___ 07:00AM BLOOD Calcium-9.3 Phos-3.8 Mg-1.5* ___ 05:22AM BLOOD Calcium-9.3 Phos-4.1 Mg-1.4* ___ 02:45PM BLOOD Albumin-4.4 ___ 02:53PM BLOOD Lactate-1.7 Brief Hospital Course: Mr. ___ presented to the emergency department at ___ ___ on ___ with complaints of abdominal pain, nausea, and vomiting. The patient underwent a CT scan that showed High-grade small-bowel obstruction with abrupt transition point in the right lower quadrant and possible internal hernia, as described above. The patient was examined by and admitted to the colorectal surgery service for further management. The patient had a nasogastric tube for bowel decompression, was given bowel rest, intravenous fluids, and symptom management. His abdominal exam was monitored closely which improved daily. The output from the nasogastric tube was very high with greater than 2500cc output daily and the patient required intermittent IV fluid boluses. On ___, the patient had a bowel movement. On ___, the nasogastric tube output decreased significantly. He was given a clamping trial with residual gastric output of 100cc, the tube was sequentially removed. The patient was later advanced to and tolerated a regular diet. On ___, the patient was discharged to home. At discharge, he was tolerating a regular diet, passing flatus, voiding, and ambulating independently. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Lisinopril 40 mg PO DAILY 2. Gabapentin 300 mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. amLODIPine 5 mg PO DAILY 5. GlipiZIDE 10 mg PO BID 6. MetFORMIN (Glucophage) 1000 mg PO BID 7. Tamsulosin 0.4 mg PO QHS Discharge Medications: 1. amLODIPine 5 mg PO DAILY 2. Atorvastatin 40 mg PO QPM 3. Gabapentin 300 mg PO DAILY 4. GlipiZIDE 10 mg PO BID 5. Lisinopril 40 mg PO DAILY 6. MetFORMIN (Glucophage) 1000 mg PO BID 7. Tamsulosin 0.4 mg PO QHS Discharge Disposition: Home Discharge Diagnosis: Small bowel obstruction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to the hospital for a small bowel obstruction. You were given bowel rest, intravenous fluids, and a nasogastric tube was placed in your stomach to decompress your bowels. Your obstruction has subsequently resolved after conservative management. You are tolerating a regular diet, passing gas and your pain is controlled with pain medications by mouth. If you have any of the following symptoms please call the office or go to the emergency room if severe: increasing abdominal distension, increasing abdominal pain, nausea, vomiting, inability to tolerate food or liquids, prolonged loose stool, or extended constipation. Thank you for allowing us to participate in your care, we wish you all the best! Followup Instructions: ___
[ "K56609", "K458", "Z85038", "I10", "E119" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Abdominal pain, nausea, vomiting Major Surgical or Invasive Procedure: None History of Present Illness: Per admission note: [MASKED] Hx rectal CA s/p robotic LAR, diverting loop ileostomy (reversed), repair L ureteral injury in [MASKED] now presenting with abdominal pain and N/V. Sudden onset crampy, intermittent LLQ abdominal pain at 11 AM today that worsened during the day. Emesis x 3, bilious. +chills, no fevers. Denies nausea now. +flatus, multiple BMs last night He completed FOLFOX about 3 weeks ago. Denies history of prior bowel obstructions. In the ED, NGT was placed with 300 cc of light-colored output. Patient received 8 mg of IV morphine and 2 mg IV dilaudid. Past Medical History: PMH: rectal CA, HTN, DM PSH: [MASKED]: Reversal of ileostomy and placement of left internal jugular Port-A-Cath [MASKED]: Robotic low anterior resection, diverting loop ileostomy, repair of left ureteral injury. Social History: [MASKED] Family History: non-contributory Physical Exam: Admission Physical Exam: VS: 98.5, 104, 134/71, 18, 95% RA Gen - NAD Heart - borderline tachycardic, regular rhythm Lungs - CTAB Abdomen - soft, mildly distended, tender to deep palpation on the left, no rebound or guarding, well-healed abdominal incisions Extrem - warm, no edema ======================== Discharge Physical Exam: 98.1, 132/86, 104, 18, 100%/RA GEN: NAD, A&Ox3 HEENT: NCAT, EOMI CV: RRR, No JVD PULM: normal excursion, no respiratory distress ABD: soft, mild distension, non tender, no rebound, no guarding EXT: WWP, no CCE, 2+ B/L radial NEURO: A&Ox3, no focal neurologic deficits PSYCH: normal judgment/insight, normal memory, normal mood/affect Pertinent Results: [MASKED] 06:59AM BLOOD WBC-6.3 RBC-3.14* Hgb-9.4* Hct-29.1* MCV-93 MCH-29.9 MCHC-32.3 RDW-13.4 RDWSD-45.4 Plt [MASKED] [MASKED] 06:40AM BLOOD WBC-6.6 RBC-3.25* Hgb-9.8* Hct-30.5* MCV-94 MCH-30.2 MCHC-32.1 RDW-13.3 RDWSD-45.9 Plt [MASKED] [MASKED] 07:00AM BLOOD WBC-7.1 RBC-3.29* Hgb-10.1* Hct-30.9* MCV-94 MCH-30.7 MCHC-32.7 RDW-13.7 RDWSD-46.5* Plt [MASKED] [MASKED] 05:22AM BLOOD WBC-8.9 RBC-3.32* Hgb-10.1* Hct-30.9* MCV-93 MCH-30.4 MCHC-32.7 RDW-14.1 RDWSD-47.7* Plt [MASKED] [MASKED] 02:45PM BLOOD WBC-12.8* RBC-3.69* Hgb-11.1* Hct-33.8* MCV-92 MCH-30.1 MCHC-32.8 RDW-13.7 RDWSD-45.9 Plt [MASKED] [MASKED] 02:45PM BLOOD Neuts-87.1* Lymphs-6.7* Monos-4.1* Eos-1.1 Baso-0.5 Im [MASKED] AbsNeut-11.16* AbsLymp-0.86* AbsMono-0.53 AbsEos-0.14 AbsBaso-0.06 [MASKED] 06:59AM BLOOD Glucose-165* UreaN-10 Creat-0.9 Na-143 K-4.3 Cl-102 HCO3-29 AnGap-12 [MASKED] 06:40AM BLOOD Glucose-178* UreaN-15 Creat-1.0 Na-147 K-4.3 Cl-105 HCO3-30 AnGap-14 [MASKED] 07:00AM BLOOD Glucose-121* UreaN-21* Creat-0.9 Na-147 K-4.3 Cl-105 HCO3-33* AnGap-9* [MASKED] 05:22AM BLOOD Glucose-146* UreaN-32* Creat-1.2 Na-142 K-4.7 Cl-105 HCO3-24 AnGap-13 [MASKED] 02:45PM BLOOD Glucose-195* UreaN-24* Creat-1.0 Na-140 K-5.4 Cl-109* HCO3-16* AnGap-15 [MASKED] 02:45PM BLOOD ALT-21 AST-24 AlkPhos-138* TotBili-0.7 [MASKED] 02:45PM BLOOD Lipase-155* [MASKED] 06:59AM BLOOD Calcium-8.8 Phos-4.1 Mg-1.7 [MASKED] 06:40AM BLOOD Calcium-9.0 Phos-3.7 Mg-1.6 [MASKED] 07:00AM BLOOD Calcium-9.3 Phos-3.8 Mg-1.5* [MASKED] 05:22AM BLOOD Calcium-9.3 Phos-4.1 Mg-1.4* [MASKED] 02:45PM BLOOD Albumin-4.4 [MASKED] 02:53PM BLOOD Lactate-1.7 Brief Hospital Course: Mr. [MASKED] presented to the emergency department at [MASKED] [MASKED] on [MASKED] with complaints of abdominal pain, nausea, and vomiting. The patient underwent a CT scan that showed High-grade small-bowel obstruction with abrupt transition point in the right lower quadrant and possible internal hernia, as described above. The patient was examined by and admitted to the colorectal surgery service for further management. The patient had a nasogastric tube for bowel decompression, was given bowel rest, intravenous fluids, and symptom management. His abdominal exam was monitored closely which improved daily. The output from the nasogastric tube was very high with greater than 2500cc output daily and the patient required intermittent IV fluid boluses. On [MASKED], the patient had a bowel movement. On [MASKED], the nasogastric tube output decreased significantly. He was given a clamping trial with residual gastric output of 100cc, the tube was sequentially removed. The patient was later advanced to and tolerated a regular diet. On [MASKED], the patient was discharged to home. At discharge, he was tolerating a regular diet, passing flatus, voiding, and ambulating independently. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Lisinopril 40 mg PO DAILY 2. Gabapentin 300 mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. amLODIPine 5 mg PO DAILY 5. GlipiZIDE 10 mg PO BID 6. MetFORMIN (Glucophage) 1000 mg PO BID 7. Tamsulosin 0.4 mg PO QHS Discharge Medications: 1. amLODIPine 5 mg PO DAILY 2. Atorvastatin 40 mg PO QPM 3. Gabapentin 300 mg PO DAILY 4. GlipiZIDE 10 mg PO BID 5. Lisinopril 40 mg PO DAILY 6. MetFORMIN (Glucophage) 1000 mg PO BID 7. Tamsulosin 0.4 mg PO QHS Discharge Disposition: Home Discharge Diagnosis: Small bowel obstruction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], You were admitted to the hospital for a small bowel obstruction. You were given bowel rest, intravenous fluids, and a nasogastric tube was placed in your stomach to decompress your bowels. Your obstruction has subsequently resolved after conservative management. You are tolerating a regular diet, passing gas and your pain is controlled with pain medications by mouth. If you have any of the following symptoms please call the office or go to the emergency room if severe: increasing abdominal distension, increasing abdominal pain, nausea, vomiting, inability to tolerate food or liquids, prolonged loose stool, or extended constipation. Thank you for allowing us to participate in your care, we wish you all the best! Followup Instructions: [MASKED]
[]
[ "I10", "E119" ]
[ "K56609: Unspecified intestinal obstruction, unspecified as to partial versus complete obstruction", "K458: Other specified abdominal hernia without obstruction or gangrene", "Z85038: Personal history of other malignant neoplasm of large intestine", "I10: Essential (primary) hypertension", "E119: Type 2 diabetes mellitus without complications" ]
19,997,576
25,548,363
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Major Surgical or Invasive Procedure: None attach Pertinent Results: ADMISSION LABS: ================ ___ 08:32AM BLOOD WBC-7.5 RBC-3.28* Hgb-13.7 Hct-40.7 MCV-124* MCH-41.8* MCHC-33.7 RDW-12.1 RDWSD-55.6* Plt ___ ___ 08:32AM BLOOD ___ PTT-66.7* ___ ___ 08:32AM BLOOD Plt ___ ___ 09:10PM BLOOD LD(___)-297* ___ 08:32AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 08:32AM BLOOD Calcium-9.0 Phos-3.5 Mg-2.4 PERTINENT LABS: ================ ___ 07:00PM BLOOD cTropnT-<0.01 proBNP-2117* ___ 09:10PM BLOOD CK-MB-1 cTropnT-<0.01 proBNP-829* ___ 09:10PM BLOOD LD(___)-297* IMAGING: ========= CTA ___ (___): IMPRESSION: 1. Multiple scattered pulmonary emboli involving lobar and segmental branches bilaterally, largest within the right main pulmonary artery and bifurcation of the left main pulmonary artery. Evidence of right heart strain. 2. Multiple pulmonary nodules in the right upper lobe and right lower lobe measuring up to 3 mm. Several are stable although a few may be new. In a low risk patient, no follow-up suggested. In high risk patient, follow-up chest CT in ___ year can be performed. 3. No discrete infarct or infiltrate. Mild mosaic attenuation the lungs likely sequela of vascular occlusive disease, in the setting of pulmonary emboli. 4. Asymmetric focal soft tissue opacities in the right breast and mild sub areolar thickening. Suggest correlation with mammogram 5. Heterogeneous right lobe of the thyroid gland, suboptimally visualized. Consider correlation with thyroid ultrasound 6. Small hiatal hernia. Possible hepatic steatosis. LLE US ___ (___): IMPRESSION: In the left leg, there is occlusive thrombus within the popliteal vein and occlusive thrombus within the posterior tibial vein of the calf. Prior ___ left lower extremity venous ultrasound showed no DVT. CXR ___: IMPRESSION: There are patchy opacities in the left lung base which may represent pulmonary infarcts or infection. There is no pulmonary edema, pleural effusion or pneumothorax. The cardiomediastinal silhouette is stable in appearance. There is prominence of the central pulmonary arteries. No acute osseous abnormalities are identified. TTE ___: Quantitative biplane left ventricular ejection fraction is 71 % (normal 54-73%). IMPRESSION: Mildly dilated right ventricle with mild free wall hypokinesis. Mild tricuspid regurgitation with moderate pulmonary arterial systolic hypertension. Normal left ventricular wall thickness, cavity size and regional/global systolic function. DISCHARGE LABS: ================= ___ 06:35AM BLOOD WBC-5.9 RBC-2.88* Hgb-12.0 Hct-36.3 MCV-126* MCH-41.7* MCHC-33.1 RDW-11.9 RDWSD-55.8* Plt ___ ___ 06:35AM BLOOD ___ PTT-73.0* ___ ___ 06:35AM BLOOD Plt ___ ___ 06:35AM BLOOD Glucose-100 UreaN-13 Creat-0.7 Na-142 K-4.7 Cl-104 HCO3-25 AnGap-13 ___ 06:35AM BLOOD Calcium-8.9 Phos-4.4 Mg-2.3 DISCHARGE PHYSICAL EXAM: ========================= VITALS: ___ 0744 Temp: 97.6 PO BP: 138/83 R Lying HR: 83 RR: 18 O2 sat: 94% O2 delivery: Ra GENERAL: Well-appearing elderly female in no acute distress. NECK: Supple. HEART: Regular rate and rhythm, normal S1, S2, no murmurs, rubs or gallops LUNGS: Clear to auscultation bilaterally; expiratory wheezes diffusely ABDOMEN: Soft, nontender, nondistended with normoactive bowel sounds throughout. EXTREMITIES: Warm, well-perfused, slight edema on left ankle but improved skin slightly red Brief Hospital Course: SUMMARY: =========== Ms. ___ is a ___ Female with a past medical history of myeloproliferative disorder stable on hydroxyurea, remote DVT not on AC, HTN, seizures, and thyroid disease who presented with two weeks of shortness of breath and leg swelling, found to have PE on outpatient work up, admitted for further management. She was started on anticoagulation with a heparin gtt and ultimately discharged on ___ bridge to warfarin as an outpatient. TRANSITIONAL ISSUE: =================== [ ] Discharged on lovenox bridge to warfarin [ ] Follow up with PCP and need for ___ clinic [ ] Lisinopril held in the setting of normal BP/PE. Consider restarting as an outpatient [ ] Will need follow-up with vascular medicine and heme/onc in ___ months [ ] if she ever comes off phenytoin, she will be a candidate for DOAC ACUTE ISSUES: ============= #Submassive PE Patient with a history of DVT in ___ in the setting of Jak-2 + myeloproliferative disease, no other identified provoking factors, which was treated with lovenox/coumadin until her counts normalized with hydroxyurea in ___. Presented with two weeks of LLE swelling and dyspnea. Outpatient work up included LLE DVT ultrasound which was positive for DVT and CT showed "multiple scattered pulmonary emboli involving lobar and segmental branches bilaterally, largest within the right main pulmonary artery and bifurcation of the left main pulmonary artery along with evidence of right heart strain." Labs were notable for elevated trop-T to 0.021 and proBNP to 2168 and TTE had mildly dilated right ventricle with mild free wall hypokinesis with PASP 38, concerning for submassive PE. MASCOT was consulted and recommended heparin without thrombolysis given clinical stability. She was started on heparin gtt and improved clinically. She was transitioned to lovenox bridge to warfarin. She should follow up with her PCP and heme/onc provider for further management. Etiology felt ___ her myeloproliferative disorder; she will likely need lifelong anticoagulation given recurrent thromboembolic events. CHRONIC/STABLE ISSUES: ======================== #Hypothyroidism: - Continued home levothyroxine #Seizure: - Continued home Levetiracetam 500 BID - Continued home Phenytonin 100 mg BID except 200 mg QPM on ___ and ___ #Hypertention: -Held home Lisinopril given hypotension, restarted upon discharge when became hypertensive Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 40 mg PO DAILY 2. LevETIRAcetam 500 mg PO BID 3. Hydroxyurea 500 mg PO DAILY 4. Phenytoin Sodium Extended 100 mg PO QAM 5. Phenytoin Sodium Extended 200 mg PO 2X/WEEK (MO,TH) 6. Aspirin 81 mg PO DAILY 7. Levothyroxine Sodium 100 mcg PO DAILY 8. Phenytoin (Suspension) 100 mg PO 5X/WEEK (___) Discharge Medications: 1. Enoxaparin Sodium 60 mg SC Q12H 2. Warfarin 5 mg PO DAILY16 RX *warfarin [Coumadin] 5 mg 1 tablet(s) by mouth once a day Disp #*10 Tablet Refills:*0 3. Aspirin 81 mg PO DAILY 4. Hydroxyurea 500 mg PO DAILY 5. LevETIRAcetam 500 mg PO BID 6. Levothyroxine Sodium 100 mcg PO DAILY 7. Phenytoin Sodium Extended 100 mg PO QAM 8. Phenytoin Sodium Extended 200 mg PO 2X/WEEK (MO,TH) 9. HELD- Lisinopril 40 mg PO DAILY This medication was held. Do not restart Lisinopril until instructed by your primary care provider ___: Home Discharge Diagnosis: #Primary Submassive PE DVT Acute hypoxic respiratory failure #Secondary Hypothyroidism Seizure Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a privilege taking care of you at ___ ___. WHY WAS I ADMITTED TO THE HOSPITAL? =================================== - Your primary care doctor was worried about your left leg swelling and shortness of breath WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? ========================================== - You were found to have a blood clot in your lungs, and were started on blood thinners to treat the clot. 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. We wish you all the best! Sincerely, Your ___ Care Team Followup Instructions: ___
[ "I2694", "I82492", "Z86718", "I10", "Z7901", "Z87891", "D473", "Z85828", "G40909" ]
Allergies: No Known Allergies / Adverse Drug Reactions Major Surgical or Invasive Procedure: None attach Pertinent Results: ADMISSION LABS: ================ [MASKED] 08:32AM BLOOD WBC-7.5 RBC-3.28* Hgb-13.7 Hct-40.7 MCV-124* MCH-41.8* MCHC-33.7 RDW-12.1 RDWSD-55.6* Plt [MASKED] [MASKED] 08:32AM BLOOD [MASKED] PTT-66.7* [MASKED] [MASKED] 08:32AM BLOOD Plt [MASKED] [MASKED] 09:10PM BLOOD LD([MASKED])-297* [MASKED] 08:32AM BLOOD CK-MB-2 cTropnT-<0.01 [MASKED] 08:32AM BLOOD Calcium-9.0 Phos-3.5 Mg-2.4 PERTINENT LABS: ================ [MASKED] 07:00PM BLOOD cTropnT-<0.01 proBNP-2117* [MASKED] 09:10PM BLOOD CK-MB-1 cTropnT-<0.01 proBNP-829* [MASKED] 09:10PM BLOOD LD([MASKED])-297* IMAGING: ========= CTA [MASKED] ([MASKED]): IMPRESSION: 1. Multiple scattered pulmonary emboli involving lobar and segmental branches bilaterally, largest within the right main pulmonary artery and bifurcation of the left main pulmonary artery. Evidence of right heart strain. 2. Multiple pulmonary nodules in the right upper lobe and right lower lobe measuring up to 3 mm. Several are stable although a few may be new. In a low risk patient, no follow-up suggested. In high risk patient, follow-up chest CT in [MASKED] year can be performed. 3. No discrete infarct or infiltrate. Mild mosaic attenuation the lungs likely sequela of vascular occlusive disease, in the setting of pulmonary emboli. 4. Asymmetric focal soft tissue opacities in the right breast and mild sub areolar thickening. Suggest correlation with mammogram 5. Heterogeneous right lobe of the thyroid gland, suboptimally visualized. Consider correlation with thyroid ultrasound 6. Small hiatal hernia. Possible hepatic steatosis. LLE US [MASKED] ([MASKED]): IMPRESSION: In the left leg, there is occlusive thrombus within the popliteal vein and occlusive thrombus within the posterior tibial vein of the calf. Prior [MASKED] left lower extremity venous ultrasound showed no DVT. CXR [MASKED]: IMPRESSION: There are patchy opacities in the left lung base which may represent pulmonary infarcts or infection. There is no pulmonary edema, pleural effusion or pneumothorax. The cardiomediastinal silhouette is stable in appearance. There is prominence of the central pulmonary arteries. No acute osseous abnormalities are identified. TTE [MASKED]: Quantitative biplane left ventricular ejection fraction is 71 % (normal 54-73%). IMPRESSION: Mildly dilated right ventricle with mild free wall hypokinesis. Mild tricuspid regurgitation with moderate pulmonary arterial systolic hypertension. Normal left ventricular wall thickness, cavity size and regional/global systolic function. DISCHARGE LABS: ================= [MASKED] 06:35AM BLOOD WBC-5.9 RBC-2.88* Hgb-12.0 Hct-36.3 MCV-126* MCH-41.7* MCHC-33.1 RDW-11.9 RDWSD-55.8* Plt [MASKED] [MASKED] 06:35AM BLOOD [MASKED] PTT-73.0* [MASKED] [MASKED] 06:35AM BLOOD Plt [MASKED] [MASKED] 06:35AM BLOOD Glucose-100 UreaN-13 Creat-0.7 Na-142 K-4.7 Cl-104 HCO3-25 AnGap-13 [MASKED] 06:35AM BLOOD Calcium-8.9 Phos-4.4 Mg-2.3 DISCHARGE PHYSICAL EXAM: ========================= VITALS: [MASKED] 0744 Temp: 97.6 PO BP: 138/83 R Lying HR: 83 RR: 18 O2 sat: 94% O2 delivery: Ra GENERAL: Well-appearing elderly female in no acute distress. NECK: Supple. HEART: Regular rate and rhythm, normal S1, S2, no murmurs, rubs or gallops LUNGS: Clear to auscultation bilaterally; expiratory wheezes diffusely ABDOMEN: Soft, nontender, nondistended with normoactive bowel sounds throughout. EXTREMITIES: Warm, well-perfused, slight edema on left ankle but improved skin slightly red Brief Hospital Course: SUMMARY: =========== Ms. [MASKED] is a [MASKED] Female with a past medical history of myeloproliferative disorder stable on hydroxyurea, remote DVT not on AC, HTN, seizures, and thyroid disease who presented with two weeks of shortness of breath and leg swelling, found to have PE on outpatient work up, admitted for further management. She was started on anticoagulation with a heparin gtt and ultimately discharged on [MASKED] bridge to warfarin as an outpatient. TRANSITIONAL ISSUE: =================== [ ] Discharged on lovenox bridge to warfarin [ ] Follow up with PCP and need for [MASKED] clinic [ ] Lisinopril held in the setting of normal BP/PE. Consider restarting as an outpatient [ ] Will need follow-up with vascular medicine and heme/onc in [MASKED] months [ ] if she ever comes off phenytoin, she will be a candidate for DOAC ACUTE ISSUES: ============= #Submassive PE Patient with a history of DVT in [MASKED] in the setting of Jak-2 + myeloproliferative disease, no other identified provoking factors, which was treated with lovenox/coumadin until her counts normalized with hydroxyurea in [MASKED]. Presented with two weeks of LLE swelling and dyspnea. Outpatient work up included LLE DVT ultrasound which was positive for DVT and CT showed "multiple scattered pulmonary emboli involving lobar and segmental branches bilaterally, largest within the right main pulmonary artery and bifurcation of the left main pulmonary artery along with evidence of right heart strain." Labs were notable for elevated trop-T to 0.021 and proBNP to 2168 and TTE had mildly dilated right ventricle with mild free wall hypokinesis with PASP 38, concerning for submassive PE. MASCOT was consulted and recommended heparin without thrombolysis given clinical stability. She was started on heparin gtt and improved clinically. She was transitioned to lovenox bridge to warfarin. She should follow up with her PCP and heme/onc provider for further management. Etiology felt [MASKED] her myeloproliferative disorder; she will likely need lifelong anticoagulation given recurrent thromboembolic events. CHRONIC/STABLE ISSUES: ======================== #Hypothyroidism: - Continued home levothyroxine #Seizure: - Continued home Levetiracetam 500 BID - Continued home Phenytonin 100 mg BID except 200 mg QPM on [MASKED] and [MASKED] #Hypertention: -Held home Lisinopril given hypotension, restarted upon discharge when became hypertensive Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 40 mg PO DAILY 2. LevETIRAcetam 500 mg PO BID 3. Hydroxyurea 500 mg PO DAILY 4. Phenytoin Sodium Extended 100 mg PO QAM 5. Phenytoin Sodium Extended 200 mg PO 2X/WEEK (MO,TH) 6. Aspirin 81 mg PO DAILY 7. Levothyroxine Sodium 100 mcg PO DAILY 8. Phenytoin (Suspension) 100 mg PO 5X/WEEK ([MASKED]) Discharge Medications: 1. Enoxaparin Sodium 60 mg SC Q12H 2. Warfarin 5 mg PO DAILY16 RX *warfarin [Coumadin] 5 mg 1 tablet(s) by mouth once a day Disp #*10 Tablet Refills:*0 3. Aspirin 81 mg PO DAILY 4. Hydroxyurea 500 mg PO DAILY 5. LevETIRAcetam 500 mg PO BID 6. Levothyroxine Sodium 100 mcg PO DAILY 7. Phenytoin Sodium Extended 100 mg PO QAM 8. Phenytoin Sodium Extended 200 mg PO 2X/WEEK (MO,TH) 9. HELD- Lisinopril 40 mg PO DAILY This medication was held. Do not restart Lisinopril until instructed by your primary care provider [MASKED]: Home Discharge Diagnosis: #Primary Submassive PE DVT Acute hypoxic respiratory failure #Secondary Hypothyroidism Seizure Hypertension 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 at [MASKED] [MASKED]. WHY WAS I ADMITTED TO THE HOSPITAL? =================================== - Your primary care doctor was worried about your left leg swelling and shortness of breath WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? ========================================== - You were found to have a blood clot in your lungs, and were started on blood thinners to treat the clot. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? ============================================ - Please continue to take all your medications and follow up with your doctors at your [MASKED] appointments. We wish you all the best! Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "Z86718", "I10", "Z7901", "Z87891" ]
[ "I2694: Multiple subsegmental pulmonary emboli without acute cor pulmonale", "I82492: Acute embolism and thrombosis of other specified deep vein of left lower extremity", "Z86718: Personal history of other venous thrombosis and embolism", "I10: Essential (primary) hypertension", "Z7901: Long term (current) use of anticoagulants", "Z87891: Personal history of nicotine dependence", "D473: Essential (hemorrhagic) thrombocythemia", "Z85828: Personal history of other malignant neoplasm of skin", "G40909: Epilepsy, unspecified, not intractable, without status epilepticus" ]
19,997,752
29,452,285
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: Status post aortic valve replacement with a 21 ___ ___ History of Present Illness: ___ with known h/o of aortic stenosis, initially admitted to ___ on ___ for worsening DOE, now transferred to ___ for evaluation for TAVR. DOE onset was over about ___ weeks prior to admission. Of note, patient reports that she has lost about 20 lbs over the past year. Was 175 lbs (79.4 kg) on a standing scale at home a few days prior to presenting to ___. Per ___ discharge summary, the patient has a history of known aortic stenosis for which she saw Dr. ___ ___ 2 months prior to admission. She had been having palpitations at that time and had a Holter monitor in ___ which showed PVCs and PACs. TTE in ___ had showed moderate-severe AS with mild MR and stage I diastolic dysfunction with EF 60-65%. At ___, CXR was within normal limits on ___. TTE, LHC and RHC were performed. It does not appear that any diuretics were given. Labs at ___: Cr 0.9 w/ eGFR of 67 (___) Trop-I negative x1 (___) CK-MB 2.1 (___) EKG at ___ on ___ showed SR at 68bpm, ___, RBBB, first degree AV block (PR 213ms). TTE on ___: normal EF (60-65%) and LV cavity size, moderately increased LV wall thickness. Normal RV size, thickness and function. Severe thickening of AV and severe aortic stenosis. Peak gradient 65mmHg. Mean gradient 40mmHg. AV area 0.44 cm2. Trace/trivial AR. All other valves normal functioning. Mild PA systolic hypertension (TR gradient 30mmHg). No effusion. RHC ___: - RA ___ (mean 7) - RV ___ (mean 8) - PCW ___ (mean 7) - PA ___ (mean 16) - Ao 130/63 (mean 90) - Fick: 4.77 / 2.49 (CO/CI) - Thermodilution: 3.8 / 1.98 (CO/CI) - AV gradient 60mmHg - AV area 0.55 cm2 LHC (___): - LM: No CAD - LAD: No CAD - LCx: No CAD - RCA: Non-dominant, No CAD On arrival to ___, patient has no complaints. She reports that no diuretics were administered at ___. No chest pain at rest or with exertion. No SOB at present (and never had it at rest, even on day of admission to ___. Still has SOB with exertion to the point where she can't climb 2 flights of stairs. Past Medical History: - Severe aortic stenosis - Hypertension - H/o coarctation of aorta (s/p repair at ___ years of age) - H/o patent foramen ovale (s/p closure at ___ years of age) - H/o rheumatic fever 3x - H/o breast reduction surgery - H/o bladder suspension Social History: ___ Family History: Mother: s/p ___ MIs and AAA. Physical Exam: ADMISSION EXAM =================== Vital Signs: T 98.0, 158/71, 73, 18, 98%RA Weight: 80.0 kg on admission standing General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL NECK: No JVD CV: Regular rate and rhythm, ___ systolic murmur appreciated at base 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, trace bilateral pitting edema Neuro: CNII-XII intact, ___ strength upper/lower extremities Access: PIV Discharge exam: Neuro: alert, oriented and intact CV: SR-ST, S1S2 no m/r/g Resp: bibasilar rales GI: soft, flat, non tender, + BS GU: voids Skin: midline incision c/d/I well appreoximated Pertinent Results: ADMISSION LABS ====================== ___ 06:35AM BLOOD WBC-6.2 RBC-4.44 Hgb-12.7 Hct-39.1 MCV-88 MCH-28.6 MCHC-32.5 RDW-13.3 RDWSD-43.1 Plt ___ ___ 06:35AM BLOOD Neuts-59.1 ___ Monos-8.4 Eos-2.9 Baso-0.5 Im ___ AbsNeut-3.67 AbsLymp-1.79 AbsMono-0.52 AbsEos-0.18 AbsBaso-0.03 ___ 06:35AM BLOOD ___ PTT-31.2 ___ ___ 06:35AM BLOOD Glucose-87 UreaN-19 Creat-0.9 Na-141 K-4.0 Cl-104 HCO3-26 AnGap-15 ___ 06:35AM BLOOD ALT-45* AST-42* LD(LDH)-227 AlkPhos-76 TotBili-0.4 ___ 07:25AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 06:35AM BLOOD Albumin-3.8 Calcium-9.4 Phos-4.4 Mg-2.1 ___ 06:35AM BLOOD TSH-5.5* ___ 06:35AM BLOOD %HbA1c-5.0 eAG-97 IMAGING/STUDIES ====================== CXR ___: IMPRESSION: There are no prior chest radiographs available for review. Or lingula projecting over the region of the aortic valve on the lateral view obscures heavy calcifications. ECHO: ___ The left atrium is normal in size. Left ventricular wall thicknesses and cavity size are normal. Left ventricular systolic function is hyperdynamic (EF>75%). There is a mild resting left ventricular outflow tract obstruction (less than apical gradient). An apical intracavitary gradient is identified with peak gradient 30mmHg. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. A bioprosthetic aortic valve prosthesis is present. The aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. The effective orifice area/m2 is normal (1.0; nl >0.9 cm2/m2). No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. IMPRESSION: Well seated aortic valve bioprosthesis with hyperdynamic systolic function and normal transvalvular gradients. Small posterior pericardial effusion without tamponade. Dilated thoracic aorta. Moderate pulmonary hypertension. Lungs fully expanded and clear. Cardiomediastinal and hilar silhouettes and pleural surfaces are normal. CT CHEST ___: IMPRESSION: 1. Heavily calcified aortic valve, in keeping with history of severe aortic stenosis. Non dilated thoracic aorta, with only minimal atheromatous calcifications. These images are available for review for preoperative planning. 2. 3 incidentally detected small pulmonary nodules are statistically very likely benign though require no definite further imaging followup in the absence of risk factors for lung cancer such as cigarette smoking history. If the patient has risk factors for lung cancer, a ___ year followup CT would be recommended. Brief Hospital Course: ___ y/o F w/ PMH aortic stenosis, HTN, childhood history of aortic coarctation repair transferred from OSH w/ 2 wk hx progressive DOE, found to have severe aortic stenosis on echo. Admitted to ___ on ___ and evaluated by cardiac surgery and after pre-op work up completed she was taken to the operating room on ___ where she underwent an AVR(#21mm ___ tissue). See operative notes for details. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable on no inotropic or vasopressor support. Post-operatively she developed CHB and wenchbach requiring temporary epicardial pacing to maintain hemodynamic stability. She also developed acute kidney injury and responded to volume resuscitation with albumin and PRBC for acute blood loss anemia. She remained in the ICU until her native sinus rhythm returned and her ___ resolved. Once hemodynamically stable in sinus rhythm with a normal creat, low dose betablocker was started and uptitrated to oprimize HR and BP. She was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD #8 the patient was deconditioned and ambulating with asssit, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to ___ TCU in good condition with appropriate follow up instructions. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. calcium carb-vitamin D3-vit K2 500 mg calcium- 200 unit-90 mcg oral DAILY 2. Vitamin D 1000 UNIT PO DAILY 3. irbesartan-hydrochlorothiazide 300-12.5 mg oral DAILY 4. Multivitamins 1 TAB PO DAILY 5. Omeprazole 40 mg PO BID 6. Phenylephrine 0.5% Nasal Spray 2 SPRY NU BID:PRN congestion 7. Ranitidine 150 mg PO QHS 8. Semprex-D (acrivastine-pseudoephedrine) ___ mg oral BID:PRN congestion 9. Simvastatin 20 mg PO QPM Discharge Medications: 1. Aspirin EC 81 mg PO DAILY 2. azelastine 137 mcg (0.1 %) nasal BID 3. Docusate Sodium 100 mg PO BID 4. Furosemide 40 mg PO BID Duration: 7 Days 5. Metoprolol Tartrate 25 mg PO TID 6. Potassium Chloride 20 mEq PO BID Duration: 7 Days 7. Senna 8.6 mg PO BID:PRN constipation 8. TraMADol ___ mg PO Q6H:PRN Pain - Moderate RX *tramadol 50 mg ___ tablet(s) by mouth every 6 hours Disp #*45 Tablet Refills:*0 9. calcium carb-vitamin D3-vit K2 500 mg calcium- 200 unit-90 mcg oral DAILY 10. Multivitamins 1 TAB PO DAILY 11. Omeprazole 40 mg PO BID 12. Ranitidine 150 mg PO QHS 13. Simvastatin 20 mg PO QPM 14. Vitamin D 1000 UNIT PO DAILY 15. HELD- irbesartan-hydrochlorothiazide 300-12.5 mg oral DAILY This medication was held. Do not restart irbesartan-hydrochlorothiazide until you see your cardiologist Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Status post aortic valve replacement with a 21 ___ ___ Secondary: Severe aortic stenosis Hypertension Coarctation of aorta s/p repair Patent foramen ovale s/p closure Rheumatic fever 3x Hyperlipidemia Gastroesophageal reflux disease Squamous Cell carcinoma s/p excision Stress incontinence s/p bladder suspension Stage 1 diastolic dysfunction based on echo Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Edema: trace ___ Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns ___ **Please call cardiac surgery office with any questions or concerns ___. Answering service will contact on call person during off hours** Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: ___
[ "I080", "I442", "N179", "I110", "I5030", "I452", "D62", "I440", "E785", "K219", "Z006", "Z8774", "Z8589" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: Status post aortic valve replacement with a 21 [MASKED] [MASKED] History of Present Illness: [MASKED] with known h/o of aortic stenosis, initially admitted to [MASKED] on [MASKED] for worsening DOE, now transferred to [MASKED] for evaluation for TAVR. DOE onset was over about [MASKED] weeks prior to admission. Of note, patient reports that she has lost about 20 lbs over the past year. Was 175 lbs (79.4 kg) on a standing scale at home a few days prior to presenting to [MASKED]. Per [MASKED] discharge summary, the patient has a history of known aortic stenosis for which she saw Dr. [MASKED] [MASKED] 2 months prior to admission. She had been having palpitations at that time and had a Holter monitor in [MASKED] which showed PVCs and PACs. TTE in [MASKED] had showed moderate-severe AS with mild MR and stage I diastolic dysfunction with EF 60-65%. At [MASKED], CXR was within normal limits on [MASKED]. TTE, LHC and RHC were performed. It does not appear that any diuretics were given. Labs at [MASKED]: Cr 0.9 w/ eGFR of 67 ([MASKED]) Trop-I negative x1 ([MASKED]) CK-MB 2.1 ([MASKED]) EKG at [MASKED] on [MASKED] showed SR at 68bpm, [MASKED], RBBB, first degree AV block (PR 213ms). TTE on [MASKED]: normal EF (60-65%) and LV cavity size, moderately increased LV wall thickness. Normal RV size, thickness and function. Severe thickening of AV and severe aortic stenosis. Peak gradient 65mmHg. Mean gradient 40mmHg. AV area 0.44 cm2. Trace/trivial AR. All other valves normal functioning. Mild PA systolic hypertension (TR gradient 30mmHg). No effusion. RHC [MASKED]: - RA [MASKED] (mean 7) - RV [MASKED] (mean 8) - PCW [MASKED] (mean 7) - PA [MASKED] (mean 16) - Ao 130/63 (mean 90) - Fick: 4.77 / 2.49 (CO/CI) - Thermodilution: 3.8 / 1.98 (CO/CI) - AV gradient 60mmHg - AV area 0.55 cm2 LHC ([MASKED]): - LM: No CAD - LAD: No CAD - LCx: No CAD - RCA: Non-dominant, No CAD On arrival to [MASKED], patient has no complaints. She reports that no diuretics were administered at [MASKED]. No chest pain at rest or with exertion. No SOB at present (and never had it at rest, even on day of admission to [MASKED]. Still has SOB with exertion to the point where she can't climb 2 flights of stairs. Past Medical History: - Severe aortic stenosis - Hypertension - H/o coarctation of aorta (s/p repair at [MASKED] years of age) - H/o patent foramen ovale (s/p closure at [MASKED] years of age) - H/o rheumatic fever 3x - H/o breast reduction surgery - H/o bladder suspension Social History: [MASKED] Family History: Mother: s/p [MASKED] MIs and AAA. Physical Exam: ADMISSION EXAM =================== Vital Signs: T 98.0, 158/71, 73, 18, 98%RA Weight: 80.0 kg on admission standing General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL NECK: No JVD CV: Regular rate and rhythm, [MASKED] systolic murmur appreciated at base 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, trace bilateral pitting edema Neuro: CNII-XII intact, [MASKED] strength upper/lower extremities Access: PIV Discharge exam: Neuro: alert, oriented and intact CV: SR-ST, S1S2 no m/r/g Resp: bibasilar rales GI: soft, flat, non tender, + BS GU: voids Skin: midline incision c/d/I well appreoximated Pertinent Results: ADMISSION LABS ====================== [MASKED] 06:35AM BLOOD WBC-6.2 RBC-4.44 Hgb-12.7 Hct-39.1 MCV-88 MCH-28.6 MCHC-32.5 RDW-13.3 RDWSD-43.1 Plt [MASKED] [MASKED] 06:35AM BLOOD Neuts-59.1 [MASKED] Monos-8.4 Eos-2.9 Baso-0.5 Im [MASKED] AbsNeut-3.67 AbsLymp-1.79 AbsMono-0.52 AbsEos-0.18 AbsBaso-0.03 [MASKED] 06:35AM BLOOD [MASKED] PTT-31.2 [MASKED] [MASKED] 06:35AM BLOOD Glucose-87 UreaN-19 Creat-0.9 Na-141 K-4.0 Cl-104 HCO3-26 AnGap-15 [MASKED] 06:35AM BLOOD ALT-45* AST-42* LD(LDH)-227 AlkPhos-76 TotBili-0.4 [MASKED] 07:25AM BLOOD CK-MB-2 cTropnT-<0.01 [MASKED] 06:35AM BLOOD Albumin-3.8 Calcium-9.4 Phos-4.4 Mg-2.1 [MASKED] 06:35AM BLOOD TSH-5.5* [MASKED] 06:35AM BLOOD %HbA1c-5.0 eAG-97 IMAGING/STUDIES ====================== CXR [MASKED]: IMPRESSION: There are no prior chest radiographs available for review. Or lingula projecting over the region of the aortic valve on the lateral view obscures heavy calcifications. ECHO: [MASKED] The left atrium is normal in size. Left ventricular wall thicknesses and cavity size are normal. Left ventricular systolic function is hyperdynamic (EF>75%). There is a mild resting left ventricular outflow tract obstruction (less than apical gradient). An apical intracavitary gradient is identified with peak gradient 30mmHg. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. A bioprosthetic aortic valve prosthesis is present. The aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. The effective orifice area/m2 is normal (1.0; nl >0.9 cm2/m2). No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. IMPRESSION: Well seated aortic valve bioprosthesis with hyperdynamic systolic function and normal transvalvular gradients. Small posterior pericardial effusion without tamponade. Dilated thoracic aorta. Moderate pulmonary hypertension. Lungs fully expanded and clear. Cardiomediastinal and hilar silhouettes and pleural surfaces are normal. CT CHEST [MASKED]: IMPRESSION: 1. Heavily calcified aortic valve, in keeping with history of severe aortic stenosis. Non dilated thoracic aorta, with only minimal atheromatous calcifications. These images are available for review for preoperative planning. 2. 3 incidentally detected small pulmonary nodules are statistically very likely benign though require no definite further imaging followup in the absence of risk factors for lung cancer such as cigarette smoking history. If the patient has risk factors for lung cancer, a [MASKED] year followup CT would be recommended. Brief Hospital Course: [MASKED] y/o F w/ PMH aortic stenosis, HTN, childhood history of aortic coarctation repair transferred from OSH w/ 2 wk hx progressive DOE, found to have severe aortic stenosis on echo. Admitted to [MASKED] on [MASKED] and evaluated by cardiac surgery and after pre-op work up completed she was taken to the operating room on [MASKED] where she underwent an AVR(#21mm [MASKED] tissue). See operative notes for details. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable on no inotropic or vasopressor support. Post-operatively she developed CHB and wenchbach requiring temporary epicardial pacing to maintain hemodynamic stability. She also developed acute kidney injury and responded to volume resuscitation with albumin and PRBC for acute blood loss anemia. She remained in the ICU until her native sinus rhythm returned and her [MASKED] resolved. Once hemodynamically stable in sinus rhythm with a normal creat, low dose betablocker was started and uptitrated to oprimize HR and BP. She was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD #8 the patient was deconditioned and ambulating with asssit, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to [MASKED] TCU in good condition with appropriate follow up instructions. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. calcium carb-vitamin D3-vit K2 500 mg calcium- 200 unit-90 mcg oral DAILY 2. Vitamin D 1000 UNIT PO DAILY 3. irbesartan-hydrochlorothiazide 300-12.5 mg oral DAILY 4. Multivitamins 1 TAB PO DAILY 5. Omeprazole 40 mg PO BID 6. Phenylephrine 0.5% Nasal Spray 2 SPRY NU BID:PRN congestion 7. Ranitidine 150 mg PO QHS 8. Semprex-D (acrivastine-pseudoephedrine) [MASKED] mg oral BID:PRN congestion 9. Simvastatin 20 mg PO QPM Discharge Medications: 1. Aspirin EC 81 mg PO DAILY 2. azelastine 137 mcg (0.1 %) nasal BID 3. Docusate Sodium 100 mg PO BID 4. Furosemide 40 mg PO BID Duration: 7 Days 5. Metoprolol Tartrate 25 mg PO TID 6. Potassium Chloride 20 mEq PO BID Duration: 7 Days 7. Senna 8.6 mg PO BID:PRN constipation 8. TraMADol [MASKED] mg PO Q6H:PRN Pain - Moderate RX *tramadol 50 mg [MASKED] tablet(s) by mouth every 6 hours Disp #*45 Tablet Refills:*0 9. calcium carb-vitamin D3-vit K2 500 mg calcium- 200 unit-90 mcg oral DAILY 10. Multivitamins 1 TAB PO DAILY 11. Omeprazole 40 mg PO BID 12. Ranitidine 150 mg PO QHS 13. Simvastatin 20 mg PO QPM 14. Vitamin D 1000 UNIT PO DAILY 15. HELD- irbesartan-hydrochlorothiazide 300-12.5 mg oral DAILY This medication was held. Do not restart irbesartan-hydrochlorothiazide until you see your cardiologist Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Status post aortic valve replacement with a 21 [MASKED] [MASKED] Secondary: Severe aortic stenosis Hypertension Coarctation of aorta s/p repair Patent foramen ovale s/p closure Rheumatic fever 3x Hyperlipidemia Gastroesophageal reflux disease Squamous Cell carcinoma s/p excision Stress incontinence s/p bladder suspension Stage 1 diastolic dysfunction based on echo Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Edema: trace [MASKED] Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [MASKED] **Please call cardiac surgery office with any questions or concerns [MASKED]. Answering service will contact on call person during off hours** Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: [MASKED]
[]
[ "N179", "I110", "D62", "E785", "K219" ]
[ "I080: Rheumatic disorders of both mitral and aortic valves", "I442: Atrioventricular block, complete", "N179: Acute kidney failure, unspecified", "I110: Hypertensive heart disease with heart failure", "I5030: Unspecified diastolic (congestive) heart failure", "I452: Bifascicular block", "D62: Acute posthemorrhagic anemia", "I440: Atrioventricular block, first degree", "E785: Hyperlipidemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "Z006: Encounter for examination for normal comparison and control in clinical research program", "Z8774: Personal history of (corrected) congenital malformations of heart and circulatory system", "Z8589: Personal history of malignant neoplasm of other organs and systems" ]
19,997,843
20,277,361
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Allergies/ADRs on File Attending: ___. Chief Complaint: agitation Major Surgical or Invasive Procedure: Intubation ___ Extubation ___ History of Present Illness: Mr. ___ is a ___ ___ year old M w/ hx of EtOH use disorder presenting from ___ Center detoxification presenting with acute agitation. At around 8 ___, patient became acutely agitated at detox, swinging at staff members. He reportedly was new to the program in the last day or so. Police were called who patient was placed in handcuffs and brought here without medication. In the ED, he was unable to give a coherent history. He denies other drug use except for taking a cup of an unknown drink while at detox. In the ED, initial vitals were notable for tachycardia, tachypnea, and hypertension. He was noted to be diaphoretic, tachycardic, hypertensive, and tremulous. Serum and urine tox screens were negative. Given agitation and being a danger to himself, he was given 4 mg IV Ativan then Ketamine 300 mg IM with no response. He began to be a danger to himself and the decision was made to intubate. He was induced with etomidate and rocuronium and started on propofol and fentanyl drips afterwards. Toxicology was consulted who recommended adding on a midazolam gtt for concern for severe EtOH withdrawal. Given concern for possible pneumonia on chest x-ray, he was started on ceftriaxone and azithromycin initially. He was also given a liter of IV fluids and Tylenol for fever. Given altered mental status upon admission, a head CT was ordered and the lumbar puncture was performed. He was given vanc and ceftriaxone. Vital signs after intubation still notable for tachycardia, hypertension, and fever to 102.8. Past Medical History: EtOH use disorder Suspected EtOH cirrhosis Social History: ___ Family History: No family history of liver disease Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: T 98.7 HR 86 BP 94/63 RR 35 SPO2 99% FIO2 GEN: Chronically ill appearing male laying in bed, intubated and sedated HEENT: Pupils pinpoint, minimally reactive. No facial droop. ETT and OGT in place. Dried blood in oropharynx. R posterior hematoma. NECK: Elevated JVP CV: RRR. Nl s1/s2. Grade ___ systolic murmur heard throughout precordium RESP: CTAB anteriorly. No wheezes, rales, or rhonchi. GI: Abd soft, non-tender, mildly distended. Hepatomegaly present. No fluid wave. No caput medusae. EXT: No ___. Diffuse ecchymoses on lower extremities. SKIN: Jaundiced. Spider angiomas on chest. NEURO: Intubated and sedated. Moving upper extremities when agitated. DISCHARGE PHYSICAL EXAM: ======================== VITALS: T: 98.2 PO BP: 112 / 73 R Sitting HR: 84 RR: 17 SO2: 96 RA GEN: Well appearing HEENT: No scleral icterus. MMM. CV: RRR, ___ systolic murmur throughout. RESP: CTAB ABD: soft, NDNT EXT: No c/c/e. Diffuse ecchymoses on lower extremities. SKIN: No jaundice. No spider angiomata. NEURO: Alert, oriented x3, intact attention. CN ___ intact. Strength ___ throughout. Gait normal. Pertinent Results: =============== Admission labs =============== ___ 09:40PM BLOOD WBC-12.4* RBC-4.49* Hgb-14.8 Hct-46.1 MCV-103* MCH-33.0* MCHC-32.1 RDW-13.3 RDWSD-50.4* Plt ___ ___ 09:40PM BLOOD Neuts-57.2 ___ Monos-12.8 Eos-0.4* Baso-0.4 Im ___ AbsNeut-7.07* AbsLymp-3.55 AbsMono-1.58* AbsEos-0.05 AbsBaso-0.05 ___ 09:40PM BLOOD ___ PTT-30.3 ___ ___ 09:40PM BLOOD Glucose-164* UreaN-11 Creat-1.1 Na-138 K-3.2* Cl-100 HCO3-10* AnGap-28* ___ 09:40PM BLOOD ALT-107* AST-345* CK(CPK)-8309* AlkPhos-241* TotBili-4.5* DirBili-2.5* IndBili-2.0 ___ 09:40PM BLOOD Albumin-4.2 Calcium-9.4 Phos-3.3 Mg-2.1 ___ 12:00AM BLOOD Type-ART PEEP-5 pO2-128* pCO2-49* pH-7.29* calTCO2-25 Base XS--3 Intubat-INTUBATED ___ 10:31PM BLOOD Lactate-9.6* =============== Pertinent labs =============== ___ 03:01AM BLOOD VitB12-356 ___ 09:40PM BLOOD TSH-4.9* ___ 03:01AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-POS* HAV Ab-POS* ___ 09:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG ___ 03:01AM BLOOD HCV Ab-NEG =============== Discharge labs =============== ___ 07:55AM BLOOD WBC-5.9 RBC-3.89* Hgb-13.0* Hct-40.3 MCV-104* MCH-33.4* MCHC-32.3 RDW-14.5 RDWSD-54.5* Plt ___ ___ 07:55AM BLOOD ___ ___ 07:55AM BLOOD Glucose-97 UreaN-6 Creat-0.6 Na-140 K-3.7 Cl-106 HCO3-25 AnGap-9* ___ 07:55AM BLOOD Calcium-8.1* Phos-2.5* Mg-2.0 ___ 07:55AM BLOOD ALT-84* AST-117* AlkPhos-234* TotBili-2.6* =============== Studies =============== CXR ___: IMPRESSION: Status post intubation with appropriate positioning of the endotracheal tube in the lower trachea. Patchy bibasilar opacities which likely represent mild atelectasis. Infection versus aspiration at the right lung base would be possible. CT head w/o contrast ___: IMPRESSION: 1. No acute intracranial abnormality on noncontrast CT head. Specifically, no acute large territory infarct or intracranial hemorrhage. 2. 1.8 cm subcutaneous soft tissue density about the right parietal scalp could represent a scalp hematoma in the posttraumatic setting. Direct inspection recommended. 3. Extensive paranasal sinus disease. 4. Nasal cavity opacification is likely related to intubation. 5. Increased prominence of intracranial vessels without definitive evidence for inflammatory stranding of uncertain clinical significance. The superior ophthalmic veins do not appear significantly enlarged nor do the extraocular eye muscles to suggest cavernous sinus thrombosis or fistula. CT abd/pelvis ___: IMPRESSION: 1. Bibasilar pulmonary consolidations worrisome for aspiration/pneumonia. 2. No evidence of acute cholecystitis. 3. Hepatomegaly with diffuse decrease in parenchymal attenuation could suggest steatosis or acute hepatitis. ECG ___: Normal sinus rhythm. Prolonged QTc CXR ___: IMPRESSION: Low bilateral lung volumes. Increased bibasilar opacities, left greater than right could reflect atelectasis however pneumonia, particularly in the left lower lobe should be considered. New pulmonary vascular congestion and small bilateral pleural effusions. =============== Microbiology =============== ___ 1:50 am CSF;SPINAL FLUID # 3. GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Preliminary): NO GROWTH. URINE CULTURE ___: NEGATIVE BLOOD CULTURES ___: NEGATIVE Brief Hospital Course: SUMMARY: ___ y/o ___ immigrant with h/o alcohol use disorder, no prior medical care, admitted from ___ detox for alcohol withdrawal seizure requiring intubation and phenobarb load. Course c/b aspiration pneumonia, alcoholic hepatitis, possible cirrhosis, and paranoid delusions. Discharge delayed by lack of insurance. # Complex Alcohol Withdrawal with Seizures (resolved): Patient presented with agitation, tachycardia, hypertension, and fevers, most likely due to alcohol withdrawal, resolved with phenobarb load. Workup for alternate cause has been negative including tox screen, CT head, LP, and EEG. # Alcohol Use Disorder: # Suicide Attempt: He reports he was drinking ___ bottles of vodka daily with the intention to harm himself after being accused by friends of crimes that he reports he did not commit. He denies any prior problems with alcohol use. He endorsed ongoing passive SI to MICU team but no longer endorses this to floor team and does not appear to be an acute threat to himself or others. He is motivated to quit drinking through religion (interested in AA) and amenable to medication assisted treatment. Addiction Psychiatry was consulted, started on oral naltrexone. # Resources: Does not have health insurance or PCP though should be eligible for limited ___. High risk for alcohol relapse and recurrent seizures, hepatitis, and psychiatric decompensation unless has ongoing follow-up. He is scheduled for follow-up at ___. # Paranoid delusions: # ?Traumatic brain injury: Patient's mental status has improved but he continues to have fixed paranoid delusions regarding medical staff preventing friends from visiting. Family confirms that patient has had these symptoms for at least several weeks prior to hospitalization. His mental status appeared to worsen after he was hit by a car several weeks ago. He did not seek medical attention due to lack of insurance and instead turned to alcohol for analgesia. They also report he has struggled with significant significant psychosocial stress (wife imprisoned in ___, leaving his two teenage daughters without an adult caretaker; no stable employment or insurance). Workup for an organic cause for his symptoms has been negative including CT head, LP, EEG, and thiamine load. He does not appear to be an acute threat to himself but would benefit from close mental health f/u for further assessment. # Acute Alcoholic Hepatitis # Possible Cirrhosis # Positive HBV core antibody with negative viral load: LFT abnormalities concerning for alcoholic hepatitis and RUQUS concerning for underlying cirrhosis. HAV/HCV negative, HBV core antibody positive but viral load undetectable. His exam, labs, and imaging are concerning for underlying alcoholic cirrhosis and he should have further eval as outpatient. Fibroscan as outpatient, if cirrhosis confirmed, would benefit from HCC and variceal screening. Offered HBV and PPSV-23 vaccines he is declining ___ will need both as outpatient. RESOLVED: # Aspiration PNA (resolved): Imaging consistent with aspiration PNA. Afebrile now on Augmenting, no worsening respiratory symptoms. No evidence for hepatobiliary source on RUQUS. Cultures thus far negative. Finished 7-day total course of antibiotics with amoxicillin/clavulanate. # Thrombocytopenia (resolved): # Mild Coagulopathy: Plt nadired in ___ but now have normalized. Ongoing mild ___ derangement not improved with Vitamin K. Likely underlying cirrhosis (see above). No e/o bleeding. # Rhabdomyolysis (resolved): Likely due to seizures and/or alcohol use. No known downtime or other trauma. Drug-induced rhabdo possible but tox screen negative. Renal function fortunately has remained stable. CK downtrended appropriately. # Tongue Swelling (resolved): Likely in setting of tongue biting during seizure. s/p dexamethasone 10 mg x 3 doses but no evidence of anaphylaxis or angioedema. # Epigastric Pain: Suspect alcohol-related esophagitis/gastritis vs alcoholic hepatitis. ECG non-ischemic. Resolved while inpatient could consider ongoing omeprezaole, evaluation for H/ Pylori if needed. # TSH Elevation: TSH elevated to 4.9 but unreliable iso critical illness. Would repeat in ___ weeks. TRANSITIONAL ISSUES: - repeat TSH in ___ weeks (elevated to 4.9 iso acute illness) - would continue nalexone (prvodied with one month prescription at discharge) - would consider IM naltrexone - would ensure routine healthcare screening including HIV is up to date - will need to complete HBV series (s/p HBV and pneumonia vaccines on ___ - fibroscan as outpatient - If cirrhosis confirmed, would benefit from ___ and variceal screening - was ordered for Hep B series, he declined - if recurrent epigastric pain while not drinking EtOH would consider mgmt./evaluation for GERD vs peptic ulcer disease - #CONTACTS: ___ (Son) ___ ___ (friend who is staying with) ___ - #CODE STATUS: Full, presumed Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ___ Original (aspirin-sod bicarb-citric acid) 325-1,916-1,000 mg oral DAILY:PRN indigestion Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES # Complex Alcohol Withdrawal with Seizures # Alcohol Use Disorder # Acute Alcoholic Hepatitis # Possible Cirrhosis # Aspiration Pneumonia # Thrombocytopenia # Coagulopathy # Rhabdomyolysis # Lack of health insurance Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ___, Fue un placer atenderlo en ___ Médico ___ Deaconess. ¿POR QUÉ ESTABA ___ ___ HOSPITAL? - Tuvo una convulsión - Tuvo daño en ___ hígado. - Tuvo una infección en ___ (neumonía). ¿QUÉ ME PASÓ ___ ___ HOSPITAL? - ___ y se mejoró. ¿QUÉ ___ DESPUÉS DE ___ HOSPITAL? - ___ de tomar alcohol. - Vaya a Alcohólicos Anónimos y tome ___ para reducir ___. - ___ una cita con ___ doctor ___. ___ deseamos lo mejor! Sinceramente, ___ de ___ ========================= Dear Mr. ___, It was a pleasure caring for you at ___ ___. WHY WAS I IN THE HOSPITAL? - You had a seizure - You had damage to your liver - You had an infection in your lungs (pneumonia) WHAT HAPPENED TO ME IN THE HOSPITAL? - We gave you medications and you got better WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Stop drinking alcohol. - Go to Alcoholics Anonymous and take your medicine to reduce cravings. - Make an appointment with your new doctor. We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___
[ "F10231", "J690", "G92", "G4089", "M6282", "E872", "K7030", "K7010", "T510X2A", "F22", "D696", "S069X0A", "R1013", "R946", "Z597", "E876", "I4581", "S0093XA", "F209", "F39", "F6089", "R791", "D531", "R61", "I10", "G252", "S098XXA" ]
Allergies: No Allergies/ADRs on File Chief Complaint: agitation Major Surgical or Invasive Procedure: Intubation [MASKED] Extubation [MASKED] History of Present Illness: Mr. [MASKED] is a [MASKED] [MASKED] year old M w/ hx of EtOH use disorder presenting from [MASKED] Center detoxification presenting with acute agitation. At around 8 [MASKED], patient became acutely agitated at detox, swinging at staff members. He reportedly was new to the program in the last day or so. Police were called who patient was placed in handcuffs and brought here without medication. In the ED, he was unable to give a coherent history. He denies other drug use except for taking a cup of an unknown drink while at detox. In the ED, initial vitals were notable for tachycardia, tachypnea, and hypertension. He was noted to be diaphoretic, tachycardic, hypertensive, and tremulous. Serum and urine tox screens were negative. Given agitation and being a danger to himself, he was given 4 mg IV Ativan then Ketamine 300 mg IM with no response. He began to be a danger to himself and the decision was made to intubate. He was induced with etomidate and rocuronium and started on propofol and fentanyl drips afterwards. Toxicology was consulted who recommended adding on a midazolam gtt for concern for severe EtOH withdrawal. Given concern for possible pneumonia on chest x-ray, he was started on ceftriaxone and azithromycin initially. He was also given a liter of IV fluids and Tylenol for fever. Given altered mental status upon admission, a head CT was ordered and the lumbar puncture was performed. He was given vanc and ceftriaxone. Vital signs after intubation still notable for tachycardia, hypertension, and fever to 102.8. Past Medical History: EtOH use disorder Suspected EtOH cirrhosis Social History: [MASKED] Family History: No family history of liver disease Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: T 98.7 HR 86 BP 94/63 RR 35 SPO2 99% FIO2 GEN: Chronically ill appearing male laying in bed, intubated and sedated HEENT: Pupils pinpoint, minimally reactive. No facial droop. ETT and OGT in place. Dried blood in oropharynx. R posterior hematoma. NECK: Elevated JVP CV: RRR. Nl s1/s2. Grade [MASKED] systolic murmur heard throughout precordium RESP: CTAB anteriorly. No wheezes, rales, or rhonchi. GI: Abd soft, non-tender, mildly distended. Hepatomegaly present. No fluid wave. No caput medusae. EXT: No [MASKED]. Diffuse ecchymoses on lower extremities. SKIN: Jaundiced. Spider angiomas on chest. NEURO: Intubated and sedated. Moving upper extremities when agitated. DISCHARGE PHYSICAL EXAM: ======================== VITALS: T: 98.2 PO BP: 112 / 73 R Sitting HR: 84 RR: 17 SO2: 96 RA GEN: Well appearing HEENT: No scleral icterus. MMM. CV: RRR, [MASKED] systolic murmur throughout. RESP: CTAB ABD: soft, NDNT EXT: No c/c/e. Diffuse ecchymoses on lower extremities. SKIN: No jaundice. No spider angiomata. NEURO: Alert, oriented x3, intact attention. CN [MASKED] intact. Strength [MASKED] throughout. Gait normal. Pertinent Results: =============== Admission labs =============== [MASKED] 09:40PM BLOOD WBC-12.4* RBC-4.49* Hgb-14.8 Hct-46.1 MCV-103* MCH-33.0* MCHC-32.1 RDW-13.3 RDWSD-50.4* Plt [MASKED] [MASKED] 09:40PM BLOOD Neuts-57.2 [MASKED] Monos-12.8 Eos-0.4* Baso-0.4 Im [MASKED] AbsNeut-7.07* AbsLymp-3.55 AbsMono-1.58* AbsEos-0.05 AbsBaso-0.05 [MASKED] 09:40PM BLOOD [MASKED] PTT-30.3 [MASKED] [MASKED] 09:40PM BLOOD Glucose-164* UreaN-11 Creat-1.1 Na-138 K-3.2* Cl-100 HCO3-10* AnGap-28* [MASKED] 09:40PM BLOOD ALT-107* AST-345* CK(CPK)-8309* AlkPhos-241* TotBili-4.5* DirBili-2.5* IndBili-2.0 [MASKED] 09:40PM BLOOD Albumin-4.2 Calcium-9.4 Phos-3.3 Mg-2.1 [MASKED] 12:00AM BLOOD Type-ART PEEP-5 pO2-128* pCO2-49* pH-7.29* calTCO2-25 Base XS--3 Intubat-INTUBATED [MASKED] 10:31PM BLOOD Lactate-9.6* =============== Pertinent labs =============== [MASKED] 03:01AM BLOOD VitB12-356 [MASKED] 09:40PM BLOOD TSH-4.9* [MASKED] 03:01AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-POS* HAV Ab-POS* [MASKED] 09:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG [MASKED] 03:01AM BLOOD HCV Ab-NEG =============== Discharge labs =============== [MASKED] 07:55AM BLOOD WBC-5.9 RBC-3.89* Hgb-13.0* Hct-40.3 MCV-104* MCH-33.4* MCHC-32.3 RDW-14.5 RDWSD-54.5* Plt [MASKED] [MASKED] 07:55AM BLOOD [MASKED] [MASKED] 07:55AM BLOOD Glucose-97 UreaN-6 Creat-0.6 Na-140 K-3.7 Cl-106 HCO3-25 AnGap-9* [MASKED] 07:55AM BLOOD Calcium-8.1* Phos-2.5* Mg-2.0 [MASKED] 07:55AM BLOOD ALT-84* AST-117* AlkPhos-234* TotBili-2.6* =============== Studies =============== CXR [MASKED]: IMPRESSION: Status post intubation with appropriate positioning of the endotracheal tube in the lower trachea. Patchy bibasilar opacities which likely represent mild atelectasis. Infection versus aspiration at the right lung base would be possible. CT head w/o contrast [MASKED]: IMPRESSION: 1. No acute intracranial abnormality on noncontrast CT head. Specifically, no acute large territory infarct or intracranial hemorrhage. 2. 1.8 cm subcutaneous soft tissue density about the right parietal scalp could represent a scalp hematoma in the posttraumatic setting. Direct inspection recommended. 3. Extensive paranasal sinus disease. 4. Nasal cavity opacification is likely related to intubation. 5. Increased prominence of intracranial vessels without definitive evidence for inflammatory stranding of uncertain clinical significance. The superior ophthalmic veins do not appear significantly enlarged nor do the extraocular eye muscles to suggest cavernous sinus thrombosis or fistula. CT abd/pelvis [MASKED]: IMPRESSION: 1. Bibasilar pulmonary consolidations worrisome for aspiration/pneumonia. 2. No evidence of acute cholecystitis. 3. Hepatomegaly with diffuse decrease in parenchymal attenuation could suggest steatosis or acute hepatitis. ECG [MASKED]: Normal sinus rhythm. Prolonged QTc CXR [MASKED]: IMPRESSION: Low bilateral lung volumes. Increased bibasilar opacities, left greater than right could reflect atelectasis however pneumonia, particularly in the left lower lobe should be considered. New pulmonary vascular congestion and small bilateral pleural effusions. =============== Microbiology =============== [MASKED] 1:50 am CSF;SPINAL FLUID # 3. GRAM STAIN (Final [MASKED]: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Preliminary): NO GROWTH. URINE CULTURE [MASKED]: NEGATIVE BLOOD CULTURES [MASKED]: NEGATIVE Brief Hospital Course: SUMMARY: [MASKED] y/o [MASKED] immigrant with h/o alcohol use disorder, no prior medical care, admitted from [MASKED] detox for alcohol withdrawal seizure requiring intubation and phenobarb load. Course c/b aspiration pneumonia, alcoholic hepatitis, possible cirrhosis, and paranoid delusions. Discharge delayed by lack of insurance. # Complex Alcohol Withdrawal with Seizures (resolved): Patient presented with agitation, tachycardia, hypertension, and fevers, most likely due to alcohol withdrawal, resolved with phenobarb load. Workup for alternate cause has been negative including tox screen, CT head, LP, and EEG. # Alcohol Use Disorder: # Suicide Attempt: He reports he was drinking [MASKED] bottles of vodka daily with the intention to harm himself after being accused by friends of crimes that he reports he did not commit. He denies any prior problems with alcohol use. He endorsed ongoing passive SI to MICU team but no longer endorses this to floor team and does not appear to be an acute threat to himself or others. He is motivated to quit drinking through religion (interested in AA) and amenable to medication assisted treatment. Addiction Psychiatry was consulted, started on oral naltrexone. # Resources: Does not have health insurance or PCP though should be eligible for limited [MASKED]. High risk for alcohol relapse and recurrent seizures, hepatitis, and psychiatric decompensation unless has ongoing follow-up. He is scheduled for follow-up at [MASKED]. # Paranoid delusions: # ?Traumatic brain injury: Patient's mental status has improved but he continues to have fixed paranoid delusions regarding medical staff preventing friends from visiting. Family confirms that patient has had these symptoms for at least several weeks prior to hospitalization. His mental status appeared to worsen after he was hit by a car several weeks ago. He did not seek medical attention due to lack of insurance and instead turned to alcohol for analgesia. They also report he has struggled with significant significant psychosocial stress (wife imprisoned in [MASKED], leaving his two teenage daughters without an adult caretaker; no stable employment or insurance). Workup for an organic cause for his symptoms has been negative including CT head, LP, EEG, and thiamine load. He does not appear to be an acute threat to himself but would benefit from close mental health f/u for further assessment. # Acute Alcoholic Hepatitis # Possible Cirrhosis # Positive HBV core antibody with negative viral load: LFT abnormalities concerning for alcoholic hepatitis and RUQUS concerning for underlying cirrhosis. HAV/HCV negative, HBV core antibody positive but viral load undetectable. His exam, labs, and imaging are concerning for underlying alcoholic cirrhosis and he should have further eval as outpatient. Fibroscan as outpatient, if cirrhosis confirmed, would benefit from HCC and variceal screening. Offered HBV and PPSV-23 vaccines he is declining [MASKED] will need both as outpatient. RESOLVED: # Aspiration PNA (resolved): Imaging consistent with aspiration PNA. Afebrile now on Augmenting, no worsening respiratory symptoms. No evidence for hepatobiliary source on RUQUS. Cultures thus far negative. Finished 7-day total course of antibiotics with amoxicillin/clavulanate. # Thrombocytopenia (resolved): # Mild Coagulopathy: Plt nadired in [MASKED] but now have normalized. Ongoing mild [MASKED] derangement not improved with Vitamin K. Likely underlying cirrhosis (see above). No e/o bleeding. # Rhabdomyolysis (resolved): Likely due to seizures and/or alcohol use. No known downtime or other trauma. Drug-induced rhabdo possible but tox screen negative. Renal function fortunately has remained stable. CK downtrended appropriately. # Tongue Swelling (resolved): Likely in setting of tongue biting during seizure. s/p dexamethasone 10 mg x 3 doses but no evidence of anaphylaxis or angioedema. # Epigastric Pain: Suspect alcohol-related esophagitis/gastritis vs alcoholic hepatitis. ECG non-ischemic. Resolved while inpatient could consider ongoing omeprezaole, evaluation for H/ Pylori if needed. # TSH Elevation: TSH elevated to 4.9 but unreliable iso critical illness. Would repeat in [MASKED] weeks. TRANSITIONAL ISSUES: - repeat TSH in [MASKED] weeks (elevated to 4.9 iso acute illness) - would continue nalexone (prvodied with one month prescription at discharge) - would consider IM naltrexone - would ensure routine healthcare screening including HIV is up to date - will need to complete HBV series (s/p HBV and pneumonia vaccines on [MASKED] - fibroscan as outpatient - If cirrhosis confirmed, would benefit from [MASKED] and variceal screening - was ordered for Hep B series, he declined - if recurrent epigastric pain while not drinking EtOH would consider mgmt./evaluation for GERD vs peptic ulcer disease - #CONTACTS: [MASKED] (Son) [MASKED] [MASKED] (friend who is staying with) [MASKED] - #CODE STATUS: Full, presumed Medications on Admission: The Preadmission Medication list is accurate and complete. 1. [MASKED] Original (aspirin-sod bicarb-citric acid) 325-1,916-1,000 mg oral DAILY:PRN indigestion Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES # Complex Alcohol Withdrawal with Seizures # Alcohol Use Disorder # Acute Alcoholic Hepatitis # Possible Cirrhosis # Aspiration Pneumonia # Thrombocytopenia # Coagulopathy # Rhabdomyolysis # Lack of health insurance Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: [MASKED], Fue un placer atenderlo en [MASKED] Médico [MASKED] Deaconess. ¿POR QUÉ ESTABA [MASKED] [MASKED] HOSPITAL? - Tuvo una convulsión - Tuvo daño en [MASKED] hígado. - Tuvo una infección en [MASKED] (neumonía). ¿QUÉ ME PASÓ [MASKED] [MASKED] HOSPITAL? - [MASKED] y se mejoró. ¿QUÉ [MASKED] DESPUÉS DE [MASKED] HOSPITAL? - [MASKED] de tomar alcohol. - Vaya a Alcohólicos Anónimos y tome [MASKED] para reducir [MASKED]. - [MASKED] una cita con [MASKED] doctor [MASKED]. [MASKED] deseamos lo mejor! Sinceramente, [MASKED] de [MASKED] ========================= Dear Mr. [MASKED], It was a pleasure caring for you at [MASKED] [MASKED]. WHY WAS I IN THE HOSPITAL? - You had a seizure - You had damage to your liver - You had an infection in your lungs (pneumonia) WHAT HAPPENED TO ME IN THE HOSPITAL? - We gave you medications and you got better WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Stop drinking alcohol. - Go to Alcoholics Anonymous and take your medicine to reduce cravings. - Make an appointment with your new doctor. We wish you the best! Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "E872", "D696", "I10" ]
[ "F10231: Alcohol dependence with withdrawal delirium", "J690: Pneumonitis due to inhalation of food and vomit", "G92: Toxic encephalopathy", "G4089: Other seizures", "M6282: Rhabdomyolysis", "E872: Acidosis", "K7030: Alcoholic cirrhosis of liver without ascites", "K7010: Alcoholic hepatitis without ascites", "T510X2A: Toxic effect of ethanol, intentional self-harm, initial encounter", "F22: Delusional disorders", "D696: Thrombocytopenia, unspecified", "S069X0A: Unspecified intracranial injury without loss of consciousness, initial encounter", "R1013: Epigastric pain", "R946: Abnormal results of thyroid function studies", "Z597: Insufficient social insurance and welfare support", "E876: Hypokalemia", "I4581: Long QT syndrome", "S0093XA: Contusion of unspecified part of head, initial encounter", "F209: Schizophrenia, unspecified", "F39: Unspecified mood [affective] disorder", "F6089: Other specific personality disorders", "R791: Abnormal coagulation profile", "D531: Other megaloblastic anemias, not elsewhere classified", "R61: Generalized hyperhidrosis", "I10: Essential (primary) hypertension", "G252: Other specified forms of tremor", "S098XXA: Other specified injuries of head, initial encounter" ]
19,997,886
20,793,010
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: All allergies / adverse drug reactions previously recorded have been deleted Attending: ___ Chief Complaint: abdominal distension Major Surgical or Invasive Procedure: Diagnostic and therapeutic paracentesis bedside ___ Diagnostic and therapeutic paracentesis bedside ___ ___ TIPS ___ Central venous line insertion ___ Diagnostic paracentesis ___ History of Present Illness: ___ year old man with PBC c/b esophageal varices and ascites and schizoaffective disorder who presented to clinic yesterday with worsening abdominal distention in the setting of not taking his diuretics. He has lost a tremendous amount of weight and he has not been able to eat. Per OMR on ___, his PCP spoke to him because she had received an email from his psychiatrist that he reported that he is no longer taking his Lasix due to concerns that it is an amphetamine and concerns about dizziness. At that point he agreed to restart his Lasix and spironolactone but his PCP did not feel confident in him following through with this. On ___ there is a note from his psychiatrist that he had been seen in the ___ ED 3 days prior with dizziness causing him to be unable to ambulate. He was seen by ___, labs were checked, and he was discharged home. He had self decreased his Seroquel from 300 to 200 mg qHS and his psychiatrist recommended decreasing his lamotrigine from 200 to 100 due to the concern that dizziness may have been related to this medication. A serum level of the medication was checked while he was on 200 mg which was within normal limits and thus it was felt that the lamotrigine was less likely to be causing his dizziness. On ___ he was seen by psychiatry at which point he had been doing "all right" on the reduced doses of his psychiatric medications. In the ED initial vitals: Temperature 97.4, heart rate 97, blood pressure 143/91, respiratory rate 18, 98% on room air - Exam notable for: Tense, distended abdomen, non-tender. Breathing comfortable on room air with crackles at bilateral bases - Labs notable for: CBC: Hemoglobin 12.9, otherwise unremarkable Chem7: Unremarkable LFTs: Unremarkable, except for albumin of 3.1 Coags: Not obtained Ascites: TNC of 685, 6% polys Urinalysis: 9 WBCs, 0 epis, 10 ketones, few bacteria, negative nitrite - Imaging notable for: RUQUS with Doppler: 1. Cirrhosis with large ascites. 2. Patent portal vein. CXR: Low lung volumes without focal consolidation or pulmonary edema. - Patient was given: Nothing - ED Course: Patient underwent diagnostic and therapeutic paracentesis for 2 L with improvement in symptoms. On arrival to the floor he says he feels better after therapeutic paracentesis. He says that last ___ he started to feel tired and fatigued and had some shortness of breath which has been worsening over the last 6 months or so. He can only walk about 7 blocks before feeling tired and short of breath at this time. He does state that he feels that the diuretics are making him dizzy and so he has been only taking them about twice a week. He denies dysuria, urinary frequency, hematuria, hematochezia, melena. He endorses swelling around his ankles. He endorses chills but no fevers. He says that over the last ___ weeks he only ate ___ boosts per day in addition to some juice and coffee and water. He says that he has been doing this in order to make his stool softer and is afraid to eat regular food because it will make him constipated. He says he did have a soft bowel movement over the weekend but still feels constipated. He does say that people have told him that he looks much thinner than previously. Past Medical History: BPH Depression Schizoaffective disorder Colon polyps Portal hypertensive gastropathy Primary biliary cirrhosis complicated by ascites s/p banding and ascites Chronic cough, improved Social History: ___ Family History: Father died from complications from polio. His mother died at the age of ___ and she had a tumor removed at some point (he thinks from her abdomen). Brother with stage IV rectal cancer who recently underwent surgery. He was diagnosed with colon cancer in his late ___. Physical Exam: ADMISSION EXAM: =============== VS: 98.1F, 129/84, HR 77, RR 18, on room air GENERAL: NAD, appears markedly cachectic with muscle wasting and temporal wasting HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM NECK: supple, no LAD, no JVD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: Breathing comfortable on room air, crackles at the bases of his lungs bilaterally ABDOMEN: distended but soft, nontender in all quadrants, no rebound/guarding, normoactive bowel sounds, right sided para site with bloody bandage in place EXTREMITIES: 2+ pitting edema to the knees bilaterally PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, moving all 4 extremities with purpose, no asterixis DISCHARGE EXAM: =============== VS: 24 HR Data (last updated ___ @ 2340) Temp: 98.3 (Tm 100.3), BP: 127/72 (112-127/68-72), HR: 105 (82-105), RR: 20 (___), O2 sat: 91% (89-100), O2 delivery: 2 L Nc Fluid Balance (last updated ___ @ 530) Last 8 hours Total cumulative 873ml IN: Total 873ml, TF/Flush Amt 447ml, IV Amt Infused 426ml OUT: Total 0ml, Urine Amt 0ml Last 24 hours Total cumulative 2001ml IN: Total 4061ml, PO Amt 120ml, TF/Flush Amt 748ml, IV Amt Infused 3193ml OUT: Total 2060ml, Urine Amt 2060ml, Flexiseal 0ml GEN: Elderly, frail man, lying in bed, appears uncomfortable HEENT: Anicteric sclerae. NG tube in place, dried blood in nares. CV: Normal rate and rhythm. Grade ___ systolic murmur. Lungs: Clear to auscultation bilaterally without wheezes, rhonchi, or rales in anterior fields. Abdomen: Hyperactive bowel sounds throughout. Soft. Significantly distended, tympanitic to percussion. Mildly tender to deep palpation diffusely, no rebound or guarding. Extremities: Warm. No pitting edema. Neuro: Alert. Oriented to self, place ___ building"). Not oriented to year. Does not answer all questions or follow commands appropriately. Dysarthric. No asterixis appreciated. Pertinent Results: ADMISSION LABS: =============== ___ 05:53PM WBC-7.4 RBC-4.41* HGB-12.9* HCT-41.4 MCV-94 MCH-29.3 MCHC-31.2* RDW-17.3* RDWSD-60.1* ___ 05:53PM PLT COUNT-183 ___ 05:53PM NEUTS-72.6* LYMPHS-15.0* MONOS-11.2 EOS-0.8* BASOS-0.3 IM ___ AbsNeut-5.36 AbsLymp-1.11* AbsMono-0.83* AbsEos-0.06 AbsBaso-0.02 ___ 05:53PM GLUCOSE-76 UREA N-14 CREAT-0.8 SODIUM-139 POTASSIUM-4.8 CHLORIDE-102 TOTAL CO2-27 ANION GAP-10 ___ 05:53PM ALT(SGPT)-32 AST(SGOT)-38 ALK PHOS-109 TOT BILI-1.5 ___ 05:53PM proBNP-560* ___ 05:53PM LIPASE-15 ___ 05:53PM ALBUMIN-3.1* CALCIUM-9.1 PHOSPHATE-2.7 MAGNESIUM-2.2 PERTINENT LABS: =============== ___ 07:05PM BLOOD 25VitD-49 ___ 04:41AM BLOOD CRP-52.0* ___ 02:12PM ASCITES TNC-1131* RBC-120* Polys-48* Lymphs-2* Monos-10* Mesothe-5* Macroph-32* Other-3* ___ 03:40PM URINE RBC-65* WBC-83* Bacteri-FEW* Yeast-NONE Epi-<1 DISCHARGE LABS: =============== ___ 03:51AM BLOOD WBC-15.5* RBC-2.80* Hgb-8.4* Hct-27.1* MCV-97 MCH-30.0 MCHC-31.0* RDW-21.0* RDWSD-73.1* Plt ___ ___ 03:51AM BLOOD ___ PTT-46.5* ___ ___ 07:58AM BLOOD Glucose-150* UreaN-28* Creat-0.7 Na-150* K-4.1 Cl-114* HCO3-23 AnGap-13 ___ 03:51AM BLOOD ALT-27 AST-42* AlkPhos-109 TotBili-3.0* DirBili-0.9* IndBili-2.1 ___ 07:58AM BLOOD Calcium-9.0 Phos-2.5* Mg-2.1 ___ 06:18AM BLOOD ___ pO2-206* pCO2-38 pH-7.42 calTCO2-25 Base XS-0 Comment-GREEN TOP ___ 10:32AM BLOOD Lactate-2.1* PERTINENT MICROBIOLOGY: ======================= __________________________________________________________ ___ 10:52 pm STOOL CONSISTENCY: LOOSE Source: Stool. C. difficile PCR (Pending): __________________________________________________________ ___ 9:45 pm BLOOD CULTURE 2 OF 2. Blood Culture, Routine (Pending): __________________________________________________________ ___ 9:30 pm BLOOD CULTURE Source: Line-CVL. Blood Culture, Routine (Pending): __________________________________________________________ ___ 3:40 pm URINE Source: Catheter. URINE CULTURE (Pending): __________________________________________________________ ___ 5:13 pm MRSA SCREEN Source: Nasal swab. **FINAL REPORT ___ MRSA SCREEN (Final ___: No MRSA isolated. __________________________________________________________ ___ 2:12 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES PERITONEAL FLUID. Fluid Culture in Bottles (Pending): No growth to date. __________________________________________________________ ___ 2:12 pm PERITONEAL FLUID PERITONEAL FLUID. GRAM STAIN (Final ___: 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count, if applicable. FLUID CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. __________________________________________________________ Time Taken Not Noted Log-In Date/Time: ___ 11:44 am STOOL CONSISTENCY: FORMED Source: Stool. **FINAL REPORT ___ C. difficile PCR (Final ___: NEGATIVE. (Reference Range-Negative). The C. difficile PCR is highly sensitive for toxigenic strains of C. difficile and detects both C. difficile infection (CDI) and asymptomatic carriage. A negative C. diff PCR test indicates a low likelihood of CDI or carriage. __________________________________________________________ Time Taken Not Noted Log-In Date/Time: ___ 11:03 am URINE **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. __________________________________________________________ ___ 9:13 am BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date. __________________________________________________________ ___ 4:30 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES PERITONEAL FLUID. **FINAL REPORT ___ Fluid Culture in Bottles (Final ___: NO GROWTH. __________________________________________________________ PERTINENT IMAGING: =================== LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of ___ IMPRESSION: 1. Limited evaluation of the left hepatic lobe due to poor sonographic windows. 2. Cirrhosis with large volume ascites. 3. Patent portal vein. Transthoracic Echocardiogram Report ___ IMPRESSION: Normal biventricular cavity sizes and regional/global biventricular systolic function. Mild mitral regurgitation. Dilated thoracic aorta. CT CHEST W/CONTRAST Study Date of ___ IMPRESSION: Mild-to-moderate diffuse interstitial lung disease may explain chronic cough. NS IP is the most likely diagnosis alternatively severe elevation of the diaphragm due to ascites may be triggering coughing. Fusiform aneurysm noncalcified ascending thoracic aorta, 50 mm diameter. CT ABD & PELVIS WITH CONTRAST Study Date of ___ IMPRESSION: 1. Cirrhotic liver without focal liver lesions. Evaluation for HCC is limited on this portal venous phase contrast-enhanced study. Recommend further evaluation a dedicated liver CT which includes the noncontrast, arterial, and 3 minutes delayed phases. The portal venous phase does not need to be repeated. 2. Large volume ascites, splenomegaly, and portosystemic varices compatible with sequela of portal hypertension. 3. Multiple pancreatic cystic lesions better evaluated on MR, likely represent side branch IPMNs. Recommend attention on follow-up imaging. 4. Please refer to separate report of CT chest performed on the same day for description of the thoracic findings. TIPS Study Date of ___ FINDINGS: 1. Pre-TIPS right atrial pressure of 11 mm Hg and balloon-occluded portal pressure measurement of 31 mm Hg resulting in portosystemic gradient of 20 mmHg. 2. CO2 portal venogram predominantly shunted into alternative hepatic veins with minimal opacification of the portal vein. 3. Contrast enhanced portal venogram showing patent portal venous system and hepatopetal flow. 4. Post-TIPS portal venogram showing predominant flow of contrast through the TIPS. 5. Post-TIPS right atrial pressure of 14 mm Hg and portal pressure of 20 mmHg resulting in portosystemic gradient of 6 mmHg. 6. Right upper quadrant ultrasound demonstrated trace ascites, too small volume for paracentesis IMPRESSION: Successful transjugular intrahepatic portosystemic shunt placement with decrease in porto-systemic pressure gradient from 20 to 6 mmHg. DUPLEX DOPP ABD/PEL Study Date of ___ IMPRESSION: Patent TIPS in this baseline ultrasound. Velocities as reported. CT ABD & PELVIS WITH CONTRAST Study Date of ___ IMPRESSION: 1. No evidence of perforation. Air and fluid filled mildly dilated colon. 2. Patent TIPS 3. Cirrhosis and findings compatible with portal hypertension. Interval decrease in extent of abdominopelvic ascites. 4. Unchanged pancreatic hypodensities, presumably reflecting IPMNs. PORTABLE ABDOMEN Study Date of ___ IMPRESSION: Dilated colonic bowel loops measuring up to 10 cm. Evaluation for small bowel dilatation is limited. CHEST (PORTABLE AP) Study Date of ___ IMPRESSION: 1. Unchanged bibasilar opacities may represent atelectasis or pneumonia/aspiration. 2. Mild interstitial pulmonary edema. 3. Multiple dilated colonic loops. MR HEAD W & W/O CONTRAST Study Date of ___ IMPRESSION: Moderately motion limited exam. No evidence for an acute infarction or other acute intracranial abnormalities. Brief Hospital Course: BRIEF DISCHARGE SUMMARY ========================= Mr. ___ is a ___ man with PBC c/b cirrhosis (c/b esophageal varices and ascites) and schizoaffective disorder who presented from clinic with worsening abdominal distension in the setting of not taking his diuretics due to dizziness. We found that he had lost a tremendous amount of weight and was fearful of eating because of chronic constipation. Given his anorexia and significant weight loss, there was concern for malignancy. A CT torso showed no evidence of cancer. We placed a feeding tube and had it advanced post-pyloric and initiated tube feeds for nutrition. We did a TTE that showed no significant cardiac abnormalities and did two bedside paracenteses for comfort. We recommended a TIPS procedure, which was done on ___ after Mr. ___ son was able to visit from ___. His post-TIPS course was complicated by ongoing fluid overload, and septic shock secondary to spontaneous bacterial peritonitis. After discussion with his family, patient was transitioned to comfort care and was discharged to hospice. TRANSITIONAL ISSUES =================== [ ] NG tube to suction kept in place at discharge for symptom relief of colonic and intestinal distension. ACTIVE ISSUES ============= #Primary biliary cholangitis #Acute decompensated cirrhosis #Refractory ascites s/p TIPS MELD 12 and CHILDS B on admission. Presented with large volume ascites in the setting of not taking diuretics due to persistent dizziness. RUQUS showed no evidence of PVT, infectious workup was negative, and he had no signs of bleeding. He had a paracentesis in the ED to remove 2L fluid which resulted in significant improvement in symptoms. He was actively diuresed with IV furosemide, which removed significant volume clinically but caused low blood pressures (systolics ___, asymptomatic). Additional large volume paracenteses were performed for ongoing reaccumulation of ascites. Patient underwent a TIPS procedure on ___. His post-TIPS course was complicated by volume overload requiring additional diuresis, hepatic encephalopathy requiring lactulose and rifaximin, and septic shock secondary to SBP (see below). Given his poor prognosis, a discussion was held with his sister and son, and the decision was made to transition the patient to comfort care and discharge to hospice. #Septic shock #Spontaneous bacterial peritonitis #Hospital acquired pneumonia Patient developed fever, hypotension, and tachycardia, concerning for infection. Infectious workup was significant for ascites fluid with PMN>250. Patient was transferred to the ICU and maintained on pressors. Patient was started on antibiotics for SBP. Chest imaging was also concerning for a pulmonary consolidation, so he was maintained on broad spectrum Vancomycin, cefepime, and metronidazole. He was stabilized and transferred back to the general medical floor. Antibiotics were discontinued after patient was transitioned to comfort care. #Acute colonic pseudoobstruction Patient developed worsening abdominal distension and tenderness. Imaging revealed dilated colonic bowel loops measuring up to 10cm. Patient was evaluated by the surgical service, who recommended strict NPO and maintaining NG tube to suction for decompression. #Severe malnutrition #Weight loss Reported purposeful food restriction because of concern for constipation and that he was mostly drinking Ensures. His significant weight loss raised concern for malignancy and he had a CT torso, which showed no evidence of cancer. A colonoscopy was deferred given his significant improvement with treatment of his liver disease. Nutrition was consulted and a dobhoff was placed (and advanced post-pyloric) to initiate tube feeds. Tube feeds were subsequently held after development of acute colonic pseudoobstruction. #Dyspnea #Lower extremity edema Appeared significantly volume overloaded on exam with crackles in bilateral bases, subjective shortness of breath, and 2+ pitting edema to his knees bilaterally. Likely in the setting of not taking his diuretics due to persistent dizziness. His symptoms improved with diuresis and therapeutic paracentesis. BNP and TTE on admission were unremarkable so there was less concern for a cardiogenic cause of his volume overload. Given diuretic intolerance, a TIPS procedure was performed. He had ongoing peripheral edema after his TIPS that required diuresis. #Asymptomatic bacteriuria UA showed pyuria and bacteriuria but patient had no symptoms. Treatment was therefore deferred. CHRONIC ISSUES =============== #Depression #Schizoaffective disorder Continued home seroquel 100mg QHS. Psychiatry initially recommended continuing the seroquel and then follow up after discharge to consider cross downtitration with another medication as seroquel can be constipating. However, after discussion with the family, patient was transitioned to comfort care, and this plan was not undertaken. Of note, we discontinued his home lamotrigine per recommendation from his outpatient psychiatrist Dr. ___ due to conflicting reports about whether he was taking/stopping/restarting this medication. Per Dr. ___, patient is not a good candidate for lamotrigine with risk of abrupt start/stop and risk for SJS. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Furosemide 20 mg PO DAILY 2. LamoTRIgine 100 mg PO DAILY 3. QUEtiapine Fumarate 100 mg PO DAILY 4. Spironolactone 50 mg PO DAILY 5. Ursodiol 500 mg PO BID 6. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line 7. Calcium Carbonate 500 mg PO DAILY 8. Vitamin D 400 UNIT PO DAILY 9. Polyethylene Glycol 17 g PO BID 10. Vitamin A ___ UNIT PO DAILY Discharge Medications: 1. rifAXIMin 550 mg PO BID 2. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line 3. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line 4. QUEtiapine Fumarate 100 mg PO DAILY Discharge Disposition: Expired Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS ================= ACUTE DECOMPENSATED CIRRHOSIS SECONDARY DIAGNOSES =================== PRIMARY BILIARY CHOLANGITIS LIVER CIRRHOSIS ASCITES SPONTANEOUS BACTERIAL PERITONITIS ACUTE COLONIC PSEUDOOBSTRUCTION SEPTIC SHOCK SEVERE MALNUTRITION WEIGHT LOSS ANOREXIA SHORTNESS OF BREATH LOWER EXTREMITY EDEMA ASYMPTOMATIC BACTERIURIA CONSTIPATION DEPRESSION SCHIZOAFFECTIVE DISORDER Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr ___, It was our pleasure to take care of you at ___. You came to the hospital because your abdomen was getting very big. WHAT HAPPENED IN THE HOSPITAL? - We removed extra fluid from your belly through a procedure known as a paracentesis - You had a TIPS procedure, which was done to help reduce the amount of fluid that built up in your belly - We treated you for an infection in the fluid in your belly. You were briefly in the intensive care unit because the infection made you very sick. - We placed a tube through your nose into your stomach to remove the gas and help make you feel more comfortable - We discussed with you and your family and decided to no longer perform any invasive procedures, and rather to focus on symptom management and helping you feel comfortable. - You were discharged to hospice. WHAT SHOULD YOU DO WHEN YOU LEAVE? - You should enjoy spending time with your family We wish you the best, Sincerely, Your care team at ___ Followup Instructions: ___
[ "K7460", "E43", "K652", "A419", "J189", "R6521", "K7200", "R188", "K766", "K56699", "T8140XA", "N400", "F329", "F259", "K3189", "K5900", "K743", "Z515", "E8770", "R8271", "Z66", "Z6821" ]
Allergies: All allergies / adverse drug reactions previously recorded have been deleted Chief Complaint: abdominal distension Major Surgical or Invasive Procedure: Diagnostic and therapeutic paracentesis bedside [MASKED] Diagnostic and therapeutic paracentesis bedside [MASKED] [MASKED] TIPS [MASKED] Central venous line insertion [MASKED] Diagnostic paracentesis [MASKED] History of Present Illness: [MASKED] year old man with PBC c/b esophageal varices and ascites and schizoaffective disorder who presented to clinic yesterday with worsening abdominal distention in the setting of not taking his diuretics. He has lost a tremendous amount of weight and he has not been able to eat. Per OMR on [MASKED], his PCP spoke to him because she had received an email from his psychiatrist that he reported that he is no longer taking his Lasix due to concerns that it is an amphetamine and concerns about dizziness. At that point he agreed to restart his Lasix and spironolactone but his PCP did not feel confident in him following through with this. On [MASKED] there is a note from his psychiatrist that he had been seen in the [MASKED] ED 3 days prior with dizziness causing him to be unable to ambulate. He was seen by [MASKED], labs were checked, and he was discharged home. He had self decreased his Seroquel from 300 to 200 mg qHS and his psychiatrist recommended decreasing his lamotrigine from 200 to 100 due to the concern that dizziness may have been related to this medication. A serum level of the medication was checked while he was on 200 mg which was within normal limits and thus it was felt that the lamotrigine was less likely to be causing his dizziness. On [MASKED] he was seen by psychiatry at which point he had been doing "all right" on the reduced doses of his psychiatric medications. In the ED initial vitals: Temperature 97.4, heart rate 97, blood pressure 143/91, respiratory rate 18, 98% on room air - Exam notable for: Tense, distended abdomen, non-tender. Breathing comfortable on room air with crackles at bilateral bases - Labs notable for: CBC: Hemoglobin 12.9, otherwise unremarkable Chem7: Unremarkable LFTs: Unremarkable, except for albumin of 3.1 Coags: Not obtained Ascites: TNC of 685, 6% polys Urinalysis: 9 WBCs, 0 epis, 10 ketones, few bacteria, negative nitrite - Imaging notable for: RUQUS with Doppler: 1. Cirrhosis with large ascites. 2. Patent portal vein. CXR: Low lung volumes without focal consolidation or pulmonary edema. - Patient was given: Nothing - ED Course: Patient underwent diagnostic and therapeutic paracentesis for 2 L with improvement in symptoms. On arrival to the floor he says he feels better after therapeutic paracentesis. He says that last [MASKED] he started to feel tired and fatigued and had some shortness of breath which has been worsening over the last 6 months or so. He can only walk about 7 blocks before feeling tired and short of breath at this time. He does state that he feels that the diuretics are making him dizzy and so he has been only taking them about twice a week. He denies dysuria, urinary frequency, hematuria, hematochezia, melena. He endorses swelling around his ankles. He endorses chills but no fevers. He says that over the last [MASKED] weeks he only ate [MASKED] boosts per day in addition to some juice and coffee and water. He says that he has been doing this in order to make his stool softer and is afraid to eat regular food because it will make him constipated. He says he did have a soft bowel movement over the weekend but still feels constipated. He does say that people have told him that he looks much thinner than previously. Past Medical History: BPH Depression Schizoaffective disorder Colon polyps Portal hypertensive gastropathy Primary biliary cirrhosis complicated by ascites s/p banding and ascites Chronic cough, improved Social History: [MASKED] Family History: Father died from complications from polio. His mother died at the age of [MASKED] and she had a tumor removed at some point (he thinks from her abdomen). Brother with stage IV rectal cancer who recently underwent surgery. He was diagnosed with colon cancer in his late [MASKED]. Physical Exam: ADMISSION EXAM: =============== VS: 98.1F, 129/84, HR 77, RR 18, on room air GENERAL: NAD, appears markedly cachectic with muscle wasting and temporal wasting HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM NECK: supple, no LAD, no JVD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: Breathing comfortable on room air, crackles at the bases of his lungs bilaterally ABDOMEN: distended but soft, nontender in all quadrants, no rebound/guarding, normoactive bowel sounds, right sided para site with bloody bandage in place EXTREMITIES: 2+ pitting edema to the knees bilaterally PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, moving all 4 extremities with purpose, no asterixis DISCHARGE EXAM: =============== VS: 24 HR Data (last updated [MASKED] @ 2340) Temp: 98.3 (Tm 100.3), BP: 127/72 (112-127/68-72), HR: 105 (82-105), RR: 20 ([MASKED]), O2 sat: 91% (89-100), O2 delivery: 2 L Nc Fluid Balance (last updated [MASKED] @ 530) Last 8 hours Total cumulative 873ml IN: Total 873ml, TF/Flush Amt 447ml, IV Amt Infused 426ml OUT: Total 0ml, Urine Amt 0ml Last 24 hours Total cumulative 2001ml IN: Total 4061ml, PO Amt 120ml, TF/Flush Amt 748ml, IV Amt Infused 3193ml OUT: Total 2060ml, Urine Amt 2060ml, Flexiseal 0ml GEN: Elderly, frail man, lying in bed, appears uncomfortable HEENT: Anicteric sclerae. NG tube in place, dried blood in nares. CV: Normal rate and rhythm. Grade [MASKED] systolic murmur. Lungs: Clear to auscultation bilaterally without wheezes, rhonchi, or rales in anterior fields. Abdomen: Hyperactive bowel sounds throughout. Soft. Significantly distended, tympanitic to percussion. Mildly tender to deep palpation diffusely, no rebound or guarding. Extremities: Warm. No pitting edema. Neuro: Alert. Oriented to self, place [MASKED] building"). Not oriented to year. Does not answer all questions or follow commands appropriately. Dysarthric. No asterixis appreciated. Pertinent Results: ADMISSION LABS: =============== [MASKED] 05:53PM WBC-7.4 RBC-4.41* HGB-12.9* HCT-41.4 MCV-94 MCH-29.3 MCHC-31.2* RDW-17.3* RDWSD-60.1* [MASKED] 05:53PM PLT COUNT-183 [MASKED] 05:53PM NEUTS-72.6* LYMPHS-15.0* MONOS-11.2 EOS-0.8* BASOS-0.3 IM [MASKED] AbsNeut-5.36 AbsLymp-1.11* AbsMono-0.83* AbsEos-0.06 AbsBaso-0.02 [MASKED] 05:53PM GLUCOSE-76 UREA N-14 CREAT-0.8 SODIUM-139 POTASSIUM-4.8 CHLORIDE-102 TOTAL CO2-27 ANION GAP-10 [MASKED] 05:53PM ALT(SGPT)-32 AST(SGOT)-38 ALK PHOS-109 TOT BILI-1.5 [MASKED] 05:53PM proBNP-560* [MASKED] 05:53PM LIPASE-15 [MASKED] 05:53PM ALBUMIN-3.1* CALCIUM-9.1 PHOSPHATE-2.7 MAGNESIUM-2.2 PERTINENT LABS: =============== [MASKED] 07:05PM BLOOD 25VitD-49 [MASKED] 04:41AM BLOOD CRP-52.0* [MASKED] 02:12PM ASCITES TNC-1131* RBC-120* Polys-48* Lymphs-2* Monos-10* Mesothe-5* Macroph-32* Other-3* [MASKED] 03:40PM URINE RBC-65* WBC-83* Bacteri-FEW* Yeast-NONE Epi-<1 DISCHARGE LABS: =============== [MASKED] 03:51AM BLOOD WBC-15.5* RBC-2.80* Hgb-8.4* Hct-27.1* MCV-97 MCH-30.0 MCHC-31.0* RDW-21.0* RDWSD-73.1* Plt [MASKED] [MASKED] 03:51AM BLOOD [MASKED] PTT-46.5* [MASKED] [MASKED] 07:58AM BLOOD Glucose-150* UreaN-28* Creat-0.7 Na-150* K-4.1 Cl-114* HCO3-23 AnGap-13 [MASKED] 03:51AM BLOOD ALT-27 AST-42* AlkPhos-109 TotBili-3.0* DirBili-0.9* IndBili-2.1 [MASKED] 07:58AM BLOOD Calcium-9.0 Phos-2.5* Mg-2.1 [MASKED] 06:18AM BLOOD [MASKED] pO2-206* pCO2-38 pH-7.42 calTCO2-25 Base XS-0 Comment-GREEN TOP [MASKED] 10:32AM BLOOD Lactate-2.1* PERTINENT MICROBIOLOGY: ======================= [MASKED] [MASKED] 10:52 pm STOOL CONSISTENCY: LOOSE Source: Stool. C. difficile PCR (Pending): [MASKED] [MASKED] 9:45 pm BLOOD CULTURE 2 OF 2. Blood Culture, Routine (Pending): [MASKED] [MASKED] 9:30 pm BLOOD CULTURE Source: Line-CVL. Blood Culture, Routine (Pending): [MASKED] [MASKED] 3:40 pm URINE Source: Catheter. URINE CULTURE (Pending): [MASKED] [MASKED] 5:13 pm MRSA SCREEN Source: Nasal swab. **FINAL REPORT [MASKED] MRSA SCREEN (Final [MASKED]: No MRSA isolated. [MASKED] [MASKED] 2:12 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES PERITONEAL FLUID. Fluid Culture in Bottles (Pending): No growth to date. [MASKED] [MASKED] 2:12 pm PERITONEAL FLUID PERITONEAL 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, if applicable. FLUID CULTURE (Final [MASKED]: NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. [MASKED] Time Taken Not Noted Log-In Date/Time: [MASKED] 11:44 am STOOL CONSISTENCY: FORMED Source: Stool. **FINAL REPORT [MASKED] C. difficile PCR (Final [MASKED]: NEGATIVE. (Reference Range-Negative). The C. difficile PCR is highly sensitive for toxigenic strains of C. difficile and detects both C. difficile infection (CDI) and asymptomatic carriage. A negative C. diff PCR test indicates a low likelihood of CDI or carriage. [MASKED] Time Taken Not Noted Log-In Date/Time: [MASKED] 11:03 am URINE **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: NO GROWTH. [MASKED] [MASKED] 9:13 am BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date. [MASKED] [MASKED] 4:30 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES PERITONEAL FLUID. **FINAL REPORT [MASKED] Fluid Culture in Bottles (Final [MASKED]: NO GROWTH. [MASKED] PERTINENT IMAGING: =================== LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of [MASKED] IMPRESSION: 1. Limited evaluation of the left hepatic lobe due to poor sonographic windows. 2. Cirrhosis with large volume ascites. 3. Patent portal vein. Transthoracic Echocardiogram Report [MASKED] IMPRESSION: Normal biventricular cavity sizes and regional/global biventricular systolic function. Mild mitral regurgitation. Dilated thoracic aorta. CT CHEST W/CONTRAST Study Date of [MASKED] IMPRESSION: Mild-to-moderate diffuse interstitial lung disease may explain chronic cough. NS IP is the most likely diagnosis alternatively severe elevation of the diaphragm due to ascites may be triggering coughing. Fusiform aneurysm noncalcified ascending thoracic aorta, 50 mm diameter. CT ABD & PELVIS WITH CONTRAST Study Date of [MASKED] IMPRESSION: 1. Cirrhotic liver without focal liver lesions. Evaluation for HCC is limited on this portal venous phase contrast-enhanced study. Recommend further evaluation a dedicated liver CT which includes the noncontrast, arterial, and 3 minutes delayed phases. The portal venous phase does not need to be repeated. 2. Large volume ascites, splenomegaly, and portosystemic varices compatible with sequela of portal hypertension. 3. Multiple pancreatic cystic lesions better evaluated on MR, likely represent side branch IPMNs. Recommend attention on follow-up imaging. 4. Please refer to separate report of CT chest performed on the same day for description of the thoracic findings. TIPS Study Date of [MASKED] FINDINGS: 1. Pre-TIPS right atrial pressure of 11 mm Hg and balloon-occluded portal pressure measurement of 31 mm Hg resulting in portosystemic gradient of 20 mmHg. 2. CO2 portal venogram predominantly shunted into alternative hepatic veins with minimal opacification of the portal vein. 3. Contrast enhanced portal venogram showing patent portal venous system and hepatopetal flow. 4. Post-TIPS portal venogram showing predominant flow of contrast through the TIPS. 5. Post-TIPS right atrial pressure of 14 mm Hg and portal pressure of 20 mmHg resulting in portosystemic gradient of 6 mmHg. 6. Right upper quadrant ultrasound demonstrated trace ascites, too small volume for paracentesis IMPRESSION: Successful transjugular intrahepatic portosystemic shunt placement with decrease in porto-systemic pressure gradient from 20 to 6 mmHg. DUPLEX DOPP ABD/PEL Study Date of [MASKED] IMPRESSION: Patent TIPS in this baseline ultrasound. Velocities as reported. CT ABD & PELVIS WITH CONTRAST Study Date of [MASKED] IMPRESSION: 1. No evidence of perforation. Air and fluid filled mildly dilated colon. 2. Patent TIPS 3. Cirrhosis and findings compatible with portal hypertension. Interval decrease in extent of abdominopelvic ascites. 4. Unchanged pancreatic hypodensities, presumably reflecting IPMNs. PORTABLE ABDOMEN Study Date of [MASKED] IMPRESSION: Dilated colonic bowel loops measuring up to 10 cm. Evaluation for small bowel dilatation is limited. CHEST (PORTABLE AP) Study Date of [MASKED] IMPRESSION: 1. Unchanged bibasilar opacities may represent atelectasis or pneumonia/aspiration. 2. Mild interstitial pulmonary edema. 3. Multiple dilated colonic loops. MR HEAD W & W/O CONTRAST Study Date of [MASKED] IMPRESSION: Moderately motion limited exam. No evidence for an acute infarction or other acute intracranial abnormalities. Brief Hospital Course: BRIEF DISCHARGE SUMMARY ========================= Mr. [MASKED] is a [MASKED] man with PBC c/b cirrhosis (c/b esophageal varices and ascites) and schizoaffective disorder who presented from clinic with worsening abdominal distension in the setting of not taking his diuretics due to dizziness. We found that he had lost a tremendous amount of weight and was fearful of eating because of chronic constipation. Given his anorexia and significant weight loss, there was concern for malignancy. A CT torso showed no evidence of cancer. We placed a feeding tube and had it advanced post-pyloric and initiated tube feeds for nutrition. We did a TTE that showed no significant cardiac abnormalities and did two bedside paracenteses for comfort. We recommended a TIPS procedure, which was done on [MASKED] after Mr. [MASKED] son was able to visit from [MASKED]. His post-TIPS course was complicated by ongoing fluid overload, and septic shock secondary to spontaneous bacterial peritonitis. After discussion with his family, patient was transitioned to comfort care and was discharged to hospice. TRANSITIONAL ISSUES =================== [ ] NG tube to suction kept in place at discharge for symptom relief of colonic and intestinal distension. ACTIVE ISSUES ============= #Primary biliary cholangitis #Acute decompensated cirrhosis #Refractory ascites s/p TIPS MELD 12 and CHILDS B on admission. Presented with large volume ascites in the setting of not taking diuretics due to persistent dizziness. RUQUS showed no evidence of PVT, infectious workup was negative, and he had no signs of bleeding. He had a paracentesis in the ED to remove 2L fluid which resulted in significant improvement in symptoms. He was actively diuresed with IV furosemide, which removed significant volume clinically but caused low blood pressures (systolics [MASKED], asymptomatic). Additional large volume paracenteses were performed for ongoing reaccumulation of ascites. Patient underwent a TIPS procedure on [MASKED]. His post-TIPS course was complicated by volume overload requiring additional diuresis, hepatic encephalopathy requiring lactulose and rifaximin, and septic shock secondary to SBP (see below). Given his poor prognosis, a discussion was held with his sister and son, and the decision was made to transition the patient to comfort care and discharge to hospice. #Septic shock #Spontaneous bacterial peritonitis #Hospital acquired pneumonia Patient developed fever, hypotension, and tachycardia, concerning for infection. Infectious workup was significant for ascites fluid with PMN>250. Patient was transferred to the ICU and maintained on pressors. Patient was started on antibiotics for SBP. Chest imaging was also concerning for a pulmonary consolidation, so he was maintained on broad spectrum Vancomycin, cefepime, and metronidazole. He was stabilized and transferred back to the general medical floor. Antibiotics were discontinued after patient was transitioned to comfort care. #Acute colonic pseudoobstruction Patient developed worsening abdominal distension and tenderness. Imaging revealed dilated colonic bowel loops measuring up to 10cm. Patient was evaluated by the surgical service, who recommended strict NPO and maintaining NG tube to suction for decompression. #Severe malnutrition #Weight loss Reported purposeful food restriction because of concern for constipation and that he was mostly drinking Ensures. His significant weight loss raised concern for malignancy and he had a CT torso, which showed no evidence of cancer. A colonoscopy was deferred given his significant improvement with treatment of his liver disease. Nutrition was consulted and a dobhoff was placed (and advanced post-pyloric) to initiate tube feeds. Tube feeds were subsequently held after development of acute colonic pseudoobstruction. #Dyspnea #Lower extremity edema Appeared significantly volume overloaded on exam with crackles in bilateral bases, subjective shortness of breath, and 2+ pitting edema to his knees bilaterally. Likely in the setting of not taking his diuretics due to persistent dizziness. His symptoms improved with diuresis and therapeutic paracentesis. BNP and TTE on admission were unremarkable so there was less concern for a cardiogenic cause of his volume overload. Given diuretic intolerance, a TIPS procedure was performed. He had ongoing peripheral edema after his TIPS that required diuresis. #Asymptomatic bacteriuria UA showed pyuria and bacteriuria but patient had no symptoms. Treatment was therefore deferred. CHRONIC ISSUES =============== #Depression #Schizoaffective disorder Continued home seroquel 100mg QHS. Psychiatry initially recommended continuing the seroquel and then follow up after discharge to consider cross downtitration with another medication as seroquel can be constipating. However, after discussion with the family, patient was transitioned to comfort care, and this plan was not undertaken. Of note, we discontinued his home lamotrigine per recommendation from his outpatient psychiatrist Dr. [MASKED] due to conflicting reports about whether he was taking/stopping/restarting this medication. Per Dr. [MASKED], patient is not a good candidate for lamotrigine with risk of abrupt start/stop and risk for SJS. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Furosemide 20 mg PO DAILY 2. LamoTRIgine 100 mg PO DAILY 3. QUEtiapine Fumarate 100 mg PO DAILY 4. Spironolactone 50 mg PO DAILY 5. Ursodiol 500 mg PO BID 6. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line 7. Calcium Carbonate 500 mg PO DAILY 8. Vitamin D 400 UNIT PO DAILY 9. Polyethylene Glycol 17 g PO BID 10. Vitamin A [MASKED] UNIT PO DAILY Discharge Medications: 1. rifAXIMin 550 mg PO BID 2. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line 3. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line 4. QUEtiapine Fumarate 100 mg PO DAILY Discharge Disposition: Expired Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSIS ================= ACUTE DECOMPENSATED CIRRHOSIS SECONDARY DIAGNOSES =================== PRIMARY BILIARY CHOLANGITIS LIVER CIRRHOSIS ASCITES SPONTANEOUS BACTERIAL PERITONITIS ACUTE COLONIC PSEUDOOBSTRUCTION SEPTIC SHOCK SEVERE MALNUTRITION WEIGHT LOSS ANOREXIA SHORTNESS OF BREATH LOWER EXTREMITY EDEMA ASYMPTOMATIC BACTERIURIA CONSTIPATION DEPRESSION SCHIZOAFFECTIVE DISORDER Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr [MASKED], It was our pleasure to take care of you at [MASKED]. You came to the hospital because your abdomen was getting very big. WHAT HAPPENED IN THE HOSPITAL? - We removed extra fluid from your belly through a procedure known as a paracentesis - You had a TIPS procedure, which was done to help reduce the amount of fluid that built up in your belly - We treated you for an infection in the fluid in your belly. You were briefly in the intensive care unit because the infection made you very sick. - We placed a tube through your nose into your stomach to remove the gas and help make you feel more comfortable - We discussed with you and your family and decided to no longer perform any invasive procedures, and rather to focus on symptom management and helping you feel comfortable. - You were discharged to hospice. WHAT SHOULD YOU DO WHEN YOU LEAVE? - You should enjoy spending time with your family We wish you the best, Sincerely, Your care team at [MASKED] Followup Instructions: [MASKED]
[]
[ "N400", "F329", "K5900", "Z515", "Z66" ]
[ "K7460: Unspecified cirrhosis of liver", "E43: Unspecified severe protein-calorie malnutrition", "K652: Spontaneous bacterial peritonitis", "A419: Sepsis, unspecified organism", "J189: Pneumonia, unspecified organism", "R6521: Severe sepsis with septic shock", "K7200: Acute and subacute hepatic failure without coma", "R188: Other ascites", "K766: Portal hypertension", "K56699: Other intestinal obstruction unspecified as to partial versus complete obstruction", "T8140XA: Infection following a procedure, unspecified, initial encounter", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "F329: Major depressive disorder, single episode, unspecified", "F259: Schizoaffective disorder, unspecified", "K3189: Other diseases of stomach and duodenum", "K5900: Constipation, unspecified", "K743: Primary biliary cirrhosis", "Z515: Encounter for palliative care", "E8770: Fluid overload, unspecified", "R8271: Bacteriuria", "Z66: Do not resuscitate", "Z6821: Body mass index [BMI] 21.0-21.9, adult" ]
19,997,887
21,708,644
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: Dilaudid Attending: ___. Chief Complaint: right knee OA Major Surgical or Invasive Procedure: right knee replacement ___, ___ History of Present Illness: ___ year old female with right knee OA s/p right TKR. Past Medical History: PMH: Obesity, anxiety, depression, GERD, asthma. BP at PAT 160/87 PShx: L knee athroscopy, C-section Social History: ___ Family History: Non-contributory Physical Exam: Well appearing in no acute distress Afebrile with stable vital signs Pain well-controlled Respiratory: CTAB Cardiovascular: RRR Gastrointestinal: NT/ND Genitourinary: Voiding independently Neurologic: Intact with no focal deficits Psychiatric: Pleasant, A&O x3 Musculoskeletal Lower Extremity: * Aquacel dressing with scant serosanguinous drainage * Thigh full but soft * No calf tenderness * ___ strength * SILT, NVI distally * Toes warm Pertinent Results: ___ 06:55AM BLOOD Hgb-11.6 Hct-35.5 ___ 06:55AM BLOOD Creat-0.7 Brief Hospital Course: The patient was admitted to the Orthopaedic surgery service and was taken to the operating room for above described procedure. Please see separately dictated operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Patient received perioperative IV antibiotics. Postoperative course was remarkable for the following: POD#0, the patient was unable to void post-operatively and a foley catheter was placed. This was discontinued at midnight and the patient was able to void independently thereafter. Otherwise, pain was controlled with a combination of IV and oral pain medications. The patient received Aspirin 81 mg twice daily for DVT prophylaxis starting on the morning of POD#1. The surgical dressing will remain on until POD#7 after surgery. The patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was acceptable and pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact and the dressing was intact. The patient's weight-bearing status is weight bearing as tolerated on the operative extremity with no range of motion restrictions. Please use walker or 2 crutches, wean as able. Ms. ___ is discharged to home with services in stable condition. Medications on Admission: 1. GuaiFENesin-CODEINE Phosphate ___ mL PO BID:PRN cough 2. Metoprolol Succinate XL 25 mg PO DAILY 3. Fluticasone Propionate NASAL 1 SPRY NU BID 4. fluticasone propion-salmeterol 115-21 mcg/actuation inhalation BID 5. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild 6. Omeprazole 40 mg PO DAILY 7. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN cough Discharge Medications: 1. Acetaminophen w/Codeine ___ TAB PO Q4H:PRN Pain - Moderate 2. Aspirin EC 81 mg PO BID 3. Docusate Sodium 100 mg PO BID 4. Gabapentin 100 mg PO TID 5. Senna 8.6 mg PO BID 6. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN cough 7. fluticasone propion-salmeterol 115-21 mcg/actuation inhalation BID 8. Fluticasone Propionate NASAL 1 SPRY NU BID 9. GuaiFENesin-CODEINE Phosphate ___ mL PO BID:PRN cough 10. Metoprolol Succinate XL 25 mg PO DAILY 11. Omeprazole 40 mg PO DAILY Take daily while on Aspirin 12. HELD- Ibuprofen 800 mg PO Q8H:PRN Pain - Mild This medication was held. Do not restart Ibuprofen until you've been cleared by your surgeon Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: right knee OA Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as Colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon. 6. Please call your surgeon's office to schedule or confirm your follow-up appointment. 7. SWELLING: Ice the operative joint 20 minutes at a time, especially after activity or physical therapy. Do not place ice directly on the skin. You may wrap the knee with an ace bandage for added compression. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as Celebrex, ibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by your physician. 8. ANTICOAGULATION: Please continue your Aspirin 81 twice daily with food for four (4) weeks to help prevent deep vein thrombosis (blood clots). Continue Omeprazole daily while on Aspirin to prevent GI upset (x 4 weeks). If you were taking Aspirin prior to your surgery, take it at 81 mg twice daily until the end of the 4 weeks, then you can go back to your normal dosing. 9. WOUND CARE: Please remove Aquacel dressing on POD#7 after surgery. It is okay to shower after surgery after 5 days but no tub baths, swimming, or submerging your incision until after your four (4) week checkup. Please place a dry sterile dressing on the wound after aqaucel is removed each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed by your doctor at follow-up appointment approximately 2 weeks after surgery. 10. ___ (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 RLE No range of motion restrictions Mobilize frequently Wean assistive devices as able (i.e., 2 crutches, walker) Treatments Frequency: remove aquacel POD#7 after surgery apply dry sterile dressing daily if needed after aquacel dressing is removed wound checks daily after aquacel removed staple removal and replace with steri-strips at follow up visit in clinic Followup Instructions: ___
[ "M1711", "F329", "F419", "K219", "J45909", "Z87891", "R339", "E669", "Z6833", "Z006" ]
Allergies: Dilaudid Chief Complaint: right knee OA Major Surgical or Invasive Procedure: right knee replacement [MASKED], [MASKED] History of Present Illness: [MASKED] year old female with right knee OA s/p right TKR. Past Medical History: PMH: Obesity, anxiety, depression, GERD, asthma. BP at PAT 160/87 PShx: L knee athroscopy, C-section Social History: [MASKED] Family History: Non-contributory Physical Exam: Well appearing in no acute distress Afebrile with stable vital signs Pain well-controlled Respiratory: CTAB Cardiovascular: RRR Gastrointestinal: NT/ND Genitourinary: Voiding independently Neurologic: Intact with no focal deficits Psychiatric: Pleasant, A&O x3 Musculoskeletal Lower Extremity: * Aquacel dressing with scant serosanguinous drainage * Thigh full but soft * No calf tenderness * [MASKED] strength * SILT, NVI distally * Toes warm Pertinent Results: [MASKED] 06:55AM BLOOD Hgb-11.6 Hct-35.5 [MASKED] 06:55AM BLOOD Creat-0.7 Brief Hospital Course: The patient was admitted to the Orthopaedic surgery service and was taken to the operating room for above described procedure. Please see separately dictated operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Patient received perioperative IV antibiotics. Postoperative course was remarkable for the following: POD#0, the patient was unable to void post-operatively and a foley catheter was placed. This was discontinued at midnight and the patient was able to void independently thereafter. Otherwise, pain was controlled with a combination of IV and oral pain medications. The patient received Aspirin 81 mg twice daily for DVT prophylaxis starting on the morning of POD#1. The surgical dressing will remain on until POD#7 after surgery. The patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was acceptable and pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact and the dressing was intact. The patient's weight-bearing status is weight bearing as tolerated on the operative extremity with no range of motion restrictions. Please use walker or 2 crutches, wean as able. Ms. [MASKED] is discharged to home with services in stable condition. Medications on Admission: 1. GuaiFENesin-CODEINE Phosphate [MASKED] mL PO BID:PRN cough 2. Metoprolol Succinate XL 25 mg PO DAILY 3. Fluticasone Propionate NASAL 1 SPRY NU BID 4. fluticasone propion-salmeterol 115-21 mcg/actuation inhalation BID 5. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild 6. Omeprazole 40 mg PO DAILY 7. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN cough Discharge Medications: 1. Acetaminophen w/Codeine [MASKED] TAB PO Q4H:PRN Pain - Moderate 2. Aspirin EC 81 mg PO BID 3. Docusate Sodium 100 mg PO BID 4. Gabapentin 100 mg PO TID 5. Senna 8.6 mg PO BID 6. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN cough 7. fluticasone propion-salmeterol 115-21 mcg/actuation inhalation BID 8. Fluticasone Propionate NASAL 1 SPRY NU BID 9. GuaiFENesin-CODEINE Phosphate [MASKED] mL PO BID:PRN cough 10. Metoprolol Succinate XL 25 mg PO DAILY 11. Omeprazole 40 mg PO DAILY Take daily while on Aspirin 12. HELD- Ibuprofen 800 mg PO Q8H:PRN Pain - Mild This medication was held. Do not restart Ibuprofen until you've been cleared by your surgeon Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: right knee OA Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as Colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon. 6. Please call your surgeon's office to schedule or confirm your follow-up appointment. 7. SWELLING: Ice the operative joint 20 minutes at a time, especially after activity or physical therapy. Do not place ice directly on the skin. You may wrap the knee with an ace bandage for added compression. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as Celebrex, ibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by your physician. 8. ANTICOAGULATION: Please continue your Aspirin 81 twice daily with food for four (4) weeks to help prevent deep vein thrombosis (blood clots). Continue Omeprazole daily while on Aspirin to prevent GI upset (x 4 weeks). If you were taking Aspirin prior to your surgery, take it at 81 mg twice daily until the end of the 4 weeks, then you can go back to your normal dosing. 9. WOUND CARE: Please remove Aquacel dressing on POD#7 after surgery. It is okay to shower after surgery after 5 days but no tub baths, swimming, or submerging your incision until after your four (4) week checkup. Please place a dry sterile dressing on the wound after aqaucel is removed each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed by your doctor at follow-up appointment approximately 2 weeks after surgery. 10. [MASKED] (once at home): Home [MASKED], dressing changes as instructed, and wound checks. 11. ACTIVITY: Weight bearing as tolerated on the operative extremity. Two crutches or walker. Wean assistive device as able. Mobilize. ROM as tolerated. No strenuous exercise or heavy lifting until follow up appointment. Physical Therapy: WBAT RLE No range of motion restrictions Mobilize frequently Wean assistive devices as able (i.e., 2 crutches, walker) Treatments Frequency: remove aquacel POD#7 after surgery apply dry sterile dressing daily if needed after aquacel dressing is removed wound checks daily after aquacel removed staple removal and replace with steri-strips at follow up visit in clinic Followup Instructions: [MASKED]
[]
[ "F329", "F419", "K219", "J45909", "Z87891", "E669" ]
[ "M1711: Unilateral primary osteoarthritis, right knee", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "J45909: Unspecified asthma, uncomplicated", "Z87891: Personal history of nicotine dependence", "R339: Retention of urine, unspecified", "E669: Obesity, unspecified", "Z6833: Body mass index [BMI] 33.0-33.9, adult", "Z006: Encounter for examination for normal comparison and control in clinical research program" ]
19,997,887
25,047,276
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Left knee pain Major Surgical or Invasive Procedure: ___ - Total Knee Arthroplasty, Left Knee History of Present Illness: ___ year old female with left knee osteoarthritis, unresponsive to conservative management, who has elected to proceed with a left total knee replacement on ___. Past Medical History: PMH: Obesity, anxiety, depression, GERD, asthma. BP at PAT 160/87 PShx: L knee athroscopy, C-section Social History: ___ Family History: Non-contributory Physical Exam: Well appearing in no acute distress Afebrile with stable vital signs Pain well-controlled Respiratory: CTAB Cardiovascular: RRR Gastrointestinal: NT/ND Genitourinary: Voiding independently Neurologic: Intact with no focal deficits Psychiatric: Pleasant, A&O x3 Musculoskeletal Lower Extremity: * Incision healing well with staples * Scant serosanguinous drainage * Thigh full but soft * No calf tenderness * ___ strength * SILT, NVI distally * Toes warm Pertinent Results: ___ 07:55AM BLOOD WBC-11.4* RBC-3.28* Hgb-10.2* Hct-31.1* MCV-95 MCH-31.1 MCHC-32.8 RDW-12.3 RDWSD-42.7 Plt ___ ___ 03:00PM BLOOD WBC-13.5* RBC-3.29* Hgb-10.4* Hct-30.8* MCV-94 MCH-31.6 MCHC-33.8 RDW-12.1 RDWSD-41.7 Plt ___ ___ 07:50AM BLOOD WBC-15.9*# RBC-3.59* Hgb-11.3 Hct-33.5* MCV-93 MCH-31.5 MCHC-33.7 RDW-12.0 RDWSD-41.3 Plt ___ ___ 07:55AM BLOOD Plt ___ ___ 03:00PM BLOOD Plt ___ ___ 07:50AM BLOOD Plt ___ ___ 07:55AM BLOOD Glucose-115* UreaN-16 Creat-0.7 Na-141 K-3.9 Cl-103 HCO3-29 AnGap-13 ___ 07:50AM BLOOD Glucose-168* UreaN-15 Creat-0.6 Na-132* K-3.9 Cl-98 HCO3-23 AnGap-15 ___ 07:50AM BLOOD estGFR-Using this ___ 07:55AM BLOOD Calcium-8.8 Phos-2.5* Mg-2.2 ___ 07:50AM BLOOD Calcium-8.6 Phos-3.4 Mg-1.8 Brief Hospital Course: The patient was admitted to the orthopedic surgery service and was taken to the operating room for above described procedure. Please see separately dictated operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Patient received perioperative IV antibiotics. Postoperative course was remarkable for the following: On POD#1 Ms. ___ was afebrile with a WBC of 15.9. Urinalysis and urine cultures were sent. Urinalysis was negative for UTI. Urine cultures were pending at time of discharge. Also, the patient's sodium was 132. She was placed on a fluid restriction. The following day, her sodium improved to 141. Otherwise, pain was controlled with a combination of IV and oral pain medications. The patient received Lovenox for DVT prophylaxis starting on the morning of POD#1. The foley was removed and the patient was voiding independently thereafter. The surgical dressing was changed on POD#2 and the surgical incision was found to be clean and intact without erythema or abnormal drainage. The patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was acceptable and pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact and the wound was benign. The patient's weight-bearing status is weight bearing as tolerated on the operative extremity. Ms. ___ is discharged to home with services in stable condition. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation QID:PRN cough 2. Citalopram 20 mg PO DAILY 3. codeine-guaifenesin ___ mg/5 mL oral BID:PRN 4. fluticasone 50 mcg/actuation nasal DAILY:PRN 5. Ibuprofen 800 mg PO Q8H:PRN pain 6. Omeprazole 40 mg PO DAILY:PRN heartburn Discharge Medications: 1. fluticasone 50 mcg/actuation nasal DAILY:PRN 2. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation QID:PRN cough 3. Acetaminophen 1000 mg PO Q8H 4. Docusate Sodium 100 mg PO BID 5. Enoxaparin Sodium 40 mg SC DAILY Duration: 28 Days Start: ___, First Dose: Next Routine Administration Time 6. Gabapentin 300 mg PO TID 7. Senna 8.6 mg PO BID 8. codeine-guaifenesin ___ mg/5 mL oral BID:PRN 9. Omeprazole 40 mg PO DAILY:PRN heartburn 10. TraMADol 50 mg PO Q4H:PRN pain Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Osteoarthritis, Left Knee 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). 8. ANTICOAGULATION: Please continue your Lovenox for four (4) weeks to help prevent deep vein thrombosis (blood clots). If you were taking aspirin prior to your surgery, it is OK to continue at your previous dose while taking this medication. 9. WOUND CARE: Please keep your incision clean and dry. It is okay to shower five days after surgery but no tub baths, swimming, or submerging your incision until after your four (4) week checkup. Please place a dry sterile dressing on the wound each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed at your follow-up appointment in two weeks. 10. ___ (once at home): Home ___, dressing changes as instructed, wound checks. 11. ACTIVITY: Weight bearing as tolerated on the operative extremity. Mobilize. ROM as tolerated. No strenuous exercise or heavy lifting until follow up appointment. Physical Therapy: WBAT LLE No range of motion restrictions Use of assistive ambulatory device, wean as able Treatments Frequency: dry sterile dressing changes daily monitor incision for drainage elevate and ice the operative extremity staples to be removed at first ___ clinic visit Followup Instructions: ___
[ "M170", "F329", "E669", "Z6832", "F419", "K219", "J45909", "Z87891", "D72829", "G8918", "R110", "I9581" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Left knee pain Major Surgical or Invasive Procedure: [MASKED] - Total Knee Arthroplasty, Left Knee History of Present Illness: [MASKED] year old female with left knee osteoarthritis, unresponsive to conservative management, who has elected to proceed with a left total knee replacement on [MASKED]. Past Medical History: PMH: Obesity, anxiety, depression, GERD, asthma. BP at PAT 160/87 PShx: L knee athroscopy, C-section Social History: [MASKED] Family History: Non-contributory Physical Exam: Well appearing in no acute distress Afebrile with stable vital signs Pain well-controlled Respiratory: CTAB Cardiovascular: RRR Gastrointestinal: NT/ND Genitourinary: Voiding independently Neurologic: Intact with no focal deficits Psychiatric: Pleasant, A&O x3 Musculoskeletal Lower Extremity: * Incision healing well with staples * Scant serosanguinous drainage * Thigh full but soft * No calf tenderness * [MASKED] strength * SILT, NVI distally * Toes warm Pertinent Results: [MASKED] 07:55AM BLOOD WBC-11.4* RBC-3.28* Hgb-10.2* Hct-31.1* MCV-95 MCH-31.1 MCHC-32.8 RDW-12.3 RDWSD-42.7 Plt [MASKED] [MASKED] 03:00PM BLOOD WBC-13.5* RBC-3.29* Hgb-10.4* Hct-30.8* MCV-94 MCH-31.6 MCHC-33.8 RDW-12.1 RDWSD-41.7 Plt [MASKED] [MASKED] 07:50AM BLOOD WBC-15.9*# RBC-3.59* Hgb-11.3 Hct-33.5* MCV-93 MCH-31.5 MCHC-33.7 RDW-12.0 RDWSD-41.3 Plt [MASKED] [MASKED] 07:55AM BLOOD Plt [MASKED] [MASKED] 03:00PM BLOOD Plt [MASKED] [MASKED] 07:50AM BLOOD Plt [MASKED] [MASKED] 07:55AM BLOOD Glucose-115* UreaN-16 Creat-0.7 Na-141 K-3.9 Cl-103 HCO3-29 AnGap-13 [MASKED] 07:50AM BLOOD Glucose-168* UreaN-15 Creat-0.6 Na-132* K-3.9 Cl-98 HCO3-23 AnGap-15 [MASKED] 07:50AM BLOOD estGFR-Using this [MASKED] 07:55AM BLOOD Calcium-8.8 Phos-2.5* Mg-2.2 [MASKED] 07:50AM BLOOD Calcium-8.6 Phos-3.4 Mg-1.8 Brief Hospital Course: The patient was admitted to the orthopedic surgery service and was taken to the operating room for above described procedure. Please see separately dictated operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Patient received perioperative IV antibiotics. Postoperative course was remarkable for the following: On POD#1 Ms. [MASKED] was afebrile with a WBC of 15.9. Urinalysis and urine cultures were sent. Urinalysis was negative for UTI. Urine cultures were pending at time of discharge. Also, the patient's sodium was 132. She was placed on a fluid restriction. The following day, her sodium improved to 141. Otherwise, pain was controlled with a combination of IV and oral pain medications. The patient received Lovenox for DVT prophylaxis starting on the morning of POD#1. The foley was removed and the patient was voiding independently thereafter. The surgical dressing was changed on POD#2 and the surgical incision was found to be clean and intact without erythema or abnormal drainage. The patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was acceptable and pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact and the wound was benign. The patient's weight-bearing status is weight bearing as tolerated on the operative extremity. Ms. [MASKED] is discharged to home with services in stable condition. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation QID:PRN cough 2. Citalopram 20 mg PO DAILY 3. codeine-guaifenesin [MASKED] mg/5 mL oral BID:PRN 4. fluticasone 50 mcg/actuation nasal DAILY:PRN 5. Ibuprofen 800 mg PO Q8H:PRN pain 6. Omeprazole 40 mg PO DAILY:PRN heartburn Discharge Medications: 1. fluticasone 50 mcg/actuation nasal DAILY:PRN 2. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation QID:PRN cough 3. Acetaminophen 1000 mg PO Q8H 4. Docusate Sodium 100 mg PO BID 5. Enoxaparin Sodium 40 mg SC DAILY Duration: 28 Days Start: [MASKED], First Dose: Next Routine Administration Time 6. Gabapentin 300 mg PO TID 7. Senna 8.6 mg PO BID 8. codeine-guaifenesin [MASKED] mg/5 mL oral BID:PRN 9. Omeprazole 40 mg PO DAILY:PRN heartburn 10. TraMADol 50 mg PO Q4H:PRN pain Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Osteoarthritis, Left Knee 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). 8. ANTICOAGULATION: Please continue your Lovenox for four (4) weeks to help prevent deep vein thrombosis (blood clots). If you were taking aspirin prior to your surgery, it is OK to continue at your previous dose while taking this medication. 9. WOUND CARE: Please keep your incision clean and dry. It is okay to shower five days after surgery but no tub baths, swimming, or submerging your incision until after your four (4) week checkup. Please place a dry sterile dressing on the wound each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed at your follow-up appointment in two weeks. 10. [MASKED] (once at home): Home [MASKED], dressing changes as instructed, wound checks. 11. ACTIVITY: Weight bearing as tolerated on the operative extremity. Mobilize. ROM as tolerated. No strenuous exercise or heavy lifting until follow up appointment. Physical Therapy: WBAT LLE No range of motion restrictions Use of assistive ambulatory device, wean as able Treatments Frequency: dry sterile dressing changes daily monitor incision for drainage elevate and ice the operative extremity staples to be removed at first [MASKED] clinic visit Followup Instructions: [MASKED]
[]
[ "F329", "E669", "F419", "K219", "J45909", "Z87891" ]
[ "M170: Bilateral primary osteoarthritis of knee", "F329: Major depressive disorder, single episode, unspecified", "E669: Obesity, unspecified", "Z6832: Body mass index [BMI] 32.0-32.9, adult", "F419: Anxiety disorder, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "J45909: Unspecified asthma, uncomplicated", "Z87891: Personal history of nicotine dependence", "D72829: Elevated white blood cell count, unspecified", "G8918: Other acute postprocedural pain", "R110: Nausea", "I9581: Postprocedural hypotension" ]
19,997,911
20,274,882
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Codeine Attending: ___. Chief Complaint: nausea, epigastric pain, & coffee ground emesis Major Surgical or Invasive Procedure: Endoscopic gastroduodenoscopy (___) History of Present Illness: ___ y.o woman with h/o cardiomyopathy, HTN, HLD, GERD/gastritis/hiatal hernia, and recent indirect inguinal hernia repair (___) who presented to the ED with one day of epigastric pain and coffee ground emesis iso several years of intermittent epigastric pain with self-induced emesis. A day prior to admission (___), the patient developed epigastric pain after consuming eggplant salad and crabmeat for lunch, which her husband also ate with no illness. She describes the pain as ___ "pressure," which she has had intermittently for the past few years, occasionally accompanied by diaphoresis, substernal burning pain, and left shoulder pain. The pain does not occur with exertion or worsen with activity. She usually induces vomiting (with resultant coffee ground emesis) with her finger, which typically relieves the pain. However, after inducing vomiting the afternoon of ___, she continued to have >10 emesis throughout the evening with persistent pain unresponsive to omeprazole. Due to her continued emesis, she presented to the ED. She reported passing gas and denied constipation (last BM ___, diarrhea, black stools, or bloody stools. She denied She denied fever, chills. sick contacts, recent travel, or recent NSAID, corticosteroid, EtOH, or tobacco use. She denied chest pain, palpitations, or shortness of breath. Past Medical History: PAST MEDICAL HISTORY: -Angina Pectoris -Osteoarthritis of the knees and spine. -Temporal arteritis/polymyalgia rheumatica. -Osteoporosis. -Hyperlipidemia. -Hypertension. -LBBB. -Multiple bowel movements. When she's constipated she will take MiraLAX and then have about six bowel movements a day -Erosive gastritis, GERD, hiatal hernia -Recurrent rectal prolapse PSH: -B/L knee replacement ___ -Vaginal hysterectomy, ___. -Excision of lipoma-upper back -Surgeries multiple for rectal prolapse -Colonoscopies ___ last polyps Social History: ___ Family History: Mother ___ MURDERED ___ Father ___ MURDERED ___ Physical Exam: ADMISSION PHYSICAL EXAM Vitals: 97.9 165/85 77 18 99%2L General: Alert, oriented, no acute distress HEENT: Sclerae anicteric, bilateral surgical defects in ___ (L > R), MMM, oropharynx clear Neck: supple, no LAD or thyromegaly Lungs: CTAB, no wheezes, rales, rhonchi CV: NRRR, Nl S1, S2, ___ holosystolic murmur loudest at left lower sternal border Abdomen: soft, mild tenderness with palpation of LUQ, 3 cm incision over RLQ with mild tenderness to palpation but no erythema non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis, trace edema bilaterally in lower extremities Neuro: CN3-12 intact, no focal deficits DISCHARGE PHYSICAL EXAM PHYSICAL EXAM: Vitals: T 98 141/54 96 2L ___ General: Alert, oriented, no acute distress HEENT: Sclerae anicteric, bilateral surgical defects in ___ (L > R), oropharynx clear, mucous membranes dry Neck: supple, no LAD or thyromegaly Lungs: CTAB, no wheezes, rales, rhonchi CV: NRRR, Nl S1, S2, ___ holosystolic murmur loudest at left lower sternal border Abdomen: soft, nondistended, nontender in upper quadrants, 3 cm incision over RLQ with mild tenderness to palpation but no erythema, drainage, or induration, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis, trace edema bilaterally in lower extremities Neuro: CN3-12 intact, no focal deficits Pertinent Results: ADMISSION LABS ___ 02:30AM BLOOD WBC-9.3 RBC-3.45* Hgb-9.3* Hct-29.2* MCV-85 MCH-27.0 MCHC-31.8* RDW-16.0* RDWSD-48.9* Plt ___ ___ 02:30AM BLOOD Neuts-90.7* Lymphs-5.7* Monos-2.8* Eos-0.1* Baso-0.2 Im ___ AbsNeut-8.43* AbsLymp-0.53* AbsMono-0.26 AbsEos-0.01* AbsBaso-0.02 ___ 02:30AM BLOOD ___ PTT-21.5* ___ ___ 02:30AM BLOOD Glucose-172* UreaN-37* Creat-1.3* Na-146* K-3.6 Cl-95* HCO3-38* AnGap-17 ___ 02:30AM BLOOD ALT-12 AST-17 LD(LDH)-207 AlkPhos-76 TotBili-0.3 ___ 02:30AM BLOOD Lipase-26 ___ 02:30AM BLOOD cTropnT-<0.01 Negative stool guaiac IMAGING Upper GI series (___): Mild tertiary contractions and gastroesophageal reflux. Brief holdup of 13-mm barium tablet at the gastroesophageal junction. ENDOSOCOPY EGD (___): Diffuse erythema and patulous esophagus. The erythema seemed most likely secondary to her recent vomiting. Over 1 liter of fluid was suctioned out of the stomach upon entrance into the stomach. There was a very large hiatal hernia and the stomach anatomy was all distorted. over an hour was spent attempting to find and intubate the pylorus but this could not be located. Otherwise normal EGD to stomach DISCHARGE LABS ___ 6.8RBC 2.91 Hgb 8.0 Hct26.3 MCV 90MCH 27.5MCHC 30.4RDW 15.8RDWSD 52.0Plt Ct ___ ___ Glucose 891 UreaN 38Creat 1.3 Na 142K 4.2Cl 99HCO3 34 AnGap ___ y.o woman with h/o cardiomyopathy, HTN/HLD, GERD/gastritis/hiatal hernia, and recent indirect inguinal hernia repair (___) presented with one day of epigastric pain and coffee ground emesis, concerning for upper GI bleed, likely d/t erosive esophagitis found on EGD. BRIEF HOSPTIAL COURSE ======================= ACTIVE ISSUES ------------- #Upper GI bleed secondary to erosive esophagitis: The patient presented with epigastric pain and coffee ground emesis iso years of epigastric pain with self-induced vomiting. She was found to be afebrile and hemodynamically stable with exam notable for mild tenderness with palpation of the epigastric area. Initial labs revealed a drop in H/H from her baseline chronic normocytic anemia with a normal WBC count, LFTs, amylase, and troponin. She was made NPO and started on IV pantoprazole. with her home aspirin and antihypertensives discontinued. An EGD revealed erosive esophagitis and gastric outlet obstruction. The patient was advanced to water with the head of the bed raised with no ensuing emesis. However, due to a ___ H/H (Hgb 9.3 to 7), she was transfused 1uRBC with stable post-transfusion H/H (Hgb 7.6 and 8.9). An upper GI series showed only slight gastric outlet obstruction with no focal lesions. Her presentation was thought to be consistent with an upper GI bleed due to erosive esophagitis. Her epigastric pain, nausea, and vomiting resolved, and her H/H remained stable at discharge. #Metabolic alkalosis with prerenal ___: At presentation, the patient had an elevated bicarbonate with decreased chloride, reflecting metabolic alkalosis from emesis. Her Cr was also elevated from baseline (1.3 from 1) with BUN/Cre >20, consistent with prerenal ___ from volume depletion. Given her history of cardiomyopathy, she was given gentle resuscitation when NPO. At time of discharge, her metabolic alkalosis had improved with Cr ___. #Hypoxic respiratory failure of unclear etiology: The patient had a new oxygen requirement (~97% on 2L) while hospitalized, with desaturations in the ___ with walking. As the patient was afebrile with clear pulmonary exam and essentially normal WBC (peak of 10.2), her hypoxia was thought to reflect atelectasis rather than aspiration pneumonia. CHRONIC ISSUES --------------- #Anemia: Patient's H/H returned to her baseline normocytic anemia by discharge. #CKD-Stable, with superimposed ___ and ___ Cr at discharge. #HTN- Patient discontinued amlodipine and ACEi due to risk of hypotension. She will resume these medications on discharge. #HL-Patient was continued on her home statin, which she will continue at discharge. #Insomnia-Patient's mirtazapine was held while NPO. She will resume this medication on discharge. TRANSITIONAL ISSUES ===================== [ ] Esophagitis: Patient with stabilized hematocrit, discharge Hgb 8. Please consider rechecking as outpatient. [ ] PPI: Patient to continue PPI, and f/u with outpatient GI # CODE STATUS: DNR/DNI # CONTACT: daughter ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amlodipine 5 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Mirtazapine 7.5 mg PO QHS 4. Omeprazole 20 mg PO DAILY 5. Align (bifidobacterium infantis) 4 mg oral DAILY 6. Atorvastatin 20 mg PO QPM 7. Lisinopril 20 mg PO DAILY 8. Vitamin D 1000 UNIT PO DAILY 9. Calcium Carbonate 750 mg PO QID:PRN gastric upset Discharge Medications: 1. Amlodipine 5 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 20 mg PO QPM 4. Calcium Carbonate 750 mg PO QID:PRN gastric upset 5. Mirtazapine 7.5 mg PO QHS 6. Vitamin D 1000 UNIT PO DAILY 7. Omeprazole 40 mg PO DAILY RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*0 8. Lisinopril 20 mg PO DAILY 9. Align (bifidobacterium infantis) 4 mg oral DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS ================== Upper gastrointestinal bleeding Erosive esophagiitis SECONDARY DIAGNOSES ===================== Hiatal hernia Gastroesophageal reflux disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear ___, ___ were admitted to ___ due to stomach pain, nausea, and vomiting blood, which was concerning for bleeding from your GI tract. ___ were started on a medication to block acid production in your stomach, and some of your home medications were temporarily discontinued while hospitalized, such as aspirin, due to the risk of bleeding. Your labs showed a drop in red blood cells in your blood, and ___ needed a blood transfusion to replace some of the lost blood. In order to identify the source of bleeding, ___ underwent an endoscopy looking at your esophagus and stomach. We were not able to look at your small intestine. This endoscopy showed irritation to your esophagus, which we think was caused by your hiatal hernia and causing yourself to vomit. ___ also underwent an upper GI series, which did not show ulcers in your small intestine and only showed very mild blockage of small intestine. Based on these results, we think that your bleeding was ultimately caused by the irritation in your esophagus. At discharge, your lab tests showed that your red blood cells had remained stable, suggesting that the bleeding had stopped. At home, ___ will be on a higher dose of omeprazole, which can help prevent bleeding from the GI tract and prevent pain in your stomach and esophagus. ___ will follow-up with your PCP. If ___ start to throw up blood again or feel lightheaded and weak, ___ should return to the ED. It was a pleasure taking care of ___. Best regards, Your ___ medicine team Followup Instructions: ___
[ "K311", "K2211", "N179", "E873", "K920", "I429", "M316", "N183", "D62", "J9811", "K210", "K449", "E860", "M353", "K5790", "I25119", "M479", "M810", "E785", "Z96653", "I447", "K2970", "K623", "Z86010", "Z87891", "R0902", "I129", "G4700", "Z66" ]
Allergies: Penicillins / Codeine Chief Complaint: nausea, epigastric pain, & coffee ground emesis Major Surgical or Invasive Procedure: Endoscopic gastroduodenoscopy ([MASKED]) History of Present Illness: [MASKED] y.o woman with h/o cardiomyopathy, HTN, HLD, GERD/gastritis/hiatal hernia, and recent indirect inguinal hernia repair ([MASKED]) who presented to the ED with one day of epigastric pain and coffee ground emesis iso several years of intermittent epigastric pain with self-induced emesis. A day prior to admission ([MASKED]), the patient developed epigastric pain after consuming eggplant salad and crabmeat for lunch, which her husband also ate with no illness. She describes the pain as [MASKED] "pressure," which she has had intermittently for the past few years, occasionally accompanied by diaphoresis, substernal burning pain, and left shoulder pain. The pain does not occur with exertion or worsen with activity. She usually induces vomiting (with resultant coffee ground emesis) with her finger, which typically relieves the pain. However, after inducing vomiting the afternoon of [MASKED], she continued to have >10 emesis throughout the evening with persistent pain unresponsive to omeprazole. Due to her continued emesis, she presented to the ED. She reported passing gas and denied constipation (last BM [MASKED], diarrhea, black stools, or bloody stools. She denied She denied fever, chills. sick contacts, recent travel, or recent NSAID, corticosteroid, EtOH, or tobacco use. She denied chest pain, palpitations, or shortness of breath. Past Medical History: PAST MEDICAL HISTORY: -Angina Pectoris -Osteoarthritis of the knees and spine. -Temporal arteritis/polymyalgia rheumatica. -Osteoporosis. -Hyperlipidemia. -Hypertension. -LBBB. -Multiple bowel movements. When she's constipated she will take MiraLAX and then have about six bowel movements a day -Erosive gastritis, GERD, hiatal hernia -Recurrent rectal prolapse PSH: -B/L knee replacement [MASKED] -Vaginal hysterectomy, [MASKED]. -Excision of lipoma-upper back -Surgeries multiple for rectal prolapse -Colonoscopies [MASKED] last polyps Social History: [MASKED] Family History: Mother [MASKED] MURDERED [MASKED] Father [MASKED] MURDERED [MASKED] Physical Exam: ADMISSION PHYSICAL EXAM Vitals: 97.9 165/85 77 18 99%2L General: Alert, oriented, no acute distress HEENT: Sclerae anicteric, bilateral surgical defects in [MASKED] (L > R), MMM, oropharynx clear Neck: supple, no LAD or thyromegaly Lungs: CTAB, no wheezes, rales, rhonchi CV: NRRR, Nl S1, S2, [MASKED] holosystolic murmur loudest at left lower sternal border Abdomen: soft, mild tenderness with palpation of LUQ, 3 cm incision over RLQ with mild tenderness to palpation but no erythema non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis, trace edema bilaterally in lower extremities Neuro: CN3-12 intact, no focal deficits DISCHARGE PHYSICAL EXAM PHYSICAL EXAM: Vitals: T 98 141/54 96 2L [MASKED] General: Alert, oriented, no acute distress HEENT: Sclerae anicteric, bilateral surgical defects in [MASKED] (L > R), oropharynx clear, mucous membranes dry Neck: supple, no LAD or thyromegaly Lungs: CTAB, no wheezes, rales, rhonchi CV: NRRR, Nl S1, S2, [MASKED] holosystolic murmur loudest at left lower sternal border Abdomen: soft, nondistended, nontender in upper quadrants, 3 cm incision over RLQ with mild tenderness to palpation but no erythema, drainage, or induration, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis, trace edema bilaterally in lower extremities Neuro: CN3-12 intact, no focal deficits Pertinent Results: ADMISSION LABS [MASKED] 02:30AM BLOOD WBC-9.3 RBC-3.45* Hgb-9.3* Hct-29.2* MCV-85 MCH-27.0 MCHC-31.8* RDW-16.0* RDWSD-48.9* Plt [MASKED] [MASKED] 02:30AM BLOOD Neuts-90.7* Lymphs-5.7* Monos-2.8* Eos-0.1* Baso-0.2 Im [MASKED] AbsNeut-8.43* AbsLymp-0.53* AbsMono-0.26 AbsEos-0.01* AbsBaso-0.02 [MASKED] 02:30AM BLOOD [MASKED] PTT-21.5* [MASKED] [MASKED] 02:30AM BLOOD Glucose-172* UreaN-37* Creat-1.3* Na-146* K-3.6 Cl-95* HCO3-38* AnGap-17 [MASKED] 02:30AM BLOOD ALT-12 AST-17 LD(LDH)-207 AlkPhos-76 TotBili-0.3 [MASKED] 02:30AM BLOOD Lipase-26 [MASKED] 02:30AM BLOOD cTropnT-<0.01 Negative stool guaiac IMAGING Upper GI series ([MASKED]): Mild tertiary contractions and gastroesophageal reflux. Brief holdup of 13-mm barium tablet at the gastroesophageal junction. ENDOSOCOPY EGD ([MASKED]): Diffuse erythema and patulous esophagus. The erythema seemed most likely secondary to her recent vomiting. Over 1 liter of fluid was suctioned out of the stomach upon entrance into the stomach. There was a very large hiatal hernia and the stomach anatomy was all distorted. over an hour was spent attempting to find and intubate the pylorus but this could not be located. Otherwise normal EGD to stomach DISCHARGE LABS [MASKED] 6.8RBC 2.91 Hgb 8.0 Hct26.3 MCV 90MCH 27.5MCHC 30.4RDW 15.8RDWSD 52.0Plt Ct [MASKED] [MASKED] Glucose 891 UreaN 38Creat 1.3 Na 142K 4.2Cl 99HCO3 34 AnGap [MASKED] y.o woman with h/o cardiomyopathy, HTN/HLD, GERD/gastritis/hiatal hernia, and recent indirect inguinal hernia repair ([MASKED]) presented with one day of epigastric pain and coffee ground emesis, concerning for upper GI bleed, likely d/t erosive esophagitis found on EGD. BRIEF HOSPTIAL COURSE ======================= ACTIVE ISSUES ------------- #Upper GI bleed secondary to erosive esophagitis: The patient presented with epigastric pain and coffee ground emesis iso years of epigastric pain with self-induced vomiting. She was found to be afebrile and hemodynamically stable with exam notable for mild tenderness with palpation of the epigastric area. Initial labs revealed a drop in H/H from her baseline chronic normocytic anemia with a normal WBC count, LFTs, amylase, and troponin. She was made NPO and started on IV pantoprazole. with her home aspirin and antihypertensives discontinued. An EGD revealed erosive esophagitis and gastric outlet obstruction. The patient was advanced to water with the head of the bed raised with no ensuing emesis. However, due to a [MASKED] H/H (Hgb 9.3 to 7), she was transfused 1uRBC with stable post-transfusion H/H (Hgb 7.6 and 8.9). An upper GI series showed only slight gastric outlet obstruction with no focal lesions. Her presentation was thought to be consistent with an upper GI bleed due to erosive esophagitis. Her epigastric pain, nausea, and vomiting resolved, and her H/H remained stable at discharge. #Metabolic alkalosis with prerenal [MASKED]: At presentation, the patient had an elevated bicarbonate with decreased chloride, reflecting metabolic alkalosis from emesis. Her Cr was also elevated from baseline (1.3 from 1) with BUN/Cre >20, consistent with prerenal [MASKED] from volume depletion. Given her history of cardiomyopathy, she was given gentle resuscitation when NPO. At time of discharge, her metabolic alkalosis had improved with Cr [MASKED]. #Hypoxic respiratory failure of unclear etiology: The patient had a new oxygen requirement (~97% on 2L) while hospitalized, with desaturations in the [MASKED] with walking. As the patient was afebrile with clear pulmonary exam and essentially normal WBC (peak of 10.2), her hypoxia was thought to reflect atelectasis rather than aspiration pneumonia. CHRONIC ISSUES --------------- #Anemia: Patient's H/H returned to her baseline normocytic anemia by discharge. #CKD-Stable, with superimposed [MASKED] and [MASKED] Cr at discharge. #HTN- Patient discontinued amlodipine and ACEi due to risk of hypotension. She will resume these medications on discharge. #HL-Patient was continued on her home statin, which she will continue at discharge. #Insomnia-Patient's mirtazapine was held while NPO. She will resume this medication on discharge. TRANSITIONAL ISSUES ===================== [ ] Esophagitis: Patient with stabilized hematocrit, discharge Hgb 8. Please consider rechecking as outpatient. [ ] PPI: Patient to continue PPI, and f/u with outpatient GI # CODE STATUS: DNR/DNI # CONTACT: daughter [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amlodipine 5 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Mirtazapine 7.5 mg PO QHS 4. Omeprazole 20 mg PO DAILY 5. Align (bifidobacterium infantis) 4 mg oral DAILY 6. Atorvastatin 20 mg PO QPM 7. Lisinopril 20 mg PO DAILY 8. Vitamin D 1000 UNIT PO DAILY 9. Calcium Carbonate 750 mg PO QID:PRN gastric upset Discharge Medications: 1. Amlodipine 5 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 20 mg PO QPM 4. Calcium Carbonate 750 mg PO QID:PRN gastric upset 5. Mirtazapine 7.5 mg PO QHS 6. Vitamin D 1000 UNIT PO DAILY 7. Omeprazole 40 mg PO DAILY RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*0 8. Lisinopril 20 mg PO DAILY 9. Align (bifidobacterium infantis) 4 mg oral DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS ================== Upper gastrointestinal bleeding Erosive esophagiitis SECONDARY DIAGNOSES ===================== Hiatal hernia Gastroesophageal reflux disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear [MASKED], [MASKED] were admitted to [MASKED] due to stomach pain, nausea, and vomiting blood, which was concerning for bleeding from your GI tract. [MASKED] were started on a medication to block acid production in your stomach, and some of your home medications were temporarily discontinued while hospitalized, such as aspirin, due to the risk of bleeding. Your labs showed a drop in red blood cells in your blood, and [MASKED] needed a blood transfusion to replace some of the lost blood. In order to identify the source of bleeding, [MASKED] underwent an endoscopy looking at your esophagus and stomach. We were not able to look at your small intestine. This endoscopy showed irritation to your esophagus, which we think was caused by your hiatal hernia and causing yourself to vomit. [MASKED] also underwent an upper GI series, which did not show ulcers in your small intestine and only showed very mild blockage of small intestine. Based on these results, we think that your bleeding was ultimately caused by the irritation in your esophagus. At discharge, your lab tests showed that your red blood cells had remained stable, suggesting that the bleeding had stopped. At home, [MASKED] will be on a higher dose of omeprazole, which can help prevent bleeding from the GI tract and prevent pain in your stomach and esophagus. [MASKED] will follow-up with your PCP. If [MASKED] start to throw up blood again or feel lightheaded and weak, [MASKED] should return to the ED. It was a pleasure taking care of [MASKED]. Best regards, Your [MASKED] medicine team Followup Instructions: [MASKED]
[]
[ "N179", "D62", "E785", "Z87891", "I129", "G4700", "Z66" ]
[ "K311: Adult hypertrophic pyloric stenosis", "K2211: Ulcer of esophagus with bleeding", "N179: Acute kidney failure, unspecified", "E873: Alkalosis", "K920: Hematemesis", "I429: Cardiomyopathy, unspecified", "M316: Other giant cell arteritis", "N183: Chronic kidney disease, stage 3 (moderate)", "D62: Acute posthemorrhagic anemia", "J9811: Atelectasis", "K210: Gastro-esophageal reflux disease with esophagitis", "K449: Diaphragmatic hernia without obstruction or gangrene", "E860: Dehydration", "M353: Polymyalgia rheumatica", "K5790: Diverticulosis of intestine, part unspecified, without perforation or abscess without bleeding", "I25119: Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris", "M479: Spondylosis, unspecified", "M810: Age-related osteoporosis without current pathological fracture", "E785: Hyperlipidemia, unspecified", "Z96653: Presence of artificial knee joint, bilateral", "I447: Left bundle-branch block, unspecified", "K2970: Gastritis, unspecified, without bleeding", "K623: Rectal prolapse", "Z86010: Personal history of colonic polyps", "Z87891: Personal history of nicotine dependence", "R0902: Hypoxemia", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "G4700: Insomnia, unspecified", "Z66: Do not resuscitate" ]
19,997,911
25,785,472
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Codeine Attending: ___ ___ Complaint: asymptomatic hyponatremia Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ with PMH of HTN, backpain, GERD who pw hyponatremia. Patient originally presented to emergency department 2 days ago for a mechanical fall (CT head and neck negative) at which time she was noted to have hyponatremia with sodium of 125. Patient was given IV fluids but repeat ___ was still low at 126. She then left the ED against medical advice due to long wait. For the last 2 days since that prior ED visit, she has been drinking ___ glasses of water per day. Of note, she was started on HCTZ for HTN on ___, which was stopped 2 days ago due to low ___. She also recently had her mirtazapine increased from 15 to 30 mg per day in ___. In clinic today with her PCP, her ___ was 122 and pt was somewhat confused with slower speech than usual so she was sent to ED today for eval. Today she denies fevers, chills, HA, lightheadedness, nausea, vomiting, chest pain, shortness of breath, focal neurologic deficits. Past Medical History: (per chart, confirmed with pt and updated): -Osteoarthritis of the knees and spine. -Temporal arteritis/polymyalgia rheumatica. -Osteoporosis. -Hyperlipidemia. -Hypertension. -LBBB. -Multiple bowel movements. When she's constipated she will take MiraLAX and then have about six bowel movements a day -Erosive gastritis, GERD, hiatal hernia PSH: -B/L knee replacement ___ -Vaginal hysterectomy, ___. -Excision of lipoma-upper back -Surgeries multiple for rectal prolapse -Colonoscopies ___ last polyps -Recurrent rectal prolapse Social History: ___ Family History: Mother and father died in the ___. No known medical problems. Physical Exam: ADMISSION PHYSICAL EXAM: VITALS: T 97.8, BP 183/63, HR 53, RR 18, O2 Sat: 95% RA GENERAL: Alert and interactive. In no acute distress. HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM. NECK: No cervical lymphadenopathy. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. ABDOMEN: Soft, non distended, non-tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES: No clubbing, cyanosis, or edema. Radial pulses 3+ bilaterally. SKIN: Warm. Cap refill <2s. No rashes. NEUROLOGIC: AOx3. Moving all 4 limbs spontaneously. DISCHARGE PHYSICAL EXAM: VITALS: 24 HR Data (last updated ___ @ 2201) Temp: 98.1 (Tm 98.1), BP: 147/62 (103-147/47-80), HR: 54 (43-71), RR: 18, O2 sat: 93%, O2 delivery: Ra GENERAL: pleasant lady lying in bed, NAD. Alert and interactive. In no acute distress. HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM. NECK: Supple, normal range of motion, JVP @ 6cm. CARDIAC: RRR, normal S1/S2, II/VI systolic murmur best heard at RUSB, no other r/g LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. ABDOMEN: Soft, non distended, non-tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES: No clubbing, cyanosis, or edema. Radial pulses 2+ bilaterally. SKIN: Warm. Cap refill <2s. No rashes. NEUROLOGIC: AOx3. Moving all 4 limbs spontaneously. Pertinent Results: ADMISSION LABS: ___ 02:00PM BLOOD WBC-9.1 RBC-3.52* Hgb-10.7* Hct-32.1* MCV-91 MCH-30.4 MCHC-33.3 RDW-13.4 RDWSD-45.1 Plt Ct-UNABLE TO ___ 02:00PM BLOOD Neuts-84.1* Lymphs-9.2* Monos-4.9* Eos-0.8* Baso-0.1 Im ___ AbsNeut-7.63* AbsLymp-0.83* AbsMono-0.44 AbsEos-0.07 AbsBaso-0.01 ___ 02:00PM BLOOD ___ PTT-28.8 ___ ___ 09:45AM BLOOD UreaN-20 Creat-0.9 ___ K-4.0 Cl-86* HCO3-26 AnGap-13 ___ 02:00PM BLOOD ALT-18 AST-24 AlkPhos-67 TotBili-0.5 ___ 02:00PM BLOOD Lipase-57 ___ 02:00PM BLOOD Albumin-3.9 Calcium-9.0 Phos-3.1 Mg-1.7 ___ 02:00PM BLOOD Osmolal-253* ___ 07:20PM BLOOD ___ DISCHARGE LABS: ___ 05:25AM BLOOD WBC-9.3 RBC-3.52* Hgb-11.0* Hct-33.5* MCV-95 MCH-31.3 MCHC-32.8 RDW-13.9 RDWSD-48.7* Plt Ct-UNABLE TO ___ 05:25AM BLOOD Glucose-106* UreaN-36* Creat-1.0 ___ K-4.7 Cl-97 HCO3-25 AnGap-13 ___ 05:25AM BLOOD Calcium-9.0 Phos-3.6 Mg-1.8 ___ 06:00AM BLOOD TSH-2.5 ___ 06:00AM BLOOD Cortsol-16.0 ___ 05:41PM BLOOD ___ ___ 09:43PM BLOOD ___ ___ 01:22AM BLOOD ___ ___ 05:45AM BLOOD ___ IMAGING: MICRO: ___ 2:44 pm URINE URINE CULTURE (Pending): Brief Hospital Course: Ms. ___ is a ___ with PMH of HTN, backpain, GERD who pw asymptomatic hyponatremia to 122 in setting of recent HCTZ use and increased PO free water intake, now off diuretic and on fluid restriction c/b rapid ___ correction but now at a safer level, most recently ___. TRANSITIONAL ISSUES =================== [] Please draw chem-10 on ___ to check sodium (DC sodium 132 on ___ ACUTE/ACTIVE ISSUES: ==================== # SIADH ___ mirtazapine Pt found to have serum ___ of 122 two days prior to admission. Pt had recently been started on HCTZ, which was stopped. She had also increased her free water PO intake (6 glasses per day). Her serum and urine studies were consistent with SIADH. Her SIADH was thought to be secondary to her Mirtazapine so this was held as well. There was some concern for overcorrection so she got one dose of DDAVP. Her sodiums were then trended carefully and she was discharged with the plan for repeat labs on ___, and PCP follow up on ___. # HTN Pt was started on ___ in ___ for HTN as above. HCTZ stopped CHRONIC/STABLE ISSUES: ====================== # GERD Continue 20mg omeprazole BID. # back pain Received Tylenol ___ TID PRN. # CODE: DNR/DNI confirmed with patient and HCP # ___ (HCP, daughter, ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 30 mg PO DAILY 2. Calcium Carbonate 750 mg PO BID 3. Mirtazapine 30 mg PO QHS 4. amLODIPine 5 mg PO HS 5. Atorvastatin 20 mg PO QPM 6. Ferrous Sulfate 325 mg PO 2X/WEEK (MO,FR) 7. Omeprazole 20 mg PO BID 8. Aspirin 81 mg PO DAILY 9. Vitamin D 1000 UNIT PO DAILY Discharge Medications: 1. amLODIPine 5 mg PO HS 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 20 mg PO QPM 4. Calcium Carbonate 750 mg PO BID 5. Ferrous Sulfate 325 mg PO 2X/WEEK (MO,FR) 6. Lisinopril 30 mg PO DAILY 7. Omeprazole 20 mg PO BID 8. Vitamin D 1000 UNIT PO DAILY 9.Outpatient Lab Work Please draw Chem-10 on ___ E22.2 PCP: ___., MD NP: ___ Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: syndrome of inappropriate antiduretic hormone secondary to mirtazapine Secondary diagnosis: hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure caring for you at ___ ___. WHY WERE YOU IN THE HOSPITAL? - You were admitted to the hospital for very low sodium levels in your blood. WHAT HAPPENED WHEN YOU WERE IN THE HOSPITAL? - The amount of liquids you were able to receive and drink was lowered - You received a medication to help control the amount of water in your blood - You received frequent blood draws to test the amount of sodium in your blood WHAT SHOULD YOU DO AFTER YOU LEAVE THE HOSPITAL? - Continue to take all your medicines as prescribed below. - Show up to your appointments as listed below. - Do not drink more than one (1) liter of fluids per day - It is important to keep track of the amount of liquids you are drinking at home to make sure that your sodium doesn't drop too low. - Salty soups, milk, protein shakes, and eating foods such as eggs are good to keep the amount of sodium in your blood safe - You will have your labs checked on ___ and you will have follow up with your primary care doctor after that We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___
[ "E222", "I5022", "I110", "T43025A", "K219", "Z96653", "M549", "Z66", "M810", "E7800", "F4320", "F329", "Y92531", "Z9181" ]
Allergies: Penicillins / Codeine [MASKED] Complaint: asymptomatic hyponatremia Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] with PMH of HTN, backpain, GERD who pw hyponatremia. Patient originally presented to emergency department 2 days ago for a mechanical fall (CT head and neck negative) at which time she was noted to have hyponatremia with sodium of 125. Patient was given IV fluids but repeat [MASKED] was still low at 126. She then left the ED against medical advice due to long wait. For the last 2 days since that prior ED visit, she has been drinking [MASKED] glasses of water per day. Of note, she was started on HCTZ for HTN on [MASKED], which was stopped 2 days ago due to low [MASKED]. She also recently had her mirtazapine increased from 15 to 30 mg per day in [MASKED]. In clinic today with her PCP, her [MASKED] was 122 and pt was somewhat confused with slower speech than usual so she was sent to ED today for eval. Today she denies fevers, chills, HA, lightheadedness, nausea, vomiting, chest pain, shortness of breath, focal neurologic deficits. Past Medical History: (per chart, confirmed with pt and updated): -Osteoarthritis of the knees and spine. -Temporal arteritis/polymyalgia rheumatica. -Osteoporosis. -Hyperlipidemia. -Hypertension. -LBBB. -Multiple bowel movements. When she's constipated she will take MiraLAX and then have about six bowel movements a day -Erosive gastritis, GERD, hiatal hernia PSH: -B/L knee replacement [MASKED] -Vaginal hysterectomy, [MASKED]. -Excision of lipoma-upper back -Surgeries multiple for rectal prolapse -Colonoscopies [MASKED] last polyps -Recurrent rectal prolapse Social History: [MASKED] Family History: Mother and father died in the [MASKED]. No known medical problems. Physical Exam: ADMISSION PHYSICAL EXAM: VITALS: T 97.8, BP 183/63, HR 53, RR 18, O2 Sat: 95% RA GENERAL: Alert and interactive. In no acute distress. HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM. NECK: No cervical lymphadenopathy. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. ABDOMEN: Soft, non distended, non-tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES: No clubbing, cyanosis, or edema. Radial pulses 3+ bilaterally. SKIN: Warm. Cap refill <2s. No rashes. NEUROLOGIC: AOx3. Moving all 4 limbs spontaneously. DISCHARGE PHYSICAL EXAM: VITALS: 24 HR Data (last updated [MASKED] @ 2201) Temp: 98.1 (Tm 98.1), BP: 147/62 (103-147/47-80), HR: 54 (43-71), RR: 18, O2 sat: 93%, O2 delivery: Ra GENERAL: pleasant lady lying in bed, NAD. Alert and interactive. In no acute distress. HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM. NECK: Supple, normal range of motion, JVP @ 6cm. CARDIAC: RRR, normal S1/S2, II/VI systolic murmur best heard at RUSB, no other r/g LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. ABDOMEN: Soft, non distended, non-tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES: No clubbing, cyanosis, or edema. Radial pulses 2+ bilaterally. SKIN: Warm. Cap refill <2s. No rashes. NEUROLOGIC: AOx3. Moving all 4 limbs spontaneously. Pertinent Results: ADMISSION LABS: [MASKED] 02:00PM BLOOD WBC-9.1 RBC-3.52* Hgb-10.7* Hct-32.1* MCV-91 MCH-30.4 MCHC-33.3 RDW-13.4 RDWSD-45.1 Plt Ct-UNABLE TO [MASKED] 02:00PM BLOOD Neuts-84.1* Lymphs-9.2* Monos-4.9* Eos-0.8* Baso-0.1 Im [MASKED] AbsNeut-7.63* AbsLymp-0.83* AbsMono-0.44 AbsEos-0.07 AbsBaso-0.01 [MASKED] 02:00PM BLOOD [MASKED] PTT-28.8 [MASKED] [MASKED] 09:45AM BLOOD UreaN-20 Creat-0.9 [MASKED] K-4.0 Cl-86* HCO3-26 AnGap-13 [MASKED] 02:00PM BLOOD ALT-18 AST-24 AlkPhos-67 TotBili-0.5 [MASKED] 02:00PM BLOOD Lipase-57 [MASKED] 02:00PM BLOOD Albumin-3.9 Calcium-9.0 Phos-3.1 Mg-1.7 [MASKED] 02:00PM BLOOD Osmolal-253* [MASKED] 07:20PM BLOOD [MASKED] DISCHARGE LABS: [MASKED] 05:25AM BLOOD WBC-9.3 RBC-3.52* Hgb-11.0* Hct-33.5* MCV-95 MCH-31.3 MCHC-32.8 RDW-13.9 RDWSD-48.7* Plt Ct-UNABLE TO [MASKED] 05:25AM BLOOD Glucose-106* UreaN-36* Creat-1.0 [MASKED] K-4.7 Cl-97 HCO3-25 AnGap-13 [MASKED] 05:25AM BLOOD Calcium-9.0 Phos-3.6 Mg-1.8 [MASKED] 06:00AM BLOOD TSH-2.5 [MASKED] 06:00AM BLOOD Cortsol-16.0 [MASKED] 05:41PM BLOOD [MASKED] [MASKED] 09:43PM BLOOD [MASKED] [MASKED] 01:22AM BLOOD [MASKED] [MASKED] 05:45AM BLOOD [MASKED] IMAGING: MICRO: [MASKED] 2:44 pm URINE URINE CULTURE (Pending): Brief Hospital Course: Ms. [MASKED] is a [MASKED] with PMH of HTN, backpain, GERD who pw asymptomatic hyponatremia to 122 in setting of recent HCTZ use and increased PO free water intake, now off diuretic and on fluid restriction c/b rapid [MASKED] correction but now at a safer level, most recently [MASKED]. TRANSITIONAL ISSUES =================== [] Please draw chem-10 on [MASKED] to check sodium (DC sodium 132 on [MASKED] ACUTE/ACTIVE ISSUES: ==================== # SIADH [MASKED] mirtazapine Pt found to have serum [MASKED] of 122 two days prior to admission. Pt had recently been started on HCTZ, which was stopped. She had also increased her free water PO intake (6 glasses per day). Her serum and urine studies were consistent with SIADH. Her SIADH was thought to be secondary to her Mirtazapine so this was held as well. There was some concern for overcorrection so she got one dose of DDAVP. Her sodiums were then trended carefully and she was discharged with the plan for repeat labs on [MASKED], and PCP follow up on [MASKED]. # HTN Pt was started on [MASKED] in [MASKED] for HTN as above. HCTZ stopped CHRONIC/STABLE ISSUES: ====================== # GERD Continue 20mg omeprazole BID. # back pain Received Tylenol [MASKED] TID PRN. # CODE: DNR/DNI confirmed with patient and HCP # [MASKED] (HCP, daughter, [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 30 mg PO DAILY 2. Calcium Carbonate 750 mg PO BID 3. Mirtazapine 30 mg PO QHS 4. amLODIPine 5 mg PO HS 5. Atorvastatin 20 mg PO QPM 6. Ferrous Sulfate 325 mg PO 2X/WEEK (MO,FR) 7. Omeprazole 20 mg PO BID 8. Aspirin 81 mg PO DAILY 9. Vitamin D 1000 UNIT PO DAILY Discharge Medications: 1. amLODIPine 5 mg PO HS 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 20 mg PO QPM 4. Calcium Carbonate 750 mg PO BID 5. Ferrous Sulfate 325 mg PO 2X/WEEK (MO,FR) 6. Lisinopril 30 mg PO DAILY 7. Omeprazole 20 mg PO BID 8. Vitamin D 1000 UNIT PO DAILY 9.Outpatient Lab Work Please draw Chem-10 on [MASKED] E22.2 PCP: [MASKED]., MD NP: [MASKED] Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: syndrome of inappropriate antiduretic hormone secondary to mirtazapine Secondary diagnosis: hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], It was a pleasure caring for you at [MASKED] [MASKED]. WHY WERE YOU IN THE HOSPITAL? - You were admitted to the hospital for very low sodium levels in your blood. WHAT HAPPENED WHEN YOU WERE IN THE HOSPITAL? - The amount of liquids you were able to receive and drink was lowered - You received a medication to help control the amount of water in your blood - You received frequent blood draws to test the amount of sodium in your blood WHAT SHOULD YOU DO AFTER YOU LEAVE THE HOSPITAL? - Continue to take all your medicines as prescribed below. - Show up to your appointments as listed below. - Do not drink more than one (1) liter of fluids per day - It is important to keep track of the amount of liquids you are drinking at home to make sure that your sodium doesn't drop too low. - Salty soups, milk, protein shakes, and eating foods such as eggs are good to keep the amount of sodium in your blood safe - You will have your labs checked on [MASKED] and you will have follow up with your primary care doctor after that We wish you the best! Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "I110", "K219", "Z66", "F329" ]
[ "E222: Syndrome of inappropriate secretion of antidiuretic hormone", "I5022: Chronic systolic (congestive) heart failure", "I110: Hypertensive heart disease with heart failure", "T43025A: Adverse effect of tetracyclic antidepressants, initial encounter", "K219: Gastro-esophageal reflux disease without esophagitis", "Z96653: Presence of artificial knee joint, bilateral", "M549: Dorsalgia, unspecified", "Z66: Do not resuscitate", "M810: Age-related osteoporosis without current pathological fracture", "E7800: Pure hypercholesterolemia, unspecified", "F4320: Adjustment disorder, unspecified", "F329: Major depressive disorder, single episode, unspecified", "Y92531: Health care provider office as the place of occurrence of the external cause", "Z9181: History of falling" ]
19,997,911
27,144,120
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Penicillins / Codeine Attending: ___. Chief Complaint: Coffee ground emesis Major Surgical or Invasive Procedure: ___ Laparascopic gastropexy, percutaneous gastrostomy (PEG) tube placement (Dr ___ History of Present Illness: Ms ___ is a pleasant ___ with hx cardiomyopathy, HTN, HLD, GERD/gastritis recent hx erosive esophagitis GIB (___) presenting with worsening abd pain and coffee ground emesis. When she presented in ___, she underwent EGD which showed esophagitis and was treated with PPI. On this occasion, pt states she had LUQ pain, nausea and coffee ground emesis x6. Her LUQ pain is chronic ___ yrs however had been getting worse recently, states improves with simethecone. She also endorses diaphoresis and weakness. No CP/SOB/dizziness. Of note, pt has been inducing vomiting previously as she feels that this makes her belly pain better. Prior to this admission she vomited spontaneously due to the pain. In the ED, initial vitals were: 97 80 152/62 16 96% RA. Exam was notable for LUQ tenderness. Labs were notable for sodium of 147, creatinine of 1.4, BUN 45, crit 32.5 (near ___ Guiac was negative. Pt was given dilaudid, Zofran, pantoprazole and IVF. GI was notified and agreed with admission. On the floor, she c/o ongoing ___ LUQ pain which is preventing her from sleeping. She has not had any further vomiting since arrival in the ED. Denies CP/SOB. + wt loss. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies diarrhea, constipation. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. 10 pt ros otherwise negative. Past Medical History: (per chart, confirmed with pt and updated): -Osteoarthritis of the knees and spine. -Temporal arteritis/polymyalgia rheumatica. -Osteoporosis. -Hyperlipidemia. -Hypertension. -LBBB. -Multiple bowel movements. When she's constipated she will take MiraLAX and then have about six bowel movements a day -Erosive gastritis, GERD, hiatal hernia PSH: -B/L knee replacement ___ -Vaginal hysterectomy, ___. -Excision of lipoma-upper back -Surgeries multiple for rectal prolapse -Colonoscopies ___ last polyps -Recurrent rectal prolapse Social History: ___ Family History: Mother and father died in the holocaust. No known medical problems. Physical Exam: ADMISSION EXAM: Vitals: 97.5 130/60 69 18 97% RA Constitutional: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: Supple CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Respiratory: Clear to auscultation bilaterally, no wheezes, rales, rhonchi GI: Soft, ttp diffusely, worse in LUQ, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, no CCE Neuro: aaox3 CNII-XII and strength grossly intact Skin: no rashes or lesions DISCHARGE PHYSICAL EXAM: Gen: NAD, A&Ox3 HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: Supple CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Respiratory: Clear to auscultation bilaterally, no wheezes, rales, rhonchi GI: soft, incisionally tender, nondistended; incisions c/d/I; PEG in the left upper quadrant is capped. Ext: Warm, well perfused, no CCE Pertinent Results: LABS: See below, prior labs reviewed in ___ Prior records and imaging reviewed by me MICRO: none STUDIES: EGD ___ Impression: Diffuse erythema and patulous esophagus. The erythema seemed most likely secondary to her recent vomiting. Over 1 liter of fluid was suctioned out of the stomach upon entrance into the stomach. There were a few streaks of hematin in the fluid but it was unclear if this was secondary to scope trauma from suctioning or prior bleeding. There were a few areas of mild erythema but again this could have been from the scope. There was a very large hiatal hernia and the stomach anatomy was all distorted. over an hour was spent attempting to find and intubate the pylorus but this could not be located. A regular scope was used and then a therapeutic scope was used for the increased stiffness but again the pylorus could not be identified and the scope kept looping. The procedure was then aborted. Otherwise normal EGD to stomach EKG: LBBB, unchanged from prior ___ 11:35PM PLT SMR-NORMAL PLT COUNT-235# ___ 10:02PM LACTATE-1.6 ___ 09:41PM GLUCOSE-153* UREA N-45* CREAT-1.4* SODIUM-147* POTASSIUM-3.5 CHLORIDE-100 TOTAL CO2-33* ANION GAP-18 ___ 09:41PM estGFR-Using this ___ 09:41PM ALT(SGPT)-13 AST(SGOT)-23 ALK PHOS-65 TOT BILI-0.3 ___ 09:41PM LIPASE-47 ___ 09:41PM ALBUMIN-4.5 ___ 09:41PM WBC-10.0# RBC-3.77* HGB-10.3* HCT-32.5* MCV-86 MCH-27.3 MCHC-31.7* RDW-16.6* RDWSD-51.2* ___ 09:41PM NEUTS-86.9* LYMPHS-8.1* MONOS-4.1* EOS-0.2* BASOS-0.1 IM ___ AbsNeut-8.71* AbsLymp-0.81* AbsMono-0.41 AbsEos-0.02* AbsBaso-0.01 ___ 09:41PM PLT SMR-UNABLE TO PLT COUNT-UNABLE TO ___ 09:41PM ___ PTT-27.8 ___ year old female with history of cardiomyopathy, HTN, HLD, GERD/gastritis recent history of erosive esophagitis GIB (___) presenting with worsening abdominal pain and coffee ground emesis concerning for recurrent upper GI bleed. CT abdomen showed organoaxial gastric volvulus. NGT was placed, and she was taken to the operating room on ___ for gastropexy and PEG placement. She tolerated the procedure well, was tolerating a regular diet, and her pain was well controlled on oral regimen. She was discharged to rehab on ___ with plan to follow up with Dr. ___ in 3 weeks. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amlodipine 5 mg PO DAILY 2. Atorvastatin 20 mg PO QPM 3. Calcium Carbonate 750 mg PO QID:PRN gastric upset 4. Mirtazapine 7.5 mg PO QHS 5. Vitamin D 1000 UNIT PO DAILY 6. Omeprazole 40 mg PO DAILY 7. Align (bifidobacterium infantis) 4 mg oral DAILY 8. Valsartan 80 mg PO DAILY Discharge Medications: 1. Align (bifidobacterium infantis) 4 mg oral DAILY 2. Amlodipine 5 mg PO DAILY 3. Atorvastatin 20 mg PO QPM 4. Calcium Carbonate 750 mg PO QID:PRN gastric upset 5. Mirtazapine 7.5 mg PO QHS 6. Omeprazole 40 mg PO DAILY 7. Valsartan 80 mg PO DAILY 8. Vitamin D 1000 UNIT PO DAILY 9. TraMADol 50 mg PO Q4H:PRN Severe pain Take as prescribed. Do not drive or drink alcohol. RX *tramadol 50 mg 1 tablet(s) by mouth every four (4) hours Disp #*42 Tablet Refills:*0 10. Docusate Sodium 100 mg PO BID Take with plenty of fluids for constipation. RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*20 Capsule Refills:*0 11. Acetaminophen 650 mg PO Q6H:PRN Pain DO not exceed 4000 mg in 24 hours Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Gastric volvulus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mrs. ___, ___ were admitted to the hospital for treatment of gastric volvulus, which required a surgery called laparascopic gastropexy and percutaneous gastrostomy (PEG) tube placement. ___ tolerated the procedure well, and are now ready to be discharged home to complete your recovery. Please follow these instructions to ensure timely recovery. DIET: ___ may resume regular diet without restrictions. Eat small frequent meals. Sit in chair for all meals. Remain sitting up for ___ minutes after all meals, do not lie down or eat prior to bedtime. If ___ develop symptoms of obstruction (nausea, vomiting), ___ may vent your PEG tube to release the pressure. Otherwise keep the tube clamped. ACTIVITY: Avoid heavy lifting for ___ weeks after surgery to ensure the integrity of your incisions, otherwise ___ may resume regular activity as before. ___ may drive and walk without restrictions. ___ may shower. Your incisions are covered with thin strips of tape called Sterristrips. They will fall off on their own, do not attempt to remove them as this may rip your stitches. Your stitches are dissolvable, they will disappear on their own and will not need to be removed. MEDICATIONS: ___ may resume your other regular medications as before. FOLLOW-UP: ___ will need to follow up with Dr. ___ in ___ weeks. Our office will call ___ to schedule an appointment. Thank ___ for letting us participate in your care! Good luck! Followup Instructions: ___
[ "K3189", "I429", "N179", "E870", "D62", "K922", "K449", "K219", "E785", "M810", "I447", "M1710", "M479", "I129", "N189", "G4700", "Z96653", "Z66", "Z86010", "Z87440", "M353" ]
Allergies: Penicillins / Codeine Chief Complaint: Coffee ground emesis Major Surgical or Invasive Procedure: [MASKED] Laparascopic gastropexy, percutaneous gastrostomy (PEG) tube placement (Dr [MASKED] History of Present Illness: Ms [MASKED] is a pleasant [MASKED] with hx cardiomyopathy, HTN, HLD, GERD/gastritis recent hx erosive esophagitis GIB ([MASKED]) presenting with worsening abd pain and coffee ground emesis. When she presented in [MASKED], she underwent EGD which showed esophagitis and was treated with PPI. On this occasion, pt states she had LUQ pain, nausea and coffee ground emesis x6. Her LUQ pain is chronic [MASKED] yrs however had been getting worse recently, states improves with simethecone. She also endorses diaphoresis and weakness. No CP/SOB/dizziness. Of note, pt has been inducing vomiting previously as she feels that this makes her belly pain better. Prior to this admission she vomited spontaneously due to the pain. In the ED, initial vitals were: 97 80 152/62 16 96% RA. Exam was notable for LUQ tenderness. Labs were notable for sodium of 147, creatinine of 1.4, BUN 45, crit 32.5 (near [MASKED] Guiac was negative. Pt was given dilaudid, Zofran, pantoprazole and IVF. GI was notified and agreed with admission. On the floor, she c/o ongoing [MASKED] LUQ pain which is preventing her from sleeping. She has not had any further vomiting since arrival in the ED. Denies CP/SOB. + wt loss. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies diarrhea, constipation. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. 10 pt ros otherwise negative. Past Medical History: (per chart, confirmed with pt and updated): -Osteoarthritis of the knees and spine. -Temporal arteritis/polymyalgia rheumatica. -Osteoporosis. -Hyperlipidemia. -Hypertension. -LBBB. -Multiple bowel movements. When she's constipated she will take MiraLAX and then have about six bowel movements a day -Erosive gastritis, GERD, hiatal hernia PSH: -B/L knee replacement [MASKED] -Vaginal hysterectomy, [MASKED]. -Excision of lipoma-upper back -Surgeries multiple for rectal prolapse -Colonoscopies [MASKED] last polyps -Recurrent rectal prolapse Social History: [MASKED] Family History: Mother and father died in the holocaust. No known medical problems. Physical Exam: ADMISSION EXAM: Vitals: 97.5 130/60 69 18 97% RA Constitutional: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: Supple CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Respiratory: Clear to auscultation bilaterally, no wheezes, rales, rhonchi GI: Soft, ttp diffusely, worse in LUQ, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, no CCE Neuro: aaox3 CNII-XII and strength grossly intact Skin: no rashes or lesions DISCHARGE PHYSICAL EXAM: Gen: NAD, A&Ox3 HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: Supple CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Respiratory: Clear to auscultation bilaterally, no wheezes, rales, rhonchi GI: soft, incisionally tender, nondistended; incisions c/d/I; PEG in the left upper quadrant is capped. Ext: Warm, well perfused, no CCE Pertinent Results: LABS: See below, prior labs reviewed in [MASKED] Prior records and imaging reviewed by me MICRO: none STUDIES: EGD [MASKED] Impression: Diffuse erythema and patulous esophagus. The erythema seemed most likely secondary to her recent vomiting. Over 1 liter of fluid was suctioned out of the stomach upon entrance into the stomach. There were a few streaks of hematin in the fluid but it was unclear if this was secondary to scope trauma from suctioning or prior bleeding. There were a few areas of mild erythema but again this could have been from the scope. There was a very large hiatal hernia and the stomach anatomy was all distorted. over an hour was spent attempting to find and intubate the pylorus but this could not be located. A regular scope was used and then a therapeutic scope was used for the increased stiffness but again the pylorus could not be identified and the scope kept looping. The procedure was then aborted. Otherwise normal EGD to stomach EKG: LBBB, unchanged from prior [MASKED] 11:35PM PLT SMR-NORMAL PLT COUNT-235# [MASKED] 10:02PM LACTATE-1.6 [MASKED] 09:41PM GLUCOSE-153* UREA N-45* CREAT-1.4* SODIUM-147* POTASSIUM-3.5 CHLORIDE-100 TOTAL CO2-33* ANION GAP-18 [MASKED] 09:41PM estGFR-Using this [MASKED] 09:41PM ALT(SGPT)-13 AST(SGOT)-23 ALK PHOS-65 TOT BILI-0.3 [MASKED] 09:41PM LIPASE-47 [MASKED] 09:41PM ALBUMIN-4.5 [MASKED] 09:41PM WBC-10.0# RBC-3.77* HGB-10.3* HCT-32.5* MCV-86 MCH-27.3 MCHC-31.7* RDW-16.6* RDWSD-51.2* [MASKED] 09:41PM NEUTS-86.9* LYMPHS-8.1* MONOS-4.1* EOS-0.2* BASOS-0.1 IM [MASKED] AbsNeut-8.71* AbsLymp-0.81* AbsMono-0.41 AbsEos-0.02* AbsBaso-0.01 [MASKED] 09:41PM PLT SMR-UNABLE TO PLT COUNT-UNABLE TO [MASKED] 09:41PM [MASKED] PTT-27.8 [MASKED] year old female with history of cardiomyopathy, HTN, HLD, GERD/gastritis recent history of erosive esophagitis GIB ([MASKED]) presenting with worsening abdominal pain and coffee ground emesis concerning for recurrent upper GI bleed. CT abdomen showed organoaxial gastric volvulus. NGT was placed, and she was taken to the operating room on [MASKED] for gastropexy and PEG placement. She tolerated the procedure well, was tolerating a regular diet, and her pain was well controlled on oral regimen. She was discharged to rehab on [MASKED] with plan to follow up with Dr. [MASKED] in 3 weeks. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amlodipine 5 mg PO DAILY 2. Atorvastatin 20 mg PO QPM 3. Calcium Carbonate 750 mg PO QID:PRN gastric upset 4. Mirtazapine 7.5 mg PO QHS 5. Vitamin D 1000 UNIT PO DAILY 6. Omeprazole 40 mg PO DAILY 7. Align (bifidobacterium infantis) 4 mg oral DAILY 8. Valsartan 80 mg PO DAILY Discharge Medications: 1. Align (bifidobacterium infantis) 4 mg oral DAILY 2. Amlodipine 5 mg PO DAILY 3. Atorvastatin 20 mg PO QPM 4. Calcium Carbonate 750 mg PO QID:PRN gastric upset 5. Mirtazapine 7.5 mg PO QHS 6. Omeprazole 40 mg PO DAILY 7. Valsartan 80 mg PO DAILY 8. Vitamin D 1000 UNIT PO DAILY 9. TraMADol 50 mg PO Q4H:PRN Severe pain Take as prescribed. Do not drive or drink alcohol. RX *tramadol 50 mg 1 tablet(s) by mouth every four (4) hours Disp #*42 Tablet Refills:*0 10. Docusate Sodium 100 mg PO BID Take with plenty of fluids for constipation. RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*20 Capsule Refills:*0 11. Acetaminophen 650 mg PO Q6H:PRN Pain DO not exceed 4000 mg in 24 hours Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Gastric volvulus 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 the hospital for treatment of gastric volvulus, which required a surgery called laparascopic gastropexy and percutaneous gastrostomy (PEG) tube placement. [MASKED] tolerated the procedure well, and are now ready to be discharged home to complete your recovery. Please follow these instructions to ensure timely recovery. DIET: [MASKED] may resume regular diet without restrictions. Eat small frequent meals. Sit in chair for all meals. Remain sitting up for [MASKED] minutes after all meals, do not lie down or eat prior to bedtime. If [MASKED] develop symptoms of obstruction (nausea, vomiting), [MASKED] may vent your PEG tube to release the pressure. Otherwise keep the tube clamped. ACTIVITY: Avoid heavy lifting for [MASKED] weeks after surgery to ensure the integrity of your incisions, otherwise [MASKED] may resume regular activity as before. [MASKED] may drive and walk without restrictions. [MASKED] may shower. Your incisions are covered with thin strips of tape called Sterristrips. They will fall off on their own, do not attempt to remove them as this may rip your stitches. Your stitches are dissolvable, they will disappear on their own and will not need to be removed. MEDICATIONS: [MASKED] may resume your other regular medications as before. FOLLOW-UP: [MASKED] will need to follow up with Dr. [MASKED] in [MASKED] weeks. Our office will call [MASKED] to schedule an appointment. Thank [MASKED] for letting us participate in your care! Good luck! Followup Instructions: [MASKED]
[]
[ "N179", "D62", "K219", "E785", "I129", "N189", "G4700", "Z66" ]
[ "K3189: Other diseases of stomach and duodenum", "I429: Cardiomyopathy, unspecified", "N179: Acute kidney failure, unspecified", "E870: Hyperosmolality and hypernatremia", "D62: Acute posthemorrhagic anemia", "K922: Gastrointestinal hemorrhage, unspecified", "K449: Diaphragmatic hernia without obstruction or gangrene", "K219: Gastro-esophageal reflux disease without esophagitis", "E785: Hyperlipidemia, unspecified", "M810: Age-related osteoporosis without current pathological fracture", "I447: Left bundle-branch block, unspecified", "M1710: Unilateral primary osteoarthritis, unspecified knee", "M479: Spondylosis, unspecified", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N189: Chronic kidney disease, unspecified", "G4700: Insomnia, unspecified", "Z96653: Presence of artificial knee joint, bilateral", "Z66: Do not resuscitate", "Z86010: Personal history of colonic polyps", "Z87440: Personal history of urinary (tract) infections", "M353: Polymyalgia rheumatica" ]
19,998,198
25,917,036
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: transfer for preeclampsia Major Surgical or Invasive Procedure: primary high transverse cesarean section History of Present Illness: ___ is a ___ G1 at 28 weeks and 2 days transferred from ___ with ___ w/o SF. She wad diagnosed with gestational hypertension at 27 weeks. She was seen for routine care on ___ and had a BP at 146/79 and labs were sent. Serum labs were wnl, although uric acid was 5.3, urine protein was 678. First dose of betamethasone administered at 1015 (___). Today she feels well. Denies HA, visual changes, RUQ pain and SOB. She reports that her swelling has gotten progressively worse, but denies calf tenderness or pain. She denies ctx, VB, LOF. Endorses active fetal movement. ROS: Denies fevers/chills or recent illness. Denies HA, vision changes. Denies chest pain/shortness of breath/palpitations. Denies abdominal pain. Denies recent falls or abdominal trauma. Denies any unusual foods/undercooked foods, nausea, vomiting, diarrhea. Past Medical History: PNC: - ___ ___ by LMP, c/w ___ trimester u/s - B+/Abs-/RPRNR/RI/HBsAg-/HIV-/GC-/CT-/GBS+ (urine) - Screening: FFS wnl, CF/FXS/SMA- - GLT 95 - Issues #Hypothyroidism: 75mcg levothyroxine; ___ trimester TSH: 2.8 #Mumps/Rubeola NI: [ ] postpartum vaccine #Vaginal bleeding ___ necrotic cervical polyp, resolved OBHx: - G1 GynHx: - denies abnormal Pap or cervical procedures - denies fibroids/endometriosis/cysts - denies STIs, including HSV PMH: obesity, anxiety, depression, ADD Surgical Hx: wisdom teeth extraction Social History: ___ Family History: denies family history of gynecologic cancers Physical Exam: On admission: Gen: A&O, comfortable CV: RRR PULM: CTAB Abd: soft, gravid, nontender Ext: no calf tenderness, +2 DTR bilateral patellar reflexes SVE: deferred Toco FHT 130/moderate variability/+accels/-decels Pertinent Results: ___ WBC-11.0 RBC-4.28 Hgb-11.8 Hct-35.7 MCV-83 Plt-216 ___ WBC-10.3 RBC-4.33 Hgb-12.3 Hct-36.3 MCV-84 Plt-238 ___ WBC-12.4 RBC-4.11 Hgb-11.5 Hct-33.9 MCV-83 Plt-148 ___ WBC-11.2 RBC-4.39 Hgb-12.1 Hct-35.8 MCV-82 Plt-151 ___ WBC-11.7 RBC-4.13 Hgb-11.5 Hct-34.2 MCV-83 Plt-110 ___ WBC-11.9 RBC-4.33 Hgb-12.1 Hct-35.3 MCV-82 Plt-108 ___ WBC-13.9 RBC-4.24 Hgb-12.1 Hct-35.0 MCV-83 Plt-113 ___ WBC-12.3 RBC-4.34 Hgb-12.3 Hct-37.0 MCV-85 Plt-96 ___ WBC-12.5 RBC-4.22 Hgb-11.8 Hct-34.6 MCV-82 Plt-92 ___ WBC-12.8 RBC-3.84 Hgb-10.9 Hct-32.2 MCV-84 Plt-99 ___ ___ PTT-26.0 ___ ___ ___ PTT-27.1 ___ ___ ___ PTT-25.4 ___ ___ ___ PTT-24.2 ___ ___ Glucose-151* UreaN-11 Creat-0.7 ___ Creat-0.6 ___ Glucose-97 UreaN-12 Creat-0.7 Na-134* K-5.0 Cl-105 HCO3-17* AnGap-12 ___ UreaN-11 Creat-0.6 ___ UreaN-12 Creat-0.6 ___ UreaN-14 Creat-0.6 ___ Creat-0.6 ___ UreaN-11 Creat-0.6 ___ 07:58PM BLOOD ALT-15 AST-11 LD(LDH)-159 TotBili-<0.2 ___ 04:56AM BLOOD ALT-16 AST-22 ___ 12:55AM BLOOD ALT-73* AST-71* ___ 05:54AM BLOOD ALT-87* AST-92* LD(___)-516* TotBili-0.3 ___ 04:27PM BLOOD ALT-89* AST-63* LD(___)-275* TotBili-0.3 ___ 05:17AM BLOOD ALT-79* AST-44* LD(___)-289* TotBili-0.2 ___ 11:15AM BLOOD ALT-74* AST-36 LD(___)-273* TotBili-0.2 ___ 09:52PM BLOOD ALT-64* AST-30 TotBili-0.3 ___ 05:22AM BLOOD ALT-59* AST-25 LD(LDH)-251* ___ 10:40AM BLOOD ALT-57* AST-30 LD(LDH)-325* ___ 09:12PM BLOOD ALT-53* AST-30 ___ 07:58PM BLOOD Hapto-136 ___ 05:54AM BLOOD Hapto-78 ___ 04:27PM BLOOD Hapto-69 ___ 11:10PM BLOOD Hapto-55 ___ 11:15AM BLOOD Hapto-57 ___ 05:22AM BLOOD Hapto-77 ___ 12:09PM BLOOD ___ pO2-18* pCO2-44 pH-7.26* calTCO2-21 Base XS--8 Comment-CORD VEIN Brief Hospital Course: ___ G1 transferred from ___ at 28w2d with preeclampsia. On admission, she had mild range blood pressures and normal labs. Fetal testing was reassuring. By HD#2, she was started on po Nifedipine for severe range blood pressures, which was uptitrated to Nifedipine 60mg daily on HD#2. Her 24 hour urine was positive with 678mg of protein. She was made betamethasone complete on ___. She remained stable until 29w0d when she again developed severe range blood pressures, epigastric pain, and a transaminitis. She was transferred to labor and delivery for induction due to preeclampsia with severe features. She was started on Magnesium for seizure prophylaxis and her induction was begun with cytotec followed by Pitocin. She progressed to 4cm, however, developed a Category 2 tracing remove from delivery. Delivery by cesarean section was recommended. She underwent a primary high transverse cesarean section and delivered (at 29w2d) a liveborn female weighing 1050 grams with Apgars of 5 and 9. NICU staff was present for delivery. Please see operative report for delivery. Her postoperative course was uncomplicated. Her pain was well-controlled with an epidural for 24 hours after her procedure and she was transitioned to oral medications without issue. She received magnesium for 24 hours post delivery. She was continued on nifedipine 60mg qAM/30mg qPM and her blood pressures remained within goal. By postoperative day 4, she was meeting all milestones and her blood pressures were well controlled. She was discharged in stable condition with outpatient follow up scheduled. Medications on Admission: PNV, levothyroxine 75mcg Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever RX *acetaminophen 650 mg 1 tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills:*3 2. Citalopram 10 mg PO DAILY RX *citalopram [Celexa] 10 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*3 3. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*30 Capsule Refills:*3 4. Ibuprofen 600 mg PO Q6H:PRN Pain - Moderate RX *ibuprofen [IBU] 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills:*3 5. NIFEdipine (Extended Release) 60 mg PO QAM RX *nifedipine 60 mg 1 tablet(s) by mouth daily in the morning Disp #*30 Tablet Refills:*0 6. NIFEdipine (Extended Release) 30 mg PO QPM RX *nifedipine 30 mg 1 tablet(s) by mouth daily at night Disp #*30 Tablet Refills:*0 7. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Severe RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*25 Capsule Refills:*0 8. Levothyroxine Sodium 75 mcg PO DAILY Discharge Disposition: Home Discharge Diagnosis: cesarean delivery severe pre-eclampsia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Nothing in the vagina for 6 weeks (No sex, douching, tampons) No heavy lifting for 6 weeks Do not drive while taking narcotics (i.e. Dilaudid, Percocet) Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs Do not take more than 2400mg ibuprofen in 24 hrs Please call the on-call doctor at ___ if you develop shortness of breath, dizziness, palpitations, fever of 100.4 or above, abdominal pain, increased redness or drainage from your incision, nausea/vomiting, heavy vaginal bleeding, or any other concerns. You should continue to monitor your blood pressure at home and take medications as prescribed. If the systolic blood pressure (top number) is more than 150 or the diastolic blood pressure (bottom number) is more than 100, please call your doctor. If the systolic blood pressure is less than 110 or the diastolic blood pressure is less than 60, please don't take the medication and call your doctor. Followup Instructions: ___
[ "O1424", "O76", "O99824", "O99214", "O99284", "E039", "O99344", "F419", "Z370", "Z3A28" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: transfer for preeclampsia Major Surgical or Invasive Procedure: primary high transverse cesarean section History of Present Illness: [MASKED] is a [MASKED] G1 at 28 weeks and 2 days transferred from [MASKED] with [MASKED] w/o SF. She wad diagnosed with gestational hypertension at 27 weeks. She was seen for routine care on [MASKED] and had a BP at 146/79 and labs were sent. Serum labs were wnl, although uric acid was 5.3, urine protein was 678. First dose of betamethasone administered at 1015 ([MASKED]). Today she feels well. Denies HA, visual changes, RUQ pain and SOB. She reports that her swelling has gotten progressively worse, but denies calf tenderness or pain. She denies ctx, VB, LOF. Endorses active fetal movement. ROS: Denies fevers/chills or recent illness. Denies HA, vision changes. Denies chest pain/shortness of breath/palpitations. Denies abdominal pain. Denies recent falls or abdominal trauma. Denies any unusual foods/undercooked foods, nausea, vomiting, diarrhea. Past Medical History: PNC: - [MASKED] [MASKED] by LMP, c/w [MASKED] trimester u/s - B+/Abs-/RPRNR/RI/HBsAg-/HIV-/GC-/CT-/GBS+ (urine) - Screening: FFS wnl, CF/FXS/SMA- - GLT 95 - Issues #Hypothyroidism: 75mcg levothyroxine; [MASKED] trimester TSH: 2.8 #Mumps/Rubeola NI: [ ] postpartum vaccine #Vaginal bleeding [MASKED] necrotic cervical polyp, resolved OBHx: - G1 GynHx: - denies abnormal Pap or cervical procedures - denies fibroids/endometriosis/cysts - denies STIs, including HSV PMH: obesity, anxiety, depression, ADD Surgical Hx: wisdom teeth extraction Social History: [MASKED] Family History: denies family history of gynecologic cancers Physical Exam: On admission: Gen: A&O, comfortable CV: RRR PULM: CTAB Abd: soft, gravid, nontender Ext: no calf tenderness, +2 DTR bilateral patellar reflexes SVE: deferred Toco FHT 130/moderate variability/+accels/-decels Pertinent Results: [MASKED] WBC-11.0 RBC-4.28 Hgb-11.8 Hct-35.7 MCV-83 Plt-216 [MASKED] WBC-10.3 RBC-4.33 Hgb-12.3 Hct-36.3 MCV-84 Plt-238 [MASKED] WBC-12.4 RBC-4.11 Hgb-11.5 Hct-33.9 MCV-83 Plt-148 [MASKED] WBC-11.2 RBC-4.39 Hgb-12.1 Hct-35.8 MCV-82 Plt-151 [MASKED] WBC-11.7 RBC-4.13 Hgb-11.5 Hct-34.2 MCV-83 Plt-110 [MASKED] WBC-11.9 RBC-4.33 Hgb-12.1 Hct-35.3 MCV-82 Plt-108 [MASKED] WBC-13.9 RBC-4.24 Hgb-12.1 Hct-35.0 MCV-83 Plt-113 [MASKED] WBC-12.3 RBC-4.34 Hgb-12.3 Hct-37.0 MCV-85 Plt-96 [MASKED] WBC-12.5 RBC-4.22 Hgb-11.8 Hct-34.6 MCV-82 Plt-92 [MASKED] WBC-12.8 RBC-3.84 Hgb-10.9 Hct-32.2 MCV-84 Plt-99 [MASKED] [MASKED] PTT-26.0 [MASKED] [MASKED] [MASKED] PTT-27.1 [MASKED] [MASKED] [MASKED] PTT-25.4 [MASKED] [MASKED] [MASKED] PTT-24.2 [MASKED] [MASKED] Glucose-151* UreaN-11 Creat-0.7 [MASKED] Creat-0.6 [MASKED] Glucose-97 UreaN-12 Creat-0.7 Na-134* K-5.0 Cl-105 HCO3-17* AnGap-12 [MASKED] UreaN-11 Creat-0.6 [MASKED] UreaN-12 Creat-0.6 [MASKED] UreaN-14 Creat-0.6 [MASKED] Creat-0.6 [MASKED] UreaN-11 Creat-0.6 [MASKED] 07:58PM BLOOD ALT-15 AST-11 LD(LDH)-159 TotBili-<0.2 [MASKED] 04:56AM BLOOD ALT-16 AST-22 [MASKED] 12:55AM BLOOD ALT-73* AST-71* [MASKED] 05:54AM BLOOD ALT-87* AST-92* LD([MASKED])-516* TotBili-0.3 [MASKED] 04:27PM BLOOD ALT-89* AST-63* LD([MASKED])-275* TotBili-0.3 [MASKED] 05:17AM BLOOD ALT-79* AST-44* LD([MASKED])-289* TotBili-0.2 [MASKED] 11:15AM BLOOD ALT-74* AST-36 LD([MASKED])-273* TotBili-0.2 [MASKED] 09:52PM BLOOD ALT-64* AST-30 TotBili-0.3 [MASKED] 05:22AM BLOOD ALT-59* AST-25 LD(LDH)-251* [MASKED] 10:40AM BLOOD ALT-57* AST-30 LD(LDH)-325* [MASKED] 09:12PM BLOOD ALT-53* AST-30 [MASKED] 07:58PM BLOOD Hapto-136 [MASKED] 05:54AM BLOOD Hapto-78 [MASKED] 04:27PM BLOOD Hapto-69 [MASKED] 11:10PM BLOOD Hapto-55 [MASKED] 11:15AM BLOOD Hapto-57 [MASKED] 05:22AM BLOOD Hapto-77 [MASKED] 12:09PM BLOOD [MASKED] pO2-18* pCO2-44 pH-7.26* calTCO2-21 Base XS--8 Comment-CORD VEIN Brief Hospital Course: [MASKED] G1 transferred from [MASKED] at 28w2d with preeclampsia. On admission, she had mild range blood pressures and normal labs. Fetal testing was reassuring. By HD#2, she was started on po Nifedipine for severe range blood pressures, which was uptitrated to Nifedipine 60mg daily on HD#2. Her 24 hour urine was positive with 678mg of protein. She was made betamethasone complete on [MASKED]. She remained stable until 29w0d when she again developed severe range blood pressures, epigastric pain, and a transaminitis. She was transferred to labor and delivery for induction due to preeclampsia with severe features. She was started on Magnesium for seizure prophylaxis and her induction was begun with cytotec followed by Pitocin. She progressed to 4cm, however, developed a Category 2 tracing remove from delivery. Delivery by cesarean section was recommended. She underwent a primary high transverse cesarean section and delivered (at 29w2d) a liveborn female weighing 1050 grams with Apgars of 5 and 9. NICU staff was present for delivery. Please see operative report for delivery. Her postoperative course was uncomplicated. Her pain was well-controlled with an epidural for 24 hours after her procedure and she was transitioned to oral medications without issue. She received magnesium for 24 hours post delivery. She was continued on nifedipine 60mg qAM/30mg qPM and her blood pressures remained within goal. By postoperative day 4, she was meeting all milestones and her blood pressures were well controlled. She was discharged in stable condition with outpatient follow up scheduled. Medications on Admission: PNV, levothyroxine 75mcg Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever RX *acetaminophen 650 mg 1 tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills:*3 2. Citalopram 10 mg PO DAILY RX *citalopram [Celexa] 10 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*3 3. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*30 Capsule Refills:*3 4. Ibuprofen 600 mg PO Q6H:PRN Pain - Moderate RX *ibuprofen [IBU] 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills:*3 5. NIFEdipine (Extended Release) 60 mg PO QAM RX *nifedipine 60 mg 1 tablet(s) by mouth daily in the morning Disp #*30 Tablet Refills:*0 6. NIFEdipine (Extended Release) 30 mg PO QPM RX *nifedipine 30 mg 1 tablet(s) by mouth daily at night Disp #*30 Tablet Refills:*0 7. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain - Severe RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*25 Capsule Refills:*0 8. Levothyroxine Sodium 75 mcg PO DAILY Discharge Disposition: Home Discharge Diagnosis: cesarean delivery severe pre-eclampsia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Nothing in the vagina for 6 weeks (No sex, douching, tampons) No heavy lifting for 6 weeks Do not drive while taking narcotics (i.e. Dilaudid, Percocet) Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs Do not take more than 2400mg ibuprofen in 24 hrs Please call the on-call doctor at [MASKED] if you develop shortness of breath, dizziness, palpitations, fever of 100.4 or above, abdominal pain, increased redness or drainage from your incision, nausea/vomiting, heavy vaginal bleeding, or any other concerns. You should continue to monitor your blood pressure at home and take medications as prescribed. If the systolic blood pressure (top number) is more than 150 or the diastolic blood pressure (bottom number) is more than 100, please call your doctor. If the systolic blood pressure is less than 110 or the diastolic blood pressure is less than 60, please don't take the medication and call your doctor. Followup Instructions: [MASKED]
[]
[ "E039", "F419" ]
[ "O1424: HELLP syndrome, complicating childbirth", "O76: Abnormality in fetal heart rate and rhythm complicating labor and delivery", "O99824: Streptococcus B carrier state complicating childbirth", "O99214: Obesity complicating childbirth", "O99284: Endocrine, nutritional and metabolic diseases complicating childbirth", "E039: Hypothyroidism, unspecified", "O99344: Other mental disorders complicating childbirth", "F419: Anxiety disorder, unspecified", "Z370: Single live birth", "Z3A28: 28 weeks gestation of pregnancy" ]
19,999,043
21,756,272
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: incomplete abortion Major Surgical or Invasive Procedure: none Physical Exam: Discharge physical exam Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, appropriately tender, no rebound/guarding Ext: no TTP Pertinent Results: ___ 06:02PM WBC-7.9 RBC-4.39 HGB-13.0 HCT-37.3 MCV-85 MCH-29.6 MCHC-34.9 RDW-11.9 RDWSD-36.4 ___ 06:02PM PLT COUNT-273 Brief Hospital Course: On ___, Ms. ___ was admitted to the gynecology service for an incomplete abortion at 6 weeks gestation. She was given misoprostol and monitored overnight. Her vital signs and CBC were normal. She was given Doxycycline for infection prophylaxis. She was placed on a regular diet, and was kept NPO after midnight on ___ for possible ultrasound-guided D&C in the operative room. She was given oral acetaminophen and oxycodone for pain. She passed some blood and tissue vaginally overnight, which was sent to pathology for further analysis. On hospital day 1, her HCG was 4394. Ultrasound showed: "The uterus is anteverted and measures 7 x 3 x 4.5 cm cm. The endometrial cavity demonstrates heterogeneity and debris with internal color Doppler vascularity seen at the corpus, particularly at the fundus. The cervical canal is open and demonstrates heterogeneous contents without internal vascularity. The findings are compatible with expulsion of retained products of conception, vascularized at the corpus and either blood products or devascularized retained products of conception in the endocervical canal. The ovaries are normal. There is no free fluid. IMPRESSION: Prolapsing retained products of conception with vascularity seen within the corpus and either blood clots or devascularized products of conception in the cervical canal." She continued to improve clinically with mild vaginal bleeding and normal vital signs. She was then discharged to home in stable condition with outpatient follow-up as scheduled, and plan to repeat HCG in 4 days, and trend weekly until value is zero. Medications on Admission: citalopram 40mg, levothyroxine 25mcg, zolpidem 10mg Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild Do not exceed 4,000mg in 24 hours RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*30 Tablet Refills:*0 2. Docusate Sodium 100 mg PO BID:PRN constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily Disp #*30 Capsule Refills:*2 3. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild Take with food or milk RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*30 Tablet Refills:*0 4. Citalopram 40 mg PO DAILY 5. Levothyroxine Sodium 25 mcg PO DAILY 6. LORazepam 1 mg PO BID 7. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia Discharge Disposition: Home Discharge Diagnosis: incomplete abortion 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. 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. 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: ___
[ "O031", "O99281", "E039", "O99341", "F418", "O09811" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: incomplete abortion Major Surgical or Invasive Procedure: none Physical Exam: Discharge physical exam Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, appropriately tender, no rebound/guarding Ext: no TTP Pertinent Results: [MASKED] 06:02PM WBC-7.9 RBC-4.39 HGB-13.0 HCT-37.3 MCV-85 MCH-29.6 MCHC-34.9 RDW-11.9 RDWSD-36.4 [MASKED] 06:02PM PLT COUNT-273 Brief Hospital Course: On [MASKED], Ms. [MASKED] was admitted to the gynecology service for an incomplete abortion at 6 weeks gestation. She was given misoprostol and monitored overnight. Her vital signs and CBC were normal. She was given Doxycycline for infection prophylaxis. She was placed on a regular diet, and was kept NPO after midnight on [MASKED] for possible ultrasound-guided D&C in the operative room. She was given oral acetaminophen and oxycodone for pain. She passed some blood and tissue vaginally overnight, which was sent to pathology for further analysis. On hospital day 1, her HCG was 4394. Ultrasound showed: "The uterus is anteverted and measures 7 x 3 x 4.5 cm cm. The endometrial cavity demonstrates heterogeneity and debris with internal color Doppler vascularity seen at the corpus, particularly at the fundus. The cervical canal is open and demonstrates heterogeneous contents without internal vascularity. The findings are compatible with expulsion of retained products of conception, vascularized at the corpus and either blood products or devascularized retained products of conception in the endocervical canal. The ovaries are normal. There is no free fluid. IMPRESSION: Prolapsing retained products of conception with vascularity seen within the corpus and either blood clots or devascularized products of conception in the cervical canal." She continued to improve clinically with mild vaginal bleeding and normal vital signs. She was then discharged to home in stable condition with outpatient follow-up as scheduled, and plan to repeat HCG in 4 days, and trend weekly until value is zero. Medications on Admission: citalopram 40mg, levothyroxine 25mcg, zolpidem 10mg Discharge Medications: 1. Acetaminophen [MASKED] mg PO Q6H:PRN Pain - Mild Do not exceed 4,000mg in 24 hours RX *acetaminophen 500 mg [MASKED] tablet(s) by mouth every 6 hours Disp #*30 Tablet Refills:*0 2. Docusate Sodium 100 mg PO BID:PRN constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily Disp #*30 Capsule Refills:*2 3. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild Take with food or milk RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*30 Tablet Refills:*0 4. Citalopram 40 mg PO DAILY 5. Levothyroxine Sodium 25 mcg PO DAILY 6. LORazepam 1 mg PO BID 7. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia Discharge Disposition: Home Discharge Diagnosis: incomplete abortion 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. 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. 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]
[]
[ "E039" ]
[ "O031: Delayed or excessive hemorrhage following incomplete spontaneous abortion", "O99281: Endocrine, nutritional and metabolic diseases complicating pregnancy, first trimester", "E039: Hypothyroidism, unspecified", "O99341: Other mental disorders complicating pregnancy, first trimester", "F418: Other specified anxiety disorders", "O09811: Supervision of pregnancy resulting from assisted reproductive technology, first trimester" ]
19,999,043
23,037,011
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: acute situational anxiety related to pregnancy Major Surgical or Invasive Procedure: Dilation and evacuation Physical Exam: Discharge physical exam Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, appropriately tender, no rebound/guarding, incision c/d/i Ext: no TTP Pertinent Results: ___ 09:45AM WBC-31.2* RBC-2.82* HGB-8.8* HCT-24.7* MCV-88 MCH-31.2 MCHC-35.6 RDW-13.6 RDWSD-43.3 ___ 09:45AM PLT COUNT-159 ___ 09:45AM ___ PTT-26.2 ___ ___ 09:45AM ___ 09:02AM HGB-8.1* calcHCT-24 Brief Hospital Course: On ___, Ms. ___ was admitted to the gynecology service after undergoing dilation and evacuation, which was complicated by a 2L blood loss due to prolonged surgical time and twin gestation. Please see the operative report for full details. Immediately post-op, her pain was controlled with IV dilaudid/toradol. She had symptoms of dizziness and fatigue, and found to have a hematocrit nadir at 20.2. She was given a total of 4 units of packed red blood cells during her hospital admission, with symptomatic improvement. On post-operative day 1, her diet was advanced without difficulty and she was transitioned to acetaminophen/ibuprofen/oxycodone (pain meds). 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: levothyroxine, aspirin 81mg, PNV Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild Do not take more than 4000mg in 24 hours. RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills:*1 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily Disp #*60 Capsule Refills:*1 3. Ibuprofen 600 mg PO Q6H take with food. RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills:*1 4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate Do not drink alcohol or drive while taking this medication. RX *oxycodone 5 mg ___ capsule(s) by mouth every 4 hours Disp #*15 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Acute situational anxiety related to pregnancy 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. 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: ___
[ "O0489", "D62", "I959", "N9961", "O30042", "O09522", "R000", "O09812", "Z3A20", "O359XX2", "Y92234" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: acute situational anxiety related to pregnancy Major Surgical or Invasive Procedure: Dilation and evacuation Physical Exam: Discharge physical exam Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, appropriately tender, no rebound/guarding, incision c/d/i Ext: no TTP Pertinent Results: [MASKED] 09:45AM WBC-31.2* RBC-2.82* HGB-8.8* HCT-24.7* MCV-88 MCH-31.2 MCHC-35.6 RDW-13.6 RDWSD-43.3 [MASKED] 09:45AM PLT COUNT-159 [MASKED] 09:45AM [MASKED] PTT-26.2 [MASKED] [MASKED] 09:45AM [MASKED] 09:02AM HGB-8.1* calcHCT-24 Brief Hospital Course: On [MASKED], Ms. [MASKED] was admitted to the gynecology service after undergoing dilation and evacuation, which was complicated by a 2L blood loss due to prolonged surgical time and twin gestation. Please see the operative report for full details. Immediately post-op, her pain was controlled with IV dilaudid/toradol. She had symptoms of dizziness and fatigue, and found to have a hematocrit nadir at 20.2. She was given a total of 4 units of packed red blood cells during her hospital admission, with symptomatic improvement. On post-operative day 1, her diet was advanced without difficulty and she was transitioned to acetaminophen/ibuprofen/oxycodone (pain meds). 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: levothyroxine, aspirin 81mg, PNV Discharge Medications: 1. Acetaminophen [MASKED] mg PO Q6H:PRN Pain - Mild Do not take more than 4000mg in 24 hours. RX *acetaminophen 500 mg [MASKED] tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills:*1 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily Disp #*60 Capsule Refills:*1 3. Ibuprofen 600 mg PO Q6H take with food. RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills:*1 4. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain - Moderate Do not drink alcohol or drive while taking this medication. RX *oxycodone 5 mg [MASKED] capsule(s) by mouth every 4 hours Disp #*15 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Acute situational anxiety related to pregnancy 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. 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]
[]
[ "D62" ]
[ "O0489: (Induced) termination of pregnancy with other complications", "D62: Acute posthemorrhagic anemia", "I959: Hypotension, unspecified", "N9961: Intraoperative hemorrhage and hematoma of a genitourinary system organ or structure complicating a genitourinary system procedure", "O30042: Twin pregnancy, dichorionic/diamniotic, second trimester", "O09522: Supervision of elderly multigravida, second trimester", "R000: Tachycardia, unspecified", "O09812: Supervision of pregnancy resulting from assisted reproductive technology, second trimester", "Z3A20: 20 weeks gestation of pregnancy", "O359XX2: Maternal care for (suspected) fetal abnormality and damage, unspecified, fetus 2", "Y92234: Operating room of hospital as the place of occurrence of the external cause" ]
19,999,043
24,799,384
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: vaginal bleeding Major Surgical or Invasive Procedure: dilation and curettage History of Present Illness: ___ yo ___ s/p D&E ___ presents with heavy vaginal bleeding x1 day. The patient reports daily bleeding since her procedure on ___, requiring ___ pads, with new heavy vaginal bleeding and passage of clots since this morning. She reports multiple large gushes soaking her clothes and covering the floor beneath her, then subsequently going through "at least 10" pads. Reports multiple grapefruit sized clots. She endorses some crampy abdominal discomfort. Denies nausea or vomiting. Denies abnormal bowel movements, no blood in the stool. Denies urinary symptoms. She has not been sexually active. Of note, the D&E on ___ was performed at 21 weeks for anomalous fetuses, complicated by a large intraoperative blood loss of 2L requiring transfusion and admission for observation overnight. She has done well since then, aside from daily bleeding and this recent new onset heavy bleeding. Past Medical History: OBHx: G3P0 G1: TAB at the age of ___, no complications G2: IVF with SAB -> D&C G3: IVF conceived dichorionic twins, one with an ONTD and one with the abnormal microarray (same abnormality that her partner carries); had D&E at 21 week complicated by hemorrhage requiring blood transfusion GYNHx: Denies hx of abnormal Pap testing or STIs PMHx: - hypothyroidism - depression/anxiety - infertility PSHx: - lsc right salpingectomy (hydrosalpinx discovered on HSG for infertility workup) - D&C x2 - D&E - tonsillectomy - knee arthroscopy Social History: ___ Family History: Non contributory Physical Exam: Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, appropriately tender, no rebound/guarding GU: scant spotting on pad Ext: no TTP Pertinent Results: ___ 01:15AM BLOOD WBC-10.3* RBC-3.79* Hgb-10.9* Hct-33.9* MCV-89 MCH-28.8 MCHC-32.2 RDW-11.9 RDWSD-38.1 Plt ___ ___ 05:30PM BLOOD WBC-7.4 RBC-4.07 Hgb-11.7 Hct-36.2 MCV-89 MCH-28.7 MCHC-32.3 RDW-11.9 RDWSD-38.8 Plt ___ ___ 11:50AM BLOOD WBC-8.0# RBC-4.41# Hgb-12.6# Hct-39.0# MCV-88 MCH-28.6 MCHC-32.3 RDW-12.0 RDWSD-38.7 Plt ___ ___ 11:50AM BLOOD Neuts-68.7 ___ Monos-6.7 Eos-1.0 Baso-0.4 Im ___ AbsNeut-5.50 AbsLymp-1.83 AbsMono-0.54 AbsEos-0.08 AbsBaso-0.03 ___ 11:50AM BLOOD ___ PTT-34.6 ___ ___ 11:50AM BLOOD Glucose-88 UreaN-12 Creat-0.6 Na-140 K-4.0 Cl-100 HCO3-26 AnGap-18 Brief Hospital Course: On ___, Ms. ___ was admitted to the gynecology service after undergoing attempted dilation and curettage for retained products of conception. Please see the operative report for full details. Products of conception were not able to be completely evacuated because of hemorrhage during the case. An intrauterine foley balloon was placed. Ms. ___ bleeding was stable after the case, and her hematocrit was also stable. She underwent ultrasound imaging on postoperative day 1 to better characterized the retained products of conception. Ultrasound was concerning for an arteriovenous malformation as well as further retained products. AVM was better characterized on MRI imaging. The decision was made, after discussion with the interventional radiology team, to proceed with ___ embolization, which occurred on ___. On ___, the intrauterine foley was removed without complication. Ms. ___ spiked a fever during the intrauterine foley removal; this was thought to be most likely in the setting of the uterine artery embolization, and she was kept on gentamicin/clindamycin until she had been afebrile for 24 hours (___). Patient requested HIV and hepatitis B and C testing in the setting of recent blood transfusion. Testing was negative during this admission (though HCV viral load pending at time of discharge). By ___, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She had only minor spotting from the vagina. She was then discharged home in stable condition with outpatient follow-up scheduled. Medications on Admission: Active Medication list as of ___: Medications - Prescription CITALOPRAM - citalopram 20 mg tablet. 1 tablet(s) by mouth once a day LEVOTHYROXINE - Dosage uncertain - (Prescribed by Other Provider; daily) ZOLPIDEM [AMBIEN] - Dosage uncertain - (Prescribed by Other Provider; bedtime) Medications - OTC FOLIC ACID - folic acid ___ mcg tablet. 2 tablet(s) by mouth once a day - (Prescribed by Other Provider) IBUPROFEN [ADVIL] - Dosage uncertain - (Prescribed by Other Provider; as needed) IRON - Dosage uncertain - (Prescribed by Other Provider; daily) PRENATAL - Prenatal 27 mg-0.8 mg tablet. 1 tablet(s) by mouth once a day - (Prescribed by Other Provider) Discharge Disposition: Home Discharge Diagnosis: Retained products of conception s/p D&E Arteriovenous malformation, now s/p embolization Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. ___ MD ___ Completed by: ___
[ "O046", "F329", "E039", "F419", "N979", "O021", "Q2732" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: vaginal bleeding Major Surgical or Invasive Procedure: dilation and curettage History of Present Illness: [MASKED] yo [MASKED] s/p D&E [MASKED] presents with heavy vaginal bleeding x1 day. The patient reports daily bleeding since her procedure on [MASKED], requiring [MASKED] pads, with new heavy vaginal bleeding and passage of clots since this morning. She reports multiple large gushes soaking her clothes and covering the floor beneath her, then subsequently going through "at least 10" pads. Reports multiple grapefruit sized clots. She endorses some crampy abdominal discomfort. Denies nausea or vomiting. Denies abnormal bowel movements, no blood in the stool. Denies urinary symptoms. She has not been sexually active. Of note, the D&E on [MASKED] was performed at 21 weeks for anomalous fetuses, complicated by a large intraoperative blood loss of 2L requiring transfusion and admission for observation overnight. She has done well since then, aside from daily bleeding and this recent new onset heavy bleeding. Past Medical History: OBHx: G3P0 G1: TAB at the age of [MASKED], no complications G2: IVF with SAB -> D&C G3: IVF conceived dichorionic twins, one with an ONTD and one with the abnormal microarray (same abnormality that her partner carries); had D&E at 21 week complicated by hemorrhage requiring blood transfusion GYNHx: Denies hx of abnormal Pap testing or STIs PMHx: - hypothyroidism - depression/anxiety - infertility PSHx: - lsc right salpingectomy (hydrosalpinx discovered on HSG for infertility workup) - D&C x2 - D&E - tonsillectomy - knee arthroscopy Social History: [MASKED] Family History: Non contributory Physical Exam: Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, appropriately tender, no rebound/guarding GU: scant spotting on pad Ext: no TTP Pertinent Results: [MASKED] 01:15AM BLOOD WBC-10.3* RBC-3.79* Hgb-10.9* Hct-33.9* MCV-89 MCH-28.8 MCHC-32.2 RDW-11.9 RDWSD-38.1 Plt [MASKED] [MASKED] 05:30PM BLOOD WBC-7.4 RBC-4.07 Hgb-11.7 Hct-36.2 MCV-89 MCH-28.7 MCHC-32.3 RDW-11.9 RDWSD-38.8 Plt [MASKED] [MASKED] 11:50AM BLOOD WBC-8.0# RBC-4.41# Hgb-12.6# Hct-39.0# MCV-88 MCH-28.6 MCHC-32.3 RDW-12.0 RDWSD-38.7 Plt [MASKED] [MASKED] 11:50AM BLOOD Neuts-68.7 [MASKED] Monos-6.7 Eos-1.0 Baso-0.4 Im [MASKED] AbsNeut-5.50 AbsLymp-1.83 AbsMono-0.54 AbsEos-0.08 AbsBaso-0.03 [MASKED] 11:50AM BLOOD [MASKED] PTT-34.6 [MASKED] [MASKED] 11:50AM BLOOD Glucose-88 UreaN-12 Creat-0.6 Na-140 K-4.0 Cl-100 HCO3-26 AnGap-18 Brief Hospital Course: On [MASKED], Ms. [MASKED] was admitted to the gynecology service after undergoing attempted dilation and curettage for retained products of conception. Please see the operative report for full details. Products of conception were not able to be completely evacuated because of hemorrhage during the case. An intrauterine foley balloon was placed. Ms. [MASKED] bleeding was stable after the case, and her hematocrit was also stable. She underwent ultrasound imaging on postoperative day 1 to better characterized the retained products of conception. Ultrasound was concerning for an arteriovenous malformation as well as further retained products. AVM was better characterized on MRI imaging. The decision was made, after discussion with the interventional radiology team, to proceed with [MASKED] embolization, which occurred on [MASKED]. On [MASKED], the intrauterine foley was removed without complication. Ms. [MASKED] spiked a fever during the intrauterine foley removal; this was thought to be most likely in the setting of the uterine artery embolization, and she was kept on gentamicin/clindamycin until she had been afebrile for 24 hours ([MASKED]). Patient requested HIV and hepatitis B and C testing in the setting of recent blood transfusion. Testing was negative during this admission (though HCV viral load pending at time of discharge). By [MASKED], she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She had only minor spotting from the vagina. She was then discharged home in stable condition with outpatient follow-up scheduled. Medications on Admission: Active Medication list as of [MASKED]: Medications - Prescription CITALOPRAM - citalopram 20 mg tablet. 1 tablet(s) by mouth once a day LEVOTHYROXINE - Dosage uncertain - (Prescribed by Other Provider; daily) ZOLPIDEM [AMBIEN] - Dosage uncertain - (Prescribed by Other Provider; bedtime) Medications - OTC FOLIC ACID - folic acid [MASKED] mcg tablet. 2 tablet(s) by mouth once a day - (Prescribed by Other Provider) IBUPROFEN [ADVIL] - Dosage uncertain - (Prescribed by Other Provider; as needed) IRON - Dosage uncertain - (Prescribed by Other Provider; daily) PRENATAL - Prenatal 27 mg-0.8 mg tablet. 1 tablet(s) by mouth once a day - (Prescribed by Other Provider) Discharge Disposition: Home Discharge Diagnosis: Retained products of conception s/p D&E Arteriovenous malformation, now s/p embolization Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. [MASKED] MD [MASKED] Completed by: [MASKED]
[]
[ "F329", "E039", "F419" ]
[ "O046: Delayed or excessive hemorrhage following (induced) termination of pregnancy", "F329: Major depressive disorder, single episode, unspecified", "E039: Hypothyroidism, unspecified", "F419: Anxiety disorder, unspecified", "N979: Female infertility, unspecified", "O021: Missed abortion", "Q2732: Arteriovenous malformation of vessel of lower limb" ]
19,999,204
29,046,609
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Abdominal distention, umbilical hernia fluid leakage Major Surgical or Invasive Procedure: Diagnostic Paracentesis ___ Therapeutic Paracentesis ___ History of Present Illness: Mr. ___ is a ___ history of HCV cirrhosis c/b HCC s/p TACE (___) at ___, HTN, EtOH abuse, OA on chronic disability, initially presenting to ___ with worsening abdominal distention and ___ ascitic fluid leakage transferred here for further management. Patient has had fluid leakage from umbilical hernia since ___, initially yellow straw color, however now has become more bloody since starting earlier today. His periumbilical fluid leakage has been quite intermittent, states it worsens when he bends over or lifts heavy materials at work where he does ___. Patient reports fluid drainage has been a recurring issue and he has been evaluated at both ___ and ___ and surgical intervention has so far been deferred. He recently underwent a therapeutic paracentesis on ___ with 4.8L serosanguinous fluid removed. He was referred to surgery at ___ with Dr. ___ prior to admission who applied silver nitrate to umbilical hernia with temporary improvement in leaking. This morning he had some worsening leakage again in additional to abdominal distention and presented to ___. Denies any fever, chills, nausea, vomiting, no changes in bowel movements. Given medical complexity was transferred here for further management. In the ED, initial VS were: T 98.1 HR 66 Bp 145/85 RR 16 O2 100%RA Exam notable for: General- NAD HEENT- PERRL, EOMI Lungs- Non-labored breathing, CTAB CV- RRR, no murmurs, normal S1, S2, no S3/S4 Abd-very distended, soft, large umbilical hernia with serosanguineous drainage, nontender Msk- No spine tenderness Neuro-A&O x3, CN ___ intact, normal strength and sensation in all extremities, normal coordination and gait. Ext- No edema, cyanosis, or clubbing Labs notable for: - WBC 10.0, Hb 11.7, HCT 34.5, PLT 149 - Na 132, K 4.3, BUN 10, Cr 0.9, Glc 82 - ___ 14.2, PTT 32.9, INR 1.3 - ALT 33, AST 65, ALP 156, T. bili 1.4, Albumin ___ - S/p diagnostic para: TNC 476, RBP ___ with 26% polys and 41% lymphs Imaging: RUQUS with duplex/Doppler ___: 1. Patent hepatic vasculature. Eccentric filling defect in the right portal vein may represent nonocclusive thrombus. 2. Cirrhotic liver with 5.4 cm hypoechoic partially cystic hepatic mass, likely HCC, if clinically indicated further evaluation can be performed with a liver MRI or multiphase CT. 3. Moderate intrahepatic biliary dilatation. 4. Moderate to large volume ascites. 5. Cholelithiasis. Consults: - Hepatology consulted: Recommending completing infectious work-up, holding diuretics pending rule out of infection, if significant leakage albumin 25% x1 Administered: ___ 15:02 PO OxyCODONE (Immediate Release) 5 mg ___ 16:30 PO/NG Lactulose 15 mL Subjective: On arrival to the floor, patient confirms the above history. At present, states that his periumbilical hernia is not leaking any ascitic fluid. Describes some abdominal distention, however denies any abdominal pain at this time. No nausea or vomiting. Denies any recent fevers, chills, cough, hematemesis, no bloody stools, no changes in bowel habits recently. Past Medical History: - HCV cirrhosis c/b HCC s/p TACE (___) at ___ - COPD - HTN - EtOH abuse - OA on chronic disability, Social History: ___ Family History: No family history of cirrhosis or ___ Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: T 97.9 BP 155/79 HR 68 RR 18 O2 99%RA GENERAL: Comfortable, NAD HEENT: NC/AT, PERRL, EOMI Lungs: Clear to auscultation bilaterally, no wheezes, rales, or rhonchi CV: Regular rate and rhythm. No murmurs, rubs, or gallops Abd: Distended. Periumbilical hernia no drainage observed, mild overlying erythema although non-tender to palpation. Reducible. Abdomen otherwise nontender throughout, no peritoneal signs. Ext: 2+ peripheral pulses. 1+ pitting edema to hips bilaterally. Neuro: CN II-XII intact. No focal neurological deficits. Motor strength intact throughout. DISCHARGE PHYSICAL EXAM: ======================== Vitals: Afebrile, BP: 139/79, HR: 77, RR: 18, O2: 98% RA GENERAL: Comfortable, NAD HEENT: NC/AT, PERRL, EOMI Lungs: Clear to auscultation bilaterally, no wheezes, rales, or rhonchi CV: Regular rate and rhythm. No murmurs, rubs, or gallops Abd: Mildly distended, NABS. Periumbilical hernia no drainage observed, mild overlying erythema although non-tender to palpation. Reducible. Abdomen otherwise nontender throughout, no peritoneal signs. Ext: 2+ peripheral pulses. 1+ pitting edema to hips bilaterally. Neuro: CN II-XII intact. No focal neurological deficits. Motor strength intact throughout. Pertinent Results: ADMISSION LABS: =============== ___ 02:50PM BLOOD WBC-10.0 RBC-3.95* Hgb-11.7* Hct-34.5* MCV-87 MCH-29.6 MCHC-33.9 RDW-15.9* RDWSD-50.8* Plt ___ ___ 02:50PM BLOOD ___ PTT-32.9 ___ ___ 02:50PM BLOOD Glucose-82 UreaN-10 Creat-0.9 Na-132* K-4.3 Cl-94* HCO3-29 AnGap-9* ___ 02:50PM BLOOD ALT-33 AST-65* AlkPhos-156* TotBili-1.4 ___ 06:14AM BLOOD Albumin-2.2* Calcium-8.1* Phos-3.3 Mg-1.6 ___ 06:14AM BLOOD HBsAg-NEG HBsAb-Borderline HBcAb-POS* ___ 06:10AM BLOOD AFP-44.8* ___ 06:14AM BLOOD HCV Ab-POS* ___ 06:10AM BLOOD HCV VL-3.5* ___ 07:05AM BLOOD HBV VL-NOT DETECT ___ 06:21AM URINE Color-Yellow Appear-Clear Sp ___ ___ 06:21AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG ASCITIC FLUID ANALYSIS: ======================= Diagnostic para ___ 03:30PM ASCITES TNC-476* ___ Polys-26* Lymphs-41* Monos-0 Plasma-1* Mesothe-10* Macroph-22* ___ 03:30PM ASCITES TotPro-1.6 LD(LDH)-89 Albumin-0.6 Therapeutic para ___ 03:30PM ASCITES TNC-453* ___ Polys-9* Lymphs-51* ___ Mesothe-3* Macroph-37* ___ 03:30PM ASCITES TotPro-1.3 Albumin-0.4 DISCHARGE LABS: =============== ___ 06:15AM BLOOD WBC-11.7* RBC-3.56* Hgb-10.8* Hct-32.1* MCV-90 MCH-30.3 MCHC-33.6 RDW-15.9* RDWSD-52.6* Plt ___ ___ 06:15AM BLOOD Glucose-90 UreaN-17 Creat-1.2 Na-130* K-4.6 Cl-90* HCO3-29 AnGap-11 ___ 06:15AM BLOOD ALT-41* AST-68* AlkPhos-122 TotBili-1.0 ___ 06:15AM BLOOD Calcium-9.1 Phos-3.9 Mg-1.8 IMAGING STUDIES: ================ RUQ U/S (___): 1. Patent main portal vein. Apparent eccentric filling defect in the right portal vein may represent nonocclusive thrombus. 2. Cirrhotic liver with 5.4 cm hypoechoic partially cystic hepatic mass, concerning for HCC. Multiphasic liver MRI is suggested to further characterize. Evaluation of the right portal vein can be performed at this time as well. 3. Moderate focal intrahepatic biliary dilatation. 4. Moderate to large volume ascites. 5. Cholelithiasis. CXR (___): Slightly limited study with exclusion of bilateral costophrenic angles revealing no acute radiographic cardiopulmonary abnormality. CT ABD/PELVIS (___): 1. Cirrhotic liver morphology with findings of portal hypertension. Moderate ascites. 2. Dominant, heterogeneously enhancing mass in segment 6 is likely HCC, presumably previously treated. There is residual nodular enhancement suggesting active tumor. 3. Ill-defined arterial enhancement in segment 8 associated with localized biliary dilation, incompletely characterized but concerning for HCC. 4. Numerous arterially enhancing nodular foci throughout the liver, a few of which demonstrate mild portal venous washout but no definite capsular enhancement. 5. MRI could be considered for further evaluation of the above abnormalities, if there is not a recent outside MRI study for review. CT CHEST (___): 1. No evidence of metastasis to the chest. 2. Evidence of cirrhosis with hypodense lesion in the right lobe of liver which could represent patient's treated HCC. 3. Ascites. 4. Lack of intravenous contrast limits evaluation of the liver. MRI LIVER (___): 1. Multifocal HCC as described above with 2 lesions meeting OPTN 5B criteria and 2 lesions meeting OPTN 5A criteria. 2. The largest HCC extends exophytically through the liver capsule. A smaller HCC in segment ___ causes upstream biliary obstruction. 3. Post treatment changes in segment II related to prior ablation without definite local recurrence. 4. Cirrhotic liver with sequelae of portal hypertension including moderate ascites and variceal formation. TTE (___): CONCLUSION: The left atrial volume index is mildly increased. The right atrium is mildly enlarged. The right atrial pressure could not be estimated. There is normal left ventricular wall thickness with a normal cavity size. There is normal regional and global left ventricular systolic function. Quantitative biplane left ventricular ejection fraction is 66 %. Left ventricular cardiac index is high (>4.0 L/min/m2). There is no resting left ventricular outflow tract gradient. No ventricular septal defect is seen. Normal right ventricular cavity size with normal free wall motion. The aortic sinus diameter is normal for gender with mildly dilated ascending aorta. The aortic arch diameter is normal with a normal descending aorta diameter. The aortic valve leaflets (3) appear structurally normal. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral valve leaflets appear structurally normal with no mitral valve prolapse. There is mild [1+] mitral regurgitation. The tricuspid valve leaflets appear structurally normal. There is physiologic tricuspid regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Ascites is seen. IMPRESSION: Normal regional and global biventricular systolic function. Mild mitral regurgitation. Normal pulmonary artery systolic pressure. Mildly dilated ascending aorta. BONE SCAN (___): IMPRESSION: No areas of focally increased uptake. As such, no evidence of metastatic disease. MICROBIOLOGY: ============= __________________________________________________________ ___ 3:30 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES PERITONEAL FLUID. **FINAL REPORT ___ Fluid Culture in Bottles (Final ___: NO GROWTH. __________________________________________________________ ___ 4:03 pm PERITONEAL FLUID PERITONEAL FLUID. **FINAL REPORT ___ GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Final ___: NO GROWTH. __________________________________________________________ ___ 6:14 am BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 11:55 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 3:30 pm PERITONEAL FLUID PERITONEAL FLUID. **FINAL REPORT ___ GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Final ___: NO GROWTH. CYTOLOGY: ========= Peritoneal fluid (___): NEGATIVE FOR MALIGNANT CELLS. - Mesothelial cells, histiocytes, and lymphocytes. Brief Hospital Course: SUMMARY: ======== Mr. ___ is a ___ history of HCV cirrhosis c/b HCC s/p TACE (most recently ___ at ___, HTN, EtOH abuse, OA on chronic disability, initially presenting to ___ with abdominal distention and ascitic fluid leakage from umbilical hernia, transferred to ___ for further management. ACUTE ISSUES: ============= #HCV/ETOH Cirrhosis #Umbilical Hernia #Hepatocellular carcinoma History of HCV cirrhosis with HCC s/p TACE (___) at ___, c/b recurrent, large volume ascites (last LVP for 4.8 L on ___, and periumbilical hernia. He was transferred to ___ with worsening abdominal distention and ascetic fluid leakage from umbilical hernia. He underwent diagnostic paracentesis here on admission, without evidence of SBP, followed by therapeutic paracentesis on ___ for 3.8L. Leaking from hernia has since resolved after silver nitrate application at ___. CT on admission was notable for multiple concerning lesions for HCC, although we do not have prior imaging for comparison. Hepatology was consulted, and patient underwent re-staging of ___ to determine next steps in treatment. MRI was notable for multi-focal HCC with 2 lesions meeting OPTN 5B criteria and 2 lesions meeting OPTN 5A criteria, with the largest HCC extending through the liver capsule. CT chest and bone scan otherwise negative for metastasis. Multi-disciplinary liver tumor conference was held to discuss next steps moving forward. Per hepatology recommendations, will first optimize ascites, with up-titration of diuretics as an outpatient +/- therapeutic paracentesis PRN. If ascites is refractory, will consider TIPS procedure at that point. There is still an option to treat his HCC with locoreginal therapy, however will need to optimize ascites and consider elective hernia repair as an outpatient before ___ intervention. He will be discharged on Lasix 40mg/spironolactone 100mg BID, with liver tumor clinic and transplant surgery follow up on ___. Will also continue lactulose 30ml daily. #Hepatitis C HCV viral load 3.5, untreated. Per hepatology, unlikely to be a candidate for HCV treatment at this time given poor prognosis. Will follow up in liver clinic as above. #Hyponatremia Hyponatremic to 132, improving, likely in setting of cirrhosis. Continue low Na+ diet and diuresis as above. #Anemia Hb 11.7, unknown baseline. No obvious signs of bleeding. Possibly ___ splenomegaly, alcohol use, and anemia of chronic disease. Consider sending iron studies as an outpatient. #Malnutrition Nutrition consulted on admission. Recommending Ensure Enlive TID with meals and multi-vitamin with minerals. CHRONIC ISSUES: =============== #HTN Continue home norvasc and metoprolol. #EtOH abuse Drinks several cans of beers daily. Currently no signs of withdrawal, continue to encourage abstinence as an outpatient. #OA on chronic disability On narcotics agreement at ___. Takes oxycodone at home for hip, back, and abdominal pain. Given stable on current home regimen, will continue oxycodone 10mg PO Q6H:PRN. TRANSITIONAL ISSUES: ==================== [] Started on Lasix 40mg BID and spironolactone 100mg BID for ascites [] Please repeat chemistry panel, LFTs, albumin, INR at PCP follow up and fax results to Dr. ___: ___, phone: ___ [] Please continue to monitor abdominal exam for re-accumulation of ascites, as patient may need interval therapeutic paracentesis vs. up-titration of diuretics as an outpatient [] If ascites becomes refractory to medical management, patient will likely need TIPs procedure [] Please ensure outpatient Liver Tumor MDC follow up as well as follow up with Dr. ___ in transplant surgery clinic for elective hernia repair (scheduled for ___ [] Patient has undergone re-staging of HCC during this admission. MRI was notable for multi-focal HCC with 2 lesions meeting OPTN 5B criteria and 2 lesions meeting OPTN 5A criteria. No metastasis on bone scan/CT chest. Per hepatology, there is still an option to treat his HCC with locoreginal therapy, however, will need to optimize ascites control and consider repairing hernia before ___ intervention. Please ensure follow up with liver clinic as above to discuss next steps in treatment. #CODE: Full (presumed) #CONTACT: Name of health care proxy: ___ Phone number: ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Spironolactone 50 mg PO DAILY 2. Furosemide 20 mg PO DAILY 3. Metoprolol Succinate XL 50 mg PO DAILY 4. amLODIPine 10 mg PO DAILY 5. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain - Moderate 6. LORazepam 1 mg PO QHS:PRN insomnia 7. Lactulose 15 mL PO QID 8. Vitamin D 1000 UNIT PO DAILY Discharge Medications: 1. Multivitamins 1 TAB PO DAILY 2. Furosemide 40 mg PO BID RX *furosemide [Lasix] 40 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 3. Lactulose 30 mL PO DAILY RX *lactulose 10 gram/15 mL (15 mL) 30 mL by mouth once a day Disp #*60 Package Refills:*0 4. Spironolactone 100 mg PO BID RX *spironolactone 100 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 5. amLODIPine 10 mg PO DAILY 6. LORazepam 1 mg PO QHS:PRN insomnia 7. Metoprolol Succinate XL 50 mg PO DAILY 8. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain - Moderate 9. Vitamin D 1000 UNIT PO DAILY 10.Outpatient Lab Work Labs: Chem 10, LFTs, INR, albumin Date: ___ ICD10: ___ Please fax results to Dr. ___ 11.Nutrition Ensure Enlive Supplements TID with meals Dispense: 90 shakes Refills: 0 ICD 10: E44.0 Discharge Disposition: Home Discharge Diagnosis: #Hepatocellular carcinoma #ETOH/HCV cirrhosis #Large volume ascites #Leakage of ascites fluid via periumbilical hernia #Anemia #Hyponatremia 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 admitted to the hospital? - You were admitted because you had abdominal swelling. You also needed repeat staging tests for your liver cancer. What happened while I was in the hospital? - You had a paracentesis to drain the fluid in your abdomen. You are likely accumulating this fluid because of your cirrhosis and liver cancer. - You were started on diuretics (Lasix, spironolactone) to help prevent this abdominal fluid from re-accumulating. - You underwent multiple CT scans and a bone scan to evaluate your liver cancer. You were seen by our liver team who are recommending follow up as an outpatient for further treatment of your cancer. What should I do after leaving the hospital? - Please take your medications as listed in discharge summary and follow up at the listed appointments. Thank you for allowing us to be involved in your care, we wish you all the best! Sincerely, Your ___ Team Followup Instructions: ___
[ "C220", "E871", "E440", "K766", "K7031", "B1920", "I10", "F1010", "D6489", "J449", "F17210", "M1990", "K429", "Z6828" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Abdominal distention, umbilical hernia fluid leakage Major Surgical or Invasive Procedure: Diagnostic Paracentesis [MASKED] Therapeutic Paracentesis [MASKED] History of Present Illness: Mr. [MASKED] is a [MASKED] history of HCV cirrhosis c/b HCC s/p TACE ([MASKED]) at [MASKED], HTN, EtOH abuse, OA on chronic disability, initially presenting to [MASKED] with worsening abdominal distention and [MASKED] ascitic fluid leakage transferred here for further management. Patient has had fluid leakage from umbilical hernia since [MASKED], initially yellow straw color, however now has become more bloody since starting earlier today. His periumbilical fluid leakage has been quite intermittent, states it worsens when he bends over or lifts heavy materials at work where he does [MASKED]. Patient reports fluid drainage has been a recurring issue and he has been evaluated at both [MASKED] and [MASKED] and surgical intervention has so far been deferred. He recently underwent a therapeutic paracentesis on [MASKED] with 4.8L serosanguinous fluid removed. He was referred to surgery at [MASKED] with Dr. [MASKED] prior to admission who applied silver nitrate to umbilical hernia with temporary improvement in leaking. This morning he had some worsening leakage again in additional to abdominal distention and presented to [MASKED]. Denies any fever, chills, nausea, vomiting, no changes in bowel movements. Given medical complexity was transferred here for further management. In the ED, initial VS were: T 98.1 HR 66 Bp 145/85 RR 16 O2 100%RA Exam notable for: General- NAD HEENT- PERRL, EOMI Lungs- Non-labored breathing, CTAB CV- RRR, no murmurs, normal S1, S2, no S3/S4 Abd-very distended, soft, large umbilical hernia with serosanguineous drainage, nontender Msk- No spine tenderness Neuro-A&O x3, CN [MASKED] intact, normal strength and sensation in all extremities, normal coordination and gait. Ext- No edema, cyanosis, or clubbing Labs notable for: - WBC 10.0, Hb 11.7, HCT 34.5, PLT 149 - Na 132, K 4.3, BUN 10, Cr 0.9, Glc 82 - [MASKED] 14.2, PTT 32.9, INR 1.3 - ALT 33, AST 65, ALP 156, T. bili 1.4, Albumin [MASKED] - S/p diagnostic para: TNC 476, RBP [MASKED] with 26% polys and 41% lymphs Imaging: RUQUS with duplex/Doppler [MASKED]: 1. Patent hepatic vasculature. Eccentric filling defect in the right portal vein may represent nonocclusive thrombus. 2. Cirrhotic liver with 5.4 cm hypoechoic partially cystic hepatic mass, likely HCC, if clinically indicated further evaluation can be performed with a liver MRI or multiphase CT. 3. Moderate intrahepatic biliary dilatation. 4. Moderate to large volume ascites. 5. Cholelithiasis. Consults: - Hepatology consulted: Recommending completing infectious work-up, holding diuretics pending rule out of infection, if significant leakage albumin 25% x1 Administered: [MASKED] 15:02 PO OxyCODONE (Immediate Release) 5 mg [MASKED] 16:30 PO/NG Lactulose 15 mL Subjective: On arrival to the floor, patient confirms the above history. At present, states that his periumbilical hernia is not leaking any ascitic fluid. Describes some abdominal distention, however denies any abdominal pain at this time. No nausea or vomiting. Denies any recent fevers, chills, cough, hematemesis, no bloody stools, no changes in bowel habits recently. Past Medical History: - HCV cirrhosis c/b HCC s/p TACE ([MASKED]) at [MASKED] - COPD - HTN - EtOH abuse - OA on chronic disability, Social History: [MASKED] Family History: No family history of cirrhosis or [MASKED] Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: T 97.9 BP 155/79 HR 68 RR 18 O2 99%RA GENERAL: Comfortable, NAD HEENT: NC/AT, PERRL, EOMI Lungs: Clear to auscultation bilaterally, no wheezes, rales, or rhonchi CV: Regular rate and rhythm. No murmurs, rubs, or gallops Abd: Distended. Periumbilical hernia no drainage observed, mild overlying erythema although non-tender to palpation. Reducible. Abdomen otherwise nontender throughout, no peritoneal signs. Ext: 2+ peripheral pulses. 1+ pitting edema to hips bilaterally. Neuro: CN II-XII intact. No focal neurological deficits. Motor strength intact throughout. DISCHARGE PHYSICAL EXAM: ======================== Vitals: Afebrile, BP: 139/79, HR: 77, RR: 18, O2: 98% RA GENERAL: Comfortable, NAD HEENT: NC/AT, PERRL, EOMI Lungs: Clear to auscultation bilaterally, no wheezes, rales, or rhonchi CV: Regular rate and rhythm. No murmurs, rubs, or gallops Abd: Mildly distended, NABS. Periumbilical hernia no drainage observed, mild overlying erythema although non-tender to palpation. Reducible. Abdomen otherwise nontender throughout, no peritoneal signs. Ext: 2+ peripheral pulses. 1+ pitting edema to hips bilaterally. Neuro: CN II-XII intact. No focal neurological deficits. Motor strength intact throughout. Pertinent Results: ADMISSION LABS: =============== [MASKED] 02:50PM BLOOD WBC-10.0 RBC-3.95* Hgb-11.7* Hct-34.5* MCV-87 MCH-29.6 MCHC-33.9 RDW-15.9* RDWSD-50.8* Plt [MASKED] [MASKED] 02:50PM BLOOD [MASKED] PTT-32.9 [MASKED] [MASKED] 02:50PM BLOOD Glucose-82 UreaN-10 Creat-0.9 Na-132* K-4.3 Cl-94* HCO3-29 AnGap-9* [MASKED] 02:50PM BLOOD ALT-33 AST-65* AlkPhos-156* TotBili-1.4 [MASKED] 06:14AM BLOOD Albumin-2.2* Calcium-8.1* Phos-3.3 Mg-1.6 [MASKED] 06:14AM BLOOD HBsAg-NEG HBsAb-Borderline HBcAb-POS* [MASKED] 06:10AM BLOOD AFP-44.8* [MASKED] 06:14AM BLOOD HCV Ab-POS* [MASKED] 06:10AM BLOOD HCV VL-3.5* [MASKED] 07:05AM BLOOD HBV VL-NOT DETECT [MASKED] 06:21AM URINE Color-Yellow Appear-Clear Sp [MASKED] [MASKED] 06:21AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG ASCITIC FLUID ANALYSIS: ======================= Diagnostic para [MASKED] 03:30PM ASCITES TNC-476* [MASKED] Polys-26* Lymphs-41* Monos-0 Plasma-1* Mesothe-10* Macroph-22* [MASKED] 03:30PM ASCITES TotPro-1.6 LD(LDH)-89 Albumin-0.6 Therapeutic para [MASKED] 03:30PM ASCITES TNC-453* [MASKED] Polys-9* Lymphs-51* [MASKED] Mesothe-3* Macroph-37* [MASKED] 03:30PM ASCITES TotPro-1.3 Albumin-0.4 DISCHARGE LABS: =============== [MASKED] 06:15AM BLOOD WBC-11.7* RBC-3.56* Hgb-10.8* Hct-32.1* MCV-90 MCH-30.3 MCHC-33.6 RDW-15.9* RDWSD-52.6* Plt [MASKED] [MASKED] 06:15AM BLOOD Glucose-90 UreaN-17 Creat-1.2 Na-130* K-4.6 Cl-90* HCO3-29 AnGap-11 [MASKED] 06:15AM BLOOD ALT-41* AST-68* AlkPhos-122 TotBili-1.0 [MASKED] 06:15AM BLOOD Calcium-9.1 Phos-3.9 Mg-1.8 IMAGING STUDIES: ================ RUQ U/S ([MASKED]): 1. Patent main portal vein. Apparent eccentric filling defect in the right portal vein may represent nonocclusive thrombus. 2. Cirrhotic liver with 5.4 cm hypoechoic partially cystic hepatic mass, concerning for HCC. Multiphasic liver MRI is suggested to further characterize. Evaluation of the right portal vein can be performed at this time as well. 3. Moderate focal intrahepatic biliary dilatation. 4. Moderate to large volume ascites. 5. Cholelithiasis. CXR ([MASKED]): Slightly limited study with exclusion of bilateral costophrenic angles revealing no acute radiographic cardiopulmonary abnormality. CT ABD/PELVIS ([MASKED]): 1. Cirrhotic liver morphology with findings of portal hypertension. Moderate ascites. 2. Dominant, heterogeneously enhancing mass in segment 6 is likely HCC, presumably previously treated. There is residual nodular enhancement suggesting active tumor. 3. Ill-defined arterial enhancement in segment 8 associated with localized biliary dilation, incompletely characterized but concerning for HCC. 4. Numerous arterially enhancing nodular foci throughout the liver, a few of which demonstrate mild portal venous washout but no definite capsular enhancement. 5. MRI could be considered for further evaluation of the above abnormalities, if there is not a recent outside MRI study for review. CT CHEST ([MASKED]): 1. No evidence of metastasis to the chest. 2. Evidence of cirrhosis with hypodense lesion in the right lobe of liver which could represent patient's treated HCC. 3. Ascites. 4. Lack of intravenous contrast limits evaluation of the liver. MRI LIVER ([MASKED]): 1. Multifocal HCC as described above with 2 lesions meeting OPTN 5B criteria and 2 lesions meeting OPTN 5A criteria. 2. The largest HCC extends exophytically through the liver capsule. A smaller HCC in segment [MASKED] causes upstream biliary obstruction. 3. Post treatment changes in segment II related to prior ablation without definite local recurrence. 4. Cirrhotic liver with sequelae of portal hypertension including moderate ascites and variceal formation. TTE ([MASKED]): CONCLUSION: The left atrial volume index is mildly increased. The right atrium is mildly enlarged. The right atrial pressure could not be estimated. There is normal left ventricular wall thickness with a normal cavity size. There is normal regional and global left ventricular systolic function. Quantitative biplane left ventricular ejection fraction is 66 %. Left ventricular cardiac index is high (>4.0 L/min/m2). There is no resting left ventricular outflow tract gradient. No ventricular septal defect is seen. Normal right ventricular cavity size with normal free wall motion. The aortic sinus diameter is normal for gender with mildly dilated ascending aorta. The aortic arch diameter is normal with a normal descending aorta diameter. The aortic valve leaflets (3) appear structurally normal. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral valve leaflets appear structurally normal with no mitral valve prolapse. There is mild [1+] mitral regurgitation. The tricuspid valve leaflets appear structurally normal. There is physiologic tricuspid regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Ascites is seen. IMPRESSION: Normal regional and global biventricular systolic function. Mild mitral regurgitation. Normal pulmonary artery systolic pressure. Mildly dilated ascending aorta. BONE SCAN ([MASKED]): IMPRESSION: No areas of focally increased uptake. As such, no evidence of metastatic disease. MICROBIOLOGY: ============= [MASKED] [MASKED] 3:30 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES PERITONEAL FLUID. **FINAL REPORT [MASKED] Fluid Culture in Bottles (Final [MASKED]: NO GROWTH. [MASKED] [MASKED] 4:03 pm PERITONEAL FLUID PERITONEAL FLUID. **FINAL REPORT [MASKED] GRAM STAIN (Final [MASKED]: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [MASKED]: NO GROWTH. ANAEROBIC CULTURE (Final [MASKED]: NO GROWTH. [MASKED] [MASKED] 6:14 am BLOOD CULTURE **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] [MASKED] 11:55 pm BLOOD CULTURE **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] [MASKED] 3:30 pm PERITONEAL FLUID PERITONEAL FLUID. **FINAL REPORT [MASKED] GRAM STAIN (Final [MASKED]: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [MASKED]: NO GROWTH. ANAEROBIC CULTURE (Final [MASKED]: NO GROWTH. CYTOLOGY: ========= Peritoneal fluid ([MASKED]): NEGATIVE FOR MALIGNANT CELLS. - Mesothelial cells, histiocytes, and lymphocytes. Brief Hospital Course: SUMMARY: ======== Mr. [MASKED] is a [MASKED] history of HCV cirrhosis c/b HCC s/p TACE (most recently [MASKED] at [MASKED], HTN, EtOH abuse, OA on chronic disability, initially presenting to [MASKED] with abdominal distention and ascitic fluid leakage from umbilical hernia, transferred to [MASKED] for further management. ACUTE ISSUES: ============= #HCV/ETOH Cirrhosis #Umbilical Hernia #Hepatocellular carcinoma History of HCV cirrhosis with HCC s/p TACE ([MASKED]) at [MASKED], c/b recurrent, large volume ascites (last LVP for 4.8 L on [MASKED], and periumbilical hernia. He was transferred to [MASKED] with worsening abdominal distention and ascetic fluid leakage from umbilical hernia. He underwent diagnostic paracentesis here on admission, without evidence of SBP, followed by therapeutic paracentesis on [MASKED] for 3.8L. Leaking from hernia has since resolved after silver nitrate application at [MASKED]. CT on admission was notable for multiple concerning lesions for HCC, although we do not have prior imaging for comparison. Hepatology was consulted, and patient underwent re-staging of [MASKED] to determine next steps in treatment. MRI was notable for multi-focal HCC with 2 lesions meeting OPTN 5B criteria and 2 lesions meeting OPTN 5A criteria, with the largest HCC extending through the liver capsule. CT chest and bone scan otherwise negative for metastasis. Multi-disciplinary liver tumor conference was held to discuss next steps moving forward. Per hepatology recommendations, will first optimize ascites, with up-titration of diuretics as an outpatient +/- therapeutic paracentesis PRN. If ascites is refractory, will consider TIPS procedure at that point. There is still an option to treat his HCC with locoreginal therapy, however will need to optimize ascites and consider elective hernia repair as an outpatient before [MASKED] intervention. He will be discharged on Lasix 40mg/spironolactone 100mg BID, with liver tumor clinic and transplant surgery follow up on [MASKED]. Will also continue lactulose 30ml daily. #Hepatitis C HCV viral load 3.5, untreated. Per hepatology, unlikely to be a candidate for HCV treatment at this time given poor prognosis. Will follow up in liver clinic as above. #Hyponatremia Hyponatremic to 132, improving, likely in setting of cirrhosis. Continue low Na+ diet and diuresis as above. #Anemia Hb 11.7, unknown baseline. No obvious signs of bleeding. Possibly [MASKED] splenomegaly, alcohol use, and anemia of chronic disease. Consider sending iron studies as an outpatient. #Malnutrition Nutrition consulted on admission. Recommending Ensure Enlive TID with meals and multi-vitamin with minerals. CHRONIC ISSUES: =============== #HTN Continue home norvasc and metoprolol. #EtOH abuse Drinks several cans of beers daily. Currently no signs of withdrawal, continue to encourage abstinence as an outpatient. #OA on chronic disability On narcotics agreement at [MASKED]. Takes oxycodone at home for hip, back, and abdominal pain. Given stable on current home regimen, will continue oxycodone 10mg PO Q6H:PRN. TRANSITIONAL ISSUES: ==================== [] Started on Lasix 40mg BID and spironolactone 100mg BID for ascites [] Please repeat chemistry panel, LFTs, albumin, INR at PCP follow up and fax results to Dr. [MASKED]: [MASKED], phone: [MASKED] [] Please continue to monitor abdominal exam for re-accumulation of ascites, as patient may need interval therapeutic paracentesis vs. up-titration of diuretics as an outpatient [] If ascites becomes refractory to medical management, patient will likely need TIPs procedure [] Please ensure outpatient Liver Tumor MDC follow up as well as follow up with Dr. [MASKED] in transplant surgery clinic for elective hernia repair (scheduled for [MASKED] [] Patient has undergone re-staging of HCC during this admission. MRI was notable for multi-focal HCC with 2 lesions meeting OPTN 5B criteria and 2 lesions meeting OPTN 5A criteria. No metastasis on bone scan/CT chest. Per hepatology, there is still an option to treat his HCC with locoreginal therapy, however, will need to optimize ascites control and consider repairing hernia before [MASKED] intervention. Please ensure follow up with liver clinic as above to discuss next steps in treatment. #CODE: Full (presumed) #CONTACT: Name of health care proxy: [MASKED] Phone number: [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Spironolactone 50 mg PO DAILY 2. Furosemide 20 mg PO DAILY 3. Metoprolol Succinate XL 50 mg PO DAILY 4. amLODIPine 10 mg PO DAILY 5. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain - Moderate 6. LORazepam 1 mg PO QHS:PRN insomnia 7. Lactulose 15 mL PO QID 8. Vitamin D 1000 UNIT PO DAILY Discharge Medications: 1. Multivitamins 1 TAB PO DAILY 2. Furosemide 40 mg PO BID RX *furosemide [Lasix] 40 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 3. Lactulose 30 mL PO DAILY RX *lactulose 10 gram/15 mL (15 mL) 30 mL by mouth once a day Disp #*60 Package Refills:*0 4. Spironolactone 100 mg PO BID RX *spironolactone 100 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 5. amLODIPine 10 mg PO DAILY 6. LORazepam 1 mg PO QHS:PRN insomnia 7. Metoprolol Succinate XL 50 mg PO DAILY 8. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain - Moderate 9. Vitamin D 1000 UNIT PO DAILY 10.Outpatient Lab Work Labs: Chem 10, LFTs, INR, albumin Date: [MASKED] ICD10: [MASKED] Please fax results to Dr. [MASKED] 11.Nutrition Ensure Enlive Supplements TID with meals Dispense: 90 shakes Refills: 0 ICD 10: E44.0 Discharge Disposition: Home Discharge Diagnosis: #Hepatocellular carcinoma #ETOH/HCV cirrhosis #Large volume ascites #Leakage of ascites fluid via periumbilical hernia #Anemia #Hyponatremia 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 admitted to the hospital? - You were admitted because you had abdominal swelling. You also needed repeat staging tests for your liver cancer. What happened while I was in the hospital? - You had a paracentesis to drain the fluid in your abdomen. You are likely accumulating this fluid because of your cirrhosis and liver cancer. - You were started on diuretics (Lasix, spironolactone) to help prevent this abdominal fluid from re-accumulating. - You underwent multiple CT scans and a bone scan to evaluate your liver cancer. You were seen by our liver team who are recommending follow up as an outpatient for further treatment of your cancer. What should I do after leaving the hospital? - Please take your medications as listed in discharge summary and follow up at the listed appointments. Thank you for allowing us to be involved in your care, we wish you all the best! Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "E871", "I10", "J449", "F17210" ]
[ "C220: Liver cell carcinoma", "E871: Hypo-osmolality and hyponatremia", "E440: Moderate protein-calorie malnutrition", "K766: Portal hypertension", "K7031: Alcoholic cirrhosis of liver with ascites", "B1920: Unspecified viral hepatitis C without hepatic coma", "I10: Essential (primary) hypertension", "F1010: Alcohol abuse, uncomplicated", "D6489: Other specified anemias", "J449: Chronic obstructive pulmonary disease, unspecified", "F17210: Nicotine dependence, cigarettes, uncomplicated", "M1990: Unspecified osteoarthritis, unspecified site", "K429: Umbilical hernia without obstruction or gangrene", "Z6828: Body mass index [BMI] 28.0-28.9, adult" ]
19,999,464
23,033,573
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Asacol / Dipentum / Mercaptopurine Attending: ___. Chief Complaint: Bloody didarrhea Major Surgical or Invasive Procedure: Vedolizumab infusion (___) History of Present Illness: ___ is a ___ yo woman with PMH of ulcerative colitis, incomplete pancreas divisum, pancreatitis, lactose intolerance who presents with headache and persistent diarrhea. Patient follows with Dr. ___ pan-UC. Colitis first diagnosed on colonoscopy in early ___. She has had a number of subsequent colonoscopies over the years, with biopsies showing active disease. Her most recent scope was done in ___, which showed rectal scarring and no signs of active disease. A biopsy of colonic and rectal tissue showed normal mucosa. Patient states that the last time she felt well was ___. Since then, she has had persistent diarrhea. It has increased in frequency, is almost always bloody, and often associated with abdominal pain, bloating and cramping. During this time, she was on treatment with Humira. She saw Dr. ___ in ___, at which time she was started on daily prednisone 30 mg, with plan to start vedolizumab (anti-integrin monoclonal antibody inhibits T cell migration). She recalls some improvement in diarrhea while on steroid, but she felt fatigued/generally unwell. She was instructed to start tapering, but she thinks she may have tapered too quickly. She finished her steroid taper in early ___. She received her first vedolizumab treatment on ___. She continues to have bloody bowel movements about 10x/day, and she reports being unable to keep hydrated due to constant fluid loss. She also developed a headache around ___, for which she took Aleve and tylenol and did not feel relief. She describes the headache as constant, localized to the occiput and forehead bilaterally. She denies photophobia, phonophobia, nausea, or vomiting. She does not typically have headache like this. In the ED: - Initial vital signs were notable for: Afebrile, HR 85, BP 114/69 - Exam notable for: abdomen soft, nontender - Labs were notable for: Hb 11.8 - Studies performed include: none - Patient was given: Tylenol, prochlorperazine, Benadryl - Consults: GI GI evaluated the patient in the ED and recommended stool studies, inflammatory markers, and prep for flex sig in the morning. Vitals on transfer: Temp 98.0, BP 110 / 73, HR 78, RR 18, 97 Ra Upon arrival to the floor, patient describes history as above. She continues to have headache. She denies abdominal pain, nausea. She is worried about dehydration. Past Medical History: Pancreas divisum w/ pancreatitis, s/p sphincterotomy ___ Lactose intolerance Ulcerative colitis Seasonal allergies Vitamin D deficiency Social History: ___ Family History: Mother: constipation Father: coronary artery disease, pancreatitis Per OMR review: Father had a myocardial infarction at age ___. No family history of colon cancer or inflammatory bowel disease. Physical Exam: ADMISSION PHYSICAL EXAM: VITALS: GENERAL: Alert and interactive. Occasionally touches her head in discomfort. HEENT: mucous membranes moist. No oral lesions. Sclera anicteric. Pupils equal and reactive to light. EOMI. 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. Cap refill <2s. No rash. NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal sensation. DISCHARGE PHYSICAL EXAM: VITALS: ___ 1325 Temp: 98.3 PO BP: 117/76 HR: 97 RR: 18 O2 sat: 96% O2 delivery: RA GENERAL: Alert and interactive. Pleasant, alert and appropriate. HEENT: Mucous membranes moist. Sclerae anicteric. CARDIAC: RRR, normal 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. Abdomen is soft, non distended, nontender to palpation without rebound or guarding. EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. Cap refill <2s. No rash. NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal sensation. Pertinent Results: ADMISSION LABS: ___ 06:56PM LACTATE-0.8 ___ 06:52PM URINE HOURS-RANDOM ___ 06:52PM URINE UHOLD-HOLD ___ 06:52PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 06:52PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR* BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-SM* ___ 06:52PM URINE RBC-0 WBC-2 BACTERIA-FEW* YEAST-NONE EPI-2 TRANS EPI-<1 ___ 06:52PM URINE MUCOUS-OCC* ___ 06:44PM GLUCOSE-79 UREA N-13 CREAT-0.6 SODIUM-143 POTASSIUM-4.2 CHLORIDE-111* TOTAL CO2-22 ANION GAP-10 ___ 06:44PM estGFR-Using this ___ 06:44PM ALT(SGPT)-19 AST(SGOT)-21 ALK PHOS-91 TOT BILI-0.3 ___ 06:44PM LIPASE-17 ___ 06:44PM ALBUMIN-3.8 CALCIUM-8.6 PHOSPHATE-3.2 MAGNESIUM-1.9 ___ 06:44PM CRP-1.7 ___ 06:44PM WBC-6.6 RBC-4.27 HGB-11.8 HCT-38.2 MCV-90 MCH-27.6 MCHC-30.9* RDW-13.2 RDWSD-43.1 ___ 06:44PM NEUTS-58.6 ___ MONOS-9.1 EOS-4.4 BASOS-0.6 IM ___ AbsNeut-3.88 AbsLymp-1.79 AbsMono-0.60 AbsEos-0.29 AbsBaso-0.04 ___ 06:44PM PLT COUNT-280 PERTINENT IMAGING: FLEXIBLE SIGMOIDOSCOPY (___): -Erythema, congestion and friability in the rectum and sigmoid colon to 30cm (biopsy). -Normal mucosa in the sigmoid colon and descending colon starting at 30-50cm (biopsy). PERTINENT MICROBIOLOGY: Stool C. diff (___): Negative Stool culture (___): Pending, negative to date Stool O&P (___): Pending, negative to date Blood cultures (___): Pending, NGTD Urine culture (___): No growth, final DISCHARGE LABS: ___ 06:31AM BLOOD WBC-8.8 RBC-4.05 Hgb-11.4 Hct-35.1 MCV-87 MCH-28.1 MCHC-32.5 RDW-13.1 RDWSD-40.9 Plt ___ ___ 06:31AM BLOOD Glucose-134* UreaN-9 Creat-0.6 Na-144 K-4.4 Cl-107 HCO3-27 AnGap-10 ___ 06:31AM BLOOD Calcium-9.3 Phos-4.0 Mg-1.8 ___ 06:31AM BLOOD CRP-1.___ with PMHx ulcerative colitis, incomplete pancreas divisum, and lactose intolerance who presented with headaches and bloody diarrhea concerning for ulcerative colitis flare. ACTIVE ISSUES: # MODERATE-TO-SEVERE PANULCERATIVE COLITIS with # ACUTE FLARE OF ULCERATIVE COLITIS: Had been having diarrhea since ___ that briefly improved with a steroid burst. It started to worse, to greater than 10 bloody bowel movements per day. Her arrival lab work was notable for CRP within normal limits (1.7), with subsequent CRP's also within normal. Stool culture and C. diff PCR negative; O&P pending at time of discharge. She was given IV methylprednisolone for 3d, and received her scheduled dose of vedolizumab (300mg) on ___ without difficulty. Her bowel movements decreased in frequency, from greater than 10 per day, to less than 4. She felt markedly improved at discharge and was sent home with a course of 40mg prednisone for at least 2 weeks (or until such time as she follows up with her gastroenterologist, ___, on ___. # HEADACHES: Pt with constant frontal headache since ___, for which she took Aleve + Tylenol without relief. No other neurologic symptoms associated with it. Initially improved with fioricet, but also improved with hydration in the ED and standing PO Tylenol. She was without headaches at time of discharge. TRANSITIONAL ISSUES: #CODE: Full, presumed #CONTACT: ___, spouse, ___ [ ] MEDICATION CHANGES: -Added: Prednisone 40mg daily (D1 ___ - D14 ___, or until such time as seen by Dr. ___, pantoprazole 40mg daily (for GI prophylaxis while on prolonged taper). [ ] PROLONGED STEROID COURSE: -Written for a 14d course of 40mg prednisone daily. Depending on the length of the patient's taper, consider Bactrim for PJP prophylaxis if her course exceeds the equivalent of 20mg prednisone x 30d. [ ] HEADACHES: -If recurrent or persistent headaches, consider referral to Neurology Headache Clinic. Her headaches here did not seem typical for migraines. ============ > 30 minutes in patient care and coordination of discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN nasal congestion 2. Nasonex (*NF*) 50 mcg Other BID:PRN 3. Cetirizine 10 mg PO DAILY:PRN allergies 4. Vitamin D Dose is Unknown PO DAILY 5. Multivitamins 1 TAB PO DAILY 6. vedolizumab 300 mg injection unknown Discharge Medications: 1. Pantoprazole 40 mg PO Q24H RX *pantoprazole 40 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 2. PredniSONE 40 mg PO DAILY Duration: 14 Doses RX *prednisone 20 mg 2 tablet(s) by mouth Daily Disp #*28 Tablet Refills:*0 3. Cetirizine 10 mg PO DAILY:PRN allergies 4. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN nasal congestion 5. Multivitamins 1 TAB PO DAILY 6. Nasonex (*NF*) 50 mcg Other BID:PRN 7. vedolizumab 300 mg injection unknown 8. Vitamin D 400 UNIT PO DAILY Take whatever dosage you were previously taking. Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: Flare of ulcerative colitis Headaches Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms ___, It was a pleasure caring for you at the ___ ___. WHY WAS I SEEN IN THE HOSPITAL? -You were having headaches and bad diarrhea. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? -The stomach doctors looked at your bowels ("sigmoidoscopy"), where they saw that you have a likely ulcerative colitis flare. -You got steroids through the IV to help with your flare. -You received your usually-scheduled medicine ("entyvio," or "vedolizumab") to help with your ulcerative colitis. WHAT SHOULD I DO WHEN I AM AT HOME? -Take your medications, including your steroids, as listed below. -Please follow up with the specialists as listed below. We wish you the best, Your ___ Care Team Followup Instructions: ___
[ "K51011", "Q453", "R51", "R197", "E559" ]
Allergies: Sulfa (Sulfonamide Antibiotics) / Asacol / Dipentum / Mercaptopurine Chief Complaint: Bloody didarrhea Major Surgical or Invasive Procedure: Vedolizumab infusion ([MASKED]) History of Present Illness: [MASKED] is a [MASKED] yo woman with PMH of ulcerative colitis, incomplete pancreas divisum, pancreatitis, lactose intolerance who presents with headache and persistent diarrhea. Patient follows with Dr. [MASKED] pan-UC. Colitis first diagnosed on colonoscopy in early [MASKED]. She has had a number of subsequent colonoscopies over the years, with biopsies showing active disease. Her most recent scope was done in [MASKED], which showed rectal scarring and no signs of active disease. A biopsy of colonic and rectal tissue showed normal mucosa. Patient states that the last time she felt well was [MASKED]. Since then, she has had persistent diarrhea. It has increased in frequency, is almost always bloody, and often associated with abdominal pain, bloating and cramping. During this time, she was on treatment with Humira. She saw Dr. [MASKED] in [MASKED], at which time she was started on daily prednisone 30 mg, with plan to start vedolizumab (anti-integrin monoclonal antibody inhibits T cell migration). She recalls some improvement in diarrhea while on steroid, but she felt fatigued/generally unwell. She was instructed to start tapering, but she thinks she may have tapered too quickly. She finished her steroid taper in early [MASKED]. She received her first vedolizumab treatment on [MASKED]. She continues to have bloody bowel movements about 10x/day, and she reports being unable to keep hydrated due to constant fluid loss. She also developed a headache around [MASKED], for which she took Aleve and tylenol and did not feel relief. She describes the headache as constant, localized to the occiput and forehead bilaterally. She denies photophobia, phonophobia, nausea, or vomiting. She does not typically have headache like this. In the ED: - Initial vital signs were notable for: Afebrile, HR 85, BP 114/69 - Exam notable for: abdomen soft, nontender - Labs were notable for: Hb 11.8 - Studies performed include: none - Patient was given: Tylenol, prochlorperazine, Benadryl - Consults: GI GI evaluated the patient in the ED and recommended stool studies, inflammatory markers, and prep for flex sig in the morning. Vitals on transfer: Temp 98.0, BP 110 / 73, HR 78, RR 18, 97 Ra Upon arrival to the floor, patient describes history as above. She continues to have headache. She denies abdominal pain, nausea. She is worried about dehydration. Past Medical History: Pancreas divisum w/ pancreatitis, s/p sphincterotomy [MASKED] Lactose intolerance Ulcerative colitis Seasonal allergies Vitamin D deficiency Social History: [MASKED] Family History: Mother: constipation Father: coronary artery disease, pancreatitis Per OMR review: Father had a myocardial infarction at age [MASKED]. No family history of colon cancer or inflammatory bowel disease. Physical Exam: ADMISSION PHYSICAL EXAM: VITALS: GENERAL: Alert and interactive. Occasionally touches her head in discomfort. HEENT: mucous membranes moist. No oral lesions. Sclera anicteric. Pupils equal and reactive to light. EOMI. 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. Cap refill <2s. No rash. NEUROLOGIC: CN2-12 intact. [MASKED] strength throughout. Normal sensation. DISCHARGE PHYSICAL EXAM: VITALS: [MASKED] 1325 Temp: 98.3 PO BP: 117/76 HR: 97 RR: 18 O2 sat: 96% O2 delivery: RA GENERAL: Alert and interactive. Pleasant, alert and appropriate. HEENT: Mucous membranes moist. Sclerae anicteric. CARDIAC: RRR, normal 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. Abdomen is soft, non distended, nontender to palpation without rebound or guarding. EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. Cap refill <2s. No rash. NEUROLOGIC: CN2-12 intact. [MASKED] strength throughout. Normal sensation. Pertinent Results: ADMISSION LABS: [MASKED] 06:56PM LACTATE-0.8 [MASKED] 06:52PM URINE HOURS-RANDOM [MASKED] 06:52PM URINE UHOLD-HOLD [MASKED] 06:52PM URINE COLOR-Straw APPEAR-Clear SP [MASKED] [MASKED] 06:52PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR* BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-SM* [MASKED] 06:52PM URINE RBC-0 WBC-2 BACTERIA-FEW* YEAST-NONE EPI-2 TRANS EPI-<1 [MASKED] 06:52PM URINE MUCOUS-OCC* [MASKED] 06:44PM GLUCOSE-79 UREA N-13 CREAT-0.6 SODIUM-143 POTASSIUM-4.2 CHLORIDE-111* TOTAL CO2-22 ANION GAP-10 [MASKED] 06:44PM estGFR-Using this [MASKED] 06:44PM ALT(SGPT)-19 AST(SGOT)-21 ALK PHOS-91 TOT BILI-0.3 [MASKED] 06:44PM LIPASE-17 [MASKED] 06:44PM ALBUMIN-3.8 CALCIUM-8.6 PHOSPHATE-3.2 MAGNESIUM-1.9 [MASKED] 06:44PM CRP-1.7 [MASKED] 06:44PM WBC-6.6 RBC-4.27 HGB-11.8 HCT-38.2 MCV-90 MCH-27.6 MCHC-30.9* RDW-13.2 RDWSD-43.1 [MASKED] 06:44PM NEUTS-58.6 [MASKED] MONOS-9.1 EOS-4.4 BASOS-0.6 IM [MASKED] AbsNeut-3.88 AbsLymp-1.79 AbsMono-0.60 AbsEos-0.29 AbsBaso-0.04 [MASKED] 06:44PM PLT COUNT-280 PERTINENT IMAGING: FLEXIBLE SIGMOIDOSCOPY ([MASKED]): -Erythema, congestion and friability in the rectum and sigmoid colon to 30cm (biopsy). -Normal mucosa in the sigmoid colon and descending colon starting at 30-50cm (biopsy). PERTINENT MICROBIOLOGY: Stool C. diff ([MASKED]): Negative Stool culture ([MASKED]): Pending, negative to date Stool O&P ([MASKED]): Pending, negative to date Blood cultures ([MASKED]): Pending, NGTD Urine culture ([MASKED]): No growth, final DISCHARGE LABS: [MASKED] 06:31AM BLOOD WBC-8.8 RBC-4.05 Hgb-11.4 Hct-35.1 MCV-87 MCH-28.1 MCHC-32.5 RDW-13.1 RDWSD-40.9 Plt [MASKED] [MASKED] 06:31AM BLOOD Glucose-134* UreaN-9 Creat-0.6 Na-144 K-4.4 Cl-107 HCO3-27 AnGap-10 [MASKED] 06:31AM BLOOD Calcium-9.3 Phos-4.0 Mg-1.8 [MASKED] 06:31AM BLOOD CRP-1.[MASKED] with PMHx ulcerative colitis, incomplete pancreas divisum, and lactose intolerance who presented with headaches and bloody diarrhea concerning for ulcerative colitis flare. ACTIVE ISSUES: # MODERATE-TO-SEVERE PANULCERATIVE COLITIS with # ACUTE FLARE OF ULCERATIVE COLITIS: Had been having diarrhea since [MASKED] that briefly improved with a steroid burst. It started to worse, to greater than 10 bloody bowel movements per day. Her arrival lab work was notable for CRP within normal limits (1.7), with subsequent CRP's also within normal. Stool culture and C. diff PCR negative; O&P pending at time of discharge. She was given IV methylprednisolone for 3d, and received her scheduled dose of vedolizumab (300mg) on [MASKED] without difficulty. Her bowel movements decreased in frequency, from greater than 10 per day, to less than 4. She felt markedly improved at discharge and was sent home with a course of 40mg prednisone for at least 2 weeks (or until such time as she follows up with her gastroenterologist, [MASKED], on [MASKED]. # HEADACHES: Pt with constant frontal headache since [MASKED], for which she took Aleve + Tylenol without relief. No other neurologic symptoms associated with it. Initially improved with fioricet, but also improved with hydration in the ED and standing PO Tylenol. She was without headaches at time of discharge. TRANSITIONAL ISSUES: #CODE: Full, presumed #CONTACT: [MASKED], spouse, [MASKED] [ ] MEDICATION CHANGES: -Added: Prednisone 40mg daily (D1 [MASKED] - D14 [MASKED], or until such time as seen by Dr. [MASKED], pantoprazole 40mg daily (for GI prophylaxis while on prolonged taper). [ ] PROLONGED STEROID COURSE: -Written for a 14d course of 40mg prednisone daily. Depending on the length of the patient's taper, consider Bactrim for PJP prophylaxis if her course exceeds the equivalent of 20mg prednisone x 30d. [ ] HEADACHES: -If recurrent or persistent headaches, consider referral to Neurology Headache Clinic. Her headaches here did not seem typical for migraines. ============ > 30 minutes in patient care and coordination of discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN nasal congestion 2. Nasonex (*NF*) 50 mcg Other BID:PRN 3. Cetirizine 10 mg PO DAILY:PRN allergies 4. Vitamin D Dose is Unknown PO DAILY 5. Multivitamins 1 TAB PO DAILY 6. vedolizumab 300 mg injection unknown Discharge Medications: 1. Pantoprazole 40 mg PO Q24H RX *pantoprazole 40 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 2. PredniSONE 40 mg PO DAILY Duration: 14 Doses RX *prednisone 20 mg 2 tablet(s) by mouth Daily Disp #*28 Tablet Refills:*0 3. Cetirizine 10 mg PO DAILY:PRN allergies 4. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN nasal congestion 5. Multivitamins 1 TAB PO DAILY 6. Nasonex (*NF*) 50 mcg Other BID:PRN 7. vedolizumab 300 mg injection unknown 8. Vitamin D 400 UNIT PO DAILY Take whatever dosage you were previously taking. Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: Flare of ulcerative colitis Headaches Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms [MASKED], It was a pleasure caring for you at the [MASKED] [MASKED]. WHY WAS I SEEN IN THE HOSPITAL? -You were having headaches and bad diarrhea. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? -The stomach doctors looked at your bowels ("sigmoidoscopy"), where they saw that you have a likely ulcerative colitis flare. -You got steroids through the IV to help with your flare. -You received your usually-scheduled medicine ("entyvio," or "vedolizumab") to help with your ulcerative colitis. WHAT SHOULD I DO WHEN I AM AT HOME? -Take your medications, including your steroids, as listed below. -Please follow up with the specialists as listed below. We wish you the best, Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[]
[ "K51011: Ulcerative (chronic) pancolitis with rectal bleeding", "Q453: Other congenital malformations of pancreas and pancreatic duct", "R51: Headache", "R197: Diarrhea, unspecified", "E559: Vitamin D deficiency, unspecified" ]
19,999,784
21,739,106
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Scheduled Chemotherapy and Port Placement Major Surgical or Invasive Procedure: ___ - Port Placement History of Present Illness: ___ yo male with a history of recently diagnosed neurolymphomatosis who is admitted for port placement and cycle 1 methotrexate. The patient states he has been feeling well and denies any recent fevers, headaches, shortness of breath, nausea, diarrhea, dysuria, or rashes. He occasionally has some pain or tiredness feeling in his legs. Of note he was recently admitted from ___ - ___ with a CSF leak so his chemotherapy was delayed. He received rituxan on ___. Past Medical History: PAST ONCOLOGIC HISTORY: - Neurolymphomatosis (1) swallowing study on ___ showed oropharyngeal and esophageal dysphagia on the right-sided, (2) gadolinium-enhanced thoracic and lumbar MRI on ___ showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side, (3) CT of the torso on ___ showed no malignancy, (4) lumbar puncture on ___ showed ___ WBC, ___ RBC, 114 protein, 63 glucose, 19 LDH, beta-2-microglobulin 1.87 (normal 0.36-2.56), CA ___ <6, VDRL non-reactive, and negative cytology for malignant cells, (5) bone marrow aspiration on ___ showed lambda restricted plasma cells, (6) gadolinium-enhanced lumbar MRI performed on ___ again showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side, and this enhancement appears slightly more prominent, (7) lumbar puncture on ___ showed 26 WBC, 4 RBC, 146 protein, 57 glucose, 23 LDH, and atypical large lymphoid cells in cytology, (8) lumbar puncture on ___ showed 27 WBC, 0 RBC, 88 protein, 55 glucose, 33 LDH, beta-2-microglobulion 2.50 (range 0.36-2.56) and presence of oligoclonal bands, (9) laminectomy L2-5 for right L5 nerve resection on ___ by Dr. ___ and the pathology showed neurolymphomatosis, (10) HBV core antibody positive on ___ and ___, (11) HIV negative on ___, (12) echocardiogram showed LVEF >55%, (13) FDG-PET showed uptake in the lower spinal cord but no systemic uptake, (14) PICC line insertion on ___, (15) started C1W1 rituximab 375 mg/m2 and lamivudine 100 mg QD on ___, (16) CSF leak on ___, (17) discontinuation of lamuvidine and dexamethasone on ___, (18) repair of CSF leak on ___ by Dr. ___ (19) Rituxan ___. Social History: ___ Family History: Father had prostate cancer. Denies otherwise history of blood or oncologic history. Physical Exam: ======================== Admission Physical Exam: ======================== General: NAD. VITAL SIGNS: T 97.5 BP 127/74 HR 97 RR 18 O2 100% RA. HEENT: MMM, no OP lesions. CV: RR, NL S1S2. PULM: CTAB. ABD: Soft, NTND, no masses or hepatosplenomegaly. LIMBS: No edema, clubbing, tremors, or asterixis. SKIN: No rashes or skin breakdown, Lumbar surgical incision well healing without drainage or opening. NEURO: Alert and oriented, Cranial nerves II-XII are within normal limits excluding visual acuity which was not assessed, no nystagmus; strength is ___ of the proximal and distal upper and lower extremities; no focal deficits. ======================== Discharge Physical Exam: ======================== VS: 97.7, BP 141/80, HR 79, RR 18, O2 sat 99% RA. Right chest wall port. Exam otherwise unchanged. Pertinent Results: =============== Admission Labs: =============== ___ 01:28PM BLOOD WBC-4.4 RBC-3.83* Hgb-10.3* Hct-31.9* MCV-83 MCH-26.9 MCHC-32.3 RDW-14.0 RDWSD-42.6 Plt ___ ___ 01:28PM BLOOD Neuts-66.5 ___ Monos-7.8 Eos-1.8 Baso-0.5 Im ___ AbsNeut-2.90 AbsLymp-1.01* AbsMono-0.34 AbsEos-0.08 AbsBaso-0.02 ___ 01:28PM BLOOD ___ PTT-28.7 ___ ___ 01:28PM BLOOD Glucose-82 UreaN-10 Creat-0.7 Na-140 K-4.1 Cl-102 HCO3-26 AnGap-12 ___ 01:28PM BLOOD ALT-15 AST-12 AlkPhos-75 TotBili-0.3 ___ 01:28PM BLOOD Calcium-9.3 Phos-3.8 Mg-2.1 =============== Discharge Labs: =============== ___ 02:00AM BLOOD WBC-4.5 RBC-3.52* Hgb-9.7* Hct-29.1* MCV-83 MCH-27.6 MCHC-33.3 RDW-14.1 RDWSD-42.3 Plt ___ ___ 02:00AM BLOOD Glucose-97 UreaN-7 Creat-0.9 Na-142 K-3.5 Cl-98 HCO3-34* AnGap-10 ___ 02:00AM BLOOD ALT-59* AST-31 AlkPhos-68 TotBili-0.3 ___ 02:00AM BLOOD Calcium-8.7 Phos-3.7 Mg-2.4 ___ 01:53PM BLOOD mthotrx-0.14 ======== Imaging: ======== CXR ___ Impression: In comparison with the study of ___, the cardiac silhouette remains within normal limits without evidence of vascular congestion, pleural effusion, or acute focal pneumonia. The right subclavian PICC line remains at the midportion of the SVC. Brief Hospital Course: Mr. ___ is a ___ male with history of recently diagnosed neurolymphomatosis who is admitted for port placement and cycle 1 methotrexate. # Neurolymphomatosis: Port placed on ___. Received cycle 1 methotrexate per protocol with leucovorin and sodium bicarb and premedications which he tolerated well. His methotrexate level at discharge was 0.14. As he had not completely cleared he was discharged with 3 days of PO leucovorin and instructions to drink lots of fluids. He will return to clinic on ___ ___ for rituxan. He will return for admission for next cycle of methotrexate on ___. # Elevated Aminotransferases: Mild elevation likely secondary to methotrexate. Improving at time of discharge. # Severe Protein-Calorie Malnutrition: Meets criteria based on weight loss and decreased intake. # Anemia: Likely secondary to malignancy and inflammatory state. No evidence of bleeding. # MGUS: Needs outpatient Hematology follow-up. # BILLING: 45 minutes were spent in preparation of discharge paperwork and coordination with outpatient providers. ==================== Transitional Issues: ==================== - Plan for admission to ___ for next cycle of methotrexate on ___. Patient provided with prescription for sodium bicarbonate to take prior to scheduled admissions. - Patient discharged with leucovorin tablets and hydration instructions for 3 days as methotrexate level at discharge was slightly higher than goal at 0.14. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 2. Docusate Sodium 100 mg PO BID 3. Senna 8.6 mg PO BID:PRN constipation 4. Multivitamins 1 TAB PO DAILY 5. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild Discharge Medications: 1. Leucovorin Calcium 40 mg PO Q6H RX *leucovorin calcium 10 mg Take 4 tablets by mouth every 6 hours. Disp #*48 Tablet Refills:*0 2. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting RX *ondansetron HCl 8 mg Take 1 tablet by mouth every 8 hours Disp #*30 Tablet Refills:*0 3. Sodium Bicarbonate 1300 mg PO Q6H RX *sodium bicarbonate 650 mg Take 2 tablets by mouth every 6 hours. Disp #*64 Tablet Refills:*2 4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 5. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 6. Docusate Sodium 100 mg PO BID 7. Multivitamins 1 TAB PO DAILY 8. Senna 8.6 mg PO BID:PRN constipation Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnosis: - Neurolymphomatosis 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 ___ ___. You were admitted for your first cycle of methotrexate which you tolerated well. You also had a port placed. You methotrexate levels were monitored and were slightly high prior to discharge. Please take the leucovorin four times per day for the next 3 days for a total of 12 doses. Please also stay hydrated and drink lots of water over the next 3 days. After discussion with Dr. ___ your radiation oncologist Dr. ___, it was decided to hold off on radiation for right now so you do not have to keep your radiation mapping appointment on ___. You have an appointment on ___ for your next dose of Rituxan as below. You will return to ___ for your next cycle of methotrexate on ___. Please start taking the sodium bicarbonate pills two days prior to your methotrexate admissions. All the best, Your ___ Team Followup Instructions: ___
[ "Z5111", "E43", "C8339", "Z87891", "D630", "D472", "Z6821", "R740", "T451X5A", "Y92239" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Scheduled Chemotherapy and Port Placement Major Surgical or Invasive Procedure: [MASKED] - Port Placement History of Present Illness: [MASKED] yo male with a history of recently diagnosed neurolymphomatosis who is admitted for port placement and cycle 1 methotrexate. The patient states he has been feeling well and denies any recent fevers, headaches, shortness of breath, nausea, diarrhea, dysuria, or rashes. He occasionally has some pain or tiredness feeling in his legs. Of note he was recently admitted from [MASKED] - [MASKED] with a CSF leak so his chemotherapy was delayed. He received rituxan on [MASKED]. Past Medical History: PAST ONCOLOGIC HISTORY: - Neurolymphomatosis (1) swallowing study on [MASKED] showed oropharyngeal and esophageal dysphagia on the right-sided, (2) gadolinium-enhanced thoracic and lumbar MRI on [MASKED] showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side, (3) CT of the torso on [MASKED] showed no malignancy, (4) lumbar puncture on [MASKED] showed [MASKED] WBC, [MASKED] RBC, 114 protein, 63 glucose, 19 LDH, beta-2-microglobulin 1.87 (normal 0.36-2.56), CA [MASKED] <6, VDRL non-reactive, and negative cytology for malignant cells, (5) bone marrow aspiration on [MASKED] showed lambda restricted plasma cells, (6) gadolinium-enhanced lumbar MRI performed on [MASKED] again showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side, and this enhancement appears slightly more prominent, (7) lumbar puncture on [MASKED] showed 26 WBC, 4 RBC, 146 protein, 57 glucose, 23 LDH, and atypical large lymphoid cells in cytology, (8) lumbar puncture on [MASKED] showed 27 WBC, 0 RBC, 88 protein, 55 glucose, 33 LDH, beta-2-microglobulion 2.50 (range 0.36-2.56) and presence of oligoclonal bands, (9) laminectomy L2-5 for right L5 nerve resection on [MASKED] by Dr. [MASKED] and the pathology showed neurolymphomatosis, (10) HBV core antibody positive on [MASKED] and [MASKED], (11) HIV negative on [MASKED], (12) echocardiogram showed LVEF >55%, (13) FDG-PET showed uptake in the lower spinal cord but no systemic uptake, (14) PICC line insertion on [MASKED], (15) started C1W1 rituximab 375 mg/m2 and lamivudine 100 mg QD on [MASKED], (16) CSF leak on [MASKED], (17) discontinuation of lamuvidine and dexamethasone on [MASKED], (18) repair of CSF leak on [MASKED] by Dr. [MASKED] (19) Rituxan [MASKED]. Social History: [MASKED] Family History: Father had prostate cancer. Denies otherwise history of blood or oncologic history. Physical Exam: ======================== Admission Physical Exam: ======================== General: NAD. VITAL SIGNS: T 97.5 BP 127/74 HR 97 RR 18 O2 100% RA. HEENT: MMM, no OP lesions. CV: RR, NL S1S2. PULM: CTAB. ABD: Soft, NTND, no masses or hepatosplenomegaly. LIMBS: No edema, clubbing, tremors, or asterixis. SKIN: No rashes or skin breakdown, Lumbar surgical incision well healing without drainage or opening. NEURO: Alert and oriented, Cranial nerves II-XII are within normal limits excluding visual acuity which was not assessed, no nystagmus; strength is [MASKED] of the proximal and distal upper and lower extremities; no focal deficits. ======================== Discharge Physical Exam: ======================== VS: 97.7, BP 141/80, HR 79, RR 18, O2 sat 99% RA. Right chest wall port. Exam otherwise unchanged. Pertinent Results: =============== Admission Labs: =============== [MASKED] 01:28PM BLOOD WBC-4.4 RBC-3.83* Hgb-10.3* Hct-31.9* MCV-83 MCH-26.9 MCHC-32.3 RDW-14.0 RDWSD-42.6 Plt [MASKED] [MASKED] 01:28PM BLOOD Neuts-66.5 [MASKED] Monos-7.8 Eos-1.8 Baso-0.5 Im [MASKED] AbsNeut-2.90 AbsLymp-1.01* AbsMono-0.34 AbsEos-0.08 AbsBaso-0.02 [MASKED] 01:28PM BLOOD [MASKED] PTT-28.7 [MASKED] [MASKED] 01:28PM BLOOD Glucose-82 UreaN-10 Creat-0.7 Na-140 K-4.1 Cl-102 HCO3-26 AnGap-12 [MASKED] 01:28PM BLOOD ALT-15 AST-12 AlkPhos-75 TotBili-0.3 [MASKED] 01:28PM BLOOD Calcium-9.3 Phos-3.8 Mg-2.1 =============== Discharge Labs: =============== [MASKED] 02:00AM BLOOD WBC-4.5 RBC-3.52* Hgb-9.7* Hct-29.1* MCV-83 MCH-27.6 MCHC-33.3 RDW-14.1 RDWSD-42.3 Plt [MASKED] [MASKED] 02:00AM BLOOD Glucose-97 UreaN-7 Creat-0.9 Na-142 K-3.5 Cl-98 HCO3-34* AnGap-10 [MASKED] 02:00AM BLOOD ALT-59* AST-31 AlkPhos-68 TotBili-0.3 [MASKED] 02:00AM BLOOD Calcium-8.7 Phos-3.7 Mg-2.4 [MASKED] 01:53PM BLOOD mthotrx-0.14 ======== Imaging: ======== CXR [MASKED] Impression: In comparison with the study of [MASKED], the cardiac silhouette remains within normal limits without evidence of vascular congestion, pleural effusion, or acute focal pneumonia. The right subclavian PICC line remains at the midportion of the SVC. Brief Hospital Course: Mr. [MASKED] is a [MASKED] male with history of recently diagnosed neurolymphomatosis who is admitted for port placement and cycle 1 methotrexate. # Neurolymphomatosis: Port placed on [MASKED]. Received cycle 1 methotrexate per protocol with leucovorin and sodium bicarb and premedications which he tolerated well. His methotrexate level at discharge was 0.14. As he had not completely cleared he was discharged with 3 days of PO leucovorin and instructions to drink lots of fluids. He will return to clinic on [MASKED] [MASKED] for rituxan. He will return for admission for next cycle of methotrexate on [MASKED]. # Elevated Aminotransferases: Mild elevation likely secondary to methotrexate. Improving at time of discharge. # Severe Protein-Calorie Malnutrition: Meets criteria based on weight loss and decreased intake. # Anemia: Likely secondary to malignancy and inflammatory state. No evidence of bleeding. # MGUS: Needs outpatient Hematology follow-up. # BILLING: 45 minutes were spent in preparation of discharge paperwork and coordination with outpatient providers. ==================== Transitional Issues: ==================== - Plan for admission to [MASKED] for next cycle of methotrexate on [MASKED]. Patient provided with prescription for sodium bicarbonate to take prior to scheduled admissions. - Patient discharged with leucovorin tablets and hydration instructions for 3 days as methotrexate level at discharge was slightly higher than goal at 0.14. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 2. Docusate Sodium 100 mg PO BID 3. Senna 8.6 mg PO BID:PRN constipation 4. Multivitamins 1 TAB PO DAILY 5. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild Discharge Medications: 1. Leucovorin Calcium 40 mg PO Q6H RX *leucovorin calcium 10 mg Take 4 tablets by mouth every 6 hours. Disp #*48 Tablet Refills:*0 2. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting RX *ondansetron HCl 8 mg Take 1 tablet by mouth every 8 hours Disp #*30 Tablet Refills:*0 3. Sodium Bicarbonate 1300 mg PO Q6H RX *sodium bicarbonate 650 mg Take 2 tablets by mouth every 6 hours. Disp #*64 Tablet Refills:*2 4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 5. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 6. Docusate Sodium 100 mg PO BID 7. Multivitamins 1 TAB PO DAILY 8. Senna 8.6 mg PO BID:PRN constipation Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Primary Diagnosis: - Neurolymphomatosis 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]. You were admitted for your first cycle of methotrexate which you tolerated well. You also had a port placed. You methotrexate levels were monitored and were slightly high prior to discharge. Please take the leucovorin four times per day for the next 3 days for a total of 12 doses. Please also stay hydrated and drink lots of water over the next 3 days. After discussion with Dr. [MASKED] your radiation oncologist Dr. [MASKED], it was decided to hold off on radiation for right now so you do not have to keep your radiation mapping appointment on [MASKED]. You have an appointment on [MASKED] for your next dose of Rituxan as below. You will return to [MASKED] for your next cycle of methotrexate on [MASKED]. Please start taking the sodium bicarbonate pills two days prior to your methotrexate admissions. All the best, Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "Z87891" ]
[ "Z5111: Encounter for antineoplastic chemotherapy", "E43: Unspecified severe protein-calorie malnutrition", "C8339: Diffuse large B-cell lymphoma, extranodal and solid organ sites", "Z87891: Personal history of nicotine dependence", "D630: Anemia in neoplastic disease", "D472: Monoclonal gammopathy", "Z6821: Body mass index [BMI] 21.0-21.9, adult", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause" ]
19,999,784
23,064,891
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Neurolymphomatosis Major Surgical or Invasive Procedure: None History of Present Illness: ___ PRIMARY ONCOLOGIST: ___, MD PRIMARY CARE PHYSICIAN: ___, MD PRIMARY DIAGNOSIS: Neurolymphomatosis, MGUS TREATMENT REGIMEN: HD-MTX C4D1 ___, rituximab C4D1 ___ CC: ___ chemotherapy, neurolymphomatosis HISTORY OF PRESENTING ILLNESS: Mr. ___ is a ___ year-old gentlema with a history of MGUS and neurolymphomatosis on rituximab/HD-MTX presenting for his fifth cycle of induction HD-MTX. He has felt well since his previous discharge. He reports that the swelling in his left foot is improved as well as the strength on flexion of his left foot. He continues to have hyperpigmentation in both of his forearms which are, in his opinion, unchanged from past discharge. He asks to start his chemotherapy as soon as possible. Patient denies fevers/chills, night sweats, headache, vision changes, dizziness/lightheadedness, weakness/numbnesss, shortness of breath, cough, hemoptysis, chest pain, palpitations, abdominal pain, nausea/vomiting, diarrhea, hematemesis, hematochezia/melena, dysuria, hematuria. 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 (Per OMR, reviewed): (1) swallowing study on ___ showed oropharyngeal and esophageal dysphagia on the right-sided, (2) gadolinium-enhanced thoracic and lumbar MRI on ___ showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side, (3) CT of the torso on ___ showed no malignancy, (4) lumbar puncture on ___ showed ___ WBC, ___ RBC, 114 protein, 63 glucose, 19 LDH, beta-2-microglobulin 1.87 (normal 0.36-2.56), CA ___ <6, VDRL non-reactive, and negative cytology for malignant cells, (5) bone marrow aspiration on ___ showed lambda restricted plasma cells, (6) gadolinium-enhanced lumbar MRI performed on ___ again showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side, and this enhancement appears slightly more prominent, and (7) lumbar puncture on ___ showed 26 WBC, 4 RBC, 146 protein, 57 glucose, 23 LDH, and atypical large lymphoid cells in cytology, (8) lumbar puncture on ___ showed 27 WBC, 0 RBC, 88 protein, 55 glucose, 33 LDH, beta-2-microglobulion 2.50 (range 0.36-2.56) and presence of oligoclonal bands, (9) laminectomy L2-5 for right L5 nerve resection on ___ by Dr. ___ and the pathology showed neurolymphomatosis, (10) HBV core antibody positive on ___ and ___, (11) HIV negative on ___, (12) echocardiogram showed LVEF >55%, (13) FDG-PET from ___ showed uptake in the lower spinal cord but no systemic uptake, (14) PICC line insertion on ___, (15) started C1W1 rituximab 375 mg/m2 and lamivudine 100 mg QD on ___, (16) CSF leak on ___, (17) discontinuation of lamuvidine and dexamethasone on ___, (18) repair of CSF leak on ___ by Dr. ___, (19) received C1W1 rituximab 375 mg/m2/week on ___, (20) Portacath placement on ___, (21) received C1 high-dose methotrexate at 6 grams/m2 on ___, (22) received C1W1 rituximab 375 mg/m2/week on ___, (23) received C1W2 rituximab 375 mg/m2/week on ___, (24) received C1W3 rituximab 375 mg/m2/week on ___, (25) received C2 high-dose methotrexate at 8 grams/m2 on ___, (26) received C1W4 rituximab 375 mg/m2/week on ___, (27) received C2 rituximab 375 mg/m2/week on ___, (28) received C3 high-dose methotrexate at 8 grams/m2 on ___, and (29) received C4 high-dose methotrexate at 8 grams/m2 on ___ Social History: ___ Family History: His father died at age ___ and he had dementia and prostate cancer. His mother is alive with osteoarthritis, knee replacement, asthma and tuberculosis. He has 3 siblings and they are all healthy. He does not have children. Physical Exam: 98.5 PO 167 / 91 65 16 98 Ra GENERAL: Well- appearing gentleman, in no distress lying in bed comfortably. HEENT: Anicteric, PERLL, Mucous membranes moist, oropharynx clear. CARDIAC: Regular rate and rhythm, no murmurs, rubs or gallops. LUNG: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi. ABD: Non-distended, normal bowel sounds, soft, non-tender, no guarding. EXT: Warm, well perfused. No lower extremity edema. No erythema or tenderness. NEURO: Alert and oriented, good attention, linear thought process. CN II-XII intact. Strength full throughout except for ___ in left foot flexion. Sensation to light touch intact. SKIN: Well-demarkated hyperpigmentation of bilateral forearms both in anterior/posterior surfaces. Right chest port without erythema, secretion, tenderness. Pertinent Results: ___ 04:39AM BLOOD WBC-2.0* RBC-3.49* Hgb-9.4* Hct-29.4* MCV-84 MCH-26.9 MCHC-32.0 RDW-15.6* RDWSD-47.5* Plt ___ ___ 04:39AM BLOOD Glucose-95 UreaN-3* Creat-0.8 Na-141 K-3.4* Cl-95* HCO3-39* AnGap-7* ___ 04:39AM BLOOD ALT-50* AST-29 LD(LDH)-130 AlkPhos-83 TotBili-0.3 ___ 04:39AM BLOOD Albumin-3.3* Calcium-8.9 Phos-3.6 Mg-1.7 ___ 04:39AM BLOOD mthotrx-0.14 ___ 03:31PM BLOOD mthotrx-0.44* ___ 04:47AM BLOOD mthotrx-0.25* ___ 08:30PM BLOOD mthotrx-0.93* ___ 08:33PM BLOOD mthotrx-1.6* ___ 08:20PM BLOOD mthotrx-5.3* Brief Hospital Course: ___ w/ MGUS and neurolymphomatosis on HD MTX/Rituxan who presents for admission for C5 q 2 week induction HD MTX. # Neurolymphomatosis (on HD MTX/Rituximab) His CSF leak has resolved and continues to improve neurologically. No evidence of systemic lymphoma and is off dexamethasone and not on antiepileptics. His post laminectomy at L2-5 for nerve resection on ___ resulted in LLE weakness which is improving. He tolerated his cycle well with HD MTX except for some nausea which resolved with substituting bicarb tabs with calcium carbonate - C5 HD MTX per Dr ___ on a q 2 week cycle - MRI/PET/LP to be done within next week which will determine next cycle - Urine alkalinization w/ tums as sodium bicarb tabs causing N/V - per Dr ___ patient was clearing slowly and he was requesting to go home asap, and his level was between 0.10 and 0.30 (level was 0.14 on discharge), he will take leucovorin and bicarbonate tabs q6h - he tolerated Bicarb IV continuous @ 200 mL/hr, will go up to 250 ml/hr next cycle to help expedite clearance - Emend with the next cycle of MTX # MGUS: With rising IgG level. Will recheck IgG in 2 months # Elevated BP: Multiple SBPs >150, likely from IVF. He will obtain BP monitor for home use # HBcAb+: HbSag/ab-. HBV viral load UL. Dr ___ will discuss w/ patient whether he wants antiviral # Hypokalemia: expected from bicarb fluid and repleted FEN: Regular diet DVT PROPHYLAXIS: Lovenox 40 sc q24hr (he declined) while inpatient ACCESS: PORT CODE STATUS: Full code, presumed HCP: Health Care Proxy: ___ PCP: ___, MD DISPO: Home BILLING: >30 min spent coordinating care for discharge ________________ ___, D.___. Heme/___ Hospitalist p: ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 3. Docusate Sodium 100 mg PO BID:PRN constipation 4. Senna 8.6 mg PO BID:PRN constipation 5. Sodium Bicarbonate 1300 mg PO Q6H 6. Multivitamins 1 TAB PO DAILY 7. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting Discharge Medications: 1. Leucovorin Calcium 100 mg PO Q6H Duration: 3 Days RX *leucovorin calcium 25 mg 4 tablet(s) by mouth q6 Disp #*48 Tablet Refills:*1 2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 4. Docusate Sodium 100 mg PO BID:PRN constipation 5. Multivitamins 1 TAB PO DAILY 6. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 7. Senna 8.6 mg PO BID:PRN constipation 8. Sodium Bicarbonate 1300 mg PO Q6H Duration: 3 Days start taking 1 day before your next admission for methotrexate RX *sodium bicarbonate 650 mg 2 tablet(s) by mouth q6 Disp #*32 Tablet Refills:*6 Discharge Disposition: Home Discharge Diagnosis: Neurolymphomatosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr ___ ___ tolerated your chemotherapy well. Please take your medications as instructed and follow up with Dr ___. Do not take any aspirin or any other medications in the class of NSAIDs such as ibuprofen, motrin, aleve in preparation for your lumbar puncture with Dr. ___. Please see the attached reference for the PET CT scan preparation. ___ need to follow a strict diet for this PET scan to be successful. Because your methotrexate level was still elevated, ___ were discharged on a 3 day course of Leucovorin and Sodium Bicarbonate. Please drink at least ___ liters of fluid a day to keep your urine clear. Followup Instructions: ___
[ "Z5111", "C8599", "D472", "E876", "T451X5A", "Y92230", "R030", "F17210" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Neurolymphomatosis Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] PRIMARY ONCOLOGIST: [MASKED], MD PRIMARY CARE PHYSICIAN: [MASKED], MD PRIMARY DIAGNOSIS: Neurolymphomatosis, MGUS TREATMENT REGIMEN: HD-MTX C4D1 [MASKED], rituximab C4D1 [MASKED] CC: [MASKED] chemotherapy, neurolymphomatosis HISTORY OF PRESENTING ILLNESS: Mr. [MASKED] is a [MASKED] year-old gentlema with a history of MGUS and neurolymphomatosis on rituximab/HD-MTX presenting for his fifth cycle of induction HD-MTX. He has felt well since his previous discharge. He reports that the swelling in his left foot is improved as well as the strength on flexion of his left foot. He continues to have hyperpigmentation in both of his forearms which are, in his opinion, unchanged from past discharge. He asks to start his chemotherapy as soon as possible. Patient denies fevers/chills, night sweats, headache, vision changes, dizziness/lightheadedness, weakness/numbnesss, shortness of breath, cough, hemoptysis, chest pain, palpitations, abdominal pain, nausea/vomiting, diarrhea, hematemesis, hematochezia/melena, dysuria, hematuria. 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 (Per OMR, reviewed): (1) swallowing study on [MASKED] showed oropharyngeal and esophageal dysphagia on the right-sided, (2) gadolinium-enhanced thoracic and lumbar MRI on [MASKED] showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side, (3) CT of the torso on [MASKED] showed no malignancy, (4) lumbar puncture on [MASKED] showed [MASKED] WBC, [MASKED] RBC, 114 protein, 63 glucose, 19 LDH, beta-2-microglobulin 1.87 (normal 0.36-2.56), CA [MASKED] <6, VDRL non-reactive, and negative cytology for malignant cells, (5) bone marrow aspiration on [MASKED] showed lambda restricted plasma cells, (6) gadolinium-enhanced lumbar MRI performed on [MASKED] again showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side, and this enhancement appears slightly more prominent, and (7) lumbar puncture on [MASKED] showed 26 WBC, 4 RBC, 146 protein, 57 glucose, 23 LDH, and atypical large lymphoid cells in cytology, (8) lumbar puncture on [MASKED] showed 27 WBC, 0 RBC, 88 protein, 55 glucose, 33 LDH, beta-2-microglobulion 2.50 (range 0.36-2.56) and presence of oligoclonal bands, (9) laminectomy L2-5 for right L5 nerve resection on [MASKED] by Dr. [MASKED] and the pathology showed neurolymphomatosis, (10) HBV core antibody positive on [MASKED] and [MASKED], (11) HIV negative on [MASKED], (12) echocardiogram showed LVEF >55%, (13) FDG-PET from [MASKED] showed uptake in the lower spinal cord but no systemic uptake, (14) PICC line insertion on [MASKED], (15) started C1W1 rituximab 375 mg/m2 and lamivudine 100 mg QD on [MASKED], (16) CSF leak on [MASKED], (17) discontinuation of lamuvidine and dexamethasone on [MASKED], (18) repair of CSF leak on [MASKED] by Dr. [MASKED], (19) received C1W1 rituximab 375 mg/m2/week on [MASKED], (20) Portacath placement on [MASKED], (21) received C1 high-dose methotrexate at 6 grams/m2 on [MASKED], (22) received C1W1 rituximab 375 mg/m2/week on [MASKED], (23) received C1W2 rituximab 375 mg/m2/week on [MASKED], (24) received C1W3 rituximab 375 mg/m2/week on [MASKED], (25) received C2 high-dose methotrexate at 8 grams/m2 on [MASKED], (26) received C1W4 rituximab 375 mg/m2/week on [MASKED], (27) received C2 rituximab 375 mg/m2/week on [MASKED], (28) received C3 high-dose methotrexate at 8 grams/m2 on [MASKED], and (29) received C4 high-dose methotrexate at 8 grams/m2 on [MASKED] Social History: [MASKED] Family History: His father died at age [MASKED] and he had dementia and prostate cancer. His mother is alive with osteoarthritis, knee replacement, asthma and tuberculosis. He has 3 siblings and they are all healthy. He does not have children. Physical Exam: 98.5 PO 167 / 91 65 16 98 Ra GENERAL: Well- appearing gentleman, in no distress lying in bed comfortably. HEENT: Anicteric, PERLL, Mucous membranes moist, oropharynx clear. CARDIAC: Regular rate and rhythm, no murmurs, rubs or gallops. LUNG: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi. ABD: Non-distended, normal bowel sounds, soft, non-tender, no guarding. EXT: Warm, well perfused. No lower extremity edema. No erythema or tenderness. NEURO: Alert and oriented, good attention, linear thought process. CN II-XII intact. Strength full throughout except for [MASKED] in left foot flexion. Sensation to light touch intact. SKIN: Well-demarkated hyperpigmentation of bilateral forearms both in anterior/posterior surfaces. Right chest port without erythema, secretion, tenderness. Pertinent Results: [MASKED] 04:39AM BLOOD WBC-2.0* RBC-3.49* Hgb-9.4* Hct-29.4* MCV-84 MCH-26.9 MCHC-32.0 RDW-15.6* RDWSD-47.5* Plt [MASKED] [MASKED] 04:39AM BLOOD Glucose-95 UreaN-3* Creat-0.8 Na-141 K-3.4* Cl-95* HCO3-39* AnGap-7* [MASKED] 04:39AM BLOOD ALT-50* AST-29 LD(LDH)-130 AlkPhos-83 TotBili-0.3 [MASKED] 04:39AM BLOOD Albumin-3.3* Calcium-8.9 Phos-3.6 Mg-1.7 [MASKED] 04:39AM BLOOD mthotrx-0.14 [MASKED] 03:31PM BLOOD mthotrx-0.44* [MASKED] 04:47AM BLOOD mthotrx-0.25* [MASKED] 08:30PM BLOOD mthotrx-0.93* [MASKED] 08:33PM BLOOD mthotrx-1.6* [MASKED] 08:20PM BLOOD mthotrx-5.3* Brief Hospital Course: [MASKED] w/ MGUS and neurolymphomatosis on HD MTX/Rituxan who presents for admission for C5 q 2 week induction HD MTX. # Neurolymphomatosis (on HD MTX/Rituximab) His CSF leak has resolved and continues to improve neurologically. No evidence of systemic lymphoma and is off dexamethasone and not on antiepileptics. His post laminectomy at L2-5 for nerve resection on [MASKED] resulted in LLE weakness which is improving. He tolerated his cycle well with HD MTX except for some nausea which resolved with substituting bicarb tabs with calcium carbonate - C5 HD MTX per Dr [MASKED] on a q 2 week cycle - MRI/PET/LP to be done within next week which will determine next cycle - Urine alkalinization w/ tums as sodium bicarb tabs causing N/V - per Dr [MASKED] patient was clearing slowly and he was requesting to go home asap, and his level was between 0.10 and 0.30 (level was 0.14 on discharge), he will take leucovorin and bicarbonate tabs q6h - he tolerated Bicarb IV continuous @ 200 mL/hr, will go up to 250 ml/hr next cycle to help expedite clearance - Emend with the next cycle of MTX # MGUS: With rising IgG level. Will recheck IgG in 2 months # Elevated BP: Multiple SBPs >150, likely from IVF. He will obtain BP monitor for home use # HBcAb+: HbSag/ab-. HBV viral load UL. Dr [MASKED] will discuss w/ patient whether he wants antiviral # Hypokalemia: expected from bicarb fluid and repleted FEN: Regular diet DVT PROPHYLAXIS: Lovenox 40 sc q24hr (he declined) while inpatient ACCESS: PORT CODE STATUS: Full code, presumed HCP: Health Care Proxy: [MASKED] PCP: [MASKED], MD DISPO: Home BILLING: >30 min spent coordinating care for discharge [MASKED] [MASKED], D.[MASKED]. Heme/[MASKED] Hospitalist p: [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 3. Docusate Sodium 100 mg PO BID:PRN constipation 4. Senna 8.6 mg PO BID:PRN constipation 5. Sodium Bicarbonate 1300 mg PO Q6H 6. Multivitamins 1 TAB PO DAILY 7. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting Discharge Medications: 1. Leucovorin Calcium 100 mg PO Q6H Duration: 3 Days RX *leucovorin calcium 25 mg 4 tablet(s) by mouth q6 Disp #*48 Tablet Refills:*1 2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 4. Docusate Sodium 100 mg PO BID:PRN constipation 5. Multivitamins 1 TAB PO DAILY 6. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 7. Senna 8.6 mg PO BID:PRN constipation 8. Sodium Bicarbonate 1300 mg PO Q6H Duration: 3 Days start taking 1 day before your next admission for methotrexate RX *sodium bicarbonate 650 mg 2 tablet(s) by mouth q6 Disp #*32 Tablet Refills:*6 Discharge Disposition: Home Discharge Diagnosis: Neurolymphomatosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr [MASKED] [MASKED] tolerated your chemotherapy well. Please take your medications as instructed and follow up with Dr [MASKED]. Do not take any aspirin or any other medications in the class of NSAIDs such as ibuprofen, motrin, aleve in preparation for your lumbar puncture with Dr. [MASKED]. Please see the attached reference for the PET CT scan preparation. [MASKED] need to follow a strict diet for this PET scan to be successful. Because your methotrexate level was still elevated, [MASKED] were discharged on a 3 day course of Leucovorin and Sodium Bicarbonate. Please drink at least [MASKED] liters of fluid a day to keep your urine clear. Followup Instructions: [MASKED]
[]
[ "Y92230", "F17210" ]
[ "Z5111: Encounter for antineoplastic chemotherapy", "C8599: Non-Hodgkin lymphoma, unspecified, extranodal and solid organ sites", "D472: Monoclonal gammopathy", "E876: Hypokalemia", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "R030: Elevated blood-pressure reading, without diagnosis of hypertension", "F17210: Nicotine dependence, cigarettes, uncomplicated" ]
19,999,784
23,406,899
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: chlorhexidine Attending: ___. Chief Complaint: Elective admission for chemotherapy Major Surgical or Invasive Procedure: None History of Present Illness: ___ w/ MGUS and neurolymphomatosis on rituximab/HD-MTX presented for C11 maintenance HD-MTX. This is patient's ___ q2 month HD-MTX. He was last admitted for C10 on ___, which he tolerated well. He also received his rituximab in clinic on ___. He notes a single episode about a month ago of having transient numbness throughout his right leg - this was after he was sitting with his legs crossed and only lasted a few minutes. His only remaining neurologic complaint is weakness in dorsiflexion of his left foot which is improving. He was fitted for AFO to left foot a few months ago. No longer uses a cane to ambulate. Otherwise no headaches or visual complaints. No FC. No CP, SOB or cough. No N/V/D. Nl BM this am. No dysuria. No recent URTI. 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: (1) swallowing study on ___ showed oropharyngeal and esophageal dysphagia on the right-sided, (2) gadolinium-enhanced thoracic and lumbar MRI on ___ showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side, (3) CT of the torso on ___ showed no malignancy, (4) lumbar puncture on ___ showed ___ WBC, ___ RBC, 114 protein, 63 glucose, 19 LDH, beta-2-microglobulin 1.87 (normal 0.36-2.56), CA ___ <6, VDRL non-reactive, and negative cytology for malignant cells, (5) bone marrow aspiration on ___ showed lambda restricted plasma cells, (6) gadolinium-enhanced lumbar MRI performed on ___ again showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side, and this enhancement appears slightly more prominent, and (7) lumbar puncture on ___ showed 26 WBC, 4 RBC, 146 protein, 57 glucose, 23 LDH, and atypical large lymphoid cells in cytology, (8) lumbar puncture on ___ showed 27 WBC, 0 RBC, 88 protein, 55 glucose, 33 LDH, beta-2-microglobulion 2.50 (range 0.36-2.56) and presence of oligoclonal bands, (9) laminectomy L2-5 for right L5 nerve resection on ___ by Dr. ___ and the pathology showed neurolymphomatosis, (10) HBV core antibody positive on ___ and ___, (11) HIV negative on ___, (12) echocardiogram showed LVEF >55%, (13) FDG-PET from ___ showed uptake in the lower spinal cord but no systemic uptake, (14) PICC line insertion on ___, (15) started C1W1 rituximab 375 mg/m2 and lamivudine 100 mg QD on ___, (16) CSF leak on ___, (17) discontinuation of lamuvidine and dexamethasone on ___, (18) repair of CSF leak on ___ by Dr. ___, (19) received C1W1 rituximab 375 mg/m2/week on ___, (20) Portacath placement on ___, (21) received C1 high-dose methotrexate at 6 grams/m2 on ___, (22) received C1W1 rituximab 375 mg/m2/week on ___, (23) received C1W2 rituximab 375 mg/m2/week on ___, (24) received C1W3 rituximab 375 mg/m2/week on ___, (25) received C2 high-dose methotrexate at 8 grams/m2 on ___, (26) received C1W4 rituximab 375 mg/m2/week on ___, (27) received C2 rituximab 375 mg/m2/week on ___, (28) received C3 high-dose methotrexate at 8 grams/m2 on ___, (29) received C3 rituximab 375 mg/m2/week on ___, (30) received C4 high-dose methotrexate at 8 grams/m2 on ___, (30) received C4 rituximab 375 mg/m2/week on ___, (31) received C5 high-dose methotrexate at 8 grams/m2 on ___, (32) gadolinium-enhanced total spine MRI on ___ showed response, (33) gadolinium-enhanced head MRI on ___ showed no evidence of disease, (34) FDG-PET on ___ showed improved FDG-Avid disease at T12-L2, (35) CSF cytology showed atypical cells, (36) received C5 monthly maintenance rituximab 375 mg/m2/week on ___, (37) received C6 first monthly maintenance high-dose methotrexate at 8 grams/m2 on ___, (38) gadolinium-enhanced MRI of the lumbosacral spine performed on ___ showed no evidence of disease, (39) received C6 second monthly maintenance rituximab 375 mg/m2/week on ___, (40) received C7 second monthly maintenance high-dose methotrexate at 8 grams/m2 on ___, (41) received C7 third monthly maintenance rituximab 375 mg/m2/week on ___, (42) received C8 maintenance rituximab 375 mg/m2/week on ___ (43) received C8 third monthly maintenance rituximab 375 mg/m2/week on ___, (44) received C9 first 2-month interval rituximab 375 mg/m2/week on ___, and (45) received C9 2-month interval maintenance high-dose methotrexate at 8 grams/m2 on ___ (46) received C10 interval maintenance rituximab 375 mg/m2/week on ___. (47) received C10 ___ 2-month interval maintenance high-dose methotrexate at 8 grams/m2 on ___. (48)received C11 interval maintenance rituximab 375 mg/m2/week on ___. PAST MEDICAL HISTORY: - MGUS - Laminectomy L2-5 for nerve resection on ___ c/b CSF leak on ___ s/p subsequent repair - Left foot drop - Elbow Bursitis - HBcAb+: HbSag/ab-. HBV viral load UL. Indicative of prior infection. Discussed w/ Dr ___ by previous providers with decision to hold off on antiviral for reactivation Social History: ___ Family History: His father died at age ___ and he had dementia and prostate cancer. His mother is alive with osteoarthritis, knee replacement, asthma and tuberculosis. He has 3 siblings and they are all healthy. He does not have children. Physical Exam: ADMISSION PHYSICAL EXAM: VS: T 97.7 HR 80 BP 137/87 RR 16 SAT 100% O2 on RA GENERAL: Pleasant, lying in bed comfortably EYES: Anicteric sclerea, PERLL, EOMI; ENT: Oropharynx clear without lesion, JVD not elevated CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or gallops; 2+ radial pulses RESPIRATORY: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi GASTROINTESTINAL: Normal bowel sounds; nondistended; soft, nontender without rebound or guarding; no hepatomegaly, no splenomegaly MUSKULOSKELATAL: Warm, well perfused extremities without lower extremity edema; Normal bulk NEURO: Alert, oriented, CN III-XII intact, motor and sensory function grossly intact aside from maybe ___ left dorsiflexion SKIN: No significant rashes LYMPHATIC: No cervical, supraclavicular, submandibular lymphadenopathy. No significant ecchymoses DISCHARGE EXAM: ___ 0748 Temp: 97.9 PO BP: 144/91 L Lying HR: 53 RR: 16 O2 sat: 100% O2 delivery: RA GENERAL: Pleasant, sitting up in bed EYES: Anicteric sclerae, PERLL, EOMI; ENT: Oropharynx clear without lesion, JVD not elevated CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or gallops RESPIRATORY: Appears in no respiratory distress, clear to auscultation bilaterally GASTROINTESTINAL: Normal bowel sounds; nondistended; soft, nontender without rebound or guarding MUSKULOSKELATAL: Warm, well perfused extremities without lower extremity edema; Normal bulk NEURO: Alert, oriented, motor and sensory function grossly intact SKIN: No significant rashes Pertinent Results: ADMISSION LABS: =============== ___ 10:25AM BLOOD WBC-3.4* RBC-4.30* Hgb-11.8* Hct-36.4* MCV-85 MCH-27.4 MCHC-32.4 RDW-14.6 RDWSD-44.6 Plt ___ ___ 10:25AM BLOOD Glucose-94 UreaN-14 Creat-1.0 Na-142 K-3.9 Cl-102 HCO3-30 AnGap-10 ___ 10:25AM BLOOD ALT-16 AST-18 TotBili-0.2 ___ 10:25AM BLOOD Albumin-4.0 Calcium-9.1 Phos-3.4 Mg-2.2 DISCHARGE LABS: =============== ___ 05:46AM BLOOD WBC-2.6* RBC-4.13* Hgb-11.2* Hct-34.8* MCV-84 MCH-27.1 MCHC-32.2 RDW-13.2 RDWSD-41.0 Plt ___ ___ 03:57PM BLOOD K-3.4* ___ 05:46AM BLOOD Glucose-92 UreaN-3* Creat-0.9 Na-141 K-3.4* Cl-98 HCO3-35* AnGap-8* ___ 05:46AM BLOOD Calcium-8.7 Phos-3.2 Mg-1.8 ___ 03:57PM BLOOD mthotrx-0.31* IMAGING: ======== ___ Imaging MR ___ & W/O CONT 1. No significant change since the previous MRI study. 2. No abnormal enhancement or signal within the distal spinal cord or abnormal intraspinal enhancement. 3. Mild degenerative changes and lumbar laminectomy as before. 4. Dumping of the nerve roots in the lower lumbar region indicating arachnoiditis. Brief Hospital Course: PRINCIPLE REASON FOR ADMISSION: ___ w/ MGUS and neurolymphomatosis on rituximab/HD-MTX presented for C11 maintenance HD-MTX. He received 8g/m2 infusion on ___. As his typical course has been, he had delayed clearance, but otherwise tolerated infusion well. With prior admissions, we allowed discharge when MTX<0.3 with strict instructions to continue po leucovorin and bicarb tabs x3 days. His level ___ returned at 0.31, this was discussed with ___ who felt that it was safe to discharge him. He will follow up in ___ with PET-CT. His next HD MTX treatment is planned in three months on ___. # Encounter for HD-MTX chemotherapy: Patient presented for C11 maintenance HD-MTX. Urine was alkalanized per protocol po NaHCO3 and 150mEq NaHCO3/D5w at 250 cc/hr (as he tends to clear slowly). Underwent 8g/m2 HD-MTX infusion on ___ per OMS order set. Leucovorin rescue 24 hours post infusion. Monitored MTX levels q24 hours. As is his pattern, he had delayed MTX clearance. There was no evidence of extravascular fluid collection. As per Dr ___ admits, patient ok to discharge when level less than 0.3, with NaHCO3 1300mg q6 hours and leucovorin 40mg q6 hours for three days after admission. His level ___ returned at 0.31, this was discussed with ___ who felt that it was safe to discharge him. Maintained on MTX Diet (No carbonated beverages, no citric acid, no Vit C) and avoided PPI, bactrim, PCNs and cephalosporins w/ HD MTX. # Neurolymphomatosis: # SP laminectomy at L2-5 for nerve resection (___) # Left foot drop Patient will have yearly PET-CT in ___. Next HD-MTX treatment scheduled in 3 months, on ___. Left foot drop continues to improve. He has AFO to left foot prn. # Normocytic anemia # Leukopenia: Stable and at recent baseline. ___ with Dr. ___ ___ him for MGUS). #Hypokalemia: Expected effect of chemotherapy treatment. PRN sliding scale for repletion. #MGUS: Followed by Dr ___ as outpatient as previously scheduled #Hypertension: Not currently on meds. BP's typically 150's during admissions. Should follow up with PCP # ___: HbSag/ab-. HBV viral load negative ___. Indicative of prior infection. No plans for antiviral treatment TRANSITIONAL ISSUES: - Cont leucovorin 40mg q6 hours x3 days - Con't NaHCO3 1300mg q6 hours x3 days - ___ with PET_CT in ___ - Next HD-MTX with rituximab in 3 months (HD MTX scheduled for ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 3. Sodium Bicarbonate 1300 mg PO QID 4. Leucovorin Calcium 40 mg PO Q6H 5. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Moderate 6. Diazepam 5 mg PO Q8H:PRN muscle spasm Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Diazepam 5 mg PO Q8H:PRN muscle spasm 3. Leucovorin Calcium 40 mg PO Q6H Duration: 3 Days RX *leucovorin calcium 10 mg 4 tablet(s) by mouth four times a day Disp #*48 Tablet Refills:*3 4. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 5. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Moderate 6. Sodium Bicarbonate 1300 mg PO QID Duration: 3 Days Take for three days before and after chemotherapy RX *sodium bicarbonate 650 mg 2 tablet(s) by mouth four times a day Disp #*24 Tablet Refills:*6 Discharge Disposition: Home Discharge Diagnosis: # Admission for chemotherapy # Neurolymphomatosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you at ___ ___. You were admitted for your scheduled chemotherapy, which you tolerated well. You have a PET scan scheduled in ___, with follow up in Dr. ___ afterward. Your next planned HD-MTX treatment will be in three months on ___. Dr. ___ will arrange for rituximab before that admission. Please be sure to take your leucovorin and bicarb tabs for the next three days. Your methotrexate level prior to discharge was 0.31. We discussed this with Dr ___ works with Dr. ___. He felt that it was safe for you to leave the hospital, but it is very important to take your leucovorin and bicarbonate for the next 3 days. Sincerely, Your ___ Care Team Followup Instructions: ___
[ "Z5111", "C8589", "D472", "M21372", "Z87891", "Z8042", "D649", "D72819", "E876", "T451X5A", "Y92230", "I10" ]
Allergies: chlorhexidine Chief Complaint: Elective admission for chemotherapy Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] w/ MGUS and neurolymphomatosis on rituximab/HD-MTX presented for C11 maintenance HD-MTX. This is patient's [MASKED] q2 month HD-MTX. He was last admitted for C10 on [MASKED], which he tolerated well. He also received his rituximab in clinic on [MASKED]. He notes a single episode about a month ago of having transient numbness throughout his right leg - this was after he was sitting with his legs crossed and only lasted a few minutes. His only remaining neurologic complaint is weakness in dorsiflexion of his left foot which is improving. He was fitted for AFO to left foot a few months ago. No longer uses a cane to ambulate. Otherwise no headaches or visual complaints. No FC. No CP, SOB or cough. No N/V/D. Nl BM this am. No dysuria. No recent URTI. 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: (1) swallowing study on [MASKED] showed oropharyngeal and esophageal dysphagia on the right-sided, (2) gadolinium-enhanced thoracic and lumbar MRI on [MASKED] showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side, (3) CT of the torso on [MASKED] showed no malignancy, (4) lumbar puncture on [MASKED] showed [MASKED] WBC, [MASKED] RBC, 114 protein, 63 glucose, 19 LDH, beta-2-microglobulin 1.87 (normal 0.36-2.56), CA [MASKED] <6, VDRL non-reactive, and negative cytology for malignant cells, (5) bone marrow aspiration on [MASKED] showed lambda restricted plasma cells, (6) gadolinium-enhanced lumbar MRI performed on [MASKED] again showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side, and this enhancement appears slightly more prominent, and (7) lumbar puncture on [MASKED] showed 26 WBC, 4 RBC, 146 protein, 57 glucose, 23 LDH, and atypical large lymphoid cells in cytology, (8) lumbar puncture on [MASKED] showed 27 WBC, 0 RBC, 88 protein, 55 glucose, 33 LDH, beta-2-microglobulion 2.50 (range 0.36-2.56) and presence of oligoclonal bands, (9) laminectomy L2-5 for right L5 nerve resection on [MASKED] by Dr. [MASKED] and the pathology showed neurolymphomatosis, (10) HBV core antibody positive on [MASKED] and [MASKED], (11) HIV negative on [MASKED], (12) echocardiogram showed LVEF >55%, (13) FDG-PET from [MASKED] showed uptake in the lower spinal cord but no systemic uptake, (14) PICC line insertion on [MASKED], (15) started C1W1 rituximab 375 mg/m2 and lamivudine 100 mg QD on [MASKED], (16) CSF leak on [MASKED], (17) discontinuation of lamuvidine and dexamethasone on [MASKED], (18) repair of CSF leak on [MASKED] by Dr. [MASKED], (19) received C1W1 rituximab 375 mg/m2/week on [MASKED], (20) Portacath placement on [MASKED], (21) received C1 high-dose methotrexate at 6 grams/m2 on [MASKED], (22) received C1W1 rituximab 375 mg/m2/week on [MASKED], (23) received C1W2 rituximab 375 mg/m2/week on [MASKED], (24) received C1W3 rituximab 375 mg/m2/week on [MASKED], (25) received C2 high-dose methotrexate at 8 grams/m2 on [MASKED], (26) received C1W4 rituximab 375 mg/m2/week on [MASKED], (27) received C2 rituximab 375 mg/m2/week on [MASKED], (28) received C3 high-dose methotrexate at 8 grams/m2 on [MASKED], (29) received C3 rituximab 375 mg/m2/week on [MASKED], (30) received C4 high-dose methotrexate at 8 grams/m2 on [MASKED], (30) received C4 rituximab 375 mg/m2/week on [MASKED], (31) received C5 high-dose methotrexate at 8 grams/m2 on [MASKED], (32) gadolinium-enhanced total spine MRI on [MASKED] showed response, (33) gadolinium-enhanced head MRI on [MASKED] showed no evidence of disease, (34) FDG-PET on [MASKED] showed improved FDG-Avid disease at T12-L2, (35) CSF cytology showed atypical cells, (36) received C5 monthly maintenance rituximab 375 mg/m2/week on [MASKED], (37) received C6 first monthly maintenance high-dose methotrexate at 8 grams/m2 on [MASKED], (38) gadolinium-enhanced MRI of the lumbosacral spine performed on [MASKED] showed no evidence of disease, (39) received C6 second monthly maintenance rituximab 375 mg/m2/week on [MASKED], (40) received C7 second monthly maintenance high-dose methotrexate at 8 grams/m2 on [MASKED], (41) received C7 third monthly maintenance rituximab 375 mg/m2/week on [MASKED], (42) received C8 maintenance rituximab 375 mg/m2/week on [MASKED] (43) received C8 third monthly maintenance rituximab 375 mg/m2/week on [MASKED], (44) received C9 first 2-month interval rituximab 375 mg/m2/week on [MASKED], and (45) received C9 2-month interval maintenance high-dose methotrexate at 8 grams/m2 on [MASKED] (46) received C10 interval maintenance rituximab 375 mg/m2/week on [MASKED]. (47) received C10 [MASKED] 2-month interval maintenance high-dose methotrexate at 8 grams/m2 on [MASKED]. (48)received C11 interval maintenance rituximab 375 mg/m2/week on [MASKED]. PAST MEDICAL HISTORY: - MGUS - Laminectomy L2-5 for nerve resection on [MASKED] c/b CSF leak on [MASKED] s/p subsequent repair - Left foot drop - Elbow Bursitis - HBcAb+: HbSag/ab-. HBV viral load UL. Indicative of prior infection. Discussed w/ Dr [MASKED] by previous providers with decision to hold off on antiviral for reactivation Social History: [MASKED] Family History: His father died at age [MASKED] and he had dementia and prostate cancer. His mother is alive with osteoarthritis, knee replacement, asthma and tuberculosis. He has 3 siblings and they are all healthy. He does not have children. Physical Exam: ADMISSION PHYSICAL EXAM: VS: T 97.7 HR 80 BP 137/87 RR 16 SAT 100% O2 on RA GENERAL: Pleasant, lying in bed comfortably EYES: Anicteric sclerea, PERLL, EOMI; ENT: Oropharynx clear without lesion, JVD not elevated CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or gallops; 2+ radial pulses RESPIRATORY: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi GASTROINTESTINAL: Normal bowel sounds; nondistended; soft, nontender without rebound or guarding; no hepatomegaly, no splenomegaly MUSKULOSKELATAL: Warm, well perfused extremities without lower extremity edema; Normal bulk NEURO: Alert, oriented, CN III-XII intact, motor and sensory function grossly intact aside from maybe [MASKED] left dorsiflexion SKIN: No significant rashes LYMPHATIC: No cervical, supraclavicular, submandibular lymphadenopathy. No significant ecchymoses DISCHARGE EXAM: [MASKED] 0748 Temp: 97.9 PO BP: 144/91 L Lying HR: 53 RR: 16 O2 sat: 100% O2 delivery: RA GENERAL: Pleasant, sitting up in bed EYES: Anicteric sclerae, PERLL, EOMI; ENT: Oropharynx clear without lesion, JVD not elevated CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or gallops RESPIRATORY: Appears in no respiratory distress, clear to auscultation bilaterally GASTROINTESTINAL: Normal bowel sounds; nondistended; soft, nontender without rebound or guarding MUSKULOSKELATAL: Warm, well perfused extremities without lower extremity edema; Normal bulk NEURO: Alert, oriented, motor and sensory function grossly intact SKIN: No significant rashes Pertinent Results: ADMISSION LABS: =============== [MASKED] 10:25AM BLOOD WBC-3.4* RBC-4.30* Hgb-11.8* Hct-36.4* MCV-85 MCH-27.4 MCHC-32.4 RDW-14.6 RDWSD-44.6 Plt [MASKED] [MASKED] 10:25AM BLOOD Glucose-94 UreaN-14 Creat-1.0 Na-142 K-3.9 Cl-102 HCO3-30 AnGap-10 [MASKED] 10:25AM BLOOD ALT-16 AST-18 TotBili-0.2 [MASKED] 10:25AM BLOOD Albumin-4.0 Calcium-9.1 Phos-3.4 Mg-2.2 DISCHARGE LABS: =============== [MASKED] 05:46AM BLOOD WBC-2.6* RBC-4.13* Hgb-11.2* Hct-34.8* MCV-84 MCH-27.1 MCHC-32.2 RDW-13.2 RDWSD-41.0 Plt [MASKED] [MASKED] 03:57PM BLOOD K-3.4* [MASKED] 05:46AM BLOOD Glucose-92 UreaN-3* Creat-0.9 Na-141 K-3.4* Cl-98 HCO3-35* AnGap-8* [MASKED] 05:46AM BLOOD Calcium-8.7 Phos-3.2 Mg-1.8 [MASKED] 03:57PM BLOOD mthotrx-0.31* IMAGING: ======== [MASKED] Imaging MR [MASKED] & W/O CONT 1. No significant change since the previous MRI study. 2. No abnormal enhancement or signal within the distal spinal cord or abnormal intraspinal enhancement. 3. Mild degenerative changes and lumbar laminectomy as before. 4. Dumping of the nerve roots in the lower lumbar region indicating arachnoiditis. Brief Hospital Course: PRINCIPLE REASON FOR ADMISSION: [MASKED] w/ MGUS and neurolymphomatosis on rituximab/HD-MTX presented for C11 maintenance HD-MTX. He received 8g/m2 infusion on [MASKED]. As his typical course has been, he had delayed clearance, but otherwise tolerated infusion well. With prior admissions, we allowed discharge when MTX<0.3 with strict instructions to continue po leucovorin and bicarb tabs x3 days. His level [MASKED] returned at 0.31, this was discussed with [MASKED] who felt that it was safe to discharge him. He will follow up in [MASKED] with PET-CT. His next HD MTX treatment is planned in three months on [MASKED]. # Encounter for HD-MTX chemotherapy: Patient presented for C11 maintenance HD-MTX. Urine was alkalanized per protocol po NaHCO3 and 150mEq NaHCO3/D5w at 250 cc/hr (as he tends to clear slowly). Underwent 8g/m2 HD-MTX infusion on [MASKED] per OMS order set. Leucovorin rescue 24 hours post infusion. Monitored MTX levels q24 hours. As is his pattern, he had delayed MTX clearance. There was no evidence of extravascular fluid collection. As per Dr [MASKED] admits, patient ok to discharge when level less than 0.3, with NaHCO3 1300mg q6 hours and leucovorin 40mg q6 hours for three days after admission. His level [MASKED] returned at 0.31, this was discussed with [MASKED] who felt that it was safe to discharge him. Maintained on MTX Diet (No carbonated beverages, no citric acid, no Vit C) and avoided PPI, bactrim, PCNs and cephalosporins w/ HD MTX. # Neurolymphomatosis: # SP laminectomy at L2-5 for nerve resection ([MASKED]) # Left foot drop Patient will have yearly PET-CT in [MASKED]. Next HD-MTX treatment scheduled in 3 months, on [MASKED]. Left foot drop continues to improve. He has AFO to left foot prn. # Normocytic anemia # Leukopenia: Stable and at recent baseline. [MASKED] with Dr. [MASKED] [MASKED] him for MGUS). #Hypokalemia: Expected effect of chemotherapy treatment. PRN sliding scale for repletion. #MGUS: Followed by Dr [MASKED] as outpatient as previously scheduled #Hypertension: Not currently on meds. BP's typically 150's during admissions. Should follow up with PCP # [MASKED]: HbSag/ab-. HBV viral load negative [MASKED]. Indicative of prior infection. No plans for antiviral treatment TRANSITIONAL ISSUES: - Cont leucovorin 40mg q6 hours x3 days - Con't NaHCO3 1300mg q6 hours x3 days - [MASKED] with PET CT in [MASKED] - Next HD-MTX with rituximab in 3 months (HD MTX scheduled for [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 3. Sodium Bicarbonate 1300 mg PO QID 4. Leucovorin Calcium 40 mg PO Q6H 5. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Moderate 6. Diazepam 5 mg PO Q8H:PRN muscle spasm Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Diazepam 5 mg PO Q8H:PRN muscle spasm 3. Leucovorin Calcium 40 mg PO Q6H Duration: 3 Days RX *leucovorin calcium 10 mg 4 tablet(s) by mouth four times a day Disp #*48 Tablet Refills:*3 4. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 5. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Moderate 6. Sodium Bicarbonate 1300 mg PO QID Duration: 3 Days Take for three days before and after chemotherapy RX *sodium bicarbonate 650 mg 2 tablet(s) by mouth four times a day Disp #*24 Tablet Refills:*6 Discharge Disposition: Home Discharge Diagnosis: # Admission for chemotherapy # Neurolymphomatosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], It was a pleasure taking care of you at [MASKED] [MASKED]. You were admitted for your scheduled chemotherapy, which you tolerated well. You have a PET scan scheduled in [MASKED], with follow up in Dr. [MASKED] afterward. Your next planned HD-MTX treatment will be in three months on [MASKED]. Dr. [MASKED] will arrange for rituximab before that admission. Please be sure to take your leucovorin and bicarb tabs for the next three days. Your methotrexate level prior to discharge was 0.31. We discussed this with Dr [MASKED] works with Dr. [MASKED]. He felt that it was safe for you to leave the hospital, but it is very important to take your leucovorin and bicarbonate for the next 3 days. Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "Z87891", "D649", "Y92230", "I10" ]
[ "Z5111: Encounter for antineoplastic chemotherapy", "C8589: Other specified types of non-Hodgkin lymphoma, extranodal and solid organ sites", "D472: Monoclonal gammopathy", "M21372: Foot drop, left foot", "Z87891: Personal history of nicotine dependence", "Z8042: Family history of malignant neoplasm of prostate", "D649: Anemia, unspecified", "D72819: Decreased white blood cell count, unspecified", "E876: Hypokalemia", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "I10: Essential (primary) hypertension" ]
19,999,784
23,519,817
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Scheduled Chemotherapy Major Surgical or Invasive Procedure: None History of Present Illness: ___ PMH of MGUS, Neurolymphatosis (on HD MTX/Rituximab), presents for scheduled HD MTX Cycle 3 On last admission patient left while his MTX level was slightly greater than 0.1, so was discharged on leucovorin. He noted that he was tried of being in the hospital and just wanted to be home at the time. He noted that he took the leucovorin as directed Patient noted that since then he has been afebrile, without any infectious symptoms. He noted that he was without cough, shortness of breath, rhinorrhea, abdominal pain, headache. He noted that his left leg strength continues to improve, but noted that he has persistent pedal edema in the dorsum of left foot (which is stable and thought to be ___ foot drop/inactivity). 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 Dr. ___ clinic note: "His neurologic problem began in late ___ when he noted dysphagia and dysphonia. His voice became hoarse and he developed difficulty swallowing solids and liquids. Solid foods got stuck in his throat. He had decreased PO intake and he lost about ___ lbs. He saw his primary care physician and ___ video swallowing study on ___ showed oropharyngeal and esophageal dysphagia on the right-sided. He was subsequently referred to the ___ clinic. On the day of his evaluation ___, he was found to have left lower extremity weakness. He was sent to the emergency department for evaluation and was admitted to the general neurology service for work up. He underwent a gadolinium-enhanced thoracic and lumbar MRI that showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side. His first lumbar puncture on ___ showed ___ WBC, ___ RBC, 114 protein, 63 glucose, 19 LDH, beta-2-microglobulin 1.87 (normal 0.36-2.56), CA ___ <6, VDRL non-reactive, and negative cytology for malignant cells. He also had a bone marrow aspiration on ___ that showed lambda restricted plasma cells. His repeat gadolinium-enhanced lumbar MRI performed on ___ again showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side, and this enhancement appears slightly more prominent. A second lumbar puncture on ___ showed 26 WBC, 4 RBC, 146 protein, 57 glucose, 23 LDH, and atypical large lymphoid cells in cytology. A third lumbar puncture on ___ showed 27 WBC, 0 RBC, 88 protein, 55 glucose, 33 LDH, beta-2-microglobulion 2.50 (range 0.36-2.56) and presence of oligoclonal bands. Because the diagnosis could not be established via non-invasive measn, he eventually underwent a laminectomy at L2-5 for nerve resection on ___ by Dr. ___. During the immediate postoperative period, he had C1W1 rituximab 375 mg/m2 and lamivudine 100 mg QD on ___. He experienced CSF leak on ___, and therefore lamuvidine and dexamethasone were discontinued on ___. He underwent a repair of CSF leak on ___ by Dr. ___. He re-started rituximab on ___ and high-dose methotrexate on ___ C2 MEthotrexate ___ C2 Rituxan ___ PAST MEDICAL HISTORY: -MGUS -Laminectomy L2-5 for nerve resection on ___ c/b CSF leak on ___ s/p subsequent repair -Left foot drop Social History: ___ Family History: Father had prostate cancer. Denies otherwise history of blood or oncologic history. Physical Exam: PHYSICAL EXAM: Vitals: 24 HR Data (last updated ___ @ 1023) Temp: 98.0 (Tm 98.0), BP: 145/85, HR: 81, RR: 16, O2 sat: 100%, O2 delivery: RA, Wt: 140.2 lb/63.59 kg (140.2-142.2) GENERAL: sitting upright in bed, appears well, smiling, NAD EYES: PERRLA, EOMI HEENT: OP clear, MMM NECK: supple LUNGS: CTA b/l, no wheezes/rales/rhonchi, normal RR CV: RRR normal distal perfusion no edema ABD: soft NT, ND, normoactive BS GENITOURINARY: no foley EXT: gross sensation unchanged in all extremities, but has ___ strength in all muscles of the left lower extremity, RLE/RUE/LUE ___. (maybe slightly stronger than baseline) SKIN: warm, dry, no rash NEURO: AOx3, fluent speech, CNII-XII intact without deficits, strength ___ in LLE, otherwise other extremities normal strength ACCESS: port in right chest, accessed, dressing c/d/i DISCHARGE PHYSICAL EXAM: ___ ___ Temp: 98.3 PO BP: 130/67 HR: 74 RR: 18 O2 sat: 99% O2 delivery: ra GENERAL: Pleasant and well appearing man, ambulating room comfortably EYES: PERRLA, EOMI HEENT: OP clear, MMM NECK: supple, JVD not elevated LUNGS: CTA b/l, no wheezes/rales/rhonchi, normal RR CV: RRR normal distal perfusion no edema ABD: soft NT, ND, normoactive BS EXT: Trace edema left foot with TEDS in place. Normal bulk SKIN: warm, dry, no rash NEURO: AOx3, fluent speech, strength ___ in left hip flexor and knee extensor, 3+/5 dorsiflexion, ___ strength in RLE and BUE. ACCESS: port in right chest, accessed, dressing c/d/i Pertinent Results: ADMISSION LABS: =============== ___ 11:42AM BLOOD WBC-3.8* RBC-3.48* Hgb-9.5* Hct-29.4* MCV-85 MCH-27.3 MCHC-32.3 RDW-15.6* RDWSD-47.8* Plt ___ ___ 11:42AM BLOOD ___ PTT-29.5 ___ ___ 11:42AM BLOOD Glucose-99 UreaN-6 Creat-0.8 Na-142 K-3.8 Cl-102 HCO3-27 AnGap-13 ___ 11:42AM BLOOD ALT-39 AST-24 LD(___)-149 AlkPhos-85 TotBili-0.2 ___ 11:42AM BLOOD Calcium-9.1 Phos-3.8 Mg-2.0 UricAcd-4.9 DISCHARGE LABS: =============== ___ 05:05AM BLOOD WBC-3.2* RBC-3.20* Hgb-8.6* Hct-26.7* MCV-83 MCH-26.9 MCHC-32.2 RDW-14.6 RDWSD-44.4 Plt ___ ___ 05:05AM BLOOD Plt ___ ___ 05:05AM BLOOD Glucose-89 UreaN-4* Creat-0.7 Na-141 K-3.2* Cl-95* HCO3-37* AnGap-9* ___ 05:05AM BLOOD ALT-36 AST-23 LD(___)-132 AlkPhos-70 Amylase-80 TotBili-0.3 ___ 05:05AM BLOOD Albumin-3.3* Calcium-8.6 Phos-3.1 Mg-1.9 Iron-39* ___ 05:05AM BLOOD calTIBC-199* Ferritn-245 TRF-153* ___ 05:05AM BLOOD mthotrx-0.11 IMAGING: ======== ___ Imaging VENOUS DUP EXT UNI (MAP No evidence of deep venous thrombosis in the left lower extremity veins. Brief Hospital Course: PRINCIPLE REASON FOR ADMISSION: ___ PMH of MGUS, Neurolymphatosis (on HD MTX/Rituximab), presented for scheduled HD MTX Cycle 3. # Neurolymphatosis (on HD MTX/Rituximab) Urine was alkalinized per protocol with IV and po NaHCO3. Received infusion on ___. He tolerated infusion well despite some nausea. Leucovorin rescue initiated per protocol. We monitored MTX levels q24 hours. He will continue q2 week HD MTX induction after discharge, but will start to space rituximab to q2 weeks (next will be the ___, prior to his next HD-MTX admission on ___. #Constipation history: Continued home bowel regimen #Left Foot drop c/b left foot edema Patient with slight edema in left foot but not leg, which is likely ___ venous pooling from inactivity due to foot drop. TEDS to help with limited pedal edema. Duplex left leg for DVT negative. Consider outpatient ___. # Transaminitis # Drug induced liver injury: Occurs as expected with HD MTX: Normalized prior to discharge. #Anemia/Leukopenia Indices near baseline, likely combination of Neurolymphatosis and antineoplastic therapy causing BM suppression. # Hypokalemia: Repleted per scales # Billing: >30 minutes spent coordinating and executing this discharge plan TRANSITIONAL ISSUES: ==================== - Start sodium bicarb tabs three days prior to next admission - Next rituximab ___ - Next HD-MTX ___ - Consider higher rate of HCO3 next admission to facilitate quicker clearance Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 3. Docusate Sodium 100 mg PO BID 4. Multivitamins 1 TAB PO DAILY 5. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 6. Senna 8.6 mg PO BID:PRN constipation 7. Sodium Bicarbonate 1300 mg PO Q6H Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 3. Docusate Sodium 100 mg PO BID 4. Multivitamins 1 TAB PO DAILY 5. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 6. Senna 8.6 mg PO BID:PRN constipation 7. Sodium Bicarbonate 1300 mg PO Q6H Discharge Disposition: Home Discharge Diagnosis: # Encounter for chemotherapy # Neurolymphomatosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you at ___ ___. You were admitted for your planned high dose methotrexate chemotherapy, which you tolerated well. You will need to get your next rituximab on ___ and your next HD-MTX admission is planned for ___. You can start taking the sodium bicarbonate tabs 3 days before your next admission. Sincerely, Your ___ Care Team Followup Instructions: ___
[ "Z5111", "C8599", "D701", "D472", "Z87891", "K5900", "R740", "D6481", "E876", "T451X5A", "M21372", "R600" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Scheduled Chemotherapy Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] PMH of MGUS, Neurolymphatosis (on HD MTX/Rituximab), presents for scheduled HD MTX Cycle 3 On last admission patient left while his MTX level was slightly greater than 0.1, so was discharged on leucovorin. He noted that he was tried of being in the hospital and just wanted to be home at the time. He noted that he took the leucovorin as directed Patient noted that since then he has been afebrile, without any infectious symptoms. He noted that he was without cough, shortness of breath, rhinorrhea, abdominal pain, headache. He noted that his left leg strength continues to improve, but noted that he has persistent pedal edema in the dorsum of left foot (which is stable and thought to be [MASKED] foot drop/inactivity). 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 Dr. [MASKED] clinic note: "His neurologic problem began in late [MASKED] when he noted dysphagia and dysphonia. His voice became hoarse and he developed difficulty swallowing solids and liquids. Solid foods got stuck in his throat. He had decreased PO intake and he lost about [MASKED] lbs. He saw his primary care physician and [MASKED] video swallowing study on [MASKED] showed oropharyngeal and esophageal dysphagia on the right-sided. He was subsequently referred to the [MASKED] clinic. On the day of his evaluation [MASKED], he was found to have left lower extremity weakness. He was sent to the emergency department for evaluation and was admitted to the general neurology service for work up. He underwent a gadolinium-enhanced thoracic and lumbar MRI that showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side. His first lumbar puncture on [MASKED] showed [MASKED] WBC, [MASKED] RBC, 114 protein, 63 glucose, 19 LDH, beta-2-microglobulin 1.87 (normal 0.36-2.56), CA [MASKED] <6, VDRL non-reactive, and negative cytology for malignant cells. He also had a bone marrow aspiration on [MASKED] that showed lambda restricted plasma cells. His repeat gadolinium-enhanced lumbar MRI performed on [MASKED] again showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side, and this enhancement appears slightly more prominent. A second lumbar puncture on [MASKED] showed 26 WBC, 4 RBC, 146 protein, 57 glucose, 23 LDH, and atypical large lymphoid cells in cytology. A third lumbar puncture on [MASKED] showed 27 WBC, 0 RBC, 88 protein, 55 glucose, 33 LDH, beta-2-microglobulion 2.50 (range 0.36-2.56) and presence of oligoclonal bands. Because the diagnosis could not be established via non-invasive measn, he eventually underwent a laminectomy at L2-5 for nerve resection on [MASKED] by Dr. [MASKED]. During the immediate postoperative period, he had C1W1 rituximab 375 mg/m2 and lamivudine 100 mg QD on [MASKED]. He experienced CSF leak on [MASKED], and therefore lamuvidine and dexamethasone were discontinued on [MASKED]. He underwent a repair of CSF leak on [MASKED] by Dr. [MASKED]. He re-started rituximab on [MASKED] and high-dose methotrexate on [MASKED] C2 MEthotrexate [MASKED] C2 Rituxan [MASKED] PAST MEDICAL HISTORY: -MGUS -Laminectomy L2-5 for nerve resection on [MASKED] c/b CSF leak on [MASKED] s/p subsequent repair -Left foot drop Social History: [MASKED] Family History: Father had prostate cancer. Denies otherwise history of blood or oncologic history. Physical Exam: PHYSICAL EXAM: Vitals: 24 HR Data (last updated [MASKED] @ 1023) Temp: 98.0 (Tm 98.0), BP: 145/85, HR: 81, RR: 16, O2 sat: 100%, O2 delivery: RA, Wt: 140.2 lb/63.59 kg (140.2-142.2) GENERAL: sitting upright in bed, appears well, smiling, NAD EYES: PERRLA, EOMI HEENT: OP clear, MMM NECK: supple LUNGS: CTA b/l, no wheezes/rales/rhonchi, normal RR CV: RRR normal distal perfusion no edema ABD: soft NT, ND, normoactive BS GENITOURINARY: no foley EXT: gross sensation unchanged in all extremities, but has [MASKED] strength in all muscles of the left lower extremity, RLE/RUE/LUE [MASKED]. (maybe slightly stronger than baseline) SKIN: warm, dry, no rash NEURO: AOx3, fluent speech, CNII-XII intact without deficits, strength [MASKED] in LLE, otherwise other extremities normal strength ACCESS: port in right chest, accessed, dressing c/d/i DISCHARGE PHYSICAL EXAM: [MASKED] [MASKED] Temp: 98.3 PO BP: 130/67 HR: 74 RR: 18 O2 sat: 99% O2 delivery: ra GENERAL: Pleasant and well appearing man, ambulating room comfortably EYES: PERRLA, EOMI HEENT: OP clear, MMM NECK: supple, JVD not elevated LUNGS: CTA b/l, no wheezes/rales/rhonchi, normal RR CV: RRR normal distal perfusion no edema ABD: soft NT, ND, normoactive BS EXT: Trace edema left foot with TEDS in place. Normal bulk SKIN: warm, dry, no rash NEURO: AOx3, fluent speech, strength [MASKED] in left hip flexor and knee extensor, 3+/5 dorsiflexion, [MASKED] strength in RLE and BUE. ACCESS: port in right chest, accessed, dressing c/d/i Pertinent Results: ADMISSION LABS: =============== [MASKED] 11:42AM BLOOD WBC-3.8* RBC-3.48* Hgb-9.5* Hct-29.4* MCV-85 MCH-27.3 MCHC-32.3 RDW-15.6* RDWSD-47.8* Plt [MASKED] [MASKED] 11:42AM BLOOD [MASKED] PTT-29.5 [MASKED] [MASKED] 11:42AM BLOOD Glucose-99 UreaN-6 Creat-0.8 Na-142 K-3.8 Cl-102 HCO3-27 AnGap-13 [MASKED] 11:42AM BLOOD ALT-39 AST-24 LD([MASKED])-149 AlkPhos-85 TotBili-0.2 [MASKED] 11:42AM BLOOD Calcium-9.1 Phos-3.8 Mg-2.0 UricAcd-4.9 DISCHARGE LABS: =============== [MASKED] 05:05AM BLOOD WBC-3.2* RBC-3.20* Hgb-8.6* Hct-26.7* MCV-83 MCH-26.9 MCHC-32.2 RDW-14.6 RDWSD-44.4 Plt [MASKED] [MASKED] 05:05AM BLOOD Plt [MASKED] [MASKED] 05:05AM BLOOD Glucose-89 UreaN-4* Creat-0.7 Na-141 K-3.2* Cl-95* HCO3-37* AnGap-9* [MASKED] 05:05AM BLOOD ALT-36 AST-23 LD([MASKED])-132 AlkPhos-70 Amylase-80 TotBili-0.3 [MASKED] 05:05AM BLOOD Albumin-3.3* Calcium-8.6 Phos-3.1 Mg-1.9 Iron-39* [MASKED] 05:05AM BLOOD calTIBC-199* Ferritn-245 TRF-153* [MASKED] 05:05AM BLOOD mthotrx-0.11 IMAGING: ======== [MASKED] Imaging VENOUS DUP EXT UNI (MAP No evidence of deep venous thrombosis in the left lower extremity veins. Brief Hospital Course: PRINCIPLE REASON FOR ADMISSION: [MASKED] PMH of MGUS, Neurolymphatosis (on HD MTX/Rituximab), presented for scheduled HD MTX Cycle 3. # Neurolymphatosis (on HD MTX/Rituximab) Urine was alkalinized per protocol with IV and po NaHCO3. Received infusion on [MASKED]. He tolerated infusion well despite some nausea. Leucovorin rescue initiated per protocol. We monitored MTX levels q24 hours. He will continue q2 week HD MTX induction after discharge, but will start to space rituximab to q2 weeks (next will be the [MASKED], prior to his next HD-MTX admission on [MASKED]. #Constipation history: Continued home bowel regimen #Left Foot drop c/b left foot edema Patient with slight edema in left foot but not leg, which is likely [MASKED] venous pooling from inactivity due to foot drop. TEDS to help with limited pedal edema. Duplex left leg for DVT negative. Consider outpatient [MASKED]. # Transaminitis # Drug induced liver injury: Occurs as expected with HD MTX: Normalized prior to discharge. #Anemia/Leukopenia Indices near baseline, likely combination of Neurolymphatosis and antineoplastic therapy causing BM suppression. # Hypokalemia: Repleted per scales # Billing: >30 minutes spent coordinating and executing this discharge plan TRANSITIONAL ISSUES: ==================== - Start sodium bicarb tabs three days prior to next admission - Next rituximab [MASKED] - Next HD-MTX [MASKED] - Consider higher rate of HCO3 next admission to facilitate quicker clearance Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 3. Docusate Sodium 100 mg PO BID 4. Multivitamins 1 TAB PO DAILY 5. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 6. Senna 8.6 mg PO BID:PRN constipation 7. Sodium Bicarbonate 1300 mg PO Q6H Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 3. Docusate Sodium 100 mg PO BID 4. Multivitamins 1 TAB PO DAILY 5. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 6. Senna 8.6 mg PO BID:PRN constipation 7. Sodium Bicarbonate 1300 mg PO Q6H Discharge Disposition: Home Discharge Diagnosis: # Encounter for chemotherapy # Neurolymphomatosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], It was a pleasure taking care of you at [MASKED] [MASKED]. You were admitted for your planned high dose methotrexate chemotherapy, which you tolerated well. You will need to get your next rituximab on [MASKED] and your next HD-MTX admission is planned for [MASKED]. You can start taking the sodium bicarbonate tabs 3 days before your next admission. Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "Z87891", "K5900" ]
[ "Z5111: Encounter for antineoplastic chemotherapy", "C8599: Non-Hodgkin lymphoma, unspecified, extranodal and solid organ sites", "D701: Agranulocytosis secondary to cancer chemotherapy", "D472: Monoclonal gammopathy", "Z87891: Personal history of nicotine dependence", "K5900: Constipation, unspecified", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "D6481: Anemia due to antineoplastic chemotherapy", "E876: Hypokalemia", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "M21372: Foot drop, left foot", "R600: Localized edema" ]
19,999,784
23,664,472
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: intramedullary spinal cord lesion at the conus medullaris Major Surgical or Invasive Procedure: ___: L4-L5 lumbar laminectomy and nerve root biopsy ___: Repair of Lumbar CSF Leak History of Present Illness: ___ yo male with no previous medical history who presented to the ED on ___ with new-onset LLE weakness, dysphagia, and dysphonia. He was admitted ___ to ___ to work up new left leg weakness, dysphagia, and dysphonia. MRI showed 1.5 x 0.6 x 0.5 cm T12-L1 intramedullary enhancing lesion. He was subsequently found to have monoclonal gammopathy and concern for plasma cell dyscrasia on bone marrow biopsy. CSF cytology was non-diagnostic at the time, and he was deemed high risk for biopsy of the lesion. He was discharged with outpatient follow up. He had repeat LP on ___ and repeat MRI on ___. There was concern for large lymphocytic proliferation on CSF and seemed to have expansion of lesion on MRI. After evaluation in the spine clinic, the patient ultimately decided to proceed with lumbar laminectomy and biopsy. Past Medical History: PAST ONCOLOGIC HISTORY: ___ is a ___ right-handed man, without ___ medical history, who has subacute onset of dysphagia, dysphonia and left lower extremity weakness over one month. Treatment History: (1) swallowing study on ___ showed oropharyngeal and esophageal dysphagia on the right-sided, (2) gadolinium-enhanced thoracic and lumbar MRI on ___ showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side, (3) CT of the torso on ___ showed no malignancy, (4) lumbar puncture on ___ showed ___ WBC, ___ RBC, 114 protein, 63 glucose, 19 LDH, beta-2-microglobulin 1.87 (normal 0.36-2.56), CA ___ <6, VDRL non-reactive, and negative cytology for malignant cells, and (5) bone marrow aspiration on ___ showed lambda restricted plasma cells, PAST MEDICAL HISTORY: None Social History: ___ Family History: Father had prostate cancer. Denies otherwise history of blood or oncologic history. Physical Exam: ------------- On admission: ------------- GENERAL: Pleasant, well appearing man, lying in bed comfortably EYES: Anicteric sclerea, PERLL, EOMI ENT: Oropharynx with MMM CARDIOVASCULAR: Regular rate and rhythm, 2+ radial pulses RESPIRATORY: Appears in no respiratory distress GASTROINTESTINAL: nondistended, soft, nontender without rebound or guarding MUSKULOSKELATAL: Warm, well perfused extremities without lower extremity edema SKIN: No significant rashes LYMPHATIC: No cervical, supraclavicular, submandibular LAD NEURO: Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious Orientation: [x]Person [x]Place [x]Time Follows commands: [ ]Simple [x]Complex [ ]None Pupils: PERRL ___ EOM: [x]Full [ ]Restricted Face Symmetric: [x]Yes [ ]NoTongue Midline: [x]Yes [ ]No Pronator Drift [ ]Yes [x]No Speech Fluent: [x]Yes [ ]No Comprehension intact [x]Yes [ ]No Motor: TrapDeltoidBicepTricepGrip Right5 5 5 5 5 Left5 5 5 5 5 IPQuadHamATEHLGast Right5 4 5 4 5 5 Left5 3 5 3 0 5 [x]Clonus - negative [x]Sensation decreased in BLE L>R ------------- On discharge: ------------- Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious Orientation: [x]Person [x]Place [x]Time Follows commands: [ ]Simple [x]Complex [ ]None Speech Fluent: [x]Yes [ ]No Comprehension intact [x]Yes [ ]No Motor: Bilateral upper extremity ___ IP Quad Ham AT ___ ___ Right 5 5 5 5 5 5 Left 4 4 5 2 0 5 [x]Numbness and tingling to bilateral lower extremity from knees down stable from preop. Wound: Lumbar incision: c/d/I, staples open to air Pertinent Results: Please see OMR for pertinent results. Brief Hospital Course: Mr. ___ is a ___ without significant medical history, who presented with ___ weakness, with known intramedullary spinal cord lesion and monoclonal gammopathy diagnosed on previous admission in ___. Repeat imaging was concerning for expanding mass. #Intramedullary lesion at the conus meddularis: #CNS lymphoma vs neurolymphomatosis The patient was taken to the operating room on ___ and underwent L4-L5 lumbar laminectomy with nerve root biopsy. He tolerated the procedure well and had an uneventful recovery in the PACU. He was transferred to the ward for continued care and monitoring of his neurologic status. Biopsy resulted as diffuse large B cell lymphoma (primary CNS lymphoms/neurolymphomatosis). He was transferred to ___ to initiate Chemotherapy on ___. PET scan was without additional lesions. Ophthomology was consulted for slit lamp given risk of ophtho lymphoma involvement, which was negative for no eye involvement. He was started on 4mg dexamethasone PO daily on arrival given significant neurological deficits. HbcAb positive, surface ag/ab negative so was started on entecavir for HBV prophylaix in the setting of starting rituximab ___. Planned to initiate Methotrexate ___, but he subsequently developed CSF leak (see below), and chemo was put on hold as he had to return to OR for CSF leak repair. He is cleared to resume steroids in 1 week after surgery (___), and chemo/radiation after 3 weeks (___). #CSF leak s/p durotomy: After biopsy, the patient was placed on strict flat bedrest for 48hr post-operatively. His activity out of bed and HOB status was liberalized the evening of POD2. However the morning of POD3, he was noted to have positional headaches and drainage of clear fluid to his dressings c/f CSF Leak. He was again placed on bed rest precautions with HOB flat x 24hr. On the morning of POD4 Mr. ___ denied positional headaches but his dressings were CDI without any drainage noted. His HOB status was liberalized, and later that day he was permitted OOB, which was well tolerated until ___ when he was noted to have positional headaches, fluid collection with clear fluid leaking from incision concerning for CSF leak. Incision was oversewn with suture ___, however continued with clear drainage. Given persistent leak, he retuned to the OR on ___ and he underwent repair of CSF leak with Dr. ___. Procedure was uncomplicated. He was maintained on strict flat bed rest postoperatively until POD#3. The HOB was elevated by 10 degrees per hour to maximum flexion of bed, which he tolerated well, and then was permitted to get OOB to chair, which he again tolerated well. His activity was advanced to as tolerated the same day. ___ cleared for home with services. The patient remained neurologically stable and was discharged home ___. #Plasma cell dyscresia Monoclonal spike of 730mg/dL found on prior admissions. Prior BM biopsy concerning for plasma cell dyscresia. Likely MGUS. Transitional Issues =================== []ENT follow up for vocal cord paralysis (patient is a ___) # CODE: Presumed Full # EMERGENCY CONTACT: Name of ___ care proxy: ___ ___: partner Phone number: ___ Brother ___: ___ ___ on Admission: 1. Multivitamins W/minerals 1 TAB PO DAILY 2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever Discharge Medications: 1. Bisacodyl 10 mg PO/PR DAILY constipation RX *bisacodyl [Laxative (bisacodyl)] 5 mg 2 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 2. Diazepam ___ mg PO Q8H:PRN muscle spasm or agitation RX *diazepam 2 mg ___ tablets by mouth Q8H PRN Disp #*30 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. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate ___ request partial fill. RX *oxycodone 5 mg ___ tablet(s) by mouth Q4H PRN Disp #*60 Tablet Refills:*0 5. Polyethylene Glycol 17 g PO DAILY Constipation - Third Line 6. Senna 17.2 mg PO QHS RX *sennosides [senna] 8.6 mg 2 tablets by mouth Daily Disp #*30 Tablet Refills:*0 7. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild Reason for PRN duplicate override: Patient is NPO or unable to tolerate PO 8. Multivitamins 1 TAB PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: intramedullary spinal cord lesion at the conus medullaris Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted for intramedullary spinal cord lesion and underwent L4-L5 laminectomy and nerve root biopsy on ___ and repair of CSF leak ___. Surgery •Your dressing may come off. •Your incision is closed with staples. You will need staple removal. Please keep your incision dry until staple removal. •Do not apply any lotions or creams to the site. •Please avoid swimming for two weeks after suture/staple removal. •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. ___ try to do too much all at once. •No driving while taking any narcotic or sedating medication. •No contact sports until cleared by your neurosurgeon. Medications •Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by your neurosurgeon. •You may take Ibuprofen/ Motrin for pain. •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: ___
[ "C8339", "E43", "G9782", "G960", "T8132XA", "D472", "Z720", "Y92239", "Y838", "Z6822" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: intramedullary spinal cord lesion at the conus medullaris Major Surgical or Invasive Procedure: [MASKED]: L4-L5 lumbar laminectomy and nerve root biopsy [MASKED]: Repair of Lumbar CSF Leak History of Present Illness: [MASKED] yo male with no previous medical history who presented to the ED on [MASKED] with new-onset LLE weakness, dysphagia, and dysphonia. He was admitted [MASKED] to [MASKED] to work up new left leg weakness, dysphagia, and dysphonia. MRI showed 1.5 x 0.6 x 0.5 cm T12-L1 intramedullary enhancing lesion. He was subsequently found to have monoclonal gammopathy and concern for plasma cell dyscrasia on bone marrow biopsy. CSF cytology was non-diagnostic at the time, and he was deemed high risk for biopsy of the lesion. He was discharged with outpatient follow up. He had repeat LP on [MASKED] and repeat MRI on [MASKED]. There was concern for large lymphocytic proliferation on CSF and seemed to have expansion of lesion on MRI. After evaluation in the spine clinic, the patient ultimately decided to proceed with lumbar laminectomy and biopsy. Past Medical History: PAST ONCOLOGIC HISTORY: [MASKED] is a [MASKED] right-handed man, without [MASKED] medical history, who has subacute onset of dysphagia, dysphonia and left lower extremity weakness over one month. Treatment History: (1) swallowing study on [MASKED] showed oropharyngeal and esophageal dysphagia on the right-sided, (2) gadolinium-enhanced thoracic and lumbar MRI on [MASKED] showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side, (3) CT of the torso on [MASKED] showed no malignancy, (4) lumbar puncture on [MASKED] showed [MASKED] WBC, [MASKED] RBC, 114 protein, 63 glucose, 19 LDH, beta-2-microglobulin 1.87 (normal 0.36-2.56), CA [MASKED] <6, VDRL non-reactive, and negative cytology for malignant cells, and (5) bone marrow aspiration on [MASKED] showed lambda restricted plasma cells, PAST MEDICAL HISTORY: None Social History: [MASKED] Family History: Father had prostate cancer. Denies otherwise history of blood or oncologic history. Physical Exam: ------------- On admission: ------------- GENERAL: Pleasant, well appearing man, lying in bed comfortably EYES: Anicteric sclerea, PERLL, EOMI ENT: Oropharynx with MMM CARDIOVASCULAR: Regular rate and rhythm, 2+ radial pulses RESPIRATORY: Appears in no respiratory distress GASTROINTESTINAL: nondistended, soft, nontender without rebound or guarding MUSKULOSKELATAL: Warm, well perfused extremities without lower extremity edema SKIN: No significant rashes LYMPHATIC: No cervical, supraclavicular, submandibular LAD NEURO: Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious Orientation: [x]Person [x]Place [x]Time Follows commands: [ ]Simple [x]Complex [ ]None Pupils: PERRL [MASKED] EOM: [x]Full [ ]Restricted Face Symmetric: [x]Yes [ ]NoTongue Midline: [x]Yes [ ]No Pronator Drift [ ]Yes [x]No Speech Fluent: [x]Yes [ ]No Comprehension intact [x]Yes [ ]No Motor: TrapDeltoidBicepTricepGrip Right5 5 5 5 5 Left5 5 5 5 5 IPQuadHamATEHLGast Right5 4 5 4 5 5 Left5 3 5 3 0 5 [x]Clonus - negative [x]Sensation decreased in BLE L>R ------------- On discharge: ------------- Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious Orientation: [x]Person [x]Place [x]Time Follows commands: [ ]Simple [x]Complex [ ]None Speech Fluent: [x]Yes [ ]No Comprehension intact [x]Yes [ ]No Motor: Bilateral upper extremity [MASKED] IP Quad Ham AT [MASKED] [MASKED] Right 5 5 5 5 5 5 Left 4 4 5 2 0 5 [x]Numbness and tingling to bilateral lower extremity from knees down stable from preop. Wound: Lumbar incision: c/d/I, staples open to air Pertinent Results: Please see OMR for pertinent results. Brief Hospital Course: Mr. [MASKED] is a [MASKED] without significant medical history, who presented with [MASKED] weakness, with known intramedullary spinal cord lesion and monoclonal gammopathy diagnosed on previous admission in [MASKED]. Repeat imaging was concerning for expanding mass. #Intramedullary lesion at the conus meddularis: #CNS lymphoma vs neurolymphomatosis The patient was taken to the operating room on [MASKED] and underwent L4-L5 lumbar laminectomy with nerve root biopsy. He tolerated the procedure well and had an uneventful recovery in the PACU. He was transferred to the ward for continued care and monitoring of his neurologic status. Biopsy resulted as diffuse large B cell lymphoma (primary CNS lymphoms/neurolymphomatosis). He was transferred to [MASKED] to initiate Chemotherapy on [MASKED]. PET scan was without additional lesions. Ophthomology was consulted for slit lamp given risk of ophtho lymphoma involvement, which was negative for no eye involvement. He was started on 4mg dexamethasone PO daily on arrival given significant neurological deficits. HbcAb positive, surface ag/ab negative so was started on entecavir for HBV prophylaix in the setting of starting rituximab [MASKED]. Planned to initiate Methotrexate [MASKED], but he subsequently developed CSF leak (see below), and chemo was put on hold as he had to return to OR for CSF leak repair. He is cleared to resume steroids in 1 week after surgery ([MASKED]), and chemo/radiation after 3 weeks ([MASKED]). #CSF leak s/p durotomy: After biopsy, the patient was placed on strict flat bedrest for 48hr post-operatively. His activity out of bed and HOB status was liberalized the evening of POD2. However the morning of POD3, he was noted to have positional headaches and drainage of clear fluid to his dressings c/f CSF Leak. He was again placed on bed rest precautions with HOB flat x 24hr. On the morning of POD4 Mr. [MASKED] denied positional headaches but his dressings were CDI without any drainage noted. His HOB status was liberalized, and later that day he was permitted OOB, which was well tolerated until [MASKED] when he was noted to have positional headaches, fluid collection with clear fluid leaking from incision concerning for CSF leak. Incision was oversewn with suture [MASKED], however continued with clear drainage. Given persistent leak, he retuned to the OR on [MASKED] and he underwent repair of CSF leak with Dr. [MASKED]. Procedure was uncomplicated. He was maintained on strict flat bed rest postoperatively until POD#3. The HOB was elevated by 10 degrees per hour to maximum flexion of bed, which he tolerated well, and then was permitted to get OOB to chair, which he again tolerated well. His activity was advanced to as tolerated the same day. [MASKED] cleared for home with services. The patient remained neurologically stable and was discharged home [MASKED]. #Plasma cell dyscresia Monoclonal spike of 730mg/dL found on prior admissions. Prior BM biopsy concerning for plasma cell dyscresia. Likely MGUS. Transitional Issues =================== []ENT follow up for vocal cord paralysis (patient is a [MASKED]) # CODE: Presumed Full # EMERGENCY CONTACT: Name of [MASKED] care proxy: [MASKED] [MASKED]: partner Phone number: [MASKED] Brother [MASKED]: [MASKED] [MASKED] on Admission: 1. Multivitamins W/minerals 1 TAB PO DAILY 2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever Discharge Medications: 1. Bisacodyl 10 mg PO/PR DAILY constipation RX *bisacodyl [Laxative (bisacodyl)] 5 mg 2 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 2. Diazepam [MASKED] mg PO Q8H:PRN muscle spasm or agitation RX *diazepam 2 mg [MASKED] tablets by mouth Q8H PRN Disp #*30 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. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain - Moderate [MASKED] request partial fill. RX *oxycodone 5 mg [MASKED] tablet(s) by mouth Q4H PRN Disp #*60 Tablet Refills:*0 5. Polyethylene Glycol 17 g PO DAILY Constipation - Third Line 6. Senna 17.2 mg PO QHS RX *sennosides [senna] 8.6 mg 2 tablets by mouth Daily Disp #*30 Tablet Refills:*0 7. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild Reason for PRN duplicate override: Patient is NPO or unable to tolerate PO 8. Multivitamins 1 TAB PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: intramedullary spinal cord lesion at the conus medullaris 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 for intramedullary spinal cord lesion and underwent L4-L5 laminectomy and nerve root biopsy on [MASKED] and repair of CSF leak [MASKED]. Surgery •Your dressing may come off. •Your incision is closed with staples. You will need staple removal. Please keep your incision dry until staple removal. •Do not apply any lotions or creams to the site. •Please avoid swimming for two weeks after suture/staple removal. •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. [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. Medications •Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by your neurosurgeon. •You may take Ibuprofen/ Motrin for pain. •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]
[]
[]
[ "C8339: Diffuse large B-cell lymphoma, extranodal and solid organ sites", "E43: Unspecified severe protein-calorie malnutrition", "G9782: Other postprocedural complications and disorders of nervous system", "G960: Cerebrospinal fluid leak", "T8132XA: Disruption of internal operation (surgical) wound, not elsewhere classified, initial encounter", "D472: Monoclonal gammopathy", "Z720: Tobacco use", "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", "Z6822: Body mass index [BMI] 22.0-22.9, adult" ]
19,999,784
24,755,486
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: chlorhexidine Attending: ___. Chief Complaint: MTX administration Major Surgical or Invasive Procedure: None History of Present Illness: ___ is a ___ yo man with neurolymphomatosis on HD-MTX and rituximab maintenance, who presents for scheduled chemotherapy. He saw Dr ___ in clinic ___ and received C15 of maintenance rituximab. His last PET scan was ___ which showed no evidence of systemic lymphoma. MRI L spine ___ was stable without any new findings. He returns for HD-MTX at q3 month maintenance interval. He is in his USOH. No headache, nausea, vomiting, abd pain, chest pain, SOB, fevers, chills, fatigue, appetite changes, dysuria. He started his sodium bicarb on ___ morning (>48 hrs prior to admission). Past Medical History: PAST ONCOLOGIC HISTORY: (1) swallowing study on ___ showed oropharyngeal and esophageal dysphagia on the right-sided, (2) gadolinium-enhanced thoracic and lumbar MRI on ___ showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side, (3) CT of the torso on ___ showed no malignancy, (4) lumbar puncture on ___ showed ___ WBC, ___ RBC, 114 protein, 63 glucose, 19 LDH, beta-2-microglobulin 1.87 (normal 0.36-2.56), CA ___ <6, VDRL non-reactive, and negative cytology for malignant cells, (5) bone marrow aspiration on ___ showed lambda restricted plasma cells, (6) gadolinium-enhanced lumbar MRI performed on ___ again showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side, and this enhancement appears slightly more prominent, and (7) lumbar puncture on ___ showed 26 WBC, 4 RBC, 146 protein, 57 glucose, 23 LDH, and atypical large lymphoid cells in cytology, (8) lumbar puncture on ___ showed 27 WBC, 0 RBC, 88 protein, 55 glucose, 33 LDH, beta-2-microglobulion 2.50 (range 0.36-2.56) and presence of oligoclonal bands, (9) laminectomy L2-5 for right L5 nerve resection on ___ by Dr. ___ and the pathology showed neurolymphomatosis, (10) HBV core antibody positive on ___ and ___, (11) HIV negative on ___, (12) echocardiogram showed LVEF >55%, (13) FDG-PET from ___ showed uptake in the lower spinal cord but no systemic uptake, (14) PICC line insertion on ___, (15) started C1W1 rituximab 375 mg/m2 and lamivudine 100 mg QD on ___, (16) CSF leak on ___, (17) discontinuation of lamuvidine and dexamethasone on ___, (18) repair of CSF leak on ___ by Dr. ___, (19) received C1W1 rituximab 375 mg/m2/week on ___, (20) Portacath placement on ___, (21) received C1 high-dose methotrexate at 6 grams/m2 on ___, (22) received C1W1 rituximab 375 mg/m2/week on ___, (23) received C1W2 rituximab 375 mg/m2/week on ___, (24) received C1W3 rituximab 375 mg/m2/week on ___, (25) received C2 high-dose methotrexate at 8 grams/m2 on ___, (26) received C1W4 rituximab 375 mg/m2/week on ___, (27) received C2 rituximab 375 mg/m2/week on ___, (28) received C3 high-dose methotrexate at 8 grams/m2 on ___, (29) received C3 rituximab 375 mg/m2/week on ___, (30) received C4 high-dose methotrexate at 8 grams/m2 on ___, (30) received C4 rituximab 375 mg/m2/week on ___, (31) received C5 high-dose methotrexate at 8 grams/m2 on ___, (32) gadolinium-enhanced total spine MRI on ___ showed response, (33) gadolinium-enhanced head MRI on ___ showed no evidence of disease, (34) FDG-PET on ___ showed improved FDG-Avid disease at T12-L2, (35) CSF cytology showed atypical cells, (36) received C5 monthly maintenance rituximab 375 mg/m2/week on ___, (37) received C6 first monthly maintenance high-dose methotrexate at 8 grams/m2 on ___, (38) gadolinium-enhanced MRI of the lumbosacral spine performed on ___ showed no evidence of disease, (39) received C6 second monthly maintenance rituximab 375 mg/m2/week on ___, (40) received C7 second monthly maintenance high-dose methotrexate at 8 grams/m2 on ___, (41) received C7 third monthly maintenance rituximab 375 mg/m2/week on ___, (42) received C8 maintenance rituximab 375 mg/m2/week on ___ (43) received C8 third monthly maintenance rituximab 375 mg/m2/week on ___, (44) received C9 first 2-month interval rituximab 375 mg/m2/week on ___, and (45) received C9 2-month interval maintenance high-dose methotrexate at 8 grams/m2 on ___ (___) received C10 interval maintenance rituximab 375 mg/m2/week on ___. (47) received C10 ___ 2-month interval maintenance high-dose methotrexate at 8 grams/m2 on ___. (___)received C11 interval maintenance rituximab 375 mg/m2/week on ___. (49) Received C11 2-month interval maintenance high-dose methotrexate at 8 grams/m2 on ___: stable MRI L-spine and no definite abnormal area of uptake on FDG PET. PAST MEDICAL HISTORY: - MGUS - Laminectomy L2-5 for nerve resection on ___ c/b CSF leak on ___ s/p subsequent repair - Left foot drop - Elbow Bursitis - HBcAb+: HbSag/ab-. HBV viral load UL. Indicative of prior infection. Discussed w/ Dr ___ by previous providers with decision to hold off on antiviral for reactivation Social History: ___ Family History: His father died at age ___ and he had dementia and prostate cancer. His mother is alive with osteoarthritis, knee replacement, asthma and tuberculosis. He has 3 siblings and they are all healthy. He does not have children. Physical Exam: Vitals: ___ 0727 Temp: 97.5 PO BP: 156/97 HR: 62 RR: 16 O2 sat: 100% O2 delivery: RA GENERAL: NAD, pleasant and cooperative EYES: no scleral icterus HEENT: moist mucous membranes NECK: supple LUNGS: CTAB, no wheezing or rales CV: RRR, S1, S2, no murmurs ABD: BS+; soft, non-tender, no hepatosplenomegaly GENITOURINARY: no foley EXT: moves all 4 extremeties w/ purpose SKIN: intact NEURO: AOx3; gross CNII-XII intact Pertinent Results: ___ 05:30AM BLOOD WBC-3.0* RBC-4.41* Hgb-12.0* Hct-37.5* MCV-85 MCH-27.2 MCHC-32.0 RDW-12.9 RDWSD-40.2 Plt ___ ___ 05:30AM BLOOD Neuts-62.2 ___ Monos-4.7* Eos-4.7 Baso-0.3 Im ___ AbsNeut-1.83 AbsLymp-0.82* AbsMono-0.14* AbsEos-0.14 AbsBaso-0.01 ___ 06:00AM BLOOD Poiklo-1+* Ovalocy-1+* RBC Mor-SLIDE REVI ___ 05:30AM BLOOD Glucose-99 UreaN-4* Creat-0.8 Na-139 K-3.5 Cl-97 HCO3-32 AnGap-10 ___ 05:30AM BLOOD ALT-28 AST-21 ___ 05:30AM BLOOD Albumin-3.6 Calcium-8.6 Phos-3.1 Mg-2.2 ___ 05:30AM BLOOD mthotrx-0.05 Brief Hospital Course: Mr. ___ was admitted for C15 HD-MTX. He tolerated the regimen without major complaints or complications. His levels were monitored frequently while on supportive leucovorin rescue. His level on day of discharge is 0.05. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Diazepam 5 mg PO Q8H:PRN muscle spasm 3. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 4. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Moderate 5. Sodium Bicarbonate 1300 mg PO QID 6. Fluticasone Propionate NASAL 2 SPRY NU BID:PRN allergies Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Diazepam 5 mg PO Q8H:PRN muscle spasm 3. Fluticasone Propionate NASAL 2 SPRY NU BID:PRN allergies 4. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 5. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Moderate 6. Sodium Bicarbonate 1300 mg PO QID Discharge Disposition: Home Discharge Diagnosis: Encounter for antineoplastic therapy Neurolymphomatosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You came to the hospital for MTX administration and tolerated it well. Please confirm with your ___ clinic your next admission date (tentatively scheduled for ___. Best, Your ___ team Followup Instructions: ___
[ "Z5111", "C8580", "E876", "D472", "F17210" ]
Allergies: chlorhexidine Chief Complaint: MTX administration Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] is a [MASKED] yo man with neurolymphomatosis on HD-MTX and rituximab maintenance, who presents for scheduled chemotherapy. He saw Dr [MASKED] in clinic [MASKED] and received C15 of maintenance rituximab. His last PET scan was [MASKED] which showed no evidence of systemic lymphoma. MRI L spine [MASKED] was stable without any new findings. He returns for HD-MTX at q3 month maintenance interval. He is in his USOH. No headache, nausea, vomiting, abd pain, chest pain, SOB, fevers, chills, fatigue, appetite changes, dysuria. He started his sodium bicarb on [MASKED] morning (>48 hrs prior to admission). Past Medical History: PAST ONCOLOGIC HISTORY: (1) swallowing study on [MASKED] showed oropharyngeal and esophageal dysphagia on the right-sided, (2) gadolinium-enhanced thoracic and lumbar MRI on [MASKED] showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side, (3) CT of the torso on [MASKED] showed no malignancy, (4) lumbar puncture on [MASKED] showed [MASKED] WBC, [MASKED] RBC, 114 protein, 63 glucose, 19 LDH, beta-2-microglobulin 1.87 (normal 0.36-2.56), CA [MASKED] <6, VDRL non-reactive, and negative cytology for malignant cells, (5) bone marrow aspiration on [MASKED] showed lambda restricted plasma cells, (6) gadolinium-enhanced lumbar MRI performed on [MASKED] again showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side, and this enhancement appears slightly more prominent, and (7) lumbar puncture on [MASKED] showed 26 WBC, 4 RBC, 146 protein, 57 glucose, 23 LDH, and atypical large lymphoid cells in cytology, (8) lumbar puncture on [MASKED] showed 27 WBC, 0 RBC, 88 protein, 55 glucose, 33 LDH, beta-2-microglobulion 2.50 (range 0.36-2.56) and presence of oligoclonal bands, (9) laminectomy L2-5 for right L5 nerve resection on [MASKED] by Dr. [MASKED] and the pathology showed neurolymphomatosis, (10) HBV core antibody positive on [MASKED] and [MASKED], (11) HIV negative on [MASKED], (12) echocardiogram showed LVEF >55%, (13) FDG-PET from [MASKED] showed uptake in the lower spinal cord but no systemic uptake, (14) PICC line insertion on [MASKED], (15) started C1W1 rituximab 375 mg/m2 and lamivudine 100 mg QD on [MASKED], (16) CSF leak on [MASKED], (17) discontinuation of lamuvidine and dexamethasone on [MASKED], (18) repair of CSF leak on [MASKED] by Dr. [MASKED], (19) received C1W1 rituximab 375 mg/m2/week on [MASKED], (20) Portacath placement on [MASKED], (21) received C1 high-dose methotrexate at 6 grams/m2 on [MASKED], (22) received C1W1 rituximab 375 mg/m2/week on [MASKED], (23) received C1W2 rituximab 375 mg/m2/week on [MASKED], (24) received C1W3 rituximab 375 mg/m2/week on [MASKED], (25) received C2 high-dose methotrexate at 8 grams/m2 on [MASKED], (26) received C1W4 rituximab 375 mg/m2/week on [MASKED], (27) received C2 rituximab 375 mg/m2/week on [MASKED], (28) received C3 high-dose methotrexate at 8 grams/m2 on [MASKED], (29) received C3 rituximab 375 mg/m2/week on [MASKED], (30) received C4 high-dose methotrexate at 8 grams/m2 on [MASKED], (30) received C4 rituximab 375 mg/m2/week on [MASKED], (31) received C5 high-dose methotrexate at 8 grams/m2 on [MASKED], (32) gadolinium-enhanced total spine MRI on [MASKED] showed response, (33) gadolinium-enhanced head MRI on [MASKED] showed no evidence of disease, (34) FDG-PET on [MASKED] showed improved FDG-Avid disease at T12-L2, (35) CSF cytology showed atypical cells, (36) received C5 monthly maintenance rituximab 375 mg/m2/week on [MASKED], (37) received C6 first monthly maintenance high-dose methotrexate at 8 grams/m2 on [MASKED], (38) gadolinium-enhanced MRI of the lumbosacral spine performed on [MASKED] showed no evidence of disease, (39) received C6 second monthly maintenance rituximab 375 mg/m2/week on [MASKED], (40) received C7 second monthly maintenance high-dose methotrexate at 8 grams/m2 on [MASKED], (41) received C7 third monthly maintenance rituximab 375 mg/m2/week on [MASKED], (42) received C8 maintenance rituximab 375 mg/m2/week on [MASKED] (43) received C8 third monthly maintenance rituximab 375 mg/m2/week on [MASKED], (44) received C9 first 2-month interval rituximab 375 mg/m2/week on [MASKED], and (45) received C9 2-month interval maintenance high-dose methotrexate at 8 grams/m2 on [MASKED] ([MASKED]) received C10 interval maintenance rituximab 375 mg/m2/week on [MASKED]. (47) received C10 [MASKED] 2-month interval maintenance high-dose methotrexate at 8 grams/m2 on [MASKED]. ([MASKED])received C11 interval maintenance rituximab 375 mg/m2/week on [MASKED]. (49) Received C11 2-month interval maintenance high-dose methotrexate at 8 grams/m2 on [MASKED]: stable MRI L-spine and no definite abnormal area of uptake on FDG PET. PAST MEDICAL HISTORY: - MGUS - Laminectomy L2-5 for nerve resection on [MASKED] c/b CSF leak on [MASKED] s/p subsequent repair - Left foot drop - Elbow Bursitis - HBcAb+: HbSag/ab-. HBV viral load UL. Indicative of prior infection. Discussed w/ Dr [MASKED] by previous providers with decision to hold off on antiviral for reactivation Social History: [MASKED] Family History: His father died at age [MASKED] and he had dementia and prostate cancer. His mother is alive with osteoarthritis, knee replacement, asthma and tuberculosis. He has 3 siblings and they are all healthy. He does not have children. Physical Exam: Vitals: [MASKED] 0727 Temp: 97.5 PO BP: 156/97 HR: 62 RR: 16 O2 sat: 100% O2 delivery: RA GENERAL: NAD, pleasant and cooperative EYES: no scleral icterus HEENT: moist mucous membranes NECK: supple LUNGS: CTAB, no wheezing or rales CV: RRR, S1, S2, no murmurs ABD: BS+; soft, non-tender, no hepatosplenomegaly GENITOURINARY: no foley EXT: moves all 4 extremeties w/ purpose SKIN: intact NEURO: AOx3; gross CNII-XII intact Pertinent Results: [MASKED] 05:30AM BLOOD WBC-3.0* RBC-4.41* Hgb-12.0* Hct-37.5* MCV-85 MCH-27.2 MCHC-32.0 RDW-12.9 RDWSD-40.2 Plt [MASKED] [MASKED] 05:30AM BLOOD Neuts-62.2 [MASKED] Monos-4.7* Eos-4.7 Baso-0.3 Im [MASKED] AbsNeut-1.83 AbsLymp-0.82* AbsMono-0.14* AbsEos-0.14 AbsBaso-0.01 [MASKED] 06:00AM BLOOD Poiklo-1+* Ovalocy-1+* RBC Mor-SLIDE REVI [MASKED] 05:30AM BLOOD Glucose-99 UreaN-4* Creat-0.8 Na-139 K-3.5 Cl-97 HCO3-32 AnGap-10 [MASKED] 05:30AM BLOOD ALT-28 AST-21 [MASKED] 05:30AM BLOOD Albumin-3.6 Calcium-8.6 Phos-3.1 Mg-2.2 [MASKED] 05:30AM BLOOD mthotrx-0.05 Brief Hospital Course: Mr. [MASKED] was admitted for C15 HD-MTX. He tolerated the regimen without major complaints or complications. His levels were monitored frequently while on supportive leucovorin rescue. His level on day of discharge is 0.05. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Diazepam 5 mg PO Q8H:PRN muscle spasm 3. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 4. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Moderate 5. Sodium Bicarbonate 1300 mg PO QID 6. Fluticasone Propionate NASAL 2 SPRY NU BID:PRN allergies Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Diazepam 5 mg PO Q8H:PRN muscle spasm 3. Fluticasone Propionate NASAL 2 SPRY NU BID:PRN allergies 4. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 5. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Moderate 6. Sodium Bicarbonate 1300 mg PO QID Discharge Disposition: Home Discharge Diagnosis: Encounter for antineoplastic therapy Neurolymphomatosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], You came to the hospital for MTX administration and tolerated it well. Please confirm with your [MASKED] clinic your next admission date (tentatively scheduled for [MASKED]. Best, Your [MASKED] team Followup Instructions: [MASKED]
[]
[ "F17210" ]
[ "Z5111: Encounter for antineoplastic chemotherapy", "C8580: Other specified types of non-Hodgkin lymphoma, unspecified site", "E876: Hypokalemia", "D472: Monoclonal gammopathy", "F17210: Nicotine dependence, cigarettes, uncomplicated" ]
19,999,784
24,935,234
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: weakness Major Surgical or Invasive Procedure: LP on ___ History of Present Illness: Mr. ___ is a ___ without significant medical history, but recent diagnosis of new intramedullary spinal cord lesion and monoclonal gammopathy in the setting of left leg weakness, dysphagia, and dysphonia. He was admitted ___ to ___ to work up new left leg weakness, dysphagia, and dysphonia. MRI showed 1.5 x 0.6 x 0.5 cm T12-L1 intramedullary enhancing lesion. He was subsequently found to have monoclonal gammopathy and concern for plasma cell dyscrasia on bone marrow biopsy. CSF cytology was non-diagnostic at the time, and he was deemed high risk for biopsy of the lesion. He was discharged with outpatient follow up. He had repeat LP on ___ and repeat MRI on ___. There was concern for large lymphocytic proliferation on CSF and seemed to have expansion of lesion on MRI. Due to these findings he was asked to come back to the hospital for expediated workup. In the ED, initial VS were pain 5, T 98.0, HR 91, BP 148/90, RR 16, O2 99%RA. Initial labs notable for Na 141, K 4.4, HCO3 27, Cr 0.7, WBC 4.8, HCT 38.3, PLT 257, INR 1.0. Patient was given 1g APAP. VS prior to transfer were pain 5, T 97.9, HR 82, BP 141/76, R R18, O2 99%RA. On arrival to the floor, patient only notes some back pain he has been having since his first LP. Gets up to ___, well controlled with Tylenol, and has some radicular symptoms down left leg. Otherwise notes his left leg weakness is a bit worse, but he is still ambulatory and active without assistance despite limp. He denies fevers or chills. Mild recent nasal congestion. No ST. Dysphagia seems improved, tolerates regular food with head turn. No chest pain, SOB, or cough. No N/V/D. No dysuria. No urinary retention or bowel incontinence. No new leg pain or swelling. No rashes. REVIEW OF SYSTEMS: A complete 10-point review of systems was performed and was negative unless otherwise noted in the HPI. Past Medical History: PAST ONCOLOGIC HISTORY: ___ is a ___ right-handed man, without ___ medical history, who has subacute onset of dysphagia, dysphonia and left lower extremity weakness over one month. Treatment History: (1) swallowing study on ___ showed oropharyngeal and esophageal dysphagia on the right-sided, (2) gadolinium-enhanced thoracic and lumbar MRI on ___ showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side, (3) CT of the torso on ___ showed no malignancy, (4) lumbar puncture on ___ showed ___ WBC, ___ RBC, 114 protein, 63 glucose, 19 LDH, beta-2-microglobulin 1.87 (normal 0.36-2.56), CA ___ <6, VDRL non-reactive, and negative cytology for malignant cells, and (5) bone marrow aspiration on ___ showed lambda restricted plasma cells, PAST MEDICAL HISTORY: None Social History: ___ Family History: Father had prostate cancer. Denies otherwise history of blood or oncologic history. Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: T 98.0 HR 70 BP 140/68 RR 18 SAT 99% O2 on RA GENERAL: Pleasant, well appearing man, lying in bed comfortably with excellent bed mobility EYES: Anicteric sclerea, PERLL, EOMI; ENT: Oropharynx clear without lesion, JVD not elevated CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or gallops; 2+ radial pulses RESPIRATORY: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi GASTROINTESTINAL: Normal bowel sounds; nondistended; soft, nontender without rebound or guarding; no hepatomegaly, no splenomegaly MUSKULOSKELATAL: Warm, well perfused extremities without lower extremity edema; Normal bulk NEURO: Alert, oriented, CN III-XII intact, motor strength ___ throughout except 4+/5 left hip flexion, ___nd ___ left dorsiflexion SKIN: No significant rashes LYMPHATIC: No cervical, supraclavicular, submandibular lymphadenopathy. No significant ecchymoses DISCHARGE PHYSICAL EXAM: ======================== VS: ___ 0003 Temp: 98.4 PO BP: 130/84 HR: 67 RR: 18 O2 sat: 100% O2 delivery: RA GENERAL: Pleasant, well appearing man, lying in bed comfortably EYES: Anicteric sclerea, PERLL, EOMI; ENT: Oropharynx clear without lesion, JVD not elevated CARDIOVASCULAR: RRR, no m/r/g RESPIRATORY: On room air, no increased work of breathing, no wheezes, rales or rhonchi GASTROINTESTINAL: NABS, soft, NT, ND MUSKULOSKELATAL: wwp, no edema NEURO: Alert, oriented, CN II-XII intact, motor strength ___ throughout except 3+/5 left hip flexion, ___nd ___ left dorsiflexion SKIN: No significant rashes Pertinent Results: ADMISSION LABS: =============== ___ 07:25PM BLOOD WBC-4.8 RBC-4.56* Hgb-12.6* Hct-38.3* MCV-84 MCH-27.6 MCHC-32.9 RDW-14.4 RDWSD-44.0 Plt ___ ___ 07:25PM BLOOD Neuts-60.5 ___ Monos-8.3 Eos-1.5 Baso-0.2 Im ___ AbsNeut-2.91 AbsLymp-1.41 AbsMono-0.40 AbsEos-0.07 AbsBaso-0.01 ___ 07:25PM BLOOD ___ PTT-26.0 ___ ___ 07:25PM BLOOD Plt ___ ___ 07:25PM BLOOD Glucose-89 UreaN-14 Creat-0.7 Na-141 K-4.4 Cl-102 HCO3-27 AnGap-12 ___ 06:38AM BLOOD Calcium-9.5 Phos-3.8 Mg-2.2 UricAcd-4.4 ___ 06:38AM BLOOD ALT-31 AST-20 LD(LDH)-105 AlkPhos-73 TotBili-0.4 RELEVANT LABS/IMAGING: ====================== ___ 12:30PM CEREBROSPINAL FLUID (CSF) TNC-27* RBC-0 Polys-0 ___ Macroph-4 ___ 12:30PM CEREBROSPINAL FLUID (CSF) TotProt-88* Glucose-55 LD(___)-33 ___ 12:30PM CEREBROSPINAL FLUID (CSF) CSF-PEP-OLIGOCLONA PATHOLOGY ___: =================== CSF Flow Cytometry: Diagnostic immunophenotypic features of involvement by a plasma cell dyscrasia or B cell lymphoma are not identified. CSF Protein Electropheresis: OLIGOCLONAL BANDS ARE SEEN IN CSF HOWEVER, THE SAME PATTERN IS SEEN MORE STRONGLY IN PAIRED SERUM SAMPLE PATTERN SUGGESTS LEAK OF OLIGOCLONAL IMMUNOGLOBULINS FROM SERUM AND IS NOT SPECIFIC FOR INTRATHECAL OLIGOCLONAL BANDING AND NOT SPECIFIC FOR INTRATHECAL MONOCLONAL PROCESS MICRO: ====== NONE DISCHARGE LABS: =============== ___ 06:42AM BLOOD WBC-4.3 RBC-4.67 Hgb-12.7* Hct-39.0* MCV-84 MCH-27.2 MCHC-32.6 RDW-14.3 RDWSD-42.9 Plt ___ ___ 06:42AM BLOOD Plt ___ ___ 06:42AM BLOOD ___ PTT-26.7 ___ ___ 06:42AM BLOOD Glucose-88 UreaN-15 Creat-0.8 Na-142 K-4.5 Cl-101 HCO3-27 AnGap-14 ___ 06:42AM BLOOD Calcium-10.0 Phos-4.0 Mg-2.4 Brief Hospital Course: Mr. ___ is a ___ without significant medical history, but recent diagnosis of new intramedullary spinal cord lesion and monoclonal gammopathy in the setting of left leg weakness, dysphagia, and dysphonia. # Intramedullary spinal mass # Plasma cell dyscrasia # Lymphocytic proliferation: Solitary spinal mass in setting of confirmed plasma cell dyscrasia is concering for solitary extramedullary plasmacytoma. There could also be concern of a lymphomatous lesion given the abnormal proliferation of lymphocytes. CSF PEP showed ogliclonal bands which likely from serum, no clear significance on the read. Diagnostic immunophenotypic features of involvement by a plasma cell dyscrasia or B cell lymphoma were not identified on flow cytometry. Given this, a biopsy of the mass would be the next step. Neurosurgery was contacted regarding this and the patient elected to follow-up as an outpatient. # Leg weakness # Back pain # Vocal cord paralysis: Symptoms likely due to mass effect from known spinal mass. Weakness slightly worsening on exam. Dysphonia and back pain have been stable. Steroids were held due to no signs of cord compression. Transitional Issues: [ ] f/u with neurosurgery (ideally ___ if possible) [ ] f/u with speech and swallow [ ] f/u with Dr. ___ ___ if possible) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Multivitamins W/minerals 1 TAB PO DAILY 2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 2. Multivitamins W/minerals 1 TAB PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Intramedullary Spinal Mass Plasma Cell Dyscrasia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. ___, You were admitted for an expedited work-up of your spinal mass. While you were here Dr. ___ a lumbar puncture which we sent for testing. The testing did not show any specific diagnosis which could tell us what this spinal mass is. As you requested, here are results of these tests in medical language: CSF Flow Cytometry: "Diagnostic immunophenotypic features of involvement by a plasma cell dyscrasia or B cell lymphoma are not identified." CSF Protein Electropheresis: "OLIGOCLONAL BANDS ARE SEEN IN CSF HOWEVER, THE SAME PATTERN IS SEEN MORE STRONGLY IN PAIRED SERUM SAMPLE PATTERN SUGGESTS LEAK OF OLIGOCLONAL IMMUNOGLOBULINS FROM SERUM AND IS NOT SPECIFIC FOR INTRATHECAL OLIGOCLONAL BANDING AND NOT SPECIFIC FOR INTRATHECAL MONOCLONAL PROCESS" Please call neurosurgery, Dr. ___ and speech and swallow about appointments (number list below). If you have any worsening weakness, please call Dr. ___. It was a pleasure taking care of you, -Your ___ Team Followup Instructions: ___
[ "D472", "G9589", "R531", "R1319", "R490", "R836", "F17210", "M5416", "J3801" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: weakness Major Surgical or Invasive Procedure: LP on [MASKED] History of Present Illness: Mr. [MASKED] is a [MASKED] without significant medical history, but recent diagnosis of new intramedullary spinal cord lesion and monoclonal gammopathy in the setting of left leg weakness, dysphagia, and dysphonia. He was admitted [MASKED] to [MASKED] to work up new left leg weakness, dysphagia, and dysphonia. MRI showed 1.5 x 0.6 x 0.5 cm T12-L1 intramedullary enhancing lesion. He was subsequently found to have monoclonal gammopathy and concern for plasma cell dyscrasia on bone marrow biopsy. CSF cytology was non-diagnostic at the time, and he was deemed high risk for biopsy of the lesion. He was discharged with outpatient follow up. He had repeat LP on [MASKED] and repeat MRI on [MASKED]. There was concern for large lymphocytic proliferation on CSF and seemed to have expansion of lesion on MRI. Due to these findings he was asked to come back to the hospital for expediated workup. In the ED, initial VS were pain 5, T 98.0, HR 91, BP 148/90, RR 16, O2 99%RA. Initial labs notable for Na 141, K 4.4, HCO3 27, Cr 0.7, WBC 4.8, HCT 38.3, PLT 257, INR 1.0. Patient was given 1g APAP. VS prior to transfer were pain 5, T 97.9, HR 82, BP 141/76, R R18, O2 99%RA. On arrival to the floor, patient only notes some back pain he has been having since his first LP. Gets up to [MASKED], well controlled with Tylenol, and has some radicular symptoms down left leg. Otherwise notes his left leg weakness is a bit worse, but he is still ambulatory and active without assistance despite limp. He denies fevers or chills. Mild recent nasal congestion. No ST. Dysphagia seems improved, tolerates regular food with head turn. No chest pain, SOB, or cough. No N/V/D. No dysuria. No urinary retention or bowel incontinence. No new leg pain or swelling. No rashes. REVIEW OF SYSTEMS: A complete 10-point review of systems was performed and was negative unless otherwise noted in the HPI. Past Medical History: PAST ONCOLOGIC HISTORY: [MASKED] is a [MASKED] right-handed man, without [MASKED] medical history, who has subacute onset of dysphagia, dysphonia and left lower extremity weakness over one month. Treatment History: (1) swallowing study on [MASKED] showed oropharyngeal and esophageal dysphagia on the right-sided, (2) gadolinium-enhanced thoracic and lumbar MRI on [MASKED] showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side, (3) CT of the torso on [MASKED] showed no malignancy, (4) lumbar puncture on [MASKED] showed [MASKED] WBC, [MASKED] RBC, 114 protein, 63 glucose, 19 LDH, beta-2-microglobulin 1.87 (normal 0.36-2.56), CA [MASKED] <6, VDRL non-reactive, and negative cytology for malignant cells, and (5) bone marrow aspiration on [MASKED] showed lambda restricted plasma cells, PAST MEDICAL HISTORY: None Social History: [MASKED] Family History: Father had prostate cancer. Denies otherwise history of blood or oncologic history. Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: T 98.0 HR 70 BP 140/68 RR 18 SAT 99% O2 on RA GENERAL: Pleasant, well appearing man, lying in bed comfortably with excellent bed mobility EYES: Anicteric sclerea, PERLL, EOMI; ENT: Oropharynx clear without lesion, JVD not elevated CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or gallops; 2+ radial pulses RESPIRATORY: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi GASTROINTESTINAL: Normal bowel sounds; nondistended; soft, nontender without rebound or guarding; no hepatomegaly, no splenomegaly MUSKULOSKELATAL: Warm, well perfused extremities without lower extremity edema; Normal bulk NEURO: Alert, oriented, CN III-XII intact, motor strength [MASKED] throughout except 4+/5 left hip flexion, nd [MASKED] left dorsiflexion SKIN: No significant rashes LYMPHATIC: No cervical, supraclavicular, submandibular lymphadenopathy. No significant ecchymoses DISCHARGE PHYSICAL EXAM: ======================== VS: [MASKED] 0003 Temp: 98.4 PO BP: 130/84 HR: 67 RR: 18 O2 sat: 100% O2 delivery: RA GENERAL: Pleasant, well appearing man, lying in bed comfortably EYES: Anicteric sclerea, PERLL, EOMI; ENT: Oropharynx clear without lesion, JVD not elevated CARDIOVASCULAR: RRR, no m/r/g RESPIRATORY: On room air, no increased work of breathing, no wheezes, rales or rhonchi GASTROINTESTINAL: NABS, soft, NT, ND MUSKULOSKELATAL: wwp, no edema NEURO: Alert, oriented, CN II-XII intact, motor strength [MASKED] throughout except 3+/5 left hip flexion, nd [MASKED] left dorsiflexion SKIN: No significant rashes Pertinent Results: ADMISSION LABS: =============== [MASKED] 07:25PM BLOOD WBC-4.8 RBC-4.56* Hgb-12.6* Hct-38.3* MCV-84 MCH-27.6 MCHC-32.9 RDW-14.4 RDWSD-44.0 Plt [MASKED] [MASKED] 07:25PM BLOOD Neuts-60.5 [MASKED] Monos-8.3 Eos-1.5 Baso-0.2 Im [MASKED] AbsNeut-2.91 AbsLymp-1.41 AbsMono-0.40 AbsEos-0.07 AbsBaso-0.01 [MASKED] 07:25PM BLOOD [MASKED] PTT-26.0 [MASKED] [MASKED] 07:25PM BLOOD Plt [MASKED] [MASKED] 07:25PM BLOOD Glucose-89 UreaN-14 Creat-0.7 Na-141 K-4.4 Cl-102 HCO3-27 AnGap-12 [MASKED] 06:38AM BLOOD Calcium-9.5 Phos-3.8 Mg-2.2 UricAcd-4.4 [MASKED] 06:38AM BLOOD ALT-31 AST-20 LD(LDH)-105 AlkPhos-73 TotBili-0.4 RELEVANT LABS/IMAGING: ====================== [MASKED] 12:30PM CEREBROSPINAL FLUID (CSF) TNC-27* RBC-0 Polys-0 [MASKED] Macroph-4 [MASKED] 12:30PM CEREBROSPINAL FLUID (CSF) TotProt-88* Glucose-55 LD([MASKED])-33 [MASKED] 12:30PM CEREBROSPINAL FLUID (CSF) CSF-PEP-OLIGOCLONA PATHOLOGY [MASKED]: =================== CSF Flow Cytometry: Diagnostic immunophenotypic features of involvement by a plasma cell dyscrasia or B cell lymphoma are not identified. CSF Protein Electropheresis: OLIGOCLONAL BANDS ARE SEEN IN CSF HOWEVER, THE SAME PATTERN IS SEEN MORE STRONGLY IN PAIRED SERUM SAMPLE PATTERN SUGGESTS LEAK OF OLIGOCLONAL IMMUNOGLOBULINS FROM SERUM AND IS NOT SPECIFIC FOR INTRATHECAL OLIGOCLONAL BANDING AND NOT SPECIFIC FOR INTRATHECAL MONOCLONAL PROCESS MICRO: ====== NONE DISCHARGE LABS: =============== [MASKED] 06:42AM BLOOD WBC-4.3 RBC-4.67 Hgb-12.7* Hct-39.0* MCV-84 MCH-27.2 MCHC-32.6 RDW-14.3 RDWSD-42.9 Plt [MASKED] [MASKED] 06:42AM BLOOD Plt [MASKED] [MASKED] 06:42AM BLOOD [MASKED] PTT-26.7 [MASKED] [MASKED] 06:42AM BLOOD Glucose-88 UreaN-15 Creat-0.8 Na-142 K-4.5 Cl-101 HCO3-27 AnGap-14 [MASKED] 06:42AM BLOOD Calcium-10.0 Phos-4.0 Mg-2.4 Brief Hospital Course: Mr. [MASKED] is a [MASKED] without significant medical history, but recent diagnosis of new intramedullary spinal cord lesion and monoclonal gammopathy in the setting of left leg weakness, dysphagia, and dysphonia. # Intramedullary spinal mass # Plasma cell dyscrasia # Lymphocytic proliferation: Solitary spinal mass in setting of confirmed plasma cell dyscrasia is concering for solitary extramedullary plasmacytoma. There could also be concern of a lymphomatous lesion given the abnormal proliferation of lymphocytes. CSF PEP showed ogliclonal bands which likely from serum, no clear significance on the read. Diagnostic immunophenotypic features of involvement by a plasma cell dyscrasia or B cell lymphoma were not identified on flow cytometry. Given this, a biopsy of the mass would be the next step. Neurosurgery was contacted regarding this and the patient elected to follow-up as an outpatient. # Leg weakness # Back pain # Vocal cord paralysis: Symptoms likely due to mass effect from known spinal mass. Weakness slightly worsening on exam. Dysphonia and back pain have been stable. Steroids were held due to no signs of cord compression. Transitional Issues: [ ] f/u with neurosurgery (ideally [MASKED] if possible) [ ] f/u with speech and swallow [ ] f/u with Dr. [MASKED] [MASKED] if possible) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Multivitamins W/minerals 1 TAB PO DAILY 2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 2. Multivitamins W/minerals 1 TAB PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Intramedullary Spinal Mass Plasma Cell Dyscrasia 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 an expedited work-up of your spinal mass. While you were here Dr. [MASKED] a lumbar puncture which we sent for testing. The testing did not show any specific diagnosis which could tell us what this spinal mass is. As you requested, here are results of these tests in medical language: CSF Flow Cytometry: "Diagnostic immunophenotypic features of involvement by a plasma cell dyscrasia or B cell lymphoma are not identified." CSF Protein Electropheresis: "OLIGOCLONAL BANDS ARE SEEN IN CSF HOWEVER, THE SAME PATTERN IS SEEN MORE STRONGLY IN PAIRED SERUM SAMPLE PATTERN SUGGESTS LEAK OF OLIGOCLONAL IMMUNOGLOBULINS FROM SERUM AND IS NOT SPECIFIC FOR INTRATHECAL OLIGOCLONAL BANDING AND NOT SPECIFIC FOR INTRATHECAL MONOCLONAL PROCESS" Please call neurosurgery, Dr. [MASKED] and speech and swallow about appointments (number list below). If you have any worsening weakness, please call Dr. [MASKED]. It was a pleasure taking care of you, -Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "F17210" ]
[ "D472: Monoclonal gammopathy", "G9589: Other specified diseases of spinal cord", "R531: Weakness", "R1319: Other dysphagia", "R490: Dysphonia", "R836: Abnormal cytological findings in cerebrospinal fluid", "F17210: Nicotine dependence, cigarettes, uncomplicated", "M5416: Radiculopathy, lumbar region", "J3801: Paralysis of vocal cords and larynx, unilateral" ]
19,999,784
25,180,002
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Neurolymphomatosis Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ man with history of MGUS and neurolymphomatosis on rituximab/HD-MTX presenting for C6 HD-MTX. He has felt well since his previous discharge. He received Rituximab with Dr. ___ on ___ which went fine. He notes some improvement in his arm discoloration and thinks he needs to see a Dermatologist. He has gained some weight back. He noticed a rash around his port which has improved with steroid cream. He started taking his bicab tabs on ___ prior to admission. He denies fevers/chills, night sweats, headache, vision changes, dizziness/lightheadedness, weakness/numbnesss, shortness of breath, cough, hemoptysis, chest pain, palpitations, abdominal pain, nausea/vomiting, diarrhea, hematemesis, hematochezia/melena, dysuria, and hematuria. 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: (1) Swallowing study on ___ showed oropharyngeal and esophageal dysphagia on the right-sided, (2) gadolinium-enhanced thoracic and lumbar MRI on ___ showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side, (3) CT of the torso on ___ showed no malignancy, (4) lumbar puncture on ___ showed ___ WBC, ___ RBC, 114 protein, 63 glucose, 19 LDH, beta-2-microglobulin 1.87 (normal 0.36-2.56), CA ___ <6, VDRL non-reactive, and negative cytology for malignant cells, (5) bone marrow aspiration on ___ showed lambda restricted plasma cells, (6) gadolinium-enhanced lumbar MRI performed on ___ again showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side, and this enhancement appears slightly more prominent, and (7) lumbar puncture on ___ showed 26 WBC, 4 RBC, 146 protein, 57 glucose, 23 LDH, and atypical large lymphoid cells in cytology, (8) lumbar puncture on ___ showed 27 WBC, 0 RBC, 88 protein, 55 glucose, 33 LDH, beta-2-microglobulion 2.50 (range 0.36-2.56) and presence of oligoclonal bands, (9) laminectomy L2-5 for right L5 nerve resection on ___ by Dr. ___ and the pathology showed neurolymphomatosis, (10) HBV core antibody positive on ___ and ___, (11) HIV negative on ___, (12) echocardiogram showed LVEF >55%, (13) FDG-PET from ___ showed uptake in the lower spinal cord but no systemic uptake, (14) PICC line insertion on ___, (15) started C1W1 rituximab 375 mg/m2 and lamivudine 100 mg QD on ___, (16) CSF leak on ___, (17) discontinuation of lamuvidine and dexamethasone on ___, (18) repair of CSF leak on ___ by Dr. ___, (19) received C1W1 rituximab 375 mg/m2/week on ___, (20) Portacath placement on ___, (21) received C1 high-dose methotrexate at 6 grams/m2 on ___, (22) received C1W1 rituximab 375 mg/m2/week on ___, (23) received C1W2 rituximab 375 mg/m2/week on ___, (24) received C1W3 rituximab 375 mg/m2/week on ___, (25) received C2 high-dose methotrexate at 8 grams/m2 on ___, (26) received C1W4 rituximab 375 mg/m2/week on ___, (27) received C2 rituximab 375 mg/m2/week on ___, (28) received C3 high-dose methotrexate at 8 grams/m2 on ___, (29) received C3 rituximab 375 mg/m2/week on ___, (30) received C4 high-dose methotrexate at 8 grams/m2 on ___, (30) received C4 rituximab 375 mg/m2/week on ___, (31) received C5 high-dose methotrexate at 8 grams/m2 on ___, (32) gadolinium-enhanced total spine MRI on ___ showed response, (33) gadolinium-enhanced head MRI on ___ showed no evidence of disease, (34) FDG-PET on ___ showed improved FDG-Avid disease at T12-L2, and (35) CSF cytology showed atypical cells. (36) received C5 monthly maintenance rituximab 375 mg/m2/week on ___, (37) received C6 first monthly maintenance high-dose methotrexate at 8 grams/m2 on ___, and (38) gadolinium-enhanced MRI of the lumbosacral spine performed on ___ showed no evidence of disease. PAST MEDICAL HISTORY: -Hypertension -Forearm hyperpigmentation Social History: ___ Family History: His father died at age ___ and he had dementia and prostate cancer. His mother is alive with osteoarthritis, knee replacement, asthma and tuberculosis. He has 3 siblings and they are all healthy. He does not have children. Physical Exam: ON ADMISSION ============= VS: Temp 98.3, BP 158/92, HR 84, RR 18, O2 sat 99% 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, no hepatomegaly, no splenomegaly. EXT: Warm, well perfused, no lower extremity edema, erythema or tenderness. NEURO: A&Ox3, good attention and linear thought, CN III-XII intact. Strength full throughout with 3+/5 LLE on plantarflexion. Sensation to light touch intact. gait intact without using cane ACCESS: Right chest wall port site intact. ON DISCHARGE ============ VS: 98.4 ___ 16 99%RA ENERAL: Well-appearing young 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, no hepatomegaly, no splenomegaly. 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 except for mild L foot drop. Sensation to light touch intact. ACCESS: Right chest wall port. Pertinent Results: ___ 06:19PM BLOOD mthotrx-3.2* ___ 08:27PM BLOOD mthotrx-2.9* ___ 05:44PM BLOOD mthotrx-0.85* ___ 05:24AM BLOOD mthotrx-0.64* ___ 06:00PM BLOOD mthotrx-0.63* ___ 05:15AM BLOOD mthotrx-0.37* ___ 04:17AM BLOOD mthotrx-0.17 ___ 11:51AM BLOOD mthotrx-0.___ w/ MGUS and neurolymphomatosis now in ___ ___ for C7 HD MTX/Rituxan # Neurolymphomatosis: His CSF leak resolved and is now neurologically intact except for drop foot. No evidence of systemic lymphoma. Receiving high-dose methotrexate which is a highly toxic therapy with risk of transient or permanent neurological toxicity needing close monitoring of levels to beable to provide adequate support. Received MTX 8g/m2 without complications. He had supportive hydration, alkalinization, anti-emesis and leucovorin rescue based on drug levels. Tolerated this cycle well. # MGUS: Obtained SPEP on this admission and IgG level is steady at 2k. Labs reviewed with the oncology fellow on call. Patient was made an appointment w/ Dr ___ in ___ clinic in ___ to establish care and review his findings. #Forearm hyperpigmentation: Given improvement with time, this is likely a superficial form of hyperpigmentation (epidermal) which can improved with epidermal turnover and moisturization. Continued lactic acid 12% lotion TID. # Hypertension: Multiple SBPs >150 in house during prior admissions. Likely a component of IVF. Usually asx. Have been <140 here. Pt agreed to schedule a f/u w/ PCP to follow up on this. # HBcAb+: HbSag/ab-. HBV viral load UL. Indicative of prior infection. Discussed w/ Dr ___. TRANSITIONAL ISSUES: ==================== #MGUS: Stable IgG. To be followed by Dr. ___ #Next steps: ___ Rituximab, ___ re-admission for HD-MTX Over 50 minutes spent formulating and coordinating this patient's discharge plan. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 3. Senna 8.6 mg PO BID:PRN constipation 4. Sodium Bicarbonate 1300 mg PO Q6H 3 days prior to admission 5. Lactic Acid 12% Lotion 1 Appl TP TID:PRN dry skin 6. Docusate Sodium 100 mg PO BID:PRN constipation 7. Multivitamins 1 TAB PO DAILY 8. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 9. Leucovorin Calcium 40 mg PO Q6H 10. LORazepam 0.5 mg PO Q8H:PRN nausea, insomnia, anxiety Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 3. Docusate Sodium 100 mg PO BID:PRN constipation 4. Lactic Acid 12% Lotion 1 Appl TP TID:PRN dry skin 5. Leucovorin Calcium 40 mg PO Q6H RX *leucovorin calcium 10 mg 4 tablet(s) by mouth every six (6) hours Disp #*48 Tablet Refills:*0 6. LORazepam 0.5 mg PO Q8H:PRN nausea, insomnia, anxiety 7. Multivitamins 1 TAB PO DAILY 8. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 9. Senna 8.6 mg PO BID:PRN constipation 10. Sodium Bicarbonate 1300 mg PO Q6H 3 days prior to admission RX *sodium bicarbonate 650 mg 2 tablet(s) by mouth every six (6) hours Disp #*48 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Neurolymphomatosis MGUS Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted for your seventh cycle of high dose methotrexate. You tolerated chemo well. Please return to clinic on ___ for your third monthly maintenance rituximab and on ___ for C8 or your third monthly maintenance high-dose methotrexate. Please follow up with your new hematologist, Dr ___ your blood condition called MGUS. Have a wonderful ___ weekend. Your ___ Team Followup Instructions: ___
[ "Z5111", "C8589", "D472", "I10", "L814", "M21372", "Z8619", "Z87891" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Neurolymphomatosis Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is a [MASKED] man with history of MGUS and neurolymphomatosis on rituximab/HD-MTX presenting for C6 HD-MTX. He has felt well since his previous discharge. He received Rituximab with Dr. [MASKED] on [MASKED] which went fine. He notes some improvement in his arm discoloration and thinks he needs to see a Dermatologist. He has gained some weight back. He noticed a rash around his port which has improved with steroid cream. He started taking his bicab tabs on [MASKED] prior to admission. He denies fevers/chills, night sweats, headache, vision changes, dizziness/lightheadedness, weakness/numbnesss, shortness of breath, cough, hemoptysis, chest pain, palpitations, abdominal pain, nausea/vomiting, diarrhea, hematemesis, hematochezia/melena, dysuria, and hematuria. 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: (1) Swallowing study on [MASKED] showed oropharyngeal and esophageal dysphagia on the right-sided, (2) gadolinium-enhanced thoracic and lumbar MRI on [MASKED] showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side, (3) CT of the torso on [MASKED] showed no malignancy, (4) lumbar puncture on [MASKED] showed [MASKED] WBC, [MASKED] RBC, 114 protein, 63 glucose, 19 LDH, beta-2-microglobulin 1.87 (normal 0.36-2.56), CA [MASKED] <6, VDRL non-reactive, and negative cytology for malignant cells, (5) bone marrow aspiration on [MASKED] showed lambda restricted plasma cells, (6) gadolinium-enhanced lumbar MRI performed on [MASKED] again showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side, and this enhancement appears slightly more prominent, and (7) lumbar puncture on [MASKED] showed 26 WBC, 4 RBC, 146 protein, 57 glucose, 23 LDH, and atypical large lymphoid cells in cytology, (8) lumbar puncture on [MASKED] showed 27 WBC, 0 RBC, 88 protein, 55 glucose, 33 LDH, beta-2-microglobulion 2.50 (range 0.36-2.56) and presence of oligoclonal bands, (9) laminectomy L2-5 for right L5 nerve resection on [MASKED] by Dr. [MASKED] and the pathology showed neurolymphomatosis, (10) HBV core antibody positive on [MASKED] and [MASKED], (11) HIV negative on [MASKED], (12) echocardiogram showed LVEF >55%, (13) FDG-PET from [MASKED] showed uptake in the lower spinal cord but no systemic uptake, (14) PICC line insertion on [MASKED], (15) started C1W1 rituximab 375 mg/m2 and lamivudine 100 mg QD on [MASKED], (16) CSF leak on [MASKED], (17) discontinuation of lamuvidine and dexamethasone on [MASKED], (18) repair of CSF leak on [MASKED] by Dr. [MASKED], (19) received C1W1 rituximab 375 mg/m2/week on [MASKED], (20) Portacath placement on [MASKED], (21) received C1 high-dose methotrexate at 6 grams/m2 on [MASKED], (22) received C1W1 rituximab 375 mg/m2/week on [MASKED], (23) received C1W2 rituximab 375 mg/m2/week on [MASKED], (24) received C1W3 rituximab 375 mg/m2/week on [MASKED], (25) received C2 high-dose methotrexate at 8 grams/m2 on [MASKED], (26) received C1W4 rituximab 375 mg/m2/week on [MASKED], (27) received C2 rituximab 375 mg/m2/week on [MASKED], (28) received C3 high-dose methotrexate at 8 grams/m2 on [MASKED], (29) received C3 rituximab 375 mg/m2/week on [MASKED], (30) received C4 high-dose methotrexate at 8 grams/m2 on [MASKED], (30) received C4 rituximab 375 mg/m2/week on [MASKED], (31) received C5 high-dose methotrexate at 8 grams/m2 on [MASKED], (32) gadolinium-enhanced total spine MRI on [MASKED] showed response, (33) gadolinium-enhanced head MRI on [MASKED] showed no evidence of disease, (34) FDG-PET on [MASKED] showed improved FDG-Avid disease at T12-L2, and (35) CSF cytology showed atypical cells. (36) received C5 monthly maintenance rituximab 375 mg/m2/week on [MASKED], (37) received C6 first monthly maintenance high-dose methotrexate at 8 grams/m2 on [MASKED], and (38) gadolinium-enhanced MRI of the lumbosacral spine performed on [MASKED] showed no evidence of disease. PAST MEDICAL HISTORY: -Hypertension -Forearm hyperpigmentation Social History: [MASKED] Family History: His father died at age [MASKED] and he had dementia and prostate cancer. His mother is alive with osteoarthritis, knee replacement, asthma and tuberculosis. He has 3 siblings and they are all healthy. He does not have children. Physical Exam: ON ADMISSION ============= VS: Temp 98.3, BP 158/92, HR 84, RR 18, O2 sat 99% 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, no hepatomegaly, no splenomegaly. EXT: Warm, well perfused, no lower extremity edema, erythema or tenderness. NEURO: A&Ox3, good attention and linear thought, CN III-XII intact. Strength full throughout with 3+/5 LLE on plantarflexion. Sensation to light touch intact. gait intact without using cane ACCESS: Right chest wall port site intact. ON DISCHARGE ============ VS: 98.4 [MASKED] 16 99%RA ENERAL: Well-appearing young 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, no hepatomegaly, no splenomegaly. 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 except for mild L foot drop. Sensation to light touch intact. ACCESS: Right chest wall port. Pertinent Results: [MASKED] 06:19PM BLOOD mthotrx-3.2* [MASKED] 08:27PM BLOOD mthotrx-2.9* [MASKED] 05:44PM BLOOD mthotrx-0.85* [MASKED] 05:24AM BLOOD mthotrx-0.64* [MASKED] 06:00PM BLOOD mthotrx-0.63* [MASKED] 05:15AM BLOOD mthotrx-0.37* [MASKED] 04:17AM BLOOD mthotrx-0.17 [MASKED] 11:51AM BLOOD mthotrx-0.[MASKED] w/ MGUS and neurolymphomatosis now in [MASKED] [MASKED] for C7 HD MTX/Rituxan # Neurolymphomatosis: His CSF leak resolved and is now neurologically intact except for drop foot. No evidence of systemic lymphoma. Receiving high-dose methotrexate which is a highly toxic therapy with risk of transient or permanent neurological toxicity needing close monitoring of levels to beable to provide adequate support. Received MTX 8g/m2 without complications. He had supportive hydration, alkalinization, anti-emesis and leucovorin rescue based on drug levels. Tolerated this cycle well. # MGUS: Obtained SPEP on this admission and IgG level is steady at 2k. Labs reviewed with the oncology fellow on call. Patient was made an appointment w/ Dr [MASKED] in [MASKED] clinic in [MASKED] to establish care and review his findings. #Forearm hyperpigmentation: Given improvement with time, this is likely a superficial form of hyperpigmentation (epidermal) which can improved with epidermal turnover and moisturization. Continued lactic acid 12% lotion TID. # Hypertension: Multiple SBPs >150 in house during prior admissions. Likely a component of IVF. Usually asx. Have been <140 here. Pt agreed to schedule a f/u w/ PCP to follow up on this. # HBcAb+: HbSag/ab-. HBV viral load UL. Indicative of prior infection. Discussed w/ Dr [MASKED]. TRANSITIONAL ISSUES: ==================== #MGUS: Stable IgG. To be followed by Dr. [MASKED] #Next steps: [MASKED] Rituximab, [MASKED] re-admission for HD-MTX Over 50 minutes spent formulating and coordinating this patient's discharge plan. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 3. Senna 8.6 mg PO BID:PRN constipation 4. Sodium Bicarbonate 1300 mg PO Q6H 3 days prior to admission 5. Lactic Acid 12% Lotion 1 Appl TP TID:PRN dry skin 6. Docusate Sodium 100 mg PO BID:PRN constipation 7. Multivitamins 1 TAB PO DAILY 8. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 9. Leucovorin Calcium 40 mg PO Q6H 10. LORazepam 0.5 mg PO Q8H:PRN nausea, insomnia, anxiety Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 3. Docusate Sodium 100 mg PO BID:PRN constipation 4. Lactic Acid 12% Lotion 1 Appl TP TID:PRN dry skin 5. Leucovorin Calcium 40 mg PO Q6H RX *leucovorin calcium 10 mg 4 tablet(s) by mouth every six (6) hours Disp #*48 Tablet Refills:*0 6. LORazepam 0.5 mg PO Q8H:PRN nausea, insomnia, anxiety 7. Multivitamins 1 TAB PO DAILY 8. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 9. Senna 8.6 mg PO BID:PRN constipation 10. Sodium Bicarbonate 1300 mg PO Q6H 3 days prior to admission RX *sodium bicarbonate 650 mg 2 tablet(s) by mouth every six (6) hours Disp #*48 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Neurolymphomatosis MGUS 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 for your seventh cycle of high dose methotrexate. You tolerated chemo well. Please return to clinic on [MASKED] for your third monthly maintenance rituximab and on [MASKED] for C8 or your third monthly maintenance high-dose methotrexate. Please follow up with your new hematologist, Dr [MASKED] your blood condition called MGUS. Have a wonderful [MASKED] weekend. Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "I10", "Z87891" ]
[ "Z5111: Encounter for antineoplastic chemotherapy", "C8589: Other specified types of non-Hodgkin lymphoma, extranodal and solid organ sites", "D472: Monoclonal gammopathy", "I10: Essential (primary) hypertension", "L814: Other melanin hyperpigmentation", "M21372: Foot drop, left foot", "Z8619: Personal history of other infectious and parasitic diseases", "Z87891: Personal history of nicotine dependence" ]
19,999,784
25,715,748
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Drainage from lumbar incision Major Surgical or Invasive Procedure: Previous recent admission: ___: L4-L5 lumbar laminectomy and nerve root biopsy ___: Repair of Lumbar CSF Leak Current admission: None History of Present Illness: ___ y/o male s/p L4-5 lumbar laminectomy and nerve root biopsy on ___ and s/p repair of lumbar CSF leak on ___. He was discharged to home on ___. He returned to the ED ___ with complaints of wound drainage that started overnight. He denies positional headache and describes the fluid that is draining as blood tinged. He reported of a small bump, likely fluid collection, that went away when his wound again drained. He denies any new numbness or tingling within his bilateral lower extremities. He denies any new weakness of the BLEs. Past Medical History: ___ is a ___ right-handed man, with a recent diagnosis of neurolymphomatosis, who has left lower extremity weakness and CSF fluid leak after his diagnostic laminectomy. Treatment History: (1) swallowing study on ___ showed oropharyngeal and esophageal dysphagia on the right-sided, (2) gadolinium-enhanced thoracic and lumbar MRI on ___ showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side, (3) CT of the torso on ___ showed no malignancy, (4) lumbar puncture on ___ showed ___ WBC, ___ RBC, 114 protein, 63 glucose, 19 LDH, beta-2-microglobulin 1.87 (normal 0.36-2.56), CA ___ <6, VDRL non-reactive, and negative cytology for malignant cells, (5) bone marrow aspiration on ___ showed lambda restricted plasma cells, (6) gadolinium-enhanced lumbar MRI performed on ___ again showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side, and this enhancement appears slightly more prominent, and (7) lumbar puncture on ___ showed 26 WBC, 4 RBC, 146 protein, 57 glucose, 23 LDH, and atypical large lymphoid cells in cytology, (8) lumbar puncture on ___ showed 27 WBC, 0 RBC, 88 protein, 55 glucose, 33 LDH, beta-2-microglobulion 2.50 (range 0.36-2.56) and presence of oligoclonal bands, (9) laminectomy L2-5 for right L5 nerve resection on ___ by Dr. ___ and the pathology showed neurolymphomatosis, (10) HBV core antibody positive on ___ and ___, (11) HIV negative on ___, (12) echocardiogram showed LVEF >55%, (13) FDG-PET showed uptake in the lower spinal cord but no systemic uptake, (14) PICC line insertion on ___, (15) started C1W1 rituximab 375 mg/m2 and lamivudine 100 mg QD on ___, (16) CSF leak on ___, (17) discontinuation of lamuvidine and dexamethasone on ___, and (18) repair of CSF leak on ___ by Dr. ___. Social History: ___ Family History: Father had prostate cancer. Denies otherwise history of blood or oncologic history. Physical Exam: Exam at discharge: ___ 0807 Temp: 98.5 PO BP: 154/108 HR: 115 RR: 18 O2 sat: 100% O2 delivery: RA Exam: Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious Orientation: [x]Person [x]Place [x]Time Follows commands: [ ]Simple [x]Complex [ ]None Motor: TrapDeltoidBicepTricepGrip Right5 5 5 5 5 Left5 5 5 5 5 IPQuadHamATEHLGast Right5 5 55 5 5 Left4- 4 5 2 0 5 [ ] No Clonus [ ] Neg ___ Wound: [x]Clean, dry, intact, dressing dry [x]Suture [x]Staples [x] Dermabond with loose gauze, dry Pertinent Results: please see OMR for pertinent results Brief Hospital Course: Mr. ___ was admitted to the Neurosurgery floor for continued monitoring of his wound drainage. #CSF leak CT L spine in the ED showed near resolution of previously seen fluid collection in surgical bed and stable 3 cm x 3.5 cm x 1.6 cm collection along the right margin of L3 spinous process. A single figure-of-8 suture was oversown the area of drainage. Mr. ___ was placed on strict flat bedrest. He was noted to be noncompliant with this activity order, and was found OOB to the bathroom and OOB changing his clothes, or sitting up in bed. Frequent encouragement and reminders of his strict flat bed rest status were provided to the patient, and he proved more compliant with strict flat bedrest by ___. From ___ - ___ he continued to have intermittent episodes of drainage from the inferior portion of his lumbar incision with small quantity serosanguinous fluid that was expressible from the incision upon firm palpation. At no time did his incision display signs of fluctuance, nor signs of local/systemic infection. An MRI of the lumbar spine was obtained on ___ and was revealing of a fluid collection in the soft tissues immediately posterior to the thecal sac, with communication to an opening in the skin via a small fistulous tract; c/w possible recurrent CSF leak and sinus. Two layers of dermabond were applied to the incision on ___. On ___ his incision remained clean, dry, and intact without drainage, and continued to remain dry through ___ when the head of his bed was incrementally raised 20 degrees per hour. He tolerated this and mobilized out of bed without incisional drainage or positional headaches. He was discharged on ___ to home under self care to resume home ___ services. # neurolymphomatosis All steroid, chemotherapeutic, and radiation therapies continued to be held during his hospitalization. It was conveyed to his oncology and radiation team that he may resume steroid, chemotherapeutic, and radiation therapies on ___. -Mr. ___ was scheduled to follow up with radiation oncology on ___ at 2:00pm. - He was provided the clinic phone numbers to follow up with Dr. ___ and Hematology Oncology (for review of bone marrow biopsy results, concerning for plasma cell dyscrasia/MGUS), to schedule outpatient follow-up. #vocal cord paralysis, patient is a singer -Mr. ___ was provided the clinic phone number for the ___ ___ clinic, and directed to schedule an outpatient appointment for follow-up. Mr. ___ was discharged on ___. At the time of discharge, the patient was doing well, afebrile and hemodynamically stable. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: Acetaminophen 650mg PO Q6H PRN pain; Bisacodyl 10mg PO Daily PRN constipation; Diazepam 2mg PO Q6H PRN muscle spasm; Docusate Sodium 100mg PO PO BID; Oxycodone ___ PO Q4H PRN pain; Senna 17.2mg PO QHS Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Moderate 2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 3. Docusate Sodium 100 mg PO BID 4. Polyethylene Glycol 17 g PO DAILY:PRN constipation 5. Senna 8.6 mg PO BID:PRN constipation Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Incisional drainage Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted for monitoring of your wound with concern for recurrent CSF leak. You underwent L4-L5 laminectomy and nerve root biopsy on ___ and repair of CSF leak ___. You were discharged last on ___. Your discharge instructions are largely unchanged, please see below. Recent Surgery • Your incision is closed with staples and a small portion of suture with overlying dermabond (surgical skin glue). You will need staple/suture removal in about a week. Please keep your incision dry until your staples/sutures are removed. • Do not apply any lotions or creams to the site. • Please avoid swimming for two weeks after suture/staple removal. • Call your surgeon if there are any signs of infection like redness, fever, or drainage. Activity • We recommend that you lay flat as much as possible while at home to support wound healing and minimize risk of CSF leak. • We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. • You make take leisurely walks and slowly increase your activity at your own pace. ___ try to do too much all at once. • No driving while taking any narcotic or sedating medication. • No contact sports until cleared by your neurosurgeon. Medications • Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by your neurosurgeon. • You may take Ibuprofen/ Motrin for pain. • 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: ___
[ "G9782", "G960", "C8599", "J3800", "Y838", "Y92234", "Z9119" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Drainage from lumbar incision Major Surgical or Invasive Procedure: Previous recent admission: [MASKED]: L4-L5 lumbar laminectomy and nerve root biopsy [MASKED]: Repair of Lumbar CSF Leak Current admission: None History of Present Illness: [MASKED] y/o male s/p L4-5 lumbar laminectomy and nerve root biopsy on [MASKED] and s/p repair of lumbar CSF leak on [MASKED]. He was discharged to home on [MASKED]. He returned to the ED [MASKED] with complaints of wound drainage that started overnight. He denies positional headache and describes the fluid that is draining as blood tinged. He reported of a small bump, likely fluid collection, that went away when his wound again drained. He denies any new numbness or tingling within his bilateral lower extremities. He denies any new weakness of the BLEs. Past Medical History: [MASKED] is a [MASKED] right-handed man, with a recent diagnosis of neurolymphomatosis, who has left lower extremity weakness and CSF fluid leak after his diagnostic laminectomy. Treatment History: (1) swallowing study on [MASKED] showed oropharyngeal and esophageal dysphagia on the right-sided, (2) gadolinium-enhanced thoracic and lumbar MRI on [MASKED] showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side, (3) CT of the torso on [MASKED] showed no malignancy, (4) lumbar puncture on [MASKED] showed [MASKED] WBC, [MASKED] RBC, 114 protein, 63 glucose, 19 LDH, beta-2-microglobulin 1.87 (normal 0.36-2.56), CA [MASKED] <6, VDRL non-reactive, and negative cytology for malignant cells, (5) bone marrow aspiration on [MASKED] showed lambda restricted plasma cells, (6) gadolinium-enhanced lumbar MRI performed on [MASKED] again showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side, and this enhancement appears slightly more prominent, and (7) lumbar puncture on [MASKED] showed 26 WBC, 4 RBC, 146 protein, 57 glucose, 23 LDH, and atypical large lymphoid cells in cytology, (8) lumbar puncture on [MASKED] showed 27 WBC, 0 RBC, 88 protein, 55 glucose, 33 LDH, beta-2-microglobulion 2.50 (range 0.36-2.56) and presence of oligoclonal bands, (9) laminectomy L2-5 for right L5 nerve resection on [MASKED] by Dr. [MASKED] and the pathology showed neurolymphomatosis, (10) HBV core antibody positive on [MASKED] and [MASKED], (11) HIV negative on [MASKED], (12) echocardiogram showed LVEF >55%, (13) FDG-PET showed uptake in the lower spinal cord but no systemic uptake, (14) PICC line insertion on [MASKED], (15) started C1W1 rituximab 375 mg/m2 and lamivudine 100 mg QD on [MASKED], (16) CSF leak on [MASKED], (17) discontinuation of lamuvidine and dexamethasone on [MASKED], and (18) repair of CSF leak on [MASKED] by Dr. [MASKED]. Social History: [MASKED] Family History: Father had prostate cancer. Denies otherwise history of blood or oncologic history. Physical Exam: Exam at discharge: [MASKED] 0807 Temp: 98.5 PO BP: 154/108 HR: 115 RR: 18 O2 sat: 100% O2 delivery: RA Exam: Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious Orientation: [x]Person [x]Place [x]Time Follows commands: [ ]Simple [x]Complex [ ]None Motor: TrapDeltoidBicepTricepGrip Right5 5 5 5 5 Left5 5 5 5 5 IPQuadHamATEHLGast Right5 5 55 5 5 Left4- 4 5 2 0 5 [ ] No Clonus [ ] Neg [MASKED] Wound: [x]Clean, dry, intact, dressing dry [x]Suture [x]Staples [x] Dermabond with loose gauze, dry Pertinent Results: please see OMR for pertinent results Brief Hospital Course: Mr. [MASKED] was admitted to the Neurosurgery floor for continued monitoring of his wound drainage. #CSF leak CT L spine in the ED showed near resolution of previously seen fluid collection in surgical bed and stable 3 cm x 3.5 cm x 1.6 cm collection along the right margin of L3 spinous process. A single figure-of-8 suture was oversown the area of drainage. Mr. [MASKED] was placed on strict flat bedrest. He was noted to be noncompliant with this activity order, and was found OOB to the bathroom and OOB changing his clothes, or sitting up in bed. Frequent encouragement and reminders of his strict flat bed rest status were provided to the patient, and he proved more compliant with strict flat bedrest by [MASKED]. From [MASKED] - [MASKED] he continued to have intermittent episodes of drainage from the inferior portion of his lumbar incision with small quantity serosanguinous fluid that was expressible from the incision upon firm palpation. At no time did his incision display signs of fluctuance, nor signs of local/systemic infection. An MRI of the lumbar spine was obtained on [MASKED] and was revealing of a fluid collection in the soft tissues immediately posterior to the thecal sac, with communication to an opening in the skin via a small fistulous tract; c/w possible recurrent CSF leak and sinus. Two layers of dermabond were applied to the incision on [MASKED]. On [MASKED] his incision remained clean, dry, and intact without drainage, and continued to remain dry through [MASKED] when the head of his bed was incrementally raised 20 degrees per hour. He tolerated this and mobilized out of bed without incisional drainage or positional headaches. He was discharged on [MASKED] to home under self care to resume home [MASKED] services. # neurolymphomatosis All steroid, chemotherapeutic, and radiation therapies continued to be held during his hospitalization. It was conveyed to his oncology and radiation team that he may resume steroid, chemotherapeutic, and radiation therapies on [MASKED]. -Mr. [MASKED] was scheduled to follow up with radiation oncology on [MASKED] at 2:00pm. - He was provided the clinic phone numbers to follow up with Dr. [MASKED] and Hematology Oncology (for review of bone marrow biopsy results, concerning for plasma cell dyscrasia/MGUS), to schedule outpatient follow-up. #vocal cord paralysis, patient is a singer -Mr. [MASKED] was provided the clinic phone number for the [MASKED] [MASKED] clinic, and directed to schedule an outpatient appointment for follow-up. Mr. [MASKED] was discharged on [MASKED]. At the time of discharge, the patient was doing well, afebrile and hemodynamically stable. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: Acetaminophen 650mg PO Q6H PRN pain; Bisacodyl 10mg PO Daily PRN constipation; Diazepam 2mg PO Q6H PRN muscle spasm; Docusate Sodium 100mg PO PO BID; Oxycodone [MASKED] PO Q4H PRN pain; Senna 17.2mg PO QHS Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Moderate 2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 3. Docusate Sodium 100 mg PO BID 4. Polyethylene Glycol 17 g PO DAILY:PRN constipation 5. Senna 8.6 mg PO BID:PRN constipation Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Incisional drainage 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 for monitoring of your wound with concern for recurrent CSF leak. You underwent L4-L5 laminectomy and nerve root biopsy on [MASKED] and repair of CSF leak [MASKED]. You were discharged last on [MASKED]. Your discharge instructions are largely unchanged, please see below. Recent Surgery • Your incision is closed with staples and a small portion of suture with overlying dermabond (surgical skin glue). You will need staple/suture removal in about a week. Please keep your incision dry until your staples/sutures are removed. • Do not apply any lotions or creams to the site. • Please avoid swimming for two weeks after suture/staple removal. • Call your surgeon if there are any signs of infection like redness, fever, or drainage. Activity • We recommend that you lay flat as much as possible while at home to support wound healing and minimize risk of CSF leak. • 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. Medications • Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by your neurosurgeon. • You may take Ibuprofen/ Motrin for pain. • 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]
[]
[]
[ "G9782: Other postprocedural complications and disorders of nervous system", "G960: Cerebrospinal fluid leak", "C8599: Non-Hodgkin lymphoma, unspecified, extranodal and solid organ sites", "J3800: Paralysis of vocal cords and larynx, 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", "Y92234: Operating room of hospital as the place of occurrence of the external cause", "Z9119: Patient's noncompliance with other medical treatment and regimen" ]
19,999,784
26,194,817
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: LLE weakness, dysphagia Major Surgical or Invasive Procedure: Lumbar puncture Bone marrow biopsy History of Present Illness: ___ is a ___ year-old right-handed male without ___ medical history who presents to the ED for evaluation of LLE weakness. He was seen in ___ outpatient clinic this morning for evaluation of new dysphasia and dysphonia (began ___. He reports that he had gone to bed the previous day feeling normal but woke up with new difficulty swallowing as well as a change in his voice (more raspy, hoarse). With regards to his dysphagia, he describes feeling that solids "won't go down...the food gets stuck" but he has not had any difficulties with liquids. He was seen by a community physician who told him that he likely had sinus disease and recommended a few days of Sudafed. When the symptoms persisted and he had lost 15 pounds due to difficulty eating, he had a video swallow test performed ___, see below) which revealed "significant oropharyngeal and esophageal dysphagia most notable for diffuse right-sided weakness." This prompted referral to ___ clinic, where he was seen today and diagnosed with right vocal fold paralysis. He was noted to have LLE weakness, so was prompted to come to the ED for further evaluation. He reports that the LLE weakness began gradually, probably over the ___. This did not impair him in any way until the last week of ___ when he was unable to stand up from a squatting position without the use of his hands. Overall, his weakness has been progessively worsening since that time. In particular, he notices difficulty with lifting his left leg up in order to cross it over the right leg, difficulty going upstairs > downstairs -- and needs to hold onto the railing for both. He is able to stand up out of a chair without difficulty but cannot stand from the floor. He has not had any foot drop or toe stubbing. He has not had any difficulty with the right leg or either arm. On neuro ROS, Mr. ___ denies headache, loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal numbness or parasthesiae. No bowel or bladder incontinence or retention. On general review of systems, this is notable for + unintentional weight loss over the past 2 weeks (15 pounds), which he attributes to his dysphagia. He has also noticed saliva pooling in his mouth which he sometimes has difficulty swallowing. He has been coughing more, but he attributes this to the irritation in his throat, as he has not had any nasal congestion or "deep cough." He denies recent fever or chills. No night sweats. Denies shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: Tobacco use disorder Social History: ___ Family History: - Great nephew ___ years) with recently diagnosed epilepsy - Father (now deceased) had prostate cancer. Physical Exam: ADMISSION Physical Exam: ============================ Vitals ___, time: 14:23): T: 98.6 HR: 80 RR: 18 BP: 161/100 SaO2: 100% on RA General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, full ROM Pulmonary: breathing comfortably on RA Cardiac: warm and well-perfused with brisk capillary refill Abdomen: ND Extremities: + signficant atrophy of the left thigh. No C/C/E bilaterally. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name ___ backward without difficulty. Language is fluent with intact comprehension. Normal prosody. There were no paraphasic errors. Pt was able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. The pt had good knowledge of current events. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. Fundoscopic exam revealed no disc blurring, exudates, or hemorrhages. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric at rest and upon activation. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. + gag on the left, equivocal on the right XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline; + fasciculations. -Motor: Normal tone throughout. Significantly decreased bulk in the L thigh. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. ___ strength throughout with the following exceptions: - Bilateral abductor pollicis brevis: 4+/5 - Left IP: 2+/5 - Left Quad: 2+/5 - Left Hamstring: 4+/5 - Left ___: 4+/5 Reflexes: Bi ___ Pat Ach L 3 3 tr* 1 R 3 3 2* 1 *: with reinforcement Of note: + spread (finger flexion) in the bilateral UE reflexes Plantar response was upgoing in the left, mute on the right. ___: negative -Sensory: No deficits to light touch, pinprick, cold sensation, vibratory sense, proprioception throughout. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF bilaterally. -Gait: Good initiation. Narrow-based, normal stride and arm swing. Romberg absent. DISCHARGE Physical Exam: ======================== Vitals: T: 98.6 BP: 113/79 HR: 98 RR: 18 SpO2: 99% RA General: awake, cooperative, NAD HEENT: NC/AT, no scleral icterus noted, MMM Pulmonary: breathing comfortably, no tachypnea or increased WOB Cardiac: skin warm, well-perfused Abdomen: soft, ND Extremities: symmetric, no edema Neurologic: -Mental Status: Alert, cooperative. Language is fluent with intact comprehension. Able to follow both midline and appendicular commands. -Cranial Nerves: PERRL (3 to 2 mm ___. EOMI without nystagmus. Face symmetric at rest and with activation. Hearing intact to conversation. Palatal elevation symmetric. Tongue protrudes in midline. -Motor: No pronator drift bilaterally. No adventitious movements, such as tremor, noted. Delt Bic Tri WrE FE IP Quad Ham TA Gastroc L 5 ___ 5 4+ 3 5 5 5 R 5 ___ ___ 5 5 5 -Sensory: Intact to LT throughout. No extinction to DSS. -DTRs: Bi ___ Pat Ach L 2 2 1 1 R 2 2 1 1 -Coordination: No intention tremor or dysmetria on FNF bilaterally. Pertinent Results: ADMISSION LABS: =============== ___ 04:30PM URINE HOURS-RANDOM ___ 04:30PM URINE HOURS-RANDOM ___ 04:30PM URINE HOURS-RANDOM ___ 04:30PM URINE UHOLD-HOLD ___ 04:30PM URINE GR HOLD-HOLD ___ 04:30PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG ___ 04:10PM GLUCOSE-89 UREA N-13 CREAT-1.0 SODIUM-143 POTASSIUM-4.9 CHLORIDE-102 TOTAL CO2-26 ANION GAP-15 ___ 04:10PM estGFR-Using this ___ 04:10PM CALCIUM-10.1 PHOSPHATE-3.7 MAGNESIUM-2.2 ___ 04:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 04:10PM WBC-3.3* RBC-5.41 HGB-14.8 HCT-44.9 MCV-83 MCH-27.4 MCHC-33.0 RDW-13.4 RDWSD-40.1 ___ 04:10PM NEUTS-53.8 ___ MONOS-6.9 EOS-0.6* BASOS-0.6 IM ___ AbsNeut-1.78 AbsLymp-1.25 AbsMono-0.23 AbsEos-0.02* AbsBaso-0.02 ___ 04:10PM PLT COUNT-241 INTERVAL LABS: ============== ___ 05:40AM BLOOD calTIBC-251* VitB12-722 Ferritn-172 TRF-193* ___ 01:14PM BLOOD ANCA-NEGATIVE ___ 10:34AM BLOOD CEA-3.4 ___ 01:14PM BLOOD RheuFac-<10 ___ ___ 02:40PM BLOOD CRP-1.5 ___ 05:25AM BLOOD ___ Fr K/L-1.1 ___ 10:34AM BLOOD PEP-ABNORMAL B IgG-2326* IgA-204 IgM-44 IFE-MONOCLONAL ___ 01:14PM BLOOD C3-114 C4-20 ___ 02:40PM BLOOD HIV Ab-NEG ___ 04:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 10:34AM BLOOD QUANTIFERON-TB GOLD-Test ___ 10:34AM BLOOD TOXOCARA (T. CANIS & T. CATI) ANTIBODY-Test ___ 10:34AM BLOOD CA ___ -Test ___ 01:14PM BLOOD RO & ___ ___ 01:14PM BLOOD HTLV I AND II, WITH REFLEX TO WESTERN BLOT-Test ___ 01:14PM BLOOD ANGIOTENSIN 1 - CONVERTING ___ ___ 02:40PM BLOOD SED RATE-Test ___ 02:40PM BLOOD PARANEOPLASTIC AUTOANTIBODY EVALUATION-CANCELLED ___ 02:40PM BLOOD ENCEPHALOPATHY, AUTOIMMUNE EVALUATION, SERUM-PND ___ 10:00AM URINE U-PEP-NO PROTEIN IFE-NEGATIVE F ___ 10:00AM URINE Hours-RANDOM Creat-153 TotProt-12 Prot/Cr-0.1 ___ 04:55PM CEREBROSPINAL FLUID (CSF) TNC-6* RBC-1 Polys-2 ___ Monos-9 Promyel-0 Plasma-3 Other-0 ___ 04:55PM CEREBROSPINAL FLUID (CSF) TNC-18* RBC-4 Polys-4 ___ Monos-6 Eos-1 Plasma-2 Other-0 ___ 04:55PM CEREBROSPINAL FLUID (CSF) TotProt-114* Glucose-63 ___ Misc-BODY FLUID ___ 04:55PM CEREBROSPINAL FLUID (CSF) BETA 2 MICROGLOBULIN-Test ___ 04:55PM CEREBROSPINAL FLUID (CSF) CA ___ ___ 04:55PM CEREBROSPINAL FLUID (CSF) VDRL-Test ___ 04:55PM CEREBROSPINAL FLUID (CSF) TOXOPLASMA GONDII BY PCR-Test ___ 04:55PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS PCR-Test Name ___ 04:55PM CEREBROSPINAL FLUID (CSF) CYTOMEGALOVIRUS DNA, QUALITATIVE, PCR-Test ___ 04:55PM CEREBROSPINAL FLUID (CSF) ANGIOTENSIN 1 CONVERTING ENZYME-Test ___ 04:55PM CEREBROSPINAL FLUID (CSF) BORRELIA BURGDORFERI ANTIBODY INDEX FOR CNS INFECTION-CANCELLED IMAGING: ======== + MRI of L-spine notable for mild expansion in T2/STIR hyperintensity of the distal lumbar spinal cord with differential including infectious, inflammatory etiologies, or intramedullary neoplasm. On the contrast-enhanced study, this is described as 1.5 x 0.6 x 0.5 cm with associated cord expansion and extensive leptomeningeal involvement extending superiorly and inferiorly beyond the margins of the intramedullary lesion with possible involvement of the adjacent nerve roots. Abnormal bone marrow signal diffusely is also noted. Brief Hospital Course: BRIEF HOSPITAL COURSE Mr. ___ was admitted to the Neurology service for evaluation of subacute progressive LLE weakness as well as dysphagia and dysphonia, found on ENT evaluation to be due to right-sided vocal cord paralysis. Despite initial concern for motor neuron disease, his EMG instead revealed a moderate to severe, chronic and ongoing left L4-L5 radiculopathy, without electrophysiologic evidence for a more generalized disorder of motor neurons or their axons. Follow-up MR imaging of the neuraxis was notable for: 1. Multilevel patchy cervical vertebral body T1 hypointensities with possible minimal postcontrast enhancement concerning for a potential marrow infiltrative process; 2. A 1.5 x 0.6 x 0.5 cm T12-L1 intramedullary enhancing focus with surrounding STIR/T2 signal abnormality and associated cord expansion, along with extensive leptomeningeal involvement and possible involvement of the adjacent nerve roots. These findings were concerning for infectious, inflammatory, or neoplastic processes. Inflammatory evaluation revealed unremarkable CSF ACE, ESR, CRP, and SS-A and SS-B Ab. Infectious evaluation revealed negative Lyme serologies, CSF culture, RPR/VDRL, Toxoplasma serologies and CSF PCR, HSV/CMV PCR, QuantiFERON Gold, and HTLV I/II Ab. Neoplastic evaluation revealed negative ___ and CSF cytology and flow cytometry. CT chest/abdomen/pelvis was also negative for additional malignancy. SPEP, however, revealed a monoclonal gammopathy, though with negative skeletal survey and absence of renal findings to suggest multiple myeloma; in consultation with the Hematology/Oncology service, a bone marrow-biopsy was obtained that preliminarily revealed plasma cells as well as abnormal proliferation of lymphocytes concerning for lymphoma. As it remained unclear whether the bone marrow findings could also be implicated in the intramedullary spinal cord lesion and leptomeningeal/radicular enhancement seen on imaging, the Hematology/Oncology and Neuro-oncology teams deferred inpatient treatment in lieu of close outpatient follow-up for repeat imaging, repeat lumbar puncture, and follow up of molecular testing. With respect to Mr. ___ leg and vocal cord symptoms, these may be related to the leptomeningeal/nerve root infiltrative process noted on imaging. During admission he also developed mild hyperreflexia and spasticity in the RLE (without weakness), indicating myelopathy, in line with cord signal abnormalities seen on imaging. Accordingly, Mr. ___ was evaluated by ___ and SLP as an inpatient, with plans for outpatient follow-up. Mr. ___ was cleared for a regular diet and advised to turn his head to the right to facilitate swallowing. TRANSITIONAL ISSUES: =================== [] Follow-up outpatient MRI. [] Follow up with Neuro-oncology and Hematology/Oncology as noted above. [] Follow up final report from bone marrow biopsy as well as serum autoimmune encephalopathy panel. [] Outpatient ___ and SLP follow up as noted above. Medications on Admission: None Discharge Medications: 1. Multivitamins W/minerals 1 TAB PO DAILY RX *multivitamin,tx-minerals [Vitamins and Minerals] 1 (One) tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 2.Outpatient Physical Therapy Diagnosis: Left leg weakness, L4/L5 radiculopathy 3.Outpatient Speech/Swallowing Therapy Diagnosis: right vocal cord paralysis, dysphonia Please continue to evaluate and treat dysphagia and dysphonia Discharge Disposition: Home Discharge Diagnosis: Lumbar Radiculopathy Lumbar myelopathy Intramedullary intradural spinal cord lesion Vocal cord paralysis Monoclonal gammopathy Suspected lymphoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to ___ for evaluation of difficulty swallowing and speaking, as well as left leg weakness. Imaging of your spine showed an area of swelling and inflammation affecting your spinal cord and surrounding coverings; blood and cerebrospinal fluid tests did not show signs of an infection or inflammation, so there is concern that the spine findings may be due to cancer. Although imaging of your chest, abdomen, and pelvis did not show signs of additional cancer, your bone marrow did have abnormal blood cells (lymphocytes) that could reflect lymphoma. In order to further direct treatment of your spinal cord lesion, a follow-up appointment has been scheduled for you with Dr. ___ in Neruo-oncology; you are also scheduled for a repeat MRI the day prior. A follow-up appointment was also requested with Hematology/Oncology regarding your bone marrow biopsy findings; you may call ___ to follow up on this appointment with Drs. ___. Please also follow-up with a speech and swallow specialist for your voice as well as swallowing function and for speech therapy. We have written a prescription for outpatient speech therapy. Your follow-up is being coordinated by ___. Please call the number below (under recommended follow-up section) to follow-up regarding your appointment. It was a pleasure taking care of you at ___. Sincerely, Neurology at ___ Followup Instructions: ___
[ "C8599", "G959", "J3801", "E440", "F17210", "M5416", "D472", "D649", "D72819", "Z6823" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: LLE weakness, dysphagia Major Surgical or Invasive Procedure: Lumbar puncture Bone marrow biopsy History of Present Illness: [MASKED] is a [MASKED] year-old right-handed male without [MASKED] medical history who presents to the ED for evaluation of LLE weakness. He was seen in [MASKED] outpatient clinic this morning for evaluation of new dysphasia and dysphonia (began [MASKED]. He reports that he had gone to bed the previous day feeling normal but woke up with new difficulty swallowing as well as a change in his voice (more raspy, hoarse). With regards to his dysphagia, he describes feeling that solids "won't go down...the food gets stuck" but he has not had any difficulties with liquids. He was seen by a community physician who told him that he likely had sinus disease and recommended a few days of Sudafed. When the symptoms persisted and he had lost 15 pounds due to difficulty eating, he had a video swallow test performed [MASKED], see below) which revealed "significant oropharyngeal and esophageal dysphagia most notable for diffuse right-sided weakness." This prompted referral to [MASKED] clinic, where he was seen today and diagnosed with right vocal fold paralysis. He was noted to have LLE weakness, so was prompted to come to the ED for further evaluation. He reports that the LLE weakness began gradually, probably over the [MASKED]. This did not impair him in any way until the last week of [MASKED] when he was unable to stand up from a squatting position without the use of his hands. Overall, his weakness has been progessively worsening since that time. In particular, he notices difficulty with lifting his left leg up in order to cross it over the right leg, difficulty going upstairs > downstairs -- and needs to hold onto the railing for both. He is able to stand up out of a chair without difficulty but cannot stand from the floor. He has not had any foot drop or toe stubbing. He has not had any difficulty with the right leg or either arm. On neuro ROS, Mr. [MASKED] denies headache, loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal numbness or parasthesiae. No bowel or bladder incontinence or retention. On general review of systems, this is notable for + unintentional weight loss over the past 2 weeks (15 pounds), which he attributes to his dysphagia. He has also noticed saliva pooling in his mouth which he sometimes has difficulty swallowing. He has been coughing more, but he attributes this to the irritation in his throat, as he has not had any nasal congestion or "deep cough." He denies recent fever or chills. No night sweats. Denies shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: Tobacco use disorder Social History: [MASKED] Family History: - Great nephew [MASKED] years) with recently diagnosed epilepsy - Father (now deceased) had prostate cancer. Physical Exam: ADMISSION Physical Exam: ============================ Vitals [MASKED], time: 14:23): T: 98.6 HR: 80 RR: 18 BP: 161/100 SaO2: 100% on RA General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, full ROM Pulmonary: breathing comfortably on RA Cardiac: warm and well-perfused with brisk capillary refill Abdomen: ND Extremities: + signficant atrophy of the left thigh. No C/C/E bilaterally. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name [MASKED] backward without difficulty. Language is fluent with intact comprehension. Normal prosody. There were no paraphasic errors. Pt was able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. The pt had good knowledge of current events. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. Fundoscopic exam revealed no disc blurring, exudates, or hemorrhages. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric at rest and upon activation. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. + gag on the left, equivocal on the right XI: [MASKED] strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline; + fasciculations. -Motor: Normal tone throughout. Significantly decreased bulk in the L thigh. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. [MASKED] strength throughout with the following exceptions: - Bilateral abductor pollicis brevis: 4+/5 - Left IP: 2+/5 - Left Quad: 2+/5 - Left Hamstring: 4+/5 - Left [MASKED]: 4+/5 Reflexes: Bi [MASKED] Pat Ach L 3 3 tr* 1 R 3 3 2* 1 *: with reinforcement Of note: + spread (finger flexion) in the bilateral UE reflexes Plantar response was upgoing in the left, mute on the right. [MASKED]: negative -Sensory: No deficits to light touch, pinprick, cold sensation, vibratory sense, proprioception throughout. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF bilaterally. -Gait: Good initiation. Narrow-based, normal stride and arm swing. Romberg absent. DISCHARGE Physical Exam: ======================== Vitals: T: 98.6 BP: 113/79 HR: 98 RR: 18 SpO2: 99% RA General: awake, cooperative, NAD HEENT: NC/AT, no scleral icterus noted, MMM Pulmonary: breathing comfortably, no tachypnea or increased WOB Cardiac: skin warm, well-perfused Abdomen: soft, ND Extremities: symmetric, no edema Neurologic: -Mental Status: Alert, cooperative. Language is fluent with intact comprehension. Able to follow both midline and appendicular commands. -Cranial Nerves: PERRL (3 to 2 mm [MASKED]. EOMI without nystagmus. Face symmetric at rest and with activation. Hearing intact to conversation. Palatal elevation symmetric. Tongue protrudes in midline. -Motor: No pronator drift bilaterally. No adventitious movements, such as tremor, noted. Delt Bic Tri WrE FE IP Quad Ham TA Gastroc L 5 [MASKED] 5 4+ 3 5 5 5 R 5 [MASKED] [MASKED] 5 5 5 -Sensory: Intact to LT throughout. No extinction to DSS. -DTRs: Bi [MASKED] Pat Ach L 2 2 1 1 R 2 2 1 1 -Coordination: No intention tremor or dysmetria on FNF bilaterally. Pertinent Results: ADMISSION LABS: =============== [MASKED] 04:30PM URINE HOURS-RANDOM [MASKED] 04:30PM URINE HOURS-RANDOM [MASKED] 04:30PM URINE HOURS-RANDOM [MASKED] 04:30PM URINE UHOLD-HOLD [MASKED] 04:30PM URINE GR HOLD-HOLD [MASKED] 04:30PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG [MASKED] 04:10PM GLUCOSE-89 UREA N-13 CREAT-1.0 SODIUM-143 POTASSIUM-4.9 CHLORIDE-102 TOTAL CO2-26 ANION GAP-15 [MASKED] 04:10PM estGFR-Using this [MASKED] 04:10PM CALCIUM-10.1 PHOSPHATE-3.7 MAGNESIUM-2.2 [MASKED] 04:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [MASKED] 04:10PM WBC-3.3* RBC-5.41 HGB-14.8 HCT-44.9 MCV-83 MCH-27.4 MCHC-33.0 RDW-13.4 RDWSD-40.1 [MASKED] 04:10PM NEUTS-53.8 [MASKED] MONOS-6.9 EOS-0.6* BASOS-0.6 IM [MASKED] AbsNeut-1.78 AbsLymp-1.25 AbsMono-0.23 AbsEos-0.02* AbsBaso-0.02 [MASKED] 04:10PM PLT COUNT-241 INTERVAL LABS: ============== [MASKED] 05:40AM BLOOD calTIBC-251* VitB12-722 Ferritn-172 TRF-193* [MASKED] 01:14PM BLOOD ANCA-NEGATIVE [MASKED] 10:34AM BLOOD CEA-3.4 [MASKED] 01:14PM BLOOD RheuFac-<10 [MASKED] [MASKED] 02:40PM BLOOD CRP-1.5 [MASKED] 05:25AM BLOOD [MASKED] Fr K/L-1.1 [MASKED] 10:34AM BLOOD PEP-ABNORMAL B IgG-2326* IgA-204 IgM-44 IFE-MONOCLONAL [MASKED] 01:14PM BLOOD C3-114 C4-20 [MASKED] 02:40PM BLOOD HIV Ab-NEG [MASKED] 04:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [MASKED] 10:34AM BLOOD QUANTIFERON-TB GOLD-Test [MASKED] 10:34AM BLOOD TOXOCARA (T. CANIS & T. CATI) ANTIBODY-Test [MASKED] 10:34AM BLOOD CA [MASKED] -Test [MASKED] 01:14PM BLOOD RO & [MASKED] [MASKED] 01:14PM BLOOD HTLV I AND II, WITH REFLEX TO WESTERN BLOT-Test [MASKED] 01:14PM BLOOD ANGIOTENSIN 1 - CONVERTING [MASKED] [MASKED] 02:40PM BLOOD SED RATE-Test [MASKED] 02:40PM BLOOD PARANEOPLASTIC AUTOANTIBODY EVALUATION-CANCELLED [MASKED] 02:40PM BLOOD ENCEPHALOPATHY, AUTOIMMUNE EVALUATION, SERUM-PND [MASKED] 10:00AM URINE U-PEP-NO PROTEIN IFE-NEGATIVE F [MASKED] 10:00AM URINE Hours-RANDOM Creat-153 TotProt-12 Prot/Cr-0.1 [MASKED] 04:55PM CEREBROSPINAL FLUID (CSF) TNC-6* RBC-1 Polys-2 [MASKED] Monos-9 Promyel-0 Plasma-3 Other-0 [MASKED] 04:55PM CEREBROSPINAL FLUID (CSF) TNC-18* RBC-4 Polys-4 [MASKED] Monos-6 Eos-1 Plasma-2 Other-0 [MASKED] 04:55PM CEREBROSPINAL FLUID (CSF) TotProt-114* Glucose-63 [MASKED] Misc-BODY FLUID [MASKED] 04:55PM CEREBROSPINAL FLUID (CSF) BETA 2 MICROGLOBULIN-Test [MASKED] 04:55PM CEREBROSPINAL FLUID (CSF) CA [MASKED] [MASKED] 04:55PM CEREBROSPINAL FLUID (CSF) VDRL-Test [MASKED] 04:55PM CEREBROSPINAL FLUID (CSF) TOXOPLASMA GONDII BY PCR-Test [MASKED] 04:55PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS PCR-Test Name [MASKED] 04:55PM CEREBROSPINAL FLUID (CSF) CYTOMEGALOVIRUS DNA, QUALITATIVE, PCR-Test [MASKED] 04:55PM CEREBROSPINAL FLUID (CSF) ANGIOTENSIN 1 CONVERTING ENZYME-Test [MASKED] 04:55PM CEREBROSPINAL FLUID (CSF) BORRELIA BURGDORFERI ANTIBODY INDEX FOR CNS INFECTION-CANCELLED IMAGING: ======== + MRI of L-spine notable for mild expansion in T2/STIR hyperintensity of the distal lumbar spinal cord with differential including infectious, inflammatory etiologies, or intramedullary neoplasm. On the contrast-enhanced study, this is described as 1.5 x 0.6 x 0.5 cm with associated cord expansion and extensive leptomeningeal involvement extending superiorly and inferiorly beyond the margins of the intramedullary lesion with possible involvement of the adjacent nerve roots. Abnormal bone marrow signal diffusely is also noted. Brief Hospital Course: BRIEF HOSPITAL COURSE Mr. [MASKED] was admitted to the Neurology service for evaluation of subacute progressive LLE weakness as well as dysphagia and dysphonia, found on ENT evaluation to be due to right-sided vocal cord paralysis. Despite initial concern for motor neuron disease, his EMG instead revealed a moderate to severe, chronic and ongoing left L4-L5 radiculopathy, without electrophysiologic evidence for a more generalized disorder of motor neurons or their axons. Follow-up MR imaging of the neuraxis was notable for: 1. Multilevel patchy cervical vertebral body T1 hypointensities with possible minimal postcontrast enhancement concerning for a potential marrow infiltrative process; 2. A 1.5 x 0.6 x 0.5 cm T12-L1 intramedullary enhancing focus with surrounding STIR/T2 signal abnormality and associated cord expansion, along with extensive leptomeningeal involvement and possible involvement of the adjacent nerve roots. These findings were concerning for infectious, inflammatory, or neoplastic processes. Inflammatory evaluation revealed unremarkable CSF ACE, ESR, CRP, and SS-A and SS-B Ab. Infectious evaluation revealed negative Lyme serologies, CSF culture, RPR/VDRL, Toxoplasma serologies and CSF PCR, HSV/CMV PCR, QuantiFERON Gold, and HTLV I/II Ab. Neoplastic evaluation revealed negative [MASKED] and CSF cytology and flow cytometry. CT chest/abdomen/pelvis was also negative for additional malignancy. SPEP, however, revealed a monoclonal gammopathy, though with negative skeletal survey and absence of renal findings to suggest multiple myeloma; in consultation with the Hematology/Oncology service, a bone marrow-biopsy was obtained that preliminarily revealed plasma cells as well as abnormal proliferation of lymphocytes concerning for lymphoma. As it remained unclear whether the bone marrow findings could also be implicated in the intramedullary spinal cord lesion and leptomeningeal/radicular enhancement seen on imaging, the Hematology/Oncology and Neuro-oncology teams deferred inpatient treatment in lieu of close outpatient follow-up for repeat imaging, repeat lumbar puncture, and follow up of molecular testing. With respect to Mr. [MASKED] leg and vocal cord symptoms, these may be related to the leptomeningeal/nerve root infiltrative process noted on imaging. During admission he also developed mild hyperreflexia and spasticity in the RLE (without weakness), indicating myelopathy, in line with cord signal abnormalities seen on imaging. Accordingly, Mr. [MASKED] was evaluated by [MASKED] and SLP as an inpatient, with plans for outpatient follow-up. Mr. [MASKED] was cleared for a regular diet and advised to turn his head to the right to facilitate swallowing. TRANSITIONAL ISSUES: =================== [] Follow-up outpatient MRI. [] Follow up with Neuro-oncology and Hematology/Oncology as noted above. [] Follow up final report from bone marrow biopsy as well as serum autoimmune encephalopathy panel. [] Outpatient [MASKED] and SLP follow up as noted above. Medications on Admission: None Discharge Medications: 1. Multivitamins W/minerals 1 TAB PO DAILY RX *multivitamin,tx-minerals [Vitamins and Minerals] 1 (One) tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 2.Outpatient Physical Therapy Diagnosis: Left leg weakness, L4/L5 radiculopathy 3.Outpatient Speech/Swallowing Therapy Diagnosis: right vocal cord paralysis, dysphonia Please continue to evaluate and treat dysphagia and dysphonia Discharge Disposition: Home Discharge Diagnosis: Lumbar Radiculopathy Lumbar myelopathy Intramedullary intradural spinal cord lesion Vocal cord paralysis Monoclonal gammopathy Suspected lymphoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], You were admitted to [MASKED] for evaluation of difficulty swallowing and speaking, as well as left leg weakness. Imaging of your spine showed an area of swelling and inflammation affecting your spinal cord and surrounding coverings; blood and cerebrospinal fluid tests did not show signs of an infection or inflammation, so there is concern that the spine findings may be due to cancer. Although imaging of your chest, abdomen, and pelvis did not show signs of additional cancer, your bone marrow did have abnormal blood cells (lymphocytes) that could reflect lymphoma. In order to further direct treatment of your spinal cord lesion, a follow-up appointment has been scheduled for you with Dr. [MASKED] in Neruo-oncology; you are also scheduled for a repeat MRI the day prior. A follow-up appointment was also requested with Hematology/Oncology regarding your bone marrow biopsy findings; you may call [MASKED] to follow up on this appointment with Drs. [MASKED]. Please also follow-up with a speech and swallow specialist for your voice as well as swallowing function and for speech therapy. We have written a prescription for outpatient speech therapy. Your follow-up is being coordinated by [MASKED]. Please call the number below (under recommended follow-up section) to follow-up regarding your appointment. It was a pleasure taking care of you at [MASKED]. Sincerely, Neurology at [MASKED] Followup Instructions: [MASKED]
[]
[ "F17210", "D649" ]
[ "C8599: Non-Hodgkin lymphoma, unspecified, extranodal and solid organ sites", "G959: Disease of spinal cord, unspecified", "J3801: Paralysis of vocal cords and larynx, unilateral", "E440: Moderate protein-calorie malnutrition", "F17210: Nicotine dependence, cigarettes, uncomplicated", "M5416: Radiculopathy, lumbar region", "D472: Monoclonal gammopathy", "D649: Anemia, unspecified", "D72819: Decreased white blood cell count, unspecified", "Z6823: Body mass index [BMI] 23.0-23.9, adult" ]
19,999,784
27,192,150
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: chlorhexidine Attending: ___. Chief Complaint: Scheduled Chemotherapy Major Surgical or Invasive Procedure: None History of Present Illness: ___ w/ MGUS and neurolymphomatosis on rituximab/HD-MTX presenting for C8 HD-MTX. He received cycle 7 rituximab in clinic on ___. He states he is feeling well with stability of his foot drop. No new neurologic symptoms. foot drop. No new c/o. Last MRI L-spine ___ revealed no evidence of disease 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: (1) Swallowing study on ___ showed oropharyngeal and esophageal dysphagia on the right-sided, (2) gadolinium-enhanced thoracic and lumbar MRI on ___ showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side, (3) CT of the torso on ___ showed no malignancy, (4) lumbar puncture on ___ showed ___ WBC, ___ RBC, 114 protein, 63 glucose, 19 LDH, beta-2-microglobulin 1.87 (normal 0.36-2.56), CA ___ <6, VDRL non-reactive, and negative cytology for malignant cells, (5) bone marrow aspiration on ___ showed lambda restricted plasma cells, (6) gadolinium-enhanced lumbar MRI performed on ___ again showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side, and this enhancement appears slightly more prominent, and (7) lumbar puncture on ___ showed 26 WBC, 4 RBC, 146 protein, 57 glucose, 23 LDH, and atypical large lymphoid cells in cytology, (8) lumbar puncture on ___ showed 27 WBC, 0 RBC, 88 protein, 55 glucose, 33 LDH, beta-2-microglobulion 2.50 (range 0.36-2.56) and presence of oligoclonal bands, (9) laminectomy L2-5 for right L5 nerve resection on ___ by Dr. ___ and the pathology showed neurolymphomatosis, (10) HBV core antibody positive on ___ and ___, (11) HIV negative on ___, (12) echocardiogram showed LVEF >55%, (13) FDG-PET from ___ showed uptake in the lower spinal cord but no systemic uptake, (14) PICC line insertion on ___, (15) started C1W1 rituximab 375 mg/m2 and lamivudine 100 mg QD on ___, (16) CSF leak on ___, (17) discontinuation of lamuvidine and dexamethasone on ___, (18) repair of CSF leak on ___ by Dr. ___, (19) received C1W1 rituximab 375 mg/m2/week on ___, (20) Portacath placement on ___, (21) received C1 high-dose methotrexate at 6 grams/m2 on ___, (22) received C1W1 rituximab 375 mg/m2/week on ___, (23) received C1W2 rituximab 375 mg/m2/week on ___, (24) received C1W3 rituximab 375 mg/m2/week on ___, (25) received C2 high-dose methotrexate at 8 grams/m2 on ___, (26) received C1W4 rituximab 375 mg/m2/week on ___, (27) received C2 rituximab 375 mg/m2/week on ___, (28) received C3 high-dose methotrexate at 8 grams/m2 on ___, (29) received C3 rituximab 375 mg/m2/week on ___, (30) received C4 high-dose methotrexate at 8 grams/m2 on ___, (30) received C4 rituximab 375 mg/m2/week on ___, (31) received C5 high-dose methotrexate at 8 grams/m2 on ___, (32) gadolinium-enhanced total spine MRI on ___ showed response, (33) gadolinium-enhanced head MRI on ___ showed no evidence of disease, (34) FDG-PET on ___ showed improved FDG-Avid disease at T12-L2, and (35) CSF cytology showed atypical cells. (36) received C5 monthly maintenance rituximab 375 mg/m2/week on ___, (37) received C6 first monthly maintenance high-dose methotrexate at 8 grams/m2 on ___, and (38) gadolinium-enhanced MRI of the lumbosacral spine performed on ___ showed no evidence of disease. (39) received C6 second monthly maintenance rituximab 375 mg/m2/week on ___, and (40) received C7 second monthly maintenance high-dose methotrexate at 8 grams/m2 on ___. (41) received C7 maintenance ritixumab on ___ (42) admitted to oncology for C8 maintenance HD-MTX on ___ PAST MEDICAL HISTORY: None prior. Social History: ___ Family History: His father died at age ___ and he had dementia and prostate cancer. His mother is alive with osteoarthritis, knee replacement, asthma and tuberculosis. He has 3 siblings and they are all healthy. He does not have children. Physical Exam: ADMISSION PHYSICAL EXAM: VS: ___ 1039 Temp: 98.3 PO BP: 136/87 L Sitting HR: 84 RR: 16 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, no hepatomegaly, no splenomegaly. EXT: Warm, well perfused, no lower extremity edema, erythema or tenderness. NEURO: A&Ox3, good attention and linear thought, CN III-XII intact. Strength full throughout with 3+/5 LLE on plantarflexion. Sensation to light touch intact. gait intact without using cane ACCESS: Right chest wall port site intact. DISCHARGE EXAM: Temp: 97.8 PO BP: 157/81 HR: 62 RR: 18 O2 sat: 100% 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, no hepatomegaly, no splenomegaly. EXT: Warm, well perfused, no lower extremity edema, erythema or tenderness. NEURO: A&Ox3, good attention and linear thought, CN III-XII intact. Strength full throughout with ___ LLE on plantar flexion. Sensation to light touch intact. gait intact ACCESS: Right chest wall port site intact. Pertinent Results: ADMISSION LABS: =============== ___ 11:00AM BLOOD WBC-2.8* RBC-4.04* Hgb-11.0* Hct-33.8* MCV-84 MCH-27.2 MCHC-32.5 RDW-15.8* RDWSD-47.9* Plt ___ ___ 11:00AM BLOOD Glucose-88 UreaN-15 Creat-0.8 Na-139 K-4.3 Cl-100 HCO3-27 AnGap-12 ___ 11:00AM BLOOD ALT-21 AST-17 LD(LDH)-120 AlkPhos-83 TotBili-0.2 ___ 11:00AM BLOOD Albumin-3.9 Calcium-9.2 Phos-3.9 Mg-2.0 DISCHARGE LABS: =============== ___ 05:23AM BLOOD WBC-2.9* RBC-3.98* Hgb-10.8* Hct-32.9* MCV-83 MCH-27.1 MCHC-32.8 RDW-14.1 RDWSD-42.4 Plt ___ ___ 06:54AM BLOOD Neuts-55.3 ___ Monos-4.3* Eos-3.9 Baso-0.0 Im ___ AbsNeut-1.41* AbsLymp-0.92* AbsMono-0.11* AbsEos-0.10 AbsBaso-0.00* ___ 05:23AM BLOOD Glucose-100 UreaN-5* Creat-0.9 Na-141 K-3.7 Cl-97 HCO3-36* AnGap-8* ___ 05:23AM BLOOD ALT-34 AST-23 LD(LDH)-128 AlkPhos-78 TotBili-0.6 ___ 05:23AM BLOOD Calcium-9.1 Phos-3.4 Mg-1.___ w/ MGUS and neurolymphomatosis on rituximab/HD-MTX presenting for C8 HD-MTX. He received cycle 7 rituximab in clinic on ___. # Neurolymphomatosis: Urine was alkalinized with HCO3 per protocol and he underwent 8g/m2 infusion on ___. Leucovorin rescue 24 hours after infusion per protocol. He tolerated treatment well without significant side effects. He was somewhat slow to clear MTX and HCO3 was kept at 200/hour. Day of discharge level was 0.2 and downtrending. He requested DC home. We provided him with three days of leucovorin and NaHCO3 tabs to take at home. He will need follow up for C8 monthly rituximab , C9 monthly rituximab, and C9 HD MTX ___ 2-month dose). # MGUS: - He has follow up with Dr. ___ on ___. # Hypertension: Multiple SBPs >150 in house during prior admissions. Likely a component of IVF. Asymptomatic. # HBcAb+: HbSag/ab-. HBV viral load UL. Indicative of prior infection. # Billing: >30 minutes spent coordinating and executing this discharge plan TRANSITIONAL ISSUES: - Leucovorin 100mg qid through ___ - NaHCO3 1300mg qid through ___ - Tentatively scheduled for Rituximab on ___ and ___ Next HD MTX on ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 3. Docusate Sodium 100 mg PO BID:PRN constipation 4. Lactic Acid 12% Lotion 1 Appl TP TID:PRN dry skin 5. LORazepam 0.5 mg PO Q8H:PRN nausea, insomnia, anxiety 6. Multivitamins 1 TAB PO DAILY 7. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 8. Senna 8.6 mg PO BID:PRN constipation 9. Sodium Bicarbonate 1300 mg PO Q6H 3 days prior to admission 10. Leucovorin Calcium 40 mg PO Q6H Discharge Medications: 1. Leucovorin Calcium 40 mg PO Q6H RX *leucovorin calcium 10 mg 4 tablet(s) by mouth four times a day Disp #*48 Tablet Refills:*0 2. Sodium Bicarbonate 1300 mg PO QID RX *sodium bicarbonate 650 mg 2 tablet(s) by mouth four times a day Disp #*48 Tablet Refills:*0 3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 4. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 5. Docusate Sodium 100 mg PO BID:PRN constipation 6. Lactic Acid 12% Lotion 1 Appl TP TID:PRN dry skin 7. LORazepam 0.5 mg PO Q8H:PRN nausea, insomnia, anxiety 8. Multivitamins 1 TAB PO DAILY 9. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 10. Senna 8.6 mg PO BID:PRN constipation Discharge Disposition: Home Discharge Diagnosis: # Admission for chemotherapy # Neurolymphomatosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you at ___ ___. You were admitted for your scheduled high-dose methotrexate. You tolerated your treatment well. Please continue to take leucovorin and sodium bicarbonate tabs four times daily for the next three days to help clear the remaining methotrexate. You will continue monthly rituximab and space out your HD-MTX to every two months. Sincerely, Your ___ Care Team Followup Instructions: ___
[ "Z5111", "C8599", "D472", "Z8619", "Z87891" ]
Allergies: chlorhexidine Chief Complaint: Scheduled Chemotherapy Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] w/ MGUS and neurolymphomatosis on rituximab/HD-MTX presenting for C8 HD-MTX. He received cycle 7 rituximab in clinic on [MASKED]. He states he is feeling well with stability of his foot drop. No new neurologic symptoms. foot drop. No new c/o. Last MRI L-spine [MASKED] revealed no evidence of disease 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: (1) Swallowing study on [MASKED] showed oropharyngeal and esophageal dysphagia on the right-sided, (2) gadolinium-enhanced thoracic and lumbar MRI on [MASKED] showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side, (3) CT of the torso on [MASKED] showed no malignancy, (4) lumbar puncture on [MASKED] showed [MASKED] WBC, [MASKED] RBC, 114 protein, 63 glucose, 19 LDH, beta-2-microglobulin 1.87 (normal 0.36-2.56), CA [MASKED] <6, VDRL non-reactive, and negative cytology for malignant cells, (5) bone marrow aspiration on [MASKED] showed lambda restricted plasma cells, (6) gadolinium-enhanced lumbar MRI performed on [MASKED] again showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side, and this enhancement appears slightly more prominent, and (7) lumbar puncture on [MASKED] showed 26 WBC, 4 RBC, 146 protein, 57 glucose, 23 LDH, and atypical large lymphoid cells in cytology, (8) lumbar puncture on [MASKED] showed 27 WBC, 0 RBC, 88 protein, 55 glucose, 33 LDH, beta-2-microglobulion 2.50 (range 0.36-2.56) and presence of oligoclonal bands, (9) laminectomy L2-5 for right L5 nerve resection on [MASKED] by Dr. [MASKED] and the pathology showed neurolymphomatosis, (10) HBV core antibody positive on [MASKED] and [MASKED], (11) HIV negative on [MASKED], (12) echocardiogram showed LVEF >55%, (13) FDG-PET from [MASKED] showed uptake in the lower spinal cord but no systemic uptake, (14) PICC line insertion on [MASKED], (15) started C1W1 rituximab 375 mg/m2 and lamivudine 100 mg QD on [MASKED], (16) CSF leak on [MASKED], (17) discontinuation of lamuvidine and dexamethasone on [MASKED], (18) repair of CSF leak on [MASKED] by Dr. [MASKED], (19) received C1W1 rituximab 375 mg/m2/week on [MASKED], (20) Portacath placement on [MASKED], (21) received C1 high-dose methotrexate at 6 grams/m2 on [MASKED], (22) received C1W1 rituximab 375 mg/m2/week on [MASKED], (23) received C1W2 rituximab 375 mg/m2/week on [MASKED], (24) received C1W3 rituximab 375 mg/m2/week on [MASKED], (25) received C2 high-dose methotrexate at 8 grams/m2 on [MASKED], (26) received C1W4 rituximab 375 mg/m2/week on [MASKED], (27) received C2 rituximab 375 mg/m2/week on [MASKED], (28) received C3 high-dose methotrexate at 8 grams/m2 on [MASKED], (29) received C3 rituximab 375 mg/m2/week on [MASKED], (30) received C4 high-dose methotrexate at 8 grams/m2 on [MASKED], (30) received C4 rituximab 375 mg/m2/week on [MASKED], (31) received C5 high-dose methotrexate at 8 grams/m2 on [MASKED], (32) gadolinium-enhanced total spine MRI on [MASKED] showed response, (33) gadolinium-enhanced head MRI on [MASKED] showed no evidence of disease, (34) FDG-PET on [MASKED] showed improved FDG-Avid disease at T12-L2, and (35) CSF cytology showed atypical cells. (36) received C5 monthly maintenance rituximab 375 mg/m2/week on [MASKED], (37) received C6 first monthly maintenance high-dose methotrexate at 8 grams/m2 on [MASKED], and (38) gadolinium-enhanced MRI of the lumbosacral spine performed on [MASKED] showed no evidence of disease. (39) received C6 second monthly maintenance rituximab 375 mg/m2/week on [MASKED], and (40) received C7 second monthly maintenance high-dose methotrexate at 8 grams/m2 on [MASKED]. (41) received C7 maintenance ritixumab on [MASKED] (42) admitted to oncology for C8 maintenance HD-MTX on [MASKED] PAST MEDICAL HISTORY: None prior. Social History: [MASKED] Family History: His father died at age [MASKED] and he had dementia and prostate cancer. His mother is alive with osteoarthritis, knee replacement, asthma and tuberculosis. He has 3 siblings and they are all healthy. He does not have children. Physical Exam: ADMISSION PHYSICAL EXAM: VS: [MASKED] 1039 Temp: 98.3 PO BP: 136/87 L Sitting HR: 84 RR: 16 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, no hepatomegaly, no splenomegaly. EXT: Warm, well perfused, no lower extremity edema, erythema or tenderness. NEURO: A&Ox3, good attention and linear thought, CN III-XII intact. Strength full throughout with 3+/5 LLE on plantarflexion. Sensation to light touch intact. gait intact without using cane ACCESS: Right chest wall port site intact. DISCHARGE EXAM: Temp: 97.8 PO BP: 157/81 HR: 62 RR: 18 O2 sat: 100% 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, no hepatomegaly, no splenomegaly. EXT: Warm, well perfused, no lower extremity edema, erythema or tenderness. NEURO: A&Ox3, good attention and linear thought, CN III-XII intact. Strength full throughout with [MASKED] LLE on plantar flexion. Sensation to light touch intact. gait intact ACCESS: Right chest wall port site intact. Pertinent Results: ADMISSION LABS: =============== [MASKED] 11:00AM BLOOD WBC-2.8* RBC-4.04* Hgb-11.0* Hct-33.8* MCV-84 MCH-27.2 MCHC-32.5 RDW-15.8* RDWSD-47.9* Plt [MASKED] [MASKED] 11:00AM BLOOD Glucose-88 UreaN-15 Creat-0.8 Na-139 K-4.3 Cl-100 HCO3-27 AnGap-12 [MASKED] 11:00AM BLOOD ALT-21 AST-17 LD(LDH)-120 AlkPhos-83 TotBili-0.2 [MASKED] 11:00AM BLOOD Albumin-3.9 Calcium-9.2 Phos-3.9 Mg-2.0 DISCHARGE LABS: =============== [MASKED] 05:23AM BLOOD WBC-2.9* RBC-3.98* Hgb-10.8* Hct-32.9* MCV-83 MCH-27.1 MCHC-32.8 RDW-14.1 RDWSD-42.4 Plt [MASKED] [MASKED] 06:54AM BLOOD Neuts-55.3 [MASKED] Monos-4.3* Eos-3.9 Baso-0.0 Im [MASKED] AbsNeut-1.41* AbsLymp-0.92* AbsMono-0.11* AbsEos-0.10 AbsBaso-0.00* [MASKED] 05:23AM BLOOD Glucose-100 UreaN-5* Creat-0.9 Na-141 K-3.7 Cl-97 HCO3-36* AnGap-8* [MASKED] 05:23AM BLOOD ALT-34 AST-23 LD(LDH)-128 AlkPhos-78 TotBili-0.6 [MASKED] 05:23AM BLOOD Calcium-9.1 Phos-3.4 Mg-1.[MASKED] w/ MGUS and neurolymphomatosis on rituximab/HD-MTX presenting for C8 HD-MTX. He received cycle 7 rituximab in clinic on [MASKED]. # Neurolymphomatosis: Urine was alkalinized with HCO3 per protocol and he underwent 8g/m2 infusion on [MASKED]. Leucovorin rescue 24 hours after infusion per protocol. He tolerated treatment well without significant side effects. He was somewhat slow to clear MTX and HCO3 was kept at 200/hour. Day of discharge level was 0.2 and downtrending. He requested DC home. We provided him with three days of leucovorin and NaHCO3 tabs to take at home. He will need follow up for C8 monthly rituximab , C9 monthly rituximab, and C9 HD MTX [MASKED] 2-month dose). # MGUS: - He has follow up with Dr. [MASKED] on [MASKED]. # Hypertension: Multiple SBPs >150 in house during prior admissions. Likely a component of IVF. Asymptomatic. # HBcAb+: HbSag/ab-. HBV viral load UL. Indicative of prior infection. # Billing: >30 minutes spent coordinating and executing this discharge plan TRANSITIONAL ISSUES: - Leucovorin 100mg qid through [MASKED] - NaHCO3 1300mg qid through [MASKED] - Tentatively scheduled for Rituximab on [MASKED] and [MASKED] Next HD MTX on [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 3. Docusate Sodium 100 mg PO BID:PRN constipation 4. Lactic Acid 12% Lotion 1 Appl TP TID:PRN dry skin 5. LORazepam 0.5 mg PO Q8H:PRN nausea, insomnia, anxiety 6. Multivitamins 1 TAB PO DAILY 7. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 8. Senna 8.6 mg PO BID:PRN constipation 9. Sodium Bicarbonate 1300 mg PO Q6H 3 days prior to admission 10. Leucovorin Calcium 40 mg PO Q6H Discharge Medications: 1. Leucovorin Calcium 40 mg PO Q6H RX *leucovorin calcium 10 mg 4 tablet(s) by mouth four times a day Disp #*48 Tablet Refills:*0 2. Sodium Bicarbonate 1300 mg PO QID RX *sodium bicarbonate 650 mg 2 tablet(s) by mouth four times a day Disp #*48 Tablet Refills:*0 3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 4. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 5. Docusate Sodium 100 mg PO BID:PRN constipation 6. Lactic Acid 12% Lotion 1 Appl TP TID:PRN dry skin 7. LORazepam 0.5 mg PO Q8H:PRN nausea, insomnia, anxiety 8. Multivitamins 1 TAB PO DAILY 9. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 10. Senna 8.6 mg PO BID:PRN constipation Discharge Disposition: Home Discharge Diagnosis: # Admission for chemotherapy # Neurolymphomatosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], It was a pleasure taking care of you at [MASKED] [MASKED]. You were admitted for your scheduled high-dose methotrexate. You tolerated your treatment well. Please continue to take leucovorin and sodium bicarbonate tabs four times daily for the next three days to help clear the remaining methotrexate. You will continue monthly rituximab and space out your HD-MTX to every two months. Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "Z87891" ]
[ "Z5111: Encounter for antineoplastic chemotherapy", "C8599: Non-Hodgkin lymphoma, unspecified, extranodal and solid organ sites", "D472: Monoclonal gammopathy", "Z8619: Personal history of other infectious and parasitic diseases", "Z87891: Personal history of nicotine dependence" ]
19,999,784
27,319,264
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: chlorhexidine Attending: ___. Chief Complaint: Scheduled Chemotherapy Major Surgical or Invasive Procedure: None History of Present Illness: As per admitting MD: Mr. ___ is a pleasant ___ w/ MGUS and neurolymphomatosis on rituximab/HD-MTX presenting for C9 maintenance HD-MTX. He states he is feeling well with continued improvement of his foot drop. Gadolinium-enhanced MRI of the lumbosacral spine performed on ___ showed no evidence of disease. Took 3 bicarb tabs q6h x 2 days. urine PH on admission 8. Past Medical History: As per admitting MD: PAST ONCOLOGIC HISTORY: (1) Swallowing study on ___ showed oropharyngeal and esophageal dysphagia on the right-sided, (2) gadolinium-enhanced thoracic and lumbar MRI on ___ showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side, (3) CT of the torso on ___ showed no malignancy, (4) lumbar puncture on ___ showed ___ WBC, ___ RBC, 114 protein, 63 glucose, 19 LDH, beta-2-microglobulin 1.87 (normal 0.36-2.56), CA ___ <6, VDRL non-reactive, and negative cytology for malignant cells, (5) bone marrow aspiration on ___ showed lambda restricted plasma cells, (6) gadolinium-enhanced lumbar MRI performed on ___ again showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side, and this enhancement appears slightly more prominent, and (7) lumbar puncture on ___ showed 26 WBC, 4 RBC, 146 protein, 57 glucose, 23 LDH, and atypical large lymphoid cells in cytology, (8) lumbar puncture on ___ showed 27 WBC, 0 RBC, 88 protein, 55 glucose, 33 LDH, beta-2-microglobulion 2.50 (range 0.36-2.56) and presence of oligoclonal bands, (9) laminectomy L2-5 for right L5 nerve resection on ___ by Dr. ___ and the pathology showed neurolymphomatosis, (10) HBV core antibody positive on ___ and ___, (11) HIV negative on ___, (12) echocardiogram showed LVEF >55%, (13) FDG-PET from ___ showed uptake in the lower spinal cord but no systemic uptake, (14) PICC line insertion on ___, (15) started C1W1 rituximab 375 mg/m2 and lamivudine 100 mg QD on ___, (16) CSF leak on ___, (17) discontinuation of lamuvidine and dexamethasone on ___, (18) repair of CSF leak on ___ by Dr. ___, (19) received C1W1 rituximab 375 mg/m2/week on ___, (20) Portacath placement on ___, (21) received C1 high-dose methotrexate at 6 grams/m2 on ___, (22) received C1W1 rituximab 375 mg/m2/week on ___, (23) received C1W2 rituximab 375 mg/m2/week on ___, (24) received C1W3 rituximab 375 mg/m2/week on ___, (25) received C2 high-dose methotrexate at 8 grams/m2 on ___, (26) received C1W4 rituximab 375 mg/m2/week on ___, (27) received C2 rituximab 375 mg/m2/week on ___, (28) received C3 high-dose methotrexate at 8 grams/m2 on ___, (29) received C3 rituximab 375 mg/m2/week on ___, (30) received C4 high-dose methotrexate at 8 grams/m2 on ___, (30) received C4 rituximab 375 mg/m2/week on ___, (31) received C5 high-dose methotrexate at 8 grams/m2 on ___, (32) gadolinium-enhanced total spine MRI on ___ showed response, (33) gadolinium-enhanced head MRI on ___ showed no evidence of disease, (34) FDG-PET on ___ showed improved FDG-Avid disease at T12-L2, and (35) CSF cytology showed atypical cells. (36) received C5 monthly maintenance rituximab 375 mg/m2/week on ___, (37) received C6 first monthly maintenance high-dose methotrexate at 8 grams/m2 on ___, and (38) gadolinium-enhanced MRI of the lumbosacral spine performed on ___ showed no evidence of disease. (38) gadolinium-enhanced MRI of the lumbosacral spine performed on ___ showed no evidence of disease, (39) received C6 second monthly maintenance rituximab 375 mg/m2/week on ___, (40) received C7 second monthly maintenance high-dose methotrexate at 8 grams/m2 on ___, (41) received C8 third monthly maintenance rituximab 375 mg/m2/week on ___, and (42) received C9 third maintenance rituximab 375 mg/m2/week on ___ given at every 2-month interval. PAST MEDICAL HISTORY: None prior Social History: ___ Family History: As per admitting MD: His father died at age ___ and he had dementia and prostate cancer. His mother is alive with osteoarthritis, knee replacement, asthma and tuberculosis. He has 3 siblings and they are all healthy. He does not have children. Physical Exam: Admission: VS: Temp 98.3, BP 158/92, HR 84, RR 18, O2 sat 99% 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, no hepatomegaly, no splenomegaly. EXT: Warm, well perfused, no lower extremity edema, erythema or tenderness. NEURO: A&Ox3, good attention and linear thought, CN III-XII intact. Strength full throughout with ___ LLE on dorsiflexion. Sensation to light touch intact. ACCESS: Right chest wall port site intact, dressing c/d/I Discharge: GENERAL: Pleasant man, in no distress, sitting on bed comfortably, calm, talkative 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. normal RR ABD: Soft, non-tender, non-distended, normal bowel sounds, no hepatomegaly, no splenomegaly. EXT: Warm, well perfused, no lower extremity edema, erythema or tenderness. normal sensation to light touch. upper extremities with normal strength and ROM. Has non tender, non erythematous bursitis of left elbow, not warm to touch (unchanged) NEURO: A&Ox3, good attention and linear thought, Strength full throughout except for ___ LLE. Sensation to light touch intact. ACCESS: Right chest wall port site intact, dressing c/d/i Pertinent Results: Admit: ___ 02:20PM BLOOD WBC-4.1 RBC-4.16* Hgb-11.0* Hct-33.8* MCV-81* MCH-26.4 MCHC-32.5 RDW-15.3 RDWSD-45.1 Plt ___ ___ 02:20PM BLOOD Glucose-91 UreaN-12 Creat-0.9 Na-138 K-4.4 Cl-98 HCO3-27 AnGap-13 ___ 02:20PM BLOOD ALT-12 AST-14 LD(LDH)-104 AlkPhos-91 TotBili-0.3 ___ 02:20PM BLOOD Calcium-9.4 Phos-3.6 Mg-2.1 Discharge: ___ 05:04AM BLOOD WBC-2.3* RBC-3.86* Hgb-10.3* Hct-32.0* MCV-83 MCH-26.7 MCHC-32.2 RDW-14.4 RDWSD-43.2 Plt ___ ___ 05:04AM BLOOD Glucose-89 UreaN-4* Creat-0.8 Na-140 K-3.4* Cl-96 HCO3-33* AnGap-11 ___ 05:04AM BLOOD ALT-20 AST-17 AlkPhos-92 TotBili-0.5 ___ 05:04AM BLOOD Calcium-8.9 Phos-3.4 Mg-1.8 ___ 05:04AM BLOOD mthotrx-0.14 Micro/Imaging: None Brief Hospital Course: ___ w/ MGUS and neurolymphomatosis on rituximab/HD-MTX presented for C9 maintenance HD-MTX which he tolerated well with hospital course c/b bursitis #Left elbow bursitis Nontraumatic, unclear etiology. No tenderness, warmth, erythema to suggest infection or crystalline disease so was not aspirated. Patient was instructed that he can not take naproxen until he completely clears MTX. In order to ensure he is cleared, he should not start naproxen until ___ #Neurolymphomatosis: His CSF leak has previously resolved and patient continues to improve neurologically. Last PET w/ low-level FDG uptake centered in the spinal canal at T12-L2, which is significantly improved in comparison to the prior examination and may be within normal limits. Pt is off dexamethasone and not on antiepileptics. His post laminectomy at L2-5 for nerve resection on ___ resulted in LLE weakness which is improving. He tolerated prior cycles well with HD MTX except for delayed clearance and nausea. On this cycle patient was asymptomatic but again had delayed clearance. #MTX Discharge Level As per Dr ___, on future admits, patient can leave when level is <0.3. Dr ___ that given his age, and reliability in taking leucovorin tablets at home, could be safely discharged at that level so long as there are no other complicating factors. Patient is to be scheduled for an MRI of L/S Spine in ___ weeks, then f/u with Dr ___, and be re-admitted for next cycle in 2 months ___ #Leukopenia Patient known to develop leukopenia during previous administrations likely ___ BM suppression from MTX, which spontaneously resolves with time. Patient is to have leukopenia re-evaluated at next outpatient f/u appt. Transitional Issues: 1. Bursitis to be followed up in outpatient setting 2. Patient is to be scheduled for an MRI of L/S Spine in ___ weeks, then f/u with Dr ___, and be re-admitted for next cycle in 2 months ___ 3. Patient is to have leukopenia re-evaluated at next outpatient f/u appt. I personally spent 43 minutes coordinating care with outpatient providers, preparing discharge paperwork, educating patient and answering questions. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 3. Docusate Sodium 100 mg PO BID:PRN constipation 4. Lactic Acid 12% Lotion 1 Appl TP TID:PRN dry skin 5. LORazepam 0.5 mg PO Q8H:PRN nausea, insomnia, anxiety 6. Multivitamins 1 TAB PO DAILY 7. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 8. Senna 8.6 mg PO BID:PRN constipation 9. Sodium Bicarbonate 1300 mg PO QID 10. Leucovorin Calcium 40 mg PO Q6H Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 3. Docusate Sodium 100 mg PO BID:PRN constipation 4. Lactic Acid 12% Lotion 1 Appl TP TID:PRN dry skin 5. Leucovorin Calcium 40 mg PO Q6H RX *leucovorin calcium 10 mg 4 tablet(s) by mouth every six (6) hours Disp #*100 Tablet Refills:*0 6. LORazepam 0.5 mg PO Q8H:PRN nausea, insomnia, anxiety 7. Multivitamins 1 TAB PO DAILY 8. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 9. Senna 8.6 mg PO BID:PRN constipation 10. Sodium Bicarbonate 1300 mg PO QID RX *sodium bicarbonate 650 mg 2 tablet(s) by mouth four times a day Disp #*100 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: #Left elbow bursitis #Neurolymphomatosis #Hypokalemia #Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr ___ ___ was a pleasure taking care of you while you received your chemo. Dr ___ that although your level was not ___ you were ok to go home as long as you continued to take leucovorin. Please take your bicarb for 1 more day, and your leucovorin for 2 more days (ending ___ Dr ___ will call you for a follow up appointment in ___ weeks when you will get a L/S spine MRI beforehand. You will be re-admitted for next cycle in 2 months (___) As you know, you were found to have a condition called bursitis, which will improve with time. Remember, you are not to start Aleve to help its resolution until ___ Followup Instructions: ___
[ "Z5111", "C8331", "R1312", "D472", "Z87891", "I10", "E876", "M7032", "M6281" ]
Allergies: chlorhexidine Chief Complaint: Scheduled Chemotherapy Major Surgical or Invasive Procedure: None History of Present Illness: As per admitting MD: Mr. [MASKED] is a pleasant [MASKED] w/ MGUS and neurolymphomatosis on rituximab/HD-MTX presenting for C9 maintenance HD-MTX. He states he is feeling well with continued improvement of his foot drop. Gadolinium-enhanced MRI of the lumbosacral spine performed on [MASKED] showed no evidence of disease. Took 3 bicarb tabs q6h x 2 days. urine PH on admission 8. Past Medical History: As per admitting MD: PAST ONCOLOGIC HISTORY: (1) Swallowing study on [MASKED] showed oropharyngeal and esophageal dysphagia on the right-sided, (2) gadolinium-enhanced thoracic and lumbar MRI on [MASKED] showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side, (3) CT of the torso on [MASKED] showed no malignancy, (4) lumbar puncture on [MASKED] showed [MASKED] WBC, [MASKED] RBC, 114 protein, 63 glucose, 19 LDH, beta-2-microglobulin 1.87 (normal 0.36-2.56), CA [MASKED] <6, VDRL non-reactive, and negative cytology for malignant cells, (5) bone marrow aspiration on [MASKED] showed lambda restricted plasma cells, (6) gadolinium-enhanced lumbar MRI performed on [MASKED] again showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side, and this enhancement appears slightly more prominent, and (7) lumbar puncture on [MASKED] showed 26 WBC, 4 RBC, 146 protein, 57 glucose, 23 LDH, and atypical large lymphoid cells in cytology, (8) lumbar puncture on [MASKED] showed 27 WBC, 0 RBC, 88 protein, 55 glucose, 33 LDH, beta-2-microglobulion 2.50 (range 0.36-2.56) and presence of oligoclonal bands, (9) laminectomy L2-5 for right L5 nerve resection on [MASKED] by Dr. [MASKED] and the pathology showed neurolymphomatosis, (10) HBV core antibody positive on [MASKED] and [MASKED], (11) HIV negative on [MASKED], (12) echocardiogram showed LVEF >55%, (13) FDG-PET from [MASKED] showed uptake in the lower spinal cord but no systemic uptake, (14) PICC line insertion on [MASKED], (15) started C1W1 rituximab 375 mg/m2 and lamivudine 100 mg QD on [MASKED], (16) CSF leak on [MASKED], (17) discontinuation of lamuvidine and dexamethasone on [MASKED], (18) repair of CSF leak on [MASKED] by Dr. [MASKED], (19) received C1W1 rituximab 375 mg/m2/week on [MASKED], (20) Portacath placement on [MASKED], (21) received C1 high-dose methotrexate at 6 grams/m2 on [MASKED], (22) received C1W1 rituximab 375 mg/m2/week on [MASKED], (23) received C1W2 rituximab 375 mg/m2/week on [MASKED], (24) received C1W3 rituximab 375 mg/m2/week on [MASKED], (25) received C2 high-dose methotrexate at 8 grams/m2 on [MASKED], (26) received C1W4 rituximab 375 mg/m2/week on [MASKED], (27) received C2 rituximab 375 mg/m2/week on [MASKED], (28) received C3 high-dose methotrexate at 8 grams/m2 on [MASKED], (29) received C3 rituximab 375 mg/m2/week on [MASKED], (30) received C4 high-dose methotrexate at 8 grams/m2 on [MASKED], (30) received C4 rituximab 375 mg/m2/week on [MASKED], (31) received C5 high-dose methotrexate at 8 grams/m2 on [MASKED], (32) gadolinium-enhanced total spine MRI on [MASKED] showed response, (33) gadolinium-enhanced head MRI on [MASKED] showed no evidence of disease, (34) FDG-PET on [MASKED] showed improved FDG-Avid disease at T12-L2, and (35) CSF cytology showed atypical cells. (36) received C5 monthly maintenance rituximab 375 mg/m2/week on [MASKED], (37) received C6 first monthly maintenance high-dose methotrexate at 8 grams/m2 on [MASKED], and (38) gadolinium-enhanced MRI of the lumbosacral spine performed on [MASKED] showed no evidence of disease. (38) gadolinium-enhanced MRI of the lumbosacral spine performed on [MASKED] showed no evidence of disease, (39) received C6 second monthly maintenance rituximab 375 mg/m2/week on [MASKED], (40) received C7 second monthly maintenance high-dose methotrexate at 8 grams/m2 on [MASKED], (41) received C8 third monthly maintenance rituximab 375 mg/m2/week on [MASKED], and (42) received C9 third maintenance rituximab 375 mg/m2/week on [MASKED] given at every 2-month interval. PAST MEDICAL HISTORY: None prior Social History: [MASKED] Family History: As per admitting MD: His father died at age [MASKED] and he had dementia and prostate cancer. His mother is alive with osteoarthritis, knee replacement, asthma and tuberculosis. He has 3 siblings and they are all healthy. He does not have children. Physical Exam: Admission: VS: Temp 98.3, BP 158/92, HR 84, RR 18, O2 sat 99% 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, no hepatomegaly, no splenomegaly. EXT: Warm, well perfused, no lower extremity edema, erythema or tenderness. NEURO: A&Ox3, good attention and linear thought, CN III-XII intact. Strength full throughout with [MASKED] LLE on dorsiflexion. Sensation to light touch intact. ACCESS: Right chest wall port site intact, dressing c/d/I Discharge: GENERAL: Pleasant man, in no distress, sitting on bed comfortably, calm, talkative 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. normal RR ABD: Soft, non-tender, non-distended, normal bowel sounds, no hepatomegaly, no splenomegaly. EXT: Warm, well perfused, no lower extremity edema, erythema or tenderness. normal sensation to light touch. upper extremities with normal strength and ROM. Has non tender, non erythematous bursitis of left elbow, not warm to touch (unchanged) NEURO: A&Ox3, good attention and linear thought, Strength full throughout except for [MASKED] LLE. Sensation to light touch intact. ACCESS: Right chest wall port site intact, dressing c/d/i Pertinent Results: Admit: [MASKED] 02:20PM BLOOD WBC-4.1 RBC-4.16* Hgb-11.0* Hct-33.8* MCV-81* MCH-26.4 MCHC-32.5 RDW-15.3 RDWSD-45.1 Plt [MASKED] [MASKED] 02:20PM BLOOD Glucose-91 UreaN-12 Creat-0.9 Na-138 K-4.4 Cl-98 HCO3-27 AnGap-13 [MASKED] 02:20PM BLOOD ALT-12 AST-14 LD(LDH)-104 AlkPhos-91 TotBili-0.3 [MASKED] 02:20PM BLOOD Calcium-9.4 Phos-3.6 Mg-2.1 Discharge: [MASKED] 05:04AM BLOOD WBC-2.3* RBC-3.86* Hgb-10.3* Hct-32.0* MCV-83 MCH-26.7 MCHC-32.2 RDW-14.4 RDWSD-43.2 Plt [MASKED] [MASKED] 05:04AM BLOOD Glucose-89 UreaN-4* Creat-0.8 Na-140 K-3.4* Cl-96 HCO3-33* AnGap-11 [MASKED] 05:04AM BLOOD ALT-20 AST-17 AlkPhos-92 TotBili-0.5 [MASKED] 05:04AM BLOOD Calcium-8.9 Phos-3.4 Mg-1.8 [MASKED] 05:04AM BLOOD mthotrx-0.14 Micro/Imaging: None Brief Hospital Course: [MASKED] w/ MGUS and neurolymphomatosis on rituximab/HD-MTX presented for C9 maintenance HD-MTX which he tolerated well with hospital course c/b bursitis #Left elbow bursitis Nontraumatic, unclear etiology. No tenderness, warmth, erythema to suggest infection or crystalline disease so was not aspirated. Patient was instructed that he can not take naproxen until he completely clears MTX. In order to ensure he is cleared, he should not start naproxen until [MASKED] #Neurolymphomatosis: His CSF leak has previously resolved and patient continues to improve neurologically. Last PET w/ low-level FDG uptake centered in the spinal canal at T12-L2, which is significantly improved in comparison to the prior examination and may be within normal limits. Pt is off dexamethasone and not on antiepileptics. His post laminectomy at L2-5 for nerve resection on [MASKED] resulted in LLE weakness which is improving. He tolerated prior cycles well with HD MTX except for delayed clearance and nausea. On this cycle patient was asymptomatic but again had delayed clearance. #MTX Discharge Level As per Dr [MASKED], on future admits, patient can leave when level is <0.3. Dr [MASKED] that given his age, and reliability in taking leucovorin tablets at home, could be safely discharged at that level so long as there are no other complicating factors. Patient is to be scheduled for an MRI of L/S Spine in [MASKED] weeks, then f/u with Dr [MASKED], and be re-admitted for next cycle in 2 months [MASKED] #Leukopenia Patient known to develop leukopenia during previous administrations likely [MASKED] BM suppression from MTX, which spontaneously resolves with time. Patient is to have leukopenia re-evaluated at next outpatient f/u appt. Transitional Issues: 1. Bursitis to be followed up in outpatient setting 2. Patient is to be scheduled for an MRI of L/S Spine in [MASKED] weeks, then f/u with Dr [MASKED], and be re-admitted for next cycle in 2 months [MASKED] 3. Patient is to have leukopenia re-evaluated at next outpatient f/u appt. I personally spent 43 minutes coordinating care with outpatient providers, preparing discharge paperwork, educating patient and answering questions. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 3. Docusate Sodium 100 mg PO BID:PRN constipation 4. Lactic Acid 12% Lotion 1 Appl TP TID:PRN dry skin 5. LORazepam 0.5 mg PO Q8H:PRN nausea, insomnia, anxiety 6. Multivitamins 1 TAB PO DAILY 7. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 8. Senna 8.6 mg PO BID:PRN constipation 9. Sodium Bicarbonate 1300 mg PO QID 10. Leucovorin Calcium 40 mg PO Q6H Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 3. Docusate Sodium 100 mg PO BID:PRN constipation 4. Lactic Acid 12% Lotion 1 Appl TP TID:PRN dry skin 5. Leucovorin Calcium 40 mg PO Q6H RX *leucovorin calcium 10 mg 4 tablet(s) by mouth every six (6) hours Disp #*100 Tablet Refills:*0 6. LORazepam 0.5 mg PO Q8H:PRN nausea, insomnia, anxiety 7. Multivitamins 1 TAB PO DAILY 8. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 9. Senna 8.6 mg PO BID:PRN constipation 10. Sodium Bicarbonate 1300 mg PO QID RX *sodium bicarbonate 650 mg 2 tablet(s) by mouth four times a day Disp #*100 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: #Left elbow bursitis #Neurolymphomatosis #Hypokalemia #Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr [MASKED] [MASKED] was a pleasure taking care of you while you received your chemo. Dr [MASKED] that although your level was not [MASKED] you were ok to go home as long as you continued to take leucovorin. Please take your bicarb for 1 more day, and your leucovorin for 2 more days (ending [MASKED] Dr [MASKED] will call you for a follow up appointment in [MASKED] weeks when you will get a L/S spine MRI beforehand. You will be re-admitted for next cycle in 2 months ([MASKED]) As you know, you were found to have a condition called bursitis, which will improve with time. Remember, you are not to start Aleve to help its resolution until [MASKED] Followup Instructions: [MASKED]
[]
[ "Z87891", "I10" ]
[ "Z5111: Encounter for antineoplastic chemotherapy", "C8331: Diffuse large B-cell lymphoma, lymph nodes of head, face, and neck", "R1312: Dysphagia, oropharyngeal phase", "D472: Monoclonal gammopathy", "Z87891: Personal history of nicotine dependence", "I10: Essential (primary) hypertension", "E876: Hypokalemia", "M7032: Other bursitis of elbow, left elbow", "M6281: Muscle weakness (generalized)" ]
19,999,784
28,216,091
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Scheduled Chemotherapy Major Surgical or Invasive Procedure: None History of Present Illness: ___ PMH of MGUS, Neurolymphatosis (on HD MTX/Rituximab), presents for scheduled HD MTX Cycle 2 Patient noted that prior to this admission was feeling in his USOH. He denied fever, chills, sore throat, cough, shortness of breath, nausea, vomiting, diarrhea, abdominal pain, dysuria, rash. He noted that he was without headache, vision/hearing changes. He noted that his left leg is weak, but feels that it has improved slightly s/p recent chemotherapy. 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 Dr. ___ clinic note: "His neurologic problem began in late ___ when he noted dysphagia and dysphonia. His voice became hoarse and he developed difficulty swallowing solids and liquids. Solid foods got stuck in his throat. He had decreased PO intake and he lost about ___ lbs. He saw his primary care physician and ___ video swallowing study on ___ showed oropharyngeal and esophageal dysphagia on the right-sided. He was subsequently referred to the ___ clinic. On the day of his evaluation ___, he was found to have left lower extremity weakness. He was sent to the emergency department for evaluation and was admitted to the general neurology service for work up. He underwent a gadolinium-enhanced thoracic and lumbar MRI that showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side. His first lumbar puncture on ___ showed ___ WBC, ___ RBC, 114 protein, 63 glucose, 19 LDH, beta-2-microglobulin 1.87 (normal 0.36-2.56), CA ___ <6, VDRL non-reactive, and negative cytology for malignant cells. He also had a bone marrow aspiration on ___ that showed lambda restricted plasma cells. His repeat gadolinium-enhanced lumbar MRI performed on ___ again showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side, and this enhancement appears slightly more prominent. A second lumbar puncture on ___ showed 26 WBC, 4 RBC, 146 protein, 57 glucose, 23 LDH, and atypical large lymphoid cells in cytology. A third lumbar puncture on ___ showed 27 WBC, 0 RBC, 88 protein, 55 glucose, 33 LDH, beta-2-microglobulion 2.50 (range 0.36-2.56) and presence of oligoclonal bands. Because the diagnosis could not be established via non-invasive measn, he eventually underwent a laminectomy at L2-5 for nerve resection on ___ by Dr. ___. During the immediate postoperative period, he had C1W1 rituximab 375 mg/m2 and lamivudine 100 mg QD on ___. He experienced CSF leak on ___, and therefore lamuvidine and dexamethasone were discontinued on ___. He underwent a repair of CSF leak on ___ by Dr. ___. He re-started rituximab on ___ and high-dose methotrexate on ___ PAST MEDICAL HISTORY: MGUS Laminectomy L2-5 for nerve resection on ___ c/b CSF leak on ___ s/p subsequent repair Social History: ___ Family History: Father had prostate cancer. Denies otherwise history of blood or oncologic history. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: ___ 1025 Temp: 98.0 PO BP: 160/89 HR: 100 RR: 18 O2 sat: 100% O2 delivery: RA GENERAL: sitting upright in bed, appears well, smiling, NAD EYES: PERRLA, EOMI HEENT: OP clear, MMM NECK: supple LUNGS: CTA b/l, no wheezes/rales/rhonchi, normal RR CV: RRR normal distal perfusion no edema ABD: soft NT, ND, normoactive BS GENITOURINARY: no foley EXT: gross sensation unchanged in all extremities, but has ___ strength in all muscles of the left lower extremity, RLE/RUE/LUE ___. PAtient noted that this is his baseline SKIN: warm, dry, no rash NEURO: AOx3, fluent speech, CNII-XII intact without deficits, strength ___ in LLE, otherwise other extremities normal strength ACCESS: port in right chest, no yet accessed DISCHARGE PHYSICAL EXAM: ___ ___ Temp: 98.7 PO BP: 151/87 HR: 67 RR: 18 O2 sat: 100% O2 delivery: Ra GENERAL: Pleasant and well appearing man sitting up in bed in NAD EYES: PERRLA, EOMI, sclerae are anicteric HEENT: OP clear, MMM NECK: supple LUNGS: CTA b/l, no wheezes/rales/rhonchi, normal RR CV: RRR normal distal perfusion no edema ABD: soft NT, ND, normoactive BS, nontender, no HSM GENITOURINARY: no foley EXT: No edema, normal bulk SKIN: warm, dry, no rash NEURO: AOx3, fluent speech, CNIII-XII intact without deficits, strength ___ in LLE with foot drop, otherwise other extremities normal strength ACCESS: port in right chest Pertinent Results: ADMISSION LABS: =============== ___ 11:20AM BLOOD WBC-4.6 RBC-3.54* Hgb-9.6* Hct-29.4* MCV-83 MCH-27.1 MCHC-32.7 RDW-14.8 RDWSD-45.1 Plt ___ ___ 11:20AM BLOOD ___ PTT-28.9 ___ ___ 11:20AM BLOOD Glucose-92 UreaN-10 Creat-0.8 Na-140 K-4.1 Cl-101 HCO3-30 AnGap-9* ___ 11:20AM BLOOD ALT-36 AST-18 LD(___)-122 AlkPhos-85 TotBili-0.2 ___ 11:20AM BLOOD Calcium-9.2 Phos-3.8 Mg-2.0 UricAcd-4.5 DISCHARGE LABS: =============== ___ 05:34AM BLOOD WBC-3.0* RBC-3.48* Hgb-9.3* Hct-29.2* MCV-84 MCH-26.7 MCHC-31.8* RDW-14.5 RDWSD-43.8 Plt ___ ___ 05:34AM BLOOD Glucose-85 UreaN-5* Creat-0.8 Na-141 K-3.7 Cl-96 HCO3-38* AnGap-7* ___ 05:34AM BLOOD ALT-86* AST-39 LD(LDH)-133 AlkPhos-86 TotBili-0.6 ___ 05:34AM BLOOD Calcium-8.9 Phos-3.2 Mg-1.9 MTX: ==== ___ 08:15PM BLOOD mthotrx-10.6* ___ 06:04PM BLOOD mthotrx-0.69* ___ 06:19PM BLOOD mthotrx-0.20 ___ 05:34AM BLOOD mthotrx-0.14 ___ 05:10PM BLOOD mthotrx-0.14 Brief Hospital Course: PRINCIPLE REASON FOR ADMISSION: =============================== ___ PMH of MGUS, Neurolymphatosis (on HD MTX/Rituximab), presents for scheduled HD MTX Cycle 2. #Neurolymphatosis (on HD MTX/Rituximab): Urine was alkalnized with sodium bicarb per protocol. He received 8g/m2 per OMS order set on ___ without incident. Leucovorin rescue was initiated 24 hours after infusion per protocol. MTX levels were monitored q24 hours. MTX on discharge was 0.14. After discussion with patient he elected to be discharged despite MTX >0.1. He was provided with rx for leucovorin 40mg q6 hours x3 days and sodium bicarb 1300mg q6 hours x3 days. He will follow up in clinic on ___ for rituximab. He will be readmitted on ___ for his next HD-MTX. #Transaminitis: Due to MTX infusion. Down trending prior to discharge. # Weakness # Foot drop: Much improved, overall. Will continue home ___ with plans for PFO. #Nausea: Stable/improving. Due to methotrexate/leucovorin #Constipation history: Continued home bowel regimen #Billing: >30 minutes spent coordinating and executing this discharge plan. TRANSITIONAL ISSUES: ==================== - Con't leucovorin and sodium bicarb tabs for three days (through ___, or as otherwise directed) - ___ in clinic on ___ for rituximab - Next cycle of HD MTX on ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 2. Docusate Sodium 100 mg PO BID 3. Multivitamins 1 TAB PO DAILY 4. Senna 8.6 mg PO BID:PRN constipation 5. Sodium Bicarbonate 1300 mg PO Q6H 6. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 7. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting Discharge Medications: 1. Leucovorin Calcium 40 mg PO Q6H Take through ___ RX *leucovorin calcium 10 mg 4 tablet(s) by mouth q6 hours Disp #*48 Tablet Refills:*0 2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 4. Docusate Sodium 100 mg PO BID 5. Multivitamins 1 TAB PO DAILY 6. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 7. Senna 8.6 mg PO BID:PRN constipation 8. Sodium Bicarbonate 1300 mg PO Q6H Take for three days (through ___ RX *sodium bicarbonate 650 mg 2 tablet(s) by mouth q6 hours Disp #*24 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Neurolymphomatosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you at ___ ___. You were admitted for your planned HD-MTX chemotherapy, which you tolerated well. You will need to follow up in clinic on ___ for rituximab and then return for your next HD-MTX on ___ for your next HD-MTX. Because your MTX level is still a little high you should take Sodium Bicarb and Leucovorin tabs for the next three days. Sincerely, Your ___ Care Team Followup Instructions: ___
[ "Z5111", "C8599", "D472", "Z87891", "M21379", "R748", "R110", "T451X5A", "Y92239" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Scheduled Chemotherapy Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] PMH of MGUS, Neurolymphatosis (on HD MTX/Rituximab), presents for scheduled HD MTX Cycle 2 Patient noted that prior to this admission was feeling in his USOH. He denied fever, chills, sore throat, cough, shortness of breath, nausea, vomiting, diarrhea, abdominal pain, dysuria, rash. He noted that he was without headache, vision/hearing changes. He noted that his left leg is weak, but feels that it has improved slightly s/p recent chemotherapy. 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 Dr. [MASKED] clinic note: "His neurologic problem began in late [MASKED] when he noted dysphagia and dysphonia. His voice became hoarse and he developed difficulty swallowing solids and liquids. Solid foods got stuck in his throat. He had decreased PO intake and he lost about [MASKED] lbs. He saw his primary care physician and [MASKED] video swallowing study on [MASKED] showed oropharyngeal and esophageal dysphagia on the right-sided. He was subsequently referred to the [MASKED] clinic. On the day of his evaluation [MASKED], he was found to have left lower extremity weakness. He was sent to the emergency department for evaluation and was admitted to the general neurology service for work up. He underwent a gadolinium-enhanced thoracic and lumbar MRI that showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side. His first lumbar puncture on [MASKED] showed [MASKED] WBC, [MASKED] RBC, 114 protein, 63 glucose, 19 LDH, beta-2-microglobulin 1.87 (normal 0.36-2.56), CA [MASKED] <6, VDRL non-reactive, and negative cytology for malignant cells. He also had a bone marrow aspiration on [MASKED] that showed lambda restricted plasma cells. His repeat gadolinium-enhanced lumbar MRI performed on [MASKED] again showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side, and this enhancement appears slightly more prominent. A second lumbar puncture on [MASKED] showed 26 WBC, 4 RBC, 146 protein, 57 glucose, 23 LDH, and atypical large lymphoid cells in cytology. A third lumbar puncture on [MASKED] showed 27 WBC, 0 RBC, 88 protein, 55 glucose, 33 LDH, beta-2-microglobulion 2.50 (range 0.36-2.56) and presence of oligoclonal bands. Because the diagnosis could not be established via non-invasive measn, he eventually underwent a laminectomy at L2-5 for nerve resection on [MASKED] by Dr. [MASKED]. During the immediate postoperative period, he had C1W1 rituximab 375 mg/m2 and lamivudine 100 mg QD on [MASKED]. He experienced CSF leak on [MASKED], and therefore lamuvidine and dexamethasone were discontinued on [MASKED]. He underwent a repair of CSF leak on [MASKED] by Dr. [MASKED]. He re-started rituximab on [MASKED] and high-dose methotrexate on [MASKED] PAST MEDICAL HISTORY: MGUS Laminectomy L2-5 for nerve resection on [MASKED] c/b CSF leak on [MASKED] s/p subsequent repair Social History: [MASKED] Family History: Father had prostate cancer. Denies otherwise history of blood or oncologic history. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: [MASKED] 1025 Temp: 98.0 PO BP: 160/89 HR: 100 RR: 18 O2 sat: 100% O2 delivery: RA GENERAL: sitting upright in bed, appears well, smiling, NAD EYES: PERRLA, EOMI HEENT: OP clear, MMM NECK: supple LUNGS: CTA b/l, no wheezes/rales/rhonchi, normal RR CV: RRR normal distal perfusion no edema ABD: soft NT, ND, normoactive BS GENITOURINARY: no foley EXT: gross sensation unchanged in all extremities, but has [MASKED] strength in all muscles of the left lower extremity, RLE/RUE/LUE [MASKED]. PAtient noted that this is his baseline SKIN: warm, dry, no rash NEURO: AOx3, fluent speech, CNII-XII intact without deficits, strength [MASKED] in LLE, otherwise other extremities normal strength ACCESS: port in right chest, no yet accessed DISCHARGE PHYSICAL EXAM: [MASKED] [MASKED] Temp: 98.7 PO BP: 151/87 HR: 67 RR: 18 O2 sat: 100% O2 delivery: Ra GENERAL: Pleasant and well appearing man sitting up in bed in NAD EYES: PERRLA, EOMI, sclerae are anicteric HEENT: OP clear, MMM NECK: supple LUNGS: CTA b/l, no wheezes/rales/rhonchi, normal RR CV: RRR normal distal perfusion no edema ABD: soft NT, ND, normoactive BS, nontender, no HSM GENITOURINARY: no foley EXT: No edema, normal bulk SKIN: warm, dry, no rash NEURO: AOx3, fluent speech, CNIII-XII intact without deficits, strength [MASKED] in LLE with foot drop, otherwise other extremities normal strength ACCESS: port in right chest Pertinent Results: ADMISSION LABS: =============== [MASKED] 11:20AM BLOOD WBC-4.6 RBC-3.54* Hgb-9.6* Hct-29.4* MCV-83 MCH-27.1 MCHC-32.7 RDW-14.8 RDWSD-45.1 Plt [MASKED] [MASKED] 11:20AM BLOOD [MASKED] PTT-28.9 [MASKED] [MASKED] 11:20AM BLOOD Glucose-92 UreaN-10 Creat-0.8 Na-140 K-4.1 Cl-101 HCO3-30 AnGap-9* [MASKED] 11:20AM BLOOD ALT-36 AST-18 LD([MASKED])-122 AlkPhos-85 TotBili-0.2 [MASKED] 11:20AM BLOOD Calcium-9.2 Phos-3.8 Mg-2.0 UricAcd-4.5 DISCHARGE LABS: =============== [MASKED] 05:34AM BLOOD WBC-3.0* RBC-3.48* Hgb-9.3* Hct-29.2* MCV-84 MCH-26.7 MCHC-31.8* RDW-14.5 RDWSD-43.8 Plt [MASKED] [MASKED] 05:34AM BLOOD Glucose-85 UreaN-5* Creat-0.8 Na-141 K-3.7 Cl-96 HCO3-38* AnGap-7* [MASKED] 05:34AM BLOOD ALT-86* AST-39 LD(LDH)-133 AlkPhos-86 TotBili-0.6 [MASKED] 05:34AM BLOOD Calcium-8.9 Phos-3.2 Mg-1.9 MTX: ==== [MASKED] 08:15PM BLOOD mthotrx-10.6* [MASKED] 06:04PM BLOOD mthotrx-0.69* [MASKED] 06:19PM BLOOD mthotrx-0.20 [MASKED] 05:34AM BLOOD mthotrx-0.14 [MASKED] 05:10PM BLOOD mthotrx-0.14 Brief Hospital Course: PRINCIPLE REASON FOR ADMISSION: =============================== [MASKED] PMH of MGUS, Neurolymphatosis (on HD MTX/Rituximab), presents for scheduled HD MTX Cycle 2. #Neurolymphatosis (on HD MTX/Rituximab): Urine was alkalnized with sodium bicarb per protocol. He received 8g/m2 per OMS order set on [MASKED] without incident. Leucovorin rescue was initiated 24 hours after infusion per protocol. MTX levels were monitored q24 hours. MTX on discharge was 0.14. After discussion with patient he elected to be discharged despite MTX >0.1. He was provided with rx for leucovorin 40mg q6 hours x3 days and sodium bicarb 1300mg q6 hours x3 days. He will follow up in clinic on [MASKED] for rituximab. He will be readmitted on [MASKED] for his next HD-MTX. #Transaminitis: Due to MTX infusion. Down trending prior to discharge. # Weakness # Foot drop: Much improved, overall. Will continue home [MASKED] with plans for PFO. #Nausea: Stable/improving. Due to methotrexate/leucovorin #Constipation history: Continued home bowel regimen #Billing: >30 minutes spent coordinating and executing this discharge plan. TRANSITIONAL ISSUES: ==================== - Con't leucovorin and sodium bicarb tabs for three days (through [MASKED], or as otherwise directed) - [MASKED] in clinic on [MASKED] for rituximab - Next cycle of HD MTX on [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 2. Docusate Sodium 100 mg PO BID 3. Multivitamins 1 TAB PO DAILY 4. Senna 8.6 mg PO BID:PRN constipation 5. Sodium Bicarbonate 1300 mg PO Q6H 6. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 7. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting Discharge Medications: 1. Leucovorin Calcium 40 mg PO Q6H Take through [MASKED] RX *leucovorin calcium 10 mg 4 tablet(s) by mouth q6 hours Disp #*48 Tablet Refills:*0 2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 4. Docusate Sodium 100 mg PO BID 5. Multivitamins 1 TAB PO DAILY 6. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 7. Senna 8.6 mg PO BID:PRN constipation 8. Sodium Bicarbonate 1300 mg PO Q6H Take for three days (through [MASKED] RX *sodium bicarbonate 650 mg 2 tablet(s) by mouth q6 hours Disp #*24 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Neurolymphomatosis 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 [MASKED] [MASKED]. You were admitted for your planned HD-MTX chemotherapy, which you tolerated well. You will need to follow up in clinic on [MASKED] for rituximab and then return for your next HD-MTX on [MASKED] for your next HD-MTX. Because your MTX level is still a little high you should take Sodium Bicarb and Leucovorin tabs for the next three days. Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "Z87891" ]
[ "Z5111: Encounter for antineoplastic chemotherapy", "C8599: Non-Hodgkin lymphoma, unspecified, extranodal and solid organ sites", "D472: Monoclonal gammopathy", "Z87891: Personal history of nicotine dependence", "M21379: Foot drop, unspecified foot", "R748: Abnormal levels of other serum enzymes", "R110: Nausea", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause" ]
19,999,784
29,234,099
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: neurolymphomatosis, scheduled chemotherapy Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ man with history of MGUS and neurolymphomatosis on rituximab/HD-MTX presenting for C6 HD-MTX. He has felt well since his previous discharge. He received Rituximab with Dr. ___ on ___ which went fine. He notes some improvement in his arm discoloration and thinks he needs to see a Dermatologist. He has gained some weight back. He noticed a rash around his port which has improved with steroid cream. He started taking his bicab tabs on ___ prior to admission. He denies fevers/chills, night sweats, headache, vision changes, dizziness/lightheadedness, weakness/numbnesss, shortness of breath, cough, hemoptysis, chest pain, palpitations, abdominal pain, nausea/vomiting, diarrhea, hematemesis, hematochezia/melena, dysuria, and hematuria. 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: (1) Swallowing study on ___ showed oropharyngeal and esophageal dysphagia on the right-sided, (2) gadolinium-enhanced thoracic and lumbar MRI on ___ showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side, (3) CT of the torso on ___ showed no malignancy, (4) lumbar puncture on ___ showed ___ WBC, ___ RBC, 114 protein, 63 glucose, 19 LDH, beta-2-microglobulin 1.87 (normal 0.36-2.56), CA ___ <6, VDRL non-reactive, and negative cytology for malignant cells, (5) bone marrow aspiration on ___ showed lambda restricted plasma cells, (6) gadolinium-enhanced lumbar MRI performed on ___ again showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side, and this enhancement appears slightly more prominent, and (7) lumbar puncture on ___ showed 26 WBC, 4 RBC, 146 protein, 57 glucose, 23 LDH, and atypical large lymphoid cells in cytology, (8) lumbar puncture on ___ showed 27 WBC, 0 RBC, 88 protein, 55 glucose, 33 LDH, beta-2-microglobulion 2.50 (range 0.36-2.56) and presence of oligoclonal bands, (9) laminectomy L2-5 for right L5 nerve resection on ___ by Dr. ___ and the pathology showed neurolymphomatosis, (10) HBV core antibody positive on ___ and ___, (11) HIV negative on ___, (12) echocardiogram showed LVEF >55%, (13) FDG-PET from ___ showed uptake in the lower spinal cord but no systemic uptake, (14) PICC line insertion on ___, (15) started C1W1 rituximab 375 mg/m2 and lamivudine 100 mg QD on ___, (16) CSF leak on ___, (17) discontinuation of lamuvidine and dexamethasone on ___, (18) repair of CSF leak on ___ by Dr. ___, (19) received C1W1 rituximab 375 mg/m2/week on ___, (20) Portacath placement on ___, (21) received C1 high-dose methotrexate at 6 grams/m2 on ___, (22) received C1W1 rituximab 375 mg/m2/week on ___, (23) received C1W2 rituximab 375 mg/m2/week on ___, (24) received C1W3 rituximab 375 mg/m2/week on ___, (25) received C2 high-dose methotrexate at 8 grams/m2 on ___, (26) received C1W4 rituximab 375 mg/m2/week on ___, (27) received C2 rituximab 375 mg/m2/week on ___, (28) received C3 high-dose methotrexate at 8 grams/m2 on ___, (29) received C3 rituximab 375 mg/m2/week on ___, (30) received C4 high-dose methotrexate at 8 grams/m2 on ___, (30) received C4 rituximab 375 mg/m2/week on ___, (31) received C5 high-dose methotrexate at 8 grams/m2 on ___, (32) gadolinium-enhanced total spine MRI on ___ showed response, (33) gadolinium-enhanced head MRI on ___ showed no evidence of disease, (34) FDG-PET on ___ showed improved FDG-Avid disease at T12-L2, and (35) CSF cytology showed atypical cells. (36) C6 HD-MTX (8g/m2) ___ PAST MEDICAL HISTORY: -Hypertension -Forearm hyperpigmentation Social History: ___ Family History: His father died at age ___ and he had dementia and prostate cancer. His mother is alive with osteoarthritis, knee replacement, asthma and tuberculosis. He has 3 siblings and they are all healthy. He does not have children. Physical Exam: ON ADMISSSION ============== VS: Temp 98.3, BP 158/92, HR 84, RR 18, O2 sat 99% 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, no hepatomegaly, no splenomegaly. 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. ACCESS: Right chest wall port. ON DISCHARGE ============ VS: 98.0 ___ 20 100%RA GENERAL: Pleasant, well-appearing, in no distress, lying in bed comfortably. 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: Non-distended, normal bowel sounds, soft, non-tendedr. 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.L-foot-drop. SKIN: Hyperpigmentation in both fore-arms decreasing in extension. ACCESS: Right chest wall port Pertinent Results: ___ 10:23AM BLOOD WBC-3.4* RBC-4.07* Hgb-11.1* Hct-34.4* MCV-85 MCH-27.3 MCHC-32.3 RDW-16.5* RDWSD-51.4* Plt ___ ___ 05:52AM BLOOD WBC-2.7* RBC-4.05* Hgb-11.0* Hct-33.9* MCV-84 MCH-27.2 MCHC-32.4 RDW-15.6* RDWSD-47.3* Plt ___ ___ 10:23AM BLOOD Glucose-92 UreaN-10 Creat-0.8 Na-140 K-3.9 Cl-101 HCO3-29 AnGap-10 ___ 05:52AM BLOOD Glucose-94 UreaN-4* Creat-0.8 Na-139 K-3.4* Cl-94* HCO3-36* AnGap-9* ___ 08:24PM BLOOD mthotrx-3.7* ___ 08:26PM BLOOD mthotrx-1.6* ___ 08:28PM BLOOD mthotrx-0.43* ___ 01:15PM BLOOD mthotrx-0.43* ___ 06:08AM BLOOD mthotrx-0.13 Brief Hospital Course: Mr. ___ is a ___ year-old gentleman with history of MGUS and neurolymphomatosis on rituximab/HD-MTX admitted his for C6 HD-MTX which he tolerated well. # Neurolymphomatosis: His CSF leak has resolved and he continues to improve neurologically. No evidence of systemic lymphoma and is off dexamethasone and not on antiepileptics. Received high-dose methotrexate which is a highly toxic therapy with risk of transient or permanent neurological toxicity needing close monitoring of levels to be able to provide adequate support. Required IV NaHCO3 250cc/h. He tolerated this cycle with only mild intermittent headache and nausea which responded to supportive antiemesis and analgesia. #Forearm hyperpigmentation: Given improvement with time, this is likely a superficial form of hyperpigmentation (epidermal) which can improved with epidermal turnover and moisturization. Started on lactic acid 12% lotion TID. # MGUS: With rising IgG level. No intervention # Hypertension: Multiple SBPs >150 in house during prior admissions. TRANSITIONAL ISSUES ==================== 1. HYPERTENSION: Patient is hypertensive up to 160s during all his admissions. It is unclear whether he is not hypertensive while not receiving IVF. 2. Next admission for HD MTX to be in ~1 month 3. Discharged on po leucovorin x3d and MTX diet given tendency to have rising levels after apparent clearance 40 minutes were spent formulating and coordinating this patient's discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 3. Multivitamins 1 TAB PO DAILY 4. Senna 8.6 mg PO BID:PRN constipation 5. Sodium Bicarbonate 1300 mg PO Q6H 3 days prior to admission 6. Docusate Sodium 100 mg PO BID:PRN constipation 7. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting Discharge Medications: 1. Lactic Acid 12% Lotion 1 Appl TP TID RX *ammonium lactate [AmLactin] 12 % apply to both forearms three times a day Refills:*0 2. Leucovorin Calcium 40 mg PO Q6H Duration: 3 Days RX *leucovorin calcium 10 mg 4 tablet(s) by mouth every six (6) hours Disp #*48 Tablet Refills:*0 3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 4. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 5. Docusate Sodium 100 mg PO BID:PRN constipation 6. Multivitamins 1 TAB PO DAILY 7. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 8. Senna 8.6 mg PO BID:PRN constipation 9. Sodium Bicarbonate 1300 mg PO Q6H 3 days prior to admission Discharge Disposition: Home Discharge Diagnosis: Encounter for antineoplastic chemotherapy Neurolymphomatosis Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted for another cycle of your high dose methotrexate chemotherapy which you tolerated well. It was a pleasure to take care of you, Your ___ Team Followup Instructions: ___
[ "Z5111", "C8589", "Z87891", "D472", "I10", "R51", "R112", "L818" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: neurolymphomatosis, scheduled chemotherapy Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is a [MASKED] man with history of MGUS and neurolymphomatosis on rituximab/HD-MTX presenting for C6 HD-MTX. He has felt well since his previous discharge. He received Rituximab with Dr. [MASKED] on [MASKED] which went fine. He notes some improvement in his arm discoloration and thinks he needs to see a Dermatologist. He has gained some weight back. He noticed a rash around his port which has improved with steroid cream. He started taking his bicab tabs on [MASKED] prior to admission. He denies fevers/chills, night sweats, headache, vision changes, dizziness/lightheadedness, weakness/numbnesss, shortness of breath, cough, hemoptysis, chest pain, palpitations, abdominal pain, nausea/vomiting, diarrhea, hematemesis, hematochezia/melena, dysuria, and hematuria. 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: (1) Swallowing study on [MASKED] showed oropharyngeal and esophageal dysphagia on the right-sided, (2) gadolinium-enhanced thoracic and lumbar MRI on [MASKED] showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side, (3) CT of the torso on [MASKED] showed no malignancy, (4) lumbar puncture on [MASKED] showed [MASKED] WBC, [MASKED] RBC, 114 protein, 63 glucose, 19 LDH, beta-2-microglobulin 1.87 (normal 0.36-2.56), CA [MASKED] <6, VDRL non-reactive, and negative cytology for malignant cells, (5) bone marrow aspiration on [MASKED] showed lambda restricted plasma cells, (6) gadolinium-enhanced lumbar MRI performed on [MASKED] again showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side, and this enhancement appears slightly more prominent, and (7) lumbar puncture on [MASKED] showed 26 WBC, 4 RBC, 146 protein, 57 glucose, 23 LDH, and atypical large lymphoid cells in cytology, (8) lumbar puncture on [MASKED] showed 27 WBC, 0 RBC, 88 protein, 55 glucose, 33 LDH, beta-2-microglobulion 2.50 (range 0.36-2.56) and presence of oligoclonal bands, (9) laminectomy L2-5 for right L5 nerve resection on [MASKED] by Dr. [MASKED] and the pathology showed neurolymphomatosis, (10) HBV core antibody positive on [MASKED] and [MASKED], (11) HIV negative on [MASKED], (12) echocardiogram showed LVEF >55%, (13) FDG-PET from [MASKED] showed uptake in the lower spinal cord but no systemic uptake, (14) PICC line insertion on [MASKED], (15) started C1W1 rituximab 375 mg/m2 and lamivudine 100 mg QD on [MASKED], (16) CSF leak on [MASKED], (17) discontinuation of lamuvidine and dexamethasone on [MASKED], (18) repair of CSF leak on [MASKED] by Dr. [MASKED], (19) received C1W1 rituximab 375 mg/m2/week on [MASKED], (20) Portacath placement on [MASKED], (21) received C1 high-dose methotrexate at 6 grams/m2 on [MASKED], (22) received C1W1 rituximab 375 mg/m2/week on [MASKED], (23) received C1W2 rituximab 375 mg/m2/week on [MASKED], (24) received C1W3 rituximab 375 mg/m2/week on [MASKED], (25) received C2 high-dose methotrexate at 8 grams/m2 on [MASKED], (26) received C1W4 rituximab 375 mg/m2/week on [MASKED], (27) received C2 rituximab 375 mg/m2/week on [MASKED], (28) received C3 high-dose methotrexate at 8 grams/m2 on [MASKED], (29) received C3 rituximab 375 mg/m2/week on [MASKED], (30) received C4 high-dose methotrexate at 8 grams/m2 on [MASKED], (30) received C4 rituximab 375 mg/m2/week on [MASKED], (31) received C5 high-dose methotrexate at 8 grams/m2 on [MASKED], (32) gadolinium-enhanced total spine MRI on [MASKED] showed response, (33) gadolinium-enhanced head MRI on [MASKED] showed no evidence of disease, (34) FDG-PET on [MASKED] showed improved FDG-Avid disease at T12-L2, and (35) CSF cytology showed atypical cells. (36) C6 HD-MTX (8g/m2) [MASKED] PAST MEDICAL HISTORY: -Hypertension -Forearm hyperpigmentation Social History: [MASKED] Family History: His father died at age [MASKED] and he had dementia and prostate cancer. His mother is alive with osteoarthritis, knee replacement, asthma and tuberculosis. He has 3 siblings and they are all healthy. He does not have children. Physical Exam: ON ADMISSSION ============== VS: Temp 98.3, BP 158/92, HR 84, RR 18, O2 sat 99% 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, no hepatomegaly, no splenomegaly. 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. ACCESS: Right chest wall port. ON DISCHARGE ============ VS: 98.0 [MASKED] 20 100%RA GENERAL: Pleasant, well-appearing, in no distress, lying in bed comfortably. 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: Non-distended, normal bowel sounds, soft, non-tendedr. 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.L-foot-drop. SKIN: Hyperpigmentation in both fore-arms decreasing in extension. ACCESS: Right chest wall port Pertinent Results: [MASKED] 10:23AM BLOOD WBC-3.4* RBC-4.07* Hgb-11.1* Hct-34.4* MCV-85 MCH-27.3 MCHC-32.3 RDW-16.5* RDWSD-51.4* Plt [MASKED] [MASKED] 05:52AM BLOOD WBC-2.7* RBC-4.05* Hgb-11.0* Hct-33.9* MCV-84 MCH-27.2 MCHC-32.4 RDW-15.6* RDWSD-47.3* Plt [MASKED] [MASKED] 10:23AM BLOOD Glucose-92 UreaN-10 Creat-0.8 Na-140 K-3.9 Cl-101 HCO3-29 AnGap-10 [MASKED] 05:52AM BLOOD Glucose-94 UreaN-4* Creat-0.8 Na-139 K-3.4* Cl-94* HCO3-36* AnGap-9* [MASKED] 08:24PM BLOOD mthotrx-3.7* [MASKED] 08:26PM BLOOD mthotrx-1.6* [MASKED] 08:28PM BLOOD mthotrx-0.43* [MASKED] 01:15PM BLOOD mthotrx-0.43* [MASKED] 06:08AM BLOOD mthotrx-0.13 Brief Hospital Course: Mr. [MASKED] is a [MASKED] year-old gentleman with history of MGUS and neurolymphomatosis on rituximab/HD-MTX admitted his for C6 HD-MTX which he tolerated well. # Neurolymphomatosis: His CSF leak has resolved and he continues to improve neurologically. No evidence of systemic lymphoma and is off dexamethasone and not on antiepileptics. Received high-dose methotrexate which is a highly toxic therapy with risk of transient or permanent neurological toxicity needing close monitoring of levels to be able to provide adequate support. Required IV NaHCO3 250cc/h. He tolerated this cycle with only mild intermittent headache and nausea which responded to supportive antiemesis and analgesia. #Forearm hyperpigmentation: Given improvement with time, this is likely a superficial form of hyperpigmentation (epidermal) which can improved with epidermal turnover and moisturization. Started on lactic acid 12% lotion TID. # MGUS: With rising IgG level. No intervention # Hypertension: Multiple SBPs >150 in house during prior admissions. TRANSITIONAL ISSUES ==================== 1. HYPERTENSION: Patient is hypertensive up to 160s during all his admissions. It is unclear whether he is not hypertensive while not receiving IVF. 2. Next admission for HD MTX to be in ~1 month 3. Discharged on po leucovorin x3d and MTX diet given tendency to have rising levels after apparent clearance 40 minutes were spent formulating and coordinating this patient's discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 3. Multivitamins 1 TAB PO DAILY 4. Senna 8.6 mg PO BID:PRN constipation 5. Sodium Bicarbonate 1300 mg PO Q6H 3 days prior to admission 6. Docusate Sodium 100 mg PO BID:PRN constipation 7. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting Discharge Medications: 1. Lactic Acid 12% Lotion 1 Appl TP TID RX *ammonium lactate [AmLactin] 12 % apply to both forearms three times a day Refills:*0 2. Leucovorin Calcium 40 mg PO Q6H Duration: 3 Days RX *leucovorin calcium 10 mg 4 tablet(s) by mouth every six (6) hours Disp #*48 Tablet Refills:*0 3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 4. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 5. Docusate Sodium 100 mg PO BID:PRN constipation 6. Multivitamins 1 TAB PO DAILY 7. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 8. Senna 8.6 mg PO BID:PRN constipation 9. Sodium Bicarbonate 1300 mg PO Q6H 3 days prior to admission Discharge Disposition: Home Discharge Diagnosis: Encounter for antineoplastic chemotherapy Neurolymphomatosis Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], You were admitted for another cycle of your high dose methotrexate chemotherapy which you tolerated well. It was a pleasure to take care of you, Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "Z87891", "I10" ]
[ "Z5111: Encounter for antineoplastic chemotherapy", "C8589: Other specified types of non-Hodgkin lymphoma, extranodal and solid organ sites", "Z87891: Personal history of nicotine dependence", "D472: Monoclonal gammopathy", "I10: Essential (primary) hypertension", "R51: Headache", "R112: Nausea with vomiting, unspecified", "L818: Other specified disorders of pigmentation" ]
19,999,784
29,324,445
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: chlorhexidine Attending: ___ Chief Complaint: Scheduled Chemotherapy Major Surgical or Invasive Procedure: None History of Present Illness: ================================================================ Oncology Hospitalist Admission Date: ___ ================================================================ PRIMARY ONCOLOGIST: ___ PRIMARY DIAGNOSIS: neurolymphomatosis TREATMENT REGIMEN: HD MTX CHIEF COMPLAINT: Scheduled Chemotherapy HISTORY OF PRESENT ILLNESS: ___ w/ MGUS and neurolymphomatosis on rituximab/HD-MTX presented for C10 maintenance HD-MTX As per review of notes, last MRI of L spine was in ___ revealed that the hyperintensities, cord expansion and enhancement in the distal spinal cord seen on the MRI of ___ had resolved with subtle T2 hyperintensities remaining in the region, without new areas of enhancement or new T2 abnormalities within the distal spinal cord. Patient is therefore continuing on 2 month maintenance HD MTX for which he presents today for cycle 10. Pt reports that he was recently fitted for left foot orthotic and feels that his left leg strength is robust, and only has lingering weakness in dorsiflexion of left foot. Reported that gait was normal. Otherwise was eating, drinking, voiding, stooling without difficulty. Reported he was in good spirits. Denied fever or chills. Reported that weight is stable. He reported receiving rituximab in clinic several days ago. 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 Dr ___: "(1) swallowing study on ___ showed oropharyngeal and esophageal dysphagia on the right-sided, (2) gadolinium-enhanced thoracic and lumbar MRI on ___ showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side, (3) CT of the torso on ___ showed no malignancy, (4) lumbar puncture on ___ showed ___ WBC, ___ RBC, 114 protein, 63 glucose, 19 LDH, beta-2-microglobulin 1.87 (normal 0.36-2.56), CA ___ <6, VDRL non-reactive, and negative cytology for malignant cells, (5) bone marrow aspiration on ___ showed lambda restricted plasma cells, (6) gadolinium-enhanced lumbar MRI performed on ___ again showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side, and this enhancement appears slightly more prominent, and (7) lumbar puncture on ___ showed 26 WBC, 4 RBC, 146 protein, 57 glucose, 23 LDH, and atypical large lymphoid cells in cytology, (8) lumbar puncture on ___ showed 27 WBC, 0 RBC, 88 protein, 55 glucose, 33 LDH, beta-2-microglobulion 2.50 (range 0.36-2.56) and presence of oligoclonal bands, (9) laminectomy L2-5 for right L5 nerve resection on ___ by Dr. ___ and the pathology showed neurolymphomatosis, (10) HBV core antibody positive on ___ and ___, (11) HIV negative on ___, (12) echocardiogram showed LVEF >55%, (13) FDG-PET from ___ showed uptake in the lower spinal cord but no systemic uptake, (14) PICC line insertion on ___, (15) started C1W1 rituximab 375 mg/m2 and lamivudine 100 mg QD on ___, (16) CSF leak on ___, (17) discontinuation of lamuvidine and dexamethasone on ___, (18) repair of CSF leak on ___ by Dr. ___, (19) received C1W1 rituximab 375 mg/m2/week on ___, (20) Portacath placement on ___, (21) received C1 high-dose methotrexate at 6 grams/m2 on ___, (22) received C1W1 rituximab 375 mg/m2/week on ___, (23) received C1W2 rituximab 375 mg/m2/week on ___, (24) received C1W3 rituximab 375 mg/m2/week on ___, (25) received C2 high-dose methotrexate at 8 grams/m2 on ___, (26) received C1W4 rituximab 375 mg/m2/week on ___, (27) received C2 rituximab 375 mg/m2/week on ___, (28) received C3 high-dose methotrexate at 8 grams/m2 on ___, (29) received C3 rituximab 375 mg/m2/week on ___, (30) received C4 high-dose methotrexate at 8 grams/m2 on ___, (30) received C4 rituximab 375 mg/m2/week on ___, (31) received C5 high-dose methotrexate at 8 grams/m2 on ___, (32) gadolinium-enhanced total spine MRI on ___ showed response, (33) gadolinium-enhanced head MRI on ___ showed no evidence of disease, (34) FDG-PET on ___ showed improved FDG-Avid disease at T12-L2, (35) CSF cytology showed atypical cells, (36) received C5 monthly maintenance rituximab 375 mg/m2/week on ___, (37) received C6 first monthly maintenance high-dose methotrexate at 8 grams/m2 on ___, (38) gadolinium-enhanced MRI of the lumbosacral spine performed on ___ showed no evidence of disease, (39) received C6 second monthly maintenance rituximab 375 mg/m2/week on ___, (40) received C7 second monthly maintenance high-dose methotrexate at 8 grams/m2 on ___, (41) received C7 third monthly maintenance rituximab 375 mg/m2/week on ___, (42) received C8 third maintenance rituximab 375 mg/m2/week on ___ given at every 2-month interval (43) received C8 third monthly maintenance rituximab 375 mg/m2/week on ___, (___) received C9 first 2-month interval rituximab 375 mg/m2/week on ___, and (45) received C9 first 2-month interval maintenance high-dose methotrexate at 8 grams/m2 on ___ PAST MEDICAL HISTORY: -MGUS -Laminectomy L2-5 for nerve resection on ___ c/b CSF leak on ___ s/p subsequent repair -Left foot drop -Elbow Bursitis -HBcAb+: HbSag/ab-. HBV viral load UL. Indicative of prior infection. Discussed w/ Dr ___ by previous providers with decision to hold off on antiviral for reactivation Social History: ___ Family History: His father died at age ___ and he had dementia and prostate cancer. His mother is alive with osteoarthritis, knee replacement, asthma and tuberculosis. He has 3 siblings and they are all healthy. He does not have children. Physical Exam: Vitals: Temp: 97.8 PO BP: 143/85 HR: 61 RR: 18 O2 sat: 98% O2 delivery: Ra Dyspnea: 0 RASS: 0 Pain Score: ___ GENERAL: Pleasant man, in no distress, sitting in bed, calm, talkative 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. normal RR ABD: Soft, non-tender, non-distended, normal bowel sounds EXT: Warm, well perfused, no lower extremity edema, erythema or tenderness. normal sensation to light touch. upper extremities with normal strength and ROM. NEURO: A&Ox3, good attention and linear thought, Strength full throughout except for ___ dorsiflexion of left foot. Sensation to light touch intact. ACCESS: Right chest wall port site intact, dressing c/d/I Pertinent Results: ___ 06:30PM BLOOD mthotrx-3.1* ___ 06:25PM BLOOD mthotrx-1.6* ___ 06:25PM BLOOD mthotrx-1.6* ___ 06:00AM BLOOD mthotrx-1.1* ___ 06:11PM BLOOD mthotrx-1.4* ___ 06:30AM BLOOD mthotrx-0.45* ___ 02:25PM BLOOD mthotrx-0.32* ___ 05:04AM BLOOD mthotrx-0.___ w/ MGUS and neurolymphomatosis on rituximab/HD-MTX presenting for C10 maintenance HD-MTX # Neurolymphomatosis: He is post laminectomy at L2-5 for nerve resection on ___ which resulted in LLE weakness which is improving gradually over time. He tolerated prior cycles well with HD MTX except for delayed clearance and nausea. Last MRI of L spine was in ___ revealed that the hyperintensities, cord expansion and enhancement in the distal spinal cord seen on the MRI of ___ had resolved with subtle T2 hyperintensities remaining in the region, without new areas of enhancement or new T2 abnormalities within the distal spinal cord. Patient is therefore continuing on 2 month maintenance HD MTX for which he presented for cycle 10. He tolerated the chemo well. [] benefits from Emend premed significantly, cont on next admit [] despite IVF 250 ml/hr entire course, cleared slowly (4.5 days) [] level 0.15 on d/c, will go home on PO LV and Bicarb [] MRI ___, then will see Dr ___ to determine next chemo # Hypokalemia: expected, repleted PO # MGUS: Followed by Dr ___ # Hypertension: SBP 130s-150s # HBcAb+: HbSag/ab-. HBV viral load UL. Indicative of prior infection. Discussed w/ Dr ___. Holding off on antiviral PPX: Lovenox 40mg QD ordered but he refused, ambulated frequently ACCESS: POC CODE: Full Code (confirmed on admission) EMERGENCY CONTACT HCP: ___ (partner) ___ DISPO: Home 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. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 3. Docusate Sodium 100 mg PO BID:PRN constipation 4. LORazepam 0.5 mg PO Q8H:PRN nausea, insomnia, anxiety 5. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 6. Senna 8.6 mg PO BID:PRN constipation 7. Sodium Bicarbonate 1300 mg PO QID 8. Leucovorin Calcium 40 mg PO Q6H 9. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Lidocaine-Prilocaine 1 Appl TP DAILY:PRN port access RX *lidocaine-prilocaine 2.5 %-2.5 % apply to port site daily prn prior to getting port accessed Refills:*0 2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 4. Docusate Sodium 100 mg PO BID:PRN constipation 5. Leucovorin Calcium 40 mg PO Q6H Duration: 2 Days 6. LORazepam 0.5 mg PO Q8H:PRN nausea, insomnia, anxiety 7. Multivitamins 1 TAB PO DAILY 8. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 9. Senna 8.6 mg PO BID:PRN constipation 10. Sodium Bicarbonate 1300 mg PO QID Discharge Disposition: Home Discharge Diagnosis: Neurolymphomatosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You tolerated your chemotherapy well. Please take your bicarb for 1 more day, and your leucovorin for 2 more days. Please follow up with Dr ___ in clinic. Followup Instructions: ___
[ "Z5111", "C8331", "D472", "E876", "I10", "Z87891" ]
Allergies: chlorhexidine Chief Complaint: Scheduled Chemotherapy Major Surgical or Invasive Procedure: None History of Present Illness: ================================================================ Oncology Hospitalist Admission Date: [MASKED] ================================================================ PRIMARY ONCOLOGIST: [MASKED] PRIMARY DIAGNOSIS: neurolymphomatosis TREATMENT REGIMEN: HD MTX CHIEF COMPLAINT: Scheduled Chemotherapy HISTORY OF PRESENT ILLNESS: [MASKED] w/ MGUS and neurolymphomatosis on rituximab/HD-MTX presented for C10 maintenance HD-MTX As per review of notes, last MRI of L spine was in [MASKED] revealed that the hyperintensities, cord expansion and enhancement in the distal spinal cord seen on the MRI of [MASKED] had resolved with subtle T2 hyperintensities remaining in the region, without new areas of enhancement or new T2 abnormalities within the distal spinal cord. Patient is therefore continuing on 2 month maintenance HD MTX for which he presents today for cycle 10. Pt reports that he was recently fitted for left foot orthotic and feels that his left leg strength is robust, and only has lingering weakness in dorsiflexion of left foot. Reported that gait was normal. Otherwise was eating, drinking, voiding, stooling without difficulty. Reported he was in good spirits. Denied fever or chills. Reported that weight is stable. He reported receiving rituximab in clinic several days ago. 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 Dr [MASKED]: "(1) swallowing study on [MASKED] showed oropharyngeal and esophageal dysphagia on the right-sided, (2) gadolinium-enhanced thoracic and lumbar MRI on [MASKED] showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side, (3) CT of the torso on [MASKED] showed no malignancy, (4) lumbar puncture on [MASKED] showed [MASKED] WBC, [MASKED] RBC, 114 protein, 63 glucose, 19 LDH, beta-2-microglobulin 1.87 (normal 0.36-2.56), CA [MASKED] <6, VDRL non-reactive, and negative cytology for malignant cells, (5) bone marrow aspiration on [MASKED] showed lambda restricted plasma cells, (6) gadolinium-enhanced lumbar MRI performed on [MASKED] again showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side, and this enhancement appears slightly more prominent, and (7) lumbar puncture on [MASKED] showed 26 WBC, 4 RBC, 146 protein, 57 glucose, 23 LDH, and atypical large lymphoid cells in cytology, (8) lumbar puncture on [MASKED] showed 27 WBC, 0 RBC, 88 protein, 55 glucose, 33 LDH, beta-2-microglobulion 2.50 (range 0.36-2.56) and presence of oligoclonal bands, (9) laminectomy L2-5 for right L5 nerve resection on [MASKED] by Dr. [MASKED] and the pathology showed neurolymphomatosis, (10) HBV core antibody positive on [MASKED] and [MASKED], (11) HIV negative on [MASKED], (12) echocardiogram showed LVEF >55%, (13) FDG-PET from [MASKED] showed uptake in the lower spinal cord but no systemic uptake, (14) PICC line insertion on [MASKED], (15) started C1W1 rituximab 375 mg/m2 and lamivudine 100 mg QD on [MASKED], (16) CSF leak on [MASKED], (17) discontinuation of lamuvidine and dexamethasone on [MASKED], (18) repair of CSF leak on [MASKED] by Dr. [MASKED], (19) received C1W1 rituximab 375 mg/m2/week on [MASKED], (20) Portacath placement on [MASKED], (21) received C1 high-dose methotrexate at 6 grams/m2 on [MASKED], (22) received C1W1 rituximab 375 mg/m2/week on [MASKED], (23) received C1W2 rituximab 375 mg/m2/week on [MASKED], (24) received C1W3 rituximab 375 mg/m2/week on [MASKED], (25) received C2 high-dose methotrexate at 8 grams/m2 on [MASKED], (26) received C1W4 rituximab 375 mg/m2/week on [MASKED], (27) received C2 rituximab 375 mg/m2/week on [MASKED], (28) received C3 high-dose methotrexate at 8 grams/m2 on [MASKED], (29) received C3 rituximab 375 mg/m2/week on [MASKED], (30) received C4 high-dose methotrexate at 8 grams/m2 on [MASKED], (30) received C4 rituximab 375 mg/m2/week on [MASKED], (31) received C5 high-dose methotrexate at 8 grams/m2 on [MASKED], (32) gadolinium-enhanced total spine MRI on [MASKED] showed response, (33) gadolinium-enhanced head MRI on [MASKED] showed no evidence of disease, (34) FDG-PET on [MASKED] showed improved FDG-Avid disease at T12-L2, (35) CSF cytology showed atypical cells, (36) received C5 monthly maintenance rituximab 375 mg/m2/week on [MASKED], (37) received C6 first monthly maintenance high-dose methotrexate at 8 grams/m2 on [MASKED], (38) gadolinium-enhanced MRI of the lumbosacral spine performed on [MASKED] showed no evidence of disease, (39) received C6 second monthly maintenance rituximab 375 mg/m2/week on [MASKED], (40) received C7 second monthly maintenance high-dose methotrexate at 8 grams/m2 on [MASKED], (41) received C7 third monthly maintenance rituximab 375 mg/m2/week on [MASKED], (42) received C8 third maintenance rituximab 375 mg/m2/week on [MASKED] given at every 2-month interval (43) received C8 third monthly maintenance rituximab 375 mg/m2/week on [MASKED], ([MASKED]) received C9 first 2-month interval rituximab 375 mg/m2/week on [MASKED], and (45) received C9 first 2-month interval maintenance high-dose methotrexate at 8 grams/m2 on [MASKED] PAST MEDICAL HISTORY: -MGUS -Laminectomy L2-5 for nerve resection on [MASKED] c/b CSF leak on [MASKED] s/p subsequent repair -Left foot drop -Elbow Bursitis -HBcAb+: HbSag/ab-. HBV viral load UL. Indicative of prior infection. Discussed w/ Dr [MASKED] by previous providers with decision to hold off on antiviral for reactivation Social History: [MASKED] Family History: His father died at age [MASKED] and he had dementia and prostate cancer. His mother is alive with osteoarthritis, knee replacement, asthma and tuberculosis. He has 3 siblings and they are all healthy. He does not have children. Physical Exam: Vitals: Temp: 97.8 PO BP: 143/85 HR: 61 RR: 18 O2 sat: 98% O2 delivery: Ra Dyspnea: 0 RASS: 0 Pain Score: [MASKED] GENERAL: Pleasant man, in no distress, sitting in bed, calm, talkative 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. normal RR ABD: Soft, non-tender, non-distended, normal bowel sounds EXT: Warm, well perfused, no lower extremity edema, erythema or tenderness. normal sensation to light touch. upper extremities with normal strength and ROM. NEURO: A&Ox3, good attention and linear thought, Strength full throughout except for [MASKED] dorsiflexion of left foot. Sensation to light touch intact. ACCESS: Right chest wall port site intact, dressing c/d/I Pertinent Results: [MASKED] 06:30PM BLOOD mthotrx-3.1* [MASKED] 06:25PM BLOOD mthotrx-1.6* [MASKED] 06:25PM BLOOD mthotrx-1.6* [MASKED] 06:00AM BLOOD mthotrx-1.1* [MASKED] 06:11PM BLOOD mthotrx-1.4* [MASKED] 06:30AM BLOOD mthotrx-0.45* [MASKED] 02:25PM BLOOD mthotrx-0.32* [MASKED] 05:04AM BLOOD mthotrx-0.[MASKED] w/ MGUS and neurolymphomatosis on rituximab/HD-MTX presenting for C10 maintenance HD-MTX # Neurolymphomatosis: He is post laminectomy at L2-5 for nerve resection on [MASKED] which resulted in LLE weakness which is improving gradually over time. He tolerated prior cycles well with HD MTX except for delayed clearance and nausea. Last MRI of L spine was in [MASKED] revealed that the hyperintensities, cord expansion and enhancement in the distal spinal cord seen on the MRI of [MASKED] had resolved with subtle T2 hyperintensities remaining in the region, without new areas of enhancement or new T2 abnormalities within the distal spinal cord. Patient is therefore continuing on 2 month maintenance HD MTX for which he presented for cycle 10. He tolerated the chemo well. [] benefits from Emend premed significantly, cont on next admit [] despite IVF 250 ml/hr entire course, cleared slowly (4.5 days) [] level 0.15 on d/c, will go home on PO LV and Bicarb [] MRI [MASKED], then will see Dr [MASKED] to determine next chemo # Hypokalemia: expected, repleted PO # MGUS: Followed by Dr [MASKED] # Hypertension: SBP 130s-150s # HBcAb+: HbSag/ab-. HBV viral load UL. Indicative of prior infection. Discussed w/ Dr [MASKED]. Holding off on antiviral PPX: Lovenox 40mg QD ordered but he refused, ambulated frequently ACCESS: POC CODE: Full Code (confirmed on admission) EMERGENCY CONTACT HCP: [MASKED] (partner) [MASKED] DISPO: Home 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. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 3. Docusate Sodium 100 mg PO BID:PRN constipation 4. LORazepam 0.5 mg PO Q8H:PRN nausea, insomnia, anxiety 5. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 6. Senna 8.6 mg PO BID:PRN constipation 7. Sodium Bicarbonate 1300 mg PO QID 8. Leucovorin Calcium 40 mg PO Q6H 9. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Lidocaine-Prilocaine 1 Appl TP DAILY:PRN port access RX *lidocaine-prilocaine 2.5 %-2.5 % apply to port site daily prn prior to getting port accessed Refills:*0 2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 4. Docusate Sodium 100 mg PO BID:PRN constipation 5. Leucovorin Calcium 40 mg PO Q6H Duration: 2 Days 6. LORazepam 0.5 mg PO Q8H:PRN nausea, insomnia, anxiety 7. Multivitamins 1 TAB PO DAILY 8. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 9. Senna 8.6 mg PO BID:PRN constipation 10. Sodium Bicarbonate 1300 mg PO QID Discharge Disposition: Home Discharge Diagnosis: Neurolymphomatosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You tolerated your chemotherapy well. Please take your bicarb for 1 more day, and your leucovorin for 2 more days. Please follow up with Dr [MASKED] in clinic. Followup Instructions: [MASKED]
[]
[ "I10", "Z87891" ]
[ "Z5111: Encounter for antineoplastic chemotherapy", "C8331: Diffuse large B-cell lymphoma, lymph nodes of head, face, and neck", "D472: Monoclonal gammopathy", "E876: Hypokalemia", "I10: Essential (primary) hypertension", "Z87891: Personal history of nicotine dependence" ]
19,999,784
29,355,057
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Scheduled Chemotherapy Major Surgical or Invasive Procedure: None History of Present Illness: As per admitting MD: Mr. ___ is a pleasant ___ w/ MGUS and neurolymphomatosis on HD MTX/Rituxan who presents for admission for C4 q 2 week induction HD MTX. He has been doing well after his last cycle. His left foot drop which occured due to a laminectomy at L2-5 for nerve resection on ___ continues to improve. He took his sodium bicarb tabs q6hrs x 3 days and surprised on arrival pH still 6. Past Medical History: As per admitting MD: Social History: ___ Family History: As per admitting MD: Father had prostate cancer. Denies otherwise history of blood or oncologic history. Physical Exam: Admission: VITAL SIGNS: ___ 1041 Temp: 97.9 PO BP: 160/84 L Lying HR: 84 RR: 18 O2 sat: 100% O2 delivery: RA General: NAD, Resting in bed comfortably HEENT: MMM, no OP lesions, no cervical/supraclavicular adenopathy 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, no ___, no tremors SKIN: No rashes on the extremities, R chest port site intact NEURO: Grossly normal with exception of ___ strength in all muscles of LLE ___ dorsiflexion, 4+/5 plantarflexion), otherwise RLE/RUE/LUE ___. Discharge: General: NAD, sitting in bed comfortably, pleasant, talkative EYES: PERRLA, anicteric HEENT: MMM, no OP lesions CV: RRR, No murmurs, normal distal perfusion without edema PULM: CTAB, no w/r/r, no accessory muscle use. ABD: BS+, soft, NTND, no ascites LIMBS: WWP, no ___, no tremors, normal muscle bulk, has ___ strength on LLE which is unchanged from prior admissions SKIN: hyperpigmentation and xerosis on b/l forearm extending slightly above the elbow which was flat without erythema/warmth/tenderness, R chest port site intact without e/o infection NEURO: Grossly normal with exception of ___ strength in all muscles of LLE PSYCH: Normal mood, insight, judgment, affect ACCESS: Right chest port with c/d/I dressing Pertinent Results: Admission: ___ 11:54AM BLOOD WBC-4.0 RBC-3.46* Hgb-9.3* Hct-29.5* MCV-85 MCH-26.9 MCHC-31.5* RDW-16.0* RDWSD-49.2* Plt ___ ___ 11:54AM BLOOD ___ PTT-31.3 ___ ___ 11:54AM BLOOD Glucose-92 UreaN-9 Creat-0.8 Na-142 K-4.1 Cl-103 HCO3-26 AnGap-13 ___ 11:54AM BLOOD ALT-34 AST-23 LD(LDH)-157 AlkPhos-79 TotBili-0.2 ___ 11:54AM BLOOD Albumin-3.7 Calcium-9.1 Phos-4.1 Mg-2.1 ___ 09:06PM BLOOD mthotrx-7.1* Discharge: ___ 05:45AM BLOOD WBC-2.4* RBC-3.43* Hgb-9.2* Hct-28.6* MCV-83 MCH-26.8 MCHC-32.2 RDW-14.9 RDWSD-45.1 Plt ___ ___ 05:45AM BLOOD ___ PTT-27.1 ___ ___ 05:45AM BLOOD Neuts-41.5 ___ Monos-9.5 Eos-10.0* Baso-0.8 Im ___ AbsNeut-1.00* AbsLymp-0.91* AbsMono-0.23 AbsEos-0.24 AbsBaso-0.02 ___ 05:45AM BLOOD Glucose-94 UreaN-3* Creat-0.8 Na-142 K-3.7 Cl-97 HCO3-35* AnGap-10 ___ 05:45AM BLOOD ALT-46* AST-26 LD(LDH)-153 AlkPhos-80 TotBili-0.3 ___ 05:45AM BLOOD Calcium-9.1 Phos-3.8 Mg-1.8 UricAcd-4.1 ___ 05:45AM BLOOD mthotrx-0.10 CXR ___: Lungs are clear. Right-sided Port-A-Cath tip projects over the SVC. Cardiomediastinal silhouette is stable. There is no pleural effusion. No pneumothorax is seen Brief Hospital Course: ___ PMH MGUS and neurolymphomatosis on HD MTX/Rituxan who presented for admission for C4 q 2 week induction HD MTX, who has tolerated regimen well with exception of slight transaminitis, and fluctuating MTX levels, who eventually cleared with higher rate of IVF, and was discharged with outpatient neuro-oncology followup # Neurolymphomatosis (on HD MTX/Rituximab) No evidence of systemic lymphoma and is off dexamethasone and not on antiepileptics. His post laminectomy at L2-5 for nerve resection on ___ resulted in LLE weakness which is improving. Methotrexate clearance stalled with levels fluctuating without clear trend, difficult to say what was causing it. Pathology attending/resident reviewed quality control measures and machine was apparently functioning well, patient without third spacing on exam, and weight decreased since admission so unclear cause. Pt eventually discharged once value 0.1. As per Dr ___ have patient on IV Bicarb fluids at 200cc/hr on future admits to hopefully prevent such issue from recurring. Patient should also likely be started on 100 Leucovorin given his delay in clearing MTX. Patient is to have repeat LP, MRI and PET scan in ___ per Dr ___, with radmission ___ (email sent to neuro-onc discharge clinic). Lastly, pt is to receive rituxan in clinic q2 weeks, next on ___ (while apt not in system, patient is aware of date/time). #Neutropenia/Leukopenia On prior admits patient had leukopenia that was mild by end of stay likely ___ MTX. On this admission MTX clearance was delayed so patient had more severe leukopenia/neutropenia with ANC of 984 on discharge. I expect that value will increase in the coming days now that methotrexate now excreted. Patient was instructed to return if he has fever/chills or infectious symptoms given risk of rapid progression while neutropenic. He was informed to have his CBC re-checked at next outpatient neuro-oncology appointment next week. #Hyperpigmentation of both forearms On day of discharge patient had hyperpigmentation and xerosis with sharp demarcations of both forearms extending slightly above elbow which were not raised, warm, erythematous, tender so unlikely infectious/allergic/inflammatory. He noted that they were asymptomatic. As per Dr ___, reaction to ___ (MTX) seemed less likely. Given xerosis and distribution, contact irritation was considered (possibly new sweater that patient was wearing), so he was informed to moisturize BID and to followup with dermatology if progressed. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 3. Docusate Sodium 100 mg PO BID:PRN constipation 4. Multivitamins 1 TAB PO DAILY 5. Senna 8.6 mg PO BID:PRN constipation 6. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 7. Sodium Bicarbonate 1300 mg PO Q6H Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 3. Docusate Sodium 100 mg PO BID:PRN constipation 4. Multivitamins 1 TAB PO DAILY 5. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 6. Senna 8.6 mg PO BID:PRN constipation 7. Sodium Bicarbonate 1300 mg PO Q6H Discharge Disposition: Home Discharge Diagnosis: Neurolymphomatosis Leukopenia/Neutropenia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr ___, It was a pleasure taking care of you in the hospital. You were admitted for chemotherapy and you did well. Please take your medications as instructed and follow up as noted below. Followup Instructions: ___
[ "Z5111", "C8599", "D701", "D472", "M21372", "Z87891", "G8314", "T451X5A", "Y92239", "L259" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Scheduled Chemotherapy Major Surgical or Invasive Procedure: None History of Present Illness: As per admitting MD: Mr. [MASKED] is a pleasant [MASKED] w/ MGUS and neurolymphomatosis on HD MTX/Rituxan who presents for admission for C4 q 2 week induction HD MTX. He has been doing well after his last cycle. His left foot drop which occured due to a laminectomy at L2-5 for nerve resection on [MASKED] continues to improve. He took his sodium bicarb tabs q6hrs x 3 days and surprised on arrival pH still 6. Past Medical History: As per admitting MD: Social History: [MASKED] Family History: As per admitting MD: Father had prostate cancer. Denies otherwise history of blood or oncologic history. Physical Exam: Admission: VITAL SIGNS: [MASKED] 1041 Temp: 97.9 PO BP: 160/84 L Lying HR: 84 RR: 18 O2 sat: 100% O2 delivery: RA General: NAD, Resting in bed comfortably HEENT: MMM, no OP lesions, no cervical/supraclavicular adenopathy 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, no [MASKED], no tremors SKIN: No rashes on the extremities, R chest port site intact NEURO: Grossly normal with exception of [MASKED] strength in all muscles of LLE [MASKED] dorsiflexion, 4+/5 plantarflexion), otherwise RLE/RUE/LUE [MASKED]. Discharge: General: NAD, sitting in bed comfortably, pleasant, talkative EYES: PERRLA, anicteric HEENT: MMM, no OP lesions CV: RRR, No murmurs, normal distal perfusion without edema PULM: CTAB, no w/r/r, no accessory muscle use. ABD: BS+, soft, NTND, no ascites LIMBS: WWP, no [MASKED], no tremors, normal muscle bulk, has [MASKED] strength on LLE which is unchanged from prior admissions SKIN: hyperpigmentation and xerosis on b/l forearm extending slightly above the elbow which was flat without erythema/warmth/tenderness, R chest port site intact without e/o infection NEURO: Grossly normal with exception of [MASKED] strength in all muscles of LLE PSYCH: Normal mood, insight, judgment, affect ACCESS: Right chest port with c/d/I dressing Pertinent Results: Admission: [MASKED] 11:54AM BLOOD WBC-4.0 RBC-3.46* Hgb-9.3* Hct-29.5* MCV-85 MCH-26.9 MCHC-31.5* RDW-16.0* RDWSD-49.2* Plt [MASKED] [MASKED] 11:54AM BLOOD [MASKED] PTT-31.3 [MASKED] [MASKED] 11:54AM BLOOD Glucose-92 UreaN-9 Creat-0.8 Na-142 K-4.1 Cl-103 HCO3-26 AnGap-13 [MASKED] 11:54AM BLOOD ALT-34 AST-23 LD(LDH)-157 AlkPhos-79 TotBili-0.2 [MASKED] 11:54AM BLOOD Albumin-3.7 Calcium-9.1 Phos-4.1 Mg-2.1 [MASKED] 09:06PM BLOOD mthotrx-7.1* Discharge: [MASKED] 05:45AM BLOOD WBC-2.4* RBC-3.43* Hgb-9.2* Hct-28.6* MCV-83 MCH-26.8 MCHC-32.2 RDW-14.9 RDWSD-45.1 Plt [MASKED] [MASKED] 05:45AM BLOOD [MASKED] PTT-27.1 [MASKED] [MASKED] 05:45AM BLOOD Neuts-41.5 [MASKED] Monos-9.5 Eos-10.0* Baso-0.8 Im [MASKED] AbsNeut-1.00* AbsLymp-0.91* AbsMono-0.23 AbsEos-0.24 AbsBaso-0.02 [MASKED] 05:45AM BLOOD Glucose-94 UreaN-3* Creat-0.8 Na-142 K-3.7 Cl-97 HCO3-35* AnGap-10 [MASKED] 05:45AM BLOOD ALT-46* AST-26 LD(LDH)-153 AlkPhos-80 TotBili-0.3 [MASKED] 05:45AM BLOOD Calcium-9.1 Phos-3.8 Mg-1.8 UricAcd-4.1 [MASKED] 05:45AM BLOOD mthotrx-0.10 CXR [MASKED]: Lungs are clear. Right-sided Port-A-Cath tip projects over the SVC. Cardiomediastinal silhouette is stable. There is no pleural effusion. No pneumothorax is seen Brief Hospital Course: [MASKED] PMH MGUS and neurolymphomatosis on HD MTX/Rituxan who presented for admission for C4 q 2 week induction HD MTX, who has tolerated regimen well with exception of slight transaminitis, and fluctuating MTX levels, who eventually cleared with higher rate of IVF, and was discharged with outpatient neuro-oncology followup # Neurolymphomatosis (on HD MTX/Rituximab) No evidence of systemic lymphoma and is off dexamethasone and not on antiepileptics. His post laminectomy at L2-5 for nerve resection on [MASKED] resulted in LLE weakness which is improving. Methotrexate clearance stalled with levels fluctuating without clear trend, difficult to say what was causing it. Pathology attending/resident reviewed quality control measures and machine was apparently functioning well, patient without third spacing on exam, and weight decreased since admission so unclear cause. Pt eventually discharged once value 0.1. As per Dr [MASKED] have patient on IV Bicarb fluids at 200cc/hr on future admits to hopefully prevent such issue from recurring. Patient should also likely be started on 100 Leucovorin given his delay in clearing MTX. Patient is to have repeat LP, MRI and PET scan in [MASKED] per Dr [MASKED], with radmission [MASKED] (email sent to neuro-onc discharge clinic). Lastly, pt is to receive rituxan in clinic q2 weeks, next on [MASKED] (while apt not in system, patient is aware of date/time). #Neutropenia/Leukopenia On prior admits patient had leukopenia that was mild by end of stay likely [MASKED] MTX. On this admission MTX clearance was delayed so patient had more severe leukopenia/neutropenia with ANC of 984 on discharge. I expect that value will increase in the coming days now that methotrexate now excreted. Patient was instructed to return if he has fever/chills or infectious symptoms given risk of rapid progression while neutropenic. He was informed to have his CBC re-checked at next outpatient neuro-oncology appointment next week. #Hyperpigmentation of both forearms On day of discharge patient had hyperpigmentation and xerosis with sharp demarcations of both forearms extending slightly above elbow which were not raised, warm, erythematous, tender so unlikely infectious/allergic/inflammatory. He noted that they were asymptomatic. As per Dr [MASKED], reaction to [MASKED] (MTX) seemed less likely. Given xerosis and distribution, contact irritation was considered (possibly new sweater that patient was wearing), so he was informed to moisturize BID and to followup with dermatology if progressed. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 3. Docusate Sodium 100 mg PO BID:PRN constipation 4. Multivitamins 1 TAB PO DAILY 5. Senna 8.6 mg PO BID:PRN constipation 6. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 7. Sodium Bicarbonate 1300 mg PO Q6H Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 3. Docusate Sodium 100 mg PO BID:PRN constipation 4. Multivitamins 1 TAB PO DAILY 5. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 6. Senna 8.6 mg PO BID:PRN constipation 7. Sodium Bicarbonate 1300 mg PO Q6H Discharge Disposition: Home Discharge Diagnosis: Neurolymphomatosis Leukopenia/Neutropenia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr [MASKED], It was a pleasure taking care of you in the hospital. You were admitted for chemotherapy and you did well. Please take your medications as instructed and follow up as noted below. Followup Instructions: [MASKED]
[]
[ "Z87891" ]
[ "Z5111: Encounter for antineoplastic chemotherapy", "C8599: Non-Hodgkin lymphoma, unspecified, extranodal and solid organ sites", "D701: Agranulocytosis secondary to cancer chemotherapy", "D472: Monoclonal gammopathy", "M21372: Foot drop, left foot", "Z87891: Personal history of nicotine dependence", "G8314: Monoplegia of lower limb affecting left nondominant side", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "L259: Unspecified contact dermatitis, unspecified cause" ]
19,999,784
29,889,147
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: chlorhexidine Attending: ___. Chief Complaint: Elective admission for chemotherapy Major Surgical or Invasive Procedure: None History of Present Illness: ___ w/ MGUS and neurolymphomatosis on rituximab/HD-MTX presented for C12 maintenance HD-MTX. He was last admitted for C11 on ___, which he tolerated well. As was the case on prior admits, he was discharged when MTX level roughly 0.3 with plan to continue bicarb and leucovorin tabs at home. Cycle 12 of Rituxan was given on ___. Patient noted that he was without complaint, was at his baseline health without any new neurologic deficits/abnormalities. reported that he is tolerating a normal diet, voiding/stooling without difficulty. Denied any fever or chills. Past Medical History: PAST ONCOLOGIC HISTORY: (1) swallowing study on ___ showed oropharyngeal and esophageal dysphagia on the right-sided, (2) gadolinium-enhanced thoracic and lumbar MRI on ___ showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side, (3) CT of the torso on ___ showed no malignancy, (4) lumbar puncture on ___ showed ___ WBC, ___ RBC, 114 protein, 63 glucose, 19 LDH, beta-2-microglobulin 1.87 (normal 0.36-2.56), CA ___ <6, VDRL non-reactive, and negative cytology for malignant cells, (5) bone marrow aspiration on ___ showed lambda restricted plasma cells, (6) gadolinium-enhanced lumbar MRI performed on ___ again showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side, and this enhancement appears slightly more prominent, and (7) lumbar puncture on ___ showed 26 WBC, 4 RBC, 146 protein, 57 glucose, 23 LDH, and atypical large lymphoid cells in cytology, (8) lumbar puncture on ___ showed 27 WBC, 0 RBC, 88 protein, 55 glucose, 33 LDH, beta-2-microglobulion 2.50 (range 0.36-2.56) and presence of oligoclonal bands, (9) laminectomy L2-5 for right L5 nerve resection on ___ by Dr. ___ and the pathology showed neurolymphomatosis, (10) HBV core antibody positive on ___ and ___, (11) HIV negative on ___, (12) echocardiogram showed LVEF >55%, (13) FDG-PET from ___ showed uptake in the lower spinal cord but no systemic uptake, (14) PICC line insertion on ___, (15) started C1W1 rituximab 375 mg/m2 and lamivudine 100 mg QD on ___, (16) CSF leak on ___, (17) discontinuation of lamuvidine and dexamethasone on ___, (18) repair of CSF leak on ___ by Dr. ___, (19) received C1W1 rituximab 375 mg/m2/week on ___, (20) Portacath placement on ___, (21) received C1 high-dose methotrexate at 6 grams/m2 on ___, (22) received C1W1 rituximab 375 mg/m2/week on ___, (23) received C1W2 rituximab 375 mg/m2/week on ___, (24) received C1W3 rituximab 375 mg/m2/week on ___, (25) received C2 high-dose methotrexate at 8 grams/m2 on ___, (26) received C1W4 rituximab 375 mg/m2/week on ___, (27) received C2 rituximab 375 mg/m2/week on ___, (28) received C3 high-dose methotrexate at 8 grams/m2 on ___, (29) received C3 rituximab 375 mg/m2/week on ___, (30) received C4 high-dose methotrexate at 8 grams/m2 on ___, (30) received C4 rituximab 375 mg/m2/week on ___, (31) received C5 high-dose methotrexate at 8 grams/m2 on ___, (32) gadolinium-enhanced total spine MRI on ___ showed response, (33) gadolinium-enhanced head MRI on ___ showed no evidence of disease, (34) FDG-PET on ___ showed improved FDG-Avid disease at T12-L2, (35) CSF cytology showed atypical cells, (36) received C5 monthly maintenance rituximab 375 mg/m2/week on ___, (37) received C6 first monthly maintenance high-dose methotrexate at 8 grams/m2 on ___, (38) gadolinium-enhanced MRI of the lumbosacral spine performed on ___ showed no evidence of disease, (39) received C6 second monthly maintenance rituximab 375 mg/m2/week on ___, (40) received C7 second monthly maintenance high-dose methotrexate at 8 grams/m2 on ___, (41) received C7 third monthly maintenance rituximab 375 mg/m2/week on ___, (42) received C8 maintenance rituximab 375 mg/m2/week on ___ (43) received C8 third monthly maintenance rituximab 375 mg/m2/week on ___, (44) received C9 first 2-month interval rituximab 375 mg/m2/week on ___, and (45) received C9 2-month interval maintenance high-dose methotrexate at 8 grams/m2 on ___ (___) received C10 interval maintenance rituximab 375 mg/m2/week on ___. (47) received C10 ___ 2-month interval maintenance high-dose methotrexate at 8 grams/m2 on ___. (48)received C11 interval maintenance rituximab 375 mg/m2/week on ___. (49) Received C11 2-month interval maintenance high-dose methotrexate at 8 grams/m2 on ___: stable MRI L-spine and no definite abnormal area of uptake on FDG PET. PAST MEDICAL HISTORY: - MGUS - Laminectomy L2-5 for nerve resection on ___ c/b CSF leak on ___ s/p subsequent repair - Left foot drop - Elbow Bursitis - HBcAb+: HbSag/ab-. HBV viral load UL. Indicative of prior infection. Discussed w/ Dr ___ by previous providers with decision to hold off on antiviral for reactivation Physical Exam: General: Well appearing pleasant ___ man ambulating around room, packing up his belongings HEENT: No lesions in the oropharynx, MMM. Small erosions over the lower lip from yesterday have healed CV: RRR, no murmurs PULM: CTAB ABD: Soft nontender nondistended, normoactive bowel sounds LIMBS: WWP no edema SKIN: No rashes NEURO: Alert, answers questions appropriately, PERRL, palate elevates symmetrically, ambulating around room without difficulty ACCESS: POC c/d/i Pertinent Results: DISCHARGE LABS ___ 06:43AM BLOOD WBC-2.9* RBC-4.02* Hgb-11.1* Hct-33.9* MCV-84 MCH-27.6 MCHC-32.7 RDW-13.2 RDWSD-40.9 Plt ___ ___ 06:43AM BLOOD UreaN-5* Creat-0.8 Na-143 K-3.5 Cl-100 HCO3-35* AnGap-8* ___ 06:43AM BLOOD ALT-26 AST-19 AlkPhos-73 TotBili-0.7 ___ 06:43AM BLOOD Calcium-8.4 Phos-2.7 Mg-1.8 METHOTREXATE LEVELS: ___ 05:59PM BLOOD mthotrx-3.2* ___ 06:30PM BLOOD mthotrx-1.9* ___ 06:16PM BLOOD mthotrx-1.5* ___ 05:48PM BLOOD mthotrx-0.33* ___ 09:15AM BLOOD mthotrx-0.17 ___ 04:08PM BLOOD mthotrx-0.15 ___ 06:43AM BLOOD mthotrx-0.09 Brief Hospital Course: ___ is a ___ year old man with MGUS and neurolymphomatosis on rituximab/HD-MTX presented for C12 maintenance HD-MTX. He tolerated HD-MTX well apart from some nausea and mild transaminitis. He cleared methotrexate on day 6. #Neurolymphomatosis: Pt is off dexamethasone and not on antiepileptics. No new/worsening neurologic changes. Recent MRI spine and PET without e/o disease recurrence. Received Rituximab prior to admission. He tolerated C12 HD-MTX well apart from some mild nausea, hypokalemia, and transaminitis (AST/ALT peaked at 79/57 on ___. He will return for follow up PET ___ followed by MRI L spine ___ prior to appointment with Dr ___. He should return in 3 months for his next cycle of HD-MTX. For next cycle: - Alkainization w/ 150mEq NaHCO3/D5w at 250 cc/hr as he tends to clear slowly - Per Dr ___ need to wait until level is less than 0.1, can no longer leave at 0.3. #Bleeding at Urethra: He had one episode on ___ where he noticed blood at the tip of the penis. He was not thrombocytopenic and had not had any trauma. There were no recurrent episodes. He can consider outpatient GU follow up if recurrent. - consider outpatient GU f/u #MGUS: Follow up scheduled with Dr ___ ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Sodium Bicarbonate 1300 mg PO QID 3. Diazepam 5 mg PO Q8H:PRN muscle spasm 4. Leucovorin Calcium 40 mg PO ASDIR 5. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 6. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Moderate Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Diazepam 5 mg PO Q8H:PRN muscle spasm 3. Leucovorin Calcium 40 mg PO ASDIR 4. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 5. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Moderate 6. Sodium Bicarbonate 1300 mg PO QID Discharge Disposition: Home Discharge Diagnosis: Encounter for chemotherapy Neurolymphomatosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. ___ MD ___ Completed by: ___
[ "Z5111", "C8599", "B1910", "D472", "Z87891", "F1290", "E876", "I10", "R109", "R112", "N368" ]
Allergies: chlorhexidine Chief Complaint: Elective admission for chemotherapy Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] w/ MGUS and neurolymphomatosis on rituximab/HD-MTX presented for C12 maintenance HD-MTX. He was last admitted for C11 on [MASKED], which he tolerated well. As was the case on prior admits, he was discharged when MTX level roughly 0.3 with plan to continue bicarb and leucovorin tabs at home. Cycle 12 of Rituxan was given on [MASKED]. Patient noted that he was without complaint, was at his baseline health without any new neurologic deficits/abnormalities. reported that he is tolerating a normal diet, voiding/stooling without difficulty. Denied any fever or chills. Past Medical History: PAST ONCOLOGIC HISTORY: (1) swallowing study on [MASKED] showed oropharyngeal and esophageal dysphagia on the right-sided, (2) gadolinium-enhanced thoracic and lumbar MRI on [MASKED] showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side, (3) CT of the torso on [MASKED] showed no malignancy, (4) lumbar puncture on [MASKED] showed [MASKED] WBC, [MASKED] RBC, 114 protein, 63 glucose, 19 LDH, beta-2-microglobulin 1.87 (normal 0.36-2.56), CA [MASKED] <6, VDRL non-reactive, and negative cytology for malignant cells, (5) bone marrow aspiration on [MASKED] showed lambda restricted plasma cells, (6) gadolinium-enhanced lumbar MRI performed on [MASKED] again showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side, and this enhancement appears slightly more prominent, and (7) lumbar puncture on [MASKED] showed 26 WBC, 4 RBC, 146 protein, 57 glucose, 23 LDH, and atypical large lymphoid cells in cytology, (8) lumbar puncture on [MASKED] showed 27 WBC, 0 RBC, 88 protein, 55 glucose, 33 LDH, beta-2-microglobulion 2.50 (range 0.36-2.56) and presence of oligoclonal bands, (9) laminectomy L2-5 for right L5 nerve resection on [MASKED] by Dr. [MASKED] and the pathology showed neurolymphomatosis, (10) HBV core antibody positive on [MASKED] and [MASKED], (11) HIV negative on [MASKED], (12) echocardiogram showed LVEF >55%, (13) FDG-PET from [MASKED] showed uptake in the lower spinal cord but no systemic uptake, (14) PICC line insertion on [MASKED], (15) started C1W1 rituximab 375 mg/m2 and lamivudine 100 mg QD on [MASKED], (16) CSF leak on [MASKED], (17) discontinuation of lamuvidine and dexamethasone on [MASKED], (18) repair of CSF leak on [MASKED] by Dr. [MASKED], (19) received C1W1 rituximab 375 mg/m2/week on [MASKED], (20) Portacath placement on [MASKED], (21) received C1 high-dose methotrexate at 6 grams/m2 on [MASKED], (22) received C1W1 rituximab 375 mg/m2/week on [MASKED], (23) received C1W2 rituximab 375 mg/m2/week on [MASKED], (24) received C1W3 rituximab 375 mg/m2/week on [MASKED], (25) received C2 high-dose methotrexate at 8 grams/m2 on [MASKED], (26) received C1W4 rituximab 375 mg/m2/week on [MASKED], (27) received C2 rituximab 375 mg/m2/week on [MASKED], (28) received C3 high-dose methotrexate at 8 grams/m2 on [MASKED], (29) received C3 rituximab 375 mg/m2/week on [MASKED], (30) received C4 high-dose methotrexate at 8 grams/m2 on [MASKED], (30) received C4 rituximab 375 mg/m2/week on [MASKED], (31) received C5 high-dose methotrexate at 8 grams/m2 on [MASKED], (32) gadolinium-enhanced total spine MRI on [MASKED] showed response, (33) gadolinium-enhanced head MRI on [MASKED] showed no evidence of disease, (34) FDG-PET on [MASKED] showed improved FDG-Avid disease at T12-L2, (35) CSF cytology showed atypical cells, (36) received C5 monthly maintenance rituximab 375 mg/m2/week on [MASKED], (37) received C6 first monthly maintenance high-dose methotrexate at 8 grams/m2 on [MASKED], (38) gadolinium-enhanced MRI of the lumbosacral spine performed on [MASKED] showed no evidence of disease, (39) received C6 second monthly maintenance rituximab 375 mg/m2/week on [MASKED], (40) received C7 second monthly maintenance high-dose methotrexate at 8 grams/m2 on [MASKED], (41) received C7 third monthly maintenance rituximab 375 mg/m2/week on [MASKED], (42) received C8 maintenance rituximab 375 mg/m2/week on [MASKED] (43) received C8 third monthly maintenance rituximab 375 mg/m2/week on [MASKED], (44) received C9 first 2-month interval rituximab 375 mg/m2/week on [MASKED], and (45) received C9 2-month interval maintenance high-dose methotrexate at 8 grams/m2 on [MASKED] ([MASKED]) received C10 interval maintenance rituximab 375 mg/m2/week on [MASKED]. (47) received C10 [MASKED] 2-month interval maintenance high-dose methotrexate at 8 grams/m2 on [MASKED]. (48)received C11 interval maintenance rituximab 375 mg/m2/week on [MASKED]. (49) Received C11 2-month interval maintenance high-dose methotrexate at 8 grams/m2 on [MASKED]: stable MRI L-spine and no definite abnormal area of uptake on FDG PET. PAST MEDICAL HISTORY: - MGUS - Laminectomy L2-5 for nerve resection on [MASKED] c/b CSF leak on [MASKED] s/p subsequent repair - Left foot drop - Elbow Bursitis - HBcAb+: HbSag/ab-. HBV viral load UL. Indicative of prior infection. Discussed w/ Dr [MASKED] by previous providers with decision to hold off on antiviral for reactivation Physical Exam: General: Well appearing pleasant [MASKED] man ambulating around room, packing up his belongings HEENT: No lesions in the oropharynx, MMM. Small erosions over the lower lip from yesterday have healed CV: RRR, no murmurs PULM: CTAB ABD: Soft nontender nondistended, normoactive bowel sounds LIMBS: WWP no edema SKIN: No rashes NEURO: Alert, answers questions appropriately, PERRL, palate elevates symmetrically, ambulating around room without difficulty ACCESS: POC c/d/i Pertinent Results: DISCHARGE LABS [MASKED] 06:43AM BLOOD WBC-2.9* RBC-4.02* Hgb-11.1* Hct-33.9* MCV-84 MCH-27.6 MCHC-32.7 RDW-13.2 RDWSD-40.9 Plt [MASKED] [MASKED] 06:43AM BLOOD UreaN-5* Creat-0.8 Na-143 K-3.5 Cl-100 HCO3-35* AnGap-8* [MASKED] 06:43AM BLOOD ALT-26 AST-19 AlkPhos-73 TotBili-0.7 [MASKED] 06:43AM BLOOD Calcium-8.4 Phos-2.7 Mg-1.8 METHOTREXATE LEVELS: [MASKED] 05:59PM BLOOD mthotrx-3.2* [MASKED] 06:30PM BLOOD mthotrx-1.9* [MASKED] 06:16PM BLOOD mthotrx-1.5* [MASKED] 05:48PM BLOOD mthotrx-0.33* [MASKED] 09:15AM BLOOD mthotrx-0.17 [MASKED] 04:08PM BLOOD mthotrx-0.15 [MASKED] 06:43AM BLOOD mthotrx-0.09 Brief Hospital Course: [MASKED] is a [MASKED] year old man with MGUS and neurolymphomatosis on rituximab/HD-MTX presented for C12 maintenance HD-MTX. He tolerated HD-MTX well apart from some nausea and mild transaminitis. He cleared methotrexate on day 6. #Neurolymphomatosis: Pt is off dexamethasone and not on antiepileptics. No new/worsening neurologic changes. Recent MRI spine and PET without e/o disease recurrence. Received Rituximab prior to admission. He tolerated C12 HD-MTX well apart from some mild nausea, hypokalemia, and transaminitis (AST/ALT peaked at 79/57 on [MASKED]. He will return for follow up PET [MASKED] followed by MRI L spine [MASKED] prior to appointment with Dr [MASKED]. He should return in 3 months for his next cycle of HD-MTX. For next cycle: - Alkainization w/ 150mEq NaHCO3/D5w at 250 cc/hr as he tends to clear slowly - Per Dr [MASKED] need to wait until level is less than 0.1, can no longer leave at 0.3. #Bleeding at Urethra: He had one episode on [MASKED] where he noticed blood at the tip of the penis. He was not thrombocytopenic and had not had any trauma. There were no recurrent episodes. He can consider outpatient GU follow up if recurrent. - consider outpatient GU f/u #MGUS: Follow up scheduled with Dr [MASKED] [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Sodium Bicarbonate 1300 mg PO QID 3. Diazepam 5 mg PO Q8H:PRN muscle spasm 4. Leucovorin Calcium 40 mg PO ASDIR 5. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 6. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Moderate Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Diazepam 5 mg PO Q8H:PRN muscle spasm 3. Leucovorin Calcium 40 mg PO ASDIR 4. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 5. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Moderate 6. Sodium Bicarbonate 1300 mg PO QID Discharge Disposition: Home Discharge Diagnosis: Encounter for chemotherapy Neurolymphomatosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. [MASKED] MD [MASKED] Completed by: [MASKED]
[]
[ "Z87891", "I10" ]
[ "Z5111: Encounter for antineoplastic chemotherapy", "C8599: Non-Hodgkin lymphoma, unspecified, extranodal and solid organ sites", "B1910: Unspecified viral hepatitis B without hepatic coma", "D472: Monoclonal gammopathy", "Z87891: Personal history of nicotine dependence", "F1290: Cannabis use, unspecified, uncomplicated", "E876: Hypokalemia", "I10: Essential (primary) hypertension", "R109: Unspecified abdominal pain", "R112: Nausea with vomiting, unspecified", "N368: Other specified disorders of urethra" ]
19,999,784
29,956,342
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: chlorhexidine Attending: ___ Chief Complaint: admission for chemo Major Surgical or Invasive Procedure: none History of Present Illness: DATE: ___ PRIMARY ONCOLOGIST: ___., MD PRIMARY DIAGNOSIS: neurolymphomatosis TREATMENT REGIMEN: HD-MTX and rituximab maintenance === HPI === Chief Complaint: Scheduled chemotherapy ___ is a ___ yo man with neurolymphomatosis on HD-MTX and rituximab maintenance, who presents for scheduled chemotherapy. He saw Dr ___ in clinic ___ and received C14 of maintenance rituximab. His last PET scan was ___ which showed no evidence of systemic lymphoma. MRI L spine ___ was stable without any new findings. He returns for HD-MTX at q3 month maintenance interval. He is in his USOH. No headache, nausea, vomiting, abd pain, chest pain, SOB, fevers, chills, fatigue, appetite changes, dysuria. He started his sodium bicarb on ___ morning (>48 hrs prior to admission). Past Medical History: PAST ONCOLOGIC HISTORY: (1) swallowing study on ___ showed oropharyngeal and esophageal dysphagia on the right-sided, (2) gadolinium-enhanced thoracic and lumbar MRI on ___ showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side, (3) CT of the torso on ___ showed no malignancy, (4) lumbar puncture on ___ showed ___ WBC, ___ RBC, 114 protein, 63 glucose, 19 LDH, beta-2-microglobulin 1.87 (normal 0.36-2.56), CA ___ <6, VDRL non-reactive, and negative cytology for malignant cells, (5) bone marrow aspiration on ___ showed lambda restricted plasma cells, (6) gadolinium-enhanced lumbar MRI performed on ___ again showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side, and this enhancement appears slightly more prominent, and (7) lumbar puncture on ___ showed 26 WBC, 4 RBC, 146 protein, 57 glucose, 23 LDH, and atypical large lymphoid cells in cytology, (8) lumbar puncture on ___ showed 27 WBC, 0 RBC, 88 protein, 55 glucose, 33 LDH, beta-2-microglobulion 2.50 (range 0.36-2.56) and presence of oligoclonal bands, (9) laminectomy L2-5 for right L5 nerve resection on ___ by Dr. ___ and the pathology showed neurolymphomatosis, (10) HBV core antibody positive on ___ and ___, (11) HIV negative on ___, (12) echocardiogram showed LVEF >55%, (13) FDG-PET from ___ showed uptake in the lower spinal cord but no systemic uptake, (14) PICC line insertion on ___, (15) started C1W1 rituximab 375 mg/m2 and lamivudine 100 mg QD on ___, (16) CSF leak on ___, (17) discontinuation of lamuvidine and dexamethasone on ___, (18) repair of CSF leak on ___ by Dr. ___, (19) received C1W1 rituximab 375 mg/m2/week on ___, (20) Portacath placement on ___, (21) received C1 high-dose methotrexate at 6 grams/m2 on ___, (22) received C1W1 rituximab 375 mg/m2/week on ___, (23) received C1W2 rituximab 375 mg/m2/week on ___, (24) received C1W3 rituximab 375 mg/m2/week on ___, (25) received C2 high-dose methotrexate at 8 grams/m2 on ___, (26) received C1W4 rituximab 375 mg/m2/week on ___, (27) received C2 rituximab 375 mg/m2/week on ___, (28) received C3 high-dose methotrexate at 8 grams/m2 on ___, (29) received C3 rituximab 375 mg/m2/week on ___, (30) received C4 high-dose methotrexate at 8 grams/m2 on ___, (30) received C4 rituximab 375 mg/m2/week on ___, (31) received C5 high-dose methotrexate at 8 grams/m2 on ___, (32) gadolinium-enhanced total spine MRI on ___ showed response, (33) gadolinium-enhanced head MRI on ___ showed no evidence of disease, (34) FDG-PET on ___ showed improved FDG-Avid disease at T12-L2, (35) CSF cytology showed atypical cells, (36) received C5 monthly maintenance rituximab 375 mg/m2/week on ___, (37) received C6 first monthly maintenance high-dose methotrexate at 8 grams/m2 on ___, (38) gadolinium-enhanced MRI of the lumbosacral spine performed on ___ showed no evidence of disease, (39) received C6 second monthly maintenance rituximab 375 mg/m2/week on ___, (40) received C7 second monthly maintenance high-dose methotrexate at 8 grams/m2 on ___, (41) received C7 third monthly maintenance rituximab 375 mg/m2/week on ___, (42) received C8 maintenance rituximab 375 mg/m2/week on ___ (43) received C8 third monthly maintenance rituximab 375 mg/m2/week on ___, (44) received C9 first 2-month interval rituximab 375 mg/m2/week on ___, and (45) received C9 2-month interval maintenance high-dose methotrexate at 8 grams/m2 on ___ (46) received C10 interval maintenance rituximab 375 mg/m2/week on ___. (47) received C10 ___ 2-month interval maintenance high-dose methotrexate at 8 grams/m2 on ___. (___)received C11 interval maintenance rituximab 375 mg/m2/week on ___. (___) Received C11 2-month interval maintenance high-dose methotrexate at 8 grams/m2 on ___: stable MRI L-spine and no definite abnormal area of uptake on FDG PET. PAST MEDICAL HISTORY: - MGUS - Laminectomy L2-5 for nerve resection on ___ c/b CSF leak on ___ s/p subsequent repair - Left foot drop - Elbow Bursitis - HBcAb+: HbSag/ab-. HBV viral load UL. Indicative of prior infection. Discussed w/ Dr ___ by previous providers with decision to hold off on antiviral for reactivation Social History: ___ Family History: His father died at age ___ and he had dementia and prostate cancer. His mother is alive with osteoarthritis, knee replacement, asthma and tuberculosis. He has 3 siblings and they are all healthy. He does not have children. Physical Exam: 0716 Temp: 98.2 PO BP: 143/83 R Sitting HR: 55 RR: 18 O2 sat: 98% O2 delivery: RA General: Well appearing pleasant man resting in bed in no acute distress HEENT: Oropharynx clear, MMM, no lesions CV: RRR no murmurs PULM: CTAB ABD: Soft, nontender, nondistended. Bowel sounds present LIMBS: WWP, no peripheral edema SKIN: No obvious acute rashes NEURO: Alert, oriented, PERRL, palate elevate symmetrically ACCESS: R POC Pertinent Results: ___ 05:52PM BLOOD WBC-3.4* RBC-4.20* Hgb-11.6* Hct-35.2* MCV-84 MCH-27.6 MCHC-33.0 RDW-13.1 RDWSD-40.1 Plt ___ ___ 05:52PM BLOOD Neuts-60.9 ___ Monos-2.6* Eos-2.6 Baso-0.3 Im ___ AbsNeut-2.08 AbsLymp-1.14* AbsMono-0.09* AbsEos-0.09 AbsBaso-0.01 ___ 05:03AM BLOOD Glucose-98 UreaN-4* Creat-0.9 Na-140 K-3.5 Cl-97 HCO3-34* AnGap-9* ___ 05:52PM BLOOD ALT-33 AST-24 AlkPhos-82 TotBili-0.7 ___ 05:03AM BLOOD Calcium-8.8 Phos-3.1 Mg-1.9 ___ 05:03AM BLOOD mthotrx-0.14 ___ 05:52PM BLOOD mthotrx-0.46* ___ 06:00PM BLOOD mthotrx-1.4* ___ 05:35PM BLOOD mthotrx-1.5* ___ 05:38PM BLOOD mthotrx-3.2* Brief Hospital Course: ___ with neurolymphomatosis on HD-MTX and rituximab maintenance, who presents for C14 HD-MTX. MRI spine and PET ___ without e/o disease recurrence. Received C14 rituximab ___ and now here for C14 HD-MTX. Tolerated it well with IVF running at 250 ml/hr (w/ condom cath per his request). ___ clinic will contact pt when able to schedule repeat admission in 3 mo. His level was 0.14 and he requested to be discharged and agreed to take LV/bicarb at home for the next 3 days. # Hypokalemia: repleted # HBcAb+: HbSag/ab-. HBV viral load negative ___. Indicative of prior infection. No plans for antiviral treatment as per Dr ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Diazepam 5 mg PO Q8H:PRN muscle spasm 3. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Moderate 4. Sodium Bicarbonate 1300 mg PO QID 5. Leucovorin Calcium 40 mg PO ASDIR 6. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting Discharge Medications: 1. Leucovorin Calcium 40 mg PO Q6H Duration: 3 Days 2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 3. Diazepam 5 mg PO Q8H:PRN muscle spasm 4. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 5. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Moderate 6. Sodium Bicarbonate 1300 mg PO QID take for 3 days following discharge and again 2 days PRIOR to your next MTX admission Discharge Disposition: Home Discharge Diagnosis: Neurolymphomatosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___ ___ tolerated your MTX well. ___ didn't fully clear it at time of discharge so please continue taking your leucovorin and bicarbonate for the next 3 days. Please confirm with your ___ clinic your next admission date. Your ___ team Followup Instructions: ___
[ "Z5111", "C8589", "E876", "Z87891", "Z8619" ]
Allergies: chlorhexidine Chief Complaint: admission for chemo Major Surgical or Invasive Procedure: none History of Present Illness: DATE: [MASKED] PRIMARY ONCOLOGIST: [MASKED]., MD PRIMARY DIAGNOSIS: neurolymphomatosis TREATMENT REGIMEN: HD-MTX and rituximab maintenance === HPI === Chief Complaint: Scheduled chemotherapy [MASKED] is a [MASKED] yo man with neurolymphomatosis on HD-MTX and rituximab maintenance, who presents for scheduled chemotherapy. He saw Dr [MASKED] in clinic [MASKED] and received C14 of maintenance rituximab. His last PET scan was [MASKED] which showed no evidence of systemic lymphoma. MRI L spine [MASKED] was stable without any new findings. He returns for HD-MTX at q3 month maintenance interval. He is in his USOH. No headache, nausea, vomiting, abd pain, chest pain, SOB, fevers, chills, fatigue, appetite changes, dysuria. He started his sodium bicarb on [MASKED] morning (>48 hrs prior to admission). Past Medical History: PAST ONCOLOGIC HISTORY: (1) swallowing study on [MASKED] showed oropharyngeal and esophageal dysphagia on the right-sided, (2) gadolinium-enhanced thoracic and lumbar MRI on [MASKED] showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side, (3) CT of the torso on [MASKED] showed no malignancy, (4) lumbar puncture on [MASKED] showed [MASKED] WBC, [MASKED] RBC, 114 protein, 63 glucose, 19 LDH, beta-2-microglobulin 1.87 (normal 0.36-2.56), CA [MASKED] <6, VDRL non-reactive, and negative cytology for malignant cells, (5) bone marrow aspiration on [MASKED] showed lambda restricted plasma cells, (6) gadolinium-enhanced lumbar MRI performed on [MASKED] again showed T12-L1 enhancement that is located in the anterior spinal cord with an exophytic component eccentric to the left side, and this enhancement appears slightly more prominent, and (7) lumbar puncture on [MASKED] showed 26 WBC, 4 RBC, 146 protein, 57 glucose, 23 LDH, and atypical large lymphoid cells in cytology, (8) lumbar puncture on [MASKED] showed 27 WBC, 0 RBC, 88 protein, 55 glucose, 33 LDH, beta-2-microglobulion 2.50 (range 0.36-2.56) and presence of oligoclonal bands, (9) laminectomy L2-5 for right L5 nerve resection on [MASKED] by Dr. [MASKED] and the pathology showed neurolymphomatosis, (10) HBV core antibody positive on [MASKED] and [MASKED], (11) HIV negative on [MASKED], (12) echocardiogram showed LVEF >55%, (13) FDG-PET from [MASKED] showed uptake in the lower spinal cord but no systemic uptake, (14) PICC line insertion on [MASKED], (15) started C1W1 rituximab 375 mg/m2 and lamivudine 100 mg QD on [MASKED], (16) CSF leak on [MASKED], (17) discontinuation of lamuvidine and dexamethasone on [MASKED], (18) repair of CSF leak on [MASKED] by Dr. [MASKED], (19) received C1W1 rituximab 375 mg/m2/week on [MASKED], (20) Portacath placement on [MASKED], (21) received C1 high-dose methotrexate at 6 grams/m2 on [MASKED], (22) received C1W1 rituximab 375 mg/m2/week on [MASKED], (23) received C1W2 rituximab 375 mg/m2/week on [MASKED], (24) received C1W3 rituximab 375 mg/m2/week on [MASKED], (25) received C2 high-dose methotrexate at 8 grams/m2 on [MASKED], (26) received C1W4 rituximab 375 mg/m2/week on [MASKED], (27) received C2 rituximab 375 mg/m2/week on [MASKED], (28) received C3 high-dose methotrexate at 8 grams/m2 on [MASKED], (29) received C3 rituximab 375 mg/m2/week on [MASKED], (30) received C4 high-dose methotrexate at 8 grams/m2 on [MASKED], (30) received C4 rituximab 375 mg/m2/week on [MASKED], (31) received C5 high-dose methotrexate at 8 grams/m2 on [MASKED], (32) gadolinium-enhanced total spine MRI on [MASKED] showed response, (33) gadolinium-enhanced head MRI on [MASKED] showed no evidence of disease, (34) FDG-PET on [MASKED] showed improved FDG-Avid disease at T12-L2, (35) CSF cytology showed atypical cells, (36) received C5 monthly maintenance rituximab 375 mg/m2/week on [MASKED], (37) received C6 first monthly maintenance high-dose methotrexate at 8 grams/m2 on [MASKED], (38) gadolinium-enhanced MRI of the lumbosacral spine performed on [MASKED] showed no evidence of disease, (39) received C6 second monthly maintenance rituximab 375 mg/m2/week on [MASKED], (40) received C7 second monthly maintenance high-dose methotrexate at 8 grams/m2 on [MASKED], (41) received C7 third monthly maintenance rituximab 375 mg/m2/week on [MASKED], (42) received C8 maintenance rituximab 375 mg/m2/week on [MASKED] (43) received C8 third monthly maintenance rituximab 375 mg/m2/week on [MASKED], (44) received C9 first 2-month interval rituximab 375 mg/m2/week on [MASKED], and (45) received C9 2-month interval maintenance high-dose methotrexate at 8 grams/m2 on [MASKED] (46) received C10 interval maintenance rituximab 375 mg/m2/week on [MASKED]. (47) received C10 [MASKED] 2-month interval maintenance high-dose methotrexate at 8 grams/m2 on [MASKED]. ([MASKED])received C11 interval maintenance rituximab 375 mg/m2/week on [MASKED]. ([MASKED]) Received C11 2-month interval maintenance high-dose methotrexate at 8 grams/m2 on [MASKED]: stable MRI L-spine and no definite abnormal area of uptake on FDG PET. PAST MEDICAL HISTORY: - MGUS - Laminectomy L2-5 for nerve resection on [MASKED] c/b CSF leak on [MASKED] s/p subsequent repair - Left foot drop - Elbow Bursitis - HBcAb+: HbSag/ab-. HBV viral load UL. Indicative of prior infection. Discussed w/ Dr [MASKED] by previous providers with decision to hold off on antiviral for reactivation Social History: [MASKED] Family History: His father died at age [MASKED] and he had dementia and prostate cancer. His mother is alive with osteoarthritis, knee replacement, asthma and tuberculosis. He has 3 siblings and they are all healthy. He does not have children. Physical Exam: 0716 Temp: 98.2 PO BP: 143/83 R Sitting HR: 55 RR: 18 O2 sat: 98% O2 delivery: RA General: Well appearing pleasant man resting in bed in no acute distress HEENT: Oropharynx clear, MMM, no lesions CV: RRR no murmurs PULM: CTAB ABD: Soft, nontender, nondistended. Bowel sounds present LIMBS: WWP, no peripheral edema SKIN: No obvious acute rashes NEURO: Alert, oriented, PERRL, palate elevate symmetrically ACCESS: R POC Pertinent Results: [MASKED] 05:52PM BLOOD WBC-3.4* RBC-4.20* Hgb-11.6* Hct-35.2* MCV-84 MCH-27.6 MCHC-33.0 RDW-13.1 RDWSD-40.1 Plt [MASKED] [MASKED] 05:52PM BLOOD Neuts-60.9 [MASKED] Monos-2.6* Eos-2.6 Baso-0.3 Im [MASKED] AbsNeut-2.08 AbsLymp-1.14* AbsMono-0.09* AbsEos-0.09 AbsBaso-0.01 [MASKED] 05:03AM BLOOD Glucose-98 UreaN-4* Creat-0.9 Na-140 K-3.5 Cl-97 HCO3-34* AnGap-9* [MASKED] 05:52PM BLOOD ALT-33 AST-24 AlkPhos-82 TotBili-0.7 [MASKED] 05:03AM BLOOD Calcium-8.8 Phos-3.1 Mg-1.9 [MASKED] 05:03AM BLOOD mthotrx-0.14 [MASKED] 05:52PM BLOOD mthotrx-0.46* [MASKED] 06:00PM BLOOD mthotrx-1.4* [MASKED] 05:35PM BLOOD mthotrx-1.5* [MASKED] 05:38PM BLOOD mthotrx-3.2* Brief Hospital Course: [MASKED] with neurolymphomatosis on HD-MTX and rituximab maintenance, who presents for C14 HD-MTX. MRI spine and PET [MASKED] without e/o disease recurrence. Received C14 rituximab [MASKED] and now here for C14 HD-MTX. Tolerated it well with IVF running at 250 ml/hr (w/ condom cath per his request). [MASKED] clinic will contact pt when able to schedule repeat admission in 3 mo. His level was 0.14 and he requested to be discharged and agreed to take LV/bicarb at home for the next 3 days. # Hypokalemia: repleted # HBcAb+: HbSag/ab-. HBV viral load negative [MASKED]. Indicative of prior infection. No plans for antiviral treatment as per Dr [MASKED] [MASKED] on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Diazepam 5 mg PO Q8H:PRN muscle spasm 3. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Moderate 4. Sodium Bicarbonate 1300 mg PO QID 5. Leucovorin Calcium 40 mg PO ASDIR 6. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting Discharge Medications: 1. Leucovorin Calcium 40 mg PO Q6H Duration: 3 Days 2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 3. Diazepam 5 mg PO Q8H:PRN muscle spasm 4. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 5. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Moderate 6. Sodium Bicarbonate 1300 mg PO QID take for 3 days following discharge and again 2 days PRIOR to your next MTX admission Discharge Disposition: Home Discharge Diagnosis: Neurolymphomatosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED] [MASKED] tolerated your MTX well. [MASKED] didn't fully clear it at time of discharge so please continue taking your leucovorin and bicarbonate for the next 3 days. Please confirm with your [MASKED] clinic your next admission date. Your [MASKED] team Followup Instructions: [MASKED]
[]
[ "Z87891" ]
[ "Z5111: Encounter for antineoplastic chemotherapy", "C8589: Other specified types of non-Hodgkin lymphoma, extranodal and solid organ sites", "E876: Hypokalemia", "Z87891: Personal history of nicotine dependence", "Z8619: Personal history of other infectious and parasitic diseases" ]
19,999,828
25,744,818
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Lamictal / hydrochlorothiazide Attending: ___. Major Surgical or Invasive Procedure: ___ Debridement of intra-abdominal fluid collection attach Pertinent Results: =============== ADMISSION LABS: =============== ___ 09:54AM BLOOD WBC-26.0* RBC-5.36* Hgb-12.3 Hct-39.2 MCV-73* MCH-22.9* MCHC-31.4* RDW-17.1* RDWSD-43.2 Plt ___ ___ 09:54AM BLOOD Neuts-81.7* Lymphs-8.2* Monos-8.9 Eos-0.0* Baso-0.3 Im ___ AbsNeut-21.26* AbsLymp-2.12 AbsMono-2.31* AbsEos-0.00* AbsBaso-0.07 ___ 09:54AM BLOOD Glucose-356* UreaN-22* Creat-0.8 Na-130* K-3.6 Cl-99 HCO3-14* AnGap-17 ___ 09:54AM BLOOD ALT-15 AST-12 AlkPhos-120* TotBili-0.4 ___ 09:54AM BLOOD Albumin-3.2* Calcium-9.6 Phos-1.9* Mg-1.9 ___ 10:03AM BLOOD Lactate-2.1* ___ 01:17PM BLOOD Glucose-318* Na-131* K-2.7* Cl-104 calHCO3-18* ===================== OTHER PERTINENT LABS: ===================== ___ 09:54AM BLOOD WBC-26.0* RBC-5.36* Hgb-12.3 Hct-39.2 MCV-73* MCH-22.9* MCHC-31.4* RDW-17.1* RDWSD-43.2 Plt ___ ___ 03:13AM BLOOD WBC-13.1* RBC-4.96 Hgb-11.5 Hct-36.8 MCV-74* MCH-23.2* MCHC-31.3* RDW-17.3* RDWSD-45.1 Plt ___ ___ 09:54AM BLOOD Glucose-356* UreaN-22* Creat-0.8 Na-130* K-3.6 Cl-99 HCO3-14* AnGap-17 ___ 11:00PM BLOOD Glucose-195* UreaN-15 Creat-0.7 Na-137 K-4.1 Cl-107 HCO3-16* AnGap-14 ___ 05:58AM BLOOD Glucose-154* UreaN-7 Creat-0.6 Na-137 K-3.7 Cl-106 HCO3-20* AnGap-11 ___ 03:40PM BLOOD %HbA1c-13.8* eAG-349* ___ 10:03AM BLOOD Lactate-2.1* ___ 08:04PM BLOOD Lactate-1.5 ___ 05:58AM BLOOD C-PEPTIDE-1.41 ___ 05:37AM BLOOD INSULIN ANTIBODIES-<0.4 ___ 05:37AM BLOOD GLUTAMIC ACID DECARBOXYLASE (GAD65) ANTIBODY ASSAY, SERUM-0.00 ___ 06:45AM BLOOD PREALBUMIN-9 ___ 06:45AM BLOOD ZINC (SPIN NVY/EDTA)-58 ================ IMAGING/STUDIES: ================ ___ US DOPPLER LOWER EXTREMITY No evidence of deep venous thrombosis in the right lower extremity veins. ___ CXR Interval removal of right-sided PICC line. Cardiomediastinal silhouette is within normal limits. There are no focal consolidations, pleural effusion, or pulmonary edema. Mild prominence of for rounded structure within the right infrahilar region, may represent the vessel. There are no pneumothoraces. ___BDOMEN/PELVIS Interval increase in size of an anterior abdominal wound, following ventral hernia repair, with a peripherally enhancing fluid collection along the left margin of the wound, which measures approximately 2.0 x 1.0 x 10.0 cm. ___ CT ABDOMEN/PELVIS WITH CONTRAST Postsurgical changes from ventral hernia repair with a large anterior abdominal wall defect. Interval placement of surgical drains along the superior margin of the abdominal wall defect with near complete resolution of the fluid collection along the left lateral margin. Multiple loops of small bowel and transverse colon abuts the anterior abdominal wall defect. A focal irregularity of the anterior abdominal wall adjacent to the mid transverse colon may represent a small colocutaneous fistula. 4. New bowel wall thickening and submucosal edema involving the ileum, which may represent developing enteritis. New fluid within the colon most likely represents diarrhea. ___ US LOWER EXTREMITY No evidence of deep venous thrombosis in the right lower extremity veins. =============== DISCHARGE LABS: =============== ___ 05:32AM BLOOD WBC-9.9 RBC-3.73* Hgb-8.6* Hct-29.2* MCV-78* MCH-23.1* MCHC-29.5* RDW-17.6* RDWSD-49.9* Plt ___ ___ 05:32AM BLOOD Glucose-139* UreaN-10 Creat-0.6 Na-142 K-4.6 Cl-101 HCO3-28 AnGap-13 ___ 05:32AM BLOOD Calcium-9.3 Phos-5.0* Mg-1.___ year old female with past medical history of type 2 diabetes, atrial fibrillation, diverticulosis status post ___ Procedure with subsequent colostomy take down complicated by ventral hernia, subsequently requiring several attempted ventral hernia repairs, most recently status post split thickness skin graft over exposed mesh and closure of enterocutaneous fistula ___ admitted ___ with DKA, abdominal wall fluid collection and recurrence of enterocutaneous fistula, status post resolution of DKA with insulin drip, treated with antibiotics and basal bolus insulin regimen, clinically improving and able to be discharged home # Abdominal wall abscess # Enterocutaneous fistula Presented with three days of weakness, abdominal pain, and increased drainage from chronic abdominal wound, with CT showing evidence of fluid collection at site of ventral hernia repair. Underwent debridement and ___ drain x2 placement with general surgery in the ED. Repeat CT abdomen/pelvis with near resolution of fluid collection and findings consistent with enterocutaneous fistula. Initially started on vancomycin/Zosyn while culture data was pending, per ID. Cultures returned positive for S. anginosus and polymicrobial infection. Per ID service, patient was transitioned to Augmentin 875mg BID on ___ with continued clinical improvement in pain. Based on imaging and exam, unclear if known abdominal mesh could be infected. Per ID, reasonable plan to continue Augmentin for ___ weeks for soft tissue infection pending repeat surgical assessment and decision regarding potential operative intervention. Patient will follow-up with ACS as an outpatient. Wound care nursing evaluated patient during admission and counseled patient regarding management of her enterocutaneous fistula. # Type II diabetes mellitus with DKA Patient with poorly controlled DM as an outpatient requiring recent initiation of insulin, with which patient has not been compliant, who presented to ___ with blood glucose >700 and anion gap of 17. Initially admitted to MICU for insulin drip, before transitioning to subcutaneous insulin per ___ recs. C-peptide 1.4 with associated glucose of 156. Anti-insulin and anti-GAD antibodies negative. Subcutaneous insulin regimen was titrated to achieve better glucose control. Patient was evaluated by the diabetic educator and given teaching regarding insulin administration and diabetes management. Patient will be followed closely by ___ following discharge to assess ongoing management. Discharge insulin regimen: insulin glargine 28 units QAM and 34 units QPM, and insulin Humalog 18 units with meals. Insulin sliding scale was discontinued at discharge as patient was not able to demonstrate safe use of same with the diabetic educator. Home glipizide and sitagliptin held at the time of discharge. Can be considered for additional agents at ___ follow-up. Continued home atorvastatin 20mg QHS for primary prevention. # Diarrhea Patient reported multiple episodes of liquid stools upon admission to ___, however this resolved over the course of hospitalization. Baseline frequency of bowel movements is one every three days. CT abdomen/pelvis with bowel wall thickening and submucosa edema was concerning for developing enteritis, with evidence of diarrhea in the GI tract, however given improvement in symptoms, no further intervention was required. Can consider repeat CT scan in ___ week to look for resolution. # Zinc deficiency Zinc level returned marginally low at 58. Patient was started on zinc 220mg daily for 14 days. Will need repeat level checked following completion of course. # Paroxysmal Atrial fibrillation Continued home diltiazem, fractionated to 30mg Q6H, which was consolidated at the time of discharge. Aspirin 81mg daily was continued. Notably patient not on anticoagulation. Would consider outpatient risk/benefit discussion regarding anticoagulation, given elevated CHADS2VASc. # Hypertension Continued home diltiazem as above. # Anxiety Continued clonidine 0.2mg TID:PRN. ==================== TRANSITIONAL ISSUES: ==================== [] ENTEROCUTANEOUS FISTULA: follow-up with ACS to determine finalized plan for management of same [] ANTIBIOTICS: Augmentin is to continue until finalized surgical plan is put in place [] DM: follow-up with ___ on ___ [] ZINC DEFICIENCY: patient needs repeat zinc level check upon completion of zinc therapy [] AF: elevated CHADS2VASC; discussion should be had re: initiation of anticoagulation as an outpatient =============================================== # CODE: Full # CONTACT: ___, mother, ___ > 30 minutes spent on discharge Medications on Admission: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Atorvastatin 20 mg PO QPM 3. CloNIDine 0.2 mg PO TID:PRN Anxiety 4. Diltiazem Extended-Release 120 mg PO DAILY 5. GlipiZIDE 10 mg PO DAILY 6. Omeprazole 20 mg PO DAILY 7. SITagliptin 100 mg oral DAILY 8. Albuterol Inhaler ___ PUFF IH Q6H:PRN Wheeze 9. Aspirin 81 mg PO DAILY 10. Cyclobenzaprine 10 mg PO TID:PRN Back pain 11. Glargine 30 Units Bedtime 12. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation 2 puffs once daily 13. Buprenorphine-Naloxone Tablet (8mg-2mg) 1 TAB SL BID Discharge Medications: 1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H 2. Zinc Sulfate 220 mg PO DAILY Duration: 14 Days 3. Glargine 28 Units Breakfast Glargine 34 Units Bedtime Humalog 18 Units Breakfast Humalog 18 Units Lunch Humalog 18 Units Dinner 4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 5. Albuterol Inhaler ___ PUFF IH Q6H:PRN Wheeze 6. Aspirin 81 mg PO DAILY 7. Atorvastatin 20 mg PO QPM 8. Buprenorphine-Naloxone Tablet (8mg-2mg) 1 TAB SL BID 9. CloNIDine 0.2 mg PO TID:PRN Anxiety 10. Cyclobenzaprine 10 mg PO TID:PRN Back pain 11. Diltiazem Extended-Release 120 mg PO DAILY 12. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation 2 puffs once daily 13. Omeprazole 20 mg PO DAILY 14. HELD- GlipiZIDE 10 mg PO DAILY This medication was held. Do not restart GlipiZIDE until informed by ___ 15. HELD- SITagliptin 100 mg oral DAILY This medication was held. Do not restart SITagliptin until informed by ___ Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: # Intra-abdominal infection/abscess # Enterocutaneous fistula # Possible mesh infection # Possible diabetic ketoacidosis # Type II diabetes mellitus # Atrial fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, WHY YOU CAME TO THE HOSPITAL? You were transferred to ___ for management of your elevated blood sugars and abdominal wound WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL? - Your blood sugars were initially managed with an insulin drip, before transitioning to insulin injections as they improved - Our surgeons drained the fluid collection in your abdomen and placed two drains to help prevent the fluid from re-accumulating - Repeat imaging showed resolution of the collection - Our infectious disease doctors helped decide the antibiotics you required - You will follow-up with the surgeons as an outpatient - Our diabetes doctors helped change the dose of your insulin to gain better control of your blood sugars WHAT YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? - Please follow-up with your outpatient doctors as arranged - ___ is important you take all of your medications as prescribed It was a pleasure taking care of you! Your ___ Healthcare Team Followup Instructions: ___
[ "T8141XA", "E1110", "K632", "D682", "L02211", "T83728A", "Y838", "Y929", "I10", "J449", "Z794", "Z87891", "Z9114", "I480", "F419", "E876", "B954", "E60", "R197" ]
Allergies: Lamictal / hydrochlorothiazide Major Surgical or Invasive Procedure: [MASKED] Debridement of intra-abdominal fluid collection attach Pertinent Results: =============== ADMISSION LABS: =============== [MASKED] 09:54AM BLOOD WBC-26.0* RBC-5.36* Hgb-12.3 Hct-39.2 MCV-73* MCH-22.9* MCHC-31.4* RDW-17.1* RDWSD-43.2 Plt [MASKED] [MASKED] 09:54AM BLOOD Neuts-81.7* Lymphs-8.2* Monos-8.9 Eos-0.0* Baso-0.3 Im [MASKED] AbsNeut-21.26* AbsLymp-2.12 AbsMono-2.31* AbsEos-0.00* AbsBaso-0.07 [MASKED] 09:54AM BLOOD Glucose-356* UreaN-22* Creat-0.8 Na-130* K-3.6 Cl-99 HCO3-14* AnGap-17 [MASKED] 09:54AM BLOOD ALT-15 AST-12 AlkPhos-120* TotBili-0.4 [MASKED] 09:54AM BLOOD Albumin-3.2* Calcium-9.6 Phos-1.9* Mg-1.9 [MASKED] 10:03AM BLOOD Lactate-2.1* [MASKED] 01:17PM BLOOD Glucose-318* Na-131* K-2.7* Cl-104 calHCO3-18* ===================== OTHER PERTINENT LABS: ===================== [MASKED] 09:54AM BLOOD WBC-26.0* RBC-5.36* Hgb-12.3 Hct-39.2 MCV-73* MCH-22.9* MCHC-31.4* RDW-17.1* RDWSD-43.2 Plt [MASKED] [MASKED] 03:13AM BLOOD WBC-13.1* RBC-4.96 Hgb-11.5 Hct-36.8 MCV-74* MCH-23.2* MCHC-31.3* RDW-17.3* RDWSD-45.1 Plt [MASKED] [MASKED] 09:54AM BLOOD Glucose-356* UreaN-22* Creat-0.8 Na-130* K-3.6 Cl-99 HCO3-14* AnGap-17 [MASKED] 11:00PM BLOOD Glucose-195* UreaN-15 Creat-0.7 Na-137 K-4.1 Cl-107 HCO3-16* AnGap-14 [MASKED] 05:58AM BLOOD Glucose-154* UreaN-7 Creat-0.6 Na-137 K-3.7 Cl-106 HCO3-20* AnGap-11 [MASKED] 03:40PM BLOOD %HbA1c-13.8* eAG-349* [MASKED] 10:03AM BLOOD Lactate-2.1* [MASKED] 08:04PM BLOOD Lactate-1.5 [MASKED] 05:58AM BLOOD C-PEPTIDE-1.41 [MASKED] 05:37AM BLOOD INSULIN ANTIBODIES-<0.4 [MASKED] 05:37AM BLOOD GLUTAMIC ACID DECARBOXYLASE (GAD65) ANTIBODY ASSAY, SERUM-0.00 [MASKED] 06:45AM BLOOD PREALBUMIN-9 [MASKED] 06:45AM BLOOD ZINC (SPIN NVY/EDTA)-58 ================ IMAGING/STUDIES: ================ [MASKED] US DOPPLER LOWER EXTREMITY No evidence of deep venous thrombosis in the right lower extremity veins. [MASKED] CXR Interval removal of right-sided PICC line. Cardiomediastinal silhouette is within normal limits. There are no focal consolidations, pleural effusion, or pulmonary edema. Mild prominence of for rounded structure within the right infrahilar region, may represent the vessel. There are no pneumothoraces. BDOMEN/PELVIS Interval increase in size of an anterior abdominal wound, following ventral hernia repair, with a peripherally enhancing fluid collection along the left margin of the wound, which measures approximately 2.0 x 1.0 x 10.0 cm. [MASKED] CT ABDOMEN/PELVIS WITH CONTRAST Postsurgical changes from ventral hernia repair with a large anterior abdominal wall defect. Interval placement of surgical drains along the superior margin of the abdominal wall defect with near complete resolution of the fluid collection along the left lateral margin. Multiple loops of small bowel and transverse colon abuts the anterior abdominal wall defect. A focal irregularity of the anterior abdominal wall adjacent to the mid transverse colon may represent a small colocutaneous fistula. 4. New bowel wall thickening and submucosal edema involving the ileum, which may represent developing enteritis. New fluid within the colon most likely represents diarrhea. [MASKED] US LOWER EXTREMITY No evidence of deep venous thrombosis in the right lower extremity veins. =============== DISCHARGE LABS: =============== [MASKED] 05:32AM BLOOD WBC-9.9 RBC-3.73* Hgb-8.6* Hct-29.2* MCV-78* MCH-23.1* MCHC-29.5* RDW-17.6* RDWSD-49.9* Plt [MASKED] [MASKED] 05:32AM BLOOD Glucose-139* UreaN-10 Creat-0.6 Na-142 K-4.6 Cl-101 HCO3-28 AnGap-13 [MASKED] 05:32AM BLOOD Calcium-9.3 Phos-5.0* Mg-1.[MASKED] year old female with past medical history of type 2 diabetes, atrial fibrillation, diverticulosis status post [MASKED] Procedure with subsequent colostomy take down complicated by ventral hernia, subsequently requiring several attempted ventral hernia repairs, most recently status post split thickness skin graft over exposed mesh and closure of enterocutaneous fistula [MASKED] admitted [MASKED] with DKA, abdominal wall fluid collection and recurrence of enterocutaneous fistula, status post resolution of DKA with insulin drip, treated with antibiotics and basal bolus insulin regimen, clinically improving and able to be discharged home # Abdominal wall abscess # Enterocutaneous fistula Presented with three days of weakness, abdominal pain, and increased drainage from chronic abdominal wound, with CT showing evidence of fluid collection at site of ventral hernia repair. Underwent debridement and [MASKED] drain x2 placement with general surgery in the ED. Repeat CT abdomen/pelvis with near resolution of fluid collection and findings consistent with enterocutaneous fistula. Initially started on vancomycin/Zosyn while culture data was pending, per ID. Cultures returned positive for S. anginosus and polymicrobial infection. Per ID service, patient was transitioned to Augmentin 875mg BID on [MASKED] with continued clinical improvement in pain. Based on imaging and exam, unclear if known abdominal mesh could be infected. Per ID, reasonable plan to continue Augmentin for [MASKED] weeks for soft tissue infection pending repeat surgical assessment and decision regarding potential operative intervention. Patient will follow-up with ACS as an outpatient. Wound care nursing evaluated patient during admission and counseled patient regarding management of her enterocutaneous fistula. # Type II diabetes mellitus with DKA Patient with poorly controlled DM as an outpatient requiring recent initiation of insulin, with which patient has not been compliant, who presented to [MASKED] with blood glucose >700 and anion gap of 17. Initially admitted to MICU for insulin drip, before transitioning to subcutaneous insulin per [MASKED] recs. C-peptide 1.4 with associated glucose of 156. Anti-insulin and anti-GAD antibodies negative. Subcutaneous insulin regimen was titrated to achieve better glucose control. Patient was evaluated by the diabetic educator and given teaching regarding insulin administration and diabetes management. Patient will be followed closely by [MASKED] following discharge to assess ongoing management. Discharge insulin regimen: insulin glargine 28 units QAM and 34 units QPM, and insulin Humalog 18 units with meals. Insulin sliding scale was discontinued at discharge as patient was not able to demonstrate safe use of same with the diabetic educator. Home glipizide and sitagliptin held at the time of discharge. Can be considered for additional agents at [MASKED] follow-up. Continued home atorvastatin 20mg QHS for primary prevention. # Diarrhea Patient reported multiple episodes of liquid stools upon admission to [MASKED], however this resolved over the course of hospitalization. Baseline frequency of bowel movements is one every three days. CT abdomen/pelvis with bowel wall thickening and submucosa edema was concerning for developing enteritis, with evidence of diarrhea in the GI tract, however given improvement in symptoms, no further intervention was required. Can consider repeat CT scan in [MASKED] week to look for resolution. # Zinc deficiency Zinc level returned marginally low at 58. Patient was started on zinc 220mg daily for 14 days. Will need repeat level checked following completion of course. # Paroxysmal Atrial fibrillation Continued home diltiazem, fractionated to 30mg Q6H, which was consolidated at the time of discharge. Aspirin 81mg daily was continued. Notably patient not on anticoagulation. Would consider outpatient risk/benefit discussion regarding anticoagulation, given elevated CHADS2VASc. # Hypertension Continued home diltiazem as above. # Anxiety Continued clonidine 0.2mg TID:PRN. ==================== TRANSITIONAL ISSUES: ==================== [] ENTEROCUTANEOUS FISTULA: follow-up with ACS to determine finalized plan for management of same [] ANTIBIOTICS: Augmentin is to continue until finalized surgical plan is put in place [] DM: follow-up with [MASKED] on [MASKED] [] ZINC DEFICIENCY: patient needs repeat zinc level check upon completion of zinc therapy [] AF: elevated CHADS2VASC; discussion should be had re: initiation of anticoagulation as an outpatient =============================================== # CODE: Full # CONTACT: [MASKED], mother, [MASKED] > 30 minutes spent on discharge Medications on Admission: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Atorvastatin 20 mg PO QPM 3. CloNIDine 0.2 mg PO TID:PRN Anxiety 4. Diltiazem Extended-Release 120 mg PO DAILY 5. GlipiZIDE 10 mg PO DAILY 6. Omeprazole 20 mg PO DAILY 7. SITagliptin 100 mg oral DAILY 8. Albuterol Inhaler [MASKED] PUFF IH Q6H:PRN Wheeze 9. Aspirin 81 mg PO DAILY 10. Cyclobenzaprine 10 mg PO TID:PRN Back pain 11. Glargine 30 Units Bedtime 12. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation 2 puffs once daily 13. Buprenorphine-Naloxone Tablet (8mg-2mg) 1 TAB SL BID Discharge Medications: 1. Amoxicillin-Clavulanic Acid [MASKED] mg PO Q12H 2. Zinc Sulfate 220 mg PO DAILY Duration: 14 Days 3. Glargine 28 Units Breakfast Glargine 34 Units Bedtime Humalog 18 Units Breakfast Humalog 18 Units Lunch Humalog 18 Units Dinner 4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 5. Albuterol Inhaler [MASKED] PUFF IH Q6H:PRN Wheeze 6. Aspirin 81 mg PO DAILY 7. Atorvastatin 20 mg PO QPM 8. Buprenorphine-Naloxone Tablet (8mg-2mg) 1 TAB SL BID 9. CloNIDine 0.2 mg PO TID:PRN Anxiety 10. Cyclobenzaprine 10 mg PO TID:PRN Back pain 11. Diltiazem Extended-Release 120 mg PO DAILY 12. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation 2 puffs once daily 13. Omeprazole 20 mg PO DAILY 14. HELD- GlipiZIDE 10 mg PO DAILY This medication was held. Do not restart GlipiZIDE until informed by [MASKED] 15. HELD- SITagliptin 100 mg oral DAILY This medication was held. Do not restart SITagliptin until informed by [MASKED] Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: # Intra-abdominal infection/abscess # Enterocutaneous fistula # Possible mesh infection # Possible diabetic ketoacidosis # Type II diabetes mellitus # Atrial fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], WHY YOU CAME TO THE HOSPITAL? You were transferred to [MASKED] for management of your elevated blood sugars and abdominal wound WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL? - Your blood sugars were initially managed with an insulin drip, before transitioning to insulin injections as they improved - Our surgeons drained the fluid collection in your abdomen and placed two drains to help prevent the fluid from re-accumulating - Repeat imaging showed resolution of the collection - Our infectious disease doctors helped decide the antibiotics you required - You will follow-up with the surgeons as an outpatient - Our diabetes doctors helped change the dose of your insulin to gain better control of your blood sugars WHAT YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? - Please follow-up with your outpatient doctors as arranged - [MASKED] is important you take all of your medications as prescribed It was a pleasure taking care of you! Your [MASKED] Healthcare Team Followup Instructions: [MASKED]
[]
[ "Y929", "I10", "J449", "Z794", "Z87891", "I480", "F419" ]
[ "T8141XA: Infection following a procedure, superficial incisional surgical site, initial encounter", "E1110: Type 2 diabetes mellitus with ketoacidosis without coma", "K632: Fistula of intestine", "D682: Hereditary deficiency of other clotting factors", "L02211: Cutaneous abscess of abdominal wall", "T83728A: Exposure of other implanted mesh into organ or tissue, initial encounter", "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", "I10: Essential (primary) hypertension", "J449: Chronic obstructive pulmonary disease, unspecified", "Z794: Long term (current) use of insulin", "Z87891: Personal history of nicotine dependence", "Z9114: Patient's other noncompliance with medication regimen", "I480: Paroxysmal atrial fibrillation", "F419: Anxiety disorder, unspecified", "E876: Hypokalemia", "B954: Other streptococcus as the cause of diseases classified elsewhere", "E60: Dietary zinc deficiency", "R197: Diarrhea, unspecified" ]
19,999,828
29,734,428
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Lamictal / hydrochlorothiazide Attending: ___. Chief Complaint: Enterocutaneous/enteroatmospheric fistula Major Surgical or Invasive Procedure: ___: 1. Split-thickness skin graft, left and right thigh to abdominal bowel site and closure of intestinal fistula. 2. VAC sponge 20 x 15 cm. History of Present Illness: Ms. ___ is a ___ F w/hx of Afib on diltizaem, Factor V not on anticoagulation, diverticulosis, HTN, COPD and DMII who presents with abdominal pain and an abdominal wound site with exposed mesh. She reports a complex surgical history including laparoscopic cholecystectomy in ___ followed by ___ Procedure for diverticulitis ___ with colostomy take down ___. After this procedure she states she developed a large ventral hernia and underwent open VHR with cadaveric underlay mesh and prolene overlay mesh ___ c/b skin dehiscence beginning in ___ and progressing until today, despite multiple debridements at ___ and the use of a wound vac, which was last used 2 mo ago. She presents to the ED for follow up of her ventral hernia since the wound continues to expand and has become more painful. 3 weeks ago, Ms. ___ developed pain at the RUQ of the wound that has since progressed and intermittent nausea without vomiting. This morning at 7 am she changed her dressings and noticed brown, foul-smelling staining in the middle of the mesh and a "nipple-like" protrusion that resolved. At 8pm in the ED, her 12x17 cm open wound with visible mesh currently had more brown staining than this morning. When she pressed on the edges of her wound, which is tender and erythematous circumferentially, pus drained out at the 10 o'clock position. She was given dilute barium contrast PO for a CT +IV +oral contrast; CTAP was not read as showing enterocutaneous fistula. However, after drinking the contrast the patient began to leak feculent material that appeared to be succus mixed with contrast. . She smokes recreational marijuana which help curb the nausea, which allows her to eat. She is passing flatus and has regular BM, though she notes her stools are hard and she has felt constipated since her last hernia repair (___). She is afraid to strain while going to the bathroom because of the pressure it puts on her hernia. She has not had any fevers, chills, diarrhea, constipation different from baseline, SOB, chest pain, or urinary symptoms. . Past Medical History: PMH a fib on diltiazem Factor V Leiden deficiency diverticulosis (with diverticulitis episodes) SBO (___) gallstones HTN COPD anxiety sciatica scoliosis varicose veins DMII PSH cholecystectomy ___, ___ umbilical hernia repair ___, ___ Left ventral hernia c/b SBO s/p colostomy (___) colostomy reversal ___, ___ ventral hernia repair w/ mesh ___, ___ ventral hernia repair, debridement ___, ___) Social History: ___ Family History: - both parents and multiple siblings have DVTs ___ Factor V Leiden deficiency Physical Exam: Discharge Physical Exam: VS: T: 98.1 PO BP: 110/74 R Sitting HR: 81 RR: 18 O2: 96% Ra GEN: A+Ox3, NAD HEENT: normocephalic, atraumatic CV: RRR PULM: CTA b/l ABD: soft, non-distended. Area of wound with skin graft about 14x16 cm, skin graft approximately 90% taken, left and right edges still not taken up skin graft, but edges beginning to scar down. EXT: wwp, no edema b/l. B/l thigh donor sites OTA, healing w/ no s/s infection Pertinent Results: ADMISSION LABS: ___ 06:04PM BLOOD WBC-9.5 RBC-4.08 Hgb-9.9* Hct-32.3* MCV-79* MCH-24.3* MCHC-30.7* RDW-15.8* RDWSD-45.4 Plt ___ ___ 06:04PM BLOOD Neuts-46.9 ___ Monos-14.4* Eos-2.5 Baso-0.6 Im ___ AbsNeut-4.47 AbsLymp-3.35 AbsMono-1.37* AbsEos-0.24 AbsBaso-0.06 ___ 06:04PM BLOOD ___ PTT-28.4 ___ ___ 06:04PM BLOOD Glucose-152* UreaN-11 Creat-0.7 Na-136 K-4.7 Cl-98 HCO3-24 AnGap-14 IMAGING: ___: CT Abdomen/Pelvis: 1. No enterocutaneous fistula or small-bowel obstruction identified. 2. Open anterior abdominal wall wound measuring up to 14.5 x 16.1 cm with moderate soft tissue thickening along the lateral borders. Small focus of subcutaneous air tracking along the right superior border suggests increasing wound extension. ___: Abdominal x-ray: No enterocutaneous fistula demonstrated radiographically. Consider a fistulogram for this purpose. ___: Dx Portable PICC: Right PICC in the mid SVC. No acute cardiopulmonary process. ___: Abdominal x-ray: No acute abnormality with nonobstructive bowel gas pattern. Interval placement of wound VAC which projects over the mid abdomen. ___: CXR: No acute cardiopulmonary process. ___ 10:16 pm URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE IDENTIFICATION. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Brief Hospital Course: Ms. ___ is a ___ year old female with a history of multiple prior abdominal surgeries most recently a ventral hernia repair at ___ (___) who presented to ___ ___ on ___ with an open abdominal wound, exposed mesh, and a low output entero-atmospheric fistula. She was admitted to the Acute Care Surgery Service for further management. The patient was kept NPO and initiated on TPN. She was started on octreotide for a short time period to help reduce fistula output. Plastic surgery was consulted to evaluate the patient in preparation for eventual abdominal wall reconstruction and offered to be available to assist with surgery when needed. Wound care nursing was also asked to assist with optimizing the patient's abdominal dressing, and a large wound manager was applied and placed to wall suction with good result. On ___, the patient was taken to the operating room and underwent an abdominal skin graft with anterior bilateral thigh donor sites. For details of the procedure, please see the surgeon's operative note. The patient tolerated the procedure well without complication and was taken to the post anesthesia care unit in stable condition. The patient was placed on bedrest precautions and then activity restrictions were liberalized and the patient ambulated. ___ was d/c'd and she voided appropriately. She was started on a regular diet which she tolerated and TPN was d/c'd. WBC was elevated on POD #3 and so PICC was d/c'd a fever work-up was sent and urine culture was positive for e.coli (sensitive to cipro). She was started on a 7 day course of cipro and WBC normalized. The patient's skin graft took approximately 90%. Non-adherent dressing were placed over the wound while ambulating and left open to the air for periods of time while in bed to let the graft dry. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged home with ___ services. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: acetaminophen PRN albuterol (proair) aspirin 81 atorvastatin 20 suboxone Clonidine 0.2 TID Diltiazem 120mg 24 hour capsule Colace Flonase Glipizide Ibuprofen Metformin 500mg daily omeprazole 20mg daily trazodone 50mg daily umeclidinium 62.6 mcg/actuation Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Ciprofloxacin HCl 250 mg PO Q12H Closely monitor your blood sugars to assess for low blood sugar while taking this medication RX *ciprofloxacin HCl 250 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*9 Tablet Refills:*0 3. Docusate Sodium 100 mg PO BID Hold for loose stool 4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: d/c oxycodone Take lowest effective dose. Patient may request partial fill. RX *hydromorphone 2 mg ___ tablet(s) by mouth every four (4) hours Disp #*20 Tablet Refills:*0 5. Atorvastatin 20 mg PO QPM 6. CloNIDine 0.2 mg PO TID 7. Diltiazem Extended-Release 120 mg PO DAILY 8. Fluticasone Propionate NASAL 1 SPRY NU DAILY PRN 9. GlipiZIDE 5 mg PO DAILY 10. MetFORMIN (Glucophage) 500 mg PO DAILY 11. Omeprazole 20 mg PO DAILY 12. Topiramate (Topamax) 50 mg PO BID 13. TraZODone 50 mg PO QHS:PRN PRN Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Giant abdominal hernia with exposed bowel and intestinal fistula. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to ___ with a large abdominal hernia after multiple prior surgeries. You had a fistula (an abnormal connection between the bowel and the skin) from the wound. You were initially placed on TPN to receive nutrition. You were later taken to the operating room and you underwent skin grafting from your thighs to your abdominal wound to protect the exposed bowel to prevent another fistula and also to close the current fistula. You tolerated this procedure well and your graft has mostly taken. You are now tolerating a regular diet, low residue diet. You were found to have a urinary tract infection and were started on a 1 (one) week course of an antibiotic, called ciprofloxacin. You will have a nurse visit you at home to check up on you to evaluate your wound and also help with your dressing changes. You are ready to be discharged home to continue your recovery. Please note the following discharge instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Followup Instructions: ___
[ "T8131XA", "T8183XA", "K632", "D6851", "N390", "Y838", "Y92018", "I480", "I10", "J449", "E119", "Z7984", "F1290", "F419", "M5430", "M419", "I8390", "Z9049", "Z87891", "B9620", "Z1611", "I9581" ]
Allergies: Lamictal / hydrochlorothiazide Chief Complaint: Enterocutaneous/enteroatmospheric fistula Major Surgical or Invasive Procedure: [MASKED]: 1. Split-thickness skin graft, left and right thigh to abdominal bowel site and closure of intestinal fistula. 2. VAC sponge 20 x 15 cm. History of Present Illness: Ms. [MASKED] is a [MASKED] F w/hx of Afib on diltizaem, Factor V not on anticoagulation, diverticulosis, HTN, COPD and DMII who presents with abdominal pain and an abdominal wound site with exposed mesh. She reports a complex surgical history including laparoscopic cholecystectomy in [MASKED] followed by [MASKED] Procedure for diverticulitis [MASKED] with colostomy take down [MASKED]. After this procedure she states she developed a large ventral hernia and underwent open VHR with cadaveric underlay mesh and prolene overlay mesh [MASKED] c/b skin dehiscence beginning in [MASKED] and progressing until today, despite multiple debridements at [MASKED] and the use of a wound vac, which was last used 2 mo ago. She presents to the ED for follow up of her ventral hernia since the wound continues to expand and has become more painful. 3 weeks ago, Ms. [MASKED] developed pain at the RUQ of the wound that has since progressed and intermittent nausea without vomiting. This morning at 7 am she changed her dressings and noticed brown, foul-smelling staining in the middle of the mesh and a "nipple-like" protrusion that resolved. At 8pm in the ED, her 12x17 cm open wound with visible mesh currently had more brown staining than this morning. When she pressed on the edges of her wound, which is tender and erythematous circumferentially, pus drained out at the 10 o'clock position. She was given dilute barium contrast PO for a CT +IV +oral contrast; CTAP was not read as showing enterocutaneous fistula. However, after drinking the contrast the patient began to leak feculent material that appeared to be succus mixed with contrast. . She smokes recreational marijuana which help curb the nausea, which allows her to eat. She is passing flatus and has regular BM, though she notes her stools are hard and she has felt constipated since her last hernia repair ([MASKED]). She is afraid to strain while going to the bathroom because of the pressure it puts on her hernia. She has not had any fevers, chills, diarrhea, constipation different from baseline, SOB, chest pain, or urinary symptoms. . Past Medical History: PMH a fib on diltiazem Factor V Leiden deficiency diverticulosis (with diverticulitis episodes) SBO ([MASKED]) gallstones HTN COPD anxiety sciatica scoliosis varicose veins DMII PSH cholecystectomy [MASKED], [MASKED] umbilical hernia repair [MASKED], [MASKED] Left ventral hernia c/b SBO s/p colostomy ([MASKED]) colostomy reversal [MASKED], [MASKED] ventral hernia repair w/ mesh [MASKED], [MASKED] ventral hernia repair, debridement [MASKED], [MASKED]) Social History: [MASKED] Family History: - both parents and multiple siblings have DVTs [MASKED] Factor V Leiden deficiency Physical Exam: Discharge Physical Exam: VS: T: 98.1 PO BP: 110/74 R Sitting HR: 81 RR: 18 O2: 96% Ra GEN: A+Ox3, NAD HEENT: normocephalic, atraumatic CV: RRR PULM: CTA b/l ABD: soft, non-distended. Area of wound with skin graft about 14x16 cm, skin graft approximately 90% taken, left and right edges still not taken up skin graft, but edges beginning to scar down. EXT: wwp, no edema b/l. B/l thigh donor sites OTA, healing w/ no s/s infection Pertinent Results: ADMISSION LABS: [MASKED] 06:04PM BLOOD WBC-9.5 RBC-4.08 Hgb-9.9* Hct-32.3* MCV-79* MCH-24.3* MCHC-30.7* RDW-15.8* RDWSD-45.4 Plt [MASKED] [MASKED] 06:04PM BLOOD Neuts-46.9 [MASKED] Monos-14.4* Eos-2.5 Baso-0.6 Im [MASKED] AbsNeut-4.47 AbsLymp-3.35 AbsMono-1.37* AbsEos-0.24 AbsBaso-0.06 [MASKED] 06:04PM BLOOD [MASKED] PTT-28.4 [MASKED] [MASKED] 06:04PM BLOOD Glucose-152* UreaN-11 Creat-0.7 Na-136 K-4.7 Cl-98 HCO3-24 AnGap-14 IMAGING: [MASKED]: CT Abdomen/Pelvis: 1. No enterocutaneous fistula or small-bowel obstruction identified. 2. Open anterior abdominal wall wound measuring up to 14.5 x 16.1 cm with moderate soft tissue thickening along the lateral borders. Small focus of subcutaneous air tracking along the right superior border suggests increasing wound extension. [MASKED]: Abdominal x-ray: No enterocutaneous fistula demonstrated radiographically. Consider a fistulogram for this purpose. [MASKED]: Dx Portable PICC: Right PICC in the mid SVC. No acute cardiopulmonary process. [MASKED]: Abdominal x-ray: No acute abnormality with nonobstructive bowel gas pattern. Interval placement of wound VAC which projects over the mid abdomen. [MASKED]: CXR: No acute cardiopulmonary process. [MASKED] 10:16 pm URINE Source: [MASKED]. **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE IDENTIFICATION. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Brief Hospital Course: Ms. [MASKED] is a [MASKED] year old female with a history of multiple prior abdominal surgeries most recently a ventral hernia repair at [MASKED] ([MASKED]) who presented to [MASKED] [MASKED] on [MASKED] with an open abdominal wound, exposed mesh, and a low output entero-atmospheric fistula. She was admitted to the Acute Care Surgery Service for further management. The patient was kept NPO and initiated on TPN. She was started on octreotide for a short time period to help reduce fistula output. Plastic surgery was consulted to evaluate the patient in preparation for eventual abdominal wall reconstruction and offered to be available to assist with surgery when needed. Wound care nursing was also asked to assist with optimizing the patient's abdominal dressing, and a large wound manager was applied and placed to wall suction with good result. On [MASKED], the patient was taken to the operating room and underwent an abdominal skin graft with anterior bilateral thigh donor sites. For details of the procedure, please see the surgeon's operative note. The patient tolerated the procedure well without complication and was taken to the post anesthesia care unit in stable condition. The patient was placed on bedrest precautions and then activity restrictions were liberalized and the patient ambulated. [MASKED] was d/c'd and she voided appropriately. She was started on a regular diet which she tolerated and TPN was d/c'd. WBC was elevated on POD #3 and so PICC was d/c'd a fever work-up was sent and urine culture was positive for e.coli (sensitive to cipro). She was started on a 7 day course of cipro and WBC normalized. The patient's skin graft took approximately 90%. Non-adherent dressing were placed over the wound while ambulating and left open to the air for periods of time while in bed to let the graft dry. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged home with [MASKED] services. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: acetaminophen PRN albuterol (proair) aspirin 81 atorvastatin 20 suboxone Clonidine 0.2 TID Diltiazem 120mg 24 hour capsule Colace Flonase Glipizide Ibuprofen Metformin 500mg daily omeprazole 20mg daily trazodone 50mg daily umeclidinium 62.6 mcg/actuation Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Ciprofloxacin HCl 250 mg PO Q12H Closely monitor your blood sugars to assess for low blood sugar while taking this medication RX *ciprofloxacin HCl 250 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*9 Tablet Refills:*0 3. Docusate Sodium 100 mg PO BID Hold for loose stool 4. HYDROmorphone (Dilaudid) [MASKED] mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: d/c oxycodone Take lowest effective dose. Patient may request partial fill. RX *hydromorphone 2 mg [MASKED] tablet(s) by mouth every four (4) hours Disp #*20 Tablet Refills:*0 5. Atorvastatin 20 mg PO QPM 6. CloNIDine 0.2 mg PO TID 7. Diltiazem Extended-Release 120 mg PO DAILY 8. Fluticasone Propionate NASAL 1 SPRY NU DAILY PRN 9. GlipiZIDE 5 mg PO DAILY 10. MetFORMIN (Glucophage) 500 mg PO DAILY 11. Omeprazole 20 mg PO DAILY 12. Topiramate (Topamax) 50 mg PO BID 13. TraZODone 50 mg PO QHS:PRN PRN Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Giant abdominal hernia with exposed bowel and intestinal fistula. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You were admitted to [MASKED] with a large abdominal hernia after multiple prior surgeries. You had a fistula (an abnormal connection between the bowel and the skin) from the wound. You were initially placed on TPN to receive nutrition. You were later taken to the operating room and you underwent skin grafting from your thighs to your abdominal wound to protect the exposed bowel to prevent another fistula and also to close the current fistula. You tolerated this procedure well and your graft has mostly taken. You are now tolerating a regular diet, low residue diet. You were found to have a urinary tract infection and were started on a 1 (one) week course of an antibiotic, called ciprofloxacin. You will have a nurse visit you at home to check up on you to evaluate your wound and also help with your dressing changes. You are ready to be discharged home to continue your recovery. Please note the following discharge instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within [MASKED] hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [MASKED] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Followup Instructions: [MASKED]
[]
[ "N390", "I480", "I10", "J449", "E119", "F419", "Z87891" ]
[ "T8131XA: Disruption of external operation (surgical) wound, not elsewhere classified, initial encounter", "T8183XA: Persistent postprocedural fistula, initial encounter", "K632: Fistula of intestine", "D6851: Activated protein C resistance", "N390: Urinary tract infection, site not specified", "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", "Y92018: Other place in single-family (private) house as the place of occurrence of the external cause", "I480: Paroxysmal atrial fibrillation", "I10: Essential (primary) hypertension", "J449: Chronic obstructive pulmonary disease, unspecified", "E119: Type 2 diabetes mellitus without complications", "Z7984: Long term (current) use of oral hypoglycemic drugs", "F1290: Cannabis use, unspecified, uncomplicated", "F419: Anxiety disorder, unspecified", "M5430: Sciatica, unspecified side", "M419: Scoliosis, unspecified", "I8390: Asymptomatic varicose veins of unspecified lower extremity", "Z9049: Acquired absence of other specified parts of digestive tract", "Z87891: Personal history of nicotine dependence", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "Z1611: Resistance to penicillins", "I9581: Postprocedural hypotension" ]